1. A QUICK TOUR OF INFERTILITY BLEEDING IN PREGNANCY REDUCED FETAL MOVEMENT AND POST DATES
Dr Sonia Asif

2. I can’t get pregnant-Background
1 in 7 couples present with infertility
Defined as failure to conceive after 2 years of regular unprotected sexual intercourse
84 % of couples will conceive after 1 year
Half of the remaining 16% will conceive after 2 years (92%)
Offer clinical investigation (ovulation test/semen analysis) after 1 year in those who
are particularly concerned
Offer early investigations to if there is a history of:-
PID
Oligoamenorrhoea
Endometriosis
female age>35
Female fertility naturally declines with age and this a significant factor to consider
when thinking about offering investigations
94% of fertile women over 35
77% of fertile women over 38 will conceive after 3 years)

3. Initial Assessment
Mr and Mrs White come to see you in the clinic concerned that they have not conceived despite trying for 3 years.
?Female history
?Male history

4. Initial Assessment Female history
Obstetric History-previous pregnancies and outcomes
Gynaecological history-cycle length/regularity(If irregular ask about symptoms of PCOS)
Sexual history-dyspareunia /postcoital bleeding/past STI
Contraception history-when stopped and what they were using?
Surgical history-previous abdominal/pelvic surgery
Smear history
Rubella status
Smoking/Alcohol/BMI
Drug history-NSAIDS/Thyroxine/Antidepressants can cause anovulation
Male history
Past conception with other partners
Impotence/Ejaculation Issue
History of diabetes/hypertension
History of trauma to the genital area/past STI
Drug history-Cimetidine/anabolic steroids/Sulphasalazine can impair semen quality
Betablockers can cause impotence
Frequency of sexual intercourse-Should ideally be 2-3 times a week
Ovulation kits are not recommended as they cause undue stress

5. Lifestyle Advice

6. Lifestyle Advice Reassure regarding natural conception (2 year rule)
Normalise BMI(19-30)-Refer to dietitician/exercise programmes
Stop Smoking/recreational drugs(refer to smoking cessation)
Reduce Alcohol(1-2 units,1-2 times a week)
Start taking folic acid (need to take for 3 months preconceptually)
Give rubella vaccination if not immune
Advise loose fitting underwear for the male partner
Minimise Stress-Refer for counselling if needed
Refer to support group if appropriate

7. Initial Investigations
Female
Male

8. Initial Investigations-Primary Care
Female Day 2-5 FSH/LH (below 10) Mid luteal progesterone-Day 21 (above 30-50) If oligoamennorrhoea-Induce a withdrawal bleed with provera and then time tests Prolactin Rubella status Recent Smear Chlamydia Screening Male Semen Analysis If abnormal repeat in 3 months

9. Further Investigations-Secondary Care
Female
Check tubal patency
Hysterosalpingogram
if no history of PID/Endometriosis/Ectopic pregnancy
Laparoscopy and Dye test
if tubal or pelvic pathology suspected
Male
If no very low concentration/no sperm:-
FSH/LH/Testosterone
CF screening/Karyotype

10. Semen Analysis-WHO classification
Factor
Normal Range
Volume
2.0mls or more
Liquefaction time
Within 60 minutes pH
7.2 or more
Total Sperm Number
>40million per ejaculate
Sperm Concentration
>20 million per ml
Motility (grade a –rapidly motile
and b-slow motility)
within 60 minutes of ejaculation
>50%
>25% rapidly motile
Morphology
15%
Vitality
75%
WBC
<1 million/ml

11. Classifying Infertility and treatments
Type of Infertility
Incidence
Treatments
Ovulation
21%
Lifestyle Advice
Clomiphene and Tamoxifen for 12 months
Add in metformin if PCOS
Ovarian Drilling
Male
20%
IUI/IVF/ICSI
Sperm Recovery/Donation
Tubal
14%
Tubal Surgery/IVF
Unexplained
8-28%
Expectant
Empirical Clomiphene
IUI
IVF
Uterine (Septum/polyps/
fibroids)
10-15%
Surgically remove cause
Endometriosis
20-30%
Surgical ablation/adhesiolysis
IUI/IVF

12. NHS Funded or not? Meets the definition of Infertility
Couples in a stable relationship for at least 2 years
No previous children for either partner
Female Age 23-40
Male Age<55
BMI 19-30
Non Smokers
Welfare of the child

13. BLEEDING IN PREGNANCY ANTEPARTUM HEAMORRHAGE
Antepartum haemorrhage is defined as bleeding from the genital tract from 24 weeks to the delivery of the fetus (>10mls is significant)
It affects 6% of pregnancies and can lead to significant maternal and fetal morbidity
Although bleeding can occur from anywhere in the genital tract, the acute and life threatening causes include placenta praevia and placental abruption 13

14. I’M PREGNANT AND I’M BLEEDING
Beyonce Knowles comes to the antenatal assessment centre .She is in her second pregnancy and his 33 weeks pregnant.
When she went to the toilet to pass urine she noticed fresh red bleeding on her underwear.
Her fetal movements are normal.
What do you need to ask in her history?
What could be the causes?
Initial management?

15. PLACENTA PRAEVIA
This is classified as a placenta lying wholly or partly in the lower uterine segment
There are 4 type depending on the coverage of the cervix
Complicates 0.5% of pregnancies at term
Usually diagnosed on detailed USS with a rescan arranged for weeks
Presents with painless bleeding which can lead to placental abruption
On abdominal palpation can lead to a high head and malpresentations (breech,transverse lie)
Vaginal delivery is only possible if the placental edge is >2cm from the cervical os 15

16. PLACENTAL ABRUPTION
This is the premature separation of the placenta from the uterine wall
Presents with painful bleeding
Can be concealed or revealed
Usually leads to fetal compromise
Diagnosis is made clinically with a tender,tense uterus and delivery should be immediate by caesarean section
Risk factors:- smoking, abdominal truama, pre- eclampsia, previous abruption,crack cocaine use 16

17. MANAGEMENT OF HEAVY BLEEDING IN PREGNANCY
CALL FOR HELP
ABC APPROACH
RESUSCITATE IF MATERNAL COMPROMISE
AIM FOR RAPID DELIVERY
ALERT BLOOD BANK
THE AIM IS TO PREVENT MORTALITY/ MORBIDITY AND THE PROGRESSION TO DISSEMINATED INTRAVASCULAR COAGULOPATHY 17

18. Reduced Fetal Movements
One of the most common cause of maternal anxiety and assessment centre consultations
1st episode-CTG and reassure
2nd episode-CTG and Growth USS
3rd episode or more
Identify risk factors and individualise care
If low risk, reassure and maybe do growth USS
If high risk, monitor more closely,2 weekly growth USS, twice weekly CTG’s
If post dates-offer IOL

19. I’ve gone over my dates Around 1% of pregnancies go over their dates
A normal placenta has a shelf life of 40 weeks and 16 days
After this the rate of still birth increases
You are the doctor in clinic and are about to see Victoria Beckham who is a G1P0 lady who is term+6.
How will you counsel her? What are her options