When a woman experiences cord prolapse, the correct position for her is on all fours, with her knees and elbows on the ground. This condition can be caused by artificial rupture of the membranes, and it is important to keep the cord warm and moist while preparing for a caesarian section. The Trendelenburg position, which involves tilting the head-end of the bed downwards, is used in abdominal surgery to shift abdominal contents upwards. The Lloyd Davis position, which involves separating the legs and tilting the head-end of the bed downwards, is used in rectal and pelvic surgery. The McRoberts manoeuvre, which involves hyperflexing the legs tightly to the abdomen, is used in cases of shoulder dystocia during delivery, but not for cord prolapse. The lithotomy position, which involves raising the legs in stirrups and separating them, is used in obstetrics and gynaecology for various procedures, but not for cord prolapse.

Understanding Umbilical Cord Prolapse

Umbilical cord prolapse is a rare but serious complication that can occur during delivery. It happens when the umbilical cord descends ahead of the presenting part of the fetus, which can lead to compression or spasm of the cord. This can cause fetal hypoxia and potentially irreversible damage or death. Certain factors increase the risk of cord prolapse, such as prematurity, multiparity, polyhydramnios, twin pregnancy, cephalopelvic disproportion, and abnormal presentations like breech or transverse lie.

Around half of all cord prolapses occur when the membranes are artificially ruptured. Diagnosis is usually made when the fetal heart rate becomes abnormal and the cord is palpable vaginally or visible beyond the introitus. Cord prolapse is an obstetric emergency that requires immediate management. The presenting part of the fetus may be pushed back into the uterus to avoid compression, and the cord should be kept warm and moist to prevent vasospasm. The patient may be asked to go on all fours or assume the left lateral position until preparations for an immediate caesarian section have been carried out. Tocolytics may be used to reduce uterine contractions, and retrofilling the bladder with saline can help elevate the presenting part. Although caesarian section is the usual first-line method of delivery, an instrumental vaginal delivery may be possible if the cervix is fully dilated and the head is low.

In conclusion, umbilical cord prolapse is a rare but serious complication that requires prompt recognition and management. Understanding the risk factors and appropriate interventions can help reduce the incidence of fetal mortality associated with this condition.

Understanding Rubella Antibody Results: IgM and IgG

Rubella, also known as German measles, is a viral infection that can cause serious complications for pregnant women and their babies. Testing for rubella antibodies can help determine if someone is immune to the virus or has recently been infected.

A negative result for rubella IgM antibodies indicates that there is no current or recent infection. However, a positive result for rubella IgG antibodies indicates that the person has either been vaccinated or previously infected with the virus, making them immune.

It is important for pregnant women to know their rubella antibody status, as contracting the virus during the first trimester can lead to miscarriage or congenital rubella syndrome in the baby. Women who are not immune to rubella are offered vaccination after pregnancy.

In summary, understanding rubella antibody results can help individuals and healthcare providers make informed decisions about vaccination and pregnancy planning.

Maternal mortality rates are still high globally due to obstetric haemorrhage. Postpartum haemorrhage is characterized by blood loss of 500 ml after vaginal delivery, not including the placenta. If blood loss exceeds 1000mls, it is classified as major postpartum haemorrhage. It is crucial to evaluate the severity of the bleeding and seek appropriate management (as outlined below).

Understanding Postpartum Haemorrhage

Postpartum haemorrhage (PPH) is a condition where a woman experiences blood loss of more than 500 ml after giving birth vaginally. It can be classified as primary or secondary. Primary PPH occurs within 24 hours after delivery and is caused by the 4 Ts: tone, trauma, tissue, and thrombin. The most common cause is uterine atony. Risk factors for primary PPH include previous PPH, prolonged labour, pre-eclampsia, increased maternal age, emergency Caesarean section, and placenta praevia.

In managing PPH, it is important to involve senior staff immediately and follow the ABC approach. This includes two peripheral cannulae, lying the woman flat, blood tests, and commencing a warmed crystalloid infusion. Mechanical interventions such as rubbing up the fundus and catheterisation are also done. Medical interventions include IV oxytocin, ergometrine, carboprost, and misoprostol. Surgical options such as intrauterine balloon tamponade, B-Lynch suture, ligation of uterine arteries, and hysterectomy may be considered if medical options fail to control the bleeding.

Secondary PPH occurs between 24 hours to 6 weeks after delivery and is typically due to retained placental tissue or endometritis. It is important to understand the causes and risk factors of PPH to prevent and manage this life-threatening emergency effectively.

Understanding Miscarriage: Types and Recurrence Rates

Miscarriage is a common experience for many women, but it can still be a difficult and emotional event. It is defined as any pregnancy loss that occurs before 24 weeks of gestation. There are several types of miscarriage, including threatened, inevitable, incomplete, complete, missed, anembryonic, septic, and recurrent. Recurrent miscarriage, which is defined as three or more consecutive losses, is a particular concern for many women. The risk of recurrence is important to consider when offering parental counseling, as it can impact the chances of a successful pregnancy. For women without specific cause for recurrence, the percentage chance of a live birth in a subsequent pregnancy decreases with each miscarriage: 85% after one, 75% after two, and 60% after three. It’s important to remember that while miscarriage can be distressing, the chances of a successful pregnancy increase with each attempt.

Understanding Different Types of Miscarriage

Miscarriage is the loss of pregnancy before 20 weeks’ gestation and can occur due to various risk factors. There are different types of miscarriage, each with its own set of symptoms and ultrasound findings.

Threatened Miscarriage: This type presents with lower abdominal pain and light brown discharge. Ultrasound reveals an intrauterine gestational sac and fetal heart rate. Patients may experience further threatened miscarriage or proceed to a complete or full-term pregnancy.

Inevitable Miscarriage: Active bleeding within the uterine cavity is suggestive of an ongoing miscarriage. The cervical os is open, and products of conception may be seen within the vagina. This type will inevitably progress to a miscarriage.

Complete Miscarriage: An empty uterus is associated with a complete miscarriage. Examination reveals a closed cervical os and may or may not be associated with vaginal bleeding.

Missed Miscarriage: A gestational sac small for dates, associated with an absent fetal heart rate, is an incidental finding. Examination is unremarkable, with a closed cervical os and no evidence of vaginal bleeding.

Incomplete Miscarriage: Products of conception are seen within the uterus, with an absent fetal heart rate. Examination reveals an open or closed cervical os and bleeding. If this miscarriage does not proceed to a complete miscarriage, it will require surgical evacuation.

Understanding the different types of miscarriage can help patients and healthcare providers manage the condition effectively.

The combined test is a screening test offered between weeks 11 and the end of the 13th week to assess the chance of fetal anomalies. While there is a small risk of miscarriage associated with diagnostic tests (such as amniocentesis and chorionic villus sampling), it is generally considered acceptable when a screening test indicates a high chance of anomaly. However, as Katie is now outside of the window for the combined test, repeating it would not be useful. Instead, it is more appropriate to progress to a diagnostic test. The quadruple test is another screening test offered between weeks 14-19, but repeating a screening test would not confirm or rule out a diagnosis. Therefore, a diagnostic test would be the next step for Katie.

NICE updated guidelines on antenatal care in 2021, recommending the combined test for screening for Down’s syndrome between 11-13+6 weeks. The test includes nuchal translucency measurement, serum B-HCG, and pregnancy-associated plasma protein A (PAPP-A). The quadruple test is offered between 15-20 weeks for women who book later in pregnancy. Results are interpreted as either a ‘lower chance’ or ‘higher chance’ of chromosomal abnormalities. If a woman receives a ‘higher chance’ result, she may be offered a non-invasive prenatal screening test (NIPT) or a diagnostic test. NIPT analyzes cell-free fetal DNA in the mother’s blood and has high sensitivity and specificity for detecting chromosomal abnormalities. Private companies offer NIPT screening from 10 weeks gestation.

Promethazine is the appropriate medication to prescribe for nausea and vomiting in pregnancy, as it is a first-line antiemetic. Metoclopramide should be avoided due to the risk of extrapyramidal effects if used for more than 5 days. While alternative methods such as ginger and acupressure bands may be discussed, as the patient has requested medication, it is appropriate to prescribe promethazine. It is also important to support the patient’s decision to continue working if that is her preference.

Hyperemesis gravidarum is an extreme form of nausea and vomiting of pregnancy that occurs in around 1% of pregnancies and is most common between 8 and 12 weeks. It is associated with raised beta hCG levels and can be caused by multiple pregnancies, trophoblastic disease, hyperthyroidism, nulliparity, and obesity. Referral criteria for nausea and vomiting in pregnancy include continued symptoms with ketonuria and/or weight loss, a confirmed or suspected comorbidity, and inability to keep down liquids or oral antiemetics. The diagnosis of hyperemesis gravidarum requires the presence of 5% pre-pregnancy weight loss, dehydration, and electrolyte imbalance. Management includes first-line use of antihistamines and oral cyclizine or promethazine, with second-line options of ondansetron and metoclopramide. Admission may be needed for IV hydration. Complications can include Wernicke’s encephalopathy, Mallory-Weiss tear, central pontine myelinolysis, acute tubular necrosis, and fetal growth issues.

The symptoms of HELLP syndrome, a severe form of pre-eclampsia, include haemolysis (H), elevated liver enzymes (EL), and low platelets (LP). A patient with this condition may experience malaise, nausea, vomiting, and headache, as well as hypertension with proteinuria and epigastric and/or upper abdominal pain. The patient in this case meets the requirements for a diagnosis of HELLP syndrome.

Liver Complications During Pregnancy

During pregnancy, there are several liver complications that may arise. One of the most common is intrahepatic cholestasis of pregnancy, which occurs in about 1% of pregnancies and is typically seen in the third trimester. Symptoms include intense itching, especially in the palms and soles, as well as elevated bilirubin levels. Treatment involves the use of ursodeoxycholic acid for relief and weekly liver function tests. Women with this condition are usually induced at 37 weeks to prevent stillbirth, although maternal morbidity is not typically increased.

Another rare complication is acute fatty liver of pregnancy, which may occur in the third trimester or immediately after delivery. Symptoms include abdominal pain, nausea and vomiting, headache, jaundice, and hypoglycemia. Severe cases may result in pre-eclampsia. ALT levels are typically elevated, and support care is the primary management until delivery can be performed once the patient is stabilized.

Finally, conditions such as Gilbert’s and Dubin-Johnson syndrome may be exacerbated during pregnancy. Additionally, HELLP syndrome, which stands for haemolysis, elevated liver enzymes, and low platelets, is a serious complication that can occur in the third trimester and requires immediate medical attention. Overall, it is important for pregnant women to be aware of these potential liver complications and to seek medical attention if any symptoms arise.

Obesity is the only factor among the given options that has been linked to miscarriage. Other factors such as heavy lifting, bumping your tummy, having sex, air travel, and being stressed have not been associated with an increased risk of miscarriage. However, factors like increased maternal age, smoking in pregnancy, consuming alcohol, recreational drug use, high caffeine intake, infections and food poisoning, health conditions, and certain medicines have been linked to an increased risk of miscarriage. Additionally, an unusual shape or structure of the womb and cervical incompetence can also increase the risk of miscarriage.

Miscarriage: Understanding the Epidemiology

Miscarriage, also known as abortion, refers to the expulsion of the products of conception before 24 weeks. To avoid any confusion, the term miscarriage is often used. According to epidemiological studies, approximately 15-20% of diagnosed pregnancies will end in miscarriage during early pregnancy. In fact, up to 50% of conceptions may not develop into a blastocyst within 14 days.

Recurrent spontaneous miscarriage, which is defined as the loss of three or more consecutive pregnancies, affects approximately 1% of women. Understanding the epidemiology of miscarriage is important for healthcare providers and patients alike. It can help to identify risk factors and provide appropriate counseling and support for those who have experienced a miscarriage. By raising awareness and promoting education, we can work towards reducing the incidence of miscarriage and improving the overall health and well-being of women and their families.

A cut-off of 110 g/L should be used in the first trimester to determine if iron supplementation is necessary. This is because pregnancy causes a high-volume, low-pressure state which can dilute the blood and lower haemoglobin levels. Therefore, a lower cut-off is used compared to the canonical 115 g/L. In women after delivery, the cut-off is haemoglobin lower than 100 g/L, while in women during the second and third trimesters, it is haemoglobin lower than 105 g/L. Haemoglobin lower than 115 g/L is the cut-off for non-pregnant women, while haemoglobin lower than 120 g/L is never used as a cut-off for iron replacement therapy as it is within the normal range.

During pregnancy, women are checked for anaemia twice – once at the initial booking visit (usually around 8-10 weeks) and again at 28 weeks. The National Institute for Health and Care Excellence (NICE) has set specific cut-off levels to determine if a pregnant woman requires oral iron therapy. These levels are less than 110 g/L in the first trimester, less than 105 g/L in the second and third trimesters, and less than 100 g/L postpartum.

If a woman’s iron levels fall below these cut-offs, she will be prescribed oral ferrous sulfate or ferrous fumarate. It is important to continue this treatment for at least three months after the iron deficiency has been corrected to allow the body to replenish its iron stores. By following these guidelines, healthcare professionals can help ensure that pregnant women receive the appropriate care to prevent and manage anaemia during pregnancy.

Physiological Changes in Pregnancy

Pregnancy is a time of significant physiological changes in a woman’s body. These changes are mainly driven by progesterone rather than oestrogen. One of the changes is vasodilation, which leads to a drop in blood pressure initially, but it normalizes by term. However, an increase in heart rate and stroke volume leads to an increase in cardiac output.

Another change is a decrease in lower oesophageal sphincter tone and vascular resistance, which causes a drop in blood pressure. This decrease occurs over the first trimester but starts to increase to normal by term. Oestrogen is responsible for this change, and it also causes symptoms of reflux.

Pregnancy also causes a mild anaemia due to a drop in red cell volume. However, this is a dilutional anaemia caused by an increase in plasma volume. Additionally, there is an increase in clotting factors II, VII, IX, and X, which makes pregnancy a hypercoagulable state.

The functional residual capacity (FRC) increases in pregnancy, leading to more rapid breathing and smaller tidal volumes. This decrease in FRC means that oxygen reserve is less in pregnant women. Minute ventilation increases due to increased oxygen consumption and increased CO2 production. This is by increased tidal volume rather than respiratory rate.

Finally, the glomerular filtration rate (GFR) decreases secondary to progesterone, facilitating an increase in fluid retention and an increase in plasma volume. However, there is also an increase in aldosterone, which acts on the kidneys producing water and sodium retention, therefore causing an increase in plasma volume.

In conclusion, pregnancy causes significant physiological changes in a woman’s body, which are mainly driven by progesterone. These changes affect various systems, including the cardiovascular, respiratory, and renal systems.

The most probable diagnosis for a patient with a distended abdomen and abnormally high serum βhCG is a complete hydatidiform mole. The serum βhCG level of 453,000 mIU/ml is significantly higher than the upper limit of expected levels in an intrauterine pregnancy during weeks 9-12. Morning sickness may also be more severe in molar pregnancies. An ultrasound scan can confirm the diagnosis by showing a snowstorm appearance, and histology can be performed after evacuation.

While acute appendicitis is a possibility, the patient’s non-tender abdomen and normal CRP and white cell count make it less likely. Appendicitis would not cause high serum βhCG. Ectopic pregnancy should also be ruled out, as it is a potential diagnosis in any woman of childbearing age with abdominal pain, vaginal bleeding, or signs of shock. However, the serum βhCG level for an ectopic pregnancy is unlikely to be as high as in a molar pregnancy. An ultrasound scan can differentiate between a normal intrauterine pregnancy and a molar pregnancy.

Characteristics of Complete Hydatidiform Mole

A complete hydatidiform mole is a rare type of pregnancy where the fertilized egg develops into a mass of abnormal cells instead of a fetus. This condition is characterized by several features, including vaginal bleeding, an enlarged uterus size that is greater than expected for gestational age, and abnormally high levels of serum hCG. Additionally, an ultrasound may reveal a snowstorm appearance of mixed echogenicity.

In simpler terms, a complete hydatidiform mole is a type of pregnancy that does not develop normally and can cause abnormal bleeding and an enlarged uterus. Doctors can detect this condition through blood tests and ultrasounds, which show a unique appearance of mixed echogenicity. It is important for women to seek medical attention if they experience any abnormal symptoms during pregnancy.

Minimizing Teratogenicity in Antiepileptic Medications for Women Wishing to Start a Family

For women with epilepsy who wish to start a family, it is crucial to minimize exposure to teratogenic antiepileptic medications while still controlling their seizures. Sodium valproate, a commonly used antiepileptic drug, is highly teratogenic and associated with congenital malformations and neural tube defects. Therefore, it is recommended to change medication prior to conception, as advised by an epilepsy specialist after a thorough evaluation of risks and benefits.

One option may be to add levetiracetam to the current medication regimen, as it is a pregnancy category C drug that may help control seizures. However, carbamazepine or lamotrigine may be preferred based on limited evidence.

Stopping sodium valproate and starting phenytoin is not recommended, as phenytoin also carries a significant risk of teratogenicity and has toxic and side effects.

Increasing the dose of sodium valproate is not advised, as it can negatively affect fetal neurodevelopment.

Similarly, stopping sodium valproate and adding phenobarbital is not indicated, as phenobarbital is also associated with an increased risk of teratogenicity.

Overall, it is important for women with epilepsy who wish to start a family to consult with an epilepsy specialist to evaluate and recommend appropriate antiepileptic medication changes to minimize teratogenicity while still controlling seizures.

It is recommended that HIV testing be included as a standard part of antenatal screening.

Antenatal Screening Policy

Antenatal screening is an important aspect of prenatal care that helps identify potential health risks for both the mother and the developing fetus. The National Screening Committee (NSC) has recommended a policy for antenatal screening that outlines the conditions for which all pregnant women should be offered screening and those for which screening should not be offered.

The NSC recommends that all pregnant women should be offered screening for anaemia, bacteriuria, blood group, Rhesus status, and anti-red cell antibodies, Down’s syndrome, fetal anomalies, hepatitis B, HIV, neural tube defects, risk factors for pre-eclampsia, syphilis, and other conditions depending on the woman’s medical history.

However, there are certain conditions for which screening should not be offered, such as gestational diabetes, gestational hypertension, and preterm labor. These conditions are typically managed through regular prenatal care and monitoring.

It is important for pregnant women to discuss their screening options with their healthcare provider to ensure that they receive appropriate care and support throughout their pregnancy. By following the NSC’s recommended policy for antenatal screening, healthcare providers can help identify potential health risks early on and provide appropriate interventions to ensure the best possible outcomes for both mother and baby.

Placental abruption is more likely to occur in older mothers, those who have had multiple pregnancies, and those who have experienced maternal trauma. Pre-eclampsia, characterized by protein in the urine and high blood pressure, is also a risk factor.

Placental Abruption: Causes, Symptoms, and Risk Factors

Placental abruption is a condition that occurs when the placenta separates from the uterine wall, leading to maternal bleeding into the space between them. Although the exact cause of this condition is unknown, certain factors have been associated with it, including proteinuric hypertension, cocaine use, multiparity, maternal trauma, and increasing maternal age. Placental abruption is not a common occurrence, affecting approximately 1 in 200 pregnancies.

The clinical features of placental abruption include shock that is disproportionate to the visible blood loss, constant pain, a tender and tense uterus, and a normal lie and presentation of the fetus. The fetal heart may be absent or distressed, and there may be coagulation problems. It is important to be aware of other conditions that may present with similar symptoms, such as pre-eclampsia, disseminated intravascular coagulation (DIC), and anuria.

In summary, placental abruption is a serious condition that can have significant consequences for both the mother and the fetus. Understanding the risk factors and symptoms of this condition is important for early detection and appropriate management.

If a woman reports reduced fetal movements and no heartbeat is detected with a handheld Doppler after 28 weeks of gestation, an immediate ultrasound should be offered according to RCOG guidelines. Repeating Doppler after an hour is not recommended. If a heartbeat is detected, cardiotocography should be used to monitor the heart rate for at least 20 minutes. Fetal blood sampling is not necessary in this situation.

Understanding Reduced Fetal Movements

Introduction:
Reduced fetal movements can indicate fetal distress and are a response to chronic hypoxia in utero. This can lead to stillbirth and fetal growth restriction. It is believed that placental insufficiency may also be linked to reduced fetal movements.

Physiology:
Quickening is the first onset of fetal movements, which usually occurs between 18-20 weeks gestation and increases until 32 weeks gestation. Multiparous women may experience fetal movements sooner. Fetal movements should not reduce towards the end of pregnancy. There is no established definition for what constitutes reduced fetal movements, but less than 10 movements within 2 hours (in pregnancies past 28 weeks gestation) is an indication for further assessment.

Epidemiology:
Reduced fetal movements affect up to 15% of pregnancies, with 3-5% of pregnant women having recurrent presentations with RFM. Fetal movements should be established by 24 weeks gestation.

Risk factors for reduced fetal movements:
Posture, distraction, placental position, medication, fetal position, body habitus, amniotic fluid volume, and fetal size can all affect fetal movement awareness.

Investigations:
Fetal movements are usually based on maternal perception, but can also be objectively assessed using handheld Doppler or ultrasonography. Investigations are dependent on gestation at onset of RFM. If concern remains, despite normal CTG, urgent (within 24 hours) ultrasound can be used.

Prognosis:
Reduced fetal movements can represent fetal distress, but in 70% of pregnancies with a single episode of reduced fetal movement, there is no onward complication. However, between 40-55% of women who suffer from stillbirth experience reduced fetal movements prior to diagnosis. Recurrent RFM requires further investigations to consider structural or genetic fetal abnormalities.

Placental Abnormalities: Understanding the Spectrum of Disease

Placental abnormalities can range from mild to severe, with varying degrees of risk to both mother and baby. Placenta increta is a condition where the placenta infiltrates into the myometrium, while placenta percreta is the most severe form where the placental fibres invade beyond the myometrium and require a hysterectomy for management. Placenta accreta is a milder form where the placental fibres attach to the superficial layer of the myometrium. Placenta praevia is a common cause of antepartum haemorrhage, where the placenta lies low and covers part of the internal cervical os. Vasa praevia is a condition where fetal vessels run across or over part of the internal cervical os, increasing the risk of bleeding and fetal distress.

Risk factors for these conditions include previous Caesarean section, myomectomy, multiparity, maternal age >35, placenta praevia, and uterine anomalies. Diagnosis is typically made through ultrasound, with MRI used in severe cases. Management may involve a Caesarean section for delivery in a controlled setting, or in severe cases, a hysterectomy. Women with vasa praevia or placenta praevia are advised to have an elective Caesarean section to reduce the risk of complications. Understanding the spectrum of placental abnormalities is crucial for appropriate management and reducing the risk of maternal and fetal complications.

Hypertension during pregnancy is a common occurrence that requires careful management. In normal pregnancies, blood pressure tends to decrease in the first trimester and then gradually increase to pre-pregnancy levels by term. However, in cases of hypertension during pregnancy, the systolic blood pressure is usually above 140 mmHg or the diastolic blood pressure is above 90 mmHg. Additionally, an increase of more than 30 mmHg systolic or 15 mmHg diastolic from the initial readings may also indicate hypertension.

There are three categories of hypertension during pregnancy: pre-existing hypertension, pregnancy-induced hypertension (PIH), and pre-eclampsia. Pre-existing hypertension refers to a history of hypertension before pregnancy or elevated blood pressure before 20 weeks gestation. PIH occurs in the second half of pregnancy and resolves after birth. Pre-eclampsia is characterized by hypertension and proteinuria, and may also involve edema.

The management of hypertension during pregnancy involves the use of antihypertensive medications such as labetalol, nifedipine, and hydralazine. In cases of pre-existing hypertension, ACE inhibitors and angiotensin II receptor blockers should be stopped immediately and alternative medications should be prescribed. Women who are at high risk of developing pre-eclampsia should take aspirin from 12 weeks until the birth of the baby. It is important to carefully monitor blood pressure and proteinuria levels during pregnancy to ensure the health of both the mother and the baby.

In the case of an umbilical cord prolapse, it is important to push the presenting part of the fetus back into the uterus to prevent compression of the cord and subsequent fetal distress. This can be aided by retro-filling the bladder with saline and positioning the mother on all fours. Administering oxytocin infusion or tocolytics to stop uterine contractions is not recommended as they can worsen the situation. The McRoberts manoeuvre is also not applicable in this scenario. It is crucial to manage the situation promptly to prevent further harm to the fetus.

Understanding Umbilical Cord Prolapse

Umbilical cord prolapse is a rare but serious complication that can occur during delivery. It happens when the umbilical cord descends ahead of the presenting part of the fetus, which can lead to compression or spasm of the cord. This can cause fetal hypoxia and potentially irreversible damage or death. Certain factors increase the risk of cord prolapse, such as prematurity, multiparity, polyhydramnios, twin pregnancy, cephalopelvic disproportion, and abnormal presentations like breech or transverse lie.

Around half of all cord prolapses occur when the membranes are artificially ruptured. Diagnosis is usually made when the fetal heart rate becomes abnormal and the cord is palpable vaginally or visible beyond the introitus. Cord prolapse is an obstetric emergency that requires immediate management. The presenting part of the fetus may be pushed back into the uterus to avoid compression, and the cord should be kept warm and moist to prevent vasospasm. The patient may be asked to go on all fours or assume the left lateral position until preparations for an immediate caesarian section have been carried out. Tocolytics may be used to reduce uterine contractions, and retrofilling the bladder with saline can help elevate the presenting part. Although caesarian section is the usual first-line method of delivery, an instrumental vaginal delivery may be possible if the cervix is fully dilated and the head is low.

In conclusion, umbilical cord prolapse is a rare but serious complication that requires prompt recognition and management. Understanding the risk factors and appropriate interventions can help reduce the incidence of fetal mortality associated with this condition.

Antepartum Haemorrhage: Causes and Symptoms

Antepartum haemorrhage is a condition where a pregnant woman experiences vaginal bleeding during the second half of pregnancy. There are several causes of antepartum haemorrhage, including placental abruption, concealed placental abruption, placenta accreta, placenta praevia, and premature labour.

Placental abruption is a condition where the placenta separates from the uterine lining, leading to bleeding. It can be revealed, with vaginal bleeding, or concealed, without vaginal bleeding. Risk factors for placental abruption include maternal hypertension, smoking, cocaine use, trauma, and bleeding post-procedures.

Concealed placental abruption is usually an incidental finding, with the mother recalling an episode of pain without vaginal bleeding. Placenta accreta occurs when part of the placenta grows into the myometrium, causing severe intrapartum and postpartum haemorrhage. Placenta praevia is a low-lying placenta that can cause painless vaginal bleeding and requires an elective Caesarean section. Premature labour is another common cause of antepartum bleeding associated with abdominal pain, with cyclical pain and variable vaginal bleeding.

It is important to seek medical attention if experiencing antepartum haemorrhage, as it can lead to significant maternal and fetal morbidity and mortality. Women with placenta praevia are advised to attend the Antenatal Unit for assessment and monitoring every time they have bleeding.

Eclampsia: Diagnosis and Treatment Options

Eclampsia is a serious complication of pregnancy that requires prompt diagnosis and treatment. It is a multisystem disorder characterized by hypertension, proteinuria, and edema, and can lead to seizures and coma if left untreated. The definitive treatment for eclampsia is delivery of the fetus, which should be undertaken as soon as the mother is stabilized.

Seizures should be treated with magnesium sulfate infusions, while phenytoin and diazepam are second-line treatment agents. Pregnant women should be monitored for signs of pre-eclampsia, which can progress to eclampsia if left untreated.

While it is important to rule out other intracranial pathology with CT imaging of the brain, it is not indicated in the treatment of eclampsia. Hydralazine or labetalol infusion is the treatment of choice for hypertension in the setting of pre-eclampsia/eclampsia.

Following an eclamptic episode, around 50% of patients may experience a transient neurological deficit. Therefore, prompt diagnosis and treatment are crucial to prevent serious complications and ensure the best possible outcome for both mother and baby.

The quadruple test result shows a decrease in AFP, oestriol, and hCG, without change in inhibin A, indicating Edward’s syndrome. This condition is caused by trisomy 18 and can present with physical features such as micrognathia, low-set ears, rocker bottom feet, and overlapping fingers. The quadruple test is a screening test used to identify pregnancies with a higher risk of Down’s syndrome, Edwards’ syndrome, Patau’s syndrome, or neural tube defects. It is typically offered to patients who discover their pregnancy late and are no longer eligible for the combined test. ARPKD cannot be diagnosed with a quadruple test, but it can be detected prenatally with an ultrasound. Down’s syndrome would present with low AFP, low unconjugated oestriol, high hCG, and inhibin A, while neural tube defects would present with high AFP and normal oestriol, hCG, and inhibin A.

NICE updated guidelines on antenatal care in 2021, recommending the combined test for screening for Down’s syndrome between 11-13+6 weeks. The test includes nuchal translucency measurement, serum B-HCG, and pregnancy-associated plasma protein A (PAPP-A). The quadruple test is offered between 15-20 weeks for women who book later in pregnancy. Results are interpreted as either a ‘lower chance’ or ‘higher chance’ of chromosomal abnormalities. If a woman receives a ‘higher chance’ result, she may be offered a non-invasive prenatal screening test (NIPT) or a diagnostic test. NIPT analyzes cell-free fetal DNA in the mother’s blood and has high sensitivity and specificity for detecting chromosomal abnormalities. Private companies offer NIPT screening from 10 weeks gestation.

The position of the head in relation to the ischial spine is referred to as the station. When the head is at the same level as the ischial spines, the station is considered to be ‘0’. If the station is described as ‘-2’, it means that the head is 2 cm above the ischial spines, while a station of ‘+2’ indicates that the head is 2 cm below the ischial spine.

Induction of labour is a process where labour is artificially started and is required in about 20% of pregnancies. It is indicated in cases of prolonged pregnancy, prelabour premature rupture of the membranes, maternal medical problems, diabetic mother over 38 weeks, pre-eclampsia, obstetric cholestasis, and intrauterine fetal death. The Bishop score is used to assess whether induction of labour is necessary and includes cervical position, consistency, effacement, dilation, and fetal station. A score of less than 5 indicates that labour is unlikely to start without induction, while a score of 8 or more indicates a high chance of spontaneous labour or response to interventions made to induce labour.

Possible methods of induction include membrane sweep, vaginal prostaglandin E2, oral prostaglandin E1, maternal oxytocin infusion, amniotomy, and cervical ripening balloon. The NICE guidelines recommend vaginal prostaglandins or oral misoprostol if the Bishop score is less than or equal to 6, while amniotomy and an intravenous oxytocin infusion are recommended if the score is greater than 6.

The main complication of induction of labour is uterine hyperstimulation, which refers to prolonged and frequent uterine contractions that can interrupt blood flow to the intervillous space and result in fetal hypoxemia and acidemia. Uterine rupture is a rare but serious complication. Management includes removing vaginal prostaglandins and stopping the oxytocin infusion if one has been started, and considering tocolysis.

Pregnant women with a first-degree relative with diabetes should be screened for gestational diabetes with an OGTT at 24-28 weeks. No further tests are required, but thyroid function tests should be done in each trimester for those with an existing diagnosis of hypothyroidism. OGTT should not be done at 18-22 weeks.

Gestational diabetes is a common medical disorder affecting around 4% of pregnancies. Risk factors include a high BMI, previous gestational diabetes, and family history of diabetes. Screening is done through an oral glucose tolerance test, and diagnostic thresholds have recently been updated. Management includes self-monitoring of blood glucose, diet and exercise advice, and medication if necessary. For pre-existing diabetes, weight loss and insulin are recommended, and tight glycemic control is important. Targets for self-monitoring include fasting glucose of 5.3 mmol/l and 1-2 hour post-meal glucose levels.

When a pregnant woman with a confirmed DVT is suspected of having a PE, the first step is to immediately administer LMWH to avoid any delay in treatment. PE during pregnancy can be life-threatening for both the mother and the foetus, causing hypoxia and even cardiac arrest. Thrombolysis is not recommended during pregnancy as it can lead to severe haemorrhage in the placenta and foetus. Apixaban is not approved for use during pregnancy and may have teratogenic effects. Similarly, warfarin is not safe during pregnancy and can cause congenital malformations and haemorrhage in the placenta. While a CTPA can be diagnostic, waiting for the scan can be risky for the mother and baby. Therefore, LMWH should be started without delay, and further investigations can be carried out to confirm or rule out a PE.

Investigation of DVT/PE during Pregnancy

Guidelines for investigating deep vein thrombosis (DVT) and pulmonary embolism (PE) during pregnancy were updated in 2015 by the Royal College of Obstetricians. For suspected DVT, compression duplex ultrasound should be performed if there is clinical suspicion. In cases of suspected PE, an ECG and chest x-ray should be performed in all patients. If a woman presents with symptoms and signs of DVT, compression duplex ultrasound should be performed. If DVT is confirmed, no further investigation is necessary, and treatment for venous thromboembolism (VTE) should continue. The decision to perform a ventilation/perfusion (V/Q) scan or computed tomography pulmonary angiography (CTPA) should be made at a local level after discussion with the patient and radiologist.

When comparing CTPA to V/Q scanning in pregnancy, it is important to note that CTPA slightly increases the lifetime risk of maternal breast cancer (up to 13.6%, with a background risk of 1/200 for the study population). Pregnancy makes breast tissue particularly sensitive to the effects of radiation. On the other hand, V/Q scanning carries a slightly increased risk of childhood cancer compared to CTPA (1/50,000 versus less than 1/1,000,000). It is also important to note that D-dimer is of limited use in the investigation of thromboembolism during pregnancy as it is often raised in pregnant women.

Gestational hypertension is a condition where a woman develops high blood pressure after 20 weeks of pregnancy, without significant protein in the urine. This woman has moderate gestational hypertension, with her systolic blood pressure ranging between 150-159 mmHg and diastolic blood pressure ranging between 100-109 mmHg.

Typically, moderate gestational hypertension does not require hospitalization and can be treated with oral labetalol. However, as this woman has a history of asthma, labetalol is not recommended. Instead, NICE guidelines suggest nifedipine or methyldopa as alternatives. Methyldopa is not recommended for patients with depression, so the best option for this woman is oral nifedipine, which is a calcium channel blocker.

In cases of eclampsia, IV magnesium sulphate is necessary. It’s important to note that lisinopril, an ACE inhibitor, is not safe for use during pregnancy.

Hypertension during pregnancy is a common occurrence that requires careful management. In normal pregnancies, blood pressure tends to decrease in the first trimester and then gradually increase to pre-pregnancy levels by term. However, in cases of hypertension during pregnancy, the systolic blood pressure is usually above 140 mmHg or the diastolic blood pressure is above 90 mmHg. Additionally, an increase of more than 30 mmHg systolic or 15 mmHg diastolic from the initial readings may also indicate hypertension.

There are three categories of hypertension during pregnancy: pre-existing hypertension, pregnancy-induced hypertension (PIH), and pre-eclampsia. Pre-existing hypertension refers to a history of hypertension before pregnancy or elevated blood pressure before 20 weeks gestation. PIH occurs in the second half of pregnancy and resolves after birth. Pre-eclampsia is characterized by hypertension and proteinuria, and may also involve edema.

The management of hypertension during pregnancy involves the use of antihypertensive medications such as labetalol, nifedipine, and hydralazine. In cases of pre-existing hypertension, ACE inhibitors and angiotensin II receptor blockers should be stopped immediately and alternative medications should be prescribed. Women who are at high risk of developing pre-eclampsia should take aspirin from 12 weeks until the birth of the baby. It is important to carefully monitor blood pressure and proteinuria levels during pregnancy to ensure the health of both the mother and the baby.

Understanding Placenta Praevia

Placenta praevia is a condition where the placenta is located wholly or partially in the lower uterine segment. It is a relatively rare condition, with only 5% of women having a low-lying placenta when scanned at 16-20 weeks gestation. However, the incidence at delivery is only 0.5%, as most placentas tend to rise away from the cervix.

There are several factors associated with placenta praevia, including multiparity, multiple pregnancy, and embryos implanting on a lower segment scar from a previous caesarean section. Clinical features of placenta praevia include shock in proportion to visible loss, no pain, a non-tender uterus, abnormal lie and presentation, and a usually normal fetal heart. Coagulation problems are rare, and small bleeds may occur before larger ones.

Diagnosis of placenta praevia should not involve digital vaginal examination before an ultrasound, as this may provoke severe haemorrhage. The condition is often picked up on routine 20-week abdominal ultrasounds, but the Royal College of Obstetricians and Gynaecologists recommends the use of transvaginal ultrasound for improved accuracy and safety. Placenta praevia is classified into four grades, with grade IV being the most severe, where the placenta completely covers the internal os.

In summary, placenta praevia is a rare condition that can have serious consequences if not diagnosed and managed appropriately. It is important for healthcare professionals to be aware of the associated factors and clinical features, and to use appropriate diagnostic methods for accurate grading and management.

To evaluate a patient with suspected premature rupture of membranes, a thorough medical history should be obtained, including the number of pregnancies. A sterile speculum examination is necessary to check for the accumulation of amniotic fluid in the posterior vaginal vault. Digital examination should be avoided to prevent infection. Serum beta-HCG is not recommended, and the patient should have had previous ultrasound scans and have confirmed her pregnancy by this stage. Ultrasound is the appropriate diagnostic tool if there is no evidence of amniotic fluid pooling in the posterior vaginal vault.

Preterm prelabour rupture of the membranes (PPROM) is a condition that occurs in approximately 2% of pregnancies, but it is responsible for around 40% of preterm deliveries. This condition can lead to various complications, including prematurity, infection, and pulmonary hypoplasia in the fetus, as well as chorioamnionitis in the mother. To confirm PPROM, a sterile speculum examination should be performed to check for pooling of amniotic fluid in the posterior vaginal vault. However, digital examination should be avoided due to the risk of infection. If pooling of fluid is not observed, testing the fluid for placental alpha microglobulin-1 protein (PAMG-1) or insulin-like growth factor binding protein-1 is recommended. Ultrasound may also be useful to show oligohydramnios.

The management of PPROM involves admission and regular observations to ensure that chorioamnionitis is not developing. Oral erythromycin should be given for ten days, and antenatal corticosteroids should be administered to reduce the risk of respiratory distress syndrome. Delivery should be considered at 34 weeks of gestation, but there is a trade-off between an increased risk of maternal chorioamnionitis and a decreased risk of respiratory distress syndrome as the pregnancy progresses. PPROM is a serious condition that requires prompt diagnosis and management to minimize the risk of complications for both the mother and the fetus.

To monitor her throughout her pregnancy and postnatal period, this woman requires a referral to a perinatal mental health team due to her increased risk of postpartum psychosis. It would have been preferable for her to receive preconception advice before becoming pregnant. The recurrence rate is not influenced by the baby’s gender.

Understanding Postpartum Mental Health Problems

Postpartum mental health problems can range from mild ‘baby-blues’ to severe puerperal psychosis. To screen for depression, healthcare professionals may use the Edinburgh Postnatal Depression Scale, which is a 10-item questionnaire that indicates how the mother has felt over the previous week. A score of more than 13 indicates a ‘depressive illness of varying severity’, with sensitivity and specificity of more than 90%. The questionnaire also includes a question about self-harm.

‘Baby-blues’ is seen in around 60-70% of women and typically occurs 3-7 days following birth. It is more common in primips, and mothers are characteristically anxious, tearful, and irritable. Reassurance and support from healthcare professionals, particularly health visitors, play a key role in managing this condition. Most women with the baby blues will not require specific treatment other than reassurance.

Postnatal depression affects around 10% of women, with most cases starting within a month and typically peaking at 3 months. The features are similar to depression seen in other circumstances, and cognitive behavioural therapy may be beneficial. Certain SSRIs such as sertraline and paroxetine may be used if symptoms are severe. Although these medications are secreted in breast milk, they are not thought to be harmful to the infant.

Puerperal psychosis affects approximately 0.2% of women and requires admission to hospital, ideally in a Mother & Baby Unit. Onset usually occurs within the first 2-3 weeks following birth, and features include severe swings in mood (similar to bipolar disorder) and disordered perception (e.g. auditory hallucinations). There is around a 25-50% risk of recurrence following future pregnancies. Paroxetine is recommended by SIGN because of the low milk/plasma ratio, while fluoxetine is best avoided due to a long half-life.

When a pregnant woman is exposed to chickenpox, the first step is to check if she has varicella antibodies. If she is unsure whether she has had chickenpox in the past, the presence or absence of antibodies will determine the next course of action.

If a pregnant woman is over 20 weeks gestation and does not have varicella antibodies, she should be given varicella-zoster immunoglobulin or oral acyclovir within 7-14 days of exposure. Delaying the administration of oral acyclovir can reduce the risk of developing chickenpox.

Oral acyclovir is also recommended if a pregnant woman over 20 weeks gestation develops chickenpox. However, caution should be exercised if the patient is under 20 weeks gestation and does not have any symptoms of chickenpox.

The varicella-zoster vaccine is not recommended for pregnant women as it is a live attenuated vaccine that can cross the placenta and cause foetal varicella syndrome. It can be given to women who have not had chickenpox and are not immune to antibody testing, but they should avoid getting pregnant for three months after receiving the vaccine.

Varicella-zoster immunoglobulin is recommended for pregnant women who are not immune to varicella on antibody testing and can receive it within 10 days of exposure. However, it provides short-lived protection, so patients should be advised to get the varicella-zoster vaccine after their pregnancy.

Chickenpox exposure in pregnancy can pose risks to both the mother and fetus, including fetal varicella syndrome. Post-exposure prophylaxis (PEP) with varicella-zoster immunoglobulin (VZIG) or antivirals should be given to non-immune pregnant women, with timing dependent on gestational age. If a pregnant woman develops chickenpox, specialist advice should be sought and oral acyclovir may be given if she is ≥ 20 weeks and presents within 24 hours of onset of the rash.