A category 1 caesarean section is necessary in cases of suspected uterine rupture, major placental abruption, cord prolapse, fetal hypoxia, or persistent fetal bradycardia. In this scenario, the most likely diagnosis is a major placental abruption due to intense abdominal pain and haemodynamic shock. Guidelines recommend a category 1 caesarean section if the foetus is alive and >36 weeks with foetal distress, as indicated by late decelerations on cardiotocography. This is because the presentation of placental abruption, haemodynamic shock, and late decelerations poses an immediate threat to the lives of both the mother and baby. Administering corticosteroids and observation is not applicable in this scenario, as the foetus is >36 weeks and foetal distress is present. Category 2 and 4 caesarean sections are also inappropriate, as they are not immediately life-threatening and are elective, respectively.

Caesarean Section: Types, Indications, and Risks

Caesarean section, also known as C-section, is a surgical procedure that involves delivering a baby through an incision in the mother’s abdomen and uterus. In recent years, the rate of C-section has increased significantly due to an increased fear of litigation. There are two main types of C-section: lower segment C-section, which comprises 99% of cases, and classic C-section, which involves a longitudinal incision in the upper segment of the uterus.

C-section may be indicated for various reasons, including absolute cephalopelvic disproportion, placenta praevia grades 3/4, pre-eclampsia, post-maturity, IUGR, fetal distress in labor/prolapsed cord, failure of labor to progress, malpresentations, placental abruption, vaginal infection, and cervical cancer. The urgency of C-section may be categorized into four categories, with Category 1 being the most urgent and Category 4 being elective.

It is important for clinicians to inform women of the serious and frequent risks associated with C-section, including emergency hysterectomy, need for further surgery, admission to intensive care unit, thromboembolic disease, bladder injury, ureteric injury, and death. C-section may also increase the risk of uterine rupture, antepartum stillbirth, placenta praevia, and placenta accreta in subsequent pregnancies. Other complications may include persistent wound and abdominal discomfort, increased risk of repeat C-section, readmission to hospital, haemorrhage, infection, and fetal lacerations.

Vaginal birth after C-section (VBAC) may be an appropriate method of delivery for pregnant women with a single previous C-section delivery, except for those with previous uterine rupture or classical C-section scar. The success rate of VBAC is around 70-75%.

After a vaginal delivery, the loss of blood exceeding 500 ml is referred to as postpartum haemorrhage.

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.

When dealing with preterm premature rupture of membranes (PPROM), it’s important to consider the possibility of chorioamnionitis in women who exhibit a combination of maternal pyrexia, maternal tachycardia, and fetal tachycardia. While other conditions like pelvic inflammatory disease and urinary tract infections may also be considered, chorioamnionitis is the most probable diagnosis. Immediate cesarean section and intravenous antibiotics will likely be necessary.

Understanding Chorioamnionitis

Chorioamnionitis is a serious medical condition that can affect both the mother and the foetus during pregnancy. It is caused by a bacterial infection that affects the amniotic fluid, membranes, and placenta. This condition is considered a medical emergency and can be life-threatening if not treated promptly. It is more likely to occur when the membranes rupture prematurely, but it can also happen when the membranes are still intact.

Prompt delivery of the foetus is crucial in treating chorioamnionitis, and a cesarean section may be necessary. Intravenous antibiotics are also administered to help fight the infection. This condition affects up to 5% of all pregnancies, and it is important for pregnant women to be aware of the symptoms and seek medical attention immediately if they suspect they may have chorioamnionitis.

Hyperemesis gravidarum is a pregnancy complication that can lead to severe dehydration, metabolic imbalances, and deficiencies in essential vitamins and minerals. If left untreated, it can also cause Wernicke’s encephalopathy, as evidenced by the patient’s diplopia and ataxia. To address this, it is recommended to supplement with thiamine (Vitamin B1) and a complex of vitamins B and C, such as Pabrinex.

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.

Management of Severe Pre-eclampsia: Medications to Consider and Avoid

Severe pre-eclampsia, characterized by high blood pressure and proteinuria, can lead to eclamptic seizures and other complications. To prevent seizures, magnesium sulphate is administered as a loading dose followed by an infusion. Labetalol is the first-line medication for controlling blood pressure, but nifedipine and methyldopa can be used if labetalol is contraindicated. Ramipril, an ACE inhibitor, and amlodipine, a calcium channel blocker, are not recommended in pregnancy due to their teratogenic effects. Atenolol, a beta blocker, is not the agent of choice for pre-eclampsia management. Aspirin may be given prophylactically to women at risk of pre-eclampsia. Delivery of the fetus is the only definitive treatment for severe pre-eclampsia.

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.

The syncytiotrophoblast secretes human chorionic gonadotrophin (HCG) into the maternal bloodstream to sustain the production of progesterone by the corpus luteum during the initial stages of pregnancy. HCG can be identified in the maternal blood as soon as day 8 following conception.

Understanding Human Chorionic Gonadotropin (hCG)

Human chorionic gonadotropin (hCG) is a hormone that is initially produced by the embryo and later by the placental trophoblast. Its primary function is to prevent the disintegration of the corpus luteum. During the first few weeks of pregnancy, hCG levels double approximately every 48 hours. These levels peak at around 8-10 weeks gestation. As a result, hCG levels are used as the basis for many pregnancy testing kits.

In summary, hCG is a hormone that plays a crucial role in pregnancy. Its levels increase rapidly during the early stages of pregnancy and peak at around 8-10 weeks gestation. By measuring hCG levels, pregnancy testing kits can accurately determine whether a woman is pregnant or not.

The macrocytic anaemia revealed by the full blood count is indicative of a megaloblastic anaemia, as per the blood films. This type of anaemia can be caused by a deficiency in folate or B12. Given that folic acid deficiency is prevalent during pregnancy, it is the most probable cause in this instance. Additionally, the likelihood of coeliac disease exacerbating malabsorption further supports this conclusion.

Folic Acid: Importance, Deficiency, and Prevention

Folic acid is a vital nutrient that is converted to tetrahydrofolate (THF) in the body. It is found in green, leafy vegetables and plays a crucial role in the transfer of 1-carbon units to essential substrates involved in the synthesis of DNA and RNA. However, certain factors such as phenytoin, methotrexate, pregnancy, and alcohol excess can cause a deficiency in folic acid. This deficiency can lead to macrocytic, megaloblastic anemia and neural tube defects.

To prevent neural tube defects during pregnancy, it is recommended that all women take 400mcg of folic acid until the 12th week of pregnancy. Women at higher risk of conceiving a child with a neural tube defect should take 5mg of folic acid from before conception until the 12th week of pregnancy. Women are considered higher risk if they or their partner has a neural tube defect, they have had a previous pregnancy affected by a neural tube defect, or they have a family history of a neural tube defect. Additionally, women with certain medical conditions such as coeliac disease, diabetes, or thalassaemia trait, or those taking antiepileptic drugs, or who are obese (BMI of 30 kg/m2 or more) are also considered higher risk.

In summary, folic acid is an essential nutrient that plays a crucial role in DNA and RNA synthesis. Deficiency in folic acid can lead to serious health consequences, including neural tube defects. However, taking folic acid supplements during pregnancy can prevent these defects and ensure a healthy pregnancy.

A raised level of maternal serum AFP is linked to fetal abdominal wall defects such as omphalocele. Conversely, low levels of maternal AFP are associated with Down’s syndrome, maternal diabetes mellitus, Edwards syndrome, and maternal obesity.

Alpha-fetoprotein (AFP) is a protein that is created by the fetus during development. When there is an increase in AFP levels, it may indicate the presence of certain conditions such as neural tube defects (meningocele, myelomeningocele and anencephaly), abdominal wall defects (omphalocele and gastroschisis), multiple pregnancy, Down’s syndrome, trisomy 18, and maternal diabetes mellitus. On the other hand, a decrease in AFP levels may also be significant and should be further investigated.

At 32 weeks gestation, this woman may be experiencing labor with ruptured membranes. It is important to admit her and administer steroids to promote the baby’s lung development. Antibiotics, such as erythromycin, should also be given to prevent sepsis and post-natal infection. Hospital guidelines should always be consulted, especially if Group B streptococcus is present, in which case penicillin and clindamycin may be used. If labor does not progress, the woman may be able to manage at home with temperature checks every 4-8 hours and returning to the hospital if a fever occurs. Delivery at 34 weeks may be considered if the risk of infection outweighs the risk of prematurity now that the baby’s lungs have matured.

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.

Treatment options for pre-existing hypertension in pregnancy

Explanation: Pre-existing hypertension in pregnancy requires careful management to ensure the safety of both the mother and the baby. When treating hypertension in pregnancy, it is important to consider the potential adverse effects of medication on fetal development.

One option is to discontinue antihypertensive treatment as blood pressure drops in the first trimester. However, this is not recommended as high blood pressure in pregnancy can have significant implications.

Continuing ramipril at the current dose or increasing the dose is not recommended as ACE inhibitors have been associated with fetal malformations. NICE guidelines suggest stopping ACE inhibitors and ARBs as soon as the patient knows she is pregnant or at the first opportunity such as the booking visit.

The first-line treatment for hypertension in pregnancy is labetalol, but it should be avoided in patients with asthma. Second-line medications include nifedipine, a calcium channel blocker, and methyldopa. Methyldopa should be avoided in patients with a history of depression. Therefore, the safest choice in this scenario is nifedipine. It is important to prescribe nifedipine by brand name and continue with the same brand throughout the course of treatment, provided there are no side-effects.

In the case of a small placental abruption without signs of foetal distress and a gestational age of less than 36 weeks, the recommended management is to admit the patient and administer steroids. While vitamin K can aid in blood clotting, it is not the optimal choice in this situation. A caesarean section is not immediately necessary as the foetus is not in distress and is under 36 weeks. Antibiotics are not indicated as there are no signs of infection and the patient is not experiencing a fever. Continuous monitoring with CTG for 24 hours is not necessary if the foetus is not displaying any distress on initial presentation and the mother has not reported a decrease in foetal movements.

Placental Abruption: Causes, Management, and Complications

Placental abruption is a condition where the placenta separates from the uterine wall, leading to maternal haemorrhage. The severity of the condition depends on the extent of the separation and the gestational age of the fetus. Management of placental abruption is crucial to prevent maternal and fetal complications.

If the fetus is alive and less than 36 weeks, immediate caesarean delivery is recommended if there is fetal distress. If there is no fetal distress, close observation, administration of steroids, and no tocolysis are recommended. The decision to deliver depends on the gestational age of the fetus. If the fetus is alive and more than 36 weeks, immediate caesarean delivery is recommended if there is fetal distress. If there is no fetal distress, vaginal delivery is recommended. If the fetus is dead, vaginal delivery should be induced.

Placental abruption can lead to various maternal complications, including shock, disseminated intravascular coagulation (DIC), renal failure, and postpartum haemorrhage (PPH). Fetal complications include intrauterine growth restriction (IUGR), hypoxia, and death. The condition is associated with a high perinatal mortality rate and is responsible for 15% of perinatal deaths.

In conclusion, placental abruption is a serious condition that requires prompt management to prevent maternal and fetal complications. Close monitoring and timely intervention can improve the prognosis for both the mother and the baby.

Understanding Down Syndrome Screening Tests

Down syndrome screening tests are important for pregnant women to determine the likelihood of their baby having the condition. One of the most common tests is the combined test, which is performed between 11+0 and 13+6 weeks’ gestation. This test involves a blood test and an ultrasound scan to measure serum pregnancy-associated plasma protein A (PAPP-A) and β-hCG, as well as nuchal translucency. The results are combined to give an individual risk of having a baby with Down syndrome.

If a woman misses the window for the combined test, she can opt for the quadruple test, which is performed between weeks 15 and 16 of gestation. This test measures four serum markers: inhibin, aFP, unconjugated oestriol, and total serum hCG. Low aFP and unconjugated oestriol, as well as raised inhibin and hCG, are associated with Down syndrome.

It is important to note that these tests are not diagnostic, but rather provide a risk assessment. Women who are classified as high risk may opt for a diagnostic test, such as amniocentesis or chorionic villous sampling, to confirm the presence of an extra chromosome. All pregnant women in the UK should be offered Down syndrome screening and given the opportunity to make an informed decision about participating in the test.

Measuring Uterine Growth During Pregnancy

During pregnancy, the size of the uterus can be used to estimate the gestational age of the fetus. At around 20 weeks, the uterus reaches the level of the umbilicus. This can be measured using the symphysio-fundal height (SFH), which is usually equal to the number of weeks of gestation (± 2 cm). To measure the SFH, the fundus of the uterus is first palpated and the tape measure is placed at this point. The tape measure is then rolled over the longitudinal axis of the uterus until it reaches the pubic symphysis, and the length in centimeters is recorded.

At 16 weeks, the uterus would not be palpable at the level of the umbilicus. The fundus of the uterus can be palpated at the midpoint between the umbilicus and the pubic symphysis. Similarly, at 18 weeks, the uterus would not be palpable at the level of the umbilicus.

By 22 weeks, the uterus would be past the level of the umbilicus. And by 24 weeks, the uterus would be higher in the abdomen than the umbilicus. Regular measurement of the SFH can help monitor fetal growth and ensure that the pregnancy is progressing normally.

The initial investigation for preterm prelabour rupture of the membranes is a thorough speculum examination to check for the accumulation of amniotic fluid in the posterior vaginal vault. It is recommended to avoid bimanual examination to minimize the risk of infection. While cardiotocography can be used to assess foetal wellbeing, it is not the preferred first-line investigation. Foetal blood sampling is not the recommended initial investigation due to the potential risks of infection and miscarriage.

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.

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.

Repair of third degree perineal tears should be carried out in a theatre by a clinician who has received appropriate training. This is because category 3 and 4 tears pose a risk of infection and have a significant impact on the patient’s health. Poor healing of perineal wounds can lead to faecal incontinence, which is a potential complication of grade 3 and 4 tears. It is advisable to pack the perineal wound for haemostasis before repairing the tear, as this will help achieve better haemostasis with sutures. Healing of perineal tears by secondary intent is not recommended, as it can result in poor healing, infection, and faecal incontinence. Additionally, the vascular nature of the perineum and anus increases the likelihood of ongoing haemorrhage if the wound is not healed. In cases of category 1 and 2 tears (involving the skin only or skin and perineal muscle), perineal tear repair can be performed immediately on the maternity ward if the clinician feels comfortable and there is adequate lighting.

Perineal tears are a common occurrence during childbirth, and the Royal College of Obstetricians and Gynaecologists (RCOG) has developed guidelines to classify them based on their severity. First-degree tears are superficial and do not require any repair, while second-degree tears involve the perineal muscle and require suturing by a midwife or clinician. Third-degree tears involve the anal sphincter complex and require repair in theatre by a trained clinician, with subcategories based on the extent of the tear. Fourth-degree tears involve the anal sphincter complex and rectal mucosa and also require repair in theatre by a trained clinician.

There are several risk factors for perineal tears, including being a first-time mother, having a large baby, experiencing a precipitant labour, and having a shoulder dystocia or forceps delivery. It is important for healthcare providers to be aware of these risk factors and to provide appropriate care and management during childbirth to minimize the risk of perineal tears. By following the RCOG guidelines and providing timely and effective treatment, healthcare providers can help ensure the best possible outcomes for both mother and baby.

When a pregnant woman reports reduced fetal movements, the first step should be to use a handheld Doppler to confirm the fetal heartbeat. Most women start feeling the baby move around 20 weeks of gestation, and reduced movements at 30 weeks could indicate fetal distress. The Royal College of Obstetrics and Gynaecology recommends that doctors attempt to listen to the fetal heart rate in any woman with reduced fetal movements. Checking a urine sample for a UTI is not a priority in this situation, and performing an ultrasound should only be done after confirming fetal viability with a handheld Doppler. Reassuring the woman that reduced movements are normal is incorrect, as it is abnormal at this stage of pregnancy. CTG is also not necessary until fetal viability has been confirmed with a Doppler.

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.

During pregnancies, immune thrombocytopenia (ITP) can become a complication if maternal antiplatelet antibodies pass through the placenta. In such cases, ventouse delivery can cause bleeding in the neonate due to the high vacuum pressure. This can worsen conditions like cephalohaematoma or subgaleal haemorrhage, especially if the neonate has thrombocytopenia. While forceps and fetal blood sampling can be used with caution, they are not as risky.

Understanding the Difference between Gestational Thrombocytopenia and Immune Thrombocytopenia (ITP)

Gestational thrombocytopenia and immune thrombocytopenia (ITP) are two conditions that affect platelet count during pregnancy. Gestational thrombocytopenia is a common condition that results from a combination of factors such as dilution, decreased production, and increased destruction of platelets. On the other hand, ITP is an autoimmune condition that is usually associated with acute purpuric episodes in children, but a chronic relapsing course may be seen more frequently in women.

Differentiating between the two conditions can be challenging and often relies on a careful history. Gestational thrombocytopenia may be considered more likely if the platelet count continues to fall as pregnancy progresses, but this is not a reliable sign. If the patient becomes dangerously thrombocytopenic, she will usually be treated with steroids, and a diagnosis of ITP assumed. Pregnant women found to have low platelets during a booking visit or those with a previous diagnosis of ITP may need to be tested for serum antiplatelet antibodies for confirmation.

It is important to note that gestational thrombocytopenia does not affect the neonate, but ITP can do if maternal antibodies cross the placenta. Depending on the degree of thrombocytopenia in the newborn, platelet transfusions may be indicated. Serial platelet counts can also be performed to see whether there is an inherited thrombocytopenia. Understanding the difference between these two conditions is crucial in ensuring proper diagnosis and management during pregnancy.

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.

Lactation mastitis is a prevalent inflammatory condition of the breast that can have infectious or non-infectious origins. The primary cause is milk stasis, which can occur due to either overproduction or insufficient removal.

In cases of non-infectious mastitis, the accumulation of milk leads to an inflammatory response. Occasionally, an infection may develop through retrograde spread via a lactiferous duct or a traumatised nipple, with Staphylococcus aureus being the most common organism.

Symptoms of lactation mastitis include breast pain (usually unilateral) accompanied by an erythematosus, warm, and tender area. Patients may also experience fever and flu-like symptoms.

The first-line approach to managing lactation mastitis is conservative, involving analgesia and encouraging effective milk removal (either through continued breastfeeding or expressing from the affected side) to prevent further milk stasis. It is also crucial to ensure proper positioning and attachment during feeding.

If symptoms do not improve after 12-24 hours of conservative management, antibiotics should be prescribed. The first-line choice is oral flucloxacillin (500 mg four times a day for 14 days), or erythromycin if the patient is allergic to penicillin. Co-amoxiclav is the second-line choice.

In cases where conservative and antibiotic management do not improve symptoms, other more serious causes, such as inflammatory breast cancer, should be considered. (Source – CKS mastitis)

Breastfeeding Problems and Their Management

Breastfeeding is a natural process, but it can come with its own set of challenges. Some of the minor problems that breastfeeding mothers may encounter include frequent feeding, nipple pain, blocked ducts, and nipple candidiasis. These issues can be managed by seeking advice on proper positioning, trying breast massage, and using appropriate medication.

Mastitis is a more serious problem that affects around 1 in 10 breastfeeding women. It is characterized by symptoms such as fever, nipple fissure, and persistent pain. Treatment involves the use of antibiotics, such as flucloxacillin, for 10-14 days. Breastfeeding or expressing milk should continue during treatment to prevent complications such as breast abscess.

Breast engorgement is another common problem that causes breast pain in breastfeeding women. It occurs in the first few days after birth and affects both breasts. Hand expression of milk can help relieve the discomfort of engorgement. Raynaud’s disease of the nipple is a less common problem that causes nipple pain and blanching. Treatment involves minimizing exposure to cold, using heat packs, and avoiding caffeine and smoking.

If a breastfed baby loses more than 10% of their birth weight in the first week of life, it may be a sign of poor weight gain. This should prompt consideration of the above breastfeeding problems and an expert review of feeding. Monitoring of weight should continue until weight gain is satisfactory.

Understanding Diabetes Tests During Pregnancy

During pregnancy, it is important for diabetic mothers to have good glycaemic control to prevent complications such as increased miscarriage rate, birth defects, and perinatal mortality. One way to measure glycaemic control is through the HbA1c test, which measures the average blood glucose concentration over the lifespan of a haemoglobin molecule. A level below 6% is considered good. Folic acid supplementation is also important to prevent neural tube defects in the baby.

The 2-hour glucose tolerance test (GTT) is used to screen for diabetes in pregnant women. However, there is no such thing as a 30-minute GTT. Random blood sugar tests only provide a snapshot measurement and do not take into account overall control or other factors that could be affecting sugar levels at that moment. Sugar series tests are not useful for pre-pregnancy counselling as they do not provide information about overall control. Diabetic mothers should be cared for by a joint obstetric-endocrine team of clinicians throughout their pregnancies.

The risk of stillbirth is higher in cases of intrahepatic cholestasis of pregnancy, also known as obstetric cholestasis. As a result, it is recommended to induce labour at 37-38 weeks gestation. It is not advisable to wait for a normal vaginal delivery, especially in primiparous women who may go past their due date. Caesarean delivery is not typically necessary for intrahepatic cholestasis, and emergency caesarean section is not warranted in this situation.

Intrahepatic Cholestasis of Pregnancy: Symptoms and Management

Intrahepatic cholestasis of pregnancy, also known as obstetric cholestasis, is a condition that affects approximately 1% of pregnancies in the UK. It is characterized by intense itching, particularly on the palms, soles, and abdomen, and may also result in clinically detectable jaundice in around 20% of patients. Raised bilirubin levels are seen in over 90% of cases.

The management of intrahepatic cholestasis of pregnancy typically involves induction of labor at 37-38 weeks, although this practice may not be evidence-based. Ursodeoxycholic acid is also widely used, although the evidence base for its effectiveness is not clear. Additionally, vitamin K supplementation may be recommended.

It is important to note that the recurrence rate of intrahepatic cholestasis of pregnancy in subsequent pregnancies is high, ranging from 45-90%. Therefore, close monitoring and management are necessary for women who have experienced this condition in the past.

During pregnancy, uterine fibroids can grow due to their sensitivity to oestrogen. If their growth exceeds their blood supply, they may undergo red or ‘carneous’ degeneration, which can cause symptoms such as low-grade fever, pain, and vomiting. Treatment typically involves rest and pain relief, and the condition should resolve within a week. It is unlikely that this is a multiple pregnancy, as it would have been detected by now, and a closed cervical os suggests that a miscarriage is not imminent.

Understanding Uterine Fibroids

Uterine fibroids are non-cancerous growths that develop in the uterus. They are more common in black women and are thought to occur in around 20% of white women in their later reproductive years. Fibroids are usually asymptomatic, but they can cause menorrhagia, which can lead to iron-deficiency anaemia. Other symptoms include lower abdominal pain, bloating, and urinary symptoms. Fibroids may also cause subfertility.

Diagnosis is usually made through transvaginal ultrasound. Asymptomatic fibroids do not require treatment, but periodic monitoring is recommended. Menorrhagia secondary to fibroids can be managed with various treatments, including the levonorgestrel intrauterine system, NSAIDs, tranexamic acid, and hormonal therapies.

Medical treatment to shrink or remove fibroids may include GnRH agonists or ulipristal acetate, although the latter is not currently recommended due to concerns about liver toxicity. Surgical options include myomectomy, hysteroscopic endometrial ablation, hysterectomy, and uterine artery embolization.

Fibroids generally regress after menopause, but complications such as subfertility and iron-deficiency anaemia can occur. Red degeneration, which is haemorrhage into the tumour, is a common complication during pregnancy.

1. The only effective treatment for pre-eclampsia is delivery, while IV magnesium sulphate is administered to prevent seizures in eclampsia.
2. Delivery on the same day is a viable option after 34 weeks.
3. Nifedipine is considered safe for breastfeeding mothers. (However, labetalol is the preferred antihypertensive medication, as beta-blockers should be avoided in patients with a history of asthma.)
4. Epidural anaesthesia can help lower blood pressure.
5. It is important to continue hypertension treatment during labour to manage blood pressure levels. Please refer to the NICE guideline on the diagnosis and management of hypertension in pregnancy for further information.

Pre-eclampsia is a condition that occurs during pregnancy and is characterized by high blood pressure, proteinuria, and edema. It can lead to complications such as eclampsia, neurological issues, fetal growth problems, liver involvement, and cardiac failure. Severe pre-eclampsia is marked by hypertension, proteinuria, headache, visual disturbances, and other symptoms. Risk factors for pre-eclampsia include hypertension in a previous pregnancy, chronic kidney disease, autoimmune disease, diabetes, chronic hypertension, first pregnancy, and age over 40. Aspirin may be recommended for women with high or moderate risk factors. Treatment involves emergency assessment, admission for observation, and medication such as labetalol, nifedipine, or hydralazine. Delivery of the baby is the most important step in management, with timing depending on the individual case.

Conduct a blood test to measure the levels of beta-human chorionic gonadotropin (hCG) in the serum, and then repeat the test after 120 hours.

Bleeding in the First Trimester: Understanding the Causes and Management

Bleeding in the first trimester of pregnancy is a common concern for many women. It can be caused by various factors, including miscarriage, ectopic pregnancy, implantation bleeding, cervical ectropion, vaginitis, trauma, and polyps. However, the most important cause to rule out is ectopic pregnancy, as it can be life-threatening if left untreated.

To manage early bleeding, the National Institute for Health and Care Excellence (NICE) released guidelines in 2019. If a woman has a positive pregnancy test and experiences pain, abdominal tenderness, pelvic tenderness, or cervical motion tenderness, she should be referred immediately to an early pregnancy assessment service. If the pregnancy is over six weeks gestation or of uncertain gestation and the woman has bleeding, she should also be referred to an early pregnancy assessment service.

A transvaginal ultrasound scan is the most important investigation to identify the location of the pregnancy and whether there is a fetal pole and heartbeat. If the pregnancy is less than six weeks gestation and the woman has bleeding but no pain or risk factors for ectopic pregnancy, she can be managed expectantly. However, she should be advised to return if bleeding continues or pain develops and to repeat a urine pregnancy test after 7-10 days and to return if it is positive. A negative pregnancy test means that the pregnancy has miscarried.

In summary, bleeding in the first trimester of pregnancy can be caused by various factors, but ectopic pregnancy is the most important cause to rule out. Early referral to an early pregnancy assessment service and a transvaginal ultrasound scan are crucial in identifying the location of the pregnancy and ensuring appropriate management. Women should also be advised to seek medical attention if they experience any worrying symptoms or if bleeding or pain persists.

In obstetric operating theatres or surgical vivas, a frequently asked question pertains to the structures that lie between the skin and the fetus during a lower segment Caesarian section. A confident and clear response indicates a sound understanding of local anatomy and the necessary incisions to reach the fetus. The layers between the skin and the fetus include the superficial fascia, deep fascia, anterior rectus sheath, rectus abdominis muscle (which is not cut but rather pushed laterally after incising the linea alba), transversalis fascia, extraperitoneal connective tissue, peritoneum, and uterus.

Caesarean Section: Types, Indications, and Risks

Caesarean section, also known as C-section, is a surgical procedure that involves delivering a baby through an incision in the mother’s abdomen and uterus. In recent years, the rate of C-section has increased significantly due to an increased fear of litigation. There are two main types of C-section: lower segment C-section, which comprises 99% of cases, and classic C-section, which involves a longitudinal incision in the upper segment of the uterus.

C-section may be indicated for various reasons, including absolute cephalopelvic disproportion, placenta praevia grades 3/4, pre-eclampsia, post-maturity, IUGR, fetal distress in labor/prolapsed cord, failure of labor to progress, malpresentations, placental abruption, vaginal infection, and cervical cancer. The urgency of C-section may be categorized into four categories, with Category 1 being the most urgent and Category 4 being elective.

It is important for clinicians to inform women of the serious and frequent risks associated with C-section, including emergency hysterectomy, need for further surgery, admission to intensive care unit, thromboembolic disease, bladder injury, ureteric injury, and death. C-section may also increase the risk of uterine rupture, antepartum stillbirth, placenta praevia, and placenta accreta in subsequent pregnancies. Other complications may include persistent wound and abdominal discomfort, increased risk of repeat C-section, readmission to hospital, haemorrhage, infection, and fetal lacerations.

Vaginal birth after C-section (VBAC) may be an appropriate method of delivery for pregnant women with a single previous C-section delivery, except for those with previous uterine rupture or classical C-section scar. The success rate of VBAC is around 70-75%.

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.

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.

Understanding Risk Factors for Intrauterine Growth Restriction (IUGR)

Intrauterine growth restriction (IUGR) is a condition where a baby does not grow properly in the womb. There are various risk factors associated with IUGR, including smoking during pregnancy, which can increase the likelihood of developing the condition.

There are two types of IUGR: symmetrical and asymmetrical. Symmetrical growth retardation occurs at the start or during early pregnancy and is characterized by a small head and short length. Asymmetrical growth retardation occurs in advanced pregnancy and is characterized by reduced abdominal growth compared to head circumference, due to selective shunting of blood to the brain.

It’s important to note that a baby with a birthweight below the tenth centile is considered small for gestational age (SGA), which may be normal or due to IUGR.

Contrary to popular belief, hypotension (low blood pressure), obesity, and stress are not recognized risk factors for IUGR. However, poorly controlled diabetes is a risk factor for IUGR, while well-controlled diabetes is not.

Understanding these risk factors can help healthcare providers identify and manage IUGR early on, leading to better outcomes for both mother and baby.