Pregnant women experiencing severe hyperemesis gravidarum before their dating scan should receive an early pregnancy ultrasound scan to detect abnormal trophoblastic disease, such as molar pregnancy or choriocarcinoma. Women with pre-existing diabetes or gestational diabetes are offered fetal growth scans every two weeks from 28 to 36 weeks’ gestation to monitor the baby’s growth and amniotic fluid levels. All pregnant women in the UK are offered a minimum of two antenatal scans, including the dating scan between 10+0 and 13+6 weeks’ gestation and the anomaly scan between 18+0 and 20+6 weeks’ gestation. The anomaly scan assesses the baby’s organs, growth, and placenta position, and can detect congenital abnormalities and small-for-gestational age babies. The first antenatal ultrasound scan can be offered as early as nine weeks’ gestation to confirm the pregnancy and determine the gestational age. The combined test, which includes nuchal translucency, PAPP-A, and hCG, can also be performed during the dating scan to assess the risk of Down syndrome.

When inducing labour in a patient who is past her due date, the main complication to watch out for is uterine hyperstimulation. The recommended method for inducing labour according to NICE guidelines is vaginal prostaglandins, which can be administered as a gel, tablet or slow-release pessary. A membrane sweep may also be performed alongside this. Vaginal prostaglandins work by ripening the cervix and stimulating uterine contractions. If uterine hyperstimulation occurs, tocolytic agents can be given to relax the uterus and slow contractions. It’s important to note that a breech presentation is not a complication of induction of labour, especially in cases where the foetus is stationed in the pelvis below the ischial spines. Chorioamnionitis, which is inflammation of the foetal membranes due to bacterial infection, is a risk during prolonged labour and repeated vaginal examinations, but it is not the main complication of induction of labour. Cord prolapse is also a possible complication, but it is more common when the presenting part of the foetus is high, which is not the case in this pregnancy where the foetal head is stationed 1 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.

1. The Bishop’s score rates the cervix out of 10, with a higher score indicating a more favorable cervix and a greater likelihood of spontaneous birth. A score below 5 suggests that labor is unlikely to begin without induction.

2. This is not a reason to induce labor.

3. It is recommended that women with uncomplicated pregnancies be offered induction between 41-42 weeks to prevent the risks associated with prolonged pregnancy.

4. A previous classical Caesarean section is an absolute contraindication for inducing labor.

5. Inducing labor is not advisable when the fetus is in a breech position.

Reference: NICE guidelines – Inducing labor and Antenatal care for uncomplicated pregnancies.

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.

If a woman with placenta praevia goes into labour, an emergency caesarean section should be performed regardless of whether there is bleeding or not. Placenta praevia is when the placenta is located partially or fully in the lower uterine segment, and it is more common in multiple and multiparous pregnancies. Sometimes it is detected incidentally during routine antenatal scanning, while in other cases, it may present with symptoms such as vaginal bleeding and haemodynamic shock. If placenta praevia is detected on routine imaging, an elective caesarean section should be considered at 37-38 weeks, especially for grade III and IV placenta praevia, due to the higher risk of postpartum haemorrhage. However, in this scenario, the patient has gone into labour spontaneously, and immediate action is necessary. Therefore, an emergency caesarean section is the correct course of action. Anti-D is recommended for pregnant women with negative rhesus status to prevent antibody production to foetal blood cells. Although the mother’s rhesus status is not given, anti-D is a sensible option when in doubt. Inducing labour with oxytocin is not recommended for patients with placenta praevia as it can stimulate vaginal delivery and increase the risk of postpartum haemorrhage. Discharging the patient to continue the pregnancy as normal is not advisable due to the serious risks involved. Tocolytics, such as nifedipine, are not routinely indicated for patients with placenta praevia in labour, and an emergency caesarean section should take priority.

Management and Prognosis of Placenta Praevia

Placenta praevia is a condition where the placenta is located wholly or partially in the lower uterine segment. If a low-lying placenta is detected at the 20-week scan, a rescan is recommended at 32 weeks. There is no need to limit activity or intercourse unless there is bleeding. If the placenta is still present at 32 weeks and is grade I/II, then a scan every two weeks is recommended. A final ultrasound at 36-37 weeks is necessary to determine the method of delivery. For grades III/IV, an elective caesarean section is recommended between 37-38 weeks. However, if the placenta is grade I, a trial of vaginal delivery may be offered. If a woman with known placenta praevia goes into labour before the elective caesarean section, an emergency caesarean section should be performed due to the risk of post-partum haemorrhage.

In cases where placenta praevia is accompanied by bleeding, the woman should be admitted and an ABC approach should be taken to stabilise her. If stabilisation is not possible, an emergency caesarean section should be performed. If the woman is in labour or has reached term, an emergency caesarean section is also necessary.

The prognosis for placenta praevia has improved significantly, and death is now extremely rare. The major cause of death in women with placenta praevia is post-partum haemorrhage.

Common Tumor Markers and their Clinical Significance

Beta human chorionic gonadotropin (β-HCG)
β-HCG levels are monitored in cases of molar pregnancy, which can present with morning sickness and symptoms of hyperthyroidism due to high levels of HCG. Monitoring levels of β-HCG is important to ensure that no fetal tissue remains after treatment to minimise the risk of developing choriocarcinoma or a persistent mole.

Alpha fetoprotein (AFP)
AFP is a marker used to screen for neural tube defects, hepatocellular carcinoma and endodermal sinus tumours.

CA-125
CA-125 is a marker of ovarian malignancy. Although it is used to monitor response to chemotherapy and tumour recurrence, it has not been widely used as a screening tool.

Lactate dehydrogenase (LDH)
Increased LDH is strongly associated with dysgerminomas.

Oestriol
Urine unconjugated oestriol is measured as part of the quadruple screen for trisomy 21. Low levels of oestriol are suggestive of Down syndrome.

Understanding Tumor Markers and their Clinical Implications

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.

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.

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.

Women on antiepileptics trying to conceive should receive 5mg folic acid. Letrozole and clomiphene are not appropriate for this patient. Adequate control of epilepsy is important and medication changes should be made by a specialist. This patient should be started on a high dose of folic acid due to the risk of neural tube defects.

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.

Episodes of decreased variability on CTG that last less than 40 minutes are often attributed to the foetus being asleep. However, if the decreased variability persists for more than 40 minutes, it can be a cause for concern. Other factors that can lead to decreased variability in foetal heart rate on CTG include maternal drug use (such as benzodiazepines, opioids or methyldopa – but not paracetamol), foetal acidosis (usually due to hypoxia), prematurity (which is not applicable in this case), foetal tachycardia (heart rate above 140 bpm, which is also not the case here), and congenital heart abnormalities.

Cardiotocography (CTG) is a medical procedure that measures pressure changes in the uterus using either internal or external pressure transducers. It is used to monitor the fetal heart rate, which normally ranges between 100-160 beats per minute. There are several features that can be observed during a CTG, including baseline bradycardia (heart rate below 100 beats per minute), which can be caused by increased fetal vagal tone or maternal beta-blocker use. Baseline tachycardia (heart rate above 160 beats per minute) can be caused by maternal pyrexia, chorioamnionitis, hypoxia, or prematurity. Loss of baseline variability (less than 5 beats per minute) can be caused by prematurity or hypoxia. Early deceleration, which is a decrease in heart rate that starts with the onset of a contraction and returns to normal after the contraction, is usually harmless and indicates head compression. Late deceleration, on the other hand, is a decrease in heart rate that lags behind the onset of a contraction and does not return to normal until after 30 seconds following the end of the contraction. This can indicate fetal distress, such as asphyxia or placental insufficiency. Variable decelerations, which are independent of contractions, may indicate cord compression.