The correct result for the quadruple test in a patient with Down’s syndrome is a decrease in AFP and oestriol, and an increase in hCG and inhibin A. This test is recommended by NICE for pregnant patients between 15-20 weeks gestation. If the screening test shows an increased risk, further diagnostic tests such as NIPT, amniocentesis, or chorionic villous sampling may be offered to confirm the diagnosis. It is important to note that a pattern of decreased AFP, decreased oestriol, decreased hCG, and normal inhibin A is suggestive of an increased risk of Edward’s syndrome. Increased AFP, increased oestriol, decreased hCG, and decreased inhibin A or any other combination of abnormal results may not be indicative of Down’s syndrome.

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.

Antepartum Haemorrhage: Causes and Differential Diagnosis

Antepartum haemorrhage can be caused by various conditions, including placenta praevia, placental abruption, genitourinary infection, and premature labour. Placenta praevia occurs when the placenta covers the internal cervical os, leading to painless vaginal bleeding. Risk factors include maternal age, multiparity, and smoking. Diagnosis is made through ultrasound scanning, and close monitoring is necessary to prevent rebleeding. Placental abruption can be revealed or concealed, with the former causing significant abdominal pain and vaginal bleeding, while the latter is confined within the uterus. Genitourinary infection should also be considered, although this patient’s urinalysis is unremarkable. Premature labour, which is associated with cyclical abdominal pain, is another possible cause of antepartum bleeding. However, this patient presents without pain. A thorough differential diagnosis is crucial in managing antepartum haemorrhage.

Smoking has been found to decrease the risk of hyperemesis gravidarum, which is believed to occur due to rapidly rising levels of human chorionic gonadotropin (HCG) and oestrogen. This is because smoking is considered to be anti-oestrogenic. Therefore, despite having other risk factors, the fact that the patient is a smoker may decrease her incidence of hyperemesis gravidarum. On the other hand, hypothyroidism is not a risk factor, but hyperthyroidism increases the risk of hyperemesis gravidarum. Obesity and underweight are associated with an increased risk of hyperemesis, but women with these conditions who smoked before pregnancy have been found to have no increased risk. Primigravida status is also associated with an increased risk of hyperemesis, but the reason for this is not clear. Finally, twin pregnancies carry an increased risk of hyperemesis gravidarum due to higher levels of beta-hCG released from the placenta.

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.

Pre-eclampsia can be diagnosed based on the presence of high levels of protein in the urine and hypertension. To prevent the development of eclampsia, magnesium sulphate is administered, while labetalol is used to manage high blood pressure. If a cardiotocography (CTG) shows late decelerations and foetal bradycardia, this is a concerning sign and may necessitate an emergency caesarean section. Induction would not be recommended if the CTG is abnormal.

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.

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.

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.

Shoulder dystocia is more likely to occur in women with diabetes mellitus. However, using forceps during delivery to pull the baby out can increase the risk of injury to the baby and cause brachial plexus injury. Therefore, it is important to consider alternative delivery methods before resorting to forceps.

Shoulder dystocia is a complication that can occur during vaginal delivery when the body of the fetus cannot be delivered after the head has already been delivered. This is usually due to the anterior shoulder of the fetus becoming stuck on the mother’s pubic bone. Shoulder dystocia can cause harm to both the mother and the fetus. Risk factors for shoulder dystocia include fetal macrosomia, high maternal body mass index, diabetes mellitus, and prolonged labor.

If shoulder dystocia is identified, it is important to call for senior help immediately. The McRoberts’ maneuver is often performed, which involves flexing and abducting the mother’s hips to increase the angle of the pelvis and facilitate delivery. An episiotomy may be performed to provide better access for internal maneuvers, but it will not relieve the bony obstruction. Symphysiotomy and the Zavanelli maneuver are not recommended as they can cause significant maternal morbidity. Oxytocin administration is not indicated for shoulder dystocia.

Complications of shoulder dystocia can include postpartum hemorrhage and perineal tears for the mother, and brachial plexus injury and neonatal death for the fetus. It is important to manage shoulder dystocia promptly and appropriately to minimize the risk of these complications.

According to the National Institute for Health and Care Excellence (NICE), if a woman has an unruptured ectopic pregnancy measuring less than 35mm without visible heartbeat, a serum B-hCG level of less than 1500 IU/L, no intrauterine pregnancy, and no pain, the recommended first-line treatment is methotrexate, provided the patient is willing to attend follow-up appointments. However, if the woman declines expectant management, which is an option for a small number of women with low B-hCG, no symptoms, and a tubal ectopic pregnancy measuring less than 35mm without heartbeat, methotrexate is the preferred treatment option. Methotrexate is a chemotherapeutic drug that interferes with DNA synthesis and disrupts cell multiplication, preventing the pregnancy from developing. Laparoscopic salpingectomy (or salpingostomy if there is a risk of infertility) is the other treatment option, which should be offered if the ectopic pregnancy is larger than 35mm, causing severe pain, or if the B-hCG level is greater than 1500. However, there is a risk of infertility if a problem arises with the remaining Fallopian tube in the future. Misoprostol and mifepristone are not recommended for the management of ectopic pregnancy.

Understanding Ectopic Pregnancy

Ectopic pregnancy occurs when a fertilized egg implants outside the uterus. This condition is characterized by lower abdominal pain and vaginal bleeding, typically occurring 6-8 weeks after the start of the last period. The pain is usually constant and may be felt on one side of the abdomen due to tubal spasm. Vaginal bleeding is usually less than a normal period and may be dark brown in color. Other symptoms may include shoulder tip pain, pain on defecation/urination, dizziness, fainting, or syncope. Breast tenderness may also be reported.

During examination, abdominal tenderness and cervical excitation may be observed. However, it is not recommended to examine for an adnexal mass due to the risk of rupturing the pregnancy. Instead, a pelvic examination to check for cervical excitation is recommended. In cases of pregnancy of unknown location, serum bHCG levels >1,500 may indicate an ectopic pregnancy. It is important to seek medical attention immediately if ectopic pregnancy is suspected as it can be life-threatening.

Newborn infants are most commonly affected by severe early-onset (< 7 days) infection caused by Group B streptococcus. Group B Streptococcus (GBS) is a common cause of severe infection in newborns. It is estimated that 20-40% of mothers carry GBS in their bowel flora, which can be passed on to their infants during labor and lead to serious infections. Prematurity, prolonged rupture of membranes, previous sibling GBS infection, and maternal pyrexia are all risk factors for GBS infection. The Royal College of Obstetricians and Gynaecologists (RCOG) has published guidelines on GBS management, which include not offering universal screening for GBS to all women and not offering screening based on maternal request. Women who have had GBS detected in a previous pregnancy should be offered intrapartum antibiotic prophylaxis (IAP) or testing in late pregnancy and antibiotics if still positive. IAP should also be offered to women with a previous baby with GBS disease, women in preterm labor, and women with a fever during labor. Benzylpenicillin is the preferred antibiotic for GBS prophylaxis.

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.

Performing any form of female genital cutting/modification for non-medical reasons, including reinfibulation of a woman with type 3 FGM after vaginal delivery, is illegal according to the Female Genital Mutilation Act 2003. It is strictly prohibited to carry out such procedures under any circumstances. However, discussing the topic is not illegal.

Understanding Female Genital Mutilation

Female genital mutilation (FGM) is a term used to describe any procedure that involves the partial or complete removal of the external female genitalia or any other injury to the female genital organs for non-medical reasons. The World Health Organization (WHO) has classified FGM into four types. Type 1 involves the partial or total removal of the clitoris and/or the prepuce, while type 2 involves the partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora. Type 3 involves the narrowing of the vaginal orifice with the creation of a covering seal by cutting and appositioning the labia minora and/or the labia majora, with or without excision of the clitoris. Finally, type 4 includes all other harmful procedures to the female genitalia for non-medical purposes, such as pricking, piercing, incising, scraping, and cauterization. It is important to understand the different types of FGM to raise awareness and prevent this harmful practice.

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.

Common Oral Abnormalities in Infants: Tongue Tie, Upper Lip Tie, Cleft Lip, and Cleft Palate

Tongue tie, also known as ankyloglossia, is a condition that affects up to 10% of live births, more commonly in boys than girls. It is characterized by a short, thickened frenulum attaching the tongue to the floor of the mouth, limiting tongue movements and causing difficulties with breastfeeding. Mothers may report that their infant takes a long time to feed, is irritable, and experiences nipple injury. Examination findings include limited tongue movements, inability to lift the tongue high or move it past the lower lip, and a characteristic heart-shaped notch when attempting to lift the tongue. Tongue tie can be anterior or posterior, with the latter being deeper in the mouth and more difficult to see.

Upper lip tie is a similar condition, with a frenulum attaching the upper lip to the gum line. This can also cause difficulties with breastfeeding due to limited movement of the upper lip.

Cleft lip and cleft palate are congenital malformations that occur when the facial structures fail to fuse properly during development. Cleft lip presents as a gap in the upper lip, while cleft palate is a gap in the roof of the mouth. Both can cause difficulties with feeding and require surgical intervention.

It is important for healthcare providers to be aware of these common oral abnormalities in infants and provide appropriate management and referrals to ensure optimal feeding and development.

A vaginal delivery is expected to be challenging due to the foetal presentation and station. Singleton pregnancies are not recommended for breech extraction, which also demands expertise. Hence, it is advisable to opt for a Caesarean section.

Breech presentation occurs when the caudal end of the fetus is in the lower segment, and it is more common at 28 weeks than near term. Risk factors include uterine malformations, placenta praevia, and fetal abnormalities. Management options include spontaneous turning, external cephalic version (ECV), planned caesarean section, or vaginal delivery. The RCOG recommends informing women that planned caesarean section reduces perinatal mortality and early neonatal morbidity, but there is no evidence that the long-term health of babies is influenced by how they are born. ECV is contraindicated in certain cases, such as where caesarean delivery is required or there is an abnormal cardiotocography.

If blood glucose targets are not achieved through diet and metformin in gestational diabetes, insulin should be added to the treatment plan. This patient was initially advised to make lifestyle changes and follow a specific diet for two weeks, as her fasting blood glucose was below 7 mmol/L. However, since she did not meet the targets, she was started on metformin monotherapy. Insulin therapy was not initiated earlier because her fasting blood glucose was below 7 mmol/L. According to NICE guidelines, if metformin monotherapy fails to achieve the desired results, insulin should be started, and lifestyle changes should be emphasized. Therefore, the correct answer is to continue metformin and add insulin to the patient’s treatment plan. The other options, such as increasing the dose of metformin, stopping metformin and starting insulin, adding gliclazide, or prescribing high-dose folic acid, are incorrect.

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.

The patient is likely suffering from obstetric cholestasis, which can increase the risk of premature birth and stillbirth. The main symptom is severe itching, and elevated serum bile acids are typically present. Liver function tests, including bilirubin levels, may not be reliable. The most effective treatment is ursodeoxycholic acid (UDCA), which is now mostly synthetic. While antihistamines and topical menthol creams can provide some relief, UDCA is more likely to improve outcomes.

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.

Managing Gestational Diabetes: Lifestyle Advice and Medication Options

Gestational diabetes is a condition that affects up to 5% of pregnancies and is characterized by carbohydrate intolerance resulting in high blood sugar levels. It is usually diagnosed after 20 weeks of gestation and is caused by hormones that increase insulin resistance in the mother’s body. Women with risk factors are screened with a 2-hour oral glucose tolerance test (OGTT) to establish a diagnosis.

The first-line management for gestational diabetes is lifestyle advice, including weight loss if the patient’s BMI is over 27 kg/m2, dietary changes, and regular physical activity. Women with a fasting plasma glucose of over 7.0 mmol/l at diagnosis are immediately started on insulin to reduce the risk of complications. Metformin may be considered for women with a fasting glucose level of less than 7.0 mmol/l who fail to control their glucose levels with lifestyle modifications alone.

Patients are given a two-week period to implement lifestyle changes and monitor their glucose levels before being reassessed. Women with gestational diabetes are reviewed every one to two weeks in a Joint Clinic (Diabetes and Antenatal) where they are closely monitored. If lifestyle changes and metformin fail to control glucose levels, combination therapy with metformin and insulin may be necessary.

Lifestyle modifications include weight loss, dietary changes, and mild physical activity. Women with a BMI over 27 kg/m2 are advised to lose weight, while dietary advice is offered by a specialist dietician. Patients are also advised to engage in mild physical activity for 30 minutes but should avoid strenuous physical activity or weightlifting.

In conclusion, managing gestational diabetes requires a combination of lifestyle modifications and medication options. Early diagnosis and close monitoring are essential to reduce the risk of complications for both the mother and the baby.

Management of Severe Pre-eclampsia with HELLP Syndrome

Severe pre-eclampsia with HELLP syndrome is a serious complication of pregnancy that requires prompt management to prevent maternal and fetal morbidity and mortality. The first-line medication for pre-eclampsia is labetalol, but if it fails to improve symptoms, second-line treatments such as intravenous hydralazine or oral nifedipine can be used. In cases of severe pre-eclampsia, delivery of the fetus is the only definitive treatment. However, if delivery is planned before 36 weeks, intramuscular betamethasone is required to protect the fetus from neonatal respiratory distress syndrome. Intravenous magnesium sulfate infusion is also necessary for neuroprotection and to lower the risk of eclampsia. It should be considered in cases of mild or moderate pre-eclampsia with certain symptoms. While these interventions are essential in managing severe pre-eclampsia with HELLP syndrome, they are not definitive treatments. Close monitoring of both the mother and fetus is necessary, and delivery should be planned as soon as possible to prevent further complications.

To ensure that a pregnant woman has not been exposed to chickenpox before, the initial step is to test her blood for varicella antibodies.

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.

Immediate insulin (with or without metformin) should be initiated if the fasting glucose level is >= 7 mmol/l at the time of gestational diabetes diagnosis. In this case, the patient has gestational diabetes and requires prompt insulin therapy. The diagnosis of gestational diabetes is based on a fasting plasma glucose level of > 5.6 mmol/L or a 2-hour plasma glucose level of >/= 7.8 mmol/L. Although dietary advice is important, insulin therapy is necessary when the fasting glucose level is greater than 7 mmol/L. Gliclazide is not recommended for pregnant women due to the risk of neonatal hypoglycaemia. Metformin can be used in gestational diabetes, but insulin is the most appropriate next step when the fasting glucose level is >=7 mmol/L. Insulin and metformin can be used together to manage gestational diabetes. There is no need to repeat the test as the results are conclusive for gestational diabetes.

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.

If a patient has an ectopic pregnancy, the treatment plan will depend on various factors such as the size and location of the pregnancy, the patient’s overall health, and the potential impact on their fertility. If the pregnancy is small and the patient’s health is stable, they may be able to receive medication to dissolve the pregnancy. However, if the pregnancy is larger or causing severe symptoms, surgery may be necessary.

In cases where surgery is required, the surgeon may attempt to preserve the affected fallopian tube if possible. However, if the tube is severely damaged or the patient has other factors that may affect their fertility, such as age or previous fertility issues, the surgeon may opt to remove the tube completely. This decision will also depend on the patient’s desire for future fertility and the likelihood of requiring further treatment with methotrexate or a salpingectomy. If the patient’s contralateral tube is unaffected, complete removal of the affected tube may be the most appropriate course of action.

Ectopic pregnancy is a serious condition that requires prompt investigation and management. Women who are stable are typically investigated and managed in an early pregnancy assessment unit, while those who are unstable should be referred to the emergency department. The investigation of choice for ectopic pregnancy is a transvaginal ultrasound, which will confirm the presence of a positive pregnancy test.

There are three ways to manage ectopic pregnancies: expectant management, medical management, and surgical management. The choice of management will depend on various criteria, such as the size of the ectopic pregnancy, whether it is ruptured or not, and the patient’s symptoms and hCG levels. Expectant management involves closely monitoring the patient over 48 hours, while medical management involves giving the patient methotrexate and requires follow-up. Surgical management can involve salpingectomy or salpingostomy, depending on the patient’s risk factors for infertility.

Salpingectomy is the first-line treatment for women without other risk factors for infertility, while salpingostomy should be considered for women with contralateral tube damage. However, around 1 in 5 women who undergo a salpingostomy require further treatment, such as methotrexate and/or a salpingectomy. It is important to carefully consider the patient’s individual circumstances and make a decision that will provide the best possible outcome.

Women with a history of gestational diabetes should be offered an OGTT immediately after booking and at 24-28 weeks to screen for gestational diabetes in subsequent pregnancies. No screening test is not recommended. OGTT at 24-28 weeks is the screening strategy for those with risk factors but no previous history of gestational diabetes.

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.

1: The occiput posterior (OP) position during delivery is feasible, but it may result in a longer and more painful labor.
2: If labor progress is slow, augmentation should be considered.
3: The use of Kielland’s forceps is linked to the most favorable outcomes, but it requires specialized skills.
4: Typically, women in the OP position will feel the urge to push earlier than those in the occiput anterior (OA) position.

Labour is divided into three stages, with stage 2 being from full dilation to delivery of the fetus. This stage can be further divided into two categories: passive second stage, which occurs without pushing, and active second stage, which involves the process of maternal pushing. The active second stage is less painful than the first stage, as pushing can mask the pain. This stage typically lasts around one hour, but if it lasts longer than that, medical interventions such as Ventouse extraction, forceps delivery, or caesarean section may be necessary. Episiotomy, a surgical cut made in the perineum to widen the vaginal opening, may also be required during crowning. However, this stage is associated with transient fetal bradycardia, which is a temporary decrease in the fetal heart rate.

It is not advisable to conduct a digital vaginal examination in cases of suspected placenta praevia without first performing an ultrasound, as this could potentially trigger a dangerous hemorrhage.

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.

Factor V Leiden is a genetic condition that causes resistance to the breakdown of Factor V by activated Protein C, leading to an increased risk of blood clots. The RCOG has issued guidelines (Green-top Guideline No.37a) for preventing blood clots in pregnant women with this condition. As this patient has a history of VTE, she is at high risk during and after pregnancy and requires both antenatal and postnatal thromboprophylaxis. It is important to note that postnatal prophylaxis must be given for six weeks following antenatal prophylaxis.

Venous Thromboembolism in Pregnancy: Risk Assessment and Prophylactic Measures

Pregnancy increases the risk of developing venous thromboembolism (VTE), a condition that can be life-threatening for both the mother and the fetus. To prevent VTE, it is important to assess a woman’s individual risk during pregnancy and initiate appropriate prophylactic measures. This risk assessment should be done at the first antenatal booking and on any subsequent hospital admission.

Women with a previous history of VTE are automatically considered high risk and require low molecular weight heparin throughout the antenatal period, as well as input from experts. Women at intermediate risk due to hospitalization, surgery, co-morbidities, or thrombophilia should also be considered for antenatal prophylactic low molecular weight heparin.

The risk assessment at booking should include factors that increase the likelihood of developing VTE, such as age over 35, body mass index over 30, parity over 3, smoking, gross varicose veins, current pre-eclampsia, immobility, family history of unprovoked VTE, low-risk thrombophilia, multiple pregnancy, and IVF pregnancy.

If a woman has four or more risk factors, immediate treatment with low molecular weight heparin should be initiated and continued until six weeks postnatal. If a woman has three risk factors, low molecular weight heparin should be initiated from 28 weeks and continued until six weeks postnatal.

If a diagnosis of deep vein thrombosis (DVT) is made shortly before delivery, anticoagulation treatment should be continued for at least three months, as in other patients with provoked DVTs. Low molecular weight heparin is the treatment of choice for VTE prophylaxis in pregnancy, while direct oral anticoagulants (DOACs) and warfarin should be avoided.

In summary, a thorough risk assessment and appropriate prophylactic measures can help prevent VTE in pregnancy, which is crucial for the health and safety of both the mother and the fetus.

The patient’s immunity to varicella-zoster needs to be determined urgently by testing for varicella-zoster IgG antibodies in the blood, as she has had some exposure to chickenpox and is unsure of her immunity status. If antibodies are detected, she is considered immune and no further action is required, but she should seek medical care immediately if she develops a rash. Varicella-zoster immunoglobulin should only be administered to non-immune patients within 10 days of exposure. It is important to note that if the patient contracts chickenpox during pregnancy, there is a risk of fetal varicella syndrome if infected before 28 weeks’ gestation. Immunisation during pregnancy is not recommended, but the patient can receive the vaccine postpartum if found to be non-immune. It is safe to receive the vaccine while breastfeeding.

The recommended medical management for a miscarriage is the administration of vaginal misoprostol, as stated in the 2018 NICE guidelines. This is particularly suitable for patients with a medical history of coagulopathy, such as Von Willebrand disease, as it is a safer option than expectant management. Oral methotrexate is not appropriate for a miscarriage, as it is used for the medical management of ectopic pregnancies. Salpingectomy is a surgical procedure used for tubular ectopic pregnancies, but not for miscarriages. Vacuum aspiration is a surgical option for miscarriages, but medical management is preferred as it is safer and allows the patient to have more control over the process.

Management Options for Miscarriage

Miscarriage can be a difficult and emotional experience for women. In the 2019 NICE guidelines, three types of management for miscarriage were discussed: expectant, medical, and surgical. Expectant management involves waiting for a spontaneous miscarriage and is considered the first-line option. However, if it is unsuccessful, medical or surgical management may be offered.

Medical management involves using tablets to expedite the miscarriage. Vaginal misoprostol, a prostaglandin analogue, is used to cause strong myometrial contractions leading to the expulsion of tissue. It is important to advise patients to contact their doctor if bleeding does not start within 24 hours. Antiemetics and pain relief should also be given.

Surgical management involves undergoing a surgical procedure under local or general anaesthetic. The two main options are vacuum aspiration (suction curettage) or surgical management in theatre. Vacuum aspiration is done under local anaesthetic as an outpatient, while surgical management is done in theatre under general anaesthetic. This was previously referred to as ‘Evacuation of retained products of conception’.

It is important to note that some situations are better managed with medical or surgical management, such as an increased risk of haemorrhage, being in the late first trimester, having coagulopathies or being unable to have a blood transfusion, previous adverse and/or traumatic experience associated with pregnancy, evidence of infection, and more. Ultimately, the management option chosen should be based on the individual patient’s needs and preferences.

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.

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.

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.