Obstetric cholestasis, which is indicated by the symptoms and blood results in a pregnant woman in the third trimester, increases the risk of stillbirth. Therefore, it is generally recommended to induce labour at 37-38 weeks gestation to minimize this risk. However, induction of labour should only be considered if there are significantly abnormal liver function tests or bile acid levels. It is not recommended before 37 weeks gestation. Women should be informed that the need for intervention may be stronger in those with more severe biochemical abnormalities.

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.

Pregnancy-induced hypertension is typically treated with Labetalol as the initial medication.

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.

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.

Galactocele and breast abscess can be distinguished based on clinical history and examination findings, without the need for further investigation.

Recent discontinuation of breastfeeding is a risk factor for both mastitis/abscess formation and galactocele formation. Galactoceles are distinguishable from breast abscesses because they are painless and non-tender upon examination, and there are no signs of infection locally or systemically.
Although the patient’s history of mastitis increases the likelihood of a breast abscess, the clinical presentation strongly suggests a galactocele (i.e. painless lump, no localized redness, and absence of fever).

Understanding Galactocele

Galactocele is a condition that commonly affects women who have recently stopped breastfeeding. It occurs when a lactiferous duct becomes blocked, leading to the accumulation of milk and the formation of a cystic lesion in the breast. Unlike an abscess, galactocele is usually painless and does not cause any local or systemic signs of infection.

In simpler terms, galactocele is a type of breast cyst that develops when milk gets trapped in a duct. It is not a serious condition and can be easily diagnosed by a doctor. Women who experience galactocele may notice a lump in their breast, but it is usually painless and does not require any treatment. However, if the lump becomes painful or infected, medical attention may be necessary. Overall, galactocele is a common and harmless condition that can be managed with proper care and monitoring.

According to the shoulder dystocia guidelines of the Royal College of Obstetrics and Gynaecology, utilizing suprapubic pressure can enhance the efficacy of the McRoberts manoeuvre.

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.

Hormonal Changes During Pregnancy

During pregnancy, there are significant hormonal changes that occur in a woman’s body. One of the most notable changes is the increase in concentration of oestriol, which is the least potent of the three oestrogens. Oestrogen plays a crucial role in controlling other hormones such as FSH and LH, stimulating and controlling the growth of the placenta, and promoting the growth of maternal breast tissue in preparation for lactation.

Another hormone that increases during pregnancy is oestradiol, which is approximately 50-fold higher. Oestrone also increases, but oestradiol is more potent as it acts on a wider range of receptors.

On the other hand, LH and FSH are downregulated during pregnancy due to the high levels of oestrogen. The release of FSH is inhibited as follicles do not need to be stimulated during pregnancy.

In summary, the hormonal changes during pregnancy are complex and necessary for the growth and development of the fetus and the preparation of the mother’s body for lactation.

Eclampsia: Symptoms and Treatment

Eclampsia is a serious medical condition that can occur during pregnancy, characterized by pre-eclampsia and seizure activity. Symptoms may include hypertension, proteinuria, mental status changes, and blurred vision. Immediate delivery is the only definitive treatment for eclampsia, but magnesium can be given to reduce the risk of seizures in women with severe pre-eclampsia who are delivering within 24 hours. Eclampsia is more common in younger women with their first pregnancy and those with underlying vascular disorders. Hydralazine can be used to manage hypertension in pregnant women, but it is not the definitive treatment for eclampsia. Conservative management, such as salt and water restriction, bed rest, and close monitoring of blood pressure, is not appropriate for patients with eclampsia and associated seizure and mental state changes. ACE inhibitors are contraindicated during pregnancy, and labetalol is the first-line antihypertensive in pregnancy. Diazepam and magnesium sulfate can reduce seizures in eclampsia, but they are not the definitive treatment.

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.

Endometriosis increases the likelihood of ectopic pregnancy, which is evident from the lower abdominal pain, vaginal bleeding, absence of gastrointestinal symptoms, and positive pregnancy test in this case. Ectopic pregnancy occurs when a fertilized egg implants outside the uterus, and endometriosis can cause scar tissue and adhesions that hinder the zygote’s journey to the uterus. The use of combined oral contraceptive pills or emergency hormonal contraception does not elevate the risk of ectopic pregnancy, as per NICE guidelines. However, a history of previous ectopic pregnancies is associated with an increased risk.

Understanding Ectopic Pregnancy: Incidence and Risk Factors

Ectopic pregnancy occurs when a fertilized egg implants outside the uterus, usually in the fallopian tubes. This condition is a serious medical emergency that requires immediate attention. According to epidemiological studies, ectopic pregnancy occurs in approximately 0.5% of all pregnancies.

Several risk factors can increase the likelihood of ectopic pregnancy. These include damage to the fallopian tubes due to pelvic inflammatory disease or surgery, a history of previous ectopic pregnancy, endometriosis, the use of intrauterine contraceptive devices (IUCDs), and the progesterone-only pill. In vitro fertilization (IVF) also increases the risk of ectopic pregnancy, with approximately 3% of IVF pregnancies resulting in ectopic implantation.

It is important to note that any factor that slows down the passage of the fertilized egg to the uterus can increase the risk of ectopic pregnancy. Early detection and prompt treatment are crucial in managing this condition and preventing serious complications.

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

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

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

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

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

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