Pregnant women who are 20 weeks or more along and contract chickenpox should receive oral acyclovir if they seek treatment within 24 hours of the rash appearing. If a pregnant woman is exposed to chickenpox, she should contact her doctor immediately to determine if she is immune and to arrange for blood tests if necessary. If a rash appears and the woman seeks treatment within 24 hours, oral acyclovir should be administered. Oral antibiotics are not necessary as there is no evidence of secondary infection. VZIG is an option for treating pregnant women who are not immune to chickenpox, but it is not effective once a rash has appeared.

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.

Labour is the process of giving birth and is divided into three stages. The first stage begins with regular contractions and ends when the cervix is fully dilated at 10 cm. This stage is further divided into a latent phase, where the cervix dilates to 4 cm, and an active phase, where the cervix dilates from 4 cm to 10 cm. The rate of cervical dilation in a nulliparous woman is approximately 1 cm per hour, while in a multiparous woman, it is approximately 2 cm per hour. The second stage of labour begins when the cervix is fully dilated and ends with the delivery of the baby. During this stage, fetal heart rate monitoring should occur at least every five minutes and after each contraction. Cervical incompetence, which involves cervical shortening and dilation in the absence of contractions, can result in premature delivery or second trimester loss and is more common in women with a multiple pregnancy, previous cervical incompetence, or a history of cervical surgery. These women can be managed with monitoring of cervical length, cervical cerclage, or progesterone cervical pessaries. The third stage of labour involves the delivery of the placenta and membranes.

When treating allergic rhinitis in pregnant women, loratadine is the recommended first-line oral antihistamine if symptoms are severe enough to require treatment. It is a non-sedative antihistamine with the most available data and no reported teratogenicity. However, it may cause mild sedation, increased appetite, and headaches. If loratadine is ineffective or causes significant side effects, cetirizine or chlorphenamine can be used. Chlorphenamine is a sedative antihistamine and should only be used if other options fail. Nasal sodium cromoglicate spray is safe to use during pregnancy and breastfeeding, but if oral antihistamines are more effective for the patient, it may not be the best option. Oral chlorphenamine is another option, but non-sedative antihistamines should be preferred if they improve symptoms. Leukotriene receptor antagonists like oral montelukast have limited data on their safety in pregnancy and should be avoided unless the benefits outweigh the risks. Pseudoephedrine hydrochloride, a decongestant, should not be used during pregnancy as it can affect uteroplacental circulation and increase the risk of fetal complications.

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

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

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.

When managing shoulder dystocia, it is important to call for extra assistance immediately. Avoid using fundal pressure and note that an episiotomy may not always be required. Inducing labor at term can lower the occurrence of shoulder dystocia in women with gestational diabetes. The McRoberts manoeuvre is the preferred initial intervention due to its simplicity, speed, and effectiveness in most cases. These guidelines are based on the RCOG Green-top guideline no. 42 from March 2012 on Shoulder Dystocia.

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.

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.

The patient is discussing the bleeding that occurs during the first two weeks after giving birth, known as lochia. It is important to note that both vaginal birth and caesarian section can result in this bleeding, but caesarian section carries a higher risk of post-partum haemorrhage. Therefore, a thorough history and examination should be conducted to identify any potential issues.

Typically, lochia begins as fresh bleeding and changes color before eventually stopping. The patient should be advised that if the bleeding becomes foul-smelling, increases in volume, or does not stop, they should seek medical attention. However, in this case, the volume of bleeding is not excessive and there are no concerning features or abnormal observations. The patient can be reassured and provided with advice regarding lochia.

Lochia refers to the discharge that is released from the vagina after childbirth. This discharge is composed of blood, mucous, and uterine tissue. It is a normal occurrence that can last for up to six weeks following delivery. During this time, the body is working to heal and recover from the physical changes that occurred during pregnancy and childbirth. It is important for new mothers to monitor their lochia and report any unusual changes or symptoms to their healthcare provider.

The appropriate course of action for a woman exhibiting symptoms of agitation and paranoid delusions after giving birth is to admit her to the hospital for urgent assessment. This is likely a case of postpartum psychosis, which is different from postnatal depression. Postpartum psychosis can include mania, depression, irritability, rapid mood changes, confusion, paranoia, delusions, and/or hallucinations. Prescribing medication to aid in sleep is not appropriate in this case, and reassurance that her low mood will improve with time is also not appropriate due to the risk to herself and her baby. Gradual titration of fluoxetine would not manage her acute symptoms and would not ensure the safety of her or her baby. Ideally, she should be hospitalized in a Mother & Baby Unit.

Understanding Postpartum Mental Health Problems

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

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

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

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

The results are typical of placenta praevia, according to the findings.
The RCOG suggests transvaginal ultrasound as it enhances the precision of placental positioning and is deemed to be safe.

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.

This pregnant woman is experiencing painful uterine contractions and has developed disseminated intravascular coagulation (DIC), which is characterized by thrombocytopenia, increased PT and PTT, elevated D-dimer, and the presence of schistocytes in a peripheral blood smear. Although she is not experiencing vaginal bleeding, the most likely cause of her DIC is placental abruption, which can occur without visible bleeding. Placental abruption presents with sudden-onset abdominal pain, contractions, vaginal bleeding, and decreased fetal movement. If there is any fetal or maternal compromise, the fetus needs to be delivered by Caesarean section as soon as possible to prevent fetal or maternal demise. DIC can present with bleeding from multiple sites, extensive bruising, low blood pressure, reduced capillary refill time, or sudden onset of high temperature, general malaise, and purpura. Management includes removing the precipitant (e.g., retained placenta) and blood products such as fibrinogen and cryoprecipitate. Other potential causes of DIC, such as lower limb deep venous thrombosis, pelvic thrombophlebitis, urinary tract infection, and sepsis, are less likely in this pregnant woman in the third trimester.

– First degree: a tear that only affects the vaginal mucosa
– Second degree: a tear that extends into the subcutaneous tissue
– Third degree: a laceration that reaches the external anal sphincter
– Fourth degree: a laceration that goes through the external anal sphincter and reaches the rectal mucosa

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.

Thyroid Screening in Pregnancy: Identifying High-Risk Patients

Pregnancy can increase the risk of developing thyroid disorders, which can have detrimental effects on both the mother and fetus. Therefore, it is important to identify high-risk patients and screen them for thyroid function early in pregnancy. According to updated guidelines, patients with a current or previous thyroid disease, family history of thyroid disease in a first-degree relative, autoimmune conditions such as coeliac disease, type 1 and type 2 diabetes mellitus, as well as gestational diabetes are considered at higher risk. These patients should be screened by performing TSH and serum fT4 levels in the preconception period, if possible, or as soon as pregnancy is confirmed.

Detecting hypothyroidism early is crucial, as symptoms can mimic those of a normal pregnancy, making detection harder. Hypothyroidism in the mother can lead to fetal demise, severe neurodevelopmental abnormalities, congenital malformations, and congenital hypothyroidism. Patients diagnosed with overt hypothyroidism in pregnancy should be started on levothyroxine immediately.

There is no recommendation to screen women with a history of chronic kidney disease or hypertension for thyroid disease in pregnancy. However, chronic kidney disease is a high-risk factor for pre-eclampsia, and commencing aspirin at 12 weeks through to delivery is essential to reduce the risk of developing pre-eclampsia or any of its complications. Women who are carriers of the thalassaemia trait are not screened for thyroid disease in pregnancy, but their partner should be tested for carrier status to assess the risk to the fetus.

In conclusion, identifying high-risk patients and screening for thyroid function early in pregnancy can help prevent adverse outcomes for both the mother and fetus.

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%.

Magnesium sulfate should be continued for at least 24 hours after delivery or the last seizure in the management of eclampsia. This patient’s condition has progressed to eclampsia, and the primary concern is preventing seizures and delivering the baby. Magnesium sulfate is the preferred agent for managing seizures and providing neuroprotection to the baby. Stopping magnesium sulfate immediately after the last seizure still poses a risk of another seizure occurring, so it should be continued for another 24 hours. Correcting hypertension alone is unlikely to resolve the seizures, so antihypertensive therapy should be given in addition to magnesium sulfate.

Understanding Eclampsia and its Treatment

Eclampsia is a condition that occurs when seizures develop in association with pre-eclampsia, a pregnancy-induced hypertension that is characterized by proteinuria and occurs after 20 weeks of gestation. To prevent seizures in patients with severe pre-eclampsia and treat seizures once they develop, magnesium sulphate is commonly used. However, it is important to note that this medication should only be given once a decision to deliver has been made. In cases of eclampsia, an IV bolus of 4g over 5-10 minutes should be given, followed by an infusion of 1g/hour. During treatment, it is crucial to monitor urine output, reflexes, respiratory rate, and oxygen saturations. Respiratory depression can occur, and calcium gluconate is the first-line treatment for magnesium sulphate-induced respiratory depression. Treatment should continue for 24 hours after the last seizure or delivery, as around 40% of seizures occur post-partum. Additionally, fluid restriction is necessary to avoid the potentially serious consequences of fluid overload.

In summary, understanding the development of eclampsia and its treatment is crucial in managing this potentially life-threatening condition. Magnesium sulphate is the primary medication used to prevent and treat seizures, but it should only be given once a decision to deliver has been made. Monitoring vital signs and urine output is essential during treatment, and calcium gluconate should be readily available in case of respiratory depression. Finally, fluid restriction is necessary to avoid complications associated with fluid overload.

Fetal Abnormalities: Causes and Characteristics

Polyhydramnios, oligohydramnios, macrosomia, fetal oedema, and microcephaly are all fetal abnormalities with distinct causes and characteristics. Polyhydramnios is an accumulation of amniotic fluid caused by impaired swallowing due to oesophageal atresia. Oligohydramnios, on the other hand, is a lack of amniotic fluid caused by various factors such as chromosomal abnormalities and renal agenesis. Macrosomia, or a large-for-gestational age baby, is commonly caused by gestational diabetes. Fetal oedema, also known as hydrops fetalis, is characterised by an excess of fluid in the fetus and can be caused by immunological or non-immunological factors. Finally, microcephaly is a congenital abnormality characterised by a small head circumference and can be caused by various factors such as chromosomal abnormalities and infections. Understanding the causes and characteristics of these fetal abnormalities is crucial for proper diagnosis and management.

Understanding Dilutional Anaemia of Pregnancy

Dilutional anaemia of pregnancy is a common condition that occurs during pregnancy. It is characterized by a normal mean cell volume (MCV) and is caused by a disproportional rise in plasma volume, which dilutes the red blood cells. This condition is the most likely option for a patient with a normal MCV.

Iron deficiency anaemia, on the other hand, is microcytic and gives a low MCV. Pancytopenia, which is the term for low haemoglobin, white cells, and platelets, is not applicable in this case as the patient’s white cells and platelets are in the normal range.

Folic acid or B12 deficiency would give rise to macrocytic anaemia with raised MCV, which is not the case for this patient. Myelodysplasia, an uncommon malignant condition that usually occurs in patients over 60, is also unlikely.

In conclusion, understanding dilutional anaemia of pregnancy is important for healthcare professionals to provide appropriate care and management for pregnant patients.

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.

NICE guidelines recommend 10 antenatal visits for first pregnancies and 7 for subsequent pregnancies if uncomplicated. The purpose of each visit is outlined, including booking visits, scans, screening for Down’s syndrome, routine care for blood pressure and urine, and discussions about labour and birth plans. Rhesus negative women are offered anti-D prophylaxis at 28 and 34 weeks. The guidelines also recommend discussing options for prolonged pregnancy at 41 weeks.

High dose 5mg folic acid should be prescribed to pregnant women with obesity (BMI >30 kg/m2) to reduce the risk of neural tube defects (NTD). Other factors that may require high dose folic acid include a history of NTD in a previous pregnancy or family history of NTD, as well as conditions such as antiepileptic drug use, coeliac disease, diabetes, and thalassaemia trait.

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.

The presence of Down’s syndrome can be indicated by an increase in beta-HCG, a decrease in PAPP-A, and the observation of a thickened nuchal translucency during ultrasound. The other options involving beta-HCG and PAPP-A are incorrect. The combined screening test is usually conducted between the 10th and 14th week of pregnancy and involves an ultrasound to measure nuchal thickness, as well as blood tests to assess beta-HCG and PAPP-A levels. A positive result suggests a higher risk of Down’s syndrome, Patau’s syndrome, and Edward’s syndrome. In such cases, amniocentesis, chorionic villus sampling, or non-invasive prenatal testing may be offered to confirm the diagnosis. The options involving inhibin A are not part of the combined screening test. If a woman presents later in pregnancy, the quadruple test may be used instead, which involves four blood markers to determine the risk of Down’s syndrome. These markers include inhibin A, alpha-fetoprotein, unconjugated oestriol, and beta-HCG. A positive result for Down’s syndrome would typically show raised beta-HCG and inhibin A, and low unconjugated oestriol and alpha-fetoprotein.

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.

Differentiating Placental Abruption from Placenta Praevia in Antepartum Haemorrhage

Antepartum haemorrhage refers to bleeding from the genital tract after 24 weeks of pregnancy but before delivery of the fetus. It is important to determine the cause of the bleeding to provide appropriate management. Two common causes of antepartum haemorrhage are placental abruption and placenta praevia.

Placental abruption is characterized by shock that is not proportional to the visible loss, constant pain, a tender and tense uterus, a normal lie and presentation, and an absent or distressed fetal heart. Coagulation problems may also be present, and healthcare providers should be cautious of pre-eclampsia, disseminated intravascular coagulation (DIC), and anuria.

On the other hand, placenta praevia is characterized by shock that is proportional to the visible loss, no pain, a uterus that is not tender, an abnormal lie and presentation, and a usually normal fetal heart. Coagulation problems are rare, and small bleeds may occur before a large one. It is important to note that vaginal examination should not be performed in primary care for suspected antepartum haemorrhage, as women with placenta praevia may experience bleeding.

In summary, distinguishing between placental abruption and placenta praevia is crucial in managing antepartum haemorrhage. Healthcare providers should carefully assess the patient’s symptoms and perform appropriate diagnostic tests to determine the cause of the bleeding.

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.

A woman with a positive pregnancy test and abdominal, pelvic or cervical motion tenderness should be immediately referred for assessment due to the risk of an ectopic pregnancy. Arranging an outpatient ultrasound or reassuring the patient is not appropriate. Urgent investigation is necessary to prevent the risk of rupture. Expectant management may be appropriate for a woman with vaginal bleeding and no pain or tenderness, but not for this patient who has both.

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.

The correct first-line surgical intervention for postpartum haemorrhage is an intra-uterine Bakri catheter. This device is used to tamponade the bleeding caused by uterine atony, which is a failure of the uterine myometrium cells to contract. Hysterectomy is not the first option as it is a last resort and will make the patient infertile. Lying the patient on her left lateral side is not relevant for a woman who has already delivered her baby. Ligation of the internal iliac artery may be used, but it is not the next most appropriate step as it may lead to ischaemic complications. Intra-uterine balloon tamponade is the first-line surgical intervention if other measures fail.

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.

A woman at 12 weeks gestation is seeking Down syndrome screening. Although her age increases the likelihood of her fetus having Down’s syndrome, it will not affect the initial screening process. The standard screening method involves an ultrasound to evaluate nuchal translucency and serum testing to measure levels of β-human chorionic gonadotropin (β-hCG) and pregnancy-associated plasma protein A (PAPP-A). This combined screening can also detect Edward’s (trisomy 18) and Patau (trisomy 13) syndromes. The triple test, which includes α-fetoprotein, unconjugated oestriol, and β-hCG, is conducted between 15-20 weeks gestation to assess for Down’s syndrome. The quadruple test is also an option for women who have missed the window for combined antenatal screening. A biophysical profile, which evaluates fetal wellbeing through ultrasound detection of heart rate, breathing, movement, tone, and amniotic fluid volume, is used to determine the need for rapid induction of labor.

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.

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

Understanding Umbilical Cord Prolapse

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

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

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

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

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

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

Cervical screening is typically postponed during pregnancy until…

Cervical Cancer Screening in the UK

Cervical cancer screening is a well-established program in the UK that aims to detect pre-malignant changes in the cervix. This program is estimated to prevent 1,000-4,000 deaths per year. However, it should be noted that around 15% of cervical adenocarcinomas are frequently undetected by screening.

The screening program has evolved significantly in recent years. Initially, smears were examined for signs of dyskaryosis, which may indicate cervical intraepithelial neoplasia. However, the introduction of HPV testing allowed for further risk stratification, and the NHS has now moved to an HPV first system. This means that a sample is tested for high-risk strains of human papillomavirus (hrHPV) first, and cytological examination is only performed if this is positive.

All women between the ages of 25-64 years are offered a smear test. Women aged 25-49 years are screened every three years, while those aged 50-64 years are screened every five years. However, cervical screening cannot be offered to women over 64. In Scotland, screening is offered from 25-64 every five years.

In special situations, cervical screening in pregnancy is usually delayed until three months post-partum, unless there are missed screenings or previous abnormal smears. Women who have never been sexually active have a very low risk of developing cervical cancer and may wish to opt-out of screening.

It is recommended to take a cervical smear around mid-cycle, although there is limited evidence to support this advice. Overall, the UK’s cervical cancer screening program is an essential tool in preventing cervical cancer and promoting women’s health.

Having had one previous caesarean section, the majority of women can have a successful vaginal delivery. A fundal placenta, which is attached at the top of the uterus away from the cervical os, is a favorable location for a placenta and does not require a caesarean section. However, a previous caesarean section does increase the risk of placenta praevia, where the placenta covers the cervical os, which may require a caesarean section. Inducing vaginal delivery at 36-37 weeks is not recommended in this case, as it is not a suitable option. While maternal age of 37 may pose some risks during pregnancy and birth, it is not a determining factor for a caesarean section unless there are other concerns.

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%.