In the event that a low-lying placenta is detected during the 20-week scan, it is recommended to undergo a follow-up scan at 32 weeks for further evaluation.

Management and Prognosis of Placenta Praevia

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

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

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

For women without other risk factors for infertility, salpingectomy is the preferred first-line treatment for ectopic pregnancy requiring surgical management, rather than salpingostomy. This is the case for a patient with visible foetal heartbeat and pain, as expectant management would be inappropriate and methotrexate is not suitable. Misoprostol is also not appropriate as it is used for incomplete miscarriages, which is not the case for this patient.

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.

Changes in Physiological Parameters during Pregnancy

During pregnancy, various physiological changes occur in a woman’s body to support the growing fetus. One of these changes is a decrease in total lung capacity by approximately 200 ml. This reduction is due to a decrease in residual volume caused by the fetus. However, the basal metabolic rate increases during pregnancy. Additionally, cardiac output can increase by up to 40%, while the glomerular filtration rate (GFR) normally increases. Maternal oxygen consumption also rises during pregnancy to meet the oxygen demands of the fetus, leading to an increase in minute volume. These changes in physiological parameters are essential for the healthy development of the fetus and the mother’s well-being during pregnancy.

Safe Pain Management Options for Breastfeeding Mothers

Breastfeeding mothers who experience pain may require medication to manage their symptoms. However, certain drugs can be harmful to both the mother and the baby. Here are some safe pain management options for breastfeeding mothers:

Ibuprofen: This is the drug of choice for managing pain in breastfeeding mothers. Although it is contraindicated in pregnancy, its transfer into breast milk is very low.

Codeine: This opioid analgesic can be used during pregnancy, but it should be avoided as the mother approaches delivery due to the risk of respiratory depression in the infant. It should also be avoided when breastfeeding, as it can cause symptoms of overdose in the baby.

Aspirin: While aspirin is used during pregnancy for prophylaxis, its use as an analgesic should be avoided during breastfeeding as it can cause Reye’s syndrome or impair neonatal platelet function.

Indometacin: This NSAID can be used for analgesia in breastfeeding, as the concentration that transfers into breast milk is relatively low.

Tramadol: Although only small amounts of this opioid analgesic are present in breast milk, the manufacturers advise avoidance due to the risk of respiratory depression in the baby.

It is important to consult with a healthcare provider before taking any medication while breastfeeding. Additionally, mothers should be aware of any contraindications and potential side effects of the medication they are taking.

When managing mastitis in breastfeeding women, it is recommended to continue breastfeeding while using simple analgesia and warm compresses. If breastfeeding is too painful, expressing milk by hand or using a pump is advised to prevent milk stasis, which is often the cause of lactational mastitis. According to NICE clinical knowledge summaries (CKS), oral antibiotics are only necessary if there is an infected nipple fissure, symptoms do not improve after 12-24 hours despite effective milk removal, or breast milk culture is positive. Flucloxacillin is the first-line antibiotic for 10-14 days, while erythromycin or clarithromycin can be used for penicillin-allergic patients. Referral to a surgical team in the hospital is only necessary if a breast abscess is suspected, which is unlikely if there is no palpable lump in the breast.

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.

Managing Chickenpox Exposure in Pregnant Women: Blood Test for Varicella-Zoster Immunoglobulin G (IgG) Antibodies

Chickenpox is a common childhood disease caused by the varicella-zoster virus. In pregnant women, exposure to chickenpox can have detrimental effects on the fetus. Therefore, strict guidelines exist for managing exposure to affected children.

If a pregnant woman has had significant exposure to chickenpox, a thorough history should be established. If there is uncertainty or no previous history or exposure, the first-line investigation is a blood test to test for the presence of varicella-zoster IgG antibodies. The presence of IgG antibodies in blood indicates that the person has immunity either by mounting a response to a previous infection or by vaccination.

Varicella-zoster immunoglobulin should not be administered to all pregnant women who report significant exposure to chickenpox, as it is of no benefit to women who are seropositive and it is a waste of resources. Seronegativity should be established first.

Admission is reserved for women who have a combination of symptoms suspicious of a primary varicella-zoster virus infection, ie chickenpox, and any of the following: immunosuppression, severe symptoms, haemorrhagic rash, and neurological or respiratory symptoms.

Testing for varicella-zoster antigen is not of clinical value and is not routinely performed when assessing a pregnant patient with significant exposure to chickenpox.

According to the Royal College of Obstetricians and Gynaecologists (RCOG) guidelines, a significant exposure is defined as contact within the same room for 15 minutes, face-to-face contact, or being in a large room such as a hospital ward or a kindergarten with a child or an adult with chickenpox during the infective period.

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. This is the appropriate course of action, as relying solely on diet and exercise advice would not be sufficient given the patient’s high fasting glucose level. It is important to monitor glucose levels regularly while managing gestational diabetes, but when the fasting glucose level is >7 mmol/L at diagnosis, insulin therapy should be started. Sulfonylureas like gliclazide are not recommended during pregnancy due to the increased risk of fetal macrosomia.

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.

Placenta praevia is a pregnancy complication characterized by the attachment of the placenta to the lower part of the uterus. The main symptom is painless bleeding occurring after the 24th week of gestation. Risk factors include a history of placenta praevia, previous caesarean section, damage to the endometrium, and multiple pregnancies. Placenta praevia frequently results in a high presenting part or abnormal lie due to the placenta’s low position.

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.

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.

The UK Medical Eligibility Criteria for Contraceptive Use states that women who are breastfeeding and less than 6 weeks postpartum should not use the combined oral contraceptive pill as it can reduce breast milk volume. However, from 6 weeks to 6 months postpartum, it is classified as UKMEC 2 and can be used. It is important to note that exclusive breastfeeding can act as an effective contraceptive method. The Mirena intrauterine system and copper IUD can be used from 4 weeks postpartum, while the progesterone-only pill can be started on or after day 21 postpartum. The progesterone-only implant can be inserted at any time, but contraception is not necessary before day 21 postpartum.

After giving birth, women need to use contraception after 21 days. The progesterone-only pill (POP) can be started at any time postpartum, according to the FSRH. Additional contraception should be used for the first two days after day 21. A small amount of progesterone enters breast milk, but it is not harmful to the infant. On the other hand, the combined oral contraceptive pill (COCP) is absolutely contraindicated (UKMEC 4) if breastfeeding is less than six weeks post-partum. If breastfeeding is between six weeks and six months postpartum, it is a UKMEC 2. The COCP may reduce breast milk production in lactating mothers. It should not be used in the first 21 days due to the increased venous thromboembolism risk post-partum. After day 21, additional contraception should be used for the first seven days. The intrauterine device or intrauterine system can be inserted within 48 hours of childbirth or after four weeks.

The lactational amenorrhoea method (LAM) is 98% effective if the woman is fully breastfeeding (no supplementary feeds), amenorrhoeic, and less than six months post-partum. It is important to note that an inter-pregnancy interval of less than 12 months between childbirth and conceiving again is associated with an increased risk of preterm birth, low birth weight, and small for gestational age babies.

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

Understanding Reduced Fetal Movements

Introduction:
Reduced fetal movements can indicate fetal distress and are a response to chronic hypoxia in utero. This can lead to stillbirth and fetal growth restriction. It is believed that placental insufficiency may also be linked to reduced fetal movements.

Physiology:
Quickening is the first onset of fetal movements, which usually occurs between 18-20 weeks gestation and increases until 32 weeks gestation. Multiparous women may experience fetal movements sooner. Fetal movements should not reduce towards the end of pregnancy. There is no established definition for what constitutes reduced fetal movements, but less than 10 movements within 2 hours (in pregnancies past 28 weeks gestation) is an indication for further assessment.

Epidemiology:
Reduced fetal movements affect up to 15% of pregnancies, with 3-5% of pregnant women having recurrent presentations with RFM. Fetal movements should be established by 24 weeks gestation.

Risk factors for reduced fetal movements:
Posture, distraction, placental position, medication, fetal position, body habitus, amniotic fluid volume, and fetal size can all affect fetal movement awareness.

Investigations:
Fetal movements are usually based on maternal perception, but can also be objectively assessed using handheld Doppler or ultrasonography. Investigations are dependent on gestation at onset of RFM. If concern remains, despite normal CTG, urgent (within 24 hours) ultrasound can be used.

Prognosis:
Reduced fetal movements can represent fetal distress, but in 70% of pregnancies with a single episode of reduced fetal movement, there is no onward complication. However, between 40-55% of women who suffer from stillbirth experience reduced fetal movements prior to diagnosis. Recurrent RFM requires further investigations to consider structural or genetic fetal abnormalities.

The correct course of action for managing gestational diabetes when the fasting glucose level is equal to or greater than 7 mmol/L at the time of diagnosis is to commence insulin. Offering a trial of diet and exercise changes or commencing metformin alone would not be appropriate in this case. However, discussing diet and exercise changes with the patient may still be helpful in managing the condition. Referral for an oral glucose tolerance test to confirm the diagnosis is not necessary in this situation, as a diagnosis can be made based on the fasting plasma glucose level or 2-hour plasma glucose level.

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.

Physiological Changes During Pregnancy

The human body undergoes significant physiological changes during pregnancy. The cardiovascular system experiences an increase in stroke volume by 30%, heart rate by 15%, and cardiac output by 40%. However, systolic blood pressure remains unchanged, while diastolic blood pressure decreases in the first and second trimesters, returning to non-pregnant levels by term. The enlarged uterus may interfere with venous return, leading to ankle edema, supine hypotension, and varicose veins.

The respiratory system sees an increase in pulmonary ventilation by 40%, with tidal volume increasing from 500 to 700 ml due to the effect of progesterone on the respiratory center. Oxygen requirements increase by only 20%, leading to over-breathing and a fall in pCO2, which can cause a sense of dyspnea accentuated by the elevation of the diaphragm. The basal metabolic rate increases by 15%, possibly due to increased thyroxine and adrenocortical hormones, making warm conditions uncomfortable for women.

The maternal blood volume increases by 30%, mostly in the second half of pregnancy. Red blood cells increase by 20%, but plasma increases by 50%, leading to a decrease in hemoglobin. There is a low-grade increase in coagulant activity, with a rise in fibrinogen and Factors VII, VIII, X. Fibrinolytic activity decreases, returning to normal after delivery, possibly due to placental suppression. This prepares the mother for placental delivery but increases the risk of thromboembolism. Platelet count falls, while white blood cell count and erythrocyte sedimentation rate rise.

The urinary system experiences an increase in blood flow by 30%, with glomerular filtration rate increasing by 30-60%. Salt and water reabsorption increase due to elevated sex steroid levels, leading to increased urinary protein losses. Trace glycosuria is common due to the increased GFR and reduction in tubular reabsorption of filtered glucose.

Calcium requirements increase during pregnancy, especially during the third trimester and lactation. Calcium is transported actively across the placenta, while serum levels of calcium and phosphate fall with a fall in protein. Ionized levels of calcium remain stable, and gut absorption of calcium increases substantially due to increased 1,25 dihydroxy vitamin D.

The liver experiences an increase in alkaline phosphatase by 50%,

Continuous CTG monitoring is recommended during labour if any of the following conditions are present or develop: suspected chorioamnionitis or sepsis, a temperature of 38°C or higher, severe hypertension with a reading of 160/110 mmHg or above, use of oxytocin, or significant meconium. In addition, the 2014 update to the guidelines added fresh vaginal bleeding as a new point of concern, as it may indicate placental rupture or placenta previa, both of which require monitoring of the baby.

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.

Sensitization occurs when fetal red blood cells, which are RhD-positive, enter the bloodstream of a mother who is RhD-negative. This can lead to the formation of antibodies in the mother’s circulation that can destroy fetal red blood cells, causing complications such as hemolytic disease of the fetus and newborn in subsequent pregnancies where the fetus is RhD-positive. To reduce the risk of sensitization, anti-D immunoglobulin is administered in situations where there is a likelihood of fetomaternal hemorrhage. Anti-D works by neutralizing RhD-antigens from fetal red cells, but it cannot reverse sensitization if the mother already has antibodies in her circulation. Prophylactic anti-D is given to non-sensitized RhD-negative women at 28 and 34 weeks to prevent small fetomaternal hemorrhages in the absence of a known sensitizing event. Various events during pregnancy, such as vaginal bleeding, chorionic villus sampling, and abdominal trauma, can potentially cause sensitization. Source: RCOG. Rhesus D prophylaxis, the use of anti-D immunoglobulin.

Rhesus negative pregnancies can lead to the formation of anti-D IgG antibodies in the mother if she delivers a Rh +ve child, which can cause haemolysis in future pregnancies. Prevention involves testing for D antibodies and giving anti-D prophylaxis to non-sensitised Rh -ve mothers at 28 and 34 weeks. Anti-D immunoglobulin should be given within 72 hours in various situations. Tests should be done on all babies born to Rh -ve mothers, and affected fetuses may experience various complications and require treatment such as transfusions and UV phototherapy.

Different Types of Incisions for Surgical Procedures

There are various types of incisions used for different surgical procedures. Here are some common types of incisions and their uses:

1. Suprapubic Incision: Also known as the Pfannenstiel incision, this is the most common incision used for Gynaecological and obstetric operations like Caesarean sections. It is made at the pubic hairline.

2. Transverse Incision just below the Umbilicus: This incision is usually too superior for a Caesarean section because the scar would be visible and does not provide direct access to the uterus as the Pfannenstiel incision.

3. Right Subcostal Incision: This incision is used to access the gallbladder and biliary tree.

4. Median Longitudinal Incision: This incision is not commonly used because of cosmetic scarring, as well as the fact that the linea alba is relatively avascular and can undergo necrosis if the edges are not aligned and stitched properly.

5. McBurney’s Point Incision: This incision is used to access the vermiform appendix and is made at the McBurney’s point, which is approximately one-third of the distance of a line, the spino-umbilical line, starting at the right anterior superior iliac spine and ending at the umbilicus.

In conclusion, the type of incision used for a surgical procedure depends on the specific needs of the operation and the surgeon’s preference.

Best Practices for Motivational Interviewing in Smoking Cessation during Pregnancy

Motivational interviewing is a patient-centered approach that aims to elicit and strengthen the patient’s own motivation and commitment to change. When it comes to smoking cessation during pregnancy, there are several best practices to follow.

Firstly, it is important to establish rapport and assess the patient’s readiness to discuss behavior change. This involves determining which stage of change the patient is at and working accordingly from there.

Next, it is important to assess the patient’s perceived difficulties and barriers to change, often using a numerical scale. However, this should not be done as the first step.

Explaining and advising why smoking is harmful in pregnancy should also not be the first step. Instead, it is best to find out what the patient understands about the risks of smoking in pregnancy and then evoke the patient’s own motivations for change, if present.

It is important to avoid trying to break down any resistance shown by the patient. Instead, a therapeutic relationship resembling a partnership or team should be used as the cornerstone from which changes can be explored or pursued.

Finally, using a numerical scale to assess the patient’s confidence and willingness to quit smoking is an important step, but should not be done in the first instance. By following these best practices, healthcare providers can effectively use motivational interviewing to support smoking cessation during pregnancy.

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.

Women who have recently given birth, whether they are breastfeeding or not, can begin taking the progesterone-only pill at any time. However, for this patient who is only 2 days postpartum, it is recommended to prescribe the progesterone-only pill as it does not contain estrogen and is less likely to affect milk production. Additionally, it does not increase the risk of venous thromboembolism, which is a concern for postpartum women until 21-28 days after giving birth. The combined oral contraceptive pill should be avoided until 21 days postpartum due to the risk of thrombosis and reduced breast milk production. The patient cannot resume her previous contraceptives at this time. While an intrauterine device can be inserted during a caesarean section, it is advisable to wait 4-6 weeks postpartum before having it inserted vaginally. It is incorrect to tell the patient that she cannot use any contraception if she wishes to breastfeed, as the progesterone-only pill has been shown to have minimal effect on milk production in breastfeeding women.

After giving birth, women need to use contraception after 21 days. The progesterone-only pill (POP) can be started at any time postpartum, according to the FSRH. Additional contraception should be used for the first two days after day 21. A small amount of progesterone enters breast milk, but it is not harmful to the infant. On the other hand, the combined oral contraceptive pill (COCP) is absolutely contraindicated (UKMEC 4) if breastfeeding is less than six weeks post-partum. If breastfeeding is between six weeks and six months postpartum, it is a UKMEC 2. The COCP may reduce breast milk production in lactating mothers. It should not be used in the first 21 days due to the increased venous thromboembolism risk post-partum. After day 21, additional contraception should be used for the first seven days. The intrauterine device or intrauterine system can be inserted within 48 hours of childbirth or after four weeks.

The lactational amenorrhoea method (LAM) is 98% effective if the woman is fully breastfeeding (no supplementary feeds), amenorrhoeic, and less than six months post-partum. It is important to note that an inter-pregnancy interval of less than 12 months between childbirth and conceiving again is associated with an increased risk of preterm birth, low birth weight, and small for gestational age babies.

Choosing the Appropriate Measurement for Estimating Embryonic Age

When estimating the age of an embryo, it is important to choose the appropriate measurement based on the anatomy and timing of the scan. In the case of a scan taken at 7 weeks post-fertilisation, the crown-rump length is the most appropriate measurement to use. The greatest width is not used for estimating embryonic age, while the greatest length is only suitable for early embryos in the third and early fourth weeks. Crown-heel length may be used for 8-week-old embryos, but requires visibility of the lower limb. Crown-elbow length is not applicable in this case as the limbs cannot be visualised. It is important to consider the specific circumstances of the scan when choosing the appropriate measurement for estimating embryonic age.

Antiretroviral Therapy Options for Pregnant Women with HIV

The British HIV Association recommends that all pregnant women who are HIV-positive should be started on combined antiretroviral therapy in the second trimester and continue it lifelong. This therapy consists of three agents. Even if the viral load is low, antiretroviral therapy is still recommended.

For women who refuse combined antiretroviral therapy, zidovudine monotherapy can be offered if the patient has a CD4 count of > 350 and a viral load of < 10 000 copies/ml and agrees to a Caesarean section. This option is less effective than combined therapy but can still be considered. If zidovudine monotherapy is chosen, it should be started in the second trimester and continued until delivery. During delivery, a zidovudine infusion should be running. If the viral load remains < 50 copies/ml, a planned vaginal delivery can be considered.

Management of Pre-eclampsia with Hypertension in Pregnancy

Pre-eclampsia is a common condition affecting pregnant women, with hypertension and proteinuria being the main clinical features. The first line of management for hypertension is oral labetalol, with close monitoring of blood pressure. In cases of mild hypertension, induction of labor is not necessary. However, admission for monitoring and commencement of labetalol is recommended. IV magnesium sulfate may be needed later on, but not initially. Discharge home is not appropriate for women with pre-eclampsia. Early recognition and management of pre-eclampsia is crucial for the well-being of both the mother and the baby.

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.

Instrumental delivery is a method used to expedite delivery during the second stage of labor in order to prevent fetal and maternal morbidity. It involves the use of traction and is indicated in cases of prolonged active second stage, maternal exhaustion, fetal distress, breech presentation, and prophylactic use in medical conditions such as cardiovascular disease and hypertension. It can also be used to rotate a malpositioned fetal head.

To be eligible for instrumental delivery, the following requirements must be met, which can be remembered using the acronym FORCEPS:

– Fully dilated cervix, indicating that the second stage of labor has been reached
– Occiput anterior (OA) position, preferably with the head in the occiput posterior (OP) position, as delivery is possible with Kielland’s forceps and ventouse. The position of the head must be known to avoid maternal or fetal trauma and failure.
– Ruptured membranes
– Cephalic presentation
– Engaged presenting part, meaning that the head is at or below the ischial spines and cannot be palpated abdominally
– Pain relief
– Sphincter (bladder) empty, which usually requires catheterization

It is important to note that there must be a clear indication for instrumental delivery.

When is a Forceps Delivery Necessary?

A forceps delivery may be necessary in certain situations during childbirth. These situations include fetal distress, maternal distress, failure to progress, and the need to control the head in a breech delivery. Fetal distress occurs when the baby is not receiving enough oxygen and can be detected through changes in the baby’s heart rate. Maternal distress can occur when the mother is exhausted or experiencing complications such as high blood pressure. Failure to progress refers to a situation where the mother has been pushing for an extended period of time without making progress. In a breech delivery, the baby’s head may need to be controlled to prevent injury. In these situations, a forceps delivery may be recommended by the healthcare provider to safely deliver the baby.

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.

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.

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.

Postpartum haemorrhage (PPH) caused by uterine atony can be treated with various medical options including oxytocin, ergometrine, carboprost, and misoprostol. Initially, non-pharmacological methods such as bimanual uterine compression and catheter insertion should be used. RCOG guidelines recommend starting with Syntocinon 5 Units by slow IV injection, followed by ergometrine (avoid in hypertension), and then a Syntocinon infusion. Carboprost (avoid in asthma) and misoprostol 1000 micrograms rectally are then recommended. If pharmacological management fails, surgical haemostasis should be initiated. In a major PPH, ABCD management should be initiated, including fluids while waiting for appropriate cross-matched blood. Primary PPH is defined as a loss of greater than 500 ml of blood within 24 hours of delivery, with minor PPH being a loss of 500-1000 ml of blood and major PPH being over 1000 ml of blood. The causes of primary PPH can be categorized into the 4 T’s: Tone, Tissue, Trauma, and Thrombin. Uterine atony is the most common cause of primary PPH.

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.

If pre-eclampsia is suspected in a woman, NICE recommends arranging emergency secondary care assessment. This is because pre-eclampsia can be asymptomatic and potentially life-threatening. In this case, the patient has high blood pressure (>=140/90 mmHg) and proteinuria (>= +1), which are features of pre-eclampsia. While a growth scan may be necessary as part of her overall management, it is not the priority at this time. Home BP monitoring is also not indicated now, as she needs further assessment first. Repeating the assessment in 24 hours is not appropriate, as emergency secondary care assessment is necessary. While labetalol may be used to manage her blood pressure, it should not be initiated before obstetric specialist investigation and input.

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 correct result for the quadruple test screening for Edward’s syndrome is ↓ AFP ↓ oestriol ↓ hCG ↔ inhibin A. This test is offered to pregnant women between 15-20 weeks gestation and measures alpha fetoprotein, unconjugated oestriol, hCG, and inhibin A levels. A ‘high chance’ result would require further screening or diagnostic tests to determine if the baby is affected by Edward’s syndrome. The incorrect answers include a result indicating a higher chance of Down’s syndrome (↑ hCG, ↓ PAPP-A, thickened nuchal translucency), neural tube defects (↑AFP ↔ oestriol ↔ hCG ↔ inhibin A), and a higher chance of Down’s syndrome (↓ AFP ↓ oestriol ↑ hCG ↑ inhibin A). It is important to note that the combined test for Down’s syndrome should not be given to women outside of the appropriate gestation bracket.

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.