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.

The risk of hyperemesis gravidarum is higher in women who are pregnant with twins. This is because each twin produces hCG, which can increase the levels of hCG in the body and lead to hyperemesis gravidarum. Hypothyroidism is not a risk factor, but hyperthyroidism is because it can increase levels of TSH, which is chemically similar to hCG. Age and previous pregnancies do not increase the risk of hyperemesis gravidarum, but a history of hyperemesis gravidarum in a previous pregnancy can increase the likelihood of developing it in future pregnancies.

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

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

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

Breast Conditions in Lactating Women

Lactating women may experience various breast conditions, including mastitis, breast abscess, cellulitis, engorged breasts, and full breasts.

Mastitis is typically caused by a blocked duct or ascending infection from nipple trauma during breastfeeding. Symptoms include unilateral pain, breast engorgement, and erythema. Treatment involves analgesia, reassurance, and continuing breastfeeding. Antibiotics may be necessary if symptoms persist or a milk culture is positive.

Breast abscess presents as a painful lump in the breast tissue, often with systemic symptoms such as fever and malaise. Immediate treatment is necessary to prevent septicaemia.

Cellulitis is an acute bacterial infection of the breast skin, presenting with erythema, tenderness, swelling, and blister formation. Non-specific symptoms such as rigors, fevers, and malaise may also occur.

Engorged breasts can be primary or secondary, causing bilateral breast pain and engorgement. The skin may appear shiny, and the nipple may appear flat due to stretching.

Full breasts are associated with lactation and cause warm, heavy, and hard breasts. This condition typically occurs between the 2nd and 6th day postpartum.

Hyperemesis gravidarum, a severe form of nausea and vomiting during pregnancy, can lead to pre-pregnancy weight loss and electrolyte imbalance. Women with multiple pregnancies, such as the patient in this case, are at a higher risk due to elevated levels of the hormone human chorionic gonadotropin (HCG). Hyperthyroidism and molar pregnancy are also risk factors, while hypothyroidism and irritable bowel syndrome are not associated with hyperemesis gravidarum. In-vitro fertilisation (IVF) indirectly increases the risk due to the higher likelihood of multiple pregnancy.

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.

Hyperemesis gravidarum is more likely to occur in women who are pregnant with multiple babies. Other factors that may increase the risk of HG include obesity, epilepsy, stress, and a family history of the condition. Treatment options may include corticosteroids like prednisolone, anti-emetic drugs such as ondansetron, and vitamins B6 and B12. While advanced maternal age can increase the risk of certain pregnancy complications, it has not been linked to an increased risk of HG. Similarly, having multiple previous pregnancies does not appear to increase the risk of HG, but a history of the condition in a previous pregnancy may be a risk factor.

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.

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.

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.

Safe and Unsafe Painkillers in Pregnancy

Pregnancy can be a challenging time for women, especially when it comes to managing pain. While some painkillers are safe to use during pregnancy, others can have harmful effects on the developing fetus. Here is a breakdown of some commonly used painkillers and their safety in pregnancy.

Codeine phosphate: Low doses of codeine phosphate are generally safe to use during pregnancy. However, if taken closer to delivery, the neonate should be observed for signs of respiratory depression, drowsiness, or opioid withdrawal.

Naproxen: Naproxen belongs to the family of NSAIDs and is contraindicated in pregnancy. However, it is safe to use in the postpartum period and by women who are breastfeeding.

Ibuprofen: Ibuprofen and other NSAIDs should be avoided during pregnancy as they are associated with teratogenic effects and other congenital problems.

Paracetamol: Paracetamol is the analgesic of choice in pregnancy and is safe to use within the recommended limits. However, patients should be cautioned against taking paracetamol and low-dose co-codamol concurrently.

Tramadol: Tramadol should be avoided in pregnancy as it has been shown to be embryotoxic in animal models.

In conclusion, it is important for pregnant women to consult with their healthcare provider before taking any painkillers to ensure the safety of both mother and fetus.

The perineal tear in this patient involves the anal sphincter complex, including both the external and internal anal sphincters, which is classified as a third-degree injury. This type of tear is typically caused by the intense pressure and stretching that occurs during childbirth, particularly in first-time mothers or those delivering larger babies, often due to undiagnosed gestational diabetes.

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.

The first step in managing chickenpox exposure during pregnancy is to confirm the patient’s immunity by checking her varicella-zoster antibodies. If the woman is unsure about her past exposure to chickenpox, this test will determine if she has antibodies to the virus. If the test confirms her immunity, no further action is necessary. Administering the varicella-zoster vaccine or IV immunoglobulin is not appropriate in this situation. Neglecting to check the patient’s immunity status can put her and her unborn child at risk.

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.

The McRobert’s manoeuvre is an efficient and uncomplicated method to address shoulder dystocia. By enhancing the flexibility of the sacroiliac joints, it facilitates pelvic rotation and the subsequent release of the fetal shoulder. It is crucial to immediately seek assistance upon identifying 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.

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

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

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

If a woman reports reduced fetal movements and no heartbeat is detected with a handheld Doppler after 28 weeks of gestation, an immediate ultrasound should be offered according to RCOG guidelines. Repeating Doppler after an hour is not recommended. If a heartbeat is detected, cardiotocography should be used to monitor the heart rate for at least 20 minutes. Fetal blood sampling is not necessary in this situation.

Understanding Reduced Fetal Movements

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

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

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

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

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

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

The preferred method for diagnosing gestational diabetes is still the oral glucose tolerance test.

Gestational diabetes is a common medical disorder affecting around 4% of pregnancies. Risk factors include a high BMI, previous gestational diabetes, and family history of diabetes. Screening is done through an oral glucose tolerance test, and diagnostic thresholds have recently been updated. Management includes self-monitoring of blood glucose, diet and exercise advice, and medication if necessary. For pre-existing diabetes, weight loss and insulin are recommended, and tight glycemic control is important. Targets for self-monitoring include fasting glucose of 5.3 mmol/l and 1-2 hour post-meal glucose levels.

If lochia continues for more than 6 weeks, an ultrasound should be performed.

During the puerperium, which is the period of around 6 weeks after childbirth when the woman’s reproductive organs return to their normal state, lochia is the discharge of blood, mucous, and uterine tissue that occurs. It is expected to stop after 4-6 weeks. However, if it persists beyond this time, an ultrasound is necessary to investigate the possibility of retained products of conception.

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.

Based on the presented symptoms, the most probable diagnosis is acute fatty liver of pregnancy. This is supported by the presence of jaundice, mild fever, elevated liver function tests, increased white blood cell count, coagulopathy, and steatosis on imaging. Acute fatty liver of pregnancy typically presents with non-specific symptoms such as fatigue, malaise, and nausea, whereas cholestasis of pregnancy is characterized by severe itching. The absence of abnormalities in hemoglobin, platelet count, and viral screening makes the diagnosis of HELLP syndrome or viral hepatitis unlikely. Additionally, pre-eclampsia is characterized by hypertension and proteinuria. It is important to note that placental ALP can cause an increase in serum ALP levels during pregnancy.

Liver Complications During Pregnancy

During pregnancy, there are several liver complications that may arise. One of the most common is intrahepatic cholestasis of pregnancy, which occurs in about 1% of pregnancies and is typically seen in the third trimester. Symptoms include intense itching, especially in the palms and soles, as well as elevated bilirubin levels. Treatment involves the use of ursodeoxycholic acid for relief and weekly liver function tests. Women with this condition are usually induced at 37 weeks to prevent stillbirth, although maternal morbidity is not typically increased.

Another rare complication is acute fatty liver of pregnancy, which may occur in the third trimester or immediately after delivery. Symptoms include abdominal pain, nausea and vomiting, headache, jaundice, and hypoglycemia. Severe cases may result in pre-eclampsia. ALT levels are typically elevated, and support care is the primary management until delivery can be performed once the patient is stabilized.

Finally, conditions such as Gilbert’s and Dubin-Johnson syndrome may be exacerbated during pregnancy. Additionally, HELLP syndrome, which stands for haemolysis, elevated liver enzymes, and low platelets, is a serious complication that can occur in the third trimester and requires immediate medical attention. Overall, it is important for pregnant women to be aware of these potential liver complications and to seek medical attention if any symptoms arise.

A raised level of maternal serum AFP is linked to fetal abdominal wall defects such as omphalocele. Conversely, low levels of maternal AFP are associated with Down’s syndrome, maternal diabetes mellitus, Edwards syndrome, and maternal obesity.

Alpha-fetoprotein (AFP) is a protein that is created by the fetus during development. When there is an increase in AFP levels, it may indicate the presence of certain conditions such as neural tube defects (meningocele, myelomeningocele and anencephaly), abdominal wall defects (omphalocele and gastroschisis), multiple pregnancy, Down’s syndrome, trisomy 18, and maternal diabetes mellitus. On the other hand, a decrease in AFP levels may also be significant and should be further investigated.

It is important for pregnant individuals with type 1 diabetes to closely monitor their blood glucose levels by testing multiple times throughout the day. This is recommended by NICE NG3.

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.

Maternal mortality rates are still high globally due to obstetric haemorrhage. Postpartum haemorrhage is characterized by blood loss of 500 ml after vaginal delivery, not including the placenta. If blood loss exceeds 1000mls, it is classified as major postpartum haemorrhage. It is crucial to evaluate the severity of the bleeding and seek appropriate management (as outlined below).

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 blood glucose targets are not achieved through diet and metformin in gestational diabetes, insulin should be introduced. This patient was diagnosed with gestational diabetes at 25 weeks due to a fasting glucose level above 5.6mmol/L. Despite lifestyle changes and the addition of metformin, her glycaemic control has not improved, and her fasting glucose level remains above the target range. Therefore, NICE recommends adding short-acting insulin to her current treatment. Switching to modified-release metformin may help patients who experience side effects, but it would not improve glycaemic control in this case. Insulin should be added in conjunction with metformin for persistent impaired glycaemic control, rather than replacing it. Sulfonylureas like glibenclamide should only be used for patients who cannot tolerate metformin or as an adjunct for those who refuse insulin treatment, and they are not the best option for this patient.

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.

Antenatal corticosteroids should be given in cases of preterm prelabour rupture of membranes to reduce the risk of respiratory distress syndrome in the neonate. IM corticosteroids are the appropriate form of administration for this purpose. Cervical cerclage is not recommended in this scenario as it is contraindicated in cases of preterm prelabour rupture of membranes. Expectant management is also not the best option as it increases the risk of intraamniotic infection. Indomethacin tocolysis is not recommended as it can cause complications such as ductus arteriosus closure and oligohydramnios. Nifedipine is the preferred medication for delaying labour in this scenario.

Preterm prelabour rupture of the membranes (PPROM) is a condition that occurs in approximately 2% of pregnancies, but it is responsible for around 40% of preterm deliveries. This condition can lead to various complications, including prematurity, infection, and pulmonary hypoplasia in the fetus, as well as chorioamnionitis in the mother. To confirm PPROM, a sterile speculum examination should be performed to check for pooling of amniotic fluid in the posterior vaginal vault. However, digital examination should be avoided due to the risk of infection. If pooling of fluid is not observed, testing the fluid for placental alpha microglobulin-1 protein (PAMG-1) or insulin-like growth factor binding protein-1 is recommended. Ultrasound may also be useful to show oligohydramnios.

The management of PPROM involves admission and regular observations to ensure that chorioamnionitis is not developing. Oral erythromycin should be given for ten days, and antenatal corticosteroids should be administered to reduce the risk of respiratory distress syndrome. Delivery should be considered at 34 weeks of gestation, but there is a trade-off between an increased risk of maternal chorioamnionitis and a decreased risk of respiratory distress syndrome as the pregnancy progresses. PPROM is a serious condition that requires prompt diagnosis and management to minimize the risk of complications for both the mother and the fetus.

Category 2 caesarean sections must be carried out within 75 minutes of the decision being made. This category is used when there is fetal or maternal compromise that is not immediately life-threatening. The delivery should be planned as soon as possible, but the target time is within 60-75 minutes. Category 1 caesarean section, on the other hand, is used when there is an immediate threat to the life of the woman or fetus, and the procedure should be performed within 30 minutes.

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%.

When women who are taking antiepileptic medication plan to conceive, they should be given a higher dose of folic acid (5mg) instead of the usual 400 mcg once daily. Folic acid is recommended during pregnancy to prevent neural tube defects, and a higher dose is necessary for women with epilepsy due to their increased risk of low serum folate levels. It is important to note that certain antiepileptic medications can interfere with folate metabolism, and switching to sodium valproate is not recommended as it is a known teratogen. It is also important for women to continue taking their medication during pregnancy to avoid an increased risk of seizures.

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

Rubella and Pregnancy: Risks, Features, Diagnosis, and Management

Rubella, also known as German measles, is a viral infection caused by the togavirus. Thanks to the introduction of the MMR vaccine, it is now rare. However, if contracted during pregnancy, there is a risk of congenital rubella syndrome, which can cause serious harm to the fetus. It is important to note that the incubation period is 14-21 days, and individuals are infectious from 7 days before symptoms appear to 4 days after the onset of the rash.

The risk of damage to the fetus is highest in the first 8-10 weeks of pregnancy, with a risk as high as 90%. However, damage is rare after 16 weeks. Features of congenital rubella syndrome include sensorineural deafness, congenital cataracts, congenital heart disease (e.g. patent ductus arteriosus), growth retardation, hepatosplenomegaly, purpuric skin lesions, ‘salt and pepper’ chorioretinitis, microphthalmia, and cerebral palsy.

If a suspected case of rubella in pregnancy arises, it should be discussed immediately with the local Health Protection Unit (HPU) as type/timing of investigations may vary. IgM antibodies are raised in women recently exposed to the virus. It should be noted that it is very difficult to distinguish rubella from parvovirus B19 clinically. Therefore, it is important to also check parvovirus B19 serology as there is a 30% risk of transplacental infection, with a 5-10% risk of fetal loss.

If a woman is tested at any point and no immunity is demonstrated, they should be advised to keep away from people who might have rubella. Non-immune mothers should be offered the MMR vaccination in the post-natal period. However, MMR vaccines should not be administered to women known to be pregnant or attempting to become pregnant.

The Sites of Haematopoiesis in the Fetus and Adult

Haematopoiesis, the process of blood cell formation, occurs in various sites throughout fetal development and in adults. The dominant site of haematopoiesis changes as the fetus develops and bones are formed. Here are the different sites of haematopoiesis and their significance:

Bone Marrow: From four months into childhood and adulthood, bone marrow becomes the primary source of hematopoiesis. Red blood cells and immune effector cells are derived from pluripotent haematopoietic cells, which are first noted in blood islands of the yolk sac. By 20 weeks, almost all of these cells are produced by the bone marrow.

Yolk Sac: Haematopoiesis begins in the yolk sac and in angiogenic cell clusters throughout the embryonic body. This involves the formation of nucleated red blood cells, which differentiate from endothelial cells in the walls of blood vessels. Yolk sac haematopoiesis peaks at about one month and becomes insignificant by three months.

Liver: By the sixth week, the fetal liver performs haematopoiesis. This peaks at 12-16 weeks and continues until approximately 36 weeks. Haematopoietic stem cells differentiate in the walls of liver sinusoids. In adults, there is a reserve haematopoietic capacity, especially in the liver.

Spleen: The spleen is a minor site of haematopoiesis, being active between the third and sixth months.

Lymph Nodes: Lymph nodes are not a significant site of haematopoiesis.

In patients with certain conditions, such as haemolytic anaemia or myeloproliferative disease, hepatic haematopoiesis may be reactivated, leading to hepatomegaly. Understanding the different sites of haematopoiesis is important for understanding blood cell formation and certain medical conditions.

When pregnant women who are at least 20 weeks along contract chickenpox, they are typically prescribed oral acyclovir if they seek treatment within 24 hours of the rash appearing. This is in accordance with RCOG guidelines and is an important topic for exams. If the patient is asymptomatic after being exposed to chickenpox and is unsure of their immunity, a blood test should be conducted urgently. If the test is negative, VZIG should be administered. However, if the patient is certain that they are not immune to chickenpox, VZIG should be given without the need for a blood test. It is incorrect to administer both VZIG and oral acyclovir once symptoms of chickenpox have appeared, as VZIG is no longer effective at that point. Intravenous acyclovir is only necessary in cases of severe chickenpox.

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.

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.

When a pregnant woman with a confirmed DVT is suspected of having a PE, the first step is to immediately administer LMWH to avoid any delay in treatment. PE during pregnancy can be life-threatening for both the mother and the foetus, causing hypoxia and even cardiac arrest. Thrombolysis is not recommended during pregnancy as it can lead to severe haemorrhage in the placenta and foetus. Apixaban is not approved for use during pregnancy and may have teratogenic effects. Similarly, warfarin is not safe during pregnancy and can cause congenital malformations and haemorrhage in the placenta. While a CTPA can be diagnostic, waiting for the scan can be risky for the mother and baby. Therefore, LMWH should be started without delay, and further investigations can be carried out to confirm or rule out a PE.

Investigation of DVT/PE during Pregnancy

Guidelines for investigating deep vein thrombosis (DVT) and pulmonary embolism (PE) during pregnancy were updated in 2015 by the Royal College of Obstetricians. For suspected DVT, compression duplex ultrasound should be performed if there is clinical suspicion. In cases of suspected PE, an ECG and chest x-ray should be performed in all patients. If a woman presents with symptoms and signs of DVT, compression duplex ultrasound should be performed. If DVT is confirmed, no further investigation is necessary, and treatment for venous thromboembolism (VTE) should continue. The decision to perform a ventilation/perfusion (V/Q) scan or computed tomography pulmonary angiography (CTPA) should be made at a local level after discussion with the patient and radiologist.

When comparing CTPA to V/Q scanning in pregnancy, it is important to note that CTPA slightly increases the lifetime risk of maternal breast cancer (up to 13.6%, with a background risk of 1/200 for the study population). Pregnancy makes breast tissue particularly sensitive to the effects of radiation. On the other hand, V/Q scanning carries a slightly increased risk of childhood cancer compared to CTPA (1/50,000 versus less than 1/1,000,000). It is also important to note that D-dimer is of limited use in the investigation of thromboembolism during pregnancy as it is often raised in pregnant women.