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Obstetrics&Gynaecology II

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André Almeida

on 7 July 2013

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Transcript of Obstetrics&Gynaecology II

Obstetrics & Gynaecology II
Balance between pro-pregnancy factors and pro-labour factors
Pro-pregnancy factors
Pro-labour factors
Prostaglandin DH
Inflammatory mediators
1. Head at pelvic brim in left or right occipitolateral position
2. Neck flexes so that the presenting diameter is suboccipitobregmatic
3. Head descends and engages
4. Head reaches the pelvic floor and occiput rotates to occipitoanterior
5. Head delivers by extension
6. Descent continues and shoulders rotate into the anteroposterior diameter of the pelvis
7. Head restitutes
8. Anterior shoulder delivered by lateral flexion from downward pressure on the baby's head; posterior shoulder delivered by lateral flexion upwards
Inlet - AP=12cm; Transverse = 13 cm
Outlet - AP=12.5cm; Transverse = 11cm
Diagnosis - uterine contraction and effacement and dilatation of the cervix - confirmed by either a blood-stained mucous discharge (show) or SROM
Pre-labour rupture of membranes - 6-12% of labours (before contractions and cervical dilatation)
First stage
Progress measured in terms of cervical dilatation and descent of fetal head
Vaginal examinations every 4 hours
Average rate of dilatation, in primips, is 1cm per hours (1/2 cm is acceptable)
Fetal head descent measure by fifths palpable abdominally - 2/5 indicates the head is engaged
Station of the fetal head with respect to the ischial spines is recorded
Second stage
Starts when the cervix is fully dilated
1. Propulssive/passive phase - from full dilatation to head reaching the pelvic floor. Head typically occipitotransverse. Mother has little urge to push
2. Expulsive/active phase - begins when fetal head reaches the pelvic floor - mother has a strong involuntary desire to push
With pushing the head delivers - normally in the occipitoanterior position; after delivery restitution happens
After delivery of anterior shoulder - a IM syntocinon is injected to prevent PPH
The umbilical cord is clamped and cut.
If there is no need for ressusciation - baby should given to mother and skin-to-skin contact encouraged
Third stage
Actively managed to reduce the risk of PPH
IM injection of syntocinon and gentle controlled cord traction using the Brandt-Andrews method
Cord traction and with the other hand maintains upwars pressure on the fundus (prevents uterine inversion)
Normal blood loss at delivery is about 300 ml
Use of syntocinon after delivery - reduces risk of PPH by 60%
Obstetric haemorrhage
No PV until no PP
Threatened miscarriage - up to 24 weeks
Antepartum H. - from 24 weeks to the onset on labour
Intrapartum H. - from the onset of labour until the end of the second stage
Pospartum H. - form the third stage of labour until the end of the puerperium
Antepartum haemorrhage
Intrapartum haemorrhage
Postpartum haemorrhage
Local - from vulva, vagina or cervix - cervical bleeding not uncommon in pregnancy - ectropion, very rarely carcinoma
Placenta previa
Placenta encroaching on the lower segment of the uterus
Risk factors: old age, previous cesarean section, high parity
I - Encroaches on lower segment
II - Reaches internal os (marginal)
III - Covers part of os (partial)
IV - Completely covers the os (complete)
Major - always get bleeding during labour
Minor - possible to deliver vaginally with success
Suitability for delivery - engagement
If not at least partially engaged - C-section
Main complication - sudden, unpredictable, major haemorrhage
Elective delivery at 38-39 weeks
If the placenta invades the myometrium - placenta accreta - increases chances of severe haemorrhage
US used to demonstrate location of the placenta
Mx: ABC, expectant, delivery by C-section(?)
Painless vaginal bleeding
Uterus SNT
Non engagement
Placental abruption
Retroplacental haemorrhage with some degree of separation
Maternal smoking is the principal risk factor!!!
Concealed abruption -considerable internal bleeding without any external loss
Major revealed haemorrhage - urgent delivery
Concealed abruption - degree of pain, uterine tenderness, evidence of shock - urgent delivery may be required
If not fetal heartbeat - vaginal delivery
Complications - hypovolemic and DIC
Pain with vaginal bleeding suggests abruption or labour
Uterine tenderness
Vaginal bleeding (not in concealed)
Possible lack of fetal heartbeat
Uterine rupture is relatively rate, but needs to be considered (esp VBAC - 1:300) - See other section for details
Placental abruption can also occur during labour
Vasa previa
Very rare
Cord vessels run in the fetal membranes and cross the internal os
Vessels can rupture during early labour - rapid fetal exsanguination
Presents - severe fetal distress or fetal death after small IPH
Kleihauer test - can distinguish between fetal and maternal RBC
Baby is delivered immediately
Always some bleeding during the third stage of labour - 200-300 ml
Primary PPH - blood loss of ≥500ml within 24h of delivery of the baby (3rd stage also counts)
Secondary PPH - any significant loss between 24h and 6 weeks after birth
Primary PPH
5% of all deliveries
Risk factors: ≥5 deliveries, multiple pregnancy, fibroids, polyhydramnios, placenta previa and a long labour, past history of PPH
Prevention - treat antenatal anaemia, give syntocinon 5IU or Syntometrine (syntocinon + ergometrine) with delivery of baby, active management of 3rd stage associated with lower incidence of PPH
Uterine atony (90%) (includes retained placenta) - lack of contraction of myometrium fails to compress blood vessels; more likely if all or part of
placenta is retained - prevents contraction from occurring.
Trauma (7%) - episiotomy, vaginal or cervical laceration; uterine rupture
Coagulation problems - DIC (3%)
Atonic uterus may fill up with blood - no external bleeding
Critical factors: signs of shock; pallor, rising pulse, falling BP
Atony - abdominal masssage may cause contraction; bimanual compression (fisting)
IV access (wide-bore)
Bloods - FBC, Clotting, Crossmatch
Syntocinon 10IU stat IV + syntocinon infusion
Fluids - crystalloid or colloid + urinary catheter
If placenta not delivered - controlled cord traction; if fails - regional block or GA - manual removal; in placenta accreta - hysterectomy might be needed
Further oxytocics - ergometrine IM, carboprost IM or misoprostol rectally
If haemorrhage continues consider:
CVP and transfusion
Correct DIC with FFP or cryoprecipitate
Brace suture (B lynch) or uterine balloon (Rusch ballon)
Hysterectomy or internal iliac artery ligation (atony)
Radiologically directed arterial embolisation (stable for transfer)
Secondary PPH
Bleeding 24 hours and 6 weeks postnatally
Retained products of conception
Vulval haematoma (rare)
Trophoblastic disease (rare)
Conservative management with antibiotics
ERPC with antibiotic cover under GA
If persistent bleeding, US can show resolution of intrauterine haematomas and identify retained products
Chance of recurrence if relatively small
Malpresentations & malpositions
Lie - long axis of the fetus in relation to the long axis of the uterus (i.e. longitudinal, transverse or oblique)
Presentation - part of the fetus presenting to the pelvic inlet; normally with the vertex (any other is malpresentation - brow, face, breech)
Position - normally occipitotransverse at the the inlet and occipitoanterior at the outlet (other ones - malposition)
Any non-vertex presentation
From cephalic presentations - presenting diameter depends on the degree of flexion or extension
Vertex - 9.5 cm
Deflexed OP - 11.5 cm
Brow - 14 cm
Face - 9.5 cm
Moulding and caput are more likely to occur in malpresentation
If face is swollen easy to confuse with breech
Enters mentotransverse
Rotates 90º to mentoanterior
If mentoposterior - obstruction and C-section
Least favourable for delivery
If brow persists - C-section
40% - at 20 weeks
25% - at 32 weeks
3-4% - at term
Associated with multiple pregnancy, bicornuate uterus, fibroids, placenta previa, polyhydramnios and oligohydramnios
At term, 65% are breech extended
Footling breech - 5-20% risk of cord prolapse
Extended, flexed and footling
There is evidence that planned C-section is associated with less perinatal mortality and less serious neonatal morbidity than planned vaginal delivery
External cephalic version (ECV)
All uncomplicated breech pregnancies should be offered ECV at term
From 36 weeks in nulliparous; 37 weeks in multiparous
No point attempting ECV with significant placenta previa (C-section still needed)
Successful in parous women, presenting part is free, normal liquor volume, soft uterus, head easy to palpate
Give anti-D if rhesus negative
Success rate - 30% for primigravidae; 50% for parous women
All babies presenting by the breech should be examined for DDH and Klumpke's paralysis
Transverse and oblique lies - <1% at term
More common in multiparous women, multiple pregnancies, preterm labour and polyhydramnios
Can be associated with previa, uterine anomalies and lower uterine fibroids
If transverse lie - US to exclude causes
ECV is possible with a transverse lie
In transverse lie - if membranes rupture, admit to hospital because of risk of cord or arm prolapse
If in labour with a transverse lie - C-Section; vertical uterine incision may be required
Normal - enters the pelvis in OT (occipitotransverse) position and then rotates into the OA position
In 10% of pregnancies - enters in a OP than rotates into OT (deliver will arrest if it is OT at the outlet) or OA - more common in anthropoid pelvis
Associated with prolongued labour and relative cephalopelvic disproportion
Obstetric emergencies
Amniotic fluid embolism
Third highest cause of maternal death
Bolus of amniotic fluid enters the maternal circulation - moves to pulmonary circulation - perfusion failure, bronchospasm and shock
Commonly occurs in labour (70%), after vaginal delivery (11%) and following c-section (19%)
Risk Factors
Placental abruption
Intrauterine death
Precipitate labour
Suction TOP
Medical TOP
Abdominal trauma
Chills, shivering, sweating, anxiety and coughing

Cyanosis, hypotension, brochospasm, tachypnoea, tachycardia, arrhythmias, MI, seizures and DIC
Perinatal mortality is around 60% (baby) and most survivors have neurological deficit
Umbilical cord prolapse
Cord can remain in the vagina (occult prolapse) or can prolapse through the introitus with loops lying outside the vagina
Incidence is related to presentation - in footling breech presentation happens in 15-18% of cases
Risk factors
Preterm gestation
Placenta previa
Long umbilical cord
Artificial rupture of membranes
Second twin
Insults to the cord
Direct compression by fetal body
Cord spasm from cool external environment and excessive handling
Lead to cessation of fetal blood flow and fetal death
CTG - deep variable decelerations or a single prolonged one
If fetal heartbeat still present, deliver
If cervix fully dilated - forceps or ventouse; if not by immediate c-section
During transfer to theatre - head down position, knee-chest position or insert Foley catheter (fill bladder with 500 ml)
Give tocolytic to minimise contractions
Fetal mortality is around 10%
Retained placenta
Failure to deliver the placenta within 30 minutes of delivery of the fetus
Increases the risk of PPH by 10 - inability of the uterus to contract
2-3% of all vaginal deliveries - more likely in preterm gestations and after a previous c-section
When over-invasion occurs, the placenta becomes abnormally adherent and is referred to as placenta accreta
With bleeding - transfer to theatre and manual removal
No bleeding - conservative approach (wait) - syntocinon, rubbing up, breastfeeding - may aid expulsion
If still retained after 1h - theatre (regional or GA) - manual removal; after - contraction rubbed up, IV syntocinon + antiobiotics
Shoulder dystocia
The fetal anterior shoulder becomes impacted behind the symphysis pubis, preventing delivery
Risk factors
Past history of dystocia
Obese mother
High parity
Male fetus
Prolonged 1st and 2nd stage
Induction of labour
Forceps/ventouse delivery
Head is delivered as far as the chin
Head often retracts tightly around perineum and vulva - turtle sign
Cord occlusion - can lead to rapid fetal hypoxia and death
Estimated that 50% of deaths occur within 5 minutes
Brachial plexus damage can happen from excessive downward traction - C5-6 Erb's palsy, C7-TI Klumpke's palsy
Mnemonic 'HELPERR'
H - Help; E -Evaluate for episiotomy; L - Legs, McRoberts; P - pressure suprapubic; E - Enter (Wood's and reverse Wood's); R - Remove fetal arm; R - Roll over, all four
Uterine inversion
Occurs with active management of the third stage (iatrogenic), associated with cord traction before the uterus contracts
More likely with fundal placenta
Risk Factors
Previous history
Fundal placenta
Uterine atony
Improper management of 3rd stage
Bluish-grey mass protruding from the vagina
Extreme cases - vaginal eversion
Placenta remains attached in 50% of cases
90% immediate, potentially life-threatening haemorrhage
Resus (ABC)
Attempt to replace the uterus
Give oxytocics
O'Sullivan's hydrostatic techinique (warm fluid into the vagina)
Uterine rupture
Complete - uterine cavity communicates with peritoneal cavity
Incomplete or uterine dehiscence - uterine cavity separated from peritoneal cavity by the visceral peritoneum
Very uncommon in multiparous women who have had only vaginal deliveries and in primigravidae
If previous c-section was a classical (midline incision) - plan for early elective c-section
Risk factors
Antepartum rupture
External trauma
Classical c-section
Previous uterine surgery
Intrapartum rupture
Previous c-section
Oxytocin (multiparous)
Obstructed labour
Operative vag delivery
Shoulder dystocia
Breech extraction
Fetal compromise (in 70%)
Maternal tachycardia
Vaginal bleeding
Abdominal pain
Easily palpable fetal parts
ABC; immediate laparotomy to deliver the baby
Hysterectomy if severe
With complete rupture and expulsion of the fetus into abdominal cavity, perinatal mortality is close to 75%
Trophoblastic disease
Incidence of molar pregnancies is higher at the extremes of age, i.e. <15 years old - 1:30 and in late 40s 1:5
Production of hCG is always retained - helpful in establishing a diagnosis and in monitoring the response to treatment
HM - hydatidiform mole
Partial HM
Error in production of oocyte or at time of fertilization
A partial molar pregnancy has 69 chromosomes (23 from the mother and 46 from the father - from the entry of two sperm)
In partial molar pregnancy there is usually an embryo - seen on early US
Symptoms: vaginal bleeding, discharge, abdominal pain or excessive morning sickness
Risk of malignant change after a partial molar pregnancy is less than 1%
Pathology: Focal hyperplasia and swelling of villi
Most present as failed pregancies
Complete HM
Correct number of chromosomes, normally 46, XX
Made up solely by paternal genetic material
Either: 1) One sperm fertilises the egg, maternal genetic material is lost, paternal chromosomes duplicate - monospermic
2) One 'empty' egg is fertilised by two sperms - dispermic
Never fetal material
Pathology - generalised hyperplasia
Bunch of grapes macroscopic appearance - 2nd trimester
Without routine US - presents with large-for-dates uterus or with hyperemesis (rarely with thyrotoxicosis from excessive hCG)
10-15% of complete molar pregnancies become malignant - require chemotherapy after evacuation
Invasive mole
Invades into the myometrium
Presents with uterine mass and high hCG
Can lead to uterine rupture - abdominal pain and bleeding
Responds well to chemotherapy
US - snowstorm appearance
Malignant transformation of trophoblastic cells
Lack villous structure of the normal throphoblast or molar pregnancy
1:50 000
Presents with persistent vaginal bleeding and a very high hCG
Remember: commonly metastasises and can present with haemoptysis or dyspnoea (lung); neurological abnormalities (brain); chronic blood loss or melaena (GI); jaudice (liver); haematuria (kidney)
No specific risk factors!!!
Uterine evacuation
with complete HM - always surgical
with partial - medical may be possible
HCG follow-up after treatment to recognise potential malignancy (6 months)
Avoid pregnancy and OCP
1:75 risk of future molar pregnancy
If malignant - methotrexate
Psychiatric problems
'Postnatal blues'
50% of women get it
Starts at days 2-4, peaks at 4-6 and last for 2-7 days
Presents: emotional liability, tearfulness, sadness, sleep disturbance, poor concentration, restlessness and headaches
Reassurance and support
Postnatal depression
Incidence 10-25% in the first postnatal year
Peak onset weeks 3-4
2/3rds is self-limiting; 1/3 may be severe
Usual features of depression, but especially irritability, tiredness, decreased libido, guilt at not loving or caring enough for the baby, undue anxieties
Associated with past history of depression
Generally good outcome
Postnatal psychosis
1:500-1:800, beginning at days 3-7 and peaking at 2 weeks
One study: 5% commit suicide; 4% kill their baby
Mood abnormality is common
Delusions, hallucinations, confusion and cognitive impairment
Associated with past history of psychosis (esp manic depression), being unmarried, having a c-section, developing an infection or suffering a perinatal death
Prognosis is good, but 20% of those who become pregnant again recur; 50% will have another psychotic episode in their lives
Uterovaginal prolapse
Predisposing factors
Suprapubic surgery for urinary incontinence
Genetic (uncommon in african pop)
Plus: obesity, chronic cough and constipation
Urethrocele - descent of the anterior part of the vaginal which is fused with the urethra
Any descent of this tissue may alter the urethrovesical angle and disrupt the continence mechanism, predisposing to stress urinary incontinence
When present together are called cystourethrocele
Urinary symptoms - SUI, frequency, urgency
Uterus and cervix
Uterine prolapse
First degree - descent of the uterus and cervix within the vagina without reaching the introitus
Second degree - descent of the cervix to the level of the introitus
Third degree - cervix and uterus protrude out of the vagina
Procidentia - cervix, uterus and vaginal wall have prolapsed through the introitus - may lead to ulceration of the cervix and thickening of the vaginal mucosa
Symptoms - bleeding and discharge
Protrusion of the rectum into the lower posterior vaginal wall
Feeling of incomplete evacuation
Only type of vaginal prolapse that is truly a hernia
Protrusion of the peritoneum of the pouch of Douglas; may contain small bowel, or omentum
Presents as a lump; or abdominal discomfort
Non-specific symptoms
Dragging feeling
Backache - improves on lying down
'Something coming down'
Coital difficulties are uncommon
Over 50% of women with SUI have a significant cystourethrocele
Large cystocele - problems of incomplete emptying of the bladder - retained urine predisposes to recurrent UTIs
Pelvic floor exercises are not effective when prolapse is well established (value as prohphylaxis)

Pessaries - commonly used; sit behind the symphysis pubis and the posterior fornix; support the uterus and the vault of the vagina; may reduce a cystocele but not a rectocele; needs chaging every 4-6 months; complications - frequency, UTI, vaginal discharge, bleeding or fistulae (if neglected)
Anterior colporrhaphy
Used for anterior vaginal wall prolapse
Vaginal hysterectomy or Manchester repair
Vaginal hysterectomy - commonly used for uterine prolapse; may not always be possible due to a large uterus (fibroids)
Manchester repair - less commonly done that VH; uterosacral ligaments are shortened and the cervix is amputated; the body of the uterus is not removed
Posterior colpo-perineorrhaphy
Done for posterior vaginal wall prolapse
Total vault prolapse (after hysterectomy)
Complete eversion of the vagina after hysterectomy
Surgical options
sacrospinous fixation
vaginal mesh insertion
Urinary incotinence
10-20% of the adult female population are incontinent of urine on one or more occasion per month
Faecal impaction
Decreased mobility
Confusional states
Drugs i.e. diuretics and hypnotics
Stress urinary incontinence
Commonest cause of urinary incontinence in adult women - 60-70% of cases
Leakage occurs when there is a rise in intra-abdominal pressure without detrusor contraction - happens on coughing, sneezing and in severe cases on walking and rising from seating
Overactive bladder
Previously called detrusor instability
Occurs in response to involuntary detrusor contraction
Accounts for 30% of cases
Women experience urgency and if the contraction continues - incontinence
Can happen both day and night - complaints of frequency and nocturia and in severe cases enuresis
Retention with overflow
Only common in elderly female patients and in those with neurological problems
Communication between the lower urinary tract and the genital tract - continuous dribbling incontinence
Risk factors
Collagen disorder
Prolapse will coexist with stress incontinence in 50% of cases
Normalise fluid intake (1.5 L p/ day)
Reduce alcohol and caffeine
Lose weight if BMI>30
Stop smoking
Avoid carbonated drinks
Treat chronic constipation
Bladder retraining
Emptying her bladder to strict time schedule (initially hourly)
1st line treatment for incontinence caused by pelvic floor dysfunction (also some benefit to those with OAB)
Muscle training using pelvic floor exercises
Cure or improvement rates after physiotherapy as high as 60% have been noted
Drug therapy
OAB - antimuscarinics/anticholinergics
e.g. oxybutinin, darifenacin, solifenacin
50% of women will have 50% improvement
S.E. dry mouth, dizziness, nausea and constipation
SUI - oestrogens or duloxetine (SNRI)
Oestrogens should be prescribed to all menopausal women with SUI who are not on HRT
S.E. (duloxetine) - GI, dry mouth, headache and suicidal ideations
SUI - responds to minimally invasive procedures
e.g. anterior colporrhaphy (50% remain continent after 5 years); open colposuspension; laparoscopic colposuspension; conventional sling surgery; tension-free vaginal tape sling (TVT - method of choice nowadays; cure rate of 94% are reported); trans-obturator tape sling (TOT - newer procedure)
OAB - e.g. sacral nerve root stimulation, botulinum toxin A injections, detrusor myectomy, augmentation cystoplasty
Precipitate and slow labour
Spontaneous - 1:3000
Risk of fetal hypoxia - interference with placental blood supply
Uterine hyperstimulation - more common - caused by use of oxytocics
Max dose of syntocinon - 20mU/min
Can also happen with prostaglandin - less if PV than oral
Precipitate labour may predispose to uterine rupture in VBAC
Dependent on fetal condition
Stop syntocinon infusion + give tocolytics e.g terbutaline, iv ritodrine
If severe fetal distress - instrumental or cesarean delivery, depending of dilation of cervix
Note: frequent contractions (1 every 2 min) can be a feature of placental abruption - tocolytics are CONTRAINDICATED (may worsen bleeding)
Fetal distress and risk of fetal hypoxic injury
Increased risk of intrauterine infection leading to fetal and maternal morbidity
Prolonged latent phase
Before full dilation of the cervix
Unfavourable cervix - more common in primigravidae
Only do AROM or give oxytocics if cervix is at least 2 to 3 cm dilated and fully effaced and the presenting part is well applied
Prolonged active phase and 2º arrest
Inadequate uterine activity
Hypoactive uterus - sparse contractions that are not painful
Incoordinate uterus - inefficient contractions, pain felt earlier in contraction
More common in primigravidae
Cephalopelvic disproportion
"True" - presenting in optimal way, but head is too large - diagnosed only if the head does not become engaged despite adequate uterine activity
"Relative" - malpresentation or malposition of baby's head (brow and face); most common - when the head rotates to the OP rather the OA position - slow first and second stages and possible secondary arrest
In practice, whether to start a syntocinon infusion or not!
With CPD - caput (swelling of the scalp) and moulding (alteration in the relation of the fetal cranial bones)
Risks of syntocinon infusion
Hyperstimulation and fetal distress
Uterine rupture (multiparous and vbac)
In primigravidae
Start syntocinon unless brow presentation
After rupture of membranes
Aim for 3-4 contractions per 10 minutes
VE every 2-3 hours
If progress is inadequate - c-section
In parous women
If previous vaginal delivery, CPD is unlikely
Syntocinon started with caution in women with no evidence of obstruction
VE every 2-3 hours
Lower threshold for c-section
Primips - average length is 8h, should not exceed 18h
Multips - average length is 5h, should not exceed 12h
Full transcript