Obstetric Case Discussions

Obstetrics Case Discussions

This is your go-to place for mastering obstetric case discussions, made just for your exams. This page breaks down the most common and important pregnancy-related scenarios into easy-to-understand questions and answers. We focus on what examiners truly want you to know. You need to learn how to figure out what’s going on with both mom and baby. Understand what tests to order and why. Learn how to manage the situation safely. Be aware of what problems might arise. Start learning, and feel ready to ace your clinical exams with confidence!

Obstetrics Long Case: Placenta Previa

Patient Summary

A 33-year-old primigravida, diagnosed with Gestational Diabetes Mellitus (GDM) at 28 weeks, presents at 34+0 weeks of gestation with painless vaginal bleeding. An anomaly scan at 20 weeks revealed a low-lying placenta. She has no other significant medical history. Her GDM has been well-controlled with diet and Metformin. Fetal movements have been normal. She has no history of previous uterine surgery. The fetus is currently in breech presentation. This is her first episode of bleeding.

How would your history taking help you differentiate between potential causes, assess severity, and identify potential complications of her vaginal bleeding?

Given the presentation of painless vaginal bleeding in the third trimester with a known low-lying placenta, placenta previa is the most likely diagnosis. My history taking would focus on confirming this, differentiating it from other causes of antepartum hemorrhage (APH), assessing the severity of bleeding, and identifying potential complications for both mother and fetus.

Key Areas of Inquiry and Their Significance:

  • Character of Bleeding:
    • Onset: Was it sudden or gradual?
    • Pain: Is the bleeding associated with any abdominal pain or uterine contractions? Significance: Painless bleeding is characteristic of placenta previa. Painful bleeding, especially with a tense uterus, is highly suggestive of placental abruption.
    • Amount: Estimate the quantity of blood loss (e.g., soaking pads, passing clots). Significance: Assesses severity of current episode.
    • Color: Bright red vs. dark red. Significance: Bright red blood suggests fresh bleeding.
    • Recurrence: Is this the first episode, or has she had previous bleeding episodes? Significance: Recurrent episodes are common with placenta previa.
  • Risk Factors for Placenta Previa/Accreta:
    • Previous Uterine Surgery: History of prior Caesarean sections, myomectomy, or D&C. Significance: This is the strongest risk factor for placenta previa and dramatically increases the risk of placenta accreta spectrum (placenta abnormally adherent to the myometrium), which can lead to catastrophic hemorrhage. (Her current history states no prior surgery, which is reassuring, but it’s important to ask systematically).
    • Multiparity: Increased number of previous pregnancies. (She is a primigravida, so this risk is lower for her).
    • Assisted Reproductive Technology (ART): History of IVF or other fertility treatments.
    • Maternal Age: Advanced maternal age. (She is 33, so moderately relevant).
    • Smoking: Inquire about smoking.
  • Fetal Well-being:
    • Fetal Movements: Any perceived reduction or absence of fetal movements? Significance: Reduced movements could indicate fetal distress due to acute blood loss or hypoxia.
    • Fluid Leakage: Any gush of fluid prior to or with the bleeding? Significance: Could indicate ruptured membranes, which can lead to vasa previa (fetal vessel rupture).
  • Associated Symptoms: Inquire about symptoms of shock (dizziness, faintness, pallor, thirst). Significance: Indicates severe blood loss.
  • Gynaecological History: Any history of cervical polyps, cervicitis, or carcinoma that could cause bleeding. Significance: These are local causes of APH, usually less severe.
Source: Obstetrics by Ten Teachers, 21st Edition, Chapter 6, 14. Eranthi Samarakoon, A Guide to the Clinical Examination in Obstetrics & Gynaecology, for Undergraduates and Postgraduates, Chapter 18, 32.
What specific findings would you look for on clinical examination and what is their significance?

The examination aims to assess the severity of bleeding, evaluate maternal hemodynamic stability, confirm the placental location (if possible clinically), and assess fetal well-being, while strictly avoiding internal vaginal examination if placenta previa is suspected.

Clinical Examination Findings and Their Significance:

  • General Examination:
    • Vital Signs:
      • Pulse Rate: Tachycardia (e.g., >100 bpm) is an early sign of hypovolemia.
      • Blood Pressure: Hypotension (e.g., <90/60 mmHg or a significant drop from baseline) is a later sign of shock.
      • Respiratory Rate: Tachypnoea may indicate shock or pain.
      • Capillary Refill Time (CRT): Prolonged CRT (>2 seconds) indicates poor peripheral perfusion.
      Significance: Provides a rapid assessment of maternal hemodynamic stability and the severity of blood loss. Young, healthy women may compensate well, so minimal changes in vital signs should not be reassuring in the face of significant bleeding.
    • Pallor: Assess for pallor of mucous membranes (conjunctiva, oral mucosa). Significance: Suggests anemia due to blood loss.
    • Consciousness: Assess level of consciousness, restlessness, or anxiety. Significance: Signs of hypovolemic shock.
  • Abdominal Examination:
    • Uterine Tone and Tenderness: Gently palpate the uterus for tone (soft vs. tense/rigid) and tenderness. Significance: A soft, non-tender uterus is typical of placenta previa. A tense, rigid, and tender uterus is characteristic of placental abruption.
    • Fetal Presentation and Lie: Determine. Significance: Malpresentations (like breech, which is present in her case) are more common with placenta previa due to the placenta occupying the lower uterine segment.
    • Fetal Heart Sounds (FHS)/Cardiotocography (CTG): Auscultate FHS or apply CTG. Significance: To assess fetal well-being. Any abnormal FHR patterns (e.g., decelerations, bradycardia) suggest fetal distress and prompt urgent intervention.
    • Symphysis-Fundal Height (SFH): Measure. Significance: May be inaccurate in cases of significant bleeding.
  • Perineal Inspection (External Visual Examination Only):
    • Vaginal Bleeding: Inspect for the amount and character (colour) of external bleeding. Look for clots or amniotic fluid. Significance: Quantifies visible blood loss.
    • NEVER perform a digital vaginal examination if placenta previa is suspected or not ruled out by ultrasound. Significance: Digital examination can directly cause massive, life-threatening hemorrhage by disrupting the placental implantation site.
    • Speculum examination: Can be performed to identify a local cause of bleeding (e.g., cervical polyp, cervicitis, or vasa previa if membranes have ruptured and fetal vessels are seen), but ONLY after a recent ultrasound confirms no placenta previa.
Source: Obstetrics by Ten Teachers, 21st Edition, Chapters 1, 6, 14. Eranthi Samarakoon, A Guide to the Clinical Examination in Obstetrics & Gynaecology, for Undergraduates and Postgraduates, Chapter 18, 32. NICE guideline [NG133] – Hypertension in pregnancy: diagnosis and management.
How would you classify the type of placenta previa and assess its severity?

The type of placenta previa is determined by the relationship of the placental edge to the internal cervical os, typically diagnosed by transvaginal ultrasound at around 32-34 weeks gestation. The severity is assessed by the degree of bleeding and its impact on maternal and fetal well-being.

Classification of Placenta Previa (based on Transvaginal Ultrasound):

At 20 weeks, a “low-lying placenta” is diagnosed if the placental edge is within 20mm of the internal os. Most of these “migrate” upwards as the lower uterine segment forms and stretches. Reassessment at 32-34 weeks is crucial to confirm the definitive type:

  • Low-lying Placenta: Placental edge within 20 mm of the internal os but not covering it. (Some guidelines use 20mm, others 20-25mm).
  • Minor/Partial Placenta Previa: Placenta partially covers the internal os when the cervix is closed.
  • Major/Complete Placenta Previa: Placenta completely covers the internal os.

Given her presentation at 34+0 weeks with bleeding, her low-lying placenta previously identified at 20 weeks is now considered a potential placenta previa. The definitive type needs to be confirmed by a current ultrasound scan.

Assessment of Severity:

The severity of placenta previa is primarily determined by the amount and nature of vaginal bleeding and its impact on maternal and fetal stability, rather than solely by the ultrasound classification.

  • Severity of Bleeding:
    • Mild: Small amount of bleeding (spotting to <500ml), no maternal hemodynamic compromise.
    • Moderate: Significant bleeding (500-1000ml), some maternal symptoms (tachycardia, mild hypotension).
    • Severe/Massive: Heavy, ongoing bleeding (>1000ml or rapid blood loss), signs of maternal shock (marked tachycardia, hypotension, pallor, restlessness, altered consciousness). This is life-threatening.
  • Maternal Condition:
    • Stable vital signs vs. signs of hypovolemic shock.
    • Need for blood transfusion.
    • Development of coagulopathy (DIC).
  • Fetal Condition:
    • Reassuring CTG vs. signs of fetal distress (e.g., decelerations, bradycardia). Fetal compromise is less common in placenta previa unless there’s massive maternal hemorrhage leading to fetal hypoxia.
  • Presence of Contractions: Bleeding in placenta previa can trigger uterine contractions, which can worsen bleeding significantly as the cervix dilates.
  • Associated Conditions:
    • Placenta Accreta Spectrum (PAS): Suspect if she has a history of previous uterine surgery (which she does not, but this would be a major concern if present). This is a life-threatening complication where the placenta is abnormally adherent to the uterine wall.

Her current presentation with “painless vaginal bleeding” needs quantification to assess severity. Even “mild” bleeding can escalate rapidly in placenta previa.

Source: Obstetrics by Ten Teachers, 21st Edition, Chapters 6, 14. Eranthi Samarakoon, A Guide to the Clinical Examination in Obstetrics & Gynaecology, for Undergraduates and Postgraduates, Chapter 18. RCOG Green-top Guideline No. 27a – Placenta praevia and placenta accreta: diagnosis and management.
How would you investigate this patient?

The investigations are crucial for confirming placenta previa, assessing the current bleeding episode’s severity, evaluating maternal and fetal well-being, and preparing for potential urgent delivery.

1. Immediate Investigations (STAT on admission for APH):

  • Transabdominal and Transvaginal Ultrasound Scan (USS):
    • Purpose: This is the most critical investigation. It will definitively confirm the placental location relative to the internal os and classify the type of placenta previa. Transvaginal scan is superior for posterior placentas and for accurately measuring the placental edge distance from the os.
    • Fetal Assessment: Assess fetal biometry (growth), amniotic fluid volume, and presentation (confirm breech).
    • Exclude Abruption: Look for retroplacental clot, though abruption is primarily a clinical diagnosis.
    • Assess for Placenta Accreta Spectrum (PAS): While she has no prior C-section, specific USS signs (e.g., loss of clear zone, placental lacunae, hypervascularity) should be sought if clinical suspicion arises (e.g., profuse bleeding with history of D&C, or manual removal of placenta in previous pregnancies).
  • Cardiotocography (CTG): Immediate continuous CTG to assess fetal well-being. Look for baseline rate, variability, accelerations, and especially decelerations or sinusoidal pattern (suggesting fetal anemia due to vasa previa rupture, though less likely with painless bleeding unless membranes are ruptured).
  • Full Blood Count (FBC):
    • Haemoglobin (Hb) & Haematocrit: To assess current anemia and the extent of blood loss.
    • Platelet Count: Essential, as coagulopathy can develop with massive hemorrhage.
  • Blood Group & Cross-match: Obtain blood group and cross-match 4-6 units of packed red blood cells immediately, given the high risk of massive hemorrhage.
  • Coagulation Profile (PT, APTT, Fibrinogen): Essential, especially with significant bleeding or if DIC is suspected.
  • Kleihauer Test: If she is Rhesus D negative (her blood group is not specified, but it’s a routine investigation). Significance: To detect feto-maternal hemorrhage and determine the dose of anti-D immunoglobulin needed post-bleeding, as fetal blood can cross into maternal circulation.

2. Other Investigations (as indicated):

  • Urinalysis: To rule out UTI, especially if any dysuria or frequency is reported.
  • Blood Glucose Monitoring: Continue close monitoring for her GDM, as stress from bleeding can affect glycemic control.
  • Infection Screen: If fever or signs of infection (e.g. vaginal discharge) are present.
Source: Obstetrics by Ten Teachers, 21st Edition, Chapters 4, 6, 14. Eranthi Samarakoon, A Guide to the Clinical Examination in Obstetrics & Gynaecology, for Undergraduates and Postgraduates, Chapter 18, 32. NICE guideline [NG133] – Hypertension in pregnancy: diagnosis and management. RCOG Green-top Guideline No. 27a – Placenta praevia and placenta accreta: diagnosis and management.
What is your management plan for this patient, considering her gestation and clinical picture?

My management plan prioritizes immediate maternal and fetal safety, management of the current bleeding episode, planning for future management, and safe delivery, all while avoiding digital vaginal examination.

1. Immediate Actions (on Admission for APH):

  • Call for Senior Help: Immediately involve the Consultant Obstetrician, Senior Registrar, and Senior Midwife. Alert the Anaesthetist and Neonatologist.
  • Resuscitation and Monitoring:
    • ABC: Ensure patent airway, provide high-flow oxygen (10-15 L/min via face mask) if hypoxemic.
    • IV Access: Establish two large-bore intravenous cannulae (14-16 gauge) for rapid fluid/blood administration.
    • Fluid Resuscitation: Begin rapid infusion of intravenous crystalloids (e.g., Hartman’s solution) while awaiting blood.
    • Monitoring: Continuous maternal vital signs (BP, pulse, RR, SpO2) and continuous CTG for fetal well-being.
    • No Vaginal Examination: Strictly forbid digital vaginal examination until placenta previa is definitively ruled out by ultrasound.

2. Management of Bleeding Episode (after stabilization):

  • Conservative Management (if bleeding is mild and settles, and fetus is stable):
    • Inpatient Observation: Admit the patient to the antenatal ward for continuous observation.
    • Expectant Management: Aim to prolong the pregnancy to improve fetal maturity.
    • Antenatal Corticosteroids: Administer a course of corticosteroids (e.g., Dexamethasone 6mg IM 12 hourly for 4 doses) to promote fetal lung maturation, as she is <34+6 weeks and likely to deliver preterm.
    • Anti-D Immunoglobulin: If she is Rhesus D negative and Kleihauer test results indicate feto-maternal hemorrhage.
    • Bed Rest: Relative bed rest; advise against intercourse.
    • Serial Monitoring: Regular FBC, coagulation profile, and CTG monitoring.
  • Active Management (if bleeding is heavy, persistent, or recurs, or fetal/maternal compromise):
    • Proceed directly to delivery.

3. Definitive Management & Delivery Planning:

  • Confirmed Placenta Previa (after USS): Once placenta previa is confirmed, vaginal delivery is contraindicated for major placenta previa due to the high risk of catastrophic hemorrhage. LSCS is the safest mode of delivery.
  • Timing of Delivery:
    • Elective LSCS: For asymptomatic or minimally bleeding patients with a confirmed placenta previa, elective LSCS is typically planned between 36+0 and 37+0 weeks of gestation (after completion of corticosteroid course if not already given). This allows for maximal fetal maturity while minimizing the risk of spontaneous labor or severe bleeding.
    • Emergency LSCS: If bleeding is heavy, persistent, or recurs, or if there’s any sign of maternal compromise or fetal distress (e.g., abnormal CTG, suspected abruption), an emergency LSCS is indicated immediately, regardless of gestation.
  • Pre-operative Preparation for LSCS:
    • Informed Consent: Detailed discussion and consent for LSCS, including the possibility of massive hemorrhage, blood transfusion, and very rarely, a hysterectomy (especially if placenta accreta spectrum is suspected).
    • Fasting: Nil by mouth for at least 6 hours (solids) and 2 hours (clear fluids).
    • Cross-matched Blood: Ensure adequate units (at least 4-6) are readily available in the theatre.
    • IV Access: Ensure adequate large-bore IV access.
    • Anaesthetic Assessment: Senior anaesthetist to assess for regional (spinal/epidural) vs. general anaesthesia, considering her condition. Regional is preferred if safe.
    • Prophylactic Antibiotics: Administer pre-operatively.
    • Foley Catheter: Inserted prior to surgery.
  • Management during LSCS (Crucial due to hemorrhage risk):
    • Careful Uterine Incision: A high vertical uterine incision might be considered if the placenta is anterior and obstructing the lower segment, to avoid cutting through the placenta.
    • Hemorrhage Control: Be prepared for massive hemorrhage. Active management of the third stage. Have uterotonics (Oxytocin, Carboprost, Misoprostol) readily available. Manual removal of the placenta should be done with extreme caution.
    • Surgical Hemostasis Techniques: Be ready for B-Lynch sutures, uterine artery ligation, internal iliac artery ligation, or, as a last resort, hysterectomy to control bleeding.
    • Neonatal Team: Neonatologist should be present at delivery, especially given preterm gestation and potential GDM complications.

4. Postnatal Management:

  • Maternal Monitoring: Close monitoring for PPH, especially for the first 24 hours. Monitor vital signs and fluid balance.
  • GDM Management: Continue to monitor blood glucose levels, adjusting Metformin or insulin as needed. Counsel on post-delivery screening for Type 2 DM.
  • Contraception: Counsel on safe contraception, emphasizing options that do not increase VTE risk.
  • Long-term Counselling: Discuss risk of recurrence in future pregnancies and implications of previous complications.
Source: Obstetrics by Ten Teachers, 21st Edition, Chapters 6, 7, 9, 12, 13, 14, 15. Eranthi Samarakoon, A Guide to the Clinical Examination in Obstetrics & Gynaecology, for Undergraduates and Postgraduates, Chapter 18, 19, 21. NICE guideline [NG133] – Hypertension in pregnancy: diagnosis and management. RCOG Green-top Guideline No. 27a – Placenta praevia and placenta accreta: diagnosis and management.
What are the potential complications for both mother and fetus in this case?

Placenta previa, especially with bleeding, carries significant risks for both the mother and the fetus. Her GDM and breech presentation add to the complexity.

Maternal Complications:

  • Massive Antepartum Hemorrhage (APH): The most significant risk. Bleeding can be sudden, heavy, and life-threatening, leading to hypovolemic shock, DIC, and maternal death.
  • Postpartum Haemorrhage (PPH): Increased risk due to:
    • Large placental bed in the lower segment which contracts poorly.
    • Possible placenta accreta spectrum (though lower risk without prior uterine surgery).
    • Need for emergency LSCS.
  • Placenta Accreta Spectrum (PAS): While she is a primigravida without previous uterine surgery, there’s always a theoretical risk, and if present, it can lead to massive hemorrhage and necessitate hysterectomy.
  • Increased Risk of Caesarean Section: Vaginal delivery is contraindicated for complete placenta previa. Her breech presentation also necessitates a C-section.
  • Blood Transfusion: High likelihood due to significant blood loss.
  • Complications of LSCS: All general surgical risks (infection, DVT/PE, organ injury, longer recovery).
  • Anesthetic Complications: Increased risk with emergency procedures or massive blood loss.
  • Psychological Impact: Anxiety and stress from bleeding episodes and uncertainty.

Fetal/Neonatal Complications:

  • Preterm Birth: Most common complication, often iatrogenic, due to bleeding necessitating early delivery. She is already at 34+0 weeks, which is preterm.
  • Fetal Distress/Hypoxia: Can occur due to severe maternal hypovolemia, placental abruption (less likely if painless), or if there is unrecognized vasa previa with fetal vessel rupture.
  • Neonatal Morbidities of Prematurity: If delivered preterm, the baby is at risk for:
    • Respiratory Distress Syndrome (RDS) due to immature lungs.
    • Intraventricular Haemorrhage (IVH).
    • Necrotizing Enterocolitis (NEC).
    • Neonatal jaundice.
    • Increased risk of NICU admission.
  • Vasa Previa: If undetected, rupture of fetal vessels (vasa previa) can occur, leading to rapid fetal exsanguination and high rates of fetal death.
  • Complications of Breech Presentation: While planned C-section mitigates risks of vaginal breech delivery, the presentation itself is a deviation from normal.
  • GDM-related neonatal complications: Despite her well-controlled GDM, her baby is still at risk of neonatal hypoglycemia, macrosomia, and jaundice.
  • Stillbirth/Intrauterine Death (IUD): The most severe fetal outcome, particularly with massive hemorrhage or undetected vasa previa.
Source: Obstetrics by Ten Teachers, 21st Edition, Chapters 3, 6, 7, 14, 15. Eranthi Samarakoon, A Guide to the Clinical Examination in Obstetrics & Gynaecology, for Undergraduates and Postgraduates, Chapter 18, 32. RCOG Green-top Guideline No. 27a – Placenta praevia and placenta accreta: diagnosis and management.
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Obstetrics Long Case: Severe/Complicated Hypertension in Pregnancy

Patient Summary

A 42-year-old G5P3 presents at 36+1 weeks of gestation with a complicated pregnancy. She has a history of chronic hypertension, for which she is on Nifedipine, and Gestational Diabetes Mellitus (GDM) managed with Metformin. Her past obstetric history includes three previous preterm labours with neonatal jaundice and NICU admissions, and two prior Caesarean sections. Her pre-pregnancy BMI was high. She is currently admitted with severe pre-eclampsia, complaining of a persistent headache and blurring of vision. Her current BP is 180/110 mmHg. She also has known anemia and a recent UTI. Her last pregnancy was complicated by polyhydramnios and macrosomia. She is scheduled for a Caesarean section tomorrow due to a history of two previous sections.

How would your history taking help you differentiate between potential causes, assess severity, and identify potential complications of her hypertension?

In a patient with pre-existing chronic hypertension and multiple comorbidities, a new presentation of severe hypertension requires immediate differentiation between worsening chronic hypertension, superimposed pre-eclampsia, or an acute hypertensive crisis from another cause. My history taking would focus on these distinctions, assessing severity, and identifying complications.

Key Areas of Inquiry and Their Significance:

  • Presenting Complaint Analysis (SOCRATES for symptoms):
    • Headache and Visual Disturbances: Character, onset, progression, associated symptoms (e.g., photophobia, scotomata, temporary blindness). Significance: These are classic “red flags” for severe pre-eclampsia or impending eclampsia, indicating cerebral irritation. Their acuity and severity are critical.
    • Epigastric or Right Upper Quadrant Pain: Character, severity, radiation, association with nausea or vomiting. Significance: Suggests liver involvement, a severe feature and component of HELLP syndrome.
    • Reduced Urine Output or Generalised Swelling: Inquire about changes in micturition frequency and volume, and any sudden increase in swelling, especially of hands and face. Significance: Indicates renal dysfunction and fluid retention, worsening pre-eclampsia.
  • Chronic Hypertension History:
    • Baseline Control: How well was her chronic hypertension controlled prior to and during pregnancy (last BP readings, medication adherence, dosage changes)? Significance: A sudden worsening suggests superimposed pre-eclampsia.
    • Known Etiology: Was her chronic hypertension investigated (e.g., for renal artery stenosis, primary aldosteronism)? Significance: Some secondary causes can have specific implications in pregnancy.
    • Complications: Any history of end-organ damage from chronic hypertension (e.g., cardiac, renal, retinal)? Significance: These patients are at higher risk for severe superimposed pre-eclampsia and specific management is needed.
  • GDM and DM Management:
    • Glycemic Control: Her current metformin dose, recent blood sugar readings (FBS, PPBS), HbA1c. Any hypoglycemic or hyperglycemic episodes? Significance: Poorly controlled diabetes can exacerbate hypertension and increase fetal risk.
    • Diabetic Complications: Inquire about retinopathy, nephropathy, or neuropathy. Significance: Pre-existing microvascular disease increases the risk of severe pre-eclampsia.
  • Previous Preterm Labours and Neonatal Outcomes: Detailed history of the reasons for preterm labour (e.g., PPROM, abruption, severe PIH), gestation at delivery, and specifics of neonatal complications (e.g., RDS, IVH, NEC). Significance: Recurrent preterm labour points to chronic uteroplacental insufficiency, increasing suspicion for FGR and severe pre-eclampsia.
  • Previous Caesarean Sections (2 sections): Indications for previous sections, type of uterine incision (lower segment vs. classical), intra-operative complications (e.g., extensions, excessive bleeding). Significance: Increased risk of placenta previa/accreta, uterine rupture (especially with a history of augmentation or short inter-delivery interval), and adhesions in future deliveries.
  • Fetal Well-being: Has she perceived normal fetal movements? Any changes? Significance: Essential for assessing fetal status.
  • Current Medications: Review all current medications and their doses, especially antihypertensives (Nifedipine), anti-diabetics (Metformin), and any other drugs (e.g., iron for anemia, antibiotics for UTI). Significance: To ensure appropriate dosing and check for contraindications or side effects.
  • Infection (UTI): Current symptoms (dysuria, frequency, flank pain, fever) and response to antibiotics. Significance: Infection can trigger or worsen hypertensive disorders and should be aggressively managed.
  • Social History: Support systems, living situation, adherence challenges (e.g., due to depression). Significance: Complex social factors can impact medical management and compliance.
Source: Obstetrics by Ten Teachers, 21st Edition, Chapters 1, 9, 10, 11, 12, 14. Eranthi Samarakoon, A Guide to the Clinical Examination in Obstetrics & Gynaecology, for Undergraduates and Postgraduates, Chapter 5. NICE guideline [NG133] – Hypertension in pregnancy: diagnosis and management.
What specific findings would you look for on clinical examination and what is their significance?

The examination aims to assess the patient’s overall clinical status, confirm the severity of hypertension, and identify signs of maternal end-organ damage and fetal compromise, especially in the context of severe pre-eclampsia.

Clinical Examination Findings and Their Significance:

  • General Examination:
    • Vital Signs:
      • Blood Pressure (BP): Re-measure and confirm. Her current BP of 180/110 mmHg is classified as severe hypertension. Significance: Immediate confirmation of severe hypertension mandates urgent intervention to prevent cerebrovascular events.
      • Pulse Rate: Assess for tachycardia. Significance: Tachycardia can indicate hypovolemia (e.g., concealed abruption), sepsis, or cardiac compromise.
      • Respiratory Rate: Assess. Significance: Tachypnoea (RR >20/min) could suggest pulmonary oedema, fluid overload, or severe metabolic acidosis.
      • Temperature: Her history includes UTI. Significance: Pyrexia could indicate worsening UTI, chorioamnionitis, or other infections that can exacerbate pre-eclampsia.
    • Oedema: Assess for extent and distribution. Pay close attention to non-dependent oedema (face, hands). Significance: While common, sudden onset or severe generalised oedema can indicate severe pre-eclampsia.
    • Pallor: Check for pallor of mucous membranes. Significance: May suggest worsening anemia or acute blood loss.
    • Icterus/Jaundice: Inspect sclera. Significance: Could indicate severe haemolysis or liver dysfunction (e.g., HELLP syndrome).
  • Abdominal Examination:
    • Uterine Tone and Tenderness: Palpate for uterine tenderness or rigidity. Significance: Essential to rule out placental abruption, a dangerous complication of severe hypertension.
    • Organomegaly: Palpate for liver tenderness or hepatomegaly. Significance: Epigastric tenderness or liver enlargement may indicate liver involvement (HELLP syndrome).
    • Fetal Assessment:
      • Symphysis-Fundal Height (SFH): Measure. Significance: To assess fetal growth. Given her history of FGR in previous pregnancies and current GDM, FGR is a concern.
      • Fetal Lie and Presentation: Determine. Significance: Essential for planning delivery.
      • Fetal Heart Sounds (FHS): Auscultate. Significance: Provides a rapid assessment of fetal well-being. Any abnormalities (e.g., bradycardia, tachycardia, decelerations) require immediate attention.
  • Neurological Examination:
    • Deep Tendon Reflexes: Elicit, particularly patellar reflexes. Check for ankle clonus. Significance: Hyperreflexia or sustained clonus (>3 beats) is a critical sign of CNS irritability and impending eclampsia.
    • Fundoscopy: Examine the optic fundi for papilloedema, retinal haemorrhages, or vascular changes. Significance: Direct visualization of hypertensive retinopathy, indicating severe end-organ damage and increased risk of stroke.
    • Level of Consciousness: Assess for confusion, drowsiness, or altered mental state. Significance: Signs of severe cerebral oedema or impending eclampsia.
  • Vaginal Examination (if indicated and safe):
    • Speculum Examination: To assess for vaginal bleeding (e.g., from abruption) or foul-smelling discharge (e.g., chorioamnionitis).
    • Digital Examination: To assess cervical status if labour is suspected or induction is planned. However, it should be approached with caution in the presence of severe pre-eclampsia or suspected abruption.
Source: Obstetrics by Ten Teachers, 21st Edition, Chapters 1, 9, 14. Eranthi Samarakoon, A Guide to the Clinical Examination in Obstetrics & Gynaecology, for Undergraduates and Postgraduates, Chapter 5. NICE guideline [NG133] – Hypertension in pregnancy: diagnosis and management.
How would you classify the severity of her condition?

Her condition can be classified as Severe Pre-eclampsia.

Justification:

  • Severe Hypertension: Her current blood pressure is 180/110 mmHg. [cite_start]According to NICE guidelines, a BP of ≥160/110 mmHg defines severe hypertension[cite: 9].
  • Symptoms of Severe Pre-eclampsia: She complains of a persistent headache and blurring of vision. These are classic “red flag” symptoms indicative of severe pre-eclampsia, suggesting cerebral irritation or involvement, and are considered signs of impending eclampsia.
  • Multisystem Involvement/Risk Factors:
      [cite_start]
    • Chronic Hypertension: Pre-existing hypertension increases the risk of superimposed pre-eclampsia and is itself a high-risk factor for adverse maternal and fetal outcomes[cite: 9].
      • [cite_start]
    • Gestational Diabetes Mellitus (GDM): Diabetes in pregnancy (both pre-existing and GDM) increases the risk of pre-eclampsia[cite: 9, 10].
      • [cite_start]
    • Previous Preterm Labours: A history of recurrent preterm deliveries suggests underlying uteroplacental insufficiency, which is the root cause of pre-eclampsia[cite: 8].
      • [cite_start]
    • High Pre-pregnancy BMI: Obesity (BMI ≥30 kg/m2) is a moderate risk factor for pre-eclampsia[cite: 9].
      • [cite_start]
    • Advanced Maternal Age (42 years): Age ≥40 years is a moderate risk factor for pre-eclampsia[cite: 9].
    • Anemia & UTI: While not direct criteria for pre-eclampsia, these comorbidities can complicate the clinical picture and management, and systemic infection can trigger or worsen pre-eclampsia.

The combination of severe hypertension and symptoms of impending eclampsia in a patient with multiple high-risk factors firmly places her in the category of Severe Pre-eclampsia, requiring urgent and intensive management.

Source: Obstetrics by Ten Teachers, 21st Edition, Chapters 8, 9, 10. Eranthi Samarakoon, A Guide to the Clinical Examination in Obstetrics & Gynaecology, for Undergraduates and Postgraduates, Chapter 5. NICE guideline [NG133] – Hypertension in pregnancy: diagnosis and management.
How would you investigate this patient?

Given the diagnosis of severe pre-eclampsia, the investigations are critical for confirming end-organ involvement, assessing severity, guiding management, and continuously monitoring both maternal and fetal well-being.

1. Maternal Laboratory Investigations (STAT & Ongoing):

  • Full Blood Count (FBC):
    • Haemoglobin (Hb) & Haematocrit: To assess for anaemia (which she is known to have) and haemoconcentration.
    • Platelet Count: Essential. A count <150 x 109/L is a feature of pre-eclampsia; [cite_start]<100 x 109/L indicates severe disease and raises suspicion for HELLP syndrome[cite: 9].
  • Renal Function Tests (RFTs):
    • Serum Creatinine & Urea: To assess kidney function. [cite_start]A creatinine >90 µmol/L (1.02 mg/dL) indicates renal insufficiency[cite: 9].
    • Uric Acid: Often elevated in pre-eclampsia due to impaired renal clearance.
    • Proteinuria Quantification (Spot Urine P:Cr or A:Cr): To confirm and quantify proteinuria. [cite_start]P:Cr >30 mg/mmol is significant[cite: 9].
  • Liver Function Tests (LFTs):
    • AST/ALT (Transaminases) & Bilirubin: To assess for liver involvement (elevated transaminases >70 IU/L are a component of HELLP syndrome).
    • LDH (Lactate Dehydrogenase): To assess for haemolysis, another component of HELLP syndrome.
  • Coagulation Profile (PT, APTT, Fibrinogen): Mandatory with severe pre-eclampsia, especially if platelet count is low, or if there’s suspicion of DIC or HELLP syndrome. This guides decisions regarding regional anesthesia and management of potential hemorrhage.
  • Blood Glucose: Monitor closely, especially with her history of GDM.
  • Inflammatory Markers (CRP): To monitor her UTI and for any other signs of infection, as infection can exacerbate her condition.

2. Fetal Assessment:

    [cite_start]
  • Continuous Cardiotocography (CTG): Mandatory and continuous to monitor fetal well-being due to severe maternal condition and risk of uteroplacental insufficiency[cite: 9]. Look for fetal tachycardia, reduced variability, and decelerations, which indicate fetal hypoxia.
  • Ultrasound Scan (USS) & Doppler Studies:
    • Fetal Biometry: To assess growth and identify Fetal Growth Restriction (FGR), common in severe pre-eclampsia.
      • [cite_start]
    • Amniotic Fluid Volume (AFV): To assess for oligohydramnios, indicating uteroplacental insufficiency[cite: 4].
    • Doppler Velocimetry: Umbilical Artery Doppler (to assess placental resistance, looking for absent or reversed end-diastolic flow), Middle Cerebral Artery (MCA) Doppler (to assess for cerebral sparing), and Ductus Venosus (DV) Doppler (an indicator of severe compromise and impending fetal death).

3. Pre-operative/Fitness for Surgery Investigations (Given scheduled LSCS):

  • ECG: To assess cardiac fitness for surgery, especially given her age and long-standing hypertension.
  • Chest X-ray: To assess for pulmonary oedema or other respiratory issues if symptomatic.
  • Cross-match Blood: At least 4-6 units due to high risk of hemorrhage (pre-eclampsia, previous sections, potential placenta accreta).

4. Imaging for Complications (if symptoms worsen/new symptoms appear):

  • Brain MRI/CT: If neurological symptoms worsen (e.g., severe refractory headache, new focal neurological deficits, seizures).
  • Abdominal USS/CT: If there is suspicion of placental abruption (retroplacental clot), worsening HELLP (subcapsular hematoma), or other acute abdominal pathology.
Source: Obstetrics by Ten Teachers, 21st Edition, Chapters 4, 9, 14. Eranthi Samarakoon, A Guide to the Clinical Examination in Obstetrics & Gynaecology, for Undergraduates and Postgraduates, Chapter 5, 21. NICE guideline [NG133] – Hypertension in pregnancy: diagnosis and management.
What is your management plan for this patient, considering her gestation and clinical picture?

My management plan is to prioritize immediate maternal stabilization and fetal well-being assessment, followed by timely delivery. Given her severe pre-eclampsia, multiple comorbidities, and scheduled Caesarean section, this is a high-acuity case requiring a multidisciplinary approach.

1. Immediate Maternal Stabilization (Hospital Admission to High Dependency Unit/Labour Ward):

  • Call for Senior Help: Immediately involve the Consultant Obstetrician, Senior Anaesthetist, Neonatologist, and Haematologist. This is a medical emergency.
  • Resuscitation and Monitoring:
    • Airway, Breathing, Circulation (ABC): Ensure patent airway, provide high-flow oxygen (10-15 L/min via face mask). Establish two large-bore intravenous cannulae (14-16 gauge).
    • BP Monitoring: Continuous BP monitoring (e.g., every 5 minutes until controlled, then every 15-30 minutes). Document on MEOWS chart.
    • Fluid Balance: Insert a Foley catheter for strict hourly urine output monitoring. Restrict fluid input to avoid fluid overload (e.g., 80 mL/hour or 1 mL/kg/hour) unless otherwise indicated for resuscitation.
  • Pharmacological Management for Severe Hypertension:
    • Urgent BP Lowering: Initiate intravenous antihypertensive drugs immediately to lower BP to <150/100 mmHg.
      • Labetalol: 20 mg IV bolus, repeat 40 mg, then 80 mg every 10-20 minutes, up to a maximum of 300 mg. Avoid in asthma/cardiac failure.
      • Hydralazine: 5 mg IV bolus, repeat 5-10 mg every 20-30 minutes. Provide 5 mL/kg 0.9% saline concurrently to prevent sudden hypotension.
      • Nifedipine: 10 mg oral/sublingual, repeated every 30 minutes (caution if patient has severe headache).
    • Seizure Prophylaxis (Magnesium Sulphate): Administer IV Magnesium Sulphate as soon as possible, as she has severe pre-eclampsia with headache and visual disturbances (impending eclampsia).
      • Loading Dose: 4g IV over 5-20 minutes.
      • Maintenance Dose: 1g/hour IV infusion for at least 24 hours after delivery or the last seizure.
      • Monitoring for Toxicity: Hourly assessment of patellar reflexes (first sign of toxicity), respiratory rate, and urine output. Have Calcium Gluconate 10% (10 mL IV slowly) readily available as an antidote.

2. Fetal Assessment and Monitoring:

  • Continuous CTG: Essential for continuous monitoring of fetal well-being, looking for signs of distress (e.g., bradycardia, severe decelerations, reduced variability).
  • Ultrasound & Doppler: Perform or review recent scans for fetal growth (FGR likely), amniotic fluid volume (oligohydramnios likely), and Doppler studies (umbilical, MCA, DV) to assess uteroplacental function and fetal compromise.

3. Management of Comorbidities:

  • GDM: Continue Metformin as prescribed, but monitor blood glucose closely. Insulin may be needed if glycemic control is difficult during stabilization.
  • Anemia: Continue iron supplementation. Cross-match 4-6 units of blood given high risk of PPH and previous sections. Blood transfusion or iron infusion if hemoglobin is significantly low or unstable.
  • UTI: Ensure she is on appropriate antibiotics (review culture & sensitivity results) and monitor response.
  • Chronic Hypertension: Manage as above; her Nifedipine dose might need adjustment or switching to IV agents.

4. Pre-operative Preparation for Caesarean Section:

Her Caesarean section is scheduled for tomorrow. This needs to be reassessed for immediate delivery once she is stabilized. Given her severe condition, delivery should not be delayed once stable, even if it means delivering today.

  • Informed Consent: Re-confirm consent for LSCS and discuss risks (e.g., hemorrhage, adhesions, possible hysterectomy due to placenta accreta, organ injury).
  • Fasting: Ensure she is nil by mouth for 6 hours (solids) and 2 hours (clear fluids).
  • Pre-medication: Administer anti-aspiration prophylaxis (e.g., Sodium Citrate 30mL orally, Ranitidine 50mg IV).
  • Antibiotics: Administer prophylactic broad-spectrum antibiotics (e.g., Cephazolin) 30-60 minutes before skin incision.
  • Anaesthetic Assessment: Senior anaesthetist will assess for regional (spinal/epidural) vs. general anaesthesia, considering her platelet count and coagulation status. Regional is preferred if safe.

5. Management during Caesarean Section:

  • Aseptic Technique: Maintain strict aseptic technique.
  • Uterine Incision: Low transverse uterine incision is standard unless contraindicated (e.g., classical incision from previous surgery, placenta previa, large fibroids).
  • Hemorrhage Control: Be prepared for massive hemorrhage. Active management of the third stage with Oxytocin. Consider uterotonics like Carboprost or Misoprostol if needed. Be ready for surgical interventions (B-Lynch suture, uterine artery ligation, hysterectomy).

6. Postnatal Management:

  • High Dependency Care: Continue management in HDU for at least 24 hours post-delivery, or longer if unstable.
  • Magnesium Sulphate: Continue infusion for 24 hours post-delivery or last seizure.
  • BP Monitoring: Continue regular BP monitoring. Gradually reduce antihypertensives as BP normalizes.
  • Complications: Monitor closely for PPH, infection, worsening renal/liver function.
  • Follow-up & Counselling:
    • 6-week Postnatal Review: For BP check and overall health. Refer to a physician if hypertension persists.
    • Contraception: Counsel on safe contraception (progesterone-only or barrier methods are preferred initially due to VTE risk).
    • Long-term Risk: Counsel about increased lifetime risk of chronic hypertension, cardiovascular disease, and recurrent pre-eclampsia in future pregnancies.
Source: Obstetrics by Ten Teachers, 21st Edition, Chapters 9, 12, 13, 14, 15. Eranthi Samarakoon, A Guide to the Clinical Examination in Obstetrics & Gynaecology, for Undergraduates and Postgraduates, Chapter 5, 19, 21. NICE guideline [NG133] – Hypertension in pregnancy: diagnosis and management.
What are the potential complications for both mother and fetus in this case?

Given her severe pre-eclampsia, chronic conditions, and complex obstetric history, she is at a significantly high risk for numerous severe maternal and fetal complications.

Maternal Complications (High Risk due to Severity and Comorbidities):

  • Eclampsia: Generalized convulsions, leading to cerebral haemorrhage and maternal death. Her current symptoms (headache, visual disturbances) indicate impending eclampsia.
  • HELLP Syndrome: (Haemolysis, Elevated Liver enzymes, Low Platelet count). A life-threatening complication characterized by rapid deterioration of liver and haematological function.
  • Cerebrovascular Accident (Stroke): Due to uncontrolled severe hypertension or eclampsia.
  • Placental Abruption: Premature placental detachment, leading to severe concealed or revealed haemorrhage, DIC, and shock. Risk is amplified by severe hypertension.
  • Disseminated Intravascular Coagulation (DIC): A severe bleeding disorder due to widespread microclotting, leading to organ damage and severe bleeding.
  • Acute Kidney Injury (AKI) / Renal Failure: Worsening of pre-existing renal compromise (if any) or new onset AKI due to severe pre-eclampsia.
  • Pulmonary Oedema: Due to fluid overload, cardiac dysfunction, or capillary leak in severe pre-eclampsia.
  • Postpartum Haemorrhage (PPH): Increased risk from uterine atony (due to over-distension from macrosomia/polyhydramnios history, prolonged induction, oxytocin use), or coagulopathy (DIC).
  • Uterine Rupture: Elevated risk due to two previous Caesarean sections, especially with possible induction/augmentation, short interpregnancy interval, or if placenta accreta is present over the old scar.
  • Organ Injury during LSCS: Increased risk of bladder or bowel injury due to adhesions from previous surgeries.
  • Anesthetic Complications: Increased risk due to severe pre-eclampsia, potential thrombocytopenia, and obesity.
  • Thromboembolism (DVT/PE): Higher risk due to pre-eclampsia, high BMI, prolonged immobility, and the hypercoagulable state of pregnancy and puerperium.
  • Worsening of Chronic Conditions: Aggravation of chronic hypertension, diabetes (e.g., ketoacidosis), and depression.
  • Long-term Cardiovascular Disease: Significantly increased lifetime risk of chronic hypertension, ischemic heart disease, and stroke.

Fetal/Neonatal Complications:

  • Fetal Growth Restriction (FGR) or Macrosomia: Both are risks due to hypertension/pre-eclampsia and GDM respectively. FGR from uteroplacental insufficiency, macrosomia from uncontrolled diabetes.
  • Oligohydramnios or Polyhydramnios: Oligohydramnios with FGR; polyhydramnios with GDM (history of polyhydramnios and macrosomia).
  • Fetal Distress/Hypoxia: Due to compromised uteroplacental blood flow in severe pre-eclampsia, especially during labour or if abruption occurs. This often leads to emergency delivery.
  • Preterm Birth: Already at 36+1 weeks, but earlier delivery may be necessitated if maternal condition deteriorates, leading to neonatal complications of late preterm birth.
  • Stillbirth/Intrauterine Death (IUD): The most severe fetal outcome, particularly with severe pre-eclampsia or abruption.
  • Neonatal Morbidities (due to prematurity/maternal conditions):
    • Respiratory Distress Syndrome (RDS): Increased risk in late preterm infants of diabetic mothers.
    • Neonatal Hypoglycaemia: Due to maternal GDM and potential fetal hyperinsulinism.
    • Neonatal Jaundice/Hyperbilirubinaemia: Common in preterm infants, especially those with NICU admissions history.
    • Birth Trauma: If macrosomic.
    • Intraventricular Haemorrhage (IVH) / Periventricular Leukomalacia (PVL): Risks associated with prematurity and severity of maternal condition.
    • Sepsis: Increased risk in neonates of mothers with GDM, UTI, or pre-eclampsia.
Source: Obstetrics by Ten Teachers, 21st Edition, Chapters 3, 4, 6, 8, 9, 10, 11, 14. Eranthi Samarakoon, A Guide to the Clinical Examination in Obstetrics & Gynaecology, for Undergraduates and Postgraduates, Chapter 5. NICE guideline [NG133] – Hypertension in pregnancy: diagnosis and management.
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Obstetrics Long Case: Hypertension in Pregnancy (Term/Near Term)

Patient Summary

A 27-year-old primigravida presents at 39+2 weeks of gestation with new-onset hypertension (BP 150/100 mmHg). Her pregnancy has otherwise been uncomplicated. She denies any pre-existing medical conditions. She occasionally reports mild headaches but no other symptoms of severe pre-eclampsia. Her booking blood pressure was normal, and a routine OGTT at 28 weeks was negative for GDM. Fetal movements have been normal. Her last full blood count at 28 weeks was within normal limits. She has no known allergies, is a non-smoker and non-drinker. Family history is unremarkable. She is awaiting induction of labour.

How would your history taking help you differentiate between potential causes, assess severity, and identify potential complications of her hypertension?

My history taking would be crucial to build a picture suggestive of either Gestational Hypertension or Pre-eclampsia, and to assess the severity and identify potential complications.

Key Areas of Inquiry and Their Significance:

  • Symptoms of Pre-eclampsia/Severity (“Red Flags”): I would meticulously inquire about the presence or absence of symptoms that define severe pre-eclampsia or organ dysfunction. Their presence would immediately suggest pre-eclampsia and indicate increased severity.
    • Headache: Character (frontal, throbbing), severity (mild vs. severe), and persistence or non-response to simple analgesia. Associated photophobia or scotomata (flashing lights, blurred vision). Significance: A new, persistent, or severe headache is a warning sign of cerebral irritation.
    • Visual disturbances: Blurring, flashing lights, temporary blindness. Significance: Indicate cerebral or retinal arterial spasm/oedema.
    • Epigastric or Right Upper Quadrant Pain: Severity, character (sharp, dull, constant), radiation, and association with nausea or vomiting. Significance: Highly suggestive of liver capsule distension, a severe feature of pre-eclampsia (e.g., HELLP syndrome).
    • Other Symptoms of Organ Dysfunction: Generalised oedema (especially sudden onset or in hands/face), sudden significant weight gain, and reduced urine output. Significance: Suggestive of systemic fluid retention and potential renal involvement.
  • Fetal Well-being:
    • Fetal Movement Chart (Kick Count): Ask about compliance with kick counts and any perceived reduction in fetal movements. Significance: Reduced movements are a crucial sign of fetal compromise due to uteroplacental insufficiency.
    • Vaginal Bleeding/Fluid Leakage: Inquire about any vaginal bleeding (amount, colour, associated pain) or fluid leakage. Significance: To rule out acute complications like placental abruption, which is more common in hypertensive pregnancies.
  • Dating the Pregnancy: I would confirm the Last Menstrual Period (LMP) and inquire about early ultrasound scans (before 20 weeks) to confirm gestational age. Significance: Accurate dating is paramount for correctly assessing fetal growth and for guiding the timing of delivery.
  • Drug History: Ask about all medications, including over-the-counter drugs, herbal remedies, and recreational drug use (e.g., cocaine, amphetamines). Significance: Some substances can cause or exacerbate hypertension and influence management.
  • Social History: Inquire about social support, living conditions, and any significant stressors. Significance: These factors can influence compliance with treatment and overall maternal well-being.
Source: Obstetrics by Ten Teachers, 21st Edition, Chapters 1, 6, 9. Eranthi Samarakoon, A Guide to the Clinical Examination in Obstetrics & Gynaecology, for Undergraduates and Postgraduates, Chapter 1, 5, 18. NICE guideline [NG133] – Hypertension in pregnancy: diagnosis and management.
What specific findings would you look for on clinical examination and what is their significance?

The examination aims to assess the patient’s general health, evaluate the severity of hypertension, and look for signs of maternal organ involvement and fetal compromise.

Clinical Examination Findings and Their Significance:

  • General Physical Examination:
    • Vital Signs:
      • Blood Pressure (BP): Re-measure and confirm the elevated BP using a calibrated device, appropriate cuff size, in a seated or semi-recumbent position, recording Korotkoff V for diastolic. Significance: Confirms the diagnosis and helps classify severity (e.g., ≥160/110 mmHg is severe).
      • Pulse Rate: Assess for tachycardia. Significance: May indicate systemic compromise, pain, or early signs of shock if significant bleeding is present (e.g., abruption).
      • Respiratory Rate: Assess. Significance: Tachypnoea could suggest pulmonary oedema or severe metabolic acidosis.
    • Oedema: Systematically assess for generalised oedema. Pay particular attention to non-dependent oedema (face, hands). Significance: While common in normal pregnancy, rapidly progressive or non-dependent oedema can be a sign of pre-eclampsia.
  • Abdominal Examination:
    • Symphysis-Fundal Height (SFH): Measure and plot on a customized growth chart. Significance: To assess current fetal growth. A smaller-than-expected SFH may suggest Fetal Growth Restriction (FGR), a common complication of pre-eclampsia.
    • Uterine Tone and Tenderness: Palpate for uterine tenderness or rigidity. Significance: Crucial to exclude placental abruption, which presents with a tense, tender uterus.
    • Fetal Lie and Presentation: Determine. Significance: Any malpresentation might affect the mode of delivery.
    • Fetal Heart Sounds (FHS): Auscultate. Significance: Confirms fetal viability and provides a rapid assessment of fetal well-being. Abnormal FHS (tachycardia, bradycardia, decelerations) may indicate fetal distress.
  • Neurological Examination:
    • Deep Tendon Reflexes: Elicit, particularly the patellar reflex, and check for ankle clonus. Significance: Hyperreflexia or sustained clonus (>3 beats) indicates central nervous system (CNS) irritability, a severe feature of pre-eclampsia that can precede eclampsia.
    • Fundoscopy: Examine the optic fundi for papilloedema or retinal haemorrhages. Significance: These are rare but definitive signs of severe hypertensive encephalopathy, indicating imminent risk of stroke or eclampsia.
  • Urinalysis: Perform a urine dipstick for protein. Significance: Proteinuria is a cardinal sign distinguishing pre-eclampsia from gestational hypertension.
Source: Obstetrics by Ten Teachers, 21st Edition, Chapters 1, 9. Eranthi Samarakoon, A Guide to the Clinical Examination in Obstetrics & Gynaecology, for Undergraduates and Postgraduates, Chapter 5, 17. NICE guideline [NG133] – Hypertension in pregnancy: diagnosis and management.
How would you classify the severity of her condition?

Based on the initial presentation, her condition can be classified as follows:

Severity Classification:

  • Hypertension: Her blood pressure is 150/100 mmHg.
    • Mild Hypertension: 140/90 – 149/99 mmHg
    • Moderate Hypertension: 150/100 – 159/109 mmHg
    • Severe Hypertension: ≥160/110 mmHg
    Therefore, her current BP of 150/100 mmHg falls into the **moderate hypertension** category.
  • Diagnosis of Gestational Hypertension vs. Pre-eclampsia:
    • Since this is new-onset hypertension after 20 weeks of gestation in a previously normotensive woman, the initial diagnosis is **Gestational Hypertension**.
    • If subsequent investigations reveal proteinuria (e.g., Protein:Creatinine ratio >30 mg/mmol) or any signs of maternal organ dysfunction (e.g., thrombocytopenia, elevated liver enzymes, renal insufficiency, or severe neurological symptoms like persistent headache, visual disturbances, epigastric pain), the diagnosis would be upgraded to **Pre-eclampsia**.
  • Overall Severity:
    • Currently, her condition appears to be **moderate gestational hypertension** given the BP reading and only mild headaches reported.
    • However, it is crucial to perform full investigations to rule out underlying pre-eclampsia and its severe features. If any severe features are present or develop, or if her BP rises to ≥160/110 mmHg, the diagnosis would become **severe pre-eclampsia** regardless of proteinuria.
Source: Obstetrics by Ten Teachers, 21st Edition, Chapter 9. Eranthi Samarakoon, A Guide to the Clinical Examination in Obstetrics & Gynaecology, for Undergraduates and Postgraduates, Chapter 5. NICE guideline [NG133] – Hypertension in pregnancy: diagnosis and management.
What is the probable diagnosis and how would you investigate this patient?

Probable Diagnosis:

Based on the new-onset hypertension (BP 150/100 mmHg) in the third trimester in a previously normotensive primigravida, the initial diagnosis is Gestational Hypertension.

If investigations reveal significant proteinuria or features of maternal organ dysfunction (e.g., thrombocytopenia, elevated liver enzymes, renal insufficiency) or uteroplacental dysfunction (e.g., FGR), the diagnosis would be Pre-eclampsia.

Given her reported mild headaches, it is crucial to perform full investigations to rule out pre-eclampsia and its severe features. Her blood pressure (150/100 mmHg) is in the moderate hypertension range.

Investigations:

The investigations aim to confirm or rule out pre-eclampsia, assess its severity, evaluate maternal organ function, and assess fetal well-being.

1. Maternal Laboratory Investigations (STAT on admission):

  • Full Blood Count (FBC):
    • Haemoglobin (Hb) & Haematocrit: To check for anaemia and assess for haemoconcentration.
    • Platelet Count: Crucial to assess for thrombocytopenia (<150 x 109/L), a hallmark of pre-eclampsia and HELLP syndrome.
  • Renal Function Tests (RFTs):
    • Serum Creatinine & Urea: To assess kidney function. Elevated levels indicate renal impairment. A creatinine >90 µmol/L (1.02 mg/dL) indicates renal insufficiency.
    • Uric Acid: Often elevated in pre-eclampsia due to impaired renal clearance.
  • Liver Function Tests (LFTs):
    • AST/ALT (Transaminases) & Bilirubin: To assess for liver involvement (part of HELLP syndrome).
  • Proteinuria Quantification:
    • Spot Urine Protein:Creatinine ratio (P:Cr) or Albumin:Creatinine ratio (A:Cr): To quantify proteinuria. A P:Cr >30 mg/mmol is significant. This is now the preferred method over 24-hour urine collection for speed and convenience.
  • Placental Growth Factor (PlGF) or sFlt-1:PlGF ratio: NICE recommends using these markers to help rule out pre-eclampsia in women between 20 and 34+6 weeks of gestation who present with suspected pre-eclampsia. While her gestation is 39+2 weeks, these tests can still provide prognostic information, though their primary diagnostic utility is earlier in gestation.
  • Coagulation Profile (PT, APTT, Fibrinogen): If platelet count is low (<100 x 109/L) or if there’s clinical suspicion of Disseminated Intravascular Coagulation (DIC), especially in severe pre-eclampsia or HELLP syndrome.

2. Fetal Assessment:

  • Cardiotocography (CTG): Immediate continuous CTG to assess fetal well-being. Look for baseline rate, variability, accelerations, and decelerations. Any pathological findings would indicate fetal compromise.
  • Ultrasound Scan (USS):
    • Fetal Biometry: To assess current fetal growth and rule out Fetal Growth Restriction (FGR).
    • Amniotic Fluid Volume (AFV): To assess for oligohydramnios, which can indicate uteroplacental insufficiency.
    • Doppler Velocimetry (Umbilical Artery, Middle Cerebral Artery): To assess uteroplacental function and signs of fetal blood flow redistribution (cerebral sparing), indicating fetal hypoxia/compromise.

3. Other Investigations (as indicated):

  • Urinalysis (repeated dipstick): To monitor for changes in proteinuria.
  • ECG: If there are any cardiac symptoms or as part of pre-operative assessment if a C-section is planned.
Source: Obstetrics by Ten Teachers, 21st Edition, Chapters 4, 9. Eranthi Samarakoon, A Guide to the Clinical Examination in Obstetrics & Gynaecology, for Undergraduates and Postgraduates, Chapter 5. NICE guideline [NG133] – Hypertension in pregnancy: diagnosis and management.
What is your management plan for this patient, considering her gestation and clinical picture?

My management plan would be systematic, prioritizing maternal and fetal safety, given her gestation near term. The goals are to confirm the diagnosis, monitor for progression, prevent complications, and plan for timely delivery.

1. Initial & Ongoing Maternal Management (Admission to Antenatal Ward with Close Monitoring):

  • Initial Assessment on Admission: Assess her general condition, re-measure BP, and quickly re-evaluate for severe symptoms of pre-eclampsia (headache, visual changes, epigastric pain, hyperreflexia, clonus).
  • Monitoring:
    • Blood Pressure (BP): Hourly monitoring for the first few hours, then every 4 hours if stable, or more frequently (e.g., every 15-30 mins) if severe hypertension is detected. All maternal observations should be documented on a Modified Early Obstetric Warning System (MEOWS) chart for early detection of deterioration.
    • Fluid Balance: Strict input and output charting, including urine output. A Foley catheter is essential in severe cases.
    • Symptoms: Continually ask about symptoms of impending eclampsia (headache, visual disturbances, epigastric pain).
  • Pharmacological Management:
    • Antihypertensives: As her BP is 150/100 mmHg, in the moderate range, I would observe for 24 hours. If it remains persistently above 150/100 mmHg, I would commence oral antihypertensives. First-line agents include Labetalol (starting with 300 mg/day in 3 divided doses, up to 1200 mg/day) or Nifedipine (starting with 40 mg/day in 2 divided doses, up to 120 mg/day). The aim is to maintain systolic BP below 150 mmHg and diastolic BP between 80-100 mmHg. Angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers, statins, and diuretics are contraindicated in pregnancy.
    • Aspirin: Since she is a primigravida, low-dose aspirin (75-150 mg daily) should have been commenced at 12 weeks to reduce the risk of pre-eclampsia.

2. Fetal Surveillance:

  • Continuous CTG: Continuous CTG monitoring should be performed regularly (e.g., daily) to assess fetal well-being.
  • Ultrasound Scan (USS): Repeat USS for fetal growth and amniotic fluid volume. Doppler studies (umbilical artery, MCA) would be performed if FGR or fetal compromise is suspected.

3. Timing and Mode of Delivery (TOD/MOD):

  • Decision: Given her gestation of 39+2 weeks and new-onset hypertension, delivery is indicated. As she is in the moderate range with mild/no symptoms, a trial of labour with induction is generally the preferred approach if her cervix is favourable.
  • Induction of Labour (IOL):
    • Cervical Assessment: Perform a vaginal examination to assess Bishop’s score. A score of ≥7 indicates a favourable cervix.
    • Method of Induction: If favourable, Artificial Rupture of Membranes (ARM) followed by an oxytocin infusion is the primary method. If the cervix is unfavourable (Bishop score <7), cervical ripening agents like vaginal Dinoprostone (PGE2) can be used (3 mg inserted, repeated after 6 hours). A Foley catheter with a 30cc bulb is also an option for cervical ripening. Oxytocin should not be commenced for 6 hours after Dinoprostone insertion.
    • Monitoring during IOL: Continuous CTG and close maternal BP monitoring are essential. Watch for uterine hyperstimulation (contractions >5 in 10 minutes or lasting >90 seconds) which can cause fetal compromise. If hyperstimulation occurs, stop the oxytocin infusion immediately and consider a tocolytic like Terbutaline.
  • Mode of Delivery: Vaginal delivery is the aim unless obstetric indications for Caesarean section (LSCS) arise (e.g., failed induction, fetal distress, cephalopelvic disproportion, malpresentation). LSCS preparation involves informed consent, ensuring fasting for 6 hours, pre-medication (e.g. Sodium Citrate), IV access, Foley catheter insertion, and prophylactic antibiotics.

4. Labour Management (if spontaneous labour/induction proceeds):

  • Monitoring: Continuous CTG and BP monitoring (hourly for mild/moderate, continuous for severe).
  • Partogram: Maintain a partogram to graphically record cervical dilatation and descent of the head to monitor labour progress.
  • Pain Relief: Epidural analgesia is generally recommended as it helps control BP and provides effective pain relief during prolonged labour.
  • Third Stage Management: Active management (Oxytocin 10 IU IM or IV slowly after delivery of the anterior shoulder) is crucial to prevent postpartum haemorrhage (PPH) due to uterine atony. Avoid ergometrine in hypertensive patients due to its vasoconstrictive effects.
  • Expedited Second Stage: Instrumental delivery may be considered to shorten the second stage and reduce maternal effort.

5. Postnatal Management:

  • Maternal Monitoring: Continue close BP monitoring (e.g., every 4-6 hours initially) for at least 24 hours, then daily until discharge.
  • Antihypertensives: Continue current antihypertensives postnatally, gradually reducing or stopping as BP normalizes (e.g., if BP falls below 140/90 mmHg). Methyldopa should be stopped within 2 days of birth.
  • Follow-up: Review at the postnatal clinic in 6 weeks for BP check and general well-being. If hypertension persists beyond 6 weeks, refer to a general physician for long-term management and investigation.
  • Contraception: Counsel regarding effective and safe contraception. Combined oral contraceptive pills are generally avoided due to increased VTE risk in the puerperium, especially with a history of hypertension. Progesterone-only methods or barrier methods are safer options.
  • Long-term Health: Inform the patient about the increased long-term risk of cardiovascular disease (e.g., chronic hypertension, ischemic heart disease, stroke) and recurrent pre-eclampsia in future pregnancies.
Source: Obstetrics by Ten Teachers, 21st Edition, Chapters 9, 12, 13, 14, 15. Eranthi Samarakoon, A Guide to the Clinical Examination in Obstetrics & Gynaecology, for Undergraduates and Postgraduates, Chapter 5, 17, 19. NICE guideline [NG133] – Hypertension in pregnancy: diagnosis and management.
What are the potential complications for both mother and fetus in this case?

Hypertensive disorders in pregnancy, especially pre-eclampsia, can lead to a range of complications for both the mother and the fetus.

Maternal Complications:

  • Progression to Severe Pre-eclampsia: Even if initially mild or moderate, the condition can rapidly worsen.
  • Eclampsia: The occurrence of generalized convulsions, which can lead to cerebral haemorrhage, stroke, and maternal death.
  • HELLP Syndrome: Haemolysis, Elevated Liver enzymes, Low Platelet count. This is a severe form of pre-eclampsia with significant maternal morbidity and mortality risks, including acute renal failure and stroke.
  • Cerebrovascular Accident (Stroke): Due to uncontrolled severe hypertension or eclampsia, leading to intracranial haemorrhage. This is a leading cause of maternal death.
  • Renal Failure: Acute kidney injury due to severe pre-eclampsia.
  • Pulmonary Oedema: Due to fluid overload or cardiac dysfunction in severe cases.
  • Placental Abruption: Premature separation of the placenta, causing severe bleeding and posing significant risk to both mother and fetus.
  • Disseminated Intravascular Coagulation (DIC): A severe bleeding disorder due to widespread activation of the coagulation system.
  • Postpartum Haemorrhage (PPH): Increased risk due to uterine atony, especially if labour is induced or augmented with oxytocin.
  • Increased Risk of Caesarean Section: Due to fetal distress, failed induction, or worsening maternal condition.
  • Long-term Cardiovascular Disease: Increased risk of chronic hypertension, ischemic heart disease, and stroke later in life.

Fetal Complications:

  • Fetal Growth Restriction (FGR): Due to uteroplacental insufficiency, where the placenta fails to provide adequate nutrients and oxygen.
  • Oligohydramnios: Reduced amniotic fluid volume, often associated with FGR and uteroplacental insufficiency.
  • Fetal Distress/Hypoxia: Due to compromised uteroplacental blood flow, particularly during labour. This can lead to abnormal CTG patterns.
  • Preterm Birth: Often iatrogenic (medically indicated) if the maternal or fetal condition deteriorates, leading to complications of prematurity.
  • Stillbirth/Intrauterine Death (IUD): The most severe fetal outcome, especially if hypertension is poorly controlled or severe pre-eclampsia develops.
  • Neonatal Complications: If born preterm, these include respiratory distress syndrome (RDS), intraventricular haemorrhage (IVH), necrotizing enterocolitis (NEC), and neonatal hypoglycaemia.
Source: Obstetrics by Ten Teachers, 21st Edition, Chapters 3, 4, 6, 9, 14. Eranthi Samarakoon, A Guide to the Clinical Examination in Obstetrics & Gynaecology, for Undergraduates and Postgraduates, Chapter 5. NICE guideline [NG133] – Hypertension in pregnancy: diagnosis and management.
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Obstetrics Long Case: Small for Gestational Age (SGA) Fetus

Patient Summary

A 28-year-old primigravida presents at 34 weeks of gestation. Her dating scan at 12 weeks confirmed dates. She is a non-smoker with no significant past medical history. Routine antenatal visits have been uneventful until now. Her community midwife noted her symphysis-fundal height (SFH) to be 28 cm, prompting a referral for an ultrasound scan due to suspected small for gestational age (SGA). The scan revealed fetal biometry measurements below the 10th centile, with a reduced amniotic fluid index. Fetal movements are reported as normal. She has no complaints of pain, bleeding, or reduced fetal movements. Her BMI at booking was 22 kg/m2.

How would your history taking help you differentiate between potential causes, assess severity, and identify potential complications of a suspected SGA fetus?

My history taking would focus on differentiating between constitutional smallness and pathological Fetal Growth Restriction (FGR), identifying risk factors for FGR, and assessing for associated complications.

Key Areas of Inquiry and Their Significance:

  • Confirmation of Dates:
    • Last Menstrual Period (LMP): Ascertain its reliability (e.g., regularity of cycles, use of contraceptives prior to conception, documentation).
    • Early Dating Scan: Confirm the presence and results of an ultrasound scan performed before 20 weeks (ideally CRL between 11-14 weeks). Significance: Wrong dates are the commonest cause of a small-for-dates uterus. [cite_start]Accurate early dating is crucial to avoid misdiagnosing FGR[cite: 13391, 13586, 13994].
  • Risk Factors for Fetal Growth Restriction (FGR): I would systematically inquire about major and minor risk factors.
    • Maternal Medical Conditions: History of chronic hypertension, pre-eclampsia, diabetes mellitus (Type 1 or 2), renal disease, antiphospholipid syndrome (APS), autoimmune diseases (e.g., SLE), chronic hypoxia (e.g., severe asthma, cyanotic heart disease). [cite_start]Significance: These conditions can affect placental function and reduce nutrient/oxygen transfer to the fetus[cite: 13947, 14634].
    • Substance Use: Smoking (including passive smoking), alcohol consumption (especially binge drinking), recreational drug use (e.g., cocaine, heroin). [cite_start]Significance: Directly impair fetal growth[cite: 13946, 14565, 14563].
    • Nutritional Status: Inquire about eating disorders, poverty, and inadequate dietary intake (e.g., low fruit intake, undernutrition). Assess BMI at booking. [cite_start]Significance: Maternal malnutrition is a major global cause of FGR[cite: 13943, 14634].
    • Previous Obstetric History: History of previous SGA fetus, stillbirth, pre-eclampsia, or placental abruption. [cite_start]Significance: Strongest predictors of recurrence[cite: 13624, 13901, 14634].
    • Infections: Any history of maternal infections (e.g., Rubella, CMV, Toxoplasma, Syphilis, Parvovirus B19) during pregnancy. [cite_start]Significance: Some congenital infections can cause symmetrical FGR[cite: 13941].
    • Heavy Manual Work/Excessive Exercise/Inadequate Rest: Inquire about physical exertion.
    • Pregnancy Interval: Short (<6 months) or very long (>5 years) interpregnancy interval.
    • Maternal Age: <20 or >35 years.
    • Multiple Pregnancy: Not applicable here, but generally a risk factor.
    • Exposure to Toxins/Radiation.
  • Fetal Well-being:
    • Fetal Movement Chart (Kick Count): Assess compliance and any perceived reduction in fetal movements. [cite_start]Significance: Reduced movements can be an early sign of fetal compromise and hypoxia[cite: 13991, 14330].
    • Any bleeding or fluid leakage: To rule out placental abruption or PPROM, which can cause oligohydramnios and FGR.
  • Symptoms of Complications: Inquire about symptoms of pre-eclampsia (headache, visual disturbances, epigastric pain), which often co-exists with FGR due to placental insufficiency.
Source: Obstetrics by Ten Teachers, 21st Edition, Chapters 1, 3, 4, 6, 9, 10. Eranthi Samarakoon, A Guide to the Clinical Examination in Obstetrics & Gynaecology, for Undergraduates and Postgraduates, Chapter 11.
What specific findings would you look for on clinical examination and what is their significance?

The examination aims to confirm the suspicion of SGA, assess fetal well-being, and identify any maternal signs suggestive of underlying causes or complications.

Clinical Examination Findings and Their Significance:

  • General Examination:
    • Maternal Weight and Height: Re-check weight and confirm height to assess BMI. [cite_start]Significance: Low BMI (<20 kg/m2) is a risk factor for spontaneous preterm delivery and FGR[cite: 18, 121].
    • Vital Signs: Blood pressure, pulse rate. [cite_start]Significance: Hypertension/Pre-eclampsia is a common cause of FGR[cite: 14634].
    • Pallor: Assess mucous membranes. Significance: Severe maternal anemia can be a cause of FGR.
    • Signs of Chronic Illness: (e.g., jaundice, clubbing, lymphadenopathy, signs of autoimmune disease) Significance: Could point to underlying maternal conditions causing FGR.
  • Abdominal Examination:
    • Symphysis-Fundal Height (SFH): Confirm the SFH measurement (28 cm at 34 weeks). [cite_start]Significance: A persistently small SFH (<10th centile or >3 cm discrepancy from gestational age after 24 weeks) is the primary clinical indicator for suspected SGA[cite: 13675].
    • Fetal Palpation:
      • Estimated Fetal Weight (EFW): Clinically estimate fetal weight. Significance: A palpably small fetus supports the diagnosis.
      • Amniotic Fluid Volume: Assess liquor content (e.g., uterus feels closely applied to fetus). [cite_start]Significance: Reduced liquor (oligohydramnios) is a key sign of uteroplacental insufficiency and FGR[cite: 14328].
      • Fetal Parts: Note if fetal parts are easily felt. Significance: Easy palpation of fetal parts suggests oligohydramnios.
      • Fetal Lie and Presentation: Determine. Significance: Although not directly related to SGA cause, malpresentations can occur with abnormal liquor volume.
    • Uterine Tenderness/Tone: Palpate for tenderness or abnormal tone. Significance: Rule out placental abruption, which can cause FGR.
    • Fetal Heart Sounds (FHS): Auscultate. Significance: Initial check of fetal viability.
  • Neurological Examination: (If indicated by history)
    • Reflexes and Fundoscopy: If there’s any suspicion of pre-eclampsia. Significance: Severe pre-eclampsia can cause FGR.
  • Urinalysis: Dipstick for protein and glucose. Significance: Proteinuria suggests pre-eclampsia; glycosuria suggests diabetes (both can cause FGR).
Source: Obstetrics by Ten Teachers, 21st Edition, Chapters 1, 3, 4, 6, 9. Eranthi Samarakoon, A Guide to the Clinical Examination in Obstetrics & Gynaecology, for Undergraduates and Postgraduates, Chapter 11.
How would you classify the severity and type of fetal growth restriction?

Classification of a small fetus involves distinguishing between a constitutionally small but healthy baby and a pathologically growth-restricted fetus, and then classifying the type of FGR.

Definition and Initial Classification:

    [cite_start]
  • Small for Gestational Age (SGA): This is a statistical definition where the estimated fetal weight (EFW) or abdominal circumference (AC) is less than the 10th centile for the gestational age[cite: 13925, 14634]. Her ultrasound findings (biometry below 10th centile) confirm she has an SGA fetus.
    • [cite_start]
  • Fetal Growth Restriction (FGR): This implies a pathological process preventing the fetus from achieving its genetic growth potential[cite: 14634]. Not all SGA fetuses are FGR, and some FGR fetuses may not be SGA (if their growth potential was very high). However, her reduced amniotic fluid index strongly suggests FGR due to uteroplacental insufficiency.

Severity of FGR:

Severity is typically assessed by the degree of deviation from the norm, onset, and presence of signs of compromise:

  • Mild: EFW 5th-10th centile, normal Doppler studies.
  • Moderate: EFW below 5th centile, early Doppler changes (e.g., umbilical artery PI >95th centile).
  • Severe: EFW below 3rd centile, significant Doppler changes (e.g., absent or reversed end-diastolic flow in umbilical artery, cerebral sparing, abnormal Ductus Venosus flow). Early onset FGR (before 32 weeks) is generally more severe.

Given her SFH of 28cm at 34 weeks (suggesting an approximate 6cm discrepancy) and reduced amniotic fluid, her SGA is likely to be **moderate FGR**. The definitive severity will depend on detailed ultrasound biometry and Doppler findings.

Types of FGR:

  • Symmetrical FGR (Early-onset, “Head Sparing” less evident):
    • Occurs early in pregnancy (e.g., <28 weeks).
    • Head circumference (HC) and Abdominal Circumference (AC) are proportionally small.
      • [cite_start]
    • Causes: Chromosomal abnormalities, congenital infections (e.g., CMV, Rubella), genetic syndromes, major fetal anomalies, early severe maternal insult[cite: 14634].
  • Asymmetrical FGR (Late-onset, “Brain Sparing” usually evident):
    • Occurs later in pregnancy (e.g., >28-30 weeks), often due to uteroplacental insufficiency.
    • The brain and heart are preferentially perfused (“brain sparing” effect), so the HC may be relatively preserved while the AC is disproportionately small. [cite_start]This is reflected in a high HC/AC ratio[cite: 14118, 14634].
      • [cite_start]
    • Causes: Chronic maternal conditions (hypertension, pre-eclampsia, diabetes with vascular complications, renal disease), smoking, substance abuse, placental pathologies (e.g., infarction, abruption)[cite: 14634].

Given her presentation at 34 weeks and reduced amniotic fluid, her FGR is most likely **asymmetrical**, suggesting uteroplacental insufficiency. Further Doppler studies would confirm the presence of brain-sparing.

Source: Obstetrics by Ten Teachers, 21st Edition, Chapters 3, 4, 9. Eranthi Samarakoon, A Guide to the Clinical Examination in Obstetrics & Gynaecology, for Undergraduates and Postgraduates, Chapter 11. RCOG Green-top Guideline No. 31 – Small-for-Gestational-Age Fetus, Investigation and Management.
How would you investigate this patient?

The investigations aim to confirm the diagnosis of FGR, identify its underlying cause, assess its severity, and monitor fetal well-being to guide the timing and mode of delivery.

1. Confirming Diagnosis and Assessing Severity:

  • Comprehensive Ultrasound Scan (USS) & Doppler Studies:
    • Fetal Biometry: Repeat detailed measurements of Biparietal Diameter (BPD), Head Circumference (HC), Abdominal Circumference (AC), and Femur Length (FL). Plot on customized growth charts. [cite_start]Significance: To confirm SGA and classify as symmetrical or asymmetrical FGR (e.g., disproportionately small AC suggests asymmetrical FGR)[cite: 14118, 14634].
    • Amniotic Fluid Volume (AFV): Measure Amniotic Fluid Index (AFI) or Maximum Vertical Pool (MVP). [cite_start]Significance: Reduced AFV (oligohydramnios) is a strong indicator of uteroplacental insufficiency and FGR[cite: 14328, 14634].
    • Doppler Velocimetry:
      • Umbilical Artery (UA) Doppler: Assess pulsatility index (PI) and end-diastolic flow. [cite_start]Significance: High PI, reduced, absent, or reversed end-diastolic flow indicates increased placental resistance and worsening FGR[cite: 14329, 14330].
      • Middle Cerebral Artery (MCA) Doppler: Assess PI. [cite_start]Significance: Reduced MCA PI indicates cerebral vasodilatation (“brain sparing”) due to fetal hypoxia[cite: 14330].
      • Cerebroplacental Ratio (CPR): Ratio of MCA PI to UA PI. [cite_start]Significance: A low CPR (<5th centile) is an early indicator of fetal compromise and adverse outcomes[cite: 14309].
      • Ductus Venosus (DV) Doppler: Assess flow pattern. [cite_start]Significance: Abnormal DV flow (e.g., reversed a-wave) is a late and severe sign of fetal cardiac compromise and impending death[cite: 14330].
    • Cardiotocography (CTG): To assess fetal well-being. A non-stress CTG should be performed regularly (e.g., daily or every other day depending on Doppler findings). [cite_start]Significance: Abnormal CTG (reduced variability, decelerations, bradycardia) indicates fetal hypoxia/acidemia[cite: 14331].

2. Identifying the Cause of FGR:

  • Maternal Blood Tests:
    • Full Blood Count (FBC): To check for anemia.
    • Urinalysis & Urine Culture: To rule out urinary tract infection.
    • Renal & Liver Function Tests (U&Es, LFTs): To screen for underlying maternal disease or pre-eclampsia.
    • Blood Glucose (FBS/OGTT/HbA1c): To screen for undiagnosed diabetes or assess control of GDM.
      • [cite_start]
    • Infection Screen: Serological screening for congenital infections (CMV, Toxoplasma, Rubella, Syphilis, Parvovirus B19) if symmetrical FGR or fetal anomalies are suspected[cite: 13941, 14634].
    • Autoantibody Screen: For antiphospholipid syndrome (APS) or Systemic Lupus Erythematosus (SLE) if indicated by history.
    • Thrombophilia Screen: If a history of VTE or recurrent FGR/stillbirths.
  • Fetal Karyotyping/Microarray:
    • Purpose: If severe, early-onset FGR (<23 weeks), or if associated with structural anomalies or normal Doppler findings. This is done via amniocentesis. [cite_start]Significance: To rule out chromosomal abnormalities (e.g., Trisomy 13, 18, 21) or genetic syndromes[cite: 13939, 14634].
  • Detailed Fetal Anomaly Scan: To look for structural abnormalities missed on earlier scans, especially if symmetrical FGR.
Source: Obstetrics by Ten Teachers, 21st Edition, Chapters 3, 4, 9. Eranthi Samarakoon, A Guide to the Clinical Examination in Obstetrics & Gynaecology, for Undergraduates and Postgraduates, Chapter 11. RCOG Green-top Guideline No. 31 – Small-for-Gestational-Age Fetus, Investigation and Management.
What is your management plan for this patient, considering her gestation and clinical picture?

My management plan focuses on continuous surveillance, optimizing maternal health, and timely delivery to prevent adverse fetal outcomes, given her FGR and reduced amniotic fluid volume at 34 weeks.

1. Initial Management & Monitoring (Admission for Surveillance):

  • Hospital Admission: Admit to the antenatal ward for continuous surveillance.
  • Maternal Optimization:
    • Diet & Rest: Advise adequate nutrition and rest. [cite_start]While bed rest is traditionally advised, its direct benefit on placental blood flow is limited[cite: 14636].
    • Avoid Harmful Substances: Reinforce cessation of smoking, alcohol, and recreational drugs.
    • Manage Comorbidities: Ensure her GDM remains well-controlled with diet and Metformin. Monitor blood glucose closely.
  • Fetal Surveillance:
    • Daily Fetal Movement Chart: Counsel on proper kick count monitoring and report any reduction immediately.
    • Daily Cardiotocography (CTG): To monitor fetal well-being, especially given reduced AFV.
    • Doppler Studies: Perform Umbilical Artery (UA), Middle Cerebral Artery (MCA), and Ductus Venosus (DV) Doppler studies. The frequency will depend on the findings:
      • If UA Doppler is normal: repeat every 14 days.
      • If UA Doppler shows reduced end-diastolic flow: repeat twice weekly.
        • [cite_start]
      • If UA Doppler shows absent or reversed end-diastolic flow: repeat daily, as delivery is likely imminent[cite: 14330].
    • Biophysical Profile (BPP): May be performed if other parameters (Doppler, CTG) are abnormal.
    • Serial Biometry: Repeat USS for fetal growth assessment every 2-3 weeks to monitor growth trajectory.

2. Timing and Mode of Delivery (TOD/MOD):

[cite_start]

The decision on TOD/MOD for FGR balances the risks of intrauterine death (if left in utero) versus morbidities of prematurity (if delivered early)[cite: 141, 14636]. Her gestation is 34 weeks.

  • General Principles:
    • UA Doppler Normal with FGR: Delivery generally recommended at 37-38 weeks.
    • UA Doppler Abnormal (Reduced/Absent/Reversed Flow) with FGR: Delivery recommended no later than 37 weeks. [cite_start]If abnormal flow is noted earlier (e.g., <32 weeks), specialized guidance (e.g., from a fetal medicine unit) is needed, and delivery is often considered by 32 weeks, especially if DV flow becomes abnormal[cite: 14636].
    • Antenatal Corticosteroids: If delivery is anticipated before 34+6 weeks (e.g., due to worsening Doppler, severe FGR, or maternal complications), administer a course of corticosteroids for fetal lung maturation. She is at 34 weeks, so this decision would be immediate if delivery is planned.
      • [cite_start]
    • Magnesium Sulphate: If delivery is anticipated before 30 weeks, administer Magnesium Sulphate for fetal neuroprotection[cite: 14052]. This is less relevant for her at 34 weeks.
  • For This Patient (34 weeks, SGA with reduced AFV):
    • If the initial Doppler studies (UA, MCA) are reassuring and her maternal condition is stable, consider expectant management until 37-38 weeks, with very close surveillance (daily CTG, frequent Dopplers).
    • If Doppler studies show worsening flow (e.g., absent end-diastolic flow in UA, or abnormal DV flow), immediate delivery is indicated, regardless of gestation.
    • Mode of Delivery:
      • Vaginal delivery can be attempted if fetal well-being is reassuring, cervical status is favourable, and no other obstetric contraindications. However, there’s a higher incidence of emergency C-section in FGR labours.
      • Caesarean section is indicated if fetal well-being is compromised (e.g., pathological CTG, abnormal Doppler indicating severe compromise), or if vaginal delivery is not feasible (e.g., persistent breech presentation). Her current breech presentation independently mandates a C-section.

3. Postnatal Management:

  • Neonatal Monitoring: The neonatologist should be informed and present at delivery, especially given her preterm status (34 weeks) and FGR. [cite_start]Closely monitor the neonate for complications of prematurity and FGR (hypoglycemia, hypothermia, jaundice, feeding difficulties)[cite: 14052, 14327].
  • GDM Management: Continue monitoring maternal blood glucose. Counsel on post-delivery screening for Type 2 DM.
    • [cite_start]
  • Follow-up: Discuss the FGR diagnosis with parents, including potential long-term risks (e.g., cardiovascular disease, diabetes)[cite: 13921, 14636].
Source: Obstetrics by Ten Teachers, 21st Edition, Chapters 3, 4, 9, 16. Eranthi Samarakoon, A Guide to the Clinical Examination in Obstetrics & Gynaecology, for Undergraduates and Postgraduates, Chapter 11. RCOG Green-top Guideline No. 31 – Small-for-Gestational-Age Fetus, Investigation and Management.
What are the potential complications for both mother and fetus in this case?

An SGA fetus, especially if due to FGR, carries significant risks for both the mother and the fetus, both during pregnancy and into later life.

Maternal Complications:

  • Increased Risk of Induction of Labour/Caesarean Section: Due to fetal compromise, failed induction, or worsening FGR.
    • [cite_start]
  • Complications of Underlying Causes: If an underlying maternal condition (e.g., pre-eclampsia, chronic hypertension, diabetes complications) is the cause of FGR, the mother is at risk of complications related to that condition (e.g., eclampsia, stroke, renal failure, PPH)[cite: 14631].
  • Iatrogenic Preterm Birth: Delivery may be medically indicated before term due to worsening FGR or fetal compromise, carrying risks of prematurity.
  • Psychological Impact: Anxiety and stress from the diagnosis, frequent monitoring, and uncertainty about fetal well-being.

Fetal/Neonatal Complications:

  • Intrauterine Hypoxia/Asphyxia: Reduced oxygen supply due to placental insufficiency, leading to fetal distress, abnormal CTG patterns, and in severe cases, brain injury.
  • Stillbirth/Intrauterine Death (IUD): The most severe and feared complication of FGR, especially with worsening Doppler abnormalities.
    • [cite_start]
  • Neonatal Hypothermia: SGA babies have reduced subcutaneous fat and are prone to heat loss[cite: 13992, 14327].
    • [cite_start]
  • Neonatal Hypoglycaemia: Reduced glycogen stores make them susceptible to low blood sugar after birth[cite: 13995, 14327].
    • [cite_start]
  • Polycythaemia: Increased red blood cell count as a compensatory mechanism for chronic hypoxia[cite: 14327].
  • Jaundice: Often associated with polycythaemia.
    • [cite_start]
  • Respiratory Distress Syndrome (RDS): Increased risk in preterm SGA babies, particularly if lung maturation is delayed[cite: 13968].
    • [cite_start]
  • Birth Asphyxia and Birth Trauma: Despite being small, if FGR is severe, they can be fragile and poorly tolerate labour[cite: 14327].
  • Increased NICU Admission: Due to any of the above complications.
    • [cite_start]
  • Long-term Neurodevelopmental Impairment: Risk of cerebral palsy, learning difficulties, and behavioral problems, especially with severe or prolonged hypoxia[cite: 13926].
    • [cite_start]
  • Long-term Metabolic and Cardiovascular Disease: Increased susceptibility to coronary heart disease, stroke, type 2 diabetes, and hypertension in adult life (DOHaD hypothesis)[cite: 13921, 14636].
Source: Obstetrics by Ten Teachers, 21st Edition, Chapters 3, 4, 9, 16. Eranthi Samarakoon, A Guide to the Clinical Examination in Obstetrics & Gynaecology, for Undergraduates and Postgraduates, Chapter 11. RCOG Green-top Guideline No. 31 – Small-for-Gestational-Age Fetus, Investigation and Management.

Obstetrics Long Case: Pregnancy Following a Previous Caesarean Section

Patient Summary

A 30-year-old G2P1 presents at 38 weeks of gestation. Her first pregnancy, 2.5 years ago, resulted in a Caesarean section at 39 weeks due to “failure to progress” at 5 cm cervical dilatation. The previous Caesarean section was an uncomplicated lower segment incision, and her baby was born healthy. She denies any intra-operative or post-operative complications from the previous surgery. She is otherwise healthy and this current pregnancy has been uncomplicated so far. Her dates were confirmed by an early ultrasound scan. She is aware of the option of a vaginal birth after Caesarean section (VBAC) and is attending for a decision on her mode of delivery.

How would your history taking help you assess the suitability for VBAC and identify potential complications?

My history taking would focus on gathering specific details about the previous Caesarean section, the current pregnancy, and her preferences to assess suitability for VBAC and anticipate potential complications, particularly uterine rupture.

Key Areas of Inquiry and Their Significance:

  • Details of Previous Caesarean Section (Crucial):
    • Indication for Previous LSCS: “Failure to progress” is noted. I would confirm if there were any other contributing factors (e.g., malpresentation, cephalopelvic disproportion, fetal distress). Significance: A non-recurrent indication (like fetal distress or malpresentation that is not present in this pregnancy) increases the chance of successful VBAC. “Failure to progress” can sometimes be recurrent (e.g., if due to true CPD).
    • Type of Uterine Incision: Confirm it was a lower segment transverse incision. Significance: A classical (vertical) upper segment incision is an absolute contraindication to VBAC due to high rupture risk.
    • Intra-operative Complications: Any extensions of the uterine incision, tears, or excessive bleeding. Significance: These can weaken the scar.
    • Post-operative Complications: Any history of infection or hematoma at the incision site. Significance: Post-operative infection can impair scar healing, increasing rupture risk.
    • Previous Baby’s Health and Birth Weight: Significance: Important for overall obstetric history and may indicate relative CPD if the baby was very large.
  • Current Pregnancy Details:
    • Confirmation of Dates: Re-confirm dates by LMP and early USS (before 20 weeks). Significance: Accurate dating is essential for timing induction or elective repeat Caesarean section (ERCS) and for assessing fetal growth.
    • Complications: Inquire about any new complications (e.g., GDM, PIH, malpresentations, placenta previa, FGR, polyhydramnios). Significance: These can be contraindications to VBAC or necessitate ERCS.
    • Fetal Movements: Regular and satisfactory. Significance: Reduced fetal movements can indicate fetal compromise.
    • Current Symptoms: Any abdominal pain (especially over the scar), bleeding, or fluid leakage. Significance: Could indicate scar dehiscence or uterine rupture.
  • Inter-delivery Interval (IDI): She had her previous delivery 2.5 years ago. Significance: An IDI of less than 18-24 months is associated with an increased risk of uterine rupture. Her IDI of 2.5 years is favorable.
  • Previous Vaginal Births: Although she is P1 (only one delivery by CS), a history of a previous successful vaginal birth (before or after the CS) is the strongest predictor of successful VBAC. Significance: Not applicable here, as she has not had one.
  • Her Preferences and Concerns: Explore her understanding of VBAC vs. ERCS, her motivation, and any fears or anxieties. Significance: Shared decision-making is paramount.
Source: Obstetrics by Ten Teachers, 21st Edition, Chapters 12, 13. Eranthi Samarakoon, A Guide to the Clinical Examination in Obstetrics & Gynaecology, for Undergraduates and Postgraduates, Chapter 12. RCOG Green-top Guideline No. 45 – Birth after previous Caesarean birth.
What specific findings would you look for on clinical examination and what is their significance?

The examination aims to assess her general fitness for labour, confirm fetal presentation and size, and identify any clinical signs that might contraindicate VBAC or suggest potential complications related to the previous scar.

Clinical Examination Findings and Their Significance:

  • General Examination:
    • Maternal Height: Short stature can be associated with a smaller pelvis and potential cephalopelvic disproportion (CPD).
    • Vital Signs: Blood pressure, pulse rate. Significance: Rule out pre-existing conditions (e.g., hypertension) or new complications.
    • Overall Health Status: Assess for any medical comorbidities that might increase surgical risk or complicate labour.
  • Abdominal Examination:
    • Uterine Scar Assessment: Inspect the previous Caesarean section scar. Look for signs of tenderness, thinning, or dehiscence (rare but possible). Significance: Tenderness over the scar is a concerning sign during labour, although it can be normal.
    • Symphysis-Fundal Height (SFH): Measure. Significance: To estimate fetal size. A very large fetus increases the risk of failed VBAC and scar rupture.
    • Fetal Lie, Presentation, and Position: Determine. Significance: VBAC is generally attempted only if the fetus is in a cephalic (head-first) presentation and occipito-anterior (OA) position. Malpresentations (e.g., breech) or malpositions are contraindications to VBAC and necessitate ERCS.
    • Engagement of the Presenting Part: Assess the degree of engagement (e.g., in fifths palpable abdominally). Significance: A non-engaged head at term, especially in a primigravida, can suggest CPD or malposition, which would lower VBAC success rates.
    • Fetal Weight Estimation: Clinically estimate. Significance: Fetal macrosomia (e.g., >4kg) is a relative contraindication to VBAC.
    • Fetal Heart Sounds (FHS): Auscultate. Significance: Initial check of fetal well-being.
  • Pelvic Examination (Digital Vaginal Examination – if contemplating VBAC and in labour or near term to assess favourability):
    • Cervical Assessment: Assess consistency, length, effacement, and dilatation (Bishop’s score). Significance: A favorable cervix indicates higher likelihood of successful induction/labour.
    • Pelvic Adequacy: Clinically assess the pelvis (pelvimetry) for adequacy. Significance: A previously untested or clinically inadequate pelvis is a contraindication to VBAC.
    • Fetal Head Station and Position: Confirm engagement and position if in labour.
    • Absence of Contraindications: Ensure no placenta previa (which should have been confirmed by ultrasound).
Source: Obstetrics by Ten Teachers, 21st Edition, Chapters 12, 13. Eranthi Samarakoon, A Guide to the Clinical Examination in Obstetrics & Gynaecology, for Undergraduates and Postgraduates, Chapter 12. RCOG Green-top Guideline No. 45 – Birth after previous Caesarean birth.
How would you assess the suitability for VBAC and classify the risk of uterine rupture in this pregnancy?

Assessing suitability for VBAC involves a comprehensive review of past and present obstetric factors, weighing the benefits and risks of both VBAC and Elective Repeat Caesarean Section (ERCS). The primary concern is the risk of uterine rupture.

Suitability for VBAC:

She is a good candidate for VBAC based on several favorable factors, but some considerations remain:

  • Favorable Factors:
    • Single Previous LSCS: Vaginal delivery is allowed after one previous Caesarean section if strict criteria are met.
    • Previous Uncomplicated Lower Segment Transverse Incision: This type of incision has the lowest risk of rupture.
    • Non-recurrent Indication for Previous CS (“Failure to Progress at 5cm”): This is often a good predictor for VBAC success, as it suggests labour was established and not due to absolute cephalopelvic disproportion.
    • Adequate Inter-delivery Interval (IDI) of 2.5 years: An IDI >18-24 months is associated with a lower risk of uterine rupture.
    • Confirmed Dates: Essential for accurate timing of labour management.
    • Uncomplicated Current Pregnancy (so far): No new complications that would contraindicate VBAC.
    • Vertex Presentation (implied, needs confirmation): VBAC is usually only offered with a cephalic presentation.
    • Patient’s Desire for VBAC: Her awareness and implied interest in VBAC are crucial for shared decision-making.
  • Factors to Re-evaluate/Consider:
    • Absence of Previous Vaginal Birth: A prior vaginal birth (before or after a CS) is the strongest predictor of VBAC success (85-90% success rate). Without this, her success rate will be lower (around 70-75%).
    • Fetal Weight: Ensure estimated fetal weight is not macrosomic (>4kg), as this reduces VBAC success and increases rupture risk.
    • Pelvic Adequacy: A clinical pelvic assessment is important to ensure no significant cephalopelvic disproportion.

Risk of Uterine Rupture:

The risk of uterine rupture is the most serious complication of VBAC, though overall it remains low. For a woman with one previous lower segment Caesarean section scar, the risk of rupture is approximately 0.5% (1 in 200) during a trial of labour, compared to 0.05% (1 in 2000) for an ERCS.

  • Her Specific Risk Factors for Rupture:
    • Single Previous LSCS: Her risk is in the range of ~0.5%.
    • Favorable IDI (2.5 years): This reduces the risk.
    • Non-recurrent indication: “Failure to progress” could be due to other factors (e.g., uterine inertia) and not necessarily a tight pelvis.
  • Factors that would Increase Rupture Risk (and thus contraindicate VBAC):
    • Previous classical (vertical) uterine incision.
    • Two or more previous Caesarean sections (risk increases with each subsequent section, e.g., ~1.5-2% after 2 sections).
    • Short interpregnancy interval (<18-24 months).
    • Previous uterine rupture.
    • Known uterine anomaly or extensive myomectomy involving the uterine cavity.
    • Induction of labour with prostaglandins (especially vaginal PGE2) carries a 2-3 fold increased risk of scar rupture compared to spontaneous labour.
    • Augmentation with high-dose oxytocin.
    • Macrosomia (>4 kg).

Overall, she is a reasonable candidate for VBAC, but careful monitoring during labour is paramount due to the inherent, albeit low, risk of uterine rupture.

Source: Obstetrics by Ten Teachers, 21st Edition, Chapter 13, 14. Eranthi Samarakoon, A Guide to the Clinical Examination in Obstetrics & Gynaecology, for Undergraduates and Postgraduates, Chapter 12. RCOG Green-top Guideline No. 45 – Birth after previous Caesarean birth.
How would you investigate this patient to finalize the plan for delivery?

The investigations would focus on confirming current fetal and maternal well-being, assessing the favourability of the cervix, and ensuring no new contraindications for VBAC have developed.

Investigations:

  • Review of Previous Records:
    • Obtain and meticulously review the full notes from her previous Caesarean section. Significance: To confirm the precise indication, exact type of uterine incision (e.g., lower segment transverse), and any intra-operative (e.g., extensions) or post-operative complications (e.g., infection) that might affect scar integrity. This is crucial for assessing rupture risk and VBAC suitability.
  • Current Fetal Assessment:
    • Ultrasound Scan (USS) at term:
      • Fetal Biometry: To estimate fetal weight and confirm it is not macrosomic (>4 kg). Significance: Macrosomia reduces VBAC success and increases rupture risk.
      • Fetal Lie and Presentation: To confirm cephalic presentation. Significance: A non-vertex presentation is a contraindication for VBAC.
      • Amniotic Fluid Volume: To check for oligohydramnios.
      • Placental Location: To confirm there is no placenta previa (even if anomaly scan was normal, a repeat check at term is useful). Significance: Placenta previa is an absolute contraindication for VBAC.
    • Cardiotocography (CTG): To assess baseline fetal well-being.
  • Maternal Assessment for Labour Readiness:
    • Clinical Pelvimetry: A clinical assessment of the maternal pelvis for adequacy. While not highly predictive of VBAC success, it helps identify grossly contracted pelves.
    • Blood Tests (if not recent): FBC (for anemia), Blood Group & Save (in case transfusion is needed).
    • Urinalysis: To rule out UTI.
Source: Obstetrics by Ten Teachers, 21st Edition, Chapters 12, 13. Eranthi Samarakoon, A Guide to the Clinical Examination in Obstetrics & Gynaecology, for Undergraduates and Postgraduates, Chapter 12. RCOG Green-top Guideline No. 45 – Birth after previous Caesarean birth.
What is your management plan for this patient, including the discussion of VBAC vs. ERCS and intrapartum care if VBAC is chosen?

My management plan involves shared decision-making with the patient regarding her mode of delivery, thorough preparation if VBAC is chosen, and meticulous intrapartum monitoring.

1. Shared Decision-Making (VBAC vs. ERCS):

At 38 weeks, a detailed discussion would take place, outlining the risks and benefits of both options. Since she is aware of VBAC, this is an opportune time to finalize her birth plan.

  • Benefits of Planned VBAC:
    • Avoidance of repeat abdominal surgery and its associated risks (infection, hemorrhage, longer recovery).
    • Lower risk of thromboembolism compared to ERCS.
    • Less likelihood of placenta previa/accreta in future pregnancies.
    • Empowerment and satisfaction of achieving a vaginal birth.
  • Risks of Planned VBAC:
    • Uterine Rupture: The most significant risk (approx. 0.5% or 1 in 200). Can lead to fetal hypoxia/death and maternal hemorrhage/hysterectomy.
    • Failed VBAC leading to Emergency LSCS: Approximately 25-30% of VBAC attempts result in emergency LSCS, which carries higher morbidity than elective LSCS.
    • Increased risk of PPH, operative vaginal delivery (forceps/ventouse), and need for blood transfusion compared to spontaneous vaginal birth.
  • Benefits of Elective Repeat Caesarean Section (ERCS):
    • Predictability and convenience.
    • Lower risk of uterine rupture compared to VBAC.
    • Avoidance of labour pain and associated interventions.
  • Risks of ERCS:
    • Surgical risks: infection, hemorrhage, organ injury (bladder, bowel), longer recovery, readmission.
    • Increased risk of transient tachypnoea of the newborn (TTN) or respiratory distress syndrome (RDS) in the baby, especially if performed before 39+0 weeks.
    • Increased risk of placenta previa/accreta in subsequent pregnancies.
    • Impact on future fertility desires and number of safe pregnancies.

Based on her favorable factors (single previous LSCS, good IDI, non-recurrent indication, confirmed dates), she is a good candidate for a trial of labour. I would support her decision after a comprehensive discussion.

2. Management if VBAC is Chosen (Trial of Labour after Caesarean – TOLAC):

Antenatal Preparation:

  • Hospital Delivery: VBAC should always be conducted in a well-equipped hospital with immediate access to theatre, blood bank, and neonatal resuscitation facilities.
  • Informed Consent: Re-confirm consent for TOLAC, emphasizing the potential for emergency LSCS and associated risks.
  • Admission Protocol: Advise her to present to the hospital immediately at the onset of labour or membrane rupture.

Intrapartum Management:

  • Monitoring:
    • Continuous Fetal Heart Rate Monitoring (CTG): Mandatory throughout labour to detect early signs of fetal distress, which can be an indicator of uterine rupture.
    • Maternal Monitoring: Close monitoring of vital signs, fluid balance, and especially abnormal pain (constant, severe, over scar site), vaginal bleeding, or cessation of contractions (signs of uterine rupture).
    • Partogram: Maintain a partogram to monitor progress of labour.
  • Labour Progression:
    • Amniotomy: Artificial Rupture of Membranes (ARM) can be used to augment labour if progress is slow, but should be done carefully to avoid cord prolapse.
    • Oxytocin Augmentation: Use with extreme caution and under direct consultant supervision, if contractions are inadequate. Lower doses and slower increments than routine augmentation are advised. Higher doses of oxytocin increase the risk of uterine rupture.
    • Avoid Prostaglandins: Prostaglandins (e.g., vaginal Dinoprostone, Misoprostol) for cervical ripening or induction are generally contraindicated in women with previous Caesarean sections due to significantly increased risk of uterine rupture (2-3 fold increase). Mechanical methods like Foley catheter can be used if induction is necessary and cervix is unfavorable.
  • Pain Relief: Epidural analgesia is generally recommended as it provides excellent pain relief without increasing the risk of uterine rupture or failed VBAC. However, ensure she can still report scar pain.
  • Mode of Delivery:
    • Vaginal Birth: Aim for spontaneous vaginal delivery.
    • Assisted Vaginal Birth: Consider forceps or vacuum if indicated in the second stage (e.g., prolonged second stage, fetal distress), but always with caution and senior presence.
    • Emergency LSCS: A low threshold for emergency LSCS if there is lack of progress despite adequate contractions, fetal distress, or any suspicion of uterine rupture.
  • Third Stage Management: Active management of the third stage (Oxytocin 10 IU IM/IV) is recommended to prevent PPH.

3. Postnatal Management:

  • Observation: Closely observe for signs of PPH or any delayed complications related to scar integrity.
  • Counselling: Debrief on the labour and delivery experience, including the outcome of VBAC attempt. Counsel on contraception and future pregnancy spacing.
Source: Obstetrics by Ten Teachers, 21st Edition, Chapters 12, 13, 14. Eranthi Samarakoon, A Guide to the Clinical Examination in Obstetrics & Gynaecology, for Undergraduates and Postgraduates, Chapter 12. RCOG Green-top Guideline No. 45 – Birth after previous Caesarean birth.
What are the potential complications for both mother and fetus in this case?

Despite being a healthy primigravida with a favorable previous CS history, a pregnancy following a previous Caesarean section carries specific risks for both mother and fetus, particularly during a trial of labour (VBAC).

Maternal Complications:

  • Uterine Rupture: The most serious complication during TOLAC, occurring in approximately 0.5% (1 in 200) of cases. It is a life-threatening event leading to massive hemorrhage, need for hysterectomy, and high risk of fetal death.
  • Uterine Dehiscence: Separation of the old scar without complete rupture of all uterine layers. May be asymptomatic or present with pain.
  • Failed VBAC leading to Emergency Caesarean Section: Occurs in approximately 25-30% of TOLACs. This carries higher morbidity (e.g., infection, hemorrhage, longer recovery) than a planned elective Caesarean section.
  • Postpartum Haemorrhage (PPH): Increased risk compared to spontaneous vaginal birth, due to increased likelihood of manual placental removal, retained products, or uterine atony, especially after a prolonged labour or if uterine rupture/dehiscence occurs.
  • Increased Risk of Operative Vaginal Delivery (Forceps/Ventouse): If a trial of labour fails to progress adequately in the second stage.
  • Infection: Higher risk compared to spontaneous vaginal birth, especially with prolonged labour or emergency CS.
  • Thromboembolism (DVT/PE): Higher risk after emergency CS compared to successful VBAC.
  • Placenta Previa in Future Pregnancies: The risk of placenta previa (and consequently placenta accreta spectrum) increases with each subsequent Caesarean section.
  • Adhesions: From previous surgery, which can complicate future abdominal surgeries.
  • Psychological Impact: Of failed VBAC, emergency surgery, or adverse outcomes.

Fetal/Neonatal Complications:

  • Fetal Distress/Hypoxia: Can occur if uterine rupture or dehiscence happens, leading to acute fetal compromise. This is the earliest sign of uterine rupture.
  • Stillbirth/Intrauterine Death (IUD): A potential consequence of uterine rupture or severe, prolonged fetal distress.
  • Neonatal Morbidities Related to Emergency Caesarean Section: If VBAC fails and emergency CS is performed, the neonate is at higher risk for:
    • Transient Tachypnoea of the Newborn (TTN) or Respiratory Distress Syndrome (RDS).
    • Increased NICU admission rates.
    • Birth trauma (though generally low with planned CS).
  • Neurological Impairment: In rare cases, severe hypoxia due to uterine rupture can lead to cerebral palsy or other long-term neurological deficits.
Source: Obstetrics by Ten Teachers, 21st Edition, Chapters 13, 14. Eranthi Samarakoon, A Guide to the Clinical Examination in Obstetrics & Gynaecology, for Undergraduates and Postgraduates, Chapter 12. RCOG Green-top Guideline No. 45 – Birth after previous Caesarean birth.

Obstetrics Long Case: Anaemia Complicating Pregnancy

Patient Summary

A 26-year-old G3P2, mother of two healthy children (aged 4 and 2 years, both term vaginal deliveries with normal birth weights), presents at 34 weeks of gestation. She reports increasing fatigue, lethargy, and occasional shortness of breath on exertion over the past month. Her booking full blood count at 10 weeks was normal. She recalls being told her haemoglobin (Hb) was slightly low at her 28-week visit but did not start the iron supplements prescribed due to nausea. She has no significant past medical or surgical history. She is a vegetarian and admits to irregular dietary iron intake. Her BMI at booking was 23 kg/m2.

How would your history taking help you differentiate between potential causes, assess severity, and identify potential complications of her anemia?

My history taking would aim to differentiate between common causes of anaemia in pregnancy, confirm the severity of her symptoms, and identify any predisposing factors or complications. [cite_start]The commonest cause of anaemia in pregnancy is iron deficiency[cite: 9676].

Key Areas of Inquiry and Their Significance:

  • Symptoms of Anaemia: I would specifically quantify her symptoms to assess severity and impact on daily life.
    • Fatigue & Lethargy: When did it start, how much does it affect daily activities, and is it worse with exertion?
    • Dyspnoea: On what level of exertion does she experience shortness of breath? Any dyspnoea at rest or nocturnal dyspnoea? Significance: Dyspnoea at rest or with minimal exertion can indicate severe anaemia or cardiac decompensation.
    • Other Symptoms: Palpitations, dizziness, faintness, pallor (though subjective).
    • Pica: Craving for non-food items (e.g., ice, clay, dirt). Significance: A specific symptom of iron deficiency.
  • Dietary History (Detailed): Since she is vegetarian and admits to irregular intake.
    • 24-hour Recall: A detailed account of food and fluid intake over the past 24 hours.
    • Sources of Iron: Specific intake of iron-rich foods (e.g., dark leafy greens, legumes, fortified cereals for vegetarians).
    • Inhibitors/Enhancers of Iron Absorption: Inquire about consumption of tea/coffee with meals (inhibitors) and Vitamin C-rich foods (enhancers). Significance: Helps assess dietary iron adequacy and absorption.
  • Iron Supplement History: She mentioned not taking supplements due to nausea.
    • Compliance: Reconfirm exact reasons for non-compliance (nausea, constipation, taste).
    • Previous Prescriptions: What type and dose of iron was prescribed?
  • Causes of Blood Loss:
    • Gynaecological: Heavy menstrual bleeding (menorrhagia) prior to pregnancy. Significance: Can deplete iron stores pre-pregnancy.
    • Gastrointestinal: History of melena, hematemesis, or chronic NSAID use. Significance: Suggests GI blood loss.
    • Obstetric: Bleeding in early pregnancy (e.g., miscarriage), antepartum haemorrhage.
  • Risk Factors for Anaemia:
    • Multiparity: She is G3P2. [cite_start]Increased parity depletes maternal iron stores with each successive pregnancy[cite: 14520].
    • Short Interpregnancy Interval: Her last child was 2 years ago. Significance: A short interval can prevent full iron store repletion.
    • Multiple Pregnancy: Not applicable here.
    • Hyperemesis Gravidarum: History of severe vomiting in early pregnancy.
    • Low Socioeconomic Status/Poor Hygiene: Inquire about, as this can increase risk of parasitic infections (e.g., hookworm) which cause chronic blood loss.
    • Family History: History of inherited blood disorders (e.g., thalassaemia, sickle cell disease, bleeding disorders). Significance: Suggests alternative or co-existing causes of anaemia.
  • Symptoms of Complications:
    • Reduced Fetal Movements: Any perceived reduction. Significance: Severe anaemia can lead to fetal hypoxia and compromise.
    • Infections: Any symptoms of recent infections. Significance: Infection can contribute to anaemia of chronic disease.
Source: Obstetrics by Ten Teachers, 21st Edition, Chapter 6, 10. Eranthi Samarakoon, A Guide to the Clinical Examination in Obstetrics & Gynaecology, for Undergraduates and Postgraduates, Chapter 10.
What specific findings would you look for on clinical examination and what is their significance?

The examination aims to confirm the clinical signs of anaemia, assess its severity, look for signs of complications, and identify any features suggesting underlying causes (e.g., other nutritional deficiencies, bleeding disorders, or chronic diseases).

Clinical Examination Findings and Their Significance:

  • General Examination:
    • Vital Signs:
      • Pulse Rate: Tachycardia (even at rest) suggests a compensatory mechanism for reduced oxygen-carrying capacity due to anaemia. Severe tachycardia can indicate cardiac decompensation.
      • Blood Pressure: Usually normal in anaemia, but may be low in very severe cases.
    • Pallor:
      • Mucous Membranes: Inspect conjunctiva, oral mucosa, and palmar creases. Significance: Clinical pallor is often a late sign of anaemia but indicates significant reduction in Hb levels.
      • Nail Beds: Look for koilonychia (spoon-shaped nails). Significance: A sign of chronic severe iron deficiency.
      • Angular Stomatitis: Cracks at the corners of the mouth. Significance: Can indicate iron or B vitamin deficiencies.
    • Weight and BMI: Calculate current BMI. Significance: Very low BMI can indicate poor nutritional status.
    • Oedema: Assess for ankle and sacral oedema. Significance: Can indicate severe anaemia leading to cardiac strain/failure.
    • Thyroid Gland: Palpate for enlargement. Significance: Thyroid dysfunction can sometimes be associated with anaemia.
    • Lymph Nodes: Palpate for generalized lymphadenopathy. Significance: Suggests systemic infection or haematological malignancy.
  • Abdominal Examination:
    • Organomegaly: Palpate for hepatosplenomegaly. Significance: Can suggest haemolytic anaemias or blood dyscrasias.
    • Uterine Assessment: Symphysis-fundal height (SFH). Significance: To ensure appropriate fetal growth. Severe maternal anaemia can rarely cause FGR.
    • Fetal Heart Sounds (FHS): Auscultate. Significance: Check fetal well-being.
  • Cardiovascular System:
    • Auscultation: Listen for flow murmurs (e.g., systolic ejection murmur at the base). Significance: Common in anaemia due to hyperdynamic circulation.
    • Signs of Cardiac Decompensation: Listen for crepitations at lung bases, assess for raised JVP. Significance: Indicate impending or overt cardiac failure due to severe anaemia.
  • Skin Examination:
    • Bleeding Manifestations: Look for petechiae, purpura, or ecchymoses. Significance: Suggests bleeding disorders or thrombocytopenia, which can cause anaemia or complicate management.
Source: Obstetrics by Ten Teachers, 21st Edition, Chapter 10. Eranthi Samarakoon, A Guide to the Clinical Examination in Obstetrics & Gynaecology, for Undergraduates and Postgraduates, Chapter 10.
How would you classify the severity and type of anemia in this patient?

Classification of anaemia in pregnancy is based on haemoglobin levels, and the type is determined by red cell indices and potential causes. The severity of symptoms also plays a crucial role.

Classification of Anaemia by Haemoglobin (Hb) Level:

[cite_start]

According to WHO guidelines, anaemia in pregnancy is defined as follows[cite: 9673, 14544]:

    [cite_start]
  • Mild Anaemia: Hb 100-109 g/L (10-10.9 g/dL)[cite: 14544].
    • [cite_start]
  • Moderate Anaemia: Hb 70-99 g/L (7-9.9 g/dL)[cite: 14544].
    • [cite_start]
  • Severe Anaemia: Hb <70 g/L (<7 g/dL)[cite: 14544].

For this patient, her Hb at 28 weeks was “slightly low” and her current symptoms (fatigue, lethargy, dyspnoea on exertion) suggest her anaemia has worsened. Without her exact Hb level, I cannot definitively classify it. However, given her symptoms and non-compliance with iron, it is likely at least moderate, potentially severe. [cite_start]The accepted level of Hb throughout pregnancy is 11 g/dL; however, 10.5 g/dL can be taken as the cut-off point to diagnose anaemia in the second and third trimesters[cite: 9673, 14544].

Classification of Anaemia by Type (Probable based on history):

    [cite_start]
  • Iron Deficiency Anaemia (IDA): This is the commonest cause of anaemia complicating pregnancy[cite: 9676]. Her history strongly suggests IDA:
      [cite_start]
    • Multiparous (G3P2): Each pregnancy depletes iron stores[cite: 14520].
    • Short interpregnancy interval (2.5 years): May not have allowed full repletion of iron stores.
    • Vegetarian diet: Potentially lower dietary iron intake, especially haem iron.
    • Non-compliance with iron supplements due to nausea.
    • Symptoms of fatigue and dyspnoea are consistent with IDA.
  • Other Potential Types (less likely given history, but must consider for investigation):
    • Mixed Nutritional Deficiency Anaemia: If there are other dietary deficiencies (e.g., B12, folate), especially in a vegetarian.
    • Thalassaemia Trait or other Haemoglobinopathies: If there’s a family history (she denies one, but would investigate if treatment fails).
    • Anaemia of Chronic Disease/Infection: Less likely given she has no significant PMH, but a chronic UTI could contribute.
    • Anaemia from Blood Loss: Less likely given no history of bleeding from other sites in pregnancy.

Severity of Symptoms:

Her reported dyspnoea on exertion indicates a symptomatic anaemia, suggesting that the degree of anaemia is significant enough to affect her daily life and oxygen-carrying capacity.

Source: Obstetrics by Ten Teachers, 21st Edition, Chapter 10. Eranthi Samarakoon, A Guide to the Clinical Examination in Obstetrics & Gynaecology, for Undergraduates and Postgraduates, Chapter 10.
How would you investigate this patient?

The investigations aim to confirm the type of anaemia (most likely iron deficiency), assess its severity, rule out other causes, and ensure fetal well-being, especially given her non-compliance with iron supplements and worsening symptoms.

1. Initial Investigations (STAT on admission/visit):

  • Full Blood Count (FBC):
    • Haemoglobin (Hb) Level: This is the most crucial test for classifying severity.
    • Red Cell Indices (MCV, MCH, MCHC): To differentiate between microcytic hypochromic (typical of IDA) and macrocytic anaemia.
    • Red Cell Count & Red Cell Distribution Width (RDW): Further aid in classification.
    [cite_start]Significance: For IDA, Hb, MCV, and MCHC will be low[cite: 9681].
  • Blood Picture (Peripheral Smear):
    • Purpose: To visualize red cell morphology.
      • [cite_start]
    • Findings: For IDA, it will show microcytic hypochromic red blood cells with anisopoikilocytosis (variation in size and shape) and pencil-shaped cells[cite: 9683]. It can also detect features of other anaemias (e.g., target cells in thalassaemia, dimorphic picture in mixed deficiency).

2. Confirmatory/Differentiating Investigations (Based on FBC & Blood Picture):

  • Serum Ferritin:
    • Purpose: This is the best indicator of body iron stores.
    • Findings: A level below 15 ng/mL is diagnostic of IDA. [cite_start]Treatment is required if below 30 ng/mL[cite: 9687].
    [cite_start]Significance: Useful in confirming iron deficiency and differentiating from thalassaemia trait (where ferritin would be normal or high despite microcytosis)[cite: 9688]. It is particularly relevant for her as a vegetarian with potential dietary inadequacy.
  • Haemoglobin Electrophoresis:
    • Purpose: To rule out haemoglobinopathies (e.g., thalassaemia trait or sickle cell trait).
    • Findings: Detects abnormal haemoglobin variants (e.g., HbA2 elevated in beta-thalassaemia trait).
    Significance: Necessary if FBC shows microcytosis with normal/high ferritin, or if there’s a family history of inherited anaemias.
  • Serum B12 and Folate Levels:
    • Purpose: To rule out megaloblastic anaemia or mixed deficiency anaemia.
    • Findings: Low levels indicate deficiency.
    Significance: Important, especially for vegetarians who are at higher risk of B12 deficiency.

3. Fetal Assessment:

  • Cardiotocography (CTG): To assess fetal well-being. Significance: Severe maternal anaemia can lead to fetal hypoxia.
  • Ultrasound Scan (USS):
    • Fetal Biometry: To assess fetal growth. Significance: Severe maternal anemia can rarely cause FGR.
    • Doppler Studies: (e.g., MCA-PSV) if severe anemia and suspected fetal anemia/hydrops (rare, usually with Hb <4 g/dL).

4. Other Investigations (if indicated by history/exam or non-response to treatment):

  • Stool for Ova and Parasites: If poor hygiene or exposure to endemic areas suggests parasitic infection (e.g., hookworm).
  • Upper/Lower GI Endoscopy: If there’s a history of GI bleeding and other causes are ruled out.
Source: Obstetrics by Ten Teachers, 21st Edition, Chapter 10. Eranthi Samarakoon, A Guide to the Clinical Examination in Obstetrics & Gynaecology, for Undergraduates and Postgraduates, Chapter 10.
What is your management plan for this patient, considering her gestation and clinical picture?

My management plan focuses on confirming iron deficiency, initiating effective iron replacement, optimizing dietary intake, and preparing for a safe delivery, given her symptomatic anaemia at 34 weeks of gestation.

1. Initial Management (After Investigations Confirm IDA):

  • Confirm Diagnosis: Based on FBC and blood picture suggestive of microcytic hypochromic anaemia, and likely low serum ferritin.
  • Patient Education & Counselling:
    • Explain the diagnosis and its potential impact on her and the baby.
    • Emphasize the importance of compliance with iron therapy.
    • Address her previous issue of nausea with oral iron.
  • Dietary Advice:
    • Advise consumption of iron-rich foods (emphasizing non-heme sources for vegetarians like fortified cereals, legumes, leafy greens).
      • [cite_start]
    • Recommend pairing iron-rich foods/supplements with Vitamin C (e.g., orange juice) to enhance absorption[cite: 9696].
      • [cite_start]
    • Advise avoiding tea/coffee with meals/iron supplements, as polyphenols inhibit iron absorption[cite: 9695].
    • Advise taking calcium supplements at a different time from iron.

2. Iron Replacement Therapy (Mainstay of Treatment):

  • Oral Iron Therapy (First Line):
    • Formulation & Dose: Ferrous fumarate (180 mg) or ferrous sulphate (300 mg) or ferrous gluconate (500 mg) provide 60 mg elemental iron. [cite_start]A double dose (120 mg elemental iron) is given initially to anaemic patients to ensure adequate intake and rapid correction[cite: 9691, 9692].
    • Administration: Take on an empty stomach (1 hour before or 2 hours after a meal) with Vitamin C.
    • Managing Side Effects: Advise starting with a lower dose (e.g., once daily) and gradually increasing, or taking with food to minimize nausea/constipation (though this can affect absorption). Switching to a different iron salt (e.g., gluconate) may help. Stool softeners for constipation.
  • Parenteral Iron Therapy (If Indicated):
    • Indications: Non-compliance or intolerance to oral iron despite modifications, malabsorption syndromes, severe anaemia at term (e.g., Hb <10 g/dL after 36 weeks, where there's insufficient time for oral iron to work), or anaemia with symptoms of decompensation (e.g., cardiac strain), or when anaemia needs to be corrected rapidly.
    • Advantages: More effective due to guaranteed compliance, replenishes stores more rapidly.
    • Disadvantages: Risk of anaphylaxis or other reactions.
  • Blood Transfusion (If Indicated):
    • Indications: Hb <7 g/dL (due to immediate risk of heart failure), or Hb <10 g/dL after 36 weeks if patient is symptomatic and cannot receive parenteral iron or is in active labour. Acute massive blood loss.

3. Monitoring Response to Treatment:

  • Repeat FBC: Assess haemoglobin level after 2 weeks of therapy. [cite_start]Significance: For a correct IDA diagnosis, Hb should rise by ≥1 g/dL (0.5-2 g/dL)[cite: 9701]. If no response, re-evaluate diagnosis and compliance, or consider parenteral iron.
  • Serial Fetal Assessment: Continue routine fetal movement charting. USS for growth only if FGR suspected.

4. Preparation for Delivery (34 weeks gestation):

    [cite_start]
  • Aim for Hb >10.5 g/dL at Term: This is the target for delivery[cite: 9727].
  • Delivery Location: Advise delivery at a tertiary care center if anaemia is still significant at term.
  • Blood Products: Cross-match 4 pints of blood before delivery if Hb remains low (<10 g/dL).
  • Labour Management:
    • Active Management of Third Stage: Crucial to prevent PPH. [cite_start]Give Oxytocin after delivery of baby[cite: 9730]. [cite_start]An oxytocin infusion may be commenced as prophylaxis against PPH[cite: 9731].
      • [cite_start]
    • Close Observation Post-delivery: For at least 4 hours in the labour ward for bleeding[cite: 9731].

5. Postnatal Management:

    [cite_start]
  • Continue Iron Therapy: Oral iron therapy should be continued for at least 3-6 months after normal Hb levels are achieved to replenish iron stores[cite: 9734].
  • Dietary Advice: Continue to advise on an iron-rich diet.
  • Contraception: Counsel on family planning. Advise a method for at least 2 years to allow iron stores to fully replenish. [cite_start]Copper IUCDs are generally avoided in those prone to heavy menstrual bleeding[cite: 9737]. [cite_start]OCPs are generally preferred for their menstrual regulating and iron-sparing effects[cite: 9738].
  • Follow-up: Regular postnatal visits and re-evaluation of Hb.
Source: Obstetrics by Ten Teachers, 21st Edition, Chapter 10. Eranthi Samarakoon, A Guide to the Clinical Examination in Obstetrics & Gynaecology, for Undergraduates and Postgraduates, Chapter 10.
What are the potential complications for both mother and fetus in this case?

Untreated or inadequately treated anaemia in pregnancy, especially severe iron deficiency, can lead to significant maternal and fetal complications.

Maternal Complications:

  • Cardiac Decompensation/Heart Failure: Especially with severe anaemia (Hb <7 g/dL) due to increased cardiac output to compensate for reduced oxygen-carrying capacity. This can lead to dyspnoea at rest, orthopnoea, and pulmonary oedema.
  • Increased Susceptibility to Infections: Anaemia can impair immune function.
    • [cite_start]
  • Increased Risk of Postpartum Haemorrhage (PPH): Although not a direct cause, severe anaemia makes the mother less tolerant of blood loss and can worsen outcomes from PPH[cite: 9732].
  • Increased Need for Blood Transfusion: During pregnancy or around delivery, increasing risks associated with transfusions (e.g., reactions, infections).
  • Fatigue and Reduced Quality of Life: Significant impact on daily activities and overall well-being.
  • Delayed Wound Healing: If she requires a Caesarean section or has a perineal tear.
  • Difficulty in Lactation: Severe anaemia can sometimes affect milk supply or maternal energy for breastfeeding.

Fetal/Neonatal Complications:

  • Fetal Growth Restriction (FGR): In very severe cases of maternal anaemia (Hb <4 g/dL), fetal oxygenation can be compromised, leading to FGR.
  • Preterm Birth: While not a direct cause, severe maternal anaemia has been associated with an increased risk of preterm delivery.
  • Fetal Distress/Hypoxia: Due to reduced oxygen-carrying capacity from severe maternal anaemia, especially during labour.
  • Increased Fetal Anemia (if severe maternal anemia): Can rarely occur in severe cases, leading to hydrops fetalis (rare with IDA).
  • Low Birth Weight: Associated with FGR.
  • Poor Iron Stores in the Neonate: Babies born to severely anemic mothers may have depleted iron stores at birth, making them prone to iron deficiency in infancy.
  • Neonatal Complications: Such as increased risk of infection, hypothermia, and feeding difficulties.
  • Stillbirth: In extremely rare and severe, untreated cases of maternal anaemia leading to cardiac decompensation.
Source: Obstetrics by Ten Teachers, 21st Edition, Chapter 10. Eranthi Samarakoon, A Guide to the Clinical Examination in Obstetrics & Gynaecology, for Undergraduates and Postgraduates, Chapter 10.

Obstetrics Long Case: Breech Presentation

Patient Summary

A 28-year-old primigravida presents at 37 weeks of gestation. Her pregnancy has been uncomplicated until now. During a routine antenatal visit, her midwife noted a firm, irregular fetal pole in the lower abdomen and a hard, ballotable head in the upper pole, clinically suspecting a breech presentation. An ultrasound scan confirmed a frank breech presentation. She has no significant past medical or surgical history. Her dates were confirmed by an early ultrasound scan. Fetal movements are normal. She has no complaints of pain or bleeding. She is keen to explore all options for delivery.

How would your history taking help you differentiate between potential causes, assess suitability for ECV, and identify factors influencing the mode of delivery?

My history taking would focus on identifying potential causes of breech presentation, assessing her suitability for External Cephalic Version (ECV), and gathering information crucial for deciding the mode of delivery (vaginal breech vs. Caesarean section).

Key Areas of Inquiry and Their Significance:

  • Confirmation of Breech Diagnosis:
    • When was it detected and confirmed by ultrasound? Significance: Spontaneous version can occur until 36 weeks. Confirmation at 37 weeks means it’s unlikely to spontaneously turn.
    • Was she informed of the diagnosis and all management options (ECV, vaginal breech delivery, elective CS) at that time? Significance: Crucial for informed consent and shared decision-making.
  • Risk Factors for Breech Presentation (Predisposing Factors): I would inquire about conditions known to predispose to breech presentation.
    • Uterine Factors: History suggestive of fibroids, congenital uterine abnormalities (e.g., bicornuate uterus), or previous uterine surgery (e.g., myomectomy). Significance: These can alter uterine shape and prevent cephalic presentation.
    • Placental Factors: History of placenta previa. Significance: A placenta praevia occupying the lower segment can prevent the head from engaging.
    • Amniotic Fluid Volume: Any history or symptoms suggestive of polyhydramnios (excessive fluid) or oligohydramnios (reduced fluid). Significance: Too much fluid can allow the fetus to move freely; too little fluid can restrict movement and prevent version.
    • Fetal Factors: Any detected fetal abnormalities (e.g., hydrocephalus, anencephaly, neuromuscular conditions). Significance: These can impede normal fetal flexion and version.
    • Previous Preterm Labour: Significance: Breech is more common at earlier gestations.
    • Multiple Gestation: Not applicable here.
  • Suitability for External Cephalic Version (ECV): I would ask questions to exclude contraindications for ECV.
    • Contraindications for Vaginal Delivery: Any reasons (e.g., placenta previa, compromised fetal condition). Significance: Absolute contraindications for ECV.
    • Recent Bleeding: Any antepartum haemorrhage within the last 7 days. Significance: Absolute contraindication for ECV.
    • Membrane Rupture: Any pre-labour rupture of membranes. Significance: Absolute contraindication due to infection risk.
    • Previous Uterine Scar: Previous Caesarean section or myomectomy. Significance: Relative contraindication for ECV due to rupture risk. She is a primigravida, so this is not a concern for her.
    • Other Medical Conditions: History of pre-eclampsia or hypertension. Significance: Relative contraindications.
    • Fetal Well-being: Any concerns about fetal movements or abnormal CTG previously. Significance: Abnormal fetal heart rate is an absolute contraindication for ECV.
  • Factors Influencing Mode of Delivery Decision (if ECV fails or is contraindicated):
    • Patient’s Preference: Her desires for vaginal birth vs. elective CS, and her understanding of the risks/benefits.
    • Past Obstetric History (if multiparous): Previous babies’ weights, duration of labour, occurrence of prolonged labour, previous Caesarean sections, instrumental deliveries. Significance: A history of uncomplicated vaginal deliveries of term babies (especially >3kg) increases suitability for vaginal breech. (Not applicable to a primigravida).
Source: Obstetrics by Ten Teachers, 21st Edition, Chapter 6. Eranthi Samarakoon, A Guide to the Clinical Examination in Obstetrics & Gynaecology, for Undergraduates and Postgraduates, Chapter 2, 3.
What specific findings would you look for on clinical examination and what is their significance?

The examination aims to confirm the breech presentation, identify the type of breech, assess fetal size, and identify any factors influencing the success of ECV or the mode of delivery.

Clinical Examination Findings and Their Significance:

  • General Examination:
    • Maternal Build: Assess maternal height and weight. Significance: Maternal weight <65kg may increase ECV success rate. Short stature may suggest a smaller pelvis.
    • Vital Signs: Blood pressure. Significance: Hypertension/pre-eclampsia is a relative contraindication for ECV.
  • Abdominal Examination (Leopold’s Maneuvers):
    • Fundal Grip: Palpate the uterine fundus. Significance: The hard, ballotable fetal head will be felt in the upper pole.
    • Lateral Grips: Palpate the sides of the uterus to determine the position of the back and limbs.
    • Pelvic Grip: Palpate the lower pole (above the symphysis pubis). Significance: The firm, irregular breech will be felt in the lower pole.
    • Engagement of Breech: Assess engagement of the breech. Significance: Non-engagement of the breech (if >38 weeks) increases the success rate of ECV. Engagement suggests a tight fit in the pelvis.
    • Estimated Fetal Weight (EFW): Clinically estimate fetal weight. [cite_start]Significance: EFW <3500g is generally preferred for vaginal breech delivery[cite: 6].
    • Amniotic Fluid Volume: Clinically assess. Significance: Adequate liquor makes ECV easier; oligohydramnios is a contraindication to ECV.
    • Uterine Irregularities: Palpate for fibroids or uterine anomalies. [cite_start]Significance: Can predispose to breech presentation[cite: 6].
  • Pelvic Examination (Digital Vaginal Examination – if contemplating vaginal breech trial and only after ECV is ruled out or failed):
    • Clinical Pelvimetry: Assess the adequacy of the maternal pelvis (inlet, mid-cavity, outlet). Significance: A clinically adequate pelvis is a prerequisite for vaginal breech delivery, especially in a primigravida where the pelvis is “untested”.
    • Cervical Status: Assess cervical favourability (Bishop’s score).
    • Fetal Presentation/Position: Confirm the breech (e.g., frank, complete, footling). Significance: Footling breech is a contraindication to vaginal breech delivery (high risk of cord prolapse). Hyperextension of the fetal head should be excluded, as it precludes safe vaginal delivery.
Source: Obstetrics by Ten Teachers, 21st Edition, Chapter 6. Eranthi Samarakoon, A Guide to the Clinical Examination in Obstetrics & Gynaecology, for Undergraduates and Postgraduates, Chapter 2.
How would you classify the type of breech presentation and assess its significance?

Breech presentation refers to the fetal buttocks or feet presenting first. Its significance lies in the potential for increased risk during labour and delivery compared to a cephalic presentation.

Types of Breech Presentation:

Breech presentations are classified based on the attitude of the fetal legs and hips:

  • Frank (Extended) Breech: (Most common, ~65-70%) Both hips are flexed, and both knees are extended. [cite_start]The buttocks present first[cite: 6].
  • Complete (Flexed) Breech: (Less common, ~10-15%) Both hips and both knees are flexed. [cite_start]The buttocks and feet present first[cite: 6].
  • Incomplete Breech: (Least common, ~5-10%) One or both hips are extended. This includes:
      [cite_start]
    • Footling Breech: One or both feet present first[cite: 6].
    • Kneeling Breech: One or both knees present first (rare).

Her case states an “frank breech presentation” was confirmed by ultrasound. This is generally considered the safest type of breech for a *potential* vaginal delivery, as the buttocks provide a better dilating wedge and there’s a lower risk of cord prolapse compared to footling breech.

Assessment of Significance/Severity:

The significance of breech presentation at term primarily stems from the increased risks during labour and delivery, regardless of the type, compared to a cephalic presentation.

  • Increased Perinatal Morbidity and Mortality: Planned vaginal delivery of a term breech singleton is associated with a 3% increased risk of death or serious morbidity to the baby compared to planned Caesarean section.
  • Higher Caesarean Section Rate: Most term breech presentations are delivered by planned Caesarean section due to safety concerns.
  • Risk of Cord Prolapse: Especially with footling breech or if membranes rupture prematurely before engagement of the presenting part.
  • Head Entrapment: The possibility of the body delivering through a partially dilated cervix, but the head becoming entrapped if it is not well-flexed or if there is fetopelvic disproportion.
  • Birth Trauma: Increased risk of neurological (brachial plexus injury), skeletal (fractures), or visceral injuries during vaginal breech delivery.
  • Maternal Morbidity: Increased risk of prolonged labour, need for intervention, or complications related to Caesarean section.

The decision on the mode of delivery will depend on balancing these risks against patient preference and specific clinical circumstances.

Source: Obstetrics by Ten Teachers, 21st Edition, Chapter 6. Eranthi Samarakoon, A Guide to the Clinical Examination in Obstetrics & Gynaecology, for Undergraduates and Postgraduates, Chapter 2.
How would you investigate this patient?

The investigations aim to confirm the breech presentation, identify its specific type, assess fetal well-being, rule out underlying causes, and gather information crucial for planning the mode of delivery.

1. Initial Confirmation & Assessment:

  • Ultrasound Scan (USS): (This has already confirmed frank breech).
    • Confirmation of Presentation: Definitive confirmation of breech presentation.
    • Type of Breech: Identify the specific type (frank, complete, footling). Significance: Footling breech is a strong contraindication to vaginal delivery.
    • Fetal Biometry: Estimate fetal weight (EFW). Significance: EFW <3500g is generally favorable for vaginal breech delivery. Macrosomia (>4000g) is a relative contraindication.
    • Amniotic Fluid Volume: Assess Amniotic Fluid Index (AFI). Significance: Oligohydramnios or polyhydramnios are contraindications for ECV and can complicate labour.
    • Placental Location: Rule out placenta previa. Significance: Placenta previa is an absolute contraindication to vaginal delivery and ECV.
    • Uterine Anomalies: Assess for fibroids or congenital uterine anomalies. Significance: These can predispose to breech.
    • Fetal Anomalies: Look for hyperextension of the fetal head (“stargazing” head) or other congenital anomalies (e.g., hydrocephalus, neuromuscular conditions). Significance: These are contraindications for vaginal breech delivery.
  • Cardiotocography (CTG): A baseline CTG is essential to assess fetal well-being before considering ECV or proceeding with labour. Significance: An abnormal CTG (e.g., non-reassuring features) is an absolute contraindication for ECV.

2. Pre-ECV/Delivery Planning Investigations:

  • Maternal Blood Group and Antibody Screen: Significance: If ECV is performed, Anti-D immunoglobulin is required for Rhesus D-negative women to prevent sensitization in case of feto-maternal hemorrhage.
  • Full Blood Count (FBC): To check for anemia and baseline status.

3. Imaging for Pelvimetry (if considering Vaginal Breech Delivery):

  • Radiological Pelvimetry (X-ray or MRI pelvimetry): To assess the adequacy of the bony pelvis. Significance: While clinical pelvimetry is performed, radiological pelvimetry can provide objective measurements of the pelvic diameters. According to some studies (e.g., PREMODA trial), performing radiological pelvimetry increases the success of vaginal breech delivery.
Source: Obstetrics by Ten Teachers, 21st Edition, Chapter 6. Eranthi Samarakoon, A Guide to the Clinical Examination in Obstetrics & Gynaecology, for Undergraduates and Postgraduates, Chapter 2.
What is your management plan for this patient, including the discussion of ECV, planned vaginal breech delivery, and elective Caesarean section?

My management plan at 37 weeks gestation would involve discussing the three main management options for breech presentation: External Cephalic Version (ECV), planned Elective Caesarean Section (ERCS), and planned Vaginal Breech Delivery. The decision would be made through shared decision-making with the patient.

1. External Cephalic Version (ECV):

This would be the first option discussed, as it aims to convert the breech to cephalic, allowing for a vaginal delivery and avoiding the risks of breech presentation and Caesarean section.

  • Discussion: Explain the procedure, its benefits (reduces CS rate due to breech, avoids fetal risks of vaginal breech delivery), success rate, and risks.
    • Success Rate: ~50% (higher in multipara, non-engaged breech, good AFI, tocolysis).
    • Risks: Placental abruption, cord compression, uterine rupture (rare), feto-maternal haemorrhage, transient fetal heart rate changes.
  • Suitability: She is a primigravida with a frank breech, normal AFI (implied by uncomplicated history), and no contraindications from history/examination.
  • Procedure (if she consents):
    • Performed from 37 weeks in primigravida by an experienced obstetrician in a setting with immediate access to emergency Caesarean section facilities.
    • Fetal heart monitoring (CTG) before, during, and after the procedure.
    • Tocolysis (e.g., Nifedipine) can be given to relax the uterus and increase success rate.
    • Anti-D immunoglobulin for Rhesus D-negative women post-procedure.

2. Planned Elective Caesarean Section (ERCS):

This is the recommended option by current guidelines (e.g., Term Breech Trial) due to reduced perinatal morbidity and mortality compared to planned vaginal breech delivery.

  • Discussion: Explain the benefits (lower risk of death or serious morbidity for the baby), and risks (surgical risks for mother, e.g., infection, hemorrhage, longer recovery; future pregnancy implications like placenta previa/accreta).
  • Timing: Typically performed at 39 weeks of gestation.
  • Pre-operative preparation: Standard for LSCS (fasting, pre-medication, IV access, antibiotics).

3. Planned Vaginal Breech Delivery (If ECV fails or is contraindicated/refused):

While less common, it remains an option for selected patients who choose it after informed counselling.

  • Discussion: Emphasize the increased risks to the baby (3% increased risk of death/serious morbidity) compared to ERCS. Discuss the criteria for selection.
  • Selection Criteria for Vaginal Breech Delivery (Strict):
    • Maternal: Clinically adequate pelvis (ideally confirmed by radiological pelvimetry), young, fertile, multipara (not applicable here as she is primigravida, but crucial criteria if applicable), no contraindications for vaginal delivery.
    • Fetal: Frank or complete breech (her case), EFW <3500g, no hyperextension of fetal head, no major fetal anomalies.
    • Labour: Spontaneous onset of labour at or before 40 weeks, continuous fetal heart rate monitoring, experienced operator available.
    • Contraindications for Vaginal Breech: Footling breech, estimated fetal weight >3800g or <2000g, previous CS, pre-eclampsia, oligohydramnios, early induction of labour. (Some are not relevant to her).
  • Intrapartum Management (if vaginal breech labour proceeds):
    • Hospital Setting: Must be in a specialized hospital with immediate access to Caesarean section.
    • Monitoring: Continuous CTG monitoring.
    • Pain Relief: Epidural analgesia is often preferred to avoid voluntary pushing before full dilatation, but needs to be carefully managed.
    • Induction/Augmentation: Induction of labour may be considered in favourable individual circumstances but augmentation is generally not recommended due to increased risks of cord prolapse and disproportion.
    • Delivery: “Masterly inactivity” approach, with assistance only when indicated (e.g., Pinard manoeuvre for extended legs, Mauriceau-Smellie-Veit manoeuvre or forceps for head delivery). Paediatrician present for delivery.
Source: Obstetrics by Ten Teachers, 21st Edition, Chapter 6. Eranthi Samarakoon, A Guide to the Clinical Examination in Obstetrics & Gynaecology, for Undergraduates and Postgraduates, Chapter 2.
What are the potential complications for both mother and fetus in this case?

Breech presentation carries specific risks for both mother and fetus, regardless of the chosen mode of delivery. These risks are generally higher with planned vaginal breech delivery compared to elective Caesarean section.

Maternal Complications:

  • With Planned Vaginal Breech Delivery:
    • Prolonged Labour: Due to less efficient cervical dilation by the breech compared to the head, or relative fetopelvic disproportion.
    • Increased Risk of Obstetric Intervention: Higher rates of oxytocin augmentation (if attempted), instrumental delivery, or emergency Caesarean section.
    • Postpartum Haemorrhage (PPH): Increased risk due to prolonged labour, uterine atony, or increased manipulation.
    • Genital Tract Trauma: Higher risk of perineal tears or vaginal lacerations.
    • Uterine Rupture: Rare, but increased risk if augmentation is used in cases of occult disproportion.
    • Psychological Impact: If vaginal breech delivery is attempted and fails, leading to emergency CS, it can be psychologically distressing.
  • With Elective Caesarean Section (ERCS):
    • Surgical Risks: Infection (wound, endometritis), hemorrhage, organ injury (bladder/bowel – rare), venous thromboembolism (DVT/PE).
    • Longer Recovery: Compared to uncomplicated vaginal delivery.
    • Future Pregnancy Implications: Increased risk of placenta previa/accreta and uterine rupture in subsequent pregnancies.

Fetal/Neonatal Complications:

  • Increased Perinatal Morbidity and Mortality: Regardless of mode of delivery, breech babies have a slightly higher risk of adverse outcomes compared to cephalic babies. This risk is notably higher with planned vaginal breech delivery compared to planned CS.
  • Birth Asphyxia: Risk of cord compression or prolonged labour leading to fetal hypoxia.
  • Birth Trauma:
    • Brachial Plexus Injury: (e.g., Erb’s palsy) due to difficulty with arm delivery.
    • Fractures: (e.g., clavicle, humerus, femur) during delivery.
    • Intracranial Haemorrhage: Due to rapid delivery of the head or head entrapment in a partially dilated cervix.
    • Visceral Injury: (e.g., liver, spleen, adrenal gland) due to manipulation.
  • Cord Prolapse: Higher risk, especially with footling breech or if membranes rupture before engagement.
  • Head Entrapment: If the body delivers but the head does not, particularly if the cervix is not fully dilated or if the head is hyperextended.
  • Fetal Anomalies: Breech presentation can be associated with fetal anomalies, some of which may be undiagnosed, leading to complications.
  • Neonatal Morbidities (if delivered by CS): Increased risk of transient tachypnoea of the newborn (TTN) or respiratory distress syndrome (RDS) compared to vaginal delivery.
Source: Obstetrics by Ten Teachers, 21st Edition, Chapter 6, 13. Eranthi Samarakoon, A Guide to the Clinical Examination in Obstetrics & Gynaecology, for Undergraduates and Postgraduates, Chapter 2.

Obstetrics Long Case: Abdominal Pain in Pregnancy

Patient Summary

A 30-year-old primigravida presents to the emergency department at 32 weeks of gestation with acute onset, severe right lower quadrant abdominal pain for the past 6 hours. The pain started suddenly, is constant, sharp, and radiates slightly towards her back. She also complains of anorexia and a single episode of vomiting. She denies any vaginal bleeding, leakage of fluid, or painful contractions. Fetal movements have been normal. Her pregnancy has been otherwise uncomplicated. She has no significant past medical or surgical history, except for a remote history of mild dysmenorrhoea.

How would your history taking help you differentiate between potential causes, assess severity, and identify potential complications of her abdominal pain?

Abdominal pain in pregnancy can be due to obstetric or non-obstetric causes, ranging from benign to life-threatening. My history taking would be systematic to cover both categories and assess the urgency.

Key Areas of Inquiry and Their Significance:

  • Detailed Pain History (SOCRATES):
    • Site: Right lower quadrant (RLQ). Significance: Points to differentials like appendicitis, right adnexal pathology, round ligament pain, pyelonephritis.
    • Onset: Acute and sudden. Significance: Suggests an acute event like rupture, torsion, abruption, or perforation rather than gradual onset conditions.
    • Character: Severe, constant, sharp. Significance: Intense pain suggests serious pathology (e.g., appendicitis, torsion, abruption). Colicky pain might suggest bowel obstruction, ureteric colic, or early labour.
    • Radiation: Towards her back. Significance: Could suggest retroperitoneal irritation (e.g., ureteric colic, pyelonephritis) or sometimes atypical appendicitis.
    • Associated Symptoms: Anorexia, single episode of vomiting. Significance: Common with acute abdominal conditions like appendicitis. Also ask about:
      • Fever/Chills: Suggests infection (e.g., pyelonephritis, appendicitis).
      • Bowel Habits: Constipation, diarrhoea, flatulence, abdominal distension. Significance: Bowel obstruction, gastroenteritis.
      • Urinary Symptoms: Dysuria, frequency, urgency, haematuria. Significance: Urinary tract infection (UTI), pyelonephritis, renal calculi.
      • Vaginal Discharge: Colour, odour. Significance: Pelvic infection (e.g., chorioamnionitis).
    • Exacerbating/Relieving Factors: Movement, position, food intake. Significance: Can help differentiate (e.g., round ligament pain exacerbated by movement, appendicitis pain worsens with coughing).
  • Obstetric History (Current Pregnancy):
    • Gestation (32 weeks): Important for considering gestational age-specific causes (e.g., preterm labour usually after 20-24 weeks, abruption more common in third trimester, round ligament pain usually 2nd trimester).
    • Fetal Movements: She denies reduced movements, which is reassuring, but any change would raise concern for fetal compromise (e.g., placental abruption).
    • Vaginal Bleeding/Fluid Leakage: She denies this. Significance: Absence of bleeding makes placental abruption less likely (though concealed abruption is possible) and rules out placenta previa as the cause of bleeding. Absence of fluid leakage rules out PROM.
    • Uterine Contractions: Ask specifically about uterine tightening, regularity, frequency, and intensity. Significance: To rule out preterm labour.
    • History of Trauma: Any recent falls or abdominal trauma. Significance: Risk factor for placental abruption.
  • Past Medical and Surgical History:
    • Previous Abdominal Surgeries: Appendicectomy, cholecystectomy, gynaecological surgeries. Significance: Can predispose to adhesions (bowel obstruction). Previous abdominal surgery can alter the presentation of appendicitis.
    • Pre-existing Conditions: Inflammatory bowel disease, gallstones, renal stones, ovarian cysts, fibroids, endometriosis. Significance: Pregnancy can exacerbate these or cause complications (e.g., red degeneration of fibroids, ovarian cyst torsion/rupture).
    • Gynaecological History: Pelvic inflammatory disease, ovarian cysts. Significance: May relate to adnexal pathology.
    • Allergies & Medications: Any chronic medications.
Source: Obstetrics by Ten Teachers, 21st Edition, Chapters 6, 12, 14, 20. Eranthi Samarakoon, A Guide to the Clinical Examination in Obstetrics & Gynaecology, for Undergraduates and Postgraduates, Chapter 1, 18.
What specific findings would you look for on clinical examination and what is their significance?

The examination aims to assess maternal stability, locate and characterize the pain, assess fetal well-being, and identify signs of inflammation, infection, or obstetric emergencies. The gravid uterus can alter physical signs, making diagnosis challenging.

Clinical Examination Findings and Their Significance:

  • General Examination:
    • Vital Signs:
      • Temperature: Fever suggests infection (e.g., appendicitis, pyelonephritis, chorioamnionitis).
      • Pulse Rate: Tachycardia can indicate pain, infection, or hypovolemia (e.g., internal bleeding).
      • Blood Pressure: Hypotension suggests shock (e.g., severe hemorrhage). Hypertension could indicate pre-eclampsia with atypical presentation.
      • Respiratory Rate: Tachypnoea indicates pain, infection, or respiratory distress.
    • General Appearance: Assess for pallor, signs of dehydration, distress, or toxicity. Significance: Helps assess overall severity and systemic involvement.
  • Abdominal Examination:
    • Inspection: Look for distension, scars, visible masses.
    • Palpation:
      • Tenderness: Localize the point of maximal tenderness (PMT). RLQ tenderness suggests appendicitis (McBurney’s point, though position can shift in pregnancy), round ligament pain, adnexal pathology.
      • Guarding & Rebound Tenderness: May be subtle in pregnancy due to stretched abdominal wall. Significance: Suggests peritoneal irritation.
      • Uterine Tone & Tenderness: Assess uterine consistency (soft vs. tense/rigid) and tenderness. Significance: A persistently tense, tender, and rigid uterus is highly suggestive of placental abruption. Localized uterine tenderness may indicate red degeneration of a fibroid.
      • Fetal Palpation: Assess fetal lie, presentation, and estimated fetal weight (EFW).
    • Percussion: Assess for percussion tenderness.
    • Auscultation: Listen for bowel sounds (present, hyperactive, or absent). Significance: Absent bowel sounds can suggest peritonitis or paralytic ileus; hyperactive sounds with pain could be obstruction.
  • Fetal Assessment:
    • Fetal Heart Sounds (FHS) / Cardiotocography (CTG): Auscultate FHS and perform a CTG. Significance: To assess fetal well-being. Any non-reassuring CTG features (e.g., decelerations, reduced variability) raise concern for fetal compromise (e.g., in abruption, severe maternal sepsis).
  • Pelvic Examination (Speculum and Bimanual – if indicated):
    • Speculum: Inspect the cervix for bleeding (exclude placenta previa or cervicitis), discharge (chorioamnionitis, vaginitis), or cervical changes (effacement, dilatation) suggestive of preterm labour. Avoid if placenta previa is not ruled out.
    • Bimanual: Assess cervical effacement and dilatation, consistency of uterus, adnexal tenderness or masses. Assess for uterine contractions manually. Significance: Differentiates preterm labour (cervical changes, palpable contractions) from other causes. Adnexal tenderness suggests ovarian pathology.
  • Renal Angle Tenderness: Percuss the costovertebral angle. Significance: Tenderness suggests pyelonephritis.
Source: Obstetrics by Ten Teachers, 21st Edition, Chapters 1, 6, 12, 14, 20. Eranthi Samarakoon, A Guide to the Clinical Examination in Obstetrics & Gynaecology, for Undergraduates and Postgraduates, Chapter 1, 18.
How would you classify the type of abdominal pain and assess its urgency?

Classifying abdominal pain in pregnancy involves considering its origin (obstetric vs. non-obstetric), character, and severity, which then guides the assessment of urgency.

Classification of Abdominal Pain:

  • Based on Origin:
    • Obstetric Causes: Directly related to pregnancy or its complications.
      • Common: Round ligament pain, Braxton Hicks contractions, preterm labour, placental abruption, red degeneration of fibroids, chorioamnionitis, uterine rupture.
      • Less Common: Early pregnancy complications (ectopic, miscarriage – not relevant at 32 weeks), ovarian torsion of corpus luteum cyst.
    • Non-Obstetric Causes: Unrelated to pregnancy, but occurring during it.
      • Common: Appendicitis, pyelonephritis/UTI, cholecystitis, gastroenteritis, renal colic, constipation.
      • Less Common: Bowel obstruction, perforated viscus, diverticulitis (rare in young), pancreatitis.
  • Based on Character/Pattern (as elicited in history):
    • Acute vs. Chronic: Her pain is acute onset.
    • Location: Right lower quadrant.
    • Type: Sharp, constant.
    • Associated Features: Anorexia, vomiting.

Her presentation (acute onset, severe, constant, sharp RLQ pain with anorexia and vomiting) points strongly towards an **acute surgical emergency**, such as **appendicitis**, which remains the most common non-obstetric surgical emergency in pregnancy. Given her lack of vaginal bleeding/fluid leakage/contractions, severe obstetric emergencies like placental abruption or preterm labour are less likely as primary diagnoses, though they must always be considered in the differential.

Assessment of Urgency:

The severity of her symptoms mandates immediate and urgent assessment and management. This is a **medical and surgical emergency** scenario, not a benign physiological pain.

  • “Red Flag” Signs and Symptoms Indicating High Urgency:
    • Severe, Acute Pain: Her described pain level.
    • Systemic Symptoms: Anorexia, vomiting, potential fever (if present).
    • Signs of Peritoneal Irritation: Guarding, rebound tenderness (though subtle in pregnancy).
    • Maternal Instability: Tachycardia, hypotension, pallor (signs of shock).
    • Fetal Compromise: Abnormal CTG, reduced fetal movements.
  • Differential Diagnoses and Urgency Levels:
    • High Urgency (Life-threatening for mother/fetus):
      • Appendicitis: Most common non-obstetric surgical emergency. Can progress to rupture and peritonitis.
      • Placental Abruption: Can cause severe maternal hemorrhage and fetal distress/demise.
      • Preterm Labour: Can lead to preterm birth with associated neonatal morbidity/mortality.
      • Ovarian Torsion/Rupture: Acute, severe pain, can lead to ovarian necrosis.
      • Acute Cholecystitis/Pancreatitis: Serious inflammatory conditions.
      • Uterine Rupture: Catastrophic event (unlikely in a primigravida without prior uterine surgery).
    • Moderate Urgency: Pyelonephritis, renal colic, red degeneration of fibroid (can be severe but generally not immediately life-threatening).
    • Low Urgency (Physiological/Benign): Round ligament pain, Braxton Hicks contractions, constipation. These are usually less severe and transient.

Given her presentation, immediate investigation and surgical consultation are paramount.

Source: Obstetrics by Ten Teachers, 21st Edition, Chapters 6, 12, 14, 20. Eranthi Samarakoon, A Guide to the Clinical Examination in Obstetrics & Gynaecology, for Undergraduates and Postgraduates, Chapter 18.
How would you investigate this patient?

The investigations aim to rapidly differentiate between the various causes of abdominal pain, particularly ruling out life-threatening obstetric and non-obstetric emergencies, and assessing maternal and fetal well-being.

1. Initial & Urgent Investigations (STAT):

  • Maternal Blood Tests:
    • Full Blood Count (FBC): To check for leukocytosis (suggests infection/inflammation like appendicitis, pyelonephritis) and haemoglobin (for anemia, e.g., from occult bleeding).
    • Inflammatory Markers (CRP, ESR): Elevated in inflammatory conditions.
    • Renal Function Tests (U&Es): Baseline, and to assess for kidney involvement (e.g., pyelonephritis, renal colic).
    • Liver Function Tests (LFTs) & Amylase/Lipase: To rule out cholecystitis or pancreatitis if suspected.
    • Blood Group & Cross-match: If suspicion of significant bleeding (e.g., abruption, ruptured ectopic – though less likely at 32 weeks, ruptured ovarian cyst) or need for surgery.
    • Blood Glucose: As a baseline.
    • Coagulation Profile: If suspicion of DIC (e.g., with severe abruption).
  • Urine Tests:
    • Urinalysis (Dipstick): For nitrites, leukocytes, blood, protein. Significance: To screen for UTI/pyelonephritis, or renal stones.
    • Midstream Urine (MSU) Culture & Sensitivity: To confirm UTI and guide antibiotic therapy.
  • Fetal Assessment:
    • Cardiotocography (CTG): Immediate and continuous CTG to assess fetal well-being. Look for baseline rate, variability, accelerations, and especially decelerations or increased uterine activity (suggesting preterm labour or abruption).

2. Imaging Studies:

  • Abdominal Ultrasound Scan (USS):
    • Obstetric USS: Assess fetal growth, amniotic fluid volume, and placental location (rule out previa, look for retroplacental clot for abruption). Assess for uterine contractions.
    • Targeted Abdominal USS: To evaluate the appendix (visualization is often difficult in advanced pregnancy), gallbladder (for stones/inflammation), kidneys (for hydronephrosis/stones), and adnexa (for ovarian cysts/torsion). Significance: Often the first-line imaging for acute abdominal pain in pregnancy due to no radiation exposure.
  • MRI (Magnetic Resonance Imaging) Abdomen & Pelvis:
    • Purpose: If ultrasound is inconclusive, MRI is the preferred next step, particularly for suspected appendicitis, as it provides excellent soft tissue detail without ionizing radiation.
  • CT Scan (Computed Tomography) Abdomen & Pelvis:
    • Purpose: Used if MRI is unavailable or inconclusive and clinical suspicion of a surgical emergency (e.g., appendicitis) remains high. Benefits of accurate diagnosis generally outweigh the low radiation risk to the fetus in urgent situations.

3. Other Investigations:

  • High Vaginal Swabs: If there’s any discharge or suspicion of chorioamnionitis.
  • Fetal Fibronectin (fFN) Test: If preterm labour is suspected and the patient is between 22-34+6 weeks of gestation. A negative result can help rule out imminent preterm birth.
Source: Obstetrics by Ten Teachers, 21st Edition, Chapters 4, 6, 12, 14, 20. Eranthi Samarakoon, A Guide to the Clinical Examination in Obstetrics & Gynaecology, for Undergraduates and Postgraduates, Chapter 18, 20. NICE guideline [NG133] – Hypertension in pregnancy: diagnosis and management. RCOG Green-top Guideline No. 42 – The investigation and management of abdominal pain in pregnancy.
What is your management plan for this patient, considering her gestation and clinical picture and the differential diagnoses?

My management plan would be structured based on the most likely differential diagnoses, with an immediate focus on stabilization, definitive diagnosis, and intervention to prevent maternal and fetal morbidity/mortality.

1. Immediate Actions (Upon Presentation):

  • Call for Senior Help: Inform the Consultant Obstetrician and the General Surgical team immediately. Anaesthetist and Neonatologist should also be on standby.
  • Resuscitation & Monitoring:
    • ABC: Ensure patent airway, provide high-flow oxygen if SpO2 <95%.
    • IV Access: Establish two large-bore intravenous cannulae.
    • Fluid Resuscitation: Start IV crystalloids (e.g., Hartman’s solution) if signs of dehydration or shock.
    • Pain Relief: Administer strong analgesia (e.g., IV opioids) while awaiting definitive diagnosis.
    • Monitoring: Continuous maternal vital signs (BP, pulse, RR, SpO2, temperature) and continuous CTG.
    • NPO: Keep patient nil per os (NPO) in anticipation of possible surgery.
  • Urgent Investigations: Send off all STAT bloods and urine for testing immediately.

2. Management Based on Differential Diagnosis:

A. If Acute Appendicitis is Suspected/Confirmed (Most Likely Diagnosis):
  • Surgical Consultation: Urgent surgical review.
  • Antibiotics: Start broad-spectrum intravenous antibiotics (e.g., Ampicillin, Gentamicin, Metronidazole) empirically immediately, covering common appendiceal flora.
  • Laparoscopic Appendicectomy: This is the treatment of choice in pregnancy. If diagnosis is certain, operate without delay, regardless of gestation. Delay increases risk of perforation and peritonitis.
  • Post-operative Monitoring: Close maternal and fetal monitoring (CTG) post-surgery.
B. If Preterm Labour is Suspected/Confirmed (Consider if uterine activity present):
  • Confirm Diagnosis: Via clinical assessment (cervical changes, regular painful contractions) and CTG. Fetal fibronectin test may aid in ruling out imminent preterm birth.
  • Tocolysis: If preterm labour is confirmed and no contraindications (e.g., abruption, chorioamnionitis, severe pre-eclampsia, fetal distress), consider Tocolysis (e.g., Nifedipine, Atosiban) to delay labour for 48 hours.
  • Antenatal Corticosteroids: Administer a course of corticosteroids (e.g., Dexamethasone 6mg IM 12 hourly for 4 doses) to promote fetal lung maturity, as she is at 32 weeks (<34+6 weeks).
  • Magnesium Sulphate: If delivery is anticipated within 24 hours and gestation is <30 weeks, administer Magnesium Sulphate for fetal neuroprotection. (Less relevant at 32 weeks unless early delivery is definite).
  • Management of Labour: If labour progresses, manage as per standard preterm labour guidelines.
C. If Placental Abruption is Suspected (Consider if pain severe, uterine tenderness, abnormal CTG, +/- bleeding):
  • Emergency Obstetric Management: This is a life-threatening emergency.
  • Resuscitation: Aggressive fluid resuscitation, massive transfusion protocol may be activated.
  • Monitoring: Continuous CTG, frequent maternal vital signs.
  • Delivery: Urgent delivery, usually by emergency Caesarean section, especially if maternal or fetal compromise or if the abruption is severe.
D. If Other Surgical/Medical Causes (e.g., ovarian torsion, renal colic, pyelonephritis, red degeneration of fibroid):
  • Ovarian Torsion: Urgent surgical exploration (laparoscopy) to untwist the ovary if viable, or oophorectomy if necrotic.
  • Renal Colic: Pain relief, hydration. May require urological consultation if persistent or signs of obstruction/infection.
  • Pyelonephritis: IV antibiotics (e.g., Ceftriaxone) immediately after MSU for C&S. Hydration.
  • Red Degeneration of Fibroid: Primarily supportive management with analgesia (NSAIDs contraindicated in pregnancy, use paracetamol/opioids), rest, and hydration. Usually self-limiting.

3. Post-Management/Postnatal Care:

  • Close Observation: Continue close maternal and fetal monitoring.
  • Post-operative Care: If surgery is performed, standard post-operative care.
  • Counselling: Discuss diagnosis, management, and implications for current and future pregnancies.
Source: Obstetrics by Ten Teachers, 21st Edition, Chapters 6, 12, 14, 20. Eranthi Samarakoon, A Guide to the Clinical Examination in Obstetrics & Gynaecology, for Undergraduates and Postgraduates, Chapter 18, 20. NICE guideline [NG133] – Hypertension in pregnancy: diagnosis and management. RCOG Green-top Guideline No. 42 – The investigation and management of abdominal pain in pregnancy.
What are the potential complications for both mother and fetus in this case, considering the various differential diagnoses?

The complications of abdominal pain in pregnancy are diverse and depend heavily on the underlying cause, ranging from relatively benign to life-threatening for both mother and fetus.

Maternal Complications:

  • For Acute Appendicitis:
    • Perforation: Leads to peritonitis, sepsis, abscess formation, increased maternal morbidity and mortality.
    • Preterm Labour: Peritonitis from perforated appendicitis can trigger preterm labour.
    • Surgical Complications: Infection, bleeding, injury to surrounding organs, anesthetic complications.
  • For Placental Abruption:
    • Haemorrhagic Shock: Due to massive concealed or revealed bleeding.
    • Disseminated Intravascular Coagulation (DIC): Due to release of thromboplastin from the abruption site.
    • Acute Kidney Injury (AKI)/Renal Failure: From hypovolemic shock.
    • Postpartum Haemorrhage (PPH): Due to uterine atony (Couvelaire uterus) or coagulopathy.
    • Sheehan’s Syndrome: Rare, due to pituitary necrosis from severe peripartum hemorrhage.
  • For Preterm Labour:
    • Complications of Tocolysis: Maternal side effects (e.g., tachycardia, pulmonary oedema with Beta-agonists, though less with Nifedipine/Atosiban).
    • Complications of Interventions: Risk of infection from prolonged rupture of membranes or multiple vaginal examinations.
  • For Ovarian Torsion/Rupture:
    • Ovarian Necrosis: If torsion is prolonged, requiring oophorectomy, impacting future fertility.
    • Internal Bleeding: From ruptured ovarian cyst, leading to hypovolemic shock.
    • Peritonitis: From rupture or necrosis.
  • For Pyelonephritis:
    • Sepsis/Urosepsis: Can be life-threatening.
    • Preterm Labour/Birth: Due to maternal infection.
    • Acute Respiratory Distress Syndrome (ARDS): In severe cases of sepsis.
  • For Red Degeneration of Fibroid:
    • Severe Pain: Requiring significant analgesia.
    • Rare Complications: Infection or necrosis of the fibroid.

Fetal/Neonatal Complications:

  • For Acute Appendicitis (especially if perforated):
    • Preterm Birth: Due to maternal infection or surgery.
    • Fetal Distress/Hypoxia: From maternal sepsis or general anesthesia.
    • Neonatal Sepsis: If maternal peritonitis is severe.
  • For Placental Abruption:
    • Fetal Distress/Hypoxia: Due to uteroplacental insufficiency.
    • Preterm Birth: Common due to necessity for urgent delivery.
    • Fetal Anaemia: If there’s significant feto-maternal haemorrhage.
    • Stillbirth/Intrauterine Death: In severe cases, due to acute hypoxia or hypovolemic shock.
  • For Preterm Labour:
    • Neonatal Morbidities of Prematurity: Respiratory Distress Syndrome (RDS), Intraventricular Haemorrhage (IVH), Necrotizing Enterocolitis (NEC), sepsis, feeding difficulties, long-term neurodevelopmental impairment.
  • For Ovarian Torsion:
    • Fetal Distress: From maternal pain or surgical intervention.
    • Preterm Labour: Due to surgical manipulation or maternal stress.
  • For Pyelonephritis:
    • Preterm Labour/Birth: Due to maternal infection.
    • Fetal Compromise: From maternal fever or sepsis.
Source: Obstetrics by Ten Teachers, 21st Edition, Chapters 6, 12, 14, 20. Eranthi Samarakoon, A Guide to the Clinical Examination in Obstetrics & Gynaecology, for Undergraduates and Postgraduates, Chapter 18, 20.

Obstetrics Long Case: Hypothyroidism in Pregnancy

Patient Summary

A 29-year-old primigravida presents at 39+6 weeks of gestation. She has a known history of hypothyroidism diagnosed 5 years ago and has been on a stable dose of Levothyroxine 100 mcg daily since then. Her thyroid function tests (TFTs) at booking (10 weeks) were within normal limits for pregnancy (TSH 2.0 mIU/L). Subsequent TFTs at 16 and 28 weeks also showed well-controlled levels. She reports good compliance with her medication. Her pregnancy has otherwise been uncomplicated, with normal fetal growth and movements. She presents for routine assessment as she is nearing her Estimated Date of Delivery (EDD).

How would your history taking help you assess the control of her hypothyroidism and identify potential complications?

My history taking would aim to ascertain the adequacy of her thyroid hormone replacement throughout pregnancy, identify any symptoms of hypo- or hyperthyroidism, and screen for potential complications associated with thyroid dysfunction.

Key Areas of Inquiry and Their Significance:

  • History of Hypothyroidism (Pre-pregnancy and During Pregnancy):
    • Diagnosis & Cause: When was she diagnosed, and what was the cause (e.g., Hashimoto’s thyroiditis, post-surgical, post-radioiodine)? Significance: Knowing the cause helps anticipate the need for dose adjustments and future monitoring. Hashimoto’s implies autoimmune etiology.
    • Pre-pregnancy Control: Was her hypothyroidism well-controlled before conception? Significance: Optimizing thyroid function preconception is crucial for fetal neurodevelopment.
    • Levothyroxine Dosage & Compliance: Her current dose (100 mcg daily). Have there been any dose adjustments during pregnancy? Is she taking her medication consistently as prescribed? Significance: Levothyroxine requirements typically increase by 25-50% during pregnancy. Non-compliance is a common reason for poor control.
    • Method of Intake: Is she taking her levothyroxine on an empty stomach, at least 30-60 minutes before food/drink (other than water) and at least 4 hours apart from iron or calcium supplements, or antacids? Significance: These can interfere with absorption.
  • Symptoms of Hypothyroidism (Symptoms of under-replacement):
    • General: Increasing fatigue, lethargy, cold intolerance, weight gain (beyond normal pregnancy weight gain).
    • Skin/Hair: Dry skin, hair loss.
    • Neuromuscular: Muscle aches, cramps, constipation.
    • Cognitive: Poor concentration, memory impairment.
    Significance: Presence of these symptoms suggests inadequate levothyroxine dose and uncontrolled hypothyroidism.
  • Symptoms of Hyperthyroidism (Symptoms of over-replacement):
    • General: Palpitations, heat intolerance, weight loss (rare in pregnancy), anxiety, tremors.
    Significance: Over-replacement can lead to iatrogenic hyperthyroidism, risking maternal cardiac complications (e.g., arrhythmias) and fetal thyroid dysfunction.
  • Obstetric Complications History (if multiparous): Inquire about previous miscarriages, preterm birth, gestational hypertension/pre-eclampsia, placental abruption, stillbirth, or fetal growth restriction (FGR). Significance: Uncontrolled hypothyroidism increases the risk of these complications.
  • Fetal Well-being: Has she perceived normal fetal movements? Any concerns? Significance: Fetal movements can be affected by severe maternal conditions.
  • Family History: Any family history of thyroid disorders, other autoimmune diseases (e.g., type 1 DM). Significance: Autoimmune thyroid disease is common.
Source: Obstetrics by Ten Teachers, 21st Edition, Chapter 10. Eranthi Samarakoon, A Guide to the Clinical Examination in Obstetrics & Gynaecology, for Undergraduates and Postgraduates, Chapter 1, 10. NICE guideline [NG201] – Thyroid disease: assessment and management.
What specific findings would you look for on clinical examination and what is their significance?

The examination aims to assess for clinical signs of hypothyroidism or hyperthyroidism, identify any associated complications of thyroid dysfunction, and assess general maternal and fetal well-being as she is at term.

Clinical Examination Findings and Their Significance:

  • General Examination:
    • Vital Signs:
      • Pulse Rate: Bradycardia (low pulse) could suggest hypothyroidism. Tachycardia (high pulse) could suggest hyperthyroidism (over-replacement).
      • Blood Pressure: Usually normal, but can be slightly lower in hypothyroidism or slightly higher in hyperthyroidism.
    • Skin & Hair: Look for dry, coarse skin, thinning hair, loss of outer third of eyebrows. Significance: Signs of hypothyroidism. Assess for pretibial myxedema (rare in primary hypothyroidism, more in Grave’s disease).
    • Oedema: Periorbital puffiness, non-pitting oedema (myxedema). Significance: Classic signs of hypothyroidism.
    • Weight: Check current weight against booking weight. Significance: Unexpected weight gain (beyond normal pregnancy) or difficulty losing weight postnatally can be a sign of uncontrolled hypothyroidism.
  • Head and Neck Examination:
    • Thyroid Gland: Gently palpate the thyroid gland for size, consistency, and nodularity. Significance: Goitre (enlarged thyroid) can be present in hypothyroidism (e.g., Hashimoto’s), but its presence/absence is not always indicative of control.
    • Eyes: Look for lid lag, proptosis. Significance: Signs of Graves’ ophthalmopathy, which would indicate autoimmune thyroid disease (hyperthyroidism).
    • Hands: Fine tremor. Significance: Sign of hyperthyroidism.
  • Cardiovascular System:
    • Heart Sounds: Listen for muffled heart sounds (pericardial effusion in severe hypothyroidism). Listen for arrhythmias (tachyarrhythmias in hyperthyroidism). Significance: Uncontrolled thyroid disease can lead to cardiac dysfunction.
  • Abdominal Examination:
    • Symphysis-Fundal Height (SFH): Measure. Significance: To confirm appropriate fetal growth. Uncontrolled hypothyroidism can be associated with FGR.
    • Fetal Heart Sounds (FHS): Auscultate. Significance: To confirm fetal well-being.
Source: Obstetrics by Ten Teachers, 21st Edition, Chapter 10. Eranthi Samarakoon, A Guide to the Clinical Examination in Obstetrics & Gynaecology, for Undergraduates and Postgraduates, Chapter 10.
How would you classify her thyroid status in pregnancy and assess its severity?

Her thyroid status needs to be classified based on pre-existing condition and current control, with severity assessed by TSH levels and clinical symptoms.

Classification of Thyroid Status:

  • Pre-existing Hypothyroidism: This is her primary classification, as she was diagnosed 5 years ago and is on Levothyroxine.
  • Euthyroid on Treatment: Based on her reported TFTs at booking and throughout pregnancy being within normal limits for pregnancy (TSH 2.0 mIU/L), she is currently classified as **euthyroid on treatment**. This implies good control.
  • Subclinical Hypothyroidism: Elevated TSH but normal free T4.
  • Overt Hypothyroidism: Elevated TSH and low free T4. This would indicate poor control.
  • Gestational Hypothyroidism: New onset hypothyroidism during pregnancy (not applicable to her).

Assessment of Severity/Control:

The severity of hypothyroidism is primarily based on **TSH (Thyroid Stimulating Hormone) levels**, as TSH is the most sensitive marker of thyroid function and reflects whether the replacement dose is adequate. Free T4 is also important.

  • Target TSH Levels in Pregnancy (RCOG/NICE guidelines):
    • First Trimester: TSH 0.1 – 2.5 mIU/L
    • Second Trimester: TSH 0.2 – 3.0 mIU/L
    • Third Trimester: TSH 0.3 – 3.0 mIU/L

Her TSH of 2.0 mIU/L at booking (10 weeks) and subsequent normal levels at 16 and 28 weeks confirm that her hypothyroidism has been **well-controlled** throughout the pregnancy. This is an optimal outcome, indicating that her Levothyroxine dose has been appropriately adjusted (or was sufficient) to meet the increased demands of pregnancy.

The absence of symptoms of hypo- or hyperthyroidism further supports her well-controlled status. This is important as uncontrolled hypothyroidism, even if subclinical, is associated with increased risks.

Source: Obstetrics by Ten Teachers, 21st Edition, Chapter 10. Eranthi Samarakoon, A Guide to the Clinical Examination in Obstetrics & Gynaecology, for Undergraduates and Postgraduates, Chapter 10. NICE guideline [NG201] – Thyroid disease: assessment and management.
How would you investigate this patient further, given her current status?

Given her well-controlled hypothyroidism and uncomplicated pregnancy at 39+6 weeks, extensive further investigations are likely not needed. The focus would be on confirming continued good control and ensuring readiness for labour and delivery.

1. Immediate & Routine Investigations (for Labour Admission):

  • Thyroid Function Tests (TFTs): While her previous TFTs were normal, it is good practice to repeat TSH and Free T4 (or total T4 if Free T4 is not readily available) upon admission for labour, or if there’s any clinical suspicion of change in thyroid status. Significance: To confirm continued euthyroid state at term. If normal, no further thyroid-specific investigations are usually needed during labour.
  • Full Blood Count (FBC): Routine for labour admission, to check for anemia and platelet count.
  • Blood Group & Cross-match/Save: Routine for labour admission, in case of hemorrhage.
  • Urinalysis: Routine to check for proteinuria, glycosuria, or signs of UTI.
  • Cardiotocography (CTG): To assess fetal well-being on admission and throughout labour.

2. Other Investigations (If her TFTs were NOT well-controlled or new symptoms emerged):

If her TSH were elevated or free T4 low (indicating uncontrolled hypothyroidism), or if she developed new symptoms, then the following would be relevant:

  • Detailed TFTs: Including Free T4, Free T3, TSH.
  • Thyroid Autoantibodies (e.g., TPO Ab, Tg Ab): If the cause of hypothyroidism was unknown or if there’s suspicion of autoimmune thyroid disease that might fluctuate (e.g., post-partum thyroiditis risk).
  • Ultrasound Scan (USS):
    • Fetal Biometry: To assess fetal growth if there was suspicion of FGR (uncontrolled hypothyroidism can rarely cause FGR).
    • Placental Location: To ensure no placenta previa, as bleeding risk can be theoretically higher with poor control.
  • ECG: If there’s any suspicion of cardiac involvement from severe hypothyroidism (e.g., arrhythmias, bradycardia, heart failure symptoms).
Source: Obstetrics by Ten Teachers, 21st Edition, Chapter 10. Eranthi Samarakoon, A Guide to the Clinical Examination in Obstetrics & Gynaecology, for Undergraduates and Postgraduates, Chapter 10. NICE guideline [NG201] – Thyroid disease: assessment and management.
What is your management plan for this patient, considering her gestation and well-controlled status?

My management plan focuses on maintaining her euthyroid state, ensuring safe labour and delivery, and providing appropriate postnatal care, given her well-controlled hypothyroidism at 39+6 weeks.

1. Management during Antenatal Period (Current Status – Well Controlled):

  • Continue Levothyroxine: Advise her to continue her current dose of Levothyroxine (100 mcg daily) without interruption. Ensure she understands proper administration (empty stomach, separated from other medications/supplements like iron/calcium).
  • Monitoring: No further routine TFTs are required at this late gestation unless clinical symptoms suggest otherwise. Continue routine antenatal care.

2. Management during Labour and Delivery (39+6 weeks, nearing EDD):

  • Labour Management:
    • Normal Labour Progression: Expect normal labour progression. Hypothyroidism usually does not affect the course of labour if well-controlled.
    • Monitoring: Routine labour monitoring (partogram for progress, intermittent auscultation or continuous CTG for fetal well-being, maternal vital signs).
    • Pain Relief: All standard pain relief options (epidural, entonox, pethidine) are safe.
    • Thyroxine Administration: Continue oral Levothyroxine during labour. If unable to take orally for a prolonged period, IV hydrocortisone may be needed to prevent adrenal crisis if co-existing adrenal insufficiency is suspected (rare, but can occur with autoimmune polyglandular syndromes). However, for routine delivery, continuation of oral dose is usually sufficient.
    • Third Stage Management: Active management of the third stage (Oxytocin 10 IU IM or IV) as per routine to prevent PPH. Hypothyroidism does not increase the risk of PPH if well-controlled.
  • Mode of Delivery:
    • Vaginal Delivery: No contraindication to vaginal delivery. Her well-controlled hypothyroidism does not necessitate a Caesarean section.
    • Caesarean Section: Only if there are obstetric indications (e.g., fetal distress, failure to progress, breech presentation, placenta previa).

3. Postnatal Management:

  • Levothyroxine Dose Adjustment:
    • Immediately after delivery, her Levothyroxine dose should be reduced back to her pre-pregnancy dose (100 mcg daily) or slightly higher if still breastfeeding, as the pregnancy-induced increase in thyroid hormone demand quickly resolves.
    • For breastfeeding mothers, a slightly higher dose might be needed due to increased metabolic rate and small amount of thyroxine excreted in breast milk.
  • Postnatal TFTs:
    • Repeat TFTs (TSH and Free T4) at 6 weeks postpartum. Significance: To confirm her thyroid status and adjust Levothyroxine dose as needed.
    • For women with Hashimoto’s thyroiditis (common cause of hypothyroidism), there is an increased risk of postpartum thyroiditis (PPT), which can present as transient hyperthyroidism followed by hypothyroidism. She should be counselled about symptoms to look for. TFTs should be performed at 6-8 weeks postpartum and then at 3 months if there is a history of PPT.
  • Contraception: Counsel on family planning. No specific contraindications related to well-controlled hypothyroidism.
  • Breastfeeding: Levothyroxine is safe during breastfeeding.
  • Long-term Counselling: Emphasize the need for lifelong treatment and regular follow-up with her endocrinologist/GP for TFT monitoring.
Source: Obstetrics by Ten Teachers, 21st Edition, Chapter 10. Eranthi Samarakoon, A Guide to the Clinical Examination in Obstetrics & Gynaecology, for Undergraduates and Postgraduates, Chapter 10. NICE guideline [NG201] – Thyroid disease: assessment and management. RCOG Green-top Guideline No. 67 – Thyroid Disease and Pregnancy.
What are the potential complications for both mother and fetus/neonate if hypothyroidism is poorly controlled in pregnancy?

While her hypothyroidism is well-controlled, it’s crucial to understand the risks of *poorly controlled* or *undiagnosed* hypothyroidism in pregnancy, as this highlights the importance of her excellent management.

Maternal Complications of Uncontrolled Hypothyroidism:

  • Increased Risk of Pregnancy Complications:
    • Miscarriage: Especially in the first trimester.
    • Gestational Hypertension/Pre-eclampsia: Increased incidence.
    • Placental Abruption: Increased risk.
    • Postpartum Haemorrhage (PPH): Due to uterine atony.
    • Preterm Birth: Increased risk.
  • Maternal Health Deterioration:
    • Exacerbation of Hypothyroid Symptoms: Severe fatigue, weight gain, constipation, cold intolerance.
    • Anaemia: Can be exacerbated or caused by hypothyroidism.
    • Cardiac Dysfunction: Bradycardia, pericardial effusion (rare in pregnancy), and in severe cases, congestive heart failure.
    • Thyroid Storm: (Extremely rare in hypothyroidism, more associated with hyperthyroidism, but severe stress can precipitate crisis).
  • Myxedema Coma: A life-threatening emergency in severe, untreated hypothyroidism (rare in pregnancy).

Fetal/Neonatal Complications of Uncontrolled Maternal Hypothyroidism:

  • Impaired Fetal Neurodevelopment: This is the most significant concern. Maternal thyroid hormones are crucial for fetal brain development, especially in the first trimester, before the fetal thyroid gland is fully functional. Uncontrolled hypothyroidism can lead to:
    • Lower IQ scores.
    • Cognitive deficits (e.g., attention, memory).
    • Learning difficulties.
    • Psychomotor delay.
  • Increased Perinatal Morbidity & Mortality:
    • Fetal Growth Restriction (FGR): Due to impaired placental development.
    • Fetal Distress: During labour.
    • Stillbirth: Increased risk.
    • Congenital Anomalies: Though a weaker association, some studies suggest a slightly increased risk.
  • Neonatal Complications:
    • Neonatal Hypothyroidism: Although rare if maternal hypothyroidism is well-controlled, it can occur, and necessitates immediate screening at birth (heel prick test).
    • Macrosomia: If associated with uncontrolled maternal diabetes.
    • Increased NICU Admissions.
Source: Obstetrics by Ten Teachers, 21st Edition, Chapter 10. Eranthi Samarakoon, A Guide to the Clinical Examination in Obstetrics & Gynaecology, for Undergraduates and Postgraduates, Chapter 10. NICE guideline [NG201] – Thyroid disease: assessment and management. RCOG Green-top Guideline No. 67 – Thyroid Disease and Pregnancy.

Obstetrics Long Case: Whitish Vaginal Discharge in Pregnancy

Patient Summary

A 25-year-old primigravida presents at 28 weeks of gestation complaining of an increase in whitish vaginal discharge for the past two weeks. She describes the discharge as thick, curdy, and associated with intense vulvar itching and burning, particularly after urination. She also notes some dyspareunia. She denies any foul odor, lower abdominal pain, fever, or painful urination. Her pregnancy has been otherwise uncomplicated, and she has no known medical conditions. Her booking vaginal swabs were normal. She denies any new sexual partners. Her partner has no symptoms.

How would your history taking help you differentiate between potential causes, assess severity, and identify potential complications of her vaginal discharge?

Vaginal discharge is a common complaint in pregnancy, often physiological. However, abnormal discharge can indicate infection. My history taking would aim to differentiate physiological from pathological discharge, identify the type of infection, assess severity, and screen for potential complications.

Key Areas of Inquiry and Their Significance:

  • Detailed Character of Discharge (SOCRATES for Discharge):
    • Colour: Whitish, yellowish, greyish, greenish. Significance: Whitish and curdy suggests Candidiasis. Greyish/thin suggests Bacterial Vaginosis (BV). Yellowish/greenish/frothy suggests Trichomoniasis. Clear/whitish non-itchy/non-odorous is often physiological.
    • Consistency: Curdy/cottage cheese-like, thin/watery, frothy. Significance: Curdy for Candidiasis. Thin for BV. Frothy for Trichomoniasis.
    • Amount: Slight, moderate, heavy. Significance: Helps assess severity and patient distress.
    • Odor: Fishy odor, especially after intercourse or washing. Significance: Fishy odor is characteristic of BV.
    • Associated Symptoms:
      • Itching (Pruritus): Intense vulvar itching. Significance: Highly suggestive of Candidiasis.
      • Burning: Particularly after urination (dysuria). Significance: Common with Candidiasis due to irritation. Also ask about vaginal burning, soreness.
      • Dyspareunia: Pain during intercourse. Significance: Common with inflammatory causes like Candidiasis, Trichomoniasis, or severe BV.
      • Lower Abdominal Pain/Fever/Chills: She denies these. Significance: Presence would suggest Pelvic Inflammatory Disease (PID) or ascending infection, which is rare in pregnancy but very serious.
      • Urinary Symptoms: Dysuria (burning on urination), frequency, urgency. Significance: To differentiate from Urinary Tract Infection (UTI), which can also cause similar lower urinary tract symptoms, or to identify concurrent infection.
  • Risk Factors for Vaginal Infections:
    • Antibiotic Use: Recent antibiotic use. Significance: Predisposes to candidiasis.
    • Diabetes Mellitus/GDM: Increased blood glucose. Significance: Uncontrolled diabetes increases risk of candidiasis. (She has GDM, so relevant).
    • Immunosuppression: Use of corticosteroids, HIV.
    • Tight/Synthetic Underwear: Creates warm, moist environment.
    • Vaginal Douching/Scented Products: Can disrupt normal vaginal flora.
    • Previous History: Recurrent vaginal candidiasis or BV. Significance: Suggests susceptibility.
  • Sexual History:
    • New Sexual Partners: She denies. Significance: New partners increase risk of Sexually Transmitted Infections (STIs), including Trichomoniasis, Chlamydia, Gonorrhea.
    • Partner Symptoms: Partner has no symptoms. Significance: Trichomoniasis can cause symptoms in male partners, who may need treatment.
    • Use of Condoms:
  • Obstetric History:
    • Gestation (28 weeks): Important for considering implications for preterm labour.
    • History of Preterm Labour/PPROM: In previous pregnancies (not applicable here as primigravida) or this pregnancy. Significance: Some vaginal infections (e.g., BV, Trichomoniasis) are associated with increased risk of preterm labour/PPROM.
Source: Obstetrics by Ten Teachers, 21st Edition, Chapter 20. Eranthi Samarakoon, A Guide to the Clinical Examination in Obstetrics & Gynaecology, for Undergraduates and Postgraduates, General Examination Principles. NICE CKS – Vaginal discharge in pregnancy. RCOG Green-top Guideline No. 36 – Bacterial Vaginosis in Pregnancy.
What specific findings would you look for on clinical examination and what is their significance?

The examination aims to confirm the nature of the discharge, identify signs of inflammation or infection, and rule out other causes of symptoms. A speculum examination is essential.

Clinical Examination Findings and Their Significance:

  • General Examination:
    • Vital Signs: Temperature, pulse. Significance: Fever or tachycardia would suggest systemic infection (e.g., chorioamnionitis if membranes ruptured, or severe UTI) and necessitate urgent action. Her symptoms of itching and burning typically do not cause systemic signs.
    • General Appearance: Assess for signs of distress, pruritus (scratch marks on vulva).
  • Abdominal Examination:
    • Fundal Height: To confirm gestational age.
    • Tenderness: Palpate for lower abdominal tenderness. Significance: Presence of suprapubic tenderness would suggest UTI/cystitis. Uterine tenderness would suggest chorioamnionitis or pre-term labour if contractions are present. Her denial of abdominal pain makes this less likely.
  • Pelvic Examination (with chaperone and consent):
    • External Genitalia: Inspect the vulva and perineum for erythema, excoriations (from scratching), oedema, or rash. Significance: Intense itching causes excoriations. Erythema and oedema are common signs of inflammation.
    • Speculum Examination: This is the most crucial part.
      • Vaginal Walls: Inspect for inflammation, erythema, plaques (adherent patches of discharge).
      • Discharge Characteristics:
        • Colour, Consistency, Amount: Observe directly. For her, whitish, thick, curdy discharge adhering to vaginal walls is characteristic of Candidiasis.
        • Odor: Perform a “whiff test” by adding a drop of 10% KOH to a sample of discharge on a slide. Significance: A fishy/amine odor is a hallmark of Bacterial Vaginosis (BV).
      • Cervix: Inspect for inflammation, discharge originating from the cervix (cervicitis), erosion, or polyps. Look for a “strawberry cervix” (punctate haemorrhages) which is characteristic of Trichomoniasis. Assess for any signs of cervical effacement or dilatation. Significance: Cervical changes would raise concern for preterm labour.
    • Bimanual Examination:
      • Cervical Os: Check for closure or dilatation.
      • Uterine Tenderness: Assess for cervical motion tenderness or uterine tenderness. Significance: Suggests PID/chorioamnionitis, though less likely given her symptoms.
      • Adnexal Tenderness/Masses: Assess.
Source: Obstetrics by Ten Teachers, 21st Edition, Chapter 20. Eranthi Samarakoon, A Guide to the Clinical Examination in Obstetrics & Gynaecology, for Undergraduates and Postgraduates, Chapter 1. NICE CKS – Vaginal discharge in pregnancy.
How would you classify the type of vaginal discharge and assess its severity?

Classifying vaginal discharge in pregnancy involves distinguishing physiological changes from pathological conditions based on its characteristics and associated symptoms. The severity is assessed by the degree of symptoms and potential impact on pregnancy.

Classification of Vaginal Discharge:

  • Physiological Discharge:
    • Characteristics: Clear, milky white, non-irritating, mild or no odor, thin consistency.
    • Significance: Common in pregnancy due to increased estrogen levels, causing increased cervical and vaginal secretions. Not associated with itching, burning, or dyspareunia.
  • Pathological Discharge (Infections):
    • Vulvovaginal Candidiasis (Yeast Infection):
      • Discharge: Her description of “whitish, thick, curdy/cottage cheese-like” discharge.
      • Symptoms: Intense vulvar itching and burning, dyspareunia, dysuria. Her symptoms fit this perfectly.
      • Odor: No characteristic foul odor.
    • Bacterial Vaginosis (BV):
      • Discharge: Thin, greyish-white, homogeneous.
      • Odor: “Fishy” odor, especially after intercourse or with alkaline substances (e.g., soap).
      • Symptoms: Often minimal itching/burning.
    • Trichomoniasis:
      • Discharge: Yellowish-green, frothy, profuse.
      • Odor: Foul-smelling.
      • Symptoms: Often associated with severe itching, burning, dysuria, and dyspareunia. May cause a “strawberry cervix.”
    • Sexually Transmitted Infections (STIs) (e.g., Chlamydia, Gonorrhea):
      • Discharge: Often mucopurulent, cervical in origin.
      • Symptoms: May be asymptomatic, or cause dysuria, pelvic pain, intermenstrual bleeding. Usually associated with cervicitis.

    Based on her description (“whitish, thick, curdy, associated with intense vulvar itching and burning, dyspareunia”), her discharge is highly characteristic of **Vulvovaginal Candidiasis**.

    Assessment of Severity:

    The severity is primarily based on the **intensity of her symptoms** and their impact on her quality of life.

    • Mild: Minimal symptoms.
    • Moderate: Clearly bothersome symptoms affecting comfort.
    • Severe: Intense itching/burning causing significant distress, sleep disturbance, or affecting daily activities. Her description of “intense vulvar itching and burning” suggests at least **moderate to severe** Candidiasis.

    While discomfort is the primary manifestation of Candidiasis, some other infections (like BV or Trichomoniasis) carry more significant pregnancy-related risks, regardless of symptom severity.

    Source: Obstetrics by Ten Teachers, 21st Edition, Chapter 20. Eranthi Samarakoon, A Guide to the Clinical Examination in Obstetrics & Gynaecology, for Undergraduates and Postgraduates, General Principles. NICE CKS – Vaginal discharge in pregnancy. RCOG Green-top Guideline No. 36 – Bacterial Vaginosis in Pregnancy.
How would you investigate this patient?

Investigations aim to confirm the specific cause of the vaginal discharge, differentiate it from other infections, and guide appropriate treatment, especially given her pregnancy status.

1. Initial & Essential Investigations:

  • Vaginal pH Measurement:
    • Method: Use pH paper to test vaginal secretions.
    • Significance:
      • Normal (acidic): pH 3.8-4.5 (consistent with Candidiasis).
      • Elevated (alkaline): pH >4.5 (suggests BV or Trichomoniasis).
  • Wet Mount Microscopy:
    • Method: A sample of vaginal discharge is mixed with normal saline and examined under a microscope. A second sample is mixed with 10% KOH (potassium hydroxide).
    • Significance:
      • Saline Wet Mount:
        • Candidiasis: Identify budding yeast, hyphae, or pseudohyphae.
        • Trichomoniasis: Identify motile trichomonads (pear-shaped flagellates).
        • BV: Identify “clue cells” (vaginal epithelial cells stippled with bacteria), absence of lactobacilli.
        • Leukocytes: Increased white blood cells may indicate inflammation.
      • KOH Wet Mount:
        • Candidiasis: Helps visualize fungal elements by dissolving epithelial cells.
        • “Whiff Test”: Addition of KOH can produce a characteristic “fishy” odor if BV is present.
  • High Vaginal Swabs (HVS) for Culture & Sensitivity:
    • Purpose: To confirm the presence of *Candida* species and identify the specific type, especially if treatment is unsuccessful or for recurrent infections. Also, to culture for other pathogens.

2. Other Investigations (If suspicion of other infections or complications):

  • Nucleic Acid Amplification Tests (NAATs) for STIs:
    • Purpose: If sexual history suggests risk, or symptoms atypical for common infections, or to specifically rule out Chlamydia and Gonorrhea.
    • Specimen: Endocervical or vaginal swab.
  • Midstream Urine (MSU) Culture & Sensitivity: If urinary symptoms are prominent or to rule out a concomitant UTI.
  • Blood Glucose Monitoring: As she has GDM, ensure her blood glucose levels are well-controlled, as hyperglycemia is a risk factor for candidiasis.
Source: Obstetrics by Ten Teachers, 21st Edition, Chapter 20. Eranthi Samarakoon, A Guide to the Clinical Examination in Obstetrics & Gynaecology, for Undergraduates and Postgraduates, General Principles. NICE CKS – Vaginal discharge in pregnancy. RCOG Green-top Guideline No. 36 – Bacterial Vaginosis in Pregnancy.
What is your management plan for this patient, considering her gestation and the likely diagnosis?

My management plan would focus on providing symptomatic relief, eradicating the infection, and preventing potential complications, considering her gestation and the strong likelihood of Vulvovaginal Candidiasis.

1. Initial Management (Assuming Candidiasis is the Likely Diagnosis):

  • Patient Education & Counselling:
    • Explain the likely diagnosis of candidiasis, its commonality in pregnancy, and that it is not sexually transmitted in the strict sense.
    • Reassure her that it does not usually harm the baby.
    • Advise on hygiene measures: wear loose-fitting cotton underwear, avoid douching or perfumed products, pat dry after washing.
    • Advise on managing her GDM to maintain good glycemic control, as this is a predisposing factor.
  • Antifungal Therapy (Safe in Pregnancy):
    • Topical Antifungals (First-line): These are preferred as they are highly effective and have minimal systemic absorption.
      • Clotrimazole: Vaginal pessary 500 mg (single dose) or 100 mg daily for 6 days. Cream 1% or 2% for external itching.
      • Miconazole: Vaginal pessary 1200 mg (single dose) or 200 mg daily for 3 days. Cream 2% for external itching.
    • Oral Antifungals (Second-line/Resistant Cases):
      • Fluconazole: Single oral dose of 150 mg is effective but generally avoided in the first trimester. In the second and third trimesters, a single dose is considered acceptable for uncomplicated cases, but topical agents are still preferred. Avoid repeated doses of high-dose oral fluconazole.
  • Symptomatic Relief:
    • Topical creams (e.g., Clotrimazole cream) for vulvar itching and burning.
    • Cool compresses to the vulva.

2. Management if Other Infections are Diagnosed:

  • Bacterial Vaginosis (BV):
    • Treatment: Oral Metronidazole 400 mg twice daily for 5-7 days or vaginal Clindamycin cream 2% for 7 days. Oral Metronidazole is generally safe in all trimesters.
    • Significance: BV is associated with an increased risk of preterm birth, PPROM, and late miscarriage, especially in symptomatic women. Treatment is recommended.
  • Trichomoniasis:
    • Treatment: Oral Metronidazole 2g single dose or 500 mg twice daily for 7 days. Both are considered safe in pregnancy, although the single 2g dose is generally avoided in the first trimester.
    • Partner Treatment: Essential to treat the sexual partner(s) simultaneously to prevent reinfection.
    • Significance: Associated with increased risk of preterm birth and PPROM.
  • Chlamydia/Gonorrhea:
    • Treatment: Specific antibiotics (e.g., Azithromycin for Chlamydia, Ceftriaxone for Gonorrhea).
    • Partner Treatment: Essential.
    • Significance: Can lead to severe maternal (PID, PPROM) and neonatal complications (ophthalmia neonatorum, pneumonia).

3. Follow-up:

  • Review: Advise her to return for review if symptoms do not improve within a few days or if they recur.
  • Repeat Swabs: Usually not necessary for uncomplicated candidiasis unless symptoms persist or recur. For BV or Trichomoniasis, a test of cure might be recommended, particularly if high risk for complications.
Source: Obstetrics by Ten Teachers, 21st Edition, Chapter 20. Eranthi Samarakoon, A Guide to the Clinical Examination in Obstetrics & Gynaecology, for Undergraduates and Postgraduates, General Principles. NICE CKS – Vaginal discharge in pregnancy. RCOG Green-top Guideline No. 36 – Bacterial Vaginosis in Pregnancy.
What are the potential complications for both mother and fetus in this case, considering the various differential diagnoses?

While physiological discharge and uncomplicated candidiasis are largely benign, other vaginal infections can lead to significant maternal and fetal complications in pregnancy.

Maternal Complications:

  • Vulvovaginal Candidiasis:
    • Severe Discomfort: Intense itching, burning, dyspareunia can significantly impact quality of life.
    • Secondary Skin Infection: From excoriations due to scratching.
    • Recurrence: Common in pregnancy.
  • Bacterial Vaginosis (BV):
    • Preterm Prelabour Rupture of Membranes (PPROM): Increased risk.
    • Preterm Labour/Birth: Increased risk, particularly in symptomatic women.
    • Chorioamnionitis: Infection of the membranes and amniotic fluid.
    • Postpartum Endometritis: Infection of the uterine lining after delivery.
  • Trichomoniasis:
    • PPROM & Preterm Birth: Increased risk.
    • Increased Risk of HIV Transmission: If the mother is HIV positive.
    • Severe Vulvovaginitis: Significant discomfort and inflammation.
  • Sexually Transmitted Infections (STIs – Chlamydia, Gonorrhea):
    • Pelvic Inflammatory Disease (PID): Although less common in pregnancy.
    • Preterm Labour/PPROM.
    • Postpartum Endometritis.

Fetal/Neonatal Complications:

  • Vulvovaginal Candidiasis:
    • Generally **no significant fetal/neonatal complications** in uncomplicated cases.
    • Rarely, oral thrush (oral candidiasis) in the newborn can occur from passage through the birth canal.
  • Bacterial Vaginosis (BV):
    • Preterm Birth: Leading to complications of prematurity (respiratory distress syndrome, intraventricular hemorrhage, necrotizing enterocolitis, sepsis, long-term neurodevelopmental issues).
    • Neonatal Sepsis/Pneumonia: Rare, but ascending infection can lead to these.
  • Trichomoniasis:
    • Preterm Birth: With associated neonatal morbidities.
    • Low Birth Weight: Associated with preterm birth.
    • Neonatal Infection: Rarely, the neonate can acquire trichomoniasis (usually vaginitis in girls, urethritis in boys).
  • Sexually Transmitted Infections (STIs – Chlamydia, Gonorrhea):
    • Ophthalmia Neonatorum: Severe conjunctivitis in the newborn.
    • Neonatal Pneumonia: (especially with Chlamydia).
    • Neonatal Sepsis.
    • Preterm Birth: With associated neonatal morbidities.
  • Chorioamnionitis: (Complication of ascending infection)
    • Fetal Sepsis.
    • Neonatal Sepsis.
    • Preterm Birth.
Source: Obstetrics by Ten Teachers, 21st Edition, Chapter 20. Eranthi Samarakoon, A Guide to the Clinical Examination in Obstetrics & Gynaecology, for Undergraduates and Postgraduates, General Principles. NICE CKS – Vaginal discharge in pregnancy. RCOG Green-top Guideline No. 36 – Bacterial Vaginosis in Pregnancy.

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