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• Placenta praevia


  Placenta moves out of position, damaging blood vessels and causing haemorrhage. Praevia means covering cervical os.
• Diagnosis of placenta praevia


  1. Ultrasound scan

  2. Transvaginal scan better at identifying internal os
• Placental abruption


  Placenta separates from uterine wall before birth, depriving baby of oxygen and nutrients, causing heavy vaginal bleeding
• Vasa praevia


  Unprotected blood vessels from umbilical cord travel across cervix, fatal if baby born vaginally
• Vasa praevia must be diagnosed before labour so it can be monitored and a C-section done
• Primary postpartum haemorrhage


  Bleeding from delivery of baby to 24hrs postpartum
• Secondary postpartum haemorrhage


  Vaginal bleeding from 24hr postpartum to 12 weeks postpartum
• Management of postpartum haemorrhage


  1. Observation, airway/breathing

  2. Cardiovascular (IV access, bloods, fluid resuscitation)

  3. Disability (trauma/uterine cavity)
• Initiate major haemorrhage protocol for 20% blood loss in 1hr or 50% blood loss in 3hr
• Hyperemesis gravidarum


  A condition which causes nausea and vomiting in pregnant women and accompanied with weight loss
• Nausea and vomiting in pregnancy

  • Only called hyperemesis gravidarum if it leads to complications like dehydration or >5% weight loss
• Hyperemesis gravidarum


  1. Experienced in the first trimester

  2. Usually resolves by week 20
• Cause of hyperemesis gravidarum


  Raised beta-hCG sensitizing the vomiting centre
• Risk factors for hyperemesis gravidarum


  • Anything which leads to raised b-hCG
  • Multiple pregnancies (twins)
  • Gestational trophoblastic disease
  • Hyperthyroidism (TSH similar to b-hCG)
  • Obesity
• Symptoms of hyperemesis gravidarum


  • Severe nausea and vomiting accompanied with weight loss
• Complications of hyperemesis gravidarum


  • Mechanical (Mallory-Weiss tear of the oesophagus)
  • Neurological (Wernicke's encephalopathy, central pontine myelinosis)
  • Renal (acute tubular necrosis, AKI due to hypovolaemia)
  • Foetal (Preterm birth and intrauterine growth restriction)
• Diagnosis of hyperemesis gravidarum


  • Nausea and vomiting plus weight loss of 5% pre-pregnancy weight, dehydration, electrolyte disturbances
• Management of hyperemesis gravidarum


  1. Check urine for ketones (if raised, admit patient)

  2. Anti-emetics (promethazine or cyclizine first line, ondansetron/metoclopramide second line)

  3. Fluids (Hartmann's solution) for rehydration with Vitamin B1 replacement

  4. Prophylactic Dalteparin (dehydrated patients at high risk of VTE)

  5. IV hydrocortisone if unresolving

  6. Termination of pregnancy as last resort
• Pregnancy-induced hypertension


  Raised blood pressure which occurs after the 20th week of pregnancy without proteinuria
• If a woman has hypertension before


  This is counted as pre-existing hypertension
• If she develops other symptoms like proteinuria and oedema


  This points to a diagnosis of pre-eclampsia
• Gestational hypertension


  Resolves after birth, but women have higher risk of pre-eclampsia in the next pregnancy
• Major risk to watch out for


  Progression to pre-eclampsia (High BP with proteinuria)
• Hypertension definition


  Two separate readings confirming either: Systolic >140mmHg or diastolic >90mmHg, or Increase above booking readings of >30mmHg systolic or >15mmHg diastolic
• Tests for pregnancy-induced hypertension


  • Urine dipstick + 24hr urine collection
  • Blood tests –> FBC, LFTs, U&Es
• Management of pregnancy-induced hypertension


  1. Antihypertensive medication –> 1st line is labetalol, 2nd line nifedipine, 3rd methyldopa

  2. Maternal monitoring –> Monitor BP weekly (aim for <135/85) and monitor urine dipstick for proteinuria

  3. Foetal monitoring –> Foetal heart auscultation at every antenatal appointment + US from 28 weeks
• Pre-eclampsia


  Pregnancy induced hypertension with proteinuria
• Risk factors for pre-eclampsia

  • type 1 and 2 diabetes
  • first preg
  • extreme of ages
  • family history
  • ckd
• Tests for pre-eclampsia


  • BP measurement and urine dipstick with 24hr collection
  • FBC –> may show low Hb, low platelets (progression to HELLP syndrome)
  • U&Es –> elevated urea and creatinine (different ranges from normal population as plasma is diluted)
  • LFTs –> elevated ALT and AST (used to assess for HELLP syndrome)
• Diagnosis of pre-eclampsia


  1. Gestation >20 weeks

  2. Hypertension: systolic >140 or diastolic >90 on two occasions 4 hour apart

  3. Proteinuria: Protein: creatinine ratio >30mg/mmol
• Eclampsia


  The development of seizures in association with pre-eclampsia
• Eclampsia


  • Occurs due to the failure of cerebral autoregulation leading to seizures and haemorrhagic stroke
  • The biggest complication is AKI which leads to pulmonary oedema (leading cause of eclampsia death)
  • Can occur any time after the 20th week of pregnancy but the highest risk if 24 hours post delivery
• Pre-eclampsia


  Pregnancy induced hypertension and proteinuria
• Symptoms of Eclampsia


  • Background of Pre-eclampsia
  • Failure of cerebral autoregulation leading to seizures and haemorrhagic stroke
• Eclampsia Management


  1. Stabilise the mother

  2. Immediate delivery of the fetus (if not yet born)

  3. Give magnesium sulphate (used to prevent and treat seizures)

  4. Mother is given an IV bolus, followed by a continuous infusion

  5. This infusion is continued for 24 hours after last seizure or delivery (whichever is later)

  6. Can lead to respiratory depression, but this can be reversed with calcium gluconate

  7. Fluid restrict to prevent pulmonary oedema

  8. Once mother is stabilised, attempt delivery (continue magnesium sulphate infusion for 24 hours after)
• HELLP syndrome


  Condition which stands for Haemolysis, Elevated Liver enzymes and Low Platelet count
• HELLP syndrome


  • Shares features with pre-eclampsia but is a separate condition
  • Pre-eclampsia is a risk factor for the development of HELLP syndrome, which is an obstetric emergency
• HELLP syndrome risk factors


  • Pre-eclampsia/eclampsia
  • Mother >25 ages
  • Previous history
  • Being Caucasian
• HELLP syndrome symptoms


  • Haemolysis –> gives low Hb and lethargy
  • Elevated liver enzymes –> Gives raised LFTs, RUQ pain and nausea/vomiting
  • Low platelet count –> Bleeding (e.g. haematuria)
  • Can lead to DIC, placental abruption and kidney failure
• HELLP syndrome diagnosis


  • Blood tests –> Shows high LFTs, low platelet, low Hb, raised LDH and bilirubin
  • Blood smear –> Shows schistocytes