Obstetrics and gynaecology

Matthew G Wood

Outline

Station 7.5: Urinary tract infection in pregnancy

Station 7.1: Preterm labour

You are the junior doctor currently rotating through obstetrics and gynaecology. You have been asked to see a new admission to the labour ward. Anne Seymour is a 29 year old, 32 weeks into her first pregnancy who attends with her husband. She has presented with a 10-hour history of acute intermittent abdominal pain which is becoming more frequent and more painful.

Patient Details

Name:	Anne Seymour
DOB:	27/03/85
Hospital Number:	2103914534
Weight:	65 kg
Height:	1.6 m
Consultant:	Dr Roy
Hospital/Ward:	LGH Ward 4
Current Medications:	None
Allergies:	No known drug allergies
Admission date:	22/10/14

Differential diagnosis of abdominal pain in pregnancy

Renal colic

Pyelonephritis

Urinary tract infection

Gallstones/cholecystitis

Braxton Hicks contractions

Management summary of preterm labour

Treat any potential cause of preterm labour, e.g. infection

Administer corticosteroids

Oxytocin receptor antagonist

Continuous CTG monitoring

Neonatal team involvement

Initial Assessment

Airway, breathing, circulation

All patients, even those that appear stable require an ABC assessment. This can, however, be done very quickly in patients that are not acutely unwell.

‘The patient is sitting up on a bed talking to her partner when you enter the room. She looks a little uncomfortable but not unwell. The midwife shows you the admission observations she has recorded. The patient has a RR of 15/min, saturations of 99% on room air, pulse 95 bpm, a blood pressure of 120/80 mmHg, CRT<2 seconds, and a temperature of 36.9°C.’

You identify that the patient is currently stable, allowing for a full history to be taken followed by examination.

History

A history and examination focused on eliminating potential differential diagnoses will quickly identify the likely diagnosis

‘The pains have the character of a tightening feeling across the abdomen. Initially they were coming every 30 minutes lasting about 10 seconds, now they are coming at least every 10 minutes, lasting up to a minute and are becoming more painful. Anne now has to stop what she is doing when the pain comes on. There are no symptoms of infection, no symptoms of pre-eclampsia, fetal movements have been normal and there has been no vaginal blood loss. Anne’s pregnancy has been uneventful up to this point. The only other important fact noted from the history was that the patient thinks she had a procedure on her cervix about a year ago following an abnormal smear.’

The history of the pains are consistent with contractions which are increasing in frequency and intensity. There is a possibility that the patient also had a large loop excision of the transformation zone, which is a risk factor for preterm labour.

Examination

Assess pallor, the pulse, and capillary refill time

Abdominal examination:

Identify areas of tenderness

Measure symphysis–fundal height (SFH)

Palpate the uterus to identify tenderness and tightening

Assess fetal lie, presentation and engagement

Speculum examination:

Always look at previous scans to confirm there is no placenta praevia before undertaking a pelvic examination

Assess vulva and vagina for any abnormalities, blood or liquor in the vagina

Obtain a good view of the cervix assessing cervical length, dilatation, and presence of blood, fluid or membranes expectorating through the os

Take a high vaginal swab (HVS) and, if appropriate, take a fetal fibronectin swab from the posterior fornix

Fetal fibronectin

Simple bedside test used between 24 and 34 weeks gestation

A negative result suggests there is a 99% chance the patient will not labour in the next 14 days, but clinical judgement must be used when interpreting the result

Bleeding, recent intercourse, previous speculum examination and use of lubrication can all produce false positive results

‘Heart rate is 80 bpm, capillary refill time is 2 seconds. The abdomen is soft with no specific areas of tenderness. SFH 31 cm, uterus is initially soft but tightenings are palpable, and no uterine tenderness. Fetus is in a longitudinal lie, cephalic presentation, three-fifths palpable.

Normal vulva and vagina, no blood or liquor seen. The cervix is posterior, 1 cm long, 1 cm dilated, no membranes or fluid leak seen. High vaginal swab taken and sent to microbiology. Fibronectin was positive’.

The examination findings support the diagnosis of threatened preterm labour.

In obstetrics there are two patients:

Assess maternal well-being first

Never forget to assess fetal well-being as well.

Initial Investigations

Urinalysis (rule out UTI). Check also if Group B Streptococcus carrier

Bloods (to assess for signs of infection and to be prepared for delivery complications such as postpartum haemorrhage): FBC, CRP, U&Es, group and save

Cardiotocography (CTG): To assess fetal well-being and frequency of contractions

In most instances all of these investigations will have been carried out by the midwife prior to your arrival.

Table 7.1

Miss Seymour’s blood results

Parameter	Value	Normal range (Units)
WCC	8×10⁹/L	4–11 (×10⁹/L)
Neutrophil	6×10⁹/L	2–7.5 (×10⁹/L)
Lymphocyte	2×10⁹/L	1.4–4 (×10⁹/L)
Platelet	300×10⁹/L	150–400 (×10⁹/L)
Haemoglobin	150 g/L	Men: 135–177 (g/L) Women: 115–155 (g/L)
CRP	3 mg/L	0–5 (mg/L)
Urea	2.5 mmol/L	2.5–6.7 (mmol/L)
Creatinine	79 μmol/L	79–118 (μmol/L)
Sodium	136 mmol/L	135–146 (mmol/L)
Potassium	5 mmol/L	3.5–5.0 (mmol/L)
eGFR	>60 ml/min	>60 (mL/min)

‘In this case, urinalysis was normal, fetal heart tracing was normal and the tocograph showed 1–2 contractions every 10 minutes. Bloods were normal.’

Management [1,2]

Treat any potentially reversible cause of preterm labour:

Chase bloods and microbiology results. Regularly reassess the patient for signs of infection and have a low threshold for commencing treatment

Optimize conditions for delivery

Give dexamethasone 12 mg IM, followed by a further dose 12 hours later to help mature the fetal lungs

Obtain intravenous access

Prescribe a tocolytic agent e.g. atosiban (oxytocin receptor antagonist):

Initially 6.75 mg IV bolus over 1 minute

Then by IV infusion 18 mg/hour for 3 hours

Then by IV infusion 6 mg/hour for up to 45 hours

(Infusion usually prepared by using 75 mg atosiban made up to 100 mL with 0.9% NaCl, set at a rate of 24 mL/h for 3 hours, then 8 mL/h for 45 hours)

The purpose of the atosiban is to attempt to prolong the pregnancy to allow the corticosteroids to take effect

Continuous CTG monitoring while on atosiban

Neonatal team involvement:

Confirm neonatal unit has a bed for this premature delivery, otherwise an intrauterine transfer to another hospital may be needed

Neonatal team to discuss likely management of the neonate with Anne and her husband

VTE prophylaxis:

LMWH should be avoided as there is a risk the patient will go on to labour. Encourage adequate hydration and mobilization, but this is a low risk patient anyway.

If VTE prophylaxis is required in a high-risk patient consider unfractionated heparin.

Keep the patient informed

This is a very stressful time for parents with a lot of information for them to take in. Make sure you allow time to answer their questions. Keep your explanations simple

If you are unsure about how to answer a question, be honest and tell the patient you don’t know the answer, but go and find a senior obstetrician or neonatologist who does

There is nothing worse for the patient than being given contradictory information

Prescribe (see Figs 7.1 and 7.2)

Corticosteroids, e.g. DEXAMETHASONE 12 mg IM STAT (and repeated 12 h later)

Oxytocin receptor antagonist, e.g. ATOSIBAN 6.75 mg IV (over 1 min), then ATOSIBAN 75 mg (in 100 mL 0.9% SODIUM CHLORIDE). Rate 24 mL/h for 3 hours, then 8 mL/h for 45 hours

Figure 7.1

Figure 7.2

Outcome

If the contractions settle and there are no signs of infection or fetal compromise, Anne will be able to go home and continue the pregnancy

If there is any sign of fetal distress delivery may be expedited (by either vaginal delivery or caesarian section)

If Anne goes on to deliver despite attempts to prevent preterm labour then we have prepared as well as possible for the preterm delivery.

Handing over to the Night Team

‘Ms Seymour presented to labour ward at 32 weeks gestation in preterm labour. This is her first pregnancy, and there is a possible history of a large loop excision of the transformation zone last year. There are no symptoms of infection, no symptoms of pre-eclampsia, fetal movements have been normal and there has been no vaginal blood loss. Anne’s pregnancy had been uneventful up to this point.

Ms Seymour is haemodynamically stable, and initial bloods are normal. The CTG shows a normal fetal heart rate, and 1–2 contractions every 10 minutes. Two doses of dexamethasone have been given and atosiban has been started. The neonatal team is aware of the patient, and mum has been counselled about the likely fetal outcomes.

Please review Ms Seymour in a few hours, she may deliver today or tomorrow. If there are any signs of fetal distress, delivery may need to be expedited.’

Station 7.2: Bleeding in pregnancy

You are the junior doctor working in the emergency department. You are asked urgently to review Susan Cox, a 32 year old who states she is 12 weeks pregnant and has presented with heavy vaginal bleeding.

Patient Details

Name:	Susan Cox
DOB:	21/03/82
Hospital Number:	2103914531
Weight:	65 kg
Height:	1.5 m
Consultant:	Dr Roy
Hospital/Ward:	LGH Ward 7
Current Medications:	None
Allergies:	No known drug allergies
Admission date:	22/10/14

Bleeding in pregnancy differential diagnosis

Miscarriage:

Threatened (bleeding, os closed). May progress to complete miscarriage

Inevitable (bleeding, os open±visible products)

Complete (bleeding settled, products passed, os closed)

Ectopic pregnancy (classically presents 5–10/40 weeks)

Cervical ectropion

Cervical cancer

Later gestation (>18/40 weeks) also:

Placenta praevia

Vasa praevia

Placental abruption

Labour (term or preterm)

Initial assessment and management summary

Resuscitate using an ABCDE approach

2×large bore cannula

FBC, clotting, U&E, G&S and cross match

IV fluid resuscitation

Regular assessment

Consider:

Blood products

Medication to stop bleeding

Early specialist input

Holistic practice

Your focus should be the physical well-being of your patient

Do not neglect the psychological stress for the patient

Keep yourself and the environment as calm as possible

Offer support and allow a relative to sit with the patient when appropriate

Initial Assessment

Airway

Assess patency of the airway

‘The patient is comfortably able to talk to you, there is no obvious airway problem.’

Breathing

Respiratory rate and oxygen saturations

Assess work of breathing

Perform a brief respiratory exam

‘RR 20/min, oxygen saturations are 97% on room air. The patient is speaking in full sentences. There is good air entry bilaterally on auscultation.’

No action is required for airway or breathing.

Circulation

Assess haemodynamic status by measuring pulse, blood pressure and capillary refill time. Attach the patient to a 3 lead ECG and a non-invasive blood pressure monitor set to recheck blood pressure every 5 minutes

Additionally, make an initial assessment of the current blood loss. This only needs to be a crude assessment by looking at the patient and the paraphernalia around the room. For example, the patient may have some blood soaked sanitary pads to show you, there may be some tennis-ball-sized blood clots on the bed that the patient has just passed, or there may be blood all over the patients clothing and blood may be all over the bed and dripping onto the floor

‘The patient’s heart rate is 134 bpm, with a BP of 100/60 mmHg and CRT of 3 seconds. You note a heavily blood-stained incontinence pad underneath the patient, but you can’t see active blood loss on this inspection.’

This patient is tachycardic and hypotensive with evidence of blood loss. She is at risk of further blood loss and hypotensive shock.

Obtain IV access with 2 large bore cannulas, taking bloods at the same time. Prescribe and commence IV fluids. Prepare to catheterize the patient.

Prescribe (see Figs 7.3–7.5)

Fluid, e.g. 0.9% SODIUM CHLORIDE 500 mL (over 15 min)

Figure 7.3

Figure 7.4

Figure 7.5

Disability

Assess the patient’s GCS or AVPU (is the patient Alert? If not, do they respond to Verbal or Painful stimuli? Or are they Unresponsive?) level

Check capillary blood glucose

‘The patient is GCS 15 (E4, M6, V5), blood glucose is 5.1 mmol/L.’

Exposure

Examine the abdomen, assess for areas of tenderness and for a palpable mass consistent with a uterus. (At 12 weeks of gestation the uterus may just be palpable above the pubic bone)

Check the temperature

Perform a speculum examination. With a lubricated Cuscoe speculum attempt to locate the cervix and assess the current active blood loss. Gauze wrapped on sponge holder forceps will likely be needed to remove clots and blood in the vagina to visualize the cervix. The important points to assess are:

Extent of active bleeding

Cervical os open or closed (open suggests miscarriage inevitable)

Are products of conception visible at the os (if so try to remove with a sponge holder)

A digital vaginal examination (PV) can be performed (ensure you know there is no placenta praevia first as this is a contraindication to PV) to assess whether the cervical os is open when it has been difficult to visualize, and to assess size, position and mobility of the uterus

Catheterization can be done after pelvic examination.

‘The patient’s abdomen is soft with mild tenderness suprapubically and a mass consistent with a 12-week-sized uterus is palpable supra-pubically. On pelvic examination, there were 2 tennis-ball-sized blood clots removed from the vagina, an open cervix was seen with fresh blood trickling through the os, no products seen. Temperature is 37°C.’

Your working diagnosis after your initial assessment is an inevitable miscarriage with active blood loss and a haemodynamically compromised patient.

Undertaking a pelvic exam

Obtain verbal consent

Wear gloves

Always have a chaperone

All equipment close to hand–speculum, lubrication, sponge holder forceps, gauze

Adequate examination light/torch

Initial Investigations

Bloods:

FBC–Assess for anaemia (may be falsely reassuring in an acute bleed prior to fluid resuscitation). Raised WCC can suggest infection which may be a cause of, or complication of miscarriage. Decreased platelets with active heavy bleeding is suggestive of consumptive loss/DIC requiring further investigation of clotting and replacement of platelets

Clotting–Raised PT/APTT with active bleeding needs urgent discussion with haematology and consideration of replacement of clotting factors with FFP or cryoprecipitate

U&Es–Baseline renal function should the patient require surgery under general anaesthesia

CRP–Additional marker of infection

Group, save and cross-match 2 units–Blood product replacement should be considered if haemoglobin<70 g/L, haemoglobin<80 g/L in a symptomatic patient, or if bleeding is heavy>1.5 L and ongoing. If surgical management is undertaken rhesus negative patients (over 12 weeks gestation) will require anti-D prophylaxis.

Table 7.2

Ms Cox’s blood results

Parameter	Value	Normal range (Units)
WCC	10×10⁹/L	4–11 (×10⁹/L)
Neutrophil	7×10⁹/L	2–7.5 (×10⁹/L)
Lymphocyte	2×10⁹/L	1.4–4 (×10⁹/L)
Platelet	250×10⁹/L	150–400 (×10⁹/L)
Haemoglobin	100 g/L	Men: 135–177 (g/L) Women: 115–155 (g/L)
PT	12 seconds	11.5–13.5 seconds
APTT	35 seconds	26–37 seconds
CRP	4 mg/L	0–5 (mg/L)
Urea	2.5 mmol/L	2.5–6.7 (mmol/L)
Creatinine	79 μmol/L	79–118 (μmol/L)
Sodium	138 mmol/L	135–146 (mmol/L)
Potassium	4 mmol/L	3.5–5.0 (mmol/L)
eGFR	>60 mL/min	>60 (mL/min)