Category: Obs & Gynae

Hypertensive Disorders in Pregnancy

  • New onset hypertension after 20 weeks of gestation (systolic blood pressure > 140 and/or diastolic blood pressure > 90)

And either

  • Proteinuria (urine protein:creatinine ratio ≥30mg/mmol)

Or

  • Other features of pre-eclampsia1:
    • AKI (creatinine ≥ 90)
    • Liver dysfunction (ALT>40)/epigastric/RUQ pain
    • New severe persistent headache without an alternative diagnosis
    • Persistent visual disturbance
    • Haematological complications (platelets <150/DIC/haemolysis)
    • Neurological complications (clonus/stroke/seizures(eclampsia))
    • Pulmonary oedema
    • Uteroplacental dysfunction (fetal growth restriction/placental abruption/intrauterine death)

Onset is usually after 20 weeks of gestation, but it can also occur up to a few weeks postpartum.

Eclampsia- This is pre-eclampsia that has progressed to seizures

Risk Factors:

Clinical features of pre-eclampsia:

  • Asymptomatic hypertension (picked up on screening or incidentally when presenting with another issue)
  • Headache (usually frontal)
  • RUQ or epigastric pain (also a symptom of HELLP syndrome)
  • Nausea and vomiting
  • Oedema (common but not specific). Especially if rapidly increasing and involving face and hands.
  • Visual disturbance (flashing lights in the visual fields or scotomata)
  • Shortness of breath (uncommon but can occur due to pulmonary oedema)
  • Hyper-reflexia and/or clonus

HELLP syndrome is a variant of severe pre-eclampsia characterised by haemolysis, elevated liver enzymes and low platelets.4

Symptoms and signs are similar to those of pre-eclampsia but also include jaundice and bleeding.

Management of Pre-eclampsia:

 

  • Contact obstetrics early
  • Manage the patient in an area with close monitoring if pre-eclampsia with severe features
  • BP management:
    • Labetalol first line unless unsuitable or contraindicated3 (e.g. asthma)
    • Nifedipine MR second line
    • Methyldopa third line (not used postpartum due to risk of depression)
  • Careful fluid balance monitoring
    • Fluid restriction to reduce the risk of pulmonary oedema
    • Monitor urine output if severe
  • Consider IV magnesium sulphate for eclampsia prophylaxis if severe features of pre-eclampsia

Definitive management:

Definitive management of pre-eclampsia is ultimately delivery of the fetus.   Timing of delivery will be decided by senior members of the obstetric team according to the severity of pre-eclampsia, the current gestation and in consultation with the patient. Following diagnosis of pre-eclampsia, the majority of women are managed as inpatients until delivery.

 

ED Management of Eclampsia:

  • Ask for help early from ITU and obstetric teams
  • ABC approach, manage in left lateral position
  • Airway and breathing assessment with high flow oxygen
  • If inadequate ventilation, consider early intubation (laryngeal oedema in pre-eclampsia and increased risk of aspiration in pregnancy)
  • Magnesium sulphate IV is treatment of choice for seizures – 4g loading dose over 5-10 mins then 1g/hr infusion for 24 hours
  • Further 2g boluses of magnesium sulphate can be given if further seizures occur after initial loading.3
  • Patients will need to be managed in HDU/ITU to stabilise blood pressure prior to delivery

Full NICE guidance is available here

Early Pregnancy: Pain and Bleeding

This pathway for patients in early pregnancy (<16/40) with pain and/or bleeding, extends from Triage to Admission, enabling the triage nurse to:

  • Decide which patients require ED assessment and treatment
  • Discharge or admit suitable patients without the need formal ED assessment

***Pregnancy MUST be confirmed with a positive pregnancy test.***

There are 3 decision trees you could follow

  1. Haemodynamically Unstable
  2. Haemodynamically Stable – Bleeding without pain
  3. Haemodynamically Stable – Pain

1. Haemodynamically UNSTABLE

Haemodynamically UNSTABLE

  1. Consider need for RESUS!
  2. Requires Assessment by ED clinicians
  3. IV access – consider need for 2 cannulae green or bigger
  4. Bloods:
    • Group and Save – Consider Crossmatch
    • FBC
    • U&E, LFT, β-HCG
  5. Treatment (not exaustive):
    • High flow oxygen
    • IV Fluid/Blood
    • Analgesia
  6. Contact Gynae SpR/MG
2. Haemodynamically STABLE – Bleeding without pain

3. Haemodynamically STABLE – Pain

Obstetric Emergencies at HRI

Pregnant patients with Severe Life threatening conditions e.g serious trauma, cardiac arrest, serious medical condition

  • Manage as per ALS/ATLS/MOET guidance (Don’t forget uterine displacement manually).
  • Complete triage of patient and assess fetal gestation and viability. This is not primarily to assess fetal well-being but to influence maternal management
  • Obstetric/Gynae Registrar to be fast bleeped and to attend resus as soon as possible. If they are not contactable or unable to immediately attend, contact the on-call obstetric consultant.
  • Phone the midwifery LDRP coordinator on Tel 01422 223524
  • Senior midwife to accompany SpR.
  • Prepare resus area for emergency caesarean section (equipment in ED).
  • Call the obstetric consultant on call if not already done.
  • Contact the neonatal unit if delivery is imminent. (But do not delay delivery awaiting neonatal team’s arrival)

 

Pregnant patients with a major medical illness potentially requiring admission, e.g. severe asthma/suspected PE

  • Manage as per normal protocols for that condition.
  • Obstetric/Midwifery input may be required, therefore contact the LDRP Coordinator telephone 01422 223524.
  • Dependent on the clinical situation, appropriate specialty team to review and/or inform the consultant of admission.
  • Daily review/status check of the patient in relevant clinical areas.

 

Minor injury or medical illness not necessarily requiring admission, e.g. minor fracture or mild asthma attack

  • Manage as per normal protocols and treat as appropriate.
  • If there are no fetal or obstetric concerns, discharge as appropriate.
  • Pregnant women attending less than 16 weeks to be discussed with the Early Pregnancy Assessment Unit( EPAU)
  • All pregnant women attending ED with reduced fetal movements should be referred to either the Maternity Assessment Centre (MAC) as soon as possible.
  • If there is a history of reduced fetal movements, bleeding per vagina, headache, raised blood pressure or history of a knock to the abdomen or abdominal pain or concerns or anxiety; then an antenatal review would be indicated by an obstetric/gynae doctor or midwife.
  • It may be appropriate for the women to be reviewed in ED or Maternity Assessment Centre (MAC) after discussion with a midwife, the obstetric registrar or SHO on call. If the woman is to be reviewed in MAC or other maternity areas she should be escorted to the area.
  • NB: have a low threshold for suspected thromboembolic disease and possibly escalate

 

Stable women with an obstetric problem with no other issues, e.g. labour, PV bleeding, abdominal pain, reduced foetal movements, raised blood pressure, or headache

  • All pregnant women attending with reduced ED with reduced fetal movements should be referred to either the Maternity Assessment Centre (MAC) or Antenatal Day Unit (ANDU) as soon as possible.
  • Contact the maternity unit via the midwifery co-ordinator on LDRP Tel 01422 223524
  • Transfer to ANDU/MAC/LDRP as advised by above.
  • If the woman is to be reviewed in ANDU/ MAC/ LDRP she should be escorted to the area.
  • Pregnant women attending less than 16 weeks to be discussed with the Early Pregnancy Assessment Unit (EPAU)
  • Ensure the woman has booked for maternity care. If she has not booked for care she should be asked to arrange the booking appointment

 

If these women have presented during working hours the on call registrar (bleep 509) can assess if the patient can be managed in ANDU at HRI depending on gestation and severity of symptoms. Out of hours contact MAC or LDRP at CRH.

 

Pregnant patients who have attempted suicide or presented with a psychiatric problem

  • Contact the mental health liaison team to come and review the patient
  • Psychiatric services to be contacted following the Guideline for. The Care of Pregnant Women Suffering Maternal Mental Health Problems available on the Intranet.
  • Associated injuries/illness to be treated appropriately as per previous categories.
  • If there is a history of reduced fetal movements, bleeding per vagina, headache, raised blood pressure or history of abdominal trauma or abdominal pain, call the obstetric Registrar on call for advice and possible review.
  • The on call team should inform the patient’s consultant or assign a consultant as per unit policy.
  • Contact the LDRP co-ordinator Tel 01422 223524 to inform community midwifery team and Perinatal Mental Health Lead.
  • Antenatal follow-up (with community midwife or consultant as appropriate) appointment to be arranged within 10 days of discharge from hospital or psychiatric care.

 

Pregnant patients who present as victims of domestic abuse (suspected or confirmed)

  • Treat any injuries sustained as discussed depending on the category.
  • If there are any obstetric concerns, a history of reduced fetal movements, bleeding per vagina, headache, raised blood pressure or history of a trauma to the abdomen or abdominal pain; or concerns raised by the woman then please contact the maternity unit via LDRP for advice and possible review.
  • Safeguarding protocols should be enacted, even if this is her first pregnancy.
  • Contact the LDRP co-ordinator Tel 01422 223524 to ensure community midwifery follow-up
  • Provide support and information, explaining that violent assault by a partner represents a real potential threat to her life in the future, the willingness of police to protect her and the availability of domestic abuse support organisations
  • Please refer to the Trust Midwifery Domestic Abuse Guideline available on the Intranet.

Sexual Health Referrals

Appropriate Conditions for GUM
  • Genital ulcers
  • Urethral discharge
  • Pelvic Inflammatory Disease (PID)
  • Testicular pain
  • Genital warts
  • Vaginal discharge
  • Emergency/ongoing Contraception
  • HIV risk concerns
  • Possible syphilis
  • PEP follow up
  • Pre-menopausal irregular vaginal bleeding
  • Known HIV patient please contact 01484 347077
PID Referral Criteria

History/Exam. – NICE CKS (Here) 

  • History:
    • Pelvic or lower abdominal pain (usually bilateral but can be unilateral).
    • Deep dyspareunia particularly of recent onset.
    • Abnormal vaginal bleeding (intermenstrual, postcoital, or ‘breakthrough’) which may be secondary to associated cervicitis and endometritis.
    • Abnormal vaginal or cervical discharge as a result of associated cervicitis, endometritis, or bacterial vaginosis. This is often very slight and may be transient, especially with chlamydial infection.
    • Right upper quadrant pain due to peri-hepatitis (Fitz–Hugh–Curtis syndrome).
    • Secondary dysmenorrhoea.
    • Ask about the possibility of pregnancy.
  • Exam: 
    • Lower abdominal tenderness (usually bilateral).
    • Adnexal tenderness (with or without a palpable mass), cervical motion tenderness, or uterine tenderness (on bimanual vaginal examination).
    • Abnormal cervical or vaginal mucopurulent discharge (on speculum examination).
    • A fever of greater than 38°C, although the temperature is often normal.

GUM Exclusions – Ref to Gynae

  • Pregnancy
  • Sepsis
  • Abscess

No GUM Exclusions – Complete following

  • Patient to preform 2 High Vaginal Swabs- Send For:
    • Chlamydia +Gonorrhoea 
    • TV
  • If Clinical Signs of PID – Treat with following (if allergies D/W Micro)
    • Ceftriaxone 1g i.m. – ONCE ONLY
    • Doxycycline 100mg twice a day & Metronidazole 400mg twice a day for 14 days
  • Refer to GUM (with/Without Signs)
Testicular Pain Criteria

GUM Exclusions – Ref to Urology

  • Torsion
  • Sepsis
  • Abscess

No GUM Exclusions – Complete following

  • 2 Urine Samples:
    • First Pass (white top) – Chlamydia +Gonorrhoea 
    • MSU (red top)
  • Treat with following (if allergies D/W Micro)
    • Doxycycline 100mg twice a day for 14 days
  • Refer to GUM 
Contacts

Kirklees

Calderdale

  • E-Mail referral (patient details and brief description): Sexualhealthservices.chft@nhs.net
  • Patient Self Referral: 01422 261370
  • Address: Broad St, Halifax, HX1 1UB

Massive Transfusion Pathway

In the case of patient with Massive Haemorrhage weather that be from Trauma, Surgical, O&G, UGIB, you can activate the MTP

Remember:

  • Do the Basics – don’t forget ABCD
  • Inform Transfusion and get someone to run a G&S sample down
  • FFP can take up to 45min and platelets come from Leeds
  • If you no longer need the MTP – inform transfusion and return products ASAP
major haemorrage

PDF:MTP

 

Anti-D immunoglobulin

Rhesus (Rh)-D negative women, pregnant with Rh-D positive foetus are at risk of developing antibodies against future pregnancies if/when they suffer a sensitising event. (Remember, this should be considered a standard treatment for all Rh-D negative women, as we are never certain of the fathers Rh-D status) Read more

Rape & Sexual Assault

Don’t

Preform intimate examinations on Sexual assault/Rape patients

  • Unless life-threatening injuries are suspected e.g Haemorrhage.
  • As our examination will inevitably destroy evidence that may aid this patient’s case

Do’s

  • Consider contamination injury (HIV, HepB, HepC) – Guide
  • Consider emergency contraception
  • Children must have police referral for safeguarding
  • Refer to The Sexual Assault Referral Centre, either via Police or Self referral

Read more

Early Pregnancy Bleed <16/40

Bleeding in early pregnancy is a relatively common problem and in the many cases (esp. with spotting) the pregnancy remains viable. However, bleeding in early pregnancy should never be thought of as normal, and it is vital that we investigate this appropriately.

 

Communication is also vital at a very stressful time

  • Who you are discussing this pregnancy in front of? – Does the patient want them to know
  • Manage expectations – There is nothing we or mum can do to change the out come of the pregnancy apart from ensuring mum is well
  • Ensure the patient has all the details they need – Return advice, clinic time, where to go, what is happening
  • Be sensitive to the patients feelings – Patients respond very differently, be careful not to impose your emotions/assumptions on the situation

Think Anti-D!

Anti-D immunoglobulin guide

 

Search: ectopic pregnancy, Ectopic Pregancy, pv bleed, MISCARRIAGE, vaginal bleed, EPAU

MHRA: Ondansetron small increased risk of oral clefts following use in the first 12 weeks of pregnancy

MHRA (Medicines & Healthcare products Regulatory Agency)  has recently published a warning regarding the use of ondasetron in early pregnancy.leading to a small but significant risk of cleft lip. – LINK HERE

“Recent epidemiological studies report a small increased risk of orofacial malformations in babies born to women who used ondansetron in early pregnancy.1 4 Key evidence was an observational study of 1.8 million pregnancies in the USA of which 88,467 (4.9%) were exposed to oral ondansetron during the first trimester of pregnancy. The study reported that ondansetron use was associated with an additional 3 oral clefts per 10,000 births (14 cases per 10,000 births versus 11 cases per 10,000 births in the unexposed population).1 These data were recently reviewed within Europe and considered to be robust.”

Patients with vomiting in early pregnancy requiring antiemetics you can review the guidance on “Hyperemesis Gravidarum”