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Ростовский Государственный Медицинский Университет
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Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2899_Библиотеки_им_академика_М_И_Перельмана

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Part9
Obstetricsandgynaecology
Antenatalcare
Antepartumhaemorrhage
Diabetesinpregnancy
Ectopicpregnancyandmiscarriage
Hypertensioninpregnancy
Intrapartumcare
Nauseaandvomitinginpregnancy
Pelvicorganprolapseinwomen
Postpartumhaemorrhage
Sepsisinandfollowingpregnancy
Thrombosisandembolismduringpregnancyandthepostnatalperiod
Urinaryincontinenceinwomen
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Chapter57
Antenatalcare
Guideline: NICE NG201 (Antenatal care):
https://www.nice.org.uk/guidance/ng201
OUPdisclaimer:OxfordUniversity Press makesno representation, express or implied, that the drugdosagesarecorrectand thatthe recommendations are an exclusive or mandatory course of care. All health professionals readingthistexthavearesponsibilitytoevaluateitsappropriatenessandtake theindividualneedsofthepatientintoaccount.
Localtrustguidelines:pleaserefertoyourlocalguidelinesasnecessary.
Overview
This chapter summarizes the antenatal care that should be received by women with uncomplicated (midwife-led) singleton pregnancies. Women with more complicated pregnancies should also receive this baseline of care and have additional scans and appointmentsasrequired.
Antenatalinformation
Thefollowingitemsshouldbediscussed:
Atthefirstcontactwithahealthcareprofessional
Folicacidsupplementation Reducingtheriskoffood-acquiredinfections Smokingcessationandavoidingdrugandalcoholuse Screeningprogrammesincludingrisksandbenefits.
Atbooking
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Fetaldevelopment Nutritionalinformation,includingvitaminDsupplementation Exercise,includingpelvicfloorexercises Placeofbirth Breastfeeding Antenatalclasses Mentalhealthissues.
Beforeorat36weeks
Breastfeeding Preparationforlabourandbirth,includingpainmanagement NeonatalvitaminKprophylaxis Newbornscreeningtests Postnatalself-care Recognitionofpostpartumdepression.
At38weeks
Optionsifthepregnancyislikelytobeoverdue.
Antenatalappointments
In anuncomplicated pregnancy, nulliparous womenshould haveten appointments, and parouswomenshouldhaveseven.SeeTable57.1.
Atallappointments:
Measurebloodpressureandtesturineforproteinuria Measureandplotsymphysis–fundalheight(after25weeks).
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Table57.1Summaryofantenatalappointments
Gestation Content
Bookingappointment(ideallyby 10weeks)
Takepastmedical,obstetricandfamily history,includingriskfactors forpre­eclampsia(seeChapter61) Identifywomenwhomayneedadditionalcare CheckFBC,bloodgroup,andrhesusDstatus Offerscreening Arrangeultrasoundscansfordatingandanomalies Measureheight,weight,andBMI Identifywomenwhohavehadfemalegenitalmutilation(FGM) Askaboutmoodandpsychiatrichistory Askaboutoccupationtoidentifypotentialrisks
16weeks
Reviewresultsofscreeningtests Startironsupplementationifanaemic
25weeks
*
Routine Discussfetalmovementsandhowtoseekmedicalhelp iftheynotice reduced fetalmovements
28weeks
Secondscreeningforanaemia,bloodgroup,andatypicalredcellalloantibodies Anti-Dprophylaxisifrhesusnegative
31weeks
*
Reviewresultsofscreeningtests
34weeks
Seconddoseofanti-Difrhesusnegative
36weeks
Offerexternalcephalicversion(ECV)ifsuspectedbreech
38weeks
Routine
40weeks
*
Routine
41weeks Forwomenwhohavenotgivenbirthby41weeks:
Offeramembranesweep Offerinductionoflabour.Ifdeclined,offer↑monitoring
*
Signifiesextraappointmentsfornulliparouswomen.
Scanning
10+0–13+6 weeks: dating scan to determine gestational age using crown–rump length
measurement(andcheckformultiplepregnancies) 18+0–20+6weeks: structural anomaly scan to look for congenital abnormalities and placental position.Iftheplacentaislow,thenare-scanshouldbebookedfor32–36weeks.
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Lifestyleconsiderations
Nutritionalsupplements
Folicacid:400microgramsperday.Ideallyfrom3monthspriortoconceptionandthroughoutthe
first12weekstoreducetheriskofneuraltubedefects Vitamin D: 10 micrograms per day during pregnancy and breastfeeding. Higher-risk women includethosewithdarkerskinorlimitedexposuretosunlight(e.g.houseboundorskincoveredfor culturalreasons)
Iron:notroutinelyofferedasthereisnobenefitifnotanaemicanditmayhavesideeffects Vitamin A: avoid supplementation (liver/liver products also contain high levels) as it may be
teratogenic.
Sleepingposition
Advisewomennottosleepontheirbackafter28weeks.
Reducingriskofinfection
Listeria
Drinkonlypasteurizedorultra-hightemperature(UHT)milk Avoideatingripenedsoftcheese,bluecheese,oranypate Avoideatingundercookedreadymeals.
Salmonella
Avoidraworpartiallycookedeggsorfoodcontainingthem(e.g.mayonnaise) Avoidraworpartiallycookedmeat,particularlypoultry.
Toxoplasmosis
Washhandsbeforehandlingfood Washallfruitsandvegetables Ensureallfoodisthoroughlycookedforconsumption Wearglovesandwashhandsaftergardening Avoidtouchingcatfaecesincatlitterorsoil.
Medication
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Fewmedicineshavebeenestablishedassafeforuseinpregnancy Prescription should be limited to situations where benefit outweighs risk. Over-the-counter medicinesandcomplementarytherapiesshouldbeavoided.
Exerciseinpregnancy
Moderate-intensityexerciseissafeinpregnancy Contactandhigh-impactsportswithriskofabdominaltraumaorfallsshouldbeavoided Scubadivingisunsafe.
Smokinginpregnancy
There is an↑riskofadversepregnancyoutcomes inwomenwhosmokeorwhoareexposedto second-handsmoke.Theseincludeintrauterinegrowthrestriction,pre-termbirth,andstillbirth Allwomenshouldhavetheirsmokingstatusexploredandbeofferedsmokingcessationadviceand referraltolocalNHSStopSmokingServicesifrequired Therisksandbenefitsofnicotinereplacementtherapyinpregnancyshouldalsobeexplored.
Travelduringpregnancy
Airtravel
Long-haul airtravel isgenerallyassociatedwithan↑riskofDVTandPE.Itisunclearwhether pregnancyincreasesthisrisk Wearingcompressionstockingsmayreducetherisk.
Cartravel
Ensurethecorrectuseofseatbelts,i.e.three-pointseatbeltaboveandbelowthebump,notoverit.
Travelabroad
Discussconsiderationssuch asflying(airlinerulesvary),travelinsurance,andvaccinations(not allvaccinationsaresafeforthefetus).
Managementofcommonpregnancysymptoms
Nauseaandvomitinginearlypregnancy
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SeeChapter63formoredetails Most cases will resolve by 20 weeks without treatment.It does not affect pregnancy outcome. First-linetreatmentoptionsinclude:
Ginger Wristacupressure Antihistamines.
Heartburn
Considerlifestyleanddietmodification.Antacidscanbetrialled,e.g.ranitidineoromeprazole.
Constipationandhaemorrhoids
Give advice regarding dietary changes such as increasing fibre intake. Consider standard haemorrhoidcreamsifnecessary.
Varicoseveins
Common,harmless pregnancysymptom. Compressionstockings mayimprove symptoms butwill notpreventvaricoseveindevelopment.
Vaginaldischarge
↑dischargeisacommonphysiologicalchange.Consideranunderlyinginfectionifitisassociated withitching,pain,offensivesmell,ordysuria 7 days of topical imidazole should be given for vaginal candidiasis. An alternative is a clotrimazolepessary(500mg,onceonly)withclotrimazoletopicalcream.Oraltreatmentsshould notbeused.
Vaginalbleeding
Unexplainedvaginalbleedingafter13weeks:
Offeranti-DifrhesusDnegativeandatriskofisoimmunization Refertosecondarycare.Thedecisiontoadmitdependsontheriskofplacentalabruptionand pre-termdelivery,severityofbleeding,andthewoman’sabilitytoreturntosecondarycarein anemergency Checkplacentallocationifunknown(?placentapraevia).
Backpain
Backpainiscommoninpregnancyandmaybeeasedbywater-basedexerciseandmassage.
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Screening
Noscreeningiscompulsory,so women should begiven sufficientinformation to make aninformeddecision.Womenshouldbemonitoredandscreenedforgestationaldiabetes (seeChapter59)andpre-eclampsia(seeChapter61)throughoutpregnancy.
Anaemia
AFBCshouldbetakenatbookingandat28weekstoscreenforanaemia Ahaemoglobinconcentrationof<110g/Latbookingor<105g/Lat28weeksshouldbetreatedwith atrialoforaliron.
Bloodgrouping
A groupand saveandantibodyscreenshould beperformed atbooking andagain at 28 weeks, irrespectiveofpreviousstatus AllwomenwhoarerhesusDnegativeshouldbegivenanti-Dprophylaxis Womenwhohaveclinicallysignificantredcellalloantibodiesshouldbereferredtofetalmedicine forfurtherinvestigationandmanagement.
Haemoglobinopathies
Preconception counselling and carrier testing should be available to those at high risk of haemoglobinopathies.
Hypertension
Blood pressure should be measured at every antenatal appointment, as well as a urinalysis to checkforproteinuria If >20+0weekswitha firstrecording ofhypertension(≥140/90mmHg), theyshould be seen in secondarycarewithin24hours If bloodpressureis≥160/110mmHg,theyshouldbeseenurgentlyinsecondary careonthesame day SeeChapter61forfurtherdetails.
Screeningforstructuralanomalies
USSforfetalanomaliesisperformedbetween18+0and20+6weeks.Identifyingfetalanomalies allows:
Terminationofpregnancy Preparationforanytreatment,disabilities,orpalliativecare Planningofbirthinaspecialistcentre.
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ScreeningforDown’ssyndrome
Ideally,screeningshouldbedoneusingthe‘combinedtest’(nuchaltranslucencyplusβHCGplus pregnancy-associatedplasmaprotein-A(PAPP-A))by13+6weeks If apatientbookslater,or wherenuchaltranslucencycannotbe measured,offerserumscreening (tripleorquadrupletest)between15+0and20+0weeks Theroutineanomalyscanshouldnot beusedfor Down’ssyndrome screening;however,ifthere aresuspiciousfindingsthewomanshouldbereferredtofetalmedicine.
Screeningforinfections
Earlyscreeningshouldbeofferedfor:
Asymptomaticbacteriuria,syphilis,HIV,andhepatitisB If<25years,directthewomantothenationalchlamydiascreeningprogramme Donotscreenfor the following: asymptomatic bacterial vaginosis, cytomegalovirus,hepatitisC virus,groupBstreptococci,rubella,ortoxoplasmosis.
Furtherreading
1.NHS.TheHealthyStartprogramme.Availableat:https://www.healthystart.nhs.uk/
2.NICE(2014, updated2020). Antenatal andpostnatalmentalhealth:clinical managementandservice guidance(CG192).Availableat:https://www.nice.org.uk/guidance/cg192
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Chapter58
Antepartumhaemorrhage
Guideline: Royal College of Obstetricians and Gynaecologists (RCOG)
GTG63 (Antepartum haemorrhage): https://www.rcog.org.uk/en/guidelines-
research-services/guidelines/gtg63/
OUPdisclaimer:OxfordUniversity Press makesno representation, express or implied, that the drugdosagesarecorrectand thatthe recommendations are an exclusive or mandatory course of care. All health professionals readingthistexthavearesponsibilitytoevaluateitsappropriatenessandtake theindividualneedsofthepatientintoaccount.
Localtrustguidelines:pleaserefertoyourlocalguidelinesasnecessary
Overview
Antepartumhaemorrhage(APH)isbleedingfromthegenitaltractbetween24+0weeks’ gestation and birth. It occurs in 3–5% of pregnancies and can affect the morbidityand mortalityofbothmotherandbaby.
Diagnosis
Causes
Labour Localbleedingfromthevulva,vagina,orcervix:
Cervicalectropionorpolyp Infection Trauma
Malignancy Placentalabruption Placentapraevia Rupturedvasaprevia Unexplained.
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