1. Obstetric Triage
Emma Egan, FY2

2. Objectives Obstetric history and examination
Common obstetric presentations
Differentials of bleeding and pain in pregnancy
Management of common obstetric conditions

3. History PC HPC History of current pregnancy Previous obstetric history
Gynaecological history
Past medical history
Drug history
Family history
Social history
Review of symptoms
HPC: SOCRATES
In pregnancy, always ask about nausea/vomiting, abdo pain, bleeding, urinary symptoms, fatigue, headache/visual changes, systemic symptoms
LMP, planned or unplanned, contraceptives, EDD, antenatal supplements.
Ask about scans, fetal movements, planned method of delivery, illness during pregnancy
Obs history: Gravidity – number of times woman has been pregnant regardless of the outcome
Parity x (any live or stillbirth after 24 weeks) + Y (number lost before 24 weeks)
Details of each pregnancy, date of delivery, singleton/twins, spontaneous labour or induced, weight of baby, current health, previous complications?
Ask about miscarriages or terminations
Gynae history – smears, STDs/PID/ectopic pregnancy, any contraception, any surgery – LETZ = increases risk of cervical incompetence, C-section = increased risk of rupture/placenta accrete/adhesions
PMH: VTE, diabetes, epilepsy, hypothyroidism, previous pre-eclampsia. Immunisations.
Drug history : Folic acid, iron, anti-emetics, antacids, ACE-I’s, valproate, methotrexate, retinoids, trimethoprim. OTC drugs, allergies.
FH: inherited genetic conditions, miscarriage or pre-eclampsia in mother/sisters.
SH: smoking, alcohol, drug use, living situation (important when considering discharge), ADLs, occupation.

4. How would you describe her gravidity and parity?
Question 1
A 38 year old woman is seen at 29 weeks gestation. She has had one normal delivery at 41 weeks, one emergency c-section at 30 weeks, two miscarriages at 10 and 12 weeks and also a termination of pregnancy at 13 weeks with a different partner when she was 16 years old.
How would you describe her gravidity and parity?
G2 P6+3
G5 P2+3
G6 P2+3
P3 G5+2
P6 G2+3 C.

5. Question 2
A 23 year old woman with a positive pregnancy test complains of lower abdominal cramping with a ‘period type’ bleed at home. On palpation there is mild suprapubic discomfort. On speculum examination a small amount of blood is seen in the vagina and the cervical os is closed. Urine dipstick is unremarkable.
What is the most likely diagnosis?
Complete miscarriage
Incomplete miscarriage
Inevitable miscarriage
Menstruation
Threatened miscarriage
E. Threatened miscarriage

6. Miscarriage Spontaneous loss of IUP before 24 weeks gestation
10-20% of pregnancies
Risk increases with maternal age
80% diagnosed between 8-12 weeks
Most commonly caused by fetal abnormalities, and infection
Most common complication of pregnancy.
Underlying causes include fetal abnormality and Toxoplasmosis, Other infections, Rubella virus, Cytomegalovirus, and Herpes simplex virus.
Other risks, fetal malformations (neural tube defects), uterine structural abnormalities, ashermans syndrome, fibroids, thrombophilia, antiphospholipid syndrome, SLE, PCOS, poorly controlled diabetes, thyroid dysfunction,.
Exercise, intercourse and emotional trauma DO NOT cause miscarriage.

7. Miscarriage Threatened miscarriage Inevitable miscarriage
Incomplete miscarriage
Complete miscarriage
Missed miscarriage
1. Threatened miscarriage The fetus is “threatened” (i.e. a miscarriage may happen). There is some vaginal bleeding BUT the cervical os is CLOSED and ultrasound reveals a VIABLE intrauterine pregnancy.
IMPORTANT TO NOTE: 90% of threatened miscarriages will continue to grow to normal gestation.
2. Inevitable miscarriage The miscarriage is “inevitable” i.e. a miscarriage is going to happen. There is vaginal bleeding +/- cramping abdominal pain AND the cervical os is OPEN but the products of conception have not yet passed.
3. Incomplete miscarriage The miscarriage is “incomplete”, i.e. currently happening. There is heavy and increased vaginal bleeding, intense lower abdominal pain and passage of some products of conception. On examination the cervical os is OPEN and there are PRODUCTS OF CONCEPTION present in the canal.
4. Complete miscarriage The miscarriage is “complete”. Products of conception have been passed. On examination the cervical os is CLOSED. Ultrasound reveals an EMPTY uterine cavity.

8. Miscarriage Expectant management Medical management
Misoprostol
Surgical Management (Dilation and Curettage)
Risks of expectant - Bleeding that may continue for several weeks, Increased pain in association with the bleeding, Infected products of conception
Risks of medical – 85% success rate. Bleeding that may continue for several weeks, Increased pain in association with the bleeding, Infected products of conception
Risk of surgical - Risks of general anaesthesia (e.g. N/V, DVT/PE ), Risks of any operation (e.g. infection, haemorrhage), Possibility of retained products after operation, Uterine perforation, Cervical tears, Intrauterine adhesions (Asherman’s syndrome)

9. What is the most likely diagnosis?
Question 3
A 39 year old, prim at 39weeks, who has had no routine antenatal care attends the labour ward complaining of heavy, unprovoked painless vaginal bleeding. On examination she has a soft, non-tender abdomen and head is not engaged. She is passing clots PV. Her pulse is 112/min and BP is 96/56. CTG is non reassuring.
What is the most likely diagnosis?
Cervical ectropion
Placental abruption
Placenta praevia
Uterine rupture
Vasa Praevia C.

10. Placenta Praevia Abnormal implantation of placenta
Placenta lies close to, or covers the internal os
Categorised as minor or major
Risk Factors:
Multiple pregnancy
Increased maternal age
Previous uterine surgery
Previous placenta praevia
Smoking
Usually detected at 20 week scan
APH – defined as bleeding after 24 weeks gestation.
2-4% of women have APH
Bleeding can be maternal, fetal, or placental. Sometimes no obvious cause.
Thought to occur where blood supply interrupted, e.g. uterine scar
Bleeding occurs secondary to shearing forces.
Minor – low lying placenta, close to but not covering os
Major – Covering internal os
Risk factors = surgery or previous praevia, increased scaring. Smoking and drug use (e.g. cocaine) increases shearing forces.
May be found at 20 week scan and if seen, a repeat scan at weeks is performed. 90% of placenta praevia seen at the 20 week scan will no longer be praevia later on as the placenta moves away from the os due to uterine growth.

12. Placenta Praevia Sudden-onset painless bleed Unprovoked or post coital
Fresh red blood PV
Soft non-tender uterus
Clinical condition of mother correlates with the visible blood loss, unlike abruption.
Maternal blood is lost so there is little risk to the fetus unless the mum becomes hypovolaemic.

13. Placenta Praevia Management: Minor placenta praevia:
May be able to deliver vaginally
Major placenta praevia:
If stable, deliver by c-section by 38 weeks
Unstable, immediate delivery
Rhesus –ve, will require anti-D
Minor; can deliver vaginally if placental edge >2cm from os, and head below placenta.
Major; C-section – can wait if pt stable. Weigh up risks/benefits of steroids/mag sulph.
Haemodynamically unstable required immediate delivery.

14. What is the most likely diagnosis?
Question 4
A 26 year old primigravida woman has been induced at 40 weeks due to moderate pre-eclampsia with 6mg vaginal prostaglandins and ARM. She is not on an oxytocin infusion. There are no other antenatal complications. On VE her cervix is 5cm dilated and fully effaced with the presenting part at station -1. She has an epidural in situ and so does not feel the contractions. Suddenly she develops abdominal pain and there are deep decelerations on the CTG. On examination her uterus feels hard. She feels faint, her blood pressure is low with a maternal tachycardia.
What is the most likely diagnosis?
Amniotic fluid emboilsm
Epidural failure
Placental abruption
Uterine hyperstimulation
Uterine rupture.
C. Placental abruption

15. Placental abruption
Separation of the placenta from the uterine wall prior to delivery
Concealed (20%) or revealed (80%)
Risk factors:
Hypertensive disorders
Previous history of abruption
PPROM
Abdominal trauma
Smoking
Cocaine use
Retroplacental bleeding results in further placental detachment which can lead to fetal and maternal compromise.

17. Placental abruption Management
Stable; can be admitted, monitored, IOL if term
Unstable:
RESUSITATE
Immediate delivery by caesarean section
15L O2
2x wide bore cannulae
Fluids
O- if shocked, crossmatch if pt can wait
Correct any coagulopathy with FFP/cryoprecipitate/platelets

18. What is the most likely diagnosis?
Question 5
A 26 year old multi-gravid woman is in spontaneous labour at 41 weeks. She has no antenatal risk factors with normal ultrasound scans. On examination, the head is 2/5th palpable per abdomen. She has SROM at 3cm with heavily blood stained liquor. The CTG shows significant abnormalities. The midwife perfoms a vaginal examination and there is no cord protruding through the cevix which is now 4cm dilated. The mother feels no pain.
What is the most likely diagnosis?
Bloody show
Placental abruption
Placenta praevia
Uterine rupture
Vasa Praevia
E. Vasa praevia

19. Vasa Praevia Rare, occurring only in 1 in 3000 pregnancies
Velamentous cord insertion
Can lead to rapid exsanguination of the fetal circulation
Highest risk when membranes rupture
Umbilical cord vessels travel away from the placenta in the membranes and overlie the internal os. The vessels can tear leading to rapid exsanguination of the fetal circulation. The risk of vessels tearing is greatest when cervical dilatation occurs and at rupture of membranes. A severely abnormal CTG is seen with only a small amount of blood loss.
Management is immediate C-section
Normally, the umbilical cord inserts into the middle of the placenta as it develops. In velamentous cord insertion, the umbilical cord inserts into the fetal membranes (choriamniotic membranes), then travels within the membranes to the placenta (between the amnion and the chorion). The exposed vessels are not protected by Wharton's jelly and hence are vulnerable to rupture. Rupture is especially likely if the vessels are near the cervix, in which case they may rupture in early labor, likely resulting in a stillbirth.

21. What is this most likely diagnosis?
Question 6
A 21 year old primigravida at 41 weeks gestation presents to obstetric triage complaining of gradual onset abdominal cramping pains every minutes. She is concerned as she has had a mucous-like pinky loss vaginally. She has good fetal movements.
What is this most likely diagnosis?
Bloody show
Cervical ectropion
Cervical polyp
Placenta praevia
Vasa praevia A.

22. What action needs to be taken regarding anti-D prophylaxis?
Question 7
A 31 year old, P0+0 at 25+0 weeks presents following a minor road traffic collision where she banged her abdomen on the steering wheel. Serious injury has been excluded but she is concerned about the baby. She has good fetal movements and no PV bleeding. FH is normal. She is RhD negative.
What action needs to be taken regarding anti-D prophylaxis?
Give antenatal anti-D prophylaxis 250iu
Give antenatal anti-D prophylaxis 500iu
Give post natal anti-D
Give routine antenatal anti-D prophylaxis at 28 weeks
No action needed at this time B.
Rhesus negative means their red blood cells lack the rhesus D antigen. This means they are at risk of developing anti-D antibodies to a RhD +ve fetus. If any fetal blood cells from a RhD +ve fetus cross into the circulation of a RHD –ve woman, she will react to the ‘foreign’ anti-D antigens on the fetus red blood cells and produce antibodies.
= Sensitising event +
No consequences on current pregnancy, however in future pregnancies, antibodies can cross the placenta and destroy the blood cells of RhD +ve fetus, resulting in haemolytic disease of newborn.
All RhD –ve women offered anti-D at 28 and 34 weeks.
Also at time of any sensitising event; APH, abdominal injury, external cephalic version, invasive prental diagnosis(amnio, CVS, fetal blood sampling), intrauterine procedures or IUD.
500 given as routine prophylaxis
250 given before 20 weeks for PSE
500 given for PSE after 20 weeks
500 given post natally

23. What is the likely diagnosis?
Question 8
A 34 year old P4 (4x SVDs) presents to the antenatal unit at 40 weeks complaining of abdominal pain associated with fevers and sweating. Initially she thought she was in labour as she had SROM four days ago, but she says the pain has become increasingly worse. O/E her uterus is very tender, and the cervix is long and closed with associated yellow/green discharge. Her temp is She has a raised WCC and CRP.
What is the likely diagnosis?
Abruption
Acute pyelonephritis
Chorioamnionitis
Uterine rupture
Urinary tract infection
C. Chorioamnionitis

24. Chorioamnionitis
Infection of the amniotic cavity and chorioamniotic membranes
Caused by E.coli, Streptococcus and Enterococcus faecalis
Normally seen after PROM
Other risk factors include:
Prolonged labour
Preterm labour
Internal fetal monitoring
Cervical examinations
Urinary tract or vaginal infection
Both mother and fetus can develop potentially life threatening septicaemia.
It is normally seen after rupture of membranes, particularly if this has been over a long period of time – although it can occur with intact membranes

25. Chorioamnionitis Abdominal pain Uterine tenderness Maternal pyrexia
Tachycardia
Raised CRP and white cell count
Meconium or foul smelling liquor
Fetal tachycardia or non reassuring CTG
Immediate delivery, IV antibiotics and paeds input
Both mother and fetus can develop potentially life threatening septicaemia.
It is normally seen after rupture of membranes, particularly if this has been over a long period of time – although it can occur with intact membranes

26. Prelabour rupture of membranes
PROM or PPROM
Sterile speculum examination to confirm
Term:
Induction of labour
Expectant management
Preterm:
Admit for monitoring and steroids
10/7 erythromycin 250mg QDS
Aim to deliver after 34/40
Do not perform digital examination as this increases risk of introducing infection.
Visualise the cervix and ask woman to cough to identify liquor coming from the cervix.
70% of patients at term go into labour within 24 hours, and 90% within 48 hours.
Expectant management should not exceed 96 hours and women are generally induced at 48 hours after SROM.

27. What is the most likely cause of her pain?
Question 9
A 34 year old woman at 40+4 gestation attends obstetric triage with constant suprapubic pain radiating to her upper thighs and perineum. It is worse on walking. She has not taken any analgesia. Her abdomen is soft, with tenderness only elicited by compressing her pelvis. There is cephalic presentation with the head 2/5th palpable and a right occipitotransverse position. Her urine dipstick showed a trace of protein only.
What is the most likely cause of her pain?
Braxton hicks contractions
Labour
Round ligament stretching
Symphysis pubis dysfunction
UTI D.

28. Symphysis pubis dysfunction
Pain and discomfort in the pelvic area which can radiate to the upper thighs or perineum.
Pain worsens as the poregnancy progresses due the to increasing weight of the uterus.
Exacerbated by walking and may be severe enough to limit mobility.

29. Round ligament pain

30. Labour
Painful, regular contractions with cervical dilatation of >4cm
Irregular contractions = Braxton hicks
Three stages of labour:
First stage: onset of established labour until full dilatation
Second stage: full dilatation until fetus is born
Third stage: delivery of placenta and membranes

31. Which antihypertensive should you use to manage her hypertension?
Question 10
A 30 year old primigravida at 34 weeks gestation attends the antenatal clinic. She has persistent hypertension of 164/112 and proteinuria. She has no visual disturbance, no epigastric pain and complains of mild headaches which are generally relieved by paracetamol. Her abdomen is soft and non tender, she has mild pedal oedema, normal reflexes and one beat of clonus. Bloods are all normal. She has asthma for which she uses a salbutamol inhaler PRN.
Which antihypertensive should you use to manage her hypertension?
Furosemide
Labetalol
Magnesium sulphate
Nifedipine
Ramipril
D. Nifedipine

32. Pre-eclampsia
Hypertension and proteinuria with or without oedema and involvement of other organs
Often asymptomatic
Sx can include headache, blurred vision and epigastric pain
Signs; high BP, hyperreflexia, proteinuria, vomiting, hepatic tenderness, oliguria, spontaneous bleeding
Indicators of severe disease are cerebral or visual disturbances, abdominal pain, fetal growth restriction, oliguria, impaired LFTs and thrombocytopaenia

33. Pre-eclampsia
BP <150 systolic or >100 diastolic should be managed with antihypertensives
First line labetalol
Second line nifedipine
Third like hydralazine
Antihypertensives do not cure the disease but it may avoid extreme prematurity by limiting the vascular damage due to uncontrolled hypertension.
Antihypertensive medication may need to be continued for 3 months post partum.

34. What is the most likely diagnosis?
Question 11
A 29 year old primigravida at 38+5 presents to the antenatal day unti after suddenly feeling unwell. She has vomited five times and complains of severe right upper quadrant pain. O/E she is tender in the right upper quadrant only. Her blood results show a mild anaemia, low platelets, deranged LFTs and a normal WCC. Obs reveal a temperature of 36.7, BP of 168/96, HR of 76 and blood glucose of 5.
What is the most likely diagnosis?
Acute fatty liver of pregnancy
Acute pyelonephritis
Cholecystitis
HELLP syndrome
Obstetric cholestasis
D. HELLP syndrome
Haemolysis, Elevated Liver enzymes and Low Platelets.

35. HELLP syndrome Hepatic manifestation of pregnancy induced hypertension
Haemolysis
Elevated Liver enzymes
Low Platelets
Presents with nausea, vomiting and epigastric/RUQ pain
Only curative treatment is delivery
RUQ pain due to haemorrhage or distension of the liver capsule
Often sudden in onset
Associated with pre-eclampsia, however 10-20% have no high blood pressure
High mortality and morbidity with progression to acute renal failure, disseminated intravascular coagulation and increased risk of abruption.
Treatment includes correction of coagulopathy, anti-seizure prophylaxis and anti-hypertensives.
Close fetal monitoring with CTG and USS
Deterioration can occur 48 hours after delivery.

36. Acute fatty liver of pregnancy
Rare but serious
Sudden onset epigastric pain, anorexia, malaise, nausea, vomiting and diarrhoea
Jaundice, mild hypertension or proteinuria
Raised bilirubin, deranged LFTs, leucocytosis, thrombocytopaenia, hypoglycaemia and coagulation defects
CT/MRI to confirm
Management- strict fluid balance, correction of coagulopathy and electrolyte disturbances and delivery
Maternal mortality of up to 20%
Presentation similar to cholecystitis
Can progress to fulminant liver failure – may require ICU admission

37. Obstetric cholestasis
Severe itching affecting limbs, trunk and palms of the hands and soles of the feet.
No abdominal pain
Impaired bile secretion and increased serum total bile acid concentration
Commonly occurs after 30 weeks
Increased risk of PTL and IUD
Symptomatic management with chlorphenamine and ursodeoxycholic acid
Increased risk of: Preterm labour, Intracranial haemorrhage, Fetal distress, Intrauterine fetal death
Diagnosis of exclusion, so required PET bloods, Liver USS, hepatitis serology, CMV and liver autoantibodies
Delivery at weeks reduces risk of IUD without increasing risks of prematurity
No long term maternal risks