Pre-conception advice

• Pre-conception - advice and management (CKS), Pregnancy and baby guide (NHS Choices)

Infertility

• Day 21 progesterone, lifestyle

• Semen analysis sperm concentration <15 million/ml (WHO lower reference value): repeat at 3M to allow time for the cycle of spermatozoa formation to be completed. If azoospermia or severe oligozoospermia repeat test ASAP. ​Infertility (CKS), Fertility problems (NICE), Artificial insemination (NHS Choices), IVF (NHS Choices), Fertility Network UK (fertilitynetwork.org), Fertility fairness (fertilityfairness.co.uk), Human Fertilisation and Embryology Authority (HFEA)​, British Infertility Counselling Association (BICA)

Antenatal care

• Gestation (G/P), SFH, FHR, BP, urinalysis, SOA

• Maternity certificate (Mat B1) to claim Statutory Maternity Pay (SMP) or maternity benefits. Complete before confinement (not >20W before EDD) or after confinement (the condition of being in childbirth)

• Antenatal care (NHS Choices), Antenatal care - uncomplicated pregnancy (CKS), Antenatal care for uncomplicated pregnancies (NICE, 2016)

• Diet & lifestyle: Diet and lifestyle during pregnancy (patient.info)

• Smoking: Nicotine replacement therapy (NRT) can be prescribed to those that have failed to quit without NRT. Only 2W supply should be prescribed from the date the patient agrees to stop and should only be continued if smoking cessation continues. Varenicline and bupropion should not be offered to pregnant or breastfeeding women. Smoking: stopping in pregnancy and after childbirth. (NICE, 2010)

• Asymptomatic bacteriuria : increased risk of pyelonephritis and subsequent risk of maternal and foetal mortality and morbidity: maternal fever, acute respiratory distress, ARF, stillbirth and preterm birth, anaemia and pre-eclampsia. Rx nitrofurantoin, amoxicillin or cefalexin for 7/7 based on recent culture and susceptibility with further urine culture following completion of treatment

• Intermittent iron supplementation: no difference in most outcomes (infant birthweight, premature birth, perinatal death, or iron deficiency in women at the end of pregnancy), fewer side-effects (constipation and nausea), decreased number of women with high Hb concentrations at term which may be harmful (increased risk of premature birth and low birthweight): Daily oral iron supplementation during pregnancy. (Cochrane)

• Due date calculator: Pregnancy due date calculator (calculations from obstetric ultrasound scan or LMP - patient.info)

• Screening: Screening tests for you and your baby (gov.uk), NHS fetal anomaly screening programmes (FASP) (gov.uk), Amniocentesis (NHS Choices) / Chorionic villus sampling (NHS Choices)​

Pregnancy problems

• Nausea & vomiting / morning sickness: Nausea/vomiting in pregnancy (CKS), Morning sickness (NHS Choices), Hyperemesis gravidarum (NHS Choices), Nausea and vomiting in pregnancy (BMJ Best Practice)

• Dyspepsia: see Dyspepsia (Upper GI)​

• Pre-eclampsia: Pre-eclampsia (NHS Choices)

• Gestational DM: offer further testing if risk factors: BMI >30, previous macrosomic baby ≥4.5 kg, previous gestational diabetes, FH of diabetes (first‑degree relative), minority ethnic family origin with a high prevalence of diabetes. Diabetes in Pregnancy: management from preconception to the postnatal period (NICE)

• Foetal alcohol syndrome: Foetal alcohol syndrome (NHS Choices)

• Trophoblastic disease: Persistent trophoblastic disease (NHS Choices)

• Polyhydramnios​: Polyhydramnios (NHS Choices)

• Pregnancy-related skin conditions / Itch: Pregnancy related skin conditions - an overview (PCDS), Itch: Itch in pregnancy (CKS)

Vaginal bleeding, pain

• Painless bleed: Advise normal activity - no evidence that bedrest influences the outcome. Anti-D immunoglobulin injection is only required for 'threatened' miscarriage if the bleeding is repeated and heavy or associated with abdominal pain. Vaginal bleeding in pregnancy (NHS Choices), Bleeding and pain in early pregnancy (RCOG patient information leaflet), Guideline for the Use of Anti-D Immunoglobulin for the Prevention of Haemolytic Disease of the Fetus and Newborn (BCSH, 2014)

Ectopic pregnancy

• Pregnancy that implants outside the uterine cavity (usually fallopian tube, rarely ovary, abdomen, cervix, C-section scar..)

• If undiagnosed and untreated, spontaneous tubal abortion occurs in about 50%. If the ectopic pregnancy persists and remains undiagnosed and untreated, the tube may rupture, causing intra-abdominal bleeding, haemodynamic instability, and maternal death. The time of rupture depends on the site of implantation and usually occurs after 6 weeks

• Leading cause of maternal death in early pregnancy (2/3 of which are associated with substandard care). Women who do not seek medical help readily (e.g. recent migrants, refugees, difficulty reading or speaking English) are particularly vulnerable.

• Non-tubal ectopic pregnancies (particularly interstitial and cornual ectopic pregnancies) are associated with significantly higher mortality and morbidity than tubal ectopic pregnancies because they are often difficult to diagnose and tend to present late with sudden rupture

Risk Factors

• Previous ectopic pregnancy (recurrence rate approx. 18.5%), PID, surgery, h/o infertility, IVF, smoking, age>35, multiple sexual partners, contraception (no identifiable RF in 1/3)

Symptoms

• Generally appear 6–8W after the LMP (or much later for a non-tubal ectopic pregnancy): pain, amenorrhoea/missed period, vaginal bleeding (with or without clots). Less common: breast tenderness, GI sx (e.g. D&V may be the presenting symptoms of abdominal bleeding), dizziness, fainting, syncope, shoulder tip pain (irritation of the diaphragm due to leakage of blood from the implantation site), urinary symptoms, passage of tissue, rectal pressure or pain on defecation.

Signs

• Abdo/pelvic/adnexal tenderness. Peritoneal signs, abdominal distension, enlarged uterus. Pallor, high HR, low BP, and shock or collapse may indicate tubal rupture and severe bleeding

Investigations

• Urine pregnancy test

• DD: Pregnancy-related conditions bleeding in the 1st/2nd trimester: miscarriage, molar pregnancy (slow-growing cystic tumour which develops from trophoblastic cells after fertilization)

• DD pregnancy-related conditions that can cause abdominal pain in the 1st/2nd trimester: miscarriage, ruptured ovarian corpus luteal cyst, pregnancy-related degeneration of a fibroid.

• Non-pregnancy-related conditions that can cause bleeding in early pregnancy: urethral bleeding, haemorrhoids, trauma of the cervix, vagina, or vulva, cancer of the cervix, vagina, or vulva, vaginitis, cervicitis, cervical ectropion, or cervical polyps.

• Non-pregnancy-related conditions that can cause abdominal pain in early pregnancy: musculoskeletal, UTI, constipation, IBS, PID, appendicitis, renal colic, bowel obstruction, adhesions., ovarian cyst (due to torsion, rupture, or bleeding), torsion of a fibroid, pelvic vein thrombosis.

• Management: if suspect ectopic, refer gynae

Resources

• Ectopic pregnancy (NHS Choices), Ectopic pregnancy and miscarriage: diagnosis and initial management (NICE), Ectopic pregnancy (CKS) ​

Miscarriage

• Recurrent miscarriage: lupus anticoagulant, antiphospholipid antibodies (rx prophylactic LMWH +/- aspirin). Miscarriage (NHS Choices), Miscarriage (CKS), Miscarriage Association (miscarriageassociation.org.uk)

Labour and post-partum

• Labour & delivery: Labour (NHS Choices), Epidural anaesthesia (NHS Choices), Episiotomy & perineal tears (NHS Choices), Caesarean section (NHS Choices), Stretch marks (NHS Choices)

• If ≥20/40 IVC compression may occur and it should be relieved either by manually displacing the uterus to the left (pulling or pushing depending on the side of the patient) with one or two hands (keeping the chest supine) or by tilting the mother (head to toe) to the left (15–30 degrees) provided she is on a firm surface (e.g. tilting table or spinal board), so that the efficacy of chest compressions is not compromised.

• If the gestational age is not known and the mother is obese i.e. the uterus not necessarily visible, but it can be palpated at the level of the umbilicus then again IVC compression is possible and uterine displacement should be attempted. If the mother is known to be <20/40 BUT (because of polyhydramnios or multiple pregnancies) the uterus is clearly visible and/or palpable at the level of the umbilicus, then IVC compression may still occur and uterine displacement should once again be attempted. Clearly if the mother is known to be pregnant but no uterus can be seen or felt (or if palpable, does not reach the umbilicus) then IVC compression is highly unlikely and no displacement manoeuvres need be attempted.

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• Normal birth wt: 2.5kg (5.5lb) - 4.5kg (10lb)

• Postnatal check: Postnatal check (NHS Choices)

• Mental health: ​Postpartum psychosis (NHS Choices), Antenatal / postnatal depression - see Mood/Affective disorders