There are several criteria that aid in the diagnosis of gestational diabetes in pregnancy including NICE, WHO and modified WHO:
GDM Diagnostic Criteria:
NICE: Immediate FBG >5.6, 2 hour glucose >7.8
WHO: Immediate FBG >6.1, 2 hour glucose >7.8
Modified WHO: Immediate FBG >7.1, 2 hour glucose >7.8

Random glucose and OGTT 2 hour readings of >11.1 are diagnostic of diabetes in non-pregnant states but are not part of the gestational diabetes criteria.

Patients with a threatened abortion should be managed expectantly until their symptoms resolve. Patients should be monitored for progression to an inevitable, incomplete, or complete abortion. Analgesia will help relieve pain from cramping. Bed rest has not been shown to improve outcomes but commonly is recommended. Physical activity precautions and abstinence from sexual intercourse are also commonly advised. Repeat pelvic ultrasound weekly until a viable pregnancy is confirmed or excluded. A miscarriage cannot be avoided or prevented, and the patients should be educated as such. Intercourse and tampons should be avoided to decrease the chance of infection. A warning should be given to the patient to return to the emergency department if there is heavy bleeding or if the patient is experiencing light-headedness or dizziness. Heavy bleeding is defined as more than one pad per hour for six hours. The patient should also be given instructions to return if they experience increased pain or fever. All patients with vaginal bleeding who are Rh-negative should be treated with Rhogam. Because the total fetal blood volume in less than 4.2 mL at 12 weeks, the likelihood of fetal blood mixture is small in the first trimester. A smaller RhoGAM dose can be considered in the first trimester. A dose of 50 micrograms to 150 micrograms has been recommended. A full dose can also be used. Rhogam should ideally be administered before discharge. However, it can also be administered by the patient’s obstetrician within 72 hours if the vaginal bleeding has been present for several days or weeks.

The anal sphincters are responsible for closing the anal canal to the passage of faeces and flatus. The smooth muscle or involuntary internal sphincter sustains contraction to prevent the leakage of faeces between bowel movements and is innervated by the pelvic splanchnic nerves, which are a branch of the spinal segment 4. The external sphincter is made up of skeletal muscle and can therefore contract and relax voluntarily. Its innervation comes from the inferior rectal branch of the pudendal nerve, and the perineal branch of S4 nerve roots.

Combined oral contraceptive pills (COCPs) can be started immediately following abortion or miscarriage. Note following childbirth COCPs should not be restarted for 3 weeks (assuming the patient is not breastfeeding).

Fetal hypoxia may cause absent, increased or decreased variability. Other causes of decreased variability include: normal fetal sleep-wake pattern, prematurity and following maternal administration of certain drugs including opioids.

Variability Range:
Normal – 5 bpm – 25bpm
Increased – >25 bpm
Decreased – <5 bpm
Absent – <2 bpm

This is a patient that recently gave birth and is still breastfeeding presenting with dyspareunia. The most likely cause would be a thin atrophic vaginal epithelium. This is very common presentation and is due to the low oestrogen levels due to the prolactin elevation from breastfeeding.

An unrecognised and unsutured vaginal tear should have healed by this time and should not be causing issues.

Endometriosis tends to resolve during a pregnancy, but if this was the issue, it would have caused dyspareunia prior to pregnancy.

Vaginal infective causes of dyspareunia, such as monilial or trichomonal infections, are rare in amenorrhoeic women.

The half life of oxytocin is 5 mins, which is why is should be started as an infusion at a low rate.

The uterine artery arises from the internal iliac artery, in particular the anterior division of the internal iliac artery. Some older texts refer to the internal iliac as the hypogastric artery. The vaginal artery typically arises as its own branch of the internal iliac artery. The ovarian arteries are branches of the aorta

The patient most likely suffered a uterine rupture. It occurs most often in multiparous women and is less often associated with external haemorrhage. Shock develops shortly after rupture due to the extent of concealed bleeding.

Uterine inversion rarely occurs when after a spontaneous and normal third stage of labour. Although it can lead to shock, it is usually associated with a history of controlled cord traction or Dublin method of placenta delivery before the uterus has contracted. This diagnosis is also strongly considered when shock is out of proportion to the amount of blood loss.

An overwhelming infection is unlikely in this case when labour occurred for a short period of time. Uterine atony and amniotic fluid embolism are more associated with excessive vaginal bleeding, which is not evident in this case.

Call for help.
• Ensure personnel are available to ‘scribe’.
Document the time the head delivered, which shoulder is anterior (this is the arm most vulnerable to injury) and the times at which each manoeuvre is employed.
• Drop the level of the delivery bed as low as it will go, and flatten the back of the bed so the woman is completely flat. Remove the foot of the bed to allow access.
• Assess for and perform an episiotomy, if needed.
• Using one assistant on each of the mother’s legs, flex and abduct the legs at the hip (thighs to abdomen, known as McRoberts manoeuvre). This flattens the lumbosacral spine and will facilitate delivery is around 90 per cent of cases.
• If this fails, suprapubic pressure should be
applied by another assistant. This should be
applied over the posterior aspect of the anterior fetal shoulder and will act to push the shoulders together. It can be used in a constant and then rocking motion.
• If both these fail, then internal manoeuvres are necessary. The order of these will depend on the skill and experience of the person conducting the delivery and the individual case. These manoeuvres have been named after famous obstetricians, but it is the process rather than the name that is important:
• An attempt can be made to rotate the baby, so that the shoulders enter the diagonal to allow delivery. The first procedure is usually to insert a hand behind the anterior shoulder, and push it towards the chest (Rubin II). This will adduct the shoulders then push them into the diagonal. This can be combined with pressure on the
anterior aspect of the posterior shoulder
to aid rotation (Woods’ screw). If this fails,
an attempt can be made to rotate the baby
in the opposite direction (reverse Woods’
screw). Delivery of the posterior arm can be
attempted passing a hand into the vagina, in
front of the posterior shoulder and deliver
the posterior arm by swinging it in front of
the fetal chest.
If these all fail, the patient can be moved on to all fours as this increases the anterior–posterior diameter of the inlet. In this position, the posterior arm can be delivered.
After this, manoeuvres of last resort include a symphysiotomy, in which the maternal symphysis is divided, Zavanelli’s, in which the head is reduced back into the vagina and a Caesarean section performed and intentional fracture of the fetal
clavicle.