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Obstetric Cases OBSTETRIC CASES Dr Ishita Saini Important tips: Settings : GP : Rural / Metro Hospital Age of the patient Presenting complaint (vitals unstable , bleeding, pain , vomiting) hemodynamic stability (resuscitation room , iv line, take blood for investigation and manage accordingly) Tasks Obstetrics history: Menstrual history: LMP (corresponding to gestational age or not), regularity, confirm pregnancy Office test- Pregnancy symptoms (morning sickness, nausea vomiting, breast tenderness) if pregnancy not confirmed. History of any miscarriages or previous pregnancies. How was delivery? NVD/CS? Sexual history: STI? Contraception? PAP smear? Regular antenatal checks? Blood group? Folic acid (0.5 mg/ day),USG at 18-20 weeks (single pregnancy/multiple, placenta position) Sweet drink test and 26/28 weeks (OGTT diagnostic), bug test (GBS) at 36 weeks. Passed 20 weeks- baby kicking well or not Support – support to be taken through out pregnancy and delivery. Smoking, alcohol, illicit drugs, Pap smear (can be done after 20 weeks) any medical conditions? Surgeries? Regular Medicine? 5P’s Period Pills Previous pregnancy Pap Smear Partner Obstetrics examination: General appearance : Pallor, Icterus, clubbing, cyanosis, edema Vitals: Blood pressure, temperature, RR, SpO2 Per Abdomen examination: Before 12 weeks : any mass ( multiple pregnancy, H. mole). After 12 weeks : Fundal height (from symphysis pubis to upper part of abdomen), FHR : 110-160 (in distress do CTG), Lie and presentation. Pelvic exam: Inspection : bleeding, rash, discharge, vesicles Sterile speculum exam: cervical os : open (inevitable abortion, incomplete abortion, preterm labour. Closed (threatened abortion) Per vaginal and bimanual exam: Don’t go for PV exam after 20 weeks. Contraindications PROM APH hemorrhages (Placenta previa, abruptio placenta) not sexually active females. Fundal Height Measurement Summary FIRST ANTENATAL VISIT IN PREGNANCY 1.Confirming pregnancy and establishing the best estimate of gestational age and due date. Where gestational age is uncertain a dating ultrasound may be performed or organised. 2.A comprehensive clinical and psycho-social assessment in order to determine any conditions or circumstances that may be of relevance to the pregnancy; with a view to planning the management of these conditions; and 3.Obtaining general advice regarding common issues of concern in early pregnancy. Clinical Assessment A careful medical history and appropriate clinical examination should be undertaken. Height and weight should be recorded, and BMI calculated. The following investigations are recommended (in the absence of specific complications): Full blood examination. Hb level (anaemia), mean corpuscular volume (MCV)(thalassemia or iron deficiency)and platelet count (TCP). Blood group and antibody screen. The antibody screen should be repeated at the beginning of each pregnancy. Rubella antibody status. All women should have their rubella antibody titre measured for each pregnancy. Although the past antibodies titres from a previous pregnancy screens may have been used to exclude a further antenatal test, there is evidence that levels may decline, particularly following immunization as compared to natural infection. Syphilis serology. Syphilis testing should be performed by screening with a specific treponema pallidum assay, for example, Treponema pallidum haemaglutination assay (TPHA), Treponema pallidum particle agglutination assay (TPPA). The non-specific Treponema pallidum assays, such as the rapid plasma regain (RPR) or Veneral Diseases Reference Laboratory (VDRL)tests, although cheaper, are less likely to pick up latent infection. Midstream urine. Biochemical analysis and culture to identify asymptomatic bacteriuria. Chlamydia Selective testing Chlamydia should be considered for those who may be at increased risk HIV All pregnant women should be recommended to have HIV screening at the first antenatal visit. Hepatitis B serology. Women found to be chronic carriers of Hepatitis B, should have an assessment of their viral replicative status (i.e. HBV DNA level and HBe antigen status) and liver function performed, and be referred for specialist support. Hepatitis C serology. Offered according to risk factors or universally. Women who are known to be Hepatitis C antibody positive should have liver function tests performed and an assessment of their viral load (Hepatitis C RNA PCR). Consider referral to an appropriate specialist for counselling and planning postnatal follow up. Varicella. Consideration should be given to checking varicella antibodies at the first visit where there is no definite history of chicken pox. Cervical screening. Recommended at the first antenatal visit if this would fall due during the pregnancy, according to cervical screening guidelines. Screening for Down syndrome. Screening for haemoglobinopathies As a minimum, all women should be screened with MCV. Specific haemoglobinopathy evaluation with hemoglobinelectrophoresis or high performance liquid chromatography and exclusion of iron deficiency (ferritin level)should be performed in the event of low MCV. DNA analysis for alpha-thalassaemia Full assessment of fetal risk requires investigation of the partner (father). Vitamin D Pregnant women at risk for vitamin D deficiency should be tested in early pregnancy OR provided with vitamin D supplementation. Cytomegalovirus (CMV) Routine serological screening for CMV infection in pregnancy is not recommended. Toxoplasmosis Routine serological screening in pregnancy is not recommended. TSH Screening for thyroid dysfunction to be considered for at risk groups. General advice All women in early pregnancy should be informed with respect to: Potential teratogens (medications, alcohol, X-rays etc) Lifestyle advice which may include dietary precautions in pregnancy, cessation of cigarette smoking and other recreational drug use, optimal gestational weight gain in pregnancy, exercise in pregnancy, work and travel precautions Influenza and pertussis vaccination recommendations Vitamin and Mineral Supplementation in Pregnancy Model of care, expected visit frequency, place of booking for confinement, expected costs for both pregnancy and confinement where relevant Antenatal education options. Investigations recommended are: Obstetric ultrasound scan All women should be offered an obstetric ultrasound before 20 weeks' gestation. This will include an ultrasound for fetal morphology and placental localisation usually at 18-20 weeks gestation Gestational diabetes Screening Group B Streptococcal Disease Blood group antibody testing. Further screening is recommended for Rh negative women at approximately 28 weeks gestation. Full blood examination at 28 weeks The haemoglobin level and platelet count should be repeated at 28 weeks gestation. If anaemia or thrombocytopenia are detected, further investigation is warranted. Syphilis, Hepatitis B, Hepatitis C, HIV. Consider repeat screening at 28 weeks in high-risk populations. Influenza vaccination of pregnant ANTENATAL CARE Case 1 You next patient in general practice is a 24 year old Mrs. Jane Hicks who is planning her first pregnancy and she wants your advice regarding antenatal care. YOUR TASK IS TO: Outline the content of an antenatal care plan to the patient BASIC ANTENATAL CARE: The major goal of prenatal care is to ensure the birth of a healthy baby with minimal risk for the mother. There are several components involved in achieving this objective: Patient education and communication Pre conceptual care Anticipatory guidance about what to expect during normal pregnancy (heartburn, leg cramps, backache, various fears and anxieties) Awareness of avoiding infections like varicella, parvovirus, toxoplasmosis, cytomegalovirus, listeria and infections associated with pets or rodents. Early, accurate estimation of gestational age Identification of the patient at risk for complications (high risk pregnancy) Ongoing evaluation of the health status of both mother and foetus. Anticipation of problems and intervention, if possible, to prevent or minimize morbidity HISTORY: Personal and demographic information Obstetrical history (PG, miscarriages, difficulties) Menstrual and Gynaecological history Medical history (diabetes, anaemia, rubella, rheumatic fever, heart or kidney disease, jaundice, depression, transfusion, RH status, surgeries) family history Psycho social (incl. domestic violence, emotional attitude) medication genetic history current pregnancy history (planned or unintended, potential barriers to care eg, communication, transportation, child care issues, economic constraints, work schedule) After obtaining a complete history, a "problem list" is generated. These lists are useful for preventing the inadvertent omission of necessary maternal or foetal monitoring and interventions. PRECONCEPTUAL CARE: Planning of a pregnancy should include advice regarding: 1. Optimal nutrition and diet, weight control, regular exercise, discouragement of smoking, alcohol and drugs, reduce caffeine. Listeria infections (contaminated dairy products, raw vegetables and sea foods, or meats) have a very high foetal mortality! 2. Optimise diabetes / hypertension management 3. 0.5 mg folate daily 3 months before conception and continuing to 12 weeks post conception or throughout pregnancy in multiple pregnancy to prevent neural tube defects 4. Check rubella/varicella status and if indicated immunisation 3 months prior to conception 5. ANTENATAL SCREENING:
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