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:
6. BP as part of a thorough physical examination
7. Genetic counselling and screening. THE FIRST VISIT IN PREGNANCY:
Estimated date of delivery: A tentative estimated date of delivery (EDD) is calculated from the menstrual history by adding 9 months and seven days to the first day of the last menstrual period.
Accurate dating is crucial for managing the pregnancy, especially with regard to timing interventions and monitoring fetal growth.
Sonographic estimation of the EDD is mandatory when menses are irregular, the LMP is unknown, or in patients conceiving while taking oral contraceptive pills. Routine use of this test appears to be useful in the general obstetrical population, as well. Physical examination:
General appearance and fitness Vital signs, including height and weight A complete physical examination should be performed, with special attention to teeth, gums, thyroid, breasts / nipples, oedema, varicose veins, uterine size and shape and evaluation of the adnexa. Palpate for uterine size and listen to foetal heart sounds if indicated (foetal heart usually can be heard by 9 to 12 weeks of gestation using a Doppler instrument) Speculum examination incl. Pap smear and swab if indicated. Routine initial laboratory tests:
Pregnancy test (beta HCG) FBE incl. hb estimation, MCV and MCH, blood typing and Rh0(D) antibody levels hepatitis B serology, rubella titer, syphilis serology (VDRL), HIV (after counselling) Pap smear and cervical cultures for gonorrhea and chlamydial infection, urine culture, urine protein and glucose. Pelvic ultrasonography is usually performed at 18 weeks but can be done earlier (In a viable pregnancy, the Transvaginal ultrasound can visualize foetal cardiac motion as early as 5.5 to 6.0 weeks.) Oral glucose challenge test at 28 weeks, if abnormal oral glucose tolerance test (OGTT) should be organised VISITS DURING PREGNANCY:
Initial in first trimester: 8-10 weeks Up to 28 weeks: every 4-6 weeks Up to 36 weeks: every 2 weeks 36 weeks – delivery: every week During each visit the following points should be documented: Weight gain: usually 12 kg over 40 weeks, although relatively less in first half / 20 weeks (only 3 kg), then 0.5 kg / week. If maternal weight gain is excessive (> 1.4 kg/months during the early months) or inadequate (< 0.9 kg/months), diet must be modified. BP, urinalysis Uterine size, fundal height, foetal heart, foetal movements (ask patient to record day of first foetal movement), presentation and position of foetus. Any oedema to be noted. Down syndrome screening — Down syndrome is the most common chromosome abnormality among live born infants. All pregnant women should be offered Down syndrome screening. While such screening can be performed in the first or second trimester or both, first trimester screening test characteristics are better than those in the second trimester.
Work — A woman with an uncomplicated pregnancy who is employed where there are no greater potential hazards than those encountered in routine daily life may continue to work without interruption until the onset of labour. However, the physical demands of the woman's job should be considered, especially in women at higher risk of preterm delivery. Exercise — Healthy women with uncomplicated pregnancies should continue to exercise during pregnancy. Issues regarding type, frequency, and duration of exercise, as well as risks of and contraindications to exercise, are reviewed separately.
Use of medications — Medication use is common in pregnancy. All patients should be encouraged to contact their provider with any concerns and before taking any drugs (prescription, over the counter, or herbal [alternative] remedies) that were not previously approved. Information on the use of specific drugs in pregnancy is available in the Australian “MIMS”. Acetaminophen is a widely used drug for treatment of pain and fever, with no evidence in humans of increased risk of pregnancy loss, congenital anomalies, or neurodevelopmental delay. Constipation and diarrhoea can be managed with bulk-forming preparations containing fibre. Airline travel — Most airlines allow women to fly up to 35 to 36 weeks of gestation, although individual policies may vary. Commercial airline travel is generally safe for women with uncomplicated pregnancies. Foetal heart rate is not affected during flight if the mother and foetus are healthy. Maternal physiologic adaptations to high altitude include haemo concentration, increased heart rate and blood pressure, and decreased aerobic capacity with reduction of partial oxygen pressure. For these reasons and the lack of availability of emergency care, certain precautions should be taken: Women with complicated pregnancies (e.g, sickle cell anaemia, high risk of preterm delivery, preeclampsia) should avoid air travel. All airline travellers should maintain hydration, periodically move their lower extremities to avoid stasis and potential venous thrombosis, and continuously wear seat belts to protect against unexpected turbulence. Supplemental oxygen should be administered to pregnant women who must travel and may not tolerate the hypoxic environment of high altitude flying, even in pressurized aircraft (e.g., women with sickle cell or cyanotic heart disease) Signs and symptoms to be reported to the GP:
Vaginal bleeding Leakage of fluid per vagina Uterine contractions Decreased foetal activity Signs of preterm labour (e.g., low, dull backache; increased uterine activity compared to previous patterns; menstrual-like cramps; diarrhoea; increased pelvic pressure; vaginal leaking of clear fluid, spotting, or bleeding) In addition, signs or symptoms suggestive of a medical or surgical disorder should be reported. CASE SCENARIO 2
You are a GP in a metropolitan clinic. Your patient is Jane, a 40yr old single woman, who just found out that she is pregnant from a home pregnancy test. This is her first pregnancy. Task Hx Counsel Jane regarding her antenatal care. ADVANCED AGE PREGNANCY
History Ask her concerns. Planned or not. Periods- LMP, regularity. Sexual history-partner, contraception, signs of pregnancy now, PAP smear. Support, economic situation. F/H of any birth defects. Other M/S illness, medications, SAD. ADVANCED AGE PREGNANCY
Confirm pregnancy. Reassure patient that many women in advanced age, go through normal pregnancy and delivery. Regular A/N checks. Do A/N blood checks and Urine tests. Start on folic acid. Explain about the tests like U/S 18 weeks., sweet drink test at 28 weeks, GBS at 36 wks. Also BP monitoring on every visit. A/N visits- 1st trimester- every 8 weeks Up to 28 wks- every 4 weeks Up to 36 wks- every 2 weeks Up to delivery- every week. Any complications- refer to high risk pregnancy clinic. Healthy diet, regular exercise, quit smoking. RISKS
Risks to mother HT and DM as in general population.
Specific to advanced age pregnancy. 1 miscarriage 2 ectopic pregnancy 3 pregnancy induced HT 4 gestational DM 5 placenta praevia and bleeding 6 premature labor 7 increased chance of induction and C-section. RISKS TO BABY
1 Down’s syndrome. 2 Other congenital birth anomalies- deformities of heart, neural tube defects.
CHANCE OF DOWN’S SYNDROME 30yrs- 1 in 900 35yrs- 1 in 385 40 years- 1 in 106 >45yrs- 1 in 30 2 types of tests- 1 screening test. 2 diagnostic test. SCREENING TESTS FOR DOWN’S
First trimester screening- Combined test Includes blood test and U/S 1 Blood test- 9 - 13 weeks Beta HCG- increased- +ve PAPP-A- decreased- +ve.
2 U/S- nuchal translucency test- 11 - 13 weeks Detection rate- 87% Does not pose any health risks to baby. DOWN’S SYNDROME
Second trimester screening- triple test and quadruple test. Blood tests alone- 15-17 weeks 1 beta HCG- increased 2 inhibin A- increased 3 alpha feto protein- decreased 4 oestriol- decreased. 1+3+4- triple test 1+2+3+4- quadruple test. Detection rate Triple test- 71% Quadruple test- 81% DIAGNOSTIC TESTS
CVS(chorionic villous sampling)- 11-14 wks Risk of miscarriage- 1 in 100.
Amniocentesis-(15-18 wks) Risk of miscarriage- 1 in 200.
Irrespective of maternal age the risk of having a second Down’s syndrome baby is 1%. Review and reading materials. Any pre-pregnancy Counselling: Divide into Three parts- always encourage Pre Pregnancy During Pregnancy Post Pregnancy ➢Pre- Pregnancy: • Condition requirement for getting pregnant • Arrange pre-pregnancy routine Blood tests: FBE, Blood grouping and indirect coomb’s test, hepatitis screening, Syphilis screening(VDRL), Rubella serology, mid stream urine (microscopy and culture), UEC, PAPs smear (if due), BSL, LFT, Vitamin D level. Any abnormality in these should be assessed before pregnancy • Arrange blood tests specific to condition (If indicated) • Referral to specialists before getting pregnant • Start on Folic acid prophylaxis (in epilepsy case increased dosage and thr’out pregnancy) During Pregnancy: • High Risk Pregnancy→ frequent ANC visits, frequent assessment (invx like USG, CTG, Blood testing)→ to assess how you and baby is doing and to detect any complications if occurs and manage according • Managed By MDT- obstetrician, GP, specialists • Explain the risks/complication to mother and baby due to the condition. • Explain the what treatment is required for the condition during pregnancy and its s/e on pregnancy • Outcome of pregnancy Delivery and Mode: • Depends on how pregnancy progresses • Usually done in a controlled manner • Breast feeding: can be given or not • What happens to medication of condition after delivery (if relevant) • Effect on Baby of maternal condition on baby Case: 3
A 25 years woman wants to start a family. She has been suffering from generalized tonic clonic seizure since age of 12. She has taken sodium valproate since then. Task: focus history, counsel the patient. I understand that you are planning to start a family, that’s a great news and good luck with that. I would like to ask you few questions regarding your health and epilepsy.
Tell me about the epilepsy? When were you diagnosed? When was the last fit? Description of fit (tongue bite, loss of consciousness, wetting of clothes, pre-warning signs-aura), any known triggers (alcohol, excessive effort, drugs?)
When was the last assessment by her neurologist? What medication are you taking? And for how long? Any known complications? Any hospital admission? All current and previous medications used and if any complications? Any previous investigations (CT / EEG and drug serum level). How are you coping with your epilepsy? Periods: Regularity of period? Description of cycle/period (no. of days of cycle? Days of period) any painful period? Any heavy bleeding or clots?
Pills, Previous pregnancy, Pap Smear, Partner: are you sexually active? In a stable relationship? Any contraception used? Any known previous STIs?
any other associated systemic illnesses? DM? Hypertension? Social History: family History?
SADMA? Gardasil vaccination (14-26)? Blood group?
Family history of Epilepsy Counseling tips:
Remember to be positive. Your chance to conceive is equal to any other lady. More than 95% of pregnant women with epilepsy deliver a healthy baby, even under medical treatment. However, 20-30 % could experience increase in seizure and risk of developing seizure during labor is 1-2 %.
Tell criteria to be eligible for pregnancy For DM: HbA1c <7 for last 3 months Epilepsy: free of fit for 2 years SLE: no active disease for the last 6 months DVT/PE: thrombophilia screen negative Although the outcome is successful for more than 90% of epileptic women to be pregnant, there is increased risk of feto-maternal risks during pregnancy. For the mother For the baby There is increased risk of There is a risk of cleft lip, vaginal bleeding especially NTD, as AEDs decrease Vitamin K levels at the 3rd trimester. PTL(preterm labour), low birth weight, There is increased relapse of Heart and skeletal malformation, seizures more towards 3rd Complication of preterm. trimester and during labor. Increase chances of abruption placenta, preterm labor, PROM, increase chance for induction and CS. You fit the criteria to be pregnant having no fits for the last 2 years.
I will also arrange for referral to a high risk pregnancy clinic in a tertiary hospital to look after you.
Review in a MDT by Obstetrician, Neurologist, Pediatrician and GP.
Does your partner have similar condition?
Most parents with epilepsy do not have children with epilepsy and the chances of inheriting epilepsy are generally low.
The risk for any child to develop epilepsy by the age of 20 is around 1% (1 in 100), and the risk may increase to around 2 to 5 in 100 (2 - 5%) for most children of parents with epilepsy. MANAGEMENT:
Before pregnancy we’ll do routine antenatal check-up - FBE - Blood group and antibody screen - Rubella antibody status - Hepatitis B virus (hepatitis C optional) - HIV serology - Syphilis serology - Urine culture sensitivity - Pap smear - BSL, LFT,RFT I would refer you to the neurologist who will decide the best medicine and dose for you during pregnancy & delivery. Most likely your specialist will change your medicine to Carbamazepine. You need to take Folic Acid 5 mg per day 3 months before and continue up to 3 months of pregnancy. During pregnancy, you need more frequent visits and you need to take anti epileptic medication regularly.
High-risk pregnancy: combined 1st trimester screen (blood plus USG (11-13 Weeks) looking for nuchal translucency and nasal bone); if not high risk: 18-21 and 28-34 weeks.
One part of the triple screen blood test is a test for an elevated level of alpha-fetoprotein (AFP), which is associated with a higher risk of neural tube defects. All should deliver in tertiary hospital and shall have planned labor when they have completed 37 weeks.
There is increased risk of seizure recurrence in labour and delivery.
The reasons for this are multifactorial and include poor bioavailability of AEDs, compliance, sleep deprivation, anxiety and hyperventilation during labour.
Therefore, women should deliver in a center with adequate facilities for maternal and neonatal resuscitation We’ll give you vitamin K for the last 3 weeks of pregnancy to reduce the risk of bleeding problem to the baby.
After pregnancy, your baby will be delivered in a tertiary hospital or city hospital.
Once delivered, we’ll give your baby vitamin K IM to prevent hemorrhagic disease of newborn.
Breastfeeding is not contraindicated. Case: 4 A 24 years old female who was diagnosed with SLE wants to know the possibility of pregnancy. She is taking methotrexate. Task: Hx counseling and explanation. History:
I understand that you are here for advise regarding pregnancy because of the condition you have. we will talk about it. First please tell me will this be your first pregnancy? Well I want to wish you best of luck and hope that everything will be alright.
Let’s talk about SLE. When was it diagnosed? Who diagnosed it for you? What symptoms did you have? What treatment was given? Are the symptoms controlled? Which one and what dose ? For how long? Did you have any side effects from these medications? How many flare-ups have you had during the past 5 years? When was the last flare up of SLE? Have you had regular checkups with specialist? When was your last checkup? When was the last blood test done? At the moment do you have any symptoms like skin rash, joint pain, problems with waterworks? Periods: please tell me about your periods? When was your LMP? Are they regular? Any heavy bleeding or clots? Partner: are you sexually active? In a stable relationship? Any known previous STIs? Pills: Any contraception used? Previous pregnancy: any miscarriages before. Pap Smear: When was your last pap smear? How’s your general health? Any other medical conditions? Any FHx or SLE or recurrent miscarriages? What is your blood group? SADMA? Counseling:
Lupus is an autoimmune disease that tends to appear in women of childbearing age. The woman develops antibodies against her own cells, resulting in inflamed tissues in her body. Any part of the body can be affected, including joints, skin and internal organs. Depending on the areas affected, and the severity of the symptoms, lupus can be mild or life-threatening.
There is usually inflammation(swelling) of different tissues of the body especially the skin, kidneys, and joints. The exact cause is still not known but certain genes and viruses have been implicated as stimulants.
SLE unfortunately cannot be cured, but it can be very well controlled with medications to prevent flare-ups. The good news is that majority of females with SLE are able to have kids but there are certain risks that are increased in SLE.
The best way to have a safe pregnancy is to have lupus well controlled at the time of conception, so it is in your best interest to work with your healthcare team.
It is important that you should be symptom-free for at least 6 months before conception. There are certain risks associated with SLE:
Maternal risks:
pre-eclampsia (high BP in pregnancy), miscarriages (a little increased risk) Increased incidence of spontaneous abortions and stillbirth → related to lupus anticoagulant and anti-cardiolipin antibodies Fetal risks:
IUGR, prematurity (50%), Neonatal lupus syndrome: blood disorders and cardiac abnormalities in neonate. SLE: small-vessel vasculitis which also deposits in the placenta and small clots within the placenta > IUGR, Fetal death We will consider this pregnancy to be a high-risk pregnancy.
You will be managed by MDT ( the specialist rheumatologist, specialist obstetrician and GP) throughout the pregnancy.
They will decide upon the best medications for you during pregnancy.
Also as you are taking methotrexate, I will refer you to your specialist to change that medicine or I can liaise with him.
Usually, steroids are safe but dose of steroids will be managed. Can I breast feed? Yes, you can breastfeed except if you are taking medications that are contra-indicated for breastfeeding.
Will my baby get lupus like symptoms? Around one third of women with lupus have antiphospholipid antibodies (anti-Ro or anti-SSA).
These antibodies may cause lupus-like symptoms in the baby once it is born.
This is known as neonatal lupus.
Symptoms may include skin rash, unusual blood count and, rarely, heartbeat irregularities (congenital heart blocks). This lupus like syndrome is not SLE. Lupus pregnancies have increased rate of miscarriage and premature birth During pregnancy, the growing baby is nourished by the placenta. About one third of women with lupus have antiphospholipid antibodies (lupus anticoagulant and/or anti- cardiolipin antibody) that may cause blood clots and interfere with the proper functioning of the placenta. To prevent the risk of clotting problems or thrombophilia, the specialist might start you on Aspirin or LMWH that you will need to continue after delivery (especially if anticardiolipin is positive). Low dose Aspirin – given to patient with high risk of anti phospholipid in 2nd trimester. If on Warfarin, must be stopped before pregnancy. CASE 5
You are working in the primary care facility of a teaching hospital. Your patient is a woman aged 24 years (para 0, gravida 0), a known diabetic for 15 years and well controlled on insulin. She has come to see you for counselling and advice about possible future pregnancies. Your tasks are to: Take any further relevant history you require. Advise the patient of the information she needs to be given for pre- pregnancy counselling. Good to see you. I understand that you are here for pregnancy advice, we will talk about it.
Let me ask you some question regarding your diabetes. Who diagnosed it for you. Are you taking insulin? How much dose, how many injections? Are you able to keep your sugar level in normal range of 5-7? Any blurring of vision, Any tingling or numbness in the feet. Do you remain tired during the day? Any skin infections? Do you have proper support at home? How’s your general health? Any other medical condition? Family history, SADMA, any history of any miscarriage before? What about your pap smear? If a Pap smear has not been performed in the last two years, this should also be performed. The most important thing to be considered is tight glycaemic control.
It is recommended that you have sugar levels controlled before conception.
Will this be you first pregnancy? Well good, I wish you best of luck and I want to reassure you that majority of the women with diabetes have normal babies but we need to be very careful during the pregnancy. Counselling At the moment I will organise some blood test to get an idea about your sugar control. We will do HbA1C. Also I will organise antenatal blood checks. (In addition, the routine tests which would normally be performed at the first antenatal visit are better performed prior to pregnancy. These tests should include blood group and indirect Coombs test, full blood examination (FBE), hepatitis screening, Venereal Disease Research Laboratory Test (VDRL). rubella serology, and midstream urine specimen to exclude urinary infection.
I would refer you to your diabetic physician and to check the general state and he will assess kidney function( RFT and 24 hour urinary protein) and peripheral neuropathy.
The diabetic physician will adjust the dosage of insulin as your insulin requirement will markedly increase and will need to keep blood sugars between 5-7mmol/L to keep the fetal malformation rate to a minimum, and the macrosomia (large fetal size) rate to an acceptable level.
Also, ophthalmologist to check the back of your eye. Providing all of these are normal, you could attempt to become pregnant, and commence folic acid in a dosage of 0.5-1 mg per day from the time pregnancy is attempted until at least mid- gestation.
Iron and folic acid therapy should be continued throughout the pregnancy.
Also your pregnancy will be considered as high risk pregnancy.
You will be managed by a MDT.
All patients should perform home blood glucose monitoring 4 times each day before breakfast, and 2 hours after each meal. The insulin requirement after delivery usually returns to pre- pregnancy requirements within 24 hours of delivery.
Whenever you miss you next period, please come to me. We will make a management plan.
I will arrange an Ultrasound at 12 and 18 weeks looking for fetal abnormalities, and at 32 weeks looking for macrosomia.
Patients should be advised to undertake 30 minutes of exercise (e.g. brisk walk) at least 4 times per week unless medically contraindicated. Hba1c should be measured at the first visit and repeated monthly. The target level is <7.0%. In general, even where the diabetes is well controlled, delivery should be planned for 38-40 weeks in someone who has had diabetes for 15 years and is on insulin therapy. Earlier delivery might be necessary if problems occur during the pregnancy.
Despite adequate monitoring and care during pregnancy, the pregnancy is more likely to be complicated by pre- eclampsia, polyhydramnios and macrosomia of the fetus.
There is also an increased risk of unexplained fetal death- in-utero late in pregnancy and of respiratory distress in the baby after delivery.
All of these matters need to be raised with the patient prior to pregnancy, so that she can make an informed decision as to whether she wishes to proceed.
Your delivery will most likely happen in a tertiary hospital, so you and baby can have the best care. DM effect on pregnancy Fetal: Congenital malformation Spontaneous abortion Macrosomia- birth weight >4-4.5kg, can be up to 10X risk, Shoulder dystocia Hypoglycemia -all babies of mother, need special care unit, to be monitor after birth Respiratory distress syndrome Polycythaemia/jaundice Risk of DM later in life (one parent DM, 3% chance, Both parents DM, 20%) Maternal:
Polyhydramnios can happen in poor glucose control, large to date baby Pre-eclampsia Pre-term birth Perinatal mortality A newborn infant of a diabetic mother may develop one, or more, of the following:
Macrosomia Macrosomia refers to a baby that is considerably larger than normal. All of the nutrients the foetus receives come directly from the mother's blood. If the maternal blood has too much glucose, the pancreas of the foetus senses the high glucose levels and produces more insulin in an attempt to use this glucose. The foetus converts the extra glucose to fat. Even when the mother has gestational diabetes, the foetus is able to produce all the insulin it needs. The combination of high blood glucose levels from the mother and high insulin levels in the foetus results in large deposits of fat which causes the foetus to grow excessively large. Hypoglycaemia
Hypoglycaemia refers to low blood glucose in the baby immediately after delivery. This problem occurs if the mother's blood glucose levels have been consistently high, causing the foetus to have a high level of insulin in its circulation. After delivery, the baby continues to have a high insulin level, but it no longer has the high level of glucose from its mother, resulting in the newborn's blood glucose level becoming very low. The baby's blood glucose level is checked after birth, and if the level is too low, it may be necessary to give the baby glucose intravenously. Birth injury Birth injury may occur due to the baby's large size and difficulty being born.
Respiratory distress Too much insulin in a baby's system due to diabetes can delay surfactant production which is needed for lung maturation. Critical errors
Failure to ensure the patient is aware that her diabetic control prior to pregnancy should be good to ensure the risk of fetal abnormality is kept as low as possible.
Failure to do pre-pregnancy blood tests (haemoglobin estimation, blood group, rubella antibodies and tests as above) and failure to recommend pre-pregnancy and early pregnancy folic acid therapy (routine pre-pregnancy counselling). Case 6
Your next patient is a 28-year-old woman. Her last pregnancy was 18 months ago which was complicated by DVT and postpartum pulmonary embolism. She has come to see you for pre-pregnancy counselling. She has stopped warfarin 12 months ago. There are no abnormalities on PE. She is not overweight. Task History Management (before and during next pregnancy) Appreciate that she is here for pre pregnancy counselling. Tell me more about your previous pregnancy? How was it diagnosed? How was it treated? How long was it treated? any s/e due to medication? Any SOB, chest pain, swelling of legs? Any clotting problem now? Recent immobilisation?
COST VMPF→ Coagulation disorder, Obesity/operations to leg, Smoking/surgery, Trauma/travel, Varicose vein, malignancy, Pill, Family History of bleeding disorder. ➢ Period History (heavy periods), Paps smear, Contraception \, Previous antenatal History, Rubella prophylaxis ➢ Previous blood tests (in this case→ thrombophilia screening) ➢ Sexual History ➢ General Health condition ➢ Social History- Family History of bleeding disorder ➢ SADMA If examination is there→ check for obesity (BMI)
Pre-Pregnancy • Before getting pregnant→ do thrombophilia screen(Protein C & S, factor V Leiden, anti thrombin III, anticardiolipin, antiphospholipid antibodies and anti-lupus anticoagulant ) • Routine pre-pregnancy Blood tests, folic acid. • Referral to specialist During Pregnancy:
• Pregnancy→ is hypercoagulable (increased clotting) state→ positive previous history of clotting→ increased chance of recurrence. • Explain routine (High-risk, MDT- haematologist, physician, obstetrician, GP) • If thrombophilia screen→ ✓ +ve clotting prevention prophylaxis through pregnancy, puerperium and lifelong depending upon specialist consult. ✓ -ve, then also prophylaxis started at 14 weeks of pregnancy and continued post-delivery up to 4-6 weeks • LMWH injection→ injection below skin is used • Warfarin not used→ as cause abortion, bleeding in mother and baby, still birth etc. Avoid prolonged immobilisation. Advice during pregnancy→ Wear compression stockings during day Delivery and Mode
Depends on how pregnancy progresses Usually done in a controlled manner at 38-39 weeks and in presence of specialist On planned date of delivery, morning dose of heparin is withheld. After delivery, warfarin given for 4-6weeks with monitoring INR Can breast feed If thrombophilia +→ life long warfarin Critical error in this case Failure to do thrombophilia screen Advising warfarin use in pregnancy Failure to advise anticoagulant prophylaxis at least 4-6 weeks postpartum in the next pregnancy
Key issues: Ability to recognise that she is at increased risk of a recurrent thrombosis in her next pregnancy and requires at least low dose heparin during the puerperium if not for most of the antenatal period as well. Recognition of relative risks and indications for heparin and warfarin therapy Recognition of significant risks of warfarin during pregnancy. Case 7 A 10 week old pregnant old lady came for AN check- up. She drinks and smokes heavily for the last 10 years. Task: History Manage and advise the patient accordingly History ➢ Pregnancy Qs→ planned? First pregnancy? Folic acid? Blood tests? Early morning vomiting? Would like to ask you a few more questions especially with your smoking and drinking habits. Is it alright with you? ➢ Smoking History→ Since How long? How many cigarettes do you smoke per day? What is your pattern of smoking during the day? How soon do you have your first cigarette when you wake up? Have you ever tried to cut down/ quit smoking? Do you find it difficult to smoke in non-smoking areas? Have you tried to quit smoking in the past? Does your partner smoke? ➢ Drinking Qs→ For how long ?How much do you drink per week? What type of alcohol do you drink? Do you drink alone, with partner or with friends? Are you aware of the safe level of drinking? How long can you go without alcohol? Do you need it to steady your nerves? Does it help you go to sleep? Do you take a drink in the morning when you wake up? Any symptoms of agitation, sweating, nausea, or shakes if you don’t drink? How’s your family life? Any problem at work or with family relations? Any financial issues? Do you drink with smoking? CAGE? →Have you ever tried to cut down? Ever been annoyed? Do you feel guilty? Do you drink when you wake up in the morning? Do you know about its effects in pregnancy? Medical problem? ➢ General health? Amy recreational drug? Counselling: ➢ Do investigations as it is first antenatal checkup. ➢ Talk about the effects of smoking and alcohol in pregnancy ➢ The effects of alcohol in pregnancy In pregnancy, alcohol can pass through the placenta to the baby and is broken down more slowly than in adults leading to fetal alcohol spectrum disorders→ mental retardation, small eye, thin upper lips, short nose, poor memory, structural abnormalities of heart. Can lead to decreased birth weight of baby (low birth weight), Vision and hearing problems in baby Increased chance of miscarriage and delivery before expected date ➢ Smoking effects in pregnancy→
Chemicals of smoking like Nicotine and Carbon monoxide → can cause decrease oxygen supply to baby. Damage baby’s lungs and can give rise to birth defects like cleft lip and palate Can lead to decreased birth weight of baby (low birth weight), Increased risk of asthma, pneumonia, ear infections in baby after birth Small baby Can lead to still birth, placental abruption (premature separation of placenta leading to bleeding and death of baby) ➢ There is an increased chance of SIDS if parents are smoking and drinking. ➢ Worried about hearing all this→ the good news is that all of these can be avoided if stop smoking and drinking alcohol ➢ Ideal situation →stop smoking and alcohol altogether if possible ➢ The sooner quit ,the better it is for you and your baby. ➢ There is no known safe level of alcohol use in pregnancy. ➢ How to quit: It is important to understand the effects of alcohol and smoking and admit it as a problem for you and your baby Strong motivation is the key to success After making a decision, establish clear and realistic goals→ we will help you implement them to stop alcohol and smoking altogether.
Choose a quit date for both alcohol and smoking to stop.
Can arrange a family meeting to talk to your partner and advise him to stay away from alcohol and smoking.
Avoid situation where you usually drink alcohol like party and bars.
Ask family and friends to help you quit.
Let your family members, friends, and coworkers know that you’re trying to stop drinking and smoking. You can experience withdrawal symptoms like headache, shaking, sweating, N/V, anxiety, tummy pain, diarrhea, problem with sleeping, high and low BP, craving for alcohol and smoking.
When you experience these symptoms, please immediately contact me so appropriate treatment could be given.
Lifestyle modification: Deal with stress in a healthy way like exercise, sports, meditation and yoga.
Refer you to alcohol anonymous→ It is an organization composed of groups of people having problems with alcohol and who desire to stop it. Refer you to support groups – quit line for smoking and give you some reading materials. Available for you for ongoing management and support for follow-ups.
NRT→ The Australian Smoking Cessation guidelines recommend that pregnant smokers first try to quit with counselling and support. NRT should then be considered if the patient is unable to succeed without it, however, it should be used under the supervision of a suitably qualified health professional. Think about this. Will give reading material regarding it. Come back once you have come to a decision CASE 8 YOUR NEXT PATIENT IS A 38 YEAR OLD WOMAN, WHO HAS COME TO YOUR CLINIC BECAUSE OF SEVERE NAUSEA AND VOMITING FOR THE LAST 2 WEEKS IN THIS PREGNANCY. SHE IS 8 WEEKS PREGNANT AND PREGNANCY WAS CONFIRMED BY PREGNANCY TEST AND BY PELVIC EXAM. SHE HAS NO PREVIOUS OPERATION OR ILLNESS. TASK: TAKE FURTHER HISTORY PHYSICAL EXAMINATION FROM EXAMINER INVESTIGATIONS AND MANAGEMENT Differential diagnosis:
Hyperemesis Gravidarum Molar pregnancy Multiple Pregnancy UTI Bowel obstruction Brain Tumor Addison’s Disease Hemodynamic stability: General appearance: unwell and drawn. BP: 120/80 mm hg Pulse: 110/min Temperature: 36.8 C Hydration status ( tissue turgor, mucous membrane( dry and firm), CRT diminished, normal < 2 sec) Pregnancy Questions? Vomiting Questions? Any abdominal pain How are your bowel motions (constipation – obstruction, if diarrhea – gastroenteritis) How is your appetite? Do you have any heartburn? Urinary symptoms? Any frequency? Dysuria? Hematuria? Loin pains? Fever? Any vaginal bleeding? Multiple pregnancy Any family history of twins? Did you use any fertility drugs? IVF?
Any family history of any medical problem? Are you interested in taking the screening test for Down Syndrome? Further Examination: Chest and abdominal examination Check loin tenderness to rule out UTI No need to do pelvic examination – size of the uterus
Investigations: Urinary ketones( strongly positive), You have a condition called Hyperemesis gravidarum. Common condition in early pregnancy due to hormonal changes. Normally a pregnant woman may feel a bit sick and vomit a few times while some presents with exaggerated symptoms.
Apart from Urinary ketones we need to run some more investigations like USG to rule out multiple pregnancy mole and mid stream urine routine and culture to rule out UTI which are the differentials in this case. Also serum electrolytes, urea ,LFT needs to be done. Management
Hospital admission Rehydration with saline solution and additional dextrose plus vitamin B supplementation. Pyridoxine or antiemetic therapy with Maxolon or Stemetil to resolve vomiting. Usually the hyperemesis settles spontaneously, often having reached a maximum at ten weeks of pregnancy and by the time of 14 weeks most symptoms will resolved. This condition usually occurs in 10% of pregnant women. Most cases resolves in 14 weeks time. Any condition that is prolonged, we will do investigation to exclude small bowel obstruction, cerebral tumor Addison’s disease need to be excluded.
Consent about screening and procedure for Down syndrome. Key issues:
Ability to investigate and treat a woman with hyperemesis gravidarum Recognition of the need for genetic counseling in view of advanced maternal age.
Critical error Failure to recognize the need for hospitalization Failure to do ultrasound and urine examination to check pregnancy, diagnose twins, molar pregnancy, urinary infection and the presence or urinary ketones. A 25Case year-old primi 9 gravida came to your GP clinic to discuss her 18 week ultrasound result which showed an anencephalic baby.
Task ▪ History ▪ Explain the diagnosis to patient and subsequent management ▪ Advise patient regarding what you recommend in subsequent pregnancy I understand that you are here to discuss USG report, before that May I ask you few Qs ✓ Pregnancy Qs→ planned, any morning sickness – frequency, Breast tenderness, Any vaginal bleeding, Abdominal pain Have you taken folic acid, Blood group, Blood tests Have you had any viral infection, any febrile illness during this pregnancy ✓ Periods Qs, previous pregnancy(if relevant) ✓ General Health→ h/o asthma ✓ Family History of neurological conditions, birth defects ✓ SADMA Counselling Are you alone, is your partner with you here? do you want your partner to be with us while we discuss the ultrasound The ultrasound result unfortunately showed →baby has a condition called anencephaly which means the baby has an underdeveloped brain and an incomplete skull. ……PAUSE The exact cause is unknown but lack of folic acid (vitamin B9 before and after pregnancy could result in this condition. Although your baby is currently alive→ if continue pregnancy there might be some complications like: ➢ Increased fluid around baby ➢ Death of baby in womb ➢ Abnormal position of baby in womb which would result in operative delivery like forceps, C/S or vacuum ➢ Delivery of baby before date or late delivery of baby after due date ➢ Born still Even if baby is alive after birth→ may not survive for long time as brain is required for normal body function. These can be risky to you or to baby. So, the decision is completely yours to keep or terminate. As I said ,the decision is completely yours and whatever you decide I’m ready to help you with that.
If you decide to terminate→ Refer to specialist ✓ Medical termination by inserting medications down below called vaginal prostaglandins→ will get labour pains and be like normal delivery ✓ Surgical procedure→ Dilatation and evacuation→ down under general anaesthesia→ remove the products through’ cervix of womb and out vagina with the help of instruments (complication can be injury to cervix, anaesthetic complications) After termination, the product of the conception is better to be sent for post mortem studies→ to check any birth defects are there and if necessary precautions can be taken for future pregnancies For future pregnancy → at slightly higher than normal population to get the similar condition (2-5%). Before becoming pregnant: ✓ 2-3 months before to folic acid 5 mg (normal population 0.5 mg) ✓ screening at 16 weeks for alpha-feto protein (blood testing) ✓ Ultrasound
Critical Errors: ➢ Failure to recognise and advise the patient that this is a lethal abnormality to baby ➢ Failure to determine the preferences of the mother in respect to termination of pregnancy ➢ Failure to counsel patient appropriately concerning management in a subsequent pregnancy PERINATAL INFECTIONS CASE SCENARIO 10
Sarah, a 25 years old lady, is your next patient at your GP clinic. She appears concerned as she had contact with a child, having rubella at the kindergarten where she works as a teacher. She wants your advice regarding further management. TASKS 1. Relevant focused history. 2. Explain relevant investigations and management to the patient. RUBELLA EXPOSURE
HISTORY When exposed. Rubella confirmed in the child or not. Previous h/o rubella or h/o vaccination. Symptoms now- fever, sore throat, lumps/bumps around head or neck, rash. Periods- LMP, regularity, how long, severity, any pain. Sexual history- sexually active or not, stable partner, previous pregnancies/ miscarriages, contraceptive use PAP smear. Other M/S history. SAD MANAGEMENT WITH RELEVANT INVESTIGATIONS
PREGNANCY TEST - +ve. Rubella is an infectious disease caused by a viral bug. Relatively mild disease but if infected during early stages of pregnancy, complications may occur.
Congenital rubella syndrome: Could affect baby producing serious side effects like blindness( cataract), deafness, heart defects, limb defects and intellectual defects. RUBELLA EXPOSURE
Check blood for rubella antibodies which are certain factors produced by the body to fight against the infection from occurring. IgG IgM + - (patient immune so safe to continue pregnancy)
Advise patient regarding: 1 Antenatal checks- FBE- Hb, blood group and Rh, BSL, screening for syphilis( VDRL), hep B, HIV. Urine routine, C&S. 2 Regular antenatal visits- U/s at 18 weeks. 3 Start folic acid. RUBELLA EXPOSURE
IgG IgM - ve +ve
( patient is infected) Needs to consider other options.
1 Referral to high risk pregnancy clinic. 2 Patients option whether to continue pregnancy or to terminate. If continuing, needs to think about the complications that baby could have. Notify DHS. RUBELLA EXPOSURE
IgG IgM -ve -ve (Needs to repeat after 3 weeks)
Meanwhile can continue pregnancy but avoid further exposure. If then IgG becomes +ve and IgM –ve, well and good. Otherwise other options need to be considered. If non pregnant RubellaIgG IgM +ve -ve (immune) -ve +ve (infected)
1 Supportive measures- rest, fluids, panadol, red flags for complications.(arthritis, otitis media, encephalitis) 2 Review. 3 Notify DHS.
-ve -ve 1 Repeat tests after 3 weeks. If again both are –ve, give MMR. 2 Advice against becoming pregnant for 28 days. RUBELLA
NEVER GIVE MMR DURING OR WITHIN 28 Days OF PLANNING PREGNANCY.
Even if patient gives h/o rubella exposure or vaccination, if pregnant always do antibody tests. CASE 11: CHICKENPOX IN PREGNANCY HISTORY When exposed Had chicken pox been confirmed in the contact H/o chicken pox before or vaccination Symptoms now Periods- LMP, regularity Sexual history- contraception, any signs of pregnancy. MANAGEMENT
1 Confirm pregnancy 2 Explain about chicken pox 3 Risk of baby getting affected more in 1st trimester and during late pregnancy.
Fetal varicella syndrome- microcephaly, optic atrophy, IUGR, limb abnormalities and mental retardation. 4 Do IgG and IgM. CHICKEN POX
IgG Ig M +ve -ve
Safe to continue pregnancy, explain about 1st antenatal blood checks and further tests and visits, start on folic acid
-ve +ve
Give option to continue pregnancy explaining the baby risk, refer to high risk pregnancy clinic, monitor by frequent U/S, start antivirals when symptomatic. Acyclovir 800mg 5 times/day x 7 days CHICKEN POX
IgG IgM -ve -ve
Time of exposure if less than 96 hours, give varicella zoster immunoglobulin, refer to high risk pregnancy clinic, give red flags- report if signs of chicken pox
If prior to 7 days of delivery 1 Refer to high risk pregnancy clinic 2 Start antivirals 3 Give VZ Ig to newborn. CHICKEN POX
If within 4weeks after delivery 1 Give antivirals to mother 2 Vz Ig to baby 3 Encourage breast feeding. DO NOT ISOLATE BABY FROM MOTHER.
Indications for hospitalization in pregnancy 1 severe varicella. 2 complications like pneumonia. CASE :12
25 YEARS , PRIMIGRAVIDA 20 WEEK AOG COMPLAINING OF VULVAR PAIN AND VESICLES. IT IS HER FIRST ATTACK. SHE IS CONCERNED ABOUT HER PREGNANCY AND BABY.
TASK: TAKE RELEVANT HISTORY EXPLAIN TO THE PATIENT WHAT SHE HAS MANAGE HER CONDITION ADDRESS HER CONCERN History: 1st episode? Number of vesicles ? Syphilitic chancre(single), burning sensation before the onset of ulcer? Sexual history? STI screening? Pregnancy question Any medical/surgical problems? Support? SAD,PAP, medications? Allergies? Water works? Bowel habits? Physical examination: General appearance: PICKLE,BMI dehydration, Lymphadenopathy, rashes elsewhere Vitals: temperature Systemic: focused per abdomen: FH, FHR, lie , presentation Pelvic exam( consent, chaperon) inspection –rashes distribution(painful blisters), discharge, bleed. No bimanual/per speculum exam. Primary attack of herpes is more painful and carries the risk to the baby unlike the Recurrent HSV infection without active lesions.
Investigations for genital herpes are: viral culture (scraping the lesion), PCR and Blood test (HSV antibodies). Referral to high risk pregnancy clinic Advise on how to take care of rash. Do not touch/rupture, keep it dry ,wear loose cotton clothes, sitz bath.
She will be started on acyclovir for 5-7 days and will be monitored in high risk clinic.
Prophylactic antivirals from 36 weeks. She can have infection in later part of infection due to low immunity. She can go in for normal vaginal delivery if there are no active lesion at the time of labour. Active lesions at the time of labour: C section is done. Just in case baby needs to be delivered vaginally with active HSV lesion :
Give antivirals (iv acyclovir)as soon as baby is born.
HSV in neonate- viral sepsis skin, eye and mouth lesions pneumonia herpes encephalitis. Recurrent herpes.
Women with recurrent genital herpes should be informed that the risk of neonatal herpes is low, even if lesions are present at the time of delivery (0–3% for vaginal delivery).
Although there is no evidence that aciclovir is unsafe in early pregnancy, the majority of recurrent episodes of genital herpes are short-lasting and resolve within 7–10 days without antiviral treatment.
Supportive treatment measures using saline bathing and analgesia with standard doses of paracetamol alone will usually suffice.
Vaginal delivery should be anticipated in the absence of other obstetric indications for caesarean section. Daily suppressive aciclovir 400 mg three times daily should be considered from 36 weeks of gestation.
There is insufficient evidence to determine whether this reduces the incidence of neonatal herpes; however, it reduces viral shedding and recurrences at delivery so may reduce the need for caesarean section.
There is no increased risk of preterm labour, preterm premature rupture of membranes or fetal growth restriction associated with women seropositive for HSV.
The incidence of congenital abnormalities is not increased in the presence of recurrent genital herpes infection.. Case 13:
Your next patient is a 26-year-old woman who is now at 37 weeks of gestation in her first pregnancy. You have been looking after her pregnancy in a shared care arrangement in a general practice setting. All has been normal, and at 36 weeks you ordered a vaginal and rectal swab for Group B streptococcal (GBS) testing. This test has shown GBS organisms were detected in the lower vagina. She has returned to receive the results and any implications if the test is positive.
Your tasks are to: Advise the patient of the results of the GBS test. Advise her about the subsequent management you would advise There is no need for you to take any further history or to request any examination findings or investigation results from the examiner History
GM, nice to see you again. Congratulate pregnancy if planned. From the notes I understand that you are here to discuss your results. Your vaginal swab shows the presence of a bug called GBS. Before we go ahead, I would like to ask some question. Is it alright?
How is the pregnancy so far? Excited about the motherhood? Are you regular with your antenatal checkups? How were your tests? Ultrasound? Was it a single baby? What was the position of the placenta? Ask for burning sensation in urine, smelly, increased frequency, lower burning pains, change in color of urine. Are you allergic to any medications? Group B streptococcus
It is a normal vaginal bug in healthy women and is found in 18% to 27% of pregnant women is the commonest cause of perinatal sepsis.
Therefore, normally we don’t treat it if it does not cause any symptoms but in pregnancy there is risk of infection to the baby.
GBS cannot be eradicated from the vagina with certainty by treating with penicillin or Amoxycillin during pregnancy
40-50% of babies are colonized but only 1% develops neonatal sepsis.
Although only 1% gets it, it is a serious infection and carries serious mortality for the infected baby. There are some risk factors which can exaggerate the risk of infecting your baby: Preterm delivery Prolonged rupture of membrane Maternal fever >38C during labor Previous GBS infection
Reassurance → don’t worry, it’s good we have picked up at this stage and we will do our best.
During labour, we will give IV antibiotics (Benzyl Penicillin 1.2 G IV initially as LD then 600mg IV 4 hourly until delivery
(Erythromycin or clindamycin 600mg IV 8 hourly if Hypersensitive to Penicillin). Pediatric Assessment
Baby will be assessed by pediatrician.
If completely healthy, and no risk factors, no antibiotics will be given.
Parenteral penicillin to the baby after birth is optional unless signs of infection ensue or in high risk situations (such as prolonged ruptured membranes).
Give reading material and red flags.
Arrange for review after 1 week. Key issues:
Defining the management plan Counseling the patient as to why antibiotic treatment in labour is recommended.
Critical errors:
Failure to advise patient of the significance of GBS organisms to mother and baby.
Failure to advise antibiotic treatment to the pregnant women if the membrane rupture or when labour commences to protect the fetus from risk of severe infection. Case 14
You are a GP, Seeing this patient for the first time. 30year old female 12 weeks , your colleague had done antenatal bloods. Patient had come back for results. Usual GP not available today. You will be given a card inside the room with investigation findings. Tasks: · Explain results. Explain immediate and long term management. Results Blood group : 0 positive ,Rubella & varicella : antibodies positive, Hepatitis: antibodies negative, HIV: positive. Good to see you. How is everything going so far? I understand some tests has been ,do you have any idea what those were? (ask her what all she knows) Then explain tests one by one. Blood group isn’t an issue, she should try and remember that. She is vaccinated or had previous infection for rubeIla/varicella, so she is protected. She probably haven’t had hepatitis vaccine - we can give that later. Prenotice: There is some concerning news, do you want someone to be with you? HIV test has come out positive. HIV screening test is positive.
PAUSE(cries, pass tissue.)
History after warning that you will be asking sensitive questions.
Multiple partners? unprotected sex? IV drug abuser? Needle sharing? Piercing? Tattooing? The virus could be present in the system and when the helper cells(CD4) are still in normal numbers and fighting against infections body doesn't manifest major symptoms.
The probability of HIV transmission is directly correlated with the viral load, especially the viral load at the time of delivery.
Regardless of HIV viral load and CD4 count, all HIV- infected pregnant women should be offered antiretroviral therapy (ART) to reduce perinatal transmission
Combination ART is more effective than a single-drug regimen in reducing perinatal transmission. With medications- antiretroviral the disease progression can be delayed.
Further testing required to confirm the diagnosis .Viral load,CD4 count, STD screening and ANC tests needs to be done.
Contact tracing : Start with recent sexual or needle-sharing partners; outer limit is onset of risk behaviour or last known negative HIV test result Notify DHS. Management
High risk pregnancy clinic, MDT(infectious disease specialist, Obstetrician) Refer to Infectious disease specialist. Antiretroviral medications.
Possibility of vertical transmission is 30% but can decrease it to 2% with antiretroviral medication, avoiding invasive procedures, CS, bottle feeding. Delivery preferably CS safe but if viral load low-normal vaginal delivery allowed.
Four weeks of zidovudine prophylaxis should be given to infants born to mothers with suppressed viremia during pregnancy.
Six weeks of combination ART should be administered to infants born to mothers who did not receive antepartum care or did not have a sustained viral response during pregnancy. After delivery Neonatologist assessment Antivirals(post exposure prophylaxis) Bottle feeding CASE SCENARIO 15
You are an intern at the ED of a major hospital, when a 24 year old female presents to you with severe right sided abdominal pain since the past 2 hours. Tasks Relevant history. Examination findings from examiner. Investigations. Diagnosis. Management. ECTOPIC PREGNANCY
DD Ectopic PID Miscarriage Ovarian cyst torsion UTI- pyelonephritis, renal calculi Abdominal emergencies- acute appendicitis ECTOPICS History Name, offer pain killer. All pain Q’s- duration, 1st episode/not, site, radiation, type, pain scale, aggravating/relieving factors.
Associated features- Nausea, vomiting, distention( abdominal emergencies) Fever, dysuria, chills/rigor.( UTI) Abnormal vaginal discharge, fever (PID) Bleeding P/V ( ectopic). In 10-15% no bleeding. ECTOPICS
Periods- LMP, regularity. Obstetric H- partner, contraception, previous pregnancies/miscarriages, signs of pregnancy, STI,PAP smear. Other M/S(tubal surgeries) history, medications, allergy, SAD. ECTOPICS
Examination G/A- pallor. V/S- BP, temperature. Abdomen- Inspection- distention, visible masses. Palp- mass, tenderness (direct, rebound) guarding/rigidity.( rt iliac fossa) McBurney’s point tenderness. Rovsing’s sign, , psoas signs. Percussion- tympanitic. Bowel sounds. ECTOPICS
Pelvic exmn Insp: bleeding ( prune juice bleeding), abnormal vaginal discharge. Speculum exmn: CMT. Bimanual exmn: Uterus – size.(normal) Adnexa- mass, tenderness.(+) P/R exmn; tenderness in POD. Pregnancy test- positive. Urine dipstick, BSL. ECTOPICS
Pregnancy at sites other than uterus usually in the tube. Can lead to rupture of tube which is life threatening.
MANAGEMENT: 1 Admission. 2 Referral to O&G 3 Start I/V line- blood for FBE, U&E, blood group and crossmatching, coagulation profile, Beta HCG. Start I/V fluids. ( Serial estimation of beta HCG shows less increase in ectopics) ECTOPICS
4 Transvaginal U/S-empty uterus, adnexal mass/sac, fluid in POD. (when betaHCG is 1500 mIU/ml) 5 Treatment
Medical- Methotrexate- IM single or multiple injections or transvaginal into the sac. ECTOPICS
Follow up Serial beta HCG estimation. If declines and disappears- normal If remains same- methotrexate If increases- surgery. Chance of recurrence- 10- 20%. Risk in general population- 1%. ECTOPICS
Brings resorption of embryo. Adv: tube preserved. Effective if – Beta HCG < 5000 if no foetal cardiac activity. gestational sac < 4cm. Surgical : If the patient is extremely symptomatic suspecting rupture or fetal activity present or Bhcg > 5000. 1) Laparoscopy +salphingostomy : put the linear cut over the tube ,take the ectopic sac and stitch the tube 2) LAP + Segmental resection : When the portion of the tube is cut and removed with the embryo and ends are stitched back together. 2)LAP + Salphingectomy : when you remove tube as a whole. RUPTURED ECTOPIC
Symptoms- severe, excruciating, generalised abdominal pain, features of shock, shoulder pain. Examination General appearance: pallor, toxic Vitals: features of shock. Abdomen- severe tenderness. Pelvic examination: bleeding, CMT+ NO VAGINAL EXAMINATION Management
1 DRABCDE- oxygen by mask I/V cannula- blood for investigation (FBE, blood grouping, cross matching and hold, coagulation profile, Beta HCG ). Start infusion. Blood transfusion if necessary. 2 Inform O&G. 3 Urgent transfer to theatre- alert anesthetists, theatre staff. 4 Consent Surgery- Lap+ salpingectomy or
Lap+ salpingostomy or
Lap + segmental resection. Counseling after Fallopian tube removal
Explain ectopic and causes. I tube present. So chance of pregnancy is 50%. Wait for 3-6 months before becoming pregnant. Contraceptive advice- oral pills/ barrier methods. Avoid POP, IUS and emergency pills.(increases the chance of ectopic) Report as soon as possible when you miss your periods. Can do pregnancy test. If positive, serial Beta HCG estimation from day 5 should be done. Then U/S at 5-6 weeks to confirm normal pregnancy. Normal pregnancy- start folic acid, A/N blood checks, A/N tests and visits. Referral to high risk pregnancy clinic. COUNSELLING
If ectopic- admit immediate referral to O&G. Medical- methotrexate/ surgical- all will be done to preserve the tube.
If tube could not be preserved, other options like IVF. CASE 16
ED setting. A 25 years old lady with 8 weeks of pregnancy c/o right sided lower abdominal pain. Task: take relevant History, ask examination finding, investigation, diagnosis and management. DDx:
1. Ectopic pregnancy 2.Ovarian Cyst. 3. Appendicitis 4. PID 5. Normal pregnancy History: Pain Qs: Site, intensity, quality, Onset, Aggravating, Relieving .Any bleeding or d/c down below? Menstrual History (LMP - 8 weeks ago) How did you confirm your pregnancy? Is it a planned pregnancy? Do you have any symptoms, breast tenderness, nausea, vomiting Have you done US? Any urinary or bowel problem? Have you been on any contraceptive method before your conception? Which one? Have you been on a stable relationship? Have you ever been diagnosed with STD, PID? Have you gone through any gynecological or surgical procedure? When was the last PAP? Do you know your blood group? SADMA O/E:
GA, VS, CVS, RS Abdomen : - Inspection Normal - Palpation: tenderness in RIF, not localized, no rigidity, no guarding, rebound tenderness, no palpable mass - Mac Burney's point no tenderness Take consent for pelvic examination: - Inspection – any sign of trauma, discharge, bleeding - Speculum – any discharge, bleeding, OS: close - Bimanual – right adnexal tenderness, uterus is enlarged. Ix:
- FBE, Blood group cross match - B hCG test: positive - Urine dipstick - Urine microscopy, culture and sensitivity : normal - USG: Uterus large corresponding to 8 weeks gestation, intrauterine foetus present, right ovarian cyst 5.5 cm in diameter. - Doppler USG to see blood flow of ovary and to exclude torsion of the ovarian cyst. Explanation:
Congratulation for your pregnancy The good news is your pregnancy is safe and good progression of pregnancy. Unfortunately we found a cyst in your right ovary that causes pain. But the size of the cyst is small and blood flow is not affected. It is a common condition but it carries some risks such as torsion and rupture of cyst.
If <6 cm: no interference/no action required. Cyst might shrink or might grow. We need to follow up with USG in 6 weeks.
If the cyst >6 cm: under specialist consideration if simple cyst : aspiration, complex cyst ( CA 125 ): surgery.
Torsion management: immediate surgery.
the obstetrician will assess you and do some investigation such as FBE, U & E, LFT, RFT, Case 17
You are an HMO in ED and a 39-years-old female comes in complaining of vaginal bleeding and abdominal pain. LMP was 8 weeks ago.
Task History Physical examination Diagnosis and management. History: Is my patient hemodynamically unstable? How are you today? When did the bleeding start? What is the color of the bleeding? How many pads did you used since then? Were they fully soaked? Did you pass any clots or pieces of tissue? Did you see bubbles or grape-like tissues? Do you have any dizziness, SOB or fever? Is it the first time? Where is the pain? Is it there all the time or does it come and go? Does it go anywhere? How severe is the pain from 1-10? Anything that makes the pain better or worse? Any trauma or intercourse before the bleeding? Any NVD? Any trouble with waterworks? Any trouble with bowel motions? Any discomfort in breast or nipple? Are your periods regular? When was your LMP? How many days of bleeding? How many days apart? Do you have heavy periods? Are they more than their usual period? periods every 28-30 days Are you sexually active? Are you in a stable relationship? Any contraception used? Have you or your partner ever been diagnosed with STDs? Any chance you could be pregnant? Have you ever been pregnant before? Any miscarriages? Do you know your blood group? Do you have N/V/ or breast tenderness recently?
When was your last pap smear? How’s your general health?
Do you have any FHx of bleeding/clotting problems or miscarriages? (any easy bruisability or bleeding disorders) Physical Examination:
General appearance, distressed, pale or teary (distress, pale and in pain; BP 80/50, os open with POC, PR:80 → vasovagal shock; uterus enlarged, mobile, no adnexal masses/tenderness; no CMT) Vital signs, Abdomen: tender, guarding? Any mass or uterus? Pelvic Inspection: - pads are with blood and clots, → remove POC immediately!!! Speculum: where is the source of bleeding? Cervix Cervix: Open or closed – Open (incomplete or inevitable) Products of conception: yes, are sitting external os (have to be removed). If you don’t remove the products of conception in the cervix – patient will have vasovagal (Cervical) shock (parasympathetic response-Vasodilation) Bimanual examination: Uterus, tender? Adnexae Urine dipstick: blood ++++ Diagnosis and Management:
Alright, are you alone here, or anyone with you at the moment? From history and examination, I am sorry to say that this is a miscarriage.
Most of the miscarriages occur without any obvious reason. Let me reassure you that it is not your fault. You did not do anything wrong. So please do not feel any sense of guilt. Most likely in the first 14 weeks, the reason of miscarriage is due to chromosomal abnormalities. At the moment, I will admit you and will inform the Obstetrical registrar and send all the bloods (e.g. FBE, coagulation profile, blood group and cross matching) for necessary investigations. I will start IV fluids and give you some pain killer. Give oxytocin or Ergometrine or (Syntometrin) to stop bleeding. They will probably take you to the theater and do a procedure called curettage. They will empty whatever is left in the uterus to prevent any complications. Can I still get pregnant? Yes, you can still get pregnant but it is advisable to wait for at least one normal period before you get pregnant again.
What is the risk of having another abortion again? After the first miscarriage, your risk is still the same as any normal woman for the next miscarriage i.e. 20% of women will have a miscarriage in her life
I know it is a very hard time for you. Do you want me to call anyone for you? Do you have enough support?
Being 38 years old puts you at a higher risk of your child having Down syndrome. So in your next pregnancy, it is advisable for you to consider doing Down Syndrome screening.
Critical error:
Not considering anti-D Not taking out POC immediately, POC – send to histology Doing unnecessary investigations like beta-hCG and USD Case 18:
You are a GP and a 28-year-old female comes to you with vaginal bleeding after 8 weeks of amenorrhea. Task History Physical examination Investigation Management History: Is my patient hemodynamically stable? How are you today? When did the bleeding start? What is the color of the bleeding? How many pads did you used since then? Were they fully soaked? (lower tummy, comes and go, started 12 hours ago; 4-5 pads/day) Did you pass any clots or pieces of tissue? Did you see bubbles or grape-like tissues? Do you have any dizziness, SOB or fever? Is it the first time? Any fever or discharge from down below? Any NVD? Any tummy pain? Any trouble with waterworks? Any trouble with bowel motions? Any discomfort in breast or nipple? Are your periods regular? When was your LMP? How many days of bleeding? How many days apart? Do you have heavy periods? A re they more than their usual period? periods every 28-30 days. PREGNANCY TEST( home test positive) Are you sexually active? Are you in a stable relationship? Any contraception used? Have you or your partner ever been diagnosed with STDs? Any chance you could be pregnant? Have you ever been pregnant before? Any miscarriages? Do you know your blood group? When was your last pap smear? What was the result? How’s your general health? Do you have any FHx of bleeding/clotting problems or miscarriages? Any easy bruisability or bleeding disorders Physical examination General appearance Vital signs Abdominal examination: distention, tenderness especially on the RIF and LIF to look for Ectopic. Pelvic examination: amount of bleeding, color of blood, clots, discharge or signs of trauma? Sterile speculum, check os whether open or close; POC; any mass or lesion over the cervix. bimanual examination checking for size, shape and position of uterus; adnexal tenderness or mass; cervical excitation Urine dipstick, BSL, pregnancy test Diagnosis and Management:
If pregnancy test positive: most likely your condition is called threatened abortion/miscarriage
Your pregnancy test is positive, but because of your bleeding, we need to admit you to the hospital to do some tests which include FBE, U&E, blood group,
USD of the pelvis to look for the presence of a fetal sac within the uterus and to check for cardiac activity.
Depending upon the results, the OB might advise you to take rest. Sometimes, because of the attachment of the placenta to the womb, some bleeding can happen.
In majority of cases (90-95%), this bleeding is quite harmless. It will stop on its own within a few days. Your pregnancy will continue without any problems, but you need to avoid stress, anxiety, and rigorous physical activity for the rest of your pregnancy. We do not need to give you any medications as it has not shown to alter the outcome in any way. If the bleeding continues, we will repeat serial ultrasound to check for fetal viability, but you will need to stay in the hospital until the bleeding stops. If your blood group comes out to negative then we might give you Anti-D If pregnancy test negative: Most likely, this is a delayed period. Sometimes, due to stress and with the use of the pill, your periods can become irregular. If it continues for the next 2 or 3 cycles, you will need to see the specialist gynecologist. She might decide to start you on regular OCPs to regulate the cycle. CASE SCENARIO 19
28 year old Jess, who is 10 weeks pregnant, comes to your GP, with complaints of , abdominal pain and vaginal bleeding since the past 2 hours. TASKS 1 Further, relevant history. 2 Examination findings from examiner. 3 Relevant investigations. 4 Explain diagnosis and management to the patient. DD’s
1 Ectopic. 2 Miscarriage. 3 H. mole. 4 Trauma. 5 Coagulation disorders. H.MOLE
HISTORY. Haemo dynamically stable/not. All pain Q’s. Offer pain killer. Bleeding before /after pain. 1st episode/not. Duration, severity, color, clots. H/o passage of grape like materials along with blood. Blood group. H.MOLE
Tiredness/dizziness. H/o trauma. Periods- LMP. O&G- planned pregnancy/not. Confirmed. A/N checks so far. Folic acid. Any excessive vomiting. Previous h/o miscarriages/pregnancies. SAD. Other M/S illness, any medications, allergy. EXAMINATION:
G/A- pallor. V/S- BP (postural drop) Abdomen- uterus palpable P/A. ( size greater ) No fetal heart. Tenderness. Pelvic examination Insp- vesicles. Speculum- OS, CMT P/V- uterine size.( enlarged) adnexa. Tenderness in POD. H.MOLE
INVESTIGATIONS. FBE- Hb. Blood group/ cross matching and hold. Coagulation profile. S. beta HCG.- usually very high. U/S- snow storm appearance. Chest X-ray.
H.MOLE
MANAGEMENT:
H.mole is a growth of an abnormal fertilized egg or an overgrowth of tissue from placenta.(GTD) Exact cause unknown. May be due to a genetic disorder in which a sperm fertilizes an egg that is empty or 2 sperms fertilize 1 egg. The placental part starts producing fluid filled cysts which rapidly multiplies and replaces the fetus and placenta. Incidence- 1 in 2000.
H.MOLE
Occasionally, these moles burrow deep into the uterus forming invasive moles. Very rarely, they turn cancerous and can spread through blood stream and lymph to distant organs like lung called chorio Ca. Incidence- 2-3%. H. MOLE TREATMENT
1 Referral to hospital. 2 Start I/V line and take blood for investigations. Start infusion. 3 Admission at hospital. 4 Seen by O&G reg. 5 Suction and curettage under oxytocin drip. H.MOLE
FOLLOW UP. 1 Weekly S.Beta HCG till it becomes 0 ( might take 2-3 months) and then monthly for 6-12 months. 2 Vaginal exmn: and U/S after/ every 2 weeks. 3 Avoid pregnancy for 12 months after HCG becomes normal. 4 Advice COC during this period. 5 Chest X-ray/CT if beta HCG is elevated. H.MOLE
6 If HCG elevated, suspect invasive mole/chorioCa. 7 Requires immediate referral. 8 Chemotherapy with methotrexate given.
Risk of recurrence- 1- 2%. Chorio carcinoma is more common after complete mole. Case 20
37 years old Mary comes to your GP clinic. She thinks she is pregnant now as her home pregnancy test has turned out to be positive .She has a history of 3 miscarriages before. Task : History Counsel the patient accordingly. Causes
1st Trimester :
Chromosomal abnormalities Immune medicated: anti phospholipid antibody syndrome Thrombophilia Rh incompatibility. Infections : Hep B ,Hep C ,TORCH Second Trimester :
Cervical incompetence , gynecological surgeries Endocrine : Diabetes ,thyroid Epidemiological factors: Age ( 35-39 years) 25% Number of previous miscarriages – after 3 consecutive miscarriage there is a 40% chance of re miscarriage Alcohol, smoking, recreational drugs. History
Current pregnancy: LMP? Regularity? Any issue? signs of pregnancy? Tummy pain ? Discharge? Any hospital visit after confirming pregnancy? Blood tests? Folic acid? Sexual history : partner? STI? (specifically). Contraception? Pap? Any medical condition? Weather preferences , SLE, Thrombophilia ( any autoimmune diseases). Medications, blood group? SAD? Past medical, surgical history. Miscarriage questions :
When was the last miscarriage? At what week of pregnancies? ( all were 8-10 weeks). Any successful pregnancies so far? What was done at the time of miscarriage? Any chromosomal tests done at fetal parts? Any trauma prior to the miscarriages? Blood group? Family history of recurrent miscarriages Counseling
Confirm current pregnancy by office test. Explain recurrent miscarriage ( miscarriage more than 3 times) and its causes. Routine blood test –FBE, ESR,CRP, Urea electrolyte and creatinine ,BSL,TFT,STI screen with the consent of the patient ,BG and RH typing ,coagulation profile, antibodies for rubella and varicella.
Specific: 1)Refer her and partner for karyotyping 2) Screen anti phospholipid antibodies : Lupus anti coagulant, anti-cardiolipin antibodies and IgG and IgM Antibodies. 3) Thrombophilia screening – Protein S deficiency ,Factor V leiden, Factor II deficiency.(protein C and homocystein). Pelvic Ultrasound – for uterine anomalies and cervical incompetence. Routine Urine microscopy, culture and sensitivity.
Refer to high risk clinic where she will be supported and monitored by MDT. Chances of successful pregnancy is 60% She needs to do Down Syndrome Screening. Regular ANC ,Blood test ,USG to monitor pregnancy If chromosomal defect—referral to clinical genetics. If antiphospholipid antibody positive: specialist ( aspirin and LMWH) If Thrombophilia : LMWH Reading materials regarding recurrent miscarriages Refer for karyotyping and review once blood results available. Medical conditions in pregnancy CASE SCENARIO 21
32 year old Maria, who is 36 weeks pregnant, presents to your GP, with headache since the last 2 days. She had regularly done her antenatal checks with you and a week before, when you saw her, she had mild swelling of her legs. At that time all relevant investigations were done and they were all normal. TASKS 1 Relevant history. 2 Examination findings from examiner. 3 Explain diagnosis to patient. 4 Management. What are the different types of high blood pressure that affect pregnant women 1. Chronic hypertension.
Chronic, or long-standing, hypertension is high blood pressure that was present before pregnancy or high blood pressure that is diagnosed in the first half of your pregnancy (before 20 weeks). This type of hypertension usually continues after the birth of your baby. If the patient has chronic hypertension, she usually need to take medication throughout pregnancy. Women with chronic hypertension should discuss any plans for having babies with their doctor prior to conceiving in order to select a safe, effective treatment during conception and pregnancy. 2. Pregnancy-induced hypertension.
Women who develop high blood pressure in the second half of pregnancy without any effects on their kidneys or other organs have ‘pregnancy induced hypertension’ or ‘gestational hypertension’.
This condition still requires monitoring in case there is a worsening of blood pressure, or progression to pre-eclampsia. Pre-eclampsia.
Pre-eclampsia is a serious condition that only occurs in pregnant women. It begins after 20 weeks gestation and usually takes the form of high blood pressure and abnormal kidney function, but can also involve other organs, such as the liver, blood and brain.
Doctor or midwife can detect pre-eclampsia by measuring blood pressure and testing urine for protein (proteinuria).
Once pre-eclampsia develops, it does not go away until after the baby is born. Women with pre-eclampsia may require an earlier delivery, either by labour induction or caesarean section, in order to protect the health of themselves and their baby.
In some cases, pre-eclampsia can develop after childbirth. Eclampsia
is the onset of seizures (convulsions) in a woman with pre-eclampsia.
Onset may be before, during, or after delivery.
Most often it is during the second half of pregnancy.
The seizures are of the tonic–clonic type and typically last about a minute.
Following the seizure there is typically either a period of confusion or coma.
Complications include aspiration pneumonia, cerebral haemorrhage, kidney failure and cardiac arrest.
Hypertension in pregnancy: Systolic blood pressure greater than or equal to 140 mmHg and/or Diastolic blood pressure greater than or equal to 90 mmHg . Risk factors for preeclampsia are as follows: Have chronic hypertension Had pre-eclampsia in a previous pregnancy Have other medical problems, such as kidney disease, diabetes or an autoimmune disease having first baby aged 40 years or more expecting twins or triplets Have a family history of pre-eclampsia (i.e. mother had pre-eclampsia) very overweight at the beginning of pregnancy (BMI 35 or more) Have had a gap of 10 years or more since last pregnancy Conceived with in vitro fertilisation (IVF) Hemodynamic stability: BP (159/110), Pulse:80/regular, RR, temp, saturation.
Shift to resus room and open iv line, give her antihypertensive to lower BP.
Headache- site, continuous/not, radiation, relieving, aggravating.
Associated features- blurring of vision vomiting, drowsiness, tummy pain, decreased urine Baby kicking well/not. Swelling of legs increased or not. Any bleeding/discharge from down below. Obstetric H. Past h/o HT, migraine. F/H of HT. Rest of the Examination Oedema Abdomen- hepatic tenderness. Fundal height: 36 cm Foetal heart Lie Presentation. CNS- hyper reflexia, clonus evident at the knees. Fundoscopy- papilloedema. Order investigations-
office urine testing: Urine protein( ++) U&E FBE S.creatinine, RFT Coagulation profile, LFT. ECG Chest X-ray Albumin:creatinine ratio 24hr urinary protein. HELLP Condition characterized by high BP and excretion of protein through urine. Early in pregnancy, new blood vessels develop and evolve to efficiently send blood to the placenta. In women with preeclampsia, these blood vessels don't seem to develop or function properly. They're narrower than normal blood vessels and react differently to hormonal signalling, which limits the amount of blood that can flow through them. Causes of this abnormal development may include: Insufficient blood flow to the uterus Damage to the blood vessels Risks
Maternal- Seizures Stroke cardiac failure pulmonary oedema Renal Liver Coagulation failure APH Foetal-
hypoxia, IUGR, IUD, prematurity MILD MODERATE SEVERE DBP 90-99 100-109 >/= 110. SBP 140-149 150-159 >/= 160. Protein + ++ +++/more. Oedema - +/ - + Mild Preeclampsia management Can be managed at home. Bed rest Salt and protein restricted diet. Review by GP every 2nd day. Red flags. If not controlled, referral to hospital. Moderate and severe Management Immediate referral to tertiary hospital. Start I/V line- blood for investigations. Catheterise. 1st dose hydrallazine 5mg, then every 20-30 mts, max 20 mg. At hospital Admission. Seen by O&G specialist. Absolute bed rest for 24 hrs and then toiletary privilages. CTG U/S Monitoring of vitals. BP 2 hrly, fluid intake- output chart, urine protein twice daily. I/V MgSO4, 4gm I/V bolus, then 1-2 gm/hr infusion for at least 24 hrs. Plan for delivery(>37 weeks) Signs of imminent eclampsia Persistent headache. Visual disturbances. Tummy pain, vomiting. Drowsiness. Hyper reflexia, clonus. Sharp rise BP. Decreased urine. ECLAMPSIA Management
DRABCDE, Secure airway, Oxygen by mask, I/V line and blood for investigations. She needs to be transferred and admitted to hospital immediately and delivery arranged as soon as her BP and any further fitting brought under control. Prior to transfer to the hospital an anticonvulsant such as IV diazepam should be given. In the hospital: IV drip inserted and magnesium suphate commenced. BP lowered by IV hydralazine /diazoxide- oral agents are ineffective and should not be used. Tests: RFT,LFT, Hb and platelet count and coagulation profile. Fetus checked by CTG. Monitoring of patient: Pulse, BP, temperature, urine output and frequent urine testing for protein. Room should be prepared in case a further fit occurs. ECLAMPSIA
Once patient stable, consider termination by induction from >34 weeks and no fetal distress. If foetal distress- C-section. Monitor patient for further fits for 24-48 hrs. Review after 2 weeks of discharge. Case 22
Your next patient in general practice is a 35 week primigravida, Jenny Freeman, who has developed generalised oedema and has gained 2 kg of weight in the last 2 days. YOUR TASK IS TO: Take a further history Physical Examination findings from the examiner Discuss the diagnosis and management with the patient Differentials
systemic illnesses such as heart failure, liver disease, malnutrition, and thyroid disorder; local conditions such as pelvic tumours, infection, trauma, venous thrombosis; and various medications known to increase the risk of oedema of the lower extremities. History: ❑ Pregnancy Qs→ ❑ Swelling of limbs?→ sudden or gradual, unilateral/bilateral. any Calf pain, precipitating, relieving factors, rash or bites. Headache? Blurring of vision? SOB? Chest pain? racing of heart? Yellowish discoloration of skin, weather preferences? ANC visits? Blood tests? Folic acid? Sweet drink test ? Swab test? Blood group? BP? 18 week USG- baby, placenta, any abnormality Tummy pain, bleeding and leaking from down below, n/v Baby kicking ❑ General health (renal or heart diseases, HTN, DM, thyroid), previous h/o DVT, Surgeries, previous hospitalisation, H/o travel? ❑ Contraception (OCP), Pap smear ❑ Period Qs ❑ Social History ❑ SADMA Physical examination General appearance: pallor, dehydration, jaundice, edema Vital signs : pulse, BP Fundoscopy, thyroid examination Cardiovascular examination and JVP Lungs Abdomen: FH, lie, presentation, FHT, tenderness Neurological examination: Reflex Peripheries: redness, warmth, tenderness in calf, any rashes? Office test: Urine dipstick and BSL Explanation: Generalized edema of pregnancy→ It typically involves the lower extremities but occasionally it can cause swelling of the face and hands. Few reasons such as : ➢ Pregnancy hormones can cause salt retention, ➢ Increase of blood volume by 50% during pregnancy, and ➢ Enlarged womb may compress the veins (IVC) obstruction of blood flow leading edema. Can be reduced by intermittently lying on the left side, elevating the lower extremities intermittently(keeping a pillow below legs), wearing elastic compression stockings Usually resolves after birth of the baby as the uterus returns to pre-pregnancy size and the hormones return to normal At this stage there is nothing to worry about but I will run some investigations → FBE for Hb, infection, platelet, U&E, LFTs, TFTs, RFTs, and will see you back with the results.
Red flags: headache, blurring of vision, tummy pain, increased blood pressure, feeling unwell, baby not kicking, swelling not relieved by rest. CASE SCENARIO 23
Your next patient at your GP is 29 year old Maya, who is 28 weeks pregnant. She returns to you for the results of GCT done 2 days back. The value of plasma glucose level in GCT is 9.1 mmol/L after 1 hour. TASKS 1 Further relevant history. 2 Explain result to the patient. 3 Further management. GESTATIONAL DM
GCT- Screening test. No FBS. 50 gm glucose given. After 1 hour, BSL estimated- if >/ = 8 mmol/L, suspect DM.
GTT- Confirmatory test. FBS taken. Then 75 gm glucose given. After 1 and 2 hrs, BSL taken. FBS- >/= 5.5 mmol/L 1hr BSL- >/= 10 mmol/L 2 hr BSL- >/= 8 mmol/L, Gestational DM. GESTATIONAL DM
History Pregnancy going so far. All obstetric Q’s- U/S at 18 wks- multiple gestation, size of baby. Baby kicking well. Symptoms of DM- polyuria, polydypsia, miscarriage, infections of skin or genital tract. Tummy more distended than expected. (Poly hydramnios) Any headache, blurring of vision, swelling.( PET) H/O DM, F/H of DM. GESTATIONAL DM
Examination G/A- BMI, oedema. V/S. Abd: Fundal height- if > than gestational age. Foetal heart. Lie Presentation. Pelvic examination- Inspection for discharge and infections. Speculum examination. GESTATIONAL DM
BSL appears to be high in GCT which is a screening test.
Confirm by GTT- ask patient to come on empty stomach. Fasting blood sample collected. Then sweet drink given. BSL after 1 and 2 hours will be collected. If above normal, gestational DM.
Gestational DM- blood sugar higher than normal during pregnancy. Tends to come back to normal levels after delivery. Due to variations in the hormone insulin which keeps BSL under check. GESTATIONAL DM
Cause- due to anti insulin properties of Human PL, HCG cortisol and progesterone secreted by placenta and if mother cannot hike the production of insulin, gestational DM results.
Maternal risks- Miscarriage. Poly hydramnios. Preeclampsia. Placental abruption. Intercurrent infections. Increased chance of C-section and induction. GESTATIONAL DM
Foetal risks- Macrosomia or big baby. IUGR. Birth defects ( heart, vertebral) Prematurity
After birth- Hypoglycemia RDS Neonatal jaundice
Reassure patient- if BSL remains under control which is quite possible, none of these complications might occur. GESTATIONAL DM
If DM Refer to high risk pregnancy clinic- MDT of O&G specialist, endocrinologist, diabetic educator, dietician Aim is to maintain BSL < 7 mmol/L. Strict diet control for 2 weeks under the advice of dietician. BSL has to be recorded 3 times/day. Maintain a BSL diary. If not controlled, insulin under the advice from endocrinologist. Might require admission to stabilize insulin dosage. BSL recording, 3-4 times/day. Administration of insulin and usage of glucometer will be taught by diabetic educator. GESTATIONAL DM Review by ophthalmologist and nephrologist. HbA1C, FBE and urinary protein monitored. A/N visits weekly from 30 weeks. Weekly CTG from 32 weeks. U/S at 32 weeks. Repeated after 4 weeks if necessary. Aim to deliver at term the latest. At tertiary hospital. Vaginal delivery if no complications. C-section if baby baby >4 kg or maternal or fetal complications. GESTATIONAL DM
During delivery- Continuous CTG. insulin injections to mother after BSL monitoring. After delivery- Baby checked by pediatrician. Stop insulin in mother. 30% chance of developing DM later, within 10 yrs. Follow up GTT in 6-8 weeks and there after BSL checked every 2 yrs. Case 24: Your next patient in general practice is a 26 year old who is 10 weeks pregnant. She had her first antenatal check-up which was normal although she complained about becoming short of breath during exercise over the last 4 weeks. She had rheumatic fever at 10 years of age when she was in Africa because her father worked there.
YOUR TASK IS TO: Take a further history Perform a physical examination Discuss your diagnosis and suggested management with the patient History: Congratulation on being pregnant I have seen from the notes that you have SOB,
Can you tell me more about SOB? When did it start? What do you mean by SOB? When do you usually become short of breath? Exertional, at rest? Precipitating factors Aggravating factors: what make is worse or what makes it better? Can you lie flat on bed? How many pillows do you use when you sleep? Have you ever woke up at night because of SOB? (PND) Questions: Apart from SOB, do you have chest pains, palpitaions, swelling in the legs? Cough, noisy breathing, any syncope? How is your health in general? How is your appetite? Any nausea vomiting or abdominal pain? Any problem with your waterworks,Any vaginal bleeding? Any past medical conditions? (rheumatic fever) When was that? How long did you receive treatment? Have you recovered completely after that? Have you had a regular check up after that? Do you know your blood group? Do you smoke? Drink? Drugs? Medication? Allergies? Do you have family history of any heart problem? PE: Examine Cardiovascular system GA(cyanosis) Vitals JVP, carotid precordial : Tapping Apex beat loud S1 mid diastolic rumbling murmur + - thrill (MS
Examine the lungs for evidence of pulmonary edema, pleura effusion. Abdomen: for hepatomegaly Sacral edema, leg edema. DIAGNOSIS: most likely mitral valve stenosis secondary to rheumatic fever Most murmurs found in pregnant women are innocent. They are due to the increased strain on the heart because of the increased rate and stroke volume and the extra blood that women's bodies make while they are pregnant. In her situation the heart murmur might be related to mitral stenosis which can be caused by rheumatic fever. Risk factors: Risk factors for heart disease in pregnancy include a positive family history of inherited cardiac disease, hypertension, obesity and increased age. The latter is becoming an important factor, as more women in older age groups seek assisted conception. Most common is rheumatic heart disease, which affects the heart valves. A lot of it depends on whether there is critical stenosis or not. We need to do ECHO and ECG. +MV stenosis. The echo result confirmed what was I suspecting. It is very likely that your situation might worsen in late pregnancy. In pregnancy the heart works more than normal because there is more demand. Managed as high risk pregnancy – needs to be monitored by obstetrician and cardiologist. Your antenatal visits are frequent than normal (2 weekly until 28 and then weekly thereafter) The time and mode of delivery will depend on your condition and your baby’s situation. If everything is under control, you will deliver at your own time. You need to deliver in a tertiary hospital with OB present. No Lithotomy position – Head up or on lateral position. Some measures to shorten 2nd stage of labour (forceps or vacuum) After labour, there is a need for observation because of risk of decompensation. Oxygen supplementation if required. Medications to regularize heart beat if required. The fluid balance and vital signs need to be checked regularly Case 25
You are a GP and a 28 year old G4P3 Pregnant lady in 20 weeks of gestation has come to see you to know the results of the recent blood test. The blood tests haemoglobin is low, MCV is low, Transferrin high and ferritin low. Task relevant history, examination findings, and manage the case. I understand you are here for the blood results. Before that May I ask you few questions regarding you pregnancy?
How are you feeling at the moment? Do you have any SOB, palpitation tiredness, lethargy How is your pregnancy been so far? Antenatal check ups? Blood tests? USG? May I know about your previous pregnancies? ( 3 pregnancies in last 4 years) ,no PPH. Did not take iron tablets during those pregnancies because hb was always >10. Periods normal. No bleeding from the bowel, no suggestions of malaria or hook worm infestations Diet: eat meat occasionally but don't like green vegetables. No iron tables taken in this pregnancy too. No vaginal bleeding No family history of thalassemia or anemia. No Mediterranean heritage in the family. No FBE done before in this pregnancy No other health problems Knows blood group Supportive partner. EXAMINATION GA: Is my patient pale, lethargic, weak VS: HR, BP, Temp, RR, O2 Sat Skin: any bruises or petechiae Cardiac murmur (systolic) Abdominal – Uterus Size - consistent with Gestational age or not(IUGR) Any tenderness Fetal Heart Sounds
PV examination Inspection : any vaginal bleeding or discharge Speculum : any vaginal bleeding or discharge Urine dipstick and blood sugar. MANAGEMENT Anne, you’ve a condition called iron deficiency anaemia It’s the most common cause of anaemia in pregnancy. It is most often asymptomatic and detected in screening like in your case. There is a high demand of iron during pregnancy and in your case most like due to inadequate gap between pregnancy and no iron supplements. There are certain risks to you and your baby because of anaemia. To you: It can predispose to infections, excessive blood loss during pregnancy and affect your heart.
To baby: Because of less oxygen supply can lead to IUGR, fetal distress and in severe cases stillbirth. Management
We will start with iron supplements. There are certain side effects you should be aware of like nausea, tummy pain, black stool and constipation. To minimize these effects I would advise you to take more green leafy vegetables, fiber rich food and plenty of water. When iron supplements are given in a liquid form, teeth may reversibly discolour (this can be avoided through the use of a straw).
Also consume more iron rich foods like legumes, nuts, wholegrain breads, green leafy vegetables etc. There are some evidences of consuming Vitamin C improves the absorption of iron. We will stop the medication in 3 months time after adequate storage of iron. Parental iron is indicated: if close to delivery, cannot tolerate oral iron or Hb< 7 g/L. Review in 2 weeks time, if hemoglobin is not increasing then refer to hematologist for further assessment. Hb<7 irrespective of ferritin level –refer. Case 26 22 YEAR OLD LADY WHO RECENTLY HAD A SELF LIMITING FEBRILE ILLNESS HAD HER BLOOD TEST DONE. FBE SHOWED HYPOCHROMIC MICROCYTIC ANEMIA OF 108G/L. THE MEAN CORPUSCULAR VOLUME WAS BELOW 68 (N=80-101).SERUM IRON AND FERRITIN IS NORMAL. YOU SUSPECT B THALASSEMIA MINOR AND CONFIRMED BY ELECTROPHORESIS. YOU ARE AWARE OF HER GREEK DESCENT AND SHE HAS JUST BEEN ENGAGED TO BE MARRIED. HER FIANCÉ IS ALSO OF GREEK DESCENT. THE FAMILY HISTORY OF HER MOTHER, FATHER AND BROTHER ARE ALL ALIVE AND WELL. ONE OF HER FATHERS BROTHER WAS REPORTED TO HAVE DIED FROM AN UNKNOWN CAUSE. THE PATIENT IS VERY WORRIED ABOUT BEING TOLD SHE IS ANEMIC AS SHE IS TO BE MARRIED SHORTLY AND WORRIED ABOUT THE EFFECTS ON ANY CHILD SHE HOPES TO HAVE. TASKS: EXPLAIN THE NATURE OF THE CONDITION, ANSWER PATIENTS QUESTIONS AND ADVISE THE PATIENT WHAT SHOULD BE DONE NOW. Key issues
Patient counseling/education Thalassemia minor is a recessive inherited trait ( carrier state) Nature of the condition and possible consequences if conjugal partner also carries the trait Information about b thalassemia major and risks of its occurrence in offspring if both partners and carriers. Availability of antenatal diagnosis and management of pregnancy (including termination) if fetus is shown to have b thalassemia major. Thalassemia is an inherited (genetic) condition affecting the blood. There are different types of thalassemia. Depending which type you have, thalassemia may cause no illness at all, or may be a serious lifelong condition requiring treatment. The cause is an inherited (genetic) change, involving the genes which tell the body how to make an important chemical called haemoglobin. Haemoglobin is the chemical which carries oxygen in the blood - it is the one which gives blood its red colour. Haemoglobin is located in cells called red blood cells which are part of the blood Haemoglobin is made out of different parts. The main parts are called alpha chains and beta chains which are put together to make the haemoglobin molecule. In thalassemia, part of the haemoglobin is faulty - usually either the alpha chains or the beta chains. This means that some of the haemoglobin does not work properly. As a result, there is not enough normal haemoglobin and the red blood cells break down easily. This makes the person lacking in haemoglobin (anaemic), with various symptoms. Meanwhile, the body tries to make more haemoglobin and more red blood cells. So, the blood system goes into overproduction mode which can cause more symptoms and complications. The main types of thalassemia are called alpha thalassemia and beta thalassemia. (The alpha and beta refer to which haemoglobin gene is affected, and which of the haemoglobin chains is faulty.)
Each type of thalassemia (alpha and beta) is then classified into more types, according to how severe the condition is. This mainly depends on how many thalassemia genes are involved. The mildest types are called thalassemia trait (or thalassemia minor). The more severe beta types are beta thalassemia major (BTM).
It is important for her fiancé to be investigated for carrier state as for further assessment. If fiancé is negative for b thalassemia minor: 50% either son or daughter will be normal, 50% will be carrier. If fiancé have b thalassemia major: 50 % carrier(either son/daughter), 25% normal and 25% thalassemia major . Management
If the hemoglobin test for b thalassemia minor in the fiancé is negative: No further action/tests are required Explanation of carrier state is required ( can affect male or female children) each offspring will have an equal chance of being carrier or non carrier (normal) Reassure her regarding the minor effect on her health. Oral folic acid of 1 mg/day will meet the requirement of mildly increased red cell turnover. Iron therapy not indicated. If the fiancé has a positive test for b thalassemia minor, they will need counseling about risks to fetus : in utero genetic sampling in 12-14 weeks available and option for termination if the fetus is b thalassemia major.
B thalassemia major is rare, but very serious congenital anemia requiring life long transfusion support and patient with this condition also need treatment to avoid complications of iron overload related to frequent transfusions. There is markedly reduced life expectancy. CASE SCENARIO 27
A 28 year old primi gravida presents to you at 30wks of gestation with sudden onset of abdominal pain. You are a GP in a rural practice about 300km away from a hospital with O&G facility. Tasks 1 Relevant and focused history. 2 Examination findings from examiner. 3 Discuss management with patient. PRETERM LABOUR
DD Preterm labour. False labour. Abruptio placentae. UTI Trauma Abdominal emergencies. PRETERM LABOUR
Hemodynamical stability Offer pain killer. All pain q’s- duration, site, radiation, type ( interval, duration), aggravating/relieving factors, trauma. Associated symptoms- bleeding(Abruptio placentae), ROM, baby kicking. Bladder- dysuria, fever, chills/rigor.(UTI) Bowels. Nausea, vomiting or distention.(abdominal conditions) PRETERM LABOUR
Obstetric H Pregnancy going so far. Regular antenatal checks. Folic acid, blood group. U/S at 18wks Sweet drink test. Headache, oedema, visual disturbances.(PET) Other M/S illness, medications. Partner, miscarriages, STI’s, contraceptives, PAP. SAD. PRETERM LABOUR
Examination G/A- BMI, oedema, pallor. V/S- BP. Abdomen- Inspection: trauma Palp- Fundal height. Foetal heart. Presentation Lie Tenderness of uterus.( Abruptio placentae) Uterine contractions (contractions every 5 minutes lasting 1 minute) Head engaged or not. PRETERM LABOUR
Pelvic examination Inspection of vulva and vagina- watery discharge, bleeding. Sterile speculum- dilatation of cervix( dilated 3 cm),effacement: 50% NO DIGITAL EXAMINATION IF PATIENT REQUIRES TRANSFER AND IF PROM. Other systems. PRETERM LABOUR Management labour after 20wks and before 37wks. Causes Unknown Multiple pregnancy. Polyhydramnios. Cervical incompetence. Maternal illness- DM, PET, infections. PRETERM LABOUR Preterm labour if Contractions every 5- 10mts lasting 30sec-1mt. Cervix >2.5 cm dialated and effaced. Fibronectin test +ve. < 37 weeks.
Complications of prematurity Lung immaturity (NRDS) Intraventricular haemorrhage. Neonatal sepsis. Difficulty in maintaining temperature and glucose levels. Feeding difficulties. PRETERM LABOUR
Immediate transfer to tertiary hospital with neonatal intensive unit. Arrange NETS. Accompanied by doctor or midwife. Inform hospital. Insert I/V line- blood for FBE, U&E,BSL, Blood group and start transfusion. Swab from vagina for fibronectin test. Urine sample for M/C&S. 1st dose tocolytic. 1st dose steroid. PRETERM LABOUR Tocolytic Medication that prevents uterine contraction. Nifedipine- 20mg 3 doses 20mts apart, then 20mg tds for 48hrs. Others- atosiban, ritodrine. C/I- Cervix >5cm dilated and 75% effaced. Placenta praevia. Preeclampsia Foetal distress. PRETERM LABOUR
Steroid In delivery prior to 34wks. To ensure lung maturity in the baby. Prevents hyaline membrane disease in baby. 2 doses of betamethasone I/M, 24hrs apart. PRETERM LABOUR
At hospital Admission. Referral to O&G. Monitoring the progress of labour CTG. CASE SCENARIO 28
25 year old Mary, who is 32 wks pregnant, presents to you at your GP clinic with complaints of passing fluid from vagina since the past 1 hour. Tasks 1 Relevant history, 2 Examination findings from examiner. 3 Management. DD ROM Abnormal vaginal discharge Leakage of Urine History Duration, amount, color, offensive smell. Associated tummy pain.( Preterm labor) Abnormal vaginal discharge earlier. Bladder. Baby kicking well/not. Obstetric H U/S at 18 wks. Sweet drink test. Examination G/A- BMI, pallor, oedema. V/S- BP, temp Abdomen- Fundal height Foetal heart Presentation Lie Uterine tenderness. Head engaged/not. Pelvic examination
Inspection- Colour of fluid, amount, consistency, blood stained/not. Sterile speculum- Cervical dilatation/effacement- Cord prolapse Pooling of fluid in the posterior fornix. Collect swabs- Low vaginal and cervical for M/C&S Vaginal and anorectal swab for GBS Amnisure or Nitrazine test if in doubt. NO DIGITAL EXAMINATION.
PPROM Management PPROM- ROM before 37weeks PROM- ROM before labour. Cause-unknown. Similar to preterm labour. Immediate referral to tertiary hospital with neonatal intensive care unit. Insert I/V line- blood for FBE, ESR/CRP, U&E, BSL, blood grouping. Start infusion. Urine for M/C&S. 1st dose steroid. 1st dose tocolytic- gestation <34 wks in absence of infection/complication. where course of steroid not completed when patient requires transfer. 1st dose antibiotic- erythromycin 250mg (qid x 10days) prevents infection and prolongs pregnancy short term PPROM
At hospital Admission. Referral to O&G. FBE, ESR/CRP every 2-3 days. CTG daily/ every 2 days. U/S weekly. Monitoring of vitals for infection. PPROM Regarding delivery Conservative management with patient’s consent till 36 weeks. Patient made aware of increased risk of infection but decreased risk of prematurity in baby. Pregnancy >36 weeks- induce labor if no C/I. Immediate delivery if infection ( fever, tachycardia, elevated WCC/CRP) and if fetal distress. Cervical encirclage CASE SCENARIO 29
You are an HMO at the ED of a tertiary hospital when 28 year old Jenny, who is in her 34 weeks of gestation presents to you with vaginal bleeding. TASKS 1 Further history. 2 Examination findings from examiner. 3 Diagnosis and management. DD 1 Placenta praevia. 2 Abruptio placentae. 3 Trauma. 4 Preterm labour. 5 Bleeding disorders. PLACENTA PRAEVIA
History Haemo dynamically stable. Duration, amount, colour, clots, smell, continuous/intermittent. Associated tummy pain.( Abruptio placentae, preterm labour) H/o trauma including sexual intercourse. Broken waters. Any signs of Preeclampsia. Baby kicking well How far away from hospital. PLACENTA PRAEVIA
Obs History- U/S at 18 weeks, any repeat U/S. Blood group. Sweet drink test. SAD- Smoking/ cocaine predisposes. Bleeding disorders. PLACENTA PRAEVIA
Examination G/A- BMI, pallor. V/S- BP (postural drop), other signs of shock. Abdomen- Fundal height Foetal heart Presentation Lie Uterine tenderness. Pelvic examination- Inspection: bleeding,discharge Speculum- os open/closed. NEVER DO DIGITAL EXAMINATION PLACENTA PRAEVIA
Investigations FBE- Hb U&E. BSL Blood group, cross matching and hold. Coagulation profile. Pelvic U/S- position and grade of placenta. CTG. Urine routine. PLACENTA PRAEVIA
Placenta praevia- lower attachment of placenta resulting in painless bleed usually at 28-30 wks.
Grades of placenta praevia. 1- placenta in the lower segment but not near cervical os. ( low lying p p) 2- placenta up to the level of os.( marginal p p) 3- placenta covers part of os.( partial p p) 4- placenta fully covers os.( total p p)
PLACENTA PRAEVIA Management Severe bleeding-once patient becomes stable irrespective of gestational age and grade of placenta praevia, do C-section. Discuss risk of bleeding, blood transfusion, major surgical intervention like hysterectomy. Steroid if < 34 wks. If minor bleed- in grade 1 and 2 admit watchful expectancy. No bleed after 4-7 days, discharge Rest at home. Referral to high risk pregnancy clinic Red flags. PLACENTA PREAVIA
If minor bleed- in Grade 3& 4 Admit. Watchful expectancy for 4-7 days. Discharge only if < 34 weeks. If discharged- Refer to high risk clinic Rest Red flags Advice for admission at 34 weeks. PLACENTA PRAEVIA
Women with major placenta praevia( gr 3&4), who had previously bled, should be admitted and managed at hospital as IP from 34 wks even if home nearby.
Women with major placenta praevia, who had been asymptomatic, should be admitted after 34 weeks if staying far from hospital. Home based care only if close to hospital, if there is a constant companion and with patients consent.
C-section for minor at 38 weeks and major at 37 weeks
Trial of vaginal labour if placental edge >2 cm from os, in 3rd trimester after patient made aware of risks and in hospital with C-section facilities. PLACENTA PRAEVIA Risks Maternal- APH Shock DIC Preterm labor PPH
Foetal- Hypoxia IUGR Prematurity IUD. Predisposing factors-
High parity Multiple gestation Elderly age HTN Tobacco/cocaine abuse Previous C-section CASE SCENARIO 30
You are an HMO in the ED of a major hospital when 28 yr old Tracy at 34weeks gestation comes to see you with complaints of vaginal bleeding since the past 1 hour. TASKS 1 Relevant history. 2 Examination findings from examiner. 3 Diagnosis and management. ABRUPTIO PLACENTAE
DD 1 Placenta praevia. 2 Abruptio placentae 3 Trauma 4 Preterm labour. 5 Bleeding disorders. ABRUPTIO PLACENTAE
Haemodynamically stable. Duration, amount, clots, colour, smell, continuous/intermittent. Any tummy pain- + in AP. H/O trauma. All pain Q’s- associated features- dizziness/tiredness headache, blurring of vision, swelling. H/o bleeding disorders. Baby kicking well. A/N history- Blood group, U/S at 18 weeks. Any M/S illness. SAD. ABRUPTIO PLACENTAE
Examination G/A- BMI, pallor, oedema. V/S- Features of shock. Abdomen- Fundal height Foetal heart Presentation Lie Uterine tenderness- + in AP. Pelvic exmn: Inspection for bleeding. Speculum- os open/closed. NO DIGITAL EXAMINATION. MILD ABRUPTIO PLACENTA
Management Admit Immediate referral to O&G. Start I/V line- blood for FBE, U&E, Blood grouping, cross matching and hold, coagulation profile, LFT, RFT. Start infusion. U/S – to confirm diagnosis and to r/o concealed haemorrhage. CTG. Bed rest. Ambulate slowly once bleeding stops. Observe. Refer to high risk pregnancy clinic. Frequent A/N checks. If >37 weeks, delivery by induction or C-section. ABRUPTIO PLACENTAE
Mild- < 500 ml. Moderate- 1-1.5 L, severe abdominal tenderness, shock, foetal compromise. Treatment- admit, refer to O&G, stabilise patient. If baby alive and no coagulopathy, do C-section. Severe- > 1.5 L, severe abdominal tenderness, shock, baby usually dead, DIC common. Consider Anti D if Rh –ve. CASE SCENARIO 31
You are an intern at the ED of a major hospital, when 25 yr old Maria, who is 32 weeks pregnant, presents to you with severe abdominal pain since the last 2 hours. TASKS 1 Relevant history. 2 Examination findings from examiner. 3 Diagnosis. 4 Management. SEVERE ABRUPTIO PLACENTAE WITH IUD
DD 1 Preterm labour. 2 Abruptio placentae. 3 Torsion of ovarian cyst. 4 Trauma 5 UTI- pyelonephritis, calculi. 6 Abdominal emergencies- appendicitis. SEVERE ABRUPTIO PLACENTAE
Hemodyanamic stability, Offer pain killer. Pain Q’s- coming at intervals/continuous.1st episode Associated features- bleeding P/V, water broken. H/O trauma. Bowel and bladder. N/V. Baby kicking well/not. Obs H- blood group, U/S at 18 weeks. Any M/S illness( HT, DM), medications, bleeding disorders. SAD SEVERE ABRUPTIO PLACENTAE
Examination. G/A- pallor, sweating. V/S- PR, BP(postural drop), SaO2. DRABCDE IF IN SHOCK. And also U/S and CTG. Abdomen- Fundal height( increased in concealed AP) Foetal heart(- in IUD) Presentation, Lie Uterine tenderness, guarding.(+ in AP) Pelvic examination- Inspection for bleeding(concealed AP) Speculum- os closed( concealed) NO DIGITAL EXAMINATION SEVERE ABRUPTION WITH IUD
Breaking bad news. A part of the placenta, that normally attaches your womb to the baby has detached from the wall, resulting in severe bleeding which had collected inside and it had resulted in the passing away of the baby. Cause is unknown but HT, DM, multiparity and previous h/o placental abruption, trauma and smoking predisposes. When patient is stable, if baby dead, in revealed type there are 2 options.
Immediate delivery by induction or excessive bleed- CS. If baby alive, C-section when patient is stable. SEVERE CONCEALED ABRUPTION
Management Admit. Immediate referral to ED consultant and O&G specialist. C-section immediately when condition is stable, to drain the collected blood, seal the oozing blood vessels and remove the placenta and baby. Case 32
You next patient in a country clinic is a 38 weeks gestational age lady with no fetal movements in the past 12 hours. Task History Physical examination Diagnosis and management History I understand you have come to see me because you haven’t felt your baby’s movement for the past 12 hours. Is it the first time? Have you noticed that your baby is moving less in the last few days? Pregnancy Qs→ planned? First pregnancy? Folic acid? Blood tests? UTI Qs? ANC visits? Blood tests? Folic acid? Sweet drink test ? Swab test? Blood group? 18 week USG- baby, placenta, any abnormality Tummy pain, bleeding and leaking from down below, n/v? Preeclampsia Qs- blurring of vision, headache, swelling of limbs UTI Qs- burning sensation/pain while passing urine, frequency, urgency? Fever? General medical health? SADMA? Social History→ Where do you live and who you do you live with? Do you have any family members or close friends with you today? Examination: General appearance: Oedema Vital signs-BP Chest and Heart Obstetric examination: Fundal height, Uterus tender or not, lie, presentation, head (if engaged/mobile), Foetal heart rate
Office test: Urine dipstick, BSL +ve points→ can hear the fetal heart sounds Explanation: Reassure that you can hear the baby’s heart sound. There can be reasons why no movement of the baby→ The baby’s activity could be different throughout the day and absence of baby’s movement could be due to rest or sleep. However, we need to exclude the other possible cause which is fetal distress due to hypoxia or lack of oxygen to the fetus which makes your baby quiet. Therefore→ send to hospital for CTG→ simple and safe procedure→ Two sensors will be placed on your abdomen to record baby’s heart rate, uterine contractions and fetal movements. Also specialist will review in hospital→ If the CTG pattern is normal→ might have an ultrasound to assess the amount of amniotic fluid around the baby. If everything is fine→ might go home after that and maintain a kick chart for you.(Red flags) normal is aprrox 10 kicks in 2 hours, If the CTG pattern is suspicious, the doctor will most likely discuss induction of labor with you or if its is found baby is distress→ might need to have an urgent cesarean section. Provide support Case 32 28 year old Jane was brought to the ED where you are an HMO with history of MVA(motor vehicle accident). She is 32 weeks pregnant with complains of abdominal pain. Tasks: History Physical examination from examiner Management of patient. Hemodynamic stability When did the accident happen (1 hour back) If its alright with you, can you describe the accident (hit by car), Speed of the vehicle (within speed limit) Wearing seat belt? Able to walk out of the car alone? Injury to other area? Hit her head? Hit her tummy? Any LOC, headache, nausea and vomiting, blurring of vision and neck pain? Any limitation of neck movement (cervical injuries) Chest pain/SOB ( chest injury) Tummy pain : site (all over tummy) , Radiation ( lower back, inner thigh) , continuous on /off ? Is baby kicking well? Broken her water? Pregnancy : How have your pregnancy been so far? First pregnancy or not? Blood group? USG @ 18 weeks ? Single preg? Placenta position? Sweet drink test @ 26 weeks. Preeclampsia : leg swelling, edema Any other medical, surgical illness SADMA Support. Physical examination
General Appearance: Pallor, Edema , Dehydration, Bruise on any part of body? (you can see bruise along the line/area of seat belt). Vitals: BP with postural drop Head : any swelling, bogginess ENT: Bleeding from ear/ nose Throat exam Neck: midline tenderness ,limitation of movement of spine. Respiratory system: position of trachea, any local rib tenderness auscultation for air entry . CVS: S1, S2, any murmur. CNS: cranial nerve ,Upper limb, Lower limb neurovascular examination Abdomen examination: Fundal height (32) no concealed abruptio. FHR (normal) Lie: Longitudinal Presentation: Cephalic Tenderness, rigidity and guarding. Any contractions Pelvic exam: Inspection of vulva and vagina –rash, vesicle, bleeding and discharge. Per speculum: os open or closed No P/v or Bimanual exam. Management
Admission Specialist consultation Monitor vitals regularly Arrange for USG and CTG( USG to rule out abruptio and CTG every 4 hour in first 24 hours) Observe for 24 hours Ask her to monitor baby kick as well
On Discharge Red flags: recurrent pain, decrease baby movement, discharge, bleeding, leaking down If blood group negative: Take coombs test and give anti – D injection. Case 33
A 25 years primi gravida in labour at 41 weeks of gestation in a district hospital. You’re a GP. No obstetrician available. There’s a spontaneous rupture of membrane & thick meconium. Task: take history, examination, management. History: When did the membrane rupture? Contraction →When did it start? How often? How long did it last? Is the baby kicking? Are you sure about the gestational age? Antenatal check up →US; Sweet test; GBS Blood group? PMHx →DM, HTN, past surgical History Medications O/E: GA VS: T (looking for infection) Abdomen→ Soft or tender; Presentation/lie; Engagement( engaged); Fetal heart rate Speculum →Dilatation (3cm), Effacement; Cord prolapse (ask in all post term, polyhydramnios, high risk pregnancy) I have to refer you to the tertiary hospital immediately where there is an obstetrician and pediatrician to assist the delivery.
Delivery depends on the progression of the labour and continuous CTG. If progression and CTG normal, you can have vaginal delivery. But if the progression is not good and CTG abnormal, you might require manipulative delivery or caesarean section. If the baby comes out vigorous and crying, it’s good, we don’t have to do anything. But if the baby is floppy & doesn’t cry, we have to aspirate the mouth & pharynx. Meconium stained liquor
Meconium is a thick, black-green, odorless material first demonstrable in the fetal intestine during the third month of gestation, resulting from the accumulation of debris, including desquamated cells from the intestine and skin, gastrointestinal mucin, lanugo hair, fatty material from the vernix caseosa, amniotic fluid, and intestinal secretions. It contains blood group-specific glycoproteins and a small amount of lipid and protein that decreases during gestation. The black-green color results from bile pigments. Passage of meconium occurs early in the first trimester of pregnancy. Fetal defecation slows after 16 weeks gestation and becomes infrequent by 20 weeks, concurrent with innervation of the anal sphincter. From approximately 20 to 34 weeks, fetal passage of meconium remains infrequent. Almost all fetuses and newborn infants who pass meconium are at term or post term gestation. In post term pregnancies meconium staining is common and usually the baby is quite well, but if CTG shows abnormalities, further steps need to be taken like induction of labour of caesarean section. Past term, the placenta involutes, and multiple infarcts and villous degeneration produce placental insufficiency syndrome. In this syndrome, the fetus receives inadequate nutrients from the mother, resulting in soft-tissue wasting. During labor, post mature infants are prone to develop asphyxia and meconium aspiration syndrome. Critical errors:
Not checking for cervical dilatation and excluding cord prolapse Not mentioning contínuos CTG Failure to aspirate the mouth & pharynx adequately at delivery, to reduce the risk of meconium aspiration. Case 34
GP setting. A 31 years old primigravida, 41 week pregnant, is concerned about her pregnancy. Task: Take history, Physical Examination, Investigation and Management. Good to see you, tell me more about it? How did you confirm your due date? How’s your pregnancy so far? Have you done your antenatal check-up? →18w US, sweet test, GBS swab, blood group Present symptoms →abdominal pain, contraction, water leakage, bleeding Can you feel the baby kicking? Is it your first pregnancy? If not, how many children do you have? What was the mood of your delivery, any complications before, during and after the delivery? Any other symptoms like headache, blurred vision? Past history including Gynecological problem and surgical procedure Family history- Any problem in the family with regards to child birth? Smoking,alchohol,recreational drugs. How far do you live from the hospital? Whom do you live with? Who will bring you to the hospital in case of emergency? O/E: GA; vitals, system review Abdominal exam → fundal height, lie, presentation, fetal heart sound, any tenderness. pelvic exam: speculum →vaginal bleeding, any discharge, os- open or close Bimanual exam: cervix open or close, cervical dilatation and effacement. Urine dipstick Explanation: Any pregnancy is defined as post dated if it’s >42 wks. Normal pregnancy is 40 plus minus 2 wks. You’re still in the normal period. This is not an uncommon condition. Risk of post dated pregnancy: - Chance of big baby with more ossified skull and more chances of obstructed labor and less molding. - Fetal distress - Meconium aspiration - Still birth - Neonatal death - Neonatal seizure In order to find all this, we’ll do the Investigations like: - CTG - Doppler US of the cord to look for placenta insufficiency
- Biophysical profile : biophysical profile is a prenatal ultrasound evaluation of fetal well-being, involving a scoring system, 5 components: Fetal movement Fetal tone Fetal breathing Amniotic fluid volume Fetal Heart Rate I will refer you to an obstetrician: options 1) Induction of labour if there is no contraindication, vaginal prostaglandin to initiate contraction, membrane will be ruptured to initiate labour. 2) Continuation of pregnancy, close monitoring, kick chart daily, CTG 2/w, UG and Doppler 3) Elective caesarean section
The decision is yours after consultation with the specialist. Case 35
In general practice you see a new patient, a 25- year-old Primi gravida, Mrs. Janet Holmes who has moved into the area and wants you to take over her antenatal care at 32 weeks of gestation. On examination you diagnose a breech presentation, which had not been known before. Task History Physical Examination Diagnosis and management Answer questions from patient and examiner Causes of breech
Maternal: polyhydramnios, uterine abnormalities, placental abnormalities(previa) multiparity, fibroids.
Fetal: Prematurity, fetal anomalies. Complications of Breech presentation Cord prolapse – distressed baby Prolonged or obstructed labour Trauma to the baby (bone fracture – clavicle, humerus and femur) Intracranial hemorrhage – head stuck Asphyxia – suffocation of the baby Nerve injury like facial palsy or brachial plexus palsy History
Is it a planned pregnancy? Congratulations on your pregnancy. How is the pregnancy so far? Excited about the motherhood? Are you regular with your antenatal checkups? How were your tests? Ultrasound? Was it a single baby? What was the position of the placenta? Amniotic fluid? Sweet drink test? Blood group? Have you taken folic acid? Is the baby kicking normally? Are you maintaining a kick chart? Do you have any headache, dizziness, BOV or leg swelling? Do you go to washroom quite often? Do you drink a lot of water? Does your tummy feel more distended than usual? Any vaginal bleeding, discharge, tummy pain? Are you regular with the pap smear? Were you ever been diagnosed with fibroids or any other abnormality? SADMA Physical examination
General appearance, BMI, Vital signs especially BP oedema – , pallor – anaemia, Jaundice
Obstetrics examination: FH: bell shaped, lower pole of uterus is occupied by soft rounder mass that bounces between fingers. FHR, Lie (presenting part and part occupying fundus) presentation. Diagnosis and Management
From the examination, I have found that the baby position in the womb is opposite to that of the normal. We call this condition Breech presentation. Normally, the baby’s head is down and the bottom is up. In your case, the baby’s butt/bottom is presenting down.
First of all, we need to do USD to confirm the diagnosis and to find out the type of breech and exclude the causes of breech and to make sure that the baby is fine. There are three kinds of breech Frank: hips flexed and knees extended (pike position) -65% Complete: hips and knees flexed -25% Single or Double Footling: one of both legs are completely extended and present before the buttocks
In most of the cases of breech near term or at the time of delivery, baby takes the normal cephalic presentation. If not, with your consent, the specialist obstetrician will try to turn your baby in the normal position by gently pressing the tummy (36 week). This procedure is called ECV.
Do not worry. It is a painless procedure and it is done in a tertiary hospital. External cephalic version can sometimes move the fetus to vertex presentation before labor, usually at 36 weeks. This technique involves gently pressing on the maternal abdomen to reposition the fetus, but is contra-indicated once labor has started! A dose of a short-acting tocolytic (terbutaline 0.25 mg s.c.) may help. The success rate is about 50 to 75%. What about the delivery? 'What are my options regarding delivery?' Vaginal delivery carries a higher risk for the baby (almost double) than with caesarean section, although a trial is acceptable in frank and complete breech position but not in footling presentation (Mainly because of the risk of cord prolapse!). The risk includes fetal distress because of cord prolapse, hip or shoulder dislocation, fracture of humerus, femur or clavicle and asphyxia. If these develop during the trial of labor the specialist will do cesarean delivery. If footling, then always do Cesarean delivery. If you do decide to go on a trial with vaginal delivery, we will still do our best to monitor you and your baby by doing regular CTG and USD and if if shows any signs of distress then a CS will be performed. It will be done in a tertiary hospital in the care of an experienced obstetrician. We can reduce the risk of complications by 50% if we choose elective cesarean section at 39th week. Is it a serious condition? Not really, but it makes NSVD difficult but not impossible. However, you are still at 32 weeks and there is a high chance that your baby will still change its presentation. Reading material. Referral. Red Flags: bleeding, tummy pain, blurring of vision Contraindications for ECV:
Oligo hydramnios Antepartum hemorrhage Multiple pregnancy Uterine structure abnormalities Fetal abnormalities. Case 36
Julia aged 35 years presents to your surgery for routine antenatal checkup as advised by you last week. She is 38 weeks pregnant and till now her pregnancy has been progressing well. On routine questioning she tells you that today she had uncomfortable feeling in her flanks and tense feeling but no other associated symptoms. She had normal USD at 18 weeks and other blood tests performed during pregnancy. This is Julia’s 2nd pregnancy. She had one abortion when she was 32 years old. Julia lives with her partner in an apartment close to your surgery. She stopped smoking when she became pregnant but is still having a glass of wine here and there. Case 2: You are an HMO working at a district hospital and a 38- weeks multigravida who lives 80 km from the tertiary hospital was found that the baby had a transverse lie. Task Relevant history Physical Examination Management Risk factors
Multiparity Lax uterus Previous cesarean section Polyhydramnios Placenta pervia Uterine malformations Small pelvis. History How is your pregnancy so far? Did you have regular antenatal checkups? How were the blood tests? What about the mid pregnancy USD? Do you remember what the doctor said about the baby and placenta (Single baby and position of placenta)? Sweet drink test? Did you have a low vaginal swab done (GBS)? Any abdominal pain/contractions or water leakage? Any vaginal bleeding? Do you feel the baby is kicking? Are you maintaining a kick chart? Do you know your blood group? Do you feel your tummy is more distended than it should be? Did you have any infection during pregnancy? How many children did you have? What type of delivery (2 normal and 1 CS)? Were they big babies? Complications? How is your general health? Ever been diagnosed with fibroids or any uterine problems? Family history of malpresentations? SADMA? General appearance Vital signs Chest and Lungs Abdomen: broad transverse uterus with a firm ballot able round head in one iliac fossa and a softer mass in the other,). (FH does not correspond to gestational, uterus is ovoid, fundus is empty and head lies in one of the flanks, no tenderness, FHT normal) FH, FHR ( (140BPM IN THIS CASE)- to rule out fetal compromise If fundal height corresponds with age (to rule out polyhydramnios – large for date). Pelvic: Inspection and Speculum: discharge, blood, cervical os, NO PV Your baby has a transverse lie which is different from the normal or expected position during term. It is uncommon. It occurs in 1 in 300?
There are several reasons for that: Placenta previa (placenta lying in the way of the baby and prevents the baby from turning to normal position). We will need to do an ultrasound to rule out this condition and – imp Small pelvis, but it your case it is least likely because of previous pregnancy and delivery. Polyhydramnios (or increased amniotic fluid around the baby) which is also another cause of this abnormal position. The commonest reason is a relatively large and lax uterus after previous pregnancies. This cause is most likely in your case. For now, I will organize an ultrasound and CTG for you and arrange for an obstetric assessment. There are two options to manage your pregnancy. Whichever you choose, you will need to stay here until delivery: Do we have a cesarean section unit in this hospital? If not, then transfer to tertiary hospital because labor may commence soon. Why do I have to this stay in this hospital? The reason for that is if labor starts and the baby has transverse lie, it can quickly progress to obstructed labor which can lead to uterine rupture. Another risk is cord prolapse (cord can slip into vagina) after membranes rupture and it is a life-threatening condition for the baby. Let me reassure you that you and your baby will be closely monitored by the specialist. I will call the ambulance for transfer. We are quite far from a hospital with facilities and you are at term and you have options: Firstly, I would like to admit you. You need obstetric assessment and when placenta previa is excluded an obstetrician can try to rotate the baby to normal position. We call this external cephalic version. If it is successful and your cervix is favorable, OB will rupture the membrane and you will go to normal vaginal delivery. External cephalic version is quite a safe procedure. However, approximately 0.5% requires immediate cesarean section due to fetal distress or vaginal bleeding (abruption). 2nd option is of elective cesarean delivery. Regardless of your decision, we are here to help you Case 37
28 year old primigravida is 18 weeks pregnant. Her 18 weeks ultrasound showed Twin Pregnancy. The ultrasound showed 2 separate placenta and 2 separate amniotic sac, Task: tell the patient the diagnosis Advice on management and risks during pregnancy You may need to take a Brief history and a brief examination of the patient Congratulations! How is pregnancy going so far? How is the pregnancy so far? Any abdominal pain? Any vaginal bleeding or discharge? How is the baby kicking? Must feel more because its 20 weeks Any nausea vomiting? (morning sickness is exaggerated in twin pregnancy) Any urinary symptoms? (Polyuria) Any headache? Visual blurring Any leg swelling What is your blood group and Rh type if you know it? Did you take folic acid in early pregnancy? (5mg folic acid should be given, Iron throughout the pregnancy) Any past medical or surgical history? Is there any family history of twins? Any history of using fertility drugs or IVF?
Do you smoke? Do you drink alcohol? Any medication or allergies? PE: GA VS: BP Height and weight FH, FHR, leg examination for edema, Urine dipstick test
Speak to the mother: lets discuss the result of the ultrasound. The ultrasound result says that you are pregnant with twins. As I discussed before your ultrasound showed that you have a twin. Twins are of two kinds, one which comes from one egg (monozygotic) and the other from two eggs( dizygotic). your twins are dizygotic who have separate placenta (after birth) and separate sacs. Twins run in families or certain racial groups or might be due to use of fertility medications. A twin pregnancy usually is a slightly high risk than other pregnancies and the risks can include: Maternal Complications: Exaggeration of the signs and symptoms of pregnancy more nausea, backaches, gastric upset more likely to develop anamemia, varicose veins Preeclampsia Gestational diabetes Malpresentations Premature labour Antepartum hemorrhage Postpartum haemorrhage Cord prolapse And increase incidence of CS Fetal Complication Premature labour IUGR Twin to twin transfusion (Monoamniotic monochorionic) Please don’t worry, It is not necessary that your pregnancy would be complicated by this. I just need to inform you what are the possible risks. Management: I will refer you to high risk clinic. specialist there will follow you up. You need more frequent visits. You need a very good nutrition, rest and iron supplementation during the pregnancy you need frequent antenatal visits every 2 weeks until 28 weeks and weekly after. I can give you some contact of support groups for twin pregnancies. You need to have multiple ultrasound scans starting from 28 weeks and every 2-3 weeks from 28 weeks Monitor the baby’s well being by CTG by 34 weeks twice a week Mode of delivery will depend on: Presentation of the first baby and the general health of the mother. If the first baby is cephalic, vaginal delivery is possible In 45% of the twins they cephalic-cephalic In 25% - cephalic breech In 70% of cases 1st baby is cephalic If 1st baby breech – CS
Active management of 1st stage of labor – at risk of postpartum hemorrhage (due to over distention of uterus – which will cause atony) Case 38 30 year old female 26 week of gestation present to your GP clinic because of shortness of breath. She was travelling outside Australia for the last 3 months, no AN care until now. On examination, size of fetus is 30 weeks. Task: History Manage the case. Is it your first pregnancy? how was it confirmed?( home pregnancy test) have u been seen in AN care?( no) any Investigation and blood test? ( no) what was your LMP? ( don’t remember, periods were irregular) Do you have any symptoms like N, V and fever, bleeding discharge, tummy pain and any infection, SOB ( positive), palpitation? While abroad, were u careful with the food? Did u take the raw food? any chance of cats, dogs exposure? any PMH, DM and high BP? any diagnosis with uterine fibroid? any family history of multiple pregnancy, DM and birth defects SADMA blood group pap smear any co swelling of legs, blurring of vision and Headache? Differential diagnosis: Polyhydramios (DM, fetal malformation, esopheageal atresia, renal problem,, TORCH infection, chorioangioma of placenta) wrong date multiple pregnancy gestational diabetes Macrosomia Fibroid I've found everything well except for the size of the uterus which is a bit bigger than expected for this stage. According to your presentation of SOB it most likely looks like you are having a condition called poly hydramnios which means more fluid surrounding the baby second one is due to irregular cycle, GA might be more that we calculated. Third cause can be multiple pregnancy.
We will also check your blood sugar level. As high BSL can be another cause. In addition to these, you need all AN blood test; FBE, Urine M&C, Rubella, Hep B serology, blood group, Rh, USG, FBS, TORCH. I will refer you to the hospital where you will be seen by specialist, USG and CTG will be done to find out the cause of your big tummy and to see how the baby is doing. It's better to get all the test done on the hospital right now because polyhydramios is associated with the risk of PROM leading to premature labour, malpresentation of baby, difficulty in delivery, premature separation of placenta and bleeding, PIH and at risk of cord prolapse and PPH or heavy bleeding after delivery Treatment of polyhydramnios. check AFI(Amniotic fluid index) by USG, if >25 cm it is polyhydramnios if it is mild, give patient some sedation at night. moderate to severe, depends on gestational age, if it is <35 weeks, USG guided amino reduction is done. if >35 weeks, induce labour by ARM.
indomethacin for moderate to severe to reduce foetal urine production and amniotic fluid production. Case 39
Your next patient in your GP practice is a 28-year-old primi who works as a nurse in the Renal transplant unit. You have looked after her pregnancy so far, and all appeared normal up to her last visit 4 weeks ago. When she was 30 weeks AOG she had a SFH of 28cm. Today her SFH is 29 cm. TASK: Further relevant history Relevant Physical examination findings and investigation Diagnosis and subsequent management plan. ➢ Causes for small for date Oligohydramnios—liquor volume usually <500 mL ✓ Foetal abnormality→ kidney problem ✓ Placental Abnormality→ Preeclampsia ✓ Infections- TORCH ✓ Smoking ✓ Maternal conditions- SLE Small baby Intra-uterine growth restriction Wrong dates Ruptured membranes History: Pregnancy Qs→ ANC, 18 week scan (baby, placenta) Blood tests, Glucose challenge test (sweet drink test), Blood Group? Baby kicking? Kick chart? Tummy pain? Discharge and bleeding from down below? Fever? Infections? Polyuria/polydipsia Swelling of limbs? Headache? BP? (preeclampsia) Diet during pregnancy? Weight gain? Appetite? Mother general Health→ kidney problem, lupus/arthritis, any clotting problem (thrombus). Contact with dogs or cats, eat raw meat Smoking, Alcohol Menstrual History→ LMP Previous pregnancies→ abortion, Examination: General appearance: no edema Vital signs-BP : 128/80 mmhg. Chest and Heart : normal Obstetric examination: Fundal height :29 cm Presentation: cephalic Head 3 finger breadths above the pelvic brim FHR: 144 beats/min regular Tests: no proteinuria. CMV Antibodies had been tested prior to pregnancy because of her work in the renal unit ( IgG antibodies were positive).Has not been screened for toxoplasma antibodies. Explanation: From History and exam, Height of womb is less than as it should be normally at this week of gestation. It could be due to decreased fluid around the baby or small size of baby or both, wrong calculations of dates which is not in your case or any other medical conditions. Refer to specialist→ ➢ Need to confirm the cause by USG→ to check size of baby, amount of fluid around the baby, if there is any abnormality in baby(though unlikely as previous scan of baby was normal) and placenta. Probably need to be repeated every 2 weeks to assess the baby’s condition frequently. Also assess, baby's breathing and movement (Biophysical profile) ➢ CTG→ two electrodes on tummy to find the baby’s heart beating and it will also be repeated frequently ➢ Doppler USG→ to assess the amount of blood flowing from you to baby Further investigations: Serum urea, uric acid, creatinine (renal compromise) Measurement of lupus anticoagulant and anticardiolipin antibody . Antibodies for toxoplasma MANAGEMENT: High risk pregnancy clinic, MDT→ specialist referral now, and frequently visit, regular assessment Advise to maintain baby kick count Mode of delivery→ usually depends on how the pregnancy progress ,the investigation results and specialist advise. Red flags and support Case 40
A 26 year-old female came to your GP clinic because she has missed her period for 2 weeks. She has IUCD (copper T) inserted last year. Task: take history, PE, Investigation, Management. History: I understand you are here to see me because you are concerned about your period. When was your LMP? regular? How long is the cycle? How long does it lasts? Any excessive bleeding or pain during cycle? When was your last period? How’s you cycle like? Is that any chance you are pregnant? Any early signs of pregnancy like N/V, breast tenderness? Any pregnancy test done? Where and when IUCD inserted? Are there any problems at time of insertion or after insertion? How’s your period after IUCD insertion? Any heavy bleeding? Are you able to feel the strings? Pregnancy questions: Nausea, vomiting, breast tenderness . Abdominal pain, vaginal discharge Pregnancy test done? Past pregnancy? Stable relationship? STI? PAP, Blood group Any pelvic surgeries? Medication, SAD. If the pregnancy test is positive would this be a planned pregnancy? How would you feel about it? Physical examination
General appearance Vitals Abdomen: tenderness, esp. iliac fossa area (r/o PID or ectopic) Pelvic exam: Inspection Speculum : os,(string located),bleeding, discharge bimanual: size of uterus, adnexal tenderness. CMT. Urine pregnancy test (positive) and urine dipstick . Ix: USG( IUCD position, size of uterus, fetal sac) Management with the string visible: The urine pregnancy test shows you are pregnant. You have IUCD in your womb and we can locate the string which means its in place. Unfortunately every contraceptive method has a failure rate. Effectiveness of IUCD is greater than 95% but there’s still a chance for being ineffective. You don’t need to make a decision now. You can go home and discuss it with your partner. I will organize a pelvic ultrasound to identify exact position of device and pregnancy as well. If you decide to continue with pregnancy the device should be removed as it has certain risks with pregnancy like risk of miscarriage, preterm baby, infections, PROM Talk about the basic thing regarding antenatal check up and folic acid.
If she decides not to continue pregnancy then refer to specialist for termination and removal of the device then consider other contraceptives. Case 2: No thread Either uterus expelled the device or string is lost. Organize USG. If device is still inside with string – attempt of removal can be done by specialist . If device is there but no string-impossible to remove without harming pregnancy. It will get expelled along with placenta if the pregnancy goes well. Does not want to continue pregnancy- specialist referral for termination, device removal and other contraception. Case 41
ED setting. A 26 years old female at 20 weeks of gestation presented with SOB, wheeze and fever 38 degrees. She has history of asthma. Task: take history, examination finding, diagnosis and management. History: When did you start having short of breath? Is it getting worse? I know that you have asthma, how controlled is your asthma? How often do you get the attack? Do you use any regular medication for the asthma? Any previous hospital admission due to asthma? Do you have cough? Any phlegm? Any blood in the sputum? Did you have any contact with someone who had chest infection / TB ? How is your pregnancy so far? Do you feel the baby kicking? Do you have regular antenatal care? When was the last US done? Any abnormality in USG? How is your general health? DM, hypertension? Do you or your partner smoke? SADMA O/E: GA: rash, cyanosis, work of breathing increase or not VS: T, BP, PR, RR, SpO2 ENT - Tonsil Lymph node in the neck Chest (Positive findings): - Bilateral wheeze both on inspiration and expiration - Decreased air entry in the right lower lobe with crackles - Dullness on percussion Explanation:
From History and examination you are likely to have an asthma attack precipitated by chest infection (pneumonia) I’d like to admit you to the hospital and refer to obstetrician and physician. With their consult I will arrange for further Ix: FBE; ESR; CRP; Blood and sputum culture and sensitivity;; PEFR for asthma and Chest Xray with abdominal shield.
After taking the blood we will start antibiotic together with the management of asthma, such as Ventolin, Steroid, and O2. Case 42
A 10-week gestational age presented to your general practice complaining of nausea, vomiting and abdominal pain (right upper quadrant). Tasks: History Physical examination Investigation Management DDx:
Hyperemesis gravidarum Appendicitis Cystitis/UTI Cholecystitis Ectopic pregnancy Diverticular disease History: Hemodynamical stability Pain Qs, vomiting Qs. Pregnancy • Is it your first pregnancy? (If second one, ask similar episodes in the first pregnancy) • How’s your pregnancy so far? • How did you confirm your pregnancy? • Prenatal check-up • Vaginal discharge or bleeding • Blood group Waterworks • Have you been going to the toilet more frequently? • Any burning sensation? • Any change in the colour or smell of urine? • Have you had similar problem before? (recurrent UTI) Any other medical condition, past surgical history SADMA ,Trauma. O/E: GA: any signs of dehydration. Vitals: BP ( normal),Temperature( 37.6) Abdominal examination: soft, mild tender on lower abdomen but no peritoneal signs. Renal angle tenderness negative. Pelvic examination: no bleeding, discharge, Speculum examination: os closed Bimanual exam: uterus enlarged, free adnexa non tender. Urine dipstick : nitrates ++++ leucocytes +++ no blood no protein or sugar. Explanation: From History & urine dipstick, the most likely diagnosis urinary tract infection most likely cystitis. I will need to send your urine for culture and sensitivity and will start you on antibiotics( amoxicillin or cephalexin) I will review you in 3 days time but just in case you cannot tolerate food or drinks, fever chills and pain the please visit ED as soon as possible. Case 43
A 25-year-old Susan came for follow up in your GP clinic as she had still birth at 24 weeks gestation after breakage of water bag spontaneously.
Task: take history, ask for investigation result, manage the case. Second trimester miscarriage:
- Uterus abnormality - Cervical incompetence (Painless water leaking spontaneously) - Fetal abnormality Hx: Susan, from the notes I know that you lost your baby. I’m really sorry to hear about that. It must be a very difficult experience for you. All that you feel now is quite understandable.
Is it OK with you if I ask you a few Qs, so that we may find out the cause and help you for the next pregnancy or for the future.
How did it happen? What did you do when the membrane rupture? Did they do any investigation at the hospital? Did they find a cause? How was your antenatal care during pregnancy? Any previous obstetric or gynecology problem? Any cone biopsy done in the cervix? How was your baby delivered? Did you have any trauma to the abdomen? Any sexual activity prior to the membrane rupture? Bleeding or spotting during pregnancy? Infection(Did you feel feverish) STD/PID( Any abnormal vaginal discharge? How was your general health? Any History of DM, Have you or your partner ever have STD? How was your general health? Any History of DM, heart problem, SLE? Any Family of still birth and premature labor? SAD Ask for TORCH: Rubella (were you exposed to anyone with rash during the pregnancy)? Toxoplasma ( do you have pets like cat)? Was autopsy done to your baby? Blood group
O/E: all normal. Uterus has involuted. Investigations: FBE; BSL; TFT; LFT; U & E; Creatinine; Urine analysis TORCH screening STD screening Thrombophilia screening SLE Chromosomal study for both parents, karyotyping US abdomen pelvis, uterus If all normal could be cervical incompetence Explanation:
Susan, I know this is very difficult for you. At this stage, from the History & PE, we cannot be sure why your membrane rupture early. The most common cause is inherent weakness of cervix that allows bulging & rupture of the membrane. Also some chronic diseases can cause this but from your History it doesn’t seem like that. So, I’d like to refer you to O&G specialist who will perform further Ix to detect the cause They will do some blood test to rule out systemic diseases and infections and US of womb to see any abnormality in the womb. If all investigations comes out normal then most likely it is cervical incompetence. For the next pregnancy you’ll need regular antenatal care, folic acid. Gynecologist will put a suture at 14 weeks and take out before delivery. There are a lot of support groups available for females and their families that have similar experience (still birth and neonatal death society). If you would like to talk to them, I can give you the reading material and contact details
I’ll follow you up. I want to assure you that I’m available for any support you need. If you want, we can have a family meeting and explain to your partner. Case 44
28 years old Mary diagnosed of having bipolar disorder, taking lithium has come to see you because she has missed her period. Take history Counsel the patient. Good to see you, appreciate she is here to discuss. Menstrual questions: LMP, regularity, duration, any excessive pain? Pregnancy symptoms now? Home pregnancy test?
Bipolar questions: assessment of the severity of the patient’s bipolar disorder (eg frequency and number of episodes), treatment compliance, regular follow up with specialist, regular lithium blood level checked?
basic social factors that could affect the patient’s ability to care for her baby (eg housing, finances, lifestyle) social network; and capacity to care for her baby. 5PS SADMA. Management of bipolar during pregnancy and postpartum is very challenging.
The treating clinicians have to take into account various factors like: Current mental state History of the patient Past history of relapse while off medication Response to medication Time of pregnancy at which patient presents to the clinician, etc.
The choice of drug should depend on the balance between safety and efficacy profile. Whenever patient is on psychotropic medication, close and intensive monitoring should be done. Safety and Efficacy of various drugs
Among the various mood stabilizers, use of lithium during the second and third trimester appears to be safe. Valproate during first trimester is associated with major malformation and long-term sequalae in the form of developmental delay, lower intelligence quotient, and higher risk of development of autism spectrum disorder. Carbamazepine in first trimester is associated with higher risk of major congenital malformation and its use in first trimester is contraindicated. Lamotrigine (LTG) appears to be more favourable than other anti-epileptics. During lactation, use of valproate and LTG is reported to be safe. Three pharmacological strategies can be considered, depending on the severity of the patient’s bipolar disorder and her psychosocial circumstances.
The first strategy is a medication-free pregnancy and postpartum period, if asymptomatic. This option should be reserved for patients who have had few episodes of the disorder, long periods of mood stability (at least one year), low risk of self-harm, good support network, and are able to identify early warning signs, along with a strategy to seek early help.
Women will need to be slowly (over two to six weeks) discontinued from their mood stabiliser, at a time of minimal stress and time of year when relapse is unlikely, prior to conception. The second strategy is partial prophylaxis. The aim is to have a medication-free first trimester after discontinuation of mood stabilisers prior to conception.
A mood stabiliser, generally lithium, is reintroduced after organogenesis is completed and an ultrasound is unable to detect any cardiac defect.
Some women may prefer to be medication-free throughout their pregnancy, in which case, lithium prophylaxis can be initiated immediately following delivery, starting at the pre- pregnancy effective dose.
The most commonly associated complication with lithium is Ebstein's anomaly, a congenital cardiovascular defect.
Lithium use in pregnancy has been associated with a number of negative effects in the newborn including depressed neurological status, hypotonia, respiratory distress syndrome, cyanosis, lethargy, and weak suck reflexes. The third strategy is full prophylaxis With a mood stabiliser maintained throughout pregnancy.
The patient needs to be aware of the risks to the developing foetus, consent to taking a mood stabiliser, have an ultrasound and a clear plan as to what will happen if there is a significant foetal abnormality, and not breastfeed if she is taking lithium (with careful monitoring).
A second-generation antipsychotic or sodium valproate (provided she has adequate contraception) could be used as an alternative while she breastfeeds, but lithium should be reinstated following weaning. Has to been seen in High risk pregnancy clinic, MDT approach psychiatrist, psychologist for CBT, obstetrician and GP. Psychiatrist will review and monitoring patient’s clinical state, medication dose and serum levels for lithium. Thyroid function test has to be done because lithium has shown to damage thyroid gland resulting hypothyroidism. Management over the perinatal period requires a careful risk–benefit analysis of treatment options, regular review and monitoring of symptoms and medication doses, training in psychosocial risk-reduction strategies, and planning for the postpartum period. A team approach ( GP, obstetric and psychiatry teams) is encouraged, with an emphasis on rapid access to treatment should a relapse occur. CASE 45
A 26 year-old lady 40 weeks pregnant, she’s worried because last week her doctor told her that her baby’s head was 5 cm above the pelvic brim. Your task is to Take history, ask examiner about examination finding, manage the case. High mobile head at term CAUSES:
PASSAGE: 1) Cephalopelvic disproportion 2)Fibroid/ ovarian tumor 3)Placenta previa 4)Poly hydramnios
PASSENGERS 1) Malposition 2) Fetal macrosomia 3) short umbilical cord Pregnancy Questions How is your pregnancy going so far? Have you attend all antenatal check ups? Have you done your 18 weeks ultrasound (to see location of placenta & baby)any repeated scan done? What’s your blood group Is your baby kicking well, do you feel your baby’s movement Any vaginal bleeding Any gush of water Any tightening of your tummy Have you done your 28 weeks sweet test? Any leg swelling, headache, blurring of vision( preeclampsia questions) Is this your first pregnancy? If not-can you please tell me the mode of delivery? Any complication? Weight of baby? Any significant medical or surgical condition like high BP, any TORCH infection, any fibroid, any pelvic pathology, any cervical suture down below. SADMA, Pap smear --- 1.5 years ago, normal
Anyone in your family having diabetes, HTN, big babies or difficult delivery? (CPD) What is your height-----150 cm Can you tell your partner’s height ….192 cm Physical examination
General appearance Vitals Chest and heart Abdomen: FH , FHR, Lie and Presentation Head engagement: 5/5 Pelvic examination: Inspection- bleeding, discharge, rashes and vesicle. Per speculum: cervical os ,bleeding, show, any cervical suture ? bimanual examination: for bishop scoring.
Maria, As you are in 40 weeks of pregnancy and Your baby’s head can still be felt in your tummy, there are be certain causes we need to rule out. Explain her the causes. I would like to refer you to the obstetrician who will do the pelvic examination to clinically assess your pelvis for the suitable birth of your child. If needed they might consider doing scans for pelvimetry. Furthermore USG will be arranged to locate the placenta, size of baby, fluid surrounding the baby, and any other uterine abnormalities. CTG will be done to assess the well being of the baby. If everything comes out normal, It could just be a normal phenomenon where the head may go down within the next few days. You will then have the signs of labor. I would refer you to the obstetrician and also would like to advise you to maintain daily kick chart for baby’s movement.
Contracted pelvis
AP diameter < 10 cm ( 12 cm) Transverse diameter < 12 cm ( 13 cm) Diagonal conjugate < 11.5 ( 12 cm)
If contracted pelvis suspected or any maternal and fetal distress they will perform Caesarean section. Case 46
You are a HMO in O&G department. A 25 year old primi gravida has been admitted in labour ward 4 hours ago. At that time vaginal examination showed cervix was 4 cm dilated. Midwife examined her 4 hours later and cervix is 5 cm dilated. Tasks History Physical examination Management There are 4 stages of labour First stage: Onset of true labour pain to full dilatation of cervix. Normally takes 8-12 hours in primigravida and 6-8 hours in multigravida. It has 3 phases: Latent phase: 1. onset of labour – 3 cm dilatation 2. Nulligravida- 9 hrs 3. Multigravida- 5-6 hours 4. Effacement- 0-40% 5. Contactions mild. Active phase: takes 1.2cm/ hour in nulliparous and 1.5 cm in multiparous. 1. 4-7 cm dilation 2. Effacement: 40-50% 3. Contraction-(2-3 min) lasting 45-60 sec.
Transition phase: take 1 hour in nulliparous and 30 minutes in multiparous 1. 8-10 cm 2. Effacement: 80-100% 3. Contraction- less than 1 minute. Second stage of labour: lasts 1 hour in nulliparous and 30 minutes multiparous 1. Full dilatation of cervix to the birth of baby 2. Contraction: 2-3 minutes lasting 30-60 sec.
Third stage of labour: up to 30 minutes. After birth of baby to the expulsion of the placenta and membrane.
Fourth stage of labour: 1-4 hours after birth. Return of maternal physiology. When is labour classified as prolonged in the different stages of labour
Prolonged latent phase of labour: when true labour lasts for more than about 8 hours without entering into the active first stage.
Prolonged active phase of labour: when true labour takes more than about 12 hours without entering into the second stage.
Prolonged second stage of labour: Multigravida mother: when it lasts for more than 1 hour. Primigravida mother: when it lasts for more than 2 hours.
Although labour can be classed as ‘prolonged’ at any stage, you should note that obstructed labour most commonly develops after the labour has entered into the second stage. Causes for Prolonged first stage and obstructive labour.
Passenger Head: Large fetal head (big for that pelvis) Hydrocephalus (brain surrounded by fluid, which makes the skull swell)
Presentation and position: Brow, face, shoulder Persistent malposition
Twin pregnancy: Locked twins (locked at the neck) Conjoined twins (fused together with some shared organs Passage Bony pelvis: Contracted (due to malnutrition) Deformed (due to trauma, polio)
Soft tissue: Tumour in the pelvis Viral infection in the uterus or abdomen Scars Hello, how long have you been in labour ward? How long have you been having this tummy pain (8 hours)? How often do they come ? How long do they last? (2 contraction in 10 mins lasting 90 seconds) Severity –pain killer? Have you noticed any water leakage or bleeding from down below?
Just a few questions regarding your pregnancy: Is this your first pregnancy? Did you have a regular antenatal checkups? Any problem with the blood tests? Mid pregnancy ultrasound? Any issues (no)? Sweet drink test? GBS swab ? Do you know your blood group?
May I know your height (170 cm) and your partners (190 cm) height ? Any medical surgical conditions I should be aware of? Ever been diagnosed with uterine problems or fibroid (no)
If multi : detailed history regarding delivery and baby weight. Examination: (imp to r/o obstructive labour)
General appearance: signs of dehydration Vitals: (tachycardia in obstructive labour) Abdomen: Fundal height palpate uterus and assess frequency and length of contractions (2 contraction in 10 mins lasting 90 seconds) lie and presentation, FHR How much fetal head is palpable per abdomen? (5 fingers palpable head above the pelvic brim. 0 fingers means the head is already in the pelvis) ➢ Pelvic: Inspection→ edema of the vulva (prolonged pushing)bleeding, fluid, discharge Per Vaginal examination: Bishops scoring Dilated? How much? Effacement? Membranes intact or not?(if rupture exclude cord prolapse) any meconium staining The position of the head: Any mal presentation Try to find the fontanel: Anterior Fontanel: diamond shape. Occipital bone: posterior fontanel . Stations: relation to Ischial spine -5 to +5. Molding and caput. If mild molding not concerned If severe molding think of obstructive labor. I know that you have been in labour for the past 8 hours ,unfortunately your last 4 hours are not very efficient You Are at active phase of 1st stage labour→ Cervix should dilate more rapidly→ Expected rate is 1cm per hour→ it is just 1cm in last 4 hours. The most likely cause for failure for cervix to dilate in your case is inefficient uterine contractions (not getting enough contraction to delivery the baby)→ we call it as prolonged 1st stage of labour. Mechanism of labour is influenced by ➢ Power: contraction of womb ➢ Passenger: Baby→ size ➢ Passage: birth canal(shape) Specialist will assess you and assess baby’s condition by placing a probe over your tummy (CTG)→ if normal → most likely might break the water bag→ ARM( artificial rupture of the membrane) ARM→ causes release of chemical substances like prostaglandins which will enhance progress of your labour and you may get sufficient contraction to deliver the baby Don’t be stressed→ baby’s condition will be continuously monitored by CTG Also we will monitor the progress of labour→ contraction assessment, vaginal examination Might also consider starting on oxytocin drip→ which help in contractions→ but decided by specialist At any stage CTG shows abnormality or there are signs of obstruction to progress of labour→ might consider C- sections Otherwise normal vaginal delivery is possible →if once contractions are efficient Organise pain relief Case 47
27 year primi gravida in labor for the 4 hrs. Cervix is 4 cm dilated and fetal head in occipital posterior position. She wants pain Management. Task: nurse wants you to talk to the patient about the Management. Hi, How are you feeling at the moment. I understood from the notes that you wanted pain relief. Describe your pain for me please? 1-10? Allergies to any medications?’ From your assessment we have found that the baby’s position is slightly different that the normal position. Normally baby’s back which we called occiput faces towards mother’s anterior (front) of pelvis and face is down but in your case your baby’s back is facing towards your posterior( back) of pelvis and face is up towards your tummy. In occiput posterior (when baby is facing the mother's abdomen) pressure from the baby's head is applied to the mother's sacrum (the tailbone). The result can be intense discomfort and pain during labour. 20% of all fetal in early labour is in this position and there is a good chance that the head will complete turn to occipito anterior position.
I know you are in pain. We have several methods of pain relief in labour. Let me discuss about it.
Natural methods: 1. Relaxation: Being relaxed helps the natural hormones that helps progress labour (oxytocin) and natural pain relief hormone( endorphins) to release effectively. 2. warm or cold pack/ bath: increases productions of endorphins reduces the pain of contraction and pressure on pelvis and muscle. 3. Massage: can reduce muscle tension. Non pharmalogical : TENS( transcutaneous electric nerve stimulation): It is a small portable battery operated device which is worn in the body. The box is attached by the wires to sticky pads that are stuck to the skin on your back. The machine has a dial that you can adjust to control the frequency and strength of small electrical pulses that are transmitted to the body. These pads stimulate body to release endorphins. Water injection: Sterile water in injected intra cutaneous to 4 different places in lower back. It cause bee like sting and provides few hours of pain relief. No evidence of side effects. Relaxed the muscular tension and helps release endorphins.
Pharmacological: Nitrous oxide gas: Breath a mix of Nitrous oxide and oxygen through mouth piece/mask. Gas is inhaled during contraction and helps tales off the pain. May feel nauseous but no significant after effects. Pethidine/ morphine: Strong painkillers given by injection. Takes 30 minutes to work. Crosses placenta and might make baby sleepy. Pethidine can cause breathing problems in baby if given close to delivery.
Epidural: an anesthetic drug is injected into small space in back near to spinal cord by specialist. It will alter the sensation from waist down. Benefits: takes away pain of contraction, effective for hours, can be increased in strength if emergency CS needed. Effects: can cause fall in BP- therefore iv drip will be given into your arm and continuous CTG will be done for baby. Loss of sensation to pass urine hence catheter will be inserted . Now its up to you to choose the method of pain relief. Regarding the management of labor ,like I said 20% of all fetal in early labor takes this position. The possible options for you are: There is a good chance that the head will completely turn to occipital anterior position. If head remains in the same position and there is slow progress of labor in 1st stage, they will do ARM and start IV oxytocin. If there is slow progress in 2nd stage, first they will try to rotate baby manually or with forceps / instrumental delivery with vacuum or forceps , you might need CS if any fetal or maternal compromise. But let me reassure you We will closely monitor you and your baby with contínuous CTG How to know if is occipito posterior? (Q from examiner) anterior fontanels can be palpate on vaginal examination maternal abdomen is flat below umbilicus Fetal limbs can be palpated anteriorly Back pain and prolonged labour Case 48
A 22 years female G2P1 came to GP clinic asking when she needs to go to hospital for delivery. She is 24 weeks pregnant and lives 80 km away from the hospital
Task: counsel her and answer her questions Congratulations! From the notes I understand that you are concerned about when you should go to the hospital for delivery. Before I address your concern, is it OK if I ask you some Qs: How is your pregnancy so far? Have you had antenatal check up? How was your US at 18 weeks? (baby & placenta) How is the baby’s kicking? Are you aware of your blood group? Have you had any abnormal vaginal bleeding or any discharge, any abdominal pain? Any leakage of fluid down below? How was your previous pregnancy, any complications like DM or HPT? Preterm or full term? Was it normal vaginal delivery? Any complication after delivery Do you have any chronic medical condition, BP, DM, pelvic problem? Are you on any medication at the moment?
Whom do you live with? Do you have support from your partner? How long does it take you to go to the nearest hospital by car? Can anyone drive you to the hospital in case of emergency? Do you have any friends, relatives who live near the hospital where you could relocate a few weeks before the due date?
SAD Recent Pap smear. Explanation: I appreciate you coming to discuss the early warning signs when you need to go to hospital: - If you have any vaginal bleeding ,tummy pain, water leaking from down below, - Any marked reduction in fetal movement (reduce kicking) - Signs of pre-eclampsia (visual disturbance, epigastric pain, severe headache) - Any trauma to your tummy Near due date if you feel tummy pain which comes and goes in regular interval please go to the hospital as soon as possible. If there is no warning signs before 38 weeks, it would be advisable for you to relocate close to the hospital if you are able to do so. With regards to your delivery, the exact date and duration of labor is too early to predict as several factors affect the time of delivery o Size of the baby o Size of the pelvis o Presentation o Strength of the contraction Please be in regular follow up in antenatal clinic where we can monitor your and baby closely. I’ll give you some pamphlets to read. Don’t hesitate to contact me if you need any help. Good luck for the rest of the pregnancy Case 49
30 years old lady in her early pregnancy. She’s Rh (-) Task: explanation management History: (Congratulations) How did you confirm the blood group? Where did you do this test? Antenatal history according to the weeks Any trauma during the pregnancy? Any bleeding? Any invasive procedure like amniocentesis and chorionic villus biopsy? Is this the first pregnancy? Any Past history of miscarriage or termination of pregnancy Any significant medical problem? Any blood transfusion in the past? Any drug addiction ? Explanation: our blood group is a combination of the ABO system and the Rh system: Your blood group is Rh (-): If your husband is Rh (-), the baby is Rh (-) no problem If your husband is Rh (+), the baby is Rh (-) no problem If your husband is Rh (+), the baby is Rh (+) first baby is usually not affected. The baby’s blood will go to your blood and form antibody For the first pregnancy it will not be a problem. However, in the second pregnancy, the antibody will go to the baby’s blood form antigen-antibody reaction that will destroy the baby’s RBC called hemolytic disease During the pregnancy, if you’re not sensitized before, we give the anti-D injection (ready made antibody) to block or neutralize the entering fetus blood. Anti-D is given at 28 weeks of pregnancy, 34 weeks and within 72 hours of delivery. Give Anti –D in potential sensitizing events like ectopic pregnancy, termination of pregnancy, miscarriage, ultrasound guided procedures such as: - chorionic villus sampling – amniocentesis ,abdominal trauma that causes uterine activity and or abdominal pain, antepartum haemorrhage, external cephalic version, birth.
Kleihauer count (to check how much fetus blood entered mother’s blood) to calculate the dose of anti D (how much anti D should be given). Signs of hemolytic disease of the newborn include a positive direct Coombs test (The direct Coombs test is used to detect the antibodies or complement proteins that are bound to the surface of baby’s red blood cells) elevated cord bilirubin, and hemolytic anemia Hemolysis leads to elevated bilirubin levels. After delivery the symptoms of jaundice (yellowish skin and yellow discoloration of the whites of the eyes) increase within 24 hours after birth. Like other severe neonatal jaundice, there is the possibility of acute or chronic kernicterus, however the risk of kernicterus is higher because of the rapid destruction of blood cells. Untreated profound anemia can cause high- output heart failure, with pallor, enlarged liver and/or spleen, generalized swelling, and respiratory distress. After birth, treatment depends on the severity of the condition, but could include temperature stabilization and monitoring, phototherapy, transfusion with compatible packed red blood, exchange transfusion with a blood type compatible with both the infant and the mother, sodium bicarbonate for correction of acidosis and/or assisted ventilation. CASE SCENARIO 50
24 years old Rachael presents to your GP clinic. She is 35 weeks pregnant and requests you to induce labour in her as her husband is leaving overseas on a business trip. TASKS 1 Relevant history. 2 Examination findings from examiner. 3 Respond to the patients request. ELECTIVE IOL
HISTORY. When husband leaves. Any other support for her. Antenatal history. Any headache, swelling, blurring of vision. Any medical or surgical issues, PAP smear. Baby kicking. ELECTIVE IOL EXAMINATION G/A V/S. Abd- Fundal height Foetal heart. Lie, presentation. Pelvic exmn: Insp of vulva and vagina. Other systems. ELECTIVE IOL COUNSELLING. With her consent, is it possible to discuss with the husband so that he could delay his trip. Induction of labour needs to be considered when the risk- benefit analysis indicates that delivering the baby is a safer option for the baby, the mother or both rather than continuing pregnancy and when there are no indications for C-section or C/I for vaginal delivery. ELECTIVE IOL
INDICATIONS IN MOTHER. 1 Post date pregnancy. 2 Medical conditions in mother- HT, DM, PET. 3 PROM. 4 Multiple pregnancy.
INDICATIONS IN BABY. 1 IUGR. 2 Chorio amnionitis. 3 IUD. ELECTIVE IOL CONTRAINDICATIONS. 1 Big baby. 2 Small pelvis. 3 Mal presentations. 4 Previous uterine surgeries. 5 Classical C-section. 6 Prolonged labour. 7 Placenta praevia. ELECTIVE IOL RISKS ASSOCIATED WITH IOL Unsuccessful induction- might result in C- section. Cord prolapse. Prematurity in baby- leads to respiratory problems, difficulty in maintaining body temperature, sugar levels, feeding difficulties. Medications for IOL lead to non rhythmic uterine contractions out of proportion to that in comparison to normal labour which might lead to damage to uterus/ pelvic floor. ELECTIVE IOL
The more the baby is in the womb, better the outcomes of delivery. So induction is not the most best or most appropriate for the baby. Inducing labour involves making your body or baby do something that it is not yet ready to do. IOL is not a simple or quick procedure. Involves many complicated steps. IOL IS ABSOLUTELY CONTRAINDICATED FOR SOCIAL REASONS. Refer patient to specialist for second opinion if resistance. Reading materials. CASE SCENARIO- 51
Your next patient at your GP is Jenny, a 28 yr old lady, who had a previous C-section around 3yrs back. She is 8 weeks pregnant now and wants to discuss with you the possibilities of a vaginal birth this time. TASKS 1 Further focused history. 2 Ask examiner for previous medical/surgical notes of the previous C-section. 3 Discuss possibility of vaginal birth this time with patient. VBAC
HISTORY. Planned pregnancy/not. How pregnancy was confirmed. 1st antenatal visit/not. Blood group. Periods- to confirm EDC. Previous pregnancy- any complications like DM, PET, APH. Cause of C-section. Where, type, emergency/elective. Baby’s weight. Complications after C-section- infection, bleeding. Any previous uterine surgeries other than C-section. Other M/S conditions, allergy, SAD, support, other baby. VBAC
PREVIOUS MEDICAL/SURGICAL NOTES. Antenatal problems. Reason of C-section. Emergency/elective. Type. CPD. Complications after C-section. Baby’s weight. Other M/S problems. VBAC
COUNSELLING VBAC is an option for every woman who had previous C-section, provided the indication for previous C-section does not recur. In majority, successful vaginal birth is possible. Success rate- 55- 85%. Consider eligibility of the patient- any C/I from previous C- section. If any complications during pregnancy, C- section needs to be considered. If any complications during labor, C-section needs to be considered. VBAC
Arrange confirmatory pregnancy test. Antenatal blood checks. Advise about future antenatal visits and tests. Start on folic acid. Refer to high risk pregnancy clinic. Arrange an appointment with specialist at 26 weeks for discussion about possible mode of delivery and also at 36 weeks for final decision. If vaginal birth, it has to be conducted at tertiary hospital under specialist supervision and with continuous CTG monitoring. VBAC
RISKS OF VBAC. 1 In 1/5th it might proceed to C-section. 2 Rarely , uterine rupture. 3 More chance of uterine infection after birth.
ADVANTAGES OF VBAC. Avoids risks of C-section like anaesthetic complications, bleeding, infection, injury to other organs. Also pain after delivery will be less and a shorter stay at hospital. successful VBAC, you are more likely to have another one. Repeated C-sections could lead to placenta accreta, where placenta grows into the scar of your womb. VBAC
CONTRAINDICATIONS OF VBAC. 1 Previous classical C-section. 2 Previous uterine surgeries. 3 Maternal/fetal reason for C-section during current pregnancy. INTRAPARTUM MANAGEMENT.
I/V line- blood for group and hold, Hb Monitor vitals. Continuous CTG. Labour- aim to deliver within 12 hours of onset of labour. Oxytocin should be used with caution. 2nd stage should not exceed 2 hours. If prolonged instrumental/C-section. Post partum- exploration of scar not required unless there is PPH not responding to medications VBAC
Home VBAC- not advised unless fully supported by specialist. Case 52
Your next patient in a general practice setting is a 25 year old 20 weeks pregnant Mrs. Jones who would like to discuss the possibility of having a Caesarean section instead of natural birth. Task: Relevant history, Risk and benefits of C- section, further management Ask why she would like to do C-section( she was reading women’s magazine which mentioned C- section is relatively less painful than Normal vaginal delivery) Start with current pregnancy state?1st/ multi? Any issues? If multi ask about previous deliveries? Why CS in previous pregnancy 5 Ps SADMA
Caesarean section is an operation where the baby is removed by abdominal (tummy) surgery either by an incision (cut) of the stretched lower uterine segment(lower part of womb) or following the “classical” approach by vertical incision through the myometrium (muscle layer) MEDICAL INDICATIONS:
Failure of labour to progress (dystocia) Cephalopelvic disproportion Prolapsed umbilical cord Malpresentation or malposition (breech, face, transvers, etc.) Antepartum hemorrhage (abruption placentae or placenta praevia) Hypertensive disease in pregnancy Diabetes melliltus Fetal conditions like distress, isoimmunisation, very low birth weight Older primigravida Failed induction of labour Repeat C/S ADVANTAGES CS: Less pain during labour Less risk of damage to the pelvic floor and consequences like urinary and faecal incontinence(reduced from 10 to 5%) least risk for the baby( decreased RDS risk ) Less operative and anaesthetic complications
DISADVANTAGES CS: Risk of an anaesthetic Risk of bleeding and perinatal death Prolonged healing time of the abdominal wound / hernia Possible DVT secondary to immobilization Higher incidence of failure of lactation Increased risk for C/S in next pregnancy, incl. rupture of uterine segment Uterine rupture endometritis Management during delivery- Lots of reassurance and positive feedback
Start folic acid 0.5mg daily Take into consideration her preferred mode of delivery Specialist referral to check for pelvimetry and appropriate scans for r/o cephalopelvic disproportion. Once she gets preg manage preg as a high risk with regular monitoring with MDT. Delivery in tertiary care hospital Once in labour, considering no contraindications, a trial of vaginal delivery given with backup ready for urgent CS with continuous CTG monitoring for the baby. Women should be advised that a planned VBAC should be conducted in a suitably staffed and equipped delivery suite, with continuous intrapartum care and monitoring and with available resources for urgent Caesarean section and advanced neonatal resuscitation should complications such as scar rupture COMPLICATION VBAC
Uterine rupture Perinatal death Maternal death Major maternal morbidity Hysterectomy Genitourinary injury Blood transfusion Major perinatal morbidity Fetal acidosis (cord pH <7) Give reading material regarding C- section and normal vaginal birth. Discuss with partner as well. Regular antenatal follow up. Red flags. Case 52
Your next patient is a 25-year-old primi who had a normal vaginal delivery 20 minutes ago in one of the country district hospital. You are an HMO on call. Pregnancy was normal. Labor went for 14 hours and now the midwife calls you because the patient has lost 1.5L of blood. She asks you to come and help her. BP 85/50-, pale, blood clotting, uterine lax, no lacerations Task Advise her on what to do until you arrive Complete the management when you reach the hospital Post partum bleeding
Types: Primary: blood loss per vagina of more than 500 ml in the first 24 hours after delivery TONE: Atonic uterus-Most common (insufficient contraction → shortening and kinking of the uterine blood vessels and prevent further blood loss) TISSUE: Retained placental fragments → prevent placental site retraction TRAUMA: Laceration of genital tract, Uterine Rupture / Uterine inversion THROMBIN: Bleeding disorder.
Secondary: bleeding of more than 500 ml after 24 hours and between 6 weeks. Retained products of conception (placenta) Birth trauma Uterine infections (Endometritis) PRIMARY PPH
Bleeding >500ml within 24 hours of delivery.
CAUSES Uterine atony. Lacerations of birth canal. RPOC. Coagulation disorders. Inversion/ rupture uterus. PRIMARY PPH
MANAGEMENT DRABCDE. Rub up uterine fundus. I/V oxytocin 10IU followed by 40IU infusion. If placenta has not been removed, gently remove by controlled cord traction If impossible, attempt manual removal/GA. If not responding, ergometrine 0.25-0.5mg I/M or I/V. Bimanual compression of uterus for 3 mts. Intramyometrial PGF2 alpha. Surgery- uterine tamponade uterine artery /IIA ligation. hysterectomy. History
Is she hemodynamically stable? What are the vitals (85/50, 130)? Can you please secure IV lines, take blood for grouping and cross matching and coagulation profile, and start IV fluids. Is she conscious (Yes)? Is she having SOB (yes)? Can you please give her oxygen? Is she on a urinary catheter? If not, can you please insert a catheter? (a full bladder can aggravate the problem). Additional measures such as keeping the woman warm and positioned flat are also important. What was the mode of delivery (instrumental delivery with forceps)? Was it a single baby or multiple? What is the weight of the baby and how is the condition? Any genital tear? Was episiotomy done? Please examine the vagina and if you see any bleeding point please put pressure on it. What is the position of uterus? Central. Is the uterus lax or contracted (lax)? Please massage the uterus. Any oxytocin given? No. Please Give intravenous or intramuscular ergometrine (0.25 mg) or intramuscular ergometrine and oxytocin (Syntometrine®) immediately. Have you checked the placenta? Is it complete? Do you think there are retained products? What is the colour of blood? Is the blood clotting? Is the patient bleeding from anywhere else (No)? Management
Inform senior. Massage uterine fundus Start – Oxytocin- 5 IU IV followed by 40 IU infusion Or Start syntometrin (Oxytocin (10 IU + Ergometrine) Ergometrine contraindication: heart disease and hypertension. Specialist will take you to the theater to examine the uterus under anesthesia to check for any retained placental fragments followed by general blunt curettage. If it doesn’t work, they will give you intrauterine (intramyometrial) prostaglandins to promote contraction. Uterine tamponade with Sengstaken tube. If unsuccessful, they will go for internal iliac artery ligation or uterine artery ligation. If all measures fail, the last resort would be hysterectomy. However, we will do our best to prevent to control the bleeding. Case 2- There is a 2 cm cord protruding outside the vagina, - that means- retained placenta. Management- DRABC, IV line, inform the OBG Rub the uterine fundus to contract the fundus Start her on 5 IU IV oxytocin- 10 IU Remove the placenta- by specialist A gentle cord traction tries to slowly remove the placenta. If it fails then, the specialist will do a manual removal of the placenta. After this the patient needs to be on IV oxytocin infusion. Bimanual Uterine Compression CASE SCENARIO 53
You are at your GP clinic, when 30 year old Jenny, presents to you, with increased bleeding per vagina. She had given birth to her second baby 10 days back. She had a normal delivery and the baby is healthy with a birth weight of 3.5 kg. TASKS 1 Relevant history. 2 Examination findings from examiner. 3 Investigations 4 Diagnosis and management . SECONDARY PPH
CAUSES Retained POC. Laceration of birth canal. Infection of the placental site. Coagulation disorders Idiopathic sub involution of uterus. SECONDARY PPH
Haemodynamically stable. Duration, severity, color, clots/tissues, offensive smell. Blood group. Tiredness/dizziness. Fever, tummy pain, offensive vaginal discharge. (endometritis) Any bleeding disorders.( coagulation disorders) SECONDARY PPH
Delivery- episiotomy, lacerations/tears. Breast- problems with breast feeding. Bladder- dysuria, chills/rigor. Other M/S conditions, PAP smear. Family support. SECONDARY PPH EXAMINATION
G/A- pallor. V/S- features of shock. All system examination. Abdomen- uterus involuted/not./tender
Pelvic examination Insp: Episiotomy, lacerations/tears/hematoma, bleeding, offensive discharge (no)?
Speculum- Os- open/closed. Bleeding and clots present. Lacerations CMT.
Bimanual exmn:- uterine size- slightly enlarged. tenderness. Adnexa. SECONDARY PPH
INVESTIGATIONS:
FBE( Hb), U&E, ESR/CRP. Blood group, cross matching and hold. Coagulation profile. LFT. Ultrasound- look for RPOC. SECONDARY PPH
Bleeding more than 500ml occurring between 24hrs and 6 weeks postpartum. Explain causes. SECONDARY PPH
MANAGEMENT. DRABCDE. Oxygen by mask, Start I/V line, take blood for investigations, start infusion. Check for bladder fullness and catheterize if full. Immediate referral to tertiary hospital. SECONDARY PPH
AT HOSPITAL Admission. O&G consultation. Blood trans fusion if necessary. I/V oxytocin 10 IU bolus and then 40 IU infusion through normal saline/ Hartman’s. If not responding, I/M or I/V ergometrine 0.25 or 0.5. Exploration under anesthesia and gentle blunt curettage to remove the RPOC. Oxytocin infusion to be continued. If still bleeding, bimanual compression of uterus for 3 minutes. If bleeding not stopped, surgical management. SECONDARY PPH
SURGERY- uterine tamponade uterine artery/IIA ligation. hysterectomy. SECONDARY PPH DUE TO ENDOMETRITIS/ PUEPERAL INFECTION. Sympts: High fever >38 between 1-14 days of delivery. Abdominal pain. Offensive vaginal discharge. O/E G/A- pallor, dehydration, lymphadenopathy. V/S- Features of shock. Abd: uterus involuted/sub involuted, tender. Pelvic: Insp: offensive vaginal discharge. Bimanual- uterus slightly enlarged, tender. adnexal tenderness if spread. SECONDARY PPH INVESTIGATIONS. FBE- leucocytosis, neutrophilia ESR/CRP. U&E. Blood for grouping, cross matching and hold. Coagulation profile. Blood culture and sensitivity. Swab the genital tract for microscopy, C&S. Pelvic U/S. Urine M, C&S. SECONDARY PPH
MANAGEMENT. Organisms- GBS, E.coli. Admission. DRABCDE- if in shock. Mild- only febrile but not clinically ill- Amoxycillin + Potassium clavilunate for 5-7 days. If severe, I/V amox+ genta+ metronidazole Case 54
Case: You are a HMO. You have come to see a 25 year old lady after her 3rd POD of LUCS. She is requesting to go home. Her temperature is slightly high. Task: Take history Ask for PE finding from examiner Tell the patient whether she is likely to get discharge or not. Post partum pyrexia Causes 1. Endometritis/Endomyoparametritis, 2. Urinary tract infection, 3. Mastitis 4. Pneumonia\atelectasis, 5. Wound infection, and 6. Septic thrombophlebitis Risk factors for sepsis
Home birth in unhygienic conditions Low socioeconomic status/Poor nutrition Primiparity Anaemia Chronic diseases- DM, HIV Prolonged rupture of membranes Prolonged labour LSCS Obstetrical manoeuvres/repeated vaginal examinations Retained placenta History:
Congratulate for first and planned pregnancy. Q to rule out D/Ds- pain, fever, cough, headache, SOB, burning in pee, any foul smelling discharge from down below, discharge from wound site, calf pain, pain in breasts. Pregnancy and delivery? Weight of baby? How is baby doing? Any problem breast feeding? taking any medication? SADMA Examination: G/A- Pallor. V/S: BP, pulse, temperature, saturation, RR. Heart and lung auscultation Breast exam( privacy and chaperone): slightly engorged, no tenderness, no redness, nipple normal. Look for thrombophlebitis at the drip sites? Abdomen exam- any tenderness at operative site bandage soaked? Uterus palpable, tenderness? Pelvic exam: inspection and sterile speculum exam: offensive discharge, os, size of uterus and adnexa. Calf tenderness Investigations
A pelvic examination is done and samples are taken from the genital tract to identify the bacteria involved in the infection. Blood samples may also be taken for blood counts , CRP, or blood culture. A urinalysis may also be ordered, especially if the symptoms are indicative of a urinary tract infection. Chest x-ray Wound culture I understand you must be looking forward to go home but we have a issue here. You have a slight increase in temperature which we call post partum pyrexia/ fever. It has many reasons.
To rule out what’s going I will inform my senior, run all the investigations to find the focus of infection, prescribe you antipyretic.
According to the investigation finding specialist might consider starting antibiotics or if the fever subsides and investigations normal you might be discharged in due course.