COUNTDOWN 2 FINALS 2021 Obstetrics Dr Abi Hand- Clinical Fellow O&G What is covered today • Physiology of • Antenatal • Routine care, • GDM, • Pre-eclampsia • obstetric choleostasis • Labour • Stages • SROM/preterm labour • APH • Placenta praevia • Placental abruption • PPH • Shoulder dystociaPractice Questions Physiology of pregnancy • Hormonal changes • Raised Hcg-made by the syncytiotrophoblast cells • maintains corpus lutem-produces progesterone until 12 weeks then placenta takes over • Progesterone • Maintains endometrium • Relaxes blood vessels and smooth muscle • Estrogen • Induces proliferation of endometrium • Develops breast tissue • Cardiovascular • Cardiac output increases by 50% • Initially increase in stroke volume • Later on in pregnancy HR increase • To perfuse placenta • Blood pressure-remains constant • Increased blood volume • Respiratory • Oxygen consumption increased by 20% • Tidal volume increases- to expire the increased CO2 • GI • Reduced GI motility- due to progesterone • GORD-reduced tone of oesophageal sphincter and increased intra-abdominal pressure • Renal and urinary tract • Blood flow to kidneys increases, due to increase CO • eGFR increases-urine production increases • Increased renal function means fall in urea and creatinine • Increased UTI risk • LIVER • ALP increased- secreted by placenta • Oestrogen increases cholesterol and bile salt production • endocrine • Thyroid • Enlarges 50% in pregnancy • Hcg stimulates thyroxine production • Oestrogen stimulates thyroid binding globulin- remains constant • Women with underlying thyroid issues need to be closely monitored • New thyroid dysfunction may resolve after delivery • Insulin • Pregnancy initially increases sensitivity- increase glucose utilisation • mid pregnancy increased insulin resistance • Driven by oestrogen, cortisol, progesterone and hPL • Increases glucose levels-for utilization by fetus • If already underlying resistance- can lead to GDM

ANTENATAL CARE 20/40 Fetal

12/40- dating 41/40 scan and 28/40 38/40 Membrane combined test -anti D 34/40 sweep

Booking 40/40 - <10/40 36/40 25/40 31/40 Check position

16/40 Screening in the UK • Combined test (10-14weeks) • Nuchal translucency (NT) and bloods (beta hCG and PAPP-A) • NT +hCG+PAPPA+maternal age Risk of trisomy 21 with • PAPP-A low and beta HCG raised in Down’s syndrome increasing age • Quadruple test (14-20 weeks) <25 1:1500 • AFP, unconjugated oestriol, beta-HCG and inhibin A 30 1:910 35; 1:380 • AFP and unconjugated oestriol low in down’s syndrome 40 1:110 • Beta-HCG and inhibin A raised in down’s syndrome 45 1:30 • PAPP-A • Large glycoprotein produced by the placenta • May be involved in angiogenesis • Low levels reflect poor placentation • Low levels are associated with trisomies 18,21, PET, IUGR, pre-term delivery • AFP • Glycoprotein made by fetal liver • raised in abdominal wall defects,exomphalos neural tube defect Invasive testing • If risk >1 in 150- invasive test will be offered

Choriovillus sampling 10-13 weeks • Placenta sampled via transabdominal /transcervical approach under US guidance • Karyotyping takes 2 days, gene probe analysis 3 weeks • Miscarriage 1-2%

Amniocentesis >16 weeks • Amniotic fluid sample taken to assess cells from skin and gut • Needle inserted transabdominal under US guidance • 1% fetal loss rate (lower than CVS) • Full cell typing takes 3 weeks, rapid result available within 2 days by fISH and PCR 34 year old Para 1 presents to her booking appointment. She has a BMI of 42 and her previous baby weighed 4.7kg. Gestational diabetes Screening If previous GDM- OGTT asap after booking & 24-28 weeks If 1 other RF- OGTT 24-28 weeks Risk factors Dx • BMI >30 Fasting glucose >5.6 • Previous baby >4.5kg 2 hour glucose >7.8 • Previous GDM • First degree relative with Treatment GDM Seen in ANC (joint diabetes and antenatal) • South asian, afro-caribbean <7- diet and exercise Target not met in 1-2 weeks- metformin then insulin 6-6.9 Insulin if evidence of complications- macrosomia/hydramnios Pre-existing DM- stop oral hypoglycaemics- start insulin

Post delivery If GDM- STOP insulin 3 random BMs A 37 year old lady 25/40 weeks gestation presents to her GP with headaches and flashing lights across her eyes. She also has noticed that her arms and legs have got suddenly more swollen. She has a blood pressure of 150/90 and 3+ protein in urine Pre-eclampsia PC • > 20 weeks gestation • Hypertension (>140/90) + proteinuria • Headaches/visual changes • Epigastric pain • odema O/E • Hyper-reflexia, clonus • Papilloedema IX • Urine dip-proteinuria • UPCR- >30 • FBC, U&Es, LFTs, coagulation (HELLP- plts <100, raised ALT, raised creatinine) Rx • Prophylaxis-150mg Aspirin • Labetalol -200mg BD titrate until <135/85 • Nifedipine 30mg MR • Monitor 24 hours post partum- followed up by CMW for 2 weeks Severe pre-eclampsia • BP >160/100 • Worsening bloods • Rise in creatinine ->90 • ALT >70 Complications • Drop in platelets Maternal HELLP • Pulmonary odema Eclampsia • Placental abruption Suspected fetal compromise Fetal Rx Prematurity Intrauterine growth IV labetalol restriction -200mg bolus- give 4 x 50mg STAT then infusion 20mg/hr IV MgSO4 - 4g 120mls/hr then 1g/hr DELIVER BABY 26 year old woman 33 weeks pregnant presents with severe pruritus, particularly over hands and feet, worse at night. Obstetric cholestasis • PC: Pruritus in absence of skin rash usually in the third trimester • Ix; deranged LFTs (raised beyond pregnancy specific reference ranges), Raised bile acids (>10), may lead to deranged coagulation • USS abdo and liver screen • Risks; premature birth, stillbirth • Rx; IOL from 39 weeks • Symptomatic Rx;Topical emollients (aqueous cream), chlorphenamine, ursodeoxycholic acid • Follow-up • Repeat LFTs ( at least 10 days following delivery) Labour • Spontaneous labour occurs in 60% of births • Heralded by show ( the mucus plug) and rupture of membranes • Defined as the onset of regular uterine painful contractions associated with effacement and dilation of the cervix and descent of presenting part through cervix • Primps-average time in labour 8-18h • Multips average time in labour 5-12h First stage Latent Painful irregular contractions, cervical effacement and dilation Delayed labour Active - Power dilated 4cm, regular contractions 3-4 in 10 - Passage Second stage - Passenger Passive Cervix fully dilated but no pushing, descent of head to pelvic floor Active Maternal pushing until delivery of baby Third stage From delivery of baby to delivery of placenta Induction of labour • When it is thought that letting the pregnancy take its natural course is more dangerous than delivering the baby • Method differs between primiparous and multi parous women Vaginal Exam Primiparous Vaginal Exam Multiparous

Propess into posterior fornix BS >7 BS <7 until symptoms of labour start/ 24hrs ARM and oxytocin

Propess removed Mechanical induction with Foley’s catheter Vaginal Exam If unable to introduce-Prostin Leave in for BS >7 BS <7 Falls out 12hrs ARM and oxytocin Prostin (2 can be given by midwife, up to 4 following Dr review ARM +/- If BS >7 If <7 and oxytocin ARM +/- BS >7 ARM not oxytocin ARM and oxytocin possible- ? prostin 28 year old woman 30/40 weeks pregnant with twins presents with some leaking of thin watery discharge. PROM • Preterm prelabour rupture of membranes • If no evidence- amnisure Plan • Monitor for 48 hours • Steroids <35+6 • Erythromycin- 10/7 • Discharge with regular temps Preterm labour <37 weeks • Regular painful tightenings • Speculum and FFN <35+6 • CTG • Steroids <35+6 • Magnesium sulphate <30/40 ?<33+6 • Benzylpenicillin 3000mg STAT then 1500mg 6 hourly • The now 31/40 woman presents feeling with abdominal pain, temperature of 41, HR of 130. CTG shows fetal tachycardia. Chorioamnionitis • Triad • Maternal pyrexia,maternal tachycardia, fetal tachycardia • Ascending infection of amnionitic fluid/membranes/placenta • IV abx-cefuroxime and metronidazole/tazocin • Deliver!!! Endometritis • Infection of the endometrium PC • abdominal pain, • Foul smelling lochia • fever RF Image taken from pregmed.org • post delivery, post mtop, post surgery APH Bleeding in pregnancy >24 weeks gestation • Placental abruption • Placenta/vasa praevia • External • Cervical • Vaginal • Vulval Ix • FBC, XM • Kleihauer if rhesus negative • Any sensitising event >20 weeks • Anti-D • CTG • U/S 41 year old lady P0 38/40 gestation with IVF twins presents with severe abdominal pain and moderate PV bleeding. On examination she has a BP 80/40, HR of 130. On examination she has a tender ‘woody’ . Placental abruption RF • Previous abruption • IVF • PET • Multiparity • Maternal trauma • Increasing maternal age • Drug misuse PC • Severe abdominal pain • Tender, tense uterus • PV bleed Image taken from clinical obstetrics and gynaecology • Shock • Pathological CTG 29 year old woman presents at 30 weeks with painless bleeding. It is bright red but since stopped. She is otherwise stable. In her past obstetric history she has had a previous C/S Placenta praevia RF • IVF, • previous C/S, • multiparity, • previous termination or surgery PC • Often Dx on US • Repeat early in 3rd trimester • Painless bleeding • high presenting part, • abnormal fetal lie Image taken from clinical obstetrics and gynaecology 26 year old woman has had a emergency C/S following failed IOL for LFGA baby. Midwife notices 1000ml of PV blood and the emergency bell is pulled. On examination she is clinically shocked with BP of 70/50. Her uterus is decribed as ‘boggy’ PPH- post partum haemorrhage Causes • aTony • Tissue • Trauma • Thombosis RF • Previous PPH • Prolonged labour • PET • Polyhydramnios • Macrosomia

• Emergency CS Image taken from post partum haemorrhage osmosis Management • ABCDE • IV access- 2 grey cannulas • Fluid resus aTony • Fundal massage • Empty bladder • Oxytocin 5 Iv –can give repeat dose • Ergometrine 0.5mg IV • Oxytocin infusion 40 IU in 500ml 125ml/hr • Carboprost 0.25 mg IM • Surgical • Intrauterine tamponade • Suture • Internal iliac artery ligation • Image taken from post partum haemorrhage osmosis A 38 year old 36/40 goes into spontaneous labour. She has a history of GDM and macrosomia. Babies head is delivered then retracts back into the pelvis • Impaction of the anterior fetal shoulder on the maternal pubic symphisis RF • Fetal macrosomia • Raised BMI • DM • Prolonged labour HELPERR • Call for help • Evaluate for Image taken from • Legs-McRoberts teachmeobgyn.com/lab • Pressure-suprapubic our/emergencies/shoul • Enter-rotational der-dystocia • Remove posterior arm • Roll onto hands and knees • and zavanelli Image taken from clinical obstetrics and gynaecology SEE YOU LATER FOR PART 2!!!