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OBSTETRICS
AND
GYNAECOLOGY
BY:
FAREHA HATTA
MBBS (UiTM)
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OnG$
Dear%colleagues,%
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These%are%some%of%the%important%topics%in%OnG%which%I%think%will%help%most%of%us%
to% grasp% the% practical% knowledge% of% the% subject.% I% have% emphasized% on% the%
fundamental% aspect% and% stuff% that% we% need% to% know% to% achieve% a% better%
understanding% in% OnG.% Different% people% have% different% opinions% about%
management,% thus% there% is% no% exact% management% per% se.% It% is% all% about%
experience.% Always% refer% to% your% hospital% protocol% for% the% latest% updates% on%
management.%
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TOPICS!
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DEFINITION%IN%OBSTETRICS%
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IOL%&%AUGMENTATION%OF%LABOUR%
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INSTRUMENTAL%DELIVERIES%
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CAESAREAN%SECTION%
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HYPERTENSION%IN%PREGNANCY%
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GESTATIONAL%DIABETES%MELLITUS%
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PPROM%&%PROM%
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POSTPARTUM%HEMORRHAGE%
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MISCARRIAGES%
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ECTOPIC%PREGNANCY%
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GESTATIONAL%TROPHOBLASTIC%DISORDERS%
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MENORRHAGIA%
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Thank%you%Allah%for%giving%me%the%strength%and%patience%to%go%through%one%of%the%
most% difficult% postings% in% housemanship.% Alhamdulillah,% I% survived% in% OnG.% I’ve%
gained%so%much%from%this%posting%and%no%word%can%describe%my%%excitement%upon%
successful%completion%of%the%posting.%Alhamdulillah.%!%
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With%that,%I%present%to%you%my%latest%personal%HO%notes%in%OnG.%
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Dr%Nurfareha%Mohd%Hatta%
MBBS%(UiTM)%
Hosp.%Tengku%Ampuan%Rahimah,%Klang.%
DEFINITION(IN(OBSTETRICS( $ $ Presentation$ − The$part$of$the$fetus$in$the$lower$pole$of$uterus$overlying$the$pelvic$brim$ − Example:$cephalic$(vertex,$face,$brow),$breech$(frank,$complete,$footling),$shoulder$ $ Attitude$ − Relation$of$the$different$part$of$fetus$to$one$another$ $ Lie$ − The$relation$of$the$long$axis$of$the$fetus$to$the$uterus$ − Example:$longitudinal,$transverse,$oblique$ $ Position$ − The$relationship$of$the$presenting$part$to$the$mother’s$pelvis$ $ $ $ $
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Presenting$part$ − The$leading$point$of$the$fetus$in$the$lower$pole$of$uterus$overlying$the$pelvic$brim$ (on$VE)$ − Example:$vertex,$buttocks,$feet$ $ Denominator$ − Arbitrary$part$of$the$presentation$of$the$fetus$(the$bony$point)$ − Example:$occiput$in$vertex$presentation,$sacrum$in$breech$presentation,$mentum$in$ face$presentation$ $ Engagement$ − Descent$of$the$biparietal$diameter$through$the$pelvic$brim$ $ Vertex$ − DiamondLshaped$area$of$the$fetal$skull$bounded$by$the$2$parietal$eminences$and$ anterior$and$posterior$fontanelles$ $ Effacement$ − Shortening$of$the$cervix$ − Normal$cervical$length:$~$2.5$cm$ OA! OP! LOT! ROT! LOA! ROA! LOP! ROP!OnG$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$DEFINITION$
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Station$ − The$level$of$the$presenting$part$in$relation$to$ischial$spine$ $ Caput$ − Diffuse$swelling$of$the$scalp$caused$by$pressure$of$the$scalp$against$the$dilating$ cervix$during$labour$ $ Moulding$ − Overlapping$of$the$bones$of$the$fetal$head$ − Parietal$bones$overlap$occipital$and$frontal$bones$ − Significant$moulding$and$caput$!$sign$of$CPD$ − Degree$of$moulding$ • No$moulding$ • +1$–$parietal$bones$are$touching$ • +2$–$parietal$bones$are$overlapped$but$easily$reduced$ • +3$–$irreducible$(sign$of$relative/absolute$CPD)$ $ $ $ $ $ $ $ $ $INDUCTION(AND(AUGMENTATION(OF(LABOUR( $ Induction$–$Stimulation$of$contractions$before$the$spontaneous$onset$of$labour$ Augmentation$–$Stimulation$of$spontaneous$contractions$that$are$considered$inadequate$ $ Indications$of$IOL:$ − Post$dates$ − Maternal$factors$ • Significant$APH$ • Gestational$HPT$disorders$ • GDM$ • Underlying$renal$or$lung$disease$ − Fetal$factors$ • Suspected$fetal$jeopardy$ • Reduced$fetal$movement$at$term$ • Fetal$demise$(IUD),$severe$IUGR$ − MaternalOfetal$factors$ • Prolonged$PROM$(if$more$than$24$hours)$ • Chorioamnionitis$$ $ Contraindications$of$IOL$ $ Maternal$ Fetal$ Small$pelvis$(in$case$of$CPD)$ Macrosomia,$CPD$ Abnormal$placentation$ Multifetal$gestation$ Active$genital$herpes$infection$ Severe$hydrocephalus$ Cervical$abnormalities$ Malpresentation$(obstructed$labour),$ transverse$fetal$lie$ Prior$classical$or$other$high$risk$caesarean$ incision$ NonOreassuring$fetal$status$ Placenta$praevia$or$vasa$praevia$ Umbilical$cord$prolapse$ $ Bishop$score$$ − To$assess$whether$cervix$is$favourable$and$to$determine$whether$the$patient$needs$ cervical$ripening$or$to$proceed$with$augmentation$ − If$Bishop$score$<$4$!$cervix$not$favourable$ − Modified$Bishop’s$score$is$currently$used$in$practice$ $ $ 0$ 1$ 2$ Cervical$dilatation$ 0$cm$ 1$cm$ 2$cm$or$more$ Cervical$length$ 2$cm$ 1$cm$ Effaced$
Consistency$ Firm$ Soft$ Soft$and$
stretchable$
Station$ O2$ O1$ 0$
Position$ Posterior$ Axial$ Anterior$
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*A$preOIOL$CTG$of$at$least$20$minutes$recording$is$mandatory$and$reviewed$before$proceed$ with$IOL.$
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Methods$of$induction$ $ 1. Prostaglandin$E2$(Prostin)$ − To$promote$cervical$ripening$if$cervix$is$not$favourable$(Bishop$score$<$4)$ − To$assess$Bishop$score$prior$to$prostin$insertion$ − Gravida$1O5$(1.5mg$for$multigravida$with$previous$scar$or$3mg$for$no$scar)$inserted$ at$posterior$fornix$ − After$prostin$insertion,$ • CRIB$for$1$hour$ • CTG$postOprostin$1$hour$ • Review$VE$in$6$hours$ • Monitor$labour$progress$chart$(LPC)$and$FKC$ − There$should$not$be$more$than$2$prostin$insertion$in$24$hours$ − MAXIMUM$no.$of$prostin$inserted:$3$doses$ − If$the$3rd$prostin$fails,$the$specialist$will$have$to$review$and$assess$the$patient$ − Oxytocin$infusion$should$not$be$started$at$least$6$hours$after$last$prostin$insertion$ !$to$avoid$risk$of$uterine$hyperstimulation$ $ 2. Amniotomy$followed$by$oxytocin$induction$ − When$cervix$is$favourable$ − Amniotomy$(ARM)$ • Amniotic$fluid$is$rich$in$prostaglandin,$can$cause$uterine$contraction$ • Criteria$for$ARM$ " Os$is$≥$4cm$(in$active$phase)$ " Station$is$not$high$and$the$vertex$is$wellOapplied$–$to$assess$head$ engagement$on$abdominal$examination$prior$to$ARM$ " Contraction$must$be$present$ " The$umbilical$cord$or$other$fetal$part$is$not$presenting$ • Aim$of$ARM$ " To$speed$up$labour$process$ " For$internal$fetal$monitoring$ " To$look$for$presence$of$meconium$ • Is$not$part$of$a$routine$in$labour$management,$especially$in$spontaneous$ labour$ • Some$studies$show$that$early$ARM$(when$os$$<$4cm)$in$nulliparous$labour$ induction$shortened$the$time$of$delivery$by$>$2$hours$and$increased$the$ proportion$of$deliveries$within$24$hours,$given$the$fetus$head$is$engaged$ (commonly$practised$in$HTAR$when$there$is$prolonged$latent$phase$and$cervix$ is$favourable)$*$ • Complications$of$ARM$–$cord$prolapse,$infection$ − Oxytocin$induction$ • Oxytocin$is$a$polypeptide$hormone$produced$in$the$hypothalamus$and$ secreted$from$posterior$pituitary$in$a$pulsatile$fashion$ • Synthetic$oxytocin$administration$is$most$commonly$given$IV$ • Short$halfOlife:$3O6$minutes$ • How$to$dilute$–$1$ampoule$of$Syntocinon$has$10$units,$dilute$in$1000ml$normal$ saline,$yielding$an$oxytocin$concentration$of$10mU/mL$ • Dose$initiated$at$0.5O1$mU/min$and$increased$by$1$mU/min$at$30O40$minute$ intervals$using$infusion$pump$− Amniotomy$plus$oxytocin$is$MORE$EFFECTIVE$than$amniotomy$alone$!$shortened$ the$time$to$delivery$by$44$minutes$ − After$ARM,$ • For$CTG$postOARM$with$20$minutes$tracing$ • Review$VE$in$4$hours$ • Review$contractions$ • Plot$partogram$ • If$CTG$reactive,$to$start$Syntocinon$as$per$regime,$to$aim$for$moderate$ contraction$4:10$ • For$CTG$hourly$if$CTG$reactive$ • Hydration$with$1$pint$Hartmann$solution$over$4$hours$as$maintenance$ • For$IM$Pethidine$75mg$and$IM$Phenergen$25mg$stat$once$contraction$ moderate$and$CTG$reactive$OR$to$offer$epidural$ $ Augmentation$of$labour$ − Indicated$when$the$patient$is$in$labour$and$CPD$has$been$ruled$out$ − When$there$is$poor$progress$of$labour$secondary$to$poor$uterine$contractions$based$ on$the$partograph$ − Initial$steps$ • Assess$general$condition$of$mother$–$vital$signs$and$hydration$status$ • Review$partogram$and$assess$the$progress$of$labour$ • Palpate$the$abdomen$and$assess$ " Strength$&$frequency$of$contraction$ " Estimate$the$size$of$baby$(compare$with$previous$baby)$ " Engagement$of$the$head$ " ?Full$bladder$(to$catheterize$before$VE)$ • Do$VE$and$assess$ " Cervical$effacement$ " Cervical$os$dilatation$ " Position$of$fetus$–$OA/OP/OT$ " Degree$of$caput$or$moulding$if$present$ " Nature$of$liquor$if$present$ − Baseline$CTG$before$augmentation$with$at$least$20$minutes$tracing$to$ensure$fetal$ wellbeing$is$not$compromised$ − Augmentation$regime$ • Primigravida$–$2,$4,$8$units$ • Gravida$2O5$–$1,$2,$4$units$ • Multipara$with$previous$scar$–$may$consider$½,$1,$2$units$ − For$every$increase$in$the$strength$of$oxytocin$infusion,$CTG$monitoring$is$mandatory$ − Good$effective$contraction$!$4O5$contractions$in$10$mins$ $ Side$effects$of$oxytocin:$ − Uterine$hyperstimulation$(def:$>$5$contractions$in$10$mins)$ − Uterine$rupture$(especially$in$scarred$uterus)$ − Hyponatremia$due$to$excessive$water$retention$(oxytocin$has$ADH$properties,$when$ administered$in$high$doses)$ − Hypotension$(as$a$result$from$rapid$IV$injection$of$oxytocin)$ − Fetal$distress$ $
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References:$
1. HTAR$OnG$protocol$ 2. Ten$Teachers$Obstetrics$
INSTRUMENTAL+DELIVERY+ $ a.k.a$Operative$Vaginal$Delivery$ $ A$delivery$in$which$the$operator$uses$forceps$or$a$vacuum$device$to$assist$the$mother$in$ transitioning$the$fetus$to$extrauterine$life.$ $ Indications$ − Prolonged$2nd$stage$of$labour$ • Nulliparous$–$3$hours$with$regional$anaesthesia,$2$hours$without$ • Multiparous$–$2$hours$with$regional$anaesthesia,$1$hour$without$ − Maternal$distress$(underlying$cardiac$disease,$HPT$crisis,$etc)$ − Presumed$fetal$compromise$ − Maternal$exhaustion$ $ Prerequisites$ FT$Fully$dilated$cervix$ OT$OP/OA$position$ RT$Ruptured$membrane$ CT$Cephalic$ ET$Empty$bladder$(to$catheterize$first)$ PT$Pain$relief$(adequate$analgesia)$ ST$Skills,$Station$low$ $ Complications$ The$relative$merits$of$vacuum$extraction$and$forceps$have$been$evaluated$in$a$Cochrane$ Systematic$Review$of$ten$randomized$controlled$trials$involving$2923$primiparous$and$ multiparous$women$ $ Compared$with$forceps,$vacuum$extraction$is:$ • more$likely$to$fail$delivery$with$the$selected$instrument$(OR:$1.7;$95%$CI:$1.3–2.2)$ • more$likely$to$be$associated$with$cephalohaematoma$(OR:$2.4;$95%$CI:$1.7–3.4)$ • more$likely$to$be$associated$with$retinal$haemorrhage$(OR:$2.0;$95%$CI:$1.3–3.0)$ • more$likely$to$be$associated$with$maternal$worries$about$baby$(OR:$2.2;$95%$CI:$1.2– 3.9)$ • less$likely$to$be$associated$with$significant$maternal$perineal$and$vaginal$trauma$(OR:$ 0.4;$95%$CI:$0.3–0.5)$ • no$more$likely$to$be$associated$with$delivery$by$caesarean$section$(OR:$0.6;$95%$CI:$ 0.3–1.0)$ • no$more$likely$to$be$associated$with$low$5Tminute$Apgar$scores$(OR:$1.7;$95%$CI:$1.0– 2.8)$ • no$more$likely$to$be$associated$with$the$need$for$phototherapy$(OR:$1.1;$95%$CI:$0.7– 1.8).$ $ $ $ $ $ $ $
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FORCEPS$DELIVERY$ $ $ $ $ Conditions$when$forceps$are$preferable:$ − Poor$maternal$effort$ − Operator$or$maternal$preference,$when$either$instrument$would$be$suitable$ − Large$amount$of$caput$ − Gestation$of$less$than$34$weeks$ − Marked$active$bleeding$from$a$fetal$bloodTsampling$site$ − AfterTcoming$head$of$the$breech$ − Face$presentation$ $ Types$of$forceps:$ $ 1. Wrigley’s$–$for$liftTout$deliveries$and$Caesarean$section$ $ 2. Neville$Barnes$ $ $ $ $ $ $ $ $ $ $ 3. Rotational$forceps$(Kielland’s$forceps)$ $ The$blade$has$two$curves:$ Cephalic$curve$–$relates$to$ fetal$head$ Pelvic$curve$–$relates$to$ maternal$pelvis$!
Classification$of$forceps$delivery:$ $ OUTLET$ $ − Fetal$head$is$at$or$on$the$perineum$− Scalp$is$visible$at$the$introitus$without$separating$the$labia$ − Fetal$skull$has$reached$the$pelvic$floor$ − Sagittal$suture$is$in$the$AP$diameter$or$right$OA$or$OP$ − Rotation$does$not$exceed$45$degrees$ LOW$ − Leading$point$of$the$fetal$skull$is$at$the$station$+2$cm$or$ more$ • Rotation$≤$45$degrees$from$OA$position$ • Rotation$>$45$degrees$including$OP$position$ $ MID$ − Leading$point$of$the$fetal$skull$is$above$station$+2$cm$but$ not$above$the$ischial$spines$ • Rotation$≤$45$degrees$from$OA$position$ • Rotation$>$45$degrees$including$OP$position$ − Head$is$engaged$ $ Technique:$ − Procedure$explained$to$patient$ − Lithotomy$position$ − Clean,$drape$and$catheterize$ − Assemble$the$blades$ − Left$blade$applied$first$(hold$like$a$pencil)$ − Right$blade$follows$ − Proper$application$and$positioning$of$forceps$will$bring$the$blades$together$and$locks$ easily$ − If$fail,$to$proceed$with$LSCS$ $ Clinical$checks$for$forceps$application:$ − Sagittal$suture$lies$in$the$midline$of$the$shanks$ − Operator$is$unable$to$place$more$than$a$fingertip$between$the$fenestration$of$the$ blade$and$the$fetal$head$on$either$side$ − Posterior$fontanelle$is$no$more$than$a$finger$breadth$above$the$plane$of$the$shanks$of$ the$forceps$ − Apply$traction$intermittently$and$synchronously$with$uterine$contraction$ − Direction$of$traction$should$be$in$the$axis$of$the$birth$canal$ − Head$descent$must$be$present$during$each$contraction$ $ $ VENTOUSE$DELIVERY$ $ • Risk$of$damage$to$the$maternal$tissue$is$considerable$ • Preterm$pregnancy$(<$34$weeks)$–$contraindicated$ − Head$softer$ − Wider$separation$of$suture$ − Increased$risk$of$subgaleal$and$intracranial$hemorrhage$ • Can$be$applied$in$any$fetal$position$ $
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Advantages$ Disadvantages$ Avoid$marked$compression$of$the$fetal$head$ by$the$forceps$ Injuries$to$the$fetal$scalp$ Forceps$occupies$a$space$and$may$injure$the$ vagina$ Cephalohematoma$ Forceps$carries$the$infection$in$the$genital$ tract$ Intracranial$hemorrhage$ $ Types$of$cup:$ $ 1. Silastic$cup$ $ 2. Metal$cup$ $ $ $ 3. Kiwi$cup$ $ $Conditions$when$ventouse$is$preferable:$ − Urgent$low$liftTout$delivery$with$no$previous$analgesia$ − Rotational$delivery$ − Operator$or$maternal$preference,$when$either$instrument$is$suitable$ $ Technique:$ − Cup$must$be$directed$to$the$occiput$in$the$midline$of$the$head$application$diameter$at$ the$flexion$point$ − Ensure$that$maternal$tissue$have$not$caught$in$the$cup$ − Increase$the$pressure$to$0.2$kg/cm2,$check$for$maternal$tissue$entrapment$between$ the$cup$and$the$fetal$head,$then$increase$to$0.8$kg/cm2.$Recheck$for$any$maternal$ tissue$entrapment$prior$to$applying$traction$ − With$contraction,$apply$traction$downward$and$backward$with$one$hand$while$the$ other$hand$applied$to$steady$the$cup$on$the$head$ − Head$should$descend$with$each$pull$ − Delivery$should$be$completed$within$3$pulls$ − Cup$should$be$reapplied$no$more$than$twice$ − If$fail,$do$not$try$forceps$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ References:$ 1. HTAR$protocol$ 2. Royal$College$of$Obstetricians$&$Gynaecologists$–$Instrumental$Delivery$ The$flexion+point$is$located$on$the$ sagital$suture$3+cm+in+front$of$the$ posterior$fontanelle$and$+6+cm+ posterior$to$the$anterior$fontanelle$
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CAESAREAN'SECTION' $ 2$types$of$Caesarean$section:$ Lower$segment$section$ Classical$section$(Upper$segment)$ • Transverse$ incision$ made$ ~2cm$ above$symphysis$pubis$(Pfannenstiel)$ • Advantages:$
− !$adhesion$formation$ − !$blood$loss$
− !$ incidence$ of$ scar$ dehiscence$ in$ subsequent$pregnancies$
− scar$heals$well$
− short$duration$of$hospital$stay$
• Midline$ longitudinal$ incision$ made$ in$ uterine$upper$segment$
• Indications:$
− Fibroid$distorting$the$uterus$
− Anterior$ PP$ with$ abnormally$ vascular$lower$uterine$segment$ − Poorly$formed$lower$segment$ • Advantages:$ − Rapid$delivery$ − !$risk$of$bladder$injury$ $ Layers$cut$in$CS:$ − Skin$ − Subcutaneous$layer$(Camper$&$Scarpa$fascia)$ − Rectus$sheath$(aponeuroses$of$the$external$oblique,$internal$oblique,$and$tranversus$ abdominis$muscles$ − Rectus$abdominis$muscle$ − Transversalis$fascia$ − Peritoneum$$ $ PreQOp$ • Keep$patient$NBM$with$IV$Drip$5$pints$(3$pints$NS$+$2$pints$D5%)$ − If$patient$planned$for$elective$CS,$to$keep$NBM$at$12am$ • Consent$form,$blood$transfusion$form$signed$ • For$baseline$blood$investigations$–$FBC,$GSH$ • Prepare$GXM$2$units$packed$cells$ • Shave$the$pubic$area$ • Bladder$catheterization$ • Prophylactic$antibiotic$–$IV$Cefuroxime$1.5g$stat$&$IV$Flagyl$500mg$stat$ • Pre$med$–$IV$Ranitidine$50mg,$IV$Maxolon$10mg,$Oral$Sodium$citrate$30ml$given$stat$ • Presence$of$Anaes$and$Paeds$ • Regional$block$–$spinal$intrathecal$morphine$ $ Post$Op$ • CRIB$for$6$hours$ • Monitor$BP/PR$–$15mins$x$4,$30mins$x$4,$1$hrly$x$4,$2$hrly$x$4,$then$4$hrly$if$stable$ • Allow$orally$as$tolerated$ • IV$drip$5$pints$(3$pints$NS$+$2$pints$D5%)$until$tolerating$orally$ • Strict$IO$charting$ • Wound$inspection$Day$2,$no$need$for$STO$ • FBC$6$hours$post$op$ • To$start$S/C$Heparin$5000$U$BD$for$1/52$after$review$FBC$post$op$ • Keep$CBD$for$1/7,$to$inform$if$bloodQstained$urine$ • Strict$pad$chart$monitoring,$to$inform$if$more$than$2$pads$soaked$ • IV$Pitocin$40$U$in$1$pint$NS$for$4Q6$hours$ • Analgesia$as$per$Anaes$order$
HYPERTENSION+IN+PREGNANCY+ BP$of$140/90$mmHg$or$more$on$2$occasions$at$least$4$hours$apart$ Definition$ 1. PregnancyHinduced$HPT$–$HPT$after$20$weeks$of$gestation$in$a$previously$normotensive$woman$ with$no$significant$proteinuria,$usually$condition$returns$to$normal$within$6$weeks$postpartum$ 2. Chronic$HPT$–$HPT$that$is$present$at$the$booking$visit$of$before$20$weeks$of$gestation$or$if$the$
woman$ is$ already$ taking$ antiHPT$ medication$ when$ referred$ to$ maternity$ services.$ (NICE$ guidelines)$
3. PreHEclampsia$ –$ BP$ of$ ≥$ 140/90$ mmHg$ with$ significant$ proteinuria$ (≥$ 300$ mg/24hrs)$ after$ 20$ weeks$of$gestation$
4. Chronic$ HPT$ with$ superimposed$ preHeclampsia$ –$ PreHeclampsia$ in$ patient$ with$ preHexisting$ hypertension$
5. Eclampsia$–$preHeclampsia$with$convulsion$
6. Severe$ PreHEclampsia$ (Impending$ Eclampsia)$ –$ PreHEclampsia$ with$ severe$ HPT$ ±$ symptoms,$ ±$ biochemical$±$haematological$impairment$
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Pathophysiology$of$preHeclampsia$
H Failure$ of$ normal$ invasion$ of$ trophoblast$ cells$ leading$ to$ maladaptation$ of$ maternal$ spiral$ arterioles$ H The$cytotrophoblast$infiltrates$the$decidual$portion$of$the$spiral$arteries,$but$fails$to$penetrate$ the$myometrial$portion,$thus$the$large,$tortuous$vascular$channels$characteristic$of$the$normal$ placenta$do$not$develop,$instead,$the$vessels$remain$narrow,$resulting$in$hypoperfusion$ H Abnormalities$of$spiral$artery$adaptation$are$immunologically$based,$with$genetic$influences$ H The$ischemic$placenta$appears$to$alter$maternal$endothelial$cell$function$and$leads$to$signs$ and$symptoms$of$preHeclampsia$ H Many$of$the$clinical$features$can$be$explained$as$clinical$response$to$generalized$endothelial$ dysfunction$ $ Risk$factors:$ H Family$history$ H Multiple$gestation$ H PreHexisting$HPT,$DM,$renal$disease$or$vascular$disease$ H Previous$severe/early$onset$PE$ H Previous$SGA$ H Age$≥$40$y/o$ H Primigravida$ H Obesity$(BMI$≥$30)$ $ Symptoms$of$impending$eclampsia$(severe$PE):$ H Severe$headache$ H Vomiting$ H Blurring$of$vision$ H Epigastric$or$RUQ$abdominal$pain$(due$to$liver$capsule$distention)$ H Sudden$onset$of$swelling$of$the$face,$hands,$feet$ $ Systemic$involvement$ H CVS:$generalised$vasospasm,$↑$peripheral$resistance$
OnG$ $ HPT$IN$PREGNANCY$ $ H CNS:$cerebral$edema,$cerebral$haemorrhage$ H Renal:$proteinuria,$↓$GFR$ H Hepatic:$subcapsular$hematoma$(which$gives$rise$to$epigastric$pain),$generalised$edema$ $ AIM$TO$KEEP$BP$<$150/100$mmHg!$ $ HELLP$syndrome$ H Hemolysis,$elevated$liver$enzymes,$low$platelet$ H Severe$form$of$preHeclampsia$ $
According$ to$ ACOG$ criteria,$ severe$ PE$ is$ considered$ if$ one$ or$ more$ of$ the$ following$ criteria$ are$ present:$ H BP$≥$160/110$on$2$occasions$at$least$4$hours$apart$ H Proteinuria$of$≥$5g/24hr$or$≥$3+$on$2$random$urine$samples,$collected$at$least$4$hours$apart$ H Oliguria$<$500ml/24hr$ H Cerebral$or$visual$disturbances$ H Pulmonary$edema$ H Epigastric$or$RUQ$pain$ H Impaired$liver$function$ H Thrombocytopenia$(<$100$x$109/L)$ H Fetal$growth$restriction$ $ Investigations$ H FBC$(platelet$count)$ H LFT,$including$AST$ H RP$(serum$creatinine)$ H Coagulation$profile$ • Usually$normal$in$PE$ • May$be$abnormal$with$advanced$disease$affecting$the$liver,$or$in$placenta$abruption$ H Serum$uric$acid$ H UFEME$and$urine$dipstick$test$$ H 24hr$urinary$protein$(standard$diagnostic$test)$ $ Antenatal$management$ H Identify$risk$factor$and$monitor$BP$ H Physical$examination$ $ 1. Outpatient/KK$ H BP$monitoring$ H Urinalysis$(check$for$urine$albumin)$ H SFH$and$liquor$volume$ H RP,$FBC,$serum$uric$acid$ H Fetal$monitoring$→$USG$monthly,$FKC$ $ 2. Inpatient$ H Monitor$BP$4$hourly,$to$inform$MO$if$BP$≥$150/100$mmHg$ H Daily/biweekly$PE$profile$$ • LFT,$coagulation$profile$if$suspected$HELLP$or$proteinuric$PIH$ H Urine$albumin$per$shift$ H Update$PE$chart$ H For$24$hour$urinary$protein$
H Watch$out$for$signs$&$symptoms$of$impending$eclampsia$ H Fetal$surveillance$→$FKC,$CTG,$USG$(for$fetal$growth,$AFI,$Doppler)$ $ $ $$$$$$$$$Timing$of$delivery$ $$$$$$$$$Uncomplicated$PIH$not$on$treatment$–$40$weeks$ $$$$$$$$$PIH$on$treatment/$complicated$PIH$–$~36$to$38$weeks$ $ $ Intrapartum$management$$ H BP/PR$half$hourly$ H If$patient$is$on$medication,$to$continue$meds$ H Strict$I/O$chart$ H Adequate$analgesia$ H CTG$monitoring$ H NOT$for$syntometrine/ergometrine!$ H To$give$Syntocinon$10$U$ $ Postpartum$management$
H Watch$ out$ for$ signs$ &$ symptoms$ of$ impending$ eclampsia$ and$ pulmonary$ edema$ (fluid$ overload)$ H BP$monitoring$ • ½$hourly$monitoring$for$at$least$2H4$hours$before$sending$to$postnatal$ward$ • 4$hourly$monitoring$in$the$ward$for$24H48$hours$before$discharge$ H Continue$with$antihypertensive$meds$(if$patient$is$on$methyldopa$→$discontinue,$in$view$of$ postpartum$depression)$ H Strict$I/O$chart$ H Daily$urine$albumin$&$PE$profile$ H If$discharge,$$ • EOD$BP$monitoring$at$KK$for$2$weeks$and$to$review$BP$in$2$weeks$by$MO$ • Continue$antihypertensive$meds$ $ The$use$of$antihypertensive$medications$in$pregnancy$ H Mild$PIH$usually$do$not$require$antiHPT$ H Consider$antiHPT$if$diastolic$BP$above$100mmHg$ H Pregnant$women$with$chronic$HPT$who$take$ACEi,$ARBs$or$thiazide$diuretics$preHpregnancy$ • To$ discontinue$ the$ meds$ in$ view$ of$ increased$ risk$ of$ congenital$ abnormalities$ during$
pregnancy$ H Indications$of$IV$antiHPT:$(as$per$protocol)$ • When$BP$>$160/110$mmHg$sustained$for$more$than$30$minutes$ • MAP$>$125$mmHg$ $ $$$$$$$$*Mean$Arterial$Pressure$(MAP)$=$DBP$+$1/3$(SBPHDBP)$ $ $ $ $ $ $ $
OnG$ $ HPT$IN$PREGNANCY$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ $ $ $ $ $ $ $ $ $ $ $ $ $$$$$$$$$$OR$ $ $ $ $ $ $ $ $ $ $ $ $ $ Source:$HTAR$protocol$ MAP+>+125mmHg+ MAP+<+125mmHg+ Repeat$Hydralazine$ every$15$mins$until$ either$cumulative$dose$ of$20mg$or$side$effects$ present$ MAP$>$125mmHg$and$ HR$>$120$bpm$or$15mg$ Hydralazine$given$ IV$Labetolol$20mg$(at$ least$1$min)$followed$at$$ 10$mins$intervals$by$40,$ 80,$80,$160$ H each$ml$contains$ 5mg$(1$ampoule$=$ 25mg$in$5ml$ Maintenance$therapy$ Hydralazine$infusion$(if$HR$<$ 120$bpm)$ H dilute$50mg$in$50cc$ normal$saline$ H start$at$5ml/hour$and$ increase$2.5$ml/hour$ every$30$minute$until$DBP$ 90H100$ Labetolol$infusion$(if$HR$>$120$ bpm$or$side$effects$of$ hydralazine)$ H 200mg$in$50cc$normal$ saline$ H start$at$5ml/hour$ (20mg/hour)$and$double$ every$30$minutes$by$10,$ 20,$40$ MAP+>+125mmHg+ IV$bolus$5mg$(2.5cc)$ Hydralazine$over$1$min$ H 1$ampoule$contains$ 20mg$in$1$ml$ H add$9cc$of$normal$ saline$in$10cc$syringe$ (0.5mg/ml)$ $ Recheck$MAP$ after$15$mins$
H AntiHPT:$ $
AntiHPT$ MOA$ Starting$dosage$ Max.$dosage$ Side$effects$ Methyldopa$ Centrally$acting$ 250mg$TDS$ 3000mg/day$ PostHpartum$
depression$
Labetolol$ α,$β$blockers$ 100mg$TDS$ 2000mg/day$ Bronchoconstriction,$ IUGR,$heart$block$ Nifedipine$ CCB$ 15mg$TDS$ 60mg/day$ Headache,$flushing$ Hydralazine$
(only$IV)$ Vasodilator$ 25mg/day$ 300mg/day$ Tachycardia,$hypotension$ $ H Role$of$Aspirin$in$PIH$and$PE$ • Women$at$high$risk$of$PE$are$advised$to$take$low$dose$aspirin$75mg$daily$starting$from$12$ weeks$ • High$risk:$previous$PIH,$chronic$hypertension,$chronic$kidney$disease,$autoimmune$ disease,$DM$ $ $ Management$of$Eclampsia$ H Obstetrical$emergency!$ H Put$on$left$lateral$position$with$head$slightly$lowered$ H Maintain$airway$ H Give$O2$by$ventimask$ H Set$2$IV$lines$(large$bore$branula)$ H Abort$fit$by$MgSO4$ • 1$ampoule$contains$2.47gm$(~2.5$gm)$of$50%$MgSO4$in$5ml$ • IV$regime$ ! LOADING$dose:$4gm$MgSO4$ H 8ml$=$4gm$(need$2$ampoules),$then$mixed$with$12ml$normal$saline$in$20cc$ syringe$ H Give$20ml$slow$bolus$IV$over$10H15$minutes$ ! Followed$by$MAINTENANCE$dose$1gm/hour$for$at$least$24$HOURS$after$last$fit$ H 5gm$of$MgSO4$(2$ampoules$=$10ml)$mixed$with$40ml$normal$saline$in$50cc$ syringe$using$infusion$pump$titrating$at$10ml/hour$ ! Recurrent$seizure$–$repeat$IV$MgSO4$but$at$a$lower$strength$dose;$2gm$given$slow$ bolus$over$10H15$minutes$ • IM$regime$(usually$given$at$KK)$ ! LOADING$dose:$10gm$MgSO4$ ! 4$ampoules$H$2$ampoules$of$10ml$(5gm)$with$1ml$lignocaine$2%$for$each$buttock$into$ upper$outer$quadrant$of$the$buttock$in$zigzag$manner$ ! MAINTENANCE$therapy$with$further$IM$5gm$MgSO4$(2$ampoules)$every$4$hours$ (alternate$buttocks)$ ! Recurrent$seizure$–$IM$5gm$MgSO4$ H After$fit$aborted,$to$take$GXM$and$PE$profile$ H Assess$GCS$level$and$neurological$status$ H Close$monitoring$of$vital$signs$ H Monitoring$during$MgSO4$therapy$ • Clinical$signs$of$MgSO4$toxicity$ ! Loss$of$deep$tendon$reflexes$(knee$jerk)$ ! Respiratory$depression$<$16/min$
OnG$ $ HPT$IN$PREGNANCY$ $ • How$to$manage:$ ! STOP$the$infusion$ ! Give$ANTIDOTE$–$IV$Calcium$Gluconate$10%$10mls$over$10$minutes$ ! Oxygen$and$maintain$the$airway$if$respiration$is$depressed$ ! If$knee$jerk$absent$but$normal$respiration$–$withhold$further$doses$of$MgSO4$until$ reflexes$return$ ! If$urine$output$<$100ml/4$hours$in$the$absence$of$above,$reduce$the$maintenance$ dose$IV$to$0.5gm/hour$or$IM$2.5gm$ • Monitor$knee$jerk,$RR,$urine$output,$SpO2$hourly$ H Control$BP$by$using$antihypertensive$ • Aim$to$keep$diastolic$BP$between$90H100$mmHg$ H DELIVERY$is$the$mainstay$of$treatment$of$eclampsia$ • Preferably$Caesarean$section$ • If$patient$is$already$in$2nd$stage,$to$proceed$with$assisted$SVD$ • Paeds$to$be$present$at$delivery$$ H Fluid$therapy$ • Fluid$restriction$of$80ml/hour$to$avoid$the$risk$of$fluid$overload$ $ Complications$of$preHeclampsia$ $ Maternal$ Fetal$ DIVC$ IUGR$ ARDS$ Abruptio$placenta$ Renal$failure$ Preterm$delivery$ Pulmonary$edema$ $ Cerebral$haemorrhage$ $ Cerebral$edema$ $ Subcapsular$hematoma$ $ $ $ References:$ 1. HTAR$OnG$protocol$ 2. NICE$clinical$guidelineH$The$management$of$hypertensive$disorders$during$pregnancy$ 3. http://www.uptodate.com/contents/gestationalHhypertension$ 4. http://www.uptodate.com/contents/pathogenesisHofHpreeclampsia$ 5. BMJ$practice$–$PreHEclampsia$ 6. Ten$Teachers$Obstetrics$ 7. American$College$of$Obstetricians$&$Gynaecologists$ $ $ $
GESTATIONAL*DIABETES*MELLITUS* Increase!in!blood!glucose!level!>!7.0mmol/L!or!>!11.1!mmol/L!2!hrs!post!prandial!(2HPP)!in!MGTT! Physiology! ↑!hPL!and!cortisol!→!insulin!antagonists!→!relative!insulin!resistance!(most!marked!during!3rd! trimester,!from!28!weeks!onwards)! ! Risk!factors!(indication!for!MGTT,!to!be!documented!in!pink!book)! P Obesity!(BMI!>30)! P Age!>35!y/o! P Family!history!of!DM! P Prev.!big!baby!(>4.0!kg)! P Prev.!unexplained!stillbirth! P Prev.!congenital!abnormalities! P Prev.!GDM! P PCOS! P Polyhydramnios! P Presence!of!glycosuria!in!>2!occasions! ! MGTT!!→!done!at!around!12P14!weeks! !!!!!!!!!!!!!→!if!normal!but!have!significant!risk!factors,!to!repeat!at!28P32! !!!!!!!!!!!!!!!!!!weeks!and!again!at!32P34!weeks! !!!!!!!!!!!!!→!if!high!risk,!to!repeat!as!early!as!24!weeks! ! !!!!!!!!!!!!!!!!!!!Normal!range!MGTT:! !!!!!!!!!!!!!!!!!!!FBS!P!<!5.6! !!!!!!!!!!!!!!!!!!!2HPP!P!<7.8! ! ! Aim!–!to!maintain!blood!glucose!level!at!4P6mmol/L! ! ! Antenatal!management! P Refer!dietician!for!diet!control! P Blood!sugar!profile!(BSP)!monitoring!2!weekly!at!KK! • Done!4!times!(fasting,!postPbreakfast,!postPlunch,!postPdinner)! ! !!!!!!!!!!!!!!!!!!!!Fasting:!3.5P5.2! PrePmeal:!3.5P5.9! 2HPP:!4.4P6.7! ! • Admission!for!BSP!stabilisation! ! FBS!≥!8!and!2HPP!≥!12!in!MGTT! ! Deranged!BSP,!at!least!2!point!≥!8!mmol/L! • BSP!monitoring!in!ward! ! On!diet!control!–!4!point!BSP!(fasting,!postPbreakfast,!postPlunch,!postPdinner/before! bed)! ! On!insulin!–!7!point!BSP!(fasting,!pre!&!post!meals)! ! Investigations:!FBC,!BUSE,!HbA1C,!UFEME! • If!patient!is!given!IM!Dexamethasone,!BSP!reading!might!be!off!because!of!the!steroid! effect!(↑!glucose)!
!OnG!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!GDM! ! Advise!patient!to!repeat!BSP!after!72hrs!of!IM!Dexa!administration! P HbA1c!!<!7.0! P SelfPmonitoring!blood!glucose!at!home! P Early!detection!of!complications! P Fetal!monitoring!for!growth!and!fetal!wellPbeing! • Ultrasound!(macrosomia,!polyhydramnios)! • Biophysical!profile! • Fetal!kick!chart! • CTG! P Insulin!therapy! • Actrapid!(short!acting,!given!before!meal)! • Insulatard!(long!acting,!given!before!bed)! P Refer!pharmacist!for!insulin!injection!technique! P Timing!of!delivery!(do!NOT!exceed!post!date!)! • On!diet!control!–!40!weeks! • On!insulin!–!38!weeks! ! Management!of!GDM!in!active!labour! *!applicable!to!all!diabetic!mothers!with!insulin!therapy!only! P Keep!NBM! P Omit!morning!!dose!of!insulin!injection!if!SI!<!20U!or!give!½!dose!if!SI!>!20U! P Hourly!DXT!monitoring! P Start!sliding!scale!(depend!on!DXT!reading)! P 4!hourly!BUSE,!RBS! P Take!GSH! P Pain!relief! P Hourly!CTG!monitoring! P Urine!ketone!2!hourly!if!labour!>!8!hours!(to!look!for!dehydration)! ! Sliding!scale!regime:! DXT! Insulin!infusion! <!4! Omit! 4!–!6! 1U/hr!(5U!insulin!in!500mls!D5%!+!1gm!KCl)! 6.1P9! 2U/hr!(10U!insulin!in!500mls!D5%!+!1gm!KCl)! 9.1P12! 3U/hr!(15U!insulin!in!500mls!D5%!+!1gm!KCl)! 12.1P15! 4U/hr!(20U!insulin!in!500mls!D5%!+!1gm!KCl)! 15.1P18! 5U/hr!(25U!insulin!in!500mls!D5%!+!1gm!KCl)! 18.1P21! 6U/hr!(30U!insulin!in!500mls!D5%!+!1gm!KCl)! ! ! DIK!regime! P A!constant!infusion!of!500!ml!of!D5%!dextrose!water!at!100mls/hr! P Preparation!of!soluble!insulin:!50U!Actrapid!in!50!ml!NS!(1U/ml)! P Baseline!BUSE,!check!K+!prior!to!KCl!infusion! P Separate!infusion!from!Syntocinon!infusion!(in!this!case,!patient!may!need!2!lines)! P Insulin!causes!potassium!shift!from!extracellular!into!intracellular!environment,!can!lead!to!↓! K+!in!the!bloodstream!→!hypokalemia!(the!reason!we!add!on!KCl)!
P Insulin!also!can!cause!hypoglycaemia!and!we!don’t!want!our!patients!to!go!into! hypoglycaemic!state!so!we!give!dextrose!solution! P DXT!monitoring!is!important!and!sliding!scale!is!adjusted!according!to!serial!DXT!reading! ! PostPpartum! P Delivery!of!baby!→!↓!insulin!requirement!→!off!insulin! P Monitor!DXT!in!baby!and!mother!prior!to!discharge! P Repeat!MGTT!in!6!weeks!post!delivery!to!check!if!GDM!has!resolved! P If!patient!is!a!known!case!of!DM,!start!back!their!prePpregnancy!dose!and!regime! P Encourage!breastfeeding! P Advice!for!contraception! ! ! Complications!of!GDM! ! Mother! Fetal! Nephropathy! Neural!tube!defect,!sacral! agenesis*! Retinopathy! Macrosomia! Coronary!artery!disease! Hypoglycaemia! Hyperglycemia/hypoglycaemia! Polycythemia! PrePeclampsia! Polyhydramnios!(fetal!polyuria)! Infection!–!UTI,!vaginal! candidiasis! Unexplained!IUD! Thromboembolism! RDS! DKA! Cardiac!anomalies! ! Hyperbilirubinemia! ! Preterm!labour! ! Birth!trauma:!shoulder!dystocia,! Erb’s!palsy! ! ! ! References:! 1. HTAR!OnG!protocol! 2. Oxford!handbook! 3. Ten!teachers!
OnG!
! !
!!!!!!!!!PPROM,(PROM!
!
PRETERM&PRELABOUR&RUPTURE&OF&MEMBRANE& ( Spontaneous(rupture(of(membrane(at(LESS(THAN(37(weeks(of(gestation(before(onset(of( labour(i.e(the(onset(of(regular(uterine(contractions.( ( − Complicates(2%(of(pregnancies(but(associated(with(40%(of(preterm(deliveries(and(can( result(in(significant(neonatal(morbidity(and(mortality( ( ALWAYS(CONFIRM(THE(GESTATION!!!( ( History(( − Sudden(gush(of(fluid(*( − Clear(fluid,(not(foul(smelling(*( − No(history(of(recent(trauma,(fall(or(abdominal(massage( − Last(sexual(intercourse?( − History(of(fever,(URTI(or(UTI(symptoms( ( Differential(diagnosis( − UTI( − Urinary(incontinence( − Vaginal(candidiasis(!(may(have(thick(curdy(discharge( ( Risk(factors( ( ( ( ( ( ( ( ( ( Investigations( − Nitrazine(testing( • Based(on(testing(the(vaginal(fluid(pH((pH:(4.5]6.0)( • Amniotic(fluid(pH:(7.1]7.3((alkaline)( • Nitrazine(paper(will(turn(blue(if(pH(>(6.0( − Microscopic(examination(of(vaginal(fluid( • Characteristic(ferning(of(the(crystalline(pattern(of(dried(amniotic(fluid(owing(to(its( sodium(chloride(and(protein(content(( − Litmus(test((red(to(blue)( − Amniocater( − High(vaginal(swab( − Ultrasound(to(look(for(oligohydramnios( ( Management(of(PPROM( − Assess(for(signs(of(infection,(watch(out(for(signs(of(chorioamnionitis( − FBC,(CRP( − Sterile(speculum(examination( • Look(for(POOLING(of(fluid(in(the(posterior(fornix( Maternal( Fetal( Infection((commonest)( Congenital(anomaly( Cervical(incompetence( Multiple(gestation( Multiparity( ( Low(socioeconomic(class( ( Poor(nutrition( ( Previous(scars( (• Cough(reflex(–(fluid(leaking(out(of(cervix( • Os(open(or(close?( • Litmus(test( • Amniocater(if(in(doubt( • Take(sample(of(HVS(for(culture( − CTG((for(>30(weeks)( − Steroids(administration(for(fetal(lung(maturity((IM(Dexamethasone(12mg(BD)(for(24] 36(weeks(of(gestation( − Start(prophylactic(antibiotic((T.(EES(250mg(QID(for(10(days)( − Strict(pad(chart(monitoring( − Avoid(digital(VE(unless(contraction(is(stronger( − Ultrasound(scan(for(fetal(assessment( − Inform(Paeds(for(neonatal(support(especially(ventilator(booking( − Monitor(vital(signs,(look(for(temperature(spike( − EXPECTANT(management:( ( Maternal( Fetal( Temperature( Fetal(movement(–FKC( FBC(and(CRP(biweekly( Growth(scan(biweekly( Pad(chart(–(change(of(liquor(colour( Daily(fetal(heart(monitoring( Uterine(assessment(](clinical( ( ( Expectant(management(is(the(preferred(management(provided(there(is(no(fetal(or(maternal( contraindication(till(34]36(weeks(of(gestation(depending(on(the(ventilator(support.( ( If(patient(is(in(labour,( − >34(weeks(:(consider(steroids(and(allow(labour(to(progress( − <34(weeks:(if(assessment(shows(no(adverse(factors,(to(proceed(with(tocolysis(and( allow(delivery(at(34(weeks( • According(to(RCOG,(tocolysis(is(not(recommended(because(this(treatment(does( not(significantly(improve(perinatal(outcome( − Intrapartum(antibiotics(as(per(protocol( ( Signs(of(chorioamnionitis:( − Maternal(pyrexia( − Tachycardia( − Leukocytosis( − Uterine(irritability( − Offensive(vaginal(discharge( − Fetal(tachycardia( ( Complications(of(PPROM( − Preterm(delivery(leading(to(prematurity( − Chorioamnionitis( − Neonatal(sepsis( − Pulmonary(hypoplasia( − Cord(prolapse( & &
OnG!
! !
!!!!!!!!!PPROM,(PROM!
!
PRELABOUR&RUPTURE&OF&MEMBRANE& ( Spontaneous(rupture(of(membrane(AFTER(37(weeks(of(gestation(before(the(onset(of(regular( uterine(contractions( ( PROM(≠(SROM( SROM(=(spontaneous(rupture(of(membrane(after(regular(uterine(contractions( ( Management(of(PROM( − Sterile(speculum(examination(to(confirm,(with(litmus(paper/(amniocater(as(an(adjunct( to(diagnosis((when(rupture(of(membrane(is(not(obvious)( − Avoid(digital(examination(as(it(can(introduce(infection( • If(per(speculum(shows(os(open,(to(proceed(with(VE(to(assess(os(dilatation( − CTG(stat(( − For(VE(upon(stronger(contractions((to(avoid(regular(VE(if(possible)( − Strict(pad(charting(with(noting(of(liquor(colour( − Monitor(vital(signs,(look(for(temperature(spike( − Watch(out(for(signs(of(chorioamnionitis( − Monitor(LPC/FKC/FHR( − To(report(any(decrease(in(fetal(movement( − IOL(if(not(delivered(within(24(hours( − Expectant(management(criteria((for(IOL(24(hours(later):( • Normal(pregnancy( • Sterile(speculum(with(NO(prior(digital(examination( • Reactive(CTG( • No(antenatal(risk(factors( • No(meconium(stained(liquor( • No(malpresentation( − Daily(CTG( − If(patient(is(in(labour,(to(commence(intrapartum(antibiotics( • To(start(IV(Benzylpenicillin(3gm(stat(and(1.5gm(TDS(if(leaking(>(18(hours((for(GBS( prophyaxis)( • Alternative:(IV(Ampicilin(2gm(stat(and(1gm(QID( ( ( ( ( ( References:( 1. HTAR(OnG(protocol( 2. Royal(College(of(Obstetricians(&(Gynaecologists(–(Preterm(Prelabour(Rupture(of( Membranes( 3. Ten(Teachers(Obstetrics(POSTPARTUM)HEMORRHAGE) $ Primary$PPH$0$Blood$loss$of$≥$500$ml$from$genital$tract$within$24$hours$after$delivery$ Secondary$PPH$0$Abnormal$or$excessive$bleeding$from$the$birth$canal$between$24$hours$and$ 6$weeks$postnatally$ $ Priorities$ − Call$for$help$(to$assist$in$controlling$bleeding)$ − Assess$the$patient’s$condition$ − Find$the$cause$of$bleeding$ − Stabilize$or$resuscitate$the$patient$ − Prevent$further$bleeding$ $ Causes$of$PPH$ 4$T$–$tone,$trauma,$tissue,$thrombin$ $ Risk$factors$ − Prolonged$3rd$stage$of$labour$ − Multiple$pregnancy$ − Caesarean$section$ − Episiotomy$ − Antepartum$hemorrhage$ − History$of$PPH$ − History$of$retained$placenta$ − Fetal$macrosomia$ − Polyhydramnios$ − Grandmultipara$ − Anemia$$ $ GENERAL$measures$in$managing$PPH$ − ABC$ − Set$2$IV$lines$(large$bore$branula)$and$take$blood$for$FBC,$GXM$(4$units),$PT,$aPTT$ − Stabilize$ patient$ with$ crystalloids$ (Hartmann’s$ or$ normal$ saline)$ or$ colloids$
(Gelafundin,$Hemacel)$and$run$fast$ − High$flow$oxygen$ − Monitor$parameters$closely$ • General$condition$ • Level$of$consciousness$ • BP,$PR$ • Pad$chart$ • Strict$I/O$charting$ − Abdominal$palpation$ • If$the$uterus$is$not$contracting$and$soft$(boggy)$!$atony$ Tone$ Uterine$atony$(most$common$cause)$
Trauma$ Genital$ tract$ trauma,$ laceration,$ hematoma,$ uterine$ inversion,$ uterine$ rupture$
Tissue$ Retained$placenta$ Thrombin$ Coagulation$disorder$
OnG$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$PPH!
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" Empty$bladder$ " Give$uterotonic$drugs$ • If$the$uterus$is$well$contracted,$the$cause$of$bleeding$is$likely$to$be$genital$tract$ trauma$ − Careful$inspection$of$cervix,$vagina,$vulva,$perianal$area$for$lacerations,$hematoma$ − Manual$exploration$of$uterine$cavity$–$remove$clots,$retained$tissue$ − Consider$coagulopathy$if$no$other$cause$identified$ $ SPECIFIC$measures$in$managing$PPH$ $ 1. Uterine$atony$− Initially$ treated$ with$ bimanual$ uterine$ compression$ and$ massage$ to$ produce$ contraction$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ − Medical$treatment:$
• IM$ Syntometrine$ 1ml$ (Syntocinon$ 5U$ +$ Ergometrine$ 0.5mg)$ –$ contraindicated$in$HPT,$heart$disease$ • IM/IV$Syntocinon$5U$if$Syntometrine$is$contraindicated$ • IV$Pitocin$40U$in$500mls$normal$saline$at$40dpm$–$may$increase$up$to$80U$ • IM$Carboprost$(Hemabate)$250mcg$–$dose$can$be$repeated$every$15$mins$ up$to$a$maximum$of$2mg$ *$Carboprost$is$150methyl$prostaglandin$F2a$
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Insert$Foley’s$catheter$to$empty$bladder!−
Check$the$placenta$for$completeness$to$rule$out$retained$placenta$and$look$for$ cervical$lacerations$to$rule$out$genital$tract$trauma!−
If$bleeding$persists$!$surgical$intervention!•
Balloon$tamponade!•
Hemostatic$brace$suturing$(B0Lynch$compression$sutures)!•
Bilateral$ligation$of$uterine$arteries!•
Selective$arterial$embolization!•
Hysterectomy$(last$resort$if$everything$fails)!!
2. Retained$placenta!−
Assess$the$patient’s$condition$&$estimate$blood$loss!−
Empty$the$bladder!−
Attempt$controlled$cord$traction$!•
If$successful,$examine$the$placenta$to$ensure$completeness.$Maintain$the$ uterine$ contractions$ by$ massaging$ the$ fundus$ of$ the$ uterus.$ Put$ up$ IV$ Pitocin$40U$in$500mls$normal$saline$and$run$over$406$hours!•
If$fails$!$manual$removal$of$placenta$under$anaesthesia!•
Cover$with$broad$spectrum$antibiotics$(IV$Cefuroxime$1.5gm$and$IV$Flagyl$ 500mg)!!
3. Genital$tract$trauma$ − Stabilize$patient$first$ − Put$patient$in$lithotomy$position$ − Find$the$bleeding$point$if$visible$and$clamp$it$ − Suture$tear$immediately$ − Watch$out$for$further$bleeding$ − For$examination$under$anaesthesia$(EUA)$if$ • Failed$to$identify$the$source$of$bleeding$ • Patient$restless$or$uncooperative$or$vital$signs$are$unstable$ • Bleeding$continues$despite$repair$done$ − Cover$with$broad$spectrum$antibiotics$ $ Prevention$of$PPH$ − Active$management$of$the$third$stage$of$labour$lowers$maternal$blood$loss$and$reduces$ the$risk$of$PPH$ − Prophylactic$oxytocics$should$be$offered$routinely$in$the$management$of$the$third$stage$ of$labour$in$all$women$as$they$reduce$the$risk$of$PPH$by$about$60%$− For$ women$ without$ risk$ factors$ for$ PPH$ delivering$ vaginally,$ oxytocin$ (10U$ by$ IM$ injection)$is$the$agent$of$choice$for$prophylaxis$in$the$third$stage$of$labour$ − For$women$delivering$by$caesarean$section,$oxytocin$(5U$by$slow$IV$injection)$should$be$ used$to$encourage$contraction$of$the$uterus$and$to$decrease$blood$loss$ $ $ References:$ 1. HTAR$OnG$protocol$ 2. American$Family$Physician$–$Prevention$&$Management$of$Postpartum$ Hemorrhage$ 3. Royal$College$of$Obstetricians$&$Gynaecologists$–$Postpartum$Hemorrhage$
OnG$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$MISCARRIAGES$
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MISCARRIAGES) ) Spontaneous$loss$of$pregnancy$before$the$fetus$reaches$viability,$before$22$weeks$of$ gestation$ $ Classification$of$miscarriage$ Types$ Description$ Threatened$miscarriage$ − PV$bleeding$or$spotting$that$may$persist$for$days$or$ weeks,$cramping$abdominal$pain$ − Cervical$os:$Closed$ − Uterus$≈$date$ − USG:$IUGS$seen,$viable$fetus,$FH$+,$fetal$echo$+$ − Plan:$Allow$discharge$with$reassurance;$TCA$2/52$to$ repeat$scan$to$confirm$fetal$viability;$TCA$stat$if$pass$out$ POC,$PV$bleed,$abdominal$pain$ − DDX:$ectopic$pregnancy,$twisted$ovarian$cyst$ Inevitable$miscarriage$ − Bleeding$is$heavy$or$increasing,$and$abdominal$cramping$ is$present$but$NO$passing$out$POC$ − Cervical$os:$Open$ − Uterus$≈$date$ − USG:$IUGS,$no$fetal$heart$beat$ − Plan:$ • Counseling$ • Keep$patient$in$ward$until$expulsion$has$occurred$ completely$ • Monitor$VS$and$pad$chart$ • Analgesics$ • Repeat$per$speculum$if$PV$bleeding$and$abdominal$ pain$increasing$ • If$expulsion$has$not$occurred$within$12$hours$for$ Cervagem$1mg$to$hasten$the$process$ Incomplete$miscarriage$ − Pass$out$parts$of$POC$but$some$remains$in$the$uterus,$PV$ bleeding$(may$be$heavy$bleeding),$abdominal$pain$ − Cervical$os:$Open$ − Uterus$<$date$ − USG:$heterogenous$tissues$in$uterus$±$gestational$sac,$ any$endometrial$thickness$ − Plan:$ • Assess$the$degree$of$PV$bleeding,$resuscitate$if$ necessary$ • If$POC$can$be$seen$on$per$speculum$!$to$remove$ with$sponge$forceps,$then$scan$to$determine$any$ retained$products$ • IM$Syntometrine$1$amp$stat;$if$contraindicated,$to$ give$IV$Syntocinon$10$U$ • If$retained$!$emergency$ERPOC$ • Allow$discharge$after$6$hours$of$ERPOC$if$stable$ • MC$for$2/52$ $ $Missed$miscarriage$ − Gestational$sac$containing$embryonic$death$but$no$ passing$out$of$POC$ − PV$bleeding,$pain,$loss$of$pregnancy$symptoms$ − Cervical$os:$Closed$ − Uterus$<$date$ − USG:$collapsed$empty$IUGS,$gestational$sac$diameter$ >20mm$with$no$fetal$pole,$no$FH$activity$ − Plan:$conservative$vs$active$management$ • Allow$discharge,$TCA$2/52$to$repeat$scan$to$confirm$$ • Conservative$–$let$POC$comes$out$naturally$ • Active$–$ERPOC$(S+C,$D+C)$ • FBC,$GSH,$screening$for$coagulopathy$ − DDX:$TRO$wrong$date,$early$pregnancy$ Complete$miscarriage$ − All$POC$have$been$expelled$ − Commonly$occurs$before$12$weeks$of$pregnancy$ − After$the$miscarriage$there$is$a$period$of$bleeding$and$ cramping,$which$resolves$without$treatment$ − Cervix$os:$Closed$ − USG:$empty$uterus$with$no$sign$of$gestational$sac$or$ embryo$seen,$endometrial$thickness$<15mm$ − Plan:$ • Examine$POC,$send$POC$for$HPE$ • Assess$bleeding$ • Scan$to$confirm$ • IM$Syntometrine$1$amp$stat,$then$reassess$in$an$ hour$ • If$bleeding$stops,$can$allow$discharge$ • MC$for$1/52$ • Avoid$sexual$intercourse$for$2^3$weeks$ • Counseling$before$discharge$ Septic$miscarriage$ − Any$abortion$that$becomes$infected$ − Symptoms$include$fever,$chills,$flu^like$aches,$abdominal$ pain,$vaginal$bleeding,$and$vaginal$discharge,$which$may$ be$thick$and$may$have$a$foul$odor$ − Commonest$organisms:$E.coli,$Streptococci,$anaerobes$ − May$lead$to$septic$shock$ − Causes$ • Delay$in$evacuation$of$uterus$ • Trauma$$ − Plan:$ • D&C$as$soon$as$possible$ • Cover$with$broad$spectrum$antibiotics$(IV$ Cefuroxime$750mg$TDS,$IV$Flagyl$500mg$TDS)$ • FBC,$RP,$blood$C+S,$urine$C+S,$HVS$C+S,$coagulation$ screening$ − Complications:$Pelvic$abscess,$septic$shock,$chronic$PID,$ uterine$synechae$ $
OnG$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$MISCARRIAGES$
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Diagnosis$ − In$some$cases,$miscarriage$can$be$diagnosed$based$upon$the$woman's$symptoms$and$ the$physical$exam$ − Ultrasound$ • In$early$pregnancy$!$TVS$$ • If$an$embryo$is$present,$its$size$is$measured$and$compared$to$the$size$that$is$ expected$at$the$woman's$stage$of$pregnancy$ • The$sac$and$other$materials$surrounding$the$embryo$are$also$examined$to$look$for$ abnormalities$in$these$structures$ − Fetal$heart$beat$ • At$about$6$weeks$after$the$LMP,$the$motion$of$the$fetal$heart$should$be$visible$on$ ultrasound$ • If$the$pregnancy$has$progressed$to$the$stage$where$a$heart$beat$should$be$present,$ the$failure$to$detect$a$heart$beat$during$an$ultrasound$exam$indicates$that$the$ pregnancy$has$likely$ended$ • On$the$other$hand,$the$presence$of$a$fetal$heart$beat$(in$the$absence$of$other$ abnormalities$in$the$pregnancy)$indicates$the$pregnancy$may$still$be$viable$and$ that$miscarriage$may$not$occur$ $ $ Counselling$before$discharge$ − Cause$of$miscarriage$ − Avoid$sexual$intercourse$for$2^3$weeks$ − Contraception$for$3$months$(incomplete$miscarriage)$ − TCA$stat$if$"$PV$bleeding,$severe$abdominal$pain,$or$pass$out$POC$ − TCA$gynae$clinic$for$assessment$ $ $ $ $ $ $ $ References:$ 1. Ten$Teachers$Gynaecology$ 2. Kedah$Hospital$Protocol$ $ECTOPIC'PREGNANCY' $ Definition:$Implantation$of$conceptus$outside$the$uterine$cavity$ $ − A$potentially$lifeAthreatening$condition$ − Ruptured$ectopic$pregnancy$is$a$gynaecological$emergency$ − Recurrence:$10%$ − 95A98%$of$ectopic$pregnancies$occur$in$Fallopian$tube$with$ampulla$is$the$most$ common$site$for$tubal$pregnancies$ $ Risk$factors$ − Advanced$maternal$age$(>$35$years$old)$ − Previous$history$of$PID$and$tubal$surgery$ − Previous$history$of$ectopic$pregnancy$ − Pregnancy$with$IUCD$in$situ$ − Infertility$ − Congenital$abnormality$of$Fallopian$tube$ − Assisted$reproductive$technique$ − Smoking$$ $ History$ − PV$bleeding$ − Severe$abdominal$pain$$ − UPT$positive$ − Shoulder$tip$pain$(blood$irritating$the$diaphragm)$ − Fainting$spells,$dizziness$ $ Physical$examination$ − Pale,$hypotension,$tachycardia$ − Abdominal$tenderness$if$intraperitoneal$bleeding$ − Pelvic$examination:$bluish$cervix$with$os$closed,$+$cervical$excitation,$adnexal/POD$ tenderness/mass$ $ TVS$(must$be$interpreted$together$with$serum$βAhCG)$ − Empty$uterus$(no$IUGS$seen)$ − Free$fluid$in$POD$(nonAspecific)$ − Ectopic$gestational$sac$(extrauterine$sac$with$an$embryo$or$embryonic$remnants)$ − Presence$of$adnexal$mass/sac$±$free$fluid$ $ Investigations$ − UPT$to$confirm$pregnancy$ − FBC$ − Coagulation$profile$if$signs$of$coagulopathy$present$$ − GXM$4$pints$packed$cell$ − Ultrasound$ − Serial$serum$βAhCG$if$diagnosis$in$doubt$$ • In$99%$of$viable$intrauterine$pregnancies$A$!$hCG$levels$of$at$least$53%$ (doubling)$in$48$hours$ • When$level$is$above$discriminatory$level$(>$1000$U/L)$&$no$sign$intrauterine$ Ruptured$ectopic$"$intraperitoneal$ bleeding$
OnG$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ECTOPIC$PREGNANCY$
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• Serum$quantitative$hCG$can$be$used$to$differentiate$between$an$ectopic$ pregnancy$&$a$failing$intrauterine$gestation$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ General$management$ − Resuscitation$ − Arrange$for$surgical$intervention$ − Counseling$regarding$the$diagnosis$and$plan$ − To$give$IM$Rhogam$500$IU$if$mother$is$Rhesus$negative$ $ Definitive$management$"$Surgery!$ − Laparoscopy$is$the$gold$standard$of$treatment$to$establish$the$diagnosis$and$should$ be$considered$in$women$with$hCG$above$the$discriminatory$level$and$absence$of$IUGS$ on$ultrasound$ − Laparoscopy/laparotomy$with$salphingectomy/salphingostomy$ $ Criteria$for$IM$Methotrexate$50mg/m2$single$dose$ − Unruptured$ectopic$<$3.0cm$ − No$fetal$heart$motion$ − Patient$being$fully$counseled$and$good$compliance$ − Decision$made$by$OnG$specialist$ − No$contraindication$to$methotrexate$such$as$ • Active$hepatic$disease$ • Renal$disease$ • Abnormal$serum$creatinine$and$SGOT$ • Active$peptic$ulcer$disease$ • Leucocyte$<3000$and$platelet$<100,000$ $ $ References:$ 1. Kedah$Hospital$Protocol$ 2. Ten$Teachers$Gynaecology$ 3. BMJ$Practice$–$Ectopic$Pregnancy$ 4. American$College$of$Obstetricians$&$Gynaecologists$–$Ectopic$Pregnancy$ A$steady$decrease$in$ hCG$in$48$hours$$ Suboptimal$increase$ (<53%)$or$plateauing$ of$hCG$values$ Failing$intrauterine$ pregnancy$ Ectopic$pregnancy$GESTATIONAL*TROPHOBLASTIC*DISORDERS* $ − Arise$from$placental$trophoblasts$ − Syncytiotrophoblasts$secrete$hCG$!$used$as$tumour$marker$ $ $ Molar$Pregnancy$ $ Complete*hydatidiform*mole* Partial*hydatidiform*mole* Generalized$swelling$of$the$villous$tissue$ Focal$swelling$of$the$villous$tissue$ Diffuse$trophoblastic$hyperplasia$ Focal$trophoblastic$hyperplasia$ No$embryonic$or$fetal$tissue$ Presence$of$embryonic$or$fetal$tissue$ Diploid$chromosomal$constitution$derived$ from$paternal$genome$&$usually$resulting$ from$ the$ fertilization$ of$ an$ oocyte$ by$ a$ diploid$spermatozoon$
Usually$ triploid$ and$ of$ diandric$ origin,$ having$ 2$ sets$ of$ chromosomes$ from$ paternal$origin$&$1$from$maternal$origin$ O$ most$ have$ a$ 69XXX$ or$ 69XXY$ genotype$ derived$ from$a$ haploid$ ovum,$with$ either$ reduplication$ of$ the$ paternal$ haploid$ set$ from$ a$ single$ sperm,$ or$ from$ dispermic$ fertilization$ $ Risk$factors$ − Advanced$maternal$age$(>35$years$old)$ − Previous$history$of$molar$pregnancy$ − Blood$group$A$(assoc.$with$choriocarcinoma)$ $ Signs$&$symptoms$ − PV$bleeding$ − Uterus$larger$than$dates$ − Abnormally$high$serum$hCG$for$gestational$age$
− Medical$ complications:$ PIH,$ hyperthyroidism,$ hyperemesis,$ anemia,$ ovarian$ theca$ lutein$cysts$
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Ultrasound$
− Uterine$ cavity$ filled$ with$ multiple$ sonolucent$ areas$ of$ varying$ size$ &$ shape$ (snowO storm$appearance)$with$no$embryonic$or$fetal$tissue$ $ $ $ $ $ $ $ $ $ $ $ $ $
OnG$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$GESTATIONAL$TROPHOBLASTIC$DISORDERS$
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Investigations$ − Serial$serum$beta$hCG$ − HPE$of$placental$tissue$:$placental$villi$with$irregular$architecture,$edema$with$true$ villous$cavitation,$and$trophoblast$hyperplasia$ $ Management$ − Uterine$evacuation$(S&C)$− Serial$ measurement$ of$ hCG$ levels$ is$ the$ gold$ standard$ for$ diagnosis$ &$ monitoring$$ the$therapeutic$response$of$GTD$
• After$ evacuation,$ hCG$ level$ should$ be$ monitored$ weekly$ until$ detectable,$ followed$by$monthly$monitoring$for$6O24$months$ $ $ Choriocarcinoma$ $ − A$highly$malignant$tumour$that$arises$from$trophoblastic$epithelium$ − Rapidly$metastasizes$to$the$lungs,$liver$and$brain$
− Following$ uterine$ evacuation,$ molar$ pregnancy$ can$ progress$ to$ develop$ choriocarcinoma$ − Many$patients$will$present$with$SOB,$neurological$symptoms$&$abdominal$pain$for$few$ weeks$or$months$ $ $ $ $ $ References:$ 1. Ten$Teachers$Gynaecology$ 2. BMJ$Practice$–$Molar$Pregnancy$
MENORRHAGIA* $ Heavy$cyclical$menstrual$blood$loss$over$several$consecutive$menstrual$cycles$in$a$woman$of$ reproductive$years,$or$more$objectively,$a$total$menstrual$blood$loss$of$more$than$80$ml$per$ menstruation$(Hallberg$et$al,$1966).$ $ Causes:$ 1. Idiopathic$–$Dysfunctional$uterine$bleeding$(DUB)$ 2. Secondary$$ − Uterine$fibroid$ − Endometrial$polyp$ − Endometriosis$ − Coagulopathy$ − Drug$therapy$(warfarin,$IUCD)$ − Hypothyroidism$ $ Dysfunctional$uterine$bleeding$ • A$diagnosis$of$exclusion$ • Abnormal$uterine$bleeding$in$the$absence$of$pregnancy,$genital$tract$pathology,$or$ systemic$disease$ • Mechanisms$of$DUB$
− Abnormal$ prostaglandin$ ratios$ and$ other$ inflammatory$ mediators$ !$ vasodilatation$&$platelet$nonTaggregation$ − Excessive$fibrinolysis$$ $ Management$of$Menorrhagia$ − Full$history$ • Pattern$of$menstrual$blood$loss$ • Association$with$dysmenorrhea$ • Symptoms$of$anemia$ • Symptoms$of$hypothyroidism$ • Bleeding$tendencies$
• Risk$ factors$ for$ endometrial$ disease$ (age$ >40,$ obesity,$ nulliparity,$ infertility,$ tamoxifen$therapy,$underlying$DM,$PCOS)$ • Smear$history$ • Use$of$contraception$ • History$of$drug$therapy$ − Physical$examination$ • Abdominal$examination$ • Per$speculum$examination$ • Bimanual$examination$ − Investigations$ • FBC,$GXM$ • TFT$and$coagulation$profile$if$clinically$indicated$ • Pap$smear$if$indicated$ • Ultrasound$$ • TVS$to$identify$fibroids$&$polyps,$measure$endometrial$thickness$(ET)$–$usually$ indicated$if$age$>40,$failed$medical$therapy,$presence$of$risk$factors$
OnG$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$MENORRHAGIA$
