OBSTETRICS
PRE-PREGNANCY AND PREGNANCY COUNSELING Unplanned PregnancyCase: Jenny is 32-years-old and has attended your surgery for routine checks for the past 3 years. She was last seen 6 months ago for pap smear which was normal. At the time of the last consultation, the BP was 130/70 and breast examination was normal. CVS and respiratory examination were normal. Jenny is married and has 2 sons, 10 and 8.
Patient Profile
- Name: Jenny Smith - DOB: 10/04/74 - No allergy
- Occupation: Nursing home receptionist - Family history: Nil
- Medication: Nil
- PMHx: antidepressant given for 2 months at the age of 20 years old; contraception: partner has vasectomy 2004
Task
a History
b Physical examination (BMI 24, PT +, urine dipstick negative, BP
c Discuss essential issues with patient and management
History
- Abdominal pain? SORTSARA? Reflux symptoms? N/V? change in bowel movements or urine? Vaginal discharge?
- Symptoms of depression? Symptoms of STD (nocturia, pain, weight loss, unexplained fever) Physical examination
- General appearance - Vital signs
- ENT:
- Chest and lungs - Cardiac - Abdomen
- PV
- Urine dipstick and BSL Management
- Offering appropriate treatment for nausea - Medications, rest and fluids
- Explore patient’s attititude towards the situation - Ensure support is available
- Offer support
- Followup management
- Plans for blood test and STD screening in the future Home Delivery
Case: Your next patient in GP practice is a 24-year-old lady who would like to discuss option of home delivery.
Task
a. Relevant history (LMP 3months ago, confirmed by home PT)
b. Examination findings
c. Investigation and Management
History
- I understand that you’re here because you wanted to discuss about home delivery. Are you pregnant at this stage? When was your LMP? How did you confirm pregnancy? How were your periods before? Did you see any doctor until now? Did you take any folic acid? Do you have any history of hypertension, epilepsy, diabetes or asthma? Any past history of admissions? Do you know about your blood group? Were you ever infected with Rubella? Is this is a planned pregnancy? SADMA? Social history? Do you have enough support? Financial problems? Do you have other kids? How far do you live from the hospital? FHx? Physical Examination
- General appearance - Vital signs
- Neck and breast - Chest and Lungs - Abdomen - Pelvic
- Urine dipstick, BSL and urine PT Management
- I appreciate your concern. Before we discuss options about home delivery, I would recommend for you to have regular antenatal care which is very important for you and your baby. As part of the routine, we will start with blood tests: FBE, Iron studies, blood group and Rh, TORCH, HIV, hepatitis B, syphilis, Pap smear if due, urine MCS, and BSL. At 18 weeks we will organize an ultrasound to check the placenta and presence of abnormalities of fetus. Around 26-28 weeks we will organize a sweet drink test for diabetes mellitus and at 36 weeks we will do a swab to detect a bug in the vagina. I would like to review you monthly up to 28 weeks then every 2 weeks from 28 weeks up to 36 weeks then weekly until delivery.
- You would like to have a home delivery. It is a good idea because you will have your family members and would be more comfortable for you. Usually, there is a 20-30% more chance of problems encountered during the first pregnancy and labor. During pregnancy, there might be an increased risk of having increased blood pressure, diabetes, antepartum bleeding, decreased fetal movements of the baby, and chance of twin pregnancy. All these things are potentially risky and can carry bad outcomes. That is the reason we are doing antenatal care to pick them up early and minimize the risk. Even with normal antenatal course, there are some unpredictable complications at the time of labor such as fetal distress,
intrapartum/postpartum hemorrhage, obstructed labor, cord prolapse, shoulder dystocia, meconium aspiration, and such complications need urgent hospital setting with all medical staff and appropriate equipments present. If you don’t like hospitals, there are birth centers or family birthing suites or units which are small and home-like, but they have midwife and specialist if required. I would recommend you to have a safe delivery at the hospital, but at the end, it is your choice. If you still want to go for home delivery, I would advise you to stay near the hospital especially towards the end of pregnancy. You must have ambulance cover in case it is required and there should be enough support at home. We will do regular antenatal care and if there are problems during the course of your pregnancy, then it is not recommended. - Reading materials. Review.
Case: G1P0 female at 24 weeks AOG asking when to go to hospital for delivery
Tasks:
a. Focused history
b. Answer patient’s questions c. Counsel accordingly Focused History:
- Congratulate patient as it is her first pregnancy - Informed consent
- How is the pregnancy? Any problems?
- Any previous miscarriages (if yes: details on why, when, AOG)
- Is this a planned pregnancy? - Regular antenatal checkups?
- Workups: blood tests? USD? – results? - PMHx: infections (esp TORCH), DM, HPN - BLOOD GROUP
- Location: how far do you live from the hospital? In emergency cases, can anyone drive you to the hospital? Do you have relatives? Who do you live with at home?
- P/SHx: smoker? Alcoholic beverage drinker? Recreational drug use?
- Any medications being taken? Allergies? - Last pap smear?
- Gardasil vaccination Counselling:
- Timing of delivery varies among women. Generally, at 40 weeks, women experience backache, tummy pain, and passage of mixture of water and blood from vagina
- Labor pains result from strong uterine contractions similar to period pain and are usually intermittent, initially after 20-45 minutes over a period of several hours grows stronger and lasts longer time to go to the hospital and MW will measure the time for the pain - Sometimes towards the end of pregnancy there are
UC that give a feeling of false pain and it is important to recognize the pattern of labor pain
- If you develop serious symptoms (bleeding, passing of blood clots, reduced fetal movements, or trauma) report to the hospital ASAP
- Sometimes PIH can occur during 2nd and 3rd trimester. Sx are headache, visual problems, swelling check BP urgently and treat rising BP to prevent any complications
- Duration of labor is not predictable because it depends on several factors:
o Size of the baby o Position of the baby o Age of the female o Size of maternal pelvis o Any form of comorbid illness
o Usually: <12 hours for multiparous and 16-18 hours for primipara
- Reassurance of support and pain relief throughout duration of labor by the MW, MDs and nurses - Advise on regular antenatal checkups
o Monthly up to 28 weeks o Fortnightly from 28-36 weeks o Weekly >36 weeks until delivery o Check BSL (OGTT) at 28 weeks AOG,
vaginal swab to check for GBS at 34 weeks) – important to predict a spontaneous and normal labor
- Give reading materials and write a script for vitamins
- Arrange for followup with MW and may arrange for specialist consultation if requested
Pre-pregnancy counseling regarding a patient with epilepsy Case: 26-year-old female presented in your GP who’s known to be epileptic and is treated by sodium valproate. Over the last 2 years, she had not fits and now in your GP clinic, asking for an advice for her chances and preparation to be pregnant. Task
a. Counsel patient (include risks) History:
- 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? 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)
- Menstrual history: date of 1st period (menarche)? Regularity of period? Description of cycle/period (no. of days of cycle? Days of period) any painful period? Any heavy bleeding or clots?
- Sexual history: are you sexually active? In a stable relationship? Any contraception used? Any known previous STIs?
- Antenatal history: details of any previous pregnancies? Any previous miscarriages?
- PMHx: any other associated systemic illnesses? DM? Hypertension?
- Social hx: family hx? SMADMA? Previous pap smear? Gardasil vaccination (14-26)? Blood group?
Counselling tips:
- Remember to be positive!
- Tell criteria to be eligible for pregnancy o For DM: HbA1c <7 for last 3 months o Epilepsy: free of fit for 2 years
o SLE: no active disease for the last 6 months o DVT/PE: thrombophilia screen negative - Mention fetomaternal risks associated with pregnancy! - The management should be by multi-disciplinary
approach.
- Are you alone? Would you like someone to be with us?
Counselling
- Although the outcome is successful for more than 90% of epileptic women to be pregnant, there is increased risk of fetomaternal risks during pregnancy. - For the mother, there is increased risk of vaginal
bleeding especially at the 3rd trimester, relapse of seizures more towards 3rd trimester and during labor. In 3rd trimester, level of absorption of medications is reduced hence, there are higher chances of relapse and bleeding.
- For the baby, there is a risk of cleft lip, NTD, PTL, low birth weight
- But, you fit the criteria to be pregnant having no fits for the last 2 years.
- The management should be by multi-disciplinary approach. I will refer you to a neurologist for review and an obstetrician. I will also arrange for referral to a high risk pregnancy clinic in a tertiary hospital to look after you. The neurologist will review your medication as I don’t think sodium valproate is the best
carbamazepine is less risky. Meanwhile, I will refer you to an obstetrician to make sure everything is alright and he will follow you up during pregnancy as well.
- All antenatal checkup tests will be done before pregnancy.
- We will start you with 5mg of folic acid from 1st visit attempting pregnancy (3 months before pregnancy up to 1st trimester).
- Vitamin K to prevent bleeding especially 26th week onwards
- Post-delivery mother should nurse baby on the floor surrounded by cushions. Breastfeeding is okay. Baby will not be epileptic. Familial tendency doesn’t increase.
- Review of anti-epileptic medications will be done by neurologist after delivery.
- High-risk pregnancy: combined 1st trimester screen (blood plus usg looking for nuchal translucency and nasal bone); if not high risk: 18-21 and 28-34 weeks - All should deliver in tertiary hospital and shall have
planned labor when they have completed 37 weeks. Pre-pegnancy DVT Counseling
Case: 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 counseling. She has stopped warfarin 12 months ago. There are no abnormalities on PE. She is not overweight.
Task
a. Take relevant history (NSVD, episiotomy scar and baby was normal; did not breastfeed; DVT happened postpartum and treated with warfarin x 6 mos) b. Management
History
- How was the previous pregnancy? When did the DVT happen and how was it treated? Have you had any clotting episodes other than that? Do you have any calf pains? Shortness of breath? Recent long immobilization? Any other bleeding problems (in the family)?
- Contraception? Periods? Are they longer? Do you bleed heavily during your periods? Blood group? - Rubella status (vaccinate and avoid pregnancy for 3
mos)?
- FHx of bleeding disorders? - SADMA?
Management
- Since you had a previous history of clotting during your first pregnancy, you have a high risk of having another one. Pregnancy itself is a hypercoagulable state because of the physiological and hormonal changes. Your pregnancy will be monitored by a physican and obstetrician and GP.
- Before you get pregnant I would like to do some tests to exclude a group of disorders that can predispose to clotting. This is known as thrombophilia screening. There are 7 things in this screening: Protein C & S, factor V Leiden, antithrombin III, anticardiolipin, antiphospholipid antibodies and anti-lupus anticoagulant
- Rubella vaccination if not yet immunized - Start taking folic acid 0.5mg OD 3 months before
pregnancy and up to first trimester of pregnancy - During pregnancy, you would be managed by a team.
We will start you on LMWH on the 14th week of gestation as a prophylactic measure until 6 weeks post delivery.
- It’s advised to wear elastic compression stockings during the day and avoid immobilization
- Labor will be in a controlled manner at 38-39 weeks. On the planned date, we will withhold the morning dose of heparin. After labor, warfarin would be given for 6 weeks (safe in breastfeeding) and we will monitor INR everyday to begin with (INR 2-3).
- If thrombophilia screen is positive: lifelong warfarin Critical issues: failure to do thrombophilia screen; failure to advise LMWH during pregnancy; and failure to advise about warfarin use in pregnancy
Pre-Pregnancy Counseling of Obese Women
Case: You are a GP and a 30-year-old female came in because she has been trying to conceive for the last 12 months. She wants your advice on that matter. Height 1.5m, BMI 40, BP Normal, BSL Normal
Task
a. History not more than 3 minutes (periods irregular, 5-6 weeks pain, stable partners, pap smear 1 year ago, junk food, no exercise)
b. Counsel regarding c. Advise Accordingly Infertility - >12 mos: investigation - >24 months: infertile History
- I can see that you have been trying to conceive. Is there anything in particular that concerns you? Do you think you might be pregnant now? N/V/mood changes? Irritability? Breast tenderness?
- May I ask if you and your partner are aware of optimal time for sexual activities? What contraceptives were you using before? How are your periods? Regular? Cycle? Any abdominal pain? Bleeding heavy? - Obstetric history: ever been pregnant? Miscarriages
before?
- I understand you are in a stable relationship. Any history of STI in yourself or your partner? PMHx or Surgical conditions especially gynecologic surgery? Thyroid problems? PCOS?
- FHx: infertility? Gyne problems? Recurrent
miscarriages? Any pregnancy-related problems (CPD, difficult delivery)
- Have you noticed any recent changes to weight? Hair growth, acne? How is your appetite? Water work? Bowel habits? How is your sleep?
- SADM (pills, steroid, anti-psychotic) A?
- I can see from your notes that your BMI is a bit high. Has it always been like this or is this a new change? Anybody in family overweight?
- Have you ever had BP, BSL, lipid level checked? What was the result? Have you have ever had joint problem? How do you feel about your weight? How does your weight affect your life?
Diagnosis
- First of all, it is very good that you have come for some advice before falling pregnant. Apparently, everything seems normal except your weight. The BMI is an indicator of your healthy weight. The normal is between 18-24. If >35 it is morbid obesity that puts the patient at a very high risk of developing
obesity-related problems (heart disease, hypertension, stroke, joint problems, DM, stress or depression).
- I can see that you are already worried about your weight. The obesity affects out health generally as well as related to pregnancy especially. Obese females have higher chance of developing menstrual irregularities, problems with ovulation that can sometimes lead to infertility. According to a study, around 40% of obese females have problems conceiving. Hence, it is very important for you to start losing weight now.
o Set a goal: 5-10% of BW in 6-12 mos o Make dietary changes – refer to dietitian o Increase energy expenditure by exercising
regularly. I will give you some written material regarding exercise
o Please keep a diary of your diet and weight o Come for regular followup
- I want you to be aware of certain obesity-related complications during your pregnancy, during labor and afterwards.
- During pregnancy, you are at risk of developing:
o GDM
o Pegnancy-induced hypertension o Sleep apnea
o Problems with baby’s growth and development (IUGR is common).
- We will check your BSL at 26 weeks and regularly at each visit. You will have regular ultrasound to check growth of baby. Your antenatal visits will be more frequent than other females. At 28-34 weeks, we will send you to specialist for anesthetic assessment because rate of CS is higher in obese females. We want to be prepared for that.
- During labor obese females have higher risk of developing:
o Shoulder dystocia o Non-progress of labor o Obstructive labor o CS and its complication
o More difficult to monitor HR and activity (fat obstructs signals)
o Pain relief might be more difficult (more adipose, more unequal distribution) - What we will do is a planned delivery in a controlled
environment under close monitoring by the specialist obstetrician. A normal vaginal delivery is encouraged as much as possible, however, they will be prepared for CS
- After labor, there is a higher risk for you to develop: o Wound infection
o Clotting problems
o Postnatal depression (more common) - We will give you some meds to prevent clotting. You
will be encouraged to breastfeed child that helps you to lose weight and to develop good bond with baby. Come back after delivery and get wound checked. Please be aware that elective CS is preferred because it is hard to do emergency cesarean sections since it is difficult to move patient. It is more difficult to give epidural anesthesia to predict effects of medication. Please bring your partner next time to discuss further complications.
- Reading material - Review
Pre-pregnancy counseling of SLE
Case: You are a GP and your next patient is a 24-year-old patient who is a diagnosed case of SLE for 5 years. She wants to become pregnant and is seeking your advice.
Task
a. Counsel the patient (steroids but no longer taking it because she is symptom-free)
b. Answer her questions SLE in Pregnancy
- Does not seem to cause exacerbations of SLE - Can adversely affect pregnancy according to disease
severity - Complications:
o Increased incidence of spontaneous abortions and stillbirth related to lupus anticoagulant and anticardiolipin antibodies o Preeclampsia
o Prematurity o IUGR
o Perital mortality
- Neonatal lupus syndrome: blood disorders and cardiac abnormalities in neonate
- Increased maternal morbidity – kidney complications and pre-eclampsia
- Management
o Preconception counseling symptom free for 6 months
o Refer for review of drugs o Corticosteroids o Low-dose aspirin
o Tests: lupus antibodies, APTI, FBE, RFTs, ultrasound
o LMWH
o Timed delivery Questions:
- Can I become pregnant like other females? - What are the risks for my baby?
- How will my SLE be affected by pregnancy? - Do I need some special medications during
pregnancy? History
- When was it diagnosed? What symptoms did you have? What treatment was given? For how long? Did you have any side effects from these medications? How many relapses have you had during the past 5 years? 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? Are you on any medications at the moment? Which one and what dose (prednisolone 5mg)?
- When was your LMP? How are your cycles? Are they regular? How many days of bleeding? How many days apart? Are you on any contraception at the moment? Is this your first pregnancy? Any
miscarriages before? How’s your general health? Any other medical conditions? Any FHx or SLE or recurrent miscarriages? When was your last pap smear? What is your blood group? SADMA? Counseling
- As you already know, SLE is an auto-immune disease which means that the body’s defense mechanism becomes active against its own tissues. There is usually inflammation 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. It is very common in females of childbearing age (20-45).
- 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. It is important that they should be symptom-free for at least 6 months before conception.
- There are certain risks associated with SLE: o 40% have exacerbations/flare-ups however
10% have remissions
o Maternal risks: 20% develop pre-eclampsia, 2nd or 3rd (25%) miscarriages,
o Fetal risks: IUGR, prematurity (50%) o Lupus-like syndrome at time of delivery (5%)
rash and abnormalities of blood cell counts. This lupus like syndrome is not SLE. This is a temporary response in the baby because of transplacental transmission of antiphospholipid antibodies from the mom to the baby. It usually resolves within the 1st 4 weeks;
o congenital heart blocks: quite rare; only 2% of pregnancies are complicated by this - SLE: small-vessel vasculitis which also deposits in the
placenta and small clots within the placenta IUGR, prematurity, death
- We will consider this pregnancy to be a high-risk pregnancy. You will be managed by the specialist throughout the pregnancy. They will decide upon the best medications for you during pregnancy. Usually, steroids are safe but dose of steroids will be managed. Sometimes, azathioprine may be used. All other cytotoxic drugs as we know are contraindicated. - We will do some blood tests and ultrasounds before
pregnancy and continue close monitoring throughout your pregnancy. To prevent the risk of clotting problems or thrombophilia, the specialist might start you on ASA or LMWH that you will need to continue after delivery (especially if anticardiolipin is positive). - The mode of delivery and timing will be best decided by the specialist according to the baby’s condition. If they have any problems with his growth, they might intervene earlier.
- I am going to write some blood tests for you: FBE, UEC, Blood group, rubella antibody status, anticardiolipin antibody, complete thrombophilia screen.
- Refer to obstetrician. - Reading material
- SLE association of Australia RH-isoimmunization Counseling
Case: You are a GP and a 25-year-old female comes to your clinic. She had a miscarriage 2 years ago and she wants to become pregnant again.
Task
a. History
b. Relevant management History
- When did you have it? What was the gestational age of the pregnancy? Why was it terminated? What method was used? Where was the termination done? Any complications afterwards? Any blood transfusions or further procedures were required? Have you been pregnant again since then? How are your periods? Are the cycles regular? Any bleeding in between? I understand you’re in a relationship, what
contraception are using? Any history of STI in yourself or partner? Any other medical or surgical conditions?
Any surgical/PM conditions? SADMA? What is your blood group? What is your partner’s blood group? Was the previous pregnancy with the same partner as now? Did you receive any anti-D injections at that time? Any history of rubella infection before? Were you tested for rubella? When was your last pap smear? What was the result? Are you vaccinated with gardasil?
Management
- From the history the only problem that I noticed is that you have a blood group that might carry some problems for you and your baby in the future. Let me explain to you about blood groups. Usually in our blood, there are blood cells that carry oxygen to the body. These cells carry proteins in the surface which are named as A, B, O, AB as well as another factor known as Rhesus factor (+ or -). The blood type is determined depending upon the presence or absence of these proteins. Around 85% of the population is positive for rhesus factor. The rest are negative. This is important if your partner is carrying it in his blood. There is a 50% chance that your baby will be Rh+. Sometimes, the baby’s blood cells cross the placenta either during pregnancy, miscarriage, with trauma, or even without any cause. In that case, the mother’s immune system produces antibodies against the baby’s cells. This phenomenon is known as isoimmunization. If the mother does not receive any anti-D injections and she becomes pregnant again, there is a very high chance that these circulating antibodies reach the baby causing: hydrops fetalis, hemolytic disease of the newborn, neonatal hemolytic anemia. This results from breakdown of the baby’s blood cells. The end result of the blood cell metabolism is bilirubin which can be checked within the amniotic fluid to check the degree of hemolysis. At the moment, what we can do is to do regular antenatal tests including your blood group and your partner’s blood group.
- You need to start taking folic acid 0.5mg OD from now onward. Once you become pregnant, at around 20 weeks of gestation, we will do a test that is called amniocentesis to check the level of bilirubin. If required, we will give you Rhogam or anti-D immunoglobulin, an injection to neutralize the antibodies. We will also test your blood for the level of antibodies to Rh group and titer. If titer goes beyond 1:8, we will do amniocentesis earlier, further followup testing and anti-D injections.
o Kleihauer test: determine how much Rhogam is required. Tries to find out how many fetal RBCs are present within the mother’s blood.
o Coombs test/antiglobulin test: done to check the level of antibody in mother’s blood.
Direct (checks the antibodies that are bound to RBC)
Indirect (check the circulating free antibodies)
- Recommendations: For all RH (-) whose pregnancy progresses to 28 and 34 weeks and postpartum within 72 hours will be given 625 Rhogam injections irrespective of antibody titers.
- If bilirubin too elevated: exchange transfusion - Refer to obstetrician for possible assessment. - Reading materials regarding isoimmunization. - Review
RH ISOIMMUNIZATION INDICATIONS
All Rh(-) and unsensitized who requires or with:
INDICATIONS DOSE
Abortion or requires D&C (give within 72 hours to 9-10 days) 250 IU IM CVS/amniocentesis 250 IU IM Threatened abortion Antepartum hemorrhage Abdominal trauma External podalic version
<20 weeks: 250 IU IM
>20 weeks: 625 IU IM
Bleeding during pregnancy @ 1st trimester single @ 1st trimester multiple @2nd/3rd trimester @ Postpartum 250 IU IM 625 IU IM 625 IU IM 625 IU IM Pregnant women at 28 weeks
34 weeks
625 IU IM 625 IU IM Rh (+) baby (give within 72 hours of delivery) 625 IU IM MISCARRIAGE AND ABORTION
Recurrent Miscarriages
Case: You are a GP and a young 26-year-old lady presents to you in your GP clinic. She has had 3 miscarriages before. She thinks she is pregnant again because she has not had her periods for the last 6 weeks. She has a family history of alpha thalassemia.
Task
a. Counsel the patient
History (miscarriages x 3 episodes around 8-10 weeks, had curettage once, irregular period 4-5weeks, Blood group B+) Case 2: You are a GP and a young 28-year-old lady presents to you in your GP clinic. She has had 3 miscarriages before at around 8-10 weeks and has had D&C done. You did some laboratory tests and she has come to collect the results. Investigation: FBE, TORCH, chromosomal analysis, APAS, TFTs, PRL, LFTs, Hepatitis B&C, Urine microscopy and culture, FBS, HIV and STDs, thrombophilia, USD of uterus.
Causes:
- Immune-mediated: APAS, SLE, HLA incompatibility between partners, thrombophilias, SLE
- Uterine abnormalities: cervical incompetence (2nd trimester), gynecological surgeries, birth defects (septate uterus)
- Infections: TORCH and STDs, Hepatitis B&C - Endocrine: DM and thyroid
- Maternal age not a cause but risk factor; females who become pregnant after 40 years has 50% chance of miscarriage within the 1st trimester
Definition
- >3 consecutive pregnancies lost by a female History
- I can see from the notes that you have a history of recurrent or repeated miscarriages. At the moment, you think that you might be pregnant. Have you done a test to check for pregnancy? Do you have any symptoms like morning sickness, breast tenderness, or irritability? I understand your LMP was 6 weeks ago, any bleeding since then? Tummy pain or discharge from down below?
- How are your cycles? How many days of bleeding? How many days apart? Please tell me more about your previous pregnancies? Have you had any kids up to now with this partner or previous partners? When
was your last pregnancy? How did you miscarry? Any trauma? Did you have a D&C during any of the pregnancies? Did they do an autopsy on the products of conception? During the last 3 pregnancies, did you suffer from any infections? Fever? Did you have the antenatal blood tests done?
- How is your general health? Any history of diabetes, thyroid problems, immune-related diseases like SLE? History of gynecological surgery? Blood group? Last pap smear? Were you on any contraceptives before this pregnancy?
- SADMA? Investigations
- We need to do a pregnancy test on you to confirm if you are pregnant. If it positive, I will refer you to the high-risk pregnancy clinic. If negative, I will refer you to a specialist clinic called recurrent miscarriage clinic where they will do some tests on you to find out the possible cause of the miscarriages. They might ask your partner to come in for a checkup as well. - I would ask the examiner for the results of the blood
tests including FBE, Blood group, Ultrasound to check any defects of the uterus, ovaries, and fallopian tubes. I would like to run a complete thrombophilia screening (Protein C, S, antithrombin III, anticardiolipin antibody, factor V leiden – most common deficiency, blood homocystein levels), TORCH, Thyroid function tests, BSL, urea and electrolytes. At the clinic they will order HLA and karyotyping for both partners.
- If PT (+): I will refer you to the high-risk clinic where you will be seen by the specialist obstetrician. Recurrent miscarriages affect 1% of all couples. Sometimes, even with extensive investigations, no cause can be found. You still have a very high chance of a normal pregnancy. After the 1st miscarriages, chances of successful pregnancy is 80%, 2nd (75%), 3rd (70%). I will ask the psychologist, midwife, and obstetrician to support you all this time whether or not you are pregnant.
- One of my friend got cervical stitch, should I have it too? It is usually done in cervical incompetence where the miscarriage occurs in the 2nd trimester. We can do ultrasound earlier this time.
- Referral letter - Written material Threatened Abortion
Case: You are a GP and a 28-year-old female comes to you with vaginal bleeding after 8 weeks of amenorrhea.
Task
a. History (2pads, clots, regular periods, B+)
b. Physical examination (moderate bleeding, clot, os is closed, uterus is normal and not enlarged, (+) CMT) c. Investigation
d. Management
Case: You are a GP in a suburban GP practice. Your next patient is a 24-year-old Mrs. Jones with heavy PV bleeding for the last 24 hours. She is 7 weeks pregnant by date and she is concerned and seeks your care.
Task
b. Physical examination c. Investigation
d. Diagnosis, management, and differential diagnosis
Differential Diagnosis
- Ectopic Pregnancy: PV bleeding + b-hCG(+)+ os closed + empty uterus
- Threatened miscarriage: PV bleeding + b-hCG (+) + os closed + intrauterine pregnancy
- Incomplete abortion + b-hCG(+) + os open + intrauterine pregnancy + POC on examination History
- Is my patient hemodynamically stable?
- Please tell me more about the bleeding? When did it start? How many pads did you use up to now? Did you pass any clots? Do you have any associated pain? Have you felt N/V/breast tenderness? Do you feel dizzy at the moment? Any fever or discharge from down below? Possibility you might be pregnant right now? When was your LMP? Are you periods regular? How many days of bleeding? How many days apart? Have you ever had spotting in between? I understand you are sexually active and in a relationship, what method of contraception do you use? Are you planning to fall pregnant? Have you ever been pregnant before? Any miscarriages? When was your last pap smear? What was the result? What is your blood group? Any past medical or surgical condition especially any bleeding disorders, thyroid problems, gynecological conditions. FHx of bleeding disorders. Have you or your partner ever been diagnosed with an STI? Any problems with waterworks like burning, frequency? How are your bowel habits? SADMA? Physical examination
- General appearance - Vital signs (postural drop)
- Abdominal examination: distention, tenderness especially on the RIF and LIF. Any visceromegaly, bowel sounds
- 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 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.
Incomplete Abortion
Case: 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
a. History (lower tummy, comes and go, started 12 hours ago; 4-5 pads/day; periods every 28-30 days, no easy bruisability or bleeding disorders)
b. Physical examination (distress, pale and in pain; BP 80/50, os open with POC, PR:80 vasovagal shock; size of uterus is 8 weeks, mobile, no adnexal masses/tenderness; no CMT)
c. Diagnosis and management History
- Is my patient hemodynamically unstable?
- 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 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?
- Are your periods regular? When was your LMP? How many days of bleeding? How many days apart? Do you have heavy periods?
- 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? Do you know your blood group? Have you ever been pregnant before? Any miscarriages? 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? Physical Examination
- General appearance - Vital signs
- Abdomen
- Pelvic remove POC immediately!!! - Urine dipstick
Diagnosis and Management - Admit the patient
- Start IV fluids and take blood for grouping and crossmatching
- Give oxytocin or ergometrine or (Syntometrin) to stop bleeding
- Refer to OB&Gyne registrar for curettage
- 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. I have admitted you, informed the registrar, and sent all the bloods for necessary investigations. 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. We will wait for your blood group report to come and if it is negative, we will give you an injection called anti-D.
- 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.
- 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
- Doing unnecessary investigations like beta-hCG and USD
EXTRAUTERINE AND ECTOPIC GESTATION Ectopic Pregnancy
Case: A 23 years old female has recently been discharged from the hospital after a procedure where the right Fallopian tube was removed because of an ectopic pregnancy. The left ovary on the ultrasound showed the presence of corpus luteum. The patient wants to know why it happened to her.
Task
a. Talk to the patient and explain about ectopic pregnancy and its causes.
- From the notes, I can see that you have recently undergone a procedure to remove a right ectopic pregnancy. How are you feeling at the moment? How are you coping with the loss of this pregnancy? - I understand why you want to know why it happened
to you. Do you know what ectopic pregnancy means? Usually, the egg from the mom and the sperm from the dad meet within the tubes to form the fetus. This fetus then travels and becomes attached to the wall of the womb. Due to certain reasons, sometimes, the fetus implants within the tubes. It is then called an ectopic or extra-uterine pregnancy. The size of the tube does not allow the fetus to grow therefore it may rupture and leads to a lot of bleeding and other complications. For you fortunately, such complications were prevented and the tube was removed. Please don't worry. You still have a chance of normal pregnancy. The risk factors for ectopic pregnancies are: previous history of PID and STI (increases risk 7x), previous surgeries of gynecologic nature especially around the tubes, history of endometriosis, IUCD use, use of emergency contraception (causes retrograde contraction of the Tubes), embryonal defects, previous history of ectopic pregnancy in the opposite tube.
- In most of the cases (97%), ectopic pregnancies are found within the tubes. Sometimes, they can be found in the ovary, peritoneal cavity, and on top of the uterus - For your next pregnancy, the chances of conception
are around 50%. Please remember that even one tube can catch the eggs from the opposite ovary. You need to wait for at least 3-6 months before trying to conceive. Give yourself some rest and have a healthy balanced diet. You can use OCPs but please avoid IUCDs, Emergency pill and POPs.
- When you miss your next period, please come and see me ASAP. We will do some tests including serial beta-hcg done starting day 5 of conception. We would like to record the quantitative increase in beta-hcg
which usually rises every 48 hours. If it doesn't, then we will do USG, progesterone (low) and CA-125 (rises during impending rupture)
- The gold standard for diagnosis remains to be laparoscopy.
- If we find that the next one is ectopic as well, depending upon the fetal viability and damage to the tube, the specialist obstetrician might decide to inject MTX within the gestational sac that will help in resorption of the fetus protecting the tube.
- If you develop tummy pain, vaginal bleeding, episodes of fainting or dizziness, or back pain (interscapular area), please come to the hospital right away because these are symptoms of early ectopic pregnancy. - The best option would be IVF if your opposite tube is
removed. Please be optimistic. You still have a very high chance of having a normal pregnancy. - General risk for ectopic pregnancy: 1%; chance of
recurrence: 10-20%
ANTEPARTUM AND OTHER COMPLICATIONS IN PREGNANCY
Antenatal Care:
- Do beta-hCg (quantitative or qualitative) - Down Syndrome risk:
o @37: 1:200 o @40: 1:100 o @45: 1:50
- Screening for down syndrome: HR: 1:200 or higher o 1st tri: 80% predicted
10-12 weeks: PAP-A and beta-hCg;
12-13 weeks: USG (nuchal translucency aneuploidy) o 2nd tri: 60-70% predicted
QUAD screen @14-20 weeks: AFP, b-Hcg, estriol, inhibin A (ACEI)
- May do dating usg during first visit
- Amniocentesis (0.5%)/CVS (1%): risk of miscarriage - Blood group
o If (-): repeat blood at 28 weeks; then give anti-D; repeat blood antibody screen at 34 weeks (2nd injection of anti-D) prevent spontaneous transplacental hemorrhage
2nd tri: 12-15% fetal RBCs can be found in maternal blood resulting in isoimmunization
3rd tri: 20-30% o Give anti-D after delivery
- FBE: consider anemia (r/o hemoglobinopathy) o Check the partner and check for trait - Screen for infections: Rubella, HIV, Hepatitis,
hepatitis B&C, syphilis
o If HbsAg (+) check partner for hepatitis b antibody; talk about safe sexual practice o For hepatits b&c refer to infectious
specialist
- MSU for micro&culture: asymptomatic bacteriuria (or in 6-8%) (+) if >100,000 col/ml; tx because increased likelihood of getting severe UTI (e.g. pyelonephritis)
- 18-22 weeks: morphology scan to check for structural abnormalities
- 28 weeks: check for anemia (FBE) – physiologic anemia and GCT
- Average gestation: 40 weeks + 2 weeks; >42-43 weeks perinatal mortality doubles;
o Concern at 41-42 weeks: do fetal well-being USD measuring umbilical artery flow (SD ratio: difference between peak systolic flow and end-diastolic flow), AFI and CTG Antenatal checkup
Case: Your next patient in your GP practice is a 24-year-old female who is 8 weeks pregnant. You saw her last week as a part of her regular antenatal checks and ordered some blood tests. Today she is here to know about the blood results. Her health and pregnancy have been good so far. She is so excited about having a healthy baby by the end of her pregnancy. Her results are as follows:
FBE: Hgb 120, WBC 8000, Plt 170,000 UEC: Na 145, K 4.4, Cl 130
LFTs: normal BSL: 4.3
Blood group: A-; Antibody screening test (-) IgG (+) for Rubella and Varicella
Urine: MCS show GBS positive HBV and HCV: negative Task
a. Explain result and advise on management Management
- Congratulate on her pregnancy
- Give anti-D at 28, 34 weeks and 72 hours after delivery if child is Rh (+) and if there are bleeding episodes
- If antibody screening test positive: measure the titers using ELISA (1:8 or 1:16 or 1:32 then check bilirubin by doing
o Amniocentesis: check bilirubin; o Umbilical cord sampling: Hct (25%) o MCA ultrasound: check velocity of blood
flow -- if there is hemolysis heart pumps faster then velocity increases; less invasive - Urine MCS: positive for GBS (asymptomatic
bacteriuria) -- treat with antibiotics because of risk of developing pyelonephritis
(Cefalexin/Augmentin/amoxicillin) - Repeat culture after 1 week - General advise for UTI - Check partner’s blood group - Advise on antenatal checkup - Dietary advice, smoking and alcohol - Down syndrome screening if older patient First Antenatal Check Up
Case: Mrs. Hasim a migrant from Sudan presents to your GP clinic for her fist antenatal visit.
Task
a. Take History
b. Your management in pregnancy
She is a professional boxer for 10 years. “Can I do exercises?” “Can I eat sushi?” “How about weight gain?”
History
- Mrs Hasim, Do you need interpreter? I understand you have come to see me regarding pregnancy. Is it your first pregnancy (Yes)? Was it planned (Yes)? Congratulations!
- When was your LMP (8 weeks ago)?
- Period questions: Do you have regular cycles? How long is the cycle? How long is the bleeding time? Any spotting in between? Do you have excessive pain or bleeding during the period? How did you confirm your pregnancy (I did pregnancy test at home)? Good on you!
- Pregnancy symptoms: Do you feel tired, nausea? Have you vomited? Breast tenderness? Tummy pain? How’s your water work? Do you have regular bowel function? Do you have unusual vaginal discharge or bleeding?
- What type of contraception did you use before you got pregnant? Have you been diagnosed with STD? When was your last PAP smear (If no for last 2years do it now!)? Do you know your blood group? Have you had Rubella in the past or have you receive vaccine for it?
- Any serious illnesses or surgeries in the past? (Heart, HTN, DM, anemia.) Is your husband generally healthy? Are you on any medication? Are you taking folic acid? Are you allergic to anything? Smoking, Alcohol and drugs? How many cups of coffee do you drink per day? What do you do for a living? When did you migrate to Australia? Do you have any family members or close friends here? Has anyone in the family had twin pregnancies? Has anyone in the family had pregnancy complicated by DM, HTN, birth defects?
Management
- We need to order some routine lab tests to identify any issue which needs to be addressed for the best outcome of your pregnancy.
o FBE exclude anemia. Hb. Iron deficiency Supplement.
o Blood group and RBC antibodies. If you are Rh-you need anti-D immunoglobin
prophylactically to prevent problem in future pregnancy. Repeat antibody test in 26weeks.
o Rubella status if you are not immunized to rubella, I recommend you receive rubella vaccination after delivery. (Contraindication during the pregnancy)
o We will also do syphilis, Hepatitis B and C and HIV screening.
o Vitamin D level.
o Midstream urine to check urinary tract infection. Sometimes it can be asymptomatic but need to be treated in pregnancy. 30% of asymptomatic UTI can become symptomatic.
o There’s another test which we offer in every women in Australia. It’s a Down’s syndrome screening test. Would you like to do it?
1st trimester: Pappa, beta HCG, Ultrasound
2nd trimester quad. Test(15-18weeks): beta HCG, AFP, oestradiol, inhibin A
o You also need 18-20weeks mid pregnancy ultrasound to make sure baby develops
properly and to look for position of the placenta.
o At 28weeks we screen for Gestational Diabetics: sweet drink test/glucose challenge test.
o At 36 weeks you will need to be advised to do a low vaginal swab to check for a bacterial infection called GBS. If found you will be given antibiotics prophylactically during delivery.
- You need to take folic acid 0.5mg for the 1st 3 months of pregnancy because it decreases the occurrence of neural tube defects.
- Moderate exercise is good for you because it improves cardiovascular and muscle strength. Best exercises are low impact aerobics, swimming, walking and yoga. No contact sport because of risk of trauma. - Weight gain should be around 11-16kg during
pregnancy. But it all depends on your pre-pregnancy state. Your diet is important, it should be well balanced. Food rich in protein, dairy food, starch food (potatoes) and plenty of fruits and vegetables. Best avoid a lot of sugary, salty and fatty food. Food delicacies: uncooked meat, egg, soft cheese, shell fish and raw fish should be avoided as they are potential sources of Listeria and Salmonella.
- No smoking, alcohol and drugs.
- What about my sexual life? Sexual life is acceptable and normal during pregnancy just follow your normal desire.
- Can I see a dentist? See your dentist in case any dental care is required and it can be carried out in the first half of the pregnancy.
Timing of Admission to Hospital
Case: your next patient in GP practice is a 24-weeks pregnant lady who has just moved into your town. She has come to see you as her first GP. She lives 80km from the main hospital Task
a. Relevant history (folic acid, regular checkup, normal USD and blood tests; history of prolonged labor because of poor contractions; instrumental delivery) b. Advise when she immediately needs to attend the
hospital or midwife c. Answer her question History
- Congratulations on your pregnancy. I can see that you’re concerned about when you should go to the hospital for delivery. I understand that you live 80km away from the hospital. Before I address your concern, is it okay if I ask you some questions? - How is your pregnancy going so far? Was it a planned
pregnancy? Are you attending regular antenatal care? How were the blood test results? Anything significant? Do you know your blood group? What about the 18th week USD? Is it a single baby? Is the placenta in the normal position? Any tummy pains or trauma so far? Any discharge or bleeding so far? Any leakage of fluid down below? Any headache, BOV, N/V? Any urgency, frequency or smelly urine? Did you take folic acid? Is your baby kicking well? Any previous pregnancy or miscarriage? How was it? Was it term or preterm? Do you know the reason for the prolonged labor? How was the baby after delivery? Any complications? What was the BW? Any previous medical or surgical issues like BP, DM? Any problem with your periods? Are you on any medications? SAD
- Do you have enough support? I understand you live 80km away, how long does it take to go to the nearest hospital by car? Can anyone drive you to the hospital in case of emergency? Do you have any friend or relatives who live near the hospital where you could relocate a few days before the due date? Is there anyone at home who will look after your first baby when you are in the hospital?
Counseling
- The first pregnancy is usually longer as compared to succeeding ones. However, there are some warning signs: if you have any contractions,any passage of mucus or water, vagina bleeding, any reduction in fetal movements, any sort of tummy pain, headache, blurry vision, cloudy urine, or other warning signs, you have to come to the hospital straight away.
- The plan for your pregnancy is to come every month until your28th week, then every fortnightly from 28-36 weeks and weekly after 36 weeks and until delivery. At 28 weeks, we will arrange a sweet drink test and around 34-46 weeks, we will do the vaginal swab to detect the bug called GBS.
- If there are no warning signs as discussed before, it is advisable to either relocate close to the hospital if you have friends or relatives or get admitted to the hospital a week or so before the due date.
- Will I have a long labor this time as well? With regards to your delivery, the exact duration of your labor is not easy to predict as it depends on several factors at the time of delivery such as medical conditions, size of the baby, size of the pelvis, presentation of the baby, and strength of the contractions. But usually, the duration of labor in 2nd pregnancy is shorter compared to the 1st.
- Right now everything sounds good. I will see you in one month time and give you a few reading materials. Down Syndrome Screening
Case: A young woman at 10 weeks’ gestational age comes to see you in your GP practice. She is concerned about having a baby with Down syndrome as recently, her sister had a baby with Down syndrome.
Task
a. Counsel patient
- Is this a planned pregnancy? Congratulations. - I understand from the notes that you are here to
discuss about Down syndrome screening. I appreciate your initiative to do that. I understand your anxiety. I will give you all the information regarding the tests which can be done and how effective they are. - How is your pregnancy going so far? Are you getting
your antenatal care? Are you done with your blood tests? Any concerns or issues?
- Down syndrome is one of the common genetic abnormality with trisomy 21. There are some indications in doing Down syndrome screening in pregnant women:
o Increased maternal age (>30) o Previous down syndrome baby o History of down syndrome in the family - We have screening tests and confirmatory tests. In the
first trimester, there is a triple test a blood test which is done at 9-13 weeks AOG. We check free beta-hCG Pregnancy Associated Placental Protein-A. We
combine it with Ultrasound and it is done at 11-13 weeks AOG. Here we check for fetal nuchal translucency. Screening tests can also be offered in the 2nd trimester between 15 and 17 weeks. These tests are not 100% confirmatory. In high-risk pregnancies, we can offer diagnostic tests: CVS or amniocentesis.
- CVS
o done ideally at 9-11 (11-12 at clinical book) weeks
o results within 24 hours o more accurate o 1% risk of abortion - Amniocentesis
o Done ideally at around 14-15
o Longer (up to 3 weeks) and less accurate o 0.5% risk of abortion
- 3 regimens:
o PAPPA and free hCG at 9-13 weeks o Nuchal thickness at 11-13 weeks (combined
tests raises detection rate from 70 to 90%) o If calculated to be more than 1/200-250
woman is offered CVS if gestation between 11 and 14 weeks or amniocentesis if at 15-16 weeks
o Combined test: AFP, unconjugated estriol and beta-hCG + Inhibin A at 15-20 weeks increases detection rate from 65 to 75-80% if inhibin A included
- If previous pregnancy was down syndrome, the risk of having Down syndrome in the next pregnancy increases by 1%.
Vaginal Birth After Cesarean Section (VBAC)
Case: You are a GP and a 28-years-old lady with previous cesarean section 2 years ago is in your GP clinic. She is now 7 weeks pregnant and she wants to have vaginal birth.
Task
a. History (CS due to fetal distress, pap smear x 1 year ago with
b. Ask examiner for previous medical/surgical notes of the LSTCS (obstructed 2nd stage of labor hence underwent CS, Apgar 6,8 BW 3kg, no CPD) c. Discuss possibility of vaginal birth to patient Predictors of successful VBAC (55-85%):
- Non-recurring indication of CS (e.g. malpresentation)
- PIH
- Previous vaginal birth
- Institutions in which success rates is high - Onset of labor is spontaneous
Contraindication
- Previous classic cesarean section birth - Some uterine surgery (hysterotomy, deep
myomectomy, corneal resection and metroplasty) - Previous uterine rupture or dehiscence
- Maternal or fetal reason for elective CS in current pregnancy
o Mother: PIH, Diabetes, Antepartum hemorrhage (previa/abruptio)
o Baby: Macrosomia, Multifetal gestation, Malpresentation (breech, face, brow, transverse lie)
o Labor: Power, Passage, Passenger Eligibility: 1 previous LSTCS and NO contraindication Induction of labor:
- Risk of uterine rupture especially if induction of labor with prostaglandin E2, oxytocin + amniotomy and misoprostol is used
o Classic (5%) o LSTCS (0.5%)
- Mechanical cervical ripening device may be used safely
- 1/5 of patients end up having cesarean section History
- Congratulations. Is it a planned pregnancy?
- What about first pregnancy? Was it your first? Was it a planned pregnancy? Did you have regular antenatal checkups? Complications of pregnancy (DM, hypertension, bleeding)? Why was the CS performed? Was it an emergency? Do you know the type of cesarean section? Complications of surgery (infections, bleeding, DVT)? CPD (height of partner and patient)? How was the baby at birth? Any resuscitation needed?
- History of previous uterine surgeries or rupture? - Are you taking folic acid?
- How is your general health? Any medical condition you have at this moment? Why do you want to have vaginal birth?
Findings from Examiner
- Reason for cesarean section
- Classical or Low-segment cesarean section - Age of gestation
- Complications: anesthetic, infection, hemorrhage, damage to the adjacent organs like bladder, large intestine etc, DVT
- Baby: weight, apgar score, resuscitation done Management
- At this stage we are not sure about the outcome of the pregnancy as it depends on its progress. However, in majority of cases and in your case, successful vaginal birth can be achieved safely. The success rate ranges from 55-85%. I will do antenatal screening tests and will monitor you during your antenatal visits to look for certain conditions which can pose a risk during vaginal delivery or which can be an indication for cesarean section. If any of these are present, you will be managed as a high-risk pregnancy.
- I will arrange an appointment with an obstetrician at 26 weeks for discussion about possible mode of delivery and at 36 weeks for definite decision regarding vaginal birth. The specialist will explain the risks and benefits of the mode of delivery to you and the final choice will be made according to your wishes and advice of the obstetrician. If vaginal birth is decided, it will take place in a well-equipped hospital under supervision of an experienced obstetrician because vaginal delivery can progress to cesarean section in 1/5 of the cases.
- Folic acid prescription - Reading material - Review
Ovarian Cyst in Pregnancy
Case: You are HMO in ED. 25yo female 8weeks pregnant c/o pain in the right lower abdominal pain.
Task
a. Take history
b. Ask for Physical Findings (All vitals stable. Healthy looking. Abdominal examination: Tender in the right iliac fossa. No organomegaly. Per speculum: no discharge, no bleeding, no poc, os is closes.)
c. Ask for one relevant investigation findings ((U/S: Intrauterine pregnancy, Cyst in the right ovary 5cm in size, no fluid in the pouch of Douglas)
d. Talk about relevant management Differential Diagnosis
- UTI
- Ectopic pregnancy History
- Is my patient haemodynamically stable?
- Pain questions: How bad? 5-6/10 dull kind of pain not radiated. Where? Go anywhere else? Does anything make it better or worse? When did it develop? Is this the first time? Any associated symptoms eg fever, N/V, bleeding from down below, discharge from down below?
- Problems with water work: burning or frequency? Bowel habits: history of constipation?
- I understand from notes you are 8 weeks pregnant. When was it confirmed? At the moment do you have symptoms like morning sickness, irritability, breast tenderness? Is this a planned pregnancy? Is this the 1st pregnancy? Any miscarriages before? History of ectopic pregnancy? LMP? Are they regular? When was the last PAP? Result?
- How’s your general health? PMHx: appendectomy. Have you or your partner ever dx with STD. History of pelvic infection or gynecological procedure done for yourself?
- SADMA? Blood group? Which contraception were you on before the pregnancy? Gardasil?
Physical Examination
- General Appearance: pallor jaundice dehydration - Vitals: ask all vitals. If suspect appendicitis ask for
Pulse and BP.
- Abdomen: Any visible distension, mass, scars? Palpate any tenderness especially McBurney’s point. - Pelvic examination:
o Inspection: Any discharge, bleeding? o Sterile speculum: discharge, bleeding, POC,
OS
o Bimanual: Any tenderness, adnexal mass, position and size of the uterus
Investigation:
- U/S: Ovarian Mass
- Ask the examiner for Doppler U/S: To see the blood flow to the ovary(torsion), To determine the nature of the cyst: homogenous mass(simple cyst) or a complex cyst (malignant in nature).
- FBE, Serum beta HCG. U/S of pelvis and abdomen looking at evidence of intrauterine pregnancy, rule out ectopic pregnancy, ovarian cyst, fluid in the pouch of Douglas.
- Tumor markers: CA125, LDH Diagnosis and Management
- From history and physical examination, most likely your pain is coming from a cyst within the ovary. Ovarian cyst is usually a benign condition where a fluid filled sac is found near the surface of the ovary. It’s quite common in female of reproductive age group the exact cause is unclear. However, the hormonal
changes during pregnancy can sometimes be responsible. Rarely certain types of nasty growth may develop within that cyst however the chances are very low at your age. The management depends upon the size of the cyst, your symptoms, and the opinions of the obstetrician
- According to JM
o If it’s a simple cyst <5cm reassess the patient clinically and with a U/S in about 6 weeks time.
o If it’s a simple cyst >5cm recommend a u/s guided aspiration.
o Complex cysts irrespectively to size, excision laparoscopically
o Any symptoms or U/S evidence of torsion of cyst: laparotomy and removal of cyst - For your case, because your cyst is still around 5cm
and your symptoms are controllable (pain killers given). I’ll ask obstetrician to come to see you. Most likely they will advice careful monitoring to lookout for any symptoms of torsion which are: severe pain all over the tummy, recurring pain, symptoms of shock (fainting, low BP). The risk of torsion is around 10-15%. At the moment once your pain settles down we will send you home. However, you need to report back to us if any symptoms develop most likely you will need to undergo surgery in that case. Usually laparoscopic surgery doesn’t affect early pregnancies. However, slight increase risk of miscarriages. But we will give you certain hormones to help maintain the pregnancy (progesterone). Do the Surgery after 15weeks with progesterone therapy. I want you to be aware of some other complication of ovarian cyst: Infection: fever, and increasing pain, Cyst might rupture, twist on its axis compromising the blood supply to the ovary. However, around 80-95% of ovarian cyst that presents to us resolves spontaneously.
- Review: in 6 weeks for U/S. Alcohol Excess in Pregnancy
Case: Your next patient is a 10 weeks old pregnant lady who came in for antenatal checkup. She is alcoholic beverage drinker and a smoker for the last 10 years.
Task
a. History (planned pregnancy; first pregnancy; not a binge drinker; drinks with partner; cannot go without alcohol for one day
b. Advise management c. Focus on issues
History
- Can you tell me a bit more about it? Is it a planned pregnancy? Is it your first pregnancy?
- I would like to ask you a few more questions especially with your smoking and drinking habits. Is it alright with you?
- For how long have you been drinking? How much do you drink per week? What type of alcohol do you drink? Do you drink a lot on the weekends? 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?
- 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?
- How many cigarettes do you smoke per day and for how long? What is your pattern of smoking during the day? How soon do you have your first cigarette when you wake up? Do you find it difficult to smoke in non-smoking areas? Have you tried to quit non-smoking in the past? Does your partner smoke?
- Any medical condition such as liver, gastrointestinal, heart? Any history of mental illness or depression? DM? Hypertension?
- Are you on any medications? do you take folic acid? Have you used illicit drugs?
Counseling
- I would like to talk about the effects of smoking and alcohol in pregnancy and I would also like to do investigations that we do during the first antenatal checkup.
- The effects of alcohol: 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. On one extreme is fetal alcohol syndrome which is main cause of mental retardation in babies. The other effects include vision and hearing problems, learning, emotional and behavioral problems, speech or language delays, low BW, and birth defects including heart, face, eyes and other organs of the body.
- In pregnancy, there is increased risk of miscarriage and premature birth. After the birth of the baby, breastmilk production can also decrease. - Unfortunately, smoking exposes the baby to some
dangerous chemicals like nicotine, tar, and CO which decrease the amount of oxygen for the baby which can affect his/her development. It can also damage baby’s lungs and can give rise to birth defects like cleft lip and palate, low BW, and once baby is born, there is increased risk of chest infection like asthma,
pneumonia, and ear infections.
- In pregnancy, smoking is a risk factor for placental abruption and stillbirth. Also, there is an increased chance of SIDS if parents are smoking and drinking. - I know you are quite worried about hearing all this, but
the good news is that all of these can be avoided if you stop smoking and drinking alcohol. The ideal situation is if you stop smoking and alcohol altogether if possible for you. The sooner you quit the better it is for you and your baby. There is no known safe level of
alcohol use in pregnancy. (Limit to 1 SD per week but any reduction is important).
- Suggestions on 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 and I will help you implement them to stop alcohol and smoking altogether. Choose a quit date for both alcohol and smoking to stop.
- I 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. - I will refer you to alcohol anonymous. It is an
organization composed of groups of people having problems with alcohol and who desire to stop it. I will also refer you to support groups – quitline for smoking and give you some reading materials. I’m available for you for ongoing management and support for follow-ups.
- RWH:
o Sometimes it is not possible to stop altogether.
o Avoid dehydration by drinking plenty of water
o Vitamin D, iron and calcium supplementation
o Folic acid for the first 3 months
o Nicotine replacement therapy shouldn’t be used in pregnancy but may refer to specialist for advice
o Medications for withdrawal: Acamprosate (champix) or naltrexone for 6-9 months; Pregnancy with IUCD
Case: A-26-year old female comes to your GP clinic complaining that her period is late. She has copper IUCD inserted.
Task
a. Take focused history
b. Ask for physical examination (size of uterus is 7 weeks, no adnexal mass)
c. Advice the management
Case 2: Same Scenario You can see the thread of the IUCD History:
- Hi. I know you are here to see me because you are concerned about your period. When was your LMP? Was it normal or light? Do you have regular cycles? How long is the cycle? How long is the bleeding time? Any spotting in between? Do you have excessive pain or bleeding during the period? When did doctor insert the contraceptive device? Did your period change after the insertion? When was the last time you checked strings or thread?
