Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Obstetrics 101: Early Pregnancy Presentations and Counselling Tabitha Hanks • Gravidity – Number of pregnancies Obstetric regardless of outcome Basics • Parity – Number of births after 24 weeks (no matter the outcome)Give it a go... Patient is currently pregnant; had two previous deliveries G3 P2Patient is not pregnant, had one previous delivery G1 P1Patient is currently pregnant, had one previous delivery and one previous miscarriage G3 P1+1 (the +1 refers to a pregnancy not carried to 24+0).Patient is not currently pregnant, had a live birth and a stillbirth (death of fetus after 24+0) G2 P2 [Macleod’s 2005, p.212] • Before 10 weeks – Booking clinic • 10 to 13 + 6 weeks – Dating scan (gestational age calculated using crown rump length) • 16 weeks - Antenatal appointment • 18 to 20 + 6 weeks – Anomaly scan Timeline of • 25, 28, 31, 34, 36, 40, 41, 42 weeks – Antenatal appointments prenatal Additional appointments if you need them: counselling • diabetes 24 – 28 weeks test – Women at risk of gestational • Anti-D injections – Rhesus negative women 28 + 34 weeks (plus any time they are at risk) • Ultrasound scan – 32 weeks for women with placenta praevia - Combined test (11-14 weeks) - Ultrasounds - Maternal blood test (BHCG and PAPPA) Additional - Triple test (14 – 20 weeks) - Maternal blood test (BHCG, AFP, oestriol) tests for - Quadruple test (14 – 20 weeks) - Maternal blood test (BHCG, AFP, oestriol, inhibin- congenital A) - These are screening tests. If risk is >1 in 150 then offer abnormalities diagnostic testing: - Amniocentesislus sampling - Non-invasive prenatal testing (the best one!) • Advice and education • Examination (symphasis – fundal height and fetal presentation) • Bloods What’s in your - Blood group - Rhesus D status average - FBC - Offered screening for HIV, Hep B, Syphilis) antenatal • BMI appointment? • Urine dip • Blood pressure • (Smoking cessation counselling)Diabetes in Pregnancy • 2 types of scenario: • diabetic woman gets pregnant • Pregnancy woman develops diabetes • Indications of GD • Glucose on dipstick • Increased amniotic Fluid • Large-for-date fetus (macrosomia) • Risk factors Gestational • Previous gestational diabetes • Previous macrosmic baby • BMI >30 Diabetes • Ethnic origin: black Caribbean, middle eastern, south Asian • Family history of diabetes (first-degree relative) • Pre-pregnancy counselling • 4mg folic acid • Control of sugarsComplications Mother: Baby: • Post-natal hypoglycaemia • Neonatal hypoglycaemia – • Insulin sensitivity improves w dextrose via NG if <2, breast breastfeeding feed w/in 30 mins • Neonatal jaundice (higher risk) • Higher chance of pre- eclampsia • Polycythemia • Higher chance of • Congenital heart deformity retinopathy/nephropathy • Cardiomyopathy • Screening: • Oral Glucose Tolerance Test • Conservative • Glucose monitoring and lifestyle • Medication: • 1st line: Metformin • 2 line: Insulin • Universal: • 5mg folic acid (instead of 0.4mg) from preconception to 12 Management: weeks • Management in joint diabetes and antenatal clinics • 4 weekly USS from 28-36 weeks • Monitor growth and amniotic fluid volume • Sliding scale insulin during labour • Retinopathy screening after booking and at 28 weeks • Pre-existing diabetes: • Planned delivery between 37-38+6 • T1DM: detailed anomaly scan at 20 weeks inc 4 chamber view of the heart • Risks to Baby – why to keep sugars in range • MSJHC – My son just hit Carlos • Macrosomia • Shoulder dystocia • Jaundice • Hypoglycemia (neonatal) Key • Cardiac issues • Advice for mother – how Information • DRNSF - DR No Sugary Food • Difficult labour – plan delivery for • Retinopathy • Nephropathy counselling • Sliding scale insulin (hypoglycemia) • Folic acid (high)Golden Rule 5,6,7,8 Blood Sugars Goals: Fasting = <5.6 After meals = <7.8Labour counselling • Introduction • Explain the patient has breech baby • When baby is bottom down or feet first rather than head down • This can be a more complicated vaginal birth as the largest part the head is last to be delivered • Causes • In early pregnancy very common with baby usually turning right way around 37 – 42 weeks • 3 in 100 babies will still be breech at term • Usually just chance, however too much or too little fluid, position of the placenta or several babies in womb can influence this • Management Breech • Three key options: • External cephalic version • If it remains breech: • C-section • Vaginal delivery • More risk in c-section for mum than baby and more risk in vaginal birth for baby than mum • Safety net • Sheet • SummaryVBAC = Vaginal Birth after C section ICE Current pregnancy Previous pregnancy • Have you thought about • Assess for risk factors: • How many prev delivery options? • extra scans pregnancies? • Are there any concerns • placenta location • How many vaginal about any of the options? births/how many c- • Is there any information or • how many children sections? help you were hoping for? planning to have • Previous C-section • Other complications (GD etc) • Why? Elective or planned? • Previous complications during or after? (infection, PPH etc)VBAC cont. • Success rate = 75% • Chances of going into labour before the planned c-section = 10% Key Info • Factors that increase success = low BMI, previous vaginal birth, labour starting naturally • Should be in hospital – delivery suite or Birth suite • Faster recovery • more chances of skin to skin contact with baby Pros • reduced initial respiratory distress for the baby • Better chance of future VB • May need emergency cesarean (1 out of 4 women) which carries more risk than a planned one • Blood transfusion • Uterine rupture risk: 0.05% - if induction agents used = 2-3x risk of uterine rupture Cons • need for assisted delivery • slightly increased risk of stillbirth or brain injury to the baby Option to have an emergency c-section if it doesn’t progress to planHome Birth ALWAYS stress that it is the woman’s choice – you can inform and advise but they have final say ICE •Do you know where you want to give birth? •Any information you wanted? •Any concerns about giving birth at home – OR about hospital? Stats •2% births in England at home •Community home birth midwife team •5/1000 – death/serious complications in hospital vs 9/1000 at home •Overall neonatal death rate (NND) was almost three times higher for babies born without congenital anomalies in the home birth groupHome Birth Cont. Pros Cons • Comfortable environment • Less likely to have intervention • Controlled environment • Delay in transfer if something goes wrong – no doctors on hand • More likely to have continuity of care – community midwife/independent • Limited analgesia – only gas and air, midwife TENS machine • Midwives will have the same equipment • Higher risk of adverse outcome for at a home birth as they would have on a mother and baby midwife-led unit eg fetal monitoring • Less likely to have intervention • Small tears can be repaired at home 1st trimester - Ectopic Early - Miscarriage pregnancy - Molar pregnancy complications (by timeline) 3rd trimester - Placental abruption - Placenta praevia - Vasa praevia • Bleeding - Miscarriage - Ectopic Early - Molar pregnancy pregnancy • Abdominal pain complications - Miscarriage - Ectopic (by - Molar pregnancy - All other non-pregnancy related abdominal pathology (appendicitis, UTI, peptic ulcer, bowel obstruction) symptoms) • Vomiting - Hyperemesis gravidarum • Define - Loss of foetus before 20 weeks (>20 weeks is stillbirth) • Causes - Chromosomal abnormalities (85%) - Maternal (diabetes, thyroid disease, antiphospholipid syndrome) Miscarriage - Age - Lifestyle (smoking, alcohol) • Investigations - A-E - Abdo exam, speculum and bimanual exam - Bloods (serum hcg) - Transvaginal ultrasoundMiscarriage cont Types Threatened Inevitable Incomplete Complete Missed PV bleeding PV bleeding PV bleeding PV bleeding No symptoms and no fetal heartbeat +/- pain Pain Pain Pain Closed cervical os Open cervical os Open cervical os Closed cervical os No products of Empty vault Some POC are in Empty conception in uterus some in vaginal vault vagina • Expectant - Watch and wait - Wait 7-14 days for miscarriage to complete spontaneously • Medical Miscarriage - Vaginal misoprostol cont - Oral mifepristone • Surgical theatrem aspiration or surgical management in - More than 9 weeks • Define - Implantation of a fertilised ovum outside the uterus I.e. ampulla, bowel tissue, ovary, cervix • Symptoms - Lower abdominal pain - PV bleeding - Peritoneal bleed causing shoulder tip pain (if rupture) • Signs Ectopic - Abdominal tenderness - Cervical excitation - Adnexal mass (DON’T TEST FOR IT) • Investigations - ABCDE - Abdominal exam, speculum exam, bimanual exam - Bloods (serum hcg) - Transvaginal ultrasound Ectopic • Expectant Serial B-HcG levels over 48 hours Ø Size <35mm Ø Unruptured to monitor Ø Asymptomatic If levels rise or symptoms manifest Ø No fetal heartbeat intervention is performed Ø HcG <1000 • Medical Ø Size <35mm Ø Unruptured Methotrexate Ø No significant pain Ø No fetal heartbeat Ø HcG <1500 • Surgical Ø Size >35mm Salpingectomy (removal of ectopic) Ø Possible rupture Ø Pain Salpingotomy (removal of tube) Ø Visible heartbeat Ø HcG >5000 • First trimester, peaking around 8 – 12 weeks gestation • The placenta produces human chorionic gonadotropin (hCG) Hyperemesis gravidarum: • More than 5 % weight loss compared with before pregnancy • Dehydration Nausea and • Electrolyte imbalance vomiting q If mild manage at home q Admit if unable to keep down fluids, more than 5% weight loss, ketones in urine, co-morbidities q Treat with antiemetics, fluids, monitoring U+Es