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Obstetrics Rapid Review Chloe Stevens, CUOGS Academic OfficerLearning Objectives • HTN in pregnancy • Diabetes in pregnancy • Hyperemesis Gravidarum ADAPTED FROM MEDED • Anti-D O+G RESOURCES (they • Abdominal Pain in pregnancy are great!) • Complications of Labour HTN in pregnancy Pre-pregnancy counselling: Essential HTN - Aim for BP <140/90 - Stop ACEi (fetal kidney damage) - Safe alternatives •Aspirin 12-36/40 if risk Pre- - Labetalol factors for preeclampsia Pregnancy - Nifedipine o - Hydralazine HTN in previous pregnancy Secondary - Methyl-dopa o CKD HTN riskigho Autoimmune disease HTN in factors (SLE, APLD) pregnancy Pregnancy Normal! o T!DM/T2DM Induced o Chronic HTN Hypertension New hypertension (BP >140/90mmHg) o First pregnancy Started in presenting after 20 weeks of pregnancy with Pregnancy Pre-eclampsia proteinuria (PCR >30mg/mmol or 300mg in 24 o >40 years 2≤ moderate hour urine collection) o BMI >35 risk factors o FHx Pre-eclampsia Eclampsia – Tonic-clonic type seizures in o Multiple pregnancy Eclampsia pregnancy without other known cause. Can present antenatally or postnatally Complications of pre-eclampsia •Maternal o Seizures, cerebral oedema, cerebral haemorrhage, strokes (thrombotic) o Hepatic failure, hepatic rupture, subcapsular haemorrhage Pre-eclampsia/Eclampsia o Haematological - DIC, HELLP o Renal failure o Pulmonary oedema - important not to overload! •Fetao --> likely to deliver prem INVESTIGATIONS Preterm delivery • Basic obs, USS growth, CTG o Stillbirth (IUFD) • Urine PCR (sig if >30) o Intrapartum fetal distress • FBCo ULook for HELLPing, G&S o Placental abruption • Haemolysis o Uteroplacental insufficiency • Elevated Liver Enzymes • Hypoxia neurological injury • Low Platelets (<100) • IUGR • Oligohydramnios MANAGEMENT Anti-HTN (e.g. IV labetalol/hydralazine) Magnesium sulphate • Bolus 4g, then 1g/hour for severe preeclamptic/eclamptic whilst you prepare to deliver and for 24h afterwards) – neuroprotective Deliver • Persistent maternal symptoms or worsen • Foetal concerns e.g. continued reduced foetal movements • CTG changes progressively worse • USS: abnormal Doppler, compromised foetal growth restriction Diabetes in Pregnancy T1DM Complications GDM Risk factors: •BMI >30 •Previous GD •ll diabetes •Previous macrosomic baby weighing 4.5kg or Pre- o Macrosomia/Polyhydramnios above Pregnancy o Unexplained IUD •1st degree FHx diabetes o Premature/traumatic/operative •Maternal age delivery •Multiple pregnancy o Neonatal hypoglycaemia T2DM •PCOS •Drugs - HIV, Antipsychotics, steroids Diabetes in pregnancy •re-existing diabetes Offer OGTT at 24-28 weeks o Miscarriage o Congenital abnormalities (heart, spina bifida, sacral agenesis) o Poor placentation - PET/IUGR Started in GDM o Infection Pregnancy Pre-existing diabetes in pregnancy Pre-pregnancy counselling Early pregnancy Late pregnancy Delivery Post-natal • Aim for <48mmols/mol • Manage in MDT • Manage in MDT • 37+0 -38+6 • Return (avoid >86) clinic clinic • Low threshold immediately to • DAFNE training • Regular review - • Scan every 4 for early delivery pre-pregnancy • Meds – only insulin and every 1-4 weeks weeks (28, 32, if doses. May need metformin! Early viability 36) • HTN to be lower • Beware hypoglycaemia! scan • BP and urine at • Poor fetal during Ensure have kit • Start aspirin each clinic growth breastfeeding available 150mg at night • Severe • Monitor mother • Check for secondary from 12 weeks macrosomia and baby for complications – • Decreasing hypoglycaemia optimise + start folic insulin (baby has acid BEFORE stopping requirement pancreatic contraception s - worry hyperplasia) placental • No maternal failure insulin with first meal after birth • Consider contraceptionGDM Antenatal care Delivery Post-natal • MDT clinic • By 40+6 (40+10-14 if • Stop all medication • Home blood glucose non-diabetic) • Diabetes test at 6-13 monitoring • Early delivery if weeks (FBS/HbA1c) • Advise on diet and • Significant • Yearly HbA1c exercise macrosomia • Advise about • Start medication • Polyhydramnios measures to reduce (metformin or insulin) • High doses of later risk if sugars high (>5.1 medication fasting or >7.8 1-hour • Aim for vaginal birth post meal) • CS if estimate fetal • Monthly growth scans weight >4.25g • Deliver by 40+6Hyperemesis Gravidarum Definition: Persistent N+V with weight loss (>5%), dehydration, electrolyte imbalance Risk factors: • Multiple pregnancies • Molar pregnancy • Previous HG Investigations: urine dip, FBC, U+E, transaminases Management: Rehydration, antiemetics (promethazine/cyclixine) ± steroids, continuing in 2 /3 trimesterophulaxis, additional fetal growth scans ifAnti-D All mothers have group and screen at booking and 28 weeks to check Rhesus status Prevention of maternal Ab development, give anti- D at: • 28 weeks gestation • Within 72 hours of a sensitising event (trauma, amnio, CVS, ECV, any bleeding e.g. placental abruption) • After delivery (if cord blood shows baby rh +ve) If mother already has Abs • Monitor levels to see if rising • If they are --> serial fetal medicine scans • If•hIn-utero blood transfusion • Delivered and transfused postnatally if near enough to term • Phototherapy if jaundiced Don’t forget non- obstetric medical and Abdominal Pain in Pregnancy surgical causes! Preterm Braxton Hicks labour abruption PET/HELLP Benign Serious Emergency Uterine Uterine fibroid rupture degeneration Chorioamnionitis Don’t forget non- obstetric medical and Abdominal Pain in Pregnancy surgical causes! •False labour pain •Uncomfortable, not painful •Differentiate from labour: o Do not increase in frequency, duration of intensity o Lessen then disappear, only reappear at some time in future Braxton Hicks o Do not cause dilation of cervix •Typically in second or third trimester (more common in late third) Benign Uterine fibroid degeneration Symptoms: constant pain, localised to side of uterus where fibroid is Management: reassurance and adequate analgesia Don’t forget non- obstetric medical and Abdominal Pain in Pregnancy surgical causes! •Risk factors: previous preterm labour, multiple pregnancy, cervical surgery •Symptoms: regular contractions or tightening, period-type pains, backache, vaginal spotting, light bleeding •Steroids (<34 weeks), IV Abx , Magnesium sulphate Preterm labour •RUQ/epigastric pain, referred pain to shoulder tip Serious PET/HELLP •HELLP (Haemolysis, Elevated liver enzymes, low platelets) more commonly experience abdo pain Chorioamnionitis •RISK FACTOR: premature rupture of fetal membranes, ascending infection! •Features: maternal pyrexia, maternal tachycardia, fetal tachycardia, uterine tenderness, purulent or foul smelling amniotic fluid •Maternal complications: increased need for C-section, endometritis, sepsis, postpartum haemorrhage •Neonatal complications: early onset sepsis, perinatal death and cerebral palsy •Management: IV Abx and expedite delivery o CS on infected organ risky! Don’t forget non- obstetric medical and Abdominal Pain in Pregnancy surgical causes! •Presentation: abdo pain +/- PV bleeding •Risk factors: hypertensive disorders of pregnancy, preterm labour, premature rupture of membranes, smoking, cocaine use •Examination: uterus large for gestation, tense and tender Placental •Treatment: delivery, high risk of maternal post-partum abruption haemorrhage and neonatal complications/death Emergency Uterine rupture •Majority prev CS, occurring during labour •Sudden tearing uterine pain continuing between contractions, vaginal haemorrhage, fetal bradycardia •Requires immediate CS Vaginal bleeding from week 24 of Placenta Praevia gestation until delivery = placenta is fully or partially attached to the lower uterine segment. Painless vaginal bleeding (antepartum haemorrhage) A-E resuscitation May be detected at 20-week US scan: •Placenta praevia minor – a repeat scan at 36 weeks is recommended, as the placenta is likely to have moved superiorly. •Placenta praevia major – a repeat scan at 32 weeks is recommended, and a plan for delivery should be made at this time. https://teachmeobgyn.com/pregnancy/medical- Caesarean section at 38 weeks is the safest mode of delivery. disorders/placenta-praevia/ Complications of Labour – slow Expect cervix to dilate at 0.5 (primip)-1cm (multip)/hour progress/obstructed labour Active first phase Second phase OBSTRUCTED LABOUR •Expect delivery in 2 hours of active 2nd stage •Failure to progress of fetal presenting part descending into for primip (about an hour in multip) pelvis despite good uterine contractions •Ensure maternal wellbeing - •Cause •Cephalopelvic disproportion or hydration, empty bladder, good o Poor contractions malpresentation/malposition position •SIGNS ARM - helps fetus to apply to o Obstructed labour o Prolonged labour • o Malposition o Exhausted mother with abnormal vital signs cervix, strengthening •Assessment o Ruptured membranes, meconium, fever contractions o Assess position of baby and signs of o Moulding of fetal skull bones --> overlapping of •Augmentation - syntocinon to skull bones which cannot be reduced improve frequency or strength obstruction o Caput - excessive swelling of head •Actions o Concentrated urine with haematuria of contractions o Syntocinon •Complocations o ?CS or instrumental delivery o Obstetric fistulastriction band around uterus o Sepsis (prolonged ROM) o PPH o Death (fetus/mother) Complications of Labour – fetal bradycardia •Obstetric emergency •Call for help 2222 •Change maternal position (rule out bradycardia due to aortocaval compression) •Stop syntocinon (terbutaline if overstimulated) •Examine to assess ?cause •Prepare deliver (3, 6, 9 mins) o 3 mins, consider may have to deliver o 6 making definite plan o 9 prepping for deliveryComplications of Labour – cord prolapse •Obstetric emergency •Call for help 2222 •Do not handle cord! •Change maternal position (knee chest position) or elevate presenting part (fill bladder) •Consider terbutaline •Transfer to theatre •Expedite delivery in fastest way possible Complications of Labour – perineal problems Episiotomyà Right medio-lateral to avoid tear Episiotomy - Wiki https://www.rcog.org.uk/for-the-public/perineal-tears-and- episiotomies-in-childbirth/perineal-tears-during-childbirth/ Complications of Labour – retained placenta •3rd stage, delayed separation (>30 mins) •Risk of bleeding •Risk factors o Uterine surgery/scarring, preterm birth, previous RP •Empty bladder •Put baby to breast •Give syntocinon •Change maternal position •Maternal expulsion attempt •MROP (maternal removal of placenta) Placenta Accreta/Increta Placenta accreta refers to when the placenta implants deeper, through and past the endometrium, making it difficult to separate the placenta after delivery of the baby. Presentation (typically diagnosed on antenatal scans): - Asymptomatic - Antepartum haemorrhage third trimester - Post partum heamorrhage CS 35-36/40. Options: •Hysterectomy with the placenta remaining in the uterus (recommended) •Uterus preserving surgery, with resection of part of the myometrium along with the placenta •Expectant management*, leaving the placenta in place to be reabsorbed over time *Expectant management comes with significant risks, particularly bleeding and infection. https://zerotofinals.com/obgyn/antenatal/placentaaccreta/ Uterotonics • Syntocinon Post-Partum Haemorrhage • Ergometrine • Syntometrine • Misoprostol (PGE1 analogue) • Carboprost (PGF2alpha analogue Major haemorrhage defined as loss of • >40% total blood volume (approx 1.5- 2L) or • 4L in 24hrs • 2L in 3 hrs • >150mL/min Primary <24hours, Secondary >24 hours (generally RPOC) RESUCSCITATION AND STOP BLEEDING Complications of Labour - Peurperal sepsis •Presentation •isk factors o Fever, rigors o Maternal o Non-specific signs e.g. lethargy, anorexia • GD/DM o D+V • Obesity o Obstetric o Breast engorgement/redness o Abdo/pelvic pain • Obstetric invasive procedures (CS, forceps, MROP) o Wound infection - spreading cellulitis/discharge • Prolonged rupture of membranes o Urinary symptoms • Contact with GAS o Delay in uterine involution, heavy/offensive lochia • Retained products of conception •Causes o Mastitis o Endometritis o Wound infection (CS/perineum) o Anaestheisa related o UTI o Skin and soft tissues o Pneumonia o Pharyngitis o Gastroenteritis •Pathogens o GAS, E.chol, Staph aureus, Strep pneumonia, MRSAFeedback form (to receive the slides!)