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Back to Basics! The essence of OBSTETRICS in one hour Karine J. Lortie, MD, FRCSC Assistant Professor Department of Ob/Gyn The Ottawa Hospital/University.

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Presentation on theme: "Back to Basics! The essence of OBSTETRICS in one hour Karine J. Lortie, MD, FRCSC Assistant Professor Department of Ob/Gyn The Ottawa Hospital/University."— Presentation transcript:

1 Back to Basics! The essence of OBSTETRICS in one hour Karine J. Lortie, MD, FRCSC Assistant Professor Department of Ob/Gyn The Ottawa Hospital/University of Ottawa

2 OVERVIEW Introduction Early pregnancy Antenatal care Teratogens Fetal growth and wellbeing Medical complications Breech Multiple pregnancy Labour

3 INTRODUCTION

4 RISK SPECTRUM IN PREGNANCY LOW RISK (75%):normal obstetrics MEDIUM RISK (20%):pre-post dates breech twins maternal age, etc.. HIGH RISK (5%):genetic disease serious obstetric maternal complications

5 RISK IN PREGNANCY Definition of Outcome Measures 1. Perinatal mortality rate all stillbirths (intrauterine deaths) > 500 grams plus all neonatal deaths per 1,000 total births 2. Neonatal death death of a live-born infant less than 7 days after birth (early) or less than 28 days (late) 3. Live birth an infant weighing 500 grams or more exhibiting any sign of life after full expulsion, whether or not the cord has been cut and whether or not the placenta is still in place

6 PERINATAL MORTALITY Prematurity Congenital anomaly Sepsis Abruption Placental insuffienciency Unexplained stillbirth Birth asphyxia Cord accident Other ie. isoimmunization

7 PERINATAL MORTALITY RATE ONTARIO:5/1000 Developing:100/1000

8 MATERNAL MORTALITY Direct Deaths Indirect deaths: < 42 days from delivery Causes: Hypertensive disorders Pulmonary embolism Anesthesia Ectopic pregnancy Amniotic fluid embolus Hemorrhage Sepsis

9 MATERNAL MORTALITY RATE ONTARIO: 5/ Developing:1000/

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11 EARLY PREGNANCY

12 Dating: 40 weeks from LMP 280 days, Naegle ’ s rule (-3 months + 7 days) Affected by cycle length Hegar ’ s sign: soft uterus Chadwicks sign: blue cervix

13 8 days 8 weeks 16 weeks 5,000 Level 100,000 doubling time 2 days Others use: Zone Mole Ectopic Ovarian cysts Hormones BhCG: A subunit similar to TSH, LH, FSH Measurable 8 days post conception Role: stimulate CL progesterone

14 Other placental hormones HPL = human placental lactogen (growth hormone) prolactin progesterone estrogen

15 Which of the following statements best describes the foramen ovale: 1.It shunts blood from right to left 2.It connects the pulmonary artery with the aorta 3.It shunts deoxygenated blood into the left atrium 4.It is an extra cardiac shunt 5.It is functional after birth

16 ANTENATAL CARE

17 Maternal physiology   RBC   plasma volume by 50%, GFR, CrCl (  creatinine), glucosuria   cardiac output (highest 1 st hour after delivery)   HR by 20%   SV Placental flow: 750ml/min at term

18 Antenatal care Antepartum history: age: >40 offer amniocentesis Parity/gravidity Medical, surgical history Family, social history Meds, allergies Routine tests: CBC (Hg), Type and Screen, prenatal antibodies VDRL, Rubella, Hep B, HIV Urine culture Pap smear, + vag swabs, cervical cultures Offer IPS GBS swab at 35 weeks

19 Antenatal Care Optional testing: Dating ultrasound, 18 weeks morphology ultrasound Hb electrophoresis (Thalassemia, sickle cell, etc.) Chicken pox, parvovirus, TSH 28 weeks glucose screening test Genetic testing: CVS Amniocentesis Scheduled visits: 0-28 weeks: q4 weeks weeks: q2 weeks 36+ weeks: q1 week

20 Scheduled visits SFH (cm): (+ 2 # of weeks) Sensitivity of 60% 12 weeks: symphysis pubis 20 weeks: umbilicus 36 weeks: siphisternum presentation Symptoms, fetal movement + urine dip: glucose, protein Blood pressure, maternal weight

21 MATERNAL WEIGHT wksgain kg kg kg Average 12 kg Underweight: lbs Normal BMI: lbs Overweight: less than 25 lbs

22 Genetic testing IPS: First Trimester screening (10.6 – 13.6 weeks) Nuchal translucency PAPP-A, BhCG Second Trimester screening (15-16 weeks) BhCG, estriol, AFP 94% detection rate MSS: weeks BhCG, estriol, AFP 70% detection rate

23 IPS vs MSS Detection rate

24  NT Suchet I, Tam W. The ultrasound of life. Interactive fetal ultrasound teaching program on DVD, 4 th Edition, 2004.

25 Screening patterns Down’s syndrome : low AFP/estriol, high BhCG Trisomy 18 : low AFP, BhCG, estriol Trisomy 13: high AFP, low BhCG/estriol NTD : high AFP

26 All of the following factors are associated with an increased risk of perinatal morbidity except: a)low socioeconomic status b)low maternal age c)heavy cigarette smoking d)alcohol abuse e)exercise

27 Appropriate screening tests in an early, uncomplicated pregnancy include all of the following except: a)repeat BhCG b)hemoglobin c)syphilis serology d)Cervical cytology e)Blood type and Rh factor

28 TERATOGENS

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32 I Q F G H J K L M N O P R S T

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35 Risk Classification System for Drug Use in Pregnancy CategoryDescription ATaken by a large number of pregnant women. No increase in malformation. BTaken by only a limited number of pregnant women and women of childbearing age. No increase in malformation. Studies in animals wither show no increase or are inadequate. CHave caused or may be suspected of causing harmful effects on the human foetus or neonate without causing malformations. These effects may be reversible. DHave caused an increased incidence of human foetal malformations or irreversible damage. XDrugs that have such a high risk of causing permanent damage to the foetus that they should not be used in pregnancy.

36 FETAL GROWTH AND WELL-BEING

37 Dating Scan Gestational sac: 5wks Fetal pole: 6wks Fetal heart: 7 wks Limb buds: 8 wks crown rump length

38 Morphology scan weeks BPD HC AC Femur length

39 Info from U/S Estimated fetal weight Twins discordance Behavioral states (BPP) Presentation Placenta (previa)

40 Anomalies: ultrasound weeks Spina Bifida Anencephaly Cardiac Renal Diaphragmatic hernia Limbs Facial Chromosomal Late > 20 weeks Renal Microcephaly Hydrocephalus Ureteral valves

41 Interventions amniocentesis, l/s ratio (lung maturity) cvs cordocentesis, transfusion paracentesis Shunts: bladder, ascites, kidney, head Liver biopsy, skin Fetal reduction

42 DEFINITION OF I.U.G.R < than 2500 grams < than 5 th centile for GA Approx. 4-7% of infants

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45 BPD AC

46 BPD AC

47 CAUSES OF IUGR Maternal: Malnutrition Drugs Substance Abuse Diseases Infections Fetal: Chromosomal Abnormality Congenital Abnormality Multiple Gestation Congenital Infection

48 CAUSES OF IUGR Placental: Perfusion Abnormalities: Abnormal Cord Insertion Abruption Circumvallate placentation Placental Hemangioma Placental Infections Twin to Twin Transfusion

49 IMMEDIATE NEONATAL MORBIDITY IN IUGR Birth asphyxia Meconium aspiration Hypoglycemia Hypocalcemia Hypothermia Polycythemia, hyperviscosity Thrombocytopenia Pulmonary hemorrhage Malformations Sepsis

50 CAUSES OF FETAL OVERGROWTH Maternal diabetes Maternal obesity Excessive maternal weight gain

51 The perinatal mortality rate is defined as: a)The number of neonatal deaths that occur per 1000 live births b)The number of stillbirths that occur per 1000 births c)The number of fetal deaths within the first week after birth d)The number of stillbirths and neonatal deaths in the first week of life per 1000 live births

52 EVALUATION OF WELL-BEING

53 BIOPHYSICAL PROFILE Graded (0 or 2 pts; max 10) NST (normal) Movement (2) Tone (2) AFI (amniotic fluid volume) Breathing (30 seconds) DOPPLER What is it? Uteroplacental waveforms Umbilical artery Carotid artery Descending aorta

54 FETAL ACTIVITY Kick counts: “count to ten “ chart towards term 10 movements in 2 hours over 12 hours

55 CARDIOTOCOGRAPHY Maybe as good as BPP 1.Non-stress test: movement uterine activity 2. Stress tests: Oxytocin infusion nipple stimulation Features of the normal CTG: rate bpm BTB variation 5-15 bpm Accelerations present (2) No decelerations (early, variable, late)

56 Which fetus to assess? Small for gestational age, postdates Maternal hypertension, diabetes Antepartum hemorrhage Decreased FM The “ high risk ” pregnancy Etc…

57 WHY FETAL ASSESSMENT? 1.? To prevent damage (asphyxia) 2.? To deter unnecessary intervention (prematurity, operative deliveries)

58 WHAT IS IT LOOKING FOR? Fetal hypoxia before asphyxia Signs of placental failure: Poor fetal growth Decr. FM Decr. AFI Atypical, abnormal NST How to test? Fetal scalp pH sampling Normal >7.25 Borderline > (repeat sampling in ½ hour) Abnormal <7.20 (deliver)

59 Criterias for asphyxia (hypoxic acidemia) umbilical cord arterial pH < 7.0 base deficit > 16 Apgar score 0-3 for >5 minutes neonatal neurologic sequelae (e.g. seizures, hypotonia, coma) evidence of multiorgan system dysfunction in the immediate neonatal period

60 NORMAL TRACE

61 Early decels

62 Late Decels

63 Variable Decels

64 Reduced Variability

65 Tachycardia

66 Characteristics or associated findings with late decelerations include all of the following except: a)They may be seen in patients with pre-eclampsia b)They may be associated with respiratory alkalosis c)They are associated with a decreased uteroplacental blood flow d)They often are accompanied by decreased PO 2 e)They usually are accompanied by an increased PCO 2

67 MEDICAL COMPLICATIONS

68 NAUSEA AND VOMITING Morning sickness: 50% Hyperemesis gravidarum: 1% Tx: Diclectin (10 mg doxylamine succinate with vit B6) Rest Avoid triggers Admit if severe (i.e. dehydration, electrolytes imbalance) TSH, LFT IV Dietitian consult Psychology

69 DIABETES Incidence : 1% GDM: 3-5% Screening: 50g GTT If > 7.8 do 75 g 2 hr OGTT > 10.3 GDM Risks factors : Previous stillbirth Previous LGA FHx Persistent glycosuria

70 ORAL GLUCOSE TOLERANCE TEST (OGTT) Criteria (ADA): Fasting > hour > hour > of the 3 values met or exceeded = GDM 1 of the values failed = impaired glucose tolerance Risks: Anomalies Infection Pre-eclampsia Macrosomia Polyhydramnios IUFD shoulder dystocia

71 Rhesus isoimmunization Incidence: 7% african-american 13% caucasion IgG anti-D in Rh –ve sensitized women Can cause : fetal anemia heart failure Hydrops fetalis Born with jaundice In-Utero Dx : Amniocentesis, Cordo, Doppler Prophylaxis : 28 wks + postpartum (newborn Rh status)

72 Antepartum hemorrage (>20 wks) Causes : Placental abruption : concealed, revealed Signs: vaginal bleeding, pain, fetal distress Causes: PIH (DIC) Cocaine SLE Smoking Trauma Previous abruption Abnormal placentation : previa, vasa previa Signs: painless vaginal bleeding

73 PPH Causes (4T): 1.Uterine aTony: Twins long labor Etc… 2.Tissue (Retained products) Infection 3.Trauma (tears) 4.Thrombin: Congenital Disorders APH

74 PPH Treatment 1.Conservative: Deliver the placental Bimanual compression Uterine packing IV, xmatch, blood bank (PRBC, FFP, …) 2.Medical: Ergot Hemabate Oxytocin cytotec

75 PPH Treatment 3. Surgical: Repair the tear D&C (explore the uterus) Ligate internal iliacs UAE B-Lynch suture Bachrey balloon Hysterectomy

76 HYPERTENSION

77 HYPERTENSION IN PREGNANCY Leading cause of maternal death and perinatal mortality/morbidity BP monitoring is major activity of antenatal care Affects up to 10 % of all pregnancies

78 TERMINOLOGY dbs wks ABNORMAL VALUES? (depends on who…) >140 / 90 DBP > 90 two readings Systolic rise >30 or diastolic >15 PROTEINURIA >0.3 g/day (mild); >5 g/day (severe)

79 Primary DiagnosisDefinition of preeclampsia Pre-existing hypertension With comorbid conditions With preeclampsia (after 20 wks GA) Gestational hypertension With comorbid conditions With preeclampsia (after 20 wks GA) Resistant HTN, or new or worsening ptnuria, or one/more adverse conditions New proteinuria, or one/more adverse conditions Classification (it changes all the time…) Eclampsia: Convulsion during pregnancy or within 7 days to 6 weeks of delivery Not caused by epilepsy

80 Risk factors Primigravida or new partner Age, race Low social class Familial trend ?single gene Underlying hypertensive disorder 20 % diabetes 50 % Twins (mono) 30 % Hydatidiform mole Previous gestational hypertension 30 %

81 Severe: DBP> 110 with proteinuria (3-5g/d) Symptoms: Headache Scotomas Epigastric pain/RUQ Vomiting Hyperreflexia

82 head ache

83 Management MILD: monitor, deliver near term SEVERE:stabilize and deliver MOTHER: Labwork: CBC, LFT, uric acid, BUN, Cr, Albumin/creatinine ratio or 24 hour urine total protein, LDH, INR/PTT Symptoms: IV, meds, …. BABY: BPP Ultrasound: growth, doppler NST Celestone, …

84 ANTIHYPERTENSIVES Short or long-term: Methyl dopa Labetolol Nifedipine Acute: Labetolol Nifedipine Hydralazine ANTICONVULSANTS Prophylaxis and treatment: Magnesium sulphate

85 ECLAMPSIA Rx: Control airway Stop convulsion reduce BP Deliver (C. Section?) watch post natally

86 BREECH

87 ETIOLOGY OF BREECH PRESENTATION prematurity Fetal abnormality Multiple pregnancy polyhydramnios Placenta previa Uterine abnormality TYPES OF BREECH PRESENTATION Extended (frank) Flexed (complete) incomplete footling

88 MANAGEMENT OF BREECH PRESENTATION If diagnosed >34 weeks, options: External cephalic version Trial of labor with vaginal delivery caesarean Criteria for TOL: At weeks: Estimated fetal weight kg Frank or complete breech presentation clinical pelvimetry adequate Fetal abnormality excluded No serious medical or obstetric complications

89 A complete breech presentation is best described by which of the following statements: a)The legs and thighs of the fetus are flexed. b)The legs are extended and the thighs are flexed. c)The arms, legs, and thighs are completely flexed. d)The legs and thighs are extended. e)None of the above

90 TRANSVERSE LIE Incidence: 1:200 at term Risk factors: Multigravidae Placental previa Fibroids Polyhydramnios Multiple pregnancy Contracted pelvis Fetal abnormality Uterine abnormality Management: Ultrasound Cesarean if doesn’t turn

91 MULTIPLE PREGNANCY

92 Twins Incidence: 1:80 (triplets 1:80 2 ) 1:320 uniovular twins worldwide superfecundation superfetation Etiology: Population based Age Parity Previous binovular twins Heredity

93 Twins Diagnosis: LGA u/s: lambda sign Increased AFP Management: Rest Serial u/s Assess presentation + 38 wks

94 Placentation Dizygotic: Separate amnion and chorion Separate placentas Presentation: Vx/Vx: 45% Vx/BR: 25% Br/Vx: 10% Br/Br: 10% Etc…..

95 Placentation DIZYGOTIC DAY 23 %0 - 3 Totally separate 75 %4 - 7 Separate fetuses & amnion single chorion with vascular connections 1%7 - 11Monoamniotic & monochorionic <1 %11+conjoined twins

96 Hazards of multiple pregnancy Increased risk pre-eclampsia (X3) pressure symptoms anemia Abortion (disappearing sac) Prematurity (approx. 30% deliver < 37/40 ) Polyhydramnios twin-twin transfusion Placenta previa APH/PPH Malpresentation cord entanglement

97 cy

98 LABOR

99 What is Labor ? (: work) Regular painful uterine contractions accompanied by progressive effacement and dilatation of the cervix.

100 Timing of Labor 40 weeks 8% deliver on E.D.C. 7% premature <37 weeks 10% post-mature >42 weeks

101 Signs of Onset of Labour “ Show ” Rupture of membranes Contractions

102 Detection of ruptured membranes Nitrazine Test: Alkaline pH of fluid turns blue Ferning: High Na+ content causes “ ferning ” on air dried slide

103 Ferning

104 Cord prolapse Only with ruptured membranes Incidence: 1/300 Risk factors: 80% happen in multigravida Malpresentation: Transverse lie Breech High head Twins Prematurity OB interference: forcep, arm

105 Cord prolapse Diagnosis: Ultrasound Pelvic exam in labour (e.g. after ROM) FHR abnormality Treatment: Don’t panic Push up presenting part Sims position or knee/chest Cesarean (forceps if fully)

106 Stages of Labor 1st stage: Onset to ‘ full dilatation Latent and active 2nd stage:Full dilatation to delivery of baby 3rd stage:Delivery of placenta 4th stage:Placenta to 6 wks PP

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111 Table Characteristics of Labor Nulliparas and Multiparas* CharacteristicAll patientsIdeal LaborAll patientsIdeal labor NulliparasMultiparas Duration of first stage (hr) Latent phase6.4(±5.1)6.1 (±4.0)4.8 (±4.9)4.5 (±4.2) Active phase4.6(±3.6)3.4(±1.5)2.4(±2.2)2.1 (±2.0) Total 11.0(±8.7)9.5(±5.5)7.2(±7.1)6.6(±6.2) Maximum rate of descent (cm/hr)3.3(±2.3)3.6(±1.9)6.6(±4.0)7.0(±3.2) Duration of second stage (hr)1.1(±0.8) 0.76(±0.5) 0.39(±0.3) 0.32(±0.3) * All values given are ± SD. (Data from Friedman EA: Labor: Clinical Evaluation and Management. 2nd ed. New York, Appleton-Century-Crofts, 1978).

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116 Cesarean Section Indications Failure to progress (Dystocia) Repeat (Failed VBAC) Fetal Distress Breech Presentation Placenta Previa Cord prolapse Abruption Diabetes Fetal Reasons (e.g. prevent infection) Social...

117 Premature labor Incidence: 7% <37 wks Major cause of perinatal morbidity Overall recurrence risk of 30% Risk factors: Previous PTD Smoking Low income Cervical surgery Uterine anomaly Multiple pregnancy

118 Premature labor Treatment: Rest Steroids (for fetal lung maturity) Tocolytics? PPROM: Mercer protocol (IV/PO ampicillin(amoxil)/erythromycin) Prevention : Ultrasound cervical length? Fetal fibronectin (predictor?)

119 Amniotic Fluid Mainly fetal urine Some from extraplacental membranes 12 wks: 50 mls 24 wks: 500 mls 36 wks: 1,000 mls Oligohydramnios: Reduced AFI on u/s: <5cm SFH: small for dates; baby easy to feel Causes: Placental insufficiency Urinary tract dysplasia Diagnosis: Ultrasound Treatment: Intensive monitoring Early delivery

120 Polyhydramnios Definition: An excess of liquor to such a degree that it is likely to influence the course or management of pregnancy. >20 cm Diagnosis: SFH increased: large for dates Tense and uncomfortable Fluid thrill Difficult to feel fetus

121 Polyhydramnios: Etiology Maternal: Multip Diabetes GHTN Infection: toxoplasmosis, CMV Fetal: Macrosomia Anencephaly, hydrocephaly Gut atresia Multiple pregnancy CAN’T SWALLOW (diaphragmatic hernia, mediastinal tumor) HYDROPS FETALIS (Rh incompatibility, infection, heart disease, thalassemia major, etc.)

122 Dystocia Definition: Abnormal progression of labour in the ACTIVE Phase Cervical dilatation of <0.5 cm/hr over a 4 hr period arrest of progress in the ACTIVE phase either in the first or second stage of labour Failure of descent of presenting part Friedman’s curve

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125 CAUSES OF DYSTOCIA Power U ncoordinated uterine action Dysfunctional Labour PassengerCephalo-pelvic disproportion Relative disproportion Massive baby! (macrosomia) PassagesDiameters (pelvic anatomy)

126 Dystocia Risk Factors: age Parity Infection Epidural Position in labor Induction Macrosomia cervix

127 Initial measure to treat dystocia Comfort wellbeing hydration B. Amniotomy C. Oxytocin if A+B fail D. Wait long enough to see a response A. Attention to:

128 Oxytocin usage Dosage: Depends on your hospital protocol Initial dose: 1 to 2 mu/min Rate increased by 1 to 2 mu/min every 30 min until contractions are considered adequate and cervical dilatation achieved Clinical response usually seen at dose levels of 8-10 mu/min

129 Reduction of risk of dystocia Avoid induction for large fetal weight Avoid oxytocin use with unfavourable cervix Avoid admission to Labour and Delivery at <4cm dilatation “ Management ” of epidural at full dilatation Avoid immediate pushing after full dilatation

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131 Supportive strategies Cervical evaluation for ripening prior to booking induction Obstetrical triage Continuous professional support in active labour Mobilization of women in active labour Minimization of motor blockage with epidural Use of amniotomy and oxytocin prior to C/S for dystocia

132 Cesarean section for dystocia Timing of procedureRate Latent phase41% Active phase38% Second stage21% Source: Stewart CMAJ 1990:142;

133 Appropriate management for slow labour (dystocia) associated with an occiput posterior presentation during the first ACTIVE stage of labour would include: a) immediate cesarean section b)forceps c)augmentation with oxytocin d)external cephalic version e)fetal blood sampling

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