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Medical disorders in Pregnancy & Complications in pregnancy Tutorial.

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Presentation on theme: "Medical disorders in Pregnancy & Complications in pregnancy Tutorial."— Presentation transcript:

1 Medical disorders in Pregnancy & Complications in pregnancy Tutorial

2 Indications for GTT BMI>30 Ethnic group (Asian) 1 st degree relative with diabetes Previous Gestational DM Previous still birth Previous big baby(>4.5kg) Persistent Glycosuria Big baby + polyhydramnios PCOS

3 Scenario 1 A 26 year old P0 attends ANC at 29weeks gestation, it is noted that the SFH measures 32 cm. Urine dipstick reveals 3+ glucose. 1. How would you investigate her GTT USS for growth /liquor volume 2. What is the most likely diagnosis Gestational DM with Macrosomia/ Polyhydramnios 3. How would you alter her antenatal management subsequently? - Combined Obstetric/ diabetic clinic - Blood sugar monitoring- Rx Diet/metformin/Insulin - Monthly HbA1c - Serial Growth scans

4 4. Think also about your plan for delivery and the post natal period - If diet controlled- aim to deliver by 40 weeks (IOL) - If Rx with Metformin/Insulin- deliver by 38-39 wk -If significant macrosomia consider C/S - Intrapartum sliding scale -Stop treatment for diabetes post delivery -Monitor baby for hypoglycemia -Post natal GTT 5. What are the long term implications of this? - GDM in subsequent pregnancy - DM in long term

5 Scenario 2 A 21 year old IDDM books for her pregnancy at 12 weeks gestation. She has been diabetic since age 5. 1.How does DM affect pregnancy and How does pregnancy affect diabetes? Fetal: - Miscarriage - Congenital- heart defect, CNS & skeletal defect - macrosomia - Still birth - Shoulder dystocia

6 -Neonatal hypoglycemia & hyperbilirubinemia Maternal- UTI - polyhydramnios - Retinopathy worse - Nephropathy & pre eclampsia - Need for elective delivery(IOL/C/S) - Wound infection 3. How would you modify her antenatal care -Anomaly scan in fetal Medicine to exclude anomalies -Same as GDM ( change to pre pregnancy Insulin & no postnatal GTT required)

7 Scenario 3 A 35 year old woman is admitted to the A&E at 26 weeks gestation with acute SOB. 1. what is your possible diagnoses? Pulmonary Embolism 2. How would you investigate her? FBC, clotting, ECG, ABG, doppler legs, CXR,V/Q scan/ CTPA, Pulm angiography (severe cases only) 3. What treatment would you recommend Treatment dose of LMWH 1mg/kg/BD

8 4. How would this affect her subsequent AN care and delivery -Continue treatment with LMWH for upto 6 wk post delivery ( Treatment dose should be continued up to 6 months after the event) -Stop Clexane with signs of labour -Epidural /Spinal can be given only if had last clexane injection> 24 hr 5. How would this affect her next pregnancy Thromboprophylaxis at least 4 weeks prior to the diagnosis in previous pregnancy i.e 22 weeks onward and continue in the postnatal period.

9 Scenario 4 A 35 year old is admitted to the A&E at 26 weeks gestation with acute SOB. She is a known asthmatic 1. what is your possible diagnoses? Severe exacerbation of asthma 2. What is your immediate management? *Management is same as out side pregnancy - High flow O2 - Salbutamol nebulizer - Ipratropium bromide neb. added if poor control - Steroids IV hydrocortisone± PO prednisolone 5/7

10 3. How would you investigate her? CXR if suspecting pneumonia/pnemothorax/ patient fail to improve. 4. How would this affect her subsequent AN care and delivery -Women on oral steroid for 2 weeks prior to delivery will require IV hydrocortisone in labour -Prostin pessary is safe for induction -Opiate for pain relief should avoided with acute attack -Syntometrine is safe for 3rd stage of labour -Spinal preferred since GA ↑ Chest infection & atelectasis -Carboprost for the mangement of PPH should be used cautiously (risk of broncoconstriction)

11 Scenario 5 A Patient with known hypertension presents for booking. She is currently on antihypertensive (enalapril). 1. How does hypertension affect pregnancy? How does pregnancy affect BP? - Superimposed pre eclampsia, eclampsia, Abruption -HELLP syndrome, CVA, Pulmonary Edema, Acute renal failure, DIC, ARDS - IUGR, HIE,IUD

12 - 2. How would you modify her antenatal care? - Stop Enlapril - Commence labetolol/methyldopa - Low dose aspirin -Uterine artery dopplers -BP monitoring -Serial growth scans -Timing /mode of delivery depends on time severity of superimposed pre eclampsia

13 Scenario 6 A 35 year old patient is admitted in her 2 nd pregnancy with convulsions. She is 29 weeks gestation 1. What is your likely diagnosis? Eclampsia 2. What is your management plan? -Observation- P/BP/O2 sat, RR,U/O; CTG - Secure airway (guedal/intubation if recurrent fit) & O2 -IV access -Magnesium sulphate -IV Antihypertensive -Deliver by C/S after stabilization

14 2. Justify your management All pregnant woman are eclamptic unless known epileptic. 3. What investigations would you perform & why? FBC – low platelet Clotting- abnormal if DIC U&E – Raised urea & creatinine Urates – raised Urine for PCR- Raised Urine for C/S Investigation- confirm the diagnosis

15 Scenario 7 A 35 year old patient is admitted in her 2nd pregnancy with convulsions. She is 29 weeks gestation. she was a known epileptic ? 1. What modifications would you make in her pre pregnancy management and why? -Preconception counselling/educating family members - Change to monotherapy – Reduce teratogenecity - Change from phenytoin/phenobarbitone to other anti epileptic (lamotrigine)

16 2. What modifications would you make in her antenatal care – justify your plans. - See in combined Obstetrics/Neurology clinic -Continue on medication as outside pregnancy. Emphasize some women experience increased seizure frequency in pregnancy & optimal drug compliance -Anti epileptics -reduction in vitamin K dependent clotting factor hence commence vitamin K from 36 weeks + neonatal vitamin K to reduce risk of neonatal hemorrhage -Drugs not contraindicated with breast feeding

17 3. What are the main risks of epilepsy in pregnancy ? Risk of Congenital abnormalities: - Continue folic acid through out pregnancy - Anomaly scan in fetal medicine (a) Phenytion- cardiac defect, cleft lip/palate (b) Sodium valproate- Neural tube defect (C) Carbamazepine- Neural tube defect Increased seizure frequency during pregnancy Reduction in vitamin K dependent clotting factor hence risk of neonatal haemorrhage

18 Breech presentation Incidence 3-5% Flexed, Extended, footling breech Predisposing factors: prematurity - multiple pregnancy - oligo/polyhyramnios - placenta previa - Abnormalities of uterine shape - fetal abn. ( hydrocephalus) - pelvic tumour - contracted pelvis

19 Management option: - Vaginal breech delivery - External cephalic version- Success 60%, 1% fetal distress, 1% reversion to breech - Caesarean section Complications associated with breech : - Birth trauma: trapped after coming head of breech, fetal distress, death, fracture skull/long bones - Cord prolapse - PPH

20 Cord prolapse Obstetric emergency Predisposing factors: Prematurity, multiparity, amniotomy, polyhydramnios with SROM, long cord Management: *AVOID HANDLING THE CORD* - If fully dilated –instrumental delivery - Otherwise - All four’s position OR - Fill the bladder with saline Proceed with emergency caesarean section

21 Antepartum haemorrhage Definition- Bleeding from the genital tract from 20 weeks gestation onwards. Causes- placenta previa - placental abruption - lower genital tract- ectropion, infection, cervical poly, Ca Cervix - vasa previa

22 Placental abruption Premature separation of normally sited placenta Causes- Frequently unknown - Severe Pre eclampsia - Raised AFP - Abdominal trauma - Cocaine - ARM/SROM

23 Clinical presentation: - Concealed/Revealed haemorrhage - Constant abdominal pain increasing in severity - Shock - hard tender uterus that does not relax - Difficulty in feeling fetal parts - Fetal distress/ Fetal heart is absent Management : - IV access, FBC, Cross match, clotting - CTG - Early delivery if fetus alive - Adequate maternal transfusion Complications: IUD,PPH, renal failure,DIC

24 Placenta Previa Definition- Placenta that is implanted in the lower uterine segment along side or in front of the presenting part Types: Minor- placenta reaches the cervix Major- placenta covers the cervix Causes: Mostly unknown - Multiparity - Multiple pregnancy - previous caesarean section

25 Clinical presentation: - Painless vaginal bleeding - Malpresentation - Soft uterus Management: - If asymptomatic: vaginal delivery if placenta 2.5 cm from internal os otherwise elective C/S. -If Symptomatic( bleeding): Conservative management if small APH otherwise C/S Complication: PPH, may require hysterectomy

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