2Case One 18 yr old primip at 28/40 Feels generally unwell. Epigastric pain.Reduced fetal movements.What should you do?
3Case One History Examination Investigation Diagnosis and plan? Uneventful pregnancy so far.Can’t remember any fetal movements todayExaminationTemp 36, HR 70, B/P 145/100Symphisis fundal height 26cm, FH heardInvestigationUrine dip, protein ++Diagnosis and plan?
4Pre-eclampsiaMore common in young/old, primip, family history, new partner, multiple pregnancy, medical problems (renal disease, diabetes, antiphospholipid).SymptomsSevere headacheBlurred visionEpigastric painVomitingSudden swelling of face and hands
5ManagementAlways remember to check b/p and urine dip in any pregnant woman who is vaguely unwell.Need same day referral to PDC if:-Diastolic >90 AND any proteinuria.Normal b/p with >2+ protein (for 1+ reassess in 1 week)No protein, but diastolic >100 (if >90, reassess in 24hrs and refer if stays up)
6Secondary Care Management Control blood pressureMethyldopa or labetalol 1st line.Atenolol, ACEi, ARBs and diuretics all contraindicated.DeliverySolves the problem by removing placenta.If <34 weeks will try and give steroids 1st
7Eclampsia Any seizure in pregnancy = eclampsia until proven otherwise. Need ABC and 999.Remember left lateral/recovery position.Give 5-10mg PR/IV diazepam.Secondary care use IV magnesium sulphate infusion.
8Case Two 28 yr old, G2P1 at 29 weeks. 2 days of central abdominal pain Several episodes of vomiting.No diarrhoea.Fetal movements as normal.
9Case Two Examination Diagnosis? Temp 37.7, B/P 110/60. HR 90. Uterus measures for dates and FH heard.Tender and guarding in right flank.Diagnosis?
10Appendicitis 1/1000 pregnancies. Due to gravid uterus, appendix is displaced.Pain may be in flank, subcostal or periumbilical areas.Fetal mortality 5% and higher risk of perforation (15-20%).Low index of suspicion and refer.
11Case Three35 yr old G4P3, 34/40.Gradual onset of suprapubic, groin and thigh pain.Getting worse over the last week.Worse on walking.Has a waddling gait.Cause?
12Symphisis Pubis Dysfunction Due to ligament laxity.More common in multips and increased gestation.Usually settles within 6 mths of birth.TreatmentSimple analgesia (paracetamol).Physio – for brace, crutches and exercises.
13Case Four 29yr old primip at 34 weeks. Smoker Sudden onset constant central abdo pain.No PV bleeding.Not felt fetal movements
14Case Four Examination Diagnosis? B/P 100/50, HR 100, temp 35.5. General uterine tenderness.FH heard, rate 200.Diagnosis?
15Placental Abruption Detachment of all or part of placenta. Risk factors – hypertension, smoking, cocaine, trauma.Presents with abdo pain and fetal distress.May not be vaginal bleeding in a concealed abruption (blood collects behind placenta).Need ABC, 999 and urgent delivery.
16Case Five 22 yr old, primip at 32/40. Abdominal pain, urinary frequency.No loin pain or temps.No PV bleeding, baby moving well.Urine dip leuc ++, nitrites ++Diagnose UTI. Which abx?
17UTI in Pregnancy Usually due to E-coli. Cefalexin 500mg bd or amoxicillin 250mg tds for 7 days.Avoid trimethoprim (esp 1st trimester) due to teratogenicity.Avoid nitrofurantoin (esp 3rd trimester) due to neonatal haemolysis.