1. Obstetrics
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2. Areas you need to cover …
Booking appointments, screening for congenital abnormalities etc
Physiology of labour
Pre-eclampsia
Diabetes in pregnancy
APH
Haemolytic disease of the newborn
Obstetric emergencies
PROM
PPH
Abnormal fetal growth
Infections in pregnancy
Preterm labour: causes and prevention
Teratogenic drugs
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3. Physiology of labour
Painful uterine contractions accompany dilation and effacement of the cervix 37 – 42 weeks gestation First stage: initiation to full cervical dilatation Second stage: full dilatation to delivery of fetus Third stage: delivery of fetus to placental delivery
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4. Physiology of labour… Mechanical factors of labour Powers Passage
Uterine contractions causing effacement and dilatation of cervix
Passage
Bony pelvis and soft tissues
Passenger
Attitude – degree of flexion of head on the neck. Ideal = vertex presentation (maximal flexion)
Rotation
Size
Problem with any  failure to progress  assisted delivery
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6. First stage
The cervix opens to ‘full dilatation’ to allow the head to pass through Latent phase: <3cm Active phase: cm Head descends in a flexed position, starts to rotate and ROM
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7. Second stage Full dilatation to delivery of the fetus
Passive stage: full dilatation until head reaches pelvic floor and woman feels desire to push
Active stage: pushing!
Average 20 mins multiparous. 40 mins nulliparous
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8. Third stage
From delivery of the fetus to complete delivery of placenta Average 15 mins with 500ml blood loss
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9. Pre-eclampsia
BP >140/90mmHg with proteinuria > 0.3g/24 hours Risk factors: nulliparity, PMH, FH, long period between pregnancies, extremes of maternal age (>40yrs), pre-existing CKD, HTN, DM, large placenta (twins, fetal hydrops), obesity Px: usually asymptomatic. Signs: HTN, oedema, epigastric tenderness
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10. Pre-eclampsia cont. Ix: Urine dipstick for protein
Protein creatinine ratio >30mg/nmol
24 hour urinary collection >0.3g protein
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11. Pre-eclampsia complications
Maternal
Eclampsia (seizures)
CVA (haemorrhagic)
Clotting problems – DIC
Organ problems – liver failure, renal failure, pulmonary oedema
HELLP
Haemolysis
Elevated Liver enzymes
Low Platelets
Fetal
IUGR
Preterm birth, hypoxia, placental abruption
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12. Pre-eclampsia management
Only cured by delivery! Admit if symptomatic, proteinuria, BP >160/110, ? fetal compromise Antihypertensives – labetalol (or nifedipine or hydralazine) Magnesium sulphate in eclampsia (+ IV labetalol or hydralazine) Steroids if preterm delivery required Mild: deliver by 37 weeks Complications or fetal distress: deliver at any gestation
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13. Antepartum haemorrhage
Bleeding from the genital tract after 24 weeks gestation Causes Common: undetermined, placental abruption, placenta praevia Rarer: incidental genital tract pathology, uterine rupture, vasa praevia
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14. Placenta praevia
Placenta implanted in uterine lower segment Complications: haemorrhage, obstructs head engagement (requires c- section), placenta acreta, placenta percreta Px: intermittent painless bleeds increasing in frequency and intensity Ix: USS, FBC and crossmatch if bleeding Tx: C-section at 39 weeks, or earlier if heavy bleeding.
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15. Placental abruption
Separation of part/all of placenta before delivery (>24 weeks) Causes: idiopathic, IUGR, pre-eclampsia, autoimmune disease, smoking, PMH, HTN Px: painful bleeding …. but MAY NOT BLEED – blood may track between membranes and myometrium, enter liquor etc. O/E: tachycardia, uterine tenderness, contractions, ‘woody uterus’, maternal collapse, abnormal fetal heart beat, hypotension (late)
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16. Placental abruption cont.
Ix: diagnosis is clinical. USS excludes placenta praevia. CTG for fetus, FBC and clotting for mother.
Complications: fetal death, massive haemorrhage, DIC, renal failure, maternal death
Tx:
Admit if suspected even without bleeding.
Resuscitate if required (blood), deliver by c-section if fetal distress/death/ > 37 weeks
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17. Vasa praevia
Fetal blood vessels running in the membranes in front of the presenting part. When membranes rupture vessels may rupture with massive fetal bleeding. Px: Moderate, painless bleeding at ROM. Severe fetal distress. Tx: C-section often not fast enough to save the fetus.
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18. Obstetric emergencies
Shoulder dystocia
Uterine rupture
Amniotic fluid embolism
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19. Shoulder dystocia
Normal downward traction fails to deliver shoulders after head. Requires urgent additional manoeuvres. Risk factors: macrosomia, PH, maternal obesity, maternal DM, short maternal height, instrumental delivery Tx: McRoberts manoeuvre and suprapubic pressure, Wood’s screw manoeuvre Complications: Erb’s palsy, fetal death High cause of medical negligence claims!!!
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20. Cord prolapse
Umbilical cord descends below presenting part after rupture of membranes Spasm/compression of cord causes fetal hypoxia Risk factors: preterm labour, breach presentation, polyhydramnios, abnormal lie, twin pregnancy Px: Fetal distress and palpable cord vaginally Tx: Prevent compression of cord by presenting part (tocolytics e.g. turbutaline/nifedipine, or manually). Immediate c-section or instrumental delivery may be appropriate
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21. Amniotic fluid embolism
Liquor enters maternal circulation causing anaphylaxis, seizures, cardiac arrest Causes DIC, pulmonary oedema, ARDS, rapid death. Risk factors: strong contractions, polyhydramnios Tx: Diagnosis usually at post-mortem!! Resuscitation and supportive treatment in ICU setting
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22. Uterine rupture
Spontaneous tear of uterus. Bleeding from rupture site, acute fetal hypoxia and massive internal maternal haemorrhage. Risk factors: scarred uterus, previous c-section, neglected obstructed labour, congenital uterine abnormalities Tx: resuscitation, urgent laparotomy for fetal delivery, repair/remove uterus
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23. Post partum haemorrhage
Loss of >500ml blood <24 hours after delivery (or >1000ml after c- section) Causes: Retained placental fragments, atonic uterus, perineal trauma, uterine rupture, cervical tear, high vaginal tear Prevention: routine use of oxytocin in third stage of labour Tx: Resuscitation, manual removal of retained placenta, identify and treat cause Persistent haemorrhage requires surgery. Hysterectomy may be required.
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24. Infections in Pregnancy
HSV
HBV
Rubella
HIV
Toxoplasmosis
HZV
CMV
Syphilis
Parvovirus
Group B Streptococcus
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25. Teratogenic drugs Warfarin ACE inhibitors
Anti-thyroid drugs: Carbimazole (recommended for 2nd and 3rd trimester – block and replace regimen contraindicated), propylthiouracil (recommended for pre-pregnancy and 1st trimester)
Angiotensin II antagonists
Antiepileptics (minus lamotrigine)
Methotrexate
Antibiotics (trimethoprim, tetracycline, doxycycline)
Isotretinoin
Alcohol, cocaine, high dose vitamin
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26. Name 1 additional test for diagnosis?
A patient has high blood pressure, feeling puffy, flashing lights and a headache.
Name 1 additional test for diagnosis?
4 further clinical and laboratory investigations to assess severity of preeclampsia?
5 complications to prevent or exclude in this patient?
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