Tag: Obstetrics

Twin pregnancy

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Twin pregnancy
Types
Monochorionic, monoamniotic
·       1 placenta, 1 amniotic sac
Monochorionic, diamniotic
·       1 placenta, 2 amniotic sacs
·       “T-sign” at intertwin membrane
Dichorionic, diamniotic
·       2 placentas, 2 amniotic sacs
·       “Lambda sign”
Maternal Comp
·       Hyperemesis gravidarum (more B-hCH)
·       PIH / GDM / IDA
Fetal Comp
·       Congenital anomalies
·       IUGR / Preterm / Breech
·       Monochorionic: Twin-twin transfusion syndrome
·       Monoamniotic: Conjoined twins / Cord entanglement

Rh Incompatibility

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Rh Incompatibility
Def
·       A ⊖ SENSITIZED Mom attacking a ⊕ baby (causing Hemolytic Disease of Newborn)
·       Hemolysis + extramedullary RBC production
·       ⤴️ Bilirubin: can be neurotoxic
·       Erythroblastosis fetalis (⤴️ CO)
·       Sensitization happens by the 1st child
Dx
Screen Shot 2019-08-31 at 7.53.17 AM
      
If both mom & dad are Rh ⊖ → Stop. The baby will never be Rh ⊕
Tx
Approach
We want to ❌ sensitization (by giving RhoGAM at specific times)
·       AT 28 weeks
·       w/I 72 h of delivery
·       if there’s maternal-fetal blood mixing for any reason (D&C, CS, surgery)
We want to handle a baby that’s attacked
·       We use Transcarotid US + PUBS
·       If >32 weeks: deliver
·       If <32 weeks: wait + transfuse blood by PUBS
Algorithm
Screen Shot 2019-08-31 at 7.53.52 AM
·      If prolonged delivery and you suspect Fetomaternal hemorrhage –> Rosetto test
·      If ⨁ –> KB Test –> then give 300 RHoGAM for every 1.5
·      If ⊖ –> RHoGAM طبيعي زي العادة

 

Indications for ppx administration of anti-D immune globulin for Rh(D)-negative patients
·       At 28-32 weeks gestation
·       <72 hours after delivery of Rh(D)-positive infant
·       <72 hours after spontaneous abortion
·       Ectopic pregnancy
·       Threatened abortion
·       Hydatidiform mole
·       CVS, amniocentesis
·       Abdominal trauma
·       2nd- & 3rd-trimester bleeding
·       External cephalic version
*Antepartum prophylaxis is not indicated if the father is Rh(D) negative.

Prenatal Care

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time
Frequency
Check for
1st
every 4 w
·       Between 11 and 14 weeks, US to confirm GA and check for nuchal translucency.
·        CBC, Pap smear, and Chlamydia tests are done.
·       Syphilis / HIV / Hep B
2nd
every 4 w
·       at 15-20: triple or quad test
⤴️ maternal serum alpha-fetoprotein
 ⤵️ maternal serum alpha-fetoprotein
·       Open neural tube defects (anencephaly, open spina bifida)
·       Ventral wall defects (eg, omphalocele, gastroschisis)
·       Multiple gestation
Aneuploidies (eg, trisomy 18 & 21)
·       24-28: check for Abs if RH ⊖ + Screen for GDM
3rd
every 2 w ➡ every 1 weeks (@ 37 w)
·       GBS
·       37 moving forward: check Cervix w/ every visit
⤴️ maternal serum alpha-fetoprotein
 ⤵️ maternal serum alpha-fetoprotein
Open neural tube defects (eg, anencephaly, open spina bifida)
Ventral wall defects (eg, omphalocele, gastroschisis)
Multiple gestation
Aneuploidies (eg, trisomy 18 & 21)
 Initial prenatal visit
·       CHECK THE BLOOD
·       Rh (D) type, antibody screen
·       Hemoglobin/hematocrit, MCV
·       CHECK FOR BAD INFXN
·       HIV, VDRL/RPR, HBsAg
·       Rubella & varicella immunity
·       Pap test (if screening indicated)
·       Chlamydia PCR
·       CHECK URINE
·       Urine cx
·       Urine protein
24-28 weeks
·       Hemoglobin/hematocrit
·       Antibody screen if Rh (D) negative
·       50-g 1-hour GCT (why? here where the hPL is secreted).
35-37 weeks
Group B Streptococcus culture
Causes of Rx Pregnancy Loss
Structural
·       Uterine: fibroids, adhesions, polyps
·       Cervical insufficiency
Chromosomal
·       Aneuploidy
·       Translocations/rearrangements
·       Mosaicism
Hematologic
·       Hypercoagulable disorders (antiphospholipid syndrome)
Endocrine
·       Thyroid disease
·       PCOS
·       Hyperprolactinemia
·       DM
Other
·       Advancing maternal age
·       Defective endometrial receptivity
·       Celiac disease

Pregnancy

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·       MCC sx? Amenorrhea 
Sign 
Physical Findings
Time from conception
Goodell sign
Softening of the cervix
4 weeks
Ladin sign
Softening of the midline of the uterus
6 weeks
Chadwick sign
Blue discoloration of vagina and cervix
6-8 weeks
Telangiectasias/palmar erythema
Small blood vessels/reddening of the palms
1st trimester
Chloasma
The “mask of pregnancy” is a hyperpigmentation of the face most commonly on forehead, nose, and cheeks; it can worsen with sun exposure.
16 weeks (2nd trimester)
Linea nigra
A line of hyperpigmentation that can extend from xiphoid process to pubic symphysis
2nd trimester
·       How to dx pregnancy? Urine/Serum ß-hCG ➡ confirm w/ US.
·       ß-hCG ⤴️until 10 weeks (doubles every 48h) then slowly ⤵️ in 2ndtrimester, then slowly ⤴️in 3rd trimester.
·       Beta-HCG >1500 or 5 weeks = gestational sac on ultrasound
Physiologic changes
Cardio
·       ⤴️ CO
·       ⤴️ HR
·       ⤵️ BP
Resp
·       ⤴️ Tidal volume
·       ⤵️ FRC
GI
·       Morning Sickness
·       Lower esophageal sphincter tone ⤵️ (GERD)
·       Large intestine motility ⤵️ (Constipation)
Renal
·       Dilation of both kidney & ureter (⤴️ risk for pyelo)
·       ⤴️ GFR
·       Hydronephrosis here is normal
Hema
·       Anemia + hypercoagulable state (by ⤴️ in fibrenogen + venous stasis – other coagulation studies are ⓝ)
Thyroid
⤴️ Thyroid (to keep up w/ demand), by:
1.     Estrogen → ⤴️ TBG → thyroid makes more hormones
2.     ßhCG stimulates TSH Receptors (⤵️  TSH)
Total T4: ⤴️ / Free T4: Ⓝ / TSH: ⤵️ 
Illicit drug abuse in pregnancy
RF
·       Adolescent pregnancy
·       Late/noncompliant prenatal care
·       Inadequate pregnancy weight gain
Comp
·       Spontaneous abortion
·       Preterm birth
·       Preeclampsia
·       Abruptio placentae
·       IUGR
·       Fetal demise
Vaccines during pregnancy
Recommended
·       Tdap
·       Inactivated influenza
·       Rho(D)GAM
Indicated for high-risk pts
·       Hepatitis B
·       Hepatitis A
·       Pneumococcus
·       Haemophilus influenzae
·       Meningococcus
·       Varicella-zoster immunoglobulin
Contraindicated
HPV (live)
MMR
Live attenuated influenza
Varicella
Pregnancy & Exercise
Absolute Contraindications
Amniotic fluid leak
Cervical incompetence
Multiple gestation
Placenta abruption or previa
Premature labor
Preeclampsia/gestational hypertension
Severe heart or lung disease
Unsafe
Contact sports (basketball, ice hockey, soccer)
High fall risk (eg, downhill skiing, gymnastics, horseback riding)
Scuba diving
Hot yoga

Postpartum Hemorrhage

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PPH
features
·       >500 ml blood loss
·       Causes: Atony, RPOC, coagulopathy, rupture
·       Sheehan syndrome after postpartum hemorrhage presents as inability to breastfeed.
S/S
bleeding
Dx
clx
Tx
·       Examine uterus: r/o rupture, infxn, no retained placenta
·       Massage
·       If failed: oxytocin
Post-partum Hemorrhage
Atony
·       Prolonged labor
·       Uterine overdistension (macrosomia, polyhydramnios)
Enlarged, boggy uterus
·       Uterine massage
·       Oxytocin
·       Uterotonic medications
Retained POC
·       Succenturiate placenta
·       Manual extraction of placenta
·       Hx of previous uterine surgery
·       Enlarged, boggy uterus
·       Placenta missing cotyledons
·       Retained placental fragments on US
Manual extraction
Trauma
Operative vaginal delivery
·       Laceration of cervix or vagina
·       Enlarging hematoma
Laceration repair
Coagulopathy
Hx of 🆎 bleeding in pt or family
Continued bleeding despite contracted uterus
Tx U/C

Abnormal labor (Cord Prolapse, Dystocia, Endometritis)

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Cord Prolapse
·       Knee chest position,
·       elevate presenting part,
·       NEVER PUT IT BAAAACK
·       give terbutaline
·       Perform immediate CS

Shoulder dystocia
Def
Failure of usual obstetric maneuvers to deliver fetal shoulders
features
·       anything that ⤴️ baby weight (DM, Obesity, Postterm)
·       Previous hx of shoulder dystocia
RF
·       Fetal macrosomia
·       Maternal obesity
·       Excessive pregnancy weight gain
·       Gestational diabetes
·       Post-term pregnancy
Warning signs
·       Protracted labor
·       Retraction of fetal head into the perineum after delivery (turtle sign)
S/S
الراس طلع بس الكتف ناشب ورا
Tx
Different maneuvers can be applied:
1˚ Roberts Maneuver (1st line)
Last maneuver to try: Zavanelli (push head back and go to CS)

 Complications of shoulder dystocia
Clavicle fx
·       Clavicular crepitus/bony irregularity
·       Moro reflex on affected side
·       Intact biceps & grasp reflexes
Humerus fx
·       Upper arm crepitus/bony irregularity
·       Moro reflex on affected side
·       Intact biceps & grasp reflexes
Erb palsy
Moro & biceps reflexes on affected side “Waiter’s tip”
·       Extended elbow
·       Pronated forearm
·       Flexed wrist & fingers
Intact grasp reflex
Klumpke palsy
·       “Claw hand”
·       Extended wrist
·       Hyperextended metacarpophalangeal joints
·       Flexed interphalangeal joints
·       Absent grasp reflex
·       Horner syndrome (ptosis, miosis) 
·       Intact Moro & biceps reflexes
Perinatal Asphyxia
·       Variable presentation depending on duration of hypoxia
·       AMS (eg, irritability, lethargy), respiratory or feeding difficulties, poor tone, seizure)
Postpartum Urinary Retention
RF
·       Primiparity
·       Regional neuraxial anesthesia
·       Operative vaginal delivery
·       Perineal injury
·       Cesarean delivery
S/S
·       Small-volume voids or inability to void
·       Incomplete bladder emptying
·       Dribbling of urine
Tx
·       Self-limited condition
·       Intermittent catheterization (do not observe)
Postpartum Endometritis
RF
·       CS
·       Chorioamnionitis
·       GBS colonization
·       Prolonged rupture of membranes
·       Operative vaginal delivery
S/S
·       Fever >24 hours postpartum
·       Uterine fundal tenderness
·       Foul-smelling discharge
👾
Polymicrobial
Tx
1˚ Clindamycin & gentamicin
If still spiking fever → Add ampicillin
Amniotic fluid embolism
RF
·       Advanced age
·       Gravida 25
·       CS or instrumental delivery
·       Placenta previa or abruption
·       PIH
Clx
·       Cardiogenic shock
·       Hypoxemic respiratory failure
·       DIC
·       Coma or SZ
Tx
·       Respiratory & hemodynamic support
·       ± Transfusion
 Sudden infant death syndrome
RF
Prevent w/
Maternal factors
·       Smoking (while pregnant or after delivery)
·       Young mom <20
·       Inconsistent prenatal care
·       Stop smoking
·       Routine prenatal care
Infant factors
·       Prone/side sleep position
·       Soft sleep surface, loose bedding
·       Bed-sharing
·       Prematurity
·       Sibling with SIDS
·       Supine sleep position
·       Firm sleep surface
·       Room-sharing
·       Pacifier use

Late Complications of Pregnancy

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Preterm Labor
RF
·       PROM
·       Multiple gestation
·       PMHx of preterm labor
·       Placental abruption
MATERNAL
·       Uterine anatomical abnormalities
·       Infections (chorioamnionitis)
·       PIH
·       Intraabdominal surgery
S/S
Labor (contractions + Cvx dilation) before 37 weeks
Dx
Clx
Tx
 
Give 1) Betamethasone + 2) Tocolytics
Tocolytics are:
·       MgSO4 (MC one, SE: flushing, depressed cardiac + resp + ⤵️ DTR)
·       CCB (SE: flushing + Headache)
·       Terbutaline
When you dont stop labor w/ tocolytics:
·       GA 34-37
·       Maternal severe HTN (preeclampsia/eclampsia)
·       Maternal cardiac disease
·       Maternal cervical dilation of more than 4 cm
·       Maternal hemorrhage (abruptio placenta, DIC)
o   Fetal death (deliver vaginally even if breach)
·       Chorioamnionitis
34-36
+/- Betamethasone
Penicillin if GBS ⊕ 
32-33
Betamethasone
Penicillin if GBS ⊕
Tocolytics
<32
Betamethasone
Penicillin if GBS ⊕
Tocolytics
Mg Sulfate

 Premature rupture of membranes (PROM)
?
PROM = rupture without contractions
S/S
·       gush or slow leak of fluid from the vagina
·       PEx: amniotic fluid exiting the cervical os + pooling in the vaginal fornix
Dx
·       Clx
·       Nitrazine paper: note that vaginal fluid is acidic (pH ~4) and amniotic fluid has a pH ~7
·       fern test: a ferning pattern is seen with amniotic fluid
Tx
·      Depends on gestational age:
·       If not viable خلاص بيموت، طلعه بس
·       If preterm 24-34 –> IP + IV Betamethasone + PPx Abx for 7 days
·       If ≥34 –> DELIVERY
·      If <32: give MgSO4, Tocolytics, Betamethasone
·      If 32-34: give tocolytics, betamethasone
·      If ≥34: deliver.
·      If pt has chorioamnitis (FEVER + ROM): Cultx + IV ABx + Delivery
Indication for abx
·        Temp more than 38
– Rupture more than 18 h
– Preterm
– Positive prenatal culture
Preterm prelabor rupture of membranes (PPROM)
?
Membrane rupture at <37 weeks w/o labor
RF
·       Prior PPROM
·       GU infection (ASB, BV)
·       Antepartum bleeding
Dx
·       Vaginal pooling or fluid from cervix
·       Nitrazine-positive (blue) fluid
·       Ferning on microscopy
Tx
·       <34 weeks (reassuring): latency Abx, CS
·       <34 weeks (nonreassuring): delivery
·       ≥34 weeks: delivery
Comp
Intraamniotic infection
Placental abruption
Umbilical cord prolapses
 IUGR 
Symmetric
 Asymmetric
Ultrasound estimated fetal weight <10th percentile for gestational age
·       1st trimester
·       Chromosomal
·       Congenital infxn
·       All the body
·       2nd/3rd trimester
·       Utero-placental insufficiency (HTN)
·       Maternal malnutrition
·       “Head-sparing”
·       Weekly biophysical profiles
·       Serial umbilical artery Doppler sonography
·       Serial growth US
Intrahepatic cholestasis of pregnancy
Clx
·       Develops in 3rd trimester
·       Generalized pruritus
·       Pruritus worse on hands & feet
·       RUQ pain
Labs
⤴️ Total bile acids (>10)
⤴️ Transaminases (<2x ⓝ)
⤴️ Total & direct bilirubin
⤴️ Risk of
·       Intrauterine fetal demise
·       Preterm delivery
·       Neonatal respiratory distress syndrome
Tx
·       Delivery at 37 weeks gestation
·       Ursodeoxycholic acid
·       Antihistamines
Intrauterine fetal demise
Def
 Fetal death at ≥20 weeks
Dx
Absence of fetal cardiac activity on US
Tx
20-23 weeks
• Dilation & evacuation
                  OR
• Vaginal delivery
≥24 weeks
• Vaginal delivery
Comp
 Coagulopathy after several weeks of fetal retention
Delivery planning for a nonviable fetus
Fetal diagnosis
·       Acardia
·       Anencephaly
·       Bilateral renal agenesis
·       Holoprosencephaly
·       Intrauterine fetal demise
·       Pulmonary hypoplasia
·       Thanatophoric dwarfism
Obstetric management
·       Vaginal delivery (even if breach)
·       No fetal monitoring
Neonatal management
Palliative care if not stillborn

3rd-Trimester Bleeding

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Previa
·      RFs:
·       Prior placenta previa
·       Prior CS
·       Multiple gestation
·      Clx: Painless vaginal bleeding weeks gestation
·      Dx: Transabdominal followed by transvaginal sonogram
·      Tx:
·       No intercourse
·       No digital cervical examination
·       Inpatient admission for bleeding episodes
·       F/U w/ pt, as previa could resolve
·       If not resolved -> CS at 36-37 weeks

Bed rest + nothing in vagina
(if husband is horny he can masturbate)
If preterm: tx as preterm
CS, if:
·       Fetal distress
·       Cx >4cm
·       Unstoppable bleeding
Abruption
RFs:
·       Maternal hypertension or preeclampsia/eclampsia
·       Abdominal trauma
·       Prior placental abruption
·       Cocaine & tobacco use
Clx
·       Sudden-onset vaginal bleeding (80%)
·       Abdominal or back pain
·       High-frequency, low-intensity contractions
·       Hypertonic, tender uterus
Dx
·       Clx Dx
·       US (not required for dx) to rule out placenta previa; may show retroplacental hematoma
CS if:
· Uncontrollable maternal hemorrhage
· Rapidly expanding concealed hemorrhage
· Fetal distress
· Rapid placental separation
NVD are indicated if:
· Placental separation is limited
· Fetal heart tracing is assuring
· Separation is extensive and fetus is dead
Accreta
If placenta cannot detach from the uterine wall after delivery → catastrophic hemorrhage and shock.
Patients require hysterectomy.
Uterine rupture
RF: multiple CS
Presentation (during labor):
·       Sudden onset of extreme abdominal pain
·       Abnormal bump in abdomen
·       No uterine contractions
·       Regression of fetus
IMMEDIATE Laparotomy 🚨

Uterine Rupture
RF
·       Prior uterine surgery (CS)
·       IOL/ ⤴️⏰ Labor
·       الطفل حجمه كبير
·       تشوهات في الرحم
Clx
·       Vaginal bleeding
·       Intraabdominal bleeding (hypotension, tachycardia)
·       Fetal heart decelerations
·       Loss of fetal station
·       Palpable fetal parts on abdominal examination
·       Loss of intrauterine pressure
Tx
Laparotomy for delivery & uterine repair
Uterine Inversion
?
·       Excessive fundal pressure
·       Excessive umbilical cord traction
S/S
·       Lower abdominal pain
·       Round mass protruding through cervix
·       Uterine fundus not palable transabdominally
·       Hemorrhage shock
Tx
·       IVF aggressive
·       Put uterus back (replacement)
·       Remove Placeta
·       Give uterotonic drugs


Normal Labor

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Stages of labor
Stage
From start to end
⏰
Stage 1
Onset of labor → full dilation of cervix
Primigravid: 6–18h
Multipara: 2–10h
Latent phase
Onset of labor → 6 cm dilation
Primigravid: 6–7h
Multipara: 4–5h
Active phase
6 cm dilation → full dilation
Primigravid: >1.2 cm/h
Multipara: >1.5cm/h
Stage 2
Full dilation of cervix → delivery of neonate
Primigravid: 30 minutes–3 hours
Multipara: 5–30 minutes
Stage 3
Delivery of neonate → delivery of placenta
30 minutes
Normal Labor
features
·       A pt is considered to be in labor when has both of the following:
1) Regular uterine contractions with at least 1 contraction every 10 minutes.
2) Cervical changes (i.e. cervical effacement and/or dilatation) or rupture of the membranes.
S/S
she’s gonna scream ☠️
Dx
Clx
Tx
The normal frequency of uterine contractions will be 3-5 times in every 10 minute period. oxytocin is used to increase the number of contractions until it reaches normal.
200 x 10 min movedo
False Labor
Latent Labor
Irregular
Infrequent
Regular
Frequent
Weak
Strong
No pain or mild pain
PAINFUL
No cervical change
⊕ Cervical change
IOL
Oxytocin
⤴️ uterine contractions
Misoprostol
·       Cervical ripening
·       do not give to asthmatics
Amniotomy
تفقع الكيس
·       Inspect for a prolapsed umbilical cord before puncturing the amniotic sac.

Infections During Pregnancy

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Perinatal Hep B infection
#
·       90% risk of vertical transmission without PPx
·       <2% risk after PPx
·       Chronic infection in 90% of perinatally infected infants
RF
·       High maternal viral load
·       Maternal HBeAg+
Transmission
·       Perinatal exposure to genital secretions (most common)
·       Transplacental (rare)
·       Not transmitted by breastfeeding ❌
Prevention
HBV vaccine (active immunization)
AND
HBIG (passive immunization)
Hepatitis C in pregnancy
Potential complications
·       Gestational diabetes
·       Cholestasis of pregnancy
·       Preterm delivery
Maternal management
·       Ribavirin is teratogenic & should be avoided
·       No indication for barrier protection in serodiscordant, monogamous couples
·       Hepatitis A & B vaccination
Prevention of vertical transmission
·       Vertical transmission strongly associated with matemal viral load
·       Cesarean delivery not protective
·       Scalp electrodes should be avoided
·       Breastfeeding should be encouraged unless matemal blood present (nipple injury)
  
HIV Tx During Pregnancy
Antepartum
·       HIV RNA viral load at initial visit
·       CD4 cell count every 3-6 months
·       Resistance testing if not previously performed
·       ART initiation as early as possible
·       Avoid amniocentesis unless viral load ≤1000
Intrapartum
Avoid artificial ROM, fetal scalp electrode, operative vaginal delivery
Viral load ≤1000: ART + vaginal delivery
Viral load >1000: ART + zidovudine + CS delivery
Postpartum
·       Mother: Continue ART
·       Infant (maternal viral load ≤1000): Zidovudine
·       Infant (maternal viral load >1000): Multi-drug ART
Asx bacteriuria
?
≥100,000 bacteria
RF
·       Pre-gestational DM
·       Hx of UTI
·       Multiparity
👾
·       Escherichia coli (most common)
·       Klebsiella
·       Enterobacter
·       GBS
Tx
·       Cephalexin
·       Amoxicillin-clavulanate
·       Nitrofurantoin
·       Fosfomycin
Preventing neonatal GBS
Screening
 Rectovaginal Cx at 35-37 w
Indications
·       PMHx delivery complicated by GBS
·       GBS bacteriuria or GBS UTI during current pregnancy (regardless of tx)
·       GBS-positive Cx
·       Unknown GBS status PLUS:
·       <37 weeks gestation
·       Intrapartum fever
·       ROM for ≥18 hours ⏰
PPx
 Penicillin
Syphilis in pregnancy
Screen
·       FOR EVERYONE: at 1st prenatal visit
·       3rd trimester & delivery (if high risk)
Dx
·       Nontreponemal (Rapid Plasma Reagin, VDRL)
·       Treponemal (FTA-ABS)
Tx
IM penicillin G benzathine
Comp
·       Intrauterine fetal demise
·       Preterm labor
Fetal effects
·       Hepatic (hepatomegaly, jaundice)
·       Hematologic (hemolytic anemia, J platelets)
·       MSK (long bone abnormalities)
·       FTT