Summary table

PHYSIOLOGICAL CHANGES IN PREGNANCYEarly pregnancy Volume homeostasis CVS Maternal brain & senses- in eraly pregnancy, developing fetus, corpus luteum and placenta produce & release increasing quantities of hromones, growth factors & other substances in maternal circulation- most pregnant women report sx of pregnancy by end of 6th weeks after last LMP

1) blood volume xpansion- maternal blood vol expands during pregnancy to allow adequate perfusion- anticipate blood loss during delivery- starts at 6-8 weeks and plateau at 32-34 POG- most marked expansions occurs in ECF esp circulating plasma vol (8-10kg weight gain)- TBW from 6.5-8.5L

2) physiological anaemia (larger increase of plasma vol relative to erythrocyte vol)

3) fluid retention- changes in osmoreg & RAAS in active sodium reabsorption in renal tubules & water retention- increased conc of ANP, natriuretichormones, atrial natriuretic peptide & progesterone- plasma osmolality decreases about 10 mOSMol/kg- decrease in thirst threshold-decreased plasma osmotic pressure & oncotic pressure- increase in GFR

- elevation of diaphragm.adjustment of lung vol & increased minute ventilation = breathlessness- edema in xtremities d/t fluid retention + venous compression- decreased venous return to heart = light-headedness & syncope- palpitations (sinus tachycardia)- premature atrial & vent ectopic beats- increased peripheral pulse- MAP & JVP unchanged- increased CO as 5 weeks POG from 4.5L to 8.4L in 2nd stage of labour d/t increased HR- increased SV- decrased DBP in antenatal = increased PP- 70% reduction in peripheral resistance by 8 weeks POG

1) maternal brain- problem with attention, conc & memory in pregnancy and early postpartum d/t lack of estrogen & increased oxytocin- sedative progesterone effect- require less LA in both epidural & intrathecal- greater tolerance for pain

2) senses- olfactory sensitivity decreases in 3rd trimester & persists after delivery- decreased odour threshold in 3rd trimester- corneal sensitivity decreasesand return to normal by 8 weeks postpartum- intolerant to contact lenses- decrease in intraocular pressure- changes in visual fields d/t increase size of pituitary gland compressing optic chiasm

Maternal adaptation to pregnancy1) increased avail of precursors for hormone production & fetal-placental metabolism- dietary intake- endocrine changes

2) improved transport capacity- increased CO- increased transport of subs to placenta & fetal waste products for disposal (10-12 weeks)- disposal through peripheral vasodilatation, increase in ventilation & renal filtration

Blood Respiratory tract

Haematology Hemostasis & coagulation Airway Ventilation- maternal Hb decreases, discrepancy 1000-1500ml inplasma while erythrocyte 280ml + transfer of iron stores to fetus- mean Hb from 13.9 = 10.9g/dl- decreased haematocrit- require increased amounts of iron (absorption of dietary iron from gut)- renal clearance of folic acid increases substantially during normal pregnancy and plasma folate conc fall- platelet count stable but maybe lower in some pt due to increased aggregation

- hypercoagulable state, returns to normal around 4 weeks after delivery- factor 7,8,9 and 12 + fibrinogen(50%) increased during pregnancy- VWF factor increased- protein S activity decrease while increase in activated protein C resistance- maternal D-dimer increase progressively from conception to delivery (cannot use to check VTE)

Increased in fibrinolytic system activation to counterbalance coag factors- endothelial-derived PAI-1 increases in late pregnancy- PAI-2 increases- plasminogen increased, α2-antiplasmin decreased

Increase in procoag is relevant at delivery = placental separation- at term, around 500ml of blood flows through placental bed every minute- myometrial contractions compress BV supplying placental bed- fibrin deposition over placental site

- neck, oropharyngeal tissues, breasts & chest wall are all affected by weight gain during pregnancy- breast engorgerment + airway edema = difficult visualization of larynx during tracheal intubation- vascularity of respi tract increases- nasal mucosa is edematous & prone to bleeding = congestion & rhinitis

- increases significantly around 8 weeks POG d/t progesterone-related sensitization of respi center to CO2 & increased metabolic rate-diaphragm is elevated 4cm by enlarging uterus- lower ribcage circumference expands by 5cm- increased relaxin = ligaments of ribcarge to relax = increased ribcage subcostal angle- increase in pulmonary blood flow in pregnancy- increased tidal volume + RR = increase in minute ventilation = SOB- 10-25% decrease in FRC and further reduced in supine position but not affect interpretation of FEv1 and PEFR

Biochemistry Oxygenation Arterial gases1) decrased albumin- decrased plasma oncotic pressure- affects peak plasma conc of protein-bound drugs- serum creatinine, uric acid & urea conc are reduced- ALP increased d/t production of placental ALP- ALT & AST decreased- rise in serum LDH after delivery is d/t involuting uterus & hemolysis from RBC in hemostasis of placental bed

- increase in 2,3-diphosphoglycerate within maternal erythrocytes = shift O2-Hb dissociation curve to right = increases avail of oxygen within tissues- oxygen consumption increases by about 45ml/min (increase 20%)- increased 02 consumption + decreased FRC = hypoxemia & hypocapnia during respi depression & apnea

- progesterone has respi stimulant properties= increased alveolar ventilation & tidal vol- marked decrase in pCO2 & slight increase in pO2- reduced pCO2 affects CA enzyme that converts carbonic acid to bicarb to H ions to restore pH = prevents alkalosis- renal excretion of bicarb increases significantly

Immune response- 30% of women develop Ig-G Ab against inherited paternal HLA of fetus- lack of maternal immune reactivity to fetus is d/t reduced CD8 & downreg of T cells- +WBC increased up to 14x109/L in 3rd trimester d/t increase of PMN- NK cells increase in early pregnancy and decrease in late gestation

Factors contributing to flui

ANTENATAL CAREBooking visit

Confirmation & dating of pregnancy Booking investigationsConfirmation of pregnancy- sx of pregnancy (breast tenderness, nausea, amenorrhea, urinary frequency and +ve UPT)- fetal heart with Doppler at 12 weeks POG

Dating the pregnancy1) Menstrual EDD- if menstrual cycle is 28 days- ovulation on day 14 of pregnancy- accurate LMP

2) Ultrasound dating- more accurate if there is irregularity about LMP- ideal = 10-14 weeks- benefits : accurate dating with irregular menstrual cycles, reduced IOL for prolonged pregnancy, maximize potential for serum screening, early detection for multiple pregnancies- CRL used up until 13+6, HC from 14-20 weeks

FBC- anaemia & thrombocytopenia- repeated at 28 weeks POG

Blood group & red cell Abs- cross-matching blood (GSH)- rhesus D negative be offered anti-D at 28 weeks POG/divide at 28 weeks & 34 weeks POG

Urinalysis- midstream urine sample to detect asx bacteriuria = reduce chance to develop PN

Rubella- certical transmission = serious congenital anomalies esp in 1st trimester- if rubella non-immune, immunize after pregnancy and avoid next pregnancy after 3 months

Hep B- Hep B S antigen = previous immunization or infection- Hep B E antigen = recent infection- vertical transmission to fetus- horizontal transmission = bodily fluids- babies give active immunization

HIV- anti-retroviral agents, elective c-sec & avoid BF to reduce vertical transmission (30%=1%)- screening : high risk patients, recent immigrants from central Africa

Syphillis- vertical transmission : prevent by Abs and screening

Hb studies- prenatal genetic testing include CVS/amniocentesis- screening : Eastern Meditteranean, Inida, West Indies, South-East Asia & Middle East- if high risk/MCV low, formal lab screening with liquid chromatography

Other investigations- cervical smears on indication

Booking history & examinationBooking history- PMH, past obstetrics, past gynaecological- familyhistory & social factors- age & racial origin

Booking examination- full PE at booking visit with CVS & respi examination, pelvic & breast- lous heart sounds & flow murmurs d/t hyperdynamic circulation- recent immigrants should have full chest & cardiac exam- must have : BP, abdominal exam to record size of uterus, ab scars, BMI, urine dip testingScreening for fetal abn Screening for clinical conditions later in pregnancy Follow-up

1) Down’s sx- nuchal translucency scan at 11-14 weeks POG- biochemical blood tests at 15-20 weeks

2) NTD- maternal serum α-fetoprotein at 15-20 weeks- structural screening at 18-20 weeks

3) structural congenital abn- U/S at 18-20+6 weeks

Gestational diabetes Pre-eclampsia & preterm - primipraous women have 2 more routine checks than multiparous d/t increased risk of pre-eclampsia- maternal BP, urine at every visit- SFH from 25 week- fetal presentation & engagement from 36weeks- maternal weight is no longer recorded routinely after first booking- anti-D either at 28wks (single dose) or divided (28/34 wks)

- all women should be assessed at booking for risk factors- if risk factors present = 2-hour OGTT at 24-28 weeks- previous history of GDM = OGTT at 16-18 weeks- if normal, repeat at 24-28 weeks

Pre-eclampsia- every antenatal visit for BP & urinalysis for protein- extra antenatal visit for women with risk factors of pre-eclampsia (booking history & exam, rise in BP, proteinuria, sx of pre-eclampsia)

Fetal well-being Pre-term labour- SFH from 25 weeks- if fetal growth slow, do U/S- fetal heart sounds

- bacterial swabs, cervical length scans

ANTENATAL IMAGING AND ASSESSMENT OF FETAL WELL-BEINGClinical applications of U/S

Diagnosis & confirmation of viability in early pregnancy

Determination of GA & assessment of fetal size & growth

Multiple pregnancy Fetal well-being

- gestational sac as early as 4-5 weeks POG and yolk sac at 5 weeks- embryo can be observed at 5-6 weeks- visible heartbeat : 6 weeks- TVS : incomplete/missed miscarriage (blighted ovum where no fetus is present), ectopic pregnancy (+ve UPT, no gestation sac within uterus, adnexal mass with/without fetal pole, fluid in pouch of Douglas)

- CRL is used up until13+6- HC from 14-20 weeks- BPD & FL- latter part pregnancy, AC & HC assess size & growth of fetus- EFW = AC+HC+BPD=FL- high risk of FGR = growth pattern (symmetrical & asymmetrical)- asymmetrical = FGR- brain-sparing = large HC:AC- Diabetic : large AC:HC- cessation of growth : placental failure- GA cannot be accurately calculated >20 weeks because of wider range pf AC & HC

- to determine chorionicity- dichorionic twin pregnancies in first trimester of pregnancy have thicker inter-twin separating membrane (septum) with very thin amnion while monochorionic have thin inter-twin membrane- appearance of septum : tongue of placental tissue within base of dichorionic membrane (twin peak/lambda), 9-10 weeks- management of twin pregnancies which maybe difficult on ab palpation : growth restriction, placenta previa, TTT sx

- evaluate fetal movements, tone & breathing in BPP- Doppler : placental f(x) & identify evidence of blood flow redistribution in fetus (hypoxia)Amniotic fluid vol- fetus swallows amniotic fluid, absorbs in gut & excretes in amniotic sac- impaired swallowing : anencephaly, esophageal atresia- impaired excretion : renal agenesis, post urethral valves- FGR is a/w reduced amniotic fluid d/t reduced renal perfusion = reduced urine output

Diagnosis of fetal abn- can be diagnosed at 20 weeks- examples : spina bifida & hydrocephalus- 1st trimester U/S ‘soft’ markers for chromosomal abn : absence of fetal nasal bone, increased fetal nuchal translucency for Down’s sx

Placental localization- localization of site of placenta & identify lower edge to exclude placenta previa- can be seen with TVS- at 20 weeks scan, it is must to identify women with low-lying placenta

Cervical length- 50% who deliver <34 weeks will have short cervix.- length of cervix can be checked by TVS

Other uses of U/S Scanning schedule AFI- intrauterine death- fetal presentation- uterine & pelvic abn eg fibromyomata & ovarian cyst- guide for invasive procedures (amniocentesis, CVS, cordocentesis, shunts)

- 10-14 weeks, 18-21 weeks- early scan : determine GA< nuchal translucency- 18-21 weeks : structural anomalies- after >21 weeks : concern about fetal well being

- influence of congenital abn with amniotic fluid vol- reduction in amniotic fluid vol = oligohydramnios- excess = polyhydramnios- max vertical pool + AFI index

Max vertical pool- <2cm = oligohydramnios- >8cm = polyhdramnios

AFI- dividing uterus into 4 ultrasound quadrants- vertical measurement is taken of the deepest cord free pool- in third trimester should be between 10& 25 cm- <5cm oligo, >25cm poly

CardiotopographBaseline fetal heart rate Baseline variability Fetal heart rate acc Fetal heart rate

delerations- normal fetal heart rate at term is 110-150bpm- higher rates are defined as fetal tachy & lower = brady- baseline fetal heart rate falls with advancing gestational age as result of maturing fetal parasymphatetic tone- prior to term 160bpm is upper limit of normal- tachy = maternal/fetal infection, acute fetal hypoxia, fetal anaemia, drugs

- short-term variability (interbal between successive heart beats) can only be measured with computer-assisted analysis- long-term variability/baseline variability can be measured between 2 & 6 times per minute- refelects fetal autonomic system- abnormal when <10- modified by fetal sleep, opiods, fetal hypoxia, fetal infection

- increases in baseline fetal heart rate of at least 15bpm, lasting at least 15 seconds- 2/more in 20-30 minuute CTG reactive trace- positive signs of fetal health

- transcient reduction of 15bpm or more, lasting for 15 sec- fetal hypoxia/umbilical cord compression- hypoxia : decelerations+reduced variability/baseline tachycardia

Biophysical profile Doppler ultrasoundUmbilical artery Fetal vessels Prediction of adverse

pregnancy outcome- long(30 minute) U/S scan which observes fetal behavior, amniotic fluid vol & CTG- score of 0,2/4 is abnormal, 8/10 normal- score of 6 is equivocal and repeat within reasonable hours to exclude fetal sleep- time consuming and does not increase long-term survival d/t severe hypoxia

- provide information on placental resistance to blood flow- indirect placenta ‘health’ and function- high diastolic component indicates low downstream resistance and implies high perfusion- normally, diastolic flow in umbilical artery increases throughout gestation- absent/reversed EDF in umbilical artery = fetal

- centralization of flow = redistribution of blood flow to protect brain, heart & adrenal glands + vasoconstriction- absent diastolic flow in fetal aorta implies fetal academia- measurement of velocity of MCA is indicator of fetal anaemia (peak systolic velocity increases) : Rhesus disease, TTT sx in

- pre-eclampsia : incomplete physiological invasion of spiral arteries by trophoblast = resultant increase in uteroplacental vascular resistance- evidence of association between high-resistance waveform patterns & adverse outcomes (pre-eclamspia, FGR & placental abruption). 60-70% at 20-24 weeks with

distress, IUD donor bilat uterine notches

Summary of aims of obstetric U/S MRIEarly pregnancy scan (11-14 weeks)

20 week scan (18-22 weeks) Third trimester

- confirm fetal viability- accurate estimation of GA- multiple gestation esp chorionicity- identify markers that would indicate risk of fetal choromosome abn eg Down’s- identify fetuses with gross structural abn

- accurate estimation of GA if early scan has not been performed- carry out detailed fetal anatomical survery to detect any fetal structural abn/markers for chromosome abn- locate placenta and identify 5% of low-lying placenta, repeat at 34 weeks- estimate amniotic fluid volume

- assess fetal growth- assess fetal well-being

- reflect composition of tissue & characterization- fetal MRI : multiplanar views, fetal brain, mode of delivery & airway mx at birth

PRENATAL DIAGNOSIS (identification of disease prior to birth)Why is it performed? Attributes of screening

testClassification Pre-test counseling

- family history (genetic disease + known recurrence risk- past obstetric history (RhD alloimmunization- serum screening tests (trisomy 21)- U/S screening (anomaly scan)

- relevance & important- affects management- sensitive/high detection rate- specificity- predictive value- affordability/cost-effective- equity/avail to all

- invasive- non-invasive

- consition suspected & severity of disease- history is correct- test is available- what sample? How it processed?- accurate assessment of risk- acceptability- is it ethical?

Option if positive test- continue pregnancy- influencing decision to terminate pregnancy- terminate pregnancy

Non-invasive tests Invasive tests Care after invasive testing1) Ultrasound- scanning for structural fetal abn eg NTD, gastrochisis, cystic adenomatoid malformation of lung, renal abn

2) free fetal DNA in cases of alloimmunization or determine sex of fetus in X-linked disorders

3) fetal RNA for aneuploidy pregnancies from maternal blood

- amniocentesis & CVS are two most common to check for karyotype of fetus, or to look single gene disorders

- accurate labeling of sample- prompt & secure transport of sample to app lab- documentation & procedure, any complications- communication with referring clinician- avoid strenuous exercise for next 24 hours- maybe exp mild ab pain, take PCM- if has any bleeding, not relieved by PCM, seek medical advice- appropriate contact numbers- process for givibg results should be agreed- if woman is RhD negative, give AntiD + Kleihauer test >20 weeks- plan of ongoing care after results

CVS/CVB Amniocentesis CordocentesisGestation age 11 weeks 15 weeks 20 weeksMiscarriage risk +2% +1% +2-5%Detailed - fetal trophoblast cells in - amniotic fluid contain - when fetalblood is

mesenchyme villi divide rapidly in first trimester- CVB take sample of these cells from developing placenta- procedure : needle into abdominal wall by ultrasound guidance into placenta/fine catheter/biopsy forceps through cervix into placenta- miscarriage = 2%- placental mosaicism = 1%

Prior scan- confirm pregnancy is viable prior procedure- single pregnancy- confirm GA (cannot be done <10 weeks)- localize placenta & determine if transab/transcervical

amniocytes & fibroblasts shed from fetal membranes, skin & fetal genitourinary tract- amniocentesis takes sample (15-20ml) of amniotic fluidby passing needle under cont direct U/S control through ab wall into amniotic cavity & aspirating the fluid- initial U/S is performed prior to procedure- can check for viral infections eg CMV & biochemical test eg α-fetoprotein & spectrophotometric for hemolytic disease- adv: can be performed earlier in pregnancy- diadv : a/w higher risk of miscarriage

needed/full culture of karyotype needed- diagnostic prenatal test to check fetal platelet count when alloimmune thrombocytopenia is suspected- a needle is passed by U/S guidance into umbilical cord cord at points it inserts the placenta (fixed)- from 20 weeks- risk of miscarriage varies with indication & position of placenta

Down’s sx NTD Gastrochisis Exomphalos a/w T18- most common eason for performing invasive testing- follows after ‘high risk’ prenatal screening- combined test between 11 & 14 weeks, combination of U/S to measure nuchal translucency scan + beta-HcG & PAPP-A in maternal blood- accuracy of screening tests for Down’s can be refined by measuring fetal nasal bone, frontomax nasal angle & presence fortricuspid regurgitation + ductus venosus wave form

- U/S : abnormal head shape, banana-shaped cerebellum, type identified at lumbar region, bilateral talipes- problems later : mobility to use wheelchair as they got older, continenece & voiding, low IQ, repeated surgery, psychological- recurrence = 5%

- U/S : irregular mass from ant ab wall at level of umbilicus tp one side of umbilical cord- maybe small, oligo- in later pregnancy, fetal bowel may dilate & become thick walled- following delivery, baby need operation to repair defect

- initaial U/S diagnosis followed with CVB- U/S : smooth protrusion on ant ab wall- covered by membrane and umbilical cord inserted into apex of protrusion- diagnosis cannot be made <12 weeks d/t physiological hernia of ab contents into umbilical cord-

ANTENATAL OBSTETRIC COMPLICATIONSMinor complications of pregnancy

Musculoskeletal problemsBackache Symphysis pubis dysfunction Carpal tunnel syndrome- extremely common d/t-- hormone-induced laxity of lig-- shifting in centre of gravity as uterus grows-- add weight gain

- cause exxagerrated lumbar lordosis- exercebate sx of prolapsed intervetbral disc = complete immobility- advice : maintenance of correct posture, avoid lifting heavy object, avoid high heels, regular physio, simple analgesia

- excruciatingly painful condition- most common in 3rd trimester- symphysis pubis joint becomes loose, causing 2 halves of pelvis to rub on one another during walking/moving- condition improves after delivery- mx : simple analgesia- low stability belt

- compression neuropathies d/t increased soft-tissue swelling- median nerve, when it passess through fibrous canal at wrist before entering hand, is most susceptible to compression- sx : numbness, tingling & weakness of thumb and forefinger, severe pain at night- mx : simple analgesia, splint, surgery (rarely performed in pregnancy)

Gastrointestinal symptomsConstipation Hyperemesis gravidarum Gastroesophageal reflux Hemorrhoids- combination of hormonal & mechanical factprs that slow gut motility- administration of iron tablets may worsen the condition- reassurance + high-fiber diet- medications are bets avoided unless necessary

- severe, intractable form of nausea & vomiting- causes imbalanes of electrolytes, distrubes nutritional intake & metabolism, physical & psychological debilitation- adverse pregnancy outcome : preterm birth, LBW babies- a/w high beta-HCG, estrogen & thyroxine- severe cases : malnutrition & vit def, Wernicke’s encephalopathy, esophageal trauma, Mallory-Weiss tears- tx : fluid replacement & thiamine supplementation, antiemetics

- altered structure & function of physiological barriers to reflux d/t weight of uterus & relaxation of esophageal sphincter- lifestyle modifications eg smoking cessation, frequent light meals & lying with head propped up at night- medicationsin stepwise fashion eg simple antacids, histamine-2 receptor antagonist, PPI- also check for severe refractory dyspeptic symptoms

- effects of circulating progesterone on vasculature, pressure of sup rectal veins by grabid uterus & increased circulating volume- conversative approach eg LA/anti-irritant creams and high-fiber diet- check if there is any tenesmus, mucus, blood mixed with stool & back passage discomfort

Varicose veins Edema Other common minor disorders

- maybe first time or pre-existing- relaxant effect of progesterone on vascular smooth muscle and dependent venous stasis caused by wiight ofpregnant uterus on IVC

- 80% of all pregnancies- generalized soft tissue swelling & increased capp permeability which allows intravascular fluid to leak into extravascular compartment

- itching- urinary incontinenece- nose bleeds- thrush (vag

- varicose veins on legs may ne sx imporved with support stockings, avoidance of standing for prolonged periods and simple analgesia- thrombophlebitis may occur in large varicose vein more commonly after delivery- large superficial varicose vein may bleed profusely if traumatized, leg must be elevated & direct pressure applied- vulval & vaginal varicosities are uncommon but sx troublesome

- fingers, toes & ankles are usually worst affected and sx aggravated by hot weather- best dealt withby frequent periods of rest with leg elevation- support stockings are indicated-maybe feature of pre-eclampsia, check for woman’s BP & urine protein- may also suggest underlying cardiac impairment/nephrotic sx

candidiasis)- headache- fainting- breast soreness- yiredness- altered taste sensation- insomnia- leg cramps- straie gravidarum & cholasma

Problems d/t abn of pelvic organsFibroids (leiomyomata) Retroversion of uterus Congenital uterine abn Ovarian cyst in pregnancy- compact masses of SM that lie in cavity of uterus (submucous), within uterine muscle (intramural), outside surface of uterus (subseruos)-may enlarge in pregnancy, present problems later in pregnancy/at delivery- fibroid at cervix or in LUS may prevent descent of presenting part & obstruct vag delivery- red degenerations is one of most common cx of fibroids inpregnancy = grows = ischaemic (acute pain, tenderness over fibroid, frequent vomiting)- if sx are severe, uterine contractions maybe precipitated = miscarriage/preterm labour- DDX of red degeneration : acute appendicitis, PN/UTI, ovarian cyst accident, placental abruption- subserous pedunculated fibroid may tort in same way that large ovarian

- 15% women have retroverted uterus will normally ‘flip’ out of pelvis and begin to fill in ab cavity- in small proportion of cases, uterus remains in retroversion and eventually fills up entire pelvic cavity & base of bladder & urethra are stretched- retention of urine, classically at 12-14 weeks- painful, may cause long-term bladder damge if bladeder becomes over-distended- catheterization is essential until position of uterus has changed

- shape of uterus is embryologically determined by fusion of Mullerisn ducts- abn of these fusion give rise to subseptate uterus through bicornuate uterus/double uterus with 2 cervices- indicental finding during laproscopy/U/S

Probs with bicornuate uterus:- miscarriage- preterm labour- PPROM- abn of lie & psn- higher C-sec

- incidence of malignancy is uncommon in childnearinga age- most common types of pathological ovarian cyst = serous, benign teratoma- corpus luteal cysts may grow to several cm but rarely requires tx-large cysts eg dermoid cysts may require surgery in pregnancy- surgery is usually postponed until late 2nd/early 3rd trimester (potential if baby delivered, it would be safe)- midline/paramedian incision, low transverse suprapubic wouldnot allow access to ovary, it is drawn upwards in later pregnancy- major prob : uterine torsion, hemorrhage/rupture, causing rupture & ab pain = pain & inflammation = miscarriage/preterm labour- full assessment must include family history of ovarian/breast cancer,

Cervical cancer- difficult to visualize at colposcopy and biopsy may cause considerable bleeding- vaginal bleeding esppostcoital- exam: friable/ulcerated lesion with bleeding & purulent discharge

cyst can (acute ab pain, tenderness)- Ix : pertinent history +U/S scan

detailed U/S of ovaries

UTIPredisposing factor- history of recurrent cystitis- renal tract abn: duplex system, scarred kidneys, ureteric damage & stones- diabetes- bladder emptying problems eg sclerosis

Symptoms in pregnancy- low back pain- general malaise + flu-like sx- exam : tachycardia, pyrexia, dehydration, loin tenderness

Investigations- FBC- midstream urine specimen for urgent microscopy, culture & sensitivities

Management- if strong clinical suspicion, start Abs immediately- drink plenty of fluids- take PCM

Common organism- E.coli, Streptococci, proteus, Pseudomonas, Kliebsiella. If more than 105 at culture = UTI

Pyelonephritis- dehydration, very high temp, systemic disturbance & shock- urgent & aggressive treatment

Substance abuse in pregnancyAlcohol Drugs Smoking- >100g/week have been related to FGR- maasive doses >2g/kg of body weight (17 drinks/day) is a/w FAS (30-

- tobacco : FGR- alcohol : fetal alcohol sx- opaitaes : preterm-labour, neonatal withdrawal syndrome- cocaine & derivative : placental

- smoking acutely reduces placental perfusion- overall perinatal mortality increased, babies are smaller at delivery- higher risk of antepartum hemorrhage

33%) abruption, FGR, preterm labour

Problems a/w drug addicts- social probs- co-existing with alcohol & smoking- malnutrition esp iron, vit B & C- viral infections eg HIV, HepB

Amniotic fluid abnormalitiesOligohydramnios Polyhydramnios- AFI <5th centeile for gestation- maybe suspected following cldar fluid leaking from vagina, may represent PPROM- on ab palpation, fetalpoles maybe obviously felt & hard- cx : pulmonary hypoplasia & limb deformities eg contractures, talipes, renal agenesis, bilat multicystic kidneys

- AFI >95th centile for gestation- CF : ab swelling & discomfort, abdomen tense & tenser, fetal parts maybe hard to palpate- principle of mx : etsblish cause, relieve discomfort of mother & assess risk of preterm labour (measurement of cervical length)

Causes oligo Diagnosed by Causes of polyRenal agenesis U/S : no renal tissue , no

bladderMaternal- diabetes

Placental- chorioangioma- arterio-venous fistula

Multicyctic kidneys U/S : enlarged kidneys with multiple cysts, no visible bladder

Fetal- multiple gestation esp TTX sx- idiopathic- esophageal fistula/trachea-esophaegal fistula- duodenal atresia- neuromuscular fetal condition (preventing swallowing- anencephaly

Urinary tract abn/obstruction

U/S : urinary tract dilatation

FGR & placental insufficiency

- clinical : reduced SFH, refuced FM, abn CTG- U/S : FGR, abn fetal Doppler

NSAIDS Withholding NSAIDS, causing amniotic fluids to re-acc

PPROM Speculum : pooling of amniotic fluid on posterior blade

Fetal malpresentation at term (presentation that is not cephalic)Breech presentation

Types of breech Predisposing factors for breech presentation

Antenatal mx of breech psn

Other fetal malpsn

- extended (flank) breech- flexed (complete) breech)- footling breech

Maternal- fibroids- congenital uterine abn, bicornuate uterus- uterine surgery

Fetal/placental- multiple gestation- prematurity- placenta previa- abn eg anencephaly, hydrocephalus- fetal neuromuscular

- if clinicaaly suspected at/or 36 weeks, should be confirmed by U/S scan (fetal biometry, amniotic fluid vol, placental site, position of fetal legs- 3 options : ECV, assisted vag delivery, elective c-sec

- transverse lie occurs when fetal long axis lie perpendicular to that of maternal long axis = shoulder psn- oblique lie occurs when long axis of fetal body crosses long axis of maternal body at angle of 45 degree- potential risk of cord prolapse & PROM- diagnosis by ab palpation

condition- oligo/poly

: asymmetrical abdomen, SFH less than expected andpalpation of fetal head/buttocks in iliac fossa, pelvic brim empty

ECV Vaginal breech delivery- performed after 37 weeks by exp obstetrician at/near delivery facilities- should be performed with tocolytics eg nifedipine- woman is laid flat with left lateral tilt and ensure she has emptied her bladder and comfortable- with U/S guidance, breech is elevated frompelvis and one hand is used to manipulate this upward in direction of forward role, while other hand applies gentle pressure to flex the fetal head and bring it down to maternal pelvis- procedure can be midly uncomfortable for mother and should not last more than 10 minutes- fetal heart trace must be performed before and after procedure and it is important to administer anti-D if woman is Rh –ve- if it fails/contraindicated, choose other option

Prerequisities for vag breech delivery

Management of labour

Feto-maternal- psn should be either extended or flexed- no evidence of CPD and EFW <3.5kg- no evidence of hyperextension of fetal head & fetal abn that would preclude safe vag delivery

- fetal well-being & progress of labour should be carefully monitored- epidural analgesia is not essential but advantegous- FBS from buttocks provides accurate assessment of acid-base status- experience operator in delivering breech babies

CI of ECV Risks of ECV Technique (hands-off tech)- fetal abn (hydropcephalus)- placenta previa- oligo/poly- history of APH-previous C-sec/myomectomy scar on uterus- multiple gestation- pre-eclampsia/HTN- plan to deliver by C-sec anyway

- placental abruption- PROM- cord accident- transplacental hemorrhage- fetal brady

Delivery of buttocks- full dilatation and descent of breech- when buttocks have become visible and begin to distend the perineum, preparations for dlivery are made- buttocks will lie in ant-post diameter- once ant buttocks is delivered and anus is seen over fourchette, episiotomy will be cut

Delivery of legs & lower body- if legs are flexed, they will deliver spon- if extended, they may need to be delivered by Pinard’s maneuver- use finger to flex leg at knee and then extend to hip, first ant then post- with contractions & maternal effort, lower body will be delivered- a loop of cord is drawn down to ensure that it is not too short

Delivery of shoulders- baby will be lying with shoulders in transverse diameter of pelvic mid-cavity- as ant shoulder rotates into ant-post diameter, spine/scapula will be visible- a finger gently placed above shoulder will help to deliver the arm- as post arm/shoulder

Delivery of head- Mauriceau-SMellie-Veit manuvre- baby lies on obs’s arm with downward traction being leveled on head via finger in mouth and one on each maxilla- delivery occurs first downward and then upward- if it is difficult, forceps need to be applies

reaches pelvic floor, it too will rotate ant (in opp direction)- once spine becomes visible delivery of second arm will follow- Loveset’s maneuver

- assistant holds babys body while foceps are applied in usual manner

TWINS AND HIGHER MULTIPLE GESTATIONS (two/more fetuses)Risk factors

OPRATIVE INTERVENTION IN OBSTETRICSEPISIOTOMY (incision thorugh perineum made to enlarge diameter of vulval outlet and assist childbirth)TECHNIQUE COMPLICATIONS PERINEAL REPAIR- episiotomy is performed in 2nd stage- if there is not good epidural, perineum should be infiltrated with LA- if an effective epidural anesthetic in place, it should be topped up for delivery with patient upright to get best coverage of perineal area- incision can be midline or at an angle from posterior end of vulva- mediolat : posterior part of fourchette, move backwards and turn medially well before border of anal sphincter, so that any extension will miss the sphincter

- hemorrhage- infection- extension to anal sphincter- dyspareunia

- ensure adequate analgesia (topping up epidural/by infiltration with LA)- place pad high up in vagina to prevent blood from uterus from obscuring the view- check extent of cuts & lacerations- first, repair vagina mucosa using rapidly absorbed suture material on latge, round body needle- start above apex of cut/tear and use cont stitch to close vaginal mucosa- interrupted sutures are then placed to close muscle layer- closure of skin follows. Interrupted sutures can be used, but cont subcuticular stitch produces more comfortable results- perform gentle VE to check for any missed tears or inappropriate apposition of anatomy- remove pad that was placed at top of vagina and check that no swabs have been left in vagina- finally, put a finger to check in rectum to check that no sutures have passed through rectal mucosa and sphincter is intact- lactulose & bulk agent eg Fybogel are recommended for 5-10 days, antibiotics(broad-spectrum) to cover possible anaerobic contamination eg metrodinazole, adequate oral analgesia- at 6-12 months, full evaluation of degree of sx with careful questioning with regard fecal & urinary sx- sx women should be offered investigation including endoanal ultrasound & manometry

Perineal traumaDefinitions- 1st = lacerations of skin/vag epit- 2nd= pernieal mucles, episiotomies- 3rd = anal sphincter complex3i : <50% external anal sphincter3ii : >50% ext anal sphincter3iii : internal anal sphincter (complete disruption of ext sphincter)- 4th = extending into rectal mucosa

Risk factors- larger infants- prolonged labour- instrumental delivery

OPERATIVE VAGINAL DELIVERY (delivery of baby

vaginally using instrument for assistance)Indications Prerequisities for any

instrumental deliveryDelivery failure Instrument choice

Maternal- maternal distress, exhaustion/undue prolongation of 2nd stage of labour (>2hours primi, >1 hour multi)- aortic valve disease with significant outflow obstruction- myasthenia gravis

Fetal- malpositions of fetal head (O-T/O-P)- presumed fetal compromise- reduced fetal weight but controversial d/t dev of intracranial hx

- confirmed rupture of membranes- cervix must be fully dilated (except 2nd twin )- vertex psn with identification of position- O-T/O-P, no part of fetal head should be palpable abdominally. For O-P, 1/5th of head maybe palpable- presenting part should be +1 or more below ischial spine- adequate analgesia/anesthesia- empty bladder/no obstruction below fetal head (contracted pelvis, pelvic kidney, ovarian cyst)- knowledgeable & exp operator with adequate preparation- adequately & informed and consented patient

- inadeqyate initial case assessment = high head, misdiagnosis of position & attitude of fetal head- failure d/t traction in wrong plane- poor maternal effort with inadequate use of Syntocinon to aid expulsive effort in 2nd stage- failure to select correct ventousecup type/incorrect cup position

Ventouse compared to forceps is significant more likely to:- fail to achieve vag delivery- a/w cephalohaematoma (subperiosteal bleed)- a/w retinal hx- a/w maternal worries about baby

Less likely to be a/w:- use of maternal RA/GA- significant maternal perineal & vaginal trauma- severe perineal pain at 24 hours

Equally likely to be a/w:- delivery by C-sect- low 5 min Apgar scores

- anal sphincter injury teice as common with forceps delivery

Contraindications Evaluation- gestations less than 35 weeks d/t cephalohaematoma & intracranial hx- face/breech psn- before full dilatation of cervix

Pelvic exam- contracted pelvis (c-sect)- shape of subpubic arch, curve of sacral hollow, presence of flat/prominent ischial spine- shape of pelvis (x rotational forceps)

Analgesia Complications Clinical risk mx- greater for forceps than vacuum- rotational forceps : RA- rigid cup ventouse: pudendal block with perineal infiltration- soft cup ventouse : minimal analgesia

Maternal- maternal death with vaccumm d/t cervical tears in women delievered before full dilatation- traumatic vag delivery = fecal incontinence in wimen- PPH (syntocinon infision post delivery, prompt suturing, careful identification of high tears)- underestimation of blood loss (measure through swabs & towels)

Fetal- cephalohaemtoma- severe intracranial injuries

Common allegations against practitioners are cited in lawsuits include :- inadequate indication- failure to exclude CPD- improper use of instruments with excessive use of force resulting in maternal/fetal injury-lack of informed i=consent- inadequate supervision

Positioning- patient in lithotomy position-aseptic technique-angle of traction needed causes foot of bed be removed- symphysis pubis dysf(x) : limit abduction of thigh- bladder emptied

Ventouse/vacuum Forceps

extractors