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In the Name of God Obstetrics Study Guide 3

In the Name of God Obstetrics Study Guide 3. Mitra Ahmad Soltani 2008. Med-ed-online.org. References. Iranian Council for graduate Medical Education. Board and pre-board Exam questions for OBS and Gyn .2001-2006

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In the Name of God Obstetrics Study Guide 3

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  1. In the Name of GodObstetrics Study Guide 3 Mitra Ahmad Soltani 2008 Med-ed-online.org

  2. References • Iranian Council for graduate Medical Education. Board and pre-board Exam questions for OBS and Gyn .2001-2006 • Panda S . IUGR. Department of Obstetrics & Gynecology Medical College of India 2002 • Pritchard JA, MacDonald PC, Gant NF. Williams Obstetrics. 22nd ed. New York, NY: McGraw-Hill; 2005. • Tan T and Yeo G. IUGR. Current Opinion in Obstetrics and Gynecology 2005, 17: 135-142 emedicine e-journal: • Butler J. postterm delivery. emedicine. June 19. 2006 • Gaufberg S. Abruptio placenta. emedicine. Aug 29. 2006 • Gibson P. HTN in Pregnancy. emedicine. DEC 13 2007 • Hernandez E . GTN. emedicine. Jan 26, 2007 • Marinnan G. Placenta Previa. emedicine. Aug 26. 2005 • Ross M. preterm. emedicine. 31 may 2007 Pictures and material of multiple pregnancy are adapted with permission from: • Zach T. multiple pregnancy.emedicine. Oct 2. 2007

  3. HTN in Pregnancy

  4. classification • Hypertension is the most common medical problem encountered during pregnancy, complicating 2-3% of pregnancies. • HTN is classified into 4 categories 1) chronic hypertension, 2) preeclampsia-eclampsia, 3) preeclampsia superimposed on chronic hypertension 4) gestational hypertension (transient hypertension of pregnancy or chronic hypertension identified in the latter half of pregnancy).

  5. Chronic HTN • blood pressure exceeding 140/90 mm Hg before pregnancy or before 20 weeks' gestation. It persists after 12 wks postpartum.

  6. Gestational Age • New-onset or worsening hypertension after 20 weeks' gestation should lead to a careful evaluation for manifestations of preeclampsia. • The diagnosis of severe hypertension or preeclampsia in the first or early second trimester necessitates exclusion of GTD and/or molar pregnancy.

  7. Maternal Risk factors • First pregnancy • New partner/paternity • Age younger than 18 or older than 35 years • History of preeclampsia • Family history of preeclampsia in a first-degree relative • Black race • Obesity (BMI >35) • Interpregnancy interval less than 2 years or more than 10 years • Chronic hypertension • Preexisting diabetes (type 1 or type 2) • Renal disease • SLE • Obesity • Thrombophilia

  8. Placental Risk factor • Multiple gestations • Hydrops fetalis • Gestational trophoblastic disease • Triploidy

  9. BP measurement Blood pressure should be measured in the sitting position, with the cuff at the level of the heart. Women should be allowed to sit quietly for 5-10 minutes before each blood pressure measurement. Korotkoff sounds I (the first sound) and V (the disappearance of sound) should be used to denote the systolic blood pressure (SBP) and DBP, respectively.

  10. Indications of preg. termination

  11. CBC • Platelet counts less than 100,000/µL suggest preeclampsia or ITP. • Hemoglobin levels greater than 13 g/dL suggest hemoconcentration. • Low Hbg levels may be due to microangiopathic hemolysis or iron deficiency.

  12. Proteinurea • Trace levels to +1 proteinuria are acceptable, but levels of +2 or greater are abnormal and should be quantified with a 24-hour urine collection or spot urine protein:creatinine ratio. • In a 24-hour urine collection, the reference range for protein excretion in pregnancy is up to 300 mg/d.

  13. Protein:Cr ratio • Creatinine clearance increases approximately 50% during pregnancy, and levels less than 100 mL/min suggest renal dysfunction that is either chronic or due to preeclampsia. • protein:Cr ratios appear to be more accurate than urinalysis, although an abnormal result should still be confirmed with a 24-hour urine collection.

  14. Coagulation tests • LDH, • bilirubin, • haptoglobin, • fibrinogen, • D-dimers • If: • PT/INR/aPTT results are abnormal, • thrombocytopenia is present, • the hemoglobin level is dropping

  15. Fetal Monitoring • Alternate a biophysical profile with a fetal NST twice each week. • Ask for Serial fetal ultrasound starting at 18 weeks.

  16. Life-threatening complications in preeclampsia • Seizures • Cerebral hemorrhage • Pulmonary edema • Acute renal failure • DIC • HELLP syndrome • Hepatic infarction/rupture and subcapsular hematoma

  17. IMP: mild preeclampsia • General: condition/position/diet =low salt,high prot • Lab: CBC ,BG, Rh, U/A,24hr urine (prot,cr,vol), BUN/Cr, PT,PTT,Fib, ALT,AST,Al P, Bil (T, D) • reserve of 2 units of PC • IV :Ringer at heparin lock • OTHER: Control of vital sign q4hrs, control of FHR, FAD chart , NST, sono OB, daily weight inform if BP>160/110, blurred vision, head ache, epigastric pain, seizure

  18. IMP: Severe preeclampsia • General: condition/position/diet =NPO • Lab: CBC ,BG, Rh, BUN/Cr, PT, PTT,Fib ,ALT,AST,Al P, Bil (T, D) • prep 2 units of PC • IV :Ringer 1000cc +10 u of oxytocin • if BP>160/110,blurred vision, head ache, epigastric pain, seizure then amp hydralazine 5 mg iv prn MgSO4 (4 gr) in 200cc DW5% in 20 min then 10 gr(1/2) im in each buttock then 5 gr im q4h If platelet is below 100000 then 20 gr in 1000cc infused in 100cc/hrs (check of I/O, RR, DTR, prep CPR set with 2 gr 20% MgSO4 ready) +Amp Dexa 6 mg bid for 4 doses OTHER: Control of vital sign q15 min , control of FHR, fix foley,

  19. Preterm Pregnancy

  20. Definition • Preterm labor is defined as the presence of uterine contractions of sufficient frequency and intensity to effect progressive effacement and dilation of the cervix prior to term gestation (between 20 and 37 wk). • It is the leading cause of neonatal mortality.

  21. Causes of preterm Labor • decidual hemorrhage, (eg, abruption, mechanical factors such as uterine overdistension from multiple gestation or polyhydramnios), • cervical incompetence (eg, trauma, cone biopsy), • uterine distortion (eg, müllerian duct abnormalities, fibroid uterus), • cervical inflammation (bacterial vaginosis [BV], trichomonas), • maternal inflammation/fever (eg, urinary tract infection), • hormonal changes (eg, mediated by maternal or fetal stress), • Uteroplacental insufficiency (eg, hypertension, insulin-dependent diabetes, drug abuse, smoking, alcohol).

  22. Risk factors of preterm birth • Demographic factors for preterm labor include nonwhite race, extremes of maternal age (<17 y or >35 y), low socioeconomic status, and low prepregnancy weight. • Preterm labor and birth can be associated with stressful life situations (eg, domestic violence; close family death; insecurity over food, home, or partner; work and home environment) • Previous preterm delivery

  23. Methods for predicting preterm birth • home uterine activity monitoring (HUAM) • salivary estriol : DHEA increases before the onset of labor. This results in an increase of maternal estriol. • FFN is a basement membrane protein that helps bind placental membranes to the decidua. FFN has a predictive value in identifying patients who will or will not deliver within the subsequent 1-2 weeks. • A short cervical length in the early or late second trimester has been associated with a markedly increased risk of preterm labor and delivery.

  24. Contraindication to tocolysis 1-Fetal growth restriction 2-Oligohydramnios 3-Nonreactive NST,Positive CST 4-Absent or reversed diastolic flow upon Doppler examination of umbilical blood flow 5-Repetitive severe variable decelerations 6-Significant vaginal bleeding consistent with abruption.

  25. Definition of IAI(Intra Amniotic Infection) A temperature greater than 38.0°C (100.0°F) and 2 of the 5 following signs: 1-WBC > 15,000 cells/mm32-Maternal HR> 100 (bpm) 3- Fetal HR> 160 bpm 4-Tender uterus 5-Foul-smelling discharge

  26. Chorioamnionitis Order • General: condition/position/diet=NPO • Lab: CBC diff, MP, WW, B/C X2, U/A , U/C,CXR,BUN/Cr • IV : 1000cc Ringer +10 units of oxytocin start at 2 drops /min, add 2 drops every 15 min if FHR and contractions are normal Amp ampicillin 2gr iv qid +gentamicinim 80mg stat then 60 mg TDS AMP clindamycin 900 mg iv TDS for allergic women to penicillin(continue antibiotics after delivery until the mother is a febrile OTHER: Control of vital sign hourly

  27. if: Check of contractions:+ U/A, U/C: - Fern:- Then: Hydrate and sedate Stop of contractions: discharge With:isoxsuprine 10 mg TDS for 10 days Contractions persist: hospitalize Next slide IMP:PLP before 37 weeks out patient:(contractions 4 in 20 min or 8 in 60 min +progressive change in cervixcervical dilation of more than onecervical effacement of more than 80 % or greater)

  28. IMP:PLP before 37 weeks, hospitalized • General: condition/position/diet • Lab: CBC, BG, Rh, U/A, U/C, fern, reserve of 2 units of PC • IV : 1-1000cc Ringer free 2-MgSO4 (4 gr) in 200cc DW5% in 20 min then 20 gr in 1000cc infused in 100cc/hrs (check of I/O, RR,DTR, prep CPR set- I/O with measure) 3-Amp pethidine 25 mg iv 25 mg im 4-Amp ampicillin 2 gr IV qid 5-Amp erythromicin 400 mg QID 6- Amp betamethasone 12 mg im, repeat after 24 hrs for GA below 34 wks • OTHER: Control of vital sign q4hrs, Inform if LP, leakage, VB, ab VS or FHR

  29. Contraindication for beta mimetics Maternal • cardiac disease • Diabetes • Thyrotoxicosis • HTN

  30. Contraindication for MgSO4 • Hypocalcemia • Myasthenia gravis • Renal failure

  31. Dosage of Ritodrine or Terbutaline for tocolysis • 50-100 mcg/min increase by 50 mcg/min every 10 min • max dose:350mcg/min If labor is arrested continue the infusion for at least 12 hrs • SC: 250 mcg q3-4 hrs

  32. Length of GA with multiple fetuses • Twin=36 wks • Triplets=33.5 wks • Quadruplets=31 wks

  33. Postterm

  34. Definition of postterm • Postterm pregnancies define pregnancies extending up to or after 42 weeks. • The reported frequency is 3-12%.

  35. Cause of postterm P. • The most frequent cause of postterm pregnancy is inaccurate dating criteria • primiparity, • prior postterm pregnancy, • male gender of the fetus, • genetic factors

  36. Risks of postterm P • Macrosomia complications like shoulder dystocia, CPD and Maternal risks like an increase in labor dystocia, perineal injuries, and cesarean deliveries. • dysmaturity syndrome: affects 20% of postterm fetuses and is thought to be caused by chronic uteroplacental insufficiency resulting in oligohydramnios, meconium aspiration, and reversible neonatal complications.

  37. surveillance • NST and AFI 2 times per week for pregnancies continuing past 41 weeks.

  38. Intra Uterine Growth Retardation

  39. Definition • Intrauterine growth restriction (IUGR) occurs when the unborn baby is at or below the 10th weight percentile for his or her age (in weeks). The fetus is affected by a pathologic restriction in its ability to grow. • Low birth weight (LBW) means a baby with a birth weight of less than 2500Gms, which could be due to IUGR or Prematurity

  40. Classification Symmetricl Asymmetrical the baby's head and body are proportionately small. may occur when the fetus experiences a problem during early development. baby's brain is abnormally large when compared to the liver. may occur when the fetus experiences a problem during later development

  41. Etiology of IUGR Idiopathic- In a majority of cases (40%)

  42. Maternal Risk Factors • Has had a previous baby with IUGR • Extremes of age • Small mothers (Ht & Wt) • poor weight gain and malnutrition during preg. • socially deprived • Substance abuse (like tobacco,narcotics, alcohol) • low total blood volume during early pregnancy

  43. Maternal Risk Factors • Multiple pregnancy • Living in High altitude locations • Drugs like anticoagulants, anticonvulsants • Cardio-vascular disease:preeclampsia, HTN, cyanotic heart disease, cardiac disease Gr III & IV, diabetic vascular lesions • Chronic kidney disease • Chronic infection- UTI, Malaria, TB, genital infections • Antibody abnormality like antiphospholipid antibody syndrome, SLE

  44. Fetal Risk Factors • Intrauterine infection:German measles (rubella), cytomegalovirus, herpes simplex, tuberculosis, syphilis, or toxoplasmosis, TB, Malaria, Parvo virus B19. • Birth defect (cardiovascular, renal, anencephally, limb defect, etc). • Chromosome defect(trisomy-18 (Edwards’ syndrome),21(Down’s syndrome), 16, 13, xo (turner’s syndrome.) • Primary disorder of bone or cartilage. • Chronic lack of oxygen during development (hypoxia). • Developed outside of the uterus. • Placenta or umbilical cord defects.

  45. Placental Factors • Uteroplacental insufficiency: • Improper / inadequate trophoblastic invasion and placentation in the first trimester. • Lateral insertion of placenta. • Reduced maternal blood flow to the placental bed. • Fetoplacetal insufficiency due to: • Vascular anomalies of placenta and cord • Decreased placental functioning mass: • Small placenta, abruptio placenta, placenta previa, post term pregnancy.

  46. Screening: • US fetal biometry: HC- BPD- AC • Uterine Doppler studies (Doppler Velocimetry): bilateral notches and a mean resistance index of at least 0.55 Or • Unilateral notches and a mean resistance index of at least 0.65 at 20 weeks. • Biochemistry: CRH level at 33 weeks

  47. Neonatal Diagnosis Low ponderal index (Wt./Fl). Decreased subcutaneous fat. Presence / appearance of – Hypoglycemia, Hyperbilirubinemia, Necrotizing enterocolitis, Hyper viscosity syndrome

  48. Prevention Strong evidence of benefit only for the following interventions: • balanced protein/energy supplementation, • strategies to reduce maternal smoking, • antibiotic administration to prevent urinary tract infections • antimalarial prophylaxis.

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