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Clinical Obstetrics - 4th Ed
Clinical Obstetrics - 4th Ed
Clinical Obstetrics - 4th Ed
OBSTETRICS NOTES
FOURTH EDITION
PRE-SUMMARIZED FOR THE TIME-POOR
READY-TO-STUDY MEDICAL, PRE-MED,
HIGH-YIELD NOTES USMLE OR PA STUDENT
123 PAGES
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Table Of Contents:
What’s included: Ready-to-study anatomy, physiology and pathology notes of the relevant clinical obstetrics topics
presented in succinct, intuitive and richly illustrated downloadable PDF documents. Once downloaded, you may
choose to either print and bind them, or make annotations digitally on your iPad or tablet PC.
Clickable Hyperlinks Below:
- OBSTETRIC DEFINITIONS
- EMBRYONIC SEXUAL DEVELOPMENT
- REVIEW OF BASIC FEMALE REPRODUCTIVE ANATOMY
- PREGNANCY
- MATERNAL PHYSIOLOGIC ADAPTATIONS TO PREGNANCY
- EMERGENCY CONTRACEPTION & ABORTION
- RHESUS DISEASE
- ANTEPARTUM CARE
o NAUSEA & VOMITING IN PREGNANCY
o PRENATAL SCREENING TESTS
o ANTENATAL FOETAL SURVEILLANCE
- OBSTETRICAL HAEMORRHAGE
o PLACENTA PREVIA
o PLACENTAL ABRUPTION
o VASA PREVIA
- OBSTETRIC COMPLICATIONS
o CHORIOCARCINOMA (MALIGNANT)
o ECTOPIC PREGNANCY
o HYDATIDIFORM MOLES – (PARTIAL & COMPLETE)
o PRETERM LABOUR
o PREMATURE RUPTURE OF MEMBRANES (PROM)
o POST-TERM PREGNANCY
o INTRAUTERINE FOETAL DEATH
o INTRAUTERINE GROWTH RESTRICTION
o MACROSOMIA
o POLYHYDRAMNIOS
o OLIGOHYDRAMNIOS
- MALPRESENTATION
- HYPERTENSION IN PREGNANCY
- NORMAL LABOUR AND DELIVERY
- INDUCTION OF LABOUR (IOL)
- NEONATAL ADAPTATIONS TO EXTRAUTERINE LIFE
o INFANT RESPIRATORY DISTRESS
o NEONATAL JAUNDICE & KERNICTERUS
- COMPLICATIONS OF LABOUR AND DELIVERY
o SHOULDER DYSTOCIA
o UMBILICAL CORD PROLAPSE
o UTERINE RUPTURE
o CHORIOAMNIONITIS
- OPERATIVE OBSTETRICS
- PUERPERAL COMPLICATIONS
o POST PARTUM HAEMORRHAGE (PPH)
- RETAINED PLACENTA
- POSTPARTUM CARE
- POSTNATAL MENSTRUATION & CONTRACEPTION
- THE 3 POSTNATAL MOOD DISORDERS
OBSTETRIC DEFINITIONS
OBSTETRIC DEFINITIONS
Timing:
Counting Babies:
AFI – Amniotic Fluid Sum of the amniotic fluid depth (cm) of the largest vertical pockets in each of the 4
Index uterine quadrants.
(N=8-24cm)
(<8= Oligohydramnios = Not Enough Amniotic Fluid)
(>24= Polyhydramnios = Too Much Amniotic Fluid)
GBS Group B Streptococcus
GDM Gestational Diabetes Mellitus
Growth Anomalies:
CPD – Cephalo-Pelvic Foetal head is too big for the maternal pelvis
Disproportion
IUGR – Intrauterine Failure to reach genetic growth potential. (Including A plateau/decline in growth
Growth Restriction velocity)
Note: Not necessarily “small for gestational age” (SGA)
LBW – Low Birth Weight LBW: Low Birth Weight <2500g
VLBW: Very low birth weight <1500g
ELBW: Extremely low birth weight <1000g
SGA/SFD Small for Gestational Age/Small for Dates = Foetus <10th percentile for Gestational
Age.
(Note: NOT necessarily IUGR)
Bleeding:
Foetal Lie Longitudinal or Transverse (Occasionally Oblique, but will → either Long/Trans during
labour)
Foetal Presentation The presenting part of the foetal body @ the birth canal.
- Cephalic or Breech (If Longitudinal Lie)
- Shoulder (If Transverse Lie)
Foetal Attitude/Posture Relation of the Foetal parts to each other
Foetal Position Right or Left side of Uterus
Breech Presentation 1. Frank Breech – Bum first, legs extended (“Pike”)
2. Complete Breech – Bum first, legs flexed (“Tuck”)
3. Footling Breech – Foot first (one or two) – (Ie: At least one hip extended)
Membrane Rupture:
Engagement Descent of the presenting part of the foetus into the mother’s pelvis.
Eg: If Cephalic, the head may be 4/5ths above the brim.
Labour Regular Painful Contractions + Cervical Dilatation/Effacement + Descent of the Foetus
- Stage 1: Onset of labour → Fully Dilated Cervix
- Stage 2: Fully Dilated Cervix → Birth of Foetus
- Stage 3: Birth → Delivery of Placenta & Membranes
Pre-Term Pre-Term: <37wks
Term Term: 37-42wks
Post-Term Post Term: >42wks
LUCS Lower-Uterine Caesarean Section (Lower horizontal incision)
(Cf. Classical Caesarean – Midline Incision)
SVD/SVB Spontaneous Vaginal Delivery/Birth
Trial of Scar/VBAC Trial of Scar = Attempt at vaginal delivery after Caesarean Section
(Vaginal Birth After VBAC = Successful Vaginal Delivery after CS
Caesar)
Perinatal:
IRDS – Infant Respiratory (AKA: “Hyaline Membrane Disease”) Signs of increased respiratory effort in a baby
Distress Syndrome due to insufficient surfactant &/or structural immaturity of the lungs.
Perinatal Period Time within 28days of a “Birth”. (Ie: Does NOT include Abortions)
EMBRYONIC SEXUAL DEVELOPMENT
EMBRYONIC SEXUAL DEVELOPMENT
Gametogenesis:
• The formation of gametes (spermatogenesis / oogenesis)
• Largely regulated by hormonal/endocrine system
• A process of meiosis
• Male: Mitotic division of Spermatogonia and entry to meiosis is continuous from onset at puberty until death
• Female: Meiotic division is discontinuous – begins in embryo, lies dormant once born & is completed upon
fertilisation by a sperm
o Events are cyclic between puberty and menopause – menstrual cycle
• Gametes are haploid cells ( ½ Chromosome number – 23 –)
o 22 pairs of somatic chromosomes
o 1 pair of sex chromosomes (X, Y)
§ Sperm contains X & Y
§ Egg only contains X & X
§ Combinations:
• XY = produces a male
• XX = produces a female
• Y is the sex determining chromosome
o Uterus - Fundus (top / head), Body, Cervix (external os, canal, internal os), Lumen (internal cavity)
§ Perimetrium – Outer wall
§ Myometrium – Middle of wall
§ Endometrium – Inner wall
https://embryology.med.unsw.edu.au/embryology/index.php?title=File:Bacteria_-_gram-
stained_vaginal_smear_05.jpg
Background Information on the Cervix:
- Note: The Transformation Zone – Commonest location of Cervical Cancer
o TZ = The location of Transition from Squamous to Columnar Epithelium
o Note: During puberty, Columnar Epithelium Migrates out of the os → Exposed to Vaginal Acidity →
Metaplasia to Squamous Epithelium
o This is the area Predisposed to Cancer
https://www.cancerjournal.net/viewimage.asp?img=JCanResTher_2015_11_1_10_154065_f2.jpg
Mikael Häggström, M.D. - Author info - Reusing images- Conflicts of interest: NoneMikael Häggström, CC0, via
Wikimedia Commons
https://unclineberger.org/cecs/for-researchers/
Overview of The Breast:
- Mammary glands:
o Exist in both sexes – only functional in females
o Contained within the breast – within the hypodermis (superficial fascia), anterior to pectoral muscles
of the thorax
- Areola – ring of pigmented skin surrounding nipple – contains large sebaceous glands (stop chapping)
- Nipple – protrudes from centre of areola
- Attached to Pec-Major by Suspensory Ligaments
- Glandular Breast Tissue:
o Approx 20 lobes/lobules → Converge to Lactiferous Ducts → Lactiferous Sinuses → Nipple
o Padded and separated from each other by connective tissue (suspensory ligaments) and fat
o Within the lobes are smaller lobules – containing glandular alveoli – produce milk during lactation
o Compound alveolar glands pass milk into the lactiferous ducts →accumulates in a lactiferous sinus
- Lymphatic Drainage:
o Supraclavicular, Infraclavicular, Parasternal, Pectoral, Axillary, Central, Subscapular
Aetiology:
- Unprotected Intercourse
- IVF (In Vitro Fertilisation)
- AI (Artificial insemination)
Clinical Features:
- Symptoms:
o Amenorrhoea
o Nausea/Vomiting
o Heartburn/Reflux
o Breast Tenderness
o Urinary Frequency
o Constipation
o Fatigue
- Signs:
o Softening of the cervix (4-6wks)
o “Chadwick’s Sign” - Bluish Hue of Vagina (Engorgement of pelvic vasculature)
o Uterine Enlargement
o Breast Enlargement & Areolar Darkening
Diagnosis of Pregnancy
- B-HCG:
o +ve in Serum @ 9days post-conception
o +ve in Urine @ 28days post-conception
- Transvaginal USS:
o 5 wks: Gestational Sac Visible
o 6 wks: Foetal Pole Visible
o 7-8wks: Foetal Heartbeat Detectable
- Trans-Abdominal USS:
o >6 wks: Pregnancy Detectable
Physiological Amenorrhoea:
- Trophoblasts secrete B-HCG (Human Chorionic Gonadotropin) → Promotes Corpus Luteum to continue
secreting Oestrogen & Progesterone (Ie: Prevent Menstruation)
- Trophoblasts → “Chorion” (continues secreting B-HCG)
o (Note: B-HCG Below expected for dates could = Ectopic/Abortion/Wrong Dates)
- Chorion → Placenta (Takes over from Corpus Luteum → Secretes ↑↑↑Oest & Prog)
Endocrine Changes:
- Pancreas:
o ↑Insulin Secretion → To compensate for HCS-Mediated Insulin Resistance
o But we still get hyperglycaemia. Why?:
§ Pregnancy induces insulin resistance to maintain the high blood sugar
§ Human placental lactogen & cortisone/cortisol & Progesterone competes with the insulin for
the receptors → Insulin ‘resistance’ (Competitive inhibition)
o (Note: Maternal Insulin does NOT cross the Placenta – Bub makes its own Insulin)
- Thyroid:
o HCG → Stimulates Thyroid (In addition to Normal TSH)
§ ↑Size & Vascularity
§ ↑Thyroid Hormone Production – but may not have hyperthyroidism. Why? – Oestrogen
increases thyroid binding globulin to decreases the ‘free thyroxin’ in the blood doesn’t
increase
§ (But normal T3/T4 levels due to ↑Thyroid-Binding Globulin)
o Human Chorionic Thyrotropin (hCT) causes hypermetabolism and increase Ca+ concentration
→ensuring mineralisation of foetus’ bones
- Parathyroid:
o ↑PTH → ↑Bone Ca-Resorption → ↑Ca Available to Foetus’s Bones
- Adrenals:
o ↑ACTH Secretion →
§ ↑Aldosterone → Water Retention → Oedema
§ ↑Cortisol → Relative Immunodeficiency (Protects Foetus from Mum)
- Pituitary:
o ↑Prolactin Secretion → Lactation
EMERGENCY CONTRACEPTION & ABORTION
EMERGENCY CONTRACEPTION & ABORTION
Emergency Contraception:
- Goal:
o Last-chance contraception if current contraceptive failed (Eg: Broken Condom)
- Timing:
o ASAP after unprotected sex (<120hrs / 5days)
o Note: Completely ineffective Post-Implantation
- Methods:
o #1 Progesterone-Only: (AKA: “Plan-B”) Single Dose – 1.5mg
§ (Effective <72hrs & Fewer Side Effects)
§ Note: NOT Effective After Implantation!!
o Copper IUD: Best efficacy; But inconvenient & invasive
§ Still Effective After Implantation
Abortion Pre-Requisites:
1. Counselling on Alternatives (Eg: Adoption)
2. Informed Consent (& any domestic legal prerequisites are met)
3. Comprehensive History
4. Discuss Contraception After Abortion
5. STI-Screen & Education
6. Antibiotic Prophylaxis Prior to Abortion
Abortion:
- Early Medical Abortion (<6wks):
o STAT DOSE - Mifepristone/RU486:
§ Progesterone Receptor Agonist → Prevents Endometrium from supporting Fertilised Egg
§ Effective <63days (7wks) since last period
§ No need to come into Hospital
o Or Methotrexate – (Used more in Ectopic Pregnancies)
- Early Surgical Abortion (<14wks):
o Dilation & Suction Curettage:
§ Available up to 14wks Gestation
- Late Medical Abortion (14-20wks):
o STAT DOSE - Mifepristone/RU486:
§ Progesterone Receptor Agonist → Prevents Endometrium from supporting Fertilised Egg
§ Effective <63days (7wks) since last period
o 48HRS LATER – Vaginal Misoprostol:
§ Synthetic Prostaglandin → Ripens Cervix & Induces Labour
§ + Analgesia, +/- Anti-Emetics, +/- Anti-D-Ig in Rh-Negative Mothers
§ Very Safe – Small risk of bleeding; <1:100000 risk of death
- (Note: In most jurisdictions, abortion beyond ~20wks is generally not permitted due to onset of legal rights
of the foetus and are only considered in extreme circumstances)
RHESUS DISEASE
RHESUS DISEASE
https://www.ncbi.nlm.nih.gov/books/NBK2267/
- 2: ‘Rh’ (Rhesus/Rh-D) Blood Group Antigens:
o Membrane-Bound protein on RBC
o Presence/Absence of the RhD’-Gene determines +ve/-ve blood type
§ Presence of RhD → Positive
§ Absence of RhD → Negative
o Relevance in Transfusions:
§ Rh-Positive Patients: Can receive either Rh-Positive OR Rh-Negative Blood
§ Rh-Negative Patients: Should ONLY receive Rh-Negative Blood (except in extreme
emergencies and Rh-Negative blood is unavailable)
o Relevance in Pregnancy:
§ If the mother is Rh-Negative, but the foetus is (potentially) Rh-Positive →
• → ‘Rh-Incompatibility’
• (If father is Rh-Positive or father’s Rh-status is unknown)
§ Normally, maternal and foetal blood don’t mix, but sometimes a sensitizing event can occur,
causing foetal blood to contact maternal blood
• Eg: Abdominal trauma during pregnancy
• Eg: Amniocentesis
• Eg: Miscarriage
• Eg: Ectopic pregnancy
• Eg: Chorionic villus sampling
• Eg: Bleeding during pregnancy
§ If Rh-Negative mother gets sensitized to Rh-Positive Foetus →
• → Mother’s immune system produces Rh-Antibodies
• → Rh-Antibodies Cross the placenta
• → Enter foetal bloodstream → Attack foetal RBC’s → Hemolytic Anemia
§ Note: You can prevent an Rh-Negative mother from being sensitized by administering Rh-
Immunoglobulin (aka: Anti-D-Antibodies) at strategic times during the pregnancy
BLOOD GROUP ANTIBODIES:
- Anti-A / Anti-B Antibodies:
o Are Naturally-Occurring Antibodies:
§ Ie: Present at birth
§ Ie: Do not require an immune-sensitizing event
o Are Immunoglobulins of type:
§ IgM type antibodies
o Are Present In plasma of people who lack the corresponding Antigen
§ Eg: A-type individual will have ‘Anti-B’ Antibodies (against B-Antigens)
§ Eg: B-Type individual will have ‘Anti-A’ Antibodies (against A-Antigens)
§ Eg: O-type individual will have ‘Anti-A’ & ‘Anti-B’ Antibodies
o If Antibodies contact their respective Antigen, A Haemolytic Reaction may occur
o Clinical significance:
§ Determines a patient’s ABO-compatibility when receiving transfusions
o Indirect (IDAT):
§ Detects antibodies against RBCs present in the patient's serum
§ Serum is extracted from the blood, and is incubated with RBCs of known antigenicity
§ If agglutination occurs, the indirect Coombs test is positive
§ It is used to detect very low concentrations of antibodies present in a patient's
plasma/serum prior to a blood transfusion
§ In antenatal care, the IAT is used to screen pregnant women for antibodies that may cause
haemolytic disease of the newborn
Pre-Conception Counselling:
- Folate Supplementation:
o 8-12 weeks pre-conception
o & During first >3mths of pregnancy
o **To prevent neural tube defects (reduce risk of Neural Tube Defects by <70%)
o 0.4-1mg daily in low-risk women
o 5mg daily in higher-risk women (Ie: Previous neural tube defects, on anticonvulsant meds, diabetes,
or obesity)
- Iron Supplementation
- Prenatal multivitamins
**
Molloy, Anne M. et al. “Genetic Risk Factors for Folate-Responsive Neural Tube Defects.” Annual review of
nutrition 37 (2017): 269-291 .
Important Immunisations:
- PRE-Conception:
o Any Live Vaccines should be avoided in pregnancy, so should only be given to a person known to
be NOT pregnant
§ Eg: Polio
§ Eg: Measles/Mumps/Rubella
§ Eg: Varicella
§ Eg: Oral Typhoid
o (Risk of placental and foetal infection)
- Intra-Partum:
o The following vaccines are SAFE to be given during pregnancy:
§ Tetanus
§ Diphtheria
§ Influenza
§ Hep B
§ Pertussis
o Influenza is recommended for all pregnant women in many health systems
- Post-Partum:
o Rubella recommended for all new non-immune mothers
o Hepatitis B recommended for all new infants (within 12hrs of birth if maternal Hep-B status is either
unknown of positive)
o Any other vaccine desired/needed is safe post-partum
Optimizing Health Status Before & During Pregnancy:
- Regular, moderate exercise (Eg: Walking)
o Helps you keep strong for the birth
o Lifts your mood
o Helps maintain a healthy weight
- Healthy eating
o keeps you feeling good
o gives your baby the essential nutrients he needs in utero
- Avoid certain foods
o Soft cheeses
o Raw fish
o Limit caffeine
- Drugs & Alcohol:
o For prescribed drugs, check with your doctor that they are safe
o Don’t smoke
o No recreational drugs
o No alcohol
https://www.shecares.com/pregnancy/healthy-pregnancy-tips
Pregnancy hormones
- Between the first 6-12 weeks of pregnancy, oestrogen rises significantly → Prevents menstruation
- These hormone levels can cause nausea and vomiting (Aka: morning sickness)
o Some women get it, some don’t
o Morning sickness usually abates after 1st 3-4mths, but can last <9mths
- Can also cause mood swings
Background:
- Almost all pregnant women experience nausea of pregnancy
- Mostly occurs in 1st Trimester
HYPEREMESIS GRAVIDARUM:
- What is it?
o Severe, intractable nausea/vomiting
- Epidemiology:
o Typically presents in first trimester
o Approximately 1% of pregnancies
- Aetiology:
o Rapidly rising HCG & oestrogen levels
- Investigations:
o Rule out other conditions:
§ Eg: Gastritis
§ Eg: Pyelonephritis / UTI
§ Eg: Thyrotoxicosis
§ Eg: HELLP syndrome
o Bloods:
§ FBE
§ Electrolytes
§ Renal function / Creatinine
§ LFTs
o Ultrasound:
§ ?Multiple gestation
§ anatomical cause
§ gallstones
- Management:
o Consider Thiamine Supplementation
o Doxylamine+B6 tablets
o Dimenhydrinate
o Pyridoxine
o Metoclopramide
o If severe, consider hospital admission for fluid/electrolyte balance correction
o If very severe (catabolic), total parenteral nutrition
- Complications:
o Fluid/Electrolyte disturbance
o Mallory-Weiss tear
o Wernicke’s encephalopathy (if severe and prolonged)
o IUGR (Intrauterine Growth Restriction)
PRENATAL SCREENING TESTS:
Ultrasound Screening:
- 8-12 weeks:
o Dating scan
o The most accurate way to estimate the gestational age of the foetus and calculate due dates
- 11-14 weeks:
o Nuchal translucency scan
o Is an early screening test for Down’s Syndrome (Trisomy 21)
o Can also detect cardiac defects & Turner’s syndrome
- 18-20 weeks:
o Growth scan
o Anatomy screen
Foetal Movements:
- Can generally be noticed by the mother around 16-20wks gestation
- Foetal movements can be counted by the mother at a time when the foetus is normally active
- All high-risk women are recommended to do Foetal Movement Counts
o >6 movements in a 2hr period is expected
o If <6 movements in a 2hr period, a mother is advised to present to her dr/midwife for assessment
https://hartfordhospital.org/services/womens-health-services/departments-services/pregnancy-
childbirth/maternal-fetal-medicine/non-stress-test-nst
OBSTETRICAL HAEMORRHAGE
OBSTETRICAL HAEMORRHAGE
(*Vaginal bleeding from 20wks gestation to term)
Differential Diagnoses:
- ‘Bloody show’ (Ie: Shedding of the cervical mucous plug)
- Placenta Previa
- Placental Abruption (Abruptio Placentae)
- Vasa Previa
- Cervical Lesions (Including cervicitis, cervical polyps, ectropion, cervical cancers)
- Uterine rupture
PLACENTA PREVIA:
- What Is It?
o Where the placenta is implanted in the lower segment of the uterus and presents ahead of the
leading pole of the foetus
- Clinical Features:
o Painless**
o Bright red, recurrent vaginal bleeding
o Varies in degree, but can be catastrophic
- Examination Findings:
o Uterus soft/non-tender
o Elevated/displaced presenting foetal part
o Normal FHR
- Investigations:
o TVUS (transvaginal US); can also use transabdominal
o Repeated TVUS in third trimester if placental is between 20mm of overlap and 20mm away from
internal os after 20wk mark
- Complications:
o Prematurity (as bleeding often requires early caesarean section
o Intrauterine hypoxia of foetus
o Foetal malpresentation
o PPROM
o <1% maternal mortality (hypovolaemic shock, acute renal failure, sheehan syndrome)
o Anaemia
o Placenta accreta
o Hysterectomy
- Management:
o Aim to maintain pregnancy until risk of continuing pregnancy outweighs risk of delivery
o Haemodynamic stabilisation (IV fluids, oxygen)
o Anti-D immunoglobulin if mother is Rh-negative
o If <37wks gestation & minimal bleeding →
§ Admit to hospital
§ Consider corticosteroids for foetal lung maturation
§ Limit physical activity to prevent triggering further bleeds
o If >37wks gestation &/or profuse bleeding →
§ Consider immediate delivery via caesarean section
OpenStax, CC BY 4.0 <https://creativecommons.org/licenses/by/4.0>, via Wikimedia Commons
PLACENTAL ABRUPTION:
- What Is It?
o Placental detachment from the uterine wall, caused by bleeding at the decidual-placental interface
- Clinical Features:
o Painful** - sudden onset, constant, localised to lower back and uterus
o Typically occurs >20wks gestation
o May be partial or total (Total → Foetal death is inevitable)
o Blood may dissect upwards towards the foetus, or downwards towards the cervix
o Vaginal bleeding unless abruption is concealed
- Examination Findings:
o Uterine tenderness
o Uterine contractions/Hypertonic uterus
o Shock/anaemia
o Foetal distress
o ~15% may present with foetal death
o Bloody amniotic fluid
- Investigations:
o Clinical diagnosis
- Complications:
o Foetal mortality 25-60%
o Foetal prematurity
o Intrauterine hypoxia
o Maternal mortality ~1%
o Risk of DIC ~20%
o Maternal shock (acute renal failure, anaemia, sheehan syndrome, amniotic fluid embolus)
- Management:
o Haemodynamic stabilisation (IV fluids, oxygen)
o Cross match and hold blood products (due to DIC risk)
o Anti-D immunoglobulin if mother is Rh-negative
o Mild Abruption:
§ <37wks: Monitor concealed bleeding with serial maternal haematocrits → consider delivery
§ >37wks: Stabilize mother and deliver
o Moderate to severe abruption:
§ Vaginal delivery if no contraindication & no foetal distress
§ If foetal distress, vaginal delivery is contraindicated, or labour fails to progress → Caesarean
CHORIOCARCINOMA (MALIGNANT):
- Aetiology:
o Risk Factors – Extremes of age <20, >40, previous abortion, abnormal gestation
o May be De-Novo (Primary) or may progress from a Complete Mole (Secondary)
- Pathogenesis:
o May be De-Novo (Primary) or may progress from a Complete Mole (Secondary)
§ High Grade Primary Malignancy of the Trophoblasts
§ May evolve Secondary to an Invasive/Complete Hydatidiform Mole
- Morphology:
o Macro:
§ Invasive
§ Haemorrhagic
§ Necrosis
- Clinical Features:
o Irregular Vaginal Bleeding
o Uneven Swelling of Uterus (Mass)
o Abdominal/Pelvic Pain
o Diagnosis:
§ Rising hCG
§ Abdo US → Abdo CT
o Metastasis to Lungs is common → Haemoptysis
- Treatment:
o Surgical Excision
o + Chemotherapy (Methotrexate) – Good Prognosis
- Prognosis:
o Types:
§ Gonadal (in the ovary – Not related to gestational) – Poor prognosis
§ Gestational (in the uterus – associated with pregnancy) – Good Prognosis – 100% cure rate
with therapy
https://www.monash.edu/museumofpathology/female-genital-tract/choriocarcinoma
ECTOPIC PREGNANCY:
- Aetiology:
o 50% Idiopathic
o Risk Factors:
§ Obstruction
§ PID
§ Fallopian Stricture
§ IUD
§ Endometriosis
- Pathogenesis:
o Implantation outside the uterus (Often within the fallopian tube wall)
- Morphology:
o Macro:
§ 90% occur in Fallopian Tubes
§ May occur in the Abdomen
o Micro:
§ Normal placental infiltration – Just in the wrong place
- Clinical Features:
o 1% of pregnancies
o Symptoms:
§ May mimic a normal early pregnancy – (Missed Periods, Breast Tenderness, Nausea)
§ *Sharp, Stabbing Pain (Pelvic/Abdominal)
§ *Vaginal Bleeding/Spotting
§ **Peritonitis/Shoulder Pain if Rupture = MEDICAL EMERGENCY
o Diagnosis:
§ B-hCG (Pregnancy Test)
§ Abdominal Ultrasound – (If scan is –Ve, re-test hCG & re-scan every 2-3 days until foetus can
be located)
o Complications:
§ **Rupture → Massive Intraperitoneal Haemorrhage → Shock → **Death
§ Spontaneous Abortion
§ Chorioamnionitis
- Treatment:
o If early – Medical Abortion (Methotrexate + Misoprostol)
o If later – Surgical Abortion (Laparoscopic Salpingotomy)
- Prognosis:
o Good if treated
o May → Some infertility
https://www.ajog.org/article/S0002-9378(18)31148-7/fulltext#relatedArticles
PRETERM LABOUR
- What is it?
o Onset of labour between 20wks & 37wks gestation
- Aetiology:
o Mostly idiopathic
o But can also be triggered by:
§ Maternal factors: Eg: infection, HTN, diabetes, injury, poor nutrition, drugs, etoh, smoking
§ PPROM
§ Polyhydramnios
§ Placenta previa/abruption/insufficiency
§ Foetal factors: Eg: Multiple gestation, congenital abnormalities, foetal stress, hydrops
§ Uterine factors: Eg: Leiomyomas, mullerian duct abnormalities
- Epidemiology:
o Accounts for approximately 10% of pregnancies
- Risk Factors:
o Prior hx of Preterm Labour
o Prior hx of cervical cone biopsies or mechanical dilation
o Cervical length on TVUS (>30mm has reduced risk of preterm labour)
o Smoking
o Later maternal age
o Multiple gestations
- Clinical Features:
o Regular contractions + Cervical dilation @ >20<37wks gestation
- Management:
o Initial Things:
§ Admit to hospital/birthing facility
§ Hydration
§ Left lateral position + bed rest
§ Foetal USS (for position, placental location)
o Suppression of Labour:
§ Aim: Delay delivery to allow for betamethasone to aid in foetal lung maturation
§ Prerequisites: Live immature foetus, intact membranes, minimally dilated cervix <4cm
§ Contraindications: Maternal bleeding, preeclampsia/eclampsia, chorioamnionitis. Or foetal
distress/demise, IUGR
o Agents:
§ Calcium channel blockers (Nifedipine)
§ Prostaglandin synthesis inhibitors (Indomethacin)
§ (Magnesium sulphate – primarily for eclampsia)
§ Betamethasone (to enhance foetal lung maturity)
- Prognosis:
o >30wks/1500g → 90% survival
o >33wks/2000g → 99% survival
Source: www.thecalgaryguide.com
PREMATURE RUPTURE OF MEMBRANES (PROM):
- Premature rupture of membranes (PROM) = Rupture of the amniotic sac before onset of labour
o Prolonged PROM = >18-24 hours before labour
- Preterm PROM (PPROM) = PROM before 37 weeks gestation
(Note: PROM is a variation of normal; whereas PPROM is often pathological and can be dangerous)
(Note: Typically, labour begins <48hrs of PROM)
(Note: Sometimes the rupture may heal spontaneously)
- Risk Factors:
o Bacterial Infection - Eg: Chorioamnionitis, Maternal Sepsis, vaginitis, cervicitis, STI, UTI
o Multiparity
o Cervical incompetence
o Multiple gestation
o Smoking
o Anatomic Defect of:
§ the amniotic sac
§ uterus
§ cervix
§ the foetus
o Previous PROM/PPROM
- Clinical Features:
o Pregnant + Sudden Fluid Gush +/- continued leakage
- Assessment
o proper medical history
o Sterile spec gynaecological exam (look for fluid pooling or leakage from cervix)
o Nitrazine paper test (Amniotic fluid turns paper blue)
o Ultrasound to rule out foetal anomalies & assess presentation
o Amniotic fluid smear cytology/microscopy (dried for 10 minutes on a slide shows a characteristic
fernlike pattern)
- Management
o PROM (>37wks):
§ Permit spontaneous labour (up to 12hrs)
§ Induction of labour (@ 12 hours) if it has not already begun
§ Consider Group B Streptococcal prophylaxis (@ 18 hours)
o PPROM (<37wks):
§ Admit mother
§ Steroids (2days)
§ Watch for Preterm Labour
§ Watch for Chorioamnionitis
§ Antibiotic prophylaxis (Ampicillin/Erythromycin) to delay delivery → ↑Foetal
Maturation, & prevent sepsis
§ Avoid labour prior to 34wks (Tocolysis may be used)
§ Induction of labour @ 34 weeks
o Infection
§ Chorioamnionitis:
§ Antibiotic therapy to avoid sepsis
§ Induction/Delivery is indicated
§ Foetal:
§ If the GBS status of the mother is unknown, Antibiotic Prophylaxis (Penicillin/other)
protects against vertical transmission of Group B streptococcal infection
• Prognosis:
o 90% of women with PROM at 28-34 wk GA go into spontaneous labour within 1 wk
o 50% of women with PROM at <26 wk GA go into spontaneous labour within 1 wk
Example of a management algorithm for PROM
*Follow your local clinical protocol*
https://www.waterloowellingtondiabetes.ca/userContent/documents/Professional-
Presentations/Pregnancy%20and%20Hyperglycemic%20Emergencies%20.pdf
Bartosz Szmyd,Małgorzata Biedrzycka,Filip Franciszek Karuga, Magdalena Rogut, Iwona Strzelecka, Maria Respondek-
Liberska, CC BY 4.0 <https://creativecommons.org/licenses/by/4.0>, via Wikimedia Commons
POLYHYDRAMNIOS
- What is it?
o Amniotic Fluid Index (AFI) >25cm
o USS: Single deepest pocket >8cm
- Aetiology:
o Mostly idiopathic
o Type 1 diabetes
o Chorioangiomas
o Multiple gestation
o Foetal chromosomal anomaly
o Foetal anencephaly/hydrocephalus/meningocoele
o Foetal tracheoesophageal fistula/duodenal atresia/facial clefts
- Epidemiology:
o 0.2-1.6% of all pregnancies
- Clinical Features:
o Uterus large for dates
o Overdistended uterus → pressure symptoms (dyspnoea, oedema, hydronephrosis)
o Possible complications: Cord prolapse, placental abruption, malpresentation, preterm labour, PPH
- Management:
o Diagnose likely cause
o If mild-moderate; expectant management
o If severe → Hospitalize and consider therapeutic amniocentesis
- Prognosis:
o 2-5x risk of perinatal mortality
OLIGOHYDRAMNIOS
- What is it?
o Amniotic Fluid Index (AFI) <5cm
o USS: Single deepest pocket <2m
- Aetiology:
o Mostly idiopathic
o Uteroplacental insufficiency (Eg: Preeclampsia)
o ACE inhibitors
o Foetal urinary tract anomalies (Eg: Renal agenesis, renal obstruction)
o Foetal demise
o IUGR
o Ruptured membranes
- Epidemiology:
o ~4.5% of all pregnancies
- Clinical Features:
o Uterus small for dates
o 15-25% chance of foetal abnormalities
o Possible complications: Cord compression, pulmonary hypoplasia, higher risk labour
- Management:
o Rule out PROM
o Monitor foetus
o USS Doppler of umbilical cord & uterine artery
o Optimise maternal hydration
o Can inject fluid by amniocentesis for temporary (1wk) relief
o Deliver if at or near term
- Prognosis:
o High foetal mortality if associated with congenital malformations / pulmonary hypoplasia
MALPRESENTATION
MALPRESENTATION
BREECH PRESENTATION
- What is it?
o Foetal buttocks/lower extremity is the presenting part
o 10% - ‘Complete breech’: Hips and knees both flexed
o 60% - ‘Frank breech’: Hips flexed, knees extended, buttocks against cervix
o 30% - ‘Incomplete / footling’: Both or one hip flexed, and both or one knee present below buttocks;
feet or knees presenting first
- Risk Factors:
o Contracted maternal pelvis
o Abnormally shaped uterus (Eg: Fibroids, uterine tumours)
o Pelvic tumours
o Placenta previa
o Poly/oligohydramnios
o Prematurity of foetus
o Multiple gestation
o Congenital malformations
- Epidemiology:
o 3-4% of pregnancies
- Management:
o External Cephalic Version (ECV):
§ → Reposition a single foetus under USS guidance
§ ~65% success rate
§ Prerequisites: >36wks, single foetus, unengaged, reactive Non-Stress test & not in labour
§ Contraindications: previous caesarean, oligohydramnios, PROM, placenta previa, IUGR
§ Anti-D-Ig administration if mother Rh negative
o If delivering vaginally:
§ Must be active; avoid foetal traction
§ Encourage maternal pushes
o Caesarean recommended if:
§ Breech hasn’t yet descended into perineum at 2hrs into labour, or if vaginal delivery is not
imminent
§ Cord presentation
§ Foetal factors not compatible with vaginal delivery (Eg: hydrocephalus, macrosomia, foetal
growth restriction)
- Prognosis:
o Complications of ECV: Abruption, cord compression, ROM, labour, foetal bradycardia, rhesus
sensitisation
o Generally higher rates of perinatal mortality
https://ranzcog.edu.au/womens-health/patient-information-resources/breech-presentation-at-the-end-of-your-
pregnancy
HYPERTENSION IN PREGNANCY
HYPERTENSION IN PREGNANCY
General Info:
- Definition:
o = “BP ≥ 140/90 measured on >2 Separate Occasions”
- Types – In Order of Severity:
o Chronic (Pre-existing) Hypertension:
§ = “HTN Before Pregnancy OR Within 1st 20wks of gestation”
§ (No associated problems; But ↑Risk of → Gestational HTN & Pre-Eclampsia)
o Gestational Hypertension:
§ = “HTN occurring After 20wks”
§ (No associated problems; But ↑Risk of → Pre-Eclampsia)
o *Pre-Eclampsia (Including Chronic HTN with Superimposed Pre-Eclampsia):
§ = “HTN in Pregnancy + ANY Sign of Organ Dysfunction”
• Eg: Kidney – (Proteinuria, ↑Creatinine)
• Eg: Liver – (↑AST/ALT, RUQ Pain, Hepatitis)
• Eg: Neuro – (Headaches, Visual Disturbance, Hyperreflexia, Clonus)
• Eg: Haem – (DIC, Consumptive Thrombocytopenia, Haemolysis)
• Eg: Placental – (Foetal Growth Restriction)
o **Eclampsia:
§ = “Pre-Eclampsia Complicated by a Generalised Tonic-Clonic Seizure”
§ (ACUTE & LIFE-THREATENING: Can → Maternal & Foetal Complications/Death)
- General Management:
o ANY HTN IN PREGNANCY NEEDS INVESTIGATION & CLOSE MONITORING!!!
GESTATIONAL HYPERTENSION:
- What is it?
o BP >140/90 developing after 20th wks gestation (in the absence of proteinuria in a woman known
to be normotensive before pregnancy)
- Risk Factors:
o Primigravidas account for >805 of gestational HTN
o First conception with new partner
o Diabetes
o Renal insufficiency
o Obesity
o extremes of maternal age (<18 or >35 yr)
o IUGR / oligohydramnios
o Multiple gestation
- Investigations:
o Clinical examination (check BMI, oedema, nervous system exam)
o Foetal non-stress test / USS for growth / Doppler flow studies
o Bloods + 24hr urine collection (for protein/albumin : creatinine ratio)
- Management:
o Pharmaceutical options: Labetolol, Nifedipine XR, or a-methyldopa
o (IV Hydralazine if severe)
o AVOID: ACE-inhibitors, Angiotensin receptor blockers, diuretics, prazosin or atenolol
- Complications:
o Maternal liver/renal dysfunction
o Eclampsia
o Placental abruption
o LVF/pulmonary oedema
o DIC
o HELLP syndrome
o Haemorrhagic stroke
o IUGR
o Foetal prematurity
PRE-ECCLAMPSIA / ECCLAMPSIA:
- Aetiology:
o Defective Placentation
o (Risk Factors – Primigravid, Older Mums, FamHx, Chronic HTN, Diabetes, Twins, Molar Pregnancy)
- Pathogenesis:
o Insufficient Placental Invasion into Spiral Arterioles → ↓Placental Blood Flow:
§ Pre-Eclampsia: Placental Ischaemia → Vasoconstrictors → HTN
§ Eclampsia: Placental Infarction → Severe HTN → Seizures & Organ Failure
- Clinical Features:
o Common: 5-10% pregnancies
o Symptoms:
§ **Headaches, Visual Disturbances (Neuro Complications)
§ * Abdo Pain (Hepatitis)
§ *Pitting Oedema (Renal Failure)
§ !!Purpura & DIC (HELLP Syndrome)
§ !!Seizures (IF Eclampsia)
- Diagnosis:
o Symptom Inquiry:
§ Headaches/Visual Disturbances?
§ Epigastric Pain?
§ Oedema? (Seen as rapid weight gain)
§ Rashes?
o Take Blood Pressure (>140/90) →
o Do Urine Dipstick/Urinalysis (Proteinuria) →
- Management:
o Admit to BS for 4hrly Monitoring:
§ Urinalysis (Protein++)
§ Serial BP’s (Seated) every 4hrs
§ Daily UECs, FBC, LFTs
§ Daily USS for Foetal Growth & Amniotic Fluid Volume
o Drugs:
§ Antenatal Corticosteroids – (Betamethasone)
§ CaChBlockers – (24hr Magnesium Sulfate Infusion or Nifedipine)
§ B-Blockers – (Labetalol)
o **Definitive = Delivery (Early Induction of Labour)
o ***If → ECCLAMPSIA (Ie: Seizures):
§ 1: Stabilize with Magnesium Sulfate (Note: Do NOT use Anticonvulsants!)
§ 2: Immediate Delivery
§ 3: Recovery in HDU/ICU for >4days AFTER BP HAS NORMALISED
o *(CONTRAINDICATED – ACEi’s/ARBs & Diuretics)
- Complications:
o Foetal Growth Restriction
o Liver Failure
o Acute Renal Failure
o HELLP Syndrome – (Haemolysis, Elevated Liver Eenzymes, Low Platelets)
§ → Jaundice, Epigastric Pain, Vomiting
o DIC
o Eclampsia → Seizures →
§ Placental Abruption
§ Cerebral Haemorrhage
§ Aspiration Pneumonia
§ Death
- Prognosis:
o Eclampsia is rare with proper treatment; BUT has 20% Mortality!!
NORMAL LABOUR AND DELIVERY
NORMAL LABOUR AND DELIVERY
Time of birth:
- 280 Days after last menstrual period +/- 15 days
o Preterm (>20 to <36+6 wk GA)
o Term (37-41+6 wk GA)
o Post term (>42 wk GA)
Definition of Labour:
- “True Labour”:
o = ‘Regular, painful contractions of increasing intensity associated with progressive dilatation and
effacement of cervix and descent of presenting part, or progression of station’
- “False Labour” (Braxton-Hicks contractions):
o = ‘Irregular contractions, with unchanged intensity and long intervals, occur throughout pregnancy
and not associated with any cervical dilatation, effacement, or descent’
Unattributable
OpenStax, CC BY 4.0 <https://creativecommons.org/licenses/by/4.0>, via Wikimedia Commons
https://www.pregnancybirthbaby.org.au/malpresentation
• Foetal presentation: The foetal body part closest to the birth canal:
o Breech (complete, frank, incomplete)
o Cephalic (vertex/occiput, face, asynclitic, brow)
o Transverse (shoulder)
o Compound (foetal extremity prolapses along with presenting part)
o All except vertex are considered malpresentations)
• Foetal position: position of presenting part of the foetus relative to the maternal pelvis
o Occiput Anterior: most common presentation (“normal”)
o Occiput Posterior: most rotate spontaneously to OA; may cause prolonged second stage of labour
o Occiput Transverse: leads to arrest of dilatation
§ (normally, foetal head enters maternal pelvis and engages in OT position)
§ Subsequently rotates to OA position (or OP in a small percentage of cases)
• Station: Position of presenting bony part relative to ischial spines – determined by vaginal exam:
- At ischial spines = station 0 = engaged
- -5 to -1 cm above ischial spines or
- +1 to +5 cm below ischial spines
https://www.medindia.net/surgicalprocedures/cervical-ripening.htm
https://www.babycenter.com/pregnancy/your-body/inducing-labor_173
Methods of Inducing Labour:
- Amniotomy:
o The artificial rupture of membranes to stimulate prostaglandin synthesis and secretion
o Can be attempted if cervix is open & soft, membranes can be felt, and head is present at the cervix
o Addition of IV oxytocin increases chance of successful induction of labour
- Oxytocin:
o Administered via IV infusion to stimulate uterine contractions
o Proven to reduce rate of unsuccessful vaginal deliveries
o Potential complications:
§ Hyperstimulation/tetanic contraction of uterus → Foetal distress / uterine rupture
§ Uterine muscle fatigue → Uterine Atony → increased risk of PPH
Unattributable
NEONATAL ADAPTATIONS TO EXTRAUTERINE LIFE
NEONATAL ADAPTATIONS TO EXTRAUTERINE LIFE
After Birth:
• Baby is cast out of its watery, warm environment
• Placental life supports are severed
• Now baby must independently breathe, obtain nutrients, excrete waste, and maintain its body temperature
Respiratory Changes:
• Cortisol stimulates surfactant production in foetal lungs - last months of pregnancy
• After birth, CO2 accumulates in blood → acidosis
o Acidosis → excites respiratory centres →triggers 1st breath
o Adrenal Medulla→Adrenaline (from stress of birthing) also supports surfactant secretion
o Surfactant in alveolar fluid → reduces surface tension in alveoli → Aids inspiration
• Surfactant reduces surface tension of alveolar fluid – makes initial breathing easier
• Premature babies (no surfactant) are treated with Cortisol OR ACTH (Adrenocorticotropic Hormone)
o Cortisol → Surfactant
o ACTH→Anterior Pituitary→Adrenal Cortex→Glucocorticoids (Eg: cortisol)→ surfactant
Circulatory Changes:
• Foetal circulation is different from neonatal circulation
o Has to integrate circulation of placenta
o Blood flow to non-functional lungs & liver are partially bypassed
• “Bypasses” / “Shunts” of foetal circulatory system:
o Ductus Venosus
§ Directs the oxygenated blood from the placental vein into inferior vena cava→heart
§ Partially bypasses the liver sinusoids
o Foramen Ovale
§ An opening in the interatrial septum loosely closed by a flap of tissue
§ Directs some of blood entering the right atrium into the left atrium → Aorta
§ Partially bypasses the lungs
o Ductus Arteriosus
§ Directs most blood from right atrium of the heart directly into aorta
§ Partially bypasses the lungs
o **All of these “shunts” are occluded at birth due to pressure changes
Thermoregulatory Changes:
• Newborns have high “Surface Area – Body Mass” ratio → potentiates heat loss
o Especially head
• Newborns cannot increase heat production by shivering
o Instead, heat is produced by uncouplers in the mitochondria of brown adipose tissue
Apgar Score:
• Measures a baby’s health against several criteria (expressed as #/10)
OpenStax, CC BY 4.0 <https://creativecommons.org/licenses/by/4.0>, via Wikimedia Commons
OpenStax, CC BY 4.0 <https://creativecommons.org/licenses/by/4.0>, via Wikimedia Commons
BABY CHECKS: THE PROCESS
Background History:
- Neonatal History
- Mum’s/Bub’s Blood Group (*Beware the Rh-Negative Mother with a Rh-Positive Baby)
- Obstetric History (Gestational Diabetes, Pre-Eclampsia)
- Method Delivery (Natural/Forceps/Suction, Caesarean)
- Risk Assessment for Sepsis
Vital Signs:
- P: **Bradycardia (Often responds to ventilation) → Resuscitate
- R: **Signs of Respiratory Distress (Treat cause) → Resuscitate
- T: **Fever could = Infection (Beware Group B Strep, and Chlamydia) → Investigate & ABs
General Inspection:
- Colour (Pink = Good; Yellow/Jaundice = Often Normal; Blue/Cyanotic = Bad)
- Distress (Respiratory/Other)
- Red Reflex of Retina (Ensure the baby has a retina)
- 10 Fingers, 10 Toes
- Patent Anus (Note: Presence of Meconium ≠ Patent Anus; Beware any Ano-Vaginal Fistulas)
- Normal Genitalia
Palpation:
- Fontanelles (Ant, Post & 2x Laterals; Beware Bulging = Hydrocephalus, & Sunken = Dehydration)
- Cleft Palate
- High-Arched Palate (Marfan’s)
- Rooting Reflex (Stroke Cheek → Baby Turns Head to That Side)
- Palmar Grasp Reflex
- Femoral Pulses (120-180bpm)
- Hip Examination (Push down onto hips through the femur with 90o Hip Flexion, then abduct both hips. Feel
for clicking/dislocation)
o “Barlow’s Hip” = Hips dislocate with the above manoeuvre
o “Ortalana Hip” = Hip/s are already dislocated
- Muscle Tone (Beware a Floppy Baby)
- Spine – Neural Tube Defects (Spina Bifida)
Auscultation:
- Heart Sounds:
o *Rate
o Murmurs are Normal
o ?Dextrocardia
- Lung Sounds:
o Crackles
o Wheezes
o Stridor
- Bowel Sounds:
o Present
o Absent
Measurements:
- Head Circumference → Record on Growth Chart (*Bad if >90th/<10th Centile)
- Length → Record on Growth Chart (*Bad if >90th/<10th Centile)
- Weight → Record on Growth Chart (*Bad if >90th/<10th Centile)
- BSL
INFANT RESPIRATORY DISTRESS
- (>23 wks & <500g = NON-Viable. Ie: A Miscarriage [Not obligated to resuscitate])
- (>24wks & >500g = Viable. Ie: A Birth [Obligated to resuscitate])
Other Causes:
Transient Tachypnoea of the Newborn (Not pathological)
Aspiration (Meconium, Milk, Blood)
Pneumothorax (Overventilation) → Requires pleural tap @ 2nd ICS
Pleural Effusion (Heart failure, Anaemia, Congenital Heart Failure)
Rarer Causes:
Cystic Fibrosis
Congenital Cyanotic Heart Diseases
Muscle Weaknesses (Myasthenia Gravis, Muscular Dystrophies, etc)
(#1 Pre-Term Cause) Surfactant Deficiency (Hyaline Membrane Disease)
(#1 Term Cause) Infection (Pneumonia) with Group B Strep, or Chlamydia
(#1 Post-Term Cause) Meconium Aspiration (Meconium is produced later once the gut is
developed)
Signs of Decompensation:
- Bradycardia
- Cyanosis
- Desaturation
Source: thecalgaryguide.com
NEONATAL JAUNDICE & KERNICTERUS
- Aetiology:
o Neonatal Jaundice due to:
§ ↑RBC Breakdown
§ & ↓Ability of Liver to Conjugate Bilirubin
- Pathogenesis:
o Neonates have shorter-living RBCs (Ie: ↑RBC Breakdown) & Immature Livers with limited
Conjugation Capacity → → Hyperbilirubinemia(Unconjugated)
o Note: If Bilirubin levels are Extreme, it can collect in Brain Tissue
§ →→ Brain Damage & Deafness
- Morphology:
o Macro:
§ “Kern”-“Icterus” = “Yellow Nuclei” = Yellowing of the Basal Ganglia & Thalamus
- Clinical Features:
o Jaundice Within 1st week of life
o Poor Feeding
o Hypersomnolence
o Absent Startle Reflex
o Bulging Fontanel
- Complications:
o High-Frequency Deafness
o Mental Retardation, Speech Difficulties
o Seizures
- Treatment:
o Phototherapy
o Exchange Transfusions
o Vitamin K
Extensive yellowing in the basal ganglia, thalamus, cerebellum, tegmentum (A) and floor of the ventricles (B)
Kernicterus; Autopsy and case reports, vol. 9, no. 1, e2018057, 2019, DOI: https://doi.org/10.4322/acr.2018.057
COMPLICATIONS OF LABOUR AND DELIVERY
COMPLICATIONS OF LABOUR AND DELIVERY
SHOULDER DYSTOCIA:
- What is it?
o Foetal shoulder impacted above pubic symphysis after foetal head has been delivered
- Aetiology:
o Occurs when width of shoulders is greater than the biparietal diameter of the head
o Risk Factors:
§ Maternal Obesity / Diabetes
§ Prolonged gestation
§ Macrosomia
§ Prolonged 2nd stage of labour
- Presentation:
o Turtle sign: Head is delivered but the retracts against the pubic symphysis
o Complications:
§ Foetal hypoxic encephalopathy
§ Brachial plexus injury
§ Fractures (Clavicle/humerus/c-spine)
§ Death
§ PPH
§ Uterine rupture
- Management:
o Set of manoeuvres designed to displace anterior shoulder from behind pubic symphysis
o (Other options include: Cleidotomy, Zavanelli manoeuvre, or symphysiotomy)
- Prognosis:
o 1% risk of disability for infant
https://www.rcog.org.uk/en/patients/patient-leaflets/shoulder-dystocia/
McRobert’s Manoeuvre:
https://www.birthinjuryhelpcenter.org/umbilical-cord-prolapse.html
UTERINE RUPTURE:
- Aetiology:
o 40% - Previous uterine scar ruptures
o Also, hyperstimulation with oxytocin / grand multiparity
- Presentation:
o Prolonged Foetal Bradycardia
o Acute, lower abdominal pain
o Vaginal bleeding
o Intra-abdominal haemorrhage
o Sudden loss of foetal descent
- Management:
o Immediate delivery of foetus is required for survival
o May require hysterectomy
o Treat shock/hypovolaemia
- Prognosis:
o 1-10% maternal mortality (haemorrhage, shock, DIC, amniotic fluid embolus)
o Up to 50% foetal mortality
Unattributable
CHORIOAMNIONITIS:
- Aetiology:
o Placental Infection
o Risk Factors:
§ Premature Birth
§ PPROM
§ PROM
§ Prolonged Labour
- Pathogenesis:
o Infection & inflammation of the Chorionic Membrane & Villi due to:
§ Ascending Infection from Vagina (Vaginal Flora, Candida, etc)
§ Blood-Spread from Systemic Infection (HSV, Syphilis, Toxoplasmosis, Rubella, CMV)
- Morphology:
o Macro:
§ May have Abscess Formation
o Micro:
§ Inflammation of Chorionic Plate (WBCs)
§ Vasculitis of Umbilical Vessels
§ Infarctions
- Clinical Features:
o Maternal Symptoms:
§ Fever
§ Uterine Tenderness
o **Neonatal Complications – (TORCHS Syndrome: Toxoplasmosis, Rubella, CMV, Herpes, Syphilis):
§ Neonatal Sepsis
§ Neonatal Asphyxia
§ Microcephaly
§ Brain Damage/Hearing Impairment
§ Neonatal Organomegaly
§ Miscarriage/Death
- Treatment:
o IV Antibiotics (Ampicillin + Gentamicin) + (Clindamycin)
o + Induction of Labour
- Prognosis:
o Low maternal mortality if treated
o Significant Risk of Neonatal Complications
https://coreem.net/core/infections-in-pregnancy/
OPERATIVE OBSTETRICS
OPERATIVE OBSTETRICS
Contraindications:
- Non-vertex cephalic presentations (Eg: Brow or face presentations)
- Non-engaged head
- Incompletely dilated cervix
https://ranzcog.edu.au/womens-health/patient-information-resources/assisted-birth
EPISIOTOMY:
- What is it?
o Incision to the perineum at the time of delivery
- Indications:
o Goal is to relieve obstruction of the perineum
o Or to expedite delivery (Eg: Foetal distress)
- Complications:
o Infection
o Haematoma
o Rectovaginal fistula formation
o Incontinence
https://elearning.rcog.org.uk//easi-resource/vacuum-extraction/delivery/assessing-need-episiotomy
Episiotomy Repair
Source: https://www.pregnancybirthbaby.org.au/caesarean
PUERPERAL COMPLICATIONS
PUERPERAL COMPLICATIONS
Risk Factors:
- Intrapartum:
o Prolonged Labour (→ Tired Uterus)
o Trauma (Instrumental/Tears)
o Caesarean Section
o Tocolytics during labour (→ ↓Contractility of Uterus)
o Dystocia (→ Prolonged Labour / ↑Risk of Tearing)
- Postpartum:
o Previous Hx of PPH
o Bleeding Disorders (Including Anticoagulation)
o Multiparity (→ Stretched Uterus)
§ Including Multiple Pregnancy (Eg: Twins/Triplets/etc)
§ Including Polyhydramnios
§ Including Macrosomia
o Chorioamnionitis
o Placental Abnormalities
§ Accreta (Abnormally Deep Placenta – Into Myometrium; 1/500 pregnancies)
§ Praevia (Placenta Close/Covering Cervical Canal)
§ Placental Abruption
o RPOC - Retained Products of Conception
Management:
- Minor PPH (500-1000mLs) (5-15% Incidence)
o Assess
o 1x Large Bore IVC
o Resuscitate with Fluids (Crystalloids)
o Call for help (Registrar/Consultant)
o Bloods: Group & Hold, X-Match, Rhesus status, FBC (Baseline Hb)
o Give Syntocinon
o Massage Fundus (of Uterus) → Expels Clots/RPOCs
o Manual Removal of RPOCs
o Bimanual Compression if bad
o +Treat Cause
- Major PPH (>1000mLs) (1-3% Incidence)
o All of Above; PLUS:
o Call Operating Theatre
o Call Anaesthetist
o Additional Large Bore IVC
o IDC – Monitor Urine Output
o Additional Oxytotics (Ie: Syntocinon/Syntometrin/Ergometrin)
o Blood Transfusion/s:
§ Packed Red Cells
§ FFP
§ Cryoprecipitate
o + Treat Cause
Goals of Treatments:
- 1: Stop Bleeding:
o Tone
§ Oxytotics: (Syntocinon/Syntometrin/Ergometrin)
§ Prostaglandins: (Misoprostol, PGF2a Injection)
§ Bimanual Compression
§ Theatre:
• Balloon Tamponade
• “B-Lynch Suture”
• Uterine Artery Ligation
• Hysterectomy
o Tissue (Manual/Surgical Removal of Incomplete RPOCs)
o Trauma (Repair tears/Uterine Ruptures/Cervical Rupture/etc)
o Thrombin (Give FFP infusion)
- 2: Transfuse (Usually by Anaesthetist):
o Packed RBCs (4-6 Units)
o FFP (4 Units [per 6units of RBCs])
o Platelets
o Cryoprecipitate/Recombinant Factor-VII
- 3: Close Monitoring in ICU for Organ Failure:
o BP
o Urine Output
SECONDARY PPH
(>24hrs after labour → 6-12mths later)
Causes:
- Infection
- RPOC
- Gestational Trophoblastic Diseases (Rare)
o Eg: Molar Pregnancy
o Eg: Invasive Trophoblastic Disease
o Eg: Choriocarcinoma
o Eg: Placental Site Tumour
Presentation:
- Typically slower bleed (A Trickle)
Management:
- Curette for RPOC
- Antibiotics
- Β-HCG (check for molar pregnancy)
- Pelvic USS
Example of management algorithm for PPH
(Note: Please follow your local therapeutic guidelines)
RETAINED PLACENTA:
- What is it?
o Placenta still not delivered by 30mins post-partum
- Aetiology:
o Placenta may have abnormal implantation:
§ Eg: Placenta accreta
§ Eg: Placenta increta
§ Eg: Placenta percreta
- Risk Factors:
o Placenta previa
o Prior caesarean
o Uterine infection
- Clinical Features:
o Increased Risk of PPH
o Increased risk of infection
- Investigations:
o Uterus exploration
- Management:
o 2x large bore cannulae
o Blood group and X-match
o ‘Brant manoeuvre’ (firm umbilical traction + suprapubic pressure to avoid uterine inversion)
o Oxytocin into umbilical vein
o Manual removal if otherwise unsuccessful
o D&C if required
https://www.aafp.org/afp/2017/0401/p442.html
POSTPARTUM CARE
POSTPARTUM CARE
Breast Feeding
- Lactation = production of milk by mammary glands
- During late pregnancy, high levels of estrogens, progesterone & lactogen → stimulates hypothalamus –
secrete prolactin-releasing hormone (PRH) → Anterior Pituitary secretes prolactin
- For first 3 days – colostrum is secreted (less lactose than milk & minimal fat – but contains more protein, Vit-
A & minerals) – Rich in IgA antibodies
- After first 3 days – true milk production begins
o Milk production depends on mechanical stimulation of nipples – sucking infant
§ Stimulates hypothalamus → secretes PRH → burst of prolactin from Anterior Pituitary
→stimulates milk production for the next feeding
§ Also stimulates hypothalamic→posterior pituitary release of oxytocin (OT) – causes the let-
down reflex, the actual ejection of milk from alveoli in both mammary glands
• Oxytocin also causes uterus to contract → to return to normal size
https://www.contemporaryobgyn.net/view/counseling-complex-contraception-dilemmas-case-2
THE 3 POSTNATAL MOOD DISORDERS:
1. “THE BABY BLUES” (MILD)
a. Affects <80% of new mothers
b. Typical onset between Day 3-10 after birth
c. Symptoms:
i. Tearfulness
ii. Anxiety
iii. mood swings
iv. irritability
d. Treatment:
i. “The Baby Blues” are transient and pass with supportive therapy
2. “POSTNATAL DEPRESSION” (MODERATE)
a. Affects 15% of women and 10% of men
b. Onset anywhere from 24 hours-several months after delivery
c. Symptoms:
i. Insomnia
ii. Anorexia
iii. Crying
iv. Acopia with daily tasks
v. Exhaustion
vi. Irritability
vii. Anxiety
viii. Fear of social contact
ix. Fear of being alone
x. Guilt
xi. Low confidence
xii. Suicidal thoughts
xiii. “There is no joy in anything anymore”
d. Treatment:
i. Emotional support from family and friends
ii. Antidepressants are also effective
3. “POSTNATAL PSYCHOSIS” (SEVERE)
a. Affects 1 in 500 mothers
b. Onset within the 1st month of delivery
c. Symptoms:
i. The mother may be unaware she is ill (Due to psychosis)
ii. Severe mood disturbance (Manic and/or Depressive)
iii. Thought disturbance (either processing or bizarre thoughts)
iv. Insomnia
v. Inappropriate responses to the baby
vi. Can be LIFE THREATENING for both mum & bub if undiagnosed
d. Treatment:
i. Requires hospitalisation
ii. Anti-psychotics and/or Antidepressants
POSTNATAL/POSTPARTUM DEPRESSION
General Overview
- = Non-psychotic depression occurring within 4-wks following delivery
- Typically lasts 2-6mths
- If severe, can lead to aversion to baby, suicidal and infanticidal ideation
- Affects 12-15% of mothers
- <50% recurrence rate
Presentation:
- Anxiety/Depression
- Referral from external source (Midwives, community health)
- Inability to cope
- Husband/family member presents with concerns
- Somatic Symptoms
- Issues with children
- Irritability & Tearfulness
- Avoiding personal discussion
- Denial
- Delayed attachment
- Negative feelings to infant
Risk Factors:
- Minority groups
- Lower Socio-economic status
- Younger age
- Absence of partner
- Medical complications
- Marital problems
- History of abuse
- Not breast-feeding
- No job to return to
- Problematic births
- Reluctance to seek help
Protective Factors:
- Optimism & Self esteem
- Higher education
- Good SES
- Strong relationship with partner
Screening:
- K10 Score (previously discussed)
- EPDS - Edinburgh postnatal depression scale (10qs, 5mins, responses graded)
Management:
- Psychotherapy (Eg: CBT)
- Pharmacological (Eg: SSRI’s)
- If severe/psychotic, consider ECT
Effect on Infant:
- Insecure infant – lack of trust, poor interaction with caregiver
- Attachment issues – discipline, behaviour & aggression problems
- Infant withdrawn, passive
- Slow to reach milestones
- High risk of mental health issues in child
Other Postpartum Distresses:
- Post-partum Anxiety
- Postpartum OCD
- Postpartum Psychosis (Hallucinations & Delusions)
- Baby Blues
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