o&g Teaching2

8/13/2019 o&g Teaching2

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Pregnancy Problems & Fetal

Growth


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Early Pregnancy


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Case: 8 weeks pregnant & vomiting ++

A 2!year!ol" primigravi"a presents at 8 weeks#gestation with a history o$ na%sea an" vomiting $orthe last 2 weeks 'owever( over the past )8 h she

in"icates that she has been %nable to keep any $oo"or "rink "own


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'yperemesisgravi"ar%m *m%ltiple

pregnancy( molar

pregnancy(thyrotoicosis,

-./ Gastroenteritis

Appen"icitis

0are problems: bowelobstr%ction( hepatic

"isr"ers( cerebralt%mo%rs

11


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'istory

Pregnancy an" vomiting o$ all $oo" an" "rink s%pport the "iagnosis o$hyperemesis( partic%larly in the $irst trimester

Ac%te onset o$ the problem wo%l" s%pport a "iagnosis s%ch asgastroenteritis or appen"icitis

A longer "%ration o$ the symptoms with pre!eisting na%seavomitingwo%l" s%pport a "iagnosis o$ hyperemesis

Associate" symptoms *eg "iarrhoea( %rinary symptoms( ab"ominalpain,( other members o$ the $amily with the same problem an" symptomso$ thyrotoicosis wo%l" s%pport a "iagnosis other than hyperemesis


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Eamination

3ook $or evi"ence o$ "ehy"ration *eg "ry mo%th(tachycar"ia or post%ral hypotension,

Ab"ominal signs o$ ten"erness an" g%ar"ing wo%l"

s%pport a "iagnosis o$ appen"icitisA large!$or!"ates %ter%s wo%l" s%ggest m%ltiple

pregnancy as a ca%se o$ hyperemesis


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/nvestigation

4 FBC : Hb, WCC for infection

4 U&Es : Dehydration

4 MSU: exclude U!

4 Urinalysis: "etones # excessi$e $o%itin

4 USS : exclude %olar 'renancy( %ulti'le'renancy

4 )F : )i$er disorders4 SH : exclude thyrotoxicosis* +SH can be

su'ressed in hy'ere%esis


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5anagement

Con"itions other than hyperemesis re6%ire treatment speci$ic to the problem *eg evac%ate molar pregnancywith appropriate $ollow!%p *%rinary an" ser%m 7hCGs an" avoi"ing pregnancy with a"e6%ate contraception%ntil normal 7hCGs have been obtaine"

H-.E/EMES!S:

SU..0/!1E

A"mit the patient to hospital

0eass%re her that this problem is likely to resolve spontaneo%sly at 29) weeks when 7hCG levels start to"ecline

$$er psychological s%pport

MED!C2)

/ntraveno%s $l%i"s

Antiemetics *prochlorpera;ine( intram%sc%lar s%ppository< intram%sc%lar metocloprami"e< intraveno%s

on"ansetron,/ntro"%ce $oo"s as appropriate in small amo%nts 9 avoi" $atty $oo"s

=teroi"s may be given in severe cases

>itamin s%pplementation *vitamin ? i$ prolonge" vomiting occ%rs,

5ay occasionally re6%ire parenteral n%trition


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Case: ?lee"ing in Early Pregnancy

A 2@!year!ol" n%lliparo%s woman has ha" weeks o$amenorrhoea =he has not been %sing anycontraception =he normally has a reg%lar menstr%alcycle every 28 "ays A pregnancy home test ispositive =he has notice" slight vaginal spotting


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5iscarriage

threatene" miscarriages 'renant and bleedin $ainally

A 2)!year!ol" woman atten"s the mi"wi$e at @8weeks# gestation =he has ha" two previo%s%ncomplicate" "eliveries( an" she is concerne" thatover the past $ew "ays she has been having a small

amo%nt o$ $resh vaginal blee"ing intermittently =hehas no ab"ominal pain an" the baby is active


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'istory

PC: at%re + onset o$ pain *history o$ painlesssmall blee"s s%pports the "iagnosis o$ placentapraevia, Constant( severe + backache

' o$ present Pregnancy: 15( Preeclampsia(previo%s -==s in this pregnancy! i"enti$y thelocation o$ the placenta

Past bstetric: Previo%s complications 9 PA( PP

Past 5e"icalGynae=%rgical: Cervical smear h

=ocial: =moking( Cocaine %se


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Eamination

P%lse & ?P sho%l" be recor"e"

Ab"ominal palpation: so$t non!ten"er %ter%s( high presenting partan" an abnormal lie s%pporting a "iagnosis o$ placenta praevia( an" atense ten"er Hwoo"yI %ter%s s%pporting a "iagnosis o$ placentalabr%ption

Fetal heart a%sc%ltation ! to ecl%"e $etal "istress( which is morecommonly associate" with placental abr%ption *Also( when $etalparts "i$$ic%lt to palpate( F'= "i$$ic%lt to hear,

/$ con$irme" that the placenta is not low *by -==,( a spec%l%m

eamination to vis%ali;e the cervi wo%l" be in"icate" -n"er nocirc%mstances sho%l" a "igital eamination be per$orme"( beca%setorrential blee"ing can be provoke" i$ a placenta praevia has $alselybeen ecl%"e" as a ca%se


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/nvestigations & 5naagement

'elp: bstetricianAnaesthetist

Airway( ?reathing( Circ%lation JJ

FBC : anaemia

Blood rou' and cross4%atch: trans$%sion is re6%ire" patientsho%l" be given anti!1 i$ her bloo" gro%p is rhes%s negative toprevent isoimm%ni;ation

USS : locali;e the placenta an" "etermine whether it is low lying(

as well as to assess $etal growth an" well!being

C3 : i"enti$y s%specte" $etal compromise

/n case blee"ing increases an" a .he


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5anagement

/$ term + AP' 9 "elivery Caesarean section sho%l" be per$orme" incases o$ maKor placenta praevia

Consi"er eamination witho%t anaesthesia an" arti$icial r%pt%re o$membranes in cases with minor "egrees o$ placenta praevia .hisproce"%re sho%l" be per$orme" in an operating theatre with a senior

anaesthetist present an" rea"y to a"minister a general anaesthetic toepe"ite "elivery i$ blee"ing is provoke" on vaginal eamination

/$ PA is s%specte" *base" on the absence o$ a low lying placenta onscan( normal appearance o$ the cervi on spec%l%m, + no evi"ence o$$etal compromise( an A05 sho%l" be per$orme" an" an oytocin

*=yntocinon, in$%sion commence" with contin%o%s monitoring o$ the$etal heart beca%se o$ the increase" risk o$ $etal hypoia


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0isks o$ antepart%m haemorrhage

'aemorrhage an" shock

0enal $ail%re

1isseminate" intravasc%lar coag%lation *1/C,

Fetal hypoia

/ntra%terine "eath


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Case: ! ha$e not felt %y baby %o$e since yesterday?

A @D!year!ol" paro%s woman at @ weeks# gestation has not$elt any $etal movements on the "ay when she presents to the"octor Fetal movements ha" been becoming less $re6%entover the last $ew "ays( b%t she ha" not been recor"ing them=he previo%sly ha" two normal "eliveries at term o$ babies o$

normal weight /n this pregnancy her scans showe" a singleton$et%s consistent with menstr%al "ates at 2 weeks an" with no$etal anomaly at 2D weeks 'er screening $or 1own#s syn"rome

was reporte" as low risk =he has been manage" as a low!riskpatient( beca%se her pregnancy has progresse" witho%t anyproblems


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Prolonge" perio"s o$ $etal sleep witho%t anycompromise

Fetal compromise

Fetal "eath


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'istory

/n most cases with the given history there is nopartic%lar obstetric problem /n this case( thepregnancy ha" been %ncomplicate" 0e"%ce"movements ha" been reporte" over several "ays(

which wo%l" warrant $%rther investigation in or"erto ecl%"e $etal compromise or "eath

.he history sho%l" eplore whether there are anyreasons *eg hypertension( "iabetes( $etal growthretar"ation an" haemorrhage, $or concern abo%t$etal compromise


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Eamination

A general eamination( incl%"ing p%lse( temperat%re*sepsis associate" with intra%terine $etal "eath, an" bloo"press%re *associate" pre!eclampsia,( is re6%ire" .heab"omen sho%l" be eamine" to "etermine the

symphysio$%n"al height( an" clinical assessment o$ li6%orvol%me sho%l" be ma"e *$etal compromise is associate"with growth restriction an" re"%ce" li6%or vol%me, .ryto stim%late $etal movements by gently moving the $et%saro%n" at the time o$ ab"ominal palpation 3isten to the

$etal heart to ecl%"e $etal "eath *i$ yo% hear silence thiswill nee" to be con$irme" by %ltraso%n",


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/nvestigations

Urinalysis : ecl%"e protein%ria to "etect pre!eclampsia

C3 : assess $etal well being

USS : *, check $etal heart rate an" *2, assess $etalwell!being by assessing li6%or vol%me( $etalmovements *which may not be perceive" by thepatient,( $etal tone( $etal respiration an" %mbilical

1oppler *absent or reverse" "iastolic $low,biophysical pro$ile


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5anagement

Con$irm $etal well!being( an" i$ this is satis$actory the patient can be"ischarge" home with a"vice to recor" "aily $etal movements *%sing a kickchart, /$ there are $ewer than D movements over a 2!h perio"( the patient

will nee" to ret%rn $or a C.G

4 /$ there is $etal growth retar"ation( investigations will have to be

per$orme" to "etermine the ca%se /n a""ition( as the pregnancy isapproaching term( "elivery may be contemplate"

4 /$ $etal "eath is con$irme"( me"ical in"%ction o$ pregnancy sho%l" becon"%cte" together with appropriate investigations *$etal postmortemeamination( chromosome analysis o$ $et%s an" parents( anticar"iolipinantibo"ies( l%p%s an" in$ection screen, an" bereavement co%nselling

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