Ward Rounds in Obstetrics and Neonatology

Tania Gurdip SinghMS (Obs and Gyne) Fellowship in Gynecological Endoscopy

Bodyline Trauma and Maternity CenterNew Delhi, India

Earl Gaganjot JaspalMBBS MD (Ped) PGPN (Boston, USA)

Consultant Pediatrician and HeadDepartment of Neonatology

Government HospitalAmbala, Haryana, India

New Delhi | London | Philadelphia | Panama

The Health Sciences Publisher

ForewordNutan Jain

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Jaypee Brothers Medical Publishers (P) Ltd

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Ward Rounds in Obstetrics and Neonatology

First Edition: 2016

ISBN 978-93-85891-65-6

Printed at

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Dedicated toOur daughter Aira, who is the ultimate source of motivation

and is a real boost in whatever we do, including this work

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Foreword

When I got the invitation to write foreword for this book, the first thought in my mind was “to read this book” because of very attractive name of the book. This book makes a solid base for MBBS, postgraduates, interns, and nursing students. After reading, I was so happy about it as it was more than what I expected. The book goes in a soft flow of rounds, OPD, antenatal ward, labor room and ending up in neonatal unit. In the section of obstetric emergency, I had developed a feeling that I am present at bedside and participating in revival of the patient. Tricky situations demanding blood transfusion and proper fluid management are dictated in such a simple manner which will raise confidence of reader ‘yeah, I can also do’. The most appreciable thing of this book is its limited length and simple language. It is amazing how the whole obstetrics and neonatology is covered in around 360 pages so fluently. Students generally struggle with multiple different books, just to find out few details or some special points which they can write down or mumble in their exams. Dr Tania Singh and Dr Earl Jaspal has reduced all their struggle and tension due in their examinations, by involving all the chapters and details in very concise form in their book. Students can go through a rapid reading and revision of this book. I must congratulate Dr Tania Singh and Dr Earl Jaspal for this rewarding hard work which will definitely help students and nursing staff who are really in need of such guidance. It will also have a place of honor in my library.

Nutan Jain MS (Obs and Gyne) Vardhman Trauma and Laparoscopy Centre Pvt Ltd

Muzaffarnagar, Uttar Pradesh, India

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Preface

Ward Rounds in Obstetrics and Neonatology extensively covers all bedside cases which are routinely met in obstetrics and neonatology, wherein main stress is laid only on diagnosis and management in wards. It does not include the time consuming etiology and pathogenesis of any disease.The book has been presented in two sections. Section 1: Obstetrics covers all the aspects related to OPD Rounds, Antenatal Cases in High-risk and Low-risk Patients, Labor in High-risk and Low-risk patients, Obstetric Emergencies, Infections in Obstetrics, Blood Transfusion and Fluid Management. Section 2: Neonatology has been added to cover all current and practical approaches in management of problems encountered in neonatal care including Prematurity and Low Birth Weight, Perinatal Asphyxia, Meconium Aspiration Syndrome, Sepsis, Neonatal Seizures, Hypoglycemia, Hypocalcemia, Fluid and Electrolyte Management, Neonatal Jaundice, Bag and Mask Ventilation and routine procedures in neonatal nursery. The book will make the ward rounds easy for students as the chapters are very small each consisting of 3–5 pages on an average. Section on OPD rounds will enable a student to counsel any patient attending obstetric OPD. A complete chapter is provided only on HIV counseling. The basic aim of this book is to provide complete and latest information in a simplified manner with focus on quality rather than quantity. The information provided in each chapter has been condensed in an easy-to-read format with a point- wise description and important points are highlighted in side boxes to allow quick but at the same time, proficient understanding of the material. This book has been exclusively designed for medical students, residents, postgraduates, fellows, interns, consultants and nursing staff working in both government and private set-up. The information provided is up-to-date and include latest protocols and clinical knowledge in fields of obstetrics and neonatology. We hope this book will provide a better understanding of basic concepts and bedside clinical approach related to all topics in management of obstetrics and neonatology.

Tania Gurdip Singh Earl Gaganjot JaspalJa

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Acknowledgments

We take this opportunity to thank all our teachers, friends and well-wishers, that is very much justified at this stage of the completion of our book. It is our great privilege, though finding words inadequate to express our indebtedness and deep gratitude to Dr Nutan Jain. Her never-ending willingness to render help, loving guidance, coupled with her rich knowledge and keen interest, were a constant source of inspiration for us throughout. We are deeply grateful to all our revered teachers and shall ever remain obliged to them. We are very grateful to Shri Jitendar P Vij (Group Chairman) and Mr Ankit Vij (Group President) for showing trust in us and getting this book published. We are sincerely thankful to Mr Tarun Duneja (Director–Publishing), Ms Samina Khan (Executive Assistant to Director–Publishing), Ms Seema Dogra (Cover Designer), Ms Hansika Seth (Copy Editor) Ms Ritu Verma (DTP Operator) of M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India, who rendered great help in the completion of this project. We shall be failing in our duty if we do not acknowledge with a deep sense of gratitude, all our patients, from whom we have learnt a lot. We cannot express in words the indebtedness we owe to our dearest parents, without whose inspiration and blessings, this work could not have been accomplished. Wholeheartedly, we are very thankful to them and entire credit goes to them. We owe our sincere admiration and thanks to Dr Gagandeep Anand and Dr Nisha Munjal Anand, for their contribution. Their valuable and constructive suggestions were the mainstream to bring this work to the present shape. And finally, we thank God for everything and pray for His continued blessings and success.

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Contents

OBSTETRICS

I. OPD Rounds 3

1. Preconceptional History and Counseling 52. Prepregnancy Counseling in a Cardiac Case 73. General History Taking 94. Routine Antenatal Checkup and Advice 115. Blood Pressure Measurement 166. Weight Gain in Pregnancy 177. Symphysis-Fundal Height Measurement 188. Gestational Age Calculation (Good Dates/Bad Dates) 209. Routine Investigations in Pregnancy 2210. Tetanus Toxoid in Pregnancy 2611. Diet in Pregnancy 2712. Advice on General Ailments in Pregnancy 3013. HIV Counseling 3214. Pelvic Assessment 3515. Twin Gestation Assessment 3716. Recurrent Pregnancy Loss Assessment 3917. Rh Negative Pregnancy 4018. Hypothyroidism in Pregnancy 42

II. High-risk Antenatal Ward Rounds 45

19. Iron Deficiency Anemia in Pregnancy 4720. Thalassemia in Pregnancy 5621. Megaloblastic Anemia 6122. Sickle Cell Disease (SCD) 6423. Medical Management of Tubal Ectopic Pregnancy 6924. Abortions 7425. Placenta Previa 7826. Placental Invasion (Accreta, Increta, Percreta) 8127. Previous LSCS 8328. Twin Pregnancy (Antenatal Management) 8629. Hypertensive Disorders in Pregnancy 91

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Ward Rounds in Obstetrics and Neonatologyxiv

30. Chronic Hypertension 94 31. Intrauterine Growth Restriction 96 32. Intrauterine Fetal Death 98 33. Diabetes in Pregnancy 101 34. Intrahepatic Cholestasis of Pregnancy 109 35. Antiphospholipid Antibody Syndrome (APAS) 112 36. Post-term Pregnancy 116 37. Polyhydramnios 118 38. Oligohydramnios 120 39. Cardiac Disease in Pregnancy 122 40. Macrosomia 125

III. Attending Obstetric Emergencies 127

41. Management of Incomplete Abortion 129 42. Ruptured Ectopic Pregnancy 130 43. Abruptio Placenta 132 44. Massive and/or Repeated Hemorrhage in Placenta Previa 135 45. Impending Eclampsia 137 46. Eclampsia 139 47. Epileptic Fit in Pregnancy 144 48. Preterm Labor 146 49. Postpartum Hemorrhage 149 50. Disseminated Intravascular Coagulopathy (DIC) 153 51. HELLP Syndrome 155 52. Acute Fatty Liver of Pregnancy 157 53. Uterine Rupture in Previous LSCS 159 54. Acute Manifestation of Sickle Cell Disease 161 55. Acute Cholecystitis/Acute Appendicitis/Degenerating Myoma/Rupture of Ovarian Cyst 163 56. Cardiac Arrest in Pregnancy 165

IV. Labor Ward Rounds 167 Labor in High-risk Patients

57. Labor in Anemia Patient 169 58. Vaginal Birth after Cesarean Section 171 59. Twin Vaginal Delivery 172 60. Vaginal Breech Delivery 175 61. Labor Management in Hypertensive Disorders 178 62. Monitoring Labor in a Diabetic Mother 179 63. Management in Molar Pregnancy 181 64. Management of Cardiac Patient in Labor 183

Labor in Low-risk Patients

65. Preinduction Score or Modified Bishop Score or Prelabor Scoring 184 66. Induction of Labor 185 67. First Stage of Labor 188 68. Second Stage of Labor 189

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Contents xv

69. Labor Analgesia and Anesthesia 191 70. Use of a Partograph 193 71. Cardiotocograph Monitoring in Labor 196 72. Fetal Blood Sampling 198 73. Meconium-stained Liquor 199 74. Third Stage of Labor 200 75. Perineal Care after Birth 201

V. Postnatal Ward Rounds 203

76. General Postnatal Care 205 77. Breastfeeding Advice 208 78. Complications after Cesarean Section 211 79. Postpartum Advice in High-risk Patients 214

VI. Ward Rounds in Antenatal and Postnatal Infections 217

80. Septic Abortion 219 81. TORCH Infection in Pregnancy 220 82. Malaria in Pregnancy 224 83. Tuberculosis in Pregnancy 226 84. Acute Pyelonephritis in Pregnancy 228 85. Acute Gastroenteritis in Pregnancy 229 86. Typhoid in Pregnancy 231 87. Chorioamnionitis in Pregnancy 233 88. HIV in Pregnancy 235 89. Hepatitis B Infection in Pregnancy 238 90. Puerperal Sepsis 241 91. Breast Infections in Puerperium 246 92. Operative Site Infections 249

VII. Blood Transfusion and Blood Components 251

93. Blood Transfusion and Blood Components 253

VIII. Fluid Management 259

94. Fluid Management 261

NEONATOLOGY

IX. Essential Newborn Care 265

95. Normal Newborn 267 96. APGAR Scoring 272 97. Bag and Mask Ventilation in Newborns 273 98. Suctioning in Newborns 276 99. Oxygen Therapy in Neonates 278 100. Preterm and Low Birth Weight Babies 282 101. Respiratory Distress Syndrome in Newborn 286 102. Transient Tachypnea of the Newborn (TTN) 293

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Ward Rounds in Obstetrics and Neonatologyxvi

103. Neonatal Jaundice 295104. Phototherapy 298 105. Exchange Transfusion 300 106. Thermoregulation 303 107. Perinatal Asphyxia 306 108. Meconium Aspiration Syndrome 312 109. Hypoglycemia in Newborns 316 110. Hypocalcemia in Newborns 320 111. Intrauterine Growth Retardation 323 112. Convulsions/Seizures in Newborns 327 113. Neonatal Sepsis 331 114. Apnea of Prematurity 336 115. Fluid and Electrolyte Management in Newborns 341 116. Feeding in Low Birth Weight Babies 346 117. Intravenous Cannulation in Neonates 350 118. Blood Sugar Estimation in Newborns 353

Index 355

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ACE Inhibitors Angiotensin converting enzyme inhibitorsADH Antidiuretic hormoneAED Antiepileptic drugAFI Amniotic fluid indexAFV Amniotic fluid volumeAIDS Acquired immunodeficiency syndromeALT Alanine aminotransferaseAnti-TPO Antithyroid peroxidase APFS Antepartum fetal surveillanceaPTT Activated partial thromboplastin time ARM Artificial rupture of membraneART Antiretroviral therapyAST Aspartate aminotransferase BMI Body mass indexBT Blood transfusionCA Cholic acid CAD Coronary artery diseaseCBC Complete blood countCCT Controlled cord tractionCDCA Chenodeoxycholic acidCFT Capillary filling timeCHC Community health centerCHF Congestive heart failureCIN Cervical intraepithelial neoplasia CMV CytomegalovirusCOC Combined oral contraceptiveCPAP Continuous positive airway pressureCPD Cephalopelvic disproportionCPR Cardiopulmonary resuscitationCTG CardiotocographyCVS Chorionic villus sampling; Cardiovascular systemDBP Diastolic blood pressureDCA Deoxycholic acidDFKC Daily fetal kick countDIC Disseminated intravascular coagulopathyDM Diabetes milletusDNA Deoxyribonucleic acidDV Doppler Ductus venosus DopplerDVT Deep vein thrombosisECV External cephalic versionEDD Expected date of deliveryEEG ElectroencephalographyEFW Estimated fetal weight

Abbreviations

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EPO ErythropoietinFHR Fetal heart rateg gauzeG6PD Glucose 6 phosphate dehydrogenaseGFR Glomerular filtration rateGGT Gamma glutamyl transpeptidaseGI GastrointestinalGIT Gastrointestinal tractgm gramsGTCS Generalized tonic-clonic seizureGTN Gestational trophoblastic neoplasiaHb HemoglobinHC Head circumferencehCG Human chorionic gonadotropinHDL High density lipoproteinsICT Indirect Coomb’s testIM IntramuscularINR International normalized ratioIQ Intelligence quotientIU International unitsIUD Intrauterine death; Intrauterine deviceIUGR Intrauterine growth restrictionIV IntravenousIVF In vitro fertilizationIWL Insensible water loss JVP Jugular venous pressureKg KilogramKMC Kangaroo mother care LCA Lithocholic acidLDH Lactate dehydrogenaseLDL Low density lipoproteinsLFT Liver function testLMP Last menstrual period LMWH Low molecular weight heparinLNG IUD Levonorgestrel intrauterine deviceLSCS Lower segment cesarean sectionLV Left ventricleMAS Meconium aspiration synrdromeMCA Middle cerebral arteryMCDA Monochorionic diamnioticmcg MicrogramsMCH Mean corpuscular hemoglobinMCHC Mean corpuscular hemoglobin concentrationMCMA Monochorionic monoamnioticMCV Mean corpuscular volumemEq MilliequalentmL MilliliterMMR Measles, mumps, rubellaMOA Mechanism of actionMRI Magnetic resonance imagingMUFA Monounsaturated fatty acidsNICU Neonatal intensive care unitNPO Nil per osNSAID Nonsteroidal anti-inflammatory drugsNST Nonstress testNTD Neural tube defect

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Abbreviations xix

NYHA class New York Heart Association classOCP Oral contraceptive pillOGTT Oral glucose tolerance testp.o per osPCV Packed cell volumePDA Patent ductus arteriosusPHC Primary health centerPI Pulsatility indexPID Pelvic inflammatory diseasePPBS Postprandial blood sugarPPD Purified protein derivativePPH Postpartum hemorrhagePPROM Preterm premature rupture of membranesPROM Premature rupture of membranesPT Prothrombin timeRBC Red blood cellRDS Respiratory distress syndromeRFT Renal function testRHD Rheumatic heart diseaseRI Resistance indexRNA Ribonucleic acidROM Rupture of membranesRPL Recurrent pregnancy lossRUQ Right upper quadrantSBP Systolic blood pressureSFH Symphysis-fundal heightSGA Small for gestational ageSIADH Syndrome of inappropriate secretion of antidiuretic hormoneSIDS Sudden infant death syndromeSLE Systemic lupus erythematosusSTD Sexually transmitted diseasesTAS Transabdominal scanTBG Thyroxine-binding globulinTFT Thyroid function testTSH Thyroid stimulating hormoneTTTS Twin to twin transfusion syndromeTVS Transvaginal scanUA Umbilical arteryUPT Urine pregnancy testUTI Urinary tract infectionvWF Von Willebrand diseaseFBS Fasting blood sugarJa

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C h a p t e r 1 1 2

Convulsions/Seizures in Newborns

• Seizures occur more frequently in the neonatal period (the first 28 days of life) than at any other time

• Incidence in newborns – 1.5–3.5 per 1000 live term births – 10–130 per 1000 live preterm births.

• Seizures are very common and occur in up to 70% of preterm infants with intraventricular hemorrhage or periventricular leukomalacia.

CAUSES OF NEONATAL SEIZURES • Hypoxic-ischemic encephalopathy (HIE)—most common • Intracranial hemorrhage

– Intraventricular hemorrhage – Intracerebral hemorrhage – Subdural hemorrhage.

• Metabolic disorders – Hypoglycemia – Hypocalcemia – Hypomagnesemia – Hypo- and hypernatremia.

• Central nervous system infection – Bacterial meningitis – Viral meningitis – Encephalitis.

• Intrauterine (TORCH) infections • Inborn errors of metabolism • Drug withdrawal syndromes • Kernicterus • Benign idiopathic neonatal convulsions • Congenital CNS malformations • Idiopathic.

TYPES OF NEONATAL SEIZURESSubtle Seizures

• More common in term babies • Occur in babies with HIE and intraventricular hemorrhage.

Clonic Type • Occurs in 50% cases • More common in term babies

Clinical Signs of Subtle Seizures

 Staring look  Blinking of eyes  Horizontal deviation

of eyes  Chewing movements  Sucking movements  Lip smacking  Repetitive mouth and

tongue movements  Boxing movements  Pedaling movements  Swimming

movements  Tachycardia  Apnea

Earl Jaspal

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Section 9: Essential Newborn Care 328

• Rhythmic jerking movements • Consciousness may be preserved • May be focal, multifocal or generalized depending upon underlying lesion • Focal clonic seizures—good prognosis.

Tonic Type • Occurs in 20% cases • More common in preterm babies • Most common in the first 24 hours of life following hypoxic—ischemic

insult • May be focal or generalized, i.e. involving one limb or the entire body • Presents as sustained extension of the upper and lower limbs or sustained

flexion of upper with extension of lower limbs.

Myoclonic • Rare in newborn period • Present as rapid isolated jerks • May be focal or generalized • Poor prognosis.

INVESTIGATIONS • Septic screen, including blood cultures • Lumbar puncture—CSF analysis • Blood glucose • Serum total and ionized calcium • Serum magnesium • Serum sodium • Serum urea and creatinine • Serum electrolytes • Metabolic screening • Blood ammonia and lactate • TORCH • Ultrasound cranium to rule out intracranial hemorrhage • MRI to confirm the cause of seizures • Electroencephalography (EEG) to predict the risk of electrographic seizures

and prognosis.

MANAGEMENT • Require urgent treatment to prevent brain injury • Maintain TABC, i.e. Temperature (T), Airway (A), Breathing (B), Circulation (C).

Correct Metabolic Disturbances (If Documented) • Hypoglycemia: 2 mL/kg IV bolus of 10% dextrose followed by continuous

intravenous infusion at the rate of 6–8 mg/kg/minute • Hypocalcemia: 2 mg/kg/dose of 10% calcium gluconate IV in 1:1 dilution

with 5% dextrose over 10–15 minutes under cardiac monitoring • Hypomagnesemia: 0.1–0.2 mL/kg of 50% MgSO4 deep I/M.

Anticonvulsant TherapyStart only after adequate ventilation and perfusion have been established.

How to differentiate jitteriness from convulsions?Jitteriness:

 No associated eye movements

 No autonomic changes, i.e. there is no tachycardia, increase blood pressure, apnea, salivation or pupillary change

 Movements start by stimulus or may be spontaneous

 Movements stop by holding the limb

 Predominant movement in jitteriness are tremors which are rhythmic and of equal rate amplitude

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Convulsions/Seizures in Newborns 329

Phenobarbitone • Drug of choice. • Initial Dose: 20 mg/kg IV slowly over 30 minutes • Repeat dose: If seizures persist after completion of this loading dose,

repeat dose of phenobarbitone 10 mg/kg every 20–30 minutes till a total dose of 40 mg/kg

• Maintenance dose: 3–4 mg/kg/day in 1–2 divided doses, started 12 hours after the loading dose

• Note—respiratory depression at higher doses of phenobarbitone • Preparations:

– 200 mg/mL–1 mL ampoule – For slow IV bolus, dilute 1:10 with 0.9% saline and give at a maximum

rate of 1 mg/kg/minute.

Phenytoin Sodium • Indication: If maximal dose of phenobarbitone (40 mg/kg) fails to resolve

seizures • Dose is 20 mg/kg slow IV infusion over 30 minutes • Caution: It should only be mixed with saline and not with dextrose as it

precipitates in dextrose • Repeat dose of 10 mg/kg may be tried in refractory seizures • Maintenance dose is 5–8 mg/kg/d in 2 divided doses, started 12 hours after

the loading dose • Discontinue before discharge • Cardiac rate and rhythm should be monitored during the infusion • Preparations: 50 mg/mL.

Duration of Anticonvulsant Therapy • Neonatal period:

– If neurological examination is normal before discharge—discontinue therapy

– If neurological examination is persistently abnormal—consider etiology, obtain EEG

– In such cases—continue phenobarbitone, discontinue phenytoin and reevaluate after 1 month.

• One month after discharge: – If neurological examination is normal—discontinue phenobarbitone – If neurological examination is persistently abnormal—obtain EEG – If no seizure activity on EEG—discontinue phenobarbitone.

MidazolamIndication

• Babies who continue to have seizures after phenobarbitone and/or phenytoin.

Dose and administration • 0.15 mg/kg IV over minimum of 5 minutes.

Continuous Infusion: • 60–400 micrograms/kg/hour.

Reconstitution and dilution • Dilute 1 mg/kg of midazolam up to a total of 50 mL with 0.9% sodium

chloride, 5% glucose or 10% glucose: 1 mL/hour = 20 micrograms/kg/hour.

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Section 9: Essential Newborn Care 330

DOCUMENTATIONDocument each episode of seizure in neonatal case record sheet.This should include:

• Date of seizure • Time of seizure • Duration of each seizure • Type of seizure (subtle, tonic, clonic, myoclonic and focal or generalized) • Any abnormal eye movements • Associated autonomic system changes, e.g. apnea, hypotension, hyper-

tension • Any provoking stimulus, e.g. handling, noise • Treatment given • Dose and route of the drug • Response to treatment.

PROGNOSIS • Depends on underlying etiology • Hypocalcemic seizures—excellent prognosis • Symptomatic hypoglycemia and meningitis—50% chance of sequelae • Hypoxic ischemic encephalopathy—prognosis depends on the grade of

HIE • CNS malformations—poor prognosis.

Complications of Neonatal Seizures

 Cerebral palsy  Hydrocephalus  Epilepsy  Learning disability  Mental retardation  Feeding difficulties

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