Comprehensive Overview of Pregnancy and Delivery Complications
| I: Start of Contraction to Full Dilation | II: Full Dilation to Delivery– Null 2 Hours!– x 1 Hour!– Using Analgesics extend it to 1 hour more! | III: Delivery to Placenta Release 30 min |
Latent:
| Propulsive:
| ^^Med Care:
|
| W 11-13 | W 18-20 |
All Women:
| US:
|
Chromosomal Testing For:
- – Women >35
- – Previous baby defect
- – Teratogenic/Mutagenic
- – Her first line family affected
- – Abnormal US/BioC
- – Missed Abortion
- – Father >43
| W 11-13 (Combined) | W 18-20 (Triple) |
I-US:
| I-US:
|
| 1/250 —> chorionic villi sampling/amniocentesis/chordocentesis 1/250-1/1000=NIPC 1/1000< Check again later | >1/250 HIGH |
| NIPS | NIPS:– Non-invasive test checks for fetal DNA in maternal blood! Karyotype: very (S) for Down Syndrome: |
^^Prenatal Investigation:
- – Prenatal US (W 11-13 & W 18-20)
- – Prenatal examination of chromosomal abnormalities
- – RF —> T1: combined test (bHCG + PAPPA)
- T2: triple test (AFP + bHCG + UE3) + NIPC
- – Chorionic Biopsy + Amniocentesis
**Prenatal Care:
| Low Risk | High Risk |
| FUH FH | FUH FH FM CTG BPP US Doppler |
***Postpartum Complications:
- – Bleeding
- – Pain
- – Infection
- – Endometritis
- – Urinary problems
- – Obstipation
- – Lactostasis, mastitis
- – Clogged Duct/Mild endometritis ———-> Oral Ax
- – Endometritis/mastitis/Postpartum sepsis —-> IV Broad spectrum
**Prolonged:
| ^^Px: Pituitary axis Placenta sulfacase ↓– Mother Line– Previous– Aging placenta | ^^Comp:– Meconium/oligohydramnios (<60) —-> Cord Compression/Instrumental– Overdue Newborn Syndrome + Macrosomia |
^^Tx:
- – W40: check fetal movement 2 x a day
- – W41: NST + AFI + Vaginal exam
- – Bishop Score >6 —> amniotomy + Labor
- – Bishop Score <6 —-> Mechanical Labor + Misoprostol
***IUGR:
| Symmetric | Asymmetric |
| – Chromosomal– Infection– Teratogenic– Fetal dysplasia | – HBP– Kidney problem– DM– Smoking– x Gestation |
^^Dx:
- – Gestational age
- – FUH
- – Fetometry!
^^Complication:
- – O2
- – Death
- – C-section
- – Glc (-)
- – RBC (++),
- – Ph ↓
- – Seizure
- – Sepsis
**Induction:
| Indication | Induction |
| – ↑ Preg– Fetal Distress– ROM– Pre-Eclampsia– IUGR– DM– HBP– Chorioamnionitis | – Membrane Sweeping– Prostaglandin E2– Artificial ROM– IV oxytocin |
***G-DM:^^Px:– Gh/Cortisol/Progesterone/HPL —> ↑ glucose + ↓ insulin (S)
| ^^Dx: | ^^Tx: |
| – W 24-28– F >5.1 /1H >10 / 2H 8.5-11.1 | – Diet– Blood glucose Monitor– Insulin (F >5.3 + 2 H >6.7)– NST + BPP (W 34-37)– US W 34-37– Postpartum W 12 OGTT |
| MOM | Fetus | Postbirth |
| HBP C-section | – Gluc (-)– Macrosomia– Malformation– O2 | Glc (-)– Resp Distress– Bilirubin! |
***Pre-GDM:– Hx of complications
^^Dx: OGTT: F >7 2H >11.1 | ^^Tx: DM I —-> insulin DM II —-> Lifestyle + metformin |
W 11-13 Endo W 24-25 W 34 Stable Glucose Deliver W 38-40 W 34 unstable Glucose **Tx All DM pts:
- 1. Level III Perinatal hospitals
- 2. OBGYN/ ENDO/ DB
- 3. Insulin (F <5/3 + 2H <6.7)
- 4. No GCD unless needed
- 5. No CSS (macrosomia, Distress retinopathy)
- 6. Postpartum: ophthalmologist/ Neonatology
***G HBP:
| ^^Gx:– HBP, W20– Prt (-)– 12 W Postpartum disappear | ^^Complication: PA IUGR SGA Preterm |
^^Tx:
- 1. CBC/CMP/UA
- 2. If BP >160/110 (Labetalol + nifedipine)
- 3. Fetal surveillance
***Preeclampsia:
| Sx | Complication | Tx |
| HBP Proteinuria Edema Liver enzyme ↑– Visual Headache | PA Liver Hematoma DIC | – Def: Delivery– MgSO4 —> Prevent seizure– Manage HBP |
I-MILD: 1-Preterm + stable —-> expectant + Dexamethasone -Term + Stable ——> induction + Vaginal Delivery + IV MgSO4II-Severe: 24-32 —-> Dexamethasone + Delivery 48 H>32 W + Stable —-> Vaginal Delivery + IV MgSO4 (seizure) + IV hydralazine + labetalol (BP)Postpartum 12-24 Mg SO4Eclampsia: Comp = PA – Hypoxia – CNS damage – Acidosis
| Stabilize | BP | Def | Postpartum |
| 1- Help 2- ABC 3- O2 mask 4- MgSO4 5 g 5- Check Status 6- Anti HBP | hydralazine + IV labetalol | Delivery WHEN stable + Dexamethasone! | 12-24 Mg SO4 |
***HELLP: Preeclampsia + ^^TX: 1- Stabilize Pts (IV Foley catheter 16 G) 2- X: 1- Anti HBP —-> Hydralazine/labetalol 2- Seizure —-> MgSO4 3- Liver platelet —-> dexamethasone! 3- CBC check 4- Anesthesia 5- Delivery: 1- unstable —-> direct delivery 2- >34W + unstable —-> DX <34 W + Stable –> dexamethasone****Rh immunization ^^Risk Group: 1- Mother Phenotype Rh(-), Ab titer 2- Father Phenotype Rh(+), homo/hetero 3- Fetal phenotype Amniocentesis ^^Dx: Screen W 11-13 + W 27 ^^Tx: RhoGAM RhIg 300mg W 28 + Postpartum 72 H ***if Mother is Rh(-), Ab(+): 1- perinatal Care 2- Observe Fetus (fetal anemia US) + Amniocentesis as the case is now High Risk —-> IC + possible blood transfusion if fetus is anemic!, High Risk ^^Risk: – Blood to Blood 1- Unsuccessful pregnancies 2- Invasive Procedures 3- ECV 4- Abdominal Trauma 5- Manual removal of placenta***Twins: W8 W10-13 chorionic DC/DA = Day 3 MC/DA = Day 4-8 MC/MA = Day 8-13 Siamese >13 D
| MC/DA | DC/DA |
| Same Sex– 1 Placenta– Membrane thin– T sign + , Lambda –– US 11-13– from W20 (4W)—> | Same Diff Sex– Placenta 2– Membrane thick– Lambda +– US W11-13, 16-18, 20-22-24-28 |
MC/MA ——-> C-section at W32****Chorioamnionitis:– Infection of chorion– Polymicrobial + ROM ^^Sx:– Fever >38 +2 (HR ↑/uterus tender/bad smell/WBC ↑ /CRP) ^^Dx: Amniocentesis + Fluid analysis (Glucose ↓ , WBC ↑ , G + Esterase (+)) ^^Tx:
- 1- Ax (Am/Gentamicin/Metronidazole)
- 2- Paracetamol
- 3- Crystalloid IV
- 4- Labour Induction!
| PA | UR | PP |
| – Uterine artery rupture 1- Painful bleeding 2- ↑ contraction 3- Distress Dx: CF US Tx: C-section ER if Stable + term Vaginal if Stable + preterm = BS | – Rupture of Uterus ^^Sx: 1- Popping sound 2- ↓ Contraction 3- Painful bleeding4- Distress ^^Dx: US ^^Tx: C-section + Repair/hysterectomy | – Placenta in lower part of uterus (marginal/partial complete) ^^Sx: Painless bleeding ^^Dx: US ^^Tx: C-section NO TOUCH! |
***PL vs PROM
| PL | PROM |
| RF:– PROM– x Gest– Oligohydramnios– UTI | RF:– URI– Bleeding in T1– Smoking– Previous surgery |
^^Dx:
| – Regular contraction– Irregular contraction– Bloody discharge | – Vaginal pH >7– + Crystal test– Oligohydramnios– Water Leak |
^^Tx:
| – Rest– CSD– CSD + Tocolytics! | Rest– Induce Labor– CSD (dexamethasone)– Ax Prophylaxis– Intrauterine Infection |
**PROM Monitoring:
| Mother | Fetus |
| – Temp– Vaginal Discharge– CBC + CRP + GBS culture– US TV | – Fetal movement 2/day– CTG (NST) daily– US (ADI + BP) |
***INF: HIV:– T1 + T3– Dx: ELISA —-> western Blot– ART therapy + No Breastfeed
| Vaginal | C-section |
| + ART | >50– + Hepatitis no ART |
| ^^Syphilis: Green discharge– 70-100%– Dx: serology RPR TPHA– Tx: penicillin | ^^GBS:– W 35-37– Tx during delivery– Tx: penicillin |
^^Asx bacteria:– W 11-13– Tx: after Urine test NITROfurantoin 100mg***Hepatitis B:– Screen T1 + T3^^Dx: serology HBsAG —> If No, come T3 —> If yes1- AntiHBV/AntiHBe/HbcAg/HBeAg2- ALT + AST3- CF 4- US AbTx: W28-32***Miscarriage:
| Causes: | ^^Examination: |
| 1- Chromosomal AbN2- Infection3- Mother Disease4- Mother Lifestyle | – Hx– PE– Anatomical exam– Immune – Thyroid! |
***Early Postpartum: in 24 H (V500ml, CSS 1L)
| ^^RF:– Uterine distention– Px Placenta– Mother >40– 5+ Preg– Chorioamnionitis | ^^Tx:1- Assess Blood Loss2- Tell the pts3- Call help4- ABC5- 4T6- Blood(CBC/Rh /CF/Blood gas)7- Def Tx |
***4T:I- Uterine Atony —-> Massage/ Bladder Empty/ Oxytocin + misoprostol/ Bimanual uterine/ Aortic compression/ LaparotomyII- Trauma: —-> Repair of Cervical & Vaginal Tear/ Open Vaginal Hematoma/ Uterine Tear/III- Tissue: —-> Evacuation of remaining products Thrombocyte: —-> Coagulopathy factor***Amenorrhea:^^Cause:– Preg/physiological– PCOS– Pit problem– Ovary Fail– Uterine problem– ↑E + T^^Dx (algo)^^TX: according to Cause!***ECTOPIC PREGNANCY:N: Fertilized Should implant into Endometrial Lining of Uterine Cavity– Ectopic = Somewhere else(Fallopian tube, Cervix, Abdomen, Pelvic cavity)^^Complication:Rupture of Fallopian (Because it’s too small!)
^^Sx:
>35Previous PID IUD devicesx partnersSmokeInduced Abortion
– Asx until Rupture(Pain, Cervical Motion tenderness + adnexal Tenderness)+ Vaginal bleeding unlike PID(No idea about menstrual period)
– B-HCG (urine + blood)– Pelvic US
^^Tx:
– Surgery (Salpingectomy)– X: Methotrexate!
***C-Section (Scheduled & emergency)Scheduled:1- Previous C-Section!2- Fetal malpresentation (Breech)3- x gestation (More than 2)ER:– UC prolapse– Breech– Preterm– Fetal condition change (Fetal distress)– Cephalo pelvic disproportion***Incontinence:^^Gx:– Involuntary Loss of Urine!^^Types:
^^Tx:
1- Methicillin (R) Ax2- Anti-staph X3- Improve breastfeeding Technique!.. encourage women to Continue breastfeeding!
^^Complication: Abscess!***Preterm Labor:^^Gx:Contraction <37 W —> Cervical change!^^Tx:1- Ax for GBS, Penicillin/ Clindamycin/Erythromycin(GBS cause many Preterm cases)2- Tocolytic (Nifedipine delay for 2 days)3- CSD(Betamethasone = 12 mg 2/day)(Dexamethasone = 6mg 4/day)***Postpartum Fever:– An umbrella term used for conditions that cause fever related to the period after delivery(Alt you can use one without postpartum)– Fever >38 X + >14 D^^Causes:1- UTI2- Wound Infection3- DVT4- X But the Main CAUSE is ENDOMETRITIS!**Endometritis:^^Gx:– Risk Increase in C Section!^^Px:– Ascending infection(E. epidermis/ E. coli/ Proteus/ Klebsiella)^^RF:
– Prolonged Labor– Prolonged ROM– Cervical Exam– Maternal Disease– Deliveries using machines
^^Sx:
– Fever + Tachycardia– Malaise– Abdominal Pain/ Tenderness– Leukocytosis
^^Dx:CF by exclusion!^^Tx:IV Ax ——> Clindamycin + Gentamicin!***Fibroids:^^Gx:
– AKA Leiomyomas– Mostly Benign tumor of SM– Most common pelvic tumor– Most women have them!– Fibroids have Estrogen (R)
^^Location:
1- Subserous2- Intramural3- Submucosal
^^Sx:1- Menorrhagia: Prolonged Duration of Menstruation(so if bleeding now occurs 5 days now it becomes 7)2- Metrorrhagia:– Menstrual bleeding @ irregular intervals (once 28 once 21 once 30 etc….)Menometrorrhagia (Combination of 2) = Choriocarcinoma3- Chronic Pain / Pressure4- Urinary Sx (Frequency and Urgency)^^Dx:– Pelvic US^^Tx:1- Asx —-> observe!2- Postmenopausal —–> lack of estrogen so they regress!3- Women who want to get Pregnant —–>– MYOMECTOMY (TAKE out FIBROIDS)– UTERINE ARTERY EMBOLIZATION4- In Severe Sx ———–> Hysterectomy!5- Anti Estrogen X: Leuprolide GnRH analogues to decrease Estrogen Production!***Endometriosis:^^Gx:– NON CANCEROUS DISORDER– The endometrial Tissue (Ovaries/ Ligaments ….)– Estrogen + Progesterone (S)^^RF:– Retrograde menstruation (menstruation backward)– Metaplasia^^Sx:
Pelvic Pain– Infertility!– Dysmenorrhea (Pain in menstruation)– Dyspareunia! (Pain during Sex)
^^Dx:
Laparoscopy! + Biopsy is a MUST
^^Tx:– NSAID– GnRH Agonist (Leuprolide)(— suppress Estrogen Production)– Excision of lesion(Uterine Artery embolization) or hysterectomy)***Amenorrhea:1: Never had period @ age 16-172: Didn’t have Period >3 Cycles + >3 M^^Causes:1- Pregnancy2- Constitutional delay of Puberty3- Antipsychotic (Dopamine down prolactin Down)4- PCOS5- Pit problem6- Ovary Fail7- Uterus structure problem– Increase in estrogen + testosterone^^Sx:***PCOS:^^Gx:
– Elevated LH– Insulin (R)
^^Px:
– Ovarian Growth– Ovarian Cyst– Androgen Production!
^^Sx (androgen Excess)– Hirsutism– Acne– Kg ↑– Irregular Menses!!—> Can lead to Infertility!^^Dx:– Serum Testosterone Level– LH (↑ + FSH (↓) —-> Ratio 3:1– Prolactin, TSH,– Pelvic US (To see enlarged follicle)(N: 2-10 mm)2 out of 3:1- Irregular Menses2- Evidence of Androgen Excess3- Polycystic ovaries (US)^^Tx:I- Not desired Preg:1- Oral Contraceptive (OCP) Suppress Androgen metabolism —-> decrease testosterone + LH levels!2- KG ↓II- Desired Preg:– Metformin —-> insulin (S)– Clomiphene