Medical disorders in Pregnancy &

Complications in pregnancy

Tutorial

Indications for GTT• BMI>30

• Ethnic group (Asian)

• 1st degree relative with diabetes

• Previous Gestational DM

• Previous still birth

• Previous big baby(>4.5kg)

• Persistent Glycosuria

• Big baby + polyhydramnios

• PCOS

Scenario 1• A 26 year old P0 attends ANC at 29weeks gestation, it

is noted that the SFH measures 32 cm. Urine dipstick reveals 3+ glucose.

1. How would you investigate her GTT USS for growth /liquor volume 2. What is the most likely diagnosis Gestational DM with Macrosomia/ Polyhydramnios 3. How would you alter her antenatal management

subsequently? - Combined Obstetric/ diabetic clinic - Blood sugar monitoring- Rx Diet/metformin/Insulin - Monthly HbA1c - Serial Growth scans

4. Think also about your plan for delivery and the post natal period

- If diet controlled- aim to deliver by 40 weeks (IOL)

- If Rx with Metformin/Insulin- deliver by 38-39 wk-If significant macrosomia consider C/S - Intrapartum sliding scale-Stop treatment for diabetes post delivery -Monitor baby for hypoglycemia-Post natal GTT

5. What are the long term implications of this?

- GDM in subsequent pregnancy

- DM in long term

Scenario 2• A 21 year old IDDM books for her pregnancy at 12

weeks gestation . She has been diabetic since age 5.

1.How does DM affect pregnancy and How does pregnancy affect diabetes?

Fetal:

- Miscarriage

- Congenital- heart defect, CNS & skeletal defect

- macrosomia

- Still birth

- Shoulder dystocia

-Neonatal hypoglycemia & hyperbilirubinemia

Maternal- UTI

- polyhydramnios

- Retinopathy worse

- Nephropathy & pre eclampsia - Need for elective delivery(IOL/C/S)

- Wound infection

3. How would you modify her antenatal care

-Anomaly scan in fetal Medicine to exclude anomalies

-Same as GDM ( change to pre pregnancy Insulin & no postnatal GTT required)

Scenario 3• A 35 year old woman is admitted to the A&E at 26 weeks

gestation with acute SOB.

1. what is your possible diagnoses?

Pulmonary Embolism

2. How would you investigate her?

FBC, clotting, ECG, ABG, doppler legs, CXR,V/Q scan/ CTPA, Pulm angiography (severe cases only)

3. What treatment would you recommend

Treatment dose of LMWH 1mg/kg/BD

4. How would this affect her subsequent AN care and delivery -Continue treatment with LMWH for upto 6 wk post delivery ( Treatment dose should be continued up to 6 months after the event)-Stop Clexane with signs of labour-Epidural /Spinal can be given only if had last clexane injection> 24 hr

5. How would this affect her next pregnancy

Thromboprophylaxis at least 4 weeks prior to the diagnosis in previous pregnancy i.e 22 weeks onward and continue in the postnatal period.

Scenario 4 A 35 year old is admitted to the A&E at 26 weeks gestation with acute

SOB. She is a known asthmatic

1. what is your possible diagnoses?

Severe exacerbation of asthma

2. What is your immediate management?

*Management is same as out side pregnancy

- High flow O2

- Salbutamol nebulizer

- Ipratropium bromide neb. added if poor control

- Steroids IV hydrocortisone± PO prednisolone 5/7

3. How would you investigate her?

CXR if suspecting pneumonia/pnemothorax/ patient fail to improve.

4. How would this affect her subsequent AN care and delivery -Women on oral steroid for 2 weeks prior to delivery will require IV hydrocortisone in labour-Prostin pessary is safe for induction-Opiate for pain relief should avoided with acute attack-Syntometrine is safe for 3rd stage of labour-Spinal preferred since GA ↑ Chest infection & atelectasis-Carboprost for the mangement of PPH should be used cautiously (risk of broncoconstriction)

Scenario 5• A Patient with known hypertension presents for

booking. She is currently on antihypertensive (enalapril).

1. How does hypertension affect pregnancy? How does pregnancy affect BP?

- Superimposed pre eclampsia, eclampsia, Abruption

-HELLP syndrome, CVA, Pulmonary Edema,

Acute renal failure, DIC, ARDS

- IUGR, HIE,IUD

- 2. How would you modify her antenatal care?

- Stop Enlapril

- Commence labetolol/methyldopa

- Low dose aspirin

- Uterine artery dopplers

- BP monitoring

- Serial growth scans

- Timing /mode of delivery depends on time severity of superimposed pre eclampsia

Scenario 6• A 35 year old patient is admitted in her 2nd pregnancy

with convulsions. She is 29 weeks gestation

1. What is your likely diagnosis?

Eclampsia

2. What is your management plan?- Observation- P/BP/O2 sat, RR,U/O; CTG

- Secure airway (guedal/intubation if recurrent fit) & O2- IV access- Magnesium sulphate

- IV Antihypertensive - Deliver by C/S after stabilization

2. Justify your management

All pregnant woman are eclamptic unless known epileptic.

3. What investigations would you perform & why?

FBC – low platelet

Clotting- abnormal if DIC

U&E – Raised urea & creatinine

Urates – raised

Urine for PCR- Raised

Urine for C/S

Investigation- confirm the diagnosis

Scenario 7• A 35 year old patient is admitted in her 2nd pregnancy

with convulsions. She is 29 weeks gestation. she was a known epileptic ?

1. What modifications would you make in her pre pregnancy management and why?

- Preconception counselling/educating family members

- Change to monotherapy – Reduce teratogenecity

- Change from phenytoin/phenobarbitone to other anti epileptic (lamotrigine)

2. What modifications would you make in her antenatal care – justify your plans.

- See in combined Obstetrics/Neurology clinic

-Continue on medication as outside pregnancy. Emphasize some women experience increased seizure frequency in pregnancy & optimal drug compliance

-Anti epileptics -reduction in vitamin K dependent clotting factor hence commence vitamin K from 36 weeks + neonatal vitamin K to reduce risk of neonatal hemorrhage

-Drugs not contraindicated with breast feeding

3. What are the main risks of epilepsy in pregnancy ?

•Risk of Congenital abnormalities:

- Continue folic acid through out pregnancy

- Anomaly scan in fetal medicine

(a) Phenytion- cardiac defect, cleft lip/palate

(b) Sodium valproate- Neural tube defect

(C) Carbamazepine- Neural tube defect

•Increased seizure frequency during pregnancy

•Reduction in vitamin K dependent clotting factor hence risk of neonatal haemorrhage

Breech presentation• Incidence 3-5%• Flexed, Extended, footling breech• Predisposing factors: prematurity

- multiple pregnancy

- oligo/polyhyramnios

- placenta previa

- Abnormalities of uterine shape

- fetal abn. ( hydrocephalus)

- pelvic tumour

- contracted pelvis

• Management option:

- Vaginal breech delivery

- External cephalic version- Success 60%, 1% fetal distress, 1% reversion to breech

- Caesarean section

• Complications associated with breech :

- Birth trauma: trapped after coming head of breech, fetal distress, death, fracture skull/long bones

- Cord prolapse

- PPH

Cord prolapse• Obstetric emergency

• Predisposing factors: Prematurity, multiparity, amniotomy, polyhydramnios with SROM, long cord

• Management: *AVOID HANDLING THE CORD*

- If fully dilated –instrumental delivery

- Otherwise - All four’s position OR

- Fill the bladder with saline

Proceed with emergency caesarean section

Antepartum haemorrhage

• Definition- Bleeding from the genital tract from 20 weeks gestation onwards.

• Causes- placenta previa

- placental abruption

- lower genital tract- ectropion, infection, cervical poly, Ca Cervix

- vasa previa

Placental abruption• Premature separation of normally sited placenta

• Causes- Frequently unknown

- Severe Pre eclampsia

- Raised AFP

- Abdominal trauma

- Cocaine

- ARM/SROM

• Clinical presentation:

- Concealed/Revealed haemorrhage

- Constant abdominal pain increasing in severity

- Shock

- hard tender uterus that does not relax

- Difficulty in feeling fetal parts

- Fetal distress/ Fetal heart is absent• Management :

- IV access, FBC, Cross match, clotting

- CTG

- Early delivery if fetus alive

- Adequate maternal transfusion • Complications: IUD,PPH, renal failure,DIC

Placenta Previa• Definition- Placenta that is implanted in the lower

uterine segment along side or in front of the presenting part

• Types: Minor- placenta reaches the cervix

Major- placenta covers the cervix

• Causes: Mostly unknown

- Multiparity

- Multiple pregnancy

- previous caesarean section

• Clinical presentation:

- Painless vaginal bleeding

- Malpresentation

- Soft uterus

• Management:

- If asymptomatic: vaginal delivery if placenta 2.5 cm from internal os otherwise elective C/S.

- If Symptomatic( bleeding): Conservative management if small APH otherwise C/S

• Complication: PPH, may require hysterectomy