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Medical disorders in Pregnancy & Complications in pregnancy

Medical disorders in Pregnancy & Complications in pregnancy. Tutorial. Indications for GTT. BMI>30 Ethnic group (Asian) 1 st degree relative with diabetes Previous Gestational DM Previous still birth Previous big baby(>4.5kg) Persistent Glycosuria Big baby + polyhydramnios PCOS.

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Medical disorders in Pregnancy & Complications in pregnancy

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  1. Medical disorders in Pregnancy &Complications in pregnancy Tutorial

  2. 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

  3. 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. 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

  5. Scenario 2 • A 21 year old IDDM books for her pregnancy at 12 weeks gestation . She has been diabetic since age 5. • How does DM affect pregnancy and How does pregnancy affect diabetes? Fetal: - Miscarriage - Congenital- heart defect, CNS & skeletal defect - macrosomia - Still birth - Shoulder dystocia

  6. -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)

  7. 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

  8. 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.

  9. 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

  10. 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)

  11. 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

  12. 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

  13. 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

  14. 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

  15. 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)

  16. 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

  17. 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

  18. 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

  19. 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

  20. 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

  21. 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

  22. Placental abruption • Premature separation of normally sited placenta • Causes- Frequently unknown - Severe Pre eclampsia - Raised AFP - Abdominal trauma - Cocaine - ARM/SROM

  23. Clinical presentation: - Concealed/Revealed haemorrhage - Constant abdominal pain increasing inseverity - 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

  24. 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

  25. Clinical presentation: - Painless vaginal bleeding - Malpresentation - Soft uterus • Management: - If asymptomatic: vaginal delivery if placenta 2.5 cm from internal osotherwise elective C/S. • If Symptomatic( bleeding): Conservative management if small APH otherwise C/S • Complication: PPH, may require hysterectomy

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