1
Q
A 38 year old woman has come to the GP in the 8th week of her first pregnancy with severe nausea and vomiting.
What can be the possible causes?
A
- Normal nausea and vomiting of pregnancy
- Hyperemesis Gravidarum
- Multiple pregnancy
- Molar pregnancy
- Ruptured ectopic pregnancy
- Polyhydromnios
7.GDM
8. DM
9. UTI
- Small bowel obstruction
- Cerebral tumour
- Addison disease
- Infections
2
Q
A 38 year old woman has come to the GP in the 8th week of her first pregnancy with severe nausea and vomiting.
What are the key points of this case?
A
- Exclude ALL the D/Ds
- Correct Dx : Hyperemesis Gravidarum
- Correct investigations and treatment
- Tell about Down Syndrome screening as she is advanced maternal age
- Telling her that it will be spontaneously reduced by 14weeks of gestation
3
Q
A 38 year old woman has come to the GP in the 8th week of her first pregnancy with severe nausea and vomiting.
List the Investigations and Management plan.
A
- UDT to check for ketones and BSL : If ketones present, immediately hospitalise.
- Urine MCS - to rule out UTI
- USG - to rule out Multiple pregnancy, Molar pregnancy, Ectopic pregnancy, Polyhydromnios
- FBE
- Serum UEC
- LFT
Management:
1. Investigations
2. Hospital admission
3. Treatment in the hospital:
IV saline
IV dextrose with Vit B
Antiemetic- Pyridoxine with Maloxone
4. Spontaneous resolution within 14weeks of pregnancy
5. If does not resolve, further investigations.
6. Genetic counseling and Down syndrome screening because she is advanced maternal age.
4
Q
28 year old primigravida has come on her 34weeks of gestation with fundal height 29 cm.
What are the causes of this condition?
A
Condition: Fundal height less than date causing IUGR
Causes:
In the mother:
1. Pre-existing kidney disease-
HTN, Arthritis, Lupus
2. Pre-eclampsia
3. Smoking and drinking
4. Placental dysfunction; Abruptio Placentae
5. Oligohydromnios
6. Infections - CMV & Toxoplasmosis
In the fetus:
1. Chromosomal abnormalities
2. Fetal malformations
3. Fetal infections with CMV and toxoplasmosis
5
Q
28 year old primigravida has come on her 34weeks of gestation with fundal height 29 cm.
Management of this condition.
A
- Refer to specialist:
- to confirm the diagnosis
- to rule out other dd
- to assess the severity of the condition - Investigation:
1. USG
2. CTG
3. Doppler study
4. S. urea, uric acid and creatinine
5. Lupus anticoagulant and Anticardiolipin antibodies
6. Antibodies for toxoplasmosis
7. Amniocentesis - Delivery-
- via C section
- prior to due date
- timing will be decided based on USG, CTG and fetal growth - Prognosis:
Satisfactory, given that the baby does not become hypoxic, doesn’t have any congenital anomalies or infections.
6
Q
28 year old primigravida has come on her 34weeks of gestation with fundal height 29 cm.
What investigations will you do?
A
- USG: every 2-3 weeks
- to confirm the size of the baby
- to measure the amniotic fluid volume
- to rule out any congenital anomalies - CTG: twice a week starting from now till delivery
- to assess and monitor the condition and wellbeing of the baby - Doppler study:
- to ensure blood flow in the umbilical cord - Serum urea, uric acid and creatinine
- to look for any evidence of renal compromise - Lupus anticoagulants and Anticardiolipin antibodies
- Antibodies for Toxoplasmosis
- Amniocentesis:
- to assess the karyotype of the baby
7
Q
Causes of Primary postpartum hemorrhage
A
- Uterine Atony
- Retained bits of placenta
- Genital tract lacerations
- Coagulation/Bleeding disorders
8
Q
Management of Severe Postpartum Hemorrhage due to uterine atony
A
- Stabilise the vitally unstable patient first
- Transfer the patient to the resuscitation room
- Start high flow oxygen via face mask
- Secure IV line and start IV fluids: normal saline or Hartman solution
- Take blood for grouping and cross matching and coagulation studies
- Catheterize the patient if not done already - Uterine massage
- Continue the IV fluids on a fast drip rate
- Give blood as soon as available and cross matched
- Give IV or IM Ergometrine or IM Oxytocin immediately
- Observe any clots on the blood that is passed
- Examine the placenta carefully
- Do a speculum examination for any genital or perineal tear that may require suturing
- Liase with my seniors and refer the patient to OB specialist for Examination Under Anaesthesia to ensure:
- no retained bits of placenta
- uterus is intact
- no uterine inversion
• shouldn’t be performed until blood transfusion is running
• patient is hemodynamically stable
9
Q
25 year old Karen who is a kindergarten teacher has come to the GP after a recent contact with a child in her class who has rubella.
What history will you take?
A
- When was the contact?
- Was it a confirmed case of rubella?
- Did you have any previous infection with rubella?
- Are you vaccinated against rubella?
- Have you been feeling unwell or feverish lately?
Any rash? Sore throat? Runny nose?
Any lumps or bumps in your neck or behind the ears? - 5P
- SADMA COT FP
10
Q
25 year old Karen who is a kindergarten teacher has come to the GP after a recent contact with a child in her class who has rubella.
How will you manage her? (investigations and management)
A
- Urine Pregnancy test right now
Investigations:
1. FBE with ESR and CRP
2. UEC
3. Blood grouping and Rh typing
4. BSL
5. Vitamin D levels
6. Urine - dispstick and MCS
- Rubella and Varicella serology
- STI Screening
Management:
1. 5C on Rubella
Complications- in baby Congenital Rubella Syndrome:
- deafness
- blindness
- heart defects
- limb defects
- mental disability
- Check two antibodies IgG and IgM and two scenarios can occur
- All Other antenatal advices
11
Q
20 week pregnant patient comes with painless ulcers in her private areas for the 4th time now.
What is the condition and how will you manage her?
A
Condition: Recurrent HSV infection
Management:
1. Refer to high risk pregnancy clinic where you will be seen by a obstetrician and an infectious disease specialist.
- To confirm the diagnosis: take swab from the lesion and send it for PCR
- Start Acyclovir (can be given from 20weeks) 5-7 days
- Also give Acyclovir from 36weeks until delivery to prevent any recurrence affecting the baby or the delivery
- Arrange USG scan now and repeat if necessary to monitor any defects in the baby
- If the partner has similar symptoms, test and treat him as well. Practice safe sex.
- About delivery:
- if no active lesions- vaginal delivery
- active lesions- CS
- if active lesions but patient wants vaginal delivery- IV Acyclovir given to the baby after delivery to prevent Neonatal HSV infection, causing:
- sepsis
- eye, mouth and skin infections
- pneumonia
- encephalitis - Review in 8 days
- Monitor the baby kicking and red flags
12
Q
11 week pregnant lady presented with nausea and vomiting to the ED.
What are the differentials?
A
- Normal nausea vomiting of pregnancy
- Hyperemesis Gravidarum
- Molar Pregnancy
- Multiple Pregnancy
- Ectopic pregnancy
- Polyhydromnios
- UTI/Pyelonephritis
- Gastroenteritis
- Meningitis
- Small bowel obstruction
- Acute appendicitis
13
Q
30 weeks pregnant woman presents to the GP with sudden onset of abdominal pain.
What is the diagnosis ?
A
Condition: Preterm labour
Onset of labour before 37 weeks of pregnancy.
Cause:
1. Excessive fluid in the bag surrounding the baby
2. Multiple pregnancy
3. Cervical incompetence
4. Maternal infections
5. Preeclampsia
6. GDM
Complications for the baby:
1. RDS or breathing difficulties in the baby
2. Neonatal sepsis
3. Bleeding into the brain/Intracranial hemorrhage
4. Difficulty in maintaining body temperature and sugar levels
5. Feeding difficulties
Criteria for preterm labour:
1. Contractions happening every 5-10 minutes lasting for 30seconds to 1 minute
2. Cervix >2.5cm dilated
3. Fibronectin test positive
4. Labour happening before 37weeks
14
Q
30 weeks pregnant lady comes to the GP with sudden onset of abdominal pain.
How will you manage this patient?
A
- Fibronectin test - take a vaginal swab.
If +ve = she will deliver in the next 7-10 days - Immediate transfer to the hospital with a neonatal ICU.
Arrange for an ambulance, call the hospital and make them aware of your condition so that they are ready for you once you reach. - Open an IV channel
Take blood for investigations - Give 1st dose of Steriod
- to bring lung maturity as it is <34 weeks
Give 1st dose of Tocolytics
- to prevent further uterine contractions and prolong the pregnancy - In the hospital:
- you will be seen by a specialist
- USG and CTG will be done to monitor you and your baby
- further doses of steriods and tocolytics to prolong the pregnancy as much as possible - In spite of everything, if your labour progresses and you do deliver your baby:
- baby will be taken care of in the NICU
- by the best hands - Baby kicking and red flags
15
Q
25 year od Mary who is 32 weeks pregnant comes to the GP clinic with complaints of passing fluid from the vagina since the past one hour.
What is this condition?
A
Condition: Preterm Premature Rupture of Membrane
Cause:
1. Multiple pregnancy
2. Polyhydromnios
3. Preeclampsia
4. GDM
5. Maternal infection
6. Fetal abnormalities
Complications:
1. Infections
16
Q
28 year old female presents to the ED because of severe right sided abdominal pain for the past one hour.
What can be the possible causes?
A
Gynaecological:
1. Ectopic Pregnancy
2. PID
3. Mittleschmerz
4. Ovarian cyst rupture
5. Torsion of the ovaries
Renal:
1. UTI/Pyelonephritis
2. Renal stone
Abdominal:
1. Acute Appendicitis
2. Small bowel obstruction
17
Q
28 year old female presents to the ED because of severe right sided abdominal pain for the past one.
List the investigations to do.
A
Investigations:
1. Office tests - UPT, UDT, BSL
2. Blood - FBE with ESR and CRP,
UEC
LFT
Coagulation profile
Blood grouping and Rh typing
Bhcg level
3. Transvaginal USG -
- empty uterus
- empty sac in the adnexa
- fluid in the pouch of Douglas
18
Q
28 year old female presents to the ED because of severe right sided abdominal pain for the past one hour
Management of this condition
A
- Admit to the hospital and seen by specialist
- IV access, take blood for investigations and start IV fluid
Two methods of treatment:
Conservative
Surgical
Criteria for Conservative management :
1. BHcg <5000
2. No fetal cardiac activity
Methotrexate: Intramuscular injections, single or multiple or directly into the sac under USG guidance
Followup after giving Methotrexate:
Bhcg estimation weekly
- decreasing : working
- remaining same : ectopic activity still going on so repeat methotrexate
- increasing : treatment not effective, needs to be operated.
Surgical management :
1. Laparoscopy and Salpingostomy
2. Laparoscopy and segmental resection
3. Laparoscopy and salpingectomy
19
Q
28 year old female presents to the ED because of severe right sided abdominal pain for the past one.
What is the condition?
A
Condition: Ectopic pregnancy
Cause/Risk factors:
1. Previous history of ectopic pregnancy
2. PID
3. IUCD
4. Artificial methods of conception
5. Previous abdominal surgeries
Complications:
1. Rupture
2. Peritonitis
20
Q
32 weeks pregnant lady comes to the GP with headache since the last 2 days and also had mild swelling of her legs the last time you saw her.
List the differentials.
A
- Preeclampsia/Preeclamptic toxaemia
- Migraine
- Cluster headache
- Tension headache
- Meningitis
- Encephalitis
- SAH
- EDH
- SDH
- Sinusitis
- Allergic rhinitis
- Referred pain from toothache
- Temporal arteritis
21
Q
Criteria of Preeclampsia, Preeclamptic Toxemia and Eclampsia
A
Preeclampsia:
• AOG >20 weeks
• BP >140/90
• Proteinuria
• Generalised edema
Preeclamptic Toxemia:
• Features of Preeclampsia
• Headache
• Blurring of vision
• Vomiting
• Tummy pain
• Vaginal bleeding
• Swelling of the feet upto the calves or knees/Massive edema
• Knee reflex- Hyperreflexia
• Clonus
Eclampsia:
• All the above
• Convulsions
22
Q
Management of Preeclamtic Toxemia
A
- UDT - to check for urinary protein and ketones
- Transfer to the hospital immediately to be seen by specialist.
Arrange ambulance and liase with the doctors over there so that they are prepared beforehand. - Secure IV access, take blood for investigations and start IV fluid.
-Also give 1st dose of IV Labetalol - Investigations :
- FBE with ESR &CRP
- UEC
- LFT
- Coagulation profile - In the hospital:
- USG and CTG will be done to monitor you and the baby
- Complete bed rest
- Continuous monitoring of the vitals
- BP recording every 2 hours
-Urinary proteins twice daily
- Fluid input output by catheterisation - IV Hydralazine - to control BP
IV MgSO4 - to prevent eclampsia
4g initially over 10-15minutes and then 1g/hour as continuous infusion - If everything goes well and the baby is doing well :
- induce labour by 37 weeks
- need to stay in the hospital for the rest of your pregnancy
- in case you’re fitting or the baby becomes unwell, immediate CS or IOL
23
Q
Management of Eclampsia
A
- Shift the patient to the resuscitation room and stabilize her using the DRSABCDE protocol and call for help.
- Patient in left lateral position
- High flow oxygen via face mask
- Two large bore IV access
IV fluids
Catheterization to monitor input output - If in the GP
- IV Labetalol and IV Diazepam
If in the hospital
- IV Hydralazine and IV MgSO4 - Investigations
Blood
USG
CTG - Immediate delivery of the baby either by CS or IOL (despite whatever the AOG is)
24
Q
28 year old Jenny presented to the ED at her 34 weeks of pregnancy with vaginal bleeding.
What can be the possible causes?
A
- Placenta Previa
- Abruptio Placenta
- Trauma
- Blood thinners
- Bleeding disorders
25
28 year old Jenny presented to the ED at her 34 weeks of pregnancy with vaginal bleeding but no pain.
What is the diagnosis?
Condition: Placenta Previa
The placenta descends to the lower pole of the uterus.
Cause/Risk factors:
1. Mutiparity
2. Advanced maternal age
3. Chronic hypertension
4. Smoking, alcohol, drugs
5. Previous Csection
Clinical features:
1. AOG >20 weeks
2. Painless per vaginal bleeding
The bleeding occurs because the head of the baby pressing against the low lying placenta and making it bleed
Complications:
1. Excessive bleeding leading to shock
2. Coagulation failure
3. Preterm labour
4. Hypoxia/decreased oxygen supply for the baby
5. IUGR
26
28 year old Jenny presented to the ED at her 34 weeks of pregnancy with vaginal bleeding but no pain.
What is the management of this condition?
1. Immediate admission to the hospital to be seen by specialist
2. Secure IV access
Take blood for investigations
Start IV Fluid
3. Investigations:
- FBE with ESR and CRP
- UEC
- LFT
- Coagulation profile
- USG - to confirm Placenta Previa
- CTG - to monitor the wellbeing of the baby
4. If the bleeding stops and everything goes well:
- planned C-section at 37weeks by the specialist
- need to stay in the hospital until the delivery
- if bleeding recurs, or you or the baby becomes unwell, immediate delivery by Csection will be done
27
Grades of Placenta Previa
Grade 1 : Low lying placenta previa
- Placental edge is nowhere near the OS
Grade 2 : Marginal placenta previa
- Placental edge has come upto the level of the OS
Grade 3 : Partial Placenta Previa
- Partially covers the OS
Grade 4 : Total Placenta Previa
- Totally covers the external OS
28
Different modalities of treatment of Placenta Previa
1. 34weeks, incidental finding of Placenta Previa on USG, patient completely asymptomatic :
Two treatment options for her:
1. Admit her to the hospital
Stay in the hospital until 37weeks
Planned C-section at 37weeks
2. Home management, if
- she lives nearby to the hospital
- has a constant companion
- full informed consent of the patient about the complications:
• high chances of bleeding after 34weeks
• go in shock or coagulation failure
• premature labour
• baby having hypoxia
• IUGR
2. Patient is
- hemodynamically unstable
- with heavy vaginal bleeding
- fetal distress
Stabilize the patient and
Immediate C-section no matter the grade of PP or AOG
3. If the patient insists of vaginal delivery:
- tell her that C-section is the preferred management in Placenta Previa for the betterment of her and her baby
- trial of vaginal delivery can be considered given that:
• placental edge is >2cm from the OS
• baby’s head is below the placental edge
29
34weeks pregnant lady presents to the ED with bleeding per vagina since the past one hour along with mild abdominal pain.
She is haemodynamically stable.
What is the diagnosis?
Condition: Abruptio Placenta - Mild revealed Abruptio Placenta
Cause/Risk factors:
1. Smoking, drinking alcohol and recreational drugs
2. High blood pressure and Preeclampsia
3. High blood sugar
4. Multiparity
5. Injuries and trauma
Clinical features:
1. Bleeding per vagina
2. Abdominal pain
3. Patient is hemodynamically stable
Complications:
1. Shock
2. Coagulation failure or DIC
3. Baby becoming hypoxic/short of oxygen
4. Fetal death
30
Management of mild revealed abruptio placenta
1. Admit to the hospital to be seen by a specialist
2. Secure IV access
Take blood for investigations
Start IV fluid
3. Investigations:
- FBE with ESR and CRP
- UEC
- LFT
- Coagulation profile
- Blood grouping and cross matching and hold
- USG - to confirmed the diagnosis
- to check if any blood is collecting inside
- CTG - to check the wellbeing of the baby
4. Complete bed rest until the bleeding stops
5. Once the bleeding stops, you will be asked to ambulate and we’ll check if the bleeding is recurring or not
6. If bleeding continues or you or baby becomes unwell, immediate delivery by induction or C-section
7. If bleeding does not recur and everything goes well,
- you will be discharged
- rest of the pregnancy will be monitored in high risk pregnancy clinic
- more frequent antenatal checks
8. Look out for red flags when you’re at home
- baby not kicking well
- bleeding or spotting
- tummy pain
- water breaks
If >37weeks:
Stabilize the patient
And immediate delivery by induction or csection
31
Management of moderate revealed abruptio placenta
- heavy blood loss
- severe abdominal pain
- vitals unstable
- baby in distress
Management:
1. Stabilize the patient first
2. Immediate delivery of the baby by induction or C-section
32
Management of severe revealed abruptio placenta
- heavy blood loss, >1.5L
- patient is in shock
- baby dead
Management:
1. Stabilize the patient first
2. Confirm the fetal demise by USG
3. Delivery of the dead baby:
- vaginal delivery (usually happens spontaneously within 2 weeks). Monitor the vital signs of the mother for DIC
- induction of labour
- if the patient requests, C-section
33
32 weeks pregnant Maria comes to the ED with severe abdominal pain since the last 2 hours.
What can be the possible causes?
1. Abruptio Placenta
2. Preeclampsia/Preeclamptic Toxemia
3. Preterm labour
4. Torsion of ovarian cyst
5. Trauma
6. UTI
7. Acute Appendicitis
8. Acute cholecystitis
9. Acute pancreatitis
10. Bowel obstruction
34
Clinical features of Severe concealed abruptio placenta
In history:
1. Severe abdominal pain
2. No vaginal bleeding
3. Feeling dizzy
In examination:
1. Vital signs unstable
2. Abdomen:
- Uterine tenderness
- Guarding and board like rigidity
- SFH : increased or decreased
- Lie, presentation : hard to feel
- FHR : not found
- Uterine contractions
DON’T DO PER VAGINAL EXAMINATION
35
Management of severe concealed abrupio placenta
1. Stabilize the patient using the DRSABCDE protocol
2. Breaking the bad news
- since you have not felt your baby kicking well
- during my examination I couldn’t even hear the baby’s heartbeat
- need to confirm it by USG
3. Admit to the hospital to be seen by the specialist
4. Immediate delivery by C-section
- the baby and the placenta needs to be removed
- the blood that has clotted inside needs to be removed
- leaking blood vessels need to be seen
36
23 years old Jane has come to the ED after developing vaginal bleeding after eight weeks of amenorrhoea.
What are the differential diagnosis?
1. Miscarriages- Threatened
- Complete
- Incomplete
- Inevitable
2. Ectopic pregnancy
3. Hydratidiform mole
4. Trauma
5. Bleeding disorders
6. Blood thinning medications
7. Late period
37
23 years old Jane has come to the ED after developing vaginal bleeding after eight weeks of amenorrhoea.
What are the key points and critical errors of this case?
1. Blood group
2. 5P in details
3. Do a pregnancy test
4. Arrange USG scan to check the site and viability of the pregnancy
5. If blood group is Rh-ve, must give anti-D
6. Given that the USG examinations are completely normal, the chances of having a successful pregnancy is 90-95%
38
23 years old Jane has come to the ED after developing vaginal bleeding after eight weeks of amenorrhoea. Home pregnancy test is positive and USG shows viable sac in the uterus.
What is the diagnosis?
Condition: Threatened miscarriage
Cause/Risk factors:
1. Smoking, drinking alcohol and using recreational drugs
2. Excessive coffee intake
3. Trauma
4. Infections- TORCH
5. Problems of the placenta
6. Genetic abnormalities of the baby
Course/ Prognosis:
90-95% cases have normal successful pregnancy given that the USG findings are normal
39
23 years old Jane has come to the ED after developing vaginal bleeding after eight weeks of amenorrhoea. Home pregnancy test is positive and USG shows viable sac in the uterus. Patient’s blood group in O-ve.
Tell the management of this patient.
1. Do a office pregnancy test to confirm pregnancy
2. Refer to the hospital to be seen by the specialist
3. All antenatal Investigations:
Blood - FBE with ESR and CRP
- UEC
- LFT
- TFT
- Coagulation profile
- Blood grouping and Rh typing
- Vit D levels
- BSL
- Rubella and Varicella serology
- STI screening
- TORCH screen (in this case)
- indirect Coombs test (since this patient is Rh -ve)
Urine - for MCS
Imaging - USG - to confirm the site and viability of pregnancy
- to check the sac size, liquor volume and fetal heart activity
4. If USG shows normal viable pregnancy, you can go home.
Consider giving anti-D if abortion occurs
5. At home: - avoid overexerting yourself
- no heavy lifting or active sports
- do not use tampons for the bleeding, use pads
- no sexual activity until the symptoms have completely gone for 1week.
6. I’ll start you with folic acid 0.5mg that you need to take for 3 months.
7. Repeat USG - after 1 week
- at 18 weeks
- at 32 weeks (if needed)
8. Down syndrome screening
9. Sweet drink test at 28 weeks
Bug test at 36 weeks
10. Maintain healthy diet
Coffee not more than two cups per day
11. Red flags
Review after discharge
40
25 year old married nulliparous woman presents to the GP with vaginal bleeding after eight weeks of amenorrhoea.
Tell the management of this condition.
1. The exact cause of your bleeding is still unclear. It could be - all the DDs
2. The most important thing to do is to rule out if you are pregnant or not.
For that, do a B-Hcg
• If B-Hcg is negative:
- it might just be a late period
- just wait and observe for the pattern of your periods
- do more investigations to know the cause of irregular periods (FSH, LH, Prolactin, TFT)
• If B-Hcg is positive:
- and is >1000 U/L
- do an USG scan to check the site and viability of the pregnancy, gestational age and due date.
- further investigate the causenof bleeding and treat accordingly
41
What is C-section and what are it’s indications?
• C-section is a surgery where the specialist makes a cut on the lower part of your tummy and then on your womb to deliver the baby, the placenta and it’s membranes under anaesthetia.
• We usually go for a C-section if there are definite indications.
Indications of elective CS:
1. Placenta Previa
2. Abruptio Placenta
3. Previous two CS
4. Multiple pregnancies
5. Cephalopelvic disproportion
6. Big baby
7. Abnormal lie and presentation of the baby
Indications of emergency CS:
1. Baby becomes unwell
2. Arrested labour at any point
3. Eclampsia
4. Cord prolapse
42
What are the complications and disadvantages of C-section?
Complications of C-section to the mother:
1. Anaesthetic hazards- breathing difficulties
2. Injury to surrounding organs and vessels
3. Excessive bleeding
[Although these complications are rare when done by a trained specialist]
4. Develop clots in your legs after surgery
5. Infection of the womb/Endometritis
Complications of C-section for the baby:
1. Respiratory distress
2. Breathing problems more common in babies delivered via CS than vaginal delivery
Disadvantages of C-section:
1. Longer stay in the hospital (3-5 days)
2. Longer duration of pain because in vaginal delivery you will have pain only during delivery but in C-section the pain will be there until thw wound completely heals.
3. Problems with future attempts of vaginal births like scar ruptures.
43
What are the advantages and disadvantages of Vaginal birth?
Advantages of vaginal birth over C-section:
1. Natural method of delivery
2. No risks of anaesthetic hazards or surgical complications
3. Shorter stay in the hospital
4. Shorter duration of pain
5. Recovery is quick
6. As many number of vaginal deliveries as you want in the future
Disadvantages of vaginal birth:
1. Pain during delivery
2. Damage to pelvic floor muscles leading to urinary incontinence
3. Failure leading to C-section
44
Pain relief options during vaginal delivery and prevention of urinary incontinence after vaginal delivery.
Pharmacological :
1. Epidural
- anaesthetic drugs introduced into the outer covering of your spine
- that numbs the nerves to your womb and the muscles surrounding it
- can be topped up anytime
2. Pethidine injections
3. Nitrous oxide and oxygen inhalation via face mask
Non-pharmacological :
1. Certain positions during labour can reduce pain
2. Deep breathing techniques
3. Hydrotherapy or giving birth while on water
4. TENS (transcutaneous electrical nerve stimulation)
- two electrodes placed on either side of the spine
- small electric current passed through them
- which inhibits the pain fibers
Preventing urinary incontinence:
- Pelvic floor muscles strengthening exercises called Kegel exercise
- from 6 weeks after delivery
- physiotherapist and post-natal classes that teach you this
45
Management of acute pyelonephritis in pregnancy
1. Admit to the hospital to be seen ny specialists
2. Urine for MCS
ALL other investigations
Renal USG if specialiss prefer
3. IV antibiotics - Cephalexin
4. IV fluids
5. NPO
6. Panadol for the fever
7. Repeat MCS after one week
46
Management of UTI in pregnancy
1. Take urine sample for MCS
All other investigations to rule out DD
2. Start antibiotics- Cephalexin oral
3. Panadol for fever
4. Antiemetic for vomiting
5. Drink fluids
Genital hygiene
6. Red flags
47
30 years old Mary had CS 3 days back. She has a temperature of 38C. Baby is doing fine.
List the differentials.
1. Endometritis
2. Wound infection
3. Breast abscess
4. Mastitis
5. UTI
6. DVT
48
Causes of secondary postpartum hemorrhage
1. Endometritis
2. Tear/laceration
3. Retained bits of placenta
4. Hematoma in the birth canal
49
Management of Endometritis
Condition- Endometritis
Infection of the inner lining of the womb/uterus
Cause- there are some bacteria that are part of the normal vaginal flora.
During vaginal delivery or Caesarean section, these bugs can ascend high up towards the uterus and causes infection of the innermost lining.
Commonality- not an uncommon condition
Clinical features-
1. Fever
2. Tummy pain
3. Vaginal bleeding
After 24 hours to upto 6 weeks of delivery
Complications- but if not treated immediately, the infection can become more severe and we might also need to remove the uterus.
Management:
1. Admin to the hospital immediately to be seen by the specialist.
2. Secure an IV access.
Take blood sample for investigations
and start the patient on
- IV fluids
- IV antibiotics,
- Panadol for the tummy pain and fever
- IV Oxytocin.
• If your condition is still not improving, we will also rule out other diagnosis like retained bits of placenta.
• We will explore under General Anastacia and a gentle blunt curatage will be done to remove the products of placenta. This will be done under antibiotic coverage.
• If the episiotomy is infected, a swab will be taken and the wound will be restitched
50
History to take from the nurse in case of a patient with severe postpartum hemorrhage
1. Hemodynamic stability
2. About the bleeding
3. About the delivery
4. About the baby
5. Rule out D/D
6. Management given so far
51
28 year old Emily, mom of 5 week old baby, comes to the GP, with complaints of tiredness and fever since the past two days.
What can be the possible causes?
1. Endometritis
2. Wound infection
3. Breast abscess
4. Mastitis
5. Pneumonia
6. UTI
7. DVT
52
28 year old, Emily Mom of five week old baby comes to the GP with complaints of tiredness and fever since the past two days
What history are you going to take?
1. About the fever - SOCRATES
2. About Breast-
- are you breastfeeding the baby?
- Do you have any pain lumps or redness in the breast?
- Any cracked nipples or sore nipples?
- Any discharge from the nipples
- Have you been taught the proper position and attachment of the baby to the breast and are you following that?
2. About the delivery:
- what was your mode of delivery
-and how long was the delivery?
- Was there any complications?
- Any instruments required?
- Any episiotomy done?
- Do you have any genital tears or lacerations
- any wound that’s not healing?
4. Associated questions for D/D
5. Well person questions
6. HEADSS - Are you enjoying the motherhood?
- Do you have enough support?
7. SADMA COT FP
53
28 year old, Emily Mom of five week old baby comes to the GP with complaints of tiredness and fever since the past two days.
Explain the diagnosis
Condition - Mastitis of the right breast
that is an infection of the tissue of the breast caused by a bacteria.
Cause- These bugs can enter into the breast if there are :
- any cracks in the nipple from the babies mouth
- the surrounding area of your skin
The cause of the crack nipples is usually due to poor positioning of the baby to the breast.
54
Management of postpartum mastitis
1. Start antibiotic- Flucoxacillin for 7 days
Panadol for the fever and pain.
2. Keep breastfeeding the baby, especially from the affected breast.
The breast milk is an excellent media for the bacteria to grow so it us very important that you drain the breast milk out of the affected breast.
Don’t worry it will not cause any harm to the baby as the bacteria will get neutralised in the baby’s gut.
4. For the pain - try using hot washers before breastfeeding and cold washers after breastfeeding.
5. Drink plenty of fluids
And take adequate rest
55
Management of postpartum breast abscess
1. Admit to the hospital
2. Incision and drainage of the abscess under anaesthesia
3. Antibiotics and Panadol
4. Express breastmilk with a pump while you cannot breastfeed.
56
25 years old Mary, who is seven days postpartum presents to the GP because she feels exhausted, lack of energy and quite irritable at times.
Take history.
1. About the presenting complaints- SOCRATES
2. About Pregnancy
3. About delivery
4. Associated symptoms
- Head to toe
- Thyroid
6. Well person questions
7. HEADSS
8. Psychoaocial history
9. SADMA COT FP
57
25 years old Mary, who is seven days postpartum presents to the GP because she feels exhausted, lack of energy and quite irritable at times.
Explain the condition
Condition- Postpartum blues.
Clinical features-
Mood swings
Irritability
Sudden bursting into tears
weeks after delivery.
Cause-
1. Hormonal imbalance after the delivery of the baby.
2. Social contributing factors like
- lack of social support
- physical, mental, emotional exhaustion
- sleep deprivation.
58
Management of postpartum blues
1. I’d like to arrange some basic investigations
2. Organise a social worker to help you
3. Arrange a family meeting with her husband with your permission
4. Referral to counsellor or psychologist to help you cope with the stress
5. These should be fine in around 1 to 2 weeks
6. Reassurance-
You are doing a good job as a mother.
I know it’s very difficult for the first time and lots of adjustments need to be done.
You’re not alone. We’re here to help you.
59
Explain postpartum depression with psychotic features
Condition- postpartum depression with psychotic features
Clinical features-
In this condition, you may feel
- extreme sadness,
- loss of interest and energy
- affect your sleep and eating
- Sometimes associated with impairment of perception or belief
Cause-
About half of women who experienced have no risk factors.
But women at higher risk are who have:
1. A prior history of mental illness, specially bipolar disorder
2. History of previous episode of postpartum psychosis
3. a positive family history
60
Management of postpartum depression with psychotic features
1. I’m quite concerned about you and your baby, so it would be best for me to involve the crisis assessment team.
2. According to the mental health act, I need to go for involuntary admission I’m sorry
3. In the hospital, you will be reviewed by a psychiatrist.
4. They might put you in antipsychotic and antidepressant medications and mood stabilisers.
5. If you don’t get better, the specialist might also do ECT.
6. Is good to involve your partner and other family members who can support you.
7. Organise a social worker to help you and your baby.
Most likely breastfeeding will be terminated
8. Later on, you’ll be seen by a psychologist.
They will council you by cognitive behavioural therapy.
9. Prognosis is good with early treatment, but there’s a chance of relapse in the future.
10. Reassurance
61
Management of PPROM
1. Refer to a tertiary hospital with NICU
Call an ambulance and Inform the doctors over there so that they’re ready for you.
2. Secure an intravenous access
Take blood samples for investigations:
- FBE with ESR CRP
- Urea electrolyte and creatinine blood grouping
- blood sugar level
- coagulation profile
- urine for microscopic culture sensitivity
3. I’ll give you the first dose of steroids for the lung maturation of your baby.
4. First dose of antibiotic continued for 10 days
If hospital is far, give Tocolytics
5. Once in the hospital, you will be seen by the specialist. They will do
- USG and CTG every 2 days
- blood tests every 2 to 3 days
6. If there is no signs of infection, labour will be induced at 36 completed weeks.
7. If there is any signs of infection or you develop symptoms, such as fever, or the baby becomes unwell, delivery will be planned immediately, either by induction or C-section
• If there is any cervical suture:
1. remove the cervical suture at 37-38 weeks in the hospital
2. send for microscopic culture sensitivity
3. then give her antibiotics
62
Causes of recurrent miscarriage
R I B C A G E
R= Radition
I= Immune mediated (Thrombophilia, SLE, APAS)
B=Bugs/Infections (TORCH, STI, Hep B, C)
C= Cervical Incompetence
A= Anatomical abnormality of the uterus
G= Genetic/Chromosomal abnormality in mother, father or baby
E= Endocrine (DM, Thyroid)
= Epidimiological (advanced maternal age, previous hx of miscarriages)
AMC
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