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