obstetrics for finals - wordpress.com · 2016-05-13 · 7. management of labour and delivery 8....
TRANSCRIPT
Alice Graham
FY1
OBSTETRICS FOR
FINALS
Learning outcomes
1. Basic clinical skills – history, examination, investigations…
2. Ethics and legal issues
3. Clinical governance
4. Clinical pharmacology and therapeutics
5. Antenatal care in low-risk pregnancy, recognition of high-risk
and abnormal pregnancy and appropriate modifications to
antenatal care. Importance of preconception case.
6. Maternal medicine – effect of pre-existing medical conditions
on pregnancy and effect of pregnancy on these conditions
7. Management of labour and delivery
8. Postpartum problems.
Outline
Antenatal care
Antenatal schedule
Maternal screening
Foetal screening
Pregnancy Antepartum Haemorrhage
Gestational diabetes
Preeclampsia
Labour and
delivery
Premature rupture
membranes
Obstructed labour
Post-partum haemorrhage
Case study
Amy
32 years old
G3 P1+1
BMI 30, hypothyroidism
Antenatal care - questions
1.What dose of folic acid should Amy take and for how long?
2.How many antenatal visits would a multiparous expect to have?
3.What routine tests would be carried out at antenatal visits?
1.How would Amy’s baby be screened for Down’s syndrome?
1. Schedule of antenatal care
8-12
• Booking appointment
• Screening and dating
16 • Review results of screening
18-20
• Anomaly scan
• Nulliparous – extra visit @ 25/40
28
• Second screening, antiD prophylaxis
• Nulliparous – extra visit @ 31/40
34
• 2nd antiD prophylaxis
• Labour planning
36 • Assess foetal presentation
38 • Nulliparous –extra visit @ 40/40
>41 • Weekly from 41/40
ANTENATAL CARE
2. Maternal screening in pregnancy
Blood tests
• Hb
• Blood group
• Syphilis, rubella
• HIV, HepB
Urine
• Bacteriuria
• Protein
• Glycosuria
Examination
• BP
• Fundal height
• 36/40 lie and presentation
ANTENATAL CARE
3. Foetal screening in pregnancy
• Ultrasound – ‘soft signs’
• AFP
• Amniocentesis
• Chorionic Villus Biopsy
ANTENATAL CARE
3. Foetal screening in pregnancy
ANTENATAL CARE
Down’s syndrome
Combined test
10+3 to 13+6 weeks
Nuchal translucency Free B-HCG Pregnancy
associated plasma protein
Woman’s age
Integrated test
Combined test 1st trimester
AND Quadruple test in 2nd
trimester
Quadruple test
15 to 20 weeks
Maternal AFP Unconjugated estriol
Free/total BHCG Inhibin A
Woman’s age
Case study
Amy, 32 years old
Para 1+1, Gravida 3
BMI 30, hypothyroidism
Pregnancy - questions
1. How do we differentiate between placental abruption
and placenta praevia?
2. What complications are associated with gestational
diabetes?
3. What are the symptoms of pre-eclampsia?
Case study
Amy, 32 years old
Para 1+1, Gravida 3
BMI 30, hypothyroidism
20/40 – antepartum haemorrhage
1. Antepartum Haemorrhage
Genital tract bleeding from 24weeks
abruption
• Constant pain and tender uterus
• Normal lie and presentation
• Foetal heart absent or distressed
• Shock proportionate to visible blood loss
praevia
• No pain, abdomen non-tender
• Abnormal lie/presentation
• Foetal heart normal
• Shock disproportionate
Case study
Amy, 32 years old
Para 1+1, Gravida 3
BMI 30, hypothyroidism
20/40 – small haemorrhage – simple ectropion
28/40 – fasting glucose = 6.5mmol/l
2. Gestational Diabetes
Fasting glucose >5.6mmol/l
2hour OGTT >7.8mmol/l
PREGNANCY
Maternal complications
• Instrumental delivery
• Long term diabetes
• Pre-eclampsia
Foetal complications
• Macrosomia
• Growth restriction
• Metabolic abnormalities
• Premature birth
• Miscarriage
• Still birth
• Childhood/adult obesity
Case study
Amy, 32 years old
Para 1+1, Gravida 3
BMI 30, hypothyroidism
20/40 – small haemorrhage – simple ectropion
28/40 – gestational diabetes
36/40 – proteinuria 2+
3. Pre-eclampsia
Pregnancy-induced hypertension and proteinuria
Symptoms:
•Flu – headache, vomiting, tachycardia
•Neuro – visual disturbance, hyper-reflexia, seizures
•Organ failure – liver, renal, cardiac
PREGNANCY
Case study
Amy, 32 years old
Para 1+1, Gravida 3
BMI 30, hypothyroidism
Small antepartum haemorrhage,
gestational diabetes, pre-eclampsia
Things are about to get scary…
Normal Labour
3rd stage - placental
2nd stage - expulsive
1st stage - dilatation
Latent phase Active Phase
LABOUR AND DELIVERY
Labour and Delivery
1. How do we manage PROM?
2. What are the types of operative delivery?
3. What are the risk factors for PPH?
Case study
Amy, 32 years old
Para 1+1, Gravida 3
BMI 30, hypothyroidism
gestational diabetes, pre-eclampsia
Things are about to get scary…
Admitted to hospital due to pre-eclampsia
at 36/40.
Waters break in car ride to hospital.
1. Premature rupture of membranes
Rupture of membranes before 37+6 weeks
Benefits of remaining in utero
Vs
Risk of infection
LABOUR AND DELIVERY
CTG
D
R
C
B
R
A
V
A
D
O LABOUR AND DELIVERY
Define risk
Contractions
Baseline rate
Variability
Acceleration
Decelerations
Overall Impression
CTG
LABOUR AND DELIVERY
Case study
Amy, 32 years old
Para 1+1, Gravida 3
BMI 30, hypothyroidism
gestational diabetes, pre-eclampsia
Things are about to get scary…
PROM.
Amy starts to have contractions
2. Operative delivery
LABOUR AND DELIVERY
1
2
3
Perineal tears
LABOUR AND DELIVERY
Case study
Amy, 32 years old
Para 1+1, Gravida 3
BMI 30, hypothyroidism
gestational diabetes, pre-eclampsia
Things are about to get scary…
PROM.
Amy starts to have contractions
Baby delivered using forceps.
Placenta delivered. 2nd degree tear.
Amy starts to lose a lot of blood…
3. Post partum Haemorrhage
Loss of >500mls of blood in first 24hours after delivery
LABOUR AND DELIVERY
Antenatal
• Previous PPH
• BMI>35
• Maternal anaemia
• Antepartum haemorrhage
• Multiparity
• Maternal age >35
• Uterine malformation
• Placental abnormalities
Labour
• Prolonged labour
• Induction
• Oxytocin use
• Operative birth
Case study Amy, 32 years old
Para 1+1, Gravida 3
BMI 30, hypothyroidism
gestational diabetes, pre-eclampsia
Things are about to get scary…
PROM.
Baby delivered using forceps.
Placenta delivered. 2nd degree perineal tear.
Amy starts to lose a lot of blood…
Bleeding controlled with suturing of laceration.
Amy stabilised and remains in hospital for 1 week.
Mum and baby well on discharge. THE END
Outline
Antenatal care
Antenatal schedule
Maternal screening
Foetal screening
Pregnancy Hyperemesis Gravidarum
Gestational diabetes
Preeclampsia
Labour and
delivery
Premature rupture
membranes
Obstructed labour
Post-partum haemorrhage
Alice Graham
FY1
OBSTETRICS FOR
FINALS