In the Name of God Obstetrics Study Guide 3 Mitra Ahmad Soltani 2008
References <ul><li>Iranian Council for graduate Medical Education. Board and pre-board Exam questions for OBS and Gyn .200...
HTN in Pregnancy
classification <ul><li>Hypertension is the most common medical problem encountered during pregnancy, complicating 2-3% of ...
Chronic HTN <ul><li>blood pressure exceeding 140/90 mm Hg before pregnancy or before 20 weeks' gestation. It persists afte...
Gestational Age <ul><ul><li>New-onset or worsening hypertension after 20 weeks' gestation should lead to a careful evaluat...
Maternal Risk factors
Placental Risk factor <ul><ul><li>Multiple gestations  </li></ul></ul><ul><ul><li>Hydrops fetalis  </li></ul></ul><ul><ul>...
BP measurement <ul><ul><li>Blood pressure should be measured in the sitting position, with the cuff at the level of the he...
Indications of preg. termination Mild Severe Diastolic blood pressure <100mmhg 110 mmhg or higher Proteinuria Trace to 1+ ...
CBC <ul><ul><ul><li>Platelet counts less than 100,000/µL suggest preeclampsia or ITP.  </li></ul></ul></ul><ul><ul><ul><li...
Proteinurea <ul><ul><li>Trace levels to +1 proteinuria are acceptable, but levels of +2 or greater are abnormal and should...
Protein:Cr ratio <ul><li>Creatinine clearance increases approximately 50% during pregnancy, and levels less than 100 mL/mi...
Coagulation tests <ul><ul><li>LDH,  </li></ul></ul><ul><ul><li>bilirubin,  </li></ul></ul><ul><ul><li>haptoglobin, </li></...
Fetal Monitoring <ul><ul><li>Alternate a biophysical profile with a fetal NST twice each week. </li></ul></ul><ul><ul><li>...
Methyldopa (Aldomet) Centrally acting antihypertensive agent widely considered the first-line agent for treatment of hyper...
Hydralazine (Apresoline) Intravenous form is useful when treating severe hypertension due to preeclampsia/eclampsia. 10-20...
Life-threatening complications in preeclampsia  <ul><ul><li>Seizures  </li></ul></ul><ul><ul><li>Cerebral hemorrhage  </li...
IMP: mild preeclampsia <ul><li>General: condition/position/diet =low salt,high prot </li></ul><ul><li>Lab: CBC ,BG, Rh, U/...
IMP: Severe preeclampsia <ul><li>General: condition/position/diet =NPO </li></ul><ul><li>Lab: CBC ,BG, Rh, BUN/Cr, PT, PTT...
Preterm Pregnancy
Definition <ul><li>Preterm labor is defined as the presence of uterine contractions of sufficient frequency and intensity ...
Causes of preterm Labor <ul><li>decidual hemorrhage, (eg, abruption, mechanical factors such as uterine overdistension fro...
Risk factors of preterm birth <ul><li>Demographic factors for preterm labor include nonwhite race, extremes of maternal ag...
Methods for predicting preterm birth <ul><li>home uterine activity monitoring (HUAM) </li></ul><ul><li>salivary estriol : ...
Contraindication to tocolysis <ul><li>1-Fetal growth restriction  2-Oligohydramnios  3-Nonreactive NST,Positive CST  4-Abs...
Definition of IAI (Intra Amniotic Infection) <ul><li>A temperature greater than 38.0°C (100.0°F) and  2 of the 5  followin...
Chorioamnionitis Order <ul><li>General: condition/position/diet=NPO </li></ul><ul><li>Lab: CBC diff, MP, WW, B/C X2, U/A ,...
IMP:PLP before 37 weeks out patient: (contractions 4 in 20  min or 8 in 60 min +progressive change in cervix cervical dila...
IMP:PLP before 37 weeks, hospitalized <ul><li>General: condition/position/diet </li></ul><ul><li>Lab: CBC, BG, Rh, U/A, U/...
Contraindication for beta mimetics <ul><li>Maternal  </li></ul><ul><li>cardiac disease </li></ul><ul><li>Diabetes </li></u...
Contraindication for MgSO4 <ul><li>Hypocalcemia </li></ul><ul><li>Myasthenia gravis </li></ul><ul><li>Renal failure </li><...
Dosage of Ritodrine or Terbutaline for tocolysis <ul><li>50-100 mcg/min increase by 50 mcg/min every 10 min </li></ul><ul>...
Length of GA with multiple fetuses <ul><li>Twin=36 wks </li></ul><ul><li>Triplets=33.5 wks </li></ul><ul><li>Quadruplets=3...
Postterm
Definition of postterm <ul><li>Postterm pregnancies define pregnancies extending up to or after 42 weeks.  </li></ul><ul><...
Cause of postterm P. <ul><li>The most frequent cause of postterm pregnancy is inaccurate dating criteria  </li></ul><ul><l...
Risks of postterm P <ul><li>Macrosomia complications like shoulder dystocia, </li></ul><ul><li>CPD and Maternal risks like...
surveillance <ul><li>NST and AFI 2 times per week for pregnancies continuing past 41 weeks. </li></ul>
Intra Uterine  Growth  Retardation
Definition  <ul><li>Intrauterine growth restriction (IUGR)  occurs when the unborn baby is at or below the 10th weight per...
Classification   Symmetric l A symmetrical baby's brain is abnormally large when compared to the liver . may occur when th...
Etiology of IUGR <ul><li>Idiopathic- In a majority of cases (40%) </li></ul>
Maternal Risk Factors <ul><li>Has had a previous baby with IUGR </li></ul><ul><li>Extremes of age  </li></ul><ul><li>Small...
Maternal Risk Factors <ul><li>Multiple pregnancy </li></ul><ul><li>Living in High altitude locations </li></ul><ul><li>Dru...
Fetal Risk Factors <ul><li>Intrauterine infection: German  measles  ( rubella ), cytomegalovirus,  herpes simplex, tubercu...
Placental Factors <ul><li>Uteroplacental insufficiency: </li></ul><ul><ul><li>Improper / inadequate trophoblastic invasion...
Screening:   <ul><li>US fetal biometry: HC- BPD- AC </li></ul><ul><li>Uterine Doppler studies (Doppler Velocimetry): bilat...
Neonatal Diagnosis   <ul><li>Low ponderal index (Wt./Fl). </li></ul><ul><li>Decreased subcutaneous fat. </li></ul><ul><li>...
Prevention  <ul><li>Strong  evidence of benefit only for the following interventions:  </li></ul><ul><ul><li>balanced prot...
S urveillance  <ul><li>Non-Stress Test , </li></ul><ul><li>Amniotic Fluid Index ,  </li></ul><ul><li>Doppler of the Umbili...
S urveillance  The current recommendations are that if the AFI decreases below 5 after 35 weeks, then delivery should occu...
Treatment <ul><li>Bed rest </li></ul><ul><li>Aspirin before 20 wk GA </li></ul><ul><li>Nutritional supplementation: zinc ,...
For cases termination is indicated: <ul><li>Corticosteroids with a delay in delivery for 2.4 days </li></ul><ul><li>Mode o...
Short Term Risks of IUGR for the neonate   <ul><ul><li>Meconium Aspiration Syndrome,  </li></ul></ul><ul><ul><li>infection...
Long term  Prognosis   <ul><li>Fetal Death </li></ul><ul><li>low blood sugar </li></ul><ul><li>low body temperature   </li...
abruptio
Definition <ul><li>Abruptio placentae (ie, placental abruption) refers to separation of the normally located placenta afte...
Symptoms and signs <ul><ul><li>Vaginal bleeding - 80%  </li></ul></ul><ul><ul><li>Abdominal or back pain and uterine tende...
Classification of abruptio <ul><li>extent of separation (ie, partial vs complete)  </li></ul><ul><li>location of separatio...
classification Class  VB Uterus tenderness BP-HR coagulopathy Fetal distress 0 mild --------- NL ----------- --------- 1 m...
Causes1 <ul><li>Maternal HTN(44% of all cases)  </li></ul><ul><li>Maternal trauma </li></ul><ul><li>Cigarette smoking  </l...
causes2 <ul><li>Short umbilical cord  </li></ul><ul><li>Sudden decompression of the uterus (eg, PROM, delivery of first tw...
Imaging Studies <ul><li>Ultrasonography is not very useful in diagnosing placental abruption.  </li></ul><ul><ul><li>Retro...
IMP: R/O abruption <ul><li>Condition/position/diet:NPO </li></ul><ul><li>Lab: CBD-BG-Rh-U/A-U/C-PT-PTT-Fib-FDP-D-Dimer- </...
Placenta Previa
subtypes <ul><li>(1) complete or total: the placenta covers 360° of the internal cervical os;  </li></ul><ul><li>(2) incom...
Risk factors <ul><li>prior placenta previa,  </li></ul><ul><li>prior cesarean delivery,  </li></ul><ul><li>increased mater...
Frequency <ul><li>1 in 200 deliveries </li></ul>
Vaginal Bleeding <ul><li>painless vaginal bleeding during the second half of pregnancy (70%). </li></ul><ul><li>It can occ...
management <ul><li>Patients are treated expectantly, with: </li></ul><ul><li>volume replacement,  </li></ul><ul><li>transf...
Preferred Examination <ul><li>Physical examination should be performed only with a fetus that has achieved pulmonary matur...
Preferred examination <ul><li>TA sonography is the test of choice to confirm placenta previa.  </li></ul><ul><li>When the ...
Blood loss classifications
med-ed-online 2007   Class 1 Class 2 Class 3 Class 4 Blood Loss Volume (mls) in adult 750mls 800 - 1500mls 1500 - 2000mls ...
med-ed-online 2007 Estimated blood loss Suitable fluid regimes 1000 mls 3000 mls crystalloid or 1000 mls colloid 1500 mls ...
Multiple pregnancy <ul><li>Pictures and material of multiple pregnancy are adapted from: </li></ul><ul><li>Zach T. multipl...
pathophysiology1 <ul><li>Dizygotic twins(fraternal) are produced when 2 sperm fertilize 2 ova. Separate amnions, chorions,...
Diamniotic/dichorionic placentation
pathophysiology2 <ul><li>Later splitting (ie, 3-8 d after fertilization) results in monochorionic/diamniotic placentation ...
Diamniotic/monochorionic placentation
pathophysiology3 <ul><li>If splitting occurs even later (ie, during 9-12 d after fertilization), monochorionic/monoamnioti...
Monoamniotic/monoamniotic placentation
pathophysiology4 <ul><li>Monochorionic/monoamniotic twins have a common placenta with vascular communications between the ...
pathophysiology5 <ul><li>Trizygotic triplets occur when 3 sperm fertilize 3 ova.  </li></ul><ul><li>Dizygotic triplets dev...
Frequency <ul><li>The birth rate of monozygotic twins is constant worldwide (approximately 4 per 1000 births).  </li></ul>...
mortality <ul><li>low birth weight infants( due to prematurity and (IUGR)  </li></ul><ul><li>congenital anomalies,  </li><...
History <ul><li>excessive weight gain, </li></ul><ul><li>hyperemesis gravidarum,  </li></ul><ul><li>sensation of more than...
Neonatal Lab Studies <ul><li>CBC count: In TTTS, the donor twin is frequently anemic at birth. The recipient twin is polyc...
TRAP <ul><li>Twin reversed arterial perfusion (TRAP) sequence occurs when an acardiac twin receives all of the blood suppl...
TTTS <ul><li>Occurs in monochorionic/monoamniotic or monochorionic/diamniotic twins. Vascular anastomoses in the monochori...
Conjoined twins  <ul><ul><li>Incomplete late division of monozygotic twins produces conjoined twins.  </li></ul></ul><ul><...
Discordant <ul><li>. Birth weight discrepancies of more than 20-25% are considered discordant. Discordant birth weights oc...
Gestational Trophoblastic Neoplasia
classification <ul><li>hydatidiform mole : is the most common form of gestational trophoblastic neoplasia it can behave in...
Clinical course <ul><li>In 80% of patients with a benign hydatidiform mole, serum HCG titers steadily drop to normal withi...
staging <ul><li>Stage I – Confined to the uterus  </li></ul><ul><li>Stage II – Limited to the genital structures  </li></u...
WHO prognostic criteria1 <ul><li>Age 40 years or older = 1 point  </li></ul><ul><li>Antecedent pregnancy terminated in abo...
WHO prognostic criteria 2 <ul><li>Beta-HCG level in serum is 1000 mIU/mL but less than 10,000 mIU/mL = 1 point  </li></ul>...
WHO prognostic criteria3 <ul><li>Site of metastases is gastrointestinal tract = 2 points  </li></ul><ul><li>Site of metast...
Sign and Symptoms <ul><li>Patients with a hydatidiform mole present with signs and symptoms of pregnancy.  </li></ul><ul><...
Sign and Symptoms <ul><li>Prolonged hyperemesis gravidarum  </li></ul><ul><li>preeclampsia  </li></ul><ul><li>Hyperthyroid...
Physical Exam <ul><li>a positive pregnancy test result occurs in the absence of a fetus.  </li></ul><ul><li>vesicles in th...
Cause <ul><li>A hydatidiform mole occurs when a haploid sperm fertilizes an egg that has no maternal chromosomes and then ...
Medical care1 <ul><li>Emergency department care involves : </li></ul><ul><li>starting intravenous (IV) fluids (crystalloid...
Medical Care2 <ul><li>Patients with benign do not require medical therapy.  </li></ul><ul><li>observing patients with week...
Medical care3 <ul><li>Patients with malignant nonmetastatic or metastatic low-risk GTN are treated with single-agent chemo...
Medical care4 <ul><li>Patients with high-risk metastatic are subdivided into 2 groups: </li></ul><ul><ul><li>In patients w...
Medical Care5 <ul><ul><li>Patients with WHO scores of 8 or higher are treated with a combination of etoposide, MTX, and ac...
Medical care6 <ul><ul><li>Patients with metastasis to the brain receive whole brain irradiation (3000 cGy) in combination ...
Surgical care <ul><li>The treatment of a hydatidiform mole is evacuation of the uterus by suction and sharp curettage.  </...
Further Care <ul><li>Obtain follow-up serum HCG titers : </li></ul><ul><li>once per week until 3-4 normal values are obtai...
Prognosis1 <ul><li>Nonmetastatic  GTN has a cure rate with chemotherapy of close to 100%.  </li></ul><ul><li>Metastatic lo...
Prognosis2 <ul><li>The rate of occurrence of a repeat molar pregnancy is approximately 1-2%.  </li></ul><ul><li>The rate o...
PREGNANT DIABETICS
ADAPTATION TO PREGNANCY <ul><li>In early pregnancy Estrogen  and Progesterone stimulate beta cell hyperplasia and increase...
GLUCOSE LEVELS IN NORMAL PREGNANCY <ul><li>Fasting levels decline by 10 – 11 mg/dl </li></ul><ul><li>Postprandial levels r...
CHO METABOLISM 20- 24 WEEKS <ul><li>Increased human placental lactogen – diabetogenic </li></ul><ul><li>Increased prolacti...
OTHER METABOLIC CHANGES <ul><li>Stable amounts of FFA </li></ul><ul><li>Increased cholesterol and TG </li></ul><ul><li>Red...
MATERNAL COMPLICATIONS <ul><li>Retinopathy </li></ul><ul><li>Nephropathy </li></ul><ul><li>Chronic hypertension </li></ul>...
RETINOPATHY <ul><li>Remains the leading cause of blindness in women ages 24-64 </li></ul><ul><li>Every patient with pre-ge...
NEPHROPATHY <ul><li>Accounts for 1/3 of the deaths in diabetics < 31 </li></ul><ul><li>Renal findings are present as early...
CHRONIC RENAL FAILURE <ul><li>Pregnancy is possible even in patients requiring hemodialysis </li></ul><ul><li>Reliable con...
CHRONIC HYPERTENSION <ul><li>Should be aggressively controlled </li></ul><ul><li>ACE inhibitors are contraindicated </li><...
PREECLAMPSIA <ul><li>BP > 140/90 </li></ul><ul><li>Proteinuria > 300 mg/24 hours or increase in baseline </li></ul><ul><li...
SEVERE PREECLAMPSIA <ul><li>BP > 180/110 </li></ul><ul><li>Proteinuria > 5 g/24 hours </li></ul><ul><li>Lab: elevated LFT’...
PREGNANCY COMPLICATIONS <ul><li>Hydramnios </li></ul><ul><li>Spontaneous abortions </li></ul><ul><li>Congenital malformati...
HYDRAMNIOS <ul><li>1-2 % in normals and 18% of diabetics </li></ul><ul><li>Fetal osmotic diuresis is etiologic </li></ul><...
SPONTANEOUS ABORTIONS <ul><li>In well controlled patients the rate is similar to the non-diabetic </li></ul><ul><li>Glycos...
CONGENITAL MALFORMATIONS <ul><li>Associated with periconceptual glucose control </li></ul><ul><li>In general the rate is 2...
TYPES OF CONGENITAL MALFORMATIONS <ul><li>Fetal cardiac anomalies may be complex </li></ul><ul><li>CNS – Spina Bifida, Ane...
GLYCOSYLATED HGB AND MALFORMATIONS <ul><li>HBA1C <8.5% , 3.4% malformations  </li></ul><ul><li>HBA1C > 8.5% , 22.4 % malfo...
MACROSOMIA <ul><li>Seen more frequently with GDM and IDDM without vascular complications </li></ul><ul><li>Related to leve...
DIABETIC KETOACIDOSIS <ul><li>Seen in type I DM </li></ul><ul><li>Infection, fever, beta – agonists are frequent predispos...
NEONATAL METABOLIC COMPLICATIONS <ul><li>Hypoglycemia </li></ul><ul><li>Hypocalcemia </li></ul><ul><li>Hypothermia </li></...
PRECONCEPTION COUNSELING <ul><li>“ Tight” periconceptual control is essential </li></ul><ul><li>The diabetes should be sta...
PRECONCEPTION GLUCOSE CONTROL <ul><li>Fasting blood glucose < 100 mg/dl </li></ul><ul><li>Pre-meal levels <110 mg/dl </li>...
PREVENTION OF MALFORMATIONS <ul><li>Normal glucose levels </li></ul><ul><li>Folic acid supplementation </li></ul><ul><li>D...
FOLIC ACID <ul><li>All women of reproductive age should consume at least 0.4 mg of folic acid </li></ul><ul><li>High risk ...
INDICATIONS FOR HOSPITALIZATION <ul><li>Persistent nausea and vomiting </li></ul><ul><li>Significant maternal infection </...
ASSESSMENT OF FETAL  WELL-BEING <ul><li>Daily fetal movement counting </li></ul><ul><li>Twice weekly NST by 32 weeks </li>...
FIRST PRENATAL VISIT <ul><li>Routine prenatal lab </li></ul><ul><li>Baseline 24 hour UA for protein and Cr Clearance </li>...
EARLY PREGNANCY CARE <ul><li>Diabetic education and dietary instruction </li></ul><ul><li>Multi-disciplinary care is helpf...
TIMING OF DELIVERY <ul><li>Well controlled IDDM: at term </li></ul><ul><li>Poorly controlled: after documentation of fetal...
INTRAPARTUM GLUCOSE CONTROL <ul><li>No breakfast the morning of induction </li></ul><ul><li>Establish IV with D5/.45% NaCl...
SHOULDER DYSTOCIA BW (g) No diabetes(%) Diabetes(%) < 4000 0.1-1.1 0.6-3.7 4000-4499 1.1-10.0 4.9-23.1 >  4500  4.1-22.6 2...
NERVE INJURY <ul><li>Rate varies from 4-40% following shoulder dystocia </li></ul><ul><li>Most (90%) resolve without seque...
POSTPARTUM GLUCOSE CONTROL <ul><li>Insulin requirements may fall 50% in the 1 st  24 hours </li></ul><ul><li>Little need f...
CONTRACEPTION <ul><li>Reliable contraception should be offered </li></ul><ul><li>Low-dose combination OCP’s do not signifi...
ACOG Low Risk <ul><li>Age < 25 </li></ul><ul><li>Not a member of an at risk ethnic group (Hispanic, African, Native Americ...
Screening <ul><li>If  FBS is  110-126: </li></ul><ul><li>Then 1 hr 50 gr or 3 hrs 100 gr </li></ul><ul><li>remember 105– 1...
Summary <ul><li>Every practice should adopt a screening strategy, either by historical or laboratory means </li></ul><ul><...
Some diabetic cases
Bita Hazrati   A PLP case  complicated by HTN and GD   <ul><li>24 yrs old  </li></ul><ul><li>G2 P1 L0 D1/ first fetal loss...
<ul><li>Ph E:  </li></ul><ul><li>PR= 86/min  RR:16/min  T:36  </li></ul><ul><li>BP= 140/90 mmHg </li></ul><ul><li>BS: </li...
20-30 units total : 2/3 intermediate   1/3 regular Morning: 10 units of NPH- 4 units of regular Afternoon: 4 units of NPH ...
FBS  is used to adjust evening NPH 2-hr PP (10 am)  is used to adjust  morning Regular Afternon preprandial (4 pm)  is use...
What is your management of this combined case of : 1- preeclampsia 2- GD 3- PLP
Answer: Mg so4  Ampicillin+ Erythro Isoxsuprine Sedation FBS-BS NST-FAD-OB US (AFI and GA) Insulin
Which is true about gestational diabetes? <ul><li>A-This happens during pregnancy with FBS less than 105 mg/dl. Its treatm...
Which is an independent cause of IUFD in diabetes? <ul><li>A-hydramnios </li></ul><ul><li>B-abruptio </li></ul><ul><li>C-o...
Which is not a good method of contraception in a diabetic woman?  <ul><li>A-LD OCP </li></ul><ul><li>B-medroxy progesteron...
What is the test for a 30 year old 10 wk pregnant woman whose FBS is 85/ 2hr PP is 125? <ul><li>A- 3 hr GTT </li></ul><ul>...
Which  is not  a cause of PIH for a diabetic pregnant woman? <ul><li>A-poor blood glucose control </li></ul><ul><li>B-albu...
What is the most common cause of perinatal mortality in diabetic pregnancies? <ul><li>A- malformations </li></ul><ul><li>B...
What is one stage screening test for diabetes in pregnancy? <ul><li>A-100 grs oral glucose in 24-28 wk. </li></ul><ul><li>...
What is your plan for a 35 wk diabetic pregnant woman whose BP is 140/90 mmHg/ is on 60 units of insulin /FBS=120 mg/dl? <...
What is your management of a 30 yr old 35 wk pregnant woman class R diabetic with severe retinopathy?  <ul><li>A-terminati...
Which is not among the complications of type A2 diabetes in pregnancy? <ul><li>A- macrosomia </li></ul><ul><li>B-increased...
A woman with a history of gestation diabetes is asking for follow-up management after her delivery. Her FBS is 108 mg/dl a...
In a woman with overt diabetes , BS is reported to be 130 mg/dl . What do you suggest for her IV infusion? <ul><li>A- RL a...
Points to remember about diabetic labor: <ul><li>BS below 100 mg/dl : no insulin is needed </li></ul><ul><li>100-140 mg/dl...
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Obs Study Guide 3

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  • Current available estimates confirm that intrauterine growth retardation (IUGR) is a major public health problem world-wide. The prevalence of IUGR in most developing countries is above the international cut-off point for triggering public health action, and population-wide strategies are therefore urgently needed. Being born small for gestational age (SGA), which is usually defined as having a birth weight below the 10th centile of an accepted reference, is often used as a proxy for IUGR. SGA and IUGR are not synonymous, however. Some SGA infants may merely represent the lower tail of the &apos;normal&apos; fetal growth distribution, while other infants who have been affected in utero by an inadequate nutritional milieu or other growth-inhibiting influences may nevertheless have a birth weight that is &apos;appropriate&apos; for gestational age (AGA). Variations in fetal growth over the entire distribution of birth weight may have both etiologic and prognostic importance. In individual cases, however, it is usually very difficult to determine whether an observed birth weight that is low for gestational age is the result of true in utero growth restriction or represents a &apos;normally small&apos; infant. Classification of IUGR is therefore based on the established cut-off for SGA. The higher the prevalence of low birth weight (LBW) in a given population, the greater the likelihood that the majority are a result of IUGR.
  • Description There are standards or averages in weight for unborn babies according to their age in weeks. When the baby&apos;s weight is at or below the 10th percentile for his or her age, it is called intrauterine growth retardation or fetal growth restriction. These babies are smaller than they should be for their age. How much a baby weighs at birth depends not only on how many weeks old it is, but the rate at which it has grown. This growth process is complex and delicate. There are three phases associated with the development of the baby. During the first phase, cells multiply in the baby&apos;s organs. This occurs from the beginning of development through the early part of the fourth month. During the second phase, cells continue to multiply and the organs grow. In the third phase (after 32 weeks of development), growth occurs quickly and the baby may gain as much as 7 ounces per week. If the delicate process of development and weight gain is disturbed or interrupted, the baby can suffer from restricted growth.
  • Application of the international foetal growth reference curve will vary according to its specific clinical and public health uses or purposes. Criteria for diagnosis of foetal growth restriction (e.g., SGA) should be related to evidence of increased risk for perinatal mortality and/or other indices of adverse outcomes. The new reference should provide percentiles [(e.g., 3rd, 5th, 10th, 15th, 25th, 50th (median), 75th, 85th, 90th, 95th, and 97th)] as well as z-scores [(e.g., -3, -2, -1, 0 (mean), 1, 2, and 3 SD)], so that health planners and practitioners can use the most appropriate cut off based on local circumstances. Proportionality at birth may be related to adverse outcomes. Thus there is a need to develop reference data for birth length and head circumference in relation to GA, and for birth weight in relation to birth length. Because the concepts of &apos;wasting&apos; and &apos;stunting&apos; have proven useful for categorizing undernourished infants and older children, an attempt should be made to quantify the mortality and morbidity risks associated with &apos;wasted&apos; and &apos;stunted&apos; newborns and to develop indicators for their classification.
  • In developed countries, cigarette smoking is far and away the most important etiologic determinant, but low gestational weight gain and low pre-pregnancy BMI are also determinants. The etiologic roles of pre-eclampsia, short stature, genetic factors, and alcohol and drug use during pregnancy are well-established but quantitatively less important. Socioeconomic disparities in IUGR risk within developed countries are largely attributable to socioeconomic gradients in smoking, weight gain and maternal stature. In poor urban areas where cocaine abuse is highly prevalent, this may also be important. The etiologic role of micronutrients in IUGR remains to be clarified. The best evidence concerning their importance derives from randomized trials and from systematic overviews of those trials contained in the Cochrane Collaboration Pregnancy and Childbirth database. Unfortunately, there are few supplementation or fortification trials in developing country settings where deficiencies in these micronutrients are prevalent. Trials are required to define the possible etiologic roles of iron, calcium, vitamin D, and vitamin A, especially in developing countries. The evidence concerning folate, magnesium, and zinc also looks sufficiently promising to justify further investigation.
  • The physiologic and molecular mechanisms by which nutritional or other determinants affect fetal growth are incompletely understood. Growth is determined not only by substrate availability but also by the integrity of physiologic processes necessary to ensure transfer of nutrients and oxygen to the developing fetus. Expansion of maternal plasma volume, maintenance of uterine blood flow, and development of adequate placentation are key physiologic mechanisms required for optimal fetal growth. All substances used by the fetus are transported by the placenta: some (like oxygen and most other gases) by passive diffusion, others by facilitated transport proteins (e.g., Glut 1 for glucose), and still others (e.g., amino acids) by active energy-dependent transport processes. Insulin-like growth factors (IGFs) are important mediators of substrate incorporation into fetal tissue. IGF 1 appears to induce cell differentiation, including (perhaps) oligodendrocyte development in the brain, whereas IGF 2 may function to stimulate mitosis. It remains uncertain whether these physiologic and molecular mechanisms are merely the final common pathways for genetic or environmental determinants of IUGR, or whether they themselves vary (favorably or pathologically) independently of those determinants.
  • Most of the evidence on etiologic determinants is based on observational studies and systematic overviews or meta-analyses of such studies. In developing countries, the major determinants of IUGR are nutritional: low gestational weight gain (primarily due to inadequate energy intake), low pre-pregnancy BMI (reflecting chronic maternal undernutrition), and short maternal stature (principally due to undernutrition and infection during childhood). Gastroenteritis, intestinal parasitosis, and respiratory infections are prevalent in developing countries and may also have an important impact. Malaria is a major determinant in countries where that disease is endemic. Cigarette smoking is an increasingly important factor in some settings. In developed countries, cigarette smoking is far and away the most important etiologic determinant, but low gestational weight gain and low pre-pregnancy BMI are also determinants. The etiologic roles of pre-eclampsia, short stature, genetic factors, and alcohol and drug use during pregnancy are well-established but quantitatively less important. Socioeconomic disparities in IUGR risk within developed countries are largely attributable to socioeconomic gradients in smoking, weight gain and maternal stature. In poor urban areas where cocaine abuse is highly prevalent, this may also be important.
  • The etiologic role of micronutrients in IUGR remains to be clarified. The best evidence concerning their importance derives from randomized trials and from systematic overviews of those trials contained in the Cochrane Collaboration Pregnancy and Childbirth database. Unfortunately, there are few supplementation or fortification trials in developing country settings where deficiencies in these micronutrients are prevalent. Trials are required to define the possible etiologic roles of iron, calcium, vitamin D, and vitamin A, especially in developing countries. The evidence concerning folate, magnesium, and zinc also looks sufficiently promising to justify further investigation. The physiologic and molecular mechanisms by which nutritional or other determinants affect fetal growth are incompletely understood. Growth is determined not only by substrate availability but also by the integrity of physiologic processes necessary to ensure transfer of nutrients and oxygen to the developing fetus. Expansion of maternal plasma volume, maintenance of uterine blood flow, and development of adequate placentation are key physiologic mechanisms required for optimal fetal growth. All substances used by the fetus are transported by the placenta: some (like oxygen and most other gases) by passive diffusion, others by facilitated transport proteins (e.g., Glut 1 for glucose), and still others (e.g., amino acids) by active energy-dependent transport processes. Insulin-like growth factors (IGFs) are important mediators of substrate incorporation into fetal tissue. IGF 1 appears to induce cell differentiation, including (perhaps) oligodendrocyte development in the brain, whereas IGF 2 may function to stimulate mitosis. It remains uncertain whether these physiologic and molecular mechanisms are merely the final common pathways for genetic or environmental determinants of IUGR, or whether they themselves vary (favorably or pathologically) independently of those determinants.
  • The etiologic role of micronutrients in IUGR remains to be clarified. The best evidence concerning their importance derives from randomized trials and from systematic overviews of those trials contained in the Cochrane Collaboration Pregnancy and Childbirth database. Unfortunately, there are few supplementation or fortification trials in developing country settings where deficiencies in these micronutrients are prevalent. Trials are required to define the possible etiologic roles of iron, calcium, vitamin D, and vitamin A, especially in developing countries. The evidence concerning folate, magnesium, and zinc also looks sufficiently promising to justify further investigation. The physiologic and molecular mechanisms by which nutritional or other determinants affect fetal growth are incompletely understood. Growth is determined not only by substrate availability but also by the integrity of physiologic processes necessary to ensure transfer of nutrients and oxygen to the developing fetus. Expansion of maternal plasma volume, maintenance of uterine blood flow, and development of adequate placentation are key physiologic mechanisms required for optimal fetal growth. All substances used by the fetus are transported by the placenta: some (like oxygen and most other gases) by passive diffusion, others by facilitated transport proteins (e.g., Glut 1 for glucose), and still others (e.g., amino acids) by active energy-dependent transport processes. Insulin-like growth factors (IGFs) are important mediators of substrate incorporation into fetal tissue. IGF 1 appears to induce cell differentiation, including (perhaps) oligodendrocyte development in the brain, whereas IGF 2 may function to stimulate mitosis. It remains uncertain whether these physiologic and molecular mechanisms are merely the final common pathways for genetic or environmental determinants of IUGR, or whether they themselves vary (favorably or pathologically) independently of those determinants.
  • IUGR can be difficult to diagnose and in many cases doctors are not able to make an exact diagnosis until the baby is born. A mother who has had a growth restricted baby is at risk of having another during a later pregnancy. Such mothers are closely monitored during pregnancy. The length in weeks of the pregnancy must be carefully determined so that the doctor will know if development and weight gain are appropriate. Checking the mother&apos;s weight and abdomen measurements can help diagnose cases when there are no other risk factors present. Measuring the girth of the abdomen is often used as a tool for diagnosing IUGR. During pregnancy, the healthcare provider will use a tape measure to record the height of the upper portion of the uterus (the uterine fundal height). As the pregnancy continues and the baby grows, the uterus stretches upward in the direction of the mother&apos;s head. Between 18 and 30 weeks of gestation, the uterine fundal height (in cm.) equals the weeks of gestation. If the uterine fundal height is more than 2-3 cm below normal, then IUGR is suspected. Ultrasound is used to evaluate the growth of the baby. Usually, IUGR is diagnosed after week 32 of pregnancy. This is during the phase of rapid growth when the baby should be gaining more weight. IUGR caused by genetic factors or infection may sometimes be detected earlier.
  • IUGR can be difficult to diagnose and in many cases doctors are not able to make an exact diagnosis until the baby is born. A mother who has had a growth restricted baby is at risk of having another during a later pregnancy. Such mothers are closely monitored during pregnancy. The length in weeks of the pregnancy must be carefully determined so that the doctor will know if development and weight gain are appropriate. Checking the mother&apos;s weight and abdomen measurements can help diagnose cases when there are no other risk factors present. Measuring the girth of the abdomen is often used as a tool for diagnosing IUGR. During pregnancy, the healthcare provider will use a tape measure to record the height of the upper portion of the uterus (the uterine fundal height). As the pregnancy continues and the baby grows, the uterus stretches upward in the direction of the mother&apos;s head. Between 18 and 30 weeks of gestation, the uterine fundal height (in cm.) equals the weeks of gestation. If the uterine fundal height is more than 2-3 cm below normal, then IUGR is suspected. Ultrasound is used to evaluate the growth of the baby. Usually, IUGR is diagnosed after week 32 of pregnancy. This is during the phase of rapid growth when the baby should be gaining more weight. IUGR caused by genetic factors or infection may sometimes be detected earlier.
  • A systematic review of 126 available randomized controlled trials (RCTs) has been carried out to summarize the efficacy of 36 prenatal interventions aimed at reducing IUGR. Strategies include prenatal care modalities, protein/energy supplementation, treatment of anemia, vitamin/mineral supplementation, fish oil supplementation, and prevention and treatment of hypertensive disorders, fetal compromise, and infection. Based on this review, few statistically significant reductions in the risk of IUGR have been demonstrated with these interventions. However, the point estimate (average effect) associated with some interventions suggests a potential effect of considerable magnitude; these interventions should be further evaluated by targeting populations at risk for IUGR, increasing sample size, and addressing coexisting factors limiting growth. Studies should be conducted in developed as well as developing countries.
  • Systematic reviews provide strong evidence of benefit only for the following interventions: balanced protein/energy supplementation, strategies to reduce maternal smoking, and antimalarial prophylaxis. In Jamaica, antibiotic administration to prevent urinary tract infections further reduced an already low prevalence of IUGR. Improvement of maternal nutrition should be a priority, especially in developing countries. Unless maternal undernutrition is severe, the effect of balanced protein/energy supplementation on birth weight is likely to be modest » 100 g). Reduction in maternal smoking should be encouraged, both by individual clinicians (using behavioral modification techniques, for example) and by policy makers (e.g., taxes on cigarettes and other tobacco products). Antimalarial chemoprophylaxis should be provided in endemic areas, particularly to primigravidae, although more research is needed to elucidate the ideal timing of treatment, combination of agents, and safety for the fetus.
  • Obs Study Guide 3

    1. 1. In the Name of God Obstetrics Study Guide 3 Mitra Ahmad Soltani 2008
    2. 2. References <ul><li>Iranian Council for graduate Medical Education. Board and pre-board Exam questions for OBS and Gyn .2001-2006 </li></ul><ul><li>Panda S . IUGR. Department of Obstetrics & Gynecology Medical College of India 2002 </li></ul><ul><li>Pritchard JA, MacDonald PC, Gant NF. Williams Obstetrics . 22 nd ed. New York, NY: McGraw-Hill; 2005. </li></ul><ul><li>Tan T and Yeo G. IUGR. Current Opinion in Obstetrics and Gynecology 2005, 17: 135-142 </li></ul><ul><li>emedicine e-journal: </li></ul><ul><li>Butler J. postterm delivery. emedicine. June 19. 2006 </li></ul><ul><li>Gaufberg S. Abruptio placenta. emedicine. Aug 29. 2006 </li></ul><ul><li>Gibson P. HTN in Pregnancy. emedicine. DEC 13 2007 </li></ul><ul><li>Hernandez E . GTN. emedicine. Jan 26, 2007 </li></ul><ul><li>Marinnan G. Placenta Previa. emedicine. Aug 26. 2005 </li></ul><ul><li>Ross M. preterm. emedicine. 31 may 2007 </li></ul><ul><li>Pictures and material of multiple pregnancy are adapted with permission from: </li></ul><ul><li>Zach T. multiple pregnancy.emedicine. Oct 2. 2007 </li></ul>
    3. 3. HTN in Pregnancy
    4. 4. classification <ul><li>Hypertension is the most common medical problem encountered during pregnancy, complicating 2-3% of pregnancies. </li></ul><ul><li>HTN is classified into 4 categories </li></ul><ul><li>1) chronic hypertension, </li></ul><ul><li>2) preeclampsia-eclampsia, </li></ul><ul><li>3) preeclampsia superimposed on chronic hypertension </li></ul><ul><li>4) gestational hypertension (transient hypertension of pregnancy or chronic hypertension identified in the latter half of pregnancy). </li></ul>
    5. 5. Chronic HTN <ul><li>blood pressure exceeding 140/90 mm Hg before pregnancy or before 20 weeks' gestation. It persists after 12 wks postpartum. </li></ul>
    6. 6. Gestational Age <ul><ul><li>New-onset or worsening hypertension after 20 weeks' gestation should lead to a careful evaluation for manifestations of preeclampsia. </li></ul></ul><ul><ul><li>The diagnosis of severe hypertension or preeclampsia in the first or early second trimester necessitates exclusion of GTD and/or molar pregnancy. </li></ul></ul>
    7. 7. Maternal Risk factors
    8. 8. Placental Risk factor <ul><ul><li>Multiple gestations </li></ul></ul><ul><ul><li>Hydrops fetalis </li></ul></ul><ul><ul><li>Gestational trophoblastic disease </li></ul></ul><ul><ul><li>Triploidy </li></ul></ul>
    9. 9. BP measurement <ul><ul><li>Blood pressure should be measured in the sitting position, with the cuff at the level of the heart. </li></ul></ul><ul><ul><li>Women should be allowed to sit quietly for 5-10 minutes before each blood pressure measurement. </li></ul></ul><ul><ul><li>Korotkoff sounds I (the first sound) and V (the disappearance of sound) should be used to denote the systolic blood pressure (SBP) and DBP, respectively. </li></ul></ul>
    10. 10. Indications of preg. termination Mild Severe Diastolic blood pressure <100mmhg 110 mmhg or higher Proteinuria Trace to 1+ Persistent 2+ or more Headache Absent present Visual disturbances Absent present Upper abdominal pain Absent Present Oliguria Absent Present Convulsion Absent Present Serum Cr Normal Elevated thrombocytopenia Absent Present Liver enzyme elevation Minimal Marked IUGR Absent Present Pulmonary edema Absent present
    11. 11. CBC <ul><ul><ul><li>Platelet counts less than 100,000/µL suggest preeclampsia or ITP. </li></ul></ul></ul><ul><ul><ul><li>Hemoglobin levels greater than 13 g/dL suggest hemoconcentration. </li></ul></ul></ul><ul><ul><ul><li>Low Hbg levels may be due to microangiopathic hemolysis or iron deficiency. </li></ul></ul></ul>
    12. 12. Proteinurea <ul><ul><li>Trace levels to +1 proteinuria are acceptable, but levels of +2 or greater are abnormal and should be quantified with a 24-hour urine collection or spot urine protein:creatinine ratio. </li></ul></ul><ul><ul><li>In a 24-hour urine collection, the reference range for protein excretion in pregnancy is up to 300 mg/d. </li></ul></ul>
    13. 13. Protein:Cr ratio <ul><li>Creatinine clearance increases approximately 50% during pregnancy, and levels less than 100 mL/min suggest renal dysfunction that is either chronic or due to preeclampsia. </li></ul><ul><ul><li>protein:Cr ratios appear to be more accurate than urinalysis, although an abnormal result should still be confirmed with a 24-hour urine collection. </li></ul></ul>
    14. 14. Coagulation tests <ul><ul><li>LDH, </li></ul></ul><ul><ul><li>bilirubin, </li></ul></ul><ul><ul><li>haptoglobin, </li></ul></ul><ul><ul><li>fibrinogen, </li></ul></ul><ul><ul><li>D-dimers </li></ul></ul><ul><ul><li>If: </li></ul></ul><ul><ul><li>PT/INR/aPTT results are abnormal, </li></ul></ul><ul><ul><li>thrombocytopenia is present, </li></ul></ul><ul><ul><li>the hemoglobin level is dropping </li></ul></ul>
    15. 15. Fetal Monitoring <ul><ul><li>Alternate a biophysical profile with a fetal NST twice each week. </li></ul></ul><ul><ul><li>Ask for Serial fetal ultrasound starting at 18 weeks. </li></ul></ul>
    16. 16. Methyldopa (Aldomet) Centrally acting antihypertensive agent widely considered the first-line agent for treatment of hypertension during pregnancy. 250 mg PO bid/tid; increase q2d prn; not to exceed 3 g/d
    17. 17. Hydralazine (Apresoline) Intravenous form is useful when treating severe hypertension due to preeclampsia/eclampsia. 10-20 mg/dose IV q4-6h prn initial; increase to 40 mg per dose prn BP >170/110 mm Hg: 0.1-0.2 mg/kg/dose IV q4-6h prn; not to exceed 20 mg or 1.7-3.5 mg/kg/d IV divided q4-6h
    18. 18. Life-threatening complications in preeclampsia <ul><ul><li>Seizures </li></ul></ul><ul><ul><li>Cerebral hemorrhage </li></ul></ul><ul><ul><li>Pulmonary edema </li></ul></ul><ul><ul><li>Acute renal failure </li></ul></ul><ul><ul><li>DIC </li></ul></ul><ul><ul><li>HELLP syndrome </li></ul></ul><ul><ul><li>Hepatic infarction/rupture and subcapsular hematoma </li></ul></ul>
    19. 19. IMP: mild preeclampsia <ul><li>General: condition/position/diet =low salt,high prot </li></ul><ul><li>Lab: CBC ,BG, Rh, U/A,24hr urine (prot,cr,vol), BUN/Cr, PT,PTT,Fib, ALT,AST,Al P, Bil (T, D) </li></ul><ul><li>reserve of 2 units of PC </li></ul><ul><li>IV :Ringer at heparin lock </li></ul><ul><li>OTHER: Control of vital sign q4hrs, control of FHR, FAD chart , NST, sono OB, daily weight inform if BP>160/110, blurred vision, head ache, epigastric pain, seizure </li></ul>
    20. 20. IMP: Severe preeclampsia <ul><li>General: condition/position/diet =NPO </li></ul><ul><li>Lab: CBC ,BG, Rh, BUN/Cr, PT, PTT,Fib ,ALT,AST,Al P, Bil (T, D) </li></ul><ul><li>prep 2 units of PC </li></ul><ul><li>IV :Ringer 1000cc +10 u of oxytocin </li></ul><ul><li>if BP>160/110,blurred vision, head ache, epigastric pain, seizure then amp hydralazine 5 mg iv prn </li></ul><ul><li>MgSO4 (4 gr) in 200cc DW5% in 20 min then 10 gr(1/2) im in each buttock then 5 gr im q4h </li></ul><ul><li>If platelet is below 100000 then 20 gr in 1000cc infused in 100cc/hrs (check of I/O, RR, DTR, prep CPR set with 2 gr 20% MgSO4 ready) + Amp Dexa 6 mg bid for 4 doses </li></ul><ul><li>OTHER: Control of vital sign q15 min , control of FHR, fix foley, </li></ul>
    21. 21. Preterm Pregnancy
    22. 22. Definition <ul><li>Preterm labor is defined as the presence of uterine contractions of sufficient frequency and intensity to effect progressive effacement and dilation of the cervix prior to term gestation (between 20 and 37 wk). </li></ul><ul><li>It is the leading cause of neonatal mortality. </li></ul>
    23. 23. Causes of preterm Labor <ul><li>decidual hemorrhage, (eg, abruption, mechanical factors such as uterine overdistension from multiple gestation or polyhydramnios), </li></ul><ul><li>cervical incompetence (eg, trauma, cone biopsy), </li></ul><ul><li>uterine distortion (eg, müllerian duct abnormalities, fibroid uterus), </li></ul><ul><li>cervical inflammation (bacterial vaginosis [BV], trichomonas), </li></ul><ul><li>maternal inflammation/fever (eg, urinary tract infection), </li></ul><ul><li>hormonal changes (eg, mediated by maternal or fetal stress), </li></ul><ul><li>Uteroplacental insufficiency (eg, hypertension, insulin-dependent diabetes, drug abuse, smoking, alcohol). </li></ul>
    24. 24. Risk factors of preterm birth <ul><li>Demographic factors for preterm labor include nonwhite race, extremes of maternal age (<17 y or >35 y), low socioeconomic status, and low prepregnancy weight. </li></ul><ul><li>Preterm labor and birth can be associated with stressful life situations (eg, domestic violence; close family death; insecurity over food, home, or partner; work and home environment) </li></ul><ul><li>Previous preterm delivery </li></ul>
    25. 25. Methods for predicting preterm birth <ul><li>home uterine activity monitoring (HUAM) </li></ul><ul><li>salivary estriol : DHEA increases before the onset of labor. This results in an increase of maternal estriol. </li></ul><ul><li>FFN is a basement membrane protein that helps bind placental membranes to the decidua. FFN has a predictive value in identifying patients who will or will not deliver within the subsequent 1-2 weeks. </li></ul><ul><li>A short cervical length in the early or late second trimester has been associated with a markedly increased risk of preterm labor and delivery. </li></ul>
    26. 26. Contraindication to tocolysis <ul><li>1-Fetal growth restriction 2-Oligohydramnios 3-Nonreactive NST,Positive CST 4-Absent or reversed diastolic flow upon Doppler examination of umbilical blood flow 5-Repetitive severe variable decelerations 6-Significant vaginal bleeding consistent with abruption. </li></ul>
    27. 27. Definition of IAI (Intra Amniotic Infection) <ul><li>A temperature greater than 38.0°C (100.0°F) and 2 of the 5 following signs: </li></ul><ul><li>1-WBC > 15,000 cells/mm 3 2-Maternal HR> 100 (bpm) </li></ul><ul><li>3- Fetal HR> 160 bpm 4-Tender uterus 5-Foul-smelling discharge </li></ul>
    28. 28. Chorioamnionitis Order <ul><li>General: condition/position/diet=NPO </li></ul><ul><li>Lab: CBC diff, MP, WW, B/C X2, U/A , U/C,CXR,BUN/Cr </li></ul><ul><li>IV : 1000cc Ringer +10 units of oxytocin start at </li></ul><ul><li>2 drops /min, add 2 drops every 15 min if FHR and contractions are normal </li></ul><ul><ul><li>Amp ampicillin 2gr iv qid +gentamicin im 80mg stat then 60 mg TDS </li></ul></ul><ul><ul><li>AMP clindamycin 900 mg iv TDS for allergic women to penicillin(continue antibiotics after delivery until the mother is a febrile </li></ul></ul><ul><li>OTHER: Control of vital sign hourly </li></ul>
    29. 29. IMP:PLP before 37 weeks out patient: (contractions 4 in 20 min or 8 in 60 min +progressive change in cervix cervical dilation of more than one cervical effacement of more than 80 % or greater) if: Check of contractions:+ U/A, U/C: - Fern:- Then: Hydrate and sedate Stop of contractions: discharge With:isoxsuprine 10 mg TDS for 10 days Contractions persist: hospitalize Next slide
    30. 30. IMP:PLP before 37 weeks, hospitalized <ul><li>General: condition/position/diet </li></ul><ul><li>Lab: CBC, BG, Rh, U/A, U/C, fern, reserve of 2 units of PC </li></ul><ul><li>IV : </li></ul><ul><li>1-1000cc Ringer free </li></ul><ul><li>2-MgSO4 (4 gr) in 200cc DW5% in 20 min then 20 gr in 1000cc infused in 100cc/hrs (check of I/O, RR,DTR, prep CPR set- I/O with measure) </li></ul><ul><li>3-Amp pethidine 25 mg iv 25 mg im </li></ul><ul><li>4-Amp ampicillin 2 gr IV qid </li></ul><ul><li>5-Amp erythromicin 400 mg QID </li></ul><ul><li>6- Amp betamethasone 12 mg im, repeat after 24 hrs for GA below 34 wks </li></ul><ul><li>OTHER: Control of vital sign q4hrs, Inform if LP, leakage, VB, ab VS or FHR </li></ul>
    31. 31. Contraindication for beta mimetics <ul><li>Maternal </li></ul><ul><li>cardiac disease </li></ul><ul><li>Diabetes </li></ul><ul><li>Thyrotoxicosis </li></ul><ul><li>HTN </li></ul>
    32. 32. Contraindication for MgSO4 <ul><li>Hypocalcemia </li></ul><ul><li>Myasthenia gravis </li></ul><ul><li>Renal failure </li></ul>
    33. 33. Dosage of Ritodrine or Terbutaline for tocolysis <ul><li>50-100 mcg/min increase by 50 mcg/min every 10 min </li></ul><ul><li>max dose:350mcg/min </li></ul><ul><li>If labor is arrested continue the infusion for at least 12 hrs </li></ul><ul><li>SC: </li></ul><ul><li>250 mcg q3-4 hrs </li></ul>
    34. 34. Length of GA with multiple fetuses <ul><li>Twin=36 wks </li></ul><ul><li>Triplets=33.5 wks </li></ul><ul><li>Quadruplets=31 wks </li></ul>
    35. 35. Postterm
    36. 36. Definition of postterm <ul><li>Postterm pregnancies define pregnancies extending up to or after 42 weeks. </li></ul><ul><li>The reported frequency is 3-12%. </li></ul>
    37. 37. Cause of postterm P. <ul><li>The most frequent cause of postterm pregnancy is inaccurate dating criteria </li></ul><ul><li>primiparity, </li></ul><ul><li>prior postterm pregnancy, </li></ul><ul><li>male gender of the fetus, </li></ul><ul><li>genetic factors </li></ul>
    38. 38. Risks of postterm P <ul><li>Macrosomia complications like shoulder dystocia, </li></ul><ul><li>CPD and Maternal risks like an increase in labor dystocia, perineal injuries, and cesarean deliveries. </li></ul><ul><li>dysmaturity syndrome: affects 20% of postterm fetuses and is thought to be caused by chronic uteroplacental insufficiency resulting in oligohydramnios, meconium aspiration, and reversible neonatal complications. </li></ul>
    39. 39. surveillance <ul><li>NST and AFI 2 times per week for pregnancies continuing past 41 weeks. </li></ul>
    40. 40. Intra Uterine Growth Retardation
    41. 41. Definition <ul><li>Intrauterine growth restriction (IUGR) occurs when the unborn baby is at or below the 10th weight percentile for his or her age (in weeks). The fetus is affected by a pathologic restriction in its ability to grow. </li></ul><ul><li>Low birth weight (LBW) means a baby with a birth weight of less than 2500Gms, which could be due to IUGR or Prematurity </li></ul>
    42. 42. Classification Symmetric l A symmetrical baby's brain is abnormally large when compared to the liver . may occur when the fetus experiences a problem during later development the baby's head and body are proportionately small . may occur when the fetus experiences a problem during early development.
    43. 43. Etiology of IUGR <ul><li>Idiopathic- In a majority of cases (40%) </li></ul>
    44. 44. Maternal Risk Factors <ul><li>Has had a previous baby with IUGR </li></ul><ul><li>Extremes of age </li></ul><ul><li>Small mothers (Ht & Wt) </li></ul><ul><li>poor weight gain and mal nutrition during preg. </li></ul><ul><li>socially deprived </li></ul><ul><li>Substance abuse (like tobacco,narcotics, alcohol) </li></ul><ul><li>low total blood volume during early pregnancy </li></ul>
    45. 45. Maternal Risk Factors <ul><li>Multiple pregnancy </li></ul><ul><li>Living in High altitude locations </li></ul><ul><li>Drugs like anticoagulants, anticonvulsants </li></ul><ul><li>Cardio- vascular disease:preeclampsia , HTN, cyanotic heart disease, cardiac disease Gr III & IV, diabetic vascular lesions </li></ul><ul><li>Chronic kidney disease </li></ul><ul><li>Chronic infection- UTI, Malaria, TB, genital infections </li></ul><ul><li>Antibody abnormality like antiphospholipid antibody syndrome , SLE </li></ul>
    46. 46. Fetal Risk Factors <ul><li>Intrauterine infection: German measles ( rubella ), cytomegalovirus, herpes simplex, tuberculosis , syphilis, or toxoplasmosis, TB, Malaria, Parvo virus B19. </li></ul><ul><li>Birth defect (cardiovascular , renal, anencephally, limb defect, etc ). </li></ul><ul><li>Chromosome defect( trisomy - 18 ( Edwards’ syndrome ) ,21(Down’s syndrome), 16, 13, xo (turner’s syndrome.) </li></ul><ul><li>Primary disorder of bone or cartilage. </li></ul><ul><li>Chronic lack of oxygen during development (hypoxia). </li></ul><ul><li>Developed outside of the uterus. </li></ul><ul><li>Placenta or umbilical cord defects. </li></ul>
    47. 47. Placental Factors <ul><li>Uteroplacental insufficiency: </li></ul><ul><ul><li>Improper / inadequate trophoblastic invasion and placentation in the first trimester. </li></ul></ul><ul><ul><li>Lateral insertion of placenta. </li></ul></ul><ul><ul><li>Reduced maternal blood flow to the placental bed. </li></ul></ul><ul><li>Fetoplacetal insufficiency due to: </li></ul><ul><ul><li>Vascular anomalies of placenta and cord </li></ul></ul><ul><ul><li>Decreased placental functioning mass: </li></ul></ul><ul><ul><ul><li>Small placenta, abruptio placenta, placenta previa, post term pregnancy. </li></ul></ul></ul>
    48. 48. Screening: <ul><li>US fetal biometry: HC- BPD- AC </li></ul><ul><li>Uterine Doppler studies (Doppler Velocimetry): bilateral notches and a mean resistance index of at least 0.55 </li></ul><ul><li>Or </li></ul><ul><li>Unilateral notches and a mean resistance index of at least 0.65 at 20 weeks. </li></ul><ul><li>Biochemistry: CRH level at 33 weeks </li></ul>
    49. 49. Neonatal Diagnosis <ul><li>Low ponderal index (Wt./Fl). </li></ul><ul><li>Decreased subcutaneous fat. </li></ul><ul><li>Presence / appearance of – </li></ul><ul><ul><li>Hypoglycemia, </li></ul></ul><ul><ul><li>Hyperbilirubinemia, </li></ul></ul><ul><ul><li>Necrotizing enterocolitis, </li></ul></ul><ul><ul><li>Hyper viscosity syndrome </li></ul></ul>
    50. 50. Prevention <ul><li>Strong evidence of benefit only for the following interventions: </li></ul><ul><ul><li>balanced protein/energy supplementation, </li></ul></ul><ul><ul><li>strategies to reduce maternal smoking, </li></ul></ul><ul><ul><li>antibiotic administration to prevent urinary tract infections </li></ul></ul><ul><ul><li>antimalarial prophylaxis. </li></ul></ul>
    51. 51. S urveillance <ul><li>Non-Stress Test , </li></ul><ul><li>Amniotic Fluid Index , </li></ul><ul><li>Doppler of the Umbilical Artery </li></ul><ul><li>Biophysical Profile </li></ul>
    52. 52. S urveillance The current recommendations are that if the AFI decreases below 5 after 35 weeks, then delivery should occur. <ul><li>Amniotic Fluid Index (AFI) </li></ul>
    53. 53. Treatment <ul><li>Bed rest </li></ul><ul><li>Aspirin before 20 wk GA </li></ul><ul><li>Nutritional supplementation: zinc , fish oil , hormones </li></ul><ul><li>Oxygen therapy. </li></ul>
    54. 54. For cases termination is indicated: <ul><li>Corticosteroids with a delay in delivery for 2.4 days </li></ul><ul><li>Mode of delivery depends on the bishop score and IUGR severity </li></ul><ul><li>For dichorionic twins : injection of KCl into the heart of the weaker fetus ( in most cases management is expectant) </li></ul><ul><li>For monochorionic twins photocoagulation of anastomoses or diathermy in cases of TTTS and AAA </li></ul>
    55. 55. Short Term Risks of IUGR for the neonate <ul><ul><li>Meconium Aspiration Syndrome, </li></ul></ul><ul><ul><li>infection, </li></ul></ul><ul><ul><li>hypoglycemia , </li></ul></ul><ul><ul><li>hypothermia , </li></ul></ul><ul><ul><li>Sudden Infant Death Syndrome, </li></ul></ul>
    56. 56. Long term Prognosis <ul><li>Fetal Death </li></ul><ul><li>low blood sugar </li></ul><ul><li>low body temperature </li></ul><ul><li>abnormal development of the nervous system </li></ul><ul><li>Adulthood aftermath : </li></ul><ul><li>CAD </li></ul><ul><li>HTN </li></ul><ul><li>Diabetes II </li></ul><ul><li>Dyslipidemia </li></ul><ul><li>Stroke </li></ul><ul><li>Depression </li></ul><ul><li>Suicide attempts </li></ul>
    57. 57. abruptio
    58. 58. Definition <ul><li>Abruptio placentae (ie, placental abruption) refers to separation of the normally located placenta after the 20th week of gestation. </li></ul><ul><li>Abruptio placentae occurs in about 1% of all pregnancies. </li></ul>
    59. 59. Symptoms and signs <ul><ul><li>Vaginal bleeding - 80% </li></ul></ul><ul><ul><li>Abdominal or back pain and uterine tenderness - 70% </li></ul></ul><ul><ul><li>Fetal distress - 60% </li></ul></ul><ul><ul><li>Abnormal uterine contractions (eg, hypertonic, high frequency) - 35% </li></ul></ul><ul><ul><li>Idiopathic premature labor - 25% </li></ul></ul><ul><ul><li>Fetal death - 15% </li></ul></ul>
    60. 60. Classification of abruptio <ul><li>extent of separation (ie, partial vs complete) </li></ul><ul><li>location of separation (ie, marginal vs central) </li></ul><ul><li>Clinical </li></ul>
    61. 61. classification Class VB Uterus tenderness BP-HR coagulopathy Fetal distress 0 mild --------- NL ----------- --------- 1 mild mild NL ------------- --------- 2(I=27%) Mild-mod Mod-severe Tilt + <ul><ul><li>Hypofibrinogenemia (ie, 50-250 mg/dL) </li></ul></ul>present 3(I=24%) Mild-severe tetanic shock Fib<150 mg/dl death
    62. 62. Causes1 <ul><li>Maternal HTN(44% of all cases) </li></ul><ul><li>Maternal trauma </li></ul><ul><li>Cigarette smoking </li></ul><ul><li>Alcohol consumption </li></ul><ul><li>Cocaine use </li></ul><ul><li>Advanced maternal age </li></ul>
    63. 63. causes2 <ul><li>Short umbilical cord </li></ul><ul><li>Sudden decompression of the uterus (eg, PROM, delivery of first twin) </li></ul><ul><li>Retroplacental fibromyoma </li></ul><ul><li>postamniocentesis </li></ul><ul><li>Idiopathic (probable abnormalities of uterine blood vessels and decidua) </li></ul>
    64. 64. Imaging Studies <ul><li>Ultrasonography is not very useful in diagnosing placental abruption. </li></ul><ul><ul><li>Retroplacental hematoma may be recognized in 2-25% of all abruptions. </li></ul></ul><ul><ul><li>Recognition of retroplacental hematoma depends on the degree of hematoma and on the operator's skill level. </li></ul></ul>
    65. 65. IMP: R/O abruption <ul><li>Condition/position/diet:NPO </li></ul><ul><li>Lab: CBD-BG-Rh-U/A-U/C-PT-PTT-Fib-FDP-D-Dimer- </li></ul><ul><li>Prep 4 units of crossmatched packed red blood cells </li></ul><ul><li>Prep 5 units of platelets, prep 10 units of FFP </li></ul><ul><li>Continuous high-flow supplemental oxygen </li></ul><ul><li>One or 2 large-bore IV lines with normal saline (NS) or lactated Ringer (LR) solution+10 units of oxytocin in 1 lit of ringer start at 2 drops/min add 2 drops every 15 min if fetal heart rate and uterine contractions are favorable. </li></ul><ul><li>perform amniotomy </li></ul><ul><li>Closely observe the patient. Monitor vital signs and urine output, fetal heart rate and uterine height measurement. </li></ul><ul><li>Prepare OR for emergent C/S </li></ul>
    66. 66. Placenta Previa
    67. 67. subtypes <ul><li>(1) complete or total: the placenta covers 360° of the internal cervical os; </li></ul><ul><li>(2) incomplete or partial: 0°-360° of the internal cervical os is covered by placental tissue; </li></ul><ul><li>(3) marginal: the placental tissue does not cover the internal cervical os; </li></ul><ul><li>(4) low lying: the edge of the placenta lies abnormally close to but does not abut the internal cervical os. </li></ul>
    68. 68. Risk factors <ul><li>prior placenta previa, </li></ul><ul><li>prior cesarean delivery, </li></ul><ul><li>increased maternal age, </li></ul><ul><li>large placentae (eg, multiple gestations or erythroblastosis), </li></ul><ul><li>maternal history of smoking. </li></ul>
    69. 69. Frequency <ul><li>1 in 200 deliveries </li></ul>
    70. 70. Vaginal Bleeding <ul><li>painless vaginal bleeding during the second half of pregnancy (70%). </li></ul><ul><li>It can occur without an inciting cause, although pelvic examination, intercourse, or labor may provoke it. </li></ul><ul><li>The average gestational age at presentation is 32 weeks. </li></ul><ul><li>Hemorrhage recurs, and, in nearly all cases, it is more severe the second time. </li></ul>
    71. 71. management <ul><li>Patients are treated expectantly, with: </li></ul><ul><li>volume replacement, </li></ul><ul><li>transfusions, </li></ul><ul><li>tocolytics, </li></ul><ul><li>emergent cesarean delivery </li></ul><ul><li>Without endangering the life of the mother, all attempts are made to delay delivery until the fetal lungs mature. </li></ul>
    72. 72. Preferred Examination <ul><li>Physical examination should be performed only with a fetus that has achieved pulmonary maturity and only in a fully staffed operating room. </li></ul>
    73. 73. Preferred examination <ul><li>TA sonography is the test of choice to confirm placenta previa. </li></ul><ul><li>When the internal cervical os cannot be visualized or when the results are inconclusive, transperineal or transvaginal sonography is recommended as an adjunct . </li></ul><ul><li>No increased risk of hemorrhage has been associated with transvaginal or transperineal sonography in this clinical setting. </li></ul>
    74. 74. Blood loss classifications
    75. 75. med-ed-online 2007   Class 1 Class 2 Class 3 Class 4 Blood Loss Volume (mls) in adult 750mls 800 - 1500mls 1500 - 2000mls >2000mls Blood Loss % Circ. blood volume <15% 15 - 30% 30 - 40% >40% Systolic Blood Pressure No change Normal Reduced Very low Diastolic Blood Pressure No change Raised Reduced Very low / Unrecordable Pulse (beats /min) Slight tachy- cardia 100 - 120 120 (thready) >120 (very thready) Capillary Refill Normal Slow (>2s) Slow (>2s) Undetectable Respiratory Rate Normal Normal Raised (>20/min) Raised (>20/min) Urine Flow (mls/hr) >30 20 - 30 10 - 20 0 - 10
    76. 76. med-ed-online 2007 Estimated blood loss Suitable fluid regimes 1000 mls 3000 mls crystalloid or 1000 mls colloid 1500 mls 1500 mls crystalloid & 1000mls colloid or 4500 mls crystalloid 2000 mls 1000 mls crystalloid, 1000mls colloid & 2 units blood or 3000 mls crystalloid & 2 units blood
    77. 77. Multiple pregnancy <ul><li>Pictures and material of multiple pregnancy are adapted from: </li></ul><ul><li>Zach T. multiple pregnancy. emedicine. Oct 2. 2007 </li></ul><ul><li>with permission </li></ul>
    78. 78. pathophysiology1 <ul><li>Dizygotic twins(fraternal) are produced when 2 sperm fertilize 2 ova. Separate amnions, chorions, and placentas are formed in dizygotic twins. The placentas in dizygotic twins may fuse if the implantation sites are proximate. The fused placentas can be easily separated after birth. </li></ul><ul><li>Monozygotic twins (Identical)develop when a single fertilized ovum splits during the first 2 weeks after conception. An early splitting (ie, within the first 2 d after fertilization-30%) of monozygotic twins produces separate chorions and amnions. These dichorionic twins have different placentas that can be separate or fused. </li></ul>
    79. 79. Diamniotic/dichorionic placentation
    80. 80. pathophysiology2 <ul><li>Later splitting (ie, 3-8 d after fertilization) results in monochorionic/diamniotic placentation . </li></ul><ul><li>Approximately 70% of monozygotic twins are monochorionic/diamniotic. </li></ul>
    81. 81. Diamniotic/monochorionic placentation
    82. 82. pathophysiology3 <ul><li>If splitting occurs even later (ie, during 9-12 d after fertilization), monochorionic/monoamniotic placentation occurs . </li></ul><ul><li>Monochorionic/monoamniotic twins are rare; only 1% of monozygotic twins have this form of placentation. </li></ul>
    83. 83. Monoamniotic/monoamniotic placentation
    84. 84. pathophysiology4 <ul><li>Monochorionic/monoamniotic twins have a common placenta with vascular communications between the 2 circulations. </li></ul>
    85. 85. pathophysiology5 <ul><li>Trizygotic triplets occur when 3 sperm fertilize 3 ova. </li></ul><ul><li>Dizygotic triplets develop from one set of monozygotic cotriplets and a third cotriplet derived from a different zygote. </li></ul><ul><li>Finally, 2 consecutive zygotic splittings with one split results in a vanished fetus and monozygotic triplets. </li></ul>
    86. 86. Frequency <ul><li>The birth rate of monozygotic twins is constant worldwide (approximately 4 per 1000 births). </li></ul><ul><li>Birth rates of dizygotic twins vary by race. (Highest in Africans and lowerest in Asians) </li></ul>
    87. 87. mortality <ul><li>low birth weight infants( due to prematurity and (IUGR) </li></ul><ul><li>congenital anomalies, </li></ul><ul><li>placenta previa, abruptio placenta, </li></ul><ul><li>preeclampsia, </li></ul><ul><li>cord accidents, </li></ul><ul><li>malpresentations, </li></ul><ul><li>asphyxia/perinatal depression, </li></ul><ul><li>group B streptococcal (GBS) infections, </li></ul><ul><li>hyaline membrane disease (HMD), </li></ul><ul><li>TTTS. </li></ul>
    88. 88. History <ul><li>excessive weight gain, </li></ul><ul><li>hyperemesis gravidarum, </li></ul><ul><li>sensation of more than one moving fetus </li></ul><ul><li>use of ovulation-inducing drugs </li></ul><ul><li>family history of dizygotic twins </li></ul>
    89. 89. Neonatal Lab Studies <ul><li>CBC count: In TTTS, the donor twin is frequently anemic at birth. The recipient twin is polycythemic at birth. </li></ul><ul><li>Calcium level: Hypocalcemia is common in premature infants, especially the donor twin in TTTS. </li></ul><ul><li>Glucose level: Hypoglycemia is common in premature infants, especially if TTTS is present. </li></ul><ul><li>Bilirubin level: Hyperbilirubinemia due to TTTS may develop in polycythemic infants. </li></ul>
    90. 90. TRAP <ul><li>Twin reversed arterial perfusion (TRAP) sequence occurs when an acardiac twin receives all of the blood supply from the normal &quot;pump&quot; twin. This only occurs in monochorionic twins. </li></ul>
    91. 91. TTTS <ul><li>Occurs in monochorionic/monoamniotic or monochorionic/diamniotic twins. Vascular anastomoses in the monochorionic placenta result in transfusion of blood from one twin (ie, donor) to the other twin (ie, recipient). Polyhydramnios develops in the sac of the recipient twin and oligohydramnios develops in the sac of the donor twin. </li></ul>
    92. 92. Conjoined twins <ul><ul><li>Incomplete late division of monozygotic twins produces conjoined twins. </li></ul></ul><ul><ul><li>Classification: </li></ul></ul><ul><ul><ul><li>Thoracopagus - Joined at chest (40%) </li></ul></ul></ul><ul><ul><ul><li>Xiphopagus/omphalopagus - Joined at abdomen (34%) </li></ul></ul></ul><ul><ul><ul><li>Pygopagus - Joined at buttocks (18%)  </li></ul></ul></ul><ul><ul><ul><li>Ischiopagus - Joined at ischium (6%)  </li></ul></ul></ul><ul><ul><ul><li>Craniopagus - Joined at head (2%) </li></ul></ul></ul>
    93. 93. Discordant <ul><li>. Birth weight discrepancies of more than 20-25% are considered discordant. Discordant birth weights occur in 10% of twins. </li></ul>
    94. 94. Gestational Trophoblastic Neoplasia
    95. 95. classification <ul><li>hydatidiform mole : is the most common form of gestational trophoblastic neoplasia it can behave in a malignant or benign fashion, </li></ul><ul><li>invasive mole (chorioadenoma destruens), </li></ul><ul><li>choriocarcinoma, </li></ul><ul><li>and placental site trophoblastic tumor (PSTT). </li></ul>
    96. 96. Clinical course <ul><li>In 80% of patients with a benign hydatidiform mole, serum HCG titers steadily drop to normal within 8-12 weeks after evacuation of the molar pregnancy. </li></ul><ul><li>In the other 20% of patients with a malignant hydatidiform mole, serum HCG titers either rise or plateau. </li></ul>
    97. 97. staging <ul><li>Stage I – Confined to the uterus </li></ul><ul><li>Stage II – Limited to the genital structures </li></ul><ul><li>Stage III – Lung metastases </li></ul><ul><li>Stage IV – Other metastases </li></ul>
    98. 98. WHO prognostic criteria1 <ul><li>Age 40 years or older = 1 point </li></ul><ul><li>Antecedent pregnancy terminated in abortion = 1 point </li></ul><ul><li>Antecedent full-term pregnancy = 2 points </li></ul><ul><li>Interval of 4 months to less than 7 months between antecedent pregnancy and start of chemotherapy = 1 point </li></ul><ul><li>Interval of 7-12 months between antecedent pregnancy and start of chemotherapy = 2 points </li></ul><ul><li>Interval of more than 12 months between antecedent pregnancy and start of chemotherapy = 4 points </li></ul>
    99. 99. WHO prognostic criteria 2 <ul><li>Beta-HCG level in serum is 1000 mIU/mL but less than 10,000 mIU/mL = 1 point </li></ul><ul><li>Beta-HCG level in serum is 10,000 mIU/mL but less than 100,000 mIU/mL = 2 points </li></ul><ul><li>Beta-HCG level in serum is 100,000 mIU/mL or greater = 4 points </li></ul><ul><li>Largest tumor is 3 cm but less than 5 cm = 1 point </li></ul><ul><li>Largest tumor is 5 cm or greater = 2 points </li></ul><ul><li>Site of metastases is spleen or kidney = 1 point </li></ul>
    100. 100. WHO prognostic criteria3 <ul><li>Site of metastases is gastrointestinal tract = 2 points </li></ul><ul><li>Site of metastases is brain or liver = 4 points </li></ul><ul><li>Number of metastases is 1-4 = 1 point </li></ul><ul><li>Number of metastases is 5-8 = 2 points </li></ul><ul><li>Number of metastases is more than 8 = 4 points </li></ul><ul><li>Prior chemotherapy with single drug = 2 points </li></ul><ul><li>Prior chemotherapy with multiple drugs = 4 points </li></ul>
    101. 101. Sign and Symptoms <ul><li>Patients with a hydatidiform mole present with signs and symptoms of pregnancy. </li></ul><ul><ul><li>The most frequent symptom of gestational trophoblastic neoplasia (GTN) is abnormal uterine bleeding. </li></ul></ul><ul><ul><li>Patients have a history of amenorrhea. Occasionally, the typical hydatid vesicles (edematous villi) are passed through the vagina. </li></ul></ul>
    102. 102. Sign and Symptoms <ul><li>Prolonged hyperemesis gravidarum </li></ul><ul><li>preeclampsia </li></ul><ul><li>Hyperthyroidism </li></ul><ul><li>signs and symptoms associated with the metastatic disease, such as hematuria, hemoptysis, abdominal pain, and neurologic symptoms </li></ul>
    103. 103. Physical Exam <ul><li>a positive pregnancy test result occurs in the absence of a fetus. </li></ul><ul><li>vesicles in the vagina is diagnostic </li></ul><ul><li>Enlarged ovaries secondary to theca lutein cysts are found in up to 20% of cases. </li></ul><ul><ul><li>The cysts regress after evacuation of the hydatidiform mole for 12 weeks. </li></ul></ul>
    104. 104. Cause <ul><li>A hydatidiform mole occurs when a haploid sperm fertilizes an egg that has no maternal chromosomes and then duplicates its chromosomal complement. </li></ul><ul><ul><li>Most complete hydatidiform moles are 46,XX, and all the chromosomes come from the male. </li></ul></ul><ul><ul><li>Of hydatidiform moles, 10-15% are 46,XY. This occurs when 2 sperm, 1 carrying an X and the other carrying a Y, fertilize an &quot;empty&quot; egg. </li></ul></ul><ul><li>Partial moles are 69,XXY, and 2 sets of chromosomes are of paternal origin. </li></ul>
    105. 105. Medical care1 <ul><li>Emergency department care involves : </li></ul><ul><li>starting intravenous (IV) fluids (crystalloids) </li></ul><ul><li>sending blood for type and antibody screen </li></ul><ul><li>Rh-negative patients should receive anti–RhD immune globulin, such as RhoGAM, if not already immunized </li></ul>
    106. 106. Medical Care2 <ul><li>Patients with benign do not require medical therapy. </li></ul><ul><li>observing patients with weekly serum HCG titers. </li></ul><ul><li>Only patients with rising or plateauing titers should be treated with chemotherapy. </li></ul>
    107. 107. Medical care3 <ul><li>Patients with malignant nonmetastatic or metastatic low-risk GTN are treated with single-agent chemotherapy like MTX or actinomycin D in patients with poor liver function </li></ul><ul><li>During treatment, the serum HCG titers are monitored every week. </li></ul><ul><li>One additional course of chemotherapy is administered after a normal serum HCG titer. </li></ul><ul><li>After 3-4 normal serum HCG titers, the titers are followed once per month for 1 year. </li></ul><ul><li>A switch from MTX to actinomycin D is made if the patient receiving MTX for nonmetastatic or metastatic low-risk GTN develops rising or plateauing serum HCG titers. </li></ul>
    108. 108. Medical care4 <ul><li>Patients with high-risk metastatic are subdivided into 2 groups: </li></ul><ul><ul><li>In patients with a WHO score of less than 8, a combination of MTX, actinomycin D, and cyclophosphamide can be used. This is known as the MAC regimen. This chemotherapeutic regimen is administered every 19-21 days (from day 1 of the previous chemotherapy cycle) until the serum HCG titers normalize. </li></ul></ul>
    109. 109. Medical Care5 <ul><ul><li>Patients with WHO scores of 8 or higher are treated with a combination of etoposide, MTX, and actinomycin D administered in the first week of a 2-week cycle and cyclophosphamide and vincristine (Oncovin) administered in the second week. This is known as the EMA-CO regimen. Two additional courses of EMA-CO or EMA-CE are administered after a normal serum HCG titer in very high-risk patients. </li></ul></ul>
    110. 110. Medical care6 <ul><ul><li>Patients with metastasis to the brain receive whole brain irradiation (3000 cGy) in combination with chemotherapy. Corticosteroids (Decadron) with systemic effect are administered to reduce brain edema. </li></ul></ul><ul><ul><li>Patients with liver metastasis are considered for liver irradiation (2000 cGy). </li></ul></ul>
    111. 111. Surgical care <ul><li>The treatment of a hydatidiform mole is evacuation of the uterus by suction and sharp curettage. </li></ul><ul><ul><li>To avoid excessive bleeding, oxytocin is administered intravenously at the initiation of the suctioning of the uterine contents. </li></ul></ul><ul><ul><li>The largest possible suction curet is used, usually a 10F or 12F. </li></ul></ul>
    112. 112. Further Care <ul><li>Obtain follow-up serum HCG titers : </li></ul><ul><li>once per week until 3-4 normal values are obtained. </li></ul><ul><li>Then, obtain them once per month for 6 months. </li></ul><ul><li>Have patients use reliable contraception, such as oral contraceptives or depot progesterone injections, during the period of follow-up care. </li></ul>
    113. 113. Prognosis1 <ul><li>Nonmetastatic GTN has a cure rate with chemotherapy of close to 100%. </li></ul><ul><li>Metastatic low-risk gestational trophoblastic neoplasia has a cure rate with chemotherapy of close to 100%. </li></ul><ul><li>Metastatic high-risk gestational trophoblastic neoplasia has a cure rate with chemotherapy of approximately 75%. </li></ul><ul><li>After 12 months of normal HCG titers, less than 1% of patients with malignant gestational trophoblastic neoplasia have recurrences. </li></ul>
    114. 114. Prognosis2 <ul><li>The rate of occurrence of a repeat molar pregnancy is approximately 1-2%. </li></ul><ul><li>The rate of occurrence of a repeat molar pregnancy in a patient with a history of 2 previous hydatidiform moles is approximately 10-20%. </li></ul><ul><li>The pregnancy rate after chemotherapy with MTX and cyclophosphamide is 80%. Of women treated with EMA-CO, 46% have had at least 1 live birth after chemotherapy. </li></ul><ul><li>Patients who become pregnant after treatment for GTN should have a pelvic ultrasound early during the pregnancy to confirm that the pregnancy is normal. </li></ul>
    115. 115. PREGNANT DIABETICS
    116. 116. ADAPTATION TO PREGNANCY <ul><li>In early pregnancy Estrogen and Progesterone stimulate beta cell hyperplasia and increased insulin secretion </li></ul><ul><li>Glycogenolyis and peripheral utilization increase </li></ul><ul><li>The net result is relative hypoglycemia </li></ul>
    117. 117. GLUCOSE LEVELS IN NORMAL PREGNANCY <ul><li>Fasting levels decline by 10 – 11 mg/dl </li></ul><ul><li>Postprandial levels rarely exceed 120-140 mg/dl </li></ul><ul><li>Glucose excursions with meals 30 – 35 mg/dl </li></ul><ul><li>Marked increase in insulin levels with feeding </li></ul>
    118. 118. CHO METABOLISM 20- 24 WEEKS <ul><li>Increased human placental lactogen – diabetogenic </li></ul><ul><li>Increased prolactin – insulin resistance </li></ul><ul><li>Increased cortisol – decreased glycogen storage </li></ul>
    119. 119. OTHER METABOLIC CHANGES <ul><li>Stable amounts of FFA </li></ul><ul><li>Increased cholesterol and TG </li></ul><ul><li>Reduced amino acid levels </li></ul>
    120. 120. MATERNAL COMPLICATIONS <ul><li>Retinopathy </li></ul><ul><li>Nephropathy </li></ul><ul><li>Chronic hypertension </li></ul><ul><li>Preeclampsia </li></ul>
    121. 121. RETINOPATHY <ul><li>Remains the leading cause of blindness in women ages 24-64 </li></ul><ul><li>Every patient with pre-gestational diabetes should have a retinal examination in early pregnancy </li></ul><ul><li>Laser therapy is safe and effective during pregnancy </li></ul><ul><li>Has a variable course during pregnancy </li></ul>
    122. 122. NEPHROPATHY <ul><li>Accounts for 1/3 of the deaths in diabetics < 31 </li></ul><ul><li>Renal findings are present as early as 1-2 years after diagnosis </li></ul><ul><li>Creatinine clearance may improve in pregnancy due to increased renal blood flow </li></ul><ul><li>Proteinuria may increase substantially </li></ul>
    123. 123. CHRONIC RENAL FAILURE <ul><li>Pregnancy is possible even in patients requiring hemodialysis </li></ul><ul><li>Reliable contraception is advised </li></ul><ul><li>Fertility and successful pregnancy outcomes are reduced with serum Cr > 2.0 </li></ul>
    124. 124. CHRONIC HYPERTENSION <ul><li>Should be aggressively controlled </li></ul><ul><li>ACE inhibitors are contraindicated </li></ul><ul><li>Calcium channel blockers are probably a reasonable alternative and are safe during pregnancy </li></ul><ul><li>Increases the incidence of fetal growth restriction and superimposed preeclampsia </li></ul>
    125. 125. PREECLAMPSIA <ul><li>BP > 140/90 </li></ul><ul><li>Proteinuria > 300 mg/24 hours or increase in baseline </li></ul><ul><li>May be difficult to diagnose in the presence of renal disease and chronic HTN </li></ul><ul><li>25% incidence of superimposed disease with CHTN </li></ul>
    126. 126. SEVERE PREECLAMPSIA <ul><li>BP > 180/110 </li></ul><ul><li>Proteinuria > 5 g/24 hours </li></ul><ul><li>Lab: elevated LFT’s. thrombocytopenia </li></ul><ul><li>Sxs: headache, epigastric pain, blurred vision </li></ul><ul><li>Oliguria, pulmonary edema, fetal growth restriction </li></ul>
    127. 127. PREGNANCY COMPLICATIONS <ul><li>Hydramnios </li></ul><ul><li>Spontaneous abortions </li></ul><ul><li>Congenital malformations </li></ul><ul><li>Macrosomia </li></ul><ul><li>Diabetic ketoacidosis </li></ul><ul><li>Neonatal metabolic complications </li></ul>
    128. 128. HYDRAMNIOS <ul><li>1-2 % in normals and 18% of diabetics </li></ul><ul><li>Fetal osmotic diuresis is etiologic </li></ul><ul><li>May also be due to fetal cardiac CNS malformations </li></ul><ul><li>May be associated with preterm labor </li></ul><ul><li>?Associated with level of glycemic control </li></ul>
    129. 129. SPONTANEOUS ABORTIONS <ul><li>In well controlled patients the rate is similar to the non-diabetic </li></ul><ul><li>Glycosylated hemoglobin levels are higher in women who have a SAB </li></ul><ul><li>Higher rates of spontaneous abortion in diabetics with vascular disease </li></ul>
    130. 130. CONGENITAL MALFORMATIONS <ul><li>Associated with periconceptual glucose control </li></ul><ul><li>In general the rate is 2-3 x that of the non-diabetic gravida </li></ul><ul><li>No increase when the father is diabetic </li></ul><ul><li>“ Fuel mediated teratogenesis” </li></ul>
    131. 131. TYPES OF CONGENITAL MALFORMATIONS <ul><li>Fetal cardiac anomalies may be complex </li></ul><ul><li>CNS – Spina Bifida, Anencephaly </li></ul><ul><li>Caudal regression syndrome </li></ul><ul><li>Must consider family history of other malformations that are unrelated to DM </li></ul>
    132. 132. GLYCOSYLATED HGB AND MALFORMATIONS <ul><li>HBA1C <8.5% , 3.4% malformations </li></ul><ul><li>HBA1C > 8.5% , 22.4 % malformations </li></ul><ul><li>Reflects glucose control over the preceeding 60 – 90 days </li></ul>
    133. 133. MACROSOMIA <ul><li>Seen more frequently with GDM and IDDM without vascular complications </li></ul><ul><li>Related to level of 3 rd trimester glucose control </li></ul><ul><li>May occur in up to 25% of diabetics </li></ul>
    134. 134. DIABETIC KETOACIDOSIS <ul><li>Seen in type I DM </li></ul><ul><li>Infection, fever, beta – agonists are frequent predisposing factors </li></ul><ul><li>Suspected with +serum ketones and blood glucose levels above 300 </li></ul><ul><li>Fetal distress is common </li></ul>
    135. 135. NEONATAL METABOLIC COMPLICATIONS <ul><li>Hypoglycemia </li></ul><ul><li>Hypocalcemia </li></ul><ul><li>Hypothermia </li></ul><ul><li>Hypomagnesemia </li></ul><ul><li>Hyyperbilirubinemia </li></ul>
    136. 136. PRECONCEPTION COUNSELING <ul><li>“ Tight” periconceptual control is essential </li></ul><ul><li>The diabetes should be stable </li></ul><ul><li>Multidisciplinary team maybe helpful </li></ul><ul><li>Diabetic education </li></ul><ul><li>Dietary counseling </li></ul><ul><li>Assessment of renal function </li></ul><ul><li>Retinal exam </li></ul>
    137. 137. PRECONCEPTION GLUCOSE CONTROL <ul><li>Fasting blood glucose < 100 mg/dl </li></ul><ul><li>Pre-meal levels <110 mg/dl </li></ul><ul><li>Post-meal levels <140 – 150 mg/dl </li></ul><ul><li>Avoid wide swings in control </li></ul><ul><li>Normalize hemoglobin A1C </li></ul>
    138. 138. PREVENTION OF MALFORMATIONS <ul><li>Normal glucose levels </li></ul><ul><li>Folic acid supplementation </li></ul><ul><li>Dose: 4 mg/day from 1 month pre-pregnancy to 12 weeks </li></ul>
    139. 139. FOLIC ACID <ul><li>All women of reproductive age should consume at least 0.4 mg of folic acid </li></ul><ul><li>High risk women should consume 4 mg/day </li></ul><ul><li>This reduces the risk of neural tube defects </li></ul><ul><li>Newer evidence suggests a lower risk of facial clefting and congenital heart disease as well </li></ul>
    140. 140. INDICATIONS FOR HOSPITALIZATION <ul><li>Persistent nausea and vomiting </li></ul><ul><li>Significant maternal infection </li></ul><ul><li>DKA </li></ul><ul><li>Poor control/compliance </li></ul><ul><li>Preterm labor </li></ul>
    141. 141. ASSESSMENT OF FETAL WELL-BEING <ul><li>Daily fetal movement counting </li></ul><ul><li>Twice weekly NST by 32 weeks </li></ul><ul><li>At least weekly assessment of AFV </li></ul><ul><li>OR </li></ul><ul><li>Weekly biophysical profiles </li></ul><ul><li>With more advanced disease, earlier testing is recommended </li></ul>
    142. 142. FIRST PRENATAL VISIT <ul><li>Routine prenatal lab </li></ul><ul><li>Baseline 24 hour UA for protein and Cr Clearance </li></ul><ul><li>Baseline retinal exam </li></ul><ul><li>EKG </li></ul><ul><li>Thyroid function tests in Type 1 Diabetics </li></ul><ul><li>Hemoglobin A1C </li></ul><ul><li>Schedule 10-12 week USN </li></ul>
    143. 143. EARLY PREGNANCY CARE <ul><li>Diabetic education and dietary instruction </li></ul><ul><li>Multi-disciplinary care is helpful </li></ul><ul><li>Calibrate reflectance meters </li></ul><ul><li>Adjust caloric needs for pregnancy and lactation </li></ul><ul><li>Review benefits of physical activity </li></ul>
    144. 144. TIMING OF DELIVERY <ul><li>Well controlled IDDM: at term </li></ul><ul><li>Poorly controlled: after documentation of fetal lung maturity </li></ul><ul><li>If fetal surveillance reassuring, delivery before 39 weeks should be unusual </li></ul>
    145. 145. INTRAPARTUM GLUCOSE CONTROL <ul><li>No breakfast the morning of induction </li></ul><ul><li>Establish IV with D5/.45% NaCl at 125 cc/hour </li></ul><ul><li>Capillary blood glucose levels every 1 – 2 hours </li></ul><ul><li>Begin continuous infusion of insulin with levels above 120 mg/dl </li></ul><ul><li>Avoid fluid boluses with D5 </li></ul>
    146. 146. SHOULDER DYSTOCIA BW (g) No diabetes(%) Diabetes(%) < 4000 0.1-1.1 0.6-3.7 4000-4499 1.1-10.0 4.9-23.1 > 4500 4.1-22.6 20.0-50.0
    147. 147. NERVE INJURY <ul><li>Rate varies from 4-40% following shoulder dystocia </li></ul><ul><li>Most (90%) resolve without sequelae </li></ul><ul><li>Can occur with EFW < 4000 g </li></ul><ul><li>Can occur in utero and therefore not preventable by cesarean </li></ul>
    148. 148. POSTPARTUM GLUCOSE CONTROL <ul><li>Insulin requirements may fall 50% in the 1 st 24 hours </li></ul><ul><li>Little need for treatment if under 200 mg/dl </li></ul>
    149. 149. CONTRACEPTION <ul><li>Reliable contraception should be offered </li></ul><ul><li>Low-dose combination OCP’s do not significantly impair carbohydrate metabolism </li></ul><ul><li>Progestin only oral contraceptives appear to accelerate the development of Type 2 DM in women with gestational diabetes </li></ul><ul><li>Barrier methods and even IUD may be acceptable </li></ul>
    150. 150. ACOG Low Risk <ul><li>Age < 25 </li></ul><ul><li>Not a member of an at risk ethnic group (Hispanic, African, Native American, South or East Asian, Pacific Islanders) </li></ul><ul><li>BMI < 25 (non-obese) </li></ul><ul><li>No history of abnormal glucose tolerance or FH </li></ul><ul><li>No adverse outcomes </li></ul>
    151. 151. Screening <ul><li>If FBS is 110-126: </li></ul><ul><li>Then 1 hr 50 gr or 3 hrs 100 gr </li></ul><ul><li>remember 105– 195—165---145 </li></ul>
    152. 152. Summary <ul><li>Every practice should adopt a screening strategy, either by historical or laboratory means </li></ul><ul><li>Screening best between 24-28 weeks </li></ul><ul><li>Remember to screen post delivery </li></ul>
    153. 153. Some diabetic cases
    154. 154. Bita Hazrati A PLP case complicated by HTN and GD <ul><li>24 yrs old </li></ul><ul><li>G2 P1 L0 D1/ first fetal loss due to preterm c/s delivery </li></ul><ul><li>( because of placenta previa) </li></ul><ul><li>GA on admission 32-33 w </li></ul><ul><li>CC: LP ( contractions mild/20 seconds D/ 2 in a </li></ul><ul><li>10- minute interval) </li></ul><ul><li>WB: Intact </li></ul><ul><li>ROM: - ( detected by Fern test) </li></ul><ul><li>Reduced fetal movement: - </li></ul>
    155. 155. <ul><li>Ph E: </li></ul><ul><li>PR= 86/min RR:16/min T:36 </li></ul><ul><li>BP= 140/90 mmHg </li></ul><ul><li>BS: </li></ul><ul><li>FBS=112 /10am=134 /4pm=145 /8pm=163 </li></ul>
    156. 156. 20-30 units total : 2/3 intermediate 1/3 regular Morning: 10 units of NPH- 4 units of regular Afternoon: 4 units of NPH – 4 units of regular
    157. 157. FBS is used to adjust evening NPH 2-hr PP (10 am) is used to adjust morning Regular Afternon preprandial (4 pm) is used to adjust morning NPH 2hr PP is used to adjust evening Regular
    158. 158. What is your management of this combined case of : 1- preeclampsia 2- GD 3- PLP
    159. 159. Answer: Mg so4 Ampicillin+ Erythro Isoxsuprine Sedation FBS-BS NST-FAD-OB US (AFI and GA) Insulin
    160. 160. Which is true about gestational diabetes? <ul><li>A-This happens during pregnancy with FBS less than 105 mg/dl. Its treatment is insulin. </li></ul><ul><li>B-It is a kind of type 2 diabetes. </li></ul><ul><li>C- All cases will develop overt diabetes within 20 years. </li></ul><ul><li>D- It happens because of reduced pancreas b cell function. </li></ul><ul><li>Ans:B </li></ul>
    161. 161. Which is an independent cause of IUFD in diabetes? <ul><li>A-hydramnios </li></ul><ul><li>B-abruptio </li></ul><ul><li>C-oligohydramnios </li></ul><ul><li>D-oxygen and metabolites transportation </li></ul><ul><li>Ans:D </li></ul>
    162. 162. Which is not a good method of contraception in a diabetic woman? <ul><li>A-LD OCP </li></ul><ul><li>B-medroxy progesterone acetate </li></ul><ul><li>C- HD OCP </li></ul><ul><li>D-norplant </li></ul><ul><li>Ans:C </li></ul>
    163. 163. What is the test for a 30 year old 10 wk pregnant woman whose FBS is 85/ 2hr PP is 125? <ul><li>A- 3 hr GTT </li></ul><ul><li>B-Repeat of FBS and 2hr PP next week. </li></ul><ul><li>C-Repeat of FBS and 2hr PP in 24-28 wk. </li></ul><ul><li>D-Repeat of FBS and 2hr PP in 34 wk. </li></ul><ul><li>Ans: C </li></ul>
    164. 164. Which is not a cause of PIH for a diabetic pregnant woman? <ul><li>A-poor blood glucose control </li></ul><ul><li>B-albuminurea </li></ul><ul><li>C-high creatinine </li></ul><ul><li>D-chronic HTN </li></ul><ul><li>Ans: A </li></ul>
    165. 165. What is the most common cause of perinatal mortality in diabetic pregnancies? <ul><li>A- malformations </li></ul><ul><li>B- RDS </li></ul><ul><li>C-metabolic errors </li></ul><ul><li>D- IUFD </li></ul><ul><li>Ans:A </li></ul>
    166. 166. What is one stage screening test for diabetes in pregnancy? <ul><li>A-100 grs oral glucose in 24-28 wk. </li></ul><ul><li>B-50 grs oral glucose in 20-22 wk. </li></ul><ul><li>C-75 grs oral glucose in 18-20 wk. </li></ul><ul><li>D-25 grs oral glucose in 30-32 wk. </li></ul><ul><li>Ans:A </li></ul>
    167. 167. What is your plan for a 35 wk diabetic pregnant woman whose BP is 140/90 mmHg/ is on 60 units of insulin /FBS=120 mg/dl? <ul><li>A-increasing the insulin dose </li></ul><ul><li>B- no treatment </li></ul><ul><li>C-hospitalization and adjusting insulin dose </li></ul><ul><li>D-termination of pregnancy </li></ul><ul><li>Ans:C </li></ul>
    168. 168. What is your management of a 30 yr old 35 wk pregnant woman class R diabetic with severe retinopathy? <ul><li>A-termination of pregnancy </li></ul><ul><li>B-Laser photocoagulation </li></ul><ul><li>C- high dose steroids </li></ul><ul><li>D-No action is needed now. </li></ul><ul><li>Ans:B </li></ul>
    169. 169. Which is not among the complications of type A2 diabetes in pregnancy? <ul><li>A- macrosomia </li></ul><ul><li>B-increased C/S </li></ul><ul><li>C- still birth </li></ul><ul><li>D-malformations </li></ul><ul><li>Ans:D </li></ul>
    170. 170. A woman with a history of gestation diabetes is asking for follow-up management after her delivery. Her FBS is 108 mg/dl and 2hr PP 135 mg/dl. What do you suggest? <ul><li>A-repeat of FBS and 2hr PP a year after delivery. </li></ul><ul><li>B- repeat of FBS and 2hr PP 3 yrs after delivery. </li></ul><ul><li>C-GTT with 100 grs glucose. </li></ul><ul><li>D-HbA1C 6 months after delivery. </li></ul><ul><li>Ans:B </li></ul>
    171. 171. In a woman with overt diabetes , BS is reported to be 130 mg/dl . What do you suggest for her IV infusion? <ul><li>A- RL and DW5% </li></ul><ul><li>B-RL and DW5% +insulin 1 unit/hr </li></ul><ul><li>C-NS +insulin 1.5 units/hr </li></ul><ul><li>D- NS+insulin 2 units/hr </li></ul><ul><li>Ans:B </li></ul>
    172. 172. Points to remember about diabetic labor: <ul><li>BS below 100 mg/dl : no insulin is needed </li></ul><ul><li>100-140 mg/dl:1 unit insulin </li></ul><ul><li>140-180 mg/dl:1.5 units insulin </li></ul><ul><li>180-220 mg/dl:2 units insulin </li></ul><ul><li>More than 220 mg/dl:2.5 units insulin </li></ul><ul><li>BS more than 140 mg/dl needs NS as IV infusion </li></ul>

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