Mdcu Obstetrics Tutorial

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Mdcu Obstetrics Tutorial

  1. 1. MD Chula 2010 TUTORIAL IN OBSTETRICS รศ. น.พ. ศักนัน มะโนทัย หนวยเวชศาสตรมารดาและทารกในครรภ y ภาควิชาสูติศาสตร-นรีเวชวิทยา คณะแพทยศาสตร nl จุฬาลงกรณมหาวิทยาลัย O email : manotaya@hotmail.com se U Obstetrics al rn ¨ Overview & vital statistics te ¨ ANC ¨ Early pregnancy complications In ¨ Late pregnancy complications ¨ Intrapartum care ¨ Postpartum care
  2. 2. MD Chula 2010 Overview & vital statistics ¨ Maternal mortality rate ¤ Maternal death Per 100,000 LB ¤ Direct / Indirect / Nonmaternal ¨ Stillbirth rate (per 1,000 births) y ¨ Neonatal death (per 1,000 LB) – early/late nl ¨ Perinatal mortality rate ¤ Per 1,000 births O ¨ Infant mortality rate se U Antenatal care al rn ¨ Objective te ¨ Routine care ¨ Common complaints In ¨ High risk pregnancy
  3. 3. MD Chula 2010 Objective of ANC ¨ GA estimation ¤ LMP , PE , USG ¨ Identify high-risk pregnancy ¤ History , PE , Lab y nl ¨ Management ¨ Advice O ¨ Appointment se U al Normal findings rn Naegele’s rule EDC = LMP – 3 mo. + 7 days (+1year) Weight gain total 10-12 kg te trimester 1/5/5 kg weekly 0.3-0.5 kg In Fundal height 12/16/20 1/3 , 2/3 , Θ 24/28/32 1/4 , 2/4 , 3/4 > Θ Jimenez (cm) 18-32 weeks ( ± 2 cm) Quickening nulliparous 18-20 wk multiparous 16-18 wk
  4. 4. MD Chula 2010 General advice First trimester Avoid drugs, X-ray, infection Food intake How to reduce N/V Second trimester Food supplement Common complaints Third trimester Fetal movement count y Count-to-10 modified Sardovsky nl Braxton-Hicks When to go to hospital O Any trimester Daily activity Sex seRest Drug use U Common complaint al rn Complaints Advice & Rx N/V Diet – small, frequent meals Reassure, time of improvement te Rx : dimenhydrinate, plasil Constipation High fiber diet In Rx : fiber (Mucillin, Fybogel), senokot Cramps Activity Calcium supplement Bleeding per gum Soft toothbrush, vitamin C Uterine contraction Advice Braxton-Hicks What is abnormal? Leukorrhea (non itching) reassure Numbness of hands reassure Back pain reassure
  5. 5. MD Chula 2010 High-risk pregnancy ¨ ประวัติความผิดปกติในครรภกอนๆ ¨ ประวัติปจจุบันและโรคประจําตัว ¨ การตรวจรางกาย y ¨ การตรวจครรภและการตรวจภายใน nl ¨ การตรวจทางหองปฏิบัติการ O se U Risk Action al Age 35 yrs at EDC Genetic counseling Screen DM rn Beware HT Hx preterm birth Assess cause, prevention te Hx ectopic pregnancy R/O ectopic by USG Obese, FHx of DM Screen GDM (50g GCT at 24-28 wk) In VDRL positive Confirm by TPHA or FTA-Abs Benzathine Penicillin 2.4 MU IM weekly*3 HBsAg positive HBeAg – assess infectivity HBIG for newborn, HBV vaccination Rh negative Anti-D or ICT – sensitized/unsensitized Husband - Rh Unsensitized – RH Ig at 28-32wk, PP Thalassemia carrier Identify high-risk couple -> PND (MCV < 80 fl, HbA2 > 3.5%, HbE) Rubella Ig – non-immune Postpartum vaccination (if desire more baby)
  6. 6. MD Chula 2010 y nl O se U Early pregnancy complications al rn ¨ Abortion (miscarriage) te ¨ Molar pregnancy ¨ Ectopic pregnancy In ¨ Hyperemesis gravidarum
  7. 7. MD Chula 2010 Abortion • 10-15% of clinical pregnancy • Clinical term – Threatened , incomplete , complete , missed – Time/symptom sequence y • USG term nl – Anembryonic preg (Blighted ovum), embryonic death • Management O – Expectant / Prostaglandins / Curettage • Septic abortion – se Antibiotics / Prevention of tetanus / Beware of septic shock U Ectopic pregnancy al rn • 0.5-1 % , Tubal abortion vs Tubal rupture Diagnosis te • – Symptoms and signs Pain by Hx/PE – cervical tenderness, rebound tenderness In • • Bleeding – spotting • Missed period – not always present – Urine pregnancy test – Ultrasound – absence of IUP, free fluid in CDS, adnexal mass – Culdocentesis – unclotted blood – Beta-hCG Beta-hCG vs USG / Rising level in 48 hours – Laparoscopy
  8. 8. MD Chula 2010 Ectopic pregnancy ¨ Management ¤ Salpingectomy ¤ Conservative Sx of tubes ¤ Medical Rx (MTX) y ¤ Laparoscopic Sx nl ¨ Counseling ¤ Risk of recurrence O se U Hydatidiform Mole al rn • Symptoms and signs Bleeding 90% te – – Size > Date 50% Hyperemesis 20% In – – PIH 25% – Theca lutein cysts, Hyperthyroidism – Passing molar vesicles • Diagnosis – High hCG level – USG snow storm, vesicles
  9. 9. MD Chula 2010 Hydatidiform Mole ¨ Management ¤ Evacuation n Suctioncurettage n Hysterectomy y ¤ Follow-up nl n Regression of hCG in 8-10 weeks n Clinical, CXR O n Contraception at least 1 yr se U Hyperemesis gravidarum al rn • Definition severe vomiting with te – weight loss, dehydration In – acid-base disturbance – hypokalemia • Management – Dietary modification – Supportive Rx – Antiemetics – Identify cause
  10. 10. MD Chula 2010 y nl O se U Late pregnancy complications al rn • Preterm labor te • PROM • Hypertensive disorder In • IUGR (Intrauterine growth resttriction) • Twins • Placenta previa • Hydramnios • Postterm
  11. 11. MD Chula 2010 Preterm labor ¨ Definition ¤ GA 28-36 weeks ¤ Regular uterine contractions ¤ Cervical change , 2 cm, 80% effacement ¨ GA >= 34 weeks y ¨ GA < 34 weeks nl ¤ Look for contraindications for labor inhibition ¤ Dexamethasone 6 mg IM q 12 h for 4 doses O ¤ Terbutaline/Salbutamol/Nifedipine/Indomethacin/MgSO 4 ¤ Precautions for each tocolytic agent se U PROM/PPROM al rn ¨ ROM before onset of labor cough test/nitrazine/Nile blue/fern te ¨ Cord compression / infection ¨ Term pregnancy In ¤ Induction of labor / Cesarean / wait for 12 hr ¤ GBS prophylaxis in active labor if > 18 hr ¨ Preterm ¤ No PV,PR ¤ R/O infection ¤ Antibiotics to prolong latency ¤ Steroid if < 34 weeks ¤ GBS prophylaxis
  12. 12. MD Chula 2010 GBS prophylaxis ¨ Screening-based approach culture at 35-37 wk ¨ Risk-based approach Ø preterm birth Ø ROM > 18 hr y Ø intrapartum fever nl Ø GBS in urine culture Ø Hx of GBS infection previous birth O ¨ Ampicillin 2g IV then 1g IV q 4 h until delivery (or vancomycin if allergic to penicillin) se U Hypertensive disorder al rn ¨ Classification te ¤ ChronicHT / PIH / PAH ¤ Gestational HT / Preeclampsia / Eclampsia In ¨ Hypertension SP 140 mmHg or DP 90 mmHg ¨ Proteinuria 300 mg/24h or dipstick 1+
  13. 13. MD Chula 2010 สิ่งตรวจพบ Mild preeclampsia Severe preeclampsia ความดันโลหิต นอยกวา 160/110 mmHg ตั้งแต 160/110 mmHg ขึ้นไป โปรตีนในปสสาวะ นอยกวา 5 กรัม/วัน มากกวา 5 กรัม/วัน (dipstick 1+ หรือ 2+) (dipstick 3+ หรือ 4+) ปวดศีรษะ ไมมี มี ตามัว ไมมี มี จุกแนนลิ้นป ไมมี มี Oliguria (<500 ml/24 h) ไมมี มี y ชัก ไมมี มี (eclampsia) nl Serum creatinine ปกติ สูงผิดปกติ เกร็ดเลือด ปกติ ตากวา 100,000 ตอ มม.3 O Liver enzyme ผิดปกติเล็กนอย ผิดปกติชัดเจน ทารกโตชาในครรภ ไมมี มี Pulmonary edema ไมมี se มี ACOG Recommendations based primarily on consensus and expert opinion (Level C) U al Concept of Management Delivery is always the best treatment for mother, rn but not always for the fetus te Severity Preterm Term In Mild Expectant Termination ACOG Level C recommendation Severe ??? Termination Eclampsia Termination Termination
  14. 14. MD Chula 2010 Mild preeclampsia ¨ Hospitalization, bed rest, sedation ¨ Laboratory tests to rule out severe disease, HELLP syndrome y ¨ Observe worsening clinical signs&symptoms nl ¨ Monitor fetal well-being Continue pregnancy until term, fetal distress, O ¨ or severe preeclampsia develops. se U Severe preeclampsia al rn ¨ Prevention of seizure te ¨ Control of high blood pressure In ¨ Termination of pregnancy depending on GA route
  15. 15. MD Chula 2010 Effects vs Serum Mg levels 4-7 mEq/L Anticonvulsant prophylaxis (Therapeutic level) 8-10 mEq/L Loss of DTR y 12 mEq/L Respiratory paralysis nl 15 mEq/L Cardiac arrest O se U al Magnesium sulfate rn Dosage 5 gm IV in 5 minutes te 1-3 gm IV drip per hour until 24 h PP Monitoring Urine output > 30 mL/h In DTR Respiratory rate > 12 per minute Antidote 10% Calcium gluconate 10 mL IV
  16. 16. MD Chula 2010 Severe hypertension in pregnancy Definition DP more than 110 mmHg Why is it dangerous? Intracranial hemorrhage / hypertensive encephalopathy Aim of Rx y DP 90-100 mmHg, SP 140-150 mmHg nl Treatment First choice Hydralazine IV O Alternatives Nifedipine PO Nicardipine IV Labetalol IV se U al Severe Preeclampsia Remote from Term rn ¨ GA >= 34 weeks ¤ Stabilize then TOP te ¨ GA 32-34 weeks In ¤ Stabilize ¤ Steroid to enhance fetal lung maturity (option for lung maturity testing) ¤ Maternal & fetal evaluation ¤ TOP after 48 hours
  17. 17. MD Chula 2010 Severe Preeclampsia Remote from Term ¨ GA 24-32 weeks ¤ Stabilize ¤ Steroid toenhance fetal lung maturity (option for lung maturity testing) ¤ Maternal & fetal evaluation y ¤ TOP vs continuation of pregnancy under close nl surveillance ¨ GA <24 weeks O ¤ Stabilize then termination se Skip U Twins al rn ¨ Type dizygotic, monozygotic te dichorion, monochorion (DA, MA) ¨ Chorionicity sex, membrane, placenta In ¨ MC Twin-twin transfusion ¨ F/U growth by USG q 2-4 weeks discordant twin ¨ Delivery vaginal if cephalic, bigger fetus first second twin – internal podalic version ¨ Beware PPH
  18. 18. MD Chula 2010 y nl O se U IUGR al rn ¨ Definition EFW < 10th centile less than growth potential te ¨ Type symmetrical In asymmetrical (small AC) ¨ Cause uteroplacental insufficiency maternal (heart, SLE,….) fetal (structural, chromosomal) constitutional
  19. 19. MD Chula 2010 IUGR ¨ Asymmetrical IUGR oligohydramnios grade 3 placenta abnormal Doppler ¨ Rx identify type, cause y assess fetal wellbeing NST, BPP, Doppler nl steroid if < 34 weeks USG FU growth O deliver if no growth, distress, term se U Placenta previa al rn ¨ Type totalis / marginalis / lowlying te anterior / posterior ¨ Dx USG in 3rd trimester In painless bleeding in 3rd trimester ¨ Rx expectant if preterm, no severe bleeding no PV, PR steroid if < 34 weeks tocolytics
  20. 20. MD Chula 2010 Placenta previa ¨ Cesarean if term or severe bleeding M/G at least 4 units Expert consultation Counseling y Option for Classical C/S in anterior previa nl O se U Abruptio placentae al rn Symptoms & signs te ¨ Frequent, strong, tetanic uterine contractions ¨ Vaginal bleeding + In ¨ Severity severe FDU, board-like rigidity moderate Fetal distress mild Preterm labor
  21. 21. MD Chula 2010 Abruptio placentae Rx ¨ Beware coagulapathy , M/G ¨ ARM to reduce pressure ¨ If FDU Vaginal delivery y distress Cesarean section nl O se U Vasa previa al rn ¨ Risk factor velamentous insertion twins te lowlying placenta abnormal placenta In ¨ Ruptured vasa previa ROM with blood-stained AF fetal bradycardia high fetal death rate ¨ Diagnosis suspicion nucleated RBC/Apt/Kleihauer ¨ Prevention pulsation of vessel before ARM
  22. 22. MD Chula 2010 Postterm (GA>42+0 wk) ¨ Oligohydramnios / MAS / asphyxia ¨ Verify GA (wrong GA is the most common cause) ¨ If definite postterm -> terminate pregnancy ¨ Induction of labor vs Cesarean section y ¤ Indicationfor CS nl ¤ Bishop score O n FavorableCx (>=6) Induction n Unfavorable Prostaglandin se U Hydramnios al rn ¨ Definition AFI > 25 cm te DVP > 8 cm ¨ Cause idiopathic / DM / twins (TTTS) In fetal anomalies ¨ Rx 100g OGTT, detailed USG amnioreduction if respiratory distress ¨ Labor beware abruption, prolapsed cord beware PPH
  23. 23. MD Chula 2010 y nl O se U Medical and surgical complications al rn ¨ Heart disease te ¨ Acute pyelonephritis ¨ DM In ¨ HT ¨ Acute appendicitis
  24. 24. MD Chula 2010 Heart diseases ¨ Physiologic changes CO ¨ Functional class and pathology Eisenmenger complex, Severe AS, Severe MS ¨ Management y ¤ Reduce cardiac load anemia, infection nl ¤ According to FC , option for TOP ¤ Rheumatic -> AB , Congenital -> fetal echo O ¤ Vaginal delivery, shorten 2 nd stage, IE prophylaxis se U Acute pyelonephritis al rn ¨ Asymptomatic bacteriuria > 105 cfu/ml te ¨ Dx fever, CVA tenderness, UA 3rd trim , right > left In ¨ Rx ¤ Correct dehydration, beware septic shock ¤ Parenteral AB (Ampi / Genta / Cephalosporins) ¤ Beware preterm labor ¤ FU urine culture
  25. 25. MD Chula 2010 DM ¨ Pregestational DM vs Gestational DM ¨ Complications GDM macrosomia, hydramnios, hypoglycemia, hypocalcemia, ……… y Overt anomaly nl ¨ Screening (50g GCT) 140 mg/dl O Age/FHx/obese/macrosomia anomaly/stillbirth/glycosuria se U DM al rn ¨ Diagnosis (100g OGTT) te 105/190/165/145 mg/dl In ¨ GDM A1 vs GDM A2 fasting 105 / 2hPP 120 ¨ Rx blood glucose monitoring, diet control insulin sc monitor fetus, mother intrapartum PG 80-120 mg/dl
  26. 26. MD Chula 2010 Chronic HT ¨ 15-25 % incidence of superimposed preeclampsia ¨ Work up Identify cause of HT y End-organ damage nl ¨ Appropriate control of BP O ¨ Close monitoring and early detection of superimposed preeclampsia is important se U Medical Rx of Chronic HT al rn Aim of treatment DP 90-100 mmHg te Alpha-methyldopa drug of choice In ARB, ACE inhibitor contraindicated Beta-blockers IUGR increases
  27. 27. MD Chula 2010 Acute appendicitis ¨ Location upward, more lateral ¨ More difficult to Dx ¨ DDx red degeneration of myoma (Alder’s sign) y ovarian cyst with complications nl ¨ Early explor. lap. in questionable case O se U al rn te In
  28. 28. MD Chula 2010 Intrapartum care ¨ Routine care ¤ Oxytocin use , analgesia ¨ Dystocia ¨ Fetal distress (non-reassuring fetal status) y ¨ Emergency nl ¤ Prolapsed cord ¤ Eclampsia O ¤ Shoulder dystocia se U al Initial Assessment of Parturients rn ¨ GA Assessment ¤ Preterm, Term, Postterm te ¨ Stage/Phase of labor In ¤ 1st (Latent, Active) , 2nd , 3rd , Not in labor ¨ Pelvic assessment ¨ Low risk VS. High risk cases ¤ Maternal/Fetal wellbeing
  29. 29. MD Chula 2010 Monitoring of Parturients ¨ Fetal wellbeing ¤ AF color/volume, FHS auscultation, EFM ¨ Maternal wellbeing ¤ Pain relief, hydration, psychological y support nl ¨ Progression of labor O ¤ Friedman’s curve ¤ Partogram se U al rn te In
  30. 30. MD Chula 2010 y nl O se U Dystocia al Nulliparous Multiparous rn Prolonged latent phase > 20 hr >14 hr Active phase (maximum slope) te Protracted active phase dilatation < 1.2 cm/hr < 1.5 cm/hr Secondary arrest of dilatation no progress for 2 hr no progress for 2 hr In Deceleration phase (8 cm to FD) Protracted descent < 1 cm/hr < 2 cm/hr Arrest of descent no progress for 1 hr no progress for 1 hr Prolonged deceleration phase > 3 hr > 1 hr Prolonged second stage > 2 hr > 1 hr
  31. 31. MD Chula 2010 Mx. of Prolonged Latent Phase ¨ Assess maternal wellbeing ¤ No obstetric and medical complications ¨ Assess fetal wellbeing ¤ EFM y ¤ USG : normal AFI , no IUGR nl ¨ Bed rest or Therapeutic rest ¨ Induction of labor O se U Mx. of Abnormal Active Phase al rn ¨ Assess Power-Passage-Passenger (3P) te ¤ If CPD -> Cesarean section In ¤ If Hypotonic contraction -> Oxytocin ¨ Supportive care e.g. IV fluid, Pain relief ¨ Careful fetal monitoring ¨ Reassessment after 2 hours
  32. 32. MD Chula 2010 y nl O se U NST al EFM rn te In § NST or EFM § Rate 1 or 3 cm/min § Baseline 120-160 bpm § Baseline variability 6-25 bpm § Periodic change Acceleration 2 in 20 min, 15 bpm for 15 sec Deceleration
  33. 33. In te rn al U MD Chula 2010 se O nl y
  34. 34. In te rn al U MD Chula 2010 se O nl y
  35. 35. MD Chula 2010 Fetal distress (non-reassuring fetal status) ¨ Intrauterine resuscitation ¤ Off oxytocin ¤ Left lateral position y ¤ Oxygen mask nl ¤ Close fetal heart rate monitoring O ¨ Immediate delivery if not improved by 15-20 min. se U Shoulder dystocia al rn ¨ Call for help te ¨ Suction ¨ deep episiotomy, bladder catheter In ¨ Maneuver Suprapubic pressure McRoberts’ maneuver Wood’s corkscrew deliver posterior shoulder
  36. 36. MD Chula 2010 Eclampsia - Severe Preeclampsia ¨ Airway maintenance ¨ Prevention of seizure / re-seizure n Magnesium sulfate IV loading + drip ¨ Beware abruption , fetal distress y ¨ Termination of pregnancy nl O se U Prolapsed cord al rn ¨ How to prevent ARM te ¨ Rx ¤ Assess fetal status USG, Doptone, cord pulse In ¤ If alive fetus reduce cord compression Trendelenburg position push fetal head fill bladder, tocolytics emergency CS ¤ If FDU vaginal delivery
  37. 37. MD Chula 2010 Operative Obstetrics ¨ Cesarean section ¨ Forceps extraction ¨ Vacuum extraction ¨ Shoulder dystocia y ¨ Amniotomy nl ¨ Induction of labor O se U Amniotomy (ARM) al rn ¨ Timing early / late ¨ Precaution vasa previa / prolapsed card te abruption / infection In
  38. 38. MD Chula 2010 Oxytocin ¨ Start dose 1-6 mu/min (2-12 drops/min) ¨ Half-life 3-5 min. Adjust dose q 20-30 min. ¨ Max dose 20-30 mu/min y ¨ If tetanic contraction off, intrauterine resusc nl restart at half dose O se U Forceps extraction al rn ¨ Conditions to be fulfilled FD/MR/no CPD/2+/alive te ¨ Indications prolonged/HT/heart/distress prophylactic/preterm In ¨ Instruments Simpson/Kielland/Piper ¨ Levels outlet/low/mid/high ¨ Steps pudendal block/empty bladder orientate/apply/lock/FHS/trial
  39. 39. MD Chula 2010 Vacuum extraction ¨ Conditions to be fulfilled FD/MR/no CPD/2+/alive ¨ Indications prolonged/poor expulsion/DTA ¨ C/I preterm/HIV ¨ Instruments metallic cup/silastic cup y ¨ Steps pudendal block/empty bladder nl apply/reduce pressure/trial ¨ Advantage autorotation (>45 o ,Deep transverse arrest) O less maternal injury ¨ Disadvantage longer duration / limited power se U al rn te In
  40. 40. MD Chula 2010 Postpartum care ¨ Routine care ¨ Postpartum hemorrhage ¨ Puerperal infection y nl O se U Puerperal infection al rn ¨ Puerperal morbidity 38 C x 2 in 10 days (excl first 24h) te ¨ S&S ¤ Postpartum fever In ¤ Pelvic pain, subinvolution ¤ Foul smell lochia ¤ Leucocytosis ¨ DDx UTI, atelectasis, breast engorgement
  41. 41. MD Chula 2010 Early postpartum hemorrhage (before 24 h) ¨ DDx atony / birth canal injury ruptured uterus ¨ Rx M/G , IV fluid loading atony uterine massage y oxytocin/methergin/sulprostone nl bimanual compression hypogastric/uterine artery ligation O hysterectomy birth canal repair with adequate exposure se U al rn te In

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