Antepartum Haemorrhage

' Definition Bleeding from 1 into genital tract after 28th week of but before the
pregnancy
birth of baby .

APH

Placental 15% ) Unexplained 125%)

Bleeding Extra placental causes

08

Placenta Praia 135% ) -

cervical polyp Intermediate

Abruptio placenta 135%) -

Ca cervix celebrating placental

-

Local trauma and local lesions)

parameters placenta Previa Abruptio Placenta

1. Clinical features

. Nature of Bleeding -

painless and recurrent

-

Painful ,
continuous
Revealed concealed mixed
Bleeding is always revealed or
-

Character of Blood Dark coloured

Bright Red
-

-
General condition & Anemia proportionate to visible blood loss Out of proportion to visible blood loss in
concealed or mixed variety .

-
Features of pre-eclampsia Not Relevant Present in
'
13 of the cases

2) Abdominal exam

.
Height of Uterus proportionate to gestational age May be disproportionately enlarged in concealed type

- feel of Uterus soft & Relaxed May be tense ,

tender & rigid

. Malpresentation common ; Head is high floating Unrelated ; Head may be engaged

.
Fetal Heart sound Usually present Usually absent in concealed type

3) Vaginal exam placenta felt in lower segment Placenta is not felt on lower segment
(should not be done in suspected case )

4) placentography (USGIMRD Placenta in lower segment Placenta in upper segment .

 Antepartum Haemorrhage
' Definition Bleeding from 1 into genital tract after 28th week of but before the
pregnancy
birth of baby .

APH

Placental 15% ) Unexplained 125%)

Bleeding Extra placental causes

08

Placenta Praia 135% ) -

cervical polyp Intermediate

Abruptio placenta 135%) -

Ca cervix celebrating placental

-

Local trauma and local lesions)

parameters placenta Previa Abruptio Placenta

1. Clinical features

. Nature of Bleeding -

painless and recurrent

-

Painful ,
continuous
Revealed concealed mixed
Bleeding is always revealed or
-

Character of Blood Dark coloured

Bright Red
-

-
General condition & Anemia proportionate to visible blood loss Out of proportion to visible blood loss in
concealed or mixed variety .

-
Features of pre-eclampsia Not Relevant Present in
'
13 of the cases

2) Abdominal exam

.
Height of Uterus proportionate to gestational age May be disproportionately enlarged in concealed type

- feel of Uterus soft & Relaxed May be tense ,

tender & rigid

. Malpresentation common ; Head is high floating Unrelated ; Head may be engaged

.
Fetal Heart sound Usually present Usually absent in concealed type

3) Vaginal exam placenta felt in lower segment Placenta is not felt on lower segment
(should not be done in suspected case )

4) placentography (USGIMRD Placenta in lower segment Placenta in upper segment .

 1.
Placenta previa
Incidence : 0.5 -
1%

Definition when implanted partially the lower

-
placenta is or completely over uterine

segment lover and adjacent to internal ) is called Placenta

preria.TL/pesI
os ,
it

Degrees Type I -

lying
low

type 2- marginal
Type 3- Incomplete / partial
Type 4- Central Icomplate

Revised classification ACR 2014 )

'
CACOG ,
:
a) True -
Placenta covers internal OS

b) Low lying -
Placenta lies within 2 am of

internal os but does not cover it

.

-
Risk Factors . multi parity
-
Maternal age 735 years
- Race -

Asian women

previous history of placenta preria

-

. previous H10 6CS , myomedomy hysterotomy

,

.
prior curettage
'
smoking
'
placenta succenturiata

Big placenta
'

- Clinical Features Symptoms sudden

. :
Vaginal Bleeding -

onset
-

painless
-

Apparently causeless
-

Recurrent
. Painless and recurrent vaginal bleeding in 2nd half of pregnancy should be
taken as placenta previa unless proved otherwise .

.
Signs :

1) Generate condition and anaemia : Proportionate to visible blood loss .

2) Height of uterus : proportionate to period of gestation .

3) Feel of uterus : soft & Relaxed without any localised tenderness .

4) Malpresentation (Breech ,
transverse ,
unstable lie ) is common

5) Head is high floating and can not be pushed down to pelvis .

6) Stallworthy sign : slowing of fetal heart rate on pressing head down in to pelvis

and prompt recovery on release of pressure .

*
Digital vaginal exam is contraindicated till placenta preria is ruled out
 -
Investigations 1) scenography

it Transvaginal : 1001 accuracy , inexpensive

til Trans abdominal : False positive may be seen due to full bladder or myometn.at contractions
liii ) Transperineal

2) Color doppler : Diffuse vascular lakes with turbulent flow in hypo echoic areas near

cervix is consistent with diagnosis of placenta previa

.

3) MR1

4) Blood investigations -
CBC

Blood grouping and cross matching

.MX '
Emergency MX -

.
Two wide bore IV lines
-
Iv fluids ( Crystal bids and colloids)
.
Blood transfusion ( in case of haemodynamic instability)
.
Close monitoring of maternal and fetal condition
.
confirmation of diagnosis of Placenta preria by US4
.

.
Expectant MX [ McAfee and Johnson Regimen ]
-

prerequisites :
cil Availability of blood transfusion

④I 24 hr availability of facilities for Caesarean section .

Case selection : lit Pregnancy 537 wks

Iii ) mother is haemo dynamically stable

* it there are no signs of fetal distress

Method : lit Bed rest

monitoring of patient with blood investigations E1 0SG

Liii )
supplementary hematinics
liv ) Transfusion if needed
41 tocolysiscmgs.at )
* Expectant management can be continued till 37 weeks

- Active management :

Indications : 4)
Bleeding at or after 37 weeks .

② Patient in labor

③ patient is haemo dynamically unstable

④ Baby with cardiac wind dead congenital deformity
non assuring .
or or

-
Caesarean delivery is done for most women with placenta previa .

Steroid therapy if
pregnancy duration 137 weeks
- -

'
Vaginal delivery :
May be attempted when placenta edge is dearly 2-3 em away from internal

cervical Os .

( Rarely attempted)
'
complications .
Maternal :

During pregnancy During labor During Puerperiom

-
Antepartum haemorrhage - Early rupture of membranes .
sepsis due to
. Shock - Cord prolapse -
tsed operative interference

- Malpresentation . slow dilation of cervix -

Anaemia

-
premature labor .
Intrapartum haemorrhage -
placental site near
vagina
'
PPH due to - Sub involution
-

Imperfect retraction . Embolism

-

Large surface area of placenta

Associated morbidly adherent placenta 1151)

-

-
Retained placenta

. Fetal

.
prematurity
- Low birth weight
. fetal growth restriction
-
Asphyxia
. Intrauterine death
.
Congenital malformations
-
Birth injuries due to tsed Operative interference .
 Abruptio Placentae
'
Incidence :
I %

'
Definition form of antepartum haemorrhage where bleeding occurs due to premature separation
of normally situated placenta .

-
Types 1) Revealed :
Blood insinuates blue membranes and decided and comes out of

external os .

2) Concealed : Blood collects behind separated placenta or in between the membranes

and decided .

3) Mixed

- Risk Factors 1) High birth order pregnancy with gravid 7,5 C3K more risk than 1st time)

2) Advancing age of mother

3) Smoking lvasospasm)
4) Hypertension in
pregnancy ( most important)
5) Trauma -
External

during cephalic version

-

needle puncture during amniocentesis

6) Short cord

7) Supine hypotension syndrome

8) Sudden uterine decompression following delivery of 1st baby of twins
-

Sudden escape of liquor in polyhydroamnios

premature rupture of membranes

a) prior abrupton Risk

5-17%10
40 -

of recurrence :

) deficiencyfolic Acid

11 ) placental causes ciroumvallate placenta

sick placenta (poor placentation evidenced by uterine artery doppler)
121 Uterine factors placenta implanted over septum ( septate uterus)
placenta implanted over fibroid
Torsion of uterus

B) Cocaine abuse

14 ) tnrombophilias

Hyperhomocystinemia.CH
b)

. Clinical features depend on :

Degree of placental separation

-

Speed at which separation occurs ( Acute or chronic)

-

Variety : concealed or revealed -

Symptoms
-
: -

vaginal Bleeding
-

Abdominal pain

High frequency contractions

-

signs uterine tenderness

-
: -

signs of fetal distress /death

* Abruptio placenta cause Ischemic pituitary Necrosis (Sheehan 's syndrome)
may
> symptom Failure of
-

lactation

-
Complications . Maternal :

a) Revealed type : maternal Risk is proportionate to visible blood loss .

maternal death is rare

b) concealed type :
-

Haemorrhage completely concealed 1 part revealed outside

:

Intra peritoneal ,
Broad ligament haematoma
-
Shock

D1C
-

oligun.ci/Anuria:duetoaIhypovoIemia
-

b) Serotonin from damaged uterine muscle producing

renal ischemia

c) Acute tubular necrosis

d) cortical necrosis EI Renal failure ( severe )
cases

DPH : due to a) Atony of uterus

-

b) tsed serum FDP

puerperal sepsis
-

.
fetal

a) Revealed : Fetal death in 25 -30% cases .

b) Concealed fetal death

50-100%1
: →

Deaths are due to prematurity 4 anoxia due to placental separation .

'
Investigations i. USG
placenta localisation ( mostly in upper segment)
-

Retro placental collection can be seen

Early haemorrhage is hyperechoic or isoechoic .

Acute haemorrhage can be confused with fibroid or thick placenta

-

Negative findings do not rule out abrupton .

2) Blood investigations :
-

CBC and platelet count

-

Blood grouping and cross matching

D1C profile
-

Bleeding time dotting time

-

PT , APTT
-

Serum fibrinogen
fibrin degradation product CFDP)
-
 .MX .
Emergency management :

-
a wide bore IV lines
-

IV fluids ( Ringer lactate)

-

Blood investigations
-

Blood transfusion ( if required)

-

Fresh frozen plasma and platelets transfusion in case of DK .

Close
monitoring of maternal & fetal condition .

. Pritchard 's rule for management of abrupton : keep Haematocrit at least 30% d
maintain Urine output of at least 30mi Ihr

Definitive MX Immediate delivery

. :

Abruptio Placenta

investigations i Resuscitation

✓ \

Revealed variety concealed variety

v v v

Patient patient not Delivery

in labor in labor v v

v ARMI oxytocin LSCS

ARTMI oxytocin Delivery ✓

"
v v
Vaginal
Vaginal delivery ARMI LSCS

Oxytocin

Vavginal
'
vaginal delivery is favoured in cases with :

limited placental abrupton

.

i.

2-
Reassuring FHR tracing
3. Facilities for continuous fetal monitoring available
4. Prospect of vaginal delivery is soon .

5 Placental abmption with dead fetus

'
Indications of C- section :

1) Severe abrupton with live fetus

2) Amniotomy could not be done (unfavourable cervix )

3) Amniotomy failed to control bleeding

4) Amniotomy failed to arrest process of dbruption (Rising funded height)
5) Prospect of immediate vaginal delivery is remote despite amniotomy
6) Appearance of adverse features fetal distress Using fibrinogen level

oliguria.mx
:
. ,

of complications :
manage hypovolemia shock , ,
D1C
 Postpartum Haemorrhage
-
Def .
Blood loss of 500 ml or more ( vaginal delivery ) following birth of baby .

-
Any amount of bleeding from or into genital tract following the birth of

baby upto the end of puoiperium which causes haemo dynamic instability in

the patient .

-
Avg Blood loss .
Vaginal delivery -

500mL
'
Caesarean delivery -

1000mi
'
Caesarean hysterectomy -

1500mi

-
Causes ① Atomic uterus -
Most common [80%3
'
conditions predisposing to uterine Atony :
-

Grand multipara
Over distension of uterus → Multiple pregnancies Hydra minos
[
,

malnutrition and anaemia

Antepartum haemorrhage ( Placenta previa Abruptio placenta)

-

Prolonged labour CS12 hrs)

-

Anaesthesia
-
Initiation and augmentation of delivery by oxytocin
Uterine malformation
-

Uterine fibroid
-

mismanaged 3rd stage [ Too rapid delivery ; Dulling the cord)

-

morbidly adherent placenta (Placenta accreta percreta )

-

② Traumatic

Large episiotomies
-

laceration of perineum vagina . ,

cervix in instrumental deliveries .

③ Retained tissues -

Bits of placenta ,
blood clots

④ Coagulation disorders
-

D1C

HE4P syndrome
-
'
Prevention . Antenatal

it Improvement of health status ( keep Hbllogldt )

if screening of high risk patients and delivery in well equipped hospitals .

iii) Blood grouping and cross matching

iv ) placental localisation should be done in all women with previous LSCS .

v
) Detection of morbidly adherent placenta lit present) by USG is all women with previous
LSCS

vi ) women with morbidly adherent placenta to be delivered by a senior

obstetrician .

. Intranatal :

Active management of 3rd stage

Cases with induction 1 augmentation by oxytocin ,

the infusion should be
continued till 1 hour after the birth .

'
y

Oxytocin 5N slow IV to be given to women delivered by Isis .

Exploration of utero vaginal canal for evidence of trauma

Observation for about 2 hours .

Local epidural anaesthesia is preferred over general anaesthesia

-

During Lscs , spontaneous separation and delivery of placenta reduces blood loss
-

Examination of placenta and membranes

* carbetocin
-

New drug to control PPH ( IMIIV 100dg )

'
Mx .
call for extra help Communication )
- Commence IV lines with a wide bore cannula .

.
send Blood for cross matching tests i coagulation screening and ask for atleast
i
2 units of blood .

-
Rapidly infuse Normal saline Ihaemaccel litres ) till blood is available
-
Catheterise the bladder .

BP temperature urine output oximeter

.
Monitor pulse , , . , every 15-30 mins .

Feel uterus by Abdominal Palpation

v ~

Uterus Atomic Uterus Hard & contracted

v v

Massage uterus to make it hard Traumatic PPH

-

Add oxytocin 120 units) in 500mi normal v

saline [ Rate : 40 drops per minute] Exploration

Injection Nlethergine 0.2mg IV slowly
-

v
Haemo static sutures on

A uterus remains atomic tears sites

✓

Exploration of Uterus
-

Blood transfusion
-

Continue oxytocin drip surgical Procedures :

v
① Uterine artery ligation
Uterus still atomic ② Internal iliac artery ligation [Anteriordivisonj
•
③ Uterine compression sutures
B lynch sutures
15 methy PGFa, 250mg Im
-

⑨ R3 Hayman sutures
-

Misoprostol Cho square sutures

-

1000mg per rectum

.

④ Angio graphic uterine artery embolization

titties still Atomic

Uterine tamponade
-

Balloon tamponade ( Bakri balloon i Sengs taken Blakemore tube)

Bimanual compression
-

Tight uterine packing under Anaesthesia ( Shiv Kar 's pack )

still atomic
V

''
Surgical procedures

✓
✓

Bleeding controlled Fails

v

Continuous observation Hysterectomy

in ICU
 Incidence 15%
Pre-eclampsia
primigravidae-IOI.mu/tigravidae-
' : 5-

51 .

Hypertensive disorders in pregnancy :

.

Gestational hypertension
-

Pre-eclampsia -

pregnancy induced HTN

-

Eclampsia
-

Chronic HTN
-

Superimposed pre eclampsia (on chronic HTN)

Def multisystem
It is disorder of unknown etiology characterised by development
-
a

of hypertension to the extent of 140190mm Hg or more with protein and after

the 20th week in previously normotensire and non protein uric woman .

Risk factors
primigravida young elderly
-
- : or .

'
Family history of HTN or pre
-

eclampsia .

. placental abnormalities Hyperplacental's [ Molar pregnancy ,

twins ,
diabetes]
Placental ischemia

.
Obesity CBM 1735kg Imifi Insulin resistance

.
Preexisting vascular disease

- New paternity

.
pregnancy following ART

'
H10 pre-eclampsia in previous pregnancy

-
thrombophilias : Antiphospholipid syndrome ; protein ↳ deficiency ; Factor V Leiden

'
Pathogenesis Maternal vascular Genetic immunological
,
Excessive tropho blast
disease factors

Faulty placentation
V
L
>

Endothelial -1 > Reduced Uteroplacental perfusion a ILS , cytokines ,

v lipid peroxidase
^
Endothelial Activation

v v v

Vasospasm Capillary leak Activation of coagulation

>

'

>
HTN

Nigeria
Abrupton
[>

>
Edema
Protein una
Haemo concentration
'
thrombocytopenia
 6 Elevated liver enzymes
Severe pre-eclampsia: SBP 7160 mmHg ; DBP 7110 mmHg
.

'
i. persistent
2. Oliguria K40 0MI 124 hr)
7- Persistent severe epigastric pain
edema
's 8. Retinal haemorrhage ; papill
3. platelet 5100,000 1mm
9. Fetal IUGR
4. cerebral Ivisual disturbance
10 .

serum treat 711mg 1dL

5.
pulmonary edema

-
Symptoms -
Mild : .
swelling over ankles
abdominal wall
-

Gradually swelling may extend to face ,

, other parts .

-
Alarming ! .
Headache
.
Disturbed sleep
'
Diminished urinary output LT40 0MI in 24 hrs]

.
Epigastric pain alw vomiting ( maybe coffee coloured)
.
Eye symptoms -

Scotoma , blurring

'
signs ① Abnormal weight gain ( 74lb in week in later months of pregnancy )
.

& Rise of blood pressure

③ Edema
④ oliguria
⑤ Pulmonary edema
⑥ scanty liquor may be revealed on abdominal exam CIUGR )
-
Investigations .
urine -

24 hrs protein monitoring .

protein una last feature of pre eclampsia to

-

is appear .

'
Fund copy
-

Papilledema ,
constriction of arterioles

Blood investigations CBC low platelets

-

. -

S .
creatinine 71mg 1dL
S '

uric acid 74.5 mgldl ( Biochemical marker of pre eclampsia)

Hepatic enzymes ( ALT ,
AS7) -

Elevated

Coagulation profile -

BT ,
CT , PT , APTT
•
Antenatal fetal monitoring Fetal kick count

USG ( fetal growth & liquor pockets)

Cardio topography

Biophysical profile
Umbilical artery flow velocitymetry LUA -

doppler]

-
Complications . Immediate
Maternal Fetal

During pregnancy During labor Puerperium -

Intrauterine death
-

Eclampsia -

Eclampsia -

Eclampsia
-

IUGR
-

Abrupton -

PPH -

shock -

prematurity
Preterm labor sepsis Asphyxia
-
-
-

Blindness
Oligohydroamnios
-
-

-
HELLP syndrome
-

ARDS
-

Cerebral Haemorrhage

. Remote .
-

① Residual HTN :
May persist even after 6months of delivery in 50% cases .

② Recurrent pre eclampsia

-

25% chance in subsequent pregnancies

③ chronic Renal disease
 * prophylactic Measures : .
Regular Antenatal checkups - calcium [2g Iday]
' low dose Aspirin L7S-1SO mglday]
.
Antioxidants

sildenafil.MX
-
low molecular weight Heparin
'

Objectives : ① stabilise HTN and prevent progression to severe pre eclampsia .

② Prevent the complications .

③ prevent eclampsia
④ of healthy baby optimum time
Delivery in

⑤ Restore health of mother in puerperium .

Anti Hypertensives in pregnancy

.

- d- methyl dopa :
250-500 mgtidlbid Pre-eclampsia
. labetalol :
100mg tidlqid
v
Nifedipinei.IO -20mg bid .Rest .

Hudrdlazine : to -25mg bid

times 1 day]
chatting [ 4
. .
Bp
-
Investigations
'
Max dose
. Fetal wellbeing assessment

IV Iabetalol : 300mg
If Diastolic BP > 105 mmHg
-
IV hydrdlazine 30mg :

Inti hypertensives Labetalol Going IV

every 10 mins]

Hydralazine Lsmg It every 30 mins]

OR

Nifedipine [ long oral]

÷
BP completely controlled BP persistently high persistent High Bp to

severe level 1severe pre-eclampsia

v V v

preterm Term
Try to continue V
(At least 734 wks)
In till 31 Whs (or -
Couple counselling
v
v
34 wks atleast) -
prophylactic mgsq
-
Discharge stay in hospital .
steroid therapy (if )
534 wks
-
Continue maternal till 37 weeks

$ fetal surveillance

v
V V
v

Deliver at term Delivery Delivery Delivery irrespective of

duration of gestation

Lpreknm
I

Postpartum Monitoring

'
Indications for delivery without delay :

-
Persistent symptoms of severe pre-eclampsia .
Abnormal coagulation Profile
'
pulmonary edema (Hypoxia [ Da0zl95%] .
t.GR with non reassuring fetal status

Hepatocellular injury Eclampsia

.
.

Oliguria UA Doppler REDF

. .
-
:
•
Incidence : I in 500 to 1 in 30
Eclampsia
-
Det pre eclampsia
-

complicated with Grand trial seizures ( Generalised tonic Clinic seizures)

and for coma is called eclampsia

.

'
CIF ① Premonitory stage : muscles tongue
unconsciousness ; twitching of face , ,
limbs ;

stage lasts for 30 seconds .

② Tonic stage :
-

Whole body goes into tonic spasm

.

C30 seconds) -
Limbs flexed ,
hands clenched

fixed eyeballs
-

Cyanosis appears

③ Clinic stage : -

voluntary muscles undergo alternate contraction and relaxation .

4- 4 mins) -

cyanosis gradually disappears

-

Whole body involved in convulsions .

Biting of tongue occurs

⑨ Stage of loma : lasts for a brief period or persists till another convulsion .

'
DID ① Epilepsy
② Encephalitis

③ Meningitis
④ Puerperal cerebral thrombosis
⑤ Hypertensive encephalopathy
⑥ Cerebral malaria
⑦ PRES
⑧ Intracranial tumors

-
Investigations same as pre-eclampsia

.MX
Eclampsia

-
v

Medical management Obstetric management

✓
v v

General specific Delivery

✓ v
( irrespective of age of gestation)
Supportive care -

Mgs04 v
✓

Antihypertensive Induction Lscs

-
Diuretics ARM
- Medical MX
•
Supportive care . Call for extra help
.
Put patient in left lateral recumbent position .

. prevent maternal fall and injury

.

.
maintain airway
'
Oxygen by face mask 1104 min )
'
Foley catheter with uro meter
'
IV fluids -

crystalloids (saline) or colloids (albumin / blood)

'
monitor vitals ,
urine output ,
SP02

-
Specific Mx 1) Anticonvulsant therapy -

Magnesium sulphate -
membrane stabilizer

cerebral vasodilation
Dilates uterine arteries
-

Reduces motor end plate sensitivity to Ach

Neuroprotective
-
Regimens .

1) IM -
Pritchard -

loading dose -

4g IV ( 20mL of 20% ) over 3-5 mins , immediately

followed by 10g IM ( 20mL of 50%) ( 5g in each buttock)

Maintenance dose 5g ( 50% ) every 4 hrs alternate sides

-

Im .

2) IV loading dose maintenance dose

① Zuspan 4g NL20 1g Ihr infusion

til Sibai 6g N 1201 ) 291 hr slow infusion

-
Mgs04 is continued for 24 hrs after last seizure or delivery whichever
,
is later .

. Detection of magnesium toxicity :

-

loss of deep tendon reflex

-

decreased respiratory rate Cda Imin )

Urine output 130mL Ihr

-

chest edema
pain pulmonary
-

* Doc mgS0y toxicity -

calcium gluconate 1g IV.

2) Antihypertensive -

labetalol.Hydrdlazine.tn methyl dopa -

3) Diuretics Furosemide )→ edema

Cao 40mg It in cases of
pulmonary
-
-
- Obstetric Mx clinical assessment of patient & fetal status
,

v
✓

Not in labor In labor (majority)

Fits Ion trolled fits not controlled

'

Delivery

Boiby v v

ARMI oxytocin as
1 v
v v

Term Preterm dead Delivery by CS v

Force plventhouse

steroid
therapy
V

>
Delivery '

v
v

Induction Lscs

pGEz
-

ARM

Oxytocin
I 1
I
-

Neonatal resuscitation
continue mgsoy for 24 hrs post delivery hast seizure
-

Neuro radiological monitoring in postpartum period

-

. Indications of Cs :

1) Eclampsia before 30 lots of gestation

2) Uncontrolled fits in spite of therapy
3) Unconscious patient $ poor prospect of vaginal delivery
4) Obstetric indications ( like malpresentation)

-
complications maternal fetal

1) Injuries : Tongue bite ,

from fall e) prematurity
2) Pulmonary : Edema , aspiration pneumonia ,
Embolism 2) Intrauterine asphyxia
3) cardiac : LVH , cardiomyopathy b) IUGR
4) Renal failure 4) NFD
5) CNS : cerebral edema haemorrhage ; Neurological deficits 5) Birth injuries
,

6) Hepatic Hepatic :
necrosis , sub capsular haematoma

7) Ocular : Retinal detachment

8) Haematological : thrombocytopenia ,
D1C

g) Postpartum : shock , sepsis , psychosis

. maternal mortality : 2 -30%

. Fetal mortality : 30 -50%

 Twin pregnancy 87

-
Incidence : mono zygotic : 1 in 250

variable India : Highest in Nigeria It in 20)

Dizygotic :
; 1 in 80 ;

•
Types 1) Dizygotic : Results from fertilisation of 2 Ova .

All dizygotic twins are Dichorionic 4 Diamniotic .

2) monozygoh.ci Results from fertilisation of single ovum

Timing of cleavage Placenta 's membrane status %

( 72 hrs Diamniotic dichorionic 25-30

Days 4-7 Diamniotic monochorionic 70-75

1- 2
Days 8-12 Monolhorionic mono amniotic
' 1
7 Day 13 Conjoined 1 Siamese

.
Etiology .
For mono zygotic twins -

Unknown

.
Dizygotic twins :

1) Race -

High frequency in Negroes .

lowest in mongols
2) Hereditary predisposition ( more transmitted through maternal side)

3) Advancing age of mother :

Max btw 30 and 35 years .

(Incidence of twins decreases after 35 years)

4) Increasing parity , especially from 5th granda onwards

5) Iatrogenic : ovulation induction drugs Gonadotropin therapy C20-4OI risk)

Clomiphene citrate 15-61 risk )

Lie & Presentation .

most ✓
lie of fetuses Longitudinal
.
common :

.
Most common presentation : Both vertex ✓

.
Rarest presentation : Both transverse ✓

C1F -
- .
History :
1)
History of ovulation inducing drugs
2) Family hlo twinning ✓
3) Age and parity ✓

-
symptoms ✓ 4 in nausea and vomiting in early
: -

months

✓ Cardio respiratory embarrassment in later months dyspnea palpitations

-
-

✓ Swelling
-
of legs ,
varicose veins ,
Haemorrhoids
Unusual rate of abdominal enlargement
I
-

Excessive fetal movements

 -
signs :

General exam : . Pallor

-
Excessive weight gain
'
Oedema
'
Evidence of pre eclampsia ( High Bp) -

251 .
cases

Abdominal Exam :

-
"
Inspection enlargement
Undue shaped
"

Barrel
. :
i

Palpation of uterus period r

Height
-
: -

7 of amenorrhoea
-
-

Abdominal girth at level of umbilicus is more than normal avg.at term

Palpation of too many fetal parts

=
-

Finding 2 fetal heads or 3 Fetal poles .

Auscultation
simultaneously hearing
-
' : 2 FHS with silent area in btw by 2

Observers with a difference of 10 bpm in heart rates .

-
Investigations 1) Ultrasonography
-

Confirmation of diagnosis ( as early as 10th week )

viability of fetuses , vanishing twin in second trimester

pregnancy dating
-

Fetal anomalies and fetal growth monitoring

Presentation and lie of fetuses
-

Amniotic fluid volume

-

Placenta localisation
Doppler studies Twin transfusion
-
-

Chorionic ity : Best diagnosed by Trans vaginal ultrasound .

V v

Twin peak I Lambda sign T sign 1 Inverted T sign

✓ v

Placenta intervenes btw the Right angle relation btw placenta

and fetal membranes
membranes ( thick septum > 2mm) ( thin septum 52mm )
v v

Dichorionic monochorioni city

ity

2) Biochemical tests : maternal serum gonadotropin

d- feto protein

Unconjugated estriol

3) Routine Antenatal tests

-
Complications . Maternal :

During pregnancy :
-

- Nausea and vomiting with more frequency and severity

.
Anemia

. pre -
eclampsia 125% )
-
Hydra mnios 110 %) more -

common in monozygotic ( usually involves 2nd )

sac

.
Antepartum haemorrhage -
increased incidence of placenta previa

Abrupton due to -

Need incidence of pre -

eclampsia
sudden escape of liquor following ROM

Folic acid deficiency

Sudden shrinkage of uterus following

delivery of 1st baby

'
Malpresentation ( more common for 2nd baby)
. Preterm labor 150% )
. mechanical distress -

Palpitations dyspnea , ,
varicose veins, haemorrhoids

During labor :

-
Early rupture of membranes 4 Lord Prolapse
.
prolonged labor

Bleeding
.

-
Increased operative interference
.
PPH

During Duerperium :
-
sub involution
-
Infection -

due to pre -

existing anaemia ,
4 operative interference ; A blood loss
. Lactation failure

'
Fetal :

-
4 miscarriage rate ( more with monozygotic)
-
prematurity 180% )
-
Discordant twin growth
'
Intrauterine death of 1 fetus (vanishing twin )

diagnosed
'
Appearing twin -

DX of twin missed on initial US4 & in a later scan .

fetal anomalies Anencephaly

'
-

Holoprosencephaly
-

NTD

microcephaly
-

Cardiac anomalies
-

-
Down 's syndrome
-
Asphyxia & Stillbirth
- Indications of CS for 2nd twin :
-

Larger 17201 ) 2nd twin with non cephalic presentation

-

Prompt closure of cervix after delivery of 1st baby

-
fetal distress of 2nd twin

.mx . Antenatal Mx :

-
Early diagnosis to detect chorionicity.amnioa.ly ,
fetal anomalies .

Diet :
.
Extra 300 kcal 1 day required over Singleton pregnancy
4 protein intake

Supplements
-
: Iron : 4 to 100 200mg 1 day
-

-
Folic acid :
4mg instead of 400
mcg

-
more frequent antenatal visits for
- fetal surveillance at
every 3-4 weeks by USG .

NST , Bpp and colour doppler

fetal well being

management during labor

-
:

Twin pregnancy
,
v v

1st baby vertex .

First baby non vertex
-
Monochorionic
v
.
Monoamniotic
Deliver 1st baby vaginally .
Conjoint twins

v
.
Signs of complications
cord clamped 9 divided placenta previa
-

v
-

severe pre-eclampsia
Avoid AMTSL -

cord prolapse

v
-
contracted pelvis
Assess lie of 2nd baby clinically IBYUSG . Previous Lscs

v v

Transverse lie longitudinal lie

LSCS

ARM oxytocin
External version -

cephalic ( if needed)
Podalic
✓
v

Fails If delayed
✓ v v

Internal podalic version $ Vertex Breech

Breech extraction under v v

general anaesthesia & Forceps ; Vento use Breech extraction

USG guidance

'
AMTSL to be done after delivery of 2nd baby to prevent PPH

Continue oxytocin drip for at least 1 after delivery of 2nd baby

'
hour .

'
Close monitoring of patient in postpartum period .
 Antenatal care
'
Definition systematic supervision (examination ¢ advice) of woman during pregnancy
.

It comprises of : -

Careful history taking and exam

Advice to pregnant woman

Carry out necessary investigations

-

'
Objectives it Promote and protect health of woman and unborn fetus during pregnancy .

2) Reduce maternal El perinatal morbidity and mortality .

3) Screen high risk cases

4) Prevent ,
detect and treat any complications at earliest .

5) Educate pregnant women about pregnancy , labor and complications .

6) Nutritional advice , supplementation and immunisation .

7) Education about breastfeeding , family planning and use of contraceptives .

b) Discuss with couple about place ,

time and mode of delivery .

. 1st visit . Assess health of mother and educate her on importance of regular follow up .

.
Assess gestational age and baseline investigations .

-
start iron ,
folic acid and calcium supplements if already not on it

.
History . Ask about personal details ( Name age etc) , ,
LMP , age of marriage grandad parity
,
.

.
Assign expected date of delivery .

Take complete hlo present pregnancy and hlo past pregnancies (mode of delivery complications)
.
,

i
Ask about hlo specific diseases like Dna ,
HTN ,
TB HIV Malaria
, .
,
other STDs .

i
Take No alcohol ,
smoking ,
tobacco use .

'
Physical exam .
Assess Build ,
nutrition . height , weight and vitals -

. Check for signs like pallor ,

oedema , lymphadenopathy .

Auscultate chest for cardiac 1 respiratory pathology

any underlying
- .

-
Obstetric exam : Determine symphysiotundal height and assess fetal lie and

growth by various grips

-
Breast exam
.
Speculum exam and vaginal exam

.
Pap smear
may be taken for upto logical studies .

-
Investigations 1) Blood -

CBC

AB0 blood grouping & Rh grouping

-

Blood sugar
-

TSH
-

VDRL
-

HBSAG for hepatitis B

-

HIV ( after consent and counselling)

-

Antibodies to detect Rubella immunity

 21 Urine -

proteins , sugar , pus cells

3) Dap smear and cytology

4) Genetic screening : Dual marker test : " -13 weeks

Triple marker test : 16-18 weeks } for screening of Down's syndrome

5) Maternal serum alpha feta protein test .

6) US9 transvaginal trans abdominal)

-

Detects pregnancy
-

Accurate dating

,etects
multiple and ectopic pregnancies
;DJetects gross fetal anomalies and uterine and adnexal pathologies
.
Nuchal Translucency test : IH3 weeks of gestation
-
Anomaly / malformation scan : 18-20 weeks of gestation

-
Repetition of investigations :

Hb at 28 and 36 weeks
-
Blood sugar
-

Urine checked for sugar & proteins every antenatal visit .

Dietary Advice in calory about 300kcal pregnant state

'
Increase requirement is over non
-
.

Increase in protein ,
iron and calcium requirement
.

'
supplements . Iron : 60 mg of elemental iron ( increased in case of anaemia) / day
- Folic acid : 400
mcg ( increased in case of twins and No NTD) / day
Calcium 500mg tablet 1 day
. :

. Immunisation .
2 doses of Td (tetanus & adult dip them a) given
.

IM 10.5mi) at 4- 6 weeks interval .

'
Ist dose at 16-24 weeks .

Frequency of visits 4 weeks upto 28 weeks

Every
- .

.
Every 2 weeks upto 36 weeks
.
Every week till delivery

'
WHO recommends at least 4 visits in developing countries :

1) It to weeks 3) 32 weeks

2) 24-28 weeks 4) 36 weeks

- Patient should report to hospital early I immediately in cases of :
-

Abdominal pain
-

Bleeding per vagina ( even slight)

-

Gush of watery fluid per vagina

-

toed 1 absent fetal movements

Any other abnormal symptom
-
 Changes in CVS during Pregnancy
- cardiac output .
Begins to increase at 5 weeks .

'
maximum at 28 to 32 weeks 1+40%7
. Further increases in 2nd stage of labor It 501 ) .
and following delivery H70 %) .

.co lowest in sitting & supine position ; & highest in Right I Left lateral 4 knee chest pos .

"
BI .
progesterone → smooth muscle relaxant >
+ peripheral vascular resistance > + BP .

i
t Diastolic BP and mean arterial pressure .

-
Supine hypotension syndrome :
During late pregnancy , gravid uterus produces compression
effect on Nc while in supine position .
this results in opening of collaterals by
means of para vertebral and azygous veins .
If collateral circulation fails to

open 1101 .
cases ) ,
venous return to heart is
seriously curtailed causing
hypotension tachycardia $ syncope
,
.

Normal BP is restored by turning patient to ieft lateral position .

- Venous Pressure femoral increased

venous pressure is due to pressure exerted by gravid uterus on
-

the common iliac veins ,

more on right side due to dextro rotation of the uterus

.
Apex Beat Heart rotates upwards and outwards during pregnancy ( gravid uterus pushes diaphragm) .

Hence , apex beat is shifted to 4th IC space ,

2.5cm lateral to mid davicular line .

-
EC4 Left axis deviation

-
Heart sounds . S, -
loud + wide split
.
52 -
Normal
-
Sz -
Heard

'
Murmurs :
Ejection systolic murmur (most common ) -

pulmonary area

continuous murmur ( mammary murmur ) -

tricuspid area

X
. -

ray mild cardio mega 14

-
Doppler Echocardio . 4 left ventricular end diastolic diameter .

4 & right atrial diameter

-
left .

.
cvplsvp of Ejection fraction remain unchanged .
 Managing pregnancy with heart disease
' C1F Metcalfe 's criteria for heart disease in pregnancy :

Symptoms signs
Progressive dyspnea I Orthopnoea Cyanosis
.
-

-
Nocturnal cough
.
Clubbing of fingers
.
Hemoptysis .
persistent neck vein distention

Syncope
. .
Systolic murmur grade 316 or greater
-
Chest pain .
Diastolic murmur

.
cardiomegaly
. Persistent arrhytnmi

-
Investigations 1) EC4 :
May show Twave inversion ,
biatn.at enlargement , dysrylhmias

2) Doppler echocardiography : shows -

structural abnormalities (ASD ,
VSD )
valve anatomy and function
-

-
Left ventricular ejection fraction
-

Pulmonary artery systolic pressure

-
Patient is managed by team approach of obstetrician , cardiologist ,
anaesthetist &

heonatologist .

-
Admission . Elective :

NYHA grade I: 2 weeks prior to EDD .

NYHA grade II : At 28th week .

-
NYHA grade III III : patient to be kept in hospital throughout pregnancy

Emergency
.
:

Deterioration of functional grading

-

Appearance of dyspnoeal cough 1 basal oeepitations I tachyarrythmias

-

Appearance of pregnancy complications eg

-

pre-eclampsia .

.mx of labor .
1st stage :

position : Lateral recumbent to avoid auto carat compression

5-6 llmin
-

Oxygen :

Analgesia : Epidural
-

fluids : Restrict IV fluids to 75mi hour (except AS )

-

Prophylactic antibiotics against bacterial endocarditis .

IN ampicillin 2g gentamicin ) ,

Careful monitoring of pulse , respiration , SP02 and cardiac monitoring .

Rapid digitisation by IV digoxin losing ) if HR7 1001min btw contractions .

 -
2nd stage :

Avoid maternal pushing efforts

-

Cut short and stage by using ventouse or forceps

-

Ventouse is preferable to forceps as it can be used without putting

patient in lithotomy position .

. 3rd stage :

Follow conventional management .

Oxytocin infusion may be used to prevent excessive blood loss .

-
Meth ergine is absolutely contraindicated .

Aggressive diuresis by N Furosemide to prevent postpartum pulmonary edema .

LSCS
-
Mostly done for obstetric indications .

'
Heart diseases with Lscs indication :

Coarctation of aorta
-

Aortopathy with aortic root dilation 74cm

-

Aortic dissection or
aneurysm

.
Indications for termination .
Absolute . Relative
Porous with grade I1 1TI cardiac lesion
Primary pulmonary HTN woman
-

Eisen menger 's syndrome

-

Grade IHI with previous H10 cardiac failure

Pulmonary reno occlusive disease

-
Termination should be done within 12 weeks by suction evacuation CMVA )

.
Most common valvular disease in pregnancy
: Mitral Stenosis

.MS in
valvuloplasty
.
pregnancy surgery of choice :
Balloon
'
Time of surgery : 2nd trim est 1141018 weeks
'
surgery which is contraindicated : Valve replacement
.
Follow all general measures as described above

-
Anticoagulation indications a) congenital Heart disease c) Mechanical heart valve

b) Pulmonary HTN d) Atrial fibrillation

. Low molecular weight Heparin is preferred .

-
Warfarin → crosses placenta →
Causes Dyschondroplasia
. UFH ,
LMWH & warfarin therapy do not contraindicate breastfeeding .

.
Contraception in Heart disease :

NCD Steroidal pills contraindicated → tnromboembolism

condoms
-

Progestin only pills

-

vasectomy
Tubeto my After 6 weeks of delivery
-

-
 Anemia in Pregnancy
- incidence :
developed ' 0-201

developing , 40 -80%

- Def Decrease blood due to decreased Hb

in oxygen carrying capacity of .

According to WHO ,
Anemia in pregnancy HB5
1IG 1100mi
Haematocrit 532%

Classification
physiological
- -

-
Pathological Nutritional Iron deficiency
Folic acid deficiency
Vitamin B12 deficiency
Protein deficiency

Haemorrhage Acute -

Following bleeding in early month and APH

Chronic -

Hookworm infestation , bleeding piles .

Hereditary thalassemia
Sickle haemoglobin opathies
cell

Hereditary haemolytic anaemia (spherocytosis)

Bone marrow insufficiency -

hypoplasia / aphasia

Anaemia of infection (malaria tuberculosis Kala

,
,
-

azar )

chronic disease (Renal )

Neoplasm / Haematological malignancy (leukemias lymphomas) ,

'
Most common anaemia in
pregnancy
-

Dimorphic anaemia

Physiological Anaemia maternal plasma volume by 40-501

. .
tses .

RBC by
'
volume tses 20%

-
there is marked demand of extra iron in 2nd half .

physiological anaemia is due to combined effect of Haemo dilution and

negative iron balance .

Criteria
physiological anaemia
:
-
lower limit of
during 2nd half should fulfil
following values :

1) Hb -

10g To

2) RBC -

3.2 million 1mm 's

3) PCV -

32%

4) Peripheral smear :
Normocytic and normochromic
-
Investigation is CBC -

+ Hb ,
Haematocrit , Ieukopenia , thrombocytopenia

2) for type of anaemia :

Iron deficiency Megaloblastic

-
peripheral blood smear
-

Hypo chromic ,
microastic -

macro cytes
-

Anisocytosis -

Hypersegmented neutrophils
Doikilocystosis Giant polymorphs
-

toed reticulate count -

Howell -

jolly bodies

.
Mcv toed ( 175 Us ) tsed ( 7100µs )

MCH Used ( 525 pg ) tsed ( 733ps )

-

-
NACHC toed 130% ) Normal

.
serum iron 130mg 1dL Normal Itligh

'
Total iron binding capacity 7400mg 1dL

-
Serum ferritin C15 4GK

. Serum folate 13 nglml

. Serum Biz laopglml

3) Other investigations :

stool examination to detect helminthic infestation

Urine exam pus cells protein and sugars

-
:
,

Hb electrophoresis :
Rule out thalassemia
-

other specific investigations based on history and examination .

causes Folic Acid deficiency

'
IDA

inadequate diet -

Strict vegetarian diet

malabsorption Gastritis
-
-

-
tsed demand during pregnancy
-

Gastrectomy
-

Hookworm infestation -

Crohn 's
-

metformin

Malabsorption syndromes
-
-
Complications .
During Pregnancy :

-
4 sed chances of pre-eclampsia
-

Incur rent infections

-

Heart failure at 30-32 weeks

-

Preterm labor

labor :
During
-

uterine inertia
-

Cardiac failure
-

Shock
-

postpartum haemorrhage is a threat

.
puerperiom :
puerperal sepsis
-

Sub involution
-

Poor lactation
-

Puerperal venous thrombosis

Pulmonary embolism
-

. Fetal complications
-

tsed incidence of low birth weight babies

-

Intrauterine death -

due to severe maternal anaemia

* Amount of iron transferred to fetus in unaffected even if mother suffers from
IDA .

Neonate does not suffer from anaemia at birth .

-
Complications of megaloblastic Anemia :

miscarriage
Dys maturity
-

prematurity
-

Abrupt placenta e
-

fetal malformations ( cleft lip ,

cleft palate ,
Neural Tube defects )

- Prevention .
Daily administration of 200mg ferrous sulphate ( 60mg elemental iron )
After 1st trimester ( iron can cause more nausea )

'
folic acid 1400µg daily -

should be started 1 month before pregnancy

-

4mg for women with twins and No children with NTDS .

 '
Rx .
General

Diet :
Rich in protein and iron
-

Red meat ,
chicken ,
fish ,
shellfish
-

peas ,
lentils ,
tofu , jaggery , spinach
-

Vitamin C :
Helps with absorption of iron .

cure diseases contributing to anaemia

-

Anthelmintic s for hookworm infestation

- Specific therapy :

1) Iron deficiency :

- oral Iron therapy 200mg ferrous sulphate tablet 3 tabs per day
-
-

( Ferric salts are absorbed much less )

-

side effects : -

Epigastric pain
-

Nausea , vomiting
-

Diarrhoea , constipation
-

Black colour stool

. parenteral Iron :

' IV :
Repeated doses or Total dose infusion
.
Ferrous sucrose -

100mg I dose ( 20mg elemental iron 1mL )

- Sodium Ferric gluconate complex 125mg I dose

.IM :
Injections are given daily / alternate days in doses of 2mL .

-
Iron dextran ( 50mg 1mi )
. Iron sorbitol citric acid complex

Dose :
Required iron
:(Normal Hb patient 's H b) gldl X Weight 1kg ) X 2.21 -1
-

1000mg
-

Iv

For iron stores

Indications : -

Noncom pliant patient

-

Non tolerate to oral iron

-

malabsorption syndrome
-

Advantages :
1) surety and certainty of administration
2) Helps in replenishing the iron stores faster

- Blood transfusion :
packed cell preferred over whole blood .

Indications : it severe anaemia due to blood loss and PPH .

2) Severe anaemia in early labor

3) CCF due to severe anaemia ( with diuretics)

2) megalobklstic anaemia : 4mg folic acid daily continued till 4 weeks

following delivery .

and good improve

-

1mg FA with Iron supplementation diet can pregnancy induced

megaloblastic anaemia in 7-10 days .
.MX during labor Blood to collected for grouping and cross matching and be kept ready .

.
First stage :

Patient should be in bed ( lateral and propped up position preferred )

Oxygen inhalation
-

Strict a sepsis

Avoid fluid overload

-
second stage :

maintain a sepsis

Cut short 2nd stage using prophylactic forced or vacuum .

IM oxytocin IOIU to be given soon following the delivery .

. Third stage :
-

Active management of third stage to prevent DPH .

Blood loss to be replenished with blood transfusion ,

if required .

Avoid fluid overload and watch for CCF .

-
During Duerperium :

Prophylactic antibiotics to prevent infection

-

Hematinics to be continued for at least 3 months postpartum .

patient to be warned of danger of recurrence in subsequent pregnancies .

 Abortion
I

'
Incidence : 10 -
20%
from its mother
Definition It is expulsion or extraction -
from its mother of an embryo Ifetus AI weighing 500g
or less when it is not capable of independant survival .

Classification Abortion

v v

Spontaneous Induced

( miscarriage )

legal Illegal
-
Threatened IMTP) ( unsafe )
-

Inevitable
-

complete Septic common

Incomplete
-

missed
-

septic

-
Etiology 1) Genetic :

Autosomal trisomy ( most common -

Chr 16)

Polyploidy ( triploid y is common )

X
Monosomy
-

2) Endocrine & metabolic factors :

Lutea phase defect

thyroid abnormalities
-

Deficient progesterone
-

Diabetes mellitus

3) Anatomical abnormalities :
-

cervical incompetence
-

Congenital malformation of uterus

-

Uterine fibroid
-

Intrauterine adhesions ( Asherman 's syndrome)

4) Infections :

viral : Rubella ,
CMV
-

parasitic : TWO plasma ,

malaria
-

Bacterial :
chlamydia , Bruce Ha

5) Immunological diseases :
Antiphospholipid antibody syndrome CAPAS )
-

Autoimmune : Antinuclear antibodies ( ANA )

 6) maternal medical illness :
Cynotic heart disease
-

Haemoglobin opathies

7) paternal factors :
sperm chromosomal anomaly

8) thrombophilias

a) Environmental :

cigarette smoking
-

-
Alcohol
-

Contraceptives
-

Drugs ,
chemicals , noxious agents

101 unexplained

causes during 1st trimester .

. Causes in 2nd trimester

-
Genetic - Cervical incompetence

Endocrine Mullen 'an defects (Bicornuatel septate uterus)

-
-

thrombophilias -

Synechiae
-

Immunological -

Fibroids
-

Infections

1.
Threatened Abortion clinical entity of has started not
where the process miscarriage but has yet
progressed to state from which recovery is impossible .

'
C1F
it Bleeding per vaginum
2) Pain

-
Investigations 1) transvaginal Ultrasound -

may show :
a) A well formed gestation ring with
embryo indicating healthy fetus .

b) Observation of fetal cardiac motion

c) Blighted ovum : evidenced by loss of definition of gestation sac .

2) Blood -

CBC ,
Blood grouping (AB0 , Rh ) ,
Cross matching

3) Urine -

immunological test for pregnancy remains positive for some periods even

after fetal death .

Hence , not useful .

4) serum progesterone 725 nglml indicates viable pregnancy in 95%

Serial serum
-

hCG level is helpful to assess the Fetal well being .

 Rx Rest bleeding stops
-
till
-

Drugs :
Diazepam 5mg bd for pain relief
-

Treatment with progesterone may improve outcome .

-
Advice on discharge :

patient should limit activities for at least 2 weeks .

Avoid heavy work and coitus .

Follow up with repeat sonography every 3-4 weekly .

' Incomplete Abortion When the entire products of conception are not expelled .
instead a part of it is

left inside the uterine cavity .

. C1F 1) continuation of pain in lower abdomen

2) Persistence of vaginal bleeding

On examination :
-

Uterus smaller than period of amenorrhoea

-

Datulous cervical os often admitting tip of the finger

-

varying amount of bleeding

DX
( products of conception) within
-

USG
-

Reveals echogenic material the cavity .

-
complications a) Profuse bleeding
b) Sepsis
c) Placental Polyp

- Mx .
Resuscitation

medical tablet misoprostol vaginally

-
: 200
leg

'
Early Abortion : -

Dilatation and evacuation under GA

-

Evacuation may be done with MVA

'
late of uterus Products
Abortion : Evacuation under GA .

are removed by ovum

forceps or by blunt curate .

-
for late cases ,
dilatation and curettage operation to be done to

remove bits of tissue left behind .

 Cervical incompetence
' Def
mechanical or functional defect in the cervix which leads to inability of cervix

to hold pregnancy is known as cervical incompetence -

-
Etiology .
Congenital :
uterine anomalies

.la/rogenic :
following -

a) Dilatation & curettage

b) induced abortion by DE1E
c) vaginal operative delivery through undilated cervix

d) Amputation of cervix

e) Cone biopsy of tracheotomy

-
multiple gestation
-
prior preterm birth

. C1F Painless cervical in 2nd trimester

-

dilatation
-

Premature rupture of membranes followed by expulsion of immature fetus .

-
On examination , painless cervical shortening and dilatation .

speculum exam : Dilatation of cervix & herniation of membranes seen

-

-
Investigations .
Interconceptional period :
is passage of no . 6-8 Haegar dilator without paint resistance and absence of snap
on withdraw .

ii ) Premenstrual hysterocervicography
-

shows funnel shaped shadow ( cervix is supposed

to be closed due to progesterone )

'
During pregnancy :

'
Sonography :

i) cervical length C 2.5cm : considered as short cervix

) funneling
ii of internal os 71cm

-
RX Cerdage operation -
McDonald Shirodkar .

. principle : Reinforcement of weak cervix by a non absorbable tape placed

around cervix at the level of internal os .

•
Time of operation :

prophylactic : Done around 14th week , or at least 2 weeks earlier than

last abortion .

Emergency : cervix is dilated and bulging membranes or detection of

short cervix on USG .

 🔗

Anaesthesia Regional (spinal 1 caudal block) general anaesthesia (TNA)

'
:
or short

'
McDonald 's : -

performed using a permanent suture

-

Bladder emptied d cervix is exposed

-

Purse -

string suture of non absorbable material like mersilene I

mersilk is inserted around the exocervix as high as possible
to approximate to the level of internal os .

stitch is pulled tight enough to close the internal os ,

the knot

being made in front of the cervix .

. Shirodkar 's :

the cervix is pulled down , a trans version incision is made above the

cervix and bladder is pushed well up above the internal os .

Vertical incision is made posteriorly on cervicovaginal junction .

Non absorbable suture ( men silence ) is passed submucously through the

right and left corner of the anterior incision and bring it out of

posterior incision
-

The ends of tape tied posteriorly

-

Anterior & posterior incisions are closed with chromic catgut .

-
Postoperative care :

Bed rest for 2-3 days

-

-
Uterine relaxants ltocolytics) to be given for few days .

. Advise on discharge :

Avoid intercourse
-

Routine antenatal care

Report if there is bleeding ,

leaking PV and pain in abdomen

.
stitch is removed at 37 weeks or anytime before patient goes into labor

.
Complications :

-
Immediate -

Delayed
-

Risks alw anaesthesia -

cervical dystocia with failure to dilate

-

premature labor -
cervical tear
-

premature rupture of membranes

-

Uterine rupture
Bleeding
-

Injury to cervix or Bladder

-
contraindications : -
Intrauterine infection
-

Rupture of membranes
-

Dilatation 74cm

Fetal Death
-

& Benson and Durfee Cordage : Abdominal encerdage operation .

 Ectopic Pregnancy
-
Incidence : I in 300 to 1 in 150

Definition fertilised
-
An ectopic pregnancy is one in which the ovum is implanted and

develops outside the normal endometrial cavity .

.
sites sites of implantation

Extrayterine uterine

Tubal (97%) ovarian Abdominal -

cervical
-

Angular
-

Ampulla -

primary -

comital
-

Isthmus
secondary Caesarean scar
-

Intundiblllum
Interstitial

-
Etiological Factors DID and 14
.
salpingitis risk by 6 to 10 times

Iatrogenic : 1) contraceptive failure

-
IUD

tubectomy
2) Tubal reconstructive surgery
3) Intra pelvic adhesions following surgery
4) Assisted reproductive technology
- Previous ectopic pregnancy
.
Prior induced abortion
.
Developmental defects of tube -

Elongation ,
diverticulum , accessory Ostia
. Trans peritoneal migration of the ovum .

-
Types of presentation .
Acute (Ruptured)
Un ruptured
'

.
subacute (chronic)

.
C1F . Acute :

symptoms signs
-

Abdominal pain -

Pallor
-

Amenorrhoea -

tachycardia
Bleeding per vaginum Hypotension
-
-

Synuopal Attack
-

Abdominal rigidity & tenderness

-

Dv exam : it vaginal mucosa blanched

iil Uterus normal Nightly bulky
Iii) cervical motion tenderness

if Extreme tenderness on fornix palpation

VINO mass felt through the form'X
 '
Unruptured :

symptoms signs
.
presence of delayed periods .
Bi manual exam :
gentle to avoid rupture
.
Spotting with features of
pregnancy
-
uterus is soft ,
normal or bulky
.
Hank pain : mild , colicky / continuous . pulsate ,
tender mass felt through one

Of Formicas , separate from uterus .

. Chronic Isubacute :

Symptoms : -

Short period of amenorrhoea (6-8 weeks)

-

lower abdominal pain

-

Vaginal Bleeding ( scanty ,

dark ,
continuous)
Bladder symptoms ( dysutia Med frequency)
-

Rectal tenesmus

signs :
-

Patient looks ill with varying degree of pallor

Tachycardia
-

No shock
-

Abdominal exam : 4) Tenderness & guarding on effected sign

Iii) Irregular & tender mass felt in lower abdomen
liiil Cullen 's sign : Dark Bluish discolouration around umbilicus
-
Bi manual exam : -

vagina mucosa pale

-

Uterus normal size 1 bulky ; may

be pushed to 1 side

Cervical movement tenderness tt

Ill defined tender boggy mass through posterolateral

-

, ,

for nix which may push the uterus to opposite side .

-
MX A) Acute 1 Ruptured :
-

Shock in early pregnancy should be thought due to ruptured ectopic unless

proven otherwise

•
Investigations :
As this is
emergency ,
Hb .
Blood grouping ,
cross matching done .

. RX .

Principal is Resuscitation and Laparotomy

lit 2 wide bore IV lines

lii IN fluids : RL ( crystalIoids)

Iii ) Blood transfusion ( if needed)

Exploratory laparotomy
4) Linear salpingectomy -

sent tube for histopalhology

-

Ipsilateral ovary and its vascular supply is preserved .

Oopheredomy is done only when ovary is beyond salvage

.

44 Subtotal Hysterectomy If big and condition

:
rupture is very general is

very low .
 B) Chronic :

-
Investigations :

-
Blood : CBC ,
Blood grouping ,
cross matching
-

Serial beta hCG monitoring :

Kadar 's Rule → There is 566%4 in B- hCG in case

of ectopic pregnancy .

Trans vaginal USG :

Empty USG pseudo sac maybe seen
-
- .

Echogenic fluid in pouch of douglas

-

Adhexal mass , separate from ovary

-

colour Doppler : Ring of fire appearance around the mass

-

Laparoscopy -

when patient is haemodynamically stable .

can be used therapeutically

-

Serum progesterone 25 ng 1mL → viable intrauterine pregnancy

> ( s
ng 1mL → Ectopic 1 Abnormal intrauterine pregnancy
-

ouldocentesis ( Rarely done )

-

Dilatation & curettage -

very rarely needed

.
Ri .

patient stable →
Laparoscopy

patient unstable
-

Exploitative laparotomy
-

Removal of Blood clots

-

linear Salpingectomy is gold standard Tube is sent for Histopathology .

c) Un ruptured Ectopic :

'
Investigations :
Serial beta hCG monitoring ( does not double after 48 hrs in case of ectopic)
-

-
Trans vaginal USG : presence of thick , brightly echogenic , ring like structure
located outside uterus .

Laparoscopy :
diagnostic as well as therapeutic .

. Ri :

1) Expectant Mx :
Observation in hope of spontaneous resolution .

Indications : i ) Initial serum hCG 11500 NIL ; subsequent levels are

falling
til Gestation sac 54cm

I No fetal heart beat on Tvs .

liv) No evidence of bleeding or rupture on TVs

2) Medical Mx :

Requirements patient must be a) Haemodynamically stable

-
: -

b) Serum hCG 5 3000 IU It

c) Tubal diameter 54cm without fetal cardiac

activity
d) there is no intra -

abdominal haemorrhage .

Drugs : a) Direct local ( laparoscopy loss guided) methotrexate Potassium chloride

-
-

b) ( 50mg 1ms dose)

systemic therapy : methotrexate ; Im single
.

Adinomycin

3) Surgery :

. Conservative :
a) Expressing out from distal tube ( Fimbrial expression)
b) salpingostomy
c) Linear salpingotomy

-
Extirpate.ve : at segmental resection
b) Salpingectomy

C1F suggestive of Ectopic pregnancy

V
u V

B hCG -

ve
BHCG tve BHCG He

v
patient in shock

Repeat BHCG TV5

in 1 week v

Mx as Ruptured
Negative again v v Ectopic
Intrauterine Empty uterine

pregriancy excluded Sac cavity with adneeal

v
mass

Determine viability

4- )
v
hCG 760% in 48 hrs

serum progesterone 125 hglml Laparoscopy

v
v

Intrauterine Unruptured tubal

Pregnancy ectopic pregnancy
V

mx accordingly
 Preterm Labor
-
Incidence : 5- 10%

Def
completed weeks gestation
-
Onset of labor before 37 of .

-
Etiology .
Infections : UT1 .
Bacterial vaginal's , chlamydia
-
Over distended uterus -

multiple pregnancy ; polyhydroamniose.to

- Medical 1 surgical disorders of
pregnancy
'
pregnancy complications :
pre eclampsia
-

,
APH
'
fibroids
.
smoking .
Illicit drugs Cocaine)

-
Investigations . CBC

- Urine routine ,
culture and sensitivity
.
High vaginal and cervical swab for culture
. USG for fetal biometry ,
well being , placental localisation dilatation ,
of os .

-
14 .
Bed Rest
.
Adequate hydration
.
Antibiotics ,
if infection present

-
Steroids -

Beta methadone 12mg Im 2 doses 24 hrs apart

Dexamethasone 6mg Im every 12 hrs (4 doses)

preferred because it
periventrioularleukomalacia-choriamnioni.tl
* Betamelhasohe prevents is

's and active infection of mother are only contraindications .

Repeated doses of steroids cause necrotizing enterocolitis NGR P1H

-

may
.

, ,

-
Tocolytics : used for short term ( I -3 days) .

B2 agonist
Nifedipine : Oral ( Never sublingual)
-

Indomethacin e
-

Mgs04
-

Atosiban
-
Tocolytics should preferably be avoided as their is no clear benefit .

-
Neuro protection -

Mgs 04 ( dose and monitoring same as eclampsia)

prophylactic cervical helpful

-
cordage may be .
.MX in labor . First stage :
-

Patient is put to bed

-
Ensure adequate fetal oxygenation
-

Epidural anaesthesia
-

Labor should be carefully monitored with continuous EFM .

Caesarean delivery done for obstetric

-

is reasons

.
Second stage :

the birth should be gentle and slow to prevent sudden compression and

decompression of head .

Episiotomy done to minimise head compression -

Tendency to delay is curtailed by low forceps .

Cord is to be clamped immediately at birth to prevent hypovolemia 4

hyperbilirubin emia
-

shift baby to neonatal ICU under care of a neonatologist -

- Complications complications of neonate

preterm .

1) Gene :
-

Hypothermia 9) CNS : -
Cerebral diplegia
-

Hypoglycemia
-

Intraventricular haemorrhage

Hypocakemia Peri ventricular Ieelkomalacia

-
-

Jaundice
2) GIT :
-

Narcotising enterocolitis D) Renal : -

Oliguria IAnuria
-

Gastroesophageal reflux

3) Infections : -
Pneumonia
-

meningitis
Neonatal sepsis
-

UT1

4) Respiratory system :
Respiratory distress syndrome
-

Congenital pneumonia
-

Broncho pulmonary dysplasia

-

Chronic lung disease

-

Apnea of prematurity

5) Cvs : -

PDA

Hypotension
-

6) Haematological : Anaemia due to haemorrhage .

blood loss .

7) Auditory : 4 risk of otitis media

; Hearing disorder

8) Oplhalmic :
Retinopathy of prematurity
Refractive disorders ( myopia)
Retro Iental fibroplasia
 Deep transverse arrest
Definition head is deep into cavity saggital placed transverse
-
The ; the suture is in the

bispinuous diameter and there is no progress in descent of head even after

Its -

1 hour following full dilatation of cervix .

-
Causes a) Faulty pelvic architecture (prominent ischia spines ,
flat sacrum )
b) Deflation of head

c) weak uterine contraction

d) Laxity of pelvic floor muscles

DX
- -

Head is engaged
-

sagittal suture lies in transverse bispinuous diameter .

Anterior fontane is palpable

-

faulty pelvic architecture may be detected .

'
MX found not safe ( Big baby
. If vaginal delivery is or
inadequate pelvis) : LSCS

.
If vaginal delivery is found safe :
-

Vento use : excessive traction force should not be used

-

Manual rotation and application of forceps

-

Forceps rotation and delivery with Kielland in the hands of expert .

. In modern day obstetrics LSCS is always preferred -

-
complications i. prolonged labor

2. Obstructed labor with higher incidence of rupture uterus

3. Med incidence of :

operative delivery
-

trauma to genital tract

-

DDH El puerperal infection

&
-

perinatal morbidity mortality

 Breech Presentation
'
Incidence : 201 .
at 28th week ; 5% at 34th week i 3 -4% at term
-

Most common malpresentation .

-
Lie is longitudinal ; podalic pole presents at pelvic brim .

- Varieties is complete : fftexed breech) -

Seen commonly in multipara

-

Normal altitude of full flexion is maintained

-

Thighs are flexed at hips and legs at knees .

Incomplete :
Due to varying degrees of extension of thighs or legs
.

Frank breech : thighs flexed at hip legs extended at knee joint

-
.

Commonly seen in primignavida .

Footling presentation : Both thighs and legs are partially extended .

knee presentation : thighs are extended knees , are Hexed .

-
Etiology .
prematurity ( most common cause )

.
Factors preventing spontaneous version :

Twins
-

Breech with extended legs

-

Oligohydroamnios
-

Congenital malformations :
septate Ibicornuate uterus
-

Short cord ; relative 1 absolute

-

Intrauterine death of fetus

'
Favourable adaptation :

Hydrocephalus
placenta previa
-

contracted pelvis
cornu fundat attachment of placenta
-

- Undue mobility of fetus :

-

Hydramnios
-

multipara with lax abdominal wall

Fetal abnormality :
.

Trisomy 13118,21
-

Anencephaly
myotonic dystrophy
-
 i DX Clinical fundat grip Head (suggested by hard & )
globular
. : -

: mass

pelvic grip : Breech ( suggested by soft broad and irregular mass )

-

usq confirms clinical diagnosis

- : -

Can detect fetal congenital abnormality

-

Assessment of liquor volume

-

Attitude of the head

- Mx Breech presentation

Antenatal Assessment

v v

External cephalic version 436 weeks ) Elective Caesarean Section

1438 weeks )

v v

Successful Fails

Delivery as vertex v v

Trial of Elective CS

vaginal delivery 438 weeks)

v
v

Satisfactory -

Arrest of progress

labor progress -

fetal distress
-

Cord prolapse

v t
Assisted breech labor
delivery in

.
External Cephalic version .
success rate : 65%

- Contraindications : -
APH
-

Hyper extension of head i large fetus ; IU9R

-

Multiple pregnancy
Ruptured membranes
-

previous LSCS
-

Abnormal NST
-

Contracted pelvis
pre eclampsia
-
-

-
Complications : -

fetal distress ; fetal death

-
PROM ,
premature labor
-

Abrupton
-

Amniotic fluid embolism

causes of failure Frank Uterine malformations ( Bicornuate / septate)

' : -

breech -

scanty liquor -
mechanical (obesity ,
a tone of abdominal muscles)
-

Short cord
-
vaginal Breech delivery .
criteria to be fulfilled : i) fetal weight btw 1.5kg and 25kg
ii ) flexed fetal head
it Adequate pelvis
in No complications
4 Iatuchni -

Andros score 74

vi ) facilities of continuous monitoring and emege.nu/Lscs .

Assisted breach :
it Aseptic cleaning
ii) Pudenda 1 block
iiit Episiotomy
in Delivery of arms

4 Delivery of aftercoming head Burns -

Marshall method
Forceps delivery
-

maker flexion & shoulder traction

vil Resuscitation

Breech Extraction : for delivery of 2nd twin after IPV in cord prolapse
-

or cases or .

Indications
- LSCS D
Big baby 173.5kg )
2) Small baby 41.5 kg )
3) Hyper extension of head ( stargazing fetus)
4) footling presentation ( Risk of cord prolapse )
5) Suspected pelvic contraction
6) severe IU9R
7) Any associated obstetric complications .

-
Complications . Maternal : -
Asad frequency of Lscs & operative vaginal delivery
-

Genital tract trauma

-

Anaesthesia complications

- fetal :

1) Intra partem fetal death ( Perinatal mortality is 5-35 per 1000 births )

a) Injury to brain and skull -

fracture skull ,
intracranial haemorrhage
3) Birth asphyxia
4) Birth injuries Haematoma I scm muscle thigh ) ,

Fractures 1 Femur clavicle

, , humerus ,
odontoid process)

visceral injuries
Nerves ( medullary coming , spinal cord ,
Brachial plexus - Erb 's ,
klumpke 's )

long term neurological damage .

5) Congenital malformations 12 times 4 sed chance than vertu presentation )

 Obstructed labor
-
Incidence : I-2%

'
Definition Obstructed labor where contractions the
is the one ,
in spite of good uterine ,

progressive descent of presenting part is arrested due to mechanical obstruction .

-
Causes . Fault in passage :
-

Cephalopelvic disproportion
-

Contracted pelvis
-

cervical dystonia
-

Cervical / broad ligament fibroid

-

Impacted ovarian tumor

-

Non gravid horn of bicornuate uterus

- Fault in passenger :

Transverse lie
-

Brow presentation
-

Congenital malformations → Hydrocephalus , fetal ascites

-

Big baby
-

Occipito posterior position

-

Compound presentation
-
Locked twins

-
C1F -

patient is in
agony and discomfort
-

Restlessness
-

Exhaustion

. Effects 1 complications . Maternal :

-
Immediate

i. Exhaustion

2. Dehydration
3. metabolic acidosis
4. Genital sepsis ,
choriamnionitis

5. Rupture of uterus ( spontaneous / traumatic following instrumental delivery)

6 .
PPH & shock

7. maternal morbidity & mortality ( due to Ruptured uterus ,

shock and sepsis )

Late
-

i. Genitourinary fistula
2. Vaginal atresia

3. Sheehan 's syndrome

4.
Secondary amenorrhoea ( following hysterectomy in cases of ruptured uterus )
 -
fetal :

Asphyxia (tonic uterine contractions or cord prolapse in transverse lie )

-

Acidosis ( fetal hypoxia and maternal acidosis)

-

Intracranial haemorrhage ( supermoulding ,

traumatic delivery )
-

Infections
-

Intrauterine fetal death CIUFD)

-

perinatal mortality

-
prevention .
Antenatal : Detection of factorslikely to produce prolonged labor ( big baby ,
small

women ,
hnalpresentation and position )

Intra natal continuous and timely intervention

'
:
vigilance ,
Use of pantograph ,
of a

prolonged labor due to mechanical factors .

.mx .
Preliminaries :

1- Two wide bore IV lines

2. Iv fluids : for fluid electrolyte balance ,

correction of dehydration ¢ ketoacidosis .

3 .
A vaginal swab is taken EI sent for culture 4 sensitivity .

4. Blood sample -
CBC ,
blood grouping and cross matching
5. Antibiotics : Ceftriaxone Ig IV

metronidazole by IV infusion .

'
Obstetric Mx :

Exclude rupture of uterus

-

Never wait and watch

-

Never use oxytocin

-

principles : 1) Relieve obstruction at earliest by safe delivery

2) Combat dehydration ,
keto acidosis

3) Control sepsis

.
Delivery :

there is no place of internal version in obstructed labor .

In neglected cases , baby is invariably dead and destructive operations may be

used to relieve obstruction .

If the head is low down ,

vaginal delivery is not risky and forceps extraction

may be done
-

Caesarean section gives best results if detected early ;

and would be required
in majority of cases .

.
symphysiotomy : can be used as an alternative to LSCS in developing countries .
 Ruptured Uterus
'
Incidence : I in 2000 to I in 200 deliveries .

•
Definition Disruption in continuity of all uterine layers ( endometrium myometrium and serosa )
,

anytime beyond 28 weeks of pregnancy is called rupture of uterus .

'
Etiology . During pregnancy

spontaneous Iatrogenic

Intact Uterus scarred uterus Traumatic Oxytocics

-

Multipara -

scar -

External cephalic version

-

Oxytocin
-

Congenital malformation -

Hysterotomy scar -

fall or Blow -

prostaglandins
of uterus -

previous manual removal

-

Abruptio placenta or D4C .

perforating mole
-

placenta percreta

'
During Labor :

A)
Spontaneous
✓
✓

Intact Uterus scarred uterus

u
u
-

CS1 Hysterectomy scar

Non obstructive obstructive -

myomectomy scar

Grand multipara -

following obstructed -

Repair of previous
-

Congenital malformation labor obstructive rupture

of uterus -

corneal resection of

ectopic pregnancy

B)
Iatrggenic

Traumatic oxytocics

Vaginal operative delivery oxytocin

-
-

Internal version -

prostaglandins
-

Manual removal of placenta

' DX . During Pregnancy :

a) Scar Rupture : classical / Hysterectomy

-

Dull abdominal pain over scar area .

Vaginal bleeding
-

Fetal heart sound irregular or absent .

b) Spontaneous rupture in uninjured uterus :

Abdominal pain of tenderness

-

Syncope
-

Shock
-

Superficial fetal parts may be palpated

-

Absent fetal heart sound .

'
Insidious onset may be confused with concealed Abruptio Placentae.

C) Rupture following a fall blow or external version :

,

H10 above events followed by abdominal pain & vaginal bleed

-

-
During Labor :

a) LSCS scar rupture :

Insidious onset and may be silent

-

Shock , tachycardia , Bleeding PV

-

confirmation by laparotomy .

b) Obstructive :
-
Premonitory phase :

Usually a multipara in labor with features of obstruction

-

Strong frequent uterine contractions followed by pain in supra pubic area .

Dehydration ,
exhaustion .
rise in temperature
-

Fetal distress IIUFD

presenting parts jammed in pelvis dry edema tous vagina

-

. phase of Rupture :
-

Something giving way at height of contraction

-

Cessation of contractions
-

Shock 4 exhaustion
-

Superficial fetal parts on palpation

-

Vagina varying degrees of bleeding

Recession of presenting part .

c) Following instrumental delivery :

-

Deterioration of general condition and other complaints mentioned above

following hlo manipulative 4 instrumental delivery .

 Prevention
' .
At risk mothers ,
likely to rupture should have mandatory hospital delivery .

.
Avoid undue force in external cephalic version .

-
Judicial selection of cases for vaginal birth after one LSCS .

i
Attempted forceps delivery or breech extraction through incompletely dilated cervix

should be avoided -

.
Internal podalic version and destructive operations should be avoided and if necessary

should be performed by skilled obstetrician .

.
Judicial use of oxytocin IPGS for induction of labor and careful watch .

- Use of pantograph ,
strict vigilance and timely intervention and referral if needed .

'
k . Resuscitation :

2 wide bore IV lines

Send blood for cross matching

-

IV fluids ( Ringer lactate )

-

N antibiotics I ceftriaxone)
-

Start blood transfusion

.
Laparotomy :
-

Hysterectomy :
+ Unless there is sufficient reason to presence the uterus , quick subtotal
hysterectomy is needed in most cases .

→ If condition permits and there is colporrhexis ,

total hysterectomy may be done .

Repair :

-
Mostly in case of scar rupture ,
where margins are clean or in obstructive rupture
in odd circumstances (desirous of having child) .

'
Excision of fibrous / necrosed tissue followed by suturing the defect .

-
sterilisation ( Tubal ligation) should be offered .
 Intrauterine Growth Restriction
- Incidence : 5- 15% I 2- bi . in developed countries ) 51 . in term babies 4 151 .
in post term .

' Definition Birth weight below 10th percentile of average for gestational age
.

-
Types symmetrical 120%1 Asymmetrical 180%1

-
Early onset ast trimester ) late onset

-
Uniformly small Head larger than abdomen

-
Pondered Index 72 Pondered Index 52

- Head 1 Abdomen ratio Normal Elevated

'
Femur Ittbdomen ratio Normal Elevated

' cause Intrinsic to fetus maternal -

placental insufficiency
-

Genetic
-

Infections

- Total No .
of cells Less Normal

- Cell size Normal smaller

complicated neonatal course uncomplicated neonatal course

- Brain sparing Absent Present

- Prognosis Door Good

-
Causes maternal Fetal placental Uterine

- Nutritional .
TORCH
.
Abruptio El Drevia .
Atherosclerosis of
- Anemia . Malformations - Chorioamnionitis spiral arteries
- cardiorespiratory dis . .
Multiple pregnancy
. Thrombosis ,
infarction . fibroid
( AMA syndrome)
Chromosomal connective tissue disorders
Diabetes anomaly
' . .

-
Renal disease
'
trisomy 18121,13
'
Placental cysts .
morphological abnormalities
. lircumvallate placenta
'
Alcohol smoking
-
Drugs
.
preedampsl.cl/HTN
'
DX . Clinical :

1) Palpation of uterus for funded height , liquor volume and fetal mass .

2) Symphysis -
fund at height CSFH) in Cms correlates with gestational age after 24 weeks .

Lag of 73cm suggests growth restriction .

Serial measurement is important .

3) Stationary or falling maternal weight gain during and half of pregnancy

.

4) Measurement of abdominal girth shows stationary or

falling values .

-
USG

Abdominal circumference Most sensitive

USGL parameter
1) -

on

Head circumference / Abdominal circumference ratio

2) Pondered index 17 indicates IUGR .

3) Femur length / Abdominal circumference 723.51 .

suggestive of IU9R .

=
L
Not affected in symmetric IUGR .

4) Amniotic fluid index (AFI ) -

liquor is reduced in asymmetric IU9R due to brain

=
sparing effect .

'
Color Doppler :
-

Best investigation for asymmetric IU9R .

Vessels examined : Umbilical Artery ,

Middle cerebral artery Ductus venous .

-
Umbilical

is above

( Rising
=
artery
951
doppler
for

is
gestational
is considered

age .

in
abnormal

IUGR )
if systolic 1 diastolic Is ratio )

S1D ratio earliest change

-
Absent diastolic flow in Umbilical artery -

Omnious sign ( IUFD expected in 7 days)

. Reversal of end diastolic flow in Umbilical artery 4 Ductus venous

↳ NFD will occur in 48 hours .

- In asymmetric IU9R ,
as S1D ratio increases ,
blood flow in Middle cerebral

artery increases → Brain Sparing Effect

 -
Complications .
Fetal

a) Antenatal :
chronic fetal distress

Death

b) Intra natal :
Hypoxia
Acidosis

C) After birth :

'
Immediate :

Asphyxia
-

RDS
,
Broncho pulmonary dysplasia
-

Hypoglycemia , Hypocakemia hyponatremia , ,

Hypokalemia . Hyperphosphatemid
-

meconium aspiration syndrome

-

Pulmonary haemorrhage
Narcotising enteritis
-

-
Intraventriailar haemorrhage

-
late :
Asymmetric IUGR -

catch up growth in early infancy

symmetric -

Poor prognosis .

' NK . Symmetric IU4R -

No effective treatment

.
Asymmetric IUGR Close monitoring of fetal wellbeing & timely delivery to prevent NFD
-

'
General measures :

'
Adequate bed rest in left lateral position .

. Diet -

High cats ( extra 300kcal Hay ) and high protein

'
corticosteroids prophylactic to enhance lung maturity
-
.

Avoid alcohol -
smoking
' .

'
control of blood sugar ,
HTN , pre-eclampsia ( if present) r
.
maternal hyperoxygenalion@2.as litres Hay -
. Maternal volume expansion -
'
low dose aspirin 175 -100mg )
.

✓
'
Antepartum evaluation -

USG serial color doppler monitoring

r
,

-
Test For fetal wellbeing :

Daily Fetal kick count u

NST
y
-

Bpp
-

AII ✓
-
Methods of delivery :

low rupture of membranes followed by oxytocin .

lscs → Absent 1 Reverse end diastolic How in UA is absolute indication .

IU9R

Exclude congenital anomalies genetic syndromes

,
,
infections

treat underlying pathology ( if known)

-
Gieneral measures

fetal surveillance

v
v

Pregnancy 737 weeks pregnancy C37 weeks

✓ V

Delivery steroids
1.
UA doppler

v v

Normal Abnormal

v
v

Repeat study after End diastolic volume

,
14 days v

( US4 1UA doppler ) Present Absient

0h
v v

Normal surveillance Reversed

v
v
v

continue surveillance till Deliver at Delivery by

37 weeks 34137 weeks LSCS

Deliver at 37 wed
 Puerperal pyrexia
Definition 1380C ) [ measured
A in temperature orally ]
'
rise reaching IO0-4OF or more on 2 or

more separate occasions at 24 hours apart ( excluding 1st 24 hrs) within first

10 days following delivery is called puerperal pyrexia .

. Causes .
puerperal sepsis
- UT1 :
cystitis , pyelonephritis
- mastitis ,
breast abscess
.
Wound infections ( CS or Episiotomy )
pulmonary infections Pneumonia Atelectasis Pulmonary
'
:
,
.
TB

Septic pelvic tnrombophlebitis

.

-
Recrudescence of malaria
'
Gastroenteritis
.
pharyngitis

Puerperal Sepsis
. Definition An infection of genital tract which occurs as a complication of delivery is called

puerperal sepsis .

.
predisposing factors . Antepartum :

-
Malnutrition and anaemia
-

preterm labor
-

DR0M
-

lmmunocomprised state ( HN )
-

Diabetes
-

prolonged rupture of membranes 718 hours

-
Intraparty m
-

Repeated vaginal examinations

Dehydration and keto acidosis during labor
-

traumatic vaginal delivery

-

Antepartum and postpartum haemorrhage

-

Retained bits of placental tissue or membranes

-

prolonged labor
-

Obstructed labor
-

Caesarean delivery

'
Most important risk factor is route of delivery .

metritis following caesarean delivery is more common compared to

vaginal delivery .
 -
Organisms Aerobics Anaerobes Others

Group A. B. D streptococci peptococcus Mycoplasma

. .
-

.
Enterococcus -
peptostreptococas . Neisseria gonorrhoea @
'
Staphylococcus aureus . Bacteroides ( fragilis ,
bivius ) -
chlamydia trachomatis
-
Gardnerella vaginal 's . Clostridium
-
G -

ve bacteria - Fu bacterium
-

E. coli . mobinculus
-

Klebsiella
-

Proteus

-
Pathology > Endogenous ( vaginal flora )
Bacterial -

Colonisation ,
Poly microbial proliferation
Infection >
Exogenous with tissue invasion

. UF . Endometritis :

- Fever with chills and rigor

-
Tachycardia
. Lower abdominal tenderness
-
Adnexal and parametric tenderness
-
Foul smelling Iochia ( scanty odourless Iochia in some infections caused by
Group A beta -

haemolytic streptococci )
tender and

subinvoluted.parametn.tl
- Uterus is

's :

- Onset :
Usually 7- 10th day of puerperivm
.
spiky temperature and fever with chills .

- Constant pelvic pain

.
pv : Unilateral tender indurated mass pushing the uterus to opposite side
.PK :
confirms in duration extending along uterosacral ligament

-
Wound infections :

-
Erythema ,
edema ,
tenderness out of proportion to expected postpartum .

'
Discharge from wound .

- Severe infection -
fever with chills

- Pelvic Abscess :

-
Bulging .
fluctuant mass in pouch of Douglas
-
swinging temperature
.
Diarrhea

. pelvic peritonitis :

pyrexia
'

Tachycardia
-

. Lower abdominal pain and tenderness

. Forniceal & cervical movement tenderness
-
septicemia
-
Investigations .
High vaginal and endo cervical swabs -

Culture and sensitivity

- Urine -

Routine 9 culture ( clean catch midstream sample )

. Blood CBC -

4Th in infection , t platelet in septicemia EIDK

Thick blood film for malarial parasites
culture

. Pelvis USG -

Detection of retained bits of conception within uterus

-

Locate abscess within pelvis

. CTIMRI -

if needed

. X ray chest -
rule out pulmonary TB

. Blood urea and electrolyte

-
th .
General care :

1) Isolation of patient
2) Adequate fluids and calories are maintained parenterally .

3) Correction of anaemia

4) An indwelling catheter to relieve urinary retention .

5) monitoring of pulse , temperature , respiration ,

BP .

-
Antibiotics :

-
Clindamyah 900mg It every 8 hrs + Gentamicin 12mg 1kg IV
loading dose followed

by
mglkg 1.5 8 hourly )
. Clindmicintaztreonam :
for patients with renal insufficiency .

Ampicillin Added to regimen for sepsis syndrome suspected enterococcal infection

-
:
or

.
Metronidazole IV 0.5g q8H to control anaerobic infection
.
Imipenemt like statin : Reserved For special cases .

-
Vancomycin : For MRSA

.
Surgical :
Limited role
. Wound infection : Debridement and irrigation ; site Bath ; secondary suturing
may be required after infection is controlled -

- Retained uterine products :

surgical evacuation under antibiotic coverage .

.
pelvic abscess :
Drainage by lobotomy under US4 guidance .

and of
.
Unresponsive peritonitis :
laparotomy drainage pus .

-
Hysterectomy : In cases of -

Rupture 1 perforation having multiple abscesses

1- uterus 1 gas gangrene infection
Gangrenous

.mx of septic shock :

-
monitor vitals ; maintain airway , breathing ,
circulation
-
fluid and electrolyte monitoring .

Dobutamine for cardiac support & intensive antibiotic therapy .

 Post Term Pregnancy
'
Incidence : 4- 14 I

-
Definition A pregnancy continuing beyond 42 weeks 1294 days ) OF gestation is called

post term pregnancy .

gestation]
-
A pregnancy extending beyond EDD Lie 740 weeks of is called postdate'sm .

Etiology Wrong dates due ( )

'
. : to inaccurate LMP most common

.
Biological Variability ( Hereditary )
'
maternal factors

primipan.ly
-

Previous prolonged pregnancy

-

sedentary lifestyle
Elderly multiparole
-

.
Fetal factors :
-

Anencephaly > Abnormal fetal HPA axis

-
Adrenal
hypoplasia Diminished fetal cortisol response
→

.
X linked placental sulphate deficiency low estrogen ,

CIF
stationary 1 Falling weight
- .

-
Diminished abdominal girth due to decrease in liquor
-
Uterus feels
"
Full of fetus " due to decrease in liquor
.
Hard skull bones on abdominal El vaginal exam .

Investigations
-
it usq : Estimation of gestational age by USG is more accurate than LMD because

Of poor recall of LMP .

Best time to assess gestational age by Usa : 1st trimester ( Dating scan)
V

Parameter used : Crown Rump length

2) Amniocentesis : Biochemical and cytological parameters are helpful but since it

is an invasive procedure ,
it has been mostly replaced by Usa .

'
For assessment of fetal wellbeing :
' Non stress test ( Biweekly )

Biophysical profile
'

- Amniotic fluid Index ( AF1E 5cm is indication for Induction of Labor )

'
Doppler velocimetry study of umbilical & middle cerebral arteries
-
Complications . Maternal ,

Increased risk of labor instrumental 9

-

induction of , delivery LSCS .

- Fetal :

Antenatal :

i.
Oligohydroamnios :
liquor is 800mi at 40 weeks and about 450mi at 42 weeks

2. meconium stained amniotic fluid

3 .
Fetal Hypoxia
4. sudden IUFD

Intra Dartum :

I '

fetal hypoxia & acidosis

a. meconium aspiration
2 Cord compression ( due to digohydroamnios)
4. Shoulder dystocia

5. a set incidence of birth trauma due to Big size of Baby

Non molding of head due to hardening of

skull bones
6. Ned risk of operative delivery

After birth

1. mewnium aspiration syndrome

a. Hypoglycemia

polycythemia.MX
3.

. Before formulating the management , one should be certain about the maturity of fetus .

- Increase fetal surveillance is maintained .

- Perinatal morbidity and mortality are increased when pregnancy continues beyond 41 weeks .

.
Timely delivery reduces risk of stillbirth .
 Fetal maturity ensured

continued fetal surveillance

✓ v

Uncomplicated
complicated
✓
v

Induction (7- todays ) Cervix Favourable Cervix -

unfavourable

v v
v v
ARM LSCS
Cervix -

ripe cervix -

unripe
( Electron fetal monitoring )

vagina Yad ministration

V Of PGEZ get ( 6 hourly )
stripping of membranes

cervix ripe
"

liquor dear
> ARMS

✓
✓
v Oxytocin drip
liquor liquor -
mewnium stained
clear .
Amnio infusion
✓
- Electronic fetal monitoring
Expected vaginal delivery
Oxytocin drip

✓ v

Scalp blood pH estimation fetal acidosis

( abnormal CTG trace )

Expected vvaginal delivery v

LSCS

Satisfactory fetal behaviour

Expected vaginal
delivery
 PREVIOUS LSCS
-
Complications Effects of previous LSCS :

1) On scar : scar dehiscence I scar rupture

>
Incidence :
02 -
IS i. in LSCS

4- 91 classical
in or
Hysterectomy scar

2) Pregnancy and labor :

Abortion
-

Preterm labor
-

Normal pregnancy ailments

-

tsed operative interference and incidental morbidity

-

Placenta previa
-

Adherent placenta ( Dlacenta accreta )

-

ppH
-

Peripartum hysterectomy
-
Need for repeat Caesarean section

.MX .
Regular antenatal supervision

-
classical 1 Hysterotomy fear : Admission at 36 weeks > Elective Cs at 38 weeks

. LSCS transverse scar :

- Admission at 38 weeks to assess the case and formulate line of treatment

Prevent inconvenience of patient if labor pains start earlier .

Go through available
.
previous Cs notes or discharge summary if .

Enquiry about number of previous C- sections ,

indications and complications .

'
fetal weight estimation :
clinically and US9

Clinical pelvimetry
'
: To assess adequacy of pelvis .

-
Spontaneous onset of labor is desired
Oxytocin may be used &
selectively judiciously
.

Induction of labor with prostaglandins increases risk of uterine scar rupture .

- Commence IV line with Ringer lactate solution .

Blood sample Hbt and blood

.
grouping
-

electronically for fetal behaviour

'
labor monitoring -

Clinically for scar dehiscence and .

Continuous EF1H is desirable

'

prophylactic forceps or venthouse to cut short second stage .

- Routine exploration of uterus .

- TOLAC -

Trial of labor after Caesarean

. VBAC -
Vaginal birth after Caesarean

'
Risk Factors For scar Rupture :

it more the number 172 ) of prior Caesarean delivery .

2) Interpregnancy interval I 24 months

3) Induced labor

4) Augmentation of labor with high dose oxytocin 1720 IU1 min )

5) Women having single layer uterine closure in prior .

. Selection criteria of cases For TOLAC :

1) One or two previous lower segment transverse scar .

21 Nonrecurring indication For prior cs .

3) pelvis adequate For foetus

4) Availability of resources for emergency CS within 30 minutes of decision

5) Informed consent of women .

-
Contraindications of TOLAC :

1) previous classical or inverted T -

shaped uterine incision

2) Previous two or more LSCS

3) Pelvis contracted or suspected CPD .

4) History of prior uterine rupture

5) Evidence of scar tenderness ,
dehiscence or rupture .

6) limited resources for emergency CS

7) Presence of other complications of pregnancy ( obstetric or medical)

8) Patient 's refuse For TOLAC .

.
Benefits of VBAC :

1) Decreased maternal morbidity

2) Reduced length of hospital stay
3) Decreased need For blood transfusion

4) Decreased risk of abnormal placentation & need For Cs in successive pregnancy .

- Risks of Elective Repeat Cs :

1) Increased maternal morbidity .

2) Increased length of hospital stay

3) tsed risk of haemorrhage & need for blood transfusion

4) Ned risk of abnormal placenta tion , haemorrhage & successive Cs .

-
Complications of Unsuccessful to LAC :

maternal perinatal
-

Uterine wound dehiscence -

low APGAR score

-

uterine rupture -

Admission to Nicu
-

Med blood transfusion -

Hypoxic ischemic encephalopathy

-
tsed risks of hysterectomy - Neonatal death
-

Bed chances of infections -

Stillbirth ( Rare )
-
toed maternal morbidity

management
V

Hospitalisation

↳ Is
"

Admission at 38 weeks

- Assessment of case

. formulation of method of delivery

v v

Elective LSCS TOLAC

v v

-
progress unsatisfactory labor progressing smoothly
-
Evidence of scar tenderness

"
Prophylactic tforceps El Vento use in 2nd

Caesarean delivery stage

Exploration of star after expulsion of

placenta
 Maternal Mortality
'
Definition Death of woman while pregnant or within 42 days of termination of pregnancy
irrespective of the duration and the site of pregnancy , From any cause related to

or aggravated by the pregnancy or its management but not from accidental or

incidental causes .

'
MMR MMR is expressed in terms of maternal deaths 100,000 live births
per
.

MN1R in India : 167

. Maternal Mortality Rate maternal deaths divided number of reproductive

by women of age .

For India 120

Classifications Direct : due

delivery
. .
to complications of pregnancy , or their management
-
Haemorrhage LAPH and PP43 1MK in India )
-
Unsafe abortion
-
Hypertensive disorders of pregnancy ( pre -

eclampsia , eclampsia )
'
Postpartum infections
'
Obstructed labor
.
Ectopic gestation
'
suicidal death is considered direct death

Indirect due conditions

. : to aggravated due to physiological effects of

pregnancy
.

.
Anaemia ( most common indirect cause )
.
HIV/AIDS
.
Cardiovascular diseases

. Diabetes
'
viral hepatitis
.
Thyroid diseases

.
Non Obstetric :
Infectious disease ( typhoid ) ; Accidents

'
Factors i) of
Age -

Age 118 and 735 increases chances of complications pregnancy .

2) parity -

more risk in primi and when parity Is .

3) low socioeconomic strata

4) Door antenatal care

5) Early pregnancy
6) Illiteracy
7) Uhderutisation of existing services

8) Lack of communication & referral facilities .

-
Steps to Reduce mortality .
Health sector Actions :

1) Basic antenatal , intranatal and postnatal care .

2) Risk assessment is a continued procedure throughout and not once only .

3) Hygiene should be maintained .

4) Skilled attendant should be present at birth .

5) Functioning referral system ; & Good quality obstetric services at referral centres .

6) facilities of emergency obstetric care

7) Prevention of unwanted
pregnancy and unsafe abortion .

8) maternal mortality conferences to evaluate causes of mortality and avoidable factors .

9) Periodic refresher courses for continuing education of obstetrician , general practitioners ,

midwives .

-
Community .

Society & Family Actions : Health education to ensure safe motherhood

- Health planners Actions :

1) Organise community education ,

motivation and formation of safe
motherhood committee at local level .

2) Develop written management protocols for emergencies in hospital .

b) Improve the standard and quality of care by organising refresher courses

For healthcare professional .

4) Periodic audit of the existing healthcare delivery system .

.
Legislative :
1) Girl children and adolescent should have good nutrition education
,
and economic

opportunities .

2) policies to remove barriers to access of healthcare facilities .

3) Decentralisation of services to make them available to all .

4) Safe abortion services and post abortion care .