Obstetrics Marrow Pg 315-324 (Normal Pregnancy & ANC)

Bell's Palsy

• Caused by perineural edema, hypercoagulability, and immunosuppression.
• Managed with short-term glucocorticoid treatment.
• Avoid glucocorticoids during organogenesis due to potential for cleft lip and palate.

Backache in Pregnancy

• Caused by joint laxity due to estrogen and relaxin, weight gain, faulty posture, and hyperlordosis.
• Management includes posture correction, elevating lower limbs while resting, using a hard bed, back massage, and analgesics.

Antenatal Care

Pradhan Mantri Surakshit Matritva Abhiyan

• Uses a color-coded system with green for no risk factors and red for high-risk factors requiring additional antenatal visits.

Alert Signs and Symptoms

• Advise patients to seek immediate medical attention if they experience any of the following: fever ≥ 38°C for ≥ 24 hours, persistent vomiting, headache/blurring of vision, generalized edema/puffiness of the face, discharge/bleeding from the vagina, abdominal pain, decreased fetal movements, or breathlessness at rest.

Folic Acid Supplementation

• Prophylactic dose (400 mcg/day) to prevent neural tube defects:
  • Start at least one month before conception.
  • Continue until three months after conception.
• Therapeutic dose (4 mg/day) to prevent recurrence of neural tube defects:
  • Start two to three months before conception.
  • Continue until three months after conception.
• RDA during pregnancy: 500 mcg/day.

Special Cases

• Diabetic females:
  • Prophylactic dose (400 mcg/day) before conception.
  • Therapeutic dose (4mg/day) after conception.
• Patients on anti-epileptic drugs:
  • Prophylactic dose (400 mcg/day) before conception.
  • Therapeutic dose (4 mg/day) after conception.
• Sickle cell anemia:
  • Prophylactic dose (400 mcg/day) before conception.
  • Therapeutic dose (4 mg/day) after conception.
  • 5g/day for treatment of megaloblastic anemia.
• 4th month onwards: Iron + folic acid supplementation (IFA) as per Anemia Mukt Bharat Programme.
  • 60mg elemental iron + 500mcg of folic acid (red-colored tablet).
  • 1 tablet/day to prevent anemia in pregnant females without anemia.
  • Continue throughout pregnancy or for 180 days of pregnancy and 180 days after delivery.
  • 2 tablets/day to treat anemia in pregnant females with anemia.

Management of Nausea and Vomiting in Pregnancy

• No hypovolemia:
  • Oral medications: Dimenhydrinate/diphenhydramine.
  • If no response: Metoclopramide/Promethazine.
  • If no response: Ondansetron.
• Hypovolemia present:
  • < 10 weeks: Combination of two IV drugs (e.g., IV metoclopramide + IV promethazine).
  • If no response: IV ondansetron (after 2 weeks).
  • > 10 weeks: IV ondansetron (Note: may lead to cleft lip/palate if given before 10 weeks of pregnancy).

PUQE Scoring

• 4 to 6: Mild
• 7 to 12: Moderate
• ≥13: Severe

Other Ailments in Pregnancy

Supine Hypotension Syndrome

• Symptoms: Dizziness/lightheadedness while lying supine (usually late trimester).
• Pathology: Pressure of gravid uterus on inferior vena cava causing decreased venous return, cardiac output, maternal hypotension (potentially leading to fetal distress).
• Management: Lie in left lateral position.

Antenatal Visits

• Ideal visits: 12 to 15 visits.

Frequency of Visits

First Antenatal Visit Investigations

1. ABO/Rh status:
   • If Rh-negative female, check husband's Rh status.
   • If Rh-positive, perform Indirect Coombs test (at 1st visit, repeat at 28 weeks of gestation).
2. Complete Blood Count + Hemoglobin (Hb):
   • ACOG guidelines: Repeat Hb testing at 24-28 weeks of pregnancy.
   • Indian guidelines: Repeat Hb at all 4 visits (using digital hemoglobinometer, provided under Anemia Mukt Bharat Programme).
3. Urine Routine Microscopy: In all trimesters.
4. HIV: Opt-out approach (if patient refuses to test).
   • Screening test: ELISA.
   • Diagnostic/Confirmatory: Western Blot.
5. HBsAg testing: Regardless of vaccination status.
6. VDRL test/RPR.
7. Diabetes testing: As per DIPSI guidelines (First test: at 1st visit; Second test: at 24 to 28 weeks of gestation). Also perform Urine Culture & Sensitivity test (ACOG guidelines).

Notes

• Minimum visits within 12 weeks (1st visit).
• 2nd visit: 14 to 26 weeks.
• High risk for asymptomatic bacteriuria, diabetes, and sickle cell anemia.

Document Details

• Page number: 315
• Active space: On the top right corner
• Time stamp: 00:00:45
• Document generated by: Obstetrics v1.0 Marrow 8.0. 2024

Varicose Veins

• Commonly present in lower limbs and vulva.

Pathophysiology

• Increased blood volume.
• Increased femoral venous pressure due to pressure from the gravid uterus.

Management

• Conservative approach.
• Avoid standing for long hours.
• Use compression stockings.
• Elevate lower limbs while resting.
• Lie in left lateral position.
• No medical or surgical procedures during pregnancy.

Leg Cramps

• Caused by lactic acid accumulation.

Prevention

• Massage.
• Hot shower before going to bed.
• Improve hydration.
• Extend knees and dorsiflex toes during cramps.
• Monitor magnesium levels.

Carpal Tunnel Syndrome

• Numbness and tingling in thumb, index, and middle finger due to compression of the median nerve

Management

• Symptomatic treatment.
• Apply wrist splint.
• Avoid corticosteroid injection and surgery.

Hemorrhoids

Pathophysiology

• Increased vascular resistance.
• Progesterone, a smooth muscle relaxant, contributes to relaxation of rectal muscles.

Management

• Increase fiber and fluid intake.
• Local anesthetic gels and anti-inflammatory medication for pain.

Vulval Varicosities

• Managed through vulval compressions.

Ultrasound in Pregnancy Part 1

• This document describes ultrasound findings in pregnancy.

Routine USG in Pregnancy

• Types:

  • Transabdominal scan (TAS).
  • Transvaginal scan (TVS).

• Frequency of probe:

  • TVS: 5 - 10 Hz.
  • TAS: 3 - 5 Hz.

• Modes:

  • B mode/Brightness mode: Visualize all intrauterine structures.
  • M mode/Motion mode: To see cardiac activity.

USG Findings in Pregnancy

Gestational Sac

• First structure seen on USG.
• Appearance: Symmetrical fluid-filled area with echogenic rim.
• Seen at (TVS): 4 weeks + 3 days to 5 weeks.
• Indicates: Pregnancy.
• Note: Gestational sac does not definitively confirm intrauterine pregnancy. A pseudogestational sac can be seen in ectopic pregnancy.

Yolk Sac

• Second structure seen on USG.
• Appearance: Bleb (bubble) inside gestational sac.
• Appears when mean sac diameter (MSD) is 10mm.
• Seen at (TVS): 5 weeks to 5 weeks + 3 days.
• Indicates: Intrauterine pregnancy.

Nausea and Vomiting in Pregnancy

• Also known as morning sickness.
• Cause: hCG + estrogen + progesterone.
• Can be seen at any time of the day.
• Peak: At 10 weeks of pregnancy (due to hCG peak).
• Subsides by 16 weeks of pregnancy.

Management

• Dietary modifications: Avoid spicy and fatty foods, consume small frequent meals.
• Medication:
  • Pyridoxine (10mg) + Doxylamine (10mg) (Anti-histamine).
  • If no relief: Metoclopramide/Promethazine (Orally), Ondansetron (Oral as last resort).
• Doctor: Consult a doctor.

Hyperemesis Gravidarum

• Persistent vomiting and/or weight loss ≥ 5% of pre-pregnancy weight.
• Ketonuria.
• Interferes with quality of life.
• Cause: ↑ hCG.
• Possible complications: Twin pregnancy.

Risk Factors

• ↑ risk:
  • In primigravida.
  • With female fetus.
  • High socioeconomic status.
  • Young females.
  • Previous h/o hyperemesis gravidarum/migraine/motion sickness.
  • Possible association with H.pylori.
  • Genetic predisposition.

Investigations

• Perform USG to exclude twin/molar pregnancy.

Complications

• Dehydration/Ketonuria.
• Electrolyte imbalance (Hyponatremia, Hypokalemia).
• Metabolic alkalosis.
• Mallory Weiss tear.
• Vitamin deficiencies (Vitamin K, Thiamine).
• Wernicke's encephalopathy.

Other Nutrient Requirements

Calcium

• RDA: 1000 mg.
• Given as tablets from the 4th month onwards.
• Minimum duration between calcium and iron dosage: 2 hours.

Protein

• Average additional requirement: +45g/day.
• Specifically:
  • T1: No additional requirement.
  • T2: +10g/day.
  • T3: +20g/day.

Vaccines in Pregnancy

• Live vaccines: Contraindicated (C/I).
• Killed vaccines: Not Contraindicated (Not C/I).
• Minimum period before pregnancy for safe administration of live vaccine: 1 month.
• (< 1 month: Not an indication for MTP).

Safe Vaccines

• MMR (Mumps, measles, Rubella)
• Small pox
• Chicken pox
• BCG
• HPV (Not live vaccine)
• Hep A/B
• Pneumococcus
• Meningococcus
• Influenza (In TI)
• Covid-19 (In TI)

Vaccines Given in Special Circumstances

• If traveling to an endemic area:
  • Yellow Fever.
  • Polio.

Note

• Air travel: Safe for pregnant women. Not recommended ≥ 36th week of pregnancy (Aviation restriction).
• Physical exercise: 30 to 45 minutes of walking/day recommended in all pregnant women. Severe physical exercise contraindicated (C/I) in:
  • a. PIH
  • b. Cardiac disease
  • c. Patients at risk of pre-term labor
  • d. Placenta previa

Assessments in Antenatal Visits

• In each antenatal visit:

  1. Weight
  2. Blood pressure
  3. Check for pathological edema
  4. Uterine size and fundal height

• Between 24 to 28 weeks:

  • Hb%/Hematocrit (Hct): By ACOG guidelines
  • Gestational Diabetes Mellitus (GDM): By DIPSI guidelines
  • Indirect Coombs test (if Rh-ve) at 28 weeks

Nutrition in Pregnancy

Caloric Requirements

Additional Requirement in Pregnancy

• Average: +350 Kcal/day.
• Individuals with moderate activities do not need additional calories (National guidelines).

Recommended Weight Gain

Consequences of Weight Gain

• Small for gestational age (SGA) baby.
• High blood pressure (HTN)/Pre-eclampsia (PIH).
• Macrosomia.
• Failed induction (C-section).

Factors affecting weight gain in pregnancy

1. Socioeconomic status of the patient.
2. Parity and weight gain.
3. Ethnicity.
4. Pre-pregnant weight and weight gain.

Note

• Smoking does not affect weight gain in pregnancy.

Normal Pregnancy and Antenatal Care

Optional Investigations

1. TSH:
2. Aneuploidy screening:
   • Patient susceptibility test.
   • IgM -ve.
   • IgG -ve.
3. Rubella susceptibility test:
   • Patient is susceptible to rubella.
   • Rubella vaccine: Live vaccine (C/I during pregnancy) – Vaccination after delivery.

• Note: National guidelines do not recommend routine TORCH testing. ACOG recommends Group B streptococci testing in all pregnant females between 35-37 weeks. Sample: Rectovaginal swab.

Vaccinations

1. Td (Tetanus + diphtheria toxoid) vaccine:
   • Td-1 at first visit.
   • Td-2 after 4 weeks.
   • If pregnant female received complete Td vaccination within the last 3 years: Only Td booster in current pregnancy.
2. Tdap (Tetanus + diphtheria + acellular pertussis) vaccine:
   • Single shot between weeks 27-37 (ACOG guidelines).

Identification of High Risk Pregnancy

• High Risk Factors:
  1. Extremes of age: >35 years.
  2. HIV+ve/HbsAg+ve.
  3. Severe systemic illness.
  4. Severe anaemia (Hb < 7 g/dl).
  5. Previous history of premature delivery, stillbirth, or congenital abnormalities.
  6. Multiple pregnancies (twins, triplets, etc.).
  7. Certain medical conditions: diabetes, heart disease, etc.