Obstetrics Marrow Pg 385-394 (Medical & Surgical complication of Pregnancy)

Management of Difficult Labor

• HELPERR mnemonic for managing difficult labor
• Call for help: Includes liberal episiotomy
• Legs maneuver (McRobert's maneuver): Flexes and abducts legs against abdomen, straightening the sacrum, increasing available space
• Suprapubic pressure + McRobert's maneuver: Sustained in thrusts
• Enter maneuver: Manual rotation of shoulders (Wood's corkscrew or Rubin's)
• Remove (Deliver) posterior arm of baby: Jacquemier maneuver
• Roll on all four limbs: 4-limb (Gaskin) maneuver
• Zavanelli maneuver: Last resort, pushes fetal head back into uterus, leading to cesarean
• Complications: Fractured clavicle (cleidotomy), obsolete: symphysiotomy, other measures: fundal pressure (contraindicated)

Complications

• Fetal: Erb's palsy is most common, injury to C5, C6, arm internally rotated, adducted, and pronated
• Maternal: Postpartum hemorrhage (PPH) is most common, nerve injury (most common) during McRobert's maneuver, lateral cutaneous nerve of the thigh

Termination of Pregnancy

• Type A1 GDM (well-controlled on diet): ≥ 39 weeks
• Type A2 GDM (well-controlled on drugs): ≥ 39 weeks
• Type A2 GDM (not well-controlled on drugs): ≥ 37 weeks
• Vaginal delivery is preferred, Cesarean section indicated for babies ≥ 4.5 kg

Intrapartum Management

• Mild GDM, on medical management: skip morning dose
• Hourly blood sugar monitoring with glucometer during labor
• NPO (nothing by mouth)
• IV NS @ 100ml/hr
• Insulin added to IV NS depending on blood sugar levels

Blood Sugar Levels and Insulin Dosage

• 90-120 mg/dl: No insulin added
• 120-140 mg/dl: 4U insulin added to 500ml NS
• 140-180 mg/dl: 6U insulin added to 500ml NS
• ≥ 180 mg/dl: 8U insulin added to 500ml NS
• If blood glucose < 70mg/dl (Hypoglycemia): Start IV 5% dextrose

Postpartum Management

• GDM: Check blood sugar on day 3 post delivery, discharge at 6 weeks, follow up with 75g 1hr OGTT
• Pre GDM: Insulin requirement decreases, shift back to OHA from day 2 of delivery, refer to endocrinologist if needed

Pregnancy Induced Hypertension: Part 1

• Proteinuria: ≥ 300mg/24 hours, Protein/Creatinine ≥ 0.3, urine dipstick ≥ 2+
• Signs & end organ damage: Platelet count < 100,000, liver enzymes raised, S.Creatinine ≥ 1.1 mg/dL, pulmonary edema, visual symptoms/cerebral edema
• ALP (Alkaline Phosphatase): Produced by placenta, heat stable

Antenatal visit and PIH

• Measure blood pressure (BP) at every visit
• Repeat BP after 4 hours if ≥ 140/90 mm Hg
• Screening Test: Urine dipstick for proteinuria (≥ +1)
• Diagnostic Test: 24-hour urine protein excretion (Gold standard)

Chronic HTN with superimposed pre-eclampsia:

• Hypertensive female conceives + develops uncontrollable BP, new onset proteinuria, or new onset signs of end-organ damage after 20 weeks
• Bad prognosis
• Prevention: Low dose Aspirin started daily from 12 weeks

PREGNANCY INDUCED HYPERTENSION : PART 1

• Definition: BP ≥ 140/90 mm Hg on two occasions 4 hours apart
• Exception: If BP is ≥ 160/110 mmHg, repeat in 15 minutes, start anti-hypertensive medication if still high

Chronic HTN in Pregnancy vs Pregnancy induced HTN (PIH)

• Chronic HTN in Pregnancy: Hypertensive female has conceived with past history of high blood pressure
• PIH: Normotensive female has conceived with no prior history of high blood pressure
• Chronically elevated BP: Since day 1 of pregnancy vs after 20 weeks of pregnancy
• BP Normalization: Occurs after delivery vs within 14 weeks of delivery

Pre-eclampsia vs Gestational HTN

• Pre-eclampsia: ↑ BP with proteinuria and signs of end-organ damage
• Gestational HTN: ↑ BP after 20 weeks of pregnancy without proteinuria or signs of end organ damage

Eclampsia

• Definition: Severe pre-eclampsia with generalized tonic clonic seizures
• Types: Antepartum (most common, worst prognosis), Intrapartum, and Postpartum
• Atypical Eclampsia: Onset of seizure > 48 hours after delivery or < 20 weeks of pregnancy, prolonged loss of consciousness, localized edema in posterior cerebral hemisphere (MRI)

Gestational Hypertension

• 50% cases progress to pre-eclampsia
• BP ≥ 160/110 mmHg → manage like severe Pre-eclampsia
• If no proteinuria/signs of end organ damage: Provisional diagnosis of Gestational Hypertension
• Recheck BP 12 weeks after delivery: Normalizes → Gestational HTN/Transient HTN in pregnancy, if still raised → revised diagnosis to Chronic HTN

Mild vs Severe Pre-eclampsia

• Mild Pre-eclampsia: BP ≤ 140/90 and proteinuria ≤ 300mg/24 hours
• Severe Pre-eclampsia: BP ≥ 160/110 mmHg or proteinuria ≥ 5g / 24 hours
• Complications: Severe pre-eclampsia can lead to eclampsia, maternal and fetal complications

DIABETES IN PREGNANCY: PART 3

Maternal Complications

• Hyperglycemia: Asymptomatic bacteruria, candidiasis, puerperal sepsis
• Infections: Increased risk
• Polyhydramnios: Increased risk of PTL, PROM, cord prolapse, PPH, subinvolution
• Oligohydramnios: If diabetic vasculopathy/PIH+, increased risk of PIH, placenta previa
• Increased risk of: T2DM in the future, Cesarean section, ketoacidosis

Hypoglycemia

• Blood sugar < 70 mg/dL
• Symptoms: Tremors, sweating, palpitations, extreme fatigue, tingling sensation
• Management: 3 teaspoons glucose in 100 mL water, or 6 teaspoons sugar in 100 mL water

Fetal Complications in Diabetes During Pregnancy

• Pederson's Hypothesis: Maternal hyperglycemia leads to fetal hyperglycemia and increased insulin production
• Consequences: Macrosomia, prolonged labor, increased chances of Cesarean section, IUGR, increased risk of abortion, increased risk of stillbirth, oxidative stress and edema, hypoxia, shoulder dystocia
• Neonatal Complications: Neonatal hypoglycemia, hypocalcemia, hypokalemia, hypomagnesemia, RDS, NEC, hypoxia, congenital malformations (only in pre-gestational diabetes)

Note

• Hormones for fetal growth: Insulin and Insulin-like growth factors (IGFs) are needed
• Anemia: Not usually a major issue in cases of maternal diabetes during pregnancy

PREGNANCY INDUCED HYPERTENSION PART 2

Events in Normal Pregnancy

• Extravillous trophoblast (Endovascular part): Replaces the lining of spiral arteries, converting high resistance vessels into low resistance vessels, occurs in two phases: Phase 1 (12 weeks) and Phase 2 (16-20 weeks)

Pathophysiology

• Incomplete trophoblastic invasion: Leads to high resistance in intervillous space, decreased blood volume, and placental ischemia

Medical and Surgical Complications in Pregnancy

• Late complications in child: T2DM (1-3%), obesity, metabolic X syndrome

Lung Maturity Tests

• Lecithin/Sphingomyelin ratio: mature ≥ 2:1, immature < 2:1
• Phosphatidyl glycerol: Best test (Done ≥ 35 weeks), present = mature, absent = immature
• Lamellar body count: 50,000/mL: 100% lungs mature, 30,000 - 40,000/mL AF: positive test
• Bedside test/Shake test/Bubble test: Obsolete
• Nile blue sulphate test: Obsolete

Shoulder Dystocia

• Obstetric emergency: Inability to deliver fetal shoulder within 1 min of head delivery
• Turtle sign +ve: Receding of fetal head into perineum

This quiz covers key techniques and maneuvers for managing difficult labor, focusing on the HELPERR mnemonic. It explores various methods such as the McRobert's maneuver and Zavanelli maneuver, along with potential complications for both fetal and maternal health. Test your understanding of these critical practices in obstetrics.