OBGYN Summary (Midterm & Final) PDF

Obstetrics & Gynecology Summary 1st Edition (Nov. 2022): Sarah Alobaid, Sarah Alaidarous, Sadem Alzayed, and Duaa Alhumoudi Color Index: Red - Important Green - Dr’s notes Yellow - Golden notes Blue - Reference book Gray - Extra Highlighted in red/y...

Obstetrics & Gynecology Summary 1st Edition (Nov. 2022): Sarah Alobaid, Sarah Alaidarous, Sadem Alzayed, and Duaa Alhumoudi Color Index: Red - Important Green - Dr’s notes Yellow - Golden notes Blue - Reference book Gray - Extra Highlighted in red/yellow - High yield Highlighted in purple - doctor’s review  Table of Contents Lecture Midterm Lec Anatomy of fetal skull Lec UTI & Anemia in pregnancy Lec Thromboembolic disease Lec Abnormal presentation (Fetal Malpresentation) Lec Operative Deliveries and C-section VC Preconception VC Antepartum Care Lec Antenatal fetal assessment VC Intrapartum Fetal Surveillance VC Intrapartum Care VC Postpartum Care Lec Induction of Labor VC Postterm Pregnancy VC Vaginal bleeding in 1st trimester & Spontaneous Abortion VC Ectopic Pregnancy VC Antepartum Hemorrhage VC Postpartum Hemorrhage VC Abnormal Uterine Bleeding VC Preterm labor VC PROM & pPROM VC IUGR VC IUFD VC Hypertensive Pregnancy Disorders Lec Gestational Diabetes Mellitus VC Menopause VC Puerperal Sepsis Lecture Final Lec Anatomy of placenta and fetal circulation VC Multiple pregnancies VC Cervical Intraepithelial Neoplasia (CIN) and Cancer Lec Postmenopausal bleeding & endometrial cancer Lec Uterine fibroids VC Benign & Malignant ovarian tumors VC Gestational Trophoblastic Tumors Lec PolyCystic Ovarian Syndrome VC Pelvic Organ Prolapse & Urinary incontinence Lec Rhesus Alloimmunization VC Family planning Lec Embryology overview Lec Anomalies of female genital tract Lec Disorders of Sexual Development Lec Amenorrhea Lec Puberty Disorders VC Dysmenorrhea VC Endometriosis VC Vulvovaginitis (lower genital tract infection) & Benign vulvar conditions Lec PID (upper genital tract infection) VC Infertility Lec Patient Safety - EXTRA Topics (VERY important) Gravity & parity: Gravity (G): number of times a woman has been pregnant (including the current pregnancy and any past abnormal pregnancy) Parity (P): number of pregnancies a woman has had that have reached ≥ 24 weeks of gestation Abortions (A): < 20 weeks of gestation; both spontaneous and elective Practice Q based on GTPAL system: Estimated date of delivery (EDD) 1. Regular 28 days cycle: a. Count 40 weeks past LMP b. OR LMP (-) 3 months (+) 7 days + (1) year. If LMP is at the beginning of the year (e.g., january) no need to add 1 year. 2. Irregular cycle: vaginal ultrasound, also used to confirm the EDD if the cycle is regular Apgar score: Used for standardized clinical assessment of newborns at 1 and 5 minutes after birth APGAR: ○ Appearance (skin color) ○ Pulse (HR) ○ Grimace (reflex irritability upon tactile stimulation) ○ Activity (muscle tone, movement) ○ Respirations  Anatomy of fetal skull Bones 2 frontal bones 2 parietal bones One occipital bone Sutures Frontal suture: between two frontals Sagittal suture: between two parietals Coronal suture: between frontals and parietals Lambdoidal suture: between occipital and parietals Fontanelle is where two or more sutures meet ○ Anterior Fontanelle/bregma Skull areas Mentum: chin Glabella: bridge of the nose Sinciput: forehead Vertex: between anterior & posterior fontanelles & the two parietal eminences Circumferences Sub-mento-bregmatic (9.5 cm) → face presentation → landmark: mentum ○ Presents as hyperextended fetal neck ○ Mentoanterior? Can be delivered by flexion and forceps ○ Mentoposterior? CS Sub-occipito-bregmatic (9.5 cm) → well flexed head → vertex presentation → landmark: occipital bone Mento-vertical/mento-vertex (13 cm) → brow presentation → landmark: frontal bone ○ Delivered by CS Occipito-frontal: 11.5 cm  UTI & Anemia in pregnancy UTIs Infections of the bladder, urethra, ureters, or kidneys Causative agents: ○ Enteric bacteria e.g. E.coli (most common) ○ Beta hemolytic A: more aggressive ○ Beta hemolytic B: ○ Lactobacilli does not cause UTI, it’s considered as normal flora. Can be given as vaginal\oral capsules to treat recurrent infection Classification ○ By clinical presentation: Asymptomatic bacteriuria Urinary tract infection ○ By location: Lower UTI: urethritis and cystitis Upper UTI: pyelonephritis ○ By severity: Complicated: pregnancy, male gender, etc… Uncomplicated Risk factors: ○ Female gender (due to shorter urethra) ○ Anemia ○ Functional obstruction: Pregnancy  Physiologic hydronephrosis (right kidney is more affected than left since uterus is more oriented towards the right) Hydroureters (right ureter is more affected than left) Urinary stasis in the bladder (mechanical compression of uterus) ↑ GFR: more glucose is filtered (welcoming environment for bacteria) Hormonal changes: ↑ progesterone → smooth muscle relaxant → dilation & urinary stasis Vesicoureteral reflux ○ Mechanical obstruction: Ureteropelvic junction, urethral or ureteral stenosis. Calculi or tumors ○ Others/Systemic diseases: DM: glucose will be excreted in urine which will attract bacteria Sickle cell trait/disease: due to Heme excretion (note that two mediums are favored; blood and glucose) Gout: due to uric acid build up Cystic renal disease, any kidney disease i.e. SLE Nephritis Indwelling urinary catheters Anatomical abnormalities of the urinary tract UTI recurrence: ○ Relapse: Infection by the same organism within 2-3 weeks. Secondary to perineal colonization or inadequate treatment. Given antibiotics before getting a sensitivity test ○ Reinfection: Fully treated patient but got infected by a new organism within 12 weeks Bladder bacteriuria ○ Superinfection: Infection by a new organism while on treatment ○ Recurrent UTI: Two infections in 6 months or Three or more infections in 1 year Must to be “culture proven” and are given prophylaxis accordingly Cultures must be collected (each time) to see the pattern of infection to prevent antibiotics resistance Renal US is recommended in investigating recurrent UTI in pregnancy OB triads: Infection Asymptomatic Bacteriuria Acute Cystitis Acute Pyelonephritis  About Most common UTI in Most commonly occur in pregnancy 2nd trimester Consequences If not treated, 30% will develop acute pyelonephritis The leading cause of ARDS and septic shock in pregnancy. Anemia, renal failure, preterm labor, and pulmonary dysfunction Clinical Asymptomatic patient Suprapubic pain Fever & chills presentation Dysuria Costovertebral angle (CVA) Hematuria tenderness/ Flank pain Frequency, urgency Anorexia, tachycardia N&V Diagnosis Screening for Urinalysis Signs & symptoms asymptomatic Urine culture and Urinalysis: leukocytosis bacteriuria during sensitivity Urine culture pregnancy is done with Blood culture +ve in 10% of a urine culture at 12 to cases 16 weeks of gestation or at the first prenatal visit. Urinalysis: presence of ≥ 100,000 CFU/mL in at least two voided urine samples Urine culture and sensitivity Management Outpatient & oral abx: (3-7 days) Outpatient (7-10 days) Admission & IV abx: Nitrofurantoin Nitrofurantoin IV ampicillin or 3rd gen Amoxi/clav Amoxi/clav cephalosporin 1st generation 3rd gen (cefotaxime/ceftriaxone) then cephalosporin cephalosporin PO antipyretic agent. (cephalexin) (cefotaxime/ceftriaxone IV hydration ) Analgesics Analgesics Safe antibiotics in pregnancy: ○ Oral antibiotics given for UTI in pregnancy: Cephalosporins Amoxicillin-clavulanic acid Nitrofurantoin (in 2nd and 3rd trimesters) Ciprofloxacin (restricted use)  Levofloxacin ○ IV antibiotics given for UTI in pregnancy: Cephalosporins (2nd and 3rd gen) Gentamicin Impenems Prevention: ○ Hygiene ○ Increased intake of water ○ Cranberry juice ○ Prenatal screening for asymptomatic bacteriuria in 1st trimester ○ Lactobacilli Anemia Incidence: ○ Most common medical disorder in pregnancy in KSA due to poor diet quality ○ Generally more common in developing/underdeveloped countries Causes: ○ Nutritional deficiencies: iron (most common), folate, vit B12 ○ Hemoglobinopathies: sickle cell disease/trait, thalassemia Definition: ○ A condition where circulating levels of Hb are lower than normal Symptoms (often overlaps with pregnancy symptoms): ○ Weakness, fatigue, dizziness, trouble in concentration ○ Rapid/irregular heartbeat, SOB, chest pain ○ Pale skin/lips, cold extremities Pathophysiology: ○ Blood volume: In pregnancy, blood volume (plasma) increases 40-45% , which results in a concomitant hemodilution. Although red blood cell (RBC) mass  increases as well during pregnancy, plasma volume increases more, resulting in a relative anemia ○ Red cell mass: RBC mass increase is driven by an increase in maternal erythropoietin production ○ Hematocrit: It decreases from 38% - 45% in healthy non-pregnant women to about 34% during late single pregnancy and to 30% during late multifetal pregnancy ○ Iron stores: measured by serum ferritin, depleted with each pregnancy. Too soon (non-spaced pregnancy) & too many pregnancies (multiparity) result in higher prevalence of iron deficiency anemia. Iron supplements have less pronounced changes in hemoglobin, as they increase their RBCs in a more proportionate manner than those not taking it. Effects of anemia ○ On pregnancy/mother: Risk factor for UTIs (due to heme buildup in urine), puerperal sepsis Increased bleeding risk; postpartum hemorrhage Subinvolution of uterus (slowing of uterus returning to its pre-pregnancy state) Oxytocin is responsible for the involution of the uterus Endometritis can cause subinvolution Lactation failure Mortality; due to CHF, cerebral anoxia, sepsis, and thromboembolism ○ On fetus/neonate: Higher incidence of abortions, preterm birth, intrauterine growth restriction (IUGR), intrauterine fetal death (IUFD) Low APGAR at birth Increased risk of neonatal anemia (with cognitive & affective dysfunction) Increased risk of neonatal infections Higher perinatal morbidity & mortality Critical periods: ○ From 28-30 weeks GA to early puerperium Types of anemia in pregnancy: Overview Diagnosis Management Iron deficiency Most common type of Hb 11-12 weeks ○ Evaluate for multiple gestations, uterine abnormalities, and pelvic masses i. US in first trimester (early pregnancy) is done to determine chorionicity 2nd trimester:  ○ Fetal biometry: biparietal diameter, head circumference, abdominal circumference, and femur length ○ Placental position ○ Amniotic fluid volume ○ Fetal presentation ○ Structural anomalies by fetal anatomic survey ultrasound (18-24 weeks) 3rd trimester: ○ Only as clinically indicated for growth assessment, fetal position, or amniotic fluid volume Thyroid disease in pregnancy Complications of poorly controlled thyroid disease in pregnancy (requires antenatal testing in the third trimester or sooner with more severe disease): ○ Preterm delivery ○ IUGR & IUGD ○ ↑Risk of fetal heart abnormalities ○ ↑Risk of preeclampsia Management of hyperthyroidism: ○ Propylthiouracil is safe in pregnancy (continued during pregnancy) ○ Methimazole has higher secretions into breast milk but generally considered safe Antenatal fetal assessment Overview The following tests are performed in high-risk pregnancies to assess the risk of neurological injury or antenatal fetal death to prevent perinatal morbidity and mortality. High risk patients Maternal Pregnancy complication Hypertension Preeclampsia Pre-gestational diabetes Decreased fetal movement Insulin required gestational diabetes Oligohydramnios/polyhydramnios Antiphospholipid syndrome IUGR Postterm pregnancy Preterm premature rupture of membranes (pPROM) Complications of antepartum asphyxia (injuries we’re afraid/looking for) 1. Stillbirth (Mortality) 2. Metabolic acidosis at birth 3. Hypoxic renal damage  4. Necrotizing enterocolitis 5. Intracranial hemorrhage 6. Seizures 7. Cerebral palsy Signs of fetal deoxygenation 1. Decreased amniotic fluid volume 2. Decreased fetal movement 3. Late deceleration Outline of Fetal assessment techniques Noninvasive techniques Early pregnancy assessment Late pregnancy assessment 1. FHR 1. Fetal kicks 2. Nuchal translucency 2. NST 3. Fetal movement 3. CST 4. Fetal growth 4. Amniotic fluid volume 5. Biophysical profile 6. Umbilical artery doppler assessment Invasive techniques: ○ Amniocentesis ○ Chorionic villus sampling (CVS) ○ Cordocentesis Rarely/not done anymore: ○ Fetal Lung Maturity Early pregnancy assessment of fetal well-being FHR Fetal heart activity can be detected by ultrasound from week 6 of gestation Auscultation (special stethoscope or Doppler) ~ 12 weeks. Nuchal Timing: 11 weeks - 13 weeks translucency (NT) A screening test which measures the fetal fluid collection behind the neck A thickened NT increases the likelihood for aneuploidy and cardiac disease Fetal movement Timing: 17 weeks - 20 weeks Fetal growth 1. Fundal height: measured from symphysis pubis to the highest part of fundus. Done in the clinic a. Size > dates: suspect large-for-gestational-age fetus  b. Size < dates: suspect small-for-gestational-age fetus 2. Ultrasonography: Using US we measure the following parameters a. Biometry i. Biparietal diameter (BPD) ii. Abdominal Circumference (AC) iii. Femur Length (FL) iv. Head Circumference (HC) b. Amniotic fluid Late pregnancy assessment Fetal well-being assessment Fetal kicks Fetal kick counts assessed by mother; can reduce avoidable stillbirth ○ Timing: 28 weeks in normal pregnancy. 24 weeks in high-risk pregnancy. ○ Posture: lying on her left side. ○ Approach: recognize 10 movements in 1 hr, not felt? → Retest in 1 hour, not felt? → Call the doctor. Arrange for a nonstress test and ultrasonic assessment. Nonstress test First step in assessing fetal well-being (NST) Posture: mother resting in the left lateral supine position. Procedure: using external doppler equipment, a continuous FHR tracing is obtained. Mother should report each fetal movement felt. Effects of fetal movement on FHR are determined. A fetal movement corresponds with an acceleration in FHR of: ○ If 32 weeks: 15 bpm above baseline for at least 15 secs. Reactive NST (normal/healthy activity): ≥ 2 FHR accelerations in a 20-minute interval. ○ Approach: No acceleration after 20 minutes? → proceed for another 20 mins. Non-reactive in 40mins? → proceed for contraction stress test or biophysical profile Nonreactive NST: < 2 FHR accelerations in 20 mins ○ Causes of nonreactive NST: sleeping, immature or sedated fetus; acidotic, compromised fetus Contraction Measures FHR reactivity in response to uterine contractions stress test Contractions are stimulated with oxytocin administration. (CST) Contraindications to test: previous classical uterine incision, previous myomectomy, placenta previa, incompetent cervix, preterm membrane rupture, and preterm labor. Negative CST:  ○ No late decelerations. Fetus can tolerate contraction and doesn’t become hypoxic. Positive CST: ○ Presence of late deceleration. Indicating a hypoxic fetus. ○ Management: prompt delivery. Ultrasound Determines adequacy of amniotic fluid volume exams ○ Amniotic fluid volume is assessed by the Amniotic fluid index (AFI). Important values: Normal: 5-25cm Oligohydramnios: 23cm. Suggests poor control in diabetic pregnancy or can indicate an anomaly Fetal breathing (chest wall movement) ○ Healthy/normal: 30 breathing movements in 10 mins. Fetal movement (stretching and rotational movement) ○ Healthy/normal: 3 body movements in 10 mins. Doppler Used to assess fetal artery vascular resistance. Most common arteries: umbilical artery, velocimetery uterine artery, and middle cerebral artery. Can help predict fetuses at increased risk of poor fetal outcome ○ Umbilical artery systolic/diastolic ratio: ↑vascular placental resistance→ ↓diastolic pressure→ ↑S/D ratio Most valuable in IUGR. ○ Absent / reversed end-diastolic flow predicts worse prenatal outcomes only in IUGR fetuses and it's usually an indicator for delivery Biophysical Assesses 5 parameters over 30 mins. Each parameter is given a score of 2 (yes= 2, no=0). profile  Invasive pregnancy assessment Timing Procedure Indications Complications Chorionic 10–13 weeks Transvaginally by insert Genetic disorders screening Miscarriage villus speculum and take (karyotype) (approximate risk: sampling suction of chorionic villi 1.3%) (CVS) Limb defects Amniocentesis From the AF is extracted under Early pregnancy: Premature rupture 15th week of sonographic guidance via Genetic disorders screening of the membranes pregnancy transabdominal puncture (karyotype) (approximate risk: onwards Late pregnancy: 1%) Determination of bilirubin levels Miscarriage in cases of rhesus (approximate risk: incompatibility 0.5%) Estimation of lung maturity in Infection imminent preterm delivery via Placental abruption lecithin-sphingomyelin ratio Therapeutic: Drainage of excess amniotic fluid in polyhydramnios or amniotic fluid replacement in oligohydramnios Cordocentesis After 17 Fetal blood sampling via Identify the type of fetal Micarriage weeks of ultrasound-guided hemoglobin and assess the Infection gestation transabdominal needle severity of fetal anemia Bleeding insertion into the Diagnose genetic defects in the Bradycardia umbilical cord fetus if amniocentesis, chorionic villus sampling, and/or fetal ultrasound are inconclusive Diagnose fetal infections if amniocentesis is inconclusive Fetal lung maturity Timing: From 32 weeks of gestation Procedure: through amniocentesis then measure L/S ratio. Value determines maturity. Indication: Performed before semi-elective but medically indicated births 160 bpm FHR baseline is 15 bpm for a maximum duration of 3 minutes. Overview of type of FHR changes Etiology Characteristic Acceleration Reactive FHR = OK = Normal Early deceleration Head compression A visually apparent usually symmetrical gradual decrease and return of the FHR associated with a Usually seen in 2nd stage of labor during uterine contraction. head delivery “Mirror image of uterine contraction” Decrease in fetal CTG corresponding to each contraction Late deceleration Fetal hypoxia by Placental insufficiency Deceleration is delayed in timing, with the nadir of causes: IUGR, placental abruption, the deceleration occurring after the peak preeclampsia of the contraction. Decrease in fetal CTG after each contraction Variable Cord compression/prolapse A visually apparent abrupt decrease in FHR then deceleration Causes: IUGR, oligohydramnios, PROM rapid recovery to baseline. Decrease in FHR at different time and shape Mnemonic to memorize types and etiology: FHR Classification Category I Category II Category III FHR normal FHR intermediate FHR abnormal Criteria include all of the following: Include all FHR tracings not Criteria include absent baseline FHR Baseline rate: 110–160 beats/min categorized as category I or III variability and any of the following: Baseline FHR variability: moderate and may represent an Recurrent late decelerations Late or variable decelerations: appreciable Recurrent variable decelerations absent fraction of those encountered Bradycardia Early decelerations: present or in clinical care. Sinusoidal pattern: a pattern of fixed, absent uniform fluctuations of FHR, cycle Accelerations: present or absent frequency: 3.5 \ minute for > 20 minutes. Require immediate delivery. No specific intervention 1) Evaluation & continued In utero resuscitation surveillance 2) In utero resuscitation prepare for delivery 3) Fetal scalp pH (operative vaginal or c-section) 4)Reevaluation & consider change to category I or III. Interpretation of CTG Reassuring fetal status Nonreassuring fetal status A fetal heart tracing shows: Characteristic changes in the fetal heart rate ○ Good beat to beat variability (> 6 bpm) (FHR) in response to fetal hypoxia and ○ > 2 accelerations within a 20 minute metabolic acidosis period ○ Fetal tachycardia (FHR > 160–180/min) ○ No evidence of fetal distress (e.g., fetal ○ Fetal bradycardia (FHR < 110/min) bradycardia, fetal tachycardia, late or ○ Loss of baseline variability variable decelerations, sinusoidal ○ Recurrent variable decelerations pattern) and/or late decelerations Indicates fetal well-being. Requires intrauterine resuscitation and/or immediate delivery Management of abnormal CTG (Non-reassuring fetal status) 1. Repositioning of the mother, administer O2 and possibly fluids a. Positions that reduce cord compression: lateral position (right/left side) to enhance cardiac output to placenta b. 8-10L of O2 facemask to increase delivery of maternal oxygen to the placenta. c. Augment IV fluid volume: IV bolus of normal saline 500 mL to enhance uteroplacental infusion. 2. If initial steps unsuccessful, consider: a. Amnioinfusion: instillation of saline into the amniotic cavity after. Reduces the severity of variable decelerations. b. Reduce uterine activity by giving subcutaneous terbutaline and turn off any IV oxytocin to enhance intervillous placental blood flow.  3. Other: a. Vaginal exam: to rule out prolapsed umbilical cord b. Scalp stimulation c. Delay 2nd stage of labor Fetal pH Intrapartum assessment Postpartum assessment Indication: used in labor if the EFM strip is equivocal. Indication: to confirm fetal Prerequisites: status at delivery. ○ Cervical dilation Procedure: It involves ○ Ruptured membranes obtaining both umbilical cord ○ Adequate descent of the fetal head. venous and arterial samples. Contraindication: suspected fetal blood dyscrasia. Normal fetal pH: ≥7.20 Procedure: A small, shallow fetal scalp incision is made resulting in capillary bleeding. The blood is collected in a heparinized capillary tube and sent to the laboratory for blood gas analysis. Normal fetal pH: ≥7.20 ○ Abnormal pH 4 ∼ 4 hours -Ends: complete cervical dilation hours dilation (10cm) -Cardinal movements of labor Management: occur. -Problem in maternal -Slow but progressive labor in Pelvis → C-section the first stage. -Problem in power of contraction (adequate contractions >= 200 mu in 10 minutes)(in case of maternal heart condition - can't push) → give oxytocin -Problem in fetus (size or position)(fetal intolerance of labor, anomalies/malformation) → 1) Deceleration/bradycardia → C-section 2) Fetal station +2 → vaginal delivery Stage 2 -Begins: complete cervical Descent of Regular uterine contraction and (decent) dilation the fetus, should cervical dilation 10 cm and no ∼ 2 hours + 1 hour with -Ends: delivery of baby be at station 0 descent (no engagement) change in 3 epidural -Maternal pushing efforts are hours. added to uterine contractions Ischial spines can determine that the to descend the baby. fetal head is engaged during vaginal examination.  Management: Depends on fetal location regarding mother’s ischial spine: -Above ischial spine→ C-section -Below ischial spine→ forceps or vacuum Stage 3 -Begins: delivery of baby Delivery of Failure to deliver the placenta within (expulsion) -Ends: delivery of placenta. placenta 30 minutes. ∼ 30 minutes -Signs of placental separation: 1) Gush of blood vaginally Management (can decrease 2) Change of uterus shape from postpartum hemorrhage): long to globular Fundal massage 3) Cord lengthening Gentle cord traction 4) Fundus rises up IV/IM Oxytocin Stage 4 -Not an official stage of labor but rather a critical 2hr period of close observation of the patient (postpartum care) immediately after delivery. ∼ 2 hours -Close observation of the patient: Blood pressure, pulse rate, and uterine blood loss. Pain in labor Stage Pain pathway Pain control method Stage 1 Latent Visceral pain (T10 - L1): IV Opioids: work best in the early first stage (All From uterine contractions and cervical opioids readily cross the placental barrier). Active dilation Epidural: most effective against labor pain Stage 2 Somatic pain transmitted by pudendal Epidural: most effective against labor pain nerve (S2–S4): Pudendal nerve block: relieves perineal pain as From descent of the fetal head and it anesthetizes somatic afferent nerve fibers at subsequent pressure on the pelvic sacral segments S2 to S4. floor, vagina, and perineum Lumbar epidural analgesia is the most common form of neuraxial analgesia, and its use continues to increase nationally. It may be used to provide pain relief for the first and second stages of labor. A pudendal nerve block is usually effective at relieving the perineal pain of the second stage of labor, as well as the pain of episiotomy and episiotomy repair. It does not affect the ongoing pain of uterine contractions.  Obstetric lacerations (imp) Episiotomy Procedure Midline incision of the perineum to enlarge the vaginal opening during delivery, Not routinely performed Timing: crowning of fetal head (second stage of labor) Type of incision: ○ Mediolateral: has less risk of tears. Severe pain and difficult repair. ○ Midline: has increased risk of tears. Easily repaired and has improved healing. Indication Shoulder dystocia Non-reassuring fetal monitor tracing Narrow birth canal Forceps or vacuum-assisted delivery Vaginal breech delivery Complications Vulvar hematoma - severe pain and swelling at site of episiotomy Perineal pain with lacerations Longer return to sexual activity Fecal and flatus incontinence or injury to the rectal mucosa Maternal deaths - complication of labor 1. Bleeding 2. Infection 3. High BP 4. Complications of delivery 5. Unsafe abortions Postpartum Care Postpartum care starts from the delivery of the placenta to 42 days after. (‫اﻟﻧﻔﺎس‬/‫)اﻻرﺑﻌﯾن‬  7Bs of postpartum care 1. Breast vs bottle 2. Bladder 3. Bowel movement 4. Bleeding 5. Bottom (perineum) 6. Blues 7. Birth control Normal postpartum changes: Low‑grade fever, shivering, and leukocytosis are common findings during the first 24 hours postpartum and do not necessarily indicate an infection. Reproductive tract Uterine involution: ○ Mediated by oxytocin ○ Begins immediately after birth and the delivery of the placenta ○ Afterpains: painful cramps from contractions of the uterus following childbirth, managed by analgesic ○ The uterus returns to non-pregnancy in the pelvis by 2 week postpartum, and back to normal size by 6 week postpartum Uterine fundus can be palpable at the 7th day postpartum ○ Endometritis in one of the causes of Un-involuted uterus Lochia: postpartum vaginal discharge. ○ Most women pass lochia for about 4 weeks after delivery; in some cases, this lasts for 6–8 weeks. ○ These are normal and should be differentiated from malodor discharge which might indicate infection. Lochia rubra: blood red; first few days Lochia serosa: brown red; lasts for a few weeks Lochia alba: yellow white; can last up to 6-8 weeks postpartum Vagina & vulva: ○ Painful and sore specially if lacerations occurred during delivery, managed by analgesic ○ Changes in vaginal tone/pelvic floor muscles might never return to the pre-pregnancy state (regardless of mode of delivery) and may cause urinary incontinence, Kegel’s exercise (pelvic muscle exercises) help the recovery phase. Perineum: ○ Perineal pain and discomfort from an episiotomy or perineal lacerations can be minimized in the first 24 hours with ice packs to decrease the inflammatory response edema.  ○ A heat lamp or sitz bath is more helpful after the first day to help mobilize tissue fluids. CVS Approx. 1000 cc’s of blood is lost during delivery Fluid shift from extravascular space to intravascular space leading to significant diuresis in the first 24 hours Normal CVS functions return by 2-3 weeks postpartum Coagulation VTE chances are increased postpartum, thus mothers are encouraged to walk as soon as possible and wear compression stocking System is back to normal balance state by 6-8 week postpartum. Urinary tract All women should urinate 6 hours after delivery/6 hours after catheter removal Kidney Function: GFR will remain increased up to 2-3 weeks postpartum Hypotonic Bladder: ○ Intrapartum bladder trauma can result in increased postvoid residual volumes, If the residuals exceed 250mL, the detrusor muscle can be stimulated to contract with bethanechol (parasympathomimetic) ○ Indwelling foley catheter may need to be placed for a few days. Urinary incontinence: ○ Urine outlet incompetence and loss of urine as a result of rises in bladder pressure due to intra-abdominal pressure (upon coughing/sneezing) ○ 25% of women will have stress urinary incontinence after vaginal delivery. Presents as urinary delivery. Dysuria: may be seen from urethral irritation from frequent intrapartum catheterization. Managed conservatively GIT Constipation: perineal pain → decreased motility. Managed by hydration and stool softeners. Hemorrhoids: prolonged second stage pushing efforts can exaggerate pre-existing hemorrhoids. Managed by hydration and stool softeners. Breast Changes in breast size, nipple and areola Breastfeeding: ○ It is recommended that infants be exclusively breastfed up to the age of 6 months ○ Painful at the beginning but tolerated later one ○ The first few days of breastfeeding is important as it contains large amounts of immunoglobulins. ○ Breastfeeding enhancement: by breastfeeding more (increase in the oxytocin receptors), hydration, good sleep, and herbal medications. Postpartum physiologic Issues Bonding: ○ Impaired maternal infant bonding is seen in the first few days post-delivery. ○ Risk is increased if contact with the baby is limited because of neonatal intensive care, as well as poor social support. ○ Management: psychosocial evaluation and support. Blues ○ Mood swings and tearfulness ○ Normal physical activity continues and care of self and baby is seen. ○ Management: conservative with social support Depression ○ Feelings of despair, sadness, hopelessness & anxiety. Common but frequently delayed up to a month after delivery ○ The patient often does not get out of bed with care of self and baby neglected. ○ Management: psychotherapy and antidepressants. Psychosis ○ Rare. Loss of reality, hallucinations & behavior may be bizarre ○ Develops within first weeks after delivery ○ Management: hospitalization, antipsychotic medication and psychotherapy. Postpartum contraception: Check family planning lec. Breastfeeding: ○ Partially effective ○ Associated with temporary anovulation, A definitive method should be used after three months. ○ Breastfeeding should be exclusive and every 3 hours to be an effective contraception method, and she has to be amenorrheic Diaphragm: fitted after involution of pregnancy changes approx. 6 weeks postpartum IUD: can be started immediately after delivery Progestin only pills: safely used during lactation and can be started immediately after delivery Combination modalities (estrogen & progesterone) ○ Lactating women: Should not be used because of the estrogen effect of diminishing milk production. ○ Non-lactating women: can be started at 3 weeks postpartum to allow reversal of the hypercoagulable state of pregnancy and thus decrease the risk of DVT Postpartum immunization: RhoGAM is administered within 72 hours of delivery if mother is Rh -ve and her baby is Rh +ve Rubella vaccination: given postpartum (if mother is antibody -ve) with pregnancy avoidance for 3 months following vaccination Induction of Labor Overview: Induction: labor is initiated by artificial means after appropriate assessment of mother and fetus Augmentation: artificial stimulation of labor that has begun spontaneously IOL should not be done before 38 weeks gestation because of the possibility of neonatal morbidity (unless it's urgently indicated) Bishop’s Score: Used to assess the likelihood of a successful induction Physical finding Score 0 1 2 3 Cervical position Posterior Mid Anterior - Cervical Firm Medium Soft - consistency Cervical effacement 0-30% 40-50% 60-70% ≥ 80 % Cervical dilation 0 cm 1-2 cm 3-4 cm ≥ 5 cm Fetal head station -3 -2 -1 +1 Score ≥ 8: favorable cervix for vaginal delivery Score ≤ 6: unripe or unfavorable cervix; not ready for vaginal delivery Methods of IOL: Prior to induction of labor: ○ Sweeping of the membranes ○ Cervical ripening Induction of labor: ○ Oxytocin with Amniotomy  ○ PGE2 1. Membrane Sweeping Mechanical Membrane sweeping/stripping: manual separation of the method chorioamnion from the lower uterine segment (Separation of the membranes from the cervix leads to Unfavorable the local release of prostaglandins) cervix 2. Cervical ripening Mechanical Intrauterine foley catheter: placed into the cervix and inflation method of the balloon with 10 cc of saline Hydroscopic dilators: ex. Laminaria tents. Has higher infection rate Pharmacological Prostaglandins: methods Intravaginal PGE2 (dinoprostone, known as cervidil) or PGE1 (misoprostol, known as cytotec). ○ Tablets forms are easier to remove if hyperstimulation occurs ○ Misoprostol should only be used for term fetuses ○ Cytotec can be used in medical abortion, cervical ripening Intracervical PGE2 Side effects: GIT, pyrexia, uterine hyperactivity, uterine atony, PPH Absolute Contraindication: Previous C-section (2 or more) as IOL can result in ruptured uterus 3. Initiation of uterine contractions Oxytocin Pitocin is the synthetic form of oxy The only drug approved for induction and augmentation of labor Favorable Amniotomy Also known as “artificial” rupture of membranes (AROM)  cervix Releases local PG causing cervical ripening and myometrial contractions AROM alone is not recommended Starting oxytocin at the time of amniotomy has been shown to decrease the induction delivery interval, thereby decreasing both fetal and maternal risks of sepsis Consider amniotomy (only if the cervix is partially dilated and completely effaced, and the fetal head is well applied) Indication & contraindications of IOL: Indications Contraindications Maternal Preeclampsia Contracted pelvis Gestational HTN Prior uterine surgery ○ Gestational HTN with Classic CS = vertical incision being superimposed made in the midline of the preeclampsia abdomen (upper segment) Gestational DM Previous classical (longitudinal Heart disease scar) or inverted T uterine incision Renal disease 2 or more C-sections Antiphospholipid syndrome Complete transection of uterus Multiple gestation (myomectomy, reconstruction) Overdistended uterus Previous uterine rupture Active genital herpes Invasive cervical cancer Fetoplacental Postterm pregnancy (term= 40w) Preterm fetus without lung IUGR maturity IUFD Acute fetal distress Abnormal fetal testing (such as: Abnormal presentation (breech) reduced fetal movements) Fetal lie: transverse Rhesus type incompatibility Placenta previa Fetal abnormality Vasa previa PROM Placental abruption Chorioamnionitis Indication of augmentation: Abnormal labor (in the absence of inadequate uterine activity) Prolonged latent phase Prolonged active phase Prerequisites of IOL: Assess each of the following: 1. Indications/contraindications 2. Confirm gestational age 3. Bishop score (cervix favorability) - high score suggests higher success rate of induction 4. Pelvis, fetal size, fetal presentation 5. Membrane status 6. FHR monitoring prior to IOL 7. Elective induction should be avoided (as in social/wishful reason of induction due to potential complication) Risks and possible complications of IOL: Increased rate of operative vaginal deliveries Increased rate of CS (cesarean section) Excessive uterine activity Abnormal fetal heart rate patterns Respiratory distress syndrome Uterine rupture Maternal water intoxication Delivery of preterm infants due to incorrect estimation of GA Cord prolapse with artificial rupture of membranes Meconium fetal aspiration VC: Postterm Pregnancy Definitions: Term pregnancy: > 37 completed weeks’ of GA Late term: 40 - 42 weeks of GA Postterm pregnancy: pregnancy that continues > 42 weeks Estimated date of delivery (EDD) calculated as 40 weeks from 1st day of last menstrual period (LMP) ○ Assumes regular menses, 28-day cycles ○ Assumes no recent oral contraceptive pill (OCP) usage Etiology, causes: 1. Inaccurate estimation of GA- most common cause a. Irregular menses (inconsistent ovulation) b. Recent discontinuation of OCPs c. Poor memory of LMP d. Late or no prenatal care  2. Idiopathic - most common cause in true postdates 3. Anencephaly - Longest pregnancies reported 4. Nulliparity 5. Fetal adrenal hypoplasia 6. Extrauterine pregnancy 7. Maternal obesity 8. Prior postterm delivery Diagnosis: 1. Diagnosis rests on establishment of gestational age > 42 weeks 2. Dating criteria a. LMP alone often unreliable b. Early ultrasound (6-12 weeks) more accurate to establish EDD than later c. Early prenatal care useful in establishing accurate gestational age Complications: Risk of perinatal mortality increases x2-3 folds Maternal risks of post term pregnancy: ○ Obstetric trauma (3rd- and 4th- degree perineal lacerations) ○ Increased rate of cesarean delivery (with attendant risks) Infection Postpartum hemorrhage Thromboembolic event Visceral injury - damage to nearby tissue Fetal risks of post term pregnancy: ○ Stillbirth (intrauterine fetal demise, IUFD) Risk increases after 41 weeks of GA ○ Macrosomia Occurs in 2%-10% of postterm pregnancies Defined as an abnormally large infant (>4,500 g) Associated with shoulder dystocia/birth injury, operative vaginal delivery, cesarean delivery ○ Postmaturity syndrome Associated with an aging placenta Complicated 10-20% of postterm pregnancies Typical features: loss of subcutaneous fat (long/thin body) long fingernails Dry, peeling, wrinkled skin  Abundant hair ○ Shoulder dystocia Increased ~20-fold if macrosomia Impaction of anterior shoulder behind pubic symphysis “turtle sign” Brachial plexus injury ○ Meconium aspiration syndrome. Can lead to: Low apgar score Green amniotic fluid Severe respiratory distress due to small and large airway obstruction Chemical pneumonitis ○ Oligohydramnios Amniotic fluid index (AFI) 42 weeks. 2. Favorableness of the cervix (Bishop score; 5 parameters): Assess the likelihood of successful induction of labor by assessing cervical dilatation, effacement, position, consistency and station. Patients can be classified into three groups: Date: sure Date: sure Date: unsure Cervix: favorable Cervix: unfavorable Induce labor with IV oxytocin and Cervical ripening (PGE2 Vaginal Await spontaneous labor with NST artificial rupture of membranes. pessaries) followed by IV oxytocin and AFI performed twice weekly OR await labor with NST and AFI Immediate delivery in case of fetal jeopardy (oligohydramnios or FHR decelerations) Notes from video-case: Accurate measurement of GA and EDD US measurement should be used in EDD  Membrane sweeping is associated with decreased risk of late term and post term pregnancies Antepartum fetal surveillance at 41 weeks due to risk of IUFD Induction of labor between 41 and 42 weeks Vaginal bleeding in first trimester OB/GYN DDx: Non-viable intrauterine pregnancy: ○ Spontaneous abortion (threatened, inevitable, incomplete, complete) ○ Molar pregnancy Viable intrauterine pregnancy: ○ Physiologic implantation bleeding ○ Subchorionic hemorrhage Ectopic pregnancy ○ Rupture ectopic pregnancy ○ Unruptured ectopic pregnancy Trauma (post-coital or after pelvic exam) Genital lesion (e.g. cervical polyp, neoplasms) History Questions to ask: ○ Tissue passage Physical exam Investigations Laboratory studies: ○ Serial 48 hr β-hCG level (useful in diagnosis) ○ CBC ○ group and screen U/S (confirm intrauterine pregnancy and fetal viability) Treatment IV resuscitation for hemorrhagic shock  treat the underlying cause VC: Spontaneous Abortion Definitions: Loss of pregnancy before 20 weeks' gestation 80% occur in the 1st 12 weeks Recurrent pregnancy loss: 2 or more miscarriages occuring before 20 weeks’s gestation Still birth: loss of pregnancy after 20 weeks’ gestation Etiology/Risk factors: Maternal Cervical insufficiency/incompetence: most common cause in 2nd trimester abortions ○ Risk factors: Hx of preterm birth/mid semester pregnancy loss, short cervical length, Previous obstetric or gynecological trauma (e.g., termination of pregnancy, rapid delivery, multiple gestations, or cervical cone biopsy) ○ Management: cerclage Thrombophilias e.g. Antiphospholipid syndrome: 1st trimester abortions ○ Other systemic diseases: uncontrolled diabetes mellitus, hyperthyroidism, hypothyroidism, genetic disorders, infections Septate uterus, uterine leiomyomas, uterine adhesions Fetoplacental Chromosomal abnormalities: most common cause of miscarriage in the 1st trimester Congenital anomalies Anembryonic pregnancy Miscellaneous Hx of spontaneous abortion Smoking Trauma Iatrogenic: amniocentesis, chorionic villus sampling or IUD Environmental Unknown Diagnosis/Approach: Doppler US: Absence of fetal cardiac activity should raise suspicion of spontaneous abortion  Pelvic examination: confirm that the source of bleeding is uterine. ○ Molar and ectopic pregnancy should be ruled out in all pts with early pregnancy bleeding Transvaginal ultrasound: best imaging test once there is absence of fetal cardiac activity or confirmed uterine bleeding. Findings consistent with a spontaneous abortion include: ○ Absence of fetal cardiac motion ○ Abnormalities of the yolk sac or gestational sac A downtrending β -hCG is consistent with a failed pregnancy. Hysterosalpingogram: most useful investigations in >3 consecutive 2nd trimester abortions Types: Definition Findings Threatened An abortion process that has not progressed to a state Vaginal bleeding (mild) ± cramping from which recovery is impossible (potentially Fetal activity reversible). Pregnancy is complicated by vaginal Closed cervical os bleeding before 20 weeks, in absence of other Mild pain explanation. Intact gestational sac Inevitable Vaginal bleeding and cervical dilation without Vaginal bleeding (heavy with clots) + expulsion of products of conception (POC) cramping Typically followed by partial or complete passage of No history of passage of tissue POC Fetal activity may be present. Dilated cervical os Incomplete Passage of some but not all POC Vaginal bleeding + cramping Usually occurs > 12 weeks' gestation Products of conception within the cervical canal or uterus Dilated cervical os Complete Complete passage of all POC Vaginal bleeding (heavy) Usually occurs < 12 weeks' gestation Products of conception completely Pregnancy symptoms abate & pregnancy test outside of the uterus becomes -ve Closed cervical os Severe pain that stops after a while Missed Death of a fetus without expulsion of any POC No bleeding, no pain No expulsion of the products of conception No fetal activity Closed cervical os Septic Uterine infection at any stage of pregnancy Fever, chills Complication of a missed, inevitable, or incomplete Lower abdominal discomfort abortion, in which retained products of conception Foul vaginal discharge become infected Cervical tenderness Management Threatened abortion Expectant management (Observe and reassure) +/- Rhogam depending on patient’s blood type and screen Inevitable, incomplete, Depends mostly on patient preference. or missed abortion 1. Expectant management 2. Medical evacuation: a. Misoprostol (PGE1) i. Give vaginally ONLY IF SHE IS NOT BLEEDING b. Mifepristone (progesterone antagonist); given to terminate pregnancy 3. Surgical evacuation (D&C): in septic abortion or heavy bleeding or significant maternal disease 4. +/- Rhogam depending on patient’s blood type and screen Complete abortion No management is needed +/- Rhogam depending on patient’s blood type and screen Septic abortion 1. Broad spectrum antibiotics 2. D&C 3. +/- Rhogam depending on patient’s blood type and screen 4. Misoprostol after 24hr Complications: Hemorrhage Endometritis  Retained products of conception result in release of thromboplastin into systemic circulation → disseminated intravascular coagulation VC: Ectopic Pregnancy Overview Definition: a pregnancy in which the fertilized egg attaches in a location other than the uterine endometrium It is one of the leading cause of maternal morbidity and mortality Incidence: 1% of all pregnancies Most common location: ○ Fallopian tube (∼95% of cases); most commonly in the distal ampulla (∼70% of cases) > isthmic > fimbrial ○ Ovary (∼3% ) ○ Abdomen (∼1%) ○ Cervix ( 1,500–2,000 mIU/mL; it is level at which an IUP is typically visible on ultrasound iii. Serial β-hCG measurements (every 48 hours): helps in differentiating intrauterine from ectopic pregnancies. 1. In an intrauterine pregnancy; β-hCG levels are expected to rise by a certain percentage based on the initial level after 48 hours. 2. Serial β-hCG measurements are often markedly reduced in ectopic pregnancy compared to IUP at the same gestational age b. CBC c. Blood type and screen 2. Imaging studies: a. Transvaginal ultrasound (TVUS): best initial imaging i. Can detect IUP as early as 1 week gestation; seen clearly by 5 weeks gestation ii. IUP should be visible if β-hCG > 1,500 mIU/mL b. Transabdominal ultrasound (TAUS) i. Difficult to diagnose ectopic pregnancy ii. Cannot detect IUP until 6 weeks gestation iii. β-hCG threshold is 6,500 mIU/mL c. US findings in ectopic pregnancy: i. No intrauterine pregnancy ii. Pseudosac iii. Thickened endothelium iv. Adnexal mass (Enlarged tube) v. Collection of fluid in pouch of Douglas (Blood)  3. Exploratory laparoscopy: indicated in unstable patients suspected of having an ectopic pregnancy or in pregnancy of unknown location if the location is still uncertain after 7–10 days Management Unruptured Ectopic Pregnancy Ruptured Ectopic Pregnancy Medical therapy: methotrexate 1. Stabilize the patient (ABC’s) Surgical therapy: contraindication of 2. Surgical intervention: usually laparotomy with methotrexate salpingectomy Expectant management Follow up Unruptured Ectopic Pregnancy 1. Medical: medication of choice is methotrexate a. MOA: inhibits folate-dependent steps in DNA synthesis. It's a folic acid antagonist. b. Indications: i. Mass size < 3.5 cm ii. No fetal heartbeat iii. β-hCG level < 6,000 mIU/mL iv. No history of folic supplementation c. Contraindications: i. Breastfeeding ii. Ruptured ectopic pregnancy iii. β-hCG level > 6,000 mIU/mL iv. Clinically unstable patient v. Hematological, hepatic, or renal dysfunction vi. Active lung disease (ex. Severe asthma) vii. Inability to comply with β-hCG follow up testing viii. Fetal cardiac activity (viability) ix. Heterotopic pregnancy with coexisting viable intrauterine pregnancy 2. Surgical: a. Indication: i. Contraindications for MTX ii. Unsuccessful medical treatment b. Approach: laparoscopy c. Procedure: salpingostomy, salpingectomy, segmental resection  i. Heterotopic pregnancy is defined as the presence of multiple gestations, with one being present in the uterine cavity and the other outside the uterus. In case of twin pregnancy where one is IUP and another is in the fallopian tube, Tx is laparoscopic salpingostomy of the ectopic pregnancy 3. Expectant management a. Asymptomatic patients with very low β-hCG levels may experience spontaneous resolution of ectopic pregnancy without medical or surgical treatment. 4. Follow up: patients treated with MTX or salpingostomy should be followed up by β-hCG titers until it non-detectable, to ensure complete destruction of ectopic trophoblastic villi Supportive care: Provide for all patients regardless of management approach. Anti-D immunoglobulin for Rh-negative mothers who present with bleeding Pain management Prenatal and contraceptive counseling once treatment is complete DDx Approach & management of ectopic pregnancy (Kaplan & toronto notes)  VC: Antepartum Hemorrhage Pain Additional symptoms Risk factors Diagnostics Treatment Placental Mild to Continuous vaginal HTN US, NST Vaginal delivery or abruption moderate bleeding Trauma C-section abdominal Hypertonic Cocaine/smoking depending on pain contractions patient status Uterine tenderness Fetal distress Placenta Painless Bright red vaginal Multiparity US placenta C-section previa bleeding Multiple gestation previa, possible Advanced maternal transverse lie age Vasa Painless Vaginal bleeding (fetal Velamentous cord Rupture of C-section previa blood) insertion to placenta membranes, Fetal distress bleeding Fetal bradycardia Uterine Severe Sudden pause in Previous C-section Fetal stress Emergent rupture abdominal contractions Use of oxytocin Loss of C-section pain Fetal distress contractions & Vaginal bleeding station Hemodynamic instability Placental Abruption Definition Separation of a normally implanted placenta (upper uterine segment) from the uterine wall before delivery of the fetus. Most common cause of late-trimester bleeding and coagulopathy (mostly DIC) in pregnancy Classification Complete: entire placenta separates from uterine wall Partial: part of placenta separates from uterine wall Marginal: separation limited to edges of the placenta  Etiology/Risk Hx of placental abruption: strongest risk factor, risk of recurrent abruption is 10% factors after 1 abruption and 25% after 2 abruptions Chronic hypertension: Eclampsia/pre-eclampsia Maternal abdominal blunt trauma Cocaine and smoking Abdominal trauma: car accidents, fall, iatrogenic (e.g., post amniocentesis) PROM Multiple gestations Clinical features Occurs most often in the third trimester Classical presentation: painful vaginal bleeding + abdominal/back pain ± fetal distress ± DIC ○ Fetal monitor, depending on the severity of abruption, may show tachycardia/bradycardia, decreased variability, mild/severe late decelerations, and possibly even death. ○ Fetal presentation is mainly normal ○ In ∼ 20% of cases, the hemorrhage is mainly retroplacental; vaginal bleeding does not occur. Only signs of hypovolemic shock are evident. Ultrasound visualization of a retroplacental hematoma may be seen Diagnosis A clinical diagnosis. Based on the presence of painful vaginal bleeding in association with uterine tenderness, hyperactivity, and increased tone. Ultrasound: ○ Initial exam that helps exclude placenta previa. May detect 2% of abruptions ○ Possible retroplacental hematoma Digital/vaginal exam is contraindicated, may worsen bleeding Management General approach: Same principle is applied to all causes of antepartum hemorrhage! Hemodynamic control and correct coagulopathy if necessary  Confirm normal placental implantation with sonogram and replace blood loss with crystalloid and blood products as needed. RhD prophylaxis in RhD negative mothers Specific approach: Stable mother and fetus 24-34 weeks: remote from term, ○ Fetal lung maturity induction with corticosteroids minimal/decreased ○ If necessary, tocolysis bleeding ○ Aim for a normal delivery Contractions subside 34-36 weeks: Conservative in-hospital observation Controlled heavy Vaginal delivery bleeding or pregnancy Perform amniotomy and induce labor >37 weeks (All pregnancies are Place external monitors to assess fetal heart rate delivered if acute patterns and contractions abruption occurs after Avoid cesarean delivery if the fetus is dead 36th weeks) In maternal/fetal Emergency cesarean delivery is performed as soon as the jeopardy mother is stabilized. Complications Hemorrhagic/hypovolemic shock DIC ○ Presentation: hematuria, hematemesis, oozing of blood from surgical wounds or IV lines, petechiae ↑ aPTT, ↑ PT, ↑ D-dimer, ↓ Coagulation factors, ↓ Fibrinogen, ↓ Platelet count ○ Management: correction of coagulopathy, fresh frozen plasma & cryoprecipitate PPH Acute tubular necrosis. Presentation: anuria, hematuria, flank pain. Couvelaire uterus: ○ Retroplacental hemorrhage may extend through the uterus into the peritoneum. ○ The myometrium is weakened, with possible subsequent uterine rupture during contractions. Fetal demise  Placenta Previa Definition Presence of the placenta in the lower uterine segment; partial or full obstruction of the neck of the uterus with high risk of hemorrhage (rupture of placental vessels) and birth complications. Placenta previa=placenta first (first thing within uterine cavity) Classification Placenta previa: ○ Complete: completely covering the internal os ○ Partial: partially covering the internal os Low-lying placenta: placenta lies less than 2 cm from the internal cervical os Etiology/Risk Prior uterine scarring/ surgery including Cesarean delivery D&C, myomectomy factors Maternal age > 35 years Multiparity Previous curettage Previous placenta previa Clinical features Sudden, painless, bright red vaginal bleeding Usually occurs during the 3rd trimester (before rupture of the membranes), stops spontaneously after 1–2 hours, and recurs during birth Soft, nontender uterus Usually no fetal distress Diagnosis Transvaginal ultrasound Digital vaginal examinations is contraindicated Management Asymptomatic patients (with early detection ∼18–20 weeks): Monitor placental placement ○ Follow up transvaginal ultrasound at 32 weeks for placental localization 37 weeks: immediate CS Lower segment cesarean delivery is almost always preferred Complications Placenta accreta, increta & percreta (summarized in PPH lecture) Abruption vs previa Vasa Previa Definition Fetal vessels are located in the membranes near the internal os of the cervix Etiology/Risk Placental anomalies, such as: factors ○ Velamentous umbilical cord insertion ○ Succenturiate placenta Multiparity Clinical features Painless vaginal bleeding (blood is fetal in origin) immediately after rupture of membranes Fetal distress (e.g., tachy to bradyarrhythmia in a sinusoidal pattern) Fetal death can occur quickly through exsanguination or asphyxiation Diagnosis Transabdominal or transvaginal ultrasound with color Doppler Sinusoidal rhythm tracing Management Scheduled cesarean delivery If bleeding or fetal distress: emergency cesarean delivery Complications Antepartum hemorrhage, Fetal death  Uterine Rupture Etiology/Risk Uterine scar/prior uterine surgery (e.g., C-section or myomectomy) factors Traumatic rupture Uterine distention (e.g. Grand multipara) Clinical features Severe abdominal pain Previous uterine incision Light to moderate vaginal bleeding Fetal distress, bradycardia Sudden pause in contractions Light to moderate vaginal bleeding Hemodynamic instability (as a result of abdominal bleeding) Change of fetal lie/ station Palpable fetal parts through the rupture Management Immediate laparotomy with emergency C‑section Complications Maternal hemorrhage & shock DIC. Presentation: hematuria, hematemesis, oozing of blood from surgical wounds or IV lines, petechiae Fetal distress & possible death VC: Postpartum Hemorrhage Definition Blood loss ≥ 500mL after vaginal delivery OR Blood loss ≥ 1000 mL after C-section Primary PPH: blood loss ≤ 24 hours postpartum (more common; 99% of cases) Secondary PPH: blood loss from 24 hours to 12 weeks postpartum Massive PPH: Loss of 30-40% of maternal blood (generally about 2L) Additional criteria for PPH (all of which suggest significant blood loss since measuring precise amount of blood is hard): ○ Decrease ≥10% of hematocrit from baseline ○ Changes in mother’s HR, BP & O2 saturation Etiology PPH is one of the top 3 causes of maternal mortality in both high & low income countries  Primary PPH Secondary PPH Uterine atony (80%) Retained products of conception Laceration (15%) Infection Retained placenta (5%) Inherited coagulation defect Uterine inversion Abnormal placentation DIC (leading to retained placenta) Subinvolution of the placenta site Mnemonic for causes of PPH: 4 T’s Tone - Uterine atony, uterine inversion Tissue - Retained parts, Accreta spectrum Trauma - Vaginal/cervical lacerations/contusions Thrombin - DIC, inherited coagulopathies, medications Overview Primary PPH Risk factors /etiology Clinical features Diagnostics Treatment Uterine Hx of PPH Profuse vaginal Bimanual pelvic Prevention/treatment in low resource atony Prolonged/rapid labor bleeding examination: settings: (most common) Soft, enlarged, boggy Palpable uterus Active management of the third (80% of PPH) Multiparity (≥5) ascending uterus (feels above umbilicus (it stage of labor: Bimanual uterine Overdistention of the like dough) failed to contract massage, gentle cord traction & uterus: Multiple down) IV/IM oxytocin gestations (twins), Treatment: Macrosomia, Drain the bladder Polyhydramnios Medical therapy: Exhausted ○ IM methergine. CI: myometrium: prolonged Hypertension oxytocin use ○ IM hemabate. CI: Asthma Chorioamnionitis ○ IV oxytocin Asian/Hispanic ○ Rectal misoprostol Uterine leiomyomas Surgical procedures: Medication: ○ Uterine balloon tamponade or anesthetics, MgSO4 packing Full bladder ○ B lynch suture ○ Uterine artery ligation/embolization ○ Hysterectomy Laceration Uncontrolled vaginal Identifiable laceration Based on clinical Surgical repair (birth canal delivery (most common) or tear in features injury) Difficult delivery: cervix/vagina/perineum macrosomia (15% of PPH) Operative vaginal Well contracted & delivery (commonly Palpated uterus instrumental; vacuum or forceps) Retained Prior history of retained Missing placental -Based on clinical Manual removal of placenta placenta placenta cotyledons in the features Uterine curettage under US (5% of PPH) Accessory/succinate presence of contracted -Bimanual pelvic guidance (to make sure it’s not placental lobe (most uterus (placenta examination: accreta) common) delivered in pieces) inspection of the Can cause Placenta previa placenta and fetal 2ndry PPH Placenta accreta membranes spectrum Uterine Myometrial weakness Beefy vaginal bleeding Based on clinical Uterine relaxants→ Uterine reposition inversion (most common) Failure to palpate features followed by IV oxytocin Hx of uterine inversion uterus abdominally Uncontrolled cord Protruded mass traction and/or excessive (inverted uterus) from fundal pressure during cervix/vagina the third stage of labor DIC Placental abruption Bleeding from IV sites DIC labs. Findings Removal of pregnancy tissue from Severe preeclampsia Laceration in the that raise suspicion: the uterus Amniotic fluid presence of contracted -Thrombocytopenia Selective blood-product replacement embolism uterus -↑ D-dimer Fresh frozen plasma & Prolonged retention of -↑ PT and aPTT cryoprecipitate dead fetus (IUFD) -↓ Fibrinogen ICU support Unexplained No cause can be found despite persistent bleeding Perform laparotomy and bilateral ligation of: uterine & internal iliac arteries Last resort = Hysterectomy. Secondary PPH Abnormal placentation Risk factors /etiology Clinical features Diagnostics Treatment Placenta Hx of uterine surgery Abnormal uterine Antenatal US: Disruption D&C is only rarely accreta Hx of CS bleeding of the junction between attempted in accreta Placenta previa Postpartum hemorrhage the bladder wall and Cesarean hysterectomy: (attached to myometrium) Multiparity at the time of attempted uterine serosa mode of delivery and manual separation of the Loss of clear space treatment for placenta Placenta placenta behind the placenta accreta spectrum increta (Uterine-preserving measures are relatively (invaded contraindicated in placenta myometrium)  Placenta accreta spectrum due to percreta high maternal mortality!) (penetrated myometrium+se rosa) Prevention: Active management of the third stage of labor: delivery of the placenta which involves the following component ○ Uterotonic agents (IV/IM oxytocin) ○ Controlled umbilical cord traction External compression of the uterus and bimanual uterine massage General management: Monitoring of vital signs and foley catheter to empty bladder and monitor urine output Oxygenation Management Active management of third stage of labor: Oxytocin uterine fundal massage Hemorrhage control: ABCs, call for help IV line access: 2 large bore IVs, run crystalloids wide open CBC, coagulation profile, fibrinogen, cross and type packed RBCs Give uterotonic agents: IV oxytocin (with or without IM methergine), IM carboprost, Rectal misoprostol Treat underlying cause: DIC? Transfuse fresh frozen plasma and packed RBCs Unexplained or severe bleeding? ○ Uterine balloon tamponade or packing ○ Ligation of uterine or internal iliac arteries ○ Last resort = hysterectomy Approach to Primary PPH (Online MedEd): VC: Abnormal Uterine Bleeding Definition: Menstrual bleeding that is abnormal and/or irregular in frequency, duration, and/or intensity Terminology for abnormal uterine bleeding Polymenorrhea: Abnormally frequent menses at intervals of less than 24 days Menorrhagia (hypermenorrhea): Excessive and/or prolonged menses (>80 mL and >7 days) occurring at normal intervals Metrorrhagia: Irregular episodes of uterine bleeding Menometrorrhagia: Heavy and irregular uterine bleeding Dysfunctional uterine bleeding: Bleeding caused by ovulatory dysfunction Classification/Etiology of AUB: PALM - COEIN PALM - COEIN Classification Structural Polyps Presents with infertility and/or heavy painless menstrual causes bleeding or intermenstrual bleeding Uterus is typically not enlarged, normal pelvic exam (PE)  Adenomyosis Presents with heavy menstrual bleeding Diffuse enlarged boggy/soft uterus on PE Leiomyomas Presents with heavy menstrual bleeding or intermenstrual (fibroids) bleeding, dysmenorrhea Irregular enlarged firm uterus on PE Malignancy Non-structural Coagulopathy Von Willebrand disease is the most common hereditary causes coagulation abnormality ○ Presents with menorrhagia, postpartum or postoperative bleeding easy bruising epistaxis or family history of bleeding symptoms Ovulatory Formerly known as dysfunctional uterine bleeding (DUB) dysfunction Anovulatory or oligo ovulatory bleeding. The most common cause of AUB in adolescence is anovulatory bleeding Ovulatory dysfunction is also the cause of AUB in peri-menopausal women secondary to declining ovarian function. Characteristics: ○ Hormonal imbalance ○ Irregular, unpredictable bleeding without cramping ○ Cervical mucus will be clear, thin, and watery, reflecting the estrogen dominant environment. ○ Absence of progesterone will result in: no Basal-body temperature (BBT) mid cycle rise, proliferative endometrium on endometrial biopsy Causes: ○ PCOS: Most common causes of ovulatory dysfunction in reproductive age ○ Hypo and hyperthyroidism ○ Hyperprolactinemia ○ Adrenal disorders Endometrial Iatrogenic Anticoagulants, steroid, NSAID’s, tamoxifen, IU