Summary table

PHYSIOLOGICAL CHANGES IN PREGNANCY

Early pregnancy
Volume homeostasis
- in eraly pregnancy,
developing fetus,
corpus luteum and
placenta produce &
release increasing
quantities of
hromones, growth
factors & other
substances in
maternal circulation
- most pregnant
women report sx of
pregnancy by end of
6th weeks after last
LMP
Maternal adaptation
to pregnancy
1) increased avail of
precursors for
hormone production
& fetal-placental
metabolism
- dietary intake
- endocrine changes
2) improved
transport capacity
- increased CO
- increased transport
of subs to placenta &
fetal waste products
for disposal (10-12
weeks)
- disposal through
peripheral
vasodilatation,
increase in
ventilation & renal
filtration

1) blood volume
xpansion
- maternal blood vol
expands during
pregnancy to allow
adequate perfusion
- anticipate blood
loss during delivery
- starts at 6-8 weeks
and plateau at 32-34
POG
- most marked
expansions occurs in
ECF esp circulating
plasma vol (8-10kg
weight gain)
- TBW from 6.5-8.5L
2) physiological
anaemia (larger
increase of plasma
vol relative to
erythrocyte vol)
3) fluid retention
- changes in osmoreg
& RAAS in active
sodium reabsorption
in renal tubules &
water retention
- increased conc of
ANP,
natriuretichormones,
atrial natriuretic
peptide &
progesterone
- plasma osmolality
decreases about 10
mOSMol/kg
- decrease in thirst
threshold
-decreased plasma
osmotic pressure &
oncotic pressure

CVS
- elevation of
diaphragm.adjustme
nt of lung vol &
increased minute
ventilation =
breathlessness
- edema in xtremities
d/t fluid retention +
venous compression
- decreased venous
return to heart =
light-headedness &
syncope
- palpitations (sinus
tachycardia)
- premature atrial &
vent ectopic beats
- increased
peripheral pulse
- MAP & JVP
unchanged
- increased CO as 5
weeks POG from 4.5L
to 8.4L in 2nd stage of
labour d/t increased
HR
- increased SV
- decrased DBP in
antenatal =
increased PP
- 70% reduction in
peripheral resistance
by 8 weeks POG

Maternal brain &

senses
1) maternal brain
- problem with
attention, conc &
memory in
pregnancy and early
postpartum d/t lack
of estrogen &
increased oxytocin
- sedative
progesterone effect
- require less LA in
both epidural &
intrathecal
- greater tolerance
for pain
2) senses
- olfactory sensitivity
decreases in 3rd
trimester & persists
after delivery
- decreased odour
threshold in 3rd
trimester
- corneal sensitivity
decreasesand return
to normal by 8 weeks
postpartum
- intolerant to
contact lenses
- decrease in
intraocular pressure
- changes in visual
fields d/t increase
size of pituitary
gland compressing
optic chiasm

- increase in GFR

Blood
Hemostasis &
coagulation
- maternal Hb
- hypercoagulable
decreases,
state, returns to normal
discrepancy 1000around 4 weeks after
1500ml inplasma
delivery
while erythrocyte
- factor 7,8,9 and 12 +
280ml + transfer of
fibrinogen(50%)
iron stores to fetus
increased during
- mean Hb from 13.9 = pregnancy
10.9g/dl
- VWF factor increased
- decreased
- protein S activity
haematocrit
decrease while
- require increased
increase in activated
amounts of iron
protein C resistance
(absorption of dietary
- maternal D-dimer
iron from gut)
increase progressively
- renal clearance of
from conception to
folic acid increases
delivery (cannot use to
substantially during
check VTE)
normal pregnancy and
plasma folate conc fall Increased in fibrinolytic
- platelet count stable
system activation to
but maybe lower in
counterbalance coag
some pt due to
factors
increased aggregation - endothelial-derived
PAI-1 increases in late
Haematology

Airway

Respiratory tract
Ventilation

- neck,
oropharyngeal
tissues, breasts &
chest wall are all
affected by
weight gain
during pregnancy
- breast
engorgerment +
airway edema =
difficult
visualization of
larynx during
tracheal
intubation
- vascularity of
respi tract
increases
- nasal mucosa is
edematous &
prone to bleeding
= congestion &
rhinitis

- increases
significantly around 8
weeks POG d/t
progesterone-related
sensitization of respi
center to CO2 &
increased metabolic
rate
-diaphragm is
elevated 4cm by
enlarging uterus
- lower ribcage
circumference
expands by 5cm
- increased relaxin =
ligaments of ribcarge
to relax = increased
ribcage subcostal
angle
- increase in
pulmonary blood flow
in pregnancy
- increased tidal
volume + RR =
increase in minute

pregnancy
- PAI-2 increases
- plasminogen
increased, 2antiplasmin decreased
Increase in procoag is
relevant at delivery =
placental separation
- at term, around
500ml of blood flows
through placental bed
every minute
- myometrial
contractions compress
BV supplying placental
bed
- fibrin deposition over
placental site

Biochemistry
1) decrased albumin
- decrased plasma
oncotic pressure
- affects peak plasma
conc of protein-bound
drugs
- serum creatinine,
uric acid & urea conc
are reduced
- ALP increased d/t
production of placental
ALP
- ALT & AST decreased
- rise in serum LDH
after delivery is d/t
involuting uterus &
hemolysis from RBC in
hemostasis of
placental bed
Immune response
- 30% of women develop Ig-G Ab against
inherited paternal HLA of fetus
- lack of maternal immune reactivity to fetus is
d/t reduced CD8 & downreg of T cells
- +WBC increased up to 14x109/L in 3rd
trimester d/t increase of PMN
- NK cells increase in early pregnancy and
decrease in late gestation

ventilation = SOB
- 10-25% decrease in
FRC and further
reduced in supine
position but not
affect interpretation
of FEv1 and PEFR
Oxygenation
- increase in 2,3diphosphoglycera
te within
maternal
erythrocytes =
shift O2-Hb
dissociation curve
to right =
increases avail of
oxygen within
tissues
- oxygen
consumption
increases by
about 45ml/min
(increase 20%)
- increased 02
consumption +
decreased FRC =
hypoxemia &
hypocapnia
during respi
depression &
apnea

Factors contributing to flui

ANTENATAL CARE
Confirmation & dating of
pregnancy

Booking visit
Booking investigations

Arterial gases
- progesterone has
respi stimulant
properties=
increased alveolar
ventilation & tidal vol
- marked decrase in
pCO2 & slight
increase in pO2
- reduced pCO2
affects CA enzyme
that converts
carbonic acid to
bicarb to H ions to
restore pH =
prevents alkalosis
- renal excretion of
bicarb increases
significantly

Confirmation of pregnancy
- sx of pregnancy (breast
tenderness, nausea,
amenorrhea, urinary
frequency and +ve UPT)
- fetal heart with Doppler at
12 weeks POG
Dating the pregnancy
1) Menstrual EDD
- if menstrual cycle is 28
days
- ovulation on day 14 of
pregnancy
- accurate LMP
2) Ultrasound dating
- more accurate if there is
irregularity about LMP
- ideal = 10-14 weeks
- benefits : accurate dating
with irregular menstrual
cycles, reduced IOL for
prolonged pregnancy,
maximize potential for serum
screening, early detection for
multiple pregnancies
- CRL used up until 13+6, HC
from 14-20 weeks
Booking history &
examination
Booking history
- PMH, past obstetrics, past
gynaecological
- familyhistory & social
factors
- age & racial origin
Booking examination
- full PE at booking visit with
CVS & respi examination,
pelvic & breast
- lous heart sounds & flow
murmurs d/t hyperdynamic
circulation
- recent immigrants should
have full chest & cardiac
exam

FBC
- anaemia & thrombocytopenia
- repeated at 28 weeks POG
Blood group & red cell Abs
- cross-matching blood (GSH)
- rhesus D negative be offered anti-D at 28 weeks POG/divide
at 28 weeks & 34 weeks POG
Urinalysis
- midstream urine sample to detect asx bacteriuria = reduce
chance to develop PN
Rubella
- certical transmission = serious congenital anomalies esp in
1st trimester
- if rubella non-immune, immunize after pregnancy and
avoid next pregnancy after 3 months
Hep B
- Hep B S antigen = previous immunization or infection
- Hep B E antigen = recent infection
- vertical transmission to fetus
- horizontal transmission = bodily fluids
- babies give active immunization
HIV
- anti-retroviral agents, elective c-sec & avoid BF to reduce
vertical transmission (30%=1%)
- screening : high risk patients, recent immigrants from
central Africa
Syphillis
- vertical transmission : prevent by Abs and screening
Hb studies
- prenatal genetic testing include CVS/amniocentesis
- screening : Eastern Meditteranean, Inida, West Indies,
South-East Asia & Middle East
- if high risk/MCV low, formal lab screening with liquid
chromatography
Other investigations
- cervical smears on indication

- must have : BP, abdominal

exam to record size of
uterus, ab scars, BMI, urine
dip testing

Screening for fetal

abn
1) Downs sx
- nuchal translucency
scan at 11-14 weeks
POG
- biochemical blood
tests at 15-20 weeks
2) NTD
- maternal serum fetoprotein at 15-20
weeks
- structural screening
at 18-20 weeks
3) structural
congenital abn
- U/S at 18-20+6
weeks

Screening for clinical conditions later in

pregnancy
Gestational diabetes
Pre-eclampsia &
preterm
- all women should
Pre-eclampsia
be assessed at
- every antenatal
booking for risk
visit for BP &
factors
urinalysis for protein
- if risk factors
- extra antenatal visit
present = 2-hour
for women with risk
OGTT at 24-28 weeks factors of pre- previous history of
eclampsia (booking
GDM = OGTT at 16history & exam, rise
18 weeks
in BP, proteinuria, sx
- if normal, repeat at
of pre-eclampsia)
24-28 weeks
Fetal well-being
Pre-term labour
- SFH from 25 weeks
- bacterial swabs,
- if fetal growth slow, cervical length scans
do U/S
- fetal heart sounds

ANTENATAL IMAGING AND ASSESSMENT OF FETAL WELL-BEING

Clinical applications of U/S
Diagnosis &
Determination of GA &
Multiple pregnancy
confirmation of
assessment of fetal size
viability in early
& growth
pregnancy
- gestational sac as
- CRL is used up
- to determine
early as 4-5 weeks
until13+6
chorionicity
POG and yolk sac at
- HC from 14-20 weeks
- dichorionic twin
5 weeks
- BPD & FL
pregnancies in first
- embryo can be
- latter part pregnancy,
trimester of
observed at 5-6
AC & HC assess size &
pregnancy have

Follow-up
- primipraous women
have 2 more routine
checks than
multiparous d/t
increased risk of preeclampsia
- maternal BP, urine
at every visit
- SFH from 25 week
- fetal presentation &
engagement from
36weeks
- maternal weight is
no longer recorded
routinely after first
booking
- anti-D either at
28wks (single dose)
or divided (28/34
wks)

Fetal well-being

- evaluate fetal
movements, tone &
breathing in BPP
- Doppler : placental
f(x) & identify
evidence of blood

weeks
- visible heartbeat : 6
weeks
- TVS :
incomplete/missed
miscarriage (blighted
ovum where no fetus
is present), ectopic
pregnancy (+ve UPT,
no gestation sac
within uterus,
adnexal mass
with/without fetal
pole, fluid in pouch of
Douglas)
Diagnosis of fetal
abn
- can be diagnosed at
20 weeks
- examples : spina
bifida &
hydrocephalus
- 1st trimester U/S
soft markers for
chromosomal abn :
absence of fetal
nasal bone,
increased fetal
nuchal translucency
for Downs sx
Other uses of U/S
- intrauterine
death
- fetal presentation
- uterine & pelvic
abn eg
fibromyomata &
ovarian cyst
- guide for invasive
procedures
(amniocentesis,
CVS,
cordocentesis,
shunts)

growth of fetus
- EFW =
AC+HC+BPD=FL
- high risk of FGR =
growth pattern
(symmetrical &
asymmetrical)
- asymmetrical = FGR
- brain-sparing = large
HC:AC
- Diabetic : large AC:HC
- cessation of growth :
placental failure
- GA cannot be
accurately calculated
>20 weeks because of
wider range pf AC & HC
Placental localization
- localization of site of
placenta & identify
lower edge to exclude
placenta previa
- can be seen with TVS
- at 20 weeks scan, it is
must to identify women
with low-lying placenta

Scanning schedule
- 10-14 weeks, 1821 weeks
- early scan :
determine GA<
nuchal translucency
- 18-21 weeks :
structural
anomalies
- after >21 weeks :
concern about fetal
well being

thicker inter-twin
separating
membrane
(septum) with very
thin amnion while
monochorionic
have thin inter-twin
membrane
- appearance of
septum : tongue of
placental tissue
within base of
dichorionic
membrane (twin
peak/lambda), 9-10
weeks
- management of
twin pregnancies
which maybe
difficult on ab
palpation : growth
restriction, placenta
previa, TTT sx

flow redistribution
in fetus (hypoxia)

Amniotic fluid vol

- fetus swallows
amniotic fluid,
absorbs in gut &
excretes in amniotic
sac
- impaired
swallowing :
anencephaly,
esophageal atresia
- impaired excretion
: renal agenesis,
post urethral valves
- FGR is a/w
reduced amniotic
fluid d/t reduced
renal perfusion =
reduced urine
output

Cervical length
- 50% who deliver <34 weeks will have
short cervix.
- length of cervix can be checked by TVS

- influence of
congenital abn with
amniotic fluid vol
- reduction in
amniotic fluid vol =
oligohydramnios
- excess =
polyhydramnios
- max vertical pool
+ AFI index

AFI
Max vertical pool
- <2cm =
oligohydramnios
- >8cm = polyhdramnios
AFI
- dividing uterus into 4
ultrasound quadrants
- vertical measurement is
taken of the deepest cord
free pool
- in third trimester should
be between 10& 25 cm
- <5cm oligo, >25cm poly

Cardiotopograph
Baseline fetal heart
rate
- normal fetal heart
rate at term is 110150bpm
- higher rates are
defined as fetal tachy
& lower = brady
- baseline fetal heart
rate falls with
advancing gestational
age as result of
maturing fetal
parasymphatetic tone
- prior to term 160bpm
is upper limit of
normal
- tachy =
maternal/fetal
infection, acute fetal
hypoxia, fetal
anaemia, drugs

Baseline variability

Fetal heart rate acc

- short-term variability
(interbal between
successive heart beats)
can only be measured
with computer-assisted
analysis
- long-term
variability/baseline
variability can be
measured between 2 &
6 times per minute
- refelects fetal
autonomic system
- abnormal when <10
- modified by fetal
sleep, opiods, fetal
hypoxia, fetal infection

- increases in
baseline fetal heart
rate of at least
15bpm, lasting at
least 15 seconds
- 2/more in 20-30
minuute CTG
reactive trace
- positive signs of
fetal health

Biophysical profile
Umbilical artery

- long(30 minute) U/S

scan which observes
fetal behavior,
amniotic fluid vol &
CTG
- score of 0,2/4 is
abnormal, 8/10
normal
- score of 6 is
equivocal and repeat
within reasonable
hours to exclude
fetal sleep
- time consuming
and does not
increase long-term
survival d/t severe
hypoxia

- provide information on
placental resistance to
blood flow
- indirect placenta
health and function
- high diastolic
component indicates
low downstream
resistance and implies
high perfusion
- normally, diastolic
flow in umbilical artery
increases throughout
gestation
- absent/reversed EDF
in umbilical artery =
fetal distress, IUD

Doppler ultrasound
Fetal vessels

- centralization of
flow =
redistribution of
blood flow to
protect brain, heart
& adrenal glands +
vasoconstriction
- absent diastolic
flow in fetal aorta
implies fetal
academia
- measurement of
velocity of MCA is
indicator of fetal
anaemia (peak
systolic velocity
increases) : Rhesus
disease, TTT sx in
donor

Fetal heart rate

delerations
- transcient
reduction of
15bpm or more,
lasting for 15 sec
- fetal
hypoxia/umbilical
cord compression
- hypoxia :
decelerations+red
uced
variability/baselin
e tachycardia

Prediction of
adverse pregnancy
outcome
- pre-eclampsia :
incomplete
physiological
invasion of spiral
arteries by
trophoblast =
resultant increase in
uteroplacental
vascular resistance
- evidence of
association
between highresistance
waveform patterns
& adverse
outcomes (preeclamspia, FGR &
placental
abruption). 60-70%
at 20-24 weeks with

bilat uterine
notches
Summary of aims of obstetric U/S
Early pregnancy scan 20 week scan (18-22
(11-14 weeks)
weeks)
- confirm fetal
- accurate estimation of
viability
GA if early scan has not
- accurate estimation
been performed
of GA
- carry out detailed fetal
- multiple gestation
anatomical survery to
esp chorionicity
detect any fetal structural
- identify markers
abn/markers for
that would indicate
chromosome abn
risk of fetal
- locate placenta and
choromosome abn eg identify 5% of low-lying
Downs
placenta, repeat at 34
- identify fetuses with weeks
gross structural abn
- estimate amniotic fluid
volume

MRI
Third trimester
- assess fetal
growth
- assess fetal
well-being

- reflect
composition of
tissue &
characterization
- fetal MRI :
multiplanar views,
fetal brain, mode of
delivery & airway
mx at birth

PRENATAL DIAGNOSIS (identification of disease prior to birth)

Why is it performed?
Attributes of
Classification
Pre-test counseling
screening test
- family history (genetic
- relevance &
- invasive
- consition suspected &
disease + known
important
- non-invasive
severity of disease
Option if positive - history is correct
recurrence risk
- affects
test
- past obstetric history
management
- test is available
- continue
(RhD alloimmunization
- sensitive/high
- what sample? How it
pregnancy
- serum screening tests
detection rate
processed?
influencing
(trisomy 21)
- specificity
- accurate assessment
decision to
- U/S screening (anomaly - predictive value
of risk
scan)
- affordability/cost- terminate
- acceptability
pregnancy
effective
- is it ethical?
- equity/avail to all - terminate
pregnancy
Non-invasive tests
Invasive tests
Care after invasive testing
1) Ultrasound
- amniocentesis &
- accurate labeling of sample
- scanning for structural
CVS are two most
- prompt & secure transport of sample to
fetal abn eg NTD,
common to check
app lab
gastrochisis, cystic
for karyotype of
- documentation & procedure, any
adenomatoid
fetus, or to look
complications
malformation of lung,
single gene
- communication with referring clinician
renal abn
disorders
- avoid strenuous exercise for next 24
hours
2) free fetal DNA in cases
- maybe exp mild ab pain, take PCM
of alloimmunization or
- if has any bleeding, not relieved by PCM,

determine sex of fetus in

X-linked disorders
3) fetal RNA for
aneuploidy pregnancies
from maternal blood

Gestation age
Miscarriage risk
Detailed

CVS/CVB
11 weeks
+2%
- fetal trophoblast
cells in mesenchyme
villi divide rapidly in
first trimester
- CVB take sample of
these cells from
developing placenta
- procedure : needle
into abdominal wall
by ultrasound
guidance into
placenta/fine
catheter/biopsy
forceps through
cervix into placenta
- miscarriage = 2%
- placental
mosaicism = 1%
Prior scan
- confirm pregnancy
is viable prior
procedure
- single pregnancy
- confirm GA (cannot
be done <10 weeks)
- localize placenta &
determine if
transab/transcervical

seek medical advice

- appropriate contact numbers
- process for givibg results should be
agreed
- if woman is RhD negative, give AntiD +
Kleihauer test >20 weeks
- plan of ongoing care after results

Amniocentesis
15 weeks
+1%
- amniotic fluid
contain
amniocytes &
fibroblasts shed
from fetal
membranes, skin
& fetal
genitourinary tract
- amniocentesis
takes sample (1520ml) of amniotic
fluidby passing
needle under cont
direct U/S control
through ab wall
into amniotic
cavity & aspirating
the fluid
- initial U/S is
performed prior to
procedure
- can check for
viral infections eg
CMV & biochemical
test eg fetoprotein &
spectrophotometri
c for hemolytic
disease
- adv: can be
performed earlier
in pregnancy
- diadv : a/w higher
risk of miscarriage

Cordocentesis
20 weeks
+2-5%
- when fetalblood is
needed/full culture of
karyotype needed
- diagnostic prenatal
test to check fetal
platelet count when
alloimmune
thrombocytopenia is
suspected
- a needle is passed by
U/S guidance into
umbilical cord cord at
points it inserts the
placenta (fixed)
- from 20 weeks
- risk of miscarriage
varies with indication &
position of placenta

Downs sx
- most common
eason for performing
invasive testing
- follows after high
risk prenatal
screening
- combined test
between 11 & 14
weeks, combination
of U/S to measure
nuchal translucency
scan + beta-HcG &
PAPP-A in maternal
blood
- accuracy of
screening tests for
Downs can be
refined by measuring
fetal nasal bone,
frontomax nasal
angle & presence
fortricuspid
regurgitation +
ductus venosus wave
form

NTD
- U/S : abnormal
head shape, bananashaped cerebellum,
type identified at
lumbar region,
bilateral talipes
- problems later :
mobility to use
wheelchair as they
got older,
continenece &
voiding, low IQ,
repeated surgery,
psychological
- recurrence = 5%

Gastrochisis
- U/S : irregular
mass from ant ab
wall at level of
umbilicus tp one
side of umbilical
cord
- maybe small,
oligo
- in later
pregnancy, fetal
bowel may dilate &
become thick
walled
- following
delivery, baby
need operation to
repair defect

Exomphalos a/w T18

- initaial U/S diagnosis
followed with CVB
- U/S : smooth
protrusion on ant ab
wall
- covered by membrane
and umbilical cord
inserted into apex of
protrusion
- diagnosis cannot be
made <12 weeks d/t
physiological hernia of
ab contents into
umbilical cord
-

ANTENATAL OBSTETRIC COMPLICATIONS

Minor complications of pregnancy
Musculoskeletal problems
Backache
Symphysis pubis dysfunction Carpal tunnel syndrome
- extremely common d/t
- excruciatingly painful
- compression neuropathies
-- hormone-induced laxity of
condition
d/t increased soft-tissue
lig
- most common in 3rd
swelling
-- shifting in centre of gravity trimester
- median nerve, when it
as uterus grows
- symphysis pubis joint
passess through fibrous
-- add weight gain
becomes loose, causing 2
canal at wrist before entering
halves of pelvis to rub on one hand, is most susceptible to
- cause exxagerrated lumbar another during
compression
lordosis
walking/moving
- sx : numbness, tingling &
- exercebate sx of prolapsed
- condition improves after
weakness of thumb and
intervetbral disc = complete
delivery
forefinger, severe pain at
immobility
- mx : simple analgesia
night
- advice : maintenance of
- low stability belt
- mx : simple analgesia,
correct posture, avoid lifting
splint, surgery (rarely
heavy object, avoid high
performed in pregnancy)
heels, regular physio, simple
analgesia

Constipation
- combination of
hormonal &
mechanical factprs
that slow gut motility
- administration of
iron tablets may
worsen the condition
- reassurance + highfiber diet
- medications are
bets avoided unless
necessary

Gastrointestinal symptoms
Hyperemesis
Gastroesophageal
gravidarum
reflux
- severe, intractable
- altered structure &
form of nausea &
function of
vomiting
physiological barriers
- causes imbalanes
to reflux d/t weight of
of electrolytes,
uterus & relaxation
distrubes nutritional
of esophageal
intake & metabolism, sphincter
physical &
- lifestyle
psychological
modifications eg
debilitation
smoking cessation,
- adverse pregnancy
frequent light meals
outcome : preterm
& lying with head
birth, LBW babies
propped up at night
- a/w high beta-HCG,
- medicationsin
estrogen & thyroxine stepwise fashion eg
- severe cases :
simple antacids,
malnutrition & vit
histamine-2 receptor
def, Wernickes
antagonist, PPI
encephalopathy,
- also check for
esophageal trauma,
severe refractory
Mallory-Weiss tears
dyspeptic symptoms
- tx : fluid
replacement &
thiamine
supplementation,
antiemetics

Hemorrhoids
- effects of
circulating
progesterone on
vasculature, pressure
of sup rectal veins by
grabid uterus &
increased circulating
volume
- conversative
approach eg LA/antiirritant creams and
high-fiber diet
- check if there is any
tenesmus, mucus,
blood mixed with
stool & back passage
discomfort

Varicose veins

Edema

- maybe first time or pre-existing

- relaxant effect of progesterone on
vascular smooth muscle and
dependent venous stasis caused by
wiight of
pregnant uterus on IVC
- varicose veins on legs may ne sx
imporved with support stockings,
avoidance of standing for prolonged
periods and simple analgesia
- thrombophlebitis may occur in large
varicose vein more commonly after
delivery
- large superficial varicose vein may

- 80% of all pregnancies

- generalized soft tissue swelling
& increased capp permeability
which allows intravascular fluid
to leak into extravascular
compartment
- fingers, toes & ankles are
usually worst affected and sx
aggravated by hot weather
- best dealt withby frequent
periods of rest with leg elevation
- support stockings are indicated
-maybe feature of preeclampsia, check for womans

Other
common
minor
disorders
- itching
- urinary
incontinenece
- nose bleeds
- thrush (vag
candidiasis)
- headache
- fainting
- breast
soreness
- yiredness
- altered taste
sensation
- insomnia

bleed profusely if traumatized, leg

must be elevated & direct pressure
applied
- vulval & vaginal varicosities are
uncommon but sx troublesome
Problems d/t abn of
pelvic organs
Fibroids
(leiomyomata)
- compact masses of
SM that lie in cavity
of uterus
(submucous), within
uterine muscle
(intramural), outside
surface of uterus
(subseruos)
-may enlarge in
pregnancy, present
problems later in
pregnancy/at
delivery
- fibroid at cervix or
in LUS may prevent
descent of
presenting part &
obstruct vag
delivery
- red degenerations
is one of most
common cx of
fibroids inpregnancy
= grows =
ischaemic (acute
pain, tenderness
over fibroid,
frequent vomiting)
- if sx are severe,
uterine contractions
maybe precipitated
=
miscarriage/preterm
labour
- DDX of red
degeneration : acute
appendicitis, PN/UTI,
ovarian cyst

BP & urine protein

- may also suggest underlying
cardiac impairment/nephrotic sx

Retroversion of
Congenital uterine
uterus
abn
- 15% women have
- shape of uterus is
retroverted uterus
embryologically
will normally flip
determined by
out of pelvis and
fusion of Mullerisn
begin to fill in ab
ducts
cavity
- abn of these fusion
- in small proportion
give rise to
of cases, uterus
subseptate uterus
remains in
through bicornuate
retroversion and
uterus/double uterus
eventually fills up
with 2 cervices
entire pelvic cavity
- indicental finding
& base of bladder &
during
urethra are
laproscopy/U/S
stretched
- retention of urine,
Probs with
classically at 12-14
bicornuate uterus:
weeks
- miscarriage
- painful, may cause
- preterm labour
long-term bladder
- PPROM
damge if bladeder
- abn of lie & psn
becomes over- higher C-sec
distended
- catheterization is
essential until
position of uterus
has changed
Cervical cancer
- difficult to visualize at colposcopy and
biopsy may cause considerable bleeding
- vaginal bleeding esppostcoital
- exam: friable/ulcerated lesion with
bleeding & purulent discharge

- leg cramps
- straie
gravidarum &
cholasma

Ovarian cyst in
pregnancy
- incidence of
malignancy is
uncommon in
childnearinga age
- most common
types of pathological
ovarian cyst =
serous, benign
teratoma
- corpus luteal cysts
may grow to several
cm but rarely
requires tx
-large cysts eg
dermoid cysts may
require surgery in
pregnancy
- surgery is usually
postponed until late
2nd/early 3rd
trimester (potential
if baby delivered, it
would be safe)
midline/paramedian
incision, low
transverse
suprapubic wouldnot
allow access to
ovary, it is drawn
upwards in later
pregnancy
- major prob :
uterine torsion,
hemorrhage/rupture,
causing rupture & ab
pain = pain &
inflammation =

accident, placental
abruption
- subserous
pedunculated fibroid
may tort in same
way that large
ovarian cyst can
(acute ab pain,
tenderness)
- Ix : pertinent
history +U/S scan
UTI
Predisposing factor
- history of recurrent cystitis
- renal tract abn: duplex
system, scarred kidneys,
ureteric damage & stones
- diabetes
- bladder emptying problems
eg sclerosis
Symptoms in pregnancy
- low back pain
- general malaise + flu-like
sx
- exam : tachycardia,
pyrexia, dehydration, loin
tenderness
Investigations
- FBC
- midstream urine specimen
for urgent microscopy,
culture & sensitivities
Management
- if strong clinical suspicion,
start Abs immediately
- drink plenty of fluids
- take PCM
Common organism
- E.coli, Streptococci,
proteus, Pseudomonas,
Kliebsiella. If more than 105
at culture = UTI

miscarriage/preterm
labour
- full assessment
must include family
history of
ovarian/breast
cancer, detailed U/S
of ovaries

Pyelonephritis
- dehydration, very high
temp, systemic disturbance
& shock
- urgent & aggressive
treatment
Substance abuse in pregnancy
Drugs
Smoking
- tobacco : FGR
- smoking acutely reduces
- alcohol : fetal alcohol sx
placental perfusion
- opaitaes : preterm-labour,
- overall perinatal mortality
neonatal withdrawal syndrome
increased, babies are smaller at
- cocaine & derivative : placental
delivery
abruption, FGR, preterm labour
- higher risk of antepartum
hemorrhage
Problems a/w drug addicts
- social probs
- co-existing with alcohol &
smoking
- malnutrition esp iron, vit B & C
- viral infections eg HIV, HepB
Amniotic fluid abnormalities
Oligohydramnios
Polyhydramnios
- AFI <5th centeile for gestation
- AFI >95th centile for gestation
- maybe suspected following cldar fluid leaking
- CF : ab swelling & discomfort, abdomen
from vagina, may represent PPROM
tense & tenser, fetal parts maybe hard to
- on ab palpation, fetalpoles maybe obviously
palpate
felt & hard
- principle of mx : etsblish cause, relieve
- cx : pulmonary hypoplasia & limb deformities
discomfort of mother & assess risk of
eg contractures, talipes, renal agenesis, bilat
preterm labour (measurement of cervical
multicystic kidneys
length)
Causes oligo
Diagnosed by
Causes of poly
Renal agenesis
U/S : no renal tissue ,
Maternal
Placental
no bladder
- diabetes
- chorioangioma
- arterio-venous
fistula
Multicyctic kidneys
U/S : enlarged kidneys
Fetal
with multiple cysts, no
- multiple gestation esp TTX sx
visible bladder
- idiopathic
Urinary tract
U/S : urinary tract
- esophageal fistula/trachea-esophaegal
abn/obstruction
dilatation
fistula
FGR & placental
- clinical : reduced SFH,
- duodenal atresia
insufficiency
refuced FM, abn CTG
- neuromuscular fetal condition
- U/S : FGR, abn fetal
(preventing swallowing
Doppler
- anencephaly
NSAIDS
Withholding NSAIDS,
Alcohol
- >100g/week have
been related to FGR
- maasive doses
>2g/kg of body
weight (17
drinks/day) is a/w
FAS (30-33%)

PPROM

causing amniotic fluids

to re-acc
Speculum : pooling of
amniotic fluid on
posterior blade

Fetal malpresentation at term (presentation that is not cephalic)

Breech presentation
Types of breech
Predisposing factors
Antenatal mx of
for breech
breech psn
presentation
- extended (flank)
Maternal
- if clinicaaly
breech
- fibroids
suspected at/or 36
- flexed (complete)
- congenital uterine
weeks, should be
breech)
abn, bicornuate
confirmed by U/S
- footling breech
uterus
scan (fetal biometry,
- uterine surgery
amniotic fluid vol,
placental site,
Fetal/placental
position of fetal legs
- multiple gestation
- 3 options : ECV,
- prematurity
assisted vag
- placenta previa
delivery, elective c- abn eg
sec
anencephaly,
hydrocephalus
- fetal neuromuscular
condition
- oligo/poly

ECV
- performed after 37 weeks by exp
obstetrician at/near delivery facilities

Other fetal malpsn

- transverse lie
occurs when fetal
long axis lie
perpendicular to that
of maternal long axis
= shoulder psn
- oblique lie occurs
when long axis of
fetal body crosses
long axis of maternal
body at angle of 45
degree
- potential risk of
cord prolapse &
PROM
- diagnosis by ab
palpation :
asymmetrical
abdomen, SFH less
than expected
andpalpation of fetal
head/buttocks in iliac
fossa, pelvic brim
empty

Vaginal breech delivery

Prerequisities for vag Management of
breech delivery
labour

- should be performed with tocolytics eg

nifedipine
- woman is laid flat with left lateral tilt and
ensure she has emptied her bladder and
comfortable
- with U/S guidance, breech is elevated
frompelvis and one hand is used to
manipulate this upward in direction of
forward role, while other hand applies gentle
pressure to flex the fetal head and bring it
down to maternal pelvis
- procedure can be midly uncomfortable for
mother and should not last more than 10
minutes
- fetal heart trace must be performed before
and after procedure and it is important to
administer anti-D if woman is Rh ve
- if it fails/contraindicated, choose other
option
CI of ECV
Risks of ECV
- fetal abn
- placental abruption
(hydropcephalus)
- PROM
- placenta previa
- cord accident
- oligo/poly
- transplacental
- history of APH
hemorrhage
-previous C- fetal brady
sec/myomectomy
scar on uterus
- multiple gestation
- pre-eclampsia/HTN
- plan to deliver by Csec anyway

Feto-maternal
- psn should be
either extended or
flexed
- no evidence of CPD
and EFW <3.5kg
- no evidence of
hyperextension of
fetal head & fetal
abn that would
preclude safe vag
delivery

- fetal well-being &

progress of labour
should be carefully
monitored
- epidural analgesia
is not essential but
advantegous
- FBS from buttocks
provides accurate
assessment of acidbase status
- experience operator
in delivering breech
babies

Technique (hands-off tech)

Delivery of buttocks
Delivery of legs &
- full dilatation and
lower body
descent of breech
- if legs are flexed,
- when buttocks have they will deliver spon
become visible and
- if extended, they
begin to distend the
may need to be
perineum,
delivered by Pinards
preparations for
maneuver
dlivery are made
- use finger to flex
- buttocks will lie in
leg at knee and then
ant-post diameter
extend to hip, first
- once ant buttocks is ant then post
delivered and anus is - with contractions &
seen over fourchette, maternal effort,
episiotomy will be
lower body will be
cut
delivered
- a loop of cord is
drawn down to
ensure that it is not
too short
Delivery of shoulders Delivery of head
- baby will be lying
- Mauriceau-SMelliewith shoulders in
Veit manuvre
transverse diameter
- baby lies on obss
of pelvic mid-cavity
arm with downward
- as ant shoulder
traction being
rotates into ant-post
leveled on head via
diameter,
finger in mouth and

spine/scapula will be
visible
- a finger gently
placed above
shoulder will help to
deliver the arm
- as post
arm/shoulder
reaches pelvic floor,
it too will rotate ant
(in opp direction)
- once spine
becomes visible
delivery of second
arm will follow
- Lovesets maneuver

one on each maxilla

- delivery occurs first
downward and then
upward
- if it is difficult,
forceps need to be
applies
- assistant holds
babys body while
foceps are applied in
usual manner

TWINS AND HIGHER

MULTIPLE
GESTATIONS
(two/more fetuses)
Risk factors

OPRATIVE INTERVENTION IN OBSTETRICS

EPISIOTOMY (incision thorugh perineum made
childbirth)
TECHNIQUE
COMPLICATIONS
- episiotomy is
- hemorrhage
performed in 2nd
- infection
stage
- extension to anal
- if there is not good sphincter
epidural, perineum
- dyspareunia
should be infiltrated Perineal trauma
Definitions
with LA
- 1st = lacerations of
- if an effective
skin/vag epit
epidural anesthetic
- 2nd= pernieal
in place, it should
mucles, episiotomies
be topped up for
- 3rd = anal sphincter
delivery with
complex
patient upright to
3i : <50% external
get best coverage
anal sphincter
of perineal area
3ii : >50% ext anal
- incision can be
sphincter
midline or at an
angle from posterior 3iii : internal anal
sphincter (complete
end of vulva

to enlarge diameter of vulval outlet and assist

PERINEAL REPAIR
- ensure adequate analgesia (topping up
epidural/by infiltration with LA)
- place pad high up in vagina to prevent blood
from uterus from obscuring the view
- check extent of cuts & lacerations
- first, repair vagina mucosa using rapidly
absorbed suture material on latge, round
body needle
- start above apex of cut/tear and use cont
stitch to close vaginal mucosa
- interrupted sutures are then placed to close
muscle layer
- closure of skin follows. Interrupted sutures
can be used, but cont subcuticular stitch
produces more comfortable results
- perform gentle VE to check for any missed
tears or inappropriate apposition of anatomy
- remove pad that was placed at top of vagina
and check that no swabs have been left in

- mediolat :
posterior part of
fourchette, move
backwards and turn
medially well before
border of anal
sphincter, so that
any extension will
miss the sphincter

OPERATIVE VAGINAL
DELIVERY (delivery of
baby vaginally using
instrument for
assistance)
Indications
Maternal
- maternal distress,
exhaustion/undue
prolongation of 2nd
stage of labour
(>2hours primi, >1
hour multi)
- aortic valve disease
with significant
outflow obstruction
- myasthenia gravis
Fetal
- malpositions of
fetal head (O-T/O-P)
- presumed fetal
compromise
- reduced fetal
weight but
controversial d/t dev
of intracranial hx
Contraindications

disruption of ext
sphincter)
- 4th = extending into
rectal mucosa
Risk factors
- larger infants
- prolonged labour
- instrumental
delivery

Prerequisities for any

instrumental delivery
- confirmed rupture
of membranes
- cervix must be fully
dilated (except 2nd
twin )
- vertex psn with
identification of
position
- O-T/O-P, no part of
fetal head should be
palpable
abdominally. For O-P,
1/5th of head maybe
palpable
- presenting part
should be +1 or
more below ischial
spine
- adequate
analgesia/anesthesia
- empty bladder/no

vagina
- finally, put a finger to check in rectum to
check that no sutures have passed through
rectal mucosa and sphincter is intact
- lactulose & bulk agent eg Fybogel are
recommended for 5-10 days,
antibiotics(broad-spectrum) to cover possible
anaerobic contamination eg metrodinazole,
adequate oral analgesia
- at 6-12 months, full evaluation of degree of
sx with careful questioning with regard fecal
& urinary sx
- sx women should be offered investigation
including endoanal ultrasound & manometry

Delivery failure

Instrument choice

- inadeqyate initial
case assessment =
high head,
misdiagnosis of
position & attitude of
fetal head
- failure d/t traction
in wrong plane
- poor maternal effort
with inadequate use
of Syntocinon to aid
expulsive effort in 2nd
stage
- failure to select
correct ventousecup
type/incorrect cup
position

Ventouse compared
to forceps is
significant more
likely to:
- fail to achieve vag
delivery
- a/w
cephalohaematoma
(subperiosteal bleed)
- a/w retinal hx
- a/w maternal
worries about baby

Evaluation

Less likely to be a/w:

- use of maternal
RA/GA
- significant maternal
perineal & vaginal
trauma
- severe perineal
pain at 24 hours

- gestations less than

35 weeks d/t
cephalohaematoma
& intracranial hx
- face/breech psn
- before full dilatation
of cervix

obstruction below
Pelvic exam
fetal head
- contracted pelvis
(contracted pelvis,
(c-sect)
pelvic kidney,
- shape of subpubic
ovarian cyst)
arch, curve of sacral
- knowledgeable &
hollow, presence of
exp operator with
flat/prominent ischial
adequate
spine
preparation
- shape of pelvis (x
- adequately &
rotational forceps)
informed and
consented patient
Analgesia
Complications
- greater for forceps than vacuum
Maternal
- rotational forceps : RA
- maternal death with
- rigid cup ventouse: pudendal block
vaccumm d/t cervical tears in
with perineal infiltration
women delievered before full
- soft cup ventouse : minimal
dilatation
analgesia
- traumatic vag delivery =
Positioning
fecal incontinence in wimen
- patient in lithotomy position
- PPH (syntocinon infision
-aseptic technique
post delivery, prompt
-angle of traction needed causes foot suturing, careful
of bed be removed
identification of high tears)
- symphysis pubis dysf(x) : limit
- underestimation of blood
abduction of thigh
loss (measure through swabs
- bladder emptied
& towels)
Fetal
- cephalohaemtoma
- severe intracranial injuries
Ventouse/vacuum
extractors

Forceps

Equally likely to be
a/w:
- delivery by C-sect
- low 5 min Apgar
scores
- anal sphincter
injury teice as
common with forceps
delivery
Clinical risk mx
Common allegations
against practitioners
are cited in lawsuits
include :
- inadequate
indication
- failure to exclude
CPD
- improper use of
instruments with
excessive use of
force resulting in
maternal/fetal injury
-lack of informed
i=consent
- inadequate
supervision