ObsNGyn - High Risk Pregnancy Comprehensive

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com
HYPERTENSIVE DISORDERS OF PREGNANCY [TYPES]
Definition of HTN in pregnancy:
o B P > = 1 4 0 / 9 0 m m H g o n 2 o c c a s i o n s at l e a s t 4 h o u r a p a r t
o K o r o t k o f f s ou n d 5 t h a t i s d i sa p p e a r a n c e o f t h is s o u n d i s c o n s i d e r e d a s
Diastolic blood pressure
• T y p e s o f H TN i n pr e g n a n c y :
o A n y w om a n w h o is fo u n d t o h av e a h i g h
B P af t e r 2 0 w e e k s o f g e s t a t i o n & t h e n h e r
B P c om e s t o n o r m a l w i t h i n 1 2 w e e k s
p o s t p a r t u m i s s ai d t o h a v e G e s t a t i o n a l
hypertension
o T h e r e a r e 5 0% c h an c e s t h a t t h is
g e s t a t i o n a l H T N w il l d e v e l o p i n t o p r e -
eclampsia
• P r e - e c l a m p s i a = H T N wi t h p r o t e i n u r ia & / o r e n d o r g a n c h a n g e s
o E n d o r g a n c h a ng e s
- P l a t e l e t c o u n t < 1 la c / m m 3
- S e r u m c r e a t i n i n e > 1 . 1 m g /d l
- L i v e r t r a n s am i n a s es > 2 t im e s t h e u p pe r l i m i t o f n o r m a l
- C l i n i c a l e v i d e n c e of p u lm o n a r y e d em a
- C e r e b r a l o r v is u a l c h a n g e s l ik e h e a d ac h e , b l u r r i n g o f v isi o n o r
scotoma
• S e v e r e P r e - e c l a m ps i a :
o W h e n BP i s > = 1 6 0/ 1 1 0 m m H g o r t h e r e a r e a n y e n d o r ga n c h a n g e s
o D e g r e e o f p r o t e i n ur i a n o l o n g e r c o r r e l a t e s w i t h s e v e r i t y o f p r e -
eclampsia
o O l i g u r i a & IU G R [ In t r a u t e r i n e g r o w t h r e t a r d a t i o n ] d o n ot c o r r e l a t e s
w i t h s ev e r i t y of p re - e c l a m p s i a
• C h r o n i c H y p e r t e n s io n :
o C h r o n i c H T N →H T N
▪ Before pregnancy
▪ T h a t a ri s e s < 2 0 w ee k s o f g es t a t i o n
▪ F a i l s t o b e c om e n o rm a l 1 2 w e e k s p o s t pa r t u m
o C h r o n i c H T N w i t h su p e r i m p o s e d P r e - e c l a m p s ia →
▪ N e w o n s e t p r o t e i n ur i a a f t e r 2 0 w e e k s
▪ U n c o n t r o l l e d B P aft e r 2 0 w e e ks
▪ E n d o r g a n c h a ng e s a f t e r 2 0 w e e k s
High Risk Pregnancy P a g e 1 | 50

• Delta HTN →
▪ S u d d e n ri s e i n m e an a r t e r i a l p r e ss u r e d u r i ng l as t f ew [ 2 - 3 ]
m o n t h s of p r e g n a n cy b u t s t i l l BP i s i n n o r m a l r a ng e
▪ F r e q u e n t f o l l o w u p & w a t c h t h e p a t i e nt
PATHOPHYSIOLOGY & PREDICTION OF PRE-ECLAMPSIA
• Pathophysiology → culprit is Placenta/ chorionic villi

o B u t i n P r e - e c l a m ps ia v as c u l a r
r e m o d e l i n g of s p i r al a r t e r i o l e s i s
defective, there is incomplete
t r o p h o b l a s t i n v a s i on o f s p i r a l
a r t e r i e s . A s a r es ul t t h e s p i r a l
a r t e r i e s r e m ai n n a rr o w → P l a c e n t a l
i s c h e m ia → R e l e a s e o f i n f l am m a t o r y
m e d i a t o r s l i k e T NF α , I L s →
E n d o t h e l i a l d a m ag e [ c e n t e r p i e c e o f pat h o l o g y ] c a n l e a d to →
▪ V a s o s p a sm & i s c h em i c s e q u e l a e
▪ L e a k y c a p i l l a r i e s → c o n t r i b u t i ng t o p at h o l o g i c a l e d e m a du e
AfraTafreeh.com
to leakage of proteins & water in the extravascular
intercellular space
▪ T h r o m b o t i c s e q u e l ae →
• T h r o m b o c y t o p e n i a d u e t o c o n s um p t i o n o f p l a t e l e t s
• M i c r o a n g i o p a t h i c he m o l y t i c a n em i a
• DIC
• V a s o s p a sm & Is c h e m i c S e q u e l a e →
o S y s t e m i c H T N wi l l o c c u r
o V a s o s p a sm & i s c h em i c s e q u e l a e i n
liver can lead to:
▪ P e r i p o r t a l h e m o r r ha g e
w h i c h c au s e s s t r e t c h i n g o f G l i ss o n ’ s
C a p s u l e l e a d i n g t o R i g h t u p p e r qu a d r an t
or epigastric pain
▪ Hepatic Necroses which
c a u s e s e l e v a t e d l i ve r e n z ym e s
o R e t i n a l I s c h em i a
• L e a k y c a pi l l a r i e s → c a us e
o Edema

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o H e m o c o n c e n t r a t i o n ; t h a t i s w h y t h e s e p r e g n a n t w om e n c an n o t t o l e r a t e
blood loss
o Pulmonary edema
o I n k i d n ey s i t c au s es G l o m e r u l a r e n d o t h e l i o s i s b y
c a u s i n g sw e l l i n g of e n d o t h e l i a l l i n i n g & f e n e s t r a
T h u s, G F R d e c r e a se s , i n c r e a s e i n s e rum c r e a t i ni n e &
serum uric acid
o A c u t e T ub u l a r N e c r o s i s [ A T N ] c a n o cc u r if
t h e r e i s hy p o t e n s i o n & r e n a l i s c h em i a in p r e - e c l a m p s i a
o Cerebral edema
Risk Factors:
o P r e v i o u s h / o p r e - ec l a m p s i a [ m o s t im po r t a n t f a c t o r ] → 16 - 5 5 % c h a n c e s
of recurrence
o Primiparity
o New paternity
o Extremes of age
o O b e s i t y, B M I > 3 0 k g /m 2
o Multiple pregnancy
o Molar pregnancy
o Diabetes
o C h r o n i c K i d n e y d i s ea s e
o C h r o n i c H y p e r t e n s io n
o A PLA
P r e d i c t o r s o f P r e -E c l a m p s i a :
o Hemoconcentration
o H y p e r u r i c em i a
o Decrease urinary Ca+2 exertion
o R o l l o v e r t e s t [ d o ne b e t w e e n 2 8 - 3 2 we e k ] . I n t h i s t e s t w h e n a w o m a n
s h i f t s f r om l a t e r a l p o s i t i o n t o Su p i n e p o s i t i o n t h e BP i n cr e a s e s
o P e r s i s t e n t u t e r i n e a r t e r y D o p p l e r N o t c h i n g b e y o n d 22 - 2 4 [ I t i s b e t t e r
p r e d i c t o r o f I n t r au t e r i n e g r o w t h r e ta r d a t i o n t h a n H T N i n p r e g n a n c y]
• New Predictors:
o A n gi o g e n i c f a c t o r s p r o m o t e t h e i n va s io n o f s p i r a l a r t e r i es
o I f a n gi o g e n i c f a c t o r s a r e d e c r e a s e d th e n s p i r a l a r t e r y i nv a s i o n w i l l n o t
p r o c e e d & w i l l b e pr e d i c t o r o f p r e - e c l a m p si a
E x a m p l e : V E G F , PL G F [ P l a c e n t a l G r o wt h F a c t o r ]
o A n t i - a n gi o g e n i c f a ct o r s f a v o rs t h e i n hi b i t i o n o f i n v as i o n o f s p i ra l
arterioles

o W h e n a n t i - a ng i o g e ni c f a c t o r s i n c r e a s es , i n v as i o n w i l l b e ha m p e r e d &
t h u s a c t a s p r e d i c to r s o f p r e - e c l a m p s ia
Example:
▪ S F l t – 1 [ S o l ub l e Fm s l i k e t y r o s i n e ki na s e ]
▪ S o l u b l e E n d o g li n [ S E n g ]
o W h e n e v e r f e t us h as t r i s om y 1 3 t h e r e i s i n c r e a s e d r is k o f m o t h e r f o r
p r e - e c l a m p s i a b e c au s e S F l t - 1 g e n e i s c a r r i e d o n C h r o m oso m e - 1 3 s o t h e
f e t u s s y n t h e s iz e s m o r e o f Sf l t - 1
• F I G O S c r e e n i n g P ro t o c o l :
o S c r e e n b e t w e e n 1 1 t o 1 3 w e e k s + 6 d ays
o T a k e m a t e r n a l h i s to r y t o c h e c k f o r R is k f a c t o r s
o M e a n A r t e r i a l p r e ss u r e
o U t e r i n e a r t e r y p u lsa t i l i t y i nd e x
o P l a c e n t a l G r o w t h Fa c t o r i n s e ru m
o P A P P -A i n s e ru m [ pr e g n a n c y a ss o c i a t e d p l a sm a p r o t e i n A i n m a t e r n a l
serum]
o I f a f t e r t o t a l e v a lu a t i o n , t h e r e i n c r e a s e d r is k o f P r e - E c l a m p s ia
▪ G i v e 1 5 0 m g A s pi r in d a i l y & c o n t i n u e un t i l 3 6 w e e k s [ L o w
d o s e → 8 1 m g o r 75 m g c a n b e gi v e n ]
o N o t e : A s pi r i n i s t he o n l y r e c o m m e n d ed m o d e o f p r e v e n t io n
Example:
AfraTafreeh.com
▪ P r i m p r e g n a n c y, 4 0 y e a r s, c o n c e i v e d wi t h I V F, f am i l y h / o
d i a b e t e s M e l l i t u s T y p e - I I & r ig h t n o w c a r r y i n g tw i n s & h /o -
PCOS
12 weeks pregnant:
• A s m u l t i p l e R f s a r e + n t , i t i s w is e t o gi v e A s pi r i n
b a s e d o n h is t o r y o nl y
• I f a s pi r i n i s s t a r t ed a t 1 2 w e e k s, t h e n c o n t i n u e i t
throughout
o N o t e : C a l c i um s u p pl e m e n t a t i o n h a s a ro l e i n p r e - p r e v e n t io n o n l y if
t h e r e i s C a + 2 d e f i c ie n c y
ECLAMPSIA
• E c l a m p s i a → w h e n e v e r p r e - e c l a m p s i a ge t s c o m p l i c a t e d w i th s e iz u r e s
a n d / o r c o m a t h e n th a t s t a t e is c a l l e d e c l a m p s i a
• T h e s e s e i z u r e s a r e G e n e r a l iz e d T o n i c c l o n i c S e iz u r e s

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Pathophysiology:
o E x p l a i n e d b y “T h e o r y o f v as o g e n i c e d em a ”
o T h e r e is l o ss o f c er e b r a l a u t o r e g u l a t io n w h i c h l e a d s t o
c e r e b r o v a s c u l a r hyp e r p e r f u s i o n w h i ch i s m o s t l y c o nf i n ed t o o c c i p i t a l
l o b e t h a t ’ s w h y t h er e i s:
• Throbbing occipital headache
• S c o t o m a [ p a t i e n t wi l l c o m p l a i n a b o u t b l u r r i n g of v i si o n ]
• [ T h e s e a r e a ls o sym p t o m s o f im p e n d in g e c l a m ps i a]
o S i n c e , t h e r e i s a l r ea d y e n d o t h e l i a l d am a g e a l o n g w i t h
c e r e b r o v a s c u l a r hyp e r p e r f u s i o n, c e r eb r a l e d em a o c c u rs w h i c h
f u r t h e r c a us e s c e re b r a l h y p o x i c i s c h em i a → R e l e a s e o f ex c i t a t o r y
n e u r o t r a n s m i t t e r s w h i c h l e a d s t o c o n vu l s i o n s, s e i z u r e s → H e n c e ,
eclampsia occurs
o D e p e n d i n g u p o n d e gr e e o f c e r e b r a l e de m a , p h ys i c a l m a ni fe s t a t i o n
c a n v a r y f r om b e i ng :
▪ Confused
▪ Disoriented
▪ Lethargic
▪ Comatose
o O n R a d i o g ra p h y , c er e b r a l e d e m a is s e e n a s P R E S t h a t i s P o s t e r i o r
R e v e r s ib l e E n c e p h a l o p a t h y S y n d r om e . I t i s u su a l l y c o n fi ne d t o
o c c i p i t a l & p a ri e t o t e m p o r a l a r e a s b u t c a n i n v o l v e t h e e n ti r e b r ai n
also
N o t e : A n o t h e r f e a tu r e t h a t c o m p li c a t e s e c l a m ps i a i s b li nd n e s s
o A b o u t 1 0 - 1 5 % c a s es o f e c l a m ps i a a r e c o m p l i c a t e d b y b l i nd n e s s :
▪ b l i n d n e ss is m o s t l y b e c a us e o f o c c i p i ta l e d e m a & i s c a l l e d
o c c i p i t a l b l i nd n e s s [ A m au r o s i s]
▪ T h i s f o rm o f b l i n d ne s s is m o s t l y r e v e rs i b l e
▪ B u t s om e t im e s t h e re c a n b e :
o Cerebral infarction
o R e t i n a l i nf a r c t i o n le a d i n g t o R e t i n a l de t a c h m e n t
& i s c a l l e d as P U RT S C H N E R ’ S r e t i n o p at h y
• C l i n i c a l P r e s e n t a t io n :
o h/o preeclampsia
o Convulsion
o Disorientation
o E d e m a o f l o w e r l im b s
o P u f f y f a c e & e y e l i ds
o Tongue bite

b/o convulsions
o A s pi r a t i o n p n e um o ni t i s c a n l e a d t o P u lm o n a r y e d e m a
o C a u s e o f s ud d e n d ea t h w i t h e c l a m p si a → M a ss i v e c e r e b r al
hemorrhage
o E c l a m p s i a c a n o c c ur a n y t im e :
▪ A n t e p a r t u m [ m os t d a n g e r o u s b e c a us e t h e o u t c o m e / p r o g no s i s
f o r w om a n d e p e n ds o n d u ra t i o n w om a n r e m ai n s i n s t a t e of
e c l a m p s i a]
▪ Intrapartum
▪ P o s t p a r t u m [ u s u a l l y w i t h i n 4 8 h o u r s]
• M a n a g e m e n t o f E c la m p si a :
o N o r o l e o f c o n s e r v a t i v e m a n a g em e n t
o D e f i n i t i v e T t → D e li v e r y /T e r m i n a ti o n o f p r e g n a n c y
o 1 s t f o c u s o n S t a b i l iz a t i o n
o M a i n t a i n ai r w a ys → d o n e b y G o o d e l l ’ s a i r w a y
o A n t i h y p e r t e n s iv e s if BP is hi g h
o D O C [ m o s t im p o r t an t d r u g] :
▪ M a g n e s i um S u l p h a te →
• N o t a h y p e r t e n s iv e d r u g
• I t p r e v e n t s fu r t h e r s e iz u r e s [ r is k o f f u r t h e r s e iz u r e s
is 10-15%]
AfraTafreeh.com
▪ M o A of Mg S O 4 [ c en t r a l a c t i o n ] :
• B l o c k s N M DA R e c ep t o r s
• D e c r e a s e r e l e a s e o f g lu t a m a t e
• Potentiates Adenosine
• A l s o b l o c ks C a + 2 e nt r y i n t o t h e c e l l s
o R e g im e s t o g iv e M gS O 4 :
▪ P R I T CH A R D R E G I ME [ i .m + i . v]
• T o t a l l o a d i n g d o s e = 1 4 g r am
• O u t o f 1 4 g r am , 4 g r a m i s gi v e n i n d i lu t e d f o rm t h a t i s
2 0 % s o l u t i o n g i v e n s l o w i .v
R a t e o f i n f u s i o n s ho u l d n o t b e > 1 g m /m i n
• 1 0 g r am is g i v e n a s u n d i lu t e d 5 0% s o l ut i o n i .m o n b u t t o c k s
[ 5 g r am o n e a c h b u tt o c k ]
• 1 v i a l c o n t a i n s 1 g ra m of 5 0% W/ v o f M g S O 4 i n 2 m l
solution
4 v i a ls →
o 4 g r am Mg S O 4 + d i lu t e w i t h 1 2 m l o f No r m a l sa l i n e m ak i n g
t h e t o t a l s o l u t i o n of 2 0m l w h i c h h a s 20 % c o n c e n t r a t i o n
• M a i n t e n a n c e D o s e = 5 g r am i .m o n a l t e r n a t e b u t t o c k ev e r y
4 hour

AfraTafreeh.com
▪ Z U S P AN R EG I M E [ i . v ]
• L o a d i n g d o s e = 4 - 6 g r a m i .v , d i lu t e d i n 1 0 0 m l o f N o r m a l Sa l i n e o v e r
15-20 min
• M a i n t e n a n c e d o s e = 1 - 2 g r am / h o u r i n fu s i o n i n 1 0 0m l NS
I f a f t e r g iv i n g t h e l o a d i n g, t h e r e i s re c u r r e n c e o f s e iz ur e t h e n w e c a n r e pe a t
2 g r a m i .v b o l u s
H o w l o n g t o c o n t i n ue M g S O 4 ?
F o r 2 4 h ou r s a f t e r d e l i v e r y o r s ei z u re w h i c h e v e r o c c u r s l a t e r
• M o n i t o r i n g d u r i ng g i v i ng M gS O 4
o F r e q u e n t c h a r t i n g o f vi t a l s
o I n p u t o u t p u t c h a r t in g [ i n p u t of i . v f l uid s , u r i n e o u t p u t ]
o i . v f l u id s a r e gu a r de d ( t o m i ni m i z e t h e r i sk of p u lm o n a r y e d e m a )
o C h e c k R e s p i r a t o r y R a t e & K n e e J e rk (b e c a u s e M g S O 4 c a us e s
d e c r e a s e R R, l o ss of d e e p t e n d o n r ef l e x e s )
o Check urine output:
▪ M g S O 4 d o e s n o t c au s e d e c r e a s e d u r i ne o u t p u t o r o l ig u r i a b u t i t i s
excreted renally
▪ S o if t h e r e is o l ig ur i a b e c a u s e of p r e -e c l a m p s i a / e c l am p s ia t h e n
t h e M g + 2 t o x i c i t y ca n b e p r e c i p i t a t e d
Note:
▪ T h e r a p e u t i c Mg S O 4 l e v e l s i n s e r u m → 4 - 7 m e q /L o r 4 . 8 - 8. 4 m g / d l
▪ L o s s o f k n e e j e r k at 1 0 m e q / L o r 1 2 m g / d l
▪ Respiratory arrest beyond 30 meq/L
▪ A s l o n g a s t h e r e i s l o s s o f k n e e j e r k , w e c a n s t o p t h e i nfu s i o n o r
o m i t t h e d o s e . B u t i f r e s pi r a t o r y o r c a r d i a c a r r e s t o c c u rs t h e n w e h a v e
t h e a n t i d o t e f o r Mg S O 4 t o x i c i t y → C a + 2 g l u c o n a t e i n j e c t io n 1 0 m l i . v o v e r
1 0 m i nu t e .
PRE-ECLAMPSIA MANAGEMENT
D e f i n i t i v e T t : D e l iv e r y / T e rm i n a t i o n o f p r e g n a n c y
• T i l l t h e t i m e w e d e l i v e r , w e m o n i t o r th e m a t e r n a l s t a t u s t h a t i s
m o n i t o r i n g f o r e n d o r g a n s c h a ng e s , c on t r o l t h e B P a nd m o n i t o r t h e f e t u s
• For controlling BP:

o D o e s c o n t r o l l i n g B P p r e v e n t e c l a m ps i a? N o , b e c a us e t h e
p a t h o p h y s i o l o g y has g o t t o d o w i t h e nd o t h e l i a l d a m ag e & c e r e b r a l
edema
o W e w a n t t o c o n t r o l B P t o p r e v e n t a cu t e h y p e r t e n s i v e c om p l i c a t i o n s
like:
▪ Intracerebral bleed
▪ Placental abruption
• D r u g C o n t r o l o f B P:
o S t a r t a n t i h y p e r t e ns i v e T x i f B P is p e rs i s t e n t l y > 1 5 0 / 1 0 0 m m H g
o D O C = o r a l l ab e t a l o l
1 0 0 m g T DS / Q I D [ w e c a n g o u p t i l l 400 m g Q I D ]
o O t h e r d r u g s:
▪ M e t h y l d o p a [ 2 5 0m g T DS / Q I D]
▪ O r a l N i f e d i pi n e
▪ O r a l H y d r a l az i n e
o T a r g e t o f c o n t r o l is 1 3 0 - 1 4 0 / 8 0 - 9 0 m m H g
o I f w e a r e g o i ng f o r h y p o t e n s i o n w h i l e c o n t r o l l i n g t h e B P it w i l l
l e a d t o v as c u l a r i n su f f i ci e n c y o f t h e pl a c e n t a & h e n c e , I U G R
o I f t h e r e is a c u t e hy p e r t e n s i v e c r is i s,
o E x a m p l e : i f B P i s >= 1 6 0 / 1 0 0 m m H g t he n
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D O C → i .v L ab e t a l o l → [ P r o t o c o l → 20, 4 0 , 8 0, 8 0] → M a x o f 2 2 0 m g
o f i .v l ab e t a l o l i n 1 c y c l e
• Other drugs:
o O r a l n i f e d i pi n e
I m m e di a t e r e l e a s e c a p s u l e s
o i . v H yd r a l a z i n e
o S o d i um Ni t r o p r u s sid e i . v
o N i t r o g l y c e r i n e i .v
• Note:
o D i u r e t i c s a r e n o t us e d f o r B P c o n t r o l , n o t e v e n f o r t r e a tm e n t o f
o l i g u r i a a s i t m ay wo r s e n e d e m a i n p r e g n a n t l a d i e s
o D i u r e t i c s s h o u l d b e u s e d o n l y i f t h e r e i s P u lm o n a r y e d em a
• T i m i n g o f d e l i v e r y:
o M i l d p r e - e c l a m p si a / B P c o n t r o l l e d w i t h o r wi t h o u t d r ug → t i m i n g
o f d e l i v e r y t h a t i s i n d u c t i o n o f l ab o r is d o n e af t e r 3 7 w ee k s
o S e v e r e P r e - e c l a m ps i a →
▪ A dm i t t h e p a t i e n t
▪ M o n i t o r t h e p a t i e nt b y d o i ng b a s e l i n e i n v e s ti g a t i o n l i k e C B C ,
L FT , K FT
▪ Tt of HTN should be given

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▪ W a t c h f o r S /S of im p e n d i n g e c l a m ps i a
▪ G o t h r o u g h p a t i e n t ’ s l ab r e p o r t s f r e q ue n t l y
▪ D o d a i l y u r i n e a l b um i n c h a r t i n g
▪ I f s h e s t a r t s c o m pl a i n i n g o f h e a da c h e o r b l u r r i n g o f v is io n ,
t h e n i t i n di c a t e s im p e n d i n g e c l a m ps i a
▪ R e g u l a r B P m o n i t o ri n g i n t h e w a r d
▪ T h e n s e e i f a w om an i s:
• > = 3 4 w e e k s → T e rm i n a t i o n o f p r e g n an c y
• <34 weeks →
o G i v e c o r t i c o s t e r o i d s f o r f e t a l lu n g m at u r a t i o n
o F r e q u e n t m o n i t o r i ng
o A l t e r n a t e d a y / D a i ly l a b s :
▪ I f d u ri n g t h i s t im e s h e ha s:
• S / S o f i m p e n di n g e c l a m p s i a
• Uncontrolled BP
• Pulmonary edema
• W o r s e n i n g o f LF T s , s e r um c r e a t i ni n e
• F e t a l d i s t r e ss
• Placental abruption
▪ T h e n s t o p t h e n c o ns e r v a t i v e m a n ag e m e n t &
t e r m i n a t e t h e p r e gn a n c y i r r e s p e c t i v e o f
POG
▪ A l s o g iv e p r o p h y l a ct i c M g S O 4 i n s e v e re p r e -
eclampsia
• < 2 4 w e e k s → T e rm i n a t i o n o f P r e g n a n cy [ P r e vi a b l e
fetus]
N o t e : H E L LP S y n d ro m e :
o H e m o l y si s [ H i gh b i li r u b i n , i n c r e a s e L DH , P e r i p h e r a l sm e a r
s c h i s t o c y t e s , d e c re a s e s e r um ha p t o g l o b i n
o E l e v a t e d l i v e r e nz ym e s
o Low platelets
▪ I n 1 5 % c a s e s o f H EL L P, B P c a n b e n o rm a l
▪ M o s t c o m m o n l y o c cu r s i n 3 r d t r i m es t e r
▪ M o s t c o m m o n c l i ni ca l p r e s e n t a t i o n is Ep i g a s t r i c p a i n /R i g ht
u p p e r q u ad r a n t p a in
▪ Recurrence rate is 4-7%
▪ M a n a g e m e n t : t e r m in a t i o n o f p r e g na n cy [ i m m e d ia t e l y ] +
P r o p h y l a c t i c M gS O 4
▪ T h e r e is n o r o l e o f c o r t i c o s t e r o i d s t o t r e a t l o w p l a t e l e t
count

• D i f f e r e n c e D i a g n os i s o f H EL L P S y n dr o m e :
o Acute viral hepatitis
o A c u t e f a t t y li v e r of p r e g n a n c y [ A F LP ]
o Obstetric Cholestasis
• A c u t e V i r a l H e p a t it i s :
o D i f f e r e n t i a t i n g f e at u r e i s t h a t Bi l i r ub i n wi l l b e v e r y v e r y h i g h [ >
1 0 m g / d l]
o L i v e r e n z ym e s i n 1 00 0 s
o N o f / o h em o l y s is / lo w p l a t e l e t s
o Hepatomegaly
o M a n a g e m e n t → C o ns e r v a t i v e
• A c u t e F a t t y l i v e r o f p r e g n a n c y [ A F LP ] :
o MC presents in 3rd trimester
o More common in 1st pregnancy
o C l i n i c a l l y i t i s m o r e s e v e r e f o r m o f H EL L P Sy n d r o m e
o D i f f e r e n t F e a t u r e s:
▪ H y p o g l y c em i a
▪ D e r a n g e d C o a g u l a t io n P r o f i l e
▪ AfraTafreeh.com
P a n c r e a t i t i s [ 2 0% c a s e s ]
▪ T r a n s i e n t d i ab e t e s i n si p i d us [ ~ 2 5% ] → b / o s e r v e h e p a t ic
d y s f u n c t i o n a s P l a ce n t a s e c r e t e s v as o p r e s s i n ’ s w h i c h – A D H
& c a u s e s D i ab e t e s in s p i d us
▪ Shrunken liver
N o t e : N o r m a l l iv e r m e t a b o l iz e s v a s o p re s s i n a s e s e c r e t e d b y p l a c e n t a . I n
s e v e r e h e p a t i c dy sf u n c t i o n , l i v e r c a n no t m e t a b o l iz e t h e va s s o p r e s s i n as e
c o m i n g f r om t h e p l a c e n t a a n d t h us A DH d ef i c i e n c y o c c u rs → (v a s o p r e s si n a se
m e t a b o l iz e s v a s o p re s s i n ) c au s e s t r a ns i e n t d i ab e t e s i n s ip i d u s [ D I ]
• O b s t e t r i c C h o l e s t as i s :
o A k a i n t r a h e p a t i c ch o l e s t a s i s of p r e g na n c y [ IH C P ]
o C o m m o n l y o c c u r s i n 3 r d t r im e s t e r
o Estrogen related condition
o G e n e t i c p r e d i s p os i ti o n + n t
o A B C B 4 g e n e i s i n v ol v e d
o M a i n sym p t o m = P ru r i t u s; i n v o l v e s a rm s & l e gs & t h e n ge t
g e n e r a l i z e d a l l o v er t h e b o dy t o i n v o lv e p a lm s & s o l e s a s w e l l
o J a u n d i c e i s ra r e ; i f o c c u r s i t r a r e l y e x c e e d s 5 m g / d l
o L i v e r e n z ym e s [ S G O T , SG PT ] i n c r e a s es
o D i a g n o s i s is m a d e b y r a is e d s e r u m b i l e a c i d s

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o Tt:
▪ D o c = U rs o d e o x y c h o l i c a c i d
▪ C h o l e s t y r a m i n e [ n ot u s e d a n ym o r e ]
▪ S ym p t o m a t i c R e l i e f
o T h e r a is e d b i l e a c id s c a n b e t o x i c t o f e t a l c a r d i a c m y o c y t e s & c a n
c a u s e su d d e n IU D
o T h u s, t e r m i n a t e p re g n a n c y b e t w e e n 37 - 3 8 w e e k s t o av o id f e t a l
IUD
o Recurrence Rate > 50%
FETAL GROWTH RESTRICTION
• Low Birth weight:

o Birth weight of < 2500 gram irrespective of gestational age
• Small for gestational age [SGA] →

o Estimated foetal weight < 10th percentile for that gestational age
o SGA can be of two types:
▪ Constitutionally small Foetus:
• Rate of growth of such foetus is normal
• Blood flow to foetus is normal
▪ Pathological Growth Restriction:
• Rate of growth is slow
• Compromised Blood f low
• Causes of Growth restriction:
o Maternal causes:
▪ Poor nutrition
▪ Social Deprivation
▪ Poor weight gain
o Placental Insufficiency [as seen in]
▪ HTN Disorders
▪ APLA
o Foetal causes
▪ Foetus with structural anomalies
▪ Foetus with chromosomal anomalies
▪ Foetus with trisomies
▪ Intrauterine foetal infections
▪ Multiple pregnancies

o Maternal smoking = causes O 2 deprivation & nutrient deprivation
to foetus as it thickens the placental barrier
o Maternal cyanotic heart diseases
o Maternal asthma
• What happens with Foetus growth Restriction?
o Uteroplacental insufficiency causes decreased blood supply to the
foetus:
o Redistribution of foetal blood occurs:
▪ More blood to fetal brain & heart – BRAIN SPARING
▪ Less blood to fetal kidneys; ki dneys form the foetal urine which adds
to AF volume. As the blood supply to kidney decreases, there is
decreases urine production/oliguria leading to decreases liquor →
oligohydramnios
▪ Head circumference is not affected due to sufficient blood supply to
brain but the abdominal
circumference decreases; [As
glycogen stores are depleted, liver
shrinks thus AC decreases]
▪ Asymmetrical IUGR (HC > AC)
o Sometimes, there can be
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symmetrical IUGR because of
foetal infections/ chromosomal
abnormalities
Usually caus es early onset IUGR
o both Head circumference & AC are decreased and the HC: AC
ratio is normal.
• Risks with FGR:
o Increased Risk of perinatal morbidity & mortality
o Increase risk of still birth
o Birth asphyxia
o Meconium aspiration
o Hypoglycaemia
o Hypothermia
o Respiratory Distress Syndrome
o Necrotising Enterocolitis
o Sepsis
All these conditions further increases in risk if foetus is pre -
term also alongwith being growth restricted
Note: Prognosis of IUGR new born or Neurodevelopmental outcome at 2

years of age → depends on the Gestational age at delivery & the birth
weight

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• Diagnosis of FGR:
o 1st → we suspect FGR
▪ Fundal height is not going to correspond to gestational age
Example: POG → 32 weeks, P/A → Fundal height is 28 weeks
In such case
1st step → confirm the POG [very very important]
2nd step → Foetal Biometry on USG & measure:
• HC
• Biparietal diameter [BPD]
• AC
• Femur Length
• Composite EFW
• Check Liqour
• Umblical artery doppler
▪ Example 1:
• GA → 32 weeks
• P/A foetus → 28 weeks
• On USG:
o BPD – 31 weeks
o HC – 28 weeks
o FL – 32 weeks [decreased]
o AC – 28 weeks [decreased]
o Liqour – decreased
o EFW – 1000gram
• Diagnosis is IUGR in this case.
Out of all these parameters the single best parameter to diagnose

growth disorders is Abdominal Circumference
▪ Example 2:
• GA → 32 weeks
• P/A → 30 weeks
• On USG →
o BPD – 30 weeks
o HC – 29 weeks
o AC – 29 weeks
o FL – 30 weeks
o Liqour – normal
o Doppler – Normal

• All the parameters are decreased but there is no vast
difference among the parameters, so the foetus is
smaller
• Repeat USG after 3 weeks, Now:
o BPD – 33 weeks
o MC – 32 weeks
o AC – 32 weeks
o FL – 33 weeks
o Liqour – Normal
o Doppler – Normal
• Thus, foetus has also grown in parameters
correspondingly that is 3 -week growth has been
documented
▪ Thus, it is most like case of SGA; constitutionally small foetus, whose
rate of growth is normal
o 3rd step – once the diagnosis of IUGR has been established, Gold
standard for evaluation of IUGR fetus is umbilical artery Doppler
Note:
▪ Timing of delivery also depends on umbilical artery doppler

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▪ Obstetric outcome depends on umbilical
artery doppler
• Doppler changes in FGR:
o Doppler changes reflect the status
of foetus
o When 60-70% of placental
circulation is obliterated → Doppler
becomes abnormal
• Revising fetal circulation :
o Umbilical arteries carry deoxygenated blood from foetus to
placenta
o Umbilical vein carries oxygenated blow from placenta to foetus
o Portal vein gets the venous supply from foetal gut & this portal
vein joins with umbilical vein to form ductus venosus whic h then
connects to IVC
o Now O2 blood will enters the right side of heart & it enters left
side of heart via foramen ovale; left atrium to left ventricle →
Aorta → upper part of body brain; upper limbs etc
o Some blood that has entered right ventricle goes to pulmonary
artery → lungs → then via Ductus arteriosus to the aorta

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o There is always a forward flow in umbilical artery [which should

be maintained]. Normally as
pregnancy advances → Diastolic
flow in umbilical artery increase
→ Systolic/Diastolic rate
decreases [normal S/D ratio at
term is 2]
o Now if resistance occurs at the
level of placenta b/o
uteroplacental insufficiency →
then umbilical artery has to pump blood
against that resistance → Thus, during
systole when the heart pumps blood the
forward flow in systole is maintained
→ but the diastolic flow in umbilical artery is

decreased → S/D Ratio increases
o Absent end diastolic flow

▪ When resistance at level of placenta
increases further → that the forward flow
during diastole cannot be maintained at all →
but forward flow during systole can be
maintained
o Reversed end diastolic flow

▪ Resistance at level of placenta
increases even further → There is
reversal of flow in umbilical artery
during diastole → Forward flow
during systole is present
• Pre-Terminal Doppler changes :
o Reflect impending death, foetal cardiac failure, fetal myocardia
ischemia & are:
▪ Reversible of flow in Ductus Venosus
▪ Umbilical venous pulsations
• Management of IUGR fetus :

▪ Monitoring:
• Track growth [biometry every 3 -4 weeks]

• Weekly doppler [more frequently done if already
abnormal]
• Daily foetal monitoring
▪ Uteroplacental flow can be increased by resting on left latera l
position
▪ Goal: Prolong the pregnancy as much as possible
o Timing of delivery:
▪ As long as:
• Growth is maintained
• UA Doppler is normal
• Or S/D increase
• Foetal monitoring normal
We are going to deliver after 38 weeks completed
▪ If there is absent end diastolic flow [AEDF];
▪ if pregnancy is > = 34 weeks then deliver the baby
▪ If pregnancy is < 34 weeks, then
o Start steroids
o Initiate even more intensive monitoring
▪ Reverse End dias tolic flow [REDF]; then deliver the baby irrespective
of POG. Usually C -Section done for delivery
▪ AfraTafreeh.com
If REDF occurs far away from 32 weeks → monitor Ductus venosus &
umbilical venosus doppler
PRETERM BIRTH
• D e f i n i t i o n o f p r e te r m l a b o u r →
o l a b o u r b e f o r e 3 7 we e k s o f g e s t a t i o n
o Early preterm → < 34 weeks
o L a t e p r e t e r m → 3 4- 3 7 w e e k s
• Causes:
o I d i o p a t h i c s p o n t a ne o u s p r e t e r m w i t h i n t a c t m em b ra n e s ; c a n b e
a / w u t e r i n e o v e r d i st e n s i o n
Example: Multiple pregnancy
o F o e t a l / m a t e r n a l st r e s s
o I n f e c t i o n [ b o t h sy st e m i c in f e c t i o n s & c h o r i o a m n i o n i t is ]
o P r e t e r m p r e l a b o u r r u p t u r e o f m em b ran e s [ P P R O M]
o Iatrogenic preterm
• Antecedent factors:

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o P r i o r H / o s p o n t a n eo u s p r e t e r m l a b o u r [ m o s t im p o r t a n t ]
▪ I f h / o 2 p r i o r p r e t e r m b i r t h s a t < 3 4 w e e k s o f g es t a t i o n ,
t h e n r i s k o f h a vi n g s ub s e qu e n t p r e t er m b i r t h i s 4 0%
o T h r e a t e n e d a b o r t i on
o S m ok i n g
o E x t r e m e s o f m a t e rn a l w e i g h t
o E x t r e m e s o f m a t e rn a l a g e
o I n t e r v a l b e t w e e n pr e g n a n c y [ S h o r t o r p r o l o n g e d i n t e r v a l]
o B a c t e r i a l v a g i n os i s ( sy m p t om a t i c B V in p r e g n a n c y n e e d s t o b e
treated)
o P e r i o d o n t a l d i s e as e
• P r e d i c t o r s o f P r e te r m B i r t h :
o F o e t a l f ib r o n e c t i n : c a n b e d e t e c t e d i n c e r v i c o - v a gi n a l s e c r e t i o n s
between 24-34 weeks
▪ T e s t w i l l b e p o si t i ve w i t h f o e t a l f ib r on e c t i n l e v e l s > 5 0 μ g / d l
▪ T h i s t e s t ha s a g o o d n e g a t iv e p r e d i c t iv e v a lu e t h a t i s:
• I f t e s t c om e s o u t to b e n eg a t i v e t h a t m e a n s t h e r e a r e
m i n im a l c h a n c e s of p r e t e r m l a b o u r i n ne x t 7 d a ys
• I f p o s i t iv e → c o u l d b e p r e t e r m l ab o u r
▪ C l i n i c a l l y u t i li t y o f t h i s t e s t is t o r u l e o u t p r e t e r m l a b o ur i n
a w om a n c om i n g wi t h c o m p l a i n t t o p a i n. I f F F N i s n e g a t iv e,
w o m a n c a n b e di s c ha r g e d & s e n t h om e
▪ T h u s, i f o s c l o s e d , c e r v i x is l o n g & y e t w om a n c o m p l ai n t s o f
p a i n , F F N c a n b e u se d t o r u l e o u t p r e t e r m l ab o r
o C e r v i c a l l e n g t h M an a g e m e n t :
▪ I f c e r v i c a l l e n g t h a t 2 4 w e ek s i s < 25 m m t h e n i t i s
p r e d i c t i v e o f p r e t e r m l ab o u r /b i r t h
▪ C l i n i c a l u t i l i t y o f th i s t e s t i s o n l y i n w o m e n w h o h av e h ad
p r i o r s p o n t a n e o u s pr e t e r m b i r t h s
• D i a g n o s i s o f P r e t er m L a b o u r :
o C l i n i c a l d i ag n o s is :
▪ W i t h r eg u l a r u t e r in e c o n t r a c t i o n s
▪ W i t h p r og r e s s iv e ce r v i c a l c h a n g e s
• T w o a s p e c t s o f m an a g e m e n t s :
o Steroids
o Tocolysis
• Steroid:
o G i v e n d u ri n g p r e t e r m l ab o u r t o a c h i e ve f o e t a l l u n g m a t u ri t y
o W h e n t o g i v e ? I f pr e g n a n c y is < 3 4 w ee k s , t h e n a l w ay s g iv e
steroids

o L a t e s t A C O G r e c o m m e n d a t i o n i s t h a t b e t w e e n 3 4 - 3 7 w e e ks t h a t i s
l a t e p r e t e r m → C o n s i d e r g i vi n g s t e r o i d s i n s p o n t a n e o u s pr e t e r m
labour
o E v e n i f p a t i e n t i s in a c t i v e l a b o u r →
▪ Do start steroids
▪ G i v e 1 s t c l o s e a s s om e b e n e f i t i s a c h i ev e d
o B e n e f i t o f s t e r o i d s s t a r t s 2 4 h rs af t e r t h e 1 s t d o s e & l a st s u p t o
7 d a y s . T h e r e f o r e , S i n g l e c o u rs e is r ec o m m e n d e d
o m u l t i p l e c o u r s e s of s t e r o i d a r e n o t use d b e c a us e o f ri sk o f
cerebral palsy
Q : W hi c h s t e r o i d to b e g i v e n ?
▪ B e t a m e t h a s o n e = wa s gi v e n / p r e f e r r e d e a r l i e r b e c a u s e i t
p r e v e n t e d p e r i v e n t r i c u l a r l e uk o m a l a c ia
▪ D e x a m e t h a s o n e = Pr e f e r r e d o v e r b e t am e t h a s o n e as i t is
cheaper
▪ L a t e s t r e c o m m e n d at i o n ;
• B o t h d r u gs a r e c o m p a r a b l e i n t h e i r eff i c i e n c y
• Dose:
o D e x a m e t h a s o n e → 6 m g I M 1 2 h o u r s ap a r t f o r 4
doses
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o B e t a m e t h a s o n e → 1 2 m g I M 2 4 h o u rs ap a r t f o r 2
doses
• T o c o l y s i s : 2 v a l i d in d i c a t i o n s :
o T o b u y t im e f o r s te r o i d s t o a c t
o B u y ti m e f o r r ef e r r a l
o T h e r e f o r e , i t is u su a l l y gi v e n f o r 4 8 ho u r s o n l y
o DOC:
▪ N i f e d i p i n e [ 3 0m g st a r t d o s e f o l l o w e d b y 1 0 m g 8 h o u r l y ]
W h i l e g i v i n g N i f e dip i n e m o ni t o r t h e p ul s e r a t e & B P a s i t
c a u s e s r ef l e x t a c hy c a r d i a & h y p o t e n si o n
o O t h e r d r u g s:
▪ β m im e t i c s [ β A d r e n e r g i c a g e n t s] :
• Terbutaline
• Ritodrine
• Isoxpsuprine
▪ P r o b l e m w i t h t h e s e d r u gs a r e S / E:
• Tremors
• H y p e r g l y c a em i a
• H y p o k a l a em i a
• Pulmonary edema

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• MI
N o t e : n o r o l e of r ou t i n e a n t ib i o t i c s u nl e s s t h e r e is c l i ni ca l l y e v i d e n t i n f e c t io n
o r r u p t u r e d m em b ra n e s
▪ I n d o m e t h a c i n [ N SA I D ] :
• S/E:
o C a u s e p r e m a t u r e c lo s u r e o f d u c t us a r te r i o s u s
o o l i g u r i a o f f o e t u s le a d i n g t o o l ig o h y d ra m n i o s
▪ Nitric acid donors = NTG
▪ MgSO4:
• Has tocolytic property
• B u t n o t c l i ni c a l l y us e f u l as d o s e s i n wh i c h i t h a s
tocolytic property leads to toxicity
• I f us e d f o r p r o l o n ge d d u r a t i o n [ > 5 - 7 d a y s ] t h e n i t c a n
l e a d t o b o n e t h i n n in g o r o s t e o p e n i a i n f o e t u s
▪ A t o s ib a n:
• A n o x y t o c i n a n t a g on i s t [ s t o p s u t e r i n e c o n t r a c t i o n s ]
• F D A w a r n i ng ag a i nst u s e of a t o si b a n b e c a u s e o f h i g h
r i s k o f n e o n a t a l m or b i d i t y
Note:
P r o g e s t e r o n e i s n o t a t o c o l y t i c , h o w e ve r i t is u s e d f o r p re v e n t i o n o f p r e t e rm
b i r t h o n l y if t h e r e i s :
o h / o p r i o r s p o n t a n eo u s p r e t e r m b i r t h s
o S h o r t c e r v i c a l l e ngt h w i t h n o p r i o r P T b i r t h
• T h e r e is n o r o l e o f p r o g e s t e r o n e o r to c o l y s i s o r
c e r c l a g e t o p r e v e n t p r e t e r m b i r t h w i th m u l t i p l e
pregnancies
• P r o g e s t e r o n e t h a t a r e u s e d:
o I M h y d r o x y p r o g e st e r o n e c a p r o a t e
o Vaginal micronized progesterone
Premature Rupture of Membranes
P R O M – w h e n m e m b r a n e r u p t u r e s b ef o r e o n s e t o f l a b ou r
- T e r m P R O M – o c c u rs a t m o r e t h a n 3 7 w e e k s
- P r e t e r m PR O M ( P P RO M ) – o c c u r s < 3 7 w e e k s

T h e m o r e n e a r t o t e r m t h e p a ti e n t i s, t h e e a r l i e r t h e l a b o r s t a r t s af t e r
PROM
C/F: -
P r i m a ry c om p l a i n t – l e a k i ng P /V
1 s t s t e p - E s t a b l is h h i s t o r y o f l e a k i n g
T h e n g o f o r P /S ex a m i n a t i o n
• L i q u o r i s s e e n c o m in g o u t of e x t e r n a l o s – d i ag n o s is o f PR O M is m a d e
• No leakage is seen
V u l v a a n d v a gi n a a re d r y – d o U SG t o c h e c k f o r li q u o r
- I f o n U SG , t h e r e is n o / s c a n t y / d e c r e a se d l i q u o r t h e n i t m e a n s t h a t
l e a k a g e m us t h a v e b e e n p r e s e n t e a r l i er
- I f o n U SG , t h e r e is n o r m a l l i qu o r t h e n a dm i t a nd ob s e r v e t h e
w o m a n . G i v e t h e p at i e n t s t e r i l e vu l v a p a d s a n d k e e p a c he c k
• T h e r e is p o o l i n g o f s e c r e t i o n s i n v a g i na o n t h e s p e c u l um b l a d e
W e b e c o m e u n s u r e w h e t h e r i t is l iq u o r o r c e r v i c o va g i n a l di s c h a r g e
W e c a n D o t e s t s t o c o n f i rm li q u o r ( am n i o t i c f l ui d )
- pH > 6.5 AfraTafreeh.com
- litmus paper test
- N i t r a z i n e t e s t ( c h an g e s y e l l o w t o b lu e )
- F e r n i n g of l iq u o r on g l a ss s l i d e w h i c h o c c u r s b / o N a C l p re s e n t i n
the AF
- A m n i su r e t e s t ( d e te c t s p l a c e n t a l α m ic r o g l o b u l i n )
- R o m p l u s t e s t s – d et e c t s i n s u l i n l ik e gr o w t h f a c t o r ( IG F), b i n di n g
protein 1 (BP-1)
M a n a g e m e n t o f PRO M : -
T e r m P R O M – i nd u ct i o n o f l ab o u r i s d on e
P r e t e r m PR O M
• I f p a t i e n t i s > 3 4 we e k s
- Induction of labour is done
- G i v e a n t ib i o t i c s
• < 3 4 w e e k s b u t > 24 w e e k s
G o f o r c o n s e r v a t iv e m a n ag e m e n t i . e .
- A dm i t t e d t o h o s p i ta l
- A dv i s e r e s t

AfraTafreeh.com
- Steroids
- G o f o r b a s e l i n e w or k u p
▪ TLC
▪ DLC
▪ CRP
R e p e a t i t e v e r y a l te r n a t e d a y
- G i v e a n t ib i o t i c s
▪ E r y t h r o m y c i n o r a l 2 5 0 m g Q I D x 1 0 d ay s
▪ A m p i c i l l i n + G e n t am i c i n
D o n o t g iv e am o x i -c l a v o r au gm e n t i n du e t o r is k o f n e c r ot i s i n g
e n t e r o c o l i t i s i n f o et u s
- W a t c h f o r S /S of c h o r i o a m n i o n i t is as i t m a y c a us e
▪ Maternal sepsis
▪ Sepsis neonate
▪ R e s p i r a t o r y di s t r es s s y n d r om e
▪ Seizures
▪ H i g h g r a d e f e v e r ca n c a u s e s ud d e n i n tr a u t e r i n e d e a t h ( IU D )
NOTE: -
S / S o f c h o r i o am n i on i t i s :
▪ F e v e r ( m o s t im p o r t a n t )
▪ T a c h y c a r d ia
▪ T e n d e r u t e r us
▪ F o u l sm e l l i n g v ag i na l d i s c h a rg e
▪ TLC elevated
I f a n y t im e d u r i ng co n s e r v a t i v e m a n ag e m e n t w e s e e f e a t u re s o f c h o r i o -
a m n i o n i t is t h e n w e h a v e t o t e r m i n a t e t h e p r e g n a n c y i r r e s p e c t i v e o f
gestational period
ANTEPARTUM HEMORRHAGE PLACENTAL ABRUPTION
• A n t e p a r t u m h a em o rr h a g e : B l e e d i n g f r om o n i n t o t h e g e n i ta l t r a c t a f t e r
t h e p e r i o d o f v i ab i li t y
Note:
o < 2 0 w e e k s → A b o rt i o n
o > = 2 8 w e e k s → P e r io d o f v i ab i l i t y (i n ou r s c e n a r i o)

o 2 6 w e e k s → T h r e s ho l d o f v i ab i l i t y
• A b r u p t i o p l a c e n t a & p l a c e n t a p r e v i a ar e t h e t w o c o n d i t i on s w hi c h l e a d t o
a n t e p a r t u m h a em o rr h a g e
• I n c i d e n c e o f A b r u pt i o P l a c e n t i o p l a c e nt a i s
0 . 5 % [ 1 i n 20 0 ]
• I n c i d e n c e o f P l a c en t a p r e v i a i s 0 . 3% [ 1 i n
300-400]
• P l a c e n t a l a b r u p t i on :
o P r e m a t u r e s e p a r a t io n o f a n o r m a l l y
situated placenta
o R i sk F a c t o r s :
o Pathology:
▪ B l e e d i n g o c c u r s i n to d e c i d u a b as a l i s as f r a gi l e
or defective spiral arteries get torn/ ruptured →
b l e e d i n g b e h i n d h e p l a c e n t a w h i c h f o rm a
Retroplacental haematoma
▪ This retroplacental haematoma will
c a u s e t h e u t e r u s to l o o k increased in
s i z e / l a r g e r i n f u nda l
AfraTafreeh.com height
▪ A l l t h is c o l l e c t e d b l o o d will make the
w o m a n s ym p t o m a ti c d u e to hypovolemia
▪ T h i s i n t e g ri t y b e t we e n the decidua & the
c h o r i o n w i l l g e t d isr u p t e d d u e t o t h e b l e e d i n g ; su c h di s ru p t i o n i n i ti a t e s
uterine contractions → Pain
▪ A s a r e s u l t of p l a ce n t a l a b r u p t i o n, i n t e r v i l l o u s s p a c e s g et f i l l e d w i t h
c l o t s & t h us , n o g as e o u s e x c h a n g e o c c u r s f o r t h e b ab y → F o e t a l
c o m p r o m is e / h y p o xi a wi l l o c c u r d e p e n d i n g u p o n t h e am o un t o f p l a c e n t a l
s e p a r a t i o n → C o m p le t e a b r u p t i o n c a n le a d t o I U D
N o t e : T h i s t y p e of a b r u p t i o n w h e r e t he r e i s r e t r o p l a c e n t a l h a e m a t om a &
v i s ib l e b l e e d i n g f r om t h e v a gi n a i s m i ni m a l o r ab s e n t i s c al l e d a s C o n c e a l e d
Haemorrhage
R e v e a l e d H a e m o r rh a g e :
o M a r g i n a l s e p a r a t i on o f p l a c e n t a → l e ad i n g t o s e e p i n g o u t o f b l o o d
f r o m i n b e t w e e n t he c h o r i o n & d e c i d u a c o m i ng o u t t h r o u gh t h e
v a g i n a is c a l l e d r ev e a l e d h a e m o r r h a g e

AfraTafreeh.com
Note:
▪ C o n c e a l e d h a e m o r r h a g e is m o r e
dangerous than revealed
h a e m o r r h a g e b e c a us e t h e r e i s
m o r e r is k o f D I C as m o r e t i ss u e
t h r o m b o p l a s t i n l e ak s i n t o
c i r c u l a t i o n f r om p la c e n t a
▪ [ B l o o d s e e p i n g i n t o m y o m e t r i um c a u s es a c o n d i t i o n c a l l e d C o u v e l a i r e
u t e r u s w hi c h i s s e en o n c - s e c t i o n & a /w r is k o f a t o n i c i t y a n d P PH ]
N o t e : C o u v e l a i r e u te r u s is n o t a n i n d i ca t i o n o f d o i n g h y s te r e c t o m y
D i a g n o s i s o f ab r u pt i o n o f P l a c e n t a : CF s + US G [ t o r u l e ou t P l a c e n t a p r e v i a ]
C/Fs:
▪ A n t e c e d e n t h i s t o r y o f t r au m a o r hi g h B P o r p r e e c l am p s i a c a n b e
present
▪ Pain
▪ B l e e d i n g [ a l t e r e d co l o u r e d b l e e d i n g]
▪ Features of shock
o P/A examination:
▪ U t e r u s t e n s e & t e nd e r
▪ U t e r u s t o n e i n c r e a s e s ( t h a t is i n b e t we e n c o n t r a c t i o n s u te r u s is n o t
completely relaxed)
▪ F u n d a l h ei g h t > P OG [ i f c o n c e a l e d h a em o r r h a g e ]
▪ F u n d a l h ei g h t = P OG [ i f r e v e a l e d ]
▪ F o e t a l H R → c a n b e n o r m a l / di s t r e s s e d
Note:
▪ M o s t l y w om e n wi t h p l a c e n t a l a b r u p t i o n g o i n t o l a b ou r if no t t h e n i n d u c e
l a b o u r b e c a u s e T t is a l w ay s t e r m i n a t i on
▪ M o s t c o m m o n f o e t a l c o m p l i c a t i o n w i t h a b r u p t i o n i s p r e m at u r i t y
o P / V e x am i n a t i o n:
▪ D o n o t d o P /V e x am i n a t i o n u n t i l u n l e ss y o u k n o w t h a t i t is n o t p l a c e n t a
p r e v i a i. e t h e l o c a ti o n o f p l a c e n t a h a s b e e n c o nf i rm e d o n U SG .
▪ T h e r e f o r e , I n a l l ca s e s o f a n t e p a r t um h a e m o r r h a g e i t i s v e r y im p o r t a n t
t o r u l e o u t p l a c e n ta p r e v i a b y U SG b ef o r e d o i n g P /V
o U SG : t o r u l e o u t p la c e n t a p r e v i a ; o n c e p l a c e n t a p r e v i a is r u l e d o u t
n o w y o u c a n d o t h e P / V e x am i n a t i o n
o O n P / V e x a m i n a t i o n: i f:
▪ Os open
▪ Cervix dilated

▪ Cervix is effaced
▪ T h e n d o a r t i f i c i a l ru p t u r e o f m em b r a ne s [ A R M ] w h i c h wi l l h e l p i n t w o
w a y s;
 T o f i n d o u t b l o o d st a i n e d l i qu o r , a n d th u s c o n fi rm t h e di ag n o s i s
 I t w i l l au gm e n t t h e u t e r i n e c o n t r a c t i on s
 I t a l s o d e c r e a s e s th e b l e e d i n g
Q : h o w i s t h e s ev e r i t y o f a b ru p t i o n g ra d e d ?
A c c o r d i n g t o P AG E c l a s s if i c a t i o n ,
I n m i l d e s t f o r m [ T y p e 0 ] → R e t r o s p e c t i v e D i a g n os i s [ P a t ie n t i s n o t
s y m p t om a t i c ]
[Type 1] →
▪ BPV +nt
▪ W o m a n is s t a b l e FH S i s n o r m a l
o [Type 2] →
▪ BPV +nt
▪ Severe pain
▪ Foetal distress
o I n m o s t s e v e r e f o rm [ T y p e 3] →
▪ IUD
▪ Women is in shock AfraTafreeh.com
▪ +- DIC
Management:
o Resuscitation
o T e r m i n a t i o n o f p r eg n a n c y
o N o r o l e o f c o n s e r v a t i v e m a n a g em e n t or T o c o l y si s
o M o d e o f t e rm i n a t i on :
▪ If:
• W o m a n is a l r e a d y in l a b o u r
• D e a d b ab y
• F H S is n o rm a l
• G o f o r a ug m e n t a t i on o f l ab o u r, v a g i na l d e l i v e r y s h o u l d
be attempted
▪ If:
• W o m a n is r em o t e / t o o f a r aw a y f r om de l i v e r y < 3 2
w e e k s [ n o t i n l ab o ur ] & v i ab l e f o e t u s
• O r f o e t a l d is t r e s s
• → Go for c-section
▪ I f t h e r e is D I C t he n :

AfraTafreeh.com
• G i v e FF P t r a ns f us io n
• C r y o p r e c i p i t a t e t r a n s f u si o n
• P r o c e e d w i t h v a g i na l d e l i v e r y
ANTEPARTUM HEMORRAGE; PLACENTAL PREVIA
• P l a c e n t a p r e v i a = Pl a c e n t a i s i n t h e l o w e r
u t e r i n e s e gm e n t
• Types:
o Type-1:
▪ P l a c e n t a l e d g e is wi t h i n t h e 2 cm
of internal os
▪ A k a L O W L Y I NG
o Type-2:
▪ P l a c e n t a i s j u s t c om i n g t o t h e
m a r g i ns of i n t e r v a l o s
▪ C a n b e of t w o t y p es :
• Anterior
• P o s t e r i o r : S t a l l w o r t h y s ig n s e e n i n m ar g i n a l t y p e 2
posterior placenta previa
o I n t h i s s ig n as t h e h e a d o f f o e t u s i s pu s h e d d ow n
i n t o t h e p e l vi s t h e r e i s c o m p r e ss i o n of p l a c e n t a
w h i c h l e a d s t o d e c re a s e i n f o e t a l H R
o Type-3:
▪ P l a c e n t a i s p a r t i a l ly covering
the internal os
o Type-4:
▪ P l a c e n t a i s c o m p l e te l y
covering the internal os

o T y p e 1 , 2 → Mi n o r D e g r e e o f p l a c e n ta p r e v i a
o T y p e 3 , 4 → M a j or D e g r e e o f p l a c e nt a p r e v i a
• N e w C l a ss i f i c a t i o n:
o W h e n e v e r t h e p l a ce n t a i s p a r t i a l l y o r c o m p l e t e l y c o v e r i ng t h e
i n t e r n a l o s [ m a j o r t y p e ] → i t i s c a l l e d P l a c e n t a P r e vi a
o I f p l a c e n t a l e d g e is a n yw h e r e w i t hi n 2 c m o f i n t e r n a l as → i t is
c a l l e d a s L o w - l y i ng P l a c e n t a
o I n b o t h t h e s e c a s es , g o f o r c - s e c t i o n [ N o v ag i n a l d e l i v e ry ]
• Risk factors:
o S m ok i n g
o Increase Age
o Increase Parity
o Multiple pregnancy
o h / o p r e v i o u s c - s e c ti o n [ I n c i d e n c e o f pl a c e n t a p r e v i a i n c r e a s e s 5
f o l d s wi t h a h / o p ri o r c - s e c t i o n [ 0. 4% t o 2 . 5% ]
o Endometritis
o U t e r i n e a n o m a li e s
• C l i n i c a l P r e s e n t a t io n :
o P a i n l e s s, c au s e l e s s B l e e d i n g
o F r e s h v a g i n a l b l e e di n g [ B r ig h t r e d c o l o u r ]
o
AfraTafreeh.com
1 s t e p i s o d e i s W a r ni n g H a em o r r h a g e
• P / A F i n di n g s:
o Uterus Relaxed
o F u n d a l h ei g h t = P OG [ F u nd a l h e ig h t c an b e sm a l l e r t h a n PO G if a / w
m a l p r e s e n t a t i o n E xa m p l e : T r a ns v e r s e l i e ]
o F o e t a l h e a r t S o u n d [ FH S] = n o rm a l
• P / S & P /V e x a m i n at i o n :
o N e v e r d o n e i n a d i ag n o s e d c a s e o f p l a c e n t a p r e v i a
o C a s e : w om a n i s:
▪ In labour
▪ Good uterine contractions
▪ FHS Normal
▪ B l e e d i n g P /V + n t
▪ U SG n o t av a i l ab l e
I n s u c h c o n d i t i o n we c a n d o P / V e x a m in a t i o n i n O T w i t h
e v e r y t h i n g r e a dy fo r a C - s e c t i o n
o I n v e s t i g a t i o n o f c ho i c e f o r di a g n o si s o f P l a c e n t a P r e v i a →
▪ U SG
▪ Start with TAS
▪ T VS is s a f e & b e t t e r f o r l o c a l i s a ti o n o f p o s t e r i o r p l a c e nt a

AfraTafreeh.com
• Management:
o C o n s e r v a t i v e M a n ag e m e n t : →
▪ M c C A F F EY P r o t o co l
▪ D o n e o n l y i f p a t i e nt i s:
• < 37 weeks
• Stable
• No active bleeding
• F o e t u s s h ou l d b e he a l t h y
▪ I n c o n s e r v a t i v e m an a g e m e n t p a t i e n t is :
• A dm i t t e d
• A dv i s e d t o r e s t
• S t e r o i d s if < 3 4 w ee k s
o S u r g i c a l M a n a g em en t :
▪ C-Section
▪ D o n e i f p a ti e n t i s:
• > = 3 7 w e e ks
• Unstable
• BPV Continues
• Already in labour
• D e a d b ab y
• G r o s s c o n g e n i t a l a no m a l y i n b ab y
• Foetal distress
• Placental Migration:
o I n m i d p r e g na n c y ab o u t 1 2% of a l l p l ac e n t a l a r e l o w l yi n g
o I f c o v e r i n g t h e OS → 40 % r e m a i n i n th e l o w e r u t e r i n e s e g m e n t
[ L US ]
o I f n o t c o v e r i ng o s → a l m o s t a l l w i l l m i g r a t e t o t h e u p p e r s e gm e n t
o I f t h e r e is a l o w lyi n g p l a c e n t a i n l e v el I I US G w e w i l l r e p e a t s c a n
a t 3 2 w e ek s → S t i ll l o w l yi n g → r e p e at a t 3 6 w e e k s t o c on f i r m t h e
l o c a t i o n o f p l a c e n t a a g ai n .
ABNORMALITIES OF PLACENTA, CORD & AF
• S u c c e n t u r i a t e P l a ce n t a :
o R i sk o f t h i s su c c e n t u r i a t e p l a c e n t a i s P P H
a n d r i sk o f r e t a i n ed p l a c e n t a l l o b e s

o a d d i t i o n a l l o b e a t ta c h e d t o t h e r e s t o f t h e p l a c e n t a l m ass vi a a
L e a s h of c o n n e c t i ng v es s e l s
o S o m e t im e s , T h i s a dd i t i o n a l l o b e m i g h t n o t b e c o n n e c t e d to t h e
m a i n p l a c e n t a l m a ss wi t h l e a s h o f c o n n e c t i n g v e ss e l s t h en t h i s
c o n d i t i o n i s k n ow n a s P l a c e n t a s p u r ia
o S o m e t im e s , t h e o t he r l o b e is e qu i va l e n t i n s iz e t o t h e m ain
p l a c e n t a l m a ss . T h en i t i s c a l l e d b i l o b at e p l a c e n t a
• C i r c um v a l l a t e P l a ce n t a :
o f e t a l m em b r a n e [ c ho r i o n & am n i o n]
d o u b l e b a c k o n t h e f e t a l s i d e & a r ou n d t h e
edge of the placenta.
o It occurs because the chorionic
p l a t e [ p a r t o f p l a ce n t a ] i s sm a l l e r t ha n
decidual plate
o C o m p l i c a t i o n s : I t ca n l e a d t o :
▪ Abortions
▪ IUGR
▪ P l a c e n t a l A b r u p t i on
o I t c a n b e i d e n t if i ed b y + n c e o f
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y e l l o w i s h / w h i t is h ri m o f f o l d e d
m e m b r a n e s a r o u n d t h e p e r i p h e r y o f t he p l a c e n t a
• Battledore Placenta:
o C o n d i t i o n i n w h i c h u m b i l i c a l c o r d is a tt a c h e d
to the periphery of the placenta
o R i sk is :
▪ PPH
▪ C o r d c o m p r e s si o n du r i n g l a b o r i f t h e pl a c e n t a i s i n l o w e r
u t e r i n e s e gm e n t
• V e l a m e n t o u s P l a c en t a :
o Cord is attached to
t h e m em b r a n e s i nst e a d o f
placenta

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o R i sk is :
▪ PPH
▪ C a n b e a / w v a s a p re v i a ; i n w h i c h f e t a l b l o o d v e s s e l s c o m e i n
front of the fetal head
▪ These vessels are unsupported
l y i n g o n t h e m e m b ra n e s & a r e n o t i ns id e t h e
u m b i l i c a l c o r d . S o w h e n i n t e r n a l o s d il a t e s d u r i ng
l a b o r o r ru p t u r e o f m em b r a n e s o c c u rs o r A R M i s
d o n e t h e n i t w i l l l ea d t o t e a r i n g o f f et a l b l o o d
v e s s e l s → B l e e d i n g [ F e t a l i n o r i g i n] w il l o c c u r a n d
c a n b e a /w f e t a l H R d r o p w h i c h c a n b e l i f e t h r e a t e n i n g →
G o f o r im m e d i a t e C - S e c t i o n
N o t e : W h e n e v e r t he r e i s d o u b t w h e t he r b l e e d i n g P /V i s m a t e r n a l o r f e t a l we
c a n d o t h e A P T T e st
▪ A q u a l i t a t iv e t e s t
▪ B a s e d o n a l k a l i d e na t u r a t i o n
▪ T a k e b l o o d s am p l e a d d a l ka l i [ K O H / N aO H ] →
• F e t a l b l o o d w i l l b e r e s i s t a n t t o a lk a l i [ w i l l n o t
d e n a t u r e d ] & r e m ain r e d
• Maternal blood get denatured & loses its color
• F u r c a t e c o r d i n s e rt i o n :
o The cord loses its protective wharton’s
j e l l y n e a r t h e i ns e rt i o n o f c o r d
o C o r d b e c o m e s p r o ne t o :
▪ T w is t i n g, C om p r e s si o n & T h r om b o si s
o f um b i l i c a l b l o o d ve s s e l s
• S i n g l e Um b i l i c a l a rt e r y : [ SU A ]
o N o r m a l l y , Um b i l i c a l c o r d h as :
▪ 2 arteries
▪ 1 v e i n [ L t . v ei n is le f t ]
▪ V e i n is b ig g e r w i t h 8 0 % O 2 S a t u r a t i o n
▪ U A h as f o l d s of H O B O K E N
▪ A v e r ag e l e n g t h of u m b i l i c a l c o r d → 55 c m
Short cord → < 35 cm [Can lead to abruption]
L o n g c o r d → > 7 0 cm [ c a n l e a d t o c o r d a r o u n d n e c k o r m ay b e
knots]
o I n c i d e n c e o f s i n g l e um b i l i c a l a r t e r y i s 0 . 6 - 2%
o I n c i d e n c e i s i n c r e as e d i n:

▪ M u l t i p l e p r e g n a n c i es
▪ Diabetic mother
▪ O l i g o / P o l y h y d r am n io s
o W i t h S i ng l e um b i l i ca l a r t e r y t h e r e is a p o s s ib i li t y o f G r o ss
C o n g e n i t a l a n o m a l y [ G CA ]
▪ M o s t c o m m o n r e n a l [ us u a l l y m i l d ] , C a rd i a c [ c a u s e s m o r e
p r o b l e m s]
o I f w e f i n d si n g l e UA o n USG t h e n d o d e t a i l e d t a r g e t e d so n o g r a p h y
& look for GCA:
▪ S UA + G C A → L o o k f o r a n e u p l o i d i es e sp e c i a l l y t r i s om i e s [ m c -
T r i s om y 1 8 ]
• K a r y o t y p e a n a l y si s [ I n v a si v e f e t a l t e st i n g ]
▪ N o G CA → T h e p r eg n a n c y i s s t i l l a t i nc r e a s e s r i sk o f
abortion
• Pre term delivery
• P r e m a tu r i t y
• IUGR
• P e r i n a t a l m o r b i di t y & m o r t a l i t y
• A m n i o t i c F lu i d :
o Main content:
▪ AfraTafreeh.com
W a t e r [ 98 - 9 9 % ]
▪ I t i s r e p l a c e d e v e ry 3 h o u r s [ 8 t im e s a d a y]
o Other contents:
▪ Vernix caseosa
▪ Lanugo
▪ E x f o l i a t e d f e t a l squ a m o us c e l l s
▪ P r o l a c t i n [ P r o l a c t in i n A F c om e s f r om d e c i d u a & h a v e r o le i n
m a i n t a i ni n g w a t e r b a l a n c e o f A F]
o O s m o l a l i t y:
▪ 260 mOsm/L
▪ H y p o o sm o l a r t h a n m a t e r n a l / f e t a l p l as m a
o pH → 7-7.5
o F u n c t i o n s:
▪ Protective
▪ S h o c k ab s o rb e r
▪ M a i n t a i n s e v e n t em p e r a t u r e a r o u n d t he f e t u s
▪ P r e v e n t s a s c e n di n g i n f e c t i o n s
▪ N o n u t r i t i v e f u n c t io n
o Colour:
▪ A t t e rm = S t r a w c ol o u r e d
▪ Preterm = Colourless

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▪ D a r k c o l o r e d / B l o o d s t a i n e d = A b r u p t i on
▪ T o b a c c o ju i c e = IUD
▪ S a f f r o n = P o s t m a tu r i t y
▪ G o l d e n = R h I s o i m m u n i z a ti o n
▪ Green =
• M e c o n i u m S t a i n e d li q u o r
• Unidentified breech
• F e t a l d i s t r e ss
• M a t e r n a l L i s t e r i o sis i nf e c t i o n
▪ A m o u n t → 1 6 w e e k s = 20 0 m l
3 2 - 3 4 w e e k s = 1 l i tr e [ m a x im um ]
4 0 w e e k s = 8 0 0m l
4 2 w e e k s = 2 0 0m l
o Major Source:
▪ I n 1 s t 1 2 w e e k s = u lt r a f i l t r a t i o n o f m at e r n a l p l a s m a
▪ B e t w e e n 1 2 - 2 0 w e e k s = T r a n su d a t i o n ac r o s s t h e f e t a l sk in
N o t e : f e t a l s k i n k er a t i n i z a t i o n o c c u r s b e t w e e n 2 2 - 2 5 w ee k s
▪ B e y o n d 1 8 w e ek s:
• Fetal urine
• A t t e rm 6 5 0 - 1 0 0 0m l u r i n e i s p r o d u c e d p e r d ay b y t h e
fetus
Q : W h e n d o e s t h e f e t u s s t a r t u r in e pr o d u c t i o n ?
A: 12 weeks
• R e g u l a t i o n o f AF v o l u m e a t t e r m :
o F e t a l s w a l l o w i ng s ta r t s a t 1 0 - 1 2 w e e ks . I t r em o v e s a b o ut
7 5 0 m l / d a y o f am n io t i c f l u i d v o l u m e
o L u n g s e c r e t i o n s a dd s ab o u t 3 5 0m l / d ay t o A F
o F e t a l u r i n e a d d s ab o u t 1 0 0 0 m l / d ay t o A F
o I n t r a m e m b r a n o u s f l o w a c r o s s f e t a l v e s s e l s o n p l a c e n t a l su r f a c e
r e m o v e s a b o u t 4 0 0m l / d a y
A F + n t a r o u nd t h e p l a c e n t a i s hy p o sm o l a r t o f e t a l a n d m a t e r n a l
p l a s m a → C h o r i o n i c v e ss e l s + n t o n t h e f e t a l s i d e o f p l a c e n t a .
I n s i d e t h em is t h e f e t a l b l o o d w h i c h is h y p e r o sm o l a r → S o w a t e r
c o n t e n t f r o m am n i ot i c f l ui d c a n m o v e in t o t h e c h o r i o n i c ve s s e l s →
T h i s is k n o w n a s I n t r a m e m b r a n o u s f l ow a c r o s s f e t a l v e s se l s
• Abnormalities:
o N o r m a l am o u n t of A F =
▪ AF index between 5-25 cm
▪ Single deepest pocket [SDP] 2 -8cm

o P o l y h y d r am n i o s [ I nc r e a s e d A F ] =
▪ A F I > 2 5 cm
▪ S D P > 8 cm
▪ A b s o l u t e am o u n t > 2 0 0 0 m l
o O l i g o h y d r a m ni o s ( de c r e a s e d a m ni o t i c f l u i d)
▪ A F I < 5 cm
▪ S D P < 2 cm
▪ A b s o l u t e am o u n t < 2 0 0 m l
• C a u s e s of P o l y h ydr a m n i o s →
o M o s t c o m m o n c au s e o f m i ld p o l y h yd r am n i o s is id i o p a t h i c
o M u l t i p l e p r e g n a n c i es
o C o n g e n i t a l A n om a l ie s :
▪ G I T ab n o r m a l i ti e s > N e u r a l T ub e d ef e c t s
▪ C l e f t l i p / c l e f t p a l at e [ m os t c om m o n]
▪ Esophageal atresia /Duodenal atresia
▪ Anencephaly
▪ C h o r i o - A n g i om a of p l a c e n t a
▪ Sacrococcygeal teratoma
▪ M a t e r n a l d i a b e t e s:
• M a t e r n a l H y p e r g l y ce m i a → f e t a l h y p e rg l y c e m i a → F e t a l
polyurea AfraTafreeh.com
• P r o b l e m s b / o p o l y hy d r a m ni o s →
o P o s s ib i l i t y o f G CA [ C h a n c e s o f a n om a ly i n c r e a s e s e v e n i f G CA i s
n o t i d e n t i f i e d o n US G
W i t h s e r v e p o l y hy dr a m n i o s = 1 0 % c h a nc e s o f G CA
W i t h m i l d p o l y h yd ra m n i o s = 1 - 2 % c h a nc e s o f G CA
o Unstable lie of baby
o Malpresentations
o Increased chances of c-section
o C o r d p r o l a p s e [ t h us i n p o l y h y d r am n i os → c o n t r o l l e d A R M i s d o n e i f
r e q u i r e d b / o ri s k of c o r d p r o l a p s e]
o Atonicity
• C a u s e s of O l i g o h yd r a m n i o s →
o A n om a l i e s:
▪ R e n a l a g e n e s is
▪ M u l t i c y s t i c d y s p l ast i c k id n a p
▪ Infantile PCKD
▪ Posterior urethral valve
o U t e r o p l a c e n t a l I n s u f f i ci e n c y :
▪ D e c r e a s e d r e n a l b lo o d f l o w → d e c r e a se u r i n e p r o du c t i o n →
o l i g o h y d r a m ni o s

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▪ HTN
▪ P r e - e c l a m p s i a / e c l a m p s ia
▪ IUGR
o P r e - m a t u r e r u p tu r e s o f m e m b r a n e
o P o s t t e r m p r e g n a n cy
• P r o b l e m s b / o o l ig o h y d r a m ni o s :
o Malpresentations
o C o r d c o m p r e s si o n
o Fetal HR decelerations
o M e c o n i um p as s a g e
o Increase changes of C-section
N o t e : A M N I O I NFU S I O N is r e c om m en d e d f o r f e t a l H R d e c e l e r a t i o n s i n l ab o r
w h i c h a r e a s s o c ia t e d w i t h o l i g o h y d r am n i o s
T h e s e F H R d e c e l e r a t i o n s a r e v a r i ab l e d e c e l e r a t i o n s w h i ch s ig n i fy c o r d
compressions
o O l i g o h y d r a m ni o s b ef o r e 2 0 - 2 2 w e e ks [ e a r l y o n s e t ]
o d / t R e n a l ag e n e s i s
▪ L im b C o n t r a c t u r e s
▪ C o m p r e s s i o n o f f a ce
▪ P u l m o n a r y H y p o p l a si a
• T h e s e c o n d i ti o n s +n t a l o n g wi t h b i l a t er a l r e n a l a g e n e si s
i s c a l l e d P o t t e r ’ s Sy n d r o m e
o I f s am e c o m p l i c a t io n s a r i s e w i t h o u t re n a l a g e n e s i s (d u e t o s o m e
o t h e r c a u s e o l i g o h yd r a m n i o s) t h e n t h e c o n d i t i o n i s c a l l e d P o t t e r ’ s
Sequence
TWIN PREGNANCY
• Types:
o Dizygotic twins:
▪ Two eggs fertilised by 2 separate sperms
▪ FRATERNAL twins
▪ Always dichorionic diamniotic DADC twins
▪ Incidence of DZ twins increase with:
• Increase Age of mother
• Family history
• Ovulation induction & IVF
• Varies with ethnicity

• More common than monozygotic twins
o Monozygotic twins:
▪ A single egg fertilised by a single sperm forming a zygote
▪ This zygote undergoes division
leading to twinning
▪ IDENTICAL TWINS
▪ Incidence is constant [1 in 250]
▪ According to timing of division we
get various types of monozygotic
twins
▪ If division takes place < = 3 days of fertilisation then we get
DADC twins
• Placenta can be separate or fused
• But no communication between 2 plac entas
▪ If division takes place between
4-8 days of fertilisation then we get
monochorionic diam niotic twins [MCDA]
• Sharing of placenta [Fused Placenta]
• Vascular Communication present in between
2 placentas
• AfraTafreeh.com
Two twins are separated just by the amniotic mem branes b ut there is no
intervening chorion in between
▪ If division takes place beyond 8 days but within 13 days of
fertilisation [8 -13 days] then we get monochorionic
monoamniotic twins [MCMA]
• Sharing of placenta
• Sharing of amniotic cavity that is lie
within the same am niotic sac
▪ If division takes place
beyond 13 days [> 13 days] of
fertilisation or beyond
embryonic disc formation
then we get monochorionic
monoamniotic conjoined
twins [aka SIAMESE Twins]
• Most common type is Thoracopagus

o Summary:
▪ Dizygotic twins >>>
Monozygotic twins

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▪ Dizygotic twins → always DCDA

• overall DCDA is the most common type
▪ Monozygotic twins → DCDA, MCDA, MCMA
• Among Monozygotic
• Monochorionic > Dichorionic
• Superf etation:
o Fertilisation of two eggs in 2 separate menstrual cycles
o Theoretically possible yet not
documented in humans
• Superf ecundation:
o Fertilisation of two eggs in same
menstrual cycle but with two
separate acts of coitus
• Chorionicity: Chorionicity means
placentation
o Chorionicity is very important because the outcome of twin
pregnancy depends on the chorionicity
o Determination of chorionicity → by USG
▪ Very early USG [1 s t trimester] = can show us 2 separate
placentas [Dichorionic]
▪ Twin Peak Sign:
• Aka LAMBDA sign
• thicker inter twin membrane (consisting of
two amnions & 2 chorions) and there is
dipping of chorion in between the intertwin
membrane
• Best seen at 10 -14 weeks
• If positive, it indicates DCDA twins
▪ T Sign:
• Used to confirm mo nochorionic twins
• no dipping of chorion in between the amnions.
Thinner intertwin membrane (consisting of only 2
amnions)
• It indicates +nce of MCDA twins
▪ Thickness of intertwin membrane
=
• Can be appreciated between 18 -24 weeks
• If thickness is > = 2 mm it means DCDA
twins
▪ Placental Examination:
• DCDA Placenta:

o Could be both DZ/MZ twins
• MCDA Placenta:
o MZ twins
• MCMA Placenta:
o MZ twins [No intertwin membrane]
• Determine Zygosity?
o Opposite sex → Dizygotic
o Same sex with different blood group → Dizygotic
o Same sex with same blood group → Could be DZ or MZ
o Best way to determ ine zygosity is by DNA fingerprinting
• Maternal Complications:
o Depend on the number of foetuses rather than the type of twins
▪ Anaemia
▪ HTN & Pre-eclampsia
▪ Polyhydramnios
▪
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Mechanical Distress
▪ Preterm lab our
▪ PPROM
▪ APH
▪ Malpresentations
▪ Increased risk of c -section
▪ PPH
▪ Uterine subinvolution
• Foetal Complication: More in MZ twins than DZ twins
o Abortions
o Congenital malform ations
o Low birth weight
o IUGR
o Risk of 1 twin dying
o Discordant growth
Note: When 1 twin dies:
o In very early pregnancy

▪ The dead twin vanishes
▪ No trace of gestational sac of the dead twin
▪ Known as vanishing twin

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o In early pregnancy [14 -16 weeks]:

▪ Surviving twin progresses its development
▪ Another twin gets compressed
▪ Known as Foetus papyraceous
o In later on pregnancy:
▪ If 1 twin dies then there is risk of dying to the other twin as
well
▪ More common in MC twins
▪ If another twins survives then it may have permanent
neurological impairment
• Discordant Growth:
o Twins are called discordant when [(Weight of larger twin – Weight
of Smaller twin) / weight of larger twin] is > 20%
• Complications specific to MCDA twins:
o Twin to twin transf usion syndrome [TTTS]
o Twin reversed arterial perfusion [TRAP also called acardiac twin]
o Twin Anaemia Polycythaemia Sequence [TAPS]
• Complications specific to MCMA:
o Cord entanglement
o Interlocking of twins
o There are twins which:
▪ Have maximum risk of dying
▪ Are not allowed to deliver vaginally
• TTTS:
o Specific to MCDA twins because their
placentas hav e vascular communications
o Usually, artery to artery or vein to vein
superficial anastomosis are +nt
o But sometimes, there can be deep artery to vein anastomosis in
MCDA twins that is umbilical artery of one twin to umbilical vein of
other twin
o As a result of this anastomosis the
Blood from umbilical artery of donor twin → goes to the → Umbilical
vein of Recipient twin
▪ Donor Twin: has
• Anaemia
• Growth restriction
• Oliguria
• Oligohydramnios

• Ischemia to brain leading to cerebral palsy
• Called as Stuck twin
• Looks pale
▪ Recipient Twin: has
• Plethoric appearance
• Heart failure due to circulatory over load
• Polyhydramnios
• Polycythaemia
• Hyper viscosity of blood which can lead to thrombosis of BVs
• Quintero Staging f or TTS:
TRAP:
o Aka Acardiac twin

o Umbilical artery from donor twin
carries deoxygenated blood via l arge
artery to artery anastomosis to the
umbilical artery of recipient which
then carries deO 2 b lood to iliac
vessels of recipient →
▪ So lower body of recipient twin grows but the upper part has
no heart AfraTafreeh.com
▪ & The surviving [donor] twin has high output cardiac failure
• Mode of deliv ery: Depends on the lie of 1 s t twin or presenting twin [which
comes 1 s t in birth canal]
o Most common lie → Both longitudinal
o Most common presentation → Both vertex
o If 1 s t twin is vertex [cephalic] = vaginal delivery
o If 1 s t twin is vertex & 2 n d breech = vaginal delivery + Assisted
breech vaginal deliv ery for 2 n d twin
o If 1 s t twin is vertex & 2 n d is transverse = Va ginal delivery + Internal
podalic version for 2 n d twin
o If 1 s t twin is breech transverse → C-section
o MCMA twins →
▪ Always c-section [as there is risk of interlocking]
▪ Done between 32 -34 weeks
▪ After giving a course of steroids
• Timing of delivery:
o Uncomplicated DC twins [dichorionic] → deliver after 38 weeks are
completed
o Uncomplicated MC twins → deliver after 37 weeks
o Uncomplicated Triplets → Deliver after 37 weeks

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• Prevention of preterm lab o ur in twins: Rest & monitor only

o No role of progesterone, cerclage, tocolysis
Understanding the basis of Pregnancy in
RH –ve Mother (RH incompatibility)

W h e n e v e r t h e r e is i n c o m p a t ib i l i t y b /w f e t a l R B C s A g an d m a t e r n a l RB C s i t ca n
l e a d t o h a e m o l y t i c d i s e a s e of f o e t u s an d n e w b o r n .
L e w i s A g a n d I A g a r e n o t i n v o l v e d i n h a e m o l y t i c di s e a s e o f n e w b o r n
T w o t y p es o f i n c om p a t i b i l i t y: -
1 . R H i n c o m p a ti b i li t y
• M o s t c o m m o n l y D ty p e i s i nv o l v e d i n RH in c o m p a t ib i l i t y
• R H g e n e l o c u s is o n s h o r t a rm o f C h r . 1
2 . A B O i n c o m p a ti b i li t y
R H I n c om p a t i b i l i t y:
▪ D u r i n g 1 s t p r e g n a n cy if m o t h e r is R h -v e
a n d 1 s t f o e t u s i s + ve i . e f o e t a l R B C s ar e R h
A g + v e . T h e s e f e t a l R B C s e n t e r t h e m at e r n a l
circulation through the placenta and being
f o r e i g n in n a t u r e Rh A g e l i c i t s i m m u n e
r e s p o n s e i n m o t h e r l e a d i n g t o f o rm a t io n o f
A n t i - R h a n t ib o d i e s .
N O T E : - o n 1 s t e x p o s u r e t o A g I g M t yp e o f
A b s a r e f o rm e d w hi c h d o n o t c r o s s p l a c e n t a .
T h e r e f o r e , 1 s t p r e gn a n c y is u s u a l l y s p ar e d
▪ O n 2 n d e x p o s u r e , wh e n t h e 2 n d f o e t u s i s ag a i n R h + a nd fe t a l R B C s e n t e r
t h e m a t e r n a l c i r cu la t i o n t h e n am n e s t ic r e s p o n s e is s e e n i . e i n c r e a s e d n o .
o f a n t i - R h A b s a r e f o r m e d a n d t h a t t o o o f I gG t y p e wh i ch c a n c r o ss t h e
p l a c e n t a l e a d i n g t o f o e t a l h em o l y s is .
▪ O n c e t h e w o m a n h as b e c o m e s e n s i t iz ed , t h e o u t c o m e w o r s e n s wi t h e a c h
s u c c e s s iv e p r e g n a nc y .
▪ R h i n c om p a t ib i l i t y c a n o c c u r du r i n g 1 s t p r e g n a n c y i f t h e wo m a n i s a l r e a d y
s e n s i t iz e d du e t o pr i o r i n c o m p a ti b l e b l o o d t r a n s f us i o n o r a b o r t i o n .
A B O i n c o m p a t ib i l i ty : -
▪ Mother is ‘O’ blood group

- R B C s h av e n o A n t i ge n A o r B )
- P l a s m a h as a n t i A ; a n t i B a n t i b o di e s
▪ F o e t u s is
- A –> A Ag present on RBC
- B – > B A g p r e s e n t on R B C
- A B – > A a n d B A g pr e s e n t o n R B C
▪ A B O i n c o m p a ti b i li t y is m o r e c om m o n th a t R h i n c o m p a ti b i li t y
▪ It usually does not affect the foetus beca use anti-A and anti-B
a n t i b o d i e s a r e m o st l y o f Ig M t y p e a nd t h e y d o n o t c r o s s t h e p l a c e n t a
a n d d o n o t a f f e c t t h e f o e t a l R B Cs
▪ I f t h e r e is h a em o l yt i c d i s e as e o f n e w b o r n t h e n m o s t c o m m o n c a us e is
A B O i n c o m p a ti b i li t y a n d i s m i l d e r t h an R h i n c o m pa t i b i l t y
▪ A B O i n c o m p a ti b i li t y us u a l l y d o e s n o t a f f e c t t h e f e t u s, it c a n af f e c t t h e
n e w b o r n b e c a u s e o f p r e s e n c e o f s om e I gG t y p e a n t i A a nd a n t i B A b s i n
the maternal serum
▪ A B O i n c o m p a ti b i li t y c a n p r e s e n t i n t he 1 s t b o r n
▪ W h e n e v e r R h i n c om p a t i b i l i t y a n d A B O i n c o m p a t ib i l i t y o c c u r s t o g e t h e r
( e g . w h e n m o t h e r i s O - v e a n d f o e t u s is A +v e ) t h e s e v e r i ty o f R h
i n c o m p a t ib i l i t y d e cr e a s e s b e c a u s e t h e m a t e r n a l a n t i -A A b s w i l l d e s t r o y
f o e t a l R B C s c o n t a in i n g A a n t i g e n b ef o r e t h e y a r e ab l e t o a c t i v a t e an
immune response in the mother. AfraTafreeh.com
M a n i f e s t a t i o n s of F e t a l H a e m o l y t i c D i s e a s e ( e r y t h r o b la s t o s i s f e t a l i s ):
1. Hydrops Fetalis
▪ O c c u r s if – H b o f fe t u s
< 5 gm % o r H a em a t o c r i t < 1 5 %
▪ D i a g n o s i s is m a d e if
t h e r e a r e 2 o r m o re e f f us i o n s o r
t h e r e i s 1 e f f us i o n + a n a s a r c a
▪ It can be
o P l e u r a l e f fu s i o n
o P e r i c a r d i a l e f f us i on
o A s ci t e s e f f u si o n
▪ Other associated features
o P o l y h y d r am n i o s
o Placentomegaly
o Skin edema around scalp
c a l l e d a s B u d d h a’ s s i g n / h a l o
s i g n ( s e e n o n USG

AfraTafreeh.com
N O T E : - F E T O MA T E R N A L H E M O R RH A G E
▪ 0 . 1 m l o f f e t a l R B Cs is e n o ug h t o s e n si t i z e t h e m o t h e r
▪ M a x . r i sk o f f e t o m a t e r n a l h a e m o r r h a ge i s d u r i ng d e l i v e r y i . e
i n t r a p a r t u m p e r i o d . B u t i t c a n a l s o o c c u r a n t e p a r t um w h er e r i s k
i n c r e a s e s wi t h i n c r e a s e i n P O G t h u s m a x . r i sk i n t h e a n t e p a r t u m
p e r i o d i s i n 3 r d t r im e s t e r .
S e n s i t i si n g e v e n t s t h a t c a n i n c r e a s e th e c h a n c e s o f f e t o - m a t e r n a l
haemorrhage: -
Management: -
▪ I n w o m a n w h o a r e no t y e t s e n si t i z e d (i. e
n o a n t i - D A b s a r e pr e s e n t )
▪ G o a l is t o p r e v e n t s e n s i t iz a t i o n f o r wh i c h
w e u s e r o u t i n e a n t en a t a l A n ti - D
p r o p h y l a x i s ( RA A DP )
▪ T h i s p r o p h y l a x is d ec r e a s e s t h e r is k o f
a n t e p a r t u m s e n s i t iz a t i o n f r o m 2% 0 .2%
▪ I t i s g iv e n a t 2 8 we e k s
C l i n i c a l m a n a g em e n t o f p r e g n a n c y i n R h – v e m o t h e r a n d c l i n i c a l s c e n a r i o s
C a s e 1 : -W om a n wh o i s n o t y e t s e ns it i z e d
E g : - p r e g n a n t f o r 1 s t t i m e a nd h e r b lo o d g r o u p i s R h – v e
• A sk f o r hu sb a n d ’ s b l o o d g r o u p
• I n d i r e c t c o o m b s t es t ( I CT ) – f o r p r ese n c e o f a n t i - D A b s i n m a t e r n a l
serum
NOTE: -
R h fa c t o r i s i n h e r it e d i n r e c e s si v e m an n e r
Eg: -
• M o t h e r i s R h – v e [ - - ] ; Fa t h e r i s R h – ve [ - -]
F o e t u s wi l l b e R h – v e
N o r i s k o f s e n si t i z a t i o n
• M o t h e r i s R h – v e [ - - ] ; Fa t h e r i s R h + ve [ + -, + +]
F o e t u s c a n b e R h +v e
I f I C T is n e g a t iv e i n 1 s t v i si t

Repeat it at 28 weeks
I f s t i l l – v e t h e n g iv e a n t i - D i n j e c t i o n 3 0 0 μ g = 1 5 0 0 I U i. m i n d e l t o i d
m u s c l e . T h i s is R A A D P w h i c h is gi v e n a t 2 8 w e ek s
T h i s w om a n d e l i v e rs a t 4 0 w e ek s ( t e r m )
C h e c k b ab y b l o o d gr o u p
▪ I f R h – v e – > d o n o th i n g
▪ I f R h + v e – >A n t i - D i n j e c t i o n t o m o t h e r w i t h i n 7 2 h r s o f de l i v e r y
( s o m e b e n e f i t e x i st s e v e n i f d e l a y e d t i l l 2 8 d ay s) ; D o s e = 3 0 0 μ g/
1 5 0 0 I U i .m
NOTE: -
• A n y p o t e n t i a l l y s e ns i t i z i n g e v e n t s h a ve t o b e s e p a r a t e l y c o v e r e d b y
g i v i ng a n ti - D i n j e c ti o n i r r e s p e c t i v e o f t h e r o u t i n e a n t e n at a l a n t i - D
p r o p h y l a x i s [ RA A DP ]
• I f t h e r e is ab o r t i on
< 1 2 w e e k s – gi v e 5 0 𝜇g i .m d o s e
AfraTafreeh.com
> 1 2 w e e k s – gi v e 3 00 μ g i .m d o s e
3 0 0 μ g = 1 5 0 0 I U o f a n t i - D i n j e c t i o n i .m
N e u t r a l i s e s 1 5m l of f o e t a l R B C s = 3 0 m l o f f o e t a l w h o l e b l o o d
( f e t o m a t e r n a l h a em o r r h a g e )
B u t i n 0 . 3% c a s e s f e t o m a t e r n a l h a e m or r h a g e d u ri n g t h e t i m e of d e l iv e r y
w i l l b e m o r e t h a n 30 m l . T h e n t h is d o se o f 3 0 0 μ g w i l l b e in a d e q u a t e .
• T h u s, i d e a l l y R h – v e ( n o t y e t s e n s i t iz e d ) m o t h e r w h o d e l i v e r s R h +v e
f o e t u s s h ou l d g o f or t e s t i n g f o r e x a c t a m ou n t o f f e t o - m at e r n a l
h a e m o r r h a g e c a l c u la t i o n .
• T h e t e s t u s e d i s K L E I H A U E R B E T K E Te s t = a n a c id e l u t i on t e s t w h e r e
c i t r a t e i s u s e d a s b u f f e r . I t is q u a n t i ta t i v e t e s t w h e r e we c a n c o u n t t h e
f o e t a l R B C s v s m a te r n a l R B C s
Procedure: -
W i t h i n a f e w h r s o f d e l iv e r y t ak e t h e m a t e r n a l b l o o d s am p l e a n d p r e p a r e a
slide
S l i d e is s t a i n e d b y c i t r a t e b uf f e r

AfraTafreeh.com
M a t e r n a l R B C s w i l l l o s e H b b e c a u s e t he a d u l t H b is s e n s it i v e t o a c id e l u t i o n
b u t f o e t a l R B C s wi ll r e t a i n t h e H b as it i s r e s i s t a n t t o a ci d d e n a t u r a t i o n
M a t e r n a l R B C s a r e c a l l e d g h o s t c e l l s as o n l y o u t l i n e r em a in s w hi l e f e t a l R B C s
appear red
W e c o u n t t o t a l n o . o f c e l l s ( u su a l l y 200 0 )
% f e t a l c e l l s = N o . o f f e t a l c e l l s c o u n te d x 1 0 0
T o t a l n o . o f Rb c c o un t e d
V o l u m e o f f o e t a l b lo o d (m l ) t h a t h a s le a k e d i n t o
m a t e r n a l c i r c u l a t i on ( F e t om a t e r n a l H ae m o r r h a g e )
= % of foetal cells x 50
Eg->
C a s e 2 : M o t h e r i s a l r e a d y s e ns i t iz e d i . e A l l o - i m m u niz e d P r e g n a n c y
• R h – v e m o t h e r wi t h I C T + v e
• C h e c k B G o f f a t h e r, i f R h + v e d o t h e ge n o t y p i n g o f f a t h er
Rh +ve : -
• H o m oz y g o us [ + +] – f o e t u s wi l l b e a l w ay s R h +v e
• Heterozygous [+ -] –
- 5 0 % c h a n c e s o f f oe t u s b ei n g R h – v e
- I n t h i s c a s e w e c a n g o f o r f o e t a l b l o od t e s t i n g a n d R h t e s t i n g
b y c e l l f r e e f o e t a l D N A t e s t i ng

• A l l t h is p r o c e ss o f g e n o t y p i n g a nd f e t a l D N A t e s t i n g is ve r y e x p e n s i v e i n
o u r s c e n a r i o, s o i t s u su a l l y n o t d o n e i n r o u t i n e c l i ni c a l p ra c t i s e .
• T h u s, R h – v e m o t h e r – > I C T + v e – > C a l c u l a t i o n o f T i t r e s of I C T
▪ < 1 : 1 6 [ 1 : 1 6 i s t h e c r i t i c a l t i t r e] o r <1 5 I U / L
R e p e a t I C T m o n t h ly / 2 w e e k ly t i l l i t cr o s s e s t h e c r i t i c a l t i t r e
▪ I f t i t r e s > 1: 1 6 ( e g 1 : 3 2, 1: 6 4 )
W e c h e c k t h e p e a k s ys t o l i c v e l o c i t y in m i d d l e c e r e b r a l ar t e r y w e e k l y
t o d e t e c t t h e f o e t a l a n a e m i a e a r l y (do n e b y US G D o p p l e r )
W h e n M CA - P SV i s >1 . 5 M O M ( M u l t i p l e o f m e d i a n ) i t m e a ns t h a t t h e
f o e t u s is a na e m i c . ( M C A - PS V D o p p l e r c a n b e u s e d t i l l 3 5 w e e k s o n l y)
C o r d o c e n t e s i s i s d on e n e x t , if p r e g na nc y < 34 w e e ks
C o r d o c e n t e s i s i s d on e t o c h e c k t h e b l oo d g r o u p a n d f o e t a l h a e m a t o c r i t
I f H c t < 3 0 % g iv e i n t r a u t e r i n e t r a n s fu s i o n
AfraTafreeh.com
K e e p r e p e a t i n g t h i s c y c l e o f c o r d o c e n t e s i s a n d i n t r a u t e r in e
t r a n s f u si o n e v e r y 10 - 1 5 d a y s a s t h e g oa l i s t o r e a c h > 3 4 w e e k s a t
least
A f t e r 3 4 w e ek s w e c a n d o i nd u c t i o n of l a b o u r
N o t e : - E a r l i e r am n i o c e n t e s i s w as d o n e t o d e t e c t f o e t a l a n e m i a .
( i n v as i v e t e c h n i q u e) w hi c h w e c h e c k e d t h e o p t i c a l d e ns i ty o f am n i o t i c
f l u i d a n d g r a p h s l ik e o n Q u e e n a n ’ s g r ap h , L i l e y ’ s g r a p h we r e u s e d .
C a s e 3 : - W h e n wo m a n h a s h / o p r i or a f f e c t e d p r e g n an c y
T h i s t im e t h e r e i s n o r o l e o f t i t r e s i ns t e a d s t a r t m o n i t or i n g M CA - PS V
D o p p l e r d i r e c t l y f ro m 1 8 w e e k s o n w a rd s o r 1 0 w e e ks p r i or t o t h e a ff e c t e d
pregnancy.
E g : - i n h e r p r e v i ous p r e g n a n c y h e r f oe t u s w as af f e c t e d b y h a e m o l ys i s a t 32
w e e k s , t h e n s t a r t m o n i t o r i n g t h e f o et u s a t 2 2 w e e k s i n c u r r e n t p r e g n a n c y
Extra Edge –
• S o m e t im e s w e h a v e K e l l A g o n t h e R B Cs

AfraTafreeh.com
• W h e n e v e r t h e r e is i n c o m p a t ib i l i t y o f K e l l A g t h e a n t i - K el l A b s i n m o t h e r
c a n e n t e r t h e f o e tu s t o a t t a c k -
- Foetal RBCs
- F o e t a l i m m a t u r e e r y t h r o b l a s t s ( a l s o ha v e K e l l A g)
T h u s i t w i l l l e a d t o B o n e m a r r o w s u p p re s s i o n o f f o e t us t oo .
• V e r y l i t t l e am o u n t o f A b s c a n c a us e b o n e m a r r o w s u p p r es s i o n . T hu s i t
c a u s e s m o r e s e v e r e f e t a l a n em i a .
NOTE: - Hydrops Fetalis
N o n - i m m u n e h yd r o p s ( m o s t c o m m o n ) > I m m u n e H y d r o p s
• O v e r a l l m o s t c o m m o n c a u s e of n o n - im m u n e h y d r o p s i s C VS a n om a l i e s o f
the fetus
• 2 n d m o s t c om m o n c au s e = c h r o m os o m a l a b n o r m a li t i e s i n f oe t u s
• I f h y d r o p s is d i a g no s e d a n t e n a t a l l y . Eg - h y d r o p s i n 2 n d t r i m e s t e r U SG ,
t h e n m o s t c o m m o n c a u s e is a n eu p l o i d y (m o s t c om m o n T u rn e r ’ s s y n d r om e )
• F e t a l i n f e c t i o n s [ m o s t c o m m o n P a r v o v ir u s B i nf e c t i o n )
• α t h a l a s s em i a
• inborn errors of metabolism in foetus
Pregnancy with previous caesarean
birth and rupture uterus

P a t i e n t w i t h p r e v io u s C - s e c t i o n :
1 s t c o n c e r n i s r i sk o f s c a r r u p t u r e . I t d e p e n d s o n:
• T y p e of s c a r
• N o . o f s c a r s i . e num b e r o f p r i o r C S
• Interdelivery interval
2 n d c o n c e r n i s d e l iv e r y
• W h e t h e r s h e s h o u ld b e g iv e n T O LA C i. e T ri a l o f l a b ou r af t e r C - s e c t i o n
• O r I s i t g o i ng t o b e E R C S i . e e l e c t i v e r e p e a t C - s e c t i o n
R i s k o f Ru p t u r e [ wi t h d if f . t y p e s o f ut e r i n e i n c i s i o ns ]
1. Classical C-section
• A v e r t i c a l i n c i si o n ( SA N G ER ’ s i n ci s i o n) o n
upper part

• A T - s ha p e d o r J s ha p e d i n c is i o n i n l o we r s e gm e n t
• R i sk o f r u p t u r e w i th c l a s si c a l , T s h a p ed , J s ha p e d i n ci s i on i s ab o u t
2-9%
2 . L o w e r s e gm e n t v e rt i c a l i n c i s i o n
• A k a KR O N I G S i n c isi o n
• R i sk o f r u p t u r e - 2 - 9 %
3 . L o w e r s e gm e n t t r a n s v e r s e i n c is i o n
• A k a K E RR ’ s I n c is i on
• R i sk o f r u p t u r e
- S i n g l e i n c i si o n ( 0. 2 - 0 . 9 % )
- M u l t i p l e i n c is i o n ( 0. 9 - 1 . 8 % )
Interdelievery Interval: -
• Ideally it should be >18 months

• M i n i m um in t e r p r e g n a n c y i n t e r v a l s h o ul d b e a t l e a s t 6 m on t h s
• S h o r t e r t h e i n t e r de l i v e r y i n t e r v a l m o r e c h a n c e s o f s c a r r u p t u r e
TOLAC: -
A v e r a g e s u c c e s s ra t e o f T O L A C i s 74 %
• Factors which
Increases the success rate of TOLAC
AfraTafreeh.com
i. Prior vaginal delivery (most imp)
ii. If woman is at term
iii. If woman has spontaneous labour
iv. Previous C-section for non-recurrent indication. Eg – Breech
• Decreases the success rate of TOLAC (These are relative indications of
repeat C-section
i. Post term (>40 weeks)
ii. Induced labour
iii. Macrosomia
iv. Multiple pregnancy
v. Breech in this pregnancy
vi. Pre-eclampsia
vii. Short interdelivery interval
N O T E : - i n d u c t i o n o f l ab o u r i s n o t C /I i n pa t i e n t w i t h p re v i o u s C - s e c t i o n b ut
i t i s n o t u s u a l l y d on e
A b s o l u t e I n d i c a t i on s o f E l e c t i v e r e pe a t C S :
• No consent for ToLAC

• P r e v i o u s c l a s si c a l T o r J s h a p e d i n c is io n
• Prior 2 C-section

AfraTafreeh.com
• h / o p r i o r s c a r r u p tu r e
• h / o p r i o r u t e r i n e su r g e r y w i t h c av i t y o p e n
• C P D i n cu r r e n t p r e g n a n c y ( n o t i n p a s t p r e g n a n c y )
• A n y C / I f o r v ag i n a l d e l i v e r y
R e l a t i v e I n d i c a t i o ns f o r CS i n a w om a n w i t h p r i o r C S :
• Breech
• Macrosomia
• Post term
• T w i ns
• Short interdelivery interval
R U P TU R E UT E R US
Q . C a n u ns c a r r e d ut e r u s r u p t u r e ?
A . Y es , i n c o n d i t i o ns l ik e
• O b s t r u c t e d l ab o u r
• Neglected shoulder
• Grand multiparity
• E x c e s s i v e u t e r i n e co n t r a c t i o n s
R u p t u r e o f u t e r us i s o f 2 t y p e s
1. Incomplete
▪ A l s o c a l l e d s c a r d eh i s c e n c e
▪ v i s c e r a l p e r i t o n e um o f u t e r u s o v e r l y i ng t h e s c a r is i n t a c t
2. Complete
▪ V i s c e r a l p e r i t o n e um i s a l s o ru p t u r e d
C l i n i c a l l y : - w e i de n t i f y im p e n di n g rup t u r e w h i c h c a n p ro g r e s s t o ru p t u r e
u t e r u s i n n o ti m e . W i t h ru p t u r e o f u te r u s p l a c e n t a l s e p ar a t i o n o c c u r s a n d
baby may die
C / F s of im p e n d i n g r u p t u r e : -
• M a t e r n a l t a c h y c a r di a
• S c a r t e n d e r n e s s ( in c o n s i s t e n t f e a t u re )
• F e t a l h e a r t r a t e c ha n g e s ( m os t c o n s ist e n t f i n d i ng )
1st tachycardia occurs
Variable decelerations
Late decelerations
B r a d y c a r di a

C / F s s u gg e s t i v e of R u p t u r e :
• M o t h e r h a s h y p o t en s i o n
• D e a d b o d y /f e t a l b ra d y c a r d i a
• U t e r i n e c o n t o u r l o st
• S u d d e n c es s a t i o n of u t e r i n e c o n t r a c t i o n s
P / V f i nd i n gs o f R up t u r e
• F r e s h v a g i n a l B l e e di n g
• Loss of station
• H e m a t u ri a
Management: - re s u s c i t a t i o n a n d u rg e n t C - s e c t i o n [ C a te g o r y 1 C - s e c t i o n ]
Morbidly Adherent Placenta
I n m o rb i d l y a d h e r en t p l a c e n t a , t h e p l ac e n t a i s i n v a di n g th e m y om e t r i um
i n s t e a d o f a t t a c h i ng t o t h e d e c i d u a b as a l i s . I t h a p p e n s b e c a u s e o f a b s e n c e o f
z o n e o f f ib r i n o i d ne c r o s i s w hi c h i s c a l l e d N I T A BU C H M E M B RA N E ( t h is
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m e m b r a n e i s p r e s en t o u t s i d e c y t o t r o p h o b l a s t i c s h e l l a n d p r e v e n t s d e e p e r
i n v a si o n o f t h e c y to t r o p h o b l a s t a n d sy n c y t i o t r o p h o b l a s t i n si d e )
T h e r e is ab s e n c e of s p o ng y l ay e r o f de c i d u a b a s a li s
R I S K F AC T O R S
1 . M o s t c o m m o n – p re v i o u s C - s e c t i o n
- R i sk i n c r e as e s w i t h i n c r e a s e i n n o . o f C - s e c t i o n
2. Placenta Previa
M a x . r i sk o f h av i ng m o rb i d l y a d h e r e n t p l a c e n t a i s
P l a c e n t a p r e v i a + Pr i o r C - s e c t i o n > P . pr e v i a > C - s e c t i o n
R i sk o f MA P: -
• PP + 1 prior C-section = 11%

• P P + 2 p ri o r C - s e c t io n = 4 0%
• P P + 4 p ri o r C - s e c t io n = 7 0%
3. Other risk factors =
- Previous curettage
- M a n u a l r em o v a l of p l a c e n t a
- A s h e rm a n ’ s

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- Myomectomy
TYPES: -
i. A c c r e t a – w h e n p l ac e n t a i s j u s t a t t a c h e d t o t h e m y om e t r i u m ( 8 0% )
ii. I n c r e t a – wh e n p l ac e n t a i s d e e p i n t o m y om e t r i um ( 1 5 % )
iii. P e r c r e t a – w h e n p l ac e n t a h a s c r o ss e d t h e m y om e t r i um ( 5% )
C L I N I C AL PR E S E NT A T I O N : -
• C o u l d b e i d e n t i f i e d d u r i ng m a nu a l r em o v a l o f p l a c e n t a
• C o u l d b e i d e n t i f i e d d u r i ng p l a c e n t a l re m o v a l a t C - s e c t i o n
• C o u l d b e i d e n t i f i e d w i t h i n v e r si o n o f ut e r u s
A l l t h e c o n d i t i o n s c a n p r e d i s p o s e t o PP H a n d i n v a r ia b l y wo m a n l a n ds u p i n a
hysterectomy.
W h e n e v e r s us p i c i ou s o f M AP : -
1 . N o r m a l g r e y s c a l e U SG – c a n o n l y s h ow m o t h e a t e n a p p e ar a n c e o f
p l a c e n t a ( n o t v e r y i n f o r m a t iv e )
2 . U SG D o p p l e r –
- Is better, cheaper
- Intraplacental lakes can be seen
- T u rb u l e n t f l o w i n L a c u n a r s p a c e s c a n b e s e e n
3 . M R I – i nv e s t i ga t i o n o f c h o i c e
4 . H i s t o p a t h o l o g i c a l ex a m i n a t i o n (f r o m H y s t e r e c t o m y s p e c i m e n ) – F I NA L
confirmatory DIAGNOSIS
M A N A G E M E N T: -
W h e n di a g n o si s of M A P is a l r e a d y p r es e n t i n t h e a n t e p a r t u m p e r i o d , t h e n –
• S t a n d a r d T r e a t m e nt i s – E l e c t i v e C - s ec t i o n d o n e b y c l as si c a l CA af t e r
3 4 w ks f o l l o w e d b y h y s t e r e c t o m y i n th e s am e si t t i n g . P l ac e n t a l r e m o v a l
is not attempted.
• I f a w o m a n wa n t s to c o n s e r v e u t e r us , t h e n l e a v e p l a c e n t a i n - s i tu .

Notes-
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ObsNGyn - High Risk Pregnancy Comprehensive

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AfraTafreeh.

HYPERTENSIVE DISORDERS OF PREGNANCY [TYPES]

Definition of HTN in pregnancy:

High Risk Pregnancy P a g e 1 | 50

PATHOPHYSIOLOGY & PREDICTION OF PRE-ECLAMPSIA

• Pathophysiology → culprit is Placenta/ chorionic villi

High Risk Pregnancy P a g e 2 | 50

High Risk Pregnancy P a g e 3 | 50

High Risk Pregnancy P a g e 4 | 50

High Risk Pregnancy P a g e 5 | 50

High Risk Pregnancy P a g e 6 | 50

• For controlling BP:

High Risk Pregnancy P a g e 7 | 50

High Risk Pregnancy P a g e 8 | 50

High Risk Pregnancy P a g e 9 | 50

High Risk Pregnancy P a g e 10 | 50

FETAL GROWTH RESTRICTION

• Low Birth weight:

• Small for gestational age [SGA] →

High Risk Pregnancy P a g e 11 | 50

Note: Prognosis of IUGR new born or Neurodevelopmental outcome at 2

High Risk Pregnancy P a g e 12 | 50

Out of all these parameters the single best parameter to diagnose

High Risk Pregnancy P a g e 13 | 50

▪ Timing of delivery also depends on umbilical artery doppler

High Risk Pregnancy P a g e 14 | 50

o There is always a forward flow in umbilical artery [which should

→ but the diastolic flow in umbilical artery is

o Absent end diastolic flow

o Reversed end diastolic flow

• Management of IUGR fetus :

High Risk Pregnancy P a g e 15 | 50

Example: Multiple pregnancy

High Risk Pregnancy P a g e 16 | 50

High Risk Pregnancy P a g e 17 | 50

High Risk Pregnancy P a g e 18 | 50

Premature Rupture of Membranes

High Risk Pregnancy P a g e 19 | 50

High Risk Pregnancy P a g e 20 | 50

ANTEPARTUM HEMORRHAGE PLACENTAL ABRUPTION

High Risk Pregnancy P a g e 21 | 50

High Risk Pregnancy P a g e 22 | 50

High Risk Pregnancy P a g e 23 | 50

High Risk Pregnancy P a g e 24 | 50

ANTEPARTUM HEMORRAGE; PLACENTAL PREVIA

High Risk Pregnancy P a g e 25 | 50

High Risk Pregnancy P a g e 26 | 50

ABNORMALITIES OF PLACENTA, CORD & AF

High Risk Pregnancy P a g e 27 | 50

High Risk Pregnancy P a g e 28 | 50

High Risk Pregnancy P a g e 29 | 50

High Risk Pregnancy P a g e 30 | 50

High Risk Pregnancy P a g e 31 | 50

High Risk Pregnancy P a g e 32 | 50

High Risk Pregnancy P a g e 33 | 50

• Most common type is Thoracopagus

High Risk Pregnancy P a g e 34 | 50

▪ Dizygotic twins → always DCDA

High Risk Pregnancy P a g e 35 | 50

o MZ twins [No intertwin membrane]

Note: When 1 twin dies:

o In very early pregnancy

High Risk Pregnancy P a g e 36 | 50

o In early pregnancy [14 -16 weeks]: