Intrapartum Fetal Heart Rate Monitoring (Usmle)

OBGYN: Intrapartum Fetal Heart Rate Monitoring (Usmle)

Mnemonic to remember : VEAL CHOP

Variable     Cord compression
Early          Head compression
Acceleration OK
Late         Placental Insufficiency

Early Deceleration: Head compression. Fetus deceleration is symmetrical to mother's contraction. Tx = No treatment

Late Deceleration : Placental insufficiency : Fetal deceleration is after the mother's contraction Tx= test fetal blood from scalp sample to diagnose hypoxia or acidosis.

Variable Deceleration : Cord compression. Fetal deceleration can be symmetric or after mother's contraction (Onset of fetal deceleration to the nadir should be < 30 sec.)
Tx = 1. Change the mother's position
     2. Amnioinfusion

Normal Pregnancy Complaints

Normal Pregnancy Complaints

• Back ache 
• Bleeding gums 
• Breast enlargement 
• Carpal tunnel 
• Complexion changes
• Dizziness
• Fatigue 
• Fluid retention
• Hair & nails 
• Headaches 
• Leg cramps
• Morning sickness 
• Nose bleeds
• Stretch marks
• Stress incontinence 
• Varicose veins

Teratogenic drugs and their effects

Teratogenic drugs and their effects

Alcohol in pregnancy -- Fetal Alcohol Syndrome (FAH) - Midfacial hypoplasia and Long philtrum

Using DES in pregnancy - New born with T shaped Uterus

Dilantin/Phenytoin -- Craniofacial dysmorphism (5-10%) and also nail hypoplasia

Isotretinoin (Accutane) - Microtia -small ear - severe birth defects also heart problem

Lithium - Ebstein anomaly - large Right arium

Tetracyclin - Deciduous teeth discoloration (after 4 month)

Thalidomide - Phocomelia (Limb reduction defects exposure from Day 42-48)

Valproic Acid (Depakote) - Neural Tube Defects like Spina bifida , Congenital Heart disease

Coumadin - Chondrodysplasia punctata also optic atrophy

Youngest mother in the world to give birth

Precocious Puberty

Youngest mother in the world to give birth in 1940

STD's with Ulcers and No Ulcers

STD's 

With Ulcers :

Syphilis (Painless)
LGV
Genital herpes (Painful)
Granuloma inguinale
Chancroid (Painful)

No ULCERS 

Chlamydia
HPV
Gonorrhea
Hepatitis B
HIV

Leiomyoma vs Adenomyosis - USMLE

Enlarged Uterus

Leiomyoma and Adenomyosis (Non-Pregnant) 

Urinary Incontinence and its types (Stress , Urge , Overflow , Bypass & Irritative)

Early vs Late Congenital Syphilis

Early congenital syphilis :

• Non - immune hydrops
• Macerated skin 
• Thrombocytopenia

Late congenital syphilis :

• Hutchinson teeth
• Mulberry molars
• Saber shins

Clinical Manifestations of Congenital Infections

Clinical Manifestations of Congenital Infections 

Highlight on 

CMV : Petechiae

Toxo : Chorioretinitis & Cranial Calcifications

Couvelaire uterus - (Abruptio Placenta)

It is pathological entity in association with severe form of concealed abruption placenta
There is massive intravasation of blood into the uterine musculature upto the serous coat.
The condition can only be diagnosed on laparotomy

Types of Miscarriage

Threatened 

• Vaginal bleeding
• Closed cervical os
• Fetal cardiac activity

Missed

• No vaginal bleeding
• Closed cervical os
• No fetal cardiac activity or empty sac

Inevitable

• Vaginal bleeding
• Dilated cervical os
• Products of conception may be seen or felt at or above cervical os

Incomplete 

• Vaginal bleeding
• Dilated cervical os 
• Some products of conception expelled and some remain

Complete

• Vaginal bleeding or none
• Closed cervical os 
• Products of conception completely expelled

Placental implantation

Placental implantation. (A)  Normal placenta.  (B)  Low implantation.  (C)  Partial placenta  previa.  (D)  Complete placenta  previa.

OBSTETRIC ANALGESIA AND ANESTHESIA

Uterine contractions and  cervical dilation  result in visceral pain (T10-L1).
Descent of  the  fetal  head and pressure on  the  vagina and perineum  result in somatic pain (pudendal nerve, S2-S4).
In the  absence  of a  medical  contraindication,  maternal  request  is  a  sufficient medical indication for pain relief  during labor.

Absolute  contraindications  to  regional  anesthesia  (epidural,  spinal,  or 
combination) include the following: 

• Refractory maternal hypotension 
• Maternal coagulopathy 
• Maternal  use  of  a  once-daily  close  of  low-molecular-weight heparin within  12  hours 
• Untreated  maternal bacteremia 
• Skin infection over the site  of  needle placement 
• Increase in  ICP caused by a mass lesion

WEEKS PRENATAL DIAGNOSTIC TESTING

Prenatal Diagnostic Testing Schedule

WEEKS  PRENATAL  DIAGNOSTIC TESTING

Prenatal visits  

• Weeks 0-28: Every 4 weeks. 
• Weeks 29-35: Every 2 weeks. 
• Weeks 36-birth: Every week. 

Initial visit :

Heme:  CBC, Rh factor ,  type  and  screen.

Infectious disease:

UA and culture,  rubella  antibody titer , HBsAg,
RPR/VDRL, cervical gonorrhea and chlamydia, PPD, HIV,  Pap
smear (to check for dysplasia). Consider HCV and varicella based
on history.

If indicated: HbA, sickle cell screening.
Discuss genetic screening:  Tay-Sachs disease, cystic fibrosis.

9- 14  weeks :

Offer PAPP-A +  nuchal transparency + free  B-hCG +/- chorionic
villus sampling  (CVS)

15-22 weeks :

Offer maternal  serum a-fetoprotein  (MSAFP)  or quad screen  (AFP,
estriol,  P-hCG, and inhibin A)  +/- amniocentesis.

18-20 weeks :

Ultrasound for full  anatomic screen.

24-28 weeks : 

One-hour glucose  challenge test for gestational diabetes screen.

28-30 weeks :

RhoGAM for  Rh-8 women (after antibody screen).

35-40 weeks :

Group  B  strep  culture  (GBS);  repeat CBC.

34-40 weeks :

Cervical chlamydia  and  gonorrhea cultu res,  HIV,  RPR  in high-risk patients.

Cervical insufficiency (incompetent cervix)

Painless early pregnancy dilation

Etiology

• Trauma from rapid forceful cervical dilation associated with 2nd trimester abortion
• Cervical laceration from rapid delivery
• Injury from deep cervical cone
• Congenital weakness from DES exposure

Diagnosis:

• History of 2 or more unexplained second trimester pregnancy losses.
• Benefit of cerclage is unclear  

Management: 

• Elective cerclage at 13-16 weeks gestation
• Emergency or Urgent cerclage
• Cerclage removal at 36-37 weeks

Fetoscopy

When to perform : 18-20 weeks

• its for Biopsy of fetal tissue and IU surgery
• Loss rate : 2-5 % 

Safe Motherhood initiative (ACOG)

These images are provided by ACOG (American Congress of Obstetricians and Gynecologists)

First Line Management with Hydralazine

 First Line Management with Labetalol

OBG Multiple Choice Questions

 

Maternity Blues,Postpartum Depression and Postpartum Psychosis

Puerperium

Definition

Normal puerperium

1. The time from the delivery of the placenta through the first few weeks after the delivery
2. 6 weeks in duration. 
3. By 6 weeks after delivery, most of the changes of pregnancy, labor, and delivery resolves and the body reverts to the non pregnant state.

The puerperium has been referred to as the “ fourth trimester” of pregnancy, encompassing the period between the delivery and complete physiologic involution and psychological adjustment. 

Abnormal Puerperium

• Puerperal Pyrexia
• postnatal psychosis and depression

Puerperal Pyrexia

Definition

P pyrexia is defined as temperature of 38oC ( 100.4oF) or higher on any two occasions persisting after the first 24 hrs of delivery, and within 10 days postpartum taken by mouth by a standard technique.

Cause of P. Pyrexia

1. P. Sepsis- Genital tract infection
2. UTI
3. Breast Complications
4. Wound Infections
5. Thrombophlebitis and DVT
6. Respiratory infections

Puerperal Sepsis

Definition

An infection of the genital tract which occurs as a complication of delivery is termed as P sepsis.

Vaginal flora

1. L bacillus ( 60-70%)
2. Yeast like fungus- Candida albicans ( 25%)
3. Staph albus or aureus
4. Strepto β haemolyticus
5. E coli and bacteroids
6. Cl welchii-rare

These organisms remain dormant and are harmless during normal delivery conducted in aseptic conditions. 

Predisposing factors to P Sepsis

1. Conditions lowering the resistance 
2. Malnutrition & anaemia
3. PROM
4. Chronic debilitating diseases
5. Repeated PV examination after rupture membrane
6. Traumatic manipulative & operative delivery
7. Haemorrhage 
8. RPOC- retained product of conception
9. Placenta previa

Organism responsible for P sepsis

• Aerobic- Staph, Ecoli, Klebsiella, Pseudomonas, Non-haemolyticus Strepto, 

• Anaerobic- Anaerobic streptococcus, Bacteroids, Cl welchii and tetani

Pathology and the primary site of infection

Uterus

Endomyometritis- is the most common and usually mildest form of genital infection.

4 Classical signs:

• Pyrexia 37.8-38o C
• Pulse 100-120
• Fundal height- not decreasing
• Lochia red &offensive smell

Clinical examination & Daily Charting

Investigations

1. High vaginal smear and endocervical swab for C/S
2. MSU for R/M/E & C/S
3. Blood for Hb,TC, DC & C/S
4. Blood for MP
5. Widal Test
6. X-ray chest

Treatment 

1.Adequate fluids, rest and movement of bowel- Milk of magnesia

2.Correction of anaemia

3.Antibiotics- Broad spectrum

        I/V Ampicillin 500mg  6 hrly

        I/V Metronidazole 500 mg  8 hrly

        I/V Gentamycin  3-5 mg/kg body wt in divide dose

                                    OR

        I/V Ceftriaxone / Cefotaxim 1 gm 12 hrly

                    Change according to C/S             

Urinary tract infection

• Incidence is 1-5%
• Organisms- E coli, klebsiella, Proteus, Staph aureus
• Causes- Frequent catheter, stasis of urine due to lack of bladder tone & less desire to pass urine, Asymptomatic bacteriuria becomes symptomatic, 
• Present- Fever with chills & rigor, burning micturition, frequency, nausea, vomiting, acute pain in the loins radiating to groin.
• Investigation- Urine for R/M/E and C/S
• Treatment -Antibiotics

Causes of retention urine in puerperium

1.Bruising and oedema of the bladder neck

2.Reflex from the perineal injury

3.Unaccustomed position

4.Haematoma

Treatment

• General measures
• Indwelling catheter for 48 hrs- It helps in regaining the normal bladder tone and the sensation of fullness.
• Antibiotics

Breast Complications

Common breast complications are

1.Breast engorgement

2.Cracked & retracted nipples

3.Mastitis and breast abscess

4.Failing lactation

Breast engorgement

• Due to exaggerated normal venous & lymphatic engorgement preceding lactation, preventing escape of milk from lacteal systm.
• Manifest after the milk secretion- 3rd -4th PPD
• S/S- Pain, feeling of tenseness and heaviness in both breast, malaise, ↑tempt
• Treatment-Support breast with binder & brassiere, ice bag, express milk or frequent breast feeding, analgesic
• Prevention- Manual expression of the remaining milk & frequent breast feedings

Cracked Nipple

• Due to a) loss of surface epithelium, causing a raw area b) fissure at the tip or base of nipple
• Caused by 1)unhygiene –crust over the nipple 2) retracted nipple 3) vigorous suckling
• Asymptomatic usually but if infection, it is painful due to mastitis
• Treatment-keep nipple clean & dry, nipple shield during each feed, rest if worst and feed by expression, antibiotics ( oral & applicant)  and analgesic
• Prevention-Local cleanliness during pregn and puerperium

Retracted nipple

• Primigravida
• If left uncorrected may predispose to cracked nipple- difficulty in breast feeding
• Manual lifting of the retracted nipple during pregnancy is advisable.
• After delivery, use of nipple shield is advisable.

Acute Mastitis

Mode of infection

2 different types of mastitis

• Infection follows a cracked nipple to involve the breast parenchymal tissues leading to cellulites.
• Infection gains access through the lactiferous duct leading to development of primary mammary adenitis
• Responsible organism is Staph aureus- infection comes from nasopharynx of the baby.

Clinical feature

• Symptom- Generalised malaise, headache, fever with chills
• Severe pain and tender, swelling in 1 quadrant of the breast.
• Sign- Wedge shaped swelling on the breast with the apex at the nipple
•  Over lying skin is hot, flushed, tense and tender

Treatment

• Antibiotics- Cloxacillin, Cefalosporin
• Analgesic 
• Antenatal-Wash the nipple periodically to keep the patency of the duct opening.
•  Breast feeding on the affected is suspended
• Manual expression & prevention of engorgement of breast.

Breast Abscess

• Swinging tempt
• Reddened breast
• Marked tenderness with fluctuation.

Treatment

• Antibiotics
• Incision and drainage

Wound infection

• Wound can be that of a CS or an episiotomy wound
• Infection in the wound usually develops around the 5th to 6th POD
• Take Swab from the wound and send for C/S 
• Treat with antibiotics and daily dressing
• Followed by secondary suture,

Chest infections

• Usually following general anaesthesia in CS
• Take x-ray chest and sputum for C/S
• Treatment is with physiotherapy, warm saline gurgle, steam inhalation and antibiotics

Deep Vein Thrombosis (DVT)

• Usually occurs at around 7-10th PPD
• Begins in the deep veins of the calf or soles of the feet and extend upwards
• Often symptomless
• Sharp dorsiflexion of the foot elicit pain in the calf-Homan’s sign
• Slight rise of tempt & pulse.
• These early S/S may be missed and detected only when pulmonary embolism has developed or when the generalised oedema of the leg has set.
• Exercise in early puerperium is beneficial.
• The foot end of the bed is elevated to increase the venous flow from the leg.
• Antibiotics to prevent infection
• Anticoagulant to prevent clot formation-Heparin.
• After being afebrile the pt is encouraged to walk about with the affected leg supported by elastic bandage.

Post Partum Blues, Depression and Psychosis


Post partum Blues

• Occurs in around 50% of the women
• Around 4th to 5th PPD
• Usually self limiting though in rare circumstances progresses to postnatal depression.
• Cure by support of medical practitioner is all that is required

Post natal depression

• Onset at around 4th week PP 
• Lasting for around 6 months
• Family H/O mental disorder is usually present.
• C/F are that of sleep disturbance, depression, social withdrawal, lack of worthiness of being a mother, suicidal thoughts, concern that she may harm her child
• Management- Social support, refd to psychiatrist

Puerperal Psychosis

• Occurs in 0.2% of the mothers
• Onset is earlier than the postnatal depression
• The chance that a mother may harm her baby is very high.
• Serious condition the requires an expert psychiatric evaluation and treatment