Green Book - Roopnarinesingh Textbook
Green Book - Roopnarinesingh Textbook
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CONTENTS Page
V
ANTENATAL CARE
CHAPTER ONE
ANTENATAL CARE
INTRO DUCTIO N
Many surveys have revealed that women who receive no antenatal care
have very high perinatal mortality rates. In general, perinatal mortality
shows an inverse relationship to the num ber of antenatal visits. These
findings suggest that antenatal care is beneficial and that more frequent
attendance is associated with better outcom e. This may be considered
simplistic since women who book early for antenatal care are often
healthier, better educated, more likely to be in a higher socio-econom ic
group and they tend to be more compliant with medical advice and
intervention. These confounding variables certainly play a major role in
improved perinatal and maternal outcome. The contribution which
adequate antenatal care makes to better pregnancy outcom e can only be
tested by large random ized controlled trials which are difficult to
conduct for many reasons, especially on ethical grounds.
1
ANTENATAL CARE
2
ANTENATAL CARE
History taking
• The menstrual history. The date o f the beginning of the normal
menstrual period (LMP) is carefully ascertained. The expected
date of delivery (EDD) is calculated by adding 7 days and 9
months to the LMP (N aegele’s rule). M enstrual irregularity,
recent horm onal contraception and ovulation induction may all
affect the timing of ovulation.
• Previous pregnancies with details o f any unusual events.
a) Dates of previous pregnancies.
b) Number of pregnancies- A viable pregnancy is one, which
has crossed 28 weeks (live or stillborn) and is calculated
towards the patient’s parity. Those before 28 weeks are
termed “ m iscarriages” . A patient who is currently pregnant
and has had 3 previous viable pregnancies and 2 miscarriages
is a gravida 6, para 3+2.
3
ANTENATAL CARE
Physical examination
• The patient’s height and weight are measured and the body mass
index calculated.
• Examination o f her general physical condition, especially the
mucous membranes, state of hydration, pulse rate and blood
pressure. The thyroid gland, breasts, cardio-respiratory system
and lower limbs are examined.
• A speculum examination to note the condition o f the cervix and
the presence of any vaginal discharge.
• A bimanual examination to assess the adequacy o f the pelvis, to
search for any ovarian tum ours or uterine fibroids and to
determine whether the uterine size corresponds with the
gestational age. The estimate of uterine size at this time is perhaps
more accurate than at any further occasion in pregnancy.
Investigations
• Full blood count.
• Sickle cell test and haem oglobin electrophoresis, if necessary.
4
ANTENATAL CARE
Risk Assessment
Risk assessment should be conducted by a senior officer employing a
predetermined checklist. The list should include maternal age (teenage
or advanced maternal age), parity (primigravida or grandmultiparity),
and uncertain gestation, previous obstetric problems such as medical
disorders of pregnancy, preterm deliveries, intrauterine growth
restriction, fetal anomalies, caesarean section and perinatal loss. This will
allow for the categorization of the pregnancy as high or low risk.
5
ANTENATAL CARE
6
ANTENATAL CARE
Abdominal palpation
By means of palpation, one can determine the lie, presentation, attitude
and position of the fetus. Understanding these terms is crucial and they
are defined later in this chapter. The abdom en should also be palpated
for tenderness, which may be a sign of a placental abruption whilst a
tense abdomen may be indicative o f polyhydram nios.
First manoeuvre: Facing the patient, both hands are placed laterally on
the abdomen towards the fundus of the uterus to determine its height in
relation to the umbilicus and the xiphoid, and in relation to gestational
age as calculated from the last period.
By using the fingertips, one can determine whether the breech or
the head is occupying the upper part o f the uterus. The breech is felt as
a large irregularly shaped mass, while the head is felt as a hard, round
mass which can be balloted between the hands.
Second manoeuvre: The hands are lowered on the sides o f the abdom en
and one hand is held firmly against one side while the finger-tips o f the
other hand are used to feel for small irregularly-shaped parts
(extremities) or to feel for a smooth persistent regular surface which is
interpreted as the back. When an impression is gained as to whether an
extremity or the back of the fetus is one side, this may be confirm ed by
using the finger-tips of the other hand to feel the other side o f the
abdomen.
Third manoeuvre: The thumb and first two fingers of the right hand are
placed over the lower abdomen just above the symphysis (Pawlik’s grip)
to determine what pole of the fetus is presenting, and whether engaged or
not. The other is placed at the fundus o f the uterus to stabilize it.
Fourth manoeuvre: The obstetrician faces the feet of the patient and the
four fingers o f each hand are placed over the lower abdom en just above
7
ANTENATAL CARE
the symphysis pubis and deep pressure is made downwards to feel the
features of the presenting part.
8
ANTENATAL CARE
With normal growth of the fetus the fundus of the uterus reaches
certain levels on the abdominal wall in “ clim bing” from the level of the
symphysis pubis at 12 weeks gestation to just beneath the xiphisternum
at 38 weeks gestation. If the level of the fundus is higher than expected
for the gestational age, multiple pregnancy should be suspected, as well
as other reasons for a large-for-dates uterus; if lower than expected there
could be intra-uterine growth restriction (IUGR) or fetal abnorm ality.
Disparity on clinical examination warrants re-assessment o f the gestation
based on her LMP and recourse to fetal biometric studies.
Percussion
This is done in order to detect the presence of a fluid thrill, which is a
common finding with polyhydram nios. In such a case the abdominal
girth should be measured.
Auscultation
The fetal heart sounds are heard loudest over the area at which the fetal
left scapula comes in contact with the uterus. They should be listened
for at every visit after the 24th week of gestation, using the Pinard’s
stethoscope; a rate of 110-160 beats per minute is norm al. The Sonicaid
or the Doptone (ultrasonic fetal heart detectors) will pick up fetal heart
sounds as early as the 10,h week.
DEFINITIONS
• Lie of the fetus. The lie of the fetus is the relation o f the long
axis of the fetus to the long axis of the uterus. It may be
longitudinal, transverse or oblique. When the lie is longitudinal,
either the head or the breech is directly above the brim o f the
pelvis. When the lie is transverse, the shoulder occupies the lower
pole of the uterus and the long axis o f the fetus lies across the
long axis of the uterus. It occurs when there is a lax uterine wall,
or polyhydram nios or a major placenta praevia.
• Attitude is the relation of the fetal head and limbs to its trunk.
Normally this should be one of flexion, when the trunk is bent,
the head is flexed so that the chin touches the chest, the thighs are
flexed on the abdomen and the legs are flexed on the thighs.
_
ANTENATAL CARE
10
ANTENATAL CARE
Cephalo-pelvic disproportion. This means that the head is too large for
the particular pelvis through which it must pass; it is a relative term. The
disproportion may be pelvic or cephalic in origin, due to a contracted
pelvis, a large fetus or a com bination of both. It is a matter o f concern
when the patient is of short stature; a maternal height of less than 5 feet
is considered critical.
LOP
Posterior
fontanel
11
ANTENATAL CARE
Urine examination
Urine is routinely tested for glycosuria, album inuria and ketonuria.
Proteinuria is the presence of protein in the urine in concentrations
greater than 300 mg/1 in a random urine collection, by dipstick
exam ination. The urine must be a voided clean catch specimen or one
obtained by catheterization. Proteinuria is an ominous sign of pre
eclampsia.
Blood Pressure
Ideally, when blood pressure is being taken, the patient should be sitting
on a couch, at rest. The left lateral position is also acceptable. The
sphygm om anom eter cuff should be approxim ately level with the heart.
In a norm al pregnancy, the blood pressure rarely rises above 120/80
mmHg and as a rule shows a drop in the second trimester o f pregnancy,
at which time pressures as low as 85/50 mmHg may be recorded. A B.P.
of 140/90 mmHg or more is abnormal.
Weight-gain in pregnancy
The am ount of weight gained in normal pregnancy depends on a
num ber of factors and tends to vary widely around an average o f 12 kg.
As a general rule, if the weight gained in a week is more than one kg,
there is a likelihood of the patient developing pre-eclampsia.
12
ANTENATAL CARE
Oedema
The development of oedema, especially where this involves the fingers,
may be a sign that pre-eclampsia is either present or imminent. Oedema
should be looked for, at every visit. It is usually associated with an
excess of weight-gain.
Approximately 85% of patients who develop generalized oedema
have normal pregnancies and only about 15% develop pre-eclampsia.
Hence, oedema in pregnancy may reflect changes that are physiological.
The previously held concept of treating oedema with diuretics is now
discarded. In fact, the use of diuretics in pre-eclampsia may be harm ful
as they decrease plasma volume and reduce uteroplacental perfusion.
Nutrition in Pregnancy
Pregnancy is an anabolic state and women store large quantities of
energy above the immediate needs of the growing fetus. M uch of this
storage is in the growth of tissue: the fetus, the breasts, the uterus and the
expanding blood volume.
The placenta acquires nutrients effectively for the fetus so that
plasma levels of nutrients, which are low in the mother, are much higher
in the fetus. Thus, the fetus becomes protected from the vagaries of the
maternal diet.
Special problems
Research studies in animals and observations during famine and war
show that grossly inadequate diets during pregnancy may lead to fetal
malformation, low birthweight and prematurity; in the m other it may
lead to abortion, anaemia, pre-eclampsia and inadequate lactation.
13
ANTENATAL CARE
14
ANTENATAL CARE
Hyperemesis gravidarum
The patient shows signs of dehydration, tachycardia and a low urine
output with ketonuria. She is unable to retain any liquids or solids. This
is discussed further in chapter seven.
Threatened miscarriage
The symptoms and signs are mild cramp-like pain in the lower abdom en,
backache and small loss of blood per vaginam. In a num ber o f cases the
cause is not known and no specific treatment is given. “ Rest in b e d ” is
the most practical therapy but there is no supportive evidence that this is
of benefit. Since some cases can be caused by progesterone deficiency
from ineffective corpus luteum function, some obstetricians will
empirically prescribe a progesterone supplem ent. Whereas many
patients can be treated at home, with appropriate advice and instructions,
some patients will be better off in hospital.
Habitual miscarriage
Habitual or recurrent miscarriage refers to three or more consecutive
miscarriages. It constitutes about 5 percent of all spontaneous
miscarriages. The aetiology is unknown in the majority of cases.
However, in 15% there is demonstrable maternal and fetal pathology.
15
_
ANTENATAL CARE
Exposure to rubella
The pregnant woman exposed to rubella in the first trimester has a 15 to
20 percent chance of having an abnormal baby. The risk of abnorm ality
is significantly less after 16 weeks gestation. Steps to be taken are:
• Measure rubella antibodies. If immunity is dem onstrated, the
patient can be reassured and nothing further need be done. If
titres are greater than 1:10, they indicate im m unity.
• The patient should be observed for a serologic response. A
repeat rubella titre should be done 2 to 3 weeks after the initial
one. A rising titre is indicative o f infection.
Many patients may elect to terminate the pregnancy. The
administration of gamma globulins should be considered for the infected
patient who decides to continue with the pregnancy.
16
ANTENATAL CARE
Cervical incompetence
The typical account is one of spontaneous rupture of the membranes
during the mid-trimester, followed by rapid expulsion of the fetus. The
miscarriage is described as painless, complete and almost bloodless. The
cervix prematurely dilates in the course o f early pregnancy, due to some
cervical weakness that may be due to a congenital condition or to prior
trauma from delivery or from overzealous dilatation.
17
ANTENATAL CARE
internal os, without reflecting the bladder off the cervix. This m ethod is
much simpler than the Shirodkar.
Antepartum haemorrhage
This topic is dealt with elsewhere. In most cases the signs and symptoms
are dramatic resulting in emergency admission.
Pre-eclampsia
Pre-eclampsia is associated with the following risk factors:
• Teenage pregnancies and advanced maternal age.
• Nulliparity.
• Past history of pre-eclampsia.
• Family history (m other or twin sister).
• Obesity.
• Lower socio-economic group.
• Inadequate prenatal care.
18
ANTENATAL CARE
Gestational diabetes
This is discussed in detail in chapter four. Screening is normally
performed at 28 weeks unless an indication exists to do so prior to this.
Risk factors include:
• Pregnancy itself since it is a diabetogenic state.
• Obesity and polycystic ovarian syndrom e. r
• First degree family history.
• Ethnic group (more com m on am ongst East Indians and
Asians).
• Advanced maternal age and high parity.
• Past obstetric history - recurrent miscarriages, unexplained
stillbirths, macrosomia, traumatic vaginal deliveries (e.g.
shoulder dystocia), and certain congenital abnormalities.
• Current pregnancy - persistent glycosuria, uterus is “ large-
for-dates” suggestive o f polyhydram nios or macrosomia,
recurrent vaginal candidiasis, and early- onset pre-eclampsia.
Preterm labour
Predisposing factors are:
• Teenage pregnancies.
• Low socio- economic conditions.
• Poor prenatal care.
• Drug addiction and sexually transmitted diseases.
• Past history of preterm labour, congenital uterine
abnormalities including cervical incom petence.
• Multiple pregnancy.
• Polyhydram nios and preterm rupture o f the m embranes.
• Subclinical infections in the genital tract e.g. Chlamydia,
M ycoplasma hominis and G roup B beta haemolytic
streptococci.
19
ANTENATAL CARE
CONCLUSION
Antenatal care is all about management and planning. One of its, crucial
roles is risk assessment. It is important to rem em ber that the actual
pattern of care may be less significant to the woman than the attitudes
and efficiency of those providing it. Delegation of responsibility must be
backed up by trust and support as well as a high standard of
perform ance as demonstrated by clinical audit.
20
ANTENATAL CARE
KEY POINTS
21
BONY PELVIS
CHAPTER TWO
INTR O D U C TIO N
It is of great importance for the student in Obstetrics to know the
m orphology of the pelvis in detail. It is the platform from which a more
detailed understanding of female pelvic anatom y can be developed and it
is fundam ental to the com prehension of the mechanics o f labour.
The Ilium
The parts of the ilium are the wings or alae and the body. The body
forms the superior two-fifths of the acetabulum. The following
landm arks should be identified on the ilium:
• iliac crest: it can be palpated beneath the skin throughout its entire
length.
• anterior end: anterior superior iliac spine
• posterior end: posterior superior iliac spine
• iliac tubercle
• iliac fossa
22
BONY PELVIS
The Ischium
It is subdivided into the body and the ramus. The superior extremity of
the body form s the postero-inferior part of the acetabulum . The
following landmarks should be located:
• ischial tuberosity with its falciform line
• lesser sciatic notch
• ischial spine
• greater sciatic notch
• obturator foramen
23
BONY PELVIS
The Pubis
The parts o f the pubis are the body and two rami (superior and inferior).
The following landm arks should be located:
• symphyseal surface
• pubic crest
• pubic tubercle
• pecten pubis
• iliopectineal eminence
• obturator crest
• obturator groove
• acetabulum: lunate surface
fossa acetabuli
acetabular notch
The Sacrum
The sacrum form s the base o f the vertebral colum n and is located
between, and firmly connected with, the two hip bones. In the adult, it is
form ed from fusion of the five sacral vertebrae.
The C occyx
It is form ed from the fusion o f four coccygeal vertebrae.
TH E PELVIC JOINTS
24
BONY PELVIS
In addition, there are three other strong ligaments that connect the hip
bones with the vertebral colum n. These are:
• Sacro-tuberous ligament. This passes from the posterior end of
the iliac crest, the sacrum and the coccyx to the ischial tuberosity
and sends a thin extension along the ramus o f the ischium
(falciform process), which forms the medial boundary o f the
pudendal canal.
• Sacro-spinous ligament. This passes from the sacrum and coccyx
to the ischial spine and separates the greater from the lesser sciatic
foram en. The weight of the trunk applies a downward force on
the upper part of the sacrum. This is resisted by both the sacro-
tuberous and sacro-spinous ligaments.
• Ilio-lumbar ligament. This is a strong triangular ligam ent
between the fourth and fifth lum bar vertebrae and the iliac crest.
It is an im portant structure as it prevents the fifth lum bar vertebra
from falling into the pelvic cavity under the weight o f the trunk.
Symphysis pubis
This is a secondary cartilaginous joint that is form ed by the articulation
between the symphyseal surfaces of the left and right pubic bones. The
pubic symphysis is shorter and broader in the female than in the male.
The interpubic disc is a fibro-cartilaginous plate, which is thicker in
the female than in the male. It is adherent to the hyaline cartilage
covering the symphyseal surfaces of the pubic bones. In its postero-
superior part a slit-like cavity develops near puberty. This cavity is not
lined by synovial membrane and is usually larger in the female than in
the male.
The ligaments of the pubis are (a) the superior pubic ligament
which extends laterally along the pubic crest as far as the pubic tubercle,
medially blending with the interpubic disc and (b) the arcuate pubic
ligament, which is a thick band o f fibres between the inferior pubic rami,
25
BONY PELVIS
Pelvic inlet
The pelvic inlet or pelvic brim is demarcated by a line from the superior
border o f symphysis pubis, the pubic crest and tubercle, the pecten pubis,
the arcuate line, the superior border of the ala o f the sacrum and the
sacral prom ontory.
26
BONY PELVIS
Pelvic cavity
This is a curved canal with a shallow anterior wall (about 5 cm) form ed
by the symphysis pubis and bodies of the pubic bones and a deep
concave posterior wall (about 10 cm) formed by the sacrum and coccyx.
Its lateral walls are formed by the pelvic surfaces o f the lower part of the
ilium, the ischium and rami of the pubic bones.
Pelvic outlet
This is rhom boid in shape and can be considered as being com posed of
two triangles with a common base: the line connecting the two ischial
tuberosities. The anterior triangle has as its apex the lower-most point of
the symphysis pubis, and the sides are form ed by the bones form ing the
pubic arch. The posterior triangle has as its apex the tip o f the coccyx
and its sides are form ed by the sacro-tuberous ligaments.
27
BONY PELVIS
PELVIC D IA M ETER S
Pelvic inlet
(Figure 2)
• The true conjugate is the distance between the m idpoint o f the
sacral prom ontory and the center o f the upper border of the
symphysis pubis (11.5 cm).
• The obstetric conjugate is the distance between the m idpoint of
the sacral prom ontory and the posterior surface o f the sym physis
pubis. The diam eter is of practical im portance, since it is the
smallest sagittal diam eter o f the pelvic canal. It is about 5m m less
than the true conjugate.
• The oblique diam eter is the distance between the upper border o f
the sacro-iliac joint and the ilio-pectineal em inence o f the
opposite side (12.5 cm). The right oblique diam eter starts from
the right sacro-iliac joint and the left from the left joint.
• The diagonal conjugate is the distance between the lower border
o f the sym physis and the sacral prom ontory (13 cm). It is not
exactly a m easurem ent o f the pelvic inlet, but it is m easurable per
vaginam and it gives an indication o f the size o f the true
conjugate, which is 1.5 - 2.0 cm less than the diagonal conjugate.
• The transverse diam eter is the greatest transverse m easurem ent o f
the pelvic inlet (13 cm). It divides the pelvic inlet into a fore
pelvis and hind-pelvis.
1. Obstetric Conjugate
2. Right Oblique
3. Transverse
28
BONY PELVIS
Pelvic cavity
• The antero-posterior diam eter is the distance between the junction
o f the second and third sacral vertebrae and the centre o f the
posterior surface of the sym physis pubis (12.5 cm ).
• The transverse diam eter is the greatest transverse m easurem ent o f
the pelvic cavity (12.5 cm).
• The oblique diam eter is the distance between the lower margin o f
the sacro-iliac joint and the centre of the opposite obturator
m em brane (13.0 cm).
Pelvic outlet
1. Antero-posterior
2. Transverse
3. Ischial tuberosity
4. Sacro-tuberous ligament
29
BONY PELVIS
The five critical m easurem ents o f the pelvis which can influence the
progress o f labour are the:
• true conjugate.
• transverse diam eter o f the pelvic inlet.
• diam eter between the ischial spines.
• plane o f the least pelvic dim ensions.
• subpubic angle.
30
BONY PELVIS
PELVIC AX IS V E R SU S T H E A X IS OF TH E BIR TH C A N A L
Many authors consider these two terms as synonym ous. However, by
definition, they should be different.
PELVIC - TYPES
Gynaecoid type:
• The pelvic inlet is slightly oval transversely and alm ost round.
Android type:
• The pelvic inlet is heart-shaped. The anterior segm ent is rather
triangular.
• The pelvic cavity is conical: “ fu n n el-p elv is.”
Anthropoid type:
• The transverse diam eter o f the pelvic inlet is less than the antero
posterior one.
31
BONY PELVIS
• It is oval antero-posteriorly.
• The lateral walls of the pelvis are straight.
• The subpubic arch is narrow.
Platypelloid type:
• The antero posterior diam eter of the pelvic inlet is narrow while
the transverse diameter.
• subpubic arch is wide
• sacral prom ontory can be felt per vaginam .
•
Anthropoid Platypelloid
PELVIMETRY
Pelvimetry refers to the assessment of the adequacy o f the pelvis by the
m easurem ent of various param eters for the purpose o f predicting the
course of labour. It is an essential aspect of antepartum care and its aims
are:
• To prevent a prolonged and difficult labour.
• To select patients for trial of labour.
32
BONY PELVIS
Methods
Pelvimetry can be achieved by clinical exam ination or im agery such as
X-ray, CT or MRI.
33
BONY PELVIS
34
BONY PELVIS
Views taken:
• An erect lateral view is the most useful. An isometric scale is
placed between the buttocks and is included in the film. It
provides the following information:
■ The obstetric conjugate.
■ The inclination of the brim.
■ The shape of the sacrum.
■ The width and shape o f the sacro-sciatic notch.
• An antero-posterior view of the brim to determine:
■ The shape of the inlet.
■ The A-P and transverse diameter of the pelvic brim.
■ The inter-ischial diameter.
■ Convergence of the lateral pelvic walls.
TRIAL OF LABOUR
Definition
A trial of labour is one in which labour is allowed to proceed in a
primigravida with suspected cephalopelvic disproportion at the pelvic
brim, with the head not engaged, with readiness for Caesarean section,
and with careful frequent assessment to determine the signs o f progress
of labour, maternal distress and fetal distress.
Advantages
The advantages of a trial of labour are twofold. Firstly, the Caesarean
section rate is reduced. Secondly, a successful trial guarantees that the
patient may have a vaginal delivery on the next occasion, providing that
other factors remain the same. In contrast, a failed trial implies future
abdominal deliveries for the patient.
Disadvantages
In an attempt to secure a vaginal delivery in the woman with a borderline
pelvis, one may be subjecting the fetus and the m other to unnecessary
35
BONY PELVIS
As soon as the head becomes engaged (less than two fifths of the
head are palpable abdom inally), the trial is considered to be over but it is
useful to continue electronic monitoring o f the fetus.
Contra-indications
• Elderly primigravidae (> 35 years).
• Malpresentation e.g. breech.
• Midcavity and outlet contraction.
• Pregnancy-induced hypertension.
• Diabetes mellitus.
36
BONY PELVIS
KEY POINTS
• The true pelvis is bounded above by the pelvic inlet and
below by the pelvic outlet. In between the inlet and the
outlet, is the pelvic cavity.
• The majority of cases of disproportion occur at the
pelvic inlet.
• Rotation of the head occurs in the pelvic cavity. A flat
sacrum would imply a high risk of deep transverse
arrest.
• Pelvimetry refers to the assessment of the adequacy of
the pelvis by the measurement of various param eters for
the purpose of predicting the course of labour.
• Pelvimetry can be achieved by clinical exam ination or
imagery such as X -ray, CT or MRI.
• A trial of labour is one in which labour is allowed to
proceed in a primigravida with suspected cephalopelvic
disproportion at the pelvic brim, with the head not
engaged, with readiness for Caesarean section.
37
ANAEMIA
CHAPTER THREE
ANAEMIA IN PREGNANCY
INTRODUCTION
Anaemia is probably the most frequently encountered medical
complication in pregnancy in developing countries. This condition is
still a major contributor to maternal mortality. In the West Indies, one
must be particularly vigilant, because the following conditions may exist:
The com m on types o f anaemia seen in pregnancy are preventable com m o n typ e s of anaemia usually
v i • . i- . . , . , , , .. are treated with appropriate diet
with appropriate dietary manipulation and supplem entation. Ir anaemia
is diagnosed, then further testing to determine the cause is warranted. iSmln^mlSivepostpartum
Prompt correction o f the cause and treatment are m andatory. Anaemic “jSSidnsk ofinfection
patients are at a marked disadvantage in being unable to withstand 3. increased risk of dvt
significant blood loss such as postpartum haem orrhage. They are also at
an increased risk o f developing puerperal infection and deep venous
thrombosis. Puerperal: of, relating to, or occurring
during childbirth or the period immediately
DEFINITION following
38
ANAEMIA
The red cell mass increases by about 400-500 ml (30 per cent) in Change in RBC
A physiological anaemia results from this discrepancy in com bine effect of change (Physiological Anaemia)
CLINICAL FEATURES
Symptoms would include:
• lethargy
• shortness of breath
• palpitations
• chest pain
• headaches
• dizziness and fainting
AETIOLOGY
• Nutritional deficiencies:
S Iron deficiency
S Folic acid deficiency
39
ANAEMIA
S Vitamin B ]2 deficiency
• Physiological anaemia
• Haemoglobinopathies:
S Sickle cell anaemia
S Thalassaemia syndromes
• Chronic disease such as renal failure
• Aplastic anaemia
• Haemolytic anaemia:
S Auto-im mune haemolytic anaemia
S Systemic lupus erythematosus
• Leukemia/lymphoma
When iron storage is low or depleted Iron absorption is increased when iron stores are depleted, e.g.
there is a increase in transferrin
(iron transporter) to aid in uptake o f iron
when there is a low ferritin level and a high concentration of unsaturated
Erythroid hyperplasia occurs to try
transferrin and also when there is erythroid hyperplasia with a rapid iron
and maintain RBC levels turnover.
There are 2 distinct pathways for iron absorption, viz one for
inorganic and the other for haem iron. In most foods inorganic iron is
in the ferric form and it has to be converted to the ferrous form before
2 Pathways fo r iron absorption:
absorption can take place.
1. Haem (meat) - easy uptake
2. Inorganic (plants) - need converting
In grains, iron forms a stable complex with phytates and only
Phytates prevent iron absorption
limited amounts of iron are absorbed. Similarly poor absorption o f iron
in eggs occurs because the iron is bound to phosphates. Milk is poor in
iron content. Haem iron derived from haem oglobin and m yoglobin o f
animal origin is more effectively absorbed than non-haem iron. Haem
40
ANAEMIA
iron also prom otes the absorption of inorganic iron. Populations from
the underdeveloped parts of the world subsist largely on non-haem iron
and its poor availability explains the prevalence of iron deficiency.
D ebit C redit
Investigation of patients with iron-deficiency anaemia requires a Thing to take note of:
Gynae Hx
detailed history. In the past gynaecological history, fibroids may be the 1. Fibroids - Menorrhagia & depleted stores
cause of m enorrhagia and depleted iron stores. In the obstetric history, O bsH x
high parity especially with little spacing of births or haem orrhage 1. Little spacing of children
2. Hemontiage with child bearing
complicating those pregnancies and multiple pregnancy may decrease 3. Haemorrhoids
4. Parasitic infestation
serum ferritin and thus predispose to anaemia. Chronic blood loss e.g. 5. Celiac disease
haemorrhoids or parasitic infestation (hookworm s) and past history of 6. Taking supplements as advice
Diagnosis
The haemoglobin, all the blood indices (MCV, MCH, MCHC), serum CBC
ferritin and serum iron will be low while the total iron binding capacity 1. Decrease in Hb indices
(TIBC) will be high. Serum ferritin assesses iron stores. Ferritin is stable Iron Investigations
1. Decrease in serum ferritin
and not affected by recent ingestion o f iron and in the developm ent of 2. Decrease in serum iron
3. Increase in TIBC
iron deficiency a low serum ferritin is the first abnorm al laboratory test.
Serum iron even in combination with TIBC is not a reliable indication o f Stool
1. Occult stool
iron stores because it fluctuates widely and is affected by recent ingestion 2. Ova
3. Cyst
Urine
1.Urine microscopy
Blood Film
1. Microcytic
2. Hypochromic
41 Remember serum ferritin is an
acute phase reactant and will
elevate in cases of inflammation
ANAEMIA
Side effects with oral iron are rare, mainly mild gastric upsets and
constipation, which can be alleviated by, increased fluid intake and a
high fibre-diet.
Management
• The underlying cause must be treated.
• The treatment depends o f the severity o f the anaemia, whether
symptomatic (easy fatiguability. headache, palpitation, dyspnoea,
dizziness and syncopy) or not. It also depends on the period o f
gestation.
• All patients with severe anaemia (Hb 4 g/dl) require urgent
admission to hospital. These women are at high risk o f
developing cardiac failure. They require transfusion with packed
cells.
• The aim of treatment is to achieve a haem oglobin o f at least 10.0
g/dl at 40 weeks gestation. During the first week of treatment,
there is no rise in haem oglobin; only a reticulocytosis is
observed. From the end o f week 2, the haem oglobin increases by
approximately 1 g/dl per week. Thus, if the patient is at 30 weeks
gestation and the haem oglobin is 7.0 g/dl, iron supplem entation
would suffice. It is to be expected that the haem oglobin would
rise to 10.0 g/dl by 34 weeks. On the other hand, if the
haem oglobin is 7.0 g/dl at 38 weeks, transfusion with packed cells
would be required to raise the haem oglobin to 10.0 g/dl.
42
ANAEMIA
Foods that are very rich in folate include leafy vegetables such as
spinach, but up to 90 per cent of their folate is lost with boiling and
steaming. Other rich sources are avocados and bananas.
Diagnosis
Macrocytosis as evident in a raised MCV is one of the hallmarks o f folic
acid deficiency. The blood film may show hypersegm entation of
polymorph neutrophils. Red blood cell folate is superior to plasma
43
ANAEMIA
folate levels as a confirm atory test. A stained bone marrow aspirate will
reveal megaloblastic changes.
Treatment
Prophylaxis of 200-300 meg folic acid daily should be administered to
all pregnant women. It is mandatory in grand multiparas, patients with
previous abruptio placentae and with multiple pregnancy.
VITAM IN B 12 DEFICIENCY IN PR EG N A N C Y
Vitamin B12 deficiency is uncommon in pregnancy except in strict
vegans who will not eat any animal-derived foods. Addisonian
pernicious anaemia does not usually occur during the reproductive
years. Vitamin B I2 deficiency is associated with infertility. A low serum
vitamin B12 level confirm s the diagnosis. The recom m ended intake of
vitamin B12 is 3.0 meg per day. Treatment o f Vitamin B12 deficiency is
with weekly intramuscular injections of cyanocobalam in.
HAEMOGLOBINOPATHIES
The haem oglobinopathies are inherited genetic defects of haem oglobin,
resulting from impaired globin synthesis (thalassaemia syndrom es) or
from structural abnormality of globin (haem oglobin variants such as
sickle cell disease).
44
ANAEMIA
Thalassemia
The only com m on thalassaemic syndrom es seen in pregnant women in
the Caribbean are a - and (3-thalassaemia m inor. Individuals with
Southeast Asian ancestry are at an increased risk for offspring with Hb
Bart's or Hb H disease. H aemoglobin H disease is usually associated with
mild or moderate anaem ia. Alpha-thalassaemia m ajor (Hb Bart) results in
the absence o f a -globin; this is associated with hydrops fetalis,
intrauterine death, and pre-eclampsia.
Women with beta thalassaemia m inor require the usual oral iron
and folate supplem ents in the antenatal period. Oral iron for a limited
period will not result in significant iron overload, but parenteral iron
should never be used. If the serum ferritin is high in early pregnancy,
then iron supplem ents should be withheld.
45
ANAEMIA
H om ozygous sickle cell disease (SS disease) is the most severe form
while sickle cell trait is relatively innocuous except under hypoxic
conditions. Sickle cell trait (Hb-AS) occurs in about 10 per cent o f the
West Indian population. In these patients, approximately 30% o f the red
cells have the capacity to sickle.
46
ANAEMIA
Painful Crisis
The painful crisis is one o f the most characteristic m anifestations of
sickle cell disease and the pain is felt in the extrem ities, back, abdom en,
or chest usually associated with fever and the passage o f dark or red
47
ANAEMIA
48
ANAEMIA
Acute Anaemia
This may arise from an aplastic crisis and less com m only from acute
splenic sequestration (seen mainly in the third trimester). Aplastic crisis
is a self-limited state but total arrest of erythropoietic maturation results
in an absence of reticulocytes and a rapidly falling haem oglobin level. It
may result from infection with parvovirus B19. The main clinical
features are listlessness, pale mucous membranes and an upper
respiratory tract infection. The treatment involves blood transfusion.
Spontaneous recovery of the marrow within 5 to 10 days is the norm.
49
ANAEMIA
Contraception
Sterilization should be considered as a perm anent form o f contraception
for the patient with sickle cell disease, especially when no further
pregnancies are required. It is felt that the progestogen-only pill or
depot m edroxyprogesterone acetate offer effective alternative methods
of contraception. These do not increase the risk o f throm bo-em bolism .
The new low-dose combined oral contraceptive is a convenient,
acceptable and reliable method and it can be recom m ended to some of
these sicklers. The intra-uterine device is considered contraindicated
because of an increased susceptibility to infection but this is debatable.
50
ANAEMIA
KEY POINTS
51
DIABETES
CHAPTER FOUR
DIABETES IN PREGNANCY
INTRODUCTION
During the second half of the twentieth century great strides have been
made in the understanding o f the pathophysiology, diagnosis and
treatment of diabetes in pregnancy. Better control o f diabetes resulted
with the availability of insulin, which was discovered by Banting and Best
in 1921 in Toronto.
The greater awareness of the fetal com plications and the need for
immaculate control of blood glucose levels throughout pregnancy have
resulted in a significant fall in the perinatal mortality rate from 25% in
the 1950’s to less than 5% two decades later (Abell et al, 1976). The
increased requirem ent for insulin as pregnancy advances, the problems
of pyelonephritis, polyhydram nios, pre-eclampsia, preterm labour,
congenital abnormalities, sudden unexplained late stillbirths, fetal
macrosomia and hence the risks of shoulder dystocia and birth asphyxia
form the classic picture o f a diabetic pregnancy.
CLASSIFICATION
There are three types of diabetes seen in pregnancy:
• Type 1- Insulin Dependent Diabetes Mellitus.
• Type 1 1-Non-Insulin Dependent Diabetes Mellitus.
• Gestational Diabetes Mellitus.
Type 1
This usually occurs in the young patient (under 20 years) but no age
group is exempt. Most often the diagnosis of insulin-dependent diabetes
52
DIABETES
will have been made before pregnancy, the patient presenting with weight
loss, polydypsia, and polyuria with glycosuria, hyperglycaem ia and a
tendency to ketoacidosis. Circulating insulin is usually absent, and thus
insulin therapy is necessary for m aintenance of well-being.
Type 11
This disease has an insidious onset. It usually occurs in older obese
patients who may have norm al fasting insulin levels. The insulin
secretion is inadequate to deal with hyperglycaem ia. This is largely due
to insulin resistance.
Gestational diabetes
Pregnancy is a diabetogenic state due to the presence of anti-insulin
factors (Table 1). These include hum an placental lactogen,
progesterone, prolactin and cortisol.
There is a tendency for elevation o f maternal blood glucose levels in Pregnancy is diabetogenic (increases the
probability to getting diabetes)
pregnancy. This effect is counterbalanced by an increase in insulin 1. Increase in material glucose
2. Body doubles insulin to deal with increasec
concentrations reaching almost twice non-pregnant levels (K uhl, 1975). maternal glucose
This rise is itself offset by increasing insulin resistance. The vast 3. Body increases resistance to increased
insulin to prevent hypoglycemia
majority of pregnant women m anage to maintain norm oglycaem ia, but •Occurs @ =>13 weeks or =>24 weeks
about 3-5% cannot do so, and they develop gestational diabetes (Abell *50% of individuals who get DM in pregnancy
will develop DM after 25 years
and Beischer, 1975). This abnorm ality o f interm ediary m etabolism of
carbohydrate (CHO) usually starts during the 2nd or 3rd trim ester and
disappears after delivery. The major change in CHO m etabolism during
pregnancy is a decreased sensitivity to insulin and this decreased
sensitivity increases as pregnancy advances. Pregnancy is therefore
diabetogenic. It is now recognised that as much as 50% o f gestational
53
DIABETES
SC R E E N IN G FO R G E ST A T IO N A L D IA BETES
The justification for screening for gestational diabetes is based on the
assumption that there is an increased m orbidity and mortality with this
condition. Early diagnosis and appropriate treatm ent o f gestational
diabetes can im prove the outcom e of the pregnancy.
54
DIABETES
Glycosuria
Testing for glycosuria is universally perform ed in pregnancy. This test The proximal tubule can only reabsorb a limited
amount of glucose. When the blood glucose level
is simple, inexpensive and easy to perform but glycosuria may be present exceeds about 1 6 0 -1 8 0 mg/dl, the proximal
tubule becomes overwhelmed and begins to
despite normal blood glucose levels since the renal threshold for glucose excrete glucose in the urine. This point is called the
renal threshold of glucose (RTG).
may fall in pregnancy. In many centres, urinalysis for glycosuria is no
longer perform ed.
50 g glucose screen
The patient is given a 50 £ glucose load irrespective of the time of the Giveaptsogglucose.if plasmaglucoseis>7.8
. , i i i . i i i i - 1 1 1 r mmol/L is abnormal after 1hr
a
day or last meal and a blood glucose level is measured 1 hour after. A
venous plasma glucose o f > 7.8 mmol/L (> 140 mg/dl) is abnorm al and
the patient should have a form al glucose tolerance test. The false
positive rate with the 50g glucose screening test is 10-15 per cent.
a high false negative rate. An abnorm al test warrants a full oral glucose
tolerance test. If the result of the RBS is more than 11 mmol/1 (198
mg/dl), this is already indicative o f diabetes.
Glycosylated haemoglobin Hb A le
This has proved to be a useful indicator of average long-term blood
glucose levels in clinical diabetes but is not an adequate screening test for pregnancy
gestational diabetes.
Serum fructosamine
Serum fructosamine concentrations are a measure of glycosylated correlates closely to fasting glucose.
, , , 1 , . , .. No level to state normal from abnormal
protein and correlate closely with fasting plasma glucose. The limitation
with this test is the unavailability o f a clear cut-off point that can
differentiate between normal and abnorm al glucose tolerance (Shah et al,
1982).
DIABETES
work. The patient should have a high carbohydrate diet for the VALUES TAKEN after
preceding 3 days. On the m orning o f the test, a fasting blood glucose is Administered 75g glucose within
5 mins
done and this is followed immediately by the adm inistration o f a 75g
VLAUES TAKEN 1 & 2 hrs after
oral glucose drink. The patient should drink this within 5 m inutes.
Then further blood glucose levels are taken at 1, and 2 hours. We no
longer do the 3 hour testing since it does not affect the m anagem ent.
The intravenous glucose tolerance test is reserved for women who cannot Cant tolerate OGTT then given
IGTT
tolerate the oral glucose. Im paired glucose tolerance is not discussed
separately since the m anagem ent o f this condition is similar to that o f
gestational diabetes.
56
DIABETES
Screening for diabetes should also be considered if the following indicationsfor Diabetes screening
conditions are detected in the antecedent pregnancy: early onset pre
eclampsia, polyhydram nios, macrosom ia and multiple pregnancy.
• Recurrent miscarriages.
• Congenital abnormalities involving the central nervous system. Normallythereis a2%riskoffetal
. . . . . . . . abn orm alities, w ith diabetes it is 4 tim es
cardiovascular system, renal system, gastrointestinal system, and thenormal risk
the musculo-skeletal system (see Table 5).
57
DIABETES
• Pre-eclampsia.
• Preterm labour and prem ature rupture of m em branes.
• Polyhydram nios: the cause is obscure but may be related to fetal
polyuria resulting from fetal hyperglycaem ia.
• Fetal macrosomia: this is due to poor m etabolic control o f the
m other. An increased transport of nutrients to the fetus as a
result of increased maternal substrate stimulated fetal
hyperinsulinaem ia which leads to increased anabolic activity.
M aternal insulin does not cross the placenta.
• Visceromegaly - heart, liver, lungs.
• Traum atic births particularly from shoulder dystocia.
• Late unexplained stillbirths: this may be due to a com bination o f
hyperglycaem ia, hypoglycaem ia and acidosis in the fetus.
• Neonatal metabolic problem s -
(a) hypoglycaem ia
(b) hypocalcaem ia
(c) hypom agnesaem ia
(d) hyperbilirubinaem ia - neonatal jaundice.
• Polycythaem ia may be related to fetal hypoxia and
increased erythropoietin production.
• Respiratory distress syndrom e: it has been postulated that fetal
hyperinsulinism may im pair phospholipid synthesis and this
affects the quality o f the surfactant. The surface tension in the
alveoli remains high and these neonates suffer from hyaline
membrane disease. If a diabetic woman must be delivered
before term , amniotic fluid lecithin to sphingom yelin (L/S) ratio
should be measured or the presence o f phosphatidyl choline and
phosphatidyl glycerol confirm ed. A L/S ratio o f greater than 3: 1
ensures adequate fetal m aturation in a diabetic.
• Prematurity - may be iatrogenic, for instance, with worsening
nephropathy, retinopathy or severe pre-eclam psia.
• Intra-uterine growth restriction: this is a problem with long
standing diabetes (Type 1) where there is an arteriopathy which
also impairs utero-placental perfusion.
• Increased perinatal and neonatal m orbidity and m ortality.
• M aternal mortality is unlikely.
58
DIABETES
Cardiac Cardiomyopathy
Transposition of great vessels
Ventricular and atrial septal defects
Co-arctation of the aorta
Renal Hydronephrosis
Renal agenesis
Chromosomal abnormalities
MANAGEMENT
The diabetic pregnant woman should receive her care jointly from the
obstetrician and the diabetologist. Early diagnosis in the case of
gestational diabetes, and pre-conceptional counselling in the clinical
diabetic would improve the outcom e o f the pregnancy.
Medical management
• Pre-conceptional care, which starts 3 m onths prior to conception,
allows for good control o f the metabolic state at the time of
organogenesis. This is best achieved by discontinuation of oral
hypoglycaemic drugs and the adm inistration o f insulin. The
obese patient is also advised on a weight restrictive diet. Folic acid
supplementation is com m enced then.
• Control of diabetes
a. Dietary intake-The diabetic patient is usually com m enced
on a 1600-1800 kilocalorie diet daily. The assistance o f the
dietitian is crucial since factors such as pre-pregnancy weight and
59
DIABETES
Long-acting (lente) insulin does not provide Long acting insulin NOT used
in pregnancy:
norm oglycaem ia throughout the 24-hour period, and thus lente 1. Teratogen
2. Hard to control
insulin should not be used in pregnancy. Oral hypoglycaem ic 3. > chance o f fetal
hypoglycemia
drugs are not used in pregnancy because of their teratogenic
effects (since they cross the placenta), difficulty in achieving tight
control, and the risk of severe neonatal hypoglycaem ia.
60
DIABETES
2-3 times weekly and via the telephone she is advised how to
adjust the insulin regime if this is necessary. In most developing
countries, home blood glucose m onitoring is not the routine.
Hence the diabetic pregnant women must be adm itted to hospital
on a regular basis for a blood glucose profile.
KNOW THIS
Dawn phenom enon
Blood glucose profile Normal values The dawn phe nom enon is a norm al rise In blood
sugar as a p e rso n 's bod y prepares to wake up.
Random blood glucose estimations are not precise for assessment Naegele's Rule is used to estimate the due date
of the fetus. Rule uses 28 day cycle as normal
of control in the pregnant diabetic. H aem oglobin A le 1. I.d. date of LMP
2. G o back 3 months from that date
measurements provide some idea o f the control o f the diabetic 3. Add 1 year 7 days to that date
state during the preceding 8-12 weeks. SHORT CUT = Just go back 3 months add
0 days if 21 day cycle
7 days if 28 day cycle
Every v is it
1. Fundoscopy- Eyes
• Assessment o f renal and retinal status is essential in the Type I 4 days if 32 day cycle
2. ECG - Heart (if cardio issues) diabetic. Therefore these patients should have regular renal
3. Renal - Renal Function
function tests and fundoscopy perform ed during pregnancy.
61
DIABETES
Intrapartum management
Time of delivery
40 weeks is allowed if no signs and symptoms The tim ing o f delivery is not as rigid as heretofore, and much depends
Induction of labour ideally at 38 weeks to avoid
sudden still birth
upon the p atient’s cooperation regarding control o f her diabetes and the
Delivery before 38 weeks:
A. Proliferate retinopathy
absence of pregnancy com plications. In some countries if pregnancy is
B. Renal failure norm al, it may be allowed to continue to 40 weeks thereby awaiting
C. Severe pre-eclampsia
spontaneous labour. It is still our practice, to perform an induction o f
labour at 38 weeks, and this is mainly to avoid the risk o f sudden late
stillbirths. M aternal indications for delivery prior to 38 weeks include
severe pre-eclam psia, progressive proliferative retinopathy and renal
failure.
62
DIABETES
For those who have been in poor control or have had a previous
stillborn fetus, delivery should be accom plished as soon as pulm onary
maturity has been confirm ed. The Neonatologist should be involved in
this decision.
Mode of delivery
If the pelvis is adequate and the fetus is not m acrosom ic, the aim should
be for a vaginal delivery. Diabetes by itself is not an indication for
Caesarean section.
Induction of labour
Cervical assessment is determ ined the day before the planned induction.
If the cervix is unfavourable, a prostin pessary or another ripening agent
is used to prime the cervix. On the m orning o f the induction, a fasting
blood glucose level is measured and half the usual m orning insulin dose
is given. The appropriate dose of Syntocinon is added to a litre of
Hartmann’s solution and usual titration rate is followed. Every 2 hours,
blood glucose estimations are perform ed and insulin, if needed, is given
at a dose of 1-2 units per hour. If hypoglycaem ia ensues, a 5 % dextrose
infusion is com m enced and insulin is withheld. A partogram should be
started to monitor the progress o f labour since the diabetic must not be
allowed to have a prolonged labour.
63
DIABETES
perform ed early in the m orning with the patient fasted overnight and the
m orning insulin dose withheld. A fasting blood glucose is done and a
5 % dextrose infusion is com m enced. D epending on the level o f the
blood glucose, insulin may be given.
Postpartum management
As soon as delivery has been achieved, the maternal requirem ents for
insulin decrease precipitously. Glucose levels are m onitored at 4, 8, 12
and 24 hours, and insulin is given, if indicated. Breastfeeding is not
contra-indicated for the diabetic m other. The mild diabetic can be
advised the new low-dose oral contraceptive pill but in the severe diabetic
com plicated by retinopathy and/or nephropathy, it is best to advise
sterilization.
Hyaline Membrane Disease
condition in newborn babies in which the lungs
The neonate should be admitted to the intensive care unit and
are deficient in surfactant, which prevents their
proper expansion and causes the formation of
frequent evaluation o f his metabolic state perform ed. Assisted
hyaline material in the lung spaces ventilation may be necessary if hyaline m em brane disease exists.
64
DIABETES
KEY POINTS
65
HYPERTENSION
CHAPTER FIVE
IN T R O D U C T IO N
The hypertensive disorders o f pregnancy constitute an im portant area for
all providers of Obstetric care. H ypertension, with or without proteinuria,
is one o f the com m onest com plications o f pregnancy. This medical
disorder of pregnancy is a leading cause of mortality and m orbidity to
both the m other and newborn. In Trinidad, the hypertensive diseases of
pregnancy account for 70 per cent o f all maternal deaths
(R oopnarinesingh et al, 1991) and in the United K ingdom , these
disorders rival throm boem bolism as the leading cause o f direct deaths of
pregnant women.
C LASSIFIC A TIO N
• Pre-eclampsia
• Pregnancy-induced hypertension (gestational hypertension)
• Chronic hypertension.
• Chronic hypertension with superim posed pre-eclam psia.
Pre-eclampsia
Women who have norm al blood pressures at the start of pregnancy and
develop hypertension with significant proteinuria usually in the second
half of pregnancy are said to have pre-eclam psia.
66
HYPERTENSION
67
HYPERTENSION
Eclampsia
Eclampsia is the developm ent of epileptiform convulsions in the
pregnant patient. These seizures are of the grand-m al tonic clonic type.
A bout 20% of eclam ptic convulsions occur with no prodrom al
sym ptom s, but the rem ainder present with the sym ptom s and signs of
im pending eclampsia. The incidence of eclam psia is about 1 to 3 per
thousand pregnancies. D uring the 11 years between 1981 and 1991,
there were 103 eclamptics out o f 63,574 parturients at the M ount Hope
M aternity Hospital, an incidence o f 0.16 per cent (Bassaw et al, 1994).
68
HYPERTENSION
Chronic hypertension
Some of the causes are chronic renal disease, phaeochrom ocytom a, renal
artery stenosis and coarctation o f the aorta. H ypertension will be present
before and persist after the pregnancy. There may also be associated
proteinuria with chronic disease. Some o f these patients may develop
superimposed pre-eclam psia.
PRE-ECLAMPSIA
Predisposing factors for pre-eclampsia
• Nulliparity
• Extremes o f reproductive age; it is more com m on in patients
below 16 and over 35 years o f age
• Past history of pre-eclam psia (esp. if same male partner)
• Family history of eclam psia
• Lower socio-econom ic group
• Poor prenatal care
• Chronic hypertension or renal disease
• Hyperplacentosis i.e. hydatidiform mole, diabetes mellitus and
gestational diabetes, multiple pregnancy, triploidy, and rhesus
isoimmunization
• Sickle cell anaemia (SS disease and SC disease)
• Obesity
69
HYPERTENSION
Pathophysiology of pre-eclampsia
Kidney
The most consistent renal lesion in pre-eclam psia is glom erulo-capillary
endotheliosis. The endothelial cells are so swollen as to block, partially
or even com pletely, the capillary lumen. It is believed that the renal
lesion in the true pre-eclam ptic patient is reversible and that the
occurrence o f the disease in pregnancy does not predispose to
hypertension in later years. The renal blood flow is reduced in pre
eclampsia. G lom erular function is im paired, and this is reflected by a
decrease in creatinine clearance. Proteinuria and in severe cases,
oliguria exists. Acute renal failure, usually due to acute tubular necrosis
and rarely due to cortical necrosis, is a possible com plication.
Brain
Cerebrovascular haem orrhage, vasospasm and oedem a are the
underlying pathological changes seen in patients with pre-eclam psia and
eclampsia. Convulsions are thought to be due to cerebral vasospasm and
oedem a which lead to increased neuronal activity. H eadache, visual
disturbances, nausea, vomiting and hyperreflexia seen in patients with
im pending eclam psia are due to a central cause.
Liver
Periportal haem orrhages and hepatocellular necrosis are reported with
pre-eclam psia. The epigastric or right hypochondrial pain is believed to
be a consequence o f swelling o f the G lisson’s capsule. Elevated
transaminases (10% above the norm al range) are a feature of the HELLP
syndrom e. Rarely, hepatic rupture can com plicate pre-eclam psia.
Cardio-respiratory systems
The hypertension is mainly a result o f increased peripheral resistance
from generalised vasospasm. Increased cardiac output may play a m inor
role. Cardiac failure and pulm onary oedem a are serious com plications
and it is thus prudent to restrict intravenous fluids to avoid these risks to
the m other. H aem odynam ic measurements with a Swan-Ganz catheter
are essential in the m anagem ent of a pre-eclam ptic with pulm onary
70
HYPERTENSION
Aetiology
The aetiology o f pre-eclam psia is still unclear but many theories have
been proposed to explain this multi-system disorder.
• Genetic - a family history o f eclam psia in the m other increased
the risk about seven times in daughters. This seems to be due to a
single recessive gene.
• Im m unological - this disease is mainly seen in first pregnancies
but the protective effect o f nulliparity may be lost with a new
partner. The disorder is also recurrent if the partner is the same.
This altered im m une mechanism seems to operate locally (i.e. the
placenta) and not in the entire body.
71
HYPERTENSION
72
HYPERTENSION
Management of Pre-eclampsia
The m anagem ent depends upon the severity o f the condition, the
presence of any m aternal com plications and the assessment o f the fetal
well-being and m aturity.
Antenatal Management
All patients found to have hypertension and/or proteinuria should be
referred to a tertiary centre im m ediately. The patients, irrespective o f the
severity of the disease, should be admitted to hospital or a day unit for
detailed assessment and m onitoring.
Anti-hypertensive therapy
Emergency or rapid-acting anti-hypertensive drugs used in severe pre
eclampsia include hydralazine, calcium -channel blockers, and labetalol
and to a lesser extent diazoxide and sodium nitroprusside. The chronic
management of hypertension in mild pre-eclam psia may involve the use
of drugs such as m ethyldopa, labetalol and hydralazine.
73
HYPERTENSION
Hydralazine
With severe hypertension, the blood pressure should be m onitored
continuously with a Dinamap m onitor. Hydralazine in 5 mg boluses are
administered intravenously until the diastolic blood pressure stabilises in
the range 90 to 100 mm Hg. Then a Hydralazine infusion consisting of
10 mg in 100 ml of norm al saline is titrated against the blood pressure
readings. H ydralazine is believed to increase renal blood flow and
cardiac output. Side effects include reflex tachycardia, headache and
palpitations.
Labetalol
This is an a 2 and |3-adrenergic blocker which is given as an intravenous
infusion o f 200 mg in 200 ml norm al saline starting at 20 mg/h and
doubling every 30 minutes until the diastolic pressure is below 110 mm
Hg or a m axim um dose of 160 mg/h is reached. Labetalol is claimed to
produce a smooth fall in blood pressure without hypotensive episodes.
Labetalol can also be given orally in the chronic m anagem ent of
hypertension though its use is often restricted to the third trimester.
M ethyldopa
This is primarily a central a-adrenergic stimulant which produces
peripheral vasodilatation by reducing sym pathetic nervous system
outflow. It may produce side-effects such as depression, postural
hypotension, nightm ares, and less com m only cholestatic jaundice and a
positive C o o m b 's test. There may also be a mild elevation in serum uric
acid levels. M ethyl-dopa remains the anti-hypertensive agent o f choice
for the chronic m anagem ent of hypertension.
Propranolol
The mechanism o f action involves a central adrenergic effect, blockage
o f renin secretion and in some cases decreased cardiac output. B-
adrenergic blockers such as propranolol may cause fetal and neonatal
apnea. There is also an association between high doses of propranolol
and intra-uterine growth retardation. This drug is also relatively contra
indicated in diabetes in pregnancy.
74
HYPERTENSION
Diuretics
Thiazide diuretics should not be used in pre-eclam psia since the drug
can further decrease the already depleted plasma volum e. Other
complications associated with thiazide diuretics include electrolyte
disturbance, cardiac arrhythm ias, pancreatitis, abnorm al glucose
tolerance, and throm bocytopenia. M annitol may be used with cerebral
oedema, and frusem ide (Lasix) is valuable in the treatm ent of pulm onary
oedema.
75
HYPERTENSION
Delivery
The time and m ode o f delivery require an evaluation o f the m aternal and
fetal status. With mild pre-eclam psia, it is preferable to delay delivery
until 38 weeks gestation. However, with severe pre-eclam psia delivery
may be required several weeks before term because o f a m aternal or fetal
indication.
Once the decision to deliver the patient with severe pre-eclam psia
has been m ade they should be started on m agnesium sulphate (M A G PIE
study).
76
HYPERTENSION
MANAGEMENT OF EC LA M PSIA
Resuscitation
Call for help. The initial step should be to place the patient in the left
lateral position and ensure that there is a patent airway. Attempts may be
made to insert an oropharyngeal airway though this may difficult.
Oxygen can be adm inistered by nasal prongs and intravenous access
established with two wide bore cannulae.
Anticonvulsant therapy
The Collaborative Eclampsia Trial dem onstrated that M agnesium
sulphate is the drug of choice and in general there is no need for
polypharmacy. It is a simple salt that is excreted by the kidneys and acts
both centrally and peripherally. Peripherally, it inhibits pre-synaptic
transmission at the neurom uscular junction and catecholam ine release
from the adrenal medulla. Centrally, it inhibits excitatory receptors in the
central nervous system such as the NMDA receptors and produces a
vasodilatation, which has a beneficial effect in cerebral oedem a. In
addition, it has a mild hypotensive effect, does not produce sedation and
obtunds the hypertensive response to endotracheal intubation. The
loading dose of M agnesium sulphate is 4g (20 ml o f a 20% solution)
administered intravenously over 3 to 5 minutes.
77
HYPERTENSION
78
HYPERTENSION
Stabilization
The blood pressure is m onitored continuously with a D inam ap. The
desired diastolic blood pressure is in the range o f 90-100 m m Hg and this
can be achieved with one o f the em ergency antihypertensive drugs
(Hydralazine, Nifedipine or Labetalol) m entioned earlier. There should
be strict input/output charting. A F o ley ’s catheter is inserted with an
hourly urom eter and fluid restricted to 85 millilitres per hour (1 ml/
kg/hr).
Delivery
Once the patient has been stabilised, a decision must be made to deliver
the fetus. Ideally this should occur within 12 hours o f adm ission. If the
patient is already in labour, then augm entation o f labour with an
amniotomy and a Syntocinon infusion should be perform ed. For the
patient who is not in labour, the anticipated induction-delivery interval
must be determined. If this interval is considered to be short, induction
of labour should be done. On the other hand, if the induction-delivery
79
HYPERTENSION
Postpartum
Postpartum, close m onitoring of the m other is imperative. Forty percent
o f all eclamptic episodes occur during this period and anticonvulsant
therapy should continue for at least 24 hours after the delivery or 24
hours after the last seizure, whichever is later. A nti-hypertensive
treatm ent may also be required post-delivery.
80
HYPERTENSION
KEY POINTS
81
CARDIAC DISEASE
CHAPTER SIX
IN T R O D U C T IO N
The incidence of heart disease in pregnancy is 1-2%. The maternal
mortality rate with cardiac disease in association with pregnancy is about
0.2% . Although there has been an absolute decrease in m aternal
mortality attributed to heart disease, recent Confidential Enquiries into
M aternal Deaths in England and Wales illustrated the relative im portance
o f this medical disorder as a contributor to maternal deaths.
AETIOLOGY
In developing countries, rheumatic heart disease accounts for up to 90%
o f cases seen in pregnancy. It is associated with mitral and aortic valve
stenosis and is on the decline because of the use of antibiotics in the
treatm ent o f streptococcal infection.
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CARDIAC DISEASE
On the other hand, the num ber o f females with congenital heart
disease reaching childbearing age has increased. This is due to
improvements in the m anagem ent of children with these anomalies,
particularly when am enable to surgery. In many British hospitals,
congenital heart disease is as com m on in pregnancy as rheum atic heart
disease.
CARDIOVASCULAR C H A N G E S IN PR E G N A N C Y
The work done by the heart is considerably increased during pregnancy
and this is primarily due to a com bination o f increased blood volume
and decreased peripheral resistance.
83
CARDIAC DISEASE
DIA G N O SIS
The following sym ptom s and signs are indicative o f heart disease:
• Dyspnoea
• O rthopnoea
• Paroxysmal nocturnal dyspnoea
• Haemoptysis
• Cough
• Chest pain
• Cyanosis
• Elevated jugular venous pressure
• Thrill
• Parasternal heave
• Loud ejection systolic m urm urs (grade 1 1 1-1V) which vary with
respiration
• Pansystolic m urm ur
• Diastolic m urm ur
• Cardiac arrhythm ias
• Diastolic gallop rhythm or pulsas alternans
• Click
• Pericardial friction rub suggests pericarditis.
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CARDIAC DISEASE
INVESTIGATIONS
• Haemoglobin
• Electrocardiogram
• Chest X-ray (with shielding o f the abdom en)
• Echocardiogram is the technique o f choice. It detects the
majority of structural abnorm alities.
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CARDIAC DISEASE
• Obesity
• Infection (e.g. cystitis)
• Anaemia
• Hypertension
• M ultiple pregnancy
• Blood loss
• H yperthyroidism .
M ED IC A L M A N A G E M E N T
The basic principle in the m anagem ent o f a patient with cardiac disease
in pregnancy is to limit the burden on the heart. This can be achieved
by:
• Bed rest and limitation o f strenuous physical activity. Mild
exercise is encouraged to improve physical fitness and to reduce
the risks o f venous throm bo-em bolism .
• Avoiding em otional upsets.
• Careful diet and weight control.
• Prevention and early treatm ent o f anaemia.
• Prevention and treatment of infection especially urinary and
respiratory infections.
• Prom pt treatm ent o f hypertension.
• Avoid supine position. The sem i-recum bent position is
preferable.
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CARDIAC DISEASE
OBSTETRIC M A N A G E M E N T
Ideally, delivery o f these patients should be planned with senior
anaesthetic and obstetric staff available. The patient should be allowed to
go into spontaneous labour. By itself, cardiac disease is not an indication
for induction of labour. It is also not an indication for Caesarean section.
Caesarean section is perform ed only for an obstetric indication. A
Syntocinon infusion may cause circulatory overload and artificial
rupture of m em branes may lead to chorioam nionitis and subacute
bacterial endocarditis. Vaginal delivery is therefore the preferred route
of delivery.
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CARDIAC DISEASE
Puerperium
The patient is encouraged to breast-feed. She should be advised to have
more bed rest. For patients with Class 111 or IV disease, sterilization
should be recom m ended. If this is not acceptable, then barrier
contraception is advisable.
COM PLICATIONS
• Congestive cardiac failure.
Treatm ent should be administered by a cardiologist. The patient
must be admitted to the antenatal ward or a high-dependency
area. She must be nursed in a sem i-recum bent position. O xygen
is administered and fluid restriction instituted. Her vital signs are
m onitored. Frusemide (Lasix) is given to create a diuresis.
M orphine is useful since it decreases venous return by causing
peripheral vasodilatation. Furtherm ore, M orphine is an anxiolytic
88
CARDIAC DISEASE
CARDIAC SURGERY
Cardiac surgery is not perform ed in pregnancy unless it is absolutely
necessary. By-pass operation is contra-indicated in pregnancy since the
use of the heart-lung m achine carries a high risk o f fetal wastage. A
mitral valvotomy may be perform ed between 16-20 weeks if there is a
tight mitral valve, which is causing cardiac failure that is unresponsive to
medical therapy.
CARDIAC DISEASE
KEY POINTS
90
JAUNDICE
CHAPTER SEVEN
VOMITING
JAUNDICE
ABDOMINAL PAIN IN PREGNANCY
VOMITING IN PR E G N A N C Y
INTRODUCTION
Nausea and vomiting are com m on sym ptom s of pregnancy affecting 50
to 75% of all conceptions. Usually, it is a self-limiting process beginning
in early pregnancy and resolving spontaneously after 16 weeks.
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JAUNDICE
AETIOLOGY
The precise cause o f nausea and vomiting is not known. Several theories
have been put forward and both endocrine and psychogenic factors have
been postulated. Em otional stress and fear o f m otherhood have been
cited as significant factors.
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JAUNDICE
COM PLICATIONS
Vomiting in pregnancy usually runs a benign course. Hyperem esis
gravidarum on the other hand represents the extrem e o f the process and
can result in a wide spectrum o f com plications. These include:-
• Weight loss.
• D ehydration.
• Throm boem bolism
• Electrolyte disturbance. Namely, hyponatraem ia,
hypokalaem ia and hypochloraem ia.
• M endelson’s syndrom e. M aternal deaths have been reported
in the literature secondary to this aspiration pneum onitis.
• M allory Weiss syndrom e. O esophageal m ucosal tears can
occur secondary to protracted retching.
• Vitamin deficiencies. Thiam ine ( Bl ) deficiency can lead to
W ernicke’s encephalopathy. While deficiency o f Pyridoxine
(B6) and Cyanocobalam in (B 12)may result in a
megaloblastic anaem ia and peripheral neuropathy.
• Fetal growth restriction.
INVESTIGATIONS
The following should be considered baseline investigations for all
patients who present to hospital with vomiting in pregnancy:
• Urinalysis. Two pluses or m ore o f ketonuria denotes
significant metabolic disturbance.
• Midstream urine (MSU) for m icroscopy culture and
sensitivity. The presence o f protein, blood, leucocytes or
nitrites on urinalysis warrants this investigation.
• Full Blood Count. A raised haem atocrit will be seen in the
dehydrated patient whilst throm bocytopenia will be seen in
conditions such as the HELLP syndrom e.
• Urea and Electrolytes. May reveal hyponatraem ia,
hypokalaem ia and hypochloraem ia.
• Liver Function Tests. May reveal elevated transam inases.
• Thyroid Function Tests. May be abnorm al because o f the
thyroid stimulating effect of the alpha sub-unit o f hum an
chorionic gonadotrophin. It does not usually require
treatment.
• An ultrasound scan can be perform ed to rule out multiple
pregnancy and gestational trophoblastic disease. There is no
need to repeat the scan on admission if a previous scan has
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JA UN DICE
MANAGEMENT
Simple measures
The vast majority of patients with vomiting in pregnancy respond to
simple measures. This may include reassurance and dietary advice. A
bland diet bereft of oil (for example dry crackers) and regular, small
aliquots o f simple fluids (such as water/electrolytes) may be all that is
required. A supportive family network is often helpful and it may be
that her partner can be encouraged to assume tasks that would allow her
to avoid noxious stimuli. Ginger extracts and pyridoxine are simple
remedies with antiemetic properties. Oral antiemetics can also be
prescribed. If absorption is an issue buccal, sublingual and rectal
preparations are available.
Advanced measures
The patient with hyperemesis gravidarum needs admission to hospital.
Oral intake should initially be restricted and there should be strict input
and output charting.
• Intravenous fluid therapy - is the mainstay of management.
Isotonic solutions such as H artm ann's and normal saline are
the fluid of choice.
• Biochemistry should be repeated daily and fluid therapy and
potassium chloride supplementation tailored depending on
these results. Dextrose containing fluids should be avoided as
they may precipitate W ernicke's encephalopathy.
• Antiemetic therapy - is safe in pregnancy. The drugs used
include:-
(1) The neuroleptic phenothiazines, such as
Prochlorperazine (Stemetil) and Chlorpromazine
(Largactil), are dopamine antagonists that act at the
chemoreceptor trigger zone. They may be
administered intravenously, intramuscularly, bucally
or rectally. Rarely, extrapyramidal side effects such as
tardive dyskinesia are seen. The antidote is
Benzatropine (Cogentin).
(2) Antihistamines such as Dimenhydrinate (Gravol) and
Promethazine (Phenergan). These drugs have a
94
JAUNDICE
95
JA UN DICE
KEY POINTS
• Nausea and vomiting are common symptoms of
pregnancy.
• Most patients respond to simple measures.
• Persistent, excessive vomiting that may result in
dehydration, electrolyte disturbances and
nutritional deficiencies is known as hyperemesis
gravidarum .
• Isotonic solutions are the mainstay of
intravenous fluid therapy.
• A void dextrose infusions as they may precipitate
W ernicke’s encephalopathy. Thiamine should be
prescribed to all patients with hyperemesis
gravidarum .
• Antiemetic therapy is safe in pregnancy.
• Termination of pregnancy can be considered in
the event of deterioration o f maternal status.
.JAUNDICE IN P R E G N A N CY
Maternal jaundice is a relatively rare complication encountered in
pregnancy. It occurs in approximately 1:3000 gestations and in the
developing world it makes a significant contribution to maternal
mortality. In Ibadan, Nigeria, for example, 15.3% of all maternal deaths
were associated with acute liver failure. This propensity for adverse
maternal outcome should prompt thorough investigation o f this sign of
hepatic dysfunction.
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JAUNDICE
AETIOLOGY
Jaundice can result from conditions unique to pregnancy (such as acute
fatty liver) or it may arise de novo in pregnancy from conditions that
also affect the non-pregnant patient (such as viral hepatitis). Rarely, it
may occur in patients who had liver disease prior to conception (such as
cirrhosis). The list of potential cause o f jaundice in pregnancy is
exhaustive. In this section we have confined discussion to the following
important factors:-
• Viral hepatitis
• Obstetric cholestasis
• Acute fatty liver o f pregnancy
• HELLP syndrome
• Hepatotoxic drugs
• Cirrhosis
In the Caribbean the haemolytic anaemias (especially SCD and G6PD
deficiency) and cholelithiasis are other significant causes.
Viral hepatitis
Viral hepatitis accounts for 40% of all cases o f jaundice in pregnancy.
This can be due to the hepatotrophic viruses:-
• Hepatitis viruses - A,B,CX) or E
• Cytomegalovirus (CMV)
• Epstein Barr virus (EBV)
• Herpes simplex virus (HSV)
Hepatitis A
This is a RNA virus that is transmitted by faecal contamination. There is
usually a brief attack of hepatitis followed by rapid recovery and
permanent immunity. Vertical transmission is rare but may occur if
maternal inoculation occurs around the time o f delivery. The neonate
should be given immune globulin at birth.
Hepatitis B
This is a highly infectious DNA virus that is transmitted parenterally and
through sexual contact. The major antigenic determinants of the virion
are the surface antigen (HBs Ag), the core antigen (HBc Ag) and the e
antigen (HBe Ag). These can be identified in the maternal serum.
Vertical transmission usually occurs at the time o f delivery and the risk is
greatest in mothers who are HBs Ag and HBe Ag positive. When infected,
more than 90% of newborns will become chronic carriers of the virus,
which can lead to hepatocellular carcinoma and cirrhosis. All neonates
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JAUNDICE
Hepatitis C
This is a single stranded RNA virus that is transmitted parenterally.
Vertical transmission may occur but there are no available vaccines.
Breastfeeding is not contraindicated.
Obstetric Cholestasis
This is principally a disease of late pregnancy. Although the precise
aetiology is unknown it is probably due to a multitude o f factors,
including a genetic predisposition, which result in an increased sensitivity
of the hepatocyte membrane to oestrogens.
The hallmark of the disease is that, in the absence of a rash, there
is a generalised pruritus, which characteristically affects the palms of the
hands and soles of the feet. There may be hepatomegaly though
jaundice is not a common feature. The biochemical picture is that of an
obstructive process and the most common abnormalities are elevated
transaminases and bile acids. Alanine transaminase, which is primarily a
cytosolic enzyme, is thought to be a more sensitive marker of the mild
hepatocellular damage that is seen in obstetric cholestasis. The diagnosis
is one of exclusion and the differential diagnosis would include
cholelithiasis, viral hepatitis and primary biliary cirrhosis. A liver
ultrasound and serology for hepatitis A, B and C, Epstein-Barr virus,
cytomegalovirus and liver autoantibodies should therefore be performed.
98
JAUNDICE
99
JA UN DICE
Associated factors:
• young primigravidae
• multiple pregnancy
• male offspring
Investigations:
• Haematology - full blood count and clotting profile. May reveal
thrombocytopenia, anaemia, leucocytosis and an abnormal
clotting profile.
• Biochemistry - urea and electrolytes and liver function tests.
These may reveal the following biochemical abnormalities:
hypoglycaemia, elevated transaminases, hyperbilirubinemia,
hyperuricaemia, elevated urea and creatinine and
hypoalbuminaemia.
• Liver ultrasound scan - may be normal.
• Liver biopsy - may reveal centrilobular distribution of fat within
hepatocytes with preservation of the liver architecture. Biopsy is
not safe in the presence of clotting abnormality.
Management:
An early consideration in the management of these patients should be to
expedite delivery. If a long induction to delivery is anticipated the mode
of delivery should be caesarean section. There should be a multi
disciplinary ethos to management in a high dependency or intensive care
setting. Early involvement of senior obstetricians, anaesthetists, renal
physicians, hepatologists and haematologists is mandatory.
Haematological abnormalities may need correcting with blood
component therapy such as packed cells, fresh frozen plasma or
cryoprecipitate. Hypoglycaemia can be profound and should be
corrected with dextrose infusions. There should be strict input/output
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JAUNDICE
HELLP syndrome
This is a complication of pre-eclampsia and is associated with increased
maternal morbidity and poor perinatal outcome. The hallmarks are
intravascular haemolysis (H), elevated liver enzymes (EL) and low
platelets (LP).
Hepatotoxic Drugs
Drugs are an important cause o f hepatic injury. The liver is the
predominant site of drug clearance, biotransformation and excretion. A
wide spectrum o f abnormalities is seen from minor derangement to
fulminant hepatic necrosis. The following drugs may cause hepatic
dysfunction and jaundice: acetaminophen, isoniazid, methyldopa,
chlorpromazine and methotrexate.
Cirrhosis
Cirrhosis is usually associated with infertility. Occasionally these patients
conceive. One o f the main problems in pregnancy is bleeding from
oesophageal varices.
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ABDOMINAL PAIN
KEY POINTS
A B D O M IN A L PAIN IN PR E G N A N C Y
IN T R O D U C T IO N
Abdominal pain during pregnancy may be due to a condition either in a
pelvic structure or in an abdominal organ. In many instances the pain
has a benign origin but in a few patients, it is of a more sinister nature as
in the case of abruptio placentae or uterine rupture. Pain is a subjective
experience and it cannot be precisely measured. About 90% of women
complain of this symptom during the course of pregnancy and the
incidence rises as term is approached. When pain awakens a patient or is
severe enough to require analgesia, a definite cause must be sought. This
is done chiefly by means of a careful history, physical examination and
recourse to appropriate investigations.
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ABDOMINAL PAIN
103
ABDOMINAL PAIN
C L A SSIFIC A TIO N
It is useful to divide ‘p a in ’ into the discomforts o f pregnancy and true
pain. It is our experience that almost all patients attending antenatal
clinic complain of some type of abdominal pain. In the vast majority, it
is of no consequence and should be considered as a discomfort. All that
is needed is reassurance, tact and sympathy.
Condition Examples
Increasing abdominal Multiple pregnancy
distension and over Hydramnios
distension
Epigastric pain Pre-eclampsia
Breech presentation
Stretching o f round Primigravidae
ligaments
Lower costal margin pain Primigravidae
(R>L) Large babies
Pendulous abdomen Grand multiparae
Uterine Miscarriage
Red degeneration of a fibroid
Concealed abruptio placentae
Ruptured uterus
Ruptured cornual pregnancy
Labour
Adnexal Ruptured tubal pregnancy
Tubal miscarriage
Torsion of an ovarian cyst e.g.
dermoid
Rupture of an ovarian cyst
Extra-uterine Urinary tract problems
Gastro-intestinal disturbances
Sickle-cell crisis
Extra-uterine pregnancy
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ABDOMINAL PAIN
MANAGEMENT
Uterine and adnexal origin
A vaginal examination is mandatory in early pregnancy to rule out
fibroids and ovarian cysts. An ultrasound scan is indicated if these
tumours are felt. The management o f red degeneration of a fibroid is
conservative, though these patients may require high dose opioid
analgesia. Complex ovarian masses suspicious o f malignancy require
further investigation. This may include MRI scanning or laparotomy. If
diagnosed in early pregnancy and the index o f suspicion is high, the
optimum time for surgical intervention is the second trimester. On the
other hand, torsion o f an ovarian cyst warrants immediate laparotomy
irrespective o f gestation.
Extra-uterine origin
Urinary tract problems
• Acute retention of urine may be caused by compression o f the
urethral sphincter by a retroverted gravid uterus. It typically
occurs prior to 14 weeks in patients with a generous pelvis and a
prominent sacral prom ontory. They may require catheterisation
until the uterus has migrated out o f the pelvis.
• Acute pyelonephritis occurs more com m only on the right side
and during the second trimester o f pregnancy. These patients
require admission to hospital for parenteral antibiotics.
• Renal colic from calculi is rare but occurs more com m only on
the right side and is an important cause of haematuria. The pain
is usually severe and they are best managed in hospital. The
management is initially conservative with adequate analgesia
though these patients should be promptly referred to the
urologists.
Gastro-intestinal disturbances
• Epigastric pain may be due to recurrent vomiting. It is an
ominous sign in pre-eclampsia because it suggests hepatic
involvement and distension o f G lisson’s capsule.
• Reflux oesophagitis may cause heartburn. This is due to the
pressure effect of the gravid uterus and relaxation o f the cardiac
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A B D O M IN A L PAIN
Sickle-cell crisis
• Vaso-occlusive crises in patients with sickle-cell disease in
pregnancy are extremely painful. Musculo-skeletal pain is the
most common complaint. Pain over costo-chondral junctions,
spleen and liver is seen more frequently in the older patient.
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ABDOMINAL PAIN
Extra-uterine pregnancy
• This is a rare occurrence but should be suspected in patients with
chronic pain that is worse on movement o f the fetus, and in whom
fetal parts are easily felt. An ultrasound scan should clinch the
diagnosis.
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ABDOMINAL PAIN
KEY POINTS
108
ADOLESCENT PREGNANCY
CHAPTER EIGHT
ADOLESCENT PREGNANCY
ADVANCED MATERNAL AGE
GRAND MULTIPARITY
OBESITY
ADOLESCENT PREGNANCY
INTRODUCTION
With the exception of Australia, teenage pregnancy is occurring with an
alarming frequency throughout the world, in developed as well as
developing countries. In the USA, the haunting tale o f unintended
pregnancies is rewritten every 2 minutes, when another adolescent
conceives. O f every 100 American girls, one will give birth by the age of
15 years and 33 will give birth by the age of 19 years. Each year, 1 out
of 10 adolescent girls aged 15-19 becomes pregnant. This represents
25% of those who are sexually active.
In many Caribbean countries, almost 60 percent of all first births
occur to teenagers, and one-half of these are to women 17 years and
under. Table 1 shows the num ber of births per 1000 women aged 15-19
in some countries in the region.
109
ADOLESCENT PREGNANCY
13-15 16 2 0 0 18
16 22 6 0 0 28
17 41 10 1 0 52
18 34 14 3 0 51
19 40 28 5 3 76
110
ADOLESCENT PREGNANCY
111
ADOLESCENT PREGNANCY
children are its greatest assets and no effort should be spared to bring
them up in a morally healthy environment.
ANTENATAL CARE
Pregnant adolescents require special management because of their age
and social circumstances such as marital status and educational
achievement. They should be seen early in gestation and examined once
every 4 weeks until 28 weeks, every 2 weeks until 36 weeks and weekly
thereafter.
A N T E N A T A L C O U R SE
• Nausea and vomiting (see Chapter seven).
• Hypertensive disorders of pregnancy. Essential hypertension is
rare in this age group. Pre-eclampsia has been noted to be the
commonest complication in teenage patients. The incidence
varies from 6.6% to 29.0%. In a Nigerian study, 17% of girls
aged 14 or less developed eclampsia compared with 7% of those
aged 16 years and 3% aged 20-24 years.
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ADOLESCENT PREGNANCY
IN T R A P A R T U M C O U R SE
The majority o f patients deliver vaginally with minimal problems.
Analgesics should be administered liberally. O f importance is that
teenage girls should never be left to labour alone. The doctor or mid
wife should be in constant attendance.
PO STPA R TU M C O U R SE
There is no evidence that they are more prone to postpartum
haemorrhage. Several workers have found an increased incidence of
puerperal fever from pyelonephritis and mastitis. Apart from teaching
the teenager how to breastfeed her infant, she should be strongly advised
to use contraceptives, and should be referred to a family planning clinic
in 6 weeks time.
FETAL O U TC O M E
The end result of adolescent pregnancy depends on the type o f care
administered. Prematurity and low birthweight are the chief problem s.
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ADOLESCENT PREGNANCY
PR EV EN TIO N OF T EE N A G E PR E G N A N C Y
• Provide adolescents with general information about sex and birth
control, and give them an opportunity to share their own
experiences related to dating, sex and contraception.
• Modulation of teenage behaviour. Teenagers should be
encouraged to discuss with their friends and classmates the
realities of pregnancy, delivery and childcare. Negative peer
pressure for adolescent pregnancy has been found to be an
effective approach.
• Oral contraception.
SU M M A R Y
The medical consequences of teenage pregnancy are less serious than the
social and psychological ones. The emotional immaturity and lack of
preparation for the adult responsibilities o f motherhood frequently
results in psychological crises, which may be perpetuated in marital
maladjustment. The subsequent social handicaps for the teenage mother
are greatly increased in countries with relatively high rates o f out-of-
wedlock pregnancies. The reduced life expectancy of infants born to
these unmarried teenagers is well documented.
In the West Indies, it has been found that teenage pregnancy rates
are inversely related to the degree of stability within the family where the
parents themselves are unmarried, where the fathers are multiple or
absent and where the locus of moral authority is ill defined, the incidence
of adolescent pregnancy is highest.
Each year, about 14 million young women aged 15-19 give birth
worldwide. Teenage childbearing is most com m on in the developing
world, where the proportion of women who have their first child by age
18 is often between 25 to 50 per cent. By contrast, in the developed
world, fewer than one in ten have an early first birth.
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ADVANCED MATERNAL AGE
A D V ANCED M A T E R N A L A G E
INTRODUCTION
There is ample evidence to suggest that the num ber o f deliveries am ong
women in the latter part of their childbearing years is steadily increasing.
One reason for this trend is that some women intentionally delay their
plans for having children either in pursuit o f a career or, with their
husbands, they may wish first to establish themselves financially.
Furthermore, the post-war baby boom has resulted in an unprecedented
number of pregnant patients, aged 35 years or more, in the present
decade. In our setting, the low acceptance o f family planning methods
also plays a major role.
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ADVANCED MATERNAL AGE
Hypertensive disorders
Fibroids
Anaem ia
Pyelonephritis
Preterm rupture of membranes
Antepartum haemorrhage
Diabetes mellitus
116
ADVANCED MATERNAL AGE
ANTENATAL COMPLICATIONS
Hypertension and pre-eclampsia
The hypertensive disorders of pregnancy are the commonest antepartum
complications, occurring in about one-third of elderly women.
Hypertensive vascular disease is a function o f age because as Nelson
(1955) pointed out “ after the age of 30, the blood pressure begins to
rise appreciably in the population as a whole” . Superimposed pre
eclampsia may occur in many of these patients.
Uterine fibroids
Compared to a group o f younger patients, fibroids occurred more
frequently in a group o f elderly primigravidae in a Trinidad population
(6.0% versus 0.0%). The significance of this is that multiple fibroids
predispose to abnormal fetal lie and to obstructed labour. The elective
Caesarean section rate, therefore, is increased. Other complications which
fibroids may cause are:
• Spontaneous miscarriage.
• Abdominal pain due to red degeneration or torsion.
• Postpartum haemorrhage.
Pyelonephritis
Although some authorities have reported that chronic bacteriuria or
acute pyelonephritis occurs in 7-10% of pregnancies in women over 35
years of age, this is comparable to that usually seen in any antenatal
population.
Diabetes mellitus
Diabetes may act in a manner similar to hypertension: there is an
increasing frequency by virtue of advancing age. Diabetes itself may be
associated with a higher perinatal mortality rate for older com pared to
younger pregnant women.
117
ADVANCED MATERNAL AGE
Onset of labour
The need for induction of labour arises more frequently among older
mothers. From what we have stated before, this is not surprising. The
common indications for induction are premature rupture of the
membranes, hypertension, and pre-eclampsia and postdate pregnancies.
INTRAPARTUM COMPLICATIONS
Prolonged labour
Prolonged labour is defined as labour lasting for more than 24 hours.
On review of the literature, there is a suggestion of increasing duration of
labour with advancing age among primigravidae but little evidence of an
association with age among multigravidae. Prolonged labour is
associated with maternal distress when the patient develops dehydration,
tachycardia, ketosis and fever. She is unlikely to compensate as well as
her younger counterpart.
Caesarean section
Caesarean section rates vary proportionally with maternal age. In a study
in Trinidad we found that the rate among primigravidae aged 30 years or
more was 30.8% compared to 6.7% in a group of young primigravidae,
aged 20 to 22 years. Blum (1979) reported Caesarean section rates for
primigravidae as follows: age 20 to 29 - 2.3%; age 30 to 34 - 21.6%;
and above 35 years - 49.1%. Morrison (1975) cited a rate o f 31%
compared to a rate of only 3% among primigravidae less than 35. The
chief factors accounting for this trend are uterine fibroids, prolonged
labour and intrapartum fetal distress.
118
ADVANCED MATERNAL AGE
MATERNAL OUTCOME
In present day Obstetrics there is little evidence to suggest that maternal
mortality for patients aged 35 years and older in developed countries is
any greater than their younger counterparts. However, in contrast. Figure
1 shows the increasing risk to the mother, from data obtained in Thailand
in 1970. It appears that there was a gradual increase in maternal
mortality from age 30.
FETAL OUTCOME
Spontaneous miscarriage
There is some association between maternal age and increased risk for a
first trimester spontaneous miscarriage. However, the magnitude of the
risk is not clear.
Birthweight
The Trinidad study revealed that maternal age has no bearing on
birthweight, either low birthweight (< 2500 g) or macrosomia (> 4000
g). There appears to be universal agreement on these findings.
Perinatal mortality
There is a consistent pattern of higher perinatal mortality rates among
the elderly, in the United States (Hansen, 1980) and in Scotland
(MacDonald and MacLennan, 1960). We obtained good perinatal results
in a study of elderly primigravidae in Trinidad, and this was related to a
119
ADVANCED MATERNAL AGE
120
ADVANCED MATERNAL AGE
GRAND MULTIPARITY
DEFINITION
The term grand multiparity applies to a pregnant patient who has had 5
or more deliveries bey o n d the 28th week o f p regnancy.
INCIDENCE
The problem o f grand multiparity occurs chiefly in countries o f the third
world. The World Health Organization has estimated that 40% o f women
in developing countries have more than 4 children. The total fertility rate
ranges from 2.4 to 6.5 in Latin A m erica and the Caribbean and from 5.3
to 8.3 in sub-Saharan Africa.
The main factors contributing to excessive childbearing are
poverty, lack o f education and unstable sexual relationships. The
converse o f this is also true: better educational opportunities and living
standards and a more realistic approach to contraception have been
responsible for the dramatic reduction in the incidence o f grand
multiparas in industrialized nations.
A N T E P A R T U M C O M PLIC A TIO N S
Table 6 lists the various complications, which may be encountered in the
grand multipara, during the course o f pregnancy. There is little doubt
that the induced abortion rate am ong women o f high parity is increased.
This is most likely due to the high percentage o f unwanted pregnancies.
122
ADVANCED MATERNAL AGE
INTRAPARTUM COMPLICATIONS
Preterm labour
Precipitate labour
Unstable lie
Cephalo-pelvic disproportion
Prolapse of the cord
Postpartum haemorrhage
Uterine rupture
123
ADVANCED MATERNAL AGE
managem ent for the grand multipara with an unstable lie near term is
Caesarean section.
124
ADVANCED MATERNAL AGE
TIME (HRS)
Figure 3 shows the curve for descent o f the head. Descent tends to be
minimal until the cervical dilatation is > 7 cm after which descent is
abrupt.
Figure 3. Descent.
PERINATAL OUTCOME
125
ADVANCED MATERNAL AGE
C O N T R A C E PT IO N
It is disconcerting that despite econom ic stagnation in most third world
countries, more than half of the grand multiparae refuse or are not
interested in sterilization. Male opposition to contraception is a
significant problem in the Caribbean and large families result in a short
time span. Should the woman decide to take a unilateral decision, there is
a risk o f disruption o f family life and marital disharm ony. While religion
and superstition are some o f the other reasons advanced for a large
family, we agree with Goldheizer (1979) that no com m unity can rise
from destitution to dignity without the contribution o f family planning.
OBESITY
DEFINITION
A rbitrarily, some workers have considered pregnant patients to be obese
if their weight is > 80 kg. The best criterion for determ ining obesity is a
body mass index (BMI) > 30.
A N T E N A T A L C O U R SE
• Pregnancy-induced hypertension. The incidence o f this
com plication is significantly increased am ong obese patients. In a
recent study in Trinidad, we found that this risk was 4-5 times
greater than am ong non-obese m others. However, there is
nothing we are currently able to do to prevent the developm ent of
this disease. Im position o f caloric restrictions is not
recom m ended. There is an increased incidence o f placental
abruption, which may be related to the increased incidence of
pre-eclam psia among this group.
• Diabetes mellitus. The obese m other is at an increased risk of
diabetes. Our analysis has revealed that 1 in 9 obese m others will
develop gestational diabetes. M aternal obesity is therefore an
indication for screening for diabetes.
• Difficulty in palpation is experienced because o f the presence of
abdom inal fat. This gives rise to problem s in determ ining the
presenting part and estimating fetal size. There is also difficulty
in hearing the fetal heart sound with the P in ard 's stethoscope.
126
ADVANCED MATERNAL AGE
IN TR A PA R TU M C O U R SE
• Traum atic vaginal delivery. If the birthweight exceeds 4000
grams, labour might be prolonged requiring assistance in the
second stage with forceps. Shoulder dystocia is a distinct
possibility with fetal m acrosom ia. Correct identification o f a large
baby has its limitations either by ultrasound or clinically. It is
better to err on the side o f caution and avoid the vaginal route if
macrosom ia is suspected.
• Increased rate o f Caesarean section.
• Fetal m acrosom ia. Obese m others are delivered o f m ore
m acrosomic and fewer low-birth-weight babies than are non-
obese mothers.
PERINATAL O U T C O M E
Several authors have reported that maternal obesity is associated with
poor perinatal and neonatal outcom es. The increase in perinatal
mortality rate has been attributed to the pregnancy risk factors o f
hypertension and diabetes. Fetal birth injuries from difficult vaginal
deliveries account for significant m orbidity.
127
ADVANCED MATERNAL AGE
M A T E R N A L O U TC O M E
• M aternal injuries to the genital tract are more com m on.
• Because o f overdistension o f the uterus, postpartum uterine atony
may occur. Furtherm ore, the placental site is larger with a large
baby. These two factors predispose to postpartum haem orrhage.
• Haematoma and infection o f the abdom inal wound are com m on.
• Deep vein throm bosis is more likely, because o f a sluggish
circulation.
• Increased maternal mortality.
KEY POINTS
128
FETAL BIRTHWEIGHT
CHAPTER NINE
INTRODUCTION
During its intra-uterine existence in the m other for approxim ately 266
days, the fetus may be considered as another body com partm ent,
deriving nutrients and elim inating waste products across the placenta via
the maternal circulation.
DEFINITIONS
Small-for-dates (SFD) or Sm all-for-gestational age (S G A ) indicates
that a fetus or neonate is below a defined reference range o f weight for a
129
I
FETAL BIRTHWE1GHT
F A C T O R S A F F E C T IN G B IR T H W E IG H T
T he factors affecting fetal grow th and birthw eight are m yriad and it is
som etim es difficult to separate the effect o f one fro m the other. For
exam ple, socio-econom ic status, u n d er-n u tritio n , m aternal stature, parity
and sm oking m ay each influence fetal grow th but to som e ex ten t are all
inter-related. The con d itio n s affecting fetal grow th may be general,
m aternal o r fetal.
G eneral
• E thnic g ro u p s. In the West Indies, the sm allest babies are those o f
Indian o r C hinese ancestry and the largest are o f E u ro p ean and
A frican orig in .
• A ltitude. E xposu re to high altitude causes slowing o f grow th
particularly d u rin g the third trim ester.
• Socio-econom ic factors. An association exists between p o o r
living conditions and depressed m edian birthw eight, but it is
130
FETAL BIRTHWEIGHT
Maternal
• Size. There is a positive association between m aternal stature and
birthweight. Paternal stature makes only a slight contribution.
• Parity. First babies tend to weigh less than later born babies. In
other words, there is a tendency to increasing average birthw eight
with advance in birth rank.
• Age. M others over the age o f 40 years are more likely to have
smaller babies than their younger counterparts.
• N utrition. In states o f acute or chronic nutritional deficiency,
there is a fall in average birthweight. In the Caribbean area,
however, such extrem e level o f nutritional deprivation is not
com m only encountered.
• Medical disorders. SFD babies occur in certain conditions mainly
because of placental insufficiency. Exam ples are the hypertensive
disorders o f pregnancy, severe diabetes mellitus, sickle cell
disease, pyelonephritis, malaria, tuberculosis, upper respiratory
tract infection, cyanotic congenital heart disease and recurrent
antepartum haem orrhage.
• Sm oking. Sm oking slows fetal growth possibly because o f
placental vascular pathology, and this results in a reduction in
average birthweight fo r gestation. If sm oking is stopped before
the third trim ester, the chance o f IUGR falls.
• Drugs. Intake o f certain drugs may be associated with dim inished
fetal weight e.g. steroids, warfarin and certain hypotensive agents.
Growth restriction observed in chronic alcoholism is probably
due to the direct effects o f alcohol or its m etabolite
(acetaldehyde) or to deficiencies in essential nutrients. There is
good evidence to suggest that maternal heroin addiction can
impair fetal growth.
Fetal
• Genetic variation. A small percentage o f all babies may be small-
for-dates but otherwise norm al.
• Infant sex. Males tend to grow faster than females in-utero and
they have a higher average weight at birth.
• Congenital abnorm alities. C hrom osom al aberrations are
associated with poor fetal growth from early in pregnancy and
cause symmetrical growth restriction, such as D ow n's syndrom e
131
FETAL BIRTHWEIGHT
IN TR A U TER IN E G R O W TH R E ST R IC T IO N (IU G R )
Outcome
Babies who are growth-restricted have an increased risk o f stillbirth and
neonatal death com pared with those appropriately grown for the period
o f gestation. The main causes o f death are intrapartum asphyxia,
pneum onia, pulm onary haem orrhage, hypoglycaem ia and m econium -
aspiration.
132
FETAL BIRTHWEIGHT
Diagnosis
It is estimated that less than 50% o f SFD babies are detected on routine
clinical exam ination. The diagnosis is enhanced by:
• Accurate assessment o f gestational age. A pproxim ately 20-30%
o f women in our setting are unsure o f their last m enstrual period
(LM P). In those who are sure, the expected date of delivery is
calculated by N aegele’s rule (adding 7 days and subtracting 3
months) or more correctly, by adding 280 days. This assumes a
28-day cycle length so that adjustments will have to be made for
varying lengths o f the cycle. For exam ple, if the cycle is 35 days,
then a further 7 days should be added to the calculated expected
date. Usage o f horm onal contraception must also be determ ined
since this may be followed by an ovulation o f indefinite tim ing.
The " L M P ” would therefore only equate to a withdrawal bleed.
• Assessment of m aternal w eight-gain. This is not a precise
indicator o f fetal growth, but a static or falling maternal weight
should raise o n e ’s suspicion o f IUGR. W eight-gain in norm al
pregnancy is approxim ately 4 kg in the first 20 weeks and 8kg in
the following 20 weeks, the latter rate being about 0.5 kg per
week. After 30 weeks, growth of the fetus accounts for a large
part of the total maternal gain in weight so that a poor increase in
the latter is likely to reflect inadequate fetal growth.
• Accurate estimation o f uterine and fetal size by bim anual
examination, estimation of fundal height and fetal biom etry
(ultrasound).
133
FETAL BIRTHWEIGHT
M anagement
When IUGR is suspected on clinical gro u n d s the patient should be
adm itted to the ward for fu rth er m anagem ent in ord er to:
• m onitor any associated disease process e.g. pre-eclam psia,
diabetes, sickle-cell anaem ia.
• encourage bed rest in the left lateral position because it
prom otes increased utero-placental blood flow.
• assess fetal w ell-being.
134
FETAL BIRTHWEIGHT
30
11
30
12
30
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30
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3
30
4
30
30
6
30
7
30
30
- ®
I I 9
o> 8
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e !«
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135
FETAL BIRTHWEIGHT
136
FETAL BIRTHWEIGHT
because they provide only an indirect m easure o f well-being and the test
results are not im m ediately available. H um an placental lactogen is a
polypeptide horm one produced by the placenta. M aternal serum levels
correlate well with placental weight and size, so that rising or stable high
levels suggest good placental growth and this inform ation is indirectly
related to fetal w ell-being.
FETAL M A CR O SO M IA
Fetal macrosomia (large-for-dates, birthweight m ore than 2 S.D. above
the mean or birthweight more than 4000 gram s). The large baby as a
cause for obstetric concern has, over the years, been overshadow ed by
the small-for-dates infant. However, it is also quite clear that fetal
macrosomia contributes significantly to m aternal and fetal injuries and,
to some extent, to neonatal m orbidity and m ortality.
137
FETAL BIRTHWEIGHT
D uring labour, the factors which may forewarn a large baby are:
• In the first stage - a slow active phase i.e. after cervical
effacem ent, cervical dilatation takes place at a rate slower
than 1 cm/hour.
• In the second stage - little descent o f the head on full
dilatation o f the cervix, after 1 h o u r o f m aternal expulsive
efforts.
The im portance o f identifying the m acrosom ic infant lies in the m aternal
and fetal risks chiefly during the birthing process.
Maternal risks
• Prolonged labour resulting in m aternal distress and ketosis -
this may be associated with fetal distress and also leaves the
m other in an unfavourable physical state for undergoing
operative delivery, especially if general anaesthesia is
required.
• Obstructed labour and uterine rupture, especially in grand
m ultiparous m others.
• M aternal soft tissue injury. There is an increased incidence of
second and third degree lacerations, large episiotom ies and
postpartum haem orrhage.
Fetal risks
The gravest em ergency for these babies is the occurrence o f shoulder
dystocia and associated perinatal asphyxia. This occurs when the bis
acromial diam eter (across the shoulders) exceeds the A-P diam eter of the
pelvic inlet. The posterior shoulder, therefore, enters the hollow of the
sacrum but the anterior shoulder abuts against the sym physis pubis.
Delivery entails release o f the anterior shoulder after the posterior
shoulder has been delivered. This is a tim e-consum ing procedure which
is usually traum atic to the m other and baby, and is therefore associated
with significant perinatal asphyxia and m econium aspiration. The latter is
a dangerous com plication with high m orbidity and m ortality rates. Other
138
FETAL BIRTHWEIGHT
KEY POINTS
139
MALPRESENTATION
CHAPTER TEN
FETAL MALPRESENTATION
BR EE C H PR E SE N T A TIO N
IN T R O D U C T IO N
The m ammalian dolphin always delivers by the breech and is assisted by
‘m idw ife' dolphins. By ‘masterly inactivity’, they wait for delivery of
the after-com ing head before pushing the infant upward to the surface
for its first breath. The aquatic surroundings in addition to the d o lp h in ’s
pelvic girdle seem ideal for this presentation.
140
MALPRESENTATION
AETIOLOGY
In many cases there is no obvious explanation for this m alpresentation.
However, potential causes include:
TYPES
There are three types of breech presentations (Figure 1):
• Frank
• Complete or flexed
• Incomplete or footling
Frank Breech
In this type, the thighs are flexed at the hips and the knees are extended
so that the fetus is literally looking straight ahead at its own feet. It is the
most favourable type of breech presentation if vaginal delivery is
anticipated as it fills the pelvis fairly well and presents a good dilating
wedge to the cervix. It accounts for 60-70% o f all breech presentations.
Complete Breech
The thighs are flexed at the hips and the knees are also flexed. The feet
and the buttock form the presenting part which now is irregular and does
not make a good fit with the lower segm ent. Descent and engagem ent
MALPRESENTATION
are less likely and the possibility o f cord prolapse after rupture o f the
m em branes may be up to four times m ore com m on than in the frank
breech.
Footling Breech
One or both hips are partially or fully extended. This results in one or
both lower extrem ities o f the fetus being extended below the level o f the
buttocks. The risk o f cord prolapse is real and as such an elective
caesarean section should be perform ed at term .
D IA G N O SIS
One may suspect a breech presentation when the patient com plains of
pain or discom fort in the fundal area. On exam ination the fetal head,
which is hard, round and ballotable, can be outlined in the fu n d u s and
the presenting part at the pelvic inlet feels irregular and soft. At term , the
fetal heart sounds are best heard above the um bilicus. An ultrasound
should be perform ed to confirm the diagnosis, give an estim ation o f the
fetal weight and also to rule out hyperextension o f the neck or any
predisposing factors.
142
MALPRESENTATION
Technique
ECV should be undertaken in a hospital that has facilities for perform ing
an emergency caesarean section as it may be necessary to perform this
procedure in approxim ately 0.5% o f cases. Ideally, ECV should be done
with ultrasound guidance which allows confirm ation o f successful
version and direct visualisation of fetal cardiac activity. Tocolysis may
also be helpful (e.g. terbutaline 250 /<g subcutaneously 15 m inutes prior
to ECV).
143
MALPRESENTATION
144
MALPRESENTATION
Complications o f ECV:
• Fetal distress
• Feto-m aternal transfusion
• R upture o f m em branes
• A bruptio placentae
• Uterine rupture
• A m niotic fluid em bolism (rare)
VAGINAL B R E E C H D E L IV E R Y
Some women with a breech presentation may choose to deliver vaginally.
They should be assessed carefully and advised specifically o f the
increased peril to them and their babies o f attem pting vaginal breech
birth. However, the im plication o f a successful delivery is that subsequent
pregnancies will be deem ed low risk.
Technique:
This is a high risk delivery and should take place in an institution with
facilities for em ergency caesarean section should the need arise. D uring
labour, early artificial rupture o f the m em branes should be avoided. If
they spontaneously rupture, a speculum exam ination should be done to
rule out prolapse of the um bilical cord.
MALPRESENTATION
146
MALPRESENTATION
The fetal trunk is then wrapped with a towel, while further descent
results from expulsive forces from the m other during uterine
contractions. When the scapulae appear, the shoulders are ready for
delivery. In many cases, the arms flop out but if they are extended, they
can be delivered by Lovset’s manoeuvre. With the fetal back facing
upwards, the shoulders are in the transverse plane o f the maternal pelvis.
Grasping the bony pelvis o f the baby, it is rotated through 90 degrees to
bring one shoulder under the symphysis pubis. A finger is now placed
over the fetal shoulder from the back and the hum erus is followed to the
cubital fossa. The fetal arm can now be swept across the chest and
delivered. The posterior shoulder is then rotated through 180 degrees to
bring it under the pubis and the arm is delivered in a similar fashion.
Alternatively, the posterior shoulder is delivered posteriorly by some in
an attempt to minimise potential traum a and excessive twisting o f the
back.
147
MALPRESENTATION
C A E S A R E A N SE C T IO N
In general, an elective caesarean is recom m ended in the following
circumstances:
• Large baby where the estimated fetal weight is greater than 3500
grams.
• Footling breech. This is prim arily to circum vent the risk o f cord
prolapse and head entrapm ent.
148
MALPRESENTATION
M ANAGEMENT O PTIO NS FO R TH E PR E T E R M B R EE C H
Overall, routine caesarean section is safer for the preterm or the low
birthweight breech (less than 2500 g) though the evidence is not
conclusive. Vaginal delivery may result in head entrapm ent as the
discrepancy between the size of the head and buttocks is most m arked at
these early gestations. However, the m anagem ent should be tailored on
an individual basis since caesarean delivery can be difficult, as the lower
segment may not be well form ed.
ABNORMAL LIE
Definitions
When the long axis of the fetus lies at right angles to the long axis o f the
uterus, the fetus is said to be in transverse lie and the presenting part is
frequently a shoulder. An oblique lie is another exam ple o f an abnorm al
lie where the presenting part lies in the iliac fossa.
Predisposing Factors
The several conditions which predispose to a breech presentation also
cause a transverse or oblique lie. O f im portance, are deficient tone to the
149
MALPRESENTATION
abdom inal wall muscles and a lax uterus from increasing parity, and
placenta praevia.
M anagement
In the absence of placenta praevia, ovarian cysts and uterine fibroids, an
induction-stabilization procedure at term may be attem pted to achieve a
vaginal delivery. This procedure involves
perform ing external version to make the lie longitudinal and
150
MALPRESENTATION
FACE P R E SE N T A T IO N
Face presentation is a rare occurrence in labour. It may arise as a result
of fetal abnorm ality such as anencephaly and is m ost com m on in
multiparous patients. T he aetiology is otherwise sim ilar to that for breech
presentations and transverse lie.
BROW PR E SE N T A TIO N
The incidence and aetiology are sim ilar to that for face presentation. The
mentovertical diam eter presents and it is the largest diam eter o f the fetal
head. The fate o f a brow presentation in lab o u r is that it may convert to
either a vertex or a face presentation. A bdom inal delivery is advised for
the latter.
OCC1PITO-POSTERIOR PO SITIO N
Approximately 10 percent o f cephalic presentations are in the occipito-
posterior (OP) position at the onset o f lab o u r, but in only 2 percent is
intervention required. The predisposing factors fo r this m alposition are;
an anterior placenta, a pendulous abdom en and a long oval pelvis
(anthropoid pelvis). A bdom inal exam ination reveals small fetal parts on
either side of the m id-line, a depression in the infra-um bilical region, a
high head and the fetal heart sounds are distant. V aginal exam ination in
151
MALPRESENTATION
KEY POINTS
152
TWIN PREGNANCY
CHAPTER ELEVEN
TWIN PREGNANCY
INTR O D U C TIO N
The incidence o f twins has generally been quoted as 1 in 100
pregnancies, but there is consensus that the condition occurs m ore
commonly in tropical clim ates. For exam ple, in Jam aica, the incidence is
1 in 66, in Trinidad, it is 1 in 72 and in N igeria, it is 1 in 20. Since
twinning is m ore com m on with ascending birth rank, the higher
incidence o f m ultiple pregnancies in A frica and the West Indies is
probably due to the fact that the average fam ily size is bigger than in
metropolitan countries. M ultifetal pregnancies also occur m ore often in
women with a fam ily history o f twins.
TYPES
• Monozygotic twins, result from the division o f the fertilised ovum
(zygote) at a very early stage o f developm ent. This zygote has
resulted from the fertilization o f one ovum by one sperm . If it
divides before day 3, it becom es dichorionic, diam niotic; between
days 3 and 8, m onochorionic, diam niotic; and after day 8,
monochorionic, m onoam niotic (Figure 1).
153
TWIN PREGNANCY
Di-chorionic
Di-amniotic
Mono-chorionic
Mono-amniotic
Mono-chorionic
Di-amniotic
• Dizygotic twins, result when two separate ova are fertilised by two
separate sperms. They are always dichorionic and diamniotic.
They may be o f the same or opposite sex and the risk o f trisomy
21 is twice the age related risk. There is a heritable com ponent to
dizygotic twinning and the incidence varies with age, race,
nutritional status and geographical location. Superfecundation is
the fertilisation o f two or more ova in the same m enstrual cycle
by separate sperm from separate episodes of coitus. This is a rare
occurrence and may result in a pregnancy with heteropaternal
fetuses. Superfetation is the fertilisation o f ova in different
menstrual cycles by separate sperm. It results in a pregnancy with
154
TWIN PREGNANCY
CLINICAL F E A T U R E S
Symptoms
• Hyperem esis gravidarum
• A bdom inal discom fort and backache
• Increased fetal movem ents
• H aem orrhoids and varicose veins o f the legs and vulva
• Dyspnoea; exacerbated by the splinting effect o f an enlarged uterus
on the diaphragm .
Signs
• Sym physio-fundal height, being large-for-dates
• Several small fetal parts are palpable
• There may be a dem onstrable fluid thrill indicating the presence o f
polyhydram nios.
DIAGNOSIS
As soon as a multiple pregnancy is clinically suspected or if pregnancy
has resulted from assisted reproduction, the diagnosis must be confirm ed
by ultrasound scan. Early diagnosis and establishm ent o f zygosity and
chorionicity allows for the quantification o f risk, the establishm ent o f an
appropriate plan for the pregnancy and the institution o f m easures to
minimize potential com plications.
155
TWIN PREGNANCY
twins there is a thick septum between the sacs. A fter 9 weeks, this septum
becom es progressively thinner to becom e the chorionic co m p o n en t o f
the intertwin m em brane, but it rem ains thick and easy to identify at the
base o f the m em brane as a triangular projection, the lam bda o r twin peak
sign. At 11 to 14 w eeks’ gestation, presence o f the lam bda sign provides
reliable identification o f a dichorionic twin pregnancy. In the second
trim ester discordant genitalia im ply dizygosity and thus dichorionicty
while a thin septum in concordant sex twins suggests m o n o ch o rio n icity .
M A T E R N A L C O M PL IC A T IO N S
• Spontaneous m iscarriage
• H yperem esis G ravidarum
• A naem ia. Iron and folate deficiencies occur because o f the increased
dem ands of the fetuses. The increased blood volum e along with the
increased iron and folate requirem ents, predispose the patient to
anaem ia.
• Pregnancy-induced hypertension.
• A ntepartum haem orrhage. Placenta praevia and abruptio placentae
occur more com m only. The form er is due to the larger size o f the
placenta encroaching on the lower segm ent. The latter may be
associated with the increased incidence o f hypertension.
• Polyhydram nios. It occurs m ore often in m onochorionic
pregnancies and is som etim es o f acute onset.
• Supine hypotension. The increased weight o f the uterus predisposes
to aortocaval com pression.
• Postpartum haem orrhage occurs because o f uterine atony secondary
to over-distension o f the m yom etrial fibres.
• Increased operative intervention, particularly fo r the second twin.
The need for anaesthesia is likewise increased.
FE T A L C O M PL IC A T IO N S
• C ongenital abnorm alities. There is an increased incidence of
structural abnorm alities such as open neural tube and cardiac defects.
In dizygotic pregnancies the risk o f trisom y 21 is twice the age
related risk when com pared to singleton pregnancies. In
m onozygotic pregnancies division o f the zygote after day 12 may
result in conjoined twins. These are twins that are anatom ically fused
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TWIN PREGNANCY
at different levels, for exam ple the head (craniopagus), the thorax
(thoracopagus) or the abdom en (abdom inopagus). They may share
vital organs such as the heart and liver and have com plex
interconnecting circulatory systems. Delivery is by caesarean section
and the long term prognosis is usually poor.
Preterm labour is more com m on in m ultiple gestations. Over
distension of the uterus predisposes to this. The m edian gestational
age at delivery is 39 weeks for singletons, 37 weeks for twins, 33
weeks for triplets and 31 weeks for quadruplets. The risks o f
prem aturity therefore increase as the num ber o f fetuses increases.
The resultant fetal com plications are a direct consequence o f
prem aturity and include respiratory distress syndrom e,
intraventricular haem orrhage and necrotising enterocolitis.
Intrauterine growth restriction. A pproxim ately one third o f fetuses
are growth restricted. This growth restriction may be concordant or
discordant. The growth restricted fetus tolerates hypoxic insult
poorly and there should be a low threshold for abdom inal delivery in
the presence o f growth restriction.
Abnormal lie and presentation. Table 1 shows the incidence o f fetal
presentation in twin pregnancies in Trinidad
Prolapse of the um bilical cord. This may occur due to a
combination of m alpresentation and polyhydram nios.
Cord entanglem ent. This is a potential com plication o f all
monoamniotic pregnancies.
Premature separation o f the placenta after delivery o f the first twin is
possible and the accoucheur must expedite the delivery o f the second
twin if this com plication arises.
Cervical contraction after delivery o f the first twin.
Interlocking of twins is rare and is a theoretical com plication o f
vaginal delivery when Twin A is breech and Twin B cephalic.
Twin to Twin Transfusion syndrom e (TTS) is a com plication o f
monochorial pregnancies. It is characterized by a deficiency o f
superficial vascular anastamoses and one fetus develops at the
expense of the other. The recipient fetus becom es hypervolaem ic and
plethoric and produces more am niotic fluid and as such there is
associated polyhydram nios. The d o n o r fetus becom es anaem ic,
hypovolemic and m alnourished. There is an associated
oligohydramnios. In extrem e cases, the latter may perish and becom e
a fetus papyraceous. Patients with pregnancies com plicated by TTS
are best managed by an obstetrician with a special interest in fetal
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TW IN P R E G N A N C Y
Presentation Percent
Vertex/Vertex 48.2
Vertex/Breech 32.7
Vertex/Shoulder 2.7
Breech/Vertex 13.2
Breech/Breech 2.8
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T W IN P R E G N A N C Y
INTRAPARTUM M A N A G EM EN T
Time of delivery
The time of delivery is dictated by the overall clinical scenario though
delivery is preferably delayed until fetal maturity is assured. In the
uncomplicated Dichorionic twin pregnancy we recommend elective
delivery at 38 weeks. Other units may recommend elective delivery by
40 weeks.
159
L
T W IN P R E G N A N C Y
Mode of delivery
In the absence of growth restriction or fetal distress, the prime
determinant o f the mode o f delivery is the presentation o f Twin A. If the
presentation is cephalic, we advocate a vaginal delivery. If cephalic and
undelivered by 38 weeks gestation we recom m end an induction o f
labour with or without cervical ripening.
If the presentation o f Twin A is anything other than cephalic
(breech, shoulder etc) we recommend an elective caesarean section. In
addition, we recommend an elective caesarean section for higher order
multiple pregnancies and for the M onoam niotic twin pregnancy,
regardless of the presentation of Twin A, to circumvent the problem of
cord entanglement.
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T W IN P R E G N A N C Y
161
T W IN P R E G N A N C Y
P O ST P A R T U M M A N A G E M E N T
Postpartum haem orrhage is a potentially catastrophic consequence of
multifetal pregnancy. In the absence of placental abruption, this is
primarily due to uterine atony secondary to overdistension o f the
myometrial fibres. To reduce this risk, the third stage o f labour should
be actively managed. After the second twin is delivered, Syntometrine®
(one ampoule) is given intramuscularly and 40 units of Syntocinon® are
added to one litre o f an intravenous infusion. This infusion is titrated to
ensure that the uterus remains well contracted in the immediate
postpartum period.
The placenta should be carefully inspected and sent for
histological analysis if there is evidence o f TTS or uncertainty about the
chorionicity.
P E R IN A T A L O U T C O M E
Twin pregnancies are associated with a perinatal mortality rate up to
seven times higher than that associated with singleton pregnancies.
Higher order multiples are associated with even more alarming perinatal
mortality rates. Complications of prematurity such as respiratory distress
syndrome, intraventricular haem orrhage and necrotizing enterocolitis are
the leading causes o f morbidity and mortality. Other factors include
intrauterine growth restriction, congenital anomalies, placenta praevia.
abruptio placentae, preeclampsia, cord accidents and malpresentations.
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T W IN P R E G N A N C Y
KEY POINTS
• The patient carrying more than one fetus
presents a formidable challenge.
• Twin pregnancies are associated with a
perinatal mortality rate up to seven times
higher than that associated with singleton
pregnancies.
• The perinatal mortality rate am ong
m onozygotic twins tends to be higher than in
dizygotic twins.
• Early diagnosis and establishment of zygosity
and chorionicity allows for the quantification of
risk, the establishment of an appropriate plan
for the pregnancy and the institution of
measures to minimize potential complications.
This is best achieved by an early first trimester
ultrasound exam ination.
• Serial ultrasound scrutiny should be performed
in all multiple pregnancies.
• Preterm delivery is, by far, the most important
complication and the predom inant reason for
the high perinatal loss. Improved prediction
and prevention of preterm labour would be an
important advance.
• Labour and delivery should be conducted in a
tertiary referral centre with appropriately
experienced staff available.
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IN D E T E R M IN A T E APH
CHAPTER TWELVE
ANTEPARTUM HAEMORRHAGE
IN T R O D U C T IO N
Antepartum haem orrhage constitutes a grave Obstetric em ergency which
until recently accounted for considerable perinatal loss and maternal
mortality. With improved Obstetric care, the maternal mortality rate has
fallen to less than 1 per cent but the perinatal mortality rate is 20-25 per
cent, mainly in cases of placental abruption.
A ETIO LO G Y
The causes of antepartum haem orrhage may be divided as follows:
• Placenta praevia.
• Placental abruption (abruptio placentae).
• Indeterminate:
a) haemorrhage from the edge of a normally-situated placenta
or a marginal (sinus) haemorrhage
b) lower genital tract causes e.g. vulval varicose veins, vaginal
lacerations, cervical polyp and erosion, cervicitis or rarely
cervical carcinoma
c) ‘heavy show ’
d ) vasa praevia.
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IN D E T E R M IN A T E APH
PLACENTA PRAEVIA
Placenta praevia is defined as the implantation o f the placenta in the
lower uterine segment. Its aetiology is unknown but it occurs more
commonly in multigravidae. Several clinical associations have been
established. They often involve some type o f prior uterine trauma or
disturbance to the uterine vasculature. They are: increased maternal age
and parity, previous Caesarean section, previous induced abortion,
previous dilatation and curettage, multiple pregnancy, uterine structural
anomalies and maternal smoking.
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IN D E T E R M IN A T E APH
Clinical features
The clinical picture of placenta praevia is seen during the third trimester
when the lower uterine segment begins to develop. Placental attachment
is disturbed as this area gradually thins during the latter weeks of
pregnancy. The history is one o f usually painless bright-red vaginal
bleeding, which often occurs spontaneously but may be precipitated by
coitus. In a num ber o f instances, the onset o f heavy bleeding is preceded
by small painless bleeds which occur a few weeks earlier. These are
referred to as ‘"‘w arning haem orrhages” . The blood that is lost is
maternal in origin. The mean gestational age at the onset of bleeding is
30-32 weeks.
Diagnosis
Clinically, the diagnosis could be confirm ed by feeling placental tissue
through the fornices or through the cervical os. Typically, one
appreciates a boggy feeling on digital exam ination, but clots in the upper
vagina may convey the same impression. V aginal exam ination,
how ever, is extrem ely dangerous as heavy bleeding m ay be
precipitated. Such exam ination should never be performed unless the
patient is in the operating theatre with readiness for an immediate
C aesarean delivery. Such “double set u p ’ is rarely necessary as
placental localization is done by ultrasound with much more accuracy. It
should be borne in mind that rectal exam ination carries a similar risk.
Speculum examination is advocated by some Obstetricians in order to
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IN D E T E R M IN A T E APH
Placental localization
There are several m ethods available to co n firm the diagnosis o f placenta
praevia:
• Soft-tissue rad io g rap h y - in this m ethod, one looks at the
relationship between the presenting part to the sym physis pubis
and the sacral p ro m o n to ry . It is not useful b efo re 34 weeks o f
gestation and if the presentation is not cephalic.
• Radio-isotopic localization - this is a very accurate m ethod and
involves the use o f technetium 99 or indium 1 13. The area over
the lower segm ent is scanned using a scintillation c o u n ter and the
area with a high co u n t indicates the pro b ab le location o f the
placenta. This m ethod carries the hazard o f radiation e x p o su re.
• Pelvic arteriography.
With the advent and easy availability o f u ltrason ograp h y, these
methods are now obsolete.
• Transabdom inal u ltrasonography - most widely and effectively
used m ethod.
• Exam ination un d er anaesthesia (EU A) “ D o u b le set u p ” o r at
caesarean section.
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IN D E T E R M IN A T E A PH
M anagement
All cases of antepartum haemorrhage should be managed in a hospital
with a blood bank and with facilities for performing ultrasonography
and Caesarean section. That is to say, they should be admitted to a
tertiary health-care unit.
Emergency management
The aim here is to stabilize the patient by resuscitation if needed. An
intravenous line with a wide-bore cannula is set up and blood is taken for
haemoglobin and 2 units o f cross-matched blood are reserved. Isotonic
fluids e.g. crystalloids or plasma, are used until blood is available.
Obstetric management
All patients with placenta praevia with bleeding episode after 34 weeks of
pregnancy should be admitted to the Antenatal ward for the rest of the
pregnancy. The aim of management is to prolong the pregnancy to 38
weeks. The patients who never present with bleeding episodes need not
be admitted in the hospital. However, they should be warned and
educated about sudden massive haemorrhage and preferably should live
close to the hospital. Patients with bleeding episodes far from term are
likely to be delivered preterm either because o f massive haemorrhage or
because of fetal distress.
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IN D E T E R M IN A T E APH
On occasion, a patient may present for the first time with bleeding
after the 38th week of pregnancy. In such cases, after resuscitation, the
patient is taken into the operating theatre and with the Anaesthetist
present with drugs already prepared, and the scrub-nurse and an assistant
gowned, the patient is subjected to a gentle vaginal examination. The
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IN D E T E R M IN A T E APH
Complications
• Fetal distress from prolonged separation o f the placenta however
this is not as common as with placental abruption.
• Increased perinatal mortality rate from prematurity and anoxia.
• Shock due to haemorrhage: occasionally, maternal demise.
• Postpartum haem orrhage. This is due either to a morbidly
adherent placenta or to the lack of contraction and retraction of
the lower uterine segment.
A B R U PT IO PL A C E N T A E
This is defined as the separation before delivery, of a normally sited
placenta i.e. one in the upper uterine segment. O f the major causes of
antepartum haemorrhage, placental abruption is associated with the
highest fetal morbidity and mortality.
A e t io lo g y
The aetiology of abruptio placentae is uncertain. The risk factors are as
follows:
• Sudden uterine decompression which can occur at the time of
spontaneous or artificial rupture of the membranes, especially
when there is polyhydram nios.
• External physical trauma or following external cephalic version.
• Advanced maternal age and increasing parity.
• Hypertensive disorders in pregnancy.
• Cigarette smoking and cocaine use: the risk of fetal death from
abruption is six times greater among smokers than am ong non-
smokers.
170
IN D E T E R M IN A T E A PH
Pathophysiology
The first feature of abruptio placentae is vasospasm of the uterine vessels
followed by rupture of the arterioles into the decidua basalis. The blood
beneath the decidua can dissect under the placenta, thereby extending
the degree of separation, eventually appearing through the cervix in the
vagina, or it may enter the amniotic cavity through the membranes, or
infiltrate the myometrial muscle fibers towards the serosa causing the
uterus to contract and appear bruised, purplish and mottled (Couvelaire
uterus).
Clinical features
The clinical presentation depends on the degree o f placental separation
which often is not in keeping with the external blood loss through the
vagina. In the majority of cases, the onset o f symptoms occurs before
labour. The patient presents with a sudden onset o f abdominal pain and
this progressively becomes worse in intensity and spreads. The pain is
constant in nature rather than contractile. She may feel weak and may
collapse. Vaginal bleeding may or may not be present and the condition
may therefore be revealed or concealed or both (Figure 2).
171
IN D E T E R M IN A T E APH
Diagnosis
In cases o f moderate or severe placental abruption, the diagnosis is
evident. In cases o f mild separation, however, it might be difficult to
differentiate between placenta praevia and abruptio placentae.
Essentially, the diagnosis o f placental abruption is a clinical one, but in
mild cases, ultrasonography may be useful. Here, one looks for the
presence of retroplacental clots. It should be stressed that a great deal of
operator skill is required to make this diagnosis.
172
IN D E T E R M IN A T E APH
Complications
The main m a te rn al complications are: DIC, renal failure, postpartum
haemorrhage and occasionally hypertension. Generally., DIC only occurs
in cases o f severe placental abruption, but on occasion can result in less
severe cases. It is thought to be initiated by the release o f large quantities
of thromboplastin from the decidua at the site o f separation. The
sequence o f events that follows is not completely clear and happens over
minutes. The initial coagulative state when clotting factors are rapidly
used is replaced by a fibrinolytic state when serum fibrinogen level falls
(< 150 mg/dl) and fibrin degradation products increase. Apart from
afibrinogenaemia, the platelet and other clotting factors are depleted.
Management
In very mild cases, if the pregnancy is less than 38 weeks, the patient
may be managed conservatively provided that there is no deterioration of
her clinical condition and her symptoms o f pain and vaginal bleeding
are resolving. Once the pregnancy has gone to 38 weeks or if the patient
presents thereafter, delivery should be expedited. The preferred route is
vaginal, and labour is induced by am niotom y and Syntocinon infusion.
173
IN D E T E R M IN A T E A PH
Blood investigations
Full blood count, in particular the platelet count
Prothrombin time and partial thromboplastin time
Reserve 4 units of fresh whole blood
Fibrinogen, urea and electrolytes.
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IN D E T E R M IN A T E APH
The most critical time for the patient is during the third stage o f labour.
Intravenous Syntocinon should be given with the birth o f the anterior
shoulder. In addition, it is prudent to continue a high-dose Syntocinon
infusion to reduce postpartum haem orrhage, because the Couvelaire
uterus contracts and retracts poorly during the postpartum period.
INDETERM INATE A PH
This group encompasses all o f the other causes o f antepartum
haemorrhage that are not due to placenta praevia or placental abruption.
As in the previous two conditions, the immediate m anagem ent is aimed at
resuscitation and a haem oglobin estimation is done and cross-m atched
blood requested. The patient's clinical state and the duration o f her
pregnancy will indicate further m anagem ent. T h u s if she is 38 weeks or
more, delivery should be effected as there is little or no risk of
prematurity.
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IN D E T E R M IN A T E A PH
delivery, when the placenta is exam ined. Almost always, maternal and
fetal prognosis is good.
An uncom m on cause o f antepartum h aem orrhage is that from a
ruptured fetal vessel or vasa praevia. This usually presents following
rupture of the m embranes. Bleeding is usually painless and bright-red in
colour. The diagnosis can be confirm ed by Apt test (alkali denaturation
test) or Kleihauer-Betke test (acid elution test) which detects fetal
haem oglobin. The perinatal loss from this condition is high unless
delivery is immediate and the baby transfused. This is because the blood
loss is fetal in origin and small volumes result in exsanguination.
KEY POINTS
176
R H E S U S IS O IM M U N IZ A T IO N
CHAPTER THIRTEEN
INTRO DUCTIO N
Isoimmunization is defined as the process whereby im m une antibodies
are produced in one individual in response to the injection o f antigens
from another individual o f the same species.
1963- Liley suggested that in the face o f fetal red blood cell
destruction, transfusion of rhesus negative blood to the fetus
could be undertaken during the antenatal period. This was the
procedure of intra-uterine transfusion.
177
RH ESU S IS O IM M U N IZ A T IO N
Early
1960'S- Postpartum prophylaxis was identified as a means of protecting
unsentisitized Rh negative mothers for future pregnancies. The
agent used was Rh immune globulin (Rhogam®)
Late
1 960’s- Antepartum prophylaxis was suggested. This would protect the
small percentage of women who may have had unrecognized
feto-maternal haemorrhage in the current pregnancy.
PATHOPHYSIOLOGY
Blood production in the fetus begins at about 3 weeks' and Rh antigen
has been identified in the red cell membrane as early as 38 days after
conception. The initial maternal immune response to the D antigen is
slow, sometimes taking as long as 6 months to develop.
178
R H E SU S ISO IM M U N IZ A T IO N
ANTENATAL C A R E
A blood sample taken for ABO and Rhesus grouping is a routine
procedure in the antenatal clinic. Rhesus negative individuals require
special care so that these women should all be seen in hospital clinics.
179
R H E SU S ISO IM M U N IZ A T IO N
In modern day high-risk centres that manage these cases, often early
delivery is possible rather than risk continued intrauterine existence with
the possibility of the complications described above.
Amniocentesis
An ultrasound study is performed in order to locate a pool of liquor and
to identify the placental site. A local anaesthetic is infiltrated into the
abdominal wall. A sterile 22 gauge needle is inserted into the liquor pool
and a sample obtained. At the same time, in severe conditions, evidence
of fetal ascites and hydrops fetalis may be obtained. The complications
of amniocentesis include amnionitis and preterm labour. Injury to the
fetus is very unlikely.
18 0
R H E S U S ISO IM M U N IZ A T IO N
The optical density is plotted against the period of gestation on the Liley
chart. The absolute value, plotted on the chart as well as the trend of
values, gives a prognostic indication and therefore allows form ulation of
a plan of management.
181
R H E SU S ISO IM M U N IZ A T IO N
Intra-uterine transfusion
The procedure is feasible from 22-24 weeks gestation. Under ultrasound
guidance, a needle and cannula are inserted via the maternal abdominal
wall into the fetal peritoneal cavity. Ascitic fluid is withdrawn if present.
Between 60-120 ml of Rh negative packed red blood cells are
introduced.
182
R H E SU S ISO IM M U N IZ A T IO N
• Placenta praevia.
184
R H E SU S ISO IM M U N IZ A T IO N
KEY POINTS
185
ULTRASONOGRAPHY
CHAPTER FOURTEEN
ULTRASONOGRAPHY
INTRODUCTION
Obstetric ultrasound was pioneered in the late 1 9 5 0 ’s by Professor Ian
Donald of Glasgow University. It was subsequently introduced into
clinical practice in the 1 970’s. The ultrasonic waves used to image the
fetus or other organs cannot be heard and produce no sensation to the
person (e.g. fetus) being imaged. Ultrasound is painless, safe and
reliable and is now an integral part of modern obstetric care.
186
ULTRASONOGRAPHY
BIOPHYSICS OF ULTRASOUND
Ultrasound is very high frequency sound. H um an ears can detect sound
with frequencies lying between 20 Hz and 20 kH z. Medical im aging
uses frequencies that are m uch h igher and typically fro m 3 to 15 M Hz.
These frequencies do not occur in nature and it is only within the last 50
years that the technology has existed to both generate and detect this
type of ultrasound wave in a practical way.
The device that both generates the ultrasound and detects the
returning echoes is called the transducer. Transducers are made fro m a
synthetic ceramic material, which can be m oulded into almost any shape.
187
ULTRASONOGRAPHY
188
ULTRASONOGRAPHY
The embryo
The embryo can be visualised from about 37 days using the trans-
vaginal route and is first seen as a bright linear echo, adjacent to the yolk
sac (Figure 2). At this stage, the crown-rump length (CRL) measures
around 2 mm and cardiac activity can be identified. Using trans
abdominal ultrasound, the sequence of events is one week later.
The embryo grows at around 1 mm per day. All embryos of CRL >7
mm in length should demonstrate visible cardiac activity. Once an
embryo with visible heart action is seen, the pregnancy is unlikely to end
in miscarriage.
189
ULTRASONOGRAPHY
M iscarriage
The patient may be asym ptom atic or experience brown vaginal staining
or frank bleeding. Pain may or may not be a prom inent sym ptom .
190
ULTRASONOGRAPHY
If the mean sac diam eter is less than 20 mm or CRL is less than 6
mm, a repeat scan should be undertaken to assess viability after at least 7
days.
Ectopic pregnancy
An ectopic pregnancy is defined as im plantation o f the fertilized ovum
outside the uterine cavity. Therefore if the uterine cavity appears em pty
and the patient has a definite positive pregnancy test, an ectopic
pregnancy is highly likely unless the history is suggestive o f a com plete
miscarriage. However, the intrauterine appearance may be less clear
because of the horm onal influences o f pregnancy causing the
endometrium to decidualise such that a pseudo-decidual or pseudo-
gestational sac becomes evident. This may be present in the endom etrial
cavity in up to 15% of ectopic pregnancies. A pseudo-sac contains
endometrial fluid, is usually less than 10 mm and is centrally located
within the uterine cavity. In contrast, the normal chorionic sac is
eccentrically placed within the uterine cavity and has a definite hyper-
echoic perimeter. The adenxa should always be exam ined to assess for
any associated mass. Adnexal abnorm alities are seen in 70% of ectopic
pregnancies but the appearances are variable and frequently suggestive
and not diagnostic of an ectopic pregnancy. A corpus luteum , pelvic
191
ULTRASONOGRAPHY
inflam m atory disease, endom etriosis and hydrosalpinges can all give
similar ultrasonic appearances. Evaluate the Pouch of D ouglas for free
fluid, suggestive of a haem operitoneum . If the patient has had significant
haem orrhage, an echo-free area is seen around the uterus.
Multiple pregnancy
A first trimester scan is essential for the reliable identification of
chorionicity and am nionicity in multiple pregnancies. Twins arise from
the ovulation and fertilization o f two eggs (dizygotic twins) or a single
egg (m onozygotic twins). The fertilized egg is term ed the zygote. All
dizygotic twin pairs have separate placentas and therefore separate
chorionic sacs and separate amniotic sacs. The assessment o f chorionicity
and am nionicity is im portant as the m anagem ent o f m onochorionic twin
pregnancies presents greater challenges to the obstetrician com pared with
dichorionic twins. Later in pregnancy the assessment of chorionicity is
much more difficult, thus em phasizing the im portance o f achieving a
correct diagnosis in the first trim ester. Perinatal mortality is higher in
m onochorionic twin pregnancies because o f the sharing o f a common
circulation and in m onoam niotic ones because o f sharing one sac. An
understanding o f the em bryological form ation o f a twin pregnancy is
required to aid interpretation o f the scan findings.
192
ULTRASONOGRAPHY
Learning points
• D ic h o r io n ic , d i a m n io tic p r e g n a n c i e s h a v e th e lo w e s t p e r in a t a l
m o r ta lity
• T h e la m b d a s ig n is s e e n in d i c h o r i o n ic tw in p r e g n a n c i e s
• T h e d iv id in g m e m b r a n e is th in a n d a t r ig h t a n g l e s to th e u te r in e
w a ll in m o n o c h o r i o n ic d i a m n io tic tw in p r e g n a n c i e s
193
ULTRASONOGRAPHY
C horiocarcinom a
C horiocarcinom a develops in approxim ately 1:40,000 term pregnancies
and this represents a quarter o f all cases. The other cases follow molar
disease, an abortion (spontaneous or therapeutic) or ectopic pregnancy.
The prim ary tum or is often very small and an extensive search o f the
placenta is frequently required to find the lesion.
194
ULTRASONOGRAPHY
SECOND A N D TH IRD T R IM E ST ER U L T R A SO U N D
All ultrasound exam inations benefit from a m ethodical approach.
Information regarding the gestational age, fetal anatom y, placental
morphology and the am niotic fluid volume can all be obtained. M any
obstetric units offer a routine ultrasound assessment at 1 8 - 2 2 weeks
gestation as a screening investigation to detect fetal anomalies.
195
ULTRASONOGRAPHY
196
ULTRASONOGRAPHY
197
ULTRASONOGRAPHY
99
97
95
90
75
50
25
10
5
3
1
In high risk patients, serial growth scans may be required. These will
com m ence at a gestation dictated by the clinical scenario and serial
biom etry should be undertaken at no less than 2- weekly intervals. A
shorter interval between scan m easurem ents may lead to a higher false
positive rate. An increase in AC of approxim ately 20 mm in 2 weeks is
expected for the average fetus.
198
ULTRASONOGRAPHY
Placental localisation
Accurate assessment of placental location is im portant and can be
attempted after 18 weeks gestation.
199
ULTRASONOGRAPHY
uterus. It m ight lie com pletely within the up p er part o f the uterus, with
its lower edge > 5 cm from the internal os. Such a position is usually
described as “ u p p e r ” or “ not lo w ” . A lternatively, if the leading edge
o f the placenta lies within 5 cm o f the internal os and/or appears to cover
the internal os then its position should be described as “ lo w ” and/or
“ covering the o s ” . The term “ placenta praevia” sh o u ld only be used
after 28 weeks.
Placenta praevia is divided into fo u r grades (I, II, III and IV).
Grades I and II are considered to be minor cases while grades III and IV
are m ajor. V aginal ultrasound has added a fu rth er dim ension to the
classification o f placenta praevia by enabling the distance between the
lower m argin of the placenta and the internal os to be m easured more
accurately. If the distance is less than 3 cm , this should be regarded .as in
keeping with a m ajor praevia while, distances o f 3 -5 cm are in keeping
with a m inor praevia.
200
ULTRASONOGRAPHY
201
ULTRASONOGRAPHY
IUGR - although the World Health Organisation has defined small for
gestational age at a cut-off below the 10th centile, this does not always
equate with growth restriction because some fetuses will be normally
small and have reached their m axim um biological potential; while others
may be above the 10th centile but with growth restriction as their
potential was even greater but they had stopped grow ing. It is useful to
consider two mechanism s which result in growth restriction:
Low growth potential - this means that the fetus from conception is
destined not to grow well. M easurem ents o f the fetus are typically
reduced from m id-pregnancy. The fetus tends to be short and light with
all ultrasound m easurem ents being reduced. This is term ed symmetrical
growth restriction and may be due to the m other being biologically
small (< 45 kg) or there may be a pathological cause such as a
chrom osom al abnorm ality or viral infection.
Loss of growth support - this is usually found after 30 weeks and is due
to restriction o f oxygen and nutrients owing to vascular disease affecting
the utero-placental circulation, such as pre-eclam psia. The fetus tends to
be long and light with a reduced abdom inal girth. This is termed
asymmetrical growth restriction. With starvation the glycogen stores in
the fetus becom e depleted and, because the liver stores most of the fetal
glycogen, the abdom inal circum ference m easurem ent is reduced while
the BPD, HC and FL, remain unaffected. A lthough symmetrical and
asymm etrical growth restrictions classically are described as separate
entities, in clinical practice the differentiation is less clear.
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ULTRASONOGRAPHY
Doppler
Doppler ultrasound has been used to m easure the blood flow velocity in
vessels during the cardiac cycle in the feto-placental and utero-placental
circulations. Resistance to blood flow in the uterine arteries falls with
advancing gestation due to trophoblastic invasion o f the uterine spiral
arteries. V arious indices can be used to assess um bilical artery resistance
and, if raised, may indicate a problem . M ore clinically useful is the
observation o f absent end-diastolic flow or reversed end-diastolic flow
which indicates a progressive com prom ise in the blood flow through the
umbilical arteries.
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ULTRASONOGRAPHY
A score o f 2 is given for each com ponent if the criteria are met
and zero if not. The m axim um score is 10, and scores o f 6 or below are
considered abnorm al. The purpose of the BPS is to assist in identifying
a fetus that may require delivery before becom ing seriously
com prom ised. The com ponents are illustrated in Table 1.
The fetus has a sleep-wake cycle of 20-40 minutes and hence the
observation period may take up to 30 minutes. In a com prom ised fetus
affected by hypoxia or infection, the first m arkers to go are breathing
and fetal heart rate reactivity and the last are m ovem ent and tone.
KEY POINTS
• Ultrasound is painless, safe and reliable and is
now an integral part of modern obstetric care
• Demonstration of a gestational sac within the
uterus is the earliest ultrasonic conform ation of
an intrauterine pregnancy. It is usually
visualized from 4 weeks + 3 days gestation
trans-vaginally or 5 weeks + 3 days gestation,
transabdominally.
• It is operator-dependant and appropriate
training in its use is crucial.
• The M aximum Vertical Pool o f Liquor
(M VPL) and the Amniotic Fluid Index (AFI)
are objective, reproducible measurements of
the liquor volum e.
• Biophysical profile scoring is a form alization of
fetal behavioural assessment.
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CHAPTER FIFTEEN
INTRODUCTION
Far too little attention has been paid to the exam ination o f the umbilical
cord and placenta following delivery. The practice, in most delivery
units, is to discard the placenta after perform ing a cursory exam ination
and measuring its weight, despite the fact that placental weight is seldom
an important consideration in establishing the cause o f fetal distress or
demise. This is indeed a casual m anner in which to treat an organ, which
so vital in its function to the developing fetus, may yield valuable data
and provide clues to account for some o f the “ u n e x p lain ed ” causes o f
perinatal deaths we encounter from time to time.
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CORD AND PLACENTA
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CORD AND PLACENTA
Length - the length o f the cord varies greatly from about 10 - 200
centimetres. It is not m easured routinely but a very short cord may give
rise to com plications with delivery such as a delay in the descent o f the
presenting part or it may even rupture. Alternatively an excessively long
one may be m ore likely to becom e entangled around the fetal body or
limbs or may predispose to cord prolapse.
THE PLACENTA
Placental anatomy
The mature placenta is typically round or ovoid with a sm ooth outer
border. Its colour may be reddish-grey or deep purple-red and it has a
spongy character. The average weight o f a term placenta is 450 - 550
grams. It measures about 15 cm in diam eter and 2 cm in thickness when
laid flat. The placental: fetal weight ratio is usually l:6 .T h e placenta has
two surfaces: fetal and m aternal (Figure 2).
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CORD AND PLACENTA
feud capillarte*
maternal blood pools
— maternal
venule
m aternal
arteriole
um bilical
arteries
fetal p o rtio n v
o f placenta m atern al portion
(chorion) placenta
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CORD AND PLACENTA
PLACENTAL FUNCTION
The main functions o f the placenta are as follows:
• nutritional
• respiratory
• excretory
• endocrine
• as a transient fetal liver
• as a storage organ
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CORD AND PLACENTA
The first three functions above are chiefly concerned with the
transfer o f nutrients and oxygen to the fetus, along with carbon dioxide
and waste products o f fetal metabolism to the m aternal com partm ent.
They are vital to fetal growth and survival.
PLACENTAL INSUFFICIENCY
The term ‘‘placental insufficiency” is a useful description o f the
condition associated with a reduction in placental transfer of nutrients
and waste products between the fetal and maternal com partm ents which
leads to fetal com prom ise.
Aetiology
Placental insufficiency can occur either during the antepartum period or
during labour and delivery.
a) A ntepartum - insufficiency during the latter weeks o f pregnancy
adversely affects the nutrition and developm ent o f the fetus resulting in
chronic hypoxia and intra-uterine growth restriction. Causes of this type
of placental dysfunction are:
• The hypertensive disorders o f pregnancy e.g. preeclam psia
• Sickle cell disease
• Prolonged pregnancy
• Chronic renal disease
• Smoking
• Diabetes mellitus
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CORD AND PLACENTA
212
CORD AND PLACENTA
Non-Stress Test
This is a simple test used for assessing fetal health during the antenatal
period. It correlates fetal heart rate with fetal movements. It is a means
of screening high-risk pregnancies, such as those listed in Table 1, in an
attempt to identify those babies dem onstrating signs of a com prom ised
intra-uterine environm ent while at the same time identifying those that
provide reassuring signs o f fetal well-being.
A NST is termed reactive if there have been at least two heart rate
accelerations in association with fetal movement. An acceleration is a
change in the fetal heart rate by at least 15 beats per minute above the
baseline, lasting at least 15 seconds and occurring within a 20-m inute
period. The reactive NST or the presence of fetal heart rate accelerations
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CORD AND PLACENTA
If the criteria for a reactive NST are not met after 40 m inutes, the
test is classified as a non-reactive NST. In such a situation there are no
accelerations with movements or there are no m ovem ents o f the fetus
during the period of observation.
Ultrasound
This allows visualisation o f the fetus, placenta, um bilical cord and liquor.
Growth param eters such as the biparietal diam eter (BPD), head
circum ference (HC), abdom inal circum ference (AC) and fem ur length
can be m easured and an estimation o f the fetal weight can be acquired.
These m easurem ents allow the confirm ation o f suspected IUGR and
enable the obstetrician to differentiate between the symmetrical and
asym m etrical types.
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CORD AND PLACENTA
KEY POINTS
• The umbilical cord contains two arteries, one vein,
the vitelline duct and remnants of the allantois
embedded in W harton's jelly.
• The length of the umbilical cord varies from about
10 to 200 cm.
• The average weight of a term placenta is 450 -
550g. The placental: fetal weight ratio is usuallv
1:6 .
• The term “placental insufficiency” is a useful
description of the condition associated with a
reduction in placental transfer of nutrients and
waste products between the fetal and maternal
compartments which leads to fetal com prom ise.
• Biophysical tests are the most com m only
performed placental function tests.
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A M N IO T IC F LU ID
CHAPTER SIXTEEN
AMNIOTIC FLUID
INTRODUCTION
The origin and com position o f amniotic fluid was first described by
Hippocrates who postulated that it was a product of the fetal kidneys.
The Greek, Soranus o f Ephesus, described it in the year 100 A.D., and
further observations were made by the Italian artist, Leonardo da Vinci
and the great French Obstetrician, Francois M auriceau. Prochownick
(1877) described the major solutes and Schroeder (1891) reported the
presence o f album in. In 1919, Uyeno produced a unique paper on the
biochem ical com position o f am niotic fluid, but it is only within the last
five decades that a considerable am ount of data has been obtained from
analysis of amniotic fluid and made applicable in clinical practice. It is
now possible, for exam ple, to determ ine the severity o f rhesus iso
im m unisation, the degree o f fetal m aturation and the presence of
chrom osom al abnorm alities in the fetus.
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A M N IO T IC F LU ID
Growing slowly at first, the amniotic sac later exceeds the size of
the yolk sac and fills the extra-em bryonic coelom . The em bryonic disc
also enlarges and as it does so, it folds to a tubular form in cross-section
and the attachment o f the am nion is carried round to its ventral surface.
That portion o f the am nion near the umbilicus surrounds the cord as an
external layer and thus form s a sheath for the umbilical cord.
Arm ii
Bod/stdk
Allantois
Yolksoc
Fused
and 01
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A M N IO T IC F LU ID
218
A M N IO T IC F LU ID
Circulation
In early pregnancy, there is an active exchange o f liquor through the
fetal skin and across the m em branes, to the maternal com partm ent. In
the second half of pregnancy, however, the exchange is principally at the
placental site and if there is any at all across the chorio-am nion, it must
do so by passive diffusion. In other words, the relative im portance o f the
different routes of liquor form ation and removal varies with fetal
maturity.
AFI - The maternal abdom en is divided into quadrants. The level o f the
umbilicus is used to divide the uterus into upper and lower halves and the
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A M N IO T IC F LU ID
linea nigra is used as the midline to divide the uterus into right and left
halves. The largest vertical m easurem ent of am niotic fluid in each
quadrant is recorded. The values are added together to obtain the AFI in
centim etres. Patients at term with an AFI less than 5 cm are considered
to have oligohydram nios, while an AFI greater than 25 cm signifies
polyhydram nios.
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A M N IO T IC FLU ID
COMPOSITION OF LIQUOR
From a physio-chem ical point o f view, amniotic fluid is a heterogeneous
system com posed of a solution in which undissolved material is
suspended. It consists of 98% water and 2% solids. The solids are
organic and inorganic.
Organic constituents-:
• Proteins - the following proteins and break-dow n products o f protein
metabolism are found in liquor: album in, globulins, a-fetoprotein,
amino-acids, urea, uric acid and creatinine. There is no fibrinogen in
amniotic fluid.
• Carbohydrates - glucose, fructose, lactic acid, pyruvic acid, keto-
glutamic acid and citric acid. Glucose concentration varies from 25-
40%.
• Lipids - prostaglandins (unsaturated fatty acids) and phospholipids
(lipids containing a phosphate residue).
• Enzymes - alkaline phosphatase, acetylcholinesterase, glutamic-
oxalo-acetic transaminase, and histaminase are a few exam ples which
have been identified in cell-free amniotic fluid. M econium contains
large quantities o f alkaline phosphatase.
• Hormones - oestriol, oestrone, and oestradiol, ACTH and cortisone,
HCG, pregnanediol and insulin. Erythropoietin is present in low
concentrations but rises spectacularly in erythroblastosis fetalis.
• Pigments: bilirubin
• Vitamins.
Inorganic constituents-:
Sodium, potassium, calcium, m agnesium , chloride, iron, copper,
bicarbonate and phosphate.
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A M N IO T IC FL U ID
CLINICAL APPLICATION
The status o f the fetus can be evaluated to a large extent by exam ination
o f the am niotic fluid. Apart from quantitative analysis, the application of
biochem ical, biophysical and im m unological m ethods to the analysis of
am niotic fluid has allowed determ ination o f the severity o f rhesus iso
im m unisation, the degree o f fetal lung m aturation, the presence of
chrom osom al abnorm alities and the detection o f neural tube defects.
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A M N IO T IC F LU ID
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A M N IO T IC FLU ID
AMNIOCENTESIS
Amniocentesis is the insertion o f a needle into the am niotic cavity for the
purpose of aspirating am niotic fluid or for injecting dyes and
m edications or introducing catheters. The trans-abdom inal approach is
preferred to the vaginal route.
Procedure:
The chosen puncture site is cleaned with an antiseptic solution and sterile
drapes are applied. Local anaesthetic is injected at the site and a 20-
gauge needle is directed under ultrasound guidance into a pool of
liquor. The stylette is removed and liquor is aspirated with a syringe.
The volume aspirated will vary on the tests being perform ed. The needle
is removed and a gauze swab is applied to the puncture site. Unsensitised
rhesus negative m others should be adm inistered anti-D immunoglobulin.
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A M N IO T IC F LU ID
Complications:
• Traum a to the fetus.
• Chorioam nionitis
• Premature rupture of the mem branes
• M iscarriage (1-2% )
• Traum a to the uterus: intra-peritoneal bleeding
• M aternal sensitisation in rhesus negative m others.
AMNIOINFUSION
Amnioinfusion was first perform ed by Gabbe et al in 1979, using
experimental animals. These researchers established that variable
decelerations related to oligohydram nios and cord com pression could be
corrected by this procedure. In 1983, M iyazaki and Taylor successfully
employed saline am nioinfusion in 42 women for the relief o f variable or
prolonged decelerations.
The indications for am nioinfusion have since expanded and are as
follows:
• To eliminate variable decelerations in labour, particularly in
primigravidae whose labour is slow enough to undergo treatm ent.
• To deliver antibiotics to the chorioam nion (rare).
• To restore norm al amniotic fluid volume after prem ature rupture o f
membranes (not very effective as the fluid readily leaks out again).
• To correct oligohydram nios. A m nioinfused patients have been
found to have less operative deliveries for fetal distress and had good
umbilical artery pHs at birth (however does not address the actual
aetiology fo r the oligohydram nios and many o f these fetuses just
require delivery).
• To decrease the chance o f intrapartum m econium aspiration. A bolus
of 7 0 0 -1000ml of norm al saline at room tem perature is infused
through an intra-uterine pressure catheter over 30 m inutes and this is
followed by 200 ml every 2 hours. With this protocol there has been:
a) significantly less depressed babies at birth, b) less m econium below
the vocal cords and c) fewer cases o f m econium aspiration syndrom e.
Amnioinfusion is considered a relatively safe procedure however some
isolated complications reported in the literature include:
• Hydramnios.
• Umbilical cord prolapse.
• Uterine hypertonus.
• Severe maternal cardiopulm onary com prom ise.
• Maternal demise from am niotic fluid em bolism .
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A M N IO T IC F LU ID
KEY POINTS
226
A N T E P A R T U M FET A L SU R V E IL L A N C E
CHAPTER SEVENTEEN
INTRODUCTION
The objective of antepartum fetal surveillance is to reduce perinatal
morbidity and m ortality. This can be achieved by the developm ent o f
surveillance strategies that identify the high risk population, institute the
appropriate tests in a timely fashion and em ploy interventions that
recognise the limitations of testing procedures.
Fetal anom aly, drugs and infection all make significant contributions to
adverse perinatal outcom e. However, it is fetal hypoxia that is responsible
for the lions share accounting for 70 % o f all perinatal m orbidity and
mortality. The growth-restricted fetus is particularly prone to hypoxic
insult and, for the purpose o f this chapter, antepartum fetal surveillance is
largely designed to predict and diagnose fetal hypoxia and growth
restriction so that appropriate interventions can be instituted.
INDICATIONS
Antepartum fetal surveillance should be offered to all m others with
pregnancies deemed high risk. This would include pregnancies
complicated by the following:
• Previous unexplained stillbirth.
• Decreased fetal movements or an abnorm al pattern o f
movement.
• Postdate pregnancy.
• Intrauterine growth restriction.
• Aberrant liquor volum e (Poly or oligohydram nios).
• Hypertensive disorders of pregnancy.
• Diabetes mellitus.
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A N T E P A R T U M FE T A L S U R V E IL L A N C E
Biophysical tests
The biophysical tests detailed in this chapter are:
• Assessment of fetal movement
• Assessment of sym physiofundal height
• C ardiotocography
• The biophysical profile
• Fetal biom etry
• L iquor volum e assessment
• D oppler ultrasound.
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A N T E P A R T U M FET A L SU R V E IL L A N C E
weeks and m ultigravidae two weeks earlier. M others may also recognise a
unique pattern o f activity with a large proportion of fetuses being most
active in the evening.
The SFH m easurem ent can be plotted on a growth chart that has
been customized to cater for variations such as race and m aternal body
mass index. Serial measurements plotted in these customized growth
charts allow for the identification of growth abnormalities.
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A N T E P A R T U M F E T A L SU R V E IL L A N C E
Cardiotocography
The term cardiotocography (CTG) refers to the record o f the fetal heart
(cardio) and the strength (toco) and frequency o f uterine contractions.
Application o f the term in an antepartum context would imply a
quiescent uterus, as in non-stress testing, where there is a record o f the
fetal heart response to fetal movement.
a) Non-Stress Test
The non-stress test (NST) is the most com m only perform ed test of fetal
well-being. It involves an assessment and record o f the fetal heart and
the response to fetal movement. The test is perform ed with the patient in
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A N T E P A R T U M F E T A L S U R V E IL L A N C E
the left lateral position. This elim inates aorto- caval com pression and
ensures optim al placental perfusion th ro u g h o u t the testing procedure.
The fetal heart is located with an abdom inal transducer and the m other is
instructed to indicate when m ovem ents have occurred with the aid o f a
hand held device.
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A N T E P A R T U M FET A L S U R V E IL L A N C E
c) Computerised cardiotocography
The main limitation of conventional cardiotocography is that the
interpretation is subjective. C om puter program m es have been developed
to evaluate specific param eters on the trace and provide an objective
assessment. Most o f these program m es measure the short term variability
and rely on the premise that variability is a more sensitive predictor of
fetal com prom ise than the absence o f accelerations or the presence of
decelerations.
23 2
A N T E P A R T U M FET A L SU R V E IL L A N C E
Biophysical Profile
The biophysical profile (BPP) utilizes cardiotocography and ultrasound
assessment of the fetus. The com ponents of the test are:
• Non-stress test.
• Fetal breathing m ovements - more than one episode o f 30
seconds duration or m ore within a 30 m inute period.
• Fetal body movements - four or more discrete body
movements.
• Fetal tone and posture - active extension and return to
flexion.
• Q uantification of liquor volume - one pocket greater than 2
cm is considered norm al.
The last four param eters are evaluated by sonography and each
parameter is afforded a score o f 2 for norm al and 0 for abnorm al. The
maximum cumulative score is 10. Scores o f 6 to 8 are abnorm al and the
test should be repeated in 12 to 24 hours. Scores o f 4 or less are
indications for expediting delivery. In an effort to improve the sensitivity
of the testing procedure placental grading can be incorporated into the
biophysical profile. This ‘m o d ified ’ BPP has an overall score o f 12 as
opposed to 10.
The main drawback of the BPP is that it is time consum ing and
requires considerable resources. However, it has a high negative
predictive value and norm al results can be considered valid fo r one week.
Fetal Biometry
This is considered in more detail in chapter fourteen. Biom etry is an
important intervention as it allows for the identification o f the growth
restricted fetus which is most at risk o f hypoxic insult and its sequelae.
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A N T E P A R T U M FE T A L SU R V E IL L A N C E
D oppler Ultrasound
D oppler ultrasound may be used to evaluate b lood flow patterns in
m aternal and fetal blood vessels. It can identify abnorm alities o f flow
that can occur in certain conditions. T he m ore co m m o n ly perform ed
D oppler studies are:
• Um bilical A rtery D opplers:
Rely on the fact that in the norm al fetus there is flow o f blood
from the fetus to the placenta th ro u g h o u t systole and diastole. It
is a useful test in the grow th restricted fetus where increased
vascular resistance may cause abnorm alities in this flow.
N orm al um bilical artery D oppler waveform s are dem onstrated in
figure 2.
Absent end diastolic flow (EDF) and reversed ED F are abnormal
and good predictors o f fetal hyp o x ia (see fig 3 and 4).
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A N T E P A R T U M F E T A L SU R V E IL L A N C E
Figure 2-Norm al
235
A N T E P A R T U M F E T A L SU R V E IL L A N C E
Biochemical Tests
On the whole, biochem ical testing is used with less frequency than
previously. This is primarily because o f im provem ents in biophysical
technologies and their increased availability. A num ber of m aternal
serological m arkers have been shown to be associated with reduced fetal
growth in the third trimester. These include alpha feto protein (AFP),
hum an chorionic gonadotrophin (hCG) and hum an placental lactogen
(hPL).
CONCLUSION
No test in isolation is particularly sensitive and em ploying more than one
test should improve the process. Bearing this in mind, local protocols
should be developed that encourage m ultim odality testing and m ake use
o f the available resources.
KEY POINTS
• The objective of antepartum fetal surveillance is to
reduce perinatal morbidity and mortality.
• Local protocols should be developed.
• The non-stress test is the most commonly performed test
of fetal well-being. The presence of two accelerations of
more than 15 beats for more than 15 seconds in a 20
minute period is indicative of a normal trace.
• Baseline variability is a more sensitive predictor of fetal
compromise than the absence of accelerations or the
presence of decelerations.
• Liquor volume represents an indirect assessment of
placental function.
• Umbilical artery Doppler ultrasound is a useful test in
the growth restricted fetus.
• An elevated level of AFP is associated with an increased
risk of pre-eclampsia, pre-term delivery, intrauterine
growth restriction, placental abruption and still birth.
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NORM AL LABOUR
CHAPTER EIGHTEEN
NORMAL LABOUR
EXPLANATION OF TERMS
The term labour represents the process whereby uterine contractions are
accompanied by effacem ent and dilatation of the cervix, resulting in the
expulsion o f the fetus and placenta through the birth canal.
237
NORM AL LABOUR
238
NORM A L LABOUR
T H E D IA G N O S IS O F L A B O U R
Labour com m ences when uterine contractions o f sufficient frequency,
intensity, and duration result in cervical dilatation and effacem ent.
TH E STA G ES O F LA BO U R
• First stage: from the start o f reg u lar uterine contractions to full
cervical dilatation. The first stage o f lab o u r has been subdivided
into a latent and an active phase. D uring the latent phase, uterine
contractions typically are in freq u en t and irreg u lar and gradual
cervical effacem ent and dilatation o f the cervix o ccu r (Figure 1).
The active phase o f labour begins when the cervix reaches 3-4 cm
o f dilatation. D uring the active phase, there is m ore rapid cervical
dilatation, and this is dem onstrated by a sharp gradient on a
partogram . The duration o f the first stage is variable. In the
prim igravida, it is 12-16 hours. In the m ultigravida, it is usually
shorter (6-12 hours).
• Third stage: from the delivery o f the fetus to the com plete
separation and expulsion o f the placenta and the m em branes.
This stage norm ally lasts 15 to 30 m inutes.
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NORM AL LABOUR
Some degree o f m oulding o f the fetal head norm ally takes place.
This permits it to adapt itself to the size and shape o f the maternal pelvis
through which it must pass. M oulding is the overlapping of the fetal
cranial bones which occurs as a result of the compressive forces exerted
by the maternal pelvis. The occipital bone and the two frontal bones are
driven slightly under the parietals. The parietal bone, which is posterior,
is driven under the anterior. These changes are more pronounced if there
is cephalo-pelvic disproportion.
Internal rotation
Once the cervix is fully dilated, the fetus rapidly descends to the level of
the ischial spines (station zero), where internal rotation begins as the head
meets the grooved gutter o f the levator muscles which form the floor o f
the pelvis. Further flexion o f the head takes place and anterior rotation
of the occiput takes place through 90° in the occipito-lateral, 45° in the
occipito-anterior and 135° in the occipito-posterior position o f the
vertex. This enables the occiput to become anterior, and lie behind the
symphysis pubis (Figure 3).
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NORM AL LABOUR
Extension
Under the influence of maternal bearing-dow n expulsive efforts, the
head descends further thereby stretching the vulval orifice. This is
termed crowning. That is to say, crowning occurs when the largest
diam eter of the fetal head is encircled by the vulvar ring. With further
contractions, extension o f the head occurs, and the perineum sweeps over
the forehead, base o f nose, mouth and chin to release the head.
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NORM AL LABOUR
Restitution
The fetal shoulders, which have by now entered the pelvic cavity undergo
similar movements to those recently undertaken by the fetal head. The
bis-acromial diam eter becom es antero-posterior in relation to the pelvis.
MANAGEMENT OF LABOUR
Once the diagnosis o f labour is made, the patient should be adm itted to
the labour suite. A gentle enem a may be given. Vulval shaving is not
essential but, if perform ed only in the region o f an intended episiotom y,
it facilitates a satisfactory repair.
• Posture: C om fort of the patient is im portant because it makes her
feel less vulnerable and dictated to. The sitting position is useful
because it encourages descent o f the presenting part. At no time
must the patient remain supine because of the risk o f aorto-caval
compression by the uterus. The left-lateral position or a 15-30°
lateral tilt should be encouraged to ensure adequate utero
placental perfusion.
• Intake: Once in labour, food is inadvisable. Stom ach em ptying is
greatly delayed and the need for operative intervention requiring
general anaesthesia results in a high risk of reflux and aspiration
of stomach contents. The aspiration o f acidic contents of pH 2.5
or less is universally associated with the developm ent o f the
“ acid-aspiration (M endelson’s) sy n d ro m e” which has an almost
100% mortality. It is useful therefore to adm inister alkalinising
agents such as Mist Mag Trisil Co. BPC or Sodium citrate 15 ml
every two hours. Oral fluids in strictly limited quantity may be
administered because o f the high ambient tem perature in tropical
countries. Intravenous fluids containing glucose are valuable
especially if a short labour is not expected.
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NORM AL LABOUR
244
NORM AL LABOUR
The best indicators o f progress are the rate o f cervical dilatation and the
descent o f the presenting part into the pelvis. This may be docum ented
on a partogram which provides is a graphical depiction o f the progress
of labour. Descent o f the presenting part is best determ ined by the
number of fifths palpable above the sym physis pubis. This m ethod is
superior to that using station.
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NORM AL LABOUR
246
NORM AL LABOUR
247
NORM AL LABOUR
Steady traction is applied to the cord with the right hand (Figure
4). The left hand is placed on the abdom en with the radial border or the
fingertips just above the sym physis pubis to prevent inversion o f the
uterus. The placenta and m em branes are collected, together with blood,
in a basin. The uterus is then palpated to ensure that it is firmly
contracted. The fundus is now at the level of the um bilicus and the uterus
is broad and discoid.
PERINEAL LACERATIONS
There are four degrees o f perineal lacerations:
First degree: involves the vaginal m ucosa or perineal skin,
Second degree: involves the subepithelial tissues but not the anal
sphincter or rectal mucosa,
Third degree: extends through the anal sphincter but does not
involve the anal mucosa. This can be further
classified by the extent o f sphincteric involvement
into 3a, 3b or 3c.
Fourth degree: involves the anal m ucosa.
EPISIOTOMY
Definition
An episiotom y is a deliberate incision in the perineum to enlarge the
introitus in order to facilitate delivery. The word episiotom y is derived
from the G reek words E p is e io n (external genitalia) and te m n ie n (to cut).
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NORM AL LABOUR
Indications
• Tight perineum . This usually occurs in the prim igravida. The
skin o f the perineum appears tense, smooth and glistening. A few
drops o f blood appearing at this time may be from a vaginal tear.
If an episiotom y is not done, laceration o f the introitus may
occur.
• Delay o f the presenting part at the perineum may be due to
contraction o f the pelvic outlet, especially due to a narrow
subpubic arch. In this case, the head will be displaced backwards
and the anal sphincter may be dam aged.
• O ccipito-posterior position of the head because a large diam eter
is presenting.
• Breech delivery, particularly in the prim igravida.
• Forceps delivery.
• Fetal distress in the second stage o f labour.
• Prolapse of the cord in the second stage.
• Preterm delivery: “ the smaller the baby, the bigger the
episiotom y” .
• M ultiple births. The episiotomy is done when Twin A is being
delivered.
• Cardiac disease in pregnancy in order to shorten the second stage
and prevent m aternal exhaustion.
• Previous vaginal repair. Dense perineal scar tissue from a
previous repair may be unyielding.
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NORM AL LABOUR
Technique
M aking an episiotom y without analgesia is antiquated. Load a 20-ml
syringe with 1.0% X ylocaine. Insert two fingers o f the left hand into the
fourchette between the presenting part and the vulva and infiltrate widely
as far as the anal sphincter. Gently massage the soft tissue to disperse the
analgesic agent.
Using a blunt-tipped pair o f scissors, incise the skin and
underlying perineal muscles when the presenting part is distending the
perineum and when it is anticipated that its delivery is possible with the
next one or two contractions (Figure 5).
A m edio-lateral episiotom y is preferable to the m edian incision,
in Trinidad. However, the midline cut is less vascular and less painful as it
heals; the muscles retract sym m etrically and are easier to suture, allowing
better healing and less dyspareunia. The greatest disadvantage of the
median cut is the fear that it may extend into the anal sphincter.
Mediolateral
episiotomy
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NORM AL LABOUR
Repair
Repair of the episiotom y must be undertaken imm ediately after the
placenta has been expelled. A tam pon is inserted into the vagina above
the apex. Using 2/0 Vicryl Rapide® or chrom ic catgut, the vaginal
mucosa is reapproxim ated, starting just above the apex, with a continuous
suture that is tight enough to ensure haemostasis. At the m uco-cutaneous
junction this suture is locked or tied and kept for stitching the perineal
skin. The deep tissues are rebuilt with interrupted No. 1 sutures and tied
without much tension. The perineal skin m argins are then closed with a
subcuticular continuous stitch or interrupted mattress sutures. O f
importance are adequate haemostasis and obliteration o f dead space with
a minimum o f tissue injury. At the conclusion o f the suturing, remove
the tam pon, and perform a rectal exam ination since the inadvertent
incorporation o f the rectum with a suture is likely.
After-care
This consists of daily cold sitz-baths, oral analgesics such as paracetam ol,
infra-red lamp to reduce oedem a, a low-residue diet and a mild laxative
on Day 3. N upercaine ointm ent may be applied for pain.
Complications
• Haem orrhage.
• Infection especially if contam inated with faeces.
• Pain and superficial dyspareunia
• Haematoma.
• B artholin’s cyst.
• Injury to anal sphincter.
• Recto-vaginal fistula - rare.
• Injury to the fetus.
• Cardiac arrhythm ia and anaphylactic shock from the anaesthetic.
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NORM AL LABOUR
KEY POINTS
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IN T R A P A R T U M F E T A L M O N IT O R IN G
CHAPTER NINETEEN
INTRODUCTION
Intrapartum fetal m onitoring is used to identify fetal hypoxia before the
development o f perm anent cerebral dam age and so allow timely
intervention. At present, the established techniques o f intrapartum fetal
monitoring include interm ittent auscultation o f the fetal heart rate and
continuous electronic fetal m onitoring (or continuous cardiotocographic
monitoring).
The placenta acts as the respiratory organ o f the fetus in utero for
gas exchange. D uring a uterine contraction there is cessation of blood
flow in the intram ural vessels such that replenishm ent o f blood in the
placental bed ceases. However the fetus continues to receive oxygen
from the intervillous spaces. When the uterus relaxes there is a reactive
hyperemia and the system has time to recover between contractions. If
there is uterine hypercontractility, which can occur with injudicious use
of oxytocin, this lack o f recovery will eventually lead to fetal hypoxia.
Umbilical cord com pression is another im portant cause o f fetal hypoxia.
The fetus is able to adapt to the stresses o f labour and delivery
through changes in its cardiovascular and autonom ic nervous system.
When both m other and fetus are healthy and labour is norm al, the
decrease in placental exchange of gases is usually well tolerated.
However, in the presence o f maternal disease or placental insufficiency,
the reduction in intervillous flow may com prom ise the ability o f even a
normal fetus to tolerate the stresses o f labour. Chronically com prom ised
fetuses, such as those with intrauterine growth restriction, may not be able
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IN T R A P A R T U M F E T A L M O N IT O R IN G
to tolerate the extra stresses o f labour and thus these fetuses may show
evidence o f fetal stress early in labour.
METHODS OF M ONITORING
Intrapartum fetal heart rate m onitoring includes: interm ittent auscultation
o f the fetal heart with a P in a rd ’s stethoscope (or a D oppler) or
continuous electronic m onitoring with the cardiotocographic m achine
(CTG).
Intermittent monitoring
Interm ittent m onitoring involves auscultation o f the fetal heart for one
m inute through a uterine contraction every 15 m inutes during the first
stage of labour, or every five minutes, in the second stage o f labour. The
maternal pulse should be palpated to differentiate between m aternal and
fetal heart rates. If there are abnorm alities in the baseline heart rate,
decelerations, irregular heart rate or if there is difficulty with auscultation
then continuous electronic fetal heart rate m onitoring should be
undertaken.
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I N T R A P A R T U M F E T A L M O N IT O R I N G
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IN T R A P A R T U M F E T A L M O N IT O R IN G
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IN T R A P A R T U M F E T A L M O N IT O R IN G
F etal G r o w th r e s tr ic tio n
P r e m a tu r ity
O lig o h y d r a m n io s
A b n o r m a l D o p p le r artery v e lo c im e t r y
M u lt ip le p r e g n a n c ie s
M e c o n iu m - s t a in e d liq u o r
B reech p r e s e n ta tio n
Intrapartum O x y t o c in a u g m e n t a tio n
E p id u ra l a n a lg e s ia
V a g in a l b le e d in g in la b o u r
M a te r n a l p y r e x ia
F r e sh m e c o n iu m sta in e d liq u o r
Decelerations
This is the drop in baseline o f m ore than 15 beats lasting fo r lo n g er than
15 seconds from onset to end. There are different types o f decelerations:
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IN T R A P A R T U M F E T A L M O N IT O R IN G
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I N T R A P A R T U M F E T A L M O N IT O R I N G
Meconium
Although the passage of m econium by the fetus is not always due to fetal
hypoxia, m econium -stained liquor must be considered seriously and
there should be continuous m onitoring o f the FHR by CTG in labour.
Because of the risk of m econium aspiration a Paediatrician should be
present at delivery.
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I N T R A P A R T U M F E T A L M O N IT O R I N G
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I N T R A P A R T U M F E T A L M O N IT O R I N G
• Twin B with fetal distress. This may occur, for exam ple,
following the inadvertent administration of Syntom etrine with the
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I N T R A P A R T U M F E T A L M O N IT O R I N G
KEY POINTS
262
POSTPA RTU M HA EM ORRH A GE
CHAPTER TWENTY
POSTPARTUM HAEMORRHAGE
INTRODUCTION
Postpartum haem orrhage (PPH) is one o f the principal causes o f
maternal mortality worldwide. It occurs in 4 to 9% o f all pregnancies
and is associated with significant m orbidity including loss o f fertility and
end organ dam age such as renal failure. The problem is particularly
alarming in the developing world where it is co m p ounded by
grandmultiparity, short interpregnancy intervals, p o o r nutritional status
and a lack o f access to centres with appropriate facilities to m anage this
obstetric em ergency.
DEFINITION
By convention, this has been defined as blood loss from the genital tract
in excess of 500 millitres occurring after delivery o f the baby.
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AETIOLOGY
The m nem onic, the 4 T 's (Tone, Traum a, Tissue and T hrom bogenic)
allows for the categorization o f the causes o f postpartum haem orrhage:
• Tone refers to uterine atony. This is the most com m on cause
o f postpartum haem orrhage. It may be due to uterine
overdistension as occurs in m ultiple gestations,
polyhydram nios and fetal m acrosom ia. The efficiency of
m yom etrial contractility may also be com prom ised in
chorioam nionitis, grandm ultiparity, precipitate labour,
prolonged labour and following tocolytic therapy.
A ntepartum , placental abruption may result in suffusion of
blood between the m yom etrial fibres. This is known as the
C ouvelarie’s uterus and represents an im pedim ent to
effective uterine contraction.
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PO STPA RTU M H A EM O RRH A G E
MANAGEMENT
This is an obstetric em ergency and merits the involvement o f senior
obstetricians, anaesthetists, haem atologists and midwifery staff.
M anagem ent can be thought o f broadly under the headings,
Resuscitation and Treatm ent of the causes. In practice these occur
simultaneously.
Resuscitation
Resuscitation follows a structured approach relating to the airway,
breathing and circulation. The initial step should be to call for help,
establish an airway and ensure that the patient is breathing. The
minimum requirem ent is an oropharyngeal airway though this is not
always necessary. However, massive haem orrhage may be associated with
unconsciousness and this patient is at particular risk o f an aspiration
pneumonitis. T herefore, airway protection may be required in the form
of a cuffed endotracheal tube. O xygen should be adm inistered at the rate
of 12-15 litres per minute as this will optimise oxygen delivery to
essential organs.
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PO STPA RTU M H A EM O RRH A G E
Brisk haem orrhage may respond to bim anual com pression. This
can be achieved by com pression o f the uterus between a hand on the
fundus and a fist in the vagina. Alternatively the fundus can be brought
forward with two hands and compressed against the pubic bone. These
m anoeuvres may be helpful in the short term but it is difficult to
maintain this effort for a protracted period.
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Retained Placenta
A retained placenta may be defined as a placenta that rem ains
undelivered 30 m inutes following the end o f the second stage o f labour.
It occurs in 2 % o f all deliveries and is associated with a significant risk
of haemorrhage from the placental bed. The main causes o f a retained
placenta include:
• Delayed adm inistration o f syntom etrine. It is usually given with
the birth o f the anterior shoulder.
• Inappropriate cord traction prior to placental separation. This
may sever the cord leaving the placenta in-utero.
• A m orbidly adherent placenta. This condition typically results
from faulty decidualisation at the site o f previous insult to the
endom etrium . This can occur follow ing m anual rem oval o f the
placenta, caesarean section, previous m yom ectom y (cavity
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PO STPA RTU M H A EM O R RH A G E
Uterine inversion
This is a rare condition thou g h t to occur following inappropriate cord
traction. Conditions such as a m orbidly adherent fundal placenta may
increase this risk. There is a neurogenic elem ent to the shock seen in
these patients. This may be com pounded by hypovolem ia and these
patients should be resuscitated aggressively.
Uterine restitution may be achieved bv:-
• Manual reinsertion. A m ilking technique is em ployed with the
circum ferential reinsertion o f tissue from lateral to m edial.
Manual removal o f the placenta should only be attem pted after
reinsertion.
• O ’Sullivan's technique whereby hydrostatic pressure is used to
restore norm al uterine anatom y. A wide bore hose, attached to a
reservoir, is inserted into the vagina and a seal is achieved by
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POSTPA RTU M H A EM O RRH A G E
Placental Abruption
Antepartum haem orrhage secondary to abruption is a significant risk
factor for postpartum haem orrhage. This is because:
• There is a depletion o f clotting factors secondary to blood loss.
• Throm boplastins are released into the m aternal circulation.
• There is a risk of uterine atony secondary to a Couvelaire's
uterus.
These factors conspire to make PPH in this context a potential
nightm are. Strategies to counteract this are:
• There should be a low threshold fo r blood transfusion in
abruption to reduce the risk o f clotting abnorm alities and
disseminated intravascular coagulation.
• There should be active m anagem ent o f the third stage o f labour
with a low threshold for a prophylactic syntocinon infusion.
Anticoagulation therapy
Patients may be on anticoagulant therapy in pregnancy for a number of
reasons including artificial heart valves, throm boem bolic disease and
atrial fibrillation. Bleeding is a potential com plication and these patients
should be m anaged in conjunction with a haem atologist. If the bleeding
is severe, reversal o f the anticoagulation may be warranted. This can be
achieved by the adm inistration of:
• Vitamin K to patients on warfarin.
• Protamine sulphate to patients on heparin.
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POSTPA RTU M H A EM O RRH A G E
PHARMACOTHERAPY
This section is confined to a discussion of the uterotonic agents that are
currently in use.
Oxytocin
This is a naturally occurring nonapeptide that is synthesized in the
paraventricular nuclei of the hypothalam us and stored in the posterior
pituitary gland. Synthetic oxytocin is known as Syntocinon.
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Ergom etrine
This is an am ine ergot alkaloid that stim ulates contraction o f uterine and
vascular sm ooth m uscle. It may be adm inistered intravenously or
intram uscularly and is m etabolised and excreted by the liver. Follow ing
intravenous adm inistration it exerts its uterotonic effect after 30-60
seconds with duration o f action o f 30 m inutes. Intram uscular
adm inistration may im prove its side effect profile. The usual dose is 0.2-
0.5 m g.
Syntometrine
This is form ulated as a com bination o f 5 units o f Syntocinon and 0.5 mg
o f E rgom etrine in a 1 ml am poule. This preparation benefits from the
dual action o f both drugs. It may be adm inistered intravenously or
intram uscularly. Follow ing intram uscular adm inistration it exerts its
uterotonic effect after 2-3 m inutes with a duration o f action o f 180
m inutes.
Indications fo r use:
• Active m anagem ent o f the third stage o f lab o u r. It is
adm inistered routinely, intram uscularly with the birth o f the
anterior shoulder.
• In the treatm ent o f established postpartum haem orrhage due to
uterine atony.
• Following delivery o f a retained placenta.
• Following delivery o f the fetus at the time o f a caesarean section.
• Prophylactically for all potential cases o f postpartum
haem orrhage.
C ontra-indications:
• H ypertensive disorders o f pregnancy.
• Cardiac disease in pregnancy.
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POSTPA RTU M H A EM O RRH A G E
C om plications:
• Increased incidence o f retained placenta.
• Postpartum pain.
• Tetanic contractions resulting in fetal distress in undiagnosed
twins.
Misoprostol
This is a synthetic analogue o f prostaglandin E l . It is used to treat
uterine atony in patients unresponsive to ergom etrine and oxytocin. It is
rapidly absorbed from the gastrointestinal tract and may be adm inistered
sublingually, orally, vaginally, rectally or intrauterine. It is hydrolyzed
to active com ponents, m etabolized in the liver and excreted in the urine.
The dose is 200-800 meg.
Carboprost
This is a prostaglandin F2-alpha analogue, also know n as H aem abate,
which potentiates the uterotonic effect o f oxytocin. It is used to treat
uterine atony in patients unresponsive to ergom etrine and oxytocin.
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PO STPA RTU M H A EM O RRH A G E
PROPHYLAXIS
The most im portant preventive step is to identify the patient at risk of
developing postpartum haem orrhage. The risk factors for postpartum
haem orrhage are:
• Previous history o f postpartum haem orrhage.
• A ntepartum haem orrhage
• Previous caesarean section
• Intra-uterine death
• M ultiple pregnancies
• G rand multiparity
• Fibroid uterus
• H ydram nios.
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POSTPA RTU M H A EM O RRH A G E
COMPLICATIONS O F POSTPARTUM H A EM O RR H A G E
A num ber of com plications can arise as a result o f PPH, these include:
• M aternal demise.
• Puerperal sepsis.
• Renal failure. These patients may require renal therapy (dialysis
or haem ofiltration).
• Chronic iron deficiency.
• Necrosis o f the anterior pituitary gland (S heehan’s syndrom e).
This may present with the failure o f lactation.
• Disseminated intravascular coagulation. This is a life threatening
com plication o f massive haem orrhage. The m anagem ent
involves m aintaining the intravascular volum e, arresting the
haem orrhage and administering blood and blood products as
required. A low threshold for transfusion, especially when
postpartum haem orrhage is preceded by antepartum
haem orrhage may prevent the developm ent o f DIC in the first
instance.
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PO STPA RTU M H A EM O RRH A G E
KEY POINTS
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PRETERM LABOUR
CHAPTER TWENTY-ONE
PRETERM LABOUR
PPROM
PRETERM_L_AB Q U R
INTRODUCTION
Preterm labour may be defined as labour occurring in pregnancies o f
less than 37 com pleted weeks o f am enorrhoea. A prerequisite fo r
diagnosis is that uterine contractions should last fo r at least 30 seconds,
occur every 10 m inutes or less, for at least 60 m inutes and should be
accom panied by dilatation and effacem ent o f the cervix and descent o f
the presenting part.
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PRETERM LA BO U R
ASSOCIATED FACTORS
There are a num ber o f socioeconom ic factors that increase the risk of
preterm labour. These include:
• U nderw eight m others (<55 kg)
• Chronic m alnutrition
• Sm oking
• High parity
• A m bulant occupation
• Extrem es o f m aternal age.
AETIOLOGY
There are m any factors that have been im plicated in the aetiology of
preterm labour. These may occur in isolation o r in com bination. On
occasion no specific cause is fo und. This is know n as idiopathic preterm
labour. The identifiable causes o f preterm labour include:
• M aternal febrile illness - m aternal infections such as appendicitis,
cholecystitis and b ro n ch o p n eu m o n ia are associated with preterm
labour. H aem atogenous spread o f bacteria to the uterine cavity
can occur and stimulate a cascade o f events that ultim ately leads
to prostaglandin production by the fetal m em branes.
• U rinary tract infections - These are m ore com m on in pregnancy
prim arily because of the short length o f the fem ale urethra and
the muscle relaxant properties o f progesterone. These lend
themselves to colonisation o f the urinary tract. Asymptomatic
bacteriuria, urethritis, cystitis and acute pyelonephritis can ensue.
The m echanism whereby these stim ulate preterm labour is likely
to involve an elem ent o f haem atogenous spread and
prostaglandin production.
• Genital tract infections - The most com m on infection is bacterial
vaginosis. This represents an alteration in the vaginal flora
characterised by a preponderance o f anaerobic bacteria such as
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PRETERM LA BO U R
PREDICTION
Patients at risk o f developing preterm la b o u r sh o u ld have their
pregnancy accurately dated, p referab ly with an early b o o k in g u ltraso u n d
scan. They should be screened fo r asym ptom atic b acteriu ria and vaginal
infections and they should attend the antenatal clinic reg u larly fo r a
review o f sym ptom s and fo r serial cervical ex am in atio n s. C ervical
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PRETERM LA BO U R
exam inations in the presence of intact m em branes have not been found
to be associated with an increase in the rate o f prem ature labour or
infection, but there is controversy as to w hether they are a useful
screening technique for preterm birth in women at average risk. Serial
ultrasound evaluation o f the cervix may be helpful. Cervical shortening
and funnelling on ultrasound scan may be indicative o f pre-term labour.
Fibronectin is a protein that is present in the fetal m em branes. It
may be found in the vaginal secretions o f patients at risk of preterm
labour. U nfortunately a high false positive rate means this is not a good
diagnostic test for preterm labour. However, a negative value means it is
unlikely she will labour.
DIAGNOSIS
A prerequisite for diagnosing preterm labour is that uterine contractions
should last for at least 30 seconds and occur every 10 m inutes or less, for
at least 60 m inutes. By this criterion, the majority o f patients will stop
labour without specific treatm ent apart from bed rest. However, about 25
-50% o f patients with persistent, regular, painful contractions actually
proceed to preterm delivery. Pharm acological inhibition o f labour is
indicated in this latter group o f wom en, but is not justified in all
instances. Other diagnostic criteria include:
• The passage o f a show or operculum .
• A change in cervical findings on serial vaginal
exam inations.
• A change in cervical findings on serial transvaginal
ultrasound evaluations o f the cervix.
• Rupture of the m em branes. This may herald the onset of
labour.
• A positive fetal fibronectin test in the presence o f intact
m em branes. However, as m entioned above this is not a
particularly sensitive test.
M ANAGEM ENT
The patient in preterm labour should be adm itted to hospital for bed rest
preferably in the left-lateral position. Bed rest may have a mechanical
effect by reducing the pressure o f the presenting part on the lower
segment o f the uterus. There is the additional bonus o f an improvement
in uterine perfusion. This is known to allay the intensity and frequency
o f uterine contractions. These measures in conjunction with simple
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PRETERM LABOUR
Tocolysis
At present there is no evidence to suggest that long term tocolysis
im proves neonatal survival. In current practice the role o f tocolysis is to
allow for the adm inistration o f corticosteroids and in-utero transfer to a
unit with neonatal facilities.
A num ber o f pharm acotherapeutic agents have been used. They are
considered in alphabetic order.
Anti-prostaglandins
It is now well established that prostaglandins play an im portant role in
m ediating uterine contractions. They therefore may also be involved in
triggering prem ature labour. It is not surprising then that inhibition of
prostaglandin synthesis has been fo und to be effective in preventing the
onset and progression o f prem ature uterine contractions.
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PRETERM LABOUR
in controlled studies (N iebyl et al, 1979) The dose o f Indom ethacin is 100
mg rectally follow ed by 25 m g orally every 6 hours. Despite prom ising
results, the use o f prostaglandin inhibitors d u ring p regnancy has been
questioned because o f their association with prem ature closure o f the
ductus arteriosus, pulm onary hypertension and h aem orrhagic diathesis in
the neonate.
Atosiban
Atosiban is an oxytocin receptor antagonist. It inhibits uterine activity
and is well tolerated. It is currently the drug o f choice in the U nited
K ingdom and this is largely due to its favourable side effect profile. It
has a short h alf life, is adm inistered intravenously and requires no
specific m onitoring. The main draw back is that the cost o f the d ru g can
be prohibitive.
Beta-adrenergic drugs
B eta-adrenergic receptors are situated on the o u ter surface o f the cell
m em brane in the m yom etrium . W hen they are stim ulated, for exam ple,
by a beta-adrenergic agonist, relaxation o f the uterus ensues. This
occurs because o f the release o f the enzym e adenylcyclase which
catalyses the conversion o f ATP to AM P. AM P then stim ulates the
activity o f a group o f enzym es which are responsible fo r protein
phosphorylation in the cell m em brane, the uptake and sequestration o f
intracellular calcium is increased, intracellular calcium levels fall and the
contractile state o f the m yom etrium is interfered with, resulting in
relaxation.
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PRETERM LA BO U R
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PRETERM LA BO U R
Magnesium Sulphate
M agnesium sulphate exerts its tocolytic effect by interfering with
intracellular calcium form ation. The recom m ended regim e is an
infusion of 20 g M agnesium sulphate in 1 litre 5% D extrose-w ater at a
rate of 7 ml per minute for 1 hour, then 4 ml per m inute for 1 hour,
followed by 2 ml per m inute as a m aintenance dose for approxim ately 12
hours after cessation of uterine contractions. M agnesium sulphate has a
narrow therapeutic index and potential side-effects are m aternal
respiratory depression and cardiac arrest. It is also associated with fetal
academia and significant increases in neonatal m ortality when used in
preterm labour.
Progesterone
Progesterone depresses uterine contractility. It prom otes calcium uptake
by the sarcoplasmic reticulum . C onsequently, intracellular calcium levels
diminish. However, its use in the treatm ent of prem ature labour has been
found to be disappointing. Recently, 17 alpha-hydroxy-progesterone
caproate has been com bined with cortisol, and favourable results have
been reported.
Antibiotic therapy
Routine prophylactic antibiotics are not required in idiopathic preterm
labour in the absence o f m em brane rupture. However, if given after
membrane rupture, prophylactic antibiotics significantly increase the
number of women undelivered after seven days and reduces neonatal
and maternal infection and m orbidity. The Oracle Trial dem onstrated
that:
• E rythrom ycin is the drug o f choice prescribed at 250 mg orally
four times daily for 10 days.
• Co-am oxiclav (A ugm entin) should not be prescribed as it is
associated with an increased incidence of necrotising enterocolitis
in the newborn.
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PRETERM LABOUR
Other organism s isolated on HVS or MSU may also need treating with
appropriate antibiotics.
C erclage
A small proportion o f patients benefit from elective cerclage perform ed
at the end o f the first trim ester. These are patients with cervical
incom petence which as m entioned previously accounts fo r less than 1%
o f all cases o f preterm labour. It m ay be p erform ed vaginally
(S hirodkhar or M cD o n ald ’s techniques) o r transabdom inally (Benson
and D urfee). Cerclage is not beneficial in cases o f preterm lab o u r due to
other causes such as infection, m ultiple pregnancy and polyhydram nios.
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PPROM
AETIOLOGY
The aetiology is similar to that for preterm labour and includes:
• Polyhydram nios.
• Cervical incom petence.
• M ultiple pregnancy.
• Sm oking.
• A deficiency o f copper and ascorbic acid.
• Epidem iological data suggest that sub-clinical infection may
cause an inflam m atory weakening o f the m em branes. There is a
link between recent coitus, histological chorioam nionitis and
PROM. This association becom es impressive when one considers
that the use o f a condom reduces this risk.
• It has been reported that the collagen content o f the am nion
norm ally decreases late in pregnancy. This change occurs at an
earlier gestation in patients with PPROM.
DIAGNOSIS
The patient may com plain of a gush of fluid from the vagina or a small
leak o f fluid or perineal dam pness. Vaginal exam inations should be
avoided. A sterile speculum exam ination can be perform ed to:
• Confirm that liquor is escaping from the cervical canal. A pool of
liquor may be seen in the posterior fornix.
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PPROM
MANAGEMENT
The main principle of m anagem ent is to balance the m orbidity and
m ortality associated with a preterm birth against the risk o f m aternal and
fetal infection. The dilem m a o f leaving the fetus in utero to attain
additional m aturity m ust be balanced against prophylactic induction of
labour to avoid the danger o f fetal sepsis and chorioam nionitis
com pounding the com plications o f prem aturity.
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PPROM
CONCLUSION
Preterm birth is the prim ary cause o f perinatal m orbidity and m ortality.
Complications such as respiratory distress syndrom e, intraventricular
haem orrhage and necrotizing enterocolitis are com m on in preterm
babies. The picture is further com plicated by PPROM. At present our
understanding of the pathogenesis o f preterm labour is deficient and this
has affected the developm ent o f specific therapeutic approaches. For
example, tocolytic therapy is usually initiated after the chain o f events in
uterine contractility is under way. Further research is required to predict
the onset o f preterm labour so that therapy can be instituted at an earlier
juncture.
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PPROM
KEY POINTS
• Preterm labour may be defined as labour
occurring in pregnancies of less than 37 completed
weeks of am enorrhoea.
• The combination of preterm and low birthweight
(less than 1500 gram s) accounts for 75% of all
perinatal morbidity and mortality.
• A negative fetal fibronectin test means it is unlikely
that labour will ensue.
• The mainstay of management is admission to
hospital, bed rest, antenatal corticosteroids
±tocolysis.
• The main function of tocolytics is to allow for the
administration of antenatal corticosteroids and in-
utero transfer.
• Corticosteroids stimulate the production of
surfactant by the Type II pneumocytes in the lungs.
They reduce the incidence of respiratory distress
syndrom e.
• Cerclage may be beneficial in selected patients with
cervical incompetence.
• Prophylactic erythrom ycin, if given after
membrane rupture, improves outcom e.
• PPROM precedes 30% of all cases of preterm
labour. Aim to deliver patients with PPROM at 35
weeks following conservative m anagem ent,
provided there is no indication to deliver prior to
this.
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P O S T -T E R M
CHAPTER TWENTY-TWO
POST-TERM PREGNANCY
DEFINITION
A post-term pregnancy is defined as one that has reached o r gone
beyond 42 com pleted weeks o f gestation i.e. 294 days o r m ore from the
first day of the last m enstrual period. The term “ p o std ates” is confusing
and not well defined; it should be avoided. It can define a pregnancy that
has gone beyond the expected date o f delivery.
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P O S T -T E R M
com pared to 2-3 deaths per 1000 births, for term babies. If the
pregnancy goes beyond 43 weeks, there is a six-fold increase in
m ortality.
Fetal morbidity
The incidence of fetal m acrosom ia is greater in the post-term
pregnancy. This translates to an increased risk o f the com plications o f
shoulder dystocia such as traum atic injuries to the viscera, skeletal
system, nerve palsies and hypoxem ic ischemic encephalopathy. Despite
this, there is no evidence to support routine induction o f labour as a
preventative measure.
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P O S T -T E R M
D IAGNOSIS
The key to diagnosis obviously lies with an accurate recall o f the last
menstrual period and early diagnosis o f pregnancy. Far too often in o u r
setting, this inform ation is not available.
If the patient attends the antenatal clinic in the first trim ester, an
ultrasound can be perform ed to determ ine the crow n-rum p length. In the
second trim ester, the biparietal diam eter and the fem ur length are used
(Table 1).
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PO ST -T E R M
MANAGEMENT
At 41 weeks, as previously stated, induction o f labour should be
considered. There is evidence that there will be a reduction in fetal
m ortality and m aternal m orbidity, when com pared to induction o f labour
at 42 weeks. This is especially so if the cervix is favourable.
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P O S T -T E R M
and stained with m econium . Others may have a peeling, icteric and dry
skin (Figure 1).
295
PO S T -T E R M
Babies with MAS may be sent to the neonatal intensive care unit
to be closely m onitored. Treatm ents may include:
• oxygen therapy by oxygen hood or ventilation
• antibiotics
• use of surfactant
• nitric oxide blood gases
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PO ST -T E R M
K E Y P O IN T S
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IN D U C T IO N O F L A B O U R
CHAPTER TWENTY-THREE
INDUCTION OF LABOUR
DEFINITION
Labour is the process whereby the products o f conception are expelled
after the 28th week of pregnancy through the vaginal route by rhythmic
contractions of the uterus. In the United K ingdom , 24 weeks is used to
define a viable pregnancy. The goal o f induction o f labour is therefore
to achieve a vaginal delivery by stimulating uterine contractions before
the spontaneous onset o f labour.
INDICATIONS
In m odern obstetric practice, induction o f labour is generally undertaken
if the fetal in utero environm ent is deemed to be “ h o s tile ” and there is
no contra-indication to vaginal delivery. One must rem em ber that there
are three options at this time: allow the pregnancy to continue, induce
labour or perform a caesarean section.
The most com m on indications for induction o f labour are:
CONTRAINDICATIONS
Generally, these are contraindications to vaginal delivery and include:
• A m ajor placenta praevia or a vasa praevia
• A bnorm al fetal lie
• Umbilical cord prolapse
• Previous transfundal uterine surgery
• Cephalo-pelvic disproportion
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IN D U C T IO N O F L A B O U R
CERVICAL RIPENING
The m odified Bishop scoring system is generally used to determ ine the
cervix that is unprepared and requires a prim ing agent, as well as the
cervix in which this process has already occurred (Table 1).
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IN D U C T IO N O F L A B O U R
Cervical 3 2 1 <1
Length
(cm)
Station -3 -2 -1 ,0 +1
Membrane sweeping
If the internal os can adm it a finger, the separation of the fetal
m em branes from the lower uterus has been shown to reduce the num ber
of women that will need form al induction o f labour. Prostaglandins are
released by this process.
The m other m ust be advised that the process could be painful and
cause the release o f the operculum (show) resulting in a bloodstained
vaginal loss. There is no increased risk of infection.
Priming agents
An ideal prim ing agent should fulfill the following criteria:
• It must be safe and practical.
• It should not cause m ajor fetal or m aternal effects.
• It must be econom ical.
A variety of m ethods has been used but prostaglandins are the mainstay
of induction o f labour with an unfavourable cervix.
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IN D U C T IO N O F L A B O U R
Prostaglandins
Prostaglandin E2 (PGE2) and synthetic prostaglandin E, (PGE,)
preparations are available. Two PGE2 dinoprostone preparations are
com m only available. A gel containing 1-2 mg and a vaginal pessary
containing 3mg (Prostin® ), or Cervidil®, a slow-release 10 mg
preparation (Figure 1).
O xytocin is only com m enced if m ore than six hours have passed
since the insertion of dinoprostone to reduce the risk of
hyperstim ulation.
M echanical
These are rarely em ployed in our setting. Exam ples include hygroscopic
dilators, osmotic dilators ( L a m i n a r i a j a p o n i c u m ) (Figure 2), the 24-
French Foley Balloon and the double balloon device (Atad Ripener
Device).
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IN D U C T IO N O F L A B O U R
Other M ethods
These include continuous intravenous oxytocin, extra-am niotic saline,
vaginal recom binant hum an relaxin and intracervical purified porcine
relaxin. These are rarely used except for intravenous oxytocin, which is
sometimes used in cases of prelabour rupture o f m em branes with an
unfavourable cervix.
Sexual intercourse, breast stimulation, oestrogens, enemas, warm
baths, steroids, hyaluronidase, acupuncture, m ifepristone and
homeopathic m ethods have not been shown to be as effective as
prostaglandins.
A M N IO T O M Y
Artificial rupture of m em branes may be used as a m ethod o f labour
induction or may be perform ed after the cervix has becom e favourable,
following adm inistration of the prim ing agent. The tim ing of
contractions following am niotom y is very variable and it is
recommended that an oxytocic infusion be com m enced at the same time.
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IN D U C T IO N O F L A B O U R
OXYTOCIN INFUSION
Following preparation o f the cervix and am niotom y, the next phase in
the induction of labour process is the use o f a
Syntocinon® infusion. In general, the myometrium
o f the m ultiparous patient is more sensitive to the
effects of oxytocin than in prim igravidae.
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IN D U C T IO N O F L A B O U R
The m inim um dose possible of oxytocin should be used and this should
be titrated against uterine contractions aiming for a m axim um of three to
four contractions every ten minutes. A dequate contractions may be
established at 12 milliunits per m inute. If higher doses are used the
m axim um dose used should not exceed 32 m illiunits per m inute.
HAZARDS
1. Iatrogenic preterm delivery. This can occur if there is an erro r in
the calculation o f the expected date o f delivery.
2. Fetal distress. U tero-placental insufficiency may occur due to
frequent and intense contractions not allowing time for recovery
o f blood flow.
3. C horioam nionitis. The duration o f rupture of m em branes is
related to the incidence o f ascending infection.
4. U nusual uterine activity:
• H ypertonicity- contractions>90 seconds
• Tachysystole- >5 contractions per 10 minutes
• H yperstim ulation- exaggerated uterine response with late
decelerations.
The oxytocic infusion must be stopped if this occurs.
5. Uterine rupture. Caution should be exercised especially when
used in parous women and those with previous uterine surgery.
6. Precipitate labour.
7. Fluid overload. This can occur especially if doses of more than
40 iu are used per day in isotonic intravenous solutions.
8. Failure of induction and increase in caesarean section rates.
9. Neonatal hyperbilirubinem ia. The m echanism is by oedem a o f
fetal red blood cells that are easily destroyed in the neonatal
period.
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IN D U C T IO N O F L A B O U R
KEY POINTS
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C A E S A R E A N S E C T IO N
OPERATIVE DELIVERY
INTRODUCTION
For the purpose of this chapter the term ‘Operative D elivery' is used to
encompass caesarean section, forceps delivery and vacuum extraction. A
significant proportion o f all deliveries involve operative intervention. In
general, countries with higher operative delivery rates have better
perinatal and maternal m orbidity and m ortality. However, a m ultitude of
factors impact directly on these measures and a favourable outcom e
cannot be solely attributed to intervention.
CAESAREAN SECTION
HISTORICAL BACK GROUND
The origin o f the term ‘caesarean' is obscure, but three main
explanations have been suggested. Firstly, according to legend, Julius
Caesar was delivered in this m anner. This is unlikely because as late as
the 17th century, this operation was invariably fatal. Secondly, in Roman
law, Numa Pompilius (8th century BC) ordered that the procedure be
undertaken in dying women so that the m other and infant could be
buried separately. This law, Tex reg ia’, was eventually renam ed Tex
caesarea’ and the operation itself may have later becom e known as the
caesarean operation. Thirdly, sometime in the M iddle Ages, the word
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C A E S A R E A N S E C T IO N
caesarean was derived from the Latin verb ‘cae d e re ’ (to cut).
Interestingly, the word section is derived from the word ‘s e c o ’ which
also means to cut.
Caesarean delivery was first recom m ended in the living in the
celebrated work o f Francois Rouseet (1581) entitled kTraite N ouveau de
l ’H ysterotom otokie ou L ’Enfantem ent C esarien’ when he reported on 14
successful caesarean deliveries. O f interest, he had never him self
witnessed such a delivery, but his inform ation was collated from
correspondence with friends. A turning point in the alm ost universal
mortality from this operation was achieved by Max Sanger in 1882, when
he recom m ended the suturing o f the uterine incision. This had long
been neglected because o f the false belief that sutures in the uterine
muscle would be harm ful.
Over the years, the operative technique has been refined to reduce
the attendant m orbidity and m ortality. Im portant contributions to the
safety of the procedure have been made by:
• Antibiotic prophylaxis
• Blood transfusion.
• General and regional anaesthesia.
• Lower segm ent deliveries.
• T hrom boprophylaxis.
INCIDENCE
There has been a worldwide trend o f increasing caesarean section rates
over the past few decades. This surge in rates is even m ore alarm ing in
m etropolitan countries where in the United States for exam ple, the rates
have risen from 5.5% in 1970 to 22% in 1994. In the U nited K ingdom ,
the figure rose from 3.1 to 7.5% from 1963 to 1978 and from 11.3% in
1990 to 15.5% in 1995. The incidence currently hovers around 25%.
Figures reported from Trinidad were 2.2% in 1976, 6.6% in 1985 and
9.3% in 1996. Possible explanations for this trend include:-
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C A E S A R E A N S E C T IO N
URGENCY
A num ber of classifications exist that define abdom inal delivery
further based on the urgency with which delivery is required. Below is
the one in current use in the United K ingdom .
GRADE DEFINITION
1) Emergency Immediate threat to life of woman or fetus
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C A E S A R E A N S E C T IO N
INDICATIONS
There are num erous indications for caesarean section delivery but very
few can be considered absolute. The majority o f those listed are relative
indications and it is often a com bination o f factors that guide the
ultimate decision. In this chapter, for sim plicity, we have adopted an
anatomical classification that describes the indications as either maternal
or fetoplacental. We have then discussed failure to progress in labour or
cephalopelvic disproportion separately as this is one of the more
frequent indications and warrants special consideration.
Maternal indications
• Pelvic tum ours. Fibroids in the lower segment and large ovarian
cysts may obstruct labour.
• After m yom ectom y, if the uterine cavity had been entered or
multiple incisions were em ployed.
• Previous caesarean section for a recurrent indication.
• Previous classical caesarean section.
• After vaginal repair operations for bladder descent or stress
incontinence.
• Gross pelvic contraction. This is uncom m on, but can be a result
of nutritional deficiency, trauma and rare inherited disorders.
The patient with sickle cell disease can develop pelvic contracture
as a result of multiple bony infarcts.
• Significant maternal illness where an unfavourable cervix would
imply a long induction to delivery interval. This would include
eclampsia, im pending eclampsia and severe cardiac or respiratory
disease.
• Previous traumatic vaginal delivery which resulted in birth trauma
to the infant, third and fourth degree perineal tears or vaginal
fistula form ation.
• To reduce the vertical transmission o f infections such as human
im m unodeficiency virus in m others with a high viral load, and
prim ary genital herpes that is active in the third trimester.
• M aternal request. Caesarean section is not routinely offered for
maternal request but it can be justified in exceptional
circumstances. It is imperative to explore and discuss the specific
reasons for the request and ensure that the patient is fully
inform ed of the benefits and the risks associated with abdominal
delivery including the implications for subsequent pregnancies.
Consideration should be given to referral for a second opinion
and counselling.
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C A E S A R E A N S E C T IO N
Fetoplacental indications
• Presumed fetal distress:
a) In certain cases, m econium -stained liquor may suggest
fetal distress.
b) C ardiotocographic abnorm alities.
c) A bnorm al scalp blood pH.
d) Severe intra-uterine growth restriction.
• A bnorm al presentation/lie:
a) Oblique lie.
b) Transverse lie.
c) C om pound presentation.
d) Brow/face presentation.
e) Breech (large, prem ature, footling, extended head)
• Fetal m acrosom ia.
• M ultiple pregnancy. When the first twin is non-vertex; if the
first twin has delivered and there is fetal distress in the second
with the cervix not fully dilated; triplets and higher order
multiple gestation.
• Gross fetal anom aly such as hydrocephaly.
• Placenta praevia.
• A bruptio placentae, especially if the cervix is unfavourable,
the bleeding is heavy or there is fetal distress.
• Cord prolapse o r cord presentation.
• Vasa praevia.
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C A E S A R E A N S E C T IO N
PRO CEDURE
Preparation o f the patient
For elective procedures, the m other is adm itted the day prior to surgery.
Inform ed written consent is obtained and she is reviewed by the
anaesthetist who discusses the planned anaesthesia (general, spinal or
epidural). If she has requested sterilisation at the time o f surgery she
should be advised that:
• There is a small failure rate o f 1:250. The failure rate is higher if
the procedure is perform ed at the time o f caesarean section as
opposed to as an interval procedure.
• There is a risk o f ectopic gestation in the event o f failure.
• That the procedure should be considered irreversible.
• There are alternatives such as the L evonorgestrel intrauterine
system and vasectomy which have significantly sm aller failure
rates (1:500 and 1:1000 respectively).
Blood is taken for a full blood count and 2 units o f whole blood are
cross-m atched. Oral ranitidine can be adm inistered on the evening prior
to surgery and oral intake restricted from m idnight. On the m orning of
surgery, she receives a gentle non-abrasive shave o f the pubic hair and an
indwelling Foley catheter is inserted for continuous bladder drainage. If
a neonatal problem is anticipated, the case is discussed with the
neonatologist whose presence may be required at delivery.
O perative procedure
The skin incision
There are two types o f incision that may be em ployed:
• The vertical incision:
The advantages o f this approach are that it allows very rapid entry
into the abdom inal cavity: the incision is easy to extend to allow
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C A E S A R E A N S E C T IO N
There are only a few indications for this type o f incision in present
day practice. These include:
• Lack o f access to the lower segment which may occur as a result
o f fibroids, dense adhesions from previous pelvic surgery, and the
lower segment of the preterm uterus may not be wide enough to
allow atraumatic delivery.
• Postmortem, to save a live fetus.
• Transverse lie (dorso-inferior).
• At an elective caesarean-hysterectom y.
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C A E S A R E A N S E C T IO N
G reen-A rm ytage clamps are then applied to the lateral angles and
the edges o f the lower segm ent incision. These clam ps are particularly
suited for this purpose because they are atraum atic and have a broad
base providing a wide surface area for haem ostasis. The incision is closed
in two layers. The first is the haemostatic layer while the second layer
covers the raw edges o f the first adding tensile strength to the incision.
The visceral and abdom inal peritoneum are repaired after the pelvic
structures are inspected and the abdom inal incision is closed in layers.
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C A E S A R E A N S E C T IO N
Postoperative care
First 24 hours
• Vital signs every 15 minutes for the first hour, every ho u r for the
next four hours and then every fo u r hours for the next 24 hours.
• 3 litres o f intravenous fluids such as norm al saline or
H artm ann’s.
• Input-output charting. The Foley catheter is left on continuous
drainage for 24 hours.
• Analgesia such as Pethidine, 100 mg i.m. every 4 hours for 6
doses.
• Anti-emetics such as D im enhydrinate 50 mg i.m. for 2-3 doses.
• Intravenous broad-spectrum antibiotics are recom m ended as a
single dose as soon as the cord is clam ped to reduce sepsis.
Days 1-3
The operative findings and procedure are explained to the patient. The
records are checked for the vital signs and the input-output chart. A
general exam ination is perform ed with particular em phasis on the
presence o f bowel sounds and signs o f throm boem bolic disease.
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C A E S A R E A N S E C T IO N
COMPLICATIONS
C om plications occur more com m only when the procedure is done as an
em ergency rather than as an elective.
• Anaesthetic com plications will be discussed in m ore detail in the
following chapter. They are increased when general anaesthesia
is used in preference to regional anaesthesia. With general
anaesthesia, M endelson’s syndrom e is the m ost im portant
com plication. This can be reduced by the use o f cricoid pressure
at induction and reducing the pH o f the stomach contents. If it
occurs there is a high m aternal m ortality. Com plications
associated with regional anaesthesia include hypotension,
hypotherm ia, tem porary peripheral nerve dam age and headaches.
• H aem orrhage is the m ost com m on com plication. The gravid
uterus is a vascular organ with a blood flow through the uterine
vessels at term o f 400 to 800 ml/min. Hence the need to ensure
that pre-operatively, the m other is not anaem ic and crossm atched
blood is available. R eactionary haem orrhage can o ccur as a
result of slipped ligatures or oozing from the edges o f the uterine
incision when the blood pressure rises. Secondary haem orrhage
may present 1-2 weeks following the surgery as a result o f post
operative endom etritis.
• Traum a. The bowel, bladder and the uterus are particularly at
risk. Occasionally the fetus may be at risk o f scalpel injury on
m aking the uterine incision.
• Sepsis. Peritonitis can occur, especially in the presence of
chorioam nionitis. Superficial infections occur frequently,
especially with the Pfannenstiel incision which is prone to
haem atom a collection.
• T hrom boem bolism is responsible fo r a significant contribution to
m aternal m ortality. The use o f intra-operative pneum atic calf
com pression devices, early post-operative am bulation, calf
com pression stockings and low m olecular weight heparin is
advocated.
• Paralytic ileus is uncom m on but can occur following
contam ination o f the abdom inal cavity by infected blood and
liquor.
• Respiratory m orbidity in babies born by caesarean section before
labour. The risk decreases after 39 weeks.
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C A E S A R E A N S E C T IO N
Complications of VBAC
Uterine rupture or scar dehiscence can occur. The risk is 0.4% in those
patients with one previous lower segm ent caesarean section who have
laboured spontaneously. Loss o f uterine activity, signs of hypovolaem ic
shock, bright red vaginal bleeding, ascent o f the presenting part out o f
the pelvis, fetal parts easily palpated through the abdom inal wall and an
abnormal cardiotocography are all indicative of uterine rupture. ‘Scar
tenderness’ is a rather loose term , but tenderness in the suprapubic
region should be viewed with suspicion.
CONCLUSION
Caesarean section is a deliberate operative intervention that has
implications for both m other and baby. Patients should be adequately
counselled and advised of all the available options as well as the benefits
and risks. The following is a checklist that can be used to appraise the
patient fully on the benefits and risks o f abdom inal delivery.
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C A E S A R E A N S E C T IO N
Benefits include:
• Reduced incidence o f uterovaginal prolapse.
• Reduced incidence o f urinary incontinence.
• Reduced incidence o f perineal pain.
There is an increased incidence of the following risks after caesarean
section when com pared with a norm al spontaneous vaginal delivery:
• A bdom inal pain
• Bladder injury
• Ureteric injury
• Bowel injury
• Throm boem bolism
• Hysterectomy
• Blood transfusion
• ITU admission
• M aternal death
• Placenta praevia and placenta accreta in subsequent pregnancies
• Uterine rupture in subsequent pregnancies
• Neonatal respiratory m orbidity
KEY POINTS
• The World Health Organisation recommends an
abdominal delivery rate of 10 to 15% . This is not
applicable globally.
• Failure to progress in labour is the most
commonly cited indication.
• The lower segment caesarean section is the most
commonly performed procedure. The risk of
rupture of the uterus in a subsequent pregnancy is
0.4% .
• The classical caesarean section is associated with
significant haemorrhage and is performed for a
few select indications such as a transverse lie with
the fetal back inferior. The risk of rupture of the
uterus in a subsequent pregnancy is 12%.
• The success rate of VB AC is 80% .
• Neonatal respiratory morbidity is a potential
complication if abdominal delivery takes place
prior to the onset of labour. The risk decreases
after 39 weeks.
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FORCEPS
OBSTETRIC FORCEPS
INTRODUCTION
Peter C ham berlen, a French H uguenot and “ b arber su rg e o n ” , designed
the precursor to the m odern forceps in the late 16th century. There have
since been a num ber of m odifications resulting in the instrum ents used
in contem porary clinical practice. Despite these m odifications the most
im portant factor for a successful outcom e rem ains the o p e ra to r’s skill
and familiarity with the instrum ent of choice. With this in m ind a
profound appreciation o f this topic is imperative.
The subject is considered under the following headings:-
• Incidence.
• Types o f forceps.
• Indications.
• Conditions which must apply prior to application.
• M ethod of delivery.
• Com plications.
INCIDENCE
There is wide international variation in the recourse to instrum ental
delivery. In general, the incidence has been found to be higher in centres
with higher epidural rates. The instrum ental delivery rate in the United
K ingdom is 10% of which 40% are forceps deliveries. The failure rate is
in the region o f 2-10% .
TYPES OF FORCEPS
The basic instrum ent consists o f three parts:-
• the blade.
• the shank
• the handle
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FORCEPS
The blades are curved to fit the fetal head, the cephalic curve. Some
instruments are curved to fit the curve o f the birth canal, the pelvic
curve. The short W rigley's forceps, used to deliver the head at the time
o f a Caesarean section, has no pelvic curve. Forceps can be classified into
two broad subgroups:-
• Midcavity forceps.
• Outlet forceps.
M idcavity forceps
These are applied when the head is at the level of the ischial spines or
below. There are many different types:
• Simpsons forceps
These are midcavity traction forceps with a sturdy fram e, a long
shank and a m arked pelvic curvature. See Figure 1.
• Neville B arnes' forceps
These are midcavity traction forceps, which may also be used for
delivery o f the aftercom ing head o f the breech.
• K ielland's forceps
These forceps are designed for both traction and rotation o f the
fetal head and
are especially
useful in
instances of
deep transverse
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FORCEPS
Outlet forceps
• Pipers forceps
• These instrum ents are now practically obsolete. They were
designed specifically to control the delivery and m aintain the
flexion o f the aftercom ing head o f the breech. This provides
protection for the head during its descent and minimises the
effects of the sudden pressure change. The distinguishing feature
o f the P ip e r’s forceps is the m arked curvature o f the shank.
• Wriglev ’s forceps
W rigley’s forceps perm it delivery when the fetal head is below
the level of the ischial spines. It can be applied easily and
painlessly. A m odicum o f traction is required and it is
distinguished by its light fram e and short shank.
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FORCEPS
INDICATIONS
Instrum ental vaginal delivery should be em barked upon only when a
valid indication exists for expediting delivery o f the baby. There are few
absolute indications and the decision is usually based on several factors.
M aternal indications include the following:-
• M aternal illness requiring a short second stage, for exam ple,
cardiac disease which may limit m aternal effort, pre-eclam psia
and eclampsia.
• M aternal distress.
• Prolonged second stage or failure to progress in the second stage
o f labour. That is, the second stage o f labour has exceeded one
hour in the prim igravida or 30 minutes in the m ultigravida. This
may be due to a m yriad of factors such as persistent occipito-
posterior, deep transverse arrest or ineffective uterine
contractions.
Fetal indications include:-
• Fetal distress.
• Prem aturity.
• The aftercom ing head o f the breech.
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FORCEPS
METHOD OF DELIVERY
Traction Forceps
The instrument should be assembled and checked to ensure that the
blades are com plem entary. Traction forceps are designed to fit laterally
on the fetal head. The left hand blade is usually inserted first and the
process of insertion com m ences with the instrum ent parallel to the
inguinal ligament on the contralateral side. It is slid to its position,
following the pelvic curvature; along the palm and fingers o f the right
hand which are protecting the vaginal mucosa. The process is then
repeated for the right hand blade. Once inserted the blades should lock
easily. Never force them into position. Instead, extract the blades,
recheck the position and repeat the process of application.
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FORCEPS
Rotational forceps
The K iellan d ’s forceps is typically used when the saggital suture is in the
transverse plane. The blades are designed to be inserted anterior and
posterior to the fetal head. The right hand is inserted into the vagina with
the fingers anterior to the fetal head. T he an terio r blade is grasped with
the left hand and application com m ences with the instrum ent below the
perineum in the vertical plane. It is slid along the palm and fingers of
the right hand to nestle above the fetal head. T his is the direct technique
o f insertion. O ccasionally insertion by this m eans is not possible and
one can attem pt the ‘w a n d erin g ' tech n iq u e. The anterior blade is
inserted laterally as described fo r the left blade o f the traction forceps. It
is then gently encouraged into position by w andering over the fetal face.
Due care needs to be taken to avoid injury to the pelvic structures.
C O M PLIC A TIO NS
M uch controversy has surrounded forceps since their inception, yet they
have continued to com m and an im portant role in O bstetrics. This is
m ainly due to the significant reduction in m aternal m orbidity and
neonatal asphyxia associated with ap p ro p riate forceps delivery.
Caesarean section, as an alternative, is associated with a h ig h er maternal
m orbidity and m ortality.
M aternal:
• Perineal tears. These are alm ost inevitable with the K ielland’s
forceps. There may be co m prom ise o f the anal sphincter and
extension into the anal canal and rectum .
• V aginal tears. Lateral vaginal wall tears can bleed profusely and
need careful attention. Posterior vaginal wall tears m ay extend
into the rectum , which is in direct relation to its m iddle one-third
o f the vagina.
• Cervical tears. May extend into the uterus. It must be em phasised
that forceps m ust never be used if the cervix is not fully dilated.
To do so, even with a rim o f cervix, is to invite disaster.
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FORCEPS
Fetal:
• Facial nerve palsies.
• Scalp injuries - including lacerations and crush injuries.
• C ephalhaem atom a
• Intracranial haem orrhage
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FORCEPS
KEY POINTS
• The blade, the shank and the handles are the three parts
of the forceps. The blade has both a pelvic and a
cephalic curvature.
• The Neville Barnes forceps is a m idcavity traction
forceps which may also be used for delivery of the
aftercoming head of the breech.
• The K ielland’s forceps can correct asynclytism , effect
rotation and provide traction.
• High risk deliveries such as those in which the progress
of labour has been slow from a dilatation o f 7 cm
should be conducted in the operating theatre.
• There is the potential for shoulder dystocia with all
instrumental deliveries. Senior staff should therefore be
present and prepared to deal with this obstetric
em ergency.
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VACUUM
VACUUM EXTRACTION
INTRODUCTION
The vacuum extractor or ventouse is a w onderfully simple device that has
been touted by many authors as a superior alternative to the forceps.
This is a m oot point and both instruments deserve equal consideration.
The ventouse provides traction and allows rotation o f the fetal head
in conjunction with maternal effort and can be perform ed with relatively
simple analgesia, such as perineal infiltration with local anaesthetic or a
pudendal block. Failure rates are decidedly higher than with the forceps
and are in the region o f 10-20%.
INCIDENCE
As m entioned previously, there is wide international variation in the
recourse to instrum ental delivery as a whole. The choice of ventouse as
opposed to forceps is operator dependent and varies from centre to
centre.
TYPES
The basic instrum ent is dem onstrated below. Many different types exist
with subtle variations on a com m on theme.
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VACUUM
• Silc cup
This is a silastic device best applied when easy delivery is
expected and the following conditions apply; the head is in the
occipito-anterior position, well flexed vertex presentation, no
caput and an average sized baby is expected.
• Bird anterior cup
This is a metal cup that is applied when a more difficult delivery
is anticipated. There may be caput. The head is well flexed and
in the occipito-anterior position.
• Bird posterior cup
This is a metal cup that may be used when the head is deflexed
and in the occipito-posterior position
• The Kiwi cup
This is a hand-held device. The vacuum is established by a pum p
that is built into the handle.
METHOD OF DELIVERY
As with forceps, ventouse delivery is conducted with the patient in the
lithotom y position. The m em branes should be ruptured and the position
o f the occiput known.
• Always apply the largest cup possible.
• This should be positioned over the vertex.
• The vacuum is initially built up to 0.2 kg/cm2 and a digital
exam ination perform ed to exclude entrapm ent o f vaginal and
cervical tissue.
• The vacuum is then built up to 0.8 kg/cm2 over 1-2 m inutes.
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VACUUM
INDICATIONS
These are basically the same as for forceps delivery. However, ventouse
extraction may be perform ed before full dilatation o f the cervix (> 8 cm)
in an em ergency and is safer for delivery o f the second twin. Fetal
distress in the late second stage o f labour is a classic indication fo r the
ventouse.
AD V A NTA G ES
• Reduced maternal m orbidity. Usually there are fewer birth canal
injuries with the ventouse. This is mainly due to the fact that the
ventouse occupies less space. However, cervical lacerations are a
distinct possibility.
• Recourse to general and regional anaesthesia is less likely to be
used with ventouse delivery.
• Can be used to facilitate rotation o f the head which means
avoidance of more pernicious instrum ents such as the K iellan d 's
forceps.
DISADVANTAG ES
• The application-to-delivery interval tends to be lo n g er with the
ventouse than with the forceps.
• High failure rate - 10-20% com pared with 2-10% for forceps.
The m ethod is considered a failure when the cup has slipped on
three occasions, there is no descent following three traction
efforts or delivery has not occurred after five traction efforts.
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VACUUM
CONCLUSION
In sum m ary, instrum ental delivery is an essential elem ent of Obstetric
care. Familiarity with the options is m andatory and the trainee should
acquire the necessary skill in order to achieve an appropriate
instrum ental delivery.
KEY POINTS
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A N A L G E S IA A N D A N A E S T H E S IA
INTRODUCTION
There is no doubt that the field o f obstetric anaesthesia has grown in the
past 30 years and is likely to expand even further as m ore high risk
patients becom e pregnant and caesarean section rates increase. This has
led to dedicated 24-hour obstetric anaesthetic input for provision of
epidural analgesia fo r labour and anaesthesia for operative delivery.
OBSTETRIC ANALGESIA
Analgesia improves the morale o f the patient but it is not solely
important for maternal satisfaction, since this may be influenced by other
factors such as outcom e o f labour, support from a partner or midwife,
interaction with staff and having control over pain rather than its
amelioration.
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LAM AZE
The psychoprophylactic method of Lamaze relies on positive
conditioning and patient education regarding the process o f childbirth
based on the belief that pain o f labour and delivery can be suppressed by
re-organisation of the cerebro-cortical activity. C onditioned pain
reflexes associated with uterine contraction and perineal distension can
be replaced by a ‘positive’ conditioned reflex. For exam ple, the patient
is thought to respond to the beginning o f a contraction by immediately
taking a deep ‘cleansing b reath ’ gently exhaling and breathing in a
specific shallow pattern until the contraction ends. She also focuses her
eyes on a specific object or location away from herself. She concentrates
on the release o f muscle tension, maintains the proper breathing rhythm
and listens to the reassuring words o f her instructor. The increased
concentration required by these activities distracts from or inhibits the
painful sensation associated with uterine contractions.
TENS
Electrical impulses applied to the skin o f the back via electrodes from a
battery powered stim ulator known as an ‘obstetric p u lsar’, m odulate the
transmission o f pain by closing a ‘g a te ’ in the dorsal horn o f the spinal
cord. The effect is similar to massage of the lower back, stimulating the
body to produce its own natural pain killers, endorphins. It lessens the
pain for m any, but not all, women.
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A N A L G E S IA A N D A N A E S T H E S IA
ENTONOX®
The gas mixture o f 50% oxygen and 50% nitrous oxide is stored in blue
cylinders under pressure and delivered to the patient via a dem and valve,
a tubing and a face mask or m outh piece.
OPIOIDS
Pethidine is the most widely used opioid in labour and can be given by
midwives in a dose of 1mg/kg (m axim um 150mg IM ). It lasts about 3
hours. It causes sedation and induces a feeling o f disorientation which
may make pain tolerable. M aternal gastric em ptying is reduced and it
may induce nausea and vomiting. An anti-emetic should be
administered as well. M aternal and neonatal respiratory depression are
recognized side effects. N aloxone 10 microgram s/kg reverses neonatal
respiratory depression. The lack o f efficacy o f pethidine as an analgesic
has prom pted investigation into the use o f other opioids. O f interest,
patient controlled analgesia, PCA, using rem ifentanil, an ultrashort acting
opioid which does not accum ulate, has the benefit o f giving the
parturient some degree of control. It is also advantageous in patients
where epidural analgesia is contraindicated e.g. coagulopathy. However,
it still may not give com plete pain relief and requires close m aternal and
fetal supervision as large studies are needed to ascertain the ideal dose.
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A N A L G E S IA A N D A N A E S T H E S IA
REG IO N A L A N A LG ESIA
Ovarian plexus
F ig u r e 1
D uring the first stage o f labour, pain is due to uterine contractions and
dilatation o f the cervix. Pain originating from the uterus is transm itted
via visceral afferent fibres accom panying the sym pathetic nerves and
enters the spinal cord at T10, T i l , T12 and L I . Some fibres travel via
the ovarian plexus from where they are distributed m ainly to the fundus
(fig 1). The pain resulting from the distension o f the birth canal and
perineum during the second stage o f labour is conveyed by the afferent
fibres o f the posterior roots o f S2, S3, and S4.
The spinal cord usually ends at the level o f L I in adults while the dural
sac ends at S2 (fig 2). The epidural space extends from the foram en
m agnum superiorly to the sacral hiatus caudally. It is a cylindrical space
bounded internally by the dura m ater and externally by the periosteum
o f the vertebral bodes anteriorly, ligam entum flavum posteriorly and the
intervertebral foram ina laterally.
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A N A L G E S IA A N D A N A E S T H E S IA
Posterior
longitudinal Dura
ligament
Spinal cord
Ligamentum flavum
— Interspinous ligament
Supraspirous ligament
Epidural space
Vertebral bodies
Subcutaneous tissue
F ig u r e 2
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A N A L G E S IA A N D A N A E S T H E S IA
TECHNIQUE
Resuscitation equipm ent and an oxygen source should be available and
the blood pressure m onitored. A 16G intravenous cannula is inserted
and 1 litre R inger’s lactate solution attached for easy bolus
administration if hypotension should occur by sym pathetic blockade.
The patient may be sitting or in the lateral position with the back flexed
and in line with the edge of the trolley. An aseptic technique is used and
the L3 - L4 interspace is infiltrated with 1 ml local anaesthetic.
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A N A L G E S IA A N D A N A E S T H E S IA
Ligamentum flavum
Figure 3
Fig. 3 shows that the epidural needle - 16G Tuohy -passes through the
skin, subcutaneous tissue, supraspinous ligam ent, interspinous ligam ent
and ligam entum flavum in to the epidural space. The anatom ical
landm ark is the space above the line between the left and right iliac crest
which crosses the L4 vertebra.
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A N A L G E S IA A N D A N A E S T H E S IA
PROBLEMS
• Inability to site the epidural.
• ‘Patchy B lock’ or missed segm ent. Re-siting and avoidance o f
inserting more than 4 cm o f catheter into the epidural space may
be helpful.
• Bloody tap with needle and cannula. The needle should be re
sited.
• Dural tap. 85% of women will develop a severe postural
headache caused by leakage of CSF. Each unit should have a
plan of action for inadvertent dural tap. The occurrence of a
dural tap must be docum ented and the anaesthetist must decide
whether to use the catheter for a continuous spinal technique or
whether to resite the epidural. It is no longer advocated that the
parturient should have an elective assisted delivery. But the
second stage should not be prolonged as the chances o f CSF
leakage are increased thereby making post-dural puncture
headache more likely. The definitive treatment is a ‘blood
p atch ’ - an epidural injection of 20 ml o f autologous blood -
best undertaken at 24 - 48 hours post delivery.
COM PLICATIONS
• H ypotension M anagem ent follows the ‘A B C ’ o f resuscitation
approach with relief of aorto-caval com pression.
• Local anaesthetic toxicity. Unintentional injection of local
anaesthetic into the epidural vein may cause sym ptom s and signs
o f toxicity due to high concentrations of local anaesthetic in the
CNS (table 1). The m axim um recom m ended dose of Lignocaine
is 3 mg/kg and Bupivacaine is 2 mg/kg.
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A N A L G E S IA A N D A N A E S T H E S IA
TEC H N IQ U E
The patient is placed in the supine position and aseptic routine is
followed. A needle with a blunt outer guard is used. The guard is
pressed into the lateral fornix, the needle is advanced to 1 cm , and after
ensuring that no blood is aspirated, an injection o f 5 - 10 ml o f 0.25%
Bupivacaine is given. The procedure is repeated on the other side.
Injections are usually made at 3 and 9 o ’clock positions, but they may
be made at 4 and 8 o ’clock positions to reduce the risk o f injection in to
the uterine artery (uterosacral block).
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A N A L G E S IA A N D A N A E S T H E S IA
COM PLICATIO NS
• Fetal bradycardia
• Injection into the uterine artery
• Injection into the fetus
• Overdosage
• Infection
• Laceration o f the vagina
TECHNIQUE
The transvaginal approach
The patient is placed in the lithotom y position and an aseptic procedure
is observed. A guarded needle o f the type used in paracervical block is
placed along the second and third fingers o f one hand and introduced
carefully into the vagina. The ischial spine is palpated with the tip o f the
fingers and the needle is advanced th ro u g h the vaginal wall, im m ediately
behind the ischial spine to a depth o f about 1.25 cm.
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A N A L G E S IA A N D A N A E S T H E S IA
For elective Caesarean section, fasting intervals of 6 hours for food and 2
hours for fluids (tea/coffee with semi-skimmed milk or fruit squash) are
appropriate. Ranitidine 150 mg should be prescribed 2 hours before an
elective operation and adm inistered 8 hourly to women in labour with
risk factors for Caesarean section to reduce gastric acid secretion. The
administration of a non-particulate antacid, e.g. 30m l sodium citrate,
immediately before every Caesarean section is necessary. The risk of
aspiration not only is possible during general anaesthesia but also if
protective airway reflexes are obtunded in the event o f a very high
regional block.
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A N A L G E S IA A N D A N A E S T H E S IA
Before any anaesthetic, all equipm ent must be checked including suction,
laryngoscopes and endotracheal tubes as well as drugs for induction o f
anaesthesia and em ergency drugs. A 16G intravenous cannula must be
inserted with a litre o f R in g er's lactate attached.
REGIONAL ANAESTHESIA
Single-shot spinal anaesthesia
With the advent of pencil-point tip needles, 24G Sprotte and 25G
Whitacre, the incidence o f post dural puncture headache (PDPH) has
been lowered due to loss o f leakage o f CSF, making single-shot spinal
anaesthesia the most popular technique for operative delivery.
Epidural Anaesthesia
The quality of an epidural anaesthetic is generally poorer than a spinal
anaesthetic, though it still may be desirable when gradual establishm ent
o f a block is necessary to minimize hypotension.
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A N A L G E S IA A N D A N A E S T H E S IA
GENERAL ANAESTHESIA
General anaesthesia is preferable to a regional technique in the following
circumstances:
With the patient supine and a wedge in place, the ECG, non-
invasive blood pressure and pulse oxim eter m onitors are attached to the
patient.
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A N A L G E S IA A N D A N A E S T H E S IA
KEY POINTS
344
IN F E C T IO N S IN P R E G N A N C Y
INFECTIONS IN PREGNANCY
INTRODUCTION
Infections occur quite often in pregnancy and in many cases pose a
serious threat to the m other and fetus. M aternal predilection to infection
is increased in pregnancy for a num ber o f reasons. Firstly, pregnancy is
a state of relative im m unocom prom ise due to the high levels o f steroids
(both corticosteroids and sex steroid horm ones), which are necessary to
obtund the maternal im m une response to fetal antigens and the invading
trophoblast. Secondly, a num ber o f anatom ical changes occur in
pregnancies that lend themselves to an increased susceptibility to
infection. For exam ple, urinary tract infections are m ore com m on in
pregnancy because o f the com bination of an inherently short urethra
and the stasis o f urine that results from the smooth muscle relaxation o f
the urinary tract by progesterone.
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I N F E C T I O N S IN P R E G N A N C Y
TOXOPLASM OSIS
This is caused by a unicellular protozoan, T o x o p la s m a g o n d i i. The
parasite can infect almost any living animal and is usually contracted by
hum ans from ingestion o f raw meat or contact with cat faeces. While
most infected persons have no sym ptom s, pregnant women and
im m unocom prom ised persons can develop serious problem s from this
parasite. In one study antibodies to toxoplasm a were found in 46% of
urban and 58% rural Jam aican youth (Rawlings et al 1989).
The sym ptom s o f toxoplasm osis are usually vague, often
presenting as a mild flu-like illness. O cular toxoplasm osis may present
with blurred vision and all pregnant women with abnorm al eye
com plaints should be referred to the ophthalm ologist for further
evaluation.
Diagnosis relies on the detection o f antibodies to T o x o p la s m a
g o n d i i in the m aternal serum. The most reliable o f these investigations is
the Sabin-Feldm an dye test. Other serologic tests including the indirect
haem agglutination test, the latex agglutination test, m odified
agglutination test, and the enzym e-linked im m unoadsorbent assay
(ELISA), offer some advantages. For exam ple, agglutination tests are
easy to perform . Serologic evidence of an acute acquired infection is
obtained when antibody titres rise by a factor o f 4 to 16 in serum taken 2
to 4 weeks after the initial serum collection, or when specific IgM
antibody is detected.
Pregnant women, who acquire the parasite for the first time just
prior to or in early pregnancy, can pass it to their neonate and this can
cause serious neonatal ocular or brain dam age. Intra-cerebral
calcifications on ultrasonography in the fetus or on com puterised
tom ography (CT) (caudate nucleus choroids plexus and sub-ependym al
region o f the brain) in a neonate is suggestive o f T. g o n d i i infection. The
hallmarks of congenital toxoplasm osis are intracerebral calcifications,
hydrocephalus and chorioretinitis.
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I N F E C T I O N S IN P R E G N A N C Y
RUBELLA
This is a measles-like illness (also called G erm an measles) which is very
com m on and usually of a benign nature except in early pregnancy when
it can cause serious congenital m alform ations and even perinatal death.
Most people who develop rubella have slight flu-like sym ptom s
and a rash, which is not easy to distinguish from measles. Rubella is
caused by the rubella RNA virus ( R u b iv ir u s ). The first visible sign of
rubella is a fine red rash that begins on the face and rapidly moves
downward to cover the whole body within 24 hours. The rash lasts about
three days, which is why rubella is sometimes called the three-day
measles. A low fever and swollen lym ph nodes, especially pre-auricular
and neck (cervical), often accom pany the rash. Joint pain and swelling
can occur and this may linger for a week or two. It is quite com m on to
get rubella and not show any sym ptom s (subclinical infection). M ost
people recover fully with no com plications.
The risk o f birth defects falls after the first trimester, and is rare
by week 20. In a study done in Jamaica in 1988, 22% o f children with
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IN F E C T IO N S IN P R E G N A N C Y
Figure 1
Number of reported congenital rubella syndrom e (C R S) cases versus
percentage of women seropositive for rubella antibodies in Jam aica
1972 to 1998 (adapted from King 1972, B a x terl9 8 6 and W vnter et al
1999)
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IN F E C T IO N S IN P R E G N A N C Y
CYTOM EGALOVIRUS
Cytom egalovirus (CMV) is a m em ber o f the herpes virus fam ily (DNA
viruses). It is the virus most frequently passed on to babies during
pregnancy and can cause hearing loss and other problem s in children
who contract it in utero.
A bout 1 to 3 percent o f women get CMV for the first time whilst
pregnant, and the chance o f passing the infection to the baby is much
higher (about 30%). These babies also have a m uch higher chance o f
developing serious com plications. A bout 80 to 90 percent o f babies who
get CMV this way develop problem s such as hearing or vision loss,
mental retardation, and coordination difficulties within their first few
years. Even infected babies who seem healthy at birth can develop
problem s later, most com m only hearing loss.
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I N F E C T I O N S IN P R E G N A N C Y
most babies who contract CMV during birth or from breast milk develop
few or no sym ptom s, so the benefits o f vaginal delivery and
breastfeeding outweigh any risks for women with CMV infection. CMV
may also cause intra-cerebral calcifications on CT scan o f the neonate or
infant.
In many cases the patient has recurrent outbreaks after the initial
infection. These recurrent attacks occur more com m only if the person is
im m unocom prom ised or if the individual has an intercurrent illness such
as a com m on cold or the flu (hence the term cold sore). Some women
tend to get outbreaks at the time o f m enstruation o r if they are under
stress. A fter the first herpes infection, the virus can lie dorm ant without
causing any sym ptom s for some time. The virus rem ains in the ganglion
o f a cutaneous nerve and m igrates down the nerve when the im m une
system of the individual is stressed. The infection results in tingling and
num bness, then a blister occurs which then form s a crust. The regional
nodes may becom e swollen tem porarily.
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IN F E C T IO N S IN P R E G N A N C Y
A m other who has active genital herpes can pass the infection on
to her newborn, if she delivers the baby vaginally. She should be
delivered by caesarean section. If the lesions are noted after the
m em branes have been ruptured for more than six hours, a caesarean
section may not prevent m other to child transmission o f the virus.
Prophylaxis with antiviral agents- acyclovir or valacyclovir in the last 4-6
weeks of pregnancy and during delivery may be valuable in preventing
neonatal infection.
SYPHILIS
Syphilis is a com m unicable disease caused by T r e p o n e m a p a l l i d u m ,
which belongs to the Spirochaetaceae fam ily. When untreated, syphilis is
a lifelong infection that progresses through three characteristic clinical
stages. After initial invasion through m ucous m em branes or skin, the
organism multiplies rapidly and disseminates widely. The organism
spreads through the perivascular lym phatics and then the systemic
circulation before clinical developm ent o f the prim ary lesion. The
prim ary lesion, containing infectious treponem es, occurs within hours
after infection and persists throughout prim ary and secondary disease.
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I N F E C T I O N S IN P R E G N A N C Y
Most affected infants are asym ptom atic at birth and are identified
only by routine prenatal screening. If untreated, sym ptom s develop
within weeks or m onths. The typical stillborn o r highly sym ptom atic
newborn is born prem aturely with an enlarged liver and spleen, skeletal
involvement, and often pneum onia and bullous skin lesions.
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IN F E C T IO N S IN P R E G N A N C Y
353
IN F E C T IO N S IN P R E G N A N C Y
LISTERIA M ONOCYTOGENES
L iste ria m o n o c y to g e n e s is a gram -positive non-spore form ing rod, which
has been known to cause hum an disease for many years. They are
ubiquitous in the environm ent and found worldwide. They are not
highly pathogenic to healthy adults, however, pregnant women, neonates,
the elderly and the im m unocom prom ised are at particular risk and
disease in these groups can be severe.
The bacterium has been isolated from a range o f raw foods
including vegetables and uncooked meats as well as processed foods. A
wide range of food products have been implicated in outbreaks
including soft cheeses and meat based pates. The bacterium is also
com m only carried in the human gut in about 1-10% o f people.
While m aternal infections can be asym ptom atic, it may cause a
flu-like illness or m eningo-encephalitis/septicaem ia and spontaneous
miscarriage or stillbirth. When listeria m eningitis occurs, the overall
mortality may be as high as 70%; mortality from septicemia is about
50% and from perinatal/neonatal infections greater than 80%.
The majority o f cases are believed to be food borne and its ability
to grow at a great range of tem peratures makes it particularly dangerous
as refrigeration and heating may not denature it. Some cases occur by
direct contact with animals. M other to fetus transfer in utero or during
birth, or via person-to-person spread between infants shortly after
delivery are possible routes of perinatal infection.
Diagnosis is made by culture o f the bacterium from blood or
cerebrospinal fluid. Successful treatm ent with parenteral penicillin or
ampicillin has been reported. T rim ethoprim -sulfam ethoxazole has been
shown effective in patients allergic to penicillin.
BRUCELLA ABORTUS
B r u c e lla are very small, gram -negative coccobacilli that cause a zoonosis
called brucellosis. Sym ptom s of brucellosis include fluctuating fever,
chills, sweating, headache, muscle pain, and weight loss. One species of
B r u c e lla , called B . a b o r tu s infects the placenta and fetus o f gestating
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IN F E C T IO N S IN P R E G N A N C Y
cows and causes the fetus to m iscarry. When hum ans are infected by this
organism they develop a severe fever, but do not m iscarry.
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I N F E C T I O N S IN P R E G N A N C Y
In sym ptom atic patients treatm ent may com m ence em pirically
with antibiotics such as penicillins or cephalosporins depending on
regional sensitivity patterns. A dequate analgesia should be prescribed
and liberal fluid intake encouraged. Lower urinary tract infections can
be treated satisfactorily on an outpatient basis with oral m edication.
However, patients with pyelonephritis may be constitutionally unwell and
the attendant vomiting means these patients may require admission for
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IN F E C T I O N S IN P R E G N A N C Y
PERIODONTAL DISEASE
There have been several studies, which have linked dental caries and
gingivitis to perinatal problem s. The offending organism is usually
P o r p h y r o m o n a s g in g iv a lis . These studies have linked periodontal disease
with preterm labour, growth restriction and even pre-eclam psia.
Im proving dental hygiene has been reported to reduce these problem s.
VAGINAL INFECTIONS
Bacterial vaginosis results from an im balance o f the norm al vaginal
flora with an overgrowth o f anaerobic bacteria and a lack o f the norm al
lactobacillary flora. D uring pregnancy it is associated with poor perinatal
outcom e and, in particular, preterm birth.
357
I N F E C T I O N S IN P R E G N A N C Y
358
IN F E C T IO N S IN P R E G N A N C Y
M any authors have shown that HPV infections tend to get worse
in pregnancy and regress after. This is as a result o f the relative
im m unocom prom ised state o f pregnant women. Thus multiple
pregnancies are believed to be a risk factor for persistent HPV infection
and the developm ent o f intra-epithelial neoplasia and cancer of the
vulval vagina and cervix.
359
IN F E C T IO N S IN P R E G N A N C Y
H U M A N IM M UNODEFICIENCY VIRUS
Over 40 m illion people worldwide are infected with H IV . U nlike
m any sexually transm itted diseases the num bers continue to rise as this
disease is incurable and there is no vaccine. In the C aribbean some
countries have rates, which are very high second only to Sub Saharan
A frica. AIDS is now the leading cause o f death am ong y o ung adults 15-
44 years old in the C aribbean. Unlike sub Saharan A frica where rates are
uniform ly high in m ost countries because o f land borders, in the
C aribbean the rates are not hom ogenously high and we m ust be careful
not to stigmatise all countries when we quote this problem as a C aribbean
problem . The highest rates are 6.1% in Haiti, 3.5% in the B aham as, 2.7%
in G uyana, 2.5% in D om inican R epublic and T rinidad and T o b ag o ,
1.2% in B arbados and Jamaica and less than 1% fo r m ost Eastern
C aribbean countries and Cuba (Figueroa 2 0 03). A rate o f less than 1% is
similar to most developed countries in N orth A m erica and E urope and in
some o f these countries there are higher rates in pockets o f the
population especially in Eastern E urope.
360
IN F E C T IO N S IN P R E G N A N C Y
Neonates who are at risk are also given anti retroviral therapy
nevirapine suspension soon after birth. Caesarean section is an option
especially in women with high viral loads and low CD4 counts. Providers
should practice universal safe practices when dealing with all patients
(regardless of known HIV status), as there have been reports o f health
care workers becom ing infected from needle stick injuries or contact
with infected body fluids in the eyes or cuts on the hand.
HEPATITIS
There are several viruses that can cause Hepatitis in hum ans. The most
im portant in pregnancy is Hepatitis B. Hepatitis C also has obstetric
361
I N F E C T I O N S IN P R E G N A N C Y
SCREENING
The introduction o f screening for infections in pregnancy has now
becom e an im portant part o f obstetric m anagem ent. Serological tests for
Syphilis and HIV are standard in most obstetric units. Tests for
antibodies to rubella and antigenic testing for Hepatitis B are also highly
recom m ended. Screening for BV, GBS, G onoccoccus and C hlam ydia is
also done routinely in some units. A mid stream urine looking for
asymptomatic bacteruria is recom m ended by some as m andatory in all
pregnant women. The main limiting factor to these recom m endations is
cost and most countries cannot institute universal screening fo r all o f
these conditions. However, where they are used the providers are better
able to recom m end vaccination where applicable (for future
pregnancies) or prophylactic antim icrobials for the prevention o f
m orbidity and m ortality in the m other and her baby in the present
pregnancy. This approach results in significant long term saving with
reduced hospitaliation and in some cases prevention of rehabilitation and
institutionalisation of children with serious birth defects.
362
I N F E C T I O N S IN P R E G N A N C Y
KEY POINTS
363
P U E R P E R IU M
THE PUERPERIUM
LACTATION
THE PUERPERIUM
The puerperium refers to the period following childbirth during which
the various anatom ical and physiological changes that occurred during
pregnancy revert back to the pre-pregnancy state. The duration is
typically six weeks. The process o f involution occurs exponentially, the
rate is most rapid in the first two weeks and then m ore gradual in the
subsequent weeks. Some changes such as stretch m arks can be
perm anent.
A N A TO M IC A L CH A N G ES
U te r in e in v o lu tio n
This is the process w hereby the postpartum uterus, which weighs 1kg,
reverts to its pre-pregnancy state o f less than lOOg. Im m ediately
following delivery the fundus o f the uterus is just palpable above the
um bilicus but by two weeks postpartum it is at the level o f the sym physis
pubis. Involution occurs by a process o f autolysis. The b y-products are
absorbed through the bloodstream and excreted in the urine. This
process is more rapid in women who breastfeed.
L o c h ia
Following the expulsion o f the placenta the decidua sloughs as a result o f
necrosis. M ost o f it as part o f the lochia. Initially this is dull red in colour
and by the end o f the second week it becom es reddish-brow n and then
yellowish and disappears by the 4-6 weeks after delivery. Persistent red
lochia suggests delayed involution. This could be due to infection or
retained placental tissue. Occasionally red lochia may occur during
breastfeeding.
364
P U E R P E R IU M
Cervix
The cervix is very flaccid, oedem atous, irregular and bruised
im m ediately following delivery. Small cervical lacerations are frequent
and require little attention unless bleeding. The internal os rem ains
patent until the second week but the external os takes m uch longer and
may rem ain perm anently patulous.
Urinary Tract
Initially for 2-3 days the lower urinary tract is oedem atous and bruised
and m icturition may be difficult. M arked diuresis occurs within the first
few days. By week 3 the ureteric dilatation is reduced and m ainly
com plete by 6-8 weeks. However, it may persist in some patients fo r 12
weeks and interferes with the interpretation o f an intravenous urogram
(IVU).
Breasts
These changes are described in detail at the end o f the chapter.
PH YSIOLOGICAL C H A N G ES
Horm onal
After the third stage o f labour there is a decline in the levels o f the
following horm ones: hum an placental lactogen (H PL), progesterone,
oestrogens, aldosterone, cortisol, m elanocyte stim ulating horm one
(MSH) and insulin.
365
P U E R P E R IU M
W eight loss
There is an immediate loss of 4.5-6kg following birth due to the
placenta, amniotic fluid and blood loss. By 6 weeks postpartum about
30% of women have returned to their pre-pregnancy w eight. The
rem ainder should have done so by 6 m onths if they had not experienced
excess weight gain during pregnancy. W omen who gain in excess o f
15kg may have a net gain o f m ore than 5kg at 6 m onths and this may be
indefinite.
M ANAGEM ENT
G eneral measures
Im m ediately after delivery, the baby should be offered to the m other to
be cuddled and suckle. Most w omen after this are exhausted and fall
asleep. Repair of the episiotom y and any lacerations should be
com pleted expeditiously and the m o th e r's vital signs are observed every
15 m inutes for 30-60 m inutes. The uterus should be palpated to confirm
contraction and the vulval pads exam ined for any excessive blood loss.
The patient is tidied and transferred to an observation area. She is then
offered som ething to drink and encouraged to void. If there is difficulty,
catheterization may be required. Once the m o th e r's condition is stable
she is transferred to the postnatal ward.
366
PU E R PE R IU M
The patient and her partner are taught proper infant feeding and
care practice. Observations are made to ensure successful m other/infant
bonding and help with em otional and physical support. Some maternity
units have a dom iciliary service available which can be helpful. G eneral
practitioners, com m unity midwives and public health nurses deal with
m other and infant issues in the com m unity with a low threshold for
hospital referral in the event of com plications following discharge.
The exam ination includes an assessment o f her mental and physical state
and the progress of the baby. Weight, blood pressure and urinanalysis
367
P U E R P E R IU M
are docum ented and a general, abdom inal and pelvic exam ination
perform ed. A cervical sm ear can be taken at this time if not done
previously. Special attention is paid to urine, bowel and sexual function.
Advice is given about contraception and pelvic floor exercises.
CO NTRACEPTIO N
O f the m ethods of contraception available the most reliable are
sterilization, horm onal m ethods and the intra-uterine device. Sterilization
is an effective form o f contraception but it is essentially irreversible and
hence perm anent. It can be done im m ediately postpartum o r prior to
hospital discharge by m ini-laparotom y. A fter the postnatal visit it may be
perform ed in a num ber o f fashions, one o f which is laparoscopic clip
sterilisation.
368
P U E R P E R IU M
369
P U E R P E R IU M
Mastitis
The incidence is low but may follow breast engorgem ent. The infective
organism is usually staphylococcus. Prophylaxis is by ensuring
em ptying o f the breasts after suckling. Treatm ent is with M ethicillin or
Cloxacillin. Cases of M ethicillin resistant staphylococcus are now being
reported (M RSA) in which C iprofloxacin or V ancom ycin is the drug o f
choice.
370
P U E R P E R IU M
371
P U E R P E R IU M
373
PUERPERIU M
Single m other
A ge less than 20 years
U pbringing by a single parent
P oor parental support in childhood
P oor relationship with partner
Socially disadvantaged
P oor educational achievem ent
Low self-esteem
P revious em otional problem s
Previous depressive illness
Difficult or operative delivery
P rolonged hospitalization
Stillbirth
CO U N SELLIN G AFTER PE R IN A T A L D E A T H
W hen a w om an and her fam ily experience a loss associated with
p reg n an cy , special attention is req u ired . T rain ed senior perso n n el and
specialist bereavem ent coun selo rs best handle this task. It is essential that
a robust system is in place that allows all the issues that su rro u n d a
perinatal death to be dealt with in an efficient and com passionate
m anner.
Sym ptom s o f the norm al g rie f reaction include sleeplessness,
fatigue, poor eating habits, guilt, hostility, an g er and d isru p tio n in the
norm al pattern o f daily life. C ounselling can help to identify the g rie f
coping m echanism s most suitable to the individual circum stance.
It must be em phasised that these fam ilies require sym pathy and
an o p p o rtunity to express and discuss issues in an open m an n er. M edical
professionals should be readily available to facilitate this. A ttention will
need to be directed to the legal and adm inistrative obligations follow ing
a perinatal death. N ot least o f which is the post m o rtem . In som e
circum stances, this is a m andatory legal req u irem en t in others it is
optional. In the latter circum stance the couple should be in fo rm ed o f the
p rocedure, the benefits and risks and the im plications fo r future
pregnancies. In a small percentage o f instances this m ay identify possible
preventable causes. This know ledge has im plications fo r risk assessm ent
and counselling in subsequent pregnancies.
374
L A C T A T IO N
LACTATION
ANATOMICAL CHANGES
The breasts are m ade up of glandular, adipose and connective tissue.
D uring pregnancy the breasts increase in size from proliferation of the
glandular tissue and associated ducts and from an increase in fat
deposition between the lobules. These changes are in response to the
horm ones; oestrogens, progesterone and hum an placental lactogen. The
breasts become vascular and the veins becom e visible under the skin. The
nipples and areola becom e larger and more pigm ented with the
appearance o f M ontgom ery ’s tubercles.
Pectoral
m u scle s
co n n e ctive tissu e
M am m ary du cts
375
L A C T A T IO N
PHYSIOLOGICAL CHANGES
The mechanism o f lactation is com plex involving the inter-relation of a
num ber of neuro-endocrine factors. Lactation consists of two phases:
Neural
arc
Prolactin
(in blood)
Suckling
376
L A C T A T IO N
Suckling
Colostrum
This is a thin yellowish fluid secreted by the breast that can be
expressed as early as the 16th week o f pregnancy. It has high protein
content but less carbohydrate and fat than milk. In addition the
content of sodium , potassium and chloride is higher than milk. It is
replaced by milk by the third or fourth postpartum day. The daily
377
L A C T A T IO N
BREASTFEEDING
B reastfeeding is a physiological process and breast milk is the only milk
suited for hum ans. Its com position varies slightly from feed to feed as
well as the gestational age at birth and postpartum . It is not affected by
the m o th e r’s dietary intake.
Advantages o f breastfeeding
• Breast milk is at the right tem perature and ideal nutritional value.
• C heaper than form ula feed with no need for special preparation.
• Breast milk protects against gastroenteritis, m al-absorption, cow
milk allergy, infantile eczem a, neonatal tetany and dehydration.
• Breast milk has antim icrobial properties due to the presence o f
phagocytes, m acrophages, lym phocytes, im m unoglobulins,
interferon producing cells, lysozym e and lactoferrin that protect
against bacteria and viruses by altering the gut flora.
• B reastfeeding prom otes bonding which further prom otes
breastfeeding and attachm ent between m other and her baby.
• Lactation gives some m easure o f protection against conception.
• Reduced risk o f breast cancer.
378
L A C T A T IO N
Contra-indications to breastfeeding
• Serious maternal infection e.g. HIV, HTLV-1, TB, septicaem ia or
breast abscess.
• Systemic disease e.g. cardiac failure or cancer
• M edications e.g. cytotoxic drugs or lithium
• Severe mental illness
The health authorities in the region are prom oting a UNICEF initiative to
make all maternity institutions “ b a b y -frien d ly ” .
Suppression of lactation
In the face of certain contra-indications to breastfeeding or following the
delivery o f a stillborn infant, inhibiting o f lactation becomes necessary.
Use of a tight brassiere, fluid restriction and liberal analgesics has been
shown to be just as effective as suppressive drugs. Oestogens are no
longer recom m ended due to the risk o f throm bo-em bolism . Dopam ine
receptor stimulants e.g. Brom ocriptine can be given at a dose o f 2.5m g
three times a day for 2 weeks. However concerns about massive
379
L A C T A T IO N
m yocardial infarction and the cost may limit its use. A lternatively,
cabergoline lm g orally can be adm inistered as a one o ff dose.
KEY POINTS
380
IN D E X
INDEX
A b d o m in a l, A n a e s t h e s ia , 3 4 2 -3 4 5
c irc u m fe re n c e , 1 96, 1 9 7 , 2 3 3 re g io n a l, 3 4 3
d e liv e ry, 1 4 8 -1 4 9 g e n e ra l, 3 4 4
pain, 102 -1 0 7 A n a lg e s ia a n d a n a e s t h e s ia , 3 3 1 -3 4 4
A B O in co m patib ility, 179 a n a lg e s ia o b ste tric, 3 3 1 -3 4 1
ce n tral n e u ro a x ia l b lo c k , 3 3 5 -3 3 9
A b ortion , 190,191
p a ra c e rv ic a l b lo c k , 3 3 9
th rea te n e d , 15
p u d e n d a l b lo c k , 3 4 0
habitual, 1 5 -1 6
re g io n a l, 3 3 5 -3 3 6
Abruptio placentae, 164,170-175,264 A n d ro id p e lv is , 31
a e tio lo g y of, 164 A n e n c e p h a ly , 1 3 2 , 2 2 0 , 2 2 2 , 2 2 4
a to n y o f u te ru s in, 173
A n te n a ta l
c o a g u la tio n p ro b le m s in, 173
a im s a n d o b je c tiv e s , 1-2
c o m p lic a tio n s, 173
c a r e , 1-21
A d o le s c e n t p re g n a n c y , 1 0 9 -1 1 5 e xa m in a tio n , 4
A fte rco m in g h e a d , A n te p artu m
d e liv e ry of, 1 4 7 -1 4 8 haemonbage, 18,117,122,164-176,284
A g e , a d v a n c e d , 115-121 fetal s u rv e illa n c e , 2 2 7 -2 3 6
m ate rn a l, 131 A n th ro p o id p e lv is, 32
A lb u m in u ria , 12 A n tib io tics,
A lc o h o l, 131 in c a r d ia c d is e a s e , 8 7 , 8 9
A lp h a feto protein, 3 in d ia b e tic p a tie n ts, 6 2
for p u e rp e ra l p y re x ia , 3 7 0
A m n io c e n te s is , 3, 2 2 4 -2 2 5
A n tib o d ie s s e e im m u n o g lo b u lin
A m n io in fu sio n , 2 2 5 -2 2 6
A n ti-e m e tics, 94
A m n io tic fluid, 2 1 6 -2 2 6
circu la tio n of, 2 1 9 A n tih ista m in e s, 9 4 -9 5
c o m p o sitio n of, 221 A n ti-p ro sta g la n d in s , 2 8 2 -2 8 3
cre a tin in e in, 2 2 3 A rte rio g ra p h y , 167
fetal sw a llo w in g of, 2 1 9 , 2 2 0
A s p h y x ia , 1 3 2 , 1 3 8 , 139
fetal u rinatio n in, 2 1 8
A s y m p to m a tic b a c te riu ria , 2 7 8
in d e x , 2 2 0
p h o s p h o lip id s in, 2 2 1 ,2 2 3 A to n y uterine, 2 6 4 , 2 6 6
v o lu m e of, 2 1 6 , 2 1 9 , 2 2 2 Attitude, 10
A m n io to m y, 3 0 3 A u sc u lta tio n , 9
Anaem ia, 3 8 -5 1 ,1 1 3 ,1 1 6 ,1 2 2 ,1 2 3
a e o tio lo g y , 3 9 -4 0
fo lic a c id d e fic ie n c y , 4 3
B a c te ria l v a g in o s is , 2 8 6 , 3 5 7 -3 5 8
iron d e fic ie n c y , 4 0 -4 3
p h y s io lo g ic a l, 40 B a n d l's ring, 2 6 7
B a ttle d o re p la c e n ta , 2 0 8
381
IN D EX
382
IN D EX
383
IN D EX
384
IN D EX
In ve stigatio n s, 5 L a n u g o ,219
Iron, L a rg e -fo r-d a te s, 129, 130, 137, 139
d e ficie n cy, 4 0 -4 3 Le o p o ld m an o e u vre , 7-8
p ro p h ylaxis, 42
Lie ,
requirem ents, 41
ab no rm al, 149-151
ven ofer, 43
longitudinal, 9
Isch iu m , 23 o bliqu e, 149
Iso -im m unization , 1 7 7-185 tra n ve rse , 149, 150
Iso xu p rin e, 283 u n stab le , 123
Lig h te n in g , 238
L ile y chart, 181-1 8 2
Ja u n d ic e , 9 7 -1 0 2 Liste ria m o n o c y to g e n e s, 354
Lo c h ia , 364
L o v s e t's m an o e u vre , 147
K ic k chart, 135
K id n e y,
function, 70 Macrosomia, fetal, 122,127,130,137-139,
failure, 70 292
K ie lla n d 's fo ce p s, 324 M alpresentation , 140
M a g n e siu m su lp h a te , 7 7 -7 9 , 2 8 5
Labo ur, M arginal insertion, 164
d ia g n o sis of, 239
M astitis, 370
fetal m onitoring in, 244
first sta g e of, 2 4 5 -2 4 6 M aternal m ortality, 82, 119, 164, 341
induction of, 2 9 2 , 2 9 4 , 2 9 8 -3 0 6 M a u rice a u -S m e llie -V e it, 147
m e ch a n ism of, 2 4 0 -2 4 3 Maximum vertical pool of liquor, 201,219
norm al, 2 3 7 -2 5 2
Me D o n a ld 's suture, 18
preparation for, 238
preterm , 19-20, 2 7 7 -2 8 6 M econium , 2 2 2 ,2 9 2
p ro g re ss of, 2 4 5 -2 4 6 aspiration of, 132,139,2 2 5 ,2 9 2 ,2 9 5 ,2 9 6
se c o n d sta g e of, 138, 246 M e m b ran e s,
third s ta g e of, 2 4 6 -2 4 7 ruptured, 303
trial of, 35-3 7 M e n d e lso n 's sy n d ro m e , 294
La ce ra tio n s, M enstrual history, 3 -4
ce rv ica l, 267
M ethyldopa, 74
perineal, 138, 248
uterine, 267 Mid stream urine test (M S U ), 7 6 , 356
Lactatio n, 3 7 5 -3 7 8 Milk ejection reflex, 377
su p p re ssio n , 379 M iscarriag e , 15-1 6, 190-191
Lactifero us Mitral
du cts, 375 in co m p e te n ce , 82
sin u s e s , 375 ste n o sis , 82
L a m a ze , 332 valvo to m y, 89
Lam inaria, 302, 303 M o n iliasis, 358
385
IN D E X
M o u ld in g, 241 P a r a c e r v ic a l b lo c k , 3 3 9 -3 4 0
M ultiple p r e g n a n a c y , 1 5 3 -1 6 3 P a w lik 's g rip , 8
P e lv im e try , 3 2 -3 5
N a e g e le 's rule, 3 ,2 9 3 P e lv ic
N a lo x o n e , 3 3 3 a x is , 31
b o n e s , 2 2 -2 4
N a u s e a a n d vo m itin g, 15
c a v ity , 2 7 ,2 9
N e o n a ta l, d ia m e te rs, 28-31
h y p o c a lc a e m ia , 58 inlet, 2 6 -2 8 ,
h y p o g ly c a e m ia , 58 jo in ts, 2 4 -2 6
ja u n d ic e , 58 outlet, 2 7 , 29
N ica rd ip in e , 2 8 4 ty p e s, 3 1 -3 2
N ife d ip in e , 7 4 , 2 8 4 P e lv is ,
N itrofurantoin, 3 5 7 c o n tra c te d , 12
ty p e s of, 3 1 -3 2
N itro u s o xid e , 3 3 2 ,3 4 3
P e n ic illin , 3 5 3 -3 5 4 , 3 5 7 -3 5 8
N on-stress test, 136,2 1 3 -2 1 4 ,2 3 0 -2 3 1
P e rin e a l la c e ra tio n , 2 4 8
N u c h a l tra n s lu c e n c y , 3
P e rin e u m c a r e , 3 6 7
Nutrition, 13, 131
in h y p e re m e s is , 95 P e rin a ta l d e a th , 3 7 4
Perinatal mortality, 1 1 9 ,1 2 7 ,1 4 0 ,1 6 4 ,2 9 1
O b e s ity , 7 0 , 8 5 , 1 2 6 -1 2 8 , 1 3 7 , 139 rate,
O c c ip ito -a n te rio r p o sitio n , 1 5 2 -1 5 3 P e rio d o n ta l d is e a s e , 3 5 7
O cc ip ito -p o ste rio r p o sitio n , 1 5 1 , 241 P e th id in e , 3 3 3 , 3 4 3
O e d e m a , 13 P h le b o th ro m b o sis , s e e T h ro m b o s is
O e strio l, 3, 137 P h o sp h a tid y l,
c h o lin e , 2 2 3
Oligohydramnios, 136,141,201,218-222,
ino sito l, 2 2 3
2 2 5 ,2 2 7 ,2 3 4 ,2 8 8 ,2 9 2 g ly c e ro l, 2 2 3
O p th a lm ia n e o n a to ru m , 3 5 9 P h o s p h o lip id s , 2 2 1 ,2 2 3 , 3 2 3
O p tic a l d e n sity , 2 2 2
P itu itary n e c ro s is , 2 7 5
O utlet
P la c e n ta , 1 2 9 , 2 0 7 -2 1 5
fo rc e p s, 321 ab ru p tio , 1 7 0 -1 7 5 , 2 0 9 , 2 7 0
o f p e lv is, 2 7 a c c re ta , 2 6 8
O v a ria n c y st, 141 a g in g of, 2 0 9 , 2 1 0
O x y to c in , 3 0 4 -3 0 5 b a ttled ore, 2 0 8
c irc u m v a lla te , 2 0 9
O xytocin challenge test 1 3 6 ,2 3 2 ,2 7 1
e xa m in a tio n of, 2 1 0
in cre ta, 2 6 8
in s u ffic ie n c y of, 211
P a in , lo c a liza tio n of, 1 6 7 -1 6 8 , 199
a b d o m in a l, 1 0 2 -1 0 8 m a n u a l re m o v a l of, 2 6 8 -2 6 9
relief, 331 m orb id ly a d h e re n t,
p e rcre ta , 2 6 8
P a in fu l c ris is , 4 8 , 1 0 6 -1 0 7
p e rfu sio n , 71
386
IN D E X
p ra e v ia , 1 6 5 -1 7 0 P ro lactin , 3 7 6
retain ed, 2 6 7 -2 6 9 P ro la p s e o f co rd, 123, 142, 2 9 9
se p a ra tio n of, 2 4 6 -2 4 7
su c c e n tu ria te , 2 0 9 P ro lo n g e d lab ou r, 118
M o rp ho logy, 199 P ro p ra n o lo l, 7 4 -7 5
P A P P -A , 3 P ro s ta g la n d in s , 3 0 2 , 3 0 3
P la c e n ta l, P ro te in u ria ,12, 68
function test, 2 1 2 -2 1 5 P u b is , 25
insufficiency, 1 2 9 ,1 3 5,136,211,212 P u d e n d a l n e rv e b lo ck, 340
P la s m a vo lu m e, 83 P u e rp e ra l infection, 3 6 8 -3 7 0
P la typ e llo id p e lv is, 32 P u e rp e riu m , 2 6 3 , 3 6 4 -3 7 4
Polyhydramnios, 141,201,219-220,222,227, infection, 3 6 8 -3 7 0
264 P y e lo n e p h ritis, 3 5 6
P o std a te , 139, 2 2 7 , 291
P o stm atu rity, 137, 2 9 1 ,2 9 4
P o stp a rtu m , R a n itid in e , 3 1 2
d e p re s sio n , 3 7 3 R e d -c e ll
haemorrhage, 123-124,128,138,162, m a s s , 39
173,263-276 v o lu m e , 83
P o st-te rm , 2 9 1 -2 9 7 R e g io n a l b lo ck, 3 4 2 -3 4 3
P re -e c la m p s ia , 18, 19, 6 6 -8 1 , 134 Renal
ae tio lo g y, 71 a g e n e s is , 132, 136, 2 2 2
clin ica l c o u rs e , 72 failu re , 70
P re g n a n c y Respiratory distress syndrom e, 288-289
a d o le sc e n t, 1 0 9 -1 1 5 R estitu tion , 2 4 3
e cto p ic, 1 9 1 -1 9 2
R e tra ctio n , 2 3 7
in d u ce d h yp erte n sio n , 68 , 126
m ultiple, 2 2 7 , 2 8 4 , 287 R h esu s
p ro lo n ge d , 2 9 1 -2 9 7 im m une glo b u lin , 182
p o std ate , 291 iso -im m u n iz a tio n ,122, 1 7 7 -1 8 4 ,
v ia b le , 3 222, 228
P re m a tu re R h e u m a tic heart d is e a s e , 82
rupture of membranes, 117,287,289, R h o g a m , 1 8 2 -1 8 4
345
R ito drine h y d ro ch lo rid e , 2 8 4
Prem aturity, 113 R u b e lla , 16, 132, 3 4 7 -3 4 9
P re se n ta tio n , 10
R u p tu re ,
Preterm uterine, 2 6 7 , 3 1 7
labour, 130, 2 7 7 -2 8 6 , 3 5 5 , 357 o xyto cin an d,
premature rupture of, membranes, 287- s c a r, 3 1 7
289
P rim ig ra vid a ,
elde rly, 116
S a c r o -s c ia t ic notch, 2 3
P ro g e ste ro n e , 2 8 5
387
IN D EX
V e lam e n to u s insertion, 2 0 6 -2 0 7
Ventolin, 283
V ersion ,
external ce p h a lic, 143-145
internal podalic, 161
V ia b le , 3
V illu s,
ch o ra n gio m a , 222
Vom iting, 91-96
W eight-gain, 6, 127
W e igh t-lo ss, 6
W rigley's fo rce p s, 321
Zid o vu d in e , 3