Obstetric – Extra
#Fetal Growth Restriction (FGR)
DEFINITION: Fetus whose growth velocity slows down or stops completely because
of inadequate oxygenation or nutrition supply or utilization
AETIOLOGY:
o MATERNAL FACTORS: Nutrition: BMI<19 starvation, Smoking: 460 gm lighter than
fetus with nonsmoker woman, Alcohol and drug abuse, Maternal therapeutic
drugs e.g. B blockers & Anticonvulsant , Maternal diseases (Cardiorespiratory
compromise Sickle cell dis, Collagen vascular disease, Maternal DM, Maternal
chronic hypertension, Abnormalities in the uterus)
o FETAL FACTORS: Fetal abnormalities (Chromosomal, Structural, Cardiac disease,
Gastroschisis) Infection (Varicella, CMV, Rubella, Syphilis, Toxoplasma, Malaria)
o PLACENTAL FACTORS: Placental mosaicisim –16,22 chromosome , PE -- ↓ blood
supply to placental bed
PREDICTION: BMI<19, Smoking, Past history of FGR, Congenital uterine
abnormalities, Big fibroid, Old mother>40 nulliparous, PE, Retro placental
hemorrhage in 2nd & 3rd Trim , Maternal serum screening : 2nd Tim (Alfa Feto
Protein (AFP) , E3 , Human Placental Lactogen , hCG), ULTRASOUND MARKERS
CLINICAL ASSESSMENT: Weight gain in pregnancy, Fundal height, Clinical weight
estimation of the fetus – liquor amount estimation, U/S assessment, Biometrical
measurement of the fetus, Umbilical artery Doppler velocity study
PROPHYLAXIS: Small dose aspirin, Protein energy, Stop smoking, Anti malaria, Stop
medications
LABOR: <37wk → C/S because at high risk of hypoxia & academia, If >37wk→
induction – continuous CTG, fetal scalp monitoring
Not all FGR are SGA or all SGA are FGR:
o SGA can be categorized according to the etiology into:
Normal SGA: No structural anomalies, normal liquor, normal Doppler study of
umbilical artery & normal growth velocity.
Abnormal SGA: those with structural or genetic abnormalities
FGR: those with impaired placental function identified by abnormal UADW &
reduced growth velocity.
o SGA is divided into symmetrical or unsymmetrical according to Biometrical
measurement
#Intrauterine death (still birth)
DEFINITION: Baby delivery at 24wk complete with no sign of life
AETIOLOGY:
o MATERNAL FACTORS: Obstetric. Cholestasis, Metabolic disturbances (DM
Ketoacidosis), Reduced oxygen saturation (Cystic fibrosis, Sleep apnea) , Uterine
abnormalities, Ascherman syndrome, Antibodies production (Rh, Platelet)
Alloimmunization, Congenital heart block
o FETAL FACTORS: Cord accident, Fetofetal transfusion, Feto maternal hemorrhage,
Chromosomal and genetic diseases, Structural abnormalities, Infection, Anemia of
fetal origin
DIAGNOSIS: ↓ FM, Routine U/S, Abruption or ruptured membrane, Color Flow
Mapping is definitive
INVESTIGATION: Kleihauer test, Full blood count with platelet, Blood gr, Antibody
screen, Urea & Creatinine, LFT, Uric acid, Bile acid, Syphilis & Parvovirus & CMV &
Toxoplasma serology
HOW TO DELIVER?
o Over 90% of women will deliver spontaneously within 3 weeks, conservative
management is an option that can be offered
o Vaginal delivery is the best option unless there is obstetric indications
o Induction of labor : A standard protocol for mifepristol induction, Prevention of Rh
iso immunization, Contraception, Psychological support, Follow up
#Partograph (partogram)
DEFINITION: Is a graph used in labor to monitor the parameters of progress of labor,
maternal and fetal wellbeing, and treatment administration
PRACTICAL VALUE OF USING THE PARTOGRAM:
o Offers an objective basis for overtime monitoring the progress of labor, maternal
and fetal wellbeing.
o Enables early detection of abnormalities of labor
o Prevention of obstructed labor and ruptured uterus.
o Useful in reduction of both maternal and perinatal mortalities and morbidities
COMPONENTS (Parts):
o Patient identification
o Time: It is recorded at an interval of one hour. Zero time for spontaneous labor is
time of admission in the labor ward and for induced labor is time of induction.
o Fetal heart rate: It is recorded at an interval of thirty minutes.
o State of membranes and color of liquor: "I" designates intact membranes, "C"
designates clear and "M" designates meconium stained liquor.
o Cervical dilatation and descent of head
o Uterine contractions: Squares in vertical columns are shaded according to
duration and intensity.
o Drugs and Fluids
o Blood pressure: It is recorded in vertical lines at an interval of 2 hours.
o Pulse rate: It is also recorded in vertical lines at an interval of 30 minutes.
o Oxytocin: Concentration is noted down in upper box; while dose is noted in lower
box.
o Urine analysis
o Temperature record
ADVANTAGES:
o Provides information on single sheet of paper at a glance
o No need to record labor events repeatedly
o Prediction of deviation from normal progress of labor
o Improvement in maternal morbidity, perinatal morbidity and mortality
#Ectopic pregnancy
DEFINITION: It is one in which a fertilized ovum implant & being to develop before it
reaches its natural site in the uterus. An extra uterine gestation can develop in the
ovary or in the peritoneal cavity , but 97% of ectopic pregnancy occur in the fallopian
tubes ,most commonly in the ampullary portion
CAUSES: A tubal pregnancy — the most common type of ectopic pregnancy —
happens when a fertilized egg gets stuck on its way to the uterus, often because the
fallopian tube is damaged by inflammation or is misshapen. Hormonal imbalances or
abnormal development of the fertilized egg also might play a role.
SYMPTOMS: Severe abdominal or pelvic pain accompanied by vaginal bleeding,
Extreme lightheadedness or fainting, Shoulder pain
TREATMENT: A fertilized egg can't develop normally outside the uterus. To prevent
life-threatening complications, the ectopic tissue needs to be removed. If the ectopic
pregnancy is detected early, an injection of the drug methotrexate is sometimes used
to stop cell growth and dissolve existing cells.
#Hydatidiform Mole
DEFINITION: This is an abnormal conceptus in which an embryo is absent & the
placental villi are so distended by fluid that they resemble a bunch of grapes. No
trace of an embryo, amniotic sac or umbilical cord is apparent.
CAUSES: A molar pregnancy is caused by an abnormally fertilized egg. Human cells
normally contain 23 pairs of chromosomes. In a complete molar pregnancy, all of the
fertilized egg's chromosomes come from the father. In a partial or incomplete molar
pregnancy, the mother's chromosomes remain but the father provides two sets of
chromosomes. As a result, the embryo has 69 chromosomes instead of 46.
SYMPTOMS: Dark brown to bright red vaginal bleeding during the first trimester,
severe nausea and vomiting, sometimes vaginal passage of grape-like cysts, rarely
pelvic pressure or pain.
TREATMENT: Dilation and curettage (D&C), Hysterectomy, HCG monitoring
#Fetal distress
DEFINITION: Compromise of a fetus during the antepartum period (before labor) or
intrapartum period (during the birth process). The term fetal distress is commonly
used to describe fetal hypoxia (low oxygen levels in the fetus), which can result in
fetal damage or death if it is not reversed or if the fetus is not promptly delivered.
CAUSES: Breathing problems, Abnormal position and presentation of the fetus,
Multiple births, Shoulder dystocia, Umbilical cord prolapse, Nuchal cord, Placental
abruption, Premature closure of the fetal ductus arteriosus, Uterine rupture,
Intrahepatic cholestasis of pregnancy, a liver disorder during pregnancy.
SYMPTOMS: Decreased movement felt by the mother, Meconium in the amniotic
fluid, Non-reassuring patterns seen on cardiotocography (increased or decreased
fetal heart rate, decreased variability, late decelerations), Biochemical signs (fetal
metabolic acidosis, elevated fetal blood lactate levels).
TREATMENT: rapid delivery by instrumental delivery or by caesarean section if
vaginal delivery is not advised.
#Booking visit
DEFINITION: is the first official check-up in pregnancy.
INVESTIGATION:
o Blood test: blood group, check for infections (HIV, Rubella, Measles, HBV)
o Urine test: check pre-eclampsia and gestational diabetes
o Blood pressure test: Raised blood pressure, especially later on in the
pregnancy, can be an early warning sign of pre-eclampsia.
o Ultrasound: measures baby size to confirm the gestational age and to
calculate the delivery date
#Changes in pregnancy
Changes in circulatory system:
o ↑ Heart rate (10–20 per cent).
o ↑ Stroke volume (10 per cent).
o ↑ Cardiac output (30–50 per cent).
o ↓ Mean arterial pressure (10 per cent).
o ↓ Pulse pressure.
o Maternal haemoglobin levels are decreased because of the discrepancy between
the 1000 to 1500 mL increases in plasma volume and the increase in erythrocyte
mass, which is around 280 mL. Transfer of iron stores to the fetus contributes
further to this physiological anemia.
o Palpitations are common and usually represent sinus tachycardia, which is normal
in pregnancy.
o Edema in the extremities is a common finding, and results from an increase in
total body sodium and water, as well as venous compression by the gravid uterus.
Renal changes:
o ↑ Kidney size (1 cm).
o Dilatation of renal pelvis and ureters.
o ↑ Blood flow (60–75 per cent).
o ↑ Glomerular filtration (50 per cent).
o ↑ Renal plasma flow (50–80 per cent).
o ↑ Clearance of most substances.
o ↓ Plasma creatinine, urea and urate.
o Glycosuria is normal.
o Urine output increase in first trimester, slightly decreased in the second
trimester and increase again in the third trimester
Hormonal changes: increase of estrogen, progesterone, secretion of hCG and Human
chronic lactogen, increase production of corticotrophin, thyrotropin and prolactin,
while FSH and LH decrease, Increase secretion of glucocorticoids and aldosterone,
and increase secretion of thyroxin, Parathyroid increase, Increase secretion of
vasopressin.