Master Pass in Obstetrics & Gynaecology Hiralal Konar
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SECTION - I
  • OSCE in Obstetrics
  • Self-Assessment in Obstetrics
  • OSCE in Gynaecology
  • Self-Assessment in Gynaecology

OSCE in Obstetricschapter 1

 
OBJECTIVE STRUCTURED CLINICAL EXAMINATION (OSCE)
CASE–1: SEVERE PREECLAMPSIA
‣‣ What is the probable diagnosis?
Ans. HELLP syndrome.
‣‣ How do you diagnose it?
Ans. Presence of haemolysis, elevated liver enzymes and low platelet count in a patient with severe preeclampsia.
‣‣ What do you understand by severe preeclampsia?
Ans.
  • BP > 160 mm Hg systolic or > 110 mm Hg diastolic.
  • Proteinuria > 5 gm/24 hrs.
  • Onset of acute renal failure.
  • Oliguria : Urine < 500 ml/24 hrs.
  • Pulmonary oedema.
  • HELLP syndrome.
  • Thrombocytopenia (< 100,000/μl).
  • Symptoms due to end organ involvement — Headache, epigastric pain, visual disturbances.
  • Fetal growth restriction.
4‣‣ What is the diagnostic criteria for HELLP syndrome?
Ans. Diagnostic criteria:
♦ Haemolysis
♦ LDH > 600 IU/L
♦ AST > 70 IU/L
♦ ALT > 70 IU/L
♦ Platelets < 100,000/mm3
♦ Serum bilirubin > 1.2 mg/dl
♦ Abnormal peripheral blood smear (Schistocytes).
‣‣ What other investigations should be done for her?
Ans. Other investigations to be done are: Coagulation profile, Serum uric acid, Creatinine, Urine analysis and Ophthalmoscopy.
‣‣ What is the risk of eclampsia in HELLP syndrome when compared to severe preeclampsia.
Ans. Eclampsia is more common in HELLP syndrome in comparison to severe preeclampsia.
‣‣ What would be the appropriate management of the case?
Ans. Patient should be managed in a tertiary care centre
  • (i) To stabilise maternal condition:
    • Antihypertensive therapy — Hydralazine 5 mg IV bolus to be followed by infusion (25 mg in 200 ml normal saline) at the rate of 2.5 mg/hour to be doubled every 30 min till the diastolic BP is < 110 mm Hg. Labetalol IV (200 mg in 200 ml of N saline) at the rate of 20 mg/hr can also be used as an alternative.
    • Antiseizure prophylaxis with MgSO4 (IM or IV regimen).
    • CT or USG of abdomen if subcapsular haematoma of liver is suspected.
    • To correct coagulopathy if any: Fresh (relatively) whole blood transfusion, platelet transfusion if count is < 10,000 mm3.
  • (ii) To evaluate fetal well being:
    • Nonstress test.
    • Biophysical profile.
    • Doppler flow study of umbilical artery (See Dutta's Obst. p. 110).
  • (iii) Termination of pregnancy (Delivery):
    5
CASE–2: COUNSELLING
‣‣ What are predisposing factors for preeclampsia?
Ans.
  • Young and elderly primigravidae.
  • Positive family history (genetic).
  • Pregnancy complications — Multiple pregnancy, diabetes.
  • New paternity.
  • Many others (genetic and immunological).
‣‣ Can you predict preeclampsia?
Ans. There are many screening tests. Doppler study (Fig. 1.1) to detect ‘notch’ in the early diastole wave specially in the uterine arteries, at 24 weeks can predict the possible development of preeclampsia. Other tests like ‘Roll over test’ and ‘Angiotensin infusion test’ have been tried. Unfortunately positive predictive value of all these tests are poor.
‣‣ Can you prevent preeclampsia?
Ans. Preeclampsia is not a totally preventable disease. Use of low dose aspirin, calcium, antioxidants (vit. C, vit. E) have been tried in the high risk groups to reduce the onset of severe disease.
zoom view
Fig. 1.1:
Flow velocity waveform (Doppler velocimetry) of the uterine artery at 26 weeks of gestation. This shows early diastole ‘notch’. Presence of this notch and elevated resistance index (RI) or pulsatility index (PI) at advanced weeks of gestation indicate high uterine vascular resistance and reduced placental blood flow. This is thought to be due to failure of trophoblastic invasion of the spiral arteries
6‣‣ Can you predict and prevent eclampsia?
Ans. Eclampsia may present in atypical ways though in majority it is preceded by severe preeclampsia. So effective management of preeclampsia is the only way to prevent eclampsia.7
CASE–3: ECTOPIC PREGNANCY
‣‣ What are most likely the diagnoses ?
Ans. Complications (bleeding) of early pregnancy — threatened or incomplete miscarriage (See Table Konar & Dutta's Bedside Clinic, p. 144), ectopic pregnancy.
‣‣ What investigations you will recommend?
Ans. Urine for hCG and pelvic ultrasonography (TVS).
Investigation report
  • Urine hCG = positive; serum β hCG = 1850 IU/L; Pelvic ultrasonography — Uterus : NS; Cavity: empty. Mass in the right adnexae; no fluid in the POD, left tube and ovary — not visualised. Fig. 1.2A.
‣‣ What would be your next step of management ?
Ans. Diagnostic Laparoscopy — Double puncture procedure
On Laparoscopy — Pathology revealed as in the photograph (Fig. 1.2B).
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Fig. 1.2A: Sonogram showing ectopic pregnancy[By courtesy: Dr (Mrs) S Ghosh and Prof BN Chakravorty, IRM, Calcutta]
8
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Fig. 1.2B: Laparoscopic view of tubal ectopic pregnancy (unruptured)
‣‣ What is your diagnosis?
Ans. Unruptured tubal ectopic pregnancy.
‣‣ Mention some predisposing factors to this pathology?
Ans. Pelvic inflammatory disease, previous induced abortion, tubal surgery (tubal sterilisation or reversal of sterilisation), IVF and ET.
‣‣ What is the value of serum β hCG and serum progesterone to predict the diagnosis ?
Ans. Serum β hCG > 2000 IU/L with empty uterine cavity on TVS suggests ectopic pregnancy. Serum progesterone > 25 ng/ml suggests viable intra-uterine pregnancy.
‣‣ What would be the appropriate management for her ?
Ans. Conservative management for unruptured tubal ectopic pregnancy.
Procedure may be either medical or surgical:
Medical: Systemic methotrexate (MTX) or Direct local into the sac with agents like : MTX, PGF or potassium chloride.
Surgical: Salpingostomy or Salpingotomy (Fig. 1.2C).
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Fig. 1.2C: Laparoscopic surgery for tubal ectopic pregnancy
9‣‣ Are all the cases suitable for medical management ?
Ans. No. Contraindications are: (i) tubal diameter > 4 cm; (ii) presence of fetal cardiac activity, (iii) presence of intraperitoneal bleeding or tubal rupture.
‣‣ Does she need any follow up following the initial treatment ?
Ans. She should be followed up with estimation of serum β hCG weekly till the values are normal.
  • But level of serum β hCG remained plateau on the 10th day of treatment.
‣‣ What would you do for her ?
Ans. She should be treated with systemic chemotherapy (MTX) 50 mg/M2 IM single dose.
After the completion of treatment, she wants to know from you the following.
‣‣ What is the risk of recurrence of tubal ectopic pregnancy ?
Ans. About 10–15%.
‣‣ What precautionary measures she may take to minimise the risk ?
Ans. To avoid the use of IUD contraceptive and progestin only pills.
  • She is now scared about the problem of recurrence.
‣‣ How best you can reassure her?
Ans. She is advised to report whenever she misses her period. Serum β hCG and pelvic ultrasonography should be done to confirm the diagnosis as well as to detect the site of pregnancy.10
CASE–4: ABRUPTIO PLACENTAE; PLACENTA PRAEVIA
‣‣ What is most likely the diagnosis?
Ans. Abruptio placentae.
‣‣ What other signs she may have ?
Ans. Difficulty in palpating the fetal parts, difficulty in auscultating the FHS, height of the fundus — more than the period of amenorrhoea and presence of uterine tenderness.
‣‣ What are the common causes of the problem?
Ans. The exact cause is obscure. The observed associations are:
  • Preeclampsia.
  • Sudden uterine decompre-ssion (following delivery of the first baby of twins).
  • Circumvallate placenta (Fig. 1.3A).
  • Trauma.
  • Folic acid deficiency.
  • Smoking, cocaine abuse and thrombophilias.
‣‣ What important investigations you should do for her ?
Ans. Blood for Hb%, Haematocrit, Platelets, Coagulation profile, ABO, Rh grouping and cardiotocography.
‣‣ What definitive management you would do for her?
Ans. Resuscitation and termination of pregnancy. Patient may go into labour spontaneously. Otherwise labour may be induced by ARM ± oxytocin.
‣‣ What are the indications of caesarean section in such a condition ?
Ans.
  • Evidences of fetal distress.
  • Where amniotomy could not be done as the cervix is unfavourable.
  • Nonprogress of labour even with amniotomy ± oxytocin.
  • Associated obstetric complications (breech).
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Fig. 1.3A:
Stillbirth following placental abruption in a case with circumvallate placenta
11‣‣ How do you explain the indeterminate bleeding?
Ans. The diagnosis of unclassified bleeding is made after exclusion of placental and local causes. Rupture of vasa praevia (See Dutta's Obst. p. 259, marginal sinus, circumvallate placenta (Fig. 1.3B) or marked decidual reaction on endocervix may be the possible cause.
‣‣ How do you manage a case of vasa praevia ?
Ans. Management depends on gestational age, severity and the recurrence of bleeding. Pregnancy ≥ 37 weeks → delivery. Expectant management is done in selected cases only (See Dutta's Obst. p. 259).
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Fig. 1.3B: Circumvallate placenta with abruption
‣‣ What is the relationship between previous caesarean section and incidence of placenta praevia?
Ans. Women with a previous caesarean delivery has an increased risk of abnormal placental location (placenta praevia). In addition, these women have an increased risk of morbid adherent placenta (placenta accreta, increta or percreta). Risk of placenta accreta with placenta praevia without any uterine scar is about 3%. However, this risk increases in cases with prior caesarean delivery (scarred uterus). The overall risk of placenta accreta with placenta praevia with prior caesarean delivery is 11%, 40% and 60% after the first, second and third caesarean delivery respectively. Morbid adherent placenta leads to significant haemorrhage during caesarean section. This may lead to caesarean hysterectomy. Hence, in such a case, operation should be done by an experienced person and blood or blood products should be made available.12
CASE–5: UNSTABLE LIE
‣‣ What is the diagnosis?
Ans. Unstable lie.
‣‣ What should be the appropriate investigations for her?
Ans. Ultrasonography to detect any cause for unstable lie specially placenta praevia.
‣‣ What are the important complications of this problem?
Ans. Prelabour rupture of the membranes and cord prolapse.
‣‣ What would be appropriate approach for management ?
Ans. Admission in the hospital and close monitoring.
If no cause is detected, lie may become stable. In that case she may go into spontaneous labour or may be induced (stabilising induction). Otherwise she should be delivered by caesarean section.
‣‣ What advise she should be given when she is admitted in the ward ?
Ans. To maintain kick-chart (See Dutta's Obst. p. 108). In case membrane ruptures (leakage of liquor) she should inform the on duty nurse and should not take anything orally until examined by her doctor.13
CASE–6: NONPROGRESS OF LABOUR
‣‣ What is the diagnosis?
Ans. Nonprogress of labour.
‣‣ What do you mean by nonprogress of labour?
Ans. When the rate of cervical dilatation is less than 1 cm/hr and the descent of the presenting part is less than 1 cm/hr, the condition is known as slow progress of labour. But when there is no change in terms of cervical dilatation and descent of the presenting part over a period of at least two hours, the condition is known as nonprogress of labour.
‣‣ What are the reasons for nonprogress of labour?
Ans. The underlying aetiologies are often not clearly determined. Weak or abnormal uterine contractions, deflexion of the fetal head, cephalopelvic disproportion, malposition, inadequate or lack of labour analgesia, maternal dehydration are often associated with nonprogress of labour.
‣‣ What would be the next appropriate step to rectify the abnormality?
Ans.
  • Maternal rehydration.
  • Artificial rupture of the membranes (ARM).
  • To reassess the woman once again.
‣‣ What would be the next step of management if the situation is not improved?
Ans. Once cephalopelvic disproportion has been excluded, labour process may be augmented with escalating dose of oxytocin infusion.
After four hours of regular and strong contractions, she was found fully dilated. Head was at +3 (perineum). Sagittal suture was in the anteroposterior diameter of the pelvis. She was found completely exhausted and was unable to push down (bear down).
‣‣ What would be your next step of management?
  • To continue oxytocin infusion.
  • To give her adequate analgesia.
Ans. To expedite the delivery by outlet forceps.
‣‣ What are the abnormalities of the active phase of labour?
Ans. (a) Protracted active phase and (b) Arrest of active phase.
14‣‣ What do you understand by protracted and arrest of active phase and how do you manage them?
Ans.
  1. Protraction of labour (WHO-1994) is defined when the cervical dilatation is less than 1 cm/hr for a minimum of four hours during the active phase of labour.
  2. Arrest of labour in the active phase is defined when there is no dilatation of the cervix for 2 hours or more.
Management: Protraction and arrest disorders during the active phase of labour may be due to poor or incordinated uterine contractions, malposition, malpresentations or due to cephalopelvic disproportion (CPD).
Management is initiated according to its cause. Expectant management with support and amniotomy with or without oxytocin augmentation may be effective.
Cases with CPD need to be delivered by caesarean section.15
CASE–7: CARDIOTOCOGRAPHY
‣‣ What is the baseline FHR?
Ans. 150 beat per minute (bpm).
‣‣ What is the baseline variability?
Ans. 10–20 bpm.
‣‣ Is there any sinusoidal pattern?
Ans. Nil.
‣‣ How many accelerations are there in the trace?
Ans. 6 within the period of 20 min.
‣‣ Is there any deceleration?
Ans. Nil.
‣‣ What about the nonstress test?
Ans. Fetal movements are evidenced by black blocks in the graph. Simultaneous with the fetal movements there is acceleration of the FHR.
So the nonstress test is normal (reassuring pattern).
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Fig. 1.4A: Cardiotocograph showing reactive nonstress test indicated by fetal movements (blocks) with cardiac accelerations (see arrows)
16
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Fig. 1.4B: Fetal monitor with the abdominal transducers
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Fig. 1.4C: Cardiotocography is in progress
‣‣ What are the criteria of a normal (reactive) trace?
Ans.
  • Baseline FHR between 120 and 160 bpm (FIGO: 110–150 bpm).
  • Baseline variability between 10 and 25 bpm.
  • Two accelerations in 20 min observation.
  • No deceleration.
‣‣ When a trace pattern is called abnormal?
Ans. Pathological trace:
  • Baseline heart rate < 100 bpm or > 160 bpm.
  • Baseline variability < 5 bpm for 90 min or more.
    17
  • No acceleration in 40 min.
  • Repetitive early or variable deceleration.
  • Repetitive late deceleration.
  • Sinusoidal pattern.
‣‣ Name some common causes of fetal bradycardia and tachycardia?
Ans. Fetal bradycardia
  • Fetal distress.
  • Acidosis.
  • Fetal heart conduction defect.
  • Drugs to mother (pethidine, methyldopa).
Fetal tachycardia:
  • Drugs to mother (β adrenergic agents).
  • Infection (mother or fetus).
  • Anaemia (maternal or fetal).
  • Fetal distress.
‣‣ What about the tocograph in the trace ?
Ans. The tocograph showed absence of uterine contractions.
‣‣ What are the indications of continuous electronic fetal monitoring during labour?
Ans. Where there is increased risk of intrapartum fetal hypoxia.
Conditions are:
  • IUGR.
  • Meconium stained amniotic fluid.
  • Maternal hypertension or diabetes.
  • Malposition (OP) or presentation (breech).
  • Previous caesarean section.
    18
CASE–8: CARDIOTOCOGRAPHY
‣‣ What abnormalities are shown in the trace ?
Ans. Baseline fetal heart rate was 140 bpm with unprovoked repeated decelerations lasting for more than 3 min.
‣‣ What would be the next plan of management ?
Ans. Patient should be admitted for continuous monitoring and for biophysical scoring. Further CTG showed the trace in the Fig. 1.5B.
‣‣ What abnormalities are shown in the trace (Fig. 1.5B) ?
This trace pattern remained persistent on two more occasions.
Ans. Sinusoidal pattern:
Fetal baseline heart rate is 155 bpm.
Baseline variability is < 5 bpm.
Acceleration: Nil.
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Fig. 1.5A: Abnormal nonstress test showing repeated decelerations > 40 bpm and lasting > 3 min
19
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Fig. 1.5B: Cardiotocogram showing sinusoidal pattern
‣‣ What would be your advice ?
Ans. To organise delivery.
On examination cervix was found unfavourable. She was delivered by LSCS. The baby on examination revealed : Fig. 1.5C. The baby weighted 1.2 kg.
‣‣ What are the complications for the baby?
Ans.
  • Presence of other congenital malformations.
  • Feeding problem.
  • Speech problem.
  • Delayed dentition.
  • Repeated chest infection due to regurgitation.
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Fig. 1.5C: Neonate with IUGR showing cleft lip and palate
20
CASE–9: MANAGEMENT OF LABOUR (PARTOGRAPH - I)
‣‣ What was the cervical dilatation at the time of admission at 3 am?
Ans. Cervix was only 1 cm dilated.
‣‣ At what time she entered into the active phase of labour?
Ans. At 11 am (8 hours after admission) cervix was 4 cm dilated.
‣‣ At what time she became fully dilated?
Ans. At 2 pm (11 hours since admission) cervix was 10 cm (fully) dilated.
‣‣ What was the duration of the latent phase of labour?
Ans. 8 hours (3 am – 11 am).
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Fig. 1.6: Partograph representing graphically the important observations in labour1
21‣‣ What was the duration of the active phase of labour?
Ans. 3 hours (11 am – 2 pm).
‣‣ How were the uterine contractions for the first 3 hours and the last one hour of labour since admission?
Ans. For the first 3 hours uterine contraction were 2 per 10 minutes and each lasted for less than 20 seconds. For the last one hour the frequency of uterine contractions were 4 per 10 minutes and each lasted more than 40 seconds.22
CASE–10: MANAGEMENT OF LABOUR (PARTOGRAPH - II)
‣‣ What was the total duration of labour?
Ans. 8 hours.
‣‣ What was the situation of the head at the time of admission?
Ans. Head was 5/5ths above the pelvic brim at 6 am, the time of admission.
‣‣ At what time the head was engaged?
Ans. Four hours following admission (at 10 am) head was found engaged (2/5ths were felt above the brim).
‣‣ What was the FHR and maternal blood pressure when she entered the active phase of labour?
Ans. FHR was 140 bpm; BP was 120/80 mm Hg.
‣‣ What was the colour of the liquor?
Ans. Clear (as donated by ‘C’).
‣‣ When was the cervix fully dilated?
Ans. 8 hours following admission (at 2 pm) cervix was fully dilated.
‣‣ In a labour process when is the latent phase prolonged?
Ans. When the duration is more than 8 hours, it is called prolonged latent phase.
‣‣ What should be the appropriate management for the prolonged latent phase of labour?3
Ans. To make the cervix favourable by using prostaglandin E2 gel if required. This is followed by amniotomy (ARM) and oxytocin infusion.
‣‣ Where should the plotting of cervical dilatation be in normal labour?
Ans. In a normal labour, the plotting of cervical dilatation should be either on the alert line or to the left of it.
‣‣ What is your impression when cervical dilatation plotting crosses the alert time?
Ans. The labour is going to be prolonged.
‣‣ What steps you should take when the cervical dilatation has crossed the alert line and has reached the action line?23
zoom view
Fig. 1.7: Partogram representing graphically the important observations for labour2
24Ans. To reassess the situation as regard the maternal health, uterine contractions, FHR, position of the presenting part, pelvic adequacy and colour of the liquor. Depending on these, decision is made either for termination labour or for augmentation of labour.
‣‣ What do you mean by augmentation of labour?
Ans. Amniotomy is done if the membranes are intact. Oxytocin infusion is started in an escalating drop rate at an interval of 30 min. It is adjusted against uterine contractions. Ideally 3 to 4 contractions in 10 minutes time and each lasting for 40 seconds are optimum. Infusion once started, should be maintained at that rate throughout the second and third stage of labour.
Other aspects of management are:
  • Maternal hydration must be adequately maintained.
  • Pain relief during labour must be adequate.
  • Labour should be reassessed at an frequent interval for fetal and maternal well being.
  • Labour is terminated if there is no satisfactory progress by another 4 hours time.
REFERENCES
  1. World Health Organisation. Preventing prolonged labour: A practical guide. The partograph. Unpublished document WHO/FHE/MSM/93.8/9/10/11. World Health Organisation  Geneva.  1993.
  1. World Health Organisation. Maternal Health and Safe Motherhood Programme. World Health Organisation partograph in management of labour. Lancet 1994 b; 343: 1399–1404.
  1. World Health Organisation (WHO). Care in normal birth: A practical guide WHO/FRH/MSM/96.4. Geneva, 1996.
25
 
CASE–11: PRIMARY POSTPARTUM HAEMORRHAGE
‣‣ What is this condition called?
Ans. Primary postpartum haemorrhage.
‣‣ What management you would do immediately?1
Ans. To commence IV infusion with crystalloid (Ringer's solution). To send blood for ABO grouping, Rh typing and cross matching, continuous catheterisation and to call for help of the obstetric registrar.
‣‣ What are the possible causes of this problem?
Ans. Causes are divided by ‘four Ts’:
  • Tone (atonicity)
  • Trauma (genital tract)
  • Tissue (retained products of conception)
  • Thrombin (coagulopathy).
‣‣ What are the different medical management of this problem?
Ans.
  • To massage the uterus.
  • To give Oxytocin IV by infusion (10 units in 500 ml N saline, 40 drops per minute).
  • Inj. Methergin 0.2 mg IV or Inj. 15 Methyl PGF 250 mg IM or Misoprostol (PGE1) 1000 μg per rectum — depending on the response.
‣‣ What are the different surgical management of this problem?
Ans.
  • (i) Exploration of the uterus under general anaesthesia.
  • (ii) To repair any injury to the cervix, vagina, or perineum.
  • (iii) Uterine tamponade:
    • Tight intrauterine packing
    • Bimanual compression.
    • Balloon tamponade using different types of hydrostatic balloon catheter (Foley catheter, Bakri balloon, Sengstaken–Blakemore tube, inflated with 200–500 ml of saline) has been found effective.
      26
      This can avoid hysterectomy in 78% cases. Mechanism of action is similar to tight intrauterine packing.
  • (iv) Uterine brace suture (Fig. 1.8) B-Lynch or its modification are done by oversewing the uterus.
  • (v) Uterine devascularisation procedure:
    • Ligation of uterine and ovarian vessels.
    • Ligation of internal iliac arteries.
    • Angiographic embolisation of hypogastric artery by gelfoam.
  • (vi) Hysterectomy (rarely).
    Once bleeding is controlled, patient is observed in ICU or in high-dependence unit.
zoom view
Fig. 1.8:
B-Lynch (1997) uterine brace suture. In modified brace suture, the uterine cavity is not opened. A chromic catgut (No.2) suture is passed from anterior to posterior surface of the uterus and is tied tightly over the fundus. Similar is done on the other side. This acts by compression effect
REFERENCE
  1. RCOG prevention of postpartum haemorrhage; Green Top Guidelines No. 35: 2009.
 
27CASE–12: SECONDARY POSTPARTUM HAEMORRHAGE
‣‣ What is this abnormal bleeding called?
Ans. Secondary postpartum haemorrhage.
‣‣ What is the immediate management ?
Ans. She is admitted in the hospital, IV infusion is started with Ringer's solution. Blood is sent for grouping and cross matching.
‣‣ What are the possible causes ?
Ans. Endometritis, retained products of conception, blood clots or infection.
‣‣ What investigations would you organise for her ?
Ans. Blood for Hb%, TLC, DLC, high vaginal swab and midstream urine for culture and sensitivity, ultrasonography of the uterus.
‣‣ What would be the management ?
Ans. Antibiotics (combination of ampicillin and metronidazole), blood transfusion and may need evacuation of the uterus under general anaesthesia, if retained products are there.28
CASE–13: PREGNANCY AND LABOUR IN A WOMAN WITH PRIOR CAESAREAN DELIVERY
‣‣ What would be the possible diagnosis?
Ans. Scar dehiscence or scar rupture of uterus.
‣‣ What is the immediate management?
Ans. Resuscitation of the patient with IV infusion (crystalloid), blood sample for group and cross matching and to organise urgent laparotomy.
‣‣ What would be the actual management?
Ans. This will depend on the extent and type of rupture. Delivery of the baby is done first. If it is just a scar dehiscence — repair of the uterus is done following delivery. If it is extensive — it may need subtotal hysterectomy. But in such a patient it is unlikely.
‣‣ What additional step you may consider in this case?
Ans. To consider bilateral tubectomy when repair of the scar is done. However, it depends on adequate counselling with the couple and with informed consent before she would be taken to the operation theatre.
‣‣ How are you going to deliver her in her next pregnancy?
Ans. By elective caesarean section after 37 weeks.
‣‣ Had there been a classical scar on the uterus when is it more likely to rupture?
Ans. During pregnancy — commonly in the third trimester.
‣‣ Is there any place of induction and/or augmentation of labour in a woman who is undergoing VBAC?
Ans. There is an increased risk of uterine rupture in women planned for VBAC when they were induced with prostaglandins (ACOG). However, Oxytocin can be used judiciously for induction of labour. Oxytocin can be used to augment labour when labour has started spontaneously. Labour monitoring should be close for assessment of uterine contractions and scar tenderness. Continuous electronic fetal heart rate monitoring should be used. These are important for women undergoing VBAC when oxytocin is given either for induction or augmentation.
29‣‣ After a VBAC, should the uterine scar be explored as a routine?
Ans. There is no benefit from transcervical exploration of the uterine scar following VBAC as a routine. If there is no bleeding per vaginam and the uterus is well-retracted there is no need of exploration. Asymptomatic scar dehiscence, even if present, needs no treatment. Such dehiscence generally heal well. However presence of excessive vaginal bleeding and maternal tachycardia, hypotension need prompt assessment to exclude scar rupture.
‣‣ Is there any place of epidural analgesia to a woman who is undergoing VBAC-TOL?
Ans. VBAC-TOL is not a contraindication for the use of epidural analgesia. Epidural analgesia does not mask the signs and symptoms of uterine rupture.30
CASE–14: PUERPERAL PYREXIA
‣‣ What could be the possible reasons?
Ans.
  • Infection of the episiotomy wound.
  • Breast infection.
  • Urinary tract infection.
  • Respiratory tract infection or deep vein thrombosis.
‣‣ Enumerate few important symptoms and signs for the patient.
Ans.
  • Offensive vaginal discharge and perineal pain.
  • Engorged breasts with pain and tenderness.
  • Dysuria and frequency of micturition.
  • Cough, chest pain and crepitations.
  • Swollen legs with pain and tenderness.
‣‣ Organise few important investigations for her.
Ans. It will depend on the clinical examination findings. Common investigations are:
  • Wound swab for culture and sensitivity.
  • Midstream urine for culture and sensitivity.
  • X-ray chest.
  • Ultrasound scan with Doppler flow study of the calf veins.
‣‣ She faced difficulty in breastfeeding her baby. How are you going to help her?
Ans. Correct position of the mother, frequent feeding and correct attachment of the baby with the breast can improve the outcome. For any other difficulties, a trained nurse may be helpful.31
CASE–15: MULTIPLE PREGNANCY
‣‣ What important measures in the management of multiple pregnancy may improve the perinatal outcome?
Ans.
  • (i) Early diagnosis with sonography
  • (ii) Diagnosis of chorionicity and zygocity within 14 weeks (See Master Pass, p. 325)
  • (iii) Selective fetal reduction (See Dutta's Obst. p. 211)
  • (iv) Early detection of fetal congenital malformation
  • (v) Frequent antenatal visit at every 2–3 weeks from 32 weeks onwards
  • (vi) Diet with additional calories (+300 Kcal/day)
  • (vii) Extra rest at home and early cessation of work
  • (viii) Increased supplementation of iron (100–200 mg/day), folic acid, calcium and vitamins.
  • (ix) Counselling the woman about the risks of preterm labour and preterm babies.
  • (x) Fetal growth monitoring by serial ultrasound (every 2–3 weeks interval) examinations. Early detection of IUGR.
  • (xi) Hospitalisation and management of any complications like preterm labour, preeclampsia, polyhydramnios, IUFD, twin-twin transfusion syndrome.
  • (xii) Delivery in an equipped centre with facilities of NICU.
‣‣ What happens when one twin dies in uterus?
Ans.
  • (a) When death occurs in the first trimester → the dead fetus is completely absorbed.
  • (b) Death beyond the first trimester → the dead fetus may persist as a small, dried and flattened mass known as fetus papyraceous.
    The risk to the surviving fetus is there when the death of one fetus occurs in the second or third trimester. The risk to the surviving fetus depends upon the following factors: (i) time of death (first trimester or beyond) (ii) Chorionicity and zygocity of twins (iii) time interval between the death of one-twin to the delivery of the surviving twin. Monochorionic twins are at increased risks.
‣‣ How is the diagnosis of Twin-Twin Transfusion Syndrome (TTTS) made?
Ans. The diagnosis of TTTS is made on ultrasound criteria. These are as mentioned below:
  • (a) Monochorionic placenta
  • (b) Same sex gender
  • (c) Oligohydramnios with maximum vertical pocket (MVP) < 2 cm in one sac and polyhydranios (MVP ≥ 8 cm) in other sac
    32
  • (d) Discordant growth and bladder appearance: severe TTTS
  • (e) Haemodynamic and cardiac compromise: severe TTTS.
‣‣ Discuss the pathophysiology involved in TTTS
Ans. In TTTS, blood is transfused from the donor twin to its recipient. Donor becomes, anaemic, growth restricted, hypovolemic, pale and oliguric whereas the recipient becomes polycythemic, hypervolemic plethoric and polyuric. The recipient suffers from the problem of cardiac failure due to circulatory overload. There is differences in the amniotic fluid between the two sacs Donor twin suffers oligohydramnios whereas the recipient develops polyhydramnios. Due to oligohydramnios in the donor twin sac, the fetus fails to move (stuck twin). The polyhydramnios and oligohydramnios complex (“poly-oli” syndrome) results in IUGR, pulmonary hypoplasia of one (donor) twin and cardiac failure and PROM in the other (recipient) twin.
In TTTS there is unidirectional flow through arteriovenous anastomoses. This unidirectional flow leads to an imbalance in blood volumes. Deoxygenated blood from a donor is pumped into the recipient.
In the donor twin ischaemia may be due to hypotension, anaemia or due to both. The recipient twin also suffers from ischaemia due to episodes of hypotension.
Neurological damage in multiple pregnancy is due to ischaemic necrosis.
Cerebral pathology is due to cavitary lesions following ischaemia. Cerebral palsy, microcephaly, or encephalomalacia are the common cerebral lesions.
‣‣ Why is selective fetal reduction in multiple gestation done?
Ans. Maternal and perinatal complications are more in pregnancy complicated by quadruplets or greater number of fetuses. Pregnancy outcome is improved significantly by reducing the number of fetuses in early pregnancy. Selective fetal reduction is usually done at 10–13 weeks of pregnancy. Intracardiac injection of potassium chloride is usually done under ultrasound guidance.33
FETAL CONGENITAL MALFORMATIONS
CASE–16: NEURAL TUBE DEFECTS
‣‣ What is most likely the diagnosis ?
Ans. Open neural tube defects—encephalocele with spina bifida.
‣‣ How the prenatal diagnosis could have been made ?
Ans. Fetal anatomy scan with ultrasound.
‣‣ What biochemical test is helpful to make the diagnosis ?
Ans. Estimation of maternal serum alpha fetoprotein (MSAFP) at 15–18 weeks of gestation. The level is elevated (> 2.5 MOM) in such a case (p. 144).
‣‣ Who are the mothers that have the high risk for this abnormality ?
Ans.
  • Women over 35 years of age.
  • Family history or previous birth of neural tube defects.
  • History of recurrent miscarriage.
  • Epileptic mother with sodium val-proate.
  • Diabetic mother.
‣‣ What is the risk of recurrence and how could this be prevented ?
Ans. Recurrence risk after one child is 4%.
Pregnancy counselling is essential. Folic acid supplementation (4 mg daily) beginning 1 month before conception to about 12 weeks of pregnancy is recommended.
zoom view
Fig. 1.9: Encephalocele with spina bifida
34
CASE–17: ANENCEPHALY
‣‣ What is the diagnosis?
Ans. Anencephaly — defect of the neural tube.
‣‣ What are the possible pregnancy complications with this abnormality ?
Ans. Hydramnios (70%), malpresentation — breech, tendency of postmaturity, failure of induction, shoulder dystocia.
‣‣ How the prenatal diagnosis could be made?
Ans.
  • Sonography.
  • Elevated maternal serum alpha feto- protein (MSAFP) estimation at 15–18 weeks of gestation.
‣‣ What is the risk of future pregnancy?
Ans. Recurrence rate after one affected child is 4%.
‣‣ How the recurrence of this abnormality could be prevented?
Ans. Prepregnancy counselling is important. Folic acid supplementation (4 mg daily) beginning 1 month before conception to about 12 weeks of pregnancy.
‣‣ Who are the high risk women for neural tube defects?
Ans. It is not possible to identify all the high-risk women. But in general the high-risk women are:
  • Woman with a previous pregnancy affected with NTD.
  • Maternal diabetes mellitus.
  • Maternal drug intake—valproic acid, carbamazepine.
  • Woman with her husband or close relative who has an NTD.
zoom view
Fig. 1.10: Anencephaly, absence of cranial vault (calvarium) and telencephalon
35‣‣ Why folic acid supplementation is recommended before conception?
Ans. Randomised controlled trials have shown that women who had a previous child with a NTD, high dose folic acid (4 mg/day) decreased the risk by 70%. Centre for Disease Control and Prevention (CDC) recommends that women who had one previous NTD affected pregnancy should be supplemented with 4 mg of folic acid per day. Therapy should begin at least 4 weeks before conception and to be continued through the first trimester.
Women with no history of NTD affected pregnancy, should take 400 μg of folic acid similar to that of the high-risk women.36
CASE–18: HYDROCEPHALUS
‣‣ What is the abnormality?
Ans. Hydrocephalus.
‣‣ What are the pregnancy complications with this abnormality ?
Ans. Undiagnosed cases when left uncared for, labour will become prolonged and obstructed. Rupture of uterus may occur. Fetal outcome is extremely poor.
‣‣ How could it be diagnosed pre-natally ?
Ans. Ultrasonography: Dilated lateral ventricles and thinning out of cortex (Fig. 1.11B). Clinical examination during labour — gaping of suture lines and tense fontanelles.
zoom view
Fig. 1.11A: Hydrocephalus
‣‣ How could the baby be delivered vaginally where there is no other contraindication?
Ans. In labour when the cervix is 3–4 cm dilated, decompression of the head (cephalic presentation) is done by sharp pointed scissors or a perforator.
In breech presentation during assisted vaginal breech delivery, to deliver the after coming head, laminectomy at the cervical region is done to open up the spinal canal to drain CSF and for decompression.
Abdominal decompression (cephalocentesis) with a large bore lumbar puncture needle may also be done.
‣‣ What is the risk of future pregnancy?
Ans. Risk of recurrence in subsequent pregnancy is about 5%.
zoom view
Fig. 1.11B:
Ultrasonography showing marked ventricular enlargement (F. flax) with thinning of the cortex (V)
37
CASE–19: CYSTIC HYGROMA
‣‣ What is the abnormality?
Ans. Huge cystic hygroma.
‣‣ What are the common causes of the abnormality ?
Ans. Turner's syndrome (45XO).
Trisomy 18; Trisomy 21; Triploidy.
‣‣ How is it diagnosed prenatally ?
Ans. Ultrasonography (Figs 1.12B and C).
Important markers are:
  • Nuchal thickness > 3 mm (subcutaneous oedema at the level of the neck due to dilatation of the lymphatic capillaries) is associated with chromosomal abnormalities like 45X, trisomies (13, 18, 21), triploidy and aneuploidy.
  • Hydrops — Trisomy (13, 18, 21), 45XO.
  • Short femur — Trisomy 21.
  • Banana sign (banana configuration of the cerebellum) — dysplastic cerebellum.
  • Lemon sign (Frontal concave scalloping) — Fig. 1.12C, arrow.
    Banana sign and Lemon signs are observed in cases with open spina bifida.
zoom view
Fig. 1.12A: Cystic hygroma (fetus with Turner's syndrome)
zoom view
Fig. 1.12B: Ultrasonography of the fetus showing thickened nuchal translucency (arrow)
zoom view
Fig. 1.12C: Ultrasonography showing lemon sign and banana sign (arrow)
38‣‣ What are the high-risk factors for such an abnormality?
Ans.
  • History of recurrent miscarriage.
  • Previous birth of a chromosomally abnormal fetus.
  • Previous child mentally retarded.
  • Family history of chromosomal abnormality.
  • Parental chromosomal abnormality (translocation).
‣‣ Who are the high-risk women to have an infant with chromosomal abnormality?
Ans.
  • Maternal age ≥ 35 years.
  • Previous baby with NTD.
  • Previous baby with chromosomal abnormality.
  • Family history of NTD.
  • Abnormal maternal serum screening tests (See Dutta's Obst. p. 108).
  • Abnormal fetus on ultrasound.
  • Chromosomal abnormality in either parent (aneuploidy, balanced translocation).
‣‣ What different investigations are performed to detect fetal genetic, chromosomal and structural abnormalities?
Ans. Screening and diagnostic procedures for early detection of fetal (i) genetic (ii) chromosomal and (iii) structural abnormalities are as below:
Tests for Prenatal Diagnosis
Screening tests
Diagnostic tests
  • Maternal serum alpha fetoprotein (MSAFP) p. 106
  • Triple test (combined test) : ↓ MSAFP, ↓ unconjugated oestriol (E3) and ↑ hCG (p. 106)
  • Quadruple test : ↓ MSAFP, ↓ UE3, ↑ hCG, ↑ inhibin (p. 493)
  • Integrated test (See Master Pass, p. 334)
  • Integrated serum test
    (See Master Pass, p. 334)
  • High resolution ultrasonography (p.643)
  • 3-D or 4-D ultrasound with increased resolution (See Dutta's Obst, p.641).
  • Chorion villus biopsy (p. 108)
  • Amniocentesis (p. 107, 647)
  • Cordocentesis (p. 108)
  • Fetoscopy (p. 494)
  • Fetal cell isolation from maternal blood.
    Genetic analysis from isolated fetal nucleated red blood cells or trophoblast cells (free fetal DNA).
  • Peri-implantation genetic diagnosis (p.494)
39‣‣ What is the current recommendation for prenatal genetic diagnosis?
Ans. All pregnant women should be offered screening for Down's syndrome (RCOG clinical guideline 2007), with a test which provides detection rate above 75% and a false-positive rate of less than 3%. These tests should be age standardised and based on a cut off value of 1 in 250 or greater.