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Clinics in Obstetrics
Tania Gurdip Singh
SECTION 1: LONG CASES
CHAPTER 1:
Antenatal Care
First Trimester (First 12 Weeks of Pregnancy)
CLINICAL FEATURES
Symptoms
Signs
Breast Signs
Pelvic Signs
Uterus
Vagina and Vulva
LABORATORY TESTS
Immunological Tests for the Diagnosis of Pregnancy
Principle
Tests Used
Progesterone
Early Pregnancy Factor
Home Pregnancy Tests
Reading the Test
Other Routine Blood Tests
Indications for Prenatal Counseling and Screening
Interpretation of Various Markers
ULTRASONOGRAPHY
Transvaginal
Nuchal Translucency (NT)
How to Measure?
Possible Causes for Increased Fluid-filled Space
Nasal Bone
How to Visualize?
Optimal Timing of USG for Fetal Anomalies
Following Important Points to be Explained at this Juncture
PREGNANCY DIET AND WEIGHT GAIN
Types of Diet
General Principles
Calorie Chart for Basic Food Items
Fruits per 100 Grams
Vegetables per 100 Grams
Cereals per 100 Grams
Indian Breads (Per Piece)
Milk and Milk Products (Per Cup)
Calories in Other Items
Weight Gain in Pregnancy
Second Trimester (13–28 Weeks)
CLINICAL FEATURES
Symptoms
Signs
Vaginal Examination
14–16 Weeks
18–20 Weeks
24–25 Weeks
Fundal height (McDonald’s Rule)
Symphysis—Fundal Height (by Tape)
ULTRASOUND
Level II Scan
Amniotic Fluid
Appearance
Quantity and Constituents
Quantity Changes
Functions
Placenta
Third Trimester (29–40 Weeks)
Signs and Symptoms
Examination
‘Lie’
‘Presentation’
‘Presenting Part’
‘Attitude’
‘Denominator’
‘Position’
Edema
Physiological Edema
Approach to a Patient of Edema
28–30 Weeks
32–34 Weeks
Leopold’s Maneuvers
First Maneuver: Fundal Grip
Second Maneuver: Umbilical Grip or Lateral Grip
Third Maneuver: First Pelvic Grip
Fourth Maneuver: Pawlick’s Grip (Second Pelvic Grip)
To Summarize
36–38 Weeks
Pelvic Assessment
Sacral Promontory
Curvature of the Sacral Curve
Pelvic Side Walls
Ischial Spines
Sacrosciatic Notch
Posterior Surface of Symphysis Pubis
Pubic Arch
Subpubic Angle
Now take out your fingers
Intertuberous Diameter
Conclusion
40–41 Weeks
Modified Bishop Score or Prelabor Scoring or Preinduction Score
Interpretation
ULTRASOUND
Calculation of Gestational Age
Menstruation—Labor Interval (Naegele’s rule)
A General History in Pregnancy
Chief complaints of the patient
Past Obstetric History (Gravida, Parity, Abortions, Ectopic, Twins, Death)
Importance
Present Pregnancy
Menstrual History
Importance
Past Personal History/History of Medications, Surgeries, Allergies(Some medical conditions may become worse during pregnancy)
Family History
Social Circumstances of the Patient
Kuppuswamy Scale (2012)
Physical Examination
General Appearance
Systemic Examination
To Summarize
Few Other Queries are Always in a Pregnant Woman’s Mind
Lifestyle Considerations
Food-acquired Infections
Medicines
Exercise in Pregnancy
Sexual Intercourse in Pregnancy
Alcohol Consumption in Pregnancy
Smoking in Pregnancy
Air Travel during Pregnancy
Car Travel during Pregnancy
Travelling Abroad during Pregnancy
Management of Common Symptoms of Pregnancy
Nausea and Vomiting in Early Pregnancy
Heartburn
Constipation
Hemorrhoids
Varicose Veins
Leg Cramps
Vaginal Discharge
Backache
Breast Care
Prediction, Detection and Initial Management of Mental Disorders
Topics to be discussed during health education sessions
Preconception History and Counseling
HISTORY
Genetic History
Risk Factors
Family History
Genetic Disorders in the Family
Multifactorial Congenital Malformations
Familial Diseases with a Major Genetic Component
Age
Health History
Chronic Conditions
Infectious Conditions
Reproductive History
Lifestyle Assessment
COUNSELING
CHAPTER 2:
Anemia in Pregnancy
HISTORY IN A CASE OF ANEMIA AND SIGNIFICANCE OF EACH CONTENT
General Information
HISTORY OF PRESENT ILLNESS (HOPI)
Obstetric History
Past History
Family History
History of Chronic Illness (Anemia of Chronic Disease)
General/Local Examination
Signs (Clinical Clues)
Differentiation of Erythrocyte
Regulatory Factors
Role of Hepcidin in Iron Deficiency Anemia
Maturation
Vitamins
Minerals
Proteins
Hemoglobin
Classification of Anemia
Acquired
Inherited
Concept of Physiological Anemia in Pregnancy
Benefits
Harmful Effects
Daily Intake of Dietary Iron
Factors Leading to Anemia during Pregnancy
MANANGEMENT OF IRON DEFICIENCY ANEMIA
I. Iron demand in pregnancy
III. Preventive measures
Micronutrient Deficiencies: Risk Factors and Health Consequences
Iron
Folate (Vitamin B9)
Vitamin B12 (Cobalamin)
Calcium
Vitamin D
National Anemia Prophylaxis Program
WHO Recommendations
Focused Antenatal Care (FANC) by WHO
Intervention Strategies which Help Provide the Neonate with Adequate Iron Reserve
Prevention of Parasitic Infections
IV. Treatment Proper
Newer Oral Iron Preparations
Iron III Hydroxide Polymaltose Complex (Mumfer)
Iron Bisglycinate
Carbonyl Iron
Na Feredetate
Gastric Delivery Systems
Short Gun Therapy of Anemia
Parenteral Administration
Indications for Parenteral Therapy
Contraindications
Preparations
Routes
Severe Anemia in Late Pregnancy and Labor
Late Pregnancy
Labor/Delivery
Postpartum
Failure of Treatment in Case of Iron Deficiency Anemia
Causes
Place of Blood Transfusion in Case of Iron Deficiency Anemia
Place of Exchange Transfusion
Role of Erythropoietin in Anemia
Indications
Product Detail (In India)
Drug Administration
NRHM (NATIONAL RURAL HEALTH MISSION) RECOMMENDATIONS, 2013
Antepartum
Hb between 9 and 11 g/dL
Hb between 8 and 9 g/dL
Hb between 7 and 8 g/dL
Hb between 5 and 7 g/dL
Hb <5 g/dL
Postpartum
IMPORTANT POINTS
Hemochromatosis:
SIDEROBLASTIC ANEMIA
PORPHYRIA
HEMOGLOBINOPATHY
Thalassemia
Step I: RBC Indices
Step II: Confirm by Electrophoresis
Step III: Investigations of the Partner
Beta Thalassemia
Alpha Thalassemia
Pathophysiology of the Disease
SICKLE CELL DISEASE (SCD)
Definition
Epidemiology
Pathology
Understanding the Disease
Cause
Clinical Manifestations
Chronic Manifestation
Acute Manifestation
Consequences of Anemia
Management
Preconceptional Counseling
Effect of Pregnancy on Sickle Cell Disease
Effect of Sickle Cell Disease on Pregnancy
Antepartum Management
Intrapartum Care
Postpartum Care
Complications
Painful Crisis
Acute Chest Syndrome
Acute Stroke
Acute Anemia
Prognosis
MEGALOBLASTIC ANEMIA
What is Megaloblastic Anemia?
Mechanism
Why is There Impaired DNA Synthesis or Abnormal Maturation?
Folic Acid (An Overview)
Incidence
Why is Vitamin B12 Deficiency Rare?
Causes of Megaloblastic Anemia in Pregnancy
Other Investigations which can Confirm Diagnosis of Megaloblastic Anemia
Hemogram
Peripheral Smear
Other Findings
Diagnostic (Definitive)
Rarely Done
Which is more Dangerous. Iron Deficiency Anemia or Megaloblastic Anemia?
How would You Treat this Patient?
Conditions where Folate Requirement is increased even in Nonpregnant State
Maternal and Fetal Complications
CHAPTER 3:
Recurrent Pregnancy Loss
IMPORTANT POINTS IN HISTORY
Age of Both Partners
Obstetrics History
Menstrual History
Past History
Family History
General Physical Examination
P/A
P/S
P/V
Special Investigations
QUESTIONS LIKELY TO BE ASKED
Total Number
Trisomy (50%)
Monosomy X (20%)
Triploidy (15%)
Tetraploidy (5%)
Structure
Inversions (0.3%)/Intrachromosomal Rearrangements
Paracentric
Pericentric
Recent Advances
DIAGNOSIS OF RPL
Genetic Causes
Immunological Causes (Cellular Immune)
Humoral Immune Mechanisms
Lupus Anticoagulant
Anticardiolipin (aCL) antibodies: IgG and IgM (sensitivity 80–90%) → ELISA
Anti-β2 GP1 antibodies
Diagnostic Criteria/Sapporo’s Revised Criteria, 2006
Three Prominent Features of the Updated APAS Classification
Risk of Pregnancy Loss with APAS
APAS and Thrombosis
Association with DVT
Association with Arterial Thrombosis
Tests to be Done
APAS and Pregnancy
INHERITED THROMBOPHILIAS
Hyperhomocysteinemia
ANATOMIC CAUSES
Congenital Malformations
Diagnostic Signs
Diagnostic Procedures
ENDOCRINE ABNORMALITY
Thyroid Disorders
TREATMENT OF RPL
Therapeutic Options
Genetic Abnormality
3 Alternatives
Anatomic Abnormality
Inherited Causes
Clinical Features
Treatment
Acquired Causes
Endocrine Abnormality
LPD
Hyperinsulinemia
DM/Hypothyroidism/Hyperprolactinemia →Treat accordingly
Humoral Cell Mechanisms
Low-dose Aspirin (75–80 mg)
Heparin (1st Line Therapy)
Low Molecular Weight Heparin
LMWH
SCHEME OF MANAGEMENT IN CASE OF APLA POSITIVE
With Previous History of Thrombosis
With Previous Pregnancy Mishap
Warfarin
Glucocorticoids
Intravenous Immunoglobulins
Hydroxychloroquine
Infection
Unexplained RPL
CHAPTER 4:
Antepartum Hemorrhage in Early Pregnancy
CERTAIN IMPORTANT THINGS NEED TO BE DISCUSSED BEFORE PROCEEDING TO THE ACTUAL TOPIC
Normal Early Intrauterine Pregnancy
Abnormal Early Intrauterine Pregnancy
Molar Pregnancy
Corpus Luteal Cyst
PUL (Pregnancy of Unknown Location) or Negative Pelvic Sonogram
ECTOPIC PREGNANCY
An Overview
Prevalence
Implantation Sites
Extrauterine (98%)
Intrauterine (1.5–2%)
Tubal Ectopic Pregnancy
Etiology
Risk Factors
Presentation
Diagnosis
Treatment
Surgical Route
Persistent Ectopic
Medical Management
Methotrexate Therapy
Protocols
Single Dose (Without Folinic Acid)
Fixed Multiple Dose (Alternated with Folinic Acid – Leucovorin)
Effects Related to Drug
Effects Related to Treatment
Advice to patients on Methotrexate Therapy
Congenital Anomalies Associated with MTX
Predictors of MTX Treatment Failure
Future Fertility and Risk of Recurrence
Expectant Management
Heterotopic Pregnancy
Interstitial Pregnancy
Cornual Pregnancy
Cervical Pregnancy
Hoffman Criteria for Cervical Pregnancy
Ovarian Pregnancy
Scar (cesarean) Pregnancy
Intra-abdominal Pregnancy
ABORTION
Types
Missed Abortion
History
Diagnosis
USG
Complications (though rare)
Management
Threatened Abortion
Diagnosis
USG
Management
Advice on Discharge
Inevitable Abortion
Diagnosis
USG
Management
Incomplete Abortion
Diagnosis
USG
Management
Complete Abortion
History
USG
Management
Anembryonic Gestation
Definition
USG
MEDICAL TERMINATION OF PREGNANCY
Regimen I
Regimen II
SURGICAL TERMINATION OF PREGNANCY
GESTATIONAL TROPHOBLASTIC DISEASE (GTD)
Classification
Incidence and Risk Factors
Hydatidiform Mole
Complete Hydatidiform Mole
Partial Hydatidiform Mole
Suspicion of Persistent Disease
Management
Evacuation of Molar Pregnancy
Hysterectomy
Anesthesia during Evacuation
FIGO ANATOMICAL STAGING
EMA-CO REGIMEN
GESTATIONAL TROPHOBLASTIC NEOPLASIA
Overview
Invasive Mole (Chorioadenoma Destruens)
Choriocarcinoma
Treatment
Placental Site Trophoblastic Tumour (PSTT)
Management
Resistant to Chemotherapy
Survival Rate
Epithelioid Trophoblastic Tumour (ETT)
Management
Follow-up after Treatment for GTN
Management
Recurrent or Chemoresistant Gestational Trophoblastic Neoplasia
Quiescent Gestational Trophoblastic Disease
Ultrasound Features of Molar Pregnancies
Complete Hydatidiform Mole
Partial Molar Pregnancy
Persistent Trophoblastic Neoplasia
Placental Site Trophoblastic Tumour
CHAPTER 5:
Antepartum Hemorrhage in Late Gestation
Management of the Patient Presenting with Antepartum Hemorrhage
Complete History
ANTEPARTUM HEMORRHAGE
ABRUPTIO PLACENTA
Definition
Incidence
Risk Factors
Pathophysiology
Theory I
Theory II
Classification
Ernest Page’s Classification
Sher’s Classification
Clinical Features
Role of Sonography
Management
Active Management
Expectant Management
Management Proper
Disseminated Intravascular Coagulopathy (DIC)
Naturally Occurring Anticoagulants
What is DIC?
Conditions Associated with DIC
Stimulation of Coagulation Activity and Possible Consequences
Clinical Features of DIC
Diagnosis
Management
Blood Component Therapy
PLACENTA PREVIA
Jauniaux and Campbell Classification
Risk Factors
Etiopathogenesis
Clinical Suspicion
Definitive Diagnosis
Advantages of TVS over TAS
Few Observed Technical Difficulties
PLACENTAL INVASION (Accreta, Increta, Percreta)
Incidence
Definition
Etiology
Risk Factors
Complications of Placenta Percreta
Imaging Modalities in Placenta Accreta, Increta or Percreta
Grayscale Ultrasound
2D Color Doppler
3D Power Doppler
MRI
Antenatal Management
Risks
Delivery
Mode of Delivery
Time of Delivery
Prerequisites before Delivery
Treatment of Massive Placental Invasion
Vasa Previa
Incidence
Risk Factors
Differential d iagnosis on USG
Diagnosis
Risks
Management
Cervical Polyp
Vulvovaginal Trauma
Hematuria
CHAPTER 6:
Uterine Size More than Expected
MULTIPLE GESTATION
How to Diagnose?
Role of Ultrasound in Twin Pregnancy
DETERMINATION OF CHORIONICITY AND AMNIONICITY
Chorionicity (C)
Amnionicity (A)
Assessment of C and A
Zygosity
DZ Twins (Binovular)
MZ Twins (Uniovular)
Useful Facts
COMPLICATIONS RELATED TO CHORIONICITY
Dichorionic Diamniotic
Discordant Growth
Intrauterine Death of One fetus
IUFD in Dichorionic Twins
Monochorionic Diamniotic
Twin to Twin Transfusion Syndrome (TTTS)
Intrauterine Fetal Death
Twin Reversed Arterial Perfusion Syndrome (TRAP)
Monochorionic Monoamniotic
Conjoined Twins
DETERMINATION OF GESTATIONAL AGE
SCREENING FOR ANOMALIES
First Trimester
Second Trimester
Fetal Surveillance
CERVICAL LENGTH MEASUREMENT
ASSESSMENT OF AMNIOTIC FLUID
Hellin’s Rule
Incidence of Multifetal Gestation
Multifetal Gestation
Twin Gestation
Factors Contributing to Twinning
Maternal complications
Fetal Complications
Place of Invasive Procedures
MANAGEMENT OF TWIN GESTATION
Prepregnancy (for any woman trying conception)
Antenatal
First Trimester
Second Trimester
Third Trimester
Intrapartum
Optimal Time of Delivery
Indications for Cesarean Section
Management Proper
EFW >1500 gm
EFW <1500 gm
Third Stage: Most Dangerous
Special Situations
Twins with Previous Scar
Twin Entrapment
Triplets or Higher Order
POLYHYDRAMNIOS
Definition
History
Epidemiology
Classification
Causes
Chief Complaints
Signs
GPE
Inspection
Palpation
Auscultation
Investigations
USG
USG Criteria
Important Points
How to Measure AFI?
Rationale Behind Polyhydramnios and Oligohydramnios
Management Options
Acute Polyhydramnios
HYDROPS FETALIS
Definition
Classification
IMMUNE HYDROPS
Cause
Why Named Mirror Syndrome?
Difference with Preeclampsia
NONIMMUNE FETAL HYDROPS (NIFH)
Causes and Associations of NIFH
MYOMA
OTHER PELVIC MASSES
VESICULAR MOLE
Differential Diagnosis
MACROSOMIA
Generalized Fetal Enlargement
Definition
Causes
USG
Fetal Hazards
Maternal Hazards
Treatment
WRONG DATES
Methods for Determining Menstrual Age
Good Dates
Bad Dates
Prediction of Gestational Age
Patient’s Statement
Previous Records
Objective Signs
USG
CHAPTER 7:
Uterine Size Less than Expected
BRIEF DESCRIPTION OF ALL POSSIBILITIES
Wrong Dates
Good Dates
Criteria
Bad Dates
Criteria
Constitutionally Small Fetus (Small for Gestational Age)
Criteria
Symmetrical IUGR
Criteria
Asymmetrical IUGR
Criteria
OLIGOHYDRAMNIOS
Definition
Quantitatively
Subjectively
Incidence
Causes
Fetal
Bilateral Renal Agenesis
Potter’s Facies
Diagnosis
Urinary Tract Obstruction
Maternal
Clinically
USG
Management
Role of Maternal Hydration
Role of Vesico-amniotic Shunt
Complications
INTRAUTERINE FETAL DEMISE
Definition
Incidence
Risk Factors
Morbid Pathology
Diagnosis (2 steps)
To Confirm IUD
To Find Cause of IUD
Management
IUGR
Prevalence
Diagnosis
Clinical Examination
Weight Gain
Maternal Blood Pressure
Fundal Height by (McDonald’s Rule)
Symphysis Fundal Height
Investigations
< 28 weeks (Usually Symmetrical)
>28 weeks (Usually Asymmetrical)
Common Investigations (To Both Symmetrical and Asymmetrical IUGR)
Ultrasonography
Interval Growth (on USG)
Treatment Proper
2 basic steps
APFS
DOPPLER
CHANGES IN NORMAL PREGNANCY
Normal Fetal Circulation
Venous Tributaries Entering Right Atrium
Venous Tributaries Entering Left Atrium
Fetal Hemodynamics in Growth Restriction
Uteroplacental Blood Flow Assessment
Physiology
Doppler Assessment
Resistive Index (Pourcelot Index)
Systolic/Diastolic Ratio (S:D ratio)
Pulsatility Index (PI) (Gosling Index)
Abnormal Patterns Include
Doppler in IUGR
DIAGRAM
Middle Cerebral Artery (MCA)
Normally
DIAGRAM
Fetal Venous Circulation
Umbilical Vein
IVC
DV Flow
Doppler Assessment (Normal)
DIAGRAM
DETERMINATION OF OPTIMUM TIME OF DELIVERY
>28 weeks
Follow Up
If RI/PI ↑
Indications for Termination
Modes of Termination
Important Points
Following has No Role
CHAPTER 8:
Diabetes in Pregnancy
GESTATIONAL PREDIABETES
PREGESTATIONAL DIABETES (OVERT DIABETES)
GESTATIONAL DIABETES (GDM)
Prevalence
Screening Based on Risk Factors
Low Risk
Moderate Risk
High Risk
Screening and Diagnosis Based on Laboratory Values
IADPSG (International Association of Diabetes and Pregnancy Study Group)
Carpenter and Coustan
WHO/NICE
DIPSI (Diabetes in Pregnancy Study Group India)
Prediabetes
Overt Diabetes
GDM
Classification of Diabetes
Type 1 Diabetes
Type 2 Diabetes
Other Types (Due to Other Causes)
GESTATIONAL
DIABETES MELLITUS (GDM)
Pedersen Hypothesis
Recent Advances
Risks to Mother
Risks to Fetus
Risks in Newborn
Risk to Children Born to Diabetic Mothers
Treatment in Pregnancy
Diet and Nutrition Therapy
Diet in Diabetes
Exercise
Insulin therapy
Chemistry
Physiological and Pharmacological Actions
Mechanism of Action
Sources of Exogenous Insulin
Administration
Disadvantages/Adverse Reactions
Concentration in Pregnancy
Available Types
Regimens for Administration of Insulin
Key Points
Glucose Monitoring
Future Researches
Intrapartum Management
Immediate Postpartum
Recurrence of Gestational Diabetes
Oral Hypoglycemic Agents (OHAs)
Sulphonylureas
Glyburide
Biguanides (insulin sensitizers)
Alpha Glucosidase Inhibitors
Thiazolidinediones (insulin sensitizers)
Meglitinides (insulin secretagogues)
Management Proper
Prepregnancy Counseling (in cases of pre-existing diabetes)
Antenatal management
Labor
Postpartum
Sterilization
CHAPTER 9:
Hypertensive Disorders in Pregnancy (HDP)
IMPORTANT POINTS IN THE HISTORY
Present and Past History of BP Elevation
Family History
Physical Examination
Blood Pressure Recording in Pregnancy–Ideal Method
AN OVERVIEW
Hypertension in Pregnancy (Pih is an Obsolete Term and should not be Used)
Classification
Incidence and Prevalence
Predictive Testing
Role of Uterine Artery Doppler in Prediction of Preeclampsia
Role of Mean Arterial Pressure
Can Proteinuria be Used as A Predictor of Complications?
Testing for Proteinuria
Readings of Dipstick
How Much BP is to be Lowered?
In Mild and Moderate Cases
In Severe Cases
Fundus Changes in Hypertensive Disorders
Grade I
Grade II
Grade III
Grade IV
BEFORE MOVING ONTO THE ACTUAL MANAGEMENT, LETS DISCUSS THE ROLE OF FEW DRUGS
How is Calcium Important in Hypertensive Disorders?
How is Acetyl Salicylic Acid Helpful in Preeclampsia?
Use of Diuretics During Pregnancy
Mechanism of Action
ACE Inhibitors during Pregnancy
Use in 1st trimester
Use in 2nd and 3rd Trimester
DRUGS FOR HYPERTENSIVE DISORDERS
Maternal Antihypertensive Medications Usually Compatible with Breastfeeding
Anesthesia and Fluid Management
Do not use the following to prevent hypertension
Reducing the Risk of Hypertensive Disorders in Pregnancy
GESTATIONAL HYPERTENSION
Maternal Monitoring
Mild Hypertension (140/90 to 149/99 mmHg)
Moderate Hypertension (150/100 to 159/109 mmHg)
Severe Hypertension (≥160/110 mmHg)
Fetal Monitoring
Mild and Moderate Hypertension
Severe Hypertension
Time of Delivery
Postnatal
PREECLAMPSIA (PE)
Risk Factors for Preeclampsia
Note:
Does Edema has Any Significance in Preeclampsia?
Management
Mild PE (140/90 to 149/99 mmHg)
Moderate PE (150/100 to 159/109 mmHg)
Outpatient Management (once BP stabilizes)
Severe PE
Postnatal Management
IMPENDING ECLAMPSIA
Symptoms/Signs of Impending Eclampsia
Management
Depending Upon Gestational Age
Factors Mandating Immediate Delivery
Labor Management in Hypertensive Disorders
CHRONIC HYPERTENSION
Preeclampsia Superimposed on Chronic Hypertension
WHITE COAT HYPERTENSION
Management of Chronic Hypertension
Maternal
Fetal
Postpartum Management of Hypertensive Disorders
Breastfeeding while on Antihypertensive Rx
Future Pregnancy
Risk of Recurrence
Women at High Risk of Preeclampsia
CHAPTER 10:
Previous Cesarean Section
MANAGEMENT IN LABOR
1st stage
2nd Stage
3rd Stage
CESAREAN SECTION
Average Rate of Cesarean Section Worldwide
Types of Cesarean Section
According to Timing
According to the Site of Uterine Incision
According to the Number of Operations
According to the State of Peritoneal Cavity
Indications for Cesarean Section
Common Indications
Less Common Indications
Anesthesia in Cesarean Section
Spinal Anesthesia
Epidural
General Anesthesia
Techniques of Cesarean Section
Preoperative Preparation (In Any Type)
Types of Incisions and Various Techniques for Cesarean Section
Pfannenstiel
The Pelosi-type Cesarean Section
Maylard Procedure
The Cherney Procedure
Mouchel Incision
The Joel-Cohen technique
The Misgav-Ladach Technique
Modified Misgav - Ladach Technique
Traditional Vertical (Midline and Paramedian)
Midline Vertical or Subumbilical Midline Incision
Paramedian incision
Upper Segment Cesarean Section
The Extraperitoneal Cesarean Section
Porro’s operation
Porro-Müller Operation
Porro-Veit Operation
Wound Drainage for Cesarean Section. Required?
Advantages
Disadvantages
Methods of Removal of Placenta after Cesarean Section
Is there any Role of Mechanical Dilatation of Cervix at Elective Cesarean Section?
Extra-abdominal versus Intra-abdominal Repair of the Uterine Incision at Cesarean Section
Exteriorization of the Uterus
The Other Side
Complications of Cesarean Section
Operative
Post-operative
Postoperative Care and Complications
Few Very Important Points Regarding the Post Operative Period Need a Special Mention
Fluid Management
IV Fluids
Ringer’s Lactate
Isotonic saline (0.9% NaCl-Normal saline)
Dextrose Saline (DNS)
5% Dextrose
Fluid and Electrolyte Therapy
Normal Physiology Post Operatively
Complications with Fluid and Electrolytes
Hypokalemia
Hyponatremia
How to Calculate Rate of Fluid Infusion?
Post operative Infections
Risk Factors
Fever
Non Operative Site Infections
UTI
Vascular
Phlebitis
Respiratory
Operative Site Infections
Wound complications
Physiology of Wound Healing
Post Operative Wound Complications
Surgical Wound Healing
Bowel Obstruction
Paralytic Ileus
Adhesion Formation after Cesarean Section
Pathology of Adhesion Formation
How adhesions form?
Prevention of Adhesions after Cesarean Section
CHAPTER 11:
Pain Abdomen during Pregnancy
OBSTETRIC CAUSES
Medical/Surgical Causes
GYNECOLOGICAL CAUSES
ABDOMINAL EXAMINATION WILL HAVE THE FOLLOWING CHANGES DURING PREGNANCY
OBSTETRIC CAUSES
Medical/Surgical Causes
GYNECOLOGICAL CAUSES
MEDICAL AND SURGICAL CAUSES
Acute Cystitis
Incidence
Investigations
Management
Acute Pyelonephritis
Investigations
Management
Cholelithiasis/Acute Cholecystitis
Investigations
Management
Surgery
Prognosis
Recurrence
Acute Pancreatitis
Investigations
Management
Surgery
Prognosis
Intestinal Obstruction
Causes
Investigations
Management
Prognosis
Appendicitis
General Overview
Anatomy
Diagnosis
Management
Prognosis
Urolithiasis
Investigations
Management
Prognosis
Acute Hydronephrosis
GYNECOLOGICAL CAUSES
Adnexal Masses
Ovarian Tumours
Ovarian Cancer
Rupture of Ovarian Cyst
Investigations
Management and Prognosis
Adnexal Torsion
Investigations
Management
Prognosis
Degenerating Myoma/Painful Myoma Syndrome
Investigations
Management
Effects of Fibroid on Pregnancy
Prognosis
PRETERM LABOR
Definitions
Preterm Birth
Moderately Preterm Birth
Late Preterm Birth
Very Preterm Birth
Early Term Birth
Imminent Preterm Birth
Risk Factors for Preterm Birth
Pathophysiology of Preterm Labor
Ripening of the Cervix
Stimulation and Activation of Uterine Musculature
Activation of Fetal Membranes
Conditions Causing Premature Activation
CERVICAL LENGTH AND PRETERM LABOR
Usg Evaluation of Cervix
Why not TAU and TLU?
Technique
Limitations and Pitfalls
Digital Examination – Why Not to Use?
What to Measure?
Cervical Length (CL)
Funneling
Between 10–14 weeks
After 30 weeks
Cervical Length Measurement in Women at Risk of Preterm Birth
Who Can Have a Short Cervix?
How Frequently should the Cervical Length be Measured?
Measures to be taken to Avoid Preterm Labor
Recent Terminologies
History-indicated Cerclage
Ultrasound-indicated Cerclage
Rescue Cerclage
Transvaginal Cerclage (McDonald)
High Transvaginal Cerclage (Shirodkar)
Transabdominal Cerclage
Occlusion Cerclage
Contraindications to Cervical Cerclage Insertion
Risks
Recent advances/Recommendations
Is There a Role of Cervical Length Measurement Post-cerclage?
How Far is Tocolysis Justified in Preterm Labor?
Drugs for Tocolysis
Beta Agonists (mainly Ritodrine)
Calcium Channel Blockers
Isoxsuprine
Atosiban
Indomethacin
Rofecoxib
Magnesium sulfate
Nitroglycerin
Terbutaline (Beta Mimetic)
Contraindications to Tocolysis
Absolute
Relative
Corticosteroids in Preterm Labor
An overview and Explanation
Recent Advances
Magnesium Sulfate and Neuroprotection in Preterm Births
Severe Intraventricular Hemorrhage
White Matter Injury
Cerebral Palsy
Important Points
Progesterone in Preventing Preterm Labor
Vaginal progesterone or cervical cerclage. Which is superior?
Characteristics of Preterm Babies
New Ballard Scoring System
Neuromuscular Maturity
Physical Maturity
Complications Associated with Preterm Neonates
Pulmonary Surfactant
CHAPTER 12:
Breech Presentation
DEFINITION
INCIDENCE
PREDISPOSING FACTORS
TYPES OF BREECHES
DIAGNOSIS
Vaginal versus Cesarean Section for Breech Delivery (Past Scenario)
Indications for Cesarean Section
Vaginal Breech Delivery
Precautions
General Considerations
Highlights of the Assisted Breech Delivery
Mode of Delivery
Complications
Fetal Complications
Maternal Complications
Factors Leading to Adverse Effects on the Fetal Outcome
Vaginal Versus Cesarean Delivery (Present Scenario)
Primigravida Versus Multiparous
EXTERNAL CEPHALIC VERSION
Historical Considerations
Prerequisites for ECV
Period of Gestation
Candidates for ECV
Contraindications
Absolute Contraindications
Relative Contraindications
Controversial Candidates
Procedure
Success Rate
Note:
Risks
Common Risks
Uncommon Risks
Tocolytics
Regional Anesthesia
Advantages
Disadvantages
Acoustic Stimulation
Amnioinfusion
Cesarean Section Rates after Successful Version
Breech Delivery with Hydrocephalic Head
CHAPTER 13:
Cardiac Disease in Pregnancy (Part I)
HISTORY
Cardinal Symptoms
Past History
Family History
General Physical Examination
INSPECTION
Central
Precordium
Apex Impulse
Pulsations
Dilated Veins
Peripheral
JVP
Abnormal
Pulse Rate
Features of Pulse
Pulses Parvus et Tardus
Bisferiens Pulse
Dicrotic Pulse
Pulse Alternans
Pulse Bigeminus
Pulse Paradox
Water Hammer Pulse/Collapsing Pulse/Corrigans Pulse
Blood Pressure
Korotkoff Sounds
PALPATION
Apex Beat
Parasternal Heave
Diastolic Shock (Palpable S2)
Thrill
PERCUSSION
Left Border
Upper Border
Right Border
AUSCULATION
Mitral Area
Tricuspid Area
Pulmonary Area
Aortic Area
Erb’s Area
Heart Sounds
S1
S2
S3
S4
Murmurs
Grades of Murmur (Levine and Freeman)
Organic Murmur
Significant Murmurs
Innocent Murmurs
Other Sounds
Opening Snap (OS)
Ejection Click
Pericardial Rub
QUESTIONS ASKED IN GENERAL
Heart Disease in Pregnancy
Approach to a Pregnant Patient with Cardiac Lesion
COMPENSATED
Prepregnancy Counseling
Pregnant
DECOMPENSATED
If Mild Failure
If Patient Goes in for Acute Pulmonary Edema
Management of Cardiac Patient in Labor
General Measures
Treatment Proper
Puerperium
CHAPTER 14:
Cardiac Disease in Pregnancy (Part II)
Antepartum Coagulation
WARFARIN
HEPARIN
DIFFERENT APPROACHES TO ANTICOAGULATION IN PREGNANCY
High Risk Patients (PHV in the Mitral Position, Atrial Fibrillation, History of Thromboembolism, on Anticoagulation)
First 6 Weeks (from LMP)
6–12 Weeks
12–36 Week
36 Week—7 Days Postpartum
Low Risk Patients (Second Generation PHV in the Aortic Position)
First 6 Weeks
6–12 Weeks
13–36 Weeks
36 Week-7 Days Postpartum
Lab Monitoring
aPTT
INR
Key Points
Conditions Requiring Anticoagulation in Pregnancy
Rheumatic Heart Disease
MITRAL STENOSIS (MS)
Pathophysiology (Altered Anatomy)
Severity of Stenosis
Effects on Whole Cardio Pulmonary Circulation Due to Mitral Stenosis
Symptoms
On Examination
Investigation
Management during Pregnancy
Medical Therapy
Reduction in Heart Rate
Reduction of Left Atrial Pressure
Obstetric Management
Role of Percutaneous Balloon Mitral Valvuloplasty (PBMV)
MITRAL REGURGITATION (MR)
Etiology
Pathology
During Systole
During Diastole
Symptoms
Auscultation
Management
AORTIC STENOSIS (AS)
Etiology
Critical Stenosis
Symptoms
Compensated State
Decompensated State
Signs
Prognosis
Management
Preconceptionally
Antepartumand Intrapartum
Postpartum
AORTIC REGURGITATION (AR)
Etiology
Symptoms
Signs
Auscultation
Management
Management Proper
PULMONIC STENOSIS (PS)
Etiology
Management
DUKE’S CRITERIA
Major Criteria
Minor Criteria
Definite Endocarditis
Peripartum Cardiomyopathy (PPCM)
OVERVIEW
Definition
Definitive Diagnosis
Risk Factors
Etiology
Factors Implicated in Etiology
Current Diagnostic Criteria
Clinical Presentation and Diagnosis
Differential Diagnosis
Diagnosis and Postpartum Monitoring
Investigations
Management
Compensated peripartum cardiomyopathy
General Measures
Antepartum Management
Postpartum Management
Decompensated heart failure
OVERVIEW
Airway
Breathing
Circulation
Pharmacological Management
Intravenous Loop Diuretic
Vasodilators
Inotropic Agents
Digoxin
β-Blockers
Calcium Channel Blockers
Neurohormonal Blockade
Other Measures
Assist Devices
Arrhythmia Management
Prognosis
Congenital Heart Disease (CHD)
OVERVIEW
Preconception Counseling
Antenatal Measures
Intrapartum and Postpartum Measures
ACYANOTIC HEART DEFECTS (WITH LEFT TO RIGHT SHUNT)
Atrial Septal Defect (ASD)
Ventricular Septal Defect (VSD)
Patent Ductus Arteriosus (PDA)
ACYANOTIC HEART DEFECTS (WITHOUT SHUNT)
Congenital Aortic Stenosis
Pulmonic Stenosis
Coarctation of Aorta
CYANOTIC HEART DEFECTS (RIGHT TO LEFT SHUNT)
Eisenmenger Syndrome
Tetralogy of Fallot (TOF)
AORTIC DISEASES
Marfan Syndrome
Loeys-Dietz Syndrome
Labor Induction
Delivery—Vaginal or Cesarean
Cardiac Arrest in Pregnancy
Key Interventions
Airway and Breathing
Circulation
Defibrillation
Emergency Delivery
CHAPTER 15:
Pyrexia in Pregnancy
MALARIA
Epidemiology of Malaria in Pregnancy
Causal Agents in Pregnancy
Factors Affecting Mosquito Breeding
Transmission
Human Infection (Route of Transmission)
Incubation Period
Prevention
Features
Diagnosis
Important Points Regarding RDTs
Treatment
Uncomplicated Malaria
Relapse
Artemisinin Combination Therapy (ACT)
Complicated (Severe) Malaria
Clinical Features
Requirements for Management of Complications
Treatment
Any Species
Note:
General Considerations
Obstetric Management
Recurrence in Malaria
Prevention from Malaria (Prevention of Bites)
Skin Repellents
Mosquito Sprays
Insect Treated Bed Nests
Clothing
Room Protection
Malaria Prophylaxis in Pregnancy
Dose Regimens for Prophylaxis in Pregnancy
Recent Advances
TUBERCULOSIS
History
Prevalence
Pathogenesis
Transmission
Causative Agent
Risk Factors
Signs and Symptoms
PulmonaryTB
Extrapulmonary TB
Diagnosis
Active Tuberculosis
Latent Tuberculosis
Recent Developments
Antitubercular Drugs in general - An overview
First line
Second Line
Third Line
The Standard Regimen
Monitoring DOTS and DOTS-Plus
“DOTS”
“DOTS-Plus”
Revised National TB Control Programme (RNTCP)
Non-compliance
Prevention
Modes
Vaccine
Pregnancy and TB
Difficulties in Diagnosing Tuberculosis in Pregnancy
Management (CDC)
Active Disease
Latent Tuberculosis
Postpartum
RUBELLA
Other Names
Why Called German Measles?
Infectious Agent
Mode of Transmission
Clinical Presentation
Risks
Prevention of CRS
Vertical Transmission and Fetal Infection
Diagnosis
Treatment
Vaccine
TOXOPLASMA
Diagnosis
Serological Testing
Ultrasonography
Amniocentesis
Congenital Toxoplasmosis
Screening in Pregnancy
Treatment
Only Maternal Infection
When both are Infected
Newborn
Outcome of Prenatal Treatment
CYTOMEGALOVIRUS
Spread
Clinical Manifestations
Serious Complications (though not common)
Congenital CMV
Modes of Transmission
Risk of Intrauterine Transmission
Disease Manifestations
Prenatal Diagnosis
Maternal
Fetal
Neonate
Screening
Prevention
Management
Recent Advances
HERPES SIMPLEX VIRUS
Types: 3 groups
Modes of Transmission
Risk of Transmission to the Neonate
Incubation Period
Disease Manifestations
Prodromal Stage
Entire Duration
Diagnosis
Management
Mother
Mode of Delivery
Prevention of Neonatal Herpes
Neonatal Infection
Treatment of Newborn
CHORIOAMNIONITIS
Definition
Routes of Spread
Types
Clinical Chorioamnionitis
Histological Chorioamnionitis
Microbiologic Type
Incidence
Risk Factors
Causative Agents
Pathogenesis
Clinical Signs and Symptoms
Diagnosis
Clinically
Laboratory Tests
Amniotic Fluid Testing
Placenta and Umbilical Cord Testing (Histologic chorioamnionitis)
Complications
Maternal
Fetal
Neonatal and Long Term Sequelae
Management
Prevention
Antibiotics
Antipyretics
ACUTE PYELONEPHRITIS
Overview
Presentation
Signs and symptoms
Investigations
Management
CHAPTER 16:
Postpartum Hemorrhage
SUMMARY
BLOOD TRANSFUSION
Preliminaries before Requesting for Blood
Obtaining Sample for Compatibility Testing
Storing Blood Products Prior to Transfusion
Whole Blood and Red Cells
Platelet Concentrates
Fresh Frozen Plasma
Time Limits for Infusion
Whole Blood
Platelet Concentrates
FFP and Cryoprecipitate
Administration of Blood Products
Correct IV Set Up
Needle Size
Compatible Solutions with Blood Products
NOTE
Filter (for Whole Blood/Red Cells)
Blood Warming
Receiving the Blood Bag from Blood Bank
Checking the Compatibility Label on the blood Bag
Return Blood Promptly to Blood Bank if not used
Checking the Blood Pack
MONITORING THE TRANSFUSED PATIENT (BLOOD TRANSFUSION NOTES)
General Information
Monitoring
When?
How?
Record
Blood Transfusion Reactions
Mild Reactions
Moderate Reactions
Severe Reactions
CHAPTER 17:
Puerperium
NORMAL PUERPERIUM
Immediate Postnatal Period
Early Postnatal Period
Late Postnatal Period
POSTPARTUM CARE
Hospital Care
First 24 hours
Subsequently (in the hospital)
Abdomen/Fundus
Abdominal Wound
Breasts and Feeds
In non-breastfeeding Women
Other Measures
Baby
Care at Home (Advice on Discharge)
Breasts and Feeds
Other Measures
Contraception
Examinations and Assessments at First Postnatal Visit (Usually After 1 week)
Physiological Changes Occurring in Puerperium
Uterus
Endometrium
Uterine Vessels
Placental Site Involution
Lochia
Cervix
Return of Menstruation and Ovulation
Vagina
Vulva
Perineum
Abdominal Wall
Temperature
AfterPains
Cardiovascular System
Gastrointestinal Tract
Urinary Tract
Hematologic Changes
Skin
Body Weight
Lactation
Nursing
Baby Friendly Hospital Initiative
Aims at
Criteria for a Hospital’s Baby Friendly Accreditation
Benefits
Recommendation
Reasons when Mothers Cannot Produce Enough Breast Milk
Ways to Increase Milk Secretion
Breast Milk
Production
Composition
Unique Qualities of Breast Milk
Comparison with Other Milks
Breast Milk of Diabetic Mother
CONTRACEPTION
Progestin Only Contraceptives
Estrogen-progestin Contraceptives
Contraindications to Breastfeeding
Mother
Baby
Drugs Secretion in Milk
Care of the Breasts and Nipples
Basic Principles of Storing Breast Milk
Storage of Fresh and Thawed Human Milk
FreshMilk
Thawed Milk
Thawing Breast Milk
Recommendations to a Nursing Mother while Travelling
If Mother is Travelling along the Child
If Mother is Travelling without the Child
Weaning from Breast
Refusal to Breastfeed: “Nursing Strikes”
Other Measures while Breastfeeding
BREAST PUMPS
Uses
Types of Breast Pumps
Breast Shield
Pump
Milk Container
Types of Breast Pumps
Pumping Types
General Tips for using a Breast Pump
Factors Influencing Breastfeeding/Milk Production
Factors having Positive Impact
Factors which may Negatively Impact
The First Feed
Baby Behavioral States
Feeding According to Need
Proper Positioning
Rooming in
Skin to Skin Contact
Dummy (pacifier) use
Feeding Frequency
Sucking Patterns
Non Nutritive Sucking
Nutritive Sucking
Is the baby sufficiently fed? How do you know?
Certain Facts
Domperidone or metoclopramide –Which is a better galactogogue?
Precautions
Recommendations
ABNORMAL PUERPERIUM
Puerperal Sepsis
Causes of Fever in Postpartum Period
Common Causes
Infectious Causes
NonInfectious Causes
Rare Causes
Very Rare Cause
Causal Agents
Why women catch infection easily after delivery??
Infection can extend beyond the uterus
Signs and symptoms
Sites of infection
Management
Mastitis
History
Symptoms and Signs
Tests/Investigations
Management
Complications
Urinary Tract Infection
History
Symptoms and Signs
Tests and investigations
Management
Thromboembolic Disorders
Management of DVT or SVT
Respiratory Tract Infections
Acute
Chronic
Signs and Symptoms Suggestive of RTI
Investigations
Treatment
Skin and Soft Tissue Infections
Management
Gastroenteritis (uncommon infection in puerperium)
Causal Agents
Spinal Abscess
Causal Agents
Subinvolution of Uterus
Treatment
Secondary/Late PPH
Cause
Investigations
Management
BREAST COMPLICATIONS
Breast Engorgement
Tenderness, Warmth, Throbbing (May Extend to Armpits)
Interventions
Nipple Pain (Bleeding/Cracked/Bruised Nipples)
Cracks can be
Interventions
Flat Nipple
Inverted Nipple
Lump in Axilla
Engorgement in Axillary Region
Plugged Duct
Interventions
Mastitis
Interventions
Nipple infection (Candida)
Interventions
Breast Abscess
OBSTETRICAL PARALYSIS
PSYCHOLOGICAL DISORDERS
Postpartum blues (transient depression)
Postpartum Depression
Postpartum Psychosis
SECTION 2: SHORT CASES
CHAPTER 18:
Post-term Pregnancy
DEFINITION
Incidence
Factors Influencing its Prevalence
Risk Factors
Role of LMP and USG in Calculation of Gestational Age in Post Term pregnancy
Physiological Changes Associated with Post Term Pregnancy
Placental Changes
Amniotic Fluid Changes
Cord
Meconium
Postmaturity Dysmaturity Syndrome
Fetal and Neonatal Risks in Post Term Pregnancy
Fetal risks
Maternal Risks
Management of Post-term Pregnancy
Preventive Measures
Place of Induction of Labor (IOL)
Management Proper
During pregnancy
Intrapartum
INDUCTION OF LABOR (IOL)
Definition
Indications
Obstetric Indications
Medical Conditions
Contraindications
Absolute
Relative
Extreme Caution
Risks
Factors for Successful Induction
Prerequisites for Induction
Cervical Assessment
Interpretation
METHODS OF INDUCTION
Surgical Methods
Sweeping/Stripping of Membranes
Amniotomy
Pharmacological Methods
Prostaglandins
Risks and Side Effects of Prostaglandins
Oxytocin
CHAPTER 19:
Convulsions in Pregnancy
EPILEPSY
Characteristics
Effects of Epilepsy on Pregnancy and Fetus
Effects of Pregnancy on Epilepsy
Antiepileptic Drugs (AED)
First Generation
Second Generation
Third Generation
Factors which may Alter AED Pharmacokinetics during Pregnancy
Breastfeeding
AEDs of Concern in Pregnancy
Valproic Acid
Carbamazepine (CBZ)
Lamotrigine (LTG)
Levetiracetam (LEV)
Oxcarbazepine (OXC)
Topiramate (TPM)
Gabapentin (GBP) and Pregabalin (PGB)
Zonisamide (ZNS)
Eslicarbazepine (ESL)
Other AEDs
Lacosamide and Retigabine
Dosages
During Fits
Incidence of Malformations
Preconceptional Counseling
Management
Intrapartum
Postpartum
Contraception
STATUS EPILEPTICUS
Causes
Management
Drugs and their Associated Malformations
MENINGITIS
Clinical Features
Signs
Diagnosis
Treatment
COMPLICATED FALCIPARUM MALARIA
History
Clinical Signs and Symptoms
Diagnosis
Treatment
TETANUS
Pathology
Symptoms and Signs
Neonatal Tetanus
Protection against Tetanus (Vaccines)
Safety from Tetanus
Treatment
CDC updates 2013
PUERPERAL SEPSIS
Common Risk Factors
Symptoms and Signs
Tests
Treatment
ELECTROLYTE IMBALANCE
Hyponatremia (Serum Na+ <135 mmol/L)
Symptoms
Management
Euvolemic Hyponatremia
Hypocalcemia (Check Calcium Levels)
Symptoms
Treatment
Hypoglycemia
Symptoms
Management
ECLAMPSIA
Definition
Incidence
Risk Factors
Eclampsia Unpredictable?
Why Convulsions Occur?
Pathology
Organ System Derangements in Eclampsia
CVS
Hematologic
Renal
Hepatic (at autopsy)
CNS (at autopsy)
Time of Occurrence
Atypical Eclampsia
Status Eclampticus
What are Intercurrent (Antenatal) Fits?
How much Fluid is to be given to an Eclamptic Patient?
Symptoms and Signs of Impending Eclampsia
Clinical Features
Eclamptic Fit (Grandmal Seizures)
Before Moving to the Actual Treatment, MgSO4 Needs a Special Mention
Introduction
Mechanism of Action
Normal Serum Concentrations of Mg2+
MANAGEMENT OF ECLAMPSIA
Emergency Care
Referral
Magnesium Infusion (Continuous IV Regimen)
Zuspan Regimen
Sibai Regimen
Precautions
Management of Recurrent Convulsion
Obstetric Management
Indications of Cesarean Section
Postpartum
How does Eclampsia Affect the Mother and the Fetus?
Effects on Mother
Effects on Fetus
Which Fetal Complication Occurs Immediately after an Eclamptic Fit?
For 3-5 minutes
For > 10 minutes
Omnious Features Having Worse Prognosis
Recurrence
Which are the Other Popular Drugs/Regimens for Managing Convulsions (Though Not used these Days) if MgSO4 is Not Available?
Diazepam
Phenytoin
Lytic Cocktail
STRYCHNINE POISONING
Presentation
Treatment
CHAPTER 20:
Rh Negative Pregnancy
HISTORY
Epidemiology
Problem in Rh Negative Pregnancy
Understanding The Disease
Results of Hemolysis
Now Few Questions Must be Disturbing You
Can the development of this cascade be reduced? How?
When and how can this prophylaxis be given?
Which are the other sensitizing events, when and how much anti D is required after them?
After each sensitizing event, what is the risk of development of “Alloimmunization”?
If this prophylaxis is not given, what are the chances of developing antibodies in subsequent pregnancies?
What should be the size of fetomaternal hemorrhage so as to cause sensitization?
How much fetomaternal hemorrhage usually occurs after any uncomplicated labor?
How can we calculate the dose of anti D in any amount of FMH?
How FMH is calculated?
At what period of gestation can fetal red cells be found in maternal circulation? What is the expected amount?
Why anti D is given from 28 weeks onwards? How does it help?
Recent Advances
Diagnostic Tests
Coombs Test
Direct Coombs Test
Indirect Coombs test
Amniotic Fluid Analysis
Ultrasonography
Doppler Sonography
Technique
Cell free Fetal DNA Testing
Can Rh D +ve blood transfused to an Rh D –ve woman? What precautions should be taken?
Will the first RhD +ve fetus be affected?
In which situations, quantitative tests are done?
Quantitative tests that can be performed
Scope for Future Pregnancies
Hemolytic Disease of the Newborn (HDN)
Management
Future Health Concerns
Antepartum Management of Rh Negative Pregnancy
First Pregnancy (Unaffected with No Previous Sensitizing Events)
First affected Pregnancy (Sensitized Due to Previous Event but no Severely affected Pregnancy)
First Sensitized Pregnancy/Previously affected Pregnancy
Exchange Transfusion
Indications
Blood Volume Requirement
Types of Exchange Transfusion (Depending on Volume)
Which blood product is to be used and when?
What should be the size of aliquot?
Pre Requisites for Exchange Transfusion
Equipment Required
Types of Exchange Transfusion (Depending on Procedure)
Procedure for Push and Pull Method
Post Exchange Care
Complications
CHAPTER 21:
Jaundice in Pregnancy
BILIRUBIN METABOLISM
JAUNDICE
Causes (in General)
Indirect (Unconjugated)
Direct (Conjugated)
VARIOUS FORMS OF JAUNDICE
INTRAHEPATIC CHOLESTASIS OF PREGNANCY
Epidemiology
CLINICAL FEATURES
Investigations
BILE ACIDS
Metabolism
Bile Acids in Normal Pregnancy
Bile Acids in ICP
LIVER FUNCTION TESTS (LFTS)
In Normal Pregnancy
LFTs in ICP
URINE ROUTINE/MICROSCOPY
USG
MANAGEMENT OF ICP
Treatment options
Fetal Monitoring
Elective Delivery
Drugs
Prognosis
HEPATITIS
Hepatitis A
Hepatitis B
HbsAg
HbcAg
HbeAg
Anti HbeAg
Anti HbcAg
Anti HbsAg
Hepatitis B Viral DNA
Hepatitis B Infection
Course of HBV
Risk of Transmission in Different Trimesters
The Vaccine
Available as
Response to Vaccination
Duration of Protection
Management
General Overview
Mother
Baby
Hepatitis C
The Virus
Risk of Transmission (Cochrane 2010)
Screening
Management
Hepatitis D
Hepatitis E
HELLP
Hemolysis →↓ Hb → Microangiopathic hemolytic anemia →↑ LDH
Liver
Thrombocytopenia
Clinical Symptoms
Diagnostic Criteria
Mainly 2
Class 1
Class 2
Class 3
Platelet Therapy for HELLP Syndrome
Postpartum
ACUTE FATTY LIVER OF PREGNANCY
Clinical Signs and Symptoms
Lab Abnormalities
Other Findings
Diagnosis
Treatment
Thrombotic Thrombocytopenic Purpura (TTP)
Clinical PENTAD of TTP + Normal Coagulation Tests → Pathognomonic of TTP
Hemolytic Uremic Syndrome (HUS)
Idiopathic Thrombocytopenic Purpura (ITP)
Systemic Lupus Erythematosus (SLE)
Folate Deficiency
CHAPTER 22:
HIV in Pregnancy
HISTORY
Indian Scenario (NACO Annual Report 2010-2011)
Routes of Transmission in India (2010-2011)
Perinatal Transmission
“At risk” women
Factors which Increase risk of Mother-to-child Transmission
Progression of Disease and its Clinical Manifestation
Clinical Stage I
Clinical Stage II
Clinical Stage III
Clinical Stage IV
HIV Testing
HIV Testing in Pregnancy (WHO 2013)
MANAGEMENT OF HIV INFECTED WOMAN
MEDICAL MANAGEMENT 1
I. General Overview
Nucleoside Reverse-Transcriptase Inhibitors (NRTIs)
Nucleotide Reverse-Transcriptase Inhibitors (NtRTIs)
Non-Nucleoside Reverse-Transcriptase Inhibitors (NNRTIs)
Protease Inhibitors (PIs)
Integrase Strand Transfer Inhibitors (INSTIs)
II. Revised WHO 2013 Guidelines
Antepartum and Intrapartum
First Line ART
Preferred Regimen
Alternative Regimens
Second Line ART
Preferred regimens
Alternative regimens
Major Blood Toxicities
AZT
NVP
TDF
ATVr
LPVr
Co-trimoxazole therapy
What to expect in the first months of ART?
OBSTETRIC MANAGEMENT
Prepregnancy management
Counseling
Pregnancy Management
Investigations
Mode of Delivery
General measures to be taken in case of vaginal delivery to minimize chances of transmission during labor and delivery
Postpartum
Medical management
Mother
Infant
WHO recommendations for breastfeeding in HIV mothers
Mothers known to be HIV-infected
If infant is uninfected or of unknown HIV status
When the infant is HIV-infected
Measures taken by Indian government in reducing HIV and AIDS in the country
NACP – Phase III (2007-2012)
SUGGESTED READING
CHAPTER 23:
Thyroid Disorders in Pregnancy
RELEVANT HISTORY PERTAINING TO THE CASE WITH EXPLANATIONS
Age
Why Important?
Sex
Occupation
Residence
Swelling
Pain
Pressure Effects
Symptoms
Primary Thyrotoxicosis
Secondary Thyrotoxicosis
Hypothyroidism
Past History
Family History
Physical Examination
Weight
Face
Skin (Especially Hands)
Edema
Vitals
Intelligence
Local Examination
Inspection
Palpation (Both from Back and Front)
Auscultation
Measurement
General Examination
Eye Signs
Tremor
Screening for Thyroid Dysfunction during Pregnancy
Hyperthyroidism
Causes of Hyperthyroidism in Pregnancy
THYROID NODULES AND CARCINOMA
POSTPARTUM THYROIDITIS (PPT)
Hyperthyroid Postpartum Thyroiditis
Hypothyroid Postpartum Thyroiditis
Management
Future Prognosis
Causes of Hypothyroidism in Pregnancy
Prevalence
Autoimmune Thyroid Disease
Complications of Hypothyroidism in Pregnancy
Laboratory Tests
Effects of Iodine Deficiency on Mother
Assessment before Conception
Antenatal Management
If hypothyroid (known case)
Detected for 1st time
Women with Thyroid Autoimmunity (TAI)
If previous thyroidectomy or 131 I ablation done (no native thyroid function)
Subclinical Hypothyroidism
Central Hypothyroidism
Overt Hypothyroidism
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