MATERNITY CASES A CASE 1: APH TEACHING POINTS -...

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ALSO Asia Pacific – Maternity Cases. July 2014

MATERNITY CASES A CASE 1: APH

The first case has 30 minutes allocated to it. TEACHING POINTS The main points that the participants should take away from this session are:

Immediate care of a woman with an APH Risk factors for placenta praevia and abruption Diagnosis of different types of APH Different management options depending on context/location

(Slide 2) History

You are phoned by a 32 year-old woman who says she is having some vaginal bleeding at 30 weeks into her 3rd pregnancy. She has previously had two vaginal births.

Her 18 week ultrasound had noted a posterior placenta, and a single fetus. Her recent Hb was 125, blood group B Rh negative with a negative antibody

screen (Slide 3) What else would you ask her [on the phone]? Issues to draw out from the group:

Is there any pain with the bleeding? Is there is pain – what is the intensity, is it like contraction-type pain? Has she had any other bleeding after 20 weeks? Is this post-coital? How much blood on this occasion and is it increasing or decreasing? Is the baby moving? Have her membranes ruptured? Think about what you can’t see – concealed APH – does she feel light-headed

or dizzy? What advice will you give her?

The amount of bleeding will usually determine the answer to this question. Their context (rural, remote, metro) will also dictate what advice they give.

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Invite the woman into hospital. Most people will admit her to the maternity unit. Consider the type of maternity unit she should be admitted to given she is 30 weeks pregnant.

(Slide 4) She arrives in your unit What else would you like to know about her current pregnancy?

Has her pregnancy been healthy to this point? Has anything else happened? Is the baby growing well? Has she had antenatal care.

Also might talk about risk factors in this pregnancy – smoking, drug use, trauma including domestic violence. Ask about her current social situation.

(Slide 5) Case continues

On admission her pulse is 80bpm, BP 110/70. The bleeding appears to have settled (only a scant amount now) and her

abdominal pain has eased. What do you look for on examination?

Apart from a general examination, an abdominal examination is required: Assess for tenderness, rigidity, pain and the fundal height should be

measured. The lie of the fetus is important however at 30 weeks, oblique or transverse

lie is likely so not useful for the diagnosis. A fetal heart rate should be auscultated.

What investigations will you request?

An ultrasound should be performed to exclude placenta praevia (the 18-20 scan may not diagnose placenta praevia).

An ultrasound will also assist in the assessment of fetal growth as abruption is associated with growth restriction.

Remember only 10% of abruptions are seen on US. The investigations are those for maternal and fetal well-being.

Full blood count Group and hold (or crossmatch) Clotting studies (if there is major bleed)

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A Kleihauer test to assess amount of feto-maternal haemorrhage if Rh negative

Discuss not doing a vaginal examination until you can exclude a placenta

praevia. Have a discussion about a gentle speculum examination to exclude local

causes and assess cervical dilatation (even though this is likely to be difficult). Once the US excludes placenta praevia – advisable to do a digital exam if the

membranes are intact to determine cervical dilatation – especially if transfer is being considered. The differential diagnosis is preterm labour.

A CTG should be undertaken to assess fetal well-being. The duration of the CTG if there is continued bleeding can be an interesting discussion (don’t take too much time on this as it is covered in EFM). Mention what the CTG might show given she is only 30 weeks. What treatment will you give her?

If bleeding is significant and ongoing, commence an IV infusion – if the bleeding is minor and settling this may not be necessary.

The type of fluid (crystalloid or colloid) can be discussed. Anti D immunoglobulin should be given if she is Rh negative – the dose may

be guided by the Kleihauer test. Consider corticosteroids – talk about dose and timing. Consider transfer depending on the context – consultation with transfer

teams or higher level service for advice (Slide 6) Case continues

The CTG is reassuring and the laboratory results normal. The speculum examination excluded local causes.

The ultrasound shows a postero-fundal placenta, and a normally-grown fetus.

There is no evidence of abruption. What is your diagnosis?

Causes of APH – Placenta praevia, abruption, local causes, indeterminate

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Abruption is a clinical diagnosis which cannot be excluded by a normal ultrasound.

She had had pain and bleeding which are the classic signs of an abruption – therefore this is the diagnosis.

(Slide 7) What are the risk factors for abruption?

• Hypertensive diseases of pregnancy • Smoking • Substance use (alcohol/cocaine) • Trauma • Over-distension of the uterus • Previous abruption, stillbirth or preterm birth • Placental dysfunction/insufficiency

(Slide 8) What risks are increased in the presence of abruption? Talk through the risks to the mother and the baby Risks to the fetus/baby

Prematurity Growth restriction Stillbirth

Risks to the woman

Haemorrhage Coagulopathy Hysterectomy Death

The risks are generally in relation to the degree of haemorrhage,

coagulopathy and how well these are corrected. Death is the ultimate, although rare, risk.

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(Slide 9) What are the risk factors for placenta praevia? Just briefly go back to placenta praevia even though the case is not about this – important to remind the participants’ of the risk factors.

• Previous caesarean section • Previous uterine instrumentation • High parity • Advanced maternal age • Smoking • Multiple gestation

(Slide 10) Case Update Remind the participant’s about what they now know: 32yr old G3 P2 (normal births) Hb 125 B Rh Neg - Neg antibody screen No abdo pain PV - trickle old blood CTG reassuring U/S NAD How would you manage this woman now?

She should be advised to stay in hospital. The discussion might talk about women who really want to go home or need

to go home because there is no-one else to care for her children.

Discuss transfer if relevant for the different contexts. (Slide 11) Case Continues She is admitted to hospital. During the night she has more pain and bleeding, with the onset of contractions 3:10 minutes. What do you do now?

Need to assess fetal well-being with another CTG.

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In addition, you will perform a vaginal examination to see if she is now in labour.

If steroids have not been given these should be considered. (Slide 12) Case continues A vaginal examination confirms that the cervix is 2-3 cms dilated and the CTG reveals a non-reassuring antenatal FHR pattern with recurrent variable decelerations What do you do now? Might discuss what different people would do in different contexts.

? Transfer to unit with NICU facilities

? Suppress contractions – probably not in the presence of bleeding

? wait

? C/S (Slide 13) Due to unpredictable course of a 30 week pregnancy with an abruption and non-reassuring fetal heart rate pattern – you decide to perform a CS. Might also discuss what different people would do if they did not have CS access. (Slide 14) Outcome

Live baby boy Apgars 3 at 1 min and 5 at 5 requiring active resuscitation, intubation and NICU care.

A 200ml retroplacental clot is found Post op recovery uneventful except for low Hb treated with iron

Worth talking about accurate documentation of blood loss so that a cumulative total can be made and appropriate intervention postnatally if required. (Slide 15) Summary YOU SHOULD BE 30 MINUTES INTO THE SESSION NOW.

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MATERNITY CASES A CASE 2: VTE/Pulmonary embolus

The case has 45 minutes allocated to it. TEACHING POINTS

The main points that the participants should take away from this session are: Pregnancy is a risk factor for VTE and associated with a 7-10 fold increase in

risk compared with non-pregnant women It is important to recognise risk factors and commence prophylaxis – while

there has been a significant fall in VTE deaths in the recent maternal death report in the UK (2006-2008) [see here for the UK report http://www.cmace.org.uk/Publications-Press-Releases/Report-Publications/Maternal-Mortality.aspx] it is likely that this is due to result of better recognition of at-risk women and more widespread thromboprophylaxis. VTE is the 2nd highest cause of maternal mortality in Australia.

Important to consult and refer when appropriate especially complex women. The intention of this session is to talk about risk factors – not to get into a complex discussion about the various diagnostic tests. Remember not all areas will have access to all the tests. (Slide 17) A 39 year old woman presents to your antenatal clinic at 8 weeks for booking:-

• G2 P1 • LSCS 8 yrs ago @ 5 cm for ‘failure to progress’ • Fit and well – nil of note in PMH • Family History – sister had DVT following an MVA • Normal booking, bloods & urine NAD • Booking observations - BP 100/60, Weight 110kg BMI >35 • Booked for elective repeat LSCS

(Slide 18) Is she at increased risk of Pulmonary Embolism and if so why?

http://www.cmace.org.uk/Publications-Press-Releases/Report-Publications/Maternal-Mortality.aspx

http://www.cmace.org.uk/Publications-Press-Releases/Report-Publications/Maternal-Mortality.aspx

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She has 3 risk factors – Being pregnant, being of a high BMI and her age

Obesity is a significant risk factor, particularly when compounded by immobility

Does she have a family history of DVT?

Her sister’s DVT was as a result of an accident so it is not familial and should not be counted as relevant if that was her only risk factor.

VTE occurs in 5-12:10,000 pregnancies and up to 10% of women have a

recurrence in future pregnancies. Chronic venous insufficiency is common sequelae of DVT (1/3 of women) and

a cause of significant morbidity. (Slide 19) What are some risk factors for VTE that may occur during pregnancy or labour?

• Hyperemesis • Dehydration • Pre-Eclampsia • Haemorrhage • Immobility pre and post birth • Instrumental birth • Caesarean birth • Severe infection

(Slide 20) Are pregnant women at risk of VTE in the 1st trimester?

Yes. The incidence of VTE is the same in each trimester. (Slide 21) Case continues

At nine weeks the woman represents with hyperemesis - she is vomiting 10-12 times a day, lethargic and obviously dehydrated.

She complains of painful swollen legs. What are your concerns and what is your management (beyond standard management for hyperemesis)?

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Get the participants to talk of her increased risk - She has developed more risk factors for VTE as she now is dehydrated. Management includes:

Routine treatment and investigations of hyperemesis Rehydration Mobilisation

(Slide 22) She has developed more risk factors for VTE

Consider low molecular weight heparin (LMWH) at a prophylactic dose. If there is a strong suspicion of DVT, therapeutic anticoagulant treatment

must be started BEFORE the diagnosis is confirmed/excluded by objective testing

(Slide 23) What is your primary investigation? Ultrasound – compression (Slide 24) Picture shows a Doppler ultrasound HOWEVER – if a negative result and strong clinical suspicion – continue anti-coagulation and retest one week later (Slide 25)

The ultrasound report is negative, the pain and swelling settles and the woman is discharged home

The remainder of her pregnancy is uncomplicated At 39/40 she is admitted for an elective caesarean section A live baby boy is born, 3560g, Apgars 9 + 9, recorded blood loss - 1000mls

Talk about the commencement of LMWH – the important thing here is that

participants recognise that the women is high risk and needs to be managed accordingly.

(Slide 26) What are her risk factors now?

Raised BMI >35 Blood loss 1000mls

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Caesarean Section Older maternal age

(Slide 27) What is your post-operative plan in terms of VTE prevention?

Regular observations – talk about what is regular or routine in the different settings.

o In some settings this will mean HDU Hydration TEDS Sequential Compression Devices LMWH FBC ? transfusion Early mobilisation

(Slide 28) The Caesarean section was performed under epidural block ……. when can you give the LMW Heparin in relation to taking out the epidural catheter? The LMWH should be withheld until at least 4 hrs after removal of catheter and withhold until at least 4 hrs have passed from insertion of a spinal anaesthetic to avoid epidural haematoma. (Slide 29) Her postnatal recovery was uneventful until Day 2 when she complains of shortness of breath whilst breastfeeding A variety of different diagnoses exist but pulmonary embolus should be excluded. Also consider chest infection and anaemia etc. (Slide 30) What other signs and symptoms might you look for? Tachypnoea 89% Dyspnoea 81% Pleuritic pain 72% Apprehension 59% Cough 54% Tachycardia 43% Haemoptysis 34% Pyrexia 34%

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(Slide 31) If some of these are present, what is your immediate management? If concerned enough to request further investigations then the woman requires full anticoagulation prior to doing any diagnostic investigations (to reduce risk of further emboli or extension to embolic event) (Slide 32) How can full anticoagulation be achieved? Two methods:

Bolus unfractionated Heparin 5000units over 5 minutes followed by 1300units/hr (monitor APTT)

LMWH (eg enoxaparin) dose is 1mg/kg bd or 1.5 mg / kg daily based on current weight. Dalteparin 100 units / kg BD or 200 units/kg daily.

(Slide 33) What investigations might you want to request?

CXR is the first investigation (Slide 34)

What changes are you looking for?

CXR – 30% normal; may show atelectasis “wedge shaped infiltrates” Exclude other causes for her symptoms – pneumonia, asthma

(Slide 35) Other Investigations 1) Ventilation perfusion Scan (VQ Scan) – perfusion element only - then ventilation level (if non diagnostic) Picture of VQ Scan 2) Spiral CT scan The Australian guidelines recommend that the lung perfusion element of a ventilation / perfusion (V/Q) radionucleotide scan should be the initial investigation. This facilitates the lowest radiation exposure to both mother and fetus. If this is non-diagnostic, then the ventilation portion of the scan should be performed. If PE is still unable to be excluded with certainty then CT scanning should be performed. In areas where V/Q scanning is not available, a CT pulmonary angiogram may be the appropriate investigation.

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Perfusion scan first and if non-diagnostic add ventilation scan

Isotope Ventilation/Perfusion (V/Q) scan – looking for area with ventilation but no perfusion (ie. a mismatch).

Treat if the VQ reports ‘intermediate’ or ‘high probability’ of PE If VQ reports ‘low probability’ then PE is unlikely

Spiral CT – allows direct visualization of the pulmonary vasculature and is

becoming the first line investigation of choice when clinical suspicion is high (if it is available). Negative predictive value greater than 99% means that if the result is negative then you can be 99% sure that the woman does not have a PE.

(Slide 36) After appropriate treatment and support she makes a satisfactory recovery. At discharge you have successfully converted her from LMWH to Warfarin How long should she remain on Warfarin?

Usually 6 months of Warfarin or endaparine from time of embolic event. Recommend review by haematologist

(Slide 37) How would you recommend she manages future pregnancies?

Ideally start prophylactic treatment in the first trimester (remember the majority of VTE’s occur antenatally)

Advise re pre-pregnancy weight loss

(Slide 38) Why is Warfarin not included in antenatal treatment regimens? Does Warfarin appear in significant levels in breast milk?

No – Warfarin is safe and often used as continuing treatment for antenatal PE/DVT in the postpartum period.

Remember that the conversion to Warfarin takes a few days and the women should be kept on heparin until her INR level reaches a therapeutic dose.

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(Slide 39) Summary

VTE is a major cause of maternal mortality. The incidence is rising after caesarean section as this rate increases The most important aspect of substandard care was the failure to recognise

risk factors. Even when diagnosis is made many women are not treated aggressively

enough.

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MATERNITY CASES B CASE 1: ECLAMPSIA

The case has 45 minutes allocated to it. TEACHING POINTS The main points that the participants should take away from this session are:

Proper evaluation and management of pre-eclampsia Proper use of MgSO4 – indications and its effect on the woman and baby Appropriate response to post-seizure fetal bradycardia Indications and use of antihypertensive medications Other complications that can occur with pre-eclampsia

(Slide 2) History

A 19 year-old woman having her first baby presents to your maternity unit at 39 wks gestation (by LMP) with contractions every 3 minutes.

She tells you that her pregnancy has been uncomplicated except for 1st trimester UTI. She tells you she no medical problems.

She has gained 27 kgs weight during her pregnancy and at her last visit she complained of recent generalised oedema to her usual maternity provider.

She is from out of town and visiting your area and does not have her antenatal records.

As far as she remembers all her antenatal tests were normal. (Slide 3) Examination

On examination - her blood pressure is BP 164/102, - you repeat it and it is 160/100.

You test her urine using a dipstick and find it has 1+ protein. Her membranes are intact and she has no vaginal bleeding. She says she does not have a headache, epigastric pain, visual disturbances

or any other symptoms. She is contracting every 3 minutes. You start a CTG – shows a reassuring fetal heart rate pattern - baseline FHR

140, normal variability, accelerations, no decelerations.

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You do a VE – her cervix is 4cm dilated, 100% effaced and -3 station.

You request investigations. (Slide 4) What investigations would you request? Consider and discuss:

full blood count platelets Protein/Creatinine Ratio biochemistry liver function tests uric acid clotting (PTT, PT, INR, fibrinogen).

What other information would you like at this point? Antenatal records, ultrasound reports. (Slide 5) 30 minutes later…

The woman has a grand mal seizure lasting about 1 minute. Blood results are not yet available While IV is being started, she has a 2nd grand mal seizure. CTG shows a fetal bradycardia of 80bpm post seizure.

(Slide 6) What would you do at this point? Get the group to provide the answers – write on the whiteboard

Turn the woman on her side Protect her airway – have suction available if required Give oxygen Insert IV cannulae Start CTG – use scalp clip if an abdominal trace is of insufficient quality Load with MgSO4 – 4 - 6 gms IV over 20 minutes and begin a maintenance

infusion at 2 gm/hr Insert IDC – start fluid balance chart, measure urine 1/24 Nil by mouth

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Group and hold – 3 units packed cells Rupture membranes if possible The treatment after an eclamptic seizure is stabilization first THEN proceed

to the birth.

If the woman was not in labour, induction may be commenced after the MgSO4 has been commenced and she is stabilised.

Proceed with an induction if the woman is at least 32 weeks pregnant even in the setting of an unripe cervix.

Many women with pre-eclampsia or eclampsia are easily induced and labour efficiently, even with an unfavourable cervix.

What is the significance of the fetal bradycardia?

Fetal bradycardia is a not an unexpected event after an eclamptic seizure due mainly to the maternal hypoxia and uterine hyperactivity that may result from the seizure.

It would be anticipated that in the recovery phase there would be a period of fetal tachycardia with reduced variability that follows. Once the mother has restabilised, recovery of the fetus and return of the FHR to the pattern prior to the seizure should happen over the next 10 – 20 minutes.

Would you proceed to an immediate caesarean section?

It is best to avoid an immediate CS for the fetal bradycardia as the intrauterine environment will generally improve once the maternal condition has stabilised.

Keep in mind however the possibility of a placental abruption. (Slide 7) After the seizures...

She is given MgSO4 - 4-6 gram loading dose given followed by continuous infusion of 2 gm/hr.

An IDC is inserted and the urine output is monitored hourly. An amniotomy is performed – showed scant, thin Meconium. A FSE is

applied. The fetal bradycardia recovers with control of seizures

(Slide 8) After the seizures...

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She is administered oxygen and placed in the left lateral position. The fetal heart baseline rate is now 160bpm with decreased variability. Her BP is now 180/110. She is still contracting every 2-3 minutes. The theatre team are alerted and are on stand-by if necessary.

(Slide 9) Are you worried about her BP?

Yes – blood pressures that is equal to or exceeds 160/110 should be treated with antihypertensive agents to avoid maternal CNS damage.

The goal is to lower the BP to a diastolic of about 90-100. This can happen over ½ - 1hr and doesn’t need to be a rapid

In the acute setting, IV hydralazine and oral nifedipine are commonly used.

Hydralazine 5-10mg IV every 20 minutes is historically the most common

agent (Cat B). Its duration is several hours and adequate BP control is often achieved with 1-2 doses.

Nifedipine given in this context does not suppress labour.

IV Labetolol is a good alternative and becoming more widely used in

Australia. Will the MgSO4 take care of the BP? No MgSO4 is for seizures not BP.

Although Nifedipine and MgSO4 theoretically have a synergistic drug interaction to radically reduce BP, this effect was not seen in the MAGPIE trial when these medications were used together.

What do you think of the decreased variability on the CTG? Decreased variability and fetal bradycardia should be transient.

As discussed before, it would be anticipated that in the recovery phase there would be a period of fetal tachycardia with reduced variability that follows. Once the woman is restabilised, recovery of the fetus and return of the FHR

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to the pattern prior to the seizure should happen over the next 10 – 20 minutes.

MgSO4 can cause decreased variability in the FHR due to its relaxant effects

on the central nervous system. It is however probably a little too soon for MgSO4 to be the cause of the decreased variability at this stage and is most likely the result of the seizure.

(Slide 10) The case continues After treatment, maternal BP 140/95, P 90, RR 12, T 38°C Urine output = 30 mls over past hour Blood results (taken before the seizure):

Hb = 120 g/l Haematocrit = 36%, WBC = 17,000 Platelet count = 185.109/L Liver enzymes normal except for alkaline phosphatase of 200 PTT, PT-INR, and fibrinogen levels normal Magnesium level after 1 hr = 3.5mmol/l

(Slide 11) She has another grand mal seizure What would you do next?

Resuscitate using DRABCD Women already on MgSO4 who have seizures may receive an additional

bolus of 2gs if they show no signs of magnesium toxicity. An urgent magnesium level should be undertaken to consider further bolus

doses. A second neuroleptic agent should generally be used in the woman who

continues to have seizures despite therapeutic magnesium levels. In this uncommon situation, a short acting barbiturate such as phenytoin

may need to be used. If someone wants to discuss birth as an option it is important to emphasise

the stabilsation of the mother prior to initiating birth. With these repeated seizures a VE may be warranted as she could be close to being fully dilated.

Should antibiotics be started? Is she septic?

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Have a discussion about her WCC – remember the bloods were taken before the seizure but she has a temp of 380C and the WCC is at the upper limit of normal. Discuss what the WCC and temperature might be related to especially if there are no other signs of infection.

Does she have HELLP syndrome?

No – alkaline phosphatase is normally elevated in pregnancy. One would look for haemolytic anaemia, elevated SGOT, SGPT, AST/ALT and

low platelets to diagnose HELLP syndrome. Would you manage a focal seizure differently?

Yes – this could indicate an intracranial haemorrhage and a non-contrast CT of the head would be indicated.

(Slide 12) The Birth… and then?

Labour progresses Vaginal birth of 3700g baby boy with Apgars 6/9 Placenta delivers spontaneously and appears intact No evidence of uterine atony or perineal tears

(Slide 13) When would you discontinue MgSO4?

Continue for at least 24 hours after birth or the last seizure. If uterine atony occurs, what agent would you use?

Uterine massage, oxytocin Avoid ergometrine as it may increase her BP

Would your treatment change if she had a history of grand mal epilepsy?

Check anticonvulsant levels and compliance with medications. One would still give MgSO4 but boost with anticonvulsants if the levels are

low. How would your approach change if she were 36 weeks with an unripe cervix?

A woman with eclampsia with an unripe cervix at 36 weeks should have a trial of induction of labour before a CS is undertaken.

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YOU SHOULD BE AT ABOUT 45 MINUTES INTO THE SESSION.

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MATERNITY CASES B CASE 2: CORD PROLAPSE

The case has 20 minutes allocated to it. While discussion is encouraged be careful of the timing in this case – you do not have a lot of time. Plan your time so that the majority of the time is focused on the main teaching points. TEACHING POINTS The main points that the participants should take away from this session are:

Risk factors for cord prolapse Diagnosis Immediate actions Discuss options in facilities without access to immediate CS.

Suggestions: Present the case and the vaginal examination and stop at this point asking participants what other information they require. We suggest that you only give them the information they request. As long as recognition, immediate management and facility capacity are recognised then the case can be used merely as an outline. (Slide 15) History

27-year-old woman - G4 P2 at 40+6 weeks presents in early labour (28wk U/S as her LMP was uncertain)

Her pregnancy has been healthy. An increase in fundal height was noted with size > dates noted during 3rd

trimester One week ago, an ultrasound showed an AFI of 27 and EFW of 3870 grams Today, her U/S reveals AFI of 25 cm, EFW of 4069 gms, vertex, anterior

placenta (Slide 16) Examination This is what you find on examination:

Maternal BP 130/80, afebrile Cervix is 3 cm, soft, and 50% effaced

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Contractions q5-7 minutes, Baseline FHR = 130 Frequent fetal movements, good reactivity

(Slide 17) What are you concerned about?

Dating parameters obtained late in pregnancy are less reliable. AFI is high normal AFI ranges alter throughout pregnancy and vary by

gestational age. A rule of thumb is between 5-25 is normal range– presents a risk factor for cord prolapse

Estimated fetal weight – through not always accurate in late pregnancy is over 4000 gms – may think about preparation for shoulder dystocia.

Not in active labour patterns – contractions - mild, infrequent. Need to watch progress. CTG reassuring.

Maybe someone might think about diabetes - her 28week GTT was normal What other information would you like? Pregnancy history – see the next slide (Slide 18) Further information Three previous pregnancies

1st – normal birth of a healthy baby girl (3900 gms) No problems.. 2nd – spontaneous miscarriage at 8 weeks – No problems. 3rd – spontaneous vaginal breech (3700 gms) healthy baby girl. No problems.

(Slide 19) Further information Examination

Lungs clear, no heart murmur Fundal height 42 cm Reflexes normal

Membranes – intact – no gush of fluid reported Presenting part – vertex, high, not engaged – 5/5 of the fetal head palpable (Slide 20) Further information

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Pathology Normal Hb and other bloods Urinalysis – trace protein

(Slide 21) What would you like to do now?

Some participants might send this woman home, others will suggest inducing her labour.

If participants want to send her home – say that she calls back 6 hours later reporting ruptured membranes and something hanging out – get them to talk through what they would do.

Women in the latter stages of pregnancy who are at high risk for cord prolapsed (eg polyhydramnios, footling breech etc) can often be identified.

They can be given information about examining themselves for cord prolapsed if their membranes rupture.

o If they identify a cord prolapse – talk about the knee chest position. o Call an ambulance and stay in that position until they get to hospital.

(Slide 22) Admit for observation... In this case, she is admitted for observation

Gradual progression of mild, irregular contractions q 2 - 5 minutes 4 hours later, cervix 5 cm dilated, 80% effaced IA reassuring

(Slide 23)

4 hours later she has SROM with a large quantity of greenish-brown particulate stained fluid

3 minutes after SROM-FHR is now 80-90/min What are you concerned about?

Cord prolapse should be ruled out immediately if there is fetal bradycardia after ruptured membranes.

Note meconium as a sign of fetal stress, rather than distress!

What do you want to do now? In the acute setting, a VE should be done immediately by the clinician to rule

out cord prolapse and assess labour progress.

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(Slide 24) On vaginal examination a loop of umbilical cord falls into your hand; cervix is 8-9 cm dilated What do you do now? These are the steps you hope the group describes.

Explain what is happening to the woman Elevate the presenting part Quickly assess fetal heart by monitoring or US Knee chest position or deep Trendelenburg position is also useful to reduce

pressure Tocoylsis may be helpful if the woman is contracting (note – different units

might use different drugs – this is not the point of this discussion – just acknowledge that different drugs might be used)

Fill the bladder rapidly with 500-700ml – in some reports this provides a cushion that helps by holding the presenting part up. Be careful at CS to remember that she has a full bladder. If this continues while in transit – remember to release some urine to avoid over-distention.

Manual replacement of the cord is controversial – may not work and may just waste time. Can be beneficial in some cases however. Replacing the cord may cause it to spasm. Spasm of the cord stops efficient placental – fetal blood flow and can further reduce the oxygenation of the fetus.

Heroic interventions are not required if there is no evidence of cord

pulsation – discussion and explanation with the family is obviously needed. (Slide 25) The case continues …. Evaluate for cord pulsation – it is present

Change position - Trendelenburg/Exaggerated Simms Fetal vertex elevated ?Fill bladder EFM shows FHR of 80-90 during contractions, despite tocolysis Baseline between contractions = 120 bpm

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(Slide 26) Could this have been prevented?

Prevention is difficult but may be sometimes achieved with identification of women at risk or by identifying a cord presentation on US.

Caution should always be taken when doing an ARM if the PP is high. Someone may want to discuss ‘controlled ARM’ Controlled ARM is an ARM

performed in theatres as there is no way you can control the flow of liquor once membranes are ruptures

What are the risk factors for this condition? List is on the next slide – if you have time get the group to give you them before you go to the next one. (Slide 27) Risk factors for cord prolapse Malpresentations

0.4% cephalic 0.5% frank breech 4-6% complete breech 15-18% footling breech

Prematurity Low birth weight (<2500gms) Multiple gestation Polyhydramnios Rupture of membranes prior to engagement of the PP (Slide 28) What are your options at this point?

Continue temporary measures until you can get the baby born. Remember you may need to transfer her to where a CS can be undertaken – talk about this with the group depending on where they work.

Option 1: She is multiparous and nearly fully dilated. It may be that you can get her to a vaginal birth more quickly than a CS depending on the capability of the hospital. A forceps or vacuum may be quicker than a CS.

Option 2: Proceed to emergency CS while keeping holding the pressure off

the PP. Ensure that the woman understands what you are doing in the transfer to theatre.

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Do seconds count in this situation? Through logic would suggest it does, the interval between diagnosis and

delivery (DDI) may not be the primary outcome. Gestational age and the cause for the cord prolapse are stronger predictors

of outcome than the duration of prolapse. (Slide 29) Caesarean Section performed 42 minutes after SROM, 4200g male infant Apgars = 5 and 9, cord pH = 6.97, BE -8 What are the factors that influence long-term infant outcome?

Through the outcome for most babies who have a cord prolapse is generally quite good – the rate of morbidity and mortality is about 10%.

Poor outcome is likely to be associated with congenital abnormalities and malpresentation rather than the cord prolapse itself.

Do you have a protocol in place for cord prolapse?

Talk about how important this is and the usefulness of emergency drills in the maternity unit.

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MATERNITY CASES C CASE 1: FIRST TRIMESTER BLEEDING

The case has 25 minutes allocated to it. TEACHING POINTS The main points that the participants should take away from this session are:

The need to take a full history to identify risk factors Appropriate use of investigations of bleeding in early pregnancy – think

about the context of the participants Management of threatened miscarriage Management of ectopic pregnancy

(Slide 2) History

A 27 year old woman presents to your rooms/ED/clinic. She is in her third pregnancy having had two previous termination of pregnancy.

She is complaining of left iliac fossa pain and is unsure of her LMP. She has an irregular menstrual cycle with 3-4 days bleeding. She thinks her

last period was 5-6 weeks ago. She has had 4 partners in the past 2 years. She has been with her current

partner for 4 months and she tells you they have occasional unprotected sexual intercourse.

On examination, her pulse 90/min, BP 100/60 and urine HCG is positive

(Slide 3) What other information would you like from her?

You would like to know how bad the pain is, what it is like and if she is bleeding.

Perhaps ascertain what she would like to happen – that is, what would her plans regarding the pregnancy be.

Other issues might be complications of previous terminations, STIs, supports, last Pap smear, usual bladder and bowel function.

Pain in other places (shoulder tip pain may indicate intraperitoneal bleeding). What are the causes of vaginal bleeding and abdominal pain in early pregnancy?

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Spontaneous miscarriage, threatened miscarriage, ectopic pregnancy, trophoblastic disease and local causes.

Talk about the terminology which can be confusing, inappropriate or

upsetting – ie. A miscarriage being called a spontaneous abortion

Trophoblastic disease may not be associated with pain Co-incidental including ovarian pathology most commonly corpus luteum of

pregnancy (Slide 4) What are the causes of miscarriage? NB – this detail is not on the slide – use the white board to get the group to come up with them

Chromosomal abnormalities • major genetic abnormalities (trisomy, triploidy or monosomy) account for at

least half of all spontaneous miscarriages. The incidence of spontaneous miscarriage increases with maternal age.

Internal environmental factors • Uterine anomalies • Matheral diethylstilbestrol (DES) exposure • Fibroids • ‘Incompetent’ cervix (not 1st trimester but 2nd) • Immunological factors, eg. thrombophilias External environmental factors • Infections • Tobacco, alcohol or drug use • Irradiation and occupational chemical exposure

Case Continues (Slide 5)

Examination of the woman’s abdominal – soft, minimal tenderness left side A vaginal examination reveals an anteverted uterus which is bulky with the

cervical os closed. There is mild tenderness in the left fornix, no cervical motion tenderness

(excitation) no blood in the vault

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(Slide 6) What investigations will you request?

Quantitative ßHCG Group and antibodies, FBC ? MSU/Microbiology ? U/S – preferably transvaginal

(Slide 7) Results These are the results of the investigations you arranged:

ßHCG = 657 IU/ml Hb 116 Blood Group O Neg U/S: anteverted uterus, no free fluid, no adnexal masses, no intrauterine sac

seen (Slide 8) Differential Diagnosis Differential diagnosis includes:

Non-viable pregnancy Early viable intrauterine pregnancy Ectopic pregnancy

(Slide 9) What are the risk factors for ectopic pregnancy? Talk through the risk factors

Pelvic surgery, including tubal surgery, sterilisation and/or reversal IVF pregnancy Smoking Previous caesarean section Tubal infection, including PID Failure of contraception with progesterone-only pills or intrauterine devices Previous ectopic pregnancy

(Slide 10) How would you care for this woman?

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Talk through the options with the group drawing on local contexts and availability of services.

Admit to hospital if concerned about the woman’s clinical situation or if she is unable to get to hospital if she becomes symptomatic

Repeat BHCG in 48 hours on a serial basis – these should double every 48 hours

Repeat ultrasound at BHCG >1500 . This is discussed later. A progesterone level may (<45 nmol/L) help determine whether it is a non-

viable pregnancy. There is no role for misoprostol or suction curettage at this stage as the

location or viability of the pregnancy is not known. (Slide 11) What are the landmarks visible on early pregnancy ultrasound at 5 – 7 weeks gestation? Have a brief discussion but don’t get too caught up as the next slide has the info. Note: Remember not everyone in the group will be familiar with this and could get anxious if they feel they don’t know enough! (Slide 12) Scan findings in early pregnancy Talk through the Table on the slide.

Gestational age by LMP

Transabdominal landmarks

Transvaginal landmarks

BHCG

< 5 weeks None Possible gestational sac

<1500

5-6 weeks Gestational sac Gestational sac, yolk sac

1500-3500

7 weeks 5-10mm embryo Same as transabdominal with cardiac activity

20,000

(Slide 13) The case continues

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The woman remains asymptomatic. You order serial BHCGs at 48 hours – a viable pregnancy should double the

BHCG every 2-3 days. Repeat ultrasound performed, shows a 3cm L adnexal mass, no intrauterine

pregnancy and suggestion of free fluid. Talk through when should an US be performed?

When the BHCG is around 1500. A gestational sac will be present in 91% of women with an intrauterine pregnancy at this level. Absence of an IUP is NOT confirmation of an ectopic at this level.

Talk about when/if she should be admitted?

There is probably no correct answer. Some will admit from day 1 if BHCG >1000. Certainly admit if she is symptomatic or if she cannot access the hospital if symptoms commence. She should be very aware of the symptoms and the need to present early.

(Slide 14) What are the possible treatments for ectopic pregnancies? Talk through the options:

Expectant Medical Surgical

NB Do not forget Anti D Note to instructors – it is really important to talk about the management options for ectopic (including expectant) as this is in the exam! (Slide 15) Summary Final slide for the case. YOU SHOULD BE AT ABOUT 25 MINUTES INTO THE SESSION.

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MATERNITY CASES C CASE 2: PRETERM LABOUR

This case has 35 minutes allocated to it. TEACHING POINTS The main points that the participants should take away from this session are:

Importance of the women’s history Avoidance of digital vaginal examinations in women with a history of

preterm rupture of the membranes Importance of corticosteroids if preterm birth is anticipated Awareness of risk factors for Group B Step (different places will have

different policies about routine screening) Various management options – often depends on the context and services

available. (Slide 17) History

You are conducting your antenatal clinic and seeing a woman who has just moved to your area at 26 weeks gestation.

Her first baby was born at 30 weeks gestation a year ago

(Slide 18) What other information would you like? Use the whiteboard to get the group to come up with the information they require. This is not on the slide.

You would want her antenatal records from her last pregnancy particularly the dating scan if she had one and also to look for risk factors for preterm birth to ascertain underlying (maybe treatable) causes.

You might also find out if there was a reason found for her previous preterm birth.

Ask the group to come up with the risk factors for preterm birth:

Age (adolescence, older women)

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Low socioeconomic status Previous preterm birth Preterm premature rupture of the membranes (PPROM) Maternal infections

o Asymptomatic bacteruria o Untreated pyelonephritis o Genital tract infections

Syphilis, gonorrhoea, Chlamydia o Group B strep infection through PPROM o Other systemic infections – pneumonia, malaria, typhoid

Increased uterine size (twins, polyhydramnios) History of cervical surgery (eg. Cone biopsy) History of smoking or illicit drug use Maternal trauma Previous uterine surgery (eg myomectomy, D&C) Other pregnancy complications (abruption, appendicitis, cervical

‘incompetence’, uterine abnormalities) In light of the risk factors you might ask if she had any investigations this pregnancy, for example:

Assessment of cervical length (ultrasound) Vaginal swabs Fetal fibronectin

No cause was found for her previous preterm birth, and no other risk factors

identified for this pregnancy.

What can you offer her to try to prevent another pre-term birth? o Discuss what has been tried – bedrest, home monitoring, cervical US,

fetal fibronectin. o None prevented preterm birth but a normal cervical length on US and

a negative fetal fibronectin are associated with low risk of preterm birth.

You might also talk about the importance of growth monitoring through

pregnancy and the diagnosis and treatment of any infections.

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Her pregnancy continues normally. Her BP and urinalysis are normal, as is the fetal growth. At 32 weeks she contacts the hospital (or health centre or private provider –

depending on your group), thinking her waters might have broken. (Slide 20) What advice do you give her? She should be advised to come in for assessment, initially to confirm or refute the diagnosis. If confirmed you will need to make a management plan. She comes in for assessment 2hrs later What other information do you want to obtain from her now? Use the whiteboard to get the group to come up with the information they require. This is not on the slide. Initially you need to ask about any fluid leakage:

Was there a sensation of popping or gushing of fluid? Is she wearing a pad – check loss Has she had any continued leakage with movement or change in position?

Ask about her contractions:

Is she having any? How often are they coming? How long does she think they are lasting and how strong or painful are they Are they like in her first pregnancy?

It is vital to confirm her gestation if this has not already been done. You also need to know about general risk factors:

Vaginal discharge or infection Maternal fever Dysuria History of trauma History of respiratory or other infection symptoms

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Her social situation needs to be considered:

Support at home Responsibility for her young child at home Presence of supportive partner or family

You will also need to consider any other medical problems that may need consideration (hypertension, diabetes). What do you look for on examination? On general examination you would assess her overall well-being, with particular attention to temperature and pulse. On abdominal examination you should assess:

Symphysio-fundal height (often reduced after ROM) The fetal lie and presentation (malpresentations are common in preterm

babies) Speculum examination may be performed – a pool of liquor confirms the

diagnosis of PPROM but this is not strictly necessary if liquor can be seen draining from the vagina

If cervical dilatation cannot be assessed (often very hard with a speculum) then a gentle digital VE may need to be done – especially if there is a need to transfer. (Slide 21)

She tells you she is having contractions, every 5 minutes She continues to drain clear fluid, but has no other discharge. Her other child is with her, as her partner is away working and she has no

other local support. O/E the symphysio-fundal height is 29cms. The fetal head is presenting and

is not engaged. T 370C Speculum examination shows a pool of clear liquor in the posterior fornix.

You were not able to assess the cervical dilatation. (Slide 22) What investigations do you request?

At speculum you take swabs for microscopy and culture. A low vaginal swab will sufficient to assess for Group B Strep (cervical swabs miss 50% of women with positive GBS). Discuss fetal fibronectin and its uses.

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Discuss ORACLE trial results – screening of risk factors (maternal fever more than 380C, gestational age less than 37 weeks, previous infant with GBS infection, ruptured membranes >18 hours, GBS bacteruria during pregnancy) versus universal screening. Acknowledge that many maternity units have moved to universal screening.

Other investigations – MSU, full blood count A CTG should be undertaken to assess fetal wellbeing – tachycardia may be

the first sign of an infection An ultrasound may be undertaken to assess fetal growth and size particularly

to assess if transfer required. What treatment would you advise now? You have 2 problems to treat:

1. Preterm labour 2. Respiratory difficulties in the baby if born

Go through the preterm labour first

No treatment has been shown to improve outcomes per se but the use of tocolytic drugs does allow for the administration of corticosteroids to the woman or enable transfer of her to a larger hospital with a neonatal unit.

Indomethacin is effective but increases neonatal morbidity by causing premature closure of the ductus arteriosus

Nifedipine is the currently favoured tocoyltic having fewer side-effects and greater success than Salbutamol in delaying birth.

Some places are still using Salbutamol so you may need a quick conversation about this but focus on Nifedipine.

Magnesium suphate for neuroprotection Participants may mention MgSO4 for neuroprotection. Most guidelines recommend MgSO4 for neuroprotection for women at risk of preterm birth who are at least 24 weeks and < 30 weeks gestation. The woman in this case is 32 weeks therefore MgSO4 is not indicted. Encourage the participants to go back to their service and check their own guidelines in relation to this issue. (Slide 23) Nifedipine Regime Maximum oral regime = 160mgs in 24 hrs

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Initial dose 10-20mgs stat • Further 10-20mgs may be given at 15-30min intervals for a total

maximum dose of 40mg Maintenance Dose

• 8-hourly slow-release oral medication • Total of 60-160mg per day depending on uterine activity and

other clinical information Also now talk about the reducing respiratory distress in the baby

There is no doubt that the administration of antenatal corticosteroids to the woman is highly effective in preventing respiratory distress, intraventricular haemorrhage and infant mortality.

Two regimens for steroid administration are: • betamethasone 11.4 mg (2 ampoules of 5.7mg) IM given as two doses,

24 hours apart. • dexamethasone 6 mg IM, four doses, 12 hours apart.

Even when administered to women with PPROM, steroids reduce the incidence of hyaline membrane disease by about 50% without increasing perinatal infection.


After 2 hours tocolytic therapy her contractions cease, and you arrange her transfer to a unit with appropriate neonatal facilities.

Her contractions start again despite continuation of tocolysis, and the CTG shows a fetal tachycardia.

Her temperature is 37.5ºC. (Slide 25) What would you do now? Get the group to talk about:

Reassessing the woman for signs of infection (offensive liquor, uterine tenderness – although these are very late signs)

The CTG should be assessed Commence antibiotics as her increasing temperature and feta tachycardia

are suggestive of infection

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If addition, she would appear to be in preterm labour so antibiotics are indicated.

From the Manual: Antibiotic therapy for women who have PPROM is effective at prolonging pregnancy and reducing both maternal and neonatal infectious morbidity. These data support the routine use of broad-spectrum antibiotics in PPROM. There has been widespread use of erythromycin as a result of the ORACLE trial. Amoxycillin with clavulanic acid has also been shown to increase the incidence of necrotizing enterocolitis.


She remains febrile and her contractions continue. Digital vaginal examination shows the cervix to be 8cm dilated. She says she is in a lot of pain and requests Pethidine, which had worked well

for her in her last labour. The CTG continues to show a fetal tachycardia, but is otherwise normal.

What are your concerns at this point?

Talk about analgesia – try to avoid narcotic analgesics because of their effect on the preterm baby. If you do give them, be aware of this at the birth.


Prior to the administration of analgesia she starts to push, and gives birth to a 1000g boy who cries at birth.

The 3rd stage is actively managed and the placenta and membranes deliver with minimal blood loss.

What are your concerns at this point?

This is a preterm growth restricted baby who may also have an infection. The baby will also need to be kept warm (and pink and sweet) The baby needs admission to a neonatal unit and a full infection screen (FBC,

blood culture, chest X-Ray and possibly lumber puncture). Empirical antibiotic therapy is indicated while awaiting culture results (48-72

hours). Careful monitoring of temperature and blood sugar levels are required.

(Slide 28)

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Summary Finish with a brief summary of preterm labour.

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