Obstetrics by Flow Diagrams Summary

Jacob Matthews

jake04030@hotmail.com

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06/05/2015 1

• Contents

• Pregnancy – medical conditions • Emergencies • Infections • Miscarriages + still births • TOP • Induction • C-sections • Normal Labour • Antenatal care • Post natal care

06/05/2015 2

Obstetric hx

ICE

Any questions?

Patient details

Age + parity + Current preg

weeks

First? Surprise?

Attitude to pregnancy?

Menstrual

LMP + bleeding days + regular + length + Normal

Contraception

Hx Present Preg

General health, smoking

Antenatal care?

Fetal movements?

Past Obstetric hx

How many? Date + place

Mode, problems,

length

Baby sex, weight, health

3rd stage problems?

PMHx + PSHx FHx + SHx

Smoking drugs drinking

Hereditary conditions = HT

diabetes

Occupation + Partner

Drug Hx

Chronic, otc, allergies

Ex

general

abdo

Lie, vertex, Presentation,

Position, engage

SFH + doppler

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Pregnancy Conditions

Pre-eclampsia

HELLP

Obstetric Cholestasis

Diabetes Epilepsy Anaemia Hypothyroidism Asthma VTE Multiple

pregnancies

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HT

Pre-existing HT (rBP) <20/52

BP> 140/90

STOP ACEi, Labetalol, nifedipine

Deliver <40/52

Gestational HT >20/52

>140/90

Labetalol, Aspirin <16/52

BP weekly, USS 2-4 weekly

Pre-elampsia

HT, Proetinuria >0.3g, Oedema

+ IUGR

Aspirin, delivery 37/52

Uterine artery Doppler 23/52

? Admission

Crap spiral arteries – thinks

bleeding

>160/110 Severe

Headache, N+V, Epigastric pain,

Sudden Oedema

? Admit

<34/52 Steroids+ C-

section

>34/52 induce labour

Monitor 24h – fluid, discharge

on B-blocker

Seizure, HELLP, Pain

MgSO4 iv infusion

Delivery ASAP, steroids

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BP should reduce 2nd trimester Cardiac output+ blood volume + GFR + Tidal Volume increases by 40%

Pregnancy Conditions

Pre-eclampsia Obstetric

Cholestasis Diabetes

Pre-Existing

1

Increase insulin >resistance

HbA1c <48 mmol/mol

(6.5%)

Stop ACEi + Statins

Methyldopa, Labetalol, nifedipine

Aspirin

>4kg C-section <39/52

Screen Retina + kidneys

Blood glucose 2/52 <34/52 Then weekly

2

Metformn

aspart / lispro

Short

isophane insulin

Long

Stop Oral hypoglycaemics

Gestational

Fasting >7 mmol

18, 24, 28/52

OGTT 2h >7.8

Metformin Insulin

Stop at birth OGTT 3/12

Urine dip

Epilepsy Anaemia Hypothyroidism Asthma VTE Multiple

pregnancies

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Pregnancy Conditions

Pre-eclampsia Obstetric

Cholestasis Diabetes Epilepsy Cardiac

Valve

Repair > pregnancy

Failure

Pregnancy caution

Stop ACEi, diuretics, warfarin

LMWH > warfarin

Forceps delivery reduce strain

Eisenmenger’s

Pregnancy Contra-Indicated

Arrhythmia Physiological

changes

Anaemia Hypothyroidism Asthma VTE Multiple

pregnancies

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http://www.patient.co.uk/doctor/eisenmengers-syndrome

Pregnancy Conditions

Pre-eclampsia Obstetric

Cholestasis Diabetes Epilepsy Anaemia Thyroid

Hypo

Anovulation Prem,

Miscarriage, low IQ, pre-eclampsia

Thyroxine

TSH monitor 6/52

Hyper

anovulation Foetal

thyrotoxicos, goitre

Thyroid storm

propylthiouracil

Neonatal hypo

Are NOT altered

TSH increased 1st trimester

PP thyroiditis

Post natal depression

Asthma VTE Multiple

pregnancies

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Pregnancy Conditions

Pre-eclampsia Obstetric

Cholestasis Diabetes Epilepsy Anaemia

Hypothyroidism

Asthma Prothrombotic

VTE

LWMH

Anti-phospholipid

Lupus anticoagulant

Anti-cardiolipin

Aspirin + LMWH

Anti-Thrombin def

LMWH

Factor V Leiden

Protein C/S def

Multiple pregnancies

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Pregnancy Conditions

Pre-eclampsia Obstetric

Cholestasis Diabetes Epilepsy Renal

Anaemia

Hb <11,

Severe <7

Booking , 28 + 36/52

100mg Ferrous Sulphate

IV FE <9 Blood

Transfusion

Hyrdops Fetalis

Sickel cell, Thalassemia

5mf Folic acid + Abx

Treat as high risk Creatinine >200

Contra-indicated

physiology

GFR increases

Urea + creatinine decrease

UTI

Prem, Pyelonephritis,

Nitrofurantoin

Asymptomatic

Nitrofurantoin

Hypothyroidism Asthma VTE Multiple

pregnancies

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Pregnancy Conditions

Pre-eclampsia Liver

Acute Fatty Liver

Intrahepatic cholestasis

Itchy, ?jaundice, Fhx, rLFT

Still birth + Prem

Vit K >35/52, Ursodeoxycholic

acid

Obstetric Cholestasis

Diabetes Epilepsy Anaemia Hypothyroidism Asthma VTE Multiple

pregnancies

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Puerperium

Placental delivery – 6/52

Uterus shrinks 4/52 – blood

stained discharge

Offensive? - infection

Tazoscin

PP thrombophilia

Raised platelets + clotting factors

PPH >500ml <24h,

>1000ml C-section

Tone, Trauma, Tissue, Thrombin

Prevent -Syntometrin,

Traction

ABCDE, FBC, G+S, X-Match, Fluids

Blood transfusion Treat the cause

Bimanual compression

Oxyotocin + ergometrin

Rush Balloon Uterine artery embolization

2 >24h, Tissue or infection

Endometritis - ABx

Breast feeding

Prolactin – Milk,

Oxytocin – ejection

Cholustrum 3/7 – Ig + Fat

Foremilk = Fat, Hind = Filling

Contraception

IUD – same day

POP - >4/52

COP > breast feeding

Psych

Baby blues

PND

Psychosis - admit

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Pregnancy Emergencies

Pre-eclampsia

HELLP

Seizures

ABCDE

Diazepam

Shoulder Dystocia

HELPERR

Cord Prolapse

Tocolytic

All fours

Emergency C -section

Amniotic Fluid Emboli

ABCDE

Crash call

ITU Support/ ?delivery

Uterine Rupture

ABCDE

Emergency Laparotomy

Uterine Inversion

Push it back in

Emergency surgery

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C-Section Categories

1

Immediate threat to life of woman/ foetus

<30 mins

2

Compromise not immediate

threat 2 life

<75 mins

3

No compromise but needs early

delivery

4

elective

39/52

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http://www.nice.org.uk/guidance/cg132/chapter/guidance

Small for date baby

<10th centile <3rd severe

Constitutional 2/3

Maternal height, ethnicity

Abdo circumference or estimated fetal weight x2 3/52

Umbilical artery Doppler – reduced

placental blood flow

IUGR 1/3

Slowed growth in utero 2xUSS

Stop smoking, give aspirin >16/52

Steroids, plan delivery at 37/52

Symphysial fundal height >24/52

Low PAPP-A 1st trimester, high risk

http://www.patient.co.uk/doctor/intrauterine-growth-restriction 06/05/2015 15

Pregnancy Drugs

24 – 34/52

Dexamethasone Salbutamol, terbutalin, nifedipine

Peri-labour

Oxytocin im misoprostol ARM Syntometrin - ergometrine

Analgesia Anti-D <72h,

baby +ve, mum -ve

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PROM <37/52, APH

Diabetes, IUGR, Pre-eclampsia,

rBP, 37/52

Induction >41/52

Bishop’s score <13

Membrane sweep

Bishop’s score – cervix

ripeness >8

PG pessary, Bishop’s <4

Misoprostol x3

ARM Oxytocin

Still birth risk doubles 43/52

http://perinatology.com/calculators/Bishop%20Score%20Calculator.htm 06/05/2015 17

EGG + Sperm

M23Ch + F23Ch

Normal zygote

O +23

F 23 x2

Complete Mole Hyperemesis,

bleeding Urine Preg test + bHCG, histology

M23 + F23 + F23

Partial Mole

Suction + Curetage,

histology, bHCG

Choriocarcinoma - Methotrexate

http://www.patient.co.uk/doctor/gestational-trophoblastic-disease

Father DNA = Parasitic No viable foetus Invasive mole Choriocarcinoma

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http://en.wikipedia.org/wiki/Hyperemesis_gravidarum

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Infections Pregnancy

Teratogenic

Rubella

Deafness, sight, brain, heart

CMV

IUGR, rash, cataracts, deafness, epilepsy

Toxoplasmosis

Chorioretinits, Intracerebral calcification, hydrocephaly

VZV

Limb hypoplasia, skin scarring, deaf,

delay

Listeria

Miscarriage, Prem,

Meconium, Brain bleed, pneumonitis

Any time

Chlamydia BV, TV Parvovirus

Haem anaemia, Fetal hydrops,

IU death

Birth

Herpes simplex

Skin, encephalitis

Group B Haem Strep

Septicaemia – Ben Pen

HIV

C-section, zidovudine,

HAART,

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Pregnant

Lateral pain + Bleeding + low BP

bhCG 48h apart <50% or >63% change - refer

bHCG + TV USS

Anti-D Methotrexate

HCG<1500, <35mm mass, no HR

>3-6/12 before next pregnancy

Diagnostic Lap bhCG>5000, HR,

>35mm mass

salpingECtomy salpingOStomy

FBC, G+S, x-Match

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http://www.patient.co.uk/doctor/ectopic-pregnancy-pro

Down’s Screening

Booking 10-13/52

11-14/52

USS - NT PAPP-A Low

BhCG – raised (3xCh21)

Anomaly scan 18-20/52

<20/52

BhCG - raised Inhibin -raised

AFP - low Estrodiol -

low

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PROMS

Pre-term <37/52

Admit, Temp

Abx, deliver

1/3 – spontaneous

delivery

Steroids

2/3 delay to >34/52

Erythromycin 10/7

Do no do PV exam

Pre-labour (term)

Wait 24h

Induce - PG

GBS swab

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http://www.nice.org.uk/guidance/cg132/chapter/guidance

Miscarriage

<12/52

Chromsomes AntiPhospholipid – placental clot

Aspirin + LMWH

thrombophilia

>16/52 - structural

Smokers Short cervix CIN – loop

excision

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Pregnant – bleed <24/52

Threatened – closed Os

Normal Birth Premature

Birth Complete

Miscarriage

Inevitable – Open Os

Compete Miscarriage

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Threatened miscarriage –

PV bleed

Expectant

7-14 days should bleed

Medical

Vaginal misoprostol

Anti-D >12/52, again

at 6/52

Anti-D any time if

instruments

Surgical

Manual vacuum - LA

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A = abruption

P = Praevia

H = haemorrhage of Vagina

Pregnant – bleed >24/52

Placenta praevia >20/52, painless

<2cm 32/52, accrete, increta, percreta

Planned C-section 39/52

>2cm

Normal delivery

Placental abruption, PAINFUL Woody

1/100, Fetal death 30%

Induce labour

Ex + CTG + USS

A-E, Steroids, Anti-D, Conservative /C-

section

Still birth

Dies in utero <24/52 DO NOT register

Ante-partum haem

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Emergency contraception not

covered Abortion act

A <40/52

Grave risk to life of women

In emergency only need 1 Dr

B <40/52

Prevent grave permanent

mental or physical health

C <24/52

Continuing > risk than TOP to

woman

D <24/52

Risk to existing children

E <40/52

Risk that child will be substantially

handicapped

Legal issues 2 registered

medical practioners

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TOP

<7/52 - Medical

200mg mifepristone

Shed endometrium

Misoprostol 800mcg

Opens Os + contraction

7 – 15/52

Medical Suction <12/52

>15/52

Dilation + evacuation

Medical + KCl

Legal issues Abx + blood

test

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