Abnormal labour

‐ Progress in labour is dependent on the ‘3 Ps’ : powers (uterine contraction), passages

(pelvic inlet/outlet), and passenger (baby size/position)

Poor progress in the first stage of labour

‐ defined as cervical dilatation of less than 2 cm in 4 hours, usually associated with failure
of descent and rotation of the fetal head
‐ It may relate to the powers, the passages or the passenger

1. Dysfunctional uterine activity - ‘powers’

The most common cause of poor progress in labour 3. Malpresentation - ‘passenger’
Risk factors (decrease polarity of the uterus, increase or decrease fetal
A. uterine contractions is most commonly carried out by clinical
mobility, or block the presenting part from the pelvis)
examination and by using external uterine tocography
B. Intrauterine pressure catheters are available (more accurate
Maternal factors include grand multiparity, pelvic tumors, pelvic contracture,
measurement, but they are invasive and rarely necessary)
uterine fibroids and uterine malformations.
A frequency of 3-5 contractions per 10 minutes is usually considered ideal,
Fetal factors include prematurity, multiple gestation, polyhydramnios or
with each lasting 45-60 seconds
‐ If suspected delay “1-2 contractions lasts for 30 seconds”: offer amniotomy (ARM
oligohydramnios, macrosomia, placenta previa, hydrocephaly, aneuploidy,
“artificial rupture of membranes”) and repeat vaginal examination in 2 hours anencephaly, and myotonic dystrophy
‐ If progress was < 1 cm after 2 hours, delay is confirmed:
‐ Consider use of oxytocin → If progress fails to within 4–6 hours using oxytocin → do CS
A. Breech presentation
2. Cephalopelvic disproportion (CPD) - ‘passages’ and ‘passenger’ occurs when the baby head in the uterine fundus
implies anatomical disproportion between the fetal head and maternal pelvis ‐ The incidence of breech presentation is 30% of
(it can be due to a large head, small pelvis or a combination) pregnancies at 28 weeks’ gestation, become 3-4% at
‐ diagnosed only after failed trial of labour term pregnancies

Causes of CPD The three types of breech presentation are the following:
1. Large fetus (constitutional, GDM, post maturity) Incomplete, or footling
Frank breech (50-70%) Complete breech (5-10%)
2. Abnormal fetal position (occipitoposterior) (10-30%)
3. Unusually small pelvis (previous fractures, metabolic bone disease) both hips → flexed + both both hips + both knees → one or both hips → extended
4. Contracted pelvis knees → extended. flexed
5. Pelvis of a size and/or shape that insufficient for vaginal delivery of a normal sized fetus
6. Obstructive masses in the maternal pelvis or in the fetus (hydrocephalus or fetal goitre)

Finding suggest of CPD

1. Fetal head is not engaged
2. Head is poorly applied to the cervix Risks factors
3. Progressive is slow or arrests despite efficient uterine contractions 1. Cord prolapse (15% in footling breech, 5% in complete breech, and 0.5% in frank breech)
4. Vaginal examination shows severe moulding and caput formation 2. Head entrapment
5. Hematuria 3. Spinal cord injury (with neck hyperextension)

❖ Moulding: pressure on the head caused by the tight birth canal may "mold" the head into Delivery of a fetus in a breech presentation:
an oblong ‫ مستطيل‬rather than round shape (overriding sutures) 1. External cephalic version and then allow vaginal delivery
2. Cesarean section
❖ Caput succedaneum: diffuse swelling of the fetal scalp caused by the pressure of the
3. Breech vaginal delivery
scalp against the dilating cervix during labour
External cephalic version (ECV)
is the manipulation of the fetus, through the maternal abdomen, to a cephalic
presentation When the umbilicus appears, place fingers medial to each thigh and
‐ Indication is → persistent breech presentation at term press out laterally to deliver the legs (Pinard manoeuvre)
‐ performed to avoid malpresentation in labour
‐ Done at 36-37 weeks’ gestation, Ultrasonographic guidance to confirm position and The fetus should then be rotated to the sacrum anterior position, and
monitor FHR the trunk can be wrapped in a towel to allow for application of
‐ Overall success rates are greater for multiparous women (60%) than for nulliparous downward traction. When the infant’s scapulae appear, the arms can be delivered
women (40%), Tocolysis and spinal or epidural anesthesia may improve success rates
‐ Reversion from cephalic to breech after successful ECV is rare (3%)

❖ Spontaneous version from breech to cephalic at term is about 8%

Risks of ECV
The fetus is (rotated to left side lead right arm at midline then deliver it then rotate to right side
1. The most common “risk” is failed version
lead to left arm midline then deliver it) so that the shoulder is anterior, the humerus followed
2. Compromised umbilical blood flow
down, and each arm swept across the chest and out (Lovset manoeuvre).
3. Placental abruption
4. Premature rupture of membranes
Fetal head is usually delivered spontaneously if full cervical dilation, but If not delivered
5. Fetal distress
spontaneously, 1. head may be flexed by placing downward traction and pressure on the maxillary
6. Fetal injury
ridge (Mauriceau-Smellie-Veit manoeuvre) OR 2. Direct vertical suprapubic pressure OR 3. Use
7. Fetomaternal bleeding
Piper forceps

Contraindications of ECV
1. Any conditions which labour or vaginal delivery contraindicated
2. ruptured membranes
3. third-trimester bleeding B. Face presentation:
4. oligohydramnios Face presentation results from extension of the fetal neck. The chin (mentum)
5. multiple gestations
is the presenting part
6. after labour has begun
‐ Face presentation may be diagnosed by vaginal
examination or ultrasonography
After the procedure, the patient should be
A. monitored continuously until the FHR is reactive, no decelerations are present, and no C. Brow presentation:
evidence of regular contractions exists
B. Rh-negative patients should receive anti (D) Ig after the procedure because of the Brow presentation results from partial deflexion of the fetal neck
potential for fetomaternal bleeding
D. Shoulder presentation:
Breech vaginal delivery Shoulder presentation occurs as the result of a transverse or oblique lie of the
It poses increased risk of fetal asphyxia, cord prolapse, and mortality. fetus
‐ Delay in making the diagnosis risks cord prolapse and uterine rupture
A trial of labour may be attempted if:
1. The breech is frank or complete E. Compound presentation:
2. Fetal weight is ≤ 3.8 kg when an extremity prolapses beside the presenting part
3. Fetal head is flexed ‐ Fetal risks are cord prolapse in 10% to 20% of cases and birth trauma
4. Fetus is continuously monitored including neurologic and musculoskeletal damage to the involved
5. Pelvis is adequate extremity
6. Anesthesia is immediately available ‐ The prolapsing extremity should not be manipulated ‫سحبها‬
7. A pediatrician is available ‐ Continuous fetal monitoring is recommended because compound presentation can be
8. An obstetrician is available who is experienced with vaginal breech delivery associated with occult cord prolapse

In breech presentation, the fetus usually emerges in the sacrum transverse or oblique position

As crowning occurs (the bitrochanteric diameter passes under the symphysis), an episiotomy can
be considered
 Presentation Management Obstructed labour
Breech Breech Vaginal delivery / ECV to allow vaginal delivery / CS Is arrest of vaginal delivery of the fetus due to mechanical obstruction
Face Mentum anterior (allow for flexion of the fetal head) → Vaginal delivery
Mentum posterior → CS
Brow The majority of cases spontaneously convert to a flexed attitude → vaginal It occurs when the uterus is contracting strongly, but there is arrest of cervical
persistent brow → Only CS dilatation and descent of the fetal head
Shoulder Only CS
Compound Spontaneous vaginal delivery occurs in 75% of vertex/upper extremity
presentations Bandl’s ring is a late sign of obstructed labour, the depression can be seen on
Cesarean section is indicated in cases of non-reassuring FHT, cord the abdomen at the level of the umbilicus. It signifies impending rupture of the
prolapse, and failure of labour to progress lower uterine segment.

Poor progress in the second stage of labour Complications :

Delay is diagnosed if delivery is not occur after 2 hours of pushing in a 1. Uterine rupture
nulliparous labour and 1 hour for a multipara woman 2. Recto-vaginal & vesico-vaginal
fistula
3. Pelvic floor injury
1. Secondary dysfunctional uterine activity (‘powers’): 4. Pelvic organ prolapse
A common cause of second stage delay 5. Intrapartum infection
‐ may be exacerbated by epidural analgesia 6. Nerve injury
‐ If no mechanical problem is anticipated, 7. Caput seccudenum
‐ treatment is with rehydration and IV oxytocin Management: Stabilisation, Delivery by CS

2. ‘Passages’: Precipitate labour

1. narrow midpelvis (android pelvis), which prevents internal rotation of the fetal head Strong and frequent contractions causing abnormally rapid progress of labour
2. resistant perineum, particularly in a nulliparous woman
Risk factors :
3. Malposition ‘passenger’: ‐ Strong uterine contractions
‐ Any position other than occipitoanterior, Complicates around 10% of labours ‐ Small sized baby
Occipitoposterior: ‐ Minimal soft tissue resistance
Abnormal position of the vertex where occiput is posterior over the sacro-iliac joint or directly ‐ Previous history of precipitate labour
over the sacrum
‐ Persistent occipitoposterior results from failure of rotation
Management:
‐ 90% spontaneous rotation to OA, specially if good uterine contractions, average fetal size and
adequate pelvis ‐ Discontinue oxytocin
‐ Episiotomy? (to avoid ICH and birth canal injuries)
‐ Observe mother for PPH after delivery
Diagnosis : prolonged second stage of labour
Abdominal exam: flat lower abdomen, difficult to palpate fetal back, fetal Maternal complications Fetal complications
limbs are palpable anteriorly, and fetal heart may be heard in the flanks ‐ Laceration: Cervix, vagina, and perineum. ‐ Intracranial hemorrhage
‐ Uterine inversion – PPH ‐ Fetal distress
‐ Uterine atony – PPH ‐ Delivery in inappropriate place
Vaginal exam: posterior fontanel towards the sacro-iliac joint, anterior fontanel ‐ Amniotic fluid embolism
is easily felt if flexed head, marked moulding with caput and difficulty to ‐ Infection (as a result of unsterile delivery)
assess station and position
Management: instrumental delivery or CS if deep arrest

Management options for delay in the second stage of labor

‐ Continued pushing with encouragement
‐ Regular reviews of progress and fetal wellbeing
‐ Oxytocin to augment contractions
‐ Episiotomy for a resistant perineum
‐ Instrumental vaginal birth (forceps or ventouse/vacuum)
‐ Cesarean section
 Assisted vaginal delivery B. Prerequisites in abdominal and vaginal examination
‐ refers to vaginal birth with the use of any type of forceps or vacuum extractor (ventouse) 1. Vertex presentation
‐ The terms assisted vaginal delivery, instrumental delivery, and operative vaginal delivery 2. Exact position of the fetal head has been determined
are used interchangeably 3. Head is ≤ 1/5 palpable per abdomen
‐ Between 10% - 15% of all women give birth by assisted vaginal birth 4. Station at level of ischial spines or below
‐ The alternative choice of a CS late in the 2nd stage of labour can be very challenging and 5. Cervix is fully dilated
result in significant maternal and perinatal morbidity 6. Membranes ruptured
‐ Inform women that epidural analgesia may increase the need for assisted vaginal birth 7. Pelvis is adequate

What reduces the need for assisted vaginal delivery? C. Preparation of staff
1. Encourage women to have continuous support during labour 1. Operator has the knowledge, experience and skill necessary
2. Encourage women not using epidural analgesia to adopt upright or lateral positions in 2. Personnel present who are trained in neonatal resuscitation
the 2nd stage of labour 3. Adequate facilities are available (equipment, bed, lighting)
3. Encourage women using epidural analgesia to adopt lying down lateral positions rather 4. Access to CS within 30 minutes in case of failure to deliver
than upright positions in the 2nd stage of labour 5. Expect of complications that may arise (e.g., shoulder dystocia, perineal trauma,
4. Recommend delayed pushing for 1–2 hours in nulliparous women postpartum haemorrhage)

Indications Choice of instrument

Maternal Fetal
1. Maternal exhaustion or distress Suspected/proven fetal compromise
The choice of instrument should be based on a combination of indication,
2. Medical indications to avoid Valsalva (cardiotocography pathological, abnormal experience and training.
manoeuvre, including: fetal blood sampling result, thick meconium) The aim should be to complete the delivery successfully with the lowest
a) Cardiac disease NYHA class III or IV
b) Hypertensive crisis possible morbidity and, where appropriate, the preferences of the mother
c) Myasthenia Gravis should be taken into account
d) Proliferative retinopathy
Classification
Inadequate progress: Mid Fetal head is no > 1/5 palpable per abdomen
Nulliparous women – lack of continuing progress of 2nd stage of labour Fetal skull is at station 0 or +1 cm
Two subdivision
‐ for 3 with regional analgesia
1. non rotational ≤ 45 degree
‐ or 2 hours without regional analgesia
2. rotational > 45 degree
Parous women – lack of continuing progress of 2nd stage of labour
‐ for 2 hours with regional analgesia
Low Fetal skull is at station + 2 cm, but not on perineum
Two subdivision
‐ or 1 hour without regional analgesia 1. non rotational ≤ 45 degree
2. rotational > 45 degree
Contraindications High risk of failure Outlet Fetal scalp visible without separating the labia
1. relative contraindications = Suspected fetal 1. Maternal obesity (BMI > 30) Fetal skull has reached the perineum
bleeding (hemophilia) disorders or a 2. Fetal weight > 4 kg or clinically big baby Rotation ≤ 45 degree
predisposition to fracture (osteogenesis 3. OP position
imperfecta) 4. Mid-cavity delivery or when 1/5th of the
2. Extreme prematurity head palpable per abdomen Vacuum
3. Suspected CPD Traction of fetal head by creating negative
4. A relative contraindication for the use of
pressure through a suction cup applied to
vacuum (but not forceps) is gestational age <
34 weeks the head
‐ Metal cup
‐ Silicone rubber cup
Safety criteria
‐ Omnicup (Kiwi vacuum system)
Includes A. Maternal preparation, B. Full abdominal and vaginal examination, C. Preparation of the
staff Technique
1. Determine the position of the head
A. Maternal preparation
2. Insert the cup into the vagina, Ensure that no maternal tissues are trapped by the cup
1. Clear explanation given
3. Apply the cup to the flexion point
2. Informed consent taken (usually verbal) and documented in women’s case notes
4. Pull during a contraction with a steady motion
3. Appropriate analgesia is in place
5. Remove the cup when the fetal jaw is reachable
4. Maternal bladder has been emptied
5. Indwelling catheter has been removed or balloon deflated
6. Aseptic technique Flexion point
 Failure
1. When a deliberate attempt in vaginal delivery has failed to expedite delivery
2. Fetal head does not advance with each pull
3. Fetus is not delivered after 3 pulls
4. Fetus is not delivered after 30 minutes

Complications
Maternal Risks Fetal Risks
1. Vaginal and cervical lacerations 1. Intracranial hemorrhage
2. Perineal injury (extension of episiotomy) 2. Cephalic hematoma
Failure 3. PPH 3. Facial / Brachial palsy
‐ Head does not descend with each pull 4. Injury to the soft tissues of face &
‐ Head is not delivered after 3 pulls forehead
‐ Head is not delivered after 20 minutes 5. Skull fracture
‐ The cup detached the head with maximum pressure
Complications Vacuum compared to Forceps
1. Scalp lacerations Cephalohematoma: Vacuum Disadvantages:
2. Cephalohematoma
‐ ↓ success rate in achieving vaginal birth
3. Subgaleal hematoma limited to suture line ‐ More likely to be associated with cephalhaematoma and retinal haemorrhage
4. Intracranial/retinal hemorrhage
‐ More likely to be associated with maternal worries ‫ القلق‬about baby
5. Hyperbilirubinemia/ jaundice

Vacuum Advantages:
‐ ↓ maternal perineal and vaginal trauma
Subgaleal hematoma:

crosses suture line

Sequential instruments use
Forceps
vacuum ‫ بعد فشل ال‬forceps ‫استخدام ال‬
Forceps are metal instruments used to provide traction, rotation, or both to the 1. increased risk of trauma to the infant
fetal head when the expulsive efforts of the mother are insufficient to 2. increased risk of obstetric anal sphincter injury (OASI)
accomplish safe delivery of the fetus. needs to balance the risks of a CS following failed vacuum extraction with the
risks of forceps birth following failed vacuum extraction

‐ Generally, an obstetric forceps consists of 2 mirror-image metal instruments that are

articulated or ‘locked’
‐ The blades of the forceps are maneuvered to catch the fetal head, after which traction is
applied to affect delivery
‐ The blades have a cephalic curve designed to conform to the curvature of the fetal head
while pelvic curve of classic forceps approximates the shape of the birth canal.
Technique
1. Identify and apply blades 3. Check for correct application
‐ The left blade is inserted before the right ‐ Sagittal suture in midline of shanks
‐ Inserted between the fetal head and ‐ Cannot place more than one fingertip
fingers of the operator's right hand to protect between the blade and fetal head
the vaginal wall from the blades
‐ Right blade applied in the same fashion
2. Lock the blades 4. Apply traction
‐ Should articulate with ease ‐ Steady and intermittent
‐ Downward then upward
‐ Remove blades upon crowning
 Hypertensive disorders in pregnancy 2. Address exacerbating factors and suggest lifestyle modifications (smoking cessation,
weight loss, exercise, reduced alcohol intake, and low-salt diet)
Physiological cardiovascular changes in pregnancy
3. Counsel about potential complications in pregnancy
↑ Blood volume
4. Screen for end-organ damage (e.g., creatinine levels)
↑ Cardiac output
5. Medication review
↑ Heart rate
Stop teratogenic agents (ACEIs, ARBs, Statins, Thiazide diuretics) and switch to
↓ Systemic vascular resistance
alternative
↓ Blood pressure
❖ Progesterone → relaxation of smooth muscles → ↓ BP
B. Antenatal management
1. Medications:
Blood pressure falls gradually at first trimester, reaching a lowest point around 22–24 Stop teratogenic antihypertensive agents (ACEIs, ARBs, Statins, Thiazide diuretics) and
weeks (peak of BP falling at 2nd trimester), rising again from 28 weeks, and reaching switch to one of the following:
pre-pregnancy levels at 36 weeks of gestation 1st line Labetalol → Non-selective adrenergic receptor blocker
‐ Avoid if asthmatic patient
2nd line Nifedipine → Calcium channel blocker
How to measure blood pressure accurately? 3rd line Methyldopa → Centrally acting, α2-adrenergic agonist
‐ Five-minute rest before measurement, seated at 45-degree angle, arm at the ‐ May cause tiredness, headache, depression, and hepatitis
level of the heart
‐ Avoid using automated devices (under-estimate BP) ❖ Offer pregnant women with chronic hypertension Aspirin 75–150 mg/once
‐ Use suitable cuff size (if circumference ≥ 33 cm use large cuff) daily from 12 weeks (or before 16 weeks) until birth to reduce the risk of pre-
‐ Keep the rate of deflation 2-3 mm/s eclampsia
‐ Use Korotkoff 5 sound
2. Follow-up:
‐ Avoid digit preference (143/82- not near it no 140/80)
Hypertension may improve in early pregnancy due to physiological changes
and some women may stop their medication for several weeks.
Diagnosis of hypertension:
Systolic BP > 140 mmHg OR Diastolic BP > 90 mmHg
Stop antihypertensive treatment when:
sustained systolic blood pressure < 110 mmHg
Women who are pregnant and hypertensive have either: OR
Chronic hypertension “preexisting” (with/without superimposed pre- sustained diastolic blood pressure < 70 mmHg
eclampsia)
OR Reduce antihypertensive treatment when: diastolic BP is persistently < 80
Pregnancy Induced Hypertension (PIH); which is further subdivided into:
mmHg
- Non-proteinuric PIH (Gestational hypertension) ‐ Because there’s an association between low diastolic BP in pregnancy and low birth
- Pre-eclapmsia weight
❖ Aim for a target blood pressure of ≤135/85 mmHg
Chronic Hypertension 3. Appointments
The presence of hypertension before 20 weeks’ gestation (normally fall during this period Schedule additional antenatal appointments based on the individual needs of the
and if there PIH will not obvious)
OR
woman and her baby. This may include:
Persistent hypertension > 6 weeks postpartum (any pregnancy changes will normalize within 6 ‐ Weekly appointments if hypertension is poorly controlled
weeks after delivery) ‐ Appointments every 2 to 4 weeks if hypertension is well-controlled
include measurement of BP and urine dipstick to check for proteinuria (superimposed
pre-eclampsia)
Affects 1 - 5% of pregnant women
Can be either:
Maternal complications Fetal complications
1. Essential (primary) hypertension = Multifactorial with genetic and environmental 1. Superimposed pre-eclampsia: 20-30% 1. IUGR:10-15%
contributions ‐ further increase risk of superimposed
‐ Chronic HTN patient with new onset
2. Secondary hypertension = renal disease is the most common cause in pregnant proteinuria pre-eclampsia
women 2. Deterioration of renal function 2. Prematurity: 20-30% mean delivered before
Management of chronic HTN in pregnancy start from Pre-pregnancy period, ‐ if already affected prior to pregnancy, 37 weeks
but if normal prior pregnancy will not ‐ This is frequently iatrogenic due to
then antenatal then intra-partum and post-partum maternal or fetal indications
affected during pregnancy
A. Pre-pregnancy counselling: 3. Placental abruption 3. Stillbirth
1. Optimize blood pressure control ‐ risk increased 3 folds
4. Timing of birth: ❖ Offer pregnant women with chronic hypertension Aspirin 75–150 mg/once daily from 12
weeks (or before 16 weeks) until birth to reduce the risk of pre-eclampsia (started when one
Timing of delivery should be guided by (severity of hypertension, the presence
or more of high-risk factor OR two or more of moderate risk factor)
of proteinuria, and maternal and fetal wellbeing)
B. Monitoring:
BP is stable < 160/110 and no maternal or fetal indications→ delivered after 37 In not admitted
weeks Measure BP and urine dipstick at least once or twice weekly
Measure CBC, LFT and KFT at diagnosis and then weekly
In admitted
If BP is sustained > 160/110 or there’s maternal or fetal compromise →
Measure BP every 15-30 minutes until it falls below 160/110 mmHg
planned preterm birth (after a course of antenatal corticosteroids if time Urine dipstick daily
permits) Measure CBC, LFT and KFT at diagnosis and then weekly

C. Postpartum management C. Fetal assessment:

❖ Peak postpartum BP usually occurs at 3-5 days Offer fetal heart auscultation at every antenatal appointment
❖ After delivery, aim for a target BP of < 140/90 mmHg Carry out ultrasound assessment at diagnosis and, if normal, repeat every 2 - 4
weeks
After birth should measure blood pressure: Carry out a CTG only if clinically indicated (if BP ≥ 160/110 mmHg)
‐ Daily for the first 2 days after birth
‐ At least once between day 3 and day 5 after birth D. Delivery:
‐ As clinically indicated after that
BP is stable < 160/110 and no maternal or fetal indications → delivered after 37
weeks (while monitoring closely for progression to severe hypertension, preeclampsia, and fetal
❖ If a woman has taken methyldopa to treat chronic hypertension during pregnancy, stop
growth restriction)
within 2 days after birth and change to an alternative antihypertensive treatment (to avoid
exacerbation of postnatal depression)
If BP is sustained > 160/110 or there’s maternal or fetal compromise →
Offer review at 6-8 weeks postpartum for contraceptive advice and future pre- planned preterm birth (after a course of antenatal corticosteroids if time
pregnancy counselling permits)
‐ Avoid estrogen containing contraception (combined) in women with hypertension due to
their potential to exacerbate sodium retention and hypertension
Gestational hypertension may be predictive of chronic hypertension later in
life and is important in regard to patient counselling and preventative medical
Pregnancy induced hypertension
measures
diagnostic in two separate measures = at least four hours’ time in between Blood
pressure ≥ 140 mmHg systolic OR ≥ 90 mmHg diastolic after 20 weeks gestation in a
previously normotensive woman 2. Pre-eclampsia ‫ تسمم الحمل‬/ ‫زالل‬
diagnostic in a single measure = If systolic BP > 160 mmHg OR diastolic BP > 110 mmHg diagnosed by elevated blood pressure and significant proteinuria after 20 weeks’
Final diagnosis only made postpartum (blood pressure normalizing within 6 weeks of gestation in a patient known to be previously normotensive.
delivery) ❖ Trophoblastic disease or multiple gestation can present with preeclampsia before 20
weeks’ gestation
1. Non-proteinuric PIH (Gestational hypertension)
‐ No proteinuria! A. Significant proteinuria:
‐ full assessment should be carried out (screening for any secondary cases KFT, LFT. Use an automated reagent-strip reading device for dipstick screening
CBC) for proteinuria
‐ Antenatal monitoring is needed to ensure that proteinuria does not develop, and pre- If dipstick screening is positive (1+ or more) go to quantify proteinuria in
eclampsia becomes apparent (SCREENING)
pregnant women
‐ Risk of progression to pre-eclampsia is 20-30%
1. spot (protein : creatinine) ratio (mostly used)
A. Medications: ‐ significant if ≥ 30 mg/mmol
Admit to hospital for management if BP ≥ 160/110 mmHg 2. spot (albumin : creatinine) ratio
Aim for a BP ≤ 135/85 (but avoid hypotension) ‐ significant if ≥ 8 mg/mmol
Start Antihypertensive treatment for all women diagnosed with PIH 3. Gold standard test to quantify proteinuria: 24-hour urine collection
1st line Labetalol (Inconvenient so not routinely recommended)
2nd line Nifedipine ‐ significant if ≥ 300 mg
3rd line Methyldopa
Risk factors of pre- eclampsia ❖ Fetal findings could indicate to preeclampsia but not diagnostic (intrauterine
1. Obesity (BMI ≥ 35) growth restriction (IUGR), oligohydramnios, and other signs of uteroplacental
2. Advanced maternal age (40 years) insufficiency)
3. Nulliparity
4. Interpregnancy interval > 10 years
5. Multiple gestation
Laboratory findings diagnostic of severe preeclampsia include:
6. Molar pregnancy 1. Platelet count < 150 000 platelets per µL
7. Conception via assissted reproductive technologies 2. Serum creatinine ≥ 90 micromol/litre, or a doubling of the patient’s baseline creatinine
8. Medical disorders: chronic HTN, pregestational DM, CKD level
9. Autoimmune disease: SLE or APLS 3. Liver enzyme (aspartate aminotransferase AST/alanine aminotransferase ALT) elevation
10. Personal or family History of preeclampsia of more than double the upper limit of normal (use pregnancy references)

Risk reduction in future pregnancy B. Management

❖ Offer pregnant women with chronic hypertension Aspirin 75–150 mg/once Important = Definitive management for gestational hypertension, preeclampsia, and
daily from 12 weeks (or before 16 weeks) until birth to reduce the risk of pre- eclampsia is delivery because the placenta is the insulting agent and removal of the
eclampsia (started when one or more of high risk factor OR two or more of placenta will lead to resolution of the disease process
moderate risk factor)
High risk Moderate risk pre-eclampsia without severe features (mild pre-eclampsia):
Chronic HTN BMI ≥ 35 kg/ m2 - At term: delivery, typically at 37 weeks or at time of diagnosis if after 37
Pregestational DM (type1,2) Advanced maternal age > 40 years old weeks
CKD Nulliparity (primigravida) - Preterm: optimal treatment prior to 37 weeks is usually expectant
Systemic lupus erythematosus SLE Interpregnancy interval > 10 years management
Antiphospholipid syndrome APLS Multiple gestation
Pre-eclampsia/Eclampsia in a previous
Family history of pre-eclampsia Expectant management of preterm patient with mild pre-eclampsia:
pregnancy 1. Antihypertensive treatment with aim to keep BP < 135/85
2. Monitoring of BP (at least every 48 hours), more frequently if admitted to hospital
Pathophysiology: 3. Repeat laboratory tests 2-3 times per week
preeclampsia is a systemic disease, and the placenta is the root 4. Fetal monitoring: fetal heart auscultation at every antenatal appointment,
ultrasound assessment at diagnosis, if normal then every 2 weeks. CTG at diagnosis
and repeat when indicated
Normally in early pregnancy period trophoplast (make up placenta) invades
spiral arteries (supplying nutrients to the placenta and fetus) causing vascular pre-eclampsia with severe features:
remodelling and physiological VD but in preeclampsia there is immunologic urgent delivery after maternal stabilization is indicated
alterations → no remodelling → VC → decrease perfusion and increasing 1. Admission
velocity of blood in the intervillous space → leads to both inflammation and 2. IV line, foley catheter insertion, strict intake/output recordings, fluid management
‐ Hypertension patient with fluid overload and increase their risk of pulmonary edema
endothelial damage and dysfunction. ‐ Limit maintenance fluids to 80 ml/hour unless there are other ongoing fluid losses (for
example, haemorrhage)
Pre-eclampsia with severe features: 3. Laboratory assessments (repeat every 6 hours if still not delivered)
‐ Persistent Blood pressure of 160 mmHg systolic or 110 mmHg diastolic 4. IV antihypertensive agent (+/- MgSO4)
5. Course of antenatal corticosteroids (should NOT delay urgent delivery)
‐ Signs, symptoms, or lab values of severe preeclampsia with any elevated
6. Delivery when the mother is stable (usually by CS)
blood pressure ‐ CTG should be done at diagnosis and continuous fetal heart monitoring is required if in labour
‐ Usually delivery by CS, unless mother and fetus are stable and cervix favourable then could try
IOL by vaginal prostaglandins (delivery decision regarding to bishop score)
Signs and symptoms of severe preeclampsia include (diagnostic features):
‐ If the patient is being delivered by CS, keep in mind:
1. Cerebral or visual disturbances (e.g.; persistent headache, blurred vision, scotomata) A. Anaesthesia: GA can be dangerous as endotracheal intubation can exacerbate
2. Persistent epigastric or right upper quadrant pain hypertension; regional anesthesia is preferred if time permits
3. Pulmonary edema B. Platelet count: > 80 000 per µL needed for regional anaesthesia, also if GA is being used a
Other Symptoms that can be seen with severe preeclampsia but are not diagnostic include minimum of 50 000 per µL is needed for CS
nausea and vomiting, decreased urine output, hematuria, or rapid weight gain (5 lb or more in IV antihypertensive treatment:
1 week) 1st line Labetalol: 20 mg IV bolus, wait for 10-minute intervals if
❖ An additional sign that does not diagnostic but does need increased attention for
preeclampsia is = rapid elevation of blood pressure from baseline persistently elevated: 40, 80, and 80 boluses (up to a maximum dose
of 220 mg)
 Eclampsia
2 line Hydralazine: 5 mg IV bolus, wait for 30-minute intervals if
nd
obstetric patients with new onset seizures and/or coma without a known
persistently elevated: 5, 5 boluses (up to a maximum dose of 15 mg) history of epilepsy or other causes of seizures
(500 cc Colloid should be infused prior to treatment if the baby is undelivered to protect ‐ Occurs in about 1% of patients with pre-eclampsia
the uteroplacental circulation and prevent hypotension and fetal distress) ‐ It’s an obstetric emergency that can occur antepartum, intrapartum, or
postpartum
❖ If no IV access, use immediate release oral nifedipine
Pathophysiology
eclamptic seizures is unknown but is related to arterial vasospasm and may
Magnesium Sulphate
occur when mean arterial pressure exceeds the capacity of cerebral
In severe pre-eclampsia with neurological symptoms
autoregulation, leading to cerebral edema and increased intracranial pressure
Benefits:
1. Seizure prophylaxis (decrease the risk of eclampsia by more than 50%)
2. Neuroprotection (evidence of benefit from 24 weeks till 32 weeks) Management:
Dose: 1. Appropriate management of ABCs (airway, breathing, and circulation) with measures
4 gram bolus over 5-15 minutes, then 1 g/h infusion for 24 hours taken to avoid aspiration
2. Seizure control with 6-g MgSO4 IV bolus
a. If the patient has a seizure during or after the loading dose, an additional 2-g IV
ATTENTION!! bolus of MgSO4 can be given.
‐ MgSO4 has narrow therapeutic window –therapeutic range is 4 to 6 mEq/L b. If seizures refractory to MgSO4, treat with IV phenytoin or a benzodiazepine (e.g.,
‐ Check serum magnesium level 4 hours after the loading dose and then every 6 lorazepam).
hours as needed or if symptoms suggest magnesium toxicity c. Treat status epilepticus (>5 min seizure) with lorazepam. Patients with status
epilepticus may require intubation to correct hypoxia and acidosis and to maintain a
Patients are monitored hourly for signs and symptoms of magnesium toxicity: secure airway.
‐ Loss of patellar reflexes (at 8 to 10 mEq/L) 3. Prevent maternal injury with padded bedrails and appropriate positioning.
‐ Respiratory depression or arrest (at 12 mEq/L) 4. Control of severe hypertension
‐ Mental status changes (at 12 mEq/L) followed by ECG changes and arrhythmias
Delivery
If magnesium toxicity develops: indicated after maternal stabilization, and emergency CS should always be
‐ Stop magnesium sulphate anticipated in case of rapid maternal or fetal deterioration
‐ Check the patient’s vital signs ‐ During acute eclamptic episodes, fetal bradycardia (< 100 beat/min) is
‐ Check plasma levels of magnisum common. It usually resolves in 3 to 5 minutes
‐ Administer antidote 1-g calcium gluconate IV over 3 minutes, and consider diuretics

HELLP Syndrome
complications of pre-eclampsia Hemolysis
Maternal complications Fetal complications Elevated Liver enzymes
1. CVA 1. Prematurity Low Platelets
2. Acute HF 2. IUGR
3. Pulmonary edema 3. RDS ‐ Often presents with nonspecific complaints such as malaise, abdominal pain, vomiting,
4. RF 4. IUFD shortness of breath, or bleeding
5. Thrombocytopenia
‐ Hypertension is not always a clinical feature
6. DIC

Management is the same as for severe pre-eclampsia

‐ Transfusion of red cells, platelets, or factors may be required immediately prior to
delivery depending on severity of anemia and thrombocytopenia

Postpartum management of PIH

1. BP monitoring and management of complications –shall any occur
2. Medication review
3. Follow-up at 6-8 weeks postpartum
BP monitoring:
At least 4 times a day while the woman is an inpatient
At least once between day 3 - 5 after birth (more frequent if she’s taking
antihypertensive treatment, until she’s able to stop it)

Medication review:
❖ If a woman has taken methyldopa to treat chronic hypertension during pregnancy, stop
within 2 days after birth and change to an alternative antihypertensive treatment (to avoid
exacerbation of postnatal depression)

If she’s breastfeeding, use safe antihypertensive agent:

1st line Enalapril (appropriate monitoring of maternal renal function and
maternal serum potassium) =ACEI
2nd line Nifedipine/ Amlodipine = CCB

Follow-up:
1. Make sure BP stabilized and any laboratory abnormalities resolved
2. Counselling about risk of recurrence: about 20%, if needed preterm delivery risk is higher
3. Counselling about long term risks: chronic hypertension, ischemic heart disease, and
stroke
4. Risk reduction in future pregnancies (low-dose aspirin)
 Normal labour Fetal skull anatomy and diameters
Largest and least compressible part of the fetus; it is the most important in
Definitions delivery - regardless of the presentation
Engagement when the widest diameter of the fetal presenting part has passed through
the pelvic inlet
- Assessed abdominally (rule of 1/5th) and vaginally (station of the head) Landmarks
Station the level of the denominator of the presenting part above or below the 1. Anterior fontanelle
plane of the ischial spines 2. Vertex: the area between fontanelles, bounded
Lie the relation between the longitudinal axis of the fetus and the longitudinal laterally by parietal eminences
axis of the mother’s uterus (longitudinal, transverse, oblique, unstable) 3. Posterior fontanelle
- Normal lie = longitudinal (can delivered vaginally, other only CS) 4. Occiput: the area behind and inferior to posterior
Presentation the part of the fetus that occupies the lower segment or pelvis, i.e., head fontanelle
(cephalic presentation) or buttocks (breech presentation)
5. Sinciput (brow): the area between anterior
- Normal presentation = cephalic
fontanelle and glabella
Presenting the lowest part of the fetus palpable on vaginal examination
6. Glabella: elevated area between orbital ridges
- For a cephalic presentation, this can be the vertex (flexed head), the brow
part 7. Nasion: the root of the nose
(extended) or the face (full extended), depending on the attitude
- Normal presenting part = vertex
Attitude Attitude of the head describes the degree of flexion: vertex, brow or face.
Position the relation between the denominator of the presenting part and the
maternal pelvis
- Normal position = OA “occipitoanterior” When the vertex of the fetus presents, and
The denominator: is a bony landmark on the presenting part fetal head is well flexed, the smallest
‐ In vertex → occiput anteroposterior diameter suboccipito-
‐ In brow → frontal bone bregmatic enters the birth canal
‐ In face it → mentum (chin)
‐ In breech → sacrum

Maternal pelvis anatomy

4 bones → 2 innominate, sacrum, and coccyx
3 Joints → sacroiliac “sacrum+2 innominate bones”, symphysis pubis, and
sacroccygeal
3 Pelvic Planes: imaginary flat surfaces that extend across the pelvis at
different levels
1. Inlet: transverse diameter is about 13 cm,
anteroposterior diameter 11 cm
2. Mid-pelvis: almost round, the transverse and AP
diameters are equal 12 cm
‐ On the lateral wall of the mid-pelvis, ischial spines are
palpable vaginally, Used as landmarks to assess the descent
of the head on vaginal examination (station)
3. Outlet: the anteroposterior diameter is 13 cm,
transverse diameter 11 cm
 Maternal pelvis can be classified according to its shape based on Caldwell- 5. Extension : the fetal head is delivered by extension from the flexed position as it travels
Malloy pelvic types into: beneath the symphysis pubis.
6. External rotation : the fetal head turns to realign with the long axis of the spine, allowing
1. Gynecoid pelvis: Classical female 2. Android pelvis 30% the shoulders to align in the anterior-posterior axis.
pelvis 50% ‐ Typical male pelvis
7. Expulsion : the anterior shoulder descends to the level of the symphysis pubis
‐ Most favorable for delivery ‐ Restricted at all levels, arrest of descent
‐ Inlet is round oval with largest transverse in labour is common
diameter, straight side walls, well-curved Initiation of labour
sacrum Labour is a release from the state of functional quietness maintained during
3. Anthropoid pelvis 20% 4. Platypelloid pelvis 3% pregnancy.
‐ Fetal head engages in the ‐ Oval shaped inlet with wide transverse
anteroposterior diameter of pelvis diameter 1. ↓ myometrial responsiveness to progesterone, ↑ responsiveness to estrogen
‐ Persistent occipitoposterior Position ‐ Increased risk of obstructed labour 2. Activation of the fetal hypothalamic pituitary axis → results in increased release of
cortisol, increasing the synthesis and release of PG, and formation of myometrial
gap junctions and activation of oxytocin receptors

False Labour True Labour

Irregular Regular
Contractions
Do not get closer Get closer and stronger with time
Decrease with walking/ rest/
Position Irrelevant to position
or changing position
Weak (may be strong then get
Strength Steadily increase in strength
Labour weaker)
Start in the lower back and move to
the process of fetus and the placenta are expelled from the uterus Pain site Abdomen or pelvis
the front to abdomen

Diagnosis: when painful uterine contractions occur, followed by dilatation and ❖ Braxton Hicks contractions = Irregular, painless, mild intensity contractions of uterine
effacement of the cervix smooth muscle can occur throughout the 3rd trimester, not result in cervical changes
‐ Cervical dilatation: The cervix begins dilating and stretching beyond the normal
dimensions and is measured in centimeter’s (0-10) / 10 cm full cervical dilatation
‐ Cervical effacement: thinning, softening, and shortening of the cervix.
Preparation for labour
1. Lightening
2. False labour
Normal labour 3. Cervical effacement
To be called a normal labour, it should fulfil the criteria of: VERY IMPORTANT
1. Singleton Diagnosis of labour
2. Cephalic Vertex presentation A. painful regular contractions lead to effacement and dilatation of the cervix
3. Between 37-42 weeks of gestation B. ‘show’ ( pink/white mucus plug) from the cervix (blood plugging the cervix and pass
4. Spontaneous onset (start uterine contraction at time of labour without assisted) after dilation) and/or causing release of liquor (due to rupture of the membranes)
5. Unassisted vaginal delivery
6. Within reasonable time and without complication to the mother or the fetus
Stages of labour
1st stage
The cardinal movements of labour
Begins with the onset of labour and ends with full cervical dilation (10cm).
refer to the changes in position of the fetal head during its descent through
descent, flexion and internal rotation occur
the birth canal in vertex presentation
1. Descent (lightening) : movement of the fetal head through the pelvis toward the pelvic
Duration:
floor Nulliparous: average 8 hours, no more than 18
2. Engagement : the descent of the widest diameter of the presenting fetal part below the Multiparous: average 5 hours, no more than 12
plane of the pelvic inlet It is divided into latent and active phases:
3. Flexion : a passive movement that permits the smallest diameter of the fetal head ‐ The latent phase begins = regular contractions with cervical dilation (< 4 cm)
(suboccipitobregmatic diameter) to pass through the maternal pelvis ‐ The active phase = > 4 cm cervical dilatation or increase rate of cervical dilation (more
4. Internal rotation : the fetal occiput rotates from its original position (usually transverse) than usual cervical dilation within similar time)
toward the symphysis pubis (occiput anterior) or, less commonly, toward the hollow of
the sacrum (occiput posterior “malposition”).
2nd stage Perineal trauma detected after delivery VERY IMPORTANT
interval between full cervical dilation and delivery 1st degree injury to perineal skin and/or vaginal mucosa
Descent, flexion and rotation are completed and followed by extension as the 2nd degree injury involving perineal muscles but NOT anal sphincters
head delivers 3rd degree injury to perineum involving anal sphincter complex
3a: <50% of external anal sphincter
Divided into : 3b: > 50% of external anal sphincter
‐ Passive phase → time between full dilatation and the onset of involuntary expulsive 3c: both external and internal anal sphincters torn
contractions 4th degree involving anorectal mucosa
‐ Active second stage: there is a maternal urge to push because the fetal head is low
(Voluntary).
Duration: 4th stage
Nulliparous: maximum of 2 hours (3 h allowed if on epidural anaesthesia) From delivery of the placenta to stabilization of the patient’s condition; for
Multiparous: maximum of 1 hour (2 h allowed if on epidural anaesthesia) example, suturing of perineum if needed and resolution of epidural
anaesthesia
❖ Crowning: when the largest diameter of the fetal ‐ Usually at about 1-2 hours, maximum of 6 hours postpartum

head is encircled by the vulvar ring

General care for women in labour
❖ Episiotomy: Procedure to make a controlled 1. Physical health in labour observations
‐ Contraction frequency recorded every 30 minutes
incision of the perineum for enlargement of the
‐ The temperature and blood pressure every 4 hours
vaginal orifice to facilitate difficult deliveries, ‐ Pulse every 1 hour and then every 15 minutes in the second stage
preferred in mediolateral orientation → ↓ risk of 2. Encourage her to mobilize
perineal trauma 3. Diet
‐ Encourage her to drink isotonic drinks or water. Intravenous fluid may be
3rd stage necessary if labour is prolonged)
From delivery of the fetus till delivery of placenta and ‐ Eating is often discouraged if the labour is high risk, and ranitidine “H2 blocker”
membranes is often given to reduce the stomach acidity
‐ Usually, < 30 minutes (can be up to 1 hour if no active management applied) 4. Urinary tract
‐ Normal blood loss up to 500 mL ‐ encouraged to micturate frequently in labour;
‐ if she has an epidural → catheterization to empty the bladder
Active vs. physiological management? 5. Pain relief when patient asks for it
Physiological Active ‐ Multiple non-pharmacological methods (Music, Breathing techniques,
Uterus Assess size and tone Assess size and tone Massages, Labour in water)
Uterotonic Not used Oxytocin after delivery of anterior ‐ Pharmacological pain relief:
shoulder 1. Inhalational: Etonox (50% O2/ 50% N2O)
- in CS give 5 iu IV 2. Parenteral: IV/IM opioids (morphine, pethidine)
- in vaginal delivery give 10 iu IM - Avoid pethidine: IUFD, epilepsy, sickle cell
Cord traction None Controlled cord traction (after signs 3. Regional “epidural”: offers best pain relief, might be associated with
of placental separation)
longer 2nd stage and increased risk of instrumental delivery
Cord clamping Variable Early

Management of labour
Signs of placental separation A. History –detailed history upon presentation of patient, review of antenatal
1. Fresh show of blood from the vagina
notes
2. The umbilical cord lengthens outside the vagina
‐ When did the pain start?
3. The fundus rises up
‐ Regular or not?
4. The uterus becomes firm and globular
‐ Intervals between contractions?
‐ Vaginal passage of fluid, blood, mucus?
‐ Fetal movement?
‐ Any conditions that need special care in labour?
B. Examination –full general, vital signs, obstetric and vaginal examination Low risk pregnancies
(Assess cervical dilatation, Effacement, Fetal presenting part, Position, Station, Fluid passage/ 1. Checked in partogram
bleeding)
2. Intermittent fetal heart rate auscultation
‐ Every 15 minutes during the 1st stage, and every 5 minutes in the 2nd stage
C. Assessment of labour –serial observations and examinations, monitoring of ‐ Use Pinard’s stethoscope or a hand-held Doppler to check FH for 60 seconds after a
progress (partogram –not routinely), assessment of fetal wellbeing contraction (any abnormality referred to CTG)
3. CTG –Cardiotocogram
Records the FHR on paper and electronically, either
Partogram
from a transducer placed on the abdomen or from a
‐ Graphic record of labour only used in low-risk pregnancy probe in the vagina attached to the fetal scalp. Another
‐ It allows an instant visual assessment of rate of cervical dilatation and transducer records the uterine contractions
comparison with expected norm so that slow progress can be recognized
early; and appropriate actions can be taken. When to use CTG?
‐ ‘Alert’ and ‘Action’ lines on the partogram indicate slow progress. 1. Abnormal FH on auscultation, 20-minute CTG
‐ if normal can go back to intermittent auscultation
‐ if abnormal CTG keep patient on continuous CTG

2. High risk pregnancies: continuous electronic fetal monitoring CTG

‐ Medical disorders (DM, HTN, sickle cell anemia, ….)
‐ Vaginal bleeding
‐ Meconium-stained liquor (the passage of meconium by the fetus in utero during the
antenatal period or in labour)
‐ Previous CS (VBAC)

CTG interpretation
Check:
‐ Contractions
‐ Baseline FHR
‐ Variability
‐ Accelerations
‐ Decelerations

Contractions
Once labour is established, effective uterine contractions are 3-5 contractions/
10 minutes and each lasts for 45-60 seconds
‐ Hypertonus: contractions last > 60 seconds
‐ Tachysystole: >= 6 contractions/10 minutes

In suspected fetal compromise on CTG

Assessment of fetal wellbeing in labour ‐ Correct cause
‐ Fetal blood sampling if persistent distress
Check ‐ Expedite delivery if FBS not available and persistent fetal distress (instrumental delivery
1. Colour of the liquor if applicable or urgent CS)
2. Fetal heart rate (Pinard stethoscope, Hand-held doppler,
Cardiotocography (CTG)) How we do improve placental perfusion?
3. Fetal blood sampling if indicated 1. Improve placental blood supply
‐ correct hypovolemia (IV fluids)
Fetal blood sampling interpretation ‐ correct hypotension (left lateral position to relieve aortocaval compression)
PH < 7.2 immediate delivery
‐ correct hypertonus/tachysystole (diminish uterine activity → stop oxytocin infusion,
PH 7.2 – 7.24 repeat after 30 minutes or use tocolytics if necessary)
PH > 7.25 observe labour, repeat if any concern arises 2. Vaginal examination: to exclude cord prolapse or very rapid progress
 Thromboembolic disease in pregnancy Thrombophilia
The term venous thromboembolism (VTE) encompasses deep vein thrombosis (DVT) ‐ present in 20–50% of women who experience VTE during pregnancy and postpartum
and pulmonary embolism (PE)
‐ in pregnancy 80% DVT and 20% PE inherited
‐ Pregnant women are 4 to 5 times more likely to experience a VTE, risk is further
increased in the puerperium “6 weeks postpartum” to 20 times (highest risk)

Pathophysiology
inherited

1
1
So, increased risk of VTE in pregnancy is due to:
2
1. Hypercoagulability 2
‐ Fibrinogen and coagulation factors’ levels are increased 3
‐ Free protein S levels are decreased, and fibrinolytic activity is decreased
3
2. Venous stasis and decreased outflow: compression of the inferior vena cava and
pelvic veins by the gravid uterus, decreased mobility
3. Endothelial injury (in labour) 4

‐ DVT is more common in the left lower extremity

‐ Higher frequency of iliofemoral and iliac vein involvement
‐ Proximal VTE are more common in pregnant than the non-pregnant DVT
Signs and symptoms:
Risk factors for VTE in pregnancy ‐ Leg pain and swelling (usually unilateral)
‐ Lower abdominal pain (reflecting extension of thrombus into the pelvic vessels and/or
development of a collateral circulation)
Emergent more dangerous ‐ Low-grade fever
Hyperemesis
than elective
‐ Leukocytosis
PTB = preterm birth
gravidarum
Modified wells score > 6
Ovarian Hyperstimulation
Syndrome

1. Modified wells criteria

‐ The strongest risk factor for VTE in pregnancy is a history of VTE

‐ A history of unprovoked VTE carries a greater risk than a history of provoked
VTE (Provoked VTE: VTE due to a cause like major surgery or OCPs)
 2. Prior to starting anticoagulation, samples should be sent for CBC, urea, Intravenous UFH is the preferred initial treatment in massive PE with
electrolytes, LFT and coagulation screen cardiovascular compromise (Massive PE may present with shock, refractory hypoxaemia
3. Anticoagulation should be started until diagnosis is confirmed or refuted and/or right ventricular dysfunction on echocardiogram and is a medical emergency)
Anticoagulant of choice is LMWH
o UFH may be preferred if the event occurs near delivery
A perimortem caesarean section should be performed by 5 minutes if
4. D-Dimer levels rise progressively in pregnancy and is usually 3-times normal
resuscitation is unsuccessful and the patient is > 20 weeks’ pregnant
around delivery, and therefore not helpful for the diagnosis in pregnancy
5. Thrombophilia testing should be delayed until at least 12 weeks postpartum
Consideration should be given to the use of a temporary inferior vena cava
Compression duplex ultrasound is the primary diagnostic test for DVT: filter in:
1. If positive, continue treatment with LMWH 1. The peripartum period for patients with iliac vein VTE to reduce the risk of PE
2. If negative, according to: 2. Patients with proven DVT and who have recurrent PE despite adequate
‐ Low level of clinical suspicion: anticoagulant treatment can be stopped anticoagulation
‐ High level of clinical suspicion: anticoagulant treatment should be stopped but the
ultrasound should be repeated on days 3 and 7 General point about VTE treatment

Pulmonary embolsim In the initial management of DVT?

Signs and symptoms: 1. the leg should be elevated and a graduated elastic compression stocking applied to
1. Dyspnea (most common) reduce edema
2. Palpitations/ tachycardia 2. Mobilization with graduated elastic compression stockings should be encouraged
3. Chest pain
4. Haemoptysis
5. Hypoxia/cyanosis
In clinically suspected DVT or PE? → treatment with LMWH should be started
6. Tachypnoea immediately until the diagnosis is excluded by objective testing, unless
7. Hypotension treatment is strongly contraindicated
8. Collapse
Duration of therapeutic level anticoagulation? → will be determined by the
Investigations:
circumstances of the VTE but should continue throughout pregnancy and until
1. ECG: S1, Q3, T3 appearance, P pulmonale, RBBB
at least 6 weeks postpartum, and a minimum of at least 3 months should be
2. Chest radiograph: 50% of PE show normal CXR, changes associated with PE
include atelectasis, pulmonary edema, or effusion given total
3. Computed Tomography Pulmonary Angiogram (CTPA)
4. V/Q scan When VTE occurs at term? → consideration should be given to the use of
intravenous UFH which is more easily titrated
V/Q scan:
‐ Also called: ventilation/perfusion lung scan, or ventilation/perfusion scintigraphy If the woman on LMWH for maintenance therapy? → should be advised
‐ A type of medical imaging using scintigraphy and medical isotopes to evaluate the
stopped heparin injection when she in labour
circulation of air and blood within a patient's lungs, in order to determine the
ventilation/perfusion ratio
Where delivery is planned? → LMWH maintenance therapy should be stoped
24 hours prior to Cesarean section and 12 hours prior to vaginal delivery

LMWH and regional anaesthesia

‐ Wait at least 12 hours after prophylactic dose of LMWH for siting or removal of
an epidural catheter
‐ Wait at least 24 hours after therapeutic dose of LMWH for siting or removal of
V/Q scan = 1st line to be done after ECG & CXR an epidural catheter
CTPA = Only done if V/Q scan is equivocal ‐ After removing an epidural catheter wait 4 hours before administering LMWH

Treatment
managed on an individual basis regarding intravenous UFH, thrombolytic
therapy or thoracotomy and surgical embolectomy
LMWH vs. UFH

Monitoring of treatment

➢ Women should be offered a choice of LMWH or oral anticoagulant for

postnatal therapy.
➢ In breastfeeding women the heparin (unfractionated or LMWH) nor warfarin is
contraindicated.
➢ Thrombophilia testing should be performed once anticoagulant therapy has
been stopped only

Heparin (unfractionated or LMWH)

heparin treatment should be continued until the INR is > 2.0 for at least 24
hours

1. LMWH does not require monitoring with anti-factor Xa levels, except in cases of:
‐ Extremes of weight (<50 kg or >100 kg)
‐ Renal disease
‐ VTE occurred while already on LMWH
If monitoring, sample the patient 3-5 hours after the subcutaneous injection,
activity level is considered therapeutic at 0.5-1.2 U/mL

2. Obstetric patients who are postoperative and receiving UFH should have platelet
count monitoring performed every 2–3 days from days 4 to 14 or until heparin is
stopped (To prevent the happening of Heparin-induced thrombocytopenia)

Warfarin
Postpartum warfarin should be avoided until at least the 5th day and for longer in
women at increased risk of postpartum haemorrhage.
The INR should be checked on day two of warfarin treatment and subsequent warfarin
doses titrated to maintain the INR between 2.0 and 3.0