Dr.K.

Guruparan
Senior registrar
[Obstetrics & gynaecology]

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 Prepregnancy management & counseling
 Conception
 Diagnosis of pregnancy
 Antenatal care
 Pregnancy changes
 Labour mechanism
 Labour management
 High risk pregnancy
 Minor disorders of pregnancy
 Postpartum care

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 Why important?
• Identify risk pregnancy
• Optimize disease
• Follow up
• Plan the delivery
• Postpartum care

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 History
• LMP
• Subfertility
• Past OBS Hx/ BOH
• Medical problems
• Drug history
• FH
 Congenital anomaly
 Chromosomal defects

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 Ht Wt BMI
 General exam
 CVS RS Abdomen

 Investigation

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 Rubella immunization
 Folic acid
 Heart disease Mx
 DM optimization
 Change the drugs

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 History
• LRMP
• Morning sickness
• Breast tenderness
 Examination
• Not significant
 Ix
• Urine hCG
• uss

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 Miscarriage
 Ectopic pregnancy
 Molar pregnancy
 Hyperemesis gravidarum
 UTI

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 Why? -Hormonal aetiology
 6-12 wks & then settles
 What to do?
• Support
• Antiemetics
• Iv fluids
• B cpx vitamins. Why?
• Ginger/ lemon/ orange juices
• Dexamethasone

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Presentation
• Vx Bleeding
• Low abdominal pain
• POA
 Types
• Thrtened miscarriage
• Incomplete miscarriage
• Complete miscarriage
• Missed miscarriage
• Septic miscarriage
• Recurrent miscarriage

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 Bleeding  anaemia
 infection  sepsis
 surgical complications
 Psychological trauma
 Rh isoimmunization

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 Depends on type
• Conservative Mx
• Medical Mx
• Surgical Mx
 Bld Tx
 Antibiotics
 Medical Mx [misoprostol]
 D&E/ERPC  cytology assessment
 RhoGam
 Counselling
 Follow up
• Folic acid

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 POA 6-8 wks
• Severe abd pain/Vx bleeding
• Shock  maternal death
 Tubal /abdominal / ovarian ectopic

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 Tubal rupture internal bleeding shock
 Tubal abortion
 Resolution
 Abdominal pregnancy
 Molar pregnancy -rarely

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 Depends on presentation
 Pt assessment [Hx/Ex-PR/BP]
 Resuscitation[A –B- C]
 Investigation[FBC/B hcg/Gp & save/uss]
 Mx
• Conservative
• Medical-methotrexate
• Surgical
 Laparotomy
 laparoscopy

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 2 Types [complete /partial
 Risk group
• P/H, extremes of age
 Presentation
• Heavy bleeding
• Hyperemesis gravidarum
 Mx
• FBC / bhcg/ uss/ CXR
• Medical Mx
• Sx
 Suction evacuation
 Hysterectomy sos

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 100 % chemo- sensitive [MTX]
 Avoid pregnancy until resolution
• Condoms  OK
 Serial bhcg [2 wkly]
 USS –sos
 If persisting molar pregnancy
• Chemotherapy [MTX]
• hysterectomy

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 Why ?
 Do UFR
 Mx
• Fluids
• Antibiotics
• Urine culture on follow up

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 FHMMOH VOG care BH/DGH

PH/TH

 Delivery
• government hospitals ± private hospitals
• > 90% hospital delivery

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 ‘Safe delivery of healthy baby to healthy
mother’
• Identify risk pregnancies
• Maternal monitoring [DM/PIH/anemia]
• Fetal assessment [growth/placenta]
• Prepare for delivery
• Safe delivery & Neonatal care
• Breast feeding
• Contraceptive advice & family planning

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 ~ 12-14 wks @ local ANC/MOH clinic
 History
• Urine hcg check up
• LMP & calculate EDD
• Look for active problems
 Bleeding/HEG/UTI/ disease
 Identify risk factors
• Past obstetric history
• PMH
• PSH
• Drug Hx

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 Height calculate BMI
 Weight
 Check for
• Anemia
• Dental caries
• Thyroids
• Breast & nipple
• Ankle edema

CVS- PR/BP/murmur
RS
Abdominal examination

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 Urine
• Sugar  USS
• Protein • viability
• UFR -SOS • Dating
 Bloods • ?twins/miscarriage
• GP/Rh
• FBC/Hb
• VDRL
• PPBS

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 Shared care
• Referral to VOG /specialist care
• Further Ix ordered [GCT/OGTT/echo etc]
• USS
• Categorize the pregnancy as
 Low risk or
 High risk

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Upto 28 wks 4 wkly
28-36 wks 2 wkly
36 wks to delivery Wkly

Trimesters
T1=until 14 wks
T2=14-28 wks
T3=28 to delivery

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 ‘Prepare the pregnant woman for delivery’
 Psychological support
 Advice on
• Nutrition & exercise
• Pregnancy changes & how to cope up
• Minor disorders [backaches/varicose veins ]
• How to Sleep & relax
• Sex
• What to take to hospital?
• What are procedures?
 VE/CTG/ARM/CS/Instruments etc.
• Contraception
• Breast feeding 12/08/21
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What to do in follow up visits?
 Ask FM/any symptoms
 Check
• nutritional status/ BP/ fundal height\fetal growth
• Urine albumin
• PPBS/Hb sos
• USS sos
 Conduct antenatal classes
 Look for any problems & refer sos
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 Majority are low risk pregnancy. Why?
 Risk categorized according to
• Maternal risks
• Fetal risks
• Combined risks

Some cases can be diagnosed already.

Majority are identified during the Antenatal period

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 Pre existing conditions
• DM -Chronic HT
• Epilepsy -Heart disease
• Renal diseases -Thyroid disorders
• Anaemia -Rh incompatibility
• SLE/APLS -Past CS
• Sub fertility -Short mother
• Fibroids complicating pregnancy
• BOH [IUD/SB/PTB/NND]
• Recurrent miscarriages
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 GDM
 Anaemia
 PIH
 Ante partum haemorrhage
• Thrt. miscarriage
• Placenta praevia / abruption
 Preterm labour
 Breech/ oblique lie/ transverse lie
 Multiple pregnancy
 Polyhydramnios / oligohydramnios
 Grand multipara / primi ?

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 Congenital abnormality
 Rh isoimmunization
 growth disorders
• IUGR/SGA
• LFD
 Preterm delivery

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 Diagnosed after 20 wks
 BP+ ankle edema + urine albumin =preeclampsia
 BP+ ankle edema + urine albumin + convulsions= eclampsia
 Clinical features
• Headache/ visual disturbaces / Vomiting
• Epigastric pain/ reduced UOP
• Reduced FM
• SGA
• Bleeding tendency

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 Complications
• SGA /IUD / PTB
• Abruption
• DIC
• Liver & renal failure/ pulmonary edema
• Eclampsia
 Ix
• FBC
• LFT/RFT
• Clotting profile
• Gp & save
• USS

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 GDM / pre-existing DM
 GDM
• Screening for GDM
 Whom to screen?
 Obese / large baby / pre IUD/SB/PCOS / FH of DM
 How to screen?
 PPBS /GCT
• Diagnosis
 OGTT
• Complications
 Large baby/ polyhydramnios /IUD /SB/congenital anomaly

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 Abruption / placenta praevia
 Abruption
• T3
• Painful bleeding
• Risk group
 PIH
• Complications
 IUD / DIC/ARF/ maternal death

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 placenta praevia-placenta in lower segment
 Painless bleeding
 After 20 wks diagnosed
 USS
 Past CS -high risk
 Complications
• Anaemia/ IUD / DIC / PTB

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 AFI increased
 Causes –DM / spontaneous/ fetal

anomaly
Presentation
F>D
Shiny abdomen
Reduced fetal movemnts
Dribbling

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 Uncrossmatched Bld
Tx

 Mother –Rh negative

Father -Rh positive
 If Fetus Rh positive, fetal RBC enter mother’s Bld
during delivery/abortion .
• Ab formation against fetal RBC in mother
• Mother become immune against Rh [+] RBCs
 In next pregnancy
• If fetus is Rh positive, anti Rh Ab cross placenta
• Ab causes fetal RBC lysis  fetal anemia
hydrops
IUD
RhoGam
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Wrong dates

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 F<D
 Reduced fetal movements
 USS
• Scan findings not correlating to dates

What to do?
Regular growth monitoring
Dexamethasone
Early delivery
Complications
IUD

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 Previous obstetric outcome –not satisfactory
 May be IUD/SB/recurrent miscarriage/preterm
birth/congenital anomaly
 Mx
• Identify underlying problem
• Counseling
• Maternal & fetal monitoring in current pregnancy

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 Majority of pregnancy @ term presents as
cephalic
• Other than cephalic  malpresentation
 Eg. Breech/ hand/shoulder presentation
 Problems
• Cord prolapse
• Preterm birth
• Obstructed labour
• Caesarean section

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 Diagnosed during labour
 Disproportion between fetal head & maternal
pelvis
 Problems
• Obstructed labour
Risk group
• Difficult delivery Short mother
• Instrumental use Large baby
HNE @ Term
• Maternal & neonatal injury Elderly mother
• Emergency CS
• PPH

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 Pregnancy worsens disease
• Reduced tolerance
 Risks to pregnant woman RHD
MS
• tachycardia ASD
• HT VSD
PHT
• Recurrent RTI
• Cardiac failure  death
• More hospital admissions
• Miscarriage/PTB/ medical TOP

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 Increased incidence. Why?
 Twins / triplets/ quadruplets
 Increased risk to both mother & fetus
 Types
• One egg+ one sperm  divides  monozygotic twin
 Single placenta OR DOUBLE More
risk
• Two different eggs/sperms  dizygotic twin
 Two placentae

Less
risky
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Maternal risks
 Increased mat signs & Fetal risks
symptoms  Con anomaly
 Anemia  Miscarriage
 PIH  Prematurity
 GDM  Hydrops fetalis
 PTB  IUD
 Polyhydramnios
 Early hosp admission
 APH/PPH
 Malpresentation
 Operative delivery

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 Shared care & documentation
 Multidisciplinary team involvement
 Maternal assessment
 Fetal assessment
 Counselling
 Optimize the pregnancy
 Intervention
• Insulin/dexamethasone/Bld Tx/ delivery/ transfer
 Decide on delivery
• Time
• Mode
• place

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