Back to Basics! The essence of OBSTETRICS in two hours Susan Aubin, MD, FRCSC

1. Back to Basics! The essence of OBSTETRICS in two hours Susan Aubin, MD, FRCSC Assistant Professor Department of Ob/Gyn The Ottawa Hospital/University of Ottawa SpecialThanks to: Karine J. Lortie , MD, FRCSC

2. OVERVIEW • Introduction • Early pregnancy • Antenatal care • Teratogens  • Fetal growth and wellbeing • Medical complications • Breech • Multiple pregnancy • Labour

3. INTRODUCTION

4. RISK SPECTRUM IN PREGNANCY LOW RISK (75%): normal obstetrics MEDIUM RISK (20%): pre-post dates breech twins maternal age, etc.. HIGH RISK (5%): genetic disease serious obstetric maternal complications

5. RISK IN PREGNANCY Definition of Outcome Measures • Perinatal mortality rate • all stillbirths (intrauterine deaths) > 500 grams plus all neonatal deaths per 1,000 total births • Neonatal death • death of a live-born infant less than • 7 days after birth (early) or less than 28 days (late) • Live birth • an infant weighing 500 grams or more exhibiting any sign of life after full expulsion, whether or not the cord has been cut and whether or not the placenta is still in place

6. PERINATAL MORTALITY RATE • ONTARIO: 5/1000 • Developing: 100/1000

8. PERINATAL MORTALITY • Prematurity • Congenital anomaly • Sepsis • Abruption • Placental insuffienciency • Unexplained stillbirth • Birth asphyxia • Cord accident • Other ie. isoimmunization

9. MATERNAL MORTALITY RATE • ONTARIO: 5/100 000 • Developing: 1000/100 000

10. MATERNAL MORTALITY • Direct Deaths • Indirect deaths: < 42 days from delivery • Causes: • Hypertensive disorders • Pulmonary embolism • Anesthesia • Ectopic pregnancy • Amniotic fluid embolus • Hemorrhage • Sepsis

11. EARLY PREGNANCY

12. EARLY PREGNANCY Dating: 40 weeks from LMP 280 days, Naegle’s rule (-3 months + 7 days) Affected by cycle length Hegar’s sign: soft uterus Chadwicks sign: blue cervix

13. Hormones BhCG: A subunit similar to TSH, LH, FSH Measurable 8 days post conception Role: stimulate CL progesterone 100,000 • Others use: • Zone 2000-6000 • Mole • Ectopic • Ovarian cysts Level doubling time 2 days 5,000 16 weeks 8 days 8 weeks

14. Other placental hormones • HPL = human placental lactogen (growth hormone) • prolactin • progesterone • estrogen

15. ANTENATAL CARE

16. Maternal physiology • RBC • plasma volume by 50%, GFR, CrCl (creatinine), glucosuria • cardiac output (highest 1st hour after delivery) • HR by 20% • SV • Placental flow: 750ml/min at term

17. Antenatal care Antepartum history: age: >40 offer amniocentesis Parity/gravidity Medical, surgical history Family, social history Meds, allergies Routine tests: CBC (Hg), Type and Screen, prenatal antibodies VDRL, Rubella, Hep B, HIV Urine culture Pap smear, +vag swabs, cervical cultures Offer IPS GBS swab at 35 weeks

18. Antenatal Care Other testing: Dating ultrasound, 18 weeks morphology ultrasound Hb electrophoresis (Thalassemia, sickle cell, etc.) Chicken pox, parvovirus, TSH 28 weeks glucose screening test Genetic testing: CVS Amniocentesis Scheduled visits: 0-28 weeks: q4 weeks 28-36 weeks: q2 weeks 36+ weeks: q1 week

19. Scheduled visits SFH (cm): (+ 2 # of weeks) Sensitivity of 60% 12 weeks: symphysis pubis 20 weeks: umbilicus 36 weeks: siphisternum presentation Symptoms, fetal movement + urine dip: glucose, protein Blood pressure, maternal weight

20. MATERNAL WEIGHT • wksgain • 0 - 20 4 kg • 21 - 28 4 kg • 29 - 40 4 kg • Average 12 kg • Weight Gain: • Underweight: 35-45 lbs (15-20 kg) • Normal BMI: 25-35 lbs (11-15 kg) • Overweight: less than 25 lbs (10 kg)

21. Genetic testing • IPS: • First Trimester screening (10.6 – 13.6 weeks) • Nuchal translucency • PAPP-A, (BhCG) • Second Trimester screening (15-16 weeks) • BhCG, estriol, AFP, Inhibin A • 87% detection rate, 2% false positive rate • MSS: (Quad test) • 15-19 weeks • BhCG, estriol, AFP, Inhibin A • 77% detection rate, 5% false positive rate

22. IPS vs MSS Detection rate

23. NT Suchet I, Tam W. The ultrasound of life. Interactive fetal ultrasound teaching program on DVD, 4th Edition, 2004.

24. Screening patterns Down’s syndrome: low PAPP-A, AFP, estriol, high BhCG Trisomy 18: low PAPP-A, AFP, BhCG, estriol, Inhibin A, high NT Trisomy 13: high AFP, low BhCG/estriol NTD: high AFP Low estriol – associated with many congenital anomalies

25. Which of the following statements best describes the foramen ovale: It shunts blood from right to left It connects the pulmonary artery with the aorta It shunts deoxygenated blood into the left atrium It is an extra cardiac shunt It is functional after birth

26. TERATOGENS

32. Risk Classification System for Drug Use in Pregnancy Category Description A Taken by a large number of pregnant women. No increase in malformation. B Taken by only a limited number of pregnant women and women of childbearing age. No increase in malformation. Studies in animals wither show no increase or are inadequate. C Have caused or may be suspected of causing harmful effects on the human foetus or neonate without causing malformations. These effects may be reversible. D Have caused an increased incidence of human foetal malformations or irreversible damage. X Drugs that have such a high risk of causing permanent damage to the foetus that they should not be used in pregnancy.

33. FETAL GROWTH AND WELL-BEING

34. Dating Scan Gestational sac: 5wks Fetal pole: 6wks Fetal heart: 7 wks Limb buds: 8 wks crown rump length

35. Morphology scan 18- 20 weeks BPD HC AC Femur length

36. Info from U/S • Estimated fetal weight • Twins discordance • Behavioral states (BPP) • Presentation • Placenta (previa)

37. Anomalies: ultrasound 18 - 20 weeks • Spina Bifida • Anencephaly • Cardiac • Renal • Diaphragmatic hernia • Limbs • Facial • Chromosomal • Late > 20 weeks • Renal • Microcephaly • Hydrocephalus • Ureteral valves

38. Interventions • amniocentesis, l/s ratio (lung maturity) • cvs • cordocentesis, transfusion • paracentesis • Shunts: bladder, ascites, kidney, head • Liver biopsy, skin • Fetal reduction

39. DEFINITION OF I.U.G.R • < than 2500 grams • < than 5th centile for GA • Approx. 4-7% of infants

42. BPD AC

43. BPD AC

44. CAUSES OF IUGR • Maternal: • Malnutrition • Drugs • Substance Abuse • Diseases • Infections • Fetal: • Chromosomal Abnormality • Congenital Abnormality • Multiple Gestation • Congenital Infection

45. CAUSES OF IUGR • Placental: • Perfusion • Abnormalities: • Abnormal Cord Insertion • Abruption • Circumvallate placentation • Placental Hemangioma • Placental Infections • Twin to Twin Transfusion

46. IMMEDIATE NEONATAL MORBIDITY IN IUGR • Birth asphyxia • Meconium aspiration • Hypoglycemia • Hypocalcemia • Hypothermia • Polycythemia, hyperviscosity • Thrombocytopenia • Pulmonary hemorrhage • Malformations • Sepsis

47. CAUSES OF FETAL OVERGROWTH • Maternal diabetes • Maternal obesity • Excessive maternal weight gain

48. EVALUATION OF WELL-BEING

49. FETAL ACTIVITY • Kick counts: • “count to ten “ chart • towards term • 10 movements in 2 hours over 12 hours

50. BIOPHYSICAL PROFILE • Graded (0 or 2 pts; max 10) • NST (normal) • Movement (2) • Tone (2) • AFI (amniotic fluid volume) • Breathing (30 seconds) DOPPLER • What is it? • Uteroplacental waveforms • Umbilical artery • Carotid artery • Descending aorta