Back to Basics! The essence of OBSTETRICS in one hour Dr. Glenn Posner

1. Back to Basics! The essence of OBSTETRICS in one hour Dr. Glenn Posner

2. MCCQE REVIEW Introduction Early pregnancy Antenatal care Ultrasound / fetal assessment Twins / breech Medical conditions etc. Teratogens Pregnancy Induced Hypertension Labour

3. MEDIUM RISK - PRE-POST MATURE 20% BREECH - TWINS MATERNAL AGE, ETC.. HIGH RISK - GENETIC DISEASE 5% - SERIOUS OBSTETRIC OR MATERNAL COMPLICATIONS RISK SPECTRUM IN PREGNANCY LOW RISK - NORMAL OBSTETRICS 75%

4. 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 - is 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

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

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

7. MATERNAL MORTALITY Hypertensive Disorders Pulmonary embolism Anesthesia Ectopic pregnancy Amniotic fluid embolus Hemorrhage Sepsis Direct Deaths. (Indirect deaths) < 42 days from delivery

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

11. EARLY PREGNANCY DATING: 40 weeks FROM LMP 280 days, Naegle’s rule Short cycle vs. long cycle HEGAR’S SIGN - soft uterus CHADWICKS SIGN - blue cervix

12. Which of the following statements best describes the foramen ovale: a) it shunts blood from right to left b) it connects the pulmonary artery with the aorta c) it shunts deoxygenated blood into the left atrium d) it is an extra cardiac shunt e) it is functional after birth

13. 100,000 doubling time 2 days Level 5,000 8 days 16 weeks 8 weeks progesterone ROLE - stimulate CL BHCG a sub unit similar to TSH LH FSH Measurable 8 days post conception Other uses Zone 2000-6000 Mole Ectopic Ovarian cysts Other placental hormones HPL = placental mass PROLACTIN “growth hormone” PROGESTERONE ESTROGEN

14. ANTEPARTUM HISTORY AGE ( > 35 offer AMNIOCENTESIS PARITY / GRAVIDITY MEDICAL HISTORY FAMILY HISTORY ROUTINE TESTS VAG. SWABS HIV ULTRASOUND Offer IPS Hb GROUP, RHESUS SICKLE, THAL, V.D.R.L. RUBELLA/chicken pox HEPATITIS URINE CULTURE 28 WEEK GLUCOSE SCREEN Grp B strep Swab @ 36 wks SPECIAL TESTS CVS AMNIOCENTESIS

15. aFP = alphafetoprotein SCREEN 16 WKS (Neural Tube Defects) LEVEL > 2 . 5 MOM 2. . 5 - 2 . 9 > 5 LEVEL < 0 . 5 MOM 20 % RISK 70 % DOWN ‘ S RISK

16. MSS AT 15 TO 19 WEEKS AFP, ESTRIOL, HCG AGE, WEIGHT RISK CALCULATION WITH ARBITRARY CUT-OFF DETECTS 60-70% OF DOWNS FIRST TRIMESTER 10 TO 14 WEEKS NUCHAL THICKNESS, BHCG, PAPP A INTEGRATED PRENATAL SCREEN MSS PLUS FIRST TRIMESTER DETECTS >90%, FALSE POSITIVE 2%

17. ANTENATAL CARE GENERAL EXAM PAP HISTORY / RISK FACTORS FIRST VISIT q4 weekly to 28-30 weeks q2 weekly to 36 weeks q1 weekly to delivery EACH VISIT CHECK: FUNDAL HEIGHT ( CMS ) 12 WKS = SYMPHYSIS 20 WKS = UMBILICUS 36 WKS = XIPHISTERNUM MATERNAL WEIGHT / SYMPTOMS BLOOD PRESSURE URINE PRESENTATION

18. MATERNAL PHYSIOLOGY RBC PLASMA VOLUME 50 % CARDIAC OUTPUT- highest 1st hour after delivery HEART RATE 20 % STROKE VOLUME Placenta blood flow = 750 ml / min at term Tidal volume Residual volume G F R creatinine cc glycosuria “normal proteinura” 0.3 g/l

19. All of the following factors are associated with an increased risk of perinatal morbidity except: a) low socioeconomic status b) low maternal age c) heavy cigarette smoking d) alcohol abuse e) exercise

20. Teratogens

25. I Q F G H J K L M N O P R S T

28. 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.

29. Fetal growth and well-being

30. DATING SCAN SAC 5WKS FETAL POLE 6WKS FETAL HEART 7 WKS LIMB BUDS 8 WKS HEAD 12 WKS NT 11 TO 14 WKS FULL ANOMALY 18-20 WKS CROWN RUMP LENGTH BPD HC AC FEMUR LENGTH

31. ANOMALIES – ULTRASOUND 18 TO 20 WEEKS Spina Bifida Anencephaly Cardiac Renal Diaphragmatic hernia limbs Facial Chromosomal aFP Late > 20/40 Renal Microcephaly Hydrocephalus Ureteral valves

32. ULTRASOUND GUIDANCE AMNIOCENTESIS, L/S RATIO CVS CORDOCENTESIS, TRANSFUSION PARACENTESIS SHUNTS bladder, ascites kidney, head LIVER BIOPSY, SKIN FETAL REDUCTION

33. Info from U/S Estimated fetal weight Twins discordance Behavioural states ( B.P.P. ) Presentation Placenta (previa, RPC’S)

34. DEFINITION OF I.U.G.R Less than 2500 grams SGA vs AGA Less than 5th centile for GA Approx. 4 - 7 % of all infants are IUGR

35. Appropriate screening tests in an early, uncomplicated pregnancy include all of the following except: a) repeat human chorionic gonadotropin b) hemoglobin c) syphillis serology d) cervical cytology e) blood type and Rh factor

40. CAUSES OF I.U.G.R MATERNAL FACTORS • Malnutrition • Drugs • Substance Abuse • Diseases • Infections

41. CAUSES OF I.U.G.R FETAL CAUSES - Chromosomal Abnormality - Congenital Abnormality - Multiple Gestation - Congenital Infection

42. CAUSES OF I.U.G.R PLACENTAL FACTORS Placental Perfusion Placental Abnormalities - Abnormal Cord Insertion - Abruption - Circumvallate placentation - Placental Hemangioma - Placental Infection - Twin to Twin Transfusion

43. CAUSES OF FETAL OVERGROWTH Maternal Diabetes Maternal Obesity Excessive Maternal Weight Gain

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

45. ULTRASOUND CLINICAL TESTS Growth parameters Fetal weight Amniotic fluid volume Biophysical profile score Fundal height Maternal weight Fetal Kicks BIOCHEMICAL TESTS aFP HPL estriol crf DOPPLER CARDIOTOCOGRAPHY Stress tests Non stress tests

46. FUNDAL HEIGHT S - F HEIGHT IN cms + 2 = no of weeks Sensitivity 60 % Use of S - F charts MATERNAL WEIGHT wks gain 0 - 20 4 kg 21 - 28 4 kg 29 - 40 4 kg Average 12 kg

47. BIOPHYSICAL PROFILE CTG 0 - 2 MOVEMENT TONE AMNIOTIC FLUID VOL. BREATHING MAX. 10 DOPPLER What is it? Uteroplacental waveforms Umbilical artery Carotid artery Descending aorta

48. FETAL ACTIVITY Kick counts - “count to ten “ chart towards term 10 movements in 12 hours

49. CARDIOTOCOGRAPHY Maybe as good as BPP movement Non - stress uterine activity Oxytocin infusion Stress tests nipple stimulation Features of the normal CTG rate 120 - 160 BTB variation 5 - 15 Accelerations present No decelerations

50. The perinatal mortality rate is defined as : a) the number of neonatal deaths that occur per 1000 live births b) the number of still births that occur per 1000 births c) the number of fetal deaths within the first week after birth d) the number of still births and neonatal deaths per 1000 live births