Back to Basics! The essence of OBSTETRICS in one hour Karine J. Lortie , MD, FRCSC Assistant Professor Department of Ob/

1. Back to Basics! The essence of OBSTETRICS in one hour Karine J. Lortie , MD, FRCSC Assistant Professor Department of Ob/Gyn The Ottawa Hospital/University of Ottawa

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

3. INTRODUCTION

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

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

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

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

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

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

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

15. 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

16. ANTENATAL CARE

17. 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

18. 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

19. Antenatal Care • Optional 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

20. 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

21. MATERNAL WEIGHT • wksgain • 0 - 20 4 kg • 21 - 28 4 kg • 29 - 40 4 kg • Average 12 kg • Underweight: 35-45 lbs • Normal BMI: 25-35 lbs • Overweight: less than 25 lbs

22. 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 • 94% detection rate • MSS: • 15-19 weeks • BhCG, estriol, AFP • 70% detection rate

23. IPS vs MSS Detection rate

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

25. Screening patterns • Down’s syndrome: low AFP/estriol, high BhCG • Trisomy 18: low AFP, BhCG, estriol • Trisomy 13: high AFP, low BhCG/estriol • NTD: high AFP

26. 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

27. Appropriate screening tests in an early, uncomplicated pregnancy include all of the following except: a) repeat BhCG b) hemoglobin c) syphilis serology d) Cervical cytology e) Blood type and Rh factor

28. TERATOGENS

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

35. 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.

36. FETAL GROWTH AND WELL-BEING

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

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

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

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

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

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

45. BPD AC

46. BPD AC

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

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

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

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