Course:PostgradFamilyPractice/ExamPrep/99 Priority Topics/Pregnancy

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Pregnancy - Key Features

1. In a patient who is considering pregnancy:
a) Identify risk factors for complications.
b) Recommend appropriate changes (e.g. folic acid, smoking cessation, medication changes)

Risk Modification:

• Advise all women of childbearing age to supplement diet with 0.4mg/day of Folic acid.(materna has 1 mg/day)
• Iron supplement if anemic, prenatal vitamins
• EtOH, smoking and drug cessation. Review meds/OTC meds.
• Discuss cessation of current form of birth control
• Avoidance of cats/litter/rodents, soft cheeses (listeria)
• Inquire about safety, domestic violence, genetic disease, maternal age, birth defects, multiple gestation, PmHX (heart conditions, past uterine/cervical procedures, STI's)
• Genetic screening of high risk groups (tay-sachs, sickle cell, thalessemia)


2. In a female or male patient who is sexually active, who is considering sexual activity, or who has the potential to conceive or engender a pregnancy, use available encounters to educate about fertility.

Discuss STI's, appropriate forms of contraception, and emergency contraception.

3. In a patient with suspected or confirmed pregnancy, establish the desirability of the pregnancy.

4. In a patient presenting with a confirmed pregnancy for the first encounter:
a) Assess maternal risk factors (medical and social)
b) Establish accurate dates
c) Advise the patient about ongoing care.

Definitions:
First Trimester = 0-12 wks, Second = 12-28 wks, Third = 28-40wks, Term = 37-42
Gravity = # pregnancies of any gestation, T = # of term infants, P = # premature, A = # of abortions, L = # of living Children

Pre-natal Screening:

Initial visit: (within 12 weeks of LMP) full Hx, Med review, FMHx, Social Hx, Urine R+M plus culture, Hgb, Blood type, gestational age, P/E with pelvic and pap, swabs for GC and Chlamydia, HIV, Hep B & C (if at risk), Syphilis, Rubella titre, toxoplasmosis (optional), CMV, TB, TSH(optional)
SIPS vs. IPS (SIPS + NT): Depending on the age(risk) of your patients and their desire for screening after informed consent. Amniocentisis may be offered after age 40 with no prior screening (BC Prenatal Genetic Screening Program)
Gestational DM: screen with glucose tolerance test at 24-28 weeks (2 hour 75g ogtt)
Group B Strep: screening recto-vaginal swab at 35-37 weeks.
Third trimester Hgb: screening for anemia, especially if low normal first trimester hgb.


Other:

• Nagele’s rule = 1st day of LMP + 7days – 3 months.
• Most accurate dating is early first trimester U/S (recommended if available)
• Repeat visits q4weeks until 28, q2weeks until 36, qweekly until delivery.
• Inquire about financial concerns, living situation, paternity, abuse, stresses/supports (don’t forget to FIFE the patient).
• Discuss items in question 1.
• Exercise, work (type/duration), intercourse, weight gain (for pre-pregnancy BMI)


5. In pregnant patients:
a) Identify those at high risk (e.g. teens, domestic violence victims, single parents, drug users, impoverished women)
b) Refer these high-risk patients to appropriate resources throughout the antepartum and postpartum periods.

6. In at-risk pregnant patients (e.g. HIV positive women, intravenous drug users, diabetic and epileptic women), modify antenatal care appropriately.

Diabetes: Insulin for type 1, or type II uncontrolled by diet alone. Diet usually adequate for GDM. Oral hypoglycemics (especially glyburide) are controversial. Multi-disciplinary approach with diabetes educators, dieticians, and maternity care provider.

HIV: Fetus at risk of IUGR, pre-term labor or PROM. May deliver vaginally. Combined retroviral for antepartum decrease risk of transmission to <1%. Discuss risk of transmission with breast feeding.

Epileptics: For planning a pregnancy, switch to the safest effective anti-convulsant at lowest dose(avoid valproic acid). If already pregnant, continue with same anti-convulsant meds. Folate supplementation. Vit K supplementation in final month with enzyme inducing meds. Monitor drug levels.

IVDU: Arrange supports, encourage cessation, surveilance for HIV/Hep B/C during pregnancy.

7. In a patient presenting with features of an antenatal complication (e.g. premature rupture of membranes, hypertension, bleeding):
a) Establish the diagnosis
b) Manage the complication appropriately

PPROM: ROM prior to labour at any gestational age. Associated with trauma, smoking, infection, multiple gestations, previous hx of same, or incompetent cervix. Perform sterile speculum exam, pH paper, and ferning, repeat cultures. If PROM is confirmed admit and monitor, Induce and deliver > 34-36weeks. Need antibiotic coverage if PROM < 34 weeks. Betamethasome for fetal lung maturity < 34 weeks.

UTI: treat with Amoxicillin

Pregnancy Induced Hypertension: Hypertension associated with proteinuria at greater than 20weeks gest., diagnose if >140/90. Check for proteinuria, CBC, lytes, renal function, LFTs, INR/PTT, U/S fetus, uric acid, LDH.

• Tx: mild – bed rest in LLDP, normal salt and protein intake, close monitoring for symptoms or complications. Severe – Check for HELLP syndrome, deliver when safe, MgSO4 (4g bolus, then 2g/hr until 24hrs following delivery), antihypertensives prn – Hydralazine 5-10 mg IV q15-30 mins, or Labetalol 50-100 mg po BID, or 20-80mg Iv q10min.


Third Trimester Bleeding: ddx- bloody show (most common), placenta previa, abruption, vasa previa, cervical lesion, trauma or neoplasm, uterine rupture. Perform U/S and NST, large bore IV, Rhogam (if mom Rh-). If 36 weeks and profuse bleeding – stabilize, C section.

8. In a patient presenting with dystocia (prolonged dilatation, failure of descent):
a) Diagnose the problem
b) Intervene appropriately

First stage: latent phase characterized by infrequent and irregular contractions, slow, cervical effacement, usually 3-4cm dilatation. Active phase characterized by rapid cervical dilatation, maximal slope of friedman curve, contractions approx q2-3mins

• Arrest of labour is no dilatation for >2hrs (or no further dilation past >4cm despite adequate contractions).
• Difficult to define protracted 1st stage: Much variability, many definitions.
• Consider Oxytocin augmentation: requires IV, fetal monitor, and consider epidural anesthesia.

Second Stage: full cervical dilatation until delivery

• Arrest of descent is no progress for >1hr
• Prolonged if > 2 hrs (nuliparity), or >3hrs with epidural. For multips, this is >1hr and >2hrs(epidural). No intervention strictly necessary with prolonged descent, if no fetal distress.
• look for Cephlo-pelvic-disproportion, change position, fetal monitor and consider C/S if distress.

Third Stage: Delivery of placenta

• Administer Oxytocin routinely, prolonged if >30mins.
• If prolonged, may require manual extraction.

Fourth Stage: First hour post-partum.

9. In a patient presenting with clinical evidence of complications in labour (e.g. abruption, uterine rupture, shoulder dystocia, non-reassuring fetal monitoring):
a) Diagnose the complication
b) Manage the complication accordingly

Fetal Heart-Rate Monitoring: Can be obtained via external Doppler device, or fetal scalp monitor. Accelerations are >15bpm acceleration lasting >15sec, in response to fetal movement or uterine contraction. Reassuring strips contain >2 accels in 20mins. Normal baseline 120-160bpm.

• Early decelerations – due to vagal response to head compression against cervix. Benign.
• Variable Deceleration – due to cord compression. Benign unless repetitive with slow recovery (or <60bpm, <60bpm below baseline, or for >60 secs)
• Late Deceleration – Concerning, and a sign of uteroplacental insufficiency. Must see 3 or more with same shape to define.
o Approach: Change position of mother, give 100% O2, hold oxytocin, consider fetal scalp electrode for beat to beat monitoring. Immediate delivery if recurrant prolonged bradycardia.


Shoulder dystocia: Impaction of anterior shoulder of fetus against symphysis pubus after head has been delivered. Watch for macrosomic babies, GDM moms, Obesity, prolonged gestation. May observe “turtle” sign.

• Approach: Get help -> McRobert’s Manouver -> Supra-pubic pressure -> Wood’s screw (+/- episiotomy) -> Release posterior Shoulder -> Remove posterior arm -> all fours position ->fracture clavicle -> symphysectomy/Zavanelli


Uterine Rupture: Painful hemhorrage, shocky, tender uterus with palpable fetal parts. Regression of dilation/station.

• History of uterine scar, oxytocin, trauma, CPD, Grand-multiparity.
• ABC's, STAT OR.


Abruption: Painful hemhorrage, with abdominal tenderness +/- uterine tetany. 20% are concealed, with no bleeding. These may present as tetanic contractions, fetal distress, coagulopathy. May see shock out of proportion to bleeding.

• Risk factors: previous abruption, DM, HTN, preeclamsia, renal disease, trauma, cocain use, shock from other cause.
• Do CBC, type and screen, DIC panel (abruption puts at risk for this), Ultrasound. ABC's, and consider C section if severe and vaginal delivery not imminent. If mild, may manage expectantly with serial ultrasounds/increased surveillance.


10. In a patient presenting with clinical evidence of a post-partum complication (e.g. delayed or immediate bleeding, infection):
a) Diagnose the problem (e.g. unrecognized placental products, endometritis, cervical laceration).
b) Manage the problem appropriately

Post-partum hemorrhage: Tone (uterine atony), Tissue (retained placenta), Trauma, Thrombophilia

• Manage accordingly. Large bore IV, CBC and Type/cross match 4 units, treat cause, may use oxytocin/misoprostol/hemabate. Hysterectomy as last resort.


Multiple other post-partum complications to review:

• Endometritis vs. Septic Pelvic Thrombophlebitis vs Wound Infection vs. Pelvic Abcess
• Breast Engorgement vs. Plugged ducts vs. Mastitis vs. Breast Abscess vs. Thrush
• Delayed onset Pre-Eclampsia


11. In pregnant or post-partum patients, identify post-partum depression by screening for risk factors, monitoring patients at risk, and distinguishing post-partum depression from the “blues”)

Blues: 85% of new mothers, onset day 3-10, extension of normal hormonal changes and adjustment to new baby. Self limited and resolves by 2 weeks.

Depression: Major depression occurring in women within 6 months of delivery. 10-20%. Screen all moms – if present higher risk for suicide or infanticide. Treatment: Antidepressants, ECT if severe or rapid response required. Avoid TCA’s. It is generally suggested that women not breast feed while using any psychotropic meds, but not absolutely contra-indicated. Closely monitor moms during initial 2 weeks of medication as suicide risk is elevated.

12. In a breast-feeding woman, screen for and characterize dysfunctional breast-feeding (e.g. poor latch, poor production, poor let-down.

Consider referral to lactation consultant if unfamiliar. Avoid live vaccines such as MMR.
Monitor infant weight in hospital, ensure good feeding prior to D/C.
Domperidone (10 mg po QID) trial reasonable for limited production.

Study Guide

Pregnancy

Resources

MCCQE notes 2005.
Uptodate
PEPID
BC Prenatal Genetic Screening Program www.bcprenatalscreening.ca
Previous residents “CCFP Priority Topics” document