Obstetrics

Any interruption of pregnancy beyond the age of viability with or without expulsion of the product of conception. Threatened Abortion Clinical entity in which the process of abortion has started but has not progressed to a state from which recovery is not impossible. Symptoms Amenorrhea with sign symptoms of pregnancy. Per vaginal bleeding (slight, bright red, stops spontaneously). Slight or no pain. Signs Internal os closed. Uterine size corresponds to the period of amenorrhea. Uterus & cervix feel soft. Investigations CBC Blood grouping & Rh typing Urine for pregnancy test USG of the uterus for pregnancy profile (well-formed gestational sac with central echoes). RBS, thyroid profile Treatment Observation. Rest, analgesics. Empirical use of micronized progesterone. Advice: Avoid heavy work for 2 weeks. Avoid coitus up to 12 weeks of gestation. Follow up USG after 3-4 weeks. Inevitable Abortion Type of abortion in which the changes have progressed to a level from which continuation of pregnancy is impossible. ...

Management Oral iron therapy Ferrous sulfate 200mg BD/TDS Follow up CBC after 2-3 weeks If improvement Continue oral therapy until 3 months after Hb becomes normal If no significant improvement or severe anemia or intolerance for oral iron Check serum ferritin If ferritin >= 30 mcg/L → exclude hemoglobinopathies If ferritin < 30 mcg/L → parenteral iron therapy Parenteral iron therapy Ferric carboxymaltose Dose depends on the pre-pregnancy weight or weight at the booking visit Continue oral iron after 5 days (if tolerated) Follow up CBC after 2-3 weeks Another dose of parenteral iron, if needed Indications of blood transfusion Hb <= 6 mg/dl and gestational age > 36 weeks Hb between 6-8 mg/dl with any of the following conditions: Established or incipient heart failure Pre-existing heart disease Pneumonia or any other serious bacterial infection Malaria

Management General Management Shout for help Position the patient in eclamptic position Simultaneous assessment & resuscitation: Assess airway, breathing & circulation Oxygen inhalation IV fluid Catheterization to monitor urine output Protect the patient from other injuries Nutritional support Prophylactic antibiotic (ceftriaxone 1gm IV bd) Monitoring of fetal and maternal condition Send blood for investigations (CBC, S. electrolytes, S. creatinine, ALT, S. bilirubin, etc.) Control of Convulsion Drug of choice is MgSO₄ If contraindicated or not available, give diazepam ...

History History of ovulation inducing drugs or use of ART Family history of twinning Symptoms Increased nausea & vomiting Unusual rate of abdominal enlargement Excessive fetal movement Signs General Examination Anemia (more than singleton pregnancy) Unusual weight gain Evidence of pre-eclampsia Abdominal Examination Inspection Abdomen is unduly enlarged Palpation Height of the uterus is more than the period of amenorrhea Girth of the abdomen is more than the normal average at term (100 cm) Palpation of too many fetal parts Auscultation Simultaneous auscultation of 2 distinct heart sounds Investigation USG of the pregnancy profile Treatment Antenatal Management Increased dietary supplement (extra 300 calories) Increased rest Early cessation of work Increased supplementation of iron, vitamins, calcium, folic acid More frequent antenatal visit USG every month Hospitalization if any complications or at 38 weeks of pregnancy Obstetric Management First Stage of Labor Skilled obstetrician and neonatologist should be present Patient should be in bed (to prevent early rupture of the membranes) Careful monitoring One bag of blood should be kept in hand Check for cord prolapse if membrane ruptures Delivery of the First Baby Same guidelines as normal labor Liberal episiotomy Don’t give IV ergometrine after delivery The baby is labeled as number 1 Delivery of the Second Baby ...

Management Immediate Measures Call for extra help Open IV channel by 2 wide bore cannula Send blood for grouping, cross-matching & coagulation screening Ask for blood (at least 2 units) & transfuse when available Give IV fluid (Hartmann solution) till blood is available Catheterization to monitor urine output Monitor pulse, BP, temperature, and urine output every 15-30 minutes Tranexamic acid Find out the Cause Feel the uterus by abdominal palpation: ...