Obstetric experiences

Maternal request cesarean delivery

2013-08-03T05:26:00.001-07:00

Cesarean delivery on maternal request

INTRODUCTION — Cesarean delivery on maternal request refers to a primary cesarean delivery performed because the mother requests this method of delivery in the absence of standard medical or obstetrical indications for avoiding vaginal birth. The right of patients to be actively involved in treatment decisions, including method of delivery, is now widely accepted by physicians and patients

In a well-informed patient, performing a cesarean delivery on maternal request is considered medically and ethically acceptable; in-depth reviews of the ethical issues are available elsewhere.

However, obstetricians are not obliged ethically or professionally to perform these procedures; early referral to another health care practitioner is appropriate in such cases .

PLANNED CESAREAN VERSUS PLANNED VAGINAL DELIVERY

No randomized trials on cesarean delivery for nonmedical reasons have been performed [18]. Thus, it is important to appreciate that conclusions about the risks and benefits of cesarean delivery on maternal request are not based upon high quality evidence and that the available data have serious methodological issues or provide indirect evidence from studies on cesareans performed for breech presentation.

The risks and benefits of cesarean delivery on maternal request need to be weighed against the potential outcomes from a planned vaginal delivery: uncomplicated spontaneous vaginal birth, operative vaginal delivery (vacuum or forceps), or cesarean delivery during labor because of problems such as abnormal progress of labor or nonreassuring fetal heart rate pattern.

The patient and provider also need to take into account patient-specific issues when estimating the risks and benefits of planned cesarean delivery.

Comorbid medical conditions, body mass index (BMI), future reproductive plans, prior childbirth experiences, outcome of previous surgical procedures, and the patient's personal philosophy about childbirth must be considered when choosing the method of delivery.

It is also important to inquire about the motivation for the request. Are there family pressures that should be discussed? Concerns about pain may be addressed by providing detailed information about obstetrical analgesia and anesthesia, as well as consultation with an anesthesiologist.

Fear and anxiety stemming from previous childbirth, personal trauma, or the experiences of friends and family should also be addressed. Providing these women with the best available information about pertinent childbirth issues and appropriate support may alleviate some of their concerns about attempted vaginal birth.

The decision as to whether or not to proceed with cesarean delivery should not be based on financial considerations.

REASONS WOMEN OPT FOR CESAREAN DELIVERY ON REQUEST — Reasons for choosing cesarean on request include:

Convenience of scheduled delivery
Fear of the pain, process, and complications of labor
Prior poor labor experiences
Concerns about fetal harm from labor and vaginal birth
Concerns about developing anal and/or urinary incontinence from labor and vaginal birth
Worries about the need for and risks of emergent cesarean or operative vaginal delivery

A patient’s statement during a case conference published in a journal summarizes the opinion of some women: “I feel like there's a lot more that can go wrong in a natural birth for the baby than can go wrong in the C-section for the mom, and I feel like I’m more willing to take something happening to me than something happening to my baby” [21].

POTENTIAL BENEFITS OF PLANNED CESAREAN — Although no randomized trials have been completed, planned cesarean delivery may have several potential benefits over planned vaginal birth.

Known endpoint — A planned cesarean delivery is usually scheduled. A known endpoint to the pregnancy facilitates issues related to work, child care, and help at home for the mother and her partner. It also provides an opportunity to schedule surgery with a particular provider.

On the other hand, if a known endpoint is the goal, induction of labor is a reasonable alternative, although induction may fail and lead to unscheduled cesarean delivery.

Avoidance of postterm pregnancy — Planned cesarean deliveries are typically scheduled between 39 and 40 weeks of gestation. Thus, postterm pregnancy, which is associated with higher rates of perinatal morbidity and mortality than pregnancies delivering at term, can be avoided.

On the other hand, if avoidance of postterm pregnancy is the goal, then induction of labor is a reasonable alternative, although induction may fail and lead to unscheduled cesarean delivery.

Reduction of risks associated with unplanned surgery — An emergency cesarean delivery is often a traumatic experience for women, and has been associated with postnatal depression and posttraumatic stress. Emergency surgery is also associated with slightly higher maternal and fetal risks than elective surgery. These risks include, but are not limited to, infection, accidental injury to abdominal organs, fetal laceration during hysterotomy, hemorrhage, and anesthesia-related complications.

Prevention of late stillbirth — Once the fetus is delivered, it is no longer at risk of intrauterine fetal demise and other complications of pregnancy. The clinically relevant question is: "How many fetuses reach maturity in-utero and are then involved in a catastrophe leading to severe neurologic damage or perinatal death?" [28]. The literature suggests that 1 in 500 to 1 in 1750 fetuses reach maturity in-utero and are subsequently involved in a catastrophe resulting in death or severe disability, the frequency of intrapartum fetal death is even lower (estimated as 1 in 5000 births. The large range in frequency is not surprising since many elements of the calculation cannot be defined with precision. It is clear that timely prophylactic cesarean delivery at term would save some babies destined for disaster; however, only one stillbirth would be prevented per approximately 1200 surgeries at 39 weeks of gestation.

Reduction in nonrespiratory neonatal disorders — Cesarean delivery prior to the onset of labor reduces or eliminates fetal morbidity and mortality related to the process of labor and vaginal birth. Intrapartum complications that are potentially reduced or avoided include brachial plexus injury related to shoulder dystocia, bone trauma (fracture of clavicle, skull, humerus), and asphyxia related in intrapartum events (eg, umbilical cord prolapse, abruptio placentae, uterine rupture).

Reduction in risk of pelvic floor injury — Fear of perineal injury and urinary and fecal incontinence from labor and vaginal delivery is a common reason for maternal request cesarean delivery; however, these concerns are not based on high quality evidence.

Fewer women have urinary incontinence in the months after planned cesarean delivery but, in the Term Breech Trial, urinary incontinence rates two and five years after delivery were not significantly different between women who planned cesarean delivery and those who planned vaginal births . In addition, planned cesarean delivery did not appear to confer protection against fecal incontinence compared to planned vaginal delivery. In contrast, another study of women 5 to 10 years after delivery compared outcomes between those who had had cesarean deliveries without labor (n = 200), those who had cesarean deliveries in labor (n = 400), and the remainder who had a spontaneous or operative vaginal delivery (n = 400). Compared to women with only cesarean deliveries before labor, the risk of pelvic organ prolapse was increased in women with a history of spontaneous vaginal birth or operative vaginal birth (adjusted OR 5.64, 95% CI 2.16-14.70 and aOR 7.50, 95% CI 2.70-20.87, respectively).

Thus, it appears cesarean delivery on maternal request may reduce the long-term risk of pelvic organ prolapse. However, the relationships between pelvic organprolapse/urinary incontinence/anal incontinence and pregnancy/labor/vaginal delivery/cesarean delivery are not yet well defined.

POTENTIAL DISADVANTAGES AND RISKS OF PLANNED CESAREAN — In addition to the concern that planned cesarean delivery is “not natural,” objections to planned cesarean include:

Increased risk of anesthetic complications
Longer recovery period (hospitalization and post-hospitalization), which may interfere with mother-infant interactions
Increased maternal morbidity related to surgery (eg, organ injury, wound infection, thromboembolism, intraabdominal adhesions)
Increased risk of neonatal respiratory problems
Increased risk of abnormal placentation in future pregnancies
Increased risk of uterine rupture in future pregnancies
Cost

Anesthetic complications — Given the need for surgical level anesthesia, planned cesarean is associated with a higher rate of failed regional anesthesia and conversion to general anesthesia than planned vaginal delivery.

Longer recovery period — The postpartum recovery period is longer after cesarean delivery than after vaginal delivery, and the duration of hospitalization after delivery may be longer after cesarean, as well. By three months postpartum, however, pain scores after planned cesarean and planned vaginal delivery are similar.

Increased maternal morbidity — Maternal morbidity appears to be higher with planned cesarean delivery than with planned vaginal delivery. In one of the largest series, composite severe morbidity after planned cesarean and planned vaginal delivery was 27.3 and 9.0 per 1000 deliveries, respectively (OR 3.1, 95% CI 3.0-3.3).

Compared to the planned vaginal delivery group, the planned cesarean group had a significantly higher postpartum risk of cardiac arrest (OR 5.1), wound hematoma (OR 5.1), hysterectomy (OR 3.2), major puerperal infection (OR 3.0), anesthetic complications (OR 2.3), venous thromboembolism (OR 2.2) and hemorrhage requiring hysterectomy (OR 2.1).

Increased risk of respiratory problems in offspring — Neonatal respiratory problems (eg, respiratory distress syndrome, transient tachypnea of the newborn) are more common after elective cesarean than after vaginal delivery, and may lengthen the neonate's hospital stay .

This was illustrated in a study that found the incidence of respiratory problems for neonates delivered by cesarean before the onset of labor was 35.5/1000, which was significantly higher than that for neonates who underwent cesarean during labor (12.2/1000) or vaginal delivery (5.3/1000) . An association between elective cesarean delivery and asthma and bronchiolitis has also been reported.

Respiratory problems are more frequent after cesarean delivery without labor because mechanisms to reabsorb lung fluid are not fully activated and, sometimes, as a result of iatrogenic prematurity. However, respiratory distress related to prematurity is virtually eliminated if delivery occurs after 39.0 weeks of gestation. The American College of Obstetricians and Gynecologists (ACOG) recommends that cesarean delivery on maternal request be performed at ≥39 weeks of gestation.

Increased neonatal mortality — A population-based study used birth certificate data and an intention-to-treat methodology to examine the risk of neonatal mortality for low-risk births by method of delivery. All United States live births and infant deaths from 1999 to 2002 (8,026,415 births and 17,412 infant deaths) were examined. Low-risk births were defined as singleton, term, vertex births with no medical risk factors, placenta previa, or prior cesarean delivery noted on the birth certificate. The "planned vaginal delivery" group consisted of vaginal births and those cesareans performed in the setting of labor complications or procedures (n = 7,755,236), while the "planned cesarean delivery" group comprised women who underwent cesareans with no documented labor complications or procedures (n = 271,179). After adjustment for maternal age, race/ethnicity, education, parity, smoking, infant birthweight, gestational age, and exclusion of infants with congenital anomalies, the odds of neonatal death with "planned cesarean delivery" were significantly higher than with "planned vaginal delivery" (OR 1.93, 95% CI 1.67-2.24). The accuracy of these findings is limited by (1) reliance on birth certificate data, which can be inaccurate and incomplete, (2) the absence of data on the indication for cesarean, and (3) the absence of information on the causes of neonatal death.

A subsequent retrospective cohort study of 56,549 late-preterm and term deliveries from Geneva, Switzerland also reported an increase in neonatal mortality and clinically relevant morbidities (neonatal intensive care unit [NICU] admission, respiratory problems) in term births by elective cesarean delivery compared with planned vaginal delivery. The authors speculated that a policy of restricted indications for elective cesarean delivery possibly selected pregnancies with higher neonatal risk and thus may have led to an overestimation of unfavorable outcomes.

Risks in future pregnancies — Women considering planned cesarean delivery should consider the consequences of this decision on future pregnancies. The relative risks and benefits change as the number of cesarean deliveries increases.

Increased risk of placental disorders — Placenta previa and accreta are significantly more common in pregnancies following one or more cesarean deliveries, and increase with the number of prior cesarean deliveries. Moreover, these complications may necessitate cesarean hysterectomy. For this reason, cesarean delivery on maternal request is not recommended for women desiring several children, given that the risks of placenta previa, placenta accreta, and gravid hysterectomy increase with each cesarean delivery.

First delivery by cesarean also may be associated with a higher risk of abruptio placentae in future pregnancies.

Increased risk of uterine rupture — Most uterine ruptures are related to a trial of labor after a previous cesarean delivery. Uterine rupture may require hysterectomy and is associated with an increased risk of fetal and maternal morbidity and mortality.

Complications from multiple abdominal surgeries — Adhesions increase the difficulty of future intraabdominal surgical procedures, and may increase the risk of bladder or bowel injury. There does not appear to be a causal relationship between cesarean delivery and subfertility.

Stillbirth — The effect of cesarean delivery on future stillbirth is controversial. A 2013 systematic review and meta-analysis reported a significant positive association between cesarean delivery and stillbirth anytime in a subsequent gestation; the significant association was present for both explained stillbirth (OR 2.1) and unexplained stillbirth (OR 1.47) (but not unspecified stillbirth)

OUTCOMES THAT ARE SIMILAR FOR BOTH PLANNED VAGINAL AND PLANNED CESAREAN BIRTH

Maternal mortality — Although not of high quality, the available evidence suggests there is no significant difference in maternal mortality for planned cesarean versus planned vaginal delivery . There are no data specifically addressing the maternal death rate for patient choice cesarean delivery. The lack of data is due, in large part, to the absence of well-designed clinical trials, failure to analyze existing data by intent (eg, classifying women in the vaginal delivery group if they undergo emergency cesarean in the course of planned vaginal delivery), and the rarity of maternal death in developed countries.

It is likely that the risk of maternal death from maternal request cesarean delivery is similar to that with scheduled repeat cesarean delivery prior to the onset of labor. This risk ranges from 1 in 5000 cesarean deliveries to less than 1 in 70,000 cesarean deliveries.

If cesarean is more dangerous than vaginal delivery, then one would expect a higher maternal mortality rate among populations with a high cesarean delivery rate, but this association has not been demonstrated. In fact, using national estimates of cesarean delivery rates after 1990 in 19 Latin American countries, one study demonstrated that the highest maternal mortality was found in populations in which the cesarean delivery rate was lowest. Although this does not prove cause and effect, it does cast doubt on the assumption that cesarean is more dangerous than vaginal delivery.

Postpartum sexual function — Postpartum sexual function does not appear to be related to method of delivery.

PHYSICIAN RESPONSIBILITIES — Because data are limited and recommendations are uncertain, the option of cesarean delivery on maternal request does not need not be discussed with every patient. When asked about cesarean delivery on maternal request, the clinician should find out the reasons for the patient’s request, address her concerns and any misinformation leading to those concerns (eg, unavailability of effective pain management), and provide a balanced discussion over a series of visits about the risks and benefits (relative and absolute) of the procedure with her, and possibly her support persons . Obstetricians are not obliged ethically or professionally to perform cesarean delivery on maternal request; early referral to another health care practitioner is appropriate in such cases.

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, “The Basics” and “Beyond the Basics.” The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

SUMMARY AND RECOMMENDATIONS

Cesarean delivery on maternal request refers to a primary cesarean delivery performed because the mother requests this method of delivery in the absence of conventional medical or obstetrical indications for avoiding vaginal birth.
For patients considering a planned cesarean delivery in the absence of standard indications for abdominal delivery, we have a thorough discussion of potential benefits and risks. The best available evidence suggests that planned cesarean delivery is associated with a lower risk of fetal injury than planned vaginal delivery, but longer hospital stay/recovery, an increased risk of neonatal respiratory problems, a greater risk of abnormal placentation in future pregnancies, and a greater risk of uterine rupture if a trial of labor is attempted. Planned cesarean delivery minimizes the risk of surgical complications associated with unplanned cesarean delivery, which may be necessitated during attempted vaginal delivery.
The patient and provider also need to take into account patient-specific issues when estimating the risks and benefits of planned cesarean delivery. Comorbid medical conditions, body mass index (BMI), future reproductive plans, prior childbirth experiences, outcome of previous surgical procedures, and the patient's personal philosophy about childbirth must be considered when choosing the method of delivery.

In addition, it is important to inquire about the motivation for the request, including work and family pressures, personal fears and anxieties, and concerns about pain. Providing women with the best available information about pertinent childbirth issues and appropriate support may alleviate some of their concerns about vaginal birth.

For women planning several pregnancies, it is suggested avoiding cesarean delivery on maternal request. Placenta previa and accreta are significantly more common in pregnancies following one or more cesarean deliveries. Moreover, these complications may necessitate cesarean hysterectomy. If the patient undergoes a trial of labor in the future, she will be at increased risk of uterine rupture.

For scheduled cesarean deliveries, it is suggested to scheduling the procedure at 39 to 40 weeks of gestation rather than at 37 to 38 weeks (Grade 2B).

Possible pathways for planned vagianl deliveries and cesarean delvieries

2013-08-03T04:44:00.002-07:00

Management of pregnancy in a woman with previous cardiomyopathy (Cardiomyopathy of pregnancy )

2013-07-21T16:01:00.002-07:00

Cardiomyopathy of pregnancy in literal terms is development of heart failure either during pregnancy or following delivery.

· Find out when she developed PPCM? (Antenatally or postnatally)

· Was her previous pregnancy complicated by hypertension/PET?

· Is she 40+ years old?

· Is she Afro-Caribbean descent?

· Also find out how much was her ejection fraction on cardiac echo?

Things to check at each antenatal visit:

· Maternal pulse

· respiratory rate,

· pulse oxymetry,

· Urine for proteinuria

Things to ask at each antenatal visit

· Any breathing difficulty (h/o breathlessness, SOB)

· Any h/o becoming breathless for routine tasks (Reduced physical capacity)

· Rule out palpitations

· Ask any swelling of limbs, face and back

Diagnostic criteria for PPCM

· Echo is a must to diagnose PPCM

· Left ventricular ejection fraction <45 p="">

· Fractional shortening by 30%

· Enlargement of heart and global dilation of all four chambers and markedly Lt.ventricular function

Management of pregnancy

· If develops antenatally, if baby viable and closer to term, consider elective delivery

· Thromboprophylaxis once there is impaired left ventricular dysfunction or arrhythmia

· Closely liaise with Cardiologist

· ? Three monthly cardiac echo and monthly ECG or earlier if she becomes symptomatic.

· Holter monitoring

· FBC, U/Es, LFTs

Intrapartum and postpartum management

- Consider intervening the pregnancy, only if she becomes symptomatic and echo proves PPCM

- Avoid prolongation of second stage

- Avoid ergometrine/methylergometrine. This is because following delivery, there is immediate rise in cardiac output due to the pressure off from inferior vena cava. Cardiac output increases by 70% followed by rapid decline to prelabour levels within one hour of delivery.

- Avoid excessive intravenous fluids.

- Consider giving Syntocinon by syringe driver rather than by syntocinon infusion.

- Encourage early ambulation.

Mirror Syndrome of Pregnancy

2013-07-21T10:22:00.000-07:00

It is the unusual association of fetal and placental hydrops with maternal pre-eclampsia. "Mirror syndrome" refers to the similarity between maternal oedema and fetal hydrops. Cause may be any of the variety of obstetric problems which range from Rh iso-immunisation disorders, to fetal infections, metabolic disorders, and fetal malformations. Ballantyne syndrome can result from the maternal reaction to a fetus that has hemoglobin Bart's disease due to inherited double thalassemia trait from both parents. This syndrome may present in a mother with missed Trisomy 21 screening and where in pregnancy continues and baby develops hydrops and mother may present with features of PET

Signs and Symptoms

Edema always present, mild proteinuria and PET

Differential diagnosis

The etiology of severe fetal hydrops may cause Mirror syndrome when the fetal status greatly worsens and that the syndrome is only a manifestation of the extreme severity of the fetus-placental pathology. Platelet count, ALT, AST are usually normal and may be used to distinguish from HELLP syndrome

Explaination for hemoperitoneum in abruptio placenta

2013-07-15T15:50:00.001-07:00

If you do KB count, it will be normal as most of the blood is escaped into the peritoneum. So one can have masssive abruption and almost a dead baby with normal Kleihauer count.

Preterm rupture of membranes at 28 weeks – Management

2013-07-13T17:11:00.000-07:00

In women with preterm PROM remote from term, 50% will go into labor within 24 to 48 hours and 70% to 90% within 7 days. Women with preterm PROM at 24 to 28 weeks of gestation are likely to have a longer latency period than those with preterm PROM closer to term.
Degree of oligohydramnios. The more severe the degree of oligohydramnios, the shorter the latency period.
Severe oligohydramnios may represent a larger hole in the membranes or evidence of early fetal compromise with diminished
urine output
Digital cervical examinations also cause an average nine-day decrease in the latent period. Therefore do not do digital examination

Sonographic myometrial thickness. Evidence of excessive thinning of the myometrium in nonlaboring women with preterm PROM ( 12 mm) as measured by transabdominal ultrasound has been associated with a shorter latency interval
Evidence of pregnancy complications (such as intra-amniotic infection, placental abruption, or active labor) or nonreassuring fetal testing (previously referred to as fetal distress) will lead to early delivery and a shortened latency interval.

The fetal membranes serve as a barrier to ascending infection. Once the membranes rupture, both the mother and fetus are at risk of infection and of other complications.

Multiparous woman with a non-progress of labour (Obstructed labour)

2013-07-08T15:54:00.001-07:00

Signs of Obstructed labour in a Multiparous woman at term

1. When the history was dug deeper, it is usually apparent that woman is contacting for 2-3 days. So do not take admission to labour ward as the onset of labour. The actual labour may have started few days ago.

2. Sunken eyes because of labour pains and dehydration and dehydration.

3. Urinary ketones (2+ and above)

4. Sub-umbilical flattening and evident bladder bulge. This is classical of occipitoposterior position causing obstrction of labour. Baby's sinciput hitching against pubic symphysis causing urethral swelling and swollen bladder.

5. If you scan such a woman, you will see star gazing fetus.

6. Occasionally there is presence of Bandl's ring.

Mistakes people do when confronted with Shoulder dystocia

2013-07-04T15:57:00.000-07:00

When confronted with shoulder dystocia, doctors and midwives do all sorts of mistakes. This is a situation where split second accurate decisions are required. These correct or incorrect decisions do account for the final clinical outcome.

1. The common mistake done is the belief that, just pulling the baby's head will effect the shoulder delivery. This is totally wrong.
Sinking feeling in the heart of the acoucher.
Not knowing which maneuver to do first. In the end, not doing any one maneuver properly.
Some health professionals also feel that they are going to loose the job whilst all of this is going on
It does not matter, which maneuver you select to do first, whatver you do, do it correctly.
write what time the head was born and what time the baby's body was born
Which way baby was facing when the head came out
Estimate the blood loss correctly by weighing the swabs, and do not do eyeball estimation of blood loss.
Rule out third and fourth degree tears.
Debrief the mother to say how badly your shoulders and arms are hurting to get the baby's shoulders out safely.

Resistant Hyperemesis Gravidarum Management

2013-07-03T03:27:00.001-07:00

If symptoms so out of control refer patient to Gastroenterologists for consideration of Oesophago-gastroduodenoscopy. Rule out gastric or duodenal ulcer dyspepsia.

Perform liver and gall bladder USS to rule out gall stones and liver pathology.

One can consider following,

1. Omeprazole 40mg OD

2. Regular cyclizine 50 PO/IV TDS

3. Amitriptyline 10mg OD

4. Buscopan 10 mg IM TDS

5. Magnesium Tricylicate 10mls PO TDS

6. Ranitidine 50mg IV TDS

7. Folic Acid 5mg OD

8. Thiamine 50mg PO OD. (Pabrinex)

Weekly weight monitoring, refer patient to dietitian.

But if patients’ vomiting is still continuing, I would try Ondansetron before steroids 4mg TDS and then 8mg TDS if some help.

If no help one could consider Hydrocortisone 100mg intravenous twice a day for 3 doses. If no improvement, STOP.

If symptoms improve, convert to oral Prednisolone 40 mg OD and continue for 5 days before reducing by 5 mg every week until symptoms recur and then hold at minimum dose

Intolerable Morning Sickness Management

2013-07-03T03:25:00.001-07:00

Systemic lupus erythematosus in Pregnancy

2013-06-30T16:30:00.002-07:00

Systemic lupus erythematosus in Pregnancy

SLE is known to increase the risk of spontaneous miscarriage; it can also cause fetal growth restriction and increased rates of sudden intrauterine death, pre-eclampsia and preterm delivery

Pre-pregnancy counselling :

The presence of anti-Ro/La and
antiphospholipid antibodies should be determined.

These antibodies are associated with congenital heart block

and neonatal cutaneous lupus syndrome.

Antiphospholipid

antibodies are present in about 30% of women with SLE and
are associated with arterial and venous thrombosis, recurrent
miscarriage, fetal growth restriction, fetal loss and preterm

delivery due to uteroplacental insufﬁciency.
Quiescent disease, without associated antiphospholipid syndrome (APS), hypertension or renal involvement the risks of miscarriage/stillbirth and fetal growth restriction are not signiﬁcantly increased
The risk of miscarriage and stillbirth in pregnancies complicated by lupus varies in the literature from 6–35% and from 0–22%
The great concern are women with SLE and associated pulmonary arterial hypertension who wish to conceive: maternal mortality rates have been quoted as being as high as 33%
Women should be advised not to conceive during a period of active disease, particularly with lupus nephritis, because of worse maternal and fetal outcomes
Counsel women with SLE for increased risk of pre-eclampsia, preterm delivery and fetal growth restriction
In active lupus nephritis with worsening renal function, increasing proteinuria and hypertension,it may be necessary to use such treatments as cyclophosphamide and mycophenolate mofetil, which are associated with congenital malformations if used in the ﬁrst trimester,
Pregnant women with active SLE/lupus nephritis or anti-Ro/La/antiphospholipidantibodies should be considered as a higher risk group and managed in tertiary centre
If severe disease, patients need hospitalisation
For patients with stable disease, 4-weekly reviews of disease activity and regular assessment of fetal growth, blood pressure and proteinuria are acceptable.
For those women who are anti-Ro/La positive the fetal heart rate should be monitored and recorded at each visit and fetal echocardiography assessments made at 18–20 and ~28 weeks of gestation
Women who have had a previous venous thromboembolism should receive thromboprophylaxis with low molecular weight heparin throughout pregnancy and for 6 weeks postpartum
The risk of an SLE ﬂare in pregnancy is increased with active disease in the 3–6 months prior to conception, with the majority of ﬂares occurring after the 20th weeks of pregnancy
Most ﬂares are managed expectantly with medical management and adjustments to drug therapy
At every antenatal visit, measure the BP, test the urine for proteinuria, and quantify the proteinuria by PCR or 24 hour urine proetien estimation.
The features of lupus nephritis include hypertension and proteinuria with or without haematuria and renal impairment
The presence of hematuria or red cell casts as well as a rise in anti-dsDNA titres or a fall in complement levels help to distinguish this from pre-eclampsia
In cases of lupus nephritis that fail to respond to increasing dosages of steroids and azathioprine, and where there is a deterioration of renal function and/or hypertension, other immunosuppressive drugs may be considered, such as mycophenolate mofetil or tacrolimus. Such management decisions should be undertaken in consultation with nephrologists and rheumatologists.
Premature rupture of membranes is also regarded as being more frequent in pregnancies complicated by SLE; rates vary and are generally quoted as ~20% and is common in women who are on steroids

SLE and fetal risks

Increased rates of miscarriage,
Increased risks of congenital heart block, fetal growth restriction and increased rates of preterm delivery
Scanning at least every 4 weeks to screen for fetal growth restriction in those women at risk is generally accepted and fetal echocardiography referral should be arranged for those with anti-Ro/La antibodies
Doppler studies can be used to estimate placental function
A uterine artery Doppler should be ﬁrst carried out at 20 weeks and repeated 4 weeks later if any abnormality is found
A raised pulsatility index or diastolic notching are associated with increased risk for developing pre-eclampsia, as they can indicate underlying placental dysfunction
Congenital heart block is associated with maternal anti-Ro/La autoantibodies.
usual presentation is a ﬁxed fetal bradycardia of 60–80 beats per minute on ultrasound scan.
It occurs in 2–3% of fetuses of women with the anti-Ro/La antibody
CHB is associated with signiﬁcant perinatal morbidity and mortality, with about half of infants requiring pacing by the ﬁrst year of life.
Congenital heart block develops between 18– 28 weeks of gestation and fetal echocardiography should be performed around this period to detect it. Hydrops fetalis can occur in utero and is thought to be due to the degree of endomyocardial ﬁbrosis and associated myocarditis.

Neonatal lupus rash

lesions are commonly seen on the face and scalp

and appear typically after ultraviolet exposure in the ﬁrst

2 weeks of life, but can appear up to 3–6 months postpartum

Drug treatment in SLE

Glucocorticoids, mainly in the form of prednisolone, are frequently but not exclusively used as one of the ﬁrst-line treatments in pregnancy
Women on moderate to high dosages of steroids should should be screened regularly for gestational diabetes.
Immunosuppressants that are used and are generally considered safe during pregnancy include azathioprine and hydroxychloroquine. There is no need to discontinue them during pregnancy

Postpartum management

To consider thromboprophylaxis
Manage hypertension

How to differentiate Amniotic fluid embolism and Pulmonary embolism?

2013-06-25T14:50:00.002-07:00

	Amniotic Fluid Embolism	Pulmonary Embolism
Onset of symptoms	Usually during labour	Any time in pregnancy
Early symptoms	Dyspnoea, restlessness, panic, feeling, cold, paraesthesiae. Usually no pain	Breathlessness, , cough, haemoptysis, pleuritic pain
Coagulopathy	Present	Absent
ECG	Not helpful	S1Q3T3
Chest x-ray:	Pulmonary oedema, ARDS, right atrial enlargement, prominent pulmonary artery.	Segmental collapse, raised hemidiaphragm, unilateral effusion
CTPA	Negative	Positive
Complement levels	Raised	Normal
Serum Fetal Sialyl Tn antigen	Present	Absent

Nine maternal risks of Obesity and Three fetal risks of maternal obesity

2013-06-25T14:30:00.000-07:00

Mother

1. Severe morbidity – surgical or aneshtetic

2. Cardiac disease

3. Spontaneous miscarriage

4. Pre-eclampsia

5. Gestational diabetes

6. Thromboembolism

7. Post caesarean wound infection

8. Infection from other causes

9. Post partum haemorrhage

Baby

1. Stillbirth and neonatal death

2. Congenital abnormalities (can be missed by scan)

3. Prematurity

Reasons why tachycardia is important in a pregnant patient?

2013-06-25T14:20:00.002-07:00

Presence of tachycardia is the most significant clinical feature of an unwell patient and is regularly ignored or missed or misinterpreted .

Measurements of respiratory rate and heart rate are seriously more important than measurements of blood pressure.

A normotensive patient may all too often be unwell and compensating.

A tachycardic patient is hypovolemic until proved otherwise.

A patient with tachypnea has a cardiorespiratory cause until proved otherwise.

Do not attribute presence of tachycardia and tachypnea to anxiety

Three most important causes of abdominal pain in later stages of pregnancy

2013-06-25T14:02:00.000-07:00

PET, eclampsia and HELLP syndrome, especially if the pain is epigastric or accompanied by jaundice
Placental abruption
Sepsis

Ten Red Flag Signs of Maternal sepsis

2013-06-25T13:52:00.004-07:00

1. Pyrexia > 38_C

2. Sustained tachycardia > 100 bpm

3. Breathlessness (RR > 20)

4. Abdominal or chest pain

5. Diarrhoea and/or vomiting

6. Reduced or absent fetal movements, or absent fetal heart

7. Spontaneous rupture of membranes or significant vaginal discharge

8. Uterine/renal angle pain and tenderness

9. appears or feels generally unwell

10. Unduly anxious, distressed

The combination of any of the above two makes a seriously valid case for correct thought process to rule out maternal sepsis. Of all the vital signs respiratory rate is the most important variable for assessing the clinical situation of the patient. Respiratory rate is the most sensitive indicator of patient's physiological well being.

Button hole defects of posterior rectus sheath : A real problem in patients with higher order repeat cesarean deliveries.

2013-06-25T01:33:00.001-07:00

When patients undergo higher order cesarean deliveries, the common problem noticed by me is a " button hole defect" of the posterior rectus sheath. This happens because, each time a woman undergoes cesarean delivery, her rectus sheath is cut and usually this does not require approximation. So for every repeat cesarean, the rectus sheath becomes weaker and weaker. If such defects are not looked for carefully, then few weeks later patient will present with do lower abdominal pain with swelling in the abdomen. The b examination or a CT scan will confirm incisional hernia.

How to conduct assessment of blood loss station

2013-06-23T16:37:00.001-07:00

Problems with assessing blood loss visually, when the blood is small amount eyes will say more, and when it is massive,eyes will underestimate it.

Tricks of performing cesarean section in extremely obese women (morbidly women and cesarean delivery)

2013-06-21T15:26:00.001-07:00

Do not make a cut in the skin where the skin groove between the abdomen and the loin is.
make a cut at the maximum bulge of the abdominal skin
Use a Alexis retractor (http://www.youtube.com/watch?v=CnS2mYLpTts) so that you do not need two assistants. Otherwise you will need two assistants
Always leave a peritoneal and subrectus sheath drain. As it will be extremely difficult to identify if the woman suffers postoperative bleeding.
Use mass closure technique if midline incision
Close the subcutaneous tissue if its depth exceeds a depth of 3cms.
Use metal clips for the skin as this will let the fluid and other exudates from the wound to seep out.

Ogilvie syndrome - post cesarean complication

2013-06-20T16:37:00.001-07:00

Seen usually on the second postoperative day

Symptoms are similar to bowel bowel obstruction

Chest and abdominal x-ray will give some clue ( cecal diameter of 10 cms will aid in the diagnosis)

Serum amylase may be slightly raised

Patient usually doesn't pass flatus or faeces

Drip and suck and rarely endoscopic clinic deflation is required.

For radiology interpretation, please visit

http://www.learningradiology.com/archives2011/COW%20465-Ogilvies/ogilviescorrect.htm

Reduced fetal movements at term

2013-06-20T16:26:00.001-07:00

* at term it is normal to see a pattern of reduced fetal movements
* If there are associated pain in the abdomen or bleeding per vaginum, then the symptom should be taken seriously.
* A change in quality of movements is more important than the quantity of fetal movements
* Patient should be reassured that 70% of pregnancies with a single episode of RFM are uncomplicated

PPH and Point of care coagulation tests (Thormbolestography - TEG)

2013-06-11T14:49:00.001-07:00

In the current treatment of severe PPH, first-line therapy includes -- transfusion of packed cells and fresh-frozen plasma in addition to uterotonic medical management and surgical interventions. In persistent PPH, tranexamic acid, fibrinogen, and coagulation factors are often administered.

Secondary coagulopathy due to PPH and its treatment is often underestimated and therefore remains untreated, potentially causing progression to even more severe PPH.

In most cases, medical and transfusion therapy is not based on the actual coagulation state because conventional laboratory test results are usually not available for 45 to 60 minutes

Thromboelastography and rotational thromboelastometry are point-of-care coagulation tests. A good correlation has been shown between thromboelastometric and conventional coagulation tests, and the use of these in massive bleeding in nonobstetric patients is widely practiced and it has been proven to be cost-effective. As with conventional laboratory tests, there is an influence of fluid dilution on coagulation test results, which is more pronounced with colloid fluids. Fibrinogen seems to play a major role in the course of PPH and can be an early predictor of the severity of PPH.

The FIBTEM values (in thromboelastometry, reagent specific for the fibrin polymerization process) decline even more rapidly than fibrinogen levels and can be useful for early guidance of interventions (Ref: Obs and Gynae Survey July 2012)

Autoimmune disorders and pregnancy

2013-06-07T17:13:00.000-07:00

The implications of autoimmunity and pregnancy
Two decades ago, it was suggested that women with autoimmune diseases avoid pregnancy due to inordinate risks to the mother and the child. In contrast, newer epidemiological data demonstrated that advances in the treatment of autoimmune diseases and the management of pregnant women with these diseases have similarly improved the prognosis for mother and child.
In particular, if pregnancy is planned during periods of inactive or stable disease, the result often is giving birth to healthy full-term babies without increased risks of pregnancy complications.

Nonetheless, pregnancies in most autoimmune diseases are still classified as high risk because of the potential for major complications.

These complications include disease exacerbations during gestation and increased perinatal mortality and morbidity in most autoimmune diseases, whereas fetal mortality is characteristic of the anti-phospholipid syndrome (APS).

In this review, following topics are discussed , including issues of hormones, along with potential long-term effects of the microchimerism phenomenon.

With respect to pregnancy and autoimmune diseases, epidemiological studies have attempted to address the following questions:

1) Is it safe for the mother to become pregnant or are there acute or chronic effects of pregnancy on the course of the disease?

2.Does the disease alter the course and/or the outcome of a pregnancy and thereby represent an inordinate risk for the fetus and infant? And do new therapeutic and management approaches improve the pregnancy outcomes in women with autoimmune diseases? 3) Does passage of maternal autoantibodies represent a risk to the child? 4) Do pregnancy, parity, or other factors influencing hormonal status explain the female predominance of many autoimmune diseases, and is the pregnancy effect related to microchimerism?
Answering these questions has taken on additional importance in recent decades as women in western countries now frequently choose to delay pregnancies and have some or all of their pregnancies after disease onset.

In this a primary focus is placed on APS, systemic lupus erythematosus (SLE), multiple sclerosis (MS), rheumatoid arthritis (RA), and type 1 diabetes (T1D).

This indicates that women in their childbearing years are
frequently affected.
3.1.1. Pregnancy morbidity
The specific pregnancy morbidity criteria for APS are

a) one or more unexplained deaths of a morphologically normal fetus at or
beyond the 10th week of gestation;

b) one or more premature births of a morphologically normal neonate before the 34th week of gestation because of either eclampsia or severe preeclampsia or
placental insufficiency; or
c) three or more unexplained consecutive spontaneous abortions before the 10th week of gestation in the absence of anatomic, hormonal or chromosomal causes.
This highlights one of the major differences between APS and other
autoimmune diseases: whereas other autoimmune diseases may
affect the course of pregnancy, pregnancy morbidity is a manifestation
and a defining feature of APS. While late fetal loss is
considered to be more characteristic of APS, recurrent early fetal
loss is more common.
Before the advent of treatment, the prognosis for pregnancies in
APS patients was dismal, with only 10% or less of all pregnancies
resulting in live births, although others have reported
somewhat better outcomes. It has become common practice to
treat pregnant APS patients or SLE patients with aPL even in the
absence of clinical manifestations of APS with low-dose aspirin
alone or in combination with heparin, but considerable controversy
remains as to the most appropriate approach. Since the
introduction of such preventive regimens, the pregnancy outcome
among women with APS has improved dramatically. Interestingly, there were
significant differences in the distribution of fetal losses. Mexican,
Ecuadorian, and Colombian women with APS experienced early
pregnancy loss significantly more often than their European
counterparts, whereas their late pregnancy loss rate was lower, the
latter reaching statistical significance only in patients with pAPS
. During a further 5 years of follow-up, the live birth rate in
the European cohort improved significantly to 76.2%, with early and
late pregnancy losses occurring in 17.1% and 6.7% of pregnancies,
respectively. This is consistent with numerous other studies
showing success rates of 70- 80% in pregnancies of women with
APS who receive aspirin alone or in combination with heparin or
other preventive regimens.
While the pregnancy outcome has improved significantly in
recent years, the complication rates remain high.

Typical complications in women with APS are preeclampsia/eclampsia, intrauterine growth restriction (IUGR), premature rupture of membrane,
Cesarean delivery and premature delivery, the latter being
primarily due to preeclampsia/eclampsia or placental insufficiency.
Overall, the reported rates of preeclampsia range between 0 and
51% and those for preterm delivery between 32 and 65%.

The Euro-Phospholipid study revealed preeclampsia in 9.5%, eclampsia
in 4.4%, premature rupture of membranes in 2.0%, and post-partum
cardiopulmonary syndrome in 0.5% of pregnancies

An analysis of nationwide obstetric hospitalization data in the USA
similarly showed that women with APS had a significantly
increased frequency of hypertensive disorders (13.0%), IUGR (5.1%),
premature rupture of membranes (1.8%) and cesarean delivery
(44.6%) compared to the general obstetric population [21]. Women
with APS were significantly older, but even after adjusting for age,
their risk of these pregnancy complications remained significantly
elevated. There are indications that the complication rates, particularly
for preterm delivery, giving birth to an SGA baby and
preeclampsia, are higher in women who have thrombotic manifestations
of APS.

Possible effects of pregnancy morbidity on the disease course
From the limited available data, it is difficult to determine
whether recurrent pregnancy loss represents a risk factor for
subsequent thrombosis in APS patients. One of the few prospective
studies examining this issue used a definition of 2 miscarriages as
recurrent pregnancy loss and compared patients with aPL with or
without clinical manifestations of APS [23]. In this investigation,
miscarriages were not significantly associated with the subsequent
occurrence of thrombosis, whereas a history of vascular disease
constituted a risk factor for subsequent miscarriages. This is
consistent with other observations, including the finding from the
Euro-Phospholipid cohort, where only 2.5% of women with
exclusively obstetric APS manifestations at study begin developed
a thrombotic event during 5 years of follow-up.These
findings are in marked contrast to the results of a retrospective
analysis of data from three tertiary referral centers in the USA on
65 patients whose only clinical manifestation for the diagnosis of
APS was recurrent pregnancy loss. This subgroup of APS
patients was found to be at high risk of subsequent thrombosis,
particularly when not continuously treated with low-dose aspirin
for the prevention of thrombotic events. Specifically, the nonaspirin-
treated group of 34 patients had 20 events, including
7 venous thromboses, 5 strokes, and 5 transient ischemic attacks,
during a mean follow-up of w8 years, resulting in an event rate of
7.4/100 patient-years, whereas the aspirin-treated group had an
event rate of 1.3/100 patient-years. Mean duration from initial
pregnancy loss to clinical event was 4.2 years. Of note, pregnancy
and the post-partum period may also represent a time of particular
susceptibility to catastrophic APS (for more details, the reader is
referred .

Table 6
Neonatal diseases caused by maternal autoantibodies.
Neonatal disease Maternal disease Causative antibody Proportion of antibody-positive
pregnant women
% Affected neonates of
antibody-positive mothers
Neonatal lupus syndrome SLE, SS, RA, other connective tissue
diseases, or asymptomatic
Anti-SSA/SSB 1-2% Up to 52%
Neonatal autoimmune
thrombocytopenia
Immune thrombocytopenic purpura Anti-platelet 0.1% 10%
Neonatal autoimmune neutropenia Autoimmune neutropenia Anti-neutrophil 1:50,000
Neonatal Graves' disease Graves' disease Anti-TSHa receptor 0.1- 0.4%
Autoimmune hemolytic anemia
of infancy
Autoimmune hemolytic anemia Anti-erythrocyte 1e2:100,000 Very rare
Pemphigus Anti-desmoglein 1:50,000 10e40%
Myasthenia Myasthenia gravis Anti-acetylcholine receptor 1:10,000e2:10,000 10e20%
Hypothyroidism Anti-thyroid 10e15% 0.32e0.56/100,000b
Neonatal APS Primary or secondary APS or
asymptomatic
aPL 2% 30e37%
a TSH thyroid-stimulating hormone receptor.

How to prevent incisional hernia in patients,undergoing higher order repeat Cesarean delivery?

2013-06-06T02:32:00.003-07:00

In patients who need 3rd or 4th repeat Cesarean sections, one should be careful in terms of upper rectus sheath dissection to create para-rectus sheath space for delivery of the baby. The dissected sheath will continue to get weaker and weaker after each episode.
Finally there is always a chance that patient may be left with button hole defect, which can be easily missed and later presenting as incisional hernia. The hernia bulge will be in the midline away from the pfannensteil scar.

Medical Management of Postpartum Hemorrhage

2013-06-02T15:08:00.002-07:00

Basis for management of PPH

Obstetric experiences

Maternal request cesarean delivery

Possible pathways for planned vagianl deliveries and cesarean delvieries

Management of pregnancy in a woman with previous cardiomyopathy (Cardiomyopathy of pregnancy )

Things to check at each antenatal visit:

Things to ask at each antenatal visit

Diagnostic criteria for PPCM

Management of pregnancy

Intrapartum and postpartum management

Mirror Syndrome of Pregnancy

Signs and Symptoms

Explaination for hemoperitoneum in abruptio placenta

Preterm rupture of membranes at 28 weeks – Management

Multiparous woman with a non-progress of labour (Obstructed labour)

Mistakes people do when confronted with Shoulder dystocia

Resistant Hyperemesis Gravidarum Management

Intolerable Morning Sickness Management

Systemic lupus erythematosus in Pregnancy

How to differentiate Amniotic fluid embolism and Pulmonary embolism?

Nine maternal risks of Obesity and Three fetal risks of maternal obesity

Reasons why tachycardia is important in a pregnant patient?

Three most important causes of abdominal pain in later stages of pregnancy

Ten Red Flag Signs of Maternal sepsis

Button hole defects of posterior rectus sheath : A real problem in patients with higher order repeat cesarean deliveries.

How to conduct assessment of blood loss station

Tricks of performing cesarean section in extremely obese women (morbidly women and cesarean delivery)

Ogilvie syndrome - post cesarean complication

Reduced fetal movements at term

PPH and Point of care coagulation tests (Thormbolestography - TEG)

Autoimmune disorders and pregnancy

How to prevent incisional hernia in patients,undergoing higher order repeat Cesarean delivery?

Medical Management of Postpartum Hemorrhage

Young Laplace law

F= 2T/r

F: Compressive Force (Bimanual compression/B-Lynch suture)

T: Wall tension created by Uterine Contractions (Uterotonics/Oxytocics)

r: Radius of the uterus (Retained placenta/cotyledons/RPOCs)