My Clinical Notes

• ‘Minor’ problems of pregnancy
• Backache – ue to laxity if spinal ligaments and exaggerated lumbar lordosis
• Symphysis pubis dysfunction
• Constipation – due to progesterone slowing gut motility
• Hyperemesis gravidarm
• Heartburn
• Varicose veins and piles – relaxant effect of progesterone on smooth muscle and the venous stasis caused by the weight of the pregnant uterus on the inferior vena cava
• Carpal tunnel
• Oedema

 

Problems due to abnormalities of pelvic organs

 

Fibroids

• If a large fibroid is at the uterus or lower segment it can prevent descent and obstruct delivery as well as causing Caesarean section complications
• Most common problem is red degeneration resulting in acute pain, tenderness and vomiting
• If symptoms are severe they can precipitate uterine contractions

 

Retroversion of the Uterus

• 15% of women have a retroverted uterus
• Most become anteverted during pregnancy
• If it fails to antevert can fill pelvis squashing the bladder and ureters. This can cause urinary retention and bladder over-distension

 

Congenital Uterine Anomalies

• Problems associated with a bicornuate uterus are;
• Miscarriage
• Pre-term labour
• PPROM
• Abnormal lie and presentation
• High Caesarean section rate

 

Urinary Tract Infections

 

• Common in pregnancy
• May progress to pyelonephritis
• Predisposing factors
• Hx of recurrent cystitis
• Renal tract abnormalities
• Bladder emptying problems e.g. MS
• Presenting symptoms – low back pain, malaise and flu-like symptoms
• First line treatment is amoxicillin or oral cephalosporins

 

Venous thromboembolism

 

• In pregnancy there is an increase in clotting factors VIII, IX, X and fibrinogen levels and a decreased in Protein S and anti-thrombin III levels
• Due to high levels of oestrogen
• Venous stasis also increases risk
• Pregnancy increases risk of DVT by 5 times
• Caesarean section increases risk of DVT by 10 times
• Specific risk factors associated with pregnancy;
• Multiple gestation
• Pre-eclampsia
• Multiparity
• Caesarean section
• Sepsis
• Prolonged bed rest

 

Thrombophilia

• Predisposition to thrombosis can be inherited or acquired
• Inherited conditions include, deficiencies in Protein C, Protein S and anti-thrombin III as well as resistance to activated protein C caused by Leiden mutation of Factor V
• Acquired thrombophilia is most commonly associated with anti-phospholipid syndrome which is a combination of lupus anticoagulants with or without anti-cardiolipin antibodies
• Individual should be considered for prophylaxis

 

DVT/PE

• D-Dimer can be elevated in pregnancy due to physiological changes in the coagulation system making it less useful for diagnosis
• Heparin – prolongs activated partial thromboplastin time (APPT) and is safe during pregnancy as it doesn’t cross the placenta
• Warfarin prolongs prothrombin time and crosses the placenta causing limb and facial defects in the first trimester and intracerebral haemorrhage in the second trimester

 

Antepartum Haemorrhage

 

• Defined as vaginal bleeding from 24 weeks up to delivery of the baby
• Placental causes include;
  • Placental abruption
  • Placenta praevia
  • Vasa praevia
• Local causes include;
  • Cervicitis
  • Cervical ectropion
  • Cervical carcinoma
  • Vaginal trauma
  • Vaginal infection
• Rhesus status is important, if women is rhesus negative give anti-D

 

Oligohydramnios/Polyhydramnios

 

• Amniotic fluid is produced almost exclusively from fetal urine from the second trimester onwards
• Protects baby from trauma
• Allows limb movement and development
• Allows fetal breathing – aiding lung development

 

Oligohydramnios

• Amniotic fluid index less than the 5^th centile for gestation
• Diagnosed by amniotic fluid index (AFI), an ultrasound measurement
• May be due to PPROM whereby it leaks from the vagina or conditions where there is insufficient production such as;
• Renal agenesis
• Multicystic kidneys
• Urinary tract obstruction/abnormality
• IUGR/ placental insufficiency
• Maternal drugs – NSAIDs
• Altogether may cause fetal lung problems

 

Polyhydramnios

• AFI >95% centile for gestation
• Produces severe abdominal discomfort
• May be caused be maternal, placental or fetal conditions
• Maternal;
  • Diabetes
• Placental;
  • Chorioangioma
  • Arterio-venous fistula
• Fetal;
  • Multiple gestation
  • Idiopathic
  • Oesophageal/duodenal atresia
  • Neuromuscular condition that prevent sswallowing
  • Anecephaly
• Risk of preterm labour due to overdistension
• Risk of abnormal lie and malpresentation
• To reduce liquor can use amniodrainage or NSAIDs to reduce fetal urine output

 

 

Breech presentation, oblique and transverse lie at term

 

• Breech is common before term and only becomes a problem if the baby is not cephalic by 37 weeks
• Three types are breech;
  • Extended (frank) breech
  • Flexed (complete) breech
  • Footing breech
• Cord and foot prolapse are risks
• Predisposing factors for abnormal lie or breech are
• Uterine;
  • Fibroids
  • Congenital deformities
  • Uterine surgery
  • Polyhydramnios
  • Oligohydramnios
• Fetal;
  • Multiple gestation
  • Abnormality e.g. anencephaly or hydrocephalus
  • Neuromuscular condition
• Particular problem if women is multiparous where the uterus is lax
• Elective Caesarean section is safer then vaginal delivery is baby is breech at term

 

External cephalic version

• May be performed at 36-37 weeks
• Contraindications
  • Placenta praevia
  • Oligohydramnios/polyhdramnios
  • Hx of antepartum haemorrhage
  • Previous uterine scar
  • Multiple gestation
  • Pre-eclampsia or hypertension
• Risks of ECV
  • Placental abrution
  • Premature rupture of membranes
  • Cord accident
  • Transplacental haemorrhage
  • Fetal bradycardia

 

 

 

 

This entry was posted on Sunday, September 30th, 2007 at 1:29 pm and is filed under Gynaecology/Obstetrics. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.