Case Capsules in Obstetrics

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Case studies in obstetric problems like PPROM, vulvovaginitis, ectopic pregnancy, watery leak p/v by Prof.Ayesha Jehan

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CASE CAPSULES:

CASE CAPSULES Prof. Ayesha Jehan Professor of Obstetrics & Gynaecology, Deccan College of Medical Sciences, Hyderabad

CASE 1:

CASE 1

CASE 1:

CASE 1 22/F, Primi gravida , c/o 8 months amenorrhoea and ‘watery leak’ P/V h/o recurrent attacks of VV + UTI since marriage (11 months) h/o cerclage at 18 weeks GA e/o genital herpes since 16 weeks of pregnancy AN Profile: Hb : 12 g%, Blood group: A positive OGCT: 90 mg% VDRL: NR, HIV/ HbsAg : Negative S.TSH: 1.5 uIU /ml, ECG: WNL CUE: Pus cells: 15-20/HPF, Albumin +, E/C - NIL

.. contd:

.. contd AN Exam: Uterus 30 weeks, FH<GA Irritable, FH + regular, NST reactive L/E: Herpetic vesicles seen locally over the external genitalia. P/V Cx soft, short, watery leak + P/S Thin, profuse WD +, Vagina congested. Cerclage suture + Watery leak intermixed with WD + Conclusion: PPROM + VV at 32 weeks

What is the clinical approach in this case?:

What is the clinical approach in this case? QUESTION 1

‘WATERY LEAK’ - DDx:

‘ WATERY LEAK’ - DDx Vaginal discharge Physiological vs. Pathological Amniotic fluid Gush vs. Trickle Urine

What is the significance of vaginal examination in ANC? Effects of recurrent VV infections and pid?:

What is the significance of vaginal examination in ANC? Effects of recurrent VV infections and pid ? QUESTION 2

VULVOVAGINITIS:

VULVOVAGINITIS 40-60% of AN cases Organisms commonly implicated: Trichomonas Gardenella Beta streptococci, Gonococci Candida Chlamydia TORCH, HIV, Koch’s High vaginal swab, endocervical swab indicated.

VULVOVAGINITIS:

VULVOVAGINITIS VV and PID cause: Abortions PPROM: Oligoamnios, CA, Abruptio placenta Preterm birth Placental insufficiency: IUGR, IUD PROM & PTB - Prolonged hospital stay: Psychosocial strain Thromboembolic phenomenon Puerperal sepsis Neonatal complications

VULVOVAGINITIS – PATHOGENESIS OF FETOMATERNAL EFFECTS:

VULVOVAGINITIS – PATHOGENESIS OF FETOMATERNAL EFFECTS MEMBRANE INFLAMMATION PLACENTA FOETUS TISSUE INJURY DESTABILIZATION OF LYSO MEM HYPOXIA RELEASE OF AA - PG↑ ACTIVATION OF COX/IL-6/CYT ABNORMAL UTERINE ACTIVITY ↑ IAP CERVICAL CHANGES PPROM PRETERM BIRTH INSUFFICIENCY Infection/anoxia Sepsis FD IUGR IUD MATERNAL SEPTICAEMIA

What is the cause and foetomaternal effects of genital herpes? Mode of delivery?:

What is the cause and foetomaternal effects of genital herpes? Mode of delivery? QUESTION 3

GENITAL HERPES:

GENITAL HERPES 5% of high risk pregnancies (rising trend) Caused by HSV-1 & HSV-2 (↑) M-B transmission in first trimester leads to: Congenital defects: Microcephaly, intracranial calcifications, micro- ophthalmia , chorioretinitis M-B transmission in later weeks causes neonatal herpes (SEM, CNS, disseminated herpes) 80% HSV positive infants are born to asymptomatic mothers. In primary infection, IgM + in 7-10 days, IgG low avidity+ in 4 weeks. Intrauterine foetal infection is high in the absence of IgG (Placental barrier) Ascending infection from the cervix is common. PPROM predisposes to IU spread.

GENITAL HERPES:

GENITAL HERPES Rx: Acyclovir 400mg TID x 7-10 days Valacyclovir 500mg BD x 7-10 days Famcyclovir 200mg BD x 7-10 days Obstetric management: (1998 AICOG Guidelines) No lesion – No LSCS Primary herpes – LSCS, Recurrent – LSCS +/- Invasive intrapartum procedures (FBS, CTG) and instrumental deliveries are avoided.

What is the protocol for antenatal surveillance in cases of pprom?:

What is the protocol for antenatal surveillance in cases of pprom ? QUESTION 4

ANTENATAL SURVEILLANCE PROTOCOL:

ANTENATAL SURVEILLANCE PROTOCOL Twice daily CTG / FH monitoring Maternal Vitals: PR/Temp q4h CBP twice weekly ( leucocytosis - IUI) Non-specific inflammatory markers: ESR, CRP USG: BBP, Doppler study Repeated high vaginal swabs – DEBATED ↑ ascending infections??

WHAT ARE THE C/F OF THE four MAIN COMPLICATIONS – OLIGOAMNIOS, CA, ptb, Foetal distress?:

WHAT ARE THE C/F OF THE four MAIN COMPLICATIONS – OLIGOAMNIOS, CA, ptb , Foetal distress? QUESTION 5

WHAT IS THE MANAGEMENT IN THIS CASE? - CONSERVATIVE - ACTIVE:

WHAT IS THE MANAGEMENT IN THIS CASE? - CONSERVATIVE - ACTIVE QUESTION 6

CONSERVATIVE MANAGEMENT:

CONSERVATIVE MANAGEMENT The Rule in: NIL/minimal signs of infection NO foetal compromise

CONSERVATIVE MANAGEMENT:

CONSERVATIVE MANAGEMENT Rest and Oxygen therapy Hydration: IV, Amino infusion +/- Antibiotics (Parental, oral) Steroids Tocolytics Progesterone, hCG Counselling and diet

ACTIVE MANAGEMENT:

ACTIVE MANAGEMENT Termination of pregnancy Cerclage - when to remove?

In our case…..:

In our case….. The patient was managed conservatively for 96 hours, after which pregnancy had to be terminated due to: ↑ leakage of liqour (AFI: 2) Severe variable decelerations on CTG (FD) E/O cord prolapse excluded LSCS done, alive and healthy female baby weighing 1.8kg delivered, thin MSL, cord friable, placenta showing e/o large retroplacental clots & calcifications. Baby admitted to NICU for neonatal care. Puerperum uneventful Healthy mother & baby discharged on Day 14.

TAKE HOME MESSAGES:

TAKE HOME MESSAGES A vaginal examination is mandatory in all antenatal cases High vaginal swab & endocervical swab in early pregnancy helps to predict complications Most patients remain asymptomatic but can spur surprises Check couples habits Smoking, zarda , pan Multiple partners Increased sexual activity In male: DM, UTI, Seminal infections Most infections are polymicrobial Prophylactic antibiotics ↓ complications in HR patients.

INTRAPARTUM SCREENING PROGRAMME:

INTRAPARTUM SCREENING PROGRAMME CDC recommended strategies: Strategy 1: Vaginal + Rectal swab for all patients at 35-37 weeks. Strategy 2: Intrapartum antibiotic prophylaxis. Strategy 3: Combination of 1+2 Strategy 4: Rapid bed side testing in labour Dosage recommended: Metronidazole 2g q24h x 2 days Benzyl penicillin 3g stat followed by 1.5g q4h x 2days (or) Metronidazole 200-400mg + Clindamycin 900mg q8h x 2 days Intrapartum prophylaxis is effective only if given 2 hours before delivery

VACCINES – A LONG TERM SOLUTION??:

VACCINES – A LONG TERM SOLUTION?? Vaccination of all women of child bearing age is recommended. But most pathological organisms have various strains, hence, efficacy is not yet satisfactorily established.

CASE 2:

CASE 2

CASE 2:

CASE 2 A 39 year old woman with 3 children came to the hospital with excessive bleeding P/V following 2 months amenorrhea. She felt “unmistakably pregnant”. H/O POP usage + (no slip) Cycles irregular/scanty due to POP UPT + Moderately heavy bleeding for 7 days. O/E: GC stable. Afebrile. Tachycardia + BP-110/80mmHg, All systems stable. Pallor+, No goitre . P/A: Soft, Tenderness + pelvic region. No guarding. No s/o peritonitis. Ut NS Fx free Cx excitation – ve , Bleeding PV +, no clots. Os admits tip.

Investigations::

Investigations: Hb: 11g%, B+ve, RBS: 70mg% CUE: few Pus cells, RBC +, UPT + Serum hCG: 215 IU, After 48 hours, S.hCG: 45IU TVS: Ut NS ET 7mm, Left adnexa showing thin walled ovarian cyst + 2x2cm, ↓free fluid POD Culdocentesis: No blood, 1-2ml clear fluid +

WHAT IS THE DIAGNOSIS? DEFINITIVE DIFFERENTIAL ENNUMERATE THE DDx IN THIS CASE…:

WHAT IS THE DIAGNOSIS? DEFINITIVE DIFFERENTIAL ENNUMERATE THE DDx IN THIS CASE… QUESTION 1

IN OUR CASE A DIAGNOSIS OF MISCARRIAGE + BENIGN OVARIAN CYST WAS MADE…. :

IN OUR CASE A DIAGNOSIS OF MISCARRIAGE + BENIGN OVARIAN CYST WAS MADE….

DOES AN ADNEXAL MASS (CYST) ALWAYS IMPLY ECTOPIC? INCIDENCE OF ADNEXAL CYST IN EP? DEFINITIVE FEATURES OF ECTOPIC GESTATION?:

DOES AN ADNEXAL MASS (CYST) ALWAYS IMPLY ECTOPIC? INCIDENCE OF ADNEXAL CYST IN EP? DEFINITIVE FEATURES OF ECTOPIC GESTATION? QUESTION 2

DEFINITIVE FEATURES OF ECTOPIC:

DEFINITIVE FEATURES OF ECTOPIC UNRUPTURED RUPTURED UPT + (SUBMINIMAL TITRES) EMPTY UTERINE CAVITY GESTATIONAL SAC + FOETAL POLE IN ADNEXA CULDOCENTESIS – 10ML UNCLOTTED BLOOD SHOCK + PERITONITIS ++ In the absence of definitive features, the diagnosis of ectopic pregnancy can be missed.

WHAT IS THE MANAGEMENT OF MISCARRIAGE?:

WHAT IS THE MANAGEMENT OF MISCARRIAGE? QUESTION 3

MISCARRIAGE - MANAGEMENT:

MISCARRIAGE - MANAGEMENT Medical management – Misoprostol 600-800ug in single/divided doses Check curettage Regular follow-up with S.hCG titres/UPT ↓ in 48 hours

WHAT ARE THE PROGESTERONES USED AND THEIR DOSAGES IN POP? CAN THEY CAUSE MISCARRIAGES/ECTOPIC? HOW? FAILURE RATE?:

WHAT ARE THE PROGESTERONES USED AND THEIR DOSAGES IN POP? CAN THEY CAUSE MISCARRIAGES/ECTOPIC? HOW? FAILURE RATE? QUESTION 4

PROGESTERONES IN POP:

PROGESTERONES IN POP Norethindrone: 0.35mg Norgestrel: 0.075mg Levonorgestrel: 0.03mg Desogestrel: 0.075mg (75ug) Progesterones alter tubal motility, make the endometrium hostile to nidation , alter cervical mucous. Failure rate: 0.5 to 1% Cerazette ( desogestrel 75ug) can cause abrupt follicular development in certain cycles (97-99% inhibition)

WHAT IS YOUR FURTHER CONTRACEPTIVE ADVICE TO THIS COUPLE OF 40-45 YEAR AGE GROUP?:

WHAT IS YOUR FURTHER CONTRACEPTIVE ADVICE TO THIS COUPLE OF 40-45 YEAR AGE GROUP? QUESTION 5

ALTERNATIVE CONTRACEPTIVE ADVICE:

ALTERNATIVE CONTRACEPTIVE ADVICE Permanent contraception Barrier methods Others

TAKE HOME MESSAGES:

TAKE HOME MESSAGES Contraception is no guarantee against pregnancy. Every adnexal cyst in EP does not imply an ectopic. Benign ovarian cysts like simple follicular cyst/CL cyst should be kept in mind. By TVS – incidence of ovarian cyst in EP: 30% In unruptured ectopic a definitive Dx can be made only in 30% of cases. S.hCG levels ↑ by 2/3 every 48 hours for 5 weeks on till 8 weeks normally. At 5 weeks, hCG level is 1000-1500 mIU. TVS scan is superior to TAS for early Dx of pregnancy site & viability. By TVS at 5 weeks, GS (>20mm) +; FP+, YS+, hCG level 1000mIU. B y TAS GS is seen when hCG level is 6000 mIU. Progesterone assays are helpful in predicting miscarriage > 60 nmol : Healthy pregnancy, < 20 nmol : miscarriage.

Recent terminologies:

Recent terminologies

RECENT TERMINOLOGIES:

RECENT TERMINOLOGIES The term ABORTION is OUTDATED. Pregnancy of uncertain viability: At 6 weeks: only a regular IU sac. FP+, no cardiac activity. Nil/↓ bleeding PV UPT strongly Positive Rescan in 8-10 days Common in cases of endocrinopathies

RECENT TERMINOLOGIES:

RECENT TERMINOLOGIES Pregnancy of uncertain location: UPT + No adnexal mass No IU sac/ FP – Rescan in 2 weeks/repeat S.hCG titers Pregnancy failure: Recent terminology for abortion Falling hCG & progesterone levels ‘Blighted’ / Missed gestation

Tocography – abnormal uterine contraction patterns:

Tocography – abnormal uterine contraction patterns

ABNORMAL UTERINE CONTRACTION PATTERNS:

ABNORMAL UTERINE CONTRACTION PATTERNS MINOR DEFECTS Causes: CPD Hypotonus In. UA PROM Polyam Minor defects per se do not cause foetal compromise. Can lead to major defects. Skewed contraction Paired contraction Polysystole

ABNORMAL UTERINE CONTRACTION PATTERNS:

ABNORMAL UTERINE CONTRACTION PATTERNS MAJOR DEFECTS Caused by: CPD/POP/ Abruptio / ↑ uterotonics Lead to: Foetal compromise Risk of uterine rupture Hypertonus Tachysystole Uterine tetany

Acute abdominal pain in pregnancy:

Acute abdominal pain in pregnancy DDx

ACUTE ABDOMEN IN PREGNANCY:

ACUTE ABDOMEN IN PREGNANCY Causes related to pregnancy: Early pregnancy complications – ectopic/miscarriage Abruptio placenta Uterine fibroids (red degeneration, infection, torsion) Chorioamnionitis Uterine rupture Severe pre- ecclampsia + HELLP (epigastric pain) Severe uterine torsion Normal rotation by 30-40% to right occurs in 80% cases. If > 90% rotation: S evere torsion Ovarian tumours (cysts)

ACUTE ABDOMEN IN PREGNANCY:

ACUTE ABDOMEN IN PREGNANCY Causes unrelated to pregnancy: Acute appendicitis UTI + pyelonephritis Urolithiasis Cholelithiasis APD + peptic ulceration Intestinal obstruction & Crohn’s disease Acute pancreatitis Acute fatty liver of pregnancy Rare blood dyscrasias (sickle crisis, blast crisis) Peritonitis due to intra-abdominal hemorrhage

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