7. Organisation and targets of the women’s health practice.Emergency obstetric care.

Question 1

what does perinatal mean ?

Answer 1

starts at 20-28th gestation week and ends are 1-4 week after birth

Question 2

Majority of the maternal and early newborn deaths can be avoided by ensuring availability of?

Answer 2

EmONC (emergency obstetric and newborn care) services.

and timing is critical

Question 3

why are peripartum haemorrhages very dangerous?

Answer 3

Peripartal haemorrhage kills women in less than 2 hours - for other cases the women has 6 hours or or more

Question 4

most perinatal death occurs when ?

Answer 4

during labour and delivery and the following 48 hour

Question 5

what is essential for a functional EmONC ?

Answer 5

have atleast two skilled attendants and trained support staff on duty all times

availability of treatment is very crucial

Question 6

Basic EmONC has seven components and comprehensive EmONC has three additional ones , name all of them :

Answer 6

1) parenteral treatment for infections
2) parenteral treatment of severe pre-eclampsia / eclampsia (MgSO4)
3) treatment of PPH (postpartum hemorrage) - uteronitics oxytocin
4) manual aspiration of retained products of conception
5) assisted vaginal delivery - eg vacuums assisted delivery
6) manual removal of placenta
7) newborn resuscitation station

add 3

8) surgical capability including anaesthesia and cesarian
9) blood transfusions
10) contraceptive services including sterilization and facilities of referral with transport

Question 7

what are the obstetric emergencies during pregnancy ?

Answer 7

miscarriage

Ectopic pregnancy

Placental abruption

placenta praaevia

-preeclampsia (pregnancy induced blood pressure) / eclampsia (seizures)

PROM - premature rupture of membranes

Abnormalities of the placenta ,membranes and umbilical cord

Question 8

in miscarriage the death of the baby cannot be stopped before what gestational week

Answer 8

otherwise called spontaneous abortion

loss of a baby before the 24th week of gestation cannot be stopped

if the baby dies after 24th week it is known as still birth

Question 9

common symptoms of miscarriage

Answer 9

vaginal bleeding/ and tissue substance pass through
Abdominal cramping and pain

septic abortion -rise of temperature of at least for 24 hours or more,
offensive or purulent vaginal discharge
other evidences of pelvic infection such as lower abdominal pain and tenderness.

Question 10

what are the risk factors /causes miscarriage

Answer 10

IUD in situ

miscarriages occur before the 16th week and of these about 80% occur before the 12th week of pregnancy

first trimester :
1) majorly chromosomal abnormalities
= Autosomal trisomy / trisomy 16 
= Polyploidy
= Monosomy X

2) Endocrine disorders
= Luteal Phase Defect (LPD) Deficient progesterone secretion from corpus luteum or poor endometrial response to progesterone is the cause.

thyroid abnormalities, diabetes

3) Immunological autoimmune -
>antiphospholipid syndrome = lupus anticoagulant
anticardiolipin antibodies

> Th1 response is the production of proinflammatory cytokines
Women with recurrent miscarriage have more Th 1 response

4) Infection - TORCH

^numbered in order of highest incidence ^

inherited thrombophilia

smoking - formation of carboxyhemoglobin and decreased oxygen transfer to fetus

radiation

alcohol

second trimester-
(1) Anatomic abnormalities

• Cervical incompetence (congenital or acquired).

-Müllerian fusion defects
bicornuate uterus, septate uterus.

• Uterine synechiae.( uterine adhesions)
• Uterine fibroid esp submucous variation

Question 11

miscarriage should be diagnosed only if any of the following criteria are met what are they ?

Answer 11

Low levels hCG

Internal examination reveals dilated internal os of the cervix and products of conception which escaped examined to confirm or
through which the products of conception are felt

Crown-rump length of 7 mm or > and no heartbeat.

Mean gestational sac diameter of 25 mm or > and no embryo

Absence of embryo with heartbeat at least 2 weeks after an ultrasound scan that showed a gestational sac without a yolk sac.

Absence of embryo with heartbeat at least 11 days after an ultrasound scan that showed a gestational sac with a yolk sac

Question 12

what is the management of miscarriages ?

Answer 12

the clinical management of miscarriage is that if it is in the beginning of pregnancy it usually passes by itself - complete miscarriage

In cases of an incomplete miscarriage, empty sac, or missed abortion there are three treatment options: watchful waiting, medical management(misoprosto/mifepristonel), and surgical treatment (dilation vacuum aspiration/currettage)

however if it has passed viable gestational age then cervical dilation - prostaglandin , saline infusion
misoprostol / prostaglandin , oxytocin and other uterine contractors are given to delivery the baby and the retained products of conception are suctioned and curettage

septic abortion - Broad-spectrum intravenous antibiotics should be given until the fever is gone if septic abortion first then go onto the rest

rh immunisation

Question 13

what are the two classifications for spontaneous abortion

Answer 13

isolated (sporadic)

or

recurrent

Question 14

expulsion of miscarriage before 8 weeks ?

Answer 14

embryo surrounded by the villi with the decidual coverings, is expelled out intact.

Sometimes, the external os fails to dilate so that the entire mass is accommodated in the dilated cervical canal= cervical miscarriage

Question 15

expulsion of miscarriage 8-14 weeks ?

Answer 15

Expulsion of the fetus commonly occurs leaving behind the placenta and the membranes.

A part of it may be partially separated with brisk hemorrhage or remains totally attached to the uterine wall

Question 16

what is expulsion of miscarriage after 14 weeks ?

Answer 16

process of expulsion is similar to that of a “mini labor”. The fetus is expelled first followed by expulsion of the placenta after a varying interval

Question 17

what is threatened miscarriage ?

Answer 17

process of miscarriage has started but has not progressed to a state from which recovery is impossible

Question 18

what is the clinical features of threatened miscarriage ?

Answer 18

Bleeding per vaginam which is painless and stops spontaneously

Pain appears usually following hemorrhage
mild backache or dull pain in lower abdomen

Question 19

treatment of threatened miscarriage ?

Answer 19

bed rest till bleeding stops

Relief of pain may be ensured by diazepam

some evidence that treatment with progesterone improves the outcome (hcg not preferred)

RH negative patients
anti-D gamma globulin injection intramuscularly

Question 20

diagnosis of threatened miscarriage (also bad prognosis ) ?

Answer 20

vaginal Speculum inspection reveals—bleeding if any, through the external os

CERVICAL OS closed

========
Blood—for hemoglobin, hematocrit, ABO and Rh grouping.

falling serum b-hCG,

serum progesterone value of 25 ng/mL or more generally indicates a viable pregnancy

==========
golden
TRANSVAGINAL ULTRASOUND
normal - gestational sac well formed with central echogenicity and fetal cardiac signs

decreasing size of the fetus,

irregular shape of the gestational sac and smaller mean gestational sac

decrease in fetal movement

decreasing fetal heart rate

progressing to INEVITABLE MISCARRIAGE

======
If the pregnancy continues, there is increased frequency of preterm labor, placenta previa, intrauterine growth restriction of the fetus and fetal anomalies.

Question 21

clinical features of inevitable miscarriage ?

Answer 21

in comparison to threatened miscarriage
Increased vaginal bleeding.

Aggravation of pain in the lower abdomen which may be colicky in nature

CERVICAL OS OPEN

second trimester, it may start with rupture of the membranes or intermittent lower abdominal pain -mini labor

Question 22

what is the management of inevitable miscarriage ?

Answer 22

Excessive bleeding -Methergine 0.2 mg if the cervix is dilated and the size of the uterus is less than 12 weeks.

blood loss is corrected by intravenous (IV) fluid therapy and blood transfusion.

under strict aseptic conditions

Before 12 weeks : 
Suction evacuation -6-12weeks (dilation and curettage) 
suction aspiration 
vacuum aspiration
(explained in induced abortion)

=======

After 12 weeks:
(1) cervical preparation and uterine contraction is accelerated by oxytocin drip

If the fetus is expelled and the placenta is retained, it is removed by ovum forceps, if lying separated. If the placenta not separated, manual and evacuation under general anesthesia

suction evction , folllowed by opher forceps , followed by curettage

=======
RH negative patients
anti-D gamma globulin injection intramuscularly

Question 23

what is complete miscarriage ?

Answer 23

all the pregnancy tissue has left your uterus.

Question 24

what is the clinical features for complete miscarriage ?

Answer 24

expulsion of a fleshy mass per vaginam

subsidence of abdominal pain

vaginal bleeding absent

Question 25

what is the diagnosis of complete miscarriage ?

Answer 25

internal examination
cervical os is closed
bleeding trace
examination of expelled fleshy mass is found complete

US - empty uterine cavity

Question 26

what is incomplete miscarriage ?

Answer 26

entire products of conception are not expelled, instead a part of it is left inside the uterine cavity

Question 27

clinical features of incomplete miscarriage

Answer 27

expulsion of a fleshy mass per vaginam followed by

Continuation of pain in lower abdomen.

Persistence of vaginal bleeding.

Question 28

what is the diagnosis of incomplete miscarriage ?

Answer 28

internal examination - cervical os open

examination of fleshy material is incomplete

US - revels echogenic products of the conception

Question 29

what are complications where there is retained products of conception ?

Answer 29

profuse bleeding

sepsis

placental polyp

blood coagulation - less likely

Question 30

what is the management of incomplete miscarriage?

Answer 30

expectant management if pain levels are tolerable

dilation and suction evacuation under general anaesthesia

placenta products can also be ovum forceps

blunt curette is used to scrap on the walls after the procedure

medical management by giving misprostol in the posterioir fornix of the vagina = there is less complication

Question 31

what is the MANAGEMENT of missed miscarriage when the fetus is dead inside the uterus for a variable period ?

Answer 31

uterus less than 12 weeks -
be expectant - expulsion spontaneously

then

medial manegmnet - misoprostol put in the posterioir fornix and repeated if needed products are expelled

then dilation and suction evacuation can be done under general anaesthesia

=========
uterus more than 12 weeks

misoportsol vaginally for expulsion

general anaesthesia
dilation then evacuation

Question 32

what is septic abortion?

and what are the typical microorganism causing it ?

Answer 32

Any abortion associated with clinical evidences of infection of the uterus

(a) Anaerobic—Bacteroides group (fragilis), anaerobic Streptococci,
(b) Aerobic—Escherichia coli (E. coli), Klebsiella, Staphylococcus,

Question 33

what are the clinical features of septic abortion ?

Answer 33

fever for 24hrs and more

offensive purulent vaginal discharge / pelvic abcess

other incidence f pelvic infection such as lower abdominal pain

persistent tachycardia

tachypnea

endotoxic shock - hypotension

Diarrhea and/or vomiting

Question 34

what is the diagnosis of septic abortion ?

Answer 34

cervical and high vaginal swab - culture

blood - leukocytosis
CRP
serum lactate

Ultrasound -
grade 3 - peritonitis

Question 35

what are the complications of septic abortion ?

Answer 35

most fatal complications comes from illegal induced abortions of grade 3 type

= hemorrhage

= injury of the uterus and adjacent tissues

= spread of the infection- sepsis and peritonitis

endotoxic shock - ecoli

DIC

=thrombophelbitis

= remote complications: dyspareunia , ectopic pregnancy , secondary infertility

Question 36

what is the management of septic abortion ?

Answer 36

hospitalisation and isolation

grade 1 - infection localised to uterus
-antibiotics
-Analgesics and sedatives
-evacuation should be performed at a convenient time within 24 hours following antibiotic therapy
excessive bleeding - immediate evacuation
====
grade 2 - spread beyond uterus , parametric , tubes and ovaries

combination of either piperacillin-tazobactam or carbapenem plus clindamycin (IV) gives broadest range of microbial coverage
as empirical therapy

Evacuation of the uterus
is withheld for at least 48 hours when the infection is controlled and is localized, the only exception being excessive bleeding then in all cases evacuation

Posterior colpotomy—When the infection is localized in the pouch of Douglas, pelvic abscess is formed. It is evidenced by spiky rise of temperature, rectal tenesmus (frequent loose stool mixed with mucus) and boggy mass felt through the posterior fornix.

=====
grade 3
Generalized peritonitis and/or endotoxic shock or jaundice or acute renal failure.

antibiotics as grade 2

generalized peritonitis by vigorous intravenous crystalloids infusion
laparotomy- is needed to perform a full exploration and lavage of the peritoneum

laparotomy to remove uterus indications :
Injury to the uterus or bowel
Unresponsive peritonitis
Septic shock or oliguria not responding to the conservative treatment.

Question 37

WHAT IS PROM?

Answer 37

Spontaneous rupture of the membranes any time beyond 28th week of pregnancy but before the onset of labor

Question 38

what are the different types of prom ?

Answer 38

occur beyond 37th week but before the onset of labor, it is called term PROM

occurs before 37 completed weeks, it is called preterm PROM.

Rupture of membranes for > 24 hours before delivery is called prolonged rupture of membranes.

Question 39

what is the cause of PROM

Answer 39

cause of PROM is not clearly understood

risk factors
Infections: urinary tract infection, sexually transmitted diseases, lower genital tract infections (e.g. bacterial vaginosis),

chorioamnionitis

Tobacco

Illicit drug use

Having had PROM or preterm

Polyhydramnios

Multiple gestation

Question 40

what is the signs and symptoms of PROM

Answer 40

experience a painless leakage of fluid out of the vagina

Question 41

diagnosis of PROM

Answer 41

prove that the fluid leaking from the vagina is amniotic fluid,

History: a person with PROM typically recalls a sudden “gush” of fluid loss

Speculum examination : called the Pooling test: collection of amniotic fluid seen in the posterior vaginal fornix
Sometimes leakage of fluid from the cervical opening can be seen when the person coughs or performs a valsalva maneuver

this is the put under tests :

Nitrazine test: A sterile cotton swab is used to collect fluid from the vagina and place it on nitrazine paper. Amniotic fluid is mildly basic (pH 7.1–7.3) compared to normal vaginal secretions which are acidic (pH 4.5–6).Basic fluid, like amniotic fluid, will turn the nitrazine paper from orange to dark blue.

Fern test: A sterile cotton swab is used to collect fluid from the vagina and place it on a microscope slide. After drying, amniotic fluid will form a crystallization pattern called arborization which resembles leaves of a fern plant when viewed under a microscope.

====need to monitor these below=====

US - also fetal biophysical profile

pulmonary maturity
phosphatidyl glycerol and L: S ratio

Cardiotocography for nonstress test

cervical swab and urine culture

Question 42

what is the management of PROM ?

Answer 42

near term
37 weeks - observation for 12-24 hours in which labour starts that is if no fetal distress , no signs of infections
if not labour does not start
oxytocin induction
and preparation of cervix with prostaglandins

==========

36-34 weeks -
watch for onset of labour for max 48hrs

give prophylactic antibiotics

if not induction of labour begins with oxytocin

=========

less than 34 weeks

Delivery before 32 weeks’ gestation is associated with a significant risk of neonatal morbidity and death. Because of this, attempts to prolong pregnancy if there is no maternal indication for immediate delivery.
In the presence of active labor, intrauterine infection, or evidence of fetal compromise, delivery is required

corticosteroids

broad spectrum prophylactic antibiotics

tocolytic drugs - magnesium sulfate (MgSO4), indomethacin, and nifedipine

elective delivery at 34 weeks

=======

below 24 weeks - careful observation ONLY,
NO medication is given

=====
C SECTION of ANY OF IT NOT CEPHALIC PRESENTTION

Question 43

complication of prom ?

Answer 43

premature baby and its complication - RDS , pulmonary hypoplasia

ascending infection if labour starts to fail in 24hrs = chorioamonitis = fetal infection

cord prolapse esp when associated to malpresentation

dry labour -

mother - placental abruption , retained placental , endometritis, maternal sepsis

Question 44

why is it recommended to deliver at 34 weeks in prom?

Answer 44

perinatal mortality from prematurity is less compared to infection

Question 45

Obstetric emergencies during labour /after vaginal delivery ?

Answer 45

during labour :
shoulder dystocia
prolapse of umbilical cord
rupture of uterus

========
post partum
inversion of uterus (birth trauma of mother)

uterine atony - (post partum hemorrhage )

amniotic fluid
embolism-DIC

Hypotension without significant external bleeding

retained products of conception

Question 46

what is prolapse of umbilical cord

Answer 46

the umbilical cord gets push down to vagina or cervix before birth of the baby - leading to cord being compressed - fetes does not receive oxygen - brain damage and even death of fetes

Question 47

what are the other types of cord descend ?

Answer 47

occult prolapse - the cord is placed to the side of the presenting part
it is not felt through the fingers on internal examination
but COULD BE seen in US

cord presentation - cord slipped below the presenting part and its pulsations ar felt through vaginal examinations of an intact membrane

Question 48

what is the aetiology of cord prolapse ?

Answer 48

malpresentation - transverse and breech

contracted pelvis

prematurity

trins

hydroaminos

Question 49

what is the diagnosis of cord descend ?

Answer 49

occult prolapse - difficult to diagnose should be suspected if there is variable deceleration cardiotochography

cord presentation - vaginal internal examination , pulsate of the cord through INTACT membranes

cord prolapse - cord palpated directly through the fingers if the fetus is alive - but no pulsation does not necessarily mean fetal death

Question 50

what is the management of different cord descend?

Answer 50

cord presentation
c section
exaggerated sim position to minimise cord compression

cord prolapse
baby living - c section - tocolysis if there is a wait

prior to making the abdominal incision feat hr should be checked one more time to avoid c section of dead baby

immediate safe vaginal delivery - if head is engaged delivery by forceps

bladder filling with foley catheter with saline solution- raise the presenting part from the cord

lift the presenting part of the cord through fingers introduced into he vagina and pushing the presenting part upwards remove the hand from the vagina once the presenting part is above the pelvic brim and apply continuo suprpubicpressure

SIMS position with pillow under the hips

cord replacement not advised

if the baby is dead - labour is proceeded

Question 51

what causes hypotension without significant external bleeding

Answer 51

uterine inversion,

IMPROPER sutured episiotomy,

genital tract lacerations,

retained product of conception

sort tissue hematoma - usually of vulva occur during delivery in the absence of any episiotomy

Question 52

how is the proper suturing of episiotomy done ?

Answer 52

inccoperate the cut and retracted arterioles - they can continue to bleed - creating hematoma

Question 53

hypotension without significant external bleeding is dealt how

Answer 53

blood transfusion with ringers solution

Question 54

what is the definition of recurrent miscarriage ?

Answer 54

defined as a sequence of three or more consecutive spontaneous abortion before 20 weeks.

Question 55

causes for recurrent miscarriage ?

Answer 55

infection in genital tract

genetic factors
Endocrine and metabolic:

(1) Poorly controlled diabetic

Presence of thyroid autoantibodies

Luteal phase defect (LPD) with less production of progesterone

Polycystic ovary syndrome (PCOS

Inherited thrombophilia

second trim

congenital or acquired.

Congenital anomalies may be due to defects in the Müllerian duct fusion or resorption
(e.g. unicornuate, bicornuate, septate or double uterus).

Acquired anomalies are: intrauterine adhesions, uterine fibroids and endometriosis and cervical incompetence.