Obstetrics

• Incompatible blood tranfusion
• Ectopic pregnancy
• Invasive procedures during pregnancy (e.g. amnio, D&C, cerclage)
• Any type of abortion
• Labour and delivery

Ab titres < 1:16 (meaning Ab's not picked up after dilution of 1:16). If Ab titres > 1:16, require amniocentesis to determine the severity of fetal RBC hemolysis.

Kleihauer-Betke test - fetal RBC's identified in maternal blood on a slide after treatment with acid solution

Total body swelling of fetus

• Give to all Rh -ve women in the following situations:
• at 28 weeks
• any invasive procedure in pregnancy
• within 72hrs after birth in Rh +ve fetuses
• with a postive Kleihauer-Betke test
• ectopic pregnancy
• antepartum hemorrhage
• any invasive procedure during pregnancy (e.g. amniocentesis)

• IgG antibodies developed my mom can cross the placenta and cause:
• fetal anemia (via hemolysis)
• CHF
• fetal edema
• fetal ascites
• fetal hydrops

15-40%

• Positive screen for GBS
• GBS bacteriuria (even if treated!)
• Maternal fever intrapartum
• ROM > 18hrs
• preterm labor (<37 weeks)
• previous child with GBS infection

Pneumonia, meningitis, sepsis

At 35-37 weeks (first vaginal, then anorectal swab)

• Penicillin G 5 million U, then 2.5 million U Q4H until delivery
• If mild pen allergy (no risk for anaphylaxis), can use cefazolin 2g IV, then 1g Q8H
• If true pen allergy, use clindamycin (900mg IV q8h) or erythromycin (500mg IV q6h)

• Maternal age > 35
• Teratogenic exposure during current pregnancy
• Abnormal U/S
• Abnormal prenatal screening
• Past personal history/family history of genetic disorder

• Identification of genetic anomolies (done at 15-16 weeks)
• Determination of the L:S ratio (lecithin:sphingomyelin), if >2:1, RDS is less likely. (Done in T3)
• Determination of the level of bilirubin (as a measure of fetal RBC hemolysis)

• T1: 0-12 weeks
• T2: 12-28 weeks
• T3: 28-40 weeks

• (Gravidity)
• G - Gravida: Total number of pregnancies (including abortions, molar pregnancies, ectopics). Note that twins = 1 pregnancy

• (Parity - TPAL)
• T - Term: Number of term deliveries
• P - Preterm: Number of preterm (<37 weeks) deliveries
• A - Abortions: Number of abortions (loss of pregnancy < 20 weeks or fetus < 500g)
• L - Number of living children

Softening of cervis (4-6 weeks)

Softening of the cervical isthmus (6-8 weeks)

Bluish discoloration of the cervix and vagina due to pelvic vascular engorgement (6 weeks)

• 10 IU at time of missed menses
• 100,000 IU at 10 weeks (peak)
• 10,000 IU at term

Note: B-hcg is produced by the placenta and consists of alpha and beta subunits. Plasma levels double every 1-2 days.

• Wrong dates
• Ectopic pregnancy
• Abortion

• Wrong dates
• Molar pregnancy
• Twins
• Trisomy 21

• 1-Gestational sac
• 2-Fetal pole
• 3-Fetal heart
• 4-Intrauterine pregnancy

• Increased CO/blood volume/HR
• Decreased PVR (thus decreased BP)
• Decreased venous return (due to uterus size compressing IVC), thus increased venous pressure (leading to varicose veins)

• Decreased RV, FRC and TLC
• Increased minute ventilation (RR x TV)
• Increased O2 requirements

• GERD (decreased LES tone, delayed gastric emptying -> these two due to progesterones effects). Also increased gastric pressure due to uterus.
• Gallstones (progesterone increased GB stasis)
• Constipation
• Hemorrhoids (decreased GI motility again due to progesterone)

• Urinary frequency
• Increased incidence of UTI's and pyelonephritis
• Increased glucose in urine

LMP + 7 days - 3 months.

If cycle > 28days, need to add these additional days to the formula above.

• CBC, blood group and type, Rh antibodies, Urine R&M / C&S (look for protein and bacteria), pap smear, culture for gonorrhea and chlamydia, bacterial vaginosis swab.
• Also need to screen for other infections (such as syphilis, herpes, etc).

• Q4-6 weeks until 28 weeks
• Q2 weeks from 28 - 36 weeks
• Q1 week from 36 weeks until delivery

• GA
• History of current pregnancy (fetal movements, any bleeding, any cramping, any leaking of fluid)
• Physical exam: BP, Weight, SFH, Leopold's maneuvers (T3) for position / presentation of fetus
• Investigations: Urinalysis (glucose, protein), fetal heart tones (starting at 12 weeks)

• 12 weeks: Top of uterus (fundus) located at syphysis pubis
• 20 weeks: Fundus located at umbilicus
• 27 weeks: Fundus located at sternum

Note: Between 20 and 27 weeks, SFH should be within 1-2cm of GA

< 6 movements in 2 hours is concerning. If this is the case, mother should move to quiet room, change position, drink juice and concentrate on counting babie's movements. If still < 6, contact MD.

NST stands for Non Stress Test. It consists of looking at the fetal heart rate (FHR) for at least 2 accelerations of > 15bpm lasting at least 15 seconds over a 20 minute period. If none observed in 20 minutes, change position / stimulate baby, retry. If non-reactive, move to BPP.

• BPP stands for biophysical profile. It is performed when a non-reassuring NST is performed, or if there's any indication of fetal distress or utero-placental insufficiency. It consists of looking at 4 parameters:
• 1) AFV: Amniotic fluid volume (look for at least 1 fluid pocket of 2cm x 2cm)
• 2) Fetal tone: One occurence of limb extension followed by flexion
• 3) Fetal breathing movements: One episode of breathing lasting 30 seconds
• 4) Fetal limb movements: Three discrete movements

Between 8 - 12 weeks

Between 18-20 weeks GA

Amniocentesis!

• Adv
• Can be done earlier - 10 to 12 weeks (thus enables pregnancy to be terminated earlier if desired)
• Rapid karyotyping possible (48 hours)
• High sensitivity and specificity

• Disadv
• 1-2% risk of sponatenous abortion (vs 0.5% with amnio)
• Does not screen for oNTD (whereas amnio can)
• May see false -ves due to genetic mosaicism

• Medical
• <9 weeks:Methotrexate + misoprostol
• >12 weeks:Prostaglandins or misoprostol

• Surgical
• <12-16 weeks:D&C
• >16 weeks:Dilatation and evacuation

Hemorrhage, pain, uterine perforation, infection(endometritis), Asherman's syndrome (uterine scarring causing infertility/amenorrhea), retained products of conception

True! Need to provide pregnant woman with Fe supplementation, especially during 2nd and 3rd trimester

False! It is associated with Fe deficiency anemia. Folic acid is necessary for closure of the neural tube and all women should get at least 0.4mg pre (1-3 months) and during pregnancy (especially T1). Women with past history of oNTD or diabetes or on anti-epileptics should use 4mg per day.