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Minggu, 15 November 2009

Medical Care During Pregnancy

PregnancyThe Importance Of Prenatal Care

According to the Centers for Disease Control and Prevention (CDC), almost 4 million American women give birth every year. Nearly one third of them will have some kind of pregnancy-related complication. Those who don't get adequate prenatal care run the risk that such complications will go undetected or won't be dealt with soon enough. That, in turn, can lead to potentially serious consequences for both the mother and her baby.

These statistics aren't meant to alarm you, but rather to convey the importance of starting prenatal care as early as possible — ideally, before you even become pregnant. Of course, this isn't always possible or practical. But the sooner in your pregnancy you begin, the better your chances of ensuring your own health and that of your baby.
Prenatal Care Before Becoming Pregnant

Ideally, prenatal care should start before you get pregnant. If you're planning a pregnancy, see your health care provider for a complete checkup. He or she can do routine testing to make sure you're in good health and that you don't have any illnesses or other conditions that could affect your pregnancy. If you've been experiencing any unusual symptoms, this is a good time to report them.

If you're already being treated for a chronic condition, such as diabetes, asthma, hypertension (high blood pressure), a heart problem, allergies, lupus (an inflammatory disorder that can affect several body systems), depression, or some other condition, you should talk to your doctor about how it could affect your pregnancy. In some cases, you may need to change or eliminate medications — especially during the first trimester (12 weeks) — to reduce risk to the fetus. Or, you may need to be even more vigilant about managing your condition.

For example, women with diabetes must be especially careful about keeping their blood glucose levels under control, both before they begin trying to conceive and during their pregnancy. Abnormal levels increase the risk of birth defects and other complications.

This is also a good time to talk with your health care provider about other habits that can pose a risk to your baby, such as drinking alcohol or smoking. Ask about starting a prenatal vitamin that contains folic acid, calcium, and iron.

It's especially important for women who are planning to become pregnant to take vitamins with folic acid beforehand, because neural tube defects (problems with the normal development of the spine and nervous system) happen in the first 28 days of pregnancy, often before a woman even knows she's pregnant.

If you have or your partner has a family history of a significant genetic disorder and you suspect either of you may be a carrier, then genetic testing may be advisable. Talk this over with your health care provider, who can refer you to a genetic counselor if necessary.

If you find out that you're pregnant before you do any of this, don't worry. It's not too late to get the care that will help to ensure your health and that of your baby.
Now that you're pregnant, taking care of yourself has never been more important. Of course, you'll probably get advice from everyone — your doctor, family members, friends, co-workers, and even complete strangers — about what you should and shouldn't be doing.

But staying healthy during pregnancy depends on you, so it's crucial to arm yourself with information about the many ways to keep you and your baby as healthy as possible.
Prenatal Health Care
Key to protecting the health of your child is to get regular prenatal care. If you think you're pregnant, call your health care provider to schedule an appointment. You should schedule your first examination as soon as you think that you are pregnant.

At this first visit, your health care provider likely do a pregnancy test, and will figure out how many weeks pregnant you are based on a physical examination and the date of your last period. He or she will also use this information to predict your delivery date (however, an ultrasound performed sometime during your pregnancy will help to verify that date).

If you're healthy and there are no complicating risk factors, most health care providers will want to see you:

* every 4 weeks until the 28th week of pregnancy
* then every 2 weeks until 36 weeks
* then once a week until delivery

Throughout your pregnancy, your health care provider will check your weight and blood pressure while also checking the growth and development of your baby (by doing things like feeling your abdomen, listening for the fetal heartbeat starting during the second trimester, and measuring your belly). During the span of your pregnancy, you'll also have prenatal tests, including blood, urine, and cervical tests, and probably at least one ultrasound.

If you still need to choose a health care provider to counsel and treat you during your pregnancy, there are several options:

* obstetricians/gynecologists (also known as OB/GYNs — doctors who specialize in pregnancy and childbirth, as well as women's health care)
* family practitioners (doctors who provide a range of services for patients of all ages — in some cases, this includes obstetrical care)
* certified nurse-midwives (advanced practice nurses specializing in women's health care needs, including prenatal care, labor and delivery, and postpartum care for uncomplicated pregnancies; there are also other kinds of midwives, but you should look for one with formal training who's been certified in the field)

Any of these is a good choice if you're healthy and there's no reason to anticipate complications with your pregnancy and delivery. However, nurse-midwives do need to have a doctor available for the delivery in case an unexpected problem arises or a cesarean section has to be performed.

Sabtu, 17 Oktober 2009

Post-partum Haemorrhage (PPH)

Post-partum Haemorrhage (PPH)

This is excessive bleeding following delivery and is described as primary and secondary.

The WHO definitions:
  • Primary post-partum haemorrhage is loss of blood estimated to be >500ml, from the genital tract, within 24 hours of delivery (commonest obstetric haemorrhage).
  • Secondary PPH is defined as abnormal bleeding from the genital tract, from 24 hours after delivery until 6 weeks post-partum.
Primary PPH

Aetiology

The commonest cause of PPH is uterine atony.
Other common causes are:

Atony and retained placenta are 80% of all cases, lacerations comprise the bulk of the other 20%.
Cervical lacerations, uterine rupture, broad ligament haematoma and extra genital bleeding also need to be excluded.

Epidemiology

Most studies quote an incidence of around 5%,1 but a figure of 12% of vaginal deliveries was recorded in one Australian tertiary referral hospital.2

Risk factors

  • Factors relating to the pregnancy:
  • Factors relating to delivery:
    • Emergency Caesarean section (9x risk)3
    • Elective CS (4x risk) - especially if >3 repeat procedures4
    • Retained placenta (5x risk)
    • Mediolateral episiotomy (5x risk)
    • Operative vaginal delivery (2x risk)
    • Labour of >12 hours (2x risk)
    • >4kg baby (2x risk)
    • Maternal pyrexia in labour (2x risk)
  • Pre-existing maternal haemorrhagic conditions:

Presentation

  • Symptoms: Continuous bleeding, which fails to stop after delivery of placenta - third stage
  • Signs: Loss of >1000ml may be accompanied by clinically apparent shock i.e. tachycardia, hypotension

Investigations

  • Thorough examination of the lower genital tract. This may require theatre/anaesthesia.
  • FBC, Clotting screen, Cross match
  • Hourly urine output
  • Continuous pulse/BP or CVP monitoring
  • ECG, pulse oximetry

Associated diseases

HELLP (Haemolysis, Elevated Liver enzymes and Low platelets)

Management

Non-drug

Ideally one of the emergency drills to be practised by the team on labour ward, along with shoulder dystocia.

  • Calling and alerting expert assistance. If the perceived blood loss is 500-1000ml and there are no signs of clinical shock, basic measures, (cross match 2 units, FBC, Clotting screen, IV access and monitoring clinical observations ) should suffice.
  • However loss of greater than 1000mls or any signs of shock should lead to full alert of the clinical team: experienced midwife, obstetric registrar, (alert consultant), anaesthetic registrar (alert consultant), alert haematologist, alert transfusion service, call porters for transport of specimens and blood products.

Drugs

  • Oxygen should be given by mask at 8 litres per minute.
  • Transfuse cross matched blood (6 units initially) a.s.a.p.
  • Until then infuse crystalloid or colloid as required.
  • If 3.5 litres given and no blood available, give O NEG, or uncross matched blood of own blood group.
  • Use a warming device and a pressure cuff.
  • Do not use a blood filter.
  • Do not use dextrans.
  • Give up to 1 litre of FFP and 10 units of cryoprecipitate if clinically indicated.

A new haemostatic agent- recombinant Factor VII a - has had some clinical success, but its efficacy and safety is untested in clinical trials as yet.5,6

Surgical

  • Secure IV access with 2 x14 gauge cannulae
  • Stop the bleeding
  • Exclude other causes than atony
  • Ensure bladder empty and bi-manually compress the uterus ±rub up a contraction. A Sengstaken-Blakemore tube has been used to compress the uterus. One series of 17 cases showed a 71% success rate in stopping the haemorrhage.7
  • Give IV syntocinon 10 units or IV ergometrine 500 mcg
  • Commence syntocinon infusion 30 units in 500ml
  • IM Carboprost 500mcg
  • Resort to surgery early. At laparotomy inject carboprost directly into the myometrium.
  • Bilateral ligation of the uterine arteries or bilateral ligation of the internal iliac (hypogastric) arteries.
  • An alternative to ligation is embolisation with gelatine sponge.8 Amenorrhoea has been reported following this, secondary to necrosis of the uterine wall and obliteration of the cavity.9
  • Uterine Bracing suture, (the B-Lynch suture) to anterior and posterior uterine walls has been shown to be effective and safe,10 with reports of successful pregnancy following its use.11,12
  • Hysterectomy should be considered early, especially in cases of placenta accreta or uterine rupture.

Complications

Prognosis

The Confidential Enquiry into Maternal Deaths for 2000-2002 reported 17 deaths related to obstetric haemorrhage in that triennium.13 This gives a rate of 8.5 per million.

Prevention

The Active Management of the Third stage of Labour; prophylactic oxytocics should be routinely used in the third stage of labour as they decrease the risk of PPH by 60%.14 For most women syntometrine ( ergometrine 0.5mg with 5i.u oxytocin) is the drug of choice. Oxytocin alone (10i.u) is preferred by some clinicians in women with hypertension.

Secondary PPH

This commonly presents in primary care as prolonged or excessive bleeding once the woman has returned home after delivery.

Aetiology

The two commonest causes are:

  • Infection- endometritis. Occurs in 1-3% after spontaneous vaginal delivery. It is the most common cause of postnatal morbidity between day 2 and day 10.
  • Retained products of conception (RPOC)

Endometritis risk factors

Caesarean section, prolonged rupture of membranes, severe meconium staining in liquor,15 long labour with multiple examinations, manual removal of placenta,16 mothers age at extremes of reproductive span, low socio-economic status, maternal anaemia, prolonged surgery, internal fetal monitoring and general anaesthetic.

Assessment

History: As above, also extended labour, difficult 3rd stage, ragged placenta, primary PPH.
Examination: Systemic illness, fever, rigors, tachycardia, tissue visible within loss. Suprapubic area may be tender, with elevated fundus that feels boggy in RPOC.

Investigation

  • FBC
  • Blood cultures are positive in 10-30%
  • Check MSU
  • High vaginal swab, also gonorrhoea/chlamydia
  • Ultrasound; may be used if RPOC suspected, although there may be difficulty distinguishing between clot and products. RPOC are unlikely if a normal endometrial stripe is seen.

Management

  • Speculum examination will allow visualisation of cervix and lower genital tract to exclude lacerations. If clot is visible within the cervical os, it may be removed with tissue forceps (though few GP regularly carry these), allowing the cervix to close.
  • If infection suspected, combinations of broad spectrum e.g. amoxicillin, gentamicin and metronidazole, can be given.17 Patient may need to be referred if too unwell to tolerate oral medication; IV clindamycin and gentamicin tds until afebrile for greater than 24 hours.18 Oral follow up treatment is not required. Use doxycyline if chlamydia is suspected.
  • If retained products of conception are suspected elective curettage with antibiotic cover may be required.
  • Patient may require iron supplementation if Hb has fallen. Warn of the risk of constipation.

Prognosis

90% of cases treated with antibiotics improve within 48-72 hours. If this is not the case, the patient should be re-evaluated.