Pain and Bleeding in Early Pregnancy Max Brinsmead MB BS PhD February 2015.
An Obstetric Case History for You Max Brinsmead MB BS PhD March 2014.
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Transcript of An Obstetric Case History for You Max Brinsmead MB BS PhD March 2014.
An Obstetric Case An Obstetric Case History for YouHistory for You
Max Brinsmead MB BS PhDMarch 2014
Stephanie is a 36-year old who Stephanie is a 36-year old who has been trying to have a baby has been trying to have a baby for 5 years. She has been told for 5 years. She has been told that she has endometriosis and that she has endometriosis and her husband has a low sperm her husband has a low sperm count. She has recently been to a count. She has recently been to a clinic in Bondi for IVF and thinks clinic in Bondi for IVF and thinks she might be pregnant as a she might be pregnant as a result. Today she has result. Today she has experienced a few spots of dark experienced a few spots of dark blood on her pants. She comes to blood on her pants. She comes to you for advice…you for advice…
Stephanie ?pregnant after IVF with Stephanie ?pregnant after IVF with PV bleedingPV bleeding
Do you require further history
Do you examine this patient
What tests might be useful
Stephanie ?pregnant after IVF with Stephanie ?pregnant after IVF with PV bleedingPV bleeding
Further history that is desirable
When did she have the embryo transfer procedure
Exact date Any pain or other
symptoms Luteal phase support
drugs? How many embryos
were transferred Social circumstances,
any other pregnancies or medical problems etc.
Stephanie ?pregnant after IVF with Stephanie ?pregnant after IVF with PV bleedingPV bleeding
Further history 2 embryos transferred 20 days ago
Progesterone pessaries for luteal support
Mastalgia for a week but no other pain
One spontaneous pregnancy 3 years ago. Miscarried “at 5 months”
FH of hypertension & diabetes. Non smoker. Married. School teacher.
Stephanie ?pregnant after IVF with Stephanie ?pregnant after IVF with PV bleedingPV bleeding
Examination that is essential
Why?
Vital signs
Abdominal palpation for mass or tenderness
Must exclude ruptured ectopic pregnancy before Stephanie walks out your door
Stephanie ?pregnant after IVF with Stephanie ?pregnant after IVF with PV bleedingPV bleeding
What is the best way to proceed from here?
What other tests may be desirable
A urine HCG test will confirm instantly if she is pregnant
PV ultrasound may confirm site of pregnancy and plurality
Take blood for quant. HCG, PROG and routine AN tests
Pregnancy test positive. Scan report: Pregnancy test positive. Scan report: “Twin intrauterine gestational sacs “Twin intrauterine gestational sacs identified. Both ovaries enlarged with identified. Both ovaries enlarged with cystic mixed echogenicity. Small amount cystic mixed echogenicity. Small amount of free fluid in the pelvis”of free fluid in the pelvis”
What will you tell Stephanie
What sort of twin pregnancy is this likely to be
What issues need to be explored at this stage of the pregnancy
“Twins” yet to be confirmed and reconfirmed at 12 weeks
Dichorionic and diamniotic from 2 embryos
Start planning for extra rest this pregnancy
Continue pregnancy vitamins, maybe extra iron
Issues of prenatal diagnosis
We need more information about the previous pregnancy
Stephanie with IVF Twins in the 1st Stephanie with IVF Twins in the 1st TrimesterTrimester
Subsequent ultrasound and serum biochemical testing
Further history
Confirmed a DC & DA pregnancy at 6 & 12 weeks. Low risk of aneuploidy for both.
Conception with same partner 3 yrs ago ended at 21w with PROM, pains for 2 hrs and miscarriage. Baby lived for 10 min. Autopsy NAD apart from “chorioamnionitis”
Stephanie 36 yr old G2P0 with IVF Stephanie 36 yr old G2P0 with IVF Twins in the 1st TrimesterTwins in the 1st Trimester
Stephanie wants midwife care and maybe a home birth
What do you recommend
Give facts and figures to back this
Overall perinatal mortality is 2-3x higher with twins
1:6 twin pregnancies end <30w
And a maternity hospital is best place for such to occur
Risk even higher for this patient, (age and reproductive history)
Her risk of complications of pregnancy is high eg pre eclampsia, diabetes
50% of twins are born by CS and many 2nd twins require assisted vaginal birth
Stephanie 36 yr old G2P0 with Twins Stephanie 36 yr old G2P0 with Twins at High Risk of PreTerm Deliveryat High Risk of PreTerm Delivery
What steps could be taken to reduce this patient’s risk of premature delivery
Cervical length measurements (best done serially and plotted)
Vaginal swab for vaginosis screening. GBS too.
Progesterone by injection or pessaries
Close antenatal surveillance and education
Increased rest (?hospital)Cervical suture
At 24 weeks gestation Stephanie comes At 24 weeks gestation Stephanie comes to hospital at 2 am with crampy to hospital at 2 am with crampy abdominal pain and some loss of fluid PVabdominal pain and some loss of fluid PVWhat is the
urgency for assessment
How big are the twins and what chance of survival if born now
What steps would you take to evaluate this pregnancy
Very urgentVery low chance of
survival and high risk of handicap if they do
Assess uterine activityPV speculum and test
fluidFetal Fibronectin testUltrasound for cervical
measurement and look at internal os
Irregular uterine tightenings only, cervix Irregular uterine tightenings only, cervix 2 cm long, closed at both ends but fetal 2 cm long, closed at both ends but fetal Fibronectin positive. Steroids were given Fibronectin positive. Steroids were given and Stephanie was flown to Newcastle for and Stephanie was flown to Newcastle for care.care.
What is the significance of the fetal Fibronectin test
Why steroids?
Why send this patient to Newcastle
50% risk of pre term delivery
Delivery preterm in a hospital with NICU facilities doubles the babies’ chance of survival and reduces the risk of handicap
At the John Hunter a UTI was diagnosed and treated. Stephanie was sent home after 2 weeks
A glucose challenge test was positive A glucose challenge test was positive (AGT) and follow up GTT confirmed (AGT) and follow up GTT confirmed gestational diabetesgestational diabetes
What steps are required in the management of this antenatal problem
Why
Dietary adviceSelf testing for blood
glucose, fasting and postprandial
Keep GLUC inside recommended levels with diet, insulin or Metformin
So as to avoid the complications of Diabetes in Pregnancy
At 29 weeks gestation Stephanie comes At 29 weeks gestation Stephanie comes to hospital with regular abdominal pains to hospital with regular abdominal pains and some loss PV passage of blood and and some loss PV passage of blood and mucous. Evaluation suggested premature mucous. Evaluation suggested premature labourlabour
List available tocolytic drugs and their pros and cons for this patient
IV Betamimetics eg. Salbutamol fast-acting but will complicate her diabetes
Oral Ca-channel blockers are the drug of choice. Watch BP
NSAID – adverse fetal effects
Glyceryl trinitrate patch not much used
Atobisan not available
Stephanie G2P0 at 29 weeks with DC DA Stephanie G2P0 at 29 weeks with DC DA twins in premature labour but twins in premature labour but contractions are suppressed with oral contractions are suppressed with oral NifedipineNifedipine
What other steps are required
Back your recommendations with some facts and figures
IM Betamethasone x2 over 24 hours will double survival and halve all risks of prematurity
IV Mg sulphate reduces risk of cerebral palsy 6-fold
Transfer to a hospital with NICU doubles chance of survival
Penicillin for GBSPsychological care of
the mother is important
Stephanie is transferred to Sydney and Stephanie is transferred to Sydney and delivered by Caesarean 5 days later. delivered by Caesarean 5 days later. Male 1050g and female 960g.Male 1050g and female 960g.
What problems could these babies face now and in the future
Who has the better chance of survival
Hyaline membrane disease
Temperature control and nutrition
JaundiceNecrotising
enterocolitisCerebral palsyOxygen-dependent
lung diseaseBlindnessGirls better than boys
Stephanie delivered of Twins by Stephanie delivered of Twins by Caesarean at 30 weeks. Male 1050g and Caesarean at 30 weeks. Male 1050g and female 960g.female 960g.
What are their chances?
When would the rate of survival be >95% and risk of handicap <2%
Should be 70 – 80% chance of survival and <10% risk of long term handicap
At >34 completed weeks of pregnancy given optimal perinatal care
Any Questions?Any Questions?
For copies of this Powerpoint go to www.brinsmead.net.au and follow the links
to “Postgraduates”. Called “Case of Multiple Pregnancy”