Pregnancy

  1. In a patient who is considering pregnancy:
    1. Identify risk factors for complications.
    2. Recommend appropriate changes (e.g., folic acid intake, smoking cessation, medication changes).
  2. In a female or male patient who is sexually active, who is considering sexual activity, or who has the potential to conceive or engender a pregnancy, use available encounters to educate about fertility.
  3. In a patient with suspected or confirmed pregnancy, establish the desirability of the pregnancy.
  4. In a patient presenting with a confirmed pregnancy for the first encounter:
    1. Assess maternal risk factors (medical and social).
    2. Establish accurate dates.
    3. Advise the patient about ongoing care.
  5. In pregnant patients:
    1. Identify those at high risk (e.g., teens, domestic violence victims, single parents, drug abusers, impoverished women).
    2. Refer these high-risk patients to appropriate resources throughout the antepartum and postpartum periods.
  6. In at-risk pregnant patients (e.g., women with human immunodeficiency virus infection, intravenous drug users, and diabetic or epileptic women), modify antenatal care appropriately.
  7. In a pregnant patient presenting with features of an antenatal complication (e.g., premature rupture of membranes, hypertension, bleeding):
    1. Establish the diagnosis.
    2. Manage the complication appropriately.
  8. In a patient presenting with dystocia (prolonged dilatation, failure of descent):
    1. Diagnose the problem.
    2. Intervene appropriately.
  9. In a patient with clinical evidence of complications in labour (e.g., abruption, uterine rupture, shoulder dystocia, nonreassuring fetal monitoring):
    1. Diagnose the complication.
    2. Manage the complication appropriately.
  10. In the patient presenting with clinical evidence of a postpartum complication (e.g., delayed or immediate bleeding, infection):
    1. Diagnose the problem (e.g., unrecognized retained placenta, endometritis, cervical laceration).
    2. Manage the problem appropriately.
  11. In pregnant or postpartum patients, identify postpartum depression by screening for risk factors, monitoring patients at risk, and distinguishing postpartum depression from the “blues.’’
  12. In a breast-feeding woman, screen for and characterize dysfunctional breast-feeding (e.g., poor latch, poor production, poor letdown).

Preconception Counselling

  • Risk assessment
    • Age
    • Chronic medical problems
    • Medications known to be teratogens
    • Reproductive history
    • Genetic conditions/family history
    • Substance use
    • Infection and vaccinations
    • Environmental hazards/toxins (occupational, heavy metals, pesticides, Zika)
    • Social and mental health concerns
  • Lifestyle
    • Smoking cessation
    • Weight control (under or overweight)
    • Avoid alcohol/drugs
    • Avoid consumption of undercooked meats and unpasteurized foods (risk of toxoplasmosis, CMV, listeria)
    • Avoid mosquito (clothing, repellents)
  • Education
    • Folic acid 0.4-1mg/d (high risk 5mg daily)
    • Optimizing natural fertility
      • Intercourse timing
        • Simple = 3x/week
        • Fertile during 5 days prior to ovulation until ovulation (14 days prior to onset of menses)
          • So take longest and shortest cycles (eg. 28-32 days) so ovulation on D14-18, so intercourse D9-18 q2-3d
      • >10 days of abstinence can decrease sperm quality
      • Avoid lubricants
    • Reasonable time frame to conceive (85% pregnant in one year)
    • Advise that risk of spontaneous pregnancy loss and chromosomal abnormalities increases with age of both of mother and father
    • Disease optimization (eg. glycemic control)
  • Medications
    • Stop retinoids / Vitamin A >10,000 units/day (risk of malformations in T1)
    • Stop ACE-i/ARB (risk of fetal kidney disease in T2/T3)
      • Change to methyldopa, labetalol, calcium channel blocker (Nifedipine XL)
    • Stop oral anti-hyperglycemic
      • Consider metformin or glyburide
    • Stop warfarin (risk of malformations in T1)
      • Consider heparin/LMWH
    • Avoid lithium (very low risk of Ebstein anomaly and malformations in T1)
    • Avoid valproic acid/anticonvulsants (risk of malformations in T1)
    • Avoid Sulpha drugs and Trimethoprim (anti-folate risk in T1, and kernicterus in T3)
    • Avoid tetracycline (bone development, teeth staining)
    • Avoid NSAIDs (cardiac defects, spontaneous abortion)
    • Risks of untreated depression often outweigh risks of antidepressants
      • Low risk of teratogenicity (some data suggests paroxetine may have small increase in congenital heart defects, other studies have not found this association)
      • May be associated with a small reduction in gestational age at birth that is not clinically significant

Investigations

  • STI screen
  • HbA1c
  • Rubella and Varicella
    • If lack of immunity, immunize and wait one month before conception
  • Genetic screening based on family history
    • Thalassemia (AR): CBC, Hb electrophoresis
      • Mediterranean, South East Asian, Western Pacific
    • Sickle Cell (AR) same as Thalassemia
      • African, Caribbean
    • CF (AR): CFTR gene DNA
      • Mediterranean, Finnish, Caucasian, or FHx
    • Tay Sachs (AR): Enzyme HEXA or DNA HEXA gene
      • Ashkenazi Jewish* (Canavan disease, Familial Dysautonomia, ask for Fam Hx of Gaucher, CF, Bloom, Niemann-Pick), French Canadian, Cajun
    • Fragile X (X-linked): FMR 1 gene DNA
      • Fam Hx

Pregnancy

First Visit

  • Confirm pregnancy with urine or serum bhCG
  • Accurate dates by LMP
    • Confirm with T1 dating ultrasound
    • Requisition for 20w morphology ultrasound
  • Establish desirability of pregnancy (pregnancy termination, adoption, other)
  • Maternal risk factors (medical, social, occupational)
    • Relationship, social support
    • Intimate partner violence
    • Teens, single parents, low SES
    • Substance use (IVDU)
    • HIV, diabetes, epilepsy
  • Prenatal Care Flow Sheets
  • Counselling as above (in preconception)
    • Smoking cessation, substance use
    • Lifestyle, nutrition
    • Folic acid as above
    • Diclectin PRN
    • Consider low-dose 80-160mg ASA at bedtime ideally before 16 weeks gestation, if either 1 high risk factor or 2 moderate risk factors:
      • 1 high risk factor: history of preeclampsia, multifetal gestation, chronic hypertension, DM1 or DM2, renal disease, autoimmune disease (SLE, antiphospholipid)
      • 2 moderate risk factors: Nulliparity, Obesity (BMI≥30), family history of preeclampsia, age 35 years and older, sociodemographic risk factors (low socioeconomic status, etc), or personal history factors (fetus is small for gestational age, previous adverse pregnancy outcomes, etc)
  • Routine prenatal bloodwork
    • Blood type and screen (Rh and Ab)
    • CBC
    • HIV
    • Rubella
    • Syphilis
    • HepBsAg
    • HepCAb
    • UA, UCx
    • Gono chlam
    • Consider VZV, TSH (Target <2.5, then <3 for third trimester), ferritin, Hb electrophoresis, random glucose/HbA1c/fasting glucose
  • Discuss trisomy 21 screening
    • Serum Integrated Prenatal Screen (85% detection rate [DR], 4.4% false positive [FP], covered in Quebec)
      • 9-13.6 (best 10-11.6) PAPP-A
      • 15-20.6 (best 15.2-16) AFP, uE3, hCG, inhibin-A
    • Integrated Prenatal Screen (87% DR, 1.9% FP)
      • SIPS + Nuchal Translucency ultrasound (11-13.6w, best at 12-13.3w)
    • Quad screen (77% DR, 5.2% FP)
      • 15-20.6 (best 15.2-16) AFP, uE3, hCG, inhibin-A
    • Cell-free Fetal DNA screen (99.9% DR, however confirm with amniocentesis as 33% FP)
      • After 9w
    • Chorionic villus sampling (amniocentesis to rule out false positive for mosaic karyotype)
      • 10-12w
    • Amniocentesis (if abnormal serum screen, anomalies on U/S or previously affected fetus)
      • After 15w
      • Risk <1/200 for loss of pregnancy
  • Visits monthly

Second Visit

  • Complete physical exam (height, weight, BMI, pelvic)
  • Cervical/vaginal cultures, Pap (as per regular screening)
  • If Rh negative, schedule for Rh Ig (WinRho) 300mcg IM at 28w

Second Trimester (13-28w)

  • Each visit: weight, BP, FHR (by handheld Doppler starting T2)
  • 20w - Routine ultrasound
    • Symphysis Fundal Height
    • Fetal movement should be felt
  • 26-28w - Labs
    • 50g OGT
    • CBC, ferritin
    • Repeat Type and Screen if Rh neg
  • 28w - Rh Ig (WinRho) 300mcg IM
    • Consider repeat HIV, Gono/Chlam, Syphilis if high risk

Third Trimester (29-40w)

    • Visits q2w
    • Fetal movement counts if decreased movements (NST/BPP if <6 distinct movements in 2h)
  • 35-36w - GBS vaginal and rectal swab (results valid for 5w)
    • HSV prophylaxis PRN (eg. Valtrex 500mg PO BID)
    • Give copy of prenatal sheets
    • Visits weekly
  • 38w - Consider cervical examination and membrane stripping
  • 40w - Consider induction of labour for postdates (at 41.1-41.5) vs. expectant management (fetal monitoring with NST/AFI twice weekly)

Prevention of Early-Onset Neonatal GBS

  • Screen all 35-37w (or within 5w) and treat with intrapartum Abx

Antepartum

  • Treat midstream culture positive >10^5 cfu/mL or symptomatic with >10^2cfu/mL to prevent pyelo, chorio, preterm birth
    • Amoxicillin 500mg PO TID x7d
    • Nitrofurantoin 100mg PO BID x 7d (avoid at labour because of hemolytic anemia)
    • TMP-SMX 1 DS tab BID x 3d (avoid in first trimester and near term)
    • Amoxicillin-clavulanate 500mg PO BID x7d
    • Consider repeat culture 1-2w after treatment

Intrapartum

  • Preterm labour with intact membranes - screen immediately on admission
  • IV Pen G 5mill units + 2.5 units q4h (cefazolin if low risk, clinda if high risk and sensitive or vanco if not sensitive)
    • Treat if
      • Previous infant with GBS
      • GBS bacteriuria during current pregnancy
      • Positive screen
      • GBS unknown and one of: Preterm or ROM>18h or T>38C
  • Adequate intrapartum Abx is >4h of IV Abx
    • If infant well, no need for workup (observe 24-48h)
    • If infant well, but inadequate Abx AND
      • Preterm <37w OR ROM>28h → consider Blood culture, CBC
        • If WBC <5, high risk of sepsis and consider Abx
    • If symptomatic (apnea, fever, tachypnea, tachycardia, lethargy, poor feeding) → septic workup (CBC, cultures, CXR, lumbar puncture) and early treatment

Antenatal complication

Vaginal Bleeding

Hypertensive Disorders of Pregnancy

Prelabour Rupture of Membranes (PROM)

  • History of GUSH of clear/yellow fluid from vagina
  • Risk
    • Amniocentesis
    • Cervical insuff/cerclage
    • Prior conization/LEEP
    • PPROM, preterm
    • Vaginal bleed, Placental Abruption
    • Polyhydramnios
    • Multiple pregnancy
    • Smoking
    • STI, BV
    • Low SES
  • Investigations
    • No Digital
    • Sterile speculum
      • Look for fluid from cervix, cord
      • Pooling in posterior fornix of vaginal vault
      • Ferning on microscopic examination
      • Liquid pH (>6) will turn nitrazine test blue (positive)
      • Commericial tests (AmniSure, Actim PROM, ROM Plus)
      • Consider collect fluid for lung maturity (fibronectin)
    • Culture for STI and GBS
    • Ultrasound for low AFI (Max vertical pocket <2cm or AFI ≤5 cm)
  • Complications
    • Infection (fetal/maternal), umbilical cord prolapes/compression
  • Management
    • Admit and regular vitals with daily BPP and WBC
    • Term PROM
      • Avoid Digital until labour/induction
      • Consider antibiotics if indicated (no evidence in term PROM)
      • IV Oxytocin for induction of labour in all term PROM
        • Vaginal Prostaglandin higher chorio rates (but consider in unfavourable cervix)
        • PO Misoprostol easier to administer
        • If patient chooses expectant management >24h, need to evaluate for infection, avoid digital exams
    • Preterm <37w (PPROM)
      • Unclear if expectant vs IOL (preterm vs infectious risks)
      • If <34w generally expectant, prophylaxis with antibiotics (prolongs latency)
        • Glucocorticoids (betamethasone x2) <34w
        • Magnesium sulphate for neuroprotection <32w

Pruritus

  • Look for skin lesion (polymorphic eruption of pregnancy)
  • Rule out Intrahepatic Cholestasis of Pregnancy (ICP)
    • Pruritus (hands/soles, worse at night) associated with elevated bile acids or transaminases in the absence of other causes
    • Treatment
      • Ursodeoxycholic acid 15mg/kg/day
      • Early delivery at 36w
      • Follow LFTs up to 8w post-partum

Gestational Diabetes (GDM)

  • Onset of DM2 during pregnancy
  • Complications
    • Maternal
      • Hypertension
      • Polyhydramnios
      • Retinopathy
      • Hypoglycemia
      • Pyelonephritis/UTI
    • Fetal
      • Macrosomia
      • IUGR
      • Hypoglycemia
      • Polycythemia
      • Fetal lung immaturity
  • Risk Factors
    • Obesity
    • Previous pregnancy with GDM or IGT
    • Family history of DM
  • Diagnosis
    • Screen at 24-28w with 50g OGTT, consider early HbA1c or fasting glucose if higher risk
      • 1h 50g OGTT
        • <7.8 mmol/L = normal
        • 7.8-11.0 -> Indication for 2h 75g OGTT
          • 2h 75g OGTT
            • FPG ≥ 5.3 mmol/L
            • 1h ≥ 10.6 mmol/L
            • 2h ≥ 9.0 mmol/L
        • ≥ 11.1 GDM
  • Management
    • Dietary advice
    • Pharmacotherapy (insulin, metformin, glyburide)
    • Target A1C ≤6.5 (ideally ≤6.1)
      • Blood glucose targets: Prepandial <5.3, 1h Postprandial <7.5 (or <7.8), 2h Postprandial <6.7mmol/L
    • Serial ultrasound to monitor growth
    • Induce by 40w gestation
      • Blood sugars hourly during labour
    • Follow-up with repeat 75g OGTT between 6 weeks and 6 months postpartum (risk of DM2)

Intrapartum

Labour

  • First stage - regular contractions + cervical change (dilation/effacement)
    • Latent (days):
      • Nulliparous up to 3-4cm dilation
      • Parous up to 4-5cm
    • Active
      • Contractions leading to cervical change after above cervical change
  • Second stage - Full dilation to delivery (active = pushing)
  • Third stage - Delivery of baby to placenta
  • Fourth stage - Placenta to one hour postpartum

Dystocia

  • First stage (active) 4h of <0.5cm/hr dilation or no cervical dilation>2h
    • Obstructed (lack of dilation/descent) if evidence of strong contractions
  • Second stage (active) >1h active pushing without descent
  • Search for cause
    • Power (50-60mm Hg above baseline by IUPC, >60 seconds) -oxytocin
    • Passenger (fetal position, attitude, size, abnormalities) - reposition
    • Passage (pelvic/soft tissue factors) - ensure bladder empty
    • Psyche (pain/anxiety)
  • Management:
    • Prevent
      • If epidural analgesia, augment ARM/oxytocin early
    • Analgesia, hydration, rest
    • Amniotomy
    • Oxytocin augmentation, IUPC to assess contractions,
      • Start at 1-2 mU/min increase q30mins to reach target 8-12mU/min (max at 20-30), or high-dose protocol start at 2-4mU/min
    • Assisted vaginal Birth
    • C-section

Shoulder Dystocia

  • Impaction of anterior shoulder on symphysis pubis (AP diameter)
    • See turtle sign (head delivered but retracts)
  • Risk
    • Antepartum: Suspected macrosomia (induction does not prevent risk), diabetes, GA>42w, multiparity, previous hx dystocia, previous macrosomia, weight gain, obesity
    • Intrapartum: Prolonged labour, operative vaginal delivery, labour induction, epidural anesthesia
  • Complications
    • Fetal: Hypoxia/asphyxia, fractures, brachial plexus palsy, death
      • Brachial plexus injury most common at C5-6 (forearm flexor/supinator) → waiter’s tip = Erb-Duchenne, most recover
        • C8-T1 = Klumpke (claw-hand) is rare
    • Maternal: PPH, uterine rupture, 4th degree tears
  • Avoid the 4 P’s (Pull, push, panic, pivot head)
  • Do ALARMER:
    • Ask for help, Tell patient to STOP pushing until manoeuvre completed
    • Lift legs in McRoberts
      • Flatten head of bead and hyperflex legs
    • Anterior Shoulder disimpaction (apply suprapubic pressure to the posterior anterior shoulder)
      • If steady pressure not working, try rocking pressure
      • Adduct anterior shoulder by applying pressure to posterior shoulder (Rubin) to push towards chest of baby
    • Rotate posterior shoulder like screw (Wood’s)
    • Manual removal posterior arm - Grab posterior hand and sweep across chest and deliver (can lead to fracture)
    • Roll onto all fours - allows easier access for rotation and removal of posterior arm
    • Episiotomy can facilitate above maneuvers but does not relieve dystocia

Chorioamnionitis (Intra-amniotic infection, IAI)

  • Presumptive diagnosis
    • Fever (T (≥39°C or ≥38°C on two occasions 30mins apart)
    • One of
      • Baseline FHR >160/min for ≥10 mins (excluding periods of variability)
      • Maternal WBC >15 in absence of corticosteroids (ideally showing left shift)
      • Purulent fluid from cervical os visualized by speculum
  • Treatment
    • Broad-spectrum antibiotics, eg. Ampicillin 2g IV 6h and Gentamicin 5mg/kg once daily
      • Consider Clindamycin or Metronidazole to cover aneaerobes if undergoing surgery
    • Prompt induction or augmentation of labor (cesarean only for standard obstetrical indications)

Fetal Heart Rate Monitoring

  • Normal FHR baseline 110-160, at least 2 accelerations (≥15bpm lasting ≥15s) in 40mins strip
  • Abnormal >160 for 10 mins or <110 for 10 mins, changing FHR baseline, decelerations
    • Tachy: Reposition (alleviate cord compression), rule out fever/dehydration/drug/prematurity, IV fluids, maternal pulse/BP
    • Brady: As above, check for cord prolapse
    • Decelerations: As above, check amniotic fluid for meconium, oxygen if mother hypoxic or hypovolemic
      • Early: gradual decrease, usually same time beginning, peak and ending
          • Due to fetal head compression
      • Late: gradual decrease, peak after contraction peak
          • Uteroplacental insufficiency
      • Variable: abrupt decrease (onset to nadir <30 seconds)
          • Complicated : <70bpm for >60 seconds, loss of variability, biphasic, prolonged secondary acceleration, fetal tachy/brady
          • Cord compression
    • If unresponsive to resuscitation → consider continuous EFM, fetal scalp sampling, delivery
  • Moderate variability (5-25bpm)
  • Decreased variability
    • Sleep <40 mins
    • Meds (sedative, BB, MgSO4, steroids)
    • Preterm <32w
    • Fetal tachycardia
    • Congenital Anomalies
  • Uterine activity (frequency averaged over 30 mins, duration, intensity, resting tone)
    • Normal uterine contractions = <5 in 10 minutes, lasting <90 seconds between 25-75 mmHg, resting tone <7-25mmHg
  • Assessment
    • Normal vs. Atypical (further assessment) vs. Abnormal (action required)
      • Consider fetal scalp stimulation or sampling to clarify abnormal tracing
  • Fetal resuscitation
    • Stop/decrease oxytocin
    • Change position (left/right lateral)
    • Improve hydration with IV fluids
    • Vaginal exam r/o cord
    • Amnioinfusion if variable decelerations
    • Reduce maternal anxiety
    • Consider oxygen if needed

Postpartum complications