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Part 1 book “Clinics in obstetrics” has contents: Antenatal care, anemia in pregnancy, recurrent pregnancy loss, antepartum hemorrhage in early pregnancy, antepartum hemorrhage in early pregnancy, uterine size more than expected, uterine size less than expected,… and other contents.
Clinics in Obstetrics Clinics in Obstetrics Tania Gurdip Singh MS (Obstetrics and Gynecology) Fellowship in Gynecological Endoscopy Bodyline Trauma and Maternity Center New Delhi, India Foreword Nutan Jain The Health Sciences Publishers New Delhi | London | Philadelphia | Panama Jaypee Brothers Medical Publishers (P) Ltd Headquarters Jaypee Brothers Medical Publishers (P) Ltd 4838/24, Ansari Road, Daryaganj New Delhi 110 002, India Phone: +91-11-43574357 Fax: +91-11-43574314 E-mail: jaypee@jaypeebrothers.com Overseas Offices J.P Medical Ltd 83, Victoria Street, London SW1H 0HW (UK) Phone: +44-20 3170 8910 Fax: +44(0)20 3008 6180 E-mail: info@jpmedpub.com Jaypee-Highlights Medical Publishers Inc City of Knowledge, Bld 237, Clayton Panama City, Panama Phone: +1 507-301-0496 Fax: +1 507-301-0499 E-mail: cservice@jphmedical.com Jaypee Medical Inc The Bourse 111, South Independence Mall East Suite 835, Philadelphia, PA 19106, USA Phone: +1 267-519-9789 E-mail: jpmed.us@gmail.com Jaypee Brothers Medical Publishers (P) Ltd 17/1-B, Babar Road, Block-B, Shaymali Mohammadpur, Dhaka-1207 Bangladesh Mobile: +08801912003485 E-mail: jaypeedhaka@gmail.com Jaypee Brothers Medical Publishers (P) Ltd Bhotahity, Kathmandu, Nepal Phone: +977-9741283608 E-mail: kathmandu@jaypeebrothers.com Website: www.jaypeebrothers.com Website: www.jaypeedigital.com © 2015, Jaypee Brothers Medical Publishers The views and opinions expressed in this book are solely those of the original contributor(s)/author(s) and not necessarily represent those of editor(s) of the book All rights reserved No part of this publication may be reproduced, stored or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission in writing of the publishers All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners The publisher is not associated with any product or vendor mentioned in this book Medical knowledge and practice change constantly This book is designed to provide accurate, authoritative information about the subject matter in question However, readers are advised to check the most current information available on procedures included and check information from the manufacturer of each product to be administered, to verify the recommended dose, formula, method and duration of administration, adverse effects and contraindications It is the responsibility of the practitioner to take all appropriate safety precautions Neither the publisher nor the author(s)/editor(s) assume any liability for any injury and/or damage to persons or property arising from or related to use of material in this book This book is sold on the understanding that the publisher is not engaged in providing professional medical services If such advice or services are required, the services of a competent medical professional should be sought Every effort has been made where necessary to contact holders of copyright to obtain permission to reproduce copyright material If any have been inadvertently overlooked, the publisher will be pleased to make the necessary arrangements at the first opportunity Inquiries for bulk sales may be solicited at: jaypee@jaypeebrothers.com Clinics in Obstetrics First Edition: 2015 ISBN: 978-93-5152-199-0 Printed at Dedicated to My great parents for their immense and constant support, inspiration and faith in me My beloved husband for his extreme patience, who, in his own way, tolerated and encouraged the demands of my career Together they have made this journey worth the effort Foreword Appearing for the examinations and viva voce remains a stressful task for most of the postgraduate students After completing their medical schooling, they are at the doorsteps of venturing into life as independent experts in their respective fields The challenges of clearing the examinations loom large on them Even the finest of students find it difficult to revise the entire syllabus in a short time, close to their practicals Addressing this universal problem, Dr Tania Gurdip Singh has come out with a unique book—Clinics in Obstetrics Obstetrics is ever-evolving Hitech gadgets for monitoring and treating fetus as an individual have all brought about definite changes in the management protocols Keeping the latest trends in view, all the chapters have been formulated The book is basically meant for the preparation of practical and viva voce for both the postgraduate and undergraduate students It covers history, examination and management of all the cases in obstetrics in complete detail Each chapter is discussed with a hypothetical case, followed by stepwise discussion of each differential diagnosis and how to reach the final diagnosis I feel this text will add a lot to the existing literature on obstetrics and will prove indispensable for the postgraduate students It is need-based and well fulfills its purpose Dr Tania is a dedicated and hardworking individual, with a passion for excellence I am sure her book is in accordance with her persona and will be a glittering gem in the array of existing literature in obstetrics A great academic achievement! Nutan Jain MS (Obstetrics and Gynecology) Vardhman Trauma and Laparoscopy Centre (P) Ltd Muzaffarnagar, Uttar Pradesh, India www.vardhmanhospital.com; www.drnutanjain.com Preface Obstetrics is a highly evolving field The teaching and examination in obstetrics has become more practical-oriented There is a tendency of the medical students to study the theory in depth, wherein the clinical aspect gets neglected, due to which there is a big fear when practicals and viva voce approach A very wrong belief among the students is that the questions will only be asked pertaining to the case and its final diagnosis, but, in reality, the case always goes on differential diagnosis because the examiner is aware of the fact that the students know the final diagnosis In order to be confident in clinical cases, a proper approach to practical cases is a must The time duration between the theory and practical examinations is very less and most students are weak in case presentations, which makes them grumble before practicals and fumble in practicals A student does not have time to look into different books in this short period of time What he/she has to is to just pick up this book, revise and go confidently to the examination hall This book provides unique and recent information in the most original form, and that too in a stepwise manner The book is basically meant for the preparation of practical and viva voce for both the postgraduate as well as the undergraduate students For the sake of simplicity, the book is divided into two sections: Section for Long Cases and Section for Short Cases Each chapter contains important points in history, indicating where exactly to lay stress, explaining how history differs in each case (i.e where the examiner can catch the student!) A hypothetical case is discussed, followed by stepwise discussion of each differential diagnosis and how to reach the final diagnosis All the cases have been covered in full detail Tests, which have lost their importance and are not implicated in routine practice, are not mentioned It covers the management of all the cases in complete aspect The students may not know something in recent advances but will not be spared if it comes to basics, which might look very simple but are not recollected during examination So, keeping this in mind, all the basic questions have been covered to refresh a student’s knowledge Not only for the undergraduate and postgraduate students, this book will be highly beneficial for the clinicians also, who practice in the field of obstetrics This book will prove to be useful for the nursing students as well This is a very student-friendly or, rather I would say, an examinationfriendly book, in a very comprehensive manner, with very original and authentic information, covering all the recent guidelines It is a small effort on my part to reeve all the basic information and latest updates in a single thread Tania Gurdip Singh 388 Section 1: Long Cases Cervical Length Measurement in Women at Risk of Preterm Birth Who Can Have a Short Cervix? • • • • • Patients may have a short cervix after: – DES exposure in utero – Cervical conization – LEEP procedure – Intrauterine infection/inflammation – Decline in progesterone action – Idiopathic cervical insufficiency Cervical length remains almost constant until the 3rd trimester Ranges ≈ 34–38 mm between 24–28 weeks Measurement should always exclude funneling and be taken from funnel tip to external os Studies have shown that the range of cervical length declines in those who go on to preterm labor, varies from 0.5 mm/week to mm/week How Frequently should the Cervical Length be Measured? • The greatest velocity of cervical length decline mentioned in various studies is 5–8 mm/week • Interventions should ideally be done when cervical length is15–25 mm • Schedule of the next cervical length measurement is estimated, depending on the following factors: – Previous history of the patient – Initial cervical length – Chosen threshold for intervention: - For example, if the measured cervical length is 36 mm and the threshold for intervention is 20 mm, then it is reasonable to wait for 2–2.5 weeks or even weeks to reassess cervical length - Depending upon the initial cervical length, intervals can be shorter or longer - The shorter the interval of time between cervical measurements, the higher is the observational error Measures to be Taken to Avoid Preterm Labor • Routine measurements in at risk women (Asymptomatic women at low risk should be avoided) Gestational age < 24 weeks and cervical length < 25 mm • Cervical cerclage preferably Gestational age >24 weeks • Progesterone 100–200 mg daily vaginally • Reduction of various day to day activities at work, travel, etc • Administration of corticosteroids • Relocation near tertiary care center • Adequate antenatal visits with ultrasonographic cervical assessments at regular intervals • Watch for signs and symptoms of preterm labor In patients with membrane prolapse at or beyond the external os • Emergency cerclage may be beneficial as compared to conservative management Chapter 11: Pain Abdomen during Pregnancy 389 Recent Terminologies History-indicated Cerclage • Prophylactic cerclage inserted at 12–14 weeks in an asymptomatic woman on the basis of an indication provided in her history • Indicated in women with ≥ previous 2nd trimester losses or ≥3 preterm births Ultrasound-indicated Cerclage • Therapeutic cerclage inserted on the basis of short cervical length obtained in ultrasonography, usually performed between 14–24 weeks • Placed if the diagnosed ultrasound cervical length is ≤ 25 mm and period of gestation is not more than 24 weeks • Funneling alone, is not an indication to apply this cerclage Rescue Cerclage • Salvage cerclage, inserted in cases of premature cervical dilatation (detected either on ultrasound or on per-speculum examination) and/or with fetal membranes extending beyond the external os • Cervical dilatation should not be >4 cm Transvaginal Cerclage (McDonald) • A transvaginal purse-string suture placed at the cervicovaginal junction, without bladder mobilization High Transvaginal Cerclage (Shirodkar) • A transvaginal purse-string suture placed following bladder mobilization, to allow insertion above the level of the cardinal ligaments Transabdominal Cerclage • Cerclage at the cervicoisthmic junction placed via laparotomy • Sole indication – previous failed transvaginal cerclage • Can be inserted preconceptionally or in early pregnancy but there is increased maternal morbidity, so rarely performed Occlusion Cerclage • Occlusion of the external os by placement of continuous non-absorbable suture in order to retain the mucus plug Contraindications to Cervical Cerclage Insertion • • • • Active preterm labor (≥ cm cervical dilatation) Clinical evidence of chorioamnionitis Continuing vaginal bleeding PPROM 390 Section 1: Long Cases • Evidence of fetal compromise • Gross congenital anomalies • IUD Risks • • • • • Bleeding during insertion Rupture of membranes Premature contractions Use of anesthesia during removal of cerclage inserted by Shirodkar’s technique Bucket handle tear if labor sets in, with suture in place Recent Advances/Recommendations • An ultrasound examination for cardiac activity and to rule out gross congenital anomalies, should be performed before placing cerclage • Prophylactic perioperative tocolysis and antibiotics should be offered to women undergoing cervical cerclage, though not recommended in routine practice • Higher (closer to internal os) the cerclage is sutured, the most effective is prevention of preterm birth • Abstinence should not be routinely recommended • Serial ultrasound monitoring of cervical length post-cerclage is useful for administration of steroids • Progesterone is not routinely recommended after cerclage • Usually removed at 36+1 – 37+0 weeks • Removed at the time of operation in cases of elective cesarean section • Removed earlier in cases of established preterm labor Is There a Role of Cervical Length Measurement Post-cerclage? • Various studies have shown that cervical length significantly increases post-cerclage but the overall length does not seem to predict preterm birth • There is some evidence that absent or short cervical length above the cerclage or the appearance of funneling to the level of the cerclage (at 24 to 28 weeks) increases the risk of preterm delivery • Funneling down to the cerclage has a 50% risk of PPROM • Progressive shortening may also indicate an increased risk of preterm birth How Far is Tocolysis Justified in Preterm Labor? • • There is no clear evidence that preterm labor can be stopped by the use of tocolysis therapy They can be considered in those: – Who are yet to complete a course of corticosteroids, OR – Who are in very preterm labor – To transfer the woman to a higher center with neonatal intensive care unit, OR – In women with suspected preterm labor who have had an otherwise uncomplicated pregnancy – Long-term use of tocolysis or use of multiple tocolytic drugs is not recommended, as it may lead to increase in both maternal and fetal adverse effects – There is insufficient data supporting the use of maintenance tocolytic therapy following threatened preterm labor Chapter 11: Pain Abdomen during Pregnancy 391 – Use of a tocolytic drug is not associated with a clear reduction in perinatal or neonatal morbidity or mortality – Tocolysis is mainly helpful in reducing the number of women delivering within 48 hours up to days – Nifedipine and atosiban have comparable effectiveness in delaying birth for up to seven days Compared with ritodrine, nifedipine is associated with improvement in neonatal outcome, although there are no long-term data – Other uses of tocolysis – in management of intrapartum fetal distress, impaired fetal growth and to facilitate external cephalic version at term Drugs for Tocolysis Beta Agonists (Mainly Ritodrine) • Has predominantly β2 receptor effects, relaxing the muscles in uterus, arterioles and bronchi • Dose: Initially 50 mcg/min increased by 50 mcg every 10 minutes until a max of 350 mcg/min for 48 hours • Side effects: Maternal: • Tachycardia • Palpitations • Tremor • Nausea or vomiting • Headache • Chest discomfort/pain • Dyspnea • Hypotension • Hypokalemia • Hyperglycemia • Pulmonary edema though rare but a well-documented complication following aggressive intravenous hydration Fetal: • Tachycardia • Women are far more likely to stop treatment because of adverse effects • Contraindicated in tachycardia sensitive maternal cardiac disease and poorly controlled diabetes mellitus Calcium Channel Blockers • Most studies have compared nifedipine with ritodrine Nifedipine has fewer side effects and there is less need to stop the treatment because of side effects • Has advantages of oral administration and low cost • Maternal side effects: – Flushing – Palpitations – Nausea – Vomiting – Hypotension – Dizziness 392 Section 1: Long Cases • • • • • • • – Suppression of heart rate, contractility, and left ventricular systolic pressure when used with magnesium sulfate; elevation of hepatic transaminases Fetal: – No known adverse effects Contraindicated in hypotension and preload–dependent cardiac lesions like aortic insufficiency To be used with caution in multiple pregnancy and diabetes (because of the risk of pulmonary edema) Suggested dosage: – Initial 20 mg orally followed by 10–20 mg, three to four times/day and adjusted according to uterine activity for up to 48 hours Doses > 60 mg → associated with serious adverse effects (such as headache and hypotension) Are associated with very less neonatal RDS, necrotizing enterocolitis and intraventricular hemorrhage when compared to other tocolytic drugs Though it crosses the placenta, but long-term effects on child are uncertain Isoxsuprine • Mechansm of action: – Peripheral vasodilation by a direct effect on vascular smooth muscle, primarily within skeletal muscle with little effect on cutaneous blood flow – Produces uterine relaxation through a direct effect on smooth muscles • Absorption: from GIT • Half-life: 1.25 hours • Onset of action: – Oral → hour – IV →10 minutes • Side effects to the fetus: – Crosses the placenta – Tachycardia – Hypoglycemia – Hypocalcemia – Ileus – Hypotension in the neonate – Toxicity is related directly to neonatal blood concentrations of isoxsuprine, which are affected by both gestational age and the interval between administration of isoxsuprine and delivery • Contraindications: – Cardiac disorders – Hyperthyroidism – Chorioamnionitis – Antepartum hemorrhage – Intrauterine fetal death – Eclampsia and severe preeclampsia – Pulmonary hypertension • Dosage: – Oral → 10–20 mg bid/tid – IM → 5–10 mg injection 2–3 times/day – IV → - Infusion is prepared by dilution of the injection in an appropriate quantity of 5% dextrose injection - Do not dilute in 0.9% sodium chloride because of the risk of pulmonary edema Chapter 11: Pain Abdomen during Pregnancy 393 Atosiban • Oxytocin receptor agonist • Nausea (main), vomiting, headache, chest pain, dyspnea Injection site reaction is a documented side effect, making women stop treatment with atosiban • Diabetes and cardiac disease are not contraindications • Atosiban when used in women at very early gestations (