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Problems in Prenatal Care

Problems in Prenatal Care. Core Seminar – PGY1 FM rotation Ian Casson, Dept of Family Medicine. CFPC “Key Features”. In pregnant patients: a) Identify those at high risk (e.g., teens, domestic violence victims, single parents, drug abusers, impoverished women).

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Problems in Prenatal Care

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  1. Problems in Prenatal Care Core Seminar – PGY1 FM rotation Ian Casson, Dept of Family Medicine

  2. CFPC “Key Features” • In pregnant patients: • a) Identify those at high risk (e.g., teens, domestic violence victims, single parents, drug abusers, impoverished women). • b) Refer these high-risk patients to appropriate resources throughout the antepartum and postpartum periods. • 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. • In a pregnant patient presenting with features of an antenatal complication (e.g., premature rupture of membranes, hypertension, bleeding): • a) Establish the diagnosis. • b) Manage the complication appropriately.

  3. 1. First trimester bleeding • Main concern (after the ABCs): • Ddx: intrauterine pregnancy vs. ectopic • Incidence:1-2% of pregnancies; 6-16% of first trimest bleeds in ED • History and physical • not reliable predictors of ectopic • TVUS 5w: empty gestational sac 5w 4d: yolk sac in gestational sac 6w: heart beat, small embryo if US non-diagnostic: beta HCG correlation • if BHCG >1000/2000 and no sac: ectopic until proven otherwise

  4. First trimester bleeding: Later considerations • Consider other diagnoses than miscarriage or ectopic • Cervical infection or cancer, molar preg, loss of twin, subchorionic hemorrhage, hemorrhagic corpus luteum cyst • Management: threatened abortion • WinRho 300mcg IM if Rh neg • if FH present: >95% chance of successful pregnancy • Management: miscarriage(incomplete/inevitable/missed) • expectant vs misoprostol vs D&C • expectant: if stable, afebrile, controlled pain and bleeding (e.g., to ER if soaking >2 pads/hr) • Offer info: 80% complete in 3d – 2wks; 10% require 1m • follow-up q1-2 weeks to ensure • Offer analgesics • In one series: complications in 1% (vs 2% for surgery) • misoprostol: 600-800mcg pv; repeat in 24 hrs prn • Management: ectopic • expectant vs methotrexate vs surgical

  5. 2. Gestational Hypertension (GH) • Classification • GH: onset of hypertension > 20 wks (vs “pre-existing hypertension”) • Pre-eclampsia: hypertension with proteinuria or adverse condition • Severe pre-eclampsia: <34 wk or with heavy proteinuria (3-5 gm/d) or with an “adverse condition” • Definitions • Hypertension: serial office/hospital dBP >/= 90 • If severe, >/=160/110: confirm at same visit • Proteinuria: > 300mg/24hr • or ACR >30mg/mmol • suggested by dip >/= 2+ • Management • Severe pre-eclampsia: deliver • without adverse conditions: deliver if at term (>/= 37 wks)

  6. Adverse conditions in GH • Vascular/pulmonary • BP >160 or 110, SOB, chest pain • Renal • elevated creatinine, albumin<20 • Hepatic • elevated AST, ALT, LDH; abd pain, N/V • Hematologic • e.g., platelets < 100,000 • HELLP syndrome • hemolysis, high LFTs, low platelets • CNS • new or unusual headache, visual disturbances, seizure • Fetal • prematurity, IUGR, oligo, abruption, abn UA flow

  7. 3. Post dates management • “Induction should be offered from 41+0 wk” • But it is uncertain whether induction decreases PMR (low statistical power) • Expectant management is OK • Risk of stillbirth in the week after 41w+0 is 1 in a 1000 (compared to 0.8 the week before and 1.8 the week after) • Standard practice is to do at least an NST and amniotic fluid volume twice weekly (evidence from case-control studies; no RCTs available) • Adverse effects of induction? (for an individual) • Failure to achieve labour in a timely way or vaginal delivery • Uterine hyperstimulation, fetal compromise • “Intervention cascade”? (face validity of research conclusions about CS rate) • Resource implications (25% of patients are not delivered at 41+0 w; 5% at 42+0 w)

  8. Reduction of post-dates inductions • “Early US between 11 and 14 wks” (SOGC) • use US EDC if first trimester US EDC is > 5 days different from LMP or if second trimester US EDC >10 days different than LMP • “Sweeping membranes should be offered to women, commencing at 38 to 41 wks, following a discussion of risks and benefits” (SOGC) • Risks • uncomplicated bleeding (NNH: 4) • pain (68%, although 88% would chose sweeping in a subsequent pregnancy) • ? others, e.g., rupture of membranes – for individual counselling • Benefits • reduced need to induce (NNT:8)

  9. Canadian consensus on obstetrics in rural and remote communities (2000) • Deliveries in rural hospital are OK • including induction, augmentation • including epidural anesthesia • even without local CS capability • in the context of organized rural services with local and regionalized risk management systems • and with discussion with patients and families

  10. References: SOGC Guidelines (www.sogc.org) • Guidelines relevant to problems in prenatal care can be found under categories of: • Obstetrics • Maternal Fetal Medicine • Infectious Diseases • Diagnostic Imaging

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