Pregnancy and Birth

WHO Partograph For Beginner • Dr Muhammad El Hennawy • Ob/gyn specialist • Rass el barr central hospital anddumya specialised hospital • Dumyatt - EGYPT • www.mmhennawy.8k.com

Disseminated Intravascular Coagulation (DIC) By Prof. Rifaat Al-Shimmy, Al-azhar U.Definition of DIC A pathological condition associated with activation of both: • Coagulation system and • Fibrinolytic one It should be considered as a secondary phenomena of an underlying disease as...Common Obstetric ConditionsAssociated with: • Inadequate replacement of blood loss • Pre-eclampsia-Eclampsia…HELP syndrome • Ante partum hge (abruption placenta and P.P.) • I U F D when prolonged more than 4 weeks • Blood transfusion when massive or incompatible • Septic abortion or massive tissue injury • Amniotic fluid embolism • Saline I U infusionMassive Transfusion Is defined as the replacement of a patient's total blood volume in less than 24 hours,or as the acute administration of more than half the patient's estimated blood volume per hour. DIC is commonly a consequence of delayed or inadequate resuscitation page_break@DIC: Is it Predictable? • It can probably be predicted in all the previously mentioned high risk groups, except amniotic fluid embolism, as it is an unpredictable condition. • However, in AFE, DIC it always occurs only after resuscitation from the primary shocked state. page_break@Is it Preventable? • It can be avoided in most cases by proper ‘in time’ resuscitation and management of the underlying disease in proper time, e.g. Pre-eclampsiaPathogenesis • The most accepted theory is the Cascade theory in which there is activation of both Extrinsic and Intrinsic pathways leading to activation of factor xa leading to formation of thrombin from prothrombin to form fibrin from fibrinogen • With associated activation of fibrinolytic system as a protective mechanism.Pathophysiology, continued Pregnancy is considered as a hypercoagulable state by: • An increase in all coagulation factors except FXI/FXIII. Fibrinogen which increases to 400-650mg/dl in late pregnancy. • The fibrinolytic system is depressed during normal pregnancy and labor but returns to normal one hour after delivery of the placenta.Pathophysiology, continued Decrease in platelets count is a result of: 1. Consumption 2. Aggregation of plateletsPathophysiology, continued • So DIC is a state of increase thrombin activity at first, followed by increased fibrinolytic activity, leading to… • consumption of coagulation factor (source of old name consumptive coagulopathy) and the formation of FDP impairing homeostasis.Pathophysiology, continued • Deposition of fibrin in organs and tissues may lead to ischemic tissue damage. • The decreased number of platelets and elevated FDP increase the problem of homeostasis.Symptoms of DIC It is variable according to the cause, the presentation of the primary cause with: • Generalized or localized hemorrhage • Peticheae • Thromboembolc manifestation, organ failure as: liver, lung, kidneys, brain and frank gangrene have been described. • Chronic DIC, (that occurs with IUFD) may be asymptomatic.Diagnosis Although the definite diagnosis is only by histological finding of fibrin deposits, there are many indirect tests as: • Bedside clot retraction test • Skin puncture test, measure clotting time (fibrinogen) • D. Diamer           (90%) • Platelets count   (90%) • FDP                      (90%) • Thrombin time   (80%) • PTT and PT        (60%)Bedside Clot Retraction Tes(CT) • It simply tests the clotting time - a test of decreased fibrinogen • 2 ml blood in test tube - no clot formed but if occurs it is prolonged, soft and not retracted after half an hour, leaving a clot volume more than serum volume. (the clot doesn't retract)Skin Puncture Test (bleeding time) • Prolonged skin puncture ooze is observed when the platelets count is less than 100,000/ul • Continuous bleeding at puncture site occurs when pl count is less than 30,000 /ulOther laboratory tests • Platelets count decreases in 90% of cases (count less than 100,000/dl) • PT, which measures the time required by extrinsic pathway, elevated in 80% of DIC • PPT which measure the time required by intrinsic pathway - not helpful. • Thrombin time elevated in 80% of casesOther laboratory tests • Fibrinogen level/ less than150mg. This is present in 70% of cases. • Fibrin split product >40ug/dl, 90% of cases • D-Diamer - an antigen formed as a result of plasmin digestion, elevated in 90%of cases.Treatment of DIC • Essentially treat the underlying cause. In most cases prompt termination of pregnancy is required. • Supportive therapy should be directed to the correction of shock, acidosis and tissue ischemia. • Cardiopulmonary support including inotropic therapy, blood transfusion and assisted ventilationGuidelines by the Scottish Executive Committee of the RCOG

• Medline and NHS databases • Women’s Hospitals Australasia – Clinical Practice Guidelines - Cord Prolapse – Last Reviewed June 2005 • RCOG - Green-top Guideline - No. 50 - April 2008   Levels of Evidence   Evidence Category and Source   Grading of Recommendations   Recommendation Grade  Definition Cord prolapse has been defined as descent of the umbilical cord through the cervix alongside (occult) or past the presenting part (overt) in the presence of ruptured membranes.   Definition Cord presentation is the presence of one or more loops of umbilical cord between the fetal presenting part and the cervix, without membrane rupture.   Background • The overall incidence of cord prolapse ranges from 0.1% 0.6% • With breech presentation, the incidence is just above 1% • Male fetuses seem to be predisposed. • The incidence is higher in multiple gestations.  Background Cases of cord prolapse appear consistently in perinatal mortality enquiries, and one large study found a perinatal mortality rate of 91 per 1000.  Background • Prematurity and congenital malformation account for the majority of adverse outcomes associated with cord prolapse in hospital settings, but cord prolapse is also associated with birth asphyxia and perinatal death with normally-formed term babies, particularly with home birth. • Delay in transfer to hospital appears to be an important factor with home birth.  Background • Asphyxia may also result in hypoxic-ischaemic encephalopathy and cerebral palsy. • The principal causes of asphyxia in this context are thought to be:

The catgut is fed through posteriorly and vertically over the fundus to lie anteriorly and vertically compressing the fundus on the left side as occured on the right.

Presented by Dr. Narayan M. Patel Prof. Emeritus, ob/gyn.muni.medical collage, Postal address: - Mahalaxmi institute of medical teaching3, shantiniketan park, Nr. S. P. Colony Ahmedabad-380014 Gujarat state (INDIA) Phone: - (079) 27682572 Email: narayanpatel1932@yahoo.com

TORCH INFECTIONS AND PRENATAL ULTRASOUND FINDINGS Eran Casiff M.D. Department of Obstetrics and Gynecology Kaplan Medical Center Rehovot 76100, Israel Limitations • Most infected fetuses are sonographically normal • Ultrasound findings may change with time • no correlation with infant outcome Cerebral Ventriculomegaly • Measured at the posterior aspect of the choroid plexus • Almost always symmetric • 5% of cases can be attributed to fetal infection Intracranial Calcifications • Intrauterine infection • Periventricular hyperechoic foci - the hallmark • May be located in the thalami and basal ganglia • Small with no acoustic shadowing • Most frequently seen with CMV and Toxoplasmosis Hydranencephaly • Most severe manifestation of the destructive process • Cerebral hemispheres replaced by fluid, brain stem preserved, falx present, absent or deviated, posterior fossa structures can be identified • Reported in Herpes simplex, Toxoplasmosis and CMV Microcephaly • Often associated with other CNS anomalies • Diagnosed as three SD below the mean for gestational age • Abnormal HC/AC and HC/FL ratios • Isolated microcephaly documented in CMV, Rubella and Herpes simplex Cardiac Abnormalities • Cardiomegaly, mostly in CMV • Cardiothoracic ratio • VSD, ASD, Pulmonic stenosis and coarctation of the aorta in Rubella Hepatosplenomegaly • Documented in all TORCH infection • Often a transient finding • Normograms are available   Intra-abdominal Calcifications • Typical appearance: echogenic foci with acoustic shadowing • Peritoneum, intestinal lumen, organ parenchyma, biliary tree and vascular structures • Echogenic bowel in CMV and Toxoplasmosis Hydrops, Placenta and Amniotic Fluid • Hydrops reported in most TORCH but may be transient • Placentomegaly is usually associated with intrauterine infection, but small placentae have also been reported • Hydramnios and oligohydramnios have been reported with similar frequency Fetal Growth Restriction • Estimated weight below the 10th percentile • Common feature with CMV, Rubella, Herpes simplex and Varicella • Usually not seen with Toxoplasmosis and Syphilis TOXOPLASMOSIS • Ventriculomegaly is the most frequently documented finding Intracranial calcifications, placentomegaly, liver calcifications and ascites Hyperechoic bowel have been reported Microcephaly never been reported in utero SYPHILIS • Hepatomegaly and Placentomegaly are the most frequent sonographic manifestations • Ascites, Hydrops and Hydramnios are less commonly reported • Resolution of sonographic signs have been reported with maternal antibiotic therapy RUBELLA • Incidence less than 1:100,000 live birth • Prenatal diagnosis by sonographic findings have never been reported • Potential detected abnormalities include: cardiac anomalies, microcephaly, hepatosplenomegaly, FGR, microphtalmia and cataract CMV • The most common congenital infection affecting 1% of all live births • 10% of infected neonates demonstrate clinical manifestations that potentially could be identified by prenatal sonography • Ventriculomegaly, FGR, Intracranial calcifications and oligohydramnios are the most frequently reported findings HERPES SIMPLEX • HSV are usually acquired at birth Intrauterine infections resulting in clinical signs has been reported in 100 cases worldwide • Hydranencephaly is the only sonographic sign reported antenatally • Microcephaly, interracial calcifications and FGR are potentially detectable VARICELLA ZOSTER • The most common finding is Hydramnios • Also reported: liver calcifications, hepatomegaly, hydrops, limb deformities, ventriculomegaly and FGR SUMMARY • Sonography is not a sensitive test for fetal infection • Normal fetal anatomy survey cannot predict a favorable outcome • Multiple organ systems are affected in 50% of cases THANK YOU