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CS-GYN

Oct 02, 202531 min read

اللهم يا معلّم موسى علّمني، ويا مفهم سليمان فهّمني، ويا مؤتي لقمان الحكمة وفصل الخطاب آتني الحكمة وفصل الخطاب اللهم اجعل ألستنا عامرة بذكرك، وقلوبنا بخشيتك، وأسرارنا بطاعتك، إنك على كل شيء قدير، حسبنا الله ونعم الوكيل

Updates through https://medatlax.com/Clinical/Level-11/GYN/Topics/CS-GYN/CS-GYN - will be highlighted yellow

Case scenario cases

  • Bleeding
  • Ectopic pregnancy
  • Molar Pregnancy
  • Miscarriage
  • APH
  • PPH

Emergency

  • Preeclampsia
  • Preterm LAbor

Medical

  • Medical condition chapter
    • sickle cell anemia, DM, thyroid, asthma, iron deficiency, heart disease

Ectopic Pregnancy Case Scenarios

Case 1: Intact Ectopic Pregnancy

Patient Presentation

A 25-year-old primigravida was brought to the ER with vaginal bleeding and right iliac fossa pain. She has been married for two years and has a history of amenorrhoea for 6 weeks. Her pregnancy test was positive 2 days ago.

Examination & Findings

  • On Examination (O/E): The patient is well, not pale, and hemodynamically stable, suggesting the ectopic pregnancy is not ruptured.
  • Abdomen: Localized tenderness in the right iliac fossa. Rebound tenderness may suggest peritoneal irritation or early rupture.
  • Vitals:
    • Pulse: 100 bpm
    • Blood Pressure: 110/70 mmHg
  • Ultrasound (US): Revealed an empty uterus and a complex small mass in the right fallopian tube.

Diagnosis

Intact Ectopic Pregnancy.

Differential Diagnosis

  • Early Pregnancy Bleeding:
    • Molar Pregnancy
    • Abortion
  • Acute Abdomen:
    • Cholecystitis
    • Appendicitis
    • Ovarian Torsion
    • Ruptured Ovarian Cyst
    • Ovarian Torsion
    • Other surgical and medical causes of acute abdomen.

Management Plan

  • For hemodynamically stable patients with a small mass (as in this case):
    • Medical (Methotrexate IM): Indicated if hemodynamically stable, unruptured, no fetal cardiac activity, β-hCG <5,000 IU/L, and mass size <3.5 cm. Requires serial β-hCG monitoring on days 4 and 7 post-dose.
    • Surgical: Laparoscopic Salpingostomy (if the contralateral tube is intact).
  • For hemodynamically unstable patients:
    • Surgical: Laparotomy followed by Salpingectomy. Salpingostomy may be considered if the contralateral tube is diseased.

Possible Complications

  • Immediate: Ruptured ectopic pregnancy, leading to hypovolemic shock.
  • Later: Recurrence of ectopic pregnancy, adhesions, and infertility.
  • Need for blood transfusion.

Case 2: Ruptured Ectopic Pregnancy

Patient Presentation

Shaimaa Yosef, a 25-year-old primigravida married for two years, presented to the ER with a 7-week history of amenorrhea. Her pregnancy test was positive a week ago, but no ultrasound had been performed. She presented with vaginal bleeding and lower abdominal pain.

Examination & Findings

  • On Examination (O/E): The patient appeared ill, pale, and in pain.
  • Vitals:
    • Pulse: 100 bpm
    • Blood Pressure: 90/50 mmHg
  • Abdomen: Tenderness in the left iliac fossa.
  • Ultrasound (US): Revealed an empty uterus with a fluid collection in the pouch of Douglas.
  • Pelvic Exam (PV): The cervical os was closed, with marked cervical motion tenderness (positive cervical excitation).

Diagnosis

Ruptured Ectopic Pregnancy.

Management Plan

  1. Call for help.
  2. ABC (Airway, Breathing, Circulation): Stabilize the patient.
  3. Fluid Resuscitation: Insert two wide-bore cannulas and start fluid replacement.
  4. Prepare for Transfusion: Perform blood grouping and saving.
  5. Surgical Intervention: Perform an urgent Laparotomy.
    • If the contralateral tube is intact, perform Salpingectomy.
    • If the contralateral tube is diseased, perform Salpingostomy.

Guiding Questions & Answers

Q1. Diagnosis? Ruptured Ectopic Pregnancy.

Q2. How to manage?

  1. Call for help.
  2. ABC (Airway, Breathing, Circulation).
  3. Insert 2 wide-bore cannulas and start fluid replacement.
  4. Perform blood grouping and saving.
  5. Perform an urgent Laparotomy.
    • If the contralateral tube is intact, perform Salpingectomy.
    • If the contralateral tube is diseased, perform Salpingostomy.

Q3. Risk factors for such a case?

  • Subfertility and Assisted Reproductive Technology (e.g., IVF).
  • Endometriosis.
  • History of Pelvic Inflammatory Disease (PID) or tubal surgery.
  • Previous abdominal surgery.
  • Previous ectopic pregnancy.
  • Smoking.
  • Increased maternal age.
  • Use of Progesterone-only pills or an Intrauterine contraceptive device (IUCD).

Q4. On a case of a stable patient and small Ectopic Pregnancy in general, what’s the management? Medical Treatment: Methotrexate IM injection.

Case 3: Problem-Based Questions

Problem

A 27-year-old woman, 6 weeks post-LMP, presents with abdominal pain, vaginal bleeding, and an adnexal mass on ultrasound.

1. Definition of Ectopic Pregnancy Implantation of a fertilized ovum outside the uterine cavity, most commonly (95%) in the fallopian tube.

2. Risk Factors

  • Previous ectopic pregnancy (strongest risk factor)
  • History of Pelvic Inflammatory Disease (PID) or tubal surgery
  • Pregnancy with an IUD in situ
  • Assisted Reproductive Technology (ART), e.g., IVF
  • Smoking

3. Differential Diagnosis

  • Threatened or incomplete miscarriage
  • Normal intrauterine pregnancy (IUP) with complications (e.g., corpus luteum cyst rupture)
  • Molar pregnancy
  • Non-gynecological causes (e.g., appendicitis, UTI)

4. Diagnostic Investigations

  • Serial quantitative serum β-hCG: Shows a suboptimal rise (fails to double in 48-72 hours).
  • Transvaginal Ultrasound (TVUS): Shows an empty uterus with β-hCG above the discriminatory zone (>1500-2000 mIU/mL) and/or visualizes an adnexal mass or extrauterine gestational sac.

5. Management Options

  • Medical: Methotrexate for hemodynamically stable, compliant patients with an unruptured ectopic, no fetal cardiac activity, and β-hCG < 5,000 mIU/mL.
  • Surgical: Laparoscopy is the standard.
    • Salpingostomy (tube-sparing): For unruptured ectopics in patients desiring fertility.
    • Salpingectomy (tube removal): For ruptured ectopics, severe tubal damage, or completed childbearing. Indicated for hemodynamically unstable patients.

Molar Pregnancy Case Scenarios

Case 1: Complete Molar Pregnancy

Patient Presentation

  • Patient 1: Waffa is an 18-year-old lady, married for 6 months, presenting to the ER for her first pregnancy. She has a 6-week history of amenorrhoea and recurrent vaginal bleeding of a small amount. Her pregnancy test was positive last week.
  • Patient 2: Mrs. Suzan Mohammed is 31 years old (G3 P1+1), who came to the ER with recurrent, painless, bright red vaginal bleeding. She has a two-month history of amenorrhoea, and her pregnancy test was positive one month ago. Her examination was unremarkable, the cervical os was closed, and an ultrasound showed a uterus filled with grape-like vesicles.

Examination & Findings

  • On Examination (O/E): Patient looks well, not pale.
  • Vitals:
    • Blood Pressure: 100/70 mmHg
    • Pulse: 90 bpm
  • Abdomen: Soft.
  • Ultrasound (US): Uterus shows a characteristic “snow storm” or “grape-like vesicles” appearance.

Diagnosis

Complete Molar Pregnancy.

Risk Factors

  • In this case: Young age.
  • General: Extremes of age (>40, <15), previous molar pregnancy, blood group A or O, smoking, high parity, increased paternal age.

Symptoms & Signs

  • Hyperemesis Gravidarum
  • Breathlessness
  • Embolism
  • Uterus large for date
  • Hyperthyroidism features
  • Early pre-eclampsia (1st or early 2nd trimester)

Investigations

  • Give two possible investigations for molar pregnancy in general.
    • Ultrasound (TVUS mainly).
    • Blood tests:
      • Serum bHCG.
      • FBC.
      • RFT & electrolytes.
      • LFT.
      • TFT.
    • CXRAY.
    • Group & Saving.

Management

  • Primary: Suction evacuation by expert hands.
  • Follow-up:
    • Send products to histopathology.
    • Follow-up: Monitor quantitative ß-hCG weekly until undetectable, then monthly for 6 months.
    • Advise avoiding pregnancy until follow-up is complete.
    • Contraception: Combined oral contraceptives (COCPs) are acceptable once ß-hCG levels are normalizing. An Intrauterine Device (IUD) should only be inserted after the uterus has involuted and ß-hCG has normalized. Condoms are a suitable immediate option.
    • Perform quantitative ß-hCG after any future pregnancy.

Possible Complications

  • Give two possible complications
    • Excessive intraoperative bleeding.
    • Perforation or atony (possible hysterectomy).
    • Persistent trophoblastic disease.
    • Pulmonary oedema 2ry to heart failure due to: preeclampsia, Hyperthyroidism, Anaemia, Excessive fluid overload.
    • Trophoblastic embolus, DIC, ARDS.

Case 2: Molar Pregnancy Differential Diagnosis

Patient Presentation

Soha Abass is 17 years old, married for 6 months, and came with Amenorrhoea for 7 weeks. Today she developed bright, painless vaginal bleeding. PV done, os is closed.

Differential Diagnosis

  • Threatened miscarriage.
  • Molar pregnancy.

Confirmation

How could you confirm the diagnosis?

  • By quantitative bHCG & ultrasound.

Management (if Molar Pregnancy is confirmed)

  • Group & saving.
  • Suction evacuation by the most senior one.
  • Send product to histopathology.
  • Advise contraception. Combined oral contraceptives (COCPs) are safe once ß-hCG normalizes. An IUCD should be avoided until uterine involution is complete and ß-hCG is negative.
  • Monitor serial ß-hCG weekly until negative, then monthly for 6 months. Advise avoiding pregnancy during this period.
  • Do quantitative ß-hCG after any future pregnancy.

Miscarriage Case Scenarios

Case 1: Missed Miscarriage

Patient Presentation

Mrs. Sara Ali is 32 years old (G5 P2+2), with a two-month history of amenorrhoea, who came to the ER with vaginal bleeding & minimal abdominal pain. An ultrasound was done and revealed a 6-week pregnancy with a negative fetal heart (-ve FH). A pelvic exam revealed the cervical os is closed.

Diagnosis

What is your diagnosis? Missed miscarriage (Gestational age is less than expected for dates, Fetal Heart (FH) is negative, and the cervical os is closed).

Investigations

Mention two investigations

  • CBC
  • Clotting factors.
  • Blood grouping & Rhs.

Management

How to manage?

  • Expectant or medical or surgical.
    • Expectant: Wait & see for spontaneous expulsion within 4 weeks.
    • Medical: With misoprostol.
    • Surgical: With D&C.
  • In all cases, monitor the clotting factors & send product to histopathology.

Complications

Give two possible complications of missed miscarriage (same in all types)

  • DIC
  • Infection.
  • Excessive bleeding.
  • Rh incompatibility (if –ve mother & +ve baby).
  • Psychological trauma.

Case 2: Recurrent Miscarriage

Patient Presentation

Nadia Hassan came to gynae clinic as she had miscarriage three months ago. It was her 4th miscarriage she has just one living baby.

Diagnosis

What is your diagnosis? Recurrent miscarriage.

Possible Causes

What are the possible cause (mention two)

  • APL syndrome (Antiphospholipid) syndrome.
  • Rhesus incompatibility.
  • Thyroid disease.
  • Diabetes mellitus.
  • Uterine abnormalities.
  • Advancing maternal and paternal age.
  • Obesity.
  • Balanced chromosomal translocations.
  • Infections.
  • Drugs.
  • Chemicals.

Investigations

Mention two investigations

  • According to cause (TVUS, TFT, HBA1C, APL screening).
  • Blood grouping & Rhesus.
  • Send products to histopathology.
  • Karyotyping.

Case 3: Abortion (General)

Problem

A 9-week pregnant woman presents with vaginal bleeding, clots, and cervical dilatation with tissue passage.

Differential Diagnosis for First-Trimester Bleeding

  • Threatened abortion (viable fetus)
  • Inevitable abortion (bleeding + dilated cervix)
  • Incomplete abortion (tissue passage + residual material)
  • Complete abortion (all tissue passed)
  • Missed abortion (retained non-viable fetus)
  • Septic abortion (infection superimposed)
  • Ectopic pregnancy
  • Molar pregnancy
  • Cervical/vaginal pathology (e.g., polyps, trauma)

Differentiating Types of Abortion Clinically

TypeBleedingCervical OSPainUltrasound Findings
ThreatenedMild-modClosedMildViable IUP
InevitableMod-sevOpenMod-severeViable or non-viable IUP with open cervix
IncompleteMod-sevOpenSevereRetained products
MissedScantClosedAbsent/mildNon-viable fetus (>7 weeks)
CompleteScantClosedResolvedEmpty uterus

Etiologies of Spontaneous Abortion

  • Chromosomal (50%, e.g., trisomies)
  • Maternal factors: Endocrinopathies (DM, thyroid), infections (listeria, toxoplasma), structural (uterine anomalies, fibroids)
  • Immunological: Antiphospholipid syndrome
  • Environmental: Teratogens (alcohol, radiation)
  • Luteal phase defect (low progesterone)

Complications of Spontaneous Abortion

  1. Hemorrhagic shock
  2. Infection → endometritis, sepsis. Septic abortion requires urgent management with broad-spectrum intravenous antibiotics and prompt evacuation of retained products.
  3. Disseminated intravascular coagulation (DIC)
  4. Asherman’s syndrome (uterine synechiae)
  5. Psychological trauma

Methods of Termination (Surgical and Non-Surgical)

  • Non-Surgical
    • Medical: Mifepristone (anti-progesterone) + misoprostol (PGE1) ≤10 weeks
  • Surgical
    • Vacuum aspiration (≤12-14 weeks)
    • D&C (≤12 weeks)
    • D&E (2nd trimester)

Complications of Induced Abortion

  • Immediate: Hemorrhage, uterine perforation, cervical injury, anesthetic complications, septic miscarriage, PE.
  • Early (<48h): Perforation/hemorrhage, Cervical laceration, Anesthetic complications, Uterine atony, Incomplete abortion (~2%).
  • Late (>48h): Infection, Retained POC, Asherman’s syndrome (uterine adhesions), Rhesus sensitization, Future preterm birth/subfertility.

Antepartum Hemorrhage Cases

Case 1: Hypertension in Pregnancy & Abruptio Placentae

Patient Presentation

Rana Mahmoud, a 35-year-old female (P2+0), attended the pre-pregnancy clinic. She has been hypertensive for one year.

Obstetric History:

  • 1st delivery: Term vaginal delivery.
  • 2nd delivery: Term breech, delivered by C-Section.
  • Both children are alive and well (male, 6 years; female, 3 years).

Acute Presentation

The following week, she presented with:

  • Vaginal bleeding
  • Abdominal pain
  • Vitals: BP 130/95 mmHg, Pulse 100 bpm.
  • CTG: FHR 170 bpm.

Diagnosis & Complications

  • Diagnosis: Abruptio Placentae.
  • Possible Complications:
    • Post-Partum Hemorrhage (PPH)
    • Fetal Death
    • Disseminated Intravascular Coagulation (DIC)
    • Couvelaire uterus
    • Hysterectomy

Case 2: Third Trimester Bleeding (Placenta Previa)

Problem

A 31-week pregnant woman, P3+0, with a history of 3 previous C/S, presents with painless vaginal bleeding. Her vitals are stable, there’s no ongoing bleeding, and ultrasound confirms placenta previa.

Guiding Questions & Answers

1. What is your initial approach to a patient with third-trimester bleeding?

  • ABCs stabilization: Assess airway, breathing, circulation; establish IV access (two large-bore cannulas).
  • Vital signs & resuscitation: Monitor BP, HR, O₂ saturation; administer O₂ if hypoxic; fluid resuscitation if unstable.
  • Fetal assessment: Immediate continuous CTG to evaluate fetal well-being and uterine activity.
  • History & exam: Detailed history (onset, volume, pain, trauma); avoid digital vaginal exam until placenta previa is ruled out.
  • Investigations: Complete blood count, coagulation profile, blood group/crossmatch (4 units); urgent ultrasound to identify placental location.
  • Admission: Hospitalize for monitoring even if bleeding stops, due to risk of recurrence.

2. Based on the history and examination, what are the likely causes of her bleeding?

  • Placenta previa (most likely): Confirmed by ultrasound; painless bleeding in a patient with prior uterine scars (3 C/S → high risk for previa).
  • Vasa previa: Possible given prior C/S (abnormal placental cord insertion), but less common. Screen with transvaginal color Doppler if suspected.
  • Unlikely causes:
    • Abruptio placentae (typically painful bleeding, uterine tenderness).
    • Uterine rupture (severe pain, instability; rare without labor).
    • Cervical/vaginal lesions (e.g., polyps, trauma; usually minor bleeding).

3. How would you differentiate placenta previa from abruptio placenta clinically?

FeaturePlacenta PreviaAbruptio Placentae
PainPainless vaginal bleeding.Severe abdominal or back pain, often sudden.
BleedingBright-red, sudden and intermittent.Dark red/maroon; may be concealed (≈25 % of cases).
UterusSoft, non-tender, relaxed.Firm, tender with a characteristic “woody” hardness.
Fetal presentationFrequently malpresented (e.g., breech).Usually a normal presentation.
FHR changesLate decelerations only if severe blood loss occurs.Early decelerations, reflecting hypoxia.
UltrasoundShows placenta overlying or adjacent to the internal os.May reveal a retro-placental clot (often absent).

4. What are the maternal and fetal complications of placenta previa?

  • Maternal:
    • Hemorrhage → shock, disseminated intravascular coagulation (DIC).
    • Emergency cesarean delivery (risk of intraoperative hemorrhage, hysterectomy).
    • Infection (from prolonged hospitalization/procedures).
    • Increased risk of placenta accreta (given 3 prior C/S → up to 40% risk).
  • Fetal:
    • Preterm delivery → respiratory distress syndrome, NICU admission.
    • Fetal hypoxia/anemia from acute blood loss.
    • Intrauterine growth restriction (IUGR) from placental dysfunction.
    • Stillbirth (if severe undiagnosed hemorrhage).

5. Outline your management plan for this patient.

  • Immediate:
    • Admit to antepartum unit; strict bed rest.
    • Continuous fetal monitoring (CTG) and maternal vitals q15min until stable, then q1-2h.
    • Type and crossmatch 4-6 units PRBCs; initiate IV fluids.
    • Administer corticosteroids (e.g., betamethasone) for fetal lung maturity (31 weeks).
  • Monitoring:
    • Serial Hb/Hct (q6-12h initially); ultrasound to reassess placental location (if bleeding recurs).
    • Rule out placenta accreta spectrum (MRI is recommended if suspicion is high due to prior C/S).
  • Delivery planning:
    • Expectant management until 36–37 weeks if stable.
    • Cesarean delivery scheduled at 36–37 weeks (earlier if active bleeding, distress, or accreta suspected).
    • Multidisciplinary team (OB, anesthesia, NICU, blood bank); consider cell salvage if accreta risk.
    • Avoid labor induction (placenta covers internal OS).

6. When is blood transfusion indicated, and what are its possible complications?

  • Indications:
    • Hemodynamic instability (tachycardia, hypotension) despite fluid resuscitation.
    • Symptomatic anemia (e.g., dyspnea, tachycardia at rest).
    • Hb <7 g/dL (or <8 g/dL if active bleeding, cardiac disease, or ongoing loss).
  • Possible complications:
    • Acute: Febrile non-hemolytic reaction, allergic reaction, TRALI (transfusion-related acute lung injury), TACO (transfusion-associated circulatory overload).
    • Delayed: Hemolytic reaction (if ABO mismatch), iron overload (with massive transfusion), infections (e.g., hepatitis, HIV; rare with modern screening).
    • Special in obstetrics: Alloimmunization (risk in future pregnancies), hypocalcemia (from citrate in massive transfusion).

Case 3: Threatened Miscarriage developing into Placenta Previa

Scenario

A patient presents with a viable baby and bleeding.

Guiding Questions & Answers

1. What is your diagnosis?

  • Threatened miscarriage.

2. What is the Differential Diagnosis?

  • Ectopic Pregnancy
  • Molar Pregnancy
  • Incomplete/Complete/Missed Abortion

3. What is the management?

  • Expectant management with monitoring.
  • Supportive care.

(Later in the pregnancy…) An ultrasound shows a structure close to the internal os.

4. What is the new diagnosis?

  • Placenta Previa (PP)

5. What is the new Differential Diagnosis?

  • Abruptio Placentae
  • Vasa Previa

6. What is the management?

  • As per guidelines for Placenta Previa, which may include:
    • Hospitalization and bed rest.
    • Corticosteroids for fetal lung maturity if preterm.
    • Planned Cesarean Section.

Case 4: Pre-eclampsia as a Risk Factor for Abruptio Placentae

Patient Presentation

Walaa Salah, an 18-year-old primigravida, initially presented at 34 weeks with Pregnancy-Induced Hypertension (PIH). Two weeks later, she returned with severe headache, epigastric pain, and blurring of vision. Her BP was 150/105 mmHg and urine revealed +++ protein, leading to a diagnosis of Pre-eclampsia.

Relevant Complications and Findings

  • Possible Complications of Pre-eclampsia: One of the major complications listed is Abruptio Placentae.
  • Expected Findings on Examination: Abdominal tenderness, particularly subcostal, may indicate Abruptio Placentae.

Case 5: Antiphospholipid Syndrome (APL) as a Risk Factor for Placental Abruption

Patient Presentation

Lubna Elsheikh, a 32-year-old female (G7P2+4), presents with a history of recurrent miscarriages, preeclampsia, and preterm delivery. The most likely diagnosis is Antiphospholipid Syndrome (APL).

Associated Maternal Risks

Among the maternal risks associated with APL Syndrome is Placental Abruption.

Case 6: Epilepsy in Pregnancy and Placental Abruption

Patient Presentation

Wafaa, a 29-year-old new bride with a 5-year history of epilepsy, attended a pre-pregnancy clinic.

Fetal Complications of Epilepsy in Pregnancy

One of the potential fetal complications mentioned is Placental Abruption.

Case 7: Severe Intrauterine Growth Restriction (IUGR) and Placental Abruption

Patient Presentation

Mrs. Rania Salah, a 32-year-old in her third pregnancy, is diagnosed with severe IUGR at 34 weeks.

Possible Causes

Among the placental factors listed as a possible cause for IUGR is Placental abruption.

Case 8: Breech Presentation and Antepartum Hemorrhage Risks

Patient Presentation

Sara Hussain, a 36-year-old female (G3 P2+0), is found to have a breech presentation at 35 weeks.

Questions on Antenatal Management

  • Q: What are two contraindications for External Cephalic Version (ECV)?
    • A: Any contraindication to vaginal delivery (e.g., Placenta Previa), macrosomic baby, IUGR, inadequate pelvis, footling breech, lack of a trained person.
  • Q: What are two complications of ECV?
    • A: Placental abruption, Preterm Premature Rupture of Membranes (PPROM), uterine rupture, procedure failure, fetal bradycardia, feto-maternal hemorrhage.

Case 9: Grand Multipara and Antepartum Hemorrhage Risks

Patient Presentation

Asmaa, a 39-year-old lady (G8 P6+1), came to the ANC clinic pregnant for 10 weeks.

Anticipated Complications

  • What are the anticipated complications in a grand multipara?
    • Anemia, Miscarriage, PPH, uterine prolapse, ruptured uterus or uterine inversion, higher incidence of twins, molar pregnancy, malpresentation, and an increased risk of placenta previa and abruption.

Postpartum Hemorrhage (PPH) Case Scenarios

Case 1: Grand Multipara with Anemia and PPH

Patient Presentation

Asmaa, a 39-year-old lady (G8 P6+1), came to the ANC clinic pregnant for 10 weeks. All previous births were vaginal and alive/well, with the last one being a year ago.

What are the anticipated complications in a grand multipara?

  • Iron deficiency anemia
  • Miscarriage
  • PPH
  • Uterine prolapse, ruptured uterus, or uterine inversion
  • Higher incidence of twins
  • Molar pregnancy
  • Malpresentation
  • Increased risk of placenta previa and abruption

Antenatal Period

At 20 weeks: She came for an anomaly scan and complained of shortness of breathing. CBC done revealed Hb = 9 gm/dl.

What is your diagnosis & mention the risk factors in this case?

  • Diagnosis: Iron deficiency anemia.
  • Risk Factors: Grand multiparity, nutritional deficiencies.

What are the complications of anemia in pregnancy?

  • Maternal: Miscarriage, Pre-Term Labour, PPH, Heart Failure, Need for blood transfusion.
  • Fetal: Anemia, Prematurity, IUGR/IUFD, Low Birth Weight.

Labour and Delivery

At 38 weeks: She came in with labour-like pain and leakage. On arrival: Slightly pale but on pain, BP 110/70 mmHg, pulse 88 bpm. Findings: Fundal Level at 40 weeks, Longitudinal Lie, Cephalic Presentation. PV Exam: Cx is anterior, soft, fully effaced, membranes ruptured, OS is 7 cms dilated, head at zero station & FHR was 145 bpm. Outcome: She gave birth 4 hours later to a male baby of 4100 gms.

Postpartum Complications

One hour later she developed bleeding.

What is your diagnosis? Primary PPH.

What is the most likely cause of bleeding in her condition?

  1. Anemia.
  2. Uterine atony due to over-distention.

What are the risk factors in this patient? Grand multipara, Macrosomic baby, Anemia.

Management of PPH

How will you manage her?

  1. Call for help and initiate ABCs (Airway, Breathing, Circulation).
  2. Initial Measures: Uterine massage, administer first-line uterotonics (e.g., Oxytocin infusion), and perform bi-manual compression.
  3. Examine for Cause: Transfer to theater for a thorough examination under anesthesia to identify the cause (4 T’s: Tone, Trauma, Tissue, Thrombin).
  4. Intrauterine Tamponade: If atony persists despite uterotonics, insert a Bakri balloon.
  5. Surgical Interventions: If bleeding continues, proceed to surgical measures such as:
    • B-Lynch compression suture.
    • Uterine or internal iliac artery ligation.
  6. Uterine Artery Embolization: An alternative to surgery if the patient is stable for transfer to interventional radiology.
  7. Hysterectomy: The definitive treatment if all other measures fail.

Case 2: Secondary PPH due to Puerperal Sepsis

Patient Presentation

Two weeks after delivery, a patient was brought in with a fever, bleeding, and offensive vaginal discharge. On Examination: She looked ill, febrile, and pale. BP was 100/60, pulse 96 bpm. The uterus was tender on abdominal palpation. PV Examination: Offensive discharge and bleeding were present.

Diagnosis and Management

What is your diagnosis? Secondary Post-Partum Hemorrhage (PPH) due to Puerperal Sepsis.

What are the common causes of Puerperal Sepsis?

  • Endometritis: Tender uterus and offensive vaginal discharge.
  • Mastitis: Tender, enlarged breast with milk engorgement.
  • Wound infection: Oozing and poor healing.
  • UTI (Urinary Tract Infection).
  • Chest infection.

Management?

  • Admission.
  • Investigations according to the cause and culture.
  • Cover with broad-spectrum antibiotics (Abx).

PPH as a Complication in Other Cases

Case: Iron Deficiency Anemia in Pregnancy

  • Complications → Maternal: Miscarriage, Pre-term Labour, Post-Partum Hemorrhage (PPH), Heart Failure (HF), Need for blood transfusion.

Case: Breech Presentation and Delivery

  • Q: What are two complications of Vaginal Breech delivery?
  • A: Limb fracture, cord prolapse, intracranial hemorrhage, spinal cord injury, nuchal arm, Post-Partum Hemorrhage (PPH).

Case: Hypertension in Pregnancy & Abruptio Placentae

  • Possible Complications: Post-Partum Hemorrhage (PPH), Fetal Death, Disseminated Intravascular Coagulation (DIC), Couvelaire uterus, Hysterectomy.
  • General Causes of PPH (The 4 T’s): Tone, Tissue, Trauma, Thrombin.
  • Note: Abruptio placentae can lead to PPH through uterine atony (Tone) and coagulopathy (Thrombin).

Case: Polyhydramnios

  • Give 2 complications?
  • Cord Prolapse, Post-Partum Hemorrhage (PPH), Pre-Term delivery, Malpresentation, Down Syndrome (associated with duodenal atresia), Maternal Discomfort, Amniotic fluid embolism.

Case: Diabetes Mellitus in Pregnancy

  • Effect of DM on mother: Increase risk of infection(candidacies, UTI), Infertility & subfertility, Miscarriage, Premature labour, Hypertension, PIH, Polyhydramious, PPH, Increase obstetrical interventions: C/S ,IOL ,assisted vaginal delivery.

General Questions and Management

Active Management of 3rd stage of labour (to prevent PPH):

  • Control cord traction
  • Oxytocin infusion immediately after delivery. Ergometrine is a second-line agent.

Problem-Based Question

Problem: After delivery, a patient develops bleeding within 1 hour.

  • Diagnosis? 1ry PPH
  • 4 Causes? (Refers to the 4 T’s: Tone, Tissue, Trauma, Thrombin)
  • Management? (Refer to the management steps outlined in Case 1)

Preeclampsia and Eclampsia Case Scenarios

Case 1: Pregnancy-Induced Hypertension & Pre-eclampsia

Initial Presentation (34 Weeks)

Walaa Salah, an 18-year-old primigravida, came to the Antenatal Care (ANC) unit for a follow-up visit at 34 weeks. Her pregnancy had been uneventful, and she had no complaints.

Vitals:

  • Maternal Body Index (MBI): 31
  • Blood Pressure (BP): 130/90 mmHg, rising to 135/95 mmHg four hours later.
  • Urine: Positive for protein.

What is your diagnosis? Pregnancy-Induced Hypertension (PIH).

What will be the management?

  • Medication: Start anti-hypertensives (e.g., Methyldopa, Nifedipine, Labetalol).
  • Monitoring: Increase the frequency of ANC visits.
  • Investigations: Perform necessary investigations.
  • Steroids: Administer corticosteroids if delivery is anticipated before 34 weeks.

Follow-up Presentation (Two Weeks Later)

The patient returned with severe headache, epigastric pain, and blurring of vision.

  • Vitals: BP was 150/105 mmHg.
  • Urine: Revealed +++ protein.

What is your new diagnosis? Pre-eclampsia.

What will be your management?

  • Immediate Actions: Stabilization and Delivery.
  • Medical Management:
    • Administer anti-hypertensives: Initiate treatment when systolic BP ≥140 mmHg or diastolic BP ≥90 mmHg. First-line agents include Labetalol, Nifedipine, and Hydralazine. Aim for a target BP of 130–140/80–90 mmHg.
    • Maintain fluid balance.
    • Provide seizure prophylaxis (Magnesium Sulphate): Administer a 4g IV loading dose over 20 minutes, followed by a 1g/hr infusion for 24 hours postpartum or after the last seizure.
  • Definitive Treatment: Delivery.

What are the risk factors for Pre-eclampsia?

  • Primigravida
  • Extremes of maternal age
  • Previous history of pre-eclampsia
  • Family history (mother or sister affected)
  • Multigravida with a new partner
  • Obesity (MBI > 30)
  • Pre-existing medical conditions:
    • Essential hypertension
    • Renal disease
    • Diabetes Mellitus (DM)
    • Antiphospholipid Syndrome (APL)
    • Inherited Thrombophilia
  • Ethnicity (more common in women of African descent)

What are the possible complications?

  • Eclampsia
  • Abruptio Placentae
  • HELLP Syndrome
  • Renal failure
  • Hepatic failure
  • Intrauterine Fetal Demise (IUFD)

What do you suspect to find in examination?

  • Edema
  • Fundal height less than expected for date, suggesting Intrauterine Growth Restriction (IUGR).
  • Potential for fetal heart death.
  • Abdominal tenderness, particularly subcostal, may indicate Abruptio Placentae.
  • Clonus (due to brain irritation)

What are the investigations needed?

  • Complete Blood Count (CBC)
  • 24-hour urine protein
  • Liver Function Tests (LFT)
  • Renal Function Tests (RFT)
  • Coagulation profile
  • Clotting factors
  • Ultrasound (US)

Symptoms & signs of sever preeclampsia

  • Sever headache.
  • Epigastric pain.
  • Visual disturbances.
  • Papilledema.
  • Liver tenderness.
  • Low platelets(<100).
  • Increase liver enzymes.
  • Increase creatinine.
  • Pulmonary oedema.
  • HELLP syndrome.

Eclampsia Management

  • Call for help (senior obstetrician, anesthesiologist, neonatologist).
  • Positioning: Place the patient in a left lateral position to prevent aspiration.
  • ABC:
    • Airway: Secure the airway; insert an oropharyngeal airway if needed.
    • Breathing: Ensure adequate breathing and provide oxygen (O2).
    • Circulation: Insert two wide-bore IV cannulas.
  • Seizure Control: Administer Magnesium Sulphate (MgSO4) to abort the seizure.
  • Hypertension Control: Reduce blood pressure using IV hydralazine or labetalol.
  • Monitoring:
    • Insert a urinary catheter to monitor output.
    • Take blood samples for investigation (FBC, LFTs, RFTs, clotting).
  • Definitive Treatment: Expedite delivery (usually via emergency C-Section) once the mother is stabilized.
  • Post-delivery: Continue MgSO4 for 24 hours after the last seizure and monitor vitals closely.

Preeclampsia as a Complication in Other Cases

Case: Recurrent Miscarriages & Antiphospholipid Syndrome (APL)

  • Analysis & Likely Diagnosis: Given the history of recurrent early miscarriages, preeclampsia, and preterm delivery, Antiphospholipid Syndrome (APL) is the most likely diagnosis.
  • Diagnostic Criteria for APL Syndrome: One or more preterm deliveries at <34 weeks due to preeclampsia.
  • Associated Risks of APL Syndrome: Maternal Risks: Placental Abruption, Pre-eclampsia, Deep Vein Trombosis (DVT), Recurrent Miscarriage, Pre-Term Labour.

Case: Hyperthyroidism in Pregnancy (Graves’ Disease)

  • Complications → Maternal: Hypertension, Pre-eclampsia, Heart Failure (HF).

Case: Molar Pregnancy

  • Symptoms & Signs: Early pre-eclampsia (1st or early 2nd trimester).
  • Possible Complications: Pulmonary edema due to Heart Failure, Anemia, Pre-eclampsia, or Hyperthyroidism.

Case: Pre-existing Diabetes Mellitus in Pregnancy

  • Associated Pathologies: Hypertension (HTN), Pre-eclampsia, Abruptio Placentae.
  • Maternal Complications: Pregnancy-Induced Hypertension (PIH), which can lead to pre-eclampsia.

Case: Asthma in Pregnancy

  • Maternal Complications: Pre-eclampsia, Maternal mortality, Increased need for hospitalization.

Case: Epilepsy in Pregnancy

  • Maternal Complications: Pre-eclampsia, Hemorrhage, Maternal mortality.

Case: Intrauterine Fetal Demise (IUFD)

  • Etiologies/Risk Factors: Hypertensive disorders: Preeclampsia or chronic hypertension (common in diabetics).

Case: Fetal compromise in labour

  • Risk factors for Fetal compromise in labour: Placental insufficiency, FGR and pre-eclampsia.

Preterm Labor Management

Tocolysis

  • Indication: Used to delay delivery for 48 hours between 24 and 34 weeks of gestation to allow for the administration of antenatal corticosteroids.
  • Contraindications: Chorioamnionitis, fetal compromise, and other conditions where prolonging pregnancy is unsafe.

Preterm Labor Scenarios

Preterm Labor as a Complication

Case: Antiphospholipid Syndrome (APL)

  • Maternal Risks: Placental Abruption, Pre-eclampsia, Deep Vein Trombosis (DVT), Recurrent Miscarriage, Pre-Term Labour.

Case: Iron Deficiency Anemia in Pregnancy

  • Maternal Complications: Miscarriage, Pre-term Labour, Post-Partum Hemorrhage (PPH), Heart Failure (HF), Need for blood transfusion.

Case: Heart Disease in Pregnancy (e.g., Mitral Regurgitation, Rheumatic Heart Disease)

  • Fetal Complications: Fetal Growth Restriction, Death of the mother or fetus, Pre-Term Labour, Still Birth.

Case: Pre-existing Diabetes Mellitus in Pregnancy

  • Fetal Complications: Intrauterine Growth Restriction (IUGR), Intrauterine Fetal Demise (IUFD), Pre-Term Labour, Macrosomia, Polyhydramnios, Miscarriage, Congenital Anomaly (e.g., Sacral Agenesis).

Case: Asthma in Pregnancy

  • Baby Complications: Low birth weight, Pre-term birth, Neonatal asphyxia, IUGR (Intrauterine Growth Restriction), IUFD (Intrauterine Fetal Demise).

Case: Epilepsy in Pregnancy

  • Fetal Complications: Fetal Growth Restriction, IUFD (Intrauterine Fetal Demise), Still-Birth, Pre-Term birth, Placental Abruption.

Case: Polyhydramnios

  • Complications: Cord Prolapse, Post-Partum Hemorrhage (PPH), Pre-Term delivery, Malpresentation.

Diagnosed Medical Conditions

Sickle Cell Disease in Pregnancy

Patient Presentation

A 24-year-old lady with Sickle Cell Disease, married for 3 months, attended the pre-pregnancy clinic.

Definition and Pathophysiology

Sickle cell anemia is an autosomal recessive disorder characterized by abnormal hemoglobin S (HbS). The mutation leads to the destruction of red blood cells.

Clinical Features

  • Hemolytic anemia
  • Painful crises
  • Hyposplenism
  • Increased risk of infections (UTI, pyelonephritis, pneumonia, puerperal sepsis)
  • Avascular necrosis of bone
  • Increased risk of thromboembolic disease (pulmonary embolism, stroke)
  • Acute Chest Syndrome: Fever, chest pain, tachypnea, increased WCC, pulmonary infiltrates.
  • Iron overload leading to cardiomyopathy.

Guiding Questions & Answers

What is your Pre-pregnancy advice?

  1. MDT (Multi-Disciplinary Team) approach with a Hematologist.
  2. Screening for the partner, as Sickle Cell Disease is an Autosomal Recessive (AR) condition.
  3. Transcranial Doppler screening to assess stroke risk.
  4. Stop iron chelating agents before pregnancy.
  5. Folic acid 5mg.
  6. Penicillin Prophylaxis.
  7. Screen for infection.
  8. Pneumococcal and Flu Vaccine.
  9. Prophylactic transfusions are only indicated for severe anemia (Hb <7 g/dL) or other complications.

What is the suitable contraceptive?

  • Progesterone-only pills, injections, Implanon, Mirena.
  • Avoid COCP & copper loaded IUD.

When will be the next important visit? And why?

  • At 18-22 weeks for an anomaly scan.

How will you manage the labour?

  • Aim for vaginal delivery (unless CS is indicated).
  • MDT (haematologist, obstetrician, neonatologist, midwife, nurse).
  • Adequate hydration.
  • Avoiding hypoxia.
  • Continuous fetal & maternal monitoring.
  • Thromboprophylaxis.
  • Antibiotics.

How will you manage post-delivery?

  1. VTE (Venous Thromboembolism) Prophylaxis.
  2. Penicillin Prophylaxis.
  3. Breastfeeding.
  4. Re-start medication.
  5. Contraception: Avoid estrogen.

Mention two Fetal risks in sickle cell disease.

  • Miscarriage.
  • IUGR.
  • Prematurity.
  • Stillbirth.

Diabetes Mellitus (DM) in Pregnancy

Case 1: Pre-existing Diabetes Mellitus

Patient Presentation

Nora Omer, a 35-year-old grand multipara (G8 P5+2), presented with amenorrhea for 6 weeks. Her last child is 4 years old, and she has a history of gestational diabetes in her last pregnancy, which is a significant risk factor. She has had diabetes for 7 years.

Guiding Questions & Answers

What is your Pre-pregnancy counselling / First Trimester Management?

  1. Multi-Disciplinary Team (MDT) Approach: Coordinate care with relevant specialists.
  2. Optimal Diabetes Mellitus (DM) Control: Aim for a preconception HbA1c <6.5%. Recommend continuous glucose monitoring (CGM) during pregnancy.
  3. DM Severity Assessment: Evaluate for complications such as retinopathy, nephropathy, cardiac disease, and hypertension (HTN).
  4. Aspirin Prophylaxis: Start low-dose aspirin (75–150 mg daily) from 12 weeks to reduce preeclampsia risk.
  5. General Health Optimization: Advise to stop smoking and optimize weight.
  6. Folic Acid: Supplement with 5mg daily.
  7. Rubella Status: Check for immunity.

How to manage her labour?

  • Vaginal Delivery: Monitor fetal weight.
  • Cesarean Section (CS): Consider delivery before 38 weeks of gestation. Elective CS if Estimated Fetal Weight (EFW) is >4.5kg.
  • Induction of labour at 38–39wks if there are no maternal or fetal complications.
  • Continuous electronic fetal and maternal monitoring.

Give possible complications to the mother.

  • Urinary Tract Infection (UTI)
  • Vaginal Candidiasis
  • Pregnancy-Induced Hypertension (PIH) / Pre-eclampsia
  • Obstructed Labour
  • Worsening of DM-related retinopathy, nephropathy, or cardiac issues.

Give possible complications to the child.

  • Intrauterine Growth Restriction (IUGR)
  • Intrauterine Fetal Demise (IUFD)
  • Pre-Term Labour
  • Macrosomia
  • Polyhydramnios
  • Miscarriage
  • Congenital Anomaly (e.g., Sacral Agenesis, CNS, CVS, Renal)

Give possible complications to the neonate.

  • Hypoglycemia
  • Hypomagnesemia
  • Hypothermia
  • Hypocalcemia
  • Polycythemia
  • Jaundice
  • Cardiomegaly
  • Birth trauma (shoulder dystocia, fractures, Erb’s palsy)
  • Respiratory distress syndrome

What is the best contraceptive method for her?

  • Avoid: Estrogen-containing Combined Oral Contraceptives (COCPs).
  • Recommended: Progesterone-only methods, Intrauterine Device (IUD), or sterilization if the family is complete.

Case 2: DM as a risk factor in other conditions

  • Recurrent Miscarriages: DM is listed as a general cause.
  • Pre-eclampsia: DM is a risk factor.
  • Polyhydramnios: Maternal Diabetes is a possible cause.
  • Intrauterine Growth Restriction (IUGR): Maternal DM is a possible cause.
  • Intrauterine Fetal Demise (IUFD): Diabetes mellitus is a key risk factor.

Thyroid Disease in Pregnancy

Case 1: Hyperthyroidism (Graves’ Disease)

Patient Presentation

Sara, a 28-year-old female (G2 P1+0), attended the Antenatal Care (ANC) clinic at 16 weeks gestation presenting with tachycardia, irritability, and an enlarged neck mass, suggestive of hyperthyroidism.

Diagnosis

  • Diagnosis: Graves’ Disease (95% of cases), diagnosed via Thyroid Function Test (TFT).

Clinical Features

  • Palpitation
  • Vomiting
  • Goitre
  • Palmer erythema
  • Emotional lability
  • Tremors
  • Lid lag & retraction

Complications

Maternal:

  • Hypertension
  • Pre-eclampsia
  • Heart Failure (HF)

Fetal:

  • Miscarriage
  • Intrauterine Growth Restriction (IUGR)
  • Intrauterine Fetal Demise (IUFD)
  • Pre-term birth
  • Fetal hypothyroidism (drug-induced)
  • Fetal thyrotoxicosis (due to transplacental TSI)

Management Plan

  • Medication:
    • First Trimester: Propylthiouracil (PTU).
    • Thereafter: Carbimazole.
  • Monitoring:
    • Serial ultrasounds (US) to monitor the baby’s growth.
    • Thyroid Function Tests (TFT) in each trimester.
    • Close monitoring during labor, including continuous Cardiotocography (CTG).
    • Cord blood sampling for TFT at delivery.
  • Mode of Delivery: Vaginal Delivery (VD) unless a Cesarean Section (CS) is otherwise indicated.

Case 2: Thyroid Disease as a risk factor in other conditions

  • Recurrent Miscarriages: Thyroid disease is listed as a possible cause.
  • Spontaneous Abortion: Endocrinopathies including thyroid disease are listed as a maternal factor.

Asthma in Pregnancy

Patient Presentation

A 22-year-old final year university student, known to be asthmatic since childhood, came to the gynecology clinic. Her wedding is in two months, and she wants to use contraception for one year.

Contraception and Pre-pregnancy Management

  • What is the suitable contraceptive for her?
    • Avoid estrogen. Progesterone-only pills, implants, Depo-Provera, IUDs (Mirena).
  • She came one year later to the pre-pregnancy clinic as she wants to get pregnant… What will be her pre-pregnancy management?
    1. MDT (Multi-Disciplinary Team) approach.
    2. Manage Asthma: Adjust or change medication, avoid triggers.
    3. Monitor Asthma Symptoms.
    4. Maintain a healthy lifestyle.
    5. Vaccines: Ensure Flu and Tdap vaccines are up to date.

Asthma’s Effect on Pregnancy

  • She is asking about the effect of her asthma on her pregnancy (complications to both baby & mother)?
    • Maternal: Pre-eclampsia, Maternal mortality, Increased need for hospitalization.
    • Baby: Low birth weight, Pre-term birth, Neonatal asphyxia, IUGR (Intrauterine Growth Restriction), IUFD (Intrauterine Fetal Demise).

Management of Acute Exacerbation

  • Oxygen
  • Bronchodilators (e.g., Salbutamol)
  • Steroids (oral or inhaled)
  • Antibiotics if infection is present
  • Note: Avoid Prostaglandins for induction of labor as they can exacerbate asthma.

Mode of Delivery

  • She came at 36 weeks to ANC to discuss the mode of delivery. What will be the mode of delivery?
    • Vaginal delivery, unless a Cesarean Section (CS) is otherwise indicated.

Iron Deficiency Anemia in Pregnancy

Definition

Anemia in pregnancy is defined as hemoglobin (Hb) or hematocrit (Hct) below trimester-specific cut-offs:

  • 1st trimester: Hb < 11 g/dL, Hct < 33%
  • 2nd trimester: Hb < 10.5 g/dL, Hct < 32%
  • 3rd trimester: Hb < 11 g/dL, Hct < 33%

Diagnosis

  • CBC with indices: Hb, Hct, MCV
  • Ferritin: < 30 µg/L confirms iron deficiency.
  • Peripheral blood smear: May show microcytic, hypochromic red blood cells.
  • Hemoglobin electrophoresis: If a hemoglobinopathy is suspected.

Risk Factors

  • Poor dietary intake
  • Short interpregnancy interval, teenage pregnancy, multiparity
  • Heavy menses or prior delivery blood loss
  • GI malabsorption, chronic illness
  • Hemoglobinopathies

Management

  • Nutritional Advice:
    • Eat iron-rich foods (red meat, poultry, legumes, leafy greens).
    • Vitamin C enhances iron absorption; avoid tea/coffee with meals.
  • Pharmacological Treatment:
    • Oral Iron: Ferrous sulfate is first-line. Ferrous gluconate is better tolerated.
    • Parenteral Iron: For severe anemia, oral intolerance, or poor response.
    • Blood Transfusion: Reserved for severe cases (e.g., Hb < 6 g/dL) with maternal or fetal compromise.

Complications

Maternal:

  • Fatigue, reduced work capacity
  • Increased risk of infection
  • Miscarriage
  • Pre-term Labour
  • Post-Partum Hemorrhage (PPH)
  • Heart Failure (HF)
  • Need for blood transfusion

Fetal:

  • Anemia
  • Prematurity
  • Intrauterine Growth Restriction (IUGR) or Intrauterine Fetal Demise (IUFD)
  • Low Birth Weight

Case 2: Grand Multipara with Anemia and PPH

Patient Presentation

Asmaa, a 39-year-old lady (G8 P6+1), came to the ANC clinic pregnant for 10 weeks.

Antenatal Period

At 20 weeks: She came for an anomaly scan and complained of shortness of breathing. CBC done revealed Hb = 9 gm/dl.

  • What is your diagnosis & mention the risk factors in this case?
    • Diagnosis: Iron deficiency anemia.
    • Risk Factors: Grand multiparity, nutritional deficiencies.
  • What are the complications of anemia in pregnancy?
    • Maternal: Miscarriage, Pre-Term Labour, PPH, Heart Failure, Need for blood transfusion.
    • Fetal: Anemia, Prematurity, IUGR/IUFD, Low Birth Weight.

(The case continues to develop into PPH, where anemia is a significant risk factor).

Heart Disease in Pregnancy

Case 1: Mitral Regurgitation & Pregnancy

Patient Presentation

Miss Naden Adil is a 21-year-old final year student, known to have mitral regurgitation due to rheumatic heart disease since childhood. She presented to the gynecology clinic for contraception advice as her wedding will be in two months.

Guiding Questions & Answers

What are the possible complications for her and her child?

  • Fetal: Fetal Growth Restriction, Death of the mother or fetus, Pre-Term Labour, Still Birth.
  • Maternal: Heart Failure (HF), Pericarditis, any heart disease, Anemia.

What is the Best contraceptive?

  • A: Progesterone only Pills (POPs), Implanon.

When will be the next important visits? And why?

  • A: At 18-22 weeks for an anomaly scan, and at 24 weeks for a Cardiac Scan.

What is the pre-pregnancy plan?

  • A: Multi-Disciplinary Team (MDT) care involving Cardiology and Hematology is crucial. This includes lifestyle modifications, drug dose adjustments or changes (e.g., to Folic Acid), and explaining the effects of the disease on her and her baby.

What is the mode of delivery?

  • A: Vaginal Delivery (VD) unless a Cesarean Section (CS) is indicated.

How will you manage her labour in general?

  • A:
    1. Multi-Disciplinary Team (Cardiologist, Hematologist)
    2. Continuous maternal monitoring
    3. Continuous fetal monitoring / CTG
    4. Left lateral position
    5. Cardiac Troponin
    6. Endocarditis Prophylaxis
    7. Strict Fluid Balance

How will you manage the 1st, 2nd and 3rd stages of labour?

  • A:
    • 1st Stage: Reduce pain by epidural analgesia.
    • 2nd Stage: Shortening of the 2nd stage by outlet forceps.
    • 3rd Stage: Minimize blood loss by active management and avoid Ergometrine / Syntometrine.

What will be your advice in puerperium?

  • A: Early mobilization, thrombo-prophylaxis, hydration, breastfeeding.

Case 2: Rheumatic Heart Disease in Pregnancy

Patient Presentation

Manahel is a 20-year-old known to have rheumatic heart disease since childhood.

Guiding Questions & Answers

What is the best contraceptive for her?

  • Progesterone-only Pills, Implanon. Avoid IUD and estrogen.

What are the possible complications for her and her child?

  • Fetal: Fetal Growth Restriction, Pre-Term Labour, Still Birth.
  • Maternal: Death of mother or fetus, Heart Failure (HF), Pericarditis.

How will you manage her labour in general?

  1. Multi-Disciplinary Team: Cardiologist and Hematologist.
  2. Continuous maternal and fetal monitoring.
  3. Left lateral position.
  4. Cardiac Troponin.
  5. Endocarditis Prophylaxis.
  6. Strict Fluid Balance.

How will you manage the stages of labour?

  • 1st Stage: Reduce pain by epidural analgesia.
  • 2nd Stage: Shorten the 2nd stage by outlet forceps.
  • 3rd Stage: Minimize blood loss by active management. Avoid ergometrine.

What is the postpartum management?

  • Early mobilization.
  • Thrombo-prophylaxis.
  • Hydration.
  • Breastfeeding.

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