MATERNAL DEATH REVIEW Evelina Rosario – Castro, MD, FPOGS, FPSUOG, FPCS 24 October 2013

The Case O Chief Complaint: Labor pain few hours PTA O Description of labor pain

How to tell if it is true contractions… TRUE LABOR FALSE LABOR or BRAXTON HICKS CONTRACTIONS O Come every few minutes and get more frequent over time. O Don’t go away, even when you rest. O Get stronger and more painful over time. O Come every few minutes, but they don’t get more frequent over time. O Usually go away when you rest. O Usually don’t get stronger or more painful over time

The Case O G2P1(1001) G1 – NSD at WPDH G2 – present pregnancy LMP: 13 July 2013 AOG: 41 wks (LMP); 38 6/7 wks (UTZ) EDC: 20 April 2013 O When was UTZ done? O Early O Mid O Late

Determination of AOG and EDC 1. If discrepancy of sonar aging and menstrual date is 7 days or less 2. If discrepancy is more than 7 days 1. Follow menstrual age all throughout pregnancy. 2. USE sonar age all throughout pregnancy.* * EDC that has been set early on should not be changed based on subsequent scans done in the 2 nd and 3 rd trimester.

Acceptable Error of Aging O 12 – 20 weeks: +/- 7 days O 24 – 28 weeks : +/- 14 days O > 29 weeks: +/- 21 days

Prenatal History O What are the findings every visit? O Appropriateness for age of gestation O Laboratory work – ups done

What happens during the first prenatal visit? O Ask about: O health and medical history O figure out EDC O Do a complete physical examination O Include: speculum and internal examination

What happens during the first prenatal visit? O History O Personal and demographic information O Past obstetrical history O Personal and family medical history O Past surgical history O Genetic history O Menstrual and gynecological history O Current pregnancy history O Psychosocial information

What happens during the first prenatal visit? O Estimated date of delivery O A tentative estimated date of delivery (EDD) can be calculated from the menstrual history in women with 28-day cycles by: O NAEGELE’S RULE: ADD 7 days to the first day of the last menstrual period (LMP) and then SUBTRACTING 3 months Example: 1) LMP: February 20 th EDD: November 27 th 2) LMP: May 28 th EDD: March 4 th

What happens during the first prenatal visit? O Physical examination O blood pressure O Weight and height O Calculating body mass index (BMI) helps to identify at risk populations and enables counseling of the amount of appropriate weight gain in pregnancy. O Assess uterine size and shape and evaluation of the adnexa O uterine fibroids, uterine malposition (eg, retroverted uterus), multiple gestation, and incorrect date of LMP

What happens during the first prenatal visit? O LABORATORY TESTS O Routine O Rhesus type and antibody screen — This test will detect antibodies potentially causing hemolytic disease of the newborn. O Hematocrit or hemoglobin and mean corpuscular volume — detect anemia and provide screening for thalassemia - An MCV <80 femtoliters (fL) in the absence of iron deficiency suggests thalassemia; further testing with hemoglobin electrophoresis is indicated

What happens during the first prenatal visit? O Cervical cytology cancer screening O 21 years or older who are due for screening according to standard guidelines O Pregnancy is not an indication for a change in the frequency of cervical cancer screening, but management of an abnormal test is different for pregnant women O Rubella immunity O If nonimmune, the patient should be counseled to avoid exposure to individuals with rubella and receive postpartum immunization.

What happens during the first prenatal visit? O Varicella immunity O Women who do not have evidence of immunity to varicella should be counseled to avoid exposure to individuals with varicella, may be candidates for passive immunization during pregnancy if exposed to varicella, and are candidates for varicella vaccine postpartum O Urine protein O useful as a baseline for comparison if assessment of renal function is performed later in pregnancy.

What happens during the first prenatal visit? O Urine culture O Routine urine culture is recommended because pregnant women with untreated asymptomatic bacteriuria (ASB) are at high risk of developing pyelonephritis and rapid tests for bacteriuria do not have adequate sensitivity and specificity O For women with ASB: O retesting monthly until delivery, or O giving suppressive therapy for the remainder of pregnancy if they have recurrent or persistent bacteriuria.

What happens during the first prenatal visit? O Syphilis testing O Hepatitis B antigen testing O Chlamydia testing O Human immunodeficiency virus

What will happen at each prenatal visit? O Ask symptoms and answer any questions of patient O Ask about fetal movement O Check : O BP O Weight O Fundic height O FHT (heard at about 12 weeks of pregnancy) O Fetal position (Leopold’s Maneuver) O Test your urine to check for sugar or protein

Schedule of Visits O Every 4 weeks until about 28 weeks AOG O Every 2 to 3 weeks until 36 weeks AOG O Every week until delivery

FOLLOW-UP VISITS O Routine assessments at each prenatal visit typically consist of: O Measurement of maternal blood pressure and weight O Urine dipstick for protein (although the value of this test is questionable in women with normal blood pressure) O Measurement of the uterine size or fundal height to assess fetal growth O Documentation of fetal cardiac activity O Assessment of maternal perception of fetal activity (in the second and third trimesters) O Assessment of fetal presentation (in the third trimester)

First Trimester O First trimester screening and diagnostic testing may include tests for: O Red cell antibodies O Current or past infection (eg, sexually transmitted diseases, bacteriuria, rubella immunity) O Inherited disorders (eg, cystic fibrosis, fragile X, spinal muscular atrophy, hemoglobinopathy) O Fetal aneuploidy (eg, trisomy 21) O Thyroid disease O Lead

weeks AOG O Neural tube defects O maternal serum alpha-fetoprotein O Ultrasound O Trisomy 21 O 2nd trimester: quadruple test ( ie, level of alpha- fetoprotein (AFP), unconjugated estriol (uE3), hCG, and inhibin A in maternal serum)

weeks AOG O Fetal anomalies O between 18 and 22 weeks of gestation O additional testing may be needed to confirm the suspected diagnosis O Cervical length O TVUS measurement of short cervical length between 16 to 28 weeks of gestation is associated with an increased risk of spontaneous preterm birth <35 weeks.

weeks AOG O Gestational diabetes O universal screening for gestational diabetes is recommended at 24 to 28 weeks of gestation (in the US) O Screening considered in the first trimester in women with significant risk factors (eg, body mass index >30 kg/m 2, gestational diabetes or baby >4500 g in a prior pregnancy, family history of diabetes in a first degree relative) O RBC antibodies — O In Rh(D)-negative women, red cell (RBC) antibody screening is repeated at 28 weeks of gestation and anti-D immune globulin is administered.

weeks AOG O Hemoglobin or hematocrit O To assess for anemia The Centers for Disease Control and Prevention (CDC) The World Health Organization (WHO) 1 ST TRIMESTERHgb: < 11 g/dL Hct: < 33% AnemiaHgb: < 11 g/dL Hct: < 33% 2 ND TRIMESTERHgb: < 10.5 g/dL Hct: < 32% Severe Anemia Hgb: < 7 g/dL Hct: < 33% requires medical treatment 3 RD TRIMESTERHgb: < 11 g /dL Hct: < 33% Very Severe Anemia Hgb: < 4 g/dL Hct: < 33% medical emergency due to the risk of congestive heart failure

weeks AOG O Sexually transmitted disease (STD) O The CDC recommends testing for STD (eg, HIV, syphilis, hepatitis B surface antigen, chlamydia, gonorrhea) in women who: O Were diagnosed with a STD earlier in pregnancy O Continue to have risk factors for acquiring a STD O Acquired a new risk factor during pregnancy (eg, a new or more than one sex partner, evaluation or treatment for a STD, injection of nonprescription drugs) O All women ≤25 years of age be retested for Chlamydia trachomatis late in pregnancy

weeks AOG O Group B beta-hemolytic streptococcus testing O 35 to 37 weeks of gestation O colonization with swabs of both the lower vagina and rectum O Excluded from screening: O (+) GBS bacteriuria earlier in the current pregnancy O those who gave birth to a previous infant with invasive GBS disease.

weeks AOG O Group B beta-hemolytic streptococcus testing O Those excluded from screening should receive intrapartum antibiotic prophylaxis regardless of the colonization status. O Intrapartum chemoprophylaxis of colonized women has been proven to reduce the incidence of early-onset neonatal GBS.

weeks AOG O Estimated fetal weight O Fetal assessment O High risk of fetal hypoxemia/acidosis. O ≥28 weeks of gestation, but may be initiated earlier if the fetus is believed to be at increased risk of death and delivery or another intervention is an option. O External cephalic version O 36 weeks of gestation or earlier (34 to 35 weeks) to improve the success rate

weeks AOG O Patient education in preparation for labor and delivery O Management of and support during labor O Route of delivery O Induction of labor O Postterm pregnancy O For women ≥41 weeks of gestation, we suggest induction rather than expectant management

Course in the Ward O Upon admission… O BPS? O CTG? O If there’s no CTG, do manual assessment (palpation) of uterine contraction and intermittent auscultation

How to compute for Ocytocin drip O Step 1: Determine the concentration of oxytocin/mL: 1 unit = 1,000 miliunits (mU) 10 units = 10,000 miliunits (mU) 10,000 mU = 10 mU (10 mU/1 mL) 1,000 mL 1mL OR = 1mU / 0.1 mL O Step 2: Calculate (at this concentration) how many mL/hour will be given: 1 mU/minute = 60 mU/hour (1 mU X 60mins/hour) O Step 3: Using ratio & proportion to calculate mL/hour: 10 mU:1 mL = 60 mU: X mL 10X = 60 X = 6 mL/hour

Course in the Ward O Labor curve O Precipitated delivery? O Fundal pressure?

Friedman’s Curve

4:35 pm L.T. 2 1 No (intact) 4:35 pm 7:56pm WHO Partograph

Precipitate Labor and Delivery O refers to a rapid labor and delivery of the fetus O defined as expulsion of the fetus within 2 – 3 hours of commencement of contractions

Postpartum O 8:45 PM O Hypogastric pain O Diaper soaked with blood O Contracted uterus, manual evacuation of blood, uterine massage done, ice pack on fundus O BP = 40/20 mm Hg O Estimated amount of blood loss O Contracted uterus? O Need for uterine massage? O Ice pack? O Digital assessment of uterine walls?