RCOG Royal College of Obstetricians and Gynecologists RCT randomized controlled trial REM rapid eye movement RMO registered me dical offi cer RSD re \202 ex sympathetic dystrophy RSI repetitive strain i njury; rapid sequence induction RTA road traffi c accident(s) RTS revised trauma score RUQ right upper quadrant RVH right ventricular hypertrophy S1 S2 1st and 2 nd heart sounds SAD seasonal aff ective disorder SALT speech and language thera pist SAO2 arterial blood O2 saturation, \211\210 SpO2 (allows for carboxyhaemoglobin) SBE subacute bacterial endocarditis SC subcutaneous SCBU special care baby unit SE side-eff ects sec second(s) SFH symphysis fundal heigh t SERM selective estrogen receptor modulator xiii xi Fig 1. This plan is rendered almost unintelligible by over-use of abbreviations. It might m ean: If in status quo (ISQ=no change in state) in 2 days \200\231 time (/7 in this context means days; /52 would mean weeks), refer to the Sexually Transmitted Infections clinic for treatment ( \200\224) \200\224 if it turns out he does not arrive (DNA), follow-up at the o ut-patient department.2 xi 1 Obstetrics Pre-pregnancy counseling 2 Care plans 3 Booking criteria 4 Physiological changes in pregnan cy 6 Obesity 7 Antenatal care 8 Anti-D 9 Prenatal diagnosis 10 Tests for Down \200\231s syn drome 12 Preimplatation tests 13 Placenta 14 Thromboprophylaxis 16 Minor symptoms 17 Hypere mesis gravidarum 18 Pregnancy & medical conditions \200\223 Sickle-cell disease 19 \200 \223 Cardiac disease 20 \200\223 Psychopharmacology 21 \200\223 Anemia 22 \200\223 HIV 2 3 \200\223 Diabetes mellitus 24 \200\223 Thyroid disease 25 \200\223 Jaundice 26 \200 \223 Malaria 27 \200\223 Renal disease 28 \200\223 Epilepsy 29 \200\223 Connective tissu e disease 30 \200\223 Hypertension 31 \200\223 Thromboembolism 32 \200\223 Thrombophilia 33 Ante/perinatal infection 34 \200\2237 Abdominal pain 38 Abdominal palpation 40 Pelvis a nd head 42 Fetal monitoring 44 \200\2235 Ultrasound 46 \200 Hypertension & eclampsia1 48 Prematurity 50 Small for gestational age 52 Large for ge stational age 53 Postmaturity 54 \200 Fetal distress 55 \200 Obstetric shock 55 \200 Ant epartum hemorrhage 56 Normal labor 58 Membrane rupture 60 Induction of labor 62 Active mana gement of labor 64 Pain relief in labor 66 Multiple pregnancy, IVF 68 \200\2239 Breech 70 O ther malpresentations 71 \200 Prolapsed cord 72 \200 Impacted shoulders 72 Meconium-stain ed liquor 73 Dystocia 74 Forceps/ventouse 76 Cesarean section 78 \200 Uterine rupture 80 \200 Mendelson \200\231s syndrome 80 Stillbirth 82 \200 Postpartum hemorrhage 84 Retained placenta 86 \200 Uterine inversion 86 \200 DIC and coagulation defects 88 \200 Amniotic \202 uid embolism 89 Birth injuries 90, maternal 91 Episiotomy and tears 92 Puerperium 94 Contraception after a baby 95 Maternal mortality 96 Perinatal mortality 97 Sources RCOG Green Top guidelines; Saving Mothers \200\231 Lives (Con \201 dential En- qui ry). 1 Mat mort 2011 Cochrane database (www.liv.ac.uk/lstm/ehcap/pc/nwc-pcl.html). Relevant topics elsewhere: Neonatology, p107 \200\22322; breastfeeding, p124 \200\2236; rhe- sus di sease, p116; ectopic pregnancy, p262; miscarriage/termination, p258 \200\22360; trophoblast ic disease, p264; \201 broids in pregnancy, p277; preterm/light-for- dates babies, p128; chickenpox in pregnancy, p144; parvo virus B19, p142; post- natal depression, p408. 1 The term pregnancy-induced hypertension with proteinuria is tending to replace the term p re- eclampsia. We have not followed this trend as to do so obscures the vital fact about pr e- eclampsia: it may lead on to eclampsia. We favor pre-eclampsia because it is short and s ends the shadow of a shiver down our spines, being a reminder of how dangerous it can be. W e thank Ms Alison Peattie, our Specialist Reader, and Mathuranayagham Niroshan, our Junior Reader, for their contribution to this chapter. \201\201The essence of reproductive health Pregnancy is a risky aff air for babies and mot hers. The textbook causes of maternal mortality in the UK are pulmonary embolism, eclampsia , haemor- rhage, infection, and cardiac diseases, with all the other causes being rare. But if an obstetrician could be granted one wish, it would not be to abol- ish these; rather i t would be to make every pregnancy planned and desired by the mother. Worldwide, a woman di es every minute from the eff ects of pregnancy, and most of these women never wanted to be pregnant in the \201 rst place \200\224but either had no means of contraception, or were without the skills, authority, and self-con \201 dence to negotiate with their partners. S o the real killers are poverty, ignorance, and the unwieldy desires of men, and the real so lutions entail literacy, economic growth, and an equality of dialog between the sexes. Any obstetric or governmental initiatives in reproductive health which do not recognize these f acts are doomed. 2 School-based sex education This can be eff ective, if linked to easy acc ess to contraceptive services. This is the conclusion of a meta-analysis, taking into accou nt cohort studies (if meta-analyzes con \201 ne themselves to the 15 or so randomized stud ies, no bene \201 t is shown). 3 It may be necessary to foster a knowledge-sharing, skill- promoting environment that is part of a continuing process, and not a \200\230one-off \200\231 aff air \200\224for educational programs to work. Adolescent pregnancy rates: USA: 116/1000; UK: 57/1000; Canada: 50/1000. In 2007 in England & Wales 160 pregnancy were term inated in those <14 years old (out of 200,000 terminations and 650,000 live births). 4 1 s c i r t e t s b O De \201 nitions Gravidity refers to the number of pregnancies that a woman has had (to any stage). Parity refers to pregnancies that resulted in delivery beyond 28 weeks \200\231 ge station. An example of the shorthand way of expressing pregnancies before and after 28 week s is: para 2+1. This means that she has had 2 pregnancies beyond 28 completed weeks \200 \231 gestation, and 1 which terminated prior to 28 weeks. If she is not pregnant at the tim e of describing her she is gravida 3, but if she is pregnant now she is gravida 4. Twins pr esent a problem as there is controversy as to whether they count as 1 for both parity and g ravidity or should count as 2 for parity. It is unclear whether the cut-off point in these de \201 nitions should now be 24 weeks, t o harmonize with the new de \201 nition of stillbirth (p82). In general, aim to use proper English rather than the shorthand described above, which is open to ambiguity. For example , when presenting a patient try something like: \200\230Mrs Cottard is a 32-year-old lady who is 15 weeks into her 4th pregnancy; the 3rd ended in a miscarriage at 17 weeks, and the others came to term with normal deliveries of children who are now 2 & 8. \200\231 The bal d statement \200\230Para 2+1 \200\231 is ambiguous, incomprehensible to the patient, and m isses the point that the patient is now approaching the time when she lost her last baby. Length of pregnancy: Normal pregnancy is 40 weeks from the LMP. Nae- gele \200\231s rule: e xpected delivery date (EDD) \211\210 1yr and 7 days after LMP minus 3 months (not if last period was a withdrawal bleed; for cycles shorter than 28 days, subtract the diff erence fr om 28; if longer, add the diff erence). A revised rule suggests the addition of 10 days rat her than 7 is more accurate. 2 Pre-pregnancy counseling \200 The aim is to help prospective parents embark upon pregnancy under conditions most likely t o ensure optimal fetal and maternal wellbeing. Babies conceived 18 \200\22323 months after a live birth have lowest rate of perinatal problems. \200 5 Reduce weight if obese (for ri sks of obesity see p7). Ensure the woman is rubella ( chickenpox, p144) immune prior to p regnancy; assess need for thromboprophylaxis in pregnancy (p16). Other areas include: \200 Optimal control of chronic disease (eg diabetes) before conception. This is also importan t for hypothyroidism as the fetus cannot make thyroxine until 12 weeks and under-replacemen t may aff ect neurodevelopment. Strict diet is essential peri-conceptually for women with p henylketonuria (PKU). Stop teratogens or seek expert advice prior to conception (p29, p31). Parox- etine is assoc iated with fetal heart defects in 1st trimester use, as is lithium (rate \200\200 8 : 1000 to 60 : 1000) with Ebstein \200\231s anomaly \200\200 from 1 to 10 per 20 000. \200\225 6 HIV drugs didanosine and efavirenz have teratogenic potential and avoidance may be possibl e 7 in \201 rst trimester (seek expert advice). \200 Medication to protect the fetus fr om abnormality (eg folate supplements for neural tube defects, see p140 and below). \200 Provide expert information for those at \200\200 risk of abnormality so pregnancy or its avoidance is an informed choice, and any t ests needed (eg chorionic villus sampling, p10) are planned. Regional genetic services give detailed pre- pregnancy counseling. See p154. In relevant ethnic populations, take blood f or thalassaemia and sickle-cell tests (p22). If \200\230cut \200\231 (p247) off er de \201 bulation. \200 Avoidance of infection: eg sperm washing advised if HIV+ve male partn er s c i r t e t s b O and HIV-ve woman If past/family history of thromboembolism, screen for thrombophilia. Diet To prevent neural tube defects (NTD) and cleft lip, all should have folate- rich foods + folic acid 0.4mg da ily >1 month pre-conception till 13wks (5mg/day if past NTD, on anti epileptics, p29, obese (BMI \211 30), HIV+ve on co-trimoxazole prophylaxis, 8 diabetic 9 \200\225 or sickle cell disease p19). Foods with >0.1mg of folic acid/serving: brussels sprouts, asparagus, spinac h, blackeye beans, forti \201 ed cereals. Avoid liver & vit. A (vit. A embryopathy) & caff eine. Smoking decreases ovulations, causes abnormal sperm production ( less penetrating capacity), \200\200 rates of miscarriage ( \211\2102), and is associated with preterm labo r and lighter-for-dates babies (mean is 3376g in non-smoker; smoker: 3200g), placenta praev ia and abruption. \200\225 10 Reduced reading ability in smokers \200\231 children up to 11 yrs old shows that long- term eff ects are important. 17% of smoking moth- ers stop before or in pregnancy. Alcohol consumption High levels of consump- tion are known to cause the f etal alcohol syndrome (p138). Mild drinking eg 1 \200\2232U/wk has not been shown to advers ely aff ect the fetus but alcohol does cross the placenta and may aff ect the fetal brain. Miscar- riage rates are higher among drinkers of alcohol. NICE recommends <1U/24h. Binge dr inking (>5U/session) is especially harmful. \200\225 11 To cut consumption: see p513. Spont aneous miscarriage (SM) Risk of miscarriage is 8.9% in women aged 20 \200\22340yrs, rising to 74.7% for women \211 45yrs. After 3 miscarriages, risk of next preg- nancy failure is 4 4.6% for nullips aged 25 \200\22329yrs, and 35.4% for parous women. 12 Recurrent spontaneou s miscarriage See p261. Search for those who need counseling most \200 Diabetes mellitus \200 Tropical traveler s \200 Frequent miscarriage \200 Hypothyroidism \200 Epilepsy \200 Rubella-suscepti ble \200 Pet-owners (toxo- plasmosis risk is \200\200) \200 Phenylketonuria \200 BP \200\200 \200 SLE \200 Genetic history, eg: \200 spina bi \201 da etc. \200 thalass emia \200 Duchenne \200\231s \200 cystic \201 brosis et al Individualized care plans \200\224eg for diabetes mellitus \200\2259 For optimal care, when there are many features that need to be addressed an individualized care plan can help. Th e example below is of a care plan for diabetic women. The care plan is a chance for dialog between the mother and her carers: all must sign-up to it. Placed in her notes it should be consulted throughout pregnancy when the woman is seen. In the case of a diabetic pregnancy the woman should be seen in a joint clinic where a multidisciplinary team is available com prising obstetrician, diabetes physician, diabetic specialist nurse, diabetes midwife, and dietician. 3 The care plan should cover the antenatal period and up to 6 weeks post-partum. It can be individualized, and generally includes advice about: \200 Aspirin 75mg/24h PO until delivery to reduce pre-eclampsia risk. \200 13 \200 Targets for glycae mic control (p24 for levels; pregnant mother to liaise every s c i r t e t s b O 2 weeks with diabetic team concerning blood readings). Retinal digital screening with mydriasis schedule (as soon as possible after pregnancy con \201 rmed if not screened in previous 12 months; after 1st ante- natal appointment and aga in at 16 \200\22320 weeks if retinopathy seen on initial screen in pregnancy and at 28 week s if none seen at initial screening). \200 14 Up to 20% develop proliferative retinopathy. Renal screening schedule (for microalbuminuria as well as dipstix protein, at 1st appointme nt if not screened in previous 12 months). Refer to nephrologist if creatinine \211 120 m ol/L or protein excretion >2g/day. Give thromboprophylaxis if protein excretion >5g/day. Fetal surveillance (eg 4 chamber and out \202 ow tract echo at 20 weeks; ultrasounds at 28 , 32, and 36 weeks for fetal growth and amniotic \202 uid depth and cardiotocogram eg twi ce weekly from 38 weeks if she chooses to await spontaneous labor rather than accepting ind uction/cesarean sec- tion when off ered at 38 weeks) earlier if growth restriction seen. Plan for delivery. If co-morbidity such as neuropathy or obesity arrange anesthetic assessment at 36 weeks. Diabetes care after delivery. If macrosomia is found on ultrasound the consultant obstetric ian should then write a clear plan to determine follow-up scans, fetal surveillance, and mo de and time of delivery. For postnatal care the care plan should include, as a minimum: \200 Plan for managing glycaemic control (eg return to pre-pregnancy regimen). \200 Neon atal care: feed as soon as possible then 2 \200\2233hrly to prevent hypoglycae- mia. Check glucose level at 2 \200\2234h after birth, and if signs of hypoglycaemia. Give IV glucose t o baby if symptomatically hypoglycaemic. Tube feed or give IV glucose if 2 consecutive read ings <2mmol/L despite maximal feeding or if unable to feed. Do not discharge to community u ntil >24h old, feeding well and able to maintain glucose levels. Contraception (currently mothers with the worst obstetric outcomes are the least likely to receive contraceptive advice). Follow-up care after discharge from hospital (eg glucose tolerance test 6 weeks postpartum and annually to see if still diabetic in gestational dia- betes). How to access pre-pregnancy review prior to subsequent pregnancies. \201\201The advantage of care plans is that by documenting the plan, it ena- bles members of the team (including the mother and father, for they are frequently the most reliable at making sure things happen if they know what is expected) to check that pregnan cy is monitored as planned. Booking criteria and home delivery Most women in the UK have \200\230shared obstetric care \200\231 \200\224ie most of their antenatal care is from the community midwife ( GP), wit h limited (or no) visits (usually 2) to the hospital to see the consultant under whose care they are delivered, returning home (eg after 6 \200\22372h) for postnatal care. A minority receive their complete care from hospitals and the usual reasons for this are that the com pli- cations envisaged make full consultant care desirable. Some women are cared for by com munity midwives and their GP, but increasingly, low-risk women are receiving all their care from midwives, with doctors involved only if complica- tions arise. Delivery may be in hos pital in consultant- or midwife-led units, or, more rarely, at home. \200\207There is quit e good evidence that consultant input into antenatal care of normal pregnancies achieves no added bene \201 ts (p8) \200\224but risk factors making specialist visits and booking des irable are generally agreed (see MINIBOX). 4 Is it safe for low-risk mothers to deliver in high- technology hospitals? Here intervention s with their complications are more common. In the UK this question is usually academic (un less a midwife-led delivery unit is available) as most GPs are reluctant to conduct births \200\224and 6 months \200\231 training in obstet- rics gives scant skill. The rising birth rate and service pressures are putting these big hospitals under great strain. In places (e g New Zealand, Holland) where delivery outside of big hospitals is the norm, there is fairl y clear (but not uncontested ) evidence that on all measures, and in all but the highest ri sk groups, big hospitals come out less favorably. The few trials seeming to favor high-tech nology are now recog- nized to be seriously \202 awed. Home delivery (Rare in England: 2. 8% of births in 2007 at home, 2% in freestanding midwifery units, 3% in alongside midwifery units.) Data comparing morbidity and mortality in home vs hospital delivery is sparse but a 2008 \200\22310 (N=65,438) study showed in- creased morbidity and high rate of transfer i n labor for nullips. 15 But an important observation is that rapid intervention is necessar y to save life (maternal or fetal) in 5% of low-risk pregnancies. This pin- points the nee d for any domiciliary service to have good equipment available for home delivery and good e mergency back-up (eg by emergency obstetric am- bulance units \200\224ie specially trained ambulance per- sonnel who, it is hoped, will liaise directly with senior medical obstetric staff in hospital). Birth centers off er homely birth in congenial sur- roundings (eg with purpose-designed birthing pools). Formerly, labor ward facilities were nearby, if needed, a nd the mother was attended by her GP and community midwife. A randomized trial showed that mothers \200\231 satisfaction is great, and nearly all re- quested this type of delivery fo r future births. 16 Such centers may off er a com- promise to adherents of home delivery, a nd go a long way towards celebrating rather than medicalizing birth. But we note that new U K birth centers may be en- tirely run by midwives, so if an obstetrician is needed (or an e pidural) a lengthy and possibly risky journey is needed. 17 www.birthchoiceuk.com. Risk factor \200\224vis vis: The mother \200 >40yrs old \200 Nullip <20 or >34yrs \200 History of infertility \200 \211 5 past pregnancies \200 Multip <154cm tall \200 Primip <158cm tall \200 Obese with BMI \211 35 \200 Social deprivation \200 HB SAg or HIV+ve p34 Past deliveries \200 Preterm or small (<37 s c i r t e t s b O weeks, <2.5kg) Deformity, still-birth, or neonatal death \200 Cesarean section \200 Hysterotomy \200 Retained placenta/PPH \200 Placental abruption \200 Had pelvic \202 oor repair \200 Instrumental deliverie s \200 Poor fetal growth or wellbeing Diabetes, \200\200 BP, anemia \200 Malpresentations after 34 weeks Serum \200 -fetoprotein \200\200 This pregnancy \200 Cardiac/thyroid disease \200 Ren al/liver disease \200 Multiple pregnancy \200 Rh antibodies (p116) \200 Autoimmune di sorders \200 Asthma/epilepsy 5 5 Issues surrounding home delivery1 \200\207Remember that normal delivery is a retrospective diagnosis. \200 In the UK, because of past hospital experience of many abnormal labors, GPs are often very wary of home birth. Medico-legal aspects tend to dominate thoughts about worst-case scenarios \200\224so that few GPs willingly take on intrapartum care. It \200\231s not clear who is to do the doctor \200\231s ordinary work when absent on a hom e delivery, if a mother particularly wants their GP present. Some small surgeries have had to close during delivery as no locum was available \200\224an unacceptable consequence of o ff ering mothers extra choice. NB: in the UK, midwives, but not GPs, have a statutory duty to help at home deliveries. It is not clear if there are enough doctors or midwives with the necessary experience in su turing and neonatal resuscitation. Where there is a good team, there is no doubt that home delivery can be a safe and rewarding experience. s c i r t e t s b O Decisions about the place of labor are dynamic, and need revising (eg in 29%) as events in pregnancy unfold. Necessary equipment is not readily available, eg Entonox. \200 The key factor in increa sing choice about home delivery is a good working relationship between the parents, the GP, and the midwife. Where this ex- ists, 70% of home delivery requests tend to come to fruit ion; where the GP is rated as being unsupportive, in a UK context, this \201 gure drops t o 54%. \200 Everyone needs to know that transfer in labor is common in labors start- ing off as planned home deliveries (9 \200\22314% if multip, 36 \200\22345% if primip) \200\224 and there is excess morbidity for primips, though levels are still low. 18 \200 It is sa lutary to note that <20% of pregnancies in England and Wales are considered \200\230normal \200\231 and without antenatal or postnatal complications. 19 If normal delivery is de \201 ned as delivery without use of general anesthetic, induction, epidural, instrumentatio n or surgical intervention, the normal delivery rate in England in 2003 was 51%. 20 In the 2008 \200\2232010 study it was 58% for planned obstetric unit birth, 76% alongside midwifer y unit, 83% freestanding midwifery unit and 88% for home birth. 18 However, over- medicaliz ation is a real problem too, eg in \211 20% of labors (p58). \200 Intrapartum perinatal mortality rate for intended home delivery (1994 \200\223 2003) was 0.48 : 1000 births for i ntended home delivery, 1.42 : 1000 for un- intended home delivery, and 6.05 : 1000 births f or women transferred to another place for delivery. 21 Average intrapartum mortality for En gland and Wales for all births for this period was 0.79 : 1000 births. Indications for intrapartum transfer \200 Malpresentation or breech in labor \200 Signi \201 cant meconium-stained liquor \200 Fetal heart monitoring indication including hear t rate abnormalities (p44) \200 Delay in 1st or 2nd stage labor \200 Epidural pain reli ef requested \200 Maternal To >38, or twice To >37.5, 2h apart \200 Retained placenta ( p86) \200 Maternal BP raised +140/ and/or +/90 \200 Uncertainty if fetal heart heard \200 Emergency: (ante/post-partum hemorrhage, cord presentation/prolapse, maternal collapse or need for advanced neonatal resuscitation) 3rd or 4th degree vaginal tear or other complicated perineal repair needed. When considerin g transfer bear in mind imminence of birth. Physiological changes in pregnancy 6 \200 Hormonal changes Progesterone, synthesized by the corpus luteum until 35 post-conception da ys and by the placenta mainly thereafter, decreases smooth muscle excitability (uterus, gut , ureters) and raises body temperature. Oestrogens (90% oestriol) increase breast and nippl e growth, water reten- tion, and protein synthesis. The maternal thyroid often enlarges due to in- creased colloid production. Thyroxine levels, see p25. Pituitary secretion of prola ctin rises throughout pregnancy. Maternal cortisol output is increased but unbound levels r emain constant. Genital changes The 100g non-pregnant uterus weighs 1100g by term. Mus- cle hypertrophy occurs up to 20 weeks, with stretching after that. The cervix may develop ectr opion ( \200\230erosions \200\231). Late in pregnancy cervical collagen reduc- es. Vaginal discharge increases due to cervical ectopy, cell desquamation, and \200\200 mucus producti on from a vasocongested vagina. Haemodynamic changes Blood: From 10 weeks the plasma volume rises un- til 32 weeks when it is 3.8 litres (50% >non-pregnant). Red cell volume rises fr om 1.4 litres when non-pregnant to 1.64 litres at term if iron supplements not taken ( \200 \20018%), or 1.8 litres at term ( \200\200 30%) if supplements are taken \200\224hence Hb f alls due to dilution (physiological \200\230anemia \200\231). WCC (mean 10.5 \211\210 109 /L), plate- lets, ESR (up 4-fold), cholesterol, \200 -globulin, and \201 brinogen are ra ised. Albumin and gamma-globulin fall. Urea and creatinine fall. Cardiovascular: Cardiac ou tput rises from 5 litres/min to 6.5 \200\2237 litres/min in the \201 rst 10 weeks by incr easing stroke volume (10%) and pulse rate (by 15 beats/min). Peripheral resistance falls ( due to hormonal changes). BP, particu- larly diastolic, falls during the second trimester b y 10 \200\22320mmHg, then rises to non-pregnant levels by term. With increased venous diste nsibility, and raised venous pressure (as occurs with any pelvic mass), varicose veins may form. Vasodilatation and hypotension stimulate renin and angiotensin release \200\224an imp ortant feature of BP regulation in pregnancy. Aorto-caval compression From 20 weeks the gra vid uterus compresses the inferior vena cava (and to a lesser extent the aorta) in supine w omen reducing venous return. This reduces cardiac output by 30 \200\22340% (so-called supin e hypo- tension). \200\207Placing the woman in left lateral position or wedging her tiltin g 15 to the left relieves the pressure and restores cardiac output. Other changes Ventila tion increases 40% (tidal volume rises from 500 to 700mL), the increased depth of breath be ing a progesterone eff ect. O2 con- sumption increases only 20%. Breathlessness is common a s maternal PaCO2 is set lower to allow the fetus to offl oad CO2. Gut motility is reduced, resulting in constipation, delayed gastric emptying, and, with a lax cardiac sphincter, hea rtburn. Renal size increases by 1cm in length during pregnancy. Frequency of micturition e merges early (glomerular \201 ltration rate \200\200 by 60%), later from bladder pressur e by the fetal head. The bladder muscle is lax but residual urine after micturition is not normally present. Skin pigmentation (eg in linea nigra, nipples, or as chloasma \200\224bro wn patches of pigmentation seen especially on the face), palmar erythema, spider naevi, and striae are common. Hair shedding from the head is reduced in pregnancy but the extra hairs are shed in the puerperium. Pregnancy tests Positive eg from 9 days post-conception (or fr om day 23 of a 28-day cycle) until 20 weeks of pregnancy; they remain positive for 5 days after miscarriage or fetal death. Otherwise, the false +ve rate is low. They detect the \200 -subunit of human chorionic gonadotrophin in early morning urine, so are positive in t rophoblastic disease (p264). s c i r t e t s b O 7 \201\201Pregnancy and obesity 22 (BMI >30 at booking, p530) Maternal obesity aff ects the fetus adversely, casting a long fat shadow over the baby \200\231s adult life (with risk of heart disease, diabetes, the met- abolic syndrome and some cancers, eg breast, lung). 23 E pigenetic mechanisms (p653) mean that the over- (and under)nutrition may in \202 uence not just this baby, but subsequent generations down the centuries. 24 There is also risk of ma crosomia, meconium aspiration. 25 Incidence is rising in the UK and women with a BMI >35 co nstitute 15% of mothers dying, and almost 50% of those dying from thromboembolism are obese . \200\207As mothers may be more motivated to accept lifestyle modi \201 cations, pregnan cy is a period during which obesity can be more eff ectively man- aged. Control of body wei ght during this period is vital. Aim to encour- age weight loss well before embarking on pl anned pregnancy. NB: dieting during pregnancy may not be wise as low weight gain during pre gnancy correlates with lighter babies more prone to postnatal problems. 26 Good evidence is lacking. Lowest neonatal mortality is for birth weights of 3500 \200\2234500g and maternal weight gain depending on BMI: 27 For mothers, obesity in- creases prevalence of: \200 Miscarriage \200 Pre-eclampsia \200 Gestational diabetes \200 Thromboembolism \200 Cardiac disease \200 Induced lab or \200 Cesarean section \200 Infection (eg post-op) \200 PPH \200 Maternal mortali ty \200 Feeding by bottle s c i r t e t s b O BMI <19.8 recommended total weight gain (not twins): 12.5 \200\22318kg 11.5 \200\22316kg 7 \200\22311.5kg 2* \200\2236kg 19.8 \200\22326 26.1 \200\22329.0 >29 Assuming personal coaching and using a food diary ( \200\234I didn \200\231t eat the cake a s I knew I \200\231d have to write it down, so I chose fruit instead \200\235). Some may need no weight gain. 2010 CMACE/RCOG guidelines recommend giving 5mg folic acid from 1 mon th before conception and for the \201 rst trimester if BMI \211 30 to prevent increased risk of neural tube defects. Obese women are more prone to vitamin D de \201 ciency so ens ure they are taking 10 g vitamin D supplemen- tation while pregnant and breastfeeding. If BMI \211 30, screen for diabetes, eg oral glucose tolerance test at 24 \200\22328 weeks an d consider heparin throm- boprophylaxis for 7 days postnatally if one additional thrombotic risk fac- tor (p16), with addition of TED stockings if 2 risk factors. Mobilize all obese women early. If women with BMI \211 30 require cesarean section, give IV prophylactic anti biotics and, if subcutaneous fat is >2cm thick, suture that separately, to prevent infectio n. medicinenet.com/script/main/art.asp?articlekey=100897 " t n a n g e r p g n i e b t u o b a Women with BMI \211 40 should always receive 7-day postnatal heparin prophylaxis and TED s tockings whatever the mode of delivery. They should have an antenatal consultation with an obstetric anesthetist with an an- esthetic plan made for labor and delivery, and need 3rd t rimester assess- ment to plan manual handling requirements and provision of appropriate TED stockings. When in labor inform anesthetist. They should have con- tinuous midwifery care and should have an IV sited early in labor. If opera- tive delivery is required the attendi ng anesthetic should be a consultant (or signed off obese-competent) obstetric anesthetist. g n i h t e c i n y l n o e h t s i 2 r o f g n i t a E " Antenatal care 8 \200 The aims of antenatal care are to: \200 Detect any disease in the mother \200 Ameliorat e the discomforts of pregnancy \200 Monitor and promote fetal well- being \200 Prepare mothers for birth \200 Monitor trends to prevent or detect any early complications of pre gnancy: BP is the most important variable (eclampsia, p48). \200 Is thromboprophylaxis (p 16) or aspirin (p3 and p31) needed? Who should give antenatal care? Midwives may manage car e, calling in doc- tors if risks (p4) or speci \201 c needs arise. Book by 12 weeks: see w ithin 2 weeks if already \211 12 weeks pregnant. Women with BMI \211 35 need consultant c are. The 1st antenatal visit is very comprehensive. \200\207Find a language interpreter if she needs one. Avoid using relatives (con \201 dentiality issues). History: \200 Usual cycle length; LMP (a normal period?); see Naegele \200\231s rule (p1). \200 Contraception ; drugs; past history, eg surgery to abdomen or pelvis. \200 Any fertility problems; outc ome and complications of past pregnancies. \200 Is there family history of diabetes, BP \200\200, fetal abnormality, or twins? \200 Does she have concurrent illness (p20 \200 \22335)? Has she been \200\230cut \200\231 (p247). If past or family history of DVT or embolism, screen for thrombophilia. Is gestational diabetes (GDM) a risk? Screen (75g glucose tolerance test) at 18 28wks) i f previous (GDM); at 24wks if BMI >30, previous baby >4.5kg, 1st degree relative diabetic, family origin (FO) from area of high risk of diabetes. \200 Past mental illness? If serio us (schizophrenia, bipolar disorder) or past post- natal problems, get antenatal assessment ; put management plan in notes. s c i r t e t s b O Is she poor (eg gas/electricity supply cut off )? Unmarried? Unsupported? Subject to domest ic violence? (p514) A substance abuser? (p362). \200\230Healthy Start Vitamins for Women \200\231 \200\224folic acid + vitamins C & D (10 g/d) are free to some during pregnancy an d for 1 year after birth (Healthy Start Scheme UK). \200 Avoid p t s & blue/soft cheese (eg Brie, Camembert, to avoid listeria, p35); Toxoplasmosis advice: p34. Avoid liver (p2). Advise UK mothers to have vita- min D (above) if family of origin is African, or as listed below,1 or housebound, covered when outdoors, have BMI >30, or are diet vit. D depleted.2 Examination: Check heart, lungs, BP, weight (record BMI), and abdomen. Is a cervical smear needed? Varicose veins? Sensitively ask if genitally \200\230cut \200\231 (p246). Tests: B lood: Hb, group (antibodies if Rh \200\223ve, p116), syphilis & rubella ( chick- en-pox) s erology, HBsAg (p36 & p26) HIV test; sickle test if black, Hb electro- phoresis (p22) and 2 5-hydroxyvitamin D if relevant. 28 Take an MSU (protein; bacteria). Arrange tests to exclud e Down \200\231s (p12). If she is foreign, a TB contact, or a hospital worker, consider CXR after 14 weeks. Off er early ultrasound to establish dates, exclude multiple pregnancy and aid with Down \200\231s tests and an 18 \200\22320-week anomaly scan. Suggest: Parentcraft /relaxation classes; dental visit. Enquire about problems and anxieties. Consider need for iron and folate (p85 and p22). Advise on: Smoking, alcohol, diet, correct use of seat belts (above or below the bump, not over it) and adequate rest. Ensure knowledge of social secu- rity bene \201 ts. Usual exercise and travel are OK (avoid malarious areas) up to 36 week s (singleton): 29 check with airline. Intercourse OK if no vaginal bleeding. Later visits C heck urine for albumin, BP, fundal height. Check lie and presen- tation at 36 weeks. Do Hb and Rh antibodies at 28 & 34 weeks and give anti-D then if needed (p9). Visits are at <12 w eeks then at 16, 25, 28, 31, 34, 36, 38, 40, and 41 weeks (primip). Weigh only if clinicall y indicated. The head is usually engaged (p40) by 37 weeks in Caucasian primips (if not, consider: large (or malpositioned) head, small pelvis or obstruction, placenta praevia, or wrong estimatio n of dates). 1 FO=family of origin from India, Pakistan, Bangladesh, Saudi Arabia, United Arab Emirates, Iraq, Jor- dan, Syria, Oman, Qatar, Kuwait, Lebanon, Egypt, or if black Caribbean. 2 Vitam in D containing foods include oily \201 sh, meat, eggs, forti \201 ed margarine, and bre akfast cereal. 9 9 Using anti-D immunoglobulin Dose: 250U for gestations <20 weeks, 500U if >20 weeks, (1500U if no Klei- hauer). Give in deltoid (buttock absorption too slow); IV \200\22530 or SC if bleeding disorder; as soon as possible after incident, by 72h (some protection if by 10d). From 20+0 weeks do Kleihauer test (FBC bottle of maternal blood; fetal RBCs therein are les s susceptible to lysis, so can be counted to measure the bleed \200\231s volume). Don \200 \231t give anti-D if already sensitized ie antibodies to anti-D are present. Postnatal use: 500U is the normal dose after 20+0 weeks \200\231 gestation. 37% of Rh \200\223 ve women g ive birth to Rh \200\223ve babies and these women do not need anti-D. \200 Anti-D should be given to all Rh \200\223ve women where the baby \200\231s group cannot be determined (eg macerated stillbirths), or if the baby \200\231s group is unknown 72h post delivery. s c i r t e t s b O Do a Kleihauer test on all eligible for anti-D. 500U anti-D can suppress im- munization by up to 4mL of fetal red cells (8mL of fetal blood), but 1% of women have transplacental hemo rrhage (TPH) of >4mL, especially after manual removal of placenta, and with cesarean sectio n. A Kleihauer test is especially important in stillbirth, as massive spontaneous transplac ental hemorrhage can be the cause of fetal death. Where >4mL TPH is suggested by the Kleiha uer screen, a formal estimation of the TPH volume is required and 500U anti-D given for eve ry 4mL fetal cells transfused (maximum 5000U anti-D at 2 IM sites/24h). Note: Kleihauer tes ts can be negative where there is ABO incompatibility as fetal cells are rapidly cleared fr om the maternal circulation. Liaise with the transfusion service. Check maternal blood ever y 48h to determine clearance of cells and need for continuing anti-D. Any mother receiving anti-D prenatally (see below), should also receive it postnatally unless she delivers an Rh-negative baby. Use of anti-D in miscarriage in Rh \200\223ve mothers 1 Anti-D should be given to all havin g surgical or medical terminations of pregnancy or evacuation of hytadiform mole (p264), un less they are al- ready known to have anti-D antibodies. Give 250U if <20 weeks; 500U (and Kleihauer) if >20+0 weeks \200\231 gestation. 2 Anti-D should always be given where spontaneous miscarriage is followed by medical or surgical evacuation. 3 Anti-D should be given where spontaneous complete miscarriage occurs after 12+0 weeks \200\231 gestation. 4 Threatened miscarriage \211 12+0 weeks give anti-D; if bleeding continues in- termittently give anti-D 6-weekly until delivery. 5 Routine anti-D is not recommended with threatened miscarriage before 12 weeks \200\231 ge station (but consider if viable fetus, heavy or repeated bleed- ing, and abdominal pain). Use of anti-D in pregnancy in Rh \200\223ve mothers 1 Give anti-D 500U at 28 and 34 weeks t o rhesus negative women (primip an- tenatal sensitization falls from 0.95% to 0.35%). Anti- D may still be detect- able in maternal blood at delivery. Still give postnatal anti-D, if indicated (as above). Take 28-week blood sample for antibodies before 28-week anti-D. 2 When signi \201 cant TPH may occur: with chorionic villus sampling; external cephalic ve rsion; APH; uterine procedures (eg amniocentesis, fetal blood sampling); abdominal trauma; intrauterine death. Use 250U before 20 weeks \200\231 gestation, 500U (and do Kleihauer) af ter 20 weeks. 3 Anti-D should be given in cases of ectopic pregnancy. 4 For threatened miscarriage, see a bove. Prenatal diagnosis 10 \200 