a san. refers to the pat PRESENTATION a » lower fetus occu Normal Pp’ clude fact shoulder resentation e, cord, lic. a it pe resentations is cephal breech, compound p: ~ the part of the PRESENTING PART hin the birth fetus that is foremost wit canal or the leading portion of the felt at —_ vaginal presentation examination. Nonmal presenting part is vertex. Others include face, brow etc. LIE - the relation of the long axis of fetus to the long axis of the uterus. Normal lie is longitudinal ABNORMAL LIE: Any lie other than longitudinal ATTITUDE - the relation of different parts of the fetus to one another in terms of extension and flexion, Normal attitude is flexion DENOMINATOR - are selected parts of the fetus that denotes the p ws ee Presentation, it is the face is chin, breech is sacrum POSITION _ ip which some selected ihe fetus (den : fe bee ae Part of the maternal pelvis the abdominal a n “fifth expressed it MALPRESENTATION fetus presents | than the vertex. M be breech, face, brow and compound BREECH PRESENTATION when the fetal buttoc extremities occupies pelvis. FACE PRESENTATION when fetal head is hy such that the presenting face between the chin and the presenting (submentobregmatic) is 9.5 BROW PRESENTATION: when there is a lesser de. extension than in face pre: such that presentation is 1 between face and vertex and eae diameter (mentover: SHOULDER PRESENTATION Occurs when lie of the fetus transverse 6r oblique such that Presenting part is the shoulder. SORD PRESENTATION: when the eee © the leading part Vaginal examination wit! still intact.THE Gi CORD PROLAPSI environme POLYMENORRHOEA AMENORRHEA: day (primary amenorrhes cn 7 POSTMENOPAUSAL BLEEDING: jerine that occurs more DYSPAREUNIA int urse. NB: Vaginismus is due to spasm of the ygeus muscle leading to pubococ closure of vaginal _introitus, preventing penetration. : Cyclical low HYPOMENORRHOE me menstrual loss usuaily less nl per cycle. thanHISTORY 1. BIODATA 3. PAST OBSTETRIC HISTORY Na Age; Occupat Addre (Det each pregnancy, cent) Religion anc 3); Tribe; M leve ty; Last (LMP); Expected date D); Esti Last child bi 2. REASON(S) FOR VISIT It may be for - Booking - Routine ar - New comp Ask about - Eve onset of f has she been booked? - Problems since onset of p dead) and treatm received - Number c visits 4. GYNAECOLOGICAL HISTORY arche th of menstrual cycle and foie Immunizations and age the ere h stational age they of menses were rece - Ask about history of: Menorrhagi - Regularity of intake of haematinics yspareunia; Dysmenorrhea; Problems arisen si onset of Contraception ancy and treatment pregt - Drugs she has been takir - Details of abortion if any (if not - Investigations done PCV ready detailed in history of previou Genotype, Blood group, VDRL, pregnancies above) screening for hepatitis (HBSAG, Anti -_ Last pap smear HCV), screening for HIV, Urinalysis, uss * Genotype and blood group if known * HIV status5. PAST MEDICAL HISTORY DM, T.B, Asthma Bh ‘cause Rhe Previous VVF rer allergies 6. FAMILY HISTORY DM, HTN, Twinning 7, SOCIAL HISTORY 8. DRUG HISTORY Drug of importance: Antihypertensive, Oral hypoglycemic agent, Phenytoin, Warfarin. Tacycline, 9. SYSTEMIC REVIEW 10. SUMMARY Name; Age; Gravidity; Parity; EGA; Reasons for visit: Important findings; Investigations done Calculation of EDD f Estimation of g N 5 S o > 4weeks +1Wk 8 a) > 4weeks 26/2019 9/6/2019 _» 1 week 5 days EGA= 14 weeks 5 days PHYSICAL EXAM INATION 1. OBSTETRIC EXAMINATION This is divided into;al examination Ge Note: Be 1 consent Always examine from ri patient Hair - Byes- Pallor, Jaur Tongue and Buccal m’ Pallor, Cyanosi Dental hygiene, Oral thre Peripher nodk Cervical Thyr r gol t ond - Temperat - Pedal oedema- present present, dete Seca Also note: likely to have SC (s women may fying obesity in p av norn tolerance with possible foe macrosomia 2. ABDOMINAL EXAMINATION en from breast - Expose the abd xiphisternum or just below the to pubic symphysis. This should be done by the patient. i. Symph measurement- ndus. tap tward hich is already hand, tu and read in er ment on findings as com EGA from LMP (see other sectionsTnr bun SFH _ EGA INCOMPATIBIL ITY SPH EGA = cores (-N\ | ~ 3. PELVIC EXAMINATION a. Vaginal examination ime 36, weeks NB: SFH becomes less accurate as th pregnancy gets older PALPATE THE POLE ii, Fundal pole - whether head (round, ha ballotable) or buttocks (soft broad) occupies the fundus determine ly done except in som. iii. Lower pole - To 1m b. Speculum exam (in obstetrics) whether head ot buttocks occupies the To assess cervical |; of cervix ke a cervical sme iv. Lateral palpation - To determine jij, To check for liquor drainage fetal back (firm and continuous) and i To take high vaginal limbs (irregular shapes and knuckles) rvical swab for M/C fs v. Removal of Marcelin tape lower uterine segment v. Demonstrate lie - holding cach pole with thumb and forefingers, you can check the long axis of the fetus Rote: relation to the mother. The lie canbe " If asked to do abdom longitudinal, oblique or transverse. examination, it involy ‘slight deep palpation as well tamination of the uterus Note: ¥i. Demonstrate presentation Scsten over the fetal hack or pregnant Patient (at >20w; Auscultation * To palpate for splenic enlargement anterior shoulder for fetal heart tones -$€Station), start from the LEFT ILIAC with Pinnard stethoscopeninal and as nent peks [AC THE GUIDE: ross, if into the region + Bladder she for easier P ‘examination METHODS OF FETAL WEIGE ESTIMATION (EFW) formula a. Johnson's EFW = (FH-n) * 1 n= 12when n=1when FH = fundal height b. McDonald's formula EFW = FH x . Ojua's formula EFW = 5% of mater d. Ultrasound estimation. HISTORY 1, BIODATA jame: Title, surname first name (note that first name comes before urname) Age Religion (and denomination hovah witness) especially if = Occupation; Tribe; Address - Marital status; Level of education Parity; LMP; Last child birth HISTORY 4. GYNAECOLOGICAL thoea, 2, intermenstrual bleeding, ep) duration, nia (Superficial, History of infertility termination of estational why), nancy with their ze(s), reason for termination vhere, how, complications. vii.Presence of abnormal vaginal discharg viii, Previous gynaecological treatment and surgery, last result of cervical smearegnanicy Pe tirth weight oF cme) present state ¢ RY AST MEDICAL HISTC 6 TORY (sick e 7. FAMILY HISTORY History < history of lings/ pare hypertension, diabetes mellitu: 8 SOCIAL HISTORY Marital status, husband's occup ‘i smoki lucational eve ple sexual partners. and =e alcohol, mu 9. SUMMARY Brief and co relevant po ike age, parity Presenting complaint and duration, important positives and negatives and care given so far e, should include Example I have Presented a 24yr old P1+0 woman with a 2wk history of leakage of urine: Her Jast delivery was Conducted with an instrument 18hrs after she fell in labour A DELAYED/ABSENT MENSES/CESSATIO ky Was there h menstrual flow man's syndr excessive weig! stoxic drugs : dache; visual! dis Hx of cold / heat intolerance Hx of abdominal swelling (like due to hematometra) Hx of abnormal breast discharge Beards, hoarseness of voice Hx suggestive of abnormal vaginal discharge, puerperal sepsis, post- abortal sepsis Nature and colour of discharge should be noted Hex of pelvic instrumentation eg D&c Ask about premenopausal symptoms Contraceptive use Abnormal menstrual loss Ask about the last normal menstrual period- When? CycleTHE SUE VAGINA 1 BLEEDING PER VAGINAM FE. ABDOMINAL SWELLING lity of f t Presst nt at n| nt consti Liffieulty Relati it Contraceptive hist Features of metastasis: bone pain, dated abd dlice, homoptysin ete pain yy other part of the History of w = t iywe GUIDE DIFFERENTIAL i DIAGNOSIS Vv 215 RGE AGINAL DISCHARS 1. 3 | Cervical carcinoma | Endometrial carcins - Senile vaginitis ABDOMINAL MASS: Pregnancy Fibroid ma Benign ovari = Ovarian m + Endometri Leiomyosarcoma - Tubo-ovarian mass tumor ignancy carcinoma. Mass from any other organ e.g. full bladder, colorectal carcinoma | 4. ABDOMINAL PAIN: Ectopic pregnancy | > Labour Seizure Cerebral m Hypoglycaemia tis - Encepha - HiVencer - Metabolic ¢ ernatraemia, hypocalcaemi alopathy nditions e.g 7. CAUSES OF IUGR Acronym- IUGR 1- Inherited - chromosomal or disorders U— Uterus - placental insufficiency (PE, maternal CVDs, DM, Si G - general - maternal malnutr smoking R - Rubella and other conger infection _—Pelvie organ changes a. Chadwick's sign L the vascula P purplish discol vagina and cer b. Hegar’s sign: Wid ning of the ual © McDonald's sign: Ut flexible at the (7-8 weeks) is becomes terocervical junction 4. Ladin's sign: Uterus softens in the anterior midline along the Uuterocervical junction (6 weeks), jell's 53 Fernwald’s nFer i hoea eucort Introduction d as ne first trimeste dehydration, k ical weight loss of more tt pre-pregnancy weight spells may also occur It is considered more seve morning sickness, Symptoms often get better afte 20th ek of pregnancy in about & it may last. the duration entire pregnancy Risk factors * First pregnancy * Multiple pregnancy * Obesity * Prior or family history of HGTHE GUIDE: * Tropt Causes Signs and symptoms When v in the fo © Loss of 5% or more of pre body w * Dehydration, caus constipation * Nutritional disorders: (thiamine), vit B6 (py B12 (cobalamin) deficiency * Metabolic metabolic thyrotoxico: * Physical and emotional stress Difficulty wit living. Aggravating factors * Symptoms can be aggravated by hur vitamins specially those containing iron), and , fatigue, prena od pregnancy test scan to confirm GA, exclude GTD T, pancreas etc. d assess the liv * FBC: WBCs differentials to r/o infections; hematocrit level (usually raised) * Euchre for ren: Urinalysis, urine M/C/S to r/o UTI * RBS to r/o DM ketoacidosis * Liver & thyroid function tests * Serum amylase for pancreatitis junction statusManag ANTENATAL CA * Antie Complications 3 : Maternal COMPONENTS A. Booking and registration “Cc pat * Mallory-Weiss tear, 5 syndror save B. EDUCATION ndance danger 8 Bleeding *Smull for gestational age itionTHE GUE: immunization sexuality d , HISTORY i. Biodata to ii, LMP - Ultrasonogs 2. SpecificTHE GUIDE: Note: . Traditionally, isit is ex every weekly “Focused a evidence-ba: antenatal vii achiev care “Emphasis include: eviden care, family cen not quantity of visit, care 4 ts of antepart: providers = There are 4 visits which include b Serial S r First visit sequent visits 32wks, 36w Goals of focused antenatal care: - Health d diseases n and prompt of complica x child deliver ae aseline variability = 1 more acceleratior A. HIGH RISK PREGNANCY ‘ It is a pregnancy with increased chance of having an adver: in the mother period of obsery bpm above baseline he baby compared tc the general obstetric opulatic is ae fat Obstetric population C. Investigations for exclusion of ese include; _ fetal abnormalities; a. Patient < 18yrs or >35years USS arity y - Chromosomal analysis ¢ b. Grandmultiparity / null ¢. Too short (<1.5m) Down's syndromeTHE GUIDE: = t = : = 5 S = Pp T-PARTUM CARE At , 2. Manage the 4 ge of omit eastfe 3. Care of the Vulod . F )W-UP CARE allowed after vaginal delivery TDEFINITION onset of painful ac It is char palpable contractions increasing and associate . creasing cervical efface ; rvical OS dilatation and descent of tel per delivery of num. Types Preterm labor: 28" week tc 37" week. : * Term labor: 37% completed week 42-4 week Characteristics of normal labor * Spontaneous onset (without induction). * Painful, pro, more in 10 mins) contr «Vertex presentation * Passage of show (blood tinged cervical Mucus) * Vaginal delivery occurs within 12hrs (Multigravida) or 18hrs (primigravida) sive, periodic (1 or tions. Note; Administration of Oxytocin to Onprove uterine contractions and labor progress in a woman at term y already established in the ac conside; is id normal labor if response ta mis good and eventual vaginal delivery, STAGES O FIRST STAGI THE cervix fr strong ute: tractions. * Normal duration within 2 primigravida and —10hrs : multigravida * Prolonged: When active ph S over 12 hours 2ND STAGE OF LABOUR 2 Begins with full cervical dilatation S ends with delivery of the baby Composed of 2 phases Phase 1 (Propulsive/ Passive):M May be profonged in pidural ary i THE THIRD STAGE SIGNS OF PLACENTAL SEPERATION umbilicus. delivery THE FOURTH STAGE rtum care * Immediate po: MANAGEMENT OF LABOUR rst stage of labour . tion of ‘oma . rventior required whe plications like fetal distr ypertension or rupture of fetal membranes are noticed In the active phase of tabi * Continuity of care and eme* Observation © Adequi 2. Second stage labour Monitor contraction {normal is 3-8/10min| * CTG (every 5 mini te in between con! rate bradycardia. aternal pulst cially wh © Check the 1 pressure, pr * Vaginal examination every 4ho! for size of cervical dilatation and station of fetus. ; heart condition exis * Encourag urge to bear down is imminent stension of f the active pusl * Observe progressive the perineum and visibility o presenting part * Conduct the delivery with support for the perineum to avoid tears, and use of episiotomy only where a tear is very likely * Augment labor with LV oxytocin if contraction is inadequate (with normal fetal heart rate) * Instrumental vaginal delivery (vacuum or forceps) where indicated for fetal bradycardia or no advance of the Presenting part 3. Third stage labour agement may be passive or ac tive Passive COMPONENTS OF ACTIV: mbrane NAGEMENT OF LABOL artificial d. Use of oxytocic e. Use of anal; f Companic @ Managem: ship DEFINITIONS Induction of labour is the Hutiation of uterine Parturient membranes with after the aphic monitorir of 3r contractions i intact foe age of viability——— SS THE GUMDE pefore its natural onset, with ¢ of achiev me ‘or surgical adical NB failed Induction: is fastur vaginal delivery i F followin duction irre for the failure or ication for the caesar Stimulation on of ub ont init the foetal memt labour Augmentation pote ntiation of labour that has begun spontaneously AIMS OF INDUCTION 1, To achieve vaginal delivery 1 ancy preg inuation is adjudged to F INDICATIONS Maternal « Preeclampsia/ecla «Previous precipitate |2 «Prolonged pregnancy + Antepartum haemorrhage at term ~ Previous unexplained IUFD «Rhesus iso-immunization * Medical conditions (DM. Hypertension, chronic ren?” disease) + Social (patient's convenience obstetrician's convenience} RISKS OF INDUCTION sr infant ¢ operative vaginal of birth rauma ase ri Requirements for induction factory indication = and Ir Assess ormed conse foetal maturity / irmation of g) stational age foetal Reassuring biophysical i profilei : “ . + Adequate pelvis © Exclude vaginal delive e Facility for ¢ : , tion or instr k ' Methods of ripening the cervix | aie e Membrane sweepir k a i A * = Intracervical catheter + Prostaglandin pessary aa * Oestradiol gel * Nitric oxide donors : Th 1 Table below shows the Bishop Score Syste [2 ractows —— | Posion CONSISTENCY THIN CM) ION OF THE |__| PRESENTING pas | | evrcaces — [a Duara) TOFAL SCORE 3. — 0-5 UNFAVOURABLE scope 6-13 FAVOURABLE sconeIntroduction Obstructed labour is a labour in which progress has come to a complete frat) in the presence of good and ena uterine contractions due to mechanical factors and deliver is impossible without assistance. It usually occurs as a result of failure of labour management. a. Note- this is not the same as cephalopelvic disproportion (CPD) in which delivery is still possible RISK FACTORS/AETIOLOGY A. Maternal * Bony obstruction: - Contracted pelvis. - Tumours of pelvic bones. « Soft tissue obstruction: - Uterus: impacted fibroids - Cervix: cervical stenosis, dystocia - Vagina: septa, stenosis, tumours. - Ovaries: Impacted ovarian tumours. B. Fetal -Macrosomia - Mal-positioning e.g. occipito- posterior ~Mal-presentation e.g. face, brow, shoulder dystocia, compound presentation, breech with deflexed head, impaction or extended hands - Congenital abnormalities ¢8- hydrocephalus, locked and conjoined twins, fetal tumors >Maternal Cephalopelvic disproportion zeni led birth attendants - When diagnosed early and prompt intervention is instituted - So there is no complication either to the mother or the fetus Minimal caput and moulding - More common in multigravida at term - May occur in hospital setting 2. Complicated obstructed labour - Failure of early diagnosis or intervention resulting in severe maternal/foetal morbidity and mortality. Characterized by - Excessive caput formation and moulding - Bladder oedema and bruising causing difficulty in bladder catheterization - Excessive vulva oedema - Thinning of lower uterine segment - Uterine rupture with extrusion of fetus into the abdomen (in some cases) - Fistula formation - Fetal asphyxia - Cerebral birth trauma Management Diagnosis is based essentially on the history and physical examination.LE Ac History opto jon ¢ «Onset /dura fabour- for several hours OF 8 Miensive liquor drainas *Offensi discharge a adequacy ofcontraction History of augmentatic » Hx of risk factors an difficult labour, and prolong} *Past Hx 0! } instrumental deliveries labour (pelvic factor) *None/poor attendance at clinic *Poorly supervised antenatal ised unsupervised B. Examination General: : Patient is anxious, in painful distress, exhausted, dehydrated, febrile, obvious risk factors e.g. short maternal stature, limb or pelvic deformity. RS & CVs: Increased respiratory rate, increased pulse rate, BP may be increased, normal or decreased (if complicated by uterine rupture). These are signs of metabolic acidosis, Abdominal examination: *Good uterine contractions or tense uterus (but in primigravida the contractions might have stopped) * The three (3) tumour signs 1. Oedematous enlarged bladder at the lower end 2A distended lower uterine sepment aces ring near the umbilicus * tonically contracted 1; i Segment above the Banal tag ha dilated -Severe mould - Failure of he part is high up) - Contracted ; as a cause. C. Treatment Principles of manag *Resuscitate- ABC *Control —_infection- pectrum antibiotics *Urethral catheterization urinary output, get urine san investigation * Pass NG tube e Prolonged obstructed patient has developed ileus in preventing anaesthesia *Relieve obstruction ie. delive aspirations for alsc ring, Vaginal i symphy = now out fotomny pstetric dated in due , modern © multiple i, Destructive operations fetus must be dead ¢ must be willing to fetus (because patient accept the : of mutilated dead medico-legal reasons) skillful person must be available «cervix must be fully dilated -na evidence of uterine rupture ructive operation can be: i, Craniotomy- cephalic dead foetus ‘with descent not more than 3/5. ii, Decapitation- for transverse or oblique lie iii, Geidotomy- for impacted shoulders by fracturing both clavicles. iv. Embryotomy- e.g. fetus with abdominal tumour. v. Drainage of hydrocephalic head Care after destructive operation - Evaluate for genital tract injuries and repair any if noted. ~ Continuous bladder draina, ef Jeast 10 days, ie - Broad spectrum antibiotics ~ Analgesics ~ Preconception care in the Pregnancy: a p. COMPLICATIC i. Maternal com Early _ Post-partum ha: Uterine rupture : Fistula form: - Puerperal sepsi Late Obstetric pals injury) Osteitis pubis - Prolonged amenorrt Acquired gynaet - Pressure sores - Postnatal depression - Prolonged amenorrhea " econdary infertility \d blockage following, sepsis c ii Foetal complications F - Fetal distress di - Severe perinatal asphyxia (Sy ischemic encephal i Hypoxic (HITE) - Intracranial haemorrhage - Neonatal sepsis - Other birth traumas - IUFD; Neonatal death - Neurological injuri Cerebral pal: FOOT DROP A peripheral nerve injury to nerve supplying he lower limbs Causes: oe Pressure = on the ae aes by the foetal he. ues imjury to sciatic nerve by oe hyper flexion of the th ae as lumbo-sacral trunk passes a ae joint. L4 &L5 are osest bone, So mostly affectedsy es he Clinical featur * Mainly paralysi: flexion of the foot, E xtend the tc roneous pere failur i 1° pi General mieasu _Identify at risk group - Good and adequate r - Childhood immunize Prevention of teenag Encourage ar delivery in hos ‘oid harmful cu Improved frastructures - Women empowerment Advocacy and legislation quackery - Availability of ANC 3ON inTRODUCTIO Incidence knee 3. Footling or Incomplete: - One or both limbs are extended at both hip and kn thus one or both feet lie bel buttocks. - 10-30% of cases lower 2 joints, w the e/Mat Management A. History No ific features, - Pati mt may complain of ep ubcostal discomfort (d (ii ssure of head on ribs) B. EXAMINATION = Abdominal nspection: No characteristic S findingTHE GHDE {anencepha 2. Plain abd nd not rout radiation ext D, MANAGEMENT OPTIONS: Rs (ii) Vaginal breech del aS pestetions = iii) Caesarea r : i i, External cephalic version . a ee *An_ external h to cephalicFetal 8 Diabete puscaesan Previou! - Myon Complications: Placental abruption ment Cord ent Transplacental haemorrh, Premature rupture of - Fetal bradycardia - Preterm labour - Prematurity ii, VAGINAL BREECH DELIVERY *Spontaneeus breech delivery: No ¢ infant antly in traction or manipulation o is used. This occurs pred very preterm deliveries. “Breech extraction: ~ delivery solely by obstetrici ithout maternal effort —_(not recommended) ~ the fetal feet are grabbed, and the entire fetus is extracted. should be used only for a noncephalic second twin ~ extraction for the singleton breech is associated with a birth injury tate of 25% and a mortality rate of pproximately 10% n Indications and experience ; - No contraindicatic delivery (previous C/S, , long Factors against breech delivery * Large or small baby oa * Small pelvis on pelvime' flat sacrum ze + Primigravica : * Previous cesarean sectior se * Poor obstetric history N * Long history = subfertility /assiste. Advanced materna Extended neckTHE GUIDE: Procedure: *ldeally, Once the breee *Give a pudendal block *Give episiote - For Frank breech, Pinnard manoeuvre i fi en free the co umbilicus, t and feel for pulsat: * Use a dry towel to wre hips (not the abdomen) to help w gentle traction of the infant sAllow descent until the scapula is seen, then deliver the arms jote: - Flexed arm inserting a _ finger posteriorly. - If Extended -Lovset's manoeuvre i" which; 3urns-Marshr-coming head otling and frank) anial Cervical spine injury and brachial plexus injuries Fractures of long bones femur) iii, CAESAREAN SECTION: * Indications Estimated fetal weight <800g or 00g Footling presentation Contracted pelvis Hyperextended head Secondary arrest of progress Fetal Distress Poor obstetric histo; * IUGR +/ - Primigravida Absence of experienced obstetrician ‘Any other contrain, vaginal delivery ry ication to SHOULDF! INTRODUCTION Risk factors facrosomia * Maternal DM * Previous Hx * Prolonged labor * Failure of head to desc stage of labor * Prolonged 2” stage of Iz * Assisted vaginal delive Management It is an obstetric emergency ar should be handled by expe obstetricians, + Call for help * Make generous episiotomy Sreater access to the Pelvis for am manoeuvre Manoeuvers in the delivery of shoulder dystocia : a Me Ri POSition( ng of mother’s legs Mate i ™al thigh hyperflexion ‘obert manoeuver: to correcpplies lateral s Jodge the should : If this fails b. Deliver posterior shoulder: Pass your hand ur and the posterior shoulder down. Backward p’ fossa to dis of the arm chest Afterwards, ily relieve If this fails; ¢. Wood-cock screw manoeuver: INTRODUCTION prolapse: is Internal rotation of the should from anterior - posterior t position ~ Posterior shoulde corkscrew fashi —Then apply g maternal pushi If this fails; d. i. Zavanelli manoeuvre . Fetal head is manoe returned into the uterus 4 cord presentation: is defined as the ibilical cord below the part when the sence of Ul presentit fact. performed. Or me ii, Cleidotomy INCIDENCE Complications Generally, incidence of umbilical cord prolapse is 1:500 deliveries Fetal ca —— iv t pi F? me fi ij) aly — ie aprolapse) frank _ bree tation hy : h 5 ‘ te bree i plete Soe 15% and trar RES EATUR! Sage ‘ { at the introite Feeling it ¢ Fetal bradycardia dn Fetal hypoxia a : Variable fetal heart rat ing contractions du : = Meconium staininy st time of membrane rup Risk factors for cord prolapse {£ Malpresentation ii, Multiparity iii, Mi iv. Obstetric interventions e.g artificial rupture of memt attempted external cephalic version v. Polyhydramnios vi. Cephalopelvic disproportion vii, Prematurity viii pelvic tumours e.g. fibroids ix, Narrow pelvis x. Macrosomia xi. Low-lying placenta tiple gestation nes MANAGEMENT NB: Suspect cord prolapse if there is fetal bradycardia following rupture of membranes (either spontaneous or ARM) ~ Once the diagnosis is made (on Yaginal examination), check for pulsation of the cord and confirm with fetal heart sound NB: Non pulse aot mean that pasm canfirr a. CERVIX IS NB: Station of will determine vaginal delivery performed the pres Yo an j can be su b. CERVIX NOT FULLY DIL AT epare for CS, the presenting pa * Putting p: position, ent i teduce pre rt on cord n kn * Elevating foot of the bed Trendelenburg p. * Maintaining upy Pressure off the cc * Returning cord and pack vagina with warm, moist * Instilling 400-700m1 of £ bladder ward press ainst the presenting part to ke sition) ord gauze luid into t “Oxygen should be given to the mother * Perform CS usin: midline abdominal incision 8 a generous+ A paediatric tandby in the event of uscitation of newborn Complications - Fetal distress -1UFD - Neonatal - Early neoH determining foetal outcome Factor include i gestational age ii other complications e.g. 1UG iii duration of cord compressior NB: Cerebral damage after 101 cord compression. etal death (after 20min of total cord sion) com Introduction Unstable lie ina term pregnancy In which the fetu: a changing lie be It refers to the sil is in consecutive obstetric palpatic weeks apart in the absence of a space occupying lesion in the lower uterine Segment or multiple preg™ ancy DISPOSINC fos 5 piesions ( j jower uterir Diagnosis i. History evious history of abnorma story of preterm foetal anomalies eg ydrocephalus tumors e.g, history of uterine ibroids; uterine anomalies ii. Examination a. Inspection * Asymmetric abdomen * Fullness at certain areas of abdomenb. flanks ae a eryne pole in iliac Fossa hondrium ssite hy por other in opp“ sation to a * Grip palpatic and prese entation f liquor rim might jequacy pel + Assess * Palpation « reveal an empty P ; { the uterine wall pelvis * Assess laxity of ginal examination + can be empty or other parts besides foetal head palpated Investigation ; * ultrasound scan: to rule out foet placental anomalies, pelvic anom location, foetal maturity, multiple estation and assess amount of liquor Management * Daily observation for foetal lie; with increasing gestation, the lie will usually revert to longitudinal lie and in these circumstances she can be discharged. * If the lie is stable but not longitudinal, a CS should be considered at 39 weeks. * CSis carried out if labour starts, or the membranes rupture and the lie is not longitudinal. * An external cephalic version can also be performed (from 36 weeks in nulliparous and 37 weeks irrespective of gestational age), A stabilizing induction is another option whereby the foetus is turned to Risks of abn ims = INTRODUCTION Sit It is an operation i baby via an incisi wall and anterior ute age of viabili TYPES . i. Based on indication - Emergency performed when labour has complications of pregnancy - Elective caesarean Planned during the ante and performed before onset or complication in, mother o: caesared ii, Based on type of incision * Fel Lower segment CS: - a trans a incision is made on the lower u a segment. Commonly _performe = imvolves less blood loss, lowerTHE GUE: infection, lower risk of peritoneal adhesion lower risk of uterine pregnancy. ruptur r * Classical CS: - a vert ‘on upper uterine segment SPECIFIC INDICATIONS CLASSICAL CS: Tumour in lov (e.g. Fibroid) = Transverse lie + presentation FOR Adhesions in lower uterine segment = Placenta previa with large vessel ir Jower uterine segment - Carcinoma of cervix - Postmortem CS (because classical Sis faster). INDICATIONS FOR CS Absolute: = Obstructed labour = Contracted pelvis = Major placenta prev Previous 1 classical CS - Previous two lower seg ent CS scars - Previous uterine rupture cornual ion for - Previous ectopic gestation - History of assman's operation Relative: - Fetal * Cephalopelvic disproportion * Fetal distress * Cord prolapse * Abruption with live baby *Malpositioning/ malpresentation* prematurity / large baby ae FAVOURABLE FACTORS FOR VAGINAL BIRTH AFTER CS (V BAC) Acronym- VEEBACS CS (previous it phase aa d infection or sepsis to the adjoining or, +, intestine - Repeat CS - Increased maternal mortality and morbidity - Complication of anaesthesia e.g. aspiration pneumonitis, hypotension, reaction to drug - AdhesionsPOST OPERATIVE CARE i Ni 1 A ehydration ; Urethral catheter for 24 hy I alway " ¢ 100r Pain relievers- pethidir monitoring ative PCV INTRODUCTION Hypertension seen in preg be any of these 1. Gestational hypertension a. Pregnancy induced hypertension ie. hypertension arising for the first time in the 2nd half of pregnancy and in the absence of proteinuria, and BP returns to normal within 6weeks (some authors said I2weeks) of delivery This is not associated with adverse pregnancy outcome, PRE-ECLAMPSIA (I Isam é pregnancy and resc within 6 weeks of de called toxemia NB: Pre-eclampsia 1 Hypertension, here, is define: 1. BP of at least 1 U least 4 hours apart 2. Isolated Diastolic >110mmHHg. 1 arterial pre mH, mificant proteinuria is (230mg of protein in a 241 urine collection 4) OF protein measurement of Ig albumin/L)) or strip in a randon iii) Ina dilute Urine ¢.p. urine w 1030, “proteinuria of 1 \ albumin/| ) is sig: more ine specimen nificantN.B. All other causes must be ruled « discharge, renal disorders etc Note: * Qedema is no longer a to diagnose pre-eclampsia (een in only 60% of pat “Severe oF rapidly — developin, peripheral oedema, however a pointer. * Preeclampsia has no symy except in s eclampsia. Severe oedema is that which 1. Pits after 12 ho 2, Causes wei ere cases and imminent sof b ain of >2 + Nulliparous 1 Multiparous 7% Risk factors + Extremes of maternal ag: + Black race * Twin gestation * Daughters of women w + Medical disorders eg chronic renal disease. + Socioeconomic class Hydatidiform moles & fetalis h PE ITN, DM Pathophysiology of P.E: Aetiology unknown. theories are: rease rele (thromboxane A2 d plasma end and men with PE are about 4x likely to cal theory 1 ody is a foreign explain why incidence is rin women with history of recent change of husband in a gravida with the index being the first with him pregnanc: tumor placental 5. Circulating factors: e.g. necrosis factors, IL-6, syncytiotrophoblast MN) microvillous membrane (ST LEsabe nal lipid metabole ¢ Abnormal lip ification Lapeer : M 5 elevated occassions at least “diastobc BP < 10mmbig >0.3g per Nbr urine sample “gay be aeympeoatc p >140/90 measured on thrs apart Severe PE: - >160 systolic or >110 diastolic - >5g proteinuria in 24hr urine les include- pulmonary oedema, retinal _ haemorrhage, epigastric pain, impaired hepatic liver enzymes ECLAMPSIA It isa complication of PE characterized by occurrence of fits / generalized tonic-clonic seizure in 2 woman with signs and symptoms of 7 Pre-eclampsia in the absence of underlying neurologic disease or other causes of seizure. Features are the result of vascular Spastic effect on various organs, Incidence * 115 per 1000 deliveries in Nigeria Types * Antepartum * Intrapartiem * Postpartum Management. A. HISTORY * Preeclampsia ‘of PE and Eclampsia 2 oa ens Abdom * Eclampsia a Convulsion +/- consciousness in th cvs features of severe pre-c E NB. Rapidly increasing RS gedema (symptoms = eclampsia), “sre -Coma cr =U © Gletk for history of risk factors 2: - primigravida . E = history Of the disease in pa: oF mother pC = history of recent change of | h ss 2 oultigravida with the in i Pee eneY being the first Qwith him intr HSsiOry “Suggestive of _ aes = beer ire Bidispesing system =— ©& SSential hypertension . nee Chronic rena ~ his of ‘4 inveirat ae fnter-pregnancy . * Rule out other i BE convulsion eclamptic patient Wulsior on differential ef 1526 the section "4gNOsis),THE Gumme: p. EXAMINATION Gener Peri-orbital oeder NS Loss of consciousr restlessness, hy lonus Abdomen Epigastric/ right hyr tenderness, ute gestational age wall oedema cvs = Elevated blood pressure RS Crepitations due + pedema (only in complicate © INVESTIGATIONS + Urinalysis « 24hours urina e EUCr to assess renal fu * Full blood count = PCV, Hb level In haemo-concentra = low platelet (due to intravascular destruction) * Clotting profile - Whole clotting time, PTTK and P- prolonged * Liver Function Te enzymes due necrosis * Plasma urate level - Urate usually fall in preg raised in eclampsia pre-eclamp Treatment depends on PRE-ECLAMPSIA 1. Mild 2. Severe control ind expediteBefore term, Conservative manage . ¢ term or mild P.E before ter red nd observath « Adm * Cor with IVE (Ne and do stimation or urinaly'sts 1 fetal well-being e Moni ; Jy symphysio-fundal he right daily fetal kick chart cardiotocography - weekly biophysical serial ultrasound profile « Re-assess regularly for mprovement/ worsening of signs and symptoms + Ifdelivery is planned before GA of 34 weeks, give 2 doses of 12mg IM Dexamethasone 12hours apart to hasten fetal lung maturation. Note: Ifconservative treatment is ‘suecessiul, monitor till pregnancy is term, Hicondition worsens, or foetus becomes compromised, abandon conservative treatment and deliver. Masseement of eclampsia is an : callfochelp BEY: hence, Principles of treatment are; 1 resuscitate 2) control fits 4) de Oth Protoce A. Pritchard re gimen Total loading dose - 42 slowly over 15-20mi ted as 20"y . 10g given IM; 5g - Maintenance is 53 alternate buttocks until 24 last convulsion or a 5 Al B. Zuspan regimen 4g IV + 100mls norma 5-10mins (loading dos Maintenance dose is IV infusion MgSO4 toxicity manifest - _ the first symptom is | 1 Jerk reflex. Tt occurs at >3,5-50 Serum MgSO4 level Respiratory rate < 12 cy minute i : Oliguria (urine output 251 Slurred speech and «Tit GIDE ROUTE OF DELIVERY - Pre-eclampsia Vaginal route rest as there are cont + Caesarear cervix is unf a — @Prevention Law dose aspirin (7578 y in the s patie started early in th ester inat risk trime : vit Cand E that ac ta! antioxidants + Calcium and Mg risk low dietary in! done via ul terine doppler to check for resistance uterine artery Introduction APH refers to bleeding from or into the genital tract after the age of viability (28 weeks in this environment) and prior to the onset of labour. Itis an obstetric emergency Incidence + 2-6% * — Itis associated with increased risks of fetal and maternal morbidity and morta Classification 1 Placental praevia 2 Placental abruption % Incidental causes _ & obstetrics b, non-obstetrics Cervicitis Erosior Polyps Carcinom Condyloma ac Cervical ectropi 4. Others - Inherited bleeding c 5, Hemorrha origin PLACENTA PREVIA Introduction Placenta previa Placenta which has implants partially or wholly in the low uterine segment. Lower uterine rerteret itforms after 28 week's and it has 3 definition Is that part of the uterus = Which measures about 5 cm tr internal os (me! Uss), tric definition 1Incidence 0.4 to 0.89 Classification/Degrees of Placenta previa 2. Type I (Low lying): the placent encroaches on ty does not reach the reaches the os b « Type Ul (Partial covers part of the interna ceases to do so as the cervix dilates d. Type IV (Complete) completely covers the 0s € dilated Clinical Classification Minor placenta previa - Type 1(not sub: ided into antenor and posterior) and type 2 (anterior) constitute the minor placenta previa MANAGEMENT A. HISTORY Presenting complaint: « Ther pWarning ble re may be hx of sl bleeding during 3rd trimester x of associations: uterine ntraction (10% - 20%), abdominal ‘bsent in placenta previa) aginal discharge ete: « Ask for possible risk factors+ Rule out other POS hi Hx of trauma tot aa E nal itching, dist - Hx of va (infection) mA - Hx of we abdominal + Hx of complications: fainting spells, reduces’ ht loss, anorexia, | neoplasm) swelling 15 dizzinest ions- d activity fet etc B. EXAMINATION General examination. May be restless, pal cold clammy in high nities, excessive sweat extre degree blood loss cvs ° There may be signs of shock in high degree blood loss high pulse rate; low BP Obstetrics * Uterus is soft and not tender * Contractions y be palpated * Malpresentation e.g. Breech * Abnormal lie: Transverse, Oblique or Unstable lie * Engagement: if cephalic, presenting part is often high * Foetal heart rate: shows distress (may be dead in severe haemorrhage) ginal examination * May reveal obvious bleeding per vaginam ver perform bimanual vaginal examination (to avoid Premature rupture of membrane) but can be done in the theatre a fter 38 weeks of gestation under. double Setup Routine patient care a. Conservative/ expectant b. Active he options depend on Amount of uterine bleeding Degree/ type of placenta previa Status of fetus (alive or dea Status of the cervix Um fo ee Presentation, position and : of the fetus A. Out-patient treatment For placenta previa that is discovered incid ntally during routine ultr ation. It is safe and cost Indications (Modified M/ ACAFEE) * Women who hi Ve never bled or women with pla centa previa ifpleeding has stor ‘one week. + There are complications, suck restriction + Live within 1 hospital. + Have an adult com 24 hours 2 transport the there is light bleeding ambulance for severe » Be reliable and able to maintain t rest at home * Understand the outpatient management [tinvolves counsellir + Avoidance of coitu cervical examinati + Notravel + Seek immediate medic if there is any vaginal bleeding + Women are also en avoid exercise, decrease tt activity, and no of uterine contract + Serial ultrasound ev every two to four weeks placental location and growth. the physiciar Note: for type 3 and 4, patient is admitted at 34weeks gestation and await delivery at 38weeks. A scan at 36weeks is appropriate for evidence of placental rising. B. Conservative mgt of stable preterm patient (MACAFEE mgt) Introduced by Macafee at the Royal hospital Belfast d if present and delivery mandated by the olytic may be safely utili elivery is confirmation of pulmonary maturity 1" Abdominal delivery Two to four units of PRBC should be available for the delivery - Appropriate surgical instruments for performance of a cesarean hysterectomy should also be av ailable since there is a 5 to 10 percent risk of placenta accretateru! of ki throug to cut Indications for termination of indicatio! MACAFEE regime Pregnancy > 38 weeks PROM Antepartum fetal distress Torrential bleeding Patient falls into labour Congenital anomaly IUFD C. Active mgt Acute Care of Symptomatic Placenta Previa * Large bore IV access & administration of crystalloid * Type and cros. of PRBC * Transfuse to maintain a Hb conc of 30% if the patient is actively bleeding. * Maternal pulse and blood pressure every 15 minutes to 1 hour depending upon the degree * The fetal heart rate is continuously monitored * Quantitative monitoring of vaginal bled loss. * The Source of the vaginal blood (maternal versus fetal) is intermittently assessed by either an Apt test or Kleihauer-Betke analysis (see investigations of Vasa previ details) ae match for four units term there is a non-reassuri " rate - life threatening hemorrhage Mode of deli ~ Cesarean delivery is the de route of choice (esp. type IIb, | Ivy Anterior marginal place: lower margin >2c ‘om os (by USS) may be delivered vaginally, as long as the mo remains hemodynamically stable inte VAGINAL DELIVERY * This is for types I and Ha w cephalic presentation * Hemodynamically stable * No fetal distress * Favorable bishop score Involves the following L Artificial rupture of men (ARM) i IV oxytocin HY Close foeto-matemal monitori i Emergency CS if foetal distress developsv. Vacuum ¢ and of labou COMPLICATIONS OF PLACENTA PREVIA = Maternal: + PPH + Embolism ulation defects Maternal x « Co: Foetal + Foetal distres: * Preterm birth * Foetal ha ABRUPTIO PLACENTAE Introduction It is the premature separ: normally sited implantation before delive fetus, It constitutes 30% of APHs Incidence * Associated with maternal and perinatal morbidity and mortality * It occurs 1 in 200 deliveries ; (0.5-1. * Incidence of 1 * Ittends to recur in 8.8% of patients Aetiology/risk factors The aetiology is unknown; risk factors are Clinical types ealed (80%): the bleeding placent ll vary directly blood loss b. Concealed (20%): no visible blood retained behind the placenta, patient presents with shock (severe) c. Mixed: some ‘¢ is disproportionate shock to loss, it ible, some reformed; the visible loss Grading The grading of Abruptio placentae according to SHER and STUTLANDSs FEATURES ee xi clinically nt but the fetus present but re: the fetus No coagulop: jopathy rit Sever (a) ro) Coaguk Management AHISIORT——— SOS » Biodata - advanced maternal age has higher incidence » PC: Abdominal pain, bleeding per vaginam, back pain + Hx of associat + Clerk for risk fact « Complication: » Caresof 1: Refer to section-A for rking of PC and check h placenta previa p. EXAMINATION Refer to examination of placenta prev Shock is an outstanding fe concealed type of placent 1 abry Obstetric examination (see the ta}, above) COMPARISON OF PC AND EXAMINATION FINDINGS: OF THE CLINICAL TYPES [1 Atstominal pain 1 Tendermes ZBleedingper | Bleeding) Bleed vaginam usually dark, nancoring amination Usually, will go into labour Uteras is woody hard, tender, and board like (couvellaire uterus} Patient cannot bear touch Present also I D. Thire [INVESTIGATION Ultrasound: | Coagu! jon defect: snail Blood grouping ar matchi Rhesus typing p. TREATMENT This depends on: Severity . Associated complications State of the patient . State of the fetu: _ The gestational age tial management A. Resuscitation Circulation * Quick IV access using cannula (size 16, 14) + Collect samples for - Urgent PCV - Grouping and cross-match = Coagulation profile studies - EuCr * Correction of blood loss = Give crystalloid fast before blood is available - Transfuse immediately blood is available * Catheterize for hourly urinary output monitoring, Note: This onment. difficult in our distress - immediate CS. im at vagina delivery _ Needs adequate resuscitation - ARM plus or minus oxytocin (with oxytocin, close monitoring to avoid over stimulation and uterine rupture). - Delivery should be effected within 6 hes. _ If bleeding continues and progress of labour is slow, deliver by C/S aTHE BO p. Expectant MANMEETIN a cass This may be done matt in which the Fett ‘Admit patient pain relief drt =n _ Give pa , 3 ius electronic Continuot ;onitoring s » SS for fir Repeat US ate of progres: or rate me retropla M F iL kick cour i, Daily fetal kick ii, Twice weekly CTG Twice weekly ultrase If abruption progresses soon as possible. f abruption does not continue expectant mar i deliver S7wks a COMPLICATIONS Maternal 1. _Hypovolemia 2. DIC 3. Renal failure 4, PPH 5. Perinatal/Maternal mortality Fetal + Asphyxia * Prematurity + IUGR * IUFD Incteased perinatal mortality Management of complications 4. Hemorrhagic shock Setting up IV line /collecting blood for investigations, ~ IV fluids- colloids /cry - Oxygen by face-mask, ‘stalloids. - Consult to renal p - Fluid replace monitorin ~ Diuretics (mannitol 20% and frusemide); use with cautior PROGNOSIS palpatio * The following are bad prognos a factors No ~ Excessive blood Joss assoc - Shock Lpre-ecl/? a. q DIFFERENCES BETWEEN PLACENTA P’ > ABRUPTIO F [ PLACENTA __PREVIADiag sracvia i The « membrane € ss vag jycardia med before sected when e triad of the vase upture, sinal bleeding al be rely confit This i very but may t sound ¥ ne SUST with color-flow de antenatal ul Doppler rev ps over the ng, the vessel cr membrane » internal cervical 08, The diagnosis is usually confirr after delive placenta and fetal membranes. ned ery on examination of the Most often the fetus is already dead when the diagnosis is made; because the blood loss (say 300ml) constitutes a major bulk of blood volume of the fetus (80-100ml/kg ie. 300ml approx for a 3kg fetus). Other investigations + Fetal blood detection test 1. Apttest/simple alkali denaturation test - Lysed blood + 1ml NaQH - Positive (fetal blood) if color remains pink (stable Hb) ~ Maternal blood if color change to brownish yellow (less table Hb~hematin) 2 Kleihauer -Smeared blood + acid and view under microscope - Pink color (Fetal blood) * Digital palpation of a vasa previa + Amnioscopy * Ogita * MR1has been suggested too Treatment i. Elective ¢ pisk INTRODUCTION Z PPH can be definec from the genital tract of 5 following vaginal delivery ( y, at following CS) or reduces ¢ 10% after delivery of the t amount of bleeding re cardiovascular instability Classifications A. Primary or secondary * Primary PPH: Occurs with hours of delivery ' * Secondary PPH: Any bleedir excess of lochia that occurs af hours until 6 weeks of postpartum B. Minor or major/severe * Minor; blood loss <1000ml * Major/severe: blood loss >100 Incidence . ae Percent of obstetric lemorrhages occur postpartu™ (PPH). i. PPH complicates 5-8% of vag"! deliveriesRISK FACTORS Maternal A. In index pregnancy * Multiple pregnancy + Polyhydramnios * Grand multiparity * Co-existing fibroids « Induced or augmented labour with oxytocic « Precipitate labour + Anaemia + Prolonged duration of labour * Chorioamnionitis « Abruptio placentae *Hypoxia due to hypoperfusion/ courvelaire uterus in abruptio placentae +Hypothermia due to massive resuscitation or from prolonged uterine exteriorization * Tocolytic agent — MgsOu, B- sympathomimetic, Ca" channel blocker, nitrites, NSAIDs Note: all are due to uterine over- ‘ad distension/ uterine atony id log ng i Others « Instrumental delivery, episiotomy * Nulliparity n+ Other drugs e.g- anticoagulants (e.g. Aspirin), injudicious use of oxytocic, _ anesthetic gases ml B. In previous pregnancy (ies) * Previous history of PPH, APH '* Previous instrumental delivery, i episiotomy, index pregnancy risk w+ Previous caesarean section oF “myomectomy (Uterine rupture) né' + Previous uterine rupture * High parity leading to a lax uterus not an independent risk factor) ditions c. Chroni€ medical €O * DM * Bleeding disorders . Hypertens) ver eclampsia Eclamps!@ * Maternal obesity disorders- Pre- Foetal factors * Macrosomua a = Multiple gesta00! + Fetal anomalies &-8- hydrocephalus * Fetal tumors * TUFD Causes The 4T's of PPH 1, Tone i.e. Uterine 2! factors for causes) tony (refer to risk 2, Tissue ~ Retained produets of conception. - Blood clots - Tissue al eg. * Bicornuate uterus * Placenta praevia * Morbidly adhering placenta (pacreta, accreta, increta) + Acquired structural defects (leiomyomas) * Uterine inversion + Uterine rupture * Placenta abruption + Subcenturate lobe 3. Trauma a. Planned - Duhrssen incision - 2 or 10 0! clock - Episiotomy, gishiri cut - Operative vaginal deliveryb. Unplanned ~ Vaginal / Cervical laceration ~ Surgical trauma -Blunt trauma 4. Thrombin a, Congenital - Von Willebrand disease b. Acquired - Disseminated _ intravascular coagulopathy ~ Dilutional coagulopathy - HELLP syndrome -Idiopathic -___ thrombocytopaenic purpura Management PPH is an obstetric ency, therefore, history taking, evaluation and treatment will take place — simultaneously eae A. History ‘ . * Bleeding from the genital tract onset, duration, quantity and character (fresh or clotted blood) * Place and mode of delivery (home or hospital) + Blood foes (mi) Systolic Blood ibe ‘500-1000 (10-15%) eer 1000-1500 (15-25%) ‘Slight fall ‘ EK Moderate fai * History risk factors. 14, duration, spontaneous or j,,4°P0y, difficult delivery, prolong. ts stage of labour, managemeny stage (oxytocics), history ¢,. he Ny when, route and how placen, delivered etc. (see above fo, rs factors) FINDINGS IN OBSTET IRRHAGE © Hx to identify cause. ten genital tract etc Ny * History of antepartum haemo, + . Complications- Dion weakness, syncopal attack, fi . secondary PPH, foul smelling discharge : B. EXAMINATION General examination: - Level of CONSCious, restlessness, sweatiness, py dehydration - Increased body temperature (4 usual feature) - Cold and clammy extremities Cardiovascular system: Pulse; Rate (fast), Volume (the Blood pressure (Low). Symptoms é& Degree of shock ‘Signs eer Compensated dizziness. Weakness, tachycardia & a ‘Sweating: Restiess, pallor See Moderate i Abdomen Poorly © Genitalia: Inspection: - Ascertai bleeding; ‘ uterus. - Bright laceration. laceration - Vulyak - Check | or not - Check] cc. INVES - Blood cross mate - Urgen - High. - Blood - USSt - RBG, - Clotti deranger D. MAN Practical * Help * Asse bor size set = Esta * Ma: + Ox . Shi on TarAbdomen: Poorly or uncontracted uterus if the cause is atony = In genital laceration, uteru contracted Genitalia: Inspection: - Ascertain the bleeding; vulva, vagina, cervix or uterus. - Bright red blood may point to jaceration. Check for genital tract laceration - Vulva haematoma - Check episiorrhaphy if well done source of the or not - Check Placenta for completeness Cc. INVESTIGATIONS - Blood sample for grouping and cross matching - Urgent PCV / Hb concentration - High vaginal swab for MCS - Blood culture for secondary PPH - USS to check remnant of tissue - FBC: Anaemia, thrombocytopaenia - Clotting profile: afibrinogenaemia, derangement of clotting factors. D. MANAGEMENT Practical approach (HAEMOSTASIS) + Help Vir + Assess/resuscitation (using 2 wide bore cannulas to secure IV access: size 12 or 14, take blood samples, set up IV fluid) + Establish etiology + Massage uterus % ic * Shift to theatre- EUA repair + Tamponade scgive sutures y compressive app! yelvic systematic P Syst" -ularisaion: Principles of treatment 1. Call for help 2. Resuscitation 3. Specific treatment Resuscitation Should take ion i and evaluation et ee wide bore cannula x2 (ideal) 2. Collect blood sa - Urgent PCV : - Bedside clotting time - Grouping and cross-match of at least 4 units * - Clotting profile -EUCr 3.(Crystalloid (Plasma expander), ‘Ringers lactate (6% D/W has no role in PPH mgt) Note: give as much as 3 times the blood \ loss estimate in form of crystalloids because it has been found that only 20% of crystalloids remain in circulation of critically ill patient after thr & the solution rapidly equilibrate btw the p intravascular & extravascular space | (Shoemaker et.al 1991) 4. Orby face mask (6-8 L/min) 5. Uneross matched blood can be of benefit (if cross matched blood is not available) to enhance the following ~ Replace O. carrying capacity - Prevent dilutional coagulopathy currently with mple for 46, IV antibiotics 7. Passa urethral catheter to: ~ Ensure bladder is empty ~ Monitor urine output ‘ Make a fluid balance chart . Uterine mai 6. Give IV ae 10 1.U; 1V ergometrine 500ug; IV carboprost 500ng (do not exceed 2mg) SPECIFIC ee 1. Empty bladder . 2. Perform firm vigorous uterine fundal massage. 3. If the uterus still fails to contract ly, repeatiyntocinani(oxytocin) 0 LU 1 boiuspls 40 LU in 500m! normal saline as continuous infusion; ee Be dose 600 mcg) De ; ~ If unresponsive, giv 05mg — IV/IM __ stat. 7 ximum of 2mg, giver (N.B. It should 2 be avoided in asthma, hypertension & = cardio-pulmonary disease) 4. Uterine cavity packin ig with ga 5Bi-narinal wertne ser nee 6. Uterine balloon tamponade: - Involves inflation of balloon deyi (Risch or Bakri balloon; condom + catheter) with sali, m © compression suture by B-Lync}, 7. Uterine artery ligation using anq colleagues 8. Uterine artery embolization/ligation 9. Internal iliac artery ligation 10. Subtotal/ total hysterectomy eee - If placenta is delivered, inspec 5 completeness; if uncertain, do Ug | confirm. - If not yet delivered, deliver by; - Controlled cord traction - Infusion of 0.9% N/S and oxyte,, into umbilical vein (more effective, Or tra examination and surgical olizali case that ar repair. wgulatio = Vigoror transfusion cryoprecipi - Give plat count<50x Inversion uterus is th - Evacuation of retained tissue is don, oe under GA if the uterus is not we naintain contracted: under gen Note: for abnormally — adherey, ae placenta; treatment options depend » if there is active bleeding or not.) Uterine ru includes: - Explor i. Instillation of linn «= - If min one of the uterine vessels of th i. uterine placenta left in situ and ligating te Ligation cord + patient coverage with bro — ‘i. Embol spectrum antibiotics. iii. Bilate ii, Placenta left in situ + weekly + ert antibiotic cover. = ae toe Ll iii. Subtotal hysterectomy vaginal expecte rm . " , ; : 42 days spect if bleeding persists despite wil contracted uterus. Ne Beal | lormal speculum examination - By d Tepair any laceration,- Or transfer to theatre for examination under anaesthesia (ELA) and surgical repair of laceration - Embolization is said to be of case of vaginal /vulva_ hae that are unresponsive to surgical repair. arr “fresh whole blood transfusion or fresh frozen plasma or cryoprecipitate. - Give platelet concentrates (if platelet count<50x109/L) Inversion of the uterus (when the uterus is turned inside out) - Vaginal manipulation pushing the uterus back into the abdomen to maintain its normal configuration under general anaesthesia. - Laparotomy, to pull the uterus from above. Uterine rupture: - Exploratory laparotomy - Ifminor: i. uterine repair plus Bilateral Tubal Ligation (BTL) ii, Embolization of uterine vessels iii. Bilateral iliac artery ligation SECONDARY PPH Said to occur when there is excessive vaginal bleeding in the excess of lochia after 24hrs but within 42 days of delivery. Normal changes: - By day 4, lochia rubra changes to ‘serosa nanges to-alba By 2.aweeks. serosa ck er di tii (placenta/blood clot) Retained 0 cadometritis Endodary bleedin - Submucous leiomyom"? choriocareinome Ss ommonest caus 2 tis from retained tis issue sue Mane ital signs = i e Vi tie se an important investigating tool/ sepsis workup (urine M/C/S, Blood culture) uterine curettage under anaesthesia. + Endometritis should be treated with broad spectrum antibiotics * Use of oxytocin & misoprostol is also of benefit. Complications of PPH + Hemorrhagic shock * Infection- puerperal sepsis, HIV/Hepatitis (from blood transfusion) * Disseminated intravascular coagulopathy * Thrombo-embolic phenomenon * Acute renal failure * Sheehan's syndrome (pitui' hypoperfusion) ea * Adult respiratory distress syndrome * Gl ulceration (from hypoperfusion) + Complications of massive blood transfusion: circulatory overload; hypothermia; rat hyperkalemia etc.“Surgical related complications @g. _ rman syndrome; genitourinary fistula; Vascular injury * Promote public awareness on obstetric hemorrhage through public campaign, mass media etc. * Encourage early booking of pregnancy for antenatal Antenatal: *% * Identify patient at risk by assessing for risk factors Antenatal assessment - Detection & correction of anaemia during antenatal - Coagulation studies (during acquired coagulation defects) - Imaging (MRI to R/o placenta abnormalities) * Antenatal blood donation ele ee + Avoid injudicious use of uterotonic drugs f fo partograph to prevent * Active management of th labour can prevent 99,18 al Lay atony (see chapter on norm, Management History * Biodata; Agt gestational ag pregnancy * Often asymptor * Absent and/or | lactation (most co « Symptoms of G deficiency: reduc hot flashes; deere * Symptoms of h to pituitary dysf - tiredness, cold tipation, we ymptoms of: insufficiency: fa confusion, swea Addisonian cris infection or sur; delivery * Symptoms of deficiency: fatis muscle mass * Clerk for risk SHEEHAN’S SYNDROME * Rule out oth of postpartum Introduction = - Renal: acute Itis the hypopituitarism developings _ Gr. GI ulcers a result of pituitary necrosis caused by ischemia due to hypotensive episode Examination during delivery. Also known as post- * General ¢ Prompt and skillful episiotomy * Continue oxytocic throughout stage of labor Tepair B. Secondary *Early diagnosis and treatment C. Tertiary : * Rehabilitation of patient Partum pituitary necrosis/Simmonds - Usually app disease. lethargic, det around the e Epidemiology axillary hair. ; : - Check BMI 1 in 10,000 deliveries * CVS: Brac : hypotensior Risk factors * Abdomin * Breast: D N.B. Refer to risk factors of PPHne Management History « Biodata; Age, parity, gravity gestational age of the most recen' pregnancy * Often asymptomatic * Absent and/or difficulties with lactation (most common complaint) * Symptoms of Gonadotropin deficiency: reduce or lack of menses; hot flashes; decreased libido + Symptoms of hypothyroidism due to pituitary dysfunction: - tiredness, cold intolerance, constipation, weight gain etc. * Symptoms of secondary adrenal insufficiency: fatigue, weight loss, confusion, sweating, features of Addisonian crisis, following severe infection or surgery years after delivery * Symptoms of growth hormone deficiency: fatigue and decrease muscle mass * Clerk for risk factors * Rule out other possible complication of postpartum hemorrhage - Renal: acute tubular necrosis - GI: GI uleeration— PUD Examination * General - Usually appear fatigued, maybe lethargic, dehydrated, Pale? Wrinkles around the eyes and lips, loss of axillary hair. - Check BMI * CVS: Bradycardia, arrhythmia, hypotension + Abdominal: loss of pubic hair * Breast: Decrease breast size scars from. I nvestigaion” ee * Hormona ys at n, cortisol, v4 at a ACTH depending, ] i ‘land : scan of the pituitary 8 aa Botha to exclude tumour or other pathology Treatment Lifelong hormonal therapy for the hormones that are deficient CHAPTER 15 MALARIA IN PREGNANCY INTRODUCTION - Malaria is caused by infection with sporozoites of genus plasmodium - Itisa common cause of anaemia in pregnancy EPIDEMIOLOGY - About 300 million inf sia Gee year, 1 in 10 maternal deaths, 1 infant death every 30 a 2 deaths in children / year), 6 ae as . GOPD attendance. - Malaria is n 5 pregnancy probably due to reduction of acquired in ity to :malaria tends to be : ; tion more atypical in presental probably due to the Deen immunological and haematologica changes. - In pregnancy, Burden of infection: -About acer people worldwide are exposed -Endemic in Nigeria, responsible for >60% of clinic attendance in Nigeria. -Associated with 11% of maternal deaths worldwide AETIOLOGY + It is caused by 4 species of the Protozoan genus plasmodium namely; P. falciparum, P. vivax, P. ovale, P. malariae - The most deleterious effects on the mother are caused by Plasmodium falciparum and their nature depends in - The spread is through the bite of an infected female anopheles’ mosquito. Rarely, spread could be via blood set transplacental infection Vulnerable pregnant women - Primigravidae 5 - HIV positive women - Immunosuppressed: DM, steroids Predisposing factors - Adolescents -Women living in rural -Level of andieaa innate i “HIV positive status of the w - Overcrowding accommod,, mation, = Pov erty - High rainfall area pattern - Humidity > 60mm Hg - Temperature of 20-30 degre, - Altitude < 2000 meters‘ Investigation: Definitive d nf Rapid diagn Clinical features like and Vary according to malaria plasmodium) exami transmission intensity in the gi, get Ronee. geographical area, and the ‘- - ee individual's level of acquired oe alitativ immunity. Placental - Fever Other investi - Headache, muscle aching, mala “~~ FBC: PCV - Nausea and vomiting - Dizziness may be elevi - Sleepy/drowsy - Genotype: - Shivering/chills/ rigors = pee - Anaemia - Blood gluc - Folate deficiency 5 Lumber - Pulmonary oedema unconscious - Increase perinatal and Matern Treatment morbidity and mortality ‘Treatieedin z Hypge canta 1. Treatmen ~ Congenital malaria 2. Managem 3. Preventio Management From history taken & physic 1+ Treatmer examination, diagnosis of mild; ~ Depends | Severe malaria variety should ) S*¥etity. made: = Som« contraindic History oo ne * diffi Mild Variety - fever, chills, headack p. eis a = Joint pains, nausea, vomiting aS = vere Vatiety - impait « i 6 1° trim ae Tespiratory distr’ Qray qui oe ple convulsions, circulate: Pregnancy ipse, Pulmonary oeden! (?7days))Investigations a - Definitive diagnosis pinat erapy p a »fanthrine examination for malaria artemeter * Tes Pat - Rapid diagnostic test (us 1 (coartem, ton? rt) 4 tab! ; eae like and LDH — antibc cots ahs later 4 tablets Pe Artesul te- amodiaqui™ plasmodium) PCR-based assay Antibody test (an epidemiological Complicat TV quinine therapy Fs - oie kg up t max 2 yin Booms dextrose containing fluid stat, tO “ae dose - 10mg/kg in m intenance - va (uid Shourly TUNnINE for tool) - Qualitative buffy coat Placental blood smear Other investigations _ FBC: PCV for anaemia, WBC counts 500mls TV may be elevated 4hrs - Genotype: r/o hemoglobinopathy - Urinalysis: hemoglobinuria Nate: - Blood glucose: hypoglycaemia inine i diatel; S Change to oral quinine immediately - Lumber puncture (in the the patient starts to tolerate orally unconscious patient) 1 Treatment Serr ee Treatment modalities include; z seals! antipyretic 1, Treatment of malaria intravenous fluids 2. Management of complications _ steroids SE an - blood transfusion 1. Treatment of malaria oa S ae on the gestational age and 2, Management of complications - Some anti-malarial are - Adequate calories Z Correction of fluid and electrolyte contraindicated in pregnancy and therefore treatment may become difficult, particularly in severe cases of P. falciparum malaria. | @ 1 trimester | Oral quinine is safe throughout bs pregnancy (600mg 8hrly x 21 doses EVENTION __ (7days)) Can be non-pharmacologic and pharmacologic.Non-pharmacologic Vector control: Principle is to control anopheles’ mosquito. Methods are: Biological: : > Drainage of stagnant water as it is having been found to promote growth of vector, - Surrounding bush clearing Chemical: - Insecticide treatment of stagnant water - Use of juito repellants ~ Use of ieeneee treated bed net N.B. It should be hung around the bed not on the wall or window Pharmacologic: 1. Drug prophylaxis -IPT - “ Daily use of @RetaeMnea coll patient : 2. Vaccination (not yet available) INTERMITTENT PREVENTIVE THERAPY IN PREGNANCY (IPTp) It is defined as the use of eats dose of antimalarial at pre. iol er eee Special considerations: - Given with 4, female antifolates and can cause teratogenicity - Current evidence has ¢o, the safety in administering sulfadoxine after 36 weeks co, the previous opinion of diseg, its use based on its ability to oe with bilirubin for binding site," albumin, causing hyperbilirubin, in the newborn. Mis NBs : Effects of mals Mtran Severe disen: ur, srperal sep - Maternal dea’ Effects on birt Abortion a eemends: Pry Preterm de sulfadoxine-pyrimethamine (PT, 2 Law beaks in all areas with moderate ,, he Still birth malaria transmission in Africa ), in be given to all pregnant Won, EFFECTS ON starting as early as possible ince Congenital second trimester, , Perinatal n - Not given before l6weeks becay Increased Pyrimethamineandsulfadoxinear.,,, _ St'eptococcus olatesandcancauseteratogenicity | "eduction in t ~ The women should receive at jong ee) doses of SP during her Pregnary ae with each dose being given at leas month apart (or at least 2 doses » given at 4 weeks interval) ~ SP can safely be administered , until the time of delivery. Effects of pregnancy on malaria = Immunosuppression reduction of acquired immuri maybe the reason why malaria is ma common and severe in pregnax INTRODUC compared to the general Population Mother-to-ch = Atypical presentation of malai of HIV occu Passes the vir 8 of pregnancy This can occ; a Treatment of malari = Pregnanc a is mo ; ailficult because some antimalarial # : 2 aahd y ty Ng ‘te vith Sp) ‘gh 5 te ten the se iif Effects of malaria on maternal health Severe disease - Anaemia - Puerperal sepsis - Maternal death Effects on birth outco! Abortion and premature labour - Preterm delivery - Low birth weight - Still birth me EFFECTS ON INFANTS OUTCOME Congenital infection - Perinatal mortality - Increased risk streptococcus pneumonia for measles, (due to reduction in transplacental transfer of antibodies) - Anaemia. CHAPTER INTRODUCTION Mother-to-child transmission (MTCT) of HIV occurs when infected mother passes the virus to her baby pis ean vectts isp B - Pregnancy 5 - Labour and delivery }®™ 154 Breast feeding 16 HIV IN PREGNANCY E idemiology P over 90% of HI nitaren under 15 Yer to MTCT ce of intervention iV infections in ge are due re of a n in i tion eae 2 “ie of these will acquire infe: during pregnancy : iii, 10-20% will acquire during labour and delivery jv. 15% during, preastfeeding, ction infection NB: - Delayed institution of prevention of mother- to-child transmission (PMTCT) measures — result in a higher risk of transmission of the virus to the baby - Burden of MTCT of HIV is higher in sub-Saharan Africa Risk factors for MTCT a. During pregnancy - High maternal viral load - Infection e.g. malaria in pregnancy - STIs -_ Malnutrition - Haemorrhage - antepartum haemorrhage - Invasive procedures like amniocentesis, chorionic villus sampling, external cephalic version b. During labour and delivery - High maternal viral loadwr Invasive procedures like - fetal scalp blood sampling - Instrumental delivery ‘ - Episiotomy and genital lacerations - First infant in multiple birth - Foetal genetic characteristics c. During breast feeding - High maternal viral load - Duration - Early mixed feeding - Breast fissures/ infections - Poor maternal nutrition. - Oral disease in infants N.B: In addition to the routine History, Physical examination and investigations done in each Antenatal visits, CD4 count and plasma viral load assessment (in RNA copies/ml) should be instituted. PREVENTING MOTHER-TO- CHILD TRANSMISSION (PMTCT) Elements: - 1. Primary prevention 2. Prevention of unintended/unplanned pregnancies among women infected with HIV 3. Prevention of HIV transmission from infected women to their infants 4. Provision of treatment, care, and support for women infected with HIV, their infants and their families Primary prevention ~ Prevention of HIV infection women of reproductive age group e Include the ABCs, comn iolied through health education ‘A~ abstinence (best option) B - be faithful to one y, partner Nite, C = condom use Consistent} correctly Y ap, E) - Prevention of _ Uninteng f/unplanned pregnancies, ‘ women infected with HIV "op, F - Zee siebgarst-= - Safe, consistent, and effects 2mg/ke of IV Zi : iy 2 Cunt one aaee “followed by cor - Integrate dual protection mes... 1mg/kg through: into family planning Counsel, NB: CS adds ni services " Joad is <1000c membrane has ru @ PREVENTION OF HIV TRANSMISSION FROM INFECT, 3: ART IN POST WOMEN TO THEIR INFANTS Continue combir i. Core intervention. ii. Specific intervention on iS ROPE i, CORE INTERVENTION ee - HIV testing and counseling mothers that - Antiretroviral therapy (ART) a ART prophylaxis Zidovudine + } ART is long-term use ¢ the first 6 week antiretroviral drugs to treat matem: to mothers ¢ HIV/AIDS and prevent MTCT antepartum AR - Antiretroviral prophylaxis is sh N-B: triple dru term use of ART drugs to reduce Hi] Rot Tecommenc transmission from mother to infant Note: The earl 1. ART IN PREGNANCY: - vane First line regimen: Kare pat” no TenofovirtLamivudinet+Efavirenz > 350 (current WHO recommendationin? ii, Avoid Fi single daily fixed dose) trimester, u: Alternative to first —_‘lit (concern of N Zidovudine+Lamivudine+Efavirent iii. Avoid Zic Second line regime’ Hb <8g/dlo Zidovudine+Lamivudine+Nevirapi® - Safer deli1 a 2. ART IN INTRAPARTUM: IV Zidovudine in addition to the regular antepartum regardless of the mode of Elective-CS is _preferted espe ie “airaltoad_>1000 copies, prevents _micro__ transfusion uterine contraction) pe of IV Zidovudine over 1 hour followed by continuous infusion of 1mg/kg throughout labor. NB: CS adds no benefit if the viral load is <1000copies/ml or if the membrane has ruptured. 3. ART IN POST PARTUM: Continue combined ART regimen 4.ART PROPHYLAXIS IN THE INFANTS: Zidovudine is given for the first 6 weeks_of life to infants born to mothers that received antepartum ART. Zidovudine + Nevirapine is given for the first 6 weeks of life to infants born to mothers that do not receive antepartum ART. N.B: triple drug com! not recommended bination ART is Note: The earlier the ART is started and the longer they are used, the greater the reduction in MTCT i. Avoid Nevirapine if CD4 count is > 350 : ii, Avoid Efavirenz in the first trimester, use Nevirapine instead (concern of Neural tube defect) iii, Avoid Zidovudine in women with Hb <8g/dl or PCV < 24% - Safer delivery practices ng practices malaria - Prevent am fections d treat in’ + Urinary tractinfections * t vagi candidiasis — busin mace during, childbirth - Minimize 1s! haemorrhage - Use safe (blood screened for and C viruses) - Elective CS * Consider, when safe and feasible * Doe before onset of labour or membrane rupture - Vaginal delivery When ARV prophylaxis or treatment has effectively reduced viral load and no other contraindications to vaginal delivery k of post-natal transfusion practices HIV, hepatitis B @ PROVISION OF TREATMENT, } CARE AND SUPPORT FOR ‘ WOMEN INFECTED WITH HIV, THEIR INFANTS AND THEIR FAMILIES © - Treatment of symptoms - Palliative care - Nutritional support - Reproductive health care- Psychosocial and community ‘support. Various clinical settings in a Pregnant HIV patient SET | IT MEANS THE HV positive | Pregnant woman; is eligible for HAART but not tly on it 2 | Is not eligible for HAART for her own disease but will need HAART for the preg is currently on HAART for her own disease Ts HAART eligible but HAART is not available N.B. For HIV in gynecology refer to The Guide Medicine. s HIV IN OBSTETRIC AND GYNECOLOGY PRACTICE. HIV AND PREGNANCY. PLANNING 1. For serodiscordant couple with the male uninfected; options include: a. Counselling b. Assisted reproduction techniques Sperm (best option) with the male's : ire Prophylaxis of the ce Preexposure male with Antiretroviral therapy ee a, Counselling for timeg intercourse b, Maximum viral load , in the male and Preexpos,, prophylaxis in the female With 4 before attempting sexual intg, an - Prevalence:: up, = Prey "Anemia is because of | infection, h reduce intak c. Semen analysis and washjn, de efiecte followed by intrauterine MSeMinag for nutrient. poe TOLOGY eseceuCn itera “*Note that in HIV infected men, - malaria may be high viral load in the seq,'_ -hemoglobir even after initiation of ART ang -acute blo plasma viral load has dropped j, placentae undetected level. -HIV -Nutritional 3. In seroconcordant couple; a. Counselling eS ee b. ART administration to achieve jug eae os maximum viral load suppression 25%), severe before conception (<14%) ¢. Screening and treatment of any -Based on 1r genital tract infection. * normocytic anemia, a marrow fail STU et ci * macrocytic NE IP INE arson PREGNANCY [ieee INTRODUCTION — > Itis defined as hemoglobin Presenting concentration of Sl1g/dl (33%) by - May b WHO, F on routine A In this environment, studies ’ - Patien und that there is no advé weakness, Pi grancy outcome with Hb of 10g! dizziness, (30%) and so thisis the reference v? - Losso used here._ Prevalence:30-50% of all pregnancy Signgg = Anemia is common in pre; pecause of increase susceptibility infection, hemodilution of blood, Tse reduce intake of hematinic side effects of drug, increased demand for nutrient. ETIOLOGY -Nutritional deficiency h - malaria a -hemoglobinopathies -acute blood loss eg. placentae -HIV -Nutritional deficiencies abruptio -Based on severity; Mild (26-29% PCV), moderate (19- 25%), severe (<18%), very severe (<14%) -Based on morphology: * normocytic normochromic: hemolytic anemia, acute blood _ loss, bone marrow failure. + hypochromic micracytic anaemia: iron deficiency, lead poisoning + ma ic anaemia: megaloblastic anaemia (vitB12, folate def), liver pathology MANAGEMENT A. HISTORY Presenting complaints - May be asymptomatic - find out on routine examination/ investigation Patient may complain of body | | | CLASSIFICATION | reakness, headache, easy fatigability, dizziness, palpation etc. - Loss of consciousness disposing le pr ible P ART of possi r i malaria, fections, = History nf factor e& i Jaints resenting comp? : He and characterize each complaints - History of * Malaria ~ fi appetite, history index pregnancy e i‘ Nutritional = ask about: nutritional boos? Iron and aetiological factors ever, headache, h of malaria, I oss of PT in history, any food taboos folic acid supplementation? Is she compliant age ize if present * Blood loss - characte Ss Haemoglobinopathies : - jaundice, bone pain pallor, genot (scD) = Seale from any part of the body (coagulopathy) . * Infections - Dysuriay frequency, vaginal discharge (UT!) Ki - Cough, coryza (URTI) - Nausea, vomiting, abdominal pain, diarrhea (hook worm infestation) * Others - Melaena stool (PUD), recurrent body rash + prolonged diarrhea + weight loss (AIDS) 7 - History of complications * Fainting attacks, dizziness, easy fatigability, congestive | ae etc. ' B, EXAMINATION General - pallor, jaundice, lymy iph node enlargement fy hair (malnutrition), “ ro capillary refill, there may be ae (High PR, low BP, cold