Common Cases

Normal vs. abnormal labour

Preterm labour , PROM , PPROM
Induction of labour , Caesarean section (elective / emergency)
Postnatal - SVD , Caesarean section
Post-date / Post-term pregnancy
Multiple pregnancy / Twin pregnancy
Antepartum haemorrhage - Placenta previa , placental abruption ,
vasa previa
Gestational diabetes mellitus
Hypertensive disorders in pregnancy - preeclampsia , eclampsia
Anaemia in pregnancy
Heart disease in pregnancy
Oligohydramnios with / without IUGR
Reduced fetal movements
Polyhydramnios
Abnormal / Oblique / Transverse / Unstable lie
A pregnant woman with fibroid

Uterus Smaller than Date

Mother: wrong dates, post dates,
NSAIDs, oligohydramnios, missed
miscarriage, IUD, PPROM.
Fetus: IUGR (placental
insufficiency, congenital infections),
congenital anomalies (renal
agenesis
Potters sequence, multicystic
kidney disease.)

Uterus Larger than Date

Mother : Wrong date, wrong SFH
measurement, obesity, pelvic mass,
maternal diabetes.
Fetus : Macrosomia, multiple
gestations, polyhydramnios, normal
large-for-gestation.
Placenta : Choriangioma, AVM.

Risk factors
Maternal

Oligohydramnios
Hypertension

Fetal

Chromosomal/Structural
abnormalities
Renal agenesis
Spontaneous rupture of
membrane
Intrauterine infections
Drugs

Polyhydramnios
Diabetes
Multiple pregnancy
Anencephaly
Open spina bifida
Oesophageal /
Duodenal atresia
Facial cleft or neck
masses (cystic
hydroma)
Hydrops fetalis Rh
isoimmunization
Aneuploidy

Placental

Uteroplacental insufficiency

Clinical features

Fetal parts easily palpable

Investigations
Management
Complications

Fetal pulmonary hypoplasia

Cord compression
Prolonged labour due to
inertia

True labour

Chorioangioma of the
placenta
Fetal parts difficult to
palpate
Malpresentation
Premature rupture of
membrane
Preterm labour
Early rupture of
membrane cord
prolapse and
compression
Uterine atony
postpartum
haemorrhage
Subinvolution
Hydrops fetalis

False labour

Induction of Labour

Twin Pregnancy / Multiple Gestations

Accelerated weight gain

Hyperemesis gravidarum
Sensation of moving of more than one fetus
History of assisted reproductive techniques (ART) - ovulation
induction or in-vitro fertilisation (IVF)
Increasing maternal age , high parity
Family history of dizygotic twins
History of infertility / subfertility

Complications of multiple pregnancies

Maternal
Hyperemesis gravidarum
Severe anaemia in pregnancy
DIC secondary to fetal death
Miscarriage
Preterm labour
Polyhydramnios
GDM
Preeclampsia
Placenta abruptio
Postpartum haemorrhage larger placental site and
uterine overdistension

Fetal
Intrauterine demise (IUD) of
one fetus
IUGR
Preterm delivery
Low birth weight
Acute respiratory distress
syndrome
Congenital abnormality Siamese twin

Selective IUGR

Stillbirth: a baby born with no signs of life

Perinatal death: stillbirth _24 weeks gestation or

death within 7 days of birth

Live birth: any baby that shows signs of life

irrespective of gestation.

Lambda sign
Teenage pregnancy
premature birth and low birth
weight
anaemia in pregnancy
Labor dystocia - underdeveloped
pelvis
Unsafe abortion
HIV / STDs
Basic definition of
a) Lie
b) Presentation
c) Position
Abnormal lie

Pregnancy at old age

Transverse
Oblique
Unstable

Normal position - OccipitoAnterior (OA)

Abnormal position - OccipitoPosterior (OP), OccipitoTransverse (OT)
Discharge if longitudinal lie for 3 days
Malpresentation

Breech
Face
Brow
Shoulder
Compound

Breech Presentation
- Membrane rupture
- Cord prolapse fetal hypoxia fetal death

Preterm Labour

Urinary tract infection

Cervical incompetence

Chorioamnionitis
Sterile speculum examination - cervical dilatation , pooling of liquor
Investigations
Full blood count
Urinalysis / UFEME
Assessment of fetal well-being
CTG
Ultrasound - biophysical profile
Management
Antibiotic prophylaxis
- Erythromycin

- Penicillin
IOL if PROM > 24 hours
Anaemia in Pregnancy
Complications
Maternal
Heart failure
Postpartum haemorrhage
Infection
Puerperal
Subinvolution

Fetal

Small for gestational age

IUGR in severe anaemia
Preterm labour
Perinatal mortality

Gestational diabetes mellitus

What are the indications for MGTT ?
Management of Gestational Diabetes

Pre-pregnancy

Antenatal

Intrapartum

Good glycaemic control

Prevent complication
Life-style modification
Counselling
Diabetes pregnancy risk and management
Pre-conceptional folic acid: reduced risk of NTD
Planning of the pregnancy
Early antenatal booking
Adequate BP control and monitoring
Early detection
Medical nutrition therapy
Exercise
Insulin
Patient education
Monitoring
GDM is not an indication for elective caesarian
Factors that would favour an elective caesarian
section include: Macrosomia/ Cephalo-pelvic disproportion
Previous caesarian section
Malpresentation
Evidence of fetal compromise

 Poor obstetric history

Polyhydramios (AP/ cord prolapse)
Timing:
If on insulin therapy: 38 week
If on d/c: not pass due date
Once labour is establish, no food and no insulin
Target blood sugar during labour: 3.5-8
Blood monitored at:
1. Non-insulin dependent: 4 hourly
2. Insulin requirement < 0.5u/kg/day: 2 hourly
3. Insulin requirement > 0.5u/kg/day: start DIK
regime
Who need DIK?
1. Insulin requirement >0.5u/kg/day
2. Blood sugar persistently > 8mmol/L during
labour
1. Dextrose infusion
500ml 10% dextrose at 50 ml/hr
2. Insulin infusion
50 units soluble insulin in 50ml normal saline
Adjust insulin infusion dose according to
blood sugar level
3. Potassium: depend on BUSE
Refer to local protocol
Discontinue DIK regime once placenta is delivered

Postpartum

When the patient is ready to eat

For type 1 diabetes mellitus patients:
resume pre-pregnancy insulin dose
For type 2 diabetes mellitus patients:
2/3 of pre-pregnancy dose
GDM: stop but regular monitoring
Encourage to start breastfeeding ASAP: to prevent
hypoglycaemia on baby
Arrange 6 week post-partum MGTT for GDM
Encourage to complete family ASAP
Discuss on contraception

Complications
Maternal

Fetal

Neonatal

Hypertension , preeclampsia
Nephropathy , neuropathy , retinopathy
infections - UTI , candidiasis , vulvovaginitis
Polyhdramnios Preterm labour
Coronary artery disease
Thromboembolic disease
Risk of Caesarean delivery
Congenital anomalies
Cardiac defects
Neural tube defects
Renal defects
Caudal regression syndrome
Sudden unexplained intrauterine death - possibly
due to chronic hypoxia, polycythaemia, lactic
acidosis (acidemia) , ketoacidosis
Shoulder dystocia , birth asphyxia , brachial plexus
injury , fracture of clavicle
Neonatal hypoglycaemia
Neonatal jaundice
Respiratory distress syndrome
Hypocalcemia and hypomagnesemia

Childhood

Obesity
Impaired glucose tolerance
Type 2 diabetes in adulthood
Metabolic syndrome

Hypertension
Low dose aspirin 60 mg daily beginning early in pregnancy in
potentially high risk patients is given. It selectively reduces
platelet thromboxane production. Aspirin in low doses is known
to inhibit cyclo-oxygenase in platelets thereby preventing the
formation of thromboxane A2 without interfering with
prostacyclin generation.
Ante-partum haemorrhage
Post-partum haemorrhage
UTERINE ATONY
multiple pregnancy
grand multiparity
fetal macrosomia
polyhydramnios
fibroid uterus
prolonged labour
previous postpartum haemorrhage
antepartum haemorrhage

Fibroid in pregnancy

Placenta previa
- Lower segment of uterus - 28 weeks
- Ultrasound every 2 weeks ? Placental migration ?
- Placenta - major , minor
- Accreta
- Increta
- Percreta
Placental abruption
Vasa Previa
Reduced fetal movements
Indications for C section in a case of IUGR
Intrauterine growth restriction along with reduced fetal
movements.
Presence of an obstetric complication (placenta previa,
abruption placenta, etc.).

 Nonreassuring fetal heart sound.

Meconium stained liquor.
IUGR fetus with breech presentation.