Pregnancy and Birth

AMNIOTIC FLUID EMBOLISM •AFE us thought to occur when amniotic fluid, fetal cells, hair, or other debris enter the maternal circulation. • Ricardo Meyer (1926); reported the presence of fetal cellular debris in the maternal circulation • Steiner and Luschbaugh (1941) described the autopsy findings of eight cases of AFE. Until 1950, only 17 cases had been reported • AFE was not listed as a distinct heading in causes of maternal mortality until 1957 when it was labeled as obstetric shock • Since then more than 400 cases have been documented, probably as a result of an increased awareness.

The FDA has issued a drug safety communication about fluconazole: long-term use at high dosages (400 to 800 mg/d) may be associated with a rare and distinct set of birth defects in infants whose mothers were treated with the drug during the first trimester of pregnancy.1 This risk does not appear to be associated with a single, low dose (150 mg) of fluconazole to treat vaginal yeast infection (candidiasis).

Insufficient thyroid activity during pregnancy is harmful to maternal and fetal health as well as to the child’s future intellectual development, according to emerging data that led to new guidelines released by the American Thyroid Association (ATA). These guidelines highlight the role of thyroid function tests, hypothyroidism, thyrotoxicosis, iodine, thyroid antibodies and miscarriage or preterm delivery, thyroid nodules and cancer, postpartum thyroiditis, screening recommendations during pregnancy, and areas for future research.

Proper functioning of the placenta-the life support system for the fetus-is crucial for a healthy pregnancy and healthy fetus. When placenta disorders arise, so does the likelihood of neurologic abnormalities in the fetus. Specifically, two population-based studies have shown an association between placental infarction and cerebral palsy (CP).

With the rate of diabetes and prediabetes/glucose intolerance increasing, it is imperative for clinicians to help reduce the risk of their patients developing full-blown diabetes as well as to help patients manage the illness.

Data increasingly point to the benefits of breastfeeding, both for the infant and for the mother. Now, a new study points to the relationship between postpartum depression and negative early breastfeeding experiences, just as the Centers for Disease Control and Prevention sheds light on the lack of breastfeeding support for women in hospitals.

We received the following comment from Mitch Nudelman, MD, regarding the use of office-based uterine evacuation in early pregnancy failure. Seems there’s more to the issue than the lack of physician training highlighted in a recent study.

WHO Partograph For Beginner • Dr Muhammad El Hennawy • Ob/gyn specialist • Rass el barr central hospital anddumya specialised hospital • Dumyatt - EGYPT • www.mmhennawy.8k.com

Disseminated Intravascular Coagulation (DIC) By Prof. Rifaat Al-Shimmy, Al-azhar U.Definition of DIC A pathological condition associated with activation of both: • Coagulation system and • Fibrinolytic one It should be considered as a secondary phenomena of an underlying disease as...Common Obstetric ConditionsAssociated with: • Inadequate replacement of blood loss • Pre-eclampsia-Eclampsia…HELP syndrome • Ante partum hge (abruption placenta and P.P.) • I U F D when prolonged more than 4 weeks • Blood transfusion when massive or incompatible • Septic abortion or massive tissue injury • Amniotic fluid embolism • Saline I U infusionMassive Transfusion Is defined as the replacement of a patient's total blood volume in less than 24 hours,or as the acute administration of more than half the patient's estimated blood volume per hour. DIC is commonly a consequence of delayed or inadequate resuscitation page_break@DIC: Is it Predictable? • It can probably be predicted in all the previously mentioned high risk groups, except amniotic fluid embolism, as it is an unpredictable condition. • However, in AFE, DIC it always occurs only after resuscitation from the primary shocked state. page_break@Is it Preventable? • It can be avoided in most cases by proper ‘in time’ resuscitation and management of the underlying disease in proper time, e.g. Pre-eclampsiaPathogenesis • The most accepted theory is the Cascade theory in which there is activation of both Extrinsic and Intrinsic pathways leading to activation of factor xa leading to formation of thrombin from prothrombin to form fibrin from fibrinogen • With associated activation of fibrinolytic system as a protective mechanism.Pathophysiology, continued Pregnancy is considered as a hypercoagulable state by: • An increase in all coagulation factors except FXI/FXIII. Fibrinogen which increases to 400-650mg/dl in late pregnancy. • The fibrinolytic system is depressed during normal pregnancy and labor but returns to normal one hour after delivery of the placenta.Pathophysiology, continued Decrease in platelets count is a result of: 1. Consumption 2. Aggregation of plateletsPathophysiology, continued • So DIC is a state of increase thrombin activity at first, followed by increased fibrinolytic activity, leading to… • consumption of coagulation factor (source of old name consumptive coagulopathy) and the formation of FDP impairing homeostasis.Pathophysiology, continued • Deposition of fibrin in organs and tissues may lead to ischemic tissue damage. • The decreased number of platelets and elevated FDP increase the problem of homeostasis.Symptoms of DIC It is variable according to the cause, the presentation of the primary cause with: • Generalized or localized hemorrhage • Peticheae • Thromboembolc manifestation, organ failure as: liver, lung, kidneys, brain and frank gangrene have been described. • Chronic DIC, (that occurs with IUFD) may be asymptomatic.Diagnosis Although the definite diagnosis is only by histological finding of fibrin deposits, there are many indirect tests as: • Bedside clot retraction test • Skin puncture test, measure clotting time (fibrinogen) • D. Diamer           (90%) • Platelets count   (90%) • FDP                      (90%) • Thrombin time   (80%) • PTT and PT        (60%)Bedside Clot Retraction Tes(CT) • It simply tests the clotting time - a test of decreased fibrinogen • 2 ml blood in test tube - no clot formed but if occurs it is prolonged, soft and not retracted after half an hour, leaving a clot volume more than serum volume. (the clot doesn't retract)Skin Puncture Test (bleeding time) • Prolonged skin puncture ooze is observed when the platelets count is less than 100,000/ul • Continuous bleeding at puncture site occurs when pl count is less than 30,000 /ulOther laboratory tests • Platelets count decreases in 90% of cases (count less than 100,000/dl) • PT, which measures the time required by extrinsic pathway, elevated in 80% of DIC • PPT which measure the time required by intrinsic pathway - not helpful. • Thrombin time elevated in 80% of casesOther laboratory tests • Fibrinogen level/ less than150mg. This is present in 70% of cases. • Fibrin split product >40ug/dl, 90% of cases • D-Diamer - an antigen formed as a result of plasmin digestion, elevated in 90%of cases.Treatment of DIC • Essentially treat the underlying cause. In most cases prompt termination of pregnancy is required. • Supportive therapy should be directed to the correction of shock, acidosis and tissue ischemia. • Cardiopulmonary support including inotropic therapy, blood transfusion and assisted ventilationGuidelines by the Scottish Executive Committee of the RCOG

• Medline and NHS databases • Women’s Hospitals Australasia – Clinical Practice Guidelines - Cord Prolapse – Last Reviewed June 2005 • RCOG - Green-top Guideline - No. 50 - April 2008   Levels of Evidence   Evidence Category and Source   Grading of Recommendations   Recommendation Grade  Definition Cord prolapse has been defined as descent of the umbilical cord through the cervix alongside (occult) or past the presenting part (overt) in the presence of ruptured membranes.   Definition Cord presentation is the presence of one or more loops of umbilical cord between the fetal presenting part and the cervix, without membrane rupture.   Background • The overall incidence of cord prolapse ranges from 0.1% 0.6% • With breech presentation, the incidence is just above 1% • Male fetuses seem to be predisposed. • The incidence is higher in multiple gestations.  Background Cases of cord prolapse appear consistently in perinatal mortality enquiries, and one large study found a perinatal mortality rate of 91 per 1000.  Background • Prematurity and congenital malformation account for the majority of adverse outcomes associated with cord prolapse in hospital settings, but cord prolapse is also associated with birth asphyxia and perinatal death with normally-formed term babies, particularly with home birth. • Delay in transfer to hospital appears to be an important factor with home birth.  Background • Asphyxia may also result in hypoxic-ischaemic encephalopathy and cerebral palsy. • The principal causes of asphyxia in this context are thought to be: