Contraction Stress Test complications

waveform used is systolic/diastolic ratio (SD ratio)

relation of fetal heart rate and uterine contraction normal: high velocity diastolic flow in the umbilical artery
Result Growth restricted: absent or reversed end diastolic flow
NEGATIVE: 3 UC in a 10 min period w/o late decelerations; reversal: perinatal morbidity and mortality
average baseline variability and accelerations of
FHR w/ fetal movements. Pelvic Anatomy
POSITIVE: Persistent late decelerations in more than half
of the contractions; minimal or absent variability
SUSPICIOUS (EQUIVOCAL): late decelerations occurring in
less than half of the UC
HYPERSTIMULATION: contractions occurring more than
every 2 mins or lasting longer than 90 secs, but if
with no decelerations report a negative
UNSATISFACTORY: poor tracing or no 3 contractions
occurred in 10 mins
if there are 3 adequate spontaneous contraction within a 10 minute
period and the FHR recording is of sufficient quality (without
decelerations) the test is finished.
unilateral nipple stimulation -> bilateral nipple stimulation ->
exogenous oxytocin 0.5 to 1.5 mU/min, increasing every 15
mins by 10 mU/minute until adequate contractions
Test repeated weekly unless there are some changes in the clinical
situation
Contraindication Clinical Pelvimetry
Classical CS or other uterine surgery
PPROM
Placenta previa Inlet:
Incompetent cervix 1. Diagonal Conjugate (Sacral promontory not accessible or
Hx of preterm labor approx. 12.5 cm)
Multiple gestations 2. Engagement
3. Muller-Hillis
Biophysical Profile (BPP)
Midpelvis
Variables 1. Sacrum curved
NST (can be omitted if 4 parameters are okay) 2. Ischial spines not prominent
Fetal breathing movements >1 episode of rhythmic fetal 3. Pelvic side walls not convergent
breathing movements of 30 secs or more w/in 30
mins Outlet
Fetal Movements >3 discrete body or limb movements 1. Subpubic arch >90
w/in 30 mins 2. Bituberous diameter >8.5 cm
Fetal Tone >1 one or more episode of extension of a fetal
extremity w/ return to flexion PUDENDAL BLOCK
Amniotic fluid volume (single vertical pocket >2cm or AFI
>5 cm) - Simple, safe, cost effective, easy to perform
Result - Effective for 2nd stage of labor, episiotomy and episiorrhaphy
8-10 normal - Best done transvaginally with the use of Iowa trumpet introducer
6 equivocal - Gauge 21-23 spinal needle to protrude 1-1.5cm
<4 abnormal - Fill up a 10cc syringe with 10cc Lidocaine 1-2%, inject only 5cc per
side.
Modified BPP - Connect the needle to syringe by Luer-lock
Feel for the ischial spine
Amniotic fluid volume determination together with NST
Right hand middle and index fingertips to identify right
Reactive NST with an AFI >5 cm is reassuringvillitis
ischial spine
if the result is non reassuring do the full BPP or CST should be done
Hold syringe with left hand , insert needle transvaginally
Done weekly but can be done more frequently if with DM, IUGR,
with its tip still drawn inside the introducer
HPN
Glide the needle introducer between the right index and
middle fingers
Umbilical Cord Artery Doppler Velocimetry
Palpating hand is between head of the fetus and the
assessment of pregnancies complicated by growth restriction or syringe while needle is directed tangentially and
pregnancy associated hypertension/ pre-eclampsia laterally
Umbilical arteries reflects placental circulation
increase in resistance: infarction, partial abruption, placental Prevents injection to fetal head and laceration to
scarring from intervillous thrombosis,, viral or bacterial adjacent tissues
 After needle is inserted just posterior to or underneath
the ischial spine, needle is pushed through the guide to
the vaginal mucosa until it pierces the sacrospinous
ligament
Aspirate first before administering

PUDENDAL NERVE
- S2, S3, S4
- Pelvis derives its nerve supply from the lumbar, sacral and
coccygeal plexuses from the anterior primary rami of L4 and
L5
- Major source of muscular and cutaneous innervations of the
perineum
- Leave pelvis via greater sciatic foramen , lies medial to sciatic
nerve, crosses back of ischial spine, hooks around
sacrospinous ligament Tissue forceps
- Passes forward through lesser sciatic foramen enter
pudendal (Alcocks) canal to innervate perineum
- Blocked in the area of the sacrospinous ligament

INSTRUMENTS

Hysterometer

Needle holder
Hysterometer

Spoon curette

Tenaculum

Iowa trumpet with needle

 Sharp curette

Allis forceps

Richardson and Army retractor (used to retract shallow or superficial incisions)

Uterine forceps

Amniotome

Needle

Kelly forceps (curved)

Simpson and Piper forceps

Ring and ovum (with serrations) forceps

 DIABETES MELLITUS IN PREGNANCY
Diabetes mellitus is the most common endocrine disorder of
pregnancy. Gestational diabetes mellitus (GDM) accounts for
approximately 90% to 95% of all cases.
Gestational Diabetes Mellitus
Carbohydrate intolerance of variable severity with onset or first
recognition during pregnancy
GDM and Type 2 Diabetes share impaired insulin secretion and insulin
resistance. Insulin resistance results in decreased glucose uptake in
skeletal muscles, adipose tissue, and liver and suppression of hepatic
glucose production.
Overt Diabetes
Fasting plasma glucose of >125mg/dL
Glucosuria
Ketoacidosis
Random plasma glucose level greater than 200mg/dL
Presence of classic signs and symptoms- polydipsia,
polyphagia, polyuria and unexplained weight loss
High index of suspicion if with the following- strong family
history of diabetes, previous having delivery of large infants,
unexplained fetal losses, persistent glucosuria
Screening for Gestational Diabetes
Perform between 24 and 28 weeks
Do on pregnant women not known to have glucose earlier in
pregnancy
Do a one or two step procedure
One Step Procedure
o Take a fasting blood sample
o Ask the patient to ingest 75g glucose
o Extract another blood sample 2 hours after glucose
ingestion
o An FBS value >105mg% and a 2 hour post-glucose
values of >140mg% are diagnostic of GDM
Two Step Procedure
o 50g glucose challenge test
o 100g oral glucose tolerance test is done if result of
the 50g glucose load is abnormal
Adverse Perinatal Outcome
Gestational Diabetes
Fetal Effects of Gestational Diabetes
Stillbirth
Aberrant Fetal Growth
Metabolic (hypoglycemia, hypocalcemia)
Hematologic (bilirubinemia, polycythemia)
Respiratory complications
Congenital anomalies and spontaneous abortion
Long-term complications
Maternal Effects of Gestational Diabetes
Increased frequency of hypertension and the need for
cesarean section
Maternal Effects of Overt Diabetes
Diabetic Nephropathy
Diabetic Retinopathy
Diabetic Neuropathy
Preeclampsia
Ketoacidosis
Infection
Management
Treatment Modalities in Gestational Diabetes:
1. Insulin Therapy
2. Diet
3. Exercise
4. Oral anti-diabetic drugs
Insulin Therapy
Recommended when standard dietary management does not
consistently maintain fasting plasma glucose at less than
105mg/dL or the 2-hour postprandial plasma glucose at less
than 120mg/dL. American Diabetes Association has
suggested insulin therapy when diet alone fails to maintain
fasting blood glucose at or below 95mg/dL or 2-hour
postprandial blood glucose levels at or below 120mg/dL.
For non-obese patients= 0.8 U/kg
For overweight and obese= 0.9 to 1.0 U/kg
The total insulin dose is divided so that two thirds is
administered in the morning, which is further split in a ratio
of 2:1 (intermediate and rapid-acting), and one third is
administered with supper and bedtime in a ratio of 1:1
(rapid-acting and intermediate). If after 3 to 7 days, the GDM
patient has not achieved the desired level of glycemic
control, the total insulin dose should increase by 10% to 20%
and thereafter adjusted when needed.
Diet
Diet is the mainstay of treatment in GDM
Two current approaches are recommended:
Decreasing the proportion of carbohydrates to 35% to 40% in
a daily regimen of three meals and three to four snacks
Lowering the glycemic index so that carbohydrates account
for approximately 60% of daily intake
Normal weight women= 30kcal/kg
Overweight and Obese= 25kcal/kg
Morbidly Obese= 20kcal/kg
Exercise
A moderate exercise program for pregnant diabetic women who are
willing and able may improve postprandial blood glucose levels and
insulin sensitivity.
Oral anti-diabetic drugs
The most data regarding safety in pregnancy for oral antidiabetic drugs
are with the use of metformin and glyburide.

Overt Diabetes The American Diabetes Association recommends the following for
Fetal Effects of Overt Diabetes follow-up of GDM:
Perinatal losses Women diagnosed with GDM should undergo evaluation
Abortion with a 75g oral glucose tolerance test at 6-12 weeks after
Malformations delivery.
Hydramnios Women whose 75g test is normal should be re-assessed at a
Preterm delivery minimum of 3 year interval.
Inheritance of diabetes
Altered fetal growth
HYPERTENSIVE DISEASES IN PREGNANCY
Risk Factors associated with the pregnant womans husband or
Hypertensive diseases in pregnancy continue to be a leading cause of partner:
maternal and perinatal mortality and morbidity worldwide. Local data First time father
show that they cause roughly 1 out of 4 maternal obstetric deaths. Previously fathered a pre-eclamptic pregnancy

Proteinuria Risk Factors associated with the fetus

Urinary protein of at least 300mg/24 hours urine sample or 1000mg/ Mutifetal pregnancy
random sample of urine taken 6 hours apart Hydrops/triploidy
Dipstick: Hydatidiform mole
Mild Proteinuria= traces to 1+
Heavy Proteinuria= 2+ to 4+ Laboratory Tests:
Hematocrit
Gestational Hypertension Proteinuria (>300mg/24hours)
Hypertension without proteinuria occurring after 20 weeks gestation Serum uric acid
or postpartum Hemoglobinuria, Hyperbilirubinemia, Elevated LDH, SGPT,
Thrombocytopenia= HELLP Syndrome
Pre-eclampsia
Presence of hypertension and proteinuria occurring after the 20th week Treatment
of gestation except in cases of extensive trophoblastic proliferation
Control of Convulsion
Severe Pre-eclampsia
Control of Hypertension
BP of at least 160mmHg systolic or 110mmHg diastolic
Optimum Time and Mode of Delivery
Proteinuria of at least 4g/day or a persistent qualitative 2+ or
more on dipstick
Control of Convulsion
Oliguria of less than 400cc/day
Give a loading does of 4Gm IV bolus slowly over 5 minutes
Severe headache or visual disturbances followed by a maintenance dose of 1-2 Gms per hour IV drip.
Pulmonary edema or cyanosis Give a loading dose of 4Gm IV bolus slowly over 5minutes
Intrauterine growth restriction and 10Gm IM (5Gm into each buttock) followed by a
Abdominal pain, epigastric pain or RUQ in location maintenance dose of 5 Gms every 6 hours.
Hemolysis Safety of MgSO4 is monitored using the following points:
Elevated liver enzymes Presence of deep tendon reflexes
Low platelet count Respiratory rate of >12 per minute
Urine output of at least 100cc every 4 hours
Eclampsia Serum magnesium for greater accuracy
Presence of convulsions in a woman with underlying pre-eclampsia
Control of Hypertension
Chronic Hypertension Hydralazine
Presence of blood pressure of 140/90mmHg or greater prior to o Initial dose is given as a 5mg IV bolus followed by
pregnancy or is detected before the 20th week of pregnancy and 5mg incremental increases half-hourly if diastolic
persists long after delivery. BP does not improve up to a total dose of 20mg
Nifedipine
Superimposed Pre-eclampsia
Nicardipine
Increased diastolic or systolic blood pressure over baseline
o Offers theoretical advantage over Nifedipine in
hypertensive readings and is accompanied by proteinuria and signs and
that it acts more selectively on the peripheral
symptoms of end-organ dysfunction
vasculature with less inotropic effect of tachycardia
and related symptoms of flushing and hot flushes.
Superimposed Eclampsia
Convulsion occurring in a woman with chronic hypertension and
Optimum Time and Mode of Delivery
superimposed pre-eclampsia
Current opinion states that immediate delivery may be done for the
following:
Diagnosis:
All cases of eclampsia regardless of age of gestation
Clinical History
Severe pre-eclamptics who are at least 34 weeks pregnant in
Risk Factors associated with the pregnant woman:
the presence of a mature fetal lung and adequate nursery
First pregnancy (6-7x risk)
facilities
Age under 20 or over 35
Evidence of severe maternal disease as evidenced by
High blood pressure before pregnancy
uncontrollable hypertension of 160/100mmHg, oliguria <400
Previous pre-eclamptic pregnancy
hours, thrombocytopenia <100,000/cu, pulmonary edema
Short inter-pregnancy interval and impending eclampsia
Family history (mother or sister had preeclampsia) Evidence of fetal compromise based on abnormal fetal
Obesity movement counting, CTGs, Biophysical Profile Score
Diabetes, Kidney disease, Rheumatoid arthritis, Lupus or monitoring and ARED patterns on Doppler velocimetry
Scleroderma
Low socio-economic status
Poor protein or low calcium in the diet