Obstetrics Exam Notes
CTPA vs V/Q scan in pregnancy (suspected PE)
Both are acceptable; choose based on CXR and local expertise.
- If CXR normal: Prefer V/Q scan (lower maternal breast dose; good diagnostic yield).
- If CXR abnormal, obesity, or alternate dx needed (e.g., pneumonia, aortic disease): CTPA
preferred.
- Radiation: Both give very low fetal dose (well below teratogenic thresholds).
- CTPA → higher maternal breast dose; lower fetal dose vs V/Q.
- V/Q → lower maternal breast dose; slightly higher fetal dose (still very low).
- Contrast safety: Iodinated contrast is acceptable if needed; continue breastfeeding.
Prerequisites for Induction of Labour (IOL)
- Clear indication documented; no contraindication to vaginal birth.
- Gestational age confirmed, cephalic presentation, adequate pelvis clinically.
- Fetal wellbeing reassuring, EFW noted, GBS status considered.
- Cervical assessment: Bishop score, plan method.
- Facilities & consent: ability to do emergency CS, continuous monitoring, informed consent.
- Maternal readiness: stable vitals, IV access, labs as indicated, Rh/GBS plan.
Definition of Failed Induction
Failure to achieve active labour (≥6 cm) after adequate induction:
- At least 12–18 hours of adequate uterine activity on oxytocin after amniotomy without
reaching active phase.
- Once in active phase, use arrest criteria (no dilation progress for ≥4 h with adequate
contractions or ≥6 h if inadequate).
- Do not call it failed after only a few hours with an unripe cervix.
Minimizing vertical transmission in an RVD (HIV) pregnant patient
Antenatal:
- Immediate/continued ART, aim VL <50 copies/mL by delivery.
- VL monitoring at booking, ~36 w, and if adherence concerns.
- Treat STIs, avoid invasive procedures.
Intrapartum:
- Mode: VL <50 (or <200) → vaginal birth; VL ≥1000/unknown → pre-labour CS at 38 w.
- Avoid AROM unless needed, minimize ROM duration, avoid episiotomy unless indicated.
Postpartum/Infant feeding:
- Exclusive breastfeeding if mother on ART and adherent.
- Continue ART adherence support. Mixed feeding discouraged early on.
Neonate after RVD (HIV) exposure
- Start PEP ASAP (within 6–12 h).
- Low-risk: Single-drug prophylaxis (e.g., nevirapine once daily for 6 weeks).
- High-risk: 2–3 drug regimen for 4–6 weeks.
- Testing: PCR/NAT at birth, 10 weeks, after breastfeeding, final serology at ~18 months.
- Cotrimoxazole from 6 weeks until HIV excluded.
- Ensure immunizations; link to PMTCT follow-up.
Post-delivery care after IUFD from Abruption
Medical:
- Monitor for DIC, hemorrhage, AKI, infection.
- Analgesia, uterotonics, check for retained tissue.
- Manage severe pre-eclampsia/HELLP if present.
- Rh-negative: anti-D.
- Cause evaluation: placenta histology, labs, HTN control.
Psychosocial/Bereavement:
- Offer private space, allow seeing/holding baby if desired, create mementos.
- Provide compassionate explanations; avoid blame.
- Screen for depression/PTSD; arrange follow-up.
- Offer counselling, support groups, spiritual/cultural rites.
- Discuss lactation suppression or pumping.
- Contraception discussion and future pregnancy planning.
Management of Postpartum Haemorrhage (PPH)
1) ABC + call help, IV access, fluids, TXA 1 g IV (repeat if needed).
2) Uterine massage, uterotonics in sequence: Oxytocin → Ergometrine → Carboprost →
Misoprostol.
3) Assess 4Ts:
- Tone: uterotonics, balloon, sutures.
- Tissue: remove retained placenta/tissue.
- Trauma: repair tears, inversion reduction.
- Thrombin: labs, fibrinogen/cryoprecipitate, platelets, FFP.
4) Refractory: arterial ligation, embolization, hysterectomy.
5) Warm patient, monitor urine, replace calcium with MTP.
Screening for Gestational Diabetes
- Universal 24–28 w; earlier if high risk.
- Preferred: 75-g OGTT (fasting). Diagnostic if any of:
- Fasting ≥5.1 mmol/L, 1-h ≥10.0, 2-h ≥8.5.
- Alternative 2-step: 50-g GCT → 100-g OGTT if abnormal.
Glucose profile in GDM
- Fasting and 1–2 h post-meals (4–7 points/day initially).
- Targets: Fasting ≤5.3 mmol/L, 1-h ≤7.8, 2-h ≤6.7.
- Escalate if ≥30% readings above targets after 1–2 w diet/exercise: metformin or insulin.
PPROM
Definition: ROM before 37 w and before labour.
Diagnosis: history, sterile speculum (pooling, nitrazine/ferning), US for AFI. Avoid digital
exam.
Initial management:
- Admit, monitor vitals & CTG, labs if infection.
- Antenatal steroids (24–34+6 w), MgSO4 if <32 w and delivery expected, GBS prophylaxis
intrapartum.
- Latency antibiotics: IV ampicillin + erythromycin 48 h → oral 5 days. Avoid co-amoxiclav.
- Tocolysis not recommended (except short course to complete steroids).
Delivery:
- ≥34 w: delivery.
- 24–33+6 w: expectant unless infection, fetal distress, labour, abruption.
- <24 w: individualised counselling.
Conservative Management of PPROM
- Hospital initially: monitor vitals, fetal surveillance, US twice weekly for AFI/growth.
- Avoid digital exams; pelvic rest.
- Continue latency antibiotics, steroids, MgSO4 as indicated.
- Thromboprophylaxis if reduced mobility.
- Selected outpatient follow-up with clear return precautions.
- Deliver for infection, fetal distress, abruption, labour, or at 34 w.
