Common Obstetrics Case Scenarios

Framework of viva:
- Definition of disease
- History taking (HPI, fetal and maternal complications, PMH, Obs, Gyn, Family, Social)
- Risk factors
- Risks (antenatal, intrapartum, postnatal)
- Physical Examination (vitals, abdomen, uterus size, speculum)
- Investigations (blood, urine, swab – endocervical and high vaginal, ultrasound,
invasive testing)
- Management (monitoring, expectant, drugs, surgical, counselling on mode of
delivery and future delivery)

Hypertension in pregnancy
- Definition: 20 weeks as the differentiation
a) HT: >140/90 mm Hg (mild 14x/9x, moderate 15x/10x, severe >=160/110)
b) Proteinuria: >300 mg/day of protein in 24-hour urine
c) PET: new-onset hypertension presenting after 20 wks with significant proteinuria
d) ET: convulsive condition associated with PET
e) HELLP: x3 hemolysis, high liver enzymes, low platelet

Proteinuria bf 20 wks as chronic kidney disease, after 20 wks as gestational

proteinuria
HT bf 20 wks as chronic HT, after 20 wks as gestational HT
Proteinuria + HT after 20 weeks  PET

(Scenario: BP 150/90 10 wks of gestation, persist, proteinuria 3+ 23 wks of gestation

 chronic HT with superimposed PET)
Hx: HPI (notice headache, blurred vision, retrosternal pain, periorbital and perioral
swelling, vomiting), fetal movement and labour, PMH (HT, DM, CKD, AI, previous
PET), FHx (PET, HT, DM, CKD, AI), Social Hx, Drugs (allergy, drugs using)
P/E: vitals, GE, abdomen, uterus (size, SFH)
Risk: 2-8 percent of pregnancy
Risk factors: HT in previous pregnancy, CKD, chronic HT, autoimmune diseases (e.g.
SLE), T1 or T2 DM
Complications: placenta abruption, pulmonary edema, IUGR, ET, cerebral
hemorrhage
Ix: CBC, LRFT, ultrasound (fetal well-being), doptone, CTG
Management:
a) Management of chronic HT (Tx for HT, note end-organ damage  140/90 target,
low dose aspirin for prevention – if meet any one criteria of HT chronic or preg, CKD,
AI, T1 or 2 DM)

b) Mx of gestational HT and PET (1st line: labetalol), take bloods (CBC, LRFT), monitor
BP Q6H/day, Doptone and CTG to assess for any fetal movement or deceleration

c) Delivery:
before 34 weeks: monitor condition
if severe HT refractory to Tx or affected fetal/maternal well-being, need immediate
delivery (LSCS), give steroid for lung maturation
if not, antenatal monitoring (e.g. BP measurement in-px, vitals including oxygenation,
establish IV access, CTG, Doptone, CVP, neurological assessment, Ix: CBC, LRFT, urate,
clotting profile)

34-37 weeks: same as before 34 weeks for delivery by LSCS no need steroid for
maturation

37 weeks: immediate delivery (24-48 hrs) after dx established

d) Rx
- MgSO4 (must use if severe HT, severe PET, ET, HELLP), loading dose 4g over 10 mins
and 1g/hour IV
 monitor RR, patellar reflex, urine output
- Labetalol (100 mg over 45 mins), nifedipine, hydralazine
- steroid prophylaxis and thromboprophylaxis
- delivery (timing)

e) post-partum management
- monitor BP, change methyldopa to other meds bc of post-partum depression,
MgSO4 24-48 hrs over delivery, vitals monitor (watch for sx of SOB), postnatal reiew
(risk of recurrent: GHT – 50%, PET – 16%, severe PET with birth <34 wks – 25%,
severe PET with birth <28 wks – 55 %)
Gestational diabetes
- Definition:
a) DM in pregnancy: random glucose > 11.1 in the presence of diabetes symptoms, 2-
hour glucose >11.1 after OGTT test, fasting glucose >7.0
b) gestational DM: 2-hour glucose 8.5-11.0 after OGTT, 1-hour glucose >10.0 after
OGTT, random glucose 5.1-6.9
- Risk factors: insulin resistance in maternal adipose tissue, increase in progesterone
release
- Risks/Cx: maternal complications – cephalopelvic disproportion, vulval and vaginal
infections, T2DM in the future, HTN and PET
fetal complications – LGA, RDS, prematurity, neonatal cx (e.g. HypoCa, jaundice,
HypoMg, HypoGl), polyhydramnios, stillbirth, increased risk of diabetes
- Hx taking: HPI, fetal complications (e.g. macrosomia), PMH, Obs, Gyn
(contraception), drugs (Hx and allergy), FHx, SHx
- P/E: vitals, GE, abdomen, uterus (size) +/- speculum/PV
- Ix: CBC, random glucose, OGTT (at 24-28 wks universal; 16 weeks for high risk –
GDM, PET, stillbirth, macrosomia, miscarriage, PCOS, steroid use)
- Mx: dietary control (refer to dietician, 30-35 mg/kcal per day for non-obese, 3 major
meals, exercise for 30 mins per day); insulin (2 weeks still refractory); oral
hypoglycemic agent (metformin); glucose monitoring; fetal monitoring (CTG for fetal
well-being); counselling on mode of delivery (CS if macrosomia – 4 to 4.5 kg);
intrapartum monitoring
- Counselling on future: for puerperium, usually will return to pre-hyperglycemic
state at 6-8 weeks after the delivery; consider OGTT 6-8 wks after delivery; if insulin
therapy is initiated antenatally, check blood glucose 24-72 hrs after delivery;
encourage breastfeeding; no C/I of contraception but watch out in obesity
Pre-existing Medical Diseases
a) UTI: common in pregnancy, watch out for asx bacteriuria (>10^5 CFU) and treat,
risk factors: recurrent cystitis, DM, renal tract problems, bladder abnormalities
aetiology: Klebsiella, E. Coli, Streptococci, Psuedomonas.
treatment: ampicillin, amoxicillin, cephalosporin
b) CKD: can interact with pregnancy (CKD can lead to IUGR, IUD, preterm,
miscarriage, IUD)
Mx: monitoring of BP, proteinuria, RFT, control of PET, monitoring of fetal well-being
c) Cardiac disease
- maternal (heart failure, IE, arrhythmia) and fetal risks (IUGR and preterm delivery)
- antepartum management (class III refer to cardiologist, class IV should avoid
pregnancy)
- intrapartum: monitor maternal vitals, fetal monitoring (heartbeat and CTG),
prophylactic antibiotics, adequate pain relief, shorten 2nd stage of labour, avoid
ergometrine for 3rd stage
d) Liver and GI diseases
- NAFLD: Cx – liver fibrosis, cirrhosis, T2DM; Mx – weight loss, exercise, healthy diet,
reduction in alcohol
- viral hepatitis: Hep A manage as non-pregnant; Hep B if positive, HBIg and
vaccination to baby after birth
- IBD: pregnancy increased risk of flare of UC; manage as non-pregnant (5-ASA and
sulfasalazine safe)
- PUD: manage as non-pregnant but misoprostol is C/I
e) Resp
- TB: manage as non-pregnant but give vitamin B6 to isoniazid and avoid
streptomycin (auditory nerve toxicity); prophylactic isoniazid for baby 3 mos then
BCG vaccination
- Asthma: manage as non-pregnant (B2 agonists and steroids are safe) but cover
intrapartum steroid for steroid users
f) ITP
- <150 x 10^9/L with easy bruising
- D/dx: gestational thrombocytopenia, drug induced, virus induced, platelet
clumping, HELLP, pre-eclampsia, DIC, SLE, hypersplenism
- Antepartum and intrapartum management: <50 x 10^9 give corticosteroids or IVIg,
if <80 x 10^9 avoid epidural analgesia
- can do vaginal delivery
g) thyroid diseases
- use lowest dose of carbimazole and propylthiouracil as they cross placenta
- RAI C/I in pregnancy (contraception 4 months after RAI)
- breastfeeding safe in those receiving RAI
h) epilepsy
- fetal morphology at 20-22 weeks
- treat as eclampsia until proven otherwise
- give periconceptional folic acid
- continue AED intrapartum
- prescribe vit K
i) SLE
- risks: maternal – worsening of proteinuria/nephropathy; fetal – PET, IUGR, IUD,
preterm birth, miscarriage
- Ix: ANA, anti-ds DNA, anti-Ro, anti-La, CBC, CRP, ESR, LRFT
- low dose aspirin from 12 wks prophylaxis
j) APS
- Ix: anti-cardiolipin or lupus anticoagulants

Concepts: By system (Renal – CKD and UTI, cardiovascular – structural and functional,
GI and hep – Hep ABC, NASH, IBD, PUD; resp —TB and asthma; endocrine – thyroid
(hyper and hypo); hemat – ITP and gestational thrombocytopenia; neuro – epilepsy;
rheumat – SLE and APS)
Multiple pregnancies
Definition:
DCDA -- <= 3 days (deliver at 37-38weeks)
MCDA – 4-7 days (36-37 weeks)
MCMA – 8-12 days (32-34 weeks)
conjoined twins -- > 12 days

Risk factors: ART, family Hx

Risks: prematurity, fetal abnormalities, IUGR, miscarriage, difficulty in delivery, TTTS

Maternal risks: PET, GDM, APH, PPH, increased risk of CS, hemat (anemia and
thromboembolism)

Mx
antepartum care: in-px, 11-13 weeks to look for any NT, viability, gestational age,
chorionicity; 18-22 weeks look for any fetal abnormalities
intrapartum care: NPO, IV line, T/S, epidural analgesia unless plt <80 x 10^9, deliver
first baby, then check if 2nd baby breech, if yes, ECV if not C/I, if cannot do ECV then
IPV
Postpartum counselling: risk of thromboembolism, risk of anemia, risk of PPH, social
implications of having 2 babies, family planning and contraception
Symptoms in Pregnancy
a) Antepartum
APH:
Definition: vaginal bleeding at 24 weeks onwards till delivery
Etiology (D/dx): placental abruption (painful), placenta abruption (painless), show
(mucous), vasa previa, cervical polyp or cancer, cervicitis or infections, fibroids,
adenomyosis, endometrial hyperplasia or cancer, coagulopathies, vaginal trauma,
uterine rupture
History: HPI (onset, amount of bleed – how many pads soaked? Any pain? Any
fever/LoW/LoA? Any reduced fetal movements detected? The colour and content of
bleed? Any signs/sx of labour detected?), PMH, Obs (previous pregnancies, routes,
pregnancy complications, postnatal complicaitons), Gyn (contraception, menstrual),
family Hx (history of APH/PPH), social Hx (S/D/marriage)
P/E: GE, vitals, abdomen (any pain), uterus (size/SFH/lie/pole/presentation),
speculum exam
Ix: Blood (CBC, LRFT, clotting profile, ESR, CRP, T/S, Rhesus  if +ve Kleihauer), Urine
(protein, hematuria), swabs (endocervical/high cervical), ultrasound
(pelvic/transabdominal), speculum, doptone, cardiotocogram
Mx: admission to hospital, large IV bolus cannula for resuscitation, monitor the vitals,
delivery if heavy bleeding/fetal distress/37 weeks or above, monitor if PP grades I
and II, continuous CTG and fetal heart sound monitoring, T/S
very low lying PP needs traditional CS
Cx: perinatal death, hypoxia, prematurity, maternal – severe bleed, DIC, PPH

Suprapubic pain in pregnancy

D/dx: instability of pelvic girdle due to hormonal influence (progesterone), urinary
tract infections, uterine contractions, intra-uterine infection, red degeneration of
fibroid, appendicitis
Mx: Rest, NSAIDs/paracetamol for pain control, refer to physio, counsel for symptom
recurrence

Abd Pain in pregnancy

(Definition)
Risk factors/d/dx: pregnancy-related, genital tract (structural lesion, infection,
hemorrhage), gastrointestinal, urinary (e.g. pyelonephritis), hepatobiliary, vascular
Hx
P/E
Ix
Mx

Back pain
Risk factors: postural changes, laxity of joints, separation of rectus abdominis
muscles
D/dx: labour, UTI, prolapsed IVD, suprapubic pain

N/V

Bowel Sx

Headache (rule out concurrent vomiting/PET)

Itching skin
D/dx: pemphigoid gestationis, intrahepatic cholestasis of pregnancy, polymorphic
eruption of pregnancy

Decreased fetal movements

Definition: fetal movements increase till 32 weeks then decrease. Decreased fetal
movements defined by <10 fetal movements in the conditions of (i) within 2 hours of
conscious counting; (ii) within 8 hours of normal life
RF: maternal posture, placenta and fetal position, use of sedatives, smoking
Risks: FGR, IUD, congenital malformations
History
P/E
Ix: blood, urine, ultrasound, cardiotocography
Mx: persistent DFM at term  induce labour!!
Labour and delivery

Definitions:
PROM – prelabour rupture of membranes (common)
PPROM – preterm prelabour rupture of membranes (need to treat as infection until
proven otherwise

Normal mechanisms of labour: descent, flexion, internal rotation, extension of the

fetal head, restitution (return to original position), external rotation, delivery of
shoulders

Third stage
- note any signs of placenta separation – lengthening of cord, rising of fundus, gush
of fresh blood
- Mx: IV syntocinon/syntometrine; controlled cord traction, delay 1 min for cord
clamping

Induction of labour
- indications: past term, gesetational hypertension-related disorders, gestational DM,
rupture of membrane, fetal growth restriction, suspicious fetal heart pattern,
stillbirth, multiple pregnancy
- Bishop score <7, cervical priming by prostaglandin E2

Abnormal first stage of labour:

- uterine inertia
- malposition
- malpresentation (breech, shoulder, face, cord, compound)
- abnormal fetal heart rate
- CPD (caput and moulding)

Abnormal second stage: prolonged 2nd stage (CPD, maternal exhaustion), abnormal
fetal heart rate, assisted delivery technique, shoulder dystocia

Shoulder dystocia:
RF: macrosomia, previous shoulder dystocia, GDM, induction of labour, 1st and 2nd
stage abnormal labour
Risks: fetal asphyxia, brachial plexus injury, bone fracture
Obstetric maneuver: McRobert’s maneuver
Abnormal third stage:
- Retained placenta (first line syntocinon, if still blocked, manual removal)
- Postpartum hemorrhage
(500ml of more of the blood within 24 hours of delivery)
D/dx: uterine atony (most common), genital tract trauma, retained placenta
products, coagulopathy, uterine inversion (rare)
History taking:
P/E: vitals, GE, abdomen (pain), uterus (size, tenderness)
Ix: CBC, LRFT, clotting profile, T/S
Mx: admit, large bore IV cannula, lie flat and oxygen, manage coagulopathy by
clotting factors, cryoprecipitate, vitamin K etc.
Stop bleeding in uterine atony: uterine massage, bimanual compression (first
line), if fail then syntocinon/carboprost/misoprostol
For genital tract trauma/coagulopathy/uterine inversion: treat the cause

Puerperium (6 weeks):
- physiological changes: uterus, perineum, return of ovulation, cardiovascular
system, respiratory system, urinary system, clotting factors/hematological system
- postpartum fever (infection, coincidental, breast complications, DVT)
- postpartum blues (dysthymia for some days)
- postpartum depression (depressed mood for at least 2 weeks)