Case Studies in Obstetrics Rodney K. Edwards, MD Sheri Jenkins, MD Richard O. Davis, MD UAB MaternalMaternal-Fetal Medicine
Disclosure Statement
• W...
Case Studies in Obstetrics Rodney K. Edwards, MD Sheri Jenkins, MD Richard O. Davis, MD UAB MaternalMaternal-Fetal Medicine
Disclosure Statement
• We have no conflicts of p interest to report.
Case Studies in Obstetrics Outline • Discuss 3 cases – Ultrasound diagnosis – Growing problem in pregnancy – Common reason for maternal transport
• Focus on how to improve outcome
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Case 1 • 34 y/o P5005 with one prior cesarean delivery presents for a viability ultrasound exam
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Case 1 • Diagnosis? • How to proceed?
Cesarean Scar Ectopic Epidemiology/Etiology • Uncertain incidence; more common in last few decades with increased CD rate • Conceptus implants in the cesarean scar, gaining access to the myometrium rather than endometrium
Cesarean Scar Ectopic Diagnostic Criteria • Empty uterus • Empty cervical canal • Gestationall sac in the h anterior lower uterine segment • Scant/absent myometrium between the bladder and gestational sac Seow, et al. UOG 2004
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Cesarean Scar Ectopic Treatment • Best approach unclear—literature consists of case reports/series • Options Opti ns – Systemic methotrexate – Inject KCl or MTX – Laparotomy/excision
Cesarean Scar Ectopic Natural History • If untreated, most likely will become an IUP with a placenta accreta • Recognition and treatment early – Avoids cesarean hysterectomy – Minimizes risks of morbidity and mortality
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Case 2 • 32 y/o P0020 presents for prenatal care – 2 prior spontaneous Ab’s – Height 5’9” – Weight 461 lbs – BMI 68
Obesity • What complications are more common? • What Wh t modifications m difi ti ns n need d tto b be made to usual prenatal care? • What precautions are necessary for care in L&D?
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Obesity During Pregnancy Prevalence • Defined as a BMI of 30 or more prior to pregnancy • At UAB: 16% in 1980, 1980 36% in 1999, over 40% today • Overall US rate: 28% in 1999, 34% in 2008
Obesity During Pregnancy BMI Categories • • • • •
Normal Overweight Class I Obesity Class II Obesity Class III Obesity
– 10% at UAB – 7.6% overall in US
18.5-24.9 25-29.9 30 34 9 30-34.9 35-39.9 40 or more
Obesity Trends* Among U.S. Adults BRFSS, 1990, 2000, 2010 (*BMI 30, or about 30 lbs. overweight for 5’4” person) 2000
DVT/PE Fetal death Birth defects, defects various Preterm birth Post-term birth Labor induction Anesthesia complications
Obesity During Pregnancy Complications • Obstructive sleep apnea also more likely with obesity – Usually worsens during pregnancy – Associated with HTN, stroke, cardiac dysfunction (e.g. RV failure)
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Obesity PNC Considerations • • • •
Early screening for GDM Maternal echo? Baseline l proteinuria evaluation? l Counsel re. weight gain (Per IOM 2009 recommendations, 11-20 lbs) • Nutrition counseling
Obesity PNC Considerations • Detailed fetal anatomic survey on ultrasound – Technically difficult – Up to 50% will be incomplete
• Serial exams to monitor fetal growth • Antenatal testing?
Obesity L&D Considerations • Early anesthesia consult • How much weight is supported by – Labor b b bed d – Toilet – OR table
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Obesity L&D Considerations • If cesarean necessary – If emergent indication, delivery of infant will be delayed – Will take longer; worse exposure – DVT prophylaxis – Higher dose prophylactic abx? – Where to put skin incision?
Case 3 • 23 y/o P0010 presents at 26 weeks with PROM • What Wh t are the th strategies st t i s to t minimize morbidity for the patient and her fetus?
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Preterm PROM Avoid Digital Exams • Even one digital exam decreases the latency period Alexander JM, JM et al. al AJOG 2000
• Do a speculum exam to evaluate the cervix.
Preterm PROM Mg for Neuroprotection • Reasonable for transport • Start o/w if imminent delivery
