--- module: 054-01 language: en chapter: 54 title: "Antenatal Care, Pregnancy Complications, Labour, and the Puerperium" module_title: "Foundations" source_sha256: 1d9b47bf1c4754cb7f0c9d50a86e1246545bd656f7c88590bbefe947721019af --- # Antenatal care, pregnancy complications, labour, puerperium ## Two patients, one placental circulation ### Normal adaptations can resemble disease ### Minor maternal deterioration threatens placental flow ### Management varies with gestation ## Confirmation, dating, and booking ### Human chorionic gonadotropin confirms trophoblast only #### Not location or viability ### Date by last period and early ultrasound #### Location, number, cardiac activity, crown-rump length ### Unknown location: serial assessment #### Until intrauterine, ectopic, or loss is clear ### Reconcile teratogenic and essential medicines #### Abrupt withdrawal may exceed exposure risk ### Folic acid reduces neural-tube defects ## Maternal adaptation and monitoring ### Plasma volume outpaces red-cell mass #### Physiological dilutional anaemia ### Cardiac output up, systemic resistance down ### Ventilation up, carbon dioxide and bicarbonate down ### Filtration up alters creatinine and drug clearance ### Clotting shifts toward thrombosis ### Reduced reserve for haemorrhage, embolism, infection ### Genetic screening is voluntary #### Screening versus diagnosis, false results #### Villus sampling and amniocentesis are invasive ## Early pregnancy pain and bleeding ### Miscarriage symptoms overlap viable and ectopic #### Assess perfusion, peritonism, hormone, ultrasound ### Confirmed loss: expectant, medical, or surgical ### Ectopic pregnancy mostly tubal #### Many have no risk factor #### Rupture possible at low hormone levels #### Unstable: immediate surgery and resuscitation #### Stable: methotrexate or observation ### Hyperemesis: weight loss, dehydration, ketosis #### Thiamine before substantial carbohydrate ## Hypertensive disorders ### Chronic: before pregnancy or early ### Gestational: later, no defining organ injury ### Pre-eclampsia: new hypertension with organ dysfunction #### Abnormal placentation, endothelial dysfunction, leak #### Headache, visual change, epigastric pain: urgent ### Antihypertensives reduce severe-pressure harm ### Magnesium sulphate prevents eclamptic seizure ### Delivery definitive, balanced against prematurity #### Corticosteroids mature fetal lungs ### Low-dose aspirin in selected patients ## Diabetes in pregnancy ### Placental hormones raise insulin resistance #### Gestational diabetes when beta cells fail to compensate ### Pre-existing diabetes: risk from conception ### Hyperglycaemia: anomaly, overgrowth, neonatal hypoglycaemia ### Insulin needs fall after placental delivery ### Retest postpartum for type two risk ## Placental and fetal complications ### Praevia: painless bleeding #### No digital examination until location known ### Abruption: pain, tenderness, fetal compromise #### Concealed haemorrhage underestimates severity ### Rhesus D alloimmunisation #### Anti-D prevents sensitisation ### Growth restriction: biometry, fluid, Doppler ### Preterm membrane rupture: infection risk #### Fever, tenderness, offensive fluid suggest infection ## Labour and birth ### Regular uterine activity with cervical change ### Fetal heart patterns guide correction #### Hypotension, excess contractions, cord compression ### Delay: contractions, malposition, disproportion ### Shoulder dystocia: rehearsed manoeuvres ### Cord prolapse: relieve pressure, emergency delivery ### Uterine rupture: scarred uterus, laparotomy ## Postpartum haemorrhage ### Atony, retained tissue, trauma, coagulopathy ### Help, access, warming, quantify loss ### Uterotonics and early tranexamic acid ### Escalate: balloon, embolisation, hysterectomy ### Shock may precede blood-pressure fall ## Puerperium and lactation ### Endometritis, mastitis, urinary infection, sepsis ### Leg swelling, headache, deficit are warnings #### Thromboembolism, pre-eclampsia, stroke ### Prolactin produces, oxytocin ejects milk #### Skin contact, attachment, frequent removal ### Mastitis: continue drainage, image abscess ### Blues brief, persistent symptoms urgent #### Postpartum psychosis is an emergency ### Link complications to lifelong prevention