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If platelet count is more than 100x10 /cumm then there is no 3 coagulation problem but if platelet count is less than

100x10 / cumm then give fresh frozen plasma to prevent DIC.

Pre-term labour
Spontaneous onset of regular uterine contraction with or without rupture of membrane resulting in change in state of cervix before 37 weeks of gestation is pre-term labour. It may happen due to: Previous premature delivery or second trimester abortion Multiple pregnancies and polyhydramnios Uterine malformation Placenta abruption or chorioamnionitis Severe maternal infection in illness Genital tract infection like bacterial vaginosis Foetal death

Isoxsuprine (Duvadilan): It inhibits myometrial activity with cardiovascular effect. Dose is 80 mg in 500ml of Ringer lactate solution. Start with 15 drops/min and increase to 60 drops/min if no hypotension is there. Dose is tapered on inhibition of uterine activity to 10mg IM half hourly for five doses and then oral 10mg thrice daily for three days or till 37 weeks Ritodrine Hydrochloride: It inhibits myometrial activity, bronchial smooth muscle with mild cardiovascular activity. Dose-150mg in 500 ml normal saline 0.1mg/min I.V. Increase it to 0.3mg/min till the uterine contraction ceases and then give oral 10 mg 6 hourly Potential steroids if gestation age is between 27 and 36 weeks. It is given to prevent respiratory distress syndrome in pre-term infant. Betnesol 12 mg IM is given and repeated after12 hours Check the presentation of foetus and formulate a delivery plan accordingly In case of vertex presentation, labour is accelerated by ARM and oxytocin infusion but in breech presentation C-section is justified

Steps to manage
Advise bed rest Use of tocolysis to inhibit uterine contraction. Contraindications of tocolysis
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Obstructed and prolonged labour


Prolonged labour occurs when the first stage and second stage of labour is more than 18 hours. It is common in: Primigravida Malpresentation, cephalopelvic disproportion, occipito posterior Uterine malformation Twins / hydramnios Use of analgesia / induction of labour

IUD Severe hypertension Chorioamnionitis Advanced labour APH Maternal diabetes Thyroid disease Intravenous beta-adrenergic agents are the usual first choice for the treatment of patients in established pre-term labour

It can be detected by partogram.

Prolonged latent phase


It is more than 20 hours in primi and more than 14 hours in multigravida. Usually the 80-90% effacement and 3 cm dilatation occurs in six to eight hours.

Management
IV fluid Antibiotic Acceleration of labour by Oxytocin (Syntocinon) drip. Start with two units of Oxytocin (Syntocinon) in 500ml of dextrose with 10 drops/min and then slowly increase the drop and concentration of the drip depending on the uterine contraction FHS and progress of labour If the contraction is well established and there is no progress of labour, no cervical dilatation, descent of head and there are other features of obstructed labour like caput formation, difficulty in passing urine then prepare the patient for C-section

Prolonged active phase


Arrest of head descent due to large foetus, Cephalopelvic disproportion, Occipito posterior Head descent less than 1 cm/ hr in primi and less than 2 cm/ hr in multigravida Secondary arrest of dilatation mainly in occipito posterior position Dilatation less than 1.2 cm/ hr in primi and less than 1.5 cm in multigravida. Cervix fails to dilate more than 2 cm

Intra-uterine death
It is death of the foetus after 28 weeks of gestation. To prevent intrauterine deaths high-risk cases, as given below, should be screened and treated early. Pre eclampsia APH Renal / hypertensive disease of mother Severe anaemia Syphilis / diabetes / RH negative Post maturity

Dilatation ( in cm)

Diagnosis is done on the basis of symptoms and signs and confirmation of diagnosis is done by ultrasound.

Symptoms
Duration ( in hrs)
Loss of foetal movement Dirty discharge per vagina

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Signs
No FHS by stethoscope/Doppler on repeated examination Spalding sign i.e. overlapping of sutures is found after seven days. It is the surest sign USG reveals no foetal heartbeat On per abdominal examination fundal height found to be less than what it should be due to amenorrhoea. It is usually found after four weeks of foetal death Confirm diagnosis only if clinical negative FHS is found after repeated test, over two weeks.

Syntocinon: Five hundred ml of Ringer lactate and Oxytocin (Syntocinon) are usually used for induction of labour. Dose is 10 units in first bottle and 15 units in second bottle for the first day of induction and if there is no response then again start Oxytocin (Syntocinon) drip on next day with 20 units in first bottle and 25 units in second bottle. Antibiotics should be started with induction to prevent infection Never do ARM If repeated induction fails than always exclude extra-uterine pregnancy

Investigations
Haemoglobin count, ABO RH typing TC, DC of WBC BT, CT Platelet count Blood sugar VDRL

Intra-uterine death with complication


Intra-uterine death is usually associated with haemorrhagic complications. Hypo-fibrinogenaemia may develop in about 2-10% of cases due to thromboplastin absorption resulting from prolonged retention of dead foetus for more than four weeks. This condition can suddenly cause haemorrhagic states in the patient due to defect in the blood coagulation following disseminated intra-vascular coagulation. Depletion of plasma fibrinogen, platelet and factor V111 occurs. Coagulation-related bleeding from uterus, needle prick and gums can seldom develop before, during or after expulsion of dead foetus.

Management
Expectant treatment Spontaneous expulsion occurs in two weeks in majority of cases. Do not do expectant treatment in APH, ruptured uterus, infection, psychological cases and where pregnancy is far from term. Active treatment by induction of labour Dianoprostone (Cerviprim gel): When cervix is unfavourable cerviprim gel can be given for induction of labour. Misoprostol (Misoprost): Second alternative is Misoprosot in the dosage of 100 microgram four hourly.
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Signs of coagulopathy
Prolonged BT, CT and PT Decreased platelet count

Management
Fresh blood transfusion with two units of blood Fresh frozen Plasma Platelet packs After correcting the coagulation only the induction for delivery of baby should be started
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Stillbirth
When a newborn weighing 1000gm or more shows no sign of life after 28 weeks, it is a case of stillbirth. This can be of two types: Macerated stillbirth is death of foetus before labour. This is also known as intra-uterine death. Fresh stillbirth is death of foetus during labour, also called intra-natal death.

However, for the purpose of treatment anaemia is divided into three types: Mild - 8 to 10gm% Moderate - 6 to 8gm% Severe - less than 6 gm% Before treatment the medical history of the patients need to be taken note of the factors which predispose to anaemia: Dietary history History of menorrhagia History of piles History of worms History of malaria History of UTI, respiratory tract infection, haemoglobinopathy

Causes of stillbirth
If the woman suffers from anaemia and hypertension then during labour placental insufficiency may arise leading to foetal death. Uterine cause-Abnormal uterine action in labour enhances foetal hypoxia due to placental insufficiency already existing during pregnancy. Umbilical cord accidents- Prolapse of cord in labour, cord compression by after coming head of breech, multiple turns around foetal neck are causes of foetal death. Foetal causes-Foetal hypoxia in labour and birth trauma are important causes.

Complications that may occur in anaemia during pregnancy


Maternal complications Inter-current infection, UTI, respiratory infection Heart failure Pre-term labour Anaemia associated PIH Post-partum haemorrhage Puerperal sepsis

Anaemia during pregnancy


World Health Organisation (WHO) defines anaemia in non-pregnant women when the blood haemoglobin is below12 gm% and in pregnant women when haemoglobin is below 11gm%. Clinically anaemia is of two types: Early anaemia occurs when Hb% level is 10-11 gm% Mild anaemia occurs when Hb% level is less than 10gm%

Foetal complications Stillbirth Baby with low birth weight, pre-term, IUGR Increased neo-natal death Anaemia in baby
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Management
Advise diet containing eggs, meat, liver, peas, green leafy vegetables and fruits Treatment of piles In case of worms give two to three tablets of pyrantel Pamoate in second trimester In mild case of anaemia oral tablets of ferrous sulphate are to be taken twice daily. If the rise of haemoglobin does not occur after one month then it is a case of non-responsive anaemia. If there is concurrent vitamin B complex deficiency then 10 injections of B complex should be given every alternate day In cases where Hb% is 6-8 gm% and also in cases of non-responsive mild anaemia give parenteral iron

Blood transfusion is indicated in


Severe anaemia Anaemia not responding to haematinics Infection causing anaemia Aplastic/ hypoplastic anaemia PPH/ shock

Management of anaemia when patient is in labour


Oxygen inhalation I.V fluid to be avoided Strict asepsis Ergometrine, oxytocics to prevent PPH Blood transfusion when required

Indications
Non-responsive anaemia Poor compliance Oral iron intolerance

Postnatal care is important and the patient should be given iron and folic acid tablets for three months along with good nutritious diet. Contraception advice must be given.

Contraindications
Nephritis Cardio-respiratory diseases Allergy Inject iron sorbitol citric acid complex 75mg(Jectofer) IM on upper quadrant of buttock in Z shaped fashion on alternate days after sensitivity test for at least 10 injections. Never use total dose infusion iron.

Post-partum haemorrhage (PPH)/ Post abortal haemorrhage


PPH is excess bleeding from genital tract after childbirth up to puerperium (42 days) affecting the general condition of the patient. PPH are of the following types: Third stage haemorrhage that occurs before expulsion of placenta Primary PPH occurs after third stage and within 24 hours Secondary PPH occurs after 24 hours but during puerperium

Patient should be admitted in case of


Severe anaemia. Moderate anaemia after 32 weeks of pregnancy.
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Primary PPH
PPH is predicted in some high-risk pregnancies: Prolonged/obstructed labour Grand multipara
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