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Obstetrics
Har.sukh Bcnipal, Emma Sparks, and Jane Zhu, chapter editors
Vrati M. Mehra and Chunyi Christie Tan, associate editors
Arjan S. Dhoot, EBiVl editor
Dr. Richard Pittini, Dr. Mara Sobel, and Dr. Melissa Walker, staff editors
Acronyms
Basic Anatomy Review
Pregnancy
Diagnosis of Pregnancy
Maternal Physiologic Adaptations to Pregnancy
Antepartum Care
Preconception Counselling
Initial Prenatal Visit
Nausea and Vomiting
Hyperemesis Gravidarum
Subsequent Prenatal Visits
Prenatal Screening and Diagnostic Tests
Fetal Surveillance
Counselling of thePregnant Patient
Nutrition
Lifestyle
Medications
Immunizations
Radiation
Antepartum Hemorrhage.
Placenta Previa
Placental Abruption
Vasa Previa
Obstetrical Complications
Preterm Labour
Prelabour Rupture of Membranes
Postterm Pregnancy
Intrauterine Fetal Demise
Intrauterine Growth Restriction
Macrosomia
Polyhydramnios/Oligohydramnios
Antenatal Depression
Multi-Fetal Gestation and Malpresentation.
Twin-Twin Transfusion Syndrome
Breech Presentation
Hypertensive Disorders of Pregnancy.
Hypertension in Pregnancy
Medical Complications of Pregnancy
Iron andFolate Deficiency Anemia
Diabetes Mellitus
Early-Onset Group B StreptococcusDisease
Urinary Tract Infection
Infections During Pregnancy
Venous Thromboembolism
Normal Labour and Delivery
The Cervix
The Fetus
Four Stages of Labour
The Cardinal Movements of the Fetus During Delivery
Analgesic and Anesthetic Techniques in Labour and Birth
Fetal Monitoring in Labour
Induction and Augmentation of Labouc
Induction of Labour
Methods for Induction of Labour
Augmentation of Labour
0B2 Abnormalities and Complications of Labour and Delivery OB40
Abnormal Progression of Labour (Dystocia)
Shoulder Dystocia
Umbilical Cord Prolapse
Uterine Rupture
Amniotic Fluid Embolism
Chorioamnionitis
Meconium
Operative Obstetrics.
Operative Vaginal Delivery
Forceps
Vacuum Extraction
Perineal Lacerations
Episiotomy
Caesarean Delivery
Trial of Labour after Caesarean (TOLAC)
Postpartum Period Complications
Postpartum Hemorrhage
Retained Placenta
Uterine Inversion
Postpartum Pyrexia
Mastitis
Postpartum Mood Alterations
Postpartum Care
Breastfeeding and Drugs
Common Medications
Landmark Obstetrics Trials
References
OB2
OB3
OB3
0B4
OB43
0B11
OB46
OB14
OB50
OB16 OB51
0B51
OB52
OB23
OB25
OB28
0B33
OB38
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OBI Obstetrics Toronto Notes 2023
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0B2 Obstetrics Toronto Notes 2023
Acronyms
AC abdominal circumference
ACOG American College of
Obstetricians and Gynecologists FDP
Aft amniotic fluid index
AFLP
AFV
AP anteroposterior
APGAR appearance,pulse, grimace,
activity,and respiration
aPTT activatedpartial thromboplastin GA
time
APS antiphospholipid antibody
syndrome
ARDS acute respiratory distress
syndrome
BPP biophysical profile
CD Caesarean delivery
CMV cytomegalovirus
CPD cephalopelvic disproportion
cardiotocography
CVS chorionic villus sampling
DIC disseminated intravascular
coagulation
DVT deepveinthrombosis
ECV external cephalic version
EDO estimated date of delivery
EFM electronic fetal monitoring
eFTS enhanced first trimester screen
estimated fetal weight
fibrin degradation products
fetal heart rate
intraventricular hemorrhage
US lecithin-sphingomyelin ratio
LLDP left lateral decubitus position
IMP last menstrual period
fluorescence in situ hybridization IMWH low molecular weight heparin
MSAFP maternal serum a-fetoprotein
MSS maternal serum screening
MTX methotrexate
NIPT non-invasive prenatal testing
NPO nil per os - nothing by mouth
NST non-stress test
nuchal translucency
NTD neural tube defects
OA occiput anterior
OCP oraIcontraceptive pi11
oral glucose challenge test
oral glucosetolerance test
open neural tube defect
OP occiput posterior
OT occiput transverse
PAPP-A pregnancy-associated plasma
protein A
PG plasma glucose
PPD postpartum depression
PPH postpartum hemorrhage
PPROM preterm prelabour rupture of
membranes
IVH PROM prelabour ruptureof membranes
PTL preterm labour
QF-PCR quantitative fluorescencepolymerase chain reaction
RDS respiratory distress syndrome
RhIG Rh immune globulin
ROM ruptureof membranes
SFH symphysis fundal height
SIADH syndrome of inappropriate
antidiuretic hormone secretion
SOGC Society of Obstetricians and
Gynaecologists of Canada
SVD spontaneous vaginal delivery
T1 first trimester
T2 second trimester
T3 third trimester
TENS transcutaneous electrical nerve
stimulation
TOLAC trial of labour after Caesarean
TPN total parenteralnutrition
TTP thrombotic thrombocytopenic
purpura
TVUS transvaginal ultrasound
V/Q ventilation/perfusion lung scan
VBAC vaginal birth after Caesarean
VWD von Willebrand disease
VTE venous thromboembolism
EFW
FHR
acute fatty liver of pregnancy
amniotic fluid volume
FISH
FL femur length
FM fetal movement
FPG fasting plasma glucose
first trimester screen
gestational age
Group B Streptococcus
gestational diabetes mellitus
gravida para abortus
gestational trophoblastic
neoplasia
Hepatitis B immunoglobulin
head circumference
hemolysis,elevated liver
enzymes,and low platelets
intramyometrial
induction of labour
integrated prenatal screen
immune thrombocytopenic
purpura
intrauterinefetal demise
intrauterine growth restriction
in vitro fertilisation
FTS
GiS
GDM NT
GPA
GTN
HBIG OGCT
OGTT
ONTD
HC
HELLP
ere IMM
I0L
IPS
ITP
IUFD
IUGR
IVF
Basic Anatomy Review
FETAL CIRCULATION
Umbilical arteries (deoxygenated blood!
Umbilical vein (oxygenated blood)
Umbilical cord
Amnion
Chorion
(fetal)
Cotyledons Placenta
Endometrial artery.
Decidua
_ (maternal) Endometrial vein
MATERNAL CIRCULATION
Figure 1.Placental blood flow
Placenta
• 1°site of nutrient and gas exchange between mother and fetus
• discoid mass composed of fetal (chorion frondosum) and maternal (decidua basalis) tissues divided by
fissures into cotyledons (lobules) on the uterine side
• produces hormones such as progesterone, placental lactogen, estrogen, relaxin, p-hCG, and infant
growth factors
• poor implantation can lead to spontaneous abortion
• abnormal location, implantation, or detachment can lead to antepartum hemorrhage (see Antepartum
Hemorrhage, OB14 )
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0B3Obstetrics Toronto Notes 2023
Pregnancy
Diagnosis of Pregnancy
History
• symptoms: amenorrhea,SIX, breast tenderness, urinary frequency, and fatigue
• for obstetrical and gynaecological history note: year, location, mode of deliver}
-, duration of labour,
fetalsex,GA,birth weight, and complications of every pregnancy;organize into G
'
l PAL format, LMP,
length of menstrual cycle, and use of contraception
gravidity (G)
* G:total number of pregnancies of any gestation (multiple gestation=one pregnane}')
- includes current pregnancy, abortions, ectopic pregnancies, and hydatidiform moles
Be conscious of the use of gendered
language when providing reproductive
care to transgender male and genderdiverse patients. Discuss with each
patient the terminology they are most
comfortable using in order to avoid
gender dysphoria throughout pregnancy
care
parity (TPAL)
T:number of term deliveries (>37 wk GA)
P:number of preterm deliveries (20+0 to 36+6 wk GA)
A:number of abortions and ectopic pregnancies (ending <20 wk GA)
- induced (therapeutic) and spontaneous (miscarriage)
L;number of living children
Establishing the desirability of pregnancy
in a patient with suspected or confirmed
pregnancy informs the construction of an
appropriate management plan
Physical Signs
• uterine and abdominal enlargement
• breast engorgement, areola darkening, and prominent vascular patterns
• Goodell’
ssign:softening of the cervix (4-6 wk GA)
• Chadwick’
ssign: bluish discolouration of the cervix and vagina due to pelvic vasculature engorgement
(6 wk GA)
• Hegar’ssign:softening of the cervical isthmus (6-8 wk GA)
p-hCG Rule of 10s
101U at time of missed menses
100000 IU at10 wkGA (peak)
10000 IU at term
Investigations
• (5-hCG:peptide hormone composed of (5 subunits produced by placental trophoblastic cellsmaintainsthe corpusluteum during pregnancy
positive in serum 9 d postconception, positive in urine 28 d after 1st day of LMP
plasma levels double q48h in a normally developing pregnancy from the time it becomes
detectable until it peaks at ~100000 (approximately at 8-10 wk GA) then falls but continues to be
measurable until delivery
levelsless than expected can suggest ectopic pregnancy, miscarriage,inaccurate dates,but found
in some normal pregnancies
• levels greater than expected can suggest multiple gestation, molar pregnancy,trisomy 21,
inaccurate dates,some normal pregnancies, or kidney disease (slower clearance)
• transvaginal
• 5 wk GA:gestational sac visible
• 6 wkGA:fetal pole visible
• 6-8 wk GA:fetal heart activity visible (I HR visible after 6 wk GA on TVUS)
• transabdominal
• 6-8 wk GA: intrauterine pregnancy visible
Trimesters
T1:1-14 wkGA
T2:14-28 wk GA
T3:28-42 wk GA
Normal pregnancy term:37-42 wk GA
• U/S:
Maternal Physiologic Adaptations to Pregnancy
Table 1. Physiologic Changes During Pregnancy
Changes
Skin Increased pigmentation of perineum and areola,chloasma (pigmentabon changes under eyesand on bridge of nose),
linea nigra(midline abdominal pigmentation)
Proliferation of skin tags
Spider angiomas
Palmar eryUrema due toincreased estrogen
Striae gravidarum due toconnective tissue changes
Hyper dynamic circulation
Increased cardiac output,heart rate,and blood volume
Decreased blood pressure:decreased PVR due to progesterone's effect on vascular smooth muscle and decreased
venous return from enlarging uteruscompressing IVC and pelvic veins
Increased venous pressure leads lo risk ot varicose veins,hemorrhoids,andleg edema
Hemodilution causes physiologic anemia and apparent decrease in hemoglobin andhematocrit
Increased leukocyte count but impaired function leads loimprovement msome auto mmuoe diseases
Decreased total protein largely due lo dilutionand decreased serum albumin
6eslational thrombocytopenia: mild (platelets >70000'pl) and asymptomatic,notmahees vrthm 2-12 wk following
delivery
Hypercoagulable state:increased risk of DVI and PE but also decreased bleeding at delivery
Cardiovascular
Hematologic
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PVR - pulmonary vascular resistance:IVC-interior vena cava:FEV1 -forced expiratory volume in 1second:CO- cardiac output:GFR -glomerular
filtration rate:BUN - blood urea nitrogen:GERD- gastroesophageal reflux disease
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OBI Obstetrics Toronto Notes 2023
Table 1. Physiologic Changes During Pregnancy
Changes
Respiratory Increased incidence of nasal congestion
Increased& consumption to meet increased metabolic requirements
Elevated diaphragm (i.e.appears more"
barret chested'
l
Increased minute ventilation leads to decreased C02 resulting nmlrespiratory alkalosis that helps C02 diffuse
across the placenta from fetal to maternal circulation
Decreased total lung capacity (TIC),functional residual capacity (TRC).and residual volume|RV)
No change invital capacity (VC) and fEVr
Increased incidence of gallstones due to progesterone causing increased gallbladder stasis
Constipation due loprogesterone causingdecreased Gl motility and hemorrhoids asa result of constipation and
increased intra-abdominal pressure
Increased urinary frequency due toincreased totalurinary output
Increased incidence of U1Iand pyelonephritis due tourinary stasis (see Unoaiy freerInfection.0531)
Glycosuria can be physiologic especially in13 due brenalplasmaBow increaseeiceedmg that olGFR preventing
reabsorplion of glucose as per the non-pregnant state:consider testing lor GDM if noted in first 2 trimesters
Uretericand renal pelvisdilatation (R>L) due toprogesterone induced smooth musclerelaiation and uterine
enlargement
Increased CO and thus increased GFR leads to decreased creatinine (normal irr pregnancy 35-44 mmol ).uric acid,
and BUN
Increased incidence of carpal tunnel syndrome,sciatica,andBell'
s palsy
Thyroid: moderate enlargement (not clinically detectable) andincreased basal metabolic rate
Increased total thyroxine and thyroxine binding globulin (TBG)
Normal free thyroxineindeiand TSH levels
Physiologic suppression of TSH inIIiscommon due to cross-reactivity of HCG to TSH receptors
Adrenal:increasedmaternal cortisol throughout pregnancy (total and free)
Calcium:decreased totalmaternal Ca2*
due bdecreased albumin
freeionized C a (i.e.active) proportion remains the same due todecreased parathyroid hormone (PTH),resulting
in increased bone resorption and gut absorption,and increased bone turnover (butno loss of bone density due to
estrogen inhibition) [ seeDiabetesMellitus.0528)
Gastrointestinal
Genitourinary
Neurologic
Endocrine
PVR -pulmonary vascular resistance:IVC -inferior vena cava:FEV1-breed expiratory volumein1second:CO- cardiac output GFR -glomerular
filtration rate;BUN- blood urea nitrogen;GERD -gastroesophagealreflux disease
Antepartum Care
• can be provided by an obstetrician,family physician, midwife,or multidisciplinary team (based on
patient preference and risk factors)
Preconception Counselling
Family physicians and midwives can
consider OB consultation for conditions
including:
• Insulin-dependent GDM
• TOLAC
• Multiple gestation
• Malpresentation
• Active antepartum hemorrhage
. PTL/PPROM
• Failure to progress
^descend
• Induction/augmentation if high-risk
• Tears: 3rd or 4th degree
• Retained placenta
• IUGR
• Postpartum hemorrhage
Note:Guideline*
vary by Uistitubon andby ptowniid
midwifery colege*
• 3-8 wk GA is a critical period of organogenesis,so early preparation is vital
• PMHx:optimize medical conditions and review medications prior to pregnancy (see Medical
Complications of Pregnancy,OB28and Medications,OBIS )
• supplementation
folic acid:see Counselling of the Pregnant Patient, OBI 2 and Medical Complications of Pregnancy,
OB28
• prenatal vitamins (PNV),consider iron supplementation in T 2 and T3 (earlier in cases of iron
deficiency anemia)
• lifestyle/social risk factorsshould be reviewed:smoking, alcohol (abstinence should be encouraged
leading up to and during pregnancy),substance use (can lead to intellectual deficits and behavioural
challenges in childhood), domestic violence, occupational risks, poorsocialsupport, balanced
nutrition, and physical fitness (see family Medicine)
• medications: discuss teratogenicity of medicationsso they may be adjusted, replaced, orstopped if
necessary
• infection screening: rubella, HBsAg. VDRL. Pap smear,gonorrhea/chlamydia. HIV, I B testing based
on travel and working in healthcare, history of varicella or vaccination, and parvovirusimmunity if
exposed to small children
• genetic testing as appropriate for high-risk groups (see Prenatal Screening. Table 2,OB7 ); consider
genetics referral in known carriers, recurrent pregnancy loss/stillbirth,family members with
developmental delay, birth anomalies, genetic diseases,and consanguinity
Advise all patients capable of becoming
pregnant to supplement their diet with
0.4 mgfd of folic acid (CTFPHC Grade
II-2-A Evidence)
Initial Prenatal Visit
ri
u J
• usually within 8-12 wk of the 1st day of LMP or earlier if <20 or >35 ylo,bleeding, very nauseous, or
other risk factors present
History
• GA by datesfrom the 1st day of LMP
• Naegele’s rule: 1st day of LMP + 1 yr + 7d -3mo
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0B5Obstetrics Toronto Xotcs 2023
« e.g. LMP = 1 Apr 2021, HDD = 8 Jan 2022 (modify if cycle not 28 d by adding number of d >28 or
subtracting number of d <28)
HDD by LMP not reliable if irregular menstrual cycle, or if patient unsure of the LMP
•datingVIS should be offered to all woman at 8-12 wk GA
•HDD by T1 VIS after 7 wk GA more reliable than LMP if difference is greater than 5 d from LMP due
date
•history of present pregnancy (e.g. bleeding, N/V ) and all previous pregnancies
•past medical,surgical, and gynaecological history
•prescription and non-prescription medications
•family history:diabetes, hypertension, thyroid disease, mental health issues, genetic diseases, birth
defects, multiple gestation, and consanguinity
•social history:smoking, alcohol, and substance use
•intimate partner violence screening:look for bruising, improbable injury, depression, late prenatal
care (presenting at T2 or T3), missed prenatal visits, and/or appointments cancelled on short notice
(see l-amily Medicine. Intimate Partner Violence, l
'M29)
Physical Exam
•complete physical exam to obtain baseline patient information - BP and weight important for
interpreting subsequent changes
•BM1 for risk stratification (risk of DVT, GDM,and preeclampsia all increase with greater BM1)
Investigations
•blood work
• CBC, blood group and Rh status, antibody screen, and infection screening as per preconception
counselling
•urine routine & microscopic, midstream urine C8tS
• screen for bacteriuria and proteinuria
•pelvic exam
• Pap smear (only if required according to patient history and provincial screening guidelines),
cervical or urine PGR for N.gonorrhocae (GC) and trachomatis (Cl )
In history of previous pregnancies.
ALWAYS ask:
GTPAL
Year of delivery
Fetalsex
Birth weight
Gestational age
Mode of delivery
Length of labour
Complications
Ask every woman about abuse - not just
those whose situations raise suspicion
of abuse AND ask as early as possible in
pregnancy
Estimated Date of Delivery
Determination
• By LMP if menses regular, patient
reliable historian
• By T1 U/S. the most accurate method
of establishing GA up to13*6/7
wk GA
• By embryo age and date of transfer
If IVF
• Changesto the EDO must be
documented and discussed with the
patient
• Pregnancy without U/Sconfirming or
revising the EDD prior to 22*0/7 wk
GA Is considered sub optimally dated
Nausea and Vomiting
Epidemiology
• affects 50-90% of pregnant women
• often limited to Tl but may persist beyond this
Management
• rule out other causes of N/V especially if refractory to initial therapy
• weigh frequently, assesslevel of hydration, and test urine for ketones
• non-pharntacological
frequent small meals (bland, dry,salty are better tolerated), encourage any safe appealing foods
electrolyte oral solutions(Pedialyte*,Gatorade*)
stop prenatal vitamins and if Tl,substitute with folic acid or adult/children'
s vitamins that are
low in iron
increase sleep/rest
ginger (maximum 1000 mg/d)
acupuncture, acupressure, and mindfulness-based cognitive therapy
• pharmacological
• first line: pyridoxine (vitamin Bs) monotherapy or doxylamine/pyridoxine (Diclectin*)
combination 4 tablets PO daily (1 q AM, 1 q lunch, and 2 qhs) up to maximum of 8 tablets/d
HI receptor antagonistsshould be considered for acute or chronic episodes of N/V in pregnancy
metoclopramide and phenothiazines can be used as an adjunctive therapy for severe N/V in
pregnancy
ondansetron ifsevere N/V and other anti-emetics have failed
consider use of acid-reducing medications as adjunctive therapy (e.g. antacids, H2 blockers,
proton pump inhibitors)
Hyperemesis Gravidarum
Definition
• intractable N/V,usually presents in Tl then diminishes;occasionally persists throughout pregnancy
n
L J
Epidemiology
• affects ~1% of pregnancies
Etiology
• multifactorial with hormonal, immunologic, and psychological components
• rapidly rising P-hCG ± estrogen levels may be implicated
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0B6Obstetrics Toronto Notes 2023
Investigations
• rule outsystemic causes:Gl, pyelonephritis, thyrotoxicosis
• rule out other obstetrical causes:multiple gestation,GTN
• CBC,electrolytes, BUN,creatinine, LF’
Ts, urinalysis
. U/S
Management
• thiamine supplementation may be indicated
• non-pharmacological (see Nausea and Vomiting,UBS )
• pharmacological options
• consider homecare with IV fluids and parenteral anti-emetics,and/or hospitalization
doxylamine/pyridoxine (for dosage,see Nausea and Vomiting,OB5)
• dimenhydrinate can be safely used as an adjunct to Didectin* (1 suppository BID or 25-50 mg PO
QID)
other adjuncts:hydroxyzine, pyridoxine, phenothiazine,or metoclopramide
also consider:ondansetron or methylprednisolone (avoid steroidsin T1due to increased risk of
oral defting)
ifsevere:admit to hospital, NPO initially then small frequent meals;correct hypovolemia,
electrolyte disturbance, and ketosis;TPN (if very severe) to reverse catabolic state
Complications
• maternal
dehydration,electrolyte, and acid-base disturbances
Mallory-tVeiss tear
• Wernicke’
s encephalopathy, if protracted course
death
• fetal:usually none, 1UGR is 15x more common in women losing >5"
o of pre-pregnancy weight
Subsequent Prenatal Visits
Timing
• for uncomplicated pregnancies, SOGC recommends q4-6 wk GA until 30 wk GA,q2-3wk from 30 wk
GA, and ql-2 wk from 36 wk GA until delivery
Symphysis Fuidal Height (SFH)
12 wkGA Uterine fundus at pubic
symphysis
16 wk GA Fundus halfway from pubic
symphysis to umbilicus
20 wk GA Fundus at umbilicus
20-36 wk GASFH should be within 2 cm
Assess at Every Visit
• estimated GA
• history:PM, vaginal bleeding,leaking, cramping,questions,and/or concerns
• physical exam:BP, weight gain, SFH, Leopold’s maneuvers(T3) to determine the lie, and presentation
offetus
• investigations:urinalysisfor proteinuria in high-risk women (hypertensive patients); FHR starting at
10-12 wk GA using Doppler U/S
Leopold’s Maneuvers
• performed after 30-32 wk GA
• first maneuver:to determine which fetal part islying furthest away from the pelvic inlet
• second maneuver to determine the location of the fetal back
• third maneuver to determine which fetal part islying above the pelvic inlet
• fourth maneuver to locate the fetal brow
of GA
SFH < Oates
• Date miscalculation
• IU6R
• Fetal demise
• Oligohydramnios
• Early engagement
• Transverse 6e
SFH > Dates
• Date miscalculation
• Multiple gestation
• Polyhydramnios
. Large for GA (familial.DM)
• fibroids
A First B. Second C. Third D. Fourtr
Figure 2.Leopold's maneuvers (T3)
Reprinted with permission hom Essentials ol Clinical Examination Handbook.6th ed.Lincoln.McSheltrey.Tran.Wong
n
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0B7 Obsicirics Toronto Notes 2023
Prenatal Screening and Diagnostic Tests
Screening Tests
• testing should only occur following counselling and with informed consent from the patient
Table 2. High- Risk Population Screening Tests
Disease (Inheritance) Population(s) at Risk Screening Test(s)
Thalassemia (Alt) Individuals from these regions:Mediterranean. CBC (Mean Corpuscular Volume (MCV) and
South East Asia.Western Pacifrc,Africa.Middle Mean Corpuscular Hemoglobin (MCH)),Hb
East.Caribbean.South America electrophoresis,or HPLC
Sickle Cell(AR) Individuals Irom these regions:Africa,
Caribbean.Mediterranean.Middle East. India, HPLC
South America
CBC (MCV and MCH).Hb electrophoresis,or
Cystic Fibrosis (CF) (AR) Family history olCF in patient or partner CFIit gene DNA analysis
or medical condition linked to CF like male
infertility
Ashkenati Jewish*.French Canadians. Cajun Eniymc assay HEXA or ONA analysis HEXA gene
Family history - confirmed or suspected ONA analysis:FMR -1 gene
lay Sachs Oiseasc (AR)
FragileXSyndrome (X linked)
AR - autosomal tecessive;HEXA « hexosaminidase A;HPLC 5 high peifotmance liquid chromatography
'If both partners are Ashkenazi Jewish,test for Canavan disease andFamilial Dysaulonomia (FD);if family history of a specific condition,look for
carrier status:e.g. Gaucher disease,CF,Bloom syndrome.Niemann-Pick disease,etc.In all cases,if both partners are positive,refer lor genetic
counselling.
Table 3. Gestation-Dependent Screening Investigations
Gestational Age (wk) Investigations Details
Preimplantation Preimplantation genetic testing (or aneuploidy.
Preimplantation genetic testing lor monogenic (singlegene) disorders,Preimplantation genetic testing for
structural rearrangements
Dating U/S. possiblePap smear,chlamydia/gonorrhea
testing,urine CBS (detect asymptomatic bactenuria).HIV.
VDRl, HBsAg. Rubella IgG.Parvovirus IgMilsymptomatic
pi IgG if hiqlwisk [small child at home or daycare worker/
primary teacher).Varicella IgGIIno history of disease/
immuniiation, CBC.blood groupand screen
All require IVF
Routine T2 U/S at 18-22 wk GA Helps
to Determine:
• Number of fetuses
• GA (if no prior U/S)
• Location of placenta
• Fetal anomalies
812
>10 NIPT Measures cell-free fetal DNA in maternal circulation
10-12 CVS Diagnostic test. NOT screening
11-14 eFTSor IPSPart1
1114 NT U/S Measures
1.NT on U/S
2. p-hCG
3. PAPP-A
4.Placental growth factor (eFIS only)
5. MSAFP (eFIS only)
Diagnostic lest. NOT screening
Measures
1. MSAFP
2. p- hCG
3. Uiicoii|ugnted estrogen (cslriol or pE3|
4. Inhibit)A
Measures
1. MSAFP
2. p-hCG
3.Unconjugated estrogen (estriol or pE3|
4.InhibinA
15-16 toterm Amniocentesis DDx of Increased MSAFP
• Incorrect GA
• >1fetus (e.g.twins)
• Fetal loss
. ONID
• Abdominal wall defects (e.g.
omphalocele)
15 -20 IPS Part 2
15 20 MSS
18-20 to term FM [quickening)
U/S for fetal sire,anatomy assessment,and placental
location
Gestational Diabetes Screen 0GCT SO g
Repeal CBC t ferritin
RhIG lor all Rh-negative women
GBS screen
Discuss contraception,menses,breastfeeding,
depression, mentalhealth,and support
Physical e«din:breast exam, pelvic exam including Pap
smear lonly if due as pet provincial screening),wounds
assessment (perineum or CO scar)
18-20
24-28 See Diabetes Melhtus.OBIS
28
35 37 See [oily Onset Croup 8 Streptococcus. 0830
6 wk postpartum
MSS is alsoreteucd to as IIIpie Screen;a Inhlbiri A Is also tested,aIs referred to as Quadruple Screen
Can consider ordering AFP to screen tor ONIDs in women with 8MI >40 +
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0B8 Obstetrics Toronto Notes 2023
ULTRASOUND SCREENING
• 8-12 wk GA:dating U/S (most accurate form of pregnancy dating)
measurement of crown-rump length (margin of error: ± 5 d)
• HDD should be based on T1 U/S if available
. 11-14 wk GA: U/S for NT
measures the amount of fluid behind the neck of the fetus
early screen for trisomy 21 (may also detect cardiac anomalies and other aneuploidieslike Turner
syndrome)
• NT measurement is necessary for the FI'
S and IPS Part 1
• 18-20 wk GA:growth and anatomy U/S (margin of error: ± 10 d)
• earlier or subsequent U/S performed when medically indicated
NON-INVASIVE PRENATAL TESTING (NIPT)
• analyze maternal blood for circulating cell-free fetal DNA (ccffDNA) at 9 wk GA onwards. Requires
dating U/S for accuracy
Advantages
• increased accuracy (high detection rate (UR), low false positive rate (l-
'
PR))
• trisomy 21 (UR 99%,1- PR 0.1%), highly sensitive
trisomy 18 (UR 96%, l-
'
PR 0.1%)
trisomy 13 (UR 91%, l-
'
PR 0.1%)
Turnersyndrome (UR 90%, l-
'
PR 0.2%)
• other disorders (UiGcorge syndrome, Gri Uu Ghat syndrome, Prader-Willi syndrome, Angelman
syndrome, XY disorders)
• earlier timing with results available in 1 -2 wk where parents can potentially have a CVS at 10-12 wk
GA for diagnosis over an amniocentesis after 15 wk GA
Disadvantages
• does not screen for ON'
I
'U
• not covered by most provincial health insurance systems
• need to confirm with invasive testing (it is a screening test, not a diagnostic test)
• obtaining a result depends on sufficient fetal fraction (affected by the GA, maternal obesity, and
presence of a chromosome aneuploidy in either the placenta or the mother)
• does not test for all aneuploidies
• gives no result in 1 -5% of cases (insufficient fetal fraction, more common with elevated BMl)
Table 4. Comparison of FTS, MSS, and IPS
cFTS MSS IPS
1114 wk GA: U/S- nucItal Iranslucency
1M4 wkOA: eHS blood
15 20 wk GA: MSS blood Including inhlbin A
11 link GA 1b 20 wk GA
Disk estimate lor
1.trisomy 21 (Down syndrome):increased
Nl.Increased p - hCG. decreased PAPP A
2. trisomy 18:increased Nl. decreased
PAPP A
Risk estimate lor ON ID, trisomy 21. trisomy 18
Sensitivity
-85 30%
2% FPR
2. trisomy 21: decreased MSAFP. Increased Patients with positive screen should be offered
8- hCG, decreased pF3 (sensitivity 65%) U/S and/or amniocentesis or NIPI (covered in
3. trisomy 18: decreased MSAFP. decreased some provinces,sell- pay in others)
8-hCG. decreased p!3. decreased inhibin A
(sensitivity 80%)
Only ollcred alone il patient missed the time
window lor IPSoreFIS
Risk estimate for
1.0N1D:increased MSAFP Iscnsitivity
80- 90%)
Note:Uselul when patient wants results
within II
more accurate estimate ol trisomy 21 risk
than MSS.sensitivity
-85%|whcn combined
with age)
5% FPR
Patients with positive screen should be offered Patients with positive screen should be offered
CVS.amniocentesis,or NIPI (covered in some U/S.amniocentesis, or NIPt (covered in some
provinces,self- pay in others)
8% baseline FPR for trisomy 21. lower for NIO
and trisomy 18
provinces,sell-pay in others)
Note:Intwins.eFTS. MSS.andIPS aienot applicable:screen with NT. NIPT for chromosomal abnoinialities.and MSAFP for ONTDs
Diagnostic Tests
• diagnostic tests available:
amniocentesis
CVS
Indications
• age >35 yr (increased risk of chromosomal anomalies)
• risk factorsin current pregnancy
• abnormal U/S
• abnormal prenatal screen (IPS, el'
TS,MSS,or NIPT)
• past history/familv history of:
chromosomal anomaly or genetic disease
either parent a known carrier of a genetic disorder or balanced translocation
• consanguinity
• >3spontaneous abortions
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0B9 Obstetrics Toronto Notes 2023
AMNIOCENTESIS
• U/S-guided transabdominal extraction of amniotic fluid performed as early as 15 wk GA
Compared toCVS. amniocentesis has a
higher accuracy of prenatal cytogenetic
diagnosis (99.8% vs. 97.5%) and lower
risk of spontaneous abortion <0.5% vs.
1-2%)
Indications
• identification of genetic and chromosomal anomalies (15-16 wk GA) as per indications above
• confirmation of positive NIPT testing
• positive el-TS/1PS/MSS
• assessment of fetal lung maturity (T3) via the L/S ratio
if >2:1, KDS isless likely to occur
Advantages
• also screens for ONTD (acetylcholinesterase and amniotic APP)
- 96% accurate
• in women >35 yr, the risk of chromosomal anomaly (1/180) is greater than the risk of miscarriage
from the procedure
• more accurate genetic testing than CVS
(§>
Risk Factors for Neural Tube Defects
GRIMM
Genetics:family history of NTD ( risk
of having second child with NTD is
increased to 2-5%). consanguinity,
chromosomal (characteristic of trisomy
13,18,and 21)
Race:Higher risk in Europeans and
non- Hispanic whitesthan African
Americans,3-fold higher in Htspanics
Insufficient vitamins:zinc and folate
Maternal chronic disease (e.g. DM)
Maternal use of antiepileptic drugs
Disadvantages
• 1/200 to 1/900 risk of procedure-related pregnancy loss, depending on local experience
• results take 14-28 d;QF-PCR or FISH can be done on chromosomes X, Y, 13, 18, 21, 22 to give
preliminary'results in 48 h;chromosomal microarray also readily available
CHORIONIC VILLUS SAMPLING
• biopsy of fetal-derived chorion using a transabdominal needle or transcervical catheter at 10-12 wk General population risk for NTD is 0.1%
GA
Advantages
• enables pregnancy to be terminated earlier than with amniocentesis
• rapid karyotyping and biochemical assay within 48 h, including FISH analysis
• high sensitivity and specificity
Disadvantages
• 1% risk of procedure-related pregnancy loss
• does not screen for ONTD
• 1-2% incidence of genetic mosaicism “false negative” results
ISOIMMUNIZATION SCREENING
Definition
• isoimmunization:antibodies (Ab) produced against a specific RBC antigen (Ag) as a result of
antigenic stimulation with RBC of another individual
Etiology
• maternal-fetal circulation normally separated by placental barrier, butsensitization can occur and can
affect the current pregnancy’
,or more commonly'
,future pregnancies
• anti-Rh Ab produced by a sensitized Rh-negative mother can lead to fetal hemolytic anemia
• risk of isoimmunization of an Rh-negative mother with an Rh-positive ABO-compatible infant is 16%
• sensitization routes
incompatible blood transfusions
previous fetal-maternal transplacental hemorrhage (e.g. ectopic pregnancy, trauma, abruption)
invasive proceduresin pregnancy (e.g. prenatal genetic diagnosis, cerclage, D&C)
any type of abortion
labour and delivery
trauma (e.g. car accident, fall, etc.)
Investigations
• screening with indirect Coombs test at first visit for blood group, Rh status, and antibodies
• Kleihauer-Betke test used to determine extent of fetomaternal hemorrhage by estimating volume of
fetal blood volume that entered maternal circulation
• detailed U/S for hydrops fetalis
• middle cerebral artery Dopplers are done to assess degree of fetal anemia; if not available, bilirubin is
measured by serial amniocentesis to assess the severity of hemolysis
• cordocentesis for fetal Hb should be used cautiously (not first-line)
Rh Antibody Titre
A positive titre (21:16) indicates an
increased risk of fetal hemolytic anemia
Standard dose of 300 pg of Rhogam '
sufficient for 30 mL of fetal blood. Give
additional 10 pg of Rhogam - for every
ml of fetal blood over 30 mL r
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Prophylaxis
• exogenous Rh IgG (Rhogam* or WinRho*) bindsto Rh antigens of fetal cells and prevents them from
contacting maternal immune system
• Rhogam* (120-300 pg) given to all Rh-negative and antibody screen negative women in the following
scenarios:
routinely at 28 wk GA (provides protection for ~12 wk)
within 72 h of the birth of a Rh-positive fetus
with any invasive procedure in pregnancy (CVS,amniocentesis)
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OBlOObstetrics Toronto Notes 2023
as part of management of ectopic pregnancy
• with miscarriage or therapeutic abortion
with an antepartum hemorrhage
• with trauma
•Rhogam* 300 ug providessufficient prophylaxis for 30 mL fetal Rh-positive whole blood
•a Kleihauer-Betke test or flow cytometry can be used to measure the relative quantity of fetal blood in
maternal circulation to determine if additional Rhogam* is indicated (if >30 mL fetal blood)
•if Rh-negative and Ab screen positive, follow mother with serial monthly Ab titres throughout
pregnancy + U/S ± serial amniocentesis as needed (Rhogam*
has no benefit, as B cells/antibodies
already in circulation)
Treatment
•falling biliary pigment warrants no intervention (usually indicative of either unaffected or mildly
affected fetus)
•intrauterine transfusion between 18-35 wk GA of O-negative packed RBCs may be required for
severely affected fetus
•early delivery of the fetus for exchange transfusion following 35 wk GA
Complications
•anti-Rh IgG can cross the placenta and cause fetal RBC hemolysis resulting in fetal anemia,CHF,
edema, and/or ascites
•severe cases can lead to hydrops fetalis (edema in at least two fetal compartments due to fetal heart
failure secondary to anemia) or erythroblastosisfetalis (moderate to severe immune-mediated
hemolytic anemia)
Fetal Surveillance
•patients will generally first notice FM (“quickening”) at 18-20 wk GA in primigravidas; can occur
1-2 wk earlier in multigravidas; can occur 1-2 wk later if placenta is implanted on the anterior wall of
uterus
•if there is concern about decreased FM, the patient is counselled to choose a time when the fetusis
normally active to count movements (usually recommended after 26 wk GA)
•all high-risk patientsshould be advised to do FM counts
should experience >6 perceived movementsin 2 h period
if there is a subjective decrease in FM,time how long it takes to feel 10 discrete movements (laying
on the left in a quietsetting may facilitate feeling subtle movements)
if 10 movements take more than 2 h, further assessment is indicated, and patient should present
to labour and delivery triage for assessment
DDx of Decreased Fetal Movements
DASH
De ath of fetus
Amniotic fluid decreased
Sleep cycle of fetus
Hunger.Thrrst
NON-STRESS TEST
Definition
•FHR tracing >20 min using continuous external fetal monitoring to assess FHR and its relationship to
FM (see Gynaecology. l-
'
irst and Second Trimester Bleeding, GY20)
Indication
•any suggestion of uteroplacental insufficiency orsuspected compromise in fetal well-being
Normal NST:2 accelerations, >15 bpm
from baseline,lasting >15sin 20 min
Table 5. Classification of Intrapartum EFM Tracings
Normal Tracing (Category 1) Atypical Tracing (Category Abnormal Tracing
2 ) (Category 3)
Baseline 110-160bpm 100-110 bpm or >160 bpm for
30-80 min
Rising baseline
Arrhythmia
s5(absent or minimal) for 40-80 s5 for >80min
>25 bpm for >10 min
Sinusoidal
Repetitive complicated variables
Recurrent late decelerations
Single prolonged deceleration >3
min but <10 min
Bradycardia <100 bpm
Tachycardia >160 for >80 min
Erratic baseline
Describing NSTs: baseline rate, absent'
minimatmoderate/marked variability,
accelerations present/not present
decelerations early/late/variable
Variability 6-25 bpm (moderate)
<5 (absent or minimal) for <40 min min
Decelerations Repetitive
variables
uncomplicated m
Non-repetitive complicated
variables
Intermittent late decelerations
Single prolonged deceleration >2
minbut <3 min
None
Non-repetitive uncomplicated
variable
Early decelerations
Reassuring BPP (8 8)
LAMB
Limb ectension + flexion
AFV 2 cm x 2 cm
Movement Pdiscrete)
Breathing (one episode x 30 s)
ri j
tJ
Acceleration Spontaneous accelerations but
not required
Acceleration with scalp
stimulation
No evidence of fetal compromise Physiologic response
Absence of acceleration until scalp Usually absent (accelerations,
stimulation if present,do not change
classification of tracing) +
Interpret Clinically Possible fetal compromise
Adapted from:SOGC.FetalHeallfiSurveillance:Intrapartum Consensus Guideline.March 2020
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OBU Obstetrics Toronto Notes 2023
Operating Characteristics
• false positive rate depends on duration;false negative rate = 0.2-0.3%
Interpretation
• normal, >32 wk GA:at least 2 accelerations of FHR >15 bpm from the baseline lasting >15 sin 20 min
• normal, <32 wk GA: at least 2 accelerations of F
'
HR >10 bpm from the baseline lasting >10 sin 20 min
• abnormal:<2 accelerations of F
’
HR in 40 min
• if no observed accelerations or TM in the first 20 min,stimulate fetus(fundal pressure, acoustic/
vibratory stimulation) and continue monitoring for 30 min
BIOPHYSICAL PROFILE
Definition
• U/S assessment of the fetus ± NS1
Indications
• postterm pregnancy
• decreased FM
• 1UGR
• any othersuggestion of fetal distress or uteroplacental insufficiency
Table 6. Ultrasound Scoring Components of the BPP
Parameter Reassuring (2 points)
Tone At least one episode ol Imb extension followed by flexion
Three discretemovements
At least one episode of breathing lasting at least 30s
FigId pxtetol 2 cm in 2 axes
Movement
Breathing
Amniotic fluid Volume (AFV)‘
*
AfV isa marker ot chronic hypoxia,all other parametersindicate acute hypoxia
Interpretation
• 8/10 with normal fluid or 10/10: perinatal mortality rate 1:1000;intervention for obstetric and
maternal factors
• 6-8/10 with abnormal fluid:perinatal mortality rate 9:1000;determine that there is functioning renal
tissue and intact membranes.Ifso,deliver fetus at term,continue surveillance of preterm fetus <34
wk GA to maximize fetal maturity
• 6/10 with normal fluid: perinatal mortality variable;equivocal test, repeat BPP in 24 h
• 0-4/10:perinatal mortality rate 91-600:1000;consider delivery for fetal indications
Counselling of the Pregnant Patient
Nutrition
•Canada s Food Guide to Healthy Eating suggests
• eating a varied diet with plenty of vegetables and fruits,whole grains,dairy products, and lean
meats or plant proteins
• caloric increase of -100 kCal/d in Tl,
-300 kCal/d in T2 andT3,and -450 kCal/d during lactation
(lessif BM1>25)
daily multivitamin with folic acid should be continued during pregnancy
Nutrients in Pregnancy
•folate:0.4-1 mg daily in all women starting 2-3mo preconception until 4-6 wk postpartum;4 mg if
high-risk for NTD starting at least 3 mo preconception until 12 wk GA,then continue 0.4-1 mg until
4-6 wk postpartum or as long as breastfeeding continues
supportsincrease in blood volume, growth of maternal and fetal tissue, and decrease in incidence
of NTD
• foods rich in folic acid include:spinach,lentils,chickpeas,asparagus, broccoli, peas, brussels
sprouts, com, and oranges
•calcium:1200-1500 mg/d
• maintainsintegrity of maternal bones,skeletal development of fetus, and breast milk production
•vitamin D:10001U
• promotes calcium absorption
•iron:0.8 mg/d in Tl,4-5 mg/d in T2, and >6 mg/d in T3
• supports maternal increase in blood cell mass,supportsfetal and placental tissue
required amounts exceed normal body stores and typical intake,and therefore need supplemental
iron
• iron isthe only known nutrient for which requirements during pregnancy cannot be met by diet
alone (see Iron and Folate Deficiency Anemia,UB28)
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0612Obstetrics Toronto Notes 2023
• essential fatty acids-supportsfetal neural and visual development
contained in vegetable oils, margarines, peanuts, and fatty fish
Sources of Caffeine
• 5 oz cup coffee: 40-180 mg
• 5 oz brewed tea: 20-90 mg
• 12 02 cola: 46 mg
• Red Bull
’
:67 mg
• Dark chocolate bar:10 mg
• 8 oz hot chocolate:5 mg
Caffeine
• diuretic and stimulant that readily crosses placenta
• less than 300 mg/d is considered safe
• relationship between caffeine and 1UGR is unknown (ACOG)
• SOGC states 1-2 cups/d of coffee are safe during pregnancy
Herbal Teas and Preparations
• not enough scientific information aboutsafety of various herbs and herbal productsto recommend
their use during pregnancy
• some herbal teas can have toxic or pharmacological effects on the mother or fetus
• raspberry leaf tea often used at term to promote labour
• herbal teas considered safe in moderation (2-3cups/d):citrus peel,ginger,lemon balm,linden flower
(unless cardiac condition),orange peel, and rose hip
Foodborne Illnesses
• microbiological contamination of food may occur through cross-contamination and/or improper food
handling
• listeriosis( Listeria monocj'togenes) and toxoplasmosis ( Toxoplasma gondii) are of concern during
pregnancy
avoid consumption of raw meats and fish, raw hotdogs, raw eggs, raw sprouts (especially alfalfa),
and unpasteurized dairy products or juices
avoid unpasteurized soft cheeses, deli meats, smoked salmon, and pates as they may be sources of
Listeria
• chemical contamination of food
• current guideline for mercury of 0.5 ppm in fish is not considered harmful for the general
population, including pregnant women
Health Canada advises pregnant women to limit consumption of top predator fish such asshark,
swordfish,king mackerel, and tilefish
Lifestyle
• physical activity:150 min of moderate-intensity per wk; “talk test”
= should be able to speak while
exercising;avoid supine position after 20 wk GA
• absolute contraindications of physical activity
ruptured membranes, PTL, hypertensive disorders of pregnancy,incompetent cervix,
1UGR,multiple gestations(>3),placenta previa after 28 wk GA, persistent T2 or'
13 bleeding,
uncontrolled T1DM, uncontrolled thyroid disease,serious cardiovascular or respirator)'disease,
and othersystemic disorders
• relative contraindications of physical activity
• recurrent pregnancy loss,gestational HTN, history ofspontaneous preterm birth, mild/moderate
cardiovascular or respiratory disease,symptomatic anemia, malnutrition,eating disorder, twin
pregnancy after 28 wk GA, and othersignificant medical conditions
• weight gain:optimal gain depends on pre-pregnancy BM1 (varies from 6.8-18.2 kg)
• work:strenuous work,extended hours, and shift work during pregnancy may be associated with
greater risk of low birth weight, prematurity, and spontaneous abortion
• air travel:acceptable in T2;airline cut off for travel is 36-38 wk GA depending on the airline,to avoid
giving birth on the plane
• sexual intercourse:may continue, except in patients at risk for:spontaneous abortion, PTL,or
placenta previa;breaststimulation may induce uterine activity,and is discouraged in high-risk
patients near term
• smoking:assist/encourage to reduce or quitsmoking (see Family Medicine,FM13)
increased risk of decreased birth weight, placenta previa/abruption,spontaneous abortion,PTL,
and stillbirth
psychosocial interventions considered first-line, nicotine replacement therapy,and/or
pharmacotherapy if counselling unsuccessful
lowest effective dose to minimize fetal exposure, intermittent dosage preparations preferred
• limited safety data for bupropion and varenicline use during pregnancy
. alcohol:no amount of alcohol issafe in pregnancy; encourage abstinence from alcohol during
pregnancy;alcohol increases incidence of spontaneous abortion,stillbirth,and congenital anomalies
fetal alcohol spectrum disorder (see Paediatrics. P29)
• cocaine:microcephaly, growth retardation, prematurity, and placental abruption
• cannabis:associated with low birth weight infants and risk of neurobehavioural abnormalities in
childhood
• biopsychosocial considerations: discuss adjustment to pregnancy (e.g. mood, work,stress, family) and
birth plan,refer to counselling or community resources as necessary
Weight Gain in Pregnancy
BMI Total Gain Weekly Gaia
in T2 4 T3
<18.5 28-40 lb U3Wrt
18.5-24.9 25-35 lb 1lb%t
154JW
0.40.6 Itrtrk
25-29.9 15251b
>30 11-20 6
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