practical obestetric by one student

PRACTICAL OBSTETRICS
BY
ONE
STUDENT
*_^

Edited
By
Saif Ali Abood
5th year medical student
Basrah Medical College
2014
Guidelines
This succinct about practical obstetrics can be useful for medical students at any stage .

The sources of these information are :

Textbook of : OBSTETRICS by ten teachers.
Lectures of 2014.
Pocket guide for obstetrical & gynecological history taking & examination; which edited by Dr. Ali F. Al-Assadi.
Lectures’ & sessions’ notes.


4th year medical students should not read what written in oblique lines (causes, risk factors, investigations & treatment), they should focus on how to take history , how to perform the examination, diagnosis of pregnancy & physiological changes during pregnancy.

For 5th & 6th years medical students , this succinct discussed the common cases in obstetrics in details .

This succinct contains a lot of abbreviations , all of them are commonly used by medical students, when the abbreviation mentioned for the first time, the full term is mentioned with it.

History Taking

Obstetrical & gynecological history taking should include all the following:
Identity,
Chief complaint ( C.C.),
History of present illness (H.P.I),
Review of systems(R.O.S),
Obstetric history(Obx. Hx.),
Gynecological history(Gyn. Hx.)
Past medical & surgical history(P.M.S.Hx),
Family history(F.Hx.)
Drug history,
Social history.


Identity
Patient’s full name ; for :
Communication with the patient,
Differentiate the similar names,
Recording & emergency situation.
Patient’s age; for :
Age specific diseases e.g. female complain of vaginal discharge :
-if young (18-35years)>>>>>>>>>UTI (urinary tract infection)
-if middle age(35-55years)>>>>>>Abortion
-if old age (55 & above)>>>>>>>>Malignancy
Patient’s occupation(s); for :
Certain occupations causing certain diseases e.g.
-anaesthetist & irradiation exposure>>>>abortion, congenital anomalies.
-heavy work & long standing hours>>>>preterm labour.
Reflect the socioeconomic status of the patient.
Marital status ( married, single widowed, divorced or separated), e.g.
-cervical cancer is more common in married women.
Husband’s full name; for :
Usually he is the next of kin,
For any emergency situation,
Husband’s age; for :
Age specific diseases e.g.
-young active man>>>>>>infection.
-old age man>>>>>>>>>>infertility.
Husband’s occupation(s);for :
Certain occupations causing certain diseases e.g.
-sailors >>>>>>>infertility & STD.
-soldiers>>>>>>infertility.
Reflect the socioeconomic status.
Address ; for :
Reflect the socioeconomic status.
Certain areas are endemic with certain diseases e.g.
-SCA(sickle cell anemia) is more common in Basrah/Abu-Alkhasib district.
Gravidity , parity & No. of abortions ( G P + )
Gravidity(G): No. of all pregnancies (including the present pregnancy) regardless the outcome(whether end with viable or non viable child)
-it is not equal to the No. of children ,
-it is the total No. of pregnancies ( including the abortion, ectopic &H.mole).
-multiple pregnancy calculated as one gravida.
Parity (P): No. of children born after 24 weeks(according to WHO definition) or after 28 weeks (according to Iraqi definition) of gestation regardless the outcome(viable or not).
-No. of abortions , ectopic & H.mole should not be included in the calculation of parity.
-twin pregnancy = 2 parity
-present pregnancy should not be included in the calculation of parity.
+ : include the total No. of abortion, ectopic & H.mole.
-multiple abortion calculated as +1


E.g. the patient is pregnant now, she has 4chlidren & one abortion?
G6 P4 +1
E.g. the patient is pregnant now, she has 5 live children(2 of them are twin), one died in the 8th month of gestation, has 4 abortion ( 2 of them are twin), & one ectopic ?
G10 P6 +4 ( patient has 2 set of twins & ectopic)

Note: if the patient is not pregnant now, G not calculated, only calculate

P&+.

Primigravida: pregnant for the 1st time.

Nullipara : has no child.
Primipara: 1st delivery.
Multipara: more than once & less than 5 times.
Grand multipara: from 5 to 7 times.
Great grand multipara: more than 7 times.

LMP, EDD & DOA.

LMP (last menstrual period): the date of the 1st day of the last menstrual period . It is important for the calculation of EDD & DOA.
-Criteria of LMP:
Should be preceded by 3 regular cycles at least,
Should come at its correct time,
Should be of same duration,
Should be of same amount,
Should not associated with lactation,
Should not associated with contraception especially the injection.


EDD (expected date of delivery):is the approximate date of delivery & it is estimated according to Nagel’s law:
-add 7 days to the day, and 9 months to the month ( if the month is January, February or March ) or subtract 3 months & add one year ( if the month is April and more).
-if the day is 23rd & more >>>add one month after adding 7 days then add 9months( or subtract 3).
-4% will deliver at EDD ,
-32% will deliver before EDD,
-64% will deliver after EDD.

DOA or POA ( duration or period of amenorrhea):is the duration of pregnancy & usually estimated in weeks as follows:
-start calculation from LMP if the date of today is close to it,
-or start calculation from EDD if the date of today is close to it, then subtract this duration from 40 weeks.
-1 month=4 wks(weeks),
-2months=9wks,
-3months=13wks,
-4months=18wks.

E.g. her LMP was at 15th -8-2014?

Add 7 days to 15=22
Subtract 3 months=5
Add one year=2015
EDD will be approximately at 22nd -5-2015
Date of today is 8-10-2014
DOA will be around 8wks


E.g. her LMP was at 10th -3-2014?
Add 7 days to 10=17
Add 9 months=12
EDD will be approximately at 17th-12-2014
Date of today is 8-10-2014
DOA =40-10wks & 2 days=29wks & 5 days

Blood group & Rh of the patient.

Date of admission to the hospital.

C.C.: is the main problem which bring the patient to seek for medical advice.

Duration of C.C. :
In acute attack of short duration, it is since the beginning of the attack.
In case of recurrent attacks, it will be the duration of the last attack.
In case of progressing severity, it will be the duration of the severest attack.

H.P.I. : including 5 important points:

Analysis of C.C.( will discuss later when discuss each case individually),
Reviewing the related system (s),
Patient reaction,
Hospital admission ,
Patient status now & waiting for what?(for discharge, further investigations, surgery or for blood transfusion.


R.O.S. :problem(s) patient has at time of her present illness but not related to her C.C., starting from the system nearby or could be affected by present illness moving to the other systems.
CNS:
Headache,
Dizziness,
Syncope,
Loss of consciousness,
Vertigo,
Seizure,
Paraesthesia – numbness,
Limb weakness,
Tremor,
Loss of vision,
Blurring of vision,
Hearing disturbance,
Smell & taste disturbance,
Tinnitus.
CVS( Cardio-Vascular System):
Chest pain,
Dyspnea , orthopnea & PND(paroxysmal nocturnal dyspnea),
Palpitation,
Leg swelling,
Intermittent claudication,
Syncope,
Cyanosis.
Respiratory system:
Cough,
Sputum & hemoptysis,
Dyspnea,
Chest pain,
Wheezing,
Hoarseness,
Leg swelling,
Cyanosis.
GIT:
Nausea,
Vomiting,
Loss of appetite,
Weight loss,
Water brush,
Dysphagia & odynophagia,
Heartburn,
Abdominal pain,
Bowel motion ( diarrhea or constipation ),
Malena & hematochizia,
Abdominal distension,
Flatulence,
Jaundice.
GUS (Genito-Urinary system):
loin pain,
polyurea,
oligourea,
unurea,
hematuria,
dysuria,
frequency,
hesitancy,
urgency,
nocturia,
incontinence,
vaginal bleeding,
vaginal discharge,
vaginal itching.
Skin:
Pigmentation,
Striae formation,
Itching,
Rash,
Cloasma,
Petechia,
Ulcers.
Musclo-skeletal system:
Muscle pain,
Muscle weakness,
Joint pain,
Joint stiffness,
Joint swelling,
Joint lock,
Back pain.


Obx. Hx.
Date of marriage,
Age of marriage,
Marriage-conception period,
Primary infertility: inability to conceive after 1 year of regular unprotected intercourse. In this case you should ask the followings:
Period of infertility?
Female or male cause?
Consult a doctor or not?
What treatment they received? how many course ?
Conceive in response to medication or spontaneously?
Hx. of 1st pregnancy in details,
Hx of the following pregnancies in brief,
Hx of present pregnancy in details.

How to take the history of 1st & present pregnancy??

Hx of 1st trimester (1-13wks):
Nausea & vomiting?
Radiation exposure (X-ray)?
Medical events (bleeding, fever, abdominal pain & any chronic illness)?
Hospitalization?
Blood transfusion?
Use of medication ?
AnteNatal Care (ANC)?


Hx of 2nd trimester (14-27wks):
Nausea & vomiting continued or stopped?
Quickening( is the 1st perception of fetal movement by the mother)?
Medical events (bleeding, pain, D.M., H.T., & any chronic illness)?
Hospitalization?
Use of medication ?
AnteNatal Care (ANC)?
Vaccination?

Hx of 3rd trimester (28wks-delivery):

Medical events (bleeding, pain, D.M., H.T., & any chronic illness)?
Hospitalization?
AnteNatal Care (ANC)?

ANC: is the clinical assessment of the mother & the fetus during pregnancy for the purpose of obtaining the best possible oucome for both mother & fetus.
Aims of ANC:
Maternal health checks,
Evaluation of fetal health & development ,
Disease screening,
Analysis of risk development of complications,
Provide advice & educations,
Prenatal diagnosis of fetal anomalies,
Discuss timing & mode of delivery.


Ideal ANC is 16 visits:
Every 4 wks until 30 wks
Fortnightly until 36 wks
Weekly thereafter
Adequate ANC is 5 visits:
Once in 1st trimester
Once in 2nd trimester
Twice in 3rd trimester
Once after delivery
Note: not all ANC has to be done in hospital (practitioner & midwife).

Vaccination:

Tetanus toxoid is given to the mother as following:
1st dose>>>>>>4th month
2nd dose>>>>>5th month
3rd dose>>>>>1 year after 2nd dose
4th dose>>>>>1 year after 3rd dose
5th dose>>>>>1 year after 4th dose

Hx of labour :

Site ? (home or hospital)
Onset? (gradual or sudden)
Duration? >>>>primigravida>>24hr,,,,,multipara>>16hr.
Characters of the pain ?
Spontaneous? Induced?
Term? preterm? postterm?
Term : delivery of the fetus between 37 wks completed( or 38 wks uncompleted) to 41 wks completed( or 42 wks uncompleted).
Preterm: delivery of the fetus between 24 wks completed to 37 wks uncompleted.
Postterm: delivery of the fetus between 42 wks completed to 44 wks completed.
Note: after 44 wks , fetus will die.


Hx of delivery?
Normal vaginal delivery (NVD)?
Assisted delivery by using forceps or ventose?
Caesarean section (C.S.)?

Criteria of NVD:

Spontaneous
Single
Term
Life
Vertex presentation
Without the use of any instruments like forceps or ventose (episiotomy considered normal)

Result? (Neonate)?

No.?
Sex?
Viable or not?
Weight? (normal weight is 2.5-3.5 kg)
Admitted to the NICU( neonatal ICU)?
Start lactation ? which type?
In NVD>>>>>start lactation within 30 minutes.
In C.S.>>>>>start lactation within 6 hours.
Congenital anomalies?


Cry immediately or not? In case of C.S ., these 3 points
Cyanotic? Should not be mentioned.
Jaundice?

Hx of puerperium?

Early puerperium: 1st 24 hr after delivery.
Bleeding? ( PPH-postpartum hemorrhage)
Fever? (puerperal sepsis)
Late puerperium:
Fever? Bleeding?
Infection ( UTI, DVT,……)
Breast engorgement?
Lactation? For how long? Lactational amenorrhea?
When resume her cycle?
Contraception use?
Interpregnancy interval?
When conceive again?

Puerperium: is the period that last from delivery of the placenta till 6 wks (42days) after delivery, during which pelvic organs return to non-pregnant state, metabolic changes of pregnancy reversed & lactation established.

Lochia: is normal vaginal discharge during the puerperium, which should be bright red immediately after delivery then change to brownish within 1st week then into pinkish, usually disappear after the 2nd week of puerperium.


Gyn. Hx.
Age of menarche?
Menarche : is the 1st menstrual period during puberty, usually occur between 11-14 years old , and effected by many factors:
Genetic factors,
Percentage body fat which effected by:
Nutrition ( obese girl has early menarche ),
Socioeconomic status,
Psychological problems.

Primary amenorrhea: no menstruation occur after the age of 15 years & in the presence of normal secondary sex characters.

Secondary amenorrhea: cessation of menses for more than 6 months after normal menses.

Menstrual Hx.:
length ? (normally come every 20-40 days – average 28 days)
period(menses)? ( normally 3-7 days- average 5 days)
amount ? ( normally 30-80ml-average 50m without clot)

Menstrual cycle: the time from beginning of one period to the beginning of the next.

Menstrual period: is the duration of menstrual bleeding.


Oligomenorrhea: cycle length >40 days.
Polymenorrhea: cycle length <20 days.
Hypomenorrhea: low menstrual blood loss.
Menorrhagia: heavy & regular menstrual blood loss.
Metrorrhagia: irregular menstrual cycle.
Menometrorrhagia: heavy & irregular menstrual cycle.

Dysmenorrhea?

Dysmenorrhea: is painful menstruation , its of 2 types:
Spasmodic (primary-physiological): is colicky lower abdominal pain felt few hours or one day before menses & relieves by menstrual flow.
-cause? Releasing of PG>>>>contraction of uterus>>>>ischemia.

Congestive ( secondary-pathological): is dull pain felt in the lower abdomen & back usually started few days before menses & continue throughout the menstrual period.
-causes?
Endometriosis,
Fibroid,
PID(pelvic inflammatory disease),
Congenital abnormality of the uterus,
IUCD,
CA-cervix.


Dyspareunia?
Dyspareunia: painful intercourse, its of 2 types:
Superficial: felt at the beginning of intercourse at the vulva, usually psychological due to fear from intercourse or vaginismus.
Deep: felt deep in the pelvis during penetration, usually pathological caused by:
Fibroid,
PID,
Ovarian cyst,
Endometriosis,
IUCD.

Intermenstrual bleeding?

Postcoital bleeding? Caused by:
Cervical or vaginal lesions e.g. injury, erosion, ulceration & polyp)
Gynecological operations ?
Vaginal operations:
Diagnostic curettage (D&C),
Anterior colpoperineorrhaphy,
Posterior colporrhaphy,
Cervical conization & cauterization,
Vaginal hysterectomy,
Manchester repair,
Vulvectomy,
Sling operations for stress urinary incontinence ( TOT & TVT )


Abdominal operations:
Ovarian>>>>cystectomy & oopherectomy,
Fallopian tube>>>>tubal ligation, tubal reanastamosis, fimbrioplasty & salpingectomy.
Uterus>>>>>abdominal hysterectomy, myomectomy, metroplasty.

Hx of contraception & duration of using it:

CCP(contraceptive pills),
Injection,
IUCD,
Condoms,
Subcutaneous implantation,
Suppositories,
Safe period,
Withdrawal .

P.M.S.Hx. :

Childhood: vaccination, rheumatic fever, rickets, mumps, measls,……
Adulthood: anemia, bleeding tendency, D.M., H.T., chronic renal disease, endocrine diseases (thyroid, adrenal,…..), asthma, epilepsy.
Surgery? where? when? why? complications?
Blood transfusion? No. of units? Why? When?


Fx Hx :
Diseases run in family( anemia, bleeding tendency, D.M., H.T., chronic renal disease, endocrine diseases (thyroid, adrenal,…..)SLE, asthma, epilepsy).
Hx of congenital anomalies?
Hx of recurrent abortion?
Hx of twin delivery?
Hx of death in family? Cause of death? Age at death?

Drug Hx. :

Any chronic drug use? Dose? Type?
Any allergy to food or drug( sulfa & penicillin )?

Social Hx. :

Housing ( own house or rented? Live with her own family or with her husband’s family? No. of rooms? No. of members? Electric supply? Water supply? Sanitation?
Smoking ( non, ex, active or passive )?
Alcohol drinking?
Domestic animals?

Physiological changes

Cardiovascular System:
Blood volume:
- increase (↑) from 6-8 wks of gestation, reaches maximum at 32-34wks with little changes thereafter. There is no evidence of circulatory overload because most of the added volume of blood is accounted for by ↑capacity of uterus, breast, kidney, striated muscles & cutaneous vascular systems.
- Plasma volume ↑ by 40-50% while red cell mass ↑ by about 20-30% , resulting in hemodilution & ↓Hb concentration ( dilutional anemia)>>> pregnant should receive iron & folic acid supplement.
-in primigravida>>>↑ by 1.25 L , in multipara>>>↑ by 1.5L ,, in twin>>>↑by 2L.
-↑in blood volume serves 2 purposes:
Facilitates maternal & fetal exchanges of respiratory gases, nutrients & metabolites.
↓impact of maternal blood loss at delivery (300-500ml in vaginal delivery & 750-1000ml in C.S. ) by autotransfusion (blood returns to circulation from the contracted uterus).
-↑ in :
ESR
Fibrinogen concentration>>>>>>↑ risk of DVT & ↓ risk of PPH
Activated protein C resistance
Factors VII, VIII, X & XII>>>>>>>↑ risk of DVT & ↓ risk of PPH
D-dimers
Alkaline phosphatase
-↓ in :
Hb concentration
Hematocrit
Plasma folate
Protein S activity
Creatinine, urea & uric acid


-pregnancy is regarded as hypercoagulable state but neither clotting nor bleeding times are abnormal.
-WBC are variable, usually remain in the upper limits of normal, markedly ↑ during & after delivery.
-platelets also ↑ but above upper limits of normal combined with ↓ in fibrinolytic acivity>>>these changes prevent excessive bleeding at delivery.

-cardiac output ( C.O. ):

↑by 30-40% in 1st trimester
At 8-11 wks>>>>>6.7 L/ minute
At 36-39 wks>>>>8.7L/ min
This ↑ is due to :
↑ SV(stroke volume) by 35%
↑ HR (heart rate) by 15%(10 beats)
↓in SVR(systemic vascular resistance)by effect of progesterone especially in 2nd trimester>>>↓diastolic pr.(pressure)>>>>>fainting attack.
Further ↑ during labour due to catecholamine release due to pain & due to autotransfusion .
There is ↑ in C.O., why heart failure not occur?? Due to ↓SVR.
Due to ↓SVR>>>peripheral vasodilation>>>>flushing during pregnany.

-cardiac size, position & ECG changes:

Enlarged by both chamber dilation & hypertrophy.
Dilation across tricuspid valve>>mild regurgitate>>>grade I or II systolic murmer.
Upward displacement of the diaphragm by the enlarging uterus>>>>heart shifted to the left & anteriorly, so apex beat moved outward & upward.
ECG>>>>left axis deviation, sagging ST segments & frequently inversion or flattening of the T-wave in lead III


-Blood pr.:
Systemic & pulmonary arterial pr. Never change. Why? Due to ↑C.O & ↓SVR>>>>>B.pr.=C.O. * SVR ,, so B.pr. remain stable.
↓in diastolic pr. In the 2nd trimester.
Central & brachial venous pr. Remain unchanged but femoral v. pr. Is progressively ↑due to the pr. Of gravid uterus.
From mid-pregnancy, uterus was at the level of umbilicus>>>obstruct inferior vena cava (IVC) & aorta when pt. lies supine>>>>↓venous return to heart>>>>fainting attack.

Respiratory System:

Anatomical changes:
Transverse chest diameter ↑ by 2 cm & chest circumference ↑by 6cm.
Diaphragm elevated by 4cm by the growing uterus.
Upper respiratory tract become more vascular by effect of estrogen>>>>nasal stuffiness, epistaxis & impaired hearing & sensation of fullness in the ear.
Airway resistance ↓ due to progesterone-mediated relaxation of the bronchial musculature.
Thoracic breathing replaces abdominal breathing .
↑ in :
TV (tidal volume) by 40%
RR by 15% (2-3 breaths/min)
Alveolar ventilation by 70% at end of gestation.
pO2
Maternal O2 requirements by 30-40ml/min due to acceleration of metabolic needs & ↑ tissue mass.
O2 availability to tissues & placenta.
Bicarbonate excretion.
↓ in :
ERV(expiratory reserve volume), RV (residual volume) & FRV ( functional RV) by 20% at term.
pCO2 >>>>>↑ sensitivity of respiratory center to CO2>>>dyspnea.
Chest wall compliance especially in lithotomy position while lung compliance is relatively unaffected.
TLC(total lung capacity) not effected due to ↑TV & ↓RV>>>TLC=TV*RV.


GIT :
Morning sickness.
Heart burn because the enlarging uterus causes a gradual cephalic displacement of stomach & intestines , at term stomach has attained a vertical position rather than its normal horizontal one, this lead to ↑ intra gastric pr. As well as a change in the angle of the gastroesophageal junction>>>↑ esophageal reflux.
Constipation by effect of progesterone(relaxation of sphincters).
↑gastric volume & ↓ PH .
Peak absorption occur at the same interval in all women except at time of delivery the gastric empty is delayed that’s why pregnant women at term should be fasting for 12hr before the operation.

Renal System:

↑ in :
Kidney size (1cm)
Dilatation of renal pelvis & ureters by the effect of progesterone , also with advancing pregnancy, the enlarging uterus can compress the ureters as they cross the pelvic brim & cause further dilatation by obstructing flow>>>↑ risk of UTI in 2nd trimester.
Renal plasma flow & GFR (50-60%) due to ↑ blood volume & C.O. >>>lead to overwhelm the ability of renal tubules to reabsorb leading to glucose(1-10gm/day) & protein(to 300 mg/day) losses in the urine.
Filtered sodium but tubular absorption is also ↑ by ↑ aldosterone secretion via renin- angiotensin mechanism.
Fluid retention( over the whole period of gestation there is retention of 7.5 L of water & 900mmol of sodium>>consequences of fluid retention:
↓ Hb, hematocrit & serum albumin concentration.
↑SV & renal plasma flow.
Clearance of most substances( ↑creatinine clearance).
↓ in :
Plasma creatinine , urea & urate.
Plasma osmolality.



Skin :
Hyperpigmentation.
Linear nigra (blak line from the abdomen to the pubis ).
Stria gravidarum ( pinkish lines in the abdomen & thigh).
Cloasma (melasma) (dark discoloration of the face, like mask).
Hirsuitism.
↑ sebaceous gland activity.
All the above changes are indicate the present pregnancy.
Stria albicans (silver or whitish lines in the abdomen indicate the previous pregnancy).

Reproductive Organs :

Uterus:
Ratio of muscle to connective tissue ↑ from the lower part of the uterus to the fundus.
In early pregnancy uterine growth result from both hyperplasia & hypertrophy while later hypertrophy accounts for most of increase.
It weight 1 kg at term (in pre-pregnancy 50-60gm).
Become rounded (globular) instead of flatten in anterio-posterioly.
With advance pregnancy, it divided into upper & lower uterine segment ( composed of lower part of uterus & upper cervix which composed mainly from connective tissue>>>stretched in late pregnancy).

Cervix:

Becomes softer( by effect of PGs & collagenase which act on collagen fibers) & swollen with the result columnar epithelium lining cervical canal becomes exposed to vaginal secretion.
Estrogen stimulate growth of columnar epithelium so cervix becomes violet & ectropine.
Mucous glands become distended & secret mucous which forms a mucus plug that is expelled in labour as the show.
Vagina & Vulva :
Vaginal epithelium becomes thicker.
Vaginal discharge ↑ due to ↑ desquamation of superficial vaginal cells.
Bluish discoloration of the vulva.
Genital tract becomes more soft & warm.


Breast :
The earliest changes is swelling of the breast tissue.
Dark pigmentation of the nipples & areola.
Development of secondary areola ( circular lesion formed around the primary areola & its color is lighter than the color of primary one.
↑ vascularity & appearance of prominent subcutaneous veins.
Montgomery tubercles (8th wk) at the periphery of the primary areola due to active sebaceous glands.
Colostrums at 16 wk.

Metabolism :

All metabolic functions are ↑ to provide for the demand of fetus, placenta & uterus.
↑ protein metabolism to supply substrate for maternal & fetal growth.
↑ fat metabolism>>>↑ all lipids fractions in the blood.
Nutritional demands of the growing fetus are met by the intake of glucose.
Secretion of insulin in response to glucose is augmented>>hypoglycemia.
Optimal blood glucose levels in pregnant women is 4.4-5.5mmol/L (80-100mg/dl)
Hypoglycemia in non- pregnant women is <2.2mmol/L (40mg/dl).
Hypoglycemia in pregnant women is <3.3mmol/L (60mg/dl).

Endocrine :

↑ in :
Prolactine concentration.
Corticosteroid concentration.
Aldosterone concentration & rennin-angiotensin system.
Transplacental calcium transport.
Insulin secretion.
HCG produce.
↓ in :
TSH in early pregnancy.
Free T4 in late pregnancy.
Thyroid binding globulin & bound form of T3 & T4, so generally no change in free form of T3 & T4.
Human growth hormone is suppressed .
Insulin action>>>insulin resistance.
HCG :
Secreted by trophoblast.
High level in early pregnancy to support corpus luteum secretion of estrogen & progesterone in the 1st trimester until placenta becomes able to produce these hormones.
Peak level in 12th wk, then start to ↓ afterthat.
Constant level in late pregnancy to control placental secretion of estrogen & progesterone, & to suppress maternal immune system against the fetus.
Disappear from urine 7-10 days after delivery of the placenta.


Human Placental Lactogen :
Secreted by syncytiotrophoblast.
Its level start to ↑ when HCG start to ↓.
Has no effect on fetus,, but effect :
Breast growth, production of colostrums & milk production.
Stimulate protein synthesis at cellular level.
↑ insulin secretion but ↓ its action>>>insulin resistance.
↑ lipolysis.

Estrogen :

Produce by corpus luteum in early pregnancy, & by placenta in late pregnancy.
Stimulate protein synthesis.
Polymerization of mucopolysaccarides of the ground substance leads to loose connective tissue>>>relaxation of tendons>>joint pain,
Relaxation of symphesis pubis >>>facilitate birth.

Progesterone :

Produce by corpus luteum in early pregnancy, & by placenta in late pregnancy.
Has effect on smooth muscles leads to ↓ muscle excitability leads to muscle relaxation mainly in uterus.

Diagnosis Of Pregnancy

Symptoms of Early pregnancy :
Amenorrhea :the 1st & most important symptom.
DDx of amenorrhea:
Pregnancy.
Emotional tension.
Chronic disease ( thyroid disease ).
Certain medications.
Lactation ( by effect of prolactine ).
IUD (intra uterine death) & missed abortion.
Endocrine dysfunction.


Morning sickness :
Nausea , vomiting, fatigue & swirling, ↑ from 6th wk & ↓ after 12th wk.
Causes are HCG & delay gastric empty by effect of progesterone.

Easy fatigability, lassitude & sleepiness.

Emotional changes : craving for certain foods, odors & particular objects, & disinclination to others.
Urinary symptoms:
Frequency (>8 times /day) & nocturia (>twice /night) due to ↑ GFR in early pregnancy & due to ↑ circulation & pr. On the bladder by the gravid uterus in late pregnancy.

Breast symptoms :

Mastodynia, heaviness, tingling sensation & may be discomfort or actual pain in the breast.
Constipation.
Weight gain.
Abdominal enlargement:
Women notice abdominal fullness in early pregnancy,
Later on the uterine enlargement become more evident.
DDx are 6F (fetus, fat, feces, flatus, fluid or fibroid).
Quickening : 1st perception of fetal movement by the mother.
In primigravida>>>>>>at 18-20 wks.
In multigravida>>>>>>at 14-16 wks.
Causes of early quickening :
Wrong calculation.
Grand multipara.
Thin mother.
Oligohydramnios .


Signs of Early pregnancy :
Genital organs :
Vagina: bluish or purple discoloration (congested pelvic vasculature) & ↑ vaginal discharge (by effect of estrogen & progesterone.
Cervix: 3 important signs :
Goodel sign: softening ( due to ↑ vascularity) of the cervix.
Chadwick sign: bluish discoloration of the cervix.
Hegar’s sign: softening of the utero-cervical junction (isthmus), on bimanual examination the globular fundus feel differ from still unsoft cervix, occurs at 6-10 wks, after that the whole uterus & the cervix become more soft & this sign become –ve.

Uterus: enlargement , softening (due to ↑ vascularity ).

Abdomen :
Enlargement of uterus ( noticed at 12th wk ), palpable just above the symphesis pubis.
Palmers sign : intermittent painless contraction may be even when the uterus is still in the pelvis.
Braxton-hicks contraction : intermittent painful irregular contraction when the uterus become an abdominal organ.
Uterine soufflé : increased blood flow to uterus, stethoscope pass firmily against uterine wall, hear blowing murmur synchronize with maternal pulsation.

Breast : mentioned previously in the physiological changes of pregnancy.

Laboratory tests in Early pregnancy:
PT ( pregnancy test ): based on detection of HCG in maternal blood&urine.
Urine test: called immunological test , if pregnant the color of the indicator will not change. If not pregnant the color will change ( latex particle ppt. or RBC cell agglutinated). It’s a delay test, only +ve 40 days after conception ( because HCG need to be secreted in the blood then in the urine.
Serum test: called RIA (radioimmunoassay), detect β HCG specifically , its +ve within 9-12 days after conception.
Ultrasound (U/S):
Enlargement of the uterus.
Gestational sac ( 4-5 wks of gestation ).
Embryo observed & measured at 5-6 wks.
Visible heart beat can be visualized at 6 wks.


Progesterone test.
Cervical mucus examination.
Basal body temperature ( BBT )>>>↑ by 0.5 °C by the effect of progesterone ( thermogenic ).

Diagnosis of Mid or Late pregnancy :

Enlargement of uterus :
12th wk>>>>>2 fingers above the symphesis pubis.
16th wk>>>>>mid way between the symphesis & umbilicus.
20-22th wk>>>>>at the umbilicus.
36th wk>>>>> at the xiphoid process .
40th wk>>>>> below the xiphoid process with fullness of the flank.

Fetal Movement (FM): beneficial for:

Diagnosis of pregnancy.
Duration of pregnancy.
Safety & viability of the fetus.

Fetal heart tones:

Heard at 18th – 20th wks .
Normal rate is 120-160 bpm.
Should differentiated from uterine soufflé.


Ballottement: sudden pr. On uterus leads the fetus sink into amniotic fluid & rebound to its original fluid, occur at 16th – 30th wks because at this stage the volume of the fetus is small compare with the amniotic fluid volume.
Palpation of fetal body outlines , at 20th wks.
Fetal ECG, at 12th wks.

Absolute(positive or diagnostic) signs of pregnancy

Fetal heart tones.
Palpation of fetal body outlines.
FM.
U/S.

Common Cases In Obstetric

Vaginal Bleeding (VB)
How to take Hx.?
Identity: LMP? Blood group ? age?
H.P.I.:
Onset? Gradual or sudden ?
Color of blood ? bright red or brown ?
Assessment of severity?
Contains clot ?
Floats on her legs?
No. of pads? ( normal No. during menses is 3-5 pads /day).
Interfere with the physical activity?
Symptoms of anemia? ( headache, blurring of vision, syncope, dizziness, palpitation, dyspnea & easy fatigue).
Aggravating & relieving factors ?
Associated symptoms ?( LAP, VD, FM)


Obx. Hx. : previous same condition during the present & past pregnancies.
Gyn. Hx. : focus on menstrual Hx.
P.M.S.Hx. : bleeding tendency, thyroid diseases, B.transfusion?
Fx. Hx. : Hx. of abortion or the same condition.
Drug Hx.: aspirin? NSAIDs?

Vaginal Bleeding divided into :

Early pregnancy bleeding.
APH ( Anti Partum Hemorrhage).
PPH (Post Partum Hemorrhage).

Early Pregnancy Bleeding : bleeding before 24 wks of gestation:

Abortion.
Ectopic pregnancy.
Hydatidiform Mole & Choriocarcinoma.
Implantation bleeding( at about 10-12 days after conception).
Incidental bleeding ( cervical erosion, polyp, CA, cervicitis or vaginitis.

Abortion:

Expulsion or removal of the products of conception ( fetus, placenta & membranes) before fetal viability ( 500 gm or less of fetal weight, gestational age <24 wks , in Iraq <28 wks ).


Types of abortion:
Spontaneous
Threatened
Inevitable
Induced
Medical
Criminal

Causes of abortion :

Maldevelopement of the conceptus: most common cause, 70%.
Defective implantation.
Fibroids.
Maternal infection ( fever>>>↑pyrogen>>>↑PGs>>>powerful uterine contraction>>>abortion.
STORCH ( Syphilis, Toxoplasmosis, Rubella, Cytomegalovirus & Herpes).
Medical diseases ( D.M., H.T., renal & thyroid diseases ).
Endocrine abnormality ( poor development of corpus luteum, low serum progesterone levels, inadequate secretory endometrium.
Uterine abnormality ( double uterus, unicornuate, bicornuate, septate or subseptate, or remaining infantile uterus.
Reteroversion of the uterus, usually presented with urine retention.
Cervical incompetence ( discuss later).
10.Environmental factors ( radiation, teratogenic drugs & substances & smoking)
11.Maternal age >35 years.
12.Stress & anxiety .
13.Paternal factors ( poor sperm quality or source of chromosomal abnormalities.
14.Immunological factors(SLE, antiphospholipid syndrome).


Causes of 2nd trimester abortion:
Trauma.
Multiple pregnancy.
Maternal D.M.
Cervical incompetence.
Uterine abnormality.

Threatened Abortion :

C/F ( clinical features ):
Slight LAP(lower abd. Pain) or sometimes no pain.
Scant bleeding .
Cervical os is closed.
Uterus not palpable, if palpable its soft , not tender & corresponding to the gestational age.

Inx (investigations):

PT : +ve.
U/S: viable fetus.

Rx (treatment):

Reassurance ( is the best Rx).
Rest, not necessarily bed rest, only sit until bleeding cease.
Avoid sexual intercourse, resume it 2wks after bleeding was stop.
Sedative: diazepam.
Medroxy progesterone ( palliative Rx ) & has calming effect on the uterus.
Admitted to hospital if has previous repeated abortion.


Inevitable Abortion: either complete or incomplete.
Incomplete Abortion:
C/F:
Severe pain.
Heavy & profuse bleeding with clots, even shock.
Cervical os is open & dilated.
Uterus is tender, painful & smaller than the expected.
Tissue present in the cervix.

Inx:

PT: static or slowly falling.
U/S: gestational sac is incompletely expelled , with usually the placental tissue is retained.

Rx:
Insert I.V line & draw blood for cross matching & preparation of blood.
Give any available I.V. fluid, & B. transfusion when available.
O2 for shock patient.
Pt. head down to ↑ cerebral circulation.
Oxytocic drug (PG (misoprostol), oxytocin & ergometrin) the best is PG .
Surgry>>> ERPC (Evacuate Retained Products of Conception).


Complete Abortion
C/F:
Pain & bleeding are absent, but there is Hx of severe pain & heavy bleeding with clots.
Cervical os is closed.
Uterus if palpable, it firm, contracted & smaller than expected.

Inx:

PT: falling HCG level.
U/S: empty uterus.

Rx:

Nothing , only give anti-D in case of Rh-ve mother & Rh+ve father.

Missed (Delay or Silent) Abortion:

Death of the fetus inside the uterus without expulsion, before fetal viability.
C/F :
Pain is absent.
Bleeding is scant (brown color) or absent.
Cervical os is closed.
Uterus if palpable, smaller than the expected.
Amenorrhea but others signs of pregnancy diminish.


Inx:
PT: -ve.
U/S : dead fetus.

Rx:
Correction of clotting abnormality if present (DIC).
If 12 wks & below >>>D&C (Dilatation & Curettage) because cervical os is closed.
Above 12 wks>>>PG, extraamniotic saline infusion or foley’s catheter followed by oxytocin infusion >>>>>> ERPC if needed.

Recurrent Abortion:

3 or more spontaneous successive abortions.
Rx>>>>>>Rx of the cause.

Septic Abortion

Causes: following criminal abortion or incomplete abortion.
C/F :
Pain is severe.
Bleeding is variable,, may be offensive.
Cervical os is open.
Uterus is bulky, tender & painful.
Fever, tachycardia, headache, nausea & general malaise.


Risks :
Septicemia.
Endotoxic shock.
DIC.
Liver & renal damage.
Salpingitis.
Infertility.

Inx:

High vaginal swab.
Blood culture.

Rx:
Insert I.V line & draw blood for cross matching & preparation of blood.
Give any available I.V. fluid, & B. transfusion when available.
O2 for shock patient.
Antibiotics (Abx) prior to evacuation to prevent septicemia, usually give combination of metronidazol, gentamycin, penicillin or cephalosporin) .
ERPC.

Ectopic Pregnancy :

Pregnancy that develops outside the women uterus. Most common place is in one of the fallopian tubes(95%)( commonly in the ampulla ,fimbriae, isthmus & lastly in the intra uterine part) , other places are ovaries, cervix or attached to the bowel. Occur between 5-10 wks of gestation ( after that rupture or aborted ).


Risk factors :
Previous ectopic pregnancy.
Previous surgery ( pelvic or abd.)>>>cause adhesions.
Exposure to diethylstilboestrol in utero.
Congenital abnormalities of the tube (diverticulum ).
Endometriosis.
PID.
IUCD>>>↑ risk of PID.
ART (assisted reproductive technology).
Maternal age >35years.
Prior Hx of tubal pregnancy.

Fate of ectopic :

Rupture ( if implanted in the isthmus ).
Abortion ( if implanted in the ampullary part ).

Typical C/F :

Localized colicky abd. Pain, when peritonism (blood in peritoneum) developed , pain become generalized severe abd. Pain. Pain must preceded the bleeding.
VB (due to fall in the level of HCG >>>shedding of endometrium>>>VB.
Amenorrhea.


Atypical C/F :
Shoulder pain due to irritation of the diaphragm by the massive intra peritoneal bleeding.
Abd. Distention due to peritonism.
Nausea & vomiting due to pain , not due to HCG.
Dizziness & fainting due to blood loss.
Cullen’s sign ( blue-black bruising around the umbilicus due to intra peritoneal bleeding ) indicate ruptured ectopic.

Inx:

PT : +ve but not the same level of normal pregnancy ( not good secretion of HCG).
TVs( trans vaginal U/S) : no intrauterine pregnancy.
Culdocentesis ( less common ) to look for internal bleeding.

Rx:
If the pt. has VB, pain or shock>>>>
Rx of shock ( as discusses previously ).
Surgery :
Salpingotomy( or –ostomy) is the conservative surgical Rx if the ectopic not rupture.
Salpingectomy . if the ectopic
Segmental resection. Is rupture.
Fimbrial expression(milking), in case of fimbrial ectopic.


If the pt. is stable, no VB, no pain & no shock>>>>
Expectant management :
Close follow up with HCG test every 2-7 days.
Methotrexate .

Complications :

Rupture with internal bleeding that leads to shock.
Infertility in 10-15 % due to tubal damage.
Death is rare.
Recurrent ectopic in about 10%.

Hydatidiform Mole ( H. Mole ):

Hydropic changes of the trophoblast, chorionic villi proliferate & become avascular. Found in the uterine cavity, its of 2 types:
Complete : no fetus, no amniotic fluid & membranes.
Partial : there is fetus, placenta partially undergo changes.
90% of them are 46,XX (female), 10% are 46,XY(male).

C/F :

Hyperemesis gravidarum at 6-8wks due to high levels of HCG.
No pain.
VB or bloody stained VD after period of amenorrhea.
Light pink or brown VD due to ruptured vesicles, or the vesicles detached & pass vaginally(abortion).
Anemia due to blood loss.
Early onset pre-eclampsia.
Uterine size is larger than the expected.
Uterus feels doughy or elastic on examination.
Adnexial mass : theca-lutein cysts replacing an ovary due to over stimulation by HCG.
No fetal parts, no fetal heart beats.


Inx:
Quantitative β HCG : > 100000mlU/ml.
CBC (complete blood count) .
Clotting function: DIC.
Liver function test ( because cells invade the liver).
Renal function test.
Thyroxine( pt. presented with C/F of hyperthyroidism.
U/S : classical image is snow storm pattern.
X-ray : because invade the lung.
Histopathology: edematous placental villi, hyperplasia of trophoblasts & lack or scarcity of fetal blood vessels.

Rx:
Remove all trophoblastic tissue by using vacuum aspiration or D&C.
Sometimes, mole will aborted spontaneously>> do ERPC.

Complications:

Perforation of uterus during D&C.
Hemorrhage during evacuation.
Malignant trophoblastic disease develops in 10-20%.
DIC.
Trophoblastic embolism could cause acute respiratory insufficiency.


Follow-up: its important due to high risk of choriocarcinoma.
Pregnancy should be avoided for a year due to high chance of recurrence (1.2-1.4% , ↑ to 20% after 2 moles).
IUCD & CCP should be avoided, use condom during this period.
Serial quantitative serum β HCG :
Weekly in the 1st month,
Then monthly for 6 months.
Normal level usually reached within 8-12 wks after evacuation, if remain plateau or rise>>>suggest choriocarcinoma.

Choriocarcinoma

Malignant disease of trophoblastic tissue, usually occur in the next pregnancy following evacuation of H.Mole ( more with the complete type ).
Rapidly fatal unless Rx, 95% cured by Rx.
Spread by local invasion, via blood stream & metastasize to lungs (70%), liver or brain.
Rx:
Cytotoxic drugs (methotrexate) singly or in combination.
Pregnancy should avoided for at least 1 year after therapy.
Subsequent pregnancy require close HCG monitoring as there is risk of recurrence.

Causes of DIC (Dissemenated Intravascular Coagulation):

Missed abortion.
Septic abortion.
H. Mole.
IUD.
Amniotic fluid embolism.
Abruptio placenta.


APH :
Any vaginal bleeding occur from 24wks of gestation (28wks in Iraq), or fetal weight >500 gm, to the delivery of the baby.
Causes:
Placental site bleeding:
Placenta Praevia ( PP )
Abruptio Placenta (AP) ( or Accidental hemorrhage )

Non- placental site bleeding (incidental):

Vasa praevia : fetal vessels traverse the fetal membranes over the internal cervical os. Not dangerous for the mother but is nearly always fatal for the baby.
Rupture uterus.
Cervical ectropion , polyp, cervicitis or cancer.
Vaginal varicosity, trauma or infection.

PP : placenta is implanted either wholly or partially in the lower uterine segment , it may extent to or cover the internal cervical os.
It occur in 5% in early pregnancy & called low lying placenta, & about 0.5% in late pregnancy & called PP ( this is due to placental migration )

Degrees – Types –Grades :

1st degree ( pp lateralis or low lying placenta ): lower edge of placenta reach lower uterine segment but not reach internal os.
2nd degree ( PP marginalis ): lower edge of placenta reach margin of internal cervical os but not cover it.
3rd degree (PP incomplete centralis): placenta cover internal cervical os when it is closed or partially dilated but not when fully dilated.
4th degree ( PP complete centralis ): placenta cover internal cervical os completely at any position ( dangerous type ).


Predisposing factors :
Any injury or scar in the uterus ( C.S. or vigorous D&C ). Most common.
Multipara.
Multiple pregnancy.
↑maternal age.
Previous PP (10%).
Anemia.
Congenital malformation of the uterus.
Malpresentation like breech or transverse lie.
Maternal complications :
Anemia.
Shock.
DIC.
Renal tubular necrosis.
PPH.
Complications of B. transfusion.
Infection.
Prolonged hospitalization.
Psychological sequels.
PP accrete.


Fetal complications :
Fetal hypoxia.
Small for gestational age (SGA) & intrauterine growth restriction (IUGR).
Prematurity ( iatrogenic or spontaneous ).
Death .

C/F :

Causeless , painless & recurrent bright red VB. Sometimes precipitated by sexual intercourse or by vaginal examination (PV). Sometimes associated with pain : if pt. developed labour pain, associated with premature uterine contraction(PUC) or AP at the same time.
FM still present after VB.
Symptoms of blood loss ( mentioned previously ).
On general ex.>>>signs of blood loss.
On abd ex.>>>uterus corresponding to gestational age, relaxed & not tender. Fetal parts & fetal heart sound (FHS) can be easily detected. Malpresentations are common.
PV ex. Should be avoided>>>> ppt. VB.

Inx:

U/S: placenta in the lower uterine segment.
MRI.
EUA( ex. Under anesthesia ).
CBC & coagulation profile.
RFT ( renal function test ).


Rx:
Resuscitation :
Call for help.
Insert 2 I.V. lines .
Draw blood for cross matching , coagulation screen & preparation of blood ( 4-6 units ).
Start I.V. fluid ( Ringer lactate ).
Rh –ve blood ( O- ) in life saving condition.
In case of clotting disorders>>>give fresh blood, FFP or Cryoppt.
Foley catheter for assessment of renal function.
CVP ( central venous pr.).
Definitive management : depend on severity of bleeding & gestational age(GA)
Severe bleeding (30-40% blood loss) >>>deliver by C.S. regardless the GA.
Moderate b. (15-30%)>>>
If GA>36wks >>>>deliver.
If GA <36wks >>>observation>>> if remain moderate or become severe >>>deliver by C.S.,
If become mild>>>>expectant management.
Mild b. (<15%)>>>>
If GA >36wks>>>>deliver.
If GA <36wks>>>>expectant management.
Expectant management :
Admission to hospital for bed rest.
B. transfusion.
Rx of PUC >>>>Mg sulphate , CCB , indomethacine .
Dexamethasone or betamethasone ( from 28-34wks) for acceleration of fetal lung maturity.
Some use cervical cerclage.
Repeat U/S every 2 wks.
Delivery at term if no complication.
Route of delivery:
Minor>>>>vaginal delivery
Type I PP & type II ( anterior ).
Major >>>> C.S.
Type II (posterior), Type III & IV.
If PP accreta >>>> hysterectomy.


AP :
Premature separation of the normally situated placenta after 24wks (or 28wks) of gestation.

Types :

Concealed hemorrhage : separation of placenta at the center>>>>no VB.
Revealed hemorrhage : separation of the placenta from the edge >>>VB.
Mixed type.

Risk factors :

Hypertensive diseases of pregnancy . Most coomon.
Smoking.
Substances abuse ( cocaine , ETOH).
Trauma ( direct RTA or external cephalic version ).
Polyhydramnios with rupture of membranes.
Previous AP.
Unexplained elevation of maternal serum alpha feto protein.
Placental insufficiency.
Metabolic abnormality.
Short umbilical cord.

Maternal complications :

DIC.
Acute renal failure.
PPH.
Sheehan’s syndrome.
Rh sensitization ↑.
Amniotic fluid embolism.


Fetal complications:
Prematurity.
Death.
C/F :
Acute constant severe abd pain.
Dark VB.
Cessation of FM is common.
Symptoms of blood loss signs of shock.
B.pr is not dependable because effected by bleeding.
On abd ex. >>>>uterus is larger than the expected , very tender & hard ( board – like ). Fetal parts & FHS are difficult to detected.
PV ex is contraindicated ( C/I) unless exclude PP by U/S.

Inx:

U/S : normally situated placenta with retroplacental hematoma.
CBC.
Clotting functions.

Rx:
Resuscitation ( as mentioned previously ).
Definitive management is delivery ( depend on fetal viability ).
If fetus was dead >>>aim is vaginal delivery:
Amniotomy (ARM) + oxytocine if :
Bleeding is not severe.
Vertex presentation.
Cervix is partially dilated.
Adequate pelvis with no soft tissue obstruction.
Analgesia is liberal.
C.S. after correction or exclusion of DIC is indicated in :
Severe bleeding whether fetus is dead or alive.
Living fetus &labour is expected to be long due to closed cervix.
Fetal distress.
Failure of progress after ARM+ oxytocine.
Other indications of C.S.
Post partum: because pt. is liable for uterine atony & PPH>>>>
Oxytocine is continued after delivery.
Methergin is given with delivery of the shoulders if there is no H.T.
Continuous massage of the uterus.
PPH : 2 types :
-Primary PPH : loss of => 500ml blood from genital tract within 1st 24hrs of delivery.
-Secondary PPH : loss of => 500ml blood from genital tract between 24hrs & 12wks ( or 6 wks ) post delivery.
-Occur in about 5-15% pts. After delivery.
-Causes of primary PPH : 4 T : and risk factors for each T.
Tone 70%
Uterine atony
Trauma 20%
Tissue 10%
Retained product
Thrombin 1%
Clotting disease
DIC
1.Over distension of uterus ( twin or polyhydramnios)
1.simple adhesion
1.cervical, vaginal & perineal delivery (instrumental deliveries)
1.Von Willebrands disease
2.Induction of labor
2.morbid adhesion ( accreta, increta & percreta)
2.uterine rupture (previous C.S., myomectomy, metroplasty or perforation)
2.A.P.
3.Prolonged/ppt. labor


3.extension of uterine incisions during C.S.
3.IUD
4.anasthesia

4.uterine inversion.

4.sepsis
5.tocolytics

5.massive b. loss

6.APH

6.massive b. transfusion

7.grandmultipara

7.severe PET , eclampsia

8.misRx of 3rd stage of labor

8.amniotic fluid embolism

9.full bladder

9.hepatitis

Causes of secondary PPH :
Retained products of conception.
Uterine infection.

C/F :

Blood loss
Systolic B.pr.
Symptoms & signs
10-15%
normal
Postural hypotension
15-30%
Slight fall
↑ PR, thirst, weakness
30-40%
60-80
Pallor, oligouria, confusion
40+%
40-60
Anuria, air hunger, coma, death


Complications of PPH :
Shock & DIC.
Renal failure.
Puerperal sepsis.
B. transfusion reaction.
Thromboembolism.
Sheehan’s syndrome.
Maternal death.
Prevention :
Regular ANC.
Correction of anemia.
Identification of high risk cases.
Delivery in hospital with facility for emergency obstetric care , otherwise transport to the nearest such hospital.
Local or regional anesthesia.
Active management of 3rd stage of labor:
Oxytocics ( ↓ blood loss by 30-40%).
Early cord clamping.
Controlled cord traction.
Inspection of placenta & lower genital tract.
4th stage of labor>>>>observation & oxytocin.


Rx:
Correction of hypovolemia:
Resuscitation ( as mentioned previously ).
Resuscitation & definitive management should be at same time.
Ascertain origin of bleeding.
Ensure uterine contraction ( Rx of uterine atony ):
Palpate fundus .
Uterine massage.
Bimanual examination.
Compression of aorta against sacral promontory.
Foley catheter.
Oxytocics ( oxytocin, PG, syntometrine & ergometrine).
Surgical Rx:
Repair of trauma if present.
Uterine artery ligation.
Utero-ovarain artery ligation.
Internal iliac artery ligation.
Brace suturing of uterus.
Angiographic embolisation.
Hysterectomy.
Management of Tissue:
EUA & manual removal .
If placenta accreta >>>observation >>>methotrexate >>>hysterectomy.
Management of Trauma:
Exploration of genital tract start from the uterus downward to exclude rupture uterus.
Check cervix next for any injury using sponge forceps & speculum.
Check vaginal wall for episiotomy extension, injury, laceration or hematoma.
Repair lacerations quickly.
Management of Thrombin:
Fresh blood transfusion.
Cryoppt.
FFP
Platelet concentrate.


Lower Abdominal Pain (LAP)
How to take Hx?
Identity: LMP.
H.P.I.:
Site ?
Onset ?
Character ?
Severity ?
Radiation ?
Frequency & duration of each attack ?
Aggravating & relieving factors ?
Associated symptoms ? ( VB, FM, fever ,nausea, vomiting, dysuria, frquency….)?
Reviewing of GIT & GUT?
Obx. Hx. : previous same condition during the present & past pregnancies.
Fx. Hx. : Hx. of abortion, preterm labor or the same condition.

Causes of LAP :

Obstetrical causes :
Early pregnancy (<24wks):
Abortion.
Ectopic pregnancy.
Ligament stretching.
Acute urinary retention due to retroverted gravid uterus.
Late pregnancy (>24wks):
Labor.
PUC (premature uterine contraction).
Preterm labor.
AP.
HELLP syndrome.
Uterine rupture.
Chorioamniotis.
Non- Obstetrical causes :
GIT diseases :
Peptic ulcer.
Acute appendicitis.
Acute gastroenteritis.
Acute cholecystitis.
Acute pancreatitis.
GUT diseases :
UTI( acute cystitis & acute pyelonephritis ).
Renal colic.
Torsion or degeneration of fibroid.
Ovarian cyst accident.
Other medical diseases :
SCA.
DKA (diabetic ketoacidosis ).
Pneumonia ( especially lower lobe).


Labor pain :
Regular severe colicky LAP which ↑ in intensity & frequency with time until reach 3 contraction per 10 min lasting 45-60sec, coming every 2-3 min, associated with cervical dilatation & effacement , & passage of show.
Cervical effacement : is disappearance of cervical canal with the subsequent uterine contraction.
Show: a blood stained plug of mucus passed from the cervix during labor.

PUC: irregular, doesn’t ↑ in intensity & frequency with time, doesn’t associated with cervical dilatation, effacement or passage of show.

Stages of labor:
1st stage : start from the beginning of uterine contraction to full cervical dilatation (10cm) .lasting 12-16 hrs in primigravida & 6-8 hrs in multigravida.
Phases of 1st stage of labor :
Latent phase: time from beginning of contraction to 3-4 cm dilatation. During this phase cervix become fully effaced . lasting 6-8 hrs in nullipara & 2-4 hrs in multipara.
Active phase : from 3-4 cm dilatation to full dilatation .lasting 6 hrs in nullipara & 2 hrs in multipara.cervical dilatation occur at a rate of 1cm/hr.

Management of 1st stage of labor:

Confirm diagnosis of labor.
Admission to labor room.
Assess feto-maternal condition.
Preparation of blood especially for those liable for C.S.
Augmentation of labor by ARM or with syntocinon.
Sedation ( pethidine or tramal ).
Oxygenation if any fetal compromise.
Ask pt. to walk around unless breech presentation because may end with cord prolapsed.
Glucose-water for dehydrated or exhausted women.
CTG ( cardiotocography) for : meconium stained liquor, breech delivery, precious baby or any fetal compromise.
Partogram : to asses progression of labor.


2nd stage of labor : start from full cervical dilatation to the delivery of the fetus. lasting 1 hr in primigravida & 20-30min in multigravida.
Management of 2nd stage of labor:
Pt. should kept in lithotomy position with fluid, O2 & syntocinon.
Episiotomy needed when the perineum is threaten to tear.
Syntometrine should be given with the crowing of head or with the delivery of the anterior shoulder after exclusion of 2nd twin .

3rd stage of labor: stage of delivery of the placenta. Lasting 30 min.

Management of 3rd stage of labor:
Wait for signs of placental separation :
Gush of blood.
Elongation of umbilical cord.
Globular shape of the uterus
Then just pull the placenta & membranes by brandandrews method ( sustain traction on the umbilical cord with left hand on the abd & pushing uterus upward & backward to prevent uterine inversion.
Inspect the placenta.

4th stage of labor: observe the pt. for 1-2 hrs for any bleeding or pain.

Preterm labor :
Labor occurring from 24wks completed to 37wks uncompleted. About 7%.
Causes & risk factors:
Idiopathic in 75%.
Infection>>fever>>↑IL & PG>>>contraction of uterus:
Local>>>chorioamnionitis ( infection of the gravid uterus) 10-20%
Systemic like pylenephritis.
AP ( due to ↑fibrin degradation products>>enhance contraction) & placental insufficiency(iatrogenic preterm).
Congenital anomalies of the fetus>>>polyhydramnios>>> overdistension of the uterus.
overdistension of the uterus ( polyhydramnios or twin ).
Cervical incompetence.
Demographic features ( maternal low social class, low maternal weight, stressful occupation ).


Management of pt. at risk:
Education.
Rx of any vaginal discharge.
Limitation of physical activity.
Serial U/S .

Early warning symptoms of preterm:

Menstrual like cramps constant.
Low dull bachache.
Pressure ( feels like the baby is pushing down).
Increase or change in vaginal discharge .

Management of pt. with early warning symptoms:

Oral Antibiotics.
Prophylactic oral tocolytic ( ritodrine , terbutaline, nifidipine, Mg sulphate or atosiban ).
Bed rest.

C/F of established preterm labor:

Labor pain, may associated with VD or VB .
Sinus tachycardia.
Cervical dilatation with effacement.


Management of pt. with established preterm labor:
Identification of pt. that need to be delivered :
Chorioamnionitis.
Fetal lung maturity.
Fetal growth retardation.
Fetal fatal congenital anomalies.
Maternal disease.
I.V. antibiotics.
I.V. tocolytics ( only delay labor for 1-2 days necessary for lung maturity.
Glycocorticoid treatment.

Vaginal Discharge (VD)

How to take Hx?
Identity: LMP, age.
H.P.I:
Onset ?
Color ?
Amount ?
Odor ?
Consistency ?
Aggravating & relieving factors ?
Associated symptoms ? ( fever, itching, VB, LAP, FM, dysuria ).


Obx. Hx. : previous same condition during the present & past pregnancies,
Hx of mid-pregnancy abortion?
Gyn. Hx. : focus on gynecological operations.

Causes of VD :

Normal VD during pregnancy>>>leucorrhea >>> painless, colorless & not associated with itching.
Liquor >>> gush of watery VD associated with contraction>>> in case of labor & premature preterm rupture of membranes (PPROM).
Infection>>>> yellowish-greenish , offensive& associated with itching.
Show ( discussed previously ).
Lochia ( discussed previously ).

Preterm Premature Rupture Of Membranes ( PPROM ):

Rupture of the fetal membranes between 24wks completed to 37wks uncompleted. Complicate 1/3rd of preterm deliveries. Around 1-2% of pregnancies. Majority of pts. Delivery within 1 wk.
Causes :
Polyhydramnios & multiple pregnancy.
Cervical incompetence.
Ascending genital tract infection.

C/F :

Acute gush of fluid that floating on her legs spontaneously or following an activity, of any color.
Visualization of amniotic fluid in the vagina in lithotomy position under sterile technique by using speculum & ask pt. to cough.


Inx:
Nitrazine test : amniotic fluid has PH of 7-7.5 (alkaline).
Fern test +ve.
Evaporation test +ve.
U/S.
Intraamniotic fluorescein .
Amnioscopy.
Fetal fibronectin ( if present <36wks >>>indicate PPROM).
Alpha feto protein test ( if present in the VD>>>indicate PPROM).

Complications :

Chorioamnionitis .
Hyaline membrane disease.
Pulmonary hypoplasia.
A.P.
Fetal distress .
Fetal deformities.

Rx:
Identification of pt that require delivery:
Labor.
Chorioamnionitis.
Mature fetal lung.
Fetal malformation.
Fetal distress.
Expectant management:
Bed rest.
Daily checking of vital signs & VD.
Oral antibiotics.
Oral tocolytics.
Corticosteroid treatment.


Caesarean Section (C.S.)
How to take Hx ?
Identity: LMP, name, age, blood group.
C.C. – pt. admitted for elective C.S. due to …..
H.P.I : discuss the present pregnancy in details , cause of C.S. , criteria of elective C.S. ( discuss later ), preparation for operation & pt status now.

C.C.-1st ( 2nd, 3rd ……or operative day(0day)) post operative day following elective ( or emergency) C.S. due to…….
H.P.I:
Pre op. :
Cause & criteria of elective or emergency C.S?
Symptoms pt has at that time?
Preparation?

Op. :

Date of operation & at which time?
Type of anesthesia ( general or spinal )?
Time & place of recovery?
Admitted to ICU or not?
Result (neonate)?

Post op.:

1st post op. day:
Fever?
Excessive vaginal bleeding ?
Pain at site of operation ?
Vomiting ? cough ?
Drugs? I.V. fluid ? b. transfusion ?
Foley catheter ? ask about urine color? Amount ? when removed?
Pass urine freely or not ?
Movement ?
Lactation ?
2nd post op. day:
Fever? Excessive VB ? pain ?
Pass flatus ?
Start oral feeding ?
3rd post op. day:
Bowel motion ?
Oral feeding ?
Any complications ?


C.S. : is delivery of the fetus through incision in the anterior abdominal & uterine wall.
Indications :
Maternal causes : previous 2 scar , eclampsia, severe PET , HELLP syndrome, obstruction to birth canal by fibroid or ovarian tumor, medical diseases ( D.M., & cardiac diseases ).
Fetal causes : malpresentation, cord prolapsed & fetal abnormalities.
Materno-fetal causes: dystocia,CPD, failure of induction & abnormal uterine action.
Placental causes : PP & AP.

Criteria of the elective & emergency C.S.:

Elective
Emergency
Usually done at day time
At any time
Usually at the waiting list
not
Well prepared
Not well prepared, only blood group & Hb level.
Pt go from the ward to the theatre
Pt go from labor room to the theatre
Not established labor pain
Established labor pain
No VB, VD
VB , VD


Conditions change elective C.S. to emergency C.S. :
VB
VD
LAP
↓ FM
Fever
Any acute illness.

Complications of C.S.:

Bleeding.
Post op. sepsis.
Injury to nearby structures.
Thromboembolic disease.

Hyperemesis Gravidarum (HG)

How to take Hx ?
Identity: LMP? G & P ?Set of twin ? age?
C.C. excessive vomiting.
H.P.I.:
Onset ?
Time of occurrence ? ( morning ?)
Frequency ?
Amount ?
Color ?
Odor ? taste ?
Relation to food ? before or after meals ?
Contain blood or not ?
Aggravating & relieving factors ?
Associated symptoms ? ( fever , VB, VD & LAP )
Reviewing of GIT , GUT & CNS?


Obx. Hx. : previous same condition during the present & past pregnancies, Hx of twin pregnancy ? Hx of H.mole ?
P.M.S.Hx: D.M.? , thyrotoxicosis ?
Fx. Hx. : Hx. of twin pregnancy, or the same condition.
Drug Hx : antibiotics ? iron ?

DDX :

HG.
Non- obstetrical causes :
GIT diseases ( appendicitis, cholycystitis, fatty liver, hepatitis, gastritis, bowel obstruction).
CNS ( meningitis , ↑ ICP ).
UTI.
Drug ( antibiotics & iron ).
Metabolic( DKA , thyrotoxicosis).

HG : excessive nausea & vomiting during pregnancy that interfere with the pt daily activity causing distress to the pt. occur in 0.5 – 2%.
Causes : exact cause is unknown :
Genetic factor.
Hormonal factors :
HCG : ↑sensitivity to it in the primigravida & in case of 1st pregnancy from a new partner . High level present in multiple pregnancy & H. mole .
↑ estrogen & progesterone .
Lepton ↑ ( either cause of HG or resulting from it ) .
Cytokines ↑ ( either cause of HG or resulting from it ) .
Psychological factors .
Infection with H. pylori.
Nutrient deficiency.


C/F :
Emotional stress, difficulty with activity of daily living.
Excessive nausea & vomiting , aggravated by hunger , iron intake & smell ( hyperalfaction ).
Dehydration & loss of 5% of body weight if prolonged.
Ketosis & constipation.

Dx : by exclusion of DDx.

Inx : to evaluate dehydration :
CBC , RFT , LFT , TSH.

Complications :

Hepatic fatty degeneration.
Hepato - renal-encephaly.
Dehydration.

Rx :

Dietary & life style recommendation:
Avoid large meal.
Not take fluid at morning.
Low fat diet.
Emotional support.
Use of herbal remedies like ginger & peppermint.
Drugs :
Pyridoxine ( Vit. B6 ), may combined with doxylamine.
Metoclopromide.
Corticosteroids in severe cases .
Rehydration :
1st line is oral rehydration by bland dry food & oral fluid.
Parentral rehydration if no response , fluid of choice is glucose water .
I.V. thiamine or B complex in infusion.


Hypertensive Diseases In Pregnancy
How to take Hx from pt with H.T.?
Identity: LMP, age , G&P, blood group.
C.C:
Admitted for control of hypertension ( H.T. ).
Complains from one or more of the symptoms of H.T.
H.P.I :
When Dx ?
Duration of H.T. ?
CNS symptoms ? ( headache, tinnitus , blurred vision , numbness & fit )
CVS symptoms ? ( dyspnea, orthopnea, chest pain & edema )
GIT symptoms ? ( vomiting, epigastric pain ( HELLP syndrome ))
GUT symptoms ? ( oligouea , proteinurea )
Analysis of each of the above symptom?
FM?
Hx of present pregnancy ?

Obx Hx: Hx of H.T. or PET in previous pregnancy ? Hx of IUGR ? fetal death ? AP ? multiple pregnancy ? H. mole ?
P.M.S.Hx: H.T. ? D.M. ? renal diseases ? thyroid ?
Fx Hx : Hx of PET ? H.T.?
Drug Hx : type of anti H.T. ? dose ? for how long ?
Social Hx : smoking ?


How to take Hx from pt with PET ?
Identity: LMP, age , G&P, blood group.
C.C: swelling , H.T. & proteinuria .
H.P.I :
H.P.I. of H.T. ?
Edema >>>>
Onset ?
Site ?
Extension ?
Uni or bilateral ?
Aggravating & relieving factors ?
Associated symptoms ?
Proteinuria ?
The remaining Hx is similar to the Hx of H.T.

Note: in normal pregnancy there is edema of the dependent parts of the body (legs) due to fluid retention, while the pathological edema is edema of the non dependent parts of the body ( face & hands )>>>pt has puffiness of the face & can’t wear her ring.

Sites of edema formation :

Legs.
Hands.
Face.
Sacrum.
Abdomen.


Hypertensive diseases in pregnancy include:
Chronic hypertension (H.T.).
Pregnancy induced H.T. ( PIH ).
Pre eclampsia (PET).
Eclampsia.
HELLP syndrome.

Chronic H.T. :

B.pr. =>140/90 before 20 wks of gestation & persist beyond 12 wks after delivery.

Gestational H.T. ( PIH ):

B.pr. =>140/90 on 2 or more occasions after 20 wks of gestation in previously normotensive pt , without proteinuria & return to normal 12 wks after delivery. 50% of them developed PET .

Rx of PIH :

Delivery if :
Favorable cervix & at term.
Fetal lung maturity.
Worsening of B.pr.
Development of severe PIH.
Non reassuring fetal condition.
Mode of delivery :
At term & cervix favorable>>> vaginal delivery.
At term & cervix unfavorable>>> PG >>> vaginal delivery.
If <32wks >>>>> C.S.


Expectant management if disease is mild & cervix unfavorable>>>
Close observation .
Rule out severe disease by RFT, LFT, fetal surveillance, proteinuria & coagulation profile.
Twice weekly visits.

PET :

New onset of H.T. & proteinuria in previously normotensive pt after 20wks of gestation & return after 12 wks of delivery.

PET superimposed on chronic H.T.:

New onset proteinuria (=>300 mg /day) in previously H.T. , but no proteinuria before 20wks of gestation, or platelet count <100000/cmm.
Causes of PET:
Abnormal placentation.
Inflammatory mediators ( ↓PGI2 & ↑ TXA2 ).
Genetic factors.
Immunological factors >>>exposure to sperms of new partner.

C/F : mentioned previously in the H.P.I .

Risk factors :
Nulliparity , exposure to sperms of new partner.
Hx of PET in previous pregnancy.
Hx of PET in the family.
Advanced maternal age.
Hx of AP, IUGR ,fetal death.
Maternal diseases ( obesity, H.T., D.M., thrombotic vascular diseases).
Smoking is preventive.
Multiple pregnancy , H. mole & D.M. >>>> early onset PET .


Fetal risks:
IUGR.
AP.
Placental infarcts.
Oligohydramnios.
Prematurity & perinatal death.
Utero-placental insufficiency.

Maternal risks:

Seizure & stroke.
DIC.
Renal failure.
Hepatic failure or rupture.
↑ C.S.
Death.

Prevention:

Regular ANC ( rapid gain in weight, rising B.pr. ,edema, proteinuria).
Low dose of aspirin ( ↑PGs & ↓ TXA2) in high risk group.
Antioxidants >>>Vit. C&E.
Nutritional supplementation : zinc, Mg, fish oil & law salt diet.
Calcium supplementation if women are calcium deficient.


Rx:
Anticonvulsant therapy >> Mg sulphate.
Antihypertensive therapy>> hydralazine, labetalol, nifedipine, nitroprusside, diazoxide & clonidine.
Termination of pregnancy if :
At term with mild or severe PET.
Severe PET regardless the gestational age.
Eclampsia.

HELLP syndrome:

Hemolysis, Elevated Liver enzymes & Low Platelets.
Rx of HELLP syndrome:
Immediate hospitalization.
Stabilize mother with: antihypertensives, anticonvulsants & correct coagulation abnormalities.
Assess fetal condition >> biophysical profile.
If >34wks>>>>delivery, if <34wks>>> expectant management.
Platelet transfusion if <40000 before C.S. or <20000 before VD.

Eclampsia :

New onset of seizure or unexplained coma during pregnancy or in post partum period in pt with pre-existing PET & without pre-existing neurological disorder.
-Antepartum (50%), intrapartum (30%) or post partum (20%).
Risk factors :
Maternal age <20 years.
Multigravida.
Molar pregnancy.
Triploidy.
Pre-existing H.T., renal disease , PET or eclampsia.
Non immune hydrops fetalis.
SLE.


C/F : 4 stages :
Premonitory (Aura) stage: twitching of facial muscles , tongue, limbs & eyes. Eyeballs rolled or turned to one side. 30 sec.
Tonic stage: opisthotonus, limbs flexed , hands clenched. 30 sec.
Clonic stage : tongue bite, involuntary passage of urine & feces. 1-4 min.
Coma stage.

Rx :

Insert I.V. line.
I.V. Mg sulphate.
Immediate termination of pregnancy.

Diabetes Mellitus ( D.M. )

How to take Hx ?
Identity : LMP, age, G&P.
C.C. –pt admitted for control of D.M.
-complains of one or more of the symptoms of D.M.
H.P.I:
When Dx ?
Duration of D.M. ?
Polyurea? Polyphagia? Polydepsia?
CNS symptoms ? ( blurred vision , numbness )
GUT symptoms ? ( oligouea , itching,VD, VB )
Analysis of each of the above symptom?
FM?
Fever ? pain ?
Hx of present pregnancy?


Obx Hx: Hx of H.T. or PET in previous pregnancy ? Hx of macrosomic baby ? fetal death ? mid pregnancy abortion ? congenital malformation ? preterm labor? Polyhydramnios?
P.M.S.Hx: D.M. ?
Fx Hx : D.M.?
Drug Hx : type of hypoglycemic drugs ? dose ? for how long ?
Social Hx : diet pattern ? obesity ?

D.M. in pregnancy :

Pre-existing D.M.
Gestational D.M.

Gestational D.M.:

State of glucose intolerance ( FBS=>8mmol/L or post prandial =>11mmol/L) which occurs at the end of 2nd trimester or early 3rd trimester & return to normal after puerperium .
Causes :
Development of insulin resistance during pregnancy.
Placental hormones ( human placental lactogen ).

Screening for D.M.: no single test has been shown to be perfect. GTT (glucose tolerance test ) is diagnostic & screening for high risk group, but on low risk group can’t be justified .

High risk group :

Family Hx of D.M.
Poor obstetrical Hx ( abortion, still birth ).
Polyhydramnios, preterm labor.
Macrosomia (fetal weight >4 kg).
Obese mother.
Advanced maternal age.
Glycosuria on 2 occasions , first in the morning ( not dependable test because it is normal in normal pregnancy ).


Effects of D.M. on pregnancy :
Fetal & neonatal complications :
Early &Mid pregnancy abortion (due to congenital malformation ).
Unexplained still birth ( due to fluctuation in blood glucose >> ↑viscosity >>> vasculopathy ).
Fetal macrosomia ( due to continuous passage of glucose during day & night >> islet cells hyperplasia >> hyperinsulinemia>> growth promotion ).
Polyhydramnios , preterm.
Neonatal hypoglycemia, polycythemia, hyperbilirubinemia, hypoglycemia & hypomagnesemia.
Birth asphyxia due to macrosomia.
Respiratory distress syndrome.

Maternal complications :

↑ risk of early onset PET.
Infection >> UTI, candidiasis ( due to ↓PH of vagina by ↑lactic acid & flushing of urine on vulva ).
Nephropathy.
Retinopathy.
Severe hypo or hyperglycemia.
↑ Operative delivery rate 50%.

Effects of pregnancy on D.M.:

Difficulty in control (due to nausea & vomiting & ↑GFR in 1st trimester & development of insulin resistance with advance pregnancy ).
Risk of deterioration of pre-existing retinopathy.
Risk of deterioration of pre-existing nephropathy.
Change in eating pattern.
↑ risk of severe hypoglycemia.


Management :
Antipartum :
Admission to hospital.
Change in dietary life style.
Insulin >short acting + intermediate in 2 divided doses> dose of insulin :
Body weight * 0.6 in 1st trimester.
Body weight * 0.7 in 2nd trimester.
Body weight * 0.8 in 3rd trimester.

Intrapartum :

Continuous infusion of 5-10% dextrose + 0.5-2 units of insulin.
Measure blood glucose every 2hrs ( aim to keep level 80-100 mg/dl).
Fetal scalp electrode.
Aim is vaginal delivery until there is other obstetrical complications.

Postpartum :

In 1st 48 hrs, most of pt don’t require insulin.
After that>>> for every 50 mg glucose above 150mg/dl>>give 10 unites of insulin.
Encourage breast feeding.
Use barrier method of contraception.
Consult for next pregnancy.


Anemia

How to take Hx ?

Identity: age, LMP, G&P, blood group.
C.C. :
Admitted for blood transfusion.
Symptoms of anemia.
Symptoms of sickle cell crises.

H.P.I :

When Dx ?
Duration ?
CNS symptoms ? ( blurred vision , headache, numbness )
CVS symptoms ? (palpitation, dyspnea )?
Respiratory symptoms ? ( cough , dyspnea ?
GIT symptoms ? ( nausea, vomiting )
GUT symptoms ? ( dysuria , itching, VB )
Analysis of each of the above symptom?
FM?
Fever ? pain ?
Hx of present pregnancy?
Symptoms of sickle cell crises ? :
Sudden severe bone pain .
Chest pain.
Hematuria.
Cough sometimes.


Obx Hx: Hx of multiple pregnancy ? interval between pregnancies? Prolonged lactation ? APH? PPH? PET? IUGR ? IUD? congenital anomalies?
P.M.S.Hx: hemoglobinopathy ? bleeding tendency ?
Fx Hx : hemoglobinopathy?
Drug Hx : sulpha drugs ?

Anemia in pregnancy : Hb level <11g/dl.

Types of anemia :
Physiological : dilutional anemia.
Pathological :
Nutritional anemia :
Iron deficiency anemia (IDA).
Foliate deficiency anemia.
B12 deficiency anemia.
Hemolytic anemia :
Hemoglobinopathy ( SCA , thalassemia ).
G6PD deficiency.
Hereditary spherocytosis.
Autoimmune hemolytic anemia.
Chronic anemia :
Chronic liver diseases.
Chronic renal diseases.
Infection.
Infestation.
Risk factors :
Malnutrition.
Multipara.
Low social class.
Poor education.
Short interval between pregnancies.
Prolonged lactation.
Teenage female.


Maternal risks :
Difficult to perform usual work.
Easy to get infection.
APH.
PPH.
PET.
Recurrent UTI.
Delay recovery from anesthesia & wound healing after C/S.

Fetal risks :

Congenital defect as neural tube defect.
Preterm delivery.
IUGR.
IUD.
Death.
Neonatal anemia>>>> low I.Q.

IDA :

Causes:
↓ iron store.
↓ dietary intake of elemental iron.
Poor intestinal absorption.
↑ demand in pregnancy by ↑ red cell mass ( 500-600 mg) & 300 mg for fetus & placenta.


Inx:
↓ serum ferritin level.
↓ serum iron level.
↑ total iron binding capacity level.
Blood film >>> microcytic hypochromic anemia .
Bone marrow >>> absence of stainable iron.

Rx :

Oral iron : ferrous sulphate, ferrous fumerate & ferrous gluconate.
Parentral iron : iron dextran & iron sorbitol.
B. transfusion in late pregnancy as Hb level is =<8mg/dl.

Foliate deficiency anemia :

Causes:
↓ dietary intake.
↑ clearance by kidney.
Transfer to fetus ( 800 Ug) at term.
↑ demand by ↑ red cell mass & uterine hypertrophy.

Inx :

↓ serum foliate level.
↓ red cell foliate level.
↓ reticulocytes.
Blood film>>> macrocytic anemia with hypersegmentaion of nuclei of neutrophil.
Bone marrow >>> large erythroblasts & giant metamylocyte.


Rx :
Folic acid 5 mg tablet.

B12 deficiency :

Causes : rare, caused by ↓ dietary intake.
Inx: ↓ serum B12 level.
Rx : B12 injection 1000Ug – once weekly.

Inx for hemoglobinopathy :

↑ reticulocytes & ↓ platelets & WBCs count.
Blood film >>> + sickling test ( sickle shape RBC when exposed to reducing agents or hypoxia.
Features of hyposplenism (Howell jolly bodies).
Normal MCV & MCHC.
↑ serum bilirubin level.
Hb electrophoresis.

Rx of hemoglobinopathy :

Oral folic acid 5 mg tablet.
Iron therapy in HbAS & thalassemia minor but not in HbSS as there is risk of hemosiderosis.
Screening & Rx of UTI & chest infection.
B. transfusion in any trimester.
Hydroxyurea should be discontinue because it is teratogenic.


Rx of sickle cell crises :
Adequate hydration : I.V. glucose water.
Adequate O2 supply.
Adequate analgesia & pain killer.
Screen for UTI & chest infection.
Antibiotics.
B. transfusion if Hb <8g/dl.
Thrombo-prophylaxis.
Fetal monitoring.
Early mobilization & chest physiotherapy after C.S.
Termination of pregnancy is not indicated.

Decrease or Cessation of FM

How to take Hx ?
Identity : age, LMP, G&P.
H.P.I.:
Onset ?
Duration ?
VB? VD? LAP? Fever ?
Symptoms of pregnancy ?
Symptoms of H.T.? D.M. ? anemia ? abortion ?
U/S result ?
Kick count at hospital ?


Obx Hx : multiple pregnancy ? H.T.? IUGR? IUD?
P.M.S.Hx: H.T.? D.M.? anemia?
Fx Hx : H.T.? D.M.? Anemia? Twin pregnancy ?
Drug Hx : hypnotic drugs? Teratogenic drugs?

Causes of decrease or cessation of FM :

IUGR ( Intra Uterine Growth Restriction ).
Post term pregnancy.
Fetal distress.
IUD ( Intra Uterine Death).

IUGR :

Failure of a fetus to grow according to its genetic potential (body weight < the expected ). Its pathological.

SGA ( Small for Gestational Age ):

Infants weight are below the 10th percentile for their gestational age ( body weight < population norms ). Its pathological or non-pathological.

Note : not all IUGR are SGA & not all SGA are IUGR.

Risk factors :
Medical diseases ( H.T.).
Malnutrition.
Multiple pregnancy.
Primigravida.
Grand multipara.
Teenage pregnancy.
Small stature – low pre pregnancy weight.
Drugs e.g. warfarin.
Hypoxemia ( high altitude ).
Fetal congenital anomalies , cardiovascular diseases , congenital infection or inborn errors of metabolism.


IUGR is of 2 types :
Symmetrical : due to early pregnancy insult, the result is proportionate reduction in both head & body size.
Asymmetrical : due to late pregnancy insult( placental insufficiency)>> ↓ glucose transfer & hepatic storage >>> reduction of fetal abdominal circumference only.

Dx :

Symphyseofundal height : if there is deficiency of 4cm from the expected height>> IUGR may be suspected.
Accurate assessment of gestational age by 1st trimester U/S(±1wk).
U/S biometry :
Abdominal circumference (AC).
Biparietal diameter (BPD).
Head circumference (HC).
Femur length (FL).
Estimated fetal weight (EFW).
HC/AC & FL/AC ratio.
Doppler velocimetry :
Umbilical artery Doppler show :
↓ end diastolic flow.
Absent end diastolic flow.
Reversal of flow.
Middle cerebral artery Doppler:
↓ resistance in middle cerebral artery>>> brain sparing.
Venous Doppler:
Absent or reduce flow in the ductus venosus.
Inferior vena cava & umbilical vein pulsations are terminal signs.
Amniocentesis or fetal blood sampling to karyotype the fetus.


Rx:
Rx of maternal diseases.
Adequate bed rest.
Antepartum surveilleance:
Admission to hospital & kick count monitoring.
Biophysical profile (BPP).
Delivery :
At 36 wks>> delivery of all cases with abnormal Doppler, reduced fetal growth & severe oligohydramnios.
32-36 wks >> delivery if NST become abnormal, absent end diastolic flow, venous pulsation or reversal of flow.
C.S. indicated in case of reversal of end diastolic flow, abnormal venous Doppler or non reactive NST.

BPP
variable
Score 2
Score 0
NST (non stress test)
reactive
Non reactive
Fetal breathing movement ( 17-18wks )
1 or more lasting=> 30sec in 30 min. hiccups are considered breathing activity.
<30sec in 30min
FM
3 body or limb movements
2 or less within 30 min
Fetal tone (7-9 wks)
1 or more episode of extension with return to flexion of the limbs, opening & closing of hand.
No extension- flexion
Amniotic fluid volume
At least 1cm diameter of amniotic fluid in 2 perpendicular planes, single 2cm* 2cm pocket is considered adequate.
Largest single pocket 2cm or less.
BPP of 8-10 score is acceptable, of 0-2 score indicate termination of pregnancy.


Postterm pregnancy :
delivery of the fetus between 42 wks completed to 44 wks completed.
Post date pregnancy : past the calculated EDD before 42 wks.

Risk factors :

Nullipara.
Previous postterm pregnancy.
Male fetus.
Obesity.

Complications :

Maternal :
Anxiety.
Birth trauma.
PPH.
↑ C.S. rate.
Fetal :
Fetal distress.
Macrosomia.
Trauma.
Perinatal mortality.
Dysmaturity syndrome.


Management :
Confirm gestational sge by Hx & 1st trimester U/S.
Asses fetal wellbeing ( BPP).
Delivery:
Dates are certain & cervix is favotable>> ARM+oxytocin.
Dates are certain but cervix is unfavorable >>
Delivery if ripe cervix, oligohydramnios, macrosomia, meconium stained liquor or abnormal NST,BPP.
Otherwise>>expectant management with twice weekly NST & AFI(amniotic fluid index).
Dates are unsure>>>expectant management.

IUD :

Fetal death after 28th wk of gestation & before onset of labor.
Causes:
Unknown causes in 50% of cases.
Placental complications.
H.T.
Immunological diseases.
Erythoplastosis fetalis.
Congenital anomalies.
Infection (STORCH & listeria).


Dx :
Absent of FM.
↓symptoms & signs of pregnancy.
Smaller than date uterus.
Fetal heart tone not detected by Doppler.
U/S>>>no FM, no FHS, collapse of fetal body & overlapping of cranial bones.
X-ray: gas in CVS 2-3 days after fetal death, overlapping of fetal skull ( spalding sign) , marked curvature or angulation of fetal spine.
Amniocantesis: dark turbid brown fluid with ↑ creatine phosphokinase.

Rx :

Monitoring & correction of clotting disease.
If cervix is favorable>>> oxytocin>>delivery.
If cervix is unfavorable>>> intrauterine catheterization with extraamniotic fluid installation of normal saline or use of lamineria tent.

Fetal distress :

Depletion of O2 & accumulation of CO2 leading to state of hypoxia & acidosis , either acute ( ante & intrapartum) or chronic ( always antepartum).
Causes:
PIH.
Severe anemia.
APH.
Shock & acute infection.
Obstruction of uteroplacental blood flow.
Obstruction of umbilical blood flow.
Dysfunction of the placenta.
Malformation of fetal CVS.
Intrauterine infection.


Dx :
↓ FM.
Meconium stained liquor.
CTG:
FHR>180bpm or <100bpm.
Repeated late deceleration (LD).
Variable deceleration (VD).
FBS (fetal blood sample):
PH <7.20.
pO2 <10mmHg.
pCO2 >60mmHg.

Rx :

remove the inducing factors.
Correction of acidosis>>>5% NaHCO3 250ml.
Termination of pregnancy.

Cervical Incompetence & Cervical cerclage

Cervical Incompetence :
Cervix width at the internal cervical os is >2.5 cm ( normally 2 cm).
Causes:
Laceration of cervix or undue stretching of internal os as a result of previous abortion, still birth, instrumental delivery, Manchester opertaion or D&C.


Characters of abortion due to cervical incompetence:
At mid pregnancy.
Sudden gush of painless watery vaginal discharge ,
Followed by VB & pain.

Dx :

Before pregnancy >>> HSG (hystero- salpingio-gram).
During pregnancy >>> U/S.

Cervical Cerclage:

-Time of operation : 14-16 wks.
-Time of removal : 38 wks.

Indications :

Cervical incompetence.
Preterm labor.

Contraindications ( or Indications of removal) :

Bleeding.
Rupture of membranes (PROM).
Missed abortion.
Infection.
Congenital anomalies.


Examination (EX.)

General principles :

Introduce yourself .
Check patient’s identity.
Explain what you intend to do.
Gain consent.
Wash hands.
Chaperone or a nurse.
Stand on the right side of the patient.
Exposed only the part needed for ex.

General EX. ( ABCEP + JACCOL )

ABCDE :
A: age ( young, middle ).
B: built ( thin, average, obese ).
C: conscious level & orientation to time, place & person.
E: expression or look ( pale, dyspnic , in pain , anxious ).
P: position ( sitting , lying on bed ).
JACCOL:
J: jaundice >>> on sun light & ask the pt to look down ( follow your finger) while you elevate the upper eyelids to examin the upper sclera of both eyes for jaundice.
A: anemia: site to be ex. Are :
Conjunctiva.
Mucus membrane of the mouth.
Palm & palmer creases.
Nail for koilonychias.
Capillary refilling time.
Pulse rate.
C: clubbing of the nails.
C: cyanosis , tongue for central cyanosis & hands, tip of the nose for peripheral cyanosis.
O: oedema, stand at the end of the bed & expose pt legs up to the knee, press with both thumb on the shin of the tibia of both legs at the same time ,about 10cm above the medial malleolus for 30-60sec , always look to the pt face not to the pt legs.
L: lymph nodes ex. , cervical L.N.>>> ex. The anterior group (submental, submandibular , preauricular & supraclavicular L.N.) from posterior & posterior group( postauricular & occipital L.N.) from anterior.


Vital signs :
Pulse rate : check rate, rhythm, volume, character ) of radial artery.
Normal PR is 60-90 bpm, regular, of good volume.
Respiratory rate : normally 14-16 cycles /min.
Temperature : normal oral temp. is 37±0.2 °C, when measure axillary temp. add 0.5 °C to the reading, & when measure rectal temp. subtract 0.5 °C from the reading.
Blood pressure:
Pt should be sitting or in semi recumbent position .
Use appropriately sized cuff.
Cuff should be at the level of the heart.
Use palpatory or auscultotary method.
Normal B.pr is : diastolic 60-90mmHg, systolic 100-140mmHg.
In pregnancy diastolic B.pr. indicated by muffling of the sound ( Korotkoff sound IV) because usually sound not disappear ( Korotkoff sound V ).

Systemic EX. :

Head : cloasma , gum hypertrophy, salivery secretion , pallor & check the orifices ( mouth, eyes, nose & ears ).
Neck : L.Ns. ex. , thyroid ex., neck veins & tracheal position.
Chest : breast changes during pregnancy is very important.
Abdomen:
You should expose the pt from the nipples down to the mid thigh but due to social reason expose the pt from xiphisternum down to symphesis pubis.
Pt should be in supine position & one pillow below her head.
Ask about full or empty bladder ?
Abdominal ex include inspection, palpation, percussion & auscultation.
Inspection :
From the end of the bed inspect for shape( flat, distended or scaphoid )& symmetry of the abd & movement with respiration.
From the side of the bed inspect for:
Umbilicus >>> site, shape ( flat, inverted or everted) & any discharge.
Pigmentations & striae .
Scars .
Hair distribution.
Dilated veins.
Epigastric pulsation .
Hernia orifices.
FM.
Palpation:
Superficial palpation for superficial tenderness & mass.
Deep palpation for deep tenderness & mass.
Organomegally.
Note : warm your hands, always look for the pt face & start away from the site of pain, if no pain start from the left iliac fossa in anti clock wise pattern.


Obstetrical Ex.
Ask about abdominal pain?
Loss of patient cooperation.
Ask about full bladder?
Causes large for date uterus in early pregnancy.
Patient discomfort by pressing on full bladder.
It is part of abdominal palpation.
Superficial palpation of the uterus is done at the same time of abdominal superficial palpation (consistency & superficial tenderness).
Deep palpation of the uterus = Leopold’s maneuver.
Always look to the patient’s face to exclude tenderness.

Fundal height : 2 methods :

Symphesis- fundal height (SFH) by using tape measure:
Feel for top of fundus.
Feel for symphysis pubis – GENTLE.
Place tape on symphysis pubis.
Measure to top of fundus.
cm down, then turn tape over.
SFH (cm) = gestation (weeks) ± 2 weeks.

Anatomical landmarks :

Feel for top of fundus with the ulnar border of left hand.
Relate the level of the fundus to the following land marks:
Xiphisternum = 36 wks.
Umblicus = 22 wks.
One finger below the umbilicus = 20 wks.
Just palpable at the pubic symphysis = 12 wks.
Between the umbilicus & xiphisternum is divided by 2 equal points = 28- 32wks & 34 or 40(with fullness of the flunk) wks.
Between the pubic symphysis & umbilicus is divided by 2 equal points = 16 wks & 18 wks.


Small for date uterus :
A uterine size smaller than expected from the LMP.
Causes are:
Wrong dates.
Constitutionally small.
Oligohydramnios.
Intrauterine growth restriction.
Intrauterine death.
Abnormal fetal lie (transverse).
Missed abortion .

Large for date uterus :

A uterine size larger than expected from the LMP.
Causes:
Wrong dates.
Constitutionally large.
Full bladder.
Multiple pregnancy.
Polyhydramnios.
Maternal D.M.
Pelvic tumors, fibroid.
Macrosomic fetus.
H. mole.


Fundal grip :
Palpation of the fundal part.
Used to determine which part of the fetus occupying the uterine fundus.
Head Smooth outline, hard, rounded & ballotable.
Breech Soft, irregular & non ballotable.

Lateral grip :

Palpation of the lateral aspect of the uterus.
Fix one hand & palpate with the other one.
Determine the lie of the fetus (longitudinal or transverse).
Determine the direction of the fetal back
( localize the best site for fetal heart auscultation).

Pelvic grip :

1st pelvic grip :
Palpation of the lower uterine segment.
Using both hands ( parallel to the inguinal ligaments), face is to the pt legs.
Identify the fetal presenting part ( presentation).
Determine engagement of the presenting part (how many fifths are palpable). Engaged is 2/5th palpable. Engagement occur after 36wks in primigravida & at term in multigravida.
2nd pelvic grip :
Using one hand, press the presenting part.
Look to the pt face.
To confirm finding of 1st pelvic grip.


Fetal heart auscultation :
Sonicaid from 14 wks onward.
U/S >>> from 7wks onward.
Pinnard stethoscope from 22 wks onwrad.
The best site for auscultation is over the fetal back, below the umbilicus in cephalic presentation & above the umbilicus in breech presentation.

Describing the findings of obstetric ex. :

A pregnant uterus, about 34 wks size, containing a singleton fetus, longitudinal lie, the back is to the left, cephalic presentation, which is floating & I need a Pinard stethoscope to listen for the fetal heart.

Notes:

If you asked to ex. The abdomen>>>> you should perform both abdominal & obstetrical ex.
If you asked to ex. The gravid uterus >>>> you should start with superficial palpation of the abdomen + obstetrical ex.
If the gestational age is <28wks>>> check the fundal height & fetal heart only.
If the gestational age =>28wks>>> perform all the obstetrical ex.
In case of uterine contraction during ex.>>> wait until the contraction is stopped & assess time of uterine contraction>>> you should mention that during the description.

Post op. EX . of the abdomen :

Same general principles in the obstetrical ex.
Inspect & describe the site of incision .
Palpate site of incision for any tenderness or hematoma collection starting from the umbilicus down ward.
Normally after delivery the uterus will be just below the umbilicus.


Sub Involuted Uterus :
Uterus after delivery is above the umbilicus.
Causes :
Full bladder.
Fibroid.
Ovarian cyst, or any pelvic mass.
Over distension of the uterus before delivery ( multiple pregnancy & polyhydramnios ).
Hematoma.
Retained placenta.
Infection ( acute endometriotis ).