Unit one

Review of anatomy and physiology of female

reproductive system
1.1. Anatomy of female reproductive system
1.1.1. Anatomy of female pelvis
A. Bones of female pelvis- pelvis is made up of three type of bones which are four un number these are:
Two innominate bones
One sacrum and
One coccyx
1. Innominate bones- are the widest bones of the pelvis. Each innominate bone is constituted by the
fusion of three bones namely the illium, ischium and pubis around a cup like cavity called
acetabulem. All the three part of the bone contribute to the acetabulemin the following proportion:
two fifth ilium, two fifth ischium and one fifth pubic bone.
The ilium-is the large flared out part of the pelvic bone. When the hand is placed on the hip it
rests on the iliac crest which is the upper border of the bone. At the front of iliac crest is a bony
prominence known as anterior superior iliac spine. A short distance below it is anterioinferior
iliac spine. There are two similar points at the posterior end of the iliac crest namely the
posteriosuperior and posteriorinferior iliac spines. The concave anterior surface of the ilium is
the called iliac fossa.
The ischium- is the thick lower pare of the innomonate bones. It has a large prominence known
as the ischial tubiresity on which the body rests when setting. Behind and a little above the
tuboresity is an inward projection of the bone called the ischial spine. During labour the station of
the fetal head is estimated in relation to the ischial spines.
The pubis- is the anterior part of the innominate bones. It has a body and two oars like projection,
the superior ramus and the inferior ramus. The two pubic bones meet at the symphysis pubis and
the two inferior rami forms the pubic arch merging in to the similar ramus in the ischium. The
space enclosed by body of pubic bone, rami and ischium is called obturator foramina.
2. Sacrum- is a triangular shaped bone having its base above and its apex below. It is formed by fusion
of five sacral vertebras. The upper border of the first sacral vertebra forms a prominence called sacral
promontory. At the side the side the sacrum has two wings like processes called ala of the sacrum
which articulate with innominate bones. The anterior surface of the sacrum is concave and is referred
to us the hollow of the sacrum. It has four pairs of opening in which nerves that are emerged from the
cauda equine passes through to supply the pelvic viscera called sacral foramina. The posterior
surface of the sacrum is roughened to receive attachments of muscle.
3. Coccyx- is formed by the fusion of four vertebrae and it articulate superiorly with tip of sacrum.
B. Joints of the pelvis- there are four joints with in the pelvis that joins the four pelvic bones in to one.
Two sacroiliac joint
One symphisis pubis
One sacro coccygeal joint
The sacroiliac joint-is a joint in which the sacrum is articulated with the innominate bones. It is
the strongest joint in the body.
The symphisis pubis- is a cartilaginous joint formed by the junction between the two pubic bones
along the mid line.
The sacro-coccygeal joint- is formed where the base of coccyx articulate with the tip of the
sacrum. It has a great obstetric importance during delivery. During pregnancy the hormone
progesterone relaxes the ligaments and allows greater mobility and increase the available space in
the pelvis.
C. Pelvic ligaments- each of the pelvic joints is held together by ligaments for example:
q Inter pubic ligament at the symphysis pubis
q Sacroiliac ligament at the Sacroiliac joint
q Sacrococcygeal ligament at the Sacrococcygeal joint
There are two important ligaments important in obstetrics
q Sacrotuberous ligament- runs from the sacrum to the ischial tuberosity and
q Sacro spinous ligament-from the sacrum to the ischial spine.
D. Parts of the pelvis-the female pelvis consists of two parts; the false pelvis and the true pelvis.
False pelvis- is the part of the pelvis above the pelvic brim. It is formed by the upper flaired
out part of the iliac bones and it does not play any significant role in the process of child
birth.
True pelvis- is the true bony birth canal through which the baby must pass during birth. It
has a brim, a cavity and an out let.
1. The pelvic brim- id rounded except where the sacral promontory project in to it. The promontory
forms its posterior border, the iliac bones its lateral border and the pubic bones its anterior border.
The nurse needs to be familiar with the fixed points on the pelvic brim which are known as land
marks. Starting from the posterior these are:
O Sacral promontory
O ala of the sacrum
O Sacro-iliac joint
O Iliopestineal line
O Iliopectinial eminence
O Superior ramus of pubic bone
O Upper inner border of the body of pubic bone
O Upper inner border of symphysis pubis
Diameters of the brim- there are three type of diameters measured with in the pelvis.
- The anterioposterior diameter- is a line from the sacral promontory to the upper border of
symphysis pubis. When the line is taken to the upper most point of symphysis pubis it is
called the anatomical conjugate and is 12cm. when it is taken to the posterior border of the
upper part of sumphysis pubis it is called the obstetric conjugate (true conjugate) and
measured to be 11cm. the obstetric conjugate tells us the true available space for the passage
of the fetus. The diagonal conjugate is also measured anterio posteriorly from the lower
border of the symphsis pubis to the sacral promontory. It may be estimated per vaginum as
part of pelvic assessment and should measure 12-13cm.
- The transverse diameter-is a line between the points furthest apart on the iliopectineal lines
and measures 13cm.
- The oblique diameter- is a line from one sacroiliac joint to the iliopectineal eminence on the
opposite side of the pelvis and it measures 12cm. There are two oblique diameters each takes
its name from the sacroiliac joint it arises that is, the left oblique diameter arises from the left
iliac joint.
2. The pelvic cavity- extends from the brim above to the out let below. The anterior wall is formed by
the curve of sacrum which is 12cm in length. The cavity is circular in shape and although it is
difficult to measure its diameters exactly they are all considered to be 12cm.
3. The pelvic out let there are two out lets in the pelvis; the anatomical and obstetric out let. The
anatomical outlet is formed by the lower border of each bone; lower border of symphysis pubis, the
ischial tuberosity, and the tip of the coccyx while the obstetric out let is formed by the lower border
of symphysis pubis, the two ischial spines, and the sacro coccygial joint. The obstetrical out let has
great obstetric significance because it is the narrow pelvic outlet through which the baby must pass.
This out let is a diamond shape and its three diameters are as follows.
- The anterioposterior diameter- is a line from the lower border of symphysis pubis to the
sacrococcygeal joint. It measures 13cm.
- The oblique diameter- is said to be between the obturator foramina and the sacrospinous
ligament although there is no fixed point. The measurement is taken to be 12cm.
- The transverse diameter- is a line between the two ischial spines and measures 10-11cm. it is
the narrowest diameter in the pelvis.
E. Types of pelvis- can be grouped in to four categories according to the shape of the pelvis brim.
O The gynacoid pelvis is the ideal pelvis for child bearing. Its main feature are rounded brim,
straight side wall, shallow cavity with a broad, well curved sacrum, blunt ischial spine, a wide
sciatic notch and pubic arch of 90
o
. It is found in women of average build and height.
O The android pelvis- is so called because it resembles the male pelvis. Its brim is heart shaped. It is
found in short and heavy build women who have a tendency to hirsute. This type of pelvis
predisposes for OPP (ociputoposterior position) and is least suited for child bearing.
O The anthropoid pelvis has long oval brim in which the AP diameter is longer than the
transverse. Women with this type of pelvis tend to be tall with narrow shoulder. Labour does not
usually present any difficulty.
O The platiploid pelvis- is flat with kidney shaped brim in which the AP diameter is reduced and the
transverse one increased. In this type of pelvis the head must engage with the sagital seture in the
transverse diameter but descends with the pelvic cavity with out any difficulty.
NB:-keeping all the above measurements in mind the fetal head is the best pelvimeter.
1.1.2.Anatomy of genital organs
A. External genitalia (syn: vulva, pudendum)- is a term used to describe the externally visible pat of
female genitalia and is composed of mones pubis, labia majora, lavia mainora, clitoris, vestibule and
perineum. This vulva is bounded by mones pubis anteriorly, labua majora laterally, and the perineum
posteriorly.
Mons pubis (monis veneris) - is a pad of subcutaneous fatty tissue above the pubic bone. In adults
it is covered by pubic hair in an inverted triangle fashion.
Labia majors- are also called the greater lips of vagina. They are an elevation of skin and
subcutaneous tissue arising from monis pubis anteriorlly and will fuse medially to form the
posterior commeasure. It contains the sebaceous gland and the hair follicule. It is richly supplied
with venous plexus and it is homologus with scrotem of male.
Labia manors- are also called the lesser lip of vagina. It is a thick fold of skin devoid of fat lying on
either sides and with in the labia majora. It is composed of two devided lip that will fuse at some
points with in the vulva for example the upper part of labia minoras fuses in front and behind the
clitoris to form pre puse and franulem respectively and the lower part of labia manor fuse
posteriorly to form forchette. Alike the labia majoras it doesnt contain hair follicle and it is
homologues with the veneral aspect of penis.
Clitoris- is a small cylindrical erectile body situated in the most anterior part of the vulva. It
consists of glans, body, and two crura. The glans is richly supplied with nerves. Clitoris is
homologues with penis of male.
Vestibule- is a triangular space bounded by clitoris anteriorly, forchette posteriorly, and the two
labia majors laterally. There are four openings with in the vestibule.
1. Urethral opening- mid line just in front (above) the vaginal orifice.
2. Vaginal orifice- is an opening situated in the posterior end of the vestibule and it is of varying
size and shape. In virgins, it is incompletely closed with septum of mucus membrane called
hymen. The membrane will rupture during six, child bearing and rarely during stranious
exercise. There are different types of hymen.
3. Openings of bartholins gland- bartholins glands are two pea sized glands situated on either
sides of the vaginal orifice. During sexual excitement it secret an alkaline mucous which helps
in lubrication. Each gland has got a duct that opens in the vestibule out side the hymen opening
but with in the labia minora. It is homologues with the bulbo urethral gland of the male.
Perineum- is the area located between vagina and anal opening
B.Internal genitalia: - these are genital organs that are not visible in the normal circumstance that means
they need special instrument for inspection. They include vagina, uterus, fallopian tube and ovary.
Vagina: - is a fibro-muscular membranous sheet communicating the uterine cavity with the external
environment at the valve.
Position-The canal of vagina is upward and backward forming 90% with cervix and 45
0
with the
horizontal in erect position. The diameter of the canal is about 2.5 cm being wider in the upper
part and narrow at the introits.
Function of vagina: - is excretory channel for the uterine secretion and menstrual blood
- Is the organ of copulation
- It forms the birth cannel of parturition.
Walls: - vagina has get and anterior, posterior and two lateral walls. The length of the anterior
wall is about 7cm and that of posterior wall is 9cm
Farnices: - the projection of cervix through the anterior vaginal wall at the top of vagina forms a
cleft known as fornices. There are four fornicel (anterior , posterior and two lateral), the posterior
one being deeper and the anterior one is the most shallow.
Layer: - the vaginal wall is composed of 4 layers. The four layers from within to out ward are:
1. Mucous layer: - is lined by stratified squamous epithelium with out any secreting
gland.
2. Sub mucus layer
3. Muscular layers:- consist of inner circular and outer longitudinal
4. Fibrous coat
Epithelium: - the vaginal epithelium is under the action of sex hormone especially estrogen.
+ At birth and up to 10-14 days, the epithelium is stratified squamous under the action of
maternal estrogen circulating in the newborn
+ Form puberty till menopause the vaginal epithelium is stratified squamous and is composed
of 3 district layers; the basal call, intermediate call and superficial call. The intermediate
and superficial cells contain glycogen. The superficial calls exfoliate constantly and
replacement occurs from basal calls when they become exposed to the dry external
environment during which karatinization will occur. Unlike it does not contain hair follicle,
sweet and sebaceous gland.
Secretion:- the vaginal secretion is vary small in amount but it become little excess
During mid menstrual or just prior to menstruation,
During pregnancy and
During sexual excitement
The pH of the vagina- ranging form 4- 5.5 the average being 4.5 secretion is acidic but it varies
during phases of life. The acidic nature of vaginal is because of the conversion glycogen to lactic
acid by the red shaped bacteria known as dodarils bacillus which is dependant on estrogen.
Relations
Antariarly :- it is related with the upper base of bladder and urethral
Postariarly:- it is related with rectal wall separated with pouch of Douglas, recto
vaginal septum & perennial body
Superiorly:- it is in relation with the uterus specially cervix
Uterus: - is hallow muscular organ situated within pelvic cavity
Parts: - the uterus has three parts which are:
1. Body or corpus: - is apart of uterus found above the isthmus and is further divided in to
fundus (dome shaped part that lies above the opening of the tubes) and body proper (a part
found b/n the opening of the tube and the isthmus). carnua is the upper outer angle of the
body and it is the site of attachment for fallopian-tube, round ligament and ovaries ligament.
2. Isthmus:- is the constricted part b/n the body and cervix
3. Cervix: - is the lower most part of the uterus which is cylindrical in shape. it is divided in
to supra vaginal part, a part that lies about the vaginal and a vaginal part, a part found with in
the vagina each measuring 1.25 cm. in null parous the vaginal parts is conical with the
external 0s looking circular where as in parous it cylindrical with the external as having
bilateral slit, a slit formed by the damage of inner circular muscles of cervix during child
birth which will form anterior and posterior lip of cervix.
Structure of the uterus: - the wall of the body of the uterus consists of three layers the layers. The
layers from outside to in ward are:
1. Perimetrium: is a double serous membrane that is an extension of the partition , which
cover all but narrow strip on either side and anterior wall of supra vaginal cervix from where
it is reflected up over the bladder
2. The myometrium:- is a thick burner of smooth muscle arranged in outer longitudinal
which is continuous with uterine tuba , uterine ligament and vagina ;middle uterine tuber,
3. The endometrium- is the mucus lining of the cavity of the uterus.it consists of
laminaproper and surface epithelium. The surface epithelium is ciliated simple columenar
while the lamina proper contain stromal cells, endometrial gland , vessels and nerves. During
the time of pregnancy the endometrium is called deciduas. The cervix is mainly composed of
fibrous connective tissue only 10-15%is smooth muscle,the endocervix is lined by tall
columenar epithelium while the exocervix or the vaginal part is covered by stratified
squamous epithelium. Between the two there is a space which consists of endocervical glands
and stroma covered by squamous epithelium which is known as squamocolumnar junction or
transitional zone.the zone is not static rather it changes with hormonal level of estrogen. This
site irritated not only by estrogen but also by infection and trauma. Thus there is a high risk
of CIN or even invasive cancer.
Secretion- the endometrial secretion is scanty and watery while the physical and chemical
property of cervical secretion changes with menstrual cycle and with pregnancy.the cervix secrets
alkaline mucus with PH of 7.8 which is rich in fructose, glycoprotine and muco polysacride. The
fructose has nutritive value for the spermatozoa.
Relation of the uterus
Anteriorly-it is related with the bladder and uterovesical pauch.
Posteriorly- it forms the anterior wall of the pouch of dogulas
Laterally- it is related with broad ligament
Position of the uterus- the normal position of the uterus is anti version (the long axis of the uterus
especially the cervix makes 90
0
with the long axis of the vagina which means it leans forward)
anti flexion (the long axis of the body of the uterus forms 120
0
with the long axis of the cervix
which means it is curved by itself at the level of internal os)
Function- mainly the uterus shelters the fetus during pregnancy and it expels its content when it
is contracted during labour.
Support of the uterus-the uterus is supported by pelvic floor and maintain in position by several
ligaments of which those at the level of cervix are the most important.
The transcervical ligament- is some times known as cardinal ligament. It runs out from the
side wall of pelvis to side wall of cervix.
The uterosacral ligament- passes backward from cervix to the sacrum.
The pubocercical ligament- passes forward from cervix under bladder to the pubic bone.
The broad ligament- is a double fold of peritoneum which spreads from the side of the
uterus to the lateral pelvic wall of the pelvis.
The broad ligament- arise from cornua and passes through broad ligament inserted in labia
majora. They have little value as a support but used to maintain the antiverted position of the
uterus.
Fallopian tube (syn:uterine tube or oviduct)- are paired structure found in the pelvic cavity. Each
tube has got two opening one communicating with the uterine cavity called the uterine opning and the
other on the lateral end of the tube called pelvic opning or abdominal ostium.
Parts- the tube has four parts. The part from medial to lateral are:
1. Intramural (interstitial) - is the part that lies in the uterine cavity.
2. Isthmus
3. Ampula- is the widest part through which fertilization occur.
4. Infundibulem- is the lateral end of the tube.
The abdominal ostium of the tube is surrounded by a number of finger like projections called
fimbria. One of which is longer than the other and is attached to the outer pole of the ovary called
the ovarian fimbrea.
Structure of the tube- the tube consists of three layers.
1. Serous coat
2. Muscular layer- arranged in inner circular and outer longtudnal fasion.
3. Mucous membrane-which is lined by partially ciliated and non ciliated columnar
epithelium.
Function-the important function of the tube are:
- Transporting male gamete to the site of fertilization and zygote to the uterine
cavity by its cilliary function.
- Nourish and protect the zygote
Ovaries- are paired sex glands or gonads in the female which are concerned with two function.
Maturation and release of ovum
Steroidogenesis
Relation
- Anteriorly the ovary is attached to the posterior wall of the broad ligament by mesovarium
- Posteriorly it is free
- Laterally it is attached to the cornua and pelvic wall by ovarian and suspensery ligaments
respectively.
Structure- the ovary is covered by single layer of cubical cel known as germinal epithelium. The
ovary consists of the outer cortex and inner medulla. The cortex is the functional unit of the ovary
and it is composed of primordial follicle, primary follicle, secondary follicle, mature (graafian
follicle), corpus luteum and corpus albican. While the medulla consists of losse connective tissue,
muscle, blood vessel and nerve.
1.1.3. Anatomy of fetal skull
The fetal head is the most difficult part to deliver weather it comes first or last. It is large in comparison
with the pelvis and some adaption must be take place during labour. An understanding of the landmarks
and measurements of the fetal skull enable the nurse to recognize the normal presentation and position
and to facilitate delivery with least trauma to the mother and the fetus.
A. Bones of the fetal skull- the skull is divided in to three regions the vault, the base and the face.
1) The vault- is the large dome shaped part above the imaginary line drowns from the orbit to the
nape of the neck. There are five main bones in the vault of the fetal skull.
One occipital bone- lies at the back of the head and forms the occipital region. At the center
of this bone is a prominence called occipital protuberance. Below this prominence there is a
large opening for the passage of spinal cord called foramen magnum.
The two parital bones- lie on either side of the skull. At the center of each parital bones there
is an ossification center called parital eminence.
The two frontal bones- lie on the front of thr skull and forms the forehead or sinciput. At the
center of each is frontal eminence (frontal boss) which is the ossification center of these bines.
The frontal bones fuse in to one bone by the age of 8 years.
2) The face
3) The base
B. Sutures of fetal skull- sutures are cranial joints which are firmed where two bones adjoin. There are
several sutures in the fetal skull. That of the most obstetric important ones are:
q Lambdoidal suture- is so called because it resembles the greek leter lambda ( ). It separates the
occipital bone fron the two parital bones.
q Sagital suture- lies between the two parital bones.
q Coronal suture- separates the frontal bones from the parital bones.
q Frontal suture- rummes between the two halves of the frontal bone.
C. Fontanelles- are membranious gaps between skull bones formed where two or more suture meets.
There are two major fontanels in the fetal skull.
Posterior fontanelle (lambda)- is the small triangular junction of sagital and lambdoidal sutures.
It can be recognized vaginally because sutures leave from each of the three angles. It normally
closes by the age of 6 weeks.
Anterior fontanelle (bregma)- is a diamond shaped fontanel found at the junction of sagital,
coronal and frontal sutures. It also can be recognized vaginally because a suture leave from each
of the four corners. It normally closes by the time of 18 months.
Advantages of sutures and fontanelles
Because they consist of membraninos space, they allow some degree of overlapping of the
skull bones during labour and delivery the process called moulding.
Are used as land mark to identify the presenting part and position of the fetus during
cephalic (head) presentation.
D. Region and land markes of the fetal skull
The occiput- is a region between foramen magnum and posterior fontanelle. The part below the
occipital protuberence is called the suboccipital region.
The vertex- is the area bounded by the posterior fontanelle, the two parital eminence and anterior
fontanelle. It is the most common and normal presenting part of the fetus (95%).
The sinciput or brow- extends from the anterior fontanelle and coronal suture to the orbit ridg.
The glabella- is the part between the eye brows.
The mentum- is the medical name of chin.
The face- extendes from the orbit ridge to the junction of neck and chin.
E. Diameters of the fetal skull- the measurement of the skull are important because a nurse need a
special understanding of the relation ship between fetal head and maternal pelvis. It will become clear
that some diameters are more favorable for easy passage through pelvis canal.
O Transverse diameters- there are two transverse diameters.
- Bi parietal diameter- is a diameter between the two parietal eminences and is measured to be
9.5cm.
- Bi temporal diameter- is between the furthest point of the coronal suture and is measured to be
8.2cm.
OAnterioposterior or longitudinal diameter
- Suboccipito bregmatic- is from the below of occipital protuberance (sub occipital region) to
the center of bregma. It is measured to be 9.5cm.
- Sub occipito frontal- is from the below of the occipital protuberance to the center of frontal
suture. It measures 10cm.
- Occipitofrontal- from the occipital protuberance to the glagella. It is 10cms long.
- Mento vertical- is from the point of the chin to the highest point of vertex (slightly nearer to
kposterior than anterior fontanelle). It measure the longest diameter in the skull which is
13.5cm.
- Submento vertical- is from the point where the chin joins the neck to the highest point on the
vertex. It is 11.5cms long.
- Submento bregmatic- is from the point where the chin joins the neck to the cnter of bregma. It
is 9.5cms long.
F. Attitude of the fetal head- is the relation ship berween the long axis of the body of the ferus with
fetal head. It is a term used to descrihe the degree of flexion and extension of the head on the neck.
The attitude of the head determine which diameter and part will present in labour and there fore
influence the out come. For example when the head fully flexes, the vertex presents and the
presenting diameter will be suboccipito bregmatic. Flexion of the fetal head enable the smallest
diameter possible resulting in easear labour.
G. Presenting diameters- are diameters of the fetal head at right angle with the curve of carus.
H. Presenting- is part of the presenting part (mostly the head) which lies first at the brim of the pelvis on
the lower pole of the uterus. The most common presentation of the head are:
Vertex presentation
Brow presentation and
face presentation
1.2. Physiology of female reproductive system- The physiology of female reproductive system is
mainly dependant on the action of the three organs the hypothalamus, pituitary, and ovary commonly
known as the H-P-O axis. All must function appropriately for normal reproduction to occur.
1. Hypothalamus- is a small neural structure situated at the base of the brain above the optic chiasm
and below the third ventricle. the hormonal products of this gland are:
Gonadotrophic releasing hormone (GnRH) - is concerned with the release of FSH and LH
from pituitary.
Thyrotrophic releasing hormone (TRH)- stimulate the release of TSH
Corticotrophin releasing hormone (CRH)-stimulate the release of ACTH
Growth hormone releasing hormone (GHRH)- stimulate the release of GH
Prolactine releasing hormone (PRH)- stimulate the release of prolactine
Prolactine inhibiting factor (PIF)- inhibits the release of prolactine
Somatostatine- inhibit GH and TSH secretion
2. Pituitary- is suspended from the hypothalamus by a stalk called infundibrum and is housed in
selaturcica of the sphenoid bone. It is composed of two structures, the amterior lobe also called the
adeno hypophysis and the posterior lobe also called neuro hypophysis.
The anterior lobe (adeno hypophysis) - constitute the anterior of the pituitary. Because it is
connected to the hypothalamus by blood vessels (hypophysusl portal system), it synthesizes and
secret six principal hormones by the command of the hypothalamus.
Follicle stimulating hormonr (FSH)
Lutenising hormone (LH)
Thyroid stimulating hormone (TSH)
Adreno cortico tropic hormone (ACTH)
Growth hormone (GH) and
Prolactin(PRL)
The posterior lobe (nurohypophysis)- constitute the posterior of the pituitary. It is not a true
gland rather a mass of nuroglia and nerve fibers that arise from the cell body in the hypothalamus.
The hypothalamus neurons synthesize, transport them down a stalk and store them in the posterior
lobe. Finally the posterior lobe releases them when command arises.
Oxytocin- read the function
Arginine-vasopressin (AVP) also known as anti-diuretic hormone (ADH).
3. Ovaries- are both endocrine and exocrine glands. Their exocrine products are eggs and their
endocrine products are:
Estrogen by the granulose cell of the ovary
Progesterone also by the granulose cell of the ovary
Androgen by theca cells of the ovary
Inhibin and relaxin
1.2.1. Puberty
During early time of pregnancy the two sexes are indistinguishable. But after 8 to 10 wks the two female
reproductive tracts develop from the para mesonephric duct because of the absence of testestrone and
mulerian inhibiting factor (MIF). During the time of birth the ovarian cortex contains one to two million
oocytes with in primordial follicles but they are dormant till the time of sexual maturity.
From infancy onwards the hypothalamus is very much sensitive to negative feedback by even a small
amount of estrogen (estrogen produced by peripheral conversion of testestrone produced by the adrenal
gland) hence FSH and LH secretion are inhibited. But approximately around age of 12-13years, the
hypothalamus is very much insensitive to the negative feed back. Hence increased amount of GnRH will
be secreted by it. This will stimulate the pituitary to secret:
FSH and LH- which intern stimulate the ovary to secret estrogen and progesterone.
GH- which will either directly act on muscle and bones or will act on the liver to stimulate the
secretion of (IGF) insulin like growth factor.
This will eventually results in dramatic growth of the body of the girl and maturation of the reproductive
organs. This stage of spurt growth and maturation is called puberty. It is a stage of life in which
secondary sexual characteristics develop.
Although there is a wide variation in the time that adolescents move through developmental stages, the
sequential order however is fairly constant. In girls the pubertal changes typically occur in order of:
1) Marked physical change
2) Increase in the transverse diameter of the pelvis
3) Telarche, the development of the breast
4) Adrenarche (pubarche), the appearance of pubic and axillary hair and finally
5) Menarche, onset of vaginal menstruation.
1.2.2. Menstrual Cycle
Menstrual Cycle is the orderly cyclic hormone production and parallel proliferation of the uterine lining
prepare it for implantation of the embryo. The normal human menstrual cycle can be divided into two
segments: the ovarian cycle and the uterine cycle, based on the organ under examination.
A. The ovarian cycle- is the cyclic hormonal changes and other serious of changes that occur in the
ovary to mature the immature follicle and recruit the oocyte. It may be further divided into:
q Follicular phase extends from the beginning of menstruation (day 1) to the onset of ovulation. The
average length of the human follicular phase ranges from 10 to 14 days, and variability in this
length is responsible for most variations in total cycle length. the principal processes in this phase
are:
1) Rise in FHS secretion stimulates 20 to 25 primordial oocytes to begin meiosis I.
2) The follicle around the oocyte develop and become primary follicle the cell of the follicle
further enlarge and become condensed to form teca folliculi. Its other layer the teca externa,
become fibrous capsule while the internal layer, the teca interna, secrets androgen which the
granulose cell the granulasa cells convert it to estrogen.
3) In fewer day of the follicular phase the follicular cells began to secret estrogen rich follicular
fluid. Thus the follicle will form a fluid filled cavity called antrum. The follicle is now called
secondary or antral follicle and follicular cells lining it are called granulose cell. The
granulose cell secrets a clear layer of gelll between themselves and the oocyte called zona
pelucida. The inner most layer of the granulose cell in contact with the zona pelucida is
called corona radiate, this is a state of development around 5 days.
4) The growing follicle secret increasing amount of estrogen which at same time reduces FSH
secretion by pituitary and makes the follicle more sensitive to FSH by producing increasing
amount of FSH receptors on the granulose cell of its own follicle. FSH intern stimulates this
follicle to produce still more amount of estrogen but the most advanced follicle reduce FSH
supply to other follicles while at the same time it makes itself more sensitive to FSH.
5) The less developed, less sensitive follicle undergoes atresia while the most developed follicle
protrudes from the surface of the ovary like blister. This follicle is called mature (graafian)
follicle.
6) As the follicle mature the primary oocytes complets meiosis I and become secondary oocyte.
This cell began miosis II but it stops at metaphase II. The ovum is now ready for ovulation.
7) FSH and estrogen stimulste the mature follicle to produc the LH receptors.
8) In the last one or two day of the follicular phase because the estrogen level is very high it
stimulate the anterior pituitary LH the hypothalamus to secret GnRH which intern stimulates
the anterior pituitary to secret FSH and LH because of this the LH level will increase
markedly 36 hours before the time of ovulation and is called LH surg.
9) The LH increases the blood flow to follicle allowing more serous fluid from the capillary to
the antrum which causes the follicle to swell. Meanwhile LH also stimulate the teca interna
to secret collaginase (lytic enzyme), an enzyme that weakens the ovarian wall.
10) Follicular fluid slips from the nipple like appearance on the ovarian surface over the
follicle for 1-2 min and then the follicle rupture. This process is called ovulation. The
remaining fluid oozes out carrying the oocyte and the surrounding cells of corona radiate.
q luteal phase (post ovulstory phase) extends from ovulation to the beginning of menstruation.
Unlike the follicular phase this phase is most predictable and constant (14 days) in length. the major
development of this phase assuming pregnancy does not occur are as follows:
11) After the follicle expels the oocyte to the fallopian tube, it collapses and the granulose and
teca interna cells multiply to fill the antrum. The ovulated follicle now become corpus luteum
(yellow body)
12) The anterior pituitary continues to secret LH which regulates the further growth of corpus luteum.
13) The cprpus luteum produce mainly androgen which the granulose cells of the ovary convert to
progesterone and small amount of estrogen. The corpus luteum also secret innhibin which suppresses FSH
secretion which prevents new follicles development.
14) The corpus luteum grows secret more and more progesterone but if there is no sexual
intercource in this period, the increased amount of progesterone will inhibit LH and FSH
secretion by negative feed back. When the LH level falls critically low, the corpus lutem
involutes or atrophy (24-26 day). The atrophy of corpus lutem will result in decline of
progesterone secretion. By the day 26 or so, the atrophy completes and the corpus lutem has
become an inactive scar called the corpus albican.
B. The uterine cycle- is the periodic endometrial growth to prepare itself for the implantation of the
fertilized ovum. it can be divided into corresponding proliferative and secretary phases.
q Proliferative phase- is the time from first day of menstrual flow till ovulation which is
characterized by rebuilding of the endometrium but the true proliferation is from the end of
menstruation. the principal processes in this phase are:
O At the end of menstruation (at around 5
th
day), the endometrium is about 0.5cms thick
and consists of only stratum basalis. The stratum functionalis is bult by this phase by
mitotic division.
O Estrogen from the ovary stimulates the mitotic division of the stratum basalis and the proliferative
growth of the blood vessels.
O Estrogen also stimulates the endometrium to produce progesterone receptors to prepare itself for
the next phase. Now the endometrium is about 2-3cms thick.
q Secretary phase- is a period of further endometrial thickening. It extends from day 15 (after
ovulation) to the onset of menses. The principal processes in this phase are:
O The corpus lutem formed after ovulation secrets progesterone. Progesterone stimulates the glands
of the endometrium to accumulate glycogen. The endometrial gland become longer, wider and
more coiled and secret a glycogen rich fluid in to the lemun.
O Know (at around 26
th
day)m, the endometrum is about 5-6 cm thick, asoft, wet, nutritious bed
available for embryonic development in the event of pregnancy.
O In the absence of pregnancy, the corpus luteum atrophies and progesterone level falls sharply. In
the absence of progesterone the spiral artery of the endometrium exhibits spasmodic contraction
that causes endometrial ischemia. Ischemia leads to tissue necrosis.
O Necrotic endometrium falls away from the uterine wall, mixes with blood in the lemun and forms
the menstrual fluid.
Menstruation- is a periodic sloughing of endometrium which accompanied by bleeding.A Menstruation
to be normal:
The cyclic length must be 21 to 35 days on average 28 days
The duration of flaw must be 2 to 7 days on average 5 days
The amount of blood loss must be 10 to 80 ML on average 30 ml
The color of the bleeding must be dark red.
1.2.3.Fertilization- is the process of union of sperm (male gamete) and ovum (female gamete). It
occurs in the ampula of the tube. When the sperm encounters an egg it releases an enzymes needed to
penetrate the egg. The two acrosomal enzymes are:
Hayaluronidase- which digests the hayaluronic acid that binds the granulose cells together &
Acrosin- which is a protease
When the path has been cleared, the sperm binds to zona pellucida and release its enzyme, digesting it
until it contacts the egg itself. When it reaches the egg the head and mid pice will enter to the egg but the
egg destroys the mitochondria of the sperm and only the maternal mitochondria will pass to the offspring.
The two nucleuses will fuse combining the haploid (n) set of chromosome of the sperm with the haploid
chromosome of the egg producing a cell with a diploid (2n) set of chromosome called zygote.
After fertilization of the egg by sperm, the zone reaction prevents entry of any more sperm. The egg has
two mechanisms to prevent this, the sloe block and the fast block.
a) Fast block- the binding of a sperm to the egg will open the Na
+
channels of the egg membrane.
The rapid inflow of Na+ ion depolarizes the membrane that inhibits the entry of any more sperm
to it.
b) Slow block- involves secretary vesicles called cortical granules just beneath the membrane. Sperm
penetration triggers a cortical reaction in which the cortical granules release their secretion
beneath the zona pellucida. The secretion swells the membrane and pushes any remaining sperm
away from the egg and creates an impenetrable membrane.
1.2.4.Development of the fertilized ovum (zygote) - the prenatal development of the fertilized ovum
goes through three phases.
1. Ovular or germinal phase- it extends from the time of fertilization for the next 2 weeks. During this
period the zygote is designated as ovum. This phase involves three major processes cleavage,
implantation and embryogenesis.
A. Cleavage-refers to the mitotic division that occurs in the 1
st
3 days. The 1
st
cleavage occurs about 30
hours after fertilization and produces two daughter cells called blastomer. These blastomers divide
and re divide doubling the number of blastomers each times by the time the zygote reaches the
uterus (about 72 hour after ovulation), it forms a cluster of cells consisting of 160 or more cells and
is now called morula. For few days the morula lies free on the uterine cavity and divides in to 100 or
so. During this time it is nourished by nutrients that were stored in the egg cytoplasm and
endometrial secretion called uterine milk. During this nourishment the morula will form a fluid filled
cavity which separates the cells inn to two groups.
The outer cell mass- is also called trophoblast. It lines the inside of the zona pellucida. In the
future they will form the placenta and chorion.
The inner cell mass- the remaining cells clumped together at one end forming the inner cell
mass (embryo blast) which will become fetus and amnion. A cavity appears between these two
groups of cells. The zygote is now called blastocyst. The zona pellucida thins out and
disappears and the trophoblast especially the part which lies over the inner cell mass becomes
sticky.
B. Implantation- about 6 days after ovulation, the blastocyst attaches to the endometrium usually on
the posterior wall of the fundus. This is the beginning of the imbedding of the blastocyst in to the
endometrium a process called implantation (nidation). The most important steps are
The trophoblastic cells adjacent to the inner cell mass separate in to two layers. The deeper
layer contains cells divided by membrane and is called cytotrophoblast. the superficial
layer however break down their plasma membrane and fuse in to a multi-nucleated cell
called syncytiotrophoblast which will grow in to the uterus like roots and digest
endometrial cells along the way.
The trophoblast forms finger like projection around all surface of blastocyst called
chorionic villi. The villi at the site of embedding become profound and branches rapidly to
form chorionic frondosum which will penetrate deeper in to the underlying endometrium to
eventually form placenta. The chorionic villi over the rest of the blastocyst gradually
degenerate to form chorionic leve.
The cytotrophoblast also secret a hormone called human gonadotrophic hormone (HCG)
which is responsible to inform the corpus luteum that pregnancy has began so that it will
continue producing estrogen and progesterone.
Progesterone maintain the integrity of the endometrium so that shedding does not takes
place, in other words menstruation will be suppressed.
High level of estrogen and progesterone suppresses the secretion of FSH so that no other
follicles will not grow and ovulation will suppressed.
As the trophoblast will be converted to chorion by the end of 2 month, the chorion will take
over the function of trophoblast as well as corpus luteum meaning the ovary becomes
inactive for the rest of the time.
C. Embryogenesis- during implantation the inner cell mass (embryo blast) undergoes arrangement of
the cells in to three primary germ layers: ectoderm, mesoderm and endoderm. This process is called
embryogenesis. Embryogenesis began with the inner cell mass and cytotrophoblast called amniotic
cavity. As the amniotic cavity formed the embryo blast flattens in to an embryonic disc composed of
ectoderm and endoderm. Later, as the disc elongates, a raised groove called the primitive streak
forms along the midline of the ectoderm. Cells on the surface of the ectoderm migrate medially
towards this groove and laterally between the ectoderm and endoderm. At the conclusion of the
embryogenesis the conceptus become 2 mm long and 2wks old and is now called embryo.
2. Embryonic phase- lasts from the 2
nd
wk to 8
th
week of amenorrhea or 6 wks post ovular. This is a
period of cell division and tissue differentiation. This phase also involves three major processes.
A. Placentation- is the process of formation of placenta which extends from 11
th
day through 12
weeks after conception. Most developments of this process occur in the embryonic stage. It
begins where extension of the syncytotrophoblast, called chorionic villi; penetrate more and more
deeply in to endometrium like the root of the tree penetrating in to the nourishing soil. As they
digest their way through uterine blood vessels the villi become surrounded by pool free blood that
eventually merge to form the placental sinus and ensure nourishment of the zygote.
The mature placenta is a fleshy discoid organ. It has two surfaces:
1) Fetal surface, the surface facing the fetus is smooth and the amnion covering this surface
give it a white color. Under the amnion the fetal blood vessels merges out ward at the
center of this surface forming the umbilical cord. The cord is sheathed by amnion and it
measure 35-50 cm in length. It contains two umbilical arteries and one umbilical vein.
2) Maternal surface, the surface attached to the uterine wall is rough and the mother blood
gives this surface a dark color. It is divided by sulcai in to 15 to 20 cotyledons.
Function of placenta
O Nutritive- it provide the embryo with nutrient like amino acid, glucose, fatty acid, H2O,
mineral and vitamin from maternal blood to fetus.
O Respiratory-it fevers gas exchange(provide O2 to the fetal circulation and removes CO2
from the fetal circulation)
O Excretory- it helps to clear the fetal metabolic wastes like urea and uric acid and bilirubun.
O Protection- placenta provides a limited barrier to infection with the
exceptions: T.palidum (syphilis), TB and all viruses.
- It transports maternal antibody especially IgG.
O Endocrine- placenta synthesize many hormone like:
- HCG (human chorionic gonadotrophin)
- Estrogen
- Progesterone
- Human placenta lactogen (HPL)
O Storage the placenta metabolizes glucose, stores it in the form of glycogen and reconverts
it to glucose as required. The placenta can also store nutrients such as CHO, protein, Ca,
Fe and fat soluble vitamins in early pregnancy and release them to the fetus later when
fetal demand is greater than the mother can absorb from diet.
B. Development of embryonic membrane- the placenta and umbilical cord are not the only
accessory organs of the conceptus. There are two membranes that surround the fetal sac.
1) The amnion- it is the inner most of the two membranes. It is a transparent sac that develops from
the dorsal amniotic cavity of the embryonic disk. It grows to completely enclose the embryo and
is penetrated only by umbilical cord. it becomes filled with amniotic fluid which is at first formed
by ultra filtration of mothers blood plasma but beginning at 8 to 9 wks the fetus urinate in to the
amniotic cavity about once an hour contributing substantially to the fluid volume. Secretions of
pulmonary epithelium and amnion cells also have some contribution.
Composition of amniotic fluid- amniotic fluid is a straw colored mid alkaline turbid fluid. It
contains 98-99% water and 1-2% solid constitutes. These include protein, glucose, lipid,
hormone, fetal metabolic wastes like urea, uric acid, creatinin and minerals like Na+, K+ and Cl-.
Function of amniotic fluid-
1. It allow free movement and growth of the fetus
2. Protect the fetus from injury
3. Maintain constant T
o
around the fetus
4. Protect the fetus and placenta from compression at the time of uterine contraction
5. It aids effacement and dilatation of the cervix
6. It keeps some organs of the fetus moist like skin, eye
2) The Chorion- is a thick outer membrane of the embryo. It lasts at the margin of the placenta.
C. Organogenesis- it is the formation of organ system from primary germ layers. The major
structure that arise from the primary germ layers are:
The ectoderm- mainly forms the skin and nervous system
The mesoderm- forms bones and muscle. The heart, blood vessels and certain internal
organs are also originated from the mesoderm.
The ectoderm- forms the mucous membrane and the glands of the body.
At the end of 8 wks all of the organ systems are formed and the individual is about 3cm. it is
considered as the fetus.
3. Fetal phase- lasts from the 8
th
gestational wk up to term. During this period less tissue differentiation
occurs; the principal activities are tissue growth and maturation. The fetus is the final stage of
prenatal development extending from the end of 8
th
wk till birth. The organ that formed during
embryonic stage now undergoes growth and differentiation and acquires the functional capacity to
support life out side the mother. Some aspects of the development of the development of fetal organs
and their physiology are special relevant to the nurses because their effect on the newborn.
O The liver- from 3
rd
to 6
th
month of intra uterine life the liver is responsible for the
formation of RBC, after which they are formed in the red bone marrow. Towards the end
of pregnancy iron stores are laid in the liver
O The renal system- the kidney begins to function and the fetus passes urine from 10 wks of
GA. But urine is very much diluted and does not constitute a rout for excretion since the
mother eliminates waste products through placenta.
O The adrenal gland- the fetus adrenal glands produce precursors for placenta formation of
estrogen.
O The alimentary cannel-the fetal digestive tract is mainly non functional before birth
except swallowing of the amniotic fluid about 12 wks after conception.
O The fetal circulation- the fetal hemoglobin is of different type from adult hemoglobin and
is termed as hemoglobin F. it has much higher affinity for oxygen and is found in greater
concentration (18-20g/dl at term). The reason for this is that oxygen must be obtained
from mother blood in the placenta site where the oxygen tension is lower than the
atmosphere. There are 4 other temporary structures of the fetal circulation that enable
fetal circulation to take place.
O Ductus venoses- is vein that connects the umbilical vein to the inferior vena cava
by bypassing in the liver because the liver is not yet functional to detoxify the
content of the blood. At this point the blood mixes with deoxygenated blood
returning from the lower part of the body making it partially oxygenated.
O The foramen ovale- is a temporary oval opening between the two atrials which
allows majority of blood from the inferior vena cava to pass to the left atrium
because the blood does not need to pass through the lungs since it is already
oxygenated and the lungs are not doing so.
O Ductus arteriosus- is an artery that passes blood from pulmonary artery to the
descending aorta by bypassing the lungs because of the reasons listed above.
O The hypogastric artery- are branches of the iliac artery which become the
umbilical cord.
The blood takes about half a minute to circulate the following course.
O The lung
O The CNS
O The skin
Unit two- Normal pregnancy
Definition of terms
Pregnancy (Gestation) is a condition of having a developing embryo or fetus with in the body after
conception. The period from conception to birth
Gravid (Pregnant) a mother Containing developing embryo
Gravida: Total number of pregnancies
Labour - is a process by which delivery of fetus placenta and membrane occurs through the birth canal.
Para: Total number of deliveries after 28 completed weeks of pregnancy.
Primigravida: a pregnant woman during her first pregnancy
Multigravida: A woman who has been pregnant more than one time
Nulipara: A woman who has never born a viable child
Multipara: A woman who has had two or more pregnancies which suited in viable foetus
Grand Multipara: A woman who has had 5 or more pregnancies
Prenatal - occurring before birth
Intranatal - occurring with in birth
Postnatal - occurring after birth
Singleton pregnancy: having one foetus in the uterus
Multiple pregnancies: having more than one fetus in the uterus
Term: The time of gestation from 37 completed weeks to 42 completed weeks from 1
st
day of LMP
Pre term: the time of gestation before 37 weeks
Post term: the time of gestation after 42 weeks
Conception: The onset of pregnancy/unification of spermatozoa and ovum
Conceptus: The sum of derivatives of fertilized ovum at any stage of development from fertilization to
birth
Implantation: Attachment of the blastocyst in the epithelium of the uterus
Zygote: The fertilized ovum
Embryo: The developing organism from the end of the 2
nd
week after fertilization to the end of the 8
th
week
Fetus: The unborn offspring from the 9
th
week of gestation to birth
Neonate: New born in the first 4 weeks
Infant: a baby with the age of < 1 year
Trimester: A period of three months of pregnancy
First trimester: From conception to 12 completed weeks
Second trimester: from week 13
th
to 27
th
completed week
Third trimester: from week 28
th
to 40
th
completed week
Still birth: Birth of dead fetus after 28 weeks of pregnancy
Neonatal death: Death of the baby with in the first 4 weeks after delivery
ABBREVIATIONS
ANC= antenatal care
APH = Antepartum hemorrhage
ARM = Artificial rupture of membrane
Cx = cervix
CCT= Controlled cord traction
CPD= cephalo pelvic disproportion
C/S = caesarian section
D & C = Dilatation & curettage
EDD = expected date of delivery
ECV = External cephalic version
FH = fundal height
FHB = fetal heart beat
FP = family planning
GA = gestational age
G = Gravida
Hgb = hemoglobin
INC = Intranatal care
IUFD = Intra utrine fetal death
IUGR- intra uterine growth restriction
LMP = Last menstrual period
P = Para
PA = per abdomen
PID = pelvic inflammatory disease
PNC = Postnatal care PPH = Post partum hemorrhage
PR = per rectum
PV = per vaginal examination
SVD = spontaneous vaginal delivery
UTI = urinary tract infection
Ux = uterus
Wk = week
Physiologic changes during pregnancy
All changes in a mothers body during pregnancy are associated with the effect of specific hormones.
Thus changes enable her to nurture the fetus, prepare her body for labour and develop her breast for
production of breast milk during the puriperium.
1) Physiologic changes in the reproductive organs-
A) Body of the uterus-after conception progesterone and estrogen produced by the enlarged corpus
luteum cause the deciduas to become thicker and more vascular especially at the fundus which is the
usual site of implantation. The muscle fibers also grow up to 15-20 times their non-pregnant length.
Each muscle fiber increases by 10 xs in length and 5 xs in thickness. This hyper trophy and
hyperplasia of the uterine muscle fiber is due to the effect of estrogen and progesterone.
Growth of the uterus-
12
th-
week- the Fundus reaches just above the symphysis pubis
16
th
week mid way between the symphysis pubis and the umbilicus
20
th-
week at the level of the umbilicus
30
th
week -Midway between umbilicus and xiphisternum
36
th
week- at the level of xiphesternum. It is the maximum growth of the uterus.
B) The cervix of the uterus- it acts as an effective barrio against infection during pregnancy, protects
the fetus by remaining firmly closed and by providing resistance to pressure from above when the
mother is up right position.
Under the influence of progesterone the cervical cells secret mucus which become ticker and
more viscous during pregnancy which forms cervical plug called operculum which provide
protection from ascending infection.
C) The vagina- estrogen cause changes in muscle layer and in the epithelium of the uterus the muscle
layer hypertrophy and the capacity of the vagina increase. These changes enable the uterus to dilate
during the time of delivery. There is an increased amount of normal white vaginal discharge known
as leucorrhoea.
2) Physiologic changes in the cardiovascular system profound changes takes place in the
cardiovascular system during pregnancy and understanding of these changes is important in care of
the women with preexisting cardiovascular disease
A) The heart- owing to an increase in work load, the heart muscle hypertraoophy particularly in the left
ventricle leading to an enlargement of heart. Heart sounds are changed and mormor sound is some
times common.
B) Cardiac out put- during pregnancy there is an increased HR and cardiac out put resulting in raised
cardiac out put. This is due to increased blood volume and increase requirement of oxygen by all
maternal tissue as well as by the growing fetus.
The rate may increase as early as 4 wks by 15 beat per minute.
C) Blood pressure- although the cardiac out put is increased in pregnancy, the blood pressure does not
rise because of the reduction in peripheral resistance to about 50% of non pregnant value. The
capacity of the vein can increase by liters. The most obvious cause for this is progesterone which
relaxes smooth muscle in the blood vessels.
D) Blood volume- the increase in blood volume in pregnancy may be as little as 20% or as much as
100% and varies according to the size of the women, the number of pregnancy she has had, her
parity, and weather the pregnancy is singleton or multiple the average being 40%. Raised level of
aldostrone, estrogen and progesterone during pregnancy are thought to contribute to increased blood
volume.
What is the aim of having increased circulating volume is required of blood.
To supply the extra metabolic need of the fetus
To supply the extra metabolic need of the maternal organs like kidney
To counterbalance the effect of increased arterial and venous capacity
To compensate for blood loss at delivery
E) Red cell mass- increase as a result of accelerated production of RBC in response to the extra oxygen
requirement by the maternal and fetal tissue.
NB:- as the increase in blood volume (plasma volume) is much higher than that of red cell mass increase,
hemodilution occur.
3) Physiologic changes in GIT
Progesterone relax smooth muscle of the GIT; this will slow the gastric empting and peristalaysis
in order to maximize the absorption of nutrients
Heart burn is common and is associated with gastric reflex due to the relaxation of cardiac
sphincter
4) Physiologic changes in integumentary system- increased activity of the melanonin stimulating
hormone cause deeper pigmentation during pregnancy resulting in:-
- Linea nigra
- Stria gravida
- Chloasma
5) Physiologic changes in MSS- progesterone and relaxine encourage relaxation of ligaments and
muscle reaching maximum effect during the last week of pregnancy. This relaxation allows the pelvis
to increase its capacity in readiness to accommodate the fetal presenting part at the end of pregnancy
and labour.
6) Physiologic changes in breasts
Estrogen develop the duct system
Progesterone develop the glandular tissue
Prolactine stimulate the production of colostrums.
7) Physiologic changes in respiratory system
8) Physiologic changes in endocrine system
Diagnosis of pregnancy
Sign & symptom of pregnancy- Sign & symptom of pregnancy can be classified in to three
- Presumptive
- Probable &
- Positive
1) Possible (presumptive) signs they are not true signs rather they are symptoms because it includes
what the mother will recognize. Examples of such a symptom are:
- Amenorrhea
- Morning sickness
- Early breast change - increase in size
- Darkening of areola.
- prickling sensation from 3-4 wks
- Bladder irritability and frequency of micturation
- Quickening - is the first fetal movement felt by the mother
premigravid - feels it at 18-20 week
Multigravid - feels it at 16-18 week.
2) Probable signs are true signs in which the health professional will find
- Pregnancy test presence of HCG in the
o urine or
o blood
- Jacquemiers sign violet blush discoloration of genitalia due to increased vascularity.
- Osianders sign - pulsation in lateral vaginal fornices
- Uterine growth-
- Braxton - Hicks contraction- is pain less uterine contraction felt on palpation from 16
th
wks on
ward. The contraction helps in the circulation of blood in the placenta site and in the formation of
lower uterine segment.
- Ballottement of the uterus
3) Positive signs are the real indication of pregnancy. If you get this signs there will no doubt in the
pregnancy.
Visualization of fetus by
Ultrasound - 6weeks of gestation
X - ray after 12 weeks of gestation
Hearing of Fetal heart beat by
Ultrasound
Fetoscope (20
th
to 24
th
weeks of gestation)
Fetal movement by
palpation
Visualization
Antenatal care /ANC/
Definition-it is a care given to pregnant women.
Aim of ANC-generally the aim of ANC is delivery of a healthy infant and maintaining the health of the
mother by:
Promote the physical and psychological status of the mother
Diagnosing the well being of the fetus as well as the mother
Screening high risk mothers
Treating the preexisting disease
preventing disease and further complications
preparing the mother for labour, delivery and pureperium
Components of ANC- according to WHO ANC have three components.
A. Risk assessment- risk is any condition that will expose a person to possible danger.
According to WHO all pregnant mothers are risk mothers (they need special care) but there are mothers
who are high risk.
Which mothers are high risk mothers?
- They are Mothers who need special care than normally pregnant mothers during their pregnancy,
labour, delivery and puriperium.
- They are mothers who should deliver in the hospital
- Those mothers include:
>35 or <15 year aged
Height of < 150 cm
Medical problem like- heart disease, DM, renal disease, TB, HIV/AIDS
Surgical problem like-C/S, genital surgery, pelvic surgery
Obstetric problem this may be during past or at the present pregnancy
o Twin pregnancy
o APH
o Prolonged or obstructed labour
o PROM
o Repeated abortion
o IUGR/IUFD
o Pre or post term labour
o History of neonatal death
o HDP
A. Antenatal care assessment- Pregnancy is not a disease; it is a normal physiologic state but because
of the different reasons/objectives we will follow the mother as a patient. This follow up includes:
History taking
Basic recording
Lab investigation
Physical examination
follow up
1) History taking- is assessing the health of the mother to find out any problem which may affect child
bearing.
A. Social history (biographic data) it includes age, name, marital status, occupation
B. Family history- mostly you should ask hereditary transmittable disease like;
a. Diabetes mellitus
b. Hypertension
c. Heart disease
d. Multiple pregnancy
e. Psychiatric history
f. Family history
C. Medical history- like-
a. HTN
b. DM
c. HIV/AIDS
d. TB
e. Childhood disease like polio, rickets
D. Surgical history
a. C/S
b. Genital surgery
c. Pelvic surgery
E. Obstetric history- this includes any problem of labour, pregnancy, delivery and/ or puriperium
of the current or past pregnancy.
a. Past obstetric history
i. Pregnancy history- you should ask the presence or absence of :
- Hyper emesis
- Anemia
- Pre eclampsia
- APH
- Preterm, term or post term ness of the pregnancy
ii. Labour history- the onset of labour- spontaneous or induced
- The nature of labour- prolonged, obstracted
- Rupture of membrane- spontaneous, ARM, PROM
iii. Delivery history- you should ask :
- place of delivery
- Instrumental delivery (vacume, forcepse)
- Weight of the baby
- Life status of the baby
- APGAR score of the baby
iv. Puriperial history- ask history of:
- Infection
- Breast problem (engorgement, mastitis)
- PPH
- Psychiatric history
b. Present obstetric history
1) Ask LMP (last menstrual period)- it is reliable only when:
The mother has regular menses
If the mother does not use contraceptive for the previous 6 months
2) Calculate EDD (expected date of delivery)
Way of calculating EDD
If in Gregorian calendar, add 7 days and 9months on the LMP
Example if the mothers LMP is on 10/2/2006
EDD=10/2/2006

+
7/9/0000
=17/11/2006
If in Ethiopian calendar and if the pregnancy
Does not pass pagume, add 10 days and 9 months.
Passes pagume that is 5 days, add 5 days and 9 months
Passes pagume that is 6 days, add 4 days and 9 months
Example one if the mothers LMP is on September, 10, 2002
EDD=10/01/20002

+
10/009/0000
=20/10/2002
Example two if the LMP is on may,28,2001
EDD=28/09/2001

+
05/09/0000
=03/07/2002
Example three if the LMP is on april, 18, 1999
EDD=18/08/1999

+
04/09/0000
=24/05/2000
3) Calculate GA (gestational age) - it is always calculated by wks.
Ways of calculating GA
GA=arrival date-LMP
Example: if the mothers LMP is at 4/5/99, and the arrival date is at 10/10/99
GA=10/10/99

-
4/5/99
=6/5/00 (5 months+6 days)
=150+6 days=156 days
=22wks+2days
2) Basic recording
A. Height- is usually taken at the first time visit only
- <150 cm height is risky
B. Weight- will be taken monthly to know the increased weight per month
- 10- 12.5 kg increase is a normal
- 10 kg in the 2
nd
20 wks and 2.5 kg in the first 20 wks
C. Blood pressure- should be checked and recorded per each visit.
3) Laboratory investigation
o Blood tests
Blood group
RH factor
HIV status
VDRL
HCT and Hgb- shoud be checked and recorded per each visit.
o Urine analysis
Protine
Suger
Bacteri
Ketone body
NB:- normally urine does not contain any protine, suger, bacteria or ketone body or they are trace.
4) Physical examination- during the first visit of ANC, we should do a complet (heas to toe) physical
examination which includes:
o HEANT- head- cleanness, hair distribution
Ear- discharge, growth, hearing ablity
Eye-sclera, conjunctiva, bleeding
Nose- abnormal growth, discharge, obstraction
Trought(teeth)
o Neck- enlargement of the lympnode, thyroid gland
Lympadenitis
o Breast examination
Inspection- symmetry
Skin
Areola
Nipple (normal, inverted or flat)
Milk expression
Any other discharge
Palpation- breast can be palpated in one of the two ways
q Circular palpation
q Quadrant palpation
NB: if possible breast self examnation is advisable.
o Abdominal examination
Aim of abdominal examination
q To asses the progress of pregnancy
q To asses the well being of the fetus
q To asses fetal size and growth
q To asses the presentation, position, lie, and engagement of the fetus
q To detect any devotion from the normal
o Preparation of abdominal examination
Explaining the procedure
Maintaining privacy
Positioning
Empiting the blader
o Method of abdominal examination
1. Inspection- inspect the four Ss
a. Shape of the uterus- shape of the mother is different in different situations.if the mother is:
o Primigravida, the shape will be oval
o Multi gravid, the shape will be round and pendulus
o Twin pregnancy, the shape will be irregular
o Occiputoposterior position, it will have a socker like dipresion.
b. Size of the uterus- the size of the uterus must be compaired with GA and it may be either
appropriate for GA, small for GA or large for GA.
Example if the 24 wks fetus is at the level of umbilicus, it is small for gestational age.
Differential diagnosis of LGA- large for gestational age can be mistaken by:
o Poly hydraminous (large amount of amniotic fluid)
o Multiple pregnancy
o Full blader
o Tumor
o Wrong date or it may be
o Big baby
Differential diagnosis of SGA- small for gestational age can also be mistaken by:
o Wrong date
o Oligo hydraminous (small amount of amniotic fluid)
o IUGR
o IUFD or it may be
o Small baby
NB: multiple pregnancy and poly hydraminous will enlarge both the length and breadth of the uterus
whereas large baby increase only the length of the uterus.
c. Skin of the uterus- skin change during pregnancy shoud be noticed llike:
o Linia nigra- dark line pigmentation running longtudnally in the center of the abdomen below
and some times above the umbilicus.
o Streagravida- white line in the abdomen formed due to stretch of the abdomen.
d. Scar- may indicate previous obstetric and abdominal surgery.
2. Palpation- before palpation, the hands shoud be clean and warm not to induce contraction of abdomen
and uterine muscles, arms and hands shoud be relaxed and you have to use the pads not the tip of the
fingers.
We usually use the four steps of palpation (leopolds manover) for abdominal examination.
a. Fundal palpation (1
st
leopolds maneuver) is carried out in order to:
Know what is occupied on the fundus; weither it contains breach or head. This
information will help to diagnose the lie and presentation of the futus. To do so you have
to lay both hands on the side of the fundus, fingers held together and curving around the
upper border of the uterus. Then gently appling pressure using the palmar surface of the
fingers to determine the softness (butuck) or the hardness (head) of the mass. But some
times buttuc may feel firm; in such a case,you have to asses the mobility of the mass. The
breach can not be moved indipendantls as the head can because of the free movement of
the neck joint.
Estimate period of gestation- does not always produce an accurate result because the size
and number of the fetus, amont of the amniotic fluid and maternal size and parity may
vary. You can use two methods to determin the height of the uterus.the first (sypphisis
fundal height) is the assumption of the height of the fundus will corelaate well with
gestational age especially during early wks of pregnancy. It can be done using measuring
tape (measuring from pubic bone to syphisis pubis) or by using your fingers. When using
your fingers you have to assume the umbilicus as 20 wks and one finger below the level of
the umbilicus will be recorded as 1 wks and one finger above umbilicus will be recorded
as 2wks. The second method is the estimation of the distance between the umbilicus and
the curved upper border of the fundus by placing your finger. This method will assume
xiphisternum as a 36 wks of gestation.
b. Lateral palpation- is used to locate the fetal back in order to determine the position. To do
so the hands should be plased on either side of the uterus at the level of umbilicus and
gentle pressure should be applied with alternative hands to detect which side of the uterus
offers the greater resistance (which is the back)
c. Pelvic palpation- is the palpation of the lower pole of the uterus to know what is occupied
on the pelvis, attitude and engagement. To do so the side of the uterus just below the level
of umblicusshould be grasped snougly between the palm of the hand with the fingers held
closer, pointing downward & inward. If the head presenting a hard distinctive & round
mass & smooth surface will be felt in order to know the attitude, the sinciput & occiput
should be palpated. If the head is flexed, the sinciput will be felt on the opposite side of
back & higher than the occiput if the head is deflexed, the two prominence will be at the
same level. If the head is extensed as in the face presentation, siciput will be felt on the
same side of the back
d. Pawliks grip(4
th
leopalds manuover): is used to judge size, flexion, and mobility of the
head. To do so you have to grip the lower pole of the uterus between your tumb and your
finger which should be spreed wide apart to accommodate the fetal head. Do not apply
undue pressure because it is painfull.
3. Auscultation- the fetal heart beat must be auscultated. Like all heart beats, it is a double sound but is
faster than adults (120-160). It is mostly heard clearly at the left part of fetal scapula. While listning
the ears most be closed by the total contact with the fetescope but hand should not touch it to avoide
extraneous sound.
Findings of abdominal examination
Gestational age- when the uterus is at:
o The level of symphisis pubis, it is assumed to be 12 wks fetus.
o The level of umbilicus, it is assumed to be a 20 wk fetus
o Between symphisis pubis and umbilicus, 16 wks
o The level of xiphisternum, 36 wks
NB: after 36 wks the height of the uterus will decrease because of the engagement of the head in to pelvic
bream.
Lie- is the relationship between the long axis of the fetus with the long axis of the uterus. There
are three types of lies.
A. Longitudinal lie- when the long axis of the fetus is in line with long axis of the
uterus. It can be breach or cephalic. 99.5% of all pregnancy are with longtudnal
lie.
B. Transverse lie- when the fetus lies at the right angle across the long axis of the
uterus.
C. Oblique lie- is when the fetus lies diagonally across the long axis of the uterus.
NB: oblique lie and obliquity of the uterus (the tilting of the whole uterus to one
side) are not similar.
Attitude is the relation of the head to its trunk. The attitude of the fetus shoud be one of flexion
(well felexed, deflexed or extenced).
Presentation- refers to the part of the fetus which lies at the pelvic bream or in the lower pol of the
uterus. The presentation of the fetus can be cephalic (when the head become the presenting
part),breach (when the butuckbecome th presenting part) or sholder. Vertex, face and brow
presentation are all head or cephalic presentations. When the head fully flexes, the vertex
presents; when the head fully extenced, the face presents and when the head partially extenced
(deflexed) the brow presents. It is more common for the head to present because the bulky breach
finds space in the fendus which is the widest diameter of the uterus and the heavy head lies in the
narrowlower pole.
Denominator is the name of the part of the presenting part which is used as a reference point to
know the fetal position. Each presentation has difference denominators; those are:
o Occiput in the vertex presentation
o Sacrum in the breach presentation
o mentum in athe face presentation
o acroion process and some times dorsum in shoulder presentation but
o no denominator is used in brow presentation.
Position- is the relation ship between the denominator and some points in the pelvis. There are 8
positions. For example LOA, ROA, LOL, ROL, LOP, ROP, DOP, DOA are the are the eight
positions in the vertex presentations.
Engagement- is the widest presenting transverse diameter (biparital diameterin the cephalic and
bitrochontric diameter in the breach) has passed through the brim of the pelvis. It is an important
sign of adequacy of the pelvis for the specific fetus. In primigravida it will occure early (between
36 and 38
th
weak) but in multi this may not occur because of the lax uterus.
What are the evidence of the engagement?
- Only less than half of the fetal head is palpable above pulvic brim
- The head is immobile
- Sinciput is felt less than 5cm above the brim
- The anterior sholder is little more than 5cm above the brim
Presenting part- is the part which lies over the cervical os during labour.
5) follow up- a women who had high number of risk factors identified during the intial assessment visit
or who develops complication during pregnancy will attend her antinatl care at the hospital but
womens who had no or little risk factor will follow their antenatal by appointment. There are two
type of appointment (traditional and focus nantinatal care).
A. traditional appointment-is a method of appointing amother with same frequency of time in some
duration of time in which the frequency increases as the GA advances that is:
0-28 weeks-every month
28-36 wks every two weeks
36-delivery every weak
B. Focused antenatal care- is a method that assumes four visits are enough fetal as well as
maternal well being. i.e.
1
st
visit- any time before 16 wks
2
nd
visit- at 24 wks
3
rd
visit-at 32 wks and
4
th
visit at 36 wks
B. Care provision- is a method of treating the identified existing problems. These problems can be
simple like minor disorder of pregnancy which can be managed by our selves or can need referral.
C. Health promotion- is maintaining the health of the mother by different methods like:-
Health education
Immunization
Tetanus toxoid: - because tetanus neonatorium is a great killer of new born babies the baby gets
infected when the umbilical stamp or any part of the babys body is invaded by tetanus organism
We can prevent the disease by immunizing the mother so that she pass antibody to her baby before
delivery
Unit three- abnormal pregnancy
Minor disorders of pregnancy
They are minor complaints of the mother due to the physiological and anatomical changes of the
pregnancy. They are minor and are not lives threatening which can be resolved by education that is why
they are called minor disorders.
1. Morning sickness - some degree of nausea and vomiting is common compliant during the 1
st
trimester. It can appear in any time of the day but it becomes worse early in the morning thus the
name morning sickness.
Cause- the most likely cause is the hormonal change during pregnancy that is the rising level of
HCG.
It can be aggravated by:-
smelling of foods and
Psychological problems like anxiety.
Management-it can be relived by:-
Reassuring the mother
Taking small, frequent and dry meals
Avoiding fatty foods and foods whose smell aggravates the symptom
Rest
But if not relived by the above managements give anti emetic
2. Heart burn : - is a burning sensation in the epigastric area especially during the late weeks of
pregnancy.
Cause- it is usually caused by reflex of gastric content in to esophagus due to :-
Compression of the stomach by the enlarging uterus and
Relaxation of the cardiac sphincter by the effect of progesterone
Management- it can be relived by:-
Taking small and frequent diet
Sleeping with extra pillow than usual
If not relived use anti acids like Al (OH)
3
, Mg
3
Si
2
, or the combination of the two
If not still relived use H
2
blockers like cimitidine & rantidine
3. Constipation -
Cause- the cause of this condition is delay of peristalysis which can be due to:-
Relaxation of GI smooth muscles due to the effect of progesterone
Pressure from growing uterus
Management- this condition can be treated by taking high amount of :-
Fluid
Fibrous diet
Fresh fruit, vegetable and roughage
If it is not still relived by the above management give her stool softners
4. Hemorrhoids : - is the varicosity of the rectal vein. It can be asymptomatic or may be present with
rectal bleeding, rectal pain or prolapsed mass through the uterus.
Cause- relaxation of smooth muscles due to the effect of progesterone
Pressure in the rectal vein by the growing uterus
Management- Appling topical anesthetics and anti inflammatory drugs
Warm soaks (sits bath)
Modification of bowl habits
Taking laxatives
Finally surgery if thrombosed and strangulated
5. Pica :- is craving of pregnant mother for items of low nutritional value like:-
- Clay
- Soap
- Coal
- Soil
Cause- there is no known cause
Management- educating the mother
6. Varicose vein :- is the dilatation of the superficial vein of the lower extremities.
Cause- relaxation of smooth muscles of the vein by the effect of progesterone
Decrease venous return due to the compressing effect of the growing uterus
Management- Elevating the leg during the sleep
Reduce long standing
Using elastic bandage
7. Leg cramp
8. Urinary frequency
9. Ptyalism
10. Vaginal discharge
Hyperemesis gravidarum
Definition of hyper emesis gravidarum
+ It is vomiting that starts before the 20
th
week of pregnancy and requires intervention.
+ Severe nausea and vomiting leads to dehydration electrolyte imbalance and weight loss.
+ It is a condition affecting approximately 1 in 100 pregnant women.
Causes of hyper emesis gravidarum -The etiology of hyper emesis is uncertain endocrine and
psychological factors are proposed
Rising level of oestrogen and HCG is significant
Hype emesis is common in multiple pregnancy and molar pregnancy.
Sign and symptom of hyper emesis gravidarum
- Persistent, severe nausea and vomiting in early pregnancy.
- Inability of the mother to retain food and fluid.
- Wt. loss.
- Distress due to symptoms.
- Signs of dehydration like
Rapid pulse
Low Bp (hypovolemia)
Dry tongue
- Ptyalism may occur.(contributes for dehydration)
- elevated haematocrit alteration & electrolyte balance
- sign of ketosis
The mothers breath may smell of acetone
Ketone urea.
Diagnosis: -History, P/Estrogen and Lab. Investigation.
Management
Initially nothing is given by mouth (NPO ) to allow time for the vomiting to be controlled gradual
introduction of fluids and diet as he condition improves
Hypovoluemia and electrolyte in balance are corrected by intravenous infusion.
Vitamin supplements can be given parenterally.
The mother should be encouraged to rest and may be cared for in a private room.
Some women may be given mild sedatives if they appear agitated.
A small palatable meal on regular basis helps to regain her appetite.
The use of anti emetics in pregnancy causes severe mal formation of children born so on anti
emetic being approved for Rx.
Termination of pregnancy reverse the condition ( preventing MM)
Complication -If hyper emesis is left untreated, the mothers condition worsens.
Hepatic and renal involvement lead to coma and death
Wernickes neurological disorder x-zed by confusion, drowsiness and ophthalmoplegia
encephalopathy is a complication associated with lack of vit B1 (thiamine)
Differential Diagnosis
- urinary tract infection
- Gastroenteritis.
Multiple pregnancy
Definition- is the presence of more than one fetus in the utero.
Type- multiple pregnancy can be twin pregnancy, triplet, quadruplet of other but the most common ones
are twins. There are two types of twins. This are:
A. Monozygotic /uniovular/ identical twins- is the formation of twin from single ovum and
spermatozoa. The twins are formed by mitotic division of ovum after fertilization. The two twins will
have the same sex, blood group, physical feature, ear shape, genetic composition, and eye and hair
color e.t.c. this type of twins account 30% of all twins.
B. Diazygotic /diovular/ fraternal twins- it is the formation of twin from separate ovum and
spermatozoa. The twins may have same or different sex, blood group, and physical feature but they
will have different genetic composition. This type of twins Account 30% of all twins.
Process of twining- can be expressed by two things, zygosity and chorionisity.
Zygosity- refers to the mono or diazygotic nesss of twins.
How do we determine zygosity?
- Same blood group with same sex
- Genetic composition even if it is very difficult in our setting
- Physically around two year
- Weight variation at birth
Chorionisity- is all about the number of placenta.
How do we determine chorionisity?
- All dizygotic and triplets are DADC (will have separate amnion and chorion)
- For all monozygotic the number of placenta (chorionisity) depends on the time when the mitotic
devision starts. If it starts:
<72 hour= DCDA (30% of all)
4-8 days= MCDA (70% of all)
>8day= MCMA Rare
>13 days (In separated)= conjugated twins
NB: - mono-chorionisity has high risk of fetal loss and maternal complication because of TTT.
Etiology- the etiologies listed below are for diazygotic twins than monozygotic once.
q Race- common in blacks
q Age- 37years is a pick age
q Parity- common in multipares
q Nutrition- common in well nourished
q Physical appearance- common in taller and heavier
q Family- common in female family
Diagnosis- we can diagnose twin pregnancy by:
+ History- Ask the presence or absence of all condition that will predispose the mother like:
Race
Parity
Age
Family history
- Ask 1
st
trimester history and unexpected weight gain during pregnancy.
+ Abdominal examination
Inspection- you will found big for date abdomen with round shape
- Excessive fetal movement
Palpation- palpation of multiple fetal parts
- Uterus is palpable before 12 wks of pregnancy
- Fetal head is small in relation with the size of the abdomen
Auscultation-the presence of two FHB at two different place which is confirmed by two
persons is an indication of twin pregnancy.
+ Ultra sound- if you are not shure by the above diagnostic criterias, you can confirm it by
sonography.
Complication of multiple pregnancy-always multiple pregnancy is a risk pregnancy because it has a
negative effect on pregnancy, labour and puriperium. Some of the risks are:
q Hypermisis- because it has a large amount of estrogen and HCG.
q Anemia- because of the increased requirement of Fe and folic acid
q APH- especially placenta previa. Why?
q Poly hydraminous
q Malpresentation
q Pre eclampsia-increase by 4 times because of the increased size and number of placenta.
q Cord prolapse
q PPH- because of overstretched uterus.
q Locked twins
q Preterm labour- because uterine size is one stimulus for initiation of labour.
q TTT- is the communication twins blood vessles.
Twin A (donor)
Anemia
Oligohydraminous
Growth restriction
Twin B (recipient)
- Polycytemia
- Poly hydraminous
- Macrosomia
- Cardiac failure
NB:-Both are at risk of death and preterm delivery.
Management of twin pregnancy
Antenatal management
More nutrition
More CHO, protine and vitamin
Fe and folic acid supplementation is mandatory
Intrapartem management
Labour should be attensed in the hospital
You should prepare as for two delivery(two cord tie, two delivery and episotomy set, and two
neonatal bed)
If the presentation is cephalic cephalic(has a chance of 40%), SVD is possible.
If twin A is vertex but twin B is non vertex (has a chance of 40%), we can deliver twin A by SVD
and can augment twin B.
If twin A is non vertex, c/s is indicated.
Postpartum- AMTL (active management of third stage of labour)
- Follow up of all the above complication
Antepartum hemorrhage
Definition: - is bleeding from genital tract of the pregnant mother after the fetus has reached viability
(which is after 28 complete weeks or fetal weight of 100 gm or more in our country or 20 wks according
to WHO) and before the fetus is delivered.
Cause: - the cause can be broadly categorized as:
A. Obstetric cause- are the major causes of
APH
a. Placenta previa
b. Abraptio placenta
c. Vasa previa
d. Uterine rupture
B. Non-obstetric cause
a. Cervicities
b. Cervical polyp
c. Cervical Ca
d. Traumatic lesion
1. Placenta previa - is the bleeding from the placenta that is implanted in the lower uterine segment.
Grade of placenta previa
A. Grade I (is also called low lying placenta previa)- is when the placenta is implanted in the lower
uterine segment but not reach the internal os.
B. Grade II (is also called marginalis) - is when the placenta reaches the margin of the internal os
but doesnt cover the internal os.
C. Grade III (also called partialis) - placenta covers the partial of the internal os.
D. Grade IV (also called totalis) - is when the center of placenta lies at the center of internal os and
when it covers the whole internal os even at full dilatation.
Cause- there is no single exact cause of placenta previa but the predisposing factors are;
Uterine scar secondary to-vigorous suctioning and curettage
- C/S scar
Multi parity
Multiple pregnancies. Why?
Clinical manifestation-
Pain less bleeding
Bright red bleeding
Non tunder uterus
Normal tone uterus
High presenting part even primi gravida
Usually there will be mal presentation and mal position
Maternal vital sign change in proportion to the blood loss
NB: - since it is followed by sever bleeding both vaginal and speculum examination should not be done
unless some exceptions.
Diagnosis- this condition is majorly diagnosed by the clinical manifestation but U/s can be used to
confirm and grade it. Vaginal examination is alternative only when U/s is not available and termination
of pregnancy is planed.
Management- the management of placenta previa differs according to:
The amount of bleeding
The condition of the mother
The location of placenta
The stage of pregnancy
A. Aggressive (active) management- if the amount of bleeding is life threatening, immediate
resuscitation and emergency C/S delivery is mandatory what ever the gestational age is and where
ever the location of placenta is.
Even with minimum bleeding if:-
The GA is greater than 37 complete weeks
There is fetal distress or fetal death
There is spontaneous active onset of labour; termination of pregnancy will be done.
This can be done either by:
Induction of labour- if it is grade I and II anterior or
C/S- if it is grade II posterior, III and IV
B. Expectant (conservative) management- is maintaining the health of the mother till term. After
admission if the above conditions are absent, the pregnancy should continue till full term by closely
monitoring the mother
Complete bed rest
Routine ferrous sulphate supplementation
Avoiding coitus and other vaginal manipulations
2. Abruption placenta
Definition- is a premature separation of normally implanted placenta before the third stage of labour or
before the delivery of the baby but after the 20 wks of GA.
Cause- there is no exact single cause of abraptio placenta but there are a number of factors that will
increase the risk of getting abraptio placenta.
Hypertensive disorders of pregnancy
Trauma to the abdomen
Sudden decompression of uterine volume as in case of:
Rupture of membrane of poly hydraminous mother
After the delivery of first twin
External cephalic version
Clinical manifestation
Vaginal bleeding- usually small in amount and dark red in color
Abdominal pain- ranging from labour like pain up to un relenting pain
Abdominal tenderness-
Fetal distress or death
NB:-the maternal vital sign change is not proportional to the degree of blood loss. Why?
Diagnosis- it is usually diagnosed by the clinical manifestation. If the mother comes with the above
clinical manifestation, the health personnel should ask for any history of:
Hypertensive disorder of pregnancy
History of trauma
Management- resuscitation is the first line management.
Secure IV
Determine hematocret and blood group
Prepare at least two units of compatible blood
RH factor assessment, if negative gives her 300g of anti D
Labour will start spontaneously with in hours
If do not start spontaneously and if the GA is less than 37 wks and if the mother
and fetal condition is well, continuing pregnancy till term is possible. But if the GA is
greater than 37 wks and if the maternal and fetal condition is not well, induction of labour is
mandatory.
Complication
Sever bleeding
Shock
Acute renal failure
Post partum hemorrhage
Fetal distress
IUFD
3. Vasa previa - is a bleeding from the fetal circulation secondary to velmentosa insertion of cord. It is a
rare condition but it is associated with a high degree of fetal death.
Clinical manifestation
Pain less bright red bleeding
May confuse with placenta previa but in this case the bleeding usually follows rupture of
membrane.
Diagnosis
Apt test will be done to detect the presence of fetal blood in the bleeding
Some amount of vaginal blood will be mixed with same amount of 25% sodium
hydroxide.
Maternal blood will turn light brown where as that of the fetus will not be because of its
resistance to alkali.
Management- emergency cesarean section because even small amount of bleeding is fatal to the fetus.
Rh and ABO incompatibility
Rh incompatibility
Definitions
Rh incompatibility- is the presence of different Rh types in the blood of two persons. in obstetrics
women and her fetus mostly when the fetus is Rh positive (possess D antigen in his RBC) and when the
mother is Rh negative (her RBC lacks the surface antigen D).
Rh iso-immunization (Rh sensitization) - is the production of antibody against the Rh factor by an Rh
negative women following exposure to Rh positive cells.
Pathophysiology-for iso-immunization to occur the following preconditions must be full filed.
1. RH negative mother must carry Rh positive fetus.
The chance of a mother who is Rh negative having Rh positive fetus will depend on homo or
heterozygosity of the father according to the mendelian law.
Table 6.1 -if the father is heterozygous
D D
d Dd Dd
d Dd Dd
Table 6.2- if the father is homozygous
D d
d Dd Dd
d Dd Dd
The chance of the fetus being positive is 100%
The chance of the fetus being positive is 50%
2. The Rh positive blood must enter the maternal circulation.
Ideally placenta doesnt allow communication of maternal and fetal blood but due to different reasons
there is a leakage of blood in placenta which is called feto-maternal hemorrhage. Among the reasons
the known once are:
q Trauma
q Abortion
q Ectopic pregnancy
q APH
q Manipulation of the uterus like:
Amniocentesis
External cephalic version
3. The mother must produce Rh antibody.
An individual who is Rh negative does not normally carry antibodies to the Rh factor. But if by some
meance Rh positive RBC enter her circulation they alert the immune system and The maternal
immune system will respond by producing anti D antibody of IgM type to destroy the foreign protein
but because the IgM type is too big to pass through placenta it will not affect the current fetus (99%)
but this type of communication in the next and subsequent pregnancy will result in the production of
IgM type of anti D antibody which will pass the placenta and will result in serious complications.
Once formed these antibodies are permanent.
Complications
O Hemolytic anemia
O Erythroblastosis fetalis- the presence of large number of nucleated RBC in fetal circulation to
cope the hemolytic anemia
O Hydrops fetalis- is a generalized edema and collection of serous fluid in the body cavity of the
fetus which may be secondary to:
Portal hypertension secondary to the obstruction due to destruction of RBCs.
Fall of serum albumin as a result of the replacement of liver parenchyma by hematopoietic
tissue
O CHF and tissue hypoxia secondary to progressive anemia.
O Jaundice
O Fetal death due to sever kernicterus or sever anemia
Management- the management will depend on which stage the problem is
A. Un sensitized pregnancy (negative combs test)
Monitor the combs test and report it during the 28
th
and 36
th
weeks of pregnancy
If positive manage as sensitized pregnancy but
If negative:
Provide 300 g anti D gamma globulin at 28, before procedures that will increase the risk of
FMH like amniocentesis, APH, ECV, abortion (if less than 12 wks, 50g) etc with in 72
hours of the procedure.
Immediately the baby is born, the cord must be clamped in order to prevent further Rh
antibodies from entering the circulation.
Following delivery determine the blood group and Rh factor of the fetus
If negative no further management is indicated
Ife positive,
Doing direct coombs test is mandatory to determine the presence or absence of
antibody.
If the test is negative provide anti D with in 72 hour of delivery (300g)
If the test is positive monitor the fetus for all complications and manage the second
pregnancy as sensitized.
B. Sensitized pregnancy- because these women need special follow up early referral is the correct
approach in health center setting. But if you are in referral setting,
Measure antibody level at regular interval
Amniocentesis for bilirubin level
All babies whose mother have Rh antibody should be transferred to neonatal intensive
care unit.
After delivery photo therapy and exchange transfusion can also be done
ABO incompatibility
This type of incompatibility is when O blood grouped mother carry a baby of either A or B blood groups.
Unlike Rh incompatibility, in this type the mother has naturally occurring antibody against A and B
blood groups (anti-A and anti- B). Because these antibodies are of IgM type, they are too big to cross the
placenta. But if the fetus blood leaks to the maternal circulation, the mother immune system will produce
anti bodies similar to anti A and anti B but of IgG type which can pass the placenta so that they can
destroy the fetal RBCs that carry the A and B antigens.
Unlike the Rh iso-immunization, this condition may affect the first child as much as the subsequent child
but the complications are not as such severing as that of the Rh once.
ABO incompatibility will prevent Rh iso-immunization. How?
Premature rupture of membrane
Definition- is a rupture of membrane at least one hour before the onset of labour, but after 28 weeks of GA.
Latency period- is the period between the time of rupture of membrane and the onset of true labour. If
the latency period extends more than 24 hour, it is called prolonged rupture of membrane.
Classification-
It can be either preterm PROM (rupture of membrane after 28 wks of GA but before 37 complete
wks) or
Term PROM (rupture of membrane after 37 complete wks but a hour before the onset of labour)
Etiology- there is no exact single cause for PROM but, conditions that will either increase the intra
uterine pressure or that will reduce the strength of membranes may be responsible. These conditions
include-polyhydraminous
-Multiple pregnancy
-Cervical incompitence
-trauma
-Infection
Clinical manifestation-
History of sudden gush of fluid per vagina
Persistent uncontrolled leakage
Diagnosis-
On physical examination,
moist perineum and Amniotic fluid may be seen flowing from vagina
NB:-PV is contraindicated in mothers suspected of having PROM unless delivery is planned with
in 24 hour. Instead sterile speculum examination will be done to confirm the diagnosis.
Additional tests to confirm the diagnosis
Niterazine paper test- change from yellow to deep blue.
Litmus test- change from red to blue.
Ferning test-
Management- the management of PROM depends up on co existing condition like:
Presence or absence of complication
Presence or absence of labour
The GA of pregnancy
OIn the presence of complication like chorioamnitis, fetal distress and fetal death , the management
should be termination of pregnancy either by induction or abdominally.
OIn the absence of the above complication the management depends on the GA of pregnancy.
o If the GA is 34 or above, the risk of intra uterine infection is higher than the risk of
prematurity. Therefore delivery of the fetus either by induction of C/S should be done.
o If the GA is less than 34wks, the risk of prematurity is higher than the risk of intra uterine
infection. Postponing pregnancy while closely monitoring the complications is the
management of choice.
Admit the women
Every six hour monitor her vital sign
Every day monitor
Uterine contraction
Uterine tenderness
Odor and color of the vaginal discharge
Fetal well being (FHB and thick chart)
WBC count
Weakly monitor
fetal growth by fundal height or by U/S
the maturity of the lung
Complication-
chorioamnionitis- intrauterine infection of the membrane is the most common and sever
complication of PROM.
Clinical manifestation- fever with chilis
Adominal pain
Offencive amniotic fluid
Uterine tenderness
Maternal as well as fetal tachycardia
Management- administration of broad spectrum antibiotics (ampicilline and gentamycine)
- Antibiotics should continue after termination of pregnancy and to the neonate
intramuscularly.
Cord prolapsed
Preterm labour
Oligo hydraminous
Abruptioplacenta
Neonatal infection like:
Congenital pneumonia
Sepsis
Abnormality of Amniotic fluid
1) Poly hydramnious
Definition- is the prescence of abnormallu high amount of amniotic fluid (volume of more than 2000 ml)
Type-hydramnious can be acute or chronic.
- Chronic poly hydramnious- this type is:
o Gradual onset
o It is usually starts from about 30
th
wk of pregnancy and
o It is sthe most common type
- Acute poly hydramnious-
o it usually occurs at about 20 weeks
o comes on very sudden onset (the uterus will reach xiphisternem in about 3-4 days)
o it is very rare type
Etiology
Majority (>60%) of the poly hydramnious is ideopatic
The rest arises either from the condition that increase the surface area of the placenta or disrupt
the integument of the fetus or hamper the normal swallowing process of the fetus.
- Oesophageal atresia of the fetus
- Tracheoesophageal fistula
- Open neural tube defect of the fetus
o Spinal bifida
o anecephally
- placenta tumor for example Chorioangioma, a rare tumour of the placenta
- Multiple pregnancy, especially in the monozygotic twins
- Maternal diabetic mellitus
- Rarely, Rhesus- isoimmunization
Clinical manifestation
C The mother may complain of breathlessness and discomfort
C If it is acute one, she may have severe abdominal pain
C Exacerbation of symptoms associated with pregnancy such as:
= Indigestion,
= Heart burn
= Constipation
= Oedema and varicosities of the vulva and lower limbs may be present.
Diagnosis
Abdominal examination
On inspection
O The uterus is larger than expected for the period of gestation and is globular in
shape the skin appears.
O Stretched and shiny with marked strike gravidarum and obvious superficial blood
vessels.
On palpation- the uterus feels tense and it is difficult to feel the fetal parts but the fetus
may be balloted between the two hands.
Ascultation auscultation of the fetal heart is difficult because the quantity of fluid allows
the fetus to move away from the fethoscope.
Ultrasound- will be used to confirm the diagnosis
AFV- a finding of more than 8 cm is an indication of poly hydramnious
AFI- when it exceeds 24 cm it is an indication of poly hydramnious
Management- the management of poly hydramnious is best done in well equipped setting capable of
handling the complications.
The cause of the condition should be determined if possible the mother will usually be admitted to a
consultant obstetric unit.
Subsequent care will be depending on:
1. The mothers condition
a. Mild asymptomatic poly hydramnious is managed expectantly. These women will not
usually be admitted to the hospital but will be advised to be admitted to the hospital
immediately the membrane rupture.
b. If the hydramnious is sever,
Amnio reduction will be done even if it has its own complications like:
o Infection will be introduced
o Labour will be provoked
o The fluid will rapidly accumulate again
Administration of drug indomethacin reduces fetal urine production and consequently
amniotic fluid.
2. Cause of the poly hydramnios
a. If the cause is gross fetal malformation like anacephally, labour will be induced.
b. In the absence of this, termination should be delayed as much as possible until fetal
maturity.
3. The stage of pregnancy
a. In late pregnancy the mother may need to have labour induced if the symptoms become
worse but:
The lie must be corrected if not normal
The membrane will be ruptured cautiously; allowing the amniotic fluid to drain out slowly
in order to avoid altering the lie and to prevent cord prolapse placental abruption is also a
hazard if the uterus suddenly diminishes in size.
Complications
During pregnancy
Increased fetal mobility leading to unstable lie and mal presentation
Premature labour
Cord presentation
During labour
Cord prolapse
Premature rupture of the membranes
Placental abruption when the membranes rupture
After labour
Postpartum hemorrhage
2) Oligo hydramnious
Defntion- the prescence of abnormally low amount of amniotic fluid (less than 500 ml)
Etiology
Prolonged rupture of membrane is the most common cause
Post date pregnancy
IUGR
Renal agenesis
Drug such as angiotensin converting enzyme inhibitors
Diagnosis
Abdominal examination
On inspection SGA uterus
- Reduced fetal movement
On palpation- fetal parts are easily palpable
Ascultation is normal
Ultrasound- will differentiate from IUGR
AFI-will be less than 1-2 cm
AFV-will be less than 5-7 cm
Complication
Pluminary hypoplasia
Cord compression
Amniotic bandage syndrome
IUFD
Management
Admission
If there is gross fetal anomaly like renal agenesis because the baby will not survive, termination of
pregnancy is the management of choice
If fetal anomaly is not present, sustaining pregnancy till full term is the best management
Medical disease during pregnancy
1. Anemia in pregnancy
Definition- anemia is a reduction in the oxygen carrying capacity of the blood. During pregnancy for a
mother to be anemic the hemoglobin count must be 11g/dl or less and/or the hematocrit must be < 33.
Incidence- it affects 5-50% in developing but only <2% in developed country.
Cause
Majority of the anemia during pregnancy are nutritional anemia; from which Fe deficiency
accounts 80-95% while megaloblastic anemia (anemia from vit B12 and folate deficiency)
accounts only 3-4%
Other causes
Hemolytic anemia
Anemia of chronic illness
Leukemia
Hemoglobinopathy
Predisposing factor for Fe deficiency anemia
1. Reduced intake
Food taboos
Poor dietary habit
Low socioeconomic status
2. Reduced absorption
GI disturbance (diarrhea, hyperemisis)
Intrinsic factor deficiency
3. Excess demand
Multiple pregnancy
Chronic illness
4. Low store at the beginning of pregnancy
Short interval between gestations
5. Blood loss during pregnancy
Menorrhagia
Hookworm
Malaria
Pathophysiology
Iron requirement during pregnancy increase (to around 1000mg)
Maternal RBC and uterine muscle- 450
Fetal RBC production- 270
Placenta- 90daily loss- 190
There is an additional demand for blood loss during pregnancy (190) and lactation (1mg per day)
Assuming normal store a mother should take 3.5 mg/day avragly
Failure to meat this demand eventually leads to anemia
Treatment- Depends on:
The cause
Severity and
GA of pregnancy
I. Iron deficiency anemia
A. Oral Fe
Ferrous sulphate 100mg PO
Continue for 3 month after HgB returns to normal
Ferrous fumerate
Ferrous gluconate
B. Parentral rout
In case of intolerance of oral Fe treatment
If no improvement in oral FE treatment
If very sever anemi
C. Blood transfusion
Packed RBC should be given
Sever anemia with hemoglobin <404 g/dl
If there is congestive heart failure
Anemia with sepsis
Anemia of hemoglobin <6.7 g/dl first diagnosed during labour
NB: Underlying cause should be treated (hookwarm infestation, malaria, chronic illness)
II. Megaloblastic anemia
Folic acid 5mg TID
Continue for the rest of pregnancy by 5mg/day
Complication
1. Fetal
C Spontaneous abortion
C Preterm birth
C Low birth weight
C IUGR
C Still birth
2. Maternal
C CHF
C Pluminary edema specially in
labour
C Delayed wound healing
C Increase risk of infection
Prevention of anemia
Improve diatery habit
Prevent and treat hookworm (deworming) and malaria
Child spacing (family planning)
Supplementation of Fe and folic acid for all pregnant women
Fe fortification of staple diets
Cardiac disease in pregnancy
Introduction
O A women with a known cardiac illness can become pregnant or a healthy pregnant women can
develop cardiac illness while pregnancy.
O The increase hemo dynamic burden of pregnancy, labour and delivery can aggravate or develop
cardiac illness
O The risk is higher around 24 wks of GA, labour and immediate post partum
O In labour uterine contraction increase the CO by 20%
Classification- the degree of disability of cardiac disease according to the New York heart association
classification is as follows
Class I- no symptoms limiting ordinary physical activity
Class II- slight limitation with mild to moderate activity but no symptom at rest
Class III- marked limitation with less than ordinary activity (dyspnea or pain on minimal activity)
Class IV- symptom at rest or with minimal activity
Management-
With rare exception women in class I and II (most) go through pregnancy with normal but
As much as possible patients in class III and IV should avoid pregnancy
Therapeutic abortion is the best option in early pregnancy
If pregnancy continues prolonged hospitalization and bed rest is necessary
Once diagnosed the mother should be referred for specialized care by obstetrician, internist and
neonatologist
Ante partum care
Bed rest
Moderate dietary restriction
Diuretics (chlorotiazides are accepted with potassium supplementation)
Intrapartum care
unless contraindicated vaginal rout is preferred because these mothers tolerate major surgical
procedures poorly
conduct labour in lateral decubitus position
provide pain relief
restrict IV fluids
provide oxygen and pulse oxymetry
shorten the second stage of labour by instrumental delivery
do not use ergometrine
rather use oxytocin in the third stage of labour
Post partum
keep the mother sitting to prevent post partum pluminary oedema
early ambulate the mother to prevent thrombosis
Complication of cardiac disease during pregnancy
are one of the most important non obstetric disability and death of pregnant women
maternal mortality rate ranges from 0.4 in class I and II to 68% in class III and IV
adverse fetal out come like
1 spontaneous abortion
1 preterm labour
1 low birth weight baby
1 IUFD
2. Hypertensive disorder of pregnancy
Definition of terms
Hypertension during pregnancy-
Single blood pressure 160/110 mmHg
Two cosequative blood pressure measurements of 140/90 mmHg 6 hrs apart
Sever hypertension in pregnancy-
Single diastolic measurement of 120 mmHg
Two cosequative diastolic blood pressure measurements of 110 mmHg 4 hrs apart
Protienurea- presence of protein in the urea
Significant protein urea-
Quantitative- urinary protein excretion of greater than 300 mg or more per 24 hour urine
collection
Qualitative- +2 or more protein on dipstick of two clean catch midstream specimens of
urine collected at least 4 hour apart.
Pathologic oedema
dependent oedema that persists after night rest
Non dependant oedema that involve face, hand
Abnormal weight gain >1 kg/wk
Type- according to the National High Blood Pressure Education Program Classification
Gestational hypertension - is a recurrent mild hypertension that develop between 20 WKs and 24
hour post partum with out any other sign of preeclampsia and that resolves with in 10 days
postpartum.
Chronic hypertension hypertension present before 20wks of gestation and persists after
six wks postpartum.
Preeclampsia Eclampsia syndrome
Preeclampsia - is the occurance of hypertension, significant protein urea and pathologic
edema after 20 WKsof GA and that resolves before 6 wks post partum. It can be classified
as sever and mild hypertension
Sign and symptoms of sever preeclampsia
Sever HTN
Protein urea
o 5 gm or more quantitative
o > +3 or more qualitative
Oligourea (<400 ml/24 hr)
Epigastric or right upper quadrant pain
Thrombocytopnea
Cerebral symptoms like:
o Frontal or occipital headache
o Blurring of vision
IUGR
Pluminary edema
Acute left ventricular failure
HELLPs syndrome
o Hemolysis
o Elevated liver function test
o Low platelet count
Eclampsia-is a tonic clonic convulsion or coma occurring during pregnancy, labour or with in 7
days post partum.
- It is a complication of preeclampsia
- It occurs antepartum 50%, intra partum25% and post partum 25%
- Must be un related to other cerebral conditions like epilepsy
Superimposed preeclampsia upon chronic hypertension - is the worsening of hypertension (+
30/15) and worsening or development of protein urea with or with out edema.
Incidence of HDP
1 7-10% of all pregnancies end with HDP
1 Preeclampsia occurs in 5% of pregnancy accounting for 70% of HDP
1 Eclampsia 0.1-0.5%
Etiology of preeclampsia
The exact cause of preeclampsia is unknown
A number of theories are forwarded, so preeclampsia is called a disease of theories.
Risk factor for preeclampsia
Nulliparity
Extreme reproductive age (les than 20 and grater than 35 years)
Hyperplacentosis
Multiple pregnancy
Molar pregnancy
New paternity
Family history
Diagnosis- The diagnosis of HDP is straight forward. The major task is to differentiate and identify
presence of complication
1. History- should include
Gravidity, parity
Gestational age
History of new paternity
History of pathologic edema
O Leg swelling that persists after night rest
O Tightness of the ring
O Puffiness of the face
Family history of HTN
Prescence of convulsion
Persistence headache
Blurring of vision
Epigastric or right upper quadrant pain
Visual symptom, neurologic symptom and cardiac symptom
2. Physical examination
- B/P
- Weight
- Pitting Edema- pedal, peritibial, abdominal, periorbital edema and ascites
- Decrease fetal movement
- Decrease growth
3. Laboratory
= Urine analysis
= Midstream urine for dipstick >+2
= 24 hour urine protein >300mg
= Oligourea
= Low Platlet count
4. Ultrasound
Management
1. Preeclampsia
A. Aggrieve management- is terminating pregnancy immediately
Termination of pregnancy is the defnative management and curative treatment of preeclampsia
resulting in the resolution of the condition with in 48 hours.
Most appropriate for the mother
Indication of aggressive management
GA >37 complete wks
Mature fetus
Sever preeclampsia
Worsening of preeclampsia despite conservative management
Eclampsia
HELLPs syndrome
Fetal compromise
Fetal distress
IUGR
Component of management
OAdminister short acting antihypertensive drug like
o Hydralizine(5mg IV stat followed by 5mg in 10 min then 5-10mg every 20 min to
a max of 60mg)or
o Nifedipine (10mg sublingual to be repeated after 30 min & immediately the DBP
is 110or more)
OStart infusion of parentral anticonvulsant using:
o diazepam (10-20mg by IV bolus for 2-3min followed by slow IV infusion of 30-
40mgin 100ml of 5% dextrose in water for 24 hour. 10mg IV bolus can be repeated
if convulsion recur)
o MgSO4 can be used instead of diazepam
ODecide mode of delivery (vaginal Vs C/S)
o Due to the anesthetic risk C/S is not preferable unless there is contraindication for
induction
o Shorten the second stage of labour by instrumental delivery
o In the third stage do not use ergometrine rather use oxytocin
OContinue giving antihypertensive and anti convulsant infusion for at least for 24-48 hours
post partum
OContinue monitoring
B/P
Level of consciousness and
Urine out put
B. Conservative management- if termination is not indicated, admit the mother in a hospital setting
1 Bed rest in left lateral position
1 Do not restrict salt intake rather restrict visitoirs
1 Record B/P frequently 15 min -6hour depending on severity
1 Daily check
Headache
Blurring of vision
Right upper quadrant pain
Urine out put
Fetal movement by kicks chart
Extent of edema
FHB
Urine
1 Weakly monitor
fetal growth either by U/S or fundal height
Uric acid
Renal and liver function test
Platelet count
Weight
1 Start medium acting antihypertensive drug like Alpha methyl dopa(250-500mg 6 hourly) only if
the DBP is 100mmHg
1 Diuretics and angiotension converting enzyme inhibiters are contraindicated
1 Once the condition of the patient is stabilized,
B/P between 140-160/110-90mmHg
Protein urea is <+1 in dipstick or
<500mg in 24 hour urine collection
No fetal jeopardy she may be followed out
patiently
1 Out patient management include frequent ANC follow up with
B/P and random urine protein at least twice per week
Daily fetal movement counting by the mother
1 She must report immediately when there is any danger sign
2. Eclampsia- is an acute obstetric emergency which if not managed appropriately results in the death
of the mother and fetus
The objective of this management is:
1. Control of convelsion
2. Control of HTN
3. Terminating pregnancy regardless of the GA
Component of management
O Emergency resustation (ABCs)
Clear the air way
Check and assist breathing
Oxygen administration
Artificial respiration if there is respiratory arrest
Check circulation and start IV line
O Prevent trauma to tongue by inserting a moth gage
O Catheterize the bladder
O Start short acting antihypertensive drug like
Hydralizine(5mg IV stat followed by 5mg in 10 min then 5-10mg every 20 min to
a max of 60mg)or
Nifedipine (10mg sublingual to be repeated after 30 min & immediately the DBP
is 110or more)
O Start infusion of parentral anticonvulsant using:
diazepam (10-20mg by IV bolus for 2-3min followed by slow IV infusion of 30-40mgin 100ml of
5% dextrose in water for 24 hour. 10mg IV bolus can be repeated if convulsion recur)
O Terminate pregnancy as previous
O Start prophylactic ABCs
O Monitor patient as that of aggressive management more aggressively. For example vital sign
including RR, PR and T
o
must be taken every half to one hour
O Continue monitoring for 24 hour up to 40hour after delivery
O if the patient convulses later than 48 hour after delivery other possible cause should be
entertained
Complication of preeclampsia
eclampsia
abraptio placenta
acute renal and hepatic failure
HELLPs syndrome
DIC
Cerebral hemorrhage
Pluminary edema
Heart failure
IUGR & IUFD
3. Infectious disease during pregnancy
1) Malaria in pregnancy- due to the immunity relapsing rate of dominant extra erythrocytic stage will
increase
Effects-
Maternal- anemia
- Puriperial sepsis
Fetal
Spontaneous abortion
Preterm labour
IUGR
IUFD
Management-once diagnosed it should be treated aggressively
If sever inpatient management and parental anti malaria drug
Drug use depends on the type of the plasmodium
Chloroquine and quinine are safe during pregnancy
Prophylaxis given for non immune people traveling to endemic area
The drug should be taken 1-2 wks before travel and should continue 4 wks after travel
2) HIV/AIDS during pregnancy