Dr.

Bassam notes

Folic acid from early pregnancy, ideally must be started 3 months

before conception
Pregnant women of 8 weeks came to your clinic ?-->..booking
1.history
2.physical examination
3. Labs
4. US
5.couselling
Labs (at first visit/booking )
1. CBC (HG,HTC,WBC,PLATELETS )
2. Urinalysis & Culture
3. FBS , if abnormal HA1c,
BELOW ).

(GCT,GTT IF TEHRE IS RSIK FACTOR ,,SEE

If there is risk factor for diabetes as macrosomic baby,or unexplained still

birth or if she had baby > 4.5 kg
you give 50 gm sugar and see after one hour if <130 normal if 130-200 do
OGTT if > 200 DM
4. HBs Ag
5. Rubella IgG, CMV IgG IgM.
Toxoplasmosis IgG, IgM.
Syphilis treponema pallidum
6. Blood Group RH, Indirect coombs test.
if mother is RH +ve do nothing
if mother is rh ve see husband if husband is negative do nothing
If he is positive or there is bleeding or trauma of CVS or amniocentesis , or
chorioncosentesis or previous D &C curettage ,and .. conversion , she should
take anti D as urgent tx and prophylaxis tx at 28 weeks how much ? , then
after delivery check rh of baby if as mother no need if as father , mother
shoud take anti-d , and again do coombs test if ve give anti d
7.
Genetic testing: SMA, Fragile X, CF, Thalasemia
8. TSH

Sulta: CBC AND UA but no rubella (becsuse she is immunized according to

the schedule) noTSH
When to follow up , if everything is ok

Up to 32 week every 4 weeks

32-36 week every 2 weeks
36-40 week every week
40-EDD/41/42 week every 3 days

12week
1. Check lab results
2. Blood pressure and weight measurements
3. Urine test/dipstick urine for albumin and sugar
4. U/S : for Nuchal translucency (NT) + nasal bone (absent
nasal bonesuspected down syndrome )
5. Blood test for pregnancy associated plasma protein a (PAPP a ) and
HCG

Combined test: non invasive screening test for Down

Syndroem, includes NT+(PAPP-a+HCG)

6. Start iron and vitamins supplements

NT = result give the risk :1:number

if <200 chorionic villus sampling (CVS)
200-3000triple test or quadrable test
>3000Alpha fetoprotein
Combined test: non invasive screening test for Down
Syndroem, includes NT+(PAPP-a+HCG)
Combined test is done 11-14 weeks
Abnormal combined test or of if there is history of congenital
anomalies in the family and if maternal age >35 year CVS
(AT 12 WEEK )
1ST Trimester US
- Diagnosis of Pregnancy.
- Place of pregnancy/site location

- Dating
- Viability
- No. of sacs
- ( Chorionicity and , Amnionicity ).
After first trimester chorionicity cannot be known but amnion
number still can be can

1ST Trimester Screening :

NT , HCG,PAPPA combined test
CVS .
Uterine Artery dopller.
Nasal bone US./if absent suspect down

Fetal movement at 17-18 week, Gender usually at 17 weeks,

but can be seen before if good US
16 weeks

1. Early detailed U/S ( By fetal medicine specialist )

2,Fetal Echocardiogrrhaphy.

3.Vaginal US for Cervical Length

18 weeks( can bring the test result at 20 weeks )

triple test - AFP, hCG, and Estriol
Quadrable test + Inhibin-A is another hormone made by the placenta
o 16-20 weeks
Triple Test:
AFP,HCG,UE3
o Qudraple . Test : T.T. + Inhibin A
o Amniocentesis.
o Cordocentesis.
PS : CVS : 12 / AMNIOCENTESIS AND CORDOCENTESIS AT 16-20
20 weeks
1. Ask about fetal movement
2. Ask about maternal nutrition

3. Ask about medications?

4. Blood pressure and weight measurement
5. Urinalysis
6. U/S For fundal height
7. for detailed U/S
+/- CHORDIOCENTESIS

24 week
1.
2.
3.
4.
5.
6.
7.
8.
9.

Brief history
Physical exam : abdominal exam and listen to fetal heart beat
Ask about fetal movement
Ask about maternal nutrition
Ask about medications/iron and vitamins
Blood pressure and weight measurement
6. U/S
check detailed U/S report (IF WITHIN ONE WEEK DO NOT EXAMIN ?!)
Ask GCT ( not done before 24 weeks ) unless there is Diabetes risk

10. Cbc (hg and wbc ,htc,platelets ,and to see if she is compliant to
iron or not ?
- GCT /Glucose challenge test 50 GM AND CHECK RESULTS
AFTER 1 HOUR
<130 normal
130-200--> impaired glucose tolerance do OGTT/oral glucose
tolerance test
>200DM
OGTT 100
Fasting 60 mins/1 hour then 120 mins/2 hours then 360
mins/3 hours
ALSO FE 75 Gm ?
NORMAL READINGS:
Fasting <92
1 hour ..<180
2 hours<155
3 hours <140

if 2 abnormal reading GDM start exercise and ?? if one

abnormal reading ,repeat after 4 weeks
11. women with preterm delivery risk , give Dexamethasone(24
mg) at 24 weeks , (GCT must be done before giving Dexamethasone ,
because if she is diabetic and Dexamethasone was given she may
have DKA,
If CGT showed that she is diabetic hospital admission and diabetes
control FOR 5 DAYS
FROM SLIDES 24-28 WEEK

GCT 50 gr.

OGTT 100 gr.

CBC.

Targeted Detailed US (Extended ).

Fetal echocardiogrrhaphy.

Dexamethasone ( Risk of PTL )

28 WEEKS
1. Ask about fetal movement
2. Ask about maternal nutrition
3. Ask about medications/iron and vitamins
4. FUNDAL HIFGHT (symmetrical /not, corresponding
date( older/younger)
4. For RH-ve Anti D
32 weeks
1. Growth U/S
Targeretd U/S only in case of suspected abnormality
So Amniocentesis and CVS and targeted U/s not for all pregnant
Inhibin-A is another hormone made by the placenta
34 weeks
the same but +
1.Group b sterp (GBS)vaginal culture (lower third of vagian and

perineum), must show the pregnant how to do it with the swap.

result must be given to the patient
Result either + or ve
If culture result is positive prophylaxis at labor
36 week
1. Weight and blood pressure measurement
2. urinalysis
3. Fetal movement
4. tell her that in case of abdominal pain ,bleeding , liqure, FEEVR
OR DECREaSD FETAL MOEVMNT .. go to hospital
4. Abdominal examination , fetal heart rate fundal height ,
presentation ,lie.
PS: Neural tube defectsat 12 weeks /or detailed US
3740 week every one week
1. Abdominal examination , see engagement , presentation , lie ,
heart beat, no need for vaginal exam
2. urinalysis
3. Review all tests
4. give her report of all tests from all visits
>40 week
US every 3 days biophysical profile (4 US and NST)
1.fetal breathing movement
2.fetal tone
3fetal gross movement
4.Reactive fetal heart rate/Non stress test NST
5.Qualitative amniotic fluid volume
Or modified biophysical profile :NST and liqure /fluid
if booking was done at 18 week (the first visit was at18 week)
1. Full Hx.
2. PE
3.U/S
4.labs
5. See if there is risk factors for DM (Do GCT), Or if there is risk factor for
chromosoamal anomalies ,
6. detailed US
7. And tell her to bring results after 4 weeks

COMMON diseases in special areas :

Sur Baher : Krabbe, HUPRA.

Jabal El Mukaber : Krabbe , Stuve-wiedmann
Mount of Olives/altour : NKH/nonketotic
hyperglycinemia
PCKD ANU GHOUSH
Epidermolysis bullosa jenin

Dr . Mazen notes

Dating of pregnancy 1. LMP 2. US

LMP criteria depends on history
1. First day
2. Last 3 Regualr menstrual cycles
3. Not lactating ( in the last 3 cycles
4. Not taking oral contraceptives (in the last 3 cycles
5.there was no miscarriages( in the last 3 cycles
Naegele's rule : +7 DAYS 3 months (this only if cycle =28 days )
Normal menstrual Cycle = 28+/- 7 days ( 21-35)
Example if =30 days (we add to naegles rule ,+7 +2 days -3
months
If 35 days (+7 +7 days 3 months )
21 days (+7 -7 3 months
25 days +7 -3 days 3 months
This called corrected EDD according to LMP
Many studies showed that if dating according to US occurred
early in pregnancy this lowers the risk of induction of labor
because it is more accurate
Dating by US before 20 weeks
Dating by US CRL ( the first and the most accurate way to date
by US ), criteria up to 84 mm which equivalent to 14
weeks, and regular cycle
If> 14 weeks HC (BOOKS MAY DIFFER FROM THIS BUT IN
EXAM THIS IS WHAT WE SUPPOSE TO ANSWER )
If a women who doesnt know that she is pregnant came to visit
and she is found to be 28 weeks on US , what to do ?--> HC
(BECAUSE IT IS >14 weeks )
BUT MUST not forget that accuracy <20 weeks is less than
accuracy > 20 weeks
Example: regualr cycle , pregnant of 13 weeks ,and CRL=14
weeks ?

If there is different between history and US , in the first trimester

IF Difference < 5 days is accepted if , if > 5 days WE
change date according to US
In case of HC , the difference accepted (of course >14 weeks )
some say 7 days and other say it is accepted if up to 10 days
Common 3na fe Palestine and v important to ask about in the
first visit DM (WE ARE HOT SPOT ) AND TAHLASEMIA, HTN ,
PREETRM LABOR, PREECLAMPSIA (she ) and if she is
Primigravida (Her mother and sisters ) , because there is risk
(maternal and siblings) and smoking

High BMI MORE RISK FOR GMD AND obstetrics problems

low BMI GROWTH RESTRICTION

Dr saadeh jaber notes :

Genital tract infections
Genitourianry medicine
3 names : reproductive tract infections/STD/genital tract
infections(Collectively is the one who contain the others )
Every STD is genital tract infection ,but not vice versa , means that
genital tract infections ,some are STD and others are not
Candidiasis is the most common genital tract infection but it
is nor STD
inherited Causes of genital tract liability to infections :
1. Anatomy and proximity to anal verge
2. Hygenie ?
3. Liability to trauma through ( even micro laceration during sexual
intercourse and instrumentation , and menses )
4. Free access to peritoneal cavity, all/ most of genital tract
infections are ascending ..vagina cervix uterus ,fallopian tubes
,ovaries to peritoneal cavity
comparing it to GI infection : it remains in the tarct ma btl3 lbra bedl
m7sor
5. Significant social implication (vertical and horizontal transmission )
Protective mechanisms in the genital tract :
1. Acidity : by lactobacillus (normal flora of genital tract ) causes
high acidic media ,
hostile for most pathogens, most infection in the developing countries
are iatrogenic / cause by overuse of ATB , which reduces the normal
flora ,and give change to opportunistic infections to arise ,like after
URTI , we know that M C C IS viral (85% and 15% only bacterial )

Giving ATB causes other infections . start with amoxicillin and not
cefuroxime/ zinnat 2nd genereation cephalosporin , in our countries we
have very high rsistance due to overuse of ATB
2. Water-celled closure of vagina in premenopausal state , we
have thick epithelial layer and mucus which is secreted by cervix
glands not vaginal glands(there is no vaginal glands) /

anything that interfers with this barrier: intercourse and
instrumentations-(like in post menopause state ) leads to more
infections
3. Menses : regular and normal amount it protects, but when found
in heavy amount and not regular , it contributes to more genital tract
infections
any pathology ..ma bla7k ysafet ilgranuloma ela hlmenses jay w
ma5deh kul she
4. Very rich blood supply to pelvic area :perineum ,vagina, huge
collateral circulation
like in episiotomy, healing is fast by 1 week , also means high ability
to mobiles any infection by bringing macrophages ..

General principles in genital tract infections (Diagnosis and

management )
1. Privacy : especially in STD to guarantee eltzam ilmred , to lower
stigma, to follow up with the same
2.accurate diagnosis : throughout accurate history and physical
exam
example: vaginal discharge could be due to bacterial /viral /fungal and
protozon infection like : trichomonas, and sometimes heavy discharge
could eb normal in some females
special clues in history:
very bad smell during intercourse bacterial cause
frothy secretion candida
Dysuriagonorrhea
Special clues on examination
excessive skin reaction candida
strawberry cervix trichomonas
Gonorrhea
and Wet mount. A sample of the vaginal discharge is placed on a glass slide and
mixed with a salt solution (KOH )if hyphae and spores fungal ,flagellated protozoa
trichomonas and if diplococcus gonorrhea

serology for herprs ,syphilis

DO NOT TRY TO TREAT EMPIRICALLY

3. Accurate treatment of course according to organism

+guarantee compliance (especially for those risk taking
personalities ,
through one /two doses in single day , if its hard to maintain
compliance admission and IV /hospital
4. Contact tracing :in STD we treat both partners
5. Think of association
like recurrent candidiasis DM ,Immunosuppression /compromisatio
HPV cervical cancer / 6 /11 genital warts , 16/18 cancer
Childhood / ( ) Pinworms ,foreign body: M C C of
intractable vaginal discharge in childhood
6.follow up strategy because of risk taking personality ,

hep b and drug abuser !
Gonorrhea found more symptomatic in males due to
preference of transitional epithelia ,
You can give metronidazole during pregnancy /not preferred but
you can give it
Amsel criteria hay bdon 2le b3dha
Vaginitis gardnerella and proteus in MS
Upper genital tract infections :PID, salpingitis , endometritis
Lower cervicitis , vulvovaginitis
PID : every attack causes 10% infertility 2 attacks 20 % 3
attacks 30 and so on , y3ne bt5rb 10% mn iltube
M CC OF PID Chlamydia (obligatory intracellular
organism ), dysfunctional tube , through enha bt3esh jwa w
bt5rb ilcilia , w mmkn tltube patent bs ilcilia bt5rb

Tubo-ovarian abscess rx; drainage either transvaginal/transabdominal , ro

surgical driange