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WhiteKnightLove
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WhiteKnightLove
Fertilization I
Placenta 3
Maternal adaptation 10
Diagnosis of pregnancy 16
Ante-natal care 18
Habitual abortion 33
Ectopic 40
Vesicular mole 47
Vasa previa 50
Placenta previa 51
Accidenta! hge 55
Atonic 60
Traumatic 62
Retained placenta 68
Drc 70
Acute inversion 72
Amniotic fluid embolism 73
Shock in Obstetrics 74
Obstetric trauma 75
Pre-eclampsia 76
Diabetes milletus 87
Heart disease 96
Hyperemesis g ravidarum 101
Urinary tract infection 104
Anemia 107
Thromboembolism {10
Thyroid disease 113
Respiratory disease 115
Surgery & Pain 116
WhiteKnightLove
My 2 Aims in this book to be SIMPLE and COMPLETE, so I
save no effort for doing that.
It is hoped that the readers will find this book, presented in
4 volumes (GYNECOLOGY A means volume I ), a useful
source covering their necessary basic knowledt. of
GYN ECOLOGY AND OBSTETRICS.
Your feedback and sutEestions will be valuable to us, so we
hope to contact us on Email or website
MANDOOHM@HOTMAtL.COM
WMW.DR-MANDOOH.COM
Dr Mohamed Elmandooh
WhiteKnightLove
.J -
.J -
.J
1
Fertilizotion
Plocenlo
Moternol odoplotion
Diognosis of pregnoncy
Ante-nolol core
WhiteKnightLove
@@ OVULATION l2rh Doy
Spermotozoori
ygole
trogen
Doy 5 25 30
of Morulo
Cycle
Fo I lopion tube
B lostocysl
Prim itive
trophoblost
WhiteKnightLove
zo
-t
3
Fertilization g
E
. o
Definltlon. .. ...The union of a mature ovum & a mature spermatozoon
o 1/z) --+ zygot
o
at ampulla of F.tube (bet. outer & middle =
o
=
o
o TrgnsPort of sprrns
- Mature spenns l22x or 22y) reach F.tube. ..within 40 min
- Capacitation of sperms starts. ..within the cx
\ changes in sperms tot its ability to fertilize
. Removal of excess proteins
o
. Production of enzymes e.g. hyaluronidase
o Tmns}ort of orum
- Ovulation -+ completion of meiosis I -+ 1ry oocyte + 1s polar body
- Ovum pick up occurs by the tubal fimbia -+ then it is carried by "
\ passive fluid currents (helped by ciliary action & peristalsis)
. The Unton
-
''" l sperm penetrates the ZP (Polyspermia is prevented by: Zonal block)
" b'dv .
r d,#'ffii'*:ffrt'!ffi',ft'$;H'Jf,lp"ar
Differentiation
o Zygot rapidly divides by mitosis ...2...4...8 + BmsrorueRes
o A Monum is formed (round mirss E 16 cells)
- It reaches the uterine cavity a.fter 3 days from fertilization
- It is nourished by secretions from the tube (tubal milk)
Fluid will then accumulate -+ a BtRsrocvsr
- It remains free for 3 days in uterine cavity
- It is nourished by secretions from the endometrium (uterine milk)
The blastocyst will
be divided into 2 masses:
- lruruen c€LL Mffss -+ x 100-250 cells a
will form the embryo
- OureR cett nnms -+ trophoblast O responsible for nutrition
WhiteKnightLove
Ann ioiic
Two srnoll covitie gppol, one in the ectodem formirp fhe omniotic soc,
thc othcr
in the enlodsrm - thc yolk soc.
Proiections of
proliferoiing i-
trophoblosf
cells
(primitive
villi)
invode
deciduol
vessels
Embryonic ored
--- Meoder.---
Trophobl osl
Connecling stolk -
- Ectodam
Mcsoderm
Trophoblost loyer
WhiteKnightLove
lmplantation: z
o
!
It occurs on tle 6s to 7h days after ovulation 3
o
\
by penetration of the trophoblast into the Dectpun :- o_
\
modifled secretory endomet. under efflect of both P/ a ! !q
o
o GI
Functions of the decidua
=
o
- Site of. ...rnpfantation&,natritianof fitastocyst
=
o
- Site of. ........f0*tianof tfreptacenta
- Protection ..against kws of transpkntationimrutnabg
- Protection ,dgfritt$t tfie imta$ae power of trophofifost
..
WhiteKnightLove
Deciduo bqsolis
Deciduo copuloris
Deciduo bosolis
t
I
t
I
I
I
-1+!rE
''Chorion
loeve
Deciduo
copsuloris
Deciduo
---
WhiteKnightLove
zq
3
Norrnqlstruefurc o
> Shape. ......, discoid !
> Weight. ... ...500 gm
o
od,
> Site. ..UUS (60% postenor) -+ site of implantation
o
> Size. . 18-20 cm in diameter
=
> Thickness. . . ... ... ..2.5 cm in center -+ gradually thins towards periphery o
o
> Cord insertion... . .. eccenfiic
Plecental founqfion
) Two parts
o
!(tB o sularis s
t ofthe c I
WhiteKnightLove
Moternol blood
Plocentol r "& - - ---Syncytiotrophoblost
borr;e, ---{
Endometriol glond
\
(
")oc
,
c
lj
oe
oa
4.i<F-; .J
Mesoderm
WhiteKnightLove
z
o
O I fulEchonicol ottochmont 3
r Ptocentol borrien- o o_
!-t
1- Cytotrophoblast 2- Syncitiotrophoblast (0 at 5ft- 6n'month)
o
3- Mesoderm 4- Fetal capillary endoth. + its basement memb. GI
=
o
'tThe placenta becomes thinner as pregluulcy advances '
*The placental is permeable to many drugs & organisrns e.g. =
o
- Drugs ue oral anticoagulants & oral hypoglycemics
- Bacteria us TB, syphilis, malari4 toxoplasma
- Viruses os IvIIMR, CMV, chickenpox, polio
teilcDlqcshtql unlh
- Placenta can convert cholesterol (C27) into ggsesterone (Czr)
- Placenta can convert androgens (Crq) into estroeens (C1s)
- However, placenta can't convert progesterone into androgens .'. it
must be supplied with androgens first e.g.:- DI{EA & DI{EA-S
from both mat ernaf & feta I sources ( suprarenal gland mainly )
.'. J in anencephaly "
Estrogsn Lsual
o Estrone (81), Estradiol (Eu) -+ O t00 times
. Estriot(lEs) -+ O 1.000 times (the inteao o of feto-maternal unit)
o Estetrol (E+) + only formed in preg (of little significance)
WhiteKnightLove
zPlocenlol
cotyledons
oll round
- Amniotic
covity
Plocento Membronoceo
Plocento Duplex
Plocento Biportilo
The plocento is com-
Ihe,+Iocentq is pletely divided into
portly divided two lobes, with
into lwo lobes, vessols uniting
wiih connecting to form tho cord.
vessels.
Uterine woll-__{-z
Redupl icoted
Plocentol tissue -- .'ond inforcted
- chorion
Attochment of
membrones to
fetol surfoce
WhiteKnightLove
z
o
I
> Shrm 3
o_
l. Bipartite placenta O 2 equal lobes connected by......membranes
2. Bilobate placenta 4 2 equal lobes connected by... ... placental tissue !
-t
3. Placenta fenestrata 4 a window is present (a part of placenta is missed) o
cl
5
4. Placenta succenturiata (succenturiate lobe / lobes) o
o f
- Small accessory cotyledon/s attachedto placenta by membranes
o o
- May be torn away during delivery + retention + PPHge or p.sepsis
- Diagnosed by routine examination of pl. -+ site of torn vessels on margin
5. Placenta circumvallate (extrachorial placentation)
- The chorionic plate (ch.frondosum) is < the basal plate (D.basalis)
- The fetal margin shows a white ring formed of decidua
- May lead to abortion.......CFMF, IUGR, PfL, IUFD......accidental hge
6. Placenta membranacea
- The chorion leave does not atrophy -+ large thin placenta (15-20 inches)
- May lead to placenta previa
- If accompanied by vasa previa --+ APHge of fetal origin {
> Slio
o In LUS -+ placenta previa
o On septum --+ liability to abortion, APHge, PPHge or retention
o Elsewhere (as tubes or peritoneum) -+ ectopic pregnancy
> She
o Small (associated with IUGR or infarcts) 17 placental insufficiencv
o Large (hyperplacentosis) # svphilis. Rh. DM. twins, placenta membranacea
. Syphilis: large, pale, friable / Endarteritis obliterans / Spirochetes
. Rh isoimmunization'.large, pale, edematous
WhiteKnightLove
Umbilicol vein
/\/\
i:'U.bili"ol='-'*
orteries . Arnnion
Whorton's iell/
True
knot
WhiteKnightLove
z
o
-r
Strucnre 3
o_
o Length ----r about 5O cm
!rl
o Diometer --+ about 2 cm o
o Contents --+ 2 arteies (non-O2) & I vein (O2) " carryingfulslblood along GI
with remnants of allantois in myxomatous tissue (Wharton's =
o
:,
jell). Vessels are convoluted (length of vessels > cord) o
o The omniotic membrono covers the umbilical cord '
One voln carries oxugenoted blood to the fefus
Truo orterles carry rcduced blood from the fefus to placenta
flcnomollttes
I. Length
, Vtry /orug(>100 cm) ma1 had to:
- Coiling around fetus
- True knots
o
- Cord presentation & prolapse
> Short cord (<32 cm) mry lead to:
- Failure of . engagement & descent of fetus
. presentation (malpresentation e.g. transverse lie)
. external cephalic version or forceps
- Fetal asphSn<ia (distress) or rupture of cord or
. APHge (accidental hge)
. Uterine inversion
9. Fbnqmol ottochment: may be:
> Ceatral
> Marginal (battkdore) "
> Velamentous insertion of the cord
- Vessels are inserted into the membranes (& not placenta)
- If the traversing vessels pass below the presenting part in the
region of the ceryix they are 4 called.....voso previo
- It is usually associated with placenta membranacea
3. Knots in cord, may be:
* Trwe ? fetus passes through loops of the cord + may lead to fetal distress
* False O localized varicosity in a collection of Wharton's jelly + no effect
4. Congenitol umbilico! hernio
5. Tumors / cysts (as mlxoma and sarcoma)
6. Fbsence of ono umbilicol orterg
* Common in DM
* May be associated with CFMF, IUGR, prematurity
WhiteKnightLove
AMNIOTIC FTUID
Volume
Secretion
By diffusion
thrcugh
. The fluid is reploced wery
hours.
3
The formotion ond circulo-
by omnion-- umbilicol tion is notdefinitely known. lt moy
corrd be derived from severol sources.
WhiteKnightLove
zo
> Lovers of omnlon ( 0.5 mm -i 5 layerr )
3
1. Cuboidal epithelium o_
2. Basement membrane 'u
3. Compact layer (reticular fibers arranged in bundles) o
@
4. Fibroplastic layer )
5. Spongy layer (contains mucous + can glide upon chorion) o
a
o
> Sourco of omnion ....amniogenic cells ( from fetal ectoderm )
> Volume
6wk-+5ml l0wk+30ml i20wk+300ml
30 wk -+ 600 ml 36 wk + 1.000 ml 38-40 wk + 800 ml
> Composltlon
. 99 o/o Clear watery
. 1-2o/o crTstaloids & cotloids [+vernix caseosa, desquamated epith., lanugo hair]
- CHO (glucose & fructose) - proteins (albumin & globulin) - lipids
- Hormones (E.& Pr.) - electrolytes (Na. K. cl. Cu.)
r PhySiC?l propefties
- Colorless -+ later on will be turbid
- Specific gravity -+ 1010-1020
- Reaction -+ slightly alkaline " 1l-1.51
> Functlons O
9. Durino lobor
.hotection against trauma . Thermoregulation . Helps cervical dilatation
. Allow free movement . hevents direct fetal &
.Prevents adhesions bet.
of fetus -+ muscular placental compression
fetal skin & amnion
development by the uterine wall
.hevents infection . Deve of alveoli . Wash birth canal after ROM
Rbnornolltles
o Volume (f
. .. polyhydramnios, O.. . .oligohydramnios, PROM)
WhiteKnightLove
ch
weeks 8 16 24 32 40
WhiteKnightLove
z
o
-t
* Steroids "+ estrogpn & progest .. ..from CL & placenta o 3
g
* rDroteins,+ HCG & HPL. ..,...from syncitio-ftophoblast o .9
rt
o
Gl
I ) Humon drorionic Aonodotrophin )
o
o a
> gtune o( p'wfuAnn(a glycoprotein) o
- Appears at ls day of implantation
- Can be detected within 10 days of fertilization (conception)
o
\
i.e. before missing a period
>,eed
- It O rapidly in early pregnancy --+ level doubles every 2 days
- Reaches a peak at70 day (10 wk) gestation (= 50.0fi) mlU/ml)o
- Then it $ at 100 d (1a wk) = (s.000) & remains as such till term
> Di,tappearu al
. 1-2 weeks after abortion
. 2-8 weeks after labor
.8-12 weeks after vesicular mole evacuation
> Qtoeooed&y
Urins + with latex (detects 500 rnlu/ntl)
Stide agglutination
ELISA: more sensitive (90%), (detects 50 ntlu/ntl)
Serum -+ RrA /{ the most sensitive, (detects I rtIU/rnI)
\ assess p-subunit (as a-subunif is similar to FSH, LH, TSH)
> Aaho
FuncEion Usos
Maintenance of CL
of abnormalitie
WhiteKnightLove
CIRCULATION
Heqd
/-q \
F
o
Umbilicol
vetn -
P.- Viscero
c -)
Ol
.J
J*
o-
Arch of Ductus
WhiteKnightLove
z
o
rl
O gntrauterloe 3
g
- Oxygenated blood from the placenta passes to the fetus via the E
rt
o
umbitical vein (l) -+ penetrates liver to give it small branches o
GI
- Most of the blood is directed via the ductus venosus into the IVC f
(which carries also the returning non-Oz blood from LL ' )
o
a
o
- There is only partial mixing of the 2 streams and most of the
oxygenated blood is directed by the crista diuidens ( at the
upper end of the IVC) through the foramen ovale into the
left atrium + the left ventricle -+ aorta + this relatively well
Oz blood supplies -+ the head & UL
- The remainder of the blood from the SVC mixes with that of IVC -->
passes to the right venfficle -+ very small amount of blood goes
to the lungs (high pulmonary vascular resistance " ). Most blood
passes via the ductus arteriosus to the aorta (beyond the vessels
supplying the head & upper extremities) -+ supply viscera &,LL
- Little blood actually goes to the LL. Most of it passeso into + Rt & lt
internat iliac arterios -+ umb.!!!ca!arteg.!el (2) : non Oz blood
@ flt birth
- The umbilical vessels contract in response to J temp -, J 02 tension
t
& CO, -+ stimulation of respiratory center
- Breathing -+ -ve thoracic pressure -+ strcks more blood from the
pulmonary artery into lturgs & diverting it from
the ducfus arteriosus which gradually closes
- The left atrial pressure -+ closes the foramen ovale
(0 fl.ater
- Umbilical vein -+ @(runs in the free border of the
falciform ligament in the adult)
- Umbilical arteries + hvposastric liqaments (lat. umbilical tig) "
o
- Ductus venosus -+ !!rc@enosum o
- Ductus arteriosus + lisamentum arteriosum
WhiteKnightLove
c%tes
WhiteKnightLove
WhiteKnightLove
7
weeks
"',nxhLHIElji'
At 7 weeks the uterus is the
size of o lorge hen's egg 0
At l0 weeks it is the size
of on oronge
@
At l2 weeks it
of o gropefruit
is the size
WhiteKnightLove
<> UEateauet aeelatgtEou <e
z
o
3
g
l) The uterus !
o
(o
* -+ 0 from 50 gm (10 rnl3) to -+ 1 ls (5000 d3) )
Shqps o
-+ changes from pear shape -+ globular -+ pyriform a
o
* Slzs -+ 8 wks (5 cm),...12 wks (10 cm).,.....16 wks (15 cm)
+ Then fundal level according to gestational age
-+ Till reaching 35-40 cm at term
* llgonrehium
o Hypertrophy / & hyperplasia of muscle fibers
o Contractility
- In early preg., they are detected bimanually "+ Palmer's sign
-Latq on, cont. are detected abdominally .+ Braxton Hick's
- They become perceptible & painflrl near term ,+ false labor pain
Upper segment I
I
I
Peritoneum Adherent Lgg-sg"- _ _ _ _ -_i
Dcidua Well
IlunP"lpyq$1"-
Irqldeyelqp_e$__ _ j
--i
adherent -
lgp;.ly p"g["gr."$" . " - .j
Et!
Passrye i
WhiteKnightLove
VULVA
;. Prepuce of clitoris
- z? --
$'---
.'---
r5 ----
Clitari<
- Clitoris
-.S,[-__- Frenulum of clitoris
meotus
-Urinory
jrit-
'SS_
- -----Vestibule
- - Lobium minus
- - Lobium moius
Y;.-. - _ : _- _ _-:_-
: I:;,,:;",,
:* - -- -- "
- Perineum
f*-- --Anus
i
ll
li
./\'r
,'/ \::,,
./\
WhiteKnightLove
2) The ovaries
. No oulstlon oocur3 (suppressed LH & FSH) z
o
o Ths corDu! lutsum sscretss
g3
- E&Pr + produced mainly from CL till 7 wks, then production is shared !q
o
. Rerqdn - .1'[iJff":h.ji:TJi"th'l?lf":#: fl#:[ i X; GI
a
ripening of ceruix & relaxation of pelvis at labor cf
. A CL c$t may be found in the lstrimester o
( < 6 cm disappears spontaneously (functional)
3) The fallopian tubes o enlarged, stretched, increased vascularity
4) The vulva
- f "d vasctrlarity a soft & violet (Jacque Meir sign)
- O 'dliability to ovaricose veins & edema
s) The vagina
-
O 'd vascularity a soft & violet (Chadwick sign)
-
O "d secretions a
acidic (lactobacilli )
- Epithelium is thick (smear -+ intermediate cells)
6) The ceruix
- O 'd vascularity a soft & violet (Goodell's sign)
- t 'd secretions a mucous plug obstructing cx canal (operculum)
- Epithelium:- ectopy (replacement of st.sq.epith of ectocx by columnar)
WhiteKnightLove
lncreosed metobolism
increosed heot pro-
lncreosed =
duction
9OSeOUS -+peripherol
interchonge vosodilototion to get rid
of excess heot
D FOR
ooD s
lncreosed metobolism
=increosed excretion
of woste products
:11:l:1:
:: :::i
jr::r
|!il;;,l:
li Hyperventilotion
lncreqsed lncreosed
lnspirotion Expirotion
-/
,r'
lncreosed oxygen intoke exoired oir increosed
Y
I
Lo*rnotlnol blood
High orteriol oxygen corbon dioxide
WhiteKnightLove
o z
The blood o
* Prsssrns,'+ S esp in2"d trimester 3
o_
- Placenta acts as an AV shunt ) leading to O in the P.resistance E
rt
- Vasodilator effect of progest. ) t
& of the peripheral flow o
Gl
* Votunre of Plumr ,+ increase 40-50% (max at 30-34 weeks)" =
o
* 5
Elsmenh o
o RBCs -+ increase 20-30Yo"
So, tlrere is more t in plasma volume > RBC volume -+
physiological anemia (haemodilution). Pathological if < 1lgmo/o
-+ Haematocrit -+ decreases
o Leukocytes + f slightly, esp after labor (14-16.000 /rd3)
o Blood coagulation -+ increased coagualability
- O"d factors VII-X and fibrinogen + $"6 fibrinolytic activity
- Platelets -+ mild decrease
. ESR -+ increases (due to f fibrinogen)
E
The heart....changes occur from l"ttrimester
.O'd Cop (30-5 lyA ,- (d.t. t
both SV & IIR: 10-15 bpm)
o The heart is displaced upward & laterally by the diaphragm
-+ shift of apex beat from 5ft to 4ft intercostal space
o Due to increased flow rate
- lls+t sounds
. Splitting ofthe 1* sound
. Appearance of the 3'd sound
- [lo+t murmun
. Soft systolic murmur may be present (90%)
.If diastolic murmur occur we must excludepathologt
Veins There is increased liability to varicose veins due to
- Progesterone (rela<ant effect on vessels)
- Pressure of the gravid uterus
- Increase in blood volume
WhiteKnightLove
-- --Reloxotion of sphincter +
Regurgitoiion * heqrtburn .
Reduced motiliiy of
lorge intestine -- --
lncreoses tirne for
woler obsorption, .
but olso tends to
induce
constipot ion
/l\Cro*tt, of conceptus ond
,
uterus - lncreoses oppe-
tite qnd thirst. ln lote
pregnohcy pressure of the
uterus reduces copocity
for lorge meols +
frequent smoll snocks.
WhiteKnightLove
z
o
rt
lf The mouth
3
- Morning sickness a nausea & sometimes vomiting in early pregnancy g
- Changes in appetite + longing (pica) -+ desire to certain food !{
- Ptyalism a excessive salivation (hyperemia of the gums t hypertrophy) o
GI
2f Esophagus =
o
- Relaxation of cardiac sphincter ) leads to pyrosis =
o
- Delayed gastric emptying ) : heart-burn (P. etrea)
JIrry
o Mood changes (elevated or depressed) - (sleepy or insomnia)
o Relaxation of the pelvic joints, sometimes arthropathies
o Lurnbar Lordosis -+ to compensate for the enlarged uterus
WhiteKnightLove
CARBOHYDRATE METABOLISM
WhiteKnightLove
z
o
) The pituitary rt
Increased size & vascularity (esp anterior lobe: 2-3 folds) 3
t prolactin - J rSn & LH, GH [other hormones are unaffected]
o
!
) The thyroid -
o
Slight enlargement (t fSn & chorionic thyrotropin)
GI
o =
o
t serum thvroxine (due to t tBG, free hormones are unchanoed)
f
t elr4n 25olo (due to pregnancy & not hyperthyroidism) o
> The parath5rroid
Sligtrt enlargement + t pmnrnoRMoNE to t serum Ca
but Cnlcrrouru also 1 .'. no chanoe in ionized Ca level
l. Piggnentation......d.t.O placental & adrenal steroids, also E, may have MSH like activity
o Eso in nipple, areola, axilla, vulva
o Linea nigra (dark brown line between umbilicus & symphysis)
o Chloasma oravidarum (butterfly pigmentation on face)
2. Sfiiae ggavidarum......due to O corticosteroids or by mechanical stretching
o Pink lines due to rupture of elastic fibers or SC vessels of skin of abdomen
(common), breast, thighs, buttocks. Later on after delivery + striae albicans
3. Dimfcation of recti
4. Hlpercmia + vascularity of skin & m.m. (nasal congestion)
5. Sometimes + falling of hair, palmar erythema and spider naevi
> Vitamins O t"d fat soluble vitamins + O"o water soluble vitamins
> Minerals a J serum iron (Fe stores may be depleted if no Fe supplementation is given)
But t transferrin (total iron binding capacity)
> Immunoglobulins A increased levels of IgA and IgM
WhiteKnightLove
c%tes
WhiteKnightLove
IA,;J'LEJ,LT;N
z
q
O Gastnointestina! 3
o_
) Mornlng slckness....
) Gingtvttis: hyperemic gums that may bleed with the use of a tooth brush !
) Ptyalism: excessive salivation d
@
) Heattburn: Treated by antacids, more frequent meals, avoidance of spices )
) Indigestlon: hypochlorhydria (regurgitation of alkali chyle into stomach) o
f
) Coastipation: tr fluid intake + eating whole meal bread [& not white breadl o
) Hemorrhoids: usually regress after delivery [but not completely]
O urinaru
) Frequency of micturition: d.t. pressure from the gravid uterus
) Incontinence: d.t. loss of the post urethra-vesical (PU$ angle
@ Muscuto-skeletal
) Baclache:
- Common in the last trimester
- Treatment: . Avoid wearing high-heeled shoes
. Exercises to strengthen the back muscles
> Leg cramps:
- Elearolytedisturbance
- Engorgement of lower limb veins
) Round ligament paia:
- Sharp groin pains d.t. spasm of the [igament associated with
sudden movements (esp the right side ---d.t. dextroposition)
@ Skin chanoes
) Strlae gravidarum
) Sweatlag & feeling the heat: (d,t. O peripheral circulation &VD)
> Vaginal discharge = leucorrhea: (d.t. f estrogen)
@ Nervous sustem
) Insomnia d.t. the large uterus, leg cramps & backache
) Carpal tunnel syadrome: d.t. edema -+ disappears 2 wks after delivery
> Placidity lcrlrnnessf & drowslness: d.t. O progesterone
@ Cardiovascular sumotoms
) Varicose velns: treated by :
- Patients should sit with their feet elevated whenever possible
- Nylon elastic stockings should be put in on the morning before
getting out of bed...........to be removed on sleeping
) Headaches, palpitations & fainting
) Physiological edema (below kaeef
WhiteKnightLove
1. A urine pregnancy test will often be positive at
the time of the missed menstrual cycle.
2. Physiologic changes during pregnancy, mediated
by the placental hormones, affect every organ
system.
3. Cardiovascular changes include a decrease in sys-
temic vascular resistance and blood pressure and
a 5070 rise in total blood volume.
4. Elevation in serum progesterone levels is respon-
sible for smooth muscle relaxation in the vascular
system, Gl tract, and genitourinary system,
leading to many of the concomitant physiologic
changes.
0 o Menses
7 I
14 2 Conception
2'l 3
28 4 Pregnancy t€st poGitivo Empty uterus
[menses due]
5 G€stational sac OCG >2m0lq
6 Nausea Yolk sac,
Breast tEnderness Fetal heartbeet on trarsvaginal scan
Fetal pol6 4mm
7 Fetal pole lomm
8 Fetal hesrtb€at on transabdominal soan
F€tal pde 14mm
I Fotalpolo 22mm
WhiteKnightLove
Etsgraorts of pssgm,auey
z
Ihe I'I lrimesl I3
o_
> Sumotoms
. Amenontea (Nora sunr srct.r) E
d
- may have arnenorrhea due to other causes GI
- may have bleeding in early pregnancy =
o
- o Breast symptoms as heaviness, pain, enlargement, colostrum =
o
o ihrning sickness... ..Appetite changes.. . Frequency of micturition
o Some ladies may experience fatigability &, sleepiness,
while others may have irritability & insomnia
> Slons
. Brsnst dgns
o Gerrthl slgnr
- Uulva (soft & violet). .Jaque-Mier sign
- Uagina (soft, warm & violet)... ...Chadwick sign
- [eruix (enlarged, soft & violet)...Goodell sign
- Uterus -+ 't Enlarged & soft
't Change in shape
Palmer sign
Hegar sign (d.t. softening of isthmus)o fI
Two fingers between the ant. vaginal fornix & abdomen
behind the uterus can be approximated (between 6-12 wk)
. < 6 wks -+ uterus is not soft enough
.> 12 + the baby occupies the whole uterine cavity
> lnvestlmtlons
. Pmgnqncg tests
n
Immunological [biological are obsolete]
- Urine tests (conventional pregnancy tests) +Latex & ELISA
- Serum test: B-subunit (most sensitive) a RIA
. Ultrrsonogtqlhg
- Transvaginal U/S ?5 wks (white ring)
- Transabdominal tJlS +
7 wks
d
- Detection of cardiac activity 8 wks
- Doppler (Sonicaid) <a 10 wks
O Biochemical orrcgnancv means detection of +ve P-HCG before missed period
I The windotr qap
The gap (2 week) between... ...Biochemical pregnancy (3'd wk) &
TWS visuatization of pregnancy (5tr wk)
WhiteKnightLove
r of Auscultotion
ot 24 weeks
A Plnrrd rfrdnropr.
14
rrht rh. Ph.rd f ..,10.09..
weeks lNIRt lAt IAI.IOIIEIIENT
f
24 EXIfiNAL IAI."LCIITEAIEi.|T
weeks
WhiteKnightLove
Ihe anil Irimesl z
o
rt
> Svmptoms 3
o Amenorrhea. ..Breast symptoms increase
g
o Quickening (1* perception of fetal movement)
!
o
- In PG + 18 - 20 weeks GI
- In MG -+ 16 - 18 weeks =
o
. Progressiveabdominal enlargement =
o
> Slons
. Brerst slgns
o Uterlne dgns
* Bmxton Hick's confactions
+
uterine sodfl6 may be head -+ soft blowing murmur
Synchronous to the maternal pulse (due to increased
blood flow through the dilated uterine arteries)
o Fstrl llgns
* Ballottement (due to movement of fetus within amniotic fluid)
- Intemal ballottement -+ between 16 - 28 weeks
.*dp;fl1;?*'r#x;3:ll--;J4weeks
+
Inspecfion or palpation of fetal movement
*Auscultafon of,.....fetal heart sounds by Pinard stethoscope (tS wko
)
r-r
......Umbilical souffid (funic souffld) --> Soft whistling sound
Syrchronous with the fetal heart sounds. It is due to flow of
blood in the umbilical vessels and is heard sometimes when a
loop of cord is in a close proximity to the anterior uterine wall
WhiteKnightLove
WhiteKnightLove
z
o
* Objectives 3
o_
. To try to get a healthy mother & newborn !
o Estimation of gestational age & expected delivery date o
o Early detection & treatment of any diseases during pregnancy @
o Early detection of congenital fetal malformations
f
o
=
o
* Consists of
o History taking
o Physical examination
o Investigations + Routine & screening tests
Other investigations according to flndings
o Plan for a schedule for return visits
o Instruction & advice
. Reassurance
o Plan for delivery
O Sorioeconomic
- Socioeconomic status
- Parental occupation
- Psychological e.g. excess anxiety -+ preterm labor
@ <Denograpfricfacton
- Matemal age (optimal age is between 20-30 yrs)
- Matemal education
@ *lef,uatfacton (fiseasQ
WhiteKnightLove
GRAND MULTI PARITY
WhiteKnightLove
z
o
r
> 9ersooal historv 3
9.
.lllme. ..tripleruuxe..... -u
q
o Jl+ttqlstgtu
.Pqrltg. ..... higherMMR&PNMRin.....
l. Grandmultipara P 5 deliveries) -+ liable to OOO
Pregnancv Labor
-Abortion, PTL, anemia .Uterine atony (more fibrous tissue)
.Malpresentation (lax abd. wall) .Obstructed labor -+ rupture uterus
.Placenta previa (accreta) .PPHge
.Chronic hypertension, DM
| -1-- Labor
PTL
--pregnrlg
Abortion, .Prolonged labor (tr* maternal
.Chromosomal anomalies (Down) anxiety & abnormal ut. action)
.Hyperemesis gravidarum .Rigid perineum + episiotomy
.PEt + P.abruption, DM .Higher rate of CS
. SPealrl hqbtts
* Smoking o-+ abortion,IIJFD, ruGR, perinatal death, APHge, oligoamnios
* Alcohol o -+ abortion,IUFD, ruG& perinatal deat[ CFMF, menta] handicap
* Narcotics -+ fetal depression & addiction
* Pets -+ risk of toxoplasmosis
WhiteKnightLove
WhiteKnightLove
> llleostrual histonr
. LMP + important for dating
z
o
of pregnancy (EGA) & calculation of EDD
. Must know lf it is average, regular, if sure of dates or not, 3
o
if pregnant on period of amenorrhe4 or after COC -r,
o
(o
> 0bstetric historv f
o
f
M.rmbcr . Prolonged period of D infertility o
Yeor of birth . Rapid succqssion + liability to malnutrition
WhiteKnightLove
THE FIRST EXAMINATTON
Height ond
lnspection of
Weight
Teeth
Exominotion
of Urine Exo-r inot ion
of,Abdornen:
Assessment of
Exominotion
Size of Uterus
of Pelvis
lnspection of
Exominotion
Vogino ond
of Legs
Cervix
WhiteKnightLove
z
o
rt
3
> Gereral o_
!rt
o Decubitus: dyspnea o
o Height if less thzut 150 cm -+ be aware of CPD ct
a
o Weight: if obese beware of D.M., hypertension, macrosomia & dystocia o
=
o
Fetus 3500
Maternal fat 3500
-Blood 1s00
-Extravascular fluid 1s00
Uterus 1000
Amniotic fluid 1000
- Placenta s00
- Breasts 500
Total 12.5- f3 ks
* 3 uitd data
o B.P. .for hypertensive > 140190... ..how??
o Pulse. . .. abnormal pulse, esp. in heart disease
. .
* 3 ned(
o Thyroid
o Vessels... ..engorged normally 1t blood volume)
o LNs
* 5 chest
o Chest ... ... ..chest infection, PVC
o Heart ... ... ..what are sure signs of pregnancy?
o Breast ... ... .normal changes in pregnancy, galactorrhea
* 5 others
o Gait (look for limping -+ CPD)
o Back
. Lower limb for varicosities, DVT and edema.
WhiteKnightLove
weeks
%tr\
,/ /,-32
-. Fetol
Skin skul I
ond fqi----
..- Uterine
woll
Porietol .-'
Peritoneum
(sensit ivo) Bloddcr (pcrhopo full)
WhiteKnightLove
> $bdominal
z
o
3
o
E
Shape -r
r--'_'_"-'-L"'-'-'__'-
ous cont.pelvis tation --+ linea_nigra
_-__-____r
----------l---_'-_----_. _i o
l-s"-qd-eg--r-e
"
(o
- -l Umbilicus,;ifiies
masculine
-o )
o
:- fem[pige
. S-gp1g;pubiq.trgif /
:,
o
2. Palpation (4 Leopold's maneuver)
* Fundol level by hand or in cm above S.pubis
* Umbilicol grip 20
- For lie 24120-221 Umbilicus
28
- For back & lirnbs
32
- For amount of liquor
36
- Expected fetal weight
- For any local uterine swelling
* I* & 2d Palvic Arip (Poulick's grip)
- To determine presenting part (head, breech, empty in tr. lie)
- To determine head engagement
- To determine degree of flexion of the head e.g. extended in face
3. Auscultation
--
I frc con be
Sure sign of pregnancy
ugd for t__ _ D iiiil$___
ns!|
l
,ll-o:tn-gll-o$:)_.bgtwe--e-!gmp-ilicuqft
Fetal life / distress .P. -+ at ASIS
Twins....funoux sign -+ MA at < umbilicus, MP at flank
Progress in labor .,.-B1_"_g-qt,.-r_.c_gllrplgf€-_>_.HIpF_:fi 9t!<umb_
Position & presentation . Transverse lie at one side
> %ocal
WhiteKnightLove
Ultrosonic Recording Uterine octivity recorder
FHR recorder
(ultrosonic ,,(tocogroph)
tronsducer)
Fetol
monitor
Pelv ic
brim \
WhiteKnightLove
z
o
> Routine:
o Blood for: " 3
g
- Blood group & hemoglobin %
!
- Rh (lf Rh -ve see husband,. .. .. . ..if multipara de_lermine if sensitized) o
- Blood sugar at 24 -28 weeks cl
a
. Hepatitis B surface antigen o
. Serology for syphilis )
o
. Antibody to rubella
o Urine fon Glucose.. ...Protein. , ... .Bacteriuria (not CoS ")
> Specffic:
o Accodingto history and examination
o ldeally-+ U/S t FWB tests in high risk pregnancy
* €rominoEion
- General a weight / blood pressure I edema
- Abd + fundal height, iiquor amount, presentation, position, FHS
- PV olate or in presence of abnormality (not essential).
* lnvestigotions
- Routine a.TJrine in 3'd trimester for glucose, protein
.11b% is repeated at 34 weeks
- Speciflc a
according to certain situations
WhiteKnightLove
Dlehry edvlcc ln prrtnrncy
WhiteKnightLove
zo
) Nutrition
o Caloric requiremefi-+2200 -2500 K.cal I 3
day
o Daily increase of 300 K.cal (esp. in late pregnancy)
g
!
o Meals should be well balanced & discourage overeating o
o If diet is adequate -) no need for supplementation (except....) @
a
1. Putstns o
f
Requirement 1.5 gKgd -+ addition of I kg protein to body weight o
Best if from animal sources (esp. milk)
2. Cqrbohgdrqtes + to complete the caloric requirement
3. tqB -+ to complete caloric requirement
4. Vfqmlm
A -+ 5.000 lU /d &_cgrqrs_e9iq_ft!!_El_?.]_qq_qq_&_
D-+ 400 lU /d Vjl L:l_Bttse_4le!4[s9-
Br + 1 mg /d Folic acid-+ 0.8 - 1 mg /d "
Bz -+ 1.5 ms /d _lti."gfini9_eq1d-_;,5:_!rg_E-.-___".
5. Mlnsrqls
o
- Cqlcium: I g ld (2 cups of milk),,..supplementation is not essential
E
- fron: 30-60 mg 1d........the only supplementation required I + folic acid
- Solt: no need for either supplementation or restriction (except in HTN)
) Rest
o At least 8 hrs at rught & l-2 hrs in the afternoon, better on her left side
o Helps to increase placental flow
) Exercise -+ allowed in moderation esp walking in fresh air & swimming
) Emplovment + allowed until delivery turless plrysically demanding
) Travel
o Allowed, but if > 6 lus... walking I 2ltrs to avoid DVT
o Better avoided in last month
> clothiae -+ loose unrestrictive, better no high heel
> Bathinq -+ allowed & encouraged esp tub baths (less liable to accidents)
) Douchins -+ high vaginal dotrching is condemned " . .. increases infection
) Sexual activity --> allowed unless there rs:
o Hemorrhage, risk of abortion or PTL, infections, ROM
) Coffee & tea + no harm (but excess -+ irritability g O fe absorption)
) Smokins -+ discouraged
) Alcohol -+ discouraged
) Care of teeth -+ as usual
) Medications -+ should consult the obstetrician before receiving drugs.
WhiteKnightLove
llomurunot of tprplryrlofirndrl hr[ht
WhiteKnightLove
Olstelric diagnosis z
> Name, Age, _,
Pregnant at .... wks
Para _+ o
> Presentation (cephalic, breech), not in labor 3
> complication (obstetric...... medical) o_
!
IEOO o
Qa[cutation of (o
f
> Histonr o
1. Menstrual delivery interval: 'calculated.from the l" doy oJ'LMP' =
o
- 280 days. .. ..or... .40 weeks
- l0 lunar months... or... .9 calendar m + 7 days
2. Naegel's rule
o'but on 3 conditions'
- 1't day of LMP + 7 days + 9 months or
- 1't day of LMP + 7 days - 3 months
3. Fertilization delivery interral
- Coital delivery time e.g. in IVF or rape (timed event)
- The duration is266 d or 38 wk or 9 m-7 d
4. Quickening oPG (18-20 wk)... . .MG (16-18 wk)
>Exannination
1. Fundal level O @
> Investirration
1 . Ultrasound. . .. . .esp the 1't trimester (the more accurate)
2. Doppter ..10 wks
WhiteKnightLove
c%tes
WhiteKnightLove
-14
.J -aa
.J .J
-J -a
Abortion
Ectopic
Vesiculor mole
WhiteKnightLove
WhiteKnightLove
O0stattla AauonAaga
g
o
Deflnition'o t interrupt i on of pregnancy befo re
erminat ion
o
t
O-----------Spontaneous abortion------------O
lncldanca o
o 15-20 yoo ... .mostly in the I't trimester... ..esp. in the 3d month
(due to some O in 'P' from C.L., while placenta
still not fully developed yet; Ehe ulndoul gop)
o True incidence ma)) be much more (50-80%) due to: e
- Subclinical abortion (very early < patient recognition)
- Notification is not done in all cases (esp illegal)
o Incidence increases with "
- Increuse in maternal & paternal age
- Previous abortions or stillbirth or CFMF
WhiteKnightLove
lntrauterine gestational scan containing a 6 mm
fetal pole with a yolk sac. I , ,, . ., ,ri) I(,1,)l !1,,r,1 ,rr rrv,Ly 9,r
lr,rlr\,irllirt.ll\(,lr) \i,j , ,( ,LrLr rl,,ri,,,rrirr,r ti|,1(i)|\i\l(.trtj,!,illl
'rir,r ll rr, rl .l
WhiteKnightLove
€tiology OOO
WhiteKnightLove
Threotened
oborlion
lnevitoble
obortion
WhiteKnightLove
Deflnltlon ^a attempt of the uterus to expel the fetus
leadine topartial separation of the fertilizedovum
ttnth slight haemorrhage into the chorio-deciduat space
CllnicolPlchrrc
o Sgmptoma - Amenorrhea with symptoms of early pregnancy
- Bleeding (slight: spotting)
- Pain +/- (mild lower abdominal colicky pain) g
o Sigru - Signs of early pregnancy o
- Uterus -+ coresponds to the period of amenorrhea o
- Cervix + closed
e
a
GT
lnrrestigotlors 5
.F,rdlfgnch [doernrtne Hrl[hl o
o
- u/s,+ TV-US (5 wks)... ... .TA-US (7 wks)... . ...Sonicaid (10 wks)
=
- FHCC'+doubled every 2 days !
o Fordlol@ e.g. C.L. insufficiency, DM o
(o
Fote ,.+ - Continues pregnancy -> 70 - 80% i.e. rnRr.trsNpn abortion =
o
- Bleeding increases -+ INrvltlsrp abortion =
o
- Fetus dies but retained -+ MIssBo abortion
- Infection occurs -+ Srpuc abortion
Treotmont llConservrtlye
l. Rest - Physical -+ rest in bed till bleeding stops
- Sexual -+ no sexual intercourse
- Mental + may give sedatives as valium 5-10 mg/day
2. Antispasnodics e. g. antiprostaglandins
3. Progesterone 4av.v. widely used
\ Howevet............Benefit is only proven if there is well documented CLI
.Masking effect if missed abortion or if there are CFMF
.Virilization of female fetus (.'. natural forms are used)
4. Bzslmpathomimeticsas ritodrine (more effective in2"d trimester)
5. Iron & vitamins
6. Anti-D in Rh-ve
2l Termhma ff
> Turned inevitable
- Dilatation / effacement of the cervix progressively
- Rupture of the membrane, partial protrusion of products of conception
> Turned into septic, missed
WhiteKnightLove
2.
l.
The ovum, portly or wholly de-
Hoemorrhoge occurs in the deciduo ioched, octs os o foreign body ond
bosolis leoding to loco I necrosis ond initiotes uterine controctions. The
inf lommotion. cervix begins to d i lote.
COMPLETE INCOMPLETE
WhiteKnightLove
> Definiuon complete separation ofthe fertilized ovum
withprogressive cervical dilatation & fetal expulsion
> Symptoms
-
Arnenorrhea + ryrsploms of early Fegnancy
- Bleeding -+ moderate to severe
- Pain -+ marked LowER abdominal CoLICKY pain (uterine contractions)
o
with BACKACIIE (cervical dilatation) = sacral pain
> Signs P
- General + Pallor / shock (according to amount of bleeding) o
o
- Abdominal -+ uterus corresponds to period of amenorrhea g
- Local + oPENEp cx (products of conception may be protruding) =
GI
> Treatment
f
l. Re sus citati on 1f bleedtng is excessive o
2.Eyacuation: ls trimesteric -+ evacuation by suction or curettage o
!
trimesteric -+ oxytocin or prostaglandins
2"d
3. Followed by .Ecbolics -> helps complete evacuation of remnants !-l
.Antibiotics -+ reduces possibility of postabortive inf o
ct
4. Anti-D if Rh*ve a
o
=
o
WhiteKnightLove
/ll&scd dordoa TrE drfrn of tlcpqnoncy b l8
rGGb hrt fic ucrr3 h6 crnrj! D;,ltrn ila ee
flld D af o
l,h*c* 3etaba l,lc trn atl. d&apa b flm.
WhiteKnightLove
Ceruical aboftion I Ceruical preg. (v.rare)
Dd type of inevitable abortion type of ectopic pregnancy
-+ arest of gestational sac + implantation in the
in the cervical canal endocervical canal
SgmDt pain (severe) > bleedilg bleeding > pain
:TE$_.na-g'jp-err.o--
Dilatation & curettage Hysterectomy OR conservative
P
o
o
_o
(Catwaw t+rrk,..f,esht1 r,role...bhobq mole) =
(O
> Definition retention of dead / non-viable products of conception within uterus ='
o
o
> Symptoms =
I- Amenorrhea O symptoms of pregnancy disappear. 't
2- Bleedinge rarely mild dark brown (prune juice) o
(o
. Milk secretion ' (d,t. + E). . .it r:rry occur normally in preg. a
o
. Normally E2 blocks action of prolactin on breasts in preg. 5
3- Pain ?usually absent +absent fetal movements
o
> Sigrn
* No general signs of pregnancy
'k lJterus + less than period of amenorrhea
* Cervix -+ closed firm + dark brorvn discharge '
> Investigations
l- Ultrasound -+ collapsed pregnancy sac * no fetal pulsatrons
2- frHCG &repeat in two days for doubling
3- Fibrinogen level (very important) as there may be liberation
of thromboplastin substances from the retained dead tissue
which may lead to DIC slowly. In these cases fibrinogen
level usually decreases by 50 mg/ week. it is done
weekly to avoid reaching the dangerous level (100 mg/dl)
> Complications
o Infection -+ septic abortion
o DIC (hypofibrinogenemia) -+ after 4-6 weeks
> Treatment
- a
If fibrinogen is normal TOP (acc. to gestational age) + antibiotics
- If fibrinogen is &a+ elevate 1* (fibrinogeq FFP, fresh blood) then TOP
WhiteKnightLove
/;
]r.:ere*d}r$
)-^
r
WhiteKnightLove
Definition superimposed infection on any type of abortion (esp. criminal)
Ogonlsns
- Gram +ue -+ Staph, Strept. esp Group B (GBS)
- Gram -ue + E.coli, Pseudomonas
-Anaerobic -+ anaerobic Strept, Bacteroides, clostridium (previously)
> Sures-
- Exogenous.. . .
... ... .instruments, sanitary pads g
- Endogenous. .. o
. .. ..organisms present in female genital ffact o
- Hematogenous (rafe)......from a septic focus e.g. appendicitis g
=
(o
Cllnlco! PlcUre f
o
Sumatnm^o o
. Symptoms of abortion (amenonhea....bleeding. pain)
. Followed by symptoms of infection E
- Fever, headache, anorexia, malaise, rigors o
- - Continuozs lower abdominal pain GI
a
- Offensive discharge o
a
. There may be history of atrial to induce abortion (by untained personnel) o
Siaru
+
1- General + Toxic, pale, tachycwdia,tachypnea, htgh fever
2- Abdominal
- Decreased abdominal movement with respiration
- Lower abdominal tenderness & rigidity
- Tender uterus may be fe
3- Vaginal
- Bleeding & ffinsive discharge
- Uterus is tender rarely crepitations if infected with gos
form in g or gani sm s (phy s ometr a)
- Swelling in Douglas pouch + pelvic abscess
lnvestigotions
l. FOR 0UGil0StS 0E -> dead fetus or incomplete abortion
2. rcR EIIOTOGY
- Blood+ CULTURE. TLC, ESR, CRP
- Endocervical or high vaginat swabs
- X-ray -+ physometra (gas in uterus)
3 mR O[lPtl(AIl0i6 -+ renal function test & coagulation profile
WhiteKnightLove
Exlension of
infection in
Peritonitis
Pelvic
collectiJn
of pus
WhiteKnightLove
Compllcotions O
local Geneml Orqan affection
l- Endometritis 1- Septic 1- Septic shock, ARDS
2- Myometritis thrombophlebitis 2-Actfie haennlysis
3- Salpingitis 2- Systemic (esp strept & clostr) * liver
4- Salpingoophritis pyaemia affection + jaundice
5- Parametitis 3- Generalized 3.DIC
6- Pelvic peritonitis peritonitis 4-Renal failure due to
7- Pelvic abscess the above factors.
g
Treotment o
o
l) Elevation of the eeneral condition g
+ Adlblotles (ln comblnqllon ln hlgh dosesf
)
GI
- Grsm +ve -+ penicillin G or cephalosporins a
- Gram-ve -+ aminoglycoside as gentamycin or tobrarnycin o
- Anaerobic -+ metronidazole or clindamycin o
- Ingas gangrene -+ specific antiserurn
!rt
+ Clms obseryqtlon ln the ICU (in compllcoted cesesf
o
- Vital data -+ blood pressure, pulse, temperature GI
- CVP esp. in renal affection -+ . Urine volume =
o
. Repeated renal function tests
f
o
- Blood transfusion (better fresh) and intravenous fluids
- Hydrocortisone or dexamethasone -+
t
. tissue perfusion, stabilize lysosomes & endothelium
. t gp (+ve inotropic, restore sensitivity to catecholamines)
2) Evacuation of contents
I't trimester ,+ suction evacuation (better than curettage. . . why?)
- To avoid spread of infection by opening sinuses
- To avoid perforation of the soft uterus
ld trimester '+ 'k induction of abortion by oxytocin or PG
* if failed + hysterotomy
* in severe cases -+ hysterectomy -in toto- (esp. if old,
completed her family, gas forming organisms)
3) Treat complications
1- Pelvic abscess + posterior colpotomy
2- Septic thrombophlebitis + heparin
3- Generalized peritonitis -+ drainage
4. DIC + fibrinogen, FFP, fresh blood
5- Circulatory collapse + vaso-pressors & sympathomimetic drugs
6- Renal failure + dialysis
7. RDS + assisted ventilation
WhiteKnightLove
(a) Con1cnltal m alt orm at)ons
. Miillcrian fuslon abnormali1ies
V^*,"*Y,,**
. Abnonnalftbe ducb in ubro DE9 a<pa'et
(d k4utrcdlceiono
WhiteKnightLove
Dafinltlon
Three or more successive spontaneous abortions (some say two)
(If not successive it is called repeated abortions)
lncldence
tr PG -+ lloh,thenpercentage depends upon previous abortions:
D Once -+ 20o/o g
tr Twice -+260/o(2-3 % of community) o
tr Thrice -+32Yo(< l% of commturity)o o
_o
=
GI
€ttology O.... ..5O% of coses ore ldlopothtc o ........O f
o
o
rt
O Loeal causes
!
-t
o Account to 30Yo" of 2od trimesteric abortions o
GI
o Most of them is not diagnosed before multiple pregnancy losses a
o
have occurred (because they are ...syrnptomatic) 5
o
llPatulous internal os h
2l CMF of uterus -+ septote (?5%) or bicornuste (30%)
3l Uterine hypoplasia -+ obortion in oscending monner
4l Submucous fibroid
5l Fixed RVF -+ oborfion usuolly ot 14-16 weeks
6f Congenital Asherman syndrome -+ intrquterine synechioe
O Generql ceuses
1-Endocrinal ,+ LPD.. . ., PCO... . .. .DM. .. ... .Thyroid
2- lmmunological ,+
'k .f,utoimmune + APS ,/,/r/ , SLE
* Illoim,rrrune -) . RH incompatibility
WhiteKnightLove
>Personal
- t 4t -+ chromosornal anomalies, DM hypertension
- + rural areas (Bfirrrziasis), slumareas (toxoplasmosis)
Resifunce
- Occupation + workers in heavy melal or radiation factories
>Complaint abortion >3 (2) times
o
c >HPI
o - Sgntptons of abonion + amenorrhea bleeding,pain
C
CD - Synptoms of complicotion + fever, DIC
o
o- >Past
.> - Medical +hypertensioq DItd, thyroid,hextdisease, ...
o - Surgery + on cervix:
o
.s >Farnilv
o, - Diseoses + hypertension, DM ... .
.E
t,o >Menstnral
- - Premenstrual
o spotting + LPD
o - Menorrhagia + fibroid
- Hypomenorrhea + hypoplastic utens, Ashernran S
>Obstetric
- Order + Ascending.....
Descending......
- Character of obortus + - Fresh.....
--tvracenteui'..:..
O Exarnination
>General -+ medical di e
>Irocal -+
. RVF
- Bicomurate (2 bodies)
o Cervix'. tear (PIO)
WhiteKnightLove
A/'lonogement
WhiteKnightLove
WhiteKnightLove
Potulous internol os h
> Efiototg o
o eongenital
- Increased muscle tissue in cervix > 1,0y,
- Associated with other uterine malformations as septate,
bicornuate uterus, hypoplastic uterus
- DES (diethyl-stilbesterol) exposure in utero
o OAircd. E
. t*-t"r"o?:tfrt:ff:ffiuse o
o
before tutl cervicat dilatation cL
- Breech extraction before full cervical dilatation 5'
GI
- Manual dilatation of the cervix 5
"'"i or too rapidrv
o
o
rt
#'*'ftirHlTjk ffi'ff'"'' !-l
Cone biopsy ofthe cervix
o
GI
> clnhll Dletuie J
. o
This condition usually leads to classic picture of =
- Painless effacement & dilatation ofthe cervix o
- Uterine conftactions are late & not very painful
- PROM followed by rapid delivery of a fresh abortus
with minimal disconrfort
. The abortion or premature labor usually occurs in descending
fashion i.e. at 7 months -+ 6 months -> 4 months, etc.
> lnvctl[rtlonc
1l If pregnant
- Serial U/S examination (better done transvaginally)
- to determine length (2.5-3 cm) & width (1 cm) of internal os
2l If not pregnant
- HSG -+ funneling (loss of uterine waist)
- Abihty to pass Hegar dilator No 8 or hysteroscope No 8
with no resistance & little pain I
- Pediatric Foley catheter with I ml inflated balloon can be
pulled through the os without resistance X
> Trertmerrt
1l If pregnant <? cerc/age
2l rf not pregnant o trachelurh@b @tp after cervical tears)
WhiteKnightLove
c t6 ucCq@) h@nrpoienfroa ,6 xGGk$
lnternal og
fRANSYAGINAL
TRAN9AEDOMINAL UtnroEaaral
llgaianr
WhiteKnightLove
Cercloge
> TuDes
l. ffitrs -+TOo/o success
with purse string suture (Nylon or Mersilene)
. 4 bites
. Taken around the highest portion of the portio-vaginalis.,..why?
t g
o
. Indications -+ repeated failed vaginal cerclage or short / absent cervix o
. Delivered by -+ CS (permanent cerclage)
g
. If failed < 28 wks -+ hysterotomy must be done (a great disadvantage) =
GI
-t a
lndication e PIO, uterine malformation (septate), tiplets o
lnsertion cl2-l4weeks o
-
Portoperatiue a anti-PG, progesterone, antibiotics
Removal r? 2 weeks < EDD (ev37 wks) !
o
(o
> Complhrfions
- Injuryto bladder =
o
)
- Injury to membrane + ROM -+ tape must be removed o
- Infection + tape must be removed & terminate
- Abortion orPTL
Antiphospholipid syndrome
> Dsfinltlon . autoimmune dis. forming antibodies agarnst phospholipid proteins
. it may be lry (alone) or 2ry (associated with CT disorders: SLE)
> Dlrgnolod bu OO
oo
O Recurrent
- Thrombosis -+ arterial & venous
- Fetal loss -+ . > 3 consecutive miscarriages (< l0 wks)
. > 1 fetal death (> l0 wks)
.>
PTL (< 3{ wks) due to severe PET
- PIH -+ usually severe + pl. insufficiency t ruGRt abruptio pl.
O Positive antibodies
- Anticardiolipin antibodies (ACA) hrgh )
- Lupus anticoagulant (LAC) ) false +ve
> Tmrtrnarrt
o Baby aspirin (75 mg lday) + Heparin 5.000 units SC ll2brs
orLMWheoarin /
3040 mg/day e
o Corticosteroids -+ not more used
WhiteKnightLove
CURETTAGE. A blunt cureffe moy be
tried firsf but usuolly o shorp curette is Removol of Plocentql tissue with ovum
required forceps.
"
To suction
Locol PG
lngecllon of hypprlonlc sonullon (l nlrouteilne- Exhoom nlofi cl
WhiteKnightLove
e-------------fu flsCed abOrtiOn------------e
> lndlcotlons
O lhtrual
c' Medical disorders e.g. '
-
Advanced:- Heart disease / chronic HTN I renal disease
-
Active pulmonary T.B./ severe hyperemesis
c, Malignancv g
- Genital tract lbreast malignancy o
o
- Chemotherapy or radiotherapy e
o Mental ps.vcholosical illness =
GI
@ getot 5
o Missed abortion / blighted ovum / vesicular mole o
o Exposure to teratogenic agents -+ rubella radiation o
rr
> Mehods
A- Before 14 weeks ,.+ suction evacuation Or dilatation & curettage o
r
Gl
B- After 14 weeks f
o Prostaglandins o
- Local (intra-amniotic or extra-amniotic) =
o
- Vaginal or intracervical tablets
o Oxytocin
o Intra-amniotic injection of hypertonic solutions XX
- Saline 20o/o......Urea 30-40%o. . . . ... .. Glucose 50olo
- Complications -+ danger of urfection & DIC
o Hysterotomy if all fail or there is severe bleeding
> Dcfinition: TOP for non-medical reasons (in countries where abortion is illegal)
It is called elective (voluntary) abortion (in countries where abortion is legalized)
> Mctrods uscd
1- uterine stimulation -+ methergine, purgatives
2- Intra-uterine manipulation to induce cervical dilatation or ROM
3- Evacuation by untrained Doctor under Septic conditions
> Common complications
-
Genital tract trauma e.g. uterine perforotion
-
Infection -+ sepsls
> CIP & trcamcnt as SEPTIC abortion
WhiteKnightLove
ABORTION-DI FFERENTIAL DIAG NOSIS
WhiteKnightLove
> What is medical abortion ... ... .?
E9
> What are the causes of postabortive bleeding.. ...? o
o
..AS50CtATtON g
a
GI
DIvI, PIO). This seems reasonable as most spont abortions are due to C.F.M.F.
WhiteKnightLove
Tubol pregnoncy
hr!'rrEPo'tloi23
l".rD*55r I -
hfiSrirdoa t7..ll I
Chronic solpingitis
l--
Follicle Ovum
entering
tube
Diverticu lum
WhiteKnightLove
Implantation anywhere outside the ENoonaETRIAL cAVITy
It is responsible for 10% orMMR '
IucmBNcB is t'd 4 folds in the last 20 yrs from I-+3 o/od.t. of: f o
o Miscellaneous
- Endometriosis -+ adhesions
t
- ART -+ ectopicby 5%
- Contraception:
. POP or Implants -+ O tubal motility (what about coctr ?)
. ruCD 3
-+ salpingitis, + tubal motihty (esp if +P), also it
can prevent intra- but not extra-uterine pregnancy
O Samoshmlffiftodoum
. Early disappearance of zona pellucida
o Early development of trophoblast
r External or internal migration (time consumption) X
WhiteKnightLove
RUPTURE INTO LUMEN OF TUBE RUPTURE INTO THE PERITONEAL
(TUBAL ABORTION) CAVITY
Tube lumen --
z-t
Tube woll (musculor
tissue)
Point of rupture
Blood clot collecting in -
hoemotocele.
WhiteKnightLove
PetqAeI
> Tube
n
Any partmly be affected (esp ampulla) -+ enlarged, vascular
* Rarely -+ hetero-topic (intra + extra-uterine)
* Cannot reach > 12 weeks due to early dishrbance:
- Limited tubal distension
- Poor blood supply & nutrition
- Thinner decidua + ovum penetrates deep in muscle
> Uterus
* Symmetrically enlarged (Sucrr), t'd vascularity, hypertrophy
g
o
* Decidua (but with no villi) o
* Aruls SrsrLA RsAcuoN -+ secretory, proliferative changes with e
a
(o
some atypical flndings inl0-15%of cases (non-specific)
,
> Ovary -+ one shows CL of pregnancy o
o
-t
T
-t
o
lUdisfurbed... if diagnosed early < rupture Gare). . . . . . undEsGunDod oo0" Gl
.
f
o
I Disfu rbed......... when the ectopic preg. ruptures: =
o
> Ronure tnrl&tte tr0es
o Repeated mild hge around ovum -+ tubal mole (hematosalpinx)
o If hge O -+ separation of the fertilized ovum -+tubal abortion
o Bleeding may be
- Mild O peritubal hematoma . .....suDooo6o[V @@0. @
- Severe O generalized intraperit. hge..-oou@[V dEs0 oo0" O
- Chronic O pelvic haemotocele. . . .... .. .@htronn@ dEsG oe0" @
WhiteKnightLove
WhiteKnightLove
Sgnptottu
- O Amenorrhea (short period) + symptoms of early pregnancy
- O Pain -+ slight dull aching in one iliac fossa (tubal stretch)
- I Bleeding + usually absent or slight spotting
sw
- General -+ signs of pregnancy
- Uterus + soft, slightly enlarged g
- Adenexae + . slight tenderness in one fornix o
. sometimes a swelling may be palpable (< 3cm) o
e
J
€ailr, diagrroi b needs FIrcn Lr,ver O p S usptcroN GI
- History of pdf (e.g. PID, IUCD) + you must be ectopically minded
=
- May be discovered accidentally during routine U/S of pregnancy o
o
rl
!rl
o
(Cl
Sgmpbmo
a
! Atr,tgNonnrm,A: o
- Shortperiod6-8wks =
o
- Mostly there is one missed period /
! Sudden severe PAIN:
- Dull aching + tubal distension
- Sharp stabbing -+ erosion through the wall
- Colicky --+ tubal contractiorn (tubal abortion)
! Vaginal BLEEpING:
- Drop of B-HCG J e & P -+ separation of decidua
-
- Slight dark brown (or rarely as a decidual cast)
sw
> Gorsnl
- Various degrees of shock + coma in severe cases)
- O pulse, O BP, O temp., cold clammy skin, oliguria
> Abdomlnel
-
+ed movement of lower abdomen with respiration
- T, R, RT overlower abdomen
> Vqdnql
tr
Cervix d
exfreme tendemess on movement -+IUMBIE sigzr
:
cervical motion tenderness //
o
Uterus +
difficult to palpate (tenderness) but is slightly enlarged
4
a Adenexae tender enlargement of the affected adnexum
WhiteKnightLove
hE p-brdh.mor"lrS.
adprhlctredr
4*.olnffiarym.
.r Nole
ou) uierus
plocento
ore disploced
onteriorly
WhiteKnightLove
3. Ho,rte (fulmlnottrp) Qpo
Symptnru
,.. ... .Short period of amenorrhea -+ sudden severe abdominal pain
... ....Followed by: massive intraperitoneal hge with shock & collapse
* shoulder pain: diaphragmatic initation by blood
sw
> General -+ shock (not proportional to external hge)
> Abdominal
- T,R RT over most of abdomen g
- Shifting dullness + Cullen's sign o
o
> Yaginal + difficult (marked tenderness), but may be easy if... ... . o
5'
GT
4. Chronlc peMc hernotocoole
=
o
Symptamo o
... ..There is history suggestive of disturbed ectopic preg (the triad) =
.9
. .. ..Then blood collects gradually in the D.pouch (most dependent) -t
.....Leading to pressure symptoms (backache, dysuria, dyschazia, dyspareunia)
o
Gl
5
sw o
f
> General a slight pallor + jaundice t pyrexia o
> Vaginal ? tender ill-defined boggy mass in D.pouch pushing cx anteriorly
I unhwil......... evacuation by
1- Laparotomy + strong antibiotics
2- Posterior colpotomy (or aspiration guided by TVUS)
WhiteKnightLove
Forceps holding up
o follopion tube
for inspection
Comffe sddyhCO
rndltortrg trlil <16|t tr
Rcpcth@ now
lsbt
ard {8 hqrr!
WhiteKnightLove
I I fteononqr test
- Serum P-HCG / (detects 5 mlu/ntl) is more sensitive than urine
- lntrauterine prq. anormally doubles I 2-3 days
- Ectopic preg, a subnormal rise: less than66o/o within 2 days
(But it may be non-viable intrauterine pregnancy)
9l Ultrosound
- Vaginal U/S is more sensitive than abdominalUlS
- lntrauterine preg. agestational sac in-utero (5 wks TV.. . . . 7 wks TA) g
(But it may be the decidual reaction of ectopic preg) o
o
- Ectopic preg a a small sac * fetal echoes outside the uterus e
a
(But it may be CL cyst of normal preg) (o
+ proceed =
o
o
+ =
!
o
(o
llospthllatlon & tullor up of
* Svmptoms ^'r pain a
o
a
* signs ^a detectable adnexal swelling o
*
io@!re + 12 days
O Combined U/S + p-HCG )
T\e disqiminotionvalue at which U/S can
I a.tect an intrauterine pregnancy is:- i
r es
#t)31*fiT#:J;:;#f;il::1ffi!res
detected
I
3l Othes:
. Progesterone level
a >-25 nglml -+ normal intrauterine pregnancy
<
o 5 ng /nrl -+ abnormal (ectopic or non-viable intrattterine preg)
o DaC xx a decidua but no villi (rt may disturb an early healthy preg !!)
o EUA XX 4 it may increase disfurbance
WhiteKnightLove
Gdordr*
h ub,u3
LA? ARoE/CO?IC LIN EAR gALPI N GOST OMY F OR TUOAL ECTA?IC PREGNANCT
Allncarlnalebn
|pmrtavfthttr,
lrcrwropobr
dlfihctmynar)b
almqtlv afi)- inclumcnis
nrunlabborbr allandtrhcal
otilvtallop|untuba byw,oilary
irIrnlful
l
I
fttctto?huf/,tof/r.
nru|orantrrod
*thtoroa?crd
ii4rilort
WhiteKnightLove
( Treotme[ ]
Resuseifatio n / / / -+anti-shoct measures
\ wide bore cannula + ca[ 4 help
Laparotorng (or laparoscopy)
WhiteKnightLove
Angulor Plegnoncy
Plgnoncy_llBud i"gntoly H orn
WhiteKnightLove
......trLlrc ttlp, cf *toplc
* Orcrlon pregnoncv
. Usually 2ry to tubal pregnancy
o v i s'fr1|:i'.,!il
1
:{,:;'.i:i{x::ii;i^
Gestational sac occupies position of the ovary
Ii gament
: ff#*?*i:1Tffi1'J:flJl*iH,ll ilfl'*
* Prcgnonql ln rudlmontory hom g
. Usually presents late at 16 -20 weeks o
o
o It is medial to the round ligament while tubal pregnancy is lateral g
o Treatment -+ remove horn =
(o
* flngulor (comuol) ppgnoncv =
o
o At uterine orifice of the tube, late diagnosis (14-16) , more bleeding o
o If disturbed -+ - wedge resection & repair of part of the uterus -r
- May need hysterectomy !
-t
o
rt Cenrlcoloroononq.l ttt:a GI
o Ilysterectomy if severe uncontrolled bleeding =
o
o Conservative measures: =
o
7f Suction evacuation. To reduce bleeding:
- Suturing at3,9 o'clock
- Silk suture aroturd the whole cervix (as in cerclage)
- Balloon tamponade (30 rtl) by Foley catheter
- Bilateral uterine artery embolization by gel-foam
2) Methotrexafe local injection in the sac
.......DD of ectoplc
ll Painfrom
o Aate sapingitis + no amenorrhea, no fainting, fever, pain
(usually bilateral), leucocytosis
o Conplicated ouarian nass orfibmid
o Acute +
no amenorrhea, vomiting, pain usually
appendicitis
periumbilical then at Mcburney's point
o Ana plelonepltritis -+ loin pain radiating to the groins with
fever & urinary symptoms
2l Bleeding from abortion & vesicular mole
WhiteKnightLove
thcn duplkatoo\
*ff&*@
fdploldkaryorypcvrrh
an awa(hapb?) *t,
*^*l
g;g-,$r'oR
r)
Tatanalchrcmoerlma
of
cw*rm t -
WhiteKnightLove
MalBnant
Vesicular mole *tetastatic Non-metastatic
(hydatidiformmole Choriocarcinoma .Invasive mole
.Placental site
2. Aecording to behavior
> Benign
) lnvasive mole l5oh (choriadenoma destruens) -+ if perforating the uterus
i,e. locally malignant (rarely metastasize)
) Metastasizing mole (usuatly metastasizes to lungso ) + resolves with ttt
WhiteKnightLove
Normql villus
Primitive Avosculor
Vessel /oedemotous
slromo
Chorionic
epithelium
tr
/ 7ri'i {->Cyrotrophoblosr:
cuboidol cells
Syncytium: with prominent nucl
sheets of fenestrcted
cytoplovn contoining
T.othe.noked eye the whole looks
dork ovol nuclei lrke o bunch of gropes.
Hydotidiform mole
Normql
I6 weeki
WhiteKnightLove
helbdeil
a Macroscopic
O Uter,rs ^-r enlarged, studded by vesicles 2 mm to 2 cm in
diameter, each with a small pedicle & contains
semitransluscent fluid. No psrus or pLACENTA
. May be partial or complete
o May affect one twin & not the other
@ Onru e bilateral theca lutein cysts of the ovary -60%- [due to t
B.HCG released from the proliferating trophoblastl. They g
DISArIEAR sp oNTANEousLy 2- 3 months po st- evacuation o
o
# Microscopic q
- Trophoblastic proliferation (both cyto- & syncitio- trophoblast) f
(o
- Hydropic degeneration of C.T. stroma of villi -+ vesicles
f
- No bloodvessels (AvsescurenParrunN of VnLI) o
o
!
OSvmotoms o
(o
> Otrunatafica *
syrnpt. of early pregnancy
=
o
>'llu&u Abrding (contiruous trickl ing) :,
o
> flon......&ut no l*l
maume*
- -
Dull aching (uterine stretch)
-
Colicky (expulsion)
-
Shary (perforation)
-
Acurp ABDoMEN (complicated theca lutein cyst)
oo
Crneral
weeks
"fi{<20
WhiteKnightLove
2t{ortrto
flrcc(}{UJil)
r 0000
r00000
956 ccndc
ttlor
t0 000
----- 56cdrdL
r 000
100
t0
216810
Ut& fi.r nroL.r.ormd
WhiteKnightLove
7- Ulhqsound {(hebest) + SNow Sronu appearance
Amniography -
HoNsy Corvre appearance )()(
2- p-hCC +ve in high dilutions > 100.000 (more important for foltow uo)
3- Rsdiugtqphg; - Plain X-ray: no fetal skeleton
- Chest X-ray: for metastasis
Re.suscitation *
ll Suction evacuatio n r'r' cannula
by a wide bore F
t curettage to ensure complete evacuation (risk of perforation) I
t ecbolics to O hge (risk of embolism if inductionis started by ecbolim) ,E
- Don't forget +. anti-D if Rh-ve
. specimen is sent for histopathology =.
;
2l Hysterectomy (in toto) 9
.Inoldpatients(>40yeaIS)whonvecompletedtheirfamiliesto< !
$ risk of choriocarcinoma (35% at this age) d
- Hysterectomy doesn't prevent metastasis (.'. follow up by p-hCG) E
- Theca lutein cysts arc not remov surgically ' except ,f I
complication occur (e.g. torsion or rupture)
e
s
> Bs p{ubunit of tlCG
- Every week + till -ve for 3 successive times (<5 mIU irnl)
- Usually becomes -ve within 2-3 months
- Every month -+ for l-2 yearls
> Pregnlneg ls ryolded foi l-2 geer/s:
- To O recrrrence & choriocarcinoma
- COC is used (IUCD I causes irregular bleeding')
> &ferlc uf posclble deuelopnrort of chorloc+elnonrq
,"* ME-THOTREXATE )
o p-hCG levels are:
- Rising (doubles in 2 weeks)
- Plateau (failure to S within 3 weeks)
- Returning +ve after being -ve
o Persistent or recurrent uterine bleeding
o Any evidence of metastasis e.g. chest x-ray
o Biopsy + diagnostic of choriocarcioma
WhiteKnightLove
WhiteKnightLove
-a7
-aa
-a'
-a-
r ..1 '
fi:.,
Voso Previo .: j':,. L.
Plocenlo Previo
Accidenlol hge
WhiteKnightLove
l. Nonobstetric causes of antepartum hemonhage
include cervical and vaginal lacerations, hemor-
rhoids, infections, and neoplasms.
'2. Patients typically present with spotting rather
than frank bleeding.
3. Nonobstetric causes of antepartum hemorrhage
generally require simple management and have
good outcomes.
4. Cusco sepeculum examination of the vagina & cervix is
very helptul
WhiteKnightLove
tc ;u fi1r(spaitaq llaauottAAga r,t,
Plqeentql sife
Vasa prel'ia
1. Placentaprevia 1.Local g5mecological cause
(the only
(inevihble hge) 2. Excessive show
cause of
2. Placental abruption 3. Ndaryinal sinus bleeding
fetal hge" )
accidental 4.
WhiteKnightLove
T yt,e 1 Type 2
The lower morgin of the plocento The plocento reoches the internol
cl into the lower segment. ('Low
i1,s os when closed but does not cover it.
im1;lontotion'). ('Morginol').
Iype 4
Ihc plocento covers the internol The plocento covers the os even
cs vrlrcn closed, but not when fully when the cervix is fully dlloted.
diloted, ('Portiol' or'lncomplete'). ('Centrol ' or 'Complete').
WhiteKnightLove
Phaaafia Pruvla
Incidence o 0.5%
c More conrmon in Murupenn o PRrvlous UTERINE ScRno
a Recurrence rate. ....4-8%
Etiology
- Delqgsd development of chorion ftondosum
- Ddrusd disappearance of zona pellucida
- Dmcisnt decidua (t parity, t age o, endometritis)
- Perhtsnce of villi in the decidua capsularis
'k Large placenta
- Twins, D.M., RH =
o
- Placenta membranacea E
o
-l
E
Clossificotion 3
lot
o PP lateralis 60% Lower margin of the placenta lies in LUS =
o
Yiolw Jgtrg" //but not reaching the margin of internal os 3
o
o marginalis
2no PP 30% Lower margin of the placenta reaches the
"marglna[ margin of the internal os =
o
(o
3'o
o PPcentralb incomfl@ 7% Placentapartially covers the internal os
"prtlali o
4*o PP csrtralis comffie 3% Placenta eompletely covers internal os
"lotl;t
Pothogercsis
O Pregnqnq,.
. Placenta is inelaalic so bleeding occurs due to stretch of
LUS (shearing mech.). Bleeding is augmented by the
inability of the weak LUS to compress the tom vessels
. Peak incidence of bleeding is a
30 - 34 wk'
. First bleeding episodes are usually 67 mild
o
WhiteKnightLove
An.ni.rbr pLc.nf. prroL.xt rdlng toJun
b.yondth.lnt mrlor.
Fbilo ptu,jvb-Vf,-.vo.
WhiteKnightLove
Clinicol picture
> Sigru
O General ,+ pallor or shock (according to degree of bleeding)
O Abdominal
o Palpation
* Fundal level -+ conesponds to period of amenorrhea
* Umbilical grip -+ Lax uterus, not tender
* Pelvic grrps + non-engagement t malpresentations (30%)
o Auscultation
" FHS are normal except in severe cases
(more tlnnVz placental separafion is needed for fetal
disfress to occur, this is more in cases of ... ) . T
O Vagina! t,oo
!
o Contraindicarcd 99 +
o Except if O the patient is in labor &@ has minor degree 5
- Aim is to determine the possibility of labor d
- In the operative theatre which is ready for immediate 3
interference by CS + available blood
o
t
t
- This is called a double set up technique [2 teams] =
o
- Placenta (if felt) will be a fleshy tough sponge GT
o
I"rr*igl-els_(fu:M)
'k Theonly & best method used (98% sensitivity)
'k Repeated serially (every 2 wls) to detect upward migration:
The apparent upward movement of the placenta from the
LUS (due to unequal growth of UUS & LUS). This may
lead to disappearance of p.previa or lessening of its degree
'k Thus:-
-P. previa ismore common at eadier gestational age
-P. previa ismore likely to persist if diagnosed after 30 wks
WhiteKnightLove
Risk factors for placenta acoeta
t Previous retained placenta
I High parity
r Advanced maternalage
I Placenta praevia
r Previous caesarean section
r History of dilatation and curettage or suction termination
of pregnancy
I Previous postpartum endometritis
WhiteKnightLove
Complicotions oo
D Moternol
"'*s,,r*l|1J3Hllx'#
'
fs,'*ilEffi iT[?),.**r
( cord prolapse & infection
2nd stage: difficult (obstructed labor + malpresentations)
""?';,:;:d:,,.;[T?:iffi
:J]*1iJ$*Tffi :.rna,condition)
Retained placento (5Yo) -+ placenta accreta (d.t. poor
t
decidual development) -+ incidence with no of CS o
3
..(APhge predispose to pphge).
..........(APhge weakens, pphge kills).........
t,oo
E
O Pvarparium ...S3 3
Sepsis =
o
- Poor general condition (shock + exhaustion) 3
o
- Placenta (friable + near vagina + retained parts)
- Premafure rupture ofmembranes =
o
- Increased surgical interference GI
o
Secondary postpartum hge (retained placental parts)
Subinvolution of uterus
* Fetol
WhiteKnightLove
Treotment
b AROM + oxytocin
o I't stage -+ conti nitoring
o Z'.stage -+ no fo
o 3- stoge+guard
* eup o( tfre notcttnal. cotnphcatiaru ..0finc.ft, ggfrg"
* eanp al tfrp nsafram
WhiteKnightLove
Definition a Blrponrc fromthe genital facl of placental site origin
Arrsn 20 /28 wks & BEFoRE delivery ofthe fetus
DuBro septrallon of a normatll situcted placento
l1 PDt
' .t age,parily.....smolong, alcohol
.J fofc acid', vit.C., vit.K
. Previous accidental hge
9l llqtsrnql dlseqse ,
WhiteKnightLove
Externol bleeding olone couses little up,set.
WhiteKnightLove
Types
1l Accordrng to bleeding
2] According to severity
C,PlFetuslShock Dtc
Class 0 Mildest -velgliveJ-ve -ve
Class ! Mitd +ve Al__iye_* -ve __-vo
Class Il Moderate **ve Distressed *ve -ve
--"- ',--- -- "-t
Class lll Severe +++vel Dead I ++ve i +ve
Clinico! picture f
1l Svmptoms
ooo
Pain - /
(SuooEN, SEvERE, Con-ruuuous abdominal pain) C
-
Bleeding. .. .,dark, clotted (absent in concealed type) 3
-
Shock (hypovloemic + neurogenic in concealed)
=
o
2l Siens 3
o
> General
- Signs of etiology e.g, PIH (but arterial blood pressure may be =
o
(o
apparently normal i.e. hypotension due to shock is masked by PIH o
(decapitated B,pr,) .'. Hypovolemia is better detected by CVP
- Shock [may not correspond to the external bleeding]
- Signs of complications e.g. DIC
> Abdominql
- Palpation:
'kFundal level -+ higher than period of amenorrhea
t
'r Umbilical grip -+ basal uterine tone (6urfti49rigiiiry)
'k Pelvic grip -+ normal presentation + engaged head
- Auscultation: &ccording to severity (distressed or absent) /
> Vaglnal
- Contrarndicated (No PV in ony cose of APHge)
- Only done after exclusion of P,previa by U/S *r well engaged
head & very tense membranes (if ruptured -+ bloody liquor)
WhiteKnightLove
Algorlthm for APH.
WhiteKnightLove
fnrrestigofions
l. Etiologt + preeclampsia
2. Diagnosts (U/S) -+ . exclude placenta previa {
. may find retroplacental hematoma
3. Complication -+ DIC, renal frrnction tests
Differentiol diognosis
1. Causes of acute abdomen in late pregnancy (concealed or mixed)
2. Causes of antepartum haemorrhage (revealed or mixed)
-Once j-recurrent
-hasetiolory i -causeless
- painftl - painless
- dark olots i - fresh blood
* Etiolory e.g. + PIH * no etiology
* Shock> hge. * shock: hge.
* DIC E
o
-l
l,
- no placenta - placenta felt o
r!
- cephalic - malpresentation c+
3
=
o
3
Complicotions ah ..q
=
o
a MATERNAL [MMR.... ..... lohl" @
o
)
Due to the d?elopinq hematoma
1l Shock
. Due to.......APhge, PPhge (atontc/ ttraumatic tDIC)
. Leading to - Renal failurc (shock + PET + DIC)
- Sheehan syndrome
2] DIC -+ accidental hge is the commonest cause ofDIC
I Due to the hiqh intrquterine pressure
3]Couvelaire uterus (utero-placental apoplexy) &
Rupture utents + intra-peritoneal haemorrhage
4l Amniotic fluid embolism
I Due to the etioloqt e.g. complications of preeclampsia
WhiteKnightLove
Alexandre C,ouuelaire (1873-1948) uas the first to
describe extensive haetnorrhoge into the myometriam;
he recogttiztd tbat it was impairittg the myometrium's
ability to cor,tlact, such that in the case he reported,
d cqesarean hysterectomy wos required. He also was
afl early prcponent of caesarean sectiofl for placenU
praeuia.
Couveloire uterus
WhiteKnightLove
Tneotment
a] Anti-shock measures //
bl Birth by,
1-rr-!;_-;-"1
oEspecially if the fetus is dead or the patient is advanced in labor
oUsually easy (wellengaged head) & rapidlt'd basal uterine tone)
f
.Early AROM (why .3R) t oxytocin o
r Relieve... ... .the high IUPr I,
o
b Reveal........any internal hge. -r
c
> Release... .,.PG...accelerate labor 3
ltotage -+ continuous monitoring (F & M)
P otage -+ usually rapid =
o
3
,1w atagc-+ guard against PPhge o
-t
rt
WhiteKnightLove
WhiteKnightLove
--
a
u
a
Atonic
Iroumotic
Retoined Plocento
Dlc
Acute lnversion
WhiteKnightLove
Alggtlhm for thc marugGrnent of ctdy m{.
Grtrrr'ottll{
. Tone: ubrln€ ato[?ry
. Tlssue: retalned products of conceptlon
. Trauma: gcnltal tract laceratlon
o Thrombln: clottlng abnormallties
WhiteKnightLove
?ostparttmtW
D It is haemorrhage from the genital tract
ATTER delivery of the fetus
TILLthe end of puerperium EnUgP a
- To a degree affecting maternal general condition
- More than 500 cc
- Causing haematocrit drop > l0 Yo
* Incidence has been reduced from 15 -+ So/o(d.t.t use of ecbolics)
+It is the commonest cause of MMR indeveloping counties (30%)
*More common with history of previous PPHge o
WhiteKnightLove
WhiteKnightLove
I Postpartum bleeding due to weak confiactilitv & retractivity
I Constitutes about -+ 90%o of cases (the commonest o)
=
o
GI
o
> Historv -) severe vaglnal bleeding after delivery ofthe fetus & placenta
> Examination
-
General -+ Shock
-
Abdominal + Uterus soft & enlarged
-
Vaginal -+ to exclude taumatic PPhge.
WhiteKnightLove
Bimanual Compression
SuTerior 4luteal
artnry
HY?oqast'ric
arwry
llqation elta
Extarnal
iliac
Utnttnc artnry
Ohuratr:rr aftary
Packing
WhiteKnightLove
* Prophvlactic
- Avoid all pdf . + proper ANC
- Proper management of lo,2n & 3'd stages of labor
* Active: Resuscitation +
ld Iine d) - tnqssaoe"
- Ecbolics (ox1.tocin, methergine, PGEI - misoprostone 800pg -)
- EmpU bladder + stop halothane
WhiteKnightLove
Foce
presentot i on
M.A.
Vertex
Presentotiorr
presen totion
o. P.
2nd_d"gfeglgSt
The perineol body is forn right
I down to (ond sometimes portly involv-
t - --' ing) the onol sphincter. The voginol
/i teors often extend up both sides of the
vogino.
#
3rd degree Teor - "Corp.!.t"l"or"
The whole onol sphincter is torn
oport, ond there moy be o teor of the -/__.f ,
rectol woll. Note how the ends of ihe ,
Torn ends
sphincter muscles lend to retroct.
..,1
-- of onol
This iniury, if not repoired, leoves sph i n cter
the potienf with foecol inconlinence.
A
l
complete
teor thot
hos foiled
to heol
WhiteKnightLove
tll Perineal tears
€tlologg: O
"
rui ;"".'J:T3B'rore
crowning
r t#:11ffi1T:adorbreech
3) causes in eerrsgrul,e.g.
elderry pG or previous scar)
- Edema (e.g. PET or obstructed labor)
4f Iniurv o.f perineum + forceps...ventouse... .destructive operations
WhiteKnightLove
Local
infiltration
anesth.
lignocaine 1o/o
Upper
segment
Lower
segment
Cervix
Vogino
WhiteKnightLove
Technioue of relnir
* Local infiltration is better than GEA
* Intemrpted sutures are better than continuous
* Vicryl is better than chnomic catgut
* Sutures are taken from above downwards
o Rectal mucosa -+ lruveRtrD LAMBERT sutures (to avoid mucosa)
o Ext. anal sphincter -+ approximate the 2 dimples at sides of anus (tom ends)
. Deep perineal muscles * Levator aru
o Vaginal wall -_> continuous or intemrpted stitches
o Superficial perineal muscles & then + perineal skin closure
Post-opetzthrc care
o Minor degrees + local cleanliness
o Major degrees -+
- perineum: dry, clean, antiseptic as betadine (povidone iodine)
- diet: NPO for 48 hrs, then -+ low residue + increased fluids
Laxatives are used for 2 weeks (stools should be soft)
- s2stemic antibiotics... .....intest. anliseptics (neomycin + flagyl ..5ds)
- no rcctal suppositories. . . . ..No sexuq[ intercourse for 2-3 ms
t2l Uaeinallears u
€tlology: as perineal tears
Dlognosls
o Traumatic PPhge (fresh blood *contracted uterus) :,
o EUA (with good light + retraction by Sim's speculum o
+ Auvard self retaining post vag wall retractor) I,
o
Cornplicotions
E
Earht -+ Hge (sometimes difficult to control O linfection 3
CoLPoRRrmxN (rupture of the vaginal vault or post. forrux)
Late =
o
- If bladder is involved -+ vesico-vaginal fisttrla or incontinence 3
o
- If rectum or sphincter -+ recto-vaginal fistula or incontinence
- If levator ani -+ prolapse =
o
- Poor healing -+ vaginal stenosis -+ dyspareunia GI
o
Trootment a resuscltotlon l=t
- Immediate repair (from above downwards)
- Iffaited -+ vaginal pack + catheter + abcs (for 24 hrs)
- If failed -+ bilateral internal iliac artery ligation.
WhiteKnightLove
Bo ing Thinned out lower segment
ssq
Vulval
hematoma ,l
T-)
on cervix
WhiteKnightLove
t5l Cervical tears
€tiology:
o causes in tbePassaE -+ cervical fibrosis
o causes in the?assenger -+ large baby
o causer' inpower r ppt labor
obsletric oPerations -+ forceps, ventouse , manual dilatation of cx
TVpes
I. Unilateral
2. Bilateral
i. Stellate (multiple radiating)
Diognosed by €Ufl athe cx is grasped by "4" rjnrg forceps at its 4 corners
Conrp!lcotlons
> Eerrs --HrLffiJ[:-' o
iritextended upwards
- Ureteric injury -+ during surgical repair
* Vulval finfra-levator) C
- Presence below levator ani -+ prevents its upward extension 3
- There is lense lender bluish fluctuant gwelling at the vulva =
o
- ttt ^. observation if small & localized 3
o
rt
* Paravaginal (suora-levator I rl
-
Sometimes not easily seen (felt by P/V) =
o
- May be suspected by sense of rectal straining (due to pressure) ct
o
o
-
ttt *) evacuation only if large + drain + packing the vagina
*
- Progressively expanding + broad ligamentary swelling
- It may dissect its way upwards -+ rnay even reach up to diaphragm
- t
ttt ^a laparotomy: evacuation bilateral uterine artery ligation
WhiteKnightLove
Seqr ruDture (bleeding is less as scar is fibrotic) "
WhiteKnightLove
t51 Ruptre utens h
lncldonco
'
o Varies according to level of obstetric care (1/1.000 + 1/4.000)
o Rupture uterus is the worst complication facrng the obstetrician
o It should be suspected in any patient vith collapse during or after labor
o Moro common in MG " 060/") dua to
- Passage a
weak uterine wall & pendulous abd. (-+tmalpresentations)
- Passenger at fetal size (&t o/o of DM)
- Power oll uterine contactions in response to obstruction S
- Attendant +false sense of security
€tiology O@
cr Durlnq )rsgnrnes.....APll[l
A- Spontaneous
- Ruptured previous uterine { scw o 6JUS >LUS)
- Rupture of anterior sacculation -+ in fixed RVF
- Rupture of posterior sacculation -+ in ventrofixation
- Rupture of pregnancy in rudimentary hom
- Invasive trophoblastic disease
- Placentapercreta
- Concealed accidental haemorrhage
B- Traumatic
- Traumato the abdomen (0.g. penetrating wounds, seat belts)
- External cephalic version (ECV)
ct Durln[ hbor........PP[hg
A- Spontaneous 5
- Same etiology as during pregrumcy (scar/) too
- Obstructedlabor // (the commonest) rt
- Maluse of ecbolics c-I
B- Traumatic
3
-Obsteffic operations < full cx dilatation (/forceps) =
o
-Excessive firndal pressure 3
o
-Manual dilatation of cx or extension of a cx tear rt
-l
-Manual removal of placenta
o
=
o
GI
Tt/pes o
* Cqnd€te rupture GruS) all 3 layers (including peritoneum) are ruphred
\ massive intraperitoneal haemorrhage
o
* lncorplete rmtffe (LUS) muscle layer is only ruptured with intact peritoneum
\
subperitoneal hematoma (occult ruptue) or
WhiteKnightLove
RUPTURE of CLASSICAL CAESAREAN SCAR ---+
SPONTANEOUS RUPTURE
WhiteKnightLove
Clinlcol Picture
pture
1)Obstructed lobor
o Symptoms: Of obstructed labor, then
- Cessation of labor pain + sudden severe abdominal parn f
- Vaginal bleeding (& feeling of something giving way ") o
I,
- Collapse (d.t. both vaginal & intraperitoneal hge.) o
q
WhiteKnightLove
After incision of the peritoneum ot
Division of the follopion tubes ond the site of rupfure the blodderis sfrip-
brood ligoments, leoving behind the ped from fhe uterine wqll ond o sub-
ovories ond port of fhe tubes. totol hystereclomy performed.
WhiteKnightLove
Dlfrerentlol dlognosls
ll Bleeding according to time (APhge , IPhge , PPhge)
2f Acute abdomen in pregnancy or labor
Complicotions
ll Msternql
" Martali4t(10%),+ hypovolemic shock * acute renal failure
"* *''j#{{,:T#
ffiriu*H[Til;**r
**
(as rupture is > on Lt side d.t. dextroratation)
2l torrl
* complete rupture -+ 700o/o mortality
'k incomplete rupture -+ 60Yo mortality
Treotment
> Prophvlaxis
1-PrEer antenatal care
't Early detection of any abnormality needing CS (macrosomia, CPD)
,. GMP rnust deliver inHospru.r, (why?)
* Patient with previous uterine operations must deliver in Hosprrer
- One LSCS + may try vaginal delivery
- Two or more LSCS -+ elective C.S. at completed 37 wks (38)
- One USCS or hysterotomy + always C.S.
- Previous repair of rupture should be hospitalized all-through
f
2 - Proper intranatal care o
l,
'r Early detection of signs of obstructed labor o
* Proper use of ecbolics -
c,
* Adequate precautions in operative obstetric deliveries 3
't EUA if PPhge occurred for early diagnosis o
3
> Active o
o Resuscitation
o=
o Laparotomy'midline incision' ct
-
Supravaginal hysterectomy (ideal m) //-rnxE ruE ovAruBs-o o
-
Bilateral IIA ligation may be needed to control hge.
-
Exploration of injury of other structures (bladder, ureter)
(}<
o Conservation (repair) of uterus may be done in limited cases '-a
-
PG, young patient. ...Clear cut edges, small wound
-
Patient must be hospitalized next pregnancy
WhiteKnightLove
RETAINED PLACENTA
WhiteKnightLove
Deflnltion (o.s - l%)
Failure of delivery of the placenta
within Yzholr of delivery of fetus
€tiologg OO
q Rehined seDqrqted
= ftilurc of Dlecentql descent
-uterine
-contraction (constriction) ring
-complete rupture uterus + escape of placenta to abdomen
-full urinary bladder
I Retelnsd edhorsnt
WhiteKnightLove
I. Perforation of uterus
2. Uterine irritation + fibrous tissue
3. Retained placental fragments +
-Sr
- Placental polyp
- Malignant trophoblastic disease
WhiteKnightLove
Clinicolplch.lrc
o Histor!
- Failure of placental delivery for %how
- Bleeding -+
. If the placenta is not separated at a11.....no bleeding
. If it is completely separated.....,..........minimal bleeding
. If it is partially separated. ..massive bleeding
o Examination
- General -+ shock (hypovolemic + neurogenic from Crede's method)
- Abdominal -+
. Fundal level elevated above umbilicus
. Signs of placental separation *ve or -ve
. Uterus may be atonic
Trootment resuscitation +
o Contraclion ing f
- treat by delivering under GEA (halothane) o
- if failed + give uterine relaxant as amyl nitrite or other tocolytics
E
o
Ruptur ulerus -+ laparotomy E
"
o Placenta 3
adherent
- reach the margin (line of clea\tage between placenta & uterus) =
o
- take a fold of membrane, separate the placenta by sawing flumner 3
o
- placenta must be fully inspected for missing parts.
=
o
> lf ftllsd ,.r mmDld rdherenca of Dlqcontr (o
o
"o S wprauagirual (iffutstervaoryt (ideal ttt)
Conseruation in much need of children & bleeding is not severe)
3 - Cut the cord -+ leave the placenta or do morcellation
- followed by * methotrexate, methergine, antibiotics
- BUT still remains great hazard of hge & inf. -+supravag.hyst.
WhiteKnightLove
WhiteKnightLove
foe11"iiio"]
Paradoxical situation in which both lhrombotlc &
fiffiicfttlc mechanisms are simultaneously activated -+
llrcrth coqgulqtion & @are present in the same time
Eii1. Proper
Pilluia
a
WhiteKnightLove
(rlogulatnnfactors
Chrisfinas factor
lfclcfirurp
Intsinsic
Surface activation + colla
)ilI+)il+lX+X VII+X
Assessed bl'PTT
HEMOgTAgIg OF IHE
Arcuala vcEscls iyofietial
llotc, vl,lril'r hctn0f,tasi)6'to Vtnanly dcpct:dicnt on
ad proaf4bfMia gro/,wtioi, anllc# oi t E cnquletnn ca*,adc
WhiteKnightLove
9 Corgulrtlon mofffu
1. Platelet count (N: 250,000/nrl). tlrombocytopenia is < .,. ....
2. Fibrinogen (I.t: 200-300mg% - inpregnancy : 400-600mg%)
3. Fibrin degradation products (N: 10 pgml) in DIC > 40 pg/ml
4. D-dimers (inDIC >0.5 pglml)
9 Pmlongsd
1, Bleeding time (N: 2-4 min)
2. Clotting time (N: 6-12mr$
3. Prothrombin time (fI: 12 sec.)
4. Parlial thromboplasfln time (N: 35-45 sec)
5. Thrombin time (time needed for conversion of fibrinogen to fibrin)
=
o
[3] Don't give @
o
. He?ain -+ as it increases bleeding (except in IUFD: as there is
intact vascular tree -the patient is not bleeding- then
heparin is stopped & TOP is induced after 6 hours
, Anttrtbiobticdrugs -+ as it increases thrombosis
(they atso cross placenta to the fetus)
WhiteKnightLove
First Degree (l ncomplete) Second Degree (Complete) Ib!d 9.st""
(c)
WhiteKnightLove
Dafz a condition in which the uterus is turned inside out immediately
after labor & before cx constriction (v.rare 1/3.000 - 1/30.000)
Degroes loo -+just cupping ofthe fundus
2ndo -+ inverted fundus protrudes through the cervix into vagina
Clinicol PicUre
q Hktoru
'k severelower abdominal pain with continuous bearing down
* Fullness
12"d; in or something protruding (3") from the vagina
'r PPhge (atony) may be minimal if
. Placenta is still attached
. In severe degrees with kinking of blood vessels
c+ Errmlnstion
* General -+ Shock (hypovolemic & neurogenic)
't Abdominal: ls degree -+ cup shaped fundus
.2"d & 3d" -> absent fundus
* Vaginal
:,
- 1s.-+ depressed fundts inside the uterus -i
o
I,o
: ?:l ;ffi fi ;H,"#3:,ffi'[T,lrfH" !
c
Dlfferentiol Diognosis 3
1. Causes of postpartum shock
2. Uterine prolapse (the cervix -external ostiurn- is found) =
o
3
3. Fibroid polyp (uterine sound passes all around) o
rt
Treotment
-
=
o
> Prophylaxis o
avoidpdf + proper 3d stage management GI
o
> .Ective a Resusdtation + Manual rvductioru (or hydrostatic " )
(JnderGEA (halothane / o*llnitrite / tocofitics)"
- First reposit the uterus then + remove the placenta "
_ Then + ecbolics + massage
- Then -+ Pack + antibiotics
WhiteKnightLove
WhiteKnightLove
lncldence ,,+ 1/30.0000 with 50% mortality
€tlologg
o AF may enter into the maternal circulation d.t.:-
l. Increased irutrauteine ?ressure
I accidental hge, oxytocin overdose with intact membraneso
2. Ooened uterirue or endocerviwl aeirus
\ as in genital tract lacerations e.g. rupture uterus
o The above factors also lead to fetal distress -+ meconium stained AF ->
this potentiates the toxic nature of AF + worsens the symptoms
Pothogenesis
o bumedbttefi afteradifficult delivery:-
or shortfi
- RDS & circulatory collapse (extensive pulmonary vascular
obstruction d.t. the Af' particulate maffer -)
acute cor-pulmonale -+ abrupt hypoxia & CIIF)
- DIC -+ bleeding from genitaltract & all other sites of trauma
-
- Deep coma & immediate death (>500/0)
o Recent!, it is proved to be a form of anaphvlactic shock to the
antigenic AF (thus AF embolism is a mis... ... .)
Diognosis
o Saspected in -+ any case of sudden postpartum collapse & DIC
o Proued b1 -+ finding AF debris (fetal squamous cells, lanugo haiq
vernix) in the pulmonary vessels by autops)t"
o lruuest'igations -+ECG, chest X-ray,V-Q scan
f
ooo
Monogernent
o Verl dificult (serious > pulmonary embolismo ) -+ only few cases succeed
\
o Immediate transfer to IC\J -_Cardio-pulmonary support C
-Management ofDIC 3
- Corticosteroids
=
o
Monitoring different organs 3
o
=
o
(o
o
Oh|flGctru tlorrolctdlh qrce3
- lv PPhge:- rupture / {,-,-,-,-
- Cardiogenic e.g. peripartum cardiomyopathy
- Eclanrpsia - Cerebrovascular accidents
- Pulmonary tlrombo-embolism - Anesthetic complications e.g. Mendelson $
- Amniotic fluid embolism ;$pp-phy_!ac"!ic-sho-gk
WhiteKnightLove
Resuscitation. A. Algorlthm. B. Position for
cardlopulmonary resuscltation.
WhiteKnightLove
Definition, ,"+ a state of circulatory failgre
(
hypotension, tissue hypo-perfusion
€tlo,!o9It
o Hgic *rock a bleeding in early preg., APHge, PPHge
o Hypovolomic a dehydration (hyperemesis gnvidarum)
o Neurogenic opainin early preg., pain in late preg.
o Septic a septic abortion, chorioamnionitis, puerperal sepsis
o Pul. embolisrn + amniotic fluid or tlrombus
o Splonchnic a sudden drop of infrauterine pressure (polyhdramnios, twins)
fiitni.ol f i.tuiel
) History suggestive of
-Etiology e.g..missed period + acute aMomen + disturbed ectopic
-Pdf e.g. .. ...preg comp (anemia, P[H)..lobor comp (prolonged / obstructed)
) Examination
1.General -+ shock'.- low B.Pr., subnormal temp, rapid weak pulse, pale
cold clammy skitL peripheral cyanosir, otig*iu
2. Abdominal
- T, R, RT -+ internal hge e.g. ectopic
- Bilateral adnexal swellings -+ V.mole
S.Local
-
Offensive discharge -+ sepsis
- Vaginal bleeding -+ hgic
fieotmeni
) 0enerqf o=
- Intravenous cannula..... Analgesia (morphia 15mg IV) I,o
- Raise legs... ... 02 inhalation... ...Warrnth (but not direct, to avoid VD) -t
> Monitoring (by fluid input & ou@ut chart)
c
3
- Catheteiaation -+ urine should not be < 30 ml/hr
- C\fP -+ kept between 8-12 cm I{2O =
o
- Replacement + start by available fluids till blood is ready
3
o
> Drugs
- Vaso-pressors t inotropics =
o
GI
- Corticosteroids, correction of acidosis (Na bicarb) o
- Antibiotics (in septic shock)
> Special
- Disturbed ectopic... ..laparotomy & salpingectomy
- Acc.hge. . ... ....TOP better vaginally
- Rupture uterus... .....laparotomy & supravaginal hysterectomy
WhiteKnightLove
> Typec
O Maternal
't Cenltql hqct trqurnq
o Tissue lanrations (perineal, vagrnal, cervical, uterine)
o He matom a forru ati orc (vulval, vaginal, broad ligamentary)
o Tirue neno$s (bucket handle tear of cx, necrotic fistulas)
't Non-genitel trqet hqqtnq (usuqllg d.t. forceps)
o Injuiu ofpeluicjoints & bones -+ rupture SP, cocclx, sacro-iliac lig.
o He n
1rg% ilHlxH:ffi::rTJ;:[ epigastric vesser s
More common in MP after strenuous labor efforts
May occur after cesarean section
C/P + sudden severe pain shock t
@ Fetal (esp in breech)
"' I leutl in1uryt(ICHge, fractures of the skull)
"' Padpltcrul nan'e (brachial plexus, facial, phrenic nerye palsy)
x hluvulo-.rkalata/(fracture clavicle, other long bones)
WhiteKnightLove
-r7
-1
-J
.J
Pre-eclompsio
Diobeles milletus
Heort Diseoses
Hyperemesis grovidorum
Urinory lroct infeclion
Anemio
Thromboembolism
Thyroid diseose
Respirolory diseose
Surgery & Poin
WhiteKnightLove
The
Prostaglandln metabolism.
WhiteKnightLove
, Occurrence of Hypertension, Proteinwia, p athol o gi cal Edema
. In the 2d half of pregmncy in a previously healthy woman
. Mainly affeotingPG
- Pm 4 Pregnancy Induced Hypertension (toxemia is a misnomer; PET ,()
- EPll-gestosis + Edema, Proteinuri4 Hypertension (by gestosis organization)
l4l OUothsorlc,xx
- Dietary factors. .....J vit. -t fat, salts (smohng is protectivell\)
- Cold whether. ..... .. seasonal variation (m.b.d.t. vasoconstriction)
WhiteKnightLove
i Ccabrd vesolrr rc.bt ncc
-- I nblr of -r"Ua hcrrorrrtlgr
morrttatk
,tcolosl
Hlgh rlrbtuor
Eatck.-
.homd Dopplcr. olg@nnnloo + luGR
WhiteKnightLove
o VacocpasmE+ cn.totmt|a ceu tnfury + hypertension * hypoxic injury
I - degeneration of cells & hge
o Multiple organs are involved .'. it is a sunctrcmo (not a disease)
and... ...HyprnrgNsloN... .. is the milestone of this syndrome
WhiteKnightLove
Vlsual dlsturbance
e.g. flashlng llghts and
papllledema lf severe
I Blood
! pressure
output
{Uane
'*
is#
WhiteKnightLove
> Symptoms:.. ..........oNLY tN SEVERE cASES
1l NeunolocrcAL oyMPToM6;
- Headache (frontal, persistent, not responding to analgesics)
- Nausea & vomiting
- Visual disturbance as blurring of vision up to 0 visual acuity
2l rrtonsrntc PAIN + stretch of liver capsule (or subcapstrlar hge)
3lotreunrA (<400 nfl /dzy) & RltuRre (<100 ml /day)
4l svmrro,\1s oF ANv coMpLrcATroN e.g. IIF & trulmonary edema
ll Hgpertshslon
- t
S}stofrc> 140 mrnHg or 30 mmHg over previous value
t
- Oiastofrc({)>90 mniHg or 1S mrrHg over previous value
\ IVbosurad ot semislttlng ....or .... left lotarol posltion
2l Pmtelnurlq /
- Tt[on-setecthte
. A +
glomenrlar damage
serious sign
. Detected by -+ albustix
SJEdemq
c'
- Occutta detected by rapid gain weight > 1 kg (2 pds) / 2 wks
=
o
(Normally -+<Yzkglwk in2n & 3d rimesters)
3
- folan4festa dorsum of foot, shin of tibia (rnb. normal)then become g
non-dependant -+ vulva -+ worsiens -+ abdominal watl
-o
rt
WhiteKnightLove
Ut rlna.itcry Dopplcr notchlng at 2f wccks
ls prodlctlve of prlecLmptl. and lntrautcrlne growtt
restrlctlon ln hlgh-rlsk mothcrs.
WhiteKnightLove
fo1r_effi ir_fro; other couses ofr
> Edema
Biloterol Uniloterol
| - fhysiological (at feet & ankle only)
- Generalized anasarca e.g. H.C.RN A
I:-D-YI
- veins
Varicose
I
| . Renal function fesfs: uric acid ( l't tot ' ) -+ creatinine, urea
2. Liverfunction tests
3. CBC -+ Hct, HELLP
4. Coagulation proftle -+ DIC (platelet count, antithrombin III) o
5. Fundus -+ spasm, haemorrhage, exudate, edema a
o
6. > Fetal -+FWB /
3
t [5cREENING]: 9.
. Doppler -+ high vascular resistance {/
..eafly diastolic notch 'r,
o
(o
. Roll over test 1t nfr in supine position > 20 mmHg) S
a
. Cold water immersion test (t diastolic pr >20mmHg) S o
. Angiotensin II infusiontest $ =
o
. t plasmafibronectin, J urinary calcium $
WhiteKnightLove
c%tes
WhiteKnightLove
Clossificotionl
r Pre-eclampsia may be mild or severe if:- la Q
- Stgt s'k B.Pressure [Systolic > 160 mmHg - Diastolic > 110 mmHg]
't Proteinuria ) 500 mg/dl (++) or > 5 glLl24 hr collected urine
o
trreotmeni d)
3 Prophylaxis 3
o Earty detection by regutar anc/ / -+ BPr., albumin, screening tets (esp for HRG)
o Anti-plat€l€ts + as low dose aspirrn (75mg) or juspirin (81mg)
o May sive -+ vit E (anti-oxidant o), omega 3 (fish oil).
r Mild cases ;*
1l If mature e; Ternrinate
2l Otherwise + Conserve
" Bed / Mentql rest -+ sedatives in extreme cases...e.g diazeparr (5 mg/day)
" Diet -+ balanced i.e. -+ avoid excess [salt, fats, CHO], not salt restriction
'k AntihgpertensivoJ (some sqg no need: mild ease ) f
Actlon
o
a. llethsldopr lAldomet] Cental action
The most sofe & uidelg (acts as a false tansmitter in the
used in mild coses / brain + J noradrenaline).
p-block$! (olone or + \ )
used with caution -+ it .f placental
Nenililns (AaOr4 flow & FWB (used with caution)
o
)
''' Observqtion o
- Daifi +FHS/6hrs.. .....BPr. .......Albuminuria 3
- o
lWeek! -+ FWB. .......RFT, LFT, fundus....weight (for edema)
!
> Corticosteroids may be given to enhance lung maturity f o
(o
> Conservation is continued 2[fU till mahrity (37-8 wks) unless ] f
o
- Disease > severe PET )
- Mother -+ disfress e.g HELLP syndrome
o
-Fetus > dlslresse,g abnormal CTG, IUGR
WhiteKnightLove
& Severe cases...TOP B
/
....The only cure in spite of fetal maturity...
'k Route
- IV: /,/ 44 gm slowly (over 15-20 m) then. .t-2
gmlhr by drip
....
- IM: loading 14 gm(4IV+ 10IM -5 em/buttock-).....then 5 gml 4 hrs
\better avoided + sterile abscess I very painful
'k Action
- Peripheral skeletal muscle relaxant (J e.Cn & Ca* at NMJ) /
- Mtto Subcortical depressant
- Mto Transient hypotensive effect [vasodilator + diuretic]
'k Toxicity Signs
- Absent knee reflexes... .........8-l2mBqlL
- Respiratory depression.. .....12-15 fiEq/L
- Cardiac depression ... ...30 mEqll
- On high level ..neonatal resp. depression
o
f L6s of patellar reflex
Due lo lhis narrow oaf ef,y marqin (4J mEorlL),f,he following
o Flushing muetbe checkedbefore each doset
3 Sluned speech
- Knee jerk (patellar reflex) is still present
o_ Motor weakness
WhiteKnightLove
o The aim is to prevent maternal intracranial hge or IIF; but keep diastolic
I
BPr between 90-100 mmHg (to avoid placental bl. Flow -+ IUFD) I
o Cesarean section: r
but first correct the general condition (anti-HTN,
MgSOa, correction of the severe metabolic acidosis due to fits) o
f
o
[5] Treotment of complicotiors 3
I Maternal,.. ,.. .renal shut down, IffiLLP g
r Fetal. ....IUGR 1'
o
GI
[6] Postportum a
o
Anticonvulsant therapy continued for 2448 hrs after... .
o
Antihypertensive therapy may be given if needed
Screening for PIH in next pregnancy (became high risk)
WhiteKnightLove
Gsfclmpsta *
o
D";jiliiffi + occurrence of fits (grand-mal-seizures ) io a patient with
pET
Eo"tggvj
- Cerebral irritation by edema or elecfrolyte imbalance (tNa*)
- Cerebral ischemic foci by vasospasm or platelet ttrrombi
S_lini-Sgl p-is3_u191 . . . . . .C./P of impending eclampsia -+ Fits
r Stages of fits
1l Premonitotg / (3-5 min)
Prodrome
. Twitches in muscles of eyes or face, rolling of eyes
. Severe headache, disturbed consciousness
2l Tonic phese (30 sec)
All muscles of body pass into spasm Back is arched
(episthotonos), limbs stretched, respiration stops -+ cyanosis
3l Clonic phese
Intermittent contraction & relaxation of muscles + biting of
tongue, vomiting, aspiratiog spontaneous defecation or
micturition, stertorous breathing, falling from bed -+ fractures
4l Comq ctage (d.t. severe acidosis)
Variable + may recover OR pass into another fit (recurrent or
status eclampticus) OR dies without recovery
r Types of fits
Anteperturn eclernpsie -+ 70o/o"
lnhep+fum eclernpsie -+ 20o/o
Posfpartum eclampsir -+ l0o/o (worst 9), during I't 48 hours up to... .
Ei ;r6i jr
(the disease process is continuing though pregnancy has ended)
c'
=
o
-t
;;
3 Convulsions
o_ - Cercbral epilepsy (similar!!), ICIIhge, infection, tumoq trauma
!
o
- Metabolic. hypo- or hyperglycemi4 hypocalcemia (tetany) / Tetanus
(o
)
- Poisoruingbystrychnine
o - Hysterical{
=
o Corne
- Cervbral......metabolic. ..Qoisoning
- Organ failure as uremia or hepatic failure
WhiteKnightLove
filpii.et ionsl OO(D
O Maternal (MMR e l0%)
> CornDllcqtioh of conuutsions
* Asphyxia due fo
- Tonic contraction of respiratory muscles
- Inhalation ofvomitus
- Inhalalion of blood from bitten tongue -+ aspiration pneumonia
- Tongue falls backwards
* Seuere metabolic acidosis
* Hyperpyrexia
> ComDllcstiom of PET
* Organ failure e.g. heart, renal, suprarenal, hepatic failtre
* Haemorfiaee in vital ortans e.g. IChge, abruptio placenta
r Eehmpslr morn,...
r Drugs c'
- Anti-hypertensives =
o
rt
- Mg-SO4 3
r Exsminsffon a TOP o_
WhiteKnightLove
funnwy of t]rc nwngement ol prqrcrcy-r'ndrced hypertensron
Fotential PIH Report siSdf'cant rise in Hood prssure, Ustnlt no trealrrent requiEd.
orexcessire udg*rt Bah,to obstetrkiao. See patient in 7 drF
Mild nH REport rise in Uood Fessure or excessiw Fo6siue a&nbsion to hospital. dependhg ort
ueightgain to obstetrkian socio-economk cordilions,lfnor adritted
seepatiarth3dayr,
lnmiut edampsia ThG patient,€qtire6 careftd synerrratic Magneiun srlptrate (see page 125).Tl$s
obsenation as eclarp,sia is a poslle outcome. is the feErred medcatixr
Thc Hood prcssrt requires freqrent fldralazh'nta,arcusl7
estinatlra at hGrvals determined by the Caesarcan seaion.
ob6letskian
nrU hlake and triury ouqn rr6t be
meaned nrtkdorty.and thc l,iE t6ted
qrartitati^Gly ror protein.
WhiteKnightLove
ilg{ a presence of }ITN < pregnancy....or....< 20 vrks
- Primary (essential) //
- Secondary e.g. Renal, Pheochromocytoma, Cushing
synfuome, Conn's disease,
Coarctation of aort4 Thyrotoxicosis
...........reflect chronicity..........
o ECG changes & cardiomegally
o Renal functions -+ creatinine clearance
o Fundus -+ atherosclerosis + hge
lZl
Efrcf of hsDsfurrlhna Dre[?ro'cs =
o
* Matemal -+ all complications of PE esp Accidental hge. =
o
* Fetal -+ IUG& IUFD, PTL
WhiteKnightLove
Tieat wlth anUblotks,
Uren re-chcck as above
Dlagnose essentlal
hypertension
WhiteKnightLove
ilrootmonE
* Controindicotod
. AeE inhibitors,....fetal renal failure o
i
5%
Prst historg
llg]ertonclon
-ve
> 20 wks < 20 rryks < 20 wks
:l
+ve *ve
Eemr -ve
Prohlnrnlr +ve -ve +ve cr
)
o
ECO elrrnge -ve +ve -ve 3
o_
Rarrrlfunstlon O if severe ffictedtithnme impaired .1,
o
(o
Fundur O if severe sclerotic wittr time albuminuric nephritis
a
o
rrT TOP if severe ..according to degree of M & F affection...
=
o
Squlro Recur in 30% ..condition persists & usually deteriorates...
WhiteKnightLove
I Chronic metabolic disorder of CHO metabolism
Due to absolute or relative decrease in insulin
in response to CHO challenge -+ hyperglycemia
l] Accordine
to onset
Autoimmune Familial tendency
(island cells anti- (complex & multi-
-bodies e.e. viral int. -factorial etiolo
insulin resistance
WhiteKnightLove
h
il Effects of pregnancy a D.M.
4 Effect of D.M. a
O tvlatmral
o PREENANCY
- Preeclampsia. .......in25yo"(vasculopathy)
- Polyhydramnios ....in25% of cases
(large placenta.. ..fetal polyuria. .Anencephaly)
. ..
GI
tr PUERPERIUM .......SJ a
o
- Postpartum hemorrhage (atonic, taumatic) )
o
- Puerperal sepsis
- Pulmonary embolism (obesity, vasculopathy, difficult labor)
WhiteKnightLove
Congcnttal anomallcc ln lnfanto of dlabcilla mother,c
9keletal and aent'ral
,atrlal6e\al ncruouo ayetem
defcat , anenaeVhaly
.venl,riaular oepl,al , aaudal reqreeeion
defecl, oyndrome (very
.aoaraVallon of aoft,a rara, buL highly
.tranopooition of
opecific for
Eealveeoclo diabal,os mellitue)
Ot.her ,microcc?haly
.oingla , haufAl 4st...1,9
umblllaalaftery "urt
Gaetrolnteellnal Renal
. anoractal atresia ,hydronephrooio
,duodcnal atresia ,renal agenaeio
.tracheo-esopha6eal .ureteral duplication
fistula ,polycyotic kidnayo
WhiteKnightLove
@ Fetal
> Abortion.....1 :x (if uncontrolled DM) - how?
> CFMF.........1 3x(G9%versus 2-3% inN)
- Especially ifIIbAl. is increased
- The commonest are :
{
. CVS (lDx) -+ YSD, transposition of great vessels, coarctation of aorta
. CNS (5x) -+ anencephaly, spina bifida, meningocele
. GIT.,. ..renal... ..skeletal
- A rare but very specific (pathognomonic) malforrriation is caudal
regression syndrome (sataf agerusis "). This is disproved now.
WhiteKnightLove
WhiteKnightLove
tr DM is diagnosed for the 1s time in pregnancy ingO%o of cases
o History (present, past, family, obstetric) may be suggestive but
investigations are a must... ...(as symptoms a.re query: BppD
O Screening
WhiteKnightLove
Modified Priscilta White classification C
liffiiiiiillcaH 5i',
Asymptomatic but with diabetic GTT GDM
A .....A1 : FBS <105 (+ diet )
.....A, :FBS > 105 (+ insulin)
ti it ,i:: :,i ,.,.,.,:, .::.ir,r : .
'
- ,::^:,.,:,:.,,
10-19 years...or.. l0-19 years No
'r.!'i..::1.'ri
a Tgpe l: IDDM
a Tgpe 2: NIDDM
a Tgpe 5: DGM
a Tgpe 4: IGT
WhiteKnightLove
O Gonfirmatory (GTT): glucose challenge
(Modified O'Sul I ivarr test)
WhiteKnightLove
Ultrqsonic Recording FHR recorder Uterine octivity recorder
(ultrosonic ,,'(tocogroph)
tronsducer)
Fetol
monitor
WhiteKnightLove
O Preconceptional care
tr Pctpno Fqgnrneg... .till good DM control (as evidenced by HbAr.)
tr Adutcs egtlmf pregnrnog tf
- HbA1.>72% (highriskofCFMF) \ indicotions
- Marked renal affection is present ) of therapeutic
- Progressive proliferative retinopathy \ TOP
tr 0rrltrgPqg,gesmlc drqgs els not rrssd
\ they cross the placenta: CFMF + t fetat hyperinsulinism
g fintenatd care
o Tlmg -+ 2 wks (3 itr GDM) ttll32 wks, then weekly
o Plrcs +a specialized antenatal clinic (obstetrician, physician, dietitian)
*
o Alrn -+ control ofDM & prevention of its progression
n
eady detection & management of comp. (general / obstetric: M&F)
o &ntrol 'srRrcr'/
D Diet
) Sufficient alone only in mild cases (GDM A1, IGT)
. Give CHO (5070 = 20G250 gm)falg (30%) proteins (n'/o)"
. Carbohydrates should not be in the sugar form (rapidly absorbed)
o
. Average 180tr2400 Kcal/d t 300 Cal in 3,0 trimester
. Totalcalories are divided among 3 major meals +3 snacks
) Exercise allowed -+ physical activrty should be moderated
D Diet * insulin
) Split schedule system (7 el.n& 5 pm)...regular + intermediate
) Indication
. GDMAl ifdietfailed: FBS> l05...lhrPP$140...2hr PPll2O
. GDM &, Class B-T
o lnuectlgrtlom
b Mat. comp : Of DM -+ renal FT,liverFT, fundus, serial HbAr. ET
On preg + screen for PIH, infections (urine, vaginal CeS) =
o
b Fetal sunrcillance 3
) GDM At 9.
- U/S at 38 weeks to exclude fetal macrosomia 'r,
rt
- CTG & BPP weekly starting from 34 weeks
o
GI
) cDM Aa& IDDM B-T (pregestational IDDM) =
o
- U/S at . 18 - 20 wks (excludes CFMF) ..t MS-aFP =
o
. Serially (for macrosomia or ruGR)... ... + Doppler
- CTG & BPP weekly starting from32 weeks
WhiteKnightLove
WhiteKnightLove
"9- "I:-rpil*li* -qlp-rsglusy
> Tirne
o Diabetics should not be allowed to pass dates ,,+ )40 wks X
a In mild cases under excellent control (GDM class A1) ,,+ 40 wks
a Insulin reguirins diabetics (Class A2,8, C, D)
. Well eontrolled, no F/ M complications ,+ 38-40 wks
o Not well controlled: once document maturity ,,+ 37 wks
. Earlier TOP < maturity ifFA4 distress occur ,,+ <37 wks
o In cases with repeated unexplained IUFD terminate ',+ l-2 earlier
> Mode
i Cesarean section: t- *
'kMacrosomia (> 4kg ?!). This is > in GDM
. Deposition of glycogen is more at shoulders & fetal liver
. The disproportion between fetal head / abdomen -+ sh. dystocia
'k Previous history of unexplained IUFD
r Vaginal + by AROM * syntocinon (?) + intrapartum fetal monitoring
WhiteKnightLove
Target
lnsulin Type lmpact
Time Glucose
and Dose Time Seen Level (mg/dL)
WhiteKnightLove
> lndicotions:
. GDM Ar if diet failed
. GDM A.z, Class B-T
> Dosooe
- In class B-T -+ no change in previous dosage (if sugar is controlled)
- In GDM A,2 give -+ 0.6 r/kg (ls trimester), 0.7 u/kg(2"d), 0.8 r/kg (3*)
- The calculated dose is then divided
)
Morning (7 AM) Evening (5PM) Otouoadiona, I llrhe
4l do* ll dose
Morning g _1_9_4Y
J J NPH 5 PM
1A crystalline
+ +g NPH
1/1 crystalline
+%NPH
Evening
Ie l_giM
NPH 7 AM
WhiteKnightLove
1 .
Gestational diabetes occurs in 196 to 12Vo of preg-
nant women.
2. Risk factors for gestational diabetes include
Hispanic, Asian American, Native American, and
African American ethnicity, obesity, family history
of diabetet and prior pregnancy complicated by
gestational diabetes, macrosomia, shoulder dysto-
cia, or fetal death.
3. All pregnant women should be screened for dia-
betes betvveen weeks 24 and 28. High-risk women
should also be screened at their first prenatal visit.
4. Fetal complications of gestational diabetes
include macrosomia, shoulder dystocia, and
neonatal hypoglycemia.
5. Pregnancy management should include frequent
health care visits, thorough patient education,
American Diabetic Association diet, glucose moni-
toring, fetal monitoring, and insulin or an oral
hypoglycemic agent as indicated.
6. Patients should generally be induced between 39
and 40 week gestation. lntrapartum insulin and
dextrose are used to maintain tight control during
delivery. Cesarean section is offered if fetal weight
is over 4500 g.
WhiteKnightLove
Gestotionol DM Ea
. CHO intolerance recognized for the 1$ time during pregnancy &
disappears after pregnancy (whether insulin is used or not for ttt)
. Screening for GDM should be performed between 24-28 wks
Manaqement Terminatbn
Low risk / Ar diet control Left till term (never
-"--- "-t"*-"-'*
-dates
diet + insulin I Manaeed as IDDM
8-12 16-24
Lons actins ezl,ultralente) 8 .l|2-_lQ _. 24-32
NFH ir rbe neurnal protamine of Ha4erbsn
WhiteKnightLove
c%tes
WhiteKnightLove
Rheumatic -+ 93% (MAT esp + MS)
Congenital -+ 7o/o (> in developed countries)
Others -+ lo/o (e.9. IHD, arrhy'thmias, cardiomyopathy)
Historv
> Personol
- Name I Age / Marital status lPat'r\r
- Address : --------- RHD is > in damp non-sunny area
- Occupation : ----- may need advice agarnst marked physical effort
- Special habits :--- must stop smokrng
> Comploint 6 HPI:
1l PVC - dyspnea, orthopne4 PND, cough, expectoration, hemoptysis
21 SVC - engorged neck veins, rt hypochondrial pain, ascites, LL edema
3lRheunatic artiyiU-+ carditis, arthritis, chorea gravidarum, SC nod, erythema
-
aIIEC fever, symptoms of F{F, CNS sympt., hypochondrial pain, haemattria
q
5l Aryhvthmia + palpltatlon
57 Cvaruotic heafi disease -+ cyanosis (malar llush in pregnancy) =
o
7l Ischemia -+ anginal pain 3
o_
> Monstruol hisEorv -+ for dattng !
> Obstetric historv -+ previous IIF in pregnancy o
(o
> Post historv )
- Medical -+ rheumatic fever, duration of heart disease, attacks of failure o
- Surgical -+ valve replacement =
o
- Drugs -+ anti-failure / anti-coagulant
WhiteKnightLove
Loss of inter-
villous spoce. Pulmonory
Controction of hypertension
myornetrium. ond Oedemo
I
l
+ I
Blood forced Overdistension
info of
c ircu lotion left ouricle
WhiteKnightLove
Examination
{. Peripheral ug gr.,ornatfi we couff see o
- Signs of SVC
. Neck veins _+ not reliable d.t. t.d blood volume
.Edgma may occur due to (pregnancy or pEe
. Enlarged liver + may be difficult to palpate due to large uterus
- signs of hyper-dynamic circulauon e.g. I{zo hummerpulse, cap. pulsation
WhiteKnightLove
- Doesn't cross the placenta
- Short acting (2- hrs)
- Have antidote ,"+ protamine
sulfate slowly IV
WhiteKnightLove
1. X-ray ?! (+ abdominal shield) -+ cardiomegally
2. ECG lEchocardiography
J. Rheumatic fever -+ ESR, CRP, A-SOT
O Preconceptional control
$ Pregnoncy controindicoted in: @@
is
e Antenatal care
Done in o aspecialized antenatal clinic (obstetrician, cardiologist)
Donefmo control ofHD & early detection & management of comp
o
Done euery 2 wks t11132 wks, then weekly
Done h1 o
o Rcst -+ some hospitalize at[30-34 wks] then to plan labor [36-37 wks]
o Dict -+ salt restriction
o Drugs -+
. Avoid anemia / infections (esp. resp tract) -+ ppf to heart failure
. Long acting (berzathine) penicillin 1.2 million lUlmofih {
. Class III & IV -+ digitalis, diuretics, amrnophylline
. Valve z/ replacement with pregrancy:-
C'
*Warfarin (5mg) orPhenindione (50mg) a
*BUT use Heparin (5000 ru/S.C./8hs) during ) o
3
o_
I't trim (as warfarint Crlvr as microcephaly, optic !
hy, chondrodysplasia punctata+ t feal hge) o
GI
I Z-3 weeks before delivery rP shift back to heparin
At onset of labor a stop heparin =
o
f
After labor (Glz hrs) e give OAC + heparin (till OAC acts) o
3 days later ostop heparin......then continue only by OAC
WhiteKnightLove
Etienne-Louis Arthur Falbt (1850.7911) was
a professor of fotenskmedicine and lrygiene in
Marceille. He bad a rcpatation ds afl asfrile clinician
ard fot accurate careful physical exaruinatio*.
WhiteKnightLove
O Termination
O Tirne
$ Class I & II. .. ... .left for smooth spontaneous of labor (no induction?)
$ Class III ...if completed here family -+ betterto terminate
..if insists on pregmncy -+ continue in hospital
$ Class IV ..confiol the HF ls medically, then terminate
O Route
>,oaginal //
l"t stage
- Semi-sitting positianwrttr no bearing doum
- arufgesia
"A[equaw
* Morphine (10mg) orPethidine (100mg)
* Epidural analgesia
- Interwittent02+ antifailure ttt if needed
- Chse oSseruatimt [P-BP-Temp] + FHS + Uterine contraction
- Aropfiykctir anti6iorrcr(GBS/) & delayAROM as possible
* 2 g anrpicillin + gentarnycin 1.5 mgKg
* glven I hour before placental separation
* Ampicillin is repeated once after 8 hours
2"d stage
- 'Unntry easy (small baby + soft cervix)
- Sfinrtenzd stage & avoid bearing down by low forceps or ventouse
3d stage
- Avoid ergot IV (t treart load due to VC r uterine confiaction)
/
- Lasix may bo given (ifheart failure)
- Guard againstPPhge (may give 7+ mg IM)
WhiteKnightLove
c%tes
WhiteKnightLove
4y^ Bot'rg ti{pontrxt canotac coxotrtoxe
llitrol Volve
Pathology: Myxomatous degeneration of one or both of mitral valve
leaflets + prolapse into left atium during systole
-
ClPz Asyrnptomatic mainly
- May -+ palpitation, dyspnea, chest pain, syncope
Treatment during labor: Controversial + only inderal
Most don't give antibiotics except if associated with MR
Cmrctotion of
Definition
- Hypertension only in upper limbs
- Normal / low pressure in lower limbs
- May be confined only to left arm (coarctation of left subclavian)
Route of termination
- Vaginal delivery allowed
- C.S. only in other obstetric indications
rtiorfon
o
=
o
Etaology + defective CT rl
3
Clinical picture g
- Mitral valve prolapse / incompetence !
- Aortic dissection (intimal tear) + acute chest pain + shock o
(cl
a
rn pneqnoncy
o
a
Tight Ms (< lcm) Balloon catheterization may be done (2'd trimester) o
valve reptacement is ccntraindicated (hear lung machrne * anticoagulation)
WhiteKnightLove
Ovorion hormones
Psychi I
(oestrogens,
progesterones)
Reduced
irotility ond
sectretion
rionic hormones
(oestrogens, progesterones,
chorionic aonodotrophins
hove oll been suggested)
WhiteKnightLove
O emesis gravidarum (rnorning sicknoss)
> Definition
- NaV inthe lstimester (max 6h - lzn week)
- It doesn't affect the general condition
> lncidence avery common (80%o) esp in PG, esp in the moming
> €tiologg aunknown
> Monogement
- Reassurance -+ it disappears spontaneously
- Small frequent meals +. Better dry CHO meals
. Avoid immediate recurnbency after meals
. Fe therapy is temporarily stopped (nauseating)
- If not responding -+ antiemetics
O Hgperemesis gravidarum E\
> Definition
- that ) pernicious
Severe vomiting to a degree
- Affects the general condition ) vomiEing of preg
> lncidence e01-1%
> €tiologg +theories
- Psuchologicql: as it
. Start only after knowing that she is pregnant
. Vomiting only infront of her husband @ -+ more in neurotic females
- Hormonql
. t uCe (as in V.mole & twins)
t
. Ts, Ta....transient....no need forttt
. J Corticosteroids
- Allugic -+ against CL of pregnancy, sex steroids
cr
- Defieiencs (esP Vit Br & 86)
=
o
> Pothology ovomiting ) 3
o_
- Stqrr,qtlon -+ dehydrafion -+ starvation ketosis & elect. imbalance !
- Llv$ -+fatty change & centrilobular necrosis
@
o
- Kidneg -+ tubular necrosis
=
- llerrt o
-+brown atoPhY a
- Brein -+ petechial hge & congestion o
- Retine -+ hge, optic neuritis, detachment
WhiteKnightLove
WhiteKnightLove
Clinicol Picturr
- Excessive vomiting (allover the day & not related to meals)
- Dehydration +. .[BPr, fpulse, ttemp. oliguria, constipation
. Jweight, sunken eyes + jaundice, dry inelastic skin
- CNS + . Peripheral neuritis
. Wernicke's encephalopathy - d.t. Vit B1 def
Invcstigofiorc
. Diagnosis a Urho rnrluch -+ Ketone bodies/ + no glucose
oew - t Hct.....J Gvr, K, cl)
r Etiology o llA (Twins, V.M.) + Te Ta
. Complication A Furdrt, Urer + Renrt trnctton tct
Trcotment
Ill llcilhlhrtlon ,* r€ossurofrGe (& isolation!)
tzl Dld
- NPO + IV fluids (till 48 hrs aftervomiting stops)
- Then restart gradually by clear liquids + CHO meals (no fats, spices)
- If failed + TPN + thiamine (B1)
tgl hqrr
- Sedatives -+ phenothiazines (chlorpromazine)
- Antihistaminic -+ promethazine (phenergan)
- Anilemetics -+ . metoclopramide (primperan), Cortigen B6
. navodoxine, motilium (domperidone)
- ln resistant cases + Zofran (ondansteron: 5-HT blocker ) t steroids
[alOheiuflon n
-
Vomiting: -+ frequency
-
Vital data: -+ BPr, P, T
-
Urine analysis -+ daily
-
Organ functiontests + Fundus -+ weekly
H TOP
** Xndinatfun
Deterioration of general condition in spite ofttt [P >100, T > 38]
Deterioration of organ affection [renal / hepatic / CNS I retinal
** ildftodo
< 14 weeks + Suction evacuation or DaC
> 14 weeks + may end in HvsrsnoTour .. . ... .why?
WhiteKnightLove
WhiteKnightLove
Extros
> DD of vomltlng il pregnaocXl @e
l. Morning sickness (emesis gravidarum)
2. Disturbed ectopic pregnancy
3. Vesicular mole
4....... Preeclampsia (severe)
5.......BelonephriUs
6....... Polyhydmmnios
7. Gyn. conditions + twisted ov. swelling, red degen. of fibroid
8. Medical conditions + food poisoning, hepatitis
9. Surgical conditions + appendicitis, cholecystitis, peptic trlcer
WhiteKnightLove
tuh
Dofinition (4-7o/o)
- Presence of >100.000 organisms of a single colony /ml urine
- In absence of any symptoms orpas cells
€ffecB on pregnoncg -+ t"o liability to:
- Acute $elonephritis (in 25% of cases)
- Anemia
. PIH & ruGR
. PROM&PTL
Diognosis
- No symptoms o .'. screening tests MUsr BE poNE in ls visit )
Colony cotrnt (by clean catch technique: MSI,
Treotment
1- Broad spectrum antibiotic (of high urinary concentrations) for 7-10 d
[Ampicillin / Cephalosporins / Nitrofrrantoin]
2-If failed-+ antibiotic according to CaS
o
3- Urine CaS is then repeated each timester
=
o - Ascending infection... ...along the lumen or periureteric lymphatics/
- Lynphalic spread. .. . . . ..from neighboring colon
- Blood borne from. .. .....a septic focus (rare)
WhiteKnightLove
Cllnlcol plch.lro
* SUmDtoms
- General -+ FAHMR + vomiting (sudden onset)
,'+Local + severe loin paiq dysuri4 haematuria / pyuria, frequency
Conpllcotlons
- Ehmnicity..........Pyonephrosis........ ..Perinephric abscess
- Urcruia.. ....Septicemia ......Sepfric shock
. PHOM & PTL
- Hecunenf,e in next pregnancy (20%)
Treotment
9 Gsnsnl
- Hospitahzation
- Ample fluids (oral or IV) + Analgesics + Antipyretics
WhiteKnightLove
[3] .Ecute renal failure in preg ar
> Definition + rapidly progressive azotemia
> €tiologg'
o Pre-rerualfailuru (hypovolemia: accidental hge or hyperemesis Gr.)
o Renal
- Sepsis (e.g. septic abortion)
- PET,IIELLP syndrome, DIC
o Hepato-renal-+ acute fatty liver in pregnancy
> Tuo tvpes
o Acurs TueuLanNBCRosIS (reversible)
o Bn,q.TERAr ConucerNrcnosrs (rare &, more worse)
WhiteKnightLove
Definition o + in the amount of circulating haemoglobin (N: 12-16 grn%)
Normo! chonges in Hb in pregnoncy
r PHysrolocrcRl ANrurn (haemodilution) due to
I
- RBC volume Ay ZVz} %but
I
- Plasma volume Ay +O-SO Vo
'
Lower limit is 11 glr/dl (tlct < 33%).Below this-+ PatHolocrcar ANrvra o
Clossi
Complicotions:
cr Effect of presnancv -+ anemia (worsened; d.t. t Fe & vitamin demand)
9 Effect of anemia -+ pregnancv
> Moternol
c'
=
o
rt
3
o
!rt
> Fetol o
GI
The fetus obtains all its needs of iron & vitamins from
=
o
the mother by active transport (even if she is anemic). 3
However, there may be + . PTL & RDS
o
.t Pmtm. (d.t. the maternal comp.)
WhiteKnightLove
Saving from amenorrh
approximately
WhiteKnightLove
> Pohogenosls
* Iron requirements in pregnancy are > iron absorption (inspite of itst)
o Therefore iron stores in the mother are used to conect the difference
* If iron stores are already depleted or the mother is anemic
\iron deficiency anemia occurs or is aggravated
NormolFe obsorptiono
. Daily absorption -+ 10% -td
2o%tapreg- offerous supplied (10 mg /d)
\
Non- preg. (1-2mg), early pree. Q.5 mg), late preq. (6.5 mg)
. One gram is needed forthe whole pregnancy
€tlologg (Pdfl - O nutritional intake or O stores
- 0 loss -+ hge... .vomiting. .. .piles. .. .parasitic infestations
lnvestlgotlons
. Ilb Yo-+ < 1 1 gn/dl (<10.5 mg o/o recently )
. Blood picture + hypochromic microcytio, J.o (MCV, MCH, MCHC: <30 g/dl)
. kon studies: o
- S, fenitin J (reflects BM stores) <10 ng/ml (1't abnormal test/)
- Serum iron J G'[. : 60-180 ltgldl)
- Bone marrow stores J
- Total iron bindingcapacity t (reflects J transferrin saturation by 15%) "
Treotmont
o +QtoDfrufactic
- Eradicate any pdf
-
Improve diet + iron supplementation orally (after lstrimester: N6V)
\
Iron sulfate / gluconate / fumarate (30-60 mg/day)
I Adiw
ll 0rrl hon lx3: during or after meals to supply 120-240 mg lday E
WhiteKnightLove
c%rcs
WhiteKnightLove
E DNA replication is affected -+ Jnuclear maturation -+ a.ffection ofthe 3 cell
lines -+ on emi a, I e ukop e ni a (infections), t hromb o cyt op e n i a (bl. tendency)
> thaLassemra
/, Thstsssemtq mtnor -+ J o chain synthesis -+ v. mild anernia + min. effect on preg
2- Thqtsesemie melor --> J p chain synthesis -+ severe anemia, rare to become preg
P-s,-gi-l
cr
f
> stckl€ celt an€mra o
E
/- Sickte cell trsit -+ v, mild anemia -+ min, effect on preg (UTl 3
2- Sickle cell diserse -+
)
g
!
- Occlusive crisis: obstruction of vessels + infarctions
o
- Hemolytic crisis: anemia & jaundice (o
a
by
o
TTT - Prevent occlusive crisis . Good hydration f
. Avoid hypxia & infections o
Eeps@-U9pq&jglelgp-!il{uil-o$-+-Eve!g-Hu-Q
WhiteKnightLove
E
J
o
o
o,
E
o
c
o
a
lst Znd
Trim6ts
The hvclr of thc proco.guhntr (Al irtor Vlll,
von Ullebrrnd hctor rnd (81 tbrlnogon rlrl ln pr.gn ncy.
FV factor V.
The offected leg moy fecl womer Coreful meosurcrneni moy rweol
to the bock of lhe hqnd. some swelling compored with the other
leg.
WhiteKnightLove
> lncidence e0.5-lo/o
I
> Dloonosis
* Sgnptnma
. DVT -+ acute painful swollen leg
. More corrmon in the left LL (why .?)
. More common in ilio-femoral (more dangerous > calf)
WhiteKnightLove
c%tes
WhiteKnightLove
MMR =15%. However, syndrome APS may lead 0n both
Post-phlebitic I
WhiteKnightLove
c%rcs
WhiteKnightLove
Thromboembolic disease
Risk factors for venous thromboembolism in pregnancy and the puerperium
after vaginal delivery
Thrombophilia Hyperemesis
Congenital Dehydration
Antithrombin deficiency Ovarian hyperstimulation syndrome
Protein C deficiency Severe infection e.g, pyelonephritis
Protein 5 deficiency lmmobility (>4 days bed rest)
Factor V Leiden Pre-eclampsia
Prr.rthrombin gene variant Excessive blood loss
Acquired (antiphospholipid Long haul travel
syndrome) Prolonged labour
Lupus anticoagulant Midcavity instrumental delivery
Anticardiolipin an tibodies
WhiteKnightLove
The boby should be exomined corefully ofter birth.
X-roy moy
show obsence
of bone centres.
WhiteKnightLove
O $bSnotor,icosis
> Complicotions
9 Efrct on tfifold
- Usually tolerable course during pregnancy
- Condition may improve & exacerbates after delivery
I Efhst on Pregnrncg
* Severe hyperthyroidism: usually -+ anovulation + amen. & infertility
* Maternal
- Spontaneous abortion & PTL
- PIH & Congestive IIF
- Hyperemesis gravidarum
* Fetal
- ruc& ruFD
- Fetal tachycardia, neonatal hyperthyroidism
- Fetal thyrotoxicosis & goiter d.t. passage of autoantibodies (IgG)
> Treotment
I Antithyroid drugs
o
I Beta-blocking Agents
. Propranolol (nderal) l0 mg lx3
. Block the beta-adrenergic receptors
. Prevent adrenergic effects of thyrotoxicosis
. Block the conversion of T+ -+ Tl
, The aim o + maintain the lowest possible doses of anti-thyroid drugs cr
)
o o
9 Suryera: Subtotal thyroidectomy is rarely indicated except: -t
3
- Failed medical ttt o_
- Cannot tolerate medical ttt !
-Large goiters with significant tracheal obstruction
-t
o
(o
It does not eliminate the risk of tansplacental passage of a
LATS and the possibility of fetal & neonatal thyrotoxicosis o
a
o
cr Radioactive iodine ablation (It") - I contraindicated in pregnancy "
WhiteKnightLove
O $ypothyroic{ism
> Etiology
o Prlmeru hsDothsroldism: (TSH is high)
o Hashimoto's thyroiditis (autoimmune) /{
o Iatrogenic (Radioactive-iodine 131, surgery, antithyroid drugs)
o Iodine deficiency
o Sscondqrg hgDothgroldism: (TSH is low) Rare, 2ryto.
o Hypothalamic or pituitary disease, as in Sheehan syndrome?!
o Chromophobe adenoma of pituitary gland
> Complicotions
* Maternal + abortion, PIH, & abruptio placentae, heart failure " o
* Fetal +. IUGR & IUFD
. Congenital hypothyroidism (-+ obstructed labor) occurs in:
- RAI therapy for thyrotoxicosis /
- Rarely in hypothyroidism
> Investigotions
- Low senrm T3RU
- t thyroid antibodies (antimicrosomal, antithyroglobtrlin) in Hashimoto
- TSH is low in2ry hypothyroidism
> Treotment
Replocement theropy
- L-thyroxine (Ta) 0.05-0.10 mg /day converted in body to T3
- Breast-feeding is not contraindicated
WhiteKnightLove
O lreatblessness (dyspoea)
O flateroal $noktos
> Tobocco smoke (3800 constituents)
. Nicotine + vzmoconstriction
. CO -+ combines with fetal Hb -+ carboxyhemoglobin + fetal hypoxia
' Benq@yvne -+mutagenic & carcinogenic
> Effect of smoking on pregnoncy
o rueR / Neonates are t 200 g lighter than non-smokers
Effect is dose related (nunber of cigaretteVday)
o t'PNUR -+ including sudden infant death syndrome
o SDorrhneorc -+ abortion, PTL, PROM
o APllm -+ placental abruption, placentaprevia
@ $roncbtalsstbma(l%)
> Complicotions
. Eftst of prugnrneg a uthnrq: no effect on frequency or severity
. Eftcr 0f sthrnr + Fsgnqncg: HTN, ruG& PTL
> ltonogement u
. Reggll mdicrtlons +s CONTINUED (not teratogenic) a
o
-t
o lnhqlqtlon h bsftsr thqn mql rgenh 3
o o_
. Glucocorti co ids (Betomethoso ne), Disodium cromoglycote,& i protropium
!
. gz ogonists, Theophyllines (ominophylline)' -t
o
. Asthnrl exacerbation h not rn indlcrtlon for elective delivery GI
o ]lgdrmmtilons is given during labor (300 mg /12 hrs)
=
o
. Auold the tullulng dq$ . Prostoglondin Fzo d E2 onologues (misoprostol) =
o
. Methergine, Pethidine (not o problem in proctice)
WhiteKnightLove
+ *ffssrallnpregnancrf <e &
O Acute
o
IAcute 0 Clvarian torsion
Appendicitis cholecystitis or Ruptured CL
lncidence Commonest 1t15001" 2d common 1 /4000 uncommon
Pdf Reluation of gall bladder lnduction of ovulation
Unknown
(d.t. orooest.)
o
Diagnosis difficult EASET T level of suspicion
Pain m.b. somewhat Acute unilateral pain
Same like the non-
clP upwards. This depends
pregnant
t NaV
on gest. age + Adenexal swellino
TLC is normally t.u in Bilirubin, amylase U/S is essentialfor all
lnvest. (for differentiation)
Dre0 Upper abd. U/S
Complicat. Rupture, perfor, rtion, peritonitis... .......fetus + abortion, PTL
Treatment Laparotomy * Medicalttt Look
(its site depends on gest. (Fluids, NPO, A, A, A) Cancer
age)e.9. Ratherford * lf failed (257d or Ovary
extension comolicated + suroery
WhiteKnightLove