Gynecology Flashcards
Define conception
The process of sperm and egg fusion, which consists of the acrosome reaction and impregnation.
how many days is required for spermatogenesis?
74 days
how is the ideal concentrations for sperm penetration created i the placenta?
At time of ovulation estrogen levels are high causing favorable electrolyte concentration of the cervical mucosa for sperm
The average ejaculation contains?
2-5ml semen
20-250 mill sperm
> 30% are morph normal
how many sperms cells arrive at the egg?
prox 200 sperm cells
Describe the sperm migration
- Enter the cervical os
- Goes to the cervical crypts stored for later ascent
- uterine contractions (prostaglandin in semen) propel sperm to the tubes within 5 min
what causes the contraction of the cervix by sperm?
prostaglanding by the sperm plasma
timeframe from ejaculation to fertilization?
prox 12h
what happens when the sperm reaches the ova?
capacitation of the sperm
what is sperm capacitation?
the set of natural physical changes that a spermatozoon undergoes in order to be able to fertilize the ovum. ex. acrosomal reaction
what is the acrosomal reaction?
- Sperm binds to egg
- Sperm membrane protein activated
- increase IC ca2+ i sperm
- causes release of acrosome
- This is lysosomal enzymes lysis path through egg and sperm can enter
layers of the ovum
what happens when the sperm has entered the ovum?
the cortical reaction is triggered leading to the Zona pellucida releasing granular content to prevent further penetrating by other sperm
what is formed inside the egg when the sperm fuses?
zygote restoring the diploid number of chromosomes
What is the cleavage and blastulation phase?
Cleavage: mitotic divisions without growth
Blastulation: ball of cells with a fluid filled center, and an inner mass of cells
when is the fertilized egg called a morula?
16 cell stage at day 4
How does the morula turn into the blastocyst?
- Compaction of the morula
- Means central cells pack close together and diff into two cell types:
- Embryoblast in the center
- Thropoblast in the periphery. - Embryoblast cluster in the center forming the inner cell mass and a cavity called blastocyst cavity
- It is now called a blastocyst
how many cells does the blastocyst have?
32+
cells of the blastocyst and what they develop into
Embryoblast: embryo
Trophoblast: placenta
what happens to the ZP after blastulation?
Hatching of the ZP and the trophoblast takes over as the outer membrane at day 5-6
what causes thickening of the endometrium under pregnancy?
Progesteron causes he decidua to thicken to 5-10mm
what happend to the blastocyst in the uterus?
implantation by adhering to the endometrium
when can implantation of the blastocyst happen?
the blastocyst can only adhere to the endometrum during secretory phase (luteinizing phase) also termed implantation window
what is the decidua
The decidua is the specialized layer of endometrium that forms the base of the placental bed
types of decidua?
Decidua basilaris: Basal plate of placenta at implantation site
Decidua capsulris: overlying the developing embryo
Decidua vera: remaining lining of uterine cavity
when is the space between the decidua capsularis and vera obliterated?
4th month
Trophoblast develops into 3 layers?
Syncythiotrophoblast
cytotrophoblast
extraembryonic mesoderm
these three layers are also called chorion
What does the extraembryonic mesoderm form?
connecting stalk - provide CT for the umbilical cord
what is the inner cell mass?
The embryonic disc, which diff into:
Epiblast
Hypoblast
what does the syncythiotrophoblst cells do?
Syncytiotrophoblast invades the endometric
tissue around day 9, resulting in rupture of maternal capillaries, and thus establishing an interface between maternal blood and embryonic extracellular fluid.
when is implantation complete?
end of week 2
Steps of placentation
- synsythiotrophoblast invades endometrium
- cytotrophoblast invades synsytio
- primary chorionic villi is formed
- extraembryonic mesoderm invades villi
- core of loose CT is formed
- secondary villi is formed
- 3rd week blood vessels form in villi
- tertiary villi is formed
- by day 17 maternal fetal circulation is formed
Steps of pelvic examination
- Evaluate the vulva
- use speculum to see vagnal walls
- Colposcope to look for abnormal tissue
- Pap smear
- Extended colposcope with acetic acid and iodine solution
- Bimanual pelvic exam
why do a extended colposcope?
Apply acetic acid solution and iodine solution to the surface to
better visualize possible precancerous or cancerous lesions.
what can you see when applying acetic acid solution and iodine during an extended colposcope?
Acetic acid areas of whiteness correlate with higher nuclear density. The areas that appear white are considered for biopsy.
critical area on the cervix where cancer lesions often arise
The squamocolumnar junction is a
The purpose of the Bimanual pelvic examination is?
To determine the size and nature of the uterus and the presence or absence of adnexal masses
what are the routine prenatal visits?
Every 4th week until week 28
Every 2nd week from week 28-35
Every 1 week from week 35 and to birth
If high risk every 1-2 week intervals
what do you do in the first prenatal visit
Full medical history
Estimation of due date
Physical examination
Laboratory tests
Patient education
Naeglers rule
A standard way of calculating the due date for a pregnancy:
First day of last menstrual period – 3 months + 7 days (add 1 year)
The result is approximately 280 days (40 weeks) from the start of the last menstrual period
the trimester period?
First: 1-12 weeks
Second: 13-27 weeks
Third: 28-
40 weeks
What to include in obstetric and gyno history?
gravidities
GTPAL
# Gravidity numbers: total number of pregnancies
# Term births
# Preterm births
# Abortions
# Live children
B-hCG when is it positive?
8-9 days post conception in blood
28 days in urine 1st day of LMP (last mensens)
B-hCG value pattern?
Double every 2nd day until week 10
B-hCG levels less then expected indicates
Ectopic pregnancy
Abortion
Inaccurate dates
B-hCG higher then expected indicates?
Multiple gestations
Molar pregnancy
Trisomy 21
Inaccurate dates
Peptide hormones of pregnancy
hCG
hPL (human placental lactogen)
CRH (corticotropin-release hormone)
Prolactin
Relaxin
Steroid hormones of pregnancy and other
Progesterone
Estrogen
Oxytocin
Facts about hCG
- Increase from day 8-9 - peak at day 60-80
- Secreted by trophoblastic cells of placenta
- in beginning it maintain CL ensuring progesteron release until placeta takes over release
high hCG if not pregnant indicates?
hCG producing tumors:
- Hydatidiform mole
- Choriocarcinoma
- Embryonal carcinoma
can the placenta produce estrogen from progesteron?
No, due to the lack of the enzyme 17-a-hydroxylase, must use androgens as its source of precursor for estrogen production
what is Human placental lactogen?
Antagonizs the cellular action of insulin and decrease maternal
glucose utilization, which increase glucose availability to the fetus. Low values are found with threatened abortion and IUGR
what is Corticotropin release hormone?
Made by the placenta, goes into fetal circulation at 12w stimulating ACTH which stimulates fetal adrenals to secrete DHEA’s precursor to estrogen.
what is prolactin?
The main function of prolactin is stimulation of postpartum milk production
What is relaxin?
Associated with softening of the cervix, however, its primary function appears to be in promoting implantation of the embryo
Function of progesteron in pregnancy
In the luteal phase:
Changes in the endometrium preparing it for egg implantation.
In pregnancy:
Higher levels induce decidual changes. It has a smooth muscle relaxant effect inhibiting early contractions of the myometrium
source of progesteron during pregnancy?
Up to 6th or 7th week of pregnancy: corpus luteum
Thereafter the placenta begins to play the major role
Role of estrogen during pregnancy?
- Increase uterine blood flow
- prepare breast tissue for lactation
- stimulate production of hormone binding globulin in liver
Function of oxytocin
causes uterine contractions, can be administered to induce or augment labor
what is parturition
the action of giving birth
phases of parturition?
can be divided into 4 phases
Phase 1 of parturition
QUIESCENSE (inactivity):
Myometrial activity is inhibited through pregnancy where progesteron plays a big role
Braxton hicks contractions might happen
Phase 2 of parturition
ACTIVATION
- Last 6-8 weeks
- Fetal maturity
- fetal hypothalamus secretes CRH increasing ACTH and subsequent cortisol + androgen
- Cortisol stimulate surfactant release
- major lung surfactant protein (SP-A) into amniotic fluid stimulates labor
Phase 3 of parturition
STIMULATION
- Uterine contraction
- Cervical ripening
- Decidual/fetal membrane activation
- drop in progesteron/rise in estrogen enhance expression of contraction ass proteins (CAP)
Contraction associated proteins?
Connexin-43 (gap junctions - more contractions)
Oxytocin receptors
Prostaglandin receptors
what happens when prostaglandin and Oxytocin bilds to their receptors on the myometrium
enhances contractions
Phase 4 of parturition
INVOLUTIN (puerperium)
During expulsion of the fetus there is a dramatic increase in the release of maternal oxytocin which facilitates the initiation of the final phase of labor
▪ There is placental separation and continued uterine contractions
Immune status during pregnancy?
- Mother and child are immunologic aware of each other
- Cytotoxic adaptive immune response is inactive
2 main components of fetal immune respons during pregnancy by the trophoblast cells
HLA
IDO (indoleamine 2,3-dioxygenase)
Maternal immune respons during pregnancy by trophoblast cells
Progesterone: high concentrations suppress maternal immune response by altering Th1/Th2 balance and inhibits production of TNF-a
Prostaglandin E2: makes lymphocytes proliferate poorly
How does the trophoblastic cells of fetus protect against activating maternal immune system through HLA
The extravillous trophoblasts migrate into the decidua do not express HLA-A or HLA-B class Ia antigens that are primary stimulators of classical graft rejection
Instead display HLA-E, HLA-F and HLA-G
HLA-E and HLA-G may dampen immune response by interacting with receptors on uterine NK-cells.
HLA-G is also thought to promote release of anti-inflammatory cytokines such as IL-10, has a role in maintaining pregnancy
Role of IDO in fetal immune respons by trophoblast cells
Promoting catabolism of tryptophan which is required for T cell function
why is Vit D important in immunologi during pregnancy
Both the decidua and the placenta produce the active form of vitamin D, providing the
fetus with a natural mechanism of immune surveillance
Dangerous pathogens for the mother during pregnancy?
o Viruses: hepatitis, influenza, varicella, CMV, polio
o Bacteria: listeria, streptococcus, gonorrhea, slamonella
o Parasites: malaria, coccidioidomycosis
3 main changes of the CVS during pregnancy
- Increased metabolic demands
- Expansion of vascular channels
- Increase in steroid hormones
Total body water changes during pregnancy
Increase in sodium and water retention resulting in an increase of TBW from 6 to 8L: 2/3 in the extravascular space.
The plasma volume rises as early as week 5 and reaches a plateau around 32-34 weeks’ gestation
RBC changes during pregnancy
starts to increase at the beginning of 2nd trimester and continues to rise until delivery
Dilutional anemia during pregnancy
Dilutional anemia results due to the increased in intravascular volume. Elevated EPO levels lead to a compensatory increase in total RBC mass, but never fully correct the anemia
Hb and Hct in pregnancy
Hb: non-pregnant: 12–14 g/L, pregnant: 10–14 g/L
Hematocrit: non-pregnant: 36 – 46%, pregnant: 32 – 39%
Why is there leukocytosis during pregnancy
Due to bone marrow hyperplasia
(normally 10.000 leu, in pregnancy 12.000)
hyper coagulated state during pregnancy
Fibrinogen is increased from 300 – 500/600 mg/dl
Increase in factor VII, IX, X
what is the reason behind hypercoagulated state during pregnancy
Protects the mother from excessive blood loss at delivery but also predispose to thromboembolism
The heart during pregnancy
- The heart is rotated anterior, upwards and left,
- It is enlarged due to muscle hypertrophy
- A soft systolic murmur may be heard (S3)
- The pulse rate is increased
- Blood pressure should not normally increase
CO during pregnancy?
Cardiac output rises by the 10th week of gestation
Reaching about 40% above nonpregnant levels by 20-24 weeks
pathophysiology behind increased CO during pregnancy
Early in pregnancy progesterone decrease SVR →
decreased BP → increased CO (compensation)
It is primarily due to increase in SV and to a lesser extent, heart rate
CO = HR x SV
Blood flow during pregnancy
Blood flow to most regions of the body increase, while the 2 organs with the highest increase are the kidney and the skin (due to increased need for waste elimination)
Blood flow to the uterus during pregnancy
The nonpregnant uterus usually receive around 2% of CO while the uterus at term receives as much as 17%
3 main effects on the resp system during pregnancy
- The mechanical effects of the enlarging uterus
- The increased total body O2 consumption
- The respiratory stimulant effects of progesterone (increase)
Respiratory mechanics in pregnancy:
- Diaphragm at rest rises 4cm above usual resting position
- The ribs flare outwards enlarging the chest by 2cm
This results in less negative intrathoracic pressure and a decrease in resting lung volume (decreased FRC)
There is no change in diaphragmatic muscle motion so the vital capacity remains unchanged
No change is RF but there is increased tidal volume resulting in a rise in minute ventilation
Unchanged VC + reduced FRC are analogous seen in pregnancy are also seen in which condition?
analogous to changes seen in pneumoperitoneum
Total body O2 consumption and ventilation changes during pregnancy
Total body O2 increases by 15-20% in pregnancy
CO2 decreased to 27-32 mmHg (normal 35-40mmHg)
Urinary system changes during pregnancy
Undergoes marked dilation in the 1st trimester and may persist until the 12th postpartum week.
Obstruction by the pregnant uterus may result in hydronephrosis
what is the mechanism behind dilation of organs in pregnancy
Progesterone appears to produce smooth muscle relaxation in various organs, including the ureters
Changes in renal blood flow during pregnancy
RBF and GFR increase early in pregnancy and reaches a maximum plateau level of at least 40-50% above normal by mid-gestation
what reflects the increased renal blood flow during pregnancy seen on blood tests
The elevated GFR is reflected in lower serum levels of creatinine and urea nitrogen
is glycosuria normal during pregnancy?
Glycosuria can be normal due to the increased GFR resulting in decreased resorption of glucose, but the patient should be tested for gestational diabetes
changes in the bladder during pregnancy, and what is important in a C-section?
Increase in bladder capacity from 400ml – 1500ml
Frequent urination is common due to compression
The bladder is pulled up in the abdomen and caution is important during a C-section
what is the pathophysiology behind the increased Na and water retention during pregnancy?
There is an elevated renin concentration, which is produced by the kidneys, uterus and placenta leading to a 40% increase in blood volume.
Thyroid hormone changes during pregnancy
Thyroid binding globulin increase + slight thyroid enlargement and an overall increase in hormone production but free T3 and T4 remains the same
parathyroid changes during pregnancy
Serum calcium decrease leading to an increase in PTH
Causing conversion of cholecalciferol (vitamin D3) to its active
metabolite increasing intestinal absorption of calcium
what is the risk of the increased blood flow to the pituitary
The pituitary grows in size and demand, this increase the risk for Sheehan’s syndrome (ischemic necrosis due to blood loss and hypovolemic shock during and after childbirth)
What are the four major types of hypertensive pregnancy disorders?
Chronic hypertension
Gestational hypertension
Preeclampsia
Eclampsia
Define gestational HTN
- Systolic BP ≥ 140 OR diastolic BP ≥ 90 on 2 separate measurements at least 4 hours apart
- Diagnosed post 20w’ gestation, no prior history of HTN
- Does not persist longer than 12 weeks postpartum.
Define chronic HTN in pregnancy
Hypertension diagnosed before pregnancy or in the first 20 weeks of pregnancy
Hypertensive crisis in pregnancy
Systolic BP > 160 OR diastolic BP > 110 that persists for ≥ 15 min
define preeclampsia and superimposed preeclampsia:
- New-onset gestational HTN with proteinuria or end-organ dysfunction
- Preeclampsia that occurs in a patient with chronic hypertension
Define HELLP sydrom
A life-threatening form of preeclampsia characterized by:
Hemolysis
Elevated Liver enzymes
Low Platelets
Occurrence of new-onset hypertension, proteinuria, or end-organ dysfunction at < 20 weeks’ gestation is suggestive of?
Gestational trophoblastic disease
Define eclampsia
New-onset seizures (tonic-clonic, focal, or multifocal) in the absence of other causes; a convulsive manifestation of hypertensive pregnancy disorders
Define post partum HTN
- Hypertension that persists after delivery
- Generally resolves within 12 weeks.
- If it lasts > 12 w pp, 2nd cause should be considered.
Risk factors for HTN disease in pregnancy
Thrombophilia
< 20 or > 35 years of age
Black individuals
Diabetes mellitus or gestational diabetes
Chronic hypertension
Chronic renal disease
Obesity (BMI ≥ 30)
Previous preeclampsia
Nulliparity
Multiple gestation (twins)
what is the pathophysiology behind maternal HTN
Uterine spiral arteries normally develop into high-capacity blood vessels. This process is defective in patients with preeclampsia,
Arterial hypertension with systemic vasoconstriction causes placental hypoperfusion → release of vasoactive substances → ↑ maternal blood pressure to ensure sufficient blood supply of the fetus
organ ischemia and damage in pregnancy related HTN disorders?
Preeclampsia: multiorgan involvement (primarily renal)
Eclampsia: predominantly cerebral involvement
HELLP syndrome: severe systemic inflammation with multiorgan hemorrhage and necrosis (thrombotic microangiopathy of liver)
classification of mild and severe preeclampsia
Mild: BP > 140/90 + proteinuria > 300mg/day after 20th week
Severe: BP > 160/110 + proteinuria > 5g/day after 20th week
- Thrombocytopenia (platelets < 100,000 cells)
- Serum creatinine > 1.1 mg/dL OR double of serum creatinine
- Liver tests x2 times the ULN of transaminases
warning signs of a potential eclamptic seizure.
Deterioration with headaches, RUQ pain, hyperreflexia, and visual changes
symptoms of gestational HTN
Asymptomatic hypertension
Nonspecific symptoms (morning headaches, fatigue, dizziness)
symptoms of preeclampsia
Preeclampsia without severe features
- Usually asymptomatic
Severe preeclampsia:
- Severe hypertension
- Proteinuria, oliguria
- Headache
- Visual disturbances (blurred vision, scotoma)
- RUQ or epigastric pain
- Pulmonary edema
- Cerebral symptoms (altered mental status)
symptoms of HELLP syndrome
Preeclampsia usually present (∼ 85%)
Nonspecific symptoms: nausea, vomiting, diarrhea
RUQ pain (liver capsule pain; liver hematoma)
Rapid clinical deterioration (DIC, pulmonary edema, acute renal failure, stroke, abruptio placentae)
symptoms of eclampsia
Onset: The majority of cases occur intrapartum and postpartum.
Most often associated with severe preeclampsia
Eclamptic seizures: generalized tonic-clonic seizures (usually self-limited)
HELLP syndrome diagnostic criteria
H = Hemolysis (↓ Hb, ↓ haptoglobin, ↑ LDH, and ↑ in-bilirubin)
EL = Elevated Liver enzymes (↑ AST, ↑ ALT)
LP = Low Platelets (< 100,000 cells/mm3)
pathophysiology behind the proteinuria of preeclampsia
Renal function: RBF and GFR are significantly lower due to constriction of afferent arteriole system (may result in damage to the glomerular membrane → proteinuria)
treatment of preeclampsia
only treatment is delivery
If > 37weeks → IV Mg sulfate (seizure prophylaxis) and deliver
If < 37 weeks: weigh risk: benefit; if no signs of fetal compromise and the disease is not severe → wait with close monitoring until 37w
what to ask yourself in preeclampsia
▪ Are the features of the disease process severe?
▪ Is there evidence of fetal compromise (IUGR, oligohydramnios, HR abnormalities)
Is the fetus mature for uncomplicated course after delivery
Fetal assessment in preeclampsia
- Cardiotocography (CTG): monitor fetal HR and uterine contractions
- Ultrasound
Eclampsia treatment
- Place patient in the left lateral decubitus position to prevent placental hypoperfusion due to IVC compression
- Start anticonvulsive therapy: first line: Mg-sulfate
- Start antihypertensives for urgent blood pressure control
- Indication for acute delivery regardless of gestational age
HELLP syndrom treatment
- Administer blood products (platelets, PRBCs, FFP) as needed
- Initiate anti HTN for urgent blood pressure control
- Administer magnesium sulfate for seizure prophylaxis.
- Delivery is indicated for all patients regardless
≥ 34 weeks’ gestation: Deliver immediately.
24–34 weeks’ gestation: Administer corticosteroids for lung maturity. Delivery may be delayed until 24–48 hours after administration if maternal and fetal status remains stable.
Antihypertensives for urgent blood pressure control in pregnancy
Parenteral labetalol
Nifedipine (immediate release)
Parenteral hydralazine
drugs to avoid in pregnancy if HTN
Avoid ACE inhibitors and angiotensin receptor blockers during pregnancy (especially during the 1st trimester) because of their teratogenic effect.
how to remember HTN Drugs in pregnancy?
“Hypertensive Moms Need Love”:
Hydralazine, Methyldopa, Nifedipine, or Labetalol
what do you also have to do when giving magnesium sulfate
All patients receiving magnesium need close monitoring (including continuous telemetry) for signs of hypermagnesemia.
preeclampsia prophylaxis
Aspirin for preeclampsia prophylaxis
≥ 1 high-risk or ≥ 2 moderate-risk factors for preeclampsia.
Initiate low-dose aspirin between 12–20 weeks’ gestation
maternal complications of hypertensive pregnancy disorders
Placental abruption
DIC
Cerebral hemorrhage, ischemic stroke
Acute respiratory distress syndrome (ARDS)
Acute renal failure
Fetal complications of hypertensive pregnancy disorders:
Occur due to insufficient placental perfusion
Fetal growth restriction
Preterm birth
Seizure-induced fetal hypoxia
Fetal death
classification of signs of pregnancy
Presumptive signs
Probable signs
Positive signs
First signs
Later phases complaints and signs
Presumptive signs of pregnancy
- Chadwick’s sign: bluish discoloration of the cervix and vagina due to pelvic vasculature engorgement (6th week)
- Pigmentation of the skin and abdomen
o Most common sites for pigmentation are the midline of the lower abdomen (linea nigra), over the bridge of the nose, and under the eyes (chloasma)
probable signs of pregnany
Those mainly related to changes in the uterus
- Piskacek sign: soft prominence over the site of implantation-
- Goodell’s sign: softening of the cervix (4-6 weeks)
- Hegar’s sign: softening of the cervical isthmus (6-8 weeks)
- Positive home urine pregnancy test
positive signs of pregnancy
- Detection of a fetal heartbeat
o Endovaginal US is capable of detecting fetal cardiac activity as early as 6 weeks
o Doppler techniques can detect fetal heart beat between 9-12 weeks
o Fetal heart tones can be detected with a stethoscope between 16-20 weeks - Recognition of fetal movement
o Endovaginal US is capable of detecting fetal movement from about 7-8 weeks’ gestation
o The multiparous woman generally recognize fetal movement between 15-17 weeks
o The primipara women usually does not recognize fetal movements until week 18-20
When can we detect fetal heart sounds
Endovaginal US: as early as 6 weeks
Doppler techniques: 9-12 weeks
Fetal heart tones can be detected with a stethoscope 16-20w
First signs of pregnancy
- Cessation of menstruation
- Nausea, vomiting
- Breast tenderness (mastodynia) and enlargement
- Frequent urination
- Weakness and fatigue
- Changes in eating habits: eating a lot is ok but healthy
- Changes in sensation: common to be sensitive to smell
cause of frequent micturition during pregnancy
Due to a combination of relaxing effect of progesterone on the bladder and pressure exerted on the bladder by the enlarged uterus
Inferior vena cava syndrome in pregnancy
When lying in the supine position the uterus compress the IVC
In most women there will be a compensatory rice in peripheral resistance to minimize the pressure fall
In around 10% a significant fall occur leading to nausea, dizziness and discomfort for the mother
▪ The syndrome is relieved by changing position to the left side (greater VR)
signs in late stage pregnancy
- Difficulty sleeping
- Inferior vena cava syndrome
- Hemorrhoids
- Predisposition to thrombosis
- Edema
- Poseiro effect
- Frequent urination due to compression on bladder
- Fetal heart sound
- Fetal movement: after 18-20th gestational week
- Palpable fetal body parts
- Constipation
- Tachypnoe
- Galactorrhea
- Weight gain
what is the Poseiro effect:
Late in the pregnancy the uterus may compress the aorta and its branches resulting in lower pressure in the femoral artery compared with the brachial artery. The compression may cause fetal distress when supine
Normal weight gain during pregnancy
Normal weight gain is 9-14 kg
skinny mom: SMA
Obese mom: LGA
what can be the first sign of preeclampsia
Edema might be the first sign of preeclampsia and must be taken very seriously. It can occur fast (within 5-10days) and it may increase the mothers weight with 4-5kg
Estimation of gestational age
Naegele rule
First-trimester US: estimation is based on crown-rump length
Second-trimester US: estimation based on fetal biometric parameters
Symphysis-fundal height measurement
12th Just above the symphysis
16th Between the symphysis and navel
20– 24th Navel
32nd Between the navel and xiphoid
36th Peak: at the costal arch
40th Two finger widths below the costal arch
why do we do a Symphysis-fundal height measurement
Measured from top of pubic symphysis to top of the uterus.
Fundal height can be used to monitor fetal growth or to roughly estimate gestational age in an emergency.
Screen all patients > 24 weeks’ gestation for fetal growth abnormalities using symphysis fundal height.
From 20 weeks, fundal height in centimeters should roughly approximate the week of gestation
prenatal ultrasounds
- First-trimester US is performed to estimate gestational age and assess for complications
- Second-trimester US is recommended between 18–22 weeks to assess fetal anatomy.
- Additional US may be performed for further evaluation of potential pregnancy complications,
Overview of first-trimester combined screening test results
Trisomies
Trisomy 21: Downs
Trisomy 18: Edwards
Trisomy 13: Patau
most common pregnancy and cardiovascular diseases
Ischemic heart disease
Cardiac arrhythmias
Rheumatic heart disease
Congenital heart disease
Define gestational diabetes
Impaired glucose tolerance diagnosed during pregnancy
Associated with an increased risk of maternal and fetal morbidity
Usually in the second and third trimesters
pathophysiology of gestational diabetes
The insulin requirement varies during pregnancy.
In the first trimester, insulin sensitivity increases and there is a tendency towards hypoglycemia.
In the second and third trimesters, hormonal changes trigger progressive insulin resistance that results in hyperglycemia, particularly after mealtimes.
Clinical features of gestational diabetes
Mothers usually asymptomatic or may present with edema. Warning signs include:
Polyhydramnios
Large-for-gestational age infants (> 90thpercentile)
treatment of gestational diabetes
- Dietary modifications and regular exercise (walking)
- Strict blood glucose monitoring (4x daily)
- Insulin therapy if glycemic control is insufficient with diet
- Regular ultrasound to evaluate fetal development
- Consider inducing delivery at week 39–40, if glycemic control is poor or if complications occur
treatment of gestational diabetes if insulin not working
Metformin and glyburide
Manifestations of diabetic embryopathy
Early pregnancy loss and perinatal death
Transposition of the great vessels
Ventricular septal defect
Truncus arteriosus
Coarctation of the aorta
Patent ductus arteriosus
Spina bifida
Renal agenesis
Anorectal malformations
Some of the primary factors associated with progressive
insulin resistance during pregnancy?
Human placental lactogen
Progesterone
Prolactin
Cortisol
A 2-step method is used to test for GDM
Step 1: universal screening between 24-28 weeks’ gestation with a 50g OGCT (measure after 1h)
In women with risk factors screening at 1st prenatal visit
If there are symptomsfasting glucose should be checked first
If a 1st trimester screen is done and found to be negative, it should be repeated at 24-28 weeks
What to do if the step 1 GDM test is abnormal
Performing a diagnostic 3-hour 100g OGTT
Fasting glucose is checked after overnight fast
Then the patient consume 100g glucose drink
Levels are checked hourly for 3h
If x2 abnormal values the patient is diagnosed with GDM
Caloric need calculated in GDM
o Patients < 80% of ideal body weight: 35-40kcal/kg
o Patients 80-120% of ideal body weight: 30kcal/kg
o Patients > 120-150% of ideal body weight: 24 kcal/kg
o Diet composed of 45-50% carb, 20-25% protein, 20-25% fat
o 20% breakfast, 30% lunch, 30% dinner, 20% bedtime snack
preferred pharma in GDM
Insulin is the best of choice, does not cross the placenta
A combination of rapid- or short-acting (lispro or regular) and intermediate-acting (NPH) insulin is usually given
GDM monitoring during pregnancy
o Detailed obstetric US study, fetal echocardiogram, and maternal serum a-FP should be obtained in the 2nd trimester to check for congenital malformations
o Maternal renal, cardiac, and ocular function must be closely monitored
o Glycosylated hemoglobin should be measured every trimester
o Antenatal testing with the following should be done weekly from 32 weeks to delivery: nonstress tests, biophysical profiles and kick counts
section in GDM?
C-section may be elected for large fetuses (>4500g)
maternal blood suger during delivery in GDM
Euglycemia is necessary during labor and plasma glucose levels are measured frequently, and if elevated, a continuous infusion of regular insulin is given and dose is adjusted as needed to maintain levels between 4.4 – 6.7 mmol/l
Fetal complications of GDM
- Glucose crosses the placenta causing fetal hyperglycemia
result in fetal hyperinsulinemia - Major congenital malformations and spontaneous abortion
- Fetal macrosomia, preeclampsia, spontaneous abortion, shoulder dystocia, arrested labor.
- Hypoglycemia: after delivery IV glucagon must be given
does pregnancy exacerbated renal disorders?
Pregnancy not often worsen renal disorders, it seems to only exacerbate noninfectious renal disorders when uncontrolled hypertension coexists
pregnancy and renal tansplant
the kidney has been in place for > 2years, normal renal function, no episodes of rejection, normal BP
what is often done with women with chronic kidney disease in pregnancy
Women with severe renal insufficiency may require hospitalization after 28 weeks’ gestation for bed rest, BP control, and close fetal monitoring. Cesarean delivery is very common, although vaginal delivery is possible
most common most common medical complication of pregnancy?
UTI, mostly asymptomatic bacteriuria, so must be screened.
Due to increased urinary stasis from mechanical and hormonal (progesterone) factors
Organisms include GBS as well as those that occur in non-pregnant women
should we treat asymptomatic bacteriuria in pregnancy?
Yes, due to increased risk of pyelonephritis and preterm laboure
treatment of UTI in pregnancy
First line: amoxicillin - alternatives: nitrofurantoin or cephalosporins.
If pyelonephritis hospitalization and IV antibiotics
complications of UTI in pregnancy
Increased risk of preterm labor and premature rupture of membranes with UTIs and asymptomatic bacteriuriaGI
GI disorders during pregnancy
Hyperemesis gravidarum
GERD (gastroesophageal reflux disease)
Acid aspiration syndrome (Mendelson syndrome)
IBD (Crohns disease and ulcerative colitis)
Acute fatty liver of pregnancy
Define Hyperemesis gravidarum
Severe, persistent nausea and vomiting associated with a > 5% loss of prepregnancy weight and ketonuria with no other identifiable cause. The overall incidence is about 1-2%
Risk factors for Hyperemesis gravidarum
Multiple gestation
Hydatidiform mole
Nulliparity
Migraine headaches
GERD
treatment of hyperemesis gravidarum
Pyridoxine (vitamin B6) and/or doxylamine
Refractory symptoms, add Diphenhydramine
For refractory symptoms despite combination therapy add
Metoclopramide
pathophysiology of GERD in pregnancy
Progesterone has an smooth muscle relaxant effect resulting in decreased sphincter tone + increased residual volume in the stomach (due to increased emptying time)
treatment of GERD in pregnancy
Sucralfate is useful in pregnancy: no apparent fetal toxicity
If no respons give PPI omeprazole)
what is Acid aspiration syndrome (Mendelson syndrome)
Labor increase risk of regurgitation and acid aspiration of gastric content due to delayed gastric emptying and increased intraabdominal and intragastric pressures
what is the complication of Acid aspiration syndrome (Mendelson syndrome)
Damage to the pulmonary tissue (which may cause ARDS) is greatest when the pH of aspiration fluid is < 2.5 or the volume of aspiration is >25ml
preventing Acid aspiration syndrome (Mendelson syndrome)
Preventive efforts include nothing-by-mouth during labor and no food intake for at least 6h before elective c-section
Hematological disorders of pregnancy
Anemia of pregnancy
Thromboembolic disorders
Gestational thrombocytopenia (rare)
Define anemia of pregnancy
Hb < 10g/dl and Hct < 30%
most common type of anemia during pregnancy and their prevlance
Microscytic IDA
Responsible for 80% of non-physiologic anemia
Varies from 0.5-25% depending on region, population, and diet
Treatment of IDA in pregnancy
Prevention (non-anemic): 30 mg elemental iron/d (met by most
prenatal vitamins)
Treatment (anemic): 30-120 mg elemental iron/d OR
Iron dextran 100mg IM every other day 10x over 3w
325 mg ferrous fumarate = 106 mg elemental Fe
treatment of folate deficiency anemia in pregnancy
Prevention: 0.4-1 mg folic acid PO daily for 1-3 mo preconceptually and throughout first trimester
Treat with folate 1mg po twice/day
increased riskfaktors for DVT in pregnancy
Hypercoagulability
Stasis
Endothelial damage during delivery
Hos is the riskfactors for VTE in pregnancy?
Increased risk of VTE throughout pregnancy with highest risk of DVT in T3 and post-partum period; highest risk of PE post-partum (First 6 weeks)
treatment of venous thrombus in pregnancy
LMWH preferred: should be stopped 24 h prior to delivery
Warfarin is CI in pregnancy due to potential teratogenic effects
spontaneous abortion 3 types
Spontaneous loss: of pregnancy < 24 weeks’ gestation
Early pregnancy loss: spontaneous loss before 13 weeks’
Recurrent pregnancy loss: two or more losses before 20w
Maternal causes of spontaneous abortion
Abnormalities of the reproductive organs
Septate uterus
Uterine leiomyomas
Uterine adhesions
Cervical incompetence
systemic diseases increasing risk of spontaneous abortions
Diabetes mellitus
Hyperthyroidism/hypothyroidism
Infections
Hypercoagulability (antiphospholipid syndrome, which is associated with recurrent miscarriages)
Fetoplacental risk of spontaneous abortions
Chromosomal abnormalities account for 50% of abortions.
Congenital anomalies
Anembryonic pregnancy
Prevalence of spontaneous abortions
20-30% of women with confirmed pregnancies bleed during the first 20 weeks, and half of these women spontaneously abort, thus incidence of spontaneous abortions is about 10-15% of confirmed pregnancies
Characteristics of different types of spontaneous abortions
characteristics of different types of spontaneous abortions (table)
Diagnosis of abortion
- Speculum exam
- Assess for cervical dilatation and retained POC.
- Confirm that the source of bleeding is uterine. - Transvaginal ultrasound
- Absence of fetal heart sounds - Laboratory studies
- Serial serum β-hCG: Downtrending levels
Management if threatened abortion
Expectant management: Symptoms will resolve or progress to inevitable, incomplete, or complete abortion.
Advise the patient to avoid strenuous physical activity.
Repeat pelvic ultrasound in one week.
Managment of Inevitable abortion, incomplete abortion, or missed abortion
- Expectant management
- Medical evacuation
Misoprostol is used to induce cervical ripening and expulsion of the products of conception. - Surgical evacuation
Indicated for septic abortion, heavy bleeding, or if there are maternal comorbidities
Define Threatened abortion:
vaginal bleeding occurring < 20week gestation without cervical dilation, usually no pain, indicating that spontaneous abortion may occur, do US to confirm everything is ok
Define Inevitable abortion:
vaginal bleeding or rupture of the membranes accompanied by dilation of the cervix, emergency aspiration must be done
Define septic abortion
Septic abortion: serious infection (most commonly S,aureus, E.coli and bacteroids) of the uterine contents during or shortly before or after an abortion, give antibiotics and evacuate
Define preterm delivere
Live birth between 20 weeks’ and 36 weeks gestation
Extremely preterm < 28 weeks
Very preterm 28 to 32 weeks
Moderate to late preterm 32 to 37 weeks
Epidemiology of preterm delivery
Complications of preterm birth are the leading cause of death in children < 5 years of age worldwide.
Non-modifiable risk factors of preterm delivery
History of preterm birth (greatest risk factor)
Cervical insufficiency
Short cervical length
Multiple gestations
Polyhydramnios
Preterm premature rupture of membranes (PPROM)
Antepartum hemorrhage
Modifiable riskfactors of preterm delivery
Maternal and fetal conditions
Infections (urinary tract infections, STIs, vaginal infections)
Hypertensive pregnancy disorders (preeclampsia, HELLP)
Diabetes mellitus, gestational diabetes
Lifestyle and environmental factors:
Smoking
Substance use (heavy alcohol use, heroin, cocaine)
Maternal or fetal stress
Maternal age (≤ 18 years, > 35 years)
Low maternal prepregnancy weight
Short interval between pregnancies (< 18 months)
diagnosis of preterm labor
Transvaginal ultrasound: Cervical length > 3 cm indicates a low likelihood of delivery within 14 days
Cervicovaginal fetal fibronectin (fFN) test:
Elevated levels in cervical secretions associated with increased risk of preterm delivery.
Clinically based on preterm contractions and cervical changes.
Clinical diagnosis of preterm labor
Documented uterine contractions (4/20min or 8/60min)
Documented cervical change (cervical effacement of 80% or cervical dilation of > 2cm)
Treatment of preterm labore
34 -36 weeks’ gestation: Proceed with normal delivery.
< 34 weeks’ gestation: consider tocolysis to inhibit uterine contractions and administer steroids for induction of fetal lung maturity. Administer antibiotic prophylaxis for PPROM.
< 32 weeks’ gestation: Consider magnesium sulfate for fetal neuroprotection.
what is Tocolysis
To inhibit uterine contractions and prolong pregnancy to allow for induction of fetal lung maturity and/or transfer to another medical center, if necessary.
Duration: up to 48 hours
examples of Tacolytics
Nifedipine (CCB, No known adverse effects on fetus)
Indomethacin (NSAID)
Terbutaline (beta-2 adrenergic agonist)
Define Induction of fetal lung maturity
Administration of antenatal steroids to promote the production of surfactant and thereby improve neonatal survival and fetal lung maturity
corticosteroids used in induction of fetal lung capacity
Betamethasone
Dexamethasone
Define fetal neuroprotection
administration of antenatal magnesium sulfate to reduce the risk and severity of neurological disorders (e.g., cerebral palsy)
Indication: preterm labor at < 32 weeks’ gestation
when is AB given in delivery?
GBS prophylaxis
PPROM antibiotic prophylaxis
Most common complication of prematurity
low birth weight (<2500g), IRDS, necrotizing enterocolitis, intraventricular hemorrhage, and sepsis
how can you check the cervix for risk of preterm labor and what to do?
At the 18-20 week checkup, the length of the cervix should be checked, and women with shortened cervix (10-20mm) should receive vaginal progesterone 200mg daily from 19-20 weeks
until 36 weeks
what to do when preterm labor has been diagnosed
CBC, random blood glucose levels, serum electrolyte levels, urinalysis and urine culture
- Anovaginal cultures for group B streptococci and prophylaxis initiated if necessary
- Cervical cultures to check STDs if suggested by clinical findings
- US should be done to assess fetal weight, presentation, assess cervical length and rule out the presence of any accompanying congenital malformations
AB prophylaxis if GBS before birth
o Penicillin G or ampicillin IV
o Clindamycin or erythromycin if penicillin allergy
Define IUGR
Lower than normal fetal growth characterized by an estimated fetal weight below the 10th percentile for a given gestational age.
Maternal causes of IUGR
Substance use (alcohol, cigarettes, cocaine, heroin)
Teratogenic drugs: ACEi, carbamazepine, phenytoin, warfarin
Maternal phenylketonuria
Uteroplacental causes of IUGR
Placental insufficiency (most common cause in the US)
Placenta previa
Multiple gestations
Placental abruption
Umbilical artery thrombosis/extensive infarction
Uterine malformations (e.g., fibroids)
Fetal causes of IUGR
Fetal factors
Genetic abnormalities in the fetus (e.g., aneuploidy)
Cyanotic congenital heart defects
Early intrauterine infections (TORCH)
types of IUGR
Asymmetrical IUGR: most common IUGR (∼ 70%)
- Weight, length and head circumference all < 10th percentile
- Caused by extrinsic factors
- Late onset, usually due to maternal systemic disease (hypertension) that results in placental insufficiency.
Symmetrical IUGR is less common (∼ 30%)
- Weight < 10th perc, head circumference and length preserved
- Caused by intrinsic factors
- Early onset, usually due to a genetic disorder (aneuploidy), congenital heart disease, or early intrauterine TORCH infection
Diagnosis of IUGR
Serial ultrasonography:
- Decreased fetal growth, weight below the 10thpercentile
- Oligohydramnios
Doppler velocimetry of the umbilical artery:
- Reduced or reversed diastolic flow; ↑ systolic/diastolic ratio
Nonstress test:
- Late decelerations of the fetal heartbeat, bradycardia
Treatment of IUGR
- Treatment of the underlying condition
- Close monitoring of fetal status and placental development
- If non-reassuring fetal status induce labor or cesarean
- If the infant is < 34 weeks gestation and close to delivery, administer steroids 48 hours before inducing labor.
screening for IUGR
Serial uterine fundal height measurements serves as primary screening, if the height lags >3cm behind expectations, US should be done.
Braxton Hicks contractions (false labor)
Irregular, uncoordinated uterine contractions of moderate intensity (helps with fetal positioning)
Frequency: typically ≤ 2 times/hour
Duration: ≤ 1 minute
Do not increase in frequency, intensity, or duration
Cervical changes are absent.
Cervical effacement
Thinning of the cervix that occurs during labor; usually reported in percentages
Cervix effaces and shortens → cervical dilation
Bloody show: A blood-tinged mucous plug may be discharged when the cervix shortens and dilates.
Spontaneous ROM
Delayed ROM
what causes the softening of the cervix before effacement?
as a result of increased water content and collagen lysis
stages of labor
1st stage
- Latent stage: onset of labor til 6 cm dilation
- Active stage: from 6cm til 10 cm
2nd stage: completey dilated cervix and ends with the birth
3rd stage: until complete expulsion of the placenta
4th stage: the 1–2 hour postpartum period
Types of uterin contractions
Alvarez-waves
Braxton Hicks contractions (false labor)
Prelabor contractions
Stage 1: cervical dilation and effacement
Stage 2: fetal expulsion
Stage 3: placental expulsion or afterbirth
Afterpains
What are Alvarez-waves
physiological after week 20
Low intensity, high frequency
how are prelabor contractions
Irregular contractions of high intensity, which occur every 5–10 min shortly before phase 1 begins.
They are responsible for correctly positioning the fetal head in the pelvis.
how are Stage 1: cervical dilation and effacement
Coordinated, regular, rhythmic contractions of high intensity Occur approximately every 10 minutes.
Shortly before stage 2 they occur every 2–3 min.
These contractions are responsible for cervical dilation.
how are stage 2 contractions
Coordinated and regular contractions of high intensity; occur approximately every 4–10 min and are responsible for fetal expulsion.
Towards the end of the stage, they occur very often (every 2–3 minutes) and are of higher intensity (≥ 200 Montevideo units).
how are Stage 3: placental expulsion or afterbirth
Irregular contractions of very low intensity, which force the placenta through the vaginal canal within 30 min after fetal expulsion
Abnormal labor is classified into
Active phase disorders
Second stage disorders
what are the Active phase disorders in abnormal labor
Divided into either a slower-than normal progress
(protraction disorder), or a complete cessation of progress (arrest disorder)
Active-phase arrest is defined as no dilation for 2h and is most commonly due to inadequate uterine contractions
o Protraction disorders are less well described, and the diagnosis is often made in retrospect
what are the second stage disorders in abnormal labor
Disproportion of the fetus and pelvis frequently becomes apparent during the 2nd stage
o Maternal pushing efforts may also be reduced due to analgesia or exhaustion
types of Types of uterine dysfunction during labor
Hypotonic uterine dysfunction (more common):
Hypertonic contractions
what is Hypotonic uterine dysfunction during labor
o Contractions have normal gradient pattern, but the pressure during a contraction is insufficient to cause cervical dilation
o Treatment: amniotomy, augmentation with oxytocin, assisted vaginal delivery or section
what is Hypertonic contractions during labor
o The contractions are irregular and painful
o High uterine P, may result in maternal and/or fetal distress
o Treatment: analgesics (morphine/epidural), nifedipine, move
o Colicky uterus with uncoordinated contractions
o Hyperactive lower segment (abnormal gradient pattern)
what is fetal Macrosomia
A significantly larger-than-average fetus, defined as birth weight > 90th percentile or > 4,000 g
What is dystocia
Expected patterns of descent of the presenting part and cervical dilatation fail to occur in the appropriate time frame.
* During active phase: > 4 h of < 0.5 cm/h
* During 2nd stage: > 1 h with no descent during active pushing
causes of dystocia
the 4 P’s
1. Power: contractions (hypotonic, uncoordinated)
* Passenger: fetal position, size, anomalies (hydrocephalus)
* Passage: pelvic structure, tumours, full bladder or rectum
* Psyche: hormones released in response to stress
Normal fetal presentation
cephalic, vertex, occipitoanterior
- Define fetal malpresentation?
- Define fetal malposition
- Any presentation or lie that is not the cephalic presentation
- Fetal position where fetus is in cephalic presentation but not oriented anteriorly
what are the breech presentations
Frank breech
Complete breech
Single footling breech
Double footling breech
complete breech
Both hips and knees are flexed with the feet close to the buttocks.
Frank breech
This malpresentation is characterized by flexed hips and extended knees. The buttocks of the baby are directed towards the birth canal.
Single foot breech
one foot/leg is stretched to be delivered first.
double foot breech
both feet/legs are stretched to be delivered first.
fetal malposition
Occiput posterior position
Occiput transverse position
Define fetal lie, position and presentation
Fetal lie: long axis of the fetus related to long axis of the uterus
Fetal presentation: fetal part presenting at pelvic inlet
Fetal position: position of presenting part relative to pelvis
occipital fetal positions and their outcome
Occipitoanterior (OA): normal (left more common than right)
Occipitoposterior: most rotate spontaneously to OA
Occipitotransverse: leads to arrest of dilation
what is fetal attitude during birth
o Vertex (flexed): normal
o Brow: head partially extended
o Face: head fully extended
Persistent occipitoposterior presentation and its outcome
5-15% present in OP presentation, however, it is the most common abnormal presentation
Tends to prolong 2ns stage and is more painfull
A wide mediolateral episiotomy may be required
treatment of breech position and transverse lie
< 37 weeks: no intervention necessary, as most fetuses spontaneously convert to cephalic presentation closer to term
≥ 37 weeks: Consider external cephalic version.
A planned cesarean delivery may be necessary if external cephalic version not performed, unsuccessful, or CI
Contraindications for external cephalic version
Indications for cesarean delivery
Placental abruption
Nonreassuring fetal status
Active labor or ruptured membranes
Oligohydramnios
complications of fetal malpresentation
Birth asphyxia
Infection (intrauterine and neonatal)
Intracranial hemorrhage
Birth injuries
Perinatal death
what is shoulder dystocia
An obstetric emergency in which the anterior shoulder of the fetus becomes impacted behind the maternal pubic symphysis during vaginal delivery
risk factors for shoulder dystocia
History of shoulder dystocia
Fetal macrosomia
Maternal diabetes mellitus or gestational diabetes
Maternal obesity
Prolonged second stage of labor
Clinical features of shoulder dystocia
Inability to deliver shoulder with downward traction on the fetus
Turtle sign: retraction of the partially delivered fetal head
Management of shoulder dystocia
- McRoberts maneuver (mother hip rotation)
Then:
2. Rubin II maneuver
3. Woods corkscrew maneuver
4. Zavanelli maneuver: head is pushed back into pelvis for a section to be done
OR last resort intentional clavicular fracture
etiology of macrosomia
Diabetes mellitus in pregnancy
Previous macrosomic fetus
Multiparity
Maternal obesity
Excessive gestational weight gain
Maternal birth weight (> 4,000 g)
Postterm pregnancy
complications of fetal macrosimia
Birth injuries (shoulder dystocia, brachial plexus injury)
Acute respiratory distress, transient tachypnea of the newborn
Neonatal hyperbilirubinemia
Neonatal polycythemia
Neonatal hypoglycemia
complications of shoulder dystocia
Brachial plexus palsy
(most commonly Erb palsy, less commonly Klumpes palsy), Clavicle fracture
Maternal pelvic alterations in birth
Gynecoid
Anthropoid
Android
Plateylpelloid
Cephalopelvic disproportion
The fetal size is disproportionately large for the maternal pelvis.
Can result in a prolonged second stage of labor
Best pelvic shape for birth
Because of its spacious inlet, large interspinous diameter, and wide subpubic arch, the gynecoid pelvis is the most suitable for vaginal birth. In general, the gynecoid and anthropoid pelvises are acceptably favorable; however, the android and platypelloid are known to be suboptimal.
Station (Obstetrics) at birth
Normal rupture of membranes ROM
Spontaneous ROM: usually occurs at the onset of labor and is unprovoked by health practitioners
Artificial ROM (amniotomy): A procedure in which the amniotic sac is ruptured in order to release amniotic fluid.
Delayed ROM: that occurs during fetal expulsion, after cervical dilation and effacement
define ROM
the rupture of the amniotic sac followed by the release of amniotic fluid
Abnormal ROM
Premature rupture of membranes: before contractions
Preterm premature ROM: before contractions and < 37w
Prolonged rupture of membranes:
First stage of labor: latent stage
Occurs during onset of labor and ends at 6 cm of cervical dilation
Characterized by mild, infrequent, irregular contractions with a gradual change in cervical dilation (< 1 cm / hour)
Nulla: < 20 h
Multi: < 14 h
Second stage of labor: active stage
Occurs after the latent phase at ≥ 6 cm of cervical dilation and ends with complete 10 cm cervical dilation
Characterized by increased rate of dilation (1–4 cm/hour)
Nulla: 4-6h 1.2 cm/h
Multi: 2-3h 1.5 cm/h
Second stage of labor
A stage of labor that begins once the cervix is completely dilated and ends with the birth of the infant
Regular contractions increasing in frequency and intensity
Crowning: the appearance of the fetus’s head at the vaginal
Nulla < 2h
Multi < 1h
Managment of first stage og labor
- Analgesia upon request
- Fetal heart rate monitoring
- Determine fetal position
- Regular assessment of dilation and descent of the head
Managment of second stage of labor
Help the mother to find comfortable and safe positions.
Guide the delivery of the fetus through the vaginal canal
Clamp the umbilical cord after no less than 30–60 seconds
Third stage of delivery
A stage of labor that begins with the birth of the infant and lasts until the complete expulsion of the placenta
30 minutes
Signs of placental separation
Cord lengthening
Gush of vaginal blood (usually accompanied by a blood loss of 300 mL)
Uterine fundal rebound (the uterus becomes less elongated and more spherical)
drugs given in stage 3 of labor
Administer a uterotonic drug, usually methergine or ergometrine soon after delivery of the anterior shoulder and/or oxytocin 5-10 IU IV within 1min of the birth of the baby
MAnagment of 4th stage of labor
o Monitor vital signs and bleeding
o Repair lacerations with absorbable sutures size 00
o Do a rectal examination to ensure that the sutures have not inadvertently transected the rectal mucosa
o Ensure uterus is contracted (palpate uterus and monitor uterine bleeding)
o Inspect placenta for completeness and umbilical cord for presence of 2 arteries and 1vein
Pain pathways during delivery
o T10 – L1 supply innervation to the uterus
o L1-L4 supply pain pathways to the vagina and deep pelvis
o S2 - S4 supply nerve fibers to the pudendal nerve
Non-pharmacologic methods for pain relief during labor
o Emotional support, back massage, hydrotherapy, transcutaneous electrical nerve stimulation, acupuncture
Regional anesthesia in labor
Lumbar epidural injection:
▪ The most commonly used method with an increase in use
▪ It is used during 1st and 2nd stage of labor
▪ E.g. Bupivacaine
▪ Adverse effects: hypotension and nausea from sympathetic block (give ephedrine)
The most common anesthesia used during c-section
Spinal injection:
▪ Inserted into the paraspinal subarachnoid space
▪ Not used much for vaginal deliveries due to short duration of action and has a small risk of spinal headache afterwards
▪ Vital signs checked every 5min to detect hypotension
Local anesthesia in labor
Pudendal block
Paracervical block
Not really used anymore
General anesthesia in labor
Nitrous oxide 40% with O2 may be used during vaginal delivery as long as verbal contact with the woman is maintained.
Thiopental (sedative-hypnotic) is commonly given IV for induction of general anesthesia during c-section
It is mandatory during emergency c-section
opioids during delivery?
▪ All opioids readily cross the placental barrier and may cause neonatal respiratory depression (antidote: naloxone)
▪ Fentanyl and nalbuphine are the most commonly used and have short neonatal half-lives
Indications for induction of labor
Post-term pregnancy (≥ 42 weeks of pregnancy or gestation)
PPROM after 34 weeks
PROM at term
Hypertension during pregnancy, preeclampsia, eclampsia, HELLP syndrome
Maternal diabetes to avoid post-term pregnancy (risk of macrosomia)
Maternal request at term
Intrauterine fetal demise
Contraindications for induction of labor
History of uterine rupture
Complete placenta previa
Vasa previa
Transverse fetal lie
Cord prolapse
Active maternal genital herpes
Nonreassuring fetal heart rate
scoring system used to assess the cervix and the likelihood of successful induction of labor
Bishop score
Bishop score ≥ 8: favorable cervix (ready for vaginal delivery)
Bishop score ≤ 6: unfavorable cervix (not ready for vaginal delivery)
approach in induction of labor
Membrane sweeping (shortens time to onset of labor)
If cervix is still unfavorable: cervical ripening with PG E1 or E2
Maternal oxytocin infusion
Consider amniotomy (only if the cervix is partially dilated and completely effaced, and the fetal head is well applied)
Administer under fetal heart rate monitoring.
prerequisites for induction of labor
o Capability of c-section if necessary
o Determination of gestation
o Short, thin, soft, anterior cervix with open os (“ripe”)
o Fetal: normal heart tracing, cephalic presentation, adequate fetal monitoring available
what is cervical riping
The process of softening and widening the cervix in preparation for childbirth. If Bishop score is <6 ripening is necessary
riping with foley catheter
A 30-mL to 50-mL Foley catheter filled with saline is placed in the uterus, and the balloon is filled. Direct pressure is then applied to the lower segment of the uterus and the cervix
complications of induction of labor
Uterine tachysystole (excessive uterine contractions):
▪ >5 contractions in 10min
▪ Can lead to fetal hypoxia and uterine rupture
▪ Treatment: remove prostaglandin tablet and IV oxytocin, if no good response, give terbutaline (tocolytics)
o Uterine muscle fatigue, uterine atony
o Vasopressin-like action causing anti-diuresis (brain edema)
How is augmentation of labor done
Promote adequate contractions when spontaneous contractions are inadequate and cervical dilation or descent of fetus fails to occur
Done by using oxytocin
Pelvic inlet
when is the pelvic inlet defined as contracted
If its shortest AP diameter is <10cm or if the greatest transverse diameter is < 12cm
Why is it important to identify (clinically or by imaging pelvimetry) the shortest AP diameter through
which the fetal head has to pass?
Before labor the fetal biparietal diameter has been shown to average from 9.5-9.8 cm, it might be difficult or even impossible for a fetus to pass through a pelvic inlet with AP
diameter < 10cm
Consequences of Cephalopelvic disproportion
Early spontaneous rupture of membrane
Delayed labor
Abnormal presentation
what is more common than inlet contraction
Contracted midpelvis, because the capacity of the midpelvis is smaller than that of the inlet
- It frequently causes transverse arrest of the fetal head, which can lead to a difficult midforceps operation or to c-section
major factor predesposing to breech position
Prematurity is the major factor predisposing to breech, and 20-30% of all breeches are of low birth weight (<2500g)
diagnosis of breech position
Leopold maneuver
Vaginal examination
US
Doppler
indications for breech delivery
Only for Frank or complete breech
Estimated fetal weight: 2500 – 3500g
No hyperextension of the fetal head
Capacity for emergent C-section, experienced operator Adequate progress in labor
Absence of “fetal distress”, preferably
Multiparous woman (“proven pelvis”)
3 types of breech delivery
Spontaneous breech delivery
Assisted breech delivery
Total breech extraction
what can cause head entrappment in breech delivery
The abdomen is much smaller than the head and in breech
delivery it might deliver through an incompletely dilated cervix
o This might result in the head getting stuck, which may result in fetal asphyxia and birth trauma
assisted breech delivery
The infant is allowed to spontaneously deliver up to the umbilicus, and then certain maneuvers are initiated by the clinician to aid the delivery
Total breech extraction:
Fetal feet are grasped and entire fetus is extracted by clinician
Should only be used for a noncephalic second twin
Should not be used for singleton fetuses because the cervix may not be adequately dilated to allow passage of the fetal head
indication for breech sectio
Breech + any of the following:
▪ Preterm
▪ 1st delivery
▪ PROM
▪ Incomplete breech
▪ Twins
▪ Large fetus
normal ROMProlonged ROM >18h from rupture to onset of delivery
Normal rupture of membranes is spontaneous rupture within 1h of labor onset
prolonged ROM
Prolonged ROM >18h from rupture to onset of delivery
time between f ROM and delivery
o At term, >90% of women with PROM begin labor within 24h
o At 32-34 weeks, mean latency period is about 4 days
what should you NOT do in ROM
do not insert you hand into the vagina, use speculum to avoid infection risk
what tests is done in ROM
Assess cervical dilation and length
If preterm obtain cervical cultures and amniotic fluid for pulmo maturation tests
What is diagnostic for ROM
Pool of water in posterior vaginal fornix
Valsalva maneuver or slight fundal P may expel fluid from the cervical os
US will show oligohydramnios (as expected)
Nitrazine paper test: turn blue if AF
what amniotic fluid level is indicative of delivery after ROM
Amniotic fluid index measures the amniotic fluid present in 4 quadrants, and a value < 5
is considered abnormal (delivery is indicated)
what desides if induction should be done or not after ROM
Management is largely dictated by gestational age at the time of membrane rupture
Risk/benefit for preterm
Risks are chorioamnionitis and failed induction in the mother
Signs of fetal compromise or infection
PROM > 36 weeks with favorable cervix
Induce labor 6-12h after rupture if no spontaneous contractions occur
If unfavorable cervical conditions with no evidence of infection, induction can
delay for 24h to decrease the risk of failed induction
PPROM ≤ 36 weeks: expectant management
The goal is to continue the pregnancy until the lung profile is mature
Careful surveillance for chorioamnionitis
BP, HR and temperature should be measured > 3x/day
Activity should be limited to modified bed rest
In pregnancies < 34 weeks give corticosteroids
IV MgS should be given in pregnancies < 32w
Management of chorioamnionitis
o AB only delayed only until appropriate cultures taken
o Ampicillin + gentamycin drug of choice
o Once AB started, labor should be induced
Placenta previa definition
Presence of the placenta in the lower uterine segment, which can lead to partial or full obstruction of the internal os; high risk of hemorrhage and birth complications
Risk factors for placenta previa
Maternal age > 35 years
Multiparity with short intervals between pregnancies
Previous curettage or cesarean delivery
Previous placenta previa, previous/recurrent abortions
types of placenta previa
clinical features of placenta previa
Sudden, painless, bright red vaginal bleeding
Usually occurs during the 3rd trimester (before ROM)
Initial bleeding episodes are often self-limited
Soft, nontender uterus
Usually no fetal distress
Diagnosis pf placenta previa
Routine prenatal care: transvaginal or transabdominal ultrasound to assess placental position
Management of placenta previa
Placenta previa detected on routine ultrasound during
Monitor placental placement
If placenta previa persists at ∼ 32 weeks: Repeat US at 36w
Schedule cesarean, ideally 36 and 37 weeks’ gestation.
If placenta previa is complicated by placenta accreta: Schedule delivery between 34 and 35 weeks’ gestation.
Placental attachment disorders
complication of placenta previa
Fetal malpresentation: transverse lie is common because the placenta is covering the pelvic inlet so the fetus cannot assume normal position
Other: PPROM, IUGR, vasa previa
clinical presentation of placenta attachment disorders
Delayed delivery of the placenta (>30min after fetus) with profuse bleeding during manual separation
Managment of placenta attachment disorders
When accreta is suspected, laparotomy with preparation for large-volume hemorrhage is required, an scheduled cesarean hysterectomy is done at 34 weeks (the placenta is left in
situ while hysterectomy is done)
Multiple gestations?
Pregnancy with two or more fetuses.
Twin pregnancies can be differentiated into monozygotic and dizygotic pregnancies
Definition of dizygotic or monozygotic twins
Monozygotic twin pregnancies result from the division of the fertilized oocyte into two embryonic layers
Dizygotic twin pregnancies arise from the fertilization of two oocytes with two spermatozoa.
Overview of different types of monozygotic twin pregnancy
Dichorionic-diamniotic
Monochorionic-diamniotic
Monochorionic-monoamniotic
Dichorionic-diamniotic
The twins have separate chorionic sacs (separate placentas) and separate amniotic sacs.
Monochorionic-diamniotic
The twins share a single chorionic sac (the twins share a placenta) but have a separate, individual amniotic sac.
Monochorionic-monoamniotic
The twins share a single chorionic sac (the twins share a placenta) and a single amniotic sac.
Differentiation between monochorionic and dichorionic twins during early pregnancy
Dichorionic twins?
Dichorionic twins: lambda sign on US
Differentiation between monochorionic and dichorionic twins during early pregnancy
Monochorionic twins?
Monochorionic twins: T-sign
maternal illness in twins
Preterm labor and birth (most common complication)
Hyperemesis gravidarum
Gestational diabetes
Preeclampsia, eclampsia, pregnancy-induced hypertension
Cervical incompetence, premature rupture of membranes
Placental insufficiency, hypotrophy, and intrauterine malnutrition of at least one fetus
Uterine atony
fetus innless in twins
Twin-to-twin transfusion syndrome
what is Twin-to-twin transfusion syndrome
Affects 10–15% of monochorionic twin pregnancies (share the placenta)
Blood is continuously shunted from one twin to the other through vascular anastomoses on the shared placenta, risk for both fetus
Recipient twin complications in Twin-to-twin transfusion syndrome
Recipient twin
- Polycythemia
- Hypervolemia
- Polyhydramnios in diamniotic pregnancies
Donor twin complications in Twin-to-twin transfusion syndrome
Donor twin
- Anemia
- Growth retardation
- Hypovolemia, dehydration
- Oligohydramnios in diamniotic pregnancies
indication for section in twin pregnancy
Monochorionic-monoamniotic twin pregnancies between 32–34 weeks’ gestation
what decides the arrangement of the fetal membranes and
placenta in monozygotic twins?
Monozygotic twins arise from a single fertilized egg at various stages during embryogenesis, and therefore the arrangement of the fetal membranes and placenta depend on the time at which the embryo split
division timing and result in monozygotic twins
Division within 72h of fert: diamniotic, dichorionic
Division after 4-8 days: monochorionic, diamniotic
Division after 8-13 days: monochorionic, monoamniotic
Division after 13-15 days: conjoined twins
Retained dead fetus syndrome in twin pregnancy
Demise before 12 weeks, the dead fetus will be reabsorbed
If retained > 3 w after 20 week gestation, it may result in DIC
Define placental abruption
The partial or complete separation of the placenta from the uterus prior to delivery; subsequent hemorrhage occurs from both maternal and fetal vessels.
Etiology of placental abruption
Hypertension (most common cause)
Preeclampsia/eclampsia
(Abdominal) trauma: car accidents, falls
Twin pregnancy
Sudden decrease in intrauterine pressure
Previous abruption, chorioamnionitis
Short umbilical cord
Maternal age: < 20 years and > 35 years
Alcohol and cigarette consumption, cocaine use
clinical symptoms of placental abruption
Maternal symptoms
- Sudden onset of continuous vaginal bleeding
- In 20% of cases, the hemorrhage is mainly retroplacental and vaginal bleeding does not occur
- Sudden onset of abdominal pain or back pain
- Uterine tenderness
- Hypertonic contractions (rigid uterus), premature labor
Fetal symptoms
- Fetal distress (60% of cases)
- Possible diminished or absent fetal movement
- Decelerations on fetal heart monitor
clinical presentation of retroplacental hemorrhage in placental abruption
patients may present with signs of hypovolemic shock without evident vaginal bleeding!
Management of placental abruption
Hemo unstable or moderate-severe bleeding: acute sectio
Hemo stable with mild bleeding: reassuring fetal status
< 34 weeks: expectant management, aim normal delivery.
34–36 weeks + active uterine contractions: vaginal delivery
> 36 weeks: deliver the fetus
complications of placental abruption
Intrauterine fetal death
Maternal DIC and hypovolemic shock
Uterine rupture|
where is the bleeding happening in placental abruption
into the decidua basalis with formation of a decidual hematoma
risk factors of reoccurrence of placental abruption in other pregnancies
The risk of recurrent abruption is 10% after one abruption and 25% after 2
diseases of amount of amniotic fluid
maternal causes of polyhydramnios
Diabetes mellitus
Rh incompatibility (hemolytic disease of the newborn)
Fetal causes of polyhydramnioss
GI: (esophageal or duodenal atresia and stenosis): reduced swallowing and absorption of amniotic fluid
CNS: anencephaly (impaired swallowing, leakage of CSF)
Pulmonary: cystic lung malformations
Multiple pregnancy: twin-to-twin transfusion syndrome
Fetal anemia
Chromosomal aberrations
Intrauterine infections (congenital TORCH infections)
Diagnosis of polyhydramnios
Physical examination: abdominal girth and uterine size LGA
Ultrasound: AFI ≥ 25 cm
Assess for fetal anomalies
Rh screen
Managment and indication of management of polyhydramnios
Amnioreduction: drainage of excess amniotic fluid
Indications: severe abdominal discomfort, uterine irritability, severe shortness of breath
Complications: preterm labor, premature rupture of membranes
etiology of oligohydramnios
Fetal anomalies
- Urethral obstruction (e.g., posterior urethral valves)
. Bilateral renal agenesis
Maternal conditions
- Placental insufficiency
- Late or postterm pregnancies (> 42 weeks of gestation)
- Premature rupture of membranes
diagnosis of oligohydramnios
Small abdominal girth and uterine size SGA
US: Amniotic fluid index (AFI) < 5
Amniotic fluid index (AFI) normal range
normal range: 8–18 cm
management of oligohydramnios
Amnioinfusion: into the amniotic cavity through amniocentesis
Treat underlying cause
Delivery is advised if the fetus is close to term.
amount of normal amniotic fluid
Increases in volume from 30ml at 10w to 200ml by 16w
Reaches 800ml by the mid-3rd trimester
amniotic fluid function
Creates a physical space for fetal movement
Fetal swallowing essential for GI and lung development
Guards against umbilical cord compression
Protects the fetus from trauma
4 main pathways in the regulation of the amniotic fluid
Fetal urinary production (can produce 1L/day)
Fetal swallowing (750ml/day)
Fetal lung secretion (350ml/day), half of which is swallowed
Intramembranous fluid transfer across and into fetal vessels 400ml
Postpartum hemorrhage?
Blood loss of > 500ml during or immediately after the 3rd stage of labor in vaginal delivery or
> 1000ml in a cesarean delivery
Uterine atony (atony of the uterus)
occurs when your uterus doesn’t contract (or tighten) properly during or after childbirth. It’s a serious complication that can cause life-threatening blood loss.
Etiology of PP hemorrhage
Most common cause: uterine atony (75-80%)
Vaginal or cervical laceration (2nd most common)
Uterine inversion
Retained placenta
DIC
Etiology and management of uterine atony
Uterine overdistention: twins, polyhydramnios, macrosomia Prolonged labor
Relaxant anesthetics (halothane) or tocolytics
Rapid labor
Chorioamnionitis
Manangement: uterine massage, uterotonics (oxytocin)
3 groups of Vaginal or cervical laceration
▪ Uncontrolled: fast delivery, too early pushing
▪ Traumatic: shoulder dystocia, macrosomia
▪ Operative: episiotomy, forceps, vacuum
management of PP hemorrhage
ABCs
Start 2 large bore IVs and crystalloids
CBC, coagulation profile
4 units of RBCs
Treat the underlying cause
define an inverted uterus
Rare medical emergency in which the corpus turns inside out and protrudes into the vagina
- It occurs most commonly when too much traction is applied to the umbilical cord in an attempt to deliver the placenta
Treatment of inverted uterus
Manual reduction by pushing up on the fundus until the uterus is returned to its normal position (do this before removing the placenta if it is still attached)
o IV analgesics and sedatives or general anesthetic as needed
o Once the uterus is in place, start an oxytocin infusion
Lesions of the birth canal.
Vulvovaginal lacerations
Cervical lacerations
Lacerations of the perineum
Uterine rupture
Vulvovaginal lacerations
Relatively common
Often superficial
Little or no bleeding
Repair is usually not indicated
Cervical lacerations
Superficial lacerations can be seen in >50%
Most of them are < 0.5cm
Rarely, the cervix may be entirely or partially avulsed from the vagina (colporrhexis)
Injuries sometimes follow forceps delivery
More severe lacerations may involve the uterine artery
Treatment: sutures
Lacerations of the perineum definition and risk
Tear of the perineal area due to significant or rapid stretching forces during labor and delivery
Risk factors
Macrosomia
Forceps delivery
No previous delivery
Prolonged second stage of labor
classifications of perneal tears
Class I-IV
treatment of Lacerations of the perineum
I or II degree: Minor tears (superficial, hemostatic lacerations) Left to the clinician to determine if suturing is required.
Conservative: NSAIDs, sitz baths
Third and fourth degree
Regional or general anesthesia may be used.
Reconstructive surgery to repair the anal sphincters and mucosa
Reconstruction of the distal rectovaginal septum and the perineal body
Uterine rupture
Spontaneous tearing of the uterus that may result in the fetus being expelled into the peritoneal cavity (high morbidity and mortality).
Rare, occurs most commonly (40%) along healed scar lines in women who have had prior c-section
diagnosis and management of uterine rupture
Clinical presentation: fetal bradycardia, variable decelerations, evidence of hypovolemia, loss of fetal station, severe or constant abdominal pain
Treatment: immediate laparotomy with cesarean delivery and, if necessary, hysterectomy
TORCHS
Toxoplasmosis
Others (syphilis, varicella, parvovirus B19 infection, listeriosis)
Rubella
Cytomegaly (CMV)
Herpes simplex virus (HSV) infection
Toxoplasmosis TORCHS in the child
Petechiae and purpura (blueberry muffin rash)
Chorioretinitis (a form of posterior uveitis)
Diffuse intracranial calcifications
Hydrocephalus
Epilepsy
Intellectual disability
Visual disabilities
Sensorineural hearing loss
Listeria consequence TORCHS in children
Increased risk of premature birth and spontaneous abortion
Early-onset syndrome: granulomatosis infantiseptica
Severe systemic infection characterized by disseminated abscesses (may develop in any organ system)
Most common findings: respiratory distress and skin lesions
Late-onset syndrome (1 to 3 weeks after birth): Listeria meningitis/encephalitis
parvovirus B19 TORCHS in children
Aplastic anemia
Fetal hydrops
syphilis TORCHS in children
Early congenital syphilis (onset < 2 years)
- Jaundice and hepatosplenomegaly
- Lymphadenopathy
- Nasal discharge (sniffles)
- Maculopapular rash
- Skeletal abnormalities
Late congenital syphilis (onset > 2 years)
- Frontal bossing, rhagades
- Hutchinson teeth
- Interstitial keratitis
- Sensorineural deafness
- Saber shins
Varicella TORCH in children
IUGR, premature birth
Chorioretinitis, cataract
Encephalitis
Pneumonia
CNS abnormalities
Hypoplastic limbs
Rubella TORCHS in the child
IUGR
Sensorineural deafness
Cataracts
Heart defects (PDA, pulmonary artery stenosis)
CNS abnormalities
Petechiae and purpura (blueberry muffin rash)
CMV TORCHS in child
Jaundice, hepatosplenomegaly
IUGR
Chorioretinitis
Sensorineural deafness
Periventricular calcifications
Petechiae and purpura (blueberry muffin rash)
Microcephaly
Seizures
Herpes simplex virus (HSV) TORCHS in the child
Premature birth, IUGR
Skin, eyes, and mouth involvement: vesicular lesions, keratoconjunctivitis
Localized CNS involvement: meningoencephalitis
Multiple organ involvement, sepsis
define Congenital TORCH infections
Congenital TORCH infections are vertically transmitted infections (acquired directly from the mother and transmitted to the embryo, fetus, or newborn through the placenta or birth canal) that are capable of significantly influencing fetal and neonatal morbidity and mortality
Non TORCHS infections dangerous during pregnancy
Associated with transmission during passage in birth canal
Chlamydia
Neisseria gonorrhea
Streptococcus agalactiae (group B streptococci)
Chlamydia during pregnancy
Fetal complications: pneumonia, neonatal conjunctivitis
o Diagnosis: screen with NAAT early in pregnancy
o Treatment:
▪ Fetus: silver nitrate eye drops
▪ Mother: azithromycin
Neisseria gonorrhea in pregnancy
o Pregnancy complications: chorioamnionitis, PROM
o Fetal: neonatal conjunctivitis (purulent) sepsis, meningitis, arthritis
o Diagnosis: screen with vaginal smear and culture early in pregnancy
o Treatment:
▪ Fetus: silver nitrate eye drops
▪ Mother: ceftriaxone
Streptococcus agalactiae (group B streptococci):
o Diagnosis: screening (vaginal culture) at 35-38 weeks
o Fetal complications: sepsis (12h postpartum), pneumonia, meningitis (most common cause in newborns)
o Treat with IV penicillin, ampicillin to prevent preterm labor
o Prophylactic treatment is indicated in the following conditions: GBS bacteriuria in current pregnancy, prolonged PROM, 3rd trimester culture positive for GBS, previous
neonatal sepsis due to GBS, preterm labor
Define Spontaneous abortion
spontaneous loss of pregnancy before 20 weeks’ gestation
Define intrauterine fetal death
o Intrauterine fetal demise (IUFD) is fetal death after 20 weeks’ but before the onset of labor
o It complicates about 1% of pregnancies
Maternal cause of intrauterine fetal death
Fetal-maternal hemorrhage (FMH)
Diabetes mellitus
Hypertensive pregnancy disorders (especially if complicated by placental insufficiency or placental abruption)
Uterine rupture
Advanced age
Heavy smoking
Fetal causes of intrauterine fetal death
IUGR (which is most commonly due to placental insufficiency)
Placental abnormalities (placental abruption)
Infection (especially following PROM)
Chromosomal abnormalities
Congenital malformations
Umbilical cord complications (knot leading to fetal vascular compromise)
Fetal hydrops
Diagnosis of intrauterine fetal death
Absence of movements, particularly if the uterus is small
Placenta may continue to produce bhCG so a positive pregnancy test does not exclude IUFD
Real-time US will confirm the lack of fetal movement and absence of fetal cardiac activity
Determination of cause: fetal karyotype on autopsy, maternal CBC, screening for hereditary and acquired thrombotic disorders, TORCH test, DM testing, examination of the placenta
Management of intrauterine fetal death
Spontaneous labor usually begins within 2 weeks
Vaginal (misoprostol or oxytocin infusion) safer than cesarean
Express empathy and acknowledge patient grief.
Provide privacy and emotional support.
Offer contact between parents and the stillborn baby after delivery.
define posterm pregnancy
persist beyond 42 weeks from the onset of LMP
Management of postterm pregnancy
Week 41 expectant management with surveillance every 3d
Perform induction of labor by 42 0/6 weeks’ gestation
Induction unsuccessful: Perform C-section.
Postterm infant complications
Oligohydramnios
Increased birth weight and macrosomia
Stillbirth
Low Apgar scores ( ≤ 4 points)
Meconium aspiration syndrome
Neonatal seizures
Admission to the NICU
Cerebral palsy
Postmaturity syndrome
Postmaturity syndrome?
Changes in appearance:
Weight loss
Subcutaneous wasting
Dry, peeling skin
Possibly cause: placental insufficiency and oligohydramnios
Detection of fetal jeopardy during pregnancy
Maternal self-assessment of fetal wellbeing
Non-stress test assessment (NST)
Biophysical profile
US assessment
Contraction stress test
Non-stress test assessment (NST)
Noninvasive test that measures how fetal heart rate (FHR)
Mother report movement, and effects of the fetal movements
on the HR is determined
Responds to fetal movements; a rise in fetal HR is expected
How to do an NST
Perform electronic fetal HR monitoring over a mi of 20min
Review the FHR tracing for FHR accelerations + decelerations
If no FHR accelerations are observed within the first 20min
Perform vibroacoustic stimulation.
Continue with the NST for another 20–40 minutes.
results of a NST
Nonreactive: abnormal NST shows < 2 FHR accelerations
Reactive: a normal NST that shows ≥ 2 FHR accelerations
Normal respons are acceleration in fetal HR of >15 BPM above the baseline for at least 15seconds
causes of nonreactive NST
Fetal sleep (most common)
Hypoxemia or acidemia
Neurologic or cardiac abnormalities
Fetal immaturity
Maternal drug use
what is a normal baseline fetal heart rate?
110-160BPM (bradycardia < 110, tachycardia > 160)
amniotic fluid levels in poly or oligohydramnios
o Oligohydramnios can be defined as AFI < 5cm
o Polyhydramnios can be defined as AFI > 23cm
Umbilical artery Doppler assessment:
High systolic/diastolic ratio suggest abnormal flow due to increased vascular resistance within fetal/placental circulation
o When the flow becomes very abnormal, diastolic flow ceases and there can be reversal of flow from placenta to the fetus
o If this occurs an emergency c-section is usually indicated
Biophysical profile (BPP)
Noninvasive test with US of 4 specified parameters + NST:
1. Fetal movement
2. Fetal tone
3. Fetal breathing
4. Amniotic fluid volume (AFI)
NST is performed if any US parameter is abnormal
Each parameter of the US examination and the NST is given a score of either 0 (abnormal) or 2 (normal)
Biophysical profile scoring result
A normal profile = 10 points if NST, 8 points if no NST
o 8-10 points: Reassuring
o 3-7 points: do contraction stress-test
▪ If > 36weeks, CST is not necessary, delivery is indicated
o 0-2 points: deliver by emergency c-sectio
Prenatal genetic counseling
Offer all patients genetic carrier screening and testing for chromosomal abnormalities.
Screening should preferably be offered at the initial prenatal visit.
Provide counseling prior to prenatal genetic testing to all patients.
types of screening in prenatal genetic counseling
Noninvasive aneuploidy screening of maternal serum biomarkers and US markers, or cell-free fetal DNA testing
Invasive genetic testing with amniocentesis or chorionic villus sampling
indications for prenatal genetic screening
o Advanced maternal age >35
o Positive fam history: chromosomal aberration, monogenic disorders (AR, AD) NT defect ++
o Abnormalities suspected in pregnancy
o Other high-risk factors (maternal disease, obstetric history)
pregnancy teratogens
6.5% of all birth defects are attributed to teratogens
A teratogen is a chemical, physical or biological agent capable of interfering with the development of a fetus, causing birth defects
Effect of the teratogen on the fetus depends on two things
- The pharmacological properties and dose
- Stage of pregnancy in which exposure occurs
Stage of pregnancy in which exposure of a teratogen occurs desides outcome
0–15 days after fertilization: early embryonic period
Toxicity to the developing embryo can cause spontaneous abortion (all-or-nothing effect).
First trimester
Corresponds to the period of organogenesis
Most significant period for teratogenic birth defects
Second and third trimesters
Period of fetal growth and maturation
Can lead to deficits in organ function, intellect, behavior, or minor structural malformations
Limb deformities due to a teraogen
Syndactyly: fusion of two or more fingers or toes
Polymelia/polydactyly: supernumerary limbs, fingers, or toes
Oligodactyly, adactyly: absence of one or more fingers or toes
Ectromelia: collective term for hypoplasia and/or aplasia of one or more long bones, resulting in limb deformity
Peromelia: amputation-like stump of a limb, finger, or toe
Maternal diseases that are teratogenic for the fetus
Diabetes mellitus: Diabetic embryopathy/Diabetic fetopathy
Obesity: a lot
Graves disease: Neonatal hyperthyroidism
Hypothyroidism: Congenital hypothyroidism
Phenylketonuria (maternal PKU): a lot
social drugs/substances that are teratogenic
Cigarette smoking
Alcohol
Caffeine
Aspartame
Vitamin A
Antibiotics NOT to give in pregnancy (teratogenic)
Drug effect in pregnancy
Drugs can affect the fetus directly (cross the placenta) or indirectly (constrict placental vessels, produce uterine hypertonia, cause maternal hypotension etc.)
o The effect is largely determined by fetal age at onset
FDA “the final rule”
Came in 2015 an replaces the drug categories A-X
All labeling of drugs should have a detailed subsection including summary of risks using the drug in 3 different categories (pregnancy, lactation, reproductive potential)
OTC drugs and pregnancy
Illicit drug effects in pregnancy
Cocaine:
Bath salts: designer drugs made from amphetamine-like
Hallucinogens: MDMA, ketamine, methamphetamines, LSD
Opioids: withdrawal symptoms at birth
Increased risk of: spontaneous abortion, fetal growth restriction, preterm birth, stillbirth, placental abruption, congenital malformations
Obstetrical examinations
Leopold maneuver
Uterine fundal height
Cervical cerclage
Leopold maneuver
1st: height of fundus, which fetal pole occupies the fundus
2nd: fetal lie and position
3rd: fetal presenting part and its relation to the pelvic inlet
4th: presenting part, engagement, descensus of the head
5th (Zangemeister maneuver): cephalopelvic disproportion (the head lies at the same level as or even projects above the symphysis)
Uterine fundal height
- 20 weeks: 2 fingers widths below umbilicus
- 24 weeks: at umbilicus
- 28 weeks: 2 fingers width above umbilicus
- 32 weeks: 4 fingers width above umbilicus
- 35 weeks: between umbilicus and xyphoid process
- 36 weeks: 4 fingers with below xyphoid process (xy/4)
- 37 weeks: xy/3
- 38 weeks: xy/2
- 39 weeks: xy/3
- 40 weeks: xy/4
Cervical cerclage definition and two types
Placement of a supportive suture in the cervicovaginal junction to prevent early pregnancy loss or preterm birth
McDonald cerclage: a removable suture in the cervix that allows vaginal delivery; Removal is indicated between 36–37 weeks’ gestation, before the onset of spontaneous labor.
Shirodkar cerclage: a permanent suture that is placed in the cervical submucosal tissue; Cesarean delivery is necessary.
First trimester US
11th – 13th week of gestation
Transvaginal (first) and transabdominal ultrasound
Determination number of fetuses.
Evaluation of the embryo or fetus, including:
- Cardiac activity (from week 6)
- Crown-rump length for estimating gestational age
- Nuchal translucency: patients that want aneuploidy screening
- Nasal bone
- Ductus venosus flow
Evaluation of maternal pelvic anatomy
second trimester US
18th – 20th week of gestation
Transabdominal, transvaginal if abdominal is suboptimal
Fetal biometric parameters:
- Biparietal diameter
- Fetal femoral length
- Abdominal circumference
Evaluation of amniotic fluid volume and placenta
Congenital malformations:
Duodenal atresia, omphalocele, renal dysplasia, congenital
pulmonary airway malformation
Nuchal translucency
▪ Assesses subcutaneous fluid at the level of the fetal neck
▪ >3mm can be sign of chromosomal/structural abnormalities
Early third trimester US
TAS 30th – 31st week of gestation (“fetal size screening”)
- Important to compare the measurements with previous screening to differentiate possible SGA from IUGR
- Aim: to recognize high-risk population for follow up
Check for intra uterine growth restriction (IUGR)
Check amniotic fluid, the placental location and blood supply Check late onset congenital malformations (corpus callosum)
Late third trimester US
4th US screening
TAS during the 36th – 37th week of gestation
Aim: to recognize the high-risk population
Gain information for delivery
what is the post partum period (puerperium)
The postpartum period refers to the six-to-eight-week period after the birth of a baby in which the body recovers from the changes caused by pregnancy and birth.
Normal processes during puerperium
Low‑grade fever, shivering, and leukocytosis are common
Uterine involution: first small then large, then small
Locha: women pass discharge for about 4 weeks after delivery
Types of lochia (postpartum vaginal discharge)
Lochia rubra: blood red; approx. the first 4 days after birth
Lochia serosa: brown red; watery, lasts approx. 2–3 weeks
Lochia alba: yellow white; lasts approx. 1–2 weeks
weightloss after pegnancy
Aafter delivery of baby, amniotic fluid, placenta: approx. 6 kg
Additional due to lochia and uterine involution: approx. 2–7 kg
uterus sice after delivery and in the puerperium period
1000g at delivery to normal weight of 50-100g 6 weeks postpartum
what is the bledding that occurs 1-2 weeks after delivery
Eschar from placental site sloughs off and bleeding occurs
Total blood loss is about 250ml
bodily changes after pregnancy
The perineum
Abdominal wall
Urinary tract changes
The vagina
Cardiovascular system
The urinary tract changes after pregnancy
Increased capacity and insensitivity to intravesical fluid P
Overdistension, incomplete emptying are common
The dilated ureters and renal pelvis return to prepregnant state over the course of 2-6 weeks after delivery
cardiovascular changes after delivery
Immediat increase in PVS due to removal of low-pressure uteroplacental circulatory shunt
CO and plasma volume gradually return to normal during the first 2 weeks
Leukocytosis and thrombocytosis occur during and after labor
During first few days postpartum, hb and hematocrit fluctuate
pathological post partum period
Diastasis recti
Pelvic atrophy
Hemorrhoids
Endometritis
Urinary retention
Wound infection
Puerperal sepsis
PP blues or depression
Postpartum sexual dysfunction
Septic pelvic thrombophlebitis
Postpartum endometritis
Inflammation of the endometrium, possibly also including the myometrium and parametrium:
Risk factors:
Cesarean delivery
Prolonged labor
Multiple cervical examinations
Retained products after delivery, miscarriage, or abortion
treatment of Postpartum endometritis
Antibiotic treatment: IV clindamycin and gentamicin
Uterine curettage to remove retained products of conception.
Puerperal sepsis
maternal sepsis that develops in the timeframe between birth and 6 weeks postpartum:
Fever
Pelvic pain
Abnormal vaginal discharge
Abnormal smell/foul odor discharge
Delay in uterine involution
Source
Genital tract, most common (endometritis)
Urinary tract (acute pyelonephritis)
Respiratory tract (severe pneumonia)
Breast (mastitis)
Skin/soft-tissue infections (episiotomy wound, IV, catheters)
Group A beta-hemolytic streptococcal infection (S. pyogenes)
Gastrointestinal tract
Diagnosis and treatment of Puerperal sepsis
Diagnosis: clinical + find source!!
Treatment: ABC resuscitation if necessary
Give IV clindamycin + piperacillin within 1h
immediate care of the newborn
Wipe the newborn’s mouth and nose to clear airway secretions
Dry and stimulate the newborn.
Provide warmth.
Skin-to-skin contact with mother and initiation of breastfeeding
Clamp and cut the umbilical cord.
Apgar score assessment at 1 and 5 minutes after birth
Begin resuscitation if no resp within 30–60 seconds
APGAR score
Standard clinical assessment at 1 and 5 minutes after birth
Reassuring: 7–10
Moderately abnormal: 4–6
Low: 0–3
Score <7, assessment performed 5–minute intervals for 20 min
normale measurements of a newborn
o Normal weight: 2500 – 4290g
o Normal length: 44 – 54cm
o Normal head circumference: 32 – 38cm
o Normal abdominal circumference: 17 – 24cm
Preventive measures directly after birth
Ophthalmic AB: to prevent gonococcal conjunctivitis (erythromycin ophthalmic ointment)
Vitamin K: to prevent vitamin K deficiency bleeding of the newborn (VKDB)
Rh incompatibility
Rh-negative mother and Rh-positive newborn:
Maternal exposure to fetal blood → production of maternal IgM antibodies against the Rh antigen → over time, seroconversion to Rh-IgG (able to cross the placenta)
In a subsequent pregnancy with an Rh-positive newborn: rapid production of maternal IgG anti-D antibodies to fetal RhD antigens → Rh-IgG agglutination of fetal RBCs with hemolytic anemia → risk of Hemolytic disease of the newborn with possible hydrops fetalis
is mother blood and fetus blood in contact? for sensitization of RH incompatibility
The placental barrier normally separate the fetal and maternal circulation so only small amounts of fetomaternal blood mixing occurs
Sensitization occurs when the barrier is broken, and there is more severe fetomaternal hemorrhage
etiology of RH incompatability
Fetomaternal hemorrhage:
▪ 90% occur during delivery
▪ 3rd trimester bleeding, postpartum hemorrhage, ectopic pregnancy, gestational trophoblastic disease
o Rh + transfusion
Diagnosis of Rh incompatibility
o Always determine Rh status and titers of AB during the first prenatal visit
o If the mother is Rh-negative or sensitized, paternal Rh genotyping should be done
o If father is neg, the bay will be neg, no risk of anemia
o If father is pos, fetal genotyping should be done
(cell-free fetal DNA or amniocentesis)
treamtne of Rh incompatability
Rh-negative mother not sensitized:
- Give RhoGAM at week 28 and 72h before delivery or any procedures (amniocentesis) if the baby is Rh-positive
Mother is sensitized, but the baby is not anemic and AB low:
- Close monitoring of the mother and baby every 2-4 weeks
- RhoGAM at 28 weeks
consequence of Rh incomp
Hemolytic anemia, hyperbilirubinemia (kernicterus), jaundice,
hepatosplenomegaly, portal hypertension, hypoalbuminemia
Fetal hydrops: accumulation of fluid in > 2 compartments
(subcutis, pleura, peritoneum, pericardium)
treatment in Rh incompatability
If MCA blood flow show anemic fetus further management
depend on gestation:
▪ > 34 weeks: delivery
▪ < 34 weeks: PUBS transfusion to replace fetal hemolysis every 1-2 weeks until fetal maturity
PUBS transfusion
Percutaneous Umbilical Blood Sampling
respiratory problems in the newborn
Transient tachypnea (RR > 60): follows short labor/c-section
Aspiration syndrome: Meconium in amniotic fluid
Congenital pneumonia:
Idiopathic respiratory distress syndrome: pulmonary surfactant deficiency
neonatal resuscitation
Preductal pulse oximetry
PPV at rate of 40–60/minute if inadequate respiratory HR < 100
Ventilation should be provided with room air for infants ≥ 35
Premature infants < 35 weeks: FiO2 21– 30%, titrated to SpO2
Chest compression indicated if HR is < 60 bpm despite adequate ventilation for 30 seconds
IV epinephrine if heart rate < 60 bpm despite adequate ventilation and chest compressions for at least 30–60 seconds
If there is no evidence of ROSC within 20 minutes, consider termination of resuscitation.
The most common birth defects
Heart defects, cleft lip/palate, Down syndrome and spina
bifida
congenital heart diseases
- Left to right shunts:
- Patent ductus arteriosus (PDA)
- Ventricular septal defect (VSD)(most common with 25%)
- Atrial septal defect (ASD) - Right-to-left shunts:
- Tetralogy of Fallot
- Transposition of the great arteries
- Tricuspid atresia
Acyanotic and cyanotic heart diseases
Acyanotic diseases include left-to-right shunts resulting in increased pulmonary blood flow and obstructive lesions, which usually have normal pulmonary blood flow
Cyanotic disease includes the 5 Ts:
Tetralogy of Fallot, transposition of the great arteries,
tricuspid atresia, truncus arteriosus
Etiology of cleft lip
Part of chromosomal abnormalities:
- Pierre Robin sequence
- Patau syndrome (trisomy 13)
- Edwards syndrome (trisomy 18)
Environmental factors: exposure to teratogenic substances
Nicotine and/or alcohol
Drugs: antiepileptics
Development of the face
Cleft lip
Cleft lip
Partial or total failure of primary palate formation during the 6–7th week of development
Failed fusion of the maxillary prominences and medial nasal prominences at the midline
Cleft palate
Failed formation of the secondary palate during the 8–12th week of development
Failed fusion of either the lateral palatine processes (palatine shelves) or of the palatine shelves with the nasal septum and/or primary palate
conservative treatment of cleft palate and lip before surgery
Proper feeding techniques: feeding in upright position to
prevent nasal regurgitation
Nasoalveolar molding: Use of a custom made orthodontic prosthesis to bridge and reduce the palatal gap
Nasal stent: to lift the drooping nostril and shape the nose
Lip taping: use of adhesive tape to reduce the defect; makes definitive surgery easier
Lip adhesion: suturing the edges of the cleft lip
timing of cleft lip anc cleft palate repair
Cleft lip: 3 months
Cleft palate: 6–9 months
what is spina bifida
Defective closure of the vertebral column due to a neural tube defect (folate deficiency)
Types of spina bifida
VACTERL association
The physical effects of teratogens are widely varied:
VACTERL associations
Vertebral
Anal
Cardiac
Tracheoesophageal fistula
Renal abnormalities
Limb abnormalities
Due to defect development of embryonic mesoderm
obstetric operations
Episiotomy
Cesarean delivery
Operative vaginal delivery: assisted
Episiotomy
Consists of a perineum incision (midline or mediolateral) to enlarge the vaginal opening during delivery
No longer routinely recommended.
Can be considered if vaginal delivery needs to be expedited and maternal perineal tissue is thought to pose a significant obstacle:
- Shoulder dystocia
- Inability to insert instrument for assisted vaginal delivery
- Vaginal breech delivery
Repair the incision with lidocaine and sutures after delivery
Obstetric forceps:
Forceps are instruments designed to provide traction and/or rotation of the fetal head when the expulsive efforts of the mother are insufficient
There are 2 classes of forceps: classic and specialized
indications of forceps delivery
Prolonged 2nd stage of labor
Suspicion of immediate or impending fetal compromise
To stabilize the after-coming head during a breech delivery
To shorten the 2nd stage of labor for maternal benefit
Vacuum extractor delivery
Vacuum extractor is a metal or plastic cup, attached to the fetal head with a suction device, that enables traction of the fetal head during vaginal delivery
indications for Vacuum extractor delivery
Prolonged second stage of labor
Nonreassuring fetal heart rate
complications of Vacuum extractor delivery
Maternal: suction of soft tissue: hematomas/lacerations
Fetal: cephalohematoma , scalp lacerations, life-threatening head injury (intracranial hemorrhage or subgaleal hematoma)
Maternal indications of section
Primary cesarean delivery
Placenta praevia totalis
Refractory HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count), severe preeclampsia
Severe uterine abnormalities (e.g., myoma) of the mother
Maternal skeletal deformities
indications of emergency sectio
Immediate threat to life of mother
Severe vaginal bleeding of unknown etiology (suspected placental separation)
Suspected uterine rupture
Fetal indications of sectio
Primary cesarean delivery
Fetal growth retardation with circulatory depression
Premature birth, if further risk factors are present, e.g., infection
Fetal malformations that hinder a natural birth
section procedure
Skin incision above the pubic symphysis.
Largely blunt penetration through the abdominal muscles, fascia, and peritoneum
Hysterotomy
Fetal extraction, cord clamping, and manual placental removal
Wound closure
section inscisions
Formation and structure of the umbilical cord
The umbilical cord contains 3 allantois-derived blood vessels
The normal umbilical cords are 40-70cm long
Cords are helical in nature, and can have as many as 380 helices
2 umbilical arteries: branches from the internal iliac arteries that carry deoxygenated blood from the fetus to the placenta
1 umbilical vein: supplies oxygenated, nutrient-rich blood from the placenta to the fetus (merges into the inferior vena cava via the ductus venosus)
if only one umbulical artery?
A single umbilical artery is a sign of chromosomal disease and congenital anomalies.
Vasa previa definition
Condition in which the fetal vessels are located in the membranes near the internal os of the cervix, putting them at risk of injury if the membranes rupture
umbilical cord abnormalities
Short cords
Long cord
Cord knots
Nuchal cord (neck)
Cord prolapse
Single umbilical artery
Vasa previa
neonatal mortality rate
Number of infant deaths during the first 28 days of life)/
(total number of live births) × 1,000
Late neonatal mortality rate
(number of infant deaths during postnatal days 7–28)/
(total number of live births) × 1,000
Early neonatal mortality rate
(number of infant deaths during first week after birth)/
(total number of live births) × 1,000
Fetal station
When the fetal head align with the ischial spines,b baby is in station 0
6 movements of labor
Descent
Flexion
Internal rotation,
Extension
External rotation
Expulsion
breastfeeding
Recommended that infants exclusively breastfed up of 6m
On-demand feeds are recommended.
Plays an important role in mother-child bonding.
Initiated within 30min after birth
Newborn infant nurses minimum 8-10x/day)
Lactogenesis
The process of mammary epithelial cell differentiation and milk production in the mammary gland that begins mid pregnancy as a result of increased estrogen and progesterone levels
Lactation is initiated by the delivery of the placenta → abrupt ↓ progesterone levels → ↑ prolactin → stimulation of milk secretion
maintenance of lactation after delivery
Requires suckling, which stimulates secretion of:
Prolactin from the anterior pituitary: leads to stimulation of continued lactogenesis (milk production) and disruption of pulsatile GnRH secretion (causing lactational amenorrhea)
Oxytocin from the posterior pituitary: leads to stimulation of milk ejection (letdown) and uterine contractions
Composition of breast milk
Breast milk contains all the required nutrients (except vitamin D and vitamin K) for infants up to 6 months of age
types of breast milk
Colostrum: the first milk produced during late pregnancy until 3–4 days postpartum; rich in proteins and immunoglobulins
Mature milk is composed of:
Proteins, lactose and oligosaccharides, fats, minerals, trace elements, and vitamins
Proteins and cells that provide passive immunity in neonates
Immunoglobulins (secretory IgA), lactoferrin, lysozymes
Lymphocytes, macrophages
Infant benefits of breastmilk
Decreased risk of middle-ear, respiratory, gastrointestinal, UTI
Breast milk Ig (especially IgA) and WBC provide passive immunity
Better gastrointestinal function and motility
Lower risk of asthma, allergies, obesity, and diabetes mellitus
Maternal benefits of breastfeeding
Faster uterine involution and post-partum weight loss
Lower risk of ovarian and breast cancers
Postpartum contraception (lactational amenorrhea)
Improved bonding with the infant
Reduced costs
Absolut CI of breastfeeding
Maternal factors:
HIV infection (regardless of viral load or treatment)
Infant factors: galactosemia
complications of breastfeeding
Inadequate milk production or intake
Breastfeeding jaundice
Breast milk jaundice
Mastitis
Galactocele
Nipple injury
surgery during pregnancy
Elective surgery should be avoided in pregnancy
If a must, but not emergently, 2nd trimester is the safest
why is the 2nd trimester the best timing for surgery?
During this period the risk of teratogenesis and miscarriage is much lower than in the first trimester and the risk of preterm labor is lower than in the 3rd trimester
Anestesia if surgery during pregnancy
Regional analgesia preferred: ass with lower mortality, morbidity
All pregnant women should be treated as they have full stomach Premedicated with citrate and H2-receptor blockers
what is the most common non-obstetric cause of surgical emergency during pregnancy
apendecitis
why is it difficult to diagnose appendicitis during pregnancy
Symptoms can be similar to pregnancy, although right lower abdominal pain is still the most common presentation
Leukocytosis and diminished tendency to develop hypotension and tachycardia add complexity to the diagnosis
Due to delayed diagnosis there is an increased rate of rupture
second most comon cause of surgery during pregnancy
cholelithiasis
mechanism of cholelithiasis during rpegnancy
Increase serum cholesterol and lipid levels, along with biliary stasis, leads to higher incidence of cholelithiasis, biliary obstruction and cholecystitis
Intestinal obstructions in pregnancy
Usually associated with postoperative adhesions, although
volvullus and intussusception are rare cause
It generally occur in late pregnancy and is associated with traction on adhesions as the uterus
enlarges
