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.
Normal fetal presentation
cephalic, vertex, occipitoanterior
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.
what is fetal attitude during birth
o Vertex (flexed): normal
o Brow: head partially extended
o Face: head fully extended
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
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
Station (Obstetrics) at birth
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)
Pelvic inlet
types of placenta previa
Placental attachment disorders
Overview of different types of monozygotic twin pregnancy
Dichorionic-diamniotic
Monochorionic-diamniotic
Monochorionic-monoamniotic
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
diseases of amount of amniotic fluid
classifications of perneal tears
Class I-IV
Antibiotics NOT to give in pregnancy (teratogenic)
OTC drugs and pregnancy
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
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
PUBS transfusion
Percutaneous Umbilical Blood Sampling
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
Types of spina bifida
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
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
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
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
Fetal station
When the fetal head align with the ischial spines,b baby is in station 0
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
