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Definition of
preeclampsia
eclampsia
After the 20th gestational week
Preeclampsia: BP > 140/90 mmHg
Proteinuria > 300mg/24 hours
Eclampsia: Tonic-clonic seizures
Gestational diabetes
screen at 24-28w
Fasting glucose < 5.3 mM, healthy
Fasting glucose 5.6-7.0mmol/l, Do OGTT
Fasting glucose > 7.0mmol/l on two separate measurements = DM
OGTT- 75g of glucose (fasting)
Normal
At 0 min < 7.0 mM
At 0 min 5.6-6.9 mM, Impaired fasting glucose
At 120 mins < 7.8 mM
At 120 min Impaired glucose tolerance 7.8-11.1 mM
If > 11.1 mM, DM.
Prophylactic Indications for C-section
Prophylactic: Maternal - prior C-section or myomectomy, pelvic contractions fibroids or tumor herpes late primiparity >30 yrs
Fetal -
fetal scalp pH 7.21-6.25, threatened asphyxia
placental dysfunction or hypoxia
mother received infertility treatment
Maternal/Fetal - poor history of prior deliveries / poor gestational history dystocia/prolonged labor fetopelvic disproprotion / twins malpresentation
Vital Indications for C-section
Maternal -
Congestive heart failure, pulmonary edema
Severe bleeding or DIC
Fetal - fetal scalp pH < 7.20, asphyxia cord prolapse. persistent transverse lie ascending infection
Maternal/Fetal - Ecclampsia Uterine rupture Placental previa Placental abruption
US in pregnancy
Zero: (6-7w) = Confirm pregnancy (gestational sac, HR)
Location and number of fetuses: Intra-/extrauterine
One: (11-13w) = Establish correct gestational age and check for chromosomal abnormalities.
Nuchal translucency (Down’s)
Neural tube defects, ductus venosus flow - heart
Biometrics
Two: (18-20w) = Congenital malformations and placentation.
GI defects, duodenal atresia, omphalocele, airway malformations
Locate the placental site and check fetal position
Three: (30-31w) = Fetal size, amniotic fluid, and late onset malformations
check growth pattern for IUGR or SGA
Late congenital malformations, agenesis of corpus callosum
Check AFI
Four: (36-38w) = Fetal presentation
Fetal weight, size, and position
To identify high-risk deliveries.
Diagnosing Placenta abruptio / placenta previa
Use hands to palpate the uterus
Abruptio: Painful, hard uterus, if rock hard –> emergency C-section
Previa: Painless, CTG normal
Causes of post-partum haemorrhage
Tissue: Retained placenta
Trauma: Vaginal lacerations
Thrombin: Coagulopathy (DIC)
Tone: Uterine atony (exclude other causes)
Stages of birth
- Onset of labor:
a. Latent (3cm), ~8hours/5hours, regular contractions
increasing in intensity and duration
b. Active (3-10cm) ~5-7/2-4hours
- active contractions are every 3 minutes, last 45s - Delivering fetus: 30min/3hours/5-30min
a. Propulsive phase (full dilation, descend to pelvic floor)
b. Expulsion phase (ends with delivery of baby) - Placenta: 5-30mins,
a. Expulsion of placenta
b. Expulsion of membranes - Recovery: 2-6hours after expulsion of placenta
a. Increased risk of bleeding
b. Repair lacerations
c. give RhoGAM to negative mothers with positive babies
Techniques of C-section incisions
Abdominal wall:
Transverse (Pfannenstiel) or Vertical (Midline)
Uterus:
Lower segment incision (Transverse) or Classical (Vertical)
Pearl index of different contraceptives
No. of pregnancies in 100 females/year with chosen contraceptive.
OCP: 0.1 - 2.5
Post-coital pill: 0.5 - 2.5
IUD: 0.5 - 5
Condom: 3 - 28
Surgical Sterilization: 0.3 - 6
Withdrawal: 4-22
Diaphragm: 6-12
Routine exams
Colposcopy
Cytology
Bimanual exam
Breast exam
Cytology -
- between age 21 - 29 have a Pap test every 3 years. HPV testing should not be used in this age group unless it’s needed after an abnormal Pap test result.
- 30 - 65 have Pap plus HPV co-testing every 5 years.
- Over 65 years with no abnormal test results in the last 20 years should discontinue testing.
Breast exam -
- over age 40 may begin screening mammograms if they wish
- 45 thru 54 years annual mammorgrams
- 55 and older, mammograms every 2 years, or yearly if they wish
Risks and benefits of Long-term OCP use
Benefits: decreases all of the following Ovarian/endometrial cancer Bone loss Dysmenorrhea Acne Risk of trisomies in advanced maternal age Improves cycle regularity
Bad: increases these DVT/stroke Blood pressure Weight gain Depression
Endometriosis
Endometrial-like tissue outside the uterine cavity.
Dx: Gold standard = Laparoscopic visualization
Tx: Definitive is Surgery Drugs, 1st NSAIDS, combination OCPs or progestin only OCPs, 'pseudopregnancy' then, GnRH, leuprolide to suppress. GnRH analog side effects: - Pseudomenopause - osteoperosis - decreased HDL and increased cardiovascular disease - vaginal atrophy
Urinary incontinence types (5)
Irritative:
Infection/Cystitis/tumor/urinary stone/foreign body,
frequency, urgency, and dysuria, but NO nocturia.
Urge:
Hypertonic, hyperactive detrusor muscle, also can be from cystitis, tumor, stones.
Associated with a sudden, strong, urgent desire to void and leak of urine with contractions.
Does have nocturia
Tx: Anticholinergics, botox injections to the detrusor every 6/9 months.
Stress:
Loss of bladder support, atrophy, birth. Coughing/increased pressure
Overflow incontinence, neurogenic bladder:
Hypotonic detrusor. No feelings of urge to void, with urine dribbling throughout day and night.
Tx: Cholinergics, intermittent self catherterization, indwelling catheter.
Bypass/Fistula
Main vaginal infections
Bacterial vaginosis - foul smell smell, no pain or itch. pH > 4.5. white discharge
Trichomonas - foul smell, itchy and inflamed, ph >4.5 green/yellow discharge. strawberry cervix
Mycosis (Candida) - no smell, itchy and inflamed. pH normal. thick white discharge.
Condyloma. HPV 6, 11.
Spontaneous abortion
Hx: Pain + bleeding, before 20th week.
Dx: Cervix, US, hCG
Contraindications to tocolysis
Obstetric: Severe abruption Ruptured membranes Chorioamnionitis Fetal: Fetal jeopardy Lethal anomaly Fetus is already dead
Maternal:
Eclampsia
Advanced dilation
Leopold maneuvers
- Fundal grip = Palpate upper abdomen with
both hands - Umbilical grip = Palpate to localize fetal back.
One palm to fix, while the other explores one
side then change. - Pelvic grip (1st pelvic grip) = Determine what
fetal part is lying above the inlet. Grasp lower
portion of abdomen just above the pubic
symphysis with thumb and fingers of the right
hand. - Pawlick grip (2nd pelvic grip) = Face woman’s
feet, attempt to locate fetus’ brow. Fingers of
both hands moved gently down the sides of
the uterus Pubis. The side where there is
resistance to the descent of the fingers is
greatest where the brow is located. - The Zangemeister meisterburger maneuver.
Stopping excessive/intermenstrual uterine bleeding
Young: Progesterone –> Preserves fertility
Old: D&C
Mayer-Rokitansky-Küster-Hauser Syndrome
Fancy word for Müllerian agenesis.
- Congenital malformation
- Failure of Müllerian duct to develop
o Missing uterus, cervix, upper 1/3rd of vagina
o Variable degree of upper vaginal hypoplasia (shortened)
- Causes 15% of primary amenorrhea
- Ovaries intact, ovulation usually occurs
- Will enter puberty and have secondary
sexual characteristics.
Pap smear Papanicolau classification
P0: Improper sample
P1: Negative result, superficial squamous cells
P2: No dysplasia, but benign abnormal cells present. Superficial cells and WBCs
P3: Pathologic cells present, unclear if inflammation or dysplasia.
P4: Atypical cells, Suspected malignancy
P5: True malignancy
Bethesda pap smear classification
Reporting cervical OR vaginal cytological Pap smear results.
Important steps:
1. Quality of the slide
- Whether the result is positive or negative
- Details of the slide
a) abnormal squamous
ASC-US
ASC-H, cannot exclude high grade lesion
LSIL - Low grade squamous intraepithelial lesion
HSIL - High grade squamous iel
b) abnormal glandular
AGC - atypical glandular cells, endocervical, endometrial
AIS - Adenocarcinoma in Situ - Physician recommendation of how to proceed
Prenatal care
Starts before conception.
400ug folate daily
avoid excess vitamin A and other teratogens,
control chronic diseases well and modify medications to not affect fetus.
Puerperium
Period beginning immediately after delivery of a child extending for ~ 6w.
The maternal pregnancy changes return back to normal.
-cardiovascular system 1 week
-renal system 2-8 weeks, overflow
incontenence 3-6 months in 25%
lochia: rubra->serosa->alba
uterine involution 4 weeks total, placental site 6 weeks total.
vagina, cervix
menstruation 6-8 weeks without
breastfeeding, up to 18 months if feeding.
breast engorgement
perineum and abdominal wall
leukocytosis
weight loss
