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WhiteKnightLove
Fertilization I
Placenta 3
Maternal adaptation 10
Diagnosis of pregnancy 16
Ante-natal care 18

Habitual abortion 33
Ectopic 40
Vesicular mole 47

Vasa previa 50
Placenta previa 51
Accidenta! hge 55

Atonic 60
Traumatic 62
Retained placenta 68
Drc 70
Acute inversion 72
Amniotic fluid embolism 73
Shock in Obstetrics 74
Obstetric trauma 75

Pre-eclampsia 76
Diabetes milletus 87
Heart disease 96
Hyperemesis g ravidarum 101
Urinary tract infection 104
Anemia 107
Thromboembolism {10
Thyroid disease 113
Respiratory disease 115
Surgery & Pain 116
WhiteKnightLove
My 2 Aims in this book to be SIMPLE and COMPLETE, so I
save no effort for doing that.
It is hoped that the readers will find this book, presented in
4 volumes (GYNECOLOGY A means volume I ), a useful
source covering their necessary basic knowledt. of
GYN ECOLOGY AND OBSTETRICS.
Your feedback and sutEestions will be valuable to us, so we
hope to contact us on Email or website
MANDOOHM@HOTMAtL.COM
WMW.DR-MANDOOH.COM

Dr Mohamed Elmandooh

WhiteKnightLove
.J -
.J -
.J
1

Fertilizotion
Plocenlo
Moternol odoplotion
Diognosis of pregnoncy
Ante-nolol core

WhiteKnightLove
 @@ OVULATION l2rh Doy

Spermotozoori
ygole
trogen

Doy 5 25 30
of Morulo
Cycle

Repoir Proliferotion Secretory Deciduo

Fo I lopion tube

B lostocysl

Prim itive
trophoblost

WhiteKnightLove
 zo
-t
3
Fertilization g
E
. o
Definltlon. .. ...The union of a mature ovum & a mature spermatozoon
o 1/z) --+ zygot
o
at ampulla of F.tube (bet. outer & middle =
o
=
o
o TrgnsPort of sprrns
- Mature spenns l22x or 22y) reach F.tube. ..within 40 min
- Capacitation of sperms starts. ..within the cx
\ changes in sperms tot its ability to fertilize
. Removal of excess proteins
o
. Production of enzymes e.g. hyaluronidase

o Tmns}ort of orum
- Ovulation -+ completion of meiosis I -+ 1ry oocyte + 1s polar body
- Ovum pick up occurs by the tubal fimbia -+ then it is carried by "
\ passive fluid currents (helped by ciliary action & peristalsis)
. The Unton
-
''" l sperm penetrates the ZP (Polyspermia is prevented by: Zonal block)

" b'dv .
r d,#'ffii'*:ffrt'!ffi',ft'$;H'Jf,lp"ar

Differentiation
o Zygot rapidly divides by mitosis ...2...4...8 + BmsrorueRes
o A Monum is formed (round mirss E 16 cells)
- It reaches the uterine cavity a.fter 3 days from fertilization
- It is nourished by secretions from the tube (tubal milk)
Fluid will then accumulate -+ a BtRsrocvsr
- It remains free for 3 days in uterine cavity
- It is nourished by secretions from the endometrium (uterine milk)
The blastocyst will
be divided into 2 masses:
- lruruen c€LL Mffss -+ x 100-250 cells a
will form the embryo
- OureR cett nnms -+ trophoblast O responsible for nutrition

WhiteKnightLove
 Ann ioiic

Two srnoll covitie gppol, one in the ectodem formirp fhe omniotic soc,
thc othcr
in the enlodsrm - thc yolk soc.
Proiections of
proliferoiing i-
trophoblosf
cells
(primitive
villi)
invode
deciduol
vessels

Embryonic ored
--- Meoder.---

Amn iol ic soc

Embryonic disc

, Yolk soc ...

Trophobl osl

Connecling stolk -

- Ectodam

Mcsoderm
Trophoblost loyer

WhiteKnightLove
lmplantation: z
o
!
It occurs on tle 6s to 7h days after ovulation 3
o
\
by penetration of the trophoblast into the Dectpun :- o_

\
modifled secretory endomet. under efflect of both P/ a ! !q
o
o GI
Functions of the decidua
=
o
- Site of. ...rnpfantation&,natritianof fitastocyst
=
o
- Site of. ........f0*tianof tfreptacenta
- Protection ..against kws of transpkntationimrutnabg
- Protection ,dgfritt$t tfie imta$ae power of trophofifost
..

\ invasion stops at a flbrinoid layer called Nitabiich

\ absence of this layer -+ adherent placenta -+ failed pl. delivery

Formation of the chonionic villi

o The chorionic villus is formed of 2 layers of hophoblast :-
- Ortotroohoblast = Langhan layer......inner
- Syncitiotroohoblast .........0uter
o Chorionic villi are 2 types

I Anchoring ,+ O Eixation & attachment

.Solid flnger like projections into the decidua + 1ry villi
.Mesoderm develops inthe lv villi (CT core) -+ 2ry villi
.Vascularization of Zry villi with fetal vessels -+ 3ry villi
I Free villi
,+ @ Eood & nutrition
.The trophoblast invades the endometrial vessels
1ry wave of invasion

.At 20 weeks trophoblast invades media of spiral

vessels -+ 2ry wave of in.rasion
,+ 0Eunctional unit o
.HCG -+ maintenance of CL to produce 'P' for 7-
0 wks till the placenta is formed
o
€arlg developm€nt of Cmbrgo (till 7 wks; after this + a fetus )

. 7ft day + two layers (endoderm and ectodenn)

o 101t day + amniotic caviSt andprimitiveyolksacare formed S
. 16ft day - three layered embryo (endodenn, mesodenrq ectoder

WhiteKnightLove
 Deciduo bqsolis

Deciduo copuloris

Deciduo bosolis
t
I
t
I
I
I

-1+!rE

''Chorion
loeve

Deciduo
copsuloris

Deciduo
---

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 zq
3
Norrnqlstruefurc o
> Shape. ......, discoid !
> Weight. ... ...500 gm
o

od,
> Site. ..UUS (60% postenor) -+ site of implantation
o
> Size. . 18-20 cm in diameter
=
> Thickness. . . ... ... ..2.5 cm in center -+ gradually thins towards periphery o
o
> Cord insertion... . .. eccenfiic

Plecental founqfion

> Two surfaces

o
O frm S(JRFAG is smooth & covered by omnion
O MAftRNAt stlRFAG is divided into 15-20 cotyledons (lobes)

) Two parts
o

O fEfm PARTa Chorion frondosum(chorionic plate):

Trophoblast + mesoderm + fetal vessels
projecting as villi into the intervillous space
Chorion leave
( is the rest of chorion not sharing in placental formation

O MAIIRNAL PARTa6\ecidua basalis(decidual / basal plate)

Decidua capsularis
( is the rest of the decidua overlying the developing ovum
Decidua parietalis (vera)
( is the decidua covering the rest of the uterine cavtty

!(tB o sularis s

t ofthe c I

Eetql rnernbtqhes... .2 membrones (could be seporotod)

The Amnion Tlre Chorion

-The outer membrane
- Covers the fetal surface of the - In contact wittr the uterine wall, it
ends at the marsin ofthe placenta

WhiteKnightLove
 Moternol blood
Plocentol r "& - - ---Syncytiotrophoblost
borr;e, ---{

Endometriol glond
\
(

")oc
,
c
lj
oe
oa

4.i<F-; .J

Mesoderm

WhiteKnightLove
 z
o
O I fulEchonicol ottochmont 3
r Ptocentol borrien- o o_
!-t
1- Cytotrophoblast 2- Syncitiotrophoblast (0 at 5ft- 6n'month)
o
3- Mesoderm 4- Fetal capillary endoth. + its basement memb. GI
=
o
'tThe placenta becomes thinner as pregluulcy advances '
*The placental is permeable to many drugs & organisrns e.g. =
o
- Drugs ue oral anticoagulants & oral hypoglycemics
- Bacteria us TB, syphilis, malari4 toxoplasma
- Viruses os IvIIMR, CMV, chickenpox, polio

I > Resgirotion (gas transport) by. ......simple diffusion

> Nutrition o - Water & electrol)4es.. ,.. simple diffusion
& ercrstion - Glucose, amino acids. ...facilitated difftrsion
- Ca, Fe, minerals... ... .. ..,active transport
- Immunoglobulins &LDL.. . . . . .pinocytosis

@ v Cnzgme prcduction a oxytocinase.....alkaline phosphatase... .insulinase

v Hormone prcductbn a sex steroids (estrogen & progesterone)
Source a
< 7 weeks -+ from CL mainly
7-10 weeks -+ from CL+ placenta (syncitiumo)
0 weeks -+ from placenta mainly
I runction responsibte for att changes in preg I

l€yd <athey continue to rise till end ofpreg

teilcDlqcshtql unlh
- Placenta can convert cholesterol (C27) into ggsesterone (Czr)
- Placenta can convert androgens (Crq) into estroeens (C1s)
- However, placenta can't convert progesterone into androgens .'. it
must be supplied with androgens first e.g.:- DI{EA & DI{EA-S
from both mat ernaf & feta I sources ( suprarenal gland mainly )
.'. J in anencephaly "
Estrogsn Lsual
o Estrone (81), Estradiol (Eu) -+ O t00 times
. Estriot(lEs) -+ O 1.000 times (the inteao o of feto-maternal unit)
o Estetrol (E+) + only formed in preg (of little significance)

Proqctsmns Larcl_ ,"+ 50-150 ug/ml (10 times luteal level)

WhiteKnightLove
 zPlocenlol
cotyledons
oll round
- Amniotic
covity

Plocento Membronoceo

Plocento Duplex
Plocento Biportilo
The plocento is com-
Ihe,+Iocentq is pletely divided into
portly divided two lobes, with
into lwo lobes, vessols uniting
wiih connecting to form tho cord.
vessels.

Plocento Circumvol loto.

(A voriont of Duplex)

Uterine woll-__{-z
Redupl icoted
Plocentol tissue -- .'ond inforcted
- chorion
Attochment of
membrones to
fetol surfoce

Plocento Fenestroto Bottledore Plocento

A defective oreo oppeors in the Sometimes the cord hos o morginol
middle of the plocento. lt moy be insteod ofo centrol insertion. This hos
wrongly token for the site of o missing no cl inicol significonce.
lobe.

--. Plocento Velomentoso.

-

WhiteKnightLove
 z
o
I
> Shrm 3
o_
l. Bipartite placenta O 2 equal lobes connected by......membranes
2. Bilobate placenta 4 2 equal lobes connected by... ... placental tissue !
-t
3. Placenta fenestrata 4 a window is present (a part of placenta is missed) o
cl
5
4. Placenta succenturiata (succenturiate lobe / lobes) o
o f
- Small accessory cotyledon/s attachedto placenta by membranes
o o
- May be torn away during delivery + retention + PPHge or p.sepsis
- Diagnosed by routine examination of pl. -+ site of torn vessels on margin
5. Placenta circumvallate (extrachorial placentation)
- The chorionic plate (ch.frondosum) is < the basal plate (D.basalis)
- The fetal margin shows a white ring formed of decidua
- May lead to abortion.......CFMF, IUGR, PfL, IUFD......accidental hge
6. Placenta membranacea
- The chorion leave does not atrophy -+ large thin placenta (15-20 inches)
- May lead to placenta previa
- If accompanied by vasa previa --+ APHge of fetal origin {
> Slio
o In LUS -+ placenta previa
o On septum --+ liability to abortion, APHge, PPHge or retention
o Elsewhere (as tubes or peritoneum) -+ ectopic pregnancy
> She
o Small (associated with IUGR or infarcts) 17 placental insufficiencv
o Large (hyperplacentosis) # svphilis. Rh. DM. twins, placenta membranacea
. Syphilis: large, pale, friable / Endarteritis obliterans / Spirochetes
. Rh isoimmunization'.large, pale, edematous

> Abnotmtl rdhererrce (absent Nitabuch layer)

o P. accreta --+ placenta reaches basal layers of decidua , may reach muscle
o P. increts -+ penetrates muscle but does not reach serosal surface
o P. percreta --+ perforates uterus
> Plreentr lrrfqretlons -+ esp. in PET due to narrow blood v. -+ red infarcts
Normal calcification (physiological) + white infarcts

> Tumors of Dlrcsntq

o Placental polyp -+ retained parts of placenta after delivery
o Vesicular mole & Choriocarcinoma
o Chorioangioma -J vascular malformation (tumor) --+ polyhydramnios

' Abnomtl qttqchmont of the ord.

WhiteKnightLove
 Umbilicol vein
/\/\

i:'U.bili"ol='-'*
orteries . Arnnion
Whorton's iell/

Cord Round the Neck

One or two loops of cord ore quite -----{L
often seen round the bobyts neck ot
vertex delivery ond normolly do no
horm. As soon os the neck is visible
ot the vulvo the loop should be clomp-
ed ond dividsd before delivery of the
shoulders ond trunk.

Much less frequently six or seven

loopo ore drown tightly round the neck
- -'- - As the fetus &scen& the cord tigh-
iens, the blood slpply is interrupted
ond the boby is stillborn. This is one
couse of sudden ocute fetol distrcss.

True
knot

_,.gtS Umbilicol Artery

This obnormolity is frequently o
socioted with other congenitol obnor-
molities in the fctus.

WhiteKnightLove
 z
o
-r
Strucnre 3
o_
o Length ----r about 5O cm
!rl
o Diometer --+ about 2 cm o
o Contents --+ 2 arteies (non-O2) & I vein (O2) " carryingfulslblood along GI
with remnants of allantois in myxomatous tissue (Wharton's =
o
:,
jell). Vessels are convoluted (length of vessels > cord) o
o The omniotic membrono covers the umbilical cord '
One voln carries oxugenoted blood to the fefus
Truo orterles carry rcduced blood from the fefus to placenta

flcnomollttes
I. Length
, Vtry /orug(>100 cm) ma1 had to:
- Coiling around fetus
- True knots
o
- Cord presentation & prolapse
> Short cord (<32 cm) mry lead to:
- Failure of . engagement & descent of fetus
. presentation (malpresentation e.g. transverse lie)
. external cephalic version or forceps
- Fetal asphSn<ia (distress) or rupture of cord or
. APHge (accidental hge)
. Uterine inversion
9. Fbnqmol ottochment: may be:
> Ceatral
> Marginal (battkdore) "
> Velamentous insertion of the cord
- Vessels are inserted into the membranes (& not placenta)
- If the traversing vessels pass below the presenting part in the
region of the ceryix they are 4 called.....voso previo
- It is usually associated with placenta membranacea
3. Knots in cord, may be:
* Trwe ? fetus passes through loops of the cord + may lead to fetal distress
* False O localized varicosity in a collection of Wharton's jelly + no effect
4. Congenitol umbilico! hernio
5. Tumors / cysts (as mlxoma and sarcoma)
6. Fbsence of ono umbilicol orterg
* Common in DM
* May be associated with CFMF, IUGR, prematurity

WhiteKnightLove
 AMNIOTIC FTUID

Volume

This increoses up to the 38th

week, folls slightly up to term ond
then more mpidly thereofter.
500
rnl.
Directly
fiom
motemol '.. 0
circu lotion 0 l0 20 30 40 44
--.-
- -5ource
Weeks

Secretion
By diffusion
thrcugh
. The fluid is reploced wery
hours.
3
The formotion ond circulo-
by omnion-- umbilicol tion is notdefinitely known. lt moy
corrd be derived from severol sources.

WhiteKnightLove
 zo
> Lovers of omnlon ( 0.5 mm -i 5 layerr )
3
1. Cuboidal epithelium o_
2. Basement membrane 'u
3. Compact layer (reticular fibers arranged in bundles) o
@
4. Fibroplastic layer )
5. Spongy layer (contains mucous + can glide upon chorion) o
a
o
> Sourco of omnion ....amniogenic cells ( from fetal ectoderm )

> Sour@ of omniotic f,uld

I. Motornol dtransudation (esp 1"t trimester)through placenta & cord
2. Fetol e- lJrine // (esp in the 2'd half)
Lungs (bronchial, buccal & salivary glands)
Amniotic epithelium

\ rhen i, i, *J[T il'ffX,ff#, Hi'ffi ,1;:iij]f,1:::l or* circu,arion

.

> Volume
6wk-+5ml l0wk+30ml i20wk+300ml
30 wk -+ 600 ml 36 wk + 1.000 ml 38-40 wk + 800 ml

> Composltlon
. 99 o/o Clear watery
. 1-2o/o crTstaloids & cotloids [+vernix caseosa, desquamated epith., lanugo hair]
- CHO (glucose & fructose) - proteins (albumin & globulin) - lipids
- Hormones (E.& Pr.) - electrolytes (Na. K. cl. Cu.)
r PhySiC?l propefties
- Colorless -+ later on will be turbid
- Specific gravity -+ 1010-1020
- Reaction -+ slightly alkaline " 1l-1.51
> Functlons O
9. Durino lobor
.hotection against trauma . Thermoregulation . Helps cervical dilatation
. Allow free movement . hevents direct fetal &
.Prevents adhesions bet.
of fetus -+ muscular placental compression
fetal skin & amnion
development by the uterine wall
.hevents infection . Deve of alveoli . Wash birth canal after ROM

Rbnornolltles
o Volume (f
. .. polyhydramnios, O.. . .oligohydramnios, PROM)

o Meconium staining a meconium aspiration syndrome

o lnflammation a chorioamnionitis
o Amniotic cysts........bands (may lead to amputations)

WhiteKnightLove
 ch

weeks 8 16 24 32 40

WhiteKnightLove
 z
o
-t
* Steroids "+ estrogpn & progest .. ..from CL & placenta o 3
g
* rDroteins,+ HCG & HPL. ..,...from syncitio-ftophoblast o .9
rt
o
Gl
I ) Humon drorionic Aonodotrophin )
o
o a
> gtune o( p'wfuAnn(a glycoprotein) o
- Appears at ls day of implantation
- Can be detected within 10 days of fertilization (conception)
o

\
i.e. before missing a period
>,eed
- It O rapidly in early pregnancy --+ level doubles every 2 days
- Reaches a peak at70 day (10 wk) gestation (= 50.0fi) mlU/ml)o
- Then it $ at 100 d (1a wk) = (s.000) & remains as such till term
> Di,tappearu al
. 1-2 weeks after abortion
. 2-8 weeks after labor
.8-12 weeks after vesicular mole evacuation
> Qtoeooed&y
Urins + with latex (detects 500 rnlu/ntl)
Stide agglutination
ELISA: more sensitive (90%), (detects 50 ntlu/ntl)
Serum -+ RrA /{ the most sensitive, (detects I rtIU/rnI)
\ assess p-subunit (as a-subunif is similar to FSH, LH, TSH)

> Aaho
FuncEion Usos
Maintenance of CL
of abnormalitie

9) Humon Plocpntol Loctogen (a polypeptide)'

> Uwq. oimilantueg( & p,wlaan + may stimulate growth of breasts
> &ili iruutho e4lst an el(O tr lot"
. Lipolytic + metabolism of free fatty acids
. Inhibits maternal glucose uptake & gluconeogenesis
\ spares glucose, fatty acids, amino acids for fetus

3) Othets - human chorionic GnRH, CRH, TRH, ACTH, prolactin, relaxin

- ptacental activin + stimulate GnRH & HCG while hhibin -+ inhibit them

WhiteKnightLove
 CIRCULATION
Heqd

/-q \

F
o

Umbilicol
vetn -
P.- Viscero
c -)
Ol
.J
J*
o-

Arch of Ductus

WhiteKnightLove
 z
o
rl
O gntrauterloe 3
g
- Oxygenated blood from the placenta passes to the fetus via the E
rt
o
umbitical vein (l) -+ penetrates liver to give it small branches o
GI
- Most of the blood is directed via the ductus venosus into the IVC f
(which carries also the returning non-Oz blood from LL ' )
o
a
o
- There is only partial mixing of the 2 streams and most of the
oxygenated blood is directed by the crista diuidens ( at the
upper end of the IVC) through the foramen ovale into the
left atrium + the left ventricle -+ aorta + this relatively well
Oz blood supplies -+ the head & UL
- The remainder of the blood from the SVC mixes with that of IVC -->
passes to the right venfficle -+ very small amount of blood goes
to the lungs (high pulmonary vascular resistance " ). Most blood
passes via the ductus arteriosus to the aorta (beyond the vessels
supplying the head & upper extremities) -+ supply viscera &,LL

- Little blood actually goes to the LL. Most of it passeso into + Rt & lt
internat iliac arterios -+ umb.!!!ca!arteg.!el (2) : non Oz blood

To compensate for the low arteriat PO2 in the fetus:- "

| "* Irr"reased fetal cardiac output
Increased fetal systemic blood flow rates
I -1-r-r,gr.gf9-$ #+itv- {o-t o: (l &te! -oa perry-tns -9?-p-?c--iry- --- }I-b:I)

@ flt birth
- The umbilical vessels contract in response to J temp -, J 02 tension
t
& CO, -+ stimulation of respiratory center
- Breathing -+ -ve thoracic pressure -+ strcks more blood from the
pulmonary artery into lturgs & diverting it from
the ducfus arteriosus which gradually closes
- The left atrial pressure -+ closes the foramen ovale

(0 fl.ater
- Umbilical vein -+ @(runs in the free border of the
falciform ligament in the adult)
- Umbilical arteries + hvposastric liqaments (lat. umbilical tig) "
o
- Ductus venosus -+ !!rc@enosum o
- Ductus arteriosus + lisamentum arteriosum

WhiteKnightLove
c%tes

WhiteKnightLove
WhiteKnightLove
 7
weeks
"',nxhLHIElji'
At 7 weeks the uterus is the
size of o lorge hen's egg 0
At l0 weeks it is the size
of on oronge
@
At l2 weeks it
of o gropefruit
is the size

WhiteKnightLove
<> UEateauet aeelatgtEou <e

z
o
3
g
l) The uterus !
o
(o
* -+ 0 from 50 gm (10 rnl3) to -+ 1 ls (5000 d3) )
Shqps o
-+ changes from pear shape -+ globular -+ pyriform a
o
* Slzs -+ 8 wks (5 cm),...12 wks (10 cm).,.....16 wks (15 cm)
+ Then fundal level according to gestational age
-+ Till reaching 35-40 cm at term

* Pocttlon -+ dextrorotated (,t round ligament becomes nearer to midline)

-+ dextroflexed (di. presence of sigmoid colon)
-+ soft consistency (d.t. vasculartfy - 500 mUmin' - &.amniotic fluid)

* llgonrehium
o Hypertrophy / & hyperplasia of muscle fibers
o Contractility
- In early preg., they are detected bimanually "+ Palmer's sign
-Latq on, cont. are detected abdominally .+ Braxton Hick's
- They become perceptible & painflrl near term ,+ false labor pain

* tormrtion of lorer uterlne segnrent

o Formed from rsthmus (bet. $patomical os above & [istologica] os below)

o It is 4 mm in lengh and is covered anteriorly by loose peritoneum,
o During pregnancy & labor + it is stretched to 10 cm
o It differs from the upper segment in

Upper segment I
I
I
Peritoneum Adherent Lgg-sg"- _ _ _ _ -_i
Dcidua Well
IlunP"lpyq$1"-
Irqldeyelqp_e$__ _ j
--i
adherent -
lgp;.ly p"g["gr."$" . " - .j
Et!
Passrye i

Phraiolosical retraction rins

It is a groove between the thick UUS & thin LUS below
the symphysis pubis. Normally it is not seen or pafoable

WhiteKnightLove
 VULVA

;. Prepuce of clitoris
- z? --
$'---
.'---
r5 ----
Clitari<
- Clitoris
-.S,[-__- Frenulum of clitoris
meotus
-Urinory
jrit-
'SS_
- -----Vestibule
- - Lobium minus
- - Lobium moius
Y;.-. - _ : _- _ _-:_-
: I:;,,:;",,
:* - -- -- "
- Perineum
f*-- --Anus
i
ll
li
./\'r
,'/ \::,,
./\

The breost ot l6 weeks

The breost ot 8 weeks

WhiteKnightLove
2) The ovaries
. No oulstlon oocur3 (suppressed LH & FSH) z
o
o Ths corDu! lutsum sscretss
g3
- E&Pr + produced mainly from CL till 7 wks, then production is shared !q
o
. Rerqdn - .1'[iJff":h.ji:TJi"th'l?lf":#: fl#:[ i X; GI
a
ripening of ceruix & relaxation of pelvis at labor cf
. A CL c$t may be found in the lstrimester o
( < 6 cm disappears spontaneously (functional)
3) The fallopian tubes o enlarged, stretched, increased vascularity

4) The vulva
- f "d vasctrlarity a soft & violet (Jacque Meir sign)
- O 'dliability to ovaricose veins & edema
s) The vagina
-
O 'd vascularity a soft & violet (Chadwick sign)
-
O "d secretions a
acidic (lactobacilli )
- Epithelium is thick (smear -+ intermediate cells)
6) The ceruix
- O 'd vascularity a soft & violet (Goodell's sign)
- t 'd secretions a mucous plug obstructing cx canal (operculum)
- Epithelium:- ectopy (replacement of st.sq.epith of ectocx by columnar)

't The 1* few weeks o

tenderness, tingling
(d.t. tsize, vascularity & sensitivity of nipples & breast)

'k The month

2od
t
- 'd size &nodularity of breasts
- O 'd pigmentation of lry areola & nipple
- Montgomery's tubercles appeari (sebaceous glands or pouting lips
of the orifices of the peripheral lacteals 10-20)
* The 3"d month ? colostrum appears
* Later on (5th or 6th months)
- 2ry arcolaappears (pigmentation around the 1ry areola)
- The breast shows dilated SC veins & sometimes striae

WhiteKnightLove
 lncreosed metobolism
increosed heot pro-
lncreosed =
duction
9OSeOUS -+peripherol
interchonge vosodilototion to get rid
of excess heot

D FOR
ooD s

lncreosed metobolism
=increosed excretion
of woste products

:11:l:1:
:: :::i
jr::r
|!il;;,l:

li Hyperventilotion

lncreqsed lncreosed
lnspirotion Expirotion
-/
,r'
lncreosed oxygen intoke exoired oir increosed

Y
I
Lo*rnotlnol blood
High orteriol oxygen corbon dioxide

WhiteKnightLove
 o z
The blood o
* Prsssrns,'+ S esp in2"d trimester 3
o_
- Placenta acts as an AV shunt ) leading to O in the P.resistance E
rt
- Vasodilator effect of progest. ) t
& of the peripheral flow o
Gl
* Votunre of Plumr ,+ increase 40-50% (max at 30-34 weeks)" =
o
* 5
Elsmenh o
o RBCs -+ increase 20-30Yo"
So, tlrere is more t in plasma volume > RBC volume -+
physiological anemia (haemodilution). Pathological if < 1lgmo/o
-+ Haematocrit -+ decreases
o Leukocytes + f slightly, esp after labor (14-16.000 /rd3)
o Blood coagulation -+ increased coagualability
- O"d factors VII-X and fibrinogen + $"6 fibrinolytic activity
- Platelets -+ mild decrease
. ESR -+ increases (due to f fibrinogen)
E
The heart....changes occur from l"ttrimester
.O'd Cop (30-5 lyA ,- (d.t. t
both SV & IIR: 10-15 bpm)
o The heart is displaced upward & laterally by the diaphragm
-+ shift of apex beat from 5ft to 4ft intercostal space
o Due to increased flow rate
- lls+t sounds
. Splitting ofthe 1* sound
. Appearance of the 3'd sound
- [lo+t murmun
. Soft systolic murmur may be present (90%)
.If diastolic murmur occur we must excludepathologt
Veins There is increased liability to varicose veins due to
- Progesterone (rela<ant effect on vessels)
- Pressure of the gravid uterus
- Increase in blood volume

o O 'd dyspnea in late pregnancy -+ pressure & hormonal effect

O 'd tidal volume + reserve volume decreases
a) O 'd minute respiratory volume
) progesterone effect )
d
o O minute oxygen uptake ) resp. alkalosis
o
o
lilo change...2 What aboutthe RRq

WhiteKnightLove
 -- --Reloxotion of sphincter +
Regurgitoiion * heqrtburn .

-Slight reduction in gostric

secrelion, ond diminished
gostric motility result in
slow emptying .+ More
efficient pulping of food
. .Moy olso couse nouseo,

- Reduced morility in smoll

intestine - lncreoses time
for obsorption.

Reduced motiliiy of
lorge intestine -- --
lncreoses tirne for
woler obsorption, .
but olso tends to
induce
constipot ion
/l\Cro*tt, of conceptus ond
,
uterus - lncreoses oppe-
tite qnd thirst. ln lote
pregnohcy pressure of the
uterus reduces copocity
for lorge meols +
frequent smoll snocks.

)':=- the ureters

The uretem ore soid io dilote greotly ond ogoin urine moy
stognole.

Reloxotion of blodder moy result in incomplete emptying ond

--'collection of residuol urine.
Both of these chonges tend to fovour the onset of urinory
infection.

WhiteKnightLove
 z
o
rt
lf The mouth
3
- Morning sickness a nausea & sometimes vomiting in early pregnancy g
- Changes in appetite + longing (pica) -+ desire to certain food !{
- Ptyalism a excessive salivation (hyperemia of the gums t hypertrophy) o
GI
2f Esophagus =
o
- Relaxation of cardiac sphincter ) leads to pyrosis =
o
- Delayed gastric emptying ) : heart-burn (P. etrea)

3f Stomach & lntestine

- Delayed emptying, decreased motility
- J acidity of stomach (hypochlorohydria)-+ regurgitation of alkaline chyle

4f Ltabitity to constipatlon & plles O d.t. effect of Pr & pressure of uterus

5f The liver & gdl bladder

- Changes in some liver enzymes esp alkaline phosphatase
- Tendency to cholestasis
- t'dglobulin + S*r albumin

> The kldneu

o lncreased size (by 1-1.5 cm)
o lncreased renal blood flow + increased GFR (50%)"
d( t creat. clearance -+ J serum creatinine (0.5 mgo/o), uric (3 mgo/o), BUN (8,Smgo/o)
0( I renalthreshold to glucose, amino acids & HzO soluble vitamins
> The urdsrs
o Enlarged, dilated & tortuous (d.t. progesterone & pressure at pelvic brim)
o More on right side (d,t. dextroflexion of uterus)
o Increased liability to pyelonephritis
> The bldder
o Hyperemia
o t frequency of micturition (1s trimester) & (last month d.t. engagement)
o Displacement upwards (SUI may be normal in late in pregnancy)

JIrry
o Mood changes (elevated or depressed) - (sleepy or insomnia)
o Relaxation of the pelvic joints, sometimes arthropathies
o Lurnbar Lordosis -+ to compensate for the enlarged uterus

WhiteKnightLove
CARBOHYDRATE METABOLISM

WhiteKnightLove
 z
o
) The pituitary rt
Increased size & vascularity (esp anterior lobe: 2-3 folds) 3
t prolactin - J rSn & LH, GH [other hormones are unaffected]
o
!
) The thyroid -
o
Slight enlargement (t fSn & chorionic thyrotropin)
GI
o =
o
t serum thvroxine (due to t tBG, free hormones are unchanoed)
f
t elr4n 25olo (due to pregnancy & not hyperthyroidism) o
> The parath5rroid
Sligtrt enlargement + t pmnrnoRMoNE to t serum Ca
but Cnlcrrouru also 1 .'. no chanoe in ionized Ca level

> The suprarenal gland

Little morphological changes
o
t aldosterone & renin (due to t CBG, free serum cortisol are unchanged)

l. Piggnentation......d.t.O placental & adrenal steroids, also E, may have MSH like activity
o Eso in nipple, areola, axilla, vulva
o Linea nigra (dark brown line between umbilicus & symphysis)
o Chloasma oravidarum (butterfly pigmentation on face)
2. Sfiiae ggavidarum......due to O corticosteroids or by mechanical stretching
o Pink lines due to rupture of elastic fibers or SC vessels of skin of abdomen
(common), breast, thighs, buttocks. Later on after delivery + striae albicans

3. Dimfcation of recti
4. Hlpercmia + vascularity of skin & m.m. (nasal congestion)
5. Sometimes + falling of hair, palmar erythema and spider naevi

> Body weight ? increases 12.5 kg on average

> Salt & water retention € due to increased aldosterone
> Protein metabolism e +ve nitrogen retention (1 kg increase during pregnancy)
> CHO metabolism ? pregnancy is potentially diabetogenic
o-+
> tipid metabolism a increased blood lipids & cholesterol central ftt deposition

> Vitamins O t"d fat soluble vitamins + O"o water soluble vitamins
> Minerals a J serum iron (Fe stores may be depleted if no Fe supplementation is given)
But t transferrin (total iron binding capacity)
> Immunoglobulins A increased levels of IgA and IgM

WhiteKnightLove
c%tes

WhiteKnightLove
 IA,;J'LEJ,LT;N
z
q
O Gastnointestina! 3
o_
) Mornlng slckness....
) Gingtvttis: hyperemic gums that may bleed with the use of a tooth brush !
) Ptyalism: excessive salivation d
@
) Heattburn: Treated by antacids, more frequent meals, avoidance of spices )
) Indigestlon: hypochlorhydria (regurgitation of alkali chyle into stomach) o
f
) Coastipation: tr fluid intake + eating whole meal bread [& not white breadl o
) Hemorrhoids: usually regress after delivery [but not completely]
O urinaru
) Frequency of micturition: d.t. pressure from the gravid uterus
) Incontinence: d.t. loss of the post urethra-vesical (PU$ angle
@ Muscuto-skeletal
) Baclache:
- Common in the last trimester
- Treatment: . Avoid wearing high-heeled shoes
. Exercises to strengthen the back muscles
> Leg cramps:
- Elearolytedisturbance
- Engorgement of lower limb veins
) Round ligament paia:
- Sharp groin pains d.t. spasm of the [igament associated with
sudden movements (esp the right side ---d.t. dextroposition)

@ Skin chanoes
) Strlae gravidarum
) Sweatlag & feeling the heat: (d,t. O peripheral circulation &VD)
> Vaginal discharge = leucorrhea: (d.t. f estrogen)

@ Nervous sustem
) Insomnia d.t. the large uterus, leg cramps & backache
) Carpal tunnel syadrome: d.t. edema -+ disappears 2 wks after delivery
> Placidity lcrlrnnessf & drowslness: d.t. O progesterone

@ Cardiovascular sumotoms
) Varicose velns: treated by :
- Patients should sit with their feet elevated whenever possible
- Nylon elastic stockings should be put in on the morning before
getting out of bed...........to be removed on sleeping
) Headaches, palpitations & fainting
) Physiological edema (below kaeef

WhiteKnightLove
 1. A urine pregnancy test will often be positive at
the time of the missed menstrual cycle.
2. Physiologic changes during pregnancy, mediated
by the placental hormones, affect every organ
system.
3. Cardiovascular changes include a decrease in sys-
temic vascular resistance and blood pressure and
a 5070 rise in total blood volume.
4. Elevation in serum progesterone levels is respon-
sible for smooth muscle relaxation in the vascular
system, Gl tract, and genitourinary system,
leading to many of the concomitant physiologic
changes.

0 o Menses
7 I
14 2 Conception
2'l 3
28 4 Pregnancy t€st poGitivo Empty uterus
[menses due]
5 G€stational sac OCG >2m0lq
6 Nausea Yolk sac,
Breast tEnderness Fetal heartbeet on trarsvaginal scan
Fetal pol6 4mm
7 Fetal pole lomm
8 Fetal hesrtb€at on transabdominal soan
F€tal pde 14mm
I Fotalpolo 22mm

WhiteKnightLove
Etsgraorts of pssgm,auey
z
Ihe I'I lrimesl I3
o_
> Sumotoms
. Amenontea (Nora sunr srct.r) E
d
- may have arnenorrhea due to other causes GI
- may have bleeding in early pregnancy =
o
- o Breast symptoms as heaviness, pain, enlargement, colostrum =
o
o ihrning sickness... ..Appetite changes.. . Frequency of micturition
o Some ladies may experience fatigability &, sleepiness,
while others may have irritability & insomnia
> Slons
. Brsnst dgns
o Gerrthl slgnr
- Uulva (soft & violet). .Jaque-Mier sign
- Uagina (soft, warm & violet)... ...Chadwick sign
- [eruix (enlarged, soft & violet)...Goodell sign
- Uterus -+ 't Enlarged & soft
't Change in shape
Palmer sign
Hegar sign (d.t. softening of isthmus)o fI
Two fingers between the ant. vaginal fornix & abdomen
behind the uterus can be approximated (between 6-12 wk)
. < 6 wks -+ uterus is not soft enough
.> 12 + the baby occupies the whole uterine cavity
> lnvestlmtlons
. Pmgnqncg tests
n
Immunological [biological are obsolete]
- Urine tests (conventional pregnancy tests) +Latex & ELISA
- Serum test: B-subunit (most sensitive) a RIA
. Ultrrsonogtqlhg
- Transvaginal U/S ?5 wks (white ring)
- Transabdominal tJlS +
7 wks
d
- Detection of cardiac activity 8 wks
- Doppler (Sonicaid) <a 10 wks
O Biochemical orrcgnancv means detection of +ve P-HCG before missed period
I The windotr qap
The gap (2 week) between... ...Biochemical pregnancy (3'd wk) &
TWS visuatization of pregnancy (5tr wk)

WhiteKnightLove
 r of Auscultotion
ot 24 weeks

A Plnrrd rfrdnropr.

Pinard's stethoscope uds inuented in France in 1816

by Rend-Thdopbile-Hyacinthe Laennec (17 81-1 826),
It consisted of a uooden tube and was mot,taural.
His deuice was similu to the common edr trumpet,.t
historical form of hearing aid; indaed, his inuettion
was abfiost indistittguishable in structure and
fmction from the tlurnpet, which was commonly
called a'microphone',

14
rrht rh. Ph.rd f ..,10.09..
weeks lNIRt lAt IAI.IOIIEIIENT
f

The fetus sinks ond

Top gently upvrords ond Thc fetus is disploced o gentle top is felt on
hold finger ogoinst ceNix upwor& the finger.

24 EXIfiNAL IAI."LCIITEAIEi.|T
weeks

One hond topo the

obdqnen ond sends The other irond lying
thc fetus ocroas on the ulerus per-
the uterine ceives lhe impulse.
cov ily .

WhiteKnightLove
 Ihe anil Irimesl z
o
rt
> Svmptoms 3
o Amenorrhea. ..Breast symptoms increase
g
o Quickening (1* perception of fetal movement)
!
o
- In PG + 18 - 20 weeks GI
- In MG -+ 16 - 18 weeks =
o
. Progressiveabdominal enlargement =
o
> Slons
. Brerst slgns
o Uterlne dgns
* Bmxton Hick's confactions
+
uterine sodfl6 may be head -+ soft blowing murmur
Synchronous to the maternal pulse (due to increased
blood flow through the dilated uterine arteries)
o Fstrl llgns
* Ballottement (due to movement of fetus within amniotic fluid)
- Intemal ballottement -+ between 16 - 28 weeks

.*dp;fl1;?*'r#x;3:ll--;J4weeks
+
Inspecfion or palpation of fetal movement
*Auscultafon of,.....fetal heart sounds by Pinard stethoscope (tS wko
)
r-r
......Umbilical souffid (funic souffld) --> Soft whistling sound
Syrchronous with the fetal heart sounds. It is due to flow of
blood in the umbilical vessels and is heard sometimes when a
loop of cord is in a close proximity to the anterior uterine wall

> lrvestigotions (as in 1s trimester) -+ less needed as diagnosis is usually easy

Sre sigos ol pregnamt Cs

- Ir.rspscnoN oF FETAT MoveprsNr
- Pru-penoN oF FETAr Moven,tsNr / Pnnrs
- AusculranoN oF Frrnr HsARr Souxos on UlasrlrcAr Soupp#
- UlrnnsoruocupHy on X-nRv ro MsuAlrze rue Frtus

DD of pregnanon carses of:

- Amenorrhea
- Symmetrical enlarged uterus
- Don't forget pseudocyesis

WhiteKnightLove
WhiteKnightLove
 z
o
* Objectives 3
o_
. To try to get a healthy mother & newborn !
o Estimation of gestational age & expected delivery date o
o Early detection & treatment of any diseases during pregnancy @
o Early detection of congenital fetal malformations
f
o
=
o
* Consists of
o History taking
o Physical examination
o Investigations + Routine & screening tests
Other investigations according to flndings
o Plan for a schedule for return visits
o Instruction & advice
. Reassurance
o Plan for delivery

Aim of ANC is to detect or suspect any conditions that may lead

matemal or fetal hazards i.e. to detect high-risk pregnancy D
. Pregnancv associated with inoeased risk
. Whether fmaternal or fetalJ
. Due to certain risk factors:

O Sorioeconomic
- Socioeconomic status
- Parental occupation
- Psychological e.g. excess anxiety -+ preterm labor
@ <Denograpfricfacton
- Matemal age (optimal age is between 20-30 yrs)
- Matemal education
@ *lef,uatfacton (fiseasQ

. PET . Anemia .DVT

. DM I . Renal disorders
. Heart disease . Hepatic . Respiratory
. Hyperemesis disorders disorders
gravidarum

WhiteKnightLove
GRAND MULTI PARITY

WhiteKnightLove
 z
o
r
> 9ersooal historv 3
9.
.lllme. ..tripleruuxe..... -u
q

o Age. ....lowest rate of MMR & PNMR is20-26

o
yrs. ct
a
o
Adolesccnt Dncqnonq, Prcon. in old oq3 (>35 yrs) a
o
.Nutritional deficiency (i .Nutritional def (consumption)
I ,Hyp.rt niive diiorders .FffN + DIvt I

.Dystocia (qmalt pe_Ms??) . Dy_stocia (oqteomqlqcic pefuis ??)

.Social & economic .Chromosomal ... Down syndrome

| + + Abortion, IUGR, PtL

o Jl+ttqlstgtu
.Pqrltg. ..... higherMMR&PNMRin.....
l. Grandmultipara P 5 deliveries) -+ liable to OOO
Pregnancv Labor
-Abortion, PTL, anemia .Uterine atony (more fibrous tissue)
.Malpresentation (lax abd. wall) .Obstructed labor -+ rupture uterus
.Placenta previa (accreta) .PPHge
.Chronic hypertension, DM

2. Elderly PG (> 35 yrs) -+ liable to OO@

| -1-- Labor
PTL
--pregnrlg
Abortion, .Prolonged labor (tr* maternal
.Chromosomal anomalies (Down) anxiety & abnormal ut. action)
.Hyperemesis gravidarum .Rigid perineum + episiotomy
.PEt + P.abruption, DM .Higher rate of CS

. Addr$! rP sooial conditions & environment

o 0ccuPdion a certainoccupations have certain risk e.g.

- Medical personnel -+ infectiors diseases, anesthetic gases
- Others -+ radiation (factories)

. SPealrl hqbtts
* Smoking o-+ abortion,IIJFD, ruGR, perinatal death, APHge, oligoamnios
* Alcohol o -+ abortion,IUFD, ruG& perinatal deat[ CFMF, menta] handicap
* Narcotics -+ fetal depression & addiction
* Pets -+ risk of toxoplasmosis

WhiteKnightLove
WhiteKnightLove
> llleostrual histonr
. LMP + important for dating
z
o
of pregnancy (EGA) & calculation of EDD
. Must know lf it is average, regular, if sure of dates or not, 3
o
if pregnant on period of amenorrhe4 or after COC -r,
o
(o
> 0bstetric historv f
o
f
M.rmbcr . Prolonged period of D infertility o
Yeor of birth . Rapid succqssion + liability to malnutrition

Ploce of birfh Previous uncomplicated home deliveries + reassuring

Arteportum period . Repeated hypertension -+ expect recurrence

. Previous DM -+ screen for DM
. Previous APHge or PRoM -+ rll0! |'eCUI

Durction of prq. Previous PTL -+ suspect maternalor uterine disease

Onset of delivery Spontaneous.,.... induced

rtiodc of delivcly Easy vaginal delivery -+ expect another

- lf previous complicated + plan for pssible CS
- Forceps or ventouse -+ suspect CPD
Cesarean section -+ why?
Postportum comp. PPHge

Boby . Alive, incubated, malformed, dead

. Male /female
. Weight
. Breast / bottle fed

hupenium Puerperalsepsis, DVT

> tDast historv

o Medical -+ DM: screen......Hyperlension: investigate..... DVT: prophylaxis
o Surgical-+ Previous operations
o Drugs -+ May affect pregnancy or fetus e.g. oral anticoag.
o Previous blood transfusion
o Presence of allergy to drugs

> cFamily historrr

- DM + screen
- Hypertension -+ investigate
- CFMF -+ screen
- Twins -+ suspect

WhiteKnightLove
 THE FIRST EXAMINATTON

Height ond
lnspection of
Weight
Teeth

Auscu ltot ion

of Heort ond
Lungn

Exominotion Blood Somple

of Breosts for Hb Grorp:
ond Nipples Serologicol
Test for
Syphilis

Exominotion
of Urine Exo-r inot ion
of,Abdornen:
Assessment of
Exominotion
Size of Uterus
of Pelvis

lnspection of
Exominotion
Vogino ond
of Legs
Cervix

Nikolai Sergeiuicb Korotkou (187{-.1920) uas

WhiteKnightLove
 z
o
rt
3
> Gereral o_
!rt
o Decubitus: dyspnea o
o Height if less thzut 150 cm -+ be aware of CPD ct
a
o Weight: if obese beware of D.M., hypertension, macrosomia & dystocia o
=
o
Fetus 3500
Maternal fat 3500
-Blood 1s00
-Extravascular fluid 1s00
Uterus 1000
Amniotic fluid 1000
- Placenta s00
- Breasts 500
Total 12.5- f3 ks
* 3 uitd data
o B.P. .for hypertensive > 140190... ..how??
o Pulse. . .. abnormal pulse, esp. in heart disease
. .

o Temperature...esp. in infection or PROM

* 3 colors
o Jaundice ....pregnancy zrssociated or induced
o Cyanosis
o Pallor ... ..anemia, bleeding with pregnancy

* 3 ned(
o Thyroid
o Vessels... ..engorged normally 1t blood volume)
o LNs

* 5 chest
o Chest ... ... ..chest infection, PVC
o Heart ... ... ..what are sure signs of pregnancy?
o Breast ... ... .normal changes in pregnancy, galactorrhea
* 5 others
o Gait (look for limping -+ CPD)
o Back
. Lower limb for varicosities, DVT and edema.

WhiteKnightLove
 weeks

%tr\
,/ /,-32

This exominotion must be mode syslemoticolly.

Remember thot the following tissue loyers moy
interpose between your fingers ond the fetol heod.

-. Fetol
Skin skul I
ond fqi----
..- Uterine
woll
Porietol .-'
Peritoneum
(sensit ivo) Bloddcr (pcrhopo full)

'/ / polientrs feet ond gently

fhe heod should be pol-
The honds polpote the poted, ond it should be
contours of the uterus, noted whether it is mo-
identifying the bock bile or fixed in the pel-
ond the limbs. vic brim.
ABDOMINAL PALPATTON
pushes two fingers info
fhe pelvis. This is the
best method of polpoting
the fetol heqd ond deter-
mining whether iiis fixed
or mobile.

WhiteKnightLove
> $bdominal
z
o
3
o
E
Shape -r
r--'_'_"-'-L"'-'-'__'-
ous cont.pelvis tation --+ linea_nigra
_-__-____r
----------l---_'-_----_. _i o
l-s"-qd-eg--r-e
"
(o
- -l Umbilicus,;ifiies
masculine
-o )
o
:- fem[pige
. S-gp1g;pubiq.trgif /
:,
o
2. Palpation (4 Leopold's maneuver)
* Fundol level by hand or in cm above S.pubis

* Fundol grip WEE(S LEVE

- Cephalic or breech 12 _ _ __ _$yg,p_l,y_r_L:. pg-b-ig-
- Empty .. .. . ffansverse lie 16

* Umbilicol grip 20
- For lie 24120-221 Umbilicus
28
- For back & lirnbs
32
- For amount of liquor
36
- Expected fetal weight
- For any local uterine swelling
* I* & 2d Palvic Arip (Poulick's grip)
- To determine presenting part (head, breech, empty in tr. lie)
- To determine head engagement
- To determine degree of flexion of the head e.g. extended in face

3. Auscultation
--
I frc con be
Sure sign of pregnancy
ugd for t__ _ D iiiil$___
ns!|
l
,ll-o:tn-gll-o$:)_.bgtwe--e-!gmp-ilicuqft
Fetal life / distress .P. -+ at ASIS
Twins....funoux sign -+ MA at < umbilicus, MP at flank
Progress in labor .,.-B1_"_g-qt,.-r_.c_gllrplgf€-_>_.HIpF_:fi 9t!<umb_
Position & presentation . Transverse lie at one side

> %ocal

Done ln early pregnancy for ln late pregnancy for

- Diagnosis (Hegar's sign, Ballottement) - To diagnosis labor
only
- In some complications e.g. ectopic preg - To assess pelvisfor CPD
at
- Any associated pathology e.g. prolapse - Any associated Pathology

: f_q BkS cg_.ui.g:_u-qg-it ql -s_I_nggl

WhiteKnightLove
 Ultrosonic Recording Uterine octivity recorder
FHR recorder
(ultrosonic ,,(tocogroph)
tronsducer)

Fetol
monitor

f"'-*'i' cavs?s of *t*enqa1ew.ey* of head iwP.e. T

Fetol lAof,ernol,
- Large head, Hydrocephalus - Confracted pelvis
- Malposition or malpresentation - Tunor in pelvis
- Multiple pregnancy - Placenta previa
- Short cord - Full bladder or rectum
- Polvh - No cause mav be found

Pelv ic
brim \

WhiteKnightLove
 z
o
> Routine:
o Blood for: " 3
g
- Blood group & hemoglobin %
!
- Rh (lf Rh -ve see husband,. .. .. . ..if multipara de_lermine if sensitized) o
- Blood sugar at 24 -28 weeks cl
a
. Hepatitis B surface antigen o
. Serology for syphilis )
o
. Antibody to rubella
o Urine fon Glucose.. ...Protein. , ... .Bacteriuria (not CoS ")
> Specffic:
o Accodingto history and examination
o ldeally-+ U/S t FWB tests in high risk pregnancy

- Every 4 weeks till 28 wks

- Every 2 weeks till36 wks
' Every 1 week till delivery
o If any abnormali[z present -+ more frequent visits
o At each return visit
* Hi*orv: Ask about any symptoms esp. fetal kicla )
Dauerorc symptorns'
....1n early pregnancy
- Bleeding, Pain, discharge (watery or infected)
- Fever, Dysuria
- Persistent vomiting
....1n late pregnancy (as above +)
- Symptoms of PET (bluning of vision, epigastric pain)
- symptoms of DM (polyuria, polydypsia, pruritis)
- Change in intensity or decreased fetal kick

* €rominoEion
- General a weight / blood pressure I edema
- Abd + fundal height, iiquor amount, presentation, position, FHS
- PV olate or in presence of abnormality (not essential).
* lnvestigotions
- Routine a.TJrine in 3'd trimester for glucose, protein
.11b% is repeated at 34 weeks
- Speciflc a
according to certain situations

: ;,fi[i:ffiil,1i"il1],?;,lTi ffii',:,ffi #?,T:,,,

WhiteKnightLove
 Dlehry edvlcc ln prrtnrncy

Dietary advice in pregnancy.

Soft cheees Umastafized in[k and lt6 products

may contaan lHeria Thoe€ mado lrom
pastourlz€d rdt< are sale
Raw eggs Muot be arcided 6 thel€ i8 a rbk o,
saknone[a 0ncludhg pudi]Es)
Meat or pAt6 Undercooked met may trammit
toxoplmma or rady llsterla
Fruit ThlB shoukC alwa)6 be wehed bebre
oating aB it may bo @ntarnlmted vdur
salmonelh,loxoplasma or one of s€t €ral
inteotlnal para8itos

WhiteKnightLove
 zo
) Nutrition
o Caloric requiremefi-+2200 -2500 K.cal I 3
day
o Daily increase of 300 K.cal (esp. in late pregnancy)
g
!
o Meals should be well balanced & discourage overeating o
o If diet is adequate -) no need for supplementation (except....) @
a
1. Putstns o
f
Requirement 1.5 gKgd -+ addition of I kg protein to body weight o
Best if from animal sources (esp. milk)
2. Cqrbohgdrqtes + to complete the caloric requirement
3. tqB -+ to complete caloric requirement
4. Vfqmlm
A -+ 5.000 lU /d &_cgrqrs_e9iq_ft!!_El_?.]_qq_qq_&_
D-+ 400 lU /d Vjl L:l_Bttse_4le!4[s9-
Br + 1 mg /d Folic acid-+ 0.8 - 1 mg /d "
Bz -+ 1.5 ms /d _lti."gfini9_eq1d-_;,5:_!rg_E-.-___".
5. Mlnsrqls
o
- Cqlcium: I g ld (2 cups of milk),,..supplementation is not essential
E
- fron: 30-60 mg 1d........the only supplementation required I + folic acid
- Solt: no need for either supplementation or restriction (except in HTN)
) Rest
o At least 8 hrs at rught & l-2 hrs in the afternoon, better on her left side
o Helps to increase placental flow
) Exercise -+ allowed in moderation esp walking in fresh air & swimming
) Emplovment + allowed until delivery turless plrysically demanding
) Travel
o Allowed, but if > 6 lus... walking I 2ltrs to avoid DVT
o Better avoided in last month
> clothiae -+ loose unrestrictive, better no high heel
> Bathinq -+ allowed & encouraged esp tub baths (less liable to accidents)
) Douchins -+ high vaginal dotrching is condemned " . .. increases infection
) Sexual activity --> allowed unless there rs:
o Hemorrhage, risk of abortion or PTL, infections, ROM
) Coffee & tea + no harm (but excess -+ irritability g O fe absorption)
) Smokins -+ discouraged
) Alcohol -+ discouraged
) Care of teeth -+ as usual
) Medications -+ should consult the obstetrician before receiving drugs.

WhiteKnightLove
llomurunot of tprplryrlofirndrl hr[ht

WhiteKnightLove
Olstelric diagnosis z
> Name, Age, _,
Pregnant at .... wks
Para _+ o
> Presentation (cephalic, breech), not in labor 3
> complication (obstetric...... medical) o_
!
IEOO o
Qa[cutation of (o
f
> Histonr o
1. Menstrual delivery interval: 'calculated.from the l" doy oJ'LMP' =
o
- 280 days. .. ..or... .40 weeks
- l0 lunar months... or... .9 calendar m + 7 days
2. Naegel's rule
o'but on 3 conditions'
- 1't day of LMP + 7 days + 9 months or
- 1't day of LMP + 7 days - 3 months
3. Fertilization delivery interral
- Coital delivery time e.g. in IVF or rape (timed event)
- The duration is266 d or 38 wk or 9 m-7 d
4. Quickening oPG (18-20 wk)... . .MG (16-18 wk)
>Exannination
1. Fundal level O @

Causes of FL > amenorrhea ___-C-*_r-elgf EL_S_e-llg.r,_q_nh_er._

1- Miscalculation 1- Miscalculation
2- Pregnant on period ofhge 2-Pregnant on period of amen.
3- Multiple pregnancy 3- Missed abortion
4- Macrosomia 4- IUGR
5- Polyhydramnios 5- Oligohydramnios
6- Concealed accidental hge 6- IUFD
7- Tumors: fibroids, V.mole 7- Transverse lie
2. Symphpeo-fundal height. . . ..'McDonal d rul e'
- Wks of pregnancy: height of fundus (in cm) X8l7
3. Gravidogram
- Progressive t in FL above SP (1cm /wk after 20 wk)
4. Abdominal girth
- Circumference around the umbilicus in inches: wks of preg
5. Pinard stethoscope detects FHS at 18-20 wks

> Investirration
1 . Ultrasound. . .. . .esp the 1't trimester (the more accurate)
2. Doppter ..10 wks

WhiteKnightLove
c%tes

WhiteKnightLove
 -14
.J -aa
.J .J
-J -a

Abortion
Ectopic
Vesiculor mole

WhiteKnightLove
WhiteKnightLove
O0stattla AauonAaga

Early pregtaocy 9ost 9. b€e

llrlnts - Atonic
- Abortion - Local gynecolog. - Placenta . Fetal:vasa previa - Traumatic
- Ectopic conditions previa . Rupture uterus - Retained pl.
- Vesicular - Harfnan's sign - Abruptio . Excessive show - Dtc
mo_le- i 1Dgc_iduat ltge plac-en"ta i , Mafginplpipus bl - Acute inversion

g
o
Deflnition'o t interrupt i on of pregnancy befo re
erminat ion
o
t

period of fetal viability (gestational age at which fetusis

e
f
(o
capable of extra-uterine existence)
Le. (20 weeks 500 :
gm)// in developed counffies f,
or (28 weelrs -- 1.000 gm) in developing countries
o
o
=
!
TVpes o
Spontaneous Jnducp/
GI
O Threatened a
o
I
O missed *e 0
medical indication =
septic L+
o
Therapeutic
@ inevitable
t+. I complete
@ non-medical indication
. @ incomplete L+ . Elective (votuntary)
. O cervical
. Criminal
@ If recurrent > 3 times I Habitual

O-----------Spontaneous abortion------------O
lncldanca o
o 15-20 yoo ... .mostly in the I't trimester... ..esp. in the 3d month
(due to some O in 'P' from C.L., while placenta
still not fully developed yet; Ehe ulndoul gop)
o True incidence ma)) be much more (50-80%) due to: e
- Subclinical abortion (very early < patient recognition)
- Notification is not done in all cases (esp illegal)
o Incidence increases with "
- Increuse in maternal & paternal age
- Previous abortions or stillbirth or CFMF

WhiteKnightLove
 lntrauterine gestational scan containing a 6 mm
fetal pole with a yolk sac. I , ,, . ., ,ri) I(,1,)l !1,,r,1 ,rr rrv,Ly 9,r
lr,rlr\,irllirt.ll\(,lr) \i,j , ,( ,LrLr rl,,ri,,,rrirr,r ti|,1(i)|\i\l(.trtj,!,illl
'rir,r ll rr, rl .l

An intrauterine 22 mm fetal pole, consistent with

9weeks' gestation, I It.rl lr,.rrr.r tr\^r\. ..r,.,r.r.1

An empty gestational sac at 8 weeks,gestation.

llti:;trcr;n,rrtc1,r,rs,ltJt)('n)l)t)()r)i( \()rr(,ll)li\\rr.lcrlrlLoas.r
rrl, i,1 rr irt,trri, o,,

WhiteKnightLove
€tiology OOO

A] Fetal (CFMF) ....r..........'......'...o..r.....'r'.r.....'... .........|t[!foltne/ trU!

- The conrmonest cause (5 t}o )" of I't trime c abortion
o
- May be -+ trisomy (5Oo/o),polyploidy (25o/ol, monosomy x (15%)
- gilrgfrkd auunt, (anembryonic sac) is a type of CFMF in which
tal tissue is replaced by homogenous structureless sac

B] !!g!4g!.... ,.......... ....r,................,..............m*grqtgd fottrs

t. as hype nsion or chr. renal disease
E
2. €ndptual (25o/o) o
- | progesterone -+ C. Luteum or placental insufficiency o
g
- | androgens -+ PCO :,
GI
- Other hormonal dist. -+ DM, hypo- or hyper-thyroidism
f
e. Jnlururu (sroRcH) o
...Any organism causing high fever e.g. typhoid fever... o
- Bacteria -+ Syphilis, mycoplasm4 chlamydia,listeria =
- Viruses -+ acute viral infection, rubella, CMV !
- Protozoa -+ toxoplasma?!, malaria o
ct
+. Jmrunohgi.al =
o
- Autoimmune -) SLE, APS
=
o
- Alloimmune -+ Rh isoimmunization
s. D,ug (cytotoxics) or efremirala(heavy metals) or fradiation(>5 rad)
6.9,suma+ direct/surgical (CL removal by mistake in appendectomy)

C] Local ...................................,.. .,...,.........,..........................ffeth fttu!

l. eerurirt,,+ Patulous internal os
2.'l,lle,u.o,o
- Congenital malformation: septurn, hypoplasia
- Small @vity: submucous fibroid or Asherman's $
- Limited distension: fixed RVF
- Overdistension: acute polyhdramnios
Pothogonosls
> l"' tmmester
o Triad of tD amanorvhaa ^a @ bteedtng ^'> I pain
o Usually bleeding occurs into the decidua basalis (chorio-
decidual hge) -+ uterine irritation -+ colic -+ expulsion of
the pregnancy sac (aither intoct or os frogmanted ports)

> 2"d kimestedc abortlorl

... ..amenorrhea -+ bleeding + pain , or
o Sometimes... ... .., amenorrhea + ROM -+ pain (contractions)

WhiteKnightLove
Threotened
oborlion

Bleeding is slight, not retro-

plocentol , ond cervix is closed.
Pregnoncy is likely to continue.

lnevitoble
obortion

WhiteKnightLove
Deflnltlon ^a attempt of the uterus to expel the fetus
leadine topartial separation of the fertilizedovum
ttnth slight haemorrhage into the chorio-deciduat space

CllnicolPlchrrc
o Sgmptoma - Amenorrhea with symptoms of early pregnancy
- Bleeding (slight: spotting)
- Pain +/- (mild lower abdominal colicky pain) g
o Sigru - Signs of early pregnancy o
- Uterus -+ coresponds to the period of amenorrhea o
- Cervix + closed
e
a
GT
lnrrestigotlors 5
.F,rdlfgnch [doernrtne Hrl[hl o
o
- u/s,+ TV-US (5 wks)... ... .TA-US (7 wks)... . ...Sonicaid (10 wks)
=
- FHCC'+doubled every 2 days !
o Fordlol@ e.g. C.L. insufficiency, DM o
(o
Fote ,.+ - Continues pregnancy -> 70 - 80% i.e. rnRr.trsNpn abortion =
o
- Bleeding increases -+ INrvltlsrp abortion =
o
- Fetus dies but retained -+ MIssBo abortion
- Infection occurs -+ Srpuc abortion

Treotmont llConservrtlye
l. Rest - Physical -+ rest in bed till bleeding stops
- Sexual -+ no sexual intercourse
- Mental + may give sedatives as valium 5-10 mg/day
2. Antispasnodics e. g. antiprostaglandins
3. Progesterone 4av.v. widely used
\ Howevet............Benefit is only proven if there is well documented CLI
.Masking effect if missed abortion or if there are CFMF
.Virilization of female fetus (.'. natural forms are used)
4. Bzslmpathomimeticsas ritodrine (more effective in2"d trimester)
5. Iron & vitamins
6. Anti-D in Rh-ve
2l Termhma ff
> Turned inevitable
- Dilatation / effacement of the cervix progressively
- Rupture of the membrane, partial protrusion of products of conception
> Turned into septic, missed

WhiteKnightLove

l.
Hoemorrhoge occurs in the deciduo
bosolis leoding to loco I necrosis ond
inf lommotion.
COMPLETE
Expulsion complete. The deciduo is
shed during the next few doys in the
lochiol flow.
2.
The ovum, portly or wholly de-
ioched, octs os o foreign body ond
initiotes uterine controctions. The
cervix begins to d i lote.
INCOMPLETE
WhiteKnightLove
> Definiuon complete separation ofthe fertilized ovum
withprogressive cervical dilatation & fetal expulsion
> Symptoms
-
Arnenorrhea + ryrsploms of early Fegnancy
- Bleeding -+ moderate to severe
- Pain -+ marked LowER abdominal CoLICKY pain (uterine contractions)
o
with BACKACIIE (cervical dilatation) = sacral pain
> Signs P
- General + Pallor / shock (according to amount of bleeding) o
o
- Abdominal -+ uterus corresponds to period of amenorrhea g
- Local + oPENEp cx (products of conception may be protruding) =
GI
> Treatment
f
l. Re sus citati on 1f bleedtng is excessive o
2.Eyacuation: ls trimesteric -+ evacuation by suction or curettage o
!
trimesteric -+ oxytocin or prostaglandins
2"d
3. Followed by .Ecbolics -> helps complete evacuation of remnants !-l
.Antibiotics -+ reduces possibility of postabortive inf o
ct
4. Anti-D if Rh*ve a
o
=
o

> Definition oall products of conception have been expelled

> Symptoms
- Amenorrhea + symptoms of early pregrumcy
- Bleeding -+ moderate or severe
- Pain -+ marked lower abdominal colicky pain with backache
foltowed hy ryulsian of the conceptus 4
+ bleeding & pain
> Signs - General -+ according to amount ofbleeding
- Uterus (bimanual) -+ smaller than period of amenorrhea
- Cervix (PA/) -+ closed
> Investigation U/S ^a empty uterus
> Treatment 1. Ecbolics +Antibiotics
2. However, some do + DcC (to ensure complete evacuation & J io!

> Symptoms. Signs

As inevitable abortion but part of the products of conception have been
expelled -+ therefore the uterus is < period of amenorrhea (confirmby US)
> Treatment -+ as for inevitable abortion

WhiteKnightLove
 /ll&scd dordoa TrE drfrn of tlcpqnoncy b l8
rGGb hrt fic ucrr3 h6 crnrj! D;,ltrn ila ee
flld D af o
l,h*c* 3etaba l,lc trn atl. d&apa b flm.

lf retoined for long enough, the geslotion moy end up os o

CARNEOUS MOLE OT MACERATED FETUS

\

WhiteKnightLove
 Ceruical aboftion I Ceruical preg. (v.rare)
Dd type of inevitable abortion type of ectopic pregnancy
-+ arest of gestational sac + implantation in the
in the cervical canal endocervical canal
SgmDt pain (severe) > bleedilg bleeding > pain
:TE$_.na-g'jp-err.o--
Dilatation & curettage Hysterectomy OR conservative
P
o
o
_o
(Catwaw t+rrk,..f,esht1 r,role...bhobq mole) =
(O

> Definition retention of dead / non-viable products of conception within uterus ='
o
o
> Symptoms =
I- Amenorrhea O symptoms of pregnancy disappear. 't
2- Bleedinge rarely mild dark brown (prune juice) o
(o
. Milk secretion ' (d,t. + E). . .it r:rry occur normally in preg. a
o
. Normally E2 blocks action of prolactin on breasts in preg. 5
3- Pain ?usually absent +absent fetal movements
o
> Sigrn
* No general signs of pregnancy
'k lJterus + less than period of amenorrhea
* Cervix -+ closed firm + dark brorvn discharge '
> Investigations
l- Ultrasound -+ collapsed pregnancy sac * no fetal pulsatrons
2- frHCG &repeat in two days for doubling
3- Fibrinogen level (very important) as there may be liberation
of thromboplastin substances from the retained dead tissue
which may lead to DIC slowly. In these cases fibrinogen
level usually decreases by 50 mg/ week. it is done
weekly to avoid reaching the dangerous level (100 mg/dl)

> Complications
o Infection -+ septic abortion
o DIC (hypofibrinogenemia) -+ after 4-6 weeks
> Treatment
- a
If fibrinogen is normal TOP (acc. to gestational age) + antibiotics
- If fibrinogen is &a+ elevate 1* (fibrinogeq FFP, fresh blood) then TOP

WhiteKnightLove
/;

]r.:ere*d}r$
)-^
r

WhiteKnightLove
Definition superimposed infection on any type of abortion (esp. criminal)

Ogonlsns
- Gram +ue -+ Staph, Strept. esp Group B (GBS)
- Gram -ue + E.coli, Pseudomonas
-Anaerobic -+ anaerobic Strept, Bacteroides, clostridium (previously)
> Sures-
- Exogenous.. . .
... ... .instruments, sanitary pads g
- Endogenous. .. o
. .. ..organisms present in female genital ffact o
- Hematogenous (rafe)......from a septic focus e.g. appendicitis g
=
(o
Cllnlco! PlcUre f
o
Sumatnm^o o
. Symptoms of abortion (amenonhea....bleeding. pain)
. Followed by symptoms of infection E
- Fever, headache, anorexia, malaise, rigors o
- - Continuozs lower abdominal pain GI
a
- Offensive discharge o
a
. There may be history of atrial to induce abortion (by untained personnel) o
Siaru
+
1- General + Toxic, pale, tachycwdia,tachypnea, htgh fever
2- Abdominal
- Decreased abdominal movement with respiration
- Lower abdominal tenderness & rigidity
- Tender uterus may be fe
3- Vaginal
- Bleeding & ffinsive discharge
- Uterus is tender rarely crepitations if infected with gos
form in g or gani sm s (phy s ometr a)
- Swelling in Douglas pouch + pelvic abscess

lnvestigotions
l. FOR 0UGil0StS 0E -> dead fetus or incomplete abortion
2. rcR EIIOTOGY
- Blood+ CULTURE. TLC, ESR, CRP
- Endocervical or high vaginat swabs
- X-ray -+ physometra (gas in uterus)
3 mR O[lPtl(AIl0i6 -+ renal function test & coagulation profile

WhiteKnightLove
 Exlension of
infection in
Peritonitis

Pelvic
collectiJn
of pus

WhiteKnightLove
Compllcotions O
local Geneml Orqan affection
l- Endometritis 1- Septic 1- Septic shock, ARDS
2- Myometritis thrombophlebitis 2-Actfie haennlysis
3- Salpingitis 2- Systemic (esp strept & clostr) * liver
4- Salpingoophritis pyaemia affection + jaundice
5- Parametitis 3- Generalized 3.DIC
6- Pelvic peritonitis peritonitis 4-Renal failure due to
7- Pelvic abscess the above factors.
g
Treotment o
o
l) Elevation of the eeneral condition g
+ Adlblotles (ln comblnqllon ln hlgh dosesf
)
GI
- Grsm +ve -+ penicillin G or cephalosporins a
- Gram-ve -+ aminoglycoside as gentamycin or tobrarnycin o
- Anaerobic -+ metronidazole or clindamycin o
- Ingas gangrene -+ specific antiserurn
!rt
+ Clms obseryqtlon ln the ICU (in compllcoted cesesf
o
- Vital data -+ blood pressure, pulse, temperature GI
- CVP esp. in renal affection -+ . Urine volume =
o
. Repeated renal function tests
f
o
- Blood transfusion (better fresh) and intravenous fluids
- Hydrocortisone or dexamethasone -+
t
. tissue perfusion, stabilize lysosomes & endothelium
. t gp (+ve inotropic, restore sensitivity to catecholamines)

2) Evacuation of contents
I't trimester ,+ suction evacuation (better than curettage. . . why?)
- To avoid spread of infection by opening sinuses
- To avoid perforation of the soft uterus
ld trimester '+ 'k induction of abortion by oxytocin or PG
* if failed + hysterotomy
* in severe cases -+ hysterectomy -in toto- (esp. if old,
completed her family, gas forming organisms)
3) Treat complications
1- Pelvic abscess + posterior colpotomy
2- Septic thrombophlebitis + heparin
3- Generalized peritonitis -+ drainage
4. DIC + fibrinogen, FFP, fresh blood
5- Circulatory collapse + vaso-pressors & sympathomimetic drugs
6- Renal failure + dialysis
7. RDS + assisted ventilation

WhiteKnightLove
 (a) Con1cnltal m alt orm at)ons
. Miillcrian fuslon abnormali1ies

V^*,"*Y,,**
. Abnonnalftbe ducb in ubro DE9 a<pa'et
(d k4utrcdlceiono

.. ?ata/,ftal chromo',/nal ahlr,:n,/'altbo

Reciglolc,alvanolrc*lan

1.8-*f.fl l.t--l (e-*d

Robatranbnfuobr
ffi"ffi***
o fulaalpha*dolclancy
. mctabolb dloordaa (tlryrdd., dlabctao)

WhiteKnightLove
Dafinltlon
Three or more successive spontaneous abortions (some say two)
(If not successive it is called repeated abortions)

lncldence
tr PG -+ lloh,thenpercentage depends upon previous abortions:
D Once -+ 20o/o g
tr Twice -+260/o(2-3 % of community) o
tr Thrice -+32Yo(< l% of commturity)o o
_o
=
GI
€ttology O.... ..5O% of coses ore ldlopothtc o ........O f
o
o
rt
O Loeal causes
!
-t
o Account to 30Yo" of 2od trimesteric abortions o
GI
o Most of them is not diagnosed before multiple pregnancy losses a
o
have occurred (because they are ...syrnptomatic) 5
o
llPatulous internal os h
2l CMF of uterus -+ septote (?5%) or bicornuste (30%)
3l Uterine hypoplasia -+ obortion in oscending monner
4l Submucous fibroid
5l Fixed RVF -+ oborfion usuolly ot 14-16 weeks
6f Congenital Asherman syndrome -+ intrquterine synechioe

O Generql ceuses
1-Endocrinal ,+ LPD.. . ., PCO... . .. .DM. .. ... .Thyroid
2- lmmunological ,+
'k .f,utoimmune + APS ,/,/r/ , SLE
* Illoim,rrrune -) . RH incompatibility

3-rhrombophiria * r,yp...ffifii:'h*t i}iltrcaS or Ar:

factor V Leiden J, hyper-homocysteinemia PtnZ {
4 Infections ,r| e.g. toxoplasma (recently not believed to be a cause)

O Fetql ([eneticl: 4-10oh" lstructural anomalies)

'k Translocation, inversion
'k Mosaicism, Celetion

WhiteKnightLove
 >Personal
- t 4t -+ chromosornal anomalies, DM hypertension
- + rural areas (Bfirrrziasis), slumareas (toxoplasmosis)
Resifunce
- Occupation + workers in heavy melal or radiation factories
>Complaint abortion >3 (2) times
o
c >HPI
o - Sgntptons of abonion + amenorrhea bleeding,pain
C
CD - Synptoms of complicotion + fever, DIC
o
o- >Past
.> - Medical +hypertensioq DItd, thyroid,hextdisease, ...
o - Surgery + on cervix:
o
.s >Farnilv
o, - Diseoses + hypertension, DM ... .
.E
t,o >Menstnral
- - Premenstrual
o spotting + LPD
o - Menorrhagia + fibroid
- Hypomenorrhea + hypoplastic utens, Ashernran S
>Obstetric

- Order + Ascending.....
Descending......
- Character of obortus + - Fresh.....
--tvracenteui'..:..

- Special C/P + inPIO ainlsss, smooth, rryid,eas),)

O Exarnination

>General -+ medical di e

>Irocal -+

. RVF
- Bicomurate (2 bodies)
o Cervix'. tear (PIO)

WhiteKnightLove
 A/'lonogement

Cause !nvestigation Treatment

....Pqfulous os {/
...Septate uterus If pregnant \ .....Metroplasty (only if there are
- Ultrasound repeated failures of vaginal
- better transvaginal cerclage) as it
leads to
extensive adhesions <e

....Uterine hgpoplasfa o Ifnot pregnant \ ... ..Cyclic estrogen & progest. g

...Subrnueous fibmid - HSG .....Myomectomy o
- Hysteroscope o
....Fixed RVF ... .Venfro-suspension (not fixation) e
J
(o
l- Endoerinel
='
O . J progesterone .....Progesterone (100 mg 1x2) o
LPD,/ o
O PCO . ttu&androgens ... ..Induction of ovulation
NDM o GTT .....Insulin !
o Thvroid o Tr,+TSH .....L- thyroxine o
(o
2- Irnrnunolo$cal =
o
" APS,//
o PTT, anti-Cl-, LA .....Iow dose aspirin + heparin a
t ... ..steroids
o
O
SLE CI&4,ANA
oRH incompat. o Rh titre ... ..according to titre
o HLA sharins o HLA typine ... ..immunotherapy: blocking abds

3- Thmrnbophilia o Screen for protein .....Low molecular weight

CaS orATr heparin -+ anticoagulation

4- lnfeetions o Serum titres (rising .....Specifltc ttt acc to CeS

IgM) esp. STORCH
o Cervical & endomet.
tissue cultures

.....&netie fecfors o Family history .....Counseling

o Karyotyping of both ... ..Donor gametes (unethical)
parents (or abortus)

It:t:t:r lf no cause is found (very common >50%)

- Reassurance, more periods of rest, avoid exhausting trips
- Good diet, vitamins & iron, stop smoking & alcohol
- Empirical drugs a
, Folic acid (3 months < &,> preg. -) J neurat tube defects)
. Progesterone, low dose aspirin, heparin

WhiteKnightLove
WhiteKnightLove
Potulous internol os h
> Efiototg o
o eongenital
- Increased muscle tissue in cervix > 1,0y,
- Associated with other uterine malformations as septate,
bicornuate uterus, hypoplastic uterus
- DES (diethyl-stilbesterol) exposure in utero
o OAircd. E
. t*-t"r"o?:tfrt:ff:ffiuse o
o
before tutl cervicat dilatation cL
- Breech extraction before full cervical dilatation 5'
GI
- Manual dilatation of the cervix 5
"'"i or too rapidrv
o
o
rt
#'*'ftirHlTjk ffi'ff'"'' !-l
Cone biopsy ofthe cervix
o
GI
> clnhll Dletuie J
. o
This condition usually leads to classic picture of =
- Painless effacement & dilatation ofthe cervix o
- Uterine conftactions are late & not very painful
- PROM followed by rapid delivery of a fresh abortus
with minimal disconrfort
. The abortion or premature labor usually occurs in descending
fashion i.e. at 7 months -+ 6 months -> 4 months, etc.

> lnvctl[rtlonc
1l If pregnant
- Serial U/S examination (better done transvaginally)
- to determine length (2.5-3 cm) & width (1 cm) of internal os
2l If not pregnant
- HSG -+ funneling (loss of uterine waist)
- Abihty to pass Hegar dilator No 8 or hysteroscope No 8
with no resistance & little pain I
- Pediatric Foley catheter with I ml inflated balloon can be
pulled through the os without resistance X

> Trertmerrt
1l If pregnant <? cerc/age
2l rf not pregnant o trachelurh@b @tp after cervical tears)

WhiteKnightLove
 c t6 ucCq@) h@nrpoienfroa ,6 xGGk$

Vithal Shircdkar (1899-1971) was an obstetrician

and gynaecologist from Goa who proposed a pru,se-
string suture of fascia lata arawntl an incompetent
ceruical os to preuent secand-trimester loss.
lan McDonald (1922-L990), t'rom Aus*alia,
simplified the Shirodkar operation witb the ase of a
silk pwse-sting suture around tbe ceruix,

.flvoid At, g delod

, Ends rt +"p" ore &.fi
lrnq , hongtnS h-pcl.lip o[ er

lnternal og

fRANSYAGINAL

TRAN9AEDOMINAL UtnroEaaral
llgaianr

WhiteKnightLove
Cercloge
> TuDes
l. ffitrs -+TOo/o success
with purse string suture (Nylon or Mersilene)
. 4 bites
. Taken around the highest portion of the portio-vaginalis.,..why?

2 lt[ffi truilrl -> 70o/o success

. The bladder is dissected upwards
. Thus sutures could be taken at level of internal os

t g
o
. Indications -+ repeated failed vaginal cerclage or short / absent cervix o
. Delivered by -+ CS (permanent cerclage)
g
. If failed < 28 wks -+ hysterotomy must be done (a great disadvantage) =
GI
-t a
lndication e PIO, uterine malformation (septate), tiplets o
lnsertion cl2-l4weeks o
-
Portoperatiue a anti-PG, progesterone, antibiotics
Removal r? 2 weeks < EDD (ev37 wks) !
o
(o
> Complhrfions
- Injuryto bladder =
o
)
- Injury to membrane + ROM -+ tape must be removed o
- Infection + tape must be removed & terminate
- Abortion orPTL
Antiphospholipid syndrome
> Dsfinltlon . autoimmune dis. forming antibodies agarnst phospholipid proteins
. it may be lry (alone) or 2ry (associated with CT disorders: SLE)
> Dlrgnolod bu OO
oo
O Recurrent
- Thrombosis -+ arterial & venous
- Fetal loss -+ . > 3 consecutive miscarriages (< l0 wks)
. > 1 fetal death (> l0 wks)
.>
PTL (< 3{ wks) due to severe PET
- PIH -+ usually severe + pl. insufficiency t ruGRt abruptio pl.
O Positive antibodies
- Anticardiolipin antibodies (ACA) hrgh )
- Lupus anticoagulant (LAC) ) false +ve
> Tmrtrnarrt
o Baby aspirin (75 mg lday) + Heparin 5.000 units SC ll2brs
orLMWheoarin /
3040 mg/day e
o Corticosteroids -+ not more used

WhiteKnightLove
 CURETTAGE. A blunt cureffe moy be
tried firsf but usuolly o shorp curette is Removol of Plocentql tissue with ovum
required forceps.
"

To suction

Locol PG
lngecllon of hypprlonlc sonullon (l nlrouteilne- Exhoom nlofi cl

WhiteKnightLove
 e-------------fu flsCed abOrtiOn------------e

> lndlcotlons
O lhtrual
c' Medical disorders e.g. '
-
Advanced:- Heart disease / chronic HTN I renal disease
-
Active pulmonary T.B./ severe hyperemesis
c, Malignancv g
- Genital tract lbreast malignancy o
o
- Chemotherapy or radiotherapy e
o Mental ps.vcholosical illness =
GI
@ getot 5
o Missed abortion / blighted ovum / vesicular mole o
o Exposure to teratogenic agents -+ rubella radiation o
rr

> Mehods
A- Before 14 weeks ,.+ suction evacuation Or dilatation & curettage o
r
Gl
B- After 14 weeks f
o Prostaglandins o
- Local (intra-amniotic or extra-amniotic) =
o
- Vaginal or intracervical tablets
o Oxytocin
o Intra-amniotic injection of hypertonic solutions XX
- Saline 20o/o......Urea 30-40%o. . . . ... .. Glucose 50olo
- Complications -+ danger of urfection & DIC
o Hysterotomy if all fail or there is severe bleeding

> Dcfinition: TOP for non-medical reasons (in countries where abortion is illegal)
It is called elective (voluntary) abortion (in countries where abortion is legalized)
> Mctrods uscd
1- uterine stimulation -+ methergine, purgatives
2- Intra-uterine manipulation to induce cervical dilatation or ROM
3- Evacuation by untrained Doctor under Septic conditions
> Common complications
-
Genital tract trauma e.g. uterine perforotion
-
Infection -+ sepsls
> CIP & trcamcnt as SEPTIC abortion

WhiteKnightLove
 ABORTION-DI FFERENTIAL DIAG NOSIS

TUBAL PREGNANCY PYOSALPINX

FIBROIDS OVARIAN CYST\

METROPATHIA HAEMORRHAGICA Much uterine bleeding hos no or-

moy simulote obortion so closely thot gonic explonotion ond the potient
the distinction con be mode only on the occepts or supplies o diognosis of obor-
histologicol oppeoronces. tion for wont of onything better.

1. The most common cause of first trimester abor-

l.
tions is fetal chromosomal abnormalities.
2, lt is important to rule out ectopic pregnancy with
history physical examination, laboratory studies,
Most second-trimester abortions are secondary to
uterine or cervical abnormalities, trauma, systemic
disease, or infection.

and ultrasound. 2. D&E, prostaglandins, or oxytocic agents can be

3. First trimester incomplete, inevitable, and missed
abortions are usually completed with a D&C or
medical management with prostaglandins,
although expectant management is also used.
4. RhoGAM should be given to all Rh-negative
patients with bleeding.
used for the management of spontaneous abor-
tions in the second trimester that need assistance
to complction,
The risk of uterine perforation from D&E is greater
in the second trimesterthan in the first.

WhiteKnightLove
> What is medical abortion ... ... .?

> What is the DD of abrtion. ..? Look the figure

> What are the complications of abortions... ..?

lumrorarE. .Coup. oF TNTERFERENqE . ... LoNG SEQUELAE

E9
> What are the causes of postabortive bleeding.. ...? o
o
..AS50CtATtON g
a
GI

What is the management of postabortive bleeding... ... ?

)
o
o
-t
What is the weight of the smallest fetus ever survived... ..?
't
What is the difference between term abortion / miscarriage....? o
cl
a
o
> What is the ilumagement of a case of idiopathic habitual abortion
a
.. . ..? o

DIvI, PIO). This seems reasonable as most spont abortions are due to C.F.M.F.

> What are the other tare causes of bleedi in earl

3 Locau GYNEcoLoGIcAL cAUs$
Knownby speculum examination e.g. ulcer, polyp, HPV, tumor
3 HaRtueu's stcN (scanty spottins at time of implantation)
- Due to erosions of some vessels I week after fertilization
- Importance -+ wrong calculations of EDD
3 Dectouel haemorrhage (monthly scanty bleedinq at time of menstnration)
- Due to separation between decidua capsularis & decidua parietalis
- bleeding occurs till 12 weeks (until the 2 layers fuse together)

> What are the main etioloryal_gqglg! o_11 trimesteric abortion... .?

* Cervical incompetence & other uterine malformations
* Early fetal demise (early ruFD) e.g. syphilis, Rh @oth rare now)
* Placental causes e.g. APS, circumvallate placentation
* Uterine overdistensi
| * rrauma A infectig l

WhiteKnightLove
 Tubol pregnoncy

hr!'rrEPo'tloi23
l".rD*55r I -

hfiSrirdoa t7..ll I

b ofcoltt!trr lr0ffi^lrdr dr. rcldF f4a.r{@,lrE.

Chronic solpingitis

l--
Follicle Ovum
entering
tube
Diverticu lum

WhiteKnightLove
 Implantation anywhere outside the ENoonaETRIAL cAVITy
It is responsible for 10% orMMR '
IucmBNcB is t'd 4 folds in the last 20 yrs from I-+3 o/od.t. of: f o

O STD's O contraception (IUCD) O ART [VF)

5i 'lftiline (v.rare) €tuu.-uleilru

1- Cervical 1- Tubal 99%,/,/ E
lnterstitial, isthmus, E!!!E!!g, fimbria o
2- Rudimentary hom o
3- Angular 2 t5 /eo" 5 q
2- Ovwian 0.5% a
(o
4- Intraligamentary
3 : P_-q_frl_o.pSal_
(ab$ominal ; ! l _o-1 ?:_)
=
o
o
oo =
!
O (mechanical factors) o
GI
o Congeaital <a hypoplasi4 accessory ostia, diverticula )
o
a
o
o Traumatic + surgery on tube... ..tuboplasty, tubal ligation
or surgery near tube..,..ovary, uterus, appendix

o Inflammatory ,/ " 50o/o a PID (ctrtamyoia > gonorrhea), appendicitis

\peritubal adhesions (esp on the risht side)

o Neoplastic a tumors in broad ligament, ovary, uterus

\ stretch of the tube & obstruction of ostia

o Miscellaneous
- Endometriosis -+ adhesions
t
- ART -+ ectopicby 5%
- Contraception:
. POP or Implants -+ O tubal motility (what about coctr ?)
. ruCD 3
-+ salpingitis, + tubal motihty (esp if +P), also it
can prevent intra- but not extra-uterine pregnancy

O Samoshmlffiftodoum
. Early disappearance of zona pellucida
o Early development of trophoblast
r External or internal migration (time consumption) X

WhiteKnightLove
RUPTURE INTO LUMEN OF TUBE RUPTURE INTO THE PERITONEAL
(TUBAL ABORTION) CAVITY

Tube lumen --
z-t
Tube woll (musculor
tissue)

Point of rupture
Blood clot collecting in -

Sometimes rupture is retroperiton-

eol between the leoves of the brood
ligoment - brood ligoment hoemotomo.

hoemotocele.

WhiteKnightLove
PetqAeI
> Tube
n
Any partmly be affected (esp ampulla) -+ enlarged, vascular
* Rarely -+ hetero-topic (intra + extra-uterine)
* Cannot reach > 12 weeks due to early dishrbance:
- Limited tubal distension
- Poor blood supply & nutrition
- Thinner decidua + ovum penetrates deep in muscle
> Uterus
* Symmetrically enlarged (Sucrr), t'd vascularity, hypertrophy
g
o
* Decidua (but with no villi) o
* Aruls SrsrLA RsAcuoN -+ secretory, proliferative changes with e
a
(o
some atypical flndings inl0-15%of cases (non-specific)
,
> Ovary -+ one shows CL of pregnancy o
o
-t

T
-t
o
lUdisfurbed... if diagnosed early < rupture Gare). . . . . . undEsGunDod oo0" Gl
.
f
o
I Disfu rbed......... when the ectopic preg. ruptures: =
o
> Ronure tnrl&tte tr0es
o Repeated mild hge around ovum -+ tubal mole (hematosalpinx)
o If hge O -+ separation of the fertilized ovum -+tubal abortion
o Bleeding may be
- Mild O peritubal hematoma . .....suDooo6o[V @@0. @
- Severe O generalized intraperit. hge..-oou@[V dEs0 oo0" O
- Chronic O pelvic haemotocele. . . .... .. .@htronn@ dEsG oe0" @

> Rr$frrg qfildo lfto trrlc

o Due to erosion of the tubal wall -+ tubal burst
o Earliest rupture occurs esp. in tlbal isthmus
o Rupture may be:
B Intraperitoneol
- Mild Qperitubol hematoma
- Severe 4
generalized intraperitoneal hge
- Clnonic Q pelvic haematocele
- BobV rcralyO.....zov otbdomEnon pnognonoV O
w Ef,raperitoneal
- Broad ligamentary hematoma
- BobV rorely #2ry intra-ligamentary pregnancy

WhiteKnightLove
WhiteKnightLove
Sgnptottu
- O Amenorrhea (short period) + symptoms of early pregnancy
- O Pain -+ slight dull aching in one iliac fossa (tubal stretch)
- I Bleeding + usually absent or slight spotting
sw
- General -+ signs of pregnancy
- Uterus + soft, slightly enlarged g
- Adenexae + . slight tenderness in one fornix o
. sometimes a swelling may be palpable (< 3cm) o
e
J
€ailr, diagrroi b needs FIrcn Lr,ver O p S usptcroN GI
- History of pdf (e.g. PID, IUCD) + you must be ectopically minded
=
- May be discovered accidentally during routine U/S of pregnancy o
o
rl

!rl
o
(Cl
Sgmpbmo
a
! Atr,tgNonnrm,A: o
- Shortperiod6-8wks =
o
- Mostly there is one missed period /
! Sudden severe PAIN:
- Dull aching + tubal distension
- Sharp stabbing -+ erosion through the wall
- Colicky --+ tubal contractiorn (tubal abortion)
! Vaginal BLEEpING:
- Drop of B-HCG J e & P -+ separation of decidua
-
- Slight dark brown (or rarely as a decidual cast)
sw
> Gorsnl
- Various degrees of shock + coma in severe cases)
- O pulse, O BP, O temp., cold clammy skin, oliguria
> Abdomlnel
-
+ed movement of lower abdomen with respiration
- T, R, RT overlower abdomen
> Vqdnql
tr
Cervix d
exfreme tendemess on movement -+IUMBIE sigzr
:
cervical motion tenderness //
o
Uterus +
difficult to palpate (tenderness) but is slightly enlarged
4
a Adenexae tender enlargement of the affected adnexum

WhiteKnightLove
 hE p-brdh.mor"lrS.
adprhlctredr

4*.olnffiarym.

.r Nole
ou) uierus
plocento
ore disploced
onteriorly

ABDOMINAL PREGNANCY Cu ldocentesis

WhiteKnightLove
 3. Ho,rte (fulmlnottrp) Qpo
Symptnru
,.. ... .Short period of amenorrhea -+ sudden severe abdominal pain
... ....Followed by: massive intraperitoneal hge with shock & collapse
* shoulder pain: diaphragmatic initation by blood
sw
> General -+ shock (not proportional to external hge)
> Abdominal
- T,R RT over most of abdomen g
- Shifting dullness + Cullen's sign o
o
> Yaginal + difficult (marked tenderness), but may be easy if... ... . o
5'
GT
4. Chronlc peMc hernotocoole
=
o
Symptamo o
... ..There is history suggestive of disturbed ectopic preg (the triad) =
.9
. .. ..Then blood collects gradually in the D.pouch (most dependent) -t
.....Leading to pressure symptoms (backache, dysuria, dyschazia, dyspareunia)
o
Gl
5
sw o
f
> General a slight pallor + jaundice t pyrexia o
> Vaginal ? tender ill-defined boggy mass in D.pouch pushing cx anteriorly

I unhwil......... evacuation by
1- Laparotomy + strong antibiotics
2- Posterior colpotomy (or aspiration guided by TVUS)

5. Rc,\rmced obdomlnol gegnmcg

sw
>Abdorninal-+. Abnormal lie ( e.g. high transverse lie)
. Easy palpation of fetal parts
> Vaginal -+ uterus small & separate from fetus
Jrucatig oUlS (CT, MRI):- fetus & placenta are outside uterine cavity
jrunlmut ..r..... Laparotomy
1- Laparotomy -+ remove fetus & sac (fetus is malformed in >50%)
2- Regarding placenta:
- If attached to unimportant structure as omentum -+ remove it
- If attached to important structure or great vessels -+
.Cut the cord short & leave placenta for absorption
.This takes l-2 years (methotrexate may help absorption)

WhiteKnightLove
 Forceps holding up
o follopion tube
for inspection

Loporoscope possed through connulo

PrEgn,cy o, unlgrow't locatbn (PUQ

"S..un hCG larob al0 Corlsldr bparccopy

md 40 rioin! or lapoEtomy

lnltlal l0€l <15q) lt l

<66% lnqrar. or <15%

d6r6ahg{rrn
hCGHO houE

Fccan onewekiooonf,rm R.patEUmhCOhqlo

pr8enancy locdo.r sr€* to cdrfrm trltE

Comffe sddyhCO
rndltortrg trlil <16|t tr

Rcpcth@ now
lsbt
ard {8 hqrr!

It m FtgrErcy ldt dl r!p*l

lcan drd utopfin l rbo ln lEG
cmsbar rne0loto(ela

Algprfilin iornratt.eNlttauaDacd.ctopk p?.gtrltcr,

WhiteKnightLove
I I fteononqr test
- Serum P-HCG / (detects 5 mlu/ntl) is more sensitive than urine
- lntrauterine prq. anormally doubles I 2-3 days
- Ectopic preg, a subnormal rise: less than66o/o within 2 days
(But it may be non-viable intrauterine pregnancy)

9l Ultrosound
- Vaginal U/S is more sensitive than abdominalUlS
- lntrauterine preg. agestational sac in-utero (5 wks TV.. . . . 7 wks TA) g
(But it may be the decidual reaction of ectopic preg) o
o
- Ectopic preg a a small sac * fetal echoes outside the uterus e
a
(But it may be CL cyst of normal preg) (o

+ proceed =
o
o
+ =
!
o
(o
llospthllatlon & tullor up of
* Svmptoms ^'r pain a
o
a
* signs ^a detectable adnexal swelling o
*
io@!re + 12 days
O Combined U/S + p-HCG )
T\e disqiminotionvalue at which U/S can
I a.tect an intrauterine pregnancy is:- i

- 6.000 mlu/rnl (by abdominal U/S), or

- 2.000 mlu/rnl (by vaginal probe)

r es
#t)31*fiT#:J;:;#f;il::1ffi!res
detected
I

I uggested by the progressive i

drop in Hct in absence of extemal bleeding

lf dlqgnch h stitl quorg
* LoPoroxoPv ^a both diagnostic & therapeutic //
* Culdocentesis ^a tapping of blood fromD.pouch,f

3l Othes:
. Progesterone level
a >-25 nglml -+ normal intrauterine pregnancy
<
o 5 ng /nrl -+ abnormal (ectopic or non-viable intrattterine preg)
o DaC xx a decidua but no villi (rt may disturb an early healthy preg !!)
o EUA XX 4 it may increase disfurbance

WhiteKnightLove
 Gdordr*
h ub,u3

lF frrm F dqtroca oftlpcdd r(fipt F!0db^

LA? ARoE/CO?IC LIN EAR gALPI N GOST OMY F OR TUOAL ECTA?IC PREGNANCT

Allncarlnalebn
|pmrtavfthttr,
lrcrwropobr
dlfihctmynar)b
almqtlv afi)- inclumcnis
nrunlabborbr allandtrhcal
otilvtallop|untuba byw,oilary
irIrnlful
l
I

fttctto?huf/,tof/r.
nru|orantrrod
*thtoroa?crd
ii4rilort

WhiteKnightLove
 ( Treotme[ ]
Resuseifatio n / / / -+anti-shoct measures
\ wide bore cannula + ca[ 4 help
Laparotorng (or laparoscopy)

o Peritoneal toilet -+ to remove blood

. ls inspect flre othertube (may be disease( absent, malformed)
. Sflpi4@y -+affectedtube is removed /
(the best; to avoid.....)
t . Oophrectomy )( X )
toforce the other ovary to ovulate monthly P
. No oophrectomy r
hormone production o
o
o Conservative surqerv if e
O one tube is present or =
GI
) every attempt
or
O mild cases ) should be done =
Olowparity o
) to conserve the tube o
-r
- This is in ttre form of lineqr incision (at the anti-mesenteric border)
!-l
. Salpisotomv: tube is closed by + sutures
o
. Salpineostomlr: tube is left open -+ heal by 2v intention GI
. Partial salpingectomy (never to be done).. .....high recrurence I =
o
. Milkine the tubal contents (esp if near fimbria)......the worst rr =
o
Lapamscopg (diagnostic & therapeutict
. Same procedures as in laparotomy may be done, but needs:
o Expert tearn+ special equipment + haemodynamic stability (not shockedo )
o Adv. -+ done as a day case

Medicsl tft (conservative to fertility)

' Me'[hods - .yrl:;:;:#{;::'&tffill1 (- :: * T?a;$lll 1

. PG-F2"(locally in the sac)... .. .laparoscopic or U/S guided

o
. Criteria a. Sac size < 3 cm,
-ve cardiac activity (non-viable)
(un- . F-HCG < 3000 mruiml
disturbed) . Patient haemodynamically stable

. Follow upO . serial Hb &Hctlevels, TVIJS, p-HCG

. B-HCG can rise slighfly before decline starts (day 4)
. dose is repeated if no decline by >- l1%bet days 4...7
. surgery is done ifno response after 3 doses

tr DrC mru bsdons. ...why?

tr lf Rh -us + gFs qrrfl-D

WhiteKnightLove
 Angulor Plegnoncy
Plgnoncy_llBud i"gntoly H orn

Am+bl -> Au-zrtuzlit

[@prg4
9q&ry1!?s-&'he, Colic, dull, sharp
- Bleeding
lmo
ar-{or

Examlnation - Shock Nqt uqpqdqllrl_

- nUdomirai T, R, RT
- Uterus :polqt g{alqrl U*4ly_._8 E99b
- Adenexae No swelling Swelling * tender

Decidua + clrorionic villi

TORSION of PEDICLE of OVARIAN CYST.

WhiteKnightLove
......trLlrc ttlp, cf *toplc
* Orcrlon pregnoncv
. Usually 2ry to tubal pregnancy
o v i s'fr1|:i'.,!il
1

:{,:;'.i:i{x::ii;i^
Gestational sac occupies position of the ovary
Ii gament
: ff#*?*i:1Tffi1'J:flJl*iH,ll ilfl'*
* Prcgnonql ln rudlmontory hom g
. Usually presents late at 16 -20 weeks o
o
o It is medial to the round ligament while tubal pregnancy is lateral g
o Treatment -+ remove horn =
(o
* flngulor (comuol) ppgnoncv =
o
o At uterine orifice of the tube, late diagnosis (14-16) , more bleeding o
o If disturbed -+ - wedge resection & repair of part of the uterus -r
- May need hysterectomy !
-t
o
rt Cenrlcoloroononq.l ttt:a GI
o Ilysterectomy if severe uncontrolled bleeding =
o
o Conservative measures: =
o
7f Suction evacuation. To reduce bleeding:
- Suturing at3,9 o'clock
- Silk suture aroturd the whole cervix (as in cerclage)
- Balloon tamponade (30 rtl) by Foley catheter
- Bilateral uterine artery embolization by gel-foam
2) Methotrexafe local injection in the sac

.......DD of ectoplc
ll Painfrom
o Aate sapingitis + no amenorrhea, no fainting, fever, pain
(usually bilateral), leucocytosis
o Conplicated ouarian nass orfibmid
o Acute +
no amenorrhea, vomiting, pain usually
appendicitis
periumbilical then at Mcburney's point
o Ana plelonepltritis -+ loin pain radiating to the groins with
fever & urinary symptoms
2l Bleeding from abortion & vesicular mole

....*lAtcr G/n,aftgr ectoplc ee

q Contraception + avoid IUCD and POP
o
q Prognosis -+ L59/s'. recurrence ,30qfo infertility
o

WhiteKnightLove
 thcn duplkatoo\

*ff&*@
fdploldkaryorypcvrrh
an awa(hapb?) *t,
*^*l
g;g-,$r'oR
r)

Tatanalchrcmoerlma
of
cw*rm t -

WhiteKnightLove
 MalBnant
Vesicular mole *tetastatic Non-metastatic
(hydatidiformmole Choriocarcinoma .Invasive mole
.Placental site

Benign tumor of frophoblast ccc by o trophoblastic proliferation

E
o
+ hydropic degeneration of chorionic villi o
g
a commonest in far east " 1/1000 =
GI
a
o
Fiioiogvl unknown, m.b.d.t. o
rt
o A primary oocyte abnonnality !?
o IMMIINOLOGICAL, GENETIC, NUTRITIONAL 1Jvit,A,; factors !rt
o Risk factors -+ previors VM, extremes of age (>35. ...40) o
GI
=
o
=
o

46u./ (:,ll e.e.69 wv {

esicles fetus + usually
+
aborts in midfrimester
Fertilization of one ovum Anornul wumfertrlized
by 12 spemrs or rarely I by 2 sperms or 1 sperm
spormthat divides into 2l with 46 chromosomes
follouted by ) (ureduced genome)
disappearonce of all
maternal chromosomes

2. Aecording to behavior
> Benign
) lnvasive mole l5oh (choriadenoma destruens) -+ if perforating the uterus
i,e. locally malignant (rarely metastasize)
) Metastasizing mole (usuatly metastasizes to lungso ) + resolves with ttt

WhiteKnightLove
 Normql villus

Primitive Avosculor
Vessel /oedemotous
slromo

Chorionic
epithelium

tr
/ 7ri'i {->Cyrotrophoblosr:
cuboidol cells
Syncytium: with prominent nucl
sheets of fenestrcted
cytoplovn contoining
T.othe.noked eye the whole looks
dork ovol nuclei lrke o bunch of gropes.

Hydotidiform mole

Normql
I6 weeki

WhiteKnightLove
helbdeil
a Macroscopic
O Uter,rs ^-r enlarged, studded by vesicles 2 mm to 2 cm in
diameter, each with a small pedicle & contains
semitransluscent fluid. No psrus or pLACENTA
. May be partial or complete
o May affect one twin & not the other
@ Onru e bilateral theca lutein cysts of the ovary -60%- [due to t
B.HCG released from the proliferating trophoblastl. They g
DISArIEAR sp oNTANEousLy 2- 3 months po st- evacuation o
o
# Microscopic q
- Trophoblastic proliferation (both cyto- & syncitio- trophoblast) f
(o
- Hydropic degeneration of C.T. stroma of villi -+ vesicles
f
- No bloodvessels (AvsescurenParrunN of VnLI) o
o
!
OSvmotoms o
(o
> Otrunatafica *
syrnpt. of early pregnancy
=
o
>'llu&u Abrding (contiruous trickl ing) :,
o
> flon......&ut no l*l
maume*
- -
Dull aching (uterine stretch)
-
Colicky (expulsion)
-
Shary (perforation)
-
Acurp ABDoMEN (complicated theca lutein cyst)

> QcwulO ill, anemic i shocked t

signs of comp.
> Qfrdoninal
- Uterus > period of amenorrhea
- Uterus doughy in consistency (vesicles with no fetal pafts)
- NofetalpartsorFHs(exceptifO.. .,O.. )
- Bilateral enlarged ovarian swellings
> Aqginal a passage of vesicles is diasnostic (rare)

oo
Crneral
weeks
"fi{<20

WhiteKnightLove
 2t{ortrto
flrcc(}{UJil)
r 0000

r00000
956 ccndc
ttlor
t0 000
----- 56cdrdL

r 000

100

t0

216810
Ut& fi.r nroL.r.ormd

Fhr{D ofDfir t@ok ecos.

ltorrttonc
@trrlaln95Xo,furcffi).

WhiteKnightLove
7- Ulhqsound {(hebest) + SNow Sronu appearance
Amniography -
HoNsy Corvre appearance )()(
2- p-hCC +ve in high dilutions > 100.000 (more important for foltow uo)
3- Rsdiugtqphg; - Plain X-ray: no fetal skeleton
- Chest X-ray: for metastasis

Re.suscitation *
ll Suction evacuatio n r'r' cannula
by a wide bore F
t curettage to ensure complete evacuation (risk of perforation) I
t ecbolics to O hge (risk of embolism if inductionis started by ecbolim) ,E
- Don't forget +. anti-D if Rh-ve
. specimen is sent for histopathology =.
;
2l Hysterectomy (in toto) 9
.Inoldpatients(>40yeaIS)whonvecompletedtheirfamiliesto< !
$ risk of choriocarcinoma (35% at this age) d
- Hysterectomy doesn't prevent metastasis (.'. follow up by p-hCG) E
- Theca lutein cysts arc not remov surgically ' except ,f I
complication occur (e.g. torsion or rupture)
e
s
> Bs p{ubunit of tlCG
- Every week + till -ve for 3 successive times (<5 mIU irnl)
- Usually becomes -ve within 2-3 months
- Every month -+ for l-2 yearls
> Pregnlneg ls ryolded foi l-2 geer/s:
- To O recrrrence & choriocarcinoma
- COC is used (IUCD I causes irregular bleeding')
> &ferlc uf posclble deuelopnrort of chorloc+elnonrq
,"* ME-THOTREXATE )
o p-hCG levels are:
- Rising (doubles in 2 weeks)
- Plateau (failure to S within 3 weeks)
- Returning +ve after being -ve
o Persistent or recurrent uterine bleeding
o Any evidence of metastasis e.g. chest x-ray
o Biopsy + diagnostic of choriocarcioma

WhiteKnightLove
WhiteKnightLove
-a7

-aa
-a'
-a-

r ..1 '
fi:.,
Voso Previo .: j':,. L.

Plocenlo Previo
Accidenlol hge

WhiteKnightLove
 l. Nonobstetric causes of antepartum hemonhage
include cervical and vaginal lacerations, hemor-
rhoids, infections, and neoplasms.
'2. Patients typically present with spotting rather
than frank bleeding.
3. Nonobstetric causes of antepartum hemorrhage
generally require simple management and have
good outcomes.
4. Cusco sepeculum examination of the vagina & cervix is
very helptul

1. Fetal vessel rupture is a rare obstetric complica-

tion, usually associated with multiple gestation.
2. It is due primarily to velamentous cord insertion.
3. It is associated with a perinatal mortality of 5070.
4. Patients may present with vaginal bleeding and a
sinusoidal FHR pattern.
5. Fetalvessel rupture usually requires an emer-
gency cesarean section.

WhiteKnightLove
 tc ;u fi1r(spaitaq llaauottAAga r,t,

Definition erBleeding fromthe genital tactqfter 2O,/ (29)weeks

till be{ore delivery of fetus
Etiology

Plqeentql sife
Vasa prel'ia
1. Placentaprevia 1.Local g5mecological cause
(the only
(inevihble hge) 2. Excessive show
cause of
2. Placental abruption 3. Ndaryinal sinus bleeding
fetal hge" )
accidental 4.

.r.... e ...VAga Prcvla ... d(...

Definition o fetal hge due to tear of umbilical vessels

running between the presenting part & cervix
f
-l
fncidence oyery rare: I /5000 withfetal mortality: 50-'t5yo"
o
I'
ort
Etiology - Velamentous insertion ofthe cord c+
- Placenta succenturiata, bipartate placenta 3
=
o
Diognosis 3
- Sympt. + APhge (mildbleedrngbutmarkpd fetal distress) o
-t
-
- Signs + vessels are felt as cord like bands crossing amniotic memb. =
o
- VIS -+ colored Doppler may show the vessels Gl
o
Investigotions

Treotment + immediate delivery usually by CS o

-+ rarely forceps orventouse if fully dilated

WhiteKnightLove
T yt,e 1 Type 2
The lower morgin of the plocento The plocento reoches the internol
cl into the lower segment. ('Low
i1,s os when closed but does not cover it.
im1;lontotion'). ('Morginol').

Iype 4
Ihc plocento covers the internol The plocento covers the os even
cs vrlrcn closed, but not when fully when the cervix is fully dlloted.
diloted, ('Portiol' or'lncomplete'). ('Centrol ' or 'Complete').

WhiteKnightLove
 Phaaafia Pruvla

Definition a Blnponvc from within the genital tract

Arrnn 20128 wks & Brronr delivery ofthe fetus
DuEro

Incidence o 0.5%
c More conrmon in Murupenn o PRrvlous UTERINE ScRno
a Recurrence rate. ....4-8%

Etiology
- Delqgsd development of chorion ftondosum
- Ddrusd disappearance of zona pellucida
- Dmcisnt decidua (t parity, t age o, endometritis)
- Perhtsnce of villi in the decidua capsularis
'k Large placenta
- Twins, D.M., RH =
o
- Placenta membranacea E
o
-l
E
Clossificotion 3
lot
o PP lateralis 60% Lower margin of the placenta lies in LUS =
o
Yiolw Jgtrg" //but not reaching the margin of internal os 3
o
o marginalis
2no PP 30% Lower margin of the placenta reaches the
"marglna[ margin of the internal os =
o
(o
3'o
o PPcentralb incomfl@ 7% Placentapartially covers the internal os
"prtlali o
4*o PP csrtralis comffie 3% Placenta eompletely covers internal os
"lotl;t

Pothogercsis

O Pregnqnq,.
. Placenta is inelaalic so bleeding occurs due to stretch of
LUS (shearing mech.). Bleeding is augmented by the
inability of the weak LUS to compress the tom vessels
. Peak incidence of bleeding is a
30 - 34 wk'
. First bleeding episodes are usually 67 mild
o

@ Labor: d.t. cx dilatation (rarely may occur for 1* time in labor)

WhiteKnightLove
An.ni.rbr pLc.nf. prroL.xt rdlng toJun
b.yondth.lnt mrlor.

Fbilo ptu,jvb-Vf,-.vo.

WhiteKnightLove
Clinicol picture

> Symytoms '+ Bleeding:

- Fresh bright red
- Painless. .. ... ..except if... associated with labor pains
- Causeless ... ..except if... after intercourse or pV
- Recuruent . . . ... .. . . . .except if. . . .placenta is just reaching the LUS

> Sigru
O General ,+ pallor or shock (according to degree of bleeding)

O Abdominal
o Palpation
* Fundal level -+ conesponds to period of amenorrhea
* Umbilical grip -+ Lax uterus, not tender
* Pelvic grrps + non-engagement t malpresentations (30%)
o Auscultation
" FHS are normal except in severe cases
(more tlnnVz placental separafion is needed for fetal
disfress to occur, this is more in cases of ... ) . T
O Vagina! t,oo
!
o Contraindicarcd 99 +
o Except if O the patient is in labor &@ has minor degree 5
- Aim is to determine the possibility of labor d
- In the operative theatre which is ready for immediate 3
interference by CS + available blood
o
t
t
- This is called a double set up technique [2 teams] =
o
- Placenta (if felt) will be a fleshy tough sponge GT
o
I"rr*igl-els_(fu:M)
'k Theonly & best method used (98% sensitivity)
'k Repeated serially (every 2 wls) to detect upward migration:
The apparent upward movement of the placenta from the
LUS (due to unequal growth of UUS & LUS). This may
lead to disappearance of p.previa or lessening of its degree
'k Thus:-
-P. previa ismore common at eadier gestational age
-P. previa ismore likely to persist if diagnosed after 30 wks

't other methods:- S- a"grography

- MRI -+ very accurate but expensive
- Thennography + more temp. over placenta

WhiteKnightLove
Risk factors for placenta acoeta
t Previous retained placenta
I High parity
r Advanced maternalage
I Placenta praevia
r Previous caesarean section
r History of dilatation and curettage or suction termination
of pregnancy
I Previous postpartum endometritis

Classification of abnormal placental attachment

Placentaaccreta 75-78% lnvades superficially into

the myometrium
Placenta increta 17o/o lnvades deeply into the
myometrium
Pfacentapercreta 5-7o/o Invades through
the myometrium
and penetrates the
outer serosallayer of
the uterus. lt may invade
adjacent structures,
including bladder and
bowel

WhiteKnightLove
Complicotions oo
D Moternol

o Pregnarcy '4Aphge (anemia if mild, shock if severe)

O Lobor

"'*s,,r*l|1J3Hllx'#
'
fs,'*ilEffi iT[?),.**r
( cord prolapse & infection
2nd stage: difficult (obstructed labor + malpresentations)

""?';,:;:d:,,.;[T?:iffi
:J]*1iJ$*Tffi :.rna,condition)
Retained placento (5Yo) -+ placenta accreta (d.t. poor
t
decidual development) -+ incidence with no of CS o
3
..(APhge predispose to pphge).
..........(APhge weakens, pphge kills).........
t,oo
E
O Pvarparium ...S3 3
Sepsis =
o
- Poor general condition (shock + exhaustion) 3
o
- Placenta (friable + near vagina + retained parts)
- Premafure rupture ofmembranes =
o
- Increased surgical interference GI
o
Secondary postpartum hge (retained placental parts)
Subinvolution of uterus

* Fetol

O Preterm labor. ... ...pTL ) due to

O Intrauterine growth retardation ......ruGR ) poor
O Congenital fetal malformation... .... ..CFMF ) blood
O Intrauterine fetal death. ..IUFD ) supply

taternal mortallw (<t c/o)

Perlnata! mortallty $/o)
- Hemorrhage - All complications
- Sepsis
: E-:p9_Slgty +-_{_fp1p-[urtty ]

WhiteKnightLove
 Treotment

ll Conservative // if -+ Bleeding -+ mild

.
. Fetus + not mature, not distressed
. Mother -+ not in labor
* Shtpifali,,zation...aim: keep condition under control till maturity
l.Mothor :

- Bed rest, no P y', no vaginal douching

- Correct anemia by diet, iron * blood transfusion.
- Close observation, ready blood stores
2.FeEus:
- for lung maturity
Give steroids
- Serialtests for fetal well being
3.PIoconto : follow up placental migration by U/S

2] Termination if rrrf . Bleeding + severe........or

. Fetus -+ mature or distressed ..............or
o . Mother -+ spontaneous onset oflabor
o
o O qrrg-6fucfr, mc,oawrco { /
E * gJixlh eilfrin
o
E
o
.c,
C.section //: h + severe bleedino.2nd 3rd,4

E * LSCS f -+ . better confiol of bleeding (near placental bed)

E . leaves a strong scar
o o
o If placenta is fourd anterior
I - Incise the placenta & deliver baby throughit /
- Reach round it till head is felt
E
o Control of placental bed hemorrhage
- Ecbolics + massage + hot packs
- Under-running sutures
- Uterine artery * bilateral internal artery ligation
- Supra-vaginal hysterectomy

b AROM + oxytocin
o I't stage -+ conti nitoring
o Z'.stage -+ no fo
o 3- stoge+guard
* eup o( tfre notcttnal. cotnphcatiaru ..0finc.ft, ggfrg"
* eanp al tfrp nsafram

WhiteKnightLove
Definition a Blrponrc fromthe genital facl of placental site origin
Arrsn 20 /28 wks & BEFoRE delivery ofthe fetus
DuBro septrallon of a normatll situcted placento

Tncidence e 1 / 200-500 [> in PG with PIH, elderly pG, GMp]

Etiology O idiopothic in mony coses

l1 PDt
' .t age,parily.....smolong, alcohol
.J fofc acid', vit.C., vit.K
. Previous accidental hge
9l llqtsrnql dlseqse ,

- Preeclarnpsia(the most important + 50oA {{

- Vascular wall defect (DM., collagen disease)
3l Ttqqmq to the qbdomsn
- Accident. f
- Extemal Cephalic Version (esp if faction on short cord) o
I,o
4l Sudden O in inttquterine pescure:
- After sudden ROM in polyhdraminos c
- After delivery of first twin.
3
5l Plqcentql qbnormqlltles : o=
3
- Circumvallateplacenta o
-rl
- Placenta implanted on scar, septum,fibroid
=
o
(o
Pothogenesis
o

Injtry of vessels in the choriodecidual

space -+ retroplacental
hematoma -+ automatic extension due to rupture of more
vessels by the collecting hematoma -+ more expansion of
the hematoma
Blood may escape between muscle fibres of myometrium
@ uterus / uteroplacental apoplexy) -+ black
flabby uterus incapable to contract
Extension of
blood may produce ecchymoses below
peritoneum or evenrupturetterus & intemal hemorrhage
Release of tissue thromboplastin * consumotion of the clotting
factors within the hematoma -+ will lead to DIC -+
FDP's:- (renal failure + tocolytic effect -+ atonic PPHge)

WhiteKnightLove
Externol bleeding olone couses little up,set.

Compi*r of be cfini:o, pjctlre h the

rlortor6 8iodes of aci&ntd hm,7/nge
3rr*yofUr&3
l,lodontc Savcr,c
hrhe Mchange Raised Raisd
Blood pressure No changp Loryered Lorered
Sfrock NonG Often AlwaF
Oltguria Rarc Occasixulty Conrnon
4gofOr*rngenaentia Rar! Occa$naty Corrnon
lJtcrus Nonml Tendcr Tenderand terse
Faus Ar^,r l*uafty dead Dead
Blood b6s (litres) <t t-3 3-6

WhiteKnightLove
Types
1l Accordrng to bleeding

1. Concealed The blood separates part of the placenta but does

(1096) not reach the _v-ag.ing
2. Revealed The lower margin of the placenta separates and the
(30yo) blood track down wards (between the membranes

I r. uixeo (6r,t) /1., 11 [t*i ,.*;tgg. j

2] According to severity
C,PlFetuslShock Dtc
Class 0 Mildest -velgliveJ-ve -ve
Class ! Mitd +ve Al__iye_* -ve __-vo
Class Il Moderate **ve Distressed *ve -ve
--"- ',--- -- "-t
Class lll Severe +++vel Dead I ++ve i +ve

Clinico! picture f

1l Svmptoms
ooo
Pain - /
(SuooEN, SEvERE, Con-ruuuous abdominal pain) C
-
Bleeding. .. .,dark, clotted (absent in concealed type) 3
-
Shock (hypovloemic + neurogenic in concealed)
=
o
2l Siens 3
o
> General
- Signs of etiology e.g, PIH (but arterial blood pressure may be =
o
(o
apparently normal i.e. hypotension due to shock is masked by PIH o
(decapitated B,pr,) .'. Hypovolemia is better detected by CVP
- Shock [may not correspond to the external bleeding]
- Signs of complications e.g. DIC
> Abdominql
- Palpation:
'kFundal level -+ higher than period of amenorrhea
t
'r Umbilical grip -+ basal uterine tone (6urfti49rigiiiry)
'k Pelvic grip -+ normal presentation + engaged head
- Auscultation: &ccording to severity (distressed or absent) /
> Vaglnal
- Contrarndicated (No PV in ony cose of APHge)
- Only done after exclusion of P,previa by U/S *r well engaged
head & very tense membranes (if ruptured -+ bloody liquor)

WhiteKnightLove
Algorlthm for APH.

WhiteKnightLove
fnrrestigofions
l. Etiologt + preeclampsia
2. Diagnosts (U/S) -+ . exclude placenta previa {
. may find retroplacental hematoma
3. Complication -+ DIC, renal frrnction tests

Differentiol diognosis
1. Causes of acute abdomen in late pregnancy (concealed or mixed)
2. Causes of antepartum haemorrhage (revealed or mixed)

-Once j-recurrent
-hasetiolory i -causeless
- painftl - painless
- dark olots i - fresh blood
* Etiolory e.g. + PIH * no etiology
* Shock> hge. * shock: hge.
* DIC E
o
-l
l,
- no placenta - placenta felt o
r!
- cephalic - malpresentation c+
3
=
o
3
Complicotions ah ..q

=
o
a MATERNAL [MMR.... ..... lohl" @
o
)
Due to the d?elopinq hematoma
1l Shock
. Due to.......APhge, PPhge (atontc/ ttraumatic tDIC)
. Leading to - Renal failurc (shock + PET + DIC)
- Sheehan syndrome
2] DIC -+ accidental hge is the commonest cause ofDIC
I Due to the hiqh intrquterine pressure
3]Couvelaire uterus (utero-placental apoplexy) &
Rupture utents + intra-peritoneal haemorrhage
4l Amniotic fluid embolism
I Due to the etioloqt e.g. complications of preeclampsia

ftrer,: PTL {....... IUFD {......ruGR.....(why?)

WhiteKnightLove
Alexandre C,ouuelaire (1873-1948) uas the first to
describe extensive haetnorrhoge into the myometriam;
he recogttiztd tbat it was impairittg the myometrium's
ability to cor,tlact, such that in the case he reported,
d cqesarean hysterectomy wos required. He also was
afl early prcponent of caesarean sectiofl for placenU
praeuia.
Couveloire uterus

WhiteKnightLove
Tneotment

tl Termination r'is *re usual fate, as:-

o Bleeding is usually + severe
o Fetus is usually -+ distressed
o Mother usually enters in -+ spontaneous labor

a] Anti-shock measures //
bl Birth by,

oMatemal or fetal distress & delivery is not expected soon

o Mosr IMPoRTANT -+ coagulation defects should be corrected lfurt

oHysterectomy + in severe atony or Couvelaire "

lyfiaiUa b contract)

1-rr-!;_-;-"1
oEspecially if the fetus is dead or the patient is advanced in labor
oUsually easy (wellengaged head) & rapidlt'd basal uterine tone)
f
.Early AROM (why .3R) t oxytocin o
r Relieve... ... .the high IUPr I,
o
b Reveal........any internal hge. -r
c
> Release... .,.PG...accelerate labor 3
ltotage -+ continuous monitoring (F & M)
P otage -+ usually rapid =
o
3
,1w atagc-+ guard against PPhge o
-t
rt

clTreatment of etiologA (PET) & complicatiorls (DIC)

=
o
GI
d] Care of the newborn o
2l Gonservafive, rare
o Very rare (chroruc abruption) : as once abruption occurs, there will
be -+ automatic extension -+ severity -+ complications
o Indications:
Bleeding -+ mild (usually revealed or small retroplacental hematoma).
1.
2. Fetus + not mature < 37 wks
3, Mother -+ not in labor
o Aim /o -+ control the condition till fetal maturity.
- Mother:
- Fetus:
- Placenta: serial U/S to follow srze of hematoma
o Continue -+ till any of the indications of termination occur

WhiteKnightLove
WhiteKnightLove
--

a
u
a

Atonic
Iroumotic
Retoined Plocento
Dlc
Acute lnversion

WhiteKnightLove
Alggtlhm for thc marugGrnent of ctdy m{.

Grtrrr'ottll{
. Tone: ubrln€ ato[?ry
. Tlssue: retalned products of conceptlon
. Trauma: gcnltal tract laceratlon
o Thrombln: clottlng abnormallties

WhiteKnightLove
 ?ostparttmtW
D It is haemorrhage from the genital tract
ATTER delivery of the fetus
TILLthe end of puerperium EnUgP a
- To a degree affecting maternal general condition
- More than 500 cc
- Causing haematocrit drop > l0 Yo
* Incidence has been reduced from 15 -+ So/o(d.t.t use of ecbolics)
+It is the commonest cause of MMR indeveloping counties (30%)
*More common with history of previous PPHge o

a P*meru PPhgp. (hge within 24 hours of delivery)

)1fone...............fftonic ...(90% of causes)
)!rauma.......... ..(extra-placental site hge)
t!issue.... ..(3'd stage hge )
tlnromoosis. . .. Cooou lot ion dofects.... .... .. (mostly DIC)
)Flcuto inversion of the utorus. . ......(v.v.rare)

a Secondqru-PPhgs (hge after ls day till end of puerp.) OO

l- Etiology
a- The Emmt... .......retained fragments of placentat infection
b- The most 81ffi... ....choriocarcinoma
c- iepsis. .... separation of a slough -+ bleeding 5
d- invol tion ...inversion of the uterus o
l,
e- ous polyp... ..if ulcerated o
-l
f- Others c,
- lclgynecological disease -+ cervical ulcer 3
- 8mf -+ coagulation defect =
o
2- Assessment 3
* History
o
-t
q
( mode of delivery )
'k Examination ( general , abd , local: cusco )
=
o
* lnvestigation ( U/S, p-HCG ) GI
o
3- ttt of the cause
* Retained fragments.
- if small remnant / mild bleeding + methergine + antibiotics
- if large remnants / severe bleeding + evacuation guided by U/S
'tChoriocarcinoma. ... chemotherapy

WhiteKnightLove
WhiteKnightLove
 I Postpartum bleeding due to weak confiactilitv & retractivity
I Constitutes about -+ 90%o of cases (the commonest o)

fll Durlng Dlqlnqncg

- APhge (pl. previa,
- Maternal disease (anemia ,
- Over-distended uterus (twins ,
- Long use of tocolytics

[2] Durlns lqbor

q 1't Stage ,,+ - Prolonged ls stage
- Excessive straining
- Overuse of sedatives
- Chorioamnionitis
- Full bladder/ rectum

q 2"d Stage "+ - Prolonged 2nd stage

- Excessive manipulation
- Deep anesth. esp. halothane
- Precipitate labor
a
q o
3'd Stage ,,+ Retained parts of placenta I,o
c+
-t

[3J &rrses ln the uterus 3

- Multiple fibroids
=
- Congenital malformations o
- 3
Grandmultipara o
rl

=
o
GI
o
> Historv -) severe vaglnal bleeding after delivery ofthe fetus & placenta
> Examination
-
General -+ Shock
-
Abdominal + Uterus soft & enlarged
-
Vaginal -+ to exclude taumatic PPhge.

WhiteKnightLove
 Bimanual Compression

SuTerior 4luteal
artnry
HY?oqast'ric
arwry
llqation elta

Extarnal
iliac

Utnttnc artnry

Ohuratr:rr aftary

Packing

WhiteKnightLove
* Prophvlactic
- Avoid all pdf . + proper ANC
- Proper management of lo,2n & 3'd stages of labor

* Active: Resuscitation +

ld Iine d) - tnqssaoe"
- Ecbolics (ox1.tocin, methergine, PGEI - misoprostone 800pg -)
- EmpU bladder + stop halothane

2d line O exptoration of birtht?sctundw G.^

- Exclude trauma
- Evacu,ate blood clots or retained placental parts

3d line a blmanuat compression oJ the uterus

- Closed flst of the right hand is placed into anterior fornix
- Left hand is placed abdominally to compress the uterus
inbetween -+ kink uterine vessels & compress placental site
- This is continued withthe aid of assistant every 15 min.

4th line etawrotorw

> ft.
completed her family -+ Supravaginal hysterectomy
> Pt. not completed her famrly ->
- Direct uterine massage, hot fomentations
- Intra-myometrial prostaglandins o (PG-F2")
- Bilateral uterine & ovarian artery ligation 5
- uu"i'f,1,il1iiil#'Jli?J,fr;ffi o
possibre injury to ureter, rv 1,
o Uterine blood supply willthen depend on collaterals
o
- If all failed -+ Supravaginal hysterectomy c
3
=
o
Bgentlt+ . BJynch operation (Brace suture) 3
. Balloon (hydrostatic intrauterine temponade) o
. Bilateral uterine a. embolization using
=
o
polyvinyl-alcohol particles (gelfoam) (o
o
Plwiouslv -+ methods not done nowr(r(
* Uterine douche by Bozeman double way catheter using warm
saline or antiseptic -+ stimulate contraction, remove remnants,
" Uterovaginal pack tor 24 hrs (Abcs + ecbolic + catheter) -)
stimulate crontraction, oressure over bleedino site.

WhiteKnightLove
 Foce
presentot i on
M.A.

Vertex
Presentotiorr
presen totion
o. P.

lst degree Perineol Teor

Voginol ond perineol skin ore torn,
but the perineol muscles ore itrtoct
-.-*-l i
I

2nd_d"gfeglgSt
The perineol body is forn right
I down to (ond sometimes portly involv-
t - --' ing) the onol sphincter. The voginol
/i teors often extend up both sides of the
vogino.

#
3rd degree Teor - "Corp.!.t"l"or"
The whole onol sphincter is torn
oport, ond there moy be o teor of the -/__.f ,
rectol woll. Note how the ends of ihe ,
Torn ends
sphincter muscles lend to retroct.
..,1

-- of onol
This iniury, if not repoired, leoves sph i n cter
the potienf with foecol inconlinence.

A
l
complete
teor thot
hos foiled
to heol

WhiteKnightLove
 tll Perineal tears
€tlologg: O

"
rui ;"".'J:T3B'rore
crowning

- Narrow vaginal intoitus or subpubic arch

2f Papid stretch o.f perineum

r t#:11ffi1T:adorbreech
3) causes in eerrsgrul,e.g.
elderry pG or previous scar)
- Edema (e.g. PET or obstructed labor)
4f Iniurv o.f perineum + forceps...ventouse... .destructive operations

Dqreas (incomplete or complete)

1"t degree -+ vaginal wall + perineal skin
2nd degree -+ * perineal muscles + levator ani
3'd degree -+ * external anal sphincter
4th degree -+ + rectal mucosa (some consider it 3'd degree)
* Hidden peineal tear
Tear in the perineal muscle without any visible tear of
the vagina or skin -+ predisposes liater on to rectocele
)
Conrpllcotlons
Eorly -+ Hge + infection ooo
Late . incomplete tear (1+2) -+ prolapse C
. complete tear (3+4) -+ incontinence of flatus & stools 3
. improper healing -+ recto-vaginal fistula =
o
. poor healing + scar -+dyspareunia 3
o
-l
Treotment
=
o
9 Prophylaxis e proper management of the 2"d stage + episiotomy (o
(if there is overstretch or the perineum is about to tear) o
9 Active a immediate surgical repair (within 2448 hrs of delivery)
I Old complete perineal tear
- If later -+ ) wait3-6 m (tissues may be ederratous + infected)
- Anatomical repair in layers [Lawson Tait operation]

WhiteKnightLove
 Local
infiltration
anesth.
lignocaine 1o/o

Upper
segment

Lower
segment

Cervix

Vogino

WhiteKnightLove
Technioue of relnir
* Local infiltration is better than GEA
* Intemrpted sutures are better than continuous
* Vicryl is better than chnomic catgut
* Sutures are taken from above downwards
o Rectal mucosa -+ lruveRtrD LAMBERT sutures (to avoid mucosa)
o Ext. anal sphincter -+ approximate the 2 dimples at sides of anus (tom ends)
. Deep perineal muscles * Levator aru
o Vaginal wall -_> continuous or intemrpted stitches
o Superficial perineal muscles & then + perineal skin closure

Post-opetzthrc care
o Minor degrees + local cleanliness
o Major degrees -+
- perineum: dry, clean, antiseptic as betadine (povidone iodine)
- diet: NPO for 48 hrs, then -+ low residue + increased fluids
Laxatives are used for 2 weeks (stools should be soft)
- s2stemic antibiotics... .....intest. anliseptics (neomycin + flagyl ..5ds)
- no rcctal suppositories. . . . ..No sexuq[ intercourse for 2-3 ms

t2l Uaeinallears u
€tlology: as perineal tears

Dlognosls
o Traumatic PPhge (fresh blood *contracted uterus) :,
o EUA (with good light + retraction by Sim's speculum o
+ Auvard self retaining post vag wall retractor) I,
o
Cornplicotions
E
Earht -+ Hge (sometimes difficult to control O linfection 3
CoLPoRRrmxN (rupture of the vaginal vault or post. forrux)
Late =
o
- If bladder is involved -+ vesico-vaginal fisttrla or incontinence 3
o
- If rectum or sphincter -+ recto-vaginal fistula or incontinence
- If levator ani -+ prolapse =
o
- Poor healing -+ vaginal stenosis -+ dyspareunia GI
o
Trootment a resuscltotlon l=t
- Immediate repair (from above downwards)
- Iffaited -+ vaginal pack + catheter + abcs (for 24 hrs)
- If failed -+ bilateral internal iliac artery ligation.

WhiteKnightLove
Bo ing Thinned out lower segment

$-1 Cervix. teo.rs owoy from

ssq

Vulval
hematoma ,l
T-)
on cervix

WhiteKnightLove
 t5l Cervical tears
€tiology:
o causes in tbePassaE -+ cervical fibrosis
o causes in the?assenger -+ large baby
o causer' inpower r ppt labor
obsletric oPerations -+ forceps, ventouse , manual dilatation of cx
TVpes
I. Unilateral
2. Bilateral
i. Stellate (multiple radiating)
Diognosed by €Ufl athe cx is grasped by "4" rjnrg forceps at its 4 corners
Conrp!lcotlons
> Eerrs --HrLffiJ[:-' o
iritextended upwards
- Ureteric injury -+ during surgical repair

> Lgte . Patulous internal os -+ habitual abortion & preterm labor

. Chronic cervicitis + infertility or cervical dystocia
. Ectropion -+ eversion of cervical lips in bilateral tears

Treotment ? resuscitation + suturing cx tears from apex downwards

NB: she may need cerclage in next pregnancy

t4l Genital tract lpmatomas M

:,
€tlology a . Traumaticvaginal delivery e.g. forceps o
. Sometimes occur in normal spontaneous labor
o
I,o
q

* Vulval finfra-levator) C
- Presence below levator ani -+ prevents its upward extension 3
- There is lense lender bluish fluctuant gwelling at the vulva =
o
- ttt ^. observation if small & localized 3
o
rt
* Paravaginal (suora-levator I rl

-
Sometimes not easily seen (felt by P/V) =
o
- May be suspected by sense of rectal straining (due to pressure) ct
o
o
-
ttt *) evacuation only if large + drain + packing the vagina
*
- Progressively expanding + broad ligamentary swelling
- It may dissect its way upwards -+ rnay even reach up to diaphragm
- t
ttt ^a laparotomy: evacuation bilateral uterine artery ligation

WhiteKnightLove
Seqr ruDture (bleeding is less as scar is fibrotic) "

WhiteKnightLove
 t51 Ruptre utens h
lncldonco
'
o Varies according to level of obstetric care (1/1.000 + 1/4.000)
o Rupture uterus is the worst complication facrng the obstetrician
o It should be suspected in any patient vith collapse during or after labor
o Moro common in MG " 060/") dua to
- Passage a
weak uterine wall & pendulous abd. (-+tmalpresentations)
- Passenger at fetal size (&t o/o of DM)
- Power oll uterine contactions in response to obstruction S
- Attendant +false sense of security

€tiology O@
cr Durlnq )rsgnrnes.....APll[l
A- Spontaneous
- Ruptured previous uterine { scw o 6JUS >LUS)
- Rupture of anterior sacculation -+ in fixed RVF
- Rupture of posterior sacculation -+ in ventrofixation
- Rupture of pregnancy in rudimentary hom
- Invasive trophoblastic disease
- Placentapercreta
- Concealed accidental haemorrhage
B- Traumatic
- Traumato the abdomen (0.g. penetrating wounds, seat belts)
- External cephalic version (ECV)
ct Durln[ hbor........PP[hg
A- Spontaneous 5
- Same etiology as during pregrumcy (scar/) too
- Obstructedlabor // (the commonest) rt
- Maluse of ecbolics c-I
B- Traumatic
3
-Obsteffic operations < full cx dilatation (/forceps) =
o
-Excessive firndal pressure 3
o
-Manual dilatation of cx or extension of a cx tear rt
-l
-Manual removal of placenta
o
=
o
GI
Tt/pes o
* Cqnd€te rupture GruS) all 3 layers (including peritoneum) are ruphred
\ massive intraperitoneal haemorrhage
o
* lncorplete rmtffe (LUS) muscle layer is only ruptured with intact peritoneum
\
subperitoneal hematoma (occult ruptue) or

WhiteKnightLove
RUPTURE of CLASSICAL CAESAREAN SCAR ---+

RUPTURE of o LOWER SEGMENT SCAR

SPONTANEOUS RUPTURE

WhiteKnightLove
Clinlcol Picture
pture

1) lmpendinq (threqlened) ruplure of scor

* Separation of the fibrosed edges of a scar
o
. min. symptoms (tender scar) or signs (vag. spotting) d.t. fibrosis
. The patient may even come to hospital walking (silent rupture)
" UiS -+ gapping (dehiscence) of the scar
2) Fronk rupture ulerus (acute abdomen)
o Symptoms
- Sudden severe abdominal pain, followed by
- Collapse (internal hge: usually sewre esp. if ut. vessels are tom)
o Signs
-
General -+ Shock
-
Abdominal -+ . T, R, RT (Late: Cullen's sign, shifting dullness)
. Fetus felt abdominally with -ve FHS
, Uterus retracted away & becomes lax "
-uun-'1""'":',lii,*rTr,.T#,,'ffi
orurinarybtadder)

1)Obstructed lobor
o Symptoms: Of obstructed labor, then
- Cessation of labor pain + sudden severe abdominal parn f
- Vaginal bleeding (& feeling of something giving way ") o
I,
- Collapse (d.t. both vaginal & intraperitoneal hge.) o
q

- Cessation of fetal movements c

o Signs 3
- General -+ shock + dehydration =
o
- Abdominal -+ as in preg... .. 3
o
- Vaginal -+ of obstructed labor . vulva : edematous rt
. vagina: dry hot edematous =
o
. cervix : edematous or tear GI
-+ Plus . vaginal bleeding
o
. presenting part may recede upwards

2) Trqumqlic rupture (forceps)

o Suspected by - PPhge following obsteffic operation
o Discovered by -+ Routine fundo-perineal examination

WhiteKnightLove
 After incision of the peritoneum ot
Division of the follopion tubes ond the site of rupfure the blodderis sfrip-
brood ligoments, leoving behind the ped from fhe uterine wqll ond o sub-
ovories ond port of fhe tubes. totol hystereclomy performed.

WhiteKnightLove
Dlfrerentlol dlognosls
ll Bleeding according to time (APhge , IPhge , PPhge)
2f Acute abdomen in pregnancy or labor

Complicotions
ll Msternql
" Martali4t(10%),+ hypovolemic shock * acute renal failure
"* *''j#{{,:T#
ffiriu*H[Til;**r
**
(as rupture is > on Lt side d.t. dextroratation)
2l torrl
* complete rupture -+ 700o/o mortality
'k incomplete rupture -+ 60Yo mortality

Treotment
> Prophvlaxis
1-PrEer antenatal care
't Early detection of any abnormality needing CS (macrosomia, CPD)
,. GMP rnust deliver inHospru.r, (why?)
* Patient with previous uterine operations must deliver in Hosprrer
- One LSCS + may try vaginal delivery
- Two or more LSCS -+ elective C.S. at completed 37 wks (38)
- One USCS or hysterotomy + always C.S.
- Previous repair of rupture should be hospitalized all-through
f
2 - Proper intranatal care o
l,
'r Early detection of signs of obstructed labor o
* Proper use of ecbolics -
c,
* Adequate precautions in operative obstetric deliveries 3
't EUA if PPhge occurred for early diagnosis o
3
> Active o
o Resuscitation
o=
o Laparotomy'midline incision' ct
-
Supravaginal hysterectomy (ideal m) //-rnxE ruE ovAruBs-o o
-
Bilateral IIA ligation may be needed to control hge.
-
Exploration of injury of other structures (bladder, ureter)
(}<
o Conservation (repair) of uterus may be done in limited cases '-a
-
PG, young patient. ...Clear cut edges, small wound
-
Patient must be hospitalized next pregnancy

WhiteKnightLove
RETAINED PLACENTA

WhiteKnightLove
Deflnltion (o.s - l%)
Failure of delivery of the placenta
within Yzholr of delivery of fetus

Physlology of plocentol seporotion

Depends on uterine contraction & rctraction. The placenta
being inelastic -+ can't cope with the J in uterine length:-
O Sepqrqtion of placenta at the line of cleayage between it & the uterus
@ Followed by placerfial descent through the genital tract

€tiologg OO

q Rehined seDqrqted
= ftilurc of Dlecentql descent
-uterine
-contraction (constriction) ring
-complete rupture uterus + escape of placenta to abdomen
-full urinary bladder

I Retelnsd edhorsnt

* Simple adherence due to (uterine atony, DM, RH, syphilis)

'k Morbid adherence

5
'o':'!:;:,f,!:f::"{'lili{rmyomeff o
iarinvasion I,
o
- placenta increta: > l myometrial invasion c+
-t

- placenta percreta: invading peritonium even into bladder 3

. According to number of coflledons inuolued -+
=
- adhesion may be focal , partial ,total
o
3
. Cause., of adhesions (more in GMP) o
1. Placenta previa
=
o
2. Scar tissue due to ((l
- Previous C.S. , myomectomy o
- Previous manual separation of the placenta
- Endometritis
3. Presence of congenital uterine anomaly (as septum)
4. Submucous fibroid
5. Congenital absence of layer of Nitabtch

WhiteKnightLove
I. Perforation of uterus
2. Uterine irritation + fibrous tissue
3. Retained placental fragments +
-Sr
- Placental polyp
- Malignant trophoblastic disease

WhiteKnightLove
Clinicolplch.lrc

o Histor!
- Failure of placental delivery for %how
- Bleeding -+
. If the placenta is not separated at a11.....no bleeding
. If it is completely separated.....,..........minimal bleeding
. If it is partially separated. ..massive bleeding

o Examination
- General -+ shock (hypovolemic + neurogenic from Crede's method)
- Abdominal -+
. Fundal level elevated above umbilicus
. Signs of placental separation *ve or -ve
. Uterus may be atonic

Trootment resuscitation +

> ActlYe 3dsfiqp mlnl[emont

- Ecbolics , massage , Brandt Andrews method -+
- This will deliver ilt unadherent placenta in ttre
absence of contraction ring

> lf ftllod ,+ llrnurl seDqrqtfon 0f Dlrcontr under rnssthch

o Contraclion ing f
- treat by delivering under GEA (halothane) o
- if failed + give uterine relaxant as amyl nitrite or other tocolytics
E
o
Ruptur ulerus -+ laparotomy E
"
o Placenta 3
adherent
- reach the margin (line of clea\tage between placenta & uterus) =
o
- take a fold of membrane, separate the placenta by sawing flumner 3
o
- placenta must be fully inspected for missing parts.
=
o
> lf ftllsd ,.r mmDld rdherenca of Dlqcontr (o
o
"o S wprauagirual (iffutstervaoryt (ideal ttt)
Conseruation in much need of children & bleeding is not severe)
3 - Cut the cord -+ leave the placenta or do morcellation
- followed by * methotrexate, methergine, antibiotics
- BUT still remains great hazard of hge & inf. -+supravag.hyst.

WhiteKnightLove
WhiteKnightLove
foe11"iiio"]
Paradoxical situation in which both lhrombotlc &
fiffiicfttlc mechanisms are simultaneously activated -+
llrcrth coqgulqtion & @are present in the same time

o Presence of certain causes (severe / persistent) -+ activation of coagulation

. Dissemination of thrombosis -+ tissue ischemia & infarction
/
o Consumption of platelets clotting factors + activation of
fibrinolytic system -+ failure of clotting system -+ bleeding $

"o liberation of tissue th,romboplastin

corNiurnDtion in retromembranous hematoma
- endothelial damnge + collagen exposure

o liberation of tissue thromboplastin

o procoagulant activity of amniotic fluid

liberation of tissue thromboplastin

ion in the dead fetus
o liberation oftissue thromboplastin 5
+
o release of bacterial endotoxin o
- By infiarmiotic injection of hlpertonic saline oo
-t
or urea + necrosis of uterus -+ thromboplastin c,
3
forms comolex with fibrinoqen + inactive =
o
>5 udt or old blood -+ 3
o
-t
-t

- liberation of tissue thromboplastin e.g. placenta =

o
GI
accreta. rupture uterus o

Eii1. Proper
Pilluia
a

anticipation (presence of pdf e.g. abruptio placenta)

2. Thromboembolism -+ pulmonary, renal, ... . infarctions
3. Bleeding tendency -+ petechiae , @!U!ig, PPhge, .., .

WhiteKnightLove
 (rlogulatnnfactors

Chrisfinas factor

lfclcfirurp
Intsinsic
Surface activation + colla
)ilI+)il+lX+X VII+X
Assessed bl'PTT

HEMOgTAgIg OF IHE
Arcuala vcEscls iyofietial
llotc, vl,lril'r hctn0f,tasi)6'to Vtnanly dcpct:dicnt on
ad proaf4bfMia gro/,wtioi, anllc# oi t E cnquletnn ca*,adc

Utarine art ry la brarch of iltc Wc/,natful cdl @nlractions nafio* tlr-

inurn al iliac I hypogaouk, afiz;ry) artdps ail diminieh bbcdinq

WhiteKnightLove
 9 Corgulrtlon mofffu
1. Platelet count (N: 250,000/nrl). tlrombocytopenia is < .,. ....
2. Fibrinogen (I.t: 200-300mg% - inpregnancy : 400-600mg%)
3. Fibrin degradation products (N: 10 pgml) in DIC > 40 pg/ml
4. D-dimers (inDIC >0.5 pglml)

9 Pmlongsd
1, Bleeding time (N: 2-4 min)
2. Clotting time (N: 6-12mr$
3. Prothrombin time (fI: 12 sec.)
4. Parlial thromboplasfln time (N: 35-45 sec)
5. Thrombin time (time needed for conversion of fibrinogen to fibrin)

9 Weiner rut (oht observrtlon test...poor mtn's &d sue test

elotl
- 5 ml blood rn a test tube + clot forms in6-12 min & dissolves >30 m
- Failure of clotting within 15 min -+ fibrinogen <100 mgo/,
- Early dissolution before 30 min -+ increased fibrinolysis

[1] Treatment of the cause

o In most cases by termination of pregnancy as early as possible
o Vaginal delivery is more Wkalthoagh CS is more rapid
=
o
t2l Life savinq measures uo
o Resuscitation
o Correction of coagulation defects c,
- Fresh blood transfusion 3
- FreshFrozen Plasma (fibrinogen + coagulation factors) =
o
- Cryoprecipitate (dried fibrinogen or some coagulation factors) 3
- Platelet transfusion o
-l

=
o
[3] Don't give @
o
. He?ain -+ as it increases bleeding (except in IUFD: as there is
intact vascular tree -the patient is not bleeding- then
heparin is stopped & TOP is induced after 6 hours
, Anttrtbiobticdrugs -+ as it increases thrombosis
(they atso cross placenta to the fetus)

WhiteKnightLove
 First Degree (l ncomplete) Second Degree (Complete) Ib!d 9.st""

Undue itrctlon on a tundally sltcd plrcenta wlth-

out guardlng the uterus may result ln utcdnc lnverrlon'

(c)

through the cervix

Replaclng en lnverted uterus. (At Recognition of uterine inve.sion. (B) Replacement of the uterus
(Cl Restitution of ihe uterus.

WhiteKnightLove
Dafz a condition in which the uterus is turned inside out immediately
after labor & before cx constriction (v.rare 1/3.000 - 1/30.000)
Degroes loo -+just cupping ofthe fundus
2ndo -+ inverted fundus protrudes through the cervix into vagina

3'd' -+ inverted fundus appears outside the vtrlva (the completetype)

€tiology CreJ.e'
Iatrosenic (bad 3'd $age management) {/
1. Crede's method while trterus is lax
2. Cord traction while placenta not yet separated
3. Manual removal of placenta esp. if it is adherent
Soontaneous + precipitate labor or excessive straining

Clinicol PicUre
q Hktoru
'k severelower abdominal pain with continuous bearing down
* Fullness
12"d; in or something protruding (3") from the vagina
'r PPhge (atony) may be minimal if
. Placenta is still attached
. In severe degrees with kinking of blood vessels
c+ Errmlnstion
* General -+ Shock (hypovolemic & neurogenic)
't Abdominal: ls degree -+ cup shaped fundus
.2"d & 3d" -> absent fundus
* Vaginal
:,
- 1s.-+ depressed fundts inside the uterus -i
o
I,o
: ?:l ;ffi fi ;H,"#3:,ffi'[T,lrfH" !

c
Dlfferentiol Diognosis 3
1. Causes of postpartum shock
2. Uterine prolapse (the cervix -external ostiurn- is found) =
o
3
3. Fibroid polyp (uterine sound passes all around) o
rt
Treotment
-
=
o
> Prophylaxis o
avoidpdf + proper 3d stage management GI
o
> .Ective a Resusdtation + Manual rvductioru (or hydrostatic " )
(JnderGEA (halothane / o*llnitrite / tocofitics)"
- First reposit the uterus then + remove the placenta "
_ Then + ecbolics + massage
- Then -+ Pack + antibiotics

WhiteKnightLove
WhiteKnightLove
lncldence ,,+ 1/30.0000 with 50% mortality
€tlologg
o AF may enter into the maternal circulation d.t.:-
l. Increased irutrauteine ?ressure
I accidental hge, oxytocin overdose with intact membraneso
2. Ooened uterirue or endocerviwl aeirus
\ as in genital tract lacerations e.g. rupture uterus
o The above factors also lead to fetal distress -+ meconium stained AF ->
this potentiates the toxic nature of AF + worsens the symptoms

Pothogenesis
o bumedbttefi afteradifficult delivery:-
or shortfi
- RDS & circulatory collapse (extensive pulmonary vascular
obstruction d.t. the Af' particulate maffer -)
acute cor-pulmonale -+ abrupt hypoxia & CIIF)
- DIC -+ bleeding from genitaltract & all other sites of trauma
-
- Deep coma & immediate death (>500/0)
o Recent!, it is proved to be a form of anaphvlactic shock to the
antigenic AF (thus AF embolism is a mis... ... .)
Diognosis
o Saspected in -+ any case of sudden postpartum collapse & DIC
o Proued b1 -+ finding AF debris (fetal squamous cells, lanugo haiq
vernix) in the pulmonary vessels by autops)t"
o lruuest'igations -+ECG, chest X-ray,V-Q scan
f
ooo
Monogernent
o Verl dificult (serious > pulmonary embolismo ) -+ only few cases succeed
\
o Immediate transfer to IC\J -_Cardio-pulmonary support C
-Management ofDIC 3
- Corticosteroids
=
o
Monitoring different organs 3
o
=
o
(o
o
Oh|flGctru tlorrolctdlh qrce3
- lv PPhge:- rupture / {,-,-,-,-
- Cardiogenic e.g. peripartum cardiomyopathy
- Eclanrpsia - Cerebrovascular accidents
- Pulmonary tlrombo-embolism - Anesthetic complications e.g. Mendelson $
- Amniotic fluid embolism ;$pp-phy_!ac"!ic-sho-gk

WhiteKnightLove
Resuscitation. A. Algorlthm. B. Position for
cardlopulmonary resuscltation.

WhiteKnightLove
Definition, ,"+ a state of circulatory failgre
(
hypotension, tissue hypo-perfusion

€tlo,!o9It
o Hgic *rock a bleeding in early preg., APHge, PPHge
o Hypovolomic a dehydration (hyperemesis gnvidarum)
o Neurogenic opainin early preg., pain in late preg.
o Septic a septic abortion, chorioamnionitis, puerperal sepsis
o Pul. embolisrn + amniotic fluid or tlrombus
o Splonchnic a sudden drop of infrauterine pressure (polyhdramnios, twins)

fiitni.ol f i.tuiel
) History suggestive of
-Etiology e.g..missed period + acute aMomen + disturbed ectopic
-Pdf e.g. .. ...preg comp (anemia, P[H)..lobor comp (prolonged / obstructed)
) Examination
1.General -+ shock'.- low B.Pr., subnormal temp, rapid weak pulse, pale
cold clammy skitL peripheral cyanosir, otig*iu
2. Abdominal
- T, R, RT -+ internal hge e.g. ectopic
- Bilateral adnexal swellings -+ V.mole
S.Local
-
Offensive discharge -+ sepsis
- Vaginal bleeding -+ hgic
fieotmeni
) 0enerqf o=
- Intravenous cannula..... Analgesia (morphia 15mg IV) I,o
- Raise legs... ... 02 inhalation... ...Warrnth (but not direct, to avoid VD) -t
> Monitoring (by fluid input & ou@ut chart)
c
3
- Catheteiaation -+ urine should not be < 30 ml/hr
- C\fP -+ kept between 8-12 cm I{2O =
o
- Replacement + start by available fluids till blood is ready
3
o
> Drugs
- Vaso-pressors t inotropics =
o
GI
- Corticosteroids, correction of acidosis (Na bicarb) o
- Antibiotics (in septic shock)
> Special
- Disturbed ectopic... ..laparotomy & salpingectomy
- Acc.hge. . ... ....TOP better vaginally
- Rupture uterus... .....laparotomy & supravaginal hysterectomy

WhiteKnightLove
 > Typec
O Maternal
't Cenltql hqct trqurnq
o Tissue lanrations (perineal, vagrnal, cervical, uterine)
o He matom a forru ati orc (vulval, vaginal, broad ligamentary)
o Tirue neno$s (bucket handle tear of cx, necrotic fistulas)
't Non-genitel trqet hqqtnq (usuqllg d.t. forceps)
o Injuiu ofpeluicjoints & bones -+ rupture SP, cocclx, sacro-iliac lig.
o He n
1rg% ilHlxH:ffi::rTJ;:[ epigastric vesser s
More common in MP after strenuous labor efforts
May occur after cesarean section
C/P + sudden severe pain shock t
@ Fetal (esp in breech)
"' I leutl in1uryt(ICHge, fractures of the skull)
"' Padpltcrul nan'e (brachial plexus, facial, phrenic nerye palsy)
x hluvulo-.rkalata/(fracture clavicle, other long bones)

" .\'q/i li.r.rue (stemomastoid, head, abd organs lacerations)

Lotg teru requelae

Vaeina Ceruix Uterus Leuator ani
Dvsnareunia chronic infection hysterectomy Prolapse
o Fistula Infertiliff rupture uterus m
o)
o PIO. PTL next preqnancv
E
cervical dvstocia ureteric comD.
o
E
o
.c,
E
= Sltort term
o
o - Causes of PPhge. inctuding 3'd stage hge (retained placenta)
o - Shock & its complications -+ acute renal failure & DIC
c - Amniotic fluid embolism
- Complications of anesthesia & blood fransftrsion
Long term
- On puerperium -+ 35
- Infertility --> due to hysterectomy or Ashermarur syndrome
- Prolapse & incontinence (urinary & rectal)

WhiteKnightLove
-r7

-1
-J
.J

Pre-eclompsio
Diobeles milletus
Heort Diseoses
Hyperemesis grovidorum
Urinory lroct infeclion
Anemio
Thromboembolism
Thyroid diseose
Respirolory diseose
Surgery & Poin

WhiteKnightLove
 The

Prostaglandln metabolism.

WhiteKnightLove
 , Occurrence of Hypertension, Proteinwia, p athol o gi cal Edema
. In the 2d half of pregmncy in a previously healthy woman
. Mainly affeotingPG
- Pm 4 Pregnancy Induced Hypertension (toxemia is a misnomer; PET ,()
- EPll-gestosis + Edema, Proteinuri4 Hypertension (by gestosis organization)

tid It is the conrmonest / medicaldisorder in pregnancy (s - l0%)

... ..,...... flnknown (disease of theories)...... ......?RIGO

ttl Prostqslqndin imbrlrnoet J prostacycliq PG-Ez &....nitic oxides (EDRF)

t thromboxane o & PG-F2, .&... ... ... ..fibronectin
tzlllenln-qndotolrln rstiuttton + with I sensitivity to angiotensin II
\ severe VC & aldosterone secretion

t3l Ner theoilo!

- l--urologicat -) abnonnal immune response to invading
trophoblast & fetal antigens (.'. it is > in PG)
- Gnetic predisposition -+ multifactorial ? recessive ?

l4l OUothsorlc,xx
- Dietary factors. .....J vit. -t fat, salts (smohng is protectivell\)
- Cold whether. ..... .. seasonal variation (m.b.d.t. vasoconstriction)

o Potient ccc 4 . Extemes of age (<20 or >35)

(low socio- . PG exclusively (however it may occur in MG) ('
economic . Obesity a
. +ve family history
o
class)
3
o Obstetlic disorders a PIH is more comrnon when there is large volume of o_
!
chorionic tissue . Twins )Iteven
o
. Polyhydramnios ) may occur (o
. Vesiculqr mole
) in the 1* 1/z =
o
.fff;sfetaris ) of preg a
o
o
o Medicol disolders a D.M. , chronic hypertension, chronic nephritis, SLE

WhiteKnightLove
 i Ccabrd vesolrr rc.bt ncc
-- I nblr of -r"Ua hcrrorrrtlgr

morrttatk
,tcolosl

Hlgh rlrbtuor
Eatck.-
.homd Dopplcr. olg@nnnloo + luGR

End-orgiar cfiects of f-GdamFla.

WhiteKnightLove
 o VacocpasmE+ cn.totmt|a ceu tnfury + hypertension * hypoxic injury
I - degeneration of cells & hge
o Multiple organs are involved .'. it is a sunctrcmo (not a disease)
and... ...HyprnrgNsloN... .. is the milestone of this syndrome

icotions the 2nd cause of MMR. h

O Maternal
> lmmedlqts
- CttS -+ cc[omDsEo, cerebral hge / infarction, cerebral edema
- Retina -+ papilledema & retinal hge (stellate) + detachment
- CvS -+ , hypertrophy of heart (cardiomegally)
. Up to acute FIF
- Resp -+ laryngeal edema, pulmonary edema
- Liver -+. Mainly periportal necrosis -+ Jaundice
. Subcapsular (Glisson capsule) hge & rupture
- Kidney -+
Proliferation of endothelial, epithelial, mesangial cells -+
narrowing ofthe glomerular vessels *
J Rep g J Cf'n
* Damage of glomeruli -+ proteinuria -+ edema
* Two major complications may occur
. Renal tubular necrosis (reversible)
. Renal cortical necrosis (irreversible)
- Adrenat -+ acute adrenal failure -+ Addisonian crisis
- iletabolic -+
'k Salt & lI2O retention
* Haemoconcentration o 1J intravascular volume o )
't trEGGP syndtrorc in severe cases CK
\ Hemolltic anemia, Elevated Liver enz., Low Platelet
> Remote
- Residual hypertension or proteinuria (5-10%'1
q
- Recurrence (MG) 30-50%
=
o
€) Fetal & placental 3
o_
> Normqllg -+ the trophoblast invades the media of the spiral vessels of
T'
decidua at 20 weeks (2v wave of trophoblastic rnvasion) o
(o
> tn Plll -+ this is absent -+ the media persists -t
vascular resistance f
o
\ []UGM & IUFD
JI
)
'k PTL (idiopathic or iatrogenic/) o
,r ADrrrrpGEo D[ooonGo -+ DIC

WhiteKnightLove
Vlsual dlsturbance
e.g. flashlng llghts and
papllledema lf severe

I Blood
! pressure

output
{Uane

Brisk reflexes, clonus

Signs and symptoms of

pre-eclampsia.

'*
is#

Eerly dotoctlon of prc<llmp3h Ir lmport nt, (Al

Measurement of blood pressure (reproduced with permission).
(B) Testing for urinary potein.

WhiteKnightLove
> Symptoms:.. ..........oNLY tN SEVERE cASES
1l NeunolocrcAL oyMPToM6;
- Headache (frontal, persistent, not responding to analgesics)
- Nausea & vomiting
- Visual disturbance as blurring of vision up to 0 visual acuity
2l rrtonsrntc PAIN + stretch of liver capsule (or subcapstrlar hge)
3lotreunrA (<400 nfl /dzy) & RltuRre (<100 ml /day)
4l svmrro,\1s oF ANv coMpLrcATroN e.g. IIF & trulmonary edema

> signs: ..MORE rnAp. & PRESENT < SYMPTOMS

ll Hgpertshslon
- t
S}stofrc> 140 mrnHg or 30 mmHg over previous value
t
- Oiastofrc({)>90 mniHg or 1S mrrHg over previous value
\ IVbosurad ot semislttlng ....or .... left lotarol posltion
2l Pmtelnurlq /
- Tt[on-setecthte
. A +
glomenrlar damage
serious sign
. Detected by -+ albustix

- Stgn:ftcant > 300 mgdl (1+). - normally nv 150 mgdl

lf -
\ll/bro occurcto if meosurod in 94 houts collectod urine
\ Recently spoE protoin / creotlnlna roEio ln o urlne somplo
\ Protoinurio ui*rout HTN is olso risky for both M & F
ty irlo no -symptomoti c Aestosi s (pr eoence only
of hypert eneion or Vrol,einuria may occur)

SJEdemq
c'
- Occutta detected by rapid gain weight > 1 kg (2 pds) / 2 wks
=
o
(Normally -+<Yzkglwk in2n & 3d rimesters)
3
- folan4festa dorsum of foot, shin of tibia (rnb. normal)then become g
non-dependant -+ vulva -+ worsiens -+ abdominal watl
-o
rt

@eau d'orange') -+ swollen fingers (rings become tighQ

o
@
+ puflV eye lids & papilledema. The worst is P.edema =
o
- Aisentodry pre-eclampsia (the worst 9) =
o
\€domo is d.t. (cop. domoge, hgpoprotoinomio, hgportonsion)
\€domo is not ossentiol for dlognosis 6 hos little prognostic volua

WhiteKnightLove
Ut rlna.itcry Dopplcr notchlng at 2f wccks
ls prodlctlve of prlecLmptl. and lntrautcrlne growtt
restrlctlon ln hlgh-rlsk mothcrs.

WhiteKnightLove
fo1r_effi ir_fro; other couses ofr
> Edema
Biloterol Uniloterol
| - fhysiological (at feet & ankle only)
- Generalized anasarca e.g. H.C.RN A
I:-D-YI
- veins
Varicose
I

- Endocrinal e.g. Cushing, myxedema

; L-ymp!3dS1na
> Hypertension
'k Pregnancy luouero hypertension
. PEr (PtrD
. Eclampsia: @ET + convulsions)
. Gestational (transient) hypertension is the appearance of
hypertension for ls time > 20 weeks in absence of
proteinuria & edema. It usually disappears > delivery.
'k Pregnancy Asoetarup (coincidental / chronic) hypertension
. HTN (> 140/90) present ( 20 weeks, or
. HTN l$ diagnosed in pregnancy & persists after puerperium
* Pregnancy AeeRevnreo hypertension
. Super-imposed PET (occunence of PET on top of chromc IIIN)
. Super-imposed eclampsia (occunence of ecl. on top of chronic HTN)
> Proteinuria
't False proteinuria (the commonest cause /)
\contamination from vaginal discharge; attoided by:
- Mid-stream urine sample (MSI, i.e, clean catch technique
-
Catheter specimen ,r (not preferable)
'r Urinary tract infection
'k Orthostatic (appear at end of day) -+ pr from lnrnbar spine on Lt renal vein

| . Renal function fesfs: uric acid ( l't tot ' ) -+ creatinine, urea
2. Liverfunction tests
3. CBC -+ Hct, HELLP
4. Coagulation proftle -+ DIC (platelet count, antithrombin III) o
5. Fundus -+ spasm, haemorrhage, exudate, edema a
o
6. > Fetal -+FWB /
3
t [5cREENING]: 9.
. Doppler -+ high vascular resistance {/
..eafly diastolic notch 'r,
o
(o
. Roll over test 1t nfr in supine position > 20 mmHg) S
a
. Cold water immersion test (t diastolic pr >20mmHg) S o
. Angiotensin II infusiontest $ =
o
. t plasmafibronectin, J urinary calcium $

WhiteKnightLove
c%tes

WhiteKnightLove
Clossificotionl
r Pre-eclampsia may be mild or severe if:- la Q
- Stgt s'k B.Pressure [Systolic > 160 mmHg - Diastolic > 110 mmHg]
't Proteinuria ) 500 mg/dl (++) or > 5 glLl24 hr collected urine
o

- Symptoms -+ appearance of any symptom esp;.... oliguria or anuria

- Comphcattor + Maternal (HELLP, DIC) orFetal (IUGR)
- lnverf;lgatlons -+ denoting any organ damage
r Fulminating Preeclampsia: (impending eclampsia)
- Severe PE (symptolns, severe proteinuria) + Hyperreflexia
- If left -+ may develop eclampsia [therefore ffi as eclampsia]

trreotmeni d)
3 Prophylaxis 3
o Earty detection by regutar anc/ / -+ BPr., albumin, screening tets (esp for HRG)
o Anti-plat€l€ts + as low dose aspirrn (75mg) or juspirin (81mg)
o May sive -+ vit E (anti-oxidant o), omega 3 (fish oil).

r Mild cases ;*
1l If mature e; Ternrinate
2l Otherwise + Conserve
" Bed / Mentql rest -+ sedatives in extreme cases...e.g diazeparr (5 mg/day)
" Diet -+ balanced i.e. -+ avoid excess [salt, fats, CHO], not salt restriction
'k AntihgpertensivoJ (some sqg no need: mild ease ) f
Actlon
o
a. llethsldopr lAldomet] Cental action
The most sofe & uidelg (acts as a false tansmitter in the
used in mild coses / brain + J noradrenaline).
p-block$! (olone or + \ )
used with caution -+ it .f placental
Nenililns (AaOr4 flow & FWB (used with caution)
o
)
''' Observqtion o
- Daifi +FHS/6hrs.. .....BPr. .......Albuminuria 3
- o
lWeek! -+ FWB. .......RFT, LFT, fundus....weight (for edema)
!
> Corticosteroids may be given to enhance lung maturity f o
(o
> Conservation is continued 2[fU till mahrity (37-8 wks) unless ] f
o
- Disease > severe PET )
- Mother -+ disfress e.g HELLP syndrome
o
-Fetus > dlslresse,g abnormal CTG, IUGR

WhiteKnightLove
 & Severe cases...TOP B
/
....The only cure in spite of fetal maturity...

* Eclampsia room or Obstetric-ICU

Patient lies on her side in a semi-dark quiet room with available
-+ Oz supply, mouth gag, tongue depressor, endotracheal tube,
suction machine, ant i conv ulsant drugs start ed immedi ate ly
* Obsenzation for
- Vital signs -+ BP, P, T, respiratory rate
- Level of consciousness
- Fluid intake & urine output + chart
+ During fit (emergency ffi...even done at home) -+ insert mouth
gag, avoid biting tongue, place on her side to prevent aspiration

[?l nltisgnvr.rlsont theropg_ -(.t"9 _covr-trol

& p.retent furrber frts)

Megnpsium sulfqte [MgSo+.7Hzo]

'k Route
- IV: /,/ 44 gm slowly (over 15-20 m) then. .t-2
gmlhr by drip
....
- IM: loading 14 gm(4IV+ 10IM -5 em/buttock-).....then 5 gml 4 hrs
\better avoided + sterile abscess I very painful
'k Action
- Peripheral skeletal muscle relaxant (J e.Cn & Ca* at NMJ) /
- Mtto Subcortical depressant
- Mto Transient hypotensive effect [vasodilator + diuretic]
'k Toxicity Signs
- Absent knee reflexes... .........8-l2mBqlL
- Respiratory depression.. .....12-15 fiEq/L
- Cardiac depression ... ...30 mEqll
- On high level ..neonatal resp. depression

o
f L6s of patellar reflex
Due lo lhis narrow oaf ef,y marqin (4J mEorlL),f,he following
o Flushing muetbe checkedbefore each doset
3 Sluned speech
- Knee jerk (patellar reflex) is still present
o_ Motor weakness

! R6plratory dep16slon - Respiratory rate not < 16 /min

o Cardiac arrest - Urine > 30 ml / hr (the only way for excretion)
(o
- Or the best + measure senrm Mg level
=
o
f
o 'k Duration ? continue therapy for 24-48 hrs after delivery or the lastfu
'! Antidot e o Ca# gluconate slowly 10rnl l0% solution t 02 t intubation
'k In resistant cases ? Phenytoin....or....Pentothal Na (Intraval)

WhiteKnightLove
 o The aim is to prevent maternal intracranial hge or IIF; but keep diastolic
I
BPr between 90-100 mmHg (to avoid placental bl. Flow -+ IUFD) I

Hgd?rlalne [Aprcoltne) Direct arteriolar VD

Drug of choice in t CoP, t renal flow l0 mg IV
o
Savaraao*, bolus
hbdrlol ffrrndrtel o and B blocker repeated at
It uosses placenta + fetal 15 min
bradycardia. Also contraindi- intervals
cated in pts with l'r HT block

llodtptne (AAml Potent drugs with rapid action + sudden

Sublinguol severe hlpotension -+ life threatening for
mother (cerebral fupo-perfusion) & fetus 1J
Dlrzorlde (M) utero-placental flow). Diazoxide also causes
most dongerous neonatal hyperglycemia

o Nipride (Na 4jtrogusside) r/

r) Tridil (Nilgoglyce{ne) rz

o Plosma volume exponsion o

givenwith extreme caution (volume overload)
o NO Diuretics et
hemoconc. & electrolyte imbalance (except in HF or P.edema)

[4f Terminotion /,/,/

r lnduction / augmentation of labor: r- + if delivery is expected soon
't By AROM & syntocinon
I't staqe -+ conti
2nd -+stage stage
Wg, - etrine after i ruay be given)

o Cesarean section: r
but first correct the general condition (anti-HTN,
MgSOa, correction of the severe metabolic acidosis due to fits) o
f
o
[5] Treotment of complicotiors 3
I Maternal,.. ,.. .renal shut down, IffiLLP g
r Fetal. ....IUGR 1'
o
GI
[6] Postportum a
o
Anticonvulsant therapy continued for 2448 hrs after... .
o
Antihypertensive therapy may be given if needed
Screening for PIH in next pregnancy (became high risk)

WhiteKnightLove
 Gsfclmpsta *
o
D";jiliiffi + occurrence of fits (grand-mal-seizures ) io a patient with
pET

Eo"tggvj
- Cerebral irritation by edema or elecfrolyte imbalance (tNa*)
- Cerebral ischemic foci by vasospasm or platelet ttrrombi
S_lini-Sgl p-is3_u191 . . . . . .C./P of impending eclampsia -+ Fits

r Stages of fits
1l Premonitotg / (3-5 min)
Prodrome
. Twitches in muscles of eyes or face, rolling of eyes
. Severe headache, disturbed consciousness
2l Tonic phese (30 sec)
All muscles of body pass into spasm Back is arched
(episthotonos), limbs stretched, respiration stops -+ cyanosis
3l Clonic phese
Intermittent contraction & relaxation of muscles + biting of
tongue, vomiting, aspiratiog spontaneous defecation or
micturition, stertorous breathing, falling from bed -+ fractures
4l Comq ctage (d.t. severe acidosis)
Variable + may recover OR pass into another fit (recurrent or
status eclampticus) OR dies without recovery

r Types of fits
Anteperturn eclernpsie -+ 70o/o"
lnhep+fum eclernpsie -+ 20o/o
Posfpartum eclampsir -+ l0o/o (worst 9), during I't 48 hours up to... .

Ei ;r6i jr
(the disease process is continuing though pregnancy has ended)
c'
=
o
-t
;;
3 Convulsions
o_ - Cercbral epilepsy (similar!!), ICIIhge, infection, tumoq trauma
!
o
- Metabolic. hypo- or hyperglycemi4 hypocalcemia (tetany) / Tetanus
(o
)
- Poisoruingbystrychnine
o - Hysterical{
=
o Corne
- Cervbral......metabolic. ..Qoisoning
- Organ failure as uremia or hepatic failure

WhiteKnightLove
filpii.et ionsl OO(D
O Maternal (MMR e l0%)
> CornDllcqtioh of conuutsions
* Asphyxia due fo
- Tonic contraction of respiratory muscles
- Inhalation ofvomitus
- Inhalalion of blood from bitten tongue -+ aspiration pneumonia
- Tongue falls backwards
* Seuere metabolic acidosis
* Hyperpyrexia
> ComDllcstiom of PET
* Organ failure e.g. heart, renal, suprarenal, hepatic failtre
* Haemorfiaee in vital ortans e.g. IChge, abruptio placenta

€) retat (high PNMR + Bo%)

> IUGR (placental insufficiency)
>PTL (spontaneous or iatrogenic)
>IUFD (accidental hemorrhage, nraternal hypoxia in fits)

* Bad prognostic sigrns (Eden's criteria)

1] Fits -+ recurrent (esp >6) & postpartum
2l Coma ng (esp > 6 hrs) & deep
I a1 viar a
igP. Systolic > 160 rr-ffg-Diastolic > 110 mrnHg I

* Pulse >120 .......Temp > 38oc. .RR> 40 hn:rr,

4l Oliguria, Anuria
5] Dtyeclampsia
6] Oryan damage + HELLP syndrome (olive greenjaundice).. SoS

Md ;-"! the same lines as in severe PET.

r Eehmpslr morn,...
r Drugs c'
- Anti-hypertensives =
o
rt
- Mg-SO4 3
r Exsminsffon a TOP o_

- If favorable @ishop > 8) -+ induce labor !

- If not favorable @ishop < 8) -+ CS (after correction of acidosis)
o
GI
r Cqte of erlmplicrtions =
o
- Matemal =
o
- Fetal

WhiteKnightLove
 funnwy of t]rc nwngement ol prqrcrcy-r'ndrced hypertensron

Cla$lncrtlon Nurrlng rccponrlbltlder Obttctrlcl.n3'tre.En.nt

Fotential PIH Report siSdf'cant rise in Hood prssure, Ustnlt no trealrrent requiEd.
orexcessire udg*rt Bah,to obstetrkiao. See patient in 7 drF

Mild nH REport rise in Uood Fessure or excessiw Fo6siue a&nbsion to hospital. dependhg ort
ueightgain to obstetrkian socio-economk cordilions,lfnor adritted
seepatiarth3dayr,

Moderate PIH ln hosciu[ A&nit to hoscital.

Four{ourly recordiry of the Hood pressure.
Plotein.
Iwke-daily urire testing tor
conditim,
Regular observation of the patient's
irrludhg 0uid intake and outpit.
Bed rEst, hrt tcilet prMQes allov,ed.
S€datb.r (if indkated).
Labetalol (starting) l00mg twke daity c atemlol
(startind l00rng in evenhg o o>prenolol
(startin$ 20rn8 three times daily oi rnetb/dopa
(startind 250rIl8 titree tirnes dailf
Nifedtpine l Omg sublingually repeated
as needed.

Se!€r€ PIH Trro-hourty blood presstre recording br Admil to hosfitat

6 hourrthen 4-hourfr DependirE on the saerity ofthe ilhess give:
tlirE testing for proteh and acetone a) Magnesiurn suplute (see page 126).Ttris is
twke daily. the preGned medkation
Fh.ridhtake and otrtput recorded. b) l-ly#ahzirc intraanoxly
for
Carcfrl obeervation of the patient hrraiEnous frus€rniie 20 mg or staue plavru
the signs oflrrrirrnt echrrp6i.r. protein qbstitute (SPPS), ifpeEistent oliguria.
Completc bed TEst for 24 hourr thereafter ?Caesarean secti:n.
possiUe tdht privileSes

lnmiut edampsia ThG patient,€qtire6 careftd synerrratic Magneiun srlptrate (see page 125).Tl$s
obsenation as eclarp,sia is a poslle outcome. is the feErred medcatixr
Thc Hood prcssrt requires freqrent fldralazh'nta,arcusl7
estinatlra at hGrvals determined by the Caesarcan seaion.
ob6letskian
nrU hlake and triury ouqn rr6t be
meaned nrtkdorty.and thc l,iE t6ted
qrartitati^Gly ror protein.

WhiteKnightLove
 ilg{ a presence of }ITN < pregnancy....or....< 20 vrks
- Primary (essential) //
- Secondary e.g. Renal, Pheochromocytoma, Cushing
synfuome, Conn's disease,
Coarctation of aort4 Thyrotoxicosis

- Old age, high panty, +ve family history

- Cardiovascular risk factors: smoking, tplasma lipids, obesity, DM
* 5Y/v\PTo/v\-1E55. Ask for
)
- Duration of hypertension before prsgnancy & ttt received
- Previous complications
. Medical: stroke, myocardial infarction
. Pregnancy: supenmposed PET, IUGR, IUFD
't 5lGN5
- Hypertension:
l)<20 weeks, or
2) it it persists after
I rr,rito
Moderate
I
l e9 - 10I
lOs-115
puerperiurr Severe > 115
- No edema or proteinuria (unless complicated by superimposed PE or tIF)

...........reflect chronicity..........
o ECG changes & cardiomegally
o Renal functions -+ creatinine clearance
o Fundus -+ atherosclerosis + hge

tll Efhct of Drq[nqncs a huDertuBlon

* Increased severity
ct
't Superimposed PE when s f
- Blood Pressure (S: > 30 mmHg lD: > 15 mmHg) o
- Proteinuria + Edema 3
o
- Appearance of complications pecufrarl{ toPET (M. or F.) !rt
- Lower 24tu urinary Ca* 140 mg) than in chroruc HTN (220 mg) o
GI

lZl
Efrcf of hsDsfurrlhna Dre[?ro'cs =
o
* Matemal -+ all complications of PE esp Accidental hge. =
o
* Fetal -+ IUG& IUFD, PTL

WhiteKnightLove
Tieat wlth anUblotks,
Uren re-chcck as above

24-h udne colhcton

+
blood ffifor pre-E

Exdude rcnal dlsease No secondary

(1.e. revlew renal blood cause ldentffed
resulB and urlnalysls
for mlcroscoplc
hematuda)
rcfer lf abnormal

Dlagnose essentlal
hypertension

Algorlthm for hypertension in pregnancy.

WhiteKnightLove
ilrootmonE

> Mild e nn.ren,alion

* llntihypertonsives
. I't choice -+ Mdtruldopq: check liver enzymes /trim. (liver affection)
.2nd choice -+ llgdrqtqzlns
o
.Tachyphylaxis
o,
. If > 200 mg/d for > 6m-+ lupus like syndrome fluid retention
.3'd choice -+ Lrbetqlol (200 mg tab 1x3 up to max 1.6-2.4 grdd)

* Used uith coution

. lllHipine.., safe, but may + acute hypotension
. Clonidlns,...safe, but acute withdrawal -+ hypertension

* Controindicotod
. AeE inhibitors,....fetal renal failure o

. Dlurstle!... except in severe cases (heart failure)

> Severe
- Medical treatment -+ good response -+ continue
- Failed medical conhol -+ terminate

9ET Cbronic HTN Cbroric negbritis

lncidence 75% 20%

i
5%

Prst historg

llg]ertonclon
-ve
> 20 wks < 20 rryks < 20 wks
:l
+ve *ve
Eemr -ve
Prohlnrnlr +ve -ve +ve cr
)
o
ECO elrrnge -ve +ve -ve 3
o_
Rarrrlfunstlon O if severe ffictedtithnme impaired .1,
o
(o
Fundur O if severe sclerotic wittr time albuminuric nephritis
a
o
rrT TOP if severe ..according to degree of M & F affection...
=
o
Squlro Recur in 30% ..condition persists & usually deteriorates...

WhiteKnightLove
 I Chronic metabolic disorder of CHO metabolism
Due to absolute or relative decrease in insulin
in response to CHO challenge -+ hyperglycemia

* Brpnlsrc Gr-ucos€ CoNTRot- lru PnesruANcy o

tr FIRST HALF OF PREGNANtrY

* o
improved glucose tolerance due to:
- ted insulin response to a glucose load
t
- J gluconeogenesis & glycogen deposition
tr SEtrtrND HALF EF PREGNANtrY
* o,
increased insulin resistance therefore:
- 90% of DM with preg are GDM
- GDM is not clinically apparent until ... ... ...wks
.'. Screening is better done at this time
.'. Patients with GDM escape CFtvIF'

l] Accordine
to onset
Autoimmune Familial tendency
(island cells anti- (complex & multi-
-bodies e.e. viral int. -factorial etiolo
insulin resistance

2) Accordine to stages "

o ) Potontiol D iobetos patient is not diabetic but there u fo risk esp. if:-
=
o - Positive family history (parents or hertwin)
3 - Previous delivery of macrosomic or malformed fetus
g - Parity (GNP > 5) or obesity (>120% of ideal body weight)
!
o ) LoEenE D iobetos
(o
a The patient is not diabetic but on exposure to s/ress or
o corticosteroids ,,+ GTT is diabetic (.'. GDM is one of its forms)
a
o ) Chomicol Diobotes ,+ asymptomatic patient but GTT is diabetic ( GT)
> €*oblishocj cliobetos "+ clinical diabetes (all < that is the Pre-Diabetic state)

WhiteKnightLove
 h
il Effects of pregnancy a D.M.

O Pomntrllg dlrbetogenle t xorsens Btqblhhod D.M. dueto

- Anti-insulin hormones (HPL, E, Pr., corticosteroids , prolactin)
- Insulinase activity in placenta S

O Prssrmng conDllcttlom nrlg beconre qggrrurtal

with increased liability for DKA

@ Dmcuf conhol rffi llrbllltg to hgDoducsrnlq durlnE

o PREGNANtrY
-
Renal glucosuria ltnnf -+ t CrR- J renal threshold to 150 mg9/A
-
Alimentary glucosuria
-
Morning sickness & vomiting -+ starvation ketosis
-
Glucose passes to the fetus by/acilrtated dffision... "
tr LABo R (d.t. uterine activity)
tr PUERPERTUM
-
Loss of placental hormones
-
Breast uses glucose to produce lactose

4 Effect of D.M. a
O tvlatmral
o PREENANCY
- Preeclampsia. .......in25yo"(vasculopathy)
- Polyhydramnios ....in25% of cases
(large placenta.. ..fetal polyuria. .Anencephaly)
. ..

- preterm labor.....overdistension d.t. macrosomia & polyhdramnios

- Placenta previa & abruptio placenta (PtrI) cr
- Pyelonephritis (recurrent) ... ..1 liability to infections as candidiasis =
o
rt
o PaRruRtrtou 3
- g
PROM -+ fetal & matemal infection .o
- Prolonged labor (d.t. macrosomia -+ obstructed labor -+ rupttre ut.) o
rl

GI
tr PUERPERIUM .......SJ a
o
- Postpartum hemorrhage (atonic, taumatic) )
o
- Puerperal sepsis
- Pulmonary embolism (obesity, vasculopathy, difficult labor)

WhiteKnightLove
 Congcnttal anomallcc ln lnfanto of dlabcilla mother,c
9keletal and aent'ral
,atrlal6e\al ncruouo ayetem
defcat , anenaeVhaly
.venl,riaular oepl,al , aaudal reqreeeion
defecl, oyndrome (very
.aoaraVallon of aoft,a rara, buL highly
.tranopooition of
opecific for
Eealveeoclo diabal,os mellitue)
Ot.her ,microcc?haly
.oingla , haufAl 4st...1,9
umblllaalaftery "urt
Gaetrolnteellnal Renal
. anoractal atresia ,hydronephrooio
,duodcnal atresia ,renal agenaeio
.tracheo-esopha6eal .ureteral duplication
fistula ,polycyotic kidnayo

WhiteKnightLove
@ Fetal
> Abortion.....1 :x (if uncontrolled DM) - how?
> CFMF.........1 3x(G9%versus 2-3% inN)
- Especially ifIIbAl. is increased
- The commonest are :
{
. CVS (lDx) -+ YSD, transposition of great vessels, coarctation of aorta
. CNS (5x) -+ anencephaly, spina bifida, meningocele
. GIT.,. ..renal... ..skeletal
- A rare but very specific (pathognomonic) malforrriation is caudal
regression syndrome (sataf agerusis "). This is disproved now.

> IUGR in20% of cases Qtlacental insufficiency d.t.thevascular changes)

> Fetal macrosomia l4Oo/o of cases)
- Due to increased glucose in mother -+ hyperglycemia in the fetus
f
-+ insulin from fetus -+ islet cell hyperplasia +
marked anabolic effect. There is associated stimulation
of adrenal cortex + ted steroids + Na & ft O retention
- Newborn is large heavy plethoricfattytithcushingoid features
- All this makes the baby more liable to all listed complications......

> IUFD due to

- Hyperglycemia t ketosis or Hypoglycemia
- Vascular affection -+ chronic placental insufficiency & PIH
- Congenital malformation
- Unexplained sudden IUFD (usually after 36 w@ks, repeats at same time)
@ Neonatal @O

s U - RDS (insulin ant4onizes action of corticosteroids on lung -+ J surfactant)

\ esp. Phosphatid/ glycerol
- Hypoglycemia (drc to the ted fetat insulin production)
- Hypocalcemia & hypomagnesemia -+ tetany
cr
3l . Polycythemia -+ d,t, chronic hypoxia -+ erythropoietin a
o
. Hyperbitirubinemia d.t. -+ prematurity, plycythemia, @cytocin
. Hyperviscosity syndrome -+ letldlvein thrombosis
3
o_
s D Birth trauma -+ shoulder dystocia (wider than the head) +infscl;en !rt
CFMF -+ the most common cause (4070) of PNMR /' o
GI
PNMR (4-10 o/o)
d.t. allthe above {.r causes =
o
=
o

WhiteKnightLove
WhiteKnightLove
 tr DM is diagnosed for the 1s time in pregnancy ingO%o of cases
o History (present, past, family, obstetric) may be suggestive but
investigations are a must... ...(as symptoms a.re query: BppD

O Screening

llGlqcose ln uilne (Iht uorsl) /(

't Done by: Benedict / Fehling test....or glucose strips (easier)
"' Inaccurate as glucosuria could be due to
- Renal glucosuria
- Alimentary glucosuria
- Lactosuria (some breast lactose + escape in urine)

2l F$tlng blood qlucosa (N: <105 mg/dl)..... ideal 60-90

31Ons hollt DostDEndlqf (N: <140 mg/dl) t[r hwl
4lTro hoqrc DmtDrendlql (f i: < 120 mgldl)
5l Rqndom blood surqr (N: < 200 mgldl)

3 ttre best screeninq test is Ihr-PPS ,/,/

(Glucota 1s[1-5g*-;
o Time
- For all patients (low-risk) -+ at 24J8 wks @
i.e. done for all @ pregnant women without C/O)

- For high-risk groups -+ at booking (1" antenatal visit):

1. Maternal obesity or age > 35 yrs
2. Chronic hypertension / renal disease
3. Positive family history
4. History of o
o
. GDM / IGT =
o
. Feta] macrosomia
3
. Idiopathic polyhdramnios o_
. CFMF !
. Unexplained IUFD o
GI
o Result =
o
< 140 mgo -+ no further investigations or ttt =
o
> 140 mg%o -+ 3 hr GTT

WhiteKnightLove
 Modified Priscilta White classification C

liffiiiiiillcaH 5i',
Asymptomatic but with diabetic GTT GDM
A .....A1 : FBS <105 (+ diet )
.....A, :FBS > 105 (+ insulin)
ti it ,i:: :,i ,.,.,.,:, .::.ir,r : .

>20 years...or... .. .0-9 years No

:,;;i. ::B':'.i1:,t,,

'
- ,::^:,.,:,:.,,
10-19 years...or.. l0-19 years No
'r.!'i..::1.'ri

<10 years...or.. ..>20 years Vascular / BGR

F D.M. + Nephropathy IDDM

R D.M. + Proliferative Retinopathv with
H D.M. + Ischemic Heart disease EOD
T D.M. + Renal Transplantation

National Diabeter; Data eroup classification f 1979)

a Tgpe l: IDDM
a Tgpe 2: NIDDM
a Tgpe 5: DGM
a Tgpe 4: IGT

WhiteKnightLove
O Gonfirmatory (GTT): glucose challenge
(Modified O'Sul I ivarr test)

Daily 150 gm CHO diet is allowed for 3 days (with no smoking o)

FBS is determined (after overnight fasting of 8-14 hrs)
Then give 50 (uK), 75 (wHo),100,/ (usA) gm glucose in 400 ml water
Readings are taken hourly for the next 3 hrs & a curve is drawn

Normal Renal Alirneniarnr D.M.

rBs AIl N At least 2
l-hr readings > 180 mgoh readines are
2-hr are iN N >N
3-hr normal N
Urine +ve only *ve at +ve at
sugar (W atw ntqalfuc at peak l-hr peak any time

" Single abnormal value is called + impaired glucose tolerance (IGT)

'k Normal values are to be repeated at 3d trimester in the high-risk group
E
/
'r If glucosuria found on 2 separate occasiors during ANC -+ GTT

€) Investigations for control

'k LEvel of glgeosglsted l{b GIbAr")
- This indicates the control over the previous 2-3 months (N: 5-8%)
- Above l0o/o-+ poorcontrol
- Above l2%oinearly pregnancy -+ t % of CFMF o
'! Olgcosglsted sorurn proteins; fructosamine (reflects previous ... ... control)

€) Investigations for complications

c'
'k 0n pegntneg )
- Urine analysis -+ UTI o
!
3
- Albuminuria -+ PET g
!
" 0fDM o
- Kidneyfunction tests to detect renal affection GT
- Fundus examination =
o
. Background retinopathy -+ not dangerous =
o
. Proliferative retinopathy + very serious & may lead to blindness
+ refer to laser therapy + if still progressivo + consider TOP

WhiteKnightLove
Ultrqsonic Recording FHR recorder Uterine octivity recorder
(ultrosonic ,,'(tocogroph)
tronsducer)

Fetol
monitor

WhiteKnightLove
O Preconceptional care
tr Pctpno Fqgnrneg... .till good DM control (as evidenced by HbAr.)
tr Adutcs egtlmf pregnrnog tf
- HbA1.>72% (highriskofCFMF) \ indicotions
- Marked renal affection is present ) of therapeutic
- Progressive proliferative retinopathy \ TOP
tr 0rrltrgPqg,gesmlc drqgs els not rrssd
\ they cross the placenta: CFMF + t fetat hyperinsulinism
g fintenatd care
o Tlmg -+ 2 wks (3 itr GDM) ttll32 wks, then weekly
o Plrcs +a specialized antenatal clinic (obstetrician, physician, dietitian)
*
o Alrn -+ control ofDM & prevention of its progression
n
eady detection & management of comp. (general / obstetric: M&F)
o &ntrol 'srRrcr'/
D Diet
) Sufficient alone only in mild cases (GDM A1, IGT)
. Give CHO (5070 = 20G250 gm)falg (30%) proteins (n'/o)"
. Carbohydrates should not be in the sugar form (rapidly absorbed)
o
. Average 180tr2400 Kcal/d t 300 Cal in 3,0 trimester
. Totalcalories are divided among 3 major meals +3 snacks
) Exercise allowed -+ physical activrty should be moderated
D Diet * insulin
) Split schedule system (7 el.n& 5 pm)...regular + intermediate
) Indication
. GDMAl ifdietfailed: FBS> l05...lhrPP$140...2hr PPll2O
. GDM &, Class B-T
o lnuectlgrtlom
b Mat. comp : Of DM -+ renal FT,liverFT, fundus, serial HbAr. ET
On preg + screen for PIH, infections (urine, vaginal CeS) =
o
b Fetal sunrcillance 3
) GDM At 9.
- U/S at 38 weeks to exclude fetal macrosomia 'r,
rt
- CTG & BPP weekly starting from 34 weeks
o
GI
) cDM Aa& IDDM B-T (pregestational IDDM) =
o
- U/S at . 18 - 20 wks (excludes CFMF) ..t MS-aFP =
o
. Serially (for macrosomia or ruGR)... ... + Doppler
- CTG & BPP weekly starting from32 weeks

WhiteKnightLove
WhiteKnightLove
"9- "I:-rpil*li* -qlp-rsglusy
> Tirne
o Diabetics should not be allowed to pass dates ,,+ )40 wks X
a In mild cases under excellent control (GDM class A1) ,,+ 40 wks
a Insulin reguirins diabetics (Class A2,8, C, D)
. Well eontrolled, no F/ M complications ,+ 38-40 wks
o Not well controlled: once document maturity ,,+ 37 wks
. Earlier TOP < maturity ifFA4 distress occur ,,+ <37 wks
o In cases with repeated unexplained IUFD terminate ',+ l-2 earlier

I getore any elective termination

\ Tests for fetal lung maturity should be done by amniocentesis:
- Shake test (easy)
- US ratio (more specific + widely used)
-+ RDS may occur in spite of mature US

> Mode
i Cesarean section: t- *
'kMacrosomia (> 4kg ?!). This is > in GDM
. Deposition of glycogen is more at shoulders & fetal liver
. The disproportion between fetal head / abdomen -+ sh. dystocia
'k Previous history of unexplained IUFD
r Vaginal + by AROM * syntocinon (?) + intrapartum fetal monitoring

> lnsulln mqnqAement durln[ TOP

- Keep maternal euglycemia (80-100) -r to avoid fetal hypoglycemia
- Before labor .' stop morning insulin (taken only at bedtime)
- During labor - 500cc 5% glucose + 5 units crystalline insulin by drip /5 hrs
- After labor - insulin requirements usually drop immediately
- If glucose level is > 200 + S.C. regular insulin when needed
- If glucose is persistently > 200 -+ resumo combined regular & NPH
ct
a
@ Postpartum care o
a Care of the newborn .. . ... at the NICU by expert pediatrician 3
o e.
r Breast-fe eding....encowaged (lactation is anti-diabetogenic)
!
r Contraception o
(o
- COC are contraindicated in those with vascular changes (.'.use POP) a
- IUCD are contraindicated esp. in those with depressed immunif o
f
I
Used with caution (e g. vaginal discharge) o
I
Threads cut short t prophylacflc antibiotrc

WhiteKnightLove
 Target
lnsulin Type lmpact
Time Glucose
and Dose Time Seen Level (mg/dL)

Evening NPH Fasting 70-90

Morning Hurnalog Post breakfast 100-139
Morning NPH Post lunch 100-139
Evening Humalog Post dinner 100-139

L Establish a fasting glucose level between

70-90 mg/dL.
2. Only adjust one dosing level at a time.
3. Do not change any dosage by more than 20%o per
day.

4. Wait 24 h between dosage changes to evaluate the

response.

WhiteKnightLove
 > lndicotions:
. GDM Ar if diet failed
. GDM A.z, Class B-T

> Drugs useel:

. Combination of Crystalltne (regular / short) ) better human
+ NPH (isophane / intermediate) j
u.S.Mixtard
. Long acting insuhn (protamine zinc) 1t are not used: poor control

> Dosooe
- In class B-T -+ no change in previous dosage (if sugar is controlled)
- In GDM A,2 give -+ 0.6 r/kg (ls trimester), 0.7 u/kg(2"d), 0.8 r/kg (3*)
- The calculated dose is then divided
)
Morning (7 AM) Evening (5PM) Otouoadiona, I llrhe
4l do* ll dose
Morning g _1_9_4Y
J J NPH 5 PM
1A crystalline
+ +g NPH
1/1 crystalline
+%NPH
Evening
Ie l_giM
NPH 7 AM

- Urine should be free of glucose: if present + increase the corresponding

insulin dose (but gradually!)
- Gluco-meter (capillary blood estimation) is better o used instead of urine
for follow up of dosage (d.t. gluco... ..)
- Check FBS & t hr-PPS after each meal until control, then twice weekly
-+ then once weekly (1 hr-PPS should be < 140 mg/dl' )

> In resistont coses

. May give three times daily injections (NPH at 5 PM is given I hr < bed
time snack + better control of nocturnal hypoglycemia &, FBS) o
. Continuous infusion pump (not superior on injections) =
o
3
> Site of inJectlons: given S.C. in abdomen /(?) -+ afirrs -+ thigh -+ buttocks o_
Patient is to be taught with variation of the injection site !
o
(o
=
o
(headache, sweating, palpitation, hunger, epigastric pain, dizzines s) )
& if any of these occur she should take a readily available o
carbohydrate (candy or biscuit) + J the corresponding insulin dose

WhiteKnightLove
1 .
Gestational diabetes occurs in 196 to 12Vo of preg-
nant women.
2. Risk factors for gestational diabetes include
Hispanic, Asian American, Native American, and
African American ethnicity, obesity, family history
of diabetet and prior pregnancy complicated by
gestational diabetes, macrosomia, shoulder dysto-
cia, or fetal death.
3. All pregnant women should be screened for dia-
betes betvveen weeks 24 and 28. High-risk women
should also be screened at their first prenatal visit.
4. Fetal complications of gestational diabetes
include macrosomia, shoulder dystocia, and
neonatal hypoglycemia.
5. Pregnancy management should include frequent
health care visits, thorough patient education,
American Diabetic Association diet, glucose moni-
toring, fetal monitoring, and insulin or an oral
hypoglycemic agent as indicated.
6. Patients should generally be induced between 39
and 40 week gestation. lntrapartum insulin and
dextrose are used to maintain tight control during
delivery. Cesarean section is offered if fetal weight
is over 4500 g.

1. Motcrnal complications of diabetes during preg-

nancy include hyperglycemia, hypoglycemia,
urinary tract infection, worsening renal disease,
hypertension, a nd retinopathy.
2. Fetal complications of diabetes during pregnancy
include spontaneous abortion, congenital anom-
alies, macrosomia, IUGR, neonatal hypoglycemia,
respiratory distress syndrome, and perinatal
death.
3. Pregnancy management is optimized by a pre-
conceptional visi! early prenatal care, thorough
patient education, tight glucose monitoring and
management with insulin, fetal monitoring, and
thoughtful plan for delivery.
4. Motivated type 1 diabetics can usually maintain
tighter control on an insulin pump. Management
in labor and delivery usually requires an insulin
drip; however, insulin requirements decrease dra-
matically postpartum.

WhiteKnightLove
Gestotionol DM Ea
. CHO intolerance recognized for the 1$ time during pregnancy &
disappears after pregnancy (whether insulin is used or not for ttt)
. Screening for GDM should be performed between 24-28 wks
Manaqement Terminatbn
Low risk / Ar diet control Left till term (never
-"--- "-t"*-"-'*
-dates
diet + insulin I Manaeed as IDDM

o More liable to macrosomic fetus (IDDM + CFMF & IUGR)

. Postpartum Consequences
- Risk of type II DM (50% may develop overt DM within 20 yrs) "
- Recurrence of GDM (reported in ?6 of cases - esp in obese women)
Glucose intoleronce
o If there is only one abnormal value in the 3 hr-GTT
o These patients are still at risk for -+ macrosomia & PIH
o TTT -+ only diet controlbat recheclr FBS & thr-PPS every 2 weeks
O. Tuoes of diobetic comos
-Diabeticketoacidosis
-Hypoglycemic coma
-Hyperglycemic hyperosmolarnon-ketotic
-Uremrc & cerebrovascular strokes

Q. Tvpes of insulin Beef i pork / Human // (mi$ard) better

= Onset = Peak

8-12 16-24
Lons actins ezl,ultralente) 8 .l|2-_lQ _. 24-32
NFH ir rbe neurnal protamine of Ha4erbsn

Q. Tvpes of ketone bodies -+ Acetone, Aceto-acetic, B-hydroxy-byuteric acid o

=
o
Somogvi phenomeno
- Increased morning FBS + nightmares. 3
g
- Explained by nocturnal hypoglycemia followed by exaggerated 'u
counter-regulatory mechanisrns t f gS
- o
(o
- TTT J wpH of 5-PM
- f
Doun phenomeno o
- Increased morning FBS + absent noeturnal hypoglycemia =
o
- TTT t t{Pu of -<-PM
-

WhiteKnightLove
c%tes

WhiteKnightLove
 Rheumatic -+ 93% (MAT esp + MS)
Congenital -+ 7o/o (> in developed countries)
Others -+ lo/o (e.9. IHD, arrhy'thmias, cardiomyopathy)

AncricanN Ew Y orftH eart A s sociation [NyHA] dixriied gtD inu 4 grale s

(accor[ing to t fie functiana f capacitl of t fre fieart)

GussI Organic heart disease but with za limitation ofphysical activrty

Cr,rss II Some limitation of the ordinary activity in the form of
dyspne4 fattgue, palpitation, pain. . A -+ mildlimfianon
. B + moderate limitation
CressIII Marked limitation of physical activity as it will lead
to dyspnea on less than ordinary activity
Cr,rss fV They are in heart failure with dyspnea even at rest

Historv
> Personol
- Name I Age / Marital status lPat'r\r
- Address : --------- RHD is > in damp non-sunny area
- Occupation : ----- may need advice agarnst marked physical effort
- Special habits :--- must stop smokrng
> Comploint 6 HPI:
1l PVC - dyspnea, orthopne4 PND, cough, expectoration, hemoptysis
21 SVC - engorged neck veins, rt hypochondrial pain, ascites, LL edema
3lRheunatic artiyiU-+ carditis, arthritis, chorea gravidarum, SC nod, erythema
-
aIIEC fever, symptoms of F{F, CNS sympt., hypochondrial pain, haemattria
q
5l Aryhvthmia + palpltatlon
57 Cvaruotic heafi disease -+ cyanosis (malar llush in pregnancy) =
o
7l Ischemia -+ anginal pain 3
o_
> Monstruol hisEorv -+ for dattng !
> Obstetric historv -+ previous IIF in pregnancy o
(o
> Post historv )
- Medical -+ rheumatic fever, duration of heart disease, attacks of failure o
- Surgical -+ valve replacement =
o
- Drugs -+ anti-failure / anti-coagulant

WhiteKnightLove
 Loss of inter-
villous spoce. Pulmonory
Controction of hypertension
myornetrium. ond Oedemo

I
l
+ I
Blood forced Overdistension
info of
c ircu lotion left ouricle

H.F. immediately after labor

WhiteKnightLove
 Examination
{. Peripheral ug gr.,ornatfi we couff see o
- Signs of SVC
. Neck veins _+ not reliable d.t. t.d blood volume
.Edgma may occur due to (pregnancy or pEe
. Enlarged liver + may be difficult to palpate due to large uterus
- signs of hyper-dynamic circulauon e.g. I{zo hummerpulse, cap. pulsation

* Gentral ug gtrormatty we couff ficar o

- SplitUng of the 1$ sound
- Appearance ofthe 3'd sound
- Soft systolic murmurs (< 2/6)
- Shift of apex beat from 56 to 4tr intercostal space

Ll Effects of pregnansy rrr* HD

tl Oeteriordtion fo oru cfinicatgrafi fiu to:
* Brood volume I 4O-SOo/o
* cop t loyr(due to1 blood
volume + J r.n.y
: (Heart rate t l0-15 b/m) X (Shoke volume t)
2l lteartftilttre mal ocatrin
n COp & blood volume)
)t VR to heart + tCOp
s
stage d.t.
* 3'd stase + refurn of the blood in themore bearing down)
uteroplacerta ci.cutation
(500-700) to G. circulation (aft er placental separation)
3) W{D. IEC after any procedure (esp in puerperium)
. Recurrence of rheumatic activity is rare (but serious if occurred)
4l Liahifrry to anfi1tfi:mia
S) LidSifrtl to more cyarcsisncyanotic heart disease
6l LithifrU to tfrc tfirorniloemiloticcomprLcations (due to stasis) t c'
a
Lt Effects of HD u+ pregmanqtl o
rr
* 3
Maternal o
- Polyhdraminos (d.t. congestion) !
- PTL (d.t. soft cervix)
ao
- PPhge (hypoxia + ergometrine contraindicated)
=
* o
Fetal a
- Abortion & CFMF ) Low COp -+ chronic hypoxia o
- ruGR & IUFD ) esp in cyanotic heart disease

WhiteKnightLove
- Doesn't cross the placenta
- Short acting (2- hrs)
- Have antidote ,"+ protamine
sulfate slowly IV

- The risk,of oyer or under contr.ol by heparin is more serious o than

the ndnimal,recorded risk of fetal affection d.t. OAC
- FFP qapidly reverses action.of OAC (ifbleeding occurs)
- Also, there is antidote + Vit K (for;both mother & fetus)
- NB:.- Dindivan is confaindicated during lactation o

WhiteKnightLove
 1. X-ray ?! (+ abdominal shield) -+ cardiomegally
2. ECG lEchocardiography
J. Rheumatic fever -+ ESR, CRP, A-SOT

O Preconceptional control
$ Pregnoncy controindicoted in: @@
is

'Class III & IV

'Cyanotic heart disease as Eisenmenger syndrome
. Severe Aortic stenosis or lry P. hypertension (d.t. limited COP)
'History of
- IIF in previous pregnancy
- Rheumatic activity IIE;C in the past 2 years
1 If they become pregnant, therapeutic TOP is better
done in 1$ trimester. After 14 wks inducing abortion
is more hazardous I than continuing pregnancy

e Antenatal care
Done in o aspecialized antenatal clinic (obstetrician, cardiologist)
Donefmo control ofHD & early detection & management of comp
o
Done euery 2 wks t11132 wks, then weekly
Done h1 o

o Rcst -+ some hospitalize at[30-34 wks] then to plan labor [36-37 wks]
o Dict -+ salt restriction
o Drugs -+
. Avoid anemia / infections (esp. resp tract) -+ ppf to heart failure
. Long acting (berzathine) penicillin 1.2 million lUlmofih {
. Class III & IV -+ digitalis, diuretics, amrnophylline
. Valve z/ replacement with pregrancy:-
C'
*Warfarin (5mg) orPhenindione (50mg) a
*BUT use Heparin (5000 ru/S.C./8hs) during ) o
3
o_
I't trim (as warfarint Crlvr as microcephaly, optic !
hy, chondrodysplasia punctata+ t feal hge) o
GI
I Z-3 weeks before delivery rP shift back to heparin
At onset of labor a stop heparin =
o
f
After labor (Glz hrs) e give OAC + heparin (till OAC acts) o
3 days later ostop heparin......then continue only by OAC

WhiteKnightLove
Etienne-Louis Arthur Falbt (1850.7911) was
a professor of fotenskmedicine and lrygiene in
Marceille. He bad a rcpatation ds afl asfrile clinician
ard fot accurate careful physical exaruinatio*.

WhiteKnightLove
O Termination

O Tirne
$ Class I & II. .. ... .left for smooth spontaneous of labor (no induction?)
$ Class III ...if completed here family -+ betterto terminate
..if insists on pregmncy -+ continue in hospital
$ Class IV ..confiol the HF ls medically, then terminate

O Route
>,oaginal //
l"t stage
- Semi-sitting positianwrttr no bearing doum
- arufgesia
"A[equaw
* Morphine (10mg) orPethidine (100mg)
* Epidural analgesia
- Interwittent02+ antifailure ttt if needed
- Chse oSseruatimt [P-BP-Temp] + FHS + Uterine contraction
- Aropfiykctir anti6iorrcr(GBS/) & delayAROM as possible
* 2 g anrpicillin + gentarnycin 1.5 mgKg
* glven I hour before placental separation
* Ampicillin is repeated once after 8 hours
2"d stage
- 'Unntry easy (small baby + soft cervix)
- Sfinrtenzd stage & avoid bearing down by low forceps or ventouse
3d stage
- Avoid ergot IV (t treart load due to VC r uterine confiaction)
/
- Lasix may bo given (ifheart failure)
- Guard againstPPhge (may give 7+ mg IM)

> cesgfegn sectiofl rni h*

llAortic stenosis (post-stenotic dilatation may rupture during bearing)
2l Iry pulmondry hypertension
ct
f
3f Ei s enmenger Etndrome o
3
lMarfan qmdrome (if having dissecting aortic aneurysm) g
!
O Postparhrm care o
- . tsredstfimffife-crpt *Gutri-.^.Jtffiffi E ry --_ - GI
f
o
" Atvisefsr contraaptiona Mechanical methods or Sterilization =
o
o IUCD -+ ascending infection (if used: aseptic technique + proph. abtc)
o COC -+ thrombosis (if used: POP)

WhiteKnightLove
c%tes

WhiteKnightLove
 4y^ Bot'rg ti{pontrxt canotac coxotrtoxe

llitrol Volve
Pathology: Myxomatous degeneration of one or both of mitral valve
leaflets + prolapse into left atium during systole
-
ClPz Asyrnptomatic mainly
- May -+ palpitation, dyspnea, chest pain, syncope
Treatment during labor: Controversial + only inderal
Most don't give antibiotics except if associated with MR

Definition: Dilated cardiomyopathy + IIF in 3'd trimester / puerperium

Incidence: 1/1.500 - 1/4.000
Etiology: - Unknown
- May be + viral infection, autoirrmune
- Pdf + PET, twins, genetic predisposition
Prognosis: (Fatat) . Mortality is 25-50%
. Mortality in next pregnancy is 80%
Treatment
1 . Digitatis, hospital ization

2. J afterload (Hydral azine),0 preload (diuretics)

3. Heparin (risk of thrombus formation in dilated heart)

Cmrctotion of
Definition
- Hypertension only in upper limbs
- Normal / low pressure in lower limbs
- May be confined only to left arm (coarctation of left subclavian)
Route of termination
- Vaginal delivery allowed
- C.S. only in other obstetric indications

rtiorfon
o
=
o
Etaology + defective CT rl
3
Clinical picture g
- Mitral valve prolapse / incompetence !
- Aortic dissection (intimal tear) + acute chest pain + shock o
(cl
a
rn pneqnoncy
o
a
Tight Ms (< lcm) Balloon catheterization may be done (2'd trimester) o
valve reptacement is ccntraindicated (hear lung machrne * anticoagulation)

WhiteKnightLove
Ovorion hormones
Psychi I

(oestrogens,
progesterones)

Reduced
irotility ond
sectretion

rionic hormones
(oestrogens, progesterones,
chorionic aonodotrophins
hove oll been suggested)

WhiteKnightLove
O emesis gravidarum (rnorning sicknoss)

> Definition
- NaV inthe lstimester (max 6h - lzn week)
- It doesn't affect the general condition
> lncidence avery common (80%o) esp in PG, esp in the moming
> €tiologg aunknown
> Monogement
- Reassurance -+ it disappears spontaneously
- Small frequent meals +. Better dry CHO meals
. Avoid immediate recurnbency after meals
. Fe therapy is temporarily stopped (nauseating)
- If not responding -+ antiemetics

O Hgperemesis gravidarum E\
> Definition
- that ) pernicious
Severe vomiting to a degree
- Affects the general condition ) vomiEing of preg
> lncidence e01-1%
> €tiologg +theories
- Psuchologicql: as it
. Start only after knowing that she is pregnant
. Vomiting only infront of her husband @ -+ more in neurotic females
- Hormonql
. t uCe (as in V.mole & twins)
t
. Ts, Ta....transient....no need forttt
. J Corticosteroids
- Allugic -+ against CL of pregnancy, sex steroids
cr
- Defieiencs (esP Vit Br & 86)
=
o
> Pothology ovomiting ) 3
o_
- Stqrr,qtlon -+ dehydrafion -+ starvation ketosis & elect. imbalance !
- Llv$ -+fatty change & centrilobular necrosis
@
o
- Kidneg -+ tubular necrosis
=
- llerrt o
-+brown atoPhY a
- Brein -+ petechial hge & congestion o
- Retine -+ hge, optic neuritis, detachment

WhiteKnightLove
WhiteKnightLove
Clinicol Picturr
- Excessive vomiting (allover the day & not related to meals)
- Dehydration +. .[BPr, fpulse, ttemp. oliguria, constipation
. Jweight, sunken eyes + jaundice, dry inelastic skin
- CNS + . Peripheral neuritis
. Wernicke's encephalopathy - d.t. Vit B1 def

Invcstigofiorc
. Diagnosis a Urho rnrluch -+ Ketone bodies/ + no glucose
oew - t Hct.....J Gvr, K, cl)
r Etiology o llA (Twins, V.M.) + Te Ta
. Complication A Furdrt, Urer + Renrt trnctton tct

Trcotment
Ill llcilhlhrtlon ,* r€ossurofrGe (& isolation!)

tzl Dld
- NPO + IV fluids (till 48 hrs aftervomiting stops)
- Then restart gradually by clear liquids + CHO meals (no fats, spices)
- If failed + TPN + thiamine (B1)

tgl hqrr
- Sedatives -+ phenothiazines (chlorpromazine)
- Antihistaminic -+ promethazine (phenergan)
- Anilemetics -+ . metoclopramide (primperan), Cortigen B6
. navodoxine, motilium (domperidone)
- ln resistant cases + Zofran (ondansteron: 5-HT blocker ) t steroids

[alOheiuflon n
-
Vomiting: -+ frequency
-
Vital data: -+ BPr, P, T
-
Urine analysis -+ daily
-
Organ functiontests + Fundus -+ weekly

H TOP
** Xndinatfun
Deterioration of general condition in spite ofttt [P >100, T > 38]
Deterioration of organ affection [renal / hepatic / CNS I retinal
** ildftodo
< 14 weeks + Suction evacuation or DaC
> 14 weeks + may end in HvsrsnoTour .. . ... .why?

WhiteKnightLove
WhiteKnightLove
 Extros
> DD of vomltlng il pregnaocXl @e
l. Morning sickness (emesis gravidarum)
2. Disturbed ectopic pregnancy
3. Vesicular mole
4....... Preeclampsia (severe)
5.......BelonephriUs
6....... Polyhydmmnios
7. Gyn. conditions + twisted ov. swelling, red degen. of fibroid
8. Medical conditions + food poisoning, hepatitis
9. Surgical conditions + appendicitis, cholecystitis, peptic trlcer

> ED of jauodice io pregnaocJ/ @e

- PIH & HELLP syndrorne - Hemolytic J.

- Severe hlryeremesis gravidarum - Obstructive J.
- Intrahepatic cholestasis of preg - Hepatccellular U.f. /O
- Acute fatty liver of pregnancy

> Sntrahepatic cbolestasis of pregnalq M

'rlnridence-+ the coflrmonest liver disorder IJMQT E to preg. (esp. in 3'd trim;
n
c/p + mild Jaundice, pruritus + t in Bile acids are DIAGNoSTIC
" Co*y. + PTL & IUFD
*
nwestig. - . t* (alkaline phosphatase, Bilirubin drect-, SGOT & SGPT)
' Prolonged prothrombin time
xTreatrnetr,
tr motheR. cholestyramine 4gnlx4 + Phenobarbitone for pruritus
. VitK 10 mg to improve the PT
. Corticosteroids may help
o [etus -+ TOP once mature -+ AAnpreu improvement within 2 days
o
f
*?rognosis -+ avoid use of COC to avoid recrrrrence (70yr) o
rt
3
o_
> $cute fatty liver of pregnancy (tatel u' !
o
xcft - symptoms like viral hepatitis -+ fever, NeV, Jaundice, upper aMomind pain GI
a
- Then + symptoms similar to PET -+ then acute LCF o
a
*
Comyfications -+ high XtINm, PNMR o
*(reatment -+ TOP + liver support

WhiteKnightLove
 tuh
Dofinition (4-7o/o)
- Presence of >100.000 organisms of a single colony /ml urine
- In absence of any symptoms orpas cells
€ffecB on pregnoncg -+ t"o liability to:
- Acute $elonephritis (in 25% of cases)
- Anemia
. PIH & ruGR
. PROM&PTL
Diognosis
- No symptoms o .'. screening tests MUsr BE poNE in ls visit )
Colony cotrnt (by clean catch technique: MSI,
Treotment
1- Broad spectrum antibiotic (of high urinary concentrations) for 7-10 d
[Ampicillin / Cephalosporins / Nitrofrrantoin]
2-If failed-+ antibiotic according to CaS
o
3- Urine CaS is then repeated each timester

[2] Acute Pyelitis & Pyelonephritis

Dofinition (1o/ol -+ acute infection of renal pelvis & interstitial tissues
o
Predisposing foctors
- Short urethra
- Asymptornatic bacteriuria
- Atony of the ureter (Pr. effect)
- Pressure on ureter (esp. Rt.) at pelvic brim
ct
- [atheterization (urinary tract is '' ''' '. until''"''
f Bocteriology
o
3 > Orgrnlsms
o_ o E-coli -+ the most common / (80%)"
!
rt o Others -+ Gram +ve : staph / strept ) or Mixed
o
@ Gram-ve : Klebsiella/Proteus ) Infections
=
o > Route of irrfuction

=
o - Ascending infection... ...along the lumen or periureteric lymphatics/
- Lynphalic spread. .. . . . ..from neighboring colon
- Blood borne from. .. .....a septic focus (rare)

WhiteKnightLove
Cllnlcol plch.lro
* SUmDtoms
- General -+ FAHMR + vomiting (sudden onset)
,'+Local + severe loin paiq dysuri4 haematuria / pyuria, frequency

General -+ high fever, tachycardia

local + tenderness & rigidrty in loins
lnvestlgotlons
o Urina onolgsis -+ - Pus cells, RBCs
- Acidic with fishy odour in E-coli
- Urine CsS (esp in recurrent cases)
o Renol function tesEs -+ urea & creatinine moy be affected
o Blood picture t ESR, TLC, CRP
-
Dlffercntlol dlognosls o acute pairu in pregruanry

Conpllcotlons
- Ehmnicity..........Pyonephrosis........ ..Perinephric abscess
- Urcruia.. ....Septicemia ......Sepfric shock
. PHOM & PTL
- Hecunenf,e in next pregnancy (20%)
Treotment
9 Gsnsnl
- Hospitahzation
- Ample fluids (oral or IV) + Analgesics + Antipyretics

q AffiblonB r at least for 2 wks (best according to cas)

- ful-ost commonty uset-+. Ampicillin 500 mg
1x4
. Cephalosporins 500-1000 mg
1x4
. Nitrofrrantoin 100 mg
7x4 E

- If * response witfrin 72 firs + repeat CsS =

o
-t
- In resistaflt cdses -+ postpartum IVP, U/S -+ may reveal Stones, 3
o
congenital anomalies (esp if there is hematuria, hypertension) !rl
cr Srrreru
o
GI
3
- If ureter is blocked + ureteric catheter (pig-tail) o
- If failed -+ nephrostomy =
o
q TOP er If treatment fails to confrol the condition

WhiteKnightLove
 [3] .Ecute renal failure in preg ar
> Definition + rapidly progressive azotemia
> €tiologg'
o Pre-rerualfailuru (hypovolemia: accidental hge or hyperemesis Gr.)
o Renal
- Sepsis (e.g. septic abortion)
- PET,IIELLP syndrome, DIC
o Hepato-renal-+ acute fatty liver in pregnancy
> Tuo tvpes
o Acurs TueuLanNBCRosIS (reversible)
o Bn,q.TERAr ConucerNrcnosrs (rare &, more worse)

[4] Chronic renal dis. with preg ar

> €ffect of prognooGg ,,1 renol diseose
- Mild (creatinine < 1.4 mg%).
. ... ..no change in renal function
- Moderate (creatinine 1.4 -2.5 mgy)"'deterioration ofrenal function
- Severely (creatinine > 2.5 mgy). .rsually don't get pregnant

> €ffect of ronol diseose "+ pregnoncV

o Effects
- Superimposed PE / (the most serious) t accidental haemorrhage
- Chronic anemia
- Abortion / ruGR IPTL / IUFD
o Prognosis depends on
- Development of hypertension
- Development of proteinuria
- Degree of renal impairment
- Type of renal disease (diffime & proliferative GN are worse)
c'
a > Treotment
o
rl
3
o Mild o
conserve under strict observation
o ( monitor renal firnction + antihypertensives
1'
rl o Severe 4terminate or if deteriorating
o ( advise sterilization or do it with termination
ct
= NB
o
=
o ,t Pregnancy is possible on dial:tsis (but chronic anemia is the major problem)
* Pregnancy is possible after renql trqnsplontqtion
)t Delivery is better vaginal (even after renal transplantation, as kid. is in..... ..)

WhiteKnightLove
Definition o + in the amount of circulating haemoglobin (N: 12-16 grn%)
Normo! chonges in Hb in pregnoncy
r PHysrolocrcRl ANrurn (haemodilution) due to
I
- RBC volume Ay ZVz} %but
I
- Plasma volume Ay +O-SO Vo
'
Lower limit is 11 glr/dl (tlct < 33%).Below this-+ PatHolocrcar ANrvra o

Clossi

o Mierocgtie (MCV < 80 fL) -+ iron def anemia, thalassemia

o Norrnocgic (MCV 80-1OO fL) -+ sickle cell anemia
o Maqocgfia (MCV > 100 fL) -+ vit Brz, folate def

Complicotions:
cr Effect of presnancv -+ anemia (worsened; d.t. t Fe & vitamin demand)
9 Effect of anemia -+ pregnancv

> Moternol
c'
=
o
rt
3
o
!rt
> Fetol o
GI
The fetus obtains all its needs of iron & vitamins from
=
o
the mother by active transport (even if she is anemic). 3
However, there may be + . PTL & RDS
o
.t Pmtm. (d.t. the maternal comp.)

WhiteKnightLove
Saving from amenorrh
approximately

WhiteKnightLove
> Pohogenosls
* Iron requirements in pregnancy are > iron absorption (inspite of itst)
o Therefore iron stores in the mother are used to conect the difference
* If iron stores are already depleted or the mother is anemic
\iron deficiency anemia occurs or is aggravated

NormolFe obsorptiono
. Daily absorption -+ 10% -td
2o%tapreg- offerous supplied (10 mg /d)
\
Non- preg. (1-2mg), early pree. Q.5 mg), late preq. (6.5 mg)
. One gram is needed forthe whole pregnancy
€tlologg (Pdfl - O nutritional intake or O stores
- 0 loss -+ hge... .vomiting. .. .piles. .. .parasitic infestations

CIP a Swptoms -+ ellsy fatigabihty, dyspne4 palpitation

Sisns -+ pallor (lips, nails), tachycardi4 glossitis, koilonychiq splenomegaly

lnvestlgotlons
. Ilb Yo-+ < 1 1 gn/dl (<10.5 mg o/o recently )
. Blood picture + hypochromic microcytio, J.o (MCV, MCH, MCHC: <30 g/dl)
. kon studies: o
- S, fenitin J (reflects BM stores) <10 ng/ml (1't abnormal test/)
- Serum iron J G'[. : 60-180 ltgldl)
- Bone marrow stores J
- Total iron bindingcapacity t (reflects J transferrin saturation by 15%) "
Treotmont
o +QtoDfrufactic
- Eradicate any pdf
-
Improve diet + iron supplementation orally (after lstrimester: N6V)
\
Iron sulfate / gluconate / fumarate (30-60 mg/day)
I Adiw
ll 0rrl hon lx3: during or after meals to supply 120-240 mg lday E

If + - Oral therapy fails (< 0.3-1 gm rise ofllb / wk) =

o
- Side effect: NaV, constipation occuned 3
- Rapid results are needed, severe cases. Shift to tr
g
.o
ZlPq rllron -t
o
Iron dextran (Irnferon) IV or IM X GI
Iron sorbitol fiectofer, IM) or iron sucrose (cosmofer,IY) { =
o
*o Side effects: Allergic + . M -+ painful + sterile abscess J
o
. IV + tluombophlebitis
3l lf seuers qnsirlq -+ Packed RBCs transfusion

WhiteKnightLove
c%rcs

WhiteKnightLove
 E DNA replication is affected -+ Jnuclear maturation -+ a.ffection ofthe 3 cell
lines -+ on emi a, I e ukop e ni a (infections), t hromb o cyt op e n i a (bl. tendency)

[oLrc acrO 0efrcrency r/y'

Etiologu -+ t demsnd + J intoke (no vegetcbles * fcooking)
".g.preg
Eftct + onemio + neurol tube def ects, cleft lip & polote (fetus)
lnuesfigetions
- Hb % <tl gn/dl
- CBC + mocr. hyperchr. (tu\CV >1OOfL), hypersegmented neutrophils
o

- Folic ocid level (N = 6-12 W/L)

- Bone morrow -+ megaloblasts
Tregtmert
( Prophylactic -+. Good diet + folic ocid supplements (E00 rrgld)
. Given olso for -+ hemolytic
onemic, onticonvulsont theropy
( Active -+5 mg/day + vit.Brz + Fe (to ovoid unmosking oss Fel onemio)

pepntctous faoolsonranl anGmta (vtt s,, oegl

Etiotogg -+ long term vegetorion diet " + infrinsic foclor deficiency
Rqrsto fucome pregnont (usuolly infertile)
Eftet + onemio + otrophic Anstritis + neurologicol symptoms
Tpstmert -+ porenterol vit 812 clonocobolomin (1000 pgl3 months/I[/ life)

> thaLassemra
/, Thstsssemtq mtnor -+ J o chain synthesis -+ v. mild anernia + min. effect on preg
2- Thqtsesemie melor --> J p chain synthesis -+ severe anemia, rare to become preg

P-s,-gi-l
cr
f
> stckl€ celt an€mra o
E
/- Sickte cell trsit -+ v, mild anemia -+ min, effect on preg (UTl 3
2- Sickle cell diserse -+
)
g
!
- Occlusive crisis: obstruction of vessels + infarctions
o
- Hemolytic crisis: anemia & jaundice (o
a
by
o
TTT - Prevent occlusive crisis . Good hydration f
. Avoid hypxia & infections o
Eeps@-U9pq&jglelgp-!il{uil-o$-+-Eve!g-Hu-Q

WhiteKnightLove
E
J
o
o
o,
E
o
c
o
a
lst Znd
Trim6ts
The hvclr of thc proco.guhntr (Al irtor Vlll,
von Ullebrrnd hctor rnd (81 tbrlnogon rlrl ln pr.gn ncy.
FV factor V.

Polpotion of the colf dsnonstrotes vein must olrc be pol-

tenderness ond oedsno. groin.

The offected leg moy fecl womer Coreful meosurcrneni moy rweol
to the bock of lhe hqnd. some swelling compored with the other
leg.

WhiteKnightLove
> lncidence e0.5-lo/o
I

I Incidence is -+ equal in bottr ante- & post-partum periods

Unteated DVT -+ PE in 25Yo of cases with MMR 15%
Treated DVT -+ PE in 5o/o of cases with MMR 1%

o Uother. .. t* age & pariy, obesity, ABO other than 'O'

o Deltuerg. ... operative > vaginal delivery (why??)
o Prsylors thromboemhllsm... ... .recurrence risk is l5o/o
o Thrombophilir
- Factor V Leiden deficiency -+ J antithombin III ) recurrent
- Proteinc&Sdeficiency ) TED&
- Anti-phospholipid syndrome ) fetal loss
o Chqngc ln mrchou hlqd
-
Prolonged immobilization
-
Congestive heart failure, dehydratiorq sickle cell disease

> Dloonosis
* Sgnptnma
. DVT -+ acute painful swollen leg
. More corrmon in the left LL (why .?)
. More common in ilio-femoral (more dangerous > calf)

' PE -+ sudden severe chest pain, dyspne4 cyanosis

*sw
' Homan's sign (painfirl dorsiflexion of the anHe) \ 30%
' Tender hard cord-like may be palpable ) false +ve cr
)
* Srueotigatiaru o
3
' Doppler U colored Doppkr o_
- They are slightly less accurate in Lelvic DVT (MRI may be used) !
- Yenography still has beffer results in colf DVT o
cl
f
' If Ptr, is obuious -+ start heparin immediately o
f
- No need for chest X-ray, ECG, blood gases o
- To confirmPE -+ perfrrsion (V/Q scan, CT, MRI

WhiteKnightLove
c%tes

WhiteKnightLove
 MMR =15%. However, syndrome APS may lead 0n both
Post-phlebitic I

if recovery occuned + valve destruction: to habitualabortion 1- Mother

+ is usually compleb gdefa, skin ulceration (importani 2- Fetus

activates ATrn -+ J ll a gtZ Vit. K antagonist -+ J tt A Z-tO

40.000 u/day lV for 10 days - Better for artificial valves

double APTT - ln WE, it is used for 4-6
wks postpartum
10.000 units SC, twice daily
- PT is kept 2.5 - 3 x (lNR) =
normalAPTT
international nomalized ratio
.Active bleeding, active ulcer Not usd in the 1.t trimester
. CNS aneurysms as it crosses the placenta )
. Uncontrolled fetalwarfarin
- Embryopathy
- Chondrodysplasia Punctate
- FetalHqe: I

cl.ow molecular weight (fractionated) beparin (LMWH)

. Fractionated heparin e.g. Enoxaparin (Clexane) //, Dalteparin (Fragmin)
' Dose + 1 mg lkg hrs (Prophylaxis = 3tr40 mg /12 hrs)
112
. Follow Up -+ anti-Xa / (not PTT)
ET
=
o
Mainly X I Mainly ll -t
3
4.000 - 6,500 5,000 - 30.000 o_
9070 !rt
o
_ _1nrg.{sc_gr_rl4__ _J
o
p nr [$_cJ,,,] [t 0*v) Gt
a
Allare less with LMWH o
The main disadvantage is their high ., ,. .. . o
=

WhiteKnightLove
c%rcs

WhiteKnightLove
 Thromboembolic disease
Risk factors for venous thromboembolism in pregnancy and the puerperium
after vaginal delivery

Pre-exlsting New onset or transient

Previous WE Surgical procedure in pregnancy or
puerperium, e.g. ERpC

Thrombophilia Hyperemesis
Congenital Dehydration
Antithrombin deficiency Ovarian hyperstimulation syndrome
Protein C deficiency Severe infection e.g, pyelonephritis
Protein 5 deficiency lmmobility (>4 days bed rest)
Factor V Leiden Pre-eclampsia
Prr.rthrombin gene variant Excessive blood loss
Acquired (antiphospholipid Long haul travel
syndrome) Prolonged labour
Lupus anticoagulant Midcavity instrumental delivery
Anticardiolipin an tibodies

Age >35 years lmmobility after delivery

Obesity (BMl>30 kglm'1)
Parity >4
Gross varicose veins
Paraplegia
Sickle cell disease
lnflammatory disorders, e.g. UC/Crohns
Some medical disorders, e.9. nephrotic synd
Myeloproliferative disorders, e.g. ET, PRV

Thromboembolic disease in pregnancy - points to

remember
PTE is rhe commonest clirect cause of dearh in pregnancy and the puer-
perium in the UK
a Pregnancy is associated rrith an increased risk of thrombosis.
I The risk of DlT and PTE in pregnancy increases with increasing marer-
nal age and obesin'.
En'rergencl' caesarean section is associated rrith a greater than 2Gfold
increase of dling from PTE compared to spontaneous raginal delivery.
I Objective diagnosis of D\T and PTE is rial.
I Treatnrent of \TE in pregnancr necessitates larger doses of L\[\\TI and o
a
rrarfarin is avoidecl. o
Follorr'ing acute \TE in pregnancr, L\fl\TI must be condnued for the 3
rest of che preglrancv and rhe puerperium. o_
I Decisions rega.rding rhronrboprophr{a-'ris in pregnancY relate to Past !
hisrory. of \TE, rhe presence o[ derecuble thrombophilia and the other -t
o
identifiable risk factors. o
\\'omen at high risk of recrlrrenr \TE should receile antenaal and post- =
o
natal th romboprophrlaxis rr-i th L\n\.Fl' =
o
r Lln\TI and rrarfarin are safe to use in lacating mothers'

WhiteKnightLove
The boby should be exomined corefully ofter birth.

X-roy moy
show obsence
of bone centres.

Goitre moy be present.

Protein bound iodine studies
should be mode ond onti-thyroid
qntibodies estimoted.

WhiteKnightLove
O $bSnotor,icosis
> Complicotions
9 Efrct on tfifold
- Usually tolerable course during pregnancy
- Condition may improve & exacerbates after delivery
I Efhst on Pregnrncg
* Severe hyperthyroidism: usually -+ anovulation + amen. & infertility
* Maternal
- Spontaneous abortion & PTL
- PIH & Congestive IIF
- Hyperemesis gravidarum
* Fetal
- ruc& ruFD
- Fetal tachycardia, neonatal hyperthyroidism
- Fetal thyrotoxicosis & goiter d.t. passage of autoantibodies (IgG)
> Treotment
I Antithyroid drugs
o

. Propylthiouracil (drug of choice) /-+ 200-400 mg /d

. Methimazole (carbimazole) -+ 20-40mg/d
-
They cross placenta + fetal hypothyroidism & goiter
-
They are not an absolute contraindication to breast-feeding

I Beta-blocking Agents
. Propranolol (nderal) l0 mg lx3
. Block the beta-adrenergic receptors
. Prevent adrenergic effects of thyrotoxicosis
. Block the conversion of T+ -+ Tl
, The aim o + maintain the lowest possible doses of anti-thyroid drugs cr
)
o o
9 Suryera: Subtotal thyroidectomy is rarely indicated except: -t
3
- Failed medical ttt o_
- Cannot tolerate medical ttt !
-Large goiters with significant tracheal obstruction
-t
o
(o
It does not eliminate the risk of tansplacental passage of a
LATS and the possibility of fetal & neonatal thyrotoxicosis o
a
o
cr Radioactive iodine ablation (It") - I contraindicated in pregnancy "

WhiteKnightLove
 O $ypothyroic{ism

> Etiology
o Prlmeru hsDothsroldism: (TSH is high)
o Hashimoto's thyroiditis (autoimmune) /{
o Iatrogenic (Radioactive-iodine 131, surgery, antithyroid drugs)
o Iodine deficiency
o Sscondqrg hgDothgroldism: (TSH is low) Rare, 2ryto.
o Hypothalamic or pituitary disease, as in Sheehan syndrome?!
o Chromophobe adenoma of pituitary gland

> Complicotions
* Maternal + abortion, PIH, & abruptio placentae, heart failure " o
* Fetal +. IUGR & IUFD
. Congenital hypothyroidism (-+ obstructed labor) occurs in:
- RAI therapy for thyrotoxicosis /
- Rarely in hypothyroidism
> Investigotions
- Low senrm T3RU
- t thyroid antibodies (antimicrosomal, antithyroglobtrlin) in Hashimoto
- TSH is low in2ry hypothyroidism
> Treotment
Replocement theropy
- L-thyroxine (Ta) 0.05-0.10 mg /day converted in body to T3
- Breast-feeding is not contraindicated

o Thyroid function in pregnancy

=
o o Increased due to
- td production of TSH
3
g - t'd production of thyrotropin by the placenta
't - The thyroid stimulating effect of p-HCG
o o t
Leading to -+ total serum Tt &Tq,P .1, frRU
GI
=
o However -+TBG is also td
f
o o Thus -+
- Free Tt &Tq remain normal
- TSH remain normal

WhiteKnightLove
O lreatblessness (dyspoea)

> Physiologicol -+ 50% ofnormal pteg(mechanical &prog effect)

> Pothologicol -+ don't forget pulmonary embolism (acute dyspnea)

O flateroal $noktos
> Tobocco smoke (3800 constituents)
. Nicotine + vzmoconstriction
. CO -+ combines with fetal Hb -+ carboxyhemoglobin + fetal hypoxia
' Benq@yvne -+mutagenic & carcinogenic
> Effect of smoking on pregnoncy
o rueR / Neonates are t 200 g lighter than non-smokers
Effect is dose related (nunber of cigaretteVday)
o t'PNUR -+ including sudden infant death syndrome
o SDorrhneorc -+ abortion, PTL, PROM
o APllm -+ placental abruption, placentaprevia

@ $roncbtalsstbma(l%)

> Complicotions
. Eftst of prugnrneg a uthnrq: no effect on frequency or severity
. Eftcr 0f sthrnr + Fsgnqncg: HTN, ruG& PTL

> ltonogement u
. Reggll mdicrtlons +s CONTINUED (not teratogenic) a
o
-t
o lnhqlqtlon h bsftsr thqn mql rgenh 3
o o_
. Glucocorti co ids (Betomethoso ne), Disodium cromoglycote,& i protropium
!
. gz ogonists, Theophyllines (ominophylline)' -t
o
. Asthnrl exacerbation h not rn indlcrtlon for elective delivery GI
o ]lgdrmmtilons is given during labor (300 mg /12 hrs)
=
o
. Auold the tullulng dq$ . Prostoglondin Fzo d E2 onologues (misoprostol) =
o
. Methergine, Pethidine (not o problem in proctice)

WhiteKnightLove
 + *ffssrallnpregnancrf <e &

O Acute
o
IAcute 0 Clvarian torsion
Appendicitis cholecystitis or Ruptured CL
lncidence Commonest 1t15001" 2d common 1 /4000 uncommon
Pdf Reluation of gall bladder lnduction of ovulation
Unknown
(d.t. orooest.)
o
Diagnosis difficult EASET T level of suspicion
Pain m.b. somewhat Acute unilateral pain
Same like the non-
clP upwards. This depends
pregnant
t NaV
on gest. age + Adenexal swellino
TLC is normally t.u in Bilirubin, amylase U/S is essentialfor all
lnvest. (for differentiation)
Dre0 Upper abd. U/S
Complicat. Rupture, perfor, rtion, peritonitis... .......fetus + abortion, PTL
Treatment Laparotomy * Medicalttt Look
(its site depends on gest. (Fluids, NPO, A, A, A) Cancer
age)e.9. Ratherford * lf failed (257d or Ovary
extension comolicated + suroery

Sutqeru durinq pre[nsncu y'

Be* tima is ot ... ... .mid-trimester (why?)
Beforc crrgerv. . . . . . ..document fetal life t CTG
Du rin g Er rgarv. . . . . . ..tocolytic infirsion, minimal uterine manipulations
Hfter slrgerg
Antibiotics
Tocolytic s, Profenid suppo sitory * pro gesterone
Reassess fetal viability

& ?alnlnyregnancq M h &

ct
=
o
rt
o Pregnancy
3 * Etls Abortion, ectopic, incarcerated gravid RVF uterus
o_ *kh Accidental hge, rupture uterus, acute fatty liver, acute plyhdramnio
! * lftrrc - Complicated ovarian (ruptured CL cyst or TL cyst of V,mole)
o - Comolicated fibroid (red deoeneration)
cr
a g Urinary Cvstitis. ovelonephritis, stones (renal colic)
o
f o GIT Gastroenteriti s, ral hepatitis, food poison ing
vi
o o Surgical Acute aooendicitis, acute cholecvstitis, perforated DU
6 Medical DKA, sickle cell crisis, acute porphyria, mesenteric vasc, occlusion

WhiteKnightLove