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Changes in investigations and trearment arereguired.
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2013 I 4069
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I Fertilization Placenta 3 Maternal adaptation Diagnosis of pregnancy Ante-natal care 10 16 18 Habitual
I
Fertilization
Placenta
3
Maternal adaptation
Diagnosis of pregnancy
Ante-natal care
10
16
18
Habitual abortion
Ectopic
33
40
Vesicular mole
47
Vasa previa
Placenta previa
50
51
Accidenta! hge
55
Atonic
60
Traumatic
Retained placenta
62
68
Drc
70
Acute inversion
72
Amniotic fluid embolism
73
Shock in Obstetrics
Obstetric trauma
74
75
Pre-eclampsia
76
Diabetes milletus
87
Heart disease
Hyperemesis g ravidarum
Urinary tract infection
96
101
104
Anemia
107
Thromboembolism
{10
Thyroid disease
113
Respiratory disease
115
Surgery & Pain
116

My 2 Aims in this book to be SIMPLE and COMPLETE, so I save no
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

.J

.J .J
.J
.J
Fertilizotion Plocenlo Moternol odoplotion Diognosis of pregnoncy Ante-nolol core
Fertilizotion
Plocenlo
Moternol odoplotion
Diognosis of pregnoncy
Ante-nolol core

-

-

1

@@ OVULATION l2rh Doy Spermotozoori ygole trogen Doy 5 25 30 of Morulo Cycle Repoir
@@
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

Fertilization . The union of a mature ovum & a mature spermatozoon at ampulla of
Fertilization
. The union of a mature ovum & a mature spermatozoon
at ampulla of F.tube o (bet. outer & middle 1/z) --+ zygot
o TrgnsPort of sprrns
- Mature spenns
l22x
or
22y)
reach
within
40 min
- Capacitation of sperms starts.
within
the cx
\
changes in sperms tot its ability to fertilize
.
Removal of excess proteins
.
Production of enzymes e.g. hyaluronidase o
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)
" r d,#'ffii'*:ffrt'!ffi',ft'$;H'Jf,lp"ar b'dv .
Differentiation
o
Zygot rapidly divides by mitosis
8 4 2
+ 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

Ann ioiic Two srnoll covitie gppol, one in the ectodem formirp fhe omniotic soc, thc
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

lmplantation: z o ! It occurs on tle 6s to 7h days after ovulation 3
lmplantation:
z
o !
It occurs on tle 6s to 7h days after ovulation
3
\ by penetration of the trophoblast into the Dectpun o :-
o_
!
\ modifled secretory endomet. under efflect of both P/ a !
q
o
GI
Functions of the decidua o
o
=
- Site of.
rnpfantation&,natritianof
fitastocyst
o=
f0*tianof
- Site of.
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
Formation of the chonionic villi
o The chorionic villus is formed of 2 layers of hophoblast :- - Ortotroohoblast =
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
€arlg developm€nt of Cmbrgo (till 7 wks; after this + a fetus o )
. 7ft day + two layers (endoderm and ectodenn) o 101t day + amniotic caviSt
. 7ft day + two layers (endoderm and ectodenn)
o 101t day + amniotic caviSt andprimitiveyolksacare formed S
. 16ft day - three layered embryo (endodenn, mesodenrq ectoder

Deciduo bqsolis Deciduo copuloris
Deciduo bqsolis
Deciduo copuloris
Deciduo bosolis t
Deciduo bosolis
t
I t I I I -1+!rE
I
t
I
I
I
-1+!rE
''Chorion loeve Deciduo copsuloris
''Chorion
loeve
Deciduo
copsuloris
Deciduo ---
Deciduo
---

z q 3 Norrnqlstruefurc o > Shape. , discoid ! d > 500 gm o
z
q
3
Norrnqlstruefurc
o
>
Shape.
,
discoid
!
d
>
500 gm o
o
>
Site.
UUS
(60%
postenor) -+ site of implantation
,
o
>
Size.
. 18-20 cm in diameter
o
=
>
2.5
cm in center -+ gradually thins towards periphery
>
Cord insertion
eccenfiic o
Plecental founqfion
>
Two surfaces
O frm S(JRFAG is smooth & covered by omnion o
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
sularis
!(tB o
s
ofthe
c
t
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

Plocentol r "& borr;e, ---{ Endometriol glond \ ( c ")o , c lj oe
Plocentol r
"&
borr;e, ---{
Endometriol glond \
(
c
")o
,
c lj
oe
oa
4.i<F-; .J
Mesoderm
Moternol blood - - ---Syncytiotrophoblost
Moternol blood
- - ---Syncytiotrophoblost

z o O I fulEchonicol ottochmont 3 o_ r Ptocentol borrien- o 1- Cytotrophoblast 2-
z
o
O I fulEchonicol ottochmont
3
o_
r Ptocentol borrien- o
1- Cytotrophoblast 2-
Syncitiotrophoblast
(0
at
5ft- 6n'month)
-t !
o
3- Mesoderm 4- Fetal capillary endoth. + its basement memb.
GI
o =
'tThe placenta becomes thinner as pregluulcy advances '
o =
*The placental is permeable to many drugs & organisrns e.g.
- 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 o > Nutrition - Water & electrol)4es
I
> Resgirotion (gas transport) by.
simple
diffusion
o
> Nutrition
- Water & electrol)4es
, simple diffusion
& ercrstion - Glucose, amino
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)

zPlocenlol cotyledons oll round - Amniotic covity Plocento Membronoceo
zPlocenlol
cotyledons
oll
round
- Amniotic
covity
Plocento Membronoceo
Plocento Duplex Plocento Biportilo The plocento is com- Ihe,+Iocentq is pletely divided into portly divided
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. -
--. Plocento Velomentoso.
-

z o I > Shrm 3 o_ l. Bipartite placenta O 2 equal lobes connected
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
o
3. Placenta fenestrata 4 a window is present (a part of placenta is missed)
cl 5
4. Placenta succenturiata (succenturiate lobe / lobes)
o
f
- Small accessory cotyledon/s attached to placenta by membranes o
o
- May be torn away during delivery + retention +
PPHge o 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.
' Abnomtl qttqchmont of the ord.

Umbilicol vein /\ /\
Umbilicol
vein
/\ /\
i:'U.bili"ol='-'* orteries . Arnnion Whorton's iell/
i:'U.bili"ol='-'*
orteries
.
Arnnion
Whorton's iell/
Cord Round the Neck One or two loops of cord ore quite -----{L often seen
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.

z o -r 3 Strucnre o_ o Length ----r about 5O cm ! rl o
z
o
-r
3
Strucnre
o_
o
Length ----r about 5O cm
!
rl
o
Diometer --+ about 2 cm
o
o
GI
Contents --+ 2 arteies (non-O2) & I vein (O2) " carryingfulslblood along
o
=
with remnants of allantois in myxomatous tissue (Wharton's
:,
jell). Vessels are convoluted (length of vessels > cord)
o The omniotic membrono covers the umbilical cord '
o
One voln carries oxugenoted blood to the fefus Truo orterles carry rcduced blood from the
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 -
flcnomollttes
I. Length
, Vtry /orug(>100 cm) ma1 had to:
- Coiling around fetus
- True knots
- Cord presentation & prolapse o
> 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

AMNIOTIC FTUID Volume This increoses up to the 38th week, folls slightly up to term
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
0 l0
20
circu lotion
30
40 44
--.-
-
Weeks
-
5ource
By diffusion
.
hours. The formotion ond circulo-
The fluid
is reploced
wery
3
Secretion
thrcugh
by omnion--
umbilicol
tion is
notdefinitely
known.
lt moy
corrd
be derived from severol sources.

z o > Lovers of omnlon ( 0.5 mm -i 5 layerr ) 3 1.
z
o
> Lovers of omnlon ( 0.5 mm -i
5 layerr )
3
1. Cuboidal epithelium
o_
2. Basement membrane
'u
o
3. Compact layer (reticular fibers arranged in bundles)
4. Fibroplastic layer
@ )
o
5. Spongy layer (contains mucous + can glide upon chorion)
a
o
> Sourco of omnion
amniogenic
cells ( from fetal ectoderm )
> Sour@ of omniotic f,uld
I. Motornol d
transudation (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
.
hevents direct fetal &
.Prevents adhesions bet.
fetal skin & amnion
. Allow free movement
of fetus -+ muscular
development
placental compression
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
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)

ch
ch
16 weeks 8 24 32 40
16
weeks 8
24
32
40

z o -t * 3 Steroids "+ estrogpn & progest from CL & placenta o
z
o
-t
*
3
Steroids "+ estrogpn & progest
from
CL & placenta o
g
*
rDroteins,+ HCG & HPL.
,
from
syncitio-ftophoblast o
.9
rt
o
Gl
)
I ) Humon drorionic Aonodotrophin
o a
>
gtune o( p'wfuAnn(a glycoprotein) o
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 + Stide agglutination with latex (detects 500 rnlu/ntl)
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
Maintenance of CL
Usos
of
abnormalitie
9) Humon Plocpntol Loctogen (a polypeptide)' > Uwq. oimilantueg( & p,wlaan + may stimulate growth
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

CIRCULATION Heqd \ /-q F o Umbilicol vetn - P.- Viscero Ol c -) .J
CIRCULATION
Heqd
\
/-q
F
o
Umbilicol
vetn -
P.-
Viscero
Ol c -)
.J
J*
o-
Arch of
Ductus

z o rl O gntrauterloe 3 g - Oxygenated blood from the placenta passes to
z
o rl
O gntrauterloe
3
g
- Oxygenated blood from the placenta passes to the fetus via the
rt E
o
umbitical vein (l) o -+ penetrates liver to give it small branches
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 passes into + Rt & lt
internat
iliac arterios -+ umb.!!!ca!arteg.!el (2) o : non Oz blood
To compensate for the low arteriat PO2 in the fetus:- "
|
" Irr"reased fetal cardiac output
* Increased fetal systemic
blood flow rates
o: (l
&te! -oa perry-tns -9?-p-?c--iry- --- }I-b:I)
I -1-r-r,gr.gf9-$ #+itv- {o-t
@ 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
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
- Ductus arteriosus + lisamentum
arteriosum o

c%tes
c%tes

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

<> UEateauet aeelatgtEou <e z o 3 g ! l) The uterus o (o )
<> UEateauet aeelatgtEou <e
z
o
3
g
!
l) The uterus
o
(o )
*
Shqps -+ 0 from 50 gm (10 rnl3) to -+ 1 ls (5000 d3)
o
a
-+ changes from pear shape -+ globular -+ pyriform
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
IlunP"lpyq$1"-
--i
Dcidua Well
Irqldeyelqp_e$
j
_
adherent
- lgp;.ly p"g["gr."$" . " -
.j
Et!
Passrye
i
Phraiolosical retraction rins It is a groove between the thick UUS & thin LUS below
Phraiolosical retraction rins
It is a groove between the thick UUS & thin LUS below
the symphysis pubis. Normally it is not seen or pafoable

VULVA ; Prepuce of clitoris - -- . z? $'--- .'--- - Clitari< Clitoris r5
VULVA
;
Prepuce of clitoris
-
--
. z?
$'---
.'---
- Clitari<
Clitoris
r5
----
-.S,[-
-
Frenulum of clitoris
-Urinory meotus
'SS_ jrit-
- -----Vestibule
- - Lobium minus
- - Lobium moius
Y;.-. - _ : _-
_
_-:_- :
I:;,,:;",,
"
:* - --
--
- Perineum
f*--
--Anus
ll i
li
./\'r
,'/
\::,,
./\
The breost ot l6 weeks
The breost ot 8 weeks

2) The ovaries z . No oulstlon oocur3 (suppressed LH & FSH) o 3 o
2) The ovaries
z
.
No oulstlon oocur3 (suppressed LH & FSH)
o
3
o Ths corDu! lutsum sscretss
g
- 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
c
f
.
o
A CL c$t may be found in the lstrimester
( < 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
't The 1* few weeks o tenderness, tingling
(d.t. tsize, vascularity & sensitivity of nipples & breast)
'k The 2od month
- 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

lncreosed metobolism = increosed heot pro- lncreosed duction -+peripherol 9OSeOUS vosodilototion to get rid
lncreosed metobolism
= increosed heot pro-
lncreosed
duction
-+peripherol
9OSeOUS
vosodilototion
to get
rid
interchonge
of excess heot
D FOR
ooD s
lncreosed metobolism
=increosed excretion
of woste products
:: :::i jr::r
|!il;;,l: :11:l:1:
li Hyperventilotion
lncreqsed
lncreosed
Expirotion
lnspirotion
-/
,r'
exoired oir increosed
lncreosed oxygen intoke
Lo*rnotlnol blood
I
Y
corbon dioxide
High orteriol oxygen

o z o The blood 3 * Prsssrns,'+ S esp in2"d trimester o_ - Placenta
o
z
o
The blood
3
*
Prsssrns,'+ S esp in2"d trimester
o_
- Placenta acts as an AV shunt )
leading to O in the P.resistance
E
rt
& t
o
- Vasodilator effect of progest. )
of the peripheral flow
Gl
*
Votunre of Plumr ,+ increase 40-50% (max at 30-34 weeks)"
=
o 5
o
* Elsmenh
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)
The heart
changes
occur from l"ttrimester E
.
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 )
o
O
d minute oxygen uptake ) resp. alkalosis o
lilo change
2
What aboutthe o RRq

--Reloxotion of sphincter + -- Regurgitoiion * heqrtburn . -Slight reduction in gostric secrelion, ond
--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 morility in smoll
intestine - lncreoses time
for obsorption.
Reduced motiliiy of lorge intestine -- -- lncreoses tirne for woler obsorption, . but olso
Reduced motiliiy of
lorge intestine -- --
lncreoses tirne for
woler obsorption, .
but olso tends to
induce
/l\Cro*tt,
of conceptus ond
constipot ion ,
uterus - lncreoses
oppe-
tite qnd thirst. ln lote
pregnohcy pressure of the
uterus reduces copocity
for lorge meols +
frequent smoll snocks.
)':=- Thethe
uretersuretem 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
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.

z o rt lf The mouth 3 g - Morning sickness a nausea & sometimes
z
o
rt
lf The mouth
3
g
- Morning sickness a nausea & sometimes vomiting in early pregnancy
- Changes in appetite + longing (pica) -+ desire to certain food
!
{
o
- Ptyalism a excessive salivation (hyperemia of the gums t hypertrophy)
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)-+
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 +
> 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
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

CARBOHYDRATE METABOLISM
CARBOHYDRATE METABOLISM

z o ) The pituitary rt 3 Increased size & vascularity (esp anterior lobe: 2-3
z
o
)
The pituitary
rt
3
Increased size &
vascularity
(esp
anterior lobe: 2-3 folds)
o
t
prolactin - J rSn & LH, GH [other hormones are unaffected]
!
)
The thyroid
o
-
GI
Slight enlargement (t fSn & chorionic thyrotropin)
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
t
aldosterone & renin (due to t CBG, free serum cortisol o are unchanged)
l. Piggnentation d.t.O placental & adrenal steroids, also E, may have MSH like activity o
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 €
> 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
> tipid metabolism a increased blood lipids & cholesterol o-+ 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

c%tes
c%tes

IA,;J'LEJ,LT;N z q O Gastnointestina! 3 o_ ) Mornlng slckness ) ! Gingtvttis: hyperemic gums
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
d
)
Ptyalism:
excessive salivation
)
@ )
Heattburn: Treated by antacids, more frequent meals, avoidance of spices
)
Indigestlon:
hypochlorhydria (regurgitation of alkali
chyle into stomach)
o f
o
)
Coastipation: tr fluid intake + eating whole meal bread [& not white breadl
)
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

1. A urine pregnancy test will often be positive at the time of the missed
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
I
7
14
2
Conception
2'l
3
28
4
Pregnancy t€st poGitivo
[menses due]
Empty uterus
5
G€stational sac OCG >2m0lq
6
Nausea
Breast tEnderness
Yolk sac,
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

Etsgraorts of pssgm,auey

z I Ihe I'I lrimesl 3 o_ > Sumotoms E . Amenontea (Nora sunr srct.r)
z
I
Ihe I'I lrimesl
3
o_
> Sumotoms
E
. Amenontea (Nora sunr srct.r)
d
GI
- may have arnenorrhea due to other causes
- 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
violet).
- Uulva (soft &
.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
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)

r of Auscultotion ot 24 weeks A Plnrrd rfrdnropr. Pinard's stethoscope uds inuented in France
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
weeks
frrht rh. Ph.rd f
,10.09
lNIRt lAt IAI.IOIIEIIENT
The fetus sinks ond
Top gently upvrords ond
Thc fetus is disploced
hold finger ogoinst ceNix
upwor&
o gentle top is felt on
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
cov ily .
ceives lhe impulse.

Ihe anil Irimesl z o rt > Svmptoms 3 g o Breast symptoms increase o
Ihe anil Irimesl
z
o
rt
> Svmptoms
3
g
o
Breast
symptoms increase
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 )
Umbilical
souffid (funic souffld) --> Soft whistling sound r-r
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
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
DD of pregnanon carses of:
- Amenorrhea
- Symmetrical enlarged uterus
- Don't forget pseudocyesis

z o 3 * Objectives o_ . To try to get a healthy mother &
z
o
3
* Objectives
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
@ f
o
Early detection of congenital fetal malformations
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

GRAND MULTI PARITY
GRAND MULTI PARITY

z o r 3 > 9ersooal historv 9. .lllme. -u tripleruuxe q o Age. lowest
z
o r
3
> 9ersooal historv
9.
.lllme.
-u
tripleruuxe
q
o Age.
lowest
rate of MMR & PNMR is20-26 yrs.
ct o
a
o
Adolesccnt Dncqnonq,
Prcon. in old oq3 (>35 yrs)
a
o
.Nutritional deficiency (i
I ,Hyp.rt niive diiorders
.Nutritional
def (consumption)
.FffN + DIvt
I
.Dystocia (qmalt pe_Ms??)
.Social & economic
. Dy_stocia (oqteomqlqcic pefuis ??)
.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
.Malpresentation (lax abd. wall)
.Uterine atony (more fibrous tissue)
.Obstructed labor -+ rupture uterus
.Placenta previa (accreta)
.PPHge
.Chronic hypertension, DM
2. Elderly PG (> 35 yrs) -+ liable to OO@
|
Labor
-1--
Abortion, PTL
--pregnrlg
.Prolonged labor (tr* maternal
.Chromosomal anomalies (Down) anxiety & abnormal ut. action)
.Hyperemesis gravidarum
DM
.PEt + P.abruption,
.Rigid perineum + episiotomy
.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

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

THE FIRST EXAMINATTON Height ond lnspection of Weight Teeth Auscu ltot ion of Heort ond
THE FIRST EXAMINATTON
Height ond
lnspection of
Weight
Teeth
Auscu ltot ion
of Heort ond
Lungn
Blood Somple
Exominotion
for Hb Grorp:
of Breosts
Serologicol
ond Nipples
Test for
Syphilis
Exominotion
of Urine
Exo-r inot ion
of ,Abdornen:
Exominotion
Assessment of
Size of Uterus
of Pelvis
lnspection of
Exominotion
Vogino ond
of Legs
Cervix
Nikolai Sergeiuicb Korotkou (187{-.1920) uas
n

z o rt 3 > Gereral o_ rt ! o Decubitus: dyspnea ct o o
z
o
rt
3
> Gereral
o_
rt !
o Decubitus: dyspnea
ct o
o Height if less thzut 150 cm -+ be aware of CPD
a
o
o Weight: if obese beware of D.M., hypertension, macrosomia & dystocia
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,
*
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.

weeks %tr\ ,/ /,-32 This exominotion must be mode syslemoticolly. Remember thot the following tissue
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-
pushes
two
fingers info
The honds polpote the
poted, ond it should be
noted whether it is mo-
fhe
pelvis.
This is the
contours of the uterus,
best method of polpoting
identifying the bock
bile or fixed in the pel-
the fetol heqd ond deter-
ond the limbs.
vic brim.
mining whether iiis fixed
or mobile.
ABDOMINAL PALPATTON

> $bdominal z o 3 o E ous pelvis Shape -r cont. _- - r
> $bdominal
z
o
3
o
E
ous
pelvis
Shape
-r
cont.
_-
-
r
tation --+ linea nigra
_
_i
o
r--'_'_"-'-L"'-'-'
'-
----------l---_'-_----
"
l-s"-qd-eg--r-e
(o )
-
-l
,;ifiies
-o
S-gp1g;pubiq.trgif
:-
fem[pige
/ masculine Umbilicus
o
.
:,
o
2. Palpation (4 Leopold's maneuver)
* Fundol level by hand or in cm above S.pubis
*
Fundol grip
WEE(S
LEVE
- Cephalic or breech
12
_$yg,p_l,y_r_L:. pg-b-ig-
- Empty
ffansverse lie
16
20
* Umbilicol grip
24120-221 Umbilicus
- For lie
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
iiiil$
I frc con be ugd for
t
_ -- D
l
Sure sign of pregnancy
ns!|
,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
ln early pregnancy for
ln late pregnancy for
Done
- Diagnosis (Hegar's sign, Ballottement)
-
To diagnosis labor
only
- In some complications e.g. ectopic preg
To assess pelvis for CPD
- Any associated Pathology
-
at
- Any associated pathology e.g. prolapse
: f_q BkS cg
ui.g:_u-qg-it
ql -s_I_nggl

Ultrosonic Recording Uterine octivity recorder FHR recorder (ultrosonic ,,(tocogroph) tronsducer) Fetol monitor
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 \

z o > Routine: 3 o Blood for: " g - Blood group & hemoglobin
z
o
> Routine:
3
o Blood for: "
g
-
Blood group & hemoglobin %
!
-
Rh (lf Rh -ve
see husband,.
if
.
multipara de_lermine if sensitized)
.
o
-
cl
Blood sugar at 24 -28 weeks
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
- 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
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
*
€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:,,,

Dlehry edvlcc ln prrtnrncy Dietary advice in pregnancy.
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<
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
saknone[a 0ncludhg pudi]Es)
rbk o,
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

z ) o Nutrition 3 o Caloric requiremefi-+2200 -2500 K.cal I day g o Daily
z
)
o
Nutrition
3
o Caloric requiremefi-+2200 -2500 K.cal I day
g
o Daily increase of 300 K.cal (esp. in late pregnancy)
!
o
Meals should be well balanced & discourage overeating
o
o
@
If diet is adequate -) no need for supplementation (except
)
a
1. Putstns
o f
o
Requirement 1.5 gKgd -+ addition of I kg protein to body weight
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 &_cgrqrs_e9iq_ft!!_El_?.]_qq_qq_&_ /d
3. tqB -+ to complete caloric requirement
4.
Vfqmlm
A -+ 5.000 lU
&_cgrqrs_e9iq_ft!!_El_?.]_qq_qq_&_
/d /d
D-+ 400 lU
Vjl L:l_Bttse_4le!4[s9-
/d
Br + 1 mg
Folic
acid
-+
0.8
-
1 mg
/d "
/d
Bz -+ 1.5 ms
_lti."gfini9_eq1d-_;,5:_!rg_E-.-
".
5.
Mlnsrqls
- Cqlcium: I g ld (2 cups of milk),,
supplementation
is not essential o
- fron: 30-60 mg 1d
the
only supplementation
required I E + 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.

llomurunot of tprplryrlofirndrl hr[ht
llomurunot of tprplryrlofirndrl hr[ht

Olstelric diagnosis > Name, Age, Para _+ _, Pregnant at wks > Presentation (cephalic, breech),
Olstelric diagnosis
> Name, Age, Para
_+ _,
Pregnant at
wks
> Presentation
(cephalic,
breech), not in labor
> complication (obstetric
medical)
Qa[cutation of IEOO
> Histonr 1. Menstrual delivery interval: 'calculated.from the l" doy oJ'LMP' - 280 days. or
> Histonr
1. Menstrual delivery interval: 'calculated.from the l" doy oJ'LMP'
- 280 days.
or
- l0 lunar months
or
.40 weeks
.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
.
.MG (16-18 wk)
4. Quickening oPG (18-20 wk)
>Exannination
1. Fundal level O @
Causes of FL > amenorrhea 1- Miscalculation 2- Pregnant on period ofhge 3- Multiple pregnancy
Causes of FL > amenorrhea
1- Miscalculation
2- Pregnant on period ofhge
3- Multiple pregnancy
4- Macrosomia
5- Polyhydramnios
6- Concealed accidental hge
7- Tumors: fibroids, V.mole
-C-*_r-elgf EL_S_e-llg.r,_q_nh_er 1- Miscalculation 2-Pregnant on period of amen. 3- Missed abortion 4- IUGR 5-
-C-*_r-elgf
EL_S_e-llg.r,_q_nh_er
1- Miscalculation
2-Pregnant on period of amen.
3- Missed abortion
4- IUGR
5- Oligohydramnios
6- IUFD
7- Transverse lie
2. Symphpeo-fundal 'McDonal d rul e' - Wks of pregnancy: height of fundus (in cm)
2. Symphpeo-fundal
'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 .
.esp the 1't trimester (the more accurate)
2. Doppter
10 wks

c%tes
c%tes

.J

.J

-J

Abortion

Ectopic

Vesiculor mole

-14

-aa

.J

-a

O0stattla AauonAaga Early pregtaocy 9ost 9. b€e llrlnts - Atonic - Abortion - Local gynecolog.
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
plac-en"ta i , Mafginplpipus bl
- Acute inversion
mo_le- i 1Dgc_iduat ltge
g
o
o
Deflnition'o t erminat ion t interrupt i on of pregnancy befo re
e
period of fetal viability (gestational age at which fetus is
f
(o
Le.
capable of extra-uterine existence)
in developed counffies
in developing countries
f,
(20 weeks : 500 gm)//
o
or
gm)
(28 weelrs -- 1.000
o
=
!
TVpes
o
Spontaneous
Jnducp/
GI
a
O Threatened
o
I medical indication
o
=
O missed *e
0 septic
L+ 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
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

lntrauterine gestational scan containing a 6 mm , ,, fetal pole with a yolk sac.
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
\i,j
lr,rlr\,irllirt.ll\(,lr)
, ,( ,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
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,,

€tiology OOO A] Fetal (CFMF) r ' ' o r 'r'.r ' |t[!foltne/ trU! of
€tiology
OOO
A] Fetal (CFMF)
r
'
'
o
r
'r'.r
'
|t[!foltne/
trU!
of I't trime
- The conrmonest cause (5
t}o
)"
c abortion
- May be o -+ 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
o
-
g
|
progesterone -+ C. Luteum or placental insufficiency
-
:,
|
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
=
!
o
-
Protozoa -+ toxoplasma?!, malaria
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)

Threotened oborlion Bleeding is slight, not retro- plocentol , ond cervix is closed. Pregnoncy is
Threotened
oborlion
Bleeding is slight, not retro-
plocentol
,
ond cervix is closed.
Pregnoncy is likely to continue.
lnevitoble
obortion

Deflnltlon ^a attempt of the uterus to expel the fetus leadine topartial separation of the
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
o
- Uterus -+ coresponds to the period of amenorrhea
e
- Cervix + closed
a
GT
lnrrestigotlors
5
o
. F,rdlfgnch [doernrtne Hrl[hl
o
- u/s,+ TV-US (5 wks)
.TA-US (7 wks)
Sonicaid (10 wks)
=
- FHCC'+doubled every 2 days
!
o
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
- 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

2. l. The ovum, portly or wholly de- Hoemorrhoge bosolis leoding occurs in the deciduo
2.
l.
The ovum,
portly or wholly de-
Hoemorrhoge
bosolis leoding
occurs in the deciduo
to loco I necrosis ond
ioched, octs os
initiotes uterine
o foreign
body ond
controctions.
The
inf lommotion.
cervix begins to
d i lote.
COMPLETE
INCOMPLETE
Expulsion complete. The deciduo is
shed during the next few doys in the
lochiol flow.

> Definiuon complete separation ofthe fertilized ovum withprogressive cervical dilatation & fetal expulsion
> 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)
with BACKACIIE (cervical dilatation) = sacral pain o
> Signs
P
o
- General + Pallor / shock (according to amount of bleeding)
o
g
- Abdominal -+ uterus corresponds to period of amenorrhea
- Local + oPENEp cx (products of conception may be protruding)
=
GI
> Treatment
f
l. Re suscitati on 1f bleedtng is excessive
o
2.Eyacuation: ls trimesteric -+ evacuation by suction or curettage
2"d trimesteric -+ oxytocin or prostaglandins
3. Followed by .Ecbolics -> helps complete evacuation of remnants
o !
!
-l
o
.Antibiotics -+ reduces possibility of postabortive inf
ct a
4. Anti-D if Rh*ve
o
o=
> Definition oall products of conception have been expelled > Symptoms - Amenorrhea + symptoms
> 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
> 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

/ll&scd dordoa TrE drfrn of tlcpqnoncy b l8 rGGb hrt fic ucrr3 h6 flld D
/ll&scd dordoa TrE drfrn of tlcpqnoncy b l8
rGGb hrt fic ucrr3 h6
flld
D crnrj!
D;,ltrn ila ee 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
lf retoined for long enough, the geslotion moy end up os o
CARNEOUS MOLE
OT MACERATED FETUS
\

Ceruical aboftion I Ceruical preg. (v.rare)
Ceruical aboftion I
Ceruical preg. (v.rare)
Dd type of inevitable abortion type of ectopic pregnancy -+ arest of gestational sac in
Dd
type of inevitable abortion
type of ectopic pregnancy
-+ arest of gestational sac
in the cervical canal
+
implantation
in
the
SgmDt pain (severe) > bleedilg
endocervical canal
bleeding > pain
:TE$
na-g'jp-err.o--
Dilatation & curettage
Hysterectomy OR conservative
P
o
o
_o
(Catwaw t+rrk,
(O=
f,esht1
r,role
bhobq
mole)
> Definition retention of dead / non-viable products of conception within uterus
o
='
o
> Symptoms
=
't
I- Amenorrhea O symptoms of pregnancy disappear.
2- Bleedinge rarely mild dark brown (prune juice)
o
(o
a
.
Milk secretion ' (d,t. +
.it r:rry occur normally in preg.
.
Normally E2 blocks action of prolactin on breasts in preg.
o 5
o
3- Pain ?
usually absent +
absent fetal movements
> 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
mg/ week. it is done
level usually decreases by 50
weekly to avoid reaching the dangerous level (100 mg/dl)
> Complications
o Infection -+ septic abortion
o DIC (hypofibrinogenemia) -+ after 4-6 weeks
> Treatment
- If fibrinogen is normal a TOP (acc. to gestational age) + antibiotics
- If fibrinogen is &a+ elevate 1* (fibrinogeq FFP, fresh blood) then TOP

/;

)-^ r
)-^ r

]r.:ere*d}r$

Definition superimposed infection on any type of abortion (esp. criminal) Ogonlsns - Gram +ue -+
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-
g
-
.
Exogenous
.
.instruments, sanitary pads
o
-
organisms
present in female genital ffact
o
g
-
Hematogenous (rafe)
from
a septic focus e.g. appendicitis
(o=
Cllnlco! PlcUre
f
o
Sumatnm^o
o
. Symptoms of abortion (amenonhea
bleeding.
pain)
E
. Followed by symptoms of infection
o
- Fever, headache, anorexia, malaise, rigors
-
GI
a
- Continuozs lower abdominal pain
- Offensive discharge
. There may be history of atrial to induce abortion (by untained personnel)
o
a
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

Exlension of infection in Peritonitis Pelvic collectiJn of pus
Exlension of
infection in
Peritonitis
Pelvic
collectiJn
of pus

Compllcotions O local Geneml Orqan affection l- Endometritis 1- Septic 1- Septic shock, ARDS 2-
Compllcotions
O
local
Geneml
Orqan affection
l- Endometritis
1- Septic
1- Septic shock, ARDS
2- Myometritis
thrombophlebitis
2-Actfie haennlysis
3- Salpingitis
4- Salpingoophritis
2- Systemic
pyaemia
(esp strept & clostr) * liver
affection + jaundice
5- Parametitis
6- Pelvic peritonitis
3- Generalized
3.DIC
peritonitis
4-Renal failure due to
7- Pelvic abscess
the above factors.
g
o
Treotment
o
g
l) Elevation of the eeneral condition
)
+ Adlblotles (ln comblnqllon ln hlgh dosesf
GI
- Grsm +ve -+ penicillin G or cephalosporins
a
- Gram-ve -+ aminoglycoside as gentamycin or tobrarnycin
- Anaerobic -+ metronidazole or clindamycin
- Ingas gangrene -+ specific antiserurn
o
o
!
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= f
. Repeated renal function tests
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
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

?ata/,ftal chromo',/nal ahlr,:n,/'altbo Reciglolc,alvanolrc*lan Robatranbnfuobr 1.8-*f.fl l.t--l (e-*d
?ata/,ftal chromo',/nal ahlr,:n,/'altbo
Reciglolc,alvanolrc*lan Robatranbnfuobr
1.8-*f.fl l.t--l (e-*d
(a) Con1cnltal m alt orm at)ons . Miillcrian fuslon abnormali1ies V^*,"*Y,,** . Abnonnalftbe ducb in
(a) Con1cnltal m alt orm at)ons
. Miillcrian fuslon abnormali1ies
V^*,"*Y,,**
. Abnonnalftbe ducb in ubro DE9 a<pa'et
(d k4utrcdlceiono
o fulaalpha*dolclancy
. mctabolb dloordaa (tlryrdd., dlabctao)

ffi"ffi***

Dafinltlon Three or more successive spontaneous abortions (some say two) (If not successive it is
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)
tr Thrice -+32Yo(< l% of commturity)o
o
o
_o
=
GI
€ttology O
5O%
of coses ore ldlopothtc o
O
f
o
o
rt
O
Loeal causes
!
-t
o
o Account to 30Yo" of 2od trimesteric abortions
GI
o Most of them is not diagnosed before multiple pregnancy losses
a
have occurred (because they are
syrnptomatic)
o 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
2- lmmunological ,+
., PCO
.Thyroid
.
'k .f,utoimmune + APS ,/,/r/
,
SLE
*
Illoim,rrrune -) . RH incompatibility
ffifii:'h*t
3-rhrombophiria * r,yp
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

>Personal - t 4t -+ chromosornal anomalies, DM hypertension - Resifunce + rural areas (Bfirrrziasis),
>Personal
- t 4t
-+ chromosornal anomalies, DM hypertension
- Resifunce + rural areas (Bfirrrziasis), slumareas (toxoplasmosis)
- Occupation + workers in heavy melal or radiation factories
>Complaint
abortion >3 (2) times
o
>HPI
c
o
- Sgntptons of abonion + amenorrhea bleeding,pain
C
- Synptoms of complicotion + fever, DIC
CD
o
o-
>Past
.>
- Medical +hypertensioq DItd, thyroid,hextdisease,
o
- Surgery + on cervix:
o
>Farnilv
.s
o,
-
Diseoses + hypertension, DM
.E
t, o
>Menstnral
-
o
- Premenstrual 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'.
>General -+ medical di
e
>Irocal -+
. RVF
- Bicomurate
(2 bodies)
o Cervix'. tear (PIO)

A/'lonogement Cause !nvestigation Treatment os {/ Pqfulous Septate If pregnant \ Metroplasty (only if there
A/'lonogement
Cause
!nvestigation
Treatment
os {/
Pqfulous
Septate
If pregnant \
Metroplasty
(only if there are
uterus
- Ultrasound
repeated
failures
of vaginal
cerclage) as it leads to
- better transvaginal
extensive adhesions <e
Uterine
hgpoplasfa o
Ifnot pregnant \
Cyclic
estrogen & progest.
g
Subrnueous
-
fibmid
HSG
o
Myomectomy
o
- Hysteroscope
Fixed
RVF
e
.Venfro-suspension (not fixation)
J
(o
l- Endoerinel
.
o
='
O LPD,/
J progesterone
Progesterone
(100 mg 1x2)
o
.
ttu&androgens
Induction
of ovulation
O PCO
NDM
o
Insulin
GTT
!
L-
o
thyroxine
o Thvroid
o
Tr,+TSH
(o
2- Irnrnunolo$cal
=
o
o a
" APS,//
PTT, anti-Cl-, LA
Iow
dose aspirin + heparin
o
t CI&4,ANA
steroids
O SLE
o RH incompat.
o HLA sharins
o
according
to titre
Rh titre
o
immunotherapy:
blocking abds
HLA typine
o Screen for protein
Low
molecular weight
3- Thmrnbophilia
CaS orATr
heparin -+ anticoagulation
4- lnfeetions
o Serum titres (rising
Specifltc
ttt acc to CeS
IgM) esp. STORCH
o
Cervical & endomet.
tissue cultures
&netie
o Family history
Counseling
fecfors
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,
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

h Potulous internol os
h
Potulous internol os
> Efiototg o o eongenital - Increased muscle tissue in cervix > 1,0y, - Associated
> 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
E
o
OAircd.
o
. t*-t"r"o?:tfrt:ff:ffiuse
o
before tutl cervicat dilatation
cL
5'
- Breech extraction before full cervical dilatation
GI
-
Manual dilatation of the cervix
5
o
o
rt
"'"i #'*'ftirHlTjk ffi'ff'"'' or too rapidrv
!
Cone biopsy ofthe cervix
-l
o
GI
J
> clnhll Dletuie
o
.
This condition usually leads to classic picture of
o=
- Painless effacement & dilatation ofthe cervix
- 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)

c t6 ucCq@) h@nrpoienfroa ,6 xGGk$ Vithal Shircdkar (1899-1971) was an obstetrician and gynaecologist from
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

Cercloge > TuDes l. ffitrs -+TOo/o success . 4 bites with purse string suture (Nylon
Cercloge
> TuDes
l. ffitrs
-+TOo/o success
.
4 bites with purse string suture (Nylon or Mersilene)
.
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
g
t
o
.
Indications -+ repeated failed vaginal cerclage or short / absent cervix
o
g
.
Delivered by -+ CS (permanent cerclage)
=
.
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
> Dsfinltlon . autoimmune dis. forming antibodies agarnst phospholipid proteins
. it may be lry (alone) or 2ry (associated with CT disorders: SLE)
> Dlrgnolod bu OO
O
Recurrent oo
- 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
(LAC)
- Lupus anticoagulant
) 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

CURETTAGE. A blunt cureffe moy be Removol of Plocentql tissue with ovum tried firsf but
CURETTAGE. A blunt cureffe
moy
be
Removol of Plocentql tissue with ovum
tried firsf but usuolly o shorp curette is
forceps.
required "
To suction
Locol PG
lngecllon of hypprlonlc sonullon
(l nlrouteilne- Exhoom nlofi cl

e-------------fu flsCed abOrtiOn------------e
e-------------fu flsCed abOrtiOn------------e
> lndlcotlons O lhtrual c' Medical disorders e.g. ' - Advanced:- Heart disease / chronic
> lndlcotlons
O
lhtrual
c' Medical disorders e.g. '
- Advanced:- Heart disease / chronic HTN I renal disease
- Active pulmonary T.B./ severe hyperemesis
g
c, Malignancv
o
- Genital tract lbreast malignancy
o
- Chemotherapy or radiotherapy
e
o
Mental ps.vcholosical illness
=
GI
@ getot
5
o
Missed abortion / blighted ovum / vesicular mole
o
o
o
Exposure to teratogenic agents -+ rubella radiation
rr
r
>
Mehods
o
A- Before 14 weeks ,.+ suction evacuation Or dilatation & curettage
Gl
B- After 14 weeks
f
o
o
Prostaglandins
o=
- Local (intra-amniotic or extra-amniotic)
- Vaginal or intracervical tablets
o Oxytocin
o
Intra-amniotic injection of hypertonic solutions XX
-
Saline 20o/o
Urea
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
> 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

ABORTION-DI FFERENTIAL DIAG NOSIS TUBAL PREGNANCY PYOSALPINX FIBROIDS OVARIAN CYST\ METROPATHIA HAEMORRHAGICA Much
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
the distinction con be mode only on the
gonic explonotion ond the potient
occepts or supplies o diognosis of obor-
histologicol oppeoronces.
tion for wont of onything better.
1. The most common cause of first trimester abor- tions is fetal chromosomal abnormalities. 2,
1. The most common cause of first trimester abor-
tions is fetal chromosomal abnormalities.
2, lt is important to rule out ectopic pregnancy with
history physical examination, laboratory studies,
and ultrasound.
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.
l. Most second-trimester abortions are secondary to
uterine or cervical abnormalities, trauma, systemic
disease, or infection.
2. D&E, prostaglandins, or oxytocic agents can be
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
4. RhoGAM should be given to all Rh-negative
in the second trimesterthan in the first.
patients with bleeding.

> What is medical abortion .? > What is the DD of abrtion. ? Look
> 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
o
>
What are the causes of postabortive bleeding
?
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
o
What is the difference between term abortion / miscarriage
?
cl a
o a
>
What is the ilumagement of a case of idiopathic habitual abortion
?
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
|
infectig
* rrauma A
l

Tubol pregnoncy hr!'rrEPo'tloi23 - l".rD*55r I hfiSrirdoa t7 ll I b ofcoltt!trr lr0ffi^lrdr dr. rcldF
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 Diverticu lum
l--
Follicle
Diverticu lum
Ovum entering tube
Ovum
entering
tube

Implantation anywhere outside the ENoonaETRIAL cAVITy It is responsible for 10% orMMR ' IucmBNcB is
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. f of: o
O STD's O contraception (IUCD) O ART [VF)
5i 'lftiline (v.rare) €tuu.-uleilru E 1- Cervical 2- Rudimentary hom 1- Tubal 99%,/,/ o lnterstitial,
5i
'lftiline (v.rare)
€tuu.-uleilru
E
1- Cervical
2- Rudimentary hom
1- Tubal 99%,/,/
o
lnterstitial, isthmus,
E!!!E!!g, fimbria
o
2
t5
/eo"
q
3- Angular
5
a
4- Intraligamentary
2- Ovwian 0.5%
(o
(ab$ominal ; ! l _o-1 ?:_)
3 : P_-q_frl_o.pSal_
=
o
o
oo
=
!
O
o
(mechanical factors)
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
- ART -+ t 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

RUPTURE INTO LUMEN OF TUBE (TUBAL ABORTION) RUPTURE INTO THE PERITONEAL CAVITY Tube lumen --
RUPTURE INTO LUMEN OF TUBE
(TUBAL ABORTION)
RUPTURE INTO THE PERITONEAL
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.

PetqAeI
PetqAeI
> Tube n Any partmly be affected (esp ampulla) -+ enlarged, vascular * Rarely -+
> 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
* Decidua (but with no
villi)
* Aruls SrsrLA RsAcuoN -+ secretory, proliferative changes with
some atypical flndings inl0-15%of cases (non-specific)
> Ovary -+ one shows CL of pregnancy
lUdisfurbed if diagnosed early < rupture undEsGunDod oo0" I Disfu rbed when the ectopic preg.
lUdisfurbed
if diagnosed early < rupture
undEsGunDod oo0"
I Disfu rbed
when the ectopic preg. ruptures:
> Ronure tnrl&tte tr0es o Repeated mild hge around ovum -+ tubal mole (hematosalpinx) 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
- Severe O generalized intraperit. hge
suDooo6o[V
@@0. @
-oou@[V
dEs0 oo0" O
- Chronic O pelvic
.@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

Sgnptottu

- O Amenorrhea (short period) + symptoms of early pregnancy - O Pain -+ slight
- 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
- Adenexae + . slight tenderness in one fornix
. sometimes a swelling may be palpable (< 3cm)
€ailr, diagrroi b needs FIrcn Lr,ver O p S usptcroN
- History of pdf (e.g. PID, IUCD) + you must be ectopically minded
- May be discovered accidentally during routine U/S of pregnancy
Sgmpbmo ! Atr,tgNonnrm,A: - Shortperiod6-8wks - Mostly there is one missed period / ! Sudden
Sgmpbmo
! Atr,tgNonnrm,A:
- Shortperiod6-8wks
- 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
a Adenexae 4 tender enlargement of the affected adnexum

hE p-brdh.mor"lrS. adprhlctredr 4*.olnffiarym. .r Nole ou) uierus plocento ore disploced onteriorly ABDOMINAL
hE
p-brdh.mor"lrS.
adprhlctredr
4*.olnffiarym.
.r Nole
ou) uierus
plocento
ore disploced
onteriorly
ABDOMINAL PREGNANCY
Cu ldocentesis

3. Ho,rte (fulmlnottrp) Qpo Symptnru , .Short period of amenorrhea -+ sudden severe abdominal pain
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
- Shifting dullness + Cullen's sign
> Yaginal + difficult (marked tenderness), but may be easy if
4. Chronlc peMc hernotocoole
Symptamo There is history suggestive of disturbed ectopic preg (the triad) Then blood collects gradually
Symptamo
There
is history suggestive of disturbed ectopic preg (the triad)
Then
blood collects gradually in the D.pouch (most dependent)
Leading
to pressure symptoms (backache, dysuria, dyschazia, dyspareunia)
sw
> General a slight pallor + jaundice t pyrexia
> 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) .
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)

Forceps holding up o follopion tube for inspection
Forceps holding up
o follopion tube
for inspection
Loporoscope possed through connulo
Loporoscope possed through connulo
PrEgn,cy o, unlgrow't locatbn (PUQ "S un hCG larob al0 Corlsldr bparccopy md 40 rioin!
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
ard {8 hqrr! lsbt
It m
ldt dl r!p*l
FtgrErcy
lcan drd
utopfin l rbo ln lEG
cmsbar rne0loto(ela
Algprfilin iornratt.eNlttauaDacd.ctopk p?.gtrltcr,

I I fteononqr test - Serum P-HCG / (detects 5 mlu/ntl) is more sensitive than
I I fteononqr test
- Serum P-HCG / (detects 5 mlu/ntl) is more sensitive than urine
- lntrauterine prq. a normally 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. a gestational sac in-utero (5 wks TV
7 wks TA)
(But it may be the decidual reaction of ectopic preg)
- Ectopic preg a a small sac * fetal echoes outside the uterus
(But it may be CL cyst of normal preg)
+ proceed
+
llospthllatlon & tullor up of * Svmptoms ^'r pain * signs ^a detectable adnexal swelling
llospthllatlon & tullor up of
*
Svmptoms ^'r pain
*
signs ^a detectable adnexal swelling
* 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)
detected
r
#t)31*fiT#:J;:;#f;il::1ffi!res
I
es
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

Gdordr* h ub,u3 lF frrm F dqtroca oftlpcdd r(fipt F!0db^ LA? ARoE/CO?IC LIN EAR gALPI
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
l
I
fttctto?huf/,tof/r.
nru|orantrrod
*thtoroa?crd
ii4rilort

( Treotme[ ] Resuseifatio n / / / -+anti-shoct measures \ wide bore cannula +
( 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
toforce the other ovary to ovulate monthly
P
)( X
o
. No oophrectomy r hormone production
o
e
o Conservative surqerv if
=
GI
O
one tube is present or
) every attempt
O
mild cases or
=
Olowparity
) should be done
) to conserve the tube
o
o -r
- This is in ttre form of lineqr incision (at the anti-mesenteric border)
!
.
Salpisotomv: tube is closed by + sutures
o
-l
.
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) worst rr
the
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 (- :: * 1 T?a;$lll
. PG-F2"(locally in the sac)
.laparoscopic or U/S guided
.
Criteria o
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
. surgery is done ifno response after 3 doses
7
tr
DrC mru
why?
tr
lf Rh -us + gFs qrrfl-D

Angulor Plegnoncy Plgnoncy_llBud i"gntoly H orn Am+bl -> Au-zrtuzlit [@prg4 Colic, dull, sharp
Angulor Plegnoncy
Plgnoncy_llBud i"gntoly H orn
Am+bl ->
Au-zrtuzlit
[@prg4
Colic, dull, sharp
9q&ry1!?s-&'he,
- Bleeding
lmo
ar-{or
Examlnation
- Shock
Nqt uqpqdqllrl_
- nUdomirai
T, R, RT
- :polqt g{alqrl
Uterus
U*4ly
8
E99b
- No swelling
Adenexae
Swelling * tender
Decidua + clrorionic villi
TORSION of PEDICLE of OVARIAN CYST.

trLlrc ttlp, cf *toplc * Orcrlon pregnoncv . Usually 2ry to tubal pregnancy o 1
trLlrc
ttlp, cf *toplc
* Orcrlon pregnoncv
. Usually 2ry to tubal pregnancy
o
1 v i s'fr1|:i'.,!il :{,:;'.i:i{x::ii;i^
Gestational sac occupies position of the ovary
:
ff#*?*i:1Tffi1'J:flJl*iH,ll ilfl'* I i gament
g
* Prcgnonql ln rudlmontory hom
o
. Usually presents late at 16 -20 weeks
o
g
o
It
is medial to the round ligament while tubal pregnancy is lateral
o
Treatment -+ remove horn
(o=
* flngulor (comuol) ppgnoncv
=
o
o
At uterine orifice of the tube, late diagnosis (14-16) , more bleeding
o -r
o
If disturbed -+ - wedge resection & repair of part of the uterus
- May need hysterectomy
!
o
-t
rt Cenrlcoloroononq.l a ttt:
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 appendicitis + no amenorrhea, vomiting, pain usually
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
q
Prognosis -+ L59/s'. recurrence o ,30qfo infertility o

*ff&*@

fdploldkaryorypcvrrh an awa(hapb?) *t, of Tatanalchrcmoerlma
fdploldkaryorypcvrrh
an awa(hapb?) *t, of
Tatanalchrcmoerlma

thcn duplkatoo\

*^*l

r)

g;g-,$r'oR

cw*rm t

-

MalBnant Vesicular mole *tetastatic Non-metastatic (hydatidiformmole Choriocarcinoma .Invasive mole .Placental site
MalBnant
Vesicular mole
*tetastatic
Non-metastatic
(hydatidiformmole
Choriocarcinoma
.Invasive mole
.Placental site
E
Benign tumor of frophoblast ccc by o trophoblastic proliferation
o
o
+ hydropic degeneration of chorionic villi
g
a commonest in far east " 1/1000
GI =
a
o
Fiioiogvl unknown, m.b.d.t.
rt o
o
A primary oocyte abnonnality !?
o IMMIINOLOGICAL, GENETIC, NUTRITIONAL 1Jvit,A,; factors
rt !
o Risk factors -+ previors VM, extremes of age
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
(ureduced genome)
follouted by
of )
disappearonce
all
maternal chromosomes
2. Aecording to behavior > Benign ) lnvasive mole l5oh (choriadenoma destruens) -+ if perforating
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

Normql villus Primitive Avosculor /oedemotous Vessel slromo Chorionic epithelium tr {->Cyrotrophoblosr: /
Normql villus
Primitive
Avosculor
/oedemotous
Vessel
slromo
Chorionic
epithelium
tr
{->Cyrotrophoblosr:
/ 7ri'i
cuboidol cells
Syncytium:
with prominent nucl
sheets of fenestrcted
cytoplovn contoining
T.o the.noked
eye the
whole looks
dork ovol nuclei
lrke o bunch of gropes.
Hydotidiform mole
Normql
I6 weeki

helbdeil a Macroscopic O Uter,rs ^-r enlarged, studded by vesicles 2 mm to 2 cm
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 f
- Trophoblastic proliferation (both cyto- & syncitio- trophoblast)
(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
Crneral

"fi{<20 weeks

2t{ortrto flrcc(}{UJil) r 0000 r00000 956 ccndc ttlor ----- 56cdrdL t0 000 r 000 100
2t{ortrto
flrcc(}{UJil)
r 0000
r00000
956 ccndc
ttlor
----- 56cdrdL
t0 000
r 000
100
t0
I
216810
Ut& fi.r nroL.r.ormd
ltorrttonc
ofDfir t@ok ecos.
Fhr{D
@trrlaln95Xo,furcffi).

7- Ulhqsound {(he best) + SNow Sronu appearance Amniography - HoNsy Corvre appearance )()( 2-
7-
Ulhqsound {(he best) + 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 *
Re.suscitation *
by a wide bore cannula ll Suction evacuatio n r'r' F t curettage to ensure
by a wide bore cannula
ll Suction evacuatio n r'r'
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
if Rh-ve
- Don't forget +. anti-D
. specimen is sent for histopathology
=.
;
2l Hysterectomy
(in
toto)
9
.Inoldpatients(>40yeaIS)whonvecompletedtheirfamiliesto<
!
$ risk of choriocarcinoma (35% at this age)
d
p-hCG)
- Hysterectomy doesn't
prevent
metastasis
(.'.
follow up by
E
- Theca lutein cysts arc not remov surgically '
except ,f
I
torsion or rupture)
complication occur (e.g.
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
,"*
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

-a7

-aa

-a'

-a-

Voso Previo

Plocenlo Previo Accidenlol hge
Plocenlo Previo
Accidenlol hge

l. Nonobstetric causes of antepartum hemonhage include cervical and vaginal lacerations, hemor- rhoids, infections, and
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.

tc ;u fi1r(spaitaq llaauottAAga r,t, Definition erBleeding fromthe genital tactqfter 2O,/ (29)weeks till be{ore delivery
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
accidental
3. Ndaryinal sinus bleeding
fetal hge" )
4.
.r
e
VAga
Prcvla
d(
Definition o
fetal hge due to tear of umbilical vessels
running between the presenting part & cervix
f
o -l
fncidence oyery rare: I /5000 withfetal mortality: 50-'t5yo"
I'
o
rt +
Etiology - Velamentous insertion ofthe cord
c
3
- Placenta succenturiata, bipartate placenta
o =
Diognosis
- Sympt. + APhge (mildbleedrngbutmarkpd fetal distress)
3
o
-t
-
- Signs + vessels are felt as cord like bands crossing amniotic memb.
o =
VIS
-
Gl
-+ colored Doppler may show the vessels
o
Investigotions
Treotment + immediate delivery usually by CS o -+ rarely forceps orventouse if fully dilated
Treotment + immediate delivery usually by CS o
-+ rarely forceps orventouse if fully dilated

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

Phaaafia Pruvla Definition a Blnponvc from within the genital tract Arrnn 20128 wks & Brronr
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
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
PP lateralis
o =
lot o
60%
3
Yiolw
Jgtrg" //
Lower margin of the placenta lies in LUS
but not reaching the margin of internal os
o
PP marginalis
2no o
30%
"marglna[
PPcentralb incomfl@
Lower margin of the placenta reaches the
margin of the internal os
o =
(o
3'o o
7%
Placentapartially covers the internal os
o
"prtlali
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
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)

An.ni.rbr pLc.nf. prroL.xt rdlng toJun b.yondth.lnt mrlor. Fbilo ptu,jvb-Vf,-.vo.
An.ni.rbr pLc.nf.
prroL.xt rdlng toJun
b.yondth.lnt mrlor.
Fbilo ptu,jvb-Vf,-.vo.

Clinicol picture > Symytoms '+ Bleeding: - Fresh bright red - except if - Causeless
Clinicol picture
> Symytoms '+ Bleeding:
- Fresh bright red
-
except
if
- Causeless
except
if
associated with labor pains
after intercourse or pV
- Recuruent
.except
.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
O
Abdominal
o
Palpation
*
Fundal level -+
<