Puerperium, Gestation and Teratogens

Puerperium

• Puerperium lasts about 6 weeks
• It is a period where the body returns to a non-pregnant state

Gestation

• Full term between 37-42 weeks gestation
• Effacement is how thick the cervix is

Teratogens

• Carbamazepine can cause neural tube defects
• ACEI can cause Visceral malformations and Renal Dysplasia
• Tetracyclines can cause Teeth discoloration
• Aminoglycosides can cause Sensorineural hearing loss

Examination and History

• Key features for history include age, last menstrual period, gravity and parity
• Also important, past history of contraception, medications, and bleeding conditions
• Obstetric history includes pregnancies in chronological order, date of birth, and type of delivery
• Important to ask about gynecological, STI, and sexual history
• Elicit familial history of breast, ovarian, and colon cancers
• Close familial history may need additional testing and close follow up
• Physical exam should always include vitals
• Postmenopausal patients should have their height measured to document any loss of height from osteoporosis
• Breast exam should be performed by the patient
• Patient should be advised to examine herself in the mirror and be checking for skin changes or dimpling
• Exam repeated at the same time each month (preferably 1 week after the start of menses)
• Mammograms are generally obtained every 1–2 years from 40–50 and annually thereafter
• Annual MRI is indicated only in patients with BRCA1/2 mutations or a strong family history
• Examination by a physician uses 1)Arms at side for visual exam, 2)Hands on hips, 3)Arms above head, 4)Hands on examiner's shoulders
• Bimanual palpation is performed with patient supine, arms relaxed

Abdominal Exam

• Suprapubic palpation is designed to find uterine, ovarian, or urinary bladder enlargements

Pelvic Exam

• Examine skin of the vulva, mons pubis, and perineal area for dermatitis or discoloration
• Clitoris is at the ventral confluence of the 2 labia
• Urethra is just bellow the clitoris
• The area of vestibular glands should be palpated by placing the index finger in the vagina and the thumb outside
• Pathologic hymen is when it is completely imperforate
• Vaginal exam: A speculum dampened with warm water, without lubricants, is gently inserted into the vagina
• This allows the cervix and fornices to be thoroughly visualized
• Pap smear, current recommendation, obtain the first at 21 regardless of sexual experience
• Speculum for sexually active patient is the Pederson speculum
• Huffman or nasal speculum, a large otoscope, or Kelly air cystoscope can visualize a child's vagina
• Cervix is a firm structure with the consistency of the tip of the nose
• Extremely firm cervix can mean a tumor
• In most women uterus is anteverted

Adnexa and Pregnancy History

• Ovaries are palpable in slender women
• Adnexal structures usually can not be palpated in menopausal women
• Ask pregnant women about zoonosis, feeding habits, and blood type
• Fertility formula = #pregnancies, abortions, Paras, and C-section
• Ultrasounds = at least 4 (1st to assess if not ectopic, number of babies, assess HR)
• 2nd US between 11 and 14th week (rule out trisomies)
• 3rd US= up to 18-22nd (structural abnormalities)
• 4th- 30-32w (fetal growth)
• Assess date of last menstruation, sexual history, and oncological conditions
• Assessment of Obstetric patients includes BMI, BP, and uterine height at the 2nd trimester
• Between 24-26 weeks of gestation: Leopold maneuvers conducted

Gynecological Examinations and Tests

• Must use gloves in cervical exam
• Self breast exam monthly
• Cervivovaginal cytology, Biopsy, and Colposcopy screen for precancerous lesions
• Pap smear started when sexual relations start

Pregnant Woman Studies

• Complementary tests include US, Amniocentesis, and Chorionic biopsy (not done before 10th week)
• Screening and care includes hCGH, PAPP-A, folic acid, and Nucal translucency between 11-14 weeks
• Non-invasive screening = by blood (Fetal DNA) but is expensive
• High risk patients are those w/ hereditary conditions, patients w/ previously affected children
• HPV precancerous lesions turn into cancer in around 5-10 years
• The Pap smear occurs with no menstruation, no sex, and no óvulos
• With a Papillomavirus PCR is recommended in patients with risk of high lesions after 35
• Lesions: Nick 1 and 2 (low grade) use given vitamins andscarring meds.
• May consider biopsy in Nick2
• endovaginal US = valoration of adnexos
• Begin breast exam begin from 22yrs
• Delayed Menstruation requires a pregnancy test (quantitative test- beta fraction 1500 or >)

Pregnancy and Prenatal Care

• Gestational age is the time since the first day of the last menstrual period (LMP)
• Pregnancy duration is calculated at 280 days or 40 weeks gestation
• Estimated due date: Add 7 days to 1st day of LMP, and subtracting 3m + 1yr

Embryonic & Fetal Development and Definitions

• Embryonic period is where a fetus is most susceptible to teratogens (occurs 2nd to 10th week)
• Stillbirth is used to describe fetal death ≥ 20 weeks of gestation
• Neonate is an infant within the first 4 weeks of life
• Preterm infant is defined as one born between 20 and 36 6/7 weeks of gestation
• A term infant is born between 37 0/7 and 41 6/7, weighting usually >2500g
• A postterm infant is born ≥ 42 weeks of gestation that may exhibit characteristic cutaneous changes
• Macrosomia is when there is excessive fetal size (suspect in women with DM)
• Low birth weight is <2500g

Symptoms and Signs of Pregnancy

• Main symptoms are Amenorrhea, Nausea, and vomiting that can start as early as 2 weeks gestation
• Hyperemesis gravidarum = dehydration, weight loss, and ketonuria
• Treat nausea and vomiting with frequent meals, dry diet, emotional support, and antiemetics
• Breast changes= Mastodonya (Breast tenderness ranges from tingling to pain), engorgement, colostrum
• Fetal movement occurs at 18–20 weeks' gestation in nulliparous and 14 weeks' gestation in multiparous
• Elevated body temperature (by progesterone)
• Skin changes (Cholasma, línea nigra, striae)
• Pelvic organ changes: Chadwick sign and Leukorrhea

Diagnosing and Monitoring Pregnancy

• Fetal heart tones are detectable by handheld Doppler after 10 weeks, HR is around 110-160bpm
• US: Cardiac activity at 6 weeks via transvaginal sonogram; limb buds at 7-8; movements at 9–10 weeks
• Pregnancy test (human chorionic gonadotropin) detected in maternal serum 6-12 days after conception
• Urine and serum pregnancy tests can detect as low as 2–4 mlU/mL
• Fundal height is measured in centimeters from the pubic symphysis and correlates with the gestational age

Prenatal Care Labs

• Including a full medical history and physical exam
• Labs= CBC, blood type, VDRL, HsAg, HIV, and Antibodies against rubella and Varicella Zoster
• Nuchal translucency and maternal serum screen for plasma protein A and free βhCG
• A fetoprotein needs to be drawn at 15–18 weeks to screen for open neural tube defects
• Genetic testing includes testing for - hemoglobinopathies, CF
• Invasive Dx testing offered to all women ≥ 35
• Routine urine testing for asymptomatic bacteriuria (If bacterial count is > 10 ^5 /mL)

Proteinuria

• Proteinuria ≥ 2+ on a standard dipstick can indicate renal disease or preeclampsia

Ongoing Prenatal Care

• The standard is every 4 weeks from 0 to 28, every 2 weeks from 28 to 36, and every week after 36
• At each visit, maternal weight, uterine fundal height, maternal blood pressure, and urinalysis are documented
• Women with body weight that is 15% below ideal are at risk for preterm delivery
• Obese women (≥ 30 BMI) and excess maternal weight gain have larger infants with normal BMI
• BP tends to decrease 5–7 mm early and then returns to normal in the third trimester
• Fundal height is discordant from gestational age by > 2, ultrasound is indicated
• Fetal heart tones may be auscultated by 10–12 weeks with a handheld Doppler
• Edema in late pregnancy is a natural response
• Common complaints often include Ptyalism, increased urinary frequency, veins, joint and back pain
• Antimicrobials to avoid; Sulfonamides, Aminoglycosides, Fluoroquinolones, Clarithromycin, Tetracyclines

Nutritional Requirements

• Protein needs 1 g per kilogram per day plus 20 g in the second half of pregnancy
• Calcium for pregnant adolescent and lactating women
• Women should supplement 30 g of elemental iron during the second and third trimester
• Folic acid should be initiated before conception and sustained for the first 3 months after pregnancy

Imaging

• Ultrasound in obstetrics may be 2 ways - transvaginal or transabdominal
• Probe choice depends on the structure, imaging the cervix or an early gestation works for transvaginal
• Evaluating the fetus in the third trimester requires transabdominal imaging
• Second and third trimester may be screening for chromosomal and nonchromosomal anomalies
• Valuation of fetal anatomy after 18 weeks
• Doppler = most common fetal arterial Doppler are measured in the umbilical and middle
• In hypoxemia, blood redistributes to the brain

Pregnancy and Pre-natal Care

• Manage tobacco, alcohol, DM, and asthma
• Key immunization history (contra-indicated vaccines = live vaccines = varicella, mumps, yellow fever)
• Control DM 6w prior to conception
• Considers family genetic conditions
• Reproductive history must include ectopic pregnancy, abortions, obstetric complications
• Risky ages are very young (15-19), old (>35)
• Risks= premature birth, aneuploidy, preeclampsia
• Manage weight = malnutrition, obesity, Anorexia
• Basic labs= Metabolic panel, TORCH screen, Urinalysis, and Blood type
• Nuligesta = has never been pregnant
• Best way to determine pregnancy age= 1st trimester US
• Evaluate Sociodemographic changes, Medical history, Reproductive history, and Current pregnancy

Labor and Delivery: Pathogenesis

• Prior to initiation of labor, there biochemical connective changes in the cervix

Mechanics

• Contractions assessed by palpation, external tocodynamometry, internal manometry, pressure transducers
• Presence of 3 to 5 contractions in 10 minutes has been used to define an adequate contraction
• Fetal variables include fetal size, fetal weight, fetal lie, position, and station in the pelvis
• 4 pelvic types = gynecoid, android, platypelloid, and anthropoid
• Bony pelvis is now assessed by clinical pelvimetry
• With cervical effacement, the mucus plug releases
• "Water breaking"
• True contractions to delivery take 12-18 hours versus 6-9 in multiparous

Cardinal Movements

• Engagement occurs late mostly and is common in the last 2 weeks
• Descent refers to the presenting part passing gradually through the pelvis (-5 to +5)
• Flexion = fetal head passively undergoes flexion to present its smallest diameter
• Internal Rotation = fetal shoulders rotate 45 degrees
• Extension = fetus has descended to the introitus and then deflexes
• External Rotation = after delivery, allows passage of shoulders through pelvic outlet

Labor Stages

• Expulsion occurs after anterior shoulder, posterior shoulder and rest of the body
• Stage 1 is the interval between labor onset and full cervical dilatation
• Latent is defined by painful contractions that lead to slow cervical change(<6cm cervical dilation) - at 1st irregular contractions lasting 30s e/ 5-30m
• the normal minimum rate of cervical change is now felt to be slower, varying from 0.5 to 0.7 cm per hour
• recommended fetal monitoring due to obstetric risk factors such as hypertension, preeclampsia
• Monitor uterine contractions every 30 minutes
• Stage 2 is the interval between complete or full cervical dilatation and delivery of the infant
• During the second, the fetal measured to assess labor progress
• If delivery is imminent when the fetal head is noted to crown
• Episiotomies considered if need to facilitate delivery
• Aid in delivery by gentle downward traction on the externally rotated head
• Withold clamping for 30-60 secs due to higher hemoglobin levels after delivery
• "skin to skin" results in optimum warmth for the newborn and facilitates early breastfeeding
• Stage 3 is the period between delivery of the infant and the delivery of the placenta
• Inspect cervix, vagina, and perineum for actively bleeding lacerations after baby delivery
• Placenta usually separates within 30 minutes and is marked by a fresh blood from the vagina
• traction can facilitate delivery of the placenta with the Brandt-Andrew maneuver
• Prevent excessive postpartum bleeding after, enhance uterine contractions
• recommended cord clamping (for at least 30-60 seconds) for both term and preterm
• Puerperium:
• Monitor maternal blood pressure, heart rate, and uterine blood loss
• Induction is the artificial stimulation of labor that has begun spontaneously
• Evaluation in terms of Bishop score impacts induction

Induction

• Evaluations should be highly recommended
• Safe induction performed when pelvic score is 9
• Indications include eclampsia, HELLP Sx, DM, Chronic HTN, heart disease, Fetal indications
• Contraindications include contracted pelvis, placenta previa, vasa previa, previous C section
• Uterine inertia, intrauterine infection can be be caused by induction

Inducing Methods

• Cervical ripening (process of softening) = misoprostol and dinoprostone are used
• The time to delivery was shorter and the rate of cesarean delivery was lower in the misoprostol group
• With dinoprostone, allow 12 hours prior oxytocin
• Used as a potent uterotonic agent: Oxytocin
• An iatrogenic rupture of membranes may be an effective form of labor
• Amniotomy= variable decelerations of the fetal heart rate are noted to be relatively common

Puerperium

• High yields, lasts 6weeks
• The divisions are immediate, early, and remote
• Uterine involution: Immediately after delivery, the uterus weighs approximately 1 kg,

Normal and Abnormal Processes

• Uterine involution occurs nearly completely by 6 weeks
• Normal postpartum discharge begins as lochia rubra and tapers over days
• Over-distention and incomplete emptying of the bladder with the presence of residual urine
• Return values to normal by eighth week
• Cellular breakdown due to tissue involution leads to potassium release
• After first week, indications of insulin sensitivity begin
• Safe to resume sexual activity when the woman's perineum is comfortable and bleeding is diminished
• early pelvicfloor muscle exercise appears to support function
• Inform patients that dyspareunia may happen
• concentration of hCG in plasma falls below 1000 mU/mL in nearly 48–96 hours
• lasts approximately 5 weeks in nonlactating and > 8 in lactating women
• 10–15% of nonnursing ovulate by the time of the 6week exam, and 30% within 90 days postpartum
• Fetus, hormones that induce labor, loss of factors that maintain pregnancy

Causes and Medications

• Hormones = Progesterone, Estrogen, Prostaglandin
• Braxton-Hicks don't provoke pain
• Phases = acceleration, maximal pend, desacelerartion
• Dilations = felt with fingers
• Analgesia is needed after 5 or 6 dilation

Labor Mechanisms

• Encajamineto, head to mothers pelvis, descend ,flexion, internal rotation, Extension, External rotation, Expulsion
• Active phase stages
• <4cm should not be moved to labor

Importance and 3rd stage

• Scores help predict vaginal birth from previous pregnancies
• -Use prostaglandin = induction
• 3rd Stage, administer oxytocin and abx

Maneuvers and Adaptations

• Ritgen, Brandt-Andrews
• Puerperium= lasts 6w
• Avoided adaptions = Anti-concepts with estrogen post

Maternal Main Complications

• Posthemorrhage and how it is treated

Dystocia

• defined as an inability to deliver the shoulders

Dystocia Treatment

• Various techniques may be done, versus downward
• Median time for normal bodies is 24 secs versus 79

Dystocia maternal risks

• Mother, include severe perineal tear, typically, from Atony

Management

• Recommended to perform , gestational age, and material history
• ZAVANELLI is when the material will move the fetus

Dystocia Treatment

• Attempt to rotate the shoulders by touching the fetal chest
• Montevideon should lead to activity
• Lateral may supplement main tx

Dystocia Types

• D to Hypo or Hyper dynamic (depending on contraction rates)
• Buttocks = premature risk, may lead to trauma

Abnormal Labor

• 1st buttocks and pathologies that may exist
• Factors that can exist from birth