Obstetric and Gynecology PDF

Obstetric and gynecology History of the Patient A- Patient demography: (age, weight and height). B- Obstetric history: this required definition of some terms: 1- Parity: is the number of live birth at any age or stillbirth after 24 weeks of gestation 2- Nullipara: describes a woman who ha...

Obstetric and gynecology History of the Patient A- Patient demography: (age, weight and height). B- Obstetric history: this required definition of some terms: 1- Parity: is the number of live birth at any age or stillbirth after 24 weeks of gestation 2- Nullipara: describes a woman who has never delivered a fetus or fetuses beyond 20 weeks of gestation 3- Multipara: describes a woman who has had two or more deliveries past 20 weeks of pregnancy 4- Gravida: is the total number of pregnancies regardless of how they ended (abortion, ectopic, normal pregnancy, hydatiform mole) 5- Nullgravida: a woman who has never been pregnant. 6- Primigravidra: a woman who has been pregnant once e.g. a woman who has had two spontaneous abortions and three normal intrauterine pregnancies may be described as G5 P3 A2.  C-Usual menstrual cycle history(2) 1- Age when period began (menarchae). 2- Regularity of cycle. 3- Duration of each period, length of cycle and first day of last period. e.g. 13 5/28 regular: meaning that the period began at age of 13 years, last for 5 days and occur every 28 days.  An Overview of Pregnancy A- Signs and symptoms associated with pregnancy: The signs of pregnancy can vary. Early signs can include nausea, breast tenderness, frequent urination, fatigue and headaches. Later signs can include heartburn, backache, constipation and fatigue. 1- Nausea and vomiting: Nausea predominantly affects women during the first three months of pregnancy. Hormonal changes are an attributing factor. Hyperemesis gravidarum is an extreme form of vomiting in pregnancy which can result in admission to hospital. 2 Increased need to urinate: An increased need to urinate occurs early on as well as during the last few weeks of pregnancy when it is caused by the increased pressure on the bladder from the uterus. 3- Headache: Headache occurs more frequently in pregnancy. 4- Feeling hot and sweaty because of increased cardiac output and peripheral vasodilation. 5- Dizziness and fainting. 6- Fatigue. 7- Varicose veins and hemorrhoids  Epistaxis: Epistaxis (nose bleeding) is more common in pregnancy, but is generally not serious. 9- Hypertension and pre-eclampsia 10- Thromboembolism: Thromboembolism is six times more likely in pregnancy and it is the leading cause of maternal death in the United Kingdom. Around half of cases occur in the first three months of pregnancy 11- Oedema: Oedema is common in normal pregnancies, affecting more than 80 per cent of women. 12- Breathlessness. 13- Heartburn: Heartburn is particularly common in the later stages of pregnancy. 14- Appetite and weight gain: In the early stages, appetite may be lost but the majority of pregnant women will experience increased appetite at some stage during their pregnancy. Many women also develop cravings or aversions for certain foods. Weight gain averages around l2kg. 15- Constipation and haemorrhoids. 16- Backache. 17- Leg cramp is common in pregnancy, mostly at night. 18- Hyperpigmentation and stretch marks increased pigmentation is probably due to hormonal changes. This diminishes after pregnancy.  B- Prenatal period 1- Pregnancy is usually divided into three trimesters each one approximately 13 weeks 2- Prenatal period is the development of the baby in the uterus and it is approximately 40 weeks. This is divided into(2): A- Embryonic period: is the first 8 weeks. B- Fetal period: during 9-26 weeks. C- Perinatal period: from 27 week till delivery. 3 C- EDD The EDD is calculated by adding nine calendar months and seven days (around 280 days in total) to the date of the first day of the last menstrual period (LMP). (the period from fertilization of the ovum to birth is given as 40 weeks from LMP (gestation being regarded as 38 weeks)  Abortion (Miscarriage) Abortion: Is the termination (spontaneous or induced) of established pregnancy before 20 weeks of gestational age More than 60% of spontaneous abortions result from chromosomal defects due to maternal or paternal factors about 15% appear to be associated with maternal trauma, infections, dietary deficiencies, diabetes mellitus, hypothyroidism, or anatomic malformations. There is no reliable evidence that abortion may be induced by psychic stimuli such as severe fright, anger, or anxiety. In about one-fourth of cases, the cause of abortion cannot be determined (2)  Types of abortion: 1- Threatened (( ‫مھدد‬abortion: A- It refers to intrauterine bleeding before the 20th week of gestation, with or without uterine contraction, without cervical dilatation (i.e. closed cervix), and without expulsion of the products of conception (POC) The pregnancy continues, but about 25-50% of threatened abortions eventually result in loss of pregnancy B-Management 1- Ultrasonic examination to determine whether the fetus is present if so, whether it is alive 2- Place the patient at bed rest for 24-48 hours(or until 2 day after red loss has ceased followed by gradual resumption of usual activities, with abstinence from coitus and douching. Hormonal treatment with progesterone is contraindicated (controversial) Other therapy (e.g., tocolytics) is even more questionable(3). 3- If the patient is anxious and restless, diazepam 2 mg TID is recommended  - Inevitable ‫حتمي‬abortion: A- It is the intrauterine bleeding before the 20th gestational week, with continued cervical dilatation but without expulsion of the POC. The passage of the products of conception is considered inevitable B- Management 1- The uterus usually expels its content unaided. 2- Analgesic such as Pethidine 100 mg may be injected. 3- If bleeding is heavy Ergometrine 500 mcg can be given. 3- Incomplete abortion: A- It is the expulsion of some but not all of the POC before the 20th gestational week. Some portion of the POC (usually placental) remains in the uterus. Only mild cramps are reported, but bleeding is persistent and often excessive(2). B- Management 1- Insert IV line for fluid therapy or blood transfusion to prevent complication. 2- Prompt removal (under appropriates pain control) of any products of conception remaining within the uterus is required to stop bleeding and prevent infection(2). 4- Complete abortion It is the expulsion of all the POC before the 20th gestational week. Pain ceases, but spotting may persist for a few days(3).  5- Missed abortion A- Missed abortion occurs when the embryo dies but the POC are is retained in the uterus for several weeks or months. Symptoms of pregnancy disappear. There is a brownish vaginal discharge but no free bleeding. Pain does not develop B- Management 1- Evacuate the conception surgically by aspiration is the method of choice for a missed abortion 2- Prostaglandin E2 vaginal suppositories are an effective alternative 6- Recurrent (Habitual: ( abortion It is the spontaneous, consecutive loss of 3 or more nonviable pregnancies  Treatment A. Preconception therapy(2): Preconception therapy is aimed at detection of maternal or paternal defects that may contribute to abortion. A thorough general and gynecologic examination is essential. 1- Polycystic ovaries should be ruled out. 2- A random blood glucose test and thyroid function studies (including thyroid antibodies) should be done. 3- Detection of lupus anticoagulant and other hemostatic abnormalities (proteins S and C and antithrombin III deficiency) and an antinuclear antibody test may be indicated. 4- Endometrial tissue should be examined to determine the adequacy of the response of the endometrium to hormones. 5- The hysteroscopy or hysterography used to exclude congenital anomalies. 6- Chromosomal analysis of both partners rules out balanced translocations (found in 5% of infertile couples).  B. Postconception Therapy Provide early prenatal care and schedule frequent office visits. Complete bed rest is justified only for bleeding or pain. Empiric sex steroid hormone therapy is contraindicated(2). Prognosis: The prognosis is excellent if the cause of abortion can be corrected(2).