Practical Obstetrics Past Paper (2015-2016) PDF

Practical obstetrics DONE BY:- Mohammed Ibrahim al-hamadany Omer saadallah 2015-2016 1 Index 1. OSCE slides…………………………………………………………3 2. General notes……………………………….………………….44 3. Review of lectures……………………….…………………..56 2 Slide 1...

Practical obstetrics DONE BY:- Mohammed Ibrahim al-hamadany Omer saadallah 2015-2016 1 Index 1. OSCE slides…………………………………………………………3 2. General notes……………………………….………………….44 3. Review of lectures……………………….…………………..56 2 Slide 1 - What is obstetric finding in doing abdominal examination ? 1. Calculate fundal height. 2. Grip (fundal,lateral,pelvic) 3. Fetal heart auscultation. My finding is :-  Longitudinal lie  Cephalic presentation  Head is not engaged (not reach ischial spine)  Fetal heart is +ve Slide 2 1. What is the diagnosis ? Ectopic pregnancy 2. What is the clinical presentation ? 3  Asymptomatic Sympyomatic Abdominal pain Amenorrhea Vaginal bleeding 3. What is the investigation ? Us Hcg Progesterone level Laparoscopy Culdocentesis Uterine currttage Surgery Slide 3 1. What is the diagnosis ? On the left :- cord presentation (intact membrane ). One the right :- cord prolapse (ruptured membrane). 2. Management ? Fetus a live and sufficiently mature the ideal is immediate delivery by C.S. 4 Slide 4 - What is the indication and contraindication of foreceps? - Maternal Indication: 1. Maternal distress during 2nd stage 2. Prolonged 2nd stage. 3. Cardiopulmonary or vascular disease to reduce the stress of the 2nd stage of labour. 4. Vaginal birth after previous lower segment C.S. to reduce the stress on the scar. 5. Significant vaginal bleeding. - Fetal Indications: 1. Malposition of the fetal head (OP, OT) 2. Fetal distress ( bradycardia or deceleration) and cord prolapse. 3. Preterm baby (1500 – 2500 Kg) 4. Vaginal delivery of breech : forceps for after coming head to avoid traction on the trunk and the cervical spine and produce controlled flexion of the head. Contraindication Absolute: 1. lack of engagement. 2. Condition that contraindicate vaginal delivery. pelvic abnormality , fetopelvic disproportion) 3. Fetal malposition (face ,brow 5  4. Dead fetus with postmortem changes. 5. Inability to diagnose the position of the fetal head. Relative: 1. Fetal macrosomia. 2. Lack of experience. 3. Repeated fetal scalp blood sampling or trauma 4. Fetal bleeding or suspected coagulation defect 5. Premature < 34 weeks or less than 1500 gm. Complication of assisted delivery : 1. Maternal complication :- Soft tissue injuries includes :  Genital : uterine ,cervical ,vaginal ,perineal lacerations.  Bladder and urethral injury : retention ,fistula.  Rectal injuries : laceration ,fistula ,defecation problems. 2. Fetal complication : - With forceps : 1. Transient facial marks. 2. Facial palsy. 3. Fracture of skull or facial bones. 4. Sever cervical cord damage. - With vacuum : 1. Scalp injury. 6. Fracture of skull. 2. Cephalhaematoma. 7. Neonatal jaundice 3. Subgleal haematoma. 8. Retinal haemorrhage 4. Intracranial haemorrhage.. 9. Brachial plexus injury. 5. Tentorial tears. 10. cerebral palsy. 6 Slide 5 1. What is the procedure? - Fundal grip 2. What is the aim of this procedure? - To detect which part of the baby occupy the fundus. 3. What is the sequence of examination of abdomen in pregnant? - Mentioned before in slide 1. Slide 6 1. What is the procedure ? - Pelvic grip (one hand) 2. What is the aim of this procedur e? - To detect which part of the baby occupy the lower uterine segment and to detect whether the presenting part is engaged or not. 3. What is the sequence of examination of abdomen in pregnant ? - Mentioned before in slide 1. 7 Slide 7 1. What is the procedure ? - Pelvic grip (2 hands ) Note In lateral grip the examiner face the mother face while in pelvic grip face the mother leg. Slide 8 - What is the diagnosis ? - Cloasma (mask of pregnancy ). Slide 9 - What is the diagnosis ? 8  - Straie gravidarum. Slide 10 - As previous Slide 11 1. What is the finding ? - Breech presentation. 2. Obstetric finding in abdominal examination  Calculate fundal height.  Grip (fundal,lateral,pelvic)  Fetal heart auscultation. My finding is :-  Longitudinal lie  breech presentation  Head is not engaged (not reach ischial spine)  Fetal heart is +ve 9 Slide 12 - Face presentation Slide 13 - Auscultation of fetal heart sound by fetoscope. 11 Slide 14 - Auscultation of fetal heart sound by fetoscope. Slide 15 - What is the character of normal placenta ? - Shape: discoid - Site :fundal.ant or post. - Surface: 1. Fetal surface : smooth with central insertion of umbilical cord (2 artery 1 vein). 2. Maternal surface : divide into surface called cotyledons ( 15 -20), rough surface. Weight : 1/6 of the fetus wt. (average 500 gm ). 11 Slide 16 - Placenta for twin pregnancy Slide 17 - Types of twin 12 Slide 18 - Ultrasound showing two gestational sac.( gestational sac can be seen in 5-6 weeks and fetal heart can be heard in 7 weeks ). Slide 19 - What is the causes of large or small uterus ? Small for date Large for date Intra-uterine growth Rapid fetal growth retardation (IUGR) Miscalculation (Wrong LMP) Miscalculation (Wrong LMP) Polyhydramnious Oligohydraminous Multiple pregnancies Genetics Macrosomia (diabetic mother) Transverse lie Abruption placenta A baby prematurely Multiple uterine fibroids descending into the pelvis or Edema and Full bladder settling into a breech or other  molar pregnancy unusual position  death 13  Slide 20 1. what is the diagnosis ? macrosomic baby ( more than 4 kg ) 2. what is the intrapartum complication of macrosomia ?  intracranial hemorrhage  obstructed labor  shoulder dystocia  trauma to brachial plexus  hypoxia  injury to maternal tissue slide 21 1. what is the diagnosis ? artificial rupture of the membrane (aminiotomy ). 2. What is signs of labor ?  Uterine contraction  Show 14   Rupture of membrane  Cervical dilatation 3. Complications ?  Infection  Injury to fetal head or maternal tissue  Cord prolapse Slide 22 - Uses of oxytocin:-  Induction of labor  Augmentation of labor  Delivery of placenta (active management of third stage of labor  Prevention of pph Slide 23 - Types of abortion 15  1. Threatened abortion: symptoms:  scanty uterine bleeding(fresh blood) preceded by symptoms of pregnancy(frequency urination , backache , morning sickness , amenorrhea.)  pain is usually absent but may be backache or mild lower abdominal pain. Signs (Examination( 1. uterus is enlarged corresponding with date of amenorrhoea. 2. cervix is closed. 3. no pelvic tenderness. 2. Inevetible pregnancy : Means that it is impossible for the pregnancy to continue and the process is now irreversible Symptoms: 1. severe vaginal bleeding because a large area of the placenta has detached from the uterine wall. 2. It is accompanied by acute abdominal pain which is similar to the pattern of uterine contractions in labour (intermittent). 3. No products of conception expelled yet. Signs:  Uterus is enlarged.  Internal os is dilated (open). 3. incomplete abortion Symptoms: 1. uterine bleeding which is varies may be severe to cause hypovolemia or mild 2.history of passing part of conception (Women describe the product of conception as looking like pieces of skin or liver). Sign: 1.Uterus may be smaller than expected for period of amenorrhea. 16 2.Cervix is open. 3.Speculum examination reveals dilated internal os and tissue within the endocervical canal or vagina. 4.Bleeding may be heavy. 4. Complete abortion Symptoms: Scanty blood loss and cessation of abdominal pain after history of severe abdominal pain and severe vaginal bleeding with passing product of conception. Signs 1.uterus is smaller than period of amenorrhea and firmly contracted. 2. cervix is closed or patulous in multiparous women. 5. Missed abortion Symptoms: 1.May be preceded by sign and symptom of threatened abortion. 2.Disappearance of symptoms of pregnancy. 3.Dark brown vaginal discharge. 4.Diagnosed incidentally by ultrasound(sometimes). Signs: 1.Uterus is smaller than period of amenorrhea (small for date uterus). 2.Cervix is closed. 17 Slide 24 Instrumental delivery :- foreceps & vacuum. 1. What is the indication for using the instrumental delivery ? Mentioned in slide 4. 2. What is the prerequisites for using the instrument ?  Engaged head.  Position and attitude of the head.  Clinically adequate pelvis (mid ,outlet )  Empty bladder.  Ruptured membrane.  Cervix is fully dilated.  Appropriate anaesthesia (vacuum without )  Experience of the doctor.  Well informed patient.  working equipment. 3. what is the complications ? mentioned in slide 4. 18 Slide 25 - curettage (not important ) Slide 26 - Cervical cerculage (not important ) Slide 27 - Placenta previa (important read all the lecture ). - Classification :-  Grade I :Marginal placenta previa : the edge of the placenta Is at the margin of the internal os.  Grade II : the placenta is covering the cervix when it’s closed. 19   Grade III :Major degree :Total placenta previa: internal os is covered completely by the placenta  Grade IV :Major degree :central placenta previa Symptoms  Painless vaginal bleeding  Uterine contraction Signs  abdomen is soft not tender  uterine contraction may be positive.  Uterus may be larger than date.  there may be malpresentation as breech or transverse lie or non engaged cephalic presentation.  Fetal heart is positive. Diagnosis  Examination by finger feeling the placenta near the internal os (done in operative room).  Us (trans-abdominal and trans-vaginal ). Treatment  If mild to moderate vaginal bleeding conservative management inform of correction of anemia , corticosteroid therapy  If sever and persistent vaginal bleeding and any bleeding after 36 week emergency delivery is indicated.  Patient with no vaginal bleeding should be delivered at term (38 week). Mode of delivery: CS. 21 Slide 28 - abruptio placenta (important read all the lecture ). What is abruptio placenta ? Bleeding from a normally situated placenta due to it’s premature separation ,it could be partial or complete. Risk factors:.Increased age and parity...Preeclampsia....Chronic hypertention.....Preterm rupture of membrane......Cigarette smoking.......Thrombocytopenia........Cocaine use.........Prior abruption..........External trauma...........Uterine leiomyoma. Types  revealed hemorrhage (external )  concealed hemorrhage (internal ) clinical features  painful vaginal bleeding  uterine tenderness  hyperactivity  increased tone 21 complications  shock  fetal distress  DIC  Renal failure  Couvelaire uterus Treatment  resuscitation with blood and crystalloids  delivery Slide 29 - Episiotomy :- Is a surgical incision of the perinium to increase the diameter of the vulval outlet during childbirth. Indication: Absolute: 1. Previous pelvic reconstruction. 2. Pelvic floor surgery. Relative: 1. Short rigid perineum. 2. Shoulder dystocia. 3. Fetal distress. 4. Instrumental or breech delivery. 22 Types of episiotomy:-  midline episiotomy  mediolateral  lateral instructions to women who had done episiotomy :-  hot sitz bath with salt  keep the wound dry and clean  use :- antibiotics ,analgesia  avoid conistipation and any thing that could increase intra- abdominal pressure like lifting weight.  pelvic exercise. Complications 1. Difficult repair. 2. heavy bleeding. 3. Extension to the anus. 4. Infection. 5. Pain and dyspareunia. 6. Weak point in the perineum-tear. 7. Dryness from injury to bartholine gland. Slide 30 - CS Types:-  upper incision  lower incision 23 Indication of C.S. 1. Dystocia (maternal/fetal)  CPD.  Failed induction of labour. 2. Maternal  Disease : PE , Eclampsia/DM/cardiac dis./ cervical CA.  Previous uterine surgery : Classical C.S. /Previous 2 C.S./  Previous myomectomy (Full thickness ).  Obstruction to birth canal : fibroid / ovarian tumour. 3. Fetal :  Fetal distress.  Cord prolapse.  Fetal malpresentation. 4. Placental :  placenta previa.  abruptio placentae. Preparation for C.S :-  Left lat. Position.  Empty the stomach and antacid.  Thrombo prophylaxis.  Prophylactic antibiotics.  Catheterization.  Skin preparation : shaving. iodine , chrorhexidine. 24  What we must do after cs as a doctor?  Check level of consciousness  Chart of vital signs  Use : antibiotis ,analgesia ,i.v fluid  calculate urine outcome  breast feeding  early mobilization  start oral intake  come in 7 days  give contraception slide 31 - partogram slide 32 cardiotocography (CTG) 25 slide 33 - Cardiotocography (CTG) - Probe of CTG one on abdomen & the other on the baby. slide 34 - character of normal CTG 1. 110 -160 bpm 2. two acceleration 3. no deceleration 4. baseline variability ± 5-15 bpm. abnormal CTG finding 1. persistent bradycardia (less than 110 bpm): fetal distress. 2. early deceleration (bradycardia on contraction). 3. variable deceleration :cord compression. 4. Absence of Variable baseline :fetal heart rate is always change less than 5 or more than 15. 26 slide 35 - Late deceleration. slide 36 - Macerated baby - Peeling skin, brown to blue color of the baby , hypotonic baby. Slide 37 27  - Ultrasound spalding sign : contracture of skull bone appear after 7 day in IUFD. Slide 38 - Twin to twin transfusion syndrome. Slide 39 Fundal height: Expected date, gestational age, 28 Slide 40 - IUGR Slide 41 - Amniocentesis 29 Slide 42 - Potter syndrome  Flatten of face  Lung hypoplasia  Postural deformity All are due to oligohydromnia Slide 43 - Polyhydrominia Slide 44 (not important). Slide 45 (not important). 31 Slide 46 - Rupture of membrane. - If infection occur after 48 hrs is called chorioamnionitis. Chorioamnionitis:- Is an inflammation of the fetal membranes (amnion &amp; chorion ) due to bacterial infection. Clinical features (important). 1-maternal pyrexia &gt; 38C° 2-maternal tachycardia &gt;100 beats/min. 3-uterine tenderness 4-offensive vaginal discharge. 5-fetal tachycardia &gt;160 beats/min. 6-raise C-reactive protein. 7-raise in maternal WBC count. Complications of Chorioamnionitis A-maternal 1-septicemia 2-infection in the pelvic region &amp; abdomen. 3-endometritis (an infection of the endometrium). B-newborn infant 1-sepsis 2-meningitis 3-respiratory problems. 31 Slide 47 (not important). Slide 48 - Artificial rupture of membrane Slide 49 - Uterine sound. - Aim ? to detect the length of uterine cavity. Slide 50 (not important). Slide 51 - Aminohook for artificial rupture of membrane. 32 Slide 52 (not important). Slide 53 (not important). Slide 54 - Uterine massage Slide 55 - Ergot (ergometrol ). Contraindication:-  hypertension  ischemic heart disease  varicose 33 slide 56 misoprostol. indication ?  labour  abortion  post partum hemorrhage with oxytocin slide 57 - broad ligament hematoma. slide 58 - perineal laceration. 34 Slide 59 - Hydrops fetalis Slide 60 - Chorionic villous sampling 35 Slide 61 Dead baby due to hydrops fetalis (85% due to autoimmune and 15% due to pre-eclampsia). Brown ,hypotonic ,skin peeling. Slide 62 Rupture of uterine (not important ). Slide 63 - Head not engaged 36 Slide 64 - Gynecoid pelvis Slide 65 - Transverse lie ,head in the right side. Slide 66 Right occiput , left occiput. 37 Slide 67 - Position of the fetus. Slide 68 Not important Slide 69 - External cephalic version. Indiacation ? - breech presentation. contraindication ?  Evidence of uteroplacental insufficiency.  Placenta previa. 38   Non reassuring fetal monitoring.  Hypertension.  IUGR or oligohyraminos.  History of previous uterine surgery. slide 70 - fetal skull slide 71 fetal skull 39 slide 72 - types of pelvis slide 73 A- Left occipito-tranverse. B- Right occipito-posterior. Slide 74 - Replacement of uterus manually 41 Slide 75 - What is the sign of abruptio palcenta? - Mentioned previously. slide 76 - Degree of uterine relapse Slide 77 - Curettage (mentioned before). Slide 78 - cervical dilatation (not important). 41 Slide 79 - Uterus with increta, percreta ,accreta. Slide 80 - Manual removal of the placenta. Slide 81 - Delivery of after coming head. 42 Slide 82 Complication of cord prolapse ?  Death  Stress  Psychosis Slide 83 A_20 weeks pregnant woman with vaginal bleeding with +ve heart ,diagnosis ? Abortion. B_13 weeks pregnant with vaginal bleeding ,diagnosis? Abortion. Note:- - If number of weeks less than 24 so this type of abortion , - And if number of weeks more than 36 so this abraptio blacentae. - Both of them there is vaginal bleeding. 43  - What is the difference between true and false labor? 1. True labor contraction.  Regular  Painful  Increase in severity, intensity and duration.  Associated with cervical dilatation 2. False labor contraction.  Irregular  Painless  No cervical dilatation General notes 1. GPA: G: gravida number of all pregnancies (delivered or aborted). If the patient is still pregnant at the time of history taking we can mention the gravida, but if the patient is already delivered at the time of history taking we not mention the gravida. P: para or parity number of deliveries after 24 weeks (live or dead) A: abortion number of expulsions of products of conception before 24 weeks (normal or ectopic ‫ الرحم خارج حمل‬or hydatidiform ‫حمل‬ ‫) عنقودي‬ 2. LMP: last menstrual period it is the first day of the last menstrual period the patient certainty of dates (‫) التواريخ صحة من التأكد يجب‬ ask about the regularity of the cycle ask about the usage of contraception (type-amount-duration) 3. EDD: expected date of delivery 44 Calculated by Naegele's rule EDD = LMP + 7 days – 3 months (or +9 months) this for regular cycle (28 day – not lactating – no use of contraception) For irregular cycle the date of first Ultrasound is around 20 weeks so we can calculate the EDD from this information 4. GA: gestational age Number of weeks from the beginning of pregnancy until the end (whether normal delivery or C.S or abortion) Calculated as EDD - real date of delivery or EDD - date of history taking Pre-term: 36 weeks + 6 days or less. Term: from 37 weeks to 40 weeks Post-date: from 40 weeks to 41 weeks + 6days Post-term: 42 weeks and more GA is important to know if the baby is premature so we can support the baby after delivery #Anatomy of female pelvis and fetus: The pelvic brim (inlet) transverse diameter= 13.5 cm / AP diameter= 11 cm The angle of inlet = 60 degree if increased it may delay the fetus head entering in labor. The pelvic mid cavity transverse diameter = 12 cm / AP diameter = 12 cm Ischial spine palpable vaginally / landmark to assess station and land mark for providing the anesthesia (block pudendal nerve). Pelvic axis imaginary line that shows the path that the center of the fetal head takes during its passage through the pelvis. The pelvic outlet transverse diameter = 11 cm / AP diameter = 13.5 cm The pelvic measurements affected by maternal stature, previous pelvic fractures, metabolic bone disease like rickets. Pelvic shapes: o Gynecoid pelvis most favorable for labor. o Android pelvis predispose to deep transverse arrest. 45 o Anthropoid pelvis encourages occipito-positerior position. o Platypelloid pelvis increase the risk of obstructed labor. The pelvic floor formed by two levator ani muscle + musculofasical gutter + perineal body. Episiotomy surgical incision of the perineum and posterior vaginal wall done during second stage of labor. Fetal skull made by vault, face, base. Vault formed by parietal bones and parts of the occipital, frontal, temporal bones. Membranous sutures of the vault sagittal, frontal, coronal, lambdoidal sutures. Anterior fontanel (bregma) diamond shape, junction of sagittal + frontal + coronal sutures. Posterior fontanel triangular shape, junction of sagittal + lambdoidal sutures. Moulding occur when the bones of the fetus skull become compressed and overlapped. Severe moulding can be a sign of cephalopelvic disproportion (CPD). Vertex is the area of the fetus skull that bounded by the two parietal eminences and the anterior and posterior fontanels. Attitude of the fetus head refers to the degree of flexion and extension at the upper cervical spine. Diameters of the fetus skull suboccipitobregmatic (9.5 cm), suboccipitofrontal (11.5 cm), occipitomental (13 cm), submentobregmatic (9.5 cm). #Sign & symptoms of pregnancy: 1- Positive signs Demonstration of the fetal heart beats: by pinard stethoscope or by sonic aid Quickening: first feeling of fetal movement Visualization of the fetus and measurements of its diameters: by bi- partial diameter, femoral length, CRL crown-rump length. >12 weeks of gestation 2- Probable signs Uterine enlargement: may be due to H.mole or fibroid Uterine changes in size, shape and consistency: 46 o Piskacek's sign: when implantation occurs near one of the cornua of the uterus there will be palpable asymmetrical well defined prominent and soft cornua at the site of Implantation o Hegar's sign: palpable softening of the lower uterus starts to appear at 6 weeks and most evident at 10-12 weeks of gestation o Palmer's sign: 4-8 weeks regular contractions, occur by manual palpation. o McDonald's sign: positive when the uterine body and cervix can be easily flexed against each other. Cervical changes Goodell's sign: softening of the cervix can be detected by the second month of pregnancy. In non-pregnant women the cervix is hard like the tip of the nose. While in the pregnancy the cervix will be soft like the lip. Palpation of the fetus parts: ballottement of the fetus or fetal part and mapping of the fetal outline by the palpation Braxton hick contractions Endocrine test (pregnancy test): with a possibility of false positive results 3- Presumptive signs Breast changes: swelling and tenderness Changes in the skin and mucus membrane: o Chadwick's sign (violet bluish discoloration of the vulva, vagina, cervix) at 6-8 weeks of gestation o Increased skin pigmentation (linea nigra, striae gravidarum, chloasma) o Development of abdominal striae 4- Symptoms cessation of menses: 8% of pregnancies have some source of bleeding Nausea with or without vomiting: that occur in half of pregnancies and subsides within 14 weeks of gestation Bladder irritability, frequency Easley fatigability #Changes in pregnancy 1- Hormonal changes: Increase of estrogen, progesterone, secretion of hCG and Human chronic lactogen, increase production of corticotrophin, thyrotropin and prolactin, while FSH and LH decrease, Increase secretion of 47 glucocorticoids and aldosterone, and increase secretion of thyroxin, Parathyroid increase, Increase secretion of vasopressin. 2- Endocrine changes: ↑ Prolactin concentration. Human growth hormone is suppressed. ↑ Corticosteroid concentrations. ↓ TSH in early pregnancy. ↓ fT4 in late pregnancy. hCG is produced. Insulin resistance develops. 3- Metabolism: Increases in basal metabolic rate (BMR). Weight gain during pregnancy consists of the products of conception (fetus, placenta, amniotic fluid), the increase of various maternal tissues (uterus, breasts, blood, extracellular fluid), and the increase in maternal fat stores. Body weight increase 12.5–18.0 kg in pregnancy. Carbohydrate metabolism (fasting plasma glucose concentrations are reduced, little change in insulin levels, reduced blood glucose values) During lactation, glucose levels fall and insulin resistance returns to normal, as glucose homeostasis is reset. Triacylglycerols, fatty acids, cholesterol and phospholipids, which all increase after the eighth week of pregnancy. Around 40% of circulating calcium is bound to albumin. Since plasma albumin concentrations decrease during pregnancy, total plasma calcium concentrations also decrease. 4- Volume homeostasis: The rapid expansion of blood volume begins at 6–8 weeks gestation and plateaus at 32–34 weeks gestation. The expanded extracellular fluid volume accounts for between 8 and 10 kg of the average maternal weight gain during pregnancy. Total body water increases from 6.5 to 8.5 L by the end of pregnancy. Larger increase of plasma volume relative to erythrocyte volume results in haemodilution and a physiologic anemia Factors contributing to fluid retention o Sodium retention. o Resetting of osmostat. o ↓ Thirst threshold. o ↓ Plasma oncotic pressure. Consequences of fluid retention 48 o ↓ Hemoglobin concentration. o ↓ Hematocrit. o ↓ Serum albumin concentration. o ↑ Stroke volume. o ↑ Renal blood flow. 5- Blood: Decreases in: o Hemoglobin concentration. o Hematocrit. o Plasma folate concentration. o Protein S activity. o Plasma protein concentration. o Creatinine, urea, uric acid. Increases in: o Erythrocyte sedimentation rate. o Fibrinogen concentration. o Activated protein C resistance. o Factors VII, VIII, IX, X and XII. o D-dimers. o Alkaline phosphatase. 6- Changes in circulatory system: ↑ Heart rate )10–20 per cent). ↑ Stroke volume )10 per cent). ↑ Cardiac output )30–50 per cent). ↓ Mean arterial pressure )10 per cent). ↓ Pulse pressure. Maternal hemoglobin levels are decreased because of the discrepancy between the 1000 to 1500 mL increases in plasma volume and the increase in erythrocyte mass, which is around 280 mL. Transfer of iron stores to the fetus contributes further to this physiological anemia. Palpitations are common and usually represent sinus tachycardia, which is normal in pregnancy. Edema in the extremities is a common finding, and results from an increase in total body sodium and water, as well as venous compression by the gravid uterus. 7- Respiratory system: Ventilatory changes: o Thoracic anatomy changes. o ↑ Minute ventilation. 49 o ↑ Tidal volume. o ↓ Residual volume. o ↓ Functional residual capacity. o Vital capacity unchanged or slightly increased. Blood gas and acid–base changes: o ↓ pCO2. o ↑ pO2. o PH alters little. o ↑ Bicarbonate excretion. o ↑ Oxygen availability to tissues and placenta. 8- GIT changes: Mouth: o Increased susceptibility to gingivitis. o Increased anaerobic infection. o Predispose to dental caries. o Increased tooth mobility. Gut: o The uterus displaces the stomach and intestines upwards. o Increasing gastric acidity. o Increase the incidence of reflux esophagitis and heartburn. o The pregnant woman is at increased risk of aspiration of gastric contents when sedated or anaesthetized after 16 weeks gestation. o Constipation and alter the bioavailability of medications. Liver: o Telangiectasia and palmar erythema occur normally in 60% of pregnant female. o Portal vein pressure is increased in late pregnancy. o Hepatic protein production increases, serum albumin levels decline. o Increase in serum alkaline phosphatase. o Increased production and plasma levels of fibrinogen and the clotting factors VII, VIII, X and XII. o Plasma cholesterol levels and triglycerides increased. 9- Renal changes: ↑ Kidney size (1 cm). Dilatation of renal pelvis and ureters. ↑ Blood flow )60–75 per cent). ↑ Glomerular filtration )50 per cent). ↑ Renal plasma flow )50–80 per cent). ↑ Clearance of most substances. 51 ↓ Plasma creatinine, urea and urate. Glycosuria is normal. Urine output increase in first trimester, slightly decreased in the second trimester and increase again in the third trimester 10- Skin changes: Hyperpigmentation. Striae gravidarum. Hirsutism. ↑ Sebaceous gland activity. 11- The maternal brain: Women frequently report problems with attention, concentration and memory during pregnancy and in the early postpartum period. Proposed causes include lack of estrogen or elevated levels of oxytocin, while elevated progesterone levels do not seem to be involved. Progesterone has a sedative effect and responsible for some of the difficulties staying alert. 12- The senses: Changes in the perception of odors (due to changes in both cognitive and hormonal factors). Olfactory sensitivity actually decreases. Corneal sensitivity decreases (related to an increase Partogram A graphical representation of progress of labour. This record allows visual assessment of mother pulse rate &amp; blood pressure, srength&amp;frequency of uterine contraction. #The labor: Definition regular contractions bringing about progressive cervical change. Occur with labor loss of a show + spontaneous rapture of the membrane. Estimation of fetal age Naegele's rule, fundal height, quickening, fetal weight, US Success of labor depend on the three P: P1: power = uterine contractions: 51 o Characterized by interval, duration, intensity. o Good contraction: interval = 2-3 min / duration = 45-60 sec. o Ideal contractions number 4-5 contractions per 10 minutes. o In abnormal labor weak and infrequent uterine contractions or uncoordinated contractions that occur in twos or threes then stop // treated by rehydration + IV oxytocin + artificial rupture of the membrane. P2: passenger = fetus: o Fetal variables that can affect labor fetal size, lie, presentation, attitude, position, station, number of fetuses, presence of anomalies. o Breech and face, brow presentation may lead to poor progress. o Risk factors for poor progress in labor small women, big baby, malposition, malpresentation, early membrane rapture, soft tissue/pelvic malformation. P3: passage = pelvis: o Consists of bony pelvis and soft tissues of the birth canal (cervix, pelvic floor musculature). o Small pelvic outlet can result in CPD. o Abnormalities in the passage could be due to abnormal pelvis, abnormalities in the uterus and cervix like fibroid, cervical dystocia. o Cervical dystocia non-compliant cervix which effaces but fails to dilate because severe scarring usually as result of cone biopsy and may lead to CS. Diagnosis of labor pain: o History: regular painful contractions every 5-8 min, bloody show, spontaneous rapture of membrane. o Physical examination: reduction of interval between contractions, abdominal pain, cervical effacement (50%), cervical dilatation (2 cm). 1st stage of labor: o Latent phase: from the onset of labor until 3-4 cm dilatation // lasts 3-8 in primi and shorter in multi. o Active phase: from 3-4 cm dilatation to full dilatation (10 cm) o Management of first stage Maternal vital signs, Regular recording of uterine contractions and fetal heart rate, Food / IV fluid consideration, Maternal position, Analgesic drug consideration, Record and assess progress of labor. 2nd stage of labor: o From fully dilated cervix until delivery of baby. o Moulding alternation of fetal cranial bones to each other as a result of compressive forces of the maternal bony pelvis. 52 o Caput localized edematous area on the fetal scalp caused by pressure of the cervix. o Second stage takes 2 hours in primi and 1 hour in multi. o Mechanism of labor: There are 8 cardinal movements in occiput anterior presentation. Refers to changes in the fetal head position during its passage through the canal Engagement Descent Flexion Internal rotation Extension Restitution External rotation Expulsion. 3rd stage of labor: o From delivery of the baby until delivery of the placenta. o Sings of placental separation lengthening of umbilical cord, gush of blood, fundus become globular and more anteverted against abdominal hand. o Controlled cord traction The Placenta is delivered using one hand on umbilical cord with gentle downward traction, The Other hand should be on the abdomen to support the uterine fundus, this is the active management of third stage. o Risk factor for aggressive traction is uterine inversion. o Normal duration between 0-30 min for both PrimiG and MultiG. 4th stage of labor: o Refers to the time from delivery of the placenta to 1 hour immediately postpartum. o Blood pressure, uterine blood loss, pulse rate must be monitored closely ~ 15 min. Cephalopelvic disproportion (CPD): o Implies anatomical disproportion between the fetal head and maternal pelvis. o CPD is suspected if Progress of labor is slow or arrested despite efficient uterine contractions / The fetal head is not engaged / Vaginal exam, shows severe moulding and caput formation / The head is poorly applied to the cervix. o Oxytocin can be given carefully to primigravida with mild to moderate CPD as long as the CTG is reactive. o Relative disproportion can be overcomed if the malposition is corrected (conversion to flexed OA position). Patterns of abnormal progress in labor: o Prolonged latent phase / primary dysfunctional labor / secondary arrest. o Causes: malposition, malpresentation, CPD, inefficient uterine contractions. 53 #Antepartum hemorrhage: Definition: vaginal bleeding from 24 weeks to the delivery of baby. Placental causes: placental abruption, placenta praevia, vasa praevia. Local causes: cervicitis, cervical ectorpion, cervical cancer, vaginal trauma & infection. #Polyhydramnious Definition: this is the excess of amniotic fluid more than 2000 ml Types: o Chronic (gradual accumulation noticed after 30th week of gestation) o Acute (earlier and quicker noticed, for example in the uniovlar twins)  Causes: o Fetal: Multiple pregnancies and Fetal abnormalities: anencephaly, esophageal and duodenal atresia, spina bifida, skeletal or cardiac or intrauterine infection (rubella – toxoplasma), fetal tumors o Maternal: D.M and Rh isoimmunization o Placental: chorioangioma and circumvallate placenta syndrome o Idiopathic Clinical features: unduly enlarged abdomen, usually mobile fetus, chest discomfort, dyspnea, acute type associated with abdominal pain and vomiting On examination: o large for date uterus o stretched abdominal muscles o Highly ballotable fetus o Fluid thrill and malpresentation o Edema of the abdominal wall and of the vulva o Very tense uterus especially in the acute phase Diagnostic tools o Ultrasound: the deepest pool of the AF that is free of cord and limbs, if it is more than 8 cm in vertical length is indicative for polyhydramnious 54 o AFI (amniotic fluid index) if > 23 cm Differential diagnosis: o Wrong dating o Coexisting ovarian cyst o Multiple pregnancies o Abruption placenta Effects on pregnancy and labor: o Preterm labor o Risk of placenta abruption and cord prolapse o Fetal mal-presentation o PPH o perinatal mortality Treatment: termination of pregnancy if there is any gross fetal abnormalities. #Ultrasound during pregnancy Early ultrasound (in the first trimester): o Know Site of pregnancy (normal – ectopic) o Know number of fetuses o Fetal Viability o Gestational age (G.A) o To detect any anomaly o Polyhydramnious (access of amniotic fluid) Anomaly ultrasound (18-20 weeks) o Detection of congenital anomalies o Gestational age o Twins Late ultrasound (in the third trimester) o oligo or poly hydroaminous o position of the placenta o fetal well being. 55  Review of lectures Malposition of fetus Vertex The area of the skull between the anterior and posterior fontanelles, and the parietal eminence Top of the skull Occiput Back of the fetal head behind the posterior fontanelle Sinciput That part of the fetal head in front of the anterior fontanelle.-forehead or brow Position : The relationship of a defined area on the presenting part )Denominator) to the mother’s pelvis. Types of breech presentation Frank breech (65%) - Hips flexed, knees extended Complete breech (25%) - Hips flexed, knees flexed Footling or incomplete (10%) - One or both hips extended, foot presenting 56 diagnosis Palpations and ballottement(leopold man.) Pelvic exam. Ultrasound X-ray studies. Unstable lie Is a term used when the fetal lie and presentation is repeatedly changed after 36 weeks of pregnancy. The lie being variable between longitudinal, transverse and oblique. Antepartum haemorrhage: is bleeding from the the placental site from 24 week gesation and before delivery of the fetus. Causes of antepartum haemorrhage: Common: Placenta previa.. Abruptio placentae Uncommon: Uterine rupture Fetal (chorionic) vessels rupture. Cervical or vaginal laceration. Cervical or vaginal lesions. Congenital bleeding disorders. 57 abortion Causes of spontaneous miscarriage: 1- maternal causes 2- fetal causes 1-Maternal causes :- A.General : 1-Acute febrile illness. 2-infection (bacterial vaginosis, syphilis, rubella). Any severe infection that leads to bacteraemia or viraemia can cause sporadic miscarriage. 3- Severe hypertension 4-Severe renal disease 5-Badly controlled Diabetes mellitus. 6-Hypothyrodisim. 7-Severe malnutrition 8-Trauma. -direct penetrating injury -surgery (abdominal, pelvic) -amnicentesis (aspiration of the aminiotic fluid from the amniotic sac) -chorionic villous sampling 9-Poisons (cytotoxic drug, lead, quinine, ergot, smoking, alcohol) B.local causes : 1-Uterine fibroids. (submucous fibroid related to uterine cavity ,like leomyoma). 2-Congenital abnormalities (double, septate uterus). 3-Cervical incompetence/ weakness. 58 4- Incarcerated retroverted uterus in pelvis (Fixed). 5-Asherman's syndrome (intrauterine adhesion). 6-Presence of intrauterine contraceptive device (IUCD). 7-Abnormalities of implantation (low implantation of placenta). 2-Fetal causes: -Fetal abnormalities. -multiple pregnancy. 3-immunological causes factors: a. autoimmune disease b. Rh incompatibility 4. Endocrine abnormalities: a. luteal phase inadequacy. b. hypersecration of LH. septic abortion : Occur in:- -missed abortion. -incomplete abortion. -induced abortion (criminal). Symptoms: 1-History of abortion (often criminal). 59 2-Maternal fever. 3-Lower abdominal pain. 4-Persistent vaginal bleeding. 5-Offensive vaginal discharge. Signs: 1-patient is ill, toxic. 2-Raise temperature and tachycardia. 3-Suprapubic tenderness with guarding. 4-Uterus is very tender. 5-Cervix remained patulous. 6-Offensive vaginal discharge. Investigations: Ultrasound. Vaginal and cervical swab, blood and urine culture. Complications of curettage: 1-Immediate : -haemorrhage. -uterine perforation. -cervical injury. -acute haematometra. -intra-abdominal organ injury. -increase maternal mortality. 61 2-Delayed: -infection. -retained tissue. 3-late: 1.Asherman's syndrome (intrauterine adhesions). 2.Future pregnancy adverse outcome (as cervical incompetence) 3.Rh sensitization if mother Rh negative and not receive prophylactic treatment. Hydatidifrom mole Clinical features : 1.Typical clinical feature in complete mole:  amenorrhoea.  Vaginal bleeding is most common sign of variable amount mostly in early pregnancy around 12-14 weeks.  Usually painless but sometimes associated with pain due to uterine contractions.  Symptoms of pregnancy in exaggerated form. 2. symptoms of complications of hydatidiform mole: a. pre-eclampsia early onset before 20th weeks b. hyperemesis gravidarum. c. Anaemia. d. hyperthyroidism. 61 e. complication of theca lutein cyst of ovary (rupture, torsion).molar pregnancy produces excessive hCG , which stimulates excessive growth of ovaries. h. pelvic infection. g. perforated uterus. j. disseminated intravascular coagulopathy (DIC). k. embolization and respiratory symptoms. 3. spontaneous expulsion of vesicles from vagina around 16 weeks.(if undiagnosed before). 4. discovered accidentally by ultrasound at booking which make the gestational age at evacuation of hydatidiform mole is about 9-10 weeks. investigation (diagnosis) 1. Clinical features amenorrhoea and vaginal bleeding with larger than expected size uterus. 2. Us 3. B-Hcg 4. X-ray Partial mole  Come with signs and symptoms of an incomplete or missed abortion,  bleeding,  small uterus,  low hCG levels. Treatment 62  1. Evacuation 2. Follow up to detect malignant changes. Risk of hydatidiform mole: Before evacuation: 1. pre-eclampsia early onset before 20th weeks 2. hyperemesis gravidarum. 3. Anaemia. 4. hyperthyroidism. During evacuation: 1. Bleeding can be profuse. 2. Sepsis. 3. Perforation of uterus. 4. Air embolism. 5. Incomplete evacuation of uterus. After evacuation: 1. Choriocarcinoma. 2. Increase risk of recurrence of mole. Causes of vaginal bleeding in early pregnancy: 1.miscarriage (spontaneous abortion). 2.ectopic pregnancy. 3.Hydatidiform mole. 4. Incidental cause  Cervical cause 1. 2. 63  3. 4. 5.  Vaginal cause 1. 2. 3. 5. Blood dyscarasia Vomiting in pregnancy Etiology 1. Stretch of peritoneum over the uterine. 2. High level of hcg and thyroid. 3. Allergic response of maternal tissue to fetus. 4. Psychological and emotional stress. Management 1. Exclusion of other causes. 2. Rest 3. Small and frequent meal. 4. Drugs, anti-histamine ,anti- emetic. 5. Advice that this condition is self-limiting. Prolonged pregnancy (post term- post date ). pregnancies persists beyond 42 completed weeks or more than 294 days from the onset of the last normal menstrual period (LMP). Fetal postmaturity syndrome  -30% of postterm pregnancies.  It is related to the aging and infarction of placenta 64   resulting in placental insufficiency with impaired oxygen diffusion and decreased transfer of nutrients to fetus.Fetus  is typically has loss of subcutaneous fat, long fingernails, dry, peeling skin, and abndant hair. Maternal risk of post date pregnancy 1. 2. 3. 4. Diagnosis  Accurate dating of gestation  Us Management 1. Elective induction of labour. 2. Expectant management with/ without antepartum testing Simple monitoring with Non stress test (NST) cardiotocography (CTG) and liquor assessment. Multiple pregnancy is a pregnancy with two or more fetuses. Classification:  The classification of multiple pregnancy is based on:  number of fetuses: twins, triplets, quadruplets, etc.,  number of fertilized eggs: zygosity (dizygotic &amp; monozygotic), 65   number of placentas: chorionicity (dichorionic &amp; monochorionic),  number of amniotic cavities: amnionicity (diamniotic &amp; monoamniotic) presentation (clinical fearures ). 1. exaggerated pregnancy-related symptoms. The uterus may be palpated abdominally earlier than 12 weeks gestation. 2.  large-for- dates uterine size,  higher than expected weight gain, &gt;  2 fetal poles on palpation  two or more fetal heart rates heard on auscultation. Complications     cerebral palsy.  singletons.  -related complications such as  hyperemesis gravidarum, polyhydramnios, pre-eclampsia,  anaemia, antepartum haemorrhage.  - malpresentation, cord prolapse, premature separation of placenta, cord entanglement, postpartum haemorrhage.  Labour induction: 66  contraction prior to their spontaneous onset , leading to cervical dilatation, effacement and delivery of the baby.(after 24 weeks ). Augmentation of labour (acceleration): begun normally. Indication of induction -eclampsia, eclampsia). ating maternal illness. hospital). Contraindications 67  Malpresentations )e.g., transverse or oblique lie, footling breech). Absolute cephalo-pelvic disproportion. Placenta previa. Previous major uterine surgery or classical Caesarean section. Invasive carcinoma of the cervix. Prolapsed cord. Active genital herpes. Gynecological, obstetrical, or medical conditions that preclude vaginal delivery complications 1.Failed induction. 2.Uterine hyperstimulation. 3. fetal distress. 4.Cord prolapse. 5.Abruptio placentae. 6.uterine rupture. 7.Inadvertent preterm delivery. 8.Hyponatremia 9.Neonatal hyperbilibubinemia : 10.Hypotonic uterine postpartum hemorrhage : Modified Bishop Score This score is predicting for the succession of induction of labour.(0-13) Less than 5 (unfavorable cervix) 68 9-13 (favorable cervix). Method of induction of labor  Those employed by women that do not require medical prescription: caster oil, acupuncture, breast nipple stimulation, sexual intercourse.  *Mechanical force to promote cervical effacement and dilatation and initiation of uterine contractions:(membrane sweeping, hygroscopic (synthetic osmotic dilators (e.g., Lamicel)) and mechanical dilators (Balloon devices), extra-amniotic infusion of saline, Amniotomy.  All have a similar mechanism of action as it exert local pressure that stimulates the release of prostaglandins. Complications o infection (endometritis and neonatal sepsis). o Bleeding o membrane rupture o placental disruption. Amniotomy : Manipulation of the membranes cause prostaglandin release ,uterine contractions, and cervical rippining. Complication of oxytocin : 1.Hyperstimulation. 2.water intoxication with convulsion and coma. occurred if prolonged administration of high dose of oxytocin in large volume of electrolyte-free fluid because Antidiuretic effect. 3.post partum haemorrhage: mainly due to uterine atony. 4. poor uterine action. 69  5.Neonatal hyperbilirubinemia. Anatomy SAGITTAL SUTURE lies between the superior borders of the parietal bones. FRONTAL SUTURE is a forward continuation of the sagittal suture, lies between the two parts of frontal bone. CORONAL SUTURE lies between the anterior borders of the parietal bones &amp; the posterior borders of frontal bones. ANTERIOR FONTANELLE OR BREGMA: Lies where the sagittal, frontal &amp; coronal sutures meet, is diamond shaped is present at birth &amp; takes about 20 months to close. POSTERIOR FONTANELLE: Lies at the posterior end of the sagittal suture between the two parietal bones &amp; occipital bone. Is triangular in shape &amp;it closed soon after birth. Diameters suboccipito-bregmatic diameter:9.5 cm suboccipitofrontal diameter :10 cm occipitofrontal diameter : 11.5 mento-vertical: 13 cm submento-bregmatic diameter : 9.5 cm (face presentation ). Transverse diameter : 9.5 Normal labor The show This is mucous discharge from the cervix mixed with little blood as a result of taking up of the internal os &amp; separation of membranes. 71 Lie The relation of the long axis of the fetus to the uterus, this may be longitudinal, oblique or transverse. Presentation Is that part of the fetus in or over the pelvic brim in relation to the cervix. If the head occupies the lower segment the presentation is cephalic, if is flexed on the spine the vertex presents. Position The relationship between selected part of the presenting part of the fetus to maternal pelvis [the denominator]. With vertex presentation the denominator is the occiput, with face presentation it is the chin [mentum]. Attitude Refers to the relation of different parts of the fetus to one another. The mechanism of labour in vertex presentation; -Engagement. -Descent. -Flexion. -Internal rotation. -Extention. -Restitution. -External rotation. -Shoulder rotation. -Delivery of fetal body. 71 Placenta Function of placenta: 1. Enables the fetus to take oxygen &amp; nutrients from the maternal blood. 2. Excretory function when CO2 &amp; other waste products pass from the fetus to the maternal circulation. 3. Barrier against the transfer of infection to the fetus. 4. Secrete hormones like hCG, oestrogen and progesterone. Umbilical cord Length 50 cm More 50 lead to cord prolapse and formation of knots around some parts of fetus. Less than 50 lead to delay in 2nd stage of labour, premature separation of the placenta, inversion of uterus are theoretical accidents. Fetal circulation Difference between fetal and adult circulation. & left ventricle work in parallel rather than series. (highly oxygenated blood), while the placenta & lower body receive blood from both Rt & Lt ventricle. Functions of the amniotic fluid : 72 1. Guards the fetus against mechanical shocks, and equalizes the pressure exerted by uterine contractions. 2. Room for fetal movement. 3. Maintain the temp. of the fetus. so the fetus is not subjected to heat loss. 4. It can hardly regarded as a source of nutrition since it contain small amounts of saltsand protein.( swallowing). 5. The forewater bag form a wedge which with uterine contraction dilates the internal os and the cervical canal. 6. At the rupture of the membrane during labour the fluid flushes the lower genital tract( aseptic and bactericidal). 7. The amnion produce a variety of bioactive compounds including vasoactive peptides, growth factors, and cytokines which modulates chorionic vessels flow or promotes cell replication and calcium metabolism. assessment of amniotic fluid volume 1-the deepest vertical pool (DVP) 2-amniotic fluid index (AFI) Oligohydromnios Oligohydromnios is a condition in pregnancy characterized by a deficiency of amniotic fluid, defined as AFV less than 5th percentile for gestation, AFI Less 5 or DVP less 2cm. Causes 1-preterm premature rupture of membrane (PPROM) (50%). 2-placental insufficiency commonly associated with IUGR. 3-congenital fetal anomalies.....a-renal agenesis.....b-renal dysplasia. 73....c-urethral obstruction (atresia or posterior valve). 4-prolonged pregnancy or post-term. 5-maternal drugs as NSAID. 6-maternal complications as hypertension, dehydration, preeclampsia. Complications of oligohydromnios Fetal risk 1-perinatal mortality. 2-pulmonary hypoplasia, 3-skeletal deformities. Potter syndrome is the association of flattened facies, postural deformities &amp; pulmonary hypoplasia as sequelae of oligohydromnios, first reported in association with bilateral renal agenesis. 4-prematurity. 5-fetal distress. Maternal risk 1-increase the risk of CS due to fetal distress secondary to either IUGR, malformation or cord compression. 2-high rate of physician intervention. Polyhydromnios Polyhydromnios is an excess amount of amniotic fluid it is defined as AFV above 95th centile for gestational age, AFI more 20-24 or DVP of more 8 cm. Causes 1-Maternal...DM 2-Fetal...intestinal obstruction (duodenal, esophageal atresia). 74...esophageal compression secondary to thoracic or mediastinal mass as diaphragmatic hernia....impairment of swallowing due to CNS lesion as anencephaly....chromosomal abnormalities as trisomy 18...fetal polyuria...multiple gestation (twin-twin transfusion syndrome) causing acute polyhydromnios....cardiac failure due to fetal anemia....congenital infection...fetal hydrops secondary to high output cardiac failure. Fig.3 Potter syndrome 3-Placental...chorioangioma of placenta 4-idiopathic. Complications of polyhydromnios Fetal risks 1-perinatal mortality ranging from 10-30% which is secondary to the presence of congenital abnormalities &amp; preterm delivery. 2-hypoxia secondary to cord prolapse &amp; abruption placenta. Maternal risks 1-abdominal discomfort 2-spontaneous preterm labour 3-spontaneous rupture of membrane with risk of...umbilical cord prolapse...abruption placenta due to sudden decompression of uterus. 4-malpresentation &amp; unstable lie. 5-post-partum hemorrhage due to post-partum uterine atony. 75 6-increase incidence of CS due to unstable lie &amp; placenta abruption. 7-higher incidence of pre-eclampsia that may be a manifestation of mirror syndrome in association with fetal hydrops. Signs and symptoms of pregnancy Early symptoms of pregnancy: 1. Amenorrhea 2. Breast symptoms 3. Frequency of micturition 4. Abdominal enlargement 5. Fetal movement 6. Nausea with or without vomiting 7. Fatigue 8. Faintness and dizziness Signs of pregnancy: a.Signs due to changes in the uterus: 1-Enlargement of the body of the uterus: 2-Softening of the uterus and cervix: 3-Hegar's sign 4-Progressive enlargement of the uterus: 5-Painless contractions: b.Signs due to the presence of the fetus: 1-Ballottement: 2-Fetal heart sounds: 3-Palpation of the fetal parts: 4-Fetal movements: 5-Funic soufflé: C. Signs due to changes in the breasts and the skin: -Breast changes : 76  1-Primary areola. 2-Secondary areola. 3-Montgomery tubercules. 4-Colostrums. --Skin changes : 1-Chloasma. 2-linea nigra. 3-striae gravidarum. Laboratory tests for pregnancy: 1-Urine pregnancy test: usually positive on day 35 from LMP 2-Serum pregnancy test: usually positive 7-10 days after conception. Confirming the diagnosis of pregnancy : 1-Identification of a heart beat. 2-Ultrasonographic recognition of the fetus: 3-Fetal heart activity → real time US show fetal heart after 6 weeks of gestation. Differential diagnosis of pregnancy : 1. Uterine fibroids: 2. Symmetrical enlargement of the uterus. 3. No amenorrhoea. 4. Negative PT. Puerperium The puerperium refers to the 6 week period following childbirth. Physiological changes 1-Uterine involution 77  Involution is the process by which the postpartum uterus, weighing about 1kg, returns to its pre-pregnancy state of less than 100g. 2-Genital tract changes -cevix In first few days : easy to pass two fingers By the end of first week : difficult to pass one finger By the end of second week : internal os closed. -Vagina In the first few days, the stretched vagina is smooth and oedematous, but by the third week rugae begin to reappear. 3- Lochia Lochia is the blood stained uterine discharge that is comprised of blood and necrotic decidua. 4- Abdominal wall Return to pre pregnant state. Complications of the puerperium The most serious complications are:- Other problems include:- 78  diastasis Secondary postpartum haemorrhage :- fresh bleeding from the genital tract between 24 hours and 6 weeks after delivery.The most common time is between days 7 &amp;14 Aetiology: 1. Retained placental tissue (most common). 2. Endometritis. 3. Hormonal contraception. 4. Bleeding disorders, e.g. von Willebrand’s disease. 5. choriocarcinoma Puerperal Pyrexia Is defined as a temperature of 38°C (104°F) or higher on any two of the first 10 days postpartum, exclusive of the first 24 hours. Coagulations disorders in pregnancy Normal hemostasis requires 3 main factors; *Vascular constriction. *Platelet aggregation &amp;formation of platelet plug. *Fibrin formation through coagulation system. Venous thromboembolism (VTE ), any thrombo embolic event in the venous system. 79 Deep venous thrombosis (DVT), radiologically confirmed occlusion of deep venous system of the leg sufficient to produce symptoms of pain or swelling. Pulmonary embolism (PE), radiologically confirmed occlusion of pulmonary arteries sufficient to cause symptoms of breathlessness, chest pain or both. Hemostatic problems associated with pregnancy: 1-Thromboembolism. 2-Hemorrhage with or without coagulopathy Clinical Features of Venous TE: 1-Superficial thrombophlebitis. 2-DVT. 3-PE. Diagnosis of DVT 1-Clinical features usually affects left femoral vein. 2-Investigations...Impedance plethysmography (IPG), little value in 3 rd trimester....Doppler US, same as IPG....Duplex US, used in pregnancy....Contrast venography, gold standard....Iodine 125 fibrinogen scan...D-dimer level Investigations of PE: CXR, ECG, perfusion / ventilation lung scan, arterial blood gas analysis, pulmonary angiography&amp; CT scan. Causes of DIC 1-Endothelial injury: as in 81...preeclampsia....Hypovolemia. 2-Release of thromboplastin as in:...Abruptio placentae....Amniotic fluid embolism....Retained dead fetus. 3-Release of phospholipid as in...Intravascular hemolysis...Incompatible blood transfusion Clinical features of DIC :- 1-Asymptomatic 2-Variable degrees of thrombocytopenia as in small abruptio placentae. 3-Massive uncontrollable hemorrhage as abruptio placentae, amniotic fluid embolism and eclampsia. Management:- 1-Fluid replacement to avoid renal shut down usually by simple crystalloid eg. Hartmanns solution 2-3 times the estimated volume blood loss. 2-FFP which contains all coagulation factors. 3-Fresh blood transfusion. IUGR IUGR is failure of the fetus to achieve its normal growth potential or fetuses whose growth velocity slows down or stops. CAUSES 81 Maternal facrors -1maternal disease (chronic respiratory dis). -2malnutrition -3ethinic & socio-economic factors -4maternal hypoxemia -5low pre-pregnancy weight -6primigravida -7drugs Fetal factors -1genetic disease -2structural abnormalities -3chromosomal abnormalities (trisomy)21 ،13،11 -4cardiovascular disease -5congenital infection (TORCH) -6multiple pregnancy Placental factors 1-reduced utero-placental perfusion. 2-reduced feto-placental perfusion. Complications Antepartum complications 1. still birth. 2. oligohydromnios. *During labour i. meconium aspiration ii. fetal distress iii. intrapartum fetal death 82 neonatal complications -1hypoxic ischemic encephalopathy. -3hypoglycemia. -4hypocalcemia -5defective temperature regulation. -6chronic intrauterine hypoxia... polycythemia. Adult complications -1complication in adult life) NIDDM, cardiovascular dis &.strocke.) -2educational underachievement IUFD IUFD is fetal demise after 24 weeks gestation & before the onset of labour. CAUSES Maternal causes -1medical dis. -2infection -3autoimmune disorders -4hyperpyrexia & sever anaemia -5Rh incompatibility -6drug abuse -7obstetrics causes -1cholestasis of pregnancy -9trauma Fetal causes -1malformation -2infection -3immune haemolytic dis. 83  -4metabolic dis. -5IUGR Placental causes -1placental dysfunction, previa ,abruption, infarction. -2twin-twin transfusion syndrome -3fetomaternal haemorrhage -4chorioamnionitis -5iatrogenic -6cord accident Expectant management %10will experience spontaneous onset of labour within 2-3 wks of fetal demise Intrapartum management -1membrane should be left intact as long as possible. -2morphin analgesia -3fetal death82< wks...mifepristone 200 mg then misoprostol 400mcg 82> wks...oxytocine if cervix favorable , in un favorable cervix use laminaria tents to enhance ripening then use oxytocine. -4active management of 3rd stage of labour -5prepair blood & its product. Complications -1 infection -2PPH -3retained placenta -4abruption of placenta 84 -5DIC -6sepsis -7shock, renal failure -1maternal death. Prelabor rupture of membrane Aetiology Term PROM . Programmed cell death &amp;  activation of catabolic enzymes &amp;  mechanical forces result in ruptured membrane. Preterm PROM 1-ascending infection appears one of the major causes. Most of infection appears subclinical &amp; give few signs or symptoms. 2-antepartum hemorrhage (APH). 3-cervical weakness (incompetence), failure of cervix to be a barrier to ascending infection &amp; by allowing membrane to prolapse. 4-maternal smoking. Complications (risks) of PROM. A-Maternal risks 1-intrauterine infection 2-abruption placenta 3-PPH 4-retained placenta 5-puerperal sepsis &amp; septic shock leading to maternal death. B-Fetal risks 1-infection 85 2-prematurity &amp; its complications 3-increase the risk of cord prolapse Fig.2 Speculum Examination 4-pulmonary hypoplasia 5-fetal or neonatal death. 86 87