Obstetrics and Gynecology State Exam Notes 1 PDF

1. Anatomy Of The Female Reproductive System Female internal genitalia Ovaries The ovaries are the female gonads They are almond shaped Secrete estrogen, progesterone They are situated on the lateral wall of the pelvis, on both sides of the uterus in ovarian...

1. Anatomy Of The Female Reproductive System Female internal genitalia Ovaries The ovaries are the female gonads They are almond shaped Secrete estrogen, progesterone They are situated on the lateral wall of the pelvis, on both sides of the uterus in ovarian fossa, between external and internal iliac vessels covered by peritoneum. The ovary is fixed by the supporting ligaments: Mesovarium - peritoneum part of the broad ligament of uterus Suspensory ligament of the ovary - contains ovarian vessels with connective tissue and smooth muscle fibres Proper ligament of the ovary - connects ovary with uterus The ovary has: 2 surfaces - Medial and lateral surface 2 margins - Free margin and mesovarium margin 2 extremes - Uterine extreme and tubal extreme Covering called tunica albuginea Microscopic: Outer layer: Germinal epithelium (simple squamous/cuboidal) Capsule: Tunica albuginea Cortex (contains ovarian follicles) Medulla (contains blood vessels, nerves) Helum is what the ovarian vessels pass through. In the cortex are the follicles in different stages: Primordial Primary Vesicular Graafian The medulla contains connective tissue and blood vessels Follicular development Infancy to puberty ○ Primary oocyte surrounded by granulosa cells form primary (primordial) follicle Menstrual cycle ○ Primary follicle → secondary follicle → tertiary (Graafian) follicle  Antrum forms in Graafian follicles; granulosa cells secrete nourishing fluid for primary oocyte Theca cells produce androstenedione → converted into estradiol in granulosa cells Follicular phase of menstrual cycle: ○ Graafian follicles grow Follicle with most FSH receptors becomes dominant follicle; primary oocyte → meiosis I completed; secondary oocyte formed ○ Ovulation: dominant follicle ruptures → secondary oocyte released → peritoneal cavity → pulled inside fallopian tube ○ Luteal phase: follicle remains → corpus luteum Luteinized granulosa cells secrete inhibin → decreased FSH → decreased estrogen → decreased LH Luteinized theca cells: increased progesterone → dominant hormone Fertilization If fertilization occurs → oocyte becomes mature ovum → progesterone produced until placenta forms If fertilization does not occur → corpus luteum → corpus albicans Arterial supply Ovarian artery - paired branch of abdominal aorta Venous drainage Ovarian plexus drains into the ovarian vein which drains into the IVC. Left ovarian vein first drains into the left renal vein which drains into the IVC. Lymphatics Right and left lumbar nodes Innervation Parasympathetic - Uterine plexus Sympathetic - Ovarian plexus Fallopian tubes (Uterine Tubes) 10-12 cm long Two tubes, each associated with one ovary, on side of uterus Lie in the mesosalpinx of the broad ligament of the uterus Extend from the uterine horns and open in the peritoneal cavity near the ovaries A uterine tube has 4 parts: Infundibulum - distal end that opens into the peritoneal cavity through the abdominal ostium. It has a fimbriae lining with ovarian fimbria  Ampulla - where fertilization most commonly occurs Isthmus - narrow part which enters uterine horn Uterine part - opens into the uterine cavity via uterine ostium Histology Mucosa Muscularis Serosa Mucosa Forms longitudinal folds that are different in the parts of the tube. They are very high in the ampulla. The epithelium is simple columnar epithelium. Inner mucosa provides nutrients for oocyte LP Muscularis Inner circular layer Outer longitudinal layer Cilia sweep zygote towards uterus Arterial supply Branches of ovarian artery (a branch of abdominal aorta) Branches of the uterine artery (branch of the internal iliac artery) Venous drainage Uterine venous plexus drains into uterine veins which drain into the IIV Ovarian veins → renal vein (left) & IVC (right) Lymphatics Right and left lumbar nodes Internal iliac Innervation Parasympathetic - Uterovaginal plexus Sympathetic - Ovarian plexus Uterus Thick walled, hollow, muscular organ which is adapted to the growth of the fetus and aids in childbirth It is situated posterosuperior to the urinary bladder and anterior to the rectum It is covered by peritoneum anteriorly and superiorly  Between the uterus and the urinary bladder, the peritoneum forms the vesicouterine pouch Between the uterus and the rectum is rectouterine pouch Uterus is normally anteflexed, anteverted Cervix ○ Promotes entry of sperm into the uterus for fertilization ○ Allows menstrual blood to flow from the uterus into the vagina ○ Endocervix secretes a clear, alkaline fluid to facilitate the passage of sperm Surfaces Anterior and posterior Left and right margins Ligaments: The broad ligament - a double layer of mesentery that connects the uterus to the lateral walls of the pelvis. Holds the uterus in position. Its formations are the mesosalpinx (mesentery for uterine tubes), mesovarium (mesentery for ovaries) and the mesometrium (mesentery for the uterus) The round ligament - extends from the uterotubal junction to the labia majora via the inguinal canal The proper ligament of the ovary - connects the ovaries to the uterus Parts of the uterus: Fundus: superior, rounded aspect of the uterus Body ○ Uterine horns: site of the opening of the fallopian tubes bilaterally ○ Uterine cavity: triangular, continuous with uterine tube and internal os Isthmus ○ Constriction between the body and the cervix ○ Corresponds to the level of the internal os of the uterus Cervix: fibrous, cylindrical part of the distal uterus between the internal and external orifice ○ Supravaginal cervix: portion of the cervix superior to the vagina ○ Vaginal cervix: portion of the cervix that protrudes into the fundus of the vagina ○ Cervical canal ○ Cervical os: the opening of the cervix into the vagina There are 2 surfaces: Anterior (Vesicle) Posterior (Intestinal) There are two margins  Left Right Microscopy of uterus Mucosa (Endometrium) Covered by simple columnar epithelium.(in the cervix it is stratified squamous non -k). It has 2 layers Stratum basalis Stratum functionalis Muscularis (Myometrium) Smooth muscle fibres in different directions Serosa (Perimetrium) Microscopy of cervix Endocervix: inner part of the cervix proximal to the uterine external os ○ Composed of simple columnar epithelium with mucous-producing cells Cervical transformation zone: physiologic transition zone between the endocervix and ectocervix ○ Squamocolumnar junction: border between metaplastic squamous epithelium and simple columnar epithelium Ectocervix: outer part of the cervix distal to the uterine external os ○ Composed of stratified squamous epithelium Arterial supply Uterine artery (branch of internal iliac artery) Collateral branches of ovarian arteries Venous drainage Uterine venous plexus drains into the uterine veins which drain into the internal iliac veins Lymphatic drainage Iliac lymph nodes Sacral lymph nodes Aortic lymph nodes  Inguinal lymph nodes Innervation Uterovaginal plexus Vagina 8-10 cm long musculomembranous tube Anteriorly is the fundus of the bladder and urethra Laterally is the levator ani and ureters Posteriorly is the anal canal, rectum and rectouterine pouch Extends from cervix to the vestibule between the labia minora covered by the mucosal fold of the hymen. It contains the vaginal orifice and the external urethral orifice Around the vaginal part of the cervix is formed the vaginal fornix with anterior, posterior and lateral parts. Anterior and posterior parts are situated very closely. Parts Anterior and posterior part Histology Mucosa Mucosa forms folds/ridges Stratified squamous non - k epithelium LP Muscularis Inner circular layer Outer longitudinal layer Tunica spongiosa Arterial supply  Superior - Branches of the uterine artery Middle and inferior - Vaginal and internal pudendal arteries (branch of internal iliac artery) Venous drainage Vaginal venous plexus drains into the uterine veins which drain into the internal iliac veins Lymphatic drainage Iliac lymph nodes Sacral lymph nodes Aortic lymph nodes Inguinal lymph nodes Innervation Uterovaginal plexus Female External Genitalia Mons Pubis Round fatty eminence anterior to the pubic symphysis Formed by a mass of fatty subcutaneous tissue Covered with pubic hair Labia Majora Folds of skin that provide protection for urethral and vaginal orifices. Pass inferoposteriorly from the mons pubis to the anus Contain loose subcutaneous tissue and smooth muscle and termination of the round ligament. Covered with pubic hair Form anterior commissure and posterior commissure Labia Minora Round folds of hairless skin Enclosed in pudendal cleft and surround the vestibule into which the external urethral and vaginal orifices are open Contain erectile tissue Medial laminae form frenulum of the clitoris Laterally laminae form the prepuce of clitoris Posteriorly is the frenulum of the labia minora Clitoris Located where labia minora meet anteriorly Consist of a root, body (composed of corpora cavernosa) and a glans Solely an organ of sexual arousal Vestibule Space surrounded by the labia minora into which the external urethral and vaginal orifices are open and the ducts of the greater/lesser vestibular glands which secrete mucous during sexual arousal External urethral orifice is anterior to the vaginal orifice. Lateral to the external urethral orifice are the openings of the paraurethral glands Vaginal orifice has mucous membrane called the hymen Lateral to the vaginal orifice are the bulbs of the vestibule (contain erectile tissue) Greater vestibular glands (Bartholin gland): secrete alkaline fluid for lubrication Skene glands: homologous to the male prostate gland Arterial supply External and internal pudendal arteries (branch of internal iliac artery) Venous drainage Labial veins, internal pudendal veins Lymphatic drainage Superficial and deep inguinal lymph nodes Internal iliac lymph nodes Innervation Uterovaginal plexus Pudendal branches - anterior and posterior labial branches, dorsal clitoral nerve (sensory)  Anatomy Of The Female Pelvis - Structure, Planes, Distances Pelvis Composed of the sacrum, coccyx, two innominate bones (fusion of the ilium, ischium and pubis) The two innominate bones are joined to the sacrum at the sacroiliac synchondroses and one to another at the pubic symphysis Female pelvis is divided into the ○ False pelvis (above the linea terminalis and no importance) ○ True pelvis (below the linea terminalis and related to birth) True pelvis is composed of ○ Pelvic inlet (round shaped) ○ Pelvic cavity ○ Pelvic outlet Pelvic inlet Boundaries Posteriorly - the promontory and alae of the sacrum Laterally - linea terminalis Anteriorly - horizontal rami of the pubic bones and pubic symphysis Diameters Anteroposterior ○ True conjugate (tip of the sacral promontory to the upper border of the symphysis pubis) = 11cm ○ Obstetric conjugate (between the promontory of the sacrum and most protruding point on the posterior surface of pubic symphysis) - 10.5 cm ○ Diagonal conjugate (between sacral promontory and the lower protruding part of pubic symphysis) - 12.5cm (2cm longer than obstetric conjugate) Transverse ○ Right angle to the obstetric conjugate ○ Represents the greatest distance between the linea terminalis on either side ~13cm ○ Intersects the obstetrical conjugate at a point about 5 cm in front of the promontory Two obliques ○ Extend from one of the sacroiliac synchondrosis to the iliopectineal eminence on the opposite side ○ About 12 cm Midpelvis At the level of the ischial spines Interspinous diameter 10.5 cm (smallest diameter of the pelvis)  Anteroposterior diameter is usually 11cm This is where the internal rotation of the fetal head takes place In labour, this station of the descent of the fetal head is called zero station Pelvic outlet Two triangular areas not in the same plane but having a common base, which is a line between the two ischial tuberosities Apex of the posterior triangle is at the tip of the sacrum and apex of the anterior triangle is the lower margin of the symphysis Anterior angle is formed by the area under the pubic arch Anteroposterior diameter is 9.5 cm to 11.5 cm (from lower margin of the pubic symphysis to the tip of sacrum) Traverse diameter is 11 cm and is the distance between the inner edges of the ischial tuberosities Pelvic types Gynaecoid pelvis 50% Normal female type Inlet is slightly traverse oval Wide sacrum Average concavity, inclination Side walls are straight Blunt ischial spines Subpubic angle is 90-100 degrees Anthropoid pelvis 25% Ape like type Long anteroposterior diameters Short transverse diameters Long and narrow sacrum Narrow subpubic angle Android pelvis 20% Male type Triangular/heart shaped inlet Anterior narrow spex Converging side walls (funnel shaped) Projecting ischial spines Narrow subpubic angle < 90 degrees Platypelloid pelvis 5% Flat female type Short anteroposterior diameters Long transverse diameters Wide subpubic angle  2. Fertilisation. Implantation, Fetal Development Fertilisation This is the process by which male and female gametes fuse, occurs in the ampullary region of the uterine tube Movement of cervix to oviduct can take from 30 mins to 6 days Sperm are attracted to the egg due to chemoattractants First they must undergo capacitation and acrosome reaction to acquire the capability to fertilise the egg Capacitation Period of conditioning 7 hours duration Occurs in the uterine tube Involves the epithelial interactions between sperm and mucosal surface of the tube Glycoprotein coat and seminal plasma protein are removed from the plasma membrane over the acrosomal region Only capacitated sperm can pass through the corona cells and undergo the acrosomal reaction Acrosomal reaction Occurs after binding to the zona pellucida (glycoprotein coat surrounding the egg) Induced by zona proteins Release of acrosomal enzymes (acrosin) allows sperm to penetrate the zona and contact the oocyte Zona pellucida changes permeability when the sperm contacts the oocyte surface Cortical granule release lysosomes which alter the zona pellucida to prevent other sperm penetration and inactivate sperm-specific receptor sites Fusion Plasma membranes of egg and sperm fuse Actual fusion is between the oocyte membrane and the membrane that covers posterior region of the sperm head Head and tail of sperm enter the oocyte except the plasma membrane Oocyte finishes its second meiotic division Definitive oocyte chromosomes arrange themselves into female pronucleus Male pronucleus forms and lies close to female pronucleus Tail detaches and degenerates Cell division occurs and the zygote has normal diploid number of chromosomes Days 1-5 Zygote travels down the fallopian tube towards the uterus Division of zygote into the morula and then the blastocyst Blastocyst consists of 2 cell layers: outer trophoblasts and inner embryoblasts Day 6 Implantation of the blastocyst (commonly into the anterior or posterior wall of the uterus) May result in brief implantation bleeding Day 6-12 Formation of the uteroplacental unit Trophoblast divides into ○ Syncytiotrophoblast → involved in placental development ○ Cytotrophoblast → forms chorionic cavity, which surrounds embryoblast Syncytiotrophoblast begins secreting hCG The maternal circulation is connected with the placental circulation The bilaminar embryonic disc develops 2 layers ○ Epiblast ○ Hypoblast Week 3 Gastrulation: formation of the trilaminar embryonic disc ○ Ectoderm ○ Mesoderm ○ Endoderm Neural plate begins to form from the neuroectoderm Week 3-8 Embryogenesis Organogenesis in order ○ CNS: neural tube closes by week 4 ○ Heart: begins to beat by week 4 ○ Ears and eyes ○ Upper and lower extremities ○ Teeth and gums ○ External genitalia (male/female characteristics) Week 9 onwards Fetogenesis: the fetus matures and grows  3. Placenta, Umbilical Cord, Membranes And Amniotic Fluid Placenta Mature placenta weighs approx. 500g, 2cm thick, diameter of 15-20cm Has a fetal portion and a maternal portion ○ Fetal portion is formed by the chorion frondosum ○ Maternal portion is formed by the decidua basalis On the fetal side placenta is bordered by chorionic plate On the maternal side, it is bordered by the decidual plate In the junctional zone, trophoblast and decidual plate intermingle - characterised by the decidual and syncytial giant cells, and rich in amorphous ECM. Between the chorion and decidual plates are intervillous spaces which are filled with maternal blood - derived from lacunae Villous trees grow into the intervillous blood lakes Decidua forms decidual septa which project into the intervillous spaces The septa have a core of maternal tissue but are surrounded by a syncytial layer Due to the septa, the placenta is divided into cotyledons Placental function Hormone production Site: syncytiotrophoblast Hormones Function of hormones ○ HCG ○ Continuation of ○ HPL pregnancy ○ CRH ○ Maternal adaptation to ○ Estrogen the pregnancy ○ Progesterone ○ Regulation of uterine circulation ○ Fetal development and growth ○ Inducing birth Gas and nutrient Passive transport exchange ○ Diffusion O2 CO2 Creatinine Urea Bilirubin Water Drugs ○ Facilitated diffusion Glucose Lactate Active transport ○ Amino acids, peptides,  ○ Hormones, vitamins, ○ Fatty acids, inorganic ions Pinocytosis: proteins, lipids, IgG Placental barrier Maternal and fetal circulation are separated by the placental barrier Placental barrier controls the gas and nutrient exchange Structure until the 4th month (maternal to fetal) ○ 1. Syncytiotrophoblast ○ 2. Cytotrophoblast ○ 3. Basal lamina of trophoblasts ○ 4. Villous stroma made up of connective tissue ○ 5. Basal lamina of the endothelium ○ 6. Capillary endothelium Structure from the 4th month (maternal to fetal) ○ 1. Syncytiotrophoblast ○ 2. Fused basal lamina from trophoblasts and the endothelium ○ 3. Capillary endothelium Umbilical cord Connects the fetus with the fetal part of the placenta (chorionic plate) Attaches centrally to the chorionic plate of the placenta Approx 50-70cm long by the end of pregnancy Structure of the umbilical cord Contains 3 blood vessels that carry fetal blood ○ 2 umbilical arteries: branches from the internal iliac arteries that carry deoxygenated blood from the fetus to the placenta ○ 1 umbilical vein: supplies oxygenated, nutrient-rich blood from the placenta to the fetus (merges into the inferior vena cava via the ductus venosus) Early stage in the development of the umbilical cord Connecting stalk: precursor of the mature umbilical cord Content ○ Allantois (small sac-like structure that protrudes into the connecting stalk) 3rd week: yolk sac wall forms allantois Fetal bladder develops at the transition from the allantoic epithelium to the endoderm of the hindgut ○ Vitelline duct: joins the midgut to the yolk sac Obliteration during 7th weeks  Failed obliteration → vitelline fistula, vitelline cyst, Meckel diverticulum Late stage in the development of the umbilical cord Ground substance: gelatinous connective tissue (Wharton Jelly) Cover: amniotic epithelium Content ○ Urachus (duct between fetal bladder and umbilicus) Remnant of the allantois Obliterates after birth to form the median umbilical ligament ○ Remnants of the obliterated vitelline duct Amniotic cavity As the fetus grows, the amniotic cavity expands, which eventually results in the obliteration of the chorionic cavity and the uterine cavity Development: 2nd week through migration of epiblast cells Components ○ Lined with amniotic epithelial cells ○ Filled with amniotic fluid, produced by amniotic epithelial cells Amniotic sac Composed of maternal (decidua) and fetal (chorioamniotic membranes) which surround the fetus and provide mechanical protection Amnion: inner amniotic membrane ○ Develops from the embryoblast and secretes amniotic fluid Chorion: middle amniotic membrane ○ Develops from the cytotrophoblast Decidua: outermost membrane ○ Develops from the decidua capsularis, which lies above the site of implantation Amniotic fluid Filled with clear, watery fluid that is produced by amniotic cells but is derived primarily from maternal blood Composition ○ pH: 7-7.5 ○ Proteins, glucose, urea ○ Fetal urine ○ Vernix: fetal dermal cells & sebaceous gland secretions that cover fetus’ skin Amount of fluid at: ○ 10 weeks - 30 ml ○ 20 weeks - 450 ml  ○ 37 weeks - 850-1500 ml Function ○ Protective cushion ○ Absorbs jolts ○ Prevents adherence of embryo to amnion ○ Allows for fetal movements The fetus swallows its own amniotic fluid at 5 months - 400 ml Urine is added to the fluid but it is mostly water During childbirth, it forms a hydrostatic wedge which helps to dilate the cervical canal Amniotic fluid index To determine the AFI, doctors may use a four-quadrant technique, when the deepest, unobstructed, vertical length of each pocket of fluid is measured in each quadrant and then added up to the others, or the so-called "Single Deepest Pocket" technique. An AFI < 5-6cm is considered as oligohydramnios. An AFI between 8-18cm is considered normal. Median AFI level is approximately 14 from week 20 to week 35, when the amniotic fluid begins to reduce in preparation for birth. An AFI > 24-25cm is considered as polyhydramnios. 4. Obstetric History. Gestational Age Assessment And Estimated Day Of Delivery. Previous pregnancies Date of delivery/pregnancy termination Location of delivery/pregnancy duration Duration of gestation Type of delivery Duration of labor Type of anesthesia Maternal complications Newborn weight ○ Gives indications of gestational diabetes, fetal growth problems, shoulder dystocia Newborn gender Fetal/neonatal complications Menstrual history This is a good determinant for establishing the expected date of confinement (EDC) The rule is to add 9 months and 7 days to the first day of the last normal menstrual period (LMP) LMP: July 20, 2015 EDC: April 27, 2016 Contraceptive history Hormonal contraceptives taken during early pregnancy have been associated with birth defects Retained intrauterine devices can cause early pregnancy loss, infection and premature delivery Medical history All serious medical conditions should be recorded such as diabetes mellitus, hypertension and renal disease Surgical history Chronological order of surgeries Trauma must be listed (fractured pelvis may result in diminished pelvic cavity) Social history Smoking, alcohol use and other substance abuse are important factors Patient’s contact or exposure to domesticated animals is important Exposure to solvents (carbon tetrachloride) or insulators (polychlorobromine compounds) may lead to teratogenesis or hepatic toxicity Gestational age assessment Gestational age is the number of weeks that have elapsed between 1st day of the LMP and date of delivery Obstetrics US exam is the most accurate measurement available Naegele’s rule for estimated date of delivery Add 1 year, 7 days to the 1st day of the LMP and subtract 3 months Ultrasound Measurement of the crown-rump length (CRL) in the first trimester ○ ~ 5cm at 12 weeks Measurement of biparietal diameter, fetal femoral length, abdominal circumference in 2nd & 3rd trimester Fundal height  5. Obstetric Physical Examination - Palpation (Leopold Methods), Abdominal Measurements, Pelvimetry, Auscultation Of Fetal Tones. Position Of The Fetus In The Uterus, Habitus, Situ, Position, Presentation. Physical examination General physical examination Specific examination ○ Breasts ○ Pelvis ○ External genitalia ○ Internal genitalia (speculum) Leopold Methods 1st maneuver Palpation of the fundus to determine fetal position (longitudinal/oblique/transverse) and fundal height ○ The fetal head is hard, round, and moves independently of the trunk while the buttocks feel softer, and are symmetric. ○ The shoulders and limbs have small bony processes; unlike the head, they move with the trunk. 2nd maneuver Palpating on either side of the abdomen to determine which side the fetal back lies ○ The fetal back is linear and firm whereas the extremities have multiple parts 3rd maneuver Grasping the presenting part between the thumb and third finger just above the pubic symphysis to determine the presenting part ○ The head is round and hard and the breech is irregular and soft 4th maneuver Palpating for the brow and occiput of the fetus to determine the fetal head position when the fetus is in a vertex position Best accomplished when the examiner is facing the patient's feet and placing both hands on either side of the lower abdomen just above the inlet By exerting the pressure on the direction of the pelvic inlet, the hand running along the back will bump into the occiput if the head is extended The hand on the same side of the small parts will bump into the brow if the head is flexed Abdominal inspection Note size of abdominal distension Note asymmetry Fetal movements Cutaneous signs ○ Linea nigra (dark line from xiphi sternum through the umbilicus to the suprapubic area) ○ Striae gravidarum (recent stretch marks are purplish in colour) ○ Striae albicans (old stretch marks are silvery white) ○ Flattening/eversion of umbilicus (due to increased intra-abdominal pressure) Superficial veins (due to pressure of IVC by gravid uterus) Surgical scars Pelvimetry This is assessment of the bony pelvis before the vaginal delivery CT is more favoured due to its accuracy, low radiation dose and widespread availability Specific measurements to permit a planned vaginal delivery ○ Inlet anteroposterior diameter > 105 mm ○ Inlet transverse diameter > 120 mm ○ Midpelvic interspinous diameter > 100 mm Auscultation of fetal tones Best heard at the anterior shoulder of the fetus ○ Doppler US device from 12 weeks ○ Fetal stethoscope from 24 weeks In breech presentation, best heard at, above, or level of maternal umbilicus Fetal lie (relationship of longitudinal axis of fetus to that of the uterus) Longitudinal - cephalic/breech palpable over pelvic inlet Oblique - head/breech is palpable in the iliac fossa and nothing felt in lower uterus Transverse - fetal poles felt in flanks and nothing above the brim Fetal Presentation (part of fetus overlying the pelvic brim) Cephalic (vertex, face or brow presentations) Breech (frank, complete, single footling, double footling) Shoulder (arm, shoulder, trunk w/ transverse/oblique lie) Compound (> 1 anatomical presenting part (e.g., cephalic/breech + extremity) Fetal position (relationship and orientation of presenting part to pelvis) Occiput anterior position: fetal occiput points towards symphysis pubis; fetus faces downwards  ○ Left occiput anterior (LOA): fetal back faces maternal left, anterior fontanelle faces maternal right, sagittal suture lies in the right oblique diameter ○ Right occiput anterior (ROA): fetal back faces maternal right, anterior fontanelle faces maternal left, sagittal suture lies in the left oblique diameter Occiput posterior position: fetal occiput points towards the maternal sacral promontory with face to pubis symphysis; fetus faces upwards Sacrum in breech position Mentum (chin) in extended cephalic presentation Fetal attitude (degree of extension/flexion of the fetal head during cephalic presentation) Vertex presentation (maximally flexed) Brow presentation (partially extended) Face presentation (maximally extended) ○ Mentum anterior face presentation ○ Mentum posterior face presentation Forehead presentation (partially flexed; military attitude)  6. Diagnosis Of Early And Advanced Pregnancy 1st trimester Symptoms Amenorrhea Morning sickness Frequency of micturition Breast symptoms - enlargement, sensation of fullness, tingling and tenderness Appetite changes and sleepiness Breast signs Increase in size and vascularity Increase in pigmentation of the nipple and primary areola Appearance of the secondary areola Montgomery’s follicles Expression of colostrum Uterine signs Uterus become enlarged, globular and soft Palmer’s sign - uterine contractions felt during bimanual examination Hegar sign - during bimanual examination, palpation or compression between the cervix and the fundus Vagina - dark, discoloration of the vulva (Chadwick sign) Investigations Urine pregnancy tests which depend on hCG in maternal serum and urine ○ Agglutination pregnancy test ○ Dipstick test Serum pregnancy tests ○ Serum b-hCG detectable 6-9 days after fertilization Peaks at 10 weeks ~100,000 mIU/mL) Decreases during 2nd trimester Stable during 3rd trimester US ○ Gestational sac can be detected after 4-5 weeks of amenorrhea ○ 6 weeks: Yolk sac detected ○ 7 weeks: fetal pole ○ 10-12 weeks: fetal heartbeat detected with doppler US ○ 18-20 weeks: fetal movements 2nd trimester (13-28 weeks) Symptoms Amenorrhea Morning sickness and urinary symptoms decrease Quickening - fetal sensation of the foetal movement Abdominal enlargement Breast signs Become more manifested Uterine signs Braxton Hicks contractions: intermittent painless contractions can be felt by abdominal examination Foetal signs Fetal movements felt by after 20 weeks Can be auscultated at 20-24 weeks by the Pinard’s stethoscope Umbilical souffle - murmur with same rate of FHS due to rush of blood in the umbilical arteries. Investigations Urine pregnancy tests which depend on hCG in maternal serum and urine ○ Agglutination pregnancy test ○ Dipstick test Serum pregnancy tests US ○ Gestational sac can be detected after 4-5 weeks of amenorrhea Fundal height 3rd trimester (29-40 weeks) Signs Palpation of foetal parts Palpation of foetal movements  Auscultation of foetal heart sounds US detection of all of the above 6. Diagnosis Of Early And Advanced Pregnancy Cessation of periods Most obvious symptom Nausea and vomiting Common in 1st trimester Occurs any time of day Persists throughout pregnancy Frequency of micturition Increased plasma volume Increased urine production Pressure effect of the uterus on the bladder Excessive lassitude or fatigue Common in early pregnancy Tends to disappear after 12 weeks Breast tenderness/heaviness Often seen early in pregnancy, particularly in the month after 1st period is missed Fetal movements Around 20 weeks of gestation in the nullipara 18 weeks in the multipara Others Abnormal desire to eat something not normally regarded as nutritive - Pica Clinical examination Vagina and cervix have a bluish tinge due to blood congestion Estimation of size of uterus After 12 weeks, uterus is palpable abdominally Fetal heart is heard using hand-held doppler Pregnancy test Hormone hCG is secreted by trophoblastic tissue Increased exponentially from 8 days after ovulation Peaks at 8-12 weeks gestation hCG can be measured in blood/urine  Home pregnancy test kits are available > 50 IU/L  7. Maternal Physiology And Adaptation During Pregnancy. Hygiene And Diet Pregnancy. Urogenital changes Uterus 10x increase in weight to 1000g at term Muscular hypertrophy up to 20 weeks Increased uterine blood flow from 50 mL/min at 10 weeks to 500-700 mL/min at term Hypertrophy of the uterine/ovarian arteries Uterine body Increase in shape, size, position and consistency Uterine cavity expands from 4-4000 mL Cervix Reduction in cervical collagen enables dilatation Hypertrophy of cervical glands leads to production of profuse cervical mucus and formation of thick mucus plug/operculum Increased vaginal discharge due to cervical ectopy (proliferation of columnar epithelium) into vaginal portion of cavity Vagina Rich venous vascular network in connective tissue surrounds vaginal walls with blood and gives slightly bluish appearance High oestrogen levels stimulate glycogen synthesis and deposition ○ Lactobacilli and glycogen produced lactic acid in vaginal cells ○ Lactic acid lowers vaginal pH to keep vagina relatively free from any bacterial pathogens Breast Lactiferous ducts and alveoli develop and grow under the stimulus of oestrogen, progesterone and prolactin From 3-4 days, colostrum (thick glossy protein rich fluid) can be expressed from breast Prolactin stimulates cells of alveoli to secrete milk ○ Effect is usually blocked by action of oestrogen and progesterone ○ After delivery, sudden decrease in hormones enables prolactin to act on breast and lactation begins Suckling stimulates prolactin and oxytocin release ○ Oxytocin stimulates contraction of the myoepithelial cells to cause ejection of milk Endocrine changes Progesterone Increased progesterone during pregnancy Synthesized by the corpus luteum Promotes smooth muscle relaxation Prevents preterm labour Oestrogens Increased breast and nipple growth and areola pigmentation Promote uterine flow, myometrial growth, cervical softening Increased sensitivity and expression of myometrial oxytocin receptors Increased water retention and protein synthesis Human placental lactogen Similar to growth hormone Modifies maternal metabolism to increase energy supply to fetus Increases insulin secretion and decreased insulins peripheral effect Thyroid Enlarged thyroid gland Increased renal clearance of iodine Thyroid responds by tripling iodine uptake - follicular enlargement TBG is doubled due to high oestrogen levels which leads to ○ Increased total T3 (triiodothyronine) then falls ○ Increased T4 (thyroxine) then falls Cardiovascular system Increased cardiac output to 6.5L/min Due to progressive enlargement of uterus, heart and diaphragm are displaced upwards Varicosity and edema of lower limbs Innocent systolic murmur Enlargement of heart and increase in stroke volume by 70-80 mL Blood pressure Decreases due to increased production of vasodilator prostaglandins Decreased by midpregnancy by 10-20 mm Hg Returns to normal levels by term Kidneys  Increase in size about 1cm in length Dilatation of the calyces, renal pelvis and ureter from 1st trimester Vesicoureteral reflux occurs Increase in uric acid clearance Increased renal blood flow results in ○ Increased GFR ○ Decreased plasma urea/creatinine Alimentary system Decreased tone of oesophageal sphincter and displacement through the diaphragm due to increased abdominal pressure causes reflux oesophagitis Decreased gastric motility Decreased gastric secretion Delayed gastric emptying Increased salivation Hemorrhoids Increased sodium and water absorption leads to constipation Skin Pigmentation in linea nigra, nipple and areola/chloasma Palmar erythema Spider naevi Striae due to increased production of adrenocortical hormones and stress in the skin due to expansion of abdomen Respiratory system Breathing becomes more diaphragmatic than costal Level of diaphragm rises Steeper intercostal angle Increased tidal volume due to effect of progesterone Increased inspiratory capacity in late pregnancy Breathlessness is more common as maternal partial pressure of CO is set lower to allow fetus to offload CO2 Musculoskeletal Increased lumbar lordosis and relaxation of the ligaments supporting the joints of the pelvic girdle can cause lower back pain Haemodynamics Plasma volume Increases by 10-15% at 6-12 weeks Expands rapidly at 30-34 weeks Acute excessive weight gain is due to oedema Red cell volume Rises from 1400 to 1640 mL Physiological anaemia due to increased plasma volume TWCC Increased due to increase in neutrophils Massive neutrophilia occurs during labour Decrease in eosinophils during labour Platelets Decreased slightly during pregnancy Function is unchanged Clotting factors Pregnancy is hypercoagulable state Increased clotting factors, especially fibrinogen Increased ESR Diet Calories - 1st trimester: 2200. 2nd & 3rd: 2500 kcal Recommended weight gain ○ BMI < 18.5: 12-18kg ○ BMI 18.5-24.9: 11-16kg ○ BMI 25-29.9: 7-11kg ○ BMI > 30: 5-9kg Regular physical activity recommended (walking, etc.) Proteins - 60 g Carbs - 200-400 g Lipids - should be restricted Vitamins ○ Vit A: 5000 IU ○ Vit B1- 1 mg ○ Vit B2- 11.5 mg ○ Nicotinic acid - 15 mg ○ Ascorbic acid (Vit C): 50 mg ○ Vit D: 400 IU ○ Folic acid: 0.5 mg RBC synthesis Placental/fetal growth Decreased risk of neural tube defects ○ Iron: 30-60 mg ○ Calcium: 1000 mg Daily diet One litre of milk 1-2 eggs Fresh vegetables and fruits 2 pieces of red meat replaced once weekly by sea fish and one by calf’s liver Coffee and tea should be restricted Avoid alcohol & tobacco Avoid unwashed or uncooked foods 8. Methods For Assessment Of Fetal Well Being US Measures fetal growth and volume of amniotic fluid Optimal timing is 1st trimester, 16-20 weeks of gestation Assesses ○ 1st scan uses the Crown-Rump length (CRL), 2nd scan uses biparietal diameter (BPD) for fetal size ○ IU pregnancy ○ Gestational age ○ Diagnoses multiple gestations ○ Pelvic masses ○ Uterine abnormalities ○ Ectopic pregnancy ○ Fetal abnormalities ○ Fetal growth ○ Fetal behaviour (breathing, body movement) ○ Fetal heart tones 1st trimester 2nd + 3rd trimester Gestation sac size, location, Fetal number, amnionicity and number chorionicity of multifetal gestations Embryo & yolk sac identification Fetal cardiac activity CRL Fetal presentation Fetal number, amnionicity and Placental location, appearance, chorionicity of multifetal gestations relationship to the internal cervical embryonic/fetal cardiac activity os, documentation of placental Assessment of embryonic/fetal cord insertion site when possible anatomy Amniotic fluid volume Evaluation of the maternal uterus, Gestational age assessment adnexa, cul-de-sac Fetal weight estimation Evaluation of fetal nuchal region, Fetal anatomical survey, technical fetal nuchal translucency limitations assessment Evaluation of the maternal uterus, adnexa, and cervix Cardiotocography Output of electrical monitoring of fetal heart rate Normal Baseline fetal heart rate is between 110-160 beats/min cardiotocography Heart rate should speed up by at least 15 b/min for 2 accelerations 2 acceleration should be seen in 20 mins ○ > 32 weeks: 15 bpm, > 15 secs ○ < 32 weeks: 10 bpm, > 10 secs  Abnormal tocography Failure of autonomic regulation of heart rate End stage event Excludes current compromise Only becomes abnormal in late stage of IUGR Amniocentesis Prenatal diagnosis of chromosomal anomalies is performed at 16-20 weeks gestation 0.3% pregnancy loss rate Amniotic cells require 1-2 weeks of culture before chromosomal analysis is possible Can be used to diagnose certain chromosomal disorders such as trisomy 21, 18 and 13 Other common disorders are cystic fibrosis, Tay-Sachs disease, Sickle-Cell disease and Fragile X-syndrome Complications ○ Miscarriage ○ PROM ○ Infection Biochemical testing When the fetal dorsal/ventral wall is open (neural tube defects or gastroschisis), amniotic fluid is α-fetoprotein is elevated Infections Potential infections such as cytomegalovirus, parvovirus B19, varicella zoster virus and toxoplasmosis are found on the amniotic fluid Amniotic fluid gram stain, white blood cell count, glucose level, interleukin-6 level and culture have been used to diagnose preterm chorioamnionitis Other diagnostic testing Detects pulmonary phospholipids or lamellar bodies in the fetal lungs in the case of impending premature birth or before elective delivery The presence of phosphatidylglycerol and lecithin-to-sphingomyelin ratio > 2.0 are associated with minimal risk of respiratory distress in the neonate Therapeutic amniocentesis Used to manage of polyhydramnios and twin-twin transfusion syndrome Polyhydramnios is a single deepest vertical pocket of amniotic fluid > 8 cm on ultrasound, can cause maternal respiratory embarrassment or premature labor Excessive amniotic fluid may arise from lack of fetal swallowing or from excessive fetal urination (twin-twin transfusion syndrome)  Serial amniocentesis to remove large volumes of excessive amniotic fluid from the sac of the recipient twin have been associated with improved outcome 9. Congenital Fetal Anomalies - Prenatal Screening & Diagnosis Combined test US + Blood test at 11-13+6 weeks Ultrasound (nuchal) scan measurement of the subcutaneous tissue between the skin and the soft tissue overlying the cervical spine with the fetus in the neutral position A blood test measuring ○ PAPP-A ○ hCG Triple and quadruple tests Blood tests at 16 wks Dating scan Blood tests measuring ○ Oestriol ○ hCG ○ AFP ○ Inhibin A Cell-free fetal DNA testing From 10 weeks onwards Fetal DNA is isolated from a maternal blood specimen for genetic testing Identifies chromosomal aberrations Determine the gender of the fetus Invasive testing Chorionic villus sampling - weeks 10-13 Amniocentesis - weeks 15-18 Subsequent fetal karyotyping - GOLD STANDARD Chromosomal abnormalities Trisomy 21 (Down’s syndrome) ○ NT > 4mm ○ PAPP-A: low ○ Free b-hCG: high Trisomy 18 (Edwards’ syndrome) ○ NT: increased ○ PAPP-A: low ○ Free b-hCG: low Trisomy 13 (Patau’s syndrome) ○ NT: increased ○ PAPP-A: low ○ Free b-hCG: low Turner syndrome (45 XO) Klinefelter’s syndrome (47 XXY)  10. Theories For The Onset Of Labour. Stages Of Labour. Once labour is established, uterus contracts for 45-60 seconds about every 2-4 mins The onset of labor is due to an endocrine maternal/fetal cross talk in which the fetus is in control of the timing of labor. There are hormonal changes in the build up to labor with prostaglandin synthesis and an increase in myometrial gap junction formation, and myometrial oxytocin. At some point labor begins with the activation of the fetal-hypothalamic-pituitary-adrenal axis. There are a number of signs that tell us labor is on its way: - Lightening - a few weeks before the birth, the mother feels ‘lighter’ in the abdomen. This is due to the fetus dropping into the true pelvis, a consequence of this is that we have increased micturition - An energy spurt - Exacerbations of braxton hicks - Cervical changes (softening, shortening dilating) Two signs indicate an imminent labor: - Increased vaginal discharge with a release of mucous plug also known as a ‘bloody show’ - The rupture of the amniotic sac (‘water breaking’) may also occur False Labour AKA Braxton-Hicks contractions True labour ○ Regular, increase in frequency, duration, and intensity contractions ○ Produce cervical changes ○ Pain begins in lower back, radiates to abdomen ○ Not relieved by ambulation False labour ○ Irregular, intermittent contractions ○ No cervical changes ○ Pain in abdomen ○ Walking may decrease pain True contractions o delivery ○ ~ 12-18 hours for first-time pregnancy ○ ~ 6-9 hours for subsequent pregnancies Stage 1 Lasts from diagnosis of labour until full cervical dilatation (10 cm) Membranes rupture now if not already. Lasts for about 16 hours Latent phase ○ 8-12 hours ○ Cervix dilates slowly for the first 6 cm and takes several hours ○ Cervical effacement ~ 30%  ○ Irregular, mild contractions every 5-30mins, lasting ~ 30secs Active phase ○ 3-5 hours ○ Contractions every 3-5mins, effacement: ~ 80% ○ Average cervical dilation at a rate of >1 cm/h in nulliparous women ○ Average cervical dilation at a rate of >1.2 cm/h in multiparous women ○ Progressive fetal descent Transition phase ○ 30mins - 2 hours ○ Contractions every 1.5-2mins, lasting ~60-90 secs ○ Cervical dilation 6-10cm ○ Cervical effacement 100% Stage 2 Lasts from full dilatation until delivery Once labour is established, uterus contracts for 45-60 seconds about every 2-4 mins Navigation through maternal pelvis dictated by 3 Ps ○ Power, passenger, passage Descent, flexion and rotation are commonly completed May last a few minutes Passive stage ○ Lasts from full dilatation until head reaches pelvic floor and women desires to push ○ Rotation and flexion are completed Active stage ○ Women is pushing ○ Pressure of head on pelvic floor produces urge to push down ○ Fetus is delivered on average after 40 mins (nulliparous) or 20 mins (multiparous) Delivery ○ Head reaches perineum, extends to come up out of the pelvis ○ Perineum stretches and tears but can be cut ○ Head then restitutes, rotation 90 degrees back to transverse position ○ Next contraction - shoulders delivery ○ Anterior shoulder comes out from under pubic symphysis, aided by lateral body flexion in posterior direction ○ Posterior shoulder is aided by lateral body flexion in anterior direction Stage 3 Time from delivery of fetus to the delivery of placenta Lasts up to 30 mins Uterine muscle fibres contract to compress blood vessels which supplied the placenta, which shears away from the uterine wall  Active management involves prophylactic administration of oxytocins or other uterotonics (such as prostaglandins or ergot alkaloids), cord clamping and cutting, and controlled traction of the umbilical cord Normal blood loss is 500 mL Lacerations and injuries need repair Signs of placental separation are: ○ Fresh show of blood from the vagina ○ Umbilical cord lengthens outside the vagina ○ Fundus rises up ○ Uterus becomes firm and globular Only when these signs appear, the assistant should attempt traction on the cord “Fourth stage” 2-hour postpartum period Adaptation to blood loss Start of uterine involution Requires monitoring to rule out hemorrhage or preeclampsia 11. Biomechanisms And Management Of Normal Labour Engagement Oblong-shaped head normally reaches the pelvis in the occipito-transverse position because the transverse diameter of the inlet > anteroposterior diameter Descent and flexion Head descends into the round mid-cavity and flexes until the cervix dilates Fetus moves from pelvic inlet → ischial spines → pelvic outlet → crowning at vaginal opening Fetal chin presses against chest, head meets resistance from pelvic floor Internal Rotation In the mid-cavity, the head rotates 90 degrees in two 45* movements (internal rotation) Face is now facing the sacrum, occiput is lower below the pubic symphysis (occiput-anterior) This enables it to pass through the pelvic outlet which has a wider antero-posterior than transverse diameter Rotation completes There is further descent Perineum distends Extension Fetal head lying behind the symphysis pubis and pelvic floor, acts upwards and forwards Restitution Fetal head rotates 45* in the opposite direction as it passes through the pelvic outlet External rotation Anterior shoulder rotates 45* anteriorly as it meets the maternal pelvic floor Head also rotates 45* degrees (external rotation) to the same position in which it entered the inlet Expulsion Delivery of the head, anterior shoulder slips out, followed by posterior shoulder and then rest of body. Management of first stage Maternal position Lateral recumbent position should be encouraged to provide adequate perfusion of the uteroplacental unit Fluids Avoid oral fluid due to decreased gastric emptying Give 125 mL/hr of 10% dextrose in normal saline solution - shorter labour Investigations HCT and Hb measurement Voided urine specimen should be checked for presence of protein and glucose Determine fetal position with abdominal and pelvic examination ○ US if required Monitoring Maternal pulse rate BP RR Temperature Regular assessment of cervical dilation and descent of fetal head Uterine activity Uterine contractions should be monitored every 30 mins by palpation for their frequency, duration and intensity Heart rate should also be monitored Management of second stage Maternal position Avoid supine position Any position for effective bearing down Bearing down Hold breath with each contraction and bear down with expulsive efforts Fetal monitoring Heart rate every 5 mins Episiotomy Using a midline incision of the perineum to enlarge the vaginal opening during delivery Indications: shoulder dystocia, forceps or vacuum-assisted delivery, or vaginal breech delivery Vaginal examination Progress should be recorded every 30 minutes Particular attention to the descent and flexion of the presenting part, extent of internal rotation and the developing of moulding or caput Retracted cervix is no longer palpable Delivery of fetus When delivery is imminent, the patient is placed in the lithotomy position Skin over lower abdomen, vulva, anus and upper thighs is cleansed with an antiseptic solution Supine position is now best with thighs flexed Delivery of head Airway is cleared of blood and amniotic blood using bulb suction device Oral cavity is delivered and nares are cleared Second towel is used to wipe secretions from the face and head Index finger is used to check whether the umbilical cord is wrapped around the neck If cord is too tight, it can be cut between two clamps Following delivery Shoulders descend, rotate into the anteroposterior diameter of the pelvis and are delivered Delivery of the anterior shoulder is aided by gentle downward traction on the externally rotated head Brachial plexus may be injured if excessive force is used Posterior shoulder is delivered by elevating the head Body is slowly extracted by the traction on the shoulders Delayed cord clamping is recommended for 1-2 mins Management of third stage Give uterotonics (syntometrine, oxytocin 10IU IM) Place dish to collect placenta and blood loss For prevention of postpartum hemorrhage, begin IV infusion of 40U of Pitocin in 500 mL of saline at a rate of 10 mL/min for 5 mins After infusion, the next step is uterine massage by the physician Placenta should be examined to ensure complete removal (no missing cotyledons) Cord should be cut and clamped after controlled cord traction Repair any obstetric lacerations 12. Pain Relief During Labour Labour pain relief Nitrous oxide Entonox is premixed nitrous oxide and oxygen as 50:50 mixture Self-administered Quick onset Short half life Parenteral narcotics Work best in the earlier stages Opioids readily cross the placental barrier and may cause neonatal respiratory depression They may also cause decreased fetal heart rate and impaired neonatal breastfeeding Used Fentanyl Nalbuphine Remifentanil (I.V.) - routine analgesia Neuraxial analgesia Most effective form of labour relief Lumbar epidural analgesia is the most common form of neuraxial analgesia Relief in 1st and 2nd stages of labour Relief for cesarean delivery, postpartum tubal ligation Initial bolus of anesthetic bupivacaine, ropivacaine, lidocaine as well as narcotics such as fentanyl or sufentanil to achieve T10 sensory level Followed by infusion of dilute solution of the same agents until delivery Combined spinal-epidural Popular for both labour analgesia and repeat cesarean deliveries Rapid onset for analgesia Pudendal nerve block Anaesthetizes somatic afferent nerve fiber entering spinal cord at sacral segments S2 - S4 Effective at relieving perineal pain of the 2nd stage of labour, as well as episiotomy and episiotomy repair Anesthesia for All patients requiring anesthesia for surgery must have an cesarean delivery airway examination If intubation will be difficult then patient must be given a regional anesthetic or have an awake intubation or operation must be started with the patient under local anaesthesia  Premedication with antacids Routine monitors such as ○ BP monitor ○ Electrocardiograph ○ Pulse oximeter ○ Supplemental oxygen Elective/urgent Regional anesthesia is preferred because the airway is cesarean delivery maintained GA carries a higher risk of anesthesia related mortality due to loss of airway General anaesthesia Employed in 3 situations Extreme urgency and no preexisting epidural catheter Contraindication to regional anesthesia Regional anesthesia has failed Induction agents Propofol Etomidate (when CV stability is desired) Ketamine (for hypovolemia/asthma patients) Succinylcholine (muscle relaxant) is used to facilitate intubation due to its rapid onset and brief duration of action. If contraindicated, vecuronium or rocuronium is used After induction, potent inhalational agent is administered to minimize myometrial relaxation 13. Normal Puerperium. Care Of The Parturient  Puerperium consists of the period following delivery of the baby and placenta to approximately 6 weeks postpartum. Hormones Human placental lactogen and beta hCG: levels fall rapidly Oestrogen and progesterone: non pregnant levels achieved 7 days post-partum Menstrual flows returns after 6 weeks Uterus involution Weight Uterus at birth 1000 g Uterus at 7 days 500 g Uterus at 14 days 300 g Uterus at 21 days 300 g Uterus at 6-8 weeks 70g 1st day - Fundus of uterus is at the level of the navel level 10th day - fundus of uterus is at the level of the small pelvis Uterine discharge The lochia secretion consists of endometrial cells, necrotic tissue, blood, serum and lymph Lochia rubra - blood red; first 4 days after birth Lochia serosa - brown red; watery consistency, lasts 2-3 weeks Lochia alba - yellow white; lasts 1-2 weeks Treatment Buscolysin Oxytocin Methergine 1 amp Weight loss Mean weight loss after delivery of the baby, amniotic fluid, and placenta: approx. 6kg Additional weight loss due to lochia discharge and uterine involution: approx. 2-7 kg Vagina Initially, wall is swollen but rapidly regains tone Gradually, vascularity and oedema decrease and by 4 weeks rugae appear  Rugae are less prominent than in a nullipara Cervix Cervical os gradually closes after delivery Admits 2-3 fingers for the first 4-6 days Barely dilated to 1cm by 10-14 days Breast Between 2-4th day, breast becomes engorged Vascularity increases Areolar pigmentation increases Enlargement of lobules results from an increase in number and size of alveoli Cardiovascular system After 3rd stage, cardiac output initially increases due to return of blood from contracted uterus Plasma volume rapidly decreases due to diuresis and returns to normal by 2-3 weeks postpartum Heart rate decreases and return to normal Psychosocial changes Postpartum blues due to emotional/hormonal factors Also Vit D deficiency plays a role  14. Lactation - Mechanism, Stimulation, Suppression. Care Of The Breasts During Pregnancy And Lactation Endocrinology of lactation With delivery, there is a decrease in progesterone levels and oestrogen The decrease removes the inhibitory influence of progesterone on α-lactalbumin production and stimulation lactose-synthase to increase milk lactose Progesterone withdrawal also allows prolactin to act unopposed in its stimulation of α-lactalbumin production Serotonin is produced in mammary epithelial cells and has a role in maintaining milk production Posterior pituitary secretes oxytocin in pulsatile fashion ○ This stimulates milk expression from a lactating breast by causing contraction of myoepithelial cells in the alveoli and small milk ducts ○ Suckling initiates the reflex which stimulates the posterior pituitary to release oxytocin. Breast milk composition Breast milk contains all required nutrients (except vitamin D + K) up to 6 months Colostrum ○ The first milk produced during late pregnancy until 3-4 days postpartum; rich in proteins and immunoglobulins ○ Acts as laxative; helps pass meconium Mature milk ○ Proteins, lactose and oligosaccharides, fats, minerals, trace elements, and vitamins ○ Proteins and cells that provide passive immunity in neonates Immunoglobulins (secretory IgA), lactoferrin, lysozymes Lymphocytes, macrophages ○ Bifidobacteria that contribute to the neonate’s GI flora. Care of the breasts Nipples Cleanliness Attention to skin fissures Fissured nipples cause painful nursing and deteriorate milk production Cracks also provide entry for bacteria Washing the areola before and after with water and mild soap is helpful before and after nursing If breast has not healed, a pump should be used Latch Shallow latch ○ → nipple soreness, cracking, bleeding  Good latch ○ Bottom of areola in baby’s mouth Contraindications HIV Illicit drugs Alcohol Smoking Medications (tetracycline, chloramphenicol) Benefits Reduced risk of ○ GI illness ○ UTI ○ Respiratory infections ○ Atopic illness ○ Leukemias ○ Giardiasis For mother ○ Helps uterine involution ○ Reduced PPH ○ Protects against premenopausal breast cancer, ovarian cancer and osteoporosis  15. Physiology And Immediate Care Of The Newborn Clear airway Use gauze/towel to remove secretions from face Bulb suction may be used on the oropharynx Mouth is suctioned before nose Nasal tracheal catheter reduces the risk of meconium aspiration Intubation should be performed to suction trachea of meconium Dry the newborn Place newborn in preheated environment and dry off with towel This also stimulates onset of respiration Clamp cord Delayed cord clamping has been known to confer benefit to the fetus Ensure onset of respiration Normally occurs within few seconds after birth If respiration has not commenced by 30 seconds or if the heart rate is < 100 beats/min, the infant should be sent off to resuscitation team to manage ○ Apnea ○ Low heart rate with stimulation Start positive pressure ventilation (21% oxygen) In preterm infants, start 30-40% oxygen Newborn initially starts at 60-65% ○ Increases to 85-95% saturation over the first 10 mins of life Correct surfactant deficiency Can give synthetic surfactant to modified/unmodified extracts of natural surfactant Can be given by tracheal injection at birth to prevent respiratory distress syndrome Apgar score Clinical assessment of newborns at 1 & 5 minutes after birth Assessment of 5 min score: < 7 score require further intervention ○ Reassuring: 7-10 ○ Moderately abnormal: 4-6 ○ Low: 0-3 Apgar Score 0 points 1 point 2 points Appearance Cyanotic or pale Acrocyanosis Pink body and extremities Pulse None < 100 bpm > 100 bpm Grimace None Grimace Cry or active withdrawal Activity No movement, limp Some flexion Active motion, body flexion Respirations None Weak cry, Regular breathing, irregular/slow/weak strong cry breathing or gasping  16. Medication during pregnancy Antibiotics to AVOID during pregnancy Tetracycline Bone damage Malformation and yellow discolouration of primary teeth Aminoglycoside Ototoxicity (CN VIII) & hearing loss Trimethoprim/Sulfonamide Cardiovascular birth defects combination Neonatal jaundice Chloramphenicol Grey baby syndrome: grey skin colour, cardiovascular collapse, abdominal distention Clarithromycin Embryotoxic Fluoroquinolones Bone and cartilage damage Antibiotics of CHOICE Penicillin group ○ Ampicillin ○ Amoxicillin ○ Flucloxacillin ○ Penicillin V ○ Propicillin Cephalosporins Macrolides ○ Erythromycin ○ Azithromycin Metronidazole Nitrofurantoin Antihypertensives to AVOID during pregnancy Diuretics Reduction of placental perfusion ACE inhibitors 1st trimester: cardiovascular & CNS malformation 2nd & 3rd: fetal kidney damage or death ARB Severe renal malformation Oligohydramnios Atenolol IUGR Decreased placental growth Antihypertensives of CHOICE Methyldopa in arterial hypertension and hypertensive crisis Metoprolol, labetalol in 1st, 2nd trimester. Avoid in 3rd Dihydralazine in uncontrolled hypertension Nifedipine Antifungals to AVOID during pregnancy Ketoconazole, flucytosine, griseofulvin Teratogenic, embryotoxic Itraconazole, fluconazole (> 300mg) Teratogenic, embryotoxic Iodides Congenital goiter Antifungals of CHOICE Topical: imidazoles Vaginal: nystatin Systemic: amphotericin B Antivirals to AVOID during pregnancy Efavirenz Fetal neural tube defects Ribavirin, interferon a, ribavirin + Preterm birth interferon a combination Significant teratogenic/embryocidal effects Didanosine + stavudine combination Lactic acidosis and hepatic failure → death Nevirapine Fatal hepatotoxicity Antivirals of CHOICE Acyclovir, valacyclovir for herpes Oral oseltamivir, zanamivir for influenza Zidovudine + lamivudine + nevirapine + atazanavir for HIV Anticoagulants to AVOID during pregnancy Warfarin Can cross placental barrier Spontaneous abortion, still birth, preterm death Cerebral hemorrhagic → CNS abnormalities Bone deformities Phenprocoumon Can cross placental barrier Spontaneous abortion, still birth, preterm death Cerebral hemorrhagic → CNS abnormalities Bone deformities Non-vitamin K oral Avoid in pregnancy anticoagulants (apixaban, rivaroxaban, dabigatran) Anticoagulants of CHOICE Heparin Aspirin (high doses avoided in 3rd trimester) Analgesics to AVOID in pregnancy NSAIDs (2nd + 3rd trimester) Premature closure of the ductus arteriosus Persistent pulmonary hypertension Inhibits uterine contractility Metamizole 1st + 2nd: increased occurrence of Wilm’s tumour fetus 3rd: premature closure of ductus arteriosus Analgesics of CHOICE Non-opioid analgesics ○ Paracetamol ○ NSAID only in 1st trimester Opioid analgesics ○ Fentanyl ○ Codeine Thyroid agents to AVOID during pregnancy Radioiodine therapy Ablation of fetal thyroid tissue → hypothyroidism Methimazole (1st trimester) Aplasia cutis Carbimazole Craniofacial malformations, GI Thiamazole malformations Thyroid agents of CHOICE Antithyroid drugs ○ 1st trimester: propylthiouracil ○ 2nd + 3rd: methimazole L-thyroxine  17. Prenatal outpatient care and pregnancy follow up Antenatal appointment schedule Second trimester 16 weeks ○ Discuss screening results ○ Investigate if Hb level 35 and 30 Parity Lack/shortage of prenatal care Distance to the nearest hospital Medical factors related to high maternal risk Pre-pregnancy diabetes Hypertension Endocrine, CVD, neurological, renal, pulmonary, autoimmune disorders Multiple pregnancy High BMI Previous CS Uterine scar Obstetric complications in the course of previous pregnancies/deliveries Fetal risk factors for unfavourable perinatal outcome Congenital anomalies ○ TOP allowed ○ Prenatal screening and diagnosis Preterm delivery IUGR ○ Higher perinatal mortality ○ Neonatal adaptation problems ○ Chronic pulmonary disease  I/U infections ○ HIV/AIDS ○ CMV syphilis Birth trauma ○ Adequate assessment of the mode of delivery ○ Adequate management of shoulder dystocia (trained personnel) ○ Emergency CS - access Rh sensitization ○ Anti-D immune globulin Why is it necessary to identify high risk pregnancies? Eliminate risk factors Ensure adequate pregnancy follow up Prevention of complications ○ Preeclampsia (aspirin, maternal/fetal follow up, delivery at 37 completed weeks) Time, place and mode of delivery High risk pregnancy - identification Past obstetric history Detailed family history of maternal health Detailed family history Detailed physical/gynaecological exam Adequate pregnancy follow up Methods for diagnosis US (3D and doppler assessment) Prenatal screening Invasive prenatal testing NIPT (cell free fetal DNA) Cardiotocography (CTG) BPP (biophysical profile)  19. Trophoblastic Disease Encompass a group of tumours characterised by abnormal trophoblastic proliferation and replacement of normal placental trophoblastic tissue by hydropic placental villi Divided into ○ Hydatidiform moles which are characterised by the presence of villi Benign complete hydatidiform mole (more common) No identifiable embryonic or fetal structures Partial hydatidiform mole Focal trophoblastic proliferation Degeneration of placenta Identifiable fetal or embryonic structures ○ Non-molar trophoblastic neoplasms which lack villi Malignant invasive mole Chorionic villi become edematous Develops after a molar pregnancy Choriocarcinoma Chorionic villi are not edematous Can develop after a normal or ectopic pregnancy Placental site trophoblastic tumour Epithelioid trophoblastic tumour Pathophysiology Complete mole Chromosomal empty egg fuses with normal sperm, sperm genetic material duplicates to form a 46 chromosome cell ○ No maternal chromosomes ○ Develops into a mass Partial mole Normal egg fertilized by 2 sperm cells, this forms a 69 chromosome cell ○ Develops into non-viable fetal parts Metastases Lungs Brain Kidney Liver Spleen Symptoms Hydatidiform mole Gestational neoplasia Partial mole signs + symptoms less Symptoms severe than complete mole Amenorrhea Irregular bleeding Symptoms Uterine subinvolution 1-2 months of amenorrhea Excess hCG Abnormal vaginal bleeding ○ Hyperthyroidism Anaemia ○ Theca lutein cyst Hyperemesis gravidarum Lower abdominal pain Nausea Lung metastases Vomiting ○ Hemoptysis Severe preeclampsia ○ Cough Eclampsia ○ Dyspnea Symptoms of hyperthyroidism Myometrial perforation may cause intraperitoneal hemorrhage Signs Central nervous system Tachycardia metastases Tachypnea ○ Headaches Hypertension ○ Dizzy spells Wheezing ○ Blacking out Ronchi ○ Visual disturbances Uterus too big for gestational age ○ Neuropathy Uterine enlargement with a soft GI metastases consistency ○ Rectal bleeding Absence of fetal heart sounds Vaginal metastases Ovaries contain multiple ○ Should NOT be biopsied theca-lutein cysts ○ Adnexal mass symptoms Signs Grape like vesicles of the moles Uterine enlargement Increased serum T4 Acute abdomen due to rupture of Decreased TSH the uterus, liver, theca lutein cyst Proteinuria Neurologic signs ○ Partial weakness ○ Paralysis ○ Dysphasia ○ Aphasia ○ Unreactive pupils Investigations Hydatidiform mole Gestational neoplasia β-hCG levels Complete molar pregnancy Consistently high β-hCG levels Serum β-hCG levels are ○ hCG levels plateau commonly elevated > 100,000 (within 10% of previous mIU/mL result over 3 weeks) ○ hCG levels increase Partial mole (more than 10% across 3 β-hCG levels may be elevated values over 2 weeks) but not as high as in complete ○ Detectable serum hCG mole up to 6 months after evacuation Serum: CSF β-hCG levels < 40:1 suggest CNS involvement US Complete mole Invasive mole Echogenic uterine mass Poorly defined mass Numerous anechoic cysts Anechoic areas Snowstorm appearance Doppler US: high vascular flow No amniotic fluid Absence of fetal parts! Choriocarcinoma Single mass distending the Partial mole uterus Thickened multicystic placenta Heterogenous (necrosis & Amniotic fluid is present hemorrhage) With fetus or fetal tissue ! Doppler US: high vascular flow FBC Platelet count Prothrombin time Partial thromboplastin time Fibrinogen LFTs Renal function tests CXR Cannonball or snowstorm appearance CT Abdomen Pelvis Head Bimanual Complete mole Pelvic ○ Theca lutein cysts Examination Marked bilateral  ovary enlargement secondary to hCG stimulation Uterine Complete mole evacuation ○ Microscopy: diffuse hydropic villi, marked circumferential trophoblastic proliferation Partial mole ○ Microscopy: partial occurrence of hydropic villi, minimal trophoblastic proliferation P57 staining Complete mole ○ Negative Partial mole ○ Positive Treatment Hydatidiform mole Gestational neoplasia Molar evacuation by suction Serum hCG checked weekly curettage ○ Remission: 3 consecutive Preoperative cervical dilatation with undetectable levels an osmotic agent is recommended if ○ Measured while female is on the cervix is dilated reliable contraception Oxytocin is infused to limit bleeding Chemotherapy is the best treatment Uterotonic administration and ○ Methotrexate and blood transfusion if required actinomycin D ○ Regimen is repeated until After curettage serum β-hCG levels are anti-D immunoglobulin undetectable Combination therapy Chemotherapy ○ EMA-CO Methotrexate and actinomycin D Etoposide Regimen is repeated until serum Methotrexate β-hCG levels are undetectable Actinomycin D Cyclophosphamide Oncovin Hysterectomy (last resort)  20. Spontaneous Abortion. Types, Etiology, Management Definition The fetus dies or delivers dead before 20 completed weeks of pregnancy Majority occur before 12 weeks Types Threatened miscarriage Bleeding by 20th week Lower abdominal dull pain Fetus is still alive Cervical os is closed 25% will miscarry Inevitable miscarriage Heavier bleeding Cramp like abdominal pain Fetus may still be alive Cervical os is closed/partially open Miscarriage will soon occur Incomplete miscarriage Bleeding Cramp like abdominal pain Open os Some fetal parts have been passed Complete miscarriage All fetal tissue passed Diminished bleeding No longer enlarged uterus Cervical os is closed Septic miscarriage Uterus content is infected Endometritis Vaginal loss is offensive Tender uterus Absent/present fever Pelvic infection causes abdominal pain, peritonism Missed miscarriage Fetus not developed or died in utero but this is not recognised until US Abdominal pain Loss of pregnancy symptoms Uterus is smaller than expected from dates Cervical os is closed Etiology Isolated non-recurring chromosomal abnormalities Increased maternal age Recurrent abortion (3 successive abortions) Infection Mycoplasma Listeria C. trachomatis Toxoplasma CMV Trauma Motor vehicle accidents Falls Smoking and Increased incidence of chromosomal abnormal abortions alcohol Psychosocial Greater risk of pregnancy complications stress Medical Diabetes mellitus disorders Hypothyroidism SLE PCOS Maternal age Age > 40 , the risk exceeds 10% Uterine Cervical incompetence abnormalities Congenital abnormalities Uterine leiomyomas Intrauterine synechiae (Asherman syndrome) Cervical Trauma incompetence Congenitally Submucous fibroids abnormal uterus Intrauterine fibroids Fetal factors Genetic abnormality of the conceptus ○ Autosomal trisomies ○ Triploid ○ Tetraploid ○ 45, X monosomy Placental factors Fetus is at risk before 22-24 weeks due to no enzyme protection from excessive cortisol Women with obesity have a greater risk of developing leptin which leads to intrauterine growth restriction  Chromosomal Translocation factors Inversion Immunological Thrombophilias factors ○ Factor V Leiden ○ Prothrombin G20210A mutation ○ Antithrombin III ○ Proteins C & S ○ Hyperhomocysteinemia Things that do not cause miscarriage Exercise Intercourse Stress Emotional trauma Symptoms Bleeding is usual Pain from uterine contractions can cause confusion with ectopic pregnancy Signs Uterine size depends State of the cervical os Severe tenderness Investigations Early pregnancy assessment units The US will show if the fetus is in the uterus Early pregnancy assessment units US If fetus is in uterus If fetus is viable Detects retained fetal products Blood test Increase in hCG (viable) Decrease in hCG (non-viable) Rhesus group Treatment Threatened miscarriage Reassurance Trimester screening Psychosocial support  Inevitable miscarriage Expectant management IV line and take blood for grouping/cross matching Evacuate/Removal of products of conception Incomplete miscarriage Expectant management Misoprostol IV line and take blood for grouping/cross matching Evacuate/Removal of products of conception Complete miscarriage IV line and take blood for grouping/cross matching Septic miscarriage Antibiotics Surgical intervention Missed miscarriage Expectant management Confirm by US Treatment Admission to hospital Resuscitation Removal of products of conception I.M. ergometrine will reduce bleeding by contracting uterus (non-viable) I.V. antibiotics if there is fever anti-D for rhesus negative women Non-viable miscarriage Medical management ○ Vaginal or oral prostaglandin (misoprostol) ○ Repeat urine pregnancy test Surgical management ○ Removal of products of conception ○ With anesthetic using vacuum aspiration Differential diagnosis Bleeding in first trimester Ectopic pregnancy Hydatidiform mole Cervical polyps Cervicitis Neoplasm  21. Artificial Abortion Definition Methods for terminating unwanted pregnancy in an early stage Legal limit of 24 weeks in UK Methods of termination of pregnancy Surgical < 7 weeks: conventional suction termination should be avoided 7-13 weeks: conventional suction termination > 13 weeks: dilatation and evacuation following cervical preparation ○ The greater gestation, the higher the risk of bleeding, incomplete evacuation, and perforation ○ Cervical preparation Reduces difficulties with cervical dilation Particularly if patient is 10 weeks Possible regimes include ○ Misoprostol 400 micrograms PV 3 hrs prior to surgery OR ○ Gemeprost 1mg PV 3 hrs prior to surgery, OR ○ Mifepristone 600mg PO 36-48hrs prior to surgery Medical 20 weeks) Medication used in TOP Mifepristone ○ Antiprogesterone (given 24-48h prior) ○ Results in uterine contractions, bleeding from the placental bed, and sensitization of uterus to prostaglandins Misoprostol ○ Prostaglandin E1 analogue ○ Stimulates uterine contractions Gemeprost ○ Prostaglandin E1 analogue ○ Softening and dilatation of the cervix before surgical TOP in 1st trimester and for therapeutic TOP in 2nd trimester Management before TOP Counselling/support Blood tests: ○ Hb ○ Blood group and antibody USS Prevention of infection ○ Antibiotic regimes Metronidazole 1g + doxycycline 100mg PO 7 days Metronidazole 1g PR + azithromycin 1g PO Management after TOP Anti-D to all Rh -ve women Follow-up within 2 weeks of TOP Complications of TOP Significant bleeding Genital tract infection Uterine perforation Uterine rupture Cervical trauma Failed TOP Retained products of conception Nausea, vomiting, diarrhea due to PG Psychological sequelae: short-term anxiety and depressed mood  22. Preterm Delivery This is defined as delivery after 20 weeks and before 37 completed weeks WHO subcategories ○ Extremely preterm (< 28 weeks) ○ Very preterm (28-32 weeks) ○ Moderate to late preterm (32 to < 37 weeks) Causes Spontaneous unexplained preterm labour with intact membranes Idiopathic preterm premature rupture of membranes Twins and higher-order multifetal births Induced labour by maternal/fetal indications Pregnancy associated hypertension Cervical incompetence Antepartum hemorrhage IUGR Risk factors Previous history Lower socioeconomic class Extremes of maternal age Maternal medical disease ○ Renal failure ○ Diabetes ○ Thyroid disease Pregnancy complications ○ Pre-eclampsia ○ Intrauterine growth restriction Male fetal gender High haemoglobin Sexually transmitted infections Vaginal infections Previous cervical surgery Multiple pregnancy Uterine abnormalities Fibroids Urinary infection Polyhydramnios Congenital abnormalities Antepartum hemorrhage Clinical chorioamnionitis ○ Diagnosis requires induced labour Symptoms Contractions of 4 in 20 mins or 8 in 60 mins plus progressive changes in the cervix Cervical dilation > 3cm Cervical effacement of > 80% Vaginal discharge before completed gestation ○ PROM ○ Bloody show Lower abdominal or pelvic pressure Low, dull back pain 4 pathways Infection - cervical pathway Due to bacterial vaginosis Positive fetal fibronectin test (detects shortening of cervix) - predicts spontaneous fetal preterm births Placental vascular pathway TH1 cells (embryotoxic) switch to TH2 which block antibody rejection function Failure of trophoblast to invade the spinal arteries Stress-strain pathway Both lead to release of cortisol/catecholamines Cortisol initiates release of CRH which initiates labour Catecholamines increase blood flow to the uterus and induce contractions Uterine stretch pathway Parathyroid-related protein relaxes the myometrial tissues but when stretch exceeds certain limits (multiple gestations, fetal macrosomia, polyhydramnios), PTrP fails to keep uterus relaxed Management Hospitalization Adequate hydration Continuous ante- and intrapartum surveillance of maternal and fetal status Tocolysis Mg sulfate Beta-adrenomimetics - terbutaline Calcium channel blockers - nifedipine Prostaglandin synthetase inhibitors - Indomethacin Corticosteroids Betamethasone 12 mg IM 1x daily (for pulmonary maturation)  Antibiotics Penicillin OR Ampicillin + Erythromycin OR Clindamycin Surgery Vaginal/CS as indicated Cervical cerclage ○ Stitch application to keep cervix closed if indicated Complications Neonatal respiratory distress syndrome (RDS) Bronchopulmonary dysplasia (BPD) Patent ductus arteriosus (PDA) Retinopathy of prematurity (ROP) Necrotizing enterocolitis (NEC) Periventricular leukomalacia (PVL) ○ Symmetrical, periventricular injury of cerebral white matter (necrosis and cystic formation) caused by ischemia and/or infection Neurological disorders (e.g., cerebral palsy, learning disabilities, developmental delays, ADHD) Problems of homeostasis: apea, bradycardia, hypothermia Infection and sepsis (e.g., pneumonia) Anemia of prematurity: impaired ability to produce adequate erythropoietin (EPO); should be suspected in premature infants with low hemoglobin Intraventricular hemorrhage (IVH)  23. Postterm Pregnancy. Post Term Neonate. Persists beyond 42 weeks from the onset of LMP Perinatal mortality is 2/3x times higher in these prolonged gestations Etiology Previous prolonged pregnancy Irregular ovulation Decreased fetal oestrogen production ○ Placental sulfatase deficiency ○ Anencephaly (absence of portion of brain, skull and scalp) ○ Fetal adrenal hypoplasia Extrauterine pregnancy Pathophysiological changes Placental changes such as senescence, ageing, infarcts, calcification Amniotic fluid changes such as oligohydramnios (diminished fetal urination), L/S ratio >4:1 Fetal changes Loss of subcutaneous fat Long fingernails Dry peeling skin Abundant hair Some grow t