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OBSTETRICSBolisay, Cathryn IrisBulanan, Gillian Kristine

MenarcheIntervalDurationAmountSymptoms

MENSTRUAL HISTORYMenstrual or Gestational AgeEx. LMP: Jan 1-5, 2014

EDCNaegeles Rule

JAN31 1 = 30FEB28MAR31APR30MAY 8127 days / 718-19 wks AOGMonthDayYear-3 +7+11312014-3+7+1

101820144OBSTETRICAL HISTORYG = # of pregnancies (+ present)P = Delivery of a baby of at least 28 wks

TermPretermAbortionLive>= 37 500gStillbirths (minus 1 from LAbortions>20 wks but < 500gA abortion + ectopic + hmole = first trimester bleedingsPhysiologic implantation bleedingObstetric Score: G_P_(T,P,A,L)oGravida- indicates number of pregnancyoParity- indicates number of viable birth (>20 weeks)oTerm- 37-42 weeksoPreterm- delivery before 37 weeksoAbortion- termination of pregnancy before 20 weeks or less than 500g birth weightoLiving

5HEIGHT OF THE FUNDUS

BLOOD PRESSURE and PULSE RATE2nd trimester (15-20 wks)Arterial BP decreases due to decrease in vascular resistanceHeart rate increases by 10 bpm due to the increase in plasma volume

BLOOD PRESSUREPULSE RATE

PIH occurs after the 20th weekChronic hypertension occurs before the 20th weekGestational HTN hypertension onlyPre-eclampasia before 20weeks molar pregnancies = HTN + proteinuria (24hr urinary protein > 0.3 grams)

7Weight gain in pregnancyCategoryBMIRecommended weight gain (lbs)Rate (4 weeks)Underweight< 19.828 - 405Normal weight19. 26.925 - 354Overweight26.9 2915 - 252.5Obese>29>= 152Twin35 - 406

8NAUSEA and VOMITING, HEADACHE and DIZZINESS4th 12th weekDue to increased hCG levelsHyperemesis gravidarumConfine only if with manifestation of electrolyte balanceAdvise small frequent feedingFrequent in early pregnancyDisappear by midpregnancyPregnancy-induced hypertension

Paracetamol is safe

NAUSEA and VOMITINGHEADACHE and DIZZINESS

VISUAL DISTURBANCESDecreased corneal sensitivityTransient and reversible loss of accommodation reflexIncrease in corneal thickness and curvature

Visual disturbance + hypertension + epigastric pain + edema = impending ecclampsia : EMERGENCY

10URINE OUTPUT and BOWELSAnatomical:Edema and hyperemia of the bladder resulting in diminished tonePyeloureteral dilatationCompression of the ureterHormonal changesHypertrophy of the longitudinal muscle bundles at the lower end

UTIStasis = urinary bladder compresses on uterusProgesterone diminishes contractilityTx = Amoxicillin is a safe drugMotility is affected most (progesterone)Pyosis (heartburn) decreased tone of LES (Progesterone)Epulis of pregnancy (Estrogen)Intestinal changes:Dec motility = better absorption of ferrous, Ca, and H20Flatulence and constipation -> hemorrhoids

Advise increase in fluids and fibersDocusate sodium + ferrous combinations by drug companiesSide effect of iron preparation = black stools

URINE OUTPUTBOWELS

VAGINAL BLEEDING (1st half)AbortionEctopic pregnancyGTD (H Mole)Termination of pregnancy before 20 weeks AOGImplantation of the fertilized ovum outside the uterine cavityProliferative abnormalities of the trophoblast w/c retains its ability to secrete hCG+/- passage of meaty tissuesColicky abdominal pain, amenorrhea, vaginal spottingPassage of grape-like tissues; hyperemesis gravidarumCervix closed or dilated; uterus compatible or incompatible with AOG(+) wiggling tenderness; uterus smaller than AOG; (+) adnexal tenderness/mass; +/- fullness of the cul de sacCervix dilated; uterus enlarged than AOG; boggy; ballooning of the lower uterine segmentUTZ: +/- fetal cardiac activity; retained products of conceptionUTZ: (+) adnexal mass, (-) gestationalsac when hCG > 2500mIU/mL; lower hCG & progesteroneUTZ: snow storm appearance, uterus larger than AOG, theca lutein cyst; high hCG levelsBed rest/ observation/ curettage/ prostaglandin/ cerclage(depending on the type of abortion)Methotrexate; salpingostomy/ salpingotomy/ salpingectomySuction curettage/ hysterectomy; prophylactic chemotherapy; serial monitoring of B-hCGVAGINAL BLEEDING (2ND HALF)Placenta previaAbruptio placentaTerm (In Labor)Uterine rupture Painless vaginal bleedingVaginal bleeding abdominal painPassage of mucus plug, rupture of the bag of water, contractions, cervical dilatation and effacementVaginal bleeding, abdominal pain, cessation of contractions, loss of stationAssociated w/ prior CS, multiparity, advanced maternal ageAssociated w/ hypertensive disorders, abnormal fetal presentations, smoking, PROMAssociated with prior CS, congenital uterine anomaly, uterine overdistension,Localization by UTZHistory and signs/symptomsHistory, signs and symptomsTransvaginal UTZ, MRIMaternal hypovolemia; fetal demiseShock, DIC, Couvelaire uterusPROM, Hypo/hyper-tonic uterine contractions, malposition/malpresentation (Passenger)Maternal hypovolemia; neonatal death; maternal deathOther causes of last trimester bleeding: Infraumbilical scar (vertical uterine incision) + previous CS = ruptured uterusPreterm labor13Bacterial Vaginosis

Mx: Metronidazole 500mg BID for 7 daysThin and gray whiteUnpleasant vaginal odor4 criteria for diagnosis1) homogeneous vaginal discharge2) pH of 4.5 or higher3) vaginal discharge has an amine-like odor (WHIFF TEST)4) a wet smear: clue cells more than 20% of the number of the vaginal epithelial cellsCandidiasis

Mx: Nystatin

Thick and curdy, adheres to the vaginal mucosapH is acidic fetus External ballottementSide to sideInternal ballottementwith the tip of the forefinger in the vagina, a sharp tap is made against the lower segment of the uterus; the fetus, if present, is tossed upward and (if the finger is retained in place) will be felt to strike against the wall of the uterus as it falls back.

FETAL PRESENTATIONPresenting part portion of fetal body that is either within the birth canal or in closest proximity to itTransverse shoulder Longitudinal cephalic or breech

Lie: relationship of long. axis of fetus to long.axis of uterus e.g longitudinal,transverse, oblique

21FETAL PRESENTATION: CEPHALICVERTEXSINCIPUTBROWFACEPresenting PartPosterior fontanel / OcciputAnterior fontanel / BregmaFrontumMentum AttitudeFully flexedPartially flexedPartially extendedHyperextendedAP diameter presenting into the pelvisSub-occipito-bregmaticOccipito-frontalOccipito-mentalSubmentalNormal diameter9.5 cm12.5 cm13.5 cm9.5 cm

FETAL PRESENTATION: BREECH

Frank breech - lower extremities are flexed at the hips and extended at the knees, and thus the feet lie in close proximity to the headComplete breech - one or both knees are flexedIncomplete breech - one or both hips are not flexed, and one or both feet or knees lie below the breechFootling breech - incomplete breech with one or both feet below the breech.23ID OF FETAL HEART ACTION SEPARATE AND DISTINCT FROM THE MOTHERWays to listen to the FHT:6th wk: Real time sonography6 8th wk: Echo10 12th wk: Doppler UTZ18th wk: StethoscopeOther sounds:Uterine souffle soft blowFunic souffle sharp whistleMOMBABY60 80110 - 160RTS most accurateUs passing of blood thru dilated uterine vessels24RECOGNITION OF THE EMBRYO OR FETUS BY UTZ TECHNIQUES5th wk: gestational sac6th wk: fetus within the sac and FHT detected6-12th wk: CRL = AOGDIAGNOSIS OF PREGNANCYPresumptiveProbablePositiveNausea w/ or w/o vomitingAbdominal enlargementID of fetal heart action separate and distinct from the motherDisturbances in urinationChanges in uterine shape, size, and consistencyFatigueChanges in the cervixPerception of fetal movementBraxton-Hicks contractionPerception of active fetal movement by the examiner

Breast symptomsBallottementCessation of menstruationOutlining the fetusAnatomical breast changesPositive endocrine testsRecognition of the embryo or fetus by ultrasonographic techniques

Changes in vaginal mucosaSkin pigmentation changes

MedicalSurgical

Family history- Fibroids, endometriosis, cancers, DVT/PE

27

Hair GrowthAltered by hormones

Increased shedding of hair 3-4 months after delivery main continue for 6-24 weeks

29Acne VulgarisMay be aggravated during the 1st trimester

Often improves in the 3rd trimester30ChloasmaMask of Pregnancy70% of pregnant womenHyperpigmentationforehead, cheeks, bridgeof nose, and chinBlotchy, usually symmetric pattern31SKIN PIGMENTATION CHANGES

32ANATOMICAL BREAST CHANGES6 - 8th wkVeinsSebaceous glands/ Montgomerys tuberclesAreolaNipples16th wk - colostrum

Lactiferous ducts proliferateAlveoli increase in size and numberBreasts may enlarge 2-3x pre-pregnancy sizeMay experience a sensation of fullness with tingling and tenderness

Increased glandular tissue displaces connective tissueTissue becomes softer and looserAreolae more deeply pigmenteddiameter increasesNipplesmore prominent, darker, and more erectileMontgomery tubercles developsebaceous glands hypertrophyDilated subcutaneous veins may create a network of blue tracing across the breast

2nd trimesterVascular spiders may developBluish in colorDo not blanch

33Anatomic ChangesLower ribs flare and chest expandsincreased transverse diameter (2 cm)Increased circumference (5-7 cm)

Costal angle68 degrees ~> 103 degrees (before PG) (3rd trimester)

Diaphragm rises as much as 4 cm above its usual resting position

Diaphragmatic movement increases

34ProgesteroneIncreased level of progesterone acts as a respiratory stimulant

Causes an increased tidal volume without changing respiratory frequency

Common in PG; result of normal physiological changes

AdaptationIncreased vital capacityIncreased tidal volume

Increases ventilation by breathing more deeply, not more frequently.

cardioIncreased heart rate and stroke volumeLeft ventricle increases wall thickness and massAorta, pulmonary artery, and mitral orifice increase in size by 12 weeks of pregnancymaximum size by 32-38 weeks

As the uterus enlarges, the diaphragm moves upward and the heart is shifted toward a horizontal position with slight axis rotation

Apical pulseupward and 1-1.5 cm more lateral

Heart SoundsChanges are expected because of the increased blood volume and extra effort of the heart

Audible splitting of S1 and S2S3 may be heard after 20 weeksGrade II systolic ejection murmurs heard over the pulmonic area in 90% of PG womenintensified during inspiration or expiration36Offsetting the Increased VolumeVascular resistance decreases with peripheral vasodilationPalmar erythemaSpider telangiectases

Blood pressure decreases during the 2nd trimester but returns to pre-pregnancy levels in the 3rd trimester37Blood PressureGradually falls until 16-20 weeks Then, gradually rises to pre-pregnancy levels at term

Pregnancy Induced Hypertensionsustained systolic BP >140 mm Hg or diastolic pressure >90 mm Hg38abdomenAuscultationBowel sounds will be diminished as a result of decreased peristaltic activity

InspectionStriae and linea nigra may be present

Linea nigra: midline band of pigmentation39Assessment of the abdomen includes:Uterine size estimation for gestational ageFetal growthPosition of the fetusMonitoring of fetal well-being

40Measurement of Fundal HeightHave the patient empty her bladderPatient lies supineMeasure from the upper part of the pubis symphysis to the superior fundus (over the midline)Recorded in cm.41Measurement of Fundal HeightMost accurate between 20-30 weeksFundal height (cm)=gestational age (weeks)

1cm. increase per week is expectedLarger than expected? -Consider twins or other conditions that enlarge the uterus

Smaller than expected?-Possible intrauterine growth retardation42HEIGHT OF THE FUNDUS

PELVIC EXAMINATIONInspectionPubic hair lice?Skin of perineum redness, excoriation, warty or neoplastic growths?Clitoris size and shapeHymen intact, imperforate or open?Perineal body focal point of support for pernieumPerianal area hemorrhoids, warts

PalpationAny pus expressed from the urethra should be submitted for Gram stain and cultured = gonococci

PELVIC EXAMINATIONClinical measurement of the pelvisDetermine the presenting part, station and positionDetermine consistency, effacement and dilatation of the cervix

Adequate PelvisSacral promontory accessibleIschial spines widePelvic side walls not convergentSacrum curvedSubpubic arch wideCervical ExaminationCervical effacementLength is compared with that of an uneffaced cervix. 50% effaced length of the cervix is reduced by one half100% effaced cervix becomes as thin as the adjacent lower uterine segment

Cervical dilatation Sweeping the examining finger from the margin of the cervical opening on one side to that on the opposite side. 10 cm full dilatationPresenting part of a term-size newborn usually can pass through a cervix this widely dilated.

47Position and consistency of the cervix Relationship of the cervical os to the fetal head and is categorized as posterior, midposition, or anterior. Soft, firm, or intermediate.Levelor stationIn relationship to the ischial spines0 lowermost portion of the presenting fetal part is at the level of the spines+5 cm corresponds to the fetal head being visible at the introitus

If the leading part of the fetal head is at 0 station or below, most often the fetal head has engaged48SPECULUM EXAMFull length with blades in the posterior fornix, before the blades are gently opened to expose the lateral wallsVaginal canal is inspected during the insertion of the speculum or on its removalVaginal epithelium = erythema?, lesions?Fluid discharge

Speculum should be inserted to the full length of the vagina, with the blades in the posterior fornix, before the blades are gently opened to expose the lateral walls. When it is properly placed, the patient should be comfortable and the cervix visible at the distal end of the speculum.Once the blades are inserted and the cervix is visualized, the speculum should be opened and the introitus widened so that the cervix can be adequately inspected and a Pap smear taken.Inspect the vagina and cervix. The vaginal canal is inspected during the insertion of the speculum or on its removal. The vaginal epithelium should be noted for evidence of erythema or lesions. Fluid discharge should be evaluated

https://www.youtube.com/watch?v=G9IUi_Umb18

49CervixPink, shiny, and clearPap smear To sample exfoliated cells from the endocervical canal and to scrape the transitional zone.

https://www.youtube.com/watch?v=G9IUi_Umb18

Normally, the transformation zone (i.e., the junction of squamous and columnar epithelium) is just barely visible inside the external os

https://www.youtube.com/watch?v=au3jakiaZW0&list=PL582D746D7FEAEF63

50BIMANUAL EXAMINATIONTo determine the size, nature of the uterus and the presence or absence of adnexal masses.Ovaries Palpable in premenopausal females with a normal habitusPostmenopausal have smaller ovaries, typically not palpableObesity can impair adnexal evaluationMass or any adnexal tenderness or lack of mobilityGuarding or tenderness should be notedCervix Determine the location, position, shape, form, consistency, amount of mobility, and any discomfortCervical mobility and cervical motion tenderness generally checked last51BIMANUAL EXAMINATION

RECTO-VAGINAL EXAM

Note for any thickness or mass palpated from the rectovaginal septum Any thickening or beadiness of the uterosacral ligaments may imply an inflammatory reaction or endometriosis. If the uterus is retroverted, that organ should be outlined for size, shape, and consistency at this point.Changes in Vaginal MucosaChadwicks sign6th wkVaginal mucosa: congested and violaceousDue to increased vascularity

54Changes in Uterine Shape, Size and ConsistencyHegars 6 8th wkGoodells 4th wkCyanosis and softening of the cervix

Softening of the isthmus and fundus - softening and compressibility of the lower uterine segment (the uterine isthmus) occurCompressible on bimanual exam

Cyanosis and softening of the cervix55LABORATORY EXAMComplete blood countDetermine hematologic statusRule out anemiaBlood type and Rh factorTo determine blood type, Rh status and risk of isoimmunizationPap smear screenTo screen for cervical dysplasia or cancerFasting blood sugarTo detect hyperglycemiaUrinalysis, urine culture and sensitivityTo evaluate for UTI and renal functionTo check for asymptomatic bacteremia Rubella serologyTo detect infectionSyphilis serologyTo detect infectionGonococcal cultureTo detect infectionChlamydia To detect infectionHepatitis BTo detect infectionGroup B StreptococcusTo detect infectionGBS- Asymptomatic GBS anovaginal colonization in preterm women is 20% Major cause of postpartum infection and most common cause of neonatal sepsis Penicillin 5 M units/IV then 2.5 M units/IV q 4 hours until delivery - Ampicillin 2 g/IV then 1 g/IV q 4 hours until delivery

56DIABETES MELLITUS

HEPATITIS B

IMMUNIZATIONSTextbook of Obstetrics 3rd Edition, APMCVACCINECOMMENTSTetanus-Diphtheria (Td)No administration within last 10 years BOOSTER DOSE

Previously unvaccinated COMPLETE SERIES OF 3 VACCINATIONS Schedule: after the 2nd trimester, within each dose given 4 weeks apartHepatitis B High risk patients should be vaccinatedInfluenza inactivatedRecommended during influenza seasonTetanus-Diphtheria-Pertussis (DPT)Maternal pertussis antibodies may be protective to the infants in early lifeRabiesAs post exposure prophylaxisTd the only vaccine routinely indicated for all susceptible pregnant patients59NUTRITIONRDACalories: +300kcal/day Proteins: 9g/day Carbohydrates: 50-100g/dayFats:15-25g/day

Minerals:Calcium: 900mg/dayIron: 6 - 7 mg/dayIodine: 0.15 - 0.30mg/dayVitaminsFolate: 400ud/dayVit B1: 1.3mg/dayNiacin: 1mg/day

FREQUENCY OF VISITS< 28 wks = every 4 wks28-36 wks = every 2 wks>36 wks = every week

Primipara: 18th 20th weekMultipara: 16th 18th weekQUICKENING