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    19 views396 pages

    Obgyn Pearls 2019 Compress

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    John Jaylord Farinas Solanoy

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    © All Rights Reserved
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    — ie PEARLS A QUICK REFERENCE ON COMMON CASES IN OBSTETRICS & GYNECOLOGY CAGAYAN Deed Deere ge Sar ted Per Ue GYNECOLOGY aa el MetNis ENDOCRINOLOGY Paes ae DPN chested mes osteo Ricco TECHNIQUES No 1:7\ © 11 NEIL] > MI Co] 1:7-V-1.4 eee eNO aS aS Contributing Me han Cu, MD, cme M. Ortega, MD, DPOGS, FPSRM Elaine Johanna Limkin-£l Jabbari, MD, DPBRO Karen Cybelle J. Sotalbo, MD, DPSP Criston Van Manasan, MD Mary Rani M. Cadiz, MD Ana Rose Patupat, MD Maribel Co-van der Mee, Mp Ana Kristina M. Hemnander, Mp Amanda dela Cruz-Diomamna, Katrina Aligamsia, MDM Mu Sigma Phi 2011, 2014, 2016 291 Layout Editors: Martha Camille F. Dollete, MD Marian Clare U. Toledo, MD ‘Samantha Beatrice A. de Guzman Mllustrators: Faith Baccay Nonay Dela Calzada Tisha Guevarra Mica Gonzalez Kate Regala Hazel Lapitan Ina Aguire Mikee Empleo Paula Marfor Sam de Guzman Jitka Canlas Karina Bulong Claire Jacinto Sydney Madlangsakay Janine Acoba Nicole Sacman Mary Elise Severino Gladz Facun Mary Carabbacan Kyle Antonio Illustration, Book and Cover Design by Asia F. Chan Copyright © 2019 Mu Sigma Phi Sorority Inc. Published by: Mu Sigma Phi Sorority Inc UP College of Medicine Pedro Gil t, Malate Manila City Metro Manila 1004 Printed inthe Philippines ISBN: 978-621-96083-0-5 ALL RIGHTS RESERVED. Unless otherwise stated, all parts of this book are original and are protected by the Philippine Copyright Law enshrined in Republic Act No. 8293 or the Intellectual Property Code of the Philippines. No part ofthis book may be reproduced or transmitted in any form or by any means, including as photocopies or scanned-in or other electronic copies, or utilized by any information storage and retrieval system without written permission from the copyright owners, except for brief quotations embodied in critical articles and reviews. o request permission, please contact Mu Sigma Phi Sorority Inc va email at obpear’s@gmail.com Oden) or a our official Facebook page, htps:ivmfacebook. va pus additional copies ofthis book, please call (0956) 448-7035. You may aso emallusat spam comr vst our oficial Facebok age at tpsfawfacebonk om aul to plat your orders, and to find out more information and updates. ii | Oscyn Pears NOTICE The contents of this book have been appraised and cross-referenced with legitimate and up-to-date resources available to the authors and editors as of the time of writing. Similarly, the recommendations formanagement are in accordance to current clinical practice guidelines and are partially based on the knowledge and expertise of obstetrician-gynecologists practicing in the Philippines. It must be recognized, however, that the field of Ob-Gyn, as with the practice of medicine in general, is continuously evolving and that improvements and new recommendations may occasionally arise. While the authors, editors, and publisher have utilized their best efforts in preparing this book and all its contents, they make no representations or warranties with respect to accuracy or completeness of all the information included therein and thus, do not guarantee any particular patient outcomes. Hence, the authors, editors, and publisher duly express that they are not liable for any untoward incidences related to the direct application of information from the contents of this book, nor from its limitations in terms of coverage. The parties involved would thereby like to emphasize among its readers that confirmation with other sources and consultation with and affirmation from seniors or experts in the field are still highly recommended when attempting to use the clinical approaches outlined within the bookin the actual management oftheir patients based on suitability and applicability. Nonce | iii FOREWORD first edition of OB Pearls is an exquisite manifestation of the Passion and dedicatioy Tae adam UPColegec! ede tho happen to bemyssesand bg, ne Sigma Phi led by my former: student and resident, Dr Stephanie Fay Samadan-Cagayan,q produc of blood, sweat and tears in the tradition of Mu, this book offers a concise and comprehensive a ara aiege ndinomatn geared towards medi student nthe eld of Oban? Gynecology sit fs an excell source of lerenceand review for those wh intend to purge further training in Obstetrics and Gynecology. Practicing obstetrician-gynecologists and other heath cae providers whose practices include women’shealth wil definitely find ths teratue a use reference inal aspects, covering the common ailments that women experience today, uM The contents of this book encompass a wide range of topics, from the basics of health care forwom to complicated subspecialty problems such as malignancy and infertility. The last portion of the took deals with the most common laboratory stains in Gynecology, the tumor markers, hormone levels and surgical techniques which are of obvious importance to the patient and physician critical care, “ Every effort has been done to incorporate the new and exciting changes in Obstetrics and Gynecolog; Itis the continued policy of the authors to not only provide basic knowledge in Obstetrics and 7 Gynecology, but, concepts that are novel to all practicing obstetrician-gynecologists. Indeed ths pec of iterate, which possesses the enigma of being frst, of being timeless, of being cquated with glory, is nevera destiny, but, an unwavering resolve, all for the glory of medicine and yond Prem ARETAS P, SINGSON-ALDAY, M.D., FPOGS, FPCS Dean Emeritus(2016-present) Founding Dean (1996-2013) & (Ret,) Professor Member, Board of Trustees (1997-present) University of Perpetual Help Rizal JONELTA Foundation School of Medicine Chairman Emeritus (2017-present) Department of Obstetrics & Gynecology Perpetual Help Medical Center-Las Pifias (Ret.) Professor of Obstetrics & Gynecology University ofthe Philippines College of Medicine and Philippine General Hospitl Mu Signa Phi Sorority Batch 1961 iv | Oscyn Pears PREFACE ‘OBGYN Pearls is a concise but comprehensive reference book curated for medical students and residents alte ~ featuring basic Obstetics and Gynecology information and clinical pearls deemed to be helpful in practice. With contents based on the latest clinical practice guidelines and the 25th edition of Williams Obstetrics and Gynecology books, the book covers P.E.A.R.LS, - Perinatal Care, Essentials of Obstetrics, Abnormal Gynecology, Reproductive Endocrinology, Latest Diagnostic Trends in OB-GYN, and Surgical Procedures. The chapters are meant to supplement and reinforce the medical students’ and residents knowledge with must-knows necessary to their training in the field of OB-GYN. Summary drug tables and case studies are also conveniently included to facilitate reviews. AA good quick reference guide, the OBGYN PEARLS is an easy-to-read book about basic to advanced principles of Obstetrics and Gynecology. Updated withthe latest CPGs, itis nat only useful in the proper care of pregnant patients but also those of women's health in general. Itaims to serve as a tool for aspiring health professionals fr day to day rounds, conferences, and exams. This book was made possible through the combined efforts of distinguished experts from different medical institutions together with the members of the Mu Sigma Phi Sorority alumnae and undergraduates. MARIA STEPHANIE FAY S. CAGAYAN, MD. GLADDY MAURA G. FACUN, MD SYBIL LIZANNE R. BRAVO, MD CAROLYN R. ZALAMEDA-CASTRO, MD SHERRI ANN L. SUPLIDO, MD MARIA GERALDINE N. CASTILLO-TORRALBA, MD PREFACE v PREFACE OBGYN Pearlsis a concise but comprehensive reference book curated for medical students and residents alike ~ featuring basic Obstetrics and Gynecology information and clinical pearls deemed to be helpful in practice. With contents based on the latest clinical practice guidelines and the 25th edition of Wiliams Obstetrics and Gynecology books, the book covers PE.A.R.LS. - Perinatal Care, Essentials of Obstetrics, Abnormal Gynecology, Reproductive Endocrinology, Latest Diagnostic Trends in OB-GYN, and Surgical Procedures. The chapters are meant to supplement and reinforce the medical students’ and residents knowledge with must-knows necessary to their training in the field of OB-GYN. Summary drug tables and case studies are also conveniently included to facilitate reviews. Agood quick reference guide, the OBGYN PEARLS is an easy-to-read book about basic to advanced principles of Obstetrics and Gynecology, Updated with te latest CPGs, itis not only useful in the proper care of pregnant patients but also those of women's health in general. Itaims to serve as a tool for aspiring health professionals for day to day rounds, conferences, and exams This book was made possible through the combined efforts of distinguished experts from diferent medical institutions together with the members of the Mu Sigma Phi Sorority alumnae and undergraduates. MARIA STEPHANIE FAY S. CAGAYAN, MD GLADDY MAURA G. FACUN, MD. SYBIL LIZANNE R. BRAVO, MD CAROLYN R. ZALAMEDA-CASTRO, MD SHERRI ANN L. SUPLIDO, MD MARIA GERALDINE N. CASTILLO-TORRALBA, MD Prerace | V AUTHORS MARIA STEPHANIE FAY S. CAGAYAN, MD, PhDHS (cand), FPOGS, FPssTD, FPSECP Professor? Department of Pharmacology and Toxicology Consultant Department of Obstetrics and Gynecology UP-PGH Medical Center, Manila Doctors Hospital Philippine Representative Intemational Society forthe Study ofTrophoblastic Diseases (2001-2019) Past President, Philippine Society of Experimental and Clinical Toxicology (2015-2017) Editorin Chief, Philippine Journal of Experimental and Clinical Pharmacology (2014-2019) Editor in Chief, Journal of Perinatal Association of the Philippines (2015-2019) Honorary Editorial Advisory Board Asia - MIMS Obstetrics and Gynecology Disease Management Guidelines (2005-2019) MARIA GERALDINE N. CASTILLO-TORRALBA, MD, FPOGS, FPSMFM, FPSUOG Associate Professor Ill at the UP College of Medicine Consultant at the Department of Obstetrics and Gynecology, UP-PGH Medical Center Practicing Maternal and Fetal Medicine Specialist and OB Sonologist at the UP-PGH and Manila Doctors Hospital Board Member, Philippine Society of Maternal and Fetal Medicine ‘CAROLYN R. ZALAMEDA-CASTRO, MD, FPOGS, FSGOP Clinical Associate Professor Department of Obstetrics and Gynecology UP College of Medicine Practicing Obstetrcian- Gynecologist, Gynecologic Oncologist, Colposcopist UP. Philippine General Hospital, ManilaMed (Medical Center Manila) Manila Doctors Hospital and National Kidney and Transplant Institute Board Secretary, Philippine Board of Obstetrics and Gynecology 2019 Board Member, Society of Gynecologic Oncologists ofthe Philippines, 2019-2020 Board Secretary, Philippine Society for Cervical Pathology and Calposcopy, 2019-2020 PRO, Asla-Oceania (Research Organization on) Genital infections and Neoplasia - Philippines SYBIL LIZANNE R. BRAVO, RPH, MD, MSC, FPOGS, FPIDSOG Clinical Associate Professor Department of Obstetrics and Gynecology UP College of Medicine Practicing OB GYN and Reproductive Infectious Diseases Specialist, UP-PGH, Manila Doctors Hospital, Medical Center Manila Vice President, Philippine Infectious Diseases Society for Obstetrics and Gynecology (PIDSOG) vi | Oscyn Pears SHERRI ANN L. SUPLIDO, MD, FPOGS, FPSMFM, FPSUOG Clinical Associate Professor Department of Obstetrics and Gynecology P College of Medicine ; ; - Pring Obstetrician-Gynecologist, Maternal- Fetal Medicine Specialist, Obstetric and Gynecologic Sonologist | | hae up. Philippine General Hospital ManilaMed (Medical Center Manila), Manila Doctors’ Hospital Head, Matemal-Fetal Medicine Unit, Center for Women’s Health, ManilaMed a Board Member, 2017-2019, Public Relations Offices, 2017-2018, Assistant Treasurer, 2019, Philippine Society of Matemal-Fetal Medicine ; Board Member, Public Relations Officer, 2019, Bayside Council of Obstetrics and Gynecology Member, Panel 4, University of the Philippines Manila, Research Ethics Board, 2017-2019 GLADDY MAURA G. FACUN, MD Assistant Chief Resident (2015) Fellow, Section of Gynecologic Oncology Department of Obstetrics and Gynecology UP-PGH Medical Center Reviewers FILOMENA SANTIAGO- SAN JUAN, MD, PhD, FPOGS, FSGOP, FPSUOG, FPSO, FPSSTD Professor 6 Department of Obstetrics and Gynecology University ofthe Philippines College of Medicine Chait Department of Obstetrics and Gynecology Manila Medical Center(1992-1995), Quezon City Medical Center(1995), Manila Doctors Hospital (2014-2016) Editor in Chief Philippine Journal of Obstetrics and Gyencology (2011-2013) Editor-in-Chief, Philippine Journal of Gynecologic Oncology, 2017 Founding Member(1994), President (2002) Philippine Society of Ultrasound in Obstetrics and Gynecology Founding Incorporator and President, Philippine Society of Therapeutic High Intensity Focus Ultrasound in Obstetrics and Gynecology, 2018 President Philippine Society for the Study of Trophoblastic Diseases 2013 -2014 President, Philippine Society for the Study of Cervical Pathology and Colposcopy 2017-2018 Member, Journal Committee, DOST-PCHRD Associate Member, National Research Council of the Philippines (Obstetrics and Gynecology, Gynecologic Oncology, Trophoblastic Disease) Founding Incorporator, Philippine Association of Medical Journal Editors (PAMJE) MARCELA DIANALYN SAZON-CARLOS, MD, FPOGS, FPSRM, FPSUOG, FPSGE, FIFEPAG Active Consultant and Past Chair, Angeles University Foundation Medical Center Board Member, Philippine Society of Reproductive Medicine 2018 - present MARIA ANGELA SIAN RODRIGUEZ-BANDOLA, MD, FPOGS, FPIDSOG Clinical Associate Professor, UPCM Department of OBGYN, Section of Infectious Diseases Section Chief OB-IDS St. Luke's Medical Center Global City Former Section Chief, OB-IDS UP-PGH Former President, Philippine Infectious Diseases Society for Obstetrics and Gynecology AutHors | vil pes B. 16. 17. 18, 19, 20. 2. 22. 23, 24, TABLE OF CONTENTS Foreword iv Preface v Authors vi PERINATALCARE 1 Perinatal Counseling 2 Physiological Changesin Pregnancy & Family Planning 17 Essentials of obstetrics 21 Placental Abnormalities 22 Abortion 26 Ectopic Pregnancy 34 Recurrent Pregnancy Loss 40 Gestational Trophoblastic Disease 46 Physiology of Normal labor 55 Dysfunctional Labor 63 Essential Newborn Care (ENC) and Breastfeeding 67 11a. Breastfeeding 68 Puerperium 74 The Newborn 74 Fetal Growth Disorders 80 14a. Intrauterine Growth Restriction (IUGR) 81 14b, Mactosomia 85 Disorders of Amniotic Fluid Volume a7 15a. Oligohydramnios 88 15b. Polyhydramnios 89 Preterm labor 91 Postterm Pregnancy 101 Induction of Labor 104 Breech Delivery 109 Vaginal Birth After Cesarean Section 113 Intrauterine Fetal Demise 478 Obstetric Hemorrhage 122 Multiple Gestation 128 Hypertension in Pregnancy 134 24a, HELLP Syndrome 146 2b. Eclampsia 147 vill | Oscyw Peanis 25. 26. 27, 28, 29. 30. 31, 32. 33. 34, 35 Qa 36. 37. 38. 39, 40. a. 42. 43. 44, 45. 46. 47, 48. 49, 50. 51. Cardiovascular Disorders 149 Thromboembolic Diseases 154 Diabetes Mellitus 159 Thytoid Disorders 165 282. Hyperthyroidism 165 28b. Hypothyroidism 166 Pulmonary Disorders 170 29a. Bronchial Asthma 170 29b, Pneumonia 175 29c. Pulmonary Tuberculosis 180 Anemiain Pregnancy 184 Urinary Tract Infections 189 HiVin Pregnancy 192 Seizure Disorder 194 Adnexal Masses in Pregnancy 197 Cervical Cancerin Pregnancy 200 Abnormal Gynecology 202 Reproductive Anatomy 203 Pediatric Gynecology 244 Cervicovaginitis 213 Genital Ulcers 276 Bartholin's Gland CystAbscess 220 Upper Genital Tract Infections 223 41a. Pelvicinflammatory Disease 223 4b, Tubo-Ovarian Abscess 225 41c. Abdominal Koch's Infection 226 Pelvic Organ Prolapse 229 Colposcopy 233 Endometrial Hyperplasia 236 Cervical Cancer 239 Endometrial Cancer 248 Ovarian Cancer 256 VulvarCancer 263 Vaginal Cancer 268 Diseases of the Breast 274 Scales Used in Oncology 276 iy TaBte OF CONTENTS D. 52. 53. 54. 55. 56. 57. 58. E. 59. 60. 61. 62. 63, 64, 65. 66. 67. E 68. 69, 70. 71. 72, 73. 74, REPRODUCTIVE endocrinology & infertility Menstrual Cycle 278 Amenorthea 283 ‘Abnormal Uterine Bleeding 287 Menopause 293 Polycystic Ovary Syndrome(PCOS) 296 Endometriosis 304 57a. Adenomyosis 309 Infertility 310 Latest Diagnostics & Therapeutics 315 Establishing Age of Gestation 316 Fetal Surveillance 320 Immunohistochemistry Staining for Gynecologic Neoplasms 330 Tumor Markers 331 Overview Of Laboratory Tests In Ob-Gyn 334 Ultrasound for Ovarian Masses. 337 Fluid And Electrolytes 340 Chemotherapeutic Drugs 342 Radiation Therapy 344 Surgicaltechniques 347 Endoscopy sae Laparoscopy 350 Endometrial Biopsy 352 Peripartum Hysterectomy 353, Operative Vaginal Delivery 354 72a, Forceps Delivery 354 72b. The ABCD Of Operative Vaginal Delivery 356 Abdominal incisions as9 Anesthesia For Obstetric Procedures 364 Appendix xij Case Studies xiii Approach to Cases xiii Caset xiii Case2 xy Abbreviations xvii References xx Index soeviz X | Osoyn Pears 27 PERINATAL CARE PERINATAL COUNSELING DIAGNOSIS OF PREGNANCY PROBABLE EVIDENCE «Enlargement of abdomen > Starts at 6 wks | & At12wks-fundus felt on bimanual exam, uterine body is almost 8 cmaverage diameter ; Changes in uterine size, shape, and consistency > HEGAR'S SIGN ~ 68 wks: softening of uterine isthmus Changes in cervix - © GOODELL'S SIGN - 6-8 wks: softening, change in position * BRAXTON-HICKS CONTRACTIONS © 28 wls: painless, perceptible, not regular Ballotment Physical outlining of fetus Detection of -HCG 6 days after fertilization, 8-9 days post-implantation Urine Pregnancy Test -(+) at 25 mlU (very sensitive) POSITIVE SIGNS Unquestionable proof | Globular and vty Fetal heart tone © Normal rate: 120-160 bpm © Auscultation: 17 wks (19 wks in 95%) © Doppler: 10 weeks | © Transvaginal-Uitrasound: 6 weeks | Perception of fetal movement by examiner (20 weeks AG) | Sonographic recognition of pregnancy | © Early UTZ-done before 12 wks AOG (most accurate in establishing age of gestation) * Gestational sac - first sonographic evidence of pregnancy; seen at 4-5 weeks AOG by PRESUMPTIVE Gives grounds for reasonable opinion or belief Symptoms Nausea and vomiting (morning sickness) * 6-18 wks (peak of HCG 8-10 wks) . Disturbances in urination (1 frequency) * 1and 3 trimester * Fatigue * Perception of fetal movement (quickening) * 16-18 weeks- multigravid * 18:20 weeks primigravid ———— Ls W20veets-pimigavd PERINATAL CARE aa Cessation of menses more than 10 days from expected menses © Changesin cervical mucus © Starts at 6 wks AOG * Elevated progesterone during pregnancy lowers NaCl concentration in the cervical mucus that prohibits ferning Changes inthe breast © Engorgement starts at 6-8 wks Discoloration of vaginal mucosa © Atéweeks * Chadwick sign - dark-bluish or purplish-ted and congested vaginal mucosa Thermal signs © At6weeks: T Temp = 7 Progesterone Skin pigmentation + Striae = T melanocyte stimulating hormone (MSH) * Chiloasma / Melasma - mask of pregnancy * Linea nigra darkening of linea alba © Striae Gravidarum = collagen breakdown * Spider Telangiectasia = T estrogen Il COMPONENTS OF A ROUTINE PRENATAL! CARE TABLE-1.1. Schedule of Components of a Routine Prenatal Care Sa 15. History Complete e Updated Physical examination Complete Blood pressure Matemal weight Internal exam Fundal height Fetal hear ratefposition Laboratory test Hematocttor hemoglobin Blood type and Rh factor Antibody screen PAP smear screening Glucose tolerance test ©/©/©/0/@/® ©/@|O|® Fetal aneuploidy screening B* andlor Neural tube deteet screening Urine protein assessment Urine culture |e 1, PerinatatCounseuns | 3 sacs Rubella serology Syphilis serology Gonococcal culture Chlamydia culture HepB serology sett HiV serology Group Bstreptococeus culture *18tzimester aneuploidy may be of A~testat 28 weeks indicated 8-test shouldbe offered C-high sk D- high risk E-rectovagira ature should be done between 35-37 weeks IIL, HIGH RISK PREGNANCIES Maternal age <17 Primigravidas >35 Poor OB history #2 consecutive spontaneous abortions ‘© 3 ormore repeated spontaneous abortions © Premature delivery © Fetal death in-utero * Neonatal death © Previous birth with congenital anomalies Problems in fetal aging, structure, and size * Beyond 41 weeks © Growth restriction (IUGR) © Mactosomia © Unsure of LMP * Fetal congenital anomalies * Multiple gestation Placenta previa / abruptio placenta Medical conditions Reproductive tract disorders Malignancy Psychiatric conditions / mental retardation Trophoblastic disease Oligohydramnios / polyhydramnios 10 DANGER SIGNS OF PREGNANCY © Headache * Blurring of vision * Prolonged vomiting © Fever © EpigasticiRUO pain PERINATAL CARE fered between 11-14 weeks women should be retested at the start of 3 trimester women should be screened at the first visit and re-tested at the start of 3 trimester Decrease in fetal movernent Uterine contractions Dysuria Vaginal bleeding/discharge Edema (face, fingers) EX IV, RECOMMENDATIONS FOR TOTALAND RATE OF WEIGHT GAIN DURING PREGNANCY TaBLe-1.2. Recommendations fr total and rate of weight gain during pregnancy WEIGHT FOR HEIGHT CATEGORY CE dy Mass. hg tb (Ibsiweek ann ind ‘ano a aie Underweight <185 12516 28-40 13 Noumal weight 785249 115416 25.35 08.1 Overweight 2529.9 75 15:25 0507 Obese 230 59 1120 0406 *Empical commendations for weight gain in win pregnancies include: normal BMI, 37-54 Ib; overweight ‘women, 31-50 Ib; and obese women, 25:42 Ib. BMI = (weightin kilograr/ (height meter)?) V. _ RECOMMENDED DAILY DIETARY ALLOWANCE FOR PREGNANT AND LACTATING ADOLESCENT AND ADULT TABLE-1.3. Recommended daily dietary allowance for pregnant eos ns Fatsoluble vitamins Vitamin & 770 ug 1300 pg Vitamin Da Sug 15ug Vitamin E 15mg 19 ug Vitamin Ka 90 ug 90g Water soluble vitamins Vitamin € 85mg 120mg Thiamin 14mg 14mg Riboflavin 14mg 16mg Niacin 18mg 17mg Vitamin Bo 191mg 2mg Folate 60019 500 yg Vitamin B12 26ug 28y9 Minerals Gliuma 1000 mg 1000 mg Sodium a 159 159 Potassium a 479 51g tron 27mg 9mg Tine 11mg Tamg lodine 220 1g 290 ug Selenium 60 ug 70g Protein Tig Tig Carbohydrates 1759 210g Fibera 28g 299 Recommendations measured as ad lequate intake. 4, Perinara Counseuns | 5 Vi. EXERCISEIN PREGNANCY E-1.4, Contraindications to aerobic exercises during pregnancy TABLE-1.4. een Severe anemia Unevaluated maternal cardi: Chronic bronchitis ITM Yeon iy cantheat disease Hemodynamically signifi Restrictive lung disease lac arthythmia Incompetent ceninlerdage labor Poorly controlled type 1 DM tation at risk for preterm lal ae a rtd vines teedig Extreme morbid obesity Placenta prev ale 6 weeks Extreme underweight (BMI <12) Preterm eer during he cunt pregnancy Ha si etemelsedentny Mestye tal growth restriction in cumtnt pe neo Pooty controlled hypertension =" Orthopedic limitations Poorly controlled seizure disorder Poorly controlled hyperthyroidism Heavy smoker Trivia: Sayuntis: Sayaw ng mga Buntis is an exercise program pioneered by Dra, Ma. Stephanie Fay Samadan Cagayan which aims to promote health behaviors for pregnant women by focusing ‘on proper nutrition, and appropriate exercise. VII. IMMUNIZATION DURING PREGNANCY TaBLE-1.5. Summary Table of Vaccines and Dosing Schedule for Pregnant Women rT ii En LS Ce ny Tetanus-dphtheria | Toxoid O5ml 1%-single tetanus | Updating immune (Tafetanus- toxoid given any | status shouldbe pat diphtheria-acellular time after 14th of antepartum care | pertussis (Tdap) igo | ase given as | tetanus-diphtheria- acellular pertussis (IDaP) vaccine preferably at around 28th weeks AOG 3¥dose at6 months after the first dose Booster | every 10 years | MMR tive attenuated O.5mi SC Single dose, Contraindicated | postpartum for in pregnancy . susceptible women Varicella Liveattenuated | OSmISC Two doses, 2° dose | Contraindiated should be 4-8 weeks | in pregnancy after 1*dose Hepatitis Inactivated $18yo:0.5mlIM | Twodoses,6 and postexposu® —e 2190: 1.0mlIM _ | months apart ifatrisk ; pats B Inactivated 19yo:0.5mlIM | Three dose series at | and postespesve! 220yo: 1.0mlIM _ |0,1and6 months _|atskofinfeion PERINATAL CARE mad Balas Ps sists Ray iis ‘0.5mliM One dose every year | pregnant women, Invenda hestined regardless of trimester during fluseason vated O.Smil IM (if One dose, ee polysaccharide)0.5 | revaccination mIM if conjugate) | every 35 years May be given during pregnancyif needed Inactivated O.5miiM One dose, foemsocal revaccination: after 6 years May be given during pregnancy if needed Human inactivated Smit papillomavirus Three dose series at | Not recommended O,1,and months _| in pregnant women VIII, OTHER FAQ DURING PREGNANCY Automobile + Lap belt snualy positioned under abdomen and on top of ‘upper thighs Travel ** Shoulder belt between breasts Air © Can safely fly ifless than 36 weeks Cait * Isnotharmful to pregnancy dia But should be avoided if there is isk of abortion or preterm pregnancy Caffeine intake | © Limitedto less than 300mgiday or 3-5 cupts of coffee * Causes fetal alcohol syndrome: growth restriction, Alcohol facial abnormalities and CNS. dysfunction * Avoid or stop alcohol intake * Causes preterm pregnancy, growth esticion, sudden infant death Cigarette syndrome (SIDS), abortion, fetal death, fetal digital anomalies smoking '* Smoking cessation < Nicotine medications may be recommended if non-pharmacologieintewention fled 1, PERINATAL COUNSELING | z PHYSIOLOGICAL CHANGE : PREGNANCY N A. ANATOMIC CHANGES a I f Site igh ‘© Enlarges with an average volume of 5 liters, average weight of 1100 gram, Enlargement duetostretching and mated hypertrophy of myocytes S. Uterine hypertrophy in early pregnancy due to estrogen and perhaps, prc Sphetal by 12 weeks A0G and now outside the pelvis Progesterone Dextrorotation - caused by rectosigmoid on the left Braxton-Hicks contractions ~ irregular uterine contractions more Pronounced durin, regnan theroplcentl blood flow: 450-600 ml/minute near term heady CERVIX ‘© Softening and cyanosis © Vascularity and edema ‘© Eversion ofthe columnar epithelium ‘© Beading - crystallization of cervical mucus under the microscope due to progesterone ‘© Ferning - arborization pattern under the microscope indicative of amniotic fluid leakage OVARIES * Ovulation ceases © CORPUS LUTEUM - maximum function 6-7 weeks of pregnancy or 4-5 weeks produces progesterone VAGINA AND PERINEUM © CHADWICK SIGN - violaceous color of the vagina secondary to increased vascularity Loosening of connective tissue Increase mucosal thickness Fine, hob nailed appearance of the vaginal epithelium Pst ovulation, ‘SKIN Abdominal wall STRIAE GRAVIDARUM - stretch marks DIASTASIS RECTI - separation of rectus muscles at the midline Hyperpigmentation LINEA NiGRA - hyperpigmentation of midline abdominal skin MELASMA GRAVIDARUM OR CHLOASMA - "mask of pregnancy” brownish patches onfat and neck Vascular changes Vascular spiders Palmar erythema BREASTS * Breasttenderess and paresthesia © Increase in size 8 | PERINATAL care «Nipples darken and enlarge iP lod: of Monigomer~ hypertrophic sebaceous glands Increased by additional 10% in twin gestation METABOLIC CHANGES Average weight gain = 12.5 kilos or 27.5 Ibs Increased water retention BMR by the 3* trimester is 10-20% higher Increased by additional 10% in twin gestation Protein Metabolism ‘© Products of conception, uterus, fetus are all protein rich ‘+ More eficient use of protein during pregnancy Carbohydrate Metabolism © Mild fasting hyperglycemia © Postprandial hyperglycemia © Hyperinsulinemia * Pregnancy induced peripheral insulin resistance (to sustain a postprandial supply of glucose to the fetus) HEMATOLOGIC CHANGES ‘+ Hemoglobin and hematocrit decrease + Blood viscosity decreases © "Hypervolemia of pregnancy” * Averages 40-45% above the non-pregnant volume after 32-34 weeks ¢, Tomeetthe demands of he enlarging uterus and hypertrophied vascular system * Provide nutrients for fetus and placenta ‘* Protect against impaired venous return in the supine and erect position © Safeguard against the effects of blood loss CARDIOVASCULAR SYSTEM * Changes occur as early as 8th week AOG Increased cardiac output Reduced systemic vascular resistance Increased heart rate - resting pulse rate increase of 10 bpm Displaced tothe leftand upward-large cardiac silhouette on x-ray, dificult to detect cardiomegaly Altered cardiac sounds Exaggerated splitting of the 1 heart sound No definite aortic or pulmonary elements of the 24 heart sound * Loud, easily audible 3" heart sound Heart * Systolic murmur in 90% of cases, intensified during inspiration * Increased production of prostaglandin £2 and prostacyclin (PGI2) during the latter part of Pregnancy to help regulate blood pressure and platelet function * Supine hypotension occurs in about 10% of women Secondary to compression of the great vessels by the uterus Cardiac output * MAP and vascular resistance decrease - decreased blood pressure * Basal metabolic rate and blood volume increase * Cardiac output, stroke volume and heart rate increase 2, PHYSIOLOGICAL CHANGES IN PreGNancy | 9 RESPIRATORY SYSTEM Be cretaat Diaphragm rises 4 cm during . aay rate, lung compliance, max breathing capacity, forced time vital Capacity unchanged minute ventilation increases Tidal volume and resting " Functional residual capacity and residual volume decrease because of the elevated di Maternal arteriovenous oxygen Is decreased "phtag) oxygen delivered > Increased total Increased tial volume —> Increase hemoglobi increased oxygen capacity and increased CO Stetina, URINARY SYSTEM Kidney size increases slightly : / Glomerular filtration rate and renal plasma flow increase (urinary frequency iscommen) Serum creatinine decreases; ceatinine clearance increases Glucosuria on UAmay be normal to an extent because of the increased GFR and decreaseg tubular reabsorption of glucose Proteinuria normally not evident except in small amounts or after vigorous exercise Hematuria usually because of contamination; if not, may signify urinary tract disease Ureters «Laterally displaced and compressed at the pelvic brim © Ureteral dilatation takes place (R>L) © Unequal dilatation ‘© Due to cushioning effect on the left by the sigmoid © Greater compression on the right because of dextrorotation Right ovarian complexis dilated and lies obliquely over the right ureter * Ureteral elongation accompanies distention Bladder After 12 weeks, the bladder trigone elevates «Near term, with an engaged fetus, there is impaired blood and lymph drainage from the bladder base 3 edematous, easily traumatized, prone to infection GASTROINTESTINAL TRACT Stomach and intestines are displaced by the uterus; PE findings may be greatly altered Appendix displaced upward and laterally Gastric emptying time unchanged during pregnancy but prolonged during labor (danger of aspiration during general anesthesia) Pyrosis (heartburn) caused by acid reflux * Altered position of the stomach * Decreased tone of the lower esophageal sphincter Hepatic blood flow increases Portal vein diameter increases Call bladder contractility is reduced (cholestasis of pregnancy) increased risk of gallstones 10 | PeRinatat care B. ORGAN SYSTEM PHYSIOLOGIC CHANGES CARDIOVASCULAR SYSTEM TABLE~2.1. Cardiovascular Changes in Pregnancy eats aig ALU ese | Heart size | Increases Increased diastolic filling and muscle hypertrophy | Murmurs Physiological systolic Election murmurs attributable to increased stroke and diastolic volume usually occurin early or mid-systoic and _ | are best heard along the lft sternal edge [eco Positional heart changes | Hearts pushed upward and forward, deviating result in changes that _| electrical axis tothe left by 15-20 degrees, | resemble ischemia | causing flattened or inverted Tin lead tt Cardiac output Increases 1.5Umin Greatest increase occurs immediately after delivery a with redistibution of blood flow from uterus Rhythm Increase in atrial and Supraventicular tachycardia no infrequent ventricular extra systole Heart Rate Increases from 70 10 85 beats per minute Stroke Volume _| Increases from 63 to 70.mi Systolic and Decreases soon after Supine hypotension - decreased venous return Diastolic BP beginning of pregnancy | due to compression from the gravid uterus | and mid pregnancy Increased blood flow through alternative pathways | (100.110/60-70 mean _| such as paravertebral azygous veins levels); then retums to pre-pregnant values by thisd trimester and term Pulse Pressure Increases Venous Pressure | Increases in femoral system Unchanged in arms Peripheral resistance _| Decreases Pulmonary BP | Unchanged Blood flowto uterus _| Increases by 500 ml/min _| No autoregulation Blood flow to kidneys _| Increases by 400 ml/min Blood low to skin | Increases by 300- 400 ml/min Blood flow to breasts _| Increases by 200 mln 2. PHYSIOLOGICAL CHANGES IN PREGNANCY | 1 RESPIRATORY SYSTEM TABLE-2.2. Respiratory Changes in Pregnancy nics EXPECTED CHANGE COMMENTS ‘Anatomy Increases of subcostal angle from | Increased upper respirator } 680 to 1030 -» 3 cm increase capil engorgement ca ay, in transthoracic diameter increased congestion eps and intubation trauma Tidal volume Increases by 300 ml or 40% Expiratory reserve volume Decreases by 200 ml CCephalad displacement of diaphragm Residual volume Decreases by 300 ml or 20% Inspiratory capacity Increases by 300 ml Funetional residual volume Decreases by 500 ml Minute volume Increases by 40% or 3Lmin Increased rate of induction of rd beginning in first trimester emergency from inhaled anesthetic ‘Maximum breathing capacity Unchanged Forced expiratory volume Unchanged Peak expiratory flow rate Unchanged Closing volume May increase Pulmonary difusing capacity Decreases by 4 mi/minimmHg Onygen requirement Increases by 30-40ml/min Carbon dioxide output Increases; expressed a respiratoy quotient Carbon dioxide pressure Decreases from 35-40 mmHg to 28:30 mm#tg Oxygen pressure Increases oH Mild increase (7.40-7.44 is normal) | Compensated respiratory altaloss p02 Mild increase (100-104 is normal) pco2 Decreases (30-31 mmHg is normal) RENAL SYSTEM AND HOMEOSTASIS TABLE~2.3. Renal System and Homeostasis Changes in Pregnancy PARAMETER Btu kenu Can Glomerular filtration rate Increases from 97 ml/min to 128 millmin by 10 weeks Glucose excretion Increases Random glycosuria Protein excretion| Increases Tess than 300 mg/24 hours is normal Renin, Angiotensin | and I Increases Diminished vascular respons? causes less pressor effect from angiotensin ‘Anatomic changes Dilation of renal calyces and ureters | Increased risk of pyelonephis to pelvic brim; ‘physiological’ screen for asymptomatic bate"? hydronephrosis right >left Potassium Increased retention 12 | PERINATAL CARE a Erma kenur GOs Sodiurn Increased retention Urine output No significant change Vitamin excretion Increased loss of folate, vitamin B12, and ascorbicacid 22 mEqftis normal) ‘Osmolality Decreases 10 mOsm/kg in first rimester, then stable Sodium Decreases 3 mEq/Lin fist trimester, then stable Potassium Decreases 0.5 mEq/L Calcium Decreases (total and ionized) Increased intestinal absorption of calcium and eased bone turnover Magnesium Decreases 10-20% in first half of pregnancy Zine Decreases Copper Increases from 1.14 mil. 02.03 mgfL.by term Chloride Unchanged Bicarbonate Decreases markedly (18- ‘Compensates for decrease in pCO2 Total protein Decreases from 72 g/l to 62 g/t ‘Albumin Decreases from 47 g/L.to 36 g/L Urea, creatinine, and uric acid Decrease first trimester; stabilize second trimester increase toward term Vitamin B6 Decreases Blood glucose Fasting levels decease in first | Postprandial levels remain elevated trimester, then unchanged longer, prolonging return to fasting siate Increased glucose levels allow passive difusion across placenta to fetus Folate Decreases 50% toward term Vitemin B12 Decreases 50% or more Vitamin B12 levels folate ENDOCRINE SYSTEM TABLE~2.4. Endocrine Changes in Pregnancy fina Pies nor CoE Pituitay gland Increases to 50% greater ‘Attributable to increase of prolactin weight than adult male secreting cells in anterior lobe Prolactin Increases from 300 to 5000 miU/L FSHILH Decrease to nearly undetectable ACH Increases Human growth hormone Decreases 2, PHYSIOLOGICAL CHANGES IN PREGNANCY | 13 us Ges CIT Melanoctestimulating hormone | Increases May be responsible or iney sig, hls, dnc areolae pigmentation Vasopressin Unchanged Stimulation of nerve endin s inbveast causes teeing in oxytocin and vasopressin Ongocin Unchanged Thyroid anatomy Uxioioe! ne Unchanged May be suppressed du ing Late fi toeary second timestrduety HCG-mediated increase inhyig hormone production sub efeq may be exacetbated by conden; that increase HCG levels, uch a¢ hyperemesis, molar pregnancies, and multiple pregnancy Thyroid binding globulin Inreases- doubles by end of frst trimester; triples by term Due to estrogen effect on liver Thyroxine T4) Increased total circulating level; unchanged free Fetal thyroid hormone production commences at about 18 weeks Triiodothyronine (73) Increased total circulating level unchanged free fraction Reverse 13 Unchanged in maternal circulation; increased in cord blood ‘Adrenal anatomy Unchanged cae Increases doubles by second trimester Cortisol Increases to 3 times Episodic patter of lease nonpregnant values ismaintained Aldosterone Increases 2-fld by term | Deonycortcosterone Increases by 20-100 times | Testosterone Increased total amount; | Decreased free fraction | Androstenedione Increases by 50% 10-fold increased rate | of transformation to | estradiol and estrone DHEA Unchanged orsmall decrease | Gatecholamines Unchanged | Pancreas Hypertrophy ofislets due | tohyperplasia of B cells Insulin Increased fasting levels toward term | Proportionally es inceaseof Hyperplasia of pancreatic Bells | glucagon compared toinsuln 0 insulin: glucagon ati sinceasel_ Glucagon Increased fasting levels — Glucose Slight decrease Especially fasting levels Parathyroid hormone Increased during end of pregnancy | Maintains calcium levels in face af increased real absorption | and transerto fetus 14 | Peninatat cane PARAMETER esd ate 25-hydroxyvitamin D Unchanged 4,25 Dihydroxyvtamin D Increases Calcitonin No change to slight increase Increases from 0.2 pg/ml to Production originates in corpus Progesterone 139 gm (up to 1000-old) luteum over first 7-Bveeks; then placenta takes over Estradiol Increases about $00-fld from 0.05 giml to 18 gmt “T7-Hydroxyprogesterone Increases to maximum level by week 8 Relaxin Increases Secreted by the corpus luteum as well as the decidua and the placenta ina pattem similarto that of hCG Estiol Increases Human Placental Lactogen(RPL) | Increases about 5000-old from 0,002 ,sU/ml to 10 U/ml HCG Plasma levels increases Peak 93 Uiml rapidly, doubling every 2 Term 14 U/ml daysin the first trimester GASTROINTESTINAL SYSTEM TABLE-2.5. Gastrointestinal Changes in Pregnancy eas ta els Cae Appetite Increases Gastric reflux Increases Cardiac sphincter enity and anatomic displacement Treated during labor and delivery! anesthetic procedures with non-particulate oral antacids Gestc secretion Decreased acy; increased volume | ‘ull stomach’ effect increases risk of aspiration Intubation requires cued endotracheal tube Gastric motility Decreases Intestinal absorption Increases Intestinal transit time Delayed Large intestine Greater absorption, slower transit time liver Unchanged Gallbladder Larger due to pasive dilation 2. PHYSIOLOGICAL CHANGES IN PREGNANCY | 15 HEMATOLOGIC SYSTEM TABLE-2.6. Hematologic Chan: aT Rie kee Om a r ir ona Ofsets blood loss at delivery Tauleyaniewtane [noes 15908 amen Temata paeieseae=tes® meocnaae ne, in plasma volume compated tp erythrocyte volume; less ange with iron supplementation Hemoglobin Decreases 2-10% by third trimester larvolume | Unchanged Good indicator of ton status encore Slight increase wth ron supplementation throcyte sedimentation rate | Significantly increased Provides little diagnostic value; Entheos combined with physiologic increase in WBCs can cause false suspicion for infection Wats Increase 8% by term and may Predominantly due to increase further postpartum increase in neutrophils Serum iron Decreases 25% by term Serum transferin Increases by 100% or more Total ion binding capacity by second trimester markedly increased Totalironbinding capacity | Increases by 25-100% Serum feritin Decreases markedly (even with Nadir 30% or less of normal values | iron supplementation) Bestest to assessiron defengy | ‘anemia in pregnancy | Erythropoietin Increases fold | ‘Alpha fetoprotein Increases Largerincrease in neural pha fetopr 9 tube defects abdominal wall | defects, and fetal death Glutamate-oxaloacetc Unchanged transaminase and glutamatic- | é | pytuvic transaminase Creatinine kinase Decreases frst half of pregnancy lipase Decreases Alkaline phosphatase Increases Heat table fraction formed by placenta Lipids Increase Triglycerides, cholesterol, phospholipids, and fee faty aids all increase progressively tattoge Increases 2g by term ‘Overall increased tendency tovardsthrombosis—— Factors Vit, Vil, and X Increase Factors Xland xit Decrease by about 30% Antithrombin i Decreases 16 | Perinatat care FAMILY PLANNING NATURAL METHOD These family planning methods predict the fertile days of each menstrual cycle and advise sexual abstinence during these days STANDARD DAYS METHOD The couple must avoid unprotected intercourse during cycle days 8 through 19 A prerequisite is a regular monthly cycle of 26 to 32 days; othemmise, iis not very successful They may use cycle-beads or may mark the calendar to identify the fertile days ‘CALENDAR RHYTHM METHOD The woman must count the number of days in her shortest and longest menstrual cycle during a 6-to 12-month span Eleven days are subtracted from the longest cycle duration to identify the last fertile day. While, eighteen days are subtracted from the shortest cycle duration to calculate the first fertile day. During the interval of these fertile days, unprotected sexual intercourse must be avoided. TEMPERATURE RHYTHM METHOD This method predicts the day of ovulation by detecting a slight change in basal body temperature of around 0.4°F days before the ovulation Itis most effective when the couple abstains for unprotected sexual intercourse from the first day of menstruation until the 3° day of increased basal body temperature CERVICAL MUCUS METHOD BILLINGS METHOD: Abstinence is advised from the frst of menstruation until 4 day of slippery mucus discharge. . TWO-DAY METHOD: The woman isnot fertile if she did not note mucus discharge on the day of intercourse or the day prior - SYMPTOTHERMAL METHOD: This combines the cervical mucus method to identify start of fertile period and basal body temperature method to identify end of fertile period. Itentails more complex application but does not necessarily improves the failure rate. 3. Famity PLANNING | 17 ‘TABLE~3.1. When to Start the Different Family Planning Methods early METHOD ene ba Y Not advised First day of menstruation * Quick start: onthe dayof | prescription but with at method for fist? days |» Sunday statist Sunday ter onset of menstation bt wis altemaive method forts do Combination Oral erating Contraceptive Pills not exclusively breastfeeding, start 3 weeks postpartum, For mothers who are breaste ding exclusively, ovulation during the fist 10 weeks atter delivery is unlikely The timing of initiation of Within 5 days of menstruation DMPAis controversial in breasteding patients. Depot medroxyprogesterone _| The World Health Organization acetate (DMPA) recommends thatinjetable depot medroxyprogesterone acetate should not be used Progestin Only Fill before 6 weeks postpartum. Implant Before discharge Within 5 days of menstruation 7 week postpartum or when “Anytime inthe cle Intrauterine Device uterine involution is completed at 3 to 6 weeks postpartum Progesterone only regimen as | « Combined regimen or progesin soom as possible after unprotected | only ssoanas posible ater intercourse until 72 hours after unprotected intercourse until 72 hours after ‘Yuzpe Regimen/Emergency + 4 low dose pills within 72 Contraception hsafter unrpotected coitus followed by another 4 lon dose pills ater 12 bs *# OR: 2 high dose pills followed by another 2 pil after 12h Lactational Amenorthea Immediately postpartum Not applicable | VI. COMBINATION ORAL CONTRACEPTIVE PILLS > Mechanism of Action Estrogen Suppresses FSH thereby blocking ovulation Stabilizes endometrium which prevents breakthrough bleeding Progesterone ‘Suppresses LH Thickens cervical mucus Renders endometrium unfavorable for implantation 18 | PERINATAL CARE 2 eee cee DD eee ere eee . Administration Pill is taken daily, ideally at the same time each day. The hormone pills are taken for a specified time followed by placebo pills, where withdrawal bleeding is expected. The duration of time taking the hormone, or the placebo depends on the product regimen. Contraindications Previous stroke Prior MI Hypertension ‘Smokers Older age>35 years old Diabetes Thrombophilia Migraine headaches with visual aura or other focal neurologic signs Active hepatitis Side Effects Altered drug efficacy Increase, total cholesterol, HDL, VLDL, decrease LDL Increase fibrinogen and clotting factors Increase angiotensinogen production Increase sexhormone binding globulin levels Increase Té and thytoid-binding proteins Increase risk of stroke, myocardial infarction, VTE, and pulmonary embolism in those with risk factors prior to pill use Cholestasis and cholestatic jaundice Benefits Increased bone density Reduced menstrual blood loss and anemia Decreased risk of ectopic pregnancy Improved dysmenortheal from endometriosis Fewer premenstrual complaints Decreased risk of endometrial and ovarian cancer Reduction in various benign breast diseases Inhibition of hirsutism progression Improvement of acne Prevention of atherogenesis Decreased incidence and severity of acute salpingitis Decreased activity of rheumatoid arthritis 3. Famity PLANNING | 19 20 ‘VII. PROGRESTIN ONLY PILLS > Mechanism of Action Cervical mucus thickening Endometrial atrophy = Administration The minipil shouldbe taken each day, strongly advised to be taken atthe same time each if delayed for 4 hours, another contraception method should be done forthe next 48 hous, 2 Contraindications Pregnancy © Livertumors Breast cancer * SLE Component allergy © APAs Severe, decompensated cirrhosis Side effects Irregular menstrual bleeding Weight gain Loss of bone mineral density Benefits Does not affect milk production in lactating mother meee ‘Vill, LACTATIONAL AMENORRHEA > Physiologic Basis The prolactin hormone, responsible for milk production, also suppresses the FSH and LH thereby inhibiting the return of normal menstrual cycle including ovulation All conditions must be present to use lactational amenorrhea as contraceptive Menstruation has not yet returned Infantis less than 6 months old Infantis fully breastfed most of the time Benefits No cost No side effects Promotes breastfeeding which is beneficial to both mother and child DP eee PERINATAL CARE EsseNrTIALS OF OBSTETRICS PLACENTAL ABNORMALITIEs |. PLACENTA Typical Placenta Composed ofa placental disc extraplacental membranes and thres-essel umbilical gy Weighs 470 grams, round to oval with a 22-cm diameter, with central thickness of 2 sen Sonographic, homogenous and 24cm thick is aginst the myometium an nde into the amnionic sac * Proportion of weight of baby is 1:6; occupies 30% ‘of uterine wall 8. Abnormal Placental Shapes eee TABLE-4.1, Abnormal Placental Shapes Placenta biparttaor biloba Hie es ihe + Disionis incomplete andthe vessel oft origin extend este oat tobes) ane lobe tothe other before uniting to form the fo Placenta triplex (Bdistinct lobes) umbilical cag Small accessory lobes develop in the membranes ata distance from the periphery ofthe main placenta * The tissue ofthe ring has atrophied + Rare, occuring in 1 of 6000 deliveries * Higher sk of antepartum and postpartum bleeding and fetal growth estricton + Fetal membranes ae covered by functioning vill, and ‘the placenta develops asa thin membranous structure Membranous placenta/placenta diffusa | _ occupying the entire periphery of the chorion « Placenta may not separate readily and may give rise to bleeding which resembles that sen in central placenta previa * Missing central portion ofa discodal placenta * Often mistaken asa placenta with retained cotyledons inthe tens * The fetal side is smaller than the maternal side ofthe placenta * Etiology is unknown ‘ Acental depression surrounded by a thickened, grayish-white ring, composed of a double fod of amnion and chorion with degenerated decidua and fibrin in between, is seen in the fetal surface * The chorion and arnnion are raised atthe margin by interposed decidua and fibrin, forming a ring at the placental margin Succenturiate placenta Ring shaped placenta Fenestrated placenta Extrachorial placenta Circumallate placenta Gircummarginate placenta C. Abnormal Placental Location Placenta previa © Describes a placenta that is implanted somewhere in the lower uterine segment, either over! very near the internal cervical os ‘* Clinically presents as painless bleeding during midpregnancy 22. | Essenmiats oF ossrerRics Risk Factors Maternal age >35 years Multiparity 25 Prior cesarean delivery Cigarette smoking Elevated maternal serum alpha feto protein Diagnosis Transvaginal Ultrasound -first line ¢ TRANSABDOMINAL ULTRASOUND - has average accuracy of 96% but less superior to transvaginal ultrasound © Transperineal ultrasound MRI Digital examination done only when delivery is planned and with double-set up TABLE—4.2. New Classification of Placental Location based on Standardization of Contents of OB-GYN Ultrasound Reports 2017 Gren Pesca NORMAL Inferior-most placental edge is >2 cm from internal cervical 0s Low.LVING Inferior-most placental edge is within 2 cm from the internal cervical os Placenta covers the cervical os (measure length of overlap) OR PREVIA Inferior most edge reaches the internal cenical os Management If the mother is stable and there is no persistent active bleeding, and the fetus is preterm with good fetal heart tones —» close observation at maternal unit if there is no bleeding and the fetus is near erm —> elective cesarean delivery at 36.37 weeks gestation If there is active, profuse bleeding, the mother is unstable or if there are fetal heart rate decelerations > emergency cesarean section regardless of age of gestation D. Abnormal Placental Size PLACENTOMEGALY - placentas that are thicker than 40 mm that commonly results from villous enlargement; may be caused by maternal diabetes, severe maternal anemia, fetal hydrops or infection caused by syphilis, toxoplasmosis or cytomegalovirus E. Abnormal Placental Adherence ‘© PLACENTA AccRETA - villi attached to the myometrium ‘© PLACENTA INCRETA - villi invade the myometrium, © PLACENTA PERCRETA - villi penetrate the myometrium, may affect bladder or bowels FIGURE—4.1. Different Placental Adherence 4, PLACENTAL Agnormatities [| 23 Pathology «atta or total absence ofthe decidua basls + Imperfect development of Nitabuch layer isk Factors / cee * Uterine anomalies * Prior cesarean delivery . NSAFlevels>25 MoM, Beg 55 Prior uterine curettage jo ‘© Prior uterine surgery Diagnosis © Usually presents as antepartal bleeding - © Ultrasound shows lack of the normal hypoechoic retroplacental zone «popper sTuDiEs - distance between the uterine serosa-bladder wall intera retroplacental vessels is <1 mm and with large intraplacental lacunae + MRI shows uterine bulging, heterogeneous signal intensity within the placenta and da intraplacental bands on T2-weighted imaging C8 andthe Management CS followed by hysterectomy at 36 weeks AOG © Preoperative arterial catheterization © Iffocal accreta and desirous of pregnancy, conservative management may the placenta in-situ then serial imaging to document resorption * These of methotrexate has been reported in some casestudies, but ths temains contovese UMBILICAL CORD iy be done by’ leaving ‘TABLE-4.3. Abnormal Umbilical Cord Sete Tee) i) Length ‘© NORMAL: 55 - 60 cm (Benirschke and Kaufmann, 2000) (effected by amnioticfluid | * sHoRT CORD: = 32 cm -from oligohydramnios or decreased fetal volume and fetal movement) | movement; associated with growth restriction, ‘congenital malformations, intrapartum distress, fetal death, abruption placentae, and uterine inversion '* LONG CORD: = 70 cm ~from cord stretching due to fetal movement; associated with entanglement or prolapse and with fetal anomalies, academia and demise ‘© More frequently identified in fetuses who aborted spontaneously * ASSOCIATED WITH TRISOMY 1830% HAD ASSOCIATED CONGENITAL ANOMALIES: renal aplasia, limb-reduction defects, and atresia of hollow organs (Pavlopoulos, 1998) ‘* MATERNAL RISK FACTORS: diabetes, epilepsy, antepartum hemorrhage, oligohydramnios, and hydramnios (Leung and Robson, 1989) ‘© PERSISTENCE OF RIGHT UMBILICAL VEIN: associated with congenital ‘anomalies such as ectopia cordis, atrial septal defect, symmetrical bifid liver, cleft lip and palate, arteriovenous fistulas of the placenta * PERSISTENCE OF SMALL VITELLINE ARTERIES: 10 ‘* NORMAL UMBILICAL COILING INDEX: 0.4 (antepartum taken sonographically); 0.2 (actual measurement postpartum) Cord Coiling ‘* HYPOCOILING: linked with fetal demise . * HYPERCOILING: associated with fetal growth restriction ‘and fetal demise Significant increase in meconium staining, {_preterm birt, and operative delivery for fetal distress _——~ 24 | Essenniats of OBSTETRICS Four-vessel cord Cee Cord Insertion * NORMAL: at or near the center of the fetal surface of the placenta '* MARGINAL INSERTION/BATTLEDORE PLACENTA: at the placental margin; common in multifetal pregnancy * CORD MAY BE PULLED OFF DURING DELIVERY OF THE PLACENTA * VELAMENTOUS: umbilical vessels separate in the membranes ata distance from the placental margin occurs more frequently with twins, and is almost the rule with triplets winerable to compression leading to academia and hypoperfusion ‘ VASA PREViA: fetal vessels in the membranes cross the regi of the internal os and occupy a positon ahead of the presenting part hence is vulnerable to compression and to avulsion delivery t 34 to 35 weeks by elective CS is indicated ABLE-4.4, Abnormalities in the Cord that may impede Blood Flow ABNORMALITIES IN THE CORD THAT MAY IMPEDE BLOOD FLOW True knots | Result from active fetal movements False knots | Resultfrom kinking ofthe vessels to accommodate to the length ofthe cord inogs Those with nuchal cord had more moderate or severe fetal heart 7 decelerations and a lower umbilical artery pH (Hankins, 1987) Torsion Cord normally becomes twisted as a result of fetal movement Stricture | #8clted with focal deficiency in Wharton jlly majority of ase are sen in stilborns Rupture ofa vari, usvally ofthe umbilical vein Hematoma | Can be iatrogenic through ultr-sound directed umbilical vessel venipuncture True cysts __| From remnants of the umbilical vesicle or of the allantois False cysts __| Result from liquefaction of Wharton jelly Edema Commonly seen in macerated fetuses Il, MEMBRANES © consists of two layers: the outer chorion and the inner amnion «offers support to amniotic fluid and produces the fluid TABLE—4.5. Membranes of the Umbilical Cord Meconium staining Staining of the amnion can be obvious within 1 to 3 hours Fetal infection may be from hematogenous spread ifthe mother has bacteremia Chorioamnionitis but is more likely from aspiration or direct contact with infected amniotic fluid Associated with ruptured membranes, preterm labor Amnion nodosum Characterized by numerous small, light-tan nodules on the amnion ‘Anatomic fetal disruption caused by bands of amnion that entrap ‘Amnionic band sequence | f2131 tructures and impair growth and development 4, PLACENTAL ABNorMaLITIES | 25 26 ABORTION DEFINITION <500 g or terminated before 20 weeks AOG Spontaneous vs. induced termination of pregnancy EARLY: <12 weeks AOG; management is dilatation and curettage LaTe: >12 weeks but <20 weeks AG; management is to allow for spontaneous: vaginal delivery then completion curettage PATHOLOGY: the presence of hemorrhage into the decidua basalis and necrotic changes i surrounding tissues causes detachment ofthe ovum stimulating uterine contractions thats te inexpulsion a ETIOLOGY FETAL FACTORS: Chromosomal anomalies cause atleast half of cases of early abortion 1, ABNORMAL ZYGOTE DEVELOPMENT - most common morphological finding in ey spontaneous abortions 2. Aneuploid abortion a, AUTOSOMAL TRISOMY - the most frequent identified chromosomal anomaly with fist trimester miscarriages b. MoNosomy x (45,x) - single most common specific chromosomal abnormaliy, causes Turner Syndrome TRIPLOIDY - often associated with hydropic placental degeneration d. TETRAPLOIDY - often abort early in gestation and rarely born alive @. CHROMOSOMAL STRUCTURAL ABNORMALITIES - infrequently cause abortion 3, EUPLOIDY ABORTION - causes are poorly understood 3. Maternal factors 1. INFECTIONS - systemic infections likely infect the fetoplacental unit by a blood-borne ove 2, Endocrine abnormalities a. HYPOTHYROIDISM ~ severe iodine deficiency may be associated with miscarriages b. Diabetes mellitus and progesterone deficiency - increased isk of abortion 3. Drug use and environmental factors a. TOBACCO, ALCOHOL, AND CAFFEINE - increased risk of abortion b. RADIATION ~a recognized abortifacient especially in therapeutic doses given to tet malignancy (CONTRACEPTIVES - use of intrauterine device may increase the risk for septic abortion d. ENVIRONMENTAL TOXINS - arsenic, lead, formaldehyde, benzene, and ethylene oxide may cause abortion 4, Immunological factors @, AUTOIMMUNE - antiphospholipid antibody predisposes to thrombosis by inhibiting endothelial cel from producing prostacyclin, by enhancing thromboxane release orby degrading some components of the clotting cascade; Miscarriages are more common! ia women with SLE b. ALLOIMMUNE - maternal immunity against the fetus | 5. INHERITED THROMBOPHILIA - positive association with spontaneous abortion AGING GAMETES ~ increased incidence of abortion, especially with maternal age 735) 7. PHYSICAL TRAUMA - in general, contributes minimally to the incidence of abortion | Essenmiais oF oasretmics 8. Uterine defects a, ACQUIRED - uterine synechiae (Asherman syndrome) results in amenorrhea and recurrent abortion due to insufficient endometrium to support implantation b. DEVELOPMENTAL - due to abnormal Mullerian duct development or exposure to diethylstilbestrol in utero 9, INCOMPETENT CERVIX - painless cervical dilatation in the second trimester, with prolapse and ballooning of membranes into the vagina, followed by rupture of membranes and expulsion of an immature fetus © ETIOLOGY: obscure but previous trauma to the cervix such as dilatation and curettage, conization, cauterization or amputation appears to be implicated TREATMENT: surgical; reinforcement of the weak cervix © PREOPERATIVE EVALUATION: UTZis done prior to the procedure; cerclage is delayed until after 14 weeks but not beyond 24-26 weeks © CERCLAGE PROCEDURES: McDonald, Shirodkar, and Modified Shirodkar; there is less trauma and blood loss with McDonald and Modified Shirodkar © COMPLICATIONS: high incidence of membrane rupture, chorioamnionitis, and intrauterine infection when done after 20 weeks 10. PATERNAL FACTOR - chromosomal abnormalities in sperm can lead to abortion Ill, CATEGORIES AND TREATMENT OF SPONTANEOUS ABORTION TABLE-5.1. Categories and Treatment of Spontaneous Abortion Ce a Closed | (+) | (+) | US=A0G (4) Bed rest with THREATENED adequate analgesia Closed | (-) () US

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