MEDICAL CONCERNS ON

REPRODUCTION

MARY JANE L. PUBLICO, MD, DPOGS

EFFECTS OF RAPID POPULATION
GROWTH ON THE HEALTH OF THE NATION

The population of the Philippines is estimated

to be over 92 million making it the world’s 12th
most populous country. Given its size and
increasing growth, the needs of the Philippines
are vast – education, health care and better
sanitation to name a few.
IMPORTANCE OF MATERNAL HEALTH CARE PRE, DURING
AND POST PREGNANCY
PRE-PREGNANCY
•Ante/retroverted uterus
•Polycystic ovary
•Ovarian New Growth (dermoid)
•Myoma
DURING PREGNANCY
•Spontaneous Abortion/Blighted Ovum
•Ectopic Pregnancy
•Hypertensive Disorders (Pre-eclampsia/Eclampsia)
•Placenta Previa
•Gestational DM
•Malpresentations
POST PREGNANCY
•Post Partum Disorders
•Sepsis
•Tubal Ligation
•Traditional Birth Attendants (Hilot)
IMPORTANCE OF MATERNAL HEALTH PRE,
DURING AND POST PREGNANCY

MDG 5 - Improve Maternal Health

Target: reduce by 3/4, between 1990 and
2015, the maternal mortality ratio
Indicators: Maternal mortality ratio (UNICEF-
WHO)
Proportion of births attended by
skilled health personnel (UNICEF- WHO)
Prenatal care – helps decrease risks during pregnancy
and increases the chance of a safe and healthy delivery.

During Pregnancy – regular healthcare appointments

Postpartum care – lasts between 4 to 6 weeks after

the baby is born
 PRE-PREGNANCY:
ANTE/RETROVERTED UTERUS

Anteflexed or anteverted vs. retroverted or retroflexed

(normal anatomical variance)
Both the body of the uterus and the cervix are attached
to the pelvic sidewalls by several ligaments. These
ligaments are flexible and allow the uterus to tilt slight
forward (ante) or backward (retro)
Neither position infers with a woman’s ability to get
pregnant.
 POLYCYSTIC OVARY (POLYCYSTIC
OVARIAN SYNDROME)

Clinical feature: oligomenorrhea, hirsutism, infertility,

obesity and virilisation
Oligomenorrhea
-is a condition in which you have
infrequent menstrual periods.
Some variation in menstruation is normal,
but a woman who regularly goes more than
35 days without menstruating may be
diagnosed with oligomenorrhea.
Hirsutism
is a condition of unwanted, male-
pattern hair growth in women.
Hirsutism results in excessive
amounts of dark, course hair on body
areas where men typically grow hair
— face, chest and back.
When excessively high androgen
levels cause hirsutism, other signs
might develop over time, a process
called virilization.
Signs of virilization might include:
Deepening voice
Balding
Acne
Decreased breast size
Increased muscle mass
Enlargement of the clitoris
 2003 Rotterdam criteria
1. Oligo- and/or anovulation (is when the
ovaries do not release an oocyte during a
menstrual cycle.)
2. Clinical and/or biochemical signs of
hyperandrogenism(androgen excess)
3. Polycystic Ovaries
 PCOS:
PREVALENCE:
Affects 5-10% of reproductive-aged women (1 in 15
women)
65-85% with androgen excess are diagnosed having
PCOS
- 40-60% of these are obese; 60-90% are
hirsute, 50-90% oligomenorrheic and 55-75%
infertile
80% metabolic abnormalities – insulin resistance
 PATHOPHYSIOLOGY OF PCOS
Insulin Resistance cardiovascular dse risk factors
(dyslipidaemia, HPN)
Hyperinsulinemia impaired glucose tolerance
type 2 diabetes
acanthosis nigricans
miscarriage

Functional adrenal Suppression of functional ovarian

hyperandrogenism SHBG synthesis by liver hyperandrogenism

increase in bioavailable pool oligo- or anovulation

of androgens oligo or amenorrhea
DUB; infertility
hirsutism, acne, alopecia endometrial hyperplasia/Ca
 DIAGNOSIS OF PCOS
Menstrual dysfx – common reason; 60-85%
-oligomenorrheic cycles rather than heavy menstrual
bleeding
- predisposing factors: hyperinsulinemia (a condition in
which there are excess levels of insulin circulating in the blood relative to the
level of glucose), elevated androgen levels and obesity

Androgen excess – hirsutism, oily skin, acne, oligo/amenorrhea

Hirsutism – excessive facial and/or body terminal hairs in a male

pattern distribution
 MANAGEMENT OF PCOS

LIFESTYLE MODIFICATION (weight loss

5-10% of initial body weight)
OVARIAN NEW GROWTH
(DERMOID/MATURE TERATOMA)
 DERMOID/MATURE TERATOMA
Most common ovarian tumor in prepubertal females; also in common
in teenagers
> 50% of benign teratomas are discovered in women ages 25-50 yrs.
Benign cystic tumor - combination of skin and skin appendages,
including sebaceous glands, sweat glands, hair follicles, muscle fibers,
cartilage, bone, teeth
50-60% are asymptomatic, discovered during routine pelvic
examination
Symptoms: pain and the sensation of pelvic pressure;
DX: palpation of a semisolid mass
Ultrasound
 MYOMA (FIBROIDS these are benign
tumors of smooth muscle cells of the
uterine wall that grow inside or on a
woman’s uterus
RISK FACTORS:

AGE – more common as women age, esp from the 30’s and 40’s
through menopause; occasionally in adolescents

GEOGRAPHY/RACE/ETHNIC ORIGIN – black more than white; black

women tend to be younger at the time of dx

WEIGHT/BMI/OBESITY – higher BMI; higher in women who gain

weight after age 18; Women with a BMI of 30 or more (170lbs for a
woman 5’4’’) 23% more likely to develop myomas.

GENETIC FACTOR – familial tendency

 RISK FACTORS

GRAVIDITY(number of times a female is or has been pregnant) AND

PARITY(carried the pregnancies to a viable gestational age) – decreases the risk
USE OF OCP – decreases the risk; COC does not induce growth of uterine
myomas; coc are first line medical management in women with menorrhagia or
dysmenorrhea associated with myomas.
SMOKING – decreases (due to estrogen lowering effect of smoking brought
about by increased liver metabolism of estrogen induced by smoke related
substances particarly nicotine.
MENARCHE – ealy menarche (increased risk)
DIET – high fat and eating large amount of red meats (increased)
Green vegetables (decreases)
ETIOLOGY (THEORIES)

Steroid hormones – estrogen and progesterone

(regulators of myoma growth)

Estrogen - promotes growth

- Myomas grow in the presence of high
levels of estrogen (reproductive years)
Progesterone -Size increases during tx w/ synthetic
progesterones
 SIGNS AND SYMPTOMS:

Asymptomatic and may not require intervention

Common symptoms: abnormal uterine bleeding,
pressure symptoms and pain
Abnormal bleeding pattern – characterized as heavy
menstrual bleeding
Pain – rare although distressing; other causes should be
excluded
 Myoma and Pressure sx:

A posterior wall myoma – low back pain, rectosigmoid

– GI sx like constipation and tenesmus (cramping
rectal pain)
Anterior myomas – bladder discomfort, urinary
frequency or incontinence and outflow obstruction
Intraligamentous masses may compress ureters and cause
hydroureter or hydronephrosis
Dyspareunia
Prolapsed Mass
•vaginal bleeding, urinary flow obstruction
and urinatry tract infection, pelvic
heaviness
and/or acute pain
•young women of fertile age;
•prolonged heavy menstrual bleeding
•Cervical myomas -uncommon; vaginal
myoma – rare
Myoma and Dysmenorrhea
• slight pelvic pain; dyspareunia, noncyclic
pelvic pain

Myoma and infertility

•Affects fertility if submucous
•Intramural myomas which may impinge FT
•Subserous myomas do not affect fertility
DURING PREGNANCY:
SPONTANEOUS ABORTION/BLIGHTED
OVUM
A blighted ovum (also known
as “anembryonic pregnancy”)
happens when a fertilized egg
attaches itself to the uterine wall,
but the embryo does not develop
>80% occur within the first 12 weeks of gestation
Fetal factors:
50% are anembryonic (blighted) – no identifiable embryonic
elements
50% are embryonic – display developmental abnormality of
the zygote, embryo, fetus or placenta
25% have chromosomal anomalies (aneuploid- abnormal
number of chromosomes)
25% are euploid (carrying a normal chromosomal
complement)
ANEUPLOID ABORTION
Occurs at earlier gestational ages (75% at 8 weeks aog)
– 95% of caused by maternal gametogenesis errors;
5% paternal errors
Autosomal trisomy
Monosomy X (45, X)/Turner syndrome
Triploidy
Tetraploid

EUPLOID ABORTION
Chromosomally normal fetuses abort later
(peaks approximately at 13 weeks aog)
Increases dramatically after maternal age of 35 years
•Maternal Factors

Infections – systemic and infect the

fetoplacantal unit by blood-borne organisms;
GUT infxn; uncommon cause

Medical D/O – Tb, Ca

Medications

Nutrition
ECTOPIC PREGNANCY
-fertilized egg implants in your
fallopian tube
For pregnancy to happen, the ovary has to release an
egg into the fallopian tube, where it stays for about 24
hours. There it has to come in contact with a sperm to
be fertilized. The fertilized egg stays in the fallopian
tube for 3 or 4 days before it heads to the uterus. There
it attaches to the lining and continues to grow until a
baby is born.
Symptoms:
-Light vaginal bleeding and pelvic pain
-Nausea and vomiting with pain
-Sharp abdominal cramps
-Pain on one side of your body
-Dizziness or weakness
-Pain in your shoulder, neck, or rectum
ECTOPIC PREGNANCY

-comprises 1-2% of 1st tri pregnancies.

-B-hCG and transvaginal utz

 ECTOPIC PREGNANCY
Risks: - abnormal FT anatomy
-surgeries for prior tubal pregnancy, for fertility restoration
-std or other tubal infection
-peritubal adhesions (sec to salpingitis), appendicitis, or
endometriosis
-congenital FT anomalies – in uteror exposure to DES
-ART
-smoking (unknown)
-use of contraceptive (tubal sterilization, IUD, POP pills)
Symptoms: triad – delayed menstruation, pain, vaginal bleeding/spotting
HYPERTENSIVE DISORDERS OF
PREGNANCY
 HYPERTENSIVE DISORDERS OF
PREGNANCY
Includes gestational hypertension, pre-eclampsia,
eclampsia, chronic hypertension and preeclampsia
superimposed on chronic hypertension

Pre-eclampsia – complicates 3% of pregnancies

-exact etiology is still obscure;
multifactorial
Maternal Personal Risk Factors:

•Primiparity (a woman who has given birth to one child or who

is giving birth for the first time)

•Primipaternity(The first pregnancy with a new partner)

•History of Pre eclampsia - 14%

•Obesity (BMI >/= 30) – risk increases from 4.3% for women
w/ BMI <19.8 kg/m2 to 13.3% BMI >35 kg/m2

•Family History of Preeclampsia (sisters – 37%, daughters –

26% and granddaughters – 16%)

•Ethnicity – black women

•Maternal age - >/= 40 y/o 2x the risk

Maternal Medical RF:
•Underlying Medical Conditions:
•DM
•Antiphospholipid antibody syndrome
•Systemic Lupus Erythematosus (SLE)
•Renal Disease
•Maternal Infection – UTI and periodontal
disease

Placental/fetal RF:
•Multiple Pregnancies
•Molar Pregnancy
 Diagnostic Criteria for Preeclampsia

Blood Pressure >/= 140mmHg systolic or >/= 90mmHg on 2

occassions at least 4 hours apart after 20 wks of
gestation
And
Proteinuria greater than or equal to 300mg/24 hrs urine
collection or proteinuria/creatine ratio >/= 0.3
dipstick reading of +1
in the absence of proteinuria,
New onset hypertension with new onset of any of the following:
Thrombocytopenia <100,000/uL
Renal insufficiency crea >1.1mg/dl
Impaired liver function liver transaminases 2x normal
Pulmonary edema
Cerebral or visual symptoms
PLACENTA PREVIA
 PLACENTA PREVIA
Presence of placental tissue that extends over or lies proximate to the
internal cervical os
Painless vaginal bleeding after 20 weeks of gestation
Classified: Complete previa or previa totalis (placental edge
overlapping the os)
Previa marginalis (placental edge within 1cm from the os)
Placenta 1.1-2cm away from the os
Placenta more than 2cms from the os
 PLACENTA PREVIA
Pathogenesis – unknown
Pathophysiology – placental bleeding – when gradual changes in the
cervix and lower uterine segment apply shearing forces to the inelastic
placental attachment site, resulting in partial detachment.
Prevalence – 3.5 to 4.6 per 1000 births
Risk Factors: (uncommon in 1st pregnancy)
Previous CS 0.6%
IVF 2%
Shortened birth spacing
Previous p. previa (0.7%)
GESTATIONAL DM
 CRITERIA FOR DIAGNOSIS OF GDM
75gms OGTT

FBS >92g/dl (5.1 mmol/L)

2nd hour >140mg/dL (7.8mmol/L)

 IDENTIFICATION OF HIGH RISK
GROUPS FOR GDM
Historical risk factors
Past Pregnancy abnormal glucose tolerance macrosomia
congenital malformation
recurrent abortions
unexplained intrauterine death
Present Pregnancy family history (first degree relation)
maternal obesity (>180lbs or BMI >27)
drugs affecting CHO metabolism
age 30 years/ racial predilection
Obstetric risk factors polyhydramnios
macrosomic fetus
fetal abnormality
recurrent genital tract
infections
 EVALUATION OF DIABETES IN
PREGNANT FILIPINO WOMEN
First Prenatal Visit
Draw blood for FBS, HbA1C or RBS

FBS <92mg/dl FBS >/=126mg/dl

RBS <200mg/dl RBS >/=200mg/dl
HbA1C < 6.5% HbA1C >/=6.5%
FBS >92 and <126 mg/dL
NORMAL GDM OVERT DM
MALPRESENTATION (“SUHI”)
 Risk factors:

-early gestational age -placenta previa

-fundal placental implantation -pelvic tumors
-high parity with uterine relaxation -prior breech delivery
-abnormal amniotic fluid volume -multifetal gestation
-hydrocephaly -anencephaly
-uterine anomalies
External cephalic version
- success rate 35-86%
- Before labor at 36 wks aog
Contraindicated if vaginal delivery is not an option
(placenta previa or non reassuring fetal status,
rupture of membranes, known uterine malformation,
multifetal gestation and recent uterine bleeding, prior
uterine incision is relative)

Success – multiparity, abundant amniotic fluid,

unengaged presenting parts, fetal size 2500 to
3000grms, posterior placenta and non obese patient
Complications: placental abruption, uterine rupture, fetomaternal,
preterm labor, fetal compromise and death (maternal death due to
amniotic fluid embolism)
Technique: area that has ready access to a facility equipped to perform
emergency CS
Ultrasound-confirm presentation, AF volume, exclude fetal
anomalies, placenta location
FHR monitoring (NST)
Tocolysis
Internal cephalic version – second of twin; inside uterine cavity
POST PREGNANCY
POSTPARTUM DISORDER
(POSTPARTUM BLUES)
 POST PARTUM BLUES
-time limited period of heightened emotional reactivity
experienced by half of women w/in app the 1st wk after
delivery, peaks on the 4th or 5th postpartum day and
normalizes by day 10
-prevalence 26-84%
-the predominant mood is HAPPINESS; affected mothers
are more emotionally labile, and insomnia, weepiness,
depression, anxiety, poor concentration, irritability
SEPSIS (PUERPERAL INFECTION)
Puerperal sepsis
is an infective condition in the mother
following childbirth. It is the third most
common cause of maternal death worldwide
as a result of child birth after haemorrhage
and abortion. According to World Health
Organization (WHO) estimates puerperal
sepsis accounts for 15% of the 500000
maternal deaths annually.
 PUERPERAL SEPSIS
-any bacterial infection of the genital tract after delivery
-fever T 38 C or higher
Uterine infection – postpartum uterine infection/puerperal
sepsis
Predisposing factors:
Route of delivery is the single most significant RF (increased
in CS)
ruptured membranes, prolonged labor, multiple cervical
laceration (5-6% in vaginal delivery)
TUBAL LIGATION/FAMILY
PLANNING METHODS
- puerperal sterilization performed in conjunction with cs or
vaginal delivery; non puerperal time unrelated to pregnancy
contraceptive failure: 0.5%
-surgical errors (transaction of the round ligaments/partial
transaction of the ft)
-fistulous tract or spontaneous reanastomosis
-in interval sterilization, the woman may have been pregnant at the
time of surgery