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A4 obstetrics note

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A4 obstetrics note

  1. 1. OBSTETRICS AND GYNECOLOGY FOR Health Science Students Lecture Note Hawassa Health Sciences College Hawassa University
  2. 2. Obstetrics and Gynecology For Health Science Students Lecture Note Samson Negussie, Assistant Professor M.D. Obstetrician and Gynecologist April 2006 In collaboration with The Carter Canter (EPHTI) and The Federal Democratic Republic of Ethiopia Ministry of Education and Ministry of Health
  3. 3. TABLE OF CONTENTS Preface i Acknowledgement ii About the lecture note iii Abbreviations v SECTION ONE – BASICS CHAPTER 1 Reproductive anatomy, physiology and embryology 1 CHAPTER 2 Obstetric and gynecology evaluation 9 SECTION TWO – NORMAL AND ABNORMAL PREGNANCY CHAPTER 3 Normal physiology and diagnosis of pregnancy 17 CHAPTER 4 Common minor disorders of pregnancy 22 CHAPTER 5 Antenatal care 27 CHAPTER 6 Abnormal bleeding during first and second trimesters of pregnancy 31 CHAPTER 7 Antepartum hemorrhage 44 CHAPTER 8 Hypertensive disorders of pregnancy 49 CHAPTER 9 Disturbances of amniotic fluid 55 CHAPTER 10 Premature rupture of membranes and preterm labour 58 CHAPTER11 Multiple pregnancy 63 CHAPTER12 Rh isoimmunization 67 CHAPTER13 Medical disorders of pregnancy 70 SECTION THREE – NORMAL AND ABNORMAL LABOUR CHAPTER 14 Physiology and management of normal labour 84 CHAPTER 15 Induction and augmentation of labour 92 CHAPTER 16 Operative deliveries 97 CHAPTER 17 Malpresentations and malpositions 105 CHAPTER 18 Dystocia 115 CHAPTER 19 Obstructed labour and ruptured uterus 121 CHAPTER 20 Fetal distress 127 SECTION FOUR – NORMAL AND ABNORMAL PEUPERIUM CHAPTER 21 Normal puerperium and its management 131 CHAPTER 22 Postpartum hemorrhage 135 CHAPTER 23 Postpartum complications 141 SECTION FIVE – GYNECOLOGY CHAPTER 24 Menustral cycle and its abnormalities 147 CHAPTER 25 Climacteric and related problems 158 CHAPTER 26 Vaginal discharge and vulvar pruritis 161 CHAPTER 27 Pelvic inflammatory disease 167 CHAPTER 28 Family planning 171 CHAPTER 29 Infertility 179 CHAPTER 30 Tumor conditions of the female genital tract 183 CHAPTER 31 Uterovaginal prolapse and urinary incontinence 193 PREFACE Ethiopia is one of the countries in the world with unacceptably high maternal mortality rate. Various strategies are being implemented to reduce this rate and improve the overall health of women. One such strategy is ensuring the provision of preventive, curative and i
  4. 4. rehabilitative health services to the population by improving access and quality of services by training competent midlevel and front line health workers. Currently a number of higher learning institutions are involved in the training of health officers. One of the objectives of health officer training is producing competent professionals capable of delivering comprehensive emergency obstetric care and managing other common gynecologic problems. One of the problems encountered during the training is shortage of standardized training materials gauged to meet the objective of the health officers training. Different training institutions use different text materials and the emphasis given to different topics varies. The emphasis given to common obstetric and gynecologic topics prevalent in resource poor countries varies greatly. The Ethiopian Public Health Training Initiative (EPHTI) has recognized this critical problem and was involved in development of standardized training materials (modules and lecture notes) in different public health and clinical subjects. This lecture note is prepared to help in standardizing the training in different teaching institutions. It also aims to provide a quick reference for students and is believed to initiate further reading. This final version was designed and prepared to address the needs of health officer training. It emphasizes mainly on detection, diagnosis and management of emergency obstetrics problems and common gynecologic diseases. ii
  5. 5. ACKNOWLEDGEMENT My deepest gratitude goes to The Carter Center and the Ethiopian public health training initiative for providing technical and financial support. Special thanks goes for Ato Aklilu Mullugeta whose unrelenting follow up made this lecture note a reality. The following people were involved in the development of the first draft and need to be credited: Dr. Habtemariam Tekle (Gondar University), Drs. Fassil Mengistu and Endris Mohammed (Debub University), Dr Mussie Abera (Alemaya University) and Dr. Zerai Kassaye (Jimma University). I am highly indebted to Dr. Solomon Kumli, Dr. Yirgu G/Hiwot of Addis Ababa University, Gynecology and Obstetric department for their constructive comments and suggestions without which this lecture note wouldn’t have takes its present shape. iii
  6. 6. ABOUT THE LECTURE NOTE Organization This lecture note is organized into five sections. The first section deals with the basic topics needed to deal with obstetrics and gynecology. A short summary of anatomy, physiology and embryology of the female genital tract is followed by an outline of obstetric/ gynecologic history and physical examination. The second section deals with normal changes of pregnancy, antenatal care and various antenatal complications of pregnancy. The third section gives description of normal and complicated (abnormal) labour along with their management. The fourth section is entitled for puerperium and abnormalities associated with postpartum period. The final section deals with normal menustral cycle and different gynecologic problems. Review questions follow each chapter. Because of repetition of reference materials used for each topic, the author preferred to give references for the different topics are given at the end of each section. Malpresentations are included in section three (normal and abnormal labour) because of their importance in terms of maternal and neonatal complications is related to their occurrence in labour and the need to stress the different emergency maneuvers used in malpresentation for a health officer student. In section five (gynecologic section) related topics are lumped under one chapter. Tumor conditions of the female genital tract are organized into benign and malignant conditions. Preparation Preparation of this lecture note was started some 18 months back. Representatives from four different universities (Alemaya, Jimma, Gondar and Debub now Awassa) divided the topics among themselves and took the task of developing the first draft. The then Debub University (now Awassa University) took the task of compiling and editing the first draft. During this reviewing/ editing process a number of problems were encountered. The major one is most of the draft developed was so detailed and did not take into consideration the level of competence required of a health officer. The other is failure to get the first draft from some of the universities in time. Internal reviewing done on the available draft suggested significant remodeling to be done on the first draft. Modification/ rewriting of the first draft to meet the above objective could not be done in time because of the fact that most of the professionals involved in the development of the first draft left their respective universities. So finalization of the lecture note was delayed. After discussion with the responsible people in The Carter Center, the author took the responsibility of reshaping and rewriting the final version of this lecture note. During this preparation the curriculum for health officer training, the first draft iv
  7. 7. and different references were consulted and appropriate modifications were made. Financial and other technical support was provided by The Carter Center. This final version was designed and prepared to address the needs of health officer training. It emphasizes mainly on detection, diagnosis and management of emergency obstetrics problems and common gynecologic diseases. Conditions that can not be diagnosed/ managed at a health center setting and/ or require specialist care are omitted or are briefly mentioned. Application This lecture note is designed to be used by a health officer student as a guide for further reading. It can also be used as a quick reference by other cadre of health science students (medical students, midwives and nurses) taking obstetrics and gynecology as part of their training. It can be used as a reference by instructors of Obstetrics and Gynecology. Limitations This lecture note is by no means a replacement for standard texts in obstetrics and gynecology. It only gives an outline of the important aspects of the topics that are relevant for health officer training. It omits detailed description of some aspects of the topics involved. Some topics not included in the curriculum are not included in this lecture note. Sophisticated and recent diagnostic/ treatment modalities not applicable in the setting a health officer works and details of pathogenesis are not given due emphasis. The user is thus advised to use the mentioned references for such details. v
  8. 8. ABBREVIATIONS ACTH – Adrenocorticotrophic hormone AFI – Amniotic fluid index ANC – Antenatal care ARM – Artificial rupture of membranes APH - Antepartum hemorrhage AUB – Abnormal uterine bleeding BPD – Biparietal diameter CPD – Cephalopelvic disproportion C/S – Caesarian section DNA – Deoxyribonucleic acid DUB – Dysfunctional uterine bleeding DVT – Deep vein thrombosis E&C/ D&C – Evacuation and curettage/ dilatation and curettage EDD – Expected date of delivery FHB – Fetal heart beat GH – Growth hormone GTD – Gestational trophoblastic tumors HCG – Human chorionic gonadotrophic hormone HDP – Hypertensive disorders of pregnancy HPO – Hypothalamo pitutary ovarian axis IUCD – Intrauterine contraceptive devise LMP/LNMP – Last menustral period/ last normal menustral period MSH – Melanocyte stimulating hormone MTCT – Mother to child transmission MVA – Manual vacuum aspiration vi
  9. 9. OCP – Oral contraceptive pills OL – Obstructed labour PAC – Post abortion care PID – Pelvic inflammatory disease PIF – Prolactin inhibitory factor PIH – Pregnancy induced hypertension PMI - Point of maximum impulse PMS - Premenstrual syndrome PPH - Post partum hemorrhage PROM - Premature rupture of membranes POP – Progestin only pills RH - Rhesus factor STD/STI – Sexually transmitted diseases/ sexually transmitted infections TORCH TSH – Thyroid stimulating hormone UTI – Urinary tract infection VDRL – Venereal disease research laboratory vii
  10. 10. Obstetrics and Gynecology PART I: BASICS CHAPTER 1 REPRODUCTIVE ANATOMY, PHYSIOLOGY AND EMBRYOLOGY By Dr. Habtemariam Tekle Learning objective To know the anatomy of the female reproductive system To know the physiology of the female reproductive system To know the normal development of the female genital tract Introduction It is mandatory to know the anatomy and physiology of the female reproductive system to manage obstetric and gynecologic problems. 1. ANATOMY OF THE FEMALE PELVIC ORGANS 1.1. External female genitalia (vulva or pudendum ) 1.1.1. Anatomic landmarks The vulva includes mons pubis, labia majora, labia minora, clitoris, vestibule and perineum which are all visible on external examination. It is bounded anteriorly by the mons pubis, laterally by the labia majora and posteriorly by the perineum. A. Mons Pubis It is the pad of subcutaneous fatty tissue in front of the pubis. It is covered by the pubic hair in inverted triangle fashion. B. Labia majora It is the elevation skin and subcutaneous tissue which forms the lateral boundaries of the vulva. Posteriorly each labia majora fuses medially to form the posterior commissure. The labia majora contains sebaceous glands, sweat glands and hair follicles. The dense connective tissue and adipose tissue beneath the skin is richly supplied with venous plexus which may produce hematoma, if injured. The labia majora are homologous with the scrotum in the male. 1
  11. 11. Obstetrics and Gynecology C. Labia minora These are two thick skin folds, devoid of fat, lying on either side within the labia majora. Anteriorly they are divided to enclose the clitoris and unite with each other in front and behind the clitoris to form the prepuce and frenulum respectively. Posteriorly each labia minora fuse to form a fold of skin called fourchette. Labia minora don not contain hair follicle. It is homologous with the ventral aspect of the penis. D. Clitoris This is a small cylindrical erectile body situated in the most anterior part of the vulva. It consists of the glans, body and two crura. It is analogous to the penis in the male. E. Vestibule It is a triangular space bounded anteriorly by the clitoris, posteriorly by the fourchette and on either side by labia minus. There are erectile tissues bilaterally situated beneath the mucus membrane called the vestibular bulb. Each bulb lies anterior to the Bartholin’s gland and is incorporated within the bulbocavernous muscles. They are homologous to the single bulb of the penis and corpus spongiousum in the male. There are four openings into the vestibule. I. Urethral opening which is situated in the midline just anterior to the vaginal orifice. II. Vaginal orifice which is located posterior to the urethral opening. In virgins and nulliparous the opening is closed by the labia minora but in parous, it may be exposed. The orifice is incompletely closed by a septum of mucus membrane called hymen. III. Bartholin’s duct opening (one on each side): The Bartholin’s glands are situated in the superficial perineal pouch posterior to the vestibular bulb. It secretes abundant alkaline mucus, during sexual excitement which helps in lubrication. Each gland has got a duct which opens just anterior to the Hymen. The Bartholin’s gland corresponds to the bulbourethral gland in the male. F. Perineum (Perineal body) This is a pyramidal shaped tissue where the pelvic floor and the perineal muscles and fascia meet. It is located between the vagina and the anal canal. 2
  12. 12. Obstetrics and Gynecology 1.1.2. Blood supply of the Vulva A. Arteries Branches from the internal pudendal arteries (labial artery, transverse perineal artery, artery to the vestibular bulb and deep and dorsal arteries to the clitoris) and femora artery (superficial and deep pudendal arteries) supply the different parts of the vulva. B. Veins The veins of vulva form plexus and drain into internal pudendal vein, vesical or vaginal venous plexus and the long saphenous vein. 1.1.3. Nerve supply to the vulva It is supplied by cutaneous branches from the ilioinguinal, genital branches of genitofemoral nerve, pudendal branches from the posterior cutaneous nerve of the thigh and labial and perineal branches of pudendal nerve. 1.2. Internal female genital organs The internal genital organs in female include vagina, uterus, fallopian tubes and the ovaries. These require special instruments for inspection. A. Vagina It is a fibro-musculo-membraneous canal communicating the uterine cavity to the exterior at the vulva. It has four walls: anterior, posterior and two lateral walls. The length of the anterior wall measures 7 centimeters and the posterior wall is about 9 centimeters. The projection of the cervix through the anterior vaginal wall at the top of the vagina (vault) creates clefts known as fornices. There are four fornices (anterior, posterior and two lateral). Its wall is composed of four layers. The four layers from within to outwards are mucus membrane lined by stratified squamous epithelium, sub mucous layer, muscular layer( inner circular and outer longitudinal) and fibrous coat. The vaginal secretion is very small but sufficient to make the surface moist. The pH is acidic and ranges between 4.0- 5.5 in reproductive age groups. The Doderlin’s bacilli are responsible for conversion of Glycogen from the exfoliated squamous cells to lactic acid. The vagina serves as excretory channel for menstrual blood and uterine secretions, organ for sexual intercourse and passage for the fetus during birth. 3
  13. 13. Obstetrics and Gynecology Blood supply The arteries supplying the vagina are cervico vaginal branch of the uterine artery, vaginal artery (a branch fro internal iliac artery), and middle rectal and internal pudendal artery. These anastomose with one another and form two azygous arteries, one anterior the other posterior. Veins drain into internal iliac and internal pudendal veins. B. Uterus This is a hollow pyriform muscular organ situated between bladder and rectum. It is normally anteverted and anteflexed. It measures 8 centimeters long, 5 centimeters wide and 1.25 centimeters thick. It has three parts. I. Body or corpus which is the part between the isthmus and the opening of the fallopian tubes. The part that is above the opening of the fallopian tubes is called the fundus. II. Isthmus is a constricted part situated between the body and the cervix. It measures about 0.5 centimeters. III.Cervix is the lower most part of the uterus which is cylindrical in shape and measures about 2.5 centimeters. It is divided into supravaginal part (part lying above the vagina) and portiovaginalis (which lies within the vagina). It has two openings the internal os and the external os with cervical canal in between. The uterine wall consists of three layers. I. Perimetrium is the serous coat covering the underlying myometrium II. Myometrium consists of thick bundles of smooth muscles arranged in various directions. III. Endometrium is the mucus lining of the endometrial cavity. It consists of the surface epithelium and laminia propiria.The surface epithelium is a single layer of ciliated columnar epithelium and the lamina propria contains stromal cells, endometrial glands, vessels and nerves. Blood supply The arterial supply is mainly from the uterine artery and the other sources are vaginal and ovarian arteries. The venous channel corresponds to the arterial course and drain into internal iliac veins. 4
  14. 14. Obstetrics and Gynecology C. Fallopian Tube The uterine tubes are paired structures which are attached to the lateral angle of uterine cavity. It has four parts intramural or interstitial (part inside the uterine wall), the isthmus (the straight part), ampulla (the tortuous part) and the infundibulum. The abdominal ostium is surrounded by a number of radiating fimbria, one of these is longer than the rest and is attached to the outer pole of the ovary - ovarian fimbria. D. Ovary Ovaries are paired sex glands or organs. Each measures 3centimetres by 2 centimeters by 1 centimeter. Each is attached to the uterus by the utero-ovarian ligament, to the lateral pelvic wall by infundibulopelvic ligament and to the posterior wall of the broad ligament by the meso-ovarium. They are covered by a single layer of germinal epithelium. The substance of the ovary has cortex and medulla. The cortex is the functional layers which include primordial follicles, mature follicles, Graffian follicles, corpus luteum and atretic follicles or corpus albicans. Medulla consists of loose connective tissue, muscle cells, blood vessels and nerves and hilus cells. Blood supply Arterial supply is from the ovarian artery, a branch of the abdominal aorta. Venous drainage is through pampiniform plexus to form ovarian veins which drain to inferior vena cava on the right side and to the left renal vein on the left side. Nerve supply It receives sympathetic supply from T10. 2. PHYSIOLOGY OF THE FEMALE REPRODUCTIVE ORGANS The physiology of female reproductive system is concerned with the functions from birth through puberty and adult hood to the menopause. This is achieved through the neuroendocrine mechanism that involves the cortico-hypothalamic-pituitary-ovarian axis. The hypothalamo pitutary ovarian axis is a well coordinated axis and the hormones liberated from the hypothalamus, pituitary and the ovary are dependent on one another. The secretion of the hormones from these glands is modified through feedback mechanisms operating through this axis. The axis may also be modified by hormones liberated from the thyroid and adrenal glands. 5
  15. 15. Obstetrics and Gynecology A. Hypothalamus It produces specific releasing and inhibitory hormones or factors which have effect on the production of pituitary hormones. I. Gonadotrophic releasing hormones (GnRh) is concerned with the synthesis storage and release of gonadotrophic hormones, FSH and LH. II. Prolactin inhibitory factor/ hormone (PIF) inhibits the release of prolactin. III. Thyrotrophin releasing hormone (TRH) stimulates the release of TSH. IV.Corticotrophin releasing hormone (CRH) stimulates the release of ACTH. V. Growth hormone releasing hormone stimulates the release of growth hormone. B. Pituitary It has two parts, the anterior pituitary (adenohypophysis) and the posterior pituitary (neurohypophysis). The adenohypophysis produces I. Gonadotrophins which include follicle stimulating hormone (FSH) and leutinizing hormone (LH). FSH is mainly stimulates the growth and maturation primary ooytes of which only one develops into graffian follicle. In conjunction with LH, it is also involved in ovulation and steriodeogenesis. The main function of LH is steriodeogenesis but along with FSH, it is responsible for full maturation of the Graffian follicle and ovulation. II. Prolactin is responsible for the production of the milk in the breast. III. The other hormones TSH (thyroid stimulating hormone), ACTH (adrenocorticosteroid hormone), GH (growth hormone) and MSH (melanocyte stimulating hormone). C. Ovary The function of ovary is ovulation and production of ovarian hormone. The major ovarian hormones are estrogen and progesterone, also called the female sex hormones. The other hormones produced by the ovary are androgens and inhibin. Estrogen is produced by granulosa cells. Its functions include I. Development of female secondary sexual characteristics including deposition of fat in the breast, thighs & hips and growth and development internal & external female genital organs. II. Decreases FSH and LH secretion by negative feedback mechanism during the menstrual cycle except at mid cycle at which time it increases LH secretion by positive feedback mechanism. 6
  16. 16. Obstetrics and Gynecology III. In the breast it stimulates the growth of the ducts and fat deposition. Progesterone is secreted by the lutenized theca granulosa cells. Its functions are I. Increases the glandular secretions of the endometrium and diminishes the contractility of myometrium. II. Stimulates the growth of the acini in the breast. III. In large doses it inhibits LH secretions. IV. Increases basal body temperature. Androgens are produced mainly by the theca interna cells. They are source for estrogen synthesis. Inhibin and relaxin are other hormones produced by ovary. Hypothalamo-Pituitary-Ovarian (HPO) Axis at different stages of life I. Fetal life- HPO axis remains active and functional from 20 weeks of life. II. Infancy and childhood- high level of FSH and LH at birth gradually decline and minimum level achieved by two years of age. III. Prepuberity – hypothalamus is very much sensitive to negative feedback by even a small amount of estrogens (estrogen produced by peripheral conversion of testosterone to estrogen). Hence, FSH and LH secretions are inhibited. IV. Puberty –hypothalamus become more insensitive to estrogen to estrogen negative feedback. Hence increasing amounts of GnRH, FSH and LH are secreted, which in turn stimulate the ovary to secrete estrogen and progesterone. This eventually results in thelarche, adrenarche and menarche. V. Pregnancy- the gonadotrophins level remains low. VI. Menopause- ovarian follicles become scarce and resistant. Hence FSH and LH levels increase while estrogen and progesterone levels decrease. 3. EMBRYOLOGY OF THE REPRODUCTIVE ORGANS Introduction In early pregnancy, both internal and external genital organs are undifferentiated. During development, because of “X” and “Y” chromosomes and other hormones, the undifferentiated genitalia differentiate either to male or female genital organ. Male sex is an induced sex because it requires specific messages to develop. Genital and urinary systems are in close proximity. During development of one system induces the development of the other system. This explains why congenital malformations of genital system are often associated with abnormalities of urinary and musculoskeletal system. 7
  17. 17. Obstetrics and Gynecology Development of gonads On fourth week after fertilization, primordial germ cells migrate from yolk sac through the mesentery of the hind gut to the posterior body wall mesenchyme at the tenth thoracic level. Their arrival induces proliferation of adjacent mesonephros and celomic epithelium to from the genital ridge. The celomic epithelium forms the cortex, the mesenchyme forms the medulla and the germ cells originate from the endoderm. This stage of gonadal development is called the indifferent stage (bipotential gonads). Further development is influenced by the Y chromosome which has the sex determining region (SRY). In its presence the indifferent gonad develops into testis. In its absence like in XX or XO fetus it develops into an ovary. In further development of the ovary the medulla regresses to form rete ovary and the cortex forms the ovarian follicles. Between the seventh and ninth months the ovary descends to the pelvis to be attached to the ligaments. Development of internal female genital organs Two major ducts give rise to the internal genital organs, namely the Wollfian duct (male duct) and the Mullerian duct (female duct). In the presence of testis the Wollfian duct develops (effect of testosterone produced by Leydig cells) and the Mullerian duct regresses (effect of Mullerian regressing factor produced by the Sartoli cells). But, in the absence of functional testis the reverse happens. The Mullerian duct is formed by invagination of celomic epithelium. The two Mullerian ducts grow downwards and medially. Eventually their lower ends fuse into one. Further development results in cavitations to form hollow organs at fifth month of gestation. The fallopian tubes develop from upper unfused horizontal part of the Mullerian duct. Uterus develops from intermediate horizontal and adjoining vertical part of Mullerian duct. The lining epithelium and glands develop from coelomic epithelium. Myometrium and endometrial stroma arise from mesoderm. Broad ligament is formed as a broad transverse fold as the Mullerian ducts approach midline. It extends from lateral side of fused duct to pelvic side wall. It has vestigial remnants like epoophoron, paroophoron and ducts. Vagina is formed in third month of gestation. There are two concepts for the development of vagina. One says the whole vagina is developed from the urogenital sinus. The other argues that vagina is mainly developed from Mullerian duct with only one third contributed by the urogenital sinus. 8
  18. 18. Obstetrics and Gynecology Development of External genital Organs In the fifth week of embryonic life, folds of tissue form on each side of cloacae. Development of coronal partition, called urorectal septum, separates the endodermal cloacae into two parts. The dorsal part, which at its lower end is covered by the anal membrane, develops into rectum and anal canal. The ventral part which is now called the urogenital sinus develops into the external genital organs. It lower end is lined by the bilaminar urogenital membrane. The site of fusion between urorectal septum and the urogenital membrane is the primitive perineal body. Further development of the urogenital sinus differentiates it into three parts. The upper or vesicourethral part forms the mucus membrane of bladder and major part of female urethra. The middle pelvic part receives the united caudal part the two paramesonephric (Mullerian) ducts in the midline. It later gives rise to the epithelium of the vagina, the Bartholin’s gland and the hymen. The lower phallic part is lined by the bilaminar urogenital membrane. The phallic part has one genital tubercle, and two genital folds and urogenital swellings (labioscrotal folds). Clitoris is developed from the genital tubercle. Labia minora are developed from the genital folds. Labia majora are developed from urogenital swellings (labioscrotal swellings). Bartholin’s Glands develop as out growth from the caudal part of the urogenital sinus. Vestibule develops as urogenital groove from urogenital sinus. Hymen is developed from the junction of the sinovaginal bulbs and urogenital sinus. Some congenital malformations Failure of development of both mullerian ducts results in absence fallopian tubes, uterus, and upper two thirds of vagina (Mullerian agenesis). Failure of development of one mullerian duct results in unicornuate uterus with single oviduct. Failure of recanalization of the lower part of the fused Mullarian duct results in isolated atresia of upper vagina and cervix causing hematometra. Failure of fusion of mullerian duct depending on the degree results in uterus didelphys with two cervix and vagina canals, arcuate uterus and uterus bicornis. Fallopian tube abnormalities are not common. Rarely accessory ostia or diverticulum or abnormally short or long tubes may occur. Failure of canalization of the urogenital membrane results in imperforate hymen. Failure of development of the external genitalia results in ambiguous genitalia. Reminants of Wollfian duct result in Gartner’s cyst found in the upper part of the vagina. 9
  19. 19. Obstetrics and Gynecology CHAPTER 2 OBSTETRIC AND GYNECOLOGIC EVALUATION By Dr. Habtemariam Tekle Learning objective: · To enable the student take proper history and physical examination to reach to the diagnosis. Introduction To come to a clear understanding of a patient’s problem, detailed history and physical examination is important. 1. OBSTETRICS HISTORY & PHYSICAL EXAMINATION 1. History 1.1. Identification · Name · Age – significant if less than 20 years and greater than 35 years · Martial status · Address- far distance from health institution · Religion · Occupation · Date of admission · Ward and bed number 1.2. Chief complaints- Patients may have come for routine antenatal care follow up or may come with one or more specific complaints. Note the duration of each complaint. 1.3. History of present pregnancy Get information on the following points · Gravidity- all forms of pregnancy whether it is term, live births, still birth, abortion, ectopic pregnancy or molar pregnancy. · Parity- fetus delivered after 28 weeks of gestation for Ethiopia and United kingdom and greater than or equal to 20 weeks – according to WHO 10
  20. 20. Obstetrics and Gynecology · Abortion · Last normal menstrual period (LNMP) · Expected date of delivery (EDD) which could be calculated by 1- Naegale’s rule (using European calendar) - LNMP- 3 months + 7 days 2- Ethiopian calendars · NLMP+ 9 months +10 days if pagume is not passed · NLMP+ 9 months + 5 if pagume is passed ( 4 in leap year ) · Calculate gestational age in completed weeks and days · Quickening – the first time the mother felt fetal movement - In primigravida it is around 18-20 weeks and in multigravida at 16-18 weeks of gestational age. - Used to date pregnancy if LNMP is unknown · Presence of antenatal care elsewhere. place and number of visits. · Elaboration of chief complaints · Danger symptoms of pregnancy (vaginal bleeding, severe headache, blurring of vision, epigastric or severe abdominal pain, profuse vaginal discharge, absence or reduction of fetal movement, fever, persistent vomiting) · Common complaints in pregnancy ( like nausea and vomiting, weakness · Pregnancy - unplanned , unwanted and unsupported · Ask positive and negative statement according to the patient complaints 1.4. Past obstetric history The following should be asked for all previous pregnancies in chronologic order · Date, month and year of gestation for example first delivery in May 2000 · Length of gestation - abortion (< 28 weeks), preterm (<37 completed weeks), term (>37 completed to 42 completed weeks), post term (greater than 42 completed weeks) 11
  21. 21. Obstetrics and Gynecology · Significant antenatal medical problems like hypertension, ante partum hemorrhage, diabetes · Onset of labor (spontaneous or induced) · Fetal presentation · Duration of labor · Mode of delivery (spontaneous vaginal, instrumental, caesarian section, destructive delivery) · Fetal outcome (alive or dead, sex of the newborn, weight of the newborn, malformations, current condition) · Post partum complications postpartum hemorrhage 1.5. Gynecology history · Family planning methods - use , type , duration and side effects · Sexual history- assess risk of sexually transmitted infections and HIV/AIDS · Gynecology operations- Female genital mutilation , laparatomy, dilatation and curettage ,evacuation and curettage, manual vacuum aspiration · Menstrual history ( age of menarche, interval of period 21-36 days, amount of flow 10 –80 ml, duration of flow 1-8 days, normally dark red and non-clotting). 1.6. Past medical and Surgical History · History of diabetes mellitus, hypertension, hypo or hyper thyroidism which may the affect pregnancy or get aggravated by pregnancy · Blood transfusion important in hemolytic disease of new born · Drugs risk of teratogenicity or allergic reactions · Maternal infection – TORCH Syndrome. 1.7. Personal, family and social history · Childhood development 12
  22. 22. Obstetrics and Gynecology · Educational status · Habits like alcohol , smoking and elicit drugs · Occupation- exposure to radiation, anesthesia- halothane, chemical factory and others · Income- low socio-economic status associated with obstetric problems like preeclampsia ,preterm labor · Family history- diabetes mellitus, hypertension, multiple pregnancy, genetic disorders 1.8. Review of Systems · Check all systems 2. Physical examination Examination must be done in a private room in the presence of a chaperone. Proper explanation must be offered to the patient before during and after the examination. Bladder should be emptied and the patient properly positioned on the couch. Warm hands and instruments must be used. Adequate light, appropriate gloves and swabs should be prepared. Always keep eye contact throughout the examination. 2.1. General appearance 2.2. Vital signs and anthropometric measurements · Blood pressure positions include left lateral with 300 tilt to the left to avoid supine hypotensive syndrome or sitting position in ambulatory patient. · Pulse rate -increases 10-15 beats/minute in pregnancy · Respiratory rate -increases 1-4 breath /minute in pregnancy · Temperature · Weight – increment of more than 1kg/week is abnormal · Height- less than 150 centimeters could be constitutional but may be a risk factor. Strikingly short for every society is risk factor. 2.3. HEENT 13
  23. 23. Obstetrics and Gynecology · Emphasis on conjunctiva, sclera, teeth and buccal mucus membrane to see pallor, jaundice, mucosal congestion and dental carries. 2.4. Lymphoglandular System · Thyroid gland for hyper or hypo thyroidism signs. · Breast for nipple refraction, pigmentation, lumps, discharge, colour change 2.5. Respiratory and cardiovascular system Steps in examination are essentially same as non pregnant patient. Note that the following are normal findings in pregnancy. · Decreased diaphragmatic excursion due to diaphragm elevation by gravid uterus · PMI deviation to left is possible in pregnancy · S3 gallop may be heard · Functional systolic murmur may be heard 2.6. Abdomen 2.6.1Inspection · Linea nigra- midline hyper pigmentation due to melanocyte stimulating hormone · Striae gravidarum – purplish in new striae and white in old striae. In both cases is due to distension, which causes stretching. · Umbilicus may be inverted, flat or everted · Surgical or non surgical scar · Distended veins, flank fullness, fetal movement 2.6.2. Palpation · Superficial palpation – checks for rigidity, tenderness, superficial mass and characterize it, abdominal wall defects. · Deep palpation – palpate for mass, organomegally and characterize the mass · Obstetric palpation or Leopold’s maneuver 14
  24. 24. Obstetrics and Gynecology A. The first Leopold maneuver or fundal palpation I. Fundal height measurement: first correct for asymmetry before measurement. Then use one of the following methods: 1- Finger method – one finger above umbilicus is equal to two weeks and below umbilicus one finger is equal to one week. Uterus felt at symphysis corresponds to 12 weeks. At the umbilicus it is 20 weeks and at xiphysternum it is 38 weeks. 2- Tape measurement: symphysis to funded height in centimeter with tape meter between 18-34 weeks is accurate to within two weeks of actual gestational age. II. Determine what occupies the fundus. If soft, irregular bulky mass is found it is the breech. If hard round ballotable mass is found, it is the head. B. The second Leopold maneuver or lateral palpation I. Determines the lie of the fetus which could be longitudinal, transverse or oblique lie. . II. In longitudinal lie it determines on which side of the abdomen is the fetal back. The back of the fetus is linear, rigid and smooth in outline. The extremities are felt as small irregular and bulky masses. The fetal heart beat is best heard on back side. C. The third Leopold maneuver or Pelvic palpation I. Determines what part of the fetus occupies the lower uterine pole which is also called the presentation. The possibilities are the head (cephalic presentation), the breech (breech presentation), and the shoulder (shoulder presentation). II. In cephalic presentations it determines the descent by using rule of fifth which measures the distance between upper border of the symphysis to anterior shoulder. 5/5 is floating head, 4/5 is fixed head, 2/5 denotes engaged head. III. In conjunction of the findings of the second maneuver it determines the attitude of the fetus (relation of head to the trunk). In extended attitude the cephalic prominence is on the same side of the 15
  25. 25. Obstetrics and Gynecology back. In flexed attitude the cephalic prominence is on the opposite side of the back. In military attitude the cephalic prominence is felt on both sides at the same level. D. The fourth Leopold maneuver or Pawlik grip It is the only maneuver that is done with one hand. It assesses presentation of he fetus. 2.6.3. Percussion · Shifting and flank dullness · Fluid thrill 2.6.4. Auscultation · Fetal heart beat is first heard in the back side at16-18 weeks in multiparas and 18-20 weeks in primigravida. In complete breech it is heard above umbilicus. In cephalic presentations it is below umbilicus .IN occipito posterior it is heard in the flanks. . 2.7. Genitourinary system · Costovertebral and suprapubic tenderness · Pelvic examination- to be done two times in pregnancy except in cases of complications and if labor is suspected I. First trimester (early) – To diagnose pregnancy, for dating of the pregnancy by measuring uterine size and to diagnose pelvic problems II. Late in pregnancy greater than 37 weeks A. To diagnose contracted pelvis (refer chapter on) - B. To assess Bishop score- (refer to chapter on induction) III. In labor assess cervical dilatation and effacement, status of the membranes and color of liquor, presenting part, station of presenting part and position, molding, caput, clinical pelvimetry. 2.8. Intgumentary system · Hyper pigmentation on breast, lower and mid line abdomen genitalia are normally seen in pregnancy · Vascular Changes- Spider angiomata and palmar erythema 16
  26. 26. Obstetrics and Gynecology 2.9. Extremities · Check for edema, dilated vessels and calf tenderness. Dependent edema (pretibial and pedal), seen in 80% of normal pregnancies. Pathological edema (non dependent) involves the face, fingers or the whole body. 2.10. Central nervous system · As non pregnant 2. GYNECOLOGY HISTORY AND PHYSICAL EXAMINATION 1. History 1.1. Identification · As obstetric history 1.2. Chief complaints Patient comes with the following gynecologic complaints. The common complaints are cessation of menses, vaginal bleeding and discharge, lower abdominal pain or deep pelvic pain, pain during intercourse (dysparunia), pain during menstruation (dysmenorrhea), protruding mass out of the introitus, genital ulcer, urinary incontinence and others. 1.3. History of present illness · Gravidity, parity and abortion · Detail of each complaint (localization, duration, date and time of onset, aggravating and relieving factors, sequence of symptoms, evolution with time, effect on life style, relation to menstrual cycle and others) · LMP should be included details of menstrual history if pertinent to the complaints · Negative and positive statements pertinent to the presenting complaint · Treatment received 17
  27. 27. Obstetrics and Gynecology 1.4. Menstrual history · Age of menarche · Interval between period · Duration of flow · Amount & character of flow · Dysmenorrhea , premenstrual symptoms · Age of menopause 1.5. Gynecologic history · As obstetric history 1.6. Past obstetric history · As obstetric history 1.7. Past medical and surgical history · As obstetric history 1.8. Personal social family, history · As obstetric history 1.9. Review of systems · As obstetrics history 2. Physical examination Preparation for examination is similar to obstetric examination. In addition slides, applicator, test tube, gloves, speculum and fixative are needed. 2.1. General Condition 2.2. Vital signs · Blood pressure,pulse rate, respiratory rate, temperature 2.3. HEENT · As nonpregnant 2.4. Lymphoglandular system 18
  28. 28. Obstetrics and Gynecology · Lymph nodes- to see for metastatic cancer check mainly supraclavicular and axillary nodes. · Thyroid gland- hypo and hyper thyroidism affects reproductive function · Breast examination- inspection and palpation 2.5. Chest and cardiovascular system · As non pregnant 2.6. Abdomen · As non pregnant (Inspection, auscultation, palpation and percussion) 2.7. Genitourinary system · Costovertebral and suprapubic tenderness · Pelvic examination I. Examination of external genitalia Pubic hair- diamond shaped in male and inverted triangle in female. Labia majora and minora – ulcer, swelling and ` discoloration Discharge from urethra and vaginal introitus Hymen- intact or torn II.Speculum Examination Vagina- note color (normally pink), vaginal septum, rugae folds, fornices, discharge, scar, laceration Cervix – note color (normally pink) pink, cervical os (pin- pointed in nulliparous and slit-like in multiparous), dilatation, effacement and bleeding, mass III. Digital vaginal & bimanual pelvic examination Vagina- mass and tenderness 19
  29. 29. Obstetrics and Gynecology Cervix- Closed normally, moves 2- 4cm with out discomfort, smooth surface and like tip of nose in consistency. Uterus- normally non-tender, mobile, 9 cm in length, pear shaped smooth and firm. Adnexa (tubes, ovaries, parametrium and broad ligaments): normally adenexal structure not palpable except in thin women with soft abdomen, description of masses. IV- Rectal and recto vaginal examination Rectal examination- In virgin and children Rectovaginal examination- For rectovaginal and uterosacral ligament nodularity or malignant infiltration To differentiate rectocele from enterocele 2.8. Intgumentary · As non pregnant 2.9. Extremities and central nervous system · As non pregnant PART II NORMAL AND COMPLICATED PREGNANCY 20
  30. 30. Obstetrics and Gynecology CHAPTER 3 NORMAL PHYSIOLOGY & DIAGNOSIS OF PREGNANCY Learning Objective: To describe the important physiologic changes in each organ system during pregnancy To describe the diagnosis of pregnancy 21
  31. 31. Obstetrics and Gynecology Introduction- Pregnancy results in tremendous changes in the physiologic functions of organs, systems and the body as whole. These changes ensure that the needs of the growing fetus are met and prepare the mother for parturition and lactation. Changes in the maternal endocrine system along with hormones produced by the placental / fetal unit are responsible for majority of the changes. Knowledge about changes due to normal pregnancy is important to reassure the pregnant woman and manage the minor disorders of pregnancy. Understanding the normal physiologic changes also gives us the basis to understand the abnormal conditions during pregnancy. Terminologies Pregnancy is a maternal condition of having a developing fetus in the body. It starts at fertilization where fusion of the ovum (23x) and matured spermatozoa (23x or 23y) takes place in the fallopian tubes. Zygote (46xx or 46xy) is a cell that results from fertilization. The zygote divides and redivides forming daughter cells named blastomeres. When the zygote reaches 16 cell stage, it is named morula. When fluid filled cavity appears in the morula a blastocyst is formed. The cells of a blastocyst are arranged into layers. The outer layer is called the trophoblast which eventually develops into the placenta. The inner layer is called the embryoblast which later gives rise to the fetus. The embryo is the stage after the inner layer formed two layers (bilaminar disc). The embryonic period is a period where major structures are formed and extends up to the end of seven weeks after fertilization. Developing conceptus after the embryonic period is called the fetus. All tissue products of conception (embryo/ fetus, fetal membranes and placenta) are called conceptus. On day 4 after fertilization the blastocyst enters into the uterine cavity. By day 7, it starts embedding itself into the prepared endometrium which is now called the decidua. This process is called implantation. Placenta and its hormones The placenta is formed from the trophoblast and decidua basalis. It contains villi covered by the cytotrophoblast and syncitiotrophoblast. The placental barrier (formed by the syncitiotrophoblast, cytotrophoblast, the basement membrane and the fetal vascular endothelial cells) ensures almost complete separation of the maternal and fetal blood. For this reason the human placenta is of hemo-chorio- endothelial type. In a mature placenta the villi are grouped into 15- 20 cotyledons, each supplied by one to two spiral arterioles. At 20 22
  32. 32. Obstetrics and Gynecology weeks the discoid placenta reaches full development. The placenta on average has a diameter of 18 centimeters, a thickness of 23 millimeters, a volume of 497 milliliters, a weight of 508 grams and villous surface area of 15 square meters. Placenta is a blue red discoid organ with two surfaces. The maternal surface is made of the decidua basalis with visible septated cotyledons. The fetal surface is smooth and shiny and is covered by the amnion. The branching fetal vessels are visible under the amnion. The placenta acts to the fetus as the lung (exchange of oxygen and carbon diaoxide), gastro intestinal tract (provision of nutrients), kidney (excretion of hydrogen ion and urea), liver (detoxifies drugs), immunologic system (transfer of antibodies) and endocrine gland (production of hormones). It is connected to the fetus by the umbilical cord or the funis. It has an average length of 50- 60 centimeters (range 30- 100) and diameter of 0.8- 2 centimeters. It contains two umbilical arteries and one umbilical vein. In addition to acting as conduit for umbilical vessels, it also allows fetal mobility. Placenta is a source of incredible amounts of protein and steroid hormones. The major protein hormone is human chorionic gonadotrophic hormone (HCG), also called the pregnancy hormone. It has two subunits the alpha and the beta subunits and is produced in increasing amount to reach a peak between 8 -10 weeks. It maintains the function of the corpus luteum until the placenta takes over progesterone production. It also plays important role in male sex differentiation by stimulating testosterone production by the fetal testis. It also forms the basis for laboratory diagnosis of pregnancy. In addition placenta produces a number of protein hormones. It is also a source of significant amounts of progesterone and estrogens. Since placenta lacks some of the enzymes necessary to synthesize estrogens, it relies on provision os substrates by the fetus and the mother (fetal-placental –maternal unit). Organ system changes I. Cardiovascular system Cardiac out put increases by 30-50%. The increase in cardiac output is mainly distributed to the uterus (major share), kidneys, breast and the skin. Heart rate increases by 15-20 % and stroke volume increases by 25-38%. 23
  33. 33. Obstetrics and Gynecology Blood pressure remains largely unchanged with small drop in diastolic pressure. This is the result of progesterone mediated reduction in peripheral resistance. Blood pressure highest when seated, lower when supine and lowest when ling on the side. Near term there is a tendency to develop hypotension when women lie on their back, a condition called supine hypotension syndrome. Total blood volume increases up to 45%. Plasma volume increases 35-50% where as red blood cell volume increases by 20-25%. This results in hemodilution leading to a drop of hemtocrite and is called physiologic anemia of pregnancy. Venous pressure rises in lower extremities and central venous pressure unchanged as the result of pressure by the gravid uterus. This may result in leg edema and development of varicose veins. The point of maximum impulse is shifted to the left as the result of elevation of the diaphragm. Splitting of the first and second heart sounds could be found. High cardiac out put state may result in gallop and systolic functional murmurs. II. Respiratory System Vasodilatations of the nasal vessels result in nasal stuffiness and epistaxis. Diameter and circumference of chest increase. Altered sense of smell is commonly reported. To meet the increased oxygen consumption respiratory rate increases. Because of elevation of the diaphragm by the gravid uterus, diaphragmatic excuration decreases. III. Alimentary tract Appetite increases but nausea and vomiting in the morning, which typically occur in the first trimester, may reduce food intake. Pica (craving for unusual food items of very low nutritional value like clay and soap) if excessive may result in nutritional deficiencies. Ptyalism (inability of nauseated women to swallow normal amount of saliva) is an early symptom of pregnancy. There is no increased production of saliva by the salivary glands. Gums are edematous and soft. Gum bleeding and acceleration of dental caries from reduction in oral PH occur. Epulis gravidarum, a tumorous gingivitis with pedunculated lesions rarely occurs and may cause significant bleeding. Heartburn due to relaxed esophageal sphincter is a common complaint. Decreased gastric acid secretion and increased gastric mucus secretion result in relief of symptoms of peptic 24
  34. 34. Obstetrics and Gynecology ulcer disease in majority of women. Delay in gastric emptying is responsible for increased tendency of aspiration pnumonitis in pregnant women undergoing general anesthesia. Progesterone induced reduction in peristalsis helps in absorption of nutrients and water from the small and large intestines. As the result constipation is common and hemorrhoids could occur. IN the gall bladder residual volume increases and stasis of bile occurs. This, along with increased biliary cholesterol saturation, favors gall stone formation. There are no significant changes in the anatomy of the liver. Liver function tests are normal except elevation of alkaline phosphatase, whose origin is the placenta. Spider angiomata and palmar erythema, which are signs of chronic liver disease, are normal findings in pregnancy. IV. Urinary System There is enlargement of the kidneys. The renal calyces and ureters show dilatation which causes stasis of urine. Bladder tone is also reduced resulting in increased capacity and incomplete emptying after urination. These changes make a pregnant woman vulnerable to urinary tract infections. Renal plasma flow increases by 75% and glomerular filtration rate by 50%. Creatinine clearance is also increased. Blood urea nitrogen, creatinine and uric acid levels decrease. Plasma osmolality falls. There is increased glucose and amino acid excretion. Protein loss amounts to 100-300mg/day. V. Intgumentary and skeletal system Vascular changes include spider angiomata and palmar erythema. Cortisol induced changes in connective tissue result in striae gravidarum. Increased levels of melanocyte stimulating hormone cause hyper pigmentation of the nipples, areola, axilla, perineum, umbilicus and linea Alba (forms linea nigra). The mask of pregnancy (chloasma or melasma) is seen on the cheek bones. Increased secretion of sweat and sebum are other features. Occasionally pigmented nevi are seen. In an attempt to maintain the center of gravity, there is exaggerated lordosis and drooping back of the shoulders. This leads to common complaint of back ache. Parasthesia of the hands may be caused if there is excessive drooping of the shoulders, which stretch the brachial plexus. Loosening of ligaments of symphysis pubis and sacroiliac joint by relaxin causes is aimed to facilitate vaginal delivery. Pelvic discomfort and gait problems may arise occasionally. 25
  35. 35. Obstetrics and Gynecology VI. Hematology Red blood cell indices increase. White blood cell counts rise. Platelet count falls. Most coagulation factors increase creating a hypercoagulable state. VI. Endocrine & metabolic Changes. There is massive increase in placental hormones mainly estrogen, progesterone, human chorionic gonadotrophic hormone and human placental lactogen. Of the pitutary hormones, follicle stimulating, leutinizing and growth hormones are reduced, while prolactin levels are high. There is no change in thyroid stimulating and adrenocorticotrophic hormones. Thyroid gland shows diffuse enlargement with euthyroid state. There is significant elevation of plasma cortisol levels. Pregnancy has a diabetogenic effect due to peripheral insulin resistance caused by high levels of anti insulin hormones like human placental lactogen. VII. Genital Systems Uterus increases in weight from 70 gm of non pregnant state to 1000gm at term. Uterine blood flow reaches 600ml/minute with 85% supplying the placenta. Increased vascularity gives the vagina and the cervix bluish color. The cervix becomes soft from congestion. Increased vaginal discharge may be noted. Corpus luteum begins to regress at the eight week due to negative feed back mechanism of estrogen and progesterone on pitutary. VII. Breast Both acinar and ductal breast growth occur due to increased estrogen, progesterone and prolactin levels. Erectile capacity increases. But lactation is inhibited by placental progesterone which prevents the action of prolactin on the production of lactaalbumin. VIII. Immune system HCG reduces immune response of the mother. Serum IgG, IGm and IgA decrease from tenth week to thirtieth week then they will remain at same level. IX. Weight gain in pregnancy On average 12.5 kilograms is gained during pregnancy (range 9kg -15kg).The average distribution is as follow: the fetus 3300 gm, the placenta 600 gm, amniotic fluid 800 ml, uterus 26
  36. 36. Obstetrics and Gynecology 900-1000 gm, breast 400 gm, blood 1200 ml, deposition of fat 2500gm and extra cellular fluid 2600 ml. Diagnosis of pregnancy It is based on symptoms, signs and additional investigations. I. Presumptive findings of pregnancy · Weakness or fatigue · Nausea and/or vomiting · Breast swelling and tenderness · Increased frequency of Urination · Amenorrhea · Discoloration of vaginal mucosa · Increased skin pigmentation & striae · Quickening · Constipation, weight gain II. Probable findings of pregnancy · Uterine enlargement · Change in consistency of cervix & uterus · Ballottement rebound-16-20 weeks 27
  37. 37. Obstetrics and Gynecology · Braxton Hicks contraction · Positive pregnancy test · Symptoms as presumptive finding III. Positive findings of pregnancy · Fetal movement perceived by the health personnel · Fetal heart beat heard by fetoscope (18 weeks) or Doppler (10 weeks) · Fetal heart beat and fetal body seen by ultrasound Pregnancy tests All employ changes in the levels of HCG molecule which can be detected in the maternal serum as early as nine days. Tests include biologic tests and immunologic tests (agglutination, radioimmunoassay, radio receptor assay and ELISA). Review questions 1. Describe the physiologic changes in the cardiovascular system during pregnancy. 2. Discuss the diagnosis of pregnancy. 28
  38. 38. Obstetrics and Gynecology CHAPTER 4 MINOR DISORDERS OF PREGNANCY Learning Objectives · To describe the minor disorders of pregnancy of pregnancy. · To discuss the management of the common minor disorders of pregnancy. Introduction The physiologic and anatomic changes of pregnancy may result in development of symptoms and signs that could be managed by educating and providing explanation. 1. Nausea and vomiting (morning sickness) Some degree of nausea and vomiting during first trimester especially between the first and the second missed periods is a very common complaint. It usually continues until about the fourteen weeks of gestation. It can appear at any time of the day but is generally worse in the morning, thus the name morning sickness. This condition is believed to be caused by high or rapidly rising level of human chorionic gonadotrophic hormone and estrogen. It is worse in multiple pregnancy and gestational trophoblastic diseases. Psychological problems like anxiety can aggravate the situation. Eating small feedings at more frequent intervals and avoiding food items whose smell precipitate or aggravate the symptoms helps in relieving this problem. If persistent, anti-emetics can be given. 2. Heartburn Heartburn, epigastric burning sensation, is one of the most common complaints of pregnant women especially during late pregnancy. The symptom is usually mild. It is caused by reflux of gastric content into the lower esophagus due to upward displacement and compression of the stomach by the enlarging uterus and progesterone induced relaxation of the lower esophageal sphincter. 29
  39. 39. Obstetrics and Gynecology It is relieved by having smaller meals, avoiding bending over or lying flat. Antacid preparation (aluminum hydroxide or magnesium trisilicate alone orb in combination). In severe cases H2 - blockers like cimetidine and ranitidine can be used safely. 3. Pica Pica, craving of pregnant woman for items of low nutritional value like ice (pagophagia) or clay (geophagia), can occur. No known cause has been identified but it is known to be common in patients with iron deficiency anemia. In these cases, it is relieved by correction of anemia. Some pregnant women may have the symptom with out anemia. Educating the woman is all that is needed. 4. Ptyalism Ptyalism, excessive salivation, is also common. It is not related to increased saliva production; rather it is the result of reduced swallowing from nausea. Simple explanations will suffice. 5. Constipation Progesterone induced relaxation of smooth muscles and pressure by the uterus in the latter part of pregnancy result in the common complaint of constipation. The problem is more common with consumption of low fiber diet. This condition can be treated with high fiber diet and increasing fluid intake. Sometimes bulk forming laxatives may be needed. 6. Hemorrhoids Hemorrhoids, varicosities of the rectal veins, may first appear during pregnancy. More often pregnancy causes exacerbation or recurrence of previous hemorrhoids due to increased pressure in the rectal veins caused by obstruction of venous return by the large uterus. Constipation during pregnancy also contributes for development of hemorrhoids. Hemorrhoids can be asymptomatic or present with rectal bleeding, rectal pain or as a prolapsed mass through the anal orifice. The later one can be strangulated and cause severe pain. Thrombosis occurring in the dilated veins can also cause severe pain. 30
  40. 40. Obstetrics and Gynecology Treatment includes topically applied anesthetic and anti-inflammatory agents for pain and swelling, warm soaks (sitz bath), laxatives and modification of bowel habits. Surgery is reserved for thrombosed and strangulated hemorrhoids. 7. Urinary frequency Increased glomerular filtration rate and in the latter part of pregnancy pressure by the enlarging uterus explain the common complaint of frequency of urination. Urinary tract infection is also common as the result of incomplete emptying of the bladder and stasis of urine. Microscopy of urine must be done in all cases. Once UTI is ruled out simple explanation is enough. 8. Vaginal discharge Pregnant women normally develop increased vaginal discharge in many instances. It is clear, whitish and odorless. This is the result of estrogen mediated increased mucus secretion by the cervical glands. Reassurance is usually sufficient. If it is a cause of concern vaginal douche with water mildly acidified with vinegar can be used. Vaginal infections like trichomoniasis and candidiasis should be ruled out in every patient with this symptom. Recurrent vulvo - vaginal candidiasis is common. Curd like vaginal discharge and vulvar pruritis are major manifestations. Identification of Candida albicans by potassium hydroxide stains confirms the diagnosis. Treatment with antifungal vaginal suppositories suffices. Systemic antifungals are contraindicated. . 9. Low Back and pelvic pain Exaggerated lordosis and relaxation of the lumbar ligaments cause the common complaint of low back pain. Minor degrees of pain may follow excessive strain or fatigue, bending, lifting or walking. Its severity increases with the duration of pregnancy. Low back pain can be reduced by having the woman squat rather than bending over when reaching down, providing back support with a pillow when sitting down, and avoiding high heeled shoes. 31
  41. 41. Obstetrics and Gynecology Severe back pain with localized spinal tenderness should not be attributed simply to pregnancy and further evaluation is needed. Relaxation of the joints of the pelvic girdle, cause pelvic pain and gait abnormalities. In severe cases there may be tenderness over the symphysis pubis which prevents mobility. This condition is called pelvic osteoarthropathy and necessitates admission. 10. Varicose veins Varicose veins, dilatation of the superficial veins of the lower extremities, could develop in predisposed women. It becomes more prominent as pregnancy advances, weight increases, and the length of time spent upright is prolonged. It is due to progesterone mediated smooth muscle relaxation of the blood vessels and increased venous pressure in the femoral veins due to compression by the enlarging uterus. In most, it is asymptomatic. The only concern in these women is cosmetic. In few it causes discomfort of variable degree. Treatment is periodic rest with elevation of legs and use of elastic stocking or both. Surgical corrections like injection of sclerosing agents, ligation and stripping are not generally advisable during pregnancy. 11. Dependent edema Edema of the lower extremities is common. It is as the result of increased venous pressure of the lower extremities. It appears near the end of the day and disappears after a period of rest. It is important to rule out preeclampsia especially in those with persistent dependant edema. 12. Other complaints Fatigue is the other common complaint during early pregnancy. The woman will have a desire for excessive sleep. This symptom remits spontaneously by the fourth month of the pregnancy and has no special significance. Palpitation is another common complaint. If significant, cardiac pathologies must be ruled out. Chloasma and striae are other sources of concern for which no treatment is required. These often regress but may not totally resolve after delivery. 32
  42. 42. Obstetrics and Gynecology Occasionally women complain about leg cramps. It is believed to be the result of phosphorous deficiency and is relieved by dietary adjustment. Parasthesia of the hands which usually occurs in the morning signify stretching of the roots of the brachial plexus by drooping back of the shoulders in an attempt to maintain the center of gravity. Epistaxis and gum bleeding occur as the result of vascular congestion and do not need special treatment. In rare cases surgical excision is needed for tumorous condition of the gums called Epulis gravidarum. Hyperemesis gravidarum Severe nausea and repeated vomiting that precludes oral intake and leads to dehydration and ketoacidosis is termed as hyperemesis gravidarum. I. Pathophysiology The cause is unknown but high levels of estrogen and HCG, vitamin B 6 deficiency and psychologic factors are implicated. It is common in molar pregnancy, multiple pregnancy and those with family or past history of this condition. Because of starvation ketone bodies are formed from metabolism of fatty acid. Some of the ketone bodies appear in the urine. In an attempt to restore the PH of the blood the respiratory rate increases. Inadequate fluid intake results in dehydration, weight and reduced urine output. Alkalosis from loss of gastric hydrochloric acid in the vomitus and hypokalemia also develop. II. Diagnosis Presence of exaggerated nausea, excessive vomiting, weight loss and signs of dehydration like fatigue, dry oral mucosa, weak pulse, low blood pressure and reduced urine are hallmarks of this condition. Ketone in the urine confirms the diagnosis after exclusion of other possible causes of excessive vomiting. III. Differential diagnosis 33
  43. 43. Obstetrics and Gynecology Gastroenteritis, cholecystitis, hepatitis, pyelonephritis, intestinal parasitosis, peptic ulcer disease and drug induced vomiting should be ruled out by history, physical examination and laboratory investigations. IV. Management Once the diagnosis is confirmed the woman should be admitted after counseling of the partners. The modalities include: · Restricting oral intake · Correcting dehydration and electrolyte deficit by intravenous crystalloid solution preferably lactated ringer solution to maintain fluid balance · Correcting acidosis by providing calories in the form of glucose in the intravenous fluids · Treating underlying causes by parenteral vitamin B 6 (if unavailable vitamin B complex) · Parenteral antiemetics like promethazine , chlorpromazine or metoclopramide · Treatment of identified medical problems · Monitor response to treatment by subjective feeling of the patient, weight, urine out put and urine ketone determination With clinical response, the patient can be started on oral feeding and antiemetics continued. Therapeutic abortion is an option if the condition persists despite aggressive medical treatment. V. Complication Prerenal azotemia, Mallory-Weis tears in the esophagus, in prolonged cases Werinkes encephalopathy from thiamine deficiency. 34
  44. 44. Obstetrics and Gynecology Review Questions 1. Describe the measures that may be taken in a pregnant mother with nausea and vomiting. 2. Discuss the possible causes of severe nausea and vomiting during pregnancy. 3. Describe important measures that may be taken in order to relieve the heartburn that occurs during pregnancy in some mothers. 35
  45. 45. Obstetrics and Gynecology CHAPTER 5 ANTENATAL CARE (ANC) Learning objective · To discuss the contents of ANC, frequency and time of visit · To describe the new WHO antenatal care model · To enumerate high risk factors in pregnancy Introduction- Antenatal care (ANC) is a medical and general care that is provided to pregnant woman during pregnancy. It is goal oriented with the aim of meeting both the psychological and medical needs of pregnant woman with in the context of health care delivery system, culture 36
  46. 46. Obstetrics and Gynecology and religion in which the woman lives. ANC programs should be based on local situation and should address risk assessment, health promotion and care provision. ANC has been found to be effective in the treatment anemia, hypertension and sexually transmitted diseases. Frequency and timing of visit Traditional or standard (Western) model recommends the first visit to take place as early as the first missed period. This allows accurate dating of the pregnancy and design appropriate preventive and therapeutic interventions. Thereafter, subsequent visits are planned every four weeks until 28 weeks, every two weeks between 28-36 weeks and every week after 36 weeks. More frequent visits are required for high risk patients. The new WHO ANC model recommends a minimum of four visits. It limits the number of visits and restricts laboratory tests and procedures. First visit takes place at 16 weeks or before. The second visit is planned between 24-28 weeks, the third at 32 weeks and the fourth at 36- 38 weeks. The initial visit takes 30-40 minutes and the other visits take around 20 minutes each. Women with risk factors should not be enrolled in this model. Activities of the new WHO ANC model I. First visit at 16 weeks Major activities are diagnosis of pregnancy and determination of the gestational age; risk assessment and determination of the medical status of the mother; health promotion by education on nutritional supplement, danger signs of pregnancy and finally care provision like malaria prophylaxis, control MTCT of HIV, iron supplementation and immunization with tetanus toxoid. II. Second visit between 24- 28 weeks Major activities are screening for hypertension, multiple gestation, anemia, preterm labor, diabetes mellitus and RH sensitization; further health promotion and care provision and plan birth place. III. Third visit at 32 weeks Major activities are screening for hypertension, anemia, multiple pregnancy, diabetes mellitus and RH sensitization; health promotion and care provision and plan birth place. 37
  47. 47. Obstetrics and Gynecology IV. Fourth visit at 36 weeks Major activities are screening for hypertension, antepartum hemorrhage, multiple gestations; check for fetal lie, presentation, growth and well being; health promotion and care provision and finally up date individualized birth plan. Contents of ANC visit I. Assessment Detailed history and physical examination (refer to chapter 2) along with necessary laboratory investigations should be done in the initial visit to assess the general medical status of the woman and pick risk factors. For this reason the initial visit takes 30-40 minutes. Subsequent visits look into new developments, therefore, take much shorter time. A. Initial visit The pertinent elements of the history during the initial visit include 1. History of present Pregnancy- identification (name, age, address, marital status, occupation); pregnancy facts (planned or unplanned pregnancy, wanted or unwanted, supported or unsupported); gravidity , parity, abortion, LMP, gestational age, contraceptive use prior to pregnancy, symptoms and signs of pregnancy , danger signs and symptoms, fetal quickening , client concern or complaints 2. Past history - antepartum and postpartum hemorrhage, multiple pregnancy, preeclampsia, eclampsia, sepsis, sexually transmitted infections, operative deliveries, still birth and neonatal death, preterm delivery, low birth weight baby, chronic medical illnesses (hypertension, diabetes, drug allergy and cardiac diseases) and surgical problems, genital mutilation 3. Others- personal, social and family history General physical examination as described in chapter 2 should be performed. It includes the general appearance, vital signs, weight and height, general systemic examination including checking for signs of anemia, physical abuse and surgical scars. Specific obstetric examination should focus on determining the uterine size, fetal lie and presentation, fetal growth and well being, fetal heart beat. Pelvic assessment is performed upon indications. 38
  48. 48. Obstetrics and Gynecology In the standard model baseline laboratory investigations are hemtocrite, blood group and Rhesus factor, urinalysis (protein, ketone and microscopy), VDRL and stool examination for ova and parasites. Others that could be done upon indication or when resources permit are pap smear, cervical /vaginal smear, urine culture and sensitivity, complete blood count, pregnancy test, serology for HIV, hepatitis b virus and TORCH screening, oral glucose tolerance test, maternal serum alpha fetoprotein on 16 weeks, amniocentesis ,ultrasonography and others. In the new WHO model urine dip stick for bacteria and protein, VDRL and blood group and Rhesus factor determination are only done in the first visit. Hemtocrite is only done if there are clinical signs of anemia. In the new WHO model, in the initial visit women are grouped into two using the classifying form. Women with out any risk factor are enrolled in the basic component of the new model that needs only three visits till delivery. Women with any identified risk factor need special care that may need frequent visits or even referral for specialized care. The classifying form has 18 components that are grouped into three: · Obstetric history- previous stillbirth/ neonatal loss, history of three or more consecutive abortions, birth weight of less than 2500 or more than 400 grams, admission in the last pregnancy for preeclampsia or hypertension, previous uterine or cervical surgery- · Current pregnancy - diagnosed or suspected multiple pregnancy, age less than 16 or more than 40, RH isoimmunization, vaginal bleeding, pelvic mass, diastolic blood pressure of more than 90 mmhg · General medical condition- insulin dependent diabetes mellitus, renal or cardiac disease, known substance abuse, any other severe medical illness B. Subsequent visits History focuses on new complaints and problems since the last visit, intercurrent illnesses and medications, quickening time and fetal movement, danger symptoms of pregnancy and any changes in the personal history of the woman. Physical examination focuses on the general appearance, vital signs mainly the blood pressure, weight, checking for signs of anemia, fundal height, fetal lie and presentation, fetal heart beat, leg edema and other examinations based on the complaints. 39
  49. 49. Obstetrics and Gynecology In the standard model hemtocrite is done at 24-28 and 32 weeks, antibody screening and oral glucose tolerance test at 28 weeks, ultrasound and maternal alpha feto protein at 16 weeks and fetal survellance tests starting 32 weeks. In the new WHO model dipstick of urine for bacteria is done in all visits. Urine dipstick for protein is only done for nulliparous women or for those with history of preeclampsia or hypertension currently. Hemtocrite is done at the third visit. II. Health promotion (advice and counseling) Advice the woman about the importance of balanced diet and avoidance of drugs, smoking and alcohol: adequate rest; hygiene and safe sex. Discuss about minor complaints of pregnancy and the danger symptoms of pregnancy. Discuss about whom to contact and where to go if these symptoms develop. Inform the woman to record the time of quickening. Education about labor and preparation for labor/ delivery should be done starting from the third visit. The need for clean and safe delivery should be stressed. Breast feeding and family planning after delivery should be discussed. III. Care provision (care provided) Individualized delivery plan in should be planned starting from the first visit and continued during subsequent visits including arrangement of transportation in cases of emergency. Place of birth and who attends birth should be planned. Universal ferrous sulfate prophylaxis for nutritional anemia should be given starting from the first visit. Tetanus toxoid vaccination should be given according to WHO guidelines. Appropriate prophylaxis and treatment of intestinal parasites and malaria should be offered. Where indicated antiretroviral therapy should be offered to HIV positive pregnant women. Appropriate management of complaints and identified problems/ complications should be done in each visit. Timing and importance of next visit should be discussed. Appointment should then be scheduled. High risk factors (not inclusive) I. Past obstetric history · Ectopic pregnancy and recurrent spontaneous abortion · Multiple pregnancy or preterm labor 40
  50. 50. Obstetrics and Gynecology · Antepartum or postpartum hemorrhage · Malpresentation · Intrauterine fetal death, stillbirth or early neonatal death · Birth weight of less than 2500 or greater than 4000 grams · Difficult operative deliveries and caesarian section II. Present obstetric history · Short stature (height of less than 150 cm), age of less than 16 or greater than 40 · Primigravida or grandmultiparity · Vaginal bleeding at any gestational age · Uterine size to gestational age discrepancy (big or small for date uterus) · Multiple gestation · Premature rupture of the membranes · Raised blood pressure during pregnancy · Malpresentation after 34- 36 weeks · Unwanted pregnancy · Extreme social disruption and deprivation Review questions 1. Briefly describe the new WHO ANC model. 2. List the routine laboratory investigations in ANC. 3. List the high risk factors in pregnancy. 41
  51. 51. Obstetrics and Gynecology CHAPTER 6 ABNORMAL BLEEDING DURING FIRST AND SECOND TRIMESTERS OF PREGNANCY Learning objectives · To identify the common causes of abnormal bleeding during pregnancy by trimester. · To list the different types of abortion with their clinical features. · To describe the clinical feature of ectopic pregnancy. · To describe the management the different types of abortion and ectopic pregnancy. · To define the spectrum of GTD · To discuss the clinical features of GTD 42
  52. 52. Obstetrics and Gynecology · To list the main treatment modalities of GTD · To enumerate the possible complications GTD and their treatment Introduction When a woman becomes pregnant, the menstrual bleeding stops until sometime after the end of the pregnancy. However, abnormal bleeding from the genital tract can complicate some pregnancies. Statistically, more than 25% of all gestations will present to health care provider at least in early pregnancy with vaginal bleeding and/or pelvic pain. These symptoms may indicate a minor or a life threatening condition that can result in death. Successful management of any one of these conditions is of paramount importance and rests on timely diagnosis. This in turn requires proper evaluation of the patient by taking the history and doing physical examination. There may be a need to do some laboratory studies to help the evaluation process. The primary goal of the evaluation should focus on identifying immediate life threatening conditions like shock. Generally, abnormal uterine bleeding during pregnancy can result from obstetric or non-obstetric causes. Conditions like abortion, ectopic pregnancy, placenta abnormalities like placenta previa and abruptio placentae, and gestational trophoblastic diseases are some of the obstetric causes. While conditions like genital infections, trauma to the genital organs and neoplastic changes affecting them are some of the non-obstetric causes. Systemic illnesses affecting blood coagulation can also result in abnormal bleeding during pregnancy. 1. ABORTION 1.1. Importance Abortion is an important cause of bleeding during pregnancy, as it is one of the five leading causes of maternal death in the developing world. The other causes being obstructed labor, hypertensive disorders of pregnancy, hemorrhage and infection. 1.2. Definition: Abortion is the expulsion of the fetus from the uterus or termination of pregnancy before fetal viability. This is usually taken to be so if it happens before 28 completed weeks of gestation or less than 1000g weight in Ethiopia & United Kingdom. 1.3. Classification 43
  53. 53. Obstetrics and Gynecology 1.3.1. By occurrence Abortion could occur spontaneously or could be induced. A. Spontaneous abortion An abortion is said to be spontaneous if it occurs with no intervention. The incidence of spontaneous abortion is between 10% and 20% of all pregnancies. It is most commonly due to fetal chromosomal defects such as trisomies, monosomies and polyploidy. This usually occurs during the first trimester. B .Induced abortion An abortion is said to be induced if it results from medical or surgical intervention that can cause abortion. It could be safe or unsafe abortion. Unsafe abortion characterized by lack or inadequacy of skill of provider, hazardous technique and unsanitary facilities or both. This is important type of abortion as it accounts for the major proportion of abortion and is cause of immense maternal mortality and morbidity. Moreover, it is related to unwanted pregnancy and unawareness of the reproductive physiology by the woman .It can largely be prevented if there is provision of contraceptive service and making the woman knowledgeable about her reproductive physiology. Of the 210 million pregnancies that occur each year, about 46 million (22 per cent) end in abortion. About 20 million of those abortions are unsafe –that is, performed by someone without the skills or training to perform them safely, or in a place that does not meet minimal medical standards or, both. Every year, more than 70,000 women die as a result of unsafe abortion; hundred of thousands more suffer from serious, often permanent, disabilities. Everyday, 200 women die from unsafe abortion. More than 95% of deaths and injuries occur in developing countries. In Ethiopia maternal losses from abortion and its complication account for 25-50%. The majority of deaths from abortion result from hemorrhagic shock and sepsis. Proper management of abortion can prevent the death and the other complications that result from it. C.Therapeutic abortion Subset of safe abortion which is performed for the purpose of saving the life of the mother (3) or if the fetus has congenital / chromosomal / metabolic disorders that is incompatible with life after birth. 1.3.2. By clinical stages Threatened abortion: is a clinical condition that is characterized by vaginal bleeding before 28 weeks of gestation. In addition there is crampy lower abdominal pain and the cervix 44
  54. 54. Obstetrics and Gynecology remains closed. The fetus is alive and there is a chance of continuing the pregnancy to viability. Inevitable abortion: is a clinical condition characterized by vaginal bleeding of variable amount and crampy lower abdominal pain. The cervix is open but no products of conception have been expelled. There is no chance of salvaging the pregnancy. Incomplete abortion: is a clinical condition in which vaginal bleeding continues and cervix remains open despite expulsion of part of the products of conception. Complete abortion: is a clinical condition in which vaginal bleeding stops and the cervix closes following expulsion of all products of conception. The uterus is small for the duration of the pregnancy and it is firmer. Before 14-16 weeks it is difficult to tell if an abortion is complete or not because to make sure it is complete one has to identify the fetus and the placenta with the membranes as fully formed structures. Before 14-16 weeks these structures are not sufficiently well formed. Missed abortion: is a clinical condition in which the fetus dies in utero and is retained for at least four weeks. There is usually history of threatened abortion preceding it. Decidual necrosis may result in brownish vaginal discharge. Pregnancy symptoms like morning sickness, breast tenderness and abdominal girth increment disappear. Cessation of fetal movement is reported by the mother if it occurs after 18 weeks. Failure of uterine growth results in small for gestational age uterus. Pregnancy test takes 8 weeks to become negative. 1.3.3. By associated infection Septic abortion: is a clinical condition in which offensive vaginal discharge, temperature of more than 38 o centigrade and lower abdominal pain / tenderness accompany any of the clinical stages of abortion. Majority follow unsafely induced abortions. Infection starts in the uterus and if untreated spreads to adjacent pelvic organs (pelvic peritonitis) or to the general peritoneum (generalized peritonitis) or the blood stream (sepsis). It eventually results in death by causing septic shock. Postabortal sepsis: is pelvic infection after a complete abortion. 1.3.4. Other definitions Recurrent abortion: occurrence of three or more consecutive spontaneous abortions. It was previously known as habitual abortion. 45
  55. 55. Obstetrics and Gynecology 1.4. Initial assessment Any woman of reproductive age experiencing at least two of the following symptoms should be considered as a possible abortion patient. · Vaginal bleeding · Cramping and/or lower abdominal pain · A possible history of amenorrhea Complete clinical assessment is necessary to determine all conditions that are present in order to decide the order in which to treat them. 1.4.1. History · Length of amenorrhea · Bleeding (duration, amount) · Cramping (duration and severity) · Abdominal or shoulder pain · Drug allergy · History of interference and method employed · Symptoms of infection 1.4.2. Physical examination · Check vital signs · Note general health of the women · General systemic examination · Abdominal examination Check –abdominal distension, movement with respiration, bowel sound, Location and severity of tenderness and rebound tenderness, Uterine size, masses, shifting dullness · Pelvic examination(speculum and bimanual digital examination) 46
  56. 56. Obstetrics and Gynecology Remove any visible products of conception from the vaginal canal or cervical canal. Then note for the amount of bleeding and presence of offensive discharge, the extent of cervical dilation and presence of cervical excitation tenderness, size and consistency of the uterus, adenexal masse and other pelvic masses. Check for cervical laceration 1.4.3. Laboratory examination Based on clinical assessment when indicated: - · hemoglobin / hemtocrite, blood group and rhesus factor · white cell count, erythrocyte sedimentation rate, urinalysis, renal function test, liver function test, platelet count, prothrombin time, partial thromboplastin time · Plain film of the abdomen (erect), pelvic ultrasonography · Pregnancy test 1.5. Management Life threatening conditions like shock (hypovolumic or septic), severe anemia and sepsis should be treated aggressively prior to instituting specific treatment. These include intravenous fluids, parenteral antibiotics, blood transfusion and /or other ventilatory supports. Preparations for laparatomy must be made in cases suspected or diagnosed to have uterine perforation or generalized peritonitis or pelvic abscess. Specific management for each stage of abortion should be offered only after attending to the above conditions. Appropriate and timely referrals are life saving. 1.5.1. Threatened abortion · Bed rest at home which could be reinforced by sedatives like diazepam. Women who have bled much (regardless of the gestational age) or have bad obstetric history or live far away and cannot get help if bleeding becomes much worse, especially during the night should be admitted for observation. · Avoid intercourse and douching · Monitor progress by subsequent assessment. Where available ultrasonography should be done to check for viability. · If there is any sign of pelvic infection evacuation of the uterus should be performed. 47
  57. 57. Obstetrics and Gynecology 1.5.2. Complete abortion If completeness is confirmed either by examination of the conceptus tissue or where available by ultrasound · Administer ergometrine 0.5mg · If justified provide therapeutic or prophylactic antibiotics Evacuation of the uterus must be done if completeness can not be assured as in early abortion or expulsion occurred out of the health institution. 1.5.3. Inevitable abortions A. Less than 14 weeks of gestation: Evacuation of the uterus is the mainline of treatment .Evacuation can be done either by sharp metallic curettage or by manual vacuum aspirator (MVA). MVA is much safer and recent technology which is said to be associated with less complications and pain, more efficient in evacuating the uterus in less time and thus can safely be used by lower level health professionals. Mandatory indications for evacuation 1. Considerable bleeding 2. Bleeding which continues for more than 24 hours. 3. Patients in whom the retained products of conception are obviously still present on vaginal examination.. B. More than 14 weeks of gestation In the absence of heavy bleeding evacuation of the uterus is not advised before the expulsion of the fetus .Management includes · Admission and monitoring the vital signs and the amount of bleeding · Once the fetus / placenta are expelled completeness should be checked .Evacuation of the uterus must be done if incomplete or the bleeding continues. · Ergometrine or oxytocin as drip should be given for continued bleeding after expulsion or evacuation and monitoring should continue. · Exploration of the uterus for remnants or perforation should be done if these measures fail and the patient continues to bleed. 48
  58. 58. Obstetrics and Gynecology 1.5.4. Incomplete abortion Uterine evacuation should be done preferably by MVA. Antibiotics as needed can be given. Methods of Uterine evacuation Determined by uterine size If uterine size < 14 weeks · Manual / electrical vacuum aspiration or evacuation and curettage(E&C)/dilatation and curettage (D&C)if cervix is closed If uterine size > 14 weeks · Oxytocin infusion or evacuation and curettage(E&C)/dilatation and curettage when appropriate Oxytocin administration Add 10ml (ampoules) to 1000ml lactated Ringer's solution (100mu/ml) Start at 0.5ml/mi (50mu/mi), increase at 30 to 40min intervals up to a maximum rate of 2mml/mi (200mu/min). If effective contractions are not established at this infusion rate, increase the concentration. Discard all but 500ml of the remaining solution. Add additional 5 ampoules of oxytocin (200mu/ml). Reduce the rate to 1ml/mi (200mu/mi). Increase up to 2ml/mi (400mu/mi), continue at this rate for 4-5hrs or until fetus is expelled. 1.5.5. Missed abortion A. Expectant management up to 4 weeks · This is based on the fact that 95% women with missed abortion will abort spontaneously in 4 weeks time, whatever the duration of the pregnancy. After 4 weeks the chance of developing disseminated intravascular coagulation or dead baby syndrome is significant. · During this time coagulation profile is monitored weekly. Evacuation of the uterus is done if the patient did not expel in 4 weeks or before 4 weeks if coagulation derangement occurs. B. Aggressive management 49
  59. 59. Obstetrics and Gynecology This entails evacuation of the uterus. Methods include dilatation and curettage (D&C) for uterine sizes up to 12 weeks or induction of labor by prostaglandins /oxytocin infusion if uterine size is more than 12 weeks. Since there is a risk of uterine perforation and coagulopathy with this form of management appropriate referral to proper health facility should be made. 1.5.6. Management of Complications I. Uterine perforation The following signs seen during uterine evacuation indicate perforation. · An instrument (sound, cannula, and curette) extends beyond the expected limit of the uterus. · Fat or bowel is found in the tissue removed from the uterus · Severe pain and continuous bright red bleeding · In apparent vital sign derangement (hypotension in the absence of bleeding) Management · Stabilize the patient and do not give anything per os. · Monitor vital signs · Start broad spectrum antibiotics (parenteral) · Immediate referral to a facility capable of performing gynecologic surgeries. If evacuation is complete · Give ergometrine 0.5mg · Observe her for two hours · If patient become stable and bleeding stops, give ergometrine and continue observation overnight · If the condition gets worse and the bleeding doesn’t stop emergency laparatomy is performed. If evacuation is not complete · Immediate laparatomy to complete evacuation under direct vision Depending on the findings either repair or hysterectomy is done. II. Intraabdominal injury 50
  60. 60. Obstetrics and Gynecology The following signs and symptoms indicate intra abdominal injury Symptoms · Nausea, vomiting, shoulder pain,fever,abdominal pain and cramping Signs · Distended abdomen, decreased bowel sound, tense hard abdomen · Rebound tenderness Management · Resuscitation, parenteral antibiotics, · Immediate referral for laparatomy III. Sepsis Etiology is polymicrobial (gram positives, gram negatives and anaerobes) The following symptoms and signs indicate that either local or generalized infection is likely: Symptoms · Chills, fever, sweating, history of interference · Prolonged bleeding, general discomfort, flu like symptoms Signs · Foul smelling vaginal discharge, distended abdomen · Tenderness, low blood pressure Assess women’s risk for developing septic shock Low risk · First trimester abortion, mild to moderate fever (< 38.50 c) · Stable vital signs, no evidence of Intraabdominal injury High risk · second trimester abortion, high fever (> 38.50 c) · Any evidence of intra abdominal injury, shock Management 51
  61. 61. Obstetrics and Gynecology · Resuscitation, monitor vital signs, start broad spectrum antibiotics intravenously If low risk and stable Uterine evacuation, continue antibiotics, observe for 48 hrs. If high risk · Continue antibiotics · If there is shock ---- manage as shock · If intra abdominal injury--- laparatomy · If DIC present -- treat with clotting factors and fresh blood products IV. Other complications and their management · Anemia - manage according to severity by either hemathenics or blood transfusion · Renal failure - manage accordingly · Give tetanus toxoid as indicated and tetanus antitoxin for non immune women · Give anti-D for Rh negative mothers (see protocol for management of Rh isoimmunization) 1.5.7. Post abortion family planning All women receiving post abortion care need counseling and information to ensure that they understand: · They can become pregnant again before the next menses · There are safe methods to prevent or delay pregnancy · Where and how they can obtain family planning service 1.5.8. Antibiotic choices and administration in the management of abortion Empiric therapy antibiotic covering wide variety of aerobic, anaerobic, gram negative/positive organisms is used. Regimen 1 Ampicillin or benzyl penicillin plus chloramphenicol or clindamycin or metronidazole plus gentamycin 52
  62. 62. Obstetrics and Gynecology Regimen 2 Ceftriaxone or ciprofloxacin plus gentamycin or metronidazole Regimen 3 Doxycycline with metronidazole · Once started, therapy can be continued until the patient is afebrile at least for 24 hours, preferably 48 hours · If there is no response in 48 hours the antibiotics should be changed and/or complications considered · When recovery is underway, intravenous therapy should be followed by oral medication, for 10 to 14 days. 1.5.9. Components of Post abortion care (PAC) · Emergency treatment of incomplete abortion and potentially life threatening complications · Post-abortion family planning counseling and services · Links between post-abortion emergency services and the reproductive health care system. · Community service provider partnership · Counseling 2. ECTOPIC PREGNANCY 2.1. Definition Ectopic pregnancy is implantation of the fertilized ovum outside of the uterine endometrial cavity. 2.2. Incidence and predisposing factors Ninety–nine percent of ectopic pregnancy occurs in the fallopian tube. The commonest site is the ampulla which accounts for 55% of ectopics. The rest occurs in the isthmus (25%), the fimbria (17%) and the interstitial part (2.5%). Rare forms of ectopic pregnancy include cervical ectopic, ovarian ectopic and abdominal pregnancy. Very rarely bilateral ectopic or 53