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1

Definition of preeclampsia/eclampsia

After the 20th gestational week
- Preeclampsia: BP > 140/90 mmHg
- Proteinuria > 300mg/24 hours

Eclampsia: Tonic-clonic seizures

2

Gestational diabetes

Part of screening program = check all pregnant at 24-28 gw

Fasting glucose < 5.6mmol/l => Healthy
Fasting glucose 5.6-7.0mmol/l => Do OGTT
Fasting glucose > 7.0mmol/l on two separate measurements => DM

OGTT «5,6,7,8»:
Normal at 0 min: under 5,6 mmol/l
At 120 mins:
- If < 7.8mmol/l => Impaired Fasting Glucose (IFG)
- If 7.8-11 mmol/l => Impaired Glucose Tolerance (IGT)
- If > 11 mmol/l => DM

3

Indications for C-section

6 groups:
1. Vital maternal
(HF, pulm.edema, severe hemorrhage, DIC)
2. Vital fetal
(asphyxia, cord prolapse, neglected transverse lie, ascending infection, fetal pneumonia)
3. Vital maternofetal
(ecclampsia, uterine rupture, placenta previa/abruption)

4. Prophylactic maternal
(maternal illness, previous operation uterus, decr.pelvic capacity, late primiparity (over 30 yrs))
5. Prophylactic fetal
(threatened asphyxia, placental dysfunction, or hypoxia, fetal illness, pregnancy after infertility treatment)
6. Prophylactic maternofetal
(damning gestational history, dystocia, prolonged labor, FDP, malpresentation/position, twins)
__________________________________________________
M/F:
- Cephalopelvic disproportion
- Failed induction of labor

Maternal: Eclampsia
- Cervical cancer
- Fibroids, tumor
- Herpes

Fetal:
- Non-reassuring fetal HR (bradycardia)
- Cord prolapse
- Malpresentation
- Multiple gestations
- Fetal abnormalities => Hydrocephalus

Placental:
- Previa
- Abruptio

4

US in pregnancy

0 (6-7w) = transvaginal diagnostics
- Confirm (gestational sac, HR)
- Location: Intra-/extrauterine
- Twins

I (11-13+6w) = gestational age & pathology
- Nuchal translucency (Down’s)
- Neural tube defects
- Biometrics: ductus venosus flow

II (18w) = genetic screening
- Congenital malformations
- Chromosomal abberations

III (28-32w) = fetal size screening
- IUGR
- Late congenital malformations

IV (38w) = information for delivery
- Fetal presentation
- Fetal weight
- High-risk?
*gw are from Nagy in lecture

5

Placenta abruptio / placenta previa

Hello, CTG, use hands to palpate the uterus

Abruptio: Painful, hard uterus => C-section

Previa: Painless, CTG normal

6

Post-partum haemorrhage

- Tissue: Retained placenta
- Trauma: Vaginal lacerations
- Thrombin: Coagulopathy (DIC)
- Tone: Uterine atony (exclude other causes)

7

Stages of birth

1. Onset of labor: Longest stage
a. Latent (3cm) - nulli: 8-20 hrs, multi: 5-12 hrs
b. Active (3-10cm) - nulli: 5-7 hrs, multi: 2-4 hrs

2. Birth: 30-90mins (nulli: ~2hrs, multi ~1hr)
a. Propulsive phase (full dilation, descend to pelvic floor)
b. Expulsion phase (delivery)

3. Placenta: 5-30mins
a. Separation
b. Expulsion

4. Postplacental stage: 2 hours
a. Incr. risk of bleeding
b. Repair lacerations
c. D-Ig
_____________________________________________________
Dr. Nagy times:
1: Cervix (nulli: 9-11 hrs, multi: half)
2: Fetus (nulli: 50-60 hrs, multi: half)
3. Placenta (nulli: 5-15 (max 30 min)
4. Observation: 2 hrs

8

Techniques of C-section

Abdominal wall:
- Transverse (Pfannenstiel)
- Vertical (Midline)

Uterus:
- Lower segment incision (Transverse)
- Classical (Vertical)
- (Low vertical)

9

Pearl index

No. of pregnancies in 100 females/year with chosen contraceptive.
- OCP: 0.1-2.5
- Sterilization: 0.3-6
- Post-coital pill: 0.5-2.5
- IUD: 0.5-5
- Condom: 3-28

10

Routine exams

- Colposcopy
- Cytology
- Bimanual exam
- Breast exam

11

Long-term OCP use

Good: All decreased
- Ovarian/endometrial cancer
- Bone loss
- Dysmenorrhea
- Acne
- Risk of trisomies in high maternal age
- Regulates cycle

Bad: all increased
- DVT/stroke
- BP
- Weight
- Depression

12

Endometriosis (+ Dx, Tx)

Endometrial-like tissue outside the uterine cavity.

Dx: Gold standard => Laparoscopic visualization

Tx:
- Surgery
- Drugs (Pseudopregnancy, Pseudomenopause => GnRH analogue)

13

Urinary incontinence

1) Irritative: Urinalysis => Cystitis/tumor/foreign body

2) Stress: Loss of bladder support => Cough

3) Urge: Hypertonic => overactive detrusor (Tx: Anticholinergics)

4) Overflow/neurogenic: Hypotonic w/ dribbles (Tx: Cholinergics)

5) Bypass/Fistula

14

Main vaginal infections

- Bacterial vaginosis
- Trichomonas
- Mycosis (Candida)
Mycosis has normal pH, the others have increased
Tx: metronidazole if pH increased, antifungal if not

15

Spontaneous abortion (Hx, Dx)

Hx: Pain + bleeding
Dx: Cervix, US, hCG

16

Contraindications to tocolysis

Obstetric:
- Severe abruption
- Ruptured membranes
- Chorioamnionitis

Fetal:
- Lethal anomaly
- Fetus is already dead
- Fetal jeopardy

Maternal:
- Eclampsia
- Advanced dilation

17

Leopold maneuvers

1. Fundal grip = fundal height, which pole in fundus (head, butt)
2. Umbilical grip = One hand on each side of belly (lie, position)
3. Pelvic grip (1st pelvic grip) = Grasp lower portion of abdomen just above the pubic symphysis with thumb and fingers of the right hand (presenting part and its relation to pelvic inlet (engagement))
4. Pawlick grip (2nd pelvic grip) = Face woman’s feet, attempt to locate fetus’ brow. Fingers of both hands moved gently down the sides of the uterus => Pubis. The side where there is resistance to the descent of the fingers is greatest where the brow is located (presenting part, descent, engagement)
5. Zangemeister maneuver = cephalopelvic disproportion

18

Stopping uterine bleeding

Young: Progesterone => Preserve fertility

Old: D&C

19

Mayer-Rokitansky-Küster-Hauser Syndrome

Müllerian agenesis.
- Congenital malformation
- Failure of Müllerian duct to develop
o Missing uterus, cervix, vagina
o Variable degree of upper vaginal hypoplasia (shortened)
- Causes 15% of primary amenorrhea
- Ovaries intact, ovulation usually occurs
- Enter puberty with secondary sexual characteristics

20

Papanicolau classification

P0: Improper sample
P1: Negative result
P2: No dysplasia, some benign aberration
P3: Pathologic cells, but impossible to tell due to inflammation or dysplasia
P4: Atypical cells => Suspect malignancy
P5: True malignancy

21

Bethesda

Reporting cervical or vaginal cytological Pap smear results.

Important steps:
1. Quality of the slide
2. Whether the result is positive or negative
3. Details of the slide (LSIL/HSIL)
4. Physician recommendation of how to proceed

22

Puerperium

Period beginning immediately after the birth of a child extending for ~ 6w

23

When prenatal care starts

Before conception

24

Mortality rates

Neonatal Mortality Rate: No. of neonatal deaths during the 1st month/1,000 live births.
- Early NMR: 1st week
- Late NMR: 2nd-4th weeks

Perinatal Mortality Rate: No. of perinatal deaths (stillbirths + neonatal deaths, from 22nd gestational week to 7th week postpartum)/1,000 total births.

25

To exclude ectopic pregnancy

Measure b-hCG:
- 1,000 U/L => Gestational sac
- 7,000 U/L => Yolk sac
- 10,000 U/L => Embryo

Brown spotting and abdominal pain indicates ectopic pregnancy => Check fallopian tubes.

b-hCG doubles every 2nd day. If high but not double => Ectopic pregnancy.

26

Vitamin supplements

Preconception: Folic acid up to 6 weeks before (400 microgr/day)

2nd trimester: Low dose Iron and Iodine (250 microgr/day)

27

History taking

- Previous operations
- Allergy to medications
- Obstetric anamnesis
- Illness, drugs
- First day of last menstrual period
o Naegele’s rule: Can only be applied if menses are regular and cycle is 28 days.

28

Signs of pregnancy

Presumptive: in man and woman
- Nausea, vomit

Probable: in women
- Physical changes
- Positive pregancy test

Definite sign (only in pregnant)
- Fetal HB
- Detecting fetus (US)

29

Physical signs of pregnancy

Chadwick sign: bluish discoloration over cervix and vagina (ca. 6th gw)

Piskacek sign: Soft prominence over the site of implantation

Goodell’s sign: Softening of the cervix (4-6 gw)

Hegar’s sign: Softening of the cervical isthmus (6-8 gw)

Chloasma

Linea nigra

30

Location of Bartholin’s Cyst

Lower 1/3 of labia major