Download Gestational Hypertension

OVERVIEW OF OBSTETRICS
PROF. OLUŞ APİ
Obstetrics
Obstetrics deals with the care of women's reproductive tracts
and their children during pregnancy, childbirth and the
postnatal period.
A doctor performing such practice is called Obstetrician.
LMP : Last Menstrual Period.
It is the time elapsed since 14 days prior to fertilization
EDC or EDD : The Due Date.
EDC stands for the old-fashioned "estimated date of confinement." EDD is the more
modern "Estimated Day of Delivery." The average pregnancy “gestation” is 40 weeks
or 280 days from the first day of the last menstrual period (LMP).
For a 28 day cycle, EDD is calculated by taking the LMP and adding 9 months and 7
days to it.
If the cycle is longer than 28 days, add the difference between cycle length and 28
days.
Nagele’s Rule:
•
•
Subtract 3 months from the 1st day of the LMP
Add 7 days
Gravida:
It is the number of times the mother has been pregnant, regardless of whether these
pregnancies were carried to term.
A current pregnancy, if any, is included in this count.
A nulligravida or gravida 0 is a woman who has never been pregnant.
A primigravida or gravida 1 is a woman who is pregnant for the first time or has been
pregnant one time.
A multigravida or more specifically a gravida 2 (also secundigravida), gravida 3,
and so on, is a woman who has been pregnant more than one time.
An elderly primigravida is a woman in her first pregnancy, who is at least 35 years
old.
Parity
It is the number of times the woman has delivered after the age of viability.
It includes the births after 24 weeks or those having weight of 500 grams.
TPAL method
Para is often recorded in 4 numbers:
• T= the number of term deliveries (after 37 weeks)
• P= the number of premature deliveries (> 20 and < 37 wk)
• A= the number of abortions (either spontaneous of therapeutic)
• L= the number of living children
There can be 4 numbers after the "P" for "para."
The first number is how many term pregnancies.
The second number is how many premature babies.
The third number is how many abortions or miscarriages
The fourth number is how many living children survive.
Trimester
The pregnancy is divided into 3 trimesters.
• The first one is from LMP up until 12 or 13 weeks.
• The second rimester is from 12-13 weeks until 28 weeks.
• The third trimester is from 28 weeks until delivery.
Preterm Birth
It is the birth of a baby between 24 and 37 weeks of gestational age.
Premature infants are at greater risk for short and long term complications,
including disabilities and impediments in growth and mental development.
Post term Birth
Postmaturity is when a baby has not yet been born after 42 weeks
of gestation.
Different babies will show different symptoms of postmaturity. The
most commons symptoms are dry skin, overgrown nails, creases on
the baby's palms and soles of their feet, minimal fat, a lot of hair on
their head, and either a brown, green, or yellow discoloration of
their skin. Some postmature babies will show no or little sign of
postmaturity.
Presentation
It refers to which anatomical part of the fetus is leading, that is, is closest to the
pelvic inlet of the birth canal just before the birth. According to the leading part,
this is identified as a cephalic, breech, or shoulder presentation.
Normal presentation is cephalic.
Malpresentation
A malpresentation is any other presentation than a vertex presentation
(with the top of the head first). It could be breech or shoulder presentation.
Position
It is the relationship of specific fetal denominator to maternal denominator.
It includes occipito anterior, occipito posterior, occipito transverse.
Normal position is occipito anterior.
Malposition
It is the abnormal position of the fetus in uterus. Could be occipito
posterior or occipito transverse.
Lie
It is the relationship of longitudinal axis of fetus to longitudinal
axis of mother’s pelvis.
It can be longitudinal, transverse or oblique.
Most common is longitudinal.
Variety
The relation of the given portion of the presenting part to the
anterior and/or posterior portion of mother’s pelvis
.
Engagement
Engagement is said to have taken place when the widest part of
presenting part of fetus has passed successfully through the pelvic
inlet.
The number of fifths of the fetal head palpable abdominally is often
used to describe whether engagement has taken place. If more than
two fifths of fetal head is palpable abdominally, the head is not yet
engaged.
Moulding
It is the process which effectively reduces the diameter of fetal
skull and encourages progress of delivery through maternal pelvis
without harming the fetal brain.
It is achieved due to following characteristics of fetal skull:
• Ununited sutures which help the bones to move together and
overlap during delivery.
• compressible nature of bones
• Anterior and posterior fontanelles
Effacement
It is the process by which the cervix shortens in length as it
becomes included in the lower segment of uterus.
The cervical os cannot usually begin to dilate until effacement is
complete.
Episiotomy
It is a surgically planned incision on the perineum and the posterior
vaginal wall during second stage of labor.
It is also called perineotomy.
Crown-to-Rump Length:
Measurement from the top of the baby's head to the buttocks of the
baby.
Chadwick's sign:
Dark-blue or purple discoloration of the mucosa of the vagina and
cervix during pregnancy.
NSVD
Normal Spontaneous Vaginal Delivery.
SVD
Spontaneous Vaginal Delivery - same as NSVD.
Cesarean section (delivery):
Delivery of a baby through an abdominal incision rather than through the vagina.
Primary Cesarean Section
First time a mother has delivered by Cesarean.
Secondary Cesarean Section
Mother has already had a previous Cesarean delivery, and this is a repeat Cesarean birth.
VBAC : Vaginal Birth After Cesarean.
The mother has had a previous Cesarean delivery but has now delivered vaginally.
There is a small amount of risk (less than 1%) that the old surgical scar on the
uterus will rupture when a VBAC is attempted, so mothers who wish to attempt a
VBAC must understand the risks and sign an "informed consent" that shows they
are aware of the risks/benefits.
TOL : Trial of Labor.
If a woman has had a previous Cesarean birth and wants to have a VBAC, she is
said to be undergoing a "trial of labor" when her contractions start.
VAD : Vacuum Assisted Delivery.
The doctor applies a suction cup to the baby's head and gently draws it out, when
the mother is too tired to push effectively any more but the baby is very low in
the pelvis.
Miscarriage
Miscarriage is the spontaneous end of a pregnancy before 24 weeks of
gestation.
Probable signs include:
• Low back pain or abdominal pain that is dull, sharp, or cramping
• Tissue or clot-like material that passes from the vagina
• Vaginal bleeding, with or without abdominal cramps
Cause:
Most common cause is chromosomal abnormalities. Other causes include:
• progesterone deficiency
• malformed uterus
• cervical weakness
• hormonal disorders
• severe infection
Types:
Threatened: Patient is at the risk of miscarriage. Fetus is inside the
uterus and the cervical os is closed.
Inevitable: Associated with heavy bleeding and severe pain. Cervical os
is opening up. May be complete or incomplete.
Complete: If cervical os has opened up
Incomplete: If cervical os has not opened up completely and some
products are still inside the uterus.
Missed: Fetus has died in the uterus but has not been expelled out.
Septic: Any induced miscarriage, usually done due to social
circumstances, done by untrained professional.
Recurrent: Three or more miscarriages consecutively.
Stillbirth
It is the birth of a baby after the age of viability when it has no vital
functions at birth, ie no heart rate, no umbilical cord pulsation, etc.
Causes:
• bacterial infection
• chromosomal aberrations
• maternal diabetes
• high blood pressure, including preeclampsia
• maternal consumption of recreational drugs
• placental abruptions
• physical trauma
• radiation poisoning
Ectopic Pregnancy
An ectopic pregnancy, or eccysis, is a complication of pregnancy in which the embryo implants
outside the uterine cavity.
Most ectopic pregnancies occur in the Fallopian tube, so-called tubal pregnancies), but
implantation can also occur in the cervix, ovaries, and abdomen.
Symptoms include pain in lower abdomen, during micturition, bowel movement, vaginal bleeding.
There are four types:
 Tubal Pregnancy: occurring in fallopian tube
 Non-tubal Ectopic Pregnancy: occurring in ovary, cervix or are intra-abdominal.
 Heterotopic Pregnancy: There may be two fertilized eggs, one outside the uterus and the
other inside.
 Persistent Ectopic Pregnancy: continuation of trophoplastic growth after a
surgical intervention to remove an ectopic pregnancy.
Hyperemesis
Hyperemesis gravidarum (HG) is a severe form of morning sickness, with
"unrelenting, excessive pregnancy-related nausea and/or vomiting that prevents
adequate intake of food and fluids.
It may be due to adverse hormonal effects or raised levels of Human Chorionic
Gonadotropin (HCG).
Pruritis Gravidarum:
It is the itching during pregnancy.
Postnatal Blues:
Mild depression after delivery.
Postpartum Depression:
Depression after delivery.
Ante partum Hemorrhage
Also called prepartum hemorrhage, it is the bleeding from the vagina during
pregnancy from the 24th week gestational age to term.
It should be considered a medical emergency and medical attention should be
sought immediately.
Causes:
• Placental abruption - most common pathological cause
• Placenta previa - second most common pathological cause
• Vasa previa
• Uterine rupture
• Bleeding from the lower genital tract
• Cervical bleeding - cervicitis, cervical neoplasm, cervical polyp
• Bleeding from the vagina itself - trauma, neoplasm
• Bleeding that may be confused with vaginal bleeding eg GI bleeding,
haemorrhoids, inflammatory bowel disease, urinary tract infection
Postpartum Hemorrhage
It is the loss of greater than 500 ml of blood following vaginal delivery, or 1000 ml of blood following
cesarean section.
Causes:
These include uterine atony (inability of the uterus to contract), trauma (tissue tear during delivery), retained placenta,
and bleeding coagulopathy, etc.
Management:
California Maternity Quality Care Collaborative has described a 4 staged protocol for postpartum
hemorrhage:
Stage 0: normal - treated with fundal massage and oxytocin
Stage 1: more than normal bleeding - establish large-bore intravenous access, increase oxytocin,
consider use of methergine, perform fundal massage, prepare 2 units of packed red cells.
Stage 2: bleeding continues - check coagulation status, place intrauterine balloon, administer additional
uterotonics (misoprostol, carboprost tromethamine), consider: uterine artery embolization, dilatation
and curettage, and laparotomy with uterine compression stitches or hysterectomy.
Stage 3: bleeding continues - activate massive transfusion protocol, recheck laboratory tests, perform
laparotomy, consider hysterectomy.
A Cochrane review suggests that active management (use of uterotonic drugs, cord clamping and
controlled cord traction) of the third stage of labour significantly reduces severe maternal bleeding and
anemia compared to expectant management.
Pregnancy Induced Hypertension
It is the condition of high blood pressure during pregnancy.
It is also called Gestational hypertension.
Gestational hypertension can lead to a serious condition called preeclampsia.
Types:
Chronic Hypertension: Women who have high blood pressure ( over 140/90)
before pregnancy, early in pregnancy ( before 20 weeks), or carry it on after
delivery.
Gestational Hypertension: High blood pressure that develops after week 20 in
pregnancy and goes away after delivery.
Preeclampsia: Both chronic hypertension and gestational hypertension can lead
to this severe condition after week 20 of pregnancy. Symptoms include high
blood pressure and protein in the urine and can lead to serious complications for
both mom and baby if not treated quickly.
Pre-eclampsia
It is when a pregnant woman develops high blood pressure and protein in the urine after the 20th
week of pregnancy.
Causes:
Blood vessel problems
Diet
Genes
Obesity
Being older than age 35
History of diabetes, high blood pressure, or kidney disease
Symptoms:
Symptoms of preeclampsia can include:
Swelling of the hands and face/eyes (edema)
Sudden weight gain over 1-2 days, more than 2 pounds a week
Headache
Belly pain on the right side, below the ribs. Pain may also be felt in the right shoulder
Irritability
Decreased urine output, not urinating very often
Nausea and vomiting
Vision changes
Eclampsia
It is an acute and life-threatening complication of pregnancy, is characterized by the
appearance of tonic-clonic seizures, which are not due to preexisting or organic brain
disorders, usually in a patient who has developed pre-eclampsia.
Pre-eclampsia and eclampsia are collectively called Hypertensive disorder of
pregnancy and toxemia of pregnancy.
Symptoms:
Typically patients show signs of pregnancy-induced hypertension and proteinuria prior
to the onset of the hallmark of eclampsia, the eclamptic convulsion. Other cerebral
signs may precede the convulsion such as nausea, vomiting, headaches, and cortical
blindness. In addition, with the advancement of the pathophysiological process, other
organ symptoms may be present including abdominal pain, liver failure, signs of the
HELLP syndrome, pulmonary oedema, and oliguria. The fetus may already have been
compromised by intrauterine growth retardation, and with the toxemic changes during
eclampsia may suffer fetal distress. Placental bleeding and placental abruption may
occur.
TORCH Syndrome
TORCH complex (also known as STORCH, TORCHES or the TORCH infections) is a
medical acronym for a set of perinatal infections. It is spelled as:
T – Toxoplasmosis / Toxoplasma gondii
O – Other infections (see below)
R – Rubella
C – Cytomegalovirus
H – Herpes simplex virus 2
The "other agents" included under O are Coxsackievirus, Syphilis, Varicella-Zoster Virus,
HIV, and Parvovirus B19.
Hepatitis B may also be included among "other agents", but the hepatitis B virus is a large
virus and does not cross the placenta, hence it cannot infect the fetus.
The acronym has also been listed as TORCHES, for TOxoplasmosis, Rubella,
Cytomegalovirus, HErpes simplex, Syphilis.
Maternal Mortality
It is the death of a woman while pregnant or within 42 days after termination of pregnancy
irrespective of the site and duration.
It can be:
Direct: death due to pregnancy, labour, puerperium or management of complications
Indirect: death due to a pre-existing condition in the pregnant lady that is aggravated by
pregnancy.
Incidental: death in spite of the lady being normal and healthy
Maternal Mortality Rate
It is the ratio of the number of maternal deaths per 100,000 live births
from any cause related to or aggravated by pregnancy or its management,
excluding accidental or incidental causes.
Neonatal Death
Number of deaths during the first 28 completed days of
life per 1,000 live births in a given year or period.
It is taken per 1000 live births.
Neonatal deaths may be subdivided into early neonatal
deaths, occurring during the first seven days of life, and
late neonatal deaths, occurring after the seventh day but
before the 28 completed days of life.
Perinatal Death
It is the death of the baby around birth and includes stillbirth and neonatal death.
It includes the time from 24 weeks (before birth) to 28 days after birth.
Perinatal Mortality Rate
It is the number of perinatal deaths per 1,000 total births.