SCHEME
FOR PREGNANCY DISORDERS
Definition, Etiology &
Pathology are the basic knowledge for any disease, according to them you will
be asked to conclude the items of this scheme for any specific disorder,
================================================
COMPLICATIONS FOR ANY DISEASE
DURING PREGNANCY ARE CLASSIFIED INTO
I-MATERNAL
COMPLICATIONS
|
I.1
COMPLICATIONS OF THE ASSOCIATED ETIOLOGICAL FACTOR |
e.g
other complications of ...........
|
I.2COMPLICATIONS
OF THE DISEASE ITSELF |
I.2.A-DURING PREGNANCY
1-Pathology is BLEEDING
=>
1-Rh
sensitization of Rh -ve mother
2-Anemia
3- Hypovolemic
Shock =>
4- Acute
Renal Failure,
Sheehan
syndrome only if bleeding was in late pregnancy or PPH.
2-Pathology is INFECTION:
1-Local spread of infection=>Nearby
abscess
2-Systemic Spread of infection=>Septic
shock=>ARF,DIC
3-Chronicity
4-Organ
Failure
3-Pathology involves secretion of
Huge amounts of HCG=>
1- Hyperemesis
gravidarum
2-PET
3-Thyrotoxicosis
4-Pathology involves LARGE
PLACENTA=>
1- Hyperemesis
Gravidarum
2-
Placenta previa
3-
Polyhydramnious
4-
PET=> 5- Placental Abruption
5-Due to OVERDISTENDED UTERUS=>
1-Pressure
C/O
2-
PROM => PMD
3-
PET => 4- Placental Abruption
5-
Pyelonephritis
6-DIC [Missed&Septic abortion, V.M, Accidental
Hge, PET, IUFD]
7-MALPRESENTATIONS &
MALPOSITION
8-PATHOLOGICAL FATE
9-RECURRENCE
10-Specific complication.
I.2.B-DURING LABOR
If there is malpresentation or
fetal macrosomia
=>
1-
Prolonged labor
2-
Uterine inertia
3-
Increased incidence of operative delivery and CS
4-
POSTPARTUM HEMORRHAGE
If no malpresentation or macrosomia=>
1-
POSTPARTUM HEMORRHAGE [complicates all pregnancy disorders except ;
IUGR, Oligohydramnious].
I.2.C-DURING
PUERPERIUM
All pregnancy disorders except ;
IUGR, Oligohydramnious are complicated by 3S during puerperium:
-Subinvolution
of the uterus
-Puerperal
Sepsis
-Secondary
Postpartum Hemorrhage
|
I.3-COMPLICATIONS
OF TREATMENT |
I.3.A-COMPLICATIONS OF MEDICAL
TREATMENT
e.g
complications of
I.3.B-COMPLICATIONS OF SURGICAL
INTERVENTION
e.g
complications of D&C, C.S..etc
I.3.C-COMPLICATIONS OF BLOOD
TRANSFUSION
|
================================================== |
II-FETAL COMPLICATIONS
You
will have to choose to write either 3/5 or 5/5 of the following
1-Abortion
2-CFMF
3-IUGR
4-IUFD
5-Prematurity
Specific fetal complications:
Macrosomia in D.M
Hydrops fetalis in Erythroblastosis
fetali
CLINICAL
PICTURE FOR ANY DISEASE DURING PREGNANCY
IS BASICALLY FORMED OF THE FOLLOWING ITEMS
|
I-TYPE
OF PATIENT |
write
down some epidemiologic,etiologic factors
|
II-SYMPTOMS |
A- Of early pregnancy in early
pregnancy disorders
B-Of the possible complication
-Bleeding
= > Collapse
-Infection
=> FAHM
-Overdistended
uterus = > Pressure C/O
-DIC
= > Ecchymotic patches, bleeding gums&teeth.
...etc
C-Medical symptoms
only
for medical disorders
D-Obstetric symptoms of the Disease
-Vaginal
Bleeding
-Vaginal
Discharge
-Pain
-Abdominal
enlargement
-Fetal
Kicks
|
III-SIGNS |
A-GENERAL
EXAMINATION MAY REVEAL
Signs
of early pregnancy in early pregnancy disorders
1-SIGNS
OF AN ETIOLOGICAL FACTOR
2-SIGNS
OF COMPLICATION e.g
Bleeding = > Shock -[Tachycardia,
Tachypnea,pallor sweating, hypotension, drowsiness...etc]
-[// or > expected?]
DIC = > Bed side clotting test
Infection => C/P of septic shock
Overdistended uterus => signs of
pyelonephritis
PET => Hypertension, proteinuria.
...etc.
B-ABDOMINAL
EXAMINATION
|
IN
EARLY PREGNACY |
IN LATE
PREGNANCY |
|
FOR Tenderness, Rigidity, Rebound
tenderness. Either they are present or
absent. |
1-F.L : = or > or <
amenorrhea 2-Leopold grips for: -Estimation of fetal size -Fetal presentation and position -Amount of liqour 3-FHS Auscultation may be normal
or reveal signs of distress. |
|
*Specific findings: -V.M: Soft uterus with no fetal
parts or FHS. -Acc.Hge: Tense, tender, tonic,
uterus -Placenta previa: Boggy LUS if
anterior insertion. -Polyhydramnious: Skin signs of
stretch. |
|
C-LOCAL
EXAMINATION
|
IN EARLY
PREGNACY |
IN
LATE PREGNANCY |
|
V&V: May free or soaked with blood or discharge |
OF
no value |
|
Cx: -Soft, or extremely soft -Closed or open -Tender mobility present or
absent |
may
even be contraindicated e,g in cases of -APH -PPROM |
|
Uterus: -Soft or extremely soft -Size = to, <, > than
amenorrhea -Tender or not |
|
|
Adnexa for: -Masses, Tenderness |
|
|
D.P -Free or full |
|
|
INVESTIGATIONS |
A-TO
DIAGNOSE THE DISEASE
In early pregnancy disorders you
will need :
-Pregnancy test,
-Serum B-HCG,
-U/S
In late pregnancy disorders you
will need:
-U/S
-Inv. of medical disorders
-Assessment of fetal well-being.
B-TO
DIAGNOSE POSSIBLE COMPLICATIONS e.g
-Shock
=> Renal functions
-DIC
=> Coagulation profile
-PET
=>Total proteins in urine
.....etc.
C-TO DIAGNOSE POSSIBLE AETIOLOGY
According to the aetiological factors conserned.
D-ROUTINE INVESTIGATIONS SHOULD BE ALSO CARRIED OUT
H.V, Hb%, Blood group & Rh typing, urine analysis..etc
|
TREATMENT |
TREATMENT OBJECTIVE
-For Early Pregnancy
Disorders: Objective is Termination of Pregnancy [EXCEPT cases of
threatened abortion where we should conserve pregnancy.]
-For Late Pregnancy
Disorders: Objective may be Termination of pregnancy or Conservation of
pregnancy according to the following indications:
|
Indications
for COP |
Indications
for TOP |
|
1-Immature fetus + |
1-Mature fetus or |
|
2-Fetus alive not distressed and
no malformations incompatible with life + |
2-Fetus dead, distressed or
presence of malforamtion incompatible with life, or |
|
3-Patient not in active labor + |
3-Patient in active labor or |
|
4-Disease not severe or seriously
complicated. |
4-Disease in severe state or
seriously complicated. |
|
COP |
1-Rest :
Complete bed rest is not advised
for fear of thromboembolism, however minimal activities with 2 hours afternoon
nap and 8 hours night sleep is recommended.
2-Diet : Should be nutritious and
supplemented.
3-Sedation to avoid anxiety.
4-Maternal follow up:
Main
complaint; followed up daily
Main
sign; followed up daily
Main
Investigation; at regular intervals
5-Fetal follow up:
Important
symptom: Fetal Kick chart daily
Important
sign; FHS every 6-8 hours.
Investigation
: Non-Stress test, BPP at regular intervals.
6-Management/Control of the
etiological factor
7-Management of complication
other than which indicate termination.
e.g AntiD
for Rh -ve mother with mild obstetric bleeding.
|
TOP |
I-Time
of termination
Along with correction of the general
condition.
e.g if the patient has hypovolemic
shocked = Along with management of shock.
II-Method
of termination
|
TOP
before age of fetal viability |
A-If pregnancy is IU:
|
1-Fetal size < 12 weeks (no
bones yet) => E & C |
|
2.a-Fetal size > 12 weeks
(Bone found) => Induction of abortion using : *Pg
F2 alpha intrauterine, extraamniotic *Oxytocin *Hypertonic
saline (not used any more) 2.b-Fetal size > 12 weeks
(bone found) but urgent termination is needed i.e we cannot wait for the
induction-termination interval => Hysterotomy 3-Some
selected indicated cases may need hysterectomy. |
B-If pregnancy is EU:
TOP is achieved by
1-Surgically via
laparotomy/laparoscopy/
2-Medically
|
TOP
after age of fetal viability |
A- Induction of labor:
The
patient is examined for assessment of Bishop score,
-If the cervix is not ripe:
Pg E2 vaginal tablet 1-3mg may be
inserted in the posterior vaginal fornix to induce ripening of the cervix 6-8
hours before induction.
-When the cervix is ripe:
AROM is done and if labor pains do
not start within 6 hours, oxytocin drip starting by 2 miu/ml/min is started.
-Care of the first Stage of labor:
-Strict
monitoring of labor progress and fetal condition.
-Sedation,
analgesia.
-Strict
Aspesis.
+..............................
-Care of the second stage of labor:
-Continue
maternal and fetal monitoring.
-Avoid
prolongation of second stage
+..........................................
-Care of the third stage of labor:
-Guard
against PPhge
-Guard
against P.S
+..............................
B-Indications for Caesarean
Section:
1-
2-
3-Failed
induction
4-Fetal
distress during induction
5-Associated
obstetric indication.
III-Postpartum
care
|
Mother |
-Guard against PPH / Postabortive
bleeding
-Guard agianst P.S
-Advice and educate for breast
feeding / Supression of lactation if late abortion or dead neoborn.
-Contraceptive advice
-AntiD for Rh-ve mother
-In cases of TOP before age of
fetal viability=>Histopathology of conceptus.
|
Neoborn |
-Care of premature
-Care of IUGR
-Examine for CFMF
|
MANAGEMENT
AND RESUSCITATION OF SHOCKED PATIENT |
N.B Symptoms of shock: Pallor, dyspnea, palpitation,
collapse.
Signs of shock: Tachycardia, Tachypnea,
Hypotension, Pallor, Sweating, Disturbed level of consciousness, drowsiness,
coma.
Treatment of Shock = Treatment of the cause
I-Lines
Of Resuscitation Of Shocked Patient
|
A-Ensure patent airway and O2
therapy |
|
B- Blood and fluid replacement. |
|
C-Corticosteroids to delay
transition to irreversible stage, improve tissue response to catecholamines. |
|
D-Diuretics to avoid renal
damage, in cases of UOP < 20
ml/hour |
|
E-Eliminate pain by Morphia and
strong analgesics. |
|
F-Feet elevation in
anti-Trendlenberg position to improve cerebral blood flow. |
|
G-Guard against infection of the
under-perfused tissues by adequate AB therapy. |
|
H-Hottness avoided, but warmth is
essential. |
II-Monitoring
of the shocked Patient
|
P, B.P, T, R.R |
|
U.O.P (good UOP = good tissue
perfusion) |
|
C.V.P (excellent to monitor vascular
volume, calculate deficit and avoid over or under transfusion) |
|
Pulmonary Capillary Wedge
Pressure (Better
than C.V.P but more invasive and needs
expert personnel and equipment.) |
ANTIBIOTIC
THERAPY
|
I-ROUTE |
Always start parentral till 48 hrs
after subside of fever or minmum 4 days, whatever longer.
|
II-Regimen |
Start by covering all susceptible
organisms till results of C&S are avialable then shift to the specific AB.
Some commonly used AB in
combinations as needed:
|
|
G
+ve |
G
-ve |
Anaerobes |
||
|
Regimen
1: |
|
||||
|
-Penicillins
or 1st generation cephalosporins e.g Ampicillin 1 gm / 6 hours IM Safe
in Pregnancy |
+++ |
|
|
||
|
Aminoglycoside e.g Garamycin 1.5
mg/kg/day IV or IM Fetal
Nephrotoxity, ototoxicity |
|
+++ |
|
||
|
Metronidazole 1gm/8
hrs IV drip Avoided
in pregnancy |
|
|
+++ |
||
|
Regimen 2 |
|
||||
|
-Clindamycin 900mg /
8 hrs IV. Avoided
in pregnancy |
+++ |
|
+++ |
||
|
Aminoglycoside(Gentamycin) Fetal
Nephrotoxity, ototoxicity |
|
+++ |
|
||
|
Regimen 3 |
|
||||
|
3rd Gener. Cephalosporins e.g Cefotaxime 2gm/6hrs IV Safe
in Pregnancy |
++ |
+++ |
|
||
|
Metronidazole Avoided
in Preg. |
|
|
+++ |
||
|
Regimen 4 |
|
||||
|
3rd Generation Cephalosporins Safe
in Pregnancy |
++ |
++++ |
|
||
|
Doxocyclin Not
used in Pregnancy. |
++++ |
++ |
|
||