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THE GENERAL SCHEME
This scheme is supposed to guide you through pregnancy disorders. It is also a great way to revise large bulks of text in a short time.
It is based on your knowledge of the definition, etiology and pathology. After knowing these 3 essentials, you are supposed to deduce and conclude everything else. Accordingly you will exclude or include parts of this scheme, but you will not find anything to add to it .. so study it well and enjoy the luxury of not needing to study any more.
Definition is the essential item that you should know by heart ..you are NOT allowed to use your own terms or phrases, it is put forward by governing bodies of OBGYN practice after thorough discussions. So do not rehearse its meanings ..study it as it is.
Definition will be of great help in permitting you to navigate through MCQ, essay and oral questions with "confidence".
Also definition gives you the clue as to what is the one diagnostic investigation. This investigation will simply be the one which fulfills the definition. For example when we say that Hydatiform mole is a benign tumor of the trophoblast then the only DIAGNOSTIC investigation will automatically be "Histopathology" (Tumor is a disease of cell, remember?)
Etiology is a logic scenario that leads to the pathology. I would strongly advise you to learn the most significant etiologies rather than mix them up. It is very depressing when a student is asked about the etiology of ectopic pregnancy and the start of his answer is "tubal chemotactic.....", as impressive as the phrase sounds it will attract the worst mark ever. Always say the common and significant.
I always enjoy to read about pathology, I try to logistically order events and go into depth, it just makes every step in learning the clinical aspects of disease easier.
CLASSIFICATION AND TYPES
Part of the pathology but you should ask the following:
-Is this classification pathological? Clinical? Histological? I mean what is it based on.
-What is the value of classifying this disease? will it differ in prognosis or management?
-Automatically start from this step to plan the investigation or the procedures that will enable you to classify the disease condition.
When studying complications of a disease during pregnancy you should have a broad view, a diabetic patient may suffer complications of insulin (treatment) as well a patient with bleeding placenta previa may suffer complication of blood transfusion. Also a disease in pregnancy will affect labor and puerperium as well. Also diseases occurring late in pregnancy will affect the fetus.
So I will classify complications of all obstetric disorders into:
For every category I will list all possible complications according to a specific pathology, in any disease you should choose what to include and what to exclude.
i- During Pregnancy
There are 5 main pathologies in pregnancy (listed 1 to 5) and 5 specific complications (listed 6 to 10)
1- If Pathology is BLEEDING => Bleeding will always cause:
1- Rh sensitization of Rh -ve mother
Then depending on the amount and rate of hemorrhage other complications will set in they will be
2- Anemia (If chronic and mild (rare))
OR If acute and severe:
2- Hypovolemic Shock
3- Acute Renal Failure (ARF)
& Sheehan syndrome only if bleeding occurs in late pregnancy or just after birth.
2- If Pathology is INFECTION => Infection will eventually cause:
1-Local spread of infection=>Nearby abscess (para....... abscess)
2-Systemic Spread of infection=>Septic shock=>ARF,DIC
These are the complications of any infection, for example, what are the complications of Pyelonephritis? they will essentially be:
-Local spread of infection=>Paranephric abscess
-Systemic Spread of infection=>Septic shock=>ARF,DIC
-Chronicity = Chronic pyelonephritis
-Organ Failure = Renal failure (acute or chronic)
3- If Pathology involves secretion of Huge amounts of HCG=>
1- Hyperemesis gravidarum
2- Pre-eclamptic toxaemia (PET)
4- If Pathology involves placental enlargment of edema=>
1- Placenta previa (a large placenta will encroach on the lower uterine segment)
2- Polyhydramnious ( large placenta secretes more amniotic fluid)
3- PET (large placenta in involved in the aetiology of PET)
4- Placental Abruption (Whenever you mention PET, follow it with Abruption..by law)
5- If Pathology involves an OVERDISTENDED UTERUS in LATE pregnancy=>
1- Pressure from a large uterus in the 4 directions up/down/posterior/anterior will lead to
- On the GIT: Flatulence, distention, reflux esophagitis
- On the bladder and pelvis: Frequency, heaviness, pelvic pain
- On the ureters; recurrent attacks of loin pain and pyelonephritis
- Overstretch of the skin: Stretch marks, itching.
2- Preterm delivery
3- Premature rupture of the membranes
5- Placental Abruption (by law, remember?)
6-Disseminated Intravascular Coagulopathy (DIC), occurs in 6 conditions, 3 in early pregnancy diseases and 3 in late pregnancy diseases : Missedabortion, Septic abortion, Vesicular mole and, placental abruption, Pre-eclampsia, intrauterine fetal death.
7-MALPRESENTATIONS & MALPOSITION (if the pathology "re-shapes" uterine content)
8-PATHOLOGICAL FATE (what if not treated?)
9-RECURRENCE (if not sure the magic % is 10% recurrence rate)
10-Specific complication (usually you will find a specific complication to study)
B- During Labor
if pregnancy disorder leads to malpresentation or macrosomic fetus then the complications during labor will be:
1- Prolonged labor
2- Uterine inertia
3- Increased incidence of operative delivery and CS
In addition to the famous: 4- POSTPARTUM HEMORRHAGE
If pregnancy disorders doen not lead to fetal macrosomia or fetal malpresentation then the Only complication is POSTPARTUM HEMORRHAGE which complicates all pregnancy disorders except ; IUGR, Oligohydramnious.
C- During Puerperium
All pregnancy disorders (except ; IUGR, Oligohydramnious) are complicated by 3S during puerperium:
-Subinvolution of the uterus
-Secondary Postpartum Hemorrhage
Same for all disorders, no matter what the disorder is.
1-COMPLICATIONS OF MEDICAL TREATMENT e.g complications of.............
2-COMPLICATIONS OF SURGICAL INTERVENTION e.g complications of D&C, C.S..etc
3-COMPLICATIONS OF BLOOD TRANSFUSION
e.g other complications of ..(write down the most common etiology).........
The fetus is affected during developmen, growth or delivery
If the disorders occurs late in pregnancy, then there will be 3 fetal complications, namely:
1-Intrauterine growth retardation
2-Intrauterine fetal death
While if the disorder occurs early in pregnancy it will lead to 2 more complications:
2-Congenital fetal malformations.
So for any diorder in pregnancy you will either mention 5 complications out of 5. Or only 3 complications out of the 5 complications if the disease occurs later in pregnancy.
Specific fetal complications:
Macrosomia in D.M
Hydrops fetalis in Erythroblastosis fetalis
CLINICAL PICTURE FOR ANY DISEASE DURING PREGNANCY IS BASICALLY FORMED OF THE FOLLOWING ITEMS
write down some epidemiologic,etiologic factors
1- Mention symptoms of early pregnancy in early pregnancy disorders (you may mention also if they are exaggerated -as in Hydatiform mole- or regreesing -as in missed abortion-).
2-Mention symptoms of the possible complication, indeed they may be the presenting complaint.
-If Bleeding = > the symptom is "Collapse"
-If Infection => the symptom is Fever, anorexia, headache and malaise.
-If an Overdistended uterus = > the symptoms are of pressure
-If DIC = > the symptoms are Ecchymotic patches & bleeding from gums&teeth.
only in medical disorders
4-Obstetric symptoms of the Disease:
There are 5 main complaints in pregnancy, actually the mother-to-be is not aware except of that her abdomen in enlarging without significant pain, there is no bleeding or discharge, and from 20 weeks she is aware of fetal kicks.
So symtoms of any disease in pregnancy will involve the following:
Notice that in early pregnancy abdominal enlargement and fetal kicks
are never mentioned.
You will always mention 3 items in examination, General, Abdominal and Local.
A-GENERAL EXAMINATION MAY REVEAL
1-SIGNS OF AN ETIOLOGICAL FACTOR
2-SIGNS OF COMPLICATION e.g
Bleeding = > Shock -If pathology of bleeding => Tachycardia, Tachypnea,pallor sweating, hypotension, drowsiness...etc
There is a trick here ! you should always mention if the general condition is in accordance with the amount of vaginal bleeding or if it is much worse than can be explained by the amount of vaginal bleeding. In other words there may be mild vaginal bleeding yet moderate or marked shock state, this will automatically directs attention that there must be internal bleeding.
- For DIC = > you can do a simple Bed side clotting test
- For Infection => C/P of septic shock
- For Overdistended uterus => you may find signs of pyelonephritis
- For PET => there will be the classic picture of Hypertension+proteinuria.
Notice that: Tenderness means irritation while rebound tenderness and/or rigidity signify peritonitis.
A-TO DIAGNOSE THE DISEASE
In early pregnancy disorders you will need :
In late pregnancy disorders you will need:
-Inv. of medical disorders
-Assessment of fetal well-being.
What is the diagnostic investiation? See definition
B-TO DIAGNOSE POSSIBLE COMPLICATIONS e.g
-Shock => Renal functions
-DIC => Coagulation profile
-PET =>Total proteins in urine
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
Any treatment must have a clear objective, according to the indications below you either proceed to terminate pregnancy [TOP] or to conserve pregnancy [COP] for a certain time then terminate pregnancy. So your treatment ends when the baby is DELIVERED.
-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:
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.
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
A-If pregnancy is Intra-Uterine:
B-If pregnancy is Extra-Uetrine:
TOP is achieved by
1-Surgically via laparotomy/laparoscopy/
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.
-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:
4-Fetal distress during induction
5-Associated obstetric indication.
-Guard against PPH / Postabortive bleeding
-Guard agianst P.S
-Advice and educate for breast feeding / Supression of lactation if late abortion or dead neoborn.
-AntiD for Rh-ve mother
-In cases of TOP before age of fetal viability=>Histopathology of conceptus.
-Care of premature
-Care of IUGR
-Examine for CFMF
EXTRA-NOTES THAT YOU MAY FIND USEFUL
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
II-Monitoring of the shocked Patient
Always start parentral till 48 hrs after subside of fever or minmum 4 days, whatever longer.
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:
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