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THE GENERAL SCHEME

For

PREGNANCY DISORDERS

INTRODUCTION

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.

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 

          3-Chronicity

          4-Organ Failure

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)

              3- Thyrotoxicosis

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

             4- PET

             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

-Puerperal Sepsis

         -Secondary Postpartum Hemorrhage

What is the diagnostic investiation? See definition

TREATMENT OBJECTIVE

 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:

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.

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/

2-Medically

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

-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.

-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

ANTIBIOTIC THERAPY

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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