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,

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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-Due to BLEEDING =>       Rh sensitization of Rh -ve mother

                   If Severe Hge =>   Hypovolemic Shock => Acute Renal Failure,

Sheehan syndrome only if bleeding was in late pregnancy or PPhge.

2-Due to INFECTION:

   -Local spread of infection=>Nearby abscess

   -Systemic Spread of infection=>Septic shock=>ARF,DIC 

          -Chronicity

          -Organ Failure

3-Due to Huge amounts of HCG=> Hyperemesis gravidarum

                                                          PET

                                                          Thyrotoxicosis

4-Due to LARGE PLACENTA=>  Hyperemesis Gravidarum

                                                          Placenta previa

                                                          Polyhydramnious

                                                          PET=>Accidental Hge

5-Due to OVERDISTENDED UTERUS=>    Pressure C/O

                                                                            PROM => PMD

                                                                            PET =>Acc. hge

                                                                            Pyelonephritis

                                                                            *Splanchnic shock

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

You have to decide if labor will be difficult or smooth, labor is difficult in cases where the pregnancy disorder leads to malpresentation or macrosomic fetus.

If Labor is difficult =>

          1-Write down all complications of malpresentations

          2- POSTPARTUM HEMORRHAGE

If labor is smooth=>

          Only complication is POSTPARTUM HEMORRHAGE which 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 medicine

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

Of early pregnancy in early pregnancy disorders

A-Of the possible complication

                             -Bleeding = > Collapse

                             -Infection => FAHM

                             -Overdistended uterus = > Pressure C/O

                             -DIC = > Ecchymotic patches, bleeding gums&teeth.

                                      ...etc

B-Medical symptoms

only for medical disorders

C-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.)