OB 2 SPECIAL CLASS, June 27, 2019

REPRODUCTIVE ANATOMY EXTERNAL FEMALE GENITALIA

1. External genitalia ✓Vulva

2. Internal genitalia • mons pubis
• labia – labia majora is the outer pole; labia minora is sensitive because
✓Anterior abdominal wall of nerve fibers
• Confines the abdominal viscera • clitoris
• Accommodate expanding uterus
• Provides surgical access to internal reproductive organs ✓Vestibule -almond-shaped area enclosed by
• Hartline - laterally
✓Langer lines describe the dermal fibers within the skin. • external surface of hymen - medially
• clitoral frenulum - anteriorly
✓Subcutaneous layer is separated. • fourchette - posteriorly
• Superficial fatty layer – Camper’s fascia
• Deeper membranous layer – Scarpa’s fascia *So, if you look at the drawing, the one you see in the upper part is the
vulva and the vestibule is in the lower portion and the lowermost portion
✓Beneath the subcutaneous are: is the perineum:
• Rectus abdominis
• Pyramidalis ✓ Perineum – diamond-shaped area between thighs
• External oblique Boundaries:
• Internal oblique • pubic symphysis – anteriorly
• Transversus abdominis muscle • ischiopubic rami & ischial tuberosities – anterolaterally
• sacrotuberous ligaments – posterolaterally
✓Blood supply – skin and subcutaneous • coccyx – posteriorly
• Superficial epigastric *So those are the outside area: the vulva, the vestibule, and the
• Superficial circumflex perineum.
• Superficial external pudendal arteries - arise from femoral artery

✓Innervation – entire abdominal wall innervated by

• intercostal nerves T7-11
• subcostal nerve T12
• iliohypogastric nerve
• ilioinguinal nerve

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INTERNAL FEMALE GENERATIVE ORGANS
✓Uterus – site of implantation
✓Ligaments – ligature that holds the uterus.
• Round – originates from the anterosuperior area of the uterus and
terminates in the labia majora
• Broad – upper portion of the uterus down to the base of the cardinal
ligament; considered a wing-shaped ligament
• Cardinal
• Uterosacral
*The round and the broad ligament give lesser support; major support to
the uterus -cardinal and uterosacral ligaments
✓Blood supply
• Uterine artery – originates from internal iliac artery
• Ovarian arteries – originates from the major blood supply, aorta
✓Pelvic lymphatics
• Paraaortic lymphatic nodes
• Internal iliac nodes
✓Pelvic innervation
• T10 - L2
*That’s why when you do surgery, the anesthesiologist will block
these areas especially during cesarean sections.
✓Ovaries
• rests in the fossa of Waldeyer;
• gives off most important hormones: estrogen and progesterone
• Cortex – outer layer (avascular – no blood vessels)
• Medulla – inner layer (vascular – lots of blood vessels)
✓Fallopian tubes – serves as a conduit or a passageway from the release of the
ova from the ovary that passes through the fallopian tube which is the main site
of fertilization. The ampulla is the main site of fertilization.
Divisions:
• Interstitial - attached to the uterus
• Isthmus – shortest and narrowest portion
• Ampulla – widest portion, site of fertilization
• Infundibulum/fimbrial area – finger-like structure, responsible for
catching the ovum from the ovary
*It is where the fertilization takes place to meet the sperm coming from the
vagina travelling through the cervix and then the uterine cavity going towards the
fallopian tube traversing the ciliary portion, opposite gradient. The sperm will
traverse in opposite direction. It only needs 1 sperm to fertilize an egg.
✓Planes and diameters of the pelvis
• Plane of pelvic inlet – superior strait
• Plain of pelvic outlet – inferior strait
• Plane of midpelvis – least pelvic dimension
• Plane of greatest pelvic dimension – no obstetrical significance
*Pelvic inlet – 4 diameters
1. anteroposterior diameter
a. True conjugate – upper portion of the sacrum to the
lower portion of the symphysis pubis
b. Diagonal conjugate – lower part of the sacrum to the
lower portion of the symphysis pubis
c. Obstetric conjugate – most important; from the
midpoint of the sacrum to the midpoint of the lower portion of
the symphysis pubis
2. transverse diameter
3. (2) oblique diameters
*The most important among these 4 is the plane of the pelvic inlet and the
midpelvis because if the fetal head needs to pass through the inlet, it also has to
pass through the midpelvis. If there is no passage, then it cannot get through the
pelvic outlet.

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*So, why is the obstetric conjugate very significant? Because it is the area wherein
the head must pass. The normal diameter of the obstetric conjugate should be 10
cm. The normal biparietal diameter of the fetus is between 9-10 cm. So, it should
be 10 or less. If the head is 10 or above, then it can not pass through the obstetric
conjugate.
LABOR
• Forceful and painful uterine contractions that effect cervical
dilatation and cause fetus to descend through birth canal.
*There should be cervical dilatation in order for the fetus to descend
to the birth canal. The structure that is usually affected in labor is the
uterus. Ovary has no role. Fallopian tube has no role.
✓Uterus – endometrial lining is transformed by pregnancy hormones and is
termed decidua.
*So during pregnancy, we do not call it endometrium, we term it decidua.
✓During pregnancy, the cervix serves as
• barrier to protect the reproductive tract from infection
• maintain cervical competence despite gravitational forces as the fetus
grows, it holds the fetus
• orchestration of extracellular matrix changes that allow greater tissue
compliance, to maintain the pregnancy or else the patient will have
cervical insufficiency or preterm labor.
✓Placenta
• serves as the conduit for exchange of nutrients and waste between
mother and the fetus
• the key source of steroid hormones and other mediators that maintain
pregnancy and potentially aid the transition to parturition
✓The fetal membranes
• amnion, chorion, and adjacent decidua
• make up an important tissue cell around the fetus
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amnion
• provides virtually all the fetal membrane’s tensile
strength resisting membrane tearing and rupture
*The amnion must be strong, not to rupture before
delivery. It is avascular. So, that’s the reason why if you
observe that there is a rupture of membrane, the fluid
comes out without any tinge of blood because the one
that ruptures before delivery is the amnion and it is
avascular.
Once there is rupture of membrane and there is blood,
you have to suspect a vasa previa. The vasa previa is a
placental blood vessel overlying the cervix. So, it is
encroaching the amnion. If there is tearing of the
amnion, there is bloody water that mixes with the
amniotic fluid.
• avascular tissue highly resistant to penetration by
leukocytes etc.
chorion
• protective tissue layer and provides immunological
acceptance.
• Enriched with enzymes that inactivate uterotonins
resp for uterine contractions.
✓Prostaglandins role
• Myometrial contractility
• Relaxation
• Inflammation
PARTURITION
Stages of labor – 1st, 2nd ,3rd
• Phase 1 – quiet uterus, cervical softening
• Phase 2 – preparation for labor, progesterone withdrawal, cervical
ripening
• Phase 3 – labor - characterized by effacement & dilatation of cervix
• Phase 4 – Puerperium – 6-8 weeks postpartum wherein the uterus and
the other reproductive organs go back to their normal structure.
ABNORMAL LABOR
✓Uterine dysfunction (layman’s term for abnormal labor) – uterine contractions
insufficiently strong or inappropriately coordinated to efface and dilate the
cervix. *There is a failure of the cervix to dilate despite strong contractions.
C. ruptured membranes without labor
*candidates for uterine dysfunction, normal rupture of membranes
should occur before delivery where cervix is fully dilated. Once the
membrane ruptures, the head should follow.
*most patients can not deliver vaginally, for CS section

✓Common clinical findings ✓Abnormal Labor Patterns

A. inadequate cervical dilatation or fetal descent

1. protracted labor slow labor

• Slow labor
• cervical dilatation in nullipara of less than 1 cm per hour;
less than 1.5cm in multipara. The normal cervical dilatation
is 1 cm per hour or at least 1cm per 2 hours.
2. arrested labor
• no progress
• There is no progress of labor after 4 hours wherein the
cervix retains at 3-4cm.
3. inadequate expulsive effort
• ineffective pushing
• cervix is fully dilated but the mother doesn’t want to
push; there is no effort
B. fetopelvic disproportion
1. prolongation disorder
1. excessive fetal size *Americans – 4000 gms; Filipinos – 3500 gms
2. inadequate pelvic capacity • refers to the cervical dilatation which is less than 3 cm.
3. malpresentation or position of the fetus • In nulliparas, prolongation of labor in less than 4cm for
*Normal presentation is cephalic. Any presentation aside from 14 hours, 8-11 hours in multiparas.
cephalic is considered a malpresentation like breech, transverse,
shoulder, or compound presentation (there is the head and an 2. protraction disorders
extremity)
• cervical dilatation should be at least 4cm and above.
*Normal position of the fetus is R or L occiput anterior. Any
• Protracted active phase disorders-
position deviating to this is considered a malposition. The most
• Protracted descent – there is no descent for more than
common position we encounter in practice is the persistent
1 hour in both nulliparas and multiparas.
occiput posterior or sometimes, persistent occiput transverse.
4. abnormal fetal anatomy
*big fetal head

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ABNORMAL LABOR cont. ✓Breech delivery

3. arrest disorders • Spontaneous breech delivery, partial breech delivery, total breech
• Prolonged deceleration phase delivery
*During deceleration phase, cervical dilatation is at • External cephalic version – when you revert the longitudinal lie to either
10cm and it had been there for more than 2 hours for cephalic or breech. If the first twin is delivered vaginally, then the second
nullipara and 1 hour for multipara. twin is transverse then you can do external cephalic version.
• Secondary arrest of dilatation • Several types of breech: complete, frank, incomplete/footling – total
*Cervical dilatation upon IE does not progress for at breech extraction
least 4 hours. • Breech vaginal delivery is not encouraged in preterm babies because of
• Arrest of descent the disproportionate size of the head compared to the body. Head is
• No descent for more than 1 hour for both always bigger.
nulliparas and multiparas. Cervix is NOT fully
dilated. EARLY COMPLICATIONS OF PREGNANCY
• Failure of descent
*failure of descent during the deceleration • Abortion, ectopic pregnancy, GTDs
phase when the cervix is fully dilated.
ABORTION
✓Complications with dystocia • Spontaneous or induced termination of pregnancy before fetal
viability before 20 weeks, weighing less than 500 grams.
1. maternal • First trimester spontaneous abortion within 12 weeks AOG
• Infection Pathogenesis: hge into decidua basalis – seen in the ultrasound
• Postpartum hemorrhage – subchorionic hge
• Uterine tears Fetal factors: monosomy x, triploidy
• Uterine rupture Maternal factors: infection (most common is UTI, chlamydia,
• Fistula formation STD’s), medical disorders, poorly controlled DM, obesity,
• Pelvic floor injury thyroid d/o, SLE
• Lower extremity nerve injury Cancer -radiation
2. perinatal complications Surgical procedures – abdominal trauma – *progesterone
• Sepsis supplementation for patients with twisted ovarian cyst who will
• Caput succedaneum – disappears in several hours undergo surgery to avoid abortion
• Molding Nutrition – sole deficiency of one nutrient or moderate
• Mechanical trauma deficiency of one nutrient does not appear to cause abortion
(nerve injury, fractures, cephalhematoma – disappears Social and behavioral factors – alcohol intake, smoking, illicit
in days or weeks) drugs, excessive caffeine intake may be possible cause of
miscarriage
Paternal factors-increasing paternal age - chromosomal
abnormalities of spermatozoa

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✓Spontaneous abortion clinical classification
*These can happen in the first 12 weeks of pregnancy. The cause is usually
unexplained.
1. threatened abortion
• missed period, bleeding, hypogastric pain, closed cervix
• Tx: bed rest, tocolytics – progesterone in the form of
utrogestan(orally or vaginally) and dydrogesterone in the form of
duphaston (orally only)
• isoxoprene is also given but it can cause maternal tachycardia; not
given to mothers with asthma or cardiac problem
• progesterone relaxes the uterus and prevents contractions to expel
the fetus; also helps in the maintenance of the competency of the
decidual lining. Progesterone release is taken over by the placenta
after 8 weeks of gestation; before 8 weeks, it’s the function of the
corpus luteum.
• Request for urinalysis to determine if there are infections. Positive
pus cells = give antibiotics: Penicillin, Ampicillin, Amoxicillin, and
Cephalexin
2. incomplete abortion
• bleeding, hypogastric pain, passage of meaty materials, open cervix
• Mgt: evacuation curettage or suction curettage
• Request for CBC and blood type – give IV antibiotics if there is
infection in the blood
3. complete abortion
• bleeding, hypogastric pain, passage of all products od conception
and once it is passed out, cervix will close
• request for TVS to determine if there are products of conception left
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4. missed abortion
• missed period, (positive pregnancy test), no bleeding, no
hypogastric pain, cervix is closed. Diagnosed through sonogram =
no fetal heart tone at 8 weeks; long-playing condition – weeks
before the mother can pass out the products of conception
• eveprim - primrose oil (orally /vaginally) in order to soften the
cervix. Eveprim takes longer period. Oxytocin are only effective in
latter part of pregnancy. The most effective to dilate the cervix in
case of missed abortion is misoprostol (orally/ vaginally).
Drawback: fever, diarrhea, chills. Dinoprostone – not available here
• Laminaria tents (laminaria japonicum – bark) – inserted to the
cervix in order for the cervix to soften and dilate
• If the cervix can not be dilated, last resort: hysterotomy
5. inevitable abortion
• hypogastric pain, bleeding, cervix is open, products of conception is
still inside the uterus; inevitable but it will expel any time; you can
not avoid it anymore.
• Wait for the expulsion. Fetus and placenta should be expelled. If
not, do evacuation curettage.
6. septic abortion
• retained products of conception, there is a focus of infection, fever,
body malaise, on and off bleeding, foul vaginal discharge; the most
serious – might lead to sepsis syndrome and you can have DIC –
disseminated intravascular coagulation
• evacuation curettage
• Stabilize patient first. Give IV fluid. Load patient with antibiotics.
Correct the anemia --- then do evacuation curettage.
• If fever still persists, last resort: hysterectomy
*Incomplete and septic abortion – high mortality
 ECTOPIC PREGNANCY
ABORTION cont. ✓Ectopic pregnancy – outside the endometrial cavity pregnancy
Risks:
✓Recurrent miscarriage - 2 or more abortion • Fallopian tube abnormalities
Causes: • STD
• Parental chromosomal abnormalities • Tubal infection
• Antiphospholipid antibody syndrome • Tubal sterilization
• Structural uterine abnormalities • Infertility mgt
*Request for chromosomal analysis, antiphospholipid antibody, CT scan, MRI, *The fallopian tube is not the normal site of implantation. The embryo is
hysterosalpingogram to determine structural uterine abnormalities usually implanted in the fallopian tube epithelium. So, as early as 6-7 weeks,
since it has no muscles (it’s just the epithelium), it will tend to rupture. So, as
✓Midtrimester abortion early as 6-7 weeks, the fallopian tube usually ruptures depending on the site
but especially if in the isthmus.
• Cervical insufficiency – painless cervical dilatation that the cervix cannot
carry the pregnancy to age of viability; at least more than 12 weeks – 24 ✓Pregnancy burrows in the Ft epithelium
weeks AOG
• Mgt: cerclage – prevention of the cervix to dilate Outcome:
• Progesterone has no role because there is good implantation; the
problem is the cervix so you need to do the mechanical prevention for the • Rupture – most common; if there is rupture, there will be intraperitoneal
cervix to dilate = cerclage. hemorrhage = shock.
• Tubal abortion – in cases wherein the site of the implantation is in the
✓Induced abortion – medical or surgical termination of pregnancy before the fimbria or in the ampulla. Since the fallopian tube has contractions also,
time of viability if there is necrosis, the attachment will be (*can’t interpret word) and the
tendency of the mass will be aborted so it goes into the abdominal cavity.
Classification: • Chronic-resorption – there are others who have chronic ectopic
pregnancy and it is resorbed; no signs of pain or bleeding but there is
1. therapeutic – termination of pregnancy for delay in menstruation.
medical indications
Clinical manifestation: subtle or absent (especially if chronic)
2. elective or voluntary abortion – termination of pregnancy before
viability at the request of the woman but not for medical reasons. • Delayed menstruation (amenorrhea)
• Pain – due to peritoneal irritation if there is fluid in the cul de sac and in
the peritoneal cavity
• Vaginal bleeding or vaginal spotting – the endometrial glands also grow
so when the pregnancy is terminated, these will be sloughed off = vaginal
bleeding
*Ectopic pregnancy is still considered a pregnancy so there is still
production of estrogen and progesterone in the endometrium.
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ECTOPIC PREGNANCY cont. ✓Cervical pregnancy
• placenta found below entrance of uterine vessels, endocervix is eroded
Diagnosis by trophoblast
• History and PE • massive vaginal bleeding, painless
• TVS – adnexal mass/ mass in the fallopian tube (before: use of • usually confused with incomplete abortion
culdosynthesis if there is peritoneal leak – seldom used) • diagnosis is difficult. It can be diagnosed as a mass in the cervix during
• Ring of fire – placental blood flow within the periphery of adnexal early ultrasound – 6 wks
complex (confirmatory that there is ectopic pregnancy if seen in TVS) • Mgt: if not bleeding – Methotrexate
• B-HCG – it should be lower. (higher if H. mole or pregnancy itself)
Ex: Normal B-HCG @ 18 wks = 18,000-100,000 ✓Abdominal pregnancy
Ectopic pregnancy = 5000-6000 (lower based on the AOG) • pregnancy implantation in the peritoneal cavity exclusive of tubal
• Laparoscopy – not available here ovarian or intraligamentous implantation
• diagnosis is difficult
Medical management: • abnormal fetal positions may be palpated or the cervix is displaced
• Methotrexate – resorption • maternal risk – sudden occurrence of hemorrhage
• Candidate – asymptomatic, motivated, compliant mass <3.5cm (if • suspect if the cervix is difficult to palpate, big abdomen with fetal heart
greater than 3.5cm, it is managed surgically) beat and there is bleeding
• Methotrexate
Surgical management:
• Salphingostomy – remove unruptured ectopic pregnancy GESTATIONAL TROPHOBLASTIC DISEASE – counted as pregnancy
• Salphingectomy – ruptured: remove fallopian tubes *If the patient has 1 Term, 1 H mole, 1 Aborted, 1 Living, What is the OB code?
Term -1 Preterm -0 Aborted-1 Living -1 = 1011
*Ectopic pregnancy is one of the dreaded complications of early
pregnancy and sometimes, it is mistaken as appendicitis – mot common ✓Hydatidiform mole classic to histo finding – trophoblast proliferation and villi
differential diagnosis of pregnancy. The other differentials are: torsion, with stromal edema
twisted ovarian cyst, diverticulitis, pelvic inflammatory disease. If the
hemoperitoneum is over 1000 = shoulder pain in the same side of the Classification
rupture.
*High index of suspicion is needed. All women of reproductive age • Complete mole – abnormal chorionic villi grossly appear as mass of clear
complaining of hypogastric pain should undergo pregnancy test to vesicles (seaweed like structure)
exclude the presence of pregnancy whether intrauterine or extrauterine. • Partial mole - focal less advanced hydatidiform changes and contains
some fetal tissue
✓Interstitial pregnancy – implants within the proximal tubal segment that lies
within uterine musculature (the junction between the fallopian tube and the Pathogenesis
uterus)
• Arise from chromosomally abnormal fertilization

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GTD cont. ✓Histological class of GTN
Invasive mole
Clinical findings • Most common
• Follows H. mole (Hmole before invasive mole; Holes should be completely
• Amenorrhea treated) )
• Vaginal bleed – spotting to profuse • All invasive moles arise from partial or complete.
• Nausea and vomiting
• Uterine growth larger than expected size based on AOG Gestational carcinoma
Ex: @12 wks, the fundic height is that of 5 months • Type that follow a term pregnancy or a miscarriage
• Theca lutein cysts – complete mole • Contains no villi
• Rapidly invade myometrium and blood vessels to create hemorrhage
Diagnosis and necrosis (intraperitoneally or vaginally)
• Serum beta HCG • Theca lutein cysts are present (usually bilateral and are usually seen in
Normal serum B-HCG : 0 -1 invasive mole)
*marker for surveillance: In cases of Hmole -100,000 and above (can
reach millions) Placental site trophoblastic tumor
• Sonography – snowstorm pattern • Arises from intermediate trophoblasts
• Management - molar termination via evacuation curettage/suction • High proportion of free beta HCG considered diagnostic
curettage • Resistant to chemotherapy
• Management is hysterectomy
✓Gestational trophoblastic neoplasia
Epithelioid trophoblastic tumor
• Aggressive invasion into the myometrium and propensity to • From chorionic type intermediate trophoblast
metastasize. (if there is myometrium invasion, there could be perforation • Main site: uterus
because it has invaded the muscles. It can perforate even inside the • Bleeding and low HCG levels
serosa – massive bleeding) • Management – oncologists
• Common finding: irregular vaginal bleeding associated with uterine
subinvolution (if there is subinvolution, these patients usually have ✓Subsequent pregnancy
undergone vaginal or cesarean delivery; involution means return to • Fertility not impaired
structure. So, in cases like this, the patient has undergone delivery, and • Pregnancy outcomes – normal
after 6 weeks still has irregular vaginal bleeding and the uterus is still • Delay pregnancy for 1 year
large, suspect GTN)
• Bleeding – continuous or intermittent with sudden and sometimes *Methotrexate – medical management for GTD’s except for placental site tumor
massive bleeding which is managed by hysterectomy. If the patient has completed family size (3-4
• Myometrial perforation due to trophoblastic growth – intraperitoneal children), do hysterectomy.
hemorrhage *Treatment for Hmole is 1 year – includes follow -up.

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June 28, 2019 PUERPERAL COMPLICATIONS

CESAREAN DELIVERY AND PERIPARTUM HYSTERECTOMY • Fever- 38 degree centigrade or higher

• Most are due to genital infection
✓cesarean delivery – birth of a fetus via laparotomy (open the peritoneal cavity)
then hysterotomy (open the uterus) – birth of fetus ✓Other causes of puerperal fever:

✓postmortem caesarean delivery – pregnant woman just died (and the baby is
term and you’re trying to save the baby. Should be done within 5 minutes because
oxygenation in the brain is diminished within 5 minutes Ex: patient had stroke,
accidents)
✓cesarean hysterectomy – uterus is removed at CS
✓postpartum hysterectomy – hysterectomy done short time after vaginal
delivery (massive bleeding cannot be controlled by uterotonics like oxytocin,
dinoprostone)
✓radical hysterectomy
• done with invasive cervical cancer
• removal of uterus, parametrium, proximal vagina to achieve tumor
excision with negative margins
TYPES of UTERINE INCISION
• Classical – from the fundus to the lower uterine segment
• Low transverse cesarean section – doing the CS section in the lower
uterine segment
*Read the definitions and advantages in the book.
TYPES OF ABDOMINAL INCISION
• Midline – more advantages than pfannenstiel
• Pfannenstiel – (1) better cosmetic result and (2) less pain but has more
disadvantages
Common disadvantage: re-entry – If the patient got pregnant again,
there is usually a massive blood loss – requires blood transfusion. Cannot
extend, little room for exploration
*3 most common disadvantages of pfannenstiel
• Breast engorgement
• Infection of the urinary tract/uterine infections
Factors: (1) route of delivery (Vaginal – site of placental
implantation; CS (higher risk) – site of incision in the
abdomen, site of incision in the uterus, site of placental
implantation) (2) rupture of fetal membrane,
(3) prolonged labor,
(4) multiple cervical exams
• Infections of perineal lacerations
• Infections of episiotomy or abdominal incisions
Risk factors of abdominal incisional infections:
(1) obesity (closing is difficult)
(2) diabetes (poor wound healing)
(3) corticosteroid therapy,
(4) immunosuppression,
(5) anemia,
(6) hypertension,
(6) inadequate hemostasis with hematoma formation (will become
necrotic and destroy nearby tissues; ligate bleeders)
Fever begins on the 4th day postpartum
• Respiratory complications after CS delivery
✓Acute pyelonephritis – fever- 1st sign, Costovertebral angle tenderness
associated with nausea and vomiting
✓Atelectasis – following abdominal delivery caused by hypoventilation
prevented by coughing and deep breathing on a fixed schedule following surgery.

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PUERPERAL COMPLICATIONS cont. CONTRACEPTION

✓Wound dehiscence/disruption - separation of the fascial layer ✓intrauterine device

• Manifested 5th post op day (fever, serosanguinous discharge) • Action: leads to endometrial atrophy, scant viscous cervical mucus that
• Requires secondary closure in the operating room obstructs sperm motility, endometrial inflammatory induced

✓Necrotizing fasciitis – high mortality rates • Adverse effects: (1) ectopic pregnancy
(2) lost IUD
• Tissue necrosis (3) perforation
• Risks: diabetes, obesity, hypertension (4) menstrual changes
• Occur 3-5 days after delivery (5) infection
• Early diagnosis, surgical debridement, antimicrobials, intensive care
• Pregnancy with IUD – If tail is seen in the cervical opening, remove the
✓Adnexal abscess/peritonitis IUD

• Adynamic ileus – the first sign of peritonitis (absence of bowel • IUD Insertion – timing – 6 weeks after delivery to reduce expulsion of
movement/sounds) IUD, immediately after miscarriage
• Parametrial phlegmon – induration within leaves of the broad ligaments
(CS patients)
✓Progestin implants – ex. Nexplanon
✓Toxic shock syndrome
• Implant is placed subdermally on the medial surface of the upper arm 8-
• With severe multi system derangement 10 cm from the elbow in the biceps groove and is aligned with the long
• Fever, headache, mental confusion, diffuse macular erythematous rash, axis of the arm.
subcutaneous edema, nausea, vomiting, watery diarrhea, marked
hemoconcentration • Timing: within 5 days of menstruation

✓Breast infections ✓Progestin-only contraceptives

• Staphylococcus aureus • Action and effects – block ovulation by suppressing LH effects – cervical
• Usually resolves within 24-48 hours mucus thickening (sperm cannot travel, will be stuck in the vaginal canal)
• Irregular or heavy uterine bleeding
• POP do not impair milk production (given to those who are breast
feeding)
• Contraindications: breast cancer and pregnancy

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CONTRACEPTION cont.
✓Preeclampsia superimposed on chronic hypertension
✓Hormonal contraceptives
• Diagnosed with bp 140/90 and higher before pregnancy or before 20
• Combination hormonal contraceptives weeks or both (with proteinuria)
• Action: suppression of hypothalamic gonadotropin releasing factors ---
blocks pituitary secretion of FSH and LH thus inhibit ovulation Pathogenesis: (1) vasospasm
(2) endothelial cell injury
✓Puerperal tube sterilization (3) increased pressor responses
(4) angiogenic & antiangiogenic proteins
• Timing: several days postpartum when the uterine fundus lies at the
level of the umbilicus and fallopian tubes are accessible directly beneath Pathophysiology:
the abdominal wall.
• Technique: Parkland (tie), Pomeroy (tie, cut), Modified Pomeroy (tie the • Cardiovascular – increased cardiac afterload, increased cardiac preload,
tube, cut, ligate), Fimbriectomy (cut the fimbria) endothelial activation - intraendothelial extravasation of intravascular
fluid into extravascular space and into the lungs (pulmonary edema)
HYPERTENSIVE DISORDERS OF PREGNANCY • Hemodynamic changes
- Determine myocardial function
1. preeclampsia and eclampsia syndrome - Relevant ventricular function
2. chronic hypertension of any etiology • Blood volume – hemoconcentration
3.preeclampsia superimposed on chronic hypertension • Maternal thrombocytopenia
4. gestational hypertension • Hemolysis – HELLP - (there is destruction of the RBC’s so there is
breakdown of the RBC’s – low platelet count – thrombocytopenia)
✓Gestational hypertension • Coagulation changes – intravascular coagulation and erythrocyte
destruction
• Diagnosis is made in women whose blood pressure reach 140/90 or • Endocrine and hormonal alterations – increased vasopressin
greater for the first time after midpregnancy, but in whom proteinuria (vasoconstriction) – increased proatrial natriuretic peptide
is not identified. • Fluid and electrolyte alterations – extracellular fluid manifests as
• B/P returns to normal after 12 weeks postpartum edema
• Kidney – renal blood flow and GFR are increased
✓PREECLAMPSIA SYNDROME • Liver – periportal hemorrhage in liver periphery (hepatic rupture –
capsular hematoma – RUQ pain)
• pregnancy specific syndrome that can affect virtually every organ • Brain – *seen post autopsy cortical and subcortical petechial
system hemorrhages, fibrinoid necrosis of the arterial wall and perivascular
• most important signs: (1) elevated blood pressure, (2) proteinuria, microinfarcts and hemorrhage (some go blind, comatosed)
sometimes: (3) edema • Uteroplacental perfusion -decreased with abnormal placentation,
abnormal high resistance

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HYPERTENSION cont. ✓Injuries to the birth canal
• Episiotomy and lacerations
• (smaller blood vessels – smaller blood volume – fetal hypoxia – fetal • Forceps delivery
death) • Cesarean or hysterectomy
• Uterine rupture (previously scarred uterus, high parity,
Management: hyperstimulation, obstructed labor, intrauterine manipulation,
midforceps extraction, breech extraction)
• Penultimate management – delivery
*Determine first the AOG, status of mother, status of fetus. ✓Obstetrical factors
• Antihypertensive • Obesity
• Antioxidants • Previous postpartum hemorrhage
• Antithrombotic agents • Early preterm pregnancy
• Magnesium sulphate – convulsion • Sepsis syndrome
• Preeclampsia/eclampsia
OBSTETRIC HEMORRHAGE
✓Vulnerable patients
✓Uterine atony • Chronic renal insufficiency
• Constitutionally small size patients
• uterine overdistension
Average fundic height of Filipinos: 30-32 ✓Coagulation defects
• large fetus, multiple fetuses, hydramnios, retained clots (Retained clots • Massive transfusions
can cause uterine atony if there are placental abnormalities. Inspect the • Placental abruption
cotyledons of the placenta and they should be intact.) • Sepsis syndrome
• labor induction, anesthesia, halogens, conduction anesthesia • Severe preeclampsia syndrome
• Acute fatty liver
✓Labor abnormalities – rapid labor, prolonged labor, augmented labor, • Anticoagulant treatment
chorioamnionitis • Cong.coagulopathies
• Amnionic fluid embolism
✓Previous uterine atony
• Prolonged retention of dead fetus
• Parity – primiparity and high parity
• Saline abortion
✓Abnormal placentation
✓Diagnosis
• Placenta previa
• Bioassay – determine coagulopathy
• Placental abruption
• History and PE is the best diagnostic tool
• Morbidly adherent placenta
• Lab: fibrinogen, fibrin, degradation products level, platelet count, PT and
• Ectopic pregnancy
PTT
• H. mole

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HEMORRHAGE cont. • rubella virus (German measles) – abortion – mild fever, manifested in the
extremities, post auricular area, ordinary rash – 3 days – can cause
✓Management congenital abnormality if it occurs in the first trimester – abortion – can
cause cataract, heart disease
• Recognition • respiratory viruses – hanta virus, enterovirus, west nile virus, corona
• fluid resuscitation virus, ebola virus, zika virus
• blood replacement
• Adjunctive surgical procedures ✓Protozoal infections
o uterine artery ligation
o uterine compression sutures 1. toxoplasmosis – cats
o internal iliac artery ligation 2. malaria – mosquitoes
o angiographic embolization 3. amoebiasis – oral intake
o pelvic packing
✓Mycotic infections
INFECTION
*one of the 3 leading causes of maternal death (hemorrhage, hypertension, • candidiasis/moniliasis – most common
infection) *white cottage cheese discharge, pruritus
*not common nowadays because of high end antibiotics *Diabetes Mellitus – associate with candidiasis
• coccidiomycosis
✓Fetal cell-mediated and humoral immunity begin to develop by 9-15 weeks • blastomycosis
gestation • cryptococcosis
*From the uterus @ 9 weeks, there is fetal heart beat and a well-developed brain • histoplasmosis
– it is also the beginning of immunity
✓Travel precautions during pregnancy
✓The primary fetal response to infection is Immunoglobulin M
*3 major kinds: Viral, Bacterial, Protozoal • Bioterrorism – releases of viruses, bacteria or other infectious agents to
cause illness or death
✓Viral infections o Smallpox – eradicated
o Anthrax – through mail
• cytomegalovirus – if the mother has CMV, it can be transmitted to the • Other bioterrorism agents:
fetus o Francisella tularensis
• varicella zoster virus (chicken pox) – congenital varicella syndrome – o Clostridium botulinum
highly transmissible during late stage of chicken pox o Yersinia pestis
• influenza – not much adverse effect in the fetus o Viral hemorrhagic fevers like Ebola, Marburg, Lassa,
• mumps virus – spontaneous abortion – if it occurs in the early part of the Machupo
pregnancy
• measles virus – high grade fever, manifested in all parts of the body

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SEXUALLY TRANSMITTED DISEASES PRETERM BIRTH

• Syphilis - oldest discovered, can cause abortion, can cause congenital • Born too early
abnormalities; can be transmitted vertically; transmitted when the fetus • LBW, SGA, LGA, AGA
is 18-20 weeks’ gestation; presence of chancres; resolves spontaneously • Late preterm – 34-36 weeks (Term: 37 weeks)
only to recur • Causes: Spontaneous unexplained (40-45%)
Idiopathic PPROM
• Gonorrhea – first cousin of chlamydia, care of the newborn to prevent Delivery for maternal/fetal indications
gonorrhea: Crede’s prophylaxis (Vitamin K is injected right after birth);
can not be transmitted vertically/through placenta but can be ✓Spontaneous preterm labor
transmitted through vaginal birth/contact. Presentation: dysuria (painful
urination) – burning painful urination with purulent discharge (urine with • Multifetal pregnancy
pus – pyuria) • Intrauterine infection
• Bleeding
• Chlamydial infections – most common; cousin of gonorrhea; not very • Placental infarction
symptomatic unlike gonorrhea; mucopurulent discharge • Premature cervical dilation
• Cervical insufficiency
• Herpes simplex – transmitted through sexual contact • Hydramnios
• Uterine fundal abnormalities
• Human Papilloma Virus – strains 16 and 18; can lead to cervical cancer ; • Fetal anomalies
transmitted through sexual contact • Maternal illness from infections, autoimmune dses, gestational
hypertension
• Vaginitis - Trichomoniasis, Candidiasis, Chlamydia, Bacterial vaginosis
✓Preterm premature rupture of membranes
• HIV
• Spontaneous rupture of membranes before 37 weeks and before onset
*Read on bacterial infections. of labor

• Risk: (1) lower socioeconomic status

(2) BMI <19.8 (underweight)
(3) nutritional deficiency
(4) cigarette smoking

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 PRETERM BIRTH cont. POSTTERM PREGNANCY

• Contributing factors: • Exceeds 42 weeks

• Increase stillbirth, neonatal and infant morbidity
(1) pregnancy factors • Pathophysiology:
(2) lifestyle (smoking)
(3) genetic ✓Postmaturity syndrome
(4) periodontal disease (visit dentist)
(5) interval between pregnancies • Wrinkled, patchy, peeling skin
(<18 and >59 months) • Long thin body suggesting wasting
Best time to get pregnant: more than 18 months but not after 59 months • Open eyed
– atleast 2 years • Unusually alert
(6) prior preterm birth • Appears old and worried
(7) infection (bacterial vaginosis) • Nails are long
✓Diagnosis of Preterm Birth ✓Complications

• History – symptoms, complains of hypogastric pain c/o mother • Oligohydramnios – less than 5 cm amniotic fluid index
• Cervical dilatation <2cm • Macrosomia – big baby weighing 4200-4500 gms
• Cervical change – effacement, dilatation
• Fetal fibronectin – intracellular adhesion during implantation *substance FETAL GROWTH RESTRICTION
that holds the cervix; decreased fetal fibronectin = preterm birth
• Cervical length measurement – shorter cervical canals • LBW who are small for gestational age
*Normal cervical length: 4-5cm when not pregnant; 3.5 cm average @
24 wks ✓Symmetrical growth restriction
If <2.2cm – preterm delivery • Proportionately small, early insult (Mother is malnourished from the
start)
✓Preterm birth prevention • Brain is affected
1. Cervical cerclage ✓Asymmetrical growth restriction
2. prophylaxis with progestogens • Disproportionately lagging abdominal growth compared to head growth.
*in cases of preterm birth and you plan to deliver the fetus, we give Later insult e. g. preeclampsia, HPN
prophylaxis with progestogens to prevent contractions but there is also
• Brain-sparing
a drug that would enhance the maturation of the lungs of the fetus –
corticosteroids (betamethasone 12 mg OD for 2 days or dexamethasone
6 mg every 8 hrs for 3 doses at 28-34 weeks or as early as 24 weeks.)
3. tocolysis
4. antimicrobials

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MULTIFETAL PREGNANCY MEDICAL COMPLICATIONS OF PREGNANCY

• Classification: dizygotic and monozygotic • Hyperemesis gravidarum – because of increased HCG,, disappears at 20
• Dizygotic is more common wks AOG
• Incidence influenced by: • Acute gastroenteritis
-race • Peptic ulcer disease
-heredity • Intestinal obstruction – previous CS sections
-maternal age • Appendicitis – diagnosis is difficult – appendix moves upward and
-parity outward from the right lower quadrant - pain will be elicited in the RUQ
-fertility treatment instead
*Patients taking clomiphene usually have twin pregnancy; also IVF. *Alvarado scoring: MANTRELS

• Diagnosis:
-clinical evaluation (hx and PE) *listen to fetal heart beat
-sonography – best modality
-abdominal radiography with abdominal shield; can be done only
@ 16-20 weeks AOG (average 18) - bone formation period; confirmatory
because it can visualize the heads
-magnetic resonance imaging

• Complications of multiple pregnancy:

-spontaneous abortion
-congenital malformation
- LBW
-hypertension
-preterm birth
-cognitively delayed

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 MEDICAL COMPLICATIONS cont.

• Diabetes mellitus – high risk patient: screen immediately at first visit;

low-risk patient: screen at 24 weeks

1. OGCT (Oral Glucose Challenge Test) – give 50 gms of glucose then

take the blood, if increased, request for:
2. OGTT (Oral Glucose Tolerance Test)

• Anemia *normal hemoglobin in pregnancy is 12, 11 is considered anemia

• Hepatitis B
• Thyroid d/o

SURGICAL COMPLICATIONS OF PREGNANCY

• Appendicitis
• Cholecystitis
• Choledocholithiasis
• Intestinal obstruction
• Trauma

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