AND NOTES- Wachira

REPRODUCTIVE HEALTH CONCEPT A state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity in all matters related to the reproductive system, its function and processes. Basic elements;

⋅ Ability - to reproduce, regulate fertility and enjoy healthy relationships

⋅ Success - result in child survival, growth and health development

⋅ Safety - Fertility regulation, and child health

Components of

⋅ Safe motherhood - Pre/Peri/Postnatal care, breast feeding and neonatal care

⋅ information and services

⋅ Prevention and management of and in both males and females

⋅ Prevention and management of complications of

⋅ Prevention and management of reproductive tract infections especially STDs including HIV/AIDS

⋅ Early detection of cancer of the and breast

⋅ Menopause - Prevention of osteoporosis, atherosclerosis

Major obstetric causes of maternal mortality

⋅ Hemorrhage - Pre/Peri/Postnatal

⋅ Sepsis

⋅ Pregnancy induced hypertension (especially in primigravida)

⋅ Unsafe abortion

⋅ Obstructed labor

PUBERTY Period when the endocrine and gametogenic functions of the gonads have first developed to the point where reproduction is possible This is characterized by sequence of events by which a child becomes a young adult;

⋅ The beginning of gametogenesis

⋅ Secretion of gonadal hormones

⋅ Development of secondary sexual characters and reproductive functions

⋅ Sexual dimorphism is accentuated.

Factors affecting the onset of puberty

⋅ The age of onset of puberty varies and is more closely correlated with osseous maturation than with chronological age

⋅ Genetic/Ethnic factors

⋅ Environmental/Geographical factors

Prepubertal stage (8–9 yr of age) The hypothalamic-anterior pituitary-gonadal axis is suppressed by;

⋅ Neuronal restraint pathways

⋅ Negative feedback provided by minute amounts of circulating gonadal steroids Thus there are undetectable serum levels of;

⋅ luteinizing hormone (LH)

⋅ sex hormones (i.e., estradiol in girls, testosterone in boys)

1 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

Evidence of hypothalamic-anterior pituitary-gonadal interaction during the prepubertal period resides in the fact that serum follicle-stimulating hormone (FSH) concentrations are detectable in most children and may be increased (with serum LH concentrations) in;

⋅ Turner syndrome

⋅ Anorchia

Peripubertal period (1-3 yr before the onset of puberty) Pulsatile secretion of low levels of LH during sleep secondary to endogenous episodic discharge of hypothalamic gonadotropin-releasing hormone (GnRH). Nocturnal pulses of LH continue to increase in amplitude and, to a lesser extent, in frequency as clinical puberty approaches. Serum LH concentrations rise earlier in the course of the pubertal process in boys than in girls. This pulsatile secretion of gonadotropins is responsible for;

⋅ Enlargement and maturation of the gonads

⋅ The secretion of sex hormones

⋅ Appearance of the secondary sex characteristics GnRH is the major, if not the only, hormone responsible for the onset and progression of puberty. A second critical event occurs in middle or late adolescence in girls, in whom cyclicity and ovulation occur. A positive-feedback mechanism develops whereby rising levels of estrogen in midcycle cause a distinct increase of LH.

Puberty in Girls (8-13yr)

⋅ Thelarche (Development of Breasts) - Breast bud - 10–11 yrs

⋅ Pubarche (Development of axillary and pubic hair) - Appearance of pubic hair - 6–12 mo later

⋅ Peak height velocity occurs early (at breast stage II–III, typically between 11 and 12 yr of age) in girls and always precedes menarche.

⋅ Menarche (first menstrual period) Interval to menarche - 2–2.5 yr but may be as long as 6 yr after thelarche.

⋅ Mean age of menarche - 12.75 yr. (13.5 yrs in rural girls)

Puberty in Boys (9-14yr)

⋅ Growth of the testes (>3 mL in volume or 2.5 cm in longest diameter)

⋅ Thinning of the scrotum

⋅ Pigmentation of the scrotum

⋅ Growth of the penis, seminal vesicles and prostrate

⋅ Pubic hair then appears

⋅ Appearance of axillary hair usually occurs in midpuberty, 2 yr after pubic hair.

⋅ In boys, unlike girls, acceleration of growth (5-15cm/yr in early adolescence but later drops) begins after puberty is well under way and is maximal at genital stage IV–V (typically between 13 and 14 yr of age).

⋅ In boys, the growth spurt occurs approximately 2 yr later than in girls, and growth may continue beyond 18 yr of age.

Adrenarche Adrenal cortical androgens also play a role in pubertal maturation. Serum levels of dehydroepiandrosterone (DHEA) and its sulfate (DHEAS) begin to rise at approximately 6–8 yr of age, before any increase in LH or sex hormones and before the earliest physical changes of puberty are apparent.

2 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

DHEAS is the most abundant adrenal C-19 steroid in the blood, and its serum concentration remains fairly stable over 24 hr; a single measurement of this hormone is commonly used as a marker of adrenal androgen secretion. Although adrenarche typically antedates the onset of gonadal activity (i.e., gonadarche) by a few years, the two processes do not seem to be causally related, because adrenarche and gonadarche are dissociated in conditions such as;

⋅ Central precocious puberty

⋅ Adrenocortical failure

ADOLESCENCE The period of life beginning with puberty and ending with completed growth and physical maturity. Between the ages of 10 - 19 yr (WHO), children undergo rapid changes in;

⋅ Phenotypic changes - Body size - Body shape

⋅ Neuroendocrine changes - Hormones set the developmental agenda in conjunction with social structures designed to foster the transition from childhood to adulthood.

⋅ Physiology

⋅ Psychological functioning

⋅ Social functioning

10-24 yr - Young Adults

Marshall - Tanner Classification of Sex Maturity Stages in Girls SMR Pubic Hair Breasts Stage 1 Preadolescent Preadolescent 2 Sparse, lightly pigmented, straight, medial Breast and papilla elevated as small mound; areolar border of labia diameter increased 3 Darker, beginning to curl, increased amount Breast and areola enlarged, no contour separation 4 Coarse, curly, abundant but amount less than Areola and papilla form secondary mound in adult 5 Adult feminine triangle, spread to medial Mature; nipple projects, areola part of general breast surface of thighs contour SMR = sexual maturity rating.

Marshall - Tanner Classification of Sex Maturity Stages in Boys SMR Pubic Hair Penis Testes Stage 1 None Preadolescent Preadolescent 2 Scanty, long, slightly pigmented Slight enlargement Enlarged scrotum, pink texture altered 3 Darker, starts to curl, small amount Longer Larger 4 Resembles adult type, but less in Larger; glans and breadth Larger, scrotum dark quantity; coarse, curly increase in size 5 Adult distribution, spread to medial Adult size Adult size surface of thighs SMR = sexual maturity rating.

3 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

Developmental lines occur within three periods of adolescence;

Central Issues in Early, Middle, and Late Adolescence Variable Early Adolescence Middle Adolescence Late Adolescence Age (yr) 10–13 14–16 17–20 and beyond SMR* 1–2 3–5 5 Somatic Secondary sex Height growth peaks; body shape Slower growth characteristics; beginning and composition change; acne and of rapid growth; awkward odor; menarche; spermarche Sexual Sexual interest usually Sexual drive surges; Consolidation of sexual exceeds sexual activity experimentation; questions of sexual identity orientation Cognitive and Concrete operations; Emergence of abstract thought; Idealism; absolutism moral conventional morality questioning mores; self–centered Self–concept Preoccupation with Concern with attractiveness, Relatively stable body changing body; self– increasing introspection image conscious Family Bids for increased Continued struggle for acceptance of Practical independence; independence; ambivalence greater autonomy family remains secure base Peers Same–sex groups; Dating; peer groups less important Intimacy; possibly conformity; cliques commitment Relationship Middle–school adjustment Gauging skills and opportunities Career decisions (e.g., to society dropout, college, work) SMR = sexual maturity rating.

THE MENSTRUAL CYCLE AND DEVELOPMENT OF THE EMBRYO Introduction Menstrual cycle - A periodic physiologic vaginal hemorrhage, occurring at approximately 28 ± 7 days interval (from the start of one menstrual period to the start of the next), and having its source from the shedding of uterine mucous membrane (menstruation); usually the bleeding is preceded by ovulation and predecidual changes in the . This may be teleologically regarded as periodic preparations for fertilization and pregnancy.

Ovarian Cycle During intrauterine fetal development, the develops through 3 stages;

⋅ Genital ridge stage - Sex cells can first be identified and begin as hypertrophy of the coelomic epithelium (future peritoneum) overlying the developing mesonephroi. Further growth of the ridges is dependent upon the arrival of germ cells.

⋅ Indifferent stage - Proliferation of germinal cells by mitosis and somatic cells

⋅ Sexual differentiation stage - Fundamental histologic differences between the ovary and testis are established To maintain species-specific chromosome complement;

⋅ the male gametes go through meiosis after puberty and continues throughout life owing to persistence of mitotically active “stem cells”, (spermatogonia)

4 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

⋅ the female gametes undergo meiosis during fetal life and all stem cells are eliminated during birth when meiosis is suspended in the middle of the first meiotic division to resume shortly before ovulation in response to LH surge Oogenesis In the human embryo, oogenesis begins in the ovary around the third week of gestation. Primordial germ cells appear in the , migrate to the germinal ridge, and undergo cellular divisions. Fetal contain approximately 7 million oogonia at 20 weeks' gestation. After 7 months' gestation, no new oocytes are formed. At birth, there are approximately 2 million oocytes, and by puberty this number has been reduced to 300,000. Continued reduction of oocyte number occurs during the reproductive years through ovulation and atresia. Nearly all oocytes vanish by atresia, with only 400-500 actually being ovulated.

1. Primordial germ cells (stem cells) - 3rd wk gestation embedded in the wall of the yolksac near allantois Migration to the germinal ridge

2. Oogonia From end of 2nd mo post conception - mitosis, investation with a single layer of granulosa cells, differentiation 3. Primary oocytes Prophase-I-Meiosis

4. Hibernation

Day 14 of menstrual cycle, LH surge, Meiosis I is completed

5. Haploid Secondary Oocyte + First Polar body (Small organelle-free cytoplasmic vesicle is extruded) . Metaphase-II-Meiosis . Loosening up of the coronary radiata cells and rupture on the outer surface leading to oozing out of the oocyte - Ovulation . Maturation of oocytes; - 36-37 hrs - Migration of granules from the cytoplasm to the cortex of the ooplasm providing effective block against polyspermy. . Movement of the ovum to the

6. Fertilization Meiosis II is complete

7. Mature oocyte + Second polar body (extruded)

Fusion of pronuclei

8. Diploid Zygote

Cleavage between 8 and 16 cell stage

5 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

Baker’s calculations; Age Population 2 mo gestation 600,000 germ cells 5 mo gestation 2 million oogonia 4.8 million primary oocytes New born 2 million oocytes 12-14yrs 250,000-300,000 oocytes 45-55yrs Hundreds

⋅ Day 1 - Several of these follicles enlarge, and a cavity forms around the ovum (antrum formation). This cavity is filled with follicular fluid.

⋅ Day 6 - One of the follicles in one ovary starts to grow rapidly and becomes the dominant/graafian follicle, while the others regress, forming atretic follicles. The atretic process involves apoptosis. It is uncertain how one follicle is selected to be the dominant follicle in this follicular phase of the menstrual cycle, but it seems to be related to the ability of the follicle to secrete the estrogen inside it that is needed for final maturation. When women are given highly purified human pituitary gonadotropin preparations by injection, many follicles develop simultaneously. The cells of the theca interna of the follicle are the primary source of circulating estrogens. However, the follicular fluid has a high estrogen content, and much of this estrogen comes from the granulosa cells. Just before ovulation, in response to LH surge which occurs in a strict diurnal rhythm peaking at 3am, the first meiotic division is completed. One of the daughter cells, the secondary oocyte, receives most of the cytoplasm, while the other, the first polar body, fragments and disappears. The secondary oocyte immediately begins the second meiotic division, but this division stops at metaphase and is completed only when a sperm penetrates the oocyte. At that time, the second polar body is cast off and the fertilized ovum proceeds to form a new individual.

⋅ Day 14 - The distended follicle ruptures, and the ovum is extruded into the abdominal cavity - ovulation. The ovum is picked up by the fimbriated ends of the uterine tubes (oviducts). It is transported to the and, unless fertilization occurs, on out through the . The follicle that ruptures at the time of ovulation promptly fills with blood - corpus hemorrhagicum. Minor bleeding from the follicle into the abdominal cavity may cause peritoneal irritation and fleeting lower abdominal pain -. The granulosa and theca cells of the follicle lining promptly begin to proliferate, and the clotted blood is rapidly replaced with yellowish, lipid-rich luteal cells, forming the corpus luteum. This initiates the luteal phase of the menstrual cycle, during which the luteal cells secrete estrogens and progesterone. If pregnancy occurs, the corpus luteum persists and there are usually no more periods until after delivery.

⋅ Day 24 - If there is no pregnancy; the corpus luteum begins to degenerate and is eventually replaced by scar tissue, forming a corpus albicans.

Uterine/Endometrial Cycle At the end of menstruation, all but the deep layers of the endometrium have sloughed. 1. Reepithelialization from the preceding menstruation 2. Day 5 - 14 - Proliferative/Preovulatory/follicular phase - Endometrial proliferation Under the influence of estradiol-17β secreted by the developing follicle in increasing quantities until just before ovulation, the endometrium increases rapidly in thickness, the uterine glands are drawn out so that they lengthen, but they do not become convoluted or secrete to any degree. 3. After ovulation (> Day 14) - Postovulatory/luteal/secretory phase - Prepares the uterus for implantation of the fertilized ovum. 6 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

The endometrium becomes more highly vascularized and slightly edematous under the influence of estrogen and progesterone secreted from the corpus luteum up to the midluteal phase. The glands become coiled and tortuous, and they begin to secrete a clear fluid. When fertilization fails to occur during the secretory phase, the endometrium is shed and a new cycle starts. The length of the secretory phase is remarkably constant at about 14 days, and the variations seen in the length of the menstrual cycle are due for the most part to variations in the length of the proliferative phase. Late in the luteal phase, the endometrium, like the anterior pituitary, produces prolactin, but the function of this endometrial prolactin is unknown. The endometrium is supplied by two types of arteries;

⋅ The superficial two-thirds of the endometrium that is shed during menstruation, the stratum functionale, is supplied by long, coiled spiral arteries

⋅ The deep layer that is NOT shed, the stratum basale, is supplied by short, straight basilar arteries. 4. Day 21-22 - Premenstrual ischemia - When the corpus luteum regresses, hormonal support for the endometrium is withdrawn resulting in endometrial tissue volume involution, which leads to coiling of the spiral arteries causing stasis of blood 5. Menstruation, which is preceded and accompanied by severe vasoconstriction and then necrosis of the walls of the endometrial spiral arteries and collapse and desquamation of all but the deepest layer of the endometrium leading to spotty hemorrhages that become confluent and produce the menstrual flow. The vasospasm is probably produced by locally released prostaglandins. There are large quantities of

prostaglandins in the secretory endometrium and in menstrual blood, and infusions of PGF2α produce endometrial necrosis and bleeding. One theory of the onset of menstruation holds that in necrotic endometrial cells, lysosomal membranes break down, with the release of enzymes that foster the formation of prostaglandins from cellular phospholipids. After menstruation, a new endometrium regenerates from the stratum basale.

Normal Menstruation

⋅ Regular/cyclic

⋅ Duration of periods - 28 ± 7 days. There is a slow, steady decrease in cycle length due to shortening of the follicular phase of the cycle, with the luteal phase length remaining constant. - 15 yrs - 35 days - 25 yrs - 30 days - 35 yrs - 28 days

⋅ Duration of menstrual flow - 3-5 days (1-8 days)

⋅ Amount of blood lost may range normally - 30 mL (slight spotting - 80 mL)

⋅ Menstrual blood; -75% arterial, 25% venous - Tissue debris - Prostaglandins - Fibrinolysin from endometrial tissue which lyses clots, so that menstrual blood does not normally contain clots unless the flow is excessive Factors affecting amount of flow;

⋅ Thickness of the endometrium

⋅ Medication

⋅ Diseases that affect the clotting mechanism

Anovulatory Cycles Common for the first 12-18 months after menarche and again before the onset of the menopause When ovulation does not occur, no corpus luteum is formed and the effects of progesterone on the endometrium are absent. Estrogens continue to cause growth, however, and the proliferative endometrium 7 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira becomes thick enough to break down and begins to slough. The time it takes for bleeding to occur is variable, but it usually occurs in less than 28 days from the last menstrual period. The flow is also variable and ranges from scanty to relatively profuse.

Cyclic Estrogen Progesterone changes Uterine cervix Mucus is thinner and more Mucus is thick, tenacious, and cellular alkaline - changes that promote the survival and transport of sperms Vagina Epithelium is cornified Thick mucus is secreted, and the epithelium proliferates and becomes infiltrated with leukocytes Breasts Proliferation of mammary Growth of lobules and alveoli ducts

Cyclic Changes in the Uterine Cervix The mucosa of the uterine cervix does not undergo cyclic desquamation, but there are regular changes in the cervical mucus. The mucus is thinnest at the time of ovulation, and its elasticity, or spinnbarkeit, increases so that by midcycle, a drop can be stretched into a long, thin thread that may be 8-12 cm or more in length and dries in an arborizing, fern-like pattern when a thin layer is spread on a slide. After ovulation and during pregnancy, it becomes thick and fails to form the fern pattern.

Cyclic Changes in the Breasts The breast swelling, tenderness, and pain experienced by many women during the 10 days preceding menstruation are probably due to distention of the ducts, hyperemia, and of the interstitial tissue of the breast.

Changes during Intercourse During sexual excitement in women, fluid is secreted onto the vaginal walls, probably because of release of VIP from vaginal nerves. Lubricating mucus is also secreted by the vestibular glands. The upper part of the vagina is sensitive to stretch, while tactile stimulation from the labia minora and adds to the sexual excitement. These stimuli are reinforced by tactile stimuli from the breasts and, as in men, by visual, auditory, and olfactory stimuli, which may build to the crescendo known as orgasm. During orgasm, there are autonomically mediated rhythmic contractions of the vaginal walls. Impulses also travel via the pudendal nerves and produce rhythmic contraction of the bulbocavernosus and ischiocavernosus muscles. The vaginal contractions may aid sperm transport but are not essential for it, since fertilization of the ovum is not dependent on orgasm.

Indicators of Ovulation

⋅ History - Interrupted regular periods

⋅ The finding of a secretory pattern in a biopsy specimen of the endometrium indicates that a functioning corpus luteum is present.

⋅ Less reliably, finding thick, cellular cervical mucus that does not form a fern pattern in a woman who has regular menses provided there is no cervical/vagina infection or bleeding.

8 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

⋅ A convenient and reasonably reliable indicator of the time of ovulation is a change-usually a rise-in the basal body temperature. The cause of the temperature change at the time of ovulation is probably the increase in progesterone secretion, since progesterone is thermogenic

⋅ Rise in both urinary and serum LH levels Ovulation normally occurs 36-38 hours after the start of the LH surge at midcycle. The ovum lives for approximately 72 hours after it is extruded from the follicle, but it is fertilizable for a much shorter time than this. Some sperms can survive in the female genital tract for ≤ 48 hrs and can produce fertilization for up to 120 hrs before ovulation, but the most fertile period is clearly the 48 hrs before ovulation.

Summary In the final analysis, menstruation is the consequence of the withdrawal of factors that maintain endometrial growth. Progesterone facilitates and permits decidualization of the endometrium and the maintenance of pregnancy; its withdrawal may favor the initiation of menstruation, lactation, and parturition.

FERTILIZATION Complex sequence of ‘coordinated molecular events’ that begins with contact between the male gamete - (Sperm or Spermatozoon) and the female gamete - (Ovum or Oocyte), and ends with the intermingling of maternal and paternal chromosomes at metaphase of the first mitotic division of the zygote, a unicellular embryo.

⋅ Usually occurs in the midportion of the uterine tube and takes 24hrs

⋅ 20-250 million sperms/mL are deposited on the cervix and the posterior vaginal fornix during intercourse.

⋅ Capacitation of sperms in the uterus or uterine tubes by substances secreted by these parts of the female genital tract. This is a series of enzymic changes which modify the plasma membrane of the spermatozoon, exposing specific glycoproteins or sugar residues which are then involved in the binding of the spermatozoon to the Zona Pellucida

⋅ The sperms are attracted to the ovum by an attractant or chemotactic factor produced by the ovum.

⋅ 50-100 sperms penetrate through the cellular coverings (the cumulus oophrus embedded in a sticky matrix rich in hyaluronic acid, the corona radiata) to reach the ovum and contact the zona pellucida, a membranous structure that surrounds the ovum. The acrosome contains hyaluronidase which is capable of depolymerizing hyaluronic acid hence cumulus dispersion. The action of cilia of the fallopian tube also aids the process of cumulus dispersion.

⋅ Sperms bind to a sperm receptor - ZP 3 in the zona.

⋅ Acrosomal reaction - the breakdown of the acrosome, the lysosome-like organelle on the head of the sperm triggered by specific proteins contained in the zona pellucida

⋅ Various enzymes are released, including the trypsin-like protease acrosin which facilitates the penetration of the sperm through the zona pellucida. Also esterases and neuraminidases

⋅ When one sperm reaches the membrane of the ovum, it fuses to the membrane mediated by fertilin, a protein on the surface of the sperm head that resembles the viral fusion proteins which permit viruses to attack cells. The fusion provides the signal that; - initiates development - Sets off a reduction in the membrane potential of the ovum that prevents polyspermy, the fertilization of the ovum by more than one sperm This transient potential change is followed by a structural change in the zona pellucida that provides protection against polyspermy on a more long-term basis.

9 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

⋅ Pronuclear stage - Sperm nucleus enters egg cytoplasm where it enlarges to form the male pronucleus and the tail degenerates. After entry of the sperm, the oocyte, which had been arrested in the Metaphase-II- Meiosis, completes this division and forms a mature oocyte and a second polar body. Following decondensation of the maternal chromosomes, the nucleus of the mature oocyte becomes the female pronucleus.

⋅ Zygote formation - Both pronuclei increase in size, migrate towards the center of the ovum, and fuse as the second polar body is formed and extruded from the oocyte. With the union pronuclei, the cell once again contains a diploid number of chromosomes. Membranes of pronuclei break down; the chromosomes condense and become arranged for a mitotic cell division

⋅ First cleavage division. The fertilized oocyte or zygote is a unicellular embryo with 46 chromosomes. The first mitotic division occurs, with cleavage to the 2-cell stage.

IMPLANTATION Preattachment/Apposition

⋅ Cleavage - Approximately 30 hrs after fertilization, cleavage of the zygote begins which consists of repeated mitotic divisions of the zygote, resulting in rapid increase in the number of cells and reduction in size - Blastomeres

⋅ Compaction - After the 9-cell stage, the blastomeres change their shape and tightly align themselves against each other to form a compact ball of cells mediated by cell surface glycoproteins and also the internal cells segregate to form the embryoblast of the blastocyst.

⋅ The developing embryo moves down the tube for about 3-4 days, during which the blastomere reaches the 8- or 16-cell stage - Morula and is ready to enter the uterus for further development.

⋅ Once the morula is in contact with the endometrium, a fluid filled space - Blastocyst cavity (Blastocoel) appears inside it and as the fluid increases in the cavity, the blastomere separates into 2 parts; - A thin outer cell layer - Trophoblast - which gives rise to the embryonic part of the - A group of centrally located blastomeres (inner cell mass) - Embryoblast - which gives rise to the Embryo

⋅ Shedding process - After the Blastocyst has floated in the uterine secretions for about 2 days, the zona pellucida gradually degenerates and disappears followed by the release of the Blastocyst - Hatching process permitting it to increase rapidly in size. Attachment

⋅ Day 6-8 of fertilization/Day 20/28 of menstrual cycle - Blastocyst (256 cells) attaches to the endometrial epithelium usually on the dorsal wall of the uterus, usually adjacent to the inner cell mass - embryonic pole - and the trophoblast starts to proliferate and differentiates into an; - Outer layer of syncytiotrophoblast, a multinucleate protoplasmic mass with no discernible cell boundaries - Inner layer of cytotrophoblast made up of individual cells. Invasion

⋅ Finger-like processes of syncytiotrophoblast erodes the endometrium, and the blastocyst burrows into it and within 3-5 days the embryo is completely embedded under the uterine epithelium and into the endometrial stroma. A placenta then develops, and the trophoblast remains associated with it.

THE DEVELOPMENT OF THE EMBRYO Conceptus: This term is used to refer to all tissue products of conception - embryo (), fetal membranes, and placenta. Specifically, the conceptus includes all tissues that develop from the zygote, both embryonic and extraembryonic. nd rd ⋅ At around the 2 and 3 week of development the inner cell mass differentiates into; - The outer ectoderm germ disc 10 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

- The middle mesoderm germ disc - The inner endoderm germ disc

⋅ The mesoderm grows outwards eventually lining the blastocyst - the combination of the trophoblast and primitive mesoderm -

⋅ Two cavities appear; - In the ectoderm - - In the endoderm - Yolk sac

⋅ As the embryo differentiates, the amniotic cavity expands, enfolding onto the yolk sac.

⋅ Blood vessels develop in the embryonic mesoderm and in the mesoderm of the trophoblast. Extension of these vessels along the connecting stalk results in the formation of the umbilical arteries and veins.

3rd week post fertilization - Embryonic period starts which coincides in time with the expected day that the next menstruation would have commenced. - Most pregnancy tests (for hCG) in clinical use are positive - Embryonic disc is well defined - Body stalk is differentiated - Chorionic sac is approximately 1 cm in diameter - There is a true intervillous space that contains maternal blood and villous cores in which angioblastic chorionic mesoderm can be distinguished. 4th week post fertilization - Chorionic sac is 2 to 3 cm in diameter - Embryo is about 4 to 5 mm in length - The heart and pericardium of the embryo are very prominent because of the chamber dilatation. - Arm and leg buds are present - is beginning to ensheath the body stalk, which thereafter becomes the . 6th week post fertilization - Embryo is 22 to 24 mm in length - The head is quite large compared with the trunk - Fingers and toes are present - External ears form definitive elevations on either side of the head. 8th week post fertilization - Fetal period starts / 10 weeks after the onset of the last menstrual period - Embryo-fetus is nearly 4 cm long - Few, if any, new major body structures are formed thereafter and development during this period of gestation consists of growth and maturation of structures that were formed during the embryonic period.

Gestational age - Crown-rump Weight Other features Menstrual length (cm) (gm) (weeks)

12 6-7 ⋅ Uterus is palpable just above the symphysis pubis

⋅ Centers of ossification have appeared in most of the fetal bones

⋅ Fingers and toes have become differentiated and are provided with nails

⋅ External genitalia are beginning to show definitive signs of male or female gender

⋅ Scattered rudiments of hair appear

⋅ A fetus delivered at this time, if still within the amnionic sac 11 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

Gestational age - Crown-rump Weight Other features Menstrual length (cm) (gm) (weeks) or if immersed in warm saline, may make spontaneous movements.

16 12 110 ⋅ By careful examination of the external genitalia, the phenotypic sex of the fetus can be identified. Gender can be correctly determined by experienced observers by inspection of the external genitalia by 14 (menstrual) weeks.

20 16 300 ⋅ The end of the 20th week is the midpoint of pregnancy, as gestation is estimated from the commencement of the last normal menstrual period.

⋅ The fetal skin has become less transparent

⋅ A downy lanugo covers its entire body

⋅ Some scalp hair is visible.

24 21 630 ⋅ The skin is characteristically wrinkled, and fat is deposited beneath it.

⋅ The head is still comparatively quite large; eyebrows and eyelashes are usually recognizable.

⋅ Hear

⋅ A fetus born at this period will attempt to breathe, but almost always dies shortly after birth.

28 25 1100 ⋅ The thin skin is red and covered with vernix caseosa.

⋅ The pupillary membrane has just disappeared from the eyes.

⋅ Sight

⋅ Taste

⋅ An infant born at this time moves the limbs quite energetically and cries weakly.

⋅ The otherwise normal infant of this age, with expert care, often will survive.

32 28 1800 ⋅ The surface of the skin is still red and wrinkled.

⋅ Infants born at this period, with proper care, usually survive.

36 32 2500 ⋅ Because of the deposition of subcutaneous fat, the body has become more rotund, and the previous wrinkled appearance of the face has been lost.

⋅ Infants born at this time have an excellent chance of survival with proper care.

40 36 3400 ⋅ Term is reached at 40 weeks from the onset of the last menstrual period. At this time, the fetus is fully developed, with the characteristic features of the newborn infant.

DATING PREGNANCY

⋅ Menstrual age or gestational age is considered to be the time elapsed since the first day of the last menstrual period, a time that actually precedes conception. This starting time is usually about 2 weeks before ovulation and fertilization and nearly 3 weeks before implantation of the blastocyst. Due date of a pregnancy based on menstrual cycle = first day of LMP + 7 days - 3 mo

⋅ Ovulation age/postconception age

⋅ Trimesters 12 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

MENOPAUSE Permanent cessation of menstruation following loss of ovarian activity with at least 1 year of ⋅ Climacteric/Perimenopausal period - Phase of the aging process during which a woman passes from the reproductive to the nonreproductive stage - Lasts for 15-20 yrs The signals that this period of life has been reached are referred to as "climacteric symptoms" or, if more serious, as "climacteric complaints" (not as "menopause symptomatology" or "menopausal complaints"). ⋅ Premenopause refers to the part of the climacteric before the menopause occurs, the time during which the menstrual cycle is likely to be irregular and when other climacteric symptoms or complaints may be experienced. ⋅ Menopause is the final menstruation, which occurs during the climacteric. ⋅ Postmenopause refers to the phase of life that comes after the menopause.

Normal menopausal age - 45-55yrs (40-60 in extremes) < 40yrs menopausal female - Treat with HRT >60yrs unmenopausal female - Investigate for cause

Etiology & Pathogenesis Factors influencing menopause; ⋅ Smoking is associated with early menopause ⋅ Disease processes, especially severe infections e.g. mumps, TB, or tumors of the reproductive tract, can occasionally damage the ovarian follicular structures so severely as to precipitate the menopause. ⋅ Excessive exposure to ionizing radiation ⋅ Chemotherapeutic drugs, particularly alkylating agents ⋅ Surgical procedures that impair ovarian blood supply

Marriage, childbearing, height, weight, and prolonged use of oral contraceptives do not appear to influence the age of menopause.

There are 2 types of menopause, classified according to cause; 1. Physiologic menopause - Occurs because of 2 processes; - Oocytes responsive to gonadotropins disappear from the ovary - The few remaining oocytes do not respond to gonadotropins 2. Premature menopause/ Premature ovarian cessation - Spontaneous cessation of menses before age 40 3. Artificial menopause- The permanent cessation of ovarian function brought about by surgical removal of the ovaries or by radiation therapy Artificial menopause is; ⋅ Employed as a treatment for and estrogen-sensitive neoplasms of the breast and endometrium and to prevent ovarian cancer especially in post menopausal women. ⋅ A side effect of treatment of intra-abdominal disease; e.g., ovaries are removed in premenopausal women because the gonads have been damaged by infection or neoplasia.

Changes in Hormone Metabolism Associated With the Menopause 1. Androgens - In postmenopausal women, there is a reduction of the primary ovarian androgen, androstenedione which is the major secretory product of developing follicles and the source of most of the circulating androstenedione in this period appears to be the adrenal glands, but continued secretion by the postmenopausal ovary accounts for approximately 20%.

13 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

Testosterone - Large increments in testosterone greater than those observed in premenopausal women have been found in the ovarian compared with the peripheral veins of postmenopausal women. 2. Estrogen - There is reduced endogenous estrogen production in menopause especially estradiol. The adrenal glands are the major source of the small amount of estradiol found in older women. Although both estrone and testosterone are converted in peripheral tissues to estradiol, it is conversion from estrone derived from the peripheral aromatization of androstenedione in fat, muscle, liver, bone marrow, brain, fibroblasts, and hair roots that accounts for most estradiol in older women. 3. Progesterone - In young women, the major source of progesterone is the ovarian corpus luteum following ovulation. During the follicular phase of the cycle, progesterone levels are low. With ovulation, the levels rise greatly, reflecting the secretory activity of the corpus luteum. In postmenopausal women, the ovaries do not contain functional follicles and thus ovulation does not occur and progesterone levels remain low. The source of the small amount of progesterone present in older women is felt to be due to adrenal secretion, since dexamethasone suppresses its level, adrenocorticotrophic hormone (ACTH) stimulates its concentration, and human chorionic gonadotropin (hcg) administration has no effect. 4. Gonadotropins - With the menopause, both LH and FSH levels rise substantially, with FSH usually higher than LH. This is thought to reflect the slower clearance of FSH from the circulation. The reason for the marked increase in circulating gonadotropins is the absence of the negative feed back on FSH release by the pituitary by ovarian steroids and inhibin, a polypeptide hormone that is synthesized and secreted by granulosa cells. There is increased release of the hypothalamic hormone gonadotropin-releasing hormone (GnRH) and enhanced responsiveness of the pituitary to GnRH due to low estrogen levels.

Clinical Findings Symptoms and Signs: 1. Reduced endogenous estrogens- a. Reproductive tract- *Changes in menstrual function; ⋅ Abrupt cessation of menstruation is fairly rare, because the decline of ovarian function usually proceeds slowly. ⋅ The most common pattern is a gradual decrease in both amount and duration of menstrual flow, tapering to spotting only and eventually to cessation. Irregularity of the cycle appears sooner or later, with skips and delays of menses occurring. ⋅ A minority of patients have more frequent or heavier . Bleeding between periods may also occur. The irregular episodes of vaginal bleeding in premenopausal women may be due to; - Irregular maturation of ovarian follicles with estrogen production with or without hormonal evidence of ovulation - A rise and fall of estradiol without a measurable increase in progesterone, such as is seen during anovulatory menses - Organic disease, e.g., atypical or endometrial carcinoma. As menstrual function declines, associated symptoms such as mastodynia, abdominal bloating, edema, headache, and cyclic emotional disturbances also subside, reflecting the decrease in ovarian hormone secretion. *Because estrogen functions as the major growth factor of the female reproductive tract most postmenopausal women experience varying degrees of atrophic changes of the; ⋅ vaginal epithelium ⋅ cervix and reduction of secretion of cervical mucus contributing to excessive vaginal dryness, which may cause and predispose to infections

14 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

⋅ uterus with shrinkage of both the endometrium and which is beneficial due to reduction in size and elimination of symptoms of uterine myomas and also and endometriosis, Decreased libido and genital atrophy, one cause of postmenopausal sexual dysfunction, responds to estrogen therapy. The specific impact of estrogen on libido has been difficult to determine. Improved anatomy may also have a positive psychological impact and may indirectly encourage sexual motivation. *Postmenopausal estrogen deficiency may lead to symptomatic progressive pelvic relaxation leading to vaginal/ b. Urinary tract- Estrogen plays an important role in maintaining the epithelium of the bladder and urethra and deficiency may produce atrophic changes in these organs giving rise to; ⋅ atrophic cystitis, characterized by urinary urgency, incontinence, and frequency without pyuria or Dysuria ⋅ Loss of urethral tone, with pouting of the meatus and thinning of the epithelium, which favors the formation of a urethral caruncle with resultant dysuria, meatal tenderness, and occasionally hematuria. c. Mammary glands- Regression of breast size during and after menopause is psychologically distressing to some women. To those who have been bothered by cyclic symptoms of breast pain and cystic formation, the disappearance of these symptoms postmenopausally is a great relief. d. Hot flushes- Hot flushes begin with a sensation of pressure in the head, much like a headache. This increases in intensity until the physiologic flush occurs which is characterized as a feeling of heat or burning in the face, neck, and chest, followed immediately by an outbreak of sweating that affects the entire body but is particularly prominent over the head, neck, upper chest, and back.. Palpitations may also be experienced. Less common symptoms include weakness, fatigue, faintness, and vertigo. The duration of the whole episode averages 4 minutes (varies from momentary to as long as 10 minutes. The frequency varies from 1-2 an hour to 1-2 a week. In women with severe flushes, the mean frequency is 54 minutes. Physiologic changes associated with hot flushes are due to a defect in central thermoregulatory function related either to reduction of ovarian estrogen secretion or to enhancement of pituitary gonadotropin secretion and include; ⋅ cutaneous vasodilatation ⋅ perspiration ⋅ reductions of core temperature ⋅ elevations of pulse rate Estrogens are the principal medications used to relieve hot flushes by blocking both the perceived symptoms and the physiologic changes. Progestins also block hot flushes and represent a reasonable form of substitutional therapy in women who can't take estrogens. Clonidine, an alpha-adrenergic antagonist, is more effective than a placebo but is associated with side effects. e. Osteoporosis- It is a disorder characterized by a reduction in the quantity of bone without changes in chemical composition. This loss occurs primarily in trabecular bone and is therefore most noticeable in the vertebra and distal radius and also upper femur, humerus, and ribs. This is Type I osteoporosis as compared to Type II osteoporosis which is age-related and is seen in both men and women affecting both cortical and trabecular bone. The proposed pathophysiology of osteoporosis is that monocytes contain collagen receptors that allow them to adhere to the bone with the release of interleukin-1 (IL-1) which is the most potent known stimulator of osteoclast activity. 15 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

Estrogen; ⋅ inhibits release of IL-1 by monocytes ⋅ enhances bone formation by a direct local action on Osteoblasts possibly via transforming growth factor B ⋅ may also have a direct effect on osteoclasts f. Cardiovascular system- After the menopause, a woman's risk of a heart attack, HTN and peripheral vascular disease due to abnormal lipid profiles increases progressively until age 70 when it becomes equal to men. Estrogen probably protects against coronary artery disease by; ⋅ indirect effect on circulating lipids - influence hepatic lipid metabolism and raise HDL cholesterol and triglycerides and lower LDL cholesterol ⋅ direct action on the vascular system - estrogen and progesterone receptors are present in the heart and aorta Estrogen appears to increase nitric oxide (NO) production from endothelial cells of the arteries which; - increases intracellular cyclic guanosine monophosphate in the arterial smooth muscle, which results in vasodilatation - inhibits platelet and macrophage adherence to the arterial endothelium The protective effect of estrogens on the heart is greatest in women with known risk factors for heart disease e.g. obesity, smoking, hypertension, etc. g. Skin and hair- There is generalized thinning of skin and an accompanying loss of elasticity, resulting in wrinkling. These changes are particularly prominent in the areas exposed to light, i.e., the face, neck, and hands. "Purse-string" wrinkling around the mouth and "crow's feet" around the eyes are characteristic. On the dorsum of the hands the skin may be so thin as to become almost transparent, with details of the underlying veins easily visible. There are estrogen receptors in skin especially facial skin, followed by skin of the breasts and thighs and estrogen; ⋅ may improve the vascularization of skin ⋅ increase the collagen content and thickness of the dermis After the menopause, there is a variable loss of pubic and axillary hair. Often, there is loss of lanugo hair on the upper lip, chin, and cheeks, together with increase growth of course terminal hairs; a slight mustache may become noticeable. Hair on the body and extremities may either increase or decrease. Slight balding is seen occasionally. All of these changes may be due in part to reduced levels of estrogen in the face of fairly well maintained levels of testosterone. h. Psychological changes- ⋅ Depression ⋅ Irritability ⋅ Dysphoria ⋅ Nervousness and mild anxiety ⋅ Reduced libido ⋅ Alzheimer’s

2. Excess endogenous estrogens- The principal source of estrogens in older women is the peripheral aromatization of circulating androgens. Mechanisms of increased endogenous estrogen production: ⋅ increased production of precursor androgens ⋅ enhanced aromatization of precursor androgens especially in obesity, liver disease, and hyperthyroidism ⋅ increased production of estrogens directly Symptoms and signs of estrogen excess; ⋅ Uterine bleeding which may reflect the presence of endometrial hyperplasia or adenocarcinoma. 16 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

⋅ Mastodynia ⋅ Abdominal bloating ⋅ Edema ⋅ Growth of uterine myomas ⋅ Exacerbation of endometriosis

MATERNAL ADAPTATIONS IN PREGNANCY PHYSICAL CHANGES IN PREGNANCY 1. Uterus ⋅ Hypertrophy and Dilatation especially between the 7th - 28th wks and very rapidly between the 16th - 22nd wks. - Normal uterus - 70 gm, with a cavity of ≤10 mL or less - Term uterus - 1100gm with a cavity of 5 - 20 L or more ⋅ Changes in Uterine Size, Shape, and - For the first few weeks the uterus maintains its original pear shape, but as pregnancy advances the corpus and fundus assume a more globular form, becoming almost spherical by 12th week. Subsequently, the organ increases more rapidly in length than in width and assumes an ovoid shape. ⋅ By the end of 12 weeks, the uterus has become too large to remain totally within the pelvis and ascends into the abdominal cavity undergoing dextrorotation due to the presence of the rectosigmoid on the left side of the pelvis. ⋅ Anteversion - Uterus points to the anterior abdominal wall around the 8th week. Opp. - Retroversion

2. Vagina and Perineum ⋅ Increased vascularity (especially of the vagina), hyperemia and softening of the normally abundant connective tissue of the skin and muscles of the perineum and vulva ⋅ Chadwick sign - Characteristic violet color of the vagina during pregnancy resulting chiefly from hyperemia. ⋅ Vaginal walls undergo the following changes in preparation for the distension that occurs during labor; - Increase in thickness of the mucosa - loosening of the connective tissue - Hypertrophy of the smooth-muscle cells to nearly the same extent as in the uterus - Papillae of the vaginal mucosa undergo considerable hypertrophy, creating a fine hobnailed appearance These changes effect such an increase in length of the vaginal walls that sometimes, in parous women, the lower portion of the anterior vaginal wall protrudes slightly through the vulvar opening. ⋅ Cervical and vaginal secretions increase during pregnancy due to hyperemia and hormonal influence and consist of a somewhat thick, white discharge - - due to exfoliated cells. Its pH is acidic, varying from 3.5 to 6, the result of increased production of lactic acid from glycogen in the vaginal epithelium by the action of Lactobacillus acidophilus. There is a change in the consistency of the cervical mucus during pregnancy. In the great majority of pregnant women, cervical mucus, spread and dried on a glass slide, is characterized by fragmentary crystallization, or beading, typical of the effect of progesterone. In some women, arborization of the crystals, or ferning, is observed.

3. Breasts ⋅ In the early weeks, the pregnant woman often experiences tenderness and tingling. After the second month, the breasts increase in size and become nodular as a result of hypertrophy of the mammary alveoli. As the

17 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

breasts increase in size, delicate veins become visible just beneath the skin and if the increase in size is very extensive, striations similar to those observed in the abdomen may develop. ⋅ The nipples become larger, more deeply pigmented, and more erectile. After 16 wks, a thick, yellowish fluid, colostrum, can often be expressed from the nipples by gentle massage. ⋅ At that time, the areolae become broader and more deeply pigmented. At 6 wks, Scattered through the areolae are a number of small elevations - glands of Montgomery, which are hypertrophic sebaceous glands.

4. Abdominal Wall and Skin ⋅ Pregnancy is visible from the 16th week of gestation but varies with maternal weight and height. ⋅ Striae Gravidarum - In the later months of pregnancy when tension is highest, reddish, slightly depressed streaks commonly develop in the skin of the abdomen and sometimes in the skin over the breasts and thighs. In multiparous women, in addition to the reddish striae of the present pregnancy, glistening, silvery lines that represent the cicatrices of previous striae frequently are seen. These are formed due to collagen breakdown beneath the skin. ACTH is implicated. ⋅ Diastasis Recti - Occasionally the muscles of the abdominal walls do not withstand the tension to which they are subjected, and the rectus muscles separate in the midline, creating diastasis recti of varying extent. If severe, a considerable portion of the anterior uterine wall is covered by only a layer of skin, attenuated fascia, and peritoneum. ⋅ Pigmentation - Linea nigra - In many women, the midline of the abdominal skin becomes markedly pigmented, assuming a brownish-black color - Chloasma or gravidarum (mask of pregnancy) - irregular brownish patches of varying size appearing on the face and neck Melanocyte-stimulating hormone, a polypeptide similar to corticotropin, has been shown to be elevated remarkably from the end of the second month of pregnancy until term probably due to hypertrophy of the intermediate lobe of the pituitary gland Estrogen and progesterone have melanocyte-stimulating effects. Oral contraceptives may cause similar pigmentation in these same women. ⋅ Cutaneous Vascular Changes - Vascular spiders - These are minute, red elevations on the skin, particularly common on the face, neck, upper chest, and arms, with radicles branching out from a central body. The condition is often designated as nevus, angioma, or telangiectasis. Blanch on compression. - Palmar erythema They are most likely the consequence of the hyperestrogenemia of pregnancy and are also seen in liver failure. Increased cutaneous blood flow in pregnancy serves to dissipate excess heat generated by increased metabolism.

PHYSIOLOGICAL CHANGES IN PREGNANCY 1. Metabolic Changes ⋅ Weight Gain - Attributed to; - the uterus and its contents - the breasts - increases in blood volume and extravascular extracellular fluid - maternal reserves - metabolic alterations that result in an increase in cellular water and deposition of new fat and protein Average weight gain - 8-15 kg ⋅ Water Metabolism - Increased water retention is mediated by fall in plasma osmolality induced by a resetting of osmotic thresholds for thirst and vasopressin secretion 18 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

The minimum amount of extra water that the average woman retains during normal pregnancy is about 6.5 L; # 3.5 L - in the fetus, placenta, and amnionic fluid # 3.0 L - as a result of increases in the maternal blood volume and in the size of the uterus and the breasts Pathological retention of sodium and water, however, with the development of edema, is commonly present with preeclampsia. Pitting edema of the ankles and legs is seen in pregnant women, especially at the end of the day due to; - an increase in venous pressure below the level of the uterus as a consequence of partial occlusion of the vena cava by the gravid uterus - a decrease in interstitial colloid osmotic pressure induced by hemodilution ⋅ Protein Metabolism - The products of conception, the uterus and maternal blood, are relatively rich in protein rather than fat or carbohydrate. Protein increase normally induced by pregnancy is 1000gm which is shed by; # 500 gm - as the fetus and placenta which together weigh about 4 kg at term # 500 gm - Added to the uterus as contractile protein, to the breasts primarily in the glands, and to the maternal blood in the form of hemoglobin and plasma proteins. ⋅ Carbohydrate Metabolism - Pregnancy is potentially diabetogenic. Diabetes mellitus may be aggravated by pregnancy, and clinical diabetes may appear in some women only during pregnancy. Normal pregnancy is characterized by; - mild fasting hypoglycemia - postprandial hyperglycemia - hyperinsulinemia with β-cell hypertrophy, hyperplasia, and hypersecretion ⋅ Fat Metabolism - The concentrations of lipids and lipoproteins and apolipoproteins in plasma increase appreciably during pregnancy. ⋅ Plasma Electrolytes. Despite large accumulations during pregnancy of sodium and potassium, the serum concentration of these electrolytes decreases. Fractional excretion of these electrolytes is decreased, and it has been postulated that progesterone counteracts the natriuretic and kaliuretic effects of aldosterone.

2. Hematological Changes of Normal Pregnancy ⋅ Blood Volume - maternal blood volume starts to increase during the first trimester, expands most rapidly during the second trimester (20 wks gestation), and then rises at a much slower rate during the third trimester to plateau at 40-45% above nonpregnant levels during the last several weeks of pregnancy. There is accelerated production of erythrocytes with moderate erythroid hyperplasia in the bone marrow and reticulocytosis leading to an increase in the volume of circulating erythrocytes of about 33% (450 mL). Pregnancy-induced hypervolemia serves to; - meet the demands of the enlarged uterus with its greatly hypertrophied vascular system - protect the mother, and in turn the fetus, against the deleterious effects of impaired venous return in the supine and erect positions - safeguard the mother against the adverse effects of blood loss (up to 1.5L) associated with parturition A fetus is not essential for the development of hypervolemia during pregnancy, for increases in blood volume have been demonstrated in some women with hydatidiform mole ⋅ Natriuretic Peptides are a group of biologically active peptides synthesized and secreted by atrial myocytes (ANP) and the brain and human amnion cells (BNP). BNP is a more potent vasodilator of the placental vasculature than ANP. ANP produces; - natriuresis and diuresis by increasing renal blood flow and glomerular filtration rate and decreasing renin secretion - Vasodilatation mediated through guanylate cyclase-coupled receptors 19 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

ANP rises by 40% by the third trimester and by 150% during the first week postpartum in response to the expanded blood volume of pregnancy sensed by atrial stretch receptors leading to postpartum diuresis. ⋅ Hemoglobin Concentration and Hematocrit - In spite of an augmented erythropoiesis, the concentrations of hemoglobin and erythrocytes, as well as the hematocrit, decrease slightly during normal pregnancy. Normal hemoglobin concentration at term - 12.5 g/dL A hemoglobin concentration <11.0 g/dL, especially late in pregnancy, should be considered abnormal and usually due to iron deficiency rather than to hypervolemia of pregnancy. ⋅ Iron Metabolism Iron Stores - Total iron content of normal adult women - 2.0-2.5 g. Iron Requirements - The iron requirements of normal pregnancy total about 1000 mg; # 300 mg - actively transferred to the fetus and placenta Independent of iron levels # 200 mg - lost through various normal routes of excretion # 500 mg - Augmented erythropoiesis- 1 mL normal erythrocytes has 1.1 mg iron All of the iron for these purposes is used during the latter half of pregnancy thus iron requirement during the second half of pregnancy especially in the 3rd trimester averages 6-7 mg/day. The amount of iron absorbed from diet, together with that mobilized from stores, is usually insufficient to meet the demands imposed by pregnancy thus the desired increase in maternal erythrocyte volume and hemoglobin mass will not develop unless exogenous iron is made available in adequate amounts. In the absence of added exogenous iron, the hemoglobin concentration and hematocrit fall appreciably as the maternal blood volume increases. Hemoglobin production in the fetus, however, will not be impaired, because the placenta obtains iron from the mother in amounts sufficient for the fetus to establish normal hemoglobin levels even when the mother has severe iron-deficiency anemia. The somewhat unexpected early pregnancy increases in serum iron and ferritin are thought to be due to; - minimal iron demands during the first trimester - positive iron balance because of amenorrhea ⋅ Blood Loss via the; - placental implantation site - placenta itself - episiotomy wound and lacerations - lochia - Discharges from the vagina of mucus, blood, and tissue debris, following . The average blood loss associated with cesarean delivery or with the of is about 1000 mL, or nearly twice that lost with the delivery of a single fetus. ⋅ Immunological and Leukocyte Functions - Pregnancy is associated with suppression of a variety of humoral and cellular mediated immunological functions in order to accommodate the "foreign" semiallogeneic fetal graft. The decrease in antibody titers, however, is accounted for by the hemodilutional effect of pregnancy. There is leukocytosis with neutrophilia but the chemotaxis and adherence functions are depressed. ⋅ Blood Coagulation - The levels of several blood coagulation factors, factor VII, VIII, IX, X are increased during pregnancy including fibrinogen (factor I) which contributes to the increase in the ESR in normal pregnancy and prevent excessive bleeding at delivery. ⋅ There is a moderate decrease in platelet concentration as pregnancy progresses due to dilution and increased platelet consumption with increased risk of DVT.

3. Cardiovascular System ⋅ Heart - The resting pulse rate increases about 10-15 beats per minute during pregnancy. Pregnant women have; - some degree of benign pericardial effusion. 20 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

- an exaggerated splitting of the first heart sound with increased loudness of both components; no definite changes in the aortic and pulmonary elements of the second sound; and a loud, easily heard third sound - a systolic murmur - No ECG changes In multifetal cardiac output is increased predominantly by increased inotropic effect. ⋅ Cardiac Output - During normal pregnancy, arterial blood pressure and vascular resistance decrease while blood volume, maternal weight, and basal metabolic rate increase contributing to the increase in cardiac output.

4. Urinary System Alteration Manifestation Clinical Relevance Increased renal size Renal length increased by 1-1.5cm Postpartum decreases in size should and weight not be mistaken for parenchymal loss.

Dilatation of In pregnant women, after the uterus rises Not to be mistaken for obstructive pelves(up 60ml cf completely out of the pelvis, it rests upon the uropathy; retained urine leads to 10ml in non-pregnant ureters, compressing them at the pelvic brim collection errors; upper urinary tract women), calyces, and resembling hydronephrosis and hydroureter infections are more virulent; may be ureters especially on the right. The unequal degrees responsible for distension syndrome; of dilatation may result from increased elective pyelography should be progesterone, a cushioning provided to the deferred to at least 12 wks post left ureter by the sigmoid colon and perhaps partum from greater compression of the right ureter as the consequence of dextrorotation of the uterus. The right ovarian vein complex, which is remarkably dilated during pregnancy, lies obliquely over the right ureter in the infundibulopelvic ligament and may contribute significantly to right ureteral dilatation. Also, hyperplasia of the muscles of the distal 1/3.

Increased renal Glomerular filtration rate and renal plasma Serum creatinine (from 0.7mg/dL haemodynamics flow increase by 50% to 0.5mg/dL) and urea nitrogen values (from 13mg/dL to 9mg/dL) decrease during normal gestation as a consequence of their increased glomerular filtration; Glucosuria due to appreciable increase in glomerular filtration, together with impaired tubular reabsorptive capacity Protein (500mg/24hrs cf 200- 300mg/24hrs normally), amino acid, and water-soluble vitamins excretion all increase Hematuria, if not the result of 21 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

Alteration Manifestation Clinical Relevance contamination during collection, is compatible with a diagnosis of urinary tract disease.

Changes in acid base Renal bicarbonate threshold decreases; Serum bicarbonate and pCO2 are metabolism progesterone stimulates respiratory center lowered.

Renal water handling Osmoregulation is altered: Osmotic thresholds Serum osmolality decreases; for AVP release and thirst decrease; hormonal Increased metabolism of AVP may disposal rate increases cause transient diabetes insipidus in pregnancy

Increased frequency Especially between 8-12wks and 36-40wks 8-12wks - The gravid uterus is a and urgency Bladder capacity increases to 1500mL pelvic organ 36-40wks - The presenting part of the uterus is in the pelvis.

Other changes; ⋅ Increase in total body water by 6-8L ⋅ Increase in plasma volume by 4-6L ⋅ Uric acid clearance increases thus serum levels fall ⋅ Sodium retention - 900mEq ⋅ Increase in cortisol and renin ⋅ Increased urinary stasis - up to 200mL

5. Gastrointestinal Tract ⋅ Increased salivation secondary to increased salivary gland activity ⋅ Gastric emptying and intestinal transit times are delayed in pregnancy on the basis of; - mechanical factors - Compression of the GIT by the gravid uterus - hormonal factors - Progesterone delays peristalsis. Also decreased levels of motilin, a hormonal peptide known to have smooth-muscle stimulating effects During labor, especially after administration of analgesic agents, gastric-emptying time is prolonged appreciably and regurgitation and aspiration of either food-laden or highly acidic gastric contents is a major danger of general anesthesia for cesarean delivery. ⋅ Pyrosis (heartburn), common during pregnancy, is most likely caused by reflux of acidic secretions into the lower esophagus as a result of; - altered position of the stomach - decreased lower esophageal sphincter tone due to progesterone - decreased intraesophageal pressures compared to increased intragastric pressures - lower wave speed and lower amplitude of esophageal peristalsis ⋅ Gums may become hyperemic and softened during pregnancy and may bleed when mildly traumatized, as with a toothbrush. Epulis - a focal, highly vascular swelling of the gums develops occasionally but typically regresses spontaneously after delivery. ⋅ Hemorrhoids are caused in by constipation and the elevated pressure in veins below the level of the enlarged uterus.

22 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

6. Musculoskeletal System Lordosis - shifts the center of gravity back over the lower extremities to compensate for the anterior position of the enlarging uterus. There is increased mobility of the sacroiliac, sacrococcygeal, and pubic joints during pregnancy, presumably as a result of hormonal changes and may contribute to the alteration of maternal posture, and in turn cause discomfort in the lower portion of the back, especially late in pregnancy.

DIAGNOSIS OF PREGNANCY Established by; ⋅ Hx ⋅ O/E ⋅ Ix The endocrinological, physiological, and anatomical alterations that accompany pregnancy give rise to symptoms and signs classified into three groups that provide evidence that pregnancy exists; *Presumptive evidence 1. Symptoms of Pregnancy ⋅ History of sexual contact or by Donor (AID) or Husband (AIH) ⋅ Nausea with or without Vomiting - Begins about 6 weeks after the commencement (first day) of the last menstrual period, and ordinarily disappears spontaneously 6-12 weeks later. The cause of this disorder is unknown but seems to be associated with higher levels of selected forms of hCG with the greatest thyroid- stimulating capacity. ⋅ Disturbances in Urination - During the first trimester, the enlarging uterus, by exerting pressure on the urinary bladder, may cause frequent micturition but as pregnancy progresses, the frequency of urination gradually diminishes as the uterus rises up into the abdomen. The symptom of frequent urination reappears near the end of pregnancy, however, when the fetal head descends into the maternal pelvis, impinging upon the volume capacity of the bladder. ⋅ Easy fatigability ⋅ Perception of Fetal Movement - Between 16-18wks (menstrual age) in multigravida and 18-20wks in primigravida, the pregnant woman becomes conscious of slight fluttering movements in the abdomen caused by fetal movements, and the day that these are first recognized by the pregnant woman is designated as , or the perception of life and is a milestone of the progress of pregnancy that can help to establish the duration of gestation. 2. Signs of Pregnancy ⋅ Cessation of Menses - It is not until 10 days or more after the time of expected onset of the menstrual period, therefore, that the absence of menses is a reliable indication of pregnancy. When a second menstrual period is missed, the probability of pregnancy is much greater. Conception may occur without prior menstruation, that is, in a girl before menarche. mothers, who usually sustain amenorrhea during lactation because of lactation-induced hypogonadism and , sometimes ovulate and conceive at that time; and more rarely, women who believe they have passed the menopause may ovulate again after a few months of anovulation/amenorrhea and become pregnant. Brief and scant uterine bleeding as a consequence of blastocyst implantation somewhat suggestive of menstruation occurs occasionally after conception. One or two episodes of bloody discharge, somewhat reminiscent of and sometimes misinterpreted as menstruation, are not uncommon during the first half of pregnancy. Bleeding per vagina at any time during pregnancy must be regarded as abnormal and portends an increased likelihood of serious pregnancy complications. DDx - Anovulation secondary to - severe illness

23 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

- physiological aberrations induced by emotional disorders, including the fear of pregnancy - environmental changes ⋅ Cervical Mucus - If cervical mucus is aspirated, spread on a glass slide, allowed to dry for a few minutes, and examined microscopically, characteristic patterns can be discerned that are dependent on the; - Stage of the ovarian cycle - Presence or absence of pregnancy, that is, on progesterone secretion in large amounts From about the 7th-18th day of the menstrual cycle, a fern-like pattern/process of arborization/palm leaf pattern of dried cervical mucus is seen due to crystallization of the mucus. After the 21st day, a beaded or cellular appearance forms that is also encountered in pregnancy due to progesterone production. ⋅ Changes in the Breasts DDx - prolactin-secreting pituitary tumors - Drugs e.g. benzodiazipines, which induce hyperprolactinemia - Spurious or imaginary pregnancy ⋅ Discoloration of the Vaginal Mucosa - During pregnancy, the vaginal mucosa usually appears dark bluish or purplish-red and congested; this is the so-called Chadwick sign. DDx - intense congestion of pelvic organs ⋅ Increased Skin Pigmentation and Appearance of Abdominal Striae DDx - ingestion of estrogen- progestin contraceptives ⋅ Leg swelling in late pregnancy ⋅ Other maternal adaptations in pregnancy (see related notes)

*Probable Evidence of Pregnancy ⋅ Enlargement of the Abdomen ⋅ Changes in Size, Shape, and Consistency of the Uterus 36wks------

32wks------28wks------24wks------20wks------•------

16wks------

12wks------

Average uterine diameter at 12 weeks - 8 cm Hegar sign positive by 6-8wks - DDx - when the walls of the uterus of a nonpregnant woman are excessively soft - Adnexa uteri ⋅ Changes in the Cervix - By 6-8 weeks, the cervix usually is considerably softened. In primigravidas, the consistency of cervical tissue that surrounds the external os is more similar to that of the lips of the mouth than to that of the nasal cartilage, which is characteristic of the cervix in nonpregnant women. DDx - estrogen- progestin contraceptives The cervix may remain firm during pregnancy in certain inflammatory conditions, as well as with carcinoma.

24 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

⋅ Braxton Hicks Contractions - During pregnancy, the uterus undergoes palpable but ordinarily painless contractions at irregular intervals from the early stages of gestation. DDx - - collection or retention of blood in the uterine cavity - pedunculated, submucous myomas ⋅ Ballottement - Near midpregnancy, the volume of the fetus is small compared with that of amnionic fluid. Consequently, sudden pressure exerted on the uterus may cause the fetus to sink in the amnionic fluid and then rebound to its original position; the tap produced (ballottement) is felt by the examining fingers. ⋅ Outlining the Fetus DDx - subserous myomas ⋅ Hormonal Tests of Pregnancy - The presence of human chorionic gonadotropin (hCG) in maternal plasma and its excretion in urine provides the basis for the endocrine tests for pregnancy.

*Positive Signs of Pregnancy/Estimation of fetal maturity The three positive signs of pregnancy and estimating fetal maturity are; ⋅ Identification of Fetal Heart Action - Contractions of the fetal heart can be identified by; - auscultation with a Pinard fetoscope - The fetal heartbeat can be detected 16-18 weeks, on average in thin women, and by 22-24weeks in nearly all other pregnancies in nonobese women and in he absence of hydramnios. - Doppler principle with ultrasound at 6 weeks - U/S at 4-5 weeks at the same time the fetal pole is visible Fetal heart rate - 120-160 beats per minute and is heard as a double sound resembling the tick of a watch under a pillow. Other sounds heard on abdominal auscultation; - The Funic/Fetal/Funicular/Umbilical soufflé - a sharp, whistling sound caused by the rush of blood through the umbilical arteries. It is that is synchronous with the fetal heart beat, sometimes only systolic and sometimes continuous, heard on auscultation over the pregnant uterus - The Uterine/Placental soufflé - a soft, blowing sound produced by the passage of blood through the dilated uterine vessels that is synchronous with the maternal pulse heard most distinctly during auscultation of the lower portion of the uterus from 16 wks onwards. DDx - Increased blood flow to the uterus in; - large uterine myomas - large ovarian tumors - The sounds resulting from movement of the fetus - Maternal pulse - The gurgling of gas in the intestines of the pregnant woman ⋅ Perception of Fetal Movements - Felt after about 20wks ⋅ Image Recognition of Pregnancy - A normal pregnancy may be demonstrated by abdominal pulse echo sonography after 4-5 weeks menstrual age. After 6 weeks, the small white gestational ring is characteristically visible. Embryonic poles can be demonstrated within the gestational ring by 7 weeks menstrual age. Radiography (not in use) - Foci of ossification in the fetus appears at 12-14wks; Lower femur - 36wks; Upper tibia - 37wks

Pregnancy tests - Detection of Chorionic Gonadotropin HCG is secreted by the syncytiotrophoblast to prevent the involution of the corpus luteum, the principal site of progesterone formation during the first 6 weeks of pregnancy.

25 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

HCG is a luteinizing hormone (LH)-like agent that acts as an LH surrogate in responsive tissues, such as the ovary (corpus luteum) and testis (Leydig cells). Specifically, hCG acts by way of the plasma membrane LH receptor. The chemical detection of pregnancy involves the demonstration of hCG in blood or urine of the woman to be tested. The tests for detecting hCG involve the principles of; ⋅ Immunoassays of hCG without Radioisotopes; - Agglutination Inhibition - this is the prevention of flocculation of hCG-coated particles, such as latex particles to which hCG is covalently bound. The commercially available kits that employ failure of agglutination of latex particles to detect hCG in urine contain two reagents. One is a suspension of latex particles coated with or covalently bound to hCG, and the other contains a solution of hCG antibody. To test for hCG, one drop of urine is mixed with one drop of the antibody-containing solution on a black glass slide. If hCG is not present in the test sample, antibody will remain available to agglutinate the hCG-coated latex particles, which are added subsequently. Therefore, the is positive if no agglutination occurs; the pregnancy test is negative when agglutination occurs. Results are ready in 2mins at 4 wks gestation. - Enzyme-linked immunosorbent assay (ELISA) - Time-resolved immunoflurometric assays (IFMA) ⋅ Immunoassays of hCG Using Radioisotopes - Radioimmunoassay using antibodies directed against the β-subunit of hCG (which are specific for hCG and not cross-reactive with LH cf α-subunit of hCG and LH which are identical), the pregnancy hormone can be detected in maternal plasma or urine by 8-9 days after ovulation - Immunoradiometric assay (IRMA) ⋅ Immunochromatography ⋅ Bioassays (Obsolete) - development of ovarian hyperemia in the immature rat when injected with maternal urine positive for hCG; insensitive, remarkably accurate as early as 4-5 weeks after ovulation or at least by the time of the second missed menses

DDx of pregnancy (not attended by cessation of menses) Uterine abnormalities ⋅ tumors occupying the pelvis or abdomen ⋅ Myomas ⋅ Hematometra ⋅ Adenomyosis ⋅ contiguous but extrauterine mass(es)

ESTIMATION OF FETAL MATURITY ⋅ Naegele's rule - Subtract 3 from the month of the LNMP, and add 7 to the first day of the LNMP ⋅ Normal Pregnancy Lasts (calculated from last normal menstrual period (LMNP)) - 280 days - 40 weeks - 9 calendar months - 10 lunar months (28 days) ⋅ Uterine size/ (see notes above) ⋅ Quickening (see notes above) ⋅ Fetal heart tones (see notes above)

26 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

⋅ Fetal weight - Estimation of fetal weight is important when the must decide whether to; - allow delivery to proceed as a natural event - induce labor - use tocolytic agents - perform cesarean section Johnson's formula for estimation of fetal weight in vertex presentations - Fetal weight (in grams) = fh (in centimeters) - n x 155 n = 12 if vertex is above ischial spines n = 11 if vertex is below ischial spines fh = fundal height (measured from the pubic symphysis) If the patient weighs more than 91 kg (200 lb), 1 cm is subtracted from the fundal height ⋅ Fetal Measurements (at term)- Crown-rump length - Femur length - 7.7cm - Biparietal diameter - 9.5cm - Head circumference - 34.6cm - Abdominal circumference - 35.3cm

TESTS FOR FETAL WELL BEING ⋅ Serial ultrasonography ⋅ X-ray ⋅ Magnetic resonance imaging ⋅ - Confirmation of fetal lung maturity; - Lecithin:Sphingomyelin (L/S) Ratio - determination of the the relative concentration of surfactant- active phospholipids confirms fetal lung maturity. Before 34 weeks, lecithin and sphingomyelin are present in amnionic fluid in equal concentrations. At about 34 weeks, the concentration of lecithin relative to sphingomyelin begins to rise - Lecithin:Sphingomyelin ratio of 2:1 is mature - Foam Stability (Shake) Test - The test depends upon the ability of surfactant in amnionic fluid, when mixed appropriately with ethanol, to generate stable foam at the air-liquid interface. There are two problems with the test: - slight contamination of amnionic fluid, reagents, or glassware, or errors in measurement, may alter the tests results - a false-negative test is rather common. ⋅ Chorionic villus sampling - first-trimester alternative to amniocentesis ⋅ Percutaneous umbilical cord sampling

DIAGNOSIS OF FETAL DEATH ⋅ The woman, with anxiety in her voice, reports that she has not felt fetal movement for hours or for 1-2 days ⋅ The fetal heart is not heard by auscultation or identified by real-time ultrasound examination after 10-12 wks ⋅ Fetal skull - scalp edema - On palpation, the loose bones of the fetal head feel as though these are contained in a flabby bag ⋅ maceration ⋅ an enlarged amnionic cavity, compared with the crown-rump length, in early gestation ⋅ If the fetus has been dead for some time; - the uterus does not correspond in size to the estimated duration of pregnancy, or that the uterus has actually become smaller than previously observed

27 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

- maternal weight gain ceases/slight decrease in weight - retrogressive changes in the breasts - the amnionic fluid is red to brown and usually turbid rather than nearly colorless and clear - This finding is not absolutely diagnostic of fetal death, however, because prior hemorrhage into the amnionic sac, as rarely occurs during amniocentesis, may lead to similar discoloration of the amnionic fluid even though the fetus is alive. ⋅ Radiological signs of fetal death (done late in pregnancy); - Spalding sign - Significant overlap of the skull bones, caused by liquefaction of the brain, a process that requires several days to develop. A similar sign may develop occasionally with a living fetus, as when the fetal head is compressed in the maternal pelvis. - Roberts sign - Exaggerated curvature of the fetal spine - Because this sign depends on maceration of the spinous ligaments, its development also requires several days; moreover, mild degrees of curvature of the spine in living may be misleading. - Demonstration of gas in the fetus is an uncommon but reliable sign of fetal death

NORMAL LABOUR AND DELIVERY Definitions; ⋅ Labor - process of coordinated uterine contractions leading to progressive and dilatation by which the fetus and placenta are expelled. ⋅ Precipitate labor - very rapid labor ending in delivery of the fetus. ⋅ Premature labor - onset of labor before the 36th completed week of pregnancy dated from the LNMP. ⋅ Parturient - Relating to or in the process of childbirth. ⋅ Antepartum - Before labor or childbirth ⋅ Intrapartum - During labor and delivery or childbirth ⋅ Postpartum - After childbirth.

Objectives of Labor management To deliver a normal, health, well oxygenated and mature baby without trauma Assist the mother to enjoy the process of child birth Avoid unnecessary delay, pain or trauma Prevent dehydration and infection

Antenatal management ⋅ Plan for the labor ⋅ Educate the mother ⋅ Reassure the mother ⋅ Give the mother a reconnaissance tour of the ward and take her through the steps involved ⋅ Screen the mother

Admittance Procedures ⋅ Accurate diagnosis of labor TRUE LABOR FALSE LABOR Contractions occur at regular intervals. Contractions occur at irregular intervals. Intervals gradually shorten. Intervals remain long. Intensity gradually increases. Intensity remains unchanged. 28 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

TRUE LABOR FALSE LABOR Discomfort is in back and abdomen. Discomfort is chiefly in lower abdomen. Cervix dilates and effaces Cervix does not dilate or efface. Discomfort is not stopped by sedation. Discomfort is usually relieved by sedation. Show ? No show

Cervical Effacement - "obliteration" or "taking up" of the cervix is the shortening of the cervical canal from above downward from a length of about 2 cm to a mere circular orifice with almost paper-thin edges. Show -Sign of impending labor, characterized by the discharge from the vagina of a small amount of blood- tinged mucus representing the extrusion of the mucous plug which has filled the cervical canal during pregnancy - First appearance of blood in beginning menstruation ⋅ Hx and O/E - general condition of mother and fetus - Blood pressure - Temperature - Pulse - time when they first become uncomfortable - frequency, duration, and intensity of the uterine contractions - The degree of discomfort that the mother displays - Fetal heart rate especially at the end of a contraction and immediately thereafter, to identify pathological slowing of the heart rate - Presentation - Size of the fetus - Status of the fetal membranes - Any vaginal bleeding - Whether fluid has leaked from the vagina and, if so, how much and when the leakage first commenced ⋅ Admittance Vaginal Examination - Most often, unless there has been bleeding in excess of , a vaginal examination under aseptic conditions is performed 4 hourly. - Amnionic fluid - Meconium stained liquor has 3 grades; - Tinge - Mild-consistency - Thick meconium () - Cervix - Softness - Degree of effacement (length) - Expressed in terms of the length of the cervical canal compared to that of an uneffaced cervix. When the length of the cervix is reduced by one half, it is 50 percent effaced; when the cervix becomes as thin as the adjacent lower uterine segment, it is completely, or 100 percent, effaced. - Extent of dilatation - The cervix is said to be dilated fully when the average diameter of the cervical opening measures 10cm, because the presenting part of a term-size infant (BPD = 9.5cm) usually can pass through a cervix this widely dilated - Location of the cervix with respect to the presenting part and vagina - The relationship of the cervical os to the fetal head is categorized as posterior (suggestive of preterm labor), midposition, or anterior. - Presenting part - nature - Position - Station - The degree of descent of the presenting fetal part in the birth canal in relationship to the ischial spines, which are halfway between the pelvic inlet and the pelvic outlet. The 29 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

classification of station to delivery divides the pelvis spines into fifths that represent centimeters above and below the spines. Thus, as the presenting fetal part descends from the inlet toward the ischial spines, the designation is -5/5, -4/5, -3/5, -2/5, -1/5, then 0/5 station at the level of the ischial spines when most often engagement of the head has occurred; that is, the biparietal plane of the fetal head has passed through the pelvic inlet.. Below the ischial spines, the presenting fetal part passes +1/5, +2/5, +3/5, +4/5, and +5/5 stations when the fetal head is visible at the introitus - Pelvic architecture - Adequacy of the pelvis especially in primigravida ⋅ Enema - Early in labor, a cleansing enema e.g. sodium phosphate (Fleet enema) often is given to minimize subsequent contamination by feces, which otherwise may be a problem during the second stage of labor and delivery.

Management of First Stage of Labor Beginning with the onset of uterine contractions through the period of dilation of the os uteri (10cm) Average duration of the first stage of labor in nulliparous women is about 8 hours and in parous women about 5 hours. Divided into; ⋅ Latent phase - 0-3cm cervical dilatation - In primigravida, this phase can last up to 24hrs and in multiparous mothers up to 12hrs ⋅ Active/Established phase - >4cm cervical dilatation - In primigravida, this phase proceeds at 1.2cm/hr and in multiparous mothers at 1.5cm/hr

Monitoring Fetal Well-being during Labor ⋅ Fetal Heart Rate - During the first stage of labor, in the absence of any abnormalities, the fetal heart should be checked and recorded on a partogram immediately after a contraction at least every 30 minutes and then every 15 minutes during the second stage. Normal fetal heart rate - 120-160 bpm (with undulation ± 15 bpm within this range) Periodic Fetal Heart Rate - Fetal heart rate deviations from baseline related to uterine contractions. - Acceleration - increase in fetal heart rate above baseline - Deceleration - decrease in fetal heart rate below baseline rate - Classified based on the timing of the deceleration in relation to uterine contractions; Early Late Variable Slope of fetal heart rate Gradual - Seen in Gradual - Begins at or after Abrupt and erratic change active labor between the peak of the contraction 4-7cm of cervical and returning to baseline only dilatation after the contraction has ended Clinical sign of; ⋅ head compression ⋅ uteroplacental insufficiency ⋅ cord compression ⋅ Fetal distress patterns ⋅ Fetal compromise ⋅ Fetal distress

- Fetal bradycardia - baseline fetal heart rate <120 beats/min that lasts ≥15 minutes - Fetal tachycardia - baseline fetal heart rate >160 beats/min ⋅ Uterine Contractions - Charted on partogram every 30mins - Frequency - Duration

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- Intensity

Maternal Monitoring and Management during Labor ⋅ Analgesia/Sedation - initiated on the basis of; - the woman's discomfort - a pattern of established labor - lasts almost 40secs - cervical dilatation of at least 2 cm - Pethidine - Use in early labor - Avoid in advanced labor - have naloxone at hand to use if effects pass to baby - Trenolol - Epidural block- L3,4 - Compromises symptoms characteristic of the second stage of labor, that is, an urge to bear down or "push," leading to an increased incidence of vacuum extractions and increased c/s. Can also lead to HBP thus avoid in heart disease patients. ⋅ Maternal Vital Signs - Maternal temperature and pulse are evaluated every 1-2 hours. Blood pressure usually is taken more frequently and is obtained between contractions, because it normally rises during a contraction ⋅ Urinalysis - Ketonuria - following hypoglycemia from prolonged labor - - Preeclampsia

Management of Second Stage of Labor Period of expulsive effort, beginning with complete dilation of the cervix (10cm) and ending with expulsion of the infant ⋅ Identification - With full dilatation of the cervix, which signifies the onset of the second stage of labor, the woman typically begins to bear down, and with descent of the presenting part she develops the urge to defecate. Uterine contractions and the accompanying expulsive forces may last 1 ½ minutes and recur at times after a myometrial resting phase of ≤1minute. Bearing down efforts result in increasing bulging of the perineum and the overlying skin becomes tense and glistening. At the same time, the anus becomes greatly stretched and protuberant, and the anterior wall of the rectum may be easily seen through it. When the scalp of the fetus is visible through the vulvar opening or before in instances where little perineal resistance to expulsion is anticipated, the woman and her fetus are prepared for delivery. ⋅ Duration - The median duration of the second stage is 50 minutes in nulliparas and 20 minutes in multiparas, but it can be highly variable. ⋅ Fetal Heart Rate - For the low-risk fetus, the heart rate should be auscultated during the second stage of labor at least every 15 minutes, whereas in those at high risk, 5-minute intervals are recommended. (KNH 10 mins) ⋅ Preparation for Delivery - Dorsal lithotomy position - The woman lies flat on the bed with the legs comfortably placed in stirrups and the hips flexed and abducted to increase the diameter of the pelvic outlet. Also Dorsal position in KNH - Vulvar and perineal cleansing

Spontaneous Delivery ⋅ Delivery of the Head - Crowning - encirclement of the largest head diameter by the vulvar ring ⋅ Episiotomy (See notes below)

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⋅ Ritgen Maneuver - By the time the head distends the vulva and perineum (during a contraction) enough to open the vaginal introitus to a diameter of ≥ 5 cm, a towel-draped, gloved hand may be used to exert forward pressure on the chin of the fetus through the perineum just in front of the coccyx. At the same time, the other hand exerts pressure superiorly against the occiput. Importance - allows the physician to control the delivery of the head - favors extension, so that the head is delivered with its smallest diameters passing through the introitus and over the perineum The head is delivered slowly with the base of the occiput rotating around the lower margin of the symphysis pubis as a fulcrum, while the bregma (anterior fontanel), brow, and face pass successively over the perineum ⋅ Delivery of Shoulders. After its birth, the head falls posteriorly, bringing the face almost into contact with the anus. The occiput promptly turns toward one of the maternal thighs so that the head assumes a transverse position. The movement of restitution (external rotation) indicates that the bisacromial diameter (transverse diameter of the thorax) has rotated into the anteroposterior diameter of the pelvis. Most often, the shoulders appear at the vulva just after external rotation and are born spontaneously. Occasionally, a delay occurs and immediate extraction may appear advisable; - the sides of the head are grasped with the two hands and gentle downward traction applied until the anterior shoulder appears under the pubic arch. Following delivery of the anterior shoulder to try and avoid (Difficult childbirth), suction the nasopharynx and check for a - Next, by an upward movement, the posterior shoulder is delivered ⋅ Immediately after delivery of the infant, there is usually a gush of amnionic fluid, often tinged with blood but not grossly bloody. ⋅ Clearing the Nasopharynx - To minimize the likelihood of aspiration of amnionic fluid debris and blood that might occur once the thorax is delivered and the infant can inspire, the face is quickly wiped and the nares and mouth are aspirated ⋅ Nuchal Cord - Following delivery of the anterior shoulder, the finger should be passed to the neck of the fetus to ascertain whether it is encircled by one or more coils of the umbilical cord. If a coil of umbilical cord is felt, it should be drawn down between the fingers and, if loose enough, slipped over the infant's head. If it is applied too tightly to the neck to be slipped over the head, it should be cut between two clamps and the infant promptly delivered. ⋅ Clamping the Cord - The umbilical cord is cut between two clamps placed 4-5 cm from the fetal abdomen, and later an umbilical cord clamp (plastic clamp (Hollister, Double Grip Umbilical Clamp) is applied 2- 3 cm from the fetal abdomen. Clamp the cord after first thoroughly clearing the infant's airway, all of which usually takes about 30 seconds. The infant is not elevated above the introitus at vaginal delivery or much above the maternal abdominal wall at the time of cesarean delivery to prevent placental transfusion. ⋅ Epidural anesthesia is widely accepted as causative in failure of spontaneous rotation to OA, as well as in slowing second-stage labor and decreasing maternal expulsive efforts.

Management of Third/Placental stage of Labor The period beginning at the expulsion of the infant and ending with the completed expulsion of the placenta and membranes ⋅ Signs of Placental Separation; - The uterus becomes globular and, as a rule, firmer. This sign is the earliest to appear. - There is often a sudden gush of blood. - The uterus rises in the abdomen because the placenta, having separated, passes down into the lower uterine segment and vagina, where its bulk pushes the uterus upward.

32 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

- The umbilical cord protrudes farther out of the vagina, indicating that the placenta has descended. These signs sometimes appear within about 1 minute after delivery of the infant and usually within 5 minutes. ⋅ Physiological management of the third stage - When the placenta has separated, it should be ascertained that the uterus is firmly contracted. The mother may be asked to bear down, and the intra-abdominal pressure so produced may be adequate to expel the placenta. If these efforts fail, or if spontaneous expulsion is not possible because of anesthesia, and after ensuring that the uterus is contracted firmly, pressure is exerted with the hand on the fundus to propel the detached placenta into the vagina, ⋅ Delivery of the Placenta - Placental expression should never be forced before placental separation lest the uterus be turned inside out - Inversion of the uterus. As pressure is applied to the body of the uterus, the umbilical cord is kept slightly taut - Controlled cord traction (CCT)/Bradt Andrem method. The uterus is lifted cephalad (In a direction toward the head) with the abdominal hand. This maneuver is repeated until the placenta reaches the introitus. As the placenta passes through the introitus, pressure on the uterus is stopped. The placenta is then gently lifted away from the introitus. Early delivery of the placenta is believed to decrease blood loss from the implantation site because it prevents the development of extensive retroplacental bleeding. ⋅ Manual Removal of Placenta - Indication; - Applied when the placenta will not separate promptly especially common in cases of preterm delivery - If at any time there is brisk bleeding and the placenta cannot be delivered normally ⋅ Active Management of the Third Stage

"Fourth Stage" of Labor The placenta, membranes, and umbilical cord should be examined for completeness and for anomalies. Postpartum hemorrhage as the result of is more likely at this time. The uterus and perineum is evaluated during this time the latter to detect excessive bleeding.

EPISIOTOMY AND REPAIR Episiotomy - Surgical incision of the pudenda (external genitals - vulva) to; - prevent laceration at the time of delivery - facilitate vaginal surgery Perineotomy - Incision of the perineum (commonly described as episiotomy) Should be individualized and not performed routinely. Types; ⋅ median or midline episiotomy - The incision is made in the midline ⋅ mediolateral episiotomy - The incision begins in the midline but is directed 45o laterally and downward away from the rectum

Episiotomy Characteristic Midline Mediolateral Surgical repair Easy More difficult Faulty healing Rare More common Post operative pain Minimal Common Anatomical results Excellent Occasionally faulty Blood loss Less More Dyspareunia Rare Occasional rd th Extensions Common (3 & 4 degree) Uncommon

Indications- fetal indications - shoulder dystocia

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- Breech delivery - Cephalopelvic disproportion (CPD) - Forceps or vacuum extractor operations - Occiput posterior positions - instances where failure to perform an episiotomy will result in perineal rupture Prevents pelvic relaxation, that is, , , and urinary incontinence. Obviously, if the perineal incision is not made until the time of maximal distension, this benefit is probably limited. Timing of Episiotomy - Performed when the head is visible during a contraction to a diameter of 3-4 cm therefore the head compresses the surrounding blood vessels minimizing blood loss. ⋅ If performed unnecessarily early, bleeding from the incision may be considerable during the interim between the episiotomy and the delivery. ⋅ If performed too late, the muscles of the perineal floor already will have undergone excessive stretching, and one of the objectives of the operation is defeated. Performed with the forceps in place Timing of the Repair of Episiotomy - episiotomy repair is deferred until the placenta has been delivered.

Lacerations of the vagina and perineum (Birth Canal) Such lacerations are often preventable with an appropriate episiotomy and avoidance of midforceps deliveries. Classification of mid-line episiotomies; ⋅ First-degree lacerations - involve the fourchette (frenulum of the labia minora.), perineal skin, and vaginal mucous membrane but not the underlying fascia and muscle. ⋅ Second-degree lacerations - involve, in addition to skin and mucous membrane, the fascia and muscles of the perineal body but not the rectal sphincter. These tears usually extend upward on one or both sides of the vagina, forming an irregular triangular injury. ⋅ Third-degree lacerations - extend through the skin, mucous membrane, and perineal body, and involve the anal sphincter. ⋅ Fourth-degree laceration - extends through the rectal mucosa to expose the lumen of the rectum. Tears in the region of the urethra are also likely to occur with this type of laceration unless an adequate episiotomy is performed. These periurethral tears may bleed profusely. Also leads to fistula formation.

Factors associated with an increased risk for third- and fourth-degree lacerations: ⋅ Midline episiotomy - Increases the risk of posterior tears into the external anal sphincter and/or the rectum. With a mediolateral episiotomy, the likelihood of a laceration into the rectum is reduced but not eliminated. ⋅ Anterior tears involving the urethra and labia are much more common in women in whom an episiotomy is NOT cut ⋅ Nulliparity ⋅ Second-stage arrest of labor ⋅ Persistent occiput posterior position ⋅ Mid- or low-forceps instead of a vacuum extractor ⋅ Use of local anesthetics ⋅ Asian race

OPERATIVE OBSTETRICS 1. FORCEPS DELIVERY NOT done in our region due to shorter pelvises

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CLASSIFICATION OF FORCEPS DELIVERY ACCORDING TO STATION AND ROTATION Type of Classification Procedure Outlet forceps 1. Scalp is visible at the introitus without separating the labia 2. Fetal skull has reached pelvic floor 3. Sagittal suture is in anteroposterior diameter or right or left occiput anterior or posterior position. 4. Fetal head is at or on perineum. 5. Rotation does not exceed 45o.

Low forceps Leading point of fetal skull is at station ≥ +2cm, and not on the pelvic floor. 1. Rotation ≤ 45o (left or right occiput anterior to occiput anterior, or left or right occiput posterior to occiput posterior). 2. Rotation > 45o

Midforceps Station above +2cm but head engaged. Rarely indicated for labor termination specifically for maternal reasons.

High Not included in classification. (forceps are applied before engagement)

Maternal indications (for operative vaginal delivery with either forceps or vacuum) ⋅ heart disease ⋅ pulmonary injury or compromise ⋅ intrapartum infection ⋅ certain neurological conditions ⋅ exhaustion ⋅ prolonged second-stage labor- nulliparous woman - > 3 hours with and > 2 hours without regional analgesia - Parous woman - > 2 hours with and > 1 hour without regional analgesia

Fetal indications (for operative vaginal delivery with either forceps or vacuum) ⋅ prolapse of the umbilical cord ⋅ premature separation of the placenta ⋅ non-reassuring fetal heart rate pattern

Prerequisites for Forceps Application ⋅ The head must be engaged. ⋅ The fetus must present as a vertex or by the face with the chin anterior. ⋅ The position of the fetal head must be precisely known so that cephalic placement of the forceps can be performed. ⋅ The cervix must be completely dilated before application of forceps. If prompt delivery becomes imperative before complete dilatation of the cervix, cesarean section is indicated. If done earlier, there is a risk of cervical incompetence leading to future /. ⋅ Before forceps application, the membranes must be ruptured to permit a firm grasp of the fetal head by the forceps blades. ⋅ There should be no disproportion between the size of the head and that of the pelvic inlet or the midpelvis. Maternal pelvis type must be known and must be adequate (gynecoid) - a true conjugate of >10.5cm is adequate. 35 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

⋅ Adequate analgesia if time allows ⋅ In fetal distress, someone for neonatal resuscitation should be present ⋅ Operator should be well trained and conversant with the complications

Complications Maternal ⋅ Uterine/Cervical/Vaginal lacerations ⋅ Extension of episiotomy especially midline ⋅ Bladder or urethral injuries ⋅ Urine retention ⋅ Perivaginal hematomas ⋅ Postpartum hemorrhage ⋅ UTIs

Fetal ⋅ Cephalohematomas ⋅ Bruising ⋅ Lacerations ⋅ Facial nerve injury ⋅ Skull fractures ⋅ Intracranial bleeding

2. VACUUM EXTRACTOR/VENTOUSE Traction on a soft cup so designed that the suction creates an artificial caput, or chignon, within the cup that holds firmly and allows adequate traction.

Indications and Prerequisites - See above

Relative contraindications; ⋅ face or other nonvertex presentations ⋅ extreme prematurity ⋅ fetal coagulopathies ⋅ known macrosomia ⋅ following recent scalp blood sampling

Technique ⋅ The center of the cup should be over the sagittal suture and about 3 cm in front of the posterior fontanelle. ⋅ When using rigid cups, it is recommended that the vacuum be created gradually by increasing the suction by 0.2 kg/cm2 every 2 minutes until a negative pressure of 0.8 kg/cm2 is reached (approximately over 8mins). With soft cups, negative pressure can be increased to 0.8 kg/cm2 over as little as 1 minute. ⋅ Traction should be intermittent and coordinated with maternal expulsive efforts. Traction may be initiated by using a two-handed technique; fingers of one hand are placed against the suction cup, while the other hand grasps the handle of the instrument ⋅ DO NOT continue beyond 30mins ⋅ The bladder and rectum must be empty - Catheterize the bladder and give enemas prior if need be.

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⋅ There is no place for use of this instrument above zero station (high vacuum).

Complications ⋅ scalp lacerations and bruising ⋅ subgaleal hematomas ⋅ cephalohematomas ⋅ intracranial hemorrhage ⋅ neonatal jaundice ⋅ subconjunctival hemorrhage ⋅ clavicular fracture ⋅ shoulder dystocia ⋅ injury of sixth and seventh cranial nerves ⋅ Erb palsy ⋅ retinal hemorrhage ⋅ fetal death

FORCEPS DELIVERY VACUUM EXTRACTOR Higher frequency of; ⋅ Avoidance of insertion of space-occupying steel blades within the vagina and ⋅ maternal trauma their positioning precisely over the fetal head ⋅ third- and fourth-degree ⋅ Ability to rotate the fetal head without impinging upon maternal soft tissues lacerations ⋅ Less intracranial pressure during traction ⋅ blood loss ⋅ Increased incidence of neonatal jaundice ⋅ Higher incidence of shoulder dystocia and cephalohematoma

CESAREAN DELIVERY Introduction Cesarean delivery is defined as the birth of a viable fetus(es) (≥500gm), placenta and membranes through incisions in the abdominal wall (laparotomy) and the uterine wall (hysterotomy). This definition does not include removal of the fetus from the abdominal cavity in the case of rupture of the uterus or in the case of an .

Frequency KNH - 20% (1991) On the increase due to; ⋅ There is reduced parity, and almost half of pregnant women are nulliparas. Therefore, an increased number of cesarean births might be expected for conditions that are more common in nulliparous women e.g. dystocia, PET ⋅ Older women are having children - the frequency of cesarean deliveries increases with advancing age. ⋅ Electronic fetal monitoring - concern for an abnormal fetal heart rate tracing prompts operative delivery with the listed indication being some form of labor arrest. ⋅ Breech presentations ⋅ Prior cesarean ⋅ Concern for malpractice litigation - Failure to perform a cesarean and thus avoid adverse neonatal neurological outcome or cerebral palsy and seizures is the dominant claim in obstetrical malpractice litigation ⋅ Socioeconomic and demographic factors - Maternal request 37 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

Indications Maternal ⋅ Previous cesarean - A repeat cesarean is indicated if; - Previous cesarean was a classical cesarean (suffers prior to labor or if given a trial of labor) - The previous uterine incision extended into the upper contractile portion of the myometrium - Two prior cesareans - The previous cesarean was indicated for labor arrest or dystocia ⋅ Dystocia or failure to progress in labor ⋅ Breech presentation - Fetuses presenting as a breech are at increased risk of cord prolapse and head entrapment if delivered vaginally compared with those presenting as a vertex. ⋅ Life threatening hemorrhage (APH) ⋅ - Type IIb - IV ⋅ Contracted pelvis ⋅ Following repair of (VVF) ⋅ Medical illness - severe HBP - Cerebral aneurysm - MSS disease - Neurologic - Severe cardiac and respiratory disease ⋅ Pelvic tumors obstructing labor - fibroids, entrapped ovarian tumor, genital warts. ⋅ Invasive ca cervix ⋅ Maternal preference

Fetal ⋅ Fetal distress ⋅ Poor biophysical score ⋅ Malpresentation and malposition - breech, face, brow, compound, transverse lie, unstable/oblique lie ⋅ Cord prolapse ⋅ Macrosomia (>4kg) ⋅ Multiple pregnancies - 1st non cephalic, retained 2nd , extreme preterm, discordant fetal growth, single amniotic sac, , >2 fetuses ⋅ Risk of infection - active HSV II, HPV, HIV, HBV ⋅ Fetal anomalies - hydrocephalus, sacral tumor ⋅ Others - IUGR, , thrombocytopenia

Feto-maternal ⋅ CPD ⋅ APH - placenta praevia, vas praevia, abruptio placenta

Types Based on; 1. Timing of operation ⋅ Elective

38 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

⋅ Emergency 2. Type of Uterine Incision ⋅ Classical/Vuks incision - a vertical incision into the body of the uterus above the lower uterine segment and reaching the uterine fundus. (Seldom used today) Indications- When there is a transverse lie of a large fetus, especially if the membranes are ruptured and the shoulder is impacted in the birth canal and the back faces downwards - If the lower uterine segment cannot be exposed or entered safely because the bladder is adherent densely from previous surgery - Fibroids/Tumors in the lower uterine segment - Severe kyphoscoliosis with pelvic uterus - Invasive carcinoma of the cervix - Placenta previa with anterior implantation - In some cases of very small fetuses, especially presenting as breech, in which the lower uterine segment is not thinned out. Disadvantages- Increased blood loss - Heals poorly and is delayed - Adhesions to gut leads to obstruction - Dehiscence/rupture of scar is very likely - Later delivery has to be elective cesarean ⋅ Lower Segment Transverse/Kerr Incision - operation of choice for a Advantages - results in less blood loss - is easier to repair - is located at a site least likely to rupture with extrusion of the fetus into the abdominal cavity during a subsequent pregnancy - does not promote adherence of bowel or omentum to the incision line - require only modest dissection of the bladder from the underlying myometrium Disadvantage- If the incision extends laterally, the laceration may involve one or both of the uterine vessels ⋅ Lower Segment Vertical/DeLee incision Advantage - may be extended upward so that in those circumstances where more room is needed, the incision can be carried into the body of the uterus Disadvantages- More extensive dissection of the bladder is necessary to keep the vertical incision within the lower uterine segment - If the vertical incision extends downward, it may tear through the cervix into the vagina and possibly involve the bladder - During the next pregnancy a vertical incision that extends into the upper myometrium is much more likely than is the transverse incision to rupture, especially during labor. 3. Order of the cesarean ⋅ Primary ⋅ Repeat 4. Life of mother ⋅ Ante-mortem ⋅ Peri-mortem (post mortem)

39 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

Technique of Cesarean Delivery Pre-op ⋅ Review indication and ascertain fetal maturity (early ANC, early U/S scan, amniocentesis/surfactant test), PMH, allergy ⋅ Counsel the mother and obtain an informed consent ⋅ FBC, U/E/C, GXM 2 units of blood ⋅ Give a sedative/anxiolytic the night before the surgery e.g. Diazepam 5mg ⋅ Warm bath and abdominal shaving in the morning ⋅ Pre-op observations - Urinalysis (sugar, proteins) ⋅ Pre-medication - Atropine sulphate 0.6mg ½ hr before theatre (Use hyoscine butylbromide in cardiac disease)

Intra-op ⋅ Catheterize ⋅ Put the mother in a supine position with a 15o left lateral tilt ⋅ Clean the abdomen with antiseptic solution and drape ⋅ Anaesthetize - Local/General - 100% O2 administration till delivery ⋅ Give prophylactic antibiotics ⋅ Abdominal incision - Pfannenstiel incision The skin and subcutaneous tissue are incised using a lower transverse, slightly curvilinear incision made at the level of the pubic hairline and is extended somewhat beyond the lateral borders of the rectus muscles. After the subcutaneous tissue has been separated from the underlying superficial fascia for 1 cm or so on each side, the superficial fascia is incised transversely the full length of the incision. The superior and inferior edges of the superficial fascia are grasped with suitable clamps and then elevated by the assistant as the operator separates the fascial sheath from the underlying rectus muscles by blunt dissection with the scalpel handle. Blood vessels coursing between the muscles and superficial fascia are clamped, cut, and ligated. Meticulous hemostasis is imperative. The separation is carried near enough to the umbilicus to permit an adequate midline longitudinal incision of the peritoneum. The rectus and the pyramidalis muscles are separated in the midline by sharp and blunt dissection to expose transversalis fascia and peritoneum. The transversalis fascia and preperitoneal fat are dissected carefully to reach the underlying peritoneum. The peritoneum near the upper end of the incision is opened carefully. Some elevate the peritoneum with two hemostats placed about 2 cm apart. The tented fold of peritoneum between the clamps is then visualized and palpated to be sure that omentum, bowel, or bladder are not adjacent. In women who have had previous intra- abdominal surgery, including cesareans, omentum or even bowel may be adherent to the undersurface of the peritoneum. The peritoneum is incised superiorly to the upper pole of the incision and downward to just above the peritoneal reflection over the bladder. Advantages - cosmetic advantage - incision is stronger - less likelihood of dehiscence or hernia formation. ⋅ Uterine Incision Commonly, the uterus is found to be dextrorotated so that the left round ligament is more anterior and closer to the midline than the right. With thick meconium or infected amnionic fluid, some operators prefer to lay a moistened laparotomy pack in each lateral peritoneal gutter to absorb fluid and blood that escape from the opened uterus. Typically the rather loose reflection of peritoneum above the upper margin of the bladder and overlying the anterior lower uterine segment is grasped in the midline with forceps and incised with a scalpel or scissors which are inserted between the serosa and myometrium of the lower uterine segment and are pushed laterally from the midline, while partially opening the blades intermittently, to separate a 2-cm-wide strip of serosa, 40 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

which is then incised. As the lateral margin on each side is approached, the scissors are aimed somewhat more cephalad. The lower flap of peritoneum is elevated and the bladder is gently separated by blunt or sharp dissection from the underlying myometrium. In general, the separation of bladder should not exceed 5 cm in depth and usually less. It is possible, especially with an effaced, dilated cervix, to dissect downward so deeply as inadvertently to expose and then enter the underlying vagina rather than the lower uterine segment. The uterus is opened through the lower uterine segment about 1 cm below the upper margin of the peritoneal reflection. The uterine incision is initiated by incising with a scalpel the exposed lower uterine segment transversely for 2 cm or so halfway between the lateral margins. This must be done carefully so as to cut completely through the uterine wall but not deeply enough to wound the underlying fetus. It is very important to make the uterine incision large enough to allow delivery of the head and trunk of the fetus without either tearing into or having to cut into the uterine arteries and veins that course through the lateral margins of the uterus If the placenta is encountered in the line of incision, it must either be detached or incised. When the placenta is incised, fetal hemorrhage may be severe; thus, the cord should be clamped as soon as possible in such cases. ⋅ Delivery of the Infant If the vertex is presenting, a hand is slipped into the uterine cavity between the symphysis and fetal head, and the head is elevated gently with the fingers and palm through the incision aided by modest transabdominal fundal pressure. After a long labor with cephalopelvic disproportion, the fetal head may be rather tightly wedged in the birth canal. Upward pressure exerted through the vagina by an assistant will help to dislodge the head and allow its delivery above the symphysis. To minimize aspiration by the fetus of amnionic fluid and its contents, the exposed nares and mouth are aspirated with a bulb syringe before the thorax is delivered. The shoulders then are delivered using gentle traction plus fundal pressure. The rest of the body readily follows. As soon as the shoulders are delivered, an intravenous infusion containing about 20 U of oxytocin per liter is allowed to flow at a brisk rate of 10 mL/min until the uterus contracts satisfactorily, after which the rate can be reduced. The cord is clamped with the infant held at the level of the abdominal wall, and the infant is given to the member of the team who will conduct resuscitative efforts as they are needed. The uterine incision is observed for any vigorously bleeding sites. These should be promptly clamped with Pennington or ring forceps/Green-Amytage forceps, or similar instruments. The placenta should be removed promptly manually, unless it is separating spontaneously. Fundal massage, begun as soon as the fetus is delivered, reduces bleeding and hastens delivery of the placenta. ⋅ Repair of the Uterus After delivery of the placenta, the uterus may be lifted through the incision onto the draped abdominal wall and the fundus covered with a moistened laparotomy pack - uterine exteriorization. Advantages - The relaxing uterus can be recognized quickly and massage applied - The incision and bleeding points are visualized more easily and repaired, especially if there have been extensions laterally. - Adnexal exposure is superior and thus tubal sterilization is easier Disadvantage - Discomfort and vomiting caused by traction in the woman given spinal or epidural analgesia Immediately after delivery and inspection of the placenta, the uterine cavity is inspected and is wiped out with a gauze pack to remove avulsed membranes, vernix, clots, or other debris. The uterine incision is closed with one or two layers of continuous 0 or #1 absorbable suture. The initial suture is placed just beyond one angle of the incision. A running-lock suture is then carried out, with each suture penetrating the full thickness of the myometrium and is continued just beyond the opposite incision angle. Individual bleeding sites can be secured with figure-of-eight or mattress sutures. The visceral and parietal peritoneums are left open to; - reduce the need for postoperative analgesia 41 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

- allow a quicker return of bowel function. Factors affecting healing of the uterine incision; - Hemostasis - Accuracy of apposition - Quality and amount of suture material - Avoidance of infection and tissue strangulation ⋅ Abdominal Closure As each layer is closed, bleeding sites are located, clamped, and ligated. The rectus muscles are allowed to fall into place, and the subfascial space is meticulously checked for hemostasis. The overlying rectus fascia is closed either with interrupted 0 nonabsorbable sutures that are placed well lateral to the cut fascial edges and no more than 1 cm apart, or by continuous, nonlocking suture of a long-lasting absorbable or permanent type. The skin is closed with vertical mattress sutures of 3-0 or 4-0 silk or equivalent suture or skin clips.

Post-op ⋅ Observe ½ hourly - fully awake by 4 hrs ⋅ Fluid Therapy and Diet - IVF 1L TDS - Oral at 6-24hrs then solids gradually ⋅ Analgesia - Pethidine for 24hrs ⋅ Antibiotics ⋅ Check hemoglobin 3rd day post-op ⋅ Discharge from the Hospital - Unless there are complications during the puerperium, the mother is generally discharged from the hospital on the 3rd postpartum day ⋅ Wound Care - The incision is inspected each day, and the skin sutures (or clips) are removed on the 4th postpartum day. By the third postpartum day, bathing by shower is not harmful to the incision. ⋅ TCA - 6wks

Complications & Prognosis Factors contributing heavily to postoperative complications; - prior internal monitoring - prolonged rupture of the membranes - unsuccessful prior efforts at vaginal delivery - hemorrhage - uterine rupture ⋅ Maternal Morbidity and Mortality - the risk of death following cesarean delivery is at least seven times the risk following vaginal delivery. ⋅ In a later pregnancy, pain in the area of the scar may suggest dehiscence. About 50% of all ruptures of uterine scars occur before the onset of labor. Rupture of the classic scar (1-2%) is usually catastrophic, occurring suddenly, totally, and with partial or total extrusion of the fetus into the abdominal cavity. Shock due to internal hemorrhage is a prominent sign. Rupture of the low cervical scar (0.5-1%) is usually more subtle and is characterized principally by pain and occasionally by evidence of slower internal bleeding. ⋅ Anaesthesia complications - Difficult intubation - Hypotension - Spinal headache - caused by persistent leakage of cerebrospinal fluid through the hole made by a spinal or epidural needle - Acid aspiration syndrome (mendelson syndrome) - Aspiration of gastric contents with a pH of 3.5 or less into the lungs may follow vomiting and regurgitation during general anesthesia used for obstetric

42 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

patients. Pulmonary inflammation, destruction of the alveolar lining, and transudation of fluid into the alveolar space occurs rapidly ⋅ Hemorrhage ⋅ Complications of transfusion ⋅ GIT - Paralytic ileus, Intestinal obstruction ⋅ Urinary tract - Injury, UTI ⋅ Infection ⋅ Perinatal Morbidity and Mortality - Iatrogenic prematurity - Respiratory depression - Transient tachypnea of the newborn - Intracranial hemorrhage with small incisions

PERIMORTEM CESAREAN A satisfactory fetal outcome is dependent upon; ⋅ anticipation, if possible, of the death of the mother ⋅ Nature of maternal insult ⋅ Duration since maternal collapse- <5 mins - Excellent - 5-10 - Good - 10-15 - fair - 15-20 - poor - 20-25 - unlikely - >25 mins - No survival ⋅ gestational age of fetus ⋅ availability of personnel and appropriate equipment ⋅ availability of continued postmortem ventilation and cardiac massage for the mother to relieve aortocaval compression ⋅ prompt delivery within 1 minute via an infraumbilical midline vertical incision and effective neonatal resuscitation ⋅ 50% cases have yielded a live neonate ⋅ TRIAL OF SCAR (VAGINAL BIRTH AFTER CESAREAN) In considering vaginal birth after cesarean, several criteria must be met; ⋅ Only one prior cesarean which must have been a Low-transverse/vertical cesarean confined to the relatively noncontractile lower uterine segment ⋅ Non recurring indications of previous cesarean or any other indication for a cesarean ⋅ No post-op sepsis after previous cesarean ⋅ Parity <5 ⋅ Cephalic presentation ⋅ Weight < 3.5Kg ⋅ Adequate pelvis with a true conjugate ≥ 10.5cm ⋅ Facilities for blood transfusion available ⋅ Ready theater available immediately

Management of TOS ⋅ Early ANC

43 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

⋅ Review Hx ⋅ Obstetric u/s scan in 1st ½ of pregnancy ⋅ Exploration of the lower uterine segment following TOS is dangerous, obsolete and not routine

DYSTOCIA Difficult childbirth

⋅ Fetal dystocia, dystocia due to abnormal presentation, position (both - 5% of all labors), and development of the fetus (Passenger)

⋅ Maternal dystocia, dystocia caused by an abnormality or physical problem in the mother - Passage, power

⋅ Placental dystocia, retention or difficult delivery of the placenta.

1. BREECH PRESENTATION Breech presentation occurs when the fetal pelvis or lower extremities engage in the maternal pelvic inlet. Types (according to fetal attitude) ⋅ Frank breech - the lower extremities are flexed at the hips and extended at the knees, and thus the feet lie in close proximity to the head. Appears most commonly when the diagnosis is established radiologically near term ⋅ Complete breech - the lower extremities are flexed at the hips and one or both knees are flexed ⋅ Incomplete/Footling breech - one or both hips are not flexed and one (single footling breech) or both (double footling breech) feet or knees lie below the breech, that is, a foot or knee is lowermost in the birth canal

Fetal position in breech presentation is determined by using the sacrum as the fetal point of reference to the maternal pelvis. This could be; ⋅ sacrum anterior (SA) ⋅ sacrum posterior (SP) ⋅ left sacrum transverse (LST) ⋅ right sacrum transverse (RST) ⋅ left sacrum anterior (LSA) ⋅ left sacrum posterior (LSP) ⋅ right sacrum anterior (RSA) ⋅ right sacrum posterior (RSP) The station of the breech presenting part is the location of the fetal sacrum with regard to the maternal ischial spines

Epidemiology In singleton breech presentation in which the infant is <2500gm; ⋅ 50% - Footling breech ⋅ 40% - Frank breech ⋅ 10% - Complete breech If the is >2500gm; ⋅ 65% - Frank breech ⋅ 25% - Footling breech ⋅ 10% - Complete breech

Etiology

44 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

Factors that appear to predispose to breech presentation; ⋅ Gestational age - Before 28 weeks, the fetus is small enough in relation to intrauterine volume to rotate from cephalic to breech presentation and back again with relative ease. As gestational age and fetal weight increase, the relative decrease in intrauterine volume makes such changes more difficult. In most cases, the fetus spontaneously assumes the cephalic presentation to better accommodate the bulkier breech pole in the roomier fundal portion of the uterus. ⋅ uterine relaxation associated with great parity ⋅ multiple fetuses ⋅ hydramnios ⋅ oligohydramnios ⋅ Fetal congenital malformations - hydrocephalus, anencephalus, congenital hip dislocation, spina bifida, meningomyelocoel ⋅ Chromosomal, neuromuscular and skeletal malformations that affect the function and movements of the fetus and prevent the fetus from turning ⋅ previous breech delivery ⋅ uterine anomalies - Bicornuate, septate uterus ⋅ pelvic tumors obstructing the birth canal ⋅ placenta previa ⋅ placental implantation in the cornual-fundal region

Significance In the persistent breech presentation, an increased frequency of the following complications can be anticipated; ⋅ perinatal morbidity and mortality from difficult delivery ⋅ low birthweight from preterm delivery, growth restriction, or both ⋅ prolapsed cord ⋅ placenta previa ⋅ fetal, neonatal, and infant anomalies ⋅ uterine anomalies and tumors ⋅ multiple fetuses ⋅ operative intervention, especially cesarean delivery

Diagnosis ⋅ Abdominal Examination Leopold’s maneuvers -1st - the hard, round, readily ballottable fetal head is found to occupy the fundus 2nd - indicates the back to be on one side of the abdomen and the small parts on the other. 3rd - if engagement has not occurred-that is, if the intertrochanteric diameter of the fetal pelvis has not passed through the pelvic inlet-the breech is movable above the pelvic inlet 4th - After engagement, the firm breech is beneath the symphysis Fetal heart sounds are usually heard loudest slightly above the umbilicus, whereas with engagement of the fetal head the heart sounds are loudest below the umbilicus. ⋅ Vaginal Examination - With the frank breech presentation, both ischial tuberosities, the sacrum, and the anus are usually palpable, and after further descent, the external genitalia may be distinguished. - In complete breech presentations, the feet may be felt alongside the buttocks

45 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

- In footling presentations, one or both feet are inferior to the buttocks and the foot can readily be identified as right or left on the basis of the relation to the great toe. When the breech has descended farther into the pelvic cavity, the genitalia may be felt. ⋅ Ultrasound ⋅ X-Ray Studies - Not routinely used

Management Antepartum Management Following confirmation of breech presentation, the mother must be closely followed to see if spontaneous version to cephalic presentation occurs. If breech presentation persists beyond 36 weeks, external cephalic version should be considered. The mother should be informed of the presentation and of management options.

Management During Labor: Criteria for Vaginal or cesarean delivery in breech presentation Vaginal Delivery Cesarean Delivery ⋅ Frank breech presentation ⋅ Most cases of complete or footling breech over 25wks ⋅ Some carefully selected cases of complete or gestation without detectable lethal congenital footling breech (continous electronic monitoring malformations (to prevent ). must be done to detect viable fetal heart rate Fetus with variable heart rate decelerations on electronic decelerations due to umbilical cord prolapse; if this monitoring. occurs, perform immediate cesarean delivery) ⋅ Gestational age of ≥34 weeks ⋅ Premature fetus (gestational age of 25-34wks) with the mother in either active labor or in need of delivery ⋅ Estimated fetal weight of 2000-3500gm ⋅ Estimated fetal weight of ≥3500gm ⋅ Flexed fetal head ⋅ Deflexed/Hyperextended fetal head ⋅ Adequate maternal pelvis as determined by x-ray ⋅ Contracted or borderline maternal pelvic measurements (pelvic inlet with transverse diameter or unfavorable shape of pelvis of 11.5cm and anteroposterior diameter of ⋅ No labor, with maternal or fetal indications for delivery 10.5cm; midpelvis with transverse diameter of such as pregnancy-induced hypertension or ruptured 10cm and anteroposterior diameter of 11.5cm) membranes for 12 hours or more ⋅ No maternal or fetal indications for cesarean ⋅ Severe fetal growth restriction section ⋅ Previous perinatal death or children suffering from birth ⋅ Previable fetus (gestational age < 25wks and trauma weight <700gm) ⋅ A request for sterilization ⋅ Documented lethal fetal congenital anomalies ⋅ Unengaged presenting part ⋅ Presentation of mother in advance labor with no ⋅ Uterine dysfunction fetal or maternal distress, even if cesarean delivery ⋅ Elderly primigravida was originally planned (a careful performed, ⋅ Mother with infertility problems or poor obstetric controlled vaginal delivery is safer in such cases history than a hastily executed cesarean section)

Cesarean delivery- If the lower uterine segment is well developed (generally the case in women at term who have experienced labor), or if the presenting part is not well down in the uterus, a longer transverse "lower segment" incision is adequate for easy delivery. In premature gestations, the lower uterine segment may be quite narrow, and a low vertical incision is almost always required for a traumatic delivery.

Vaginal Delivery of Breech 46 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

⋅ Spontaneous breech delivery - The infant is expelled entirely spontaneously without any traction or manipulation other than support of the infant.

⋅ Partial/Assisted breech extraction (Frank breech) - The infant is delivered spontaneously as far as the umbilicus, but the remainder of the body is extracted. Unless there is considerable relaxation of the perineum, an episiotomy should be made. The episiotomy is an important adjunct to any type of breech delivery. As the breech progressively distends the perineum, the posterior hip will deliver, usually from the 6 o'clock position, and often with sufficient pressure to evoke passage of thick meconium at this point. The anterior hip then delivers followed by external rotation to the sacrum anterior position. The mother should be encouraged to continue to push, as the cord is now drawn well down into the birth canal and is being compressed with resultant fetal bradycardia. Continued descent of the fetus will allow easy delivery of the legs by splinting the medial thighs of the fetus with the fingers positioned parallel to the femur and exertion of pressure laterally so as to sweep the legs away from the midline. Following delivery of the legs, the fetal bony pelvis is grasped with both hands utilizing a cloth towel moistened with warm water. The fingers should rest on the anterior superior iliac crest and the thumbs on the sacrum, minimizing the chance of fetal soft tissue injury. Maternal expulsive efforts are augmented by gentle downward traction until the scapulas are clearly visible.

⋅ Total breech extraction (Complete/Footling Breech) - The entire body of the infant is extracted by the obstetrician. Replaced by cesarean section due to birth trauma The hand is introduced through the vagina and both feet of the fetus are grasped. The ankles are held with the second finger lying between them; with gentle traction the feet are brought through the vulva. If difficulty is experienced in grasping both feet, first one foot should be drawn into the vagina but not through the introitus; and then the other foot should be advanced in a similar fashion. Now both feet are grasped and pulled through the vulva simultaneously. As the legs begin to emerge through the vulva, downward gentle traction is then continued. As the legs emerge, successively higher portions are grasped, first the calves and then the thighs. When the breech appears at the vulva, gentle traction is applied until the hips are delivered. As the buttocks emerge, the back of the infant usually rotates to the anterior. The thumbs are then placed over the sacrum and the fingers over the hips, and gentle downward traction is continued until the costal margins, and then the scapulas become visible.

As traction is exerted and the scapulas become visible, the back of the infant tends to turn spontaneously toward the side of the mother to which it was originally directed. If turning is not spontaneous, slight rotation should be added to the traction, with the objective of bringing the bisacromial diameter of the fetus into the anteroposterior diameter of the pelvic outlet.

Delivering the shoulders A cardinal rule in successful breech extraction is to employ steady, gentle, downward traction until the lower halves of the scapulas are delivered outside the vulva, making no attempt at delivery of the shoulders and arms until one axilla becomes visible. The appearance of one axilla indicates that the time has arrived for delivery of the shoulders. It makes little difference which shoulder is delivered first. There are two methods for delivery of the shoulders:

⋅ With the scapulas visible, the trunk is rotated in such a way that the anterior shoulder and arm appear at the vulva and can easily be released and delivered first. The body of the fetus is then rotated in the reverse direction to deliver the other shoulder and arm.

⋅ If trunk rotation was unsuccessful, the posterior shoulder must be delivered first. The feet are grasped in one hand and drawn upward over the inner thigh of the mother toward which the ventral surface of the fetus is directed. In this manner, leverage is exerted upon the posterior shoulder, which slides out over the perineal

47 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

margin, usually followed by the arm and hand. Then, by depressing the body of the fetus, the anterior shoulder emerges beneath the pubic arch, and the arm and hand usually follow spontaneously.

Delivery of the head Thereafter, the back tends to rotate spontaneously in the direction of the symphysis. If upward rotation fails to occur, it is effected by manual rotation of the body. Delivery of the head may then be accomplished with;

⋅ Forceps - Hardly used in Kenya

⋅ Mauriceau-Smellie-Veit maneuver The index and middle finger of one hand are applied over the maxilla, to flex the head, while the fetal body rests upon the palm of the hand and forearm. The forearm is straddled by the fetal legs. Two fingers of the other hand then are hooked over the fetal neck, and grasping the shoulders, downward traction is applied until the suboccipital region appears under the symphysis. Gentle suprapubic pressure simultaneously applied by an assistant helps keep the head flexed. The body of the fetus is then elevated toward the mother's abdomen, and the mouth, nose, brow, and eventually the occiput emerge successively over the perineum. Gentle traction should be exerted by the fingers over the shoulders. At the same time, appropriate suprapubic pressure applied by an assistant is helpful in delivery of the head.

Problems with Vaginal Delivery

⋅ Manual manipulations within the birth canal increase the risk of maternal infection. Intrauterine maneuvers, especially with a thinned-out lower uterine segment, or delivery of the aftercoming head through an incompletely dilated cervix, may cause rupture of the uterus, lacerations of the cervix, or both.

⋅ extensions of the episiotomy and deep perineal tears

⋅ Anesthesia sufficient to induce appreciable uterine relaxation may cause uterine atony and, in turn, postpartum hemorrhage

⋅ Delivery may be delayed many minutes while the aftercoming head accommodates to the maternal pelvis, but hypoxia and acidemia become severe

⋅ Delivery may be forced, causing trauma from compression, traction, or both

⋅ Fracture of the humerus, clavicle, femur

⋅ Paralysis of the arm may follow pressure upon the brachial plexus by the fingers in exerting traction, but more frequently it is caused by overstretching the neck while freeing the arms.

⋅ Cord prolapse

⋅ increased incidence of sudden infant death syndrome

2. FACE PRESENTATION Introduction - The head is hyperextended so that the occiput is in contact with the fetal back and the chin (mentum) is presenting. The fetal face may present with the chin (mentum) anterior or posterior, relative to the maternal symphysis pubis. In term-size fetuses, labor progression is usually impeded with mentum posterior face presentations because the fetal brow (bregma) is compressed against the maternal symphysis pubis. This position precludes flexion of the fetal head necessary to negotiate the birth canal and cesarean section is innevitable. In contrast, flexion of the head and vaginal delivery is typical with mentum anterior presentations. Many mentum posterior presentations convert spontaneously to anterior even in late labor. Incidence - 0.2% Diagnosis - Clinical diagnosis is by vaginal examination and palpation of the distinctive facial features of the mouth and nose, malar bones, and particularly the orbital ridges.

⋅ With frank breech presentation, when labor is prolonged, the buttocks may become markedly swollen, rendering differentiation of face and breech very difficult; the anus may be mistaken for the mouth, and the ischial tuberosities for the malar eminences. This is confirmed by; 48 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

⋅ the finger encounters muscular resistance with the anus, whereas the firmer, less yielding jaws are felt through the mouth

⋅ the finger, upon removal from the anus, is sometimes stained with meconium

⋅ The mouth and malar eminences form a triangular shape, while the ischial tuberosities and anus are in a straight line. The radiographic demonstration of the hyperextended head with the facial bones at or below the pelvic inlet is quite characteristic. Etiology - Anencephalic fetuses - Contracted pelvis - Large fetus - marked enlargement of the neck - Coils of cord about the neck - Multiparity

3. BROW PRESENTATION Brow presentation, the rarest presentation (0.06%), is diagnosed when that portion of the fetal head between the orbital ridge and the anterior fontanel presents at the pelvic inlet. Except when the fetal head is small or the pelvis is unusually large, engagement of the fetal head and subsequent delivery cannot take place as long as the brow presentation persists. A brow presentation is commonly unstable and often 1/3 convert to a face or an occiput presentation Etiology - See face presentation Diagnosis - The presentation may be recognized by abdominal palpation when both the occiput and chin can be palpated easily, but vaginal examination is usually necessary. The frontal sutures, large anterior fontanel, orbital ridges, eyes, and root of the nose can be felt on vaginal examination. Neither mouth nor chin is within reach, however.

4. SINCIPUT PRESENTATION The fetal head may assume a position where there is neither flexion nor extension of the fetal head with respect to the trunk of the fetus (military attitude), with the anterior (large) fontanel, or bregma, presenting. Spontaneous conversion to face, brow or vertex occurs as labor progresses.

5. TRANSVERSE LIE In a transverse lie, the long axis of the fetus is approximately perpendicular to that of the mother. When the long axis forms an acute angle, an oblique lie results which is usually only transitory, because either a longitudinal or transverse lie commonly results when labor supervenes. For this reason, the oblique lie is called an unstable lie. In transverse lies, the shoulder is usually over the pelvic inlet, with the head lying in one iliac fossa and the breech in the other. In such a , the side of the mother toward which the acromion is directed determines the designation of the lie as right or left acromial. Moreover, because in either position the back may be directed anteriorly or posteriorly, superiorly or inferiorly, it is customary to distinguish varieties as dorsoanterior and dorsoposterior. Etiology - unusual relaxation of the abdominal wall resulting from great multiparity - Preterm fetus - Placenta previa - Abnormal uterus - Excessive amnionic fluid - contracted pelvis

49 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

6. COMPOUND PRESENTATION In a compound presentation, an extremity prolapses alongside the presenting part, with both presenting in the pelvis simultaneously

7. PERSISTENT OCCIPUT POSTERIOR POSITIONS Introduction - Most often, occiput posterior positions undergo spontaneous anterior rotation followed by uncomplicated delivery. In less than 10% of cases, spontaneous rotation does not occur. Etiology - transverse narrowing of the midpelvis - Contracted anthropoid or android pelvis - Insufficient uterine power The possibilities for vaginal delivery are;

⋅ await spontaneous delivery

⋅ forceps delivery with the occiput directly posterior

⋅ forceps rotation of the occiput to the anterior position and delivery

⋅ manual rotation to the anterior position followed by spontaneous or forceps delivery Cesarean section is indicated if rotation does not occur

8. PERSISTENT OCCIPUT TRANSVERSE POSITION Introduction - In the absence of a pelvic architecture abnormality (cephalopelvic disproportion), the occiput transverse position is most likely a transitory one as the occiput rotates to the anterior position. If hypotonic uterine dysfunction, either spontaneous or the consequence of regional analgesia, does not develop, spontaneous rotation is usually completed rapidly, thus allowing the choice of spontaneous delivery or delivery with outlet forceps. If it persists, it can end up as mid-pelvic arrest at the pelvic inlet or mid inlet - cesarean section is advised

VERSION Version is a procedure in which the presentation of the fetus is altered artificially, either substituting one pole of a longitudinal presentation for the other, or converting an oblique or transverse lie into a longitudinal presentation. Types;

⋅ Cephalic - the head is made the presenting part

⋅ Podalic - the breech is made the presenting part

⋅ External version - the manipulations are performed exclusively through the abdominal wall

⋅ Internal version - the entire hand is introduced into the uterine cavity

External Cephalic Version Considerations for external cephalic version using tocolysis;

⋅ the presenting part has not descended into the pelvis (unengaged)

⋅ 37-40wks gestation

⋅ there is a normal amount of amnionic fluid

⋅ the fetal back is not positioned posteriorly

⋅ the woman is not obese

Indications

⋅ If a breech or shoulder presentation (transverse lie) is diagnosed in the last weeks of pregnancy, its conversion to a vertex may be attempted by external maneuvers, provided there is no; - marked disproportion between the size of the fetus and the pelvis

50 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

- Placenta previa If the fetus lies transversely, a change of presentation is the only alternative to cesarean delivery for a viable fetus

Contraindications

⋅ engagement of the presenting part in the pelvis

⋅ marked oligohydramnios

⋅ placenta previa

⋅ premature

⋅ previous uterine surgery (including cesarean section, myomectomy, or metroplasty)

⋅ suspected or documented congenital malformations or abnormalities (including intrauterine growth retardation)

⋅ maternal conditions that may preclude the administration of tocolytic agents; - Cardiac disease - Diabetes mellitus - Thyroid disorders

Complications

⋅ maternal mortality

⋅

⋅ Cord prolapse

⋅ uterine rupture

⋅ PROM

⋅ fetomaternal hemorrhage

⋅ isoimmunization

⋅ preterm labor

⋅ fetal distress

⋅ fetal demise due to cord entanglement

EARLY PREGNANCY BLEEDING Vaginal bleeding before fetal viability (28wks) irrespective of etiology DDx ⋅ Abortion ⋅ Hydatidiform mole ⋅ ⋅ Dysfunctional uterine bleeding ⋅ Coincidental causes - infection, neoplasm (even when pregnant)

1. ABORTION DEFINITION Expulsion from the uterus of an embryo or fetus (termination of pregnancy) by any means prior to the stage of viability - 28 wks of gestation (based upon the date of the first day of the last normal menses) WHO - 20wks gestation or fetus weighs < 500 g Essentials of Diagnosis; - Suprapubic pain and uterine cramping. - Vaginal bleeding. - Cervical dilatation 51 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

- Extrusion of products of conception. - Disappearance of symptoms and signs of pregnancy - Negative pregnancy test or quantitative β-hCG that is not properly increasing - Adverse ultrasonic findings (e.g., empty gestational sac, fetal disorganization, lack of fetal growth).

TYPES (Based on etiology) a) SPONTANEOUS Abortion that has not been artificially induced i.e. without human interference Incidence - reproductive wastage; - spontaneous abortion - 15-40% - Infertility - 15% - Prematurity -10% - Fetal death - 1% - Ectopic pregnancy -1% - Neonatal death - 1% Pathology - Hemorrhage into the decidua basalis and necrotic changes in the tissues adjacent to the bleeding result in the ovum becoming detached and stimulating uterine contractions and cervical dilatation that result in expulsion. Outcome- Maceration - The bones of the skull collapse and the abdomen becomes distended with blood- stained fluid. The skin softens and peels off in utero or at the slightest touch, leaving behind the corium. Internal organs degenerate and undergo necrosis. - Blighted ovum - there may be no visible fetus in the sac - Fetus compressus - the fetus becomes compressed upon itself and desiccated when the amnionic fluid is absorbed - Fetus papyraceous - the fetus eventually becomes so dry and compressed that it resembles parchment Etiology - Fetal Factors ⋅ Abnormal Zygote Development - Anencephaly - Neurotube defect ⋅ Aneuploid Abortion ⋅ Autosomal trisomy - 13, 16, 18, 21, and 22 - normally associated with first-trimester abortions ⋅ Triploidy - often associated with hydropic placental degeneration Maternal Factors ⋅ Infections- Genital infection with Herpes simplex in the first half of pregnancy - HIV-1 - Syphilis - Vaginal colonization with group B streptococci - Toxoplasma gondii - Malaria - Rubella - Peritonitis increases the likelihood of abortion. ⋅ Endocrine Abnormalities- uncontrolled DM (within 21 days of conception) - Insufficient progesterone secretion by the corpus luteum or placenta ⋅ Drug Use and Environmental Factors- Smoking - Alcohol - Coffee (> 4 cups per day) - Radiation 52 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

⋅ Intrauterine devices are associated with an increased incidence of septic abortion after contraceptive failure ⋅ Arsenic, lead, formaldehyde, benzene, and ethylene oxide ⋅ Aging Gametes Uterine Defects ⋅ Acquired - Uterine synechiae caused by destruction of large areas of endometrium by curettage resulting in amenorrhea and recurrent abortions due to insufficient endometrium to support implantation ⋅ Developmental - as a consequence of abnormal mullerian duct formation or fusion; or they may occur spontaneously or be induced by in utero exposure to diethylstilbestrol (DES) - Uni/Bicornuate/Septate uterus - Fibroids ⋅ Incompetent Cervix - painless cervical dilatation in the second trimester or perhaps early in the third trimester, with prolapse and ballooning of membranes into the vagina, followed by rupture of membranes and expulsion of an immature fetus

CATEGORIES AND TREAMENT i) Threatened Abortion Slight show of blood ± cramplike pains which may or may not be followed by the expulsion of the fetus during the first 20 weeks of pregnancy Uterine size = GA The pain of abortion may be; - Anterior and clearly rhythmic - A persistent low backache, associated with a feeling of pelvic pressure or - A dull, midline, suprasymphyseal discomfort Increased risk of suboptimal pregnancy outcome- preterm delivery - Low birthweight - Perinatal death DDx (Lower abdominal pain and persistent low backache do NOT accompany bleeding from these causes) - Some bleeding about the time of expected menses may be physiological - Cervical lesions especially after intercourse - Polyps presenting at the external cervical os - Decidual reaction in the cervix - Ectopic pregnancy Mx - Bed rest ± sedation - Antibiotics to cover for infections - Progesterone to r/o corpus luteum insufficiency - Pelvic u/s to confirm fetal viability Outcome - continuation of normal pregnancy - Prognosis for pregnancy continuation in the presence of bleeding and pain is poor - Inevitable abortion - Missed abortion ii) Inevitable abortion Abortion characterized by pain (uterine cramping) and intrauterine bleeding in the presence of an open cervix but without expulsion of the products of conception in a previable pregnancy (before the 20th completed weeks) Uterine size = GA Abortion is inevitable when 2 or more of the following are noted: - Moderate effacement of the cervix - Cervical dilatation greater than 3 cm 53 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

- Rupture of the membranes - Bleeding for more than 7 days - Persistence of cramps despite narcotic analgesics - Other signs of termination of pregnancy (e.g., partial extrusion of products of conception) Mx - <14wks - D&C - >14wks - Accelerate with oxytocin drip - Allow to progress iii) Missed abortions Retention of dead products of conception in utero for several weeks Why the pregnancy is maintained; ? Viable placental function ? Exogenous long-acting progestogens (Progesterone production reduces uterine contractility) C/P- Pain or tenderness is unusual - Brownish - Cervix remains firm and closed - No adnexal abnormality can be identified - Mammary changes usually regress - Pelvic u/s - shriveled sac containing a macerated fetus with no fetal cardiac activity In markedly prolonged (> 4 weeks) midtrimester missed abortion, absorption of the products of conception may result in a coagulopathy most notable for a low plasma fibrinogen. DDx - continued pregnancy - Inaccurate dating of a continuing pregnancy - Pelvic tumor without pregnancy. Mx - first trimester - suction curettage - Second trimester - Dilatation and evacuation using prostaglandin E suppositories iv) Incomplete abortion Abortion in which part of the products of conception have been passed but part (usually the placenta) remains in the uterus as evidenced by; - continued bleeding in lumps/clots - A patulous cervix - An enlarged, boggy uterus Cramps are usually present but may not be severe. Uterine size > GA Mx - Blood transfusion/fluid replacement dictated by the extent of hemorrhage and hypovolemic shock - Oxytocin - contracts the uterus, aids in the expulsion of tissue or clots, limits blood loss and decreases the possibility of uterine perforation during D&C - D&C for possible retained tissue - Antibiotics and analgesics v) Complete abortions Although slight bleeding may continue for a short time after passing the entire conceptus, complete abortion is marked by cessation of pain as well as termination of brisk bleeding Cervix is closed Uterine size < GA Mx - Ergometrin - Prophylactic antibiotics

b) INDUCED ABORTIONS Abortion brought on purposefully by drugs or mechanical means. 54 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

CATEGORIES i) Therapeutic abortion is the termination of pregnancy before the time of fetal viability for the purpose of safeguarding the health of the mother. Indications; - persistent heart disease after previous cardiac decompensation - advanced hypertensive vascular disease - Renal disease - Invasive carcinoma of the cervix - A fetus with severe physical deformities or mental retardation ii) Criminal/illegal abortion - termination of pregnancy without legal justification iii) Clandestine abortion - Professionally done criminal abortion in inappropriate conditions/environs. Infection and bleeding are common. iv) Legal abortion - Not allowed in Kenya unless (i) c) SEPTIC ABORTIONS This is when sepsis occurs during abortion Sepsis after an abortion - postabortion sepsis Etiology - Criminal/clandestine abortions due to prolonged abortion to evacuation period. Infective agents - anaerobic bacteria e.g. Bacteroides, Klebsiella, Pseudomonas, Clostridium perfringens - Coliforms - Haemophilus influenzae - Campylobacter jejuni - Group A streptococcus C/P- a malodorous discharge from the vagina and cervix - Fever -although hypothermia often heralds or accompanies endotoxic shock - Pelvic and abdominal pain O/E- marked suprapubic tenderness - Signs of peritonitis - Tenderness with movement of the uterus or cervix - Jaundice due to hemolysis or oliguria (or both) secondary to septicemia - Trauma to the cervix or upper vagina may be recognized if there has been a clumsy attempt to induce an abortion Mx - Prompt evacuation of the products of conception by D&C - Broad-spectrum antimicrobials given intravenously (e.g., ampicillin, gentamicin) - Abdominal hysterectomy should be considered when; ⋅ Clostridia is the causative organism ⋅ uterine perforation has occurred ⋅ the sepsis fails to respond adequately to treatment ⋅ the patient responds incompletely after being in septic shock - Vena caval clipping and ovarian vein ligation may be indicated when repeated septic pulmonary embolization occurs. d) HABITUAL/RECURRENT ABORTIONS Defined as 3 consecutive spontaneous pregnancy wastages before 20 weeks' gestation with a fetus weighing < 500 g Etiology ⋅ Problems of accommodation; - Anatomic Abnormalities of the Reproductive Tract; 55 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

⋅ Cervical incompetence ⋅ congenital uterine anomalies; - Bicornuate uterus - Single uterine horn - Septate uterus ⋅ submucous leiomyomas ⋅ abnormalities due to diethylstilbestrol exposure in utero ⋅ Uterine synechiae (Asherman syndrome) ⋅ Fibroids - Congenital abnormalities ⋅ Hormonal Abnormalities - thyroid dysfunction - Progesterone insufficiency (Corpus Luteum Insufficiency) - Diabetes mellitus ⋅ Infections - TO CHES, Mycoplasma, Ureaplasma urealyticum, Neisseria gonorrhoeae, Listeria monocytogenes, Brucella, and Chlamydia ⋅ Immunologic Factors ⋅ Systemic Disease- chronic hypertensive disease - Chronic renal disease - Overt diabetes mellitus - Collagen vascular disease e.g. systemic lupus erythematosus [SLE]

CERVICAL INCOMPETENCE It is characterized by painless cervical dilatation in the second trimester (14 weeks) or perhaps early in the third trimester, with prolapse and ballooning of membranes (due to filling of the amniotic sac) into the vagina, followed by rupture of membranes, drainage of liquor, uterine contractions and expulsion of an immature fetus Etiology ⋅ Previous trauma to the cervix- dilatation and curettage - Conization - Cauterization - Amputation ⋅ Abnormal cervical development, including that following exposure to diethylstilbestrol in utero ⋅ Enthusiastic gynecological exams ⋅ Fetal extraction before dilatation ⋅ Traumatic vaginal delivery ⋅ Precipitated labor (very rapid labor ending in delivery of the fetus) ⋅ Obstructed labor ⋅ Early rupture of cervix ⋅ Angular tear/distortion of cervix C/P ⋅ Normal but incompetent ⋅ Short cervix - (Normal length - 2cm) ⋅ No internal/External/both os ⋅ Loss of part of the cervix ⋅ Capsular cervix - loose ⋅ Patulous/patent cervix - cervical dilatation in a non-pregnant woman >6cm is incompetent Mx Cerclage - The placing of a nonabsorbable suture around an incompetent cervical os. 56 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

⋅ Types - Schroeder operation - McDonald operation The more advanced the pregnancy, the more likely surgical intervention will stimulate preterm labor or membrane rupture. For these reasons, some prefer bed rest rather than cerclage some time after midpregnancy. We usually do not perform cerclage after 24 to 26 weeks. Emergency Cerclage - Late second-trimester cerclage, ⋅ Complications - membrane rupture, , and intrauterine infection.

COMPLICATIONS OF ABORTION - Severe or persistent hemorrhage during or following abortion may be life-threatening - The sequelae of infection, e.g., and intrauterine synechia or infertility - Long term- chronic PID - Syndrome of chronic - Ectopic pregnancy secondary to partial closure of fallopian tubes due to trauma/infection - Social problems

ANTEPARTUM HEMORRHAGE Any bleeding after 28weeks gestation and before 2nd stage of delivery Incidence - 3-4% DDx 1. Nonobstetric causes ⋅ ; cervical eversion, erosion, polyps and other benign neoplasms, malignant neoplasms ⋅ Vaginal lacerations, varices, benign and malignant neoplasms (rare) 2. Obstetric causes ⋅ Extrusion of cervical mucus (“bloody show”) - Slight bleeding through the vagina is common during active labor. This "bloody show" is the consequence of effacement and dilatation of the cervix, with tearing of small veins and, in turn, slight shedding of blood. ⋅ Premature separation of placenta ⋅ ⋅ Marginal sinus rupture ⋅ Placenta previa - some separation of a placenta implanted in the immediate vicinity of the cervical canal ⋅ Abruptio placenta - from separation of a placenta located elsewhere in the uterine cavity ⋅ Uterine rupture ⋅ Abnormal blood clotting mechanism

PLACENTA PREVIA Definition The placenta is implanted in the lower uterine segment within the zone of effacement and dilatation of the cervix, thus constituting an obstruction to descent of the presenting part When the placenta is located over the internal os, the formation of the lower uterine segment and the dilatation of the internal os result inevitably in tearing of placental attachments. The bleeding is augmented by the inability of the myometrial fibers of the lower uterine segment to contract and thereby constrict the torn vessels.

Classification Minor - can allow vaginal delivery unless bleeding is life threatening when a C/S is indicated I - Low-lying placenta - The placenta is implanted in the lower uterine segment such that the placental edge actually does not reach the internal os but is in close proximity to it. 57 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

II anterior - Marginal placenta previa - The edge of the placenta is at the margin of the internal os.

Major - cannot allow vaginal delivery as it will be obtrusive to the presenting part with shearing and bleeding and thus a C/S is indicated. II posterior - Marginal placenta previa - The edge of the placenta is at the margin of the internal os. III - Partial placenta previa - The internal os is partially covered by placenta IV - Total placenta previa - The internal cervical os is covered completely by placenta

Etiology The major factor influencing the formation of placenta previa with implantation of the placenta in the lower uterine segment and cervical os in search of better vascularization due to presence of scarred or poorly vascularized endometrium in the corpus due to; ⋅ advancing age ⋅ multiparity ⋅ previous cesarean delivery ⋅ Prior induced abortion ⋅ Defective decidual vascularization, the possible result of inflammatory or atrophic changes ⋅ Fibroids ⋅ a large placenta as in multiple pregnancy ⋅ abnormal forms of placentation such as succenturiate lobe or placenta diffusa ⋅ rapid embryo development thus an increased average surface area of a placenta implanted in the lower uterine segment, possibly because these tissues are less well suited for nidation

C/P ⋅ Painless hemorrhage, the first episode usually beginning at some point after the 28th week and is characteristically described as being sudden, painless, and profuse bright red, clotted blood. Bleeding may be due to any of the following causes; - Mechanical separation of the placenta from its implantation site, either during the formation of the lower uterine segment or during effacement and dilatation of the cervix in labor, or as a result of intravaginal manipulation - Placentitis - Rupture of poorly supported venous lakes in the decidua basalis that have become engorged with venous blood

O/E ⋅ The uterus usually is soft, relaxed, and non-tender and equal in size to GA ⋅ A high presenting part cannot be pressed into the pelvic inlet ⋅ The infant will present in an oblique or transverse lie ⋅ NO digital exam should be performed as it will cause hemorrhage

Dx ⋅ U/S ⋅ Soft tissue placentography - Fetal spine is seen far from the pubic symphysis ⋅ Radioactive isotopes ⋅ EUA - when the decision to deliver has been reached and bleeding is not torrential

DDx 58 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

⋅ Partial premature separation of the normally implanted placenta ⋅ Circumvallate placenta ⋅ Abruptio placenta

Mx Conservative - Achieve fetal maturity without compromising maternal safety ⋅ Bed rest ⋅ Sedatives ⋅ Transfusion ⋅ Corticosteroids for fetal lung maturity Definitive - Delivery by C/S as indicated above.

ABRUPTIO PLACENTA Premature separation of the normally implanted placenta

Types ⋅ Revealed/external hemorrhage - Some of the bleeding of placental abruption usually insinuates itself between the membranes and uterus, and then escapes through the cervix ⋅ Concealed Hemorrhage - Retained, or concealed, hemorrhage is likely when; - there is an effusion of blood behind the placenta but its margins still remain adherent - the placenta is completely separated yet the membranes retain their attachment to the uterine wall - blood gains access to the amnionic cavity after breaking through the membranes - the fetal head is so closely applied to the lower uterine segment that the blood cannot make its way past it ⋅ Relatively concealed - Hemorrhage from an incompletely detached placenta may sometimes be concealed by intact membranes

Etiology ⋅ previous placental separation ⋅ Poorly formed placenta/fibrotic uterus due to previous abortion, preterm, IUGR, fetal malformations ⋅ pregnancy-induced or chronic hypertension ⋅ Preterm prematurely ruptured membranes ⋅ advanced maternal age ⋅ Grand multiparity ⋅ uterine distention (e.g., multiple pregnancy, hydramnios) ⋅ vascular deficiency or deterioration (e.g., diabetes mellitus, collagen diseases complicating pregnancy) ⋅ uterine anomalies or tumors (e.g., Uterine leiomyoma, especially if located behind the placental implantation site) ⋅ cigarette smoking ⋅ alcohol consumption (> 14 drinks per week) ⋅ Cocaine abuse ⋅ possibly maternal type O blood ⋅ Circumvallate placenta ⋅ trauma (e.g., external or internal version, automobile accident, abdominal trauma directly transmitted to an anterior placenta) ⋅ sudden reduction in uterine volume (e.g., rapid loss, delivery of a first twin)

59 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

⋅ abnormally short cord (usually only a problem during delivery, when traction is exerted on the cord as the fetus moves down the birth canal) ⋅ increased venous pressure (usually only problematic with abrupt or extreme alterations) ⋅ Nutritional deficiency - Folic acid

Pathophysiology & Pathology a) Local vascular injury due to vascular rupture into the decidua basalis, which splits, leaving a thin layer adjacent to the myometrium. This decidual hematoma leads to separation, compression, and the ultimate destruction of the placenta adjacent to it. Alternatively, a spiral artery may rupture, creating a retroplacental hematoma which as it expands disrupts more vessels to separate more placenta. The area of separation rapidly becomes more extensive and reaches the margin of the placenta. In either case, bleeding occurs, a clot forms, and the placental surface can no longer provide metabolic exchange between mother and fetus. Because the uterus is still distended by the products of conception, it is unable to sufficiently contract to compress the torn vessels that supply the placental site. The escaping blood may dissect the membranes from the uterine wall and eventually appear externally, or may be completely retained within the uterus. If the placental margins remain adherent, central placental separation may result in hemorrhage that infiltrates the uterine wall. Uterine tetany follows. Occasionally, extensive intramyometrial bleeding results in uteroplacental apoplexy-so-called , a purplish and copper-colored, ecchymotic, indurated organ that all but loses its contractile power because of disruption of the muscle bundles. Conditions predisposing to vascular injury; ⋅ preeclampsia- ⋅ chronic hypertension ⋅ diabetes mellitus ⋅ chronic renal disease b) An abrupt rise in uterine venous pressure transmitted to the intervillous space resulting in engorgement of the venous bed and the separation of all or a portion of the placenta. Factors that may predispose to an abrupt rise in uterine venous pressure; ⋅ vasodilatation secondary to shock ⋅ compensatory hypertension as a result of aortic compression ⋅ paralytic vasodilatation of conduction anesthesia

C/P Symptoms and signs correspond to the degree of separation - 50% have classical symptoms* ⋅ *Pain ⋅ *Shock ⋅ *uterine rigidity (woody hard) ⋅ *absent fetal heart sounds ⋅ Uterine tenderness ⋅ uterine size > GA ⋅ uterine tetany ⋅ fetal distress ⋅ fetal parts are hard to palpate ⋅ abdominal or back pain ⋅ disseminated intravascular coagulation ⋅ vaginal bleeding - either bright or dark red with clots depending on the rapidity of its appearance

DDx 60 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

Other causes of vaginal bleeding ⋅ Placenta previa ⋅ Uterine rupture ⋅ Acute

Complications ⋅ Anemia ⋅ Consumptive Coagulopathy ⋅ Sheehan’s Syndrome - Pituitary necrosis secondary to shock ⋅ Renal Failure due to reduced renal perfusion ⋅ Uteroplacental Apoplexy (Couvelaire Uterus) ⋅ Intrauterine anoxia/hypoxia ⋅ IUFD ⋅ Acute Cor Pulmonale - because of emboli in the pulmonary microcirculation as a result of either defibrination or the escape of amniotic cellular debris into maternal veins ⋅ Transfusion Hepatitis

Mx Conservative

Differences between Placenta previa and Abruptio placenta Feature Placenta previa Abruptio placenta Bleeding Bright red Dark brown (retention) Recurrent If revealed, continuous Painless Pain - Distension and reaction No obvious cause Associated with labor Uterus Soft and relaxed Tense and woody hard Non-tender Tender and painful Anemia and Shock Proportional to hemorrhage Disproportionate to hemorrhage Fetus Heart is easily palpable Heart is difficult to auscultate Alive Dead in 50% Malpresentation common Malpresentation not common Uterine size:GA = >

MULTIFETAL PREGNANCY Epidemiology ⋅ 1:70 Black ⋅ 1:90 White ⋅ 1:150 Asian ⋅ 1:89 Twins ⋅ 1:892 Triplets

Etiology ⋅ Identical/Uniovular/monozygotic twins - arise from a single fertilized ovum that subsequently divides into two similar structures, each with the potential for developing into a separate individual

61 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

- If division occurs before the inner cell mass (morula) is formed and the outer layer of blastocyst is not yet committed to become Chorion - that is, within the first 72 hours after fertilization - two embryos, two , and two will develop. There will evolve a diamnionic, dichorionic, monozygotic twin pregnancy. - If division occurs between the fourth and eighth day, after the inner cell mass is formed and cells destined to become chorion have already differentiated but those of the amnion have not, two embryos will develop, each in separate amnionic sacs. The two amnionic sacs will eventually be covered by a common chorion, thus giving rise to diamnionic, monochorionic, monozygotic twin pregnancy. - If, however, the amnion has already become established, which occurs about 8 days after fertilization, division will result in two embryos within a common amnionic sac, or a monoamnionic, monochorionic, monozygotic twin pregnancy. - If division is initiated even later - that is, after the embryonic disk is formed - cleavage is incomplete and conjoined/siamese twins are formed. Have an identical genotype and phenotype. ⋅ Fraternal/Biovular/dizygotic twins - result from fertilization of two separate ova Have different genotype and phenotype.

Predisposing factors to twinning ⋅ Black race ⋅ Familial - only for fraternal cases and inherited on the maternal side only (double ovulation) ⋅ Double ovulation is also increased with advancing age and increasing parity ⋅ Iatrogenic - Ovulation induction drugs e.g. HCG, FSH, Clomiphene

Complications of twin pregnancy Maternal

⋅ Polyhydramnios due to a large placenta with more amniotic fluid production

⋅ Abdominal tightness leads to maternal respiratory embarrassment

⋅ due to increased hCG (peaks at 11-12wks)

⋅ The large uterus exerts more pressure on the IVC with a reduction in venous return leading to varicose veins and hemorrhoids

⋅ Pre-eclampsia due to high blood volumes and increases pressor amines

⋅ Prolonged rupture of membranes

⋅ Placenta previa/Vasa previa due to the large size of the placenta

⋅ Velamentous insertion of the umbilical cord

⋅ Abnormal presentations (breech)

⋅ Premature labor due to over distension

⋅ Increased nutritional demand

⋅ Malpresentation (55%) - Cephalic/cephalic (45%) - Cephalic/Breech (35%) - If the breech comes out first, then the 2 heads get stuck - - and the first twin definitely dies and is decapitated and the next twin is born by C/S - Others (20%) - Breech/Transverse - Breech/Breech - Transverse/Transverse ⋅ Increases C/S rates ⋅ Post partum uterine atony - PPH; poorly responsive to ergometrin ⋅ maternal renal function may become impaired as the consequence of obstructive uropathy ⋅ Inadequate uterine contraction during labor due to the large size of the uterus 62 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

Fetal

⋅ IUGR

⋅ Prematurity as at 7mo/3wks the term fundal height is achieved

⋅ Twin-twin transfusion - An artery from one twin delivers blood that is drained into the vein of the other. The latter becomes plethoric and large while the former is anemic and small.

⋅ have an increased likelihood of entangling their cords, which may lead to asphyxia. Also, cord compression, cord prolapse

⋅ Congenital anomalies that occur predominantly in monozygotic twins

⋅ Abortion especially in triplets st nd ⋅ Undiagnosed retained second twin -On use of ergometrin after delivery of the 1 twin, the 2 dies due to tetanic contractions that cut-off blood supply to the placenta

Dx

⋅ Demonstration of 2 or more fetuses (e.g., ultrasonography, fetal heartbeats, multiplicity of fetal parts)

⋅ Disproportionately large (> 4 cm) uterus for dates DDx - Elevation of the uterus by a distended bladder - Inaccurate menstrual history - Hydramnios - Hydatidiform mole - Uterine myomas - A closely attached - Fetal macrosomia late in pregnancy ⋅ Increased and persistent fetal activity ⋅ Greater-than-expected maternal weight gain that is not explained by edema or obesity ⋅ Maternal hypochromic normocytic anemia ⋅ Earlier and more severe pressure in the pelvis resulting in - - Hyperemesis gravidarum - Backache - Varicosities - Edema - Constipation - Hemorrhoids - Abdominal distention - Difficulty in breathing. ⋅ Outline or ballottement of more than one fetus ⋅ Multiplicity of small parts ⋅ Uterus containing 3 or more large parts ⋅ Simultaneous recording of different fetal heart rates, 10 cm apart, each asynchronous with the mother's pulse and with each other and varying by at least 8 beats per minute. (The fetal heart rate may be accelerated by pressure or displacement.) ⋅ Palpation of one or more fetuses in the fundus after delivery of one infant ⋅ A familial history of twins ⋅ Recent administration of either clomiphene or pituitary gonadotropin

Ix

63 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

⋅ U/S ⋅ Plain abdominal x-ray at 36 wks - if not fully confirmed clinically - 1st trimester - Teratogenic - 2nd trimester to 36wks - Leukemia of childhood

Mx Principles ⋅ Delivery of markedly preterm infants is prevented. Several techniques have been applied in attempts to prolong multifetal gestations. These include bed rest, especially through hospitalization, prophylactic administration of β-mimetic drugs/tocolytics e.g. Ventolin, Ritodrine, and prophylactic cervical cerclage. ⋅ Failure of one or both fetuses to thrive be identified and fetuses so afflicted be delivered before they become moribund ⋅ Fetal trauma during labor and delivery be eliminated ⋅ Expert neonatal care be provided ⋅ Administration of hematinics to prevent anemia

Delivery of Twin Fetuses 1st stage ⋅ oxytocin augmentation of labor due to uterine hypotonia being common ⋅ labor is allowed only if the 1st twin is in cephalic presentation; otherwise C/S Indications for C/S; - 1st twin not in cephalic presentation - Twins with any other obstetric complications - All multifetal pregnancies > twins ⋅ IV 10% dextrose to inhibit anaerobic respiration ⋅ Twin pregnancies should not be allowed to go post date (within 2 weeks) due to increased risk of placental insufficiency (placenta degenerates after term)

2nd Stage ⋅ Episiotomy is always advised - 2nd twin’s head hardly moulds therefore risk of intracranial hemorrhage ⋅ 1st fetus is delivered in the usual way (cephalic with good contractions) ⋅ Clamp the cord at 2 points and cut it in-between ⋅ Don’t apply traction to the remaining cut cord - risk abruptio placenta which leads to death if they’re sharing one placenta ⋅ Don’t give ergometrin ⋅ Palpate via vaginal examination for the umbilical cord of the 2nd twin to r/o cord presentation/prolapse (feel a pulsation under the membranes on vaginal examination) - Membranes intact - cord presentation - ROM - cord prolapse ⋅ Palpate the abdomen for lie of 2nd twin (if there was no cord presentation/prolapse) - If not longitudinal, align it. ⋅ Palpate for presenting part; - If cephalic, then artificial rupture of membranes is done as the fundus is being pressed downwards to cause head engagement (cord can’t come out) - If breech/transverse, then do; - External cephalic version

64 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

- Internal podalic version (done with the hand in the vagina creating a breech) - Important if there’s cord prolapse in 2nd twin Breech extraction follows the IPV. ⋅ If cord prolapse with cephalic presentation, the IPV cant be done, therefore go for to prevent cord compression ⋅ After the delivery of the 1st twin, an interval of 5mins is normal before contractions resume After 5mins without contractions with a cephalic 2nd twin, then give an IV oxytocin drip to restart the contractions ⋅ Delay in 2nd twin delivery > 30mins increases neonatal mortality

3rd stage ⋅ Increased risk of post partum hemorrhage due to uterine atony. This is prevented by active management of 3rd stage; - IV ergometrin 0.5mg stat (tetanic contractions lasting 1hr) - IV oxytocin 40IU in 500ml 5% dextrose drip to run 40-60 drops/min ⋅ To sustain the contractions, run syndestrol for 4hrs by which time clots will be formed to prevent bleeding

Labor Complications ⋅ preterm labor ⋅ Uterine dysfunction ⋅ Abnormal presentations ⋅ prolapse of the umbilical cord ⋅ Premature separation of the placenta ⋅ Immediate postpartum hemorrhage

HYPERTENSIVE DISEASE IN PREGNANCY Hypertensive disorders complicating pregnancy are common and form one of the deadly triad, along with hemorrhage and infection that result in a large number of maternal deaths.

Classification of Hypertensive disorders complicating pregnancy ⋅ Pregnancy induced Hypertension: Hypertension that develops as a consequence of pregnancy and regresses postpartum. Divided into; - Hypertension without proteinuria or pathological edema - Pre-eclampsia - with proteinuria and/or pathological edema - Mild - Severe - Eclampsia - proteinuria and/or pathological edema along with convulsions ⋅ Coincidental hypertension: Chronic underlying hypertension that antecedes pregnancy or persists post partum ⋅ Pregnancy-aggravated hypertension: Underlying hypertension worsened by pregnancy - Superimposed preeclampsia - Superimposed eclampsia ⋅ Transient Hypertension: Hypertension which develops after the midtrimester of pregnancy and is characterized by mild elevations of blood pressure that do not compromise the pregnancy. This form of hypertension regresses after delivery (within 12wks), but may return in subsequent gestations.

Incidence 65 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

Major predisposing factors; ⋅ Nulliparity ⋅ familial history of preeclampsia-eclampsia ⋅ multiple fetuses ⋅ diabetes ⋅ chronic vascular disease ⋅ renal disease ⋅ hydatidiform mole ⋅ fetal hydrops Pregnancy-induced Hypertension- nulliparous women - Teenagers (<20yrs) - Multipara with multifetal pregnancy or fetal hydrops Pregnancy-aggravated hypertension - > 35 yrs - Multiparas with vascular disease, including chronic essential hypertension and diabetes, or those with coexisting renal disease.

Diagnosis of Pregnancy-induced Hypertension ⋅ The diagnosis is made when blood pressure is ≥140/90 mm Hg. ⋅ Preeclampsia is diagnosed by development of hypertension plus; - proteinuria defined as ≥300 mg of urinary protein per 24 hours, or ≥100 mg/dL in at least two random urine specimens collected ≥6 hours apart - Edema which is pathological and not just dependent; it usually involves the face and hands and persists even after arising. A useful indicator of nondependent edema is that rings have become too tight ⋅ Mild preeclampsia - Diastolic BP <100mmHg - Proteinuria - Trace - 1+ - Normal serum creatinine - Minimal liver enzyme elevation ⋅ Severe preeclampsia - Systolic ≥ 160mmHg and Diastolic >110mmHg - Persistent proteinuria of ≥2+, or 24-hour urinary excretion of ≥4 g - Epigastric or right upper quadrant pain frequently accompanied by marked elevated serum liver enzymes likely results from hepatocellular necrosis, edema, and ischemia that stretches Glisson's capsule. It usually is a sign to terminate the pregnancy. The pain presages hepatic infarction and hemorrhage as well as catastrophic rupture of a hepatic subcapsular hematoma especially in older and multiparous women. - Hyperbilirubinemia - Thrombocytopenia (<100*109/L) is characteristic of worsening preeclampsia, and probably is caused by microangiopathic hemolysis induced by severe vasospasm. Evidence of gross hemolysis such as hemoglobinemia, hemoglobinuria, or hyperbilirubinemia is indicative of severe disease. - Cardiac dysfunction with pulmonary edema - Fetal growth restriction - Glomerular filtration may be impaired - Oliguria <400mL/d - Plasma creatinine may rise - >1.2mg/dL - Headache - Visual disturbances

66 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

⋅ Eclampsia is diagnosed when grand mal convulsions appear before, during, or after labor, usually preceded by headache, visual disturbances, or epigastric pain, are precipitated by pregnancy-induced or aggravated hypertension.

Theories about the Cause of Pregnancy-induced Hypertension ⋅ Immunological Mechanisms - The risk of pregnancy-induced hypertension is appreciably enhanced in circumstances where formation of blocking antibodies to antigenic sites on the placenta might be impaired. This may arise; - during immunosuppressive therapy to protect a renal transplant - where effective immunization by a previous pregnancy is lacking, as in first pregnancies - where the number of antigenic sites provided by the placenta is unusually great compared with the amount of antibody, as with multiple fetuses ⋅ Genetic Predisposition ⋅ Dietary Deficiencies - incidence increases with calcium deficiency, obese women, and with prepregnancy weight ⋅ Vasoactive Compounds - Nitric oxide, previously termed endothelium-derived relaxing factor (EDRF), a potent vasodilator whose absence or decreased concentration might play a role in the etiology of pregnancy- induced hypertension. Cigarette smoking has been reported to reduce the incidence of pregnancy-induced hypertension ⋅ Endothelial Dysfunction - Damaged endothelium activates endothelial cells to promote coagulation, and increases sensitivity to vasopressor agents.

Pathophysiology of preeclampsia-eclampsia ⋅ Vasospasm - Vascular constriction causes resistance to blood flow and accounts for the development of arterial hypertension. It also exerts a damaging effect on vessels. Angiotensin II causes endothelial cells to contract. These changes lead to endothelial cell damage and interendothelial cell leaks through which blood constituents, including platelets and fibrinogen, are deposited subendothelially. The vascular changes, together with local hypoxia of the surrounding tissues, presumably lead to hemorrhage, necrosis, and other end-organ disturbances that have been observed at times with severe preeclampsia. With this scheme, fibrin deposition is then likely to be prominent, as seen in fatal cases. ⋅ Increased Pressor Responses in women with early preeclampsia ⋅ Supine pressor response - A hypertensive response with increased diastolic pressure of at least 20 mm Hg is induced by having the woman especially at 28 to 32 weeks assume the supine position after lying laterally recumbent

Maternal and fetal consequences of preeclampsia-eclampsia a) Maternal consequences Hemodynamic Changes- normal left ventricular filling pressures - High systemic vascular resistances - Hyperdynamic ventricular function. Blood Volume - Hemoconcentration due to vasoconstriction made worse by increased vascular permeability Hematological Changes - thrombocytopenia - decreased plasma clotting factors - Erythrocytes may be so traumatized that they display bizarre shapes and undergo rapid hemolysis Endocrine Changes - With sodium retention, hypertension, or both, renin secretion by the juxtaglomerular apparatus decreases. Because renin catalyzes the conversion of angiotensinogen to

67 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

angiotensin I (which is then transformed into angiotensin II by converting enzyme), angiotensin II levels decline, resulting in a decrease in aldosterone secretion. Fluid and Electrolyte Changes - Commonly, the volume of extracellular fluid in women with severe preeclampsia-eclampsia has expanded beyond the normally increased volume that characterizes pregnancy. The Kidney - renal perfusion and glomerular filtration are reduced - Plasma uric acid concentration is typically elevated - Plasma creatinine may be elevated two to three times over nonpregnant normal values due to a reduction in plasma clearance - Proteinuria develops late in pregnancy - Anatomical Changes - glomerular capillary endotheliosis - the glomeruli were enlarged with glomerular capillary endothelial swelling, and subendothelial deposits of fibrillary protein material - Acute renal failure characterized clinically by oliguria or anuria and rapidly developing azotemia develops from; ⋅ tubular necrosis - it is invariably induced by hypovolemic shock, usually associated with hemorrhage at delivery, for which adequate blood replacement is not given ⋅ renal cortical necrosis develops when the major portion of the cortex of both kidneys undergoes necrosis The Liver - Periportal hemorrhagic necrosis in the periphery of the liver lobule. Bleeding from these lesions may cause hepatic rupture or they may extend beneath the hepatic capsule and form a subcapsular hematoma - HELLP Syndrome. Liver involvement in preeclampsia- eclampsia is serious and is frequently accompanied by evidence of other organ involvement, especially the kidney and brain, along with hemolysis and thrombocytopenia - Hemolysis, ELevated liver enzymes, and Low Platelets. The Brain - edema, hyperemia, focal anemia, thrombosis, and hemorrhage A regular finding was fibrinoid changes in the walls of cerebral vessels. The lesions sometimes appeared to have been present for some time, as judged from the surrounding leukocytic response and hemosiderin-pigmented macrophages. These findings are consistent with the view that prodromal neurological symptoms, visual disturbances and convulsions may be related to these lesions. It is rare for a woman with eclampsia not to awaken after a seizure. It is also rare for a woman with severe preeclampsia to become comatose without an antecedent seizure. b) Placental effects Compromised placental perfusion from vasospasm is almost certainly a major culprit in the genesis of increased perinatal morbidity and mortality associated with preeclampsia.

c) Fetal effects The major cause of fetal compromise occurs as a consequence of reduced uteroplacental perfusion. ⋅ Prematurity - IUGR ⋅ Fetal distress ⋅ Oligohydramnios ⋅ IUFD

C/P ⋅ Symptoms of hypertension - headache - often frontal but may be occipital, and is resistant to relief from ordinary analgesics 68 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

- Epigastric or right upper quadrant pain - probably due to hepatic ischemia or to stretching of the hepatic capsule, possibly by edema and hemorrhage and may be indicative of imminent convulsions. - Visual disturbances are also ominous ⋅ Diastolic pressure of ≥90 mm Hg that persists ⋅ A sudden increase in weight exceeding > 2 pounds in any given week, or 6 pounds in a month due almost entirely to abnormal fluid retention (weight gain of 1 pound per week is normal) ⋅ Visible signs of nondependent edema such as swollen eyelids and puffy fingers ⋅ Proteinuria almost always develops later than hypertension and usually later than excessive weight gains

Prophylaxis and Early Treatment Warning signs; ⋅ Rapid weight gain any time during the latter half of pregnancy - Normally before 20 wks, net weight gain is 2Kg and may even have lost 2-3Kg in early pregnancy due to vomiting and poor appetite; after 20wks, weight increases by ½ Kg/wk ⋅ An upward trend in diastolic blood pressure Early prophylactic treatment with aspirin 75-100mg/d reduces incidence of preeclampsia due to selective suppression of thromboxane synthesis by platelets and sparing of endothelial prostacyclin production.

Mx Basic management objectives for any pregnancy complicated by pregnancy-induced hypertension are; ⋅ termination of pregnancy with the least possible trauma to mother and fetus ⋅ birth of an infant who subsequently thrives ⋅ complete restoration of health to the mother Manage conservatively until labor commences Hospital Management -Hospitalization is considered for women with pregnancy-induced hypertension if there is a persistent or worsened elevation in blood pressure or development of proteinuria. With hospitalization, a systematic study should be instituted that includes the following: ⋅ A detailed medical examination followed by daily searches for development clinical findings such as headache, visual disturbances, epigastric pain, and rapid weight gain. ⋅ Admittance weight and every day thereafter ⋅ Admittance analysis for proteinuria and at least every 2 days thereafter ⋅ Blood pressure readings with an appropriate-size cuff every 4 hours, except between midnight and morning, unless the midnight pressure has increased ⋅ Measurements of plasma creatinine, hematocrit, platelets, and serum liver enzymes, the frequency to be determined by the severity of hypertension ⋅ Frequent evaluation of fetal size and amnionic fluid volume by the same experienced examiner and by serial sonography if remote from term

Drug therapy Mild Preeclampsia The aim of therapy is to maintain BP at about 130/50 mmHg Sedatives - Phenobarbitone - 30mg TDS - Valium - 5mg TDS Vasodilators - Aldomet - 250mg TDS/750mg/d QID - Hydralazine - 25-50mg/d TDS CCB - Nifedipine - 20mg BD 69 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

Severe Preeclampsia - cf Eclampsia

Termination of Pregnancy Delivery is the cure for preeclampsia. Indications for termination of pregnancy; ⋅ No fetal growth ⋅ Severe oligohydramnios ⋅ Uncontrolled BP despite antihypertensive drug use ⋅ Deteriorating maternal condition - Renal, Liver and CNS

ECLAMPSIA Eclampsia is characterized by generalized tonic-clonic convulsions that develop in some women with hypertension induced or aggravated by pregnancy. Coma without convulsions has also been called eclampsia; however, it is better to limit the diagnosis to women with convulsions and to regard fatal nonconvulsive cases as due to severe preeclampsia.

Types; ⋅ Antepartum eclampsia - convulsions appear before labor ⋅ Intrapartum eclampsia - convulsions appear during labor ⋅ Postpartum eclampsia - convulsions appear after labor. Most cases of postpartum eclampsia develop within 24 hours of delivery, but otherwise typical cases are seen up to 10 days postpartum. Other diagnoses should be considered in women with the onset of convulsions > 48 hours postpartum.

Eclamptic Convulsions a) Preeclampsia - Headache, visual disturbance, and epigastric or right upper quadrant pain - precedes the onset of eclamptic convulsions b) The convulsive movements usually begin about the mouth in the form of facial twitchings. After a few seconds, the entire body becomes rigid in a generalized muscular contraction. The face is distorted, the eyes protrude, the arms are flexed, the hands are clenched, and the legs are inverted. All muscles are now in a state of tonic contraction. This phase may persist for 15 to 20 seconds. c) Suddenly the jaws begin to open and close violently, and soon after, the eyelids as well. The other facial muscles and then all muscles alternately contract and relax in rapid succession. Foam, often blood tinged, exudes from the mouth. The face is congested and the conjunctivae are injected. This phase, in which the muscles alternately contract and relax, may last about a minute. d) Gradually, the muscular movements become smaller and less frequent, and finally the woman lies motionless. Throughout the seizure the diaphragm has been fixed, with respiration halted. For a few seconds the woman appears to be dying from respiratory arrest, but just when a fatal outcome seems almost inevitable, she takes a long, deep, stertorous inhalation, and breathing is resumed e) Occasionally, coma or substantively altered consciousness follows a seizure, or may even accompany preeclampsia without convulsions. At least in some cases, this is due to extensive cerebral edema She will not remember the convulsion or, in all probability, events immediately before and afterward.

Post convulsive complications ⋅ Fever of 39°C or more is a very grave sign, because it is probably the consequence of a central nervous system hemorrhage which is more likely in older women with underlying chronic hypertension or rarely may be due to a ruptured berry aneurysm or arteriovenous malformation and may lead to sudden death synchronously with a convulsion or follows shortly thereafter. 70 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

⋅ Pulmonary edema, which is a grave prognostic sign, may follow eclamptic convulsions. There are at least two sources: - Aspiration pneumonitis may follow inhalation of gastric contents if simultaneous vomiting accompanies convulsions; - Cardiac failure may be the result of a combination of severe hypertension and vigorous intravenous fluid administration. ⋅ Blindness may follow a seizure, or it may arise spontaneously with preeclampsia. There are at least two causes: - varying degrees of retinal detachment - occipital lobe ischemia or infarction Whether due to cerebral or retinal pathology, the prognosis for return of normal vision is good and usually complete within a week ⋅ Rarely, eclampsia is followed by psychosis, and the woman becomes violent. This usually lasts for several days to 2 weeks, but the prognosis for return to normal is good, provided there was no preexisting mental illness.

Other ⋅ Proteinuria ⋅ Oliguria/ anuria ⋅ Hemoglobinuria ⋅ Edema

Recovery As with severe preeclampsia, after delivery; ⋅ an increase in urinary output is usually an early sign of improvement ⋅ Proteinuria and edema ordinarily disappear within a week ⋅ Blood pressure returns to normal within 2 weeks after delivery. The longer hypertension persists postpartum, the more likely that it is the consequence of chronic vascular or renal disease.

Differential Diagnosis Until other causes are excluded, however, all pregnant women with convulsions should be considered to have eclampsia. ⋅ Epilepsy ⋅ Encephalitis ⋅ Meningitis ⋅ Cerebral malaria ⋅ Poisoning ⋅ cerebral tumor ⋅ ruptured cerebral aneurysm ⋅ hysteria

Rx ⋅ Control of convulsions with magnesium sulfate, using an intravenously administered loading dose and periodic intramuscular injections standardized in dose and frequency of administration. ⋅ Intermittent intravenous injections of hydralazine to lower blood pressure whenever the diastolic pressure is 110 mm Hg or higher. ⋅ Avoidance of diuretics and hyperosmotic agents. 71 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

⋅ Limitation of intravenous fluid administration unless fluid loss is excessive. ⋅ Delivery

Prognosis A large percentage of women who develop recurrent hypertension during subsequent pregnancies will develop chronic hypertension Outcome for children of preeclamptic mothers is usually good if they are not born hypoxic or acidotic

PUERPERIUM Period of confinement during and 6 subsequent weeks (42 days) just after birth during which normal pregnancy involution occurs and the reproductive tract returns anatomically to a normal nonpregnant state

Involution of the Genital and Urinary Tracts ⋅ Involution of the Uterine Corpus Immediately after placental expulsion, the fundus of the contracted uterus is slightly below the umbilicus. The uterine body then consists mostly of myometrium covered by serosa and lined by basal decidua (because separation of the placenta and membranes involves the spongy layer) that has striking variations in thickness, an irregular jagged appearance, and is infiltrated with blood, especially at the placental site. The anterior and posterior walls, in close apposition, each measure 4 to 5 cm in thickness. Because its vessels are compressed by the contracted myometrium, the puerperal uterus on section appears ischemic when compared with the reddish- purple hyperemic pregnant organ. After the first 2 days, the uterus begins to shrink Within 2 weeks it has descended into the cavity of the true pelvis It regains its previous nonpregnant size within about 4 weeks. Uterine weight; ⋅ Immediately postpartum - 1000 g ⋅ 1 week later - 500 g ⋅ Second week - 300 g ⋅ Soon thereafter - ≤100 g The total number of muscle cells does not decrease appreciably; instead, the individual cells decrease markedly in size. The involution of the connective tissue framework occurs equally rapidly.

⋅ Endometrial Regeneration Within 2 or 3 days after delivery, the remaining decidua becomes differentiated into two layers; - The superficial layer becomes necrotic, and it is sloughed in the lochia - The basal layer adjacent to the myometrium remains intact and is the source of new endometrium which arises from proliferation of the endometrial glandular remnants and the stroma of the interglandular connective tissue. Endometrial regeneration is rapid, except at the placental site which within a week or so, becomes covered by epithelium, and the entire endometrium is restored during the third week.

⋅ Placental Site Involution Complete extrusion of the placental site takes up to 6 weeks. When this process is defective, late puerperal hemorrhage may ensue. Immediately after delivery, the placental site is about the size of the palm of the hand, but it rapidly decreases thereafter. By the end of the second week, it is 3 to 4 cm in diameter. Within hours of delivery, the placental

72 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira site normally consists of many thrombosed vessels that ultimately undergo the typical organization of a thrombus. Involution is not effected by absorption in situ, but rather by a process of exfoliation which is in great part brought about by the undermining of the implantation site by growth of endometrial tissue. This is affected partly by extension and downgrowth of endometrium from the margins of the placental site and partly by the development of endometrial tissue from the glands and stroma left in the depths of the decidua basalis after placental separation.

⋅ Changes in the Uterine Vessels Successful pregnancy requires a great increase in uterine blood flow; arteries and veins within the uterus, and especially to the placental site, enlarge remarkably, as do transport vessels to and from the uterus. Within the uterus, growth of new vessels also provides for the marked increase in blood flow. After delivery, the caliber of extrauterine vessels decreases. Within the puerperal uterus, blood vessels are obliterated by hyaline changes, and vessels that are smaller replace them.

⋅ Changes in the Cervix and Lower Uterine Segment The outer cervical margin, which corresponds to the external os, is usually lacerated, especially laterally. The cervical opening contracts slowly, and for a few days immediately after labor it readily admits two fingers. By the end of the first week, it has narrowed. As the opening narrows, the cervix thickens, and a canal reforms. At the completion of involution, however, the external os does not resume its pregravid appearance completely. It remains somewhat wider, and typically, bilateral depressions at the site of lacerations (fish- mouth appearance) remain as permanent changes that characterize the parous cervix (parous os) The markedly thinned-out lower uterine segment contracts and retracts but not as forcefully as the body of the uterus. Over the course of a few weeks, the lower segment is converted from a clearly evident structure, The markedly thinned-out lower uterine segment contracts and retracts but not as forcefully as the body of the uterus. Over the course of a few weeks, the lower segment is converted from a clearly evident structure,

⋅ Vagina and Vaginal Outlet Early in the puerperium, the vagina and vaginal outlet form a capacious, smooth-walled passage that gradually diminishes in size but rarely returns to nulliparous dimensions. Rugae reappear by the third week. The hymen is represented by several small tags of tissue, which during cicatrisation (The process of scar formation) are converted into the myrtiform caruncles.

⋅ Peritoneum and Abdominal Wall The broad and round ligaments are much more lax when nonpregnant, and they require considerable time to recover from the stretching and loosening that occurred during pregnancy. As a result of the rupture of elastic fibers in the skin and the prolonged distention caused by the pregnant uterus, the abdominal walls remain soft and flabby. Except for silvery striae, the abdominal wall usually resumes its prepregnancy appearance; but when muscles remain atonic, the abdominal wall also remains lax. There may be a marked separation, or diastasis, of the rectus muscles. In this condition, the abdominal wall in the vicinity of the midline is formed only by peritoneum, attenuated fascia, subcutaneous fat, and skin.

⋅ Urinary Tract Changes The puerperal bladder has an increased capacity and a relative insensitivity to intra-vesical fluid pressure. Overdistention, incomplete emptying, and excessive residual urine are common due to the paralyzing effect of anesthesia, especially conduction analgesia, and the temporarily disturbed bladder neural function.

73 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

Residual urine and bacteriuria in a traumatized bladder, coupled with the dilated renal pelves and ureters, create optimal conditions for development of urinary infection. Dilated ureters and renal pelves return to their prepregnant state from 2 to 8 weeks after delivery. Avoiding prolonged labors and catheterization promptly for bladder distention, prevents bladder hypotonia. Stress incontinence after delivery is associated with; ⋅ length of second-stage labor ⋅ infant head circumference ⋅ birthweight ⋅ episiotomy ⋅ Impaired muscle function in or around the urethra during vaginal delivery Normal micturition resumes by 3 months postpartum

⋅ Changes in Mammary Glands Colostrum is the deep lemon-yellow colored liquid secreted by the breasts by the second postpartum day persisting for about 5 days, with gradual conversion to mature milk during the ensuing 4 weeks. Compared with mature milk, colostrum contains more minerals and protein, much of which is globulin, but less sugar and fat. Immunoglobulin A protects the newborn against enteric pathogens. Also other host resistance factors - complement, macrophages, lymphocytes, lactoferrin, lactoperoxidase, and lysozymes.

Clinical and Physiological Aspects of the Puerperium ⋅ Temperature - Vascular and lymphatic engorgement of the breasts with milk, which is common on the third or fourth day, causes milk fever but it does not last > 24 hours. Any fever in the puerperium implies an infection - most likely somewhere in the genitourinary tract - until proven otherwise. ⋅ Afterpains - In primiparas the puerperal uterus tends to remain tonically contracted. Particularly in multiparas, the uterus often contracts vigorously at intervals, giving rise to afterpains. Afterpains are noticeable particularly when the infant suckles, likely because of oxytocin release. Usually, they decrease in intensity and become mild by the third postpartum day. ⋅ Lochia - Early in the puerperium, sloughing of decidual tissue results in a vaginal discharge of mucus, blood, and tissue debris of variable quantity; this is termed lochia. Microscopically, it consists of erythrocytes, shreds of decidua, epithelial cells, and bacteria. - Lochia rubra/cruenta/sanguinolenta - For the first few days after delivery, blood in the lochia is sufficient to produce thick, dark red vaginal discharge - Lochia serosa - After 3 or 4 days, lochia becomes progressively pale in color, thin and watery - Lochia alba/purulenta - After about the 10th day, because of an admixture of leukocytes and reduced fluid content, lochia assumes a white or yellowish-white color. This is the last discharge no longer tinged with blood. ⋅ Urine - Normal pregnancy is associated with an appreciable increase in extracellular water, and puerperal diuresis between the second and fifth days is a physiological reversal of this process. ⋅ Blood. Rather marked leukocytosis and thrombocytosis occur during and after labor. There is also a relative lymphopenia and an absolute eosinopenia. By 1 week after delivery, the blood volume has returned nearly to its nonpregnant level. Cardiac output remains elevated for at least 48 hours postpartum. Most likely this is due to increased stroke volume from venous return, because the heart rate falls at the same time. By 2 weeks, these changes have returned to normal nonpregnant values.

74 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

Pregnancy-induced changes in blood coagulation factors persist for variable periods during the puerperium. Elevation of plasma fibrinogen and hence the sedimentation rate are maintained at least through the first week. ⋅ Weight Loss - In addition to the loss of about 5 to 6 kg due to uterine evacuation and normal blood loss, there is usually a further decrease of 2 to 3 kg through diuresis - Factors that increased puerperal weight loss included; - Weight gain during pregnancy - Primiparity - Early return to work outside the home - Smoking. Most women approach their self-reported prepregnancy weight 6 months after delivery but still retain an average surplus of 1.4 kg (3 lbs)

Care of the Mother During the Puerperium Attention Immediately After Labor For the first hour after delivery; ⋅ blood pressure and pulse should be taken every 15 minutes ⋅ amount of vaginal bleeding is monitored ⋅ the fundus should be palpated to ensure that it is well contracted ⋅ If relaxation is detected, the uterus should be massaged through the abdominal wall until it remains contracted Because the likelihood of significant hemorrhage is greatest immediately postpartum, even in normal cases, a trained attendant should remain with the mother for at least 1 hour after completion of the third stage of labor.

Early Ambulation Early ambulation has also reduced the frequency of; ⋅ Bladder complications ⋅ Constipation ⋅ Puerperal venous thrombosis ⋅ Pulmonary

Care of the Vulva The patient should be instructed to cleanse the vulva from anterior to posterior (vulva toward anus). An ice bag applied to the perineum may help reduce edema and discomfort during the first several hours after episiotomy repair. Beginning about 24 hours after delivery, moist heat as provided with warm sitz baths can be used to reduce local discomfort.

Bladder Function As a consequence of infused fluid and the sudden withdrawal of the antidiuretic effect of oxytocin, rapid bladder filling is common. Moreover, both bladder sensation and its capability to empty spontaneously may be diminished by anesthesia, especially conduction analgesia, as well as by painful genital lesions, such as extensive episiotomy, lacerations, or hematomas. Prevention of overdistention demands observation after delivery to ensure that the bladder does not overfill and that with each voiding it empties adequately. If the woman has not voided within 4 hours after delivery, it is likely that she cannot. Whenever the bladder becomes overdistended, an indwelling catheter should be left in place until the factors causing the retention have abated. A short course of antimicrobial therapy after catheter removal is indicated to prevent UTIs.

Bowel Function 75 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

Lack of a bowel movement is no more than the expected consequence of an efficient cleansing enema administered before delivery. With both early ambulation and early feeding, constipation has become much less of a problem.

Subsequent Discomfort During the first few days after vaginal delivery, the mother may be uncomfortable due to; ⋅ Afterpains ⋅ Episiotomy ⋅ Lacerations ⋅ ⋅ Postspinal puncture headache Post C/S Mx; ⋅ the amount of bleeding from the vagina must be monitored closely ⋅ the uterine fundus must be identified frequently by palpation to assure that the uterus is remaining firmly contracted ⋅ give an effective analgesic intramuscularly or intravenously ⋅ An anti-emetic is usually given ⋅ The patient is now evaluated at least ½ hourly for 4 hours at the minimum/until conscious, and blood pressure, pulse, urine flow, amount of bleeding, and status of the uterine fundus are checked at these times. Thereafter, for the first 24 hours, these are checked at intervals of 4 hours, along with the temperature. ⋅ Fluid Therapy and Diet - 3 L of fluid should prove adequate during the first 24 hours after surgery ⋅ If urine output falls below 30 mL/hr, however, then the woman should be reevaluated promptly. The cause of the oliguria may range from unrecognized blood loss to an antidiuretic effect from infused oxytocin. ⋅ Bladder and Bowel Function -The bladder catheter most often can be removed by 12 hours after operation. In uncomplicated cases, solid food may be offered within 8 hours of surgery ⋅ In most instances, by at least the day after surgery the woman, with assistance, should get out of bed briefly at least twice. Ambulation can be timed so that a recently administered analgesic will minimize the discomfort. ⋅ Wound Care - The incision is inspected each day, and the skin sutures (or clips) are removed on the fourth day after surgery. By the third postpartum day, bathing by shower is not harmful to the incision. ⋅ Laboratory - The hematocrit is routinely measured the day after surgery. It is checked sooner when there was unusual blood loss or when there is oliguria or other evidence to suggest hypovolemia. ⋅ Breast Care - Breast feeding can be initiated by the day after surgery ⋅ Discharge from the Hospital - Unless there are complications during the puerperium, the mother is generally discharged from the hospital on the third postpartum day ⋅ An initial postpartum evaluation should be performed on the third week after delivery and then 6 weeks ⋅ Antibiotic prophylaxis

Mild Depression The transient depression or postpartum blues which usually remits after 2 to 3 days, although it sometimes persists for up to 10 days most likely is the consequence of; ⋅ the emotional letdown that follows the excitement and fears that most women experience during pregnancy and delivery ⋅ the discomforts of the early puerperium ⋅ fatigue from loss of sleep during labor and postpartum in most hospital settings ⋅ anxiety over her capabilities for caring for her infant after leaving the hospital 76 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

⋅ fears that she has become less attractive Rx - anticipation, recognition, and reassurance.

Abdominal Wall Relaxation Exercises to restore abdominal wall tone may be started any time after vaginal delivery and as soon as abdominal soreness diminishes after cesarean delivery.

Diet The diet of lactating women, compared with that consumed during pregnancy, should be increased in calories and protein.

Immunizations The D-negative woman who is not isoimmunized and whose baby is D-positive is given 300 µg of anti-D immune globulin shortly after delivery Women who are not already immune to rubella are excellent candidates for vaccination before discharge. Unless it is contraindicated, a diphtheria-tetanus toxoid booster injection may be administered at this time.

Time of Discharge Following vaginal delivery, if there are no complications, hospitalization is warranted for ≤ 48 hours. Following an uncomplicated postoperative cesarean delivery, women usually are ready for discharge on the third or fourth day. Before discharge, the woman should receive instructions concerning the anticipated normal physiological changes of the puerperium, including lochia patterns, weight loss due to diuresis, and when to expect milk let down. She also should receive instructions concerning what to do if she becomes febrile, has excessive vaginal bleeding, or develops leg pain, swelling, or tenderness. Any shortness of breath or chest pains should warrant immediate concern.

⋅ Contraception - immediately post partum if needed ⋅ Coitus - There is no definite time after delivery when coitus should be resumed; however, hemorrhage and infection are less likely 14 to 21 days postpartum. Resumption of intercourse this soon may prove to be unpleasant, if not frankly painful, due to incomplete uterine involution and incomplete healing of the episiotomy and lacerations. ⋅ Return of Menstruation and Ovulation - If the woman does not nurse her child, menses usually return within 6 to 8 weeks. In lactating women, the first period may occur as early as the second or as late as the 18th month after delivery. Dating of the endometrium, identified ovulation as early as 42 days after delivery

DIABETES IN PREGNANCY Classification Priscilla White Classification of obstetric diabetes Fasting 2-hour Postprandial Class Onset Plasma Glucose Glucose Therapy A1 Gestational <5.8mmol/L <6.7mmol/L Diet A2 Gestational >5.8mmol/L >6.7mmol/L Insulin Age of Onset Duration Vascular Class (Overt) (Years) Disease Therapy B > 20 < 10 None Insulin C 10-19 10-19 None Insulin 77 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

D <10 > 20 Benign retinopathy Insulin F Any Any Nephropathy* Insulin R Any Any Proliferative retinopathy Insulin H Any Any Coronary artery disease Insulin T Any Any Renal transplant Insulin * When diagnosed during pregnancy: ≥ 500mg/24hrs proteinuria measured before 20 weeks’ gestation.

a) Diabetes diagnosed before pregnancy - Overt Diabetes (Classified according to whether the patient requires exogenous insulin to prevent ketoacidosis) - Type 1 (insulin dependent/Juvenile) Type 1 diabetes is immune mediated and develops in genetically susceptible persons. This predisposition is permissive rather than causal and disease presumably is triggered by a viral infection. There is inflammatory insulitis with lymphocytic infiltration of islets. Subsequently, there is immune stimulation of antibodies against the β-cell. The β-cell membrane becomes susceptible to autoimmune cytotoxic antibodies, which leads to eventual destruction of the cell and resultant diabetes. - Type 2 (noninsulin dependent/maturity onset) Its pathophysiology is abnormal insulin secretion and insulin resistance in target tissues. Most patients are overtly obese, and there is speculation that peripheral insulin resistance induced by obesity leads to β-cell exhaustion.

Some general characteristics of Insulin-Dependent (Type 1) and Non-insulin-Dependent (Type 2) diabetes mellitus Characteristics Type 1 Type 2 (Insulin Dependent) (Noninsulin Dependent) Genetic locus HLA-D Chromosome 6 Chromosome 11 (?) Age at onset Young (<40) Older (>40) Habitus Normal to wasted Obese Plasma insulin Low to absent Normal to high Plasma glucagon High, suppressible High, resistant Acute complication Ketoacidosis Hyperosmolar coma Concordance in monozygotic <50% 100% twins Insulin therapy Responsive Responsive to resistant Sulfonylurea therapy Unresponsive Responsive

Diagnosis of Overt Diabetes During Pregnancy ⋅ Glucosuria - Reducing substances - lactose - are commonly found in the urine of pregnant women and glucosuria in pregnancy most often does not reflect impaired glucose tolerance, but rather augmented glomerular filtration ⋅ Ketoacidosis ⋅ Random plasma glucose level > 11.1mmol/L plus classical signs and symptoms such as; - Polydipsia - Polyuria - Weight loss

Complications

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The likelihood of successful outcomes for the fetus-infant and the overtly diabetic mother are related somewhat to the degree of diabetes control, but more importantly, to the intensity of any underlying maternal cardiovascular or renal disease.

Effects on the Fetus ⋅ Congenital malformations- Increased severe malformations are the consequence of poorly controlled diabetes both preconceptionally as well as early in pregnancy. Women with lower glycosylated hemoglobin values at conception have less anomalous fetuses compared with women with abnormally high values. Fetal anomalies correlated with diabetic vasculopathy with duration of disease > 10 years. Skeletal and CNS Caudal regression syndrome Neural tube defects excluding anencephaly Anencephaly with/without herniation of neural elements Microcephaly Cardiac TGA with/without VSD VSD Coarctation of the aorta with/without VSD or PDA Cardiomegaly Renal anomalies Hydronephrosis Renal agenesis Ureteral duplication Gastrointestinal Duodenal atresia Anorectal atresia Small left colon syndrome Other Single umbilical artery Situs inversus

⋅ "Unexplained" Fetal Demise” - without identifiable cause are a phenomenon unique to pregnancies complicated by overt diabetes. They are declared "unexplained" because no factors such as obvious placental insufficiency, abruption, fetal growth restriction, or oligohydramnios are apparent. These infants are typically large for age and die before labor, usually at about 35 weeks or later ⋅ Spontaneous abortion is associated with poor glycemic control during the first trimester; type 1 diabetic women with initial glycohemoglobin A1 concentrations > 12% or persistent pre-prandial glucose concentrations > 6.7mmol/L were at increased risk for abortion ⋅ Macrosomia - The incidence of macrosomia rises significantly when mean maternal blood glucose concentrations exceed 6.7mmol/L and appears to accrue primarily during the third trimester, although some macrosomic fetuses can be recognized before 24 weeks ⋅ Diabetic pregnancies are often complicated by hydramnios ⋅ Hyperglycemia-mediated chronic aberrations in transport of oxygen and fetal metabolites leads to decreased

fetal pH, and increased pCO2, lactate, and erythropoietin in diabetic pregnancies

Neonatal complications ⋅ Preterm births are associated with advanced diabetes and superimposed preeclampsia associated with nephropathy ⋅ Respiratory distress mostly due to gestational age, rather than overt diabetes ⋅ Hypoglycemia - A rapid decrease in plasma glucose concentration after delivery attributed to hyperplasia of the fetal β-islet cell induced by chronic maternal

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⋅ Hypocalcaemia - < 7 mg/dL - May be due to magnesium-calcium economy unique to diabetic pregnancy, asphyxia, prematurity, and preeclampsia ⋅ Hyperbilirubinemia - Factors implicated - prematurity and polycythemia (also implicated in Renal vein thrombosis) with hemolysis ⋅ Hypertrophic cardiomyopathy that occasionally progresses to congestive heart failure - These infants are typically macrosomic and fetal hyperinsulinemia has been implicated in the pathogenesis.

Effects on the Mother ⋅ Mortality is increased 10-fold, most often as a result of; - Ketoacidosis - Underlying hypertension - Preeclampsia - Pyelonephritis - Coronary artery disease (class H) ⋅ Diabetic Nephropathy (Class F) which is the leading cause of end-stage renal disease (Class T). Subclinical

diabetic nephropathy increases abruptly when hemoglobin A1 values exceed 10%. The natural history of clinically detectable nephropathy in type 1 disease begins with microalbuminuria (30 - 300 mg of albumin per 24 hours), which may occur as early as 5 years after the onset of diabetes. After another 10-15 years, overt proteinuria (> 300 mg of albumin per 24 hours) develops in patients destined to have end-stage renal disease. Hypertension invariably develops during this period, and end-stage renal disease ensues typically 20-25 years after the onset of diabetes ⋅ Preeclampsia - Women in the more advanced classes of overt diabetes increasingly developed preeclampsia and indicated preterm delivery especially women with diabetic nephropathy (class F). Hypertension induced or exacerbated by pregnancy is the major complication that most often forces preterm delivery in diabetic women. Especial risk factors for preeclampsia include any vascular complications, preexisting proteinuria, and/or chronic hypertension but is not related to glucose control. Plasma creatinine values of ≥1.5 mg/dL and protein excretion of ≥3 g /24 hours before 20 weeks' gestation were predictive for preeclampsia ⋅ Diabetic Retinopathy - Background or nonproliferative retinopathy - small microaneurysms form followed by blot hemorrhages when erythrocytes escape from the aneurysms. These areas leak serous fluid that forms hard exudates. - Preproliferative retinopathy (Class D) - With increasingly severe retinopathy, the abnormal vessels of "background" eye disease become occluded, leading to retinal ischemia with infarctions that appear as cotton wool exudates. Laser photocoagulation and good glycemic control during pregnancy minimizes the potential for deleterious effects of pregnancy ⋅ Diabetic Neuropathy - Although uncommon, some pregnant women will demonstrate peripheral symmetrical sensorimotor neuropathy due to diabetes. Another form, diabetic gastropathy, is very troublesome in pregnancy because it causes nausea and vomiting, nutritional problems, and difficulty with glucose control. ⋅ Diabetic ketoacidosis may occur as a result of; - Hyperemesis gravidarum - Use of β-sympathomimetic drugs for tocolysis - Infections - Use of corticosteroids to induce fetal lung maturation ⋅ Infections - Sites of these infections include the genital tract (e.g., antepartum candida or pelvic puerperal infection) and the respiratory tract.

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Management Preconception ⋅ Particular emphasis should be placed on normalizing blood glucose levels before conception and during early

pregnancy to reduce the risks of major birth defects. Hemoglobin A1 or A1c measurement, which expresses an average of circulating glucose for the past 4 to 6 weeks, is useful to assess early metabolic control. The most significant risk for malformations is with levels >10% ⋅ Folate, 400 µg/day, given periconceptually and during early pregnancy, decreases the risk of neural-tube defects

First Trimester Maternal glycemic control can usually be achieved with multiple daily insulin injections and adjustment of dietary intake. Oral hypoglycemic agents are not used because they may cause fetal hyperinsulinemia and congenital malformations The goals of self-monitored capillary blood glucose control recommended during pregnancy Specimen Blood Glucose (mmol/L) Fasting 3.3-5.0 Premeal 3.3-5.8 Postprandial 1 hr 5.5-6.7 0200-0600 3.3-6.7 Diabetes tends to be unstable in the first trimester, followed by a stable period, and then by an increase in insulin requirement from about 24 weeks (3rd trimester) due to the increased production of pregnancy hormones, which are insulin-antagonists

Second Trimester Maternal serum alpha-fetoprotein concentration at 16 to 20 weeks is used in association with targeted ultrasound at 18 to 20 weeks in an attempt to detect neural-tube defects and other anomalies

Third Trimester A weekly visit to monitor glucose control and to evaluate for preeclampsia is a typical recommendation. Serial ultrasonography at 3 to 4 week intervals is performed to evaluate both excessive and insufficient fetal growth as well as amnionic fluid volume.

Delivery Ideally, delivery of the diabetic woman should be accomplished near term - after 37 completed weeks. Typically the lecithin-sphingomyelin ratio is measured at about 37 weeks and, if ≥2.0, delivery is effected. Indications for cesarean section to avoid traumatic delivery of a large infant at or near term; ⋅ If severe hypertension develops even though the lecithin-sphingomyelin ratio is < 2.0. ⋅ In the overtly diabetic woman within B or C White classification or with vascular disease If preterm labor occurs, tocolytic therapy with β-sympathomimetic drugs is best avoided in women with diabetes. These medications may significantly worsen maternal glucose control, causing ketoacidosis. Caution is advised in the use of corticosteroids to promote lung maturation. It is important to considerably reduce or delete the dose of long-acting insulin given on the day of delivery. Regular insulin should be used to meet most or all of the insulin needs of the mother at this time, because insulin requirements typically drop markedly after delivery. During and after either cesarean section or labor and delivery, the mother should be hydrated adequately intravenously as well as given glucose in sufficient amounts to maintain normoglycemia.

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Infection must be detected quickly and treated promptly.

Contraception ⋅ Diabetes carries a risk of vascular disease, and the estrogens in oral contraceptives statistically increase the risk of thromboembolus, stroke, and myocardial infarction. ⋅ Use of low-dose oral contraceptives should probably be restricted to women without vasculopathy or additional risk factors such as a strong history of ischemic heart disease. ⋅ Progestin-only oral or parenteral contraceptives may be used because of minimal effects on carbohydrate metabolism. ⋅ Intrauterine devices in diabetic women are associated a possible increased risk of pelvic infections b) Diabetes diagnosed during pregnancy - Carbohydrate intolerance of variable severity with onset or first recognition during pregnancy regardless of whether or not insulin is used for treatment Gestational diabetes is maturity-onset/type 2 diabetes unmasked or discovered during pregnancy Importantly, more than half of women with gestational diabetes ultimately develop overt diabetes in the ensuing 20 years.

Carbohydrate Metabolism in pregnancy Normal pregnancy is diabetogenic as characterized by; ⋅ mild fasting hypoglycemia due to ⋅ hyperinsulinemia secondary to β-cell hypertrophy, hyperplasia, and hypersecretion probably mediated by estrogen, progesterone, and human placental lactogen ⋅ postprandial hyperglycemia After an oral glucose meal, to ensure a sustained or maintained postprandial supply of glucose to the fetus, there is; ⋅ prolonged hyperglycemia ⋅ β-cell sensitivity to a glucose challenge is increased but that the α-cell sensitivity to a glucose stimulus is unaltered leading to; - Hyperinsulinemia - Suppression of glucagon Pregnancy-induces a state of peripheral resistance to insulin, which is suggested by; ⋅ increased insulin response to glucose (increased plasma level and duration) ⋅ reduced peripheral uptake of glucose (increased plasma level and duration) ⋅ suppressed glucagon response Accelerated starvation - pregnancy-induced switch in fuels from glucose to lipids; The pregnant woman, changes rapidly from a postprandial state characterized by elevated and sustained glucose levels to a fasting state characterized by decreased plasma glucose and amino acids such as alanine and higher plasma concentrations of free fatty acids, triglycerides, and cholesterol.

Predisposing factors of Gestational Diabetes ⋅ familial history of diabetes (1st degree relative) ⋅ demonstrate persistent glucosuria on at least 2 tests ⋅ age > 30yrs ⋅ a prior macrosomic (> 4.5 Kg), malformed (renal tube defects), or stillborn infant ⋅ obesity - > 85Kg/BMI ≥ 30 ⋅ hypertension 82 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

Detection of Gestational Diabetes Gestational diabetes is typically a disorder of late gestation, hyperglycemia during the first trimester usually means overt diabetes.

Screening All pregnant women should be screened using a Mini-GTT - 50-g oral glucose tolerance test between 24 and 28 weeks without regard to time of day or last meal, and that a plasma value at 1 hour > 7.8mmol/L be used as the cutoff for performing the diagnostic 100-g 3-hour oral glucose tolerance test performed after an overnight fast

Adverse fetal consequences of gestational diabetes ⋅ Macrosomia - Insulin secreted by fetal pancreatic β-cells (fetal hyperinsulinemia) primarily during the second half of gestation resulting from maternal hyperglycemia, is believed to stimulate excessive somatic growth (except for the brain) and adiposity. This may result in birth trauma due to shoulder dystocia. Similarly, hyperinsulinemia in the infant may provoke hypoglycemia within minutes of birth.

⋅ Class A2, has been associated with unexplained ⋅ long-range complications - obesity and diabetes in the offspring

Management The goals of therapy are; - To provide the necessary nutrients for the mother and fetus - To control glucose levels - To prevent starvation ketosis

⋅ Women without persistent fasting hyperglycemia (class A1), are usually treated by diet alone. They are typically seen at 1- to 2-week intervals, and fasting and/or postprandial plasma glucose levels are measured to insure that the glucose thresholds for insulin therapy have not been exceeded. ⋅ Insulin therapy is usually recommended when standard dietary management does not consistently maintain the fasting plasma glucose at < 5.8mmol/L or the 2-hour postprandial plasma glucose at < 6.7mmol/L - Class A2. A total dose of 20 to 30 units given once daily, before breakfast, is commonly used to initiate therapy. The total dose is usually divided into 2/3 intermediate-acting insulin (NPH or Lente) and 1/3 short-acting insulin (regular). ⋅ A liberal exercise program ⋅ A woman diagnosed to have gestational diabetes should undergo a 2-hour 75-g oral glucose tolerance at the first postpartum checkup 6 to 8 weeks after delivery, or shortly after she stops breast feeding. This recommendation is based on the 50% likelihood of women with gestational diabetes developing overt diabetes within 20 years of delivery. If fasting hyperglycemia develops during pregnancy - Class A2 - diabetes is more likely to persist postpartum. Postpartum Evaluation for glucose intolerance in women with gestational diabetes 2-hr 75-g Oral Glucose Tolerance Test Plasma Glucose (mmol/L) Time Impaired Glucose Tested No Diabetes Tolerance Diabetes Fasting < 6.2 < 7.8 ≥ 7.8* ½, 1, 1½ hr All < 11.1 1 value ≥ 11.1 1 value ≥ 11.1 2 hr < 7.8 7.8 - 11.1 ≥ 11.1 *Fasting plasma glucose determination of ≥ 7.8 on 2 occasions establish the diagnosis. 83 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

⋅ Dietary management and specifically, weight reduction in obese women can significantly reduce the risk of subsequent overt diabetes.

ANEMIA IN PREGNANCY Anemia in pregnancy is defined as hemoglobin concentration < 10 g/dL during pregnancy or the puerperium. CDC definition - Anemia in pregnancy is defined as hemoglobin concentration < 11 g/dL in the first and third trimesters, and < 10.5 g/dL in the second trimester. Anemia in nonpregnant women is defined as hemoglobin concentration < 12 g/dL

Pathophysiology The modest fall in hemoglobin levels observed during pregnancy in healthy women not deficient in iron or folate is caused by a relatively greater expansion of plasma volume by 46-55% compared with the increase in hemoglobin mass by 18-25% and red cell volume normally greatest during the second trimester resulting in physiological decrease in hematocrit due to hemodilution. Late in pregnancy, plasma expansion essentially ceases while hemoglobin mass continues to increase. After delivery the hemoglobin level typically fluctuates to a modest degree around the predelivery value for a few days and then rises to the higher nonpregnant level.

Etiology Acquired Hereditary Iron-deficiency anemia Thalassemias Anemia caused by acute blood loss Sickle-cell hemoglobinopathies Anemia of inflammation or malignancy Other hemoglobinopathies Megaloblastic anemia Hereditary hemolytic anemias Acquired hemolytic anemia Aplastic or Hypoplastic anemia

Effects of Anemia on Pregnancy ⋅ Increased risk of with midtrimester anemia ⋅ Women whose hemoglobin concentration exceeded 13.2 g/dL at 13 to 18 weeks had excessive; - Perinatal mortality - Low-birthweight infants - Preterm delivery - Preeclampsia in nulliparas

Iron-deficiency Anemia The total body iron consists mostly of; ⋅ iron in hemoglobin (about 70% of total iron) ⋅ iron stored as ferritin and hemosiderin in reticuloendothelial cells in bone marrow, the spleen, and parenchymal cells of the liver (about 300 mg) ⋅ Small amounts of iron exist in myoglobin, plasma, and various enzymes. In a typical gestation with a single fetus, the maternal need for iron induced by pregnancy averages close to 1000mg which considerably exceeds the iron stores of most women; - 300 mg for the fetus and placenta - 500 mg, if available, for maternal hemoglobin mass expansion - Approximately 200 mg more are shed through the gut, urine, and skin

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With the rather rapid expansion of blood volume during the second trimester, iron lack is often manifested by an appreciable drop in hemoglobin concentration. Although the rate of expansion of blood volume is not so great in the third trimester, the need for iron is still increased because augmentation of maternal hemoglobin mass continues, and considerable iron is now transported to the fetus independent of maternal iron stores.

⋅ Etiology - Nutritional deficiency - Chronic parasitic infestation - Hookworms cause mucosal bleeding and suck blood from he patient (0.05- 0.1ml/worm/day) where as other duodenal worms block iron absorption. Also Entamoeba histolytica - Excessive blood loss with its concomitant loss of hemoglobin iron and exhaustion of iron stores in one pregnancy can be an important cause of iron-deficiency anemia in the next pregnancy

⋅ Clinical Findings The diagnosis of iron deficiency in moderately anemic pregnant women usually is presumptive and based largely on the exclusion of other causes of anemia. S/S The symptoms may be vague and nonspecific; - Pallor - General weakness - Easy fatigability, lethargy, malaise - Dizziness - Low grade fever without obvious cause - Palpitations - Tachycardia - Hemic murmur - Dyspnea on slight exertion - Moderate tachypnea at rest - Anasarca - Flabby tongue - large and sluggish - Tinge of jaundice - Albuminuria - Angular stomatitis, glossitis, and koilonychia may be present in long-standing severe anemia - In the terminal phase, acute pulmonary edema may supervene and cerebral anoxia may cause excitement and loss of consciousness Ix - Hb, Hct and red cell indices - PBF - Stool microscopy for ova and cysts - Sickle-cell tests and Hb electrophoresis - Serum iron concentration or serum ferritin level, or both - LFTs - Hypoproteinemia may be a cause - U/E/C - to r/o underlying nephrosis - CXR - r/o TB

Lab findings - The red cells are microcytic and hypochromic - The reticulocyte count is low - Platelet counts increased 85 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

- White cell counts normal - Transferin saturation < 16% - Serum ferritin concentration < 10 µg/dL - Absence of hemosiderin in the bone marrow - The serum iron-binding capacity is elevated, but by itself this is of little diagnostic value because it also is elevated during normal pregnancy in the absence of iron deficiency.

⋅ Effects on the fetus Severe iron deficiency anemia causes; - Intrauterine growth retardation - Preterm labor - Late abortion (20-28 wks) - Intrapartum asphyxia - IUFD - Neonatal death - Perinatal death - Infantile anemia 2-3 mo postpartum

Differential Diagnosis Anemia due to chronic disease or an inflammatory process (eg, rheumatoid arthritis) may be hypochromic and microcytic. A similar type of anemia in thalassemia trait can be differentiated from iron deficiency anemia by normal serum iron levels, the presence of stainable iron in the marrow, and elevated levels of hemoglobin A2.

⋅ Rx The objectives of treatment are; - Correction of the deficit in hemoglobin mass - Restitution of iron stores Oral Iron Therapy: Ferrous sulfate, 300 mg containing 60 mg of elemental iron of which about 10% is absorbed), should be given 3 times a day equal to about 200 mg of elemental iron; to replenish iron stores, oral therapy should be continued for 3 months or so after the anemia has been corrected. Supplemental folic acid 5mg/d Steroid therapy (Prednisolone 20mg/d) especially in excess hemolysis e.g. Malaria Cardiac failure therapy When the pregnant woman with moderate iron-deficiency anemia is given adequate iron therapy, a hematological response is detected by an elevated reticulocyte count. The rate of increase of hemoglobin concentration or hematocrit is slower than in nonpregnant women as newly formed hemoglobin is added to the characteristically much larger volume Transfusions of red cells or whole blood (500mL/≥ 8hrs) seldom are indicated for the treatment of iron- deficiency anemia unless hypovolemia from blood loss coexists or an emergency operative procedure must be performed on a severely anemic woman.

Labor and puerperium management The 1st 2 wks of labor and puerperium are the greatest risk to the mother and death occurs in the 1st 12hrs postpartum O2 delivery during labor to reduce risk of asphyxia Use of aseptic techniques and prophylactic antibiotics to reduce chances of infection Aim for a short 2nd stage

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Maternal complications ⋅ Angina pectoris ⋅ congestive heart failure ⋅ Death

Prevention During the course of pregnancy and the puerperium; - Ferrous sulfate, 300 mg containing 60 mg/d of elemental iron should be prescribed to prevent anemia -Supplemental folic acid 5mg/d Dietary management Prophylactic malaria treatment and prevention of hookworm infection

Anemia from Acute Blood Loss Both abruptio placentae and placenta previa may be sources of serious blood loss and of anemia before as well as after delivery. Earlier in pregnancy, anemia caused by acute blood loss is common in instances of abortion, ectopic pregnancy, and hydatidiform mole.

Anemia Associated with Chronic Disease Chronic infections, inflammation, and neoplasia cause weakness, weight loss, and pallor May be hypochromic and microcytic During pregnancy, a number of chronic diseases may cause anemia; ⋅ Chronic renal disease - Chronic renal insufficiency is characterized by anemia of variable severity, and usually is due to erythropoietin deficiency. ⋅ Suppuration - Women with severe acute pyelonephritis, but not those with asymptomatic bacteriuria or cystitis ⋅ inflammatory bowel disease ⋅ systemic lupus erythematosus ⋅ granulomatous infections ⋅ malignant neoplasms ⋅ rheumatoid arthritis As expected, anemia is intensified as plasma volume expands out of proportion to red cell mass expansion. At least some cases of so-called refractory anemia of pregnancy are the consequence of one of these diseases which has gone unrecognized.

Megaloblastic Anemia Megaloblastic anemias are a family of hematological disorders whose characteristic blood and bone marrow abnormalities are caused by impaired DNA synthesis. Megaloblastic anemia beginning during pregnancy almost always results from folic acid deficiency. Women with megaloblastic anemia may have developed troublesome nausea, vomiting, and anorexia during pregnancy. In some instances, excessive ethanol ingestion is either the cause or contributes to its development. In normal nonpregnant women, the daily folic acid requirement is 50 to 100 µg/day. During pregnancy, requirements for folic acid are increased to 400 µg/day. The fetus and placenta extract folate from maternal circulation so effectively that the fetus is not anemic even when the mother is severely anemic from folate deficiency.

Etiology

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Increased requirements in; ⋅ multifetal pregnancy ⋅ hemolytic anemia ⋅ Crohn disease ⋅ Alcoholism ⋅ some inflammatory skin disorders

Lab findings ⋅ hypersegmentation of neutrophils ⋅ macrocytic erythrocytes ⋅ nucleated erythrocyte ⋅ bone marrow discloses megaloblastic erythropoiesis ⋅ thrombocytopenia ⋅ leucopenia

Treatment The treatment of pregnancy-induced megaloblastic anemia should include folic acid, a nutritious diet, and iron. 1 mg of folic acid OD By 4 to 7 days after beginning treatment, the reticulocyte count is increased appreciably, and leucopenia and thrombocytopenia are corrected promptly. Severe megaloblastic anemia during pregnancy typically is accompanied by an appreciably smaller blood volume than that of a normal pregnancy, but soon after folic acid therapy has been started, the blood volume usually increases considerably. Therefore, even though hemoglobin is being rapidly added to the circulation, the hemoglobin concentration does not reflect precisely the total amount of additional hemoglobin because of the simultaneous expansion of blood volume.

Prevention CDC recommends that all childbearing-age women consume at least 0.4 mg of folic acid daily.

MALARIA IN PREGNANCY Since its endemicity determines the level of immunity to it in a community, pregnant women with malaria can be divided into; ⋅ Immune - native to endemic areas ⋅ Nonimmune/Highly susceptible - with no immunity (Highland malaria - P. falciparum malaria in non- immune people) Malaria in a community may be divided into; ⋅ Stable - These are areas with constant repeated infections (holoendemic areas) and the population has a high degree of immunity and epidemics have been known to occur e.g. Coast, Nyanza, and parts of Eastern ⋅ Unstable - Regions with intermittent transmission, community immunity is poorly developed and dramatic epidemics, severe attacks of cerebral malaria, black water fever and pulmonary edema can occur

Influence of pregnancy on the course of malaria Acquired immunity to malaria is a temporary phenomenon and is liable to breakdown/decline under conditions of stress e.g. pregnancy, after surgical operations due to withdrawing of protein from the immune system (immunoglobulins) in the face of increased protein requirement with insufficient dietary intake thus the ability to limit parasitemia is reduced so that both parasite rates and densities are higher and dormant exoerythrocytic infections (hypnozoites) may relapse 88 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

Effects on Pregnancy ⋅ Pregnancy enhances the severity of falciparum malaria, especially in nonimmune nulliparous women ⋅ Increased fetal loss may be related to placental and fetal infection. Parasites have an affinity for decidual vessels and may involve the placenta extensively which is a good reservoir for the parasites. The placenta acts like a spleen in malaria with intervillous spaces packed with macrophages and parasites (varying numbers apparently from the blood stream). This is characteristic of P. falciparum and is seen in the second half of pregnancy especially in the 1st pregnancy and can be inhibited by chemoprophylaxis during pregnancy. Cellular reaction in placenta interferes with maternal blood circulation and fetal growth is impaired leading to LBW babies. Placental parasitemia may lead to hemorrhage and rupture ⋅ Increased frequency and severity of maternal attacks ⋅ Anemia - secondary to hemolysis and destruction of parasitized and non-parasitized RBCs (the latter process is autoimmune mediated) ⋅ For the non-immune patient, the anemia is rapidly progressive and very severe leading to maternal and fetal mortality ⋅ Febrile attacks are more common in the last as compared to the first trimester

Effects on Labor ⋅ (Premature) labor may be precipitated by an acute attack ⋅ In severe anemia, the onset of labor is of grave significance due to likelihood of CCF ⋅ Severe infections may acutely precipitate labor; parenteral treatment and shortening of second stage may be required ⋅ Avoid PPH by massaging the uterus, covering tears and giving ergometrin ⋅ Latent infections may flare up due to stress of labor

Effects on Puerperium ⋅ Malaria is an occasional cause of puerperal pyrexia and it may precipitate labor ⋅ Can lead to sepsis ⋅ Prophylactic antimalarials should be continued until 6 wks to prevent relapses

Effects on the fetus ⋅ Abortion in the 1st trimester due to pyrexia and in the 2nd trimester due to anemia ⋅ Still births due to intrapartum asphyxia, severe anemia and placental parasitemia leading to cessation of cortisol production triggering labor ⋅ Neonatal death due to intrapartum asphyxia due to severe anemia, placental parasitemia; prematurity, congenital anomalies ⋅ Preterms secondary to pyrexia inducing labor ⋅ SGA and Low birth weight due to the cellular reaction in placenta secondary to parasitemia interfering with maternal blood circulation and fetal growth ⋅ IUFD due to - uterine irritation and tachycardia by pyrexia, severe anemia, placental parasitemia, rarely by transplacental infection especially in non-immune women ⋅ Fetal anoxia - IUGR, IUFD ⋅ Ig G readily crosses the placental barrier and the degree of immunity possessed by the baby at birth is relative to that of the mum. Congenital malaria is likely only when the level of passive immunity in the fetus is low. As a result, congenital infections are extremely rare in indigenous populations of endemic areas but not in immigrants from non-endemic areas (or areas of unstable malaria). If immunity is increased, parasites crossing the placenta (? Through placental damage) will be speedily destroyed and clinical evidence of 89 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

malaria will not appear. Parasites multiply rapidly with reduced immunity producing clinical s/s in the 1st days of life and may be fatal

S/S Symptoms are less severe in immune patients. ⋅ Spleno±hepatomegally in a young primigravida (not common in adults in holoendemic areas) ⋅ Fever - activates the uterus causing premature labor and abortions below 16 wks ⋅ flu-like symptoms including chills, headaches, myalgia, and malaise ⋅ Anemia ⋅ Jaundice

DDx ⋅ Eclampsia - convulsions, coma, hyperpyrexia and albuminuria (secondary to nephritis) - differentiated by HBP and massive albuminuria. Coma in the absence of fits is more likely to be cerebral malaria as compared to repeated epileptiform convulsions with coma in eclampsia. Hyperpyrexia is present but not invariable in cerebral malaria but pyrexia, coma and LBP may be in terminal eclampsia ⋅ Meningitis - meningism, hyperpyrexia, stupor/coma - Differentiated by a LP

Rx Once anemia is established between 20-28 wks, antimalarials alone will not correct it, but folate supplementation is necessary for hemopoiesis Antimalarials; ⋅ Fansidar - Mild/Moderate anemia and > 1st trimester ⋅ Amodiaquine - Mild/Moderate anemia, all trimesters ⋅ Artemisinins - Moderate/Severe anemia, all trimesters ⋅ Quinine - Severe (including cerebral) ⋅ Chloroquine - Resistant Hemolysis remits spontaneously especially after treatment but occasionally continues and may require transfusion and steroid treatment Hemolytic anemia is likely to remit in subsequent pregnancies but can be prevented effectively with chemoprophylaxis from the 1st trimester

Complications ⋅ Kidney failure ⋅ Coma ⋅ Death

Prophylaxis Antimalarial prophylaxis from 1st trimester to 6 wks postpartum

CARDIAC DISEASE IN PREGNANCY Heart disease complicates about 1% of pregnancies - 0.66% in KNH of which 95% are due to Rheumatic heart disease, 90% of which are due to mitral stenosis. Maternal mortality from cardiac disease - 5 per 100,000 live births - KNH - 3,200 per 100,000 live births

Pathophysiology

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⋅ Rheumatic heart disease (95%; Mitral stenosis, Mitral regurgitation, Aortic stenosis, Aortic regurgitation, Pulmonary valve and Tricuspid valve - the latter not usually a solitary lesion) ⋅ Congenital heart disease ⋅ Hypertensive heart disease (>35 yr olds) ⋅ Cor Pulmonale - following COAD e.g. severe asthma leading to pulmonary hypertension ⋅ Coronary cardiac disease (IHD) ⋅ Syphilitic cardiac disease - rare though used to cause valve prolapse and dilatation ⋅ Thyroid cardiac disease ⋅ Kyphoscoliotic cardiac disease ⋅ Idiopathic cardiomyopathy ⋅ Constrictive pericarditis ⋅ Heart block ⋅ Isolated myocarditis

Physiological Considerations Significant hemodynamic alterations are apparent early in pregnancy and maximized by midpregnancy. Cardiac output is increased by as much as 30-50% due to augmented stroke volume that apparently results from decreased vascular resistance and is accompanied by diminished blood pressure. Later in pregnancy, there is also an increased resting pulse (10-15 beats), and stroke volume is even more increased, presumably related to increased diastolic filling from the augmented blood volume. Maintenance of normal left-ventricular filling pressures comes about as the result of ventricular dilatation.

Diagnosis of Heart Disease Symptoms ⋅ Severe or progressive dyspnea secondary to reduced perfusion to the brain and pulmonary edema ⋅ Progressive orthopnea ⋅ Paroxysmal nocturnal dyspnea ⋅ Tachypnea ⋅ Hemoptysis secondary to pulmonary edema ⋅ Syncope with exertion ⋅ Chest pain related to effort or emotion due to reduced perfusion of the myocardium ⋅ Epigastric pain due to tender hepatomegaly stretching it’s capsule ⋅ Nausea, anorexia and vomiting secondary to backflow of mesenteric circulation leading to edema in the mesentery; can also be a S/E of furosemide and digoxin

Clinical findings ⋅ Cyanosis due to inadequate oxygenation ⋅ Clubbing of fingers ⋅ Splinter hemorrhages (petechiae) ⋅ Persistent neck vein distension ⋅ Systolic murmur > grade 3/6 ⋅ Diastolic murmur ⋅ Cardiomegaly ⋅ Sustained arrhythmia due to increased strain on the myocardium - tachycardia that is compensatory or an irregular pulse (fibrillary) ⋅ Persistent split second sound 91 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

⋅ Displaced apex beat ⋅ Criteria for pulmonary hypertension - increased JVP, reduced air entry at the lung bases when the patient is ambulatory and at the base posteriorly when the patient is in bed; basal crepitations ⋅ Left parasternal lift ⋅ Loud P2 ⋅ Pitting pedal edema ⋅ Smooth tender hepatomegaly - fluid in the interstitium enlarges the capsule which is smooth with pain (CCF) ⋅ CCF - The first warning sign is likely to be persistent basilar rales, frequently accompanied by a cough. Sudden diminutions in ability to carry out usual duties, increasing dyspnea on exertion, or attacks of smothering with cough are symptoms of serious heart failure. Clinical findings may include hemoptysis, progressive edema, and tachycardia.

New York Heart Association Clinical Classification ⋅ Class I - Uncompromised: Patients with cardiac disease and no limitation of physical activity. They do not have symptoms of cardiac insufficiency, nor do they experience anginal pain. ⋅ Class II - Slightly compromised: Patients with cardiac disease and slight limitation of physical activity. These women are comfortable at rest, but if ordinary physical activity is undertaken, discomfort results in the form of excessive fatigue, palpitation, dyspnea, or anginal pain. ⋅ Class III - Markedly compromised: Patients with cardiac disease and marked limitation of physical activity. They are comfortable at rest, but less than ordinary activity causes discomfort by excessive fatigue, palpitation, dyspnea, or anginal pain. ⋅ Class IV - Severely compromised: Patients with cardiac disease and inability to perform any physical activity without discomfort. Symptoms of cardiac insufficiency or angina may develop even at rest, and if any physical activity is undertaken, discomfort is increased. Past or present CCF classifies her as Grade IV unless cardiac correction has been done

Management Concepts that affect management; ⋅ the 50% increase in blood volume and cardiac output by the early third trimester ⋅ further fluctuations in volume and cardiac output in the peripartum period ⋅ a decline in systemic vascular resistance, reaching a nadir in the second trimester, and then rising to peak at 20 percent below normal by late pregnancy ⋅ hypercoagulability, of special importance in women requiring anticoagulation in the nonpregnant state with coumarin derivatives

Antenatal Management ⋅ Grade I and II as out patients ⋅ Grade III and IV should be admitted on first visit ⋅ Adequate bed rest - minimum of 10hrs at night and 2hrs at daytime ⋅ Prop up in bed ⋅ Allay anxiety - use anxiolytics prepartum and narcotic analgesics during labor ⋅ Hematinics - Iron salts and folic acid - to increase hemoglobin to reduce strain on the heart ⋅ Manage pregnancy induced hypertension within normal BP ranges ⋅ Screen for and treat infections promptly - avoid contact with persons who have respiratory infections, including the common cold as infection leads to tachycardia ⋅ Cigarette smoking is prohibited, both because of its cardiac effects as well as the propensity to cause upper respiratory infections. 92 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

⋅ Regular/weekly urinalysis to r/o asymptomatic bacteriuria ⋅ Minor heart surgery can be done e.g. closed valvotomy but major heart surgery is contraindicated because of increased risk to the mother ⋅ Post datism is not allowed ⋅ Grade III and IV should get frusemide 40mg OD and digoxin 0.25mg OD ⋅ women with a mechanical prosthetic valve generally take; - Conception - 13wks - heparin 5000IU QID SC - 13-36wks - warfarin 2.5-5mg OD PO - 36wks-delivery - Heparin - 2wks postpartum - Warfarin Warfarin Heparin Crosses the placenta Doesn’t cross the placenta Teratogenic - especially on bone, cartilage and connective tissue leading Non-teratogenic thus administered to congenital malformations thus administered after 1st trimester during the 1st trimester (13wks) (13wks) Administered PO Administered SC which is painful Warfarin has a long half life Given from 13-36wks Administered in the first 13wks and Not used during labor as it also can anticoagulate the fetus causing after 36wks when in labor intracranial hemorrhage and in the event of PPH, it’s antidote takes long to act Antidote - Vitamin K - takes long to act; Fresh frozen plasma can be Antidote - Protamine sulphate IV is used quick acting

Management of labor All cardiac patients must deliver in the hospital setup 1st stage ⋅ The patient is propped up in bed throughout labor to prevent pulmonary edema ⋅ Oxygen is administered by mask PRN ⋅ Allay anxiety with narcotic analgesics - Morphine 15mg IM or Pethidine 100mg IM ⋅ No IV fluids should be given ⋅ Limit the number of pelvic examinations to minimize risk of infection ⋅ Delay the rupture of membranes to minimize risk of infection ⋅ Use broad spectrum IV antibiotics to cover for infection - Augmentin ⋅ Labor is augmented/induced with oxytocin pump and IV frusemide is given to reduce fluid overload ⋅ Prepare a resuscitation tray containing; - Adrenaline (MI) - Aminophylline (pulmonary edema) - Hydrocortisone (MI) - Sodium Bicarbonate (Acidosis) - Calcium gluconate (Acidosis) - Oxytocin - Morphine/Pethidine (anxiety/analgesia) - Naloxone (antinarcotic) - Digoxin (CCF, MI) - Frusemide (CCF)

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2nd Stage ⋅ Patient remains propped up ⋅ The patient should not bear down ⋅ Vacuum extraction is done easily as the babies are usually small ⋅ Cesarean section is avoided due to increased risk to the mother except for obstetric reasons which are however rare in cardiac patients

3rd Stage ⋅ Patient remains propped up ⋅ Frusemide 40mg IV stat irrespective of whether it had been administered before as during uterine contraction after delivery, 1L of blood goes back into circulation and may lead to fluid overload. ⋅ DO NOT give ergometrin as this causes severe uterine contraction which hastens the return of blood into the circulation which may lead to a sudden fluid overload; instead massage the uterine to facilitate it’s gradual contraction ⋅ If massage is insufficient, give IV Oxytocin 40U in 500mL fluid to run slowly (20drops/min)

4th Stage ⋅ Patient is at risk of postpartum hemorrhage, anemia, infection, and thromboembolism ⋅ Keep the patient in the acute room for 24hrs then the postnatal ward till the 10th day post delivery - Monitor vital signs, lung fields, uterus, and lochia and for signs of DVT in the calf muscles and the femoral ⋅ Restart anticoagulants after 48hrs (if patient was on them) ⋅ Continue antibiotics for 1wk ⋅ Continue hematinics for up to 6 weeks

Prognosis The likelihood of a favorable outcome for the mother with heart disease depends upon the; ⋅ functional cardiac capacity ⋅ other complications that further increase cardiac load ⋅ quality of medical care provided Due to a high MMR, the mother should limit the family to 1-2 children by use of contraception; ⋅ BTL/Vasectomy ⋅ Progesterone only drugs (Estrogen increases blood volume) ⋅ Barrier methods - high failure rate ⋅ Natural method - high failure rate ⋅ Avoid IUCD due to increased risk of sepsis -

RENAL AND URINARY TRACT DISORDERS Pregnancy often predisposes to the development of urinary tract disorders e.g. ⋅ acute pyelonephritis ⋅ worsening of renal disease and its sequelae, as with lupus nephritis complicated by hypertension

Urinary Tract Changes During Pregnancy (see maternal changes in pregnancy) Changes predisposing to infection; ⋅ Urinary tract dilation of the renal calyces and pelves, as well as the ureters especially on the right side, is secondary to both hormonal and mechanical obstructive factors, the latter creating urinary stasis, and may lead to serious upper urinary infections

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⋅ increased vesicoureteral reflux

Urinary Tract Infections Organisms that cause urinary infections are those from the normal perineal floral; ⋅ 80% - E. Coli ⋅ 20% - Klebsiella, Enterrobacter, Seratia, Proteus.

Predisposing factors* *Urinary stasis and *vesicoureteral reflux predisposes to symptomatic upper urinary infections by Escherichia coli with adhesions or P-fimbriae, which allow bacterial attachment to glycoprotein receptors on uroepithelial cell membranes. In the early puerperium, bladder sensitivity to intravesical fluid tension is often decreased as the consequence of; ⋅ trauma of labor ⋅ analgesia, especially epidural or spinal blockade ⋅ discomfort caused by a large episiotomy, periurethral lacerations, or vaginal wall hematomas Following delivery when the oxytocin is stopped, a diuresis often follows with copious urine production and bladder distension. *Overdistention, coupled with *catheterization to provide relief, commonly leads to urinary infection.

Asymptomatic Bacteriuria Asymptomatic bacteriuria refers to persistent actively multiplying bacteria within the urinary tract excluding the urethral meatus without symptoms. Prevalence of bacteriuria during pregnancy varies from 2-7% The highest incidence has been reported in; ⋅ multiparas with sickle-cell trait ⋅ Diabetic mothers Dx ⋅ Two consecutive clean-voided urine specimens containing >100,000 organisms of a single uropathogen per mL ⋅ Direct microscopy Complications If asymptomatic bacteriuria is not treated, about 25-30% of infected women subsequently develop acute symptomatic infection (Pyelonephritis) during that pregnancy; if treated, 10%

Cystitis 1% of pregnant women S/S ⋅ Dysuria ⋅ Urgency ⋅ Frequency ⋅ Pyuria ⋅ Bacteriuria ⋅ Microscopic hematuria Complications Cystitis is usually uncomplicated; the upper urinary tract may become involved by ascending infection

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Urethritis Frequency, urgency, dysuria, and pyuria accompanied by a "sterile" urine culture may be the consequence of urethritis caused by Chlamydia trachomatis, a common pathogen of the genitourinary tract. Mucopurulent cervicitis usually coexists. Erythromycin therapy usually is effective

Acute Pyelonephritis Symptomatic infection involving the renal calyces, pelvis, and parenchyma 1-2% of pregnant women Pyelonephritis is more common after midpregnancy. ⋅ >½ - unilateral and right-sided ⋅ ¼ bilateral In most women, renal parenchymal infection is caused by bacteria that ascend from the lower tract. Effects on the fetus ⋅ SGA ⋅ Prematurity S/S ⋅ Thermoregulatory instability - High spiking fevers - Hypothermia ⋅ Transient renal dysfunction - Elevated serum creatinine - Decreased creatinine clearance ⋅ Hematological dysfunction - Anemia - Hemolysis induced by endotoxins - Bone marrow suppression with reduced RBC production - Thrombocytopenia with increased FDPs ⋅ Pulmonary dysfunction - ARDS ⋅ Others - Aching pain in one or both lumbar regions - Tenderness usually can be elicited by percussion in one or both costovertebral angles - Anorexia, nausea, and vomiting - Urinary sediment frequently contains many leukocytes, frequently in clumps, and numerous bacteria Dx ⋅ Significant bacteriuria ⋅ Pyuria ⋅ RBC casts in urine ⋅ Microscopy - 1-2 bacteria per HPF ⋅ >20 bacteria in sediment of centrifuged specimen of bladder catheter ⋅ MSSU - m/c/s ⋅ IVU ⋅ Pelvic-Abdominal u/s DDx ⋅ Labor ⋅ Chorioamnionitis ⋅ Appendicitis ⋅ placental abruption 96 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

⋅ infarcted myoma ⋅ in the puerperium - metritis with pelvic cellulitis Mx ⋅ Hospitalization ⋅ Urine and blood m/c/s ⋅ FBC + ESR ⋅ U/E/C ⋅ Monitor vital signs frequently, including urinary output (place indwelling bladder catheter if necessary) ⋅ Intravenous crystalloid to establish urinary output to at least 30mL/hr ⋅ Intravenous antimicrobial therapy - change antimicrobials if; - No improvement in 48-72hrs - After a m/c/s report ⋅ Chest X-ray if there is dyspnea or tachypnea ⋅ Repeat hematology and chemistry studies in 48hrs ⋅ Change to oral antimicrobials when afebrile ⋅ Discharge after afebrile 24hrs, consider antimicrobial therapy for 10-14 days ⋅ Urine culture 1-2 wks after antimicrobial therapy completed ⋅ Renal scan 2wks after to r/o perinephric abscess Complications ⋅ Recurrent asymptomatic bacteriuria ⋅ Recurrent pyelonephritis (10%) ⋅ Acute renal failure

Acute Renal Failure Incidence of acute renal failure associated with pregnancy - 1:2000-5000 Acute renal necrosis causes acute renal failure with oliguria or anuria, uremia, and generally death within 2 to 3 weeks unless dialysis is initiated. Causes of acute renal necrosis; ⋅ Dehydration ⋅ Reduced BP ⋅ Hemoglobinuria ⋅ Nephrotoxic arbotificients Obstetrical causes of acute renal failure; ⋅ Abruptio placentae - with total placental abruption, severe hypovolemia is common from massive concealed hemorrhage. Moreover, chronic hypertension with superimposed preeclampsia is frequent, and these women may have diminished sodium resorption. Intense consumptive coagulopathy commonly triggered by an abruption might impede the intrarenal microcirculation. It is more likely, however, that a consumptive coagulopathy causes even more blood loss from lacerations and surgical incisions resulting in further renal hypoperfusion ⋅ Preeclampsia-eclampsia - 6-10% of pregnant women Factors leading to ARF- Increased vascular reaction - Volume depletion - Coagulopathy - Hemolysis ⋅ Prolonged fetal death ⋅ Septic abortion

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⋅ Hyperemesis gravidarum - Occurs in early pregnancy due to elevated HCG levels (peaks at 10wks) leading to dehydration and metabolic chanced i.e.- Hypokalemic metabolic alkalosis - Alkaline urine - Reduced clearance of urine ⋅ Polyhydramnios ⋅ Acute fatty liver of pregnancy - 1:3000 deliveries especially in Nulliparity in the 3rd trimester or postpartum Factors leading to ARF- Volume depletion - Reduced BP - Coagulopathy Fatality due to- Hepatic failure - DIC Renal biopsy findings- Glomerular basement membrane hypercellularity - Fatty vacuolation of tubular cells - Focal tubular necrosis - Regenerative changes ⋅ Ectopic pregnancy ⋅ Chorioamnionitis ⋅ ⋅ Puerperal sepsis ⋅ HELLP syndrome ⋅ Postpartum ARF ⋅ Idiopathic ⋅ Postpartum hemorrhage

S/S ⋅ Oliguria ⋅ Prerenal azotemia; - Urine to plasma creatinine ratio of > 20 - elevated urine to plasma osmolality ratio of > 1.5 - Most filtered sodium is reabsorbed so that the urinary concentration is typically < 20 mEq/L ⋅ Jaundice ⋅ Anemia ⋅ DIC ⋅ Skin necrosis Ix ⋅ Urinalysis - proteinuria, hematuria, pigmented casts ⋅ Bacteriology Prevention Acute tubular necrosis may often be prevented by the following means: ⋅ Prompt and vigorous replacement of blood in instances of massive hemorrhage, as in placental abruption, placental previa, uterine rupture, and postpartum uterine atony ⋅ Termination of pregnancies complicated by severe preeclampsia and eclampsia with careful blood replacement if loss is excessive ⋅ Close observation for early signs of septic shock, especially in women with pyelonephritis, septic abortion, amnionitis, or sepsis from other pelvic infections ⋅ Avoidance of potent diuretics to treat oliguria before initiating appropriate efforts to assure cardiac output adequate for renal perfusion 98 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

⋅ Avoidance of vasoconstrictors to treat hypotension, unless pathological vasodilation is unequivocally the cause of the hypotension

Obstructive Renal Failure Causes; ⋅ bilateral ureteral compression by a very large pregnant uterus ⋅ Polyhydramnios ⋅ Uterine incarceration O/E ⋅ moderate to severe hydronephrosis ⋅ severe oliguria ⋅ azotemia Rx Ureteral stent placement

Renal Cortical Necrosis Bilateral cortical necrosis complicates between 10-30% of all cases of acute renal failure associated with obstetrical causes and follows the course of acute renal failure with oliguria or anuria, uremia, and generally death within 2 to 3 weeks unless dialysis is initiated. Commonest in multiparous women >30yrs Causes of ARF leading to renal cortical necrosis; ⋅ placental abruption ⋅ preeclampsia-eclampsia ⋅ endotoxin-induced shock

ECTOPIC PREGNANCIES The blastocyst normally implants in the endometrial lining of the uterine cavity. Implantation anywhere else is an ectopic pregnancy. The risk of death from an extrauterine pregnancy is 10 times greater than that for a vaginal delivery and 50 times greater than for an induced abortion

Types; ⋅ Fallopian tubes - 95% ⋅ Abdominal - 1.5% ⋅ Ovarian ⋅ Cervical - 0.05%

Etiology a) Mechanical Factors - prevent or retard passage of the fertilized ovum into the uterine; ⋅ Salpingitis - especially endosalpingitis, which causes agglutination of the arborescent folds of the tubal mucosa with narrowing of the lumen or formation of blind pockets. Reduced ciliation of the tubal mucosa due to infection also may contribute to tubal implantation of the zygote. ⋅ Peritubal adhesions subsequent to postabortal or puerperal infection, appendicitis, or endometriosis may cause kinking of the tube and narrowing of the lumen. ⋅ Developmental abnormalities of the tube, especially diverticula, accessory ostia, and hypoplasia. Such abnormalities are extremely rare but may occur following in utero exposure to diethylstilbestrol ⋅ Previous ectopic pregnancy - The increased risk likely is due to previous salpingitis 99 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

⋅ Previous operations on the tube, either to restore patency or the failure of tubal sterilization ⋅ Multiple previous induced abortions may increase the risk of ectopic pregnancy. The risk is unchanged after one induced abortion; it is doubled after two induced abortions, likely due to small increases in the incidence of salpingitis ⋅ Tumors that distort the tube, such as uterine myomas and adnexal masses. ⋅ Previous cesarean section has been linked to a small increase in ectopic pregnancy risk b) Functional Factors - delay passage of the fertilized ovum into the uterine cavity ⋅ External migration of the ovum - There may be a slightly increased risk of ectopic pregnancy for the woman with one oviduct whenever she ovulates from the contralateral ovary ⋅ Menstrual reflux ⋅ Altered tubal motility may follow changes in serum levels of estrogens and progesterone. A change in the number and affinity of adrenergic receptors in uterine and tubal smooth muscle is likely responsible. Increased incidence of ectopic pregnancies has been reported with use of; - Progestin-only oral contraceptives - Intrauterine devices (with and without progesterone) - Postovulatory high-dose estrogens to prevent pregnancy ("morning after pill,”) - After ovulation induction There is an increased incidence of ectopic pregnancies in women who were exposed in utero to diethylstilbestrol (DES), possibly as a consequence of altered tubal motility. The rate of tubal ectopic pregnancy has also been reported to be significantly increased in women with luteal phase defects ⋅ Cigarette smoking at the time of conception has been shown to increase the incidence of ectopic pregnancy

Epidemiology Ectopic pregnancy remains the 9th leading cause of maternal mortality especially in the first trimester Causes for Increased Rates of Ectopic Pregnancy; ⋅ increased prevalence of sexually transmitted tubal infection ⋅ popularity of contraception that prevents intrauterine but not extrauterine pregnancies ⋅ unsuccessful tubal sterilizations ⋅ induced abortion followed by infection ⋅ assisted reproductive techniques ⋅ previous pelvic surgery including salpingotomy for previous tubal pregnancy and tuboplasty ⋅ exposure to DES in utero ⋅ better and earlier diagnostic techniques Causes of death from ectopic pregnancies; ⋅ Massive hemorrhage was often the result of abdominal and interstitial tubal pregnancies, which were likely to become symptomatic, later in gestation and consequently have an increased blood supply ⋅ Infection

Anatomical Considerations Primary Sites of tubal implantation; ⋅ Ampullary - most frequent ⋅ Isthmic - second most frequent ⋅ Interstitial - 3% ⋅ Fimbria ⋅ Fimbria ovarica Secondary forms; ⋅ tubo-abdominal 100 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

⋅ tubo-ovarian ⋅ broad ligament

Zygote Implantation The fertilized ovum does not remain on the surface but promptly burrows through the epithelium. As the zygote penetrates the epithelium, it comes to lie in the muscular wall, because the tube lacks a submucosa. At the periphery of the zygote is a capsule of rapidly proliferating trophoblast, which invades and erodes the subjacent muscularis. At the same time, maternal blood vessels are opened, and blood pours into the spaces, lying within the trophoblast or between it and the adjacent tissue. The tube normally does not form an extensive decidua, although decidual cells usually can be recognized. Tubal wall in contact with the zygote offers only slight resistance to invasion by the trophoblast, which soon burrows through it, opening maternal vessels. The embryo or fetus in an ectopic pregnancy is often absent or stunted.

Uterine Changes Softening of the cervix and isthmus Increase in size The finding of uterine decidua without trophoblast suggests ectopic pregnancy but is not an absolute indication. Arias-Stella reaction - Epithelial cells of the endometrium are enlarged and their nuclei are hypertrophic, hyperchromatic, lobular, and irregularly shaped. There is a loss of polarity, and abnormal nuclei tend to occupy the luminal portion of the cells. Cytoplasm may be vacuolated and foamy, and occasional mitoses are found External bleeding, which is seen commonly in cases of tubal pregnancy, is uterine in origin and associated with degeneration and sloughing of the uterine decidua; hemorrhage is seldom severe. Soon after death of the fetus, the decidua degenerates and is usually shed in small pieces, but occasionally it is cast off intact, as a decidual cast of the uterine cavity.

Clinical and Laboratory Features of Tubal Pregnancy Symptoms and Signs ⋅ Normal menstruation is replaced by amenorrhea with variably delayed slight vaginal bleeding, which usually is referred to as "spotting." This occurs when endocrine support for the endometrium declines and the uterine mucosa bleeds. Bleeding is usually scanty, dark brown, and may be intermittent or continuous. ⋅ Severe sharp, stabbing, or tearing lower abdominal pain. Abdominal palpation reveals tenderness ⋅ Vertigo or syncope - The woman may or may not be hypotensive while lying supine. If she is not hypotensive when supine, she may become so when placed in a sitting position. ⋅ Vaginal examination, especially motion of the cervix, causes exquisite pain; The posterior fornix of the vagina may bulge because of blood in the cul-de-sac, or a tender, boggy mass may be felt to one side of the uterus ⋅ Symptoms of diaphragmatic irritation, characterized by pain in the neck or shoulder especially on inspiration develop in women in whom there is sizable intraperitoneal hemorrhage. This is caused by intraperitoneal blood irritating cervical sensory nerves that supply the inferior surface of the diaphragm. ⋅ Uterine Changes - Because of placental hormones, the uterus grows during the first 3 months of a tubal gestation to nearly the same size as it would with an intrauterine pregnancy. Its consistency, too, is similar as long as the fetus is alive. The uterus may be pushed to one side by an ectopic mass, or if the broad ligament is filled with blood, the uterus may be greatly displaced. ⋅ Blood Pressure and Pulse - blood pressure will fall and pulse rise if bleeding continues and hypovolemia becomes significant ⋅ Hypovolemia and shock

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⋅ Temperature - After acute hemorrhage, the temperature may be normal or even low. Fever is important, therefore, in distinguishing a ruptured tubal pregnancy from acute salpingitis.

Ix Pregnancy Tests - Ectopic pregnancy cannot be diagnosed by a positive pregnancy test alone. The key issue, however, is whether the woman is pregnant. In virtually all cases of ectopic gestation, chorionic gonadotropin will be detected in serum, but usually at markedly reduced concentrations compared with normal pregnancy.

DDx ⋅ Acute or chronic salpingitis - no missed period, and abnormal bleeding is not as common as the spotting characteristic of tubal gestation. Pain and tenderness are more likely to be bilateral ⋅ Threatened or incomplete abortion of an intrauterine pregnancy - hypovolemia is usually in proportion to the extent of vaginal bleeding. Abortion pain generally is less severe, likely to be rhythmic, and located low in the midline of the abdomen, whereas in tubal pregnancy it is unilateral or generalized. ⋅ Rupture of a corpus luteum or follicular cyst with intraperitoneal bleeding ⋅ Torsion of an - In both ovarian cyst torsion and appendicitis, signs and symptoms of pregnancy, including amenorrhea, are usually lacking, and there is rarely a history of abnormal vaginal bleeding. ⋅ Appendicitis - The pain from appendicitis, furthermore, is often localized higher, over McBurney point. ⋅ Gastroenteritis ⋅ Discomfort from an intrauterine device ⋅ Failure of tubal sterilization

Treatment and Prognosis of Tubal Pregnancy a) Surgical Management; ⋅ Salpingostomy - Salpingostomy is used to remove a small pregnancy that is usually less than 2 cm in length and located in the distal one third of the fallopian tube - the incision is left unsutured to heal by secondary intention. ⋅ Salpingotomy - is the preferred surgical method for unruptured tubal pregnancies exceeding 2 cm in length. ⋅ Salpingectomy - used for both ruptured and unruptured ectopic pregnancies. When removing the oviduct, it is advisable to excise a wedge no more than the outer third of the interstitial portion of the tube (so-called cornual resection) in an effort to minimize the rare recurrence of pregnancy in the tubal stump. ⋅ Segmental Resection and Anastomosis - Segmental resection and anastomosis is recommended for an unruptured pregnancy in the isthmic portion of the tube because salpingotomy or salpingostomy would likely cause scarring and subsequent narrowing of this small lumen ⋅ Fimbrial Evacuation - There is a temptation with distally implanted tubal pregnancies to evacuate the conceptual products by "milking" or "suctioning" the ectopic mass from the tubal lumen. This is not recommended, because the practice is associated with an ectopic recurrence rate twice that of salpingotomy b) Medical Management; ⋅ Methotrexate 50mg/m2 ⋅ Serial serum β-hCG determinations as after therapy the hormone usually disappears from plasma between 14 and 21 days.

Complications ⋅ Tubal abortion in ampullary tubal pregnancy - The immediate consequence of hemorrhage with tubal abortion is further disruption of the connection between the placenta and membranes and the tubal wall. If 102 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

placental separation is complete, all of the products of conception may be extruded through the fimbriated end into the peritoneal cavity. Some bleeding usually persists as long as the products of conception remain in the oviduct, and blood slowly trickles from the tubal fimbria into the peritoneal cavity and typically pools in the rectouterine cul-de-sac. If the fimbriated extremity is occluded, the fallopian tube may gradually become distended by blood, forming a . After incomplete tubal abortion, pieces of the placenta or membranes may remain attached to the tubal wall and, after becoming surrounded by fibrin, give rise to a placental polyp. ⋅ Tubal rupture in isthmic pregnancy especially when it ruptures in the first few weeks leading to profuse hemorrhage. Causes of rupture; - Spontaneous - Coitus - Bimanual examination

Prognosis Prognosis for a successful subsequent pregnancy is reduced especially if they are primigravid and over the age of 30

Abdominal Pregnancy Following tubal rupture, the effect upon the pregnancy will vary depending on the extent of injury sustained by the placenta. If the placenta is damaged appreciably, fetal death is inevitable; but if the greater portion of the placenta retains its attachment to the tube, further development is possible. The fetus may then survive for up to 30 wks, giving rise to an abdominal pregnancy.

VESICOVAGINAL FISTULA Abnormal communication between the vagina and the bladder

Incidence 2 million women 2-5/1000 deliveries 3000 new cases annually

Cause ⋅ Prolonged or (obstructed fistula) - 90% ⋅ Surgery - colporrhaphy (Repair of a rupture of the vagina by excision and suturing of the edges of the tear), cesarean section, total abdominal hysterectomy ⋅ Radiation cystitis secondary to radiation treatment for carcinoma of the cervix ⋅ Invasive cancer of the cervix, vagina leading to tumor invasion of the vesicovaginal septum. ⋅ Trauma - gynecologic trauma, pelvic fractures, rape, abortion, FGM ⋅ Infections - schistosomiasis, measles, TB ⋅ Congenital - ectopic ureters or vesicle (defects of the anterior abdominal wall), epispadias ⋅ Primitive obstetric practices - forceps, vacuum with vaginal wall inclusion

Etiogenesis Obstructed labor results from a large baby (CPD) or breech. There is compression of soft tissue between the fetal head and pelvic bones and within 3hrs, tissue necrosis occurs with fistula formation; ⋅ VVF - 80% 103 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

⋅ RVF - 10-15% (combined with VVF)

Communications Bladder - vagina - Bladder - Cervix and vagina - Vesicocervicalvaginal fistula Bladder - Uterus - Vesicouterocervicovaginal fistula Ureter - vagina - Ureterovaginal/Ureteric fistula

S/S ⋅ Constant urinary incontinence is the cardinal symptom. Urine can usually be seen coming through an opening in the vagina.; the vaginal ostium is at or near the vault closure ⋅ Wetness and foul smell of the vagina

Differential Diagnosis It is necessary to differentiate ureterovaginal from vesicovaginal fistula. A communication between the urinary bladder and the vagina can be demonstrated by instilling sterile milk or a dye (methylene blue or indigo carmine) into the bladder via a catheter and watching it come through into the vagina on speculum examination. Phenazopyridine (Pyridium) is given by mouth to color the urine orange. One hour later, 3 cotton pledgets are inserted into the vagina, and methylene blue solution is instilled into the bladder or the patient is given methylene blue tablets by mouth. The patient should then walk around, after which the pledgets are examined. If the proximal cotton ball is wet or stained orange, the fistula is ureterovaginal and if it contains blue fluid, the diagnosis is vesicovaginal fistula. If only the distal pledget is blue, the patient probably has urinary incontinence

Consequences ⋅ Structures at risk; - Anterior - vaginal wall, bladder and urethra - Posterior - vaginal wall, rectum - Laterally - pubococcygenous muscles (may be obliterated leaving bone) ⋅ Heal with stricture formation, stenosis, shortening or atresia due to fibrosis ⋅ Partial loss of the uterus or cervix will lead to amenorrhea and bleeding ⋅ Damage may involve nerves especially perineal with foot drop (uni/bilaterally) ⋅ Burning by urine causes dermatitis with excoriations ⋅ Anemia ⋅ Cachexia

Management a) Fresh Obstetric fistula ⋅ Catheterize with a size 16/18 Foley’s catheter for 2 weeks ⋅ Give plenty of fluids - 6-8L/d to achieve a urine volume of 4L/24hrs ⋅ DO NOT give antibiotics as it is not infective ⋅ Give hematinics ⋅ Increase protein diet to recover from trauma ⋅ Pelvic Examination- Slough - Debride/Excise the fistula edges - Advise regular intravaginal antiseptic cleaning (TDS)

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- Monitor regularly and if fistula forms and the edges are clean, then adduct the edges and keep the catheter for 4-6wks by which time - 20% close spontaneously - 15% close on adduction - 75% develop stress incontinence b) After 3-4yrs ⋅ Assess and prepare for surgery ⋅ IVU occasionally for ureteric fistula ⋅ Spinal anaesthesia - Exagerated lithotomy position with flexion at the knees and thighs slightly abducted ⋅ EUA - ID the fistula, classify and choose technique of repair

Classification of fistulae Kees Weldjik Classification (based on anatomical and physiological guidelines and has implications on the technique of repair and prognosis) I - Not involving the closing mechanism II - Involving the closing mechanism within 5cm of the external urethral meatus IIA - Without (sub) total urethral involvement a) Without circumferential defect b) With circumferential defect IIB - With (sub) total urethral involvement a) Without circumferential defect b) With circumferential defect III - Miscellaneous e.g. ureter and other not within the external urethral meatus

Further classes Small - <2cm Medium - 2-3cm Large - 4-5cm Extensive- >6cm

Repair I - Close fistula meticulously and has to be watertight (use dye and the patient coughs or compress the bladder) IIAa - Closure and something done to achieve continence IIAb - Circumferential repair by end-to-end vesicourethostomy IIBa - Urethral reconstruction with urethral tissue IIBb - Urethral reconstruction with other tissue III - Urethra reimplantation or something else

Post-op ⋅ Catheterize with a size 16/18 Foley’s catheter for 2 weeks and check regularly for blockage and flush it or change it ⋅ Give plenty of fluids - 6-8L/d to achieve a urine volume of 4L/24hrs ⋅ DO NOT give antibiotics as it is not infective ⋅ Continue hematinics ⋅ Pelvic exercises when bladder is not full - especially on day 2 ⋅ Analgesics

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⋅ Day 14 - repeat dye test and if not leaking, remove catheter and allow to continue on fluids and exercise, check for periods and stenosis in the vagina ⋅ Follow up for 6 months then discharge from clinic ⋅ If still leaking at 4 weeks, keep the catheter for 2 more weeks; if still incontinent then repeat surgery

Complications ⋅ Stress incontinence - perform n anterior fascial colpo-suspension ⋅ Urge incontinence - Strict bladder training ⋅ Urethral stricture ⋅ Urethrovesical junction/stricture with overflow - daily gentle dilatation for 2 weeks eventually combined with urethrotomy (Surgical incision of a stricture of the urethra) ⋅ Social rehabilitation ⋅ Regular ANC for future pregnancies

RECTOVAGINAL FISTULAE Causes ⋅ Malignancies of the rectum, cervix, or vagina - usually Class I ⋅ Radiation - usually Class I ⋅ Obstetrical injuries (Isolated RVFs occur as 4th perineal tears)- Usually Class II ⋅ Foreign body trauma - Usually Class III ⋅ Crohn's disease ⋅ Diverticulitis ⋅ Undrained cryptoglandular disease ⋅ Surgical extirpation of anterior rectal tumors

Classification I - Proximal II - Mid vaginal III - Distal - near the vaginal introitus IV - Abnormal e.g. vagina to ileum

S/S ⋅ Passing stool and flatus via vagina ⋅ Varying degrees of incontinence ⋅ An opening in the vagina or rectum may be visualized or palpated on physical examination.

Laboratory and Imaging Studies ⋅ A vaginogram or barium enema may identify the fistula. ⋅ If the fistula is not demonstrated on radiographic or physical examination, a dilute methylene blue enema may be administered with a tampon in the vagina. If a fistula is present, it should be confirmed by the methylene blue staining of the tampon.

Repair ⋅ Pre-op preparation like VVF ⋅ The bowel should be prepared with a low-residue diet (fluid diet for 10 days pre-op), enteric antibiotics, and cleaning enemas and stool softners given (liquid paraffin for 10 days pre-op)

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⋅ Give antibiotics intra-op - Flagyl, Gentamicin, Chloramphenical ⋅ No colostomies are done as most RVFs are amenable to surgery ⋅ Pelvic exercises should be performed for 6 months post-op when rectum is not full ⋅ SVD is allowed with a skilled birth attendant

OVARIAN TUMORS Classification Ovarian tumors may be classified as; ⋅ Functional ⋅ Benign ⋅ Neoplastic ⋅ Potentially malignant

a) Benign Ovarian Cysts Functional/Physiologic ⋅ Follicle cyst - Occasional menstrual irregularities - Occasional anovulatory with persistently proliferative endometrium - Disappears after a 2 month regimen of oral contraceptives ⋅ - Occasional delayed period - Prolonged secretory phase - Intraperitoneal bleeding occasionally ⋅ Theca lutein cyst- Amenorrhea - hCG elevated as a result of trophoblastic proliferation - Hemoperitoneum or torsion of ovary may occur - Surgery to be avoided Proliferative ⋅ Benign cystic teratoma (dermoid cyst) - Vary from a few millimeters to more than 20 cm in diameter, and the external appearance is one of a smooth, glistening, thick-walled, pearly-gray cyst. When opened, they are found to contain a thick sebaceous material, hair and occasionally bone structures and teeth (may be diagnosed by x-ray) The tumors have long pedicles and on abdominal examination are very mobile and therefore can easily undergo torsion but they normally lodge in the vesicouterine pouch on their own. ⋅ Struma ovarii - This is a benign cystic teratoma composed largely of thyroid tissue, which, if functional, may give rise to hyperthyroidism (protruding eyes, increased basal metabolism) ⋅ Serous cystadenomas ⋅ Mucinous cystadenoma Others ⋅ - Circumscribed mass of ectopic endometrial tissue in endometriosis b) Benign Solid tumors ⋅ Fibromathecomas ⋅ Fibroadenomas - A benign neoplasm derived from glandular epithelium (secretory), in which there is a conspicuous stroma of proliferating fibroblasts and connective tissue elements ⋅ Brenner tumors c) Tumors of Surface Epithelium I - Serous tumors 107 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

II - Mucinous tumors III - Endometrioid tumors IV - Mesonephroid (Clear cell) tumors V - Anaplastic tumors

Depending upon the aggressiveness, Classes I-IV are divided into 3 groups; A - Benign tumors - lined by a single layer of well oriented columnar epithelium B - Borderline tumors - or tumors with low malignancy potential have some morphological features of malignancy, apparent detachment of cellular clusters from their site of origin and essential absence of stromal invasion C - Malignant tumors - have anaplastic epithelial component, multilayering, loss of basal polarity and unquestionable stromal invasion

d) Germ Cell Tumors ⋅ Teratomas *Benign (mature, adult) teratoma - Benign cystic teratoma (dermoid cyst) - Benign solid teratoma *Monodermal or specialized teratoma - Struma ovarii ⋅ Dysgerminoma - Very sensitive to chemotherapy

e) Sex Cord Stromal Tumors ⋅ Granulosa-theca cell tumors - Granulosa cell tumor - Thecoma - Granulosa-theca cell tumor- Slow growing and produce estrogens which may be responsible for; # Young girls - precocious puberty # Women in their reproductive years - metropathia hemorrhagica - abnormal, excessive, often continuous uterine bleeding due to persistence and exaggeration of the follicular phase of the menstrual cycle; the endometrium is the seat of glandular hyperplasia with cyst formation # Older women - endometrial hyperplasia, endometrial adenocarcinoma and cystic disease of the breast. - Fibroma - A benign neoplasm derived from fibrous connective tissue; usually leiomyomata and sometimes rhabdomyoma. Associated with Meigs' syndrome/ ovarian ascites-pleural effusion syndrome - This is an acute and relapsing condition associated with benign fibroma of the ovary and pelvic tumors such as thecomas, granulosa cell tumors, Brenner tumors, cystadenomas, adenocarcinomas, and fibromyomas of the uterus. Ascites develops which is related to fluid seepage from the tumor into the peritoneal cavity, with subsequent transfer to the pleural cavity via the diaphragmatic lymphatics leading to right-sided hydrothorax. Treatment is by tumor excision. If there are no associated fibromas then it is referred to as Pseudomeigs’ syndrome ⋅ Sertoli-Leydig cell tumors - Arrhenoblastoma - Produces androgens leading to virilisation f) Potentially malignant ovarian tumors ⋅ Serous cystadenoma 108 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

⋅ Granulosa-theca cell tumors ⋅ Dysgerminomas ⋅ Sertoli-Leydig cell tumors

Predictive factors for malignancy ⋅ Age ⋅ Size of the mass ⋅ Ultrasound configuration ⋅ CA 125 levels - An elevated serum CA 125 (> 35 units) indicates a greater likelihood that an ovarian tumor is malignant. CA 125 may be elevated in premenopausal women with benign disease such as endometriosis. ⋅ Presence of symptoms ⋅ Whether the mass is unilateral or bilateral ⋅ Surgical findings Surgical finding Benign Malignant Surface papillae - ++ Intracystic papillae - ++ Solid areas - ++ Bilaterally - + Adhesions - + Ascites (100ml) - + Necrosis - + Peritoneal implants - + Capsule intact + - Totally cystic + - * - Rare/Uncommon + Common

Essentials of Diagnosis ⋅ Vague gastrointestinal discomfort ⋅ Abdominal distention and symptoms of pressure on surrounding organs are manifestations of a large tumor or of ascites resulting from peritoneal seeding. ⋅ Adnexal mass palpated during pelvic examination (only if tumor is >10cm) ⋅ Pelvic pressure and pain ⋅ Many cases of early-stage cancer are asymptomatic

Investigations ⋅ CA 125 levels ⋅ Abdominopelvic ultrasound ⋅ Abdominopelvic CT scanning ⋅ Because the ovaries are a frequent metastatic site for bowel cancer (Krukenberg's tumor), x-ray studies of the small and large intestine are indicated when ovarian cancer is suspected ⋅ Laparatomy - Midline incision - Cytologic washing from several areas of the abdomen and pelvis - Inspection of the omentum (biopsy) - Visualize all peritoneal surfaces - diaphragm, serosa and mesentery of the bowel ⋅ Chest x-ray will demonstrate pulmonary disease and pleural fluid 109 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

⋅ Culdocentesis (Aspiration of fluid from the cul-de-sac (rectouterine excavation) by puncture of the vaginal vault near the midline between the uterosacral ligaments) or paracentesis with cytologic examination of a small amount of peritoneal fluid (which is present under normal circumstances) may detect very early lesions.

Staging of ovarian cancer recommended by the International Federation of Gynecology and Obstetrics Staging of ovarian carcinoma is based on findings at clinical examination and by surgical exploration. The histological findings are to be considered in the staging, as are the cytologic findings as far as effusions are concerned. I - Growth limited to the ovaries II - Growth involving one or both ovaries, with pelvic extension III - Tumor involving one or both ovaries with peritoneal implants outside the pelvis and/or positive retroperitoneal or inguinal nodes. Superficial liver metastasis. Tumor is limited to the true pelvis but with histologically proved malignant extension to the small bowel or omentum IV - Growth involving one or both ovaries with distant metastases. Pleural effusion containing malignant cells. Parenchymal liver metastases

DDx ⋅ Pedunculated uterine myomas ⋅ ⋅ Tubal tuberculosis ⋅ Diverticulitis ⋅ Tumors of the colon, pelvic kidney, retroperitoneal tumors ⋅ Metastatic disease from distant sites

Treatment ⋅ Cystic enlargements of the ovary suspected to be physiologic (follicle and corpus luteum cysts) require only repeat examinations at intervals of 4-6 weeks to ascertain that they are regressing In a premenopausal woman, an asymptomatic, mobile, unilateral, simple cystic mass less than8-10 cm may be observed for 4-6 weeks. Most will resolve spontaneously. If the mass is larger or unchanged on repeat pelvic examination and transvaginal sonography (TVS), surgical evaluation is required. ⋅ Total abdominal hysterectomy and bilateral salpingo-oophorectomy *(with omentectomy and selective lymphadenopathy) are indicated to prevent the possible development of ovarian cancer in; - Women who are approaching the menopause - Benign uterine disease in women over age 40 - After childbearing function has been completed in younger women with strong family histories - *those who have bilateral disease - *When the disease extends beyond the ovaries into the pelvis or abdomen (stage II or III)

The omentum is removed, as it frequently contains microscopic or macroscopic metastatic disease. If complete removal of all gross tumor is not possible, remove as much as possible in order to reduce the tumor load (<2cm). Radiation therapy or chemotherapy (or both) is given as neoadjuvant or adjuvant therapy. Chemotherapy may take the form of combinations of; ⋅ Platinum compounds - Cisplatin - A/E - Vomiting, nephrotoxic especially with dehydration thus maintain hydration; OR - Carboplatin - Less vomiting ⋅ Paclitaxel (Taxol) - Vomiting (antiemetics)

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Combination therapy is given 3 times pre-op (neoadjuvant therapy) and 3 times post-op (adjuvant therapy); - Prevent resistance - Different mechanisms of action ⋅ Most effective against ovarian cancer ⋅ Should not be toxic ⋅ Give the maximum dose the patient can stand Abdominal radiation is limited to isolated metastases Histologic types respond differently to treatment - Mucinous has poor response compared to serous An antigen, CA 125, detectable in the serum, serves as a tumor marker and as a guide to the effectiveness of therapy. Estrogen replacement should be given to forestall menopausal symptoms, osteoporosis, and atherosclerosis.

Complications of tumors ⋅ Torsion of the pedicle with consequent strangulation may occur, producing abdominal pain of sudden onset, nausea and vomiting, a tender abdominopelvic mass, peritoneal irritation, slight fever, and moderate leukocytosis. ⋅ Obstruction to vaginal delivery ⋅ Rupture of a cyst or a twisted pedicle may produce symptoms of an acute abdominal emergency

GESTATIONAL TROPHOBLASTIC DISEASES Gestational trophoblastic disease refers to a spectrum of pregnancy-related trophoblastic proliferative abnormalities

Classification ⋅ Benign (Hydatidiform mole) - Complete (Classic) mole - Partial mole ⋅ Malignant - Choriocarcinoma - Invasive mole (chorioadenoma destruens) - Placental site trophoblastic tumor

a) Hydatidiform Mole () Hydatidiform moles are characterized histologically by abnormalities of the chorionic villi, consisting of varying degrees of; ⋅ hydropic degeneration and swelling/edema of the villous stroma ⋅ absence of blood vessels in the swollen villi ⋅ proliferation of the trophoblastic epithelium to a varying degree Moles usually occupy the uterine cavity; however, they may occasionally be located in the oviduct and even the ovary.

Classification (Based on the absence or presence of a fetus or embryo and amnion) Feature Complete/True Mole Partial Mole ⋅ Karyotype 46,XX or 46,XY 69,XXX or 69,XXY

⋅ Pathology 111 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

Feature Complete/True Mole Partial Mole - Fetus - + - Amnion, fetal RBCs - +

- Villous edema Diffuse mass Variable, focal - Trophoblastic proliferation Variable, slight to severe Variable, focal, slight to moderate

⋅ Clinical presentation - Diagnosis Molar gestation Missed abortion - Uterine size 50% Large for dates Small for dates - Theca lutein cysts + - - Medical complications + - - Postmolar disease + -

Complete/True Hydatidiform Mole ⋅ Chorionic villi are converted into a mass of clear vesicles ⋅ Absence of fetus and amnion. ⋅ Chromosomal composition - 46,XX, with the chromosomes completely of paternal origin. This phenomenon is referred to as androgenesis. Typically, the ovum has been fertilized by a haploid sperm, which then duplicates its own chromosomes after meiosis, and thus the chromosomes are homozygous. The chromosomes of the ovum are either absent or inactivated. OR - 46,XY, that is, heterozygous due to dispermic fertilization ⋅ 20% risk of trophoblastic tumors developing

Partial Hydatidiform Mole ⋅ Hydatidiform changes are focal and less advanced ⋅ A fetus or at least an amnionic sac is seen ⋅ The karyotype typically is triploid - 69,XXX, 69,XXY, or 69,XYY - with one maternal but usually two paternal haploid complements ⋅ The fetus of a partial mole typically has stigmata of triploidy, which includes multiple congenital malformations and growth restriction, and it is nonviable ⋅ Twin pregnancies consisting of a normal fetus and a complete mole have a relatively high risk of subsequent persistent trophoblastic disease compared with triploid partial moles

Predisposing factors ⋅ Age - high frequency among pregnancies toward the beginning (<20) or end (>40) of the childbearing period ⋅ Previous Mole - Recurrence is seen in about 1-2% the first time and 25% subsequently ⋅ Low protein and folate diets ⋅ Blood group A female with a blood group O male (worse with blood group AB male)

Clinical and diagnostic features of a complete hydatidiform mole ⋅ Continuous or intermittent bloody discharge evident by about 12 weeks, usually not profuse, and often more nearly brown rather than red ⋅ Uterine enlargement out of proportion to the duration of pregnancy in about half of the cases

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⋅ Absence of fetal parts on palpation and of fetal heart sounds even though the uterus may be enlarged to the level of the umbilicus or higher ⋅ Preeclampsia-eclampsia developing before 24 weeks ⋅ Hyperemesis gravidarum ⋅ Spontaneous expulsion around 16 weeks and is rarely delayed beyond 28 weeks of hydatid vesicles, resembling grapes, before the mole is aborted spontaneously or removed by operation ⋅ Thyrotoxicosis - Plasma thyroxine levels in women with molar pregnancy are usually elevated appreciably, but clinically apparent hyperthyroidism is unusual. ⋅ Thecalutein Cysts - multiple thecalutein cysts varying from microscopic size to 10 cm or more in diameter result from overstimulation of lutein elements by large amounts of chorionic gonadotropin secreted by proliferating trophoblast. Persistent trophoblastic disease was more likely in women with thecalutein cysts, especially if bilateral. Very large cysts in particular may undergo torsion, infarction, and hemorrhage. Oophorectomy should not be performed unless extensively infarcted; otherwise the cysts regress after delivery.

Ix ⋅ Characteristic ultrasonic appearance - Snow-storm appearance in the uterus with no fetal parts ⋅ A serum chorionic gonadotropin level higher than expected for the stage of gestation

DDx ⋅ Normal pregnancy ⋅ Uterine myoma with early pregnancy ⋅ Pregnancies with multiple fetuses ⋅ Hydramnios

Treatment Consists of two phases; ⋅ Immediate suction evacuation of the mole - Initial evaluation prior to evacuation or hysterectomy includes at least a cursory search for metastatic disease. A CXR should be done to look for pulmonary lesions. Oxytocin is given at induction of anesthesia or draping to facilitate uterine contraction to prevent excessive hemorrhage Indications when hysterectomy may be preferred to suction curettage; - Women of 40 or over - If the parity of the woman or her age are such that no further pregnancies are desired - Uncontrollable hemorrhage ⋅ Subsequent follow-up for detection of persistent trophoblastic proliferation or malignant change - Prevent pregnancy during the follow-up period - at a minimum, for 1 year. Estrogen-progestin contraceptives have often been used to prevent a subsequent pregnancy and to suppress pituitary luteinizing hormone that cross-reacts with some tests for chorionic gonadotropin. - Measure serum chorionic gonadotropin levels every week till 3 normal levels are achieved - Withhold therapy as long as these serum levels continue to regress. A rise or persistent plateau in the level signifies trophoblastic proliferation that is most likely malignant unless the woman is again pregnant and demands evaluation and usually treatment. - Once the level is normal - that is, once it has reached the lower limit of measurement - then test monthly for 6 months, and then every 2 months for a total of 1 year. - Follow-up may be discontinued and pregnancy allowed after 1 year

Treatment of Persistent Trophoblastic Tumor 113 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

Hysterectomy is indicated if; ⋅ serum chorionic gonadotropin values have plateaued or are rising ⋅ there is no evidence for disease beyond the uterus ⋅ the uterus is not important for future reproduction Chemotherapy is instituted if; ⋅ the uterus is to be preserved ⋅ there is radiographic evidence of lung lesions ⋅ there are vaginal metastases Once gonadotropin activity has decreased to the limit of measurement, therapy can be stopped safely without likelihood of recurrence. Positive tests beyond 14 weeks suggest malignancy

b) Malignant Gestational Trophoblastic Diseases ⋅ Choriocarcinoma - A highly malignant neoplasm derived from placental syncytial trophoblasts and cytotrophoblasts which forms irregular sheets and cords, which are surrounded by irregular "lakes" of blood; villi are not formed; neoplastic cells invade blood vessels. Hemorrhagic metastases develop relatively early in the course of the illness, and are frequently found in the lungs, liver, brain, and vagina and various other pelvic organs; choriocarcinoma may follow any type of pregnancy, especially hydatidiform mole, and occasionally originates in teratoid neoplasms of the ovaries or testes. ⋅ Invasive mole (chorioadenoma destruens) - hydatidiform mole in which there is an unusual degree of invasion of the myometrium or its blood vessels, causing hemorrhage, necrosis, and occasionally rupture of the uterus or embolism of molar tissue to the lungs; there is marked proliferation of the trophoblast, but avascular villi may also be found. ⋅ Placental site trophoblastic tumor - Arises from the placental implantation site following either a normal term pregnancy or abortion. This tumor is characterized histologically by predominantly cytotrophoblastic cells, and immunohistochemical staining reveals many prolactin-producing cells and few gonadotropin- producing ones. Associated with erythrocytosis

Etiology Always develops with or follows some form of pregnancy ⋅ 50% follow a hydatidiform mole ⋅ 25% follow an abortion ⋅ 25% develop after an apparently normal pregnancy

Criteria for diagnosis (any 1) - Actual level of hCG or amount of rise will be determined by individual lab investigations ⋅ A plateau of hCG lasting for 4 measurements over a period of ≥ 3wks ⋅ A rise of hCG of 3 weekly consecutive measurements or longer, over a period of a least ≥ 2wks ⋅ hCG levels remain elevated for > 6 months ⋅ Histological diagnosis

Staging (FIGO) I - Confined to the uterus II - Extends outside the uterus but confined to the genital structures (adnexa, vagina, broad ligament) III - Extends to the lungs with/without genital tract involvement IV - Distant metastases - GIT, spleen, liver, brain

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FIGO Risk Factor Scores Score* 0 1 2 4 Age (yrs) <40 40 >40 Antecedent pregnancy H. mole Abortion Term Intervals (months); ⋅ from index pregnancy <4 4-6 7-12 >12 ⋅ from treatment of abortion/delivery ⋅ from last pregnancy before GTD was diagnosed 3 3 4 4 5 5 Pre-treatment hCG (mIU/mL) <10 10 -10 10 -10 >10 Largest tumor including the uterus 3-4cm 5cm Site of metastases Spleen, Kidney GIT Brain, liver Number of metastases identified including lungs , vagina 0 1-4 5-8 >8 Previous failed chemotherapy 1drug ≥ 2 drugs * ≤ 4 - Low-risk patient (usually stage I disease) 5-7 - Medium risk patient ≥ 8 - High risk patient KNH - ≤ 4 - Low-risk patient (usually stage I disease) - > 4 - High risk patient

Ix Ultrasound MRI Presence of brain metastasis may be inferred if the CSF:Serum hCG is >1:60

Treatment Similar principles as above ⋅ Methotrexate (+ folinic acid on even days) ⋅ Actinomycin D ⋅ Cyclophosphamide ⋅ Etoposide ⋅ Oncovorin (Vincristine) ⋅ P

a) Non-metastatic disease (Stage I) ⋅ M or A

b) Metastatic low risk (Stage II/III) ⋅ M or A ⋅ Combination therapy

b) High risk Combination therapy ⋅ MAC ⋅ EMA/CO ⋅ EMA/EP - Rescue treatment when EMA/CO fails

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INFERTILITY Infertility/ Subfertility - failure to conceive after 1 year of intercourse without contraception; decrease in the ability to conceive Female sterility, the intrinsic inability of the female to conceive, due to inadequacy in structure or function of the genital organs Male sterility - the inability of the male to fertilize the ovum; it may or may not be associated with impotence. Primary infertility - applies to those who have never conceived Secondary infertility - designates those who have conceived at some time in the past Fecundity is the capacity to participate in the production of a child. Fecundability - likelihood of pregnancy per month of exposure - used to express the chances of pregnancy occurring in any interval of time

Causes Male Female Endocrine disorders Ovulatory Factor Hypothalamic dysfunction Central defects Pituitary failure Chronic hyperandrogenic anovulation Hyperprolactinemia Hyperprolactinemia (drug, tumor, empty sella) Exogenous androgens Hypothalamic insufficiency Thyroid dysfunctions Pituitary insufficiency (trauma, tumor, congenital) Adrenal hyperplasia Peripheral defects Anatomical disorders Gonadal dysgenesis Congenital absence of vas deferens Premature ovarian failure Obstruction of vas deferens Ovarian tumor Congenital abnormalities of ejaculatory system Ovarian resistance Abnormal spermatogenesis Metabolic disease Chromosomal abnormalities Thyroid disease Mumps orchitis Liver disease Cryptoorchidism Renal disease Chemical or radiation exposure Obesity Varicocele Androgen excess, adrenal or neoplastic Abnormal motility Pelvic Factor Absent cilia (Kartagener’s syndrome) Infection Varicocele Appendicitis Antibody formation Pelvic inflammatory disease Sexual dysfunction Uterine adhesions (Asherman’s syndrome) Retrograde ejaculation Endometriosis Impotence Structural abnormalities Decreased libido DES exposure Failure of normal fusion of the reproductive tract Myoma Cervical factor Congenital DES exposure Mullerian duct abnormality Acquired Surgical treatment Infection 116 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

Other Causes

⋅ age-related decline in fertility

⋅ choice of prior contraception e.g. use of some intrauterine devices (IUDs)

⋅ having an increased number of sexual partners leads to a greater potential for exposure to sexually transmitted diseases

Dx The goals of the infertility evaluation are;

⋅ to determine the probable cause of infertility

⋅ to provide accurate information regarding prognosis

⋅ to provide counseling and support and education throughout the process of evaluation

⋅ to provide guidance regarding options for treatment

Mx Evaluation of Male Factors

⋅ Semen Analysis - A semen specimen is collected after 2-3 days of abstinence (not more than 7 days), and the specimen should be received in the laboratory within 30-60 minutes of production. Normal semen parameters Liquification 30 minutes Count 20-250 million/mL Motility >50% with forward progression Volume 2-5mL Morphology >50% normal Strict criteria >14% normal Viability >50% live pH 7.2-7.8 WBC <1*106/mL *Spermiogenesis takes about 74 days * Oligospermia - < 5 million sperm per mL

⋅ Mucus Studies - The initial interaction of sperm and female genital tract can be determined by postcoital examination of the cervical mucus (Sims-Huhner test). When mucus is obtained from the cervical canal in the preovulatory phase, it normally exhibits a response to the high estrogen environment. The mucus is thin, watery, and acellular; it dries in a crystalline pattern (ferning), and acts as a facilitative reservoir for the sperm. When mucus is collected 2 hours after intercourse at the appropriate time in the cycle and examined; A satisfactory test results in large numbers of forwardly progressive sperm seen in thin, acellular mucus and indicates a healthy sperm-mucus interaction. When the mucus and timing appear favorable, but the sperm appear immobile, tests for autoantibodies, in the male (Autoimmunity is more likely in men with a history of trauma, infection, or previous surgery) or serum antibodies in the female are appropriate.

Evaluation of Female Factors

⋅ Ovulatory Factors - Follicular phase- The follicular phase can be examined with the assistance of vaginal ultrasound monitoring, so that the development of a normal dominant follicle can be detected by ultrasound around or before the 10th day of the cycle, with subsequent linear growth of about 1-2 mm per day, ultimately achieving a preovulatory size of 18-26 mm prior to rupture. 117 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

- Luteal phase-The luteal phase is characterized by the production of progesterone, and the clinical assessment of the luteal phase relies on determination of the adequacy of progesterone effects. Indirect evidence of progesterone production can be determined by assessing the following biologic effects of progesterone.

⋅ Basal body temperature- Progesterone has a central thermogenic effect; when it is produced in sufficient concentrations, it causes the basal body temperature to become elevated.

⋅ Secretory endometrium-The true adequacy of ovulation and of progesterone production is determined only by the establishment of a successful pregnancy, but the use of an endometrial biopsy near the end of the luteal phase can provide reassurance of an adequate maturational effect on the endometrial lining.

⋅ Premenstrual molimina-Premenstrual molimina are largely due to the cyclic hormonal influences of estrogen followed by progesterone with estrogen. The particular constellation of symptoms that affect each woman is usually fairly constant, so that headaches, bloating, cramping, and emotional lability may be experienced differently, but often repetitively, by different women.

⋅ Mucus changes- Within 48 hours of ovulation, the cervical mucus changes under the influence of progesterone to become thick, tacky, and cellular, with loss of the crystalline fern pattern on drying.

⋅ The Pelvic Factor The pelvic factor includes abnormalities of the uterus, fallopian tubes, ovaries, and adjacent pelvic structures. Factors in the history that are suggestive of a pelvic factor include any history of pelvic infection, such as salpingitis, appendicitis, use of intrauterine devices, endometritis, and septic abortion. Endometriosis is in- included as a pelvic factor in infertility and may be suggested by worsening , dyspareunia, or previous surgical reports. - Hysterosalpingogram - Used to determine and demonstrate the uterine contour, the patency of the tubes, and the ability of the dye to freely spill into the pelvis. The test is usually scheduled for the interval after menstrual bleeding and prior to ovulation - Laparoscopy - Tubal abnormalities such as agglutinated fimbria or filmy adhesions, which restrict motion of the tubes, or peritubal cysts, may suggest tubal disease that would not necessarily be detected on hysterosalpingogram. The diagnosis of endometriosis is usually based on laparoscopic findings.

⋅ The Cervical Factor - A cervical factor may be indicated by a history of abnormal Pap smears, , cryotherapy, conization, or DES exposure in utero.

Treatment

⋅ Artificial insemination - When semen parameters are normal but results from postcoital examinations are repeatedly poor, treatment with intrauterine insemination of washed concentrated sperm has been effective in overcoming an apparent barrier to fertility.

⋅ Induction of ovulation can be accomplished in patients with chronic anovulation and normal FSH and prolactin with the use of clomiphene citrate, Pergonal, or bromocriptine until a normal follicle with apparent ovulation has been consistently achieved - 3-6 cycles with timed intercourse/inseminations should be attempted.

⋅ Endometriosis and the effects of salpingitis are 2 of the most common problems confronting infertile couples - Corrected by; - Salpingoneostomy is the surgical creation of a new ostium in a tube whose fimbrial end is totally occluded, forming a hydrosalpinx or sactosalpinx. Depending on its location on the tube, salpingoneostomy may be terminal, ampullary, or isthmic. - Tubocornual anastomosis for pathologic cornual occlusion of the tubes due to disease process and obstructions due to cornual spasm, mucus plug, or intratubal synechiae - Tubotubal anastomosis - Fimbrioplasty involves reconstruction of existing fimbriae in a partially or totally occluded oviduct. 118 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

⋅ The absence of adequate nurturing mucus at midcycle can be treated either by attempts to improve the mucus or by bypassing the mucus with intrauterine insemination. To improve the amount of mucus, estrogen can be administered during the mid- to late follicular phase of the cycle.

⋅ The ultimate therapy for male factor infertility as shown by unfavorable sperm parameters, a negative sperm penetration assay, or both, is IVF-ET or gamete or zygote intrafallopian transfer (GIFT or ZIFT)

a) In vitro fertilization and embryo transfer (IVF-ET) Involves removing eggs from the ovary, fertilizing them in the laboratory, and replacing them into the patient's uterus Indications

⋅ Severe tubal disease/damage compromising function

⋅ Bilateral salpingectomy

⋅ Antisperm antibodies

⋅ Endometriosis

⋅ Oligospermia

⋅ Unexplained infertility

⋅ When the probability of conception by IVF-ET exceeds that of conception by conventional therapy

Technique

⋅ Superovulation - to stimulate several eggs and to better time egg aspiration; At least 2 or 3 follicles should be developing before proceeding with egg aspiration. Drugs used - Clomiphene citrate, Human menopausal gonadotropins (hMG), human follicle-stimulating hormone (hFSH), Gonadotropin-releasing hormone agonist (GnRH-a)

⋅ Evaluating the maturation and growth of the developing follicles by ultrasound scanning or serum estradiol levels

⋅ hCG is given to mature the oocytes when ultrasonography has determined the presence of an adequate number of preovulatory follicles (17-20 mm). Ovulation ordinarily begins 36 hours after hCG injection.

⋅ transvaginal aspiration of preovulatory follicles using a needle is passed through the posterior vaginal fornix using a vaginal ultrasound probe and directed into the ovary. Aspiration of the is performed approximately 34 hours after the hCG injection or 24 hours after the beginning of the natural LH surge.

⋅ Fertilization With Capacitated Sperm - Freshly ejaculated sperm cannot fertilize an egg; the sperm must be capacitated by a short incubation period in a culture medium. Between 10,000 and 50,000 motile sperm are placed with each mature egg.

⋅ Culture of Fertilized Eggs in the Laboratory for 48-72 hours

⋅ Replacement of Fertilized Egg into the Uterus - usually at the 2-cell to 8-cell stage. The embryos are aspirated into a small catheter, the catheter is passed transcervically into the uterus, and the eggs are injected into the uterine cavity.

b) Gamete Intra-Fallopian Tube Transfer (GIFT) Superovulation is induced as in IVF-ET; an hCG injection is given; and the follicles are aspirated via laparoscopy. Prior to laparoscopy, semen is collected and capacitated. The eggs are identified in the laboratory. Sperm are then mixed with the eggs and drawn up into a catheter. The sperm and eggs can also be separated by an air bubble in the catheter. The eggs and sperm are then transferred to the uterine tubes, permitting natural fertilization and cleavage. GIFT is applicable only in patients who have normal tube function.

BENIGN DISORDERS OF THE UTERINE CORPUS a) ENDOMETRIAL POLYPS 119 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

"Polyp" - spheroidal or cylindric mass of tissue that projects outward or away from the surface of surrounding tissues and may be either pedunculated (attached by a slender stalk) or sessile (relatively broad-based)

Incidence Benign endometrial polyps are common in the endometrial cavity at all ages but particularly at age 29-59; with their greatest incidence after age 50.

Pathology Macroscopic

⋅ Single or multiple smooth, red or brown, ovoid body with a velvety texture ranging from 1 to 2 mm to several centimeters to masses that fill or even distend the uterine cavity and project above the level of the adjacent endometrium.

⋅ Most polyps arise in the fundal region and extend downward. Occasionally, an may project through the external cervical os and may even extend to the vaginal introitus. Microscopic

⋅ The surface of an intact polyp in a functioning uterus usually is covered by a layer of endometrium resembling that of the remainder of the endometrial surface

⋅ Glandlike spaces, of variable size and shape, lined with endometrial epithelium that are seemingly much older, and these apparently do not participate in menstrual shedding

⋅ Large and thick-walled vascular channels

⋅ Dense fibrous tissue core -the stroma Hormone sensitivity Polyps are considered to be estrogen-sensitive; their response to estrogen is similar to that of the surrounding endometrium, and may be associated with other proliferative endometrial lesions (such as hyperplasia and endometrial carcinoma)

Diagnosis

⋅ - Irregular or excessive bleeding during menstruation and between menstrual periods. Premenstrual and postmenstrual bleeding may be because the polyp's dependent tip is the first endometrial area to degenerate and the last to obtain a new epithelial covering and cease bleeding after the menstrual slough.

⋅ Light postmenopausal bleeding often described as "staining" or "spotting" and often accompanied by crampy uterine pain, may result from an infarcting large polyp.

⋅ Post-coital bleeding

⋅ Vaginal discharge

Ix

⋅ Direct visualization and biopsy (hysteroscopy)

⋅ Polyps may be evident on a hysterosalpingogram as irregularities in the outline of the uterine cavity or as filling defects

DDx

⋅ Submucous myomas

⋅ Malignant neoplasms (especially mixed sarcomas)

⋅ Retained fragments of placental tissue (which may grossly assume a polypoid architecture)

Treatment

⋅ D & C 120 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

⋅ Surgical Excision - The stalk may be identified, and, under direct visualization, hysteroscopic instruments used to remove the polyp. With larger polyps it may be necessary to section the tumor to portions that may be removed through the cervix.

⋅ Hysterectomy - Indications; - When areas of carcinoma or sarcoma are discovered - Persistence of abnormal uterine bleeding in a premenopausal patient after removal of an apparently benign polyp (or some portion of it)

Complications

⋅ Polyps may undergo malignant change to endometrial carcinomas and sarcomas. When this occurs, the prognosis is more favorable than for uterine carcinoma or sarcoma in general, providing there is no evidence of spread beyond the polyp on analysis of the hysterectomy specimen.

⋅ Adenocarcinoma may develop within an otherwise benign polyp, usually at some distance from its base or pedicle. With basal involvement, the malignancy is most probably endometrial in origin On the other hand, a benign polyp may exist in an area of endometrial carcinoma.

⋅ A polyp exposed to trauma and vaginal pH may undergo atypical changes with squamous metaplasia and may be difficult to distinguish from malignant changes

Others

⋅ Pedunculated adenomyomas - Polyps that contain interlacing bands of smooth muscle and generally have broad bases and are associated with adenomyosis of the uterus.

⋅ Placental polyps - See above b) LEIOMYOMA OF THE UTERUS (Fibromyoma, Fibroid, Myoma, Leiomyomata) Uterine leiomyomas are benign, uterine neoplasms composed primarily of smooth muscle. Incidence Leiomyomas are present in 20-25% of reproductive-age women Being hormonally responsive they are not detectable before puberty and decrease in size and even disappear following menopause and normally grow only during the reproductive years.

Pathogenesis

⋅ Unbalanced estrogen therapy

⋅ Pregnancy

⋅ Prolonged periods of infertility

⋅ Black race

⋅ Low parity

Pathology a) Macroscopic

⋅ Buff-colored (lighter in color than the myometrium), rounded, usually firm multiple, discrete, and smooth or irregularly lobulated

⋅ They are usually less than 15 cm in size but rarely may reach enormous proportions, weighing more than 45 kg

⋅ The tumor surface projects above the surface of the surrounding musculature revealing the false capsular (pseudocapsule) covering of areolar tissue and compressed myometrium, and is clearly demarcated from the surrounding myometrium and can be easily and cleanly enucleated from the surrounding tissue

b) Microscopic 121 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

⋅ Nonstriated smooth muscle fibres are arranged in interlacing bundles of varying size running in different directions (whorled appearance) intermixed with varying amounts of connective tissue c) Secondary Changes

⋅ Benign degeneration - Atrophic-Signs and symptoms regress or disappear as the tumor size decreases at menopause or after pregnancy. - Hyaline-Mature or "old" leiomyomas are white but contain yellow, soft, and often gelatinous areas of hyaline change. These tumors are usually asymptomatic. - Cystic-Liquefaction follows extreme hyalinization, and physical stress may cause sudden evacuation of fluid contents into the uterus, the peritoneal cavity, or the retroperitoneal space. - Calcific (calcareous)-Subserous leiomyomata are most commonly affected by circulatory deprivation, which causes precipitation of calcium carbonate and phosphate within the tumor. Diagnostic “womb- stone” appearance on x-ray - Septic-Circulatory inadequacy may cause necrosis of the central portion of the tumor followed by infection. Acute pain, tenderness, and fever result. - Carneous (red)-Venous thrombosis and congestion with interstitial hemorrhage are responsible for the color of a leiomyoma undergoing red degeneration. During pregnancy, when carneous degeneration is most common, edema and hypertrophy of the myometrium occur. The physiologic changes in the leiomyoma are not the same as in the myometrium; the resultant anatomic discrepancy impedes the blood supply, resulting in aseptic degeneration and infarction.Potential complications of degeneration in pregnancy include preterm labor and, albeit rarely, initiation of disseminated intravascular coagulation. - Myxomatous (fatty)-This uncommon and asymptomatic degeneration follows hyaline and cystic degeneration.

⋅ Malignant transformation-Malignant transformation (leiomyosarcomas) are reported to develop with a frequency of 0.1-0.5% that of diagnosed leiomyomata.

d) Hormone Sensitivity Contain estrogen receptors in higher concentrations than in the surrounding myometrium but in lower concentrations than in the endometrium.

Classification (Based on anatomic location)

⋅ Submucous leiomyomas lie just beneath the endometrium and tend to compress it as they grow toward the uterine lumen. Their impact on the endometrium and its blood supply most often leads to irregular uterine bleeding. May also develop pedicles and protrude fully into the uterine cavity and occasionally they may even pass through the cervical canal while still attached within the corpus by a long stalk.

⋅ Intramural/interstitial leiomyomas lie within the uterine wall, giving it a variable consistency

⋅ Subserous or subperitoneal leiomyomata may lie just at the serosal surface of the uterus or may bulge outward from the myometrium. - May also become pedunculated and if such a tumor acquires an extrauterine blood supply from omental vessels, its pedicle may atrophy and resorb; the tumor is then said to be parasitic. - Subserous tumors arising laterally may extend between the 2 peritoneal layers of the broad ligament to become intraligamentary leiomyomas. This may lead to compromise of the ureter and/or pelvic blood supply.

Diagnosis

122 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

Most leiomyomata do not produce symptoms, and even very large ones may remain undetected, particularly by the obese patient.

⋅ Abnormal uterine bleeding - Bleeding from a submucous leiomyoma may occur from interruption of the blood supply to the endometrium, distortion and congestion of the surrounding vessels, particularly the veins, or ulceration of the overlying endometrium.

⋅ Menorrhagia (hypermenorrhea) - prolonged, heavy menses

⋅ Metrorrhagia - premenstrual spotting, or prolonged light staining following menses; may be associated with a tumor that has areas of endometrial venous thrombosis and necrosis on its surface, particularly if it is pedunculated and partially extruded through the cervical canal.

⋅ Dysmenorrhea

⋅ Pain-Leiomyomata are rarely painful unless vascular compromise occurs. Thus, pain may result from degeneration associated with vascular occlusion, infection, torsion of a pedunculated tumor, or myometrial contractions to expel a subserous myoma from the uterine cavity. The pain associated with infarction from torsion or red degeneration can be excruciating and produce a clinical picture consistent with acute abdomen.

⋅ Pressure effects- Parasitic tumors may cause intestinal obstruction if they are large or involve omentum or bowel. Cervical tumors may cause serosanguineous vaginal discharge, vaginal bleeding, dyspareunia, and infertility. Large cervical tumors may fill the true pelvis and displace or compress the ureters, bladder, or rectum.

⋅ Infertility- The association of infertility and leiomyomata may signal a pedunculated endometrial tumor; but, infertility secondary to leiomyoma may also be related to abnormal uterine bleeding (or blood flow), abnormal uterine or tubal motility or interference with sperm transport.

⋅ Spontaneous abortion

⋅ Mass: irregular enlargement of the uterus.

O/E

⋅ Bimanual examination of the uterus

⋅ Palpation of the lower abdomen

⋅ Normal uterine contour is distorted by one or more smooth, spherical, firm masses

Ix

⋅ A pelvic ultrasound generally assists in establishing the diagnosis, as well as excluding pregnancy as a cause of the uterine enlargement.

⋅ Anemia is a most common consequence of leiomyomata due to the excessive uterine bleeding and depletion of iron reserves.

⋅ Hysterosalpingography may be useful in detailing an intrauterine leiomyoma in the infertile patient.

⋅ Intravenous urography is indispensable in the workup of any pelvic mass, because it frequently reveals ureteral deviation or compression and identifies urinary anomalies. It is essential at operation to know the anatomic position and number of ureters and kidneys.

⋅ Definitive - endometrial biopsy or fractional dilation and curettage (D&C)

DDx Uterine enlargement simulating leiomyomata may be due to;

⋅ Pregnancy (including subinvolution - Arrest of the normal involution of the uterus following childbirth with the organ remaining abnormally large)

⋅ endometrial cancer

⋅ adenomyosis

⋅ myometrial hypertrophy 123 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

⋅ congenital anomalies DDx for recurrent abnormal uterine bleeding;

⋅ Adenocarcinoma of the endometrium or uterine tube

⋅ uterine sarcomas

⋅ ovarian carcinomas

⋅ Hyperplasia

⋅ Polyps

⋅ irregular shedding

⋅ dysfunctional (nonorganic) bleeding

⋅ endometriosis

⋅ adenomyosis

⋅ exogenous estrogens or steroid hormones

Treatment In most instances, myomas do not require treatment, particularly if there are no symptoms or if the patient is postmenopausal. However, other causes of pelvic masses (see earlier) must be ruled out. The clinical diagnosis of myoma must be unequivocal, and the patient should be examined every 6 months. a) Medical

⋅ Gonadotropin-releasing hormone (GnRH) analogs (Goserelin) - Indications; - Control of bleeding from leiomyomata (except the polypoid submucous, which may actually be worsened) - The unstable or unsuitable surgical candidate - For limiting the growth or to cause a decrease in tumor size sufficient to allow laparoscopically assisted vaginal hysterectomy or vaginal hysterectomy - Certain cases for myomectomy S/E - GnRH analog may be used only temporarily, because they create an artificial menopause thus combine therapy with luteinizing hormone. b) Surgical Indications; - When the mass becomes larger than a pregnant uterus of 12-14 weeks' gestation - Growing cervical myomas > 3-4 cm in diameter should be removed to avoid a more difficult operative procedure in the future - Surgical removal following pregnancy should be deferred as much as 12 weeks following delivery, when uterine vascular supply has returned to preepregnant levels, involution of the uterus has occurred, and regression of the tumor is complete

⋅ Myomectomy- Operative removal of a myoma; Indications; - Symptomatic patient who wishes to preserve fertility - For control of chronic bleeding associated with leiomyomata

⋅ Hysterectomy- Indications; - If vaginal relaxation demands repair of cystocele (Hernia of the bladder usually into the vagina and introitus), rectocele, or . - When numerous large tumors (especially intraligamentary myomas) are found, total abdominal hysterectomy is indicated - Excessive uterine bleeding from leiomyomas is one of the most common indications for hysterectomy If the ovaries are diseased or if their blood supply has been destroyed, oophorectomy is necessary; otherwise, the ovaries should be preserved in young women. c) Radiologically assisted embolization of uterine arteries - Blockage of blood supply to the fibroids leads to shrinkage 124 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

Complications Myomas and Pregnancy

⋅ During the second and third trimesters of pregnancy, myomas may rapidly increase in size and undergo vascular depravation and subsequent degenerative changes. Clinically this most commonly leads to pain and localized tenderness but may also initiate preterm labor

⋅ During labor, leiomyomas may produce uterine inertia (followed by postpartum hemorrhage), fetal malpresentation, or obstruction of the birth canal. Complications in Nonpregnant Women

⋅ Heavy bleeding with anemia

⋅ Ureteral injury or ligation is complication of surgery for leiomyomas, particularly cervical

⋅ Infertility secondary to impingement of the interstitial part of he fallopian tubes

MISCELLANEOUS *Abnormalities of fertilization;

⋅ Triploidy

⋅ Dispermy or fertilization with a diploid spermatozoon leading to the formation of a hydatidiform mole. These embryos are androgenic in origin and posses a diploid set of paternal chromosomes because the female pronucleus either fails to form or is excluded at syngamy

⋅ Non dysjunction (failure of a chromosome pair to separate) occurs during an early cleavage division of a zygote, an embryo with 2 or more cell lines with different chromosomes complements produced. *Feral Skull

⋅ Occipitofrontal (11.5 cm), which follows a line extending from a point just above the root of the nose to the most prominent portion of the occipital bone.

⋅ Biparietal (9.5 cm), the greatest transverse diameter of the head, which extends from one parietal boss to the other.

⋅ Bitemporal (8.0 cm), the greatest distance between the two temporal sutures.

⋅ Occipitomental (12.5 cm), from the chin to the most prominent portion of the occiput.

⋅ Suboccipitobregmatic (9.5 cm), which follows a line drawn from the middle of the large fontanel to the undersurface of the occipital bone just where it joins the neck. The greatest circumference of the head, which corresponds to the plane of the occipitofrontal diameter, averages 34.5 cm; and the smallest circumference, corresponding to the plane of the suboccipitobregmatic diameter, is 32 cm.

? PROM ? premature labor ? Derivatives of the germ layers ? Development of the organs timetable ? Ossification centers ? Placental development

* Cilia are destroyed in PID leading to ectopic pregnancies

* GTIs Tubes- gonococcal, Chlamydia Endometrium - TB, gonococcal, Chlamydia, Ecoli, Mycoplasma hominis

* Physiology of the fetus 125 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

Nutrition - Yolk, interstitial fluid and at 4 wks - Fetal circulation Nervous system - Movements - 10 wks Digestive system - 11 wks - Peristalsis - Meconium - Swallowing Hear - 24 wks Sight - 28 wks Taste - 28 wks

* Signs of pregnancy 1. Pelvic organs-Many changes in the pelvic organs are perceivable to the experienced physician, including the following: a. Chadwick’s sign-Congestion of the pelvic vasculature causes bluish or purplish discoloration of the vagina and cervix. b. Leukorrhea-An increase in vaginal discharge consisting of epithelial cells and cervical mucus is due to hormone stimulation. Cervical mucus that has been spread on a glass slide and allowed to dry no longer forms a fern-like pattern but has a granular appearance. c. Goodell’s sign-Cyanosis and softening of the cervix is due to increased vascularity of the cervical tissue. This change may occur as early as 4 weeks. d. Ladin’s sign-At 6 weeks, the uterus softens in the anterior midline along the uterocervical junction e. Hegar’s sign- With one hand of the examiner on the abdomen and two fingers of the other hand placed in the vagina, the still-firm cervix is felt, with the elastic body of the uterus above the compressible soft isthmus, which is between the two. This occurs by 6-8 weeks. f. McDonald’s sign-The uterus becomes flexible at the uterocervical junction at 7-8 weeks. g. Von Fernwald's sign-An irregular softening of the fundus develops over the site of implantation at 4- 5 weeks. If this occurs in the cornual area (Piskacek's sign), it may be confused with a uterine leiomyoma or abnormal uterine development. By 10 weeks, the uterus becomes symmetric and enlarges to double its nonpregnant size. h. Bones and ligaments of pelvis - relaxation of the joints most pronounced at the pubic symphysis, which may separate to an astonishing degree - problems in walking - unstable, pain - Easy angulation (Anteversion and retroversion)

* Leopold's Maneuvers These maneuvers may be difficult if not impossible to perform and interpret in; - Obese patients - If the placenta is anteriorly implanted ⋅ First Maneuver - After outlining the contour of the uterus and ascertaining how nearly the fundus approaches the xiphoid cartilage, the examiner gently palpates the fundus with the tips of the fingers of both hands in order to define which fetal pole is present in the fundus. The fetal breech gives the sensation of a large, nodular body, whereas the head feels hard and round and is more freely movable and ballottable. ⋅ Second Maneuver - After the determination of the pole of the fetus that lies in the fundus, the palms of the examiner's hands are placed on either side of the abdomen, and gentle but deep pressure is exerted. On one side, a hard, resistant structure is felt, the back; and on the other, numerous small, irregular and mobile parts are felt, the fetal extremities. In pregnant women with thin abdominal walls, the fetal extremities can often be differentiated, but in heavier women, only these irregular nodulations may be felt. In the presence of obesity or considerable amnionic fluid, the back is felt more easily by exerting deep pressure with one hand 126 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

while counter-palpating with the other. By next noting whether the back is directed anteriorly, transversely, or posteriorly, a more accurate picture of the orientation of the fetus is obtained. ⋅ Third Maneuver - Employing the thumb and fingers of one hand (Pawlick’s grip), the examiner grasps the lower portion of the maternal abdomen, just above the symphysis pubis. If the presenting part is not engaged, a movable body will be felt, usually the fetal head. The differentiation between head and breech is made as in the first maneuver. If the presenting part is not engaged, all that remains to be defined is the attitude of the head. If by careful palpation it can be shown that the cephalic prominence is on the same side as the small parts, the head must be flexed, and therefore the vertex is the presenting part. When the cephalic prominence of the fetus is on the same side as the back, the head must be extended. If the presenting part is deeply engaged, however, the findings from this maneuver are simply indicative of the fact that the lower pole of the fetus is fixed in the pelvis; the details are then defined by the last (fourth) maneuver. ⋅ Fourth Maneuver - The examiner faces the mother's feet and, with the tips of the first three fingers of each hand, exerts deep pressure in the direction of the axis of the pelvic inlet. If the head presents, one hand is arrested sooner than the other by a rounded body, the cephalic prominence, while the other hand descends more deeply into the pelvis. In vertex presentations, the prominence is on the same side as the small parts; and in face presentations, on the same side as the back. The ease with which the prominence is felt is indicative of the extent to which descent has occurred. In many instances, when the fetal head has descended into the pelvis, the anterior shoulder of the fetus may be differentiated readily by the third maneuver. In breech presentations, the information obtained from this maneuver is less precise.

* Definitions ⋅ Parity - The condition of having given birth to an infant or infants, alive or dead or completion of gestation beyond 28wks; a is considered as a single parous experience. ⋅ Para - A woman who has given birth to one or more infants. Para followed by a roman numeral or preceded by a Latin prefix (primi-, secundi-, terti-, quadri-, etc.) designates the number of times a pregnancy has culminated in a single or multiple birth. ⋅ Primipara - a woman who has given birth for the first time to a viable fetus ⋅ Nullipara - A woman who has never borne children but has ever conceived but the fetus did not get to viability ⋅ Multipara - A woman who has given birth at least two times to an infant, liveborn or not, weighing 500 g or more, or having an estimated length of gestation of at least 20 weeks. ⋅ Gravida - A pregnant woman. Gravida followed by a roman numeral or preceded by a Latin prefix (primi-, secundi-, etc.) designates the pregnant woman by number of pregnancies; e.g., gravida I, primigravida; a woman in her first pregnancy; gravida II, secundigravida; a woman in her second pregnancy. ⋅ Nulligravida - A woman who has never conceived a child ⋅ Parturient - Relating to or in the process of childbirth ⋅ Puerperal - A woman who has just given birth ⋅ Puerperium - Period from the termination of labor to complete involution of the uterus, usually defined as 42 days.

* Amnionic fluid Amniocentesis is most often performed at 15-18 weeks for prenatal diagnosis, when it is likely that there are sufficient fetal cells to allow successful culture for; ⋅ cytogenetic studies ⋅ enzyme analysis ⋅ DNA analysis Risks of amniocentesis; 127 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

⋅ maternal or fetal trauma - Perforation of the placenta may cause fetomaternal hemorrhage, which may incite or enhance maternal isoimmunization as well as initiate placental hemorrhage ⋅ infection ⋅ abortion or preterm labor Functions; ⋅ It cushions and thereby provides protection of the fetus against physical trauma to the maternal abdomen ⋅ it is a medium in which the fetus can readily move ⋅ serves to maintain an even temperature Quantity - 12 wks - 50ml - 20 wks - 400ml - Term - >1000ml Variations in quantity; Oligohydramnios - presence of an insufficient amount of amniotic fluid (< 300 ml at term) - Congenital abnormalities especially renal - IUGR Polyhydramnios - Excess amount of amniotic fluid (>1500 mL at term) - Esophageal atresia - TEF - Duodenal atresia - Neurotube defects - Multiple gestation - monozygotic twins

* Artificial rupture of membranes (ARM) ⋅ C/I especially in HIV mothers ⋅ Helps in the diagnosis of meconium aspiration ⋅ Previously thought to help prevent amniotic fluid embolism

* The major contributors to perinatal loss are;

⋅ Preterm delivery

⋅ Congenital anomalies

⋅ Birth trauma

* Investigations Recommendations of intervals for routine and indicated tests and procedures during Time (wk) Assessment Initial (as early as possible) Hemoglobin/hematocrit Urinalysis including m/c/s Blood group and D type Antibody screen Syphilis screen Hepatitis B virus screen HIV screen

8-18 Ultrasound Amniocentesis

26-28 Diabetes screening

128 OBSTETRICS AND GYNAECOLOGY NOTES- Wachira

Time (wk) Assessment Repeat hemoglobin/hematocrit

28 Repeat antibody test for unsensitized D-negative patients Prophylactic administration of anti-D immune globulin

32-36 Ultrasound Testing for STIs Repeat hemoglobin/hematocrit

* striae cutis distensae, bands of thin wrinkled skin, initially red but becoming purple and white, which occur commonly on the abdomen, buttocks, and thighs at puberty and/or during and following pregnancy, and result from atrophy of the dermis and overextension of the skin; also associated with ascites and Cushing's syndrome. SYN: atrophoderma striatum, lineae lbicantes, lineae atrophicae, linear atrophy, , striae atrophicae, striate atrophy of skin, traction atrophy, vergeture.

* BISHOP-SCORING SYSTEM USED FOR ASSESMENT OF INDUCIBILITY Factor Score Dilatation (cm) Effacement (%) Station* Cervical Consistency Position of Cervix 0 Closed 0-30 -3 Firm Posterior 1 1-2 40-50 -2 Medium Midposition 2 3-4 60-70 -1, 0 Soft Anterior 3 ≥ 5 ≥ 80 +1, +2 - - * Scoring reflects a -3 to +3 scale

* Types of Hysterectomies

⋅ Abdominal hysterectomy, removal of the uterus through an incision in the abdominal wall.

⋅ Abdominovaginal hysterectomy, a combined vaginal and abdominal surgical approach that allows partial or complete removal of vagina, vulva, rectum, and perineum (abdominoperineal approach), as well as pelvic organs; usually done in cases of advanced pelvic cancer.

⋅ Cesarean/Porro hysterectomy, cesarean section followed by hysterectomy

⋅ Subtotal/Supracervical hysterectomy, removal of the fundus of the uterus, leaving the cervix in situ.

⋅ Vaginal hysterectomy, removal of the uterus through the vagina without incising the wall of the abdomen.

129