Unit oneReview of anatomy and physiology of female

reproductive system

1.1. Anatomy of female reproductive system

1.1.1. Anatomy of female pelvis

A. Bones of female pelvis- pelvis is made up of three type of bones which are four un number these are:

Two innominate bones

One sacrum and

One coccyx

1. Innominate bones- are the widest bones of the pelvis. Each innominate bone is constituted by the fusion of three bones namely the illium, ischium and pubis around a cup like cavity called acetabulem. All the three part of the bone contribute to the acetabulemin the following proportion: two fifth ilium, two fifth ischium and one fifth pubic bone.

The ilium-is the large flared out part of the pelvic bone. When the hand is placed on the hip it rests on the iliac crest which is the upper border of the bone. At the front of iliac crest is a bony prominence known as anterior superior iliac spine. A short distance below it is anterioinferior iliac spine. There are two similar points at the posterior end of the iliac crest namely the posteriosuperior and posteriorinferior iliac spines. The concave anterior surface of the ilium is the called iliac fossa.

The ischium- is the thick lower pare of the innomonate bones. It has a large prominence known as the ischial tubiresity on which the body rests when setting. Behind and a little above the tuboresity is an inward projection of the bone called the ischial spine. During labour the station of the fetal head is estimated in relation to the ischial spines.

The pubis- is the anterior part of the innominate bones. It has a body and two oars like projection, the superior ramus and the inferior ramus. The two pubic bones meet at the symphysis pubis and the two inferior rami forms the pubic arch merging in to the similar ramus in the ischium. The space enclosed by body of pubic bone, rami and ischium is called obturator foramina.

2. Sacrum- is a triangular shaped bone having its base above and its apex below. It is formed by fusion of five sacral vertebras. The upper border of the first sacral vertebra forms a prominence called sacral promontory. At the side the side the sacrum has two wings like processes called ‘ala’ of the sacrum which articulate with innominate bones. The anterior surface of the sacrum is concave and is referred to us the hollow of the sacrum. It has four pairs of opening in which nerves that are emerged from the cauda equine passes through to supply the pelvic viscera called sacral foramina. The posterior surface of the sacrum is roughened to receive attachments of muscle.

3. Coccyx- is formed by the fusion of four vertebrae and it articulate superiorly with tip of sacrum.

B. Joints of the pelvis- there are four joints with in the pelvis that joins the four pelvic bones in to one.

Two sacroiliac joint

One symphisis pubis

One sacro coccygeal joint

The sacroiliac joint-is a joint in which the sacrum is articulated with the innominate bones. It is the strongest joint in the body.

The symphisis pubis- is a cartilaginous joint formed by the junction between the two pubic bones along the mid line.

The sacro-coccygeal joint- is formed where the base of coccyx articulate with the tip of the sacrum. It has a great obstetric importance during delivery. During pregnancy the hormone progesterone relaxes the ligaments and allows greater mobility and increase the available space in the pelvis.

C. Pelvic ligaments- each of the pelvic joints is held together by ligaments for example:

Inter pubic ligament at the symphysis pubis

Sacroiliac ligament at the Sacroiliac joint

Sacrococcygeal ligament at the Sacrococcygeal joint

There are two important ligaments important in obstetrics

Sacrotuberous ligament- runs from the sacrum to the ischial tuberosity and

Sacro spinous ligament-from the sacrum to the ischial spine.

D. Parts of the pelvis-the female pelvis consists of two parts; the false pelvis and the true pelvis.

False pelvis- is the part of the pelvis above the pelvic brim. It is formed by the upper flaired out part of the iliac bones and it does not play any significant role in the process of child birth.

True pelvis- is the true bony birth canal through which the baby must pass during birth. It has a brim, a cavity and an out let.

1. The pelvic brim- id rounded except where the sacral promontory project in to it. The promontory forms its posterior border, the iliac bones its lateral border and the pubic bones its anterior border. The nurse needs to be familiar with the fixed points on the pelvic brim which are known as land marks. Starting from the posterior these are:

Sacral promontory

‘ala’ of the sacrum

Sacro-iliac joint

Iliopestineal line

Iliopectinial eminence

Superior ramus of pubic bone

Upper inner border of the body of pubic bone

Upper inner border of symphysis pubis

Diameters of the brim- there are three type of diameters measured with in the pelvis.

The anterioposterior diameter- is a line from the sacral promontory to the upper border of symphysis pubis. When the line is taken to the upper most point of symphysis pubis it is called the anatomical conjugate and is 12cm. when it is taken to the posterior border of the upper part of sumphysis pubis it is called the obstetric conjugate (true conjugate) and measured to be 11cm. the obstetric conjugate tells us the true available space for the passage of the fetus. The diagonal conjugate is also measured anterio posteriorly from the lower border of the symphsis pubis to the sacral promontory. It may be estimated per vaginum as part of pelvic assessment and should measure 12-13cm.

The transverse diameter-is a line between the points furthest apart on the iliopectineal lines and measures 13cm.

The oblique diameter- is a line from one sacroiliac joint to the iliopectineal eminence on the opposite side of the pelvis and it measures 12cm. There are two oblique diameters each takes its name from the sacroiliac joint it arises that is, the left oblique diameter arises from the left iliac joint.

2. The pelvic cavity- extends from the brim above to the out let below. The anterior wall is formed by the curve of sacrum which is 12cm in length. The cavity is circular in shape and although it is difficult to measure its diameters exactly they are all considered to be 12cm.

3. The pelvic out let – there are two out lets in the pelvis; the anatomical and obstetric out let. The anatomical outlet is formed by the lower border of each bone; lower border of symphysis pubis, the ischial tuberosity, and the tip of the coccyx while the obstetric out let is formed by the lower border of symphysis pubis, the two ischial spines, and the sacro coccygial joint. The obstetrical out let has great obstetric significance because it is the narrow pelvic outlet through which the baby must pass. This out let is a diamond shape and its three diameters are as follows.

The anterioposterior diameter- is a line from the lower border of symphysis pubis to the sacrococcygeal joint. It measures 13cm.

The oblique diameter- is said to be between the obturator foramina and the sacrospinous ligament although there is no fixed point. The measurement is taken to be 12cm.

The transverse diameter- is a line between the two ischial spines and measures 10-11cm. it is the narrowest diameter in the pelvis.

E. Types of pelvis- can be grouped in to four categories according to the shape of the pelvis brim.

The gynacoid pelvis is the ideal pelvis for child bearing. Its main feature are rounded brim, straight side wall, shallow cavity with a broad, well curved sacrum, blunt ischial spine, a wide sciatic notch and pubic arch of 90o. It is found in women of average build and height.

The android pelvis- is so called because it resembles the male pelvis. Its brim is heart shaped. It is found in short and heavy build women who have a tendency to hirsute. This type of pelvis predisposes for OPP (ociputoposterior position) and is least suited for child bearing.

The anthropoid pelvis –has long oval brim in which the AP diameter is longer than the transverse. Women with this type of pelvis tend to be tall with narrow shoulder. Labour does not usually present any difficulty.

The platiploid pelvis- is flat with kidney shaped brim in which the AP diameter is reduced and the transverse one increased. In this type of pelvis the head must engage with the sagital seture in the transverse diameter but descends with the pelvic cavity with out any difficulty.

NB:-keeping all the above measurements in mind the fetal head is the best pelvimeter.

1.1.2. Anatomy of genital organs

A. External genitalia (syn: vulva, pudendum)- is a term used to describe the externally visible pat of female genitalia and is composed of mones pubis, labia majora, lavia mainora, clitoris, vestibule and perineum. This vulva is bounded by mones pubis anteriorly, labua majora laterally, and the perineum posteriorly.

Mons pubis (monis veneris) - is a pad of subcutaneous fatty tissue above the pubic bone. In adults it is covered by pubic hair in an inverted triangle fashion.

Labia majors- are also called the greater lips of vagina. They are an elevation of skin and subcutaneous tissue arising from monis pubis anteriorlly and will fuse medially to form the posterior commeasure. It contains the sebaceous gland and the hair follicule. It is richly supplied with venous plexus and it is homologus with scrotem of male.

Labia manors- are also called the lesser lip of vagina. It is a thick fold of skin devoid of fat lying on either sides and with in the labia majora. It is composed of two devided lip that will fuse at some points with in the vulva for example the upper part of labia minoras fuses in front and behind the clitoris to form pre puse and franulem respectively and the lower part of labia manor fuse posteriorly to form forchette. Alike the labia majoras it doesn’t contain hair follicle and it is homologues with the veneral aspect of penis.

Clitoris- is a small cylindrical erectile body situated in the most anterior part of the vulva. It consists of glans, body, and two crura. The glans is richly supplied with nerves. Clitoris is homologues with penis of male.

Vestibule- is a triangular space bounded by clitoris anteriorly, forchette posteriorly, and the two labia majors laterally. There are four openings with in the vestibule.

1. Urethral opening- mid line just in front (above) the vaginal orifice.

2. Vaginal orifice- is an opening situated in the posterior end of the vestibule and it is of varying size and shape. In virgins, it is incompletely closed with septum of mucus membrane called hymen. The membrane will rupture during six, child bearing and rarely during stranious exercise. There are different types of hymen.

3. Openings of bartholin’s gland- bartholin’s glands are two pea sized glands situated on either sides of the vaginal orifice. During sexual excitement it secret an alkaline mucous which helps in lubrication. Each gland has got a duct that opens in the vestibule out side the hymen opening but with in the labia minora. It is homologues with the bulbo urethral gland of the male.

Perineum- is the area located between vagina and anal opening

B. Internal genitalia: - these are genital organs that are not visible in the normal circumstance that means they need special instrument for inspection. They include vagina, uterus, fallopian tube and ovary.

Vagina: - is a fibro-muscular membranous sheet communicating the uterine cavity with the external environment at the valve.

Position-The canal of vagina is upward and backward forming 90% with cervix and 450with the horizontal in erect position. The diameter of the canal is about 2.5 cm being wider in the upper part and narrow at the introits.

Function of vagina: - is excretory channel for the uterine secretion and menstrual blood

Is the organ of copulation It forms the birth cannel of parturition.

Walls: - vagina has get and anterior, posterior and two lateral walls. The length of the anterior wall is about 7cm and that of posterior wall is 9cm

Farnices: - the projection of cervix through the anterior vaginal wall at the top of vagina forms a cleft known as fornices. There are four fornicel (anterior , posterior and two lateral), the posterior one being deeper and the anterior one is the most shallow.

Layer: - the vaginal wall is composed of 4 layers. The four layers from within to out ward are:

1. Mucous layer: - is lined by stratified squamous epithelium with out any secreting gland.2. Sub mucus layer3. Muscular layers:- consist of inner circular and outer longitudinal 4. Fibrous coat

Epithelium: - the vaginal epithelium is under the action of sex hormone especially estrogen.

At birth and up to 10-14 days, the epithelium is stratified squamous under the action of maternal estrogen circulating in the newborn

Form puberty till menopause the vaginal epithelium is stratified squamous and is composed of 3 district layers; the basal call, intermediate call and superficial call. The intermediate and superficial cells contain glycogen. The superficial calls exfoliate constantly and replacement occurs from basal calls when they become exposed to the dry external environment during which karatinization will occur. Unlike it does not contain hair follicle, sweet and sebaceous gland.

Secretion:- the vaginal secretion is vary small in amount but it become little excess

During mid menstrual or just prior to menstruation,

During pregnancy and

During sexual excitement

The pH of the vagina- ranging form 4- 5.5 the average being 4.5 secretion is acidic but it varies during phases of life. The acidic nature of vaginal is because of the conversion glycogen to lactic acid by the red shaped bacteria known as dodaril’s bacillus which is dependant on estrogen.

Relations

Antariarly :- it is related with the upper base of bladder and urethral Postariarly:- it is related with rectal wall separated with pouch of Douglas, recto vaginal

septum & perennial body Superiorly:- it is in relation with the uterus specially cervix

Uterus: - is hallow muscular organ situated within pelvic cavity

Parts: - the uterus has three parts which are:

1. Body or corpus: - is apart of uterus found above the isthmus and is further divided in to fundus (dome shaped part that lies above the opening of the tubes) and body proper (a part found b/n the opening of the tube and the isthmus). carnua is the upper outer angle of the body and it is the site of attachment for fallopian-tube, round ligament and ovaries ligament.

2. Isthmus:- is the constricted part b/n the body and cervix 3. Cervix: - is the lower most part of the uterus which is cylindrical in shape. it is divided in to

supra vaginal part, a part that lies about the vaginal and a vaginal part, a part found with in the vagina each measuring 1.25 cm. in null parous the vaginal parts is conical with the external 0s looking circular where as in parous it cylindrical with the external as having bilateral slit, a slit formed by the damage of inner circular muscles of cervix during child birth which will form anterior and posterior lip of cervix.

Structure of the uterus: - the wall of the body of the uterus consists of three layers the layers. The layers from outside to in ward are:

1. Perimetrium: is a double serous membrane that is an extension of the partition , which cover all but narrow strip on either side and anterior wall of supra vaginal cervix from where it is reflected up over the bladder

2. The myometrium:- is a thick burner of smooth muscle arranged in outer longitudinal which is continuous with uterine tuba , uterine ligament and vagina ;middle uterine tuber,

3. The endometrium- is the mucus lining of the cavity of the uterus.it consists of laminaproper and surface epithelium. The surface epithelium is ciliated simple columenar while the lamina proper contain stromal cells, endometrial gland , vessels and nerves. During the time of pregnancy the endometrium is called deciduas. The cervix is mainly composed of fibrous connective tissue only 10-15%is smooth muscle,the endocervix is lined by tall columenar epithelium while the exocervix or the vaginal part is covered by stratified squamous

epithelium. Between the two there is a space which consists of endocervical glands and stroma covered by squamous epithelium which is known as squamocolumnar junction or transitional zone.the zone is not static rather it changes with hormonal level of estrogen. This site irritated not only by estrogen but also by infection and trauma. Thus there is a high risk of CIN or even invasive cancer.

Secretion- the endometrial secretion is scanty and watery while the physical and chemical property of cervical secretion changes with menstrual cycle and with pregnancy.the cervix secrets alkaline mucus with PH of 7.8 which is rich in fructose, glycoprotine and muco polysacride. The fructose has nutritive value for the spermatozoa.

Relation of the uterus

Anteriorly-it is related with the bladder and uterovesical pauch.

Posteriorly- it forms the anterior wall of the pouch of dogulas

Laterally- it is related with broad ligament

Position of the uterus- the normal position of the uterus is anti version (the long axis of the uterus especially the cervix makes 900 with the long axis of the vagina which means it leans forward) anti flexion (the long axis of the body of the uterus forms 1200 with the long axis of the cervix which means it is curved by itself at the level of internal os)

Function- mainly the uterus shelters the fetus during pregnancy and it expels its content when it is contracted during labour.

Support of the uterus-the uterus is supported by pelvic floor and maintain in position by several ligaments of which those at the level of cervix are the most important.

The transcervical ligament- is some times known as cardinal ligament. It runs out from the side wall of pelvis to side wall of cervix.

The uterosacral ligament- passes backward from cervix to the sacrum.

The pubocercical ligament- passes forward from cervix under bladder to the pubic bone.

The broad ligament- is a double fold of peritoneum which spreads from the side of the uterus to the lateral pelvic wall of the pelvis.

The broad ligament- arise from cornua and passes through broad ligament inserted in labia majora. They have little value as a support but used to maintain the antiverted position of the uterus.

Fallopian tube (syn:uterine tube or oviduct)- are paired structure found in the pelvic cavity. Each tube has got two opening one communicating with the uterine cavity called the uterine opning and the other on the lateral end of the tube called pelvic opning or abdominal ostium.

Parts- the tube has four parts. The part from medial to lateral are:

1. Intramural (interstitial) - is the part that lies in the uterine cavity.

2. Isthmus

3. Ampula- is the widest part through which fertilization occur.

4. Infundibulem- is the lateral end of the tube.

The abdominal ostium of the tube is surrounded by a number of finger like projections called fimbria. One of which is longer than the other and is attached to the outer pole of the ovary called the ovarian fimbrea.

Structure of the tube- the tube consists of three layers.

1. Serous coat

2. Muscular layer- arranged in inner circular and outer longtudnal fasion.

3. Mucous membrane-which is lined by partially ciliated and non ciliated columnar epithelium.

Function-the important function of the tube are:

Transporting male gamete to the site of fertilization and zygote to the uterine cavity by its cilliary function.

Nourish and protect the zygote

Ovaries- are paired sex glands or gonads in the female which are concerned with two function.

Maturation and release of ovum

Steroidogenesis

Relation

Anteriorly the ovary is attached to the posterior wall of the broad ligament by mesovarium

Posteriorly it is free

Laterally it is attached to the cornua and pelvic wall by ovarian and suspensery ligaments respectively.

Structure- the ovary is covered by single layer of cubical cel known as germinal epithelium. The ovary consists of the outer cortex and inner medulla. The cortex is the functional unit of the ovary and it is composed of primordial follicle, primary follicle, secondary follicle, mature (graafian follicle), corpus luteum and corpus albican. While the medulla consists of losse connective tissue, muscle, blood vessel and nerve.

1.1.3. Anatomy of fetal skull

The fetal head is the most difficult part to deliver weather it comes first or last. It is large in comparison with the pelvis and some adaption must be take place during labour. An understanding of the landmarks and measurements of the fetal skull enable the nurse to recognize the normal presentation and position and to facilitate delivery with least trauma to the mother and the fetus.

A. Bones of the fetal skull- the skull is divided in to three regions the vault, the base and the face.

1) The vault- is the large dome shaped part above the imaginary line drowns from the orbit to the nape of the neck. There are five main bones in the vault of the fetal skull.

One occipital bone- lies at the back of the head and forms the occipital region. At the center of this bone is a prominence called occipital protuberance. Below this prominence there is a large opening for the passage of spinal cord called foramen magnum.

The two parital bones- lie on either side of the skull. At the center of each parital bones there is an ossification center called parital eminence.

The two frontal bones- lie on the front of thr skull and forms the forehead or sinciput. At the center of each is frontal eminence (frontal boss) which is the ossification center of these bines. The frontal bones fuse in to one bone by the age of 8 years.

2) The face

3) The base

B. Sutures of fetal skull- sutures are cranial joints which are firmed where two bones adjoin. There are several sutures in the fetal skull. That of the most obstetric important ones are:

Lambdoidal suture- is so called because it resembles the greek leter lambda (). It separates the occipital bone fron the two parital bones.

Sagital suture- lies between the two parital bones.

Coronal suture- separates the frontal bones from the parital bones.

Frontal suture- rummes between the two halves of the frontal bone.

C. Fontanelles- are membranious gaps between skull bones formed where two or more suture meets. There are two major fontanels in the fetal skull.

Posterior fontanelle (lambda)- is the small triangular junction of sagital and lambdoidal sutures. It can be recognized vaginally because sutures leave from each of the three angles. It normally closes by the age of 6 weeks.

Anterior fontanelle (bregma)- is a diamond shaped fontanel found at the junction of sagital, coronal and frontal sutures. It also can be recognized vaginally because a suture leave from each of the four corners. It normally closes by the time of 18 months.

Advantages of sutures and fontanelles

Because they consist of membraninos space, they allow some degree of overlapping of the skull bones during labour and delivery the process called moulding.

Are used as land mark to identify the presenting part and position of the fetus during cephalic (head) presentation.

D. Region and land markes of the fetal skull

The occiput- is a region between foramen magnum and posterior fontanelle. The part below the occipital protuberence is called the suboccipital region.

The vertex- is the area bounded by the posterior fontanelle, the two parital eminence and anterior fontanelle. It is the most common and normal presenting part of the fetus (95%).

The sinciput or brow- extends from the anterior fontanelle and coronal suture to the orbit ridg.

The glabella- is the part between the eye brows.

The mentum- is the medical name of chin.

The face- extendes from the orbit ridge to the junction of neck and chin.

E. Diameters of the fetal skull- the measurement of the skull are important because a nurse need a special understanding of the relation ship between fetal head and maternal pelvis. It will become clear that some diameters are more favorable for easy passage through pelvis canal.

Transverse diameters- there are two transverse diameters.

Bi parietal diameter- is a diameter between the two parietal eminences and is measured to be 9.5cm.

Bi temporal diameter- is between the furthest point of the coronal suture and is measured to be 8.2cm.

Anterioposterior or longitudinal diameter

Suboccipito bregmatic- is from the below of occipital protuberance (sub occipital region) to the center of bregma. It is measured to be 9.5cm.

Sub occipito frontal- is from the below of the occipital protuberance to the center of frontal suture. It measures 10cm.

Occipitofrontal- from the occipital protuberance to the glagella. It is 10cms long.

Mento vertical- is from the point of the chin to the highest point of vertex (slightly nearer to kposterior than anterior fontanelle). It measure the longest diameter in the skull which is 13.5cm.

Submento vertical- is from the point where the chin joins the neck to the highest point on the vertex. It is 11.5cms long.

Submento bregmatic- is from the point where the chin joins the neck to the cnter of bregma. It is 9.5cms long.

F. Attitude of the fetal head- is the relation ship berween the long axis of the body of the ferus with fetal head. It is a term used to descrihe the degree of flexion and extension of the head on the neck. The attitude of the head determine which diameter and part will present in labour and there fore influence the out come. For example when the head fully flexes, the vertex presents and the presenting diameter will be suboccipito bregmatic. Flexion of the fetal head enable the smallest diameter possible resulting in easear labour.

G. Presenting diameters- are diameters of the fetal head at right angle with the curve of carus.

H. Presenting- is part of the presenting part (mostly the head) which lies first at the brim of the pelvis on the lower pole of the uterus. The most common presentation of the head are:

Vertex presentation

Brow presentation and

face presentation

1.2. Physiology of female reproductive system- The physiology of female reproductive system is mainly dependant on the action of the three organs the hypothalamus, pituitary, and ovary commonly known as the H-P-O axis. All must function appropriately for normal reproduction to occur.

1. Hypothalamus- is a small neural structure situated at the base of the brain above the optic chiasm and below the third ventricle. the hormonal products of this gland are:

Gonadotrophic releasing hormone (GnRH) - is concerned with the release of FSH and LH from pituitary.

Thyrotrophic releasing hormone (TRH)- stimulate the release of TSH Corticotrophin releasing hormone (CRH)-stimulate the release of ACTH Growth hormone releasing hormone (GHRH)- stimulate the release of GH Prolactine releasing hormone (PRH)- stimulate the release of prolactine Prolactine inhibiting factor (PIF)- inhibits the release of prolactine Somatostatine- inhibit GH and TSH secretion

2. Pituitary- is suspended from the hypothalamus by a stalk called infundibrum and is housed in selaturcica of the sphenoid bone. It is composed of two structures, the amterior lobe also called the adeno hypophysis and the posterior lobe also called neuro hypophysis. The anterior lobe (adeno hypophysis) - constitute the anterior ¾ of the pituitary. Because it is connected to the hypothalamus by blood vessels (hypophysusl portal system), it synthesizes and secret six principal hormones by the command of the hypothalamus.

Follicle stimulating hormonr (FSH) Lutenising hormone (LH) Thyroid stimulating hormone (TSH) Adreno cortico tropic hormone (ACTH) Growth hormone (GH) and Prolactin(PRL)

The posterior lobe (nurohypophysis)- constitute the posterior ¼ of the pituitary. It is not a true gland rather a mass of nuroglia and nerve fibers that arise from the cell body in the hypothalamus. The hypothalamus neurons synthesize, transport them down a stalk and store them in the posterior lobe. Finally the posterior lobe releases them when command arises.

Oxytocin- read the function Arginine-vasopressin (AVP) also known as anti-diuretic hormone (ADH).

3. Ovaries- are both endocrine and exocrine glands. Their exocrine products are eggs and their endocrine products are:

Estrogen by the granulose cell of the ovary Progesterone also by the granulose cell of the ovary Androgen by theca cells of the ovary Inhibin and relaxin

1.2.1. Puberty

During early time of pregnancy the two sexes are indistinguishable. But after 8 to 10 wks the two female reproductive tracts develop from the para mesonephric duct because of the absence of testestrone and mulerian inhibiting factor (MIF). During the time of birth the ovarian cortex contains one to two million oocytes with in primordial follicles but they are dormant till the time of sexual maturity.

From infancy onwards the hypothalamus is very much sensitive to negative feedback by even a small amount of estrogen (estrogen produced by peripheral conversion of testestrone produced by the adrenal gland) hence FSH and LH secretion are inhibited. But approximately around age of 12-13years, the hypothalamus is very much insensitive to the negative feed back. Hence increased amount of GnRH will be secreted by it. This will stimulate the pituitary to secret:

FSH and LH- which intern stimulate the ovary to secret estrogen and progesterone.

GH- which will either directly act on muscle and bones or will act on the liver to stimulate the secretion of (IGF) insulin like growth factor.

This will eventually results in dramatic growth of the body of the girl and maturation of the reproductive organs. This stage of spurt growth and maturation is called puberty. It is a stage of life in which secondary sexual characteristics develop.

Although there is a wide variation in the time that adolescents move through developmental stages, the sequential order however is fairly constant. In girls the pubertal changes typically occur in order of:

1) Marked physical change

2) Increase in the transverse diameter of the pelvis

3) Telarche, the development of the breast

4) Adrenarche (pubarche), the appearance of pubic and axillary hair and finally

5) Menarche, onset of vaginal menstruation.

1.2.2. Menstrual Cycle

Menstrual Cycle is the orderly cyclic hormone production and parallel proliferation of the uterine lining prepare it for implantation of the embryo. The normal human menstrual cycle can be divided into two segments: the ovarian cycle and the uterine cycle, based on the organ under examination.

A. The ovarian cycle- is the cyclic hormonal changes and other serious of changes that occur in the ovary to mature the immature follicle and recruit the oocyte. It may be further divided into: Follicular phase extends from the beginning of menstruation (day 1) to the onset of ovulation. The

average length of the human follicular phase ranges from 10 to 14 days, and variability in this length is responsible for most variations in total cycle length. the principal processes in this phase are:1) Rise in FHS secretion stimulates 20 to 25 primordial oocytes to begin meiosis I. 2) The follicle around the oocyte develop and become primary follicle the cell of the follicle

further enlarge and become condensed to form teca folliculi. Its other layer the teca externa, become fibrous capsule while the internal layer, the teca interna, secrets androgen which the granulose cell the granulasa cells convert it to estrogen.

3) In fewer day of the follicular phase the follicular cells began to secret estrogen rich follicular fluid. Thus the follicle will form a fluid filled cavity called antrum. The follicle is now called secondary or antral follicle and follicular cells lining it are called granulose cell. The granulose cell secrets a clear layer of gelll between themselves and the oocyte called zona pelucida. The inner most layer of the granulose cell in contact with the zona pelucida is called corona radiate, this is a state of development around 5 days.

4) The growing follicle secret increasing amount of estrogen which at same time reduces FSH secretion by pituitary and makes the follicle more sensitive to FSH by producing increasing amount of FSH receptors on the granulose cell of its own follicle. FSH intern stimulates this follicle to produce still more amount of estrogen but the most advanced follicle reduce FSH supply to other follicles while at the same time it makes itself more sensitive to FSH.

5) The less developed, less sensitive follicle undergoes atresia while the most developed follicle protrudes from the surface of the ovary like blister. This follicle is called mature (graafian) follicle.

6) As the follicle mature the primary oocytes complets meiosis I and become secondary oocyte. This cell began miosis II but it stops at metaphase II. The ovum is now ready for ovulation.

7) FSH and estrogen stimulste the mature follicle to produc the LH receptors.8) In the last one or two day of the follicular phase because the estrogen level is very high it

stimulate the anterior pituitary LH the hypothalamus to secret GnRH which intern stimulates the anterior pituitary to secret FSH and LH because of this the LH level will increase markedly 36 hours before the time of ovulation and is called LH surg.

9) The LH increases the blood flow to follicle allowing more serous fluid from the capillary to the antrum which causes the follicle to swell. Meanwhile LH also stimulate the teca interna to secret collaginase (lytic enzyme), an enzyme that weakens the ovarian wall.

10) Follicular fluid slips from the nipple like appearance on the ovarian surface over the follicle for 1-2 min and then the follicle rupture. This process is called ovulation. The remaining fluid oozes out carrying the oocyte and the surrounding cells of corona radiate.

luteal phase (post ovulstory phase) extends from ovulation to the beginning of menstruation. Unlike the follicular phase this phase is most predictable and constant (14 days) in length. the major development of this phase assuming pregnancy does not occur are as follows:

11) After the follicle expels the oocyte to the fallopian tube, it collapses and the granulose and teca interna cells multiply to fill the antrum. The ovulated follicle now become corpus luteum (yellow body)

12) The anterior pituitary continues to secret LH which regulates the further growth of corpus luteum.

13) The cprpus luteum produce mainly androgen which the granulose cells of the ovary convert to progesterone and small amount of estrogen. The corpus luteum also secret innhibin which suppresses FSH secretion which prevents new follicles development.

14) The corpus luteum grows secret more and more progesterone but if there is no sexual intercource in this period, the increased amount of progesterone will inhibit LH and FSH secretion by negative feed back. When the LH level falls critically low, the corpus lutem involutes or atrophy (24-26 day). The atrophy of corpus lutem will result in decline of progesterone secretion. By the day 26 or so, the atrophy completes and the corpus lutem has become an inactive scar called the corpus albican.

B. The uterine cycle- is the periodic endometrial growth to prepare itself for the implantation of the fertilized ovum. it can be divided into corresponding proliferative and secretary phases. Proliferative phase- is the time from first day of menstrual flow till ovulation which is

characterized by rebuilding of the endometrium but the true proliferation is from the end of menstruation. the principal processes in this phase are:

At the end of menstruation (at around 5th day), the endometrium is about 0.5cms thick and consists of only stratum basalis. The stratum functionalis is bult by this phase by mitotic division.

Estrogen from the ovary stimulates the mitotic division of the stratum basalis and the proliferative growth of the blood vessels.

Estrogen also stimulates the endometrium to produce progesterone receptors to prepare itself for the next phase. Now the endometrium is about 2-3cms thick.

Secretary phase- is a period of further endometrial thickening. It extends from day 15 (after ovulation) to the onset of menses. The principal processes in this phase are:

The corpus lutem formed after ovulation secrets progesterone. Progesterone stimulates the glands of the endometrium to accumulate glycogen. The endometrial gland become longer, wider and more coiled and secret a glycogen rich fluid in to the lemun.

Know (at around 26th day)m, the endometrum is about 5-6 cm thick, asoft, wet, nutritious bed available for embryonic development in the event of pregnancy.

In the absence of pregnancy, the corpus luteum atrophies and progesterone level falls sharply. In the absence of progesterone the spiral artery of the endometrium exhibits spasmodic contraction that causes endometrial ischemia. Ischemia leads to tissue necrosis.

Necrotic endometrium falls away from the uterine wall, mixes with blood in the lemun and forms the menstrual fluid.

Menstruation- is a periodic sloughing of endometrium which accompanied by bleeding.A Menstruation to be normal:

The cyclic length must be 21 to 35 days on average 28 days The duration of flaw must be 2 to 7 days on average 5 days The amount of blood loss must be 10 to 80 ML on average 30 ml The color of the bleeding must be dark red.

1.2.3. Fertilization- is the process of union of sperm (male gamete) and ovum (female gamete). It occurs in the ampula of the tube. When the sperm encounters an egg it releases an enzymes needed to penetrate the egg. The two acrosomal enzymes are:

Hayaluronidase- which digests the hayaluronic acid that binds the granulose cells together & Acrosin- which is a protease

When the path has been cleared, the sperm binds to zona pellucida and release its enzyme, digesting it until it contacts the egg itself. When it reaches the egg the head and mid pice will enter to the egg but the egg destroys the mitochondria of the sperm and only the maternal mitochondria will pass to the offspring. The two nucleuses will fuse combining the haploid (n) set of chromosome of the sperm with the haploid chromosome of the egg producing a cell with a diploid (2n) set of chromosome called zygote.After fertilization of the egg by sperm, the zone reaction prevents entry of any more sperm. The egg has two mechanisms to prevent this, the sloe block and the fast block.

a) Fast block- the binding of a sperm to the egg will open the Na+ channels of the egg membrane. The rapid inflow of Na+ ion depolarizes the membrane that inhibits the entry of any more sperm to it.

b) Slow block- involves secretary vesicles called cortical granules just beneath the membrane. Sperm penetration triggers a cortical reaction in which the cortical granules release their secretion beneath the zona pellucida. The secretion swells the membrane and pushes any remaining sperm away from the egg and creates an impenetrable membrane.

1.2.4. Development of the fertilized ovum (zygote) - the prenatal development of the fertilized ovum goes through three phases. 1. Ovular or germinal phase- it extends from the time of fertilization for the next 2 weeks. During this

period the zygote is designated as ovum. This phase involves three major processes cleavage, implantation and embryogenesis.

A. Cleavage-refers to the mitotic division that occurs in the 1st 3 days. The 1st cleavage occurs about 30 hours after fertilization and produces two daughter cells called blastomer. These blastomers divide and re divide doubling the number of blastomers each times by the time the zygote reaches the uterus (about 72 hour after ovulation), it forms a cluster of cells consisting of 160 or more cells and is now called morula. For few days the morula lies free on the uterine cavity and divides in to 100 or so. During this time it is nourished by nutrients that were stored in the egg cytoplasm and endometrial secretion called uterine milk. During this nourishment the morula will form a fluid filled cavity which separates the cells inn to two groups.

The outer cell mass- is also called trophoblast. It lines the inside of the zona pellucida. In the future they will form the placenta and chorion.

The inner cell mass- the remaining cells clumped together at one end forming the inner cell mass (embryo blast) which will become fetus and amnion. A cavity appears between these two groups of cells. The zygote is now called blastocyst. The zona pellucida thins out and disappears and the trophoblast especially the part which lies over the inner cell mass becomes sticky.

B. Implantation- about 6 days after ovulation, the blastocyst attaches to the endometrium usually on the posterior wall of the fundus. This is the beginning of the imbedding of the blastocyst in to the endometrium a process called implantation (nidation). The most important steps are

The trophoblastic cells adjacent to the inner cell mass separate in to two layers. The deeper layer contains cells divided by membrane and is called cytotrophoblast. the superficial layer however break down their plasma membrane and fuse in to a multi-nucleated cell called syncytiotrophoblast which will grow in to the uterus like roots and digest endometrial cells along the way.

The trophoblast forms finger like projection around all surface of blastocyst called chorionic villi. The villi at the site of embedding become profound and branches rapidly to form chorionic frondosum which will penetrate deeper in to the underlying endometrium to eventually form placenta. The chorionic villi over the rest of the blastocyst gradually degenerate to form chorionic leve.

The cytotrophoblast also secret a hormone called human gonadotrophic hormone (HCG) which is responsible to inform the corpus luteum that pregnancy has began so that it will continue producing estrogen and progesterone.

Progesterone maintain the integrity of the endometrium so that shedding does not takes place, in other words menstruation will be suppressed.

High level of estrogen and progesterone suppresses the secretion of FSH so that no other follicles will not grow and ovulation will suppressed.

As the trophoblast will be converted to chorion by the end of 2 month, the chorion will take over the function of trophoblast as well as corpus luteum meaning the ovary becomes inactive for the rest of the time.

C. Embryogenesis- during implantation the inner cell mass (embryo blast) undergoes arrangement of the cells in to three primary germ layers: ectoderm, mesoderm and endoderm. This process is called embryogenesis. Embryogenesis began with the inner cell mass and cytotrophoblast called amniotic cavity. As the amniotic cavity formed the embryo blast flattens in to an embryonic disc composed of ectoderm and endoderm. Later, as the disc elongates, a raised groove called the primitive streak forms along the midline of the ectoderm. Cells on the surface of the ectoderm migrate medially towards this groove and laterally between the ectoderm and endoderm. At the conclusion of the embryogenesis the conceptus become 2 mm long and 2wks old and is now called embryo.

2. Embryonic phase- lasts from the 2nd wk to 8th week of amenorrhea or 6 wks post ovular. This is a period of cell division and tissue differentiation. This phase also involves three major processes.A. Placentation- is the process of formation of placenta which extends from 11th day through 12

weeks after conception. Most developments of this process occur in the embryonic stage. It begins where extension of the syncytotrophoblast, called chorionic villi; penetrate more and more deeply in to endometrium like the root of the tree penetrating in to the nourishing soil. As they digest their way through uterine blood vessels the villi become surrounded by pool free blood that eventually merge to form the placental sinus and ensure nourishment of the zygote. The mature placenta is a fleshy discoid organ. It has two surfaces:

1) Fetal surface, the surface facing the fetus is smooth and the amnion covering this surface give it a white color. Under the amnion the fetal blood vessels merges out ward at the center of this surface forming the umbilical cord. The cord is sheathed by amnion and it measure 35-50 cm in length. It contains two umbilical arteries and one umbilical vein.

2) Maternal surface, the surface attached to the uterine wall is rough and the mother blood gives this surface a dark color. It is divided by sulcai in to 15 to 20 cotyledons.

Function of placenta Nutritive- it provide the embryo with nutrient like amino acid, glucose, fatty acid, H2O,

mineral and vitamin from maternal blood to fetus. Respiratory-it fevers gas exchange(provide O2 to the fetal circulation and removes CO2

from the fetal circulation) Excretory- it helps to clear the fetal metabolic wastes like urea and uric acid and bilirubun. Protection- placenta provides a limited barrier to infection with the

exceptions: T.palidum (syphilis), TB and all viruses.- It transports maternal antibody especially IgG.

Endocrine- placenta synthesize many hormone like:- HCG (human chorionic gonadotrophin)- Estrogen - Progesterone- Human placenta lactogen (HPL)

Storage the placenta metabolizes glucose, stores it in the form of glycogen and reconverts it to glucose as required. The placenta can also store nutrients such as CHO, protein, Ca, Fe and fat soluble vitamins in early pregnancy and release them to the fetus later when fetal demand is greater than the mother can absorb from diet.

B. Development of embryonic membrane- the placenta and umbilical cord are not the only accessory organs of the conceptus. There are two membranes that surround the fetal sac.

1) The amnion- it is the inner most of the two membranes. It is a transparent sac that develops from the dorsal amniotic cavity of the embryonic disk. It grows to completely enclose the embryo and is penetrated only by umbilical cord. it becomes filled with amniotic fluid which is at first formed by ultra filtration of mothers blood plasma but beginning at 8 to 9 wks the fetus urinate in to the amniotic cavity about once an hour contributing substantially to the fluid volume. Secretions of pulmonary epithelium and amnion cells also have some contribution.Composition of amniotic fluid- amniotic fluid is a straw colored mid alkaline turbid fluid. It contains 98-99% water and 1-2% solid constitutes. These include protein, glucose, lipid, hormone, fetal metabolic wastes like urea, uric acid, creatinin and minerals like Na+, K+ and Cl-.Function of amniotic fluid-

1. It allow free movement and growth of the fetus2. Protect the fetus from injury3. Maintain constant To around the fetus4. Protect the fetus and placenta from compression at the time of uterine contraction5. It aids effacement and dilatation of the cervix6. It keeps some organs of the fetus moist like skin, eye

2) The Chorion- is a thick outer membrane of the embryo. It lasts at the margin of the placenta.C. Organogenesis- it is the formation of organ system from primary germ layers. The major

structure that arise from the primary germ layers are: The ectoderm- mainly forms the skin and nervous system The mesoderm- forms bones and muscle. The heart, blood vessels and certain internal

organs are also originated from the mesoderm. The ectoderm- forms the mucous membrane and the glands of the body.

At the end of 8 wks all of the organ systems are formed and the individual is about 3cm. it is considered as the fetus.

3. Fetal phase- lasts from the 8th gestational wk up to term. During this period less tissue differentiation occurs; the principal activities are tissue growth and maturation. The fetus is the final stage of prenatal development extending from the end of 8th wk till birth. The organ that formed during embryonic stage now undergoes growth and differentiation and acquires the functional capacity to support life out side the mother. Some aspects of the development of the development of fetal organs and their physiology are special relevant to the nurses because their effect on the newborn.

The liver- from 3rd to 6th month of intra uterine life the liver is responsible for the formation of RBC, after which they are formed in the red bone marrow. Towards the end of pregnancy iron stores are laid in the liver

The renal system- the kidney begins to function and the fetus passes urine from 10 wks of GA. But urine is very much diluted and does not constitute a rout for excretion since the mother eliminates waste products through placenta.

The adrenal gland- the fetus adrenal glands produce precursors for placenta formation of estrogen.

The alimentary cannel-the fetal digestive tract is mainly non functional before birth except swallowing of the amniotic fluid about 12 wks after conception.

The fetal circulation- the fetal hemoglobin is of different type from adult hemoglobin and is termed as hemoglobin F. it has much higher affinity for oxygen and is found in greater concentration (18-20g/dl at term). The reason for this is that oxygen must be obtained from mother blood in the placenta site where the oxygen tension is lower than the atmosphere. There are 4 other temporary structures of the fetal circulation that enable fetal circulation to take place.

Ductus venoses- is vein that connects the umbilical vein to the inferior vena cava by bypassing in the liver because the liver is not yet functional to detoxify the content of the blood. At this point the blood mixes with deoxygenated blood returning from the lower part of the body making it partially oxygenated.

The foramen ovale- is a temporary oval opening between the two atrials which allows majority of blood from the inferior vena cava to pass to the left atrium because the blood does not need to pass through the lungs since it is already oxygenated and the lungs are not doing so.

Ductus arteriosus- is an artery that passes blood from pulmonary artery to the descending aorta by bypassing the lungs because of the reasons listed above.

The hypogastric artery- are branches of the iliac artery which become the umbilical cord.

The blood takes about half a minute to circulate the following course. The lung The CNS The skin

Unit two- Normal pregnancyDefinition of terms

Pregnancy (Gestation) – is a condition of having a developing embryo or fetus with in the body after conception. The period from conception to birth

Gravid (Pregnant) – a mother Containing developing embryo

Gravida: Total number of pregnancies

Labour - is a process by which delivery of fetus placenta and membrane occurs through the birth canal.

Para: Total number of deliveries after 28 completed weeks of pregnancy.

Primigravida: a pregnant woman during her first pregnancy

Multigravida: A woman who has been pregnant more than one time

Nulipara: A woman who has never born a viable child

Multipara: A woman who has had two or more pregnancies which suited in viable foetus

Grand Multipara: A woman who has had 5 or more pregnancies

Prenatal - occurring before birth

Intranatal - occurring with in birth

Postnatal - occurring after birth

Singleton pregnancy: having one foetus in the uterus

Multiple pregnancies: having more than one fetus in the uterus

Term: The time of gestation from 37 completed weeks to 42 completed weeks from 1st day of LMP

Pre term: the time of gestation before 37 weeks

Post term: the time of gestation after 42 weeks

Conception: The onset of pregnancy/unification of spermatozoa and ovum

Conceptus: The sum of derivatives of fertilized ovum at any stage of development from fertilization to birth

Implantation: Attachment of the blastocyst in the epithelium of the uterus

Zygote: The fertilized ovum

Embryo: The developing organism from the end of the 2nd week after fertilization to the end of the 8th week

Fetus: The unborn offspring from the 9th week of gestation to birth

Neonate: New born in the first 4 weeks

Infant: a baby with the age of < 1 year

Trimester: A period of three months of pregnancy

First trimester: From conception to 12 completed weeks

Second trimester: from week 13th to 27th completed week

Third trimester: from week 28th to 40th completed week

Still birth: Birth of dead fetus after 28 weeks of pregnancy

Neonatal death: Death of the baby with in the first 4 weeks after delivery

ABBREVIATIONS

ANC= antenatal care

APH = Antepartum hemorrhage

ARM = Artificial rupture of membrane

Cx = cervix

CCT= Controlled cord traction

CPD= cephalo pelvic disproportion

C/S = caesarian section

D & C = Dilatation & curettage

EDD = expected date of delivery

ECV = External cephalic version

FH = fundal height

FHB = fetal heart beat

FP = family planning

GA = gestational age

G = Gravida

Hgb = hemoglobin

INC = Intranatal care

IUFD = Intra utrine fetal death

IUGR- intra uterine growth restriction

LMP = Last menstrual period

P = Para

PA = per abdomen

PID = pelvic inflammatory disease

PNC = Postnatal care PPH = Post partum hemorrhage

PR = per rectum

PV = per vaginal examination

SVD = spontaneous vaginal delivery

UTI = urinary tract infection

Ux = uterus

Wk = week

Physiologic changes during pregnancy

All changes in a mother’s body during pregnancy are associated with the effect of specific hormones. Thus changes enable her to nurture the fetus, prepare her body for labour and develop her breast for production of breast milk during the puriperium.

1) Physiologic changes in the reproductive organs-

A) Body of the uterus-after conception progesterone and estrogen produced by the enlarged corpus

luteum cause the deciduas to become thicker and more vascular especially at the fundus which is the

usual site of implantation. The muscle fibers also grow up to 15-20 times their non-pregnant length.

Each muscle fiber increases by 10 xs in length and 5 xs in thickness. This hyper trophy and

hyperplasia of the uterine muscle fiber is due to the effect of estrogen and progesterone.

Growth of the uterus-

12th- week- the Fundus reaches just above the symphysis pubis

16th week mid way between the symphysis pubis and the umbilicus

20th- week at the level of the umbilicus

30thweek -Midway between umbilicus and xiphisternum

36th week- at the level of xiphesternum. It is the maximum growth of the uterus.

B) The cervix of the uterus- it acts as an effective barrio against infection during pregnancy, protects

the fetus by remaining firmly closed and by providing resistance to pressure from above when the

mother is up right position.

Under the influence of progesterone the cervical cells secret mucus which become ticker and

more viscous during pregnancy which forms cervical plug called operculum which provide

protection from ascending infection.

C) The vagina- estrogen cause changes in muscle layer and in the epithelium of the uterus the muscle

layer hypertrophy and the capacity of the vagina increase. These changes enable the uterus to dilate

during the time of delivery. There is an increased amount of normal white vaginal discharge known

as leucorrhoea.

2) Physiologic changes in the cardiovascular system – profound changes takes place in the

cardiovascular system during pregnancy and understanding of these changes is important in care of

the women with preexisting cardiovascular disease

A) The heart- owing to an increase in work load, the heart muscle hypertraoophy particularly in the left

ventricle leading to an enlargement of heart. Heart sounds are changed and mormor sound is some

times common.

B) Cardiac out put- during pregnancy there is an increased HR and cardiac out put resulting in raised cardiac out put. This is due to increased blood volume and increase requirement of oxygen by all maternal tissue as well as by the growing fetus.

The rate may increase as early as 4 wks by 15 beat per minute.

C) Blood pressure- although the cardiac out put is increased in pregnancy, the blood pressure does not rise because of the reduction in peripheral resistance to about 50% of non pregnant value. The capacity of the vein can increase by liters. The most obvious cause for this is progesterone which relaxes smooth muscle in the blood vessels.

D) Blood volume- the increase in blood volume in pregnancy may be as little as 20% or as much as 100% and varies according to the size of the women, the number of pregnancy she has had, her parity, and weather the pregnancy is singleton or multiple the average being 40%. Raised level of aldostrone, estrogen and progesterone during pregnancy are thought to contribute to increased blood volume.

What is the aim of having increased circulating volume is required of blood.

To supply the extra metabolic need of the fetus

To supply the extra metabolic need of the maternal organs like kidney

To counterbalance the effect of increased arterial and venous capacity

To compensate for blood loss at delivery

E) Red cell mass- increase as a result of accelerated production of RBC in response to the extra oxygen requirement by the maternal and fetal tissue.

NB:- as the increase in blood volume (plasma volume) is much higher than that of red cell mass increase, hemodilution occur.

3) Physiologic changes in GIT

Progesterone relax smooth muscle of the GIT; this will slow the gastric empting and peristalaysis in order to maximize the absorption of nutrients

Heart burn is common and is associated with gastric reflex due to the relaxation of cardiac sphincter

4) Physiologic changes in integumentary system- increased activity of the melanonin stimulating hormone cause deeper pigmentation during pregnancy resulting in:-

Linea nigra

Stria gravida

Chloasma

5) Physiologic changes in MSS- progesterone and relaxine encourage relaxation of ligaments and muscle reaching maximum effect during the last week of pregnancy. This relaxation allows the pelvis to increase its capacity in readiness to accommodate the fetal presenting part at the end of pregnancy and labour.

6) Physiologic changes in breasts

Estrogen develop the duct system

Progesterone develop the glandular tissue

Prolactine stimulate the production of colostrums.

7) Physiologic changes in respiratory system

8) Physiologic changes in endocrine system

Diagnosis of pregnancy

Sign & symptom of pregnancy- Sign & symptom of pregnancy can be classified in to three

- Presumptive - Probable &- Positive

1) Possible (presumptive) signs –they are not true signs rather they are symptoms because it includes what the mother will recognize. Examples of such a symptom are:- Amenorrhea - Morning sickness - Early breast change - increase in size

- Darkening of areola. - prickling sensation from 3-4 wks

- Bladder irritability and frequency of micturation - Quickening - is the first fetal movement felt by the mother

premigravid - feels it at 18-20 week Multigravid - feels it at 16-18 week.

2) Probable signs are true signs in which the health professional will find

- Pregnancy test – presence of HCG in the o urine or o blood

- Jacquemier’s sign – violet blush discoloration of genitalia due to increased vascularity. - Osiander’s sign - pulsation in lateral vaginal fornices - Uterine growth- - Braxton - Hicks contraction- is pain less uterine contraction felt on palpation from 16 th wks on

ward. The contraction helps in the circulation of blood in the placenta site and in the formation of lower uterine segment.

- Ballottement of the uterus3) Positive signs are the real indication of pregnancy. If you get this signs there will no doubt in the

pregnancy.

Visualization of fetus by @ Ultrasound - 6weeks of gestation @ X - ray after 12 weeks of gestation

Hearing of Fetal heart beat by @ Ultrasound @ Fetoscope (20th to 24th weeks of gestation)

Fetal movement by@ palpation @ Visualization

Antenatal care /ANC/

Definition-it is a care given to pregnant women.

Aim of ANC-generally the aim of ANC is delivery of a healthy infant and maintaining the health of the mother by:

Promote the physical and psychological status of the mother Diagnosing the well being of the fetus as well as the mother Screening high risk mothers Treating the preexisting disease preventing disease and further complications preparing the mother for labour, delivery and pureperium

Components of ANC- according to WHO ANC have three components.

A. Risk assessment- risk is any condition that will expose a person to possible danger.

According to WHO all pregnant mothers are risk mothers (they need special care) but there are mothers who are high risk.

Which mothers are high risk mothers?

They are Mothers who need special care than normally pregnant mothers during their pregnancy, labour, delivery and puriperium.

They are mothers who should deliver in the hospital Those mothers include:

>35 or <15 year agedHeight of < 150 cm Medical problem like- heart disease, DM, renal disease, TB, HIV/AIDS………Surgical problem like-C/S, genital surgery, pelvic surgery……………Obstetric problem this may be during past or at the present pregnancyo Twin pregnancy

o APH

o Prolonged or obstructed labour

o PROM

o Repeated abortion

o IUGR/IUFD

o Pre or post term labour

o History of neonatal death

o HDP

A. Antenatal care assessment- Pregnancy is not a disease; it is a normal physiologic state but because of the different reasons/objectives we will follow the mother as a patient. This follow up includes:

History taking Basic recording Lab investigation Physical examination follow up

1) History taking- is assessing the health of the mother to find out any problem which may affect child bearing.

A. Social history (biographic data) it includes age, name, marital status, occupationB. Family history- mostly you should ask hereditary transmittable disease like;

a. Diabetes mellitusb. Hypertensionc. Heart diseased. Multiple pregnancye. Psychiatric historyf. Family history

C. Medical history- like-a. HTNb. DMc. HIV/AIDSd. TBe. Childhood disease like polio, rickets

D. Surgical historya. C/Sb. Genital surgeryc. Pelvic surgery

E. Obstetric history- this includes any problem of labour, pregnancy, delivery and/ or puriperium of the current or past pregnancy.

a. Past obstetric historyi. Pregnancy history- you should ask the presence or absence of :

Hyper emesis Anemia Pre eclampsia APH Preterm, term or post term ness of the pregnancy

ii. Labour history- the onset of labour- spontaneous or induced The nature of labour- prolonged, obstracted Rupture of membrane- spontaneous, ARM, PROM

iii. Delivery history- you should ask : place of delivery

Instrumental delivery (vacume, forcepse) Weight of the baby Life status of the baby APGAR score of the baby

iv. Puriperial history- ask history of: Infection Breast problem (engorgement, mastitis) PPH Psychiatric history

b. Present obstetric history1) Ask LMP (last menstrual period)- it is reliable only when:

– The mother has regular menses

– If the mother does not use contraceptive for the previous 6 months2) Calculate EDD (expected date of delivery)

Way of calculating EDDIf in Gregorian calendar, add 7 days and 9months on the LMP

Example if the mothers LMP is on 10/2/2006EDD=10/2/2006 +7/9/0000 =17/11/2006

If in Ethiopian calendar and if the pregnancy Does not pass pagume, add 10 days and 9 months. Passes pagume that is 5 days, add 5 days and 9 months Passes pagume that is 6 days, add 4 days and 9 months

Example one if the mother’s LMP is on September, 10, 2002EDD=10/01/20002 +10/009/0000 =20/10/2002Example two if the LMP is on may,28,2001EDD=28/09/2001 +05/09/0000 =03/07/2002Example three if the LMP is on april, 18, 1999EDD=18/08/1999 +04/09/0000 =24/05/2000

3) Calculate GA (gestational age) - it is always calculated by wks.

Ways of calculating GA

GA=arrival date-LMPExample: if the mothers LMP is at 4/5/99, and the arrival date is at 10/10/99

GA=10/10/99 - 4/5/99

=6/5/00 (5 months+6 days)=150+6 days=156 days=22wks+2days

2) Basic recording

A. Height- is usually taken at the first time visit only

- <150 cm height is risky

B. Weight- will be taken monthly to know the increased weight per month - 10- 12.5 kg increase is a normal - 10 kg in the 2nd 20 wks and 2.5 kg in the first 20 wks

C. Blood pressure- should be checked and recorded per each visit.

3) Laboratory investigationo Blood tests

Blood group RH factor HIV status VDRL HCT and Hgb- shoud be checked and recorded per each visit.

o Urine analysis

Protine Suger Bacteri Ketone body

NB:- normally urine does not contain any protine, suger, bacteria or ketone body or they are trace.

4) Physical examination- during the first visit of ANC, we should do a complet (heas to toe) physical examination which includes:o HEANT- head- cleanness, hair distribution

Ear- discharge, growth, hearing ablity Eye-sclera, conjunctiva, bleeding……… Nose- abnormal growth, discharge, obstraction Trought(teeth)

o Neck- enlargement of the lympnode, thyroid gland

Lympadenitiso Breast examination

Inspection- symmetry Skin Areola Nipple (normal, inverted or flat) Milk expression Any other discharge

Palpation- breast can be palpated in one of the two ways Circular palpation Quadrant palpation

NB: if possible breast self examnation is advisable.

o Abdominal examination

Aim of abdominal examination To asses the progress of pregnancy To asses the well being of the fetus To asses fetal size and growth To asses the presentation, position, lie, and engagement of the fetus To detect any devotion from the normal

o Preparation of abdominal examination

Explaining the procedure Maintaining privacy Positioning Empiting the blader

o Method of abdominal examination

1. Inspection- inspect the four S’sa. Shape of the uterus- shape of the mother is different in different situations.if the mother is:o Primigravida, the shape will be oval

o Multi gravid, the shape will be round and pendulus

o Twin pregnancy, the shape will be irregular

o Occiputoposterior position, it will have a socker like dipresion.

b. Size of the uterus- the size of the uterus must be compaired with GA and it may be either appropriate for GA, small for GA or large for GA.Example if the 24 wks fetus is at the level of umbilicus, it is small for gestational age.Differential diagnosis of LGA- large for gestational age can be mistaken by:o Poly hydraminous (large amount of amniotic fluid)

o Multiple pregnancy

o Full blader

o Tumor

o Wrong date or it may be

o Big baby

Differential diagnosis of SGA- small for gestational age can also be mistaken by:

o Wrong date

o Oligo hydraminous (small amount of amniotic fluid)

o IUGR

o IUFD or it may be

o Small baby

NB: multiple pregnancy and poly hydraminous will enlarge both the length and breadth of the uterus whereas large baby increase only the length of the uterus.

c. Skin of the uterus- skin change during pregnancy shoud be noticed llike:o Linia nigra- dark line pigmentation running longtudnally in the center of the abdomen below

and some times above the umbilicus.o Streagravida- white line in the abdomen formed due to stretch of the abdomen.

d. Scar- may indicate previous obstetric and abdominal surgery.2. Palpation- before palpation, the hands shoud be clean and warm not to induce contraction of abdomen

and uterine muscles, arms and hands shoud be relaxed and you have to use the pads not the tip of the fingers.

We usually use the four steps of palpation (leopolds manover) for abdominal examination.a. Fundal palpation (1st leopolds maneuver) is carried out in order to:@ Know what is occupied on the fundus; weither it contains breach or head. This

information will help to diagnose the lie and presentation of the futus. To do so you have to lay both hands on the side of the fundus, fingers held together and curving around the upper border of the uterus. Then gently appling pressure using the palmar surface of the fingers to determine the softness (butuck) or the hardness (head) of the mass. But some times buttuc may feel firm; in such a case,you have to asses the mobility of the mass. The breach can not be moved indipendantls as the head can because of the free movement of the neck joint.

@ Estimate period of gestation- does not always produce an accurate result because the size and number of the fetus, amont of the amniotic fluid and maternal size and parity may vary. You can use two methods to determin the height of the uterus.the first (sypphisis fundal height) is the assumption of the height of the fundus will corelaate well with gestational age especially during early wks of pregnancy. It can be done using measuring tape (measuring from pubic bone to syphisis pubis) or by using your fingers. When using your fingers you have to assume the umbilicus as 20 wks and one finger below the level of the umbilicus will be recorded as 1 wks and one finger above umbilicus will be recorded as 2wks. The second method is the estimation of the distance between the umbilicus and the curved upper border of the fundus by placing your finger. This method will assume xiphisternum as a 36 wks of gestation.

b. Lateral palpation- is used to locate the fetal back in order to determine the position. To do so the hands should be plased on either side of the uterus at the level of umbilicus and gentle pressure should be applied with alternative hands to detect which side of the uterus offers the greater resistance (which is the back)

c. Pelvic palpation- is the palpation of the lower pole of the uterus to know what is occupied on the pelvis, attitude and engagement. To do so the side of the uterus just below the level of umblicusshould be grasped snougly between the palm of the hand with the fingers held closer, pointing downward & inward. If the head presenting a hard distinctive & round mass & smooth surface will be felt in order to know the attitude, the sinciput & occiput should be palpated. If the head is flexed, the sinciput will be felt on the opposite side of back & higher than the occiput if the head is deflexed, the two prominence will be at the same level. If the head is extensed as in the face presentation, siciput will be felt on the same side of the back

d. Pawlik’s grip(4th leopalds manuover): is used to judge size, flexion, and mobility of the head. To do so you have to grip the lower pole of the uterus between your tumb and your finger which should be spreed wide apart to accommodate the fetal head. Do not apply undue pressure because it is painfull.

3. Auscultation- the fetal heart beat must be auscultated. Like all heart beats, it is a double sound but is faster than adults (120-160). It is mostly heard clearly at the left part of fetal scapula. While listning the ears most be closed by the total contact with the fetescope but hand should not touch it to avoide extraneous sound.

Findings of abdominal examination

Gestational age- when the uterus is at:o The level of symphisis pubis, it is assumed to be 12 wks fetus.

o The level of umbilicus, it is assumed to be a 20 wk fetus

o Between symphisis pubis and umbilicus, 16 wks

o The level of xiphisternum, 36 wks

NB: after 36 wks the height of the uterus will decrease because of the engagement of the head in to pelvic bream.

Lie- is the relationship between the long axis of the fetus with the long axis of the uterus. There are three types of lies.

A. Longitudinal lie- when the long axis of the fetus is in line with long axis of the uterus. It can be breach or cephalic. 99.5% of all pregnancy are with longtudnal lie.

B. Transverse lie- when the fetus lies at the right angle across the long axis of the uterus.

C. Oblique lie- is when the fetus lies diagonally across the long axis of the uterus.NB: oblique lie and obliquity of the uterus (the tilting of the whole uterus to one side) are not similar.

Attitude – is the relation of the head to its trunk. The attitude of the fetus shoud be one of flexion (well felexed, deflexed or extenced).

Presentation- refers to the part of the fetus which lies at the pelvic bream or in the lower pol of the uterus. The presentation of the fetus can be cephalic (when the head become the presenting part),breach (when the butuckbecome th presenting part) or sholder. Vertex, face and brow presentation are all head or cephalic presentations. When the head fully flexes, the vertex presents; when the head fully extenced, the face presents and when the head partially extenced (deflexed) the brow presents. It is more common for the head to present because the bulky breach finds space in the fendus which is the widest diameter of the uterus and the heavy head lies in the narrowlower pole.

Denominator is the name of the part of the presenting part which is used as a reference point to know the fetal position. Each presentation has difference denominators; those are:

o Occiput in the vertex presentation

o Sacrum in the breach presentation

o mentum in athe face presentation

o acroion process and some times dorsum in shoulder presentation but

o no denominator is used in brow presentation.

Position- is the relation ship between the denominator and some points in the pelvis. There are 8 positions. For example LOA, ROA, LOL, ROL, LOP, ROP, DOP, DOA are the are the eight positions in the vertex presentations.

Engagement- is the widest presenting transverse diameter (biparital diameterin the cephalic and bitrochontric diameter in the breach) has passed through the brim of the pelvis. It is an important sign of adequacy of the pelvis for the specific fetus. In primigravida it will occure early (between 36 and 38th weak) but in multi this may not occur because of the lax uterus.What are the evidence of the engagement?

Only less than half of the fetal head is palpable above pulvic brim The head is immobile Sinciput is felt less than 5cm above the brim

The anterior sholder is little more than 5cm above the brim Presenting part- is the part which lies over the cervical os during labour.

5) follow up- a women who had high number of risk factors identified during the intial assessment visit or who develops complication during pregnancy will attend her antinatl care at the hospital but womens who had no or little risk factor will follow their antenatal by appointment. There are two type of appointment (traditional and focus nantinatal care).

A. traditional appointment-is a method of appointing amother with same frequency of time in some duration of time in which the frequency increases as the GA advances that is:

@ 0-28 weeks-every month@ 28-36 wks every two weeks@ 36-delivery every weak

B. Focused antenatal care- is a method that assumes four visits are enough fetal as well as maternal well being. i.e.

@ 1st visit- any time before 16 wks@ 2nd visit- at 24 wks@ 3rd visit-at 32 wks and@ 4th visit at 36 wks

B. Care provision- is a method of treating the identified existing problems. These problems can be simple like minor disorder of pregnancy which can be managed by our selves or can need referral.

C. Health promotion- is maintaining the health of the mother by different methods like:-

Health education

Immunization

Tetanus toxoid: - because tetanus neonatorium is a great killer of new born babies the baby gets infected when the umbilical stamp or any part of the baby’s body is invaded by tetanus organism

We can prevent the disease by immunizing the mother so that she pass antibody to her baby before delivery

Unit three- abnormal pregnancyMinor disorders of pregnancy

They are minor complaints of the mother due to the physiological and anatomical changes of the pregnancy. They are minor and are not lives threatening which can be resolved by education that is why they are called minor disorders.

1. Morning sickness - some degree of nausea and vomiting is common compliant during the 1st trimester. It can appear in any time of the day but it becomes worse early in the morning thus the name morning sickness.

Cause- the most likely cause is the hormonal change during pregnancy that is the rising level of HCG.It can be aggravated by:-

@ smelling of foods and @ Psychological problems like anxiety.

Management-it can be relived by:- Reassuring the mother Taking small, frequent and dry meals Avoiding fatty foods and foods whose smell aggravates the symptom Rest But if not relived by the above managements give anti emetic

2. Heart burn : - is a burning sensation in the epigastric area especially during the late weeks of pregnancy.

Cause- it is usually caused by reflex of gastric content in to esophagus due to :-@ Compression of the stomach by the enlarging uterus and@ Relaxation of the cardiac sphincter by the effect of progesterone

Management- it can be relived by:- Taking small and frequent diet Sleeping with extra pillow than usual If not relived use anti acids like Al (OH)3, Mg3Si2, or the combination of the two If not still relived use H2 blockers like cimitidine & rantidine

3. Constipation - Cause- the cause of this condition is delay of peristalysis which can be due to:-

@ Relaxation of GI smooth muscles due to the effect of progesterone@ Pressure from growing uterus

Management- this condition can be treated by taking high amount of :- Fluid Fibrous diet Fresh fruit, vegetable and roughage

If it is not still relived by the above management give her stool softners

4. Hemorrhoids : - is the varicosity of the rectal vein. It can be asymptomatic or may be present with rectal bleeding, rectal pain or prolapsed mass through the uterus.

Cause- relaxation of smooth muscles due to the effect of progesterone@ Pressure in the rectal vein by the growing uterus

Management- Appling topical anesthetics and anti inflammatory drugs Warm soaks (sits bath) Modification of bowl habits Taking laxatives Finally surgery if thrombosed and strangulated

5. Pica :- is craving of pregnant mother for items of low nutritional value like:- Clay Soap Coal Soil

Cause- there is no known cause

Management- educating the mother

6. Varicose vein :- is the dilatation of the superficial vein of the lower extremities.

Cause- relaxation of smooth muscles of the vein by the effect of progesterone@ Decrease venous return due to the compressing effect of the growing uterus

Management- Elevating the leg during the sleep Reduce long standing Using elastic bandage

7. Leg cramp

8. Urinary frequency

9. Ptyalism

10.Vaginal discharge

Hyperemesis gravidarum

Definition of hyper emesis gravidarum

It is vomiting that starts before the 20th week of pregnancy and requires intervention. Severe nausea and vomiting leads to dehydration electrolyte imbalance and weight loss. It is a condition affecting approximately 1 in 100 pregnant women.

Causes of hyper emesis gravidarum -The etiology of hyper emesis is uncertain endocrine and psychological factors are proposed

Rising level of oestrogen and HCG is significant Hype emesis is common in multiple pregnancy and molar pregnancy.

Sign and symptom of hyper emesis gravidarum

- Persistent, severe nausea and vomiting in early pregnancy.- Inability of the mother to retain food and fluid.- Wt. loss.- Distress due to symptoms.- Signs of dehydration like

Rapid pulse Low Bp (hypovolemia) Dry tongue

- Ptyalism may occur.(contributes for dehydration) - elevated haematocrit alteration & electrolyte balance - sign of ketosis

The mother’s breath may smell of acetone Ketone urea.

Diagnosis: -History, P/Estrogen and Lab. Investigation.

Management Initially nothing is given by mouth (NPO ) to allow time for the vomiting to be controlled gradual

introduction of fluids and diet as he condition improves Hypovoluemia and electrolyte in balance are corrected by intravenous infusion. Vitamin supplements can be given parenterally. The mother should be encouraged to rest and may be cared for in a private room. Some women may be given mild sedatives if they appear agitated. A small palatable meal on regular basis helps to regain her appetite. The use of anti emetics in pregnancy causes severe mal formation of children born so on anti

emetic being approved for Rx. Termination of pregnancy reverse the condition ( preventing MM)

Complication -If hyper emesis is left untreated, the mother’s condition worsens.

Hepatic and renal involvement lead to coma and death Wernicke’s neurological disorder x-zed by confusion, drowsiness and ophthalmoplegia

encephalopathy is a complication associated with lack of vit B1 (thiamine) Differential Diagnosis

- urinary tract infection- Gastroenteritis.

Multiple pregnancy

Definition- is the presence of more than one fetus in the utero.Type- multiple pregnancy can be twin pregnancy, triplet, quadruplet of other but the most common ones are twins. There are two types of twins. This are:A. Monozygotic /uniovular/ identical twins- is the formation of twin from single ovum and

spermatozoa. The twins are formed by mitotic division of ovum after fertilization. The two twins will have the same sex, blood group, physical feature, ear shape, genetic composition, and eye and hair color e.t.c. this type of twins account 30% of all twins.

B. Diazygotic /diovular/ fraternal twins- it is the formation of twin from separate ovum and spermatozoa. The twins may have same or different sex, blood group, and physical feature but they will have different genetic composition. This type of twins Account 30% of all twins.

Process of twining- can be expressed by two things, zygosity and chorionisity. Zygosity- refers to the mono or diazygotic nesss of twins.

How do we determine zygosity? Same blood group with same sex Genetic composition even if it is very difficult in our setting Physically around two year Weight variation at birth

Chorionisity- is all about the number of placenta.How do we determine chorionisity?

All dizygotic and triplets are DADC (will have separate amnion and chorion)

For all monozygotic the number of placenta (chorionisity) depends on the time when the mitotic devision starts. If it starts:

<72 hour= DCDA (30% of all)

4-8 days= MCDA (70% of all)

>8day= MCMA Rare

>13 days (In separated)= conjugated twinsNB: - mono-chorionisity has high risk of fetal loss and maternal complication because of TTT.

Etiology- the etiologies listed below are for diazygotic twins than monozygotic once. Race- common in blacks Age- 37years is a pick age Parity- common in multipares Nutrition- common in well nourished Physical appearance- common in taller and heavier Family- common in female family

Diagnosis- we can diagnose twin pregnancy by: History- Ask the presence or absence of all condition that will predispose the mother like:

Race Parity Age Family history

- Ask 1st trimester history and unexpected weight gain during pregnancy. Abdominal examination

Inspection- you will found big for date abdomen with round shape- Excessive fetal movement

Palpation- palpation of multiple fetal parts- Uterus is palpable before 12 wks of pregnancy- Fetal head is small in relation with the size of the abdomen

Auscultation-the presence of two FHB at two different place which is confirmed by two persons is an indication of twin pregnancy.

Ultra sound- if you are not shure by the above diagnostic criterias, you can confirm it by sonography.

Complication of multiple pregnancy-always multiple pregnancy is a risk pregnancy because it has a negative effect on pregnancy, labour and puriperium. Some of the risks are:

Hypermisis- because it has a large amount of estrogen and HCG. Anemia- because of the increased requirement of Fe and folic acid APH- especially placenta previa. Why? Poly hydraminous Malpresentation Pre eclampsia-increase by 4 times because of the increased size and number of placenta. Cord prolapse PPH- because of overstretched uterus. Locked twins Preterm labour- because uterine size is one stimulus for initiation of labour. TTT- is the communication twins blood vessles.

Twin A (donor) Anemia Oligohydraminous Growth restriction

Twin B (recipient)- Polycytemia- Poly hydraminous- Macrosomia- Cardiac failure

NB:-Both are at risk of death and preterm delivery.

Management of twin pregnancyAntenatal management

More nutrition More CHO, protine and vitamin Fe and folic acid supplementation is mandatory

Intrapartem management Labour should be attensed in the hospital You should prepare as for two delivery(two cord tie, two delivery and episotomy set, and two

neonatal bed) If the presentation is cephalic cephalic(has a chance of 40%), SVD is possible. If twin A is vertex but twin B is non vertex (has a chance of 40%), we can deliver twin A by SVD

and can augment twin B. If twin A is non vertex, c/s is indicated.

Postpartum- AMTL (active management of third stage of labour)- Follow up of all the above complication

Antepartum hemorrhage

Definition: - is bleeding from genital tract of the pregnant mother after the fetus has reached viability (which is after 28 complete weeks or fetal weight of 100 gm or more in our country or 20 wks according to WHO) and before the fetus is delivered.

Cause: - the cause can be broadly categorized as:

A. Obstetric cause- are the major causes of APHa. Placenta previab. Abraptio placentac. Vasa previad. Uterine rupture

B. Non-obstetric causea. Cervicitiesb. Cervical polypc. Cervical Cad. Traumatic lesion

1. Placenta previa - is the bleeding from the placenta that is implanted in the lower uterine segment.

Grade of placenta previa

A. Grade I (is also called low lying placenta previa)- is when the placenta is implanted in the lower uterine segment but not reach the internal os.

B. Grade II (is also called marginalis) - is when the placenta reaches the margin of the internal os but doesn’t cover the internal os.

C. Grade III (also called partialis) - placenta covers the partial of the internal os.

D. Grade IV (also called totalis) - is when the center of placenta lies at the center of internal os and when it covers the whole internal os even at full dilatation.

Cause- there is no single exact cause of placenta previa but the predisposing factors are;

@ Uterine scar secondary to-vigorous suctioning and curettage

- C/S scar

@ Multi parity

@ Multiple pregnancies. Why?

Clinical manifestation- Pain less bleeding Bright red bleeding Non tunder uterus Normal tone uterus High presenting part even primi gravida Usually there will be mal presentation and mal position Maternal vital sign change in proportion to the blood loss

NB: - since it is followed by sever bleeding both vaginal and speculum examination should not be done unless some exceptions.

Diagnosis- this condition is majorly diagnosed by the clinical manifestation but U/s can be used to confirm and grade it. Vaginal examination is alternative only when U/s is not available and termination of pregnancy is planed.

Management- the management of placenta previa differs according to:

The amount of bleeding

The condition of the mother

The location of placenta

The stage of pregnancy

A. Aggressive (active) management- if the amount of bleeding is life threatening, immediate resuscitation and emergency C/S delivery is mandatory what ever the gestational age is and where ever the location of placenta is.

Even with minimum bleeding if:-

The GA is greater than 37 complete weeks

There is fetal distress or fetal death

There is spontaneous active onset of labour; termination of pregnancy will be done.

This can be done either by:

Induction of labour- if it is grade I and II anterior or

C/S- if it is grade II posterior, III and IV

B. Expectant (conservative) management- is maintaining the health of the mother till term. After admission if the above conditions are absent, the pregnancy should continue till full term by closely monitoring the mother

Complete bed rest

Routine ferrous sulphate supplementation

Avoiding coitus and other vaginal manipulations

2. Abruption placenta

Definition- is a premature separation of normally implanted placenta before the third stage of labour or before the delivery of the baby but after the 20 wks of GA.

Cause- there is no exact single cause of abraptio placenta but there are a number of factors that will increase the risk of getting abraptio placenta.

@ Hypertensive disorders of pregnancyµ

@ Trauma to the abdomen

@ Sudden decompression of uterine volume as in case of:

Rupture of membrane of poly hydraminous mother

After the delivery of first twin

@ External cephalic version

Clinical manifestation

Vaginal bleeding- usually small in amount and dark red in color

Abdominal pain- ranging from labour like pain up to un relenting pain

Abdominal tenderness-

Fetal distress or death

NB:-the maternal vital sign change is not proportional to the degree of blood loss. Why?

Diagnosis- it is usually diagnosed by the clinical manifestation. If the mother comes with the above clinical manifestation, the health personnel should ask for any history of:

♫ Hypertensive disorder of pregnancy

♫ History of trauma

Management- resuscitation is the first line management.

Secure IV

Determine hematocret and blood group

Prepare at least two units of compatible blood

RH factor assessment, if negative gives her 300µg of anti D

Labour will start spontaneously with in hours

If do not start spontaneously and if the GA is less than 37 wks and if the mother and fetal condition is well, continuing pregnancy till term is possible. But if the GA is greater than 37 wks and if the maternal and fetal condition is not well, induction of labour is mandatory.

Complication

Sever bleeding

Shock

Acute renal failure

Post partum hemorrhage

Fetal distress

IUFD

3. Vasa previa - is a bleeding from the fetal circulation secondary to velmentosa insertion of cord. It is a rare condition but it is associated with a high degree of fetal death.

Clinical manifestation

Pain less bright red bleeding

May confuse with placenta previa but in this case the bleeding usually follows rupture of membrane.

Diagnosis

♫ Apt test will be done to detect the presence of fetal blood in the bleeding

Some amount of vaginal blood will be mixed with same amount of 25% sodium hydroxide.

Maternal blood will turn light brown where as that of the fetus will not be because of its resistance to alkali.

Management- emergency cesarean section because even small amount of bleeding is fatal to the fetus.

Rh and ABO incompatibility

Rh incompatibility

Definitions

Rh incompatibility- is the presence of different Rh types in the blood of two persons. in obstetrics women and her fetus mostly when the fetus is Rh positive (possess D antigen in his RBC) and when the mother is Rh negative (her RBC lacks the surface antigen D).

Rh iso-immunization (Rh sensitization) - is the production of antibody against the Rh factor by an Rh negative women following exposure to Rh positive cells.

Pathophysiology-for iso-immunization to occur the following preconditions must be full filed.

1. RH negative mother must carry Rh positive fetus.

The chance of a mother who is Rh negative having Rh positive fetus will depend on homo or heterozygosity of the father according to the mendelian law.

Table 6.1 -if the father is heterozygous

D D

d Dd Dd

d Dd Dd

Table 6.2- if the father is homozygous

D d

d Dd Dd

d Dd Dd

The chance of the fetus being positive is 100%

The chance of the fetus being positive is 50%

2. The Rh positive blood must enter the maternal circulation.

Ideally placenta doesn’t allow communication of maternal and fetal blood but due to different reasons there is a leakage of blood in placenta which is called feto-maternal hemorrhage. Among the reasons the known once are:

Trauma

Abortion

Ectopic pregnancy

APH

Manipulation of the uterus like:

Amniocentesis

External cephalic version

3. The mother must produce Rh antibody.

An individual who is Rh negative does not normally carry antibodies to the Rh factor. But if by some meance Rh positive RBC enter her circulation they alert the immune system and The maternal immune system will respond by producing anti D antibody of IgM type to destroy the foreign protein but because the IgM type is too big to pass through placenta it will not affect the current fetus (99%) but this type of communication in the next and subsequent pregnancy will result in the production of IgM type of anti D antibody which will pass the placenta and will result in serious complications. Once formed these antibodies are permanent.

Complications

Hemolytic anemia

Erythroblastosis fetalis- the presence of large number of nucleated RBC in fetal circulation to cope the hemolytic anemia

Hydrops fetalis- is a generalized edema and collection of serous fluid in the body cavity of the fetus which may be secondary to:

Portal hypertension secondary to the obstruction due to destruction of RBCs.

Fall of serum albumin as a result of the replacement of liver parenchyma by hematopoietic tissue

CHF and tissue hypoxia secondary to progressive anemia.

Jaundice

Fetal death due to sever kernicterus or sever anemia

Management- the management will depend on which stage the problem is

A. Un sensitized pregnancy (negative comb’s test)

♫ Monitor the combs test and report it during the 28th and 36th weeks of pregnancy

If positive manage as sensitized pregnancy but

If negative:

♫ Provide 300 µg anti D gamma globulin at 28, before procedures that will increase the risk of FMH like amniocentesis, APH, ECV, abortion (if less than 12 wks, 50µg) etc with in 72 hours of the procedure.

♫ Immediately the baby is born, the cord must be clamped in order to prevent further Rh antibodies from entering the circulation.

♫ Following delivery determine the blood group and Rh factor of the fetus

If negative no further management is indicated

Ife positive,

♫ Doing direct coomb’s test is mandatory to determine the presence or absence of antibody.

♫ If the test is negative provide anti D with in 72 hour of delivery (300µg)

♫ If the test is positive monitor the fetus for all complications and manage the second pregnancy as sensitized.

B. Sensitized pregnancy- because these women need special follow up early referral is the correct approach in health center setting. But if you are in referral setting,

♫ Measure antibody level at regular interval

♫ Amniocentesis for bilirubin level

♫ All babies whose mother have Rh antibody should be transferred to neonatal intensive care unit.

♫ After delivery photo therapy and exchange transfusion can also be done

ABO incompatibility

This type of incompatibility is when O blood grouped mother carry a baby of either A or B blood groups. Unlike Rh incompatibility, in this type the mother has naturally occurring antibody against A and B blood groups (anti-A and anti- B). Because these antibodies are of IgM type, they are too big to cross the placenta. But if the fetus blood leaks to the maternal circulation, the mother immune system will produce anti bodies similar to anti A and anti B but of IgG type which can pass the placenta so that they can destroy the fetal RBCs that carry the A and B antigens.

Unlike the Rh iso-immunization, this condition may affect the first child as much as the subsequent child but the complications are not as such severing as that of the Rh once.

ABO incompatibility will prevent Rh iso-immunization. How?

Premature rupture of membrane

Definition- is a rupture of membrane at least one hour before the onset of labour, but after 28 weeks of GA.

Latency period- is the period between the time of rupture of membrane and the onset of true labour. If the latency period extends more than 24 hour, it is called prolonged rupture of membrane.

Classification-

It can be either preterm PROM (rupture of membrane after 28 wks of GA but before 37 complete wks) or

Term PROM (rupture of membrane after 37 complete wks but a hour before the onset of labour)

Etiology- there is no exact single cause for PROM but, conditions that will either increase the intra uterine pressure or that will reduce the strength of membranes may be responsible. These conditions include-polyhydraminous

-Multiple pregnancy-Cervical incompitence-trauma-Infection

Clinical manifestation-

@ History of sudden gush of fluid per vagina@ Persistent uncontrolled leakage

Diagnosis-

On physical examination,

♫ moist perineum and Amniotic fluid may be seen flowing from vagina

♫ NB:-PV is contraindicated in mothers suspected of having PROM unless delivery is planned with in 24 hour. Instead sterile speculum examination will be done to confirm the diagnosis.

Additional tests to confirm the diagnosis

♫ Niterazine paper test- change from yellow to deep blue.♫ Litmus test- change from red to blue.♫ Ferning test-

Management- the management of PROM depends up on co existing condition like:

Presence or absence of complication Presence or absence of labour The GA of pregnancy

In the presence of complication like chorioamnitis, fetal distress and fetal death , the management should be termination of pregnancy either by induction or abdominally.

In the absence of the above complication the management depends on the GA of pregnancy.

o If the GA is 34 or above, the risk of intra uterine infection is higher than the risk of

prematurity. Therefore delivery of the fetus either by induction of C/S should be done.

o If the GA is less than 34wks, the risk of prematurity is higher than the risk of intra uterine

infection. Postponing pregnancy while closely monitoring the complications is the management of choice.

Admit the women Every six hour monitor her vital sign Every day monitor

Uterine contraction Uterine tenderness Odor and color of the vaginal discharge Fetal well being (FHB and thick chart) WBC count

Weakly monitor fetal growth by fundal height or by U/S the maturity of the lung

Complication-

chorioamnionitis- intrauterine infection of the membrane is the most common and sever complication of PROM.

Clinical manifestation- fever with chilis

@ Adominal pain@ Offencive amniotic fluid@ Uterine tenderness@ Maternal as well as fetal tachycardia

Management- administration of broad spectrum antibiotics (ampicilline and gentamycine)- Antibiotics should continue after termination of pregnancy and to the neonate

intramuscularly.

Cord prolapsed Preterm labour Oligo hydraminous Abruptioplacenta Neonatal infection like:

Congenital pneumonia Sepsis

Abnormality of Amniotic fluid1) Poly hydramnious

Definition- is the prescence of abnormallu high amount of amniotic fluid (volume of more than 2000 ml)

Type-hydramnious can be acute or chronic.

Chronic poly hydramnious- this type is:o Gradual onset

o It is usually starts from about 30th wk of pregnancy and

o It is sthe most common type

Acute poly hydramnious-o it usually occurs at about 20 weeks

o comes on very sudden onset (the uterus will reach xiphisternem in about 3-4 days)

o it is very rare type

Etiology

Majority (>60%) of the poly hydramnious is ideopatic

The rest arises either from the condition that increase the surface area of the placenta or disrupt the integument of the fetus or hamper the normal swallowing process of the fetus.

Oesophageal atresia of the fetus Tracheoesophageal fistula Open neural tube defect of the fetus

o Spinal bifidao anecephally

placenta tumor for example Chorioangioma, a rare tumour of the placenta Multiple pregnancy, especially in the monozygotic twins Maternal diabetic mellitus Rarely, Rhesus- isoimmunization

Clinical manifestation The mother may complain of breathlessness and discomfort If it is acute one, she may have severe abdominal pain Exacerbation of symptoms associated with pregnancy such as:

Indigestion, Heart burn Constipation Oedema and varicosities of the vulva and lower limbs may be present.

Diagnosis Abdominal examination

On inspection The uterus is larger than expected for the period of gestation and is globular in

shape the skin appears. Stretched and shiny with marked strike gravidarum and obvious superficial blood

vessels. On palpation- the uterus feels tense and it is difficult to feel the fetal parts but the fetus

may be balloted between the two hands. Ascultation auscultation of the fetal heart is difficult because the quantity of fluid allows

the fetus to move away from the fethoscope. Ultrasound- will be used to confirm the diagnosis

AFV- a finding of more than 8 cm is an indication of poly hydramnious AFI- when it exceeds 24 cm it is an indication of poly hydramnious

Management- the management of poly hydramnious is best done in well equipped setting capable of handling the complications.The cause of the condition should be determined if possible the mother will usually be admitted to a consultant obstetric unit.Subsequent care will be depending on:

1. The mother’s conditiona. Mild asymptomatic poly hydramnious is managed expectantly. These women will not

usually be admitted to the hospital but will be advised to be admitted to the hospital immediately the membrane rupture.

b. If the hydramnious is sever, Amnio reduction will be done even if it has its own complications like:

o Infection will be introducedo Labour will be provokedo The fluid will rapidly accumulate again

Administration of drug indomethacin reduces fetal urine production and consequently amniotic fluid.

2. Cause of the poly hydramnios a. If the cause is gross fetal malformation like anacephally, labour will be induced.b. In the absence of this, termination should be delayed as much as possible until fetal

maturity.

3. The stage of pregnancya. In late pregnancy the mother may need to have labour induced if the symptoms become

worse but:The lie must be corrected if not normalThe membrane will be ruptured cautiously; allowing the amniotic fluid to drain out slowly in order to avoid altering the lie and to prevent cord prolapse placental abruption is also a hazard if the uterus suddenly diminishes in size.

Complications During pregnancy

Increased fetal mobility leading to unstable lie and mal presentation Premature labour Cord presentation

During labour Cord prolapse Premature rupture of the membranes Placental abruption when the membranes rupture

After labour Postpartum hemorrhage

2) Oligo hydramnious

Defntion- the prescence of abnormally low amount of amniotic fluid (less than 500 ml)

Etiology

♫ Prolonged rupture of membrane is the most common cause♫ Post date pregnancy♫ IUGR♫ Renal agenesis♫ Drug such as angiotensin converting enzyme inhibitors

Diagnosis Abdominal examination

On inspection –SGA uterus- Reduced fetal movement

On palpation- fetal parts are easily palpable Ascultation – is normal

Ultrasound- will differentiate from IUGR

AFI-will be less than 1-2 cm AFV-will be less than 5-7 cm

Complication

Pluminary hypoplasia Cord compression Amniotic bandage syndrome IUFD

Management@ Admission@ If there is gross fetal anomaly like renal agenesis because the baby will not survive, termination of

pregnancy is the management of choice@ If fetal anomaly is not present, sustaining pregnancy till full term is the best management

Medical disease during pregnancy

1. Anemia in pregnancy Definition- anemia is a reduction in the oxygen carrying capacity of the blood. During pregnancy for a mother to be anemic the hemoglobin count must be 11g/dl or less and/or the hematocrit must be < 33.Incidence- it affects 5-50% in developing but only <2% in developed country.Cause

Majority of the anemia during pregnancy are nutritional anemia; from which Fe deficiency accounts 80-95% while megaloblastic anemia (anemia from vit B12 and folate deficiency) accounts only 3-4%

Other causes Hemolytic anemia Anemia of chronic illness Leukemia Hemoglobinopathy

Predisposing factor for Fe deficiency anemia1. Reduced intake Food taboos Poor dietary habit Low socioeconomic status2. Reduced absorption GI disturbance (diarrhea, hyperemisis) Intrinsic factor deficiency3. Excess demand Multiple pregnancy Chronic illness4. Low store at the beginning of pregnancy Short interval between gestations5. Blood loss during pregnancy

Menorrhagia Hookworm Malaria

Pathophysiology Iron requirement during pregnancy increase (to around 1000mg)

Maternal RBC and uterine muscle- 450 Fetal RBC production- 270 Placenta- 90daily loss- 190

There is an additional demand for blood loss during pregnancy (190) and lactation (1mg per day) Assuming normal store a mother should take 3.5 mg/day avragly Failure to meat this demand eventually leads to anemia

Treatment- Depends on: The cause Severity and GA of pregnancy

I. Iron deficiency anemiaA. Oral Fe

♫ Ferrous sulphate 100mg PO ♫ Continue for 3 month after HgB returns to normal♫ Ferrous fumerate♫ Ferrous gluconate

B. Parentral rout♫ In case of intolerance of oral Fe treatment♫ If no improvement in oral FE treatment♫ If very sever anemiC. Blood transfusion

♫ Packed RBC should be given♫ Sever anemia with hemoglobin <404 g/dl♫ If there is congestive heart failure♫ Anemia with sepsis♫ Anemia of hemoglobin <6.7 g/dl first diagnosed during labour

NB: Underlying cause should be treated (hookwarm infestation, malaria, chronic illness)II. Megaloblastic anemia

♫ Folic acid 5mg TID♫ Continue for the rest of pregnancy by 5mg/day

Complication1. Fetal

Spontaneous abortion Preterm birth Low birth weight IUGR Still birth

2. Maternal CHF Pluminary edema specially in labour Delayed wound healing Increase risk of infection

Prevention of anemia Improve diatery habit Prevent and treat hookworm (deworming) and malaria Child spacing (family planning) Supplementation of Fe and folic acid for all pregnant women Fe fortification of staple diets

Cardiac disease in pregnancyIntroduction

A women with a known cardiac illness can become pregnant or a healthy pregnant women can develop cardiac illness while pregnancy.

The increase hemo dynamic burden of pregnancy, labour and delivery can aggravate or develop cardiac illness

The risk is higher around 24 wks of GA, labour and immediate post partum In labour uterine contraction increase the CO by 20%

Classification- the degree of disability of cardiac disease according to the New York heart association classification is as follows

Class I- no symptoms limiting ordinary physical activity Class II- slight limitation with mild to moderate activity but no symptom at rest Class III- marked limitation with less than ordinary activity (dyspnea or pain on minimal activity) Class IV- symptom at rest or with minimal activity

Management- With rare exception women in class I and II (most) go through pregnancy with normal but As much as possible patients in class III and IV should avoid pregnancy Therapeutic abortion is the best option in early pregnancy If pregnancy continues prolonged hospitalization and bed rest is necessary Once diagnosed the mother should be referred for specialized care by obstetrician, internist and

neonatologistAnte partum care

Bed rest Moderate dietary restriction Diuretics (chlorotiazides are accepted with potassium supplementation)

Intrapartum care unless contraindicated vaginal rout is preferred because these mothers tolerate major surgical

procedures poorly conduct labour in lateral decubitus position provide pain relief restrict IV fluids provide oxygen and pulse oxymetry shorten the second stage of labour by instrumental delivery do not use ergometrine rather use oxytocin in the third stage of labour

Post partum keep the mother sitting to prevent post partum pluminary oedema

early ambulate the mother to prevent thrombosis

Complication of cardiac disease during pregnancy

are one of the most important non obstetric disability and death of pregnant women

maternal mortality rate ranges from 0.4 in class I and II to 68% in class III and IV

adverse fetal out come like

spontaneous abortion preterm labour low birth weight baby IUFD

2. Hypertensive disorder of pregnancy

Definition of terms

Hypertension during pregnancy-

Single blood pressure 160/110 mmHg

Two cosequative blood pressure measurements of 140/90 mmHg 6 hrs apart

Sever hypertension in pregnancy-

Single diastolic measurement of 120 mmHg

Two cosequative diastolic blood pressure measurements of 110 mmHg 4 hrs apart

Protienurea- presence of protein in the urea

Significant protein urea-

Quantitative- urinary protein excretion of greater than 300 mg or more per 24 hour urine collection

Qualitative- +2 or more protein on dipstick of two clean catch midstream specimens of urine collected at least 4 hour apart.

Pathologic oedema

dependent oedema that persists after night rest

Non dependant oedema that involve face, hand…

Abnormal weight gain >1 kg/wk

Type- according to the National High Blood Pressure Education Program Classification

Gestational hypertension - is a recurrent mild hypertension that develop between 20 WKs and 24 hour post partum with out any other sign of preeclampsia and that resolves with in 10 days postpartum.

Chronic hypertension – hypertension present before 20wks of gestation and persists after six wks postpartum.

Preeclampsia Eclampsia syndrome

Preeclampsia - is the occurance of hypertension, significant protein urea and pathologic edema after 20 WKsof GA and that resolves before 6 wks post partum. It can be classified

as sever and mild hypertension

Sign and symptoms of sever preeclampsia

♫ Sever HTN♫ Protein urea

o 5 gm or more quantitative

o > +3 or more qualitative

♫ Oligourea (<400 ml/24 hr)♫ Epigastric or right upper quadrant pain♫ Thrombocytopnea♫ Cerebral symptoms like:

o Frontal or occipital headache

o Blurring of vision

♫ IUGR♫ Pluminary edema♫ Acute left ventricular failure♫ HELLPs syndrome

o Hemolysis

o Elevated liver function test

o Low platelet count

Eclampsia-is a tonic clonic convulsion or coma occurring during pregnancy, labour or with in 7 days post partum.

- It is a complication of preeclampsia- It occurs antepartum 50%, intra partum25% and post partum 25%- Must be un related to other cerebral conditions like epilepsy

Superimposed preeclampsia upon chronic hypertension - is the worsening of hypertension (+ 30/15) and worsening or development of protein urea with or with out edema.

Incidence of HDP 7-10% of all pregnancies end with HDP Preeclampsia occurs in 5% of pregnancy accounting for 70% of HDP Eclampsia 0.1-0.5%

Etiology of preeclampsia The exact cause of preeclampsia is unknown A number of theories are forwarded, so preeclampsia is called a disease of theories.

Risk factor for preeclampsia Nulliparity Extreme reproductive age (les than 20 and grater than 35 years) Hyperplacentosis

Multiple pregnancy Molar pregnancy

New paternity

Family historyDiagnosis- The diagnosis of HDP is straight forward. The major task is to differentiate and identify presence of complication1. History- should include

Gravidity, parity Gestational age History of new paternity History of pathologic edema

Leg swelling that persists after night rest Tightness of the ring Puffiness of the face

Family history of HTN Prescence of convulsion Persistence headache Blurring of vision Epigastric or right upper quadrant pain Visual symptom, neurologic symptom and cardiac symptom

2. Physical examination

B/P Weight Pitting Edema- pedal, peritibial, abdominal, periorbital edema and ascites Decrease fetal movement Decrease growth

3. Laboratory

Urine analysis Midstream urine for dipstick >+2 24 hour urine protein >300mg Oligourea Low Platlet count

4. Ultrasound

Management

1. Preeclampsia

A. Aggrieve management- is terminating pregnancy immediately Termination of pregnancy is the defnative management and curative treatment of preeclampsia

resulting in the resolution of the condition with in 48 hours. Most appropriate for the mother Indication of aggressive management

@ GA >37 complete wks@ Mature fetus@ Sever preeclampsia@ Worsening of preeclampsia despite conservative management@ Eclampsia@ HELLPs syndrome@ Fetal compromise

Fetal distress IUGR

Component of management Administer short acting antihypertensive drug like

o Hydralizine(5mg IV stat followed by 5mg in 10 min then 5-10mg every 20 min to a max

of 60mg)oro Nifedipine (10mg sublingual to be repeated after 30 min & immediately the DBP is 110or

more) Start infusion of parentral anticonvulsant using:

o diazepam (10-20mg by IV bolus for 2-3min followed by slow IV infusion of 30-

40mgin 100ml of 5% dextrose in water for 24 hour. 10mg IV bolus can be repeated if convulsion recur)

o MgSO4 can be used instead of diazepam

Decide mode of delivery (vaginal Vs C/S)o Due to the anesthetic risk C/S is not preferable unless there is contraindication for

inductiono Shorten the second stage of labour by instrumental delivery

o In the third stage do not use ergometrine rather use oxytocin

Continue giving antihypertensive and anti convulsant infusion for at least for 24-48 hours post partum

Continue monitoring

B/P Level of consciousness and Urine out put

B. Conservative management- if termination is not indicated, admit the mother in a hospital setting Bed rest in left lateral position

Do not restrict salt intake rather restrict visitoirs

Record B/P frequently 15 min -6hour depending on severity Daily check

Headache Blurring of vision Right upper quadrant pain Urine out put Fetal movement by kick’s chart Extent of edema FHB Urine

Weakly monitor

fetal growth either by U/S or fundal height Uric acid Renal and liver function test Platelet count Weight

Start medium acting antihypertensive drug like Alpha methyl dopa(250-500mg 6 hourly) only if the DBP is 100mmHg

Diuretics and angiotension converting enzyme inhibiters are contraindicated

Once the condition of the patient is stabilized,

B/P between 140-160/110-90mmHg Protein urea is <+1 in dipstick or <500mg in 24 hour urine collection No fetal jeopardy she may be followed out patiently

Out patient management include frequent ANC follow up with

B/P and random urine protein at least twice per week

Daily fetal movement counting by the mother

She must report immediately when there is any danger sign

2. Eclampsia- is an acute obstetric emergency which if not managed appropriately results in the death of the mother and fetus

The objective of this management is:1. Control of convelsion2. Control of HTN3. Terminating pregnancy regardless of the GA

Component of management Emergency resustation (ABCs)

Clear the air way Check and assist breathing

Oxygen administration Artificial respiration if there is respiratory arrest

Check circulation and start IV line Prevent trauma to tongue by inserting a moth gage Catheterize the bladder Start short acting antihypertensive drug like

@ Hydralizine(5mg IV stat followed by 5mg in 10 min then 5-10mg every 20 min to a max of 60mg)or

@ Nifedipine (10mg sublingual to be repeated after 30 min & immediately the DBP is 110or more)

Start infusion of parentral anticonvulsant using:@ diazepam (10-20mg by IV bolus for 2-3min followed by slow IV infusion of 30-40mgin 100ml

of 5% dextrose in water for 24 hour. 10mg IV bolus can be repeated if convulsion recur) Terminate pregnancy as previous Start prophylactic ABCs Monitor patient as that of aggressive management more aggressively. For example vital sign

including RR, PR and To must be taken every half to one hour Continue monitoring for 24 hour up to 40hour after delivery if the patient convulses later than 48 hour after delivery other possible cause should be

entertainedComplication of preeclampsia

♫ eclampsia♫ abraptio placenta♫ acute renal and hepatic failure♫ HELLPs syndrome♫ DIC♫ Cerebral hemorrhage♫ Pluminary edema ♫ Heart failure♫ IUGR & IUFD

3. Infectious disease during pregnancy 1) Malaria in pregnancy- due to the immunity relapsing rate of dominant extra erythrocytic stage will

increase

Effects-

Maternal- anemia- Puriperial sepsis

Fetal Spontaneous abortion Preterm labour IUGR IUFD

Management-once diagnosed it should be treated aggressively

If sever inpatient management and parental anti malaria drug

Drug use depends on the type of the plasmodium

Chloroquine and quinine are safe during pregnancy

Prophylaxis given for non immune people traveling to endemic area

The drug should be taken 1-2 wks before travel and should continue 4 wks after travel

2) HIV/AIDS during pregnancy