Fatimah Ahmed Hamattu Alhawsawi,

MD, Obstetrics & Gynecology

MNGHA-RD
Outline
• OBGYN alphabts (history and focused physical examination),
• Overview of maternal adaptation during pregnancy
• Diagnosis of pregnancy.
• Antepartum care.
• Amionitic fluid.
• Assessment of baby well being.
• How to read CTG?
• Common medical and surgical disease during pregnancy
• Gestational Trophoblastic disease & neoplasia
OB/GYN History..
1. Patient data. + GPAL ‫ﺟﺒﻞ‬J
1. G: Graviditiy (any confirm pregnancy, regardless gestational age (GA))
2. P: Parity (any pregnancy >20 weeks regardless viability)
3. A: Abortion (any death <= 20 weeks OR <=500g)
4. L: Living birth.
1. Gestational age
2. Chief complain + Duration.
1. Obstetrics: Bleeding – Discharge – Pain …
2. GYN: Infertility, pain, PCOS Sx, Incontinence…
3. History of presenting symptom
OB/GYN History..
4. Menstrual history
1. Age of Menarche, Last Menstrual period (LMP), cycle length, bleeding ch.,
Estimated date of delivery (EDD), Gestational Age (GA) : (3 M=13 Weeks)
5. Contraceptive history.
6. Obstetric history.
- Each pregnancy: current (+ve, -ve symptoms), previous (date, duration, mode
of delivery, complication during and after). Outcome: weight, APGAR, …
7. Infertility
8. PMH/ PSH/ Social/ Family Hx/ functional ..
OB/GYN Examination..
Specific..
- Abdominal Examination:
- Inspection: distended abdomen, visible fetal movement, striae, linea nigra ..
- Palpation: Leopold maneuvers
Pre-Palpation, words to know ..
• Lie: relation of the long axis of the fetus with the maternal long axis.
• Longitiudinal – Transverse
• Presentation: presenting part.
• Breech – cephalic – …
• Position: relation of presenting part to the right or left side of maternal
pelvis.
• Occiptu anterior – occiptu posterior …
Leopold Maneuvers
Fundal hight
• After 24 weeks: 1 cm = 1 week
• 37-40 weekàbaby start to desend
OB/GYN Examination..
Specific..
- Pelvic Examination:
- Inspection.
- Palpation: BISHOP score, …
- Tests: GBS, PAP smear

- AVOID in pregnant with VAGINAL Bleeding

and (Decrease) pre-mature rapture of membrane.
BISHOP Score
• Effacement: shortening of the cervical canal.
• Bishop <6 = unfavorable cervix. (not universally)

• Effacement: shortening of the cervical canal.

• Station: a level of fetal presenting part in the birth canal in relation to
the ischial spine.
Maternal adaptation
during pregnancy
 Marked increase in cardiac out put (30-50%)
First half: stroke volume. 2nd half: increase HR.;
Systemic vascular resistance decrease: effect of progestrone.

During labor: CO increase 40% above in late, ; no gravid uterus on IVC.

CVS
Blood presure: decrease

Resting maternal pulse: increase.

ECG: Left axis deviation – change in rhythm, supraventricular tachycardia

Diaphragm up by 4 cm
Hyperventilation Mainly due to progestrone.
Respiratory Compansated respiratory alkalosis, high PO2 and Low PCO2
Inc. O2 consuption
Tidal volume inc. other dec.
Kidney size, GFR àfall in serum creatinine. Decrease vascular resistance.
Hydroureter and hydronephrosis (mainky in the right)
Renal system Early: inc. frequancy - Advance gestation: inc. nocturia.
Gravid uretus affect bladder à urgency and incontinence.
-Decrease BUN, serum Createnine
 - Hypercoagulable state, Thromboembolism higher risk in puerperium than pregnancy.
- Anemia inpregnancy (<11 g/dL)
- Physiological anemia (not less than 10 g/dL)
Hematological
- Increase RBC mass à dec. Hb concentration.
- Need daily iron supplement. 30 mg/day
- Decrease hematocrit.
Thyroid: hCG à inc. T4 (in first trimester). à so supression TSH
Adrenal: inc. serum cortisol. Inc. ACTH.
Endocrine Pancreas: insulin resistance
- Pregnancy is diabetogenic state ß inc. cortisol and progesterone.
- Mainly: human placetal lactogen hPL
Gravid uterus and hormones. Change stomach and intesistine in position not in size. Liver
not change. Portal vain inc. due to inc. blood flow.
GI
Progestrone effect: relaxation of lower esophageal sphinecter (GERD) – decreased
gastrointestinal motility – impaired gallbladder contractility (Gallbladder stone).
Pregnancy is ch. By hyperpigmentation.
- Vascular spiders
Skin - Palmar erythema
- Striae Gravidarum
- Linea nigra
Linea nigra
Striae Gravidarum
Diagnosis of Pregnancy
Initial prenatal visit
1. Comperhensive history is taken.
2. Complete physical examination is performed.
• Including obstetrics pelvic examination
Diagnosis of Pregnancy
• History: Amenorrhea –missed period in reproductive age women- ,
N/V, Breast enlargment, inc. frequncy of urination without dysuria,
Fatigue.
• O/E: Uterus more globular, cervix soften, mucus membrane may
bluish.
• Chadwick sign: dark discoloration of vulva and vaginal walls.
• Lab. Finding:
• B hCG
• Serum: 6-8 days, after ovulation. (and repeated after 2 days)
• Urine.
First Ultrasound:
• Confirm intrautrine pregnancy, à useful in suspected ectopic
pregnancy
• Any pregnancy is Ectopic until proven otherwise
• Dating: Early pregnancy US Estimation SUPERIOR to LMP.
• Confirm cardiac activity
•…
Calculate gestational age(GA), EDD,
• Naegele’s rule LMP-3 Month +7 days + 1 year
• 3/10/2020= 10/7/2021
In Regular period, 28 days
• Hijri LMP – 3 Month + 14 days + 1 year
• 1/2/1441= 15/11/1442
• Definitions:
Early preterm Born before 34 weeks.
Late pre-term Born between 34-36 weeks.
Term neonate Neonate born at any time after 37 weeks
Post date neonate Born after 40 weeks
Post term neonate Born after 42 weeks
 Transvaginal Ultrasound Abdominal ultrasound
6 weeks (from last menses) 9 (12 weeks)
Cardiac activity Or hCG 17,500 IU/L, 16-20 week (by stethoscope)
mean sac diameter 5 mm
5 weeks or hCG >1500 IU/L,
Gestational Sac
mean sac diameter 25 mm
7-8 weeks
Fetal movement
Primigravida: 18-20 weeks Multiparous: 15-17 weeks.

Timing and frequency

First Scan First trimester: 7-10 (or 11-14 weeks for nuchal translucency)
Second scan Second trimester: 18 to 20 week; for anatomical survey, growth and dating.
Third scan For fetal growth and amionitic fluid.
If high risk: 1) 32 weeks. 2) 36 weeks.
• CRL: Crown-rump lenghth: measurement of length of human
embryos and fetuses from the top of head to the bottom of the
buttocks.
Most accurate method to establish or confirm GESTATIONAL AGE

Equipment calculate Estimated gestational age and Fetal weight:

1. Biparietal diameter
2. Abdominal circumference
3. Femur length.
• How to know fetal weight intrapartum in 37w?
•

• — Femur length
• — head circumflex
• — Biparietal diameter
• — Abdominal circumference (Answer)
Fetal Demise!
1. (Anembryonic pregnancy) A Gestational sac>= 25 mm WITHOUT
yolk sac or embryo.
2. An embryo with CRL >=7 mm WITHOUT cardiac activity.

3. After a pelvic US: GA WITHOUT yolk sac, absence of an embryo

with a heartbeat in >=2 weeks
4. After a pelvic US: WITH a yolk sac, absence of an embryo with a
heartbeat in >=11 days.
Antepartum care
• Nutrition and wight gain (2.72 kg/month), (11-16 kg)
• Exercise, Breast feeding
• Vaccine: PITCH
Medication
• AVOID: (ACEi, methotraxate, Lithium, Tetracyclines, Quinolones)
• SSRI: Paroxetine, if she on it cont. but no to start.
• Safe: nitrofurantoin, methyldopa and hydralazine,
• Ceftriaxone can use in pregnancy.
• Travelling
 Folic Acid supplementation
recommendation
History of neural tube defect 12
High Risk 4 mg
• Women take antiepileptic drug weeks
Advanced liver disease, 12
Moderate Risk 1 mg
week
Low risk pregnancy 12
Low Risk 0.4 mg
week

Sickle cell pregnant women reccive 5 mg/day for whole pregnancy

AED
• MOA:
Antenatal Investigation (Detect fetal
aneuploidy)not only
Non invasive Diagnostic test: Invasive Techniques for early
1. Maternal Serum Screen prenatal testing:
2. Nuchal translucency 1. Amniocentesis
3. Nuchal + Biochemistry 2. Chronic Villus Sampling
4. US
Non invasive test:
1. Maternal Serum Screen (MSS): (if +ve there is high chance)
• Triple test: (1) AFP. (2) hCG. (3) Estriol
• Quad test: + (4) Inhebin A
• False +ve in Wrong date, Twins
• Values adjusted with Maternal AGE
Timing of Maternal serum screen:
• First Trimester Screening. (10-13 weeks) : PPA, bhCG & US nuchal
• Second trimester screening (16-20 weekks): Standerd approach.
• Combined First and Second trimester screening.
• Integrated screening.
• Sequential screening.

• Third trimester screen:

• Glucose challenge test
• GBS (32-36 weeks)
Non invasive test:
2. Nuchal translucency: measure fluid back to fetal neck.
• At 11-14 weeks.
If it is increased?
• Chromosomal abnormalities, as Down
• Birth defect (Cardiac, Hernia)
• Genetic syndromes
Non invasive test:
3. First Trimester Biochemical markers
I. PAPP-A: pregnancy asscociated plasma protein A
I. LOW before 14th weeks, increase risk of Down syndrome
II. Free B-hCG:
I. Increase assciated with increase risk of Down syndrome
 Down Syndrome
High: hCG + Inhebin A
Low: AFP, Estriol
Non invasive test:
4. US
• Ex. Neural Tube defect (NTD)
• 1st Trimester (12-14 weeks)à TVU
Invasive Techniques for early prenatal
testing
• For definitive karyotype diagnosis.
• If have +ve sonographic abnormalities or Advace maternal age >32
Invasive Techniques for early prenatal
testing
Amniocentesis:
• Perform at or more 15 weeks
• Pregnancy loss 1/200
• Get risk of Trisomy (13,18,21), Turner syndrome in 48 hours with
FISH.
Chorionic Villus Sampling:
• At 10-14 weeks
• Pregnancy loss 1/100
• Associated with limb reduction
Amniotic fluid
• Embryonic period
• Early fetal period.
Source of production Source of clearance
Fetal Urine and Lung Secretion Fetal swallowing and
Major intramembranous pathway
Secretion from the fetal oral and Transmembranous pathway.
Minor
nasal cavities
• Mid and late fetal period.
How to measure amniotic fluid?
1. Single deepest pocket: vertical dimenion in cm of the largest pocket
of amniotic fluid NOT persistently containing fetal extremities or
umbilical cord.
2. Amniotic fluid index: calculate by dividing uterus into 4 quadrants,
the maximum vertical amniotic fluid poket dimeter not containing
… ??. The sum of these measurement is AFI.
Single deepest pocket AFI

Oligohydramnios <2 cm <= 5 cm

Normal >=2 cm and <8 cm >5 and <24 cm
Polyhydramnios >=8 cm >= 24 cm
Amniotic Fluid

GIT anomalies Renal anomalies

9/14/22 Fatimah Hamattu

Assessment of baby well being
1. Self assessment
2. Non-stress test. CTG
3. Ultrasound
4. Umbilical artery doppler
1- Maternal Self assessment
Kick counting
• 10 movements in 1 hours.
• Decrease fetal movement à Do non-Stress Test.
2- Non-Sress test assessment
• First step.
• Use external doppler equipment, mother in left lateral position.
• Normal response, with each fetal movement à Acceleration in fetal
herat rate.
• 2 acceleration in 20 mintues à reactive
3- Ultrasound
1. Asses the adequacy of amniotic fluid volume by real-time.
1. Oligo-hydramnios à umbilical artery compression
2. Fetal breathing (chest wall movement) and fetal movement
(streching and rotational movement).
4- Umblical artery doppler
• Provide a non-invasive measure of the fetoplacental hemodynamic state.
• DI: doppler index
• RI: resistance index
• S: peak systolic
• D: End Diastolic
• Indication: Fetal growth restriction
And hypertension.
• Consider high risk: beyond 28 wk
S/D ratio >3.0 or RI >0.6
Absence of end-distolic
flow velocity
AEDV
Reversal of end-distolic
flow velocity
REDV

Immediate delivery
Beyond 32 weeks
EXTRA!
• Non stress test: measure of fetal Biophysical profile (BPP):
heart, whichis monitored with an 1. Reactive NST (CTG)
external transducer for at least 20
minutes. 2. +VE fetal breathing movement.
• CTG: Cardiotocography 3. +ve fetal movement of body or
limb.
4. Finding of fetal tone
5. Adequate amount of amniotic
fluid.
Score 0(absent)- 2(present)
8-10 à reassuring
• BPP 8 or more
• Normal
• BPP 6 out of 10 (equivocal)
• <37 weeks è repeat after 24 hours
• >37 could consider delivery
• BPP 4 out of 10
• Consider delivery
How to read CTG?
DR C BRaVADO
• DR: Define risk
• C: Contractions
• BRa: Baseline rate
• V: Variability
• A: Accelerations
• D: Decelerations
• O: Overall impression
Baseline variability:
the variation of fetal heart rate from one beat to the next.
Variability occurs as a result of the interaction between
the nervous system, chemoreceptors, baroreceptors and cardiac responsiv
eness.
Baseline fetal heart rate

Fetal Tachycardia >160 bpm Fetal Bradycardia

Maternal cause: • Mild 100-110, Mod 80-100
• Fever, infection • Sever <80 bpm
• Anexity
Fetal cause: • Prolonged cord compression,
• Anemia cord prolapse, Epidural
anesthesia
• hypoxia
Accelerations
• abrupt increase in
the baseline fetal heart rate
of greater than 15 bpm for
greater than 15 seconds
• The presence of
accelerations is reassuring.
• The absence of acceleration
s with an
otherwise normal CTG is
of uncertain significance.
Decelerations
• Decelerations are an abrupt decrease in
the baseline fetal heart rate of greater than 15 bpm for greater tha
n 15 seconds.
Types:
1. Early (Mirror); uterine contraction. Nadir with a peak of uterine
contraction.
2. Variable; head compression
3. Late; uteroplacental inssuffency, peak of the uterine
contraction and recover after the contraction ends.
4. Prolonged; deceleration that lasts more than 2 minutes
NICHD Classification
Overall impression
• Reassuring: all four feature that are reassuring
• Non-Reassuring: one feature non reassuring, other reassuring.
• Abnormal: 2 or more non-reassuring
NICE Classification
 Sinusidal pattern

• Severe fetal hypoxia

• Severe fetal anemia
• Fetal/maternal hemorrhage
• HTN
• DM
• Intrahepatic cholestasis of pregnancy
• Cardiac disease
• Asthma
• VTE and PE
• SLE
• Thyroid disease
• Epilipsy
• Appendicitis, cholycystitis
Hypertention (HTN) in pregnancy
Types
• Chronic HTN
• Chronic HTN with superimposed pre-eclampsia
• Gestational HTN
• Pre-eclampsia
• Eclampsia
• HELLP syndrome
Mx as preeclampsia with severe features
Chronic HTN
• Definition: BP 140/90 mmhg on tow occasions at least 4 hours apart
prior to or during first 20 weeks of pregnancy. ONLY
• Advers Outcome:
• Pre-Eclampsia (Chronic HTN superimposed Pre-Eclampsia)
• IUGR. So, Assess fetal growth after 24 weeks
• Placenta Abruption
• Treamtment:
• Indicated at BP 150—160/ 100-110
• Methyldopa (‫)ﻣﺜﺎل اﻟﺪﺑﺔ ﻣﯿﻦ؟ اﻟﺤﺎﻣﻞ‬, nefidipine and labetalol.
• ACEI is Cotraindicated. X atenolol, thizide can use if start before pregnancy
but not 1st line.
• In labor: women with sever HTN à IV Labetalol or hydralazine (as
preeclampsia with sever feature)
Chronic HTN superimposed Pre-
Eclampsia
How to diagnosed? ‫إذا ﻗﺎل ﻟﻨﺎ اﻟﻮﺿﻊ أﺗﻐﯿﺮ ﻋﻠﯿﻨﺎ ﺑﺄﺣﺪ اﻷﺷﯿﺎء اﻟﺘﺎﻟﯿﺔ‬

• Develop of protinuria
• Sudden increased HTN in previous well control
• Develop severe feature of pre-eclampsia
• BP Exceeding 160/110. (1) RUQ pain. (2) headache. (3) visual changes. (4)
Pulmonary edema (? Progressive Dyspnea and tachypnea). (5) raised Cr >1.1
or dubling, raised transaminase duble normal. (6) thrombocytopenia
<100,000.
Gestational HTN
• BP 140/90 mmhg on tow occasions at least 4 hours apart AFTER 20
weeks of pregnancy. ONLY
• May presist 12 postpartum.
• May normalized BP postpartum.
• 50% develop pre-eclampsia.
• AGAIN: if BP >160/>110 à treat as Preeclampsia with severe
features.
• Induction at 37 weeks.
 If Pre-Eclampsia Occur before
Pre Eclampsia 20 weeks à GTD
• Multiorgan disease characterized by sudden increase in BP After 20
weeks of gestation (=>140/=>90) 2 times
AND either protinuria OR sever features of preclampsia.
• If 160/110 à Diagnosed (one time).
• Proteinuria:
• 300mg in 24hours (GOLD STANDER) OR urine protein cr ratio > 0.3 OR 2
reading random dipstick (+1 or more) 6 hours apart.
• NOT for screeing. • Higher protein not indicated severe of diseaes.
• Sever features of preclampsia.
Pre Eclampsia
Risk factor:
• Pre-eclampsia in prior pregnancy
• Family history (1st degree), Afreican American
• Nulliparity
• Maternal Age greater than 40
• Mutiple gestation
• Chronic HTN, DM
• BMI high
Prevention:
• Aspirin small dose in high risk
Management of Pre-Eclampsia
Without severe feature:
EXPECTANT Mangement:
WHEN? if <34 weeks and mother and fetus stable.
• twice weekly blood pressures
• Weekly lab test (CBC, ALT, LDH, Uric acid and creatinine)
• Twice weekly non stress test
• Weekly biophysical profile.
• Medications: Oral antihypertensive and corticosteroid.
• Fetal growth US every 3 weeks, if IUGR à Do doppler, if reversed à
deliver (if less 34 week give steroid).
Management of Pre-Eclampsia
Without severe feature:
• Hospitalization and delivery indicated if
• >37 weeks
• Suspected placenta abruptio.
• Pregnancy >34 weeks +
• Labor, rapture of membrane.
• Oligohydramnios.
• Abnormal maternal and fetal test result.
Management of Pre-Eclampsia 1) Mg Sulfate
With severe feature: 2) HTN med
• Admission, bed rest and careful monitor. 3) Ca (if)
GOALS: HOW to monitor Mg?
• Prevent seziure. Mg sulfate - Reflexes
• Lower BP to prevent maternal cerebral hg - Mental status
(Hydralazine IV OR Labetalol IV OR Nephidipine PO) - Respiratory status
- Urine Out put
• Expedite delivary, based on fetus and mother status.
Fetal surveillance:
• NST, Amiontic fluid measures and BPP à to assess Uteroplacental
inssuffciency
UOP should
above 30 ml/h
Management of Pre-Eclampsia DELIVARY
Is the ONLY
With sever features Cure
Indication for delivery: ?? Placenta is a source
• >34 weeks
• <34weeks with maternal/fetal instability.
• (immediate delivery after stabilization)
• 24-48 after corticosteroid
• Vaginal delivery should be conducted (not indication for CS)
• Postpartum: still risk for eclampsia, so continue Mg sulfate for first
12/24 hours.
Eclampsia
• Severe form of preeclampsia with convulsion seziures and/or coma.
Treatment:
• Stabilized the patient (airway, o2)
• Anti convulsion Mg sulfate; prevent next attack
• left lateral position
• Can go for expectent if <34 to use corticosteriod but see benefit and risk
• Deliverd once stable and seziure stopped
Pre-Existing DM

Maternal effect Fetal effect

• Increase risk of miscarriage • Increase risk of congintal
• Increase risk of preeclampsia abnormalities ((1)sacral Agnesis, (2)
nural tube defect, (3) congnital heart
• Increase risk of infection disease)
• Increase risk cesarean rate • IUGR
• Increase insulin requirments. • Increase risk of unexplained sudden
IUFD, late Still birth, cardiac
anamolies
• Perinatal mortality
• Neonatal hypoglycemia
Pre-Existing DM
• Preconception counsling: A1C <7% or <10% (different referance)
• Antenatally : A1C<6% (avoid hypoglycemia)
• Ophthalmology visit each trimester.
• Insulin is preferd use in pregnancy.
GDM
• After 20 weeks. (after first trimester)
• Risk factors: prior GDM, Age, Obesity, PCOS, FHx, prev. macrosomia
IUFD
• Adverse effect:
• Macrosomia (>4500gm) à shoulder dystocia, obstreicted labor, CS.
• Neonatal hypoglycemia,
• Presentation: not usually have symptoms.
Screening:
• High risk mother: screening done at First Antenatal visit
• BMI>25, FHx, GDM Hx, …
• Not at high risk:
• Could be for ALL women.
• Screening at 24-28 weeks due to increase Human Placental Lactogen (HPL),
TNF-Alpha.
Screening
• METHODS
• one step:
• 75gm OGTT, (sample: Fasting 8hr, after 1hr, after 2hr) anyONE reading abnormal
consider GDM
• Fasting >= 92mg/dl – 1hour >=180mg/dl – 2hours >= 153mg/dl
• Tow step:
• No fasting
• 50 gm glucose load test, measure after 1 hour. (If 130,135 or 140 mg/dl) à Abnormal
• Go for STEP 2:
• fasting>=95, 100 gm glucose, after 1 hour>=180, after 2 hours>=155, after 3 hours
>=140 mg/dl
• NOT SCREENING: If with sign and symptom: as others (fasting >126 mg/dl,
Random >200 mg/dl)
Manegement
• Diet, if controlled on diet no more monitor required (as any pregnant)
• Metformin or Insulin, need MORE monitor

• Fetal monitor in GDM:

• Fetal movement counting from 28 weeks (or 32 to 34)
• ANY patient come with decrease fetal movementà do NST
• NST: begin at 28-34 weeks : Twice weekly
• BPP: Weekly
• Contraction stress test: weekly.
• Postpartum Screening 4 and 12 weeks.
Time of delivery
• Goal:
• • Avoid late still birth
• • Complication related to cont. Growth: shoulder dystocia, CS due to failure to
progress
• 1- well controlled on Diet
• ⁃ 39+0: induction VS Expectant
• ⁃ 39+0 to 41+0: induction of labor
• 2- controlled on Medical or Insulin/ sub optimal control
• ⁃ Uncomplicated: induction at 39 weeks
• ⁃ Complicated (with HTN): before 39 weeks
• Fetal weight >= 4500 gm
• ⁃ Elective cesarean section at 39 weeks.
Intrahepatic cholestasis of pregnancy
• characterized by pruritus and an elevation in serum bile acid levels, typically developing
in the second and/or third trimester and rapidly resolving after delivery. Pruritus, which
may be intolerable, is often generalized but predominates on the palms and the soles of
the feet and is worse at night.
• Treatment: Urodeoxycholic acid
• Complication: IUFD, Meconium-stained amniotic fluid, pre-term delivery, neonatal
respiratory distress syndrome.
• Time of delivery:
Bile acid level Time of delivery

-
Ddx: acute hepatitis; pt unwell. RUQ pain, Liver enzymes 500-3000
Infectious diseases in pregnancy
Herpes CS recommended. (if rapture membrane ASAP)
Rubella If not vaccinated, avoid expoure.
HBV If high risk: take vaccine, breast feeding not contraindicated.
HIV Avoid breast feeding, recommend CS
HPV CS to avoid trauma to genital area in mother
Syphilis Associated with stillbirth, abortion and death if untreated
Gonorrhea Tetracyclines & fluoroquinolones are CI in pregnancy
Varicella Live vaccine avoid during pregnancy
Chlamydia Doxycyclin contraindication in pregnancy.
TB Can feed expressed milk to infant
Cardio in pregnancy
• When during pregnancy CARDIAC OUT PUT is highest? During
Labor
• 80% increase COP within 15 minutes of delivery, decrease to 60% if
cudal anesthesia
• When during pregnancy is priphral vascular resistance at its lowest?
Second trimester
Peripartum Cardiomyopathy
• PPCM is heart failure developing in the last month of pregnancy or
within five months of delivery in a woman without another identifiable
cause of the heart failure.
• Why Delyed diagnosis?
• Symptom dyspnea, fatigue, tachypnea are common at 3rd trimester and early
post partum.
• Treatment diffrent from non pregnant, ACEI is contraindicaed.
• If cardiac dysfunction not recover, à no more concive.
Cardiac disease contraindications
Contraindication to use
Contraindication to get PREGNANT CONTRACEPTIVE (combined)
• Sever pulmonary arterial hypertention • Cerebrovascular or coronory artery
à 30-40% risk mortality diseases, current or history
• Aortic stenosis, Maitral stenosis, • Valvular heart disease
Pulmonary stenosis, HOCM,
Coartocation of aorta
• See lecture contraceptive
• Left ventricle systolic dysfunction:
class III or EF<40%
• Marfan Syndrome (Aorta >45 or <40)
• Severe cyanosis
• Eisenmenger syndrome
Asthma in pregnancy

•Same medications (no changes)

• Except if she is HTN, Avoid BB
VTE
• Pathogenesis:
• Virchow’s Triad: (1) hypercoagulability. (2) Stasis. (3) Endothelial damage;
CS or operative SVD
• Risk Factor:
• Previous VTE/PE, Age >35, obesity, …
• Left leg > right
• Symptoms: Calf pain, tenderness, swelling, Homan’s sign,
Dicoloration.

• It’s a clinical diagnosis + lab test THEN don’t wait.

Medications
• LMWH à Agent of choice for ANC and PNC
prophylaxis (not cross placenta)
• Reduce dose in renal imperiment
• All women undergo CS à LMWH for 10 days
• Enoxaparin
• UFH à need monitor platelt count
• Warfarin à with ristriction, cross placenta, use 5-7 days post partum
• Aspirin à not recommended (aspirin for high risk eclampsia)
• Non-vit K antagonist Oral anticoagulant (NOACs)à avoid in
pregnancy
• If patient on Heparin, devolp Bleeding, (not related to
pregnancy)?

àgive her small repeated doses of Protamine sulfate

Just to know: LMWH DOSE based on KG
Pulmonary Embolism
• untreatred DVTà24% have PE, if treated 5%
• Symptoms: Tachypnea 80% / dyspnea 81% / pleuritic pain 72% /
apprehension 60% cough 54% / tachycardia43% / T > 37.5C 35%* in
those with proven PE
SLE in pregnancy
• High risk for preclampsia
• Differentiating preeclampsia from lupus nephritis is challenging.
• Both have protein uria.

Medications:
• Hydroxychloroquine à cont. to reduce flare up
• Biological (Rituximab, ..) à with caution
• Cyclophosphamide à Contraindicated
Epilipsy in pregnancy
• Preconception: 4mg Folic Acid
Increase risk of:
• Cleft palat, congintal heart disease, NTD and Fetal hydanton syndrome
• Truama of sezuires à placenta Abruption.
• Fedal death
• Fetal hydanton syndrome:
• IUGR, Microcephaly, dysmorphic feature (upturned nose, mild facial hypoplasia, long upper
lip with thin border) , mental def.
• EFFECT of Antiepiliptic drugs (AED)
• Treatment of choice: lamotrigine, levetriacetam. (Keprra)
• Valporate AVOIDED, risk for Neural Tube defect (valporate associated with
highest congnital malformation)
Epilipsy in pregnancy
Fetal surveillance:
• First trimester scan for NT
• Detailed US for morphology 17-20 weeks.
• Dedicated fetal echo
• Serial fetal growth and biophysical started at 24 weeks Q2-3weeks
Thyroid disease in pregnancy
Thyroid in pregnancy
Hyperthyroidism
• Grave’s disease
• Risk for: Abortion, PROM, Stillbirth
• Treatment: Thionamides
• Iodine is contraidicated.
• Baby delivered with hyperthyroid, in Grave’s disease
Hypothyrodism:
• Hashimotto
• Universal screening during first trimester.
• Increase dose of thyroxine 50%
• Check TSH Q6-8 Weeks.
Hyperemesis gravidarum
• Severe persistent nausea and vomitting associated with a >5% loss of pregnancy
weight and ketonuria with no other identifiable cause.
• There’re physical sign of dehydration.
• Risk factor: multiple gestation, history in prior pregnancy, hydatidiform molar
pregnancy.
• à related to High hCG
• Peaked at 9 weeks (8th to 12th weeks)
Diagnosis:
1. Electrolytes disturbances (hypokalemia & hypochloremic metabolic alkalosis)
2. Signs of dehydration (eg. Increase hematocrit)
3. Ketonuria (sign of Acute starvation)
Hyperemesis gravidarum
• To feel better? Eat small meal, avoid spicy, greasy or acidic food
• Treatment: fluid, medication to stop nausea and vomiting.

• Some patients have transient benign hyperthyroidism most likely due

to thyroid stimulation by the human chorionic gonadotropin (hCG)
molecule, which is structurally similar to TSH
Appendicitis in pregnancy
• Presentation: Most common: RLQ close to McBurney’s point, may
localize to mid or even URQ
Diagnsis:
• Histological
• US: Inatial modality of choice.
Treatment:
• Appendectomy.
Acute cholecystitis
• First and 2nd trimester (good surgical candidate) à surgical treatment
during hospatlization
• 3rd trimester --> FIRST: non operative, fluid, abx.
To allow deley till post partum.
Gestaional Trophoblastic disease
• Neoplasm Derived from Trophoblastic cell of placenta.
• Benign:
• 1. Placental site Tumor. 2. Complete AND Partial hydatiform moles
(PreMalignant)

• Malignant:
• 1. Malignant Invasive mole. 2. Choriocarcinoma. 3. Placental site
trophoblastic Tumor. 4. Epitheliod trophoblastic tumor.
Gestaional Trophoblastic disease
Other classification

1. Non-Neoplastic Trophoblastic Lesions

2. Molar Pregnancy
3. Gestational Trophoblastic Neoplasia
Molar Pregnancy
(Hydatidiform Moles)
• Excess Paternal Genitic material
in compare with maternal gentic
material
 Type Complete Partial
Empty Ovum + 2 Sperms (46 XX 90%) ALL Regular Ovum + 2 Sperms ( 69 XXY) Triploid
Pathogensis
Paternal in origim. karyotype. May survive to term
Risk factor
- Vaginal bleeding - Vaginal Bleeding
- Large of Gestational age - Missed Abortion (8-9 wks)
Presentation
- Ovarian elnlargment (theca luteal cyst) - Small of gestatinal age
- Severe hyperemesis. 1st tri Pre-eclampsia.
Confirm dx by histopath.
Investigation
- BhCG > 50 000 - BhCG Normal or low range.
- NO FETUS - FETUS
Character - SnowStorm Apearance , Hydropic sweliing - Molar Degeneration of placenta
- Grape like appearance
- Suction curettages (high risk of Hemorrhage) MUST oxytocin
- Anti D in Rh -ve
Treatment - BhCG every 1-2 weeks, until Negative twice then, Bimonthly for 1 year
- Contraceptive for 12 month.
- Chest x ray
Prognosis - 15-20% risk of Neoplasia - <5% risk of neoplasia
• Contra-Ceptive:
• OCP, Injectable or implant.
• IUD NOT used until Negative BhCGè Risk of uterine perforation (if invasive
mole)
• BhCG:
• 1-2 weeks, until Negative twice then, Bimonthly for 1 year
• If increase or Plateaued (sure not pregnant) è highly suspecion Of
trophoblastic Neoplasia
GTN
• 1. Malignant Invasive mole. 2. Choriocarcinoma. 3. Placental site trophoblastic Tumor. 4. Epitheliod
trophoblastic tumor

• Irregular bleeding.
• Unusually persistance bleeding after any type of pregnancyèmeasure
BhCG.
Chorio-Carcinoma
• Highly Malignant
• Associated (most often) with Complete Mole.
• 50% after Missed abortion. 25% after Molar Pregnancy. 25% After
Abortion.
• Plateau or rise in B-hCG
• Other symptoms, related to metastatic site. (chest pain, Hemoptysis..)
• Metastasis: Lung & Vagina
• Treatment: single Agent (Methotraxate): non-mets or low risk. Combinsed
in high-risk group. (EMA-CO).
• Once BhCG undetectable, cont. for 1 year.
• Very Good Prognosis
Refranceses
• Up to date
• BMJ practice
• AMBOSS
• ALSO Course materials
• Wiliams Obstetrics 25th edition, book.
• Obstetrics and gynecology, sixth edition, in collaboration with ACOG.
Book.
• Geeky medics.com
 Thank you

Any Questions?