Cathrine Özdemir

Intr. to GYN-OB — most important

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OB
Physiological changes in pregnancy
- The delivery:
- From the first day of last menstrual bleeding — 40 weeks — gestational weeks
- From conception — 38 weeks — weeks of fetal life
- Estimation of due date:
- Naegele rule: Last menstrual period (LMP) + 1 year - 3 months + 7 days + difference
between the patient’s cycle length and 28 days

- Pregnancy-related hormones
- hCG
- Becomes detectable in serum and urine at 7-10 days after conception
- Rapid increase till 9th week, decrease till 15th week
- Does not increase insulin resistance
- hPL
- Gradual increase until 37 weeks, then slow decrease
- Increased insulin resistance
- Preparation of mammary glands for lactation
- Progesterone
- Slow increase throughout the whole pregnancy
- Stops uterine contractions
- Increased insulin resistance
- Body changes:
- Mammary glands
- Gland hyperplasia due to estrogen
- Ductal hyperplasia due to progesterone
- Uterus
- Grows from 60 g to 1000 g
- Active growth in the first half of the pregnancy, passive enlargement in the second
half
- Ovaries
- Presence of corpus luteum until 5-9 weeks. hCH maintains CL and progesterone
production until the placenta starts its own production.
- Corpus luteum produces progesterone
- Vagina and vulva
- Changes in vaginal pH (increased) —> increased risk of infections
- Immunoglobulins IgG, IgA and IgM —> decreased risk of infections
- Body mass
- Physiological increase up to 12 kg
- Increase of caloric demand — 300 kcal/day
- Blood
- Increased blood volume until 32nd week by approx. 25% (1L)
- Anemia: 11 mg%
- Increase in leukocytes, cholesterol level and coagulation factors (hypercoagulability!)
- Decrease of serum proteins, platelet count, fibrinolytic activity
- Body temperature
- Increase by 0.5°C
- Mucosa
- Tendency to hyperplasia: nose, sinus, throat, mouth (gums)
 Cathrine Özdemir
- Patients report symptoms consistent with having a cold
- Skin and hair
- Increased pigmentation
- Chloasma in the second half of pregnancy on the face

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Prenatal care
- Pre-conception visit
- Lab tests: toxoplasmosis, cytomegalovirus, rubella, HIV, thyroid hormones, vitamin D3
- Vaccinations: hepatitis B, varicella zoster, MMR, tetanus, pertussis
- Supplementation: folic acid, iodine, vitamin D3
- Vitamin A, toxoplasmosis and rubella = most important causes of malformations
- Pregnancy diagnosis
- Blood or urine pregnancy test — hCG detectable from implantation (7-10 days after
conception)
- Transvaginal ultrasound — 7th day after expected menstruation
- Sure symptoms — feeling or visualizing fetal movements and heart rate
- First appointment before 10th week
- Blood group
- Antibodies against blood group antigen
- HIV and HCV
- Fasting glucose
- 11-14th week visit
- First trimester ultrasound
- Biochemical screening for aneuploidies (double test, PAPP-A test)
- 15-20th week visit
- AFP — high level may suggest that the developing baby has a neural tube defect, also
defects with the esophagus or a failure of the baby’s abdomen to close. However, the most
common reason is inaccurate dating of the pregnancy.

- 21-26th week visit

- Ultrasound examination
- Oral glucose tolerance test (24-28 weeks)
- Anti-Rh antibodies in Rh negative patients
- 27-32nd week visit
- Ultrasound examination
- Antibodies against blood group antigens
- In qualifying women — anti-RhD immunoglobulin administration
- 33-37th week visit
- Vaginal and anal smear for group B streptococcal infection (don’t treat!)
- 38-39th week visit
- 40th week visit
- CTG — recording of fetal heartbeat and the uterine contractions

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 Cathrine Özdemir
Pelvic canal and fetus in delivery
- Measurements
- Inlet (transverse): 13 cm
- Cavity (transverse): 12,5 cm — shape of pelvic cavity of normal female pelvis is round
- Outlet (transverse): 10,5 cm
- Intercristal diameter: 28 cm
- Interspinous diameter: 25 cm
- Intertrochanteric diameter: 31 cm
- External conjugate: 20 cm
- True/obstetrical conjugate: 10 cm — the real diameter that can be used by the fetal head
- Diagonal conjugate: 2 cm

- Fontanelles:
- Small/posterior: occipital, parietal
- Large/anterior: parietal, frontal
- Descending head circumference:
- Suboccipito-temporal: 32 cm/9,5 cm
- Fronto-occipital: 34 cm/12 cm
- Chick-occipital: 35,5 cm/13,5 cm
- Fetal body mass: normal — 2500-4500 g

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Uterine contractions
- What affects contractions?
- Mechanical factors
- Foley catheter
- Oxytocin
- Hypothalamus —> hypophysis (posterior lobe)
- Stimulate the contractile activity of myometrium
- Activity is increased by estrogens and diminished by progesterone
- Excretion increased by stimulation of breast nipples
- Influence of mechanical factors
- Progesterone
- Necessary to support pregnancy
- Prostaglandin
- Excreted by the upper part of cervix when the head put pressure on it
- Stimulates excretion of oxytocin
- Estrogen
- Unblocking of contractile mechanisms
- Decrease progesterone activity
- Release of oxytocin and prostaglandin
- Alvarez contractions
- First contractions in pregnancy, from approx. 20th week of gestational age.
- Braxton-Hicks contractions
- Predictive contractions (before delivery)
 Cathrine Özdemir
- Montevideo units
- Uterine contractile activity measurement units
- Active contraction space is defined as ratio of pressure during contraction and the number
of contractions
- 100-120 units predict labor onset
- Uterus
- Active part: uterine corpus — contracts; Passive part: cervix + lower part of corpus —
distended
- Brandl brim — border between the active and passive part of uterus
- Found in palpation above pubic symphysis
- Should always have a transverse course
- Bishop score: Pre-labor scoring system to assist in predicting whether induction of labor will be
required (>6 points)
- Effacement
- Cervix position
- Consistency
- Dilation
- Presenting part station in the birth canal
- Post partum contractions
- Decreasing contractions for 12 hours every 10-15 min
- Corpus contractions —> blood vessel occlusion —> protection against bleeding

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Physiological delivery
- Labor
- Contractions are regular, minimum every 10 minutes and lasting minimum 30 seconds
- Stages of labor
- 1st stage
- Peridural analgesics - prolong the pregnancy. Ends with complete dilation of the
cervix (approx. 10 cm)
- Primiparas: os shortening, then os dilation. Up to 18 hours.
- Multiparas: shortening and dilation simultaneously. Up to 12 hours.
- 2nd stage
- Ends when the baby is delivered
- Multiparas: perineal incision = episiotomy — prevent rupture of anal sphincter
- 3rd stage
- Separation and expulsion of the placenta
- Primiparas: central mode = Schultc mode. The rims of the placenta are till attached
to the uterus. Limited blood loss.
- Multiparas: marginal mode = Duncan mode. Separation from the lateral part and
women. Greater loss of blood.
- 4th stage
- Early puerperium (return to non-pregnant state) — 2 hours
- Rotations of head
- Optimal plane of head in labor: occipito-parietal
- 1st rotation: flexion — head enters the minor pelvis
- 2nd rotation: internal rotation — in the cavity of minor pelvis
- 3rd rotation: deflexion — in the outlet of the minor pelvis
- 4th rotation: external rotation — after head has passed the outlet
 Cathrine Özdemir
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Puerperium and lactation

- Puerperium = the 6 week period following delivery when the reproductive tract returns to its non-
pregnant state

- Uterine involution
- Immediately follows delivery, when the uterus shrinks down to the level of the umbilicus
- Returned to normal by 6 weeks post partum
- Lochia
- Decidual sloughing after delivery, resulting in a physiologic vaginal discharge
- Rubra: containing blood, shreds of tissue and decidua
- Serosa: 3-7 days
- Fusca: 1st week
- Flava: 2nd week
- Alba: 3rd week
- CV system
- Increase in clotting factors during the first 10 days after delivery is associated with a high
risk of DVT and PE.

- Ovulation
- Non-lactating women: 25-35 days post partum
- Lactating women: 6 weeks-6 months. Ovulation suppression is due to prolactin levels.
- Lactation
- There are 2 main hormonal influences on breast tissue during pregnancy: estrogen
(increases number and size of ducts) and progesterone (increases number of alveoli)
- Milk flow is stimulated by suckling:
- Prolactin induces the alveoli to secrete milk
- Oxytocin causes milk to be ejected
- Colostrum: first fluid secreted from the breasts and is rich in proteins, especially
immunoglobulins

- Complications
- Pyrexia
- Uterine infection
- Infection (in episiotomy wound or perineal tears)
- Acute mastitis
- Veins: thrombophlebitis (3-4 days), phlebothrombosis (7-10 days), DVT (3rd trimester or
within 6 weeks after delivery)
- Mental disorders: depression, psychosis, baby blues

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Delivery in abnormal fetal position

- Breech presentation
- Complete breech: all joints are flexed
- Incomplete breech:
- Frank breech: flexed hip, straight knees
- Footling breech: completely straight legs
 Cathrine Özdemir
- Breech delivery
- 1st stage: engagement of breech into the bony canal and passage to the pelvic outlet
- 2nd stage: buttocks present themselves between vulvar labias
- 3rd stage: delivery of trunk, both limbs fall out free, shoulders become engages in the
”inlet”
- 4th stage: anterior shoulder presents first, then posterior
- 5th stage: head delivery
- When fetal head enters the pelvic inlet it compresses the umbilical cord and stops blood flow.
Fetus can survive approx. 7 minutes without oxygen.

- Bracht maneuver: hand on buttock and press against during approx. four contractions
- Lövset maneuver: change anterior shoulder into posterior shoulder and then it may slip down
the canal, and repeat
- Muller maneuver: body up and down (not used!)
- Classical maneuver: liberation of fetal hands (posterior hand first)
- Veit-Smellie maneuver: 3rd index finger into mouth and the other hand on the shoulders
- Wiegand-Martin-Winckel maneuver: force on pubic symphysis

- Transverse position: pathological delivery. Internal rotation or c-section.

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Post-term and prolonged pregnancy

- Post-term pregnancy = pregnancy after the 42 weeks of gestation
- Prolonged pregnancy = naturally (biologically) prolonged pregnancy to the period when
placental insufficiency starts

- Fetal care: amnioscopy (yellow — Rh-incompatibility, green — asphyxia or infection, red —

placental abruption), fetal lung maturity assessment, sonography

- Labor induction:
- Non-pharmacological: nipple massage, warm bath, mechanical cervix dilation (Foley
catheter), amniocentesis
- Pharmacological: prostaglandin, oxytocin
- Ineffective induction: c-section

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Multifetal pregnancy
- Twin pregnancy
- Monozygotic: dichorionic/diamniotic, monochorionic/diamniotic (73%), monochorionic/
monoamniotic
- Dizygotic: dichorionic
- Hellin rule: multifetal deliveries to total deliveries in population
- Preterm delivery:
- Twins: 36 weeks
- Triplets: 34 weeks
- Quadruplets 32 weeks
- Confirmation at 11-13 weeks of gestation — up to 20% of multifetal pregnancies before 11
weeks become single (vanishing twin).
 Cathrine Özdemir
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Multifetal pregnancy complications

- TTS
- Complication of monozygotic, monochorionic pregnancy
- Imbalanced blood flow between fetuses via anastomoses in the common chorion
- Polyhydramnios, oligohydramnios. MVP (maximum vertical pockets) < 2cm in donor and >
8 cm in recipient
- Donor: hypovolemia, oliguria, anemia, hypoxia, fetal hydrops
- Recipient: hypervolemia, polyuria, polycythemia, heart problems, fetal hydrops
- May lead to miscarriage and preterm delivery
- Management:
- Pharmacotherapy: indometacin, sulindac, digoxin — prolong pregnancy
- Amnioreduction — prolong pregnancy
- Occlusion of communicating vessels
- Umbilical cord occlusion
- TRAP
- Is the presence of a fetus without hemodynamically sufficient heart in the uterus (acardiac)
- Artery to acardiac, vein from fetur to placenta or the ”pump” twin umbilical cord
- Treatment: umbilical cord occlusion and communicating vessels occlusion

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GYN
Female genital tract anatomy
- Vulva and perineum
- Fornix is divided into 4 regions: anterior, two lateral and posterior
- Uterus
- The uterus is covered on each side by two broad layers of the broad ligament
- The angle between the long axis of the corpus and the cervix varies from ante-flexion to
retroflexion, and the angle between the cervix and vagina varies from ante-version to
retroversion
- Uterine tube
- Uterine part, isthmus, ampulla, infundibulum and fimbriae. Vesicular appendix — hyatid of
morgagni
- Vulva and perineum
- Intraperitoneal location, mesovarium, proper ovarian ligament and suspensory ligament of
ovary containing ovarian vessels
- Mainly supplied by the ovarian arteries (branch of abdominal aorta). There is also supply
from uterine arteries (branch from hypogastric artery or internal iliac artery)
- Venous return from right ovarian vein into IVC or left ovarian vein into left renal vein
- Pelvic diaphragm: levator ani m., coccygeous m.
- Urogenital diaphragm: deep transverse perineal m.
- Perineal muscles: bulbo-cavernous mm., anal sphincter mm., superficial transverse
perineal m., ischiocavernous m.

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 Cathrine Özdemir
Menopause
- Peri-menopause refers to the time before menopause when vasomotor symptoms and irregular
menses often commence. Can start 5-10 years before.
- Menopause begins 12 months after the final menses and is characterized by a continuation of
vasomotor symptoms and by urogenital symptoms such as vaginal dryness and dyspareunia.
- Pre-menopause = before 40 years.
- Heavy menstruation and shorter cycles
- Delayed menopause = after 54 years
- Mean age: 50 years
- Reasons for early menopause: smoking, hysterectomy, fragile X carrier, autoimmune disorders,
living at high altitude, chemotherapy, radiotherapy

- Physiology
- FSH and LH increase
- Inhibin decrease
- Estrogen decrease
- Increased risk of: osteoporosis, cardiovascular issues, breast cancer, memory dysfunction

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Sexual maturation
- Stages of puberty:
- Fluor pubertalis
- Thelarche = breast swelling (9-10 y)
- Pubarche = pubic hair growth, activation of adrenal cortex (11 y)
- Adrenarche = axillary hair growth (12-13 y)
- Acceleration of growth (11-12 y) to complete fusion of epiphyseal plates (16 y)
- Menarche = 11-15 y
- Eumenorrhea:
- Cycles every 28 days
- Duration 3-4 days of bleeding
- Blood loss 30-80 ml
- Tanner’s stadium: mammary gland development, pubic hair development, axillary hair
development

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Menstrual cycle
- 2 phases:
- Follicular (proliferative) phase
- Luteal (secretory) phase
- Regulation:
- Gonadotrophin releasing hormone (GnRH), produced in hypothalamus and transported to
anterior lobe of pituitary gland
- Causes FSH/LH secretion
- One pulse every 60-90 minutes in follicular phase, one pulse every 2-3 hours in luteal
phase
 Cathrine Özdemir
- Gonadotropins:
- FSH
- Responsible for the production of estrogen from androgens
- Receptors are situated mainly in granulosa cells
- LH
- Responsible for the initiation of ovulation and maintenance of the luteal phase
- Receptors are present in theca cells and granulosa cells
- Sex hormones:
- Estrogen (produced in ovaries, placenta and conversion in fatty tissue into the highest
biological form called estradiol; LH acts on theca cells to stimulate the conversion of
cholesterol to androgens, under influence of FSH androgens are aromatized to form
estrogens), progesterone, androgens

- Ovarian follicles:
- Primordial follicle
- Develop in 16th week of gestation
- Number is constantly reduced
- Each month a cohort of primordial follicles is stimulated to develop into pre-antral
follicles. This process is independent from GnRH/FSH stimulation.
- Pre-antral follicle
- Growth is FSH dependent
- LH stimulate androgen production
- The rest of cohort follicles become atretic. Inhibin and activin play a role here
- Inhibin
- Secreted by granulosa cells in response to FSH
- A: under influence of LH suppress FSH during luteal phase
- B: directly suppress pituitary FSH secretion in the follicular phase
- Activin
- Augments secretion of FSH and increases the pituitary response to
GnRH
- Antral follicle
- Increasing estradiol concentrations —> LH surge
- LH surge
- 10-12 hours before ovulation
- Pre-ovulatory follicle (Graafian follicle)
- Increasing LH on granulosa cells.
- Estradiol rises rapidly (14-24 hours before ovulation)
- Ovulation:
- 24-36 hrs after E2 surge and 10-12 hrs after LH surge
- If no fertilization occurs, the oocyte will degenerate between 12 and 24 hrs after ovulation
- Corpus luteum:
- In the absence of pregnancy the CL will undergo apoptosis
- In case of pregnancy, after embryo implantation hCG maintains the CL function

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Gynecological examination
- Patient before gynecological examination should empty her bladder
- External os of the cervix — transverse = multiparous or round = nulliparous