SEVERE PRE ECLAMPSIA (PIH)

Proteinuria +1 +2 +3 +4

Idema Localized Anasarca

HPN 140/90 160/110

CARDINAL MOVEMENT
●​ no engagement anymore, part na siya ng 0 station
Note:
●​ mataas Luteinizing Hormone - indication of Ovulation
●​ 0-21 mos - pedia

CHANGES IN PREGNANCY
1ST TRIMESTER
●​ hormones
●​ nausea and vomiting; lightheadedness
2ND TRIMESTER
●​ increase size of uterus
●​ back pain and heartburn

HORMONES
A.​ HCG (Human Chorionic Gonadotropin)
●​ make pregnancy test positive
●​ maintain corpus luteum function (until placenta matures [12 weeks] ) - > estrogen
and progesterone
PREGNANCY TEST
2 lines - control line and test line
a.​ Control line - always positive (did pregnancy test)
b.​ Test line - CONTROLLING (99% except H. mole)

1.​ DONE - early morning; concentrated urine (HCG)

2.​ DURING: missed period
3.​ First appear: Blood (8-10 days after fertilization)
4.​ URINE: 14 days (Nagappear sa urine kung buntis ka)
5.​ CONTRAINDICATION: diuretics and diluted urine

B. ESTROGEN
●​ hormone of womEn - increase blood supply, increase breast size
C. PROGESTERONE
●​ hormone of Pregnant
D. HUMAN PLACENTAL LACTOGEN
●​ regulates glucose metabolism - > insulin resistance - > GDM
Prostaglandin: Dysmenorrhea
●​ Pharma: Ibuprofen - > inhibit prostaglandin synthesis

LIFE HACK
Action potential

INSIDE OUTSIDE

K Na - initiates contraction
Mg Ca - supports contractility
Cl - acts with GABA
relaxation
Contraction

Calcium blocker - di makakapasok sa cell yung calcium

Sodium blocker - di makakapasok sa cell yung sodium

Pre eclampsia (MgS04) - to relax the muscle

ABORTION
●​ termination of pregnancy <20 weeks
●​ 24 weeks Viable extra uterine
●​ 20 weeks viable inside the uterus

increase prog - relax uterus

increase prog - relax uterus

|
near term (37-42 weeks)
|
placenta
|
decreased progesterone
|
uterine contraction
|
expulsion
|
ABORTION

MENSTRUAL CYCLE
-​ periodic uterine bleeding in response to hormonal changes
A, ORGANS INVOLVED (no uterus - no menstruation)
1.​ Hypothalamus
2.​ Anterior pituitary gland
3.​ Ovaries
4.​ Uterus
Note: Any problems to organ involved affects menstruation

B. HYPOTHALAMUS
●​ initiates menstruation
●​ menarche - 1st menstruation
●​ normal - 9-17 years old
●​ average: 12.4 years old
●​ factor: wgt (43-45kg)

Cervical cancer: parent - > anti-HPV

●​ to prevent Cervical cancer
●​ decrease RF early menarche (9-11)
●​ early sexual intercourse (9-12)
●​ weight and stress

C. MENSTRUATION
1.​ Average cycle: every 28 days
2.​ Normal 23-35 days
3.​ Number of days of bleeding
a.​ excessive bleeding- more than the normal
i.​ saturated pad in an hour (menorrhagia)
4.​ Amount of bleeding: 30-80ml
a.​ 60ml, ¼ cup, 1 tbsp = 15 ml (15x4=60ml)
5.​ Sexual intercourse - not prohibited
6.​ Food restriction - no food restriction

7.​ Menstrual Cycle

1.​ MENSTRUAL PHASE (1-5 DAYS)
a.​ decrease estrogen
b.​ decrease progesterone
c.​ increase prostaglandin - vasoconstrictor uterine contraction - dysmenorrhea

Management for Dysmenorrhea

1.​ Warm compress
2.​ Hot shower
3.​ Mild exercise - release serotonin
4.​ Recipe to take/Rx - Ibuprofen (inhibits prostaglandin synthesis)
2. ESTROGENIC PHASE/FOLLICULAR PHASE (6-14 days)
●​ decrease estrogen - hypothalamus - GNRH - APG - FSH - ovaries - for the maturation of
egg cells
●​ primordial follicle (not matured)
●​ graafian follicle (matured) increase estrogen
●​ “negative feedback mechanism”
○​ if decrease estrogen - FSH
○​ increase estrogen - LH - supress FSH
3. SECRETORY PHASE/LUTEAL PHASE/PROGESTERONE PHASE (15-21 days)
●​ increased estrogen is maintained
●​ increased estrogen = LH
●​ corpus luteum - ovaries
●​ increased progesterone - suppression of LH
4. ISCHEMIC PHASE (22-28 days)
a.​ woman is not pregnant
○​ decreased estrogen
○​ decreased progesterone
○​ (corpus luteum dies/degenerated- corpus albicans)
b.​ pregnant
○​ increased estrogen
○​ increased progesterone
○​ increased HCG

OVULATION
●​ occurs 14 days before the end of menstrual cycle
●​ changes
○​ best increase level of LH
○​ unilateral pain: mittelschmerz
○​ cervical mucus changes white, menstruation, stretches (spinnbarkeit)
○​ body temperature changes
■​ day before: decreased temp. 0.5 degree fahrenheit
■​ on the day: increased temp. 0.5-1 degree fahrenheit
○​ Computation
■​ number of days of cycle normal (28 days)
●​ # of days of cycle
●​ subtract 14 to get the ovulation
●​ -5 and +5
○​ 35-14=21
○​ ovulate on 21st
○​ -5=16
○​ +5=26
■​ irregular
●​ check the cycle (6-12 consecutive)
●​ check longest subtract to 11
 ●​ check shortest subtract to 18
●​ e.g.25,28,23,29,34,35
●​ 35-11=24
●​ 23-18=5
●​ 5-24 days

GRAVIDA - pregnant women

GRAVIDITY - no. of pregnancies
TERM - 37-42 weeks
PRETERM - <36 weeks
ABORTION - <20 weeks
LIVING CHILDREN

Naegele's Rule
●​ last menstrual period (first)
●​ EDC
●​ -3 +7 +1 April to December
●​ +9 +7 January to March

UTERINE FUNDUS

●​ 20 weeks - approx 20cm (+2 & -2)

●​ 18-22cm
SIGNS OF PREGNANCY
PRESUMPTIVE
-​ subjective, weak evidence, felt by the mother

PR Prominent veins
E Easy fatigability
S Striae gravidarum
U Urinary Frequency
M Melasma - mask of pregnancy
P Perception of 1st fetal movement (quickening) - (Primi 18-20)(Multi 16-18)
T Tenderness of breast
I Increase vaginal secretion
V Vomiting and Nausea
E Enlargement of the Nose

PROBABLE
-​ objective, felt by the examiner
1.​ Chadwicks - bluish discoloration of vulva + cervix
2.​ Hegar's - softening of the uterus
3.​ Goodells - softening of the cervix
4.​ Ballottement - rebounding of fetus
5.​ Braxton Hicks - painless irregular contraction
6.​ Piskache's Sign - asymmetrical growth of uterus
●​ pregnancy test to check HCG

POSITIVE
-​ 100%
1.​ Fetal heart rate/tone (120-160)
2.​ Fetal skeleton

*uterine souffle - blood gushing to the uterus heard through auscultation

INSTRUMENTS
1.​ Doppler - 8 weeks
2.​ Fetoscope - Fetofour months
3.​ Stethoscope - 20 weeks

Cardiff method (count to ten method)

●​ monitor fetal movement
●​ 10-12 times

PRENATAL CARE
1.​ Childbearing age
●​ 18-35 or 20-40
 2.​ Weight Gain
●​ entire pregnancy
●​ 27-35lbs
●​ rapid weight gain
●​ “I can't no longer wear my wedding ring
3.​ 3 months before pregnancy
●​ folic acid 600 mg/day to prevent: spina bifida
●​ food: green leafy, lentils, strawberries, orange, sunflower seeds
4.​ Calories needed
●​ childbearing: 2, 2000 calories
●​ pregnant 300
●​ lactating (limang daan) 500
5.​ Rh Check
Mother Fetus

- -
+ -
- +
●​ possible
○​ 1st pregnancy (no problem)
○​ 2nd pregnancy (problem) - Rh Sensitization
○​ to prevent - administer RHOGAM (to prevent antibodies formation)
RH INCOMPATIBILITY
3 elements
1.​ Mother (Rh -); Fetus (Rh+)
2.​ Fetal cells will gain access to the maternal circulation
3.​ mother has an immunogenic capacity to produce antibodies

antibody antigen reaction - agglutination of RBC - destruction of RBC - anemia, liver jaundice
and irreversible brain damage (kernicterus)

Hemolytic disease
Management
1.​ Administer RHOGAM (IM)
-​ to prevent antibody formation
Coomb's test
●​ no antibody (-)
○​ give RHOGAM
○​ 72 hrs after delivery/spontaneous abortion
●​ with antibody (+)
○​ do not give RHOGAM
○​ x RHOGAM - plasmapheresis/exchange transfusion
 CROSSES THE PLACENTA DOES NOT CROSS THE PLACENTA

affects the baby

●​ alcohol ●​ Insulin
●​ cigarette smoking ●​ Heparin
●​ coffee/limit 1 cup ●​ Bacteria
●​ OHa: Oral Hypoglycemic agent ●​ Marijuana
●​ Coumadin (warfarin)
●​ Virus

PICA
-​ ice, clay, hair, booger

PRENATAL CARE

TEST IN PREGNANCY
Note: Majority of the procedures in OB instruction:
1.​ Empty the bladder!!!
●​ Amniocentesis, Paracentesis, Leopolds, Transvaginal
2.​ Full bladder
●​ Transabdominal, UTZ

A. NON-STRESS TEST
●​ non invasive procedure
●​ measures FHR during fetal movement
●​ attach to the external fetal monitor
●​ Instruction: Instruct the mother to eat a light snack - push the button whenever there is
movement
FINDINGS
1.​ REACTIVE: 120-160 (normal)
●​ 2 acceleration - increase 15 bpm for 15 seconds in 10-20 min period
2.​ NON-REACTIVE - fetal distress

B. AMNIOCENTESIS
●​ invasive procedure - informed consent, obtain: Doctor
●​ aspiration of amniotic
●​ 50-200ml
●​ amniotic fluid: 800-1,200ml (amnion and chorion)
●​ functions:
○​ protection against outside pressure (cushion)
○​ regulated temperature
○​ prevents cord compression
○​ determines kidney function
 HYDRAMNION OLIGOHYDRAMNIOS

can urinate but does not swallow ORAL-swallows but not urinate
| |
esophageal atresia kidney function
|
esophageal is closed

C. AFP: ALPHA FETO PROTEIN

●​ detects chromosomal aberrations
●​ 38-45ng/ml
●​ increase: neural tube defect
○​ e. g., spina bifida
○​ to prevent: eat folic acid
●​ decrease: down syndrome

STAGES OF LABOR
1.​ Labor Begins - Full cervical dilation and effacement
2.​ Complete dilation - Delivery of fetus
3.​ Delivery of fetus - Delivery of placenta
4.​ first 2 hours after birth
SIGNS OF LABOR
●​ Lightening
○​ multi: on the day of delivery
○​ primi: 2 weeks before
●​ Activity level increases, increase energy
●​ Begins to bear down with uterine contraction (lower then radiate to back
●​ Observe sudden gush of blood (show)
●​ Rupture of membrane
●​
PHASES OF LABOR (LAY)

LATENT ACTIVE TRANSITION

Cervix 0-3 cm 4-7 cm 8-10 cm

Frequency 10-15 mins 3-5 mins 2-3 mins

Duration 10-15 sec 30-60 sec 60-90 sec

AMNIOTIC FLUID
●​ greening - heralds/suggests fetal distress
●​ yellow: hemolytic disease
STATION
 ●​ relationship of fetal head on the ischial spine
●​ 0 - engaged @ischial spine
●​ - (negative) fetus is floating
●​ NEW: FLAG: CARDINAL MOVEMENT
●​ OLD: E(x)DFIEREE
●​ DFIEREE
○​ Descent
○​ Flexion
○​ Internal Rotation
○​ Extension
○​ Restitution
○​ External Rotation
○​ Expulsion

hypotension
↓
administer Ephedrine to counter the effect of anesthesia

PITOCIN DRIP
●​ Oxytocin - posterior pituitary gland
○​ induce labor
○​ until uterine contraction is achieved 1amp incorporate to 1L
●​ Initial:
2-8gtts/min
○​ 10gtts
○​ 20gtts
●​ Side effect
○​ Diuresis
○​ HPN
○​ Water intoxication
●​ Adverse effect
○​ Cerebral hemorrhage

THEORY OF LABOR PAIN

A.​ Bradley
○​ presence of the father during labor
B.​ Simpson
○​ 1st person who introduce anesthesia during labor
C.​ Lamaze
○​ psychological conditioning
D.​ Dick-Read
○​ pain
E.​ Mercer's and Revarubin
 ○​ Becoming a mother (Mercer's)
○​
H-MOLE/GESTATIONAL TROPHOBLASTIC
●​ Grape Like structure
Normal
●​ fertilization -> implantation -> embryo
Abnormal
●​ OVUM
○​ no nucleus
○​ kalbo
○​ bugok
○​ chaka
○​ pangit
○​ chararat
○​ no sarap
●​ SPERM
○​ touch myself
○​ multiply
Risk Factors
●​ >35 y. o.
●​ low socio economic status - x protein
●​ asians - malnourish
●​ prior molar gestation - 5x
○​ pre cancerous
Signs and Symptoms
●​ positive pregnancy test (HCG)
●​ no fetus
●​ no fetal heart rate
●​ no fetal outline
●​ brown vaginal discharge
●​ hypertension *BP
●​ fundal height is greater than the normal
Diagnostic tests
●​ UTZ
○​ grape like clusters
○​ snow storm pattern
Management
●​ D & C
●​ monitor HCG for 1 year
●​ Instruct the woman to avoid pregnancy: 1 year
●​ Intervention

ECTOPIC PREGNANCY
Normal
 ●​ implantation of the fertilized ovum inside the uterus
●​ expands as the fetus grows
Abnormal
●​ pregnancy outside the uterus
●​ Site: ampulla, isthmus, interstitial (Fallopian tube) - expand

●​ Till 12 weeks
●​ Observe severe pain ratiating to back
●​ Phrenic nerve is compressed
●​ Intervention:
○​ unruptured:methotrexate
○​ ruptured: surgery salpingectomy
●​ Complications
○​ bleeding
○​ hypovolemic shock (hypo tachy tachy)

TUBAL RUPTURE
●​ falling hematocrit and HGB levels

“embryo should gain access to placenta “

PRE ECLAMPSIA (PIH)

abnormal:
●​ narrow
○​ fibrous
○​ placental insufficiency - x placental perfusion - releases toxins - endothelial
celldamage - decrease permeability - leakage surroundings tissue (edema and
proteinuria)
Management
●​ delivery of the placenta

TYPE OF PIH
Mild
●​ Proteinuria: +1+2
●​ Idema: localized
●​ HPN: >140/90
Note: progression mild - severe
​ rapid wgt gain
“I can no longer wear my wedding ring”
Severe
●​ Proteinuria +3+4
●​ Idema Anasarca
●​ HPN >160/110
Eclampsia
●​ pre - eclamptic woman + neurological disturbance
●​ seizure, coma, death

Action potential
INSIDE OUTSIDE

K Na-initiates contraction
Mg Ca-contractility
Cl-acts as GABA
“relaxation:
give MGS04 to seizure to maintain relaxation

MGSO4 toxicity
decrease
●​ BP
●​ UO
●​ RR
●​ Patellar Reflex
ANTIDOTE: CALCIUM GLUCONATE

INCOMPETENT CERVIX
Normal
●​ Closed
●​ not dilated
●​ no efface/thins
Abnormal
●​ cervical insufficiency

RISK FACTORS
●​ structural defects
●​ repeated D & C
SIGNS AND SYMPTOMS
●​ fetal membrane canbeseen
●​ spotting
MANAGEMENT
●​ Cerclage - suture to the cervic
○​ term: 37-42 weeks
○​ removal of suture
○​ expulsion of the baby
●​ McDonald’s method
○​ temporary
●​ Shirodkar's method
○​ permanent method
 ○​ CS

PLACENTA PREVIA ABRUPTIO PREVIA

●​ previa - first ●​ premature separation of placenta to

●​ painless bleeding (no nerve endings) the decidua
●​ bright red bleeding ●​ painful bleeding (has nerve ending)
●​ soft abdomen ●​ concealed bleeding
●​ board-like, rigid abdomen

Normal pregnancy: anemia - PHYSIOLOGIC ANEMIA

●​ increase plasma (liquid) 50-55%
●​ increase RBC (mass only not the number) 33%