Obstetrics for competitive examinations

October 24, 2011 admin Obstetrics and Gynaecology 0

mansoor (1265)Dr  T  Geetha  Prasanth
Medical officer. Department of Homeopathy
Govt. of Kerala

Before beginning to go through the notes on OB and GYN, kindly revise the anatomy of the female reproductive organs and the process of fertilization.

The OB and GYN part actually start with the physiological changes of mother during pregnancy. Almost every organ and tissues of a female body undergo physiological changes during pregnancy. The metabolic, chemical and endocrine balances of the body gets altered.

The important changes

Changes in UTERUS and CERVIX

  1. Increase in weight from 50 gms. To 900 gms
  2. Increase in size from 7.5X 5X 2.5 cms to 30X 23X 20 cms
  3. Myometrium and endometrium undergo hypertrophy. The endometrium of the pregnant uterus is called deciduas.
  4. Cervix becomes softer.
  5. Cervical racemose glands secretes a tenacious mucus forming a plug (operculum) which acts as a barrier against infections
  6. Uterine contractions increases which are irregular, infrequent and painless(Braxton-Hicks contractions)

CHANGES in VAGINA

  1. Vaginal blood supply increases leaving a bluish appearance to mucosa (Jacquemier sign or Chadwick’s sign)
  2. the action of oestrogen increases the vaginal secretions
  3. Vaginal pH becomes more acidic which helps to prevent infections

CHANGES in The BREAST
Breast changes are more evident in primigravida. The changes are mostly due to oestrogen and progesterone. Oestrogen acts more on glands and ducts and progesterone on the secretory functions of the breast.Breast changes are mostly taking place during second and fifth months.

During second month : Breast increases in size, bluish discolouration and more sensitiveness.errectile nipple, deeply pigmented aerola, and prominent tubercles (Mont Gomery’s tubercles)in the areola are noted.

During fifth month, secondary areola develops, a sticky yellow fluid may be expressed from the nipple.

CHANGES IN THE SKIN
Mostly due to the action of the MSH of the anterior pituitary.

Depressed pinkish or slightly bluish lines (striae gravidarum) appear on the abdomen and thighs. Sometimes pigmentation may appear on cheeks,foreheads and around eyes which mostly disappear after the pregnancy.

WEIGHT GAIN DURING PREGNANCY
The weight gain during pregnancy is contributed by the enlarging uterus, growing foetus, placenta, liquor amnii, acquisition of fat and water reduction. It may vary from person to person. In general the average weight gain is 5 to 9 kg.

HAEMATOLOGICAL CHANGES

  1. Plasma volume increases upto 1.2 litres
  2. RBC volume increases by about 20 to 30 % (upto 350ml)
  3. Leucocytes increases predominantly neutrophils
  4. The total plasma proteins increases
  5. Albumin globulin ratio is decreased to 1:1 (normal 1.7: 1)
  6. Fibrinogen level raised by 50%
  7. ESR level increases

Cardio vascular changes

  • Cardiac output is raised by 40%.
  • Femoral venous pressure is increased
  • The blood flow to the uterus is considerably increased.
  • Pulmonary and renal blood flow is considerably increased
  • Due to venous congestion, varicose veins tend to develop more during pregnancy.

CHANGES IN URINARY SYSTEM

  1. Increase frequency of micturition due to antiverted uterus during the early weeks of pregnancy and due to descent of the presenting part in the later part of pregnancy
  2. Glycosuria is common but may not be pathological
  3. Proteinuria should be investigated thoroughly

DIAGNOSIS OF PREGNANCY

  • Normal duration of pregnancy
  • 9 months and seven days/ or 280 days or 40 weeks
  • First trimester  – first twelve weeks
  • Second trimester –  13 to 28 weeks
  • Third trimester –  29 to 40 weeks 

SIGNS AND SYMPTOMS

  1. Amenorrhoea
  2. Frequency of micturition
  3. Morning sickness
  4. Breast changes
  5. Skin changes
  6. Quickening (usually occurs between 16th and 20th week)

Probable signs

  1. Abdominal enlargement
  2. Changes in uterus
  3. Braxton Hicks contractions
  4. Chadwick sign
  5. Ociander’s sign (increase pulsation felt in the lateral vaginal fornix by about the 8th week of pregnancy)
  6. Softening of Cervix
  7. External and internal ballottement
  8. Detection of hCG in urine and blood

Positive signs of pregnancy

  1. Foetal parts and foetal movements (apprectiated by 22nd week)
  2. Foetal heart sounds. Most conclusive sign of pregnancy heard between 18 – 20th week  for the first time.
  3. Ultra sonic evidence . Gestation sac by 6th week, foetal heart beat -7th week, foetal heart rate -10th week using Doppler.
  4. Malformations detected by 18th week.

CALCULATION OF THE DATE OF DELIVERY (EDD)

By adding 7days to the first day of LMP count back 3 months  or count 9months forward to reach the EDD.

Minor disorders of pregnancy

1.Morning sickness

             Medicines. –  Sepia, Puls, Nux vom, Ignatia, Phosph, Ntrum mur, Cocculus, Colchicum, Ipecac, Symphoricarpus,

2. Acidity and Heartburn

            Medicines- Puls, Sepia, Nux vom , Colocynth ,Staphy, Carbo veg, sulphur, Lyco, Ars alb, Robinia

3.Back ache

Med- Kali bich , Actea, Ammon mur, Arnica, Rhustox, Bryonia, Phosph

  1. Constipation
  2. Varicose veins
  3. Haemorrhoids
  4. Fainting

PHYSIOLOGY OF LABOR
Defined as the process of expulsion of the foetus along with the placenta and the membranes from the uterus through the birth canal.

NORMAL LABOR

A Labor is normal, if it is

  1. Spontaneous in onset
  2. At term
  3. Vertex presentation
  4. Process completed by natural unaided efforts of the mother
  5. Time for first and second stages does not exceed 18 hours
  6. No complications arise

PROCESS OF LABOR

            The exact process of labor is not certain. But humoral and mechanical factors control labor.

Humoral control

  1. Oxytocin from posterior pituitary has a stimulating action on the pregnant uterus. Oxytocin receptors are more in the myometrium.
  2. Fall in the level of progesterone which changes the oestrogen –progesteron balance produces uterine contractions in greater amplitude.
  3. Increase in prostaglandins increases the rhythmic uterine activity and the hormonal changes that initiates the parturition.

MECHANICAL

1. Uterine distension

  • Increase in intra uterine pressure and the resultant tension enforced on uterine muscle fibre may initiate labor.
  • The stretching of lower uterine segment by the foetal head and the pressure exerted by it on the para cervical nerve ganglion may initiate labor.

SIGNS OF LABOR

  • Pre labor – These signs occur 2 or 3 weeks prior to the onset of labor.
  • Lightening which is the sinking of the presenting part into the pelvis
  • False pains- irregular dull pains appearing in the lower abdomen and  are not associated with uterine hardening.
  • Frequency of micturition
  • Cervix become soft and dilated

Signs of True Labor

  1. True labor pains- the uterine contractions become painful which are cotrolled by the nervous system and endocrine factors.
  2. Dilatation of Cervix and cervical canal. After a dilatation of 3cms  has occurred, further dilatation occurs at the rate of 1 cm per hour.
  3. Show- blood stained mucoid discharge due to the detachment of chorion is seen within two hours of starting the labor.
  4. Formation of bag of water- stretching of lower uterine segment causes a detachment of membrane . the presenting part fix into the cervix and divide the amniotic fluid into two. The presenting part forces the bag of membrane during contraction which may lead to early rupture of the membrane.

STAGES OF LABOR

STAGE 1 – Onset of true labor pain to full dilatation of cervix.

STAGE 2 – Full dilatation of cervix and expulsion of foetus

STAGE 3- Expulsion of foetus to expulsion of placenta and its membranes

MECHANISM OF NORMAL LABOR

  1. Engagement
  2. Flexion of head
  3. Internal rotation of head
  4. Crowning
  5. Delivery of head by extension
  6. Restitution of head
  7. External rotation of head
  8. Delivery of shoulders and trunk by lateral rotation

DURATION OF LABOR

Depends on

  1. Primigravida or multipara
  2. Type of pelvis
  3. Size and presentation of foetus
  4. Strength and frequency of uterine contractions

Usually in primigravida first stage last for about 12 hours, second two hours, third one fourth of an hour. In multipara, it is 6 hours, half and hour and one fourth of an hour respectively.

COMPLICATIONS OF THE THIRD STAGE OF THE LABOR

POST PARTUM HAEMORRHAGE pph. pph is severe bleeding during the third stage of labor or within 24 hours of expulsion of placenta.

Causes:

  1. Atonic uterus
  2. Traumatic causes
  3. Blood coagulation disorders.

Signs of PPH

  • Bleeding /vagina
  • Rapid pulse
  • Pallor
  • Collapse

Management

  1. Stimulation of uterus to contract by massaging
  2. Emptying of uterus fully
  3. Blood transfusion if necessary
  4. Traumatic causes should be repaired

Homoeopathic Medicines

            Caulophyllum, Actea, Pulse,Arnica, Bell, Phosoph, Ipecac, Sabina, Secale Cor.

RETAINED PLACENTA
Placenta is said to be retained, if it is not expelled even after 30 minutes of the birth of the baby.

Causes:

  1. Poor bearing down efforts
  2. Distended uterus
  3. Prolonged labor
  4. Uterine atonicity
  5. Hour glass contraction of uterus
  6. Adherent placenta

MANAGEMENT

  1. Empty the bladder with a catheter
  2. Retained placenta should be removed

Adherent Placenta (placenta accuate) it is a rare condition  in which the placenta is directly embedded into the uterine muscles . the spongy layer of decidua is absent here.

COLLAPSE AND SHOCK
It is due to hypovolumic shock associated with haemorrhage.

Signs:

  1. Pulse is rapid, soft and thready
  2. Fall in blood pressure
  3. Marked pallor
  4. Shallow respiration

MANAGEMENT

  • Restoration of the blood volume
  • Medicinal management

PUERPERIUM

It is the period which begins with the termination of the third stage of labor and last till the genital organs have assumed their pre-pregnancy stage which last for 6-8 weeks.

CHANGES IN UTERUS

  1. Reduction in weight to 60 gms
  2. Reduction in size
  3. Arteries at the placenta site undergo constriction.
  4. Decidua left after delivery undergoes necrosis and entire endometrium is restored by the third week.

THE LOCHIA
The vaginal discharge during puerperium is called lochia which may extend up to 3 weeks. Persistence of red lochia and excessive amount of lochia should be considered seriously.

The cervix never returns to the non gravid state, the external os is always patulous in a multipara. The vaginal outlet is markedly relaxed , hymen replaced by small tabs of tissue which cicatrise (carunculae myrtiformis) which is a characteristic sign of parity. The perineum is relaxed,pelvic floor regain tone with a certain amount of gaping of vulva.

The puerperal bladder has a very much increased capacity and there is oedema and hyperaemia of the bladder mucosa. Striae gravidarum appear in the abdominal wall with a certain amount of laxity and flabbiness of the abdominal muscles if proper exercises are not observed.

Milk is secreted by the mother only by the second or third day of delivery. Breast become larger, fuller, and veins become more prominent. The thin liquid secreted from the breast during the first 48 hours is rich in fat globules, lactalbumin and lactglobulin is called cholestrum.

Return of menstrual cycle takes place after about 10 weeks of pregnancy in most lactating mothers; whereas in non lactating mothers it may be as early as 4 weeks.

MANAGEMENT OF NORMAL PUERPERIUM

  1. Restoration of health of mother
  2. To prevent infection
  3. Promotion of breast feeding
  4. Motivation for adopting contraceptive measures

COMPLICATION OF PUERPERIUM

1. Puerperal sepsis:   It is an infection of genital tract occurring as a complication or abortion or child birth

Clinical features:

  • Pyrexia
  • Tachycardia
  • Brownish,profuse,foul smelling lochia
  • Large and soft uterus which is tender to touch

Treatment

  1. Adequate rest and sleep
  2. Diet should be high in calories and vitamins
  3. Adequate fluid and electrolyte balance
  4. Correction of anaemia

Medicinal Management

SUBINVOLUTION :  Slowing of the process of involution is known as subinvolution.

Causes:

  1. Retained products of conception
  2. Fibroids
  3. Overdistension
  4. Caesarian section
  5. Prolapse of uterus
  6. Retroversion of uterus
  7. Local uterine infections

Treatment : Treatment of the underlying cause and medicinal management

URINARY TRACT INFECTIONS
Causes:  Infections due to catheterization during labor or retention of urine

clinical features:       Fever with Chills and Rigor, Frequency of micturition, Dysuria, Anorexia, Nausea and Vomiting.

Treatment: Increase fluid intake, Medicinal management

RETENTION OF URINE

  • The causes are bruising and oedema of the urethra and bladder
  • Prolonged second stage of labor

Treatment :  Women should be encouraged to pass urine within 12 hours of delivery

                         Medicinal management

BREAST COMPLICATION

 Acute Mastitis:  Is the inflammation of the breast which may progress  into a breast abcess if not treated.

Clinical features: Fever with general malice and head ache, throbbing pain and tenderness in the breast

Treatment:  Frequent feeding of the baby.

                         Medicinal management

VENOUS THROMBOSIS

This is characterized by formation of thrombi in the veins which may be superficial or deep.

PULMONARY THROMBO EMBOLISM

A piece of thrombus may become detached in the veins of the pelvis or lower limbs and travels by the inferior venacava to the right side of the heart and via the pulmonary artery to the lungs.

Clinical features: Sudden chest pain with respiratory distress, haemoptysis, cyanosis, hypotension, collapse, respiratory failure and cardiac arrest. Death may occur from shock or vagal inhibition.

HYPEREMISIS GRAVIDARUM

The term hyperemisis gravidarum is applied to the excessive vomiting which persists beyond 4 months and very little nourishment is retained.

TOXAEMIAS OF PREGNANCY

1. A/c toxaemia of pregnancy (onset after the 24th week)

Pre eclampsia which may be mild or severe characterized by oedema, albuminura and hypertension.

Eclampsia characterized by the above symptoms with convulsion or coma

2. C/C HYPERTENSIVE DISEASE WITH PREGNANCY

    1. Without superimposed a/c toxaemia

                                                              i.      hypertension known to have antenatal pregnancy

                                                            ii.      hypertension observed inpregnancy

b. c/c hypertensive vascular disease with superimposed toxaemia

 3. Unclassified toxaemia

A/C MATERNAL VIRAL INFECTIONS

  1. Influenza
  2. Variola or small pox
  3. Rubella

ABORTION
Abortion is the termination of pregnancy before the foetus become viable.

Aetiology

  1. Foetal factors
    1. Intrinsic defects of fertilized ovum
    2. Cystic degenerationof chorionic villli
    3. Haemorrhage into the deciduas
    4. Low quality sperm
  2. Maternal factors

Infectious fevers
Hypertension
c/c nephritis
Syphilis
Diabetes
Trauma
Stress

  1. Uterine causes
  • Congenital malformation of uterus
  • Fibroid tumors of the uterus
  • Retroversion of the uterus
  • Ovarian tumors

4. Hormonal causes

  •  Hormonal imbalance may cause habitual abortion
  • Incompatibility of the blood of husband and wife may cause abortion.

Clinical features

  1. Pain due to uterine contractions
  2. Haemorrhage as a result of separation of ovum
  3. Dilatation of cervix
  4. Expulsion of part or entire ovum

Treatment : Removal of product of consumption when abortion is confirmed and medicinal Management

CORD PROLAPSE

It is a condition where the umbilical cord lies below the presenting part

Diagnosis:   Feeling the cord, pulsation on vaginal examination. Sometimes cord can be seen outside the vulva

Management: No management is required when the baby is dead or foeatal survival rates are very less. Otherwise cord compression reduction measures should be done to improve the condition of the foetus.

MULTIPLE PREGNANCY

Presence of more than one foetus is refered to as multiple pregnancy.

Twin pregnancy is the commonest form. Twin pregnancy can be monozygotic or uniovular or dizygotic or biovular. Diagnosis is confirmed by ultra sound examination.

ECTOPIC PREGNANCY

Implantation and development of foetus anywhere outside the uterine cavity is called ectopic pregnancy. Tubal pregnancy is the commonest form

Clinical features:

  • Short period of amenorrhoea
  • Severe lower abdominal pain with or without vaginal bleeding
  • Fainting attacks,pallor,
  • Palpation through the fornix and no mass is usually felt.

PLACENTA PRAEVIA

Is the condition where the placenta is located partially or wholly within the lower uterine segment.

Clinical features:   Sudden painless and causeless bleeding from vagina

                                     Uterus is relaxed and non tender

Fetal heart rate is decreases when the head is pushed down into the pelvis due to the embedded placental circulation by the pressure of the foetal head on the low lying placenta (stallworthy’s sign)

Management: After the diagnosis is confirmed by the ultrasound, the women are advised to take complete rest, intercourse is prohibited and medicinal management is given.

ABRUPTIO PLACENTA : It is also called as accidental haemorrhage where the cause of bleeding is premature separation of a normally situated placenta.

PROLONGED LABOR :  Labor is said to be prolonged if the duration exceeds 24 hours. The main causes are inefficient uterine contraction, contrcted pelvis, cervical dystocia. Malposition of foetus, congenital anomalies,uterine inertia, poor bearing down efforts, pelvic tumors.

Management: Prolonged labor can be prevented by the managing the causes accordingly.suppportive measures, maintenance of hydration, and medicinal management can be done.

OBSTRUCTED LABOR :   Labor is said to be obstructed when there is no advance of presenting part in spite of strong uterine contractions. It may be due to mechanical obstruction due to some fault in the birth passage or in the foetus or both.

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