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REPRODUCTIVE SYSTEM:

A. INTERNAL STRUCTURES:

1) OVARIES

❒ SHAPE: Almond-shaped

❒ COLOR: Grayish-white

❒ FUNCTIONS:

a) EXOCRINE function: secretes mucus

1. Ovum production

b) ENDOCRINE function: secretes hormones

1. Estrogen

✓ Hormone of the female’s secondary sex characteristics

2. Progesterone

✓ Hormone of the pregnant/mother

❒ 3 LAYERS OF OVARY: CCC

a) Cover Protective Layer/Epithelium/ TunicaAlbuginea

✓ Outermost layer

✓ FUNCTION: Protect the ovaries

b) Cortex (Middle, functional layer)

✓ Site of ovum maturation

IMMATURE OVUM à MATURE OVUM

PRIMORDIAL FOLLICLE

GRAAFIAN FOLLICLE

❖ High amounts ofESTROGEN

❖ Some progesterone

c) Central Medulla

✓ Innermost layer

✓ Location of the blood vessels, nerves, lymphatics, smooth muscles

2) FALLOPIAN TUBE

❒ ANOTHER TERM: Oviducts

❒ SHAPE: Funned-shaped

❒ 4 PARTS: IIAI

a) Interstitial(Intramural)	❒ Length: 1 cm ❒ SHORTEST ❒ THICKEST ❒ Most proximal ❒ Most dangerous sitefor ectopic pregnancy
b) Isthmus	❒ Length: 2 cm ❒ NARROWEST ❒ Site for Bilateral Tubal Ligation (BTL)
c) Ampulla (Middle/ Outer third/ Second half)	❒ Length: 5 cm ❒ LONGEST ❒ WIDEST ❒ MOST COMMON sitefor ectopic pregnancy ❒ Site of fertilization
d) Infundibulum	❒ Length: 2 cm ❒ Most distal ❒ Site of fimbriae ovarica

3) UTERUS

❒ Organ of reproduction & menstruation

❒ It is a floating organ which is needed ligaments

❒ SHAPE:

a) Non-Pregnant: Pear-shaped/ inverted avocado

b) Pregnant: ovoid-shaped

❒ WEIGHT:

a) Non-Pregnant: 60 g (2 oz.)

b) Pregnant: 1000 g

c) Postpartum: 80 g

❒ 3 MAIN PARTS: CIC

a) Corpus

✓ Center/Body of the uterus

✓ ABC:

1. An uppermost portion of uterus

2. Body/Bulk of organ (2/3 of the uterus)

3. Contains the growing fetus

✓ SHAPE: Upper, triangular portion

✓ 2 IMPORTANT PARTS:

1. Cornua

❖ Where the fallopian tubes are attached

2. Fundus

❖ Force of uterine contractions

❖ Use to measure fundic height (from symphysis pubis to fundus)

❖ Needs to be palpated abdominally

❖ D’ uppermost and cylindrical portion of the corpus

❖ Used to measure fundic return

❖ Site of placental implantation (upper posterior part)

− Placenta at Lower posterior part: Placenta previa

❖ Classical Cesarean Section: VERTICAL CUT

− Site of incision: FUNDUS

− Performed during emergency cases (e.g. abruptio placenta)

− No chance for future NSVDs, or else, UTERINE RUPTURE happens.

b) Isthmus

✓ Lower uterine segment

✓ Site for LTCS (Low Transverse Cesarean Section)

❖ MOST COMMON Cesarean Section

❖ Site of incision: ISTHMUS

❖ NAME of Incision: Pfannenstiel incision (Bikini cut)

❖ (+) Chance for NSVDs (called VBAC – Vaginal Birth After Cesarean Delivery)

❖ Performed during elective cases

c) Cervix

✓ Lowest uterine segment

✓ “neck” of the uterus

✓ “floor” of the uterus

✓ Lowest cylindrical portion

❒ 3 MAIN LAYERS: PME

a) Perimetrium (Parietal Peritoneum)

✓ Outermost layer

✓ Attached at broad ligament

✓ FUNCTIONS:

1. Protects the uterus

2. Strengthens the uterus

b) Myometrium (Living Ligature)

✓ Middle, largest, muscular layer

✓ The power of labor

✓ The muscles of delivery

c) Endometrium (Layer of Menses)

✓ Innermost layer

✓ Highly vascular

✓ During NON-PREGNANT State:

1. Endometrium sloughs off

2. occurrence of menses

✓ During PREGNANT State:

1. No slough off

2. Forms into a DECIDUA (pregnant uterus)

✓ After Delivery:

1. Forms into a LOCHIA

✓ In NON-PREGNANT: 2 LAYERS of ENDOMENTRIUM

BASAL LAYER(Stratum basalis)

❒ Stable

❒ Uninfluenced by hormonal changes

GLANDULAR LAYER(stratum functionalis)

❒ Unstable

❒ Influenced by hormonal changes

❒ Sloughs off during menses

✓ In PREGNANT: 3 LAYERS of ENDOMENTRIUM (Decidua)

DECIDUA BASALIS

❒ BASE

❒ Site of implantation

❒ Underlying the fetus

DECIDUA CAPSULARIS

❒ Encapsulates/ stretches out

❒ Overlying the fetus

DECIDUA VERA

❒ Remaining portion

❒ Becomes LOCHIA after delivery

❒ UTERINE BLOOD SUPPLY

Main Blood Supply

❒ Large descending abdominal aorta

❒ Travels to internal iliac artery

Direct Blood Supply

❒ Uterine arteries

Supporting Blood Supply

❒ Ovarian arteries

❒ UTERINE NERVE SUPPLY: SAME (Sensory-Afferent; Motor-Efferent)

EFFERENT (MOTOR)

❒ UPPER portion

❒ Supplied by the 5^ththoracic to 10^ththoracic spine (T5-T10)

AFFERENT (SENSORY)

❒ LOWER portion

❒ Supplied by the 11^ththoracic to 12^ththoracic spine (T11-T12)

• EPIDURAL ANESTHESIA:

✓ blocks T11-T12 ONLY

✓ Sensory ONLY

✓ (-) Pain response

✓ (+) Uterine contractions

✓ S/E:

1. Maternal Hypotension

❖ MANAGEMENT:

a. Monitor BP

b. Fast drip IV, as prescribed.

❒ DRUGS THAT AFFECTS THE UTERUS:

UTEROTONICS

❒ CONTRACTS uterus

❒ for post-term labor (To induce labor)

❒ E.g. POMS

a. Pitocin

b. Oxytocin

c. Methergine (Methylergonovine maleate)

d. Syntocinon

TOCOLYTICS

❒ RELAXES uterus

❒ For pre-term labor (to stop the labor)

❒ E.g. INMTR

a. Indomethacin

b. Nifedipine

c. Magnesium Sulfate (MgSO4)

d. Terbutaline

e. Ritodrine

❒ 6 UTERINE LIGAMENTS

CARDINAL/ TRANSVERSE-CERVICAL/ MACKENRODT LIGAMENT	❒ MAIN ligament
BROAD/ PERITONEAL LIGAMENT	❒ Supports the sides of uterus ❒ Located in the perimetrium
ROUND LIGAMENT	❒ Connects the labia majora to uterus
UTEROSACRAL LIGAMENT	❒ Connects uterus to the sacrum
ANTERIOR LIGAMENT	❒ Connects uterus to urinary bladder (bladder is anterior of uterus)
POSTERIOR LIGAMENT	❒ Connects uterus to rectum

4) VAGINA

❒ Organ of copulation

❒ PARTS:

a) Vaginal Wall

✓ Highly elastic (d/t the RUGAE)

b) Vaginal Mucus

✓ Acidic (d/t lactic acid)

✓ BACTERIA: Doderlein’s bacillus

✓ pH: 3.5-4.5

c) Vaginal Opening

✓ Circular, voluntary muscle (bulbovacernosus muscle)

✓ EXERCISE: Kegel’s Exercise

✓ VAGINISMUS (psychological)

❖ MANAGEMENT: Muscle relaxant IM

❒ FUNCTION:

a) Passageway of menses, the penis, and the fetus.

DIFFERENT CHANGES DURING PREGNANCY

PISKACEK’S SIGN	Softening of the CORPUS
VON BRAUN FERNWALD’S SIGN	Softening of the FUNDUS
DICKINSON’S SIGN	Focal softening of the placental implantation site (upper posterior part of the fundus)
HEGAR’S SIGN	Softening of the ISTHMUS
GOODELL’S SIGN	Softening of the CERVIX
CHADWICK’S SIGN/ JACQUEMIER’S SIGN	Bluish discoloration of the vagina
LADIN’S SIGN	Increased vascularity/blood vessels of the vagina
OSIANDER’S SIGN	Increased pulsations of vagina
MONTGOMERY’S SIGN	Breast changes
MCDONALD’S SIGN	Flexion of uterus
PALMER’S SIGN	Rhythmic uterine contraction after bimanual examination (Internal Examination)
HARTMAN’S SIGN	Fetal implantation bleeding

MENSTRUAL CYCLE (Ovarian Cycle)

➢ From beginning of menstruation to the beginning of the next menstruation.

➢ Episodic uterine bleeding (happens every cycle)

➢ PURPOSES:

1) Ovum maturation (for fertilization)

2) Tissue bed renewal (Endometrium renewal)

OVULATION

➢ 14 days before the next menses

➢ 14 days before the end of menstrual cycle

LAST MENSTRUAL PERIOD (LMP)

➢ 1^ST DAY of LAST menstrual period

4 ORGANS INVOLVED IN MENSTRUAL CYCLE: HAOU

1) HYPOTHALAMUS

❒ Ultimate initiator

❒ Releases GnRH (Gonadotropin-Releasing hormone)

a) Follicles-Stimulating Hormone-Releasing Hormone (FSHRH)

b) Luteinizing Hormone-Releasing Hormone (LHRH)

2) ANTERIOR PITUITARY GLAND (APG)

❒ Releases GONADOTROPINS:

a) Follicle-Stimulating Hormone (FSH)

b) Luteinizing Hormone (LH)

3) OVARIES

❒ Releases FEMALE hormones:

a) Estrogen

b) Progesterone

4) UTERUS

❒ Discharge menses

❒ NOT INVOLVED in hormonal release

HORMONES INVOLVED IN MENSTRUAL CYCLE: FELP

❒ In menses: Decreased Estrogen + Decreased Progesterone

FOLLICLE-STIMULATING HORMONE

↓

ESTROGEN

❒ Stimulate to increase ESTROGEN release

❒ FUNCTION:

a) Ovum maturation/ Development of ovum/Graafian Follicle

❒ FUNCTION:

a) Increase thickness of endometrium

LUTEINIZING HORMONE

↓

PROGESTERONE

❒ Stimulate to increase PROGESTERONErelease

❒ FUNCTION:

a) Responsible for ovulation/ Rupture of Graafian Follicle

❒ FUNCTION:

a) Increase vascularity of the endometrium (for blood supply)

4 PHASES OF MENSTRUAL CYCLE: PSIM

1) PROLIFERATIVEPHASE

ESTROGENIC PHASE (↑Estrogen)

FOLLICULAR PHASE (↑FSH)

POST-MENSTRUAL PHASE

PRE-OVULATORY PHASE

❒ Proliferate: Increase in numberof endometrial cells

❒ Thickening of uterus (↑Estrogen & ↑FSH)

❒ Increase of ESTROGEN

❒ Increase of FSH

❒ Vary in length/duration

❒ Day 6-14(Ovulation)

❒ In day 6:

a) ↓Estrogen

b) Needs positive feedback (to increase Estrogen)

c) Hypothalamus initiates GnRH (FSRH)

d) APG releases GONADOTROPINS (FSH)

e) Ovum maturation occurs in ovaries (cortex layer)

f) Immature ovum (Primordial Follicle) turns to mature ovum (Graafian Follicle)

g) Increases Estrogen levels(13^thday)

h) Increase thickness of uterus/endometrium

i) Suppress FSH (to stop stimulating estrogen)

j) Hypothalamus initiates GnRH (LHRH)

k) APG releases GONADOTROPINS (LH)

l) Ovulation occurs (14^thday)

❒ S/Sx of OVULATION (ForFertile):

a) Spinnbarkeit(cervical mucus elasticity)

b) ↑ Basal Body Temperature(after 8 hours of sleepthen take temperature)

c) Unilateral abdominal pain upon ovulation (Mittelschmerz sign)

2) SECRETORY PHASE

PROGESTERONIC PHASE (↑Progesterone)

LUTEAL PHASE (↑LH)

POST-OVULATORY PHASE

PRE-MENSTRUAL PHASE

❒ Secretes nourishing substances

❒ Best time for implantation (↑Progesterone)

• Increases blood supply at uterus

• Needed MORE by the fetus

❒ Happens day 15-21

❒ Fixed in length/duration

❒ Day 15:

a. Rupture of Graafian Follicle

b. Corpus Luteumis formed(Yellow body)

1. ↑Progesterone (Dominant)

2. Has some estrogen

c. Increases vascularity of endometrium

d. Suppress LH (to stop stimulating progesterone)

e. Relaxes uterus

3) ISCHEMIC PHASE

❒ Ischemia: ↓ blood supply at uterus

❒ Happens day 22-28

❒ Day 22 (Non-Pregnant):

a. Corpus Luteum degenerates after 8-10 days

b. Forms into Corpus Albicans (White body)

c. Corpus Albicans (↓Estrogen + ↓Progesterone)

d. Signals ischemia

e. Decrease blood supply at uterus (↓O2 + ↓Nutrients)

f. Endometrial slough-off occurs

g. Menstruation occurs

❒ Day 22 (Pregnant):

a. Corpus Luteum remains for 2 months (waiting for placenta to develop)

b. Increase of Progesterone (↑ vascularity) and Increase of some estrogen (↑thickness)

c. Thickening of uterus

4) MENSTRUAL PHASE

❒ Happens to day 1-5 (5 days duration)

❒ Occurrence of menses

❒ (+) slough-off

❒ Uterus is at its thinnest (d/t endometrial slough-off)

❒ Glandular layer slough-off (d/t progesterone withdrawal)

• ↓Progesterone

❒ Day 1:

a) ↓Estrogen + ↓Progesterone

a) Increase PROSTAGLANDINS

b) (+) uterine contractions & vasoconstriction

c) (+) Pain (e.g. dysmenorrhea)

✓ MANAGEMENT:

1. POSITIONING:

a. 1^stBEST option: PREFERRED COMFORTPOSITION TO PATIENT

b. 2^ndbest Option: KNEE-CHEST POSITION

2. EXERCISE:

a. Release of happy hormones (endorphins)

b. Relieves pain

3. WARM COMPRESS

a. Vasodilation

b. Uterine relaxation

4. MEDICATIONS:

a. Prostaglandin inhibitors (e.g. Ibuprofen)

TERMS IN RELATION TO MENSTRUAL CYCLE:

MENARCHE	First occurrence of menses
AMENORRHEA	Absence of menses
DYSMENORRHEA	Painful menses
MENOPAUSE	Stoppage of menses for 12 months
METRORRHAGIA	Bleeding between menses
❒ (N) Duration of Menses = 3-8 days
HYPOMENORRHEA	Menses less than 3 days
POLYMENORRHEA	Menses more than 8 days
❒ (N) Amount of Menses = 30-80 cc
OLIGOMENORRHEA	Menses less than 30 cc
MENORRHAGIA	Menses more than 80 cc

NORMAL CHARACTERISTICS OF MENSTRUATION:

MENARCHE	❒ NORMAL: 9-17 years old ❒ AVERAGE: 12 years old (6^th grade)
INTERVAL	❒ NORMAL: 23-35 days ❒ AVERAGE: 28 days
DURATION	❒ NORMAL: 3-8 days ❒ AVERAGE: 8 days
AMOUNT	❒ NORMAL: 30-80 cc ❒ AVERAGE: ¼ cup
ODOR	❒ NORMAL: Marigold
COLOR	❒ NORMAL: dark-red
IRON LOSS	❒ NORMAL: 11 mg

STAGES OF FETAL GROWTH: OZEF

OVUM	❒ Starts with Ovulation to Fertilization
ZYGOTE	❒ Fertilization to Implantation (2 weeks)
EMBRYO	❒ 3 to 8 weeks (2 months)
FETUS	❒ 9 weeks to birth

STAGES OF FETAL DEVELOPMENT: PEF

PRE-EMBRYONIC

❒ Starts with fertilization to implantation (2 weeks)

❒ FERTILIZATION/ CONCEPTION/ IMPREGNATION/ FECUNDATION (union of sperm & ovum)

1) OVUM

➢ Female sex cell

➢ Carries X-chromosome

➢ LIFESPAN: 24-48 hours

➢ 2 LAYERS:

a) Corona radiata (Outer layer)

b) Zona pellucida (Inner layer)

2) SPERM

➢ Male sex cell

➢ Carries X or Y-chromosome

➢ LIFESPAN: 48-72 hours

➢ 3 PARTS:

a) Head (Chromosome)

b) Neck (Source of ATP)

c) Tail (Flagella – source of motility)

d) Vitamin C – responsible for sperm’s motility

➢ 2 TYPES:

a) ANDROSPERM (Male sperm)

− Small head

− Long tail

− Carries Y-chromosome

− More motile

− More in number

− Shorter lifespan

− Survives in an alkaloticenvironment

b) GYNOSPERM (Female sperm)

− Big head

− Short tail

− Carries X-chromosome

− Less motile

− Less in number

− Longer lifespan

− Survives in an acidicenvironment

➢ XY chromosome – MALE

➢ XX chromosome = FEMALE

➢ The FATHER determines the GENDER of fetus

PRE-EMBRYONIC PROCESS

a) OVUM

b) ZYGOTE (Fertilized egg)

c) Initiates first cell division (Blastomere)

d) Increase into 16-50 cells (Morula)

e) Transforms blastocysts (structure that implants)

➢ 2 LAYERS:

1. EMBRYOBLAST(Embryo)

2. TROPHOBLAST (embryonic structures: placenta, amniotic sac & fluid, umbilical cord)

f) Implantation occurs

➢ 3 PROCESSES:

1. APPOSITION (floating blastocysts)

2. ADHESION (attachment at endometrium)

3. INVASION (settling in at endometrium)

g) Presence of Hartman’s Sign(Implantation bleeding)

h) Forms into an EMBRYO(Embryonic Stage)

i) Forms into FETUS

EMBRYONIC

❒ 3 to 8 weeks

❒ Most susceptible to teratogens

❒ Organogenesis occurs

❒ MOST COMMON TERATOGENS:

a) STEROIDS (leads to cleft lip/palate)

b) TETRACYCLINE (staining of teeth)

c) QUININE/STREPTOMYCIN (damage of CN VIII –Vestibulocochlear/Acoustic Nerve – causing DEAFNESS)

d) THALIDOMIDES/ ANTIEMETICS

− Leads to AMELIA (total absence of extremities)

− Leads to PHOCOMELIA(absence of proximal extremities with hands or feet directly attached to torso)

❒ EMBRYONIC STRUCTURES:

a) AMNIOTIC MEMBRANE

➢ Upon ROM: (-) pain of mother (no nerve supply on amniotic membrane)

➢ 2 LAYERS:

1. CHORION (transforms to amniotic sac)

2. AMNION (transforms to amniotic fluid)

b) TROPHOBLAST

➢ Layer of the blastocyst

➢ 2 LAYERS:

1. CYTOTROPHOBLAST/ LANGHAN’S LAYER(protects fetus from syphilis – Treponema pallidum)

2. SYNCYTIOTROPHO-BLAST/ SYNCYTIAL LAYER (produces maternal hormones – estrogen, progesterone, HCG, HPL, Relaxin)

➢ HCG (human chorionic gonadotropin)

− Present in first 100 days (1^st trimester)

− NOTE: HIGHER in later part of the 1^sttrimester.

− Culprit for NAUSEA & VOMITING (emesis gravidarum)

− Emesis gravidarum is NORMAL in 1^sttrimester

− Nausea & Vomiting increases at later part of 1^st trimester

− ABN: Hyperemesis gravidarum (Nausea & Vomiting occurring >1^sttrimester)

− FUNCTIONS:

a. Takes care of corpus luteum for 2 months

b. Suppresses mother’s immune system (so as not to reject the fetus -foreign body)

c. Mimics testosterone to develop the fetal male reproductive organs

➢ ESTROGEN:

a. Softening of the uterus

b. Uterine growth

c. Mammary gland development

d. Increase the thickness of uterus

➢ PROGESTERONE:

a. Hormone of pregnancy

b. Mammary gland development

c. Maintains endometrium via increasing vascularity

d. Decrease intestinal motility (constipation during pregnancy)

e. Relaxes the uterus (prevents pre-term labor)

➢ HPL (Human Placental Lactogen)/ HCS(Human Chorionic Somatomammotropin)

a. LACTOGENIC(mammary gland development)

b. Insulin antagonist (DIABETOGENIC)

− Increase glucose for organogenesis of fetus

c. Reason for GDM

➢ RELAXIN

a. SOFTENING OF JOINTS during pregnancy (leads to LORDOSIS – pride of pregnancy)

c) PLACENTA (Secundines)

➢ WEIGHT: 400-600 gms.

➢ AVERAGE: 500 gms (1 lbs.)

➢ COMPARTMENT:

1. Cotyledons (O2 reserve)

− 20-30 cotyledons

➢ SUBSTANCES TO AVOID:

1. No NICOTINE (it crosses the placental barrier)

2. No ALCOHOL (it crosses the placental barrier)

➢ FUNCTIONS:

1. Fetal Lung

− O2-CO2 Exchange (via simple diffusion)

2. Fetal GIT

− Glucose Transport (for organogenesis)

− Via facilitated diffusion

3. Fetal Endocrine System (fetal hormones)

− Estrogen is passed to the fetus

4. Fetal Kidneys

− Excretion of waste products

5. Fetal Circulatory System

− Fetoplacental circulation

− Via selective osmosis

6. Fetal Amino Acids(Proteins)

− Amino Acid Transport

− Enters via active transport

7. Virus (Rubella)

− Enters through PINOCYTOSIS

d) UMBILICAL CORD (Funis)

➢ (N) LENGTH: 50-55 cm

➢ (N) THICKNESS: 2 cm

➢ Wharton’s Jelly(cushions the cord)

➢ (N) AVA:

a. 2 Arteries (carries deoxygenated blood)

b. Vein (carries oxygenated blood)

➢ ABNORMALITIES:

1. Too Short Umbilical Cord

− Leads to ABRUPTIO PLACENTA

− Leads to UTERINE INVERSION

2. Too Long Umbilical Cord

− Leads to Cord Prolapse

− Leads to Cord Coil

3. 1 Artery & 1 Vein Umbilical Cord

− Check for cardiac/kidney anomalies

e) AMNIOTIC FLUID

➢ (N) COLOR: CLEAR(BEST ANSWER)

a. EARLY COLOR: Clear/ Transparent/ Colorless

b. LATER COLOR: Slight yellow/ amber/ straw-colored with flecks of vernix caseosa

➢ (N) VOLUME: 800-1200mL

➢ (N) pH: 7.0-7.5 (Alkaline)

➢ (N) COMPOSITION:

a. 99 % water

b. 1% solid particles

➢ (ABN) COLOR OF AMNIOTIC FLUID:

a. Greenish àMeconium Staining(sign of fetal distress)

b. Red/Pink à Bleeding

c. Dark Yellow/Golden Yellow àHyperbilirubinemia (Rh Incompatibility/ ABO Incompatibility)

d. Gray/Cloudy àInfection

e. Dark Brown/ Tea-colored/ Cola-colored à Fetal Death

➢ (ABN) VOLUME OF AMNIOTIC FLUID:

a. Oligohydramnios

− <300 mL

− Fetal Problem: Renal Agenesia

− MANAGEMENT:

❖ Amniofusion

b. Polyhydramnios

− >2000 mL

− Fetal Problem: Anencephaly/ TEFA (Tracheo-esophageal Fistula & Atresia)

− Maternal Problem: GDM(Gestational Diabetes Mellitus)

− MANAGEMENT:

❖ Amniocentesis

➢ (3) DIAGNOSTIC TESTS:

a. FERN TEST(Arborization test)

− Swab-Dry Test

− (+) Fern Test: (+) Amniotic Fluid

− (-) Fern Test: (-) Amniotic Fluid/ (+) Urine

b. NITRAZINE TEST

− Using of phenolphthaleinand litmus paper

− (+) BLUE: (+) Amniotic Fluid

− (+) RED/YELLOW: (-) Amniotic Fluid/ (+) Urine

c. AMNIOCENTESIS

− Aspiration of Amniotic Fluid under UTZ

− WHEN? 14-16 weeksAOG (2^ndtrimester)

− NOT PERFORMED in 1^st trimester (amniotic fluid is still in little amounts)

− INFORMED CONSENT should be taken (Amniocentesis is an invasive procedure)

− INDICATIONS of ordering Amniocentesis during:

1. 2^nd Trimester: ADVANCED MATERNAL AGE: increased chances of Down Syndrome (damaged ovum)

2. 3^rd Trimester: GDM: Check for fetal lung maturity

− PURPOSES:

1. Diagnose chromosomal abnormalitiesvia AFP (alpha fetoprotein) Level

❖ (N) AFP: 2.5 MOM (Multiple of Means)

❖ ↓ AFP: Down Syndrome(Trisomy 21)

❖ ↑ AFP: Neural Tube Defects (Vitamin B9/Folic Acid Deficiency)

2. Check lung maturity via SHAKE test

❖ (+) bubbles: MATURE lungs

❖ (-) Bubbles; IMMATURE Lungs

❖ (N) L/S Ratio: 2:1

❖ (ABN) L/S Ratio: 1:1

• MANAGEMENT of IMMATURE lungs:

1. Steroids IM to MOTHER (Bethamethasone/ Dexamethasone)

− COMPLICATION:

1. INFECTION

❖ EARLY: Spontaneous Abortion

❖ LATER: Preterm Labor

− Most ImportantConsideration: Needle Insertion Under UTZ

FETUS

❒ 9 weeks to birth

❒ FULL TERM: 37-42 weeksAOG

❒ 3 GERM LAYERS:

1) ECTODERM(Outermost)

➢ Brain

➢ CNS

➢ Skin

➢ 5 senses

➢ Hair

➢ Anus

➢ Mouth

➢ Nails

2) MESODERM(Middle)

➢ Heart

➢ Reproductive System

➢ Musculoskeletal System

➢ Kidneys

3) ENDODERM/ENTODERM(Innermost)

➢ Thyroid Gland

➢ Thymus

➢ Liver

➢ GIT Lining

❒ ORGANOGENESIS: Embryo Stage

1) NEUROLOGIC SYSTEM:

➢ Using of EEG at 8 weeks

2) RESPIRATORY SYSTEM:

➢ Surfactant development at 6-7 months

➢ Prevents lung collapse

3) CARDIOVASCULARSYSTEM

➢ Using of ECG at 20 weeks

➢ FETAL HEART RATE:

a) 1^st trimester: 160-170 bpm

b) 2^nd-3^rd trimester: 120-160 bpm

➢ FETAL HEARTBEAT:

a) FETAL DOPPLER by 12 weeks

b) FETOSCOPE by 16 weeks

c) STETHOSCOPE by 20 weeks

➢ (N) Fetal O2 Saturation: 80%

− To compensate: HEMOGLOBIN (17.1 g/dL)

− HEMATOCRIT (53%)

➢ (N) ADULT O2 Saturation: 95-100%

− To compensate: HEMOGLOBIN (12-16 g/dL)

− HEMATOCRIT (36-46%)

4) GIT

➢ Sterile GIT (↓ Vitamin K): risk for BLEEDING!

➢ LIVER (Active but Immature)

− Risk for hypoglycemia & hyperbilirubinemia

5) URINARY SYSTEM

➢ Urine formed at 16 weeks

➢ Urine excreted at 20 weeks

6) REPRODUCTIVE SYSTEM

➢ Gender identification via outward appearance at 12 weeks

➢ Gender identification via UTZ at 16 weeks

➢ Testes descends at 28-38 weeks

7) MUSCULOSKELETALSYSTEM

➢ Quickening (fetal movement felt by the mother) at 20 weeks

➢ If PRIMIGRAVIDA: Quickening is felt by18-20 weeks

➢ If MULTIGRAVIDA: Quickening is felt by 16-18 weeks

− Stretched out uterus

− Muscle memory/ experience of pregnancies

8) INTEGUMENTARYSYSTEM

➢ Lanugo (white downy hair) at 20 weeks

➢ Vernix Caseosa at 24 weeks

➢ Subcutaneous fats achieved by 8 months

9) IMMUNE SYSTEM

➢ IgG passed by mother to fetus intrauterine at 20-24 weeks

FETAL ASSESSMENT

1) DFMC (Daily Fetal Movement Counting)

➢ Quickening at 20 weeks

➢ WHEN: AFTER MEALS

➢ POSITION: (L) side-lying

➢ AVOID SUPINE POSITION! (Compresses the vena cava) à ↓ Venous return à HYPOTENSION SYNDROME!

➢ If (R) side-lying:

✓ Urinary bladder is located at the right side

✓ It leads to URINARY FREQUENCY

➢ (N) COUNTING:

✓ 10-12 movements/hour

✓ 1-2 movements/minute

➢ 2 WAYS of DFMC:

a) SANDOVSKY METHOD

✓ Count the number of movements PER HOUR

b) CARDIFF’S METHOD

✓ Count the DURATION in reaching 10 movements

2) ULTRASOUND

➢ 2 WAYS of UTZ:

a) TRANSVAGINAL UTZ

✓ For EARLY PREGNANCY (1^st trimester)

✓ MUST be EMPTY BLADDER!

b) ABDOMINAL UTZ/PELVIC UTZ

✓ For LATER PREGNANCY (2^nd-3^rd trimester)

✓ MUST be FULL BLADDER! (it hastens the urinary frequency)

➢ INDICATIONS OF UTZ during:

a) 1^st TRIMESTER:

✓ Confirm PREGNANCY

✓ Confirm IMPLANTATION SITE

✓ Determine AOG

✓ Determine MULTIPLE FETUS

b) 2^nd TRIMESTER:

✓ Determine GENDER

✓ Determine PLACENTAL LOCATION

c) 3^rd TRIMESTER:

1) Determine FETAL SIZE & POSITION

3) KLEINHAUER-BETKE’S TEST

➢ Differentiate maternal from fetal blood

4) BPP/BPS (BIOPHYSICAL PROFILE/ BIOPHYSICAL PROFILE SCORING)

➢ The FETAL APGAR

➢ 5 PARAMETERS:

a) Fetal Breathing	2
b) Fetal Reactivity (Heart Rate)	2
c) Fetal Movement	2
d) Fetal Tone	2
e) Amniotic Fluid Index	2
TOTAL	10

➢ SCORES:

7-10	FETAL WELL-BEING
4-6	SUSPICIOUS
0-3	FETAL DISTRESS(Assess for DELIVERY)

5) NON-STRESS TEST (NST)

➢ Check for FHR in response to fetal movement

➢ Look for ACCELERATION (N) (Increase 15 bpm of FHR from baseline after fetal movement)

➢ Performed in 20 minutes: 2-4 fetal movements (minimum of 2 movements & 2 accelerations)

✓ NOTE: NST is done after meals

➢ If 1 acceleration = REPEAT THE TEST

➢ EXAMPLE:

✓ If baseline is 135 bpm: 135 + 15 bpm (NormalAcceleration) = 150 bpm Acceleration after fetal movements

➢ RESULTS:

REACTIVE	NON-REACTIVE
REAL/GOOD	NOT GOOD
FETAL WELL-BEING	FETAL DISTRESS

➢ If RESULTS are NON-REACTIVE:

✓ To CONFIRM, use CONTRACTION STRESS TEST IS DONE.

6) CONTRACTION STRESS TEST/ OXYTOCIN CHALLENGE TEST

➢ Check FHR in response to uterine contraction

➢ HOW:

✓ BEFORE: inject synthetic oxytocin

✓ NOW: Natural Way (Nipple Stimulation)

➢ Look for DECELERATION (ABN)

➢ RESULTS:

POSITIVE	NEGATIVE
(+) DECELERATION	(-) DECELERATION
FETAL DISTRESS	FETAL WELL-BEING

➢ MANAGEMENT FOR (+) CONTRACTION STRESS TEST:

a) STOP Oxytocin

b) Turn to (L) Side-Lying Position

c) O2 Via Face Mask at 8-10 LPM

➢ 3 TYPES OF DECELERATION:

a) EARLY DECELERATION

✓ Due to HEAD COMPRESSION

✓ Stimulation of Vagus Nerve (causing Bradycardia)

b) VARIABLE DECELERATION

✓ Due to CORD COMRPESSION

c) LATE DECELERATION

✓ Due to UTEROPLACENTAL INSUFFICIENCY

❒ MNEMONIC: VEAL CHOP

VARIABLE	CORD COMPRESSION
EARLY	HEAD COMPRESSION
ACCELERATION	OKAY!
LATE	PLACENTAL INSUFFICIENCY

RULES OF PREGNANCY

1) NAEGELE’S RULE

➢ Determine the EXPECTED DATE OF BIRTH/ EXPECTED DATE OF CONFINEMENT via LMP

➢ NOTE:

✓ NO LMP = NO NAEGELE’S

✓ LEAP YEAR = FEBRUARY 29 (every 4 years)

LMP	MONTH	DAY	YEAR
Jan-Mar	+9	+7	+0
Apr-Dec	-3	+7	+1

2) BARTHOLOMEW’S RULE

➢ Determine AOG via FUNDIC LOCATION

9 MONTHS	Below Xiphoid Process (d/t lightening)
8 MONTHS	Level of XIPHOID PROCESS
7 MONTHS	Midway between Umbilicus and Xiphoid Process
6 MONTHS	2 cm above umbilicus
5 MONTHS	Level of UMBILICUS
4 MONTHS	Between Symphysis Pubis and Umbilicus
3 MONTHS	Level of SYMPHYSIS PUBIS

3) MCDONALD’S RULE

➢ Determine AOG via FUNDIC HEIGHT (FH in cm)

➢ FORMULA:

a) FH (in cm) x 8/7 – AOG (in weeks)

b) FH (in cm) x 2/7 – AOG (in months)

4) HAASE’S RULE

➢ Estimate the FETAL HEIGHT

➢ FORMULA:

a) [1-5 months]² = cm

1 month	1 cm
2 months	4 cm
3 months	9 cm
4 months	16 cm
5 months	25 cm

b) [6-9 months] x 5 = cm

6 months	30 cm
7 months	35 cm
8 months	40 cm
9 months	45 cm
10 months	50 cm

5) JOHNSON’S RULE

➢ Estimate the FETAL WEIGHT

➢ (N) WEIGHT: 2500-3500 gms

✓ <2500 gms = SGA/LBW

✓ >3500 gms = LGA

CONSTANTS
K	155
N (UNENGAGE)	11 (STATIONS: -1, -2, -3)
N (ENGAGE)	12 (STATIONS: 0, +1, +2, +3)

➢ FORMULA:

a) FH (in cm) – N(K) = grams

➢ EXAMPLE:

a) GIVEN: 32 cm; Station 0

✓ 32 – 12 (155) =

✓ 20 (155) = 3,100 gms (N)

b) GIVEN: 34 cm; Station -2

✓ 34 – 11 (155) =

✓ 23 (155) = 3,565 gms (ABN) (LGA)

SIGNS OF PREGNANCY

A. PRESUMPTIVE SIGNS

➢ SUBJECTIVE (coming from mother)

➢ BUFAMECLISQ

BREAST CHANGES	MONTGOMERY’S SIGN
URINARY FREQUENCY	❒ 1^ST TRIMESTER: ✓ PRESENT (+) ✓ D/T uterine enlargement ❒ 2^ND TRIMESTER: ✓ NOT PRESENT (-) ✓ D/T bladder has adjusted ❒ 3^RD TRIMESTER: ✓ PRESENT (+) ✓ D/T Fetal Presentation
FATIGUE/ LASSITUDE	❒ D/T increased BMR(slight enlargement of thyroid gland)
AMENORRHEA	❒ Increased Estrogen + Increased Progesterone
MORNING SICKNESS	❒ D/T Increased hCG ❒ MANGEMENT: a) Eat dry crackers before arising
ENLARGED ABDOMEN
CHLOASMA/ MELASMA/ MELANODERMA	❒ MASK of Pregnancy
LINEA NIGRA
INCREASED SKIN PIGMENTATION	❒ D/T Increased Melanocytes
STRIAE GRAVIDARUM	❒ “STRETCHMARKS” ❒ MANAGEMENT: a) Calamine Lotion b) Oatmeal
QUICKENING

B. PROBABLE SIGNS

➢ OBJECTIVE (taken by nurse)

➢ GCHELLPPBEBVOOM

GOODELL’S SIGN	Softening of the CERVIX
CHADWICK’S SIGN/ JACQUEMIERE’S SIGN	Bluish discoloration of the vagina
HEGAR’S SIGN	Softening of the ISTHMUS
ENLARGED UTERUS
LADIN’S SIGN	Increased vascularity/blood vessels of the vagina
LEUKORRHEA	❒ INCREASED vaginal discharge
PISCASEK’S SIGN	Softening of the CORPUS
POSITIVE PREGNANCY TEST
BALLOTTEMENT/ REBOUND SIGN	❒ UPWARD cervix tap ❒ (+) rebounds upon internal examination ❒ WHY PROBABLE? ✓ It may be a tumor rather than the fetal head
ELEVATED BBT (BASAL BODY TEMPERATURE)	❒ D/T increased PROGESTERONE
BRAXTON-HICKS CONTRACTIONS	❒ Irregular painless contractions
VON BRAUN FERWALD’S SIGN	Softening of the FUNDUS
OSIANDER’S SIGN	Increased pulsations of vagina
OPERCULUM (MUCUS PLUG)	❒ Serves as a SEAL at cervix (to prevent ascending infection) ❒ During LABOR: a) Mucus Plug falls-off (BLOODY SHOW)
MCDONALD’S SIGN	Flexion of uterus

C. POSITIVE SIGNS

➢ CONFIRMATORY: UTZ

➢ FETAL HOMS

FETAL HEART RATE/TONE

FETAL OUTLINE

FETAL MOVEMENT

FETAL SKELETON

PRENATAL VISIT

➢ 0-7 MONTHS = ONCE A MONTH

➢ 8 MONTHS = Every 2 weeks/Twice a month

➢ 9 MONTHS = Every week until delivery

PSYCHOLOGICAL TASKS

A. 1^ST TRIMESTER: ACCEPT PREGNANCY

➢ Mothers felt:

a) AMBIVALENCE

b) SURPRISE

c) DENIAL

➢ HEALTH TEACHING:

a) Nutrition

b) Body Changes during Pregnancy

B. 2^ND TRIMESTER: ACCEPT BABY VIA QUICKENING

➢ Mothers felt:

a) FANTASIES

b) DREAMING

c) NARCISSISTIC

➢ HEALTH TEACHING:

a) Fetal Growth & Development

C. 3^RD TRIMESTER: ACCEPT PARENTHOOD/ MOTHERHOOD

➢ Mothers felt:

a) UNPRETTY

b) UGLY

c) AWKWARD

d) IMPATIENT

➢ HEALTH TEACHING:

a) Responsible Parenthood

OB SCORING

GRAVIDA (G)

Number of pregnancies(alive or dead)

PARA (P)

Number of viable pregnancies (fetus can already survive OUTSIDE uterus/ extrauterine life)

❒ WHEN VIABLE?

✓ >20 WEEKS

TPAL:

a) TERM: 37-42 WEEKS

✓ If TWINS: COUNTS AS ONE in term

b) PRETERM: >20 WEEKS

c) ABORTION: <20 WEEKS

d) LIVING: ALIVE

✓ If TWINS: COUNTS AS TWO in term

NUTRITION

A. WEIGHT GAIN DURING PREGNANCY

➢ Minimum: 20-25 lbs.

➢ Optimum: 25-35 lbs. (single fetus)

❒ MULTIPLE FETUS: 40-45 lbs.

(lbs.)	TRIMESTER	MONTH	WEEK
1^ST	4 lbs	1.3 lbs	0.3 lbs
2^ND	12 lbs	4 lbs	1 lb
3^RD	12 lbs	4 lbs	1 lb

B. CALORIC NEEDS

PRE-PREGNANT

2,200 Kcal/day

PREGNANT

(+300 kcal/day)

2500 kcal/day

LACTATING

(+500 kcal/day)

2700 kcal/day

➢ 6-8 GLASSES of WATER per day

➢ No MINERAL OILS for CONSTIPATION (it inhibits the absorption of the fat-soluble vitamins – ADEK vitamins)

LABOR

A. PAIN MANAGEMENT DURING LABOR

1) BRADLEY METHOD (by: Dr. Robert Bradley)

➢ COACH: Partner

2) DICK-READ METHOD (by: Dr. Grantly Dick-Read)

➢ Reduce FEAR

3) PSYCHOSEXUAL METHOD (by: Dr. Sheila Kitzinger)

➢ “Just go with the flow”

4) LAMAZE METHOD (by: Dr. Ferdinand Lamaze)

➢ 4 ACTIVITIES:

a) CLEANSING BREATH

b) CONSCIOUS RELAXATION

❒ ONLY ABDOMEN contracts

❒ The rest of body relaxes

c) EFFLUERAGE

❒ Light stroking of abdomen

d) GUIDED IMAGERY

B. 4 STAGES OF LABOR

STAGE 1: CERVICAL PERIOD

FOCUS: CERVIX

2 PROCESSES:

a) EFFACEMENT (thinning of cervix)

− Measured from 0-100%

b) DILATATION (opening of cervix)

− Measured from 0-10 cm

For PRIMIGRAVIDA:

✓ Effacement FIRST, Dilatation LAST

✓ Number of hours of labor: 20 hours

For MULTIGRAVIDA:

✓ Dilatation FIRST, Effacement LAST

✓ Number of hours of labor: 14 hours

MANAGEMENT:

a) AMBULATION

b) LET THE MOTHER VOID EVERY 2 HOURS

c) DELIVERY ROOM

✓ PRIMI: 10 cm

✓ MULTI: 7-8 cm

TERMS:

a) FREQUENCY

✓ From beginningof contraction to beginning of next contraction

✓ RATE of contraction

b) INTENSITY

✓ Strength of contraction

c) DURATION

✓ From beginningof contraction to end of the same contraction

✓ LENGTH of contraction

d) INTERVAL

✓ From the end of contraction to beginning of next contraction

➢ 3 PHASES (LAT) OF 1^ST STAGE OF LABOR

3 PHASES à	LATENT	ACTIVE	TRANSITIONAL
FREQUENCY	8-15 minutes	3-5 minutes	2-3 minutes
DURATION	20-40 seconds	40-60 seconds	60-90 seconds
INTENSITY	MILD	MDOERATE	STRONG
DILATATION	0-3 cm	4-7 cm	8-10 cm
MOOD	Excited	Irritable	Loses Control
ACTIVITY	Ambulation Void every 2 hours	Comfort Measures Analgesics	2 legs UP
FHT MONITORING	Every HOUR	Every 30 MINUTES	Every 15 MINUTES

STAGE 2: FETUS PERIOD

FOCUS: FETUS

CARDINAL MOVEMENTS (ED FIRE ERE):

a) ENGAGEMENT

b) DESCENT

c) FLEXION

d) INTERNAL ROTATION

e) EXTENSION

✓ Expulsion of fetal head ONLY

✓ Check for cord coil/ nuchal cord

✓ Ritgen’s Maneuveris performed (supporting of perineum to prevent laceration)

f) EXTERNAL ROTATION

g) EXPULSION

STAGE 3: PLACENTAL PERIOD

FOCUS: PLACENTA

2 TYPES OF PLACENTA

1) SCHULTZ MECHANISM

❒ SHINY

❒ FETAL SIDE

❒ CENTRAL DETACHMENT

2) DUNCAN MECHANISM

❒ DIRTY

❒ MATERNAL SIDE

❒ MARGINAL ATTACHMENT

3 SIGNS OF PLACENTAL SEPARATION

1) GLOBULAR ABDOMEN (CULKIN’S SIGN)

❒ 1^ST SIGN of placental separation

2) SUDDEN GUSH OF BLOOD

3) LENGTHENING OF THE CORD

❒ BEST SIGN of placental separation

MANAGEMENT:

1) WEIGH PLACENTA

❒ NORMAL: 400-600 gms.

2) CHECK NUMBER OF COTYLEDONS

❒ NORMAL: 20-30 Cotyledons

3) CHECK FOR PERINEAL LACERATION

4 DEGREES OF PERINEAL LACERATION:

1) 1^st degree:

❒ Vaginal skin + mucous membranes

2) 2^nd degree:

❒ 1^st degree + vaginal muscles

3) 3^rd degree:

❒ 2^nd degree + rectal external sphincter

4) 4^th degree:

❒ 3^rd degree + rectal mucous membrane

STAGE 4: RECOVERY PERIOD

HAPPENS AFTER FIRST 4 HOURS AFTER DELIVERY

CHECK THE FF. EVERY 15 MINUTES:

1) VITAL SIGNS

2) FUNDUS

❒ (N): FIRM & CONTRACTED

❒ (ABN): SOFT & BOGGY (Sign of bleeding)

POSTPARTUM STAGE

A. RETURN OF MENSES

➢ BOTTLEFEEDING MOTHERS: return of menses after 6-8 weeks

➢ BREASTFEEDING MOTHERS: return of menses after 3-6 months

B. LOCHIA

1^st stage	RUBRA(Red)	First 3 days
2^nd stage	SEROSA(Pink to brown)	4^th-7^th day
3^rd stage	ALBA(Whitish)	8^th-14^th day

C. REVA RUBIN’S THEORY

1^st stage

TAKING IN

FOCUS: SELF (Passive)

2^ndstage

TAKING HOLD

FOCUS: BABY(Active)

3^rd stage

LETTING GO

FOCUS: FAMILY

(Interdependent)

SUDDEN PREGNANCY COMPLICATIONS

A. 1^ST TRIMESTER

1) ABORTION (termination of pregnancy before the age of viability)

❒ 2 CLASSIFICATIONS:

a) SPONTANEOUS ABORTION

✓ Due to natural causes

b) INDUCED ABORTION

✓ Deliberate termination of pregnancy

❒ TYPES OF SPONTANEOUS ABORTION

a) MISSED ABORTION

✓ Fetus died within 1 month

✓ Retention after death

✓ (-) FHR

✓ CLOSED Cervix

b) INEVITABLE ABORTION

✓ (+) FHR

✓ OPEN Cervix

c) THREATENED ABORTION

✓ (+) FHR

✓ CLOSED Cervix

✓ Slight Bleeding

d) SEPTIC ABORTION

✓ d/t infection

e) HABITUAL ABORTION

✓ More than 3 consecutive abortions

✓ d/t incompetent cervix (cervix opens prematurely)

2) ECTOPIC PREGNANCY (implantation outside the uterus)

❒ MOST COMMON SITE: Fallopian Tubes (Ampulla)

❒ MOST DANGEROUS SITE: Interstitial/Intramural

❒ CAUSES:

a) Smokers (can cause tissue adhesion d/t dryness)

b) Intrauterine Uterine Device

c) Pelvic Inflammatory Disease

✓ MOST COMMON Causative agent:GONORRHEA

❒ DIAGNOSTIC TESTS:

a) B-hCG + Transvaginal UTZ

❒ 2 TYPES OF EP:

a) Unruptured Ectopic Pregnancy (<12 weeks AOG)

✓ S/Sx: BUNP

1. Brief amenorrhea

2. Unilateral abdominal pain

3. Nausea & Vomiting

4. (+) Pregnancy test

✓ MANAGEMENT:

1. Use abortifacient

❖ Mifepristone (RU 486)

2. To prevent choriocarcinoma: NEEDS prophylaxis!

❖ Methotrexate (Anti-folic acid drug) + Leucovorin(Active folic acid)

❖ Dactinomycin

b) Ruptured Ectopic Pregnancy (>12 weeks AOG)

✓ S/Sx: SSHBR

1. Scanty, dark-brown, vaginal bleeding

2. Sudden, sharp, severe, stabbing, knife-like abdominal pain radiating to neck (Kehr’s Sign) and shoulder

3. Hemoperitoneum (increase bleeding in abdomen)

4. Bluish discoloration of umbilicus (Cullen’s Sign)

5. Rigid board-like abdomen

✓ MANAGEMENT:

1. Blood transfusion + IVF

2. Laparoscopy (to visualize abdomen)

❖ To repair/remove the affected fallopian tube

3. Salpingectomy (removal)

4. Salpingotomy (assisting incision)

5. Salpingostomy (artificial opening)

B. 2^nd TRIMESTER

1) INCOMPETENT CERVIX/ PREMATURE CERVICAL DILATATION (the cervix opens prematurely)

❒ CAUSES: TFC

a) Trauma from Forceps Delivery

b) Forced Dilatation & Curettage (D&C)

c) Congenitally Short cervix

❒ 1^st sign: OPEN Cervix

❒ MANAGEMENT:

a) Cerclage (suture cervix)

✓ Performed on 12-14 weeks AOG

✓ The earlier, the better

CRITERIA for Cerclage

NO VAGINAL BLEEDING

NO UTERINE CONTRACTIONS

INTACT MEMBRANES

CERVIX NOT DILATED

BEYOND 3 cm

✓ 2 TYPES OF CERCLAGE:

McDonald’s Cerclage	Shirodkar-Barter Cerclage
TEMPORARY suture	PERMANENT suture
Removed at 37-38 weeks AOG	C/S Delivery
NSVD

2) HYDATIDIFORM MOLE (H-mole, Molar Pregnancy, Gestational Trophoblastic Disease)

❒ Abnormal proliferation & degeneration of trophoblasts

❒ CAUSES: UNKNOWN

❒ S/Sx:

a) LGA (classic sign)

b) Increased hCG (1-2 million IU)

✓ (N) hCG: 300,000-400,000 IU

c) Hyperemesis gravidarum

d) Dark-brown, prune juice-like vaginal bleeding

e) Grape-like vesicles (hallmark sign)

❒ MANAGEMENT:

a) D&C

b) NO PREGNANCY for 1 year

c) hCG monitoring for 1 year

d) NO OXYTOCIN (to prevent pulmonary embolism)

e) PREVENT complication: Choriocarcinoma

❖ Methotrexate (Anti-folic acid drug) + Leucovorin(Active folic acid)

❖ Dactinomycin

C. 3^rd TRIMESTER

PLACENTA PREVIA	ABRUPTIO PLACENTA
DESCRIPTION
Low-lying placenta	Premature separation of placenta
Premature separation of ABNORMALLYimplanted placenta	Premature separation of NORMALLYimplanted placenta
HALLMARK SIGN
Painless, bright-red vaginal bleeding	Painful, dark-red vaginal bleeding
DIAGNOSTIC TEST
UTZ (to locate the *placenta*)	UTZ (to locate the *retroplacental clot*)
MODE OF DELVIERY
DOUBLE SET-UP ❒ 1^st Set-up: NSVD ❒ 2^nd Set-up: C/S delivery	Emergency C/S