A4 obstetrics note

OBSTETRICS AND
GYNECOLOGY
FOR
Health Science Students
Lecture Note
Hawassa Health Sciences College
Hawassa University

Obstetrics and Gynecology
For
Health Science Students
Lecture Note
Samson Negussie, Assistant Professor
M.D. Obstetrician and Gynecologist
April 2006
In collaboration with The Carter Canter (EPHTI) and The
Federal Democratic Republic of Ethiopia Ministry of
Education and Ministry of Health

TABLE OF CONTENTS
Preface i
Acknowledgement ii
About the lecture note iii
Abbreviations v
SECTION ONE – BASICS
CHAPTER 1 Reproductive anatomy, physiology and embryology 1
CHAPTER 2 Obstetric and gynecology evaluation 9
SECTION TWO – NORMAL AND ABNORMAL PREGNANCY
CHAPTER 3 Normal physiology and diagnosis of pregnancy 17
CHAPTER 4 Common minor disorders of pregnancy 22
CHAPTER 5 Antenatal care 27
CHAPTER 6 Abnormal bleeding during first and second trimesters of
pregnancy
31
CHAPTER 7 Antepartum hemorrhage 44
CHAPTER 8 Hypertensive disorders of pregnancy 49
CHAPTER 9 Disturbances of amniotic fluid 55
CHAPTER 10 Premature rupture of membranes and preterm labour 58
CHAPTER11 Multiple pregnancy 63
CHAPTER12 Rh isoimmunization 67
CHAPTER13 Medical disorders of pregnancy 70
SECTION THREE – NORMAL AND ABNORMAL LABOUR
CHAPTER 14 Physiology and management of normal labour 84
CHAPTER 15 Induction and augmentation of labour 92
CHAPTER 16 Operative deliveries 97
CHAPTER 17 Malpresentations and malpositions 105
CHAPTER 18 Dystocia 115
CHAPTER 19 Obstructed labour and ruptured uterus 121
CHAPTER 20 Fetal distress 127
SECTION FOUR – NORMAL AND ABNORMAL PEUPERIUM
CHAPTER 21 Normal puerperium and its management 131
CHAPTER 22 Postpartum hemorrhage 135
CHAPTER 23 Postpartum complications 141
SECTION FIVE – GYNECOLOGY
CHAPTER 24 Menustral cycle and its abnormalities 147
CHAPTER 25 Climacteric and related problems 158
CHAPTER 26 Vaginal discharge and vulvar pruritis 161
CHAPTER 27 Pelvic inflammatory disease 167
CHAPTER 28 Family planning 171
CHAPTER 29 Infertility 179
CHAPTER 30 Tumor conditions of the female genital tract 183
CHAPTER 31 Uterovaginal prolapse and urinary incontinence 193
PREFACE
Ethiopia is one of the countries in the world with unacceptably high maternal mortality rate.
Various strategies are being implemented to reduce this rate and improve the overall health
of women. One such strategy is ensuring the provision of preventive, curative and
i

rehabilitative health services to the population by improving access and quality of services by
training competent midlevel and front line health workers.
Currently a number of higher learning institutions are involved in the training of health
officers. One of the objectives of health officer training is producing competent professionals
capable of delivering comprehensive emergency obstetric care and managing other common
gynecologic problems.
One of the problems encountered during the training is shortage of standardized training
materials gauged to meet the objective of the health officers training. Different training
institutions use different text materials and the emphasis given to different topics varies. The
emphasis given to common obstetric and gynecologic topics prevalent in resource poor
countries varies greatly.
The Ethiopian Public Health Training Initiative (EPHTI) has recognized this critical problem
and was involved in development of standardized training materials (modules and lecture
notes) in different public health and clinical subjects.
This lecture note is prepared to help in standardizing the training in different teaching
institutions. It also aims to provide a quick reference for students and is believed to initiate
further reading. This final version was designed and prepared to address the needs of health
officer training. It emphasizes mainly on detection, diagnosis and management of emergency
obstetrics problems and common gynecologic diseases.
ii

ACKNOWLEDGEMENT
My deepest gratitude goes to The Carter Center and the Ethiopian public health training
initiative for providing technical and financial support. Special thanks goes for Ato Aklilu
Mullugeta whose unrelenting follow up made this lecture note a reality. The following people
were involved in the development of the first draft and need to be credited: Dr. Habtemariam
Tekle (Gondar University), Drs. Fassil Mengistu and Endris Mohammed (Debub University),
Dr Mussie Abera (Alemaya University) and Dr. Zerai Kassaye (Jimma University).
I am highly indebted to Dr. Solomon Kumli, Dr. Yirgu G/Hiwot of Addis Ababa University,
Gynecology and Obstetric department for their constructive comments and suggestions
without which this lecture note wouldn’t have takes its present shape.
iii

ABOUT THE LECTURE NOTE
Organization
This lecture note is organized into five sections. The first section deals with the basic topics
needed to deal with obstetrics and gynecology. A short summary of anatomy, physiology and
embryology of the female genital tract is followed by an outline of obstetric/ gynecologic
history and physical examination. The second section deals with normal changes of
pregnancy, antenatal care and various antenatal complications of pregnancy. The third
section gives description of normal and complicated (abnormal) labour along with their
management. The fourth section is entitled for puerperium and abnormalities associated with
postpartum period. The final section deals with normal menustral cycle and different
gynecologic problems. Review questions follow each chapter. Because of repetition of
reference materials used for each topic, the author preferred to give references for the
different topics are given at the end of each section. Malpresentations are included in section
three (normal and abnormal labour) because of their importance in terms of maternal and
neonatal complications is related to their occurrence in labour and the need to stress the
different emergency maneuvers used in malpresentation for a health officer student. In
section five (gynecologic section) related topics are lumped under one chapter. Tumor
conditions of the female genital tract are organized into benign and malignant conditions.
Preparation
Preparation of this lecture note was started some 18 months back. Representatives from four
different universities (Alemaya, Jimma, Gondar and Debub now Awassa) divided the topics
among themselves and took the task of developing the first draft. The then Debub University
(now Awassa University) took the task of compiling and editing the first draft. During this
reviewing/ editing process a number of problems were encountered. The major one is most
of the draft developed was so detailed and did not take into consideration the level of
competence required of a health officer. The other is failure to get the first draft from some of
the universities in time. Internal reviewing done on the available draft suggested significant
remodeling to be done on the first draft. Modification/ rewriting of the first draft to meet the
above objective could not be done in time because of the fact that most of the professionals
involved in the development of the first draft left their respective universities. So finalization of
the lecture note was delayed. After discussion with the responsible people in The Carter
Center, the author took the responsibility of reshaping and rewriting the final version of this
lecture note. During this preparation the curriculum for health officer training, the first draft
iv

and different references were consulted and appropriate modifications were made. Financial
and other technical support was provided by The Carter Center.
This final version was designed and prepared to address the needs of health officer training.
It emphasizes mainly on detection, diagnosis and management of emergency obstetrics
problems and common gynecologic diseases. Conditions that can not be diagnosed/
managed at a health center setting and/ or require specialist care are omitted or are briefly
mentioned.
Application
This lecture note is designed to be used by a health officer student as a guide for further
reading. It can also be used as a quick reference by other cadre of health science students
(medical students, midwives and nurses) taking obstetrics and gynecology as part of their
training. It can be used as a reference by instructors of Obstetrics and Gynecology.
Limitations
This lecture note is by no means a replacement for standard texts in obstetrics and
gynecology. It only gives an outline of the important aspects of the topics that are relevant for
health officer training. It omits detailed description of some aspects of the topics involved.
Some topics not included in the curriculum are not included in this lecture note. Sophisticated
and recent diagnostic/ treatment modalities not applicable in the setting a health officer works
and details of pathogenesis are not given due emphasis. The user is thus advised to use the
mentioned references for such details.
v

ABBREVIATIONS
ACTH – Adrenocorticotrophic hormone
AFI – Amniotic fluid index
ANC – Antenatal care
ARM – Artificial rupture of membranes
APH - Antepartum hemorrhage
AUB – Abnormal uterine bleeding
BPD – Biparietal diameter
CPD – Cephalopelvic disproportion
C/S – Caesarian section
DNA – Deoxyribonucleic acid
DUB – Dysfunctional uterine bleeding
DVT – Deep vein thrombosis
E&C/ D&C – Evacuation and curettage/ dilatation and curettage
EDD – Expected date of delivery
FHB – Fetal heart beat
GH – Growth hormone
GTD – Gestational trophoblastic tumors
HCG – Human chorionic gonadotrophic hormone
HDP – Hypertensive disorders of pregnancy
HPO – Hypothalamo pitutary ovarian axis
IUCD – Intrauterine contraceptive devise
LMP/LNMP – Last menustral period/ last normal menustral period
MSH – Melanocyte stimulating hormone
MTCT – Mother to child transmission
MVA – Manual vacuum aspiration
vi

OCP – Oral contraceptive pills
OL – Obstructed labour
PAC – Post abortion care
PID – Pelvic inflammatory disease
PIF – Prolactin inhibitory factor
PIH – Pregnancy induced hypertension
PMI - Point of maximum impulse
PMS - Premenstrual syndrome
PPH - Post partum hemorrhage
PROM - Premature rupture of membranes
POP – Progestin only pills
RH - Rhesus factor
STD/STI – Sexually transmitted diseases/ sexually transmitted infections
TORCH
TSH – Thyroid stimulating hormone
UTI – Urinary tract infection
VDRL – Venereal disease research laboratory
vii

PART I: BASICS
CHAPTER 1
REPRODUCTIVE ANATOMY, PHYSIOLOGY
AND EMBRYOLOGY
By Dr. Habtemariam Tekle
Learning objective
To know the anatomy of the female reproductive system
To know the physiology of the female reproductive system
To know the normal development of the female genital tract
Introduction
It is mandatory to know the anatomy and physiology of the female reproductive system to
manage obstetric and gynecologic problems.
1. ANATOMY OF THE FEMALE PELVIC ORGANS
1.1. External female genitalia (vulva or pudendum )
1.1.1. Anatomic landmarks
The vulva includes mons pubis, labia majora, labia minora, clitoris, vestibule and perineum
which are all visible on external examination. It is bounded anteriorly by the mons pubis,
laterally by the labia majora and posteriorly by the perineum.
A. Mons Pubis
It is the pad of subcutaneous fatty tissue in front of the pubis. It is covered by the pubic hair
in inverted triangle fashion.
B. Labia majora
It is the elevation skin and subcutaneous tissue which forms the lateral boundaries of the
vulva. Posteriorly each labia majora fuses medially to form the posterior commissure. The
labia majora contains sebaceous glands, sweat glands and hair follicles. The dense
connective tissue and adipose tissue beneath the skin is richly supplied with venous plexus
which may produce hematoma, if injured. The labia majora are homologous with the scrotum
in the male.
1

C. Labia minora
These are two thick skin folds, devoid of fat, lying on either side within the labia majora.
Anteriorly they are divided to enclose the clitoris and unite with each other in front and behind
the clitoris to form the prepuce and frenulum respectively. Posteriorly each labia minora fuse
to form a fold of skin called fourchette. Labia minora don not contain hair follicle. It is
homologous with the ventral aspect of the penis.
D. Clitoris
This is a small cylindrical erectile body situated in the most anterior part of the vulva. It
consists of the glans, body and two crura. It is analogous to the penis in the male.
E. Vestibule
It is a triangular space bounded anteriorly by the clitoris, posteriorly by the fourchette and on
either side by labia minus. There are erectile tissues bilaterally situated beneath the mucus
membrane called the vestibular bulb. Each bulb lies anterior to the Bartholin’s gland and is
incorporated within the bulbocavernous muscles. They are homologous to the single bulb of
the penis and corpus spongiousum in the male.
There are four openings into the vestibule.
I. Urethral opening which is situated in the midline just anterior to the vaginal orifice.
II. Vaginal orifice which is located posterior to the urethral opening. In virgins and
nulliparous the opening is closed by the labia minora but in parous, it may be
exposed. The orifice is incompletely closed by a septum of mucus membrane called
hymen.
III. Bartholin’s duct opening (one on each side): The Bartholin’s glands are situated
in the superficial perineal pouch posterior to the vestibular bulb. It secretes abundant
alkaline mucus, during sexual excitement which helps in lubrication. Each gland has
got a duct which opens just anterior to the Hymen. The Bartholin’s gland
corresponds to the bulbourethral gland in the male.
F. Perineum (Perineal body)
This is a pyramidal shaped tissue where the pelvic floor and the perineal muscles and fascia
meet. It is located between the vagina and the anal canal.
2

1.1.2. Blood supply of the Vulva
A. Arteries
Branches from the internal pudendal arteries (labial artery, transverse perineal artery, artery
to the vestibular bulb and deep and dorsal arteries to the clitoris) and femora artery
(superficial and deep pudendal arteries) supply the different parts of the vulva.
B. Veins
The veins of vulva form plexus and drain into internal pudendal vein, vesical or vaginal
venous plexus and the long saphenous vein.
1.1.3. Nerve supply to the vulva
It is supplied by cutaneous branches from the ilioinguinal, genital branches of genitofemoral
nerve, pudendal branches from the posterior cutaneous nerve of the thigh and labial and
perineal branches of pudendal nerve.
1.2. Internal female genital organs
The internal genital organs in female include vagina, uterus, fallopian tubes and the ovaries.
These require special instruments for inspection.
A. Vagina
It is a fibro-musculo-membraneous canal communicating the uterine cavity to the exterior at
the vulva. It has four walls: anterior, posterior and two lateral walls. The length of the anterior
wall measures 7 centimeters and the posterior wall is about 9 centimeters. The projection of
the cervix through the anterior vaginal wall at the top of the vagina (vault) creates clefts
known as fornices. There are four fornices (anterior, posterior and two lateral).
Its wall is composed of four layers. The four layers from within to outwards are mucus
membrane lined by stratified squamous epithelium, sub mucous layer, muscular layer( inner
circular and outer longitudinal) and fibrous coat.
The vaginal secretion is very small but sufficient to make the surface moist. The pH is acidic
and ranges between 4.0- 5.5 in reproductive age groups. The Doderlin’s bacilli are
responsible for conversion of Glycogen from the exfoliated squamous cells to lactic acid.
The vagina serves as excretory channel for menstrual blood and uterine secretions, organ for
sexual intercourse and passage for the fetus during birth.
3

Blood supply
The arteries supplying the vagina are cervico vaginal branch of the uterine artery, vaginal
artery (a branch fro internal iliac artery), and middle rectal and internal pudendal artery.
These anastomose with one another and form two azygous arteries, one anterior the other
posterior.
Veins drain into internal iliac and internal pudendal veins.
B. Uterus
This is a hollow pyriform muscular organ situated between bladder and rectum. It is normally
anteverted and anteflexed. It measures 8 centimeters long, 5 centimeters wide and 1.25
centimeters thick. It has three parts.
I. Body or corpus which is the part between the isthmus and the opening of the
fallopian tubes. The part that is above the opening of the fallopian tubes is called
the fundus.
II. Isthmus is a constricted part situated between the body and the cervix. It measures
about 0.5 centimeters.
III.Cervix is the lower most part of the uterus which is cylindrical in shape and
measures about 2.5 centimeters. It is divided into supravaginal part (part lying
above the vagina) and portiovaginalis (which lies within the vagina). It has two
openings the internal os and the external os with cervical canal in between.
The uterine wall consists of three layers.
I. Perimetrium is the serous coat covering the underlying myometrium
II. Myometrium consists of thick bundles of smooth muscles arranged in various
directions.
III. Endometrium is the mucus lining of the endometrial cavity. It consists of the
surface epithelium and laminia propiria.The surface epithelium is a single layer of
ciliated columnar epithelium and the lamina propria contains stromal cells,
endometrial glands, vessels and nerves.
Blood supply
The arterial supply is mainly from the uterine artery and the other sources are vaginal and
ovarian arteries.
The venous channel corresponds to the arterial course and drain into internal iliac veins.
4

C. Fallopian Tube
The uterine tubes are paired structures which are attached to the lateral angle of uterine
cavity. It has four parts intramural or interstitial (part inside the uterine wall), the isthmus (the
straight part), ampulla (the tortuous part) and the infundibulum. The abdominal ostium is
surrounded by a number of radiating fimbria, one of these is longer than the rest and is
attached to the outer pole of the ovary - ovarian fimbria.
D. Ovary
Ovaries are paired sex glands or organs. Each measures 3centimetres by 2 centimeters by 1
centimeter. Each is attached to the uterus by the utero-ovarian ligament, to the lateral pelvic
wall by infundibulopelvic ligament and to the posterior wall of the broad ligament by the
meso-ovarium.
They are covered by a single layer of germinal epithelium. The substance of the ovary has
cortex and medulla. The cortex is the functional layers which include primordial follicles,
mature follicles, Graffian follicles, corpus luteum and atretic follicles or corpus albicans.
Medulla consists of loose connective tissue, muscle cells, blood vessels and nerves and
hilus cells.
Blood supply
Arterial supply is from the ovarian artery, a branch of the abdominal aorta. Venous drainage
is through pampiniform plexus to form ovarian veins which drain to inferior vena cava on the
right side and to the left renal vein on the left side.
Nerve supply
It receives sympathetic supply from T10.
2. PHYSIOLOGY OF THE FEMALE REPRODUCTIVE ORGANS
The physiology of female reproductive system is concerned with the functions from birth
through puberty and adult hood to the menopause. This is achieved through the
neuroendocrine mechanism that involves the cortico-hypothalamic-pituitary-ovarian axis. The
hypothalamo pitutary ovarian axis is a well coordinated axis and the hormones liberated from
the hypothalamus, pituitary and the ovary are dependent on one another.
The secretion of the hormones from these glands is modified through feedback mechanisms
operating through this axis. The axis may also be modified by hormones liberated from the
thyroid and adrenal glands.
5

A. Hypothalamus
It produces specific releasing and inhibitory hormones or factors which have effect on the
production of pituitary hormones.
I. Gonadotrophic releasing hormones (GnRh) is concerned with the synthesis storage
and release of gonadotrophic hormones, FSH and LH.
II. Prolactin inhibitory factor/ hormone (PIF) inhibits the release of prolactin.
III. Thyrotrophin releasing hormone (TRH) stimulates the release of TSH.
IV.Corticotrophin releasing hormone (CRH) stimulates the release of ACTH.
V. Growth hormone releasing hormone stimulates the release of growth hormone.
B. Pituitary
It has two parts, the anterior pituitary (adenohypophysis) and the posterior pituitary
(neurohypophysis).
The adenohypophysis produces
I. Gonadotrophins which include follicle stimulating hormone (FSH) and leutinizing
hormone (LH). FSH is mainly stimulates the growth and maturation primary ooytes of
which only one develops into graffian follicle. In conjunction with LH, it is also involved
in ovulation and steriodeogenesis. The main function of LH is steriodeogenesis but
along with FSH, it is responsible for full maturation of the Graffian follicle and
ovulation.
II. Prolactin is responsible for the production of the milk in the breast.
III. The other hormones TSH (thyroid stimulating hormone), ACTH (adrenocorticosteroid
hormone), GH (growth hormone) and MSH (melanocyte stimulating hormone).
C. Ovary
The function of ovary is ovulation and production of ovarian hormone. The major ovarian
hormones are estrogen and progesterone, also called the female sex hormones. The other
hormones produced by the ovary are androgens and inhibin.
Estrogen is produced by granulosa cells. Its functions include
I. Development of female secondary sexual characteristics including deposition of fat in
the breast, thighs & hips and growth and development internal & external female
genital organs.
II. Decreases FSH and LH secretion by negative feedback mechanism during the
menstrual cycle except at mid cycle at which time it increases LH secretion by
positive feedback mechanism.
6

III. In the breast it stimulates the growth of the ducts and fat deposition.
Progesterone is secreted by the lutenized theca granulosa cells. Its functions are
I. Increases the glandular secretions of the endometrium and diminishes the
contractility of myometrium.
II. Stimulates the growth of the acini in the breast.
III. In large doses it inhibits LH secretions.
IV. Increases basal body temperature.
Androgens are produced mainly by the theca interna cells. They are source for estrogen
synthesis. Inhibin and relaxin are other hormones produced by ovary.
Hypothalamo-Pituitary-Ovarian (HPO) Axis at different stages of life
I. Fetal life- HPO axis remains active and functional from 20 weeks of life.
II. Infancy and childhood- high level of FSH and LH at birth gradually decline and
minimum level achieved by two years of age.
III. Prepuberity – hypothalamus is very much sensitive to negative feedback by even a
small amount of estrogens (estrogen produced by peripheral conversion of
testosterone to estrogen). Hence, FSH and LH secretions are inhibited.
IV. Puberty –hypothalamus become more insensitive to estrogen to estrogen negative
feedback. Hence increasing amounts of GnRH, FSH and LH are secreted, which in
turn stimulate the ovary to secrete estrogen and progesterone. This eventually results
in thelarche, adrenarche and menarche.
V. Pregnancy- the gonadotrophins level remains low.
VI. Menopause- ovarian follicles become scarce and resistant. Hence FSH and LH
levels increase while estrogen and progesterone levels decrease.
3. EMBRYOLOGY OF THE REPRODUCTIVE ORGANS
Introduction
In early pregnancy, both internal and external genital organs are undifferentiated. During
development, because of “X” and “Y” chromosomes and other hormones, the
undifferentiated genitalia differentiate either to male or female genital organ. Male sex is an
induced sex because it requires specific messages to develop. Genital and urinary systems
are in close proximity. During development of one system induces the development of the
other system. This explains why congenital malformations of genital system are often
associated with abnormalities of urinary and musculoskeletal system.
7

Development of gonads
On fourth week after fertilization, primordial germ cells migrate from yolk sac through the
mesentery of the hind gut to the posterior body wall mesenchyme at the tenth thoracic level.
Their arrival induces proliferation of adjacent mesonephros and celomic epithelium to from
the genital ridge. The celomic epithelium forms the cortex, the mesenchyme forms the
medulla and the germ cells originate from the endoderm. This stage of gonadal development
is called the indifferent stage (bipotential gonads).
Further development is influenced by the Y chromosome which has the sex determining
region (SRY). In its presence the indifferent gonad develops into testis. In its absence like in
XX or XO fetus it develops into an ovary.
In further development of the ovary the medulla regresses to form rete ovary and the cortex
forms the ovarian follicles. Between the seventh and ninth months the ovary descends to the
pelvis to be attached to the ligaments.
Development of internal female genital organs
Two major ducts give rise to the internal genital organs, namely the Wollfian duct (male duct)
and the Mullerian duct (female duct). In the presence of testis the Wollfian duct develops
(effect of testosterone produced by Leydig cells) and the Mullerian duct regresses (effect of
Mullerian regressing factor produced by the Sartoli cells). But, in the absence of functional
testis the reverse happens. The Mullerian duct is formed by invagination of celomic
epithelium. The two Mullerian ducts grow downwards and medially. Eventually their lower
ends fuse into one. Further development results in cavitations to form hollow organs at fifth
month of gestation.
The fallopian tubes develop from upper unfused horizontal part of the Mullerian duct. Uterus
develops from intermediate horizontal and adjoining vertical part of Mullerian duct. The lining
epithelium and glands develop from coelomic epithelium. Myometrium and endometrial
stroma arise from mesoderm. Broad ligament is formed as a broad transverse fold as the
Mullerian ducts approach midline. It extends from lateral side of fused duct to pelvic side
wall. It has vestigial remnants like epoophoron, paroophoron and ducts.
Vagina is formed in third month of gestation. There are two concepts for the development of
vagina. One says the whole vagina is developed from the urogenital sinus. The other argues
that vagina is mainly developed from Mullerian duct with only one third contributed by the
urogenital sinus.
8

Development of External genital Organs
In the fifth week of embryonic life, folds of tissue form on each side of cloacae. Development
of coronal partition, called urorectal septum, separates the endodermal cloacae into two
parts. The dorsal part, which at its lower end is covered by the anal membrane, develops into
rectum and anal canal. The ventral part which is now called the urogenital sinus develops
into the external genital organs. It lower end is lined by the bilaminar urogenital membrane.
The site of fusion between urorectal septum and the urogenital membrane is the primitive
perineal body.
Further development of the urogenital sinus differentiates it into three parts. The upper or
vesicourethral part forms the mucus membrane of bladder and major part of female urethra.
The middle pelvic part receives the united caudal part the two paramesonephric (Mullerian)
ducts in the midline. It later gives rise to the epithelium of the vagina, the Bartholin’s gland
and the hymen. The lower phallic part is lined by the bilaminar urogenital membrane. The
phallic part has one genital tubercle, and two genital folds and urogenital swellings
(labioscrotal folds).
Clitoris is developed from the genital tubercle. Labia minora are developed from the genital
folds. Labia majora are developed from urogenital swellings (labioscrotal swellings).
Bartholin’s Glands develop as out growth from the caudal part of the urogenital sinus.
Vestibule develops as urogenital groove from urogenital sinus. Hymen is developed from the
junction of the sinovaginal bulbs and urogenital sinus.
Some congenital malformations
Failure of development of both mullerian ducts results in absence fallopian tubes, uterus, and
upper two thirds of vagina (Mullerian agenesis).
Failure of development of one mullerian duct results in unicornuate uterus with single
oviduct.
Failure of recanalization of the lower part of the fused Mullarian duct results in isolated
atresia of upper vagina and cervix causing hematometra.
Failure of fusion of mullerian duct depending on the degree results in uterus didelphys with
two cervix and vagina canals, arcuate uterus and uterus bicornis.
Fallopian tube abnormalities are not common. Rarely accessory ostia or diverticulum or
abnormally short or long tubes may occur.
Failure of canalization of the urogenital membrane results in imperforate hymen. Failure of
development of the external genitalia results in ambiguous genitalia.
Reminants of Wollfian duct result in Gartner’s cyst found in the upper part of the vagina.
9

CHAPTER 2
OBSTETRIC AND GYNECOLOGIC EVALUATION
By Dr. Habtemariam Tekle
Learning objective:
· To enable the student take proper history and physical examination to reach to the
diagnosis.
Introduction
To come to a clear understanding of a patient’s problem, detailed history and physical
examination is important.
1. OBSTETRICS HISTORY & PHYSICAL EXAMINATION
1. History
1.1. Identification
· Name
· Age – significant if less than 20 years and greater than 35 years
· Martial status
· Address- far distance from health institution
· Religion
· Occupation
· Date of admission
· Ward and bed number
1.2. Chief complaints-
Patients may have come for routine antenatal care follow up or may come with one or more
specific complaints. Note the duration of each complaint.
1.3. History of present pregnancy
Get information on the following points
· Gravidity- all forms of pregnancy whether it is term, live births, still birth, abortion,
ectopic pregnancy or molar pregnancy.
· Parity- fetus delivered after 28 weeks of gestation for Ethiopia and United kingdom
and greater than or equal to 20 weeks – according to WHO
10

· Abortion
· Last normal menstrual period (LNMP)
· Expected date of delivery (EDD) which could be calculated by
1- Naegale’s rule (using European calendar)
- LNMP- 3 months + 7 days
2- Ethiopian calendars
· NLMP+ 9 months +10 days if pagume is not passed
· NLMP+ 9 months + 5 if pagume is passed ( 4 in leap year )
· Calculate gestational age in completed weeks and days
· Quickening – the first time the mother felt fetal movement
- In primigravida it is around 18-20 weeks and in multigravida
at 16-18 weeks of gestational age.
- Used to date pregnancy if LNMP is unknown
· Presence of antenatal care elsewhere. place and number of visits.
· Elaboration of chief complaints
· Danger symptoms of pregnancy (vaginal bleeding, severe headache, blurring
of vision, epigastric or severe abdominal pain, profuse vaginal discharge,
absence or reduction of fetal movement, fever, persistent vomiting)
· Common complaints in pregnancy ( like nausea and vomiting, weakness
· Pregnancy - unplanned , unwanted and unsupported
· Ask positive and negative statement according to the patient complaints
1.4. Past obstetric history
The following should be asked for all previous pregnancies in chronologic order
· Date, month and year of gestation for example first delivery in May 2000
· Length of gestation - abortion (< 28 weeks), preterm (<37 completed
weeks), term (>37 completed to 42 completed weeks), post term (greater
than 42 completed weeks)
11

· Significant antenatal medical problems like hypertension, ante partum
hemorrhage, diabetes
· Onset of labor (spontaneous or induced)
· Fetal presentation
· Duration of labor
· Mode of delivery (spontaneous vaginal, instrumental, caesarian section,
destructive delivery)
· Fetal outcome (alive or dead, sex of the newborn, weight of the newborn,
malformations, current condition)
· Post partum complications postpartum hemorrhage
1.5. Gynecology history
· Family planning methods - use , type , duration and side effects
· Sexual history- assess risk of sexually transmitted infections and
HIV/AIDS
· Gynecology operations- Female genital mutilation , laparatomy, dilatation
and curettage ,evacuation and curettage, manual vacuum aspiration
· Menstrual history ( age of menarche, interval of period 21-36 days,
amount of flow 10 –80 ml, duration of flow 1-8 days, normally dark red and
non-clotting).
1.6. Past medical and Surgical History
· History of diabetes mellitus, hypertension, hypo or hyper thyroidism
which may the affect pregnancy or get aggravated by pregnancy
· Blood transfusion important in hemolytic disease of new born
· Drugs risk of teratogenicity or allergic reactions
· Maternal infection – TORCH Syndrome.
1.7. Personal, family and social history
· Childhood development
12

· Educational status
· Habits like alcohol , smoking and elicit drugs
· Occupation- exposure to radiation, anesthesia- halothane, chemical
factory and others
· Income- low socio-economic status associated with obstetric problems like
preeclampsia ,preterm labor
· Family history- diabetes mellitus, hypertension, multiple pregnancy,
genetic disorders
1.8. Review of Systems
· Check all systems
2. Physical examination
Examination must be done in a private room in the presence of a chaperone. Proper
explanation must be offered to the patient before during and after the examination. Bladder
should be emptied and the patient properly positioned on the couch. Warm hands and
instruments must be used. Adequate light, appropriate gloves and swabs should be
prepared. Always keep eye contact throughout the examination.
2.1. General appearance
2.2. Vital signs and anthropometric measurements
· Blood pressure positions include left lateral with 300 tilt to the left to avoid
supine hypotensive syndrome or sitting position in ambulatory patient.
· Pulse rate -increases 10-15 beats/minute in pregnancy
· Respiratory rate -increases 1-4 breath /minute in pregnancy
· Temperature
· Weight – increment of more than 1kg/week is abnormal
· Height- less than 150 centimeters could be constitutional but may be a
risk factor. Strikingly short for every society is risk factor.
2.3. HEENT
13

· Emphasis on conjunctiva, sclera, teeth and buccal mucus membrane to
see pallor, jaundice, mucosal congestion and dental carries.
2.4. Lymphoglandular System
· Thyroid gland for hyper or hypo thyroidism signs.
· Breast for nipple refraction, pigmentation, lumps, discharge, colour change
2.5. Respiratory and cardiovascular system
Steps in examination are essentially same as non pregnant patient. Note that
the following are normal findings in pregnancy.
· Decreased diaphragmatic excursion due to diaphragm elevation by gravid
uterus
· PMI deviation to left is possible in pregnancy
· S3 gallop may be heard
· Functional systolic murmur may be heard
2.6. Abdomen
2.6.1Inspection
· Linea nigra- midline hyper pigmentation due to melanocyte stimulating
hormone
· Striae gravidarum – purplish in new striae and white in old striae. In both
cases is due to distension, which causes stretching.
· Umbilicus may be inverted, flat or everted
· Surgical or non surgical scar
· Distended veins, flank fullness, fetal movement
2.6.2. Palpation
· Superficial palpation – checks for rigidity, tenderness, superficial mass and
characterize it, abdominal wall defects.
· Deep palpation – palpate for mass, organomegally and characterize the
mass
· Obstetric palpation or Leopold’s maneuver
14

A. The first Leopold maneuver or fundal palpation
I. Fundal height measurement: first correct for asymmetry before
measurement. Then use one of the following methods:
1- Finger method – one finger above umbilicus is equal to two
weeks and below umbilicus one finger is equal to one week.
Uterus felt at symphysis corresponds to 12 weeks. At the
umbilicus it is 20 weeks and at xiphysternum it is 38 weeks.
2- Tape measurement: symphysis to funded height in centimeter
with tape meter between 18-34 weeks is accurate to within two
weeks of actual gestational age.
II. Determine what occupies the fundus. If soft, irregular bulky mass
is found it is the breech. If hard round ballotable mass is found, it is
the head.
B. The second Leopold maneuver or lateral palpation
I. Determines the lie of the fetus which could be longitudinal,
transverse or oblique lie. .
II. In longitudinal lie it determines on which side of the abdomen is the
fetal back. The back of the fetus is linear, rigid and smooth in outline.
The extremities are felt as small irregular and bulky masses. The fetal
heart beat is best heard on back side.
C. The third Leopold maneuver or Pelvic palpation
I. Determines what part of the fetus occupies the lower uterine pole
which is also called the presentation. The possibilities are the head
(cephalic presentation), the breech (breech presentation), and the
shoulder (shoulder presentation).
II. In cephalic presentations it determines the descent by using rule of
fifth which measures the distance between upper border of the
symphysis to anterior shoulder.
5/5 is floating head, 4/5 is fixed head, 2/5 denotes engaged head.
III. In conjunction of the findings of the second maneuver it
determines the attitude of the fetus (relation of head to the trunk). In
extended attitude the cephalic prominence is on the same side of the
15

back. In flexed attitude the cephalic prominence is on the opposite
side of the back. In military attitude the cephalic prominence is felt on
both sides at the same level.
D. The fourth Leopold maneuver or Pawlik grip
It is the only maneuver that is done with one hand. It assesses
presentation of he fetus.
2.6.3. Percussion
· Shifting and flank dullness
· Fluid thrill
2.6.4. Auscultation
· Fetal heart beat is first heard in the back side at16-18 weeks in multiparas
and 18-20 weeks in primigravida. In complete breech it is heard above
umbilicus. In cephalic presentations it is below umbilicus .IN occipito
posterior it is heard in the flanks. .
2.7. Genitourinary system
· Costovertebral and suprapubic tenderness
· Pelvic examination- to be done two times in pregnancy except in cases of
complications and if labor is suspected
I. First trimester (early) – To diagnose pregnancy, for dating of the
pregnancy by measuring uterine size and to diagnose pelvic problems
II. Late in pregnancy greater than 37 weeks
A. To diagnose contracted pelvis (refer chapter on)
- B. To assess Bishop score- (refer to chapter on induction)
III. In labor assess cervical dilatation and effacement, status of the
membranes and color of liquor, presenting part, station of presenting
part and position, molding, caput, clinical pelvimetry.
2.8. Intgumentary system
· Hyper pigmentation on breast, lower and mid line abdomen genitalia are
normally seen in pregnancy
· Vascular Changes- Spider angiomata and palmar erythema
16

2.9. Extremities
· Check for edema, dilated vessels and calf tenderness.
Dependent edema (pretibial and pedal), seen in 80% of normal pregnancies.
Pathological edema (non dependent) involves the face, fingers or the whole
body.
2.10. Central nervous system
· As non pregnant
2. GYNECOLOGY HISTORY AND PHYSICAL EXAMINATION
1. History
1.1. Identification
· As obstetric history
1.2. Chief complaints
Patient comes with the following gynecologic complaints. The
common complaints are cessation of menses, vaginal bleeding and
discharge, lower abdominal pain or deep pelvic pain, pain during intercourse
(dysparunia), pain during menstruation (dysmenorrhea), protruding mass
out of the introitus, genital ulcer, urinary incontinence and others.
1.3. History of present illness
· Gravidity, parity and abortion
· Detail of each complaint (localization, duration, date and time of onset,
aggravating and relieving factors, sequence of symptoms, evolution with
time, effect on life style, relation to menstrual cycle and others)
· LMP should be included details of menstrual history if pertinent to the
complaints
· Negative and positive statements pertinent to the presenting complaint
· Treatment received
17

1.4. Menstrual history
· Age of menarche
· Interval between period
· Duration of flow
· Amount & character of flow
· Dysmenorrhea , premenstrual symptoms
· Age of menopause
1.5. Gynecologic history
1.6. Past obstetric history
1.7. Past medical and surgical history
1.8. Personal social family, history
1.9. Review of systems
· As obstetrics history
2. Physical examination
Preparation for examination is similar to obstetric examination. In addition slides,
applicator, test tube, gloves, speculum and fixative are needed.
2.1. General Condition
2.2. Vital signs
· Blood pressure,pulse rate, respiratory rate, temperature
2.3. HEENT
· As nonpregnant
2.4. Lymphoglandular system
18

· Lymph nodes- to see for metastatic cancer check mainly
supraclavicular and axillary nodes.
· Thyroid gland- hypo and hyper thyroidism affects reproductive
function
· Breast examination- inspection and palpation
2.5. Chest and cardiovascular system
· As non pregnant
2.6. Abdomen
· As non pregnant (Inspection, auscultation, palpation and percussion)
2.7. Genitourinary system
· Costovertebral and suprapubic tenderness
· Pelvic examination
I. Examination of external genitalia
Pubic hair- diamond shaped in male and inverted
triangle in female.
Labia majora and minora – ulcer, swelling and
` discoloration
Discharge from urethra and vaginal introitus
Hymen- intact or torn
II.Speculum Examination
Vagina- note color (normally pink), vaginal
septum, rugae folds, fornices, discharge, scar,
laceration
Cervix – note color (normally pink) pink, cervical
os (pin- pointed in nulliparous and slit-like in
multiparous), dilatation, effacement and
bleeding, mass
III. Digital vaginal & bimanual pelvic examination
Vagina- mass and tenderness
19

Cervix- Closed normally, moves 2- 4cm with out discomfort,
smooth surface and like tip of nose in
consistency.
Uterus- normally non-tender, mobile, 9 cm in length,
pear shaped smooth and firm.
Adnexa (tubes, ovaries, parametrium and broad ligaments):
normally adenexal structure not palpable except in thin women
with soft abdomen, description of masses.
IV- Rectal and recto vaginal examination
Rectal examination- In virgin and children
Rectovaginal examination- For rectovaginal and uterosacral
ligament nodularity or malignant infiltration
To differentiate rectocele from enterocele
2.8. Intgumentary
· As non pregnant
2.9. Extremities and central nervous system
· As non pregnant
PART II
NORMAL AND COMPLICATED
PREGNANCY
20

CHAPTER 3
NORMAL PHYSIOLOGY & DIAGNOSIS OF PREGNANCY
Learning Objective:
To describe the important physiologic changes in each organ system during pregnancy
To describe the diagnosis of pregnancy
21

Introduction-
Pregnancy results in tremendous changes in the physiologic functions of organs, systems
and the body as whole. These changes ensure that the needs of the growing fetus are met
and prepare the mother for parturition and lactation. Changes in the maternal endocrine
system along with hormones produced by the placental / fetal unit are responsible for
majority of the changes. Knowledge about changes due to normal pregnancy is important to
reassure the pregnant woman and manage the minor disorders of pregnancy. Understanding
the normal physiologic changes also gives us the basis to understand the abnormal
conditions during pregnancy.
Terminologies
Pregnancy is a maternal condition of having a developing fetus in the body. It starts at
fertilization where fusion of the ovum (23x) and matured spermatozoa (23x or 23y) takes
place in the fallopian tubes. Zygote (46xx or 46xy) is a cell that results from fertilization. The
zygote divides and redivides forming daughter cells named blastomeres. When the zygote
reaches 16 cell stage, it is named morula. When fluid filled cavity appears in the morula a
blastocyst is formed. The cells of a blastocyst are arranged into layers. The outer layer is
called the trophoblast which eventually develops into the placenta. The inner layer is called
the embryoblast which later gives rise to the fetus. The embryo is the stage after the inner
layer formed two layers (bilaminar disc). The embryonic period is a period where major
structures are formed and extends up to the end of seven weeks after fertilization.
Developing conceptus after the embryonic period is called the fetus. All tissue products of
conception (embryo/ fetus, fetal membranes and placenta) are called conceptus. On day 4
after fertilization the blastocyst enters into the uterine cavity. By day 7, it starts embedding
itself into the prepared endometrium which is now called the decidua. This process is called
implantation.
Placenta and its hormones
The placenta is formed from the trophoblast and decidua basalis. It contains villi covered by
the cytotrophoblast and syncitiotrophoblast. The placental barrier (formed by the
syncitiotrophoblast, cytotrophoblast, the basement membrane and the fetal vascular
endothelial cells) ensures almost complete separation of the maternal and fetal blood. For
this reason the human placenta is of hemo-chorio- endothelial type. In a mature placenta the
villi are grouped into 15- 20 cotyledons, each supplied by one to two spiral arterioles. At 20
22

weeks the discoid placenta reaches full development. The placenta on average has a
diameter of 18 centimeters, a thickness of 23 millimeters, a volume of 497 milliliters, a weight
of 508 grams and villous surface area of
15 square meters. Placenta is a blue red discoid organ with two surfaces. The maternal
surface is made of the decidua basalis with visible septated cotyledons. The fetal surface is
smooth and shiny and is covered by the amnion. The branching fetal vessels are visible
under the amnion.
The placenta acts to the fetus as the lung (exchange of oxygen and carbon diaoxide), gastro
intestinal tract (provision of nutrients), kidney (excretion of hydrogen ion and urea), liver
(detoxifies drugs), immunologic system (transfer of antibodies) and endocrine gland
(production of hormones).
It is connected to the fetus by the umbilical cord or the funis. It has an average length of 50-
60 centimeters (range 30- 100) and diameter of 0.8- 2 centimeters. It contains two umbilical
arteries and one umbilical vein. In addition to acting as conduit for umbilical vessels, it also
allows fetal mobility.
Placenta is a source of incredible amounts of protein and steroid hormones. The major
protein hormone is human chorionic gonadotrophic hormone (HCG), also called the
pregnancy hormone. It has two subunits the alpha and the beta subunits and is produced in
increasing amount to reach a peak between 8 -10 weeks. It maintains the function of the
corpus luteum until the placenta takes over progesterone production. It also plays important
role in male sex differentiation by stimulating testosterone production by the fetal testis. It
also forms the basis for laboratory diagnosis of pregnancy.
In addition placenta produces a number of protein hormones. It is also a source of significant
amounts of progesterone and estrogens. Since placenta lacks some of the enzymes
necessary to synthesize estrogens, it relies on provision os substrates by the fetus and the
mother (fetal-placental –maternal unit).
Organ system changes
I. Cardiovascular system
Cardiac out put increases by 30-50%. The increase in cardiac output is mainly distributed to
the uterus (major share), kidneys, breast and the skin. Heart rate increases by 15-20 % and
stroke volume increases by 25-38%.
23

Blood pressure remains largely unchanged with small drop in diastolic pressure. This is the
result of progesterone mediated reduction in peripheral resistance. Blood pressure highest
when seated, lower when supine and lowest when ling on the side. Near term there is a
tendency to develop hypotension when women lie on their back, a condition called supine
hypotension syndrome.
Total blood volume increases up to 45%. Plasma volume increases 35-50% where as red
blood cell volume increases by 20-25%. This results in hemodilution leading to a drop of
hemtocrite and is called physiologic anemia of pregnancy.
Venous pressure rises in lower extremities and central venous pressure unchanged as the
result of pressure by the gravid uterus. This may result in leg edema and development of
varicose veins.
The point of maximum impulse is shifted to the left as the result of elevation of the
diaphragm. Splitting of the first and second heart sounds could be found. High cardiac out
put state may result in gallop and systolic functional murmurs.
II. Respiratory System
Vasodilatations of the nasal vessels result in nasal stuffiness and epistaxis. Diameter and
circumference of chest increase. Altered sense of smell is commonly reported. To meet the
increased oxygen consumption respiratory rate increases. Because of elevation of the
diaphragm by the gravid uterus, diaphragmatic excuration decreases.
III. Alimentary tract
Appetite increases but nausea and vomiting in the morning, which typically occur in the first
trimester, may reduce food intake. Pica (craving for unusual food items of very low nutritional
value like clay and soap) if excessive may result in nutritional deficiencies.
Ptyalism (inability of nauseated women to swallow normal amount of saliva) is an early
symptom of pregnancy. There is no increased production of saliva by the salivary glands.
Gums are edematous and soft. Gum bleeding and acceleration of dental caries from
reduction in oral PH occur. Epulis gravidarum, a tumorous gingivitis with pedunculated
lesions rarely occurs and may cause significant bleeding.
Heartburn due to relaxed esophageal sphincter is a common complaint. Decreased gastric
acid secretion and increased gastric mucus secretion result in relief of symptoms of peptic
24

ulcer disease in majority of women. Delay in gastric emptying is responsible for increased
tendency of aspiration pnumonitis in pregnant women undergoing general anesthesia.
Progesterone induced reduction in peristalsis helps in absorption of nutrients and water from
the small and large intestines. As the result constipation is common and hemorrhoids could
occur.
IN the gall bladder residual volume increases and stasis of bile occurs. This, along with
increased biliary cholesterol saturation, favors gall stone formation.
There are no significant changes in the anatomy of the liver. Liver function tests are normal
except elevation of alkaline phosphatase, whose origin is the placenta. Spider angiomata
and palmar erythema, which are signs of chronic liver disease, are normal findings in
pregnancy.
IV. Urinary System
There is enlargement of the kidneys. The renal calyces and ureters show dilatation which
causes stasis of urine. Bladder tone is also reduced resulting in increased capacity and
incomplete emptying after urination. These changes make a pregnant woman vulnerable to
urinary tract infections.
Renal plasma flow increases by 75% and glomerular filtration rate by 50%. Creatinine
clearance is also increased. Blood urea nitrogen, creatinine and uric acid levels decrease.
Plasma osmolality falls. There is increased glucose and amino acid excretion. Protein loss
amounts to 100-300mg/day.
V. Intgumentary and skeletal system
Vascular changes include spider angiomata and palmar erythema. Cortisol induced changes
in connective tissue result in striae gravidarum. Increased levels of melanocyte stimulating
hormone cause hyper pigmentation of the nipples, areola, axilla, perineum, umbilicus and
linea Alba (forms linea nigra). The mask of pregnancy (chloasma or melasma) is seen on the
cheek bones. Increased secretion of sweat and sebum are other features. Occasionally
pigmented nevi are seen.
In an attempt to maintain the center of gravity, there is exaggerated lordosis and drooping
back of the shoulders. This leads to common complaint of back ache. Parasthesia of the
hands may be caused if there is excessive drooping of the shoulders, which stretch the
brachial plexus.
Loosening of ligaments of symphysis pubis and sacroiliac joint by relaxin causes is aimed to
facilitate vaginal delivery. Pelvic discomfort and gait problems may arise occasionally.
25

VI. Hematology
Red blood cell indices increase. White blood cell counts rise. Platelet count falls. Most
coagulation factors increase creating a hypercoagulable state.
VI. Endocrine & metabolic Changes.
There is massive increase in placental hormones mainly estrogen, progesterone, human
chorionic gonadotrophic hormone and human placental lactogen.
Of the pitutary hormones, follicle stimulating, leutinizing and growth hormones are reduced,
while prolactin levels are high. There is no change in thyroid stimulating and
adrenocorticotrophic hormones.
Thyroid gland shows diffuse enlargement with euthyroid state. There is significant elevation
of plasma cortisol levels.
Pregnancy has a diabetogenic effect due to peripheral insulin resistance caused by high
levels of anti insulin hormones like human placental lactogen.
VII. Genital Systems
Uterus increases in weight from 70 gm of non pregnant state to 1000gm at term. Uterine
blood flow reaches 600ml/minute with 85% supplying the placenta.
Increased vascularity gives the vagina and the cervix bluish color. The cervix becomes soft
from congestion. Increased vaginal discharge may be noted.
Corpus luteum begins to regress at the eight week due to negative feed back mechanism of
estrogen and progesterone on pitutary.
VII. Breast
Both acinar and ductal breast growth occur due to increased estrogen, progesterone and
prolactin levels. Erectile capacity increases. But lactation is inhibited by placental
progesterone which prevents the action of prolactin on the production of lactaalbumin.
VIII. Immune system
HCG reduces immune response of the mother. Serum IgG, IGm and IgA decrease from
tenth week to thirtieth week then they will remain at same level.
IX. Weight gain in pregnancy
On average 12.5 kilograms is gained during pregnancy (range 9kg -15kg).The average
distribution is as follow: the fetus 3300 gm, the placenta 600 gm, amniotic fluid 800 ml, uterus
26

900-1000 gm, breast 400 gm, blood 1200 ml, deposition of fat 2500gm and extra cellular fluid
2600 ml.
Diagnosis of pregnancy
It is based on symptoms, signs and additional investigations.
I. Presumptive findings of pregnancy
· Weakness or fatigue
· Nausea and/or vomiting
· Breast swelling and tenderness
· Increased frequency of Urination
· Amenorrhea
· Discoloration of vaginal mucosa
· Increased skin pigmentation & striae
· Quickening
· Constipation, weight gain
II. Probable findings of pregnancy
· Uterine enlargement
· Change in consistency of cervix & uterus
· Ballottement rebound-16-20 weeks
27

· Braxton Hicks contraction
· Positive pregnancy test
· Symptoms as presumptive finding
III. Positive findings of pregnancy
· Fetal movement perceived by the health personnel
· Fetal heart beat heard by fetoscope (18 weeks) or Doppler (10 weeks)
· Fetal heart beat and fetal body seen by ultrasound
Pregnancy tests
All employ changes in the levels of HCG molecule which can be detected in the maternal
serum as early as nine days. Tests include biologic tests and immunologic tests
(agglutination, radioimmunoassay, radio receptor assay and ELISA).
Review questions
1. Describe the physiologic changes in the cardiovascular system during pregnancy.
2. Discuss the diagnosis of pregnancy.
28

CHAPTER 4
MINOR DISORDERS OF PREGNANCY
Learning Objectives
· To describe the minor disorders of pregnancy of pregnancy.
· To discuss the management of the common minor disorders of pregnancy.
Introduction
The physiologic and anatomic changes of pregnancy may result in development of
symptoms and signs that could be managed by educating and providing explanation.
1. Nausea and vomiting (morning sickness)
Some degree of nausea and vomiting during first trimester especially between the first and
the second missed periods is a very common complaint. It usually continues until about the
fourteen weeks of gestation. It can appear at any time of the day but is generally worse in the
morning, thus the name morning sickness. This condition is believed to be caused by high or
rapidly rising level of human chorionic gonadotrophic hormone and estrogen.
It is worse in multiple pregnancy and gestational trophoblastic diseases.
Psychological problems like anxiety can aggravate the situation.
Eating small feedings at more frequent intervals and avoiding food items whose smell
precipitate or aggravate the symptoms helps in relieving this problem. If persistent, anti-emetics
can be given.
2. Heartburn
Heartburn, epigastric burning sensation, is one of the most common complaints of pregnant
women especially during late pregnancy. The symptom is usually mild. It is caused by reflux
of gastric content into the lower esophagus due to upward displacement and compression of
the stomach by the enlarging uterus and progesterone induced relaxation of the lower
esophageal sphincter.
29

It is relieved by having smaller meals, avoiding bending over or lying flat. Antacid
preparation (aluminum hydroxide or magnesium trisilicate alone orb in combination). In
severe cases H2 - blockers like cimetidine and ranitidine can be used safely.
3. Pica
Pica, craving of pregnant woman for items of low nutritional value like ice (pagophagia) or
clay (geophagia), can occur. No known cause has been identified but it is known to be
common in patients with iron deficiency anemia. In these cases, it is relieved by correction of
anemia. Some pregnant women may have the symptom with out anemia. Educating the
woman is all that is needed.
4. Ptyalism
Ptyalism, excessive salivation, is also common. It is not related to increased saliva
production; rather it is the result of reduced swallowing from nausea. Simple explanations
will suffice.
5. Constipation
Progesterone induced relaxation of smooth muscles and pressure by the uterus in the latter
part of pregnancy result in the common complaint of constipation. The problem is more
common with consumption of low fiber diet. This condition can be treated with high fiber diet
and increasing fluid intake. Sometimes bulk forming laxatives may be needed.
6. Hemorrhoids
Hemorrhoids, varicosities of the rectal veins, may first appear during pregnancy. More often
pregnancy causes exacerbation or recurrence of previous hemorrhoids due to increased
pressure in the rectal veins caused by obstruction of venous return by the large uterus.
Constipation during pregnancy also contributes for development of hemorrhoids.
Hemorrhoids can be asymptomatic or present with rectal bleeding, rectal pain or as a
prolapsed mass through the anal orifice. The later one can be strangulated and cause severe
pain. Thrombosis occurring in the dilated veins can also cause severe pain.
30

Treatment includes topically applied anesthetic and anti-inflammatory agents for pain and
swelling, warm soaks (sitz bath), laxatives and modification of bowel habits. Surgery is
reserved for thrombosed and strangulated hemorrhoids.
7. Urinary frequency
Increased glomerular filtration rate and in the latter part of pregnancy pressure by the
enlarging uterus explain the common complaint of frequency of urination. Urinary tract
infection is also common as the result of incomplete emptying of the bladder and stasis of
urine. Microscopy of urine must be done in all cases. Once UTI is ruled out simple
explanation is enough.
8. Vaginal discharge
Pregnant women normally develop increased vaginal discharge in many instances. It is
clear, whitish and odorless. This is the result of estrogen mediated increased mucus
secretion by the cervical glands. Reassurance is usually sufficient. If it is a cause of concern
vaginal douche with water mildly acidified with vinegar can be used. Vaginal infections like
trichomoniasis and candidiasis should be ruled out in every patient with this symptom.
Recurrent vulvo - vaginal candidiasis is common. Curd like vaginal discharge and vulvar
pruritis are major manifestations. Identification of Candida albicans by potassium hydroxide
stains confirms the diagnosis. Treatment with antifungal vaginal suppositories suffices.
Systemic antifungals are contraindicated.
.
9. Low Back and pelvic pain
Exaggerated lordosis and relaxation of the lumbar ligaments cause the common complaint of
low back pain. Minor degrees of pain may follow excessive strain or fatigue, bending, lifting
or walking. Its severity increases with the duration of pregnancy. Low back pain can be
reduced by having the woman squat rather than bending over when reaching down,
providing back support with a pillow when sitting down, and avoiding high heeled shoes.
31

Severe back pain with localized spinal tenderness should not be attributed simply to
pregnancy and further evaluation is needed.
Relaxation of the joints of the pelvic girdle, cause pelvic pain and gait abnormalities. In
severe cases there may be tenderness over the symphysis pubis which prevents mobility.
This condition is called pelvic osteoarthropathy and necessitates admission.
10. Varicose veins
Varicose veins, dilatation of the superficial veins of the lower extremities, could develop in
predisposed women. It becomes more prominent as pregnancy advances, weight increases,
and the length of time spent upright is prolonged. It is due to progesterone mediated smooth
muscle relaxation of the blood vessels and increased venous pressure in the femoral veins
due to compression by the enlarging uterus.
In most, it is asymptomatic. The only concern in these women is cosmetic. In few it causes
discomfort of variable degree.
Treatment is periodic rest with elevation of legs and use of elastic stocking or both. Surgical
corrections like injection of sclerosing agents, ligation and stripping are not generally
advisable during pregnancy.
11. Dependent edema
Edema of the lower extremities is common. It is as the result of increased venous pressure of
the lower extremities. It appears near the end of the day and disappears after a period of
rest.
It is important to rule out preeclampsia especially in those with persistent dependant edema.
12. Other complaints
Fatigue is the other common complaint during early pregnancy. The woman will have a
desire for excessive sleep. This symptom remits spontaneously by the fourth month of the
pregnancy and has no special significance.
Palpitation is another common complaint. If significant, cardiac pathologies must be ruled
out.
Chloasma and striae are other sources of concern for which no treatment is required. These
often regress but may not totally resolve after delivery.
32

Occasionally women complain about leg cramps. It is believed to be the result of
phosphorous deficiency and is relieved by dietary adjustment.
Parasthesia of the hands which usually occurs in the morning signify stretching of the roots
of the brachial plexus by drooping back of the shoulders in an attempt to maintain the center
of gravity.
Epistaxis and gum bleeding occur as the result of vascular congestion and do not need
special treatment. In rare cases surgical excision is needed for tumorous condition of the
gums called Epulis gravidarum.
Hyperemesis gravidarum
Severe nausea and repeated vomiting that precludes oral intake and leads to dehydration
and ketoacidosis is termed as hyperemesis gravidarum.
I. Pathophysiology
The cause is unknown but high levels of estrogen and HCG, vitamin B 6 deficiency and
psychologic factors are implicated. It is common in molar pregnancy, multiple pregnancy and
those with family or past history of this condition.
Because of starvation ketone bodies are formed from metabolism of fatty acid. Some of the
ketone bodies appear in the urine. In an attempt to restore the PH of the blood the
respiratory rate increases. Inadequate fluid intake results in dehydration, weight and reduced
urine output. Alkalosis from loss of gastric hydrochloric acid in the vomitus and hypokalemia
also develop.
II. Diagnosis
Presence of exaggerated nausea, excessive vomiting, weight loss and signs of dehydration
like fatigue, dry oral mucosa, weak pulse, low blood pressure and reduced urine are
hallmarks of this condition. Ketone in the urine confirms the diagnosis after exclusion of other
possible causes of excessive vomiting.
III. Differential diagnosis
33

Gastroenteritis, cholecystitis, hepatitis, pyelonephritis, intestinal parasitosis, peptic ulcer
disease and drug induced vomiting should be ruled out by history, physical examination and
laboratory investigations.
IV. Management
Once the diagnosis is confirmed the woman should be admitted after counseling of the
partners. The modalities include:
· Restricting oral intake
· Correcting dehydration and electrolyte deficit by intravenous crystalloid solution
preferably lactated ringer solution to maintain fluid balance
· Correcting acidosis by providing calories in the form of glucose in the intravenous
fluids
· Treating underlying causes by parenteral vitamin B 6 (if unavailable vitamin B
complex)
· Parenteral antiemetics like promethazine , chlorpromazine or metoclopramide
· Treatment of identified medical problems
· Monitor response to treatment by subjective feeling of the patient, weight, urine out
put and urine ketone determination
With clinical response, the patient can be started on oral feeding and antiemetics continued.
Therapeutic abortion is an option if the condition persists despite aggressive medical
treatment.
V. Complication
Prerenal azotemia, Mallory-Weis tears in the esophagus, in prolonged cases Werinkes
encephalopathy from thiamine deficiency.
34

Review Questions
1. Describe the measures that may be taken in a pregnant mother with nausea and
vomiting.
2. Discuss the possible causes of severe nausea and vomiting during pregnancy.
3. Describe important measures that may be taken in order to relieve the heartburn that
occurs during pregnancy in some mothers.
35

CHAPTER 5
ANTENATAL CARE (ANC)
Learning objective
· To discuss the contents of ANC, frequency and time of visit
· To describe the new WHO antenatal care model
· To enumerate high risk factors in pregnancy
Introduction-
Antenatal care (ANC) is a medical and general care that is provided to pregnant woman
during pregnancy. It is goal oriented with the aim of meeting both the psychological and
medical needs of pregnant woman with in the context of health care delivery system, culture
36

and religion in which the woman lives. ANC programs should be based on local situation and
should address risk assessment, health promotion and care provision. ANC has been found
to be effective in the treatment anemia, hypertension and sexually transmitted diseases.
Frequency and timing of visit
Traditional or standard (Western) model recommends the first visit to take place as early
as the first missed period. This allows accurate dating of the pregnancy and design
appropriate preventive and therapeutic interventions. Thereafter, subsequent visits are
planned every four weeks until 28 weeks, every two weeks between 28-36 weeks and every
week after 36 weeks. More frequent visits are required for high risk patients.
The new WHO ANC model recommends a minimum of four visits. It limits the number of
visits and restricts laboratory tests and procedures. First visit takes place at 16 weeks or
before. The second visit is planned between 24-28 weeks, the third at 32 weeks and the
fourth at 36- 38 weeks. The initial visit takes 30-40 minutes and the other visits take around
20 minutes each. Women with risk factors should not be enrolled in this model.
Activities of the new WHO ANC model
I. First visit at 16 weeks
Major activities are diagnosis of pregnancy and determination of the gestational age; risk
assessment and determination of the medical status of the mother; health promotion by
education on nutritional supplement, danger signs of pregnancy and finally care provision like
malaria prophylaxis, control MTCT of HIV, iron supplementation and immunization with
tetanus toxoid.
II. Second visit between 24- 28 weeks
Major activities are screening for hypertension, multiple gestation, anemia, preterm labor,
diabetes mellitus and RH sensitization; further health promotion and care provision and plan
birth place.
III. Third visit at 32 weeks
Major activities are screening for hypertension, anemia, multiple pregnancy, diabetes mellitus
and RH sensitization; health promotion and care provision and plan birth place.
37

IV. Fourth visit at 36 weeks
Major activities are screening for hypertension, antepartum hemorrhage, multiple gestations;
check for fetal lie, presentation, growth and well being; health promotion and care provision
and finally up date individualized birth plan.
Contents of ANC visit
I. Assessment
Detailed history and physical examination (refer to chapter 2) along with necessary
laboratory investigations should be done in the initial visit to assess the general medical
status of the woman and pick risk factors. For this reason the initial visit takes 30-40 minutes.
Subsequent visits look into new developments, therefore, take much shorter time.
A. Initial visit
The pertinent elements of the history during the initial visit include
1. History of present Pregnancy- identification (name, age, address, marital status,
occupation); pregnancy facts (planned or unplanned pregnancy, wanted or unwanted,
supported or unsupported); gravidity , parity, abortion, LMP, gestational age,
contraceptive use prior to pregnancy, symptoms and signs of pregnancy , danger signs
and symptoms, fetal quickening , client concern or complaints
2. Past history - antepartum and postpartum hemorrhage, multiple pregnancy,
preeclampsia, eclampsia, sepsis, sexually transmitted infections, operative deliveries, still
birth and neonatal death, preterm delivery, low birth weight baby, chronic medical
illnesses (hypertension, diabetes, drug allergy and cardiac diseases) and surgical
problems, genital mutilation
3. Others- personal, social and family history
General physical examination as described in chapter 2 should be performed. It includes the
general appearance, vital signs, weight and height, general systemic examination including
checking for signs of anemia, physical abuse and surgical scars. Specific obstetric
examination should focus on determining the uterine size, fetal lie and presentation, fetal
growth and well being, fetal heart beat. Pelvic assessment is performed upon indications.
38

In the standard model baseline laboratory investigations are hemtocrite, blood group and
Rhesus factor, urinalysis (protein, ketone and microscopy), VDRL and stool examination for
ova and parasites. Others that could be done upon indication or when resources permit are
pap smear, cervical /vaginal smear, urine culture and sensitivity, complete blood count,
pregnancy test, serology for HIV, hepatitis b virus and TORCH screening, oral glucose
tolerance test, maternal serum alpha fetoprotein on 16 weeks, amniocentesis
,ultrasonography and others.
In the new WHO model urine dip stick for bacteria and protein, VDRL and blood group and
Rhesus factor determination are only done in the first visit. Hemtocrite is only done if there
are clinical signs of anemia.
In the new WHO model, in the initial visit women are grouped into two using the classifying
form. Women with out any risk factor are enrolled in the basic component of the new model
that needs only three visits till delivery. Women with any identified risk factor need special
care that may need frequent visits or even referral for specialized care.
The classifying form has 18 components that are grouped into three:
· Obstetric history- previous stillbirth/ neonatal loss, history of three or more
consecutive abortions, birth weight of less than 2500 or more than 400 grams,
admission in the last pregnancy for preeclampsia or hypertension, previous uterine or
cervical surgery-
· Current pregnancy - diagnosed or suspected multiple pregnancy, age less than 16
or more than 40, RH isoimmunization, vaginal bleeding, pelvic mass, diastolic blood
pressure of more than 90 mmhg
· General medical condition- insulin dependent diabetes mellitus, renal or cardiac
disease, known substance abuse, any other severe medical illness
B. Subsequent visits
History focuses on new complaints and problems since the last visit, intercurrent illnesses
and medications, quickening time and fetal movement, danger symptoms of pregnancy and
any changes in the personal history of the woman.
Physical examination focuses on the general appearance, vital signs mainly the blood
pressure, weight, checking for signs of anemia, fundal height, fetal lie and presentation, fetal
heart beat, leg edema and other examinations based on the complaints.
39

In the standard model hemtocrite is done at 24-28 and 32 weeks, antibody screening and
oral glucose tolerance test at 28 weeks, ultrasound and maternal alpha feto protein at 16
weeks and fetal survellance tests starting 32 weeks.
In the new WHO model dipstick of urine for bacteria is done in all visits. Urine dipstick for
protein is only done for nulliparous women or for those with history of preeclampsia or
hypertension currently. Hemtocrite is done at the third visit.
II. Health promotion (advice and counseling)
Advice the woman about the importance of balanced diet and avoidance of drugs, smoking
and alcohol: adequate rest; hygiene and safe sex.
Discuss about minor complaints of pregnancy and the danger symptoms of pregnancy.
Discuss about whom to contact and where to go if these symptoms develop.
Inform the woman to record the time of quickening. Education about labor and preparation
for labor/ delivery should be done starting from the third visit. The need for clean and safe
delivery should be stressed. Breast feeding and family planning after delivery should be
discussed.
III. Care provision (care provided)
Individualized delivery plan in should be planned starting from the first visit and continued
during subsequent visits including arrangement of transportation in cases of emergency.
Place of birth and who attends birth should be planned.
Universal ferrous sulfate prophylaxis for nutritional anemia should be given starting from the
first visit. Tetanus toxoid vaccination should be given according to WHO guidelines.
Appropriate prophylaxis and treatment of intestinal parasites and malaria should be offered.
Where indicated antiretroviral therapy should be offered to HIV positive pregnant women.
Appropriate management of complaints and identified problems/ complications should be
done in each visit.
Timing and importance of next visit should be discussed. Appointment should then be
scheduled.
High risk factors (not inclusive)
I. Past obstetric history
· Ectopic pregnancy and recurrent spontaneous abortion
· Multiple pregnancy or preterm labor
40

· Antepartum or postpartum hemorrhage
· Malpresentation
· Intrauterine fetal death, stillbirth or early neonatal death
· Birth weight of less than 2500 or greater than 4000 grams
· Difficult operative deliveries and caesarian section
II. Present obstetric history
· Short stature (height of less than 150 cm), age of less than 16 or greater than 40
· Primigravida or grandmultiparity
· Vaginal bleeding at any gestational age
· Uterine size to gestational age discrepancy (big or small for date uterus)
· Multiple gestation
· Premature rupture of the membranes
· Raised blood pressure during pregnancy
· Malpresentation after 34- 36 weeks
· Unwanted pregnancy
· Extreme social disruption and deprivation
Review questions
1. Briefly describe the new WHO ANC model.
2. List the routine laboratory investigations in ANC.
3. List the high risk factors in pregnancy.
41

CHAPTER 6
ABNORMAL BLEEDING DURING FIRST AND SECOND TRIMESTERS OF PREGNANCY
Learning objectives
· To identify the common causes of abnormal bleeding during pregnancy by trimester.
· To list the different types of abortion with their clinical features.
· To describe the clinical feature of ectopic pregnancy.
· To describe the management the different types of abortion and ectopic pregnancy.
· To define the spectrum of GTD
· To discuss the clinical features of GTD
42

· To list the main treatment modalities of GTD
· To enumerate the possible complications GTD and their treatment
Introduction
When a woman becomes pregnant, the menstrual bleeding stops until sometime after the
end of the pregnancy. However, abnormal bleeding from the genital tract can complicate
some pregnancies. Statistically, more than 25% of all gestations will present to health care
provider at least in early pregnancy with vaginal bleeding and/or pelvic pain. These
symptoms may indicate a minor or a life threatening condition that can result in death.
Successful management of any one of these conditions is of paramount importance and
rests on timely diagnosis. This in turn requires proper evaluation of the patient by taking the
history and doing physical examination. There may be a need to do some laboratory studies
to help the evaluation process. The primary goal of the evaluation should focus on identifying
immediate life threatening conditions like shock. Generally, abnormal uterine bleeding during
pregnancy can result from obstetric or non-obstetric causes. Conditions like abortion, ectopic
pregnancy, placenta abnormalities like placenta previa and abruptio placentae, and
gestational trophoblastic diseases are some of the obstetric causes. While conditions like
genital infections, trauma to the genital organs and neoplastic changes affecting them are
some of the non-obstetric causes. Systemic illnesses affecting blood coagulation can also
result in abnormal bleeding during pregnancy.
1. ABORTION
1.1. Importance
Abortion is an important cause of bleeding during pregnancy, as it is one of the five leading
causes of maternal death in the developing world. The other causes being obstructed labor,
hypertensive disorders of pregnancy, hemorrhage and infection.
1.2. Definition:
Abortion is the expulsion of the fetus from the uterus or termination of pregnancy before fetal
viability. This is usually taken to be so if it happens before 28 completed weeks of gestation
or less than 1000g weight in Ethiopia & United Kingdom.
1.3. Classification
43

1.3.1. By occurrence
Abortion could occur spontaneously or could be induced.
A. Spontaneous abortion
An abortion is said to be spontaneous if it occurs with no intervention. The incidence of
spontaneous abortion is between 10% and 20% of all pregnancies. It is most commonly due
to fetal chromosomal defects such as trisomies, monosomies and polyploidy. This usually
occurs during the first trimester.
B .Induced abortion
An abortion is said to be induced if it results from medical or surgical intervention that can
cause abortion. It could be safe or unsafe abortion. Unsafe abortion characterized by lack or
inadequacy of skill of provider, hazardous technique and unsanitary facilities or both. This is
important type of abortion as it accounts for the major proportion of abortion and is cause of
immense maternal mortality and morbidity. Moreover, it is related to unwanted pregnancy
and unawareness of the reproductive physiology by the woman .It can largely be prevented if
there is provision of contraceptive service and making the woman knowledgeable about her
reproductive physiology. Of the 210 million pregnancies that occur each year, about 46
million (22 per cent) end in abortion. About 20 million of those abortions are unsafe –that is,
performed by someone without the skills or training to perform them safely, or in a place that
does not meet minimal medical standards or, both. Every year, more than 70,000 women die
as a result of unsafe abortion; hundred of thousands more suffer from serious, often
permanent, disabilities. Everyday, 200 women die from unsafe abortion. More than 95% of
deaths and injuries occur in developing countries. In Ethiopia maternal losses from abortion
and its complication account for 25-50%. The majority of deaths from abortion result from
hemorrhagic shock and sepsis. Proper management of abortion can prevent the death and
the other complications that result from it.
C.Therapeutic abortion
Subset of safe abortion which is performed for the purpose of saving the life of the mother (3)
or if the fetus has congenital / chromosomal / metabolic disorders that is incompatible with
life after birth.
1.3.2. By clinical stages
Threatened abortion: is a clinical condition that is characterized by vaginal bleeding before
28 weeks of gestation. In addition there is crampy lower abdominal pain and the cervix
44

remains closed. The fetus is alive and there is a chance of continuing the pregnancy to
viability.
Inevitable abortion: is a clinical condition characterized by vaginal bleeding of variable
amount and crampy lower abdominal pain. The cervix is open but no products of conception
have been expelled. There is no chance of salvaging the pregnancy.
Incomplete abortion: is a clinical condition in which vaginal bleeding continues and cervix
remains open despite expulsion of part of the products of conception.
Complete abortion: is a clinical condition in which vaginal bleeding stops and the cervix
closes following expulsion of all products of conception. The uterus is small for the duration
of the pregnancy and it is firmer. Before 14-16 weeks it is difficult to tell if an abortion is
complete or not because to make sure it is complete one has to identify the fetus and the
placenta with the membranes as fully formed structures. Before 14-16 weeks these
structures are not sufficiently well formed.
Missed abortion: is a clinical condition in which the fetus dies in utero and is retained for at
least four weeks. There is usually history of threatened abortion preceding it. Decidual
necrosis may result in brownish vaginal discharge. Pregnancy symptoms like morning
sickness, breast tenderness and abdominal girth increment disappear. Cessation of fetal
movement is reported by the mother if it occurs after 18 weeks. Failure of uterine growth
results in small for gestational age uterus. Pregnancy test takes 8 weeks to become
negative.
1.3.3. By associated infection
Septic abortion: is a clinical condition in which offensive vaginal discharge, temperature of
more than 38 o centigrade and lower abdominal pain / tenderness accompany any of the
clinical stages of abortion. Majority follow unsafely induced abortions. Infection starts in the
uterus and if untreated spreads to adjacent pelvic organs (pelvic peritonitis) or to the general
peritoneum (generalized peritonitis) or the blood stream (sepsis). It eventually results in
death by causing septic shock.
Postabortal sepsis: is pelvic infection after a complete abortion.
1.3.4. Other definitions
Recurrent abortion: occurrence of three or more consecutive spontaneous abortions. It was
previously known as habitual abortion.
45

1.4. Initial assessment
Any woman of reproductive age experiencing at least two of the following symptoms should
be considered as a possible abortion patient.
· Vaginal bleeding
· Cramping and/or lower abdominal pain
· A possible history of amenorrhea
Complete clinical assessment is necessary to determine all conditions that are present in
order to decide the order in which to treat them.
1.4.1. History
· Length of amenorrhea
· Bleeding (duration, amount)
· Cramping (duration and severity)
· Abdominal or shoulder pain
· Drug allergy
· History of interference and method employed
· Symptoms of infection
1.4.2. Physical examination
· Check vital signs
· Note general health of the women
· General systemic examination
· Abdominal examination
Check –abdominal distension, movement with respiration, bowel
sound,
Location and severity of tenderness and rebound tenderness,
Uterine size, masses, shifting dullness
· Pelvic examination(speculum and bimanual digital examination)
46

Remove any visible products of conception from the vaginal canal or cervical canal.
Then note for the amount of bleeding and presence of offensive discharge, the extent
of cervical dilation and presence of cervical excitation tenderness, size and consistency
of the uterus, adenexal masse and other pelvic masses. Check for cervical laceration
1.4.3. Laboratory examination
Based on clinical assessment when indicated: -
· hemoglobin / hemtocrite, blood group and rhesus factor
· white cell count, erythrocyte sedimentation rate, urinalysis, renal function test, liver
function test, platelet count, prothrombin time, partial thromboplastin time
· Plain film of the abdomen (erect), pelvic ultrasonography
· Pregnancy test
1.5. Management
Life threatening conditions like shock (hypovolumic or septic), severe anemia and sepsis
should be treated aggressively prior to instituting specific treatment. These include
intravenous fluids, parenteral antibiotics, blood transfusion and /or other ventilatory supports.
Preparations for laparatomy must be made in cases suspected or diagnosed to have uterine
perforation or generalized peritonitis or pelvic abscess. Specific management for each stage
of abortion should be offered only after attending to the above conditions. Appropriate and
timely referrals are life saving.
1.5.1. Threatened abortion
· Bed rest at home which could be reinforced by sedatives like diazepam. Women who
have bled much (regardless of the gestational age) or have bad obstetric history or
live far away and cannot get help if bleeding becomes much worse, especially during
the night should be admitted for observation.
· Avoid intercourse and douching
· Monitor progress by subsequent assessment. Where available ultrasonography
should be done to check for viability.
· If there is any sign of pelvic infection evacuation of the uterus should be performed.
47

1.5.2. Complete abortion
If completeness is confirmed either by examination of the conceptus tissue or
where available by ultrasound
· Administer ergometrine 0.5mg
· If justified provide therapeutic or prophylactic antibiotics
Evacuation of the uterus must be done if completeness can not be assured as
in early abortion or expulsion occurred out of the health institution.
1.5.3. Inevitable abortions
A. Less than 14 weeks of gestation:
Evacuation of the uterus is the mainline of treatment .Evacuation can be done
either by sharp metallic curettage or by manual vacuum aspirator (MVA). MVA is
much safer and recent technology which is said to be associated with less
complications and pain, more efficient in evacuating the uterus in less time and
thus can safely be used by lower level health professionals.
Mandatory indications for evacuation
1. Considerable bleeding
2. Bleeding which continues for more than 24 hours.
3. Patients in whom the retained products of conception are obviously still
present on vaginal examination..
B. More than 14 weeks of gestation
In the absence of heavy bleeding evacuation of the uterus is not advised before the
expulsion of the fetus .Management includes
· Admission and monitoring the vital signs and the amount of bleeding
· Once the fetus / placenta are expelled completeness should be checked
.Evacuation of the uterus must be done if incomplete or the bleeding
continues.
· Ergometrine or oxytocin as drip should be given for continued bleeding after
expulsion or evacuation and monitoring should continue.
· Exploration of the uterus for remnants or perforation should be done if these
measures fail and the patient continues to bleed.
48

1.5.4. Incomplete abortion
Uterine evacuation should be done preferably by MVA. Antibiotics as needed can be
given.
Methods of Uterine evacuation
Determined by uterine size
If uterine size < 14 weeks
· Manual / electrical vacuum aspiration or evacuation and
curettage(E&C)/dilatation and curettage (D&C)if cervix is closed
If uterine size > 14 weeks
· Oxytocin infusion or evacuation and curettage(E&C)/dilatation and
curettage when appropriate
Oxytocin administration
Add 10ml (ampoules) to 1000ml lactated Ringer's solution (100mu/ml)
Start at 0.5ml/mi (50mu/mi), increase at 30 to 40min intervals up to a maximum rate
of 2mml/mi (200mu/min). If effective contractions are not established at this infusion
rate, increase the concentration. Discard all but 500ml of the remaining solution. Add
additional 5 ampoules of oxytocin (200mu/ml). Reduce the rate to 1ml/mi (200mu/mi).
Increase up to 2ml/mi (400mu/mi), continue at this rate for 4-5hrs or until fetus is
expelled.
1.5.5. Missed abortion
A. Expectant management up to 4 weeks
· This is based on the fact that 95% women with missed abortion will abort
spontaneously in 4 weeks time, whatever the duration of the pregnancy. After 4
weeks the chance of developing disseminated intravascular coagulation or dead
baby syndrome is significant.
· During this time coagulation profile is monitored weekly. Evacuation of the uterus
is done if the patient did not expel in 4 weeks or before 4 weeks if coagulation
derangement occurs.
B. Aggressive management
49

This entails evacuation of the uterus. Methods include dilatation and curettage
(D&C) for uterine sizes up to 12 weeks or induction of labor by prostaglandins
/oxytocin infusion if uterine size is more than 12 weeks. Since there is a risk of
uterine perforation and coagulopathy with this form of management appropriate
referral to proper health facility should be made.
1.5.6. Management of Complications
I. Uterine perforation
The following signs seen during uterine evacuation indicate perforation.
· An instrument (sound, cannula, and curette) extends beyond the expected
limit of the uterus.
· Fat or bowel is found in the tissue removed from the uterus
· Severe pain and continuous bright red bleeding
· In apparent vital sign derangement (hypotension in the absence of bleeding)
Management
· Stabilize the patient and do not give anything per os.
· Monitor vital signs
· Start broad spectrum antibiotics (parenteral)
· Immediate referral to a facility capable of performing gynecologic surgeries.
If evacuation is complete
· Give ergometrine 0.5mg
· Observe her for two hours
· If patient become stable and bleeding stops, give ergometrine and
continue observation overnight
· If the condition gets worse and the bleeding doesn’t stop
emergency laparatomy is performed.
If evacuation is not complete
· Immediate laparatomy to complete evacuation under direct vision Depending
on the findings either repair or hysterectomy is done.
II. Intraabdominal injury
50

The following signs and symptoms indicate intra abdominal injury
Symptoms
· Nausea, vomiting, shoulder pain,fever,abdominal pain and cramping
Signs
· Distended abdomen, decreased bowel sound, tense hard abdomen
· Rebound tenderness
Management
· Resuscitation, parenteral antibiotics,
· Immediate referral for laparatomy
III. Sepsis
Etiology is polymicrobial (gram positives, gram negatives and anaerobes)
The following symptoms and signs indicate that either local or generalized infection is
likely:
Symptoms
· Chills, fever, sweating, history of interference
· Prolonged bleeding, general discomfort, flu like symptoms
Signs
· Foul smelling vaginal discharge, distended abdomen
· Tenderness, low blood pressure
Assess women’s risk for developing septic shock
Low risk
· First trimester abortion, mild to moderate fever (< 38.50 c)
· Stable vital signs, no evidence of Intraabdominal injury
High risk
· second trimester abortion, high fever (> 38.50 c)
· Any evidence of intra abdominal injury, shock
Management
51

· Resuscitation, monitor vital signs, start broad spectrum antibiotics
intravenously
If low risk and stable
Uterine evacuation, continue antibiotics, observe for 48 hrs.
If high risk
· Continue antibiotics
· If there is shock ---- manage as shock
· If intra abdominal injury--- laparatomy
· If DIC present -- treat with clotting factors and fresh blood products
IV. Other complications and their management
· Anemia - manage according to severity by either hemathenics or blood
transfusion
· Renal failure - manage accordingly
· Give tetanus toxoid as indicated and tetanus antitoxin for non immune women
· Give anti-D for Rh negative mothers (see protocol for management of Rh
isoimmunization)
1.5.7. Post abortion family planning
All women receiving post abortion care need counseling and information to ensure
that they understand:
· They can become pregnant again before the next menses
· There are safe methods to prevent or delay pregnancy
· Where and how they can obtain family planning service
1.5.8. Antibiotic choices and administration in the management of abortion
Empiric therapy antibiotic covering wide variety of aerobic, anaerobic, gram
negative/positive organisms is used.
Regimen 1
Ampicillin or benzyl penicillin plus chloramphenicol or clindamycin or metronidazole
plus gentamycin
52

Regimen 2
Ceftriaxone or ciprofloxacin plus gentamycin or metronidazole
Regimen 3
Doxycycline with metronidazole
· Once started, therapy can be continued until the patient is afebrile at least for 24
hours, preferably 48 hours
· If there is no response in 48 hours the antibiotics should be changed and/or
complications considered
· When recovery is underway, intravenous therapy should be followed by oral
medication, for 10 to 14 days.
1.5.9. Components of Post abortion care (PAC)
· Emergency treatment of incomplete abortion and potentially life threatening
complications
· Post-abortion family planning counseling and services
· Links between post-abortion emergency services and the reproductive health care
system.
· Community service provider partnership
· Counseling
2. ECTOPIC PREGNANCY
2.1. Definition
Ectopic pregnancy is implantation of the fertilized ovum outside of the uterine endometrial
cavity.
2.2. Incidence and predisposing factors
Ninety–nine percent of ectopic pregnancy occurs in the fallopian tube. The commonest site is
the ampulla which accounts for 55% of ectopics. The rest occurs in the isthmus (25%), the
fimbria (17%) and the interstitial part (2.5%). Rare forms of ectopic pregnancy include
cervical ectopic, ovarian ectopic and abdominal pregnancy. Very rarely bilateral ectopic or
53

A4 obstetrics note

Recomendados

Recomendados

Más contenido relacionado

La actualidad más candente

La actualidad más candente (20)

Destacado

Destacado (20)

Similar a A4 obstetrics note

Similar a A4 obstetrics note (20)

Más de Mesfin Mulugeta

Más de Mesfin Mulugeta (20)

Último

Último (20)

A4 obstetrics note