THREATENED THREATENED ABORTION
INE@ITABE ABORTION
IN6OMPETE ABORTION
6OMPETE ABORTION
TYPES OF ABORTION ABORTION FEATURES 1. Hist Histor ory y à Mild vagial !l""dig. !l""dig. à No a!do#ial $ai or #ild a!do#ial $ai %. E&a# E&a#ia iati tio o à Good g""ral 'oditio. à T(" '"rvi& is 'los"d à T(" )t"r)s is )s)ally t(" 'orr"'t si*" +or dat" ,. U-S (i'( (i'( is "ss"tial "ss"tial +or t(" t(" diagosis diagosis S(o"d S(o"d t(" $r"s"'" o+ +"tal ("art a'tivity
1. Hist Histor ory y H"avy vagial !l""dig. it( o $assag" o + $rod)'ts 'o'"$tio 7i"vita!l"8 it( $assag" o+ $rod)'ts o+ 'o'"$tio 7i'o#$l"t" a!ortio8 S"v"r" lo"r a!do#ial $ai (i'( +ollos t(" !l""dig %. E&a# E&a#ia iati tio oss Poor g""ral 'oditio. $rod)'ts o+ 'o'"$tio #ay T(" '"rvi& is dilatig ad $rod)'ts $ass t(r) t(" os si*" +or dat" 7i"vita!l" T(" )t"r)s #ay !" t(" 'orr"'t si*" a!ortio8 or s#all +or dat" 7i'o#$l"t" a!ortio8 ,. U-S à F"tal ("art a'tivity #ay or #ay ot $r"s"t i i"vita!l" a!ortio or r"tai"d $rod)'ts o+ 'o'"$tio 7RPO68 i i'o#$l"t" a!ortio 1. Hist Histor ory y H"avy vagial !l""dig à (i'( (as !"" sto$$"d. o"r a!do#ial $ai (i'( +ollos t(" !l""dig à (i'( (as !"" sto$$"d.
MANAGEMENT 1. R"ass)r R"ass)ra'" a'" I+ I+ +"tal ("art ("art a'tivity a'tivity is $r"s"t/ 0 23 o+ 'as"s ill !" $rogr"ss"d $rogr"ss"d satis+a'torily %. Advi'"4 Advi'"4 D"'r"as" D"'r"as" $(ysi'al $(ysi'al a'tivit a'tivity/ y/ avoid it"r'o)rs" ,. Hor#o"s Hor#o"s i.". i.". Prog"st Prog"st"ro "ro" " 5 (6G to s)$$ort $r"ga'y/ 7o $rov" val)"8 9. Ati: D4 Ad";)at" Ad";)at" dos" o+ ati:D ati:D s(o)ld s(o)ld !" giv" to all R(
. AN6 as as (ig( (ig( ris? ris? $ati" $ati"ts ts 6o* lia!l" to lat" $r"ga'y 'o#$li'atios s)'( as APH ad $r"t"r# la!o)r. 1. 6B6 / !lood gro)$ gro)$ig ig / M M % )its )its o+ !lood !lood %. R"s)s R"s)s'it 'itatio atio à larg" I@ li"/ C)ids 5 !lood tras+)sio ,. O&yt O&yto& o&i' i' dr)g dr)gss à Ergo#"tri" 2.> #g IM = O&yto'i i+)sio 7%2:92 )its i >22 '' sali"8 9. Eva')a Eva')atio tio 5 ')r"tt ')r"ttag" ag".. >. Post:a!or Post:a!ortio tio #aag"#"t. #aag"#"t.
1. Eva')atio Eva')atio 5 ')r"ttag ')r"ttag" " i t(" $r"s" $r"s"'" '" o+ RPO6. %. Post:a!or Post:a!ortio tio #aag"#"t. #aag"#"t.
MISSED ABORTION
ANEMBRYONI 6 PREGNAN6Y 7BIGHTED O@UM8
%. E&a#iatio4 E&a#iatio4 T(" '"rvi& '"rvi& is 'los"d 'los"d ,. U-S 4 S(o"d S(o"d "#$ty )t"ri" )t"ri" 'avity 'avity or PROP 1. Most ar" diagos"d diagos"d a''id"tal a''id"tally ly 1. 6B6 / !lood gro)$ gro)$ig/ ig/ M M % )its )its o+ !lood !lood d)rig ro)ti" U-S i "arly $r"ga'y. %. Plat"l"ts Plat"l"ts 'o)t4 'o)t4 to to "&'l)d" "&'l)d" t(" t(" ris? o+ DI6 DI6 I so#" 'as"s t("r" #ay !" a (istory NB 4 DI6 do"s ot o'')r !"+or" > ""?s o+ #iss"d a!ortio or o+4 IUFD ad i+ o'')rr"d ill !" o+ #ild grad" ,. O$tios O$tios o+ tr"at tr"at#" #"tt E$isod"s o+ #ild vagial !l""dig 6os"rvativ" tr"at#"t4 à i+ l"+t alo" s$ota"o)s R"gr"ssio o+ "arly sy#$to#s o+ R"gr"ssio "&$)lsio ill o'')r $r"ga'y. st S)rgi'al "va')atio o+ t(" )t"r)s !y D 5 64 Idi'at"d i 1 Sto$ o+ +"tal #ov"#"ts a+t"r %2 tri#"st"r #iss"d a!ortio ""?s g"statio. M"di'al t"r#iatio o+ $r"ga'y4 $r"ga'y4 !y Miso$rostol 7PGE18 %. E&a#iatio4 E&a#iatio4 T(" )t"r)s )t"r)s #ay #ay !" st d s#all +or dat" 6ytot"'4 Idi'at"d i 1 5 % tri#"st"rs #iss"d a!ortios. ,. U-S 7"ss"t 7"ss"tial ial +or d&8 diagos diagos"d "d i+ 6ytot"' vagial 7 is t(" !"st8 or oral ta!. %22 g/ % ta!- , to )ltraso)d 7T-@ or T-A8 at l"ast (rs- )$ to > dos"s daily/ (i'( 'a !" r"$"at"d "&t day i+ days a$art s(o"d a "#!ryo o+ 0 t("r" is o r"s$os" i t(" rst day ?s g"statio 76R 0## i S)!s";)"t s)rgi'al "va')atio is ""d"d i 'as"s o+ dia#"t"r ad g"statioal sa' 0%2 RPO6 ## i dia#"t"r8 it( o "vid"'" o+ Mai sid" ""'ts o+ 'ytot"'4 Na)s"a/ vo #it 5 +"v"r. ("art a'tivity. ,. Post:a!or Post:a!ortio tio #aag"#"t. #aag"#"t.
It is d)" to a "arly d"at( ad r"sor$tio o+ t(" "#!ryo it( t(" $"rsist"'" o+ t(" $la'"tal tiss)" It is diagos"d i+ to )ltraso)d 7T-@ or T-A8 at l"ast days a$art s(o"d a+t"r ""?s o+ g"statio i.". g"statioal sa' 0%2##/ a "#$ty g"statioal sa' it( o +"tal "'(o"s s"". It is tr"at"d i a si#ilar ay to #iss"d a!ortio.
MISSED ABORTION
ANEMBRYONI 6 PREGNAN6Y 7BIGHTED O@UM8
%. E&a#iatio4 E&a#iatio4 T(" '"rvi& '"rvi& is 'los"d 'los"d ,. U-S 4 S(o"d S(o"d "#$ty )t"ri" )t"ri" 'avity 'avity or PROP 1. Most ar" diagos"d diagos"d a''id"tal a''id"tally ly 1. 6B6 / !lood gro)$ gro)$ig/ ig/ M M % )its )its o+ !lood !lood d)rig ro)ti" U-S i "arly $r"ga'y. %. Plat"l"ts Plat"l"ts 'o)t4 'o)t4 to to "&'l)d" "&'l)d" t(" t(" ris? o+ DI6 DI6 I so#" 'as"s t("r" #ay !" a (istory NB 4 DI6 do"s ot o'')r !"+or" > ""?s o+ #iss"d a!ortio or o+4 IUFD ad i+ o'')rr"d ill !" o+ #ild grad" ,. O$tios O$tios o+ tr"at tr"at#" #"tt E$isod"s o+ #ild vagial !l""dig 6os"rvativ" tr"at#"t4 à i+ l"+t alo" s$ota"o)s R"gr"ssio o+ "arly sy#$to#s o+ R"gr"ssio "&$)lsio ill o'')r $r"ga'y. st S)rgi'al "va')atio o+ t(" )t"r)s !y D 5 64 Idi'at"d i 1 Sto$ o+ +"tal #ov"#"ts a+t"r %2 tri#"st"r #iss"d a!ortio ""?s g"statio. M"di'al t"r#iatio o+ $r"ga'y4 $r"ga'y4 !y Miso$rostol 7PGE18 %. E&a#iatio4 E&a#iatio4 T(" )t"r)s )t"r)s #ay #ay !" st d s#all +or dat" 6ytot"'4 Idi'at"d i 1 5 % tri#"st"rs #iss"d a!ortios. ,. U-S 7"ss"t 7"ss"tial ial +or d&8 diagos diagos"d "d i+ 6ytot"' vagial 7 is t(" !"st8 or oral ta!. %22 g/ % ta!- , to )ltraso)d 7T-@ or T-A8 at l"ast (rs- )$ to > dos"s daily/ (i'( 'a !" r"$"at"d "&t day i+ days a$art s(o"d a "#!ryo o+ 0 t("r" is o r"s$os" i t(" rst day ?s g"statio 76R 0## i S)!s";)"t s)rgi'al "va')atio is ""d"d i 'as"s o+ dia#"t"r ad g"statioal sa' 0%2 RPO6 ## i dia#"t"r8 it( o "vid"'" o+ Mai sid" ""'ts o+ 'ytot"'4 Na)s"a/ vo #it 5 +"v"r. ("art a'tivity. ,. Post:a!or Post:a!ortio tio #aag"#"t. #aag"#"t.
It is d)" to a "arly d"at( ad r"sor$tio o+ t(" "#!ryo it( t(" $"rsist"'" o+ t(" $la'"tal tiss)" It is diagos"d i+ to )ltraso)d 7T-@ or T-A8 at l"ast days a$art s(o"d a+t"r ""?s o+ g"statio i.". g"statioal sa' 0%2##/ a "#$ty g"statioal sa' it( o +"tal "'(o"s s"". It is tr"at"d i a si#ilar ay to #iss"d a!ortio.
SEPTI6 ABORTION
D"+4 I'o#$l"t" a!ortio 'o#$li'at"d !y i+"'tio o+ t(" )t"ri" 'ot"ts. May !" d)" to 'ri#ial it"r+"r"'". it"r+"r"'". F"at)r"s F"at)r"s 4 Poor g""ral g""ral 'oditio F"at)r"s o+ i'o#$l"t" a!ortio4 S"v"r" vagial !l""dig it( F"at)r"s $assag" o+ $rod)'t o+ 'o'"$tio/ it(-it(o)t (& o+ "va')atio. F"at)r"s o+ $"lvi' i+"'tio4 Pyr"&ia / ta'(y'ardia / g""ral #alais" F"at)r"s / lo"r a! $ai/ $"lvi' t"d"r"ss 5 $)r)l"t vagial dis'(arg". Ba't"riology 4 Mi&"d i+"'tio T(" 'o##o"st orgais#s ar" 4 1. Gra# :v"4 :v"4 E.'oli E.'oli / str" str"$ $ 5 sta$( sta$( %. Aa"r Aa"ro!i o!i's4 's4 Ba't"r Ba't"roid oid"s "s ad";)at"ly. Rar"ly 6l. t"tai : $ot"tially l"t(al i+ ot tr"at"d ad";)at"ly. Ty$"s Ty$"s 4 Mild à t(" i+"'tio is 'o"d to d"'id)a 4 J23 Mod"rat" àt(" i+"'tio "&t"d"d to #yo#"tri)#1>3 "&t"d"d to $"lvis = Edoto&i' s(o'? = S"v"r" àt(" i+"'tio "&t"d"d DI6 >3
1. Iv"st Iv"stiga igatio tioss 4 6B6/ !lood gro)$ig/ M % )its o+ !lood. 6"rvi'al sa!s 7ot vagial8 +or ')lt)r" ad s"sitivity 6oag)latio $rol" / s"r)# "l"'trolyt"s 5 !lood ')lt)r" i+ $yr"&ia 0 ,J.> %. Ati!ioti's Ati!ioti's44 I@ 6"$(alos$or 6"$(alos$ori i = I@ M"troida*ol" ,. S)rgi'al S)rgi'al "va')atio "va')atio o+ )t"r)s )t"r)s à )s)ally 1% (rs a+t"r ati!ioti' t("ra$y 7)til r"asoa!l" tiss)" l"v"ls o+ ati!ioti's a'(i"v"d8 9. Post:a!or Post:a!ortio tio #aag"#"t. #aag"#"t.
RE6URREN T ABORTION
D"itio4 , or #or" 'os"')tiv" s$ota"o)s a!ortios It #ay $r"s"t"d 'lii'ally as ay o+ ot("r ty$"s o+ a!ortios . Ty$"s Ty$"s 4 Pri#ary4 All $r"ga'i"s (av" "d"d i l oss Pri#ary4 S"'odary4 O" $r"ga'y or #or" (as $ro'""d"d S"'odary4 to via!ility 70%9 ""?s g"statio8 it( all ot("rs "dig i loss. I'id"'"4 O'')rs i a!o)t 13 o+ o#" o+ r"$rod)'tiv" ag" . 6a)s"s r"')rr"t a!ortio/ i a!o)t >23/ i (i'( • Idio$at(i' r"')rr"t o 'a)s" 'a !" +o)d . t(" +olloigs 4 • T(" ?o 'a)s"s i'l)d" t(" 1. 6(ro#o 6(ro#oso# so#al al disord"r disord"rs4 s4 F"tal '(ro#oso#al a!or#aliti"s 5 str)'t)ral a!or#aliti"s Par"tal !ala'"d traslo'atio Par"tal %. Aato# Aato#i'a i'all disord disord"rs "rs44 6"rvi'al i'o#$"t"'"4 →'og"ital ad a;)ir"d Ut"ri" 'a)s"s4 → s)!#)'o)s !roids/ )t"ri" ao#ali"s 5 As("r#aKs sydro#" ,. M"di'a M"di'all diso disord" rd"rs4 rs4 t(yroid disord"rs / Edo'ri" disord"rs 4 dia!"t"s / t(yroid P6OS 5 'or$)s l)t")# is)L'i"'y. I##)ologi'al disord"rs4 Ati'ardioli$i sydro#" 5 SE. Prot"i T(ro#!o$(ilia4 'og"ital d"'i"'y o+ Prot"i 65S ad atit(ro#!i III/ 5 $r"s"'" o+ +a'tor @ "id". I+"'tios ToR6H : 6M@ #ay !" a 'a)s" 'a)s" o+ r"')rr"t r"')rr"t ToR6H
Diagosis 4 1. His Histor tory 4 Pr"vio)s a!ortios 4 g"statioal ag" ad $la'" o+ a!ortios 5 +"tal a!or#aliti"s. M"di'al (istory 4 DM / t(yroid disord"rs/ P6OS/ a)toi##)" dis"as"s 5 t(ro#!o$(ilia. %. E&a# E&a#i iat atio io 4 G""ral 4 "ig(t/ t(yroid 5 (air distri!)tio P"lvi'4 '"rvi& 7l"gt( 5 dilatatio8 ad )t"ri" si*". ,. iv" iv"st stig igat atio ioss 4 A. Iv"stigati Iv"stigatios os +or #"di'al #"di'al disord disord"rs4 "rs4 Blood gro)$ig 5 idir"'t 6oo#!Ks t"st i R(
a!ortio/ !)t ToRH ar" ot 'a)s"s o+ r"')rr"t a!ortio. G"ital tra't i+"'tio ".g Ba't"rial vagiosis R( < isoi##)i*atio
traslo'atio. F"tal ?aryoty$ig4 F"tal '(ro#oso#al ao#ali"s.
Maag"#"t Idio$at(i' R"')rr"t A!ortio I t(" Pr"s"'" o+ 6a)s" it( s)$$ort ad good at"atal 'ar" / t(" '(a'" o+ Tr"at t(" 'a)s" s)''"ss+)l s$ota"o)s $r"ga'y is a!o)t 2:23 Edo'ri" disord"rs S)$$ort 4 +ro# ()s!ad/ +a#ily 5 o!st"tri' • 6otrol DM ad t(yroid disord"rs !"+or" sta. $r"ga'y Advi'" 4 sto$ s#o?ig 5 al'o(ol ita?"/ • Ov)latio id)'tio dr)gs / ovaria drillig or I@F i P6OS. d"'r"as" $(ysi'al a'tivity • Prog"st"ro" or (6G i 'or$)s l)t")# T"d"r lovig 'ar" is)L'i"'y . Dr)g t("ra$y I ati:'ardioli$i sydro#"4 • Prog"st"ro" 5 (6G4 start +ro# t(" l)t"al o dos" as$iri 7 > #g-day 8 5 $r"disilo" • $(as" 5 )$ to 1% ""?s. 7 %2:,2 #g day8/ startig (" $r"ga'y is • o dos" as$iri 7 > #g-day 8 start +ro# diagos"d till , ""?s. t(" diagosis o+ $r"ga'y 5 )$ to , • T("s" dr)gs ar" ot t"ratog"i'. ""?s I t(ro#!o$(ilia4 • MH 7%2:92 #g-day8 start +ro# t(" o dos" as$iri 7 > #g-day8 startig (" diagosis o+ +"tal ("art a'tivity 5 )$ to , $r"ga'y is diagos"d ad lo #ol"')lar "ig(t s ("$ari i" MH 7 %2:92 #g-day8 startig (" +"tal ("art a'tivity diagos"d 5 to 'oti)" !ot( till , ""?s . I )t"ri" disord"rs • 6"rvi'al '"r'lag" i '"rvi'al i'o#$"t"'"/ !"st ti#" at t(" 19 ""?s o+ $r"ga'y. • Myo#"'to#y i s)!#)')s !roid/ "&'isio o+ )t"ri" s"$t)# i s"$tat" 5 s)!s"$tat" )t"r)s 5 ad("solysis i As("r#as sydro#". I i+"'tio44 tr"at#"t o+ t(" g"ital tra't
i+"'tio. I R( isoi##)i*atio4 R"$"at"d itra)t"ri" tras+)sio I $ar"tal !ala'"d traslo'atio • E&$lai t(" ris? o+ +"tal '(ro#oso#al disord"rs 7 a!o)t ,23 8 • E'o)rag" to try agai or ado$tio.
6OMPI6ATIONS OF ABORTION 1. Ha"#orr(ag" . %. 6o#$li'atio r"lat"d to s)rgi'al "va')atio i" E56 ad D56. – Ut"ri" $"r+oratio: (i'( #ay l"ad to r)$t)r" )t"r)s i t(" s)!s";)"t $r"ga'y. – 6"rvi'al t"ar 5 "&'"ssiv" '"rvi'al dilatatio < (i'( #ay l"ad to '"rvi'al i'o#$"t"'". – I+"'tio < #ay l"ad to i+"rtility 5 As("r#as sydro#". – E&'"ssiv" ')r"ttag" < (i'( #ay l"ad to Ad"o#yosis ,. R(: iso i##)isatio à i+ t(" ati
POST:ABORTION MANAGEMENT I 'as"s o+ i'o#$l"t"/ i"vita!l"/ 'o#$l"t"/ #iss"d 5 s"$ti' a!ortios 1. S)$$ort4 +ro# t(" ()s!ad/ +a#ily5 o!st"tri' sta %. Ati D < to all R(
MIS6ARRIAGE 7ABORTION8 D"+4 E&$)lsio or "&tra'tio o+ $rod)'ts o+ 'o'"$tio !"+or" +"tal via!ility i.". !"+or" %9 ""?s o+ g"statio. Incidence :
Is t(" 'o##o"st gya"'ologi'al 5 o!st"tri' disord"r A!o)t 1>3 o+ 'lii'ally r"'ogi*"d $r"ga'i"s "d i a!ortio 7t(is ris" to ,23 i+ )r"'ogi*"d $r"ga'i"s ar" i'l)d"d8. Most a!ortios o'')r !"t"" J ad 1% ""?s o+ $r"ga'y. ETIOOGY 1st Tri#"st"r A!ortio %d Tri#"st"r A!ortio 1. F"tal '(ro#oso#al a!or#aliti"s : $arti')larly triso#y/ tri$loidy 5 #ooso#y 1. M)lti$l" $r"ga'y : is t(" 'o##o"st 'a)s" o+ a!ortio %. 6"rvi'al i'o#$"t"'" 7'og"ital 5 : >2< 2 3 o+ t(" rst tri#"st"r a!ortios ar" d)" to '(ro#oso#al a!or#aliti"s a';)ir"d 8 : t(" i'id"'" o+ t("s" a!or#aliti"s i'r"as"d it( t(" i'r"as" i t(" #at"ral ,. Ut"ri" ao#ali"s ad s)!#)'o)s ag" !roid %. A"#!ryoi' $r"ga'y : Blig(t"d ov)# 9. G"ital tra't i+"'tio ad PROM ,. M)lti$l" $r"ga'y 9. Par"tal !ala'"d traslo'atio >. I+"'tios4 g"ital tra't i+"'tio / syst"#i' i+"'tio it( $yr"&ia 5 ToR6H sydro#" . Edo'ri" disord"rs 4 Dia!"t"s/ t(yroid disord"rs / P6OS 5 'or$)s l)t")# is)L'i"'y . Ut"ri" disord"rs4 Ut"ri" ao#ali"s / s)!#)')s !roid 5 As("r#aKs sydro#" J. T(ro#!o$(ilia4 6og"ital d"'i"'y o+ $rot"i 6 5 S/ 5 ati:t(ro#!i III . I##)ologi'al disord"rs 4 Ati'ardioli$i sydro#" ad SE 12. 6igar"tt" s#o?ig/ aa"st("ti' ag"ts 5 '("#i'al ag"ts. 11. Psy'(ologi'al disord"rs
ABOR PAIN SOUR6ES OF PAIN 1ST STAGE %ND STAGE ,RD STAGE Ut"ri" 'otra'tios 1:Ut"ri" 'otra'tios Is )s)ally "ll %:Str"t'(ig o+ t(" v)lval tol"rat"d it( (i'( 'a)s" #yo#"trial ori'" s$ota"o)s $la'"tal is'("#ia. T(" $ai +"lt ,:Pr"ss)r" o t(" $"lvi' Coor d"liv"ry. T(ro)g( (y$ogastri' Aalg"sia #ay !" $l"&)s"s/ $r" aorti' %=, +"lt t(ro)g( $)d"dal "'"ssary +or #a)al $l"&)s"s to s$ial 'ord "rv" 7S%/,/98 #aily ilio: "&tra'tio. t(ro)g( 7T12:18 ig)ial/ g"ito+"#oral/ 6"rvi'al dilatatio. F"lt t(ro)g( "rv" "t"rig to $ost"rior +"#oral ')ta"o)s "rv". sa'ral root. T(is $ai is so#ati' $ai. At t(is stag" t(is $ai is vis'"ral $ai/ di)s"/ $oorly lo'ali*"d/ i lo"r a!do#" radiat"d to t(" !a'?.
PATHAYS OF PAIN DURING ABOR • T(" !ody o+ )t"r)s ad '"rvi& ar" s)$$li"d !y a)too#i' "rvo)s syst"# 7T12:18 t(ro)g( Hy$ogastri' ad Pr": aorti' $l"&)s"s. • @)lva/ $"ri")# ar" s)$$li"d !y4: :so#ati' "rv"/ :P)d"dal N S%:S9 :G"ito+"#oral N 1:% :Post. F"#oral 'o"ta"o)s N S1: S,.
NON:PHARMAOGI6A METHOD Psy'(o$ro$(yla&is 7a#a*" #"t(od84 E#$(asi*"d r"la&atio 'o)$l"d it( a vari"ty o+ $att"r"d !r"at(ig t"'(i;)"s. E#otioal s)$$ort. Massag". ar# at"r !at(s. Tras')ta"o)s El"'tri'al N"rv" Sti#)latio 7TENS8. 7or?s o !lo'?ig $ai !"rs i t(" $ost"rior gaglia o+ t(" s$ial 'ord8. Hy$osis. A')$)'t)r".
No d"itiv" "vid"'".
ANAGESIA IN ABOR PHARMA6OOGI6A METHOD B"st Aalg"si's t(os" t(at $rovid" ra$id os"t/ it( Minimal to No i#$a't o4 Progr"ssio o+ a!or/ Mat"ral @ital Sigs/ F"tal @ital Sigs/ Mat"ral Passag"s/ ad Ut"ri" 'otra'tios INTRATHE6A ANAGESIA INHAATIONA ANAGESIA Provid" !"tt"r aalg"sia t(a Mor" ""'tiv" t(a o$ioids ad is id"ly )s"d. o $ar"t"ral o$ioids4 Most 'o##oly )s"d #i&t)r" is Etoo& 7a o Provid" ra$id os"t o+ r"li"+. ";)al #i&t)r" o+ NO 5 O&yg"8. 6a (av" a log d)ratio o+ o Provid"s ;)i'? it( s(ort d)ratio o+ ""'t. a'tio. Not s)ita!l" +or $rolog"d )s" +ro# "arly la!or/ o Ty$i'ally 'a)s" o d"gr"" o+ so #ost s)ita!l" is lat" i la!or or (il" aaitig #otor !lo'?ad". "$id)ral aalg"sia. Ro)ti"ly 'a)s" o ""'t o Adv"rs" ""'ts i'l)d" a)s"a 5 lig(t o t(" +"t)s. ("ad"d"ss. Pro!l"#s it( Itrat("'al O$iods. o It is r"#ov"d +ro# t(" !ody )'(ag"d via t(" Pr)rit)s 72:12238. l)gs/ ad do"s ot a'')#)lat" )d"r or#al 'oditios/ "&$laiig t(" ra$id os"t. Na)s"a 7%>:238. o Not s)ita!l" +or $rolog"d )s" +ro# "arly Uriary r"t"tio 712:,>38. la!or7!'o* (y$"rv"tilatio #ay r"s)lt i (y$o'a$"a / t"tay / +"tal (y$o&ia/ so #ost s)ita!l" is lat" i la!or or (il" aaitig "$id)ral aalg"sia.
ANAGESIA IN ABOR PHARMA6OOGI6A METHOD PARENTERA NAR6OTI6S Easy ad#iist"r"d. or? !"st i "arly rst stag"/ (" $ai is $ri#arily vis'"ral ad l"ss it"s". 6ross $la'"tal !arri"r ad so it a"'ts +"t)s. Nar'oti's 'a !" giv" I@/ IM or !y 6oti)o)s i+)sio/ i (at is 'all"d P6A. Nalo&o" is a ar'oti' atagoist/ t(at is i"'t"d ito t(" )#!ili'al v"i i O$ioids to&i'ity 'as"s PETHIDINE FENTANY BUTORPHANO O" o+ t(" #ost id"ly )s"d Syt("ti'/ #or" $ot"t t(a ot("r Syt("ti' aalg"si'. syst"#i' o$ioids +or la!or aalg"sia. o$ioids/ so 'a)tio is "'"ssary to 92 ti#"s #or" $ot"t t(a or? !"st i "arly 1 st stag" (" avoid s"rio)s r"s$iratory P"t(idi". d"$r"ssio. $ai is vis'"ral. D)ratio %:9 (o)rs. Ra$id os"t / S(ort a'tio. T1-%7%:9 (o)r8 It atagoi*"s t(" ar'oti' ""'ts o+ 6oti)o)s $)ls" o&i#"try Us)ally giv" IM P"t(idi"/ ad t("r"+or" ot giv" #oitorig ad 'los" )rsig )i'? $la'"tal tras+"r tog"t("r. s)rv"illa'" ar" also ""d"d. 6a)s"s drosi"ss ad di**i"ss. P"t(idi" do"s ot i(i!it )t"ri" Sid" ""'t 4 a)s"a /vo#itig "ss a)s"a ad vo#itig. 'otra'tio so (as l"ss adv"rs" /'osti$atio /drosi"ss /'o+)sio. "ss r"s$iratory d"$r"ssio. ""'ts o !a!y. Most s"rio)s sid" ""'t4 d"lay"d Dia#or$(i" is !"tt"r aalg"si' #at"ral gastri' "#$tyig 7t(" t(a $"t(idi" !)t gr"at"r dag"r to t(" #ot("r (" s(" r"s$iratory d"$r"ssat ""'t o r";)ir" GA i t(" $r"s"'" o+ +)ll "!or so " doKt )s" it sto#a'( )d"r GA r"g)rgitatio ad $)l#oary as$iratio 'a o'')r8 tt !y4 o solid +ood d)rig la!or / ati"#"ti' /H% !lo'?"r.
INTRODU6TION A"st("sia v"rs)s aalg"sia 4 A aalg"si' dr)g s)'( as as$iri #ay r"li"v" $ai !)t t(" $"rso (o ta?"s as$iri still +""ls ot("r $(ysi'al s"satio s)'( as $r"ss)r" / ("at /'old ad vi!ratio / i 'otrast a"st("ti' dr)gs !lo'?s all t("s" $(ysi'al s"satio
ANESTHESIA IN ABOR AQ GENERA ANESTHESIA INTRODU6TION BENEFITS OF GENERA GA isKt )s"d i vagial d"liv"ry. H"l$ t(" o!st"tri'ia to d"liv"r t(" GA Us"d i 6-S i '"rtai !a!y i +"tal distr"ss. Sit)atios ("r" #i)t"s #ay 'o)t 'ir')#sta'"s. +or t(" +"t)s ".g. r)$t)r"d )t"r)s/ • E&tr"#" "#"rg"'y sit)atios . $la'"tal a!r)$tio/ )#!ili'al 'ord • Ay 'otraidi'atio +or r"gioal $rola$s". a"st("sia ".g i+"'tio at ""dl" Sit)atios ("r" ra$id id)'tio is"rtio sit"/ $rior !a'? s)rg"ry/ #ay!" ""d"d +or #at"ral sa+"ty ".g. i'r"as" itra'raial $r"ss)r"/ "t'. )'otroll"d ("#orr(ag" as i 'as"s • U"&$"'t"d $rolog"d s)rg"ry. o+4 $la'"ta $r"via/ tra)#a/ $la'"tal a!r)$tio/ r)$t)r"d v"ss"ls.
INTRODU6TION D"+4 Itrod)'tio o+ a lo'al a"st("ti' ito t(" subarachnoid space. A s(ort $ro'"d)r" ti#". Ra$id os"t o+ t(" !lo'?/ ad li#it"d d)ratio o+ a'tio. Hig( s)''"ss rat". Us"d v"ry lat" i la!or.
ANESTHESIA IN ABOR BQ REGIONA ANESTHESIA SPINA ANESTHESIA INDI6ATION 6ONTRAINDI6ATION 718 O$"ratios !"lo Pati"t r"+)sal/ )#!ili')s )'oo$"rativ" $ati"ts 7%8 Ay o$"ratio i $"ri")# Hy$ovol"#ia or g"italia 6lottig disord"rs 7,8 All $ossi!l" o$"ratio o S"$ti'"#ia t(" l"g "&'"$t a#$)tatio Aato#i'al d"+or#iti"s i 798 @"ry i#$ortat to oti'" t(" $ati"t !a'? t(at s$ial a"st("sia is N")rologi'al dis"as" idi'at"d +or old"r $ati"t Iad";)at" r"s)s'itativ" it( syst"#i' dis"as" . dr)g ad ";)i$#"ts
INTRODU6TION Most ""'tiv" +or# o+ la!or $ai r"li"+/ )s"d i t(" rst ad s"'od stag"s o+ la!or. No dir"'t ""'t o +"t)s 5 do"sKt 'ross $la'"ta. I"'t"d ito t(" "$id)ral s$a'" !"t"" %: , or ,:9 it"rs$a'". A t"st dos" is giv" to 'or# t(" 'at("t"r $ositio/ i+ o )at"d sigs is o!s"rv"d a+t"r > #i o+ i"'tio/ a loadig dos" 'a !" ad#iist"r"d. Aalg"sia +or t(" $ai o+ la!or ad vagial d"liv"ry "'"ssitat"s a !lo'? +ro# t(" T12 to t(" S> d"r#ato#"s. For '"sar"a d"liv"ry/ a !lo'? "&t"dig +ro# t(" T9 to t(" S1 d"r#ato#"s is
6OMPI6ATION Hypotension/ !rady'ardia i+ !lo'? r"a'(s T%:T9.
Post spinal headache (postural)
Uriary r"t"tio Fail)r" o+ t"'(i;)" . E$id)ral or s)!ara'(oid ("#ato#a S$ial 'ord tra)#a or i+"'tio Rar"ly/ 'ov)lsios ad !lid"ss
EPIDURA ANESTHESIA INDI6ATION 6OMPI6ATIONS Pai. MATERNA IMMEDIATE Prolog"d la!or. Hy$ot"sio Mat"ral 6o#$l"t" #otor ad s"sory $aralysis. (y$"rt"siv" A:id)'"d 'ov)lsios/ )'o##o !)t disord"r. (" t("r" is (ig( s"rio)s. A:id)'"d 'ardia' arr"st. ris? o+ o$"rativ" it"rv"tio. DEAYED Hig( ris? +"t)s Post)ral $)'t)r" ("ada'(". gro)$. Ba'?a'(" t("r" is good "vid"'" t(at "$id)ral do"s ot 'a)s" !a'?a'(". 6ONTRAINDI6ATION Uriary r"t"tio To avoid t(is a 'at("t"r is Pati"t r"+)sal. $la'"d "arly. Tiglig i (ads or g"rs. 6oag)lo$at(y disord"rs. E$id)ral a!s'"ss"s "&tr"#"ly rar".
d"sir"d. T(" s$r"ad o+ t(" a"st("ti' d"$"ds )$o t(" lo'atio o+ t(" 'at("t"r ti$ t(" dos"/ 'o'"tratio/ ad vol)#" o+ a"st("ti' ag"t )s"d/ ad ("t("r t(" #ot("r is ("ad:do/ (ori*otal/ or ("ad:)$.
o'al or syst"#i' i+"'tio. Hy$ovol"#ia.
FETA No dir"'t adv"rs" ""'t o +"t)s. F"tal distr"ss 'a o'')r i+ #at"ral (y$ot"sio o'')rr"d.
SPINA ANESTHESIA AD@ANTAGE Fast"r/ T"'(i'ally "asi"r Mor" r"lia!l" : D""d "d$oit/ Mii#al '(a'" o+ $at'(y !lo'? D"s"r !lo'? o"r dr)g "&$os)r" +or #ot("r ad +"t)s No '(a'" o+ syst"#i' to&i'ity
EPIDURA ANESTHESIA AD@ANTAGE 6a tailor d)ratio to ""d o"r '(a'" o+ $ostd)ral $)'t)r" ("ada'(" B""'ial i $ati"ts it( 'ardia' ad (y$"rt"siv" disord"rs
DISAD@ANTAGE DISAD@ANTAGE i#it"d d)ratio Slo"r os"t Hig("r '(a'" o+ $ostd)ral $)'t)r" ("ada'(" Hig("r ris? o+ syst"#i' to&i'ity Ris? o+ (ig( s$ial Ris? o+ $at'(y !lo'?
ANESTHESIA IN ABOR 6Q O6A ANESTHESIA
PARA6ER@I6A BO6 INTRODU6TION D"+4 Bilat"ral trasvagial lo'al a"st"t("ti' i"'tio to !lo'? t(" +ra?(o)s"rKs gaglio lat"ral to '"rvi&. Provid"s satis+a'tory $ai r"li"+ d)rig t(" rst stag" o+ la!or. A"st("ti' ag"t is i"'t"d ito t(" '"rvi& lat"rally at , ad o'lo'?. Has a s(ort d)ratio o+ a'tio/ so $ara'"rvi'al !lo'? #ay (av" to !" r"$"at"d d)rig la!or. B"'a)s" t(" $)d"dal "rv"s ar" ot !lo'?"d/ aot("r aalg"si' $ro'"d)r" #ay !" ""d"d. Us)ally/ " )s"4 ido'ai"
6OMPI6ATION F"tal !rady'ardia 7lasts )$ to ,2 #i8 R"s)lts +ro# d"'r"as"d $la'"tal $"r+)sio/ d)" to t(" dr)g: id)'"d vaso'ostri'tio ad t("r"+or" s(o)ld ot !" )s"d i sit)atios o+ $ot"tial +"tal 'o#$ro#is".
PUDENDA BO6 D"+4 Bilat"ral trasvagial A i"'tio to !lo'? t(" $)d"dal "rv" as it $ass t(ro)g( t(" is'(ial s$i" 7origiat" +ro# S,:S98/ R"lativ"ly sa+" ad si#$l" #"t(od o+ $rovidig aalg"sia +or s$ota"o)s d"liv"ry. T(" s)''"ss+)l $)d"dal !lo'? ill allo $i'(ig o+ t(" lo"r vagia ad $ost"rior v)lva !ilat"rally it(o)t $ai. P)d"dal !lo'? )s)ally do"s ot $rovid" ad";)at" aalg"sia (" d"liv"ry r";)ir"s "&t"siv" o!st"tri'al #ai$)latio. 6o#$li'atios4 Itravas')lar i"'tio/
6(loro$ro'ai"/ > to 12 #l o+ a 13 sol)tio. 7B)$iva'ai" is 'otraidi'at"d !"'a)s" o+ 'ardioto&i'ity.8
("#ato#a/ ad rar"ly i+"'tio.
↑ris?
o+
ANEMIA IN PREGNAN6Y PHYSIOOGI6A 6HANGES IN PREGNAN6Y ANEMIA Progr"ssiv" i'r"as" i $las#a vol)#" )$ till ,%:,9 o"r H! or#al val)"s4 ""?s/ 7>238. No:Pr"gat 11.>:1% g-dl Progr"ssiv" i'r"as" i R"d 6"ll #ass/ alt(o)g( t(" Pr"gat/ '(ag" it( g"statio/ !)t g""rally 12.> $r"ga'y/ 7%>38. g-dl. Ma&i#)# $(ysiologi'al aa"#ia o'')r at ,%:,9 ""?s 6lii'al +"at)r"s4 g"statio. Mostly d"t"'t"d o ro)ti" t"stig. M6@/ M6H6 stay 'ostat/ i.". dil)tioal aa"#ia. Tir"d"ss. Progr"ssiv" +all i $lat"l"t 'o)t/ o $lat"l"ts oly i+ "t(argy. Plat"l"ts ar" 122 or $at(ologi'ally r"d)'"d 'o)t. >: Di**i"ss. 123 ill !" 122:1>2V12-l Faitig. T("r" is %:, +old i'r"as" i Iro r";)ir"#"ts i $r"ga'y Hy$"r'oag)la!l" stat". IRON DEFI6IEN6Y ANEMIA FOATE DEFI6IEN6Y ANEMIA T(" 'o##o"st i A"#ia r"s)lts i+ S"'od 'o##o"st i $r"ga'y. Stor"s ar" d"$l"t"d. $r"ga'y. T(" or#al di"tary Folat" ita?" is I'r"as"d d"#ad !y t(" Iro ita?" is $oor. iad";)at" to $r"v"t d"v"lo$ig +"t)s/ l"ads to #"galo!lasti' '(ag"s i t(" !o" A!sor$tio is $oor. i'r"as"d a!sor$tio ad #arro i %>3 o+ $r"gat ladi"s. Utilisatio is r"d)'"d. i'r"as"d #o!ilisatio +ro# D"#ad is i'r"as"d4 Pr"val"'" vari"s a''ordig to 4 stor"s. So'ial 'lass. M)lti$l" g"statios. IDA is #or" 'o##o i N)tritioal stat)s. 6(roi' !lood loss. #)lti$l" $r"ga'i"s. Fa'tors i'r"asig t(" ris? o+ FDA4 Ha"#olysis. Blood loss at d"liv"ry ill Ati'ov)lsat t("ra$y. A lot o+ $ati"ts start $r"ga'y it( +)rt("r i'r"as" #at"ral Ha"#olyti' aa"#ia. alr"ady d"$l"t"d stor"s. aa"#ia/ so it is ot oly a T(alass"#ia. M"orr(agia.
$ro!l"# 'o"d to $r"ga'y $"riod.
Iad";)at" di"t. Pr"vio)s r"'"t $r"ga'i"s 6o'"$tio (il" !r"ast +""dig.
H"r"ditary s$("ro'ytosis.
DIAGNOSIS IRON DEFI6IEN6Y ANEMIA As it is t(" 'o##o"st/ it is alays $r"s)#"d to !" t(" diagosis/ !)t s(o)ld alays !" 'or#"d. 6(ag"s i t(" idi'"s as +ollos4 M6@ r"d)'"d. M6H/ M6H6 r"d)'"d. S"r)# iro +all/ 1%##ol-l 7or#ally +alls i $r"ga'y8. Total iro !idig 'a$a'ity i'r"as"d/ sat)ratio 1>3 idi'at" aa"#ia. S"r)# +"rriti/ +all.
INTRODU6TION I'id"'" 1-%>2 d"liv"ri"s %2:,23 o+ APH Maority $r"s"t as $ail"ss vagial !l""dig !y ,2 ""?s o+ g"statio %23 !l""dig ad a!do#ial $ai I'id"tal dis'ov"ry
FOATE DEFI6IEN6Y ANEMIA M6@ i'r"as"d. M"galo!lasti' '(ag"s i t(" !o" #arro. R"d)'"d s"r)# ad r"d '"ll +olat".
MANAGEMENT Ro)ti" iro s)$$l"#"t/ as d"#ad is rar"ly #"t !y or#al iro ita?". Oral s)$$l"#"tatio is ot it(o)t sid" ""'ts4 6osti$atio. Tast". Diarr(o"a. Na)sia ad vo#itig. Alt"rat" ro)t"s ar" availa!l"4 IM. I@. T(" #a&i#)# rat" o+ ris" i H! is aro)d 1g-dl-""?. S"v"r" aa"#ia diagos"d i t(" lat"r stag"s o+ $r"ga'y #ay ""d tras+)sio. Pr"'o'"$tio advi'" +or all o#" is to ta?" +olat" s)$$l"#"t o+ 2.9#g-day to r"d)'" t(" ris? o+ NTD/ t(is ill i'r"as" to >#g-day i 'as"s o+ $r"vio)s NTD !a!y/ or i 'as" o+ ita?" o+ ati:+olat" #"di'atios
PA6ENTA PRE@IA PREDISPOSING FA6TORS 6ASSIFI6ATION M)lti$arity R"lat"d to it"ral os. I'r"as"d #at"ral Mior ag" Grad" I/ o lyig Pr"vio)s $la'"ta $la'"ta $r"via/ r"')rr"'" Grad" II at"rior/ rat" 9:J3 #argial M)lti$l" g"statio Maor Pr"vio)s '"sar"a Grad" II $ost"rior s"'tio Grad" III/ $artial Ut"ri" ao#ali"s Grad" I@/ '"tral/ 'o#$l"t".
•
•
• • •
PRESENTATION Pail"ss vagial !l""dig/ #or" s"v"r" it( #aor d"gr""s R"')rr"t !o)ts o+ !l""dig #ay !" +ro# "arly $r"ga'y Mal$r"s"tatio ad (ig( $r"s"tig $art Ut"r)s is so+t ad ot t"d"r F"t)s is )s)ally aliv" ad
•
MATERNA RIS Mat"ral #ortality 2.13 #aily +ro# ("#orr(ag" PPH A"st("sia S"$sis Air "#!olis# WW DI6/ lat" o'')rrig/ lat"
FETA RIS Hig( $"riatal #ortality VVV $r"#at)rityVVV IUGR i 1>:%23 6og"ital #al+or#atios do)!l"d U#!li'al 'ord 'o#$li'atio Mal$r"s"tatio
VE&$"'tat Maag"#"t ""$ i (os$ "s$ i #aor d"gr"" St"roids 6orr"'t a"#ia W Blood tras+)sio 6ross:#at'("d !lood s(o)ld !" availa!l" all t(" ti#" Ass"ss +"tal "ll:!"ig INTRODU6TION Pr"#at)r" s"$aratio o+ t(" $la'"ta 7!"+or" d"liv"ry o+ t(" +"t)s8 I'id"'"4 2.>:1.>3
DIAGNOSIS Ultrasoogra$(y VA!do#ial >3 a'')rat" V@agial )s)ally +or $ost $la'"ta diL')lt to d"" !y a!do#ial )ltraso)d 7do" i (os$8 V Do)!l" s"t )$ "&a#iatio rar"ly ""d"d i $ati"ts ot a'tiv"ly !l""dig
"ll Mor" s"rio)s +or #ot("r t(a +"t)s MANAGEMENT Pro$"r ass"ss#"t o+ #at"ral 'oditio ad r"s)s'itatio I s"v"r" !l""dig/ "#"rg"'y '"sar"a d"liv"ry irr"s$"'tiv" o+ g"statioal ag" I+ !l""dig a+t"r ,:, ""?s/ d"liv"r. I+ !l""dig ot s"v"r" ad "arly $r"ga'y/ "&$"'tat #aag"#"t/ att"#$tig to r"a'( +"tal #at)rity 7,:,J ?s8 it(o)t ris?ig #at"ral ("alt(
VD"liv"ry D"liv"ry is !y '"sar"a s"'tio WW At"rior #argial $la'"ta it( lo"r #argi 0%'# +ro# t(" it"ral os 7!y USS8 #ay !" d"liv"r"d vagially O!s"rv" +or PPH Pro$(yla&is +or R( isoi##)i*atio
PA6ENTA ABRUPTION PREDISPOSING FA6TORS 6ASSIFI6ATION Hy$"rt"sio/ #ostly PET/ i Grad" 2. Asy#$to#ati'/ s#all r"tro$la'"tal 'lot $r"ga'y a+t"r d"liv"ry Pr"vio)s $la'"tal a!r)$tio/ r"')rr"'" rat" a+t"r o" "$isod" J: Grad" 1. VE&t"ral vagial 13/ a+t"r to "$isod"s %>3
6INI6A FEATURES @agial !l""dig/ varia!l" a#o)t/ o !l""dig i 'o'"al"d A!do#ial $ai/ dis'o#+ort ad !a'?a'("
Tra)#a Poly(ydro#ios Pr"#at)r" r)$t)r" o+ #"#!. S(ort 'ord S#o?ig Hig( $arity ad lo so'ial 'lass Idio$at(i' MANAGEMENT
6INI6A PRESENTATION 6o'"al"d %>:,23 R"v"al"d >:J23 Ot("r4 Mild Mod"rat" S"v"r" a!r)$tio
R"ss)s'itatio/ I@ 'a)la/ I@ 'rystalloid 6ross #at'( !lood ad FFP Ass"ss#"t o+ #ot("r/ $)t &"d 'at("t"r/ 6B6/ FT/ Uri" +or $rot"i/ ad 'oag)latio $rol" Ass"ss#"t o+ +"tal "ll!"ig/ 6TG D"itiv" tr"at#"t !y d"liv"ry/ ass"ss +or la!o)r/ do ARM ad syto'io i+)sio. Ay +"tal distr"ss or d"t"rioratio o+ #at"ral 'oditio d"liv"r !y 6-S DI6/ $a'?"d RB6 ad FFP O!s"rv" +or PPH O!s"rv" )ri" o)t$)t/ ris? o+ r"al t)!)lar or 'orti'al "'rosis
!l""dig VUt"ri" t"tay ad t"d"r"ss #ay !" $r"s"t VNo sigs o+ #at"ral s(o'? VNo "vid"'" o+ +"tal distr"ss Grad" %. VE&t"ral vagial !l""dig #ay or #ay ot !" $r"s"t. VUt"ri" t"d"r ad t"tay VNo sigs o+ #at"ral s(o'?. VSigs o+ +"tal distr"ss $r"s"t. Grad" ,. 5E&t"ral !l""dig #ay or #ay ot !" $r"s"t. VMar?"d )t"ri" t"tay. VP"rsist"t a!do#ial $ai. VMat"ral s(o'?. VF"tal d"at( or distr"ss. V6oag)lo$at(y i ,23
ANTEPARTUM HEMORRHAGE @agial !l""dig a+t"r ag" o+ via!ility
i >3 o+ 'as"s Ut"ri" t"tay ad t"d"r"ss ov"r $la'"tal sit"/ #or" i 'o'"al"d Nor#al li" ad $r"s"tatio Hig( i'id"'" o+ +"tal distr"ss ad +"tal d"at(. F"t)s is d"ad i %>:,>3 o+ 'as"s at ad#issio 7$"riatal #ortality 9.9: 38 Blood $r"ss)r" #ay !" or#al or "l"vat"d/ $rot"i )r"a 7IUGR $r"s"t i J23 o+ 'as"s d"liv"r"d a+t"r , ""?s o+ g"statio8 Ov"r dist"d"d )t"r)s/ rigid/ diL')lt to +""l +"tal $arts i 'o'"al"d ("#orr(ag" Evid"'" o+ s?i "''(y#osis i 1,3 o+ 'as"s )s)ally t(os" ad#itt"d it( +"tal d"at(
Blood loss is a #aor 'a)s" o+ #at"ral d"at( I'id"'" 93 6AUSES o Pla'"ta $r"via %2:,23 o A!r)$tio $la'"ta" 1>:%23 U'lassi"d >23 o Margial s"$aratio – S(o – o'al 'a)s"s – @asa $r"via – U?o 'a)s" –
23 %23 3 2.2>3
V@asa Pr"via4 F"tal !l""dig $r"s"t"d as a ')t" +"tal distr"ss a+t"r #"#!ra"s r)$t)r"d GENITA PROAPSE4 APPROA6H HISTORY PROFIE
Na#"/ Ag"/ Gravida/ Para/ O'')$atio/ Et(i' 6-64 UMP - SOMETHING PROTRUDYING THRU INTROITUS - 6OMING DON BEO HPI )#$ aalysis4 D)ratio. Pr"s"t alays-go"s !a'? iW ↑ !y log stadig/ at "d o+ t(" day. ↓ !y lyig do I#$a't o so'ial 5 s"&)al li+" Asso'iat"d s&4 Ba'? $ai < )t"ri" $rola$s"d Uriary s&/ 'aKt "#$ty !ladd"r/ #)st r"d)'" digitally < 6ysto'"l"-)r"t(ro'"l" 6osti$/ I'o#$l"t" "va')atio/ #)st r"d)'" digitally < R"'to'"l" DD&4 Ul'"r/ !lood stai/ $)r)l"t vagial dis'(arg" < Pro'id"tia 6og"ital Gat"rKs Ris? +a'tors 'yst 6(ild!irt( < M)lti$arityW @agial d"liv"ryW og la!orW I'l)sio d"r#oid 'yst Ur"t(ral div"rti')l)# M"o$a)s" arg" '"rvi'al #ass ↑ Itra:a! $r"ss)r" < O!"s"/ 6(roi' 'o)g(/ 'osti$/ "do#"trial $oly$ P"lvi' s)rg"ry Gy"a H&4 M"o$a)s"/ HRT/ P"lvi' s)rg"ri"s Past H&4 6(roi' 'o)g( 76OPD/ Ast(#a/ P")#oia/ 6F8/ 6osti$atio/ Pr"vio)s s)rg"ri"s So'ial H&4 S#o?ig EAM P"lvi' E&a# Is$"'tio < @)lva it( 'o)g( 5 straiig < D"#ostrat" $rola$s" X i'oti"'" S$"')l)# R"'tal E&a# < to di"r"tiat" r"'to'"l" 7g"r go"s t(r)8 5 "t"ro'"l" 7g"r go"s (ig( )$8
IN@ESTIGATIONS MSU < aalysis 5 ')lt)r" R"al US 5 I@U < i $ro'id"tia 5 s"v"r" 'ysto'"l"/ to R-O (ydro)r"t"r 5 (ydro"$(rosis 6ysto#"try < to R-O )rg" i'oti"'"
PUERPERA PYREIA El"vat"d t"#$"rat)r" o+ #or" t(a ,J.%6 +or a (ol " day it(i t(" rst 12days $ost$art)#. History Itrod)'tio P"r#issio 6o#$l"t" $ati"t $rol"4 GA/ GravidaPara/ Addr"ss/ O'')$atio/ Blood gro)$ 6(i"+ 6o#$lai Aalysis o+ '(i"+ 'o#$lait4 D)ratio/ os"t/ do')#"t"d-ot R-O Edo#"tritis4 O"siv" vagial dis'(arg"/ A! $ai R-O Mastitis4 a'tatig or ot/ A!or#al !r"ast dis'(arg" R-O UTI4 Uriary s&/ Na)s"a/ vo#it/ '(ills/ rigors R-O o)d i+&4 o)d $)s/ !l""dig +ro# sit" R-O URTI4 6o)g(/ SOB R-O D@T4 "g s"llig or r"d"ss R-O Ba't"rial vagiosis4 @agial dis'(arg" d)rig $r"ga'y Itra$art)# H&4 @agial d"liv"ry-6SW El"'tiv" or "#"rg"'y 6SW Id)'tio o+ la!orW Istr)#"tal d"liv"ryW PROMW H& o+ !lood tras+)sioW Uri" 'at("t"ri*atioW H& o+ $r"ga'y4 A"#i'W Ba't"rial vagiosis d)rig $r"ga'yW H& o+ t(" sa#" $ro!l"# i $r"vio)s $r"ga'i"sW PMH-PSH Dr)g H&. Fa#ily H&. So'ial H&.
P(ysi'al E&a#iatio4 Itrod)'tio P"r#issio Priva'y. ig(tig. Hygi"". G""ral E&a#4 : 6a)la sit" 7s)$"r'ial t(ro#!o$(l"!itis8 : 6at("t"r 7)ti8 : Sigs o+ a"#ia 7a"#ia $"r s" is ris? +a'tor8 : @ital sigs Br"ast E&a# 7#astitis8 6("st E&a# 7)rti8 T(yroid E&a# A!do#ial E&a#4 : Ut"ri" t"d"r"ss 7"do#"tritis8 : Ut"ri" s)!ivol)tio 7"do#"tritis8 : Is$"'tio o+ o)d 7o)d i+&8 P"lvi' E&a#4 : 6"rvi& is o$" 7"do#"tritis8 : O"siv" vagial dis'(arg" 7"do#"tritis8 o"r i#! E&a# : "g 'ir')#+"r"'" 7dvt8 : Do$$l"r 7dvt8
URINARY IN6ONTINEN6E APPROA6H
HISTORY Ag"/ Parity Aalysis o+ I'oti"'"4 D)ratio/ +r";)"'y/ a#o)t Pr"'i$itatig +a'tors ,Ps4 Positio/ Prot"'tio/ Pro!l"# Progr"ssio Uriary Diary Asso'iatio Irritativ" s& 7Fr";/ Urg"'y/ No't)ria8 < )rg" O!str)'tiv" s& 7Poor str"a#/ I'o#$l"t" void/ Straiig8 < ov"rCo R"')rr"t UTI < )rg" Past O!s H&4 Mod" o+ D"liv"ry. Istr)#"talW/ Prolog"d % d stag"W Ba!y !irt( J. Past Gy"a H&4 S& o+ Prola$s"/ P"lvi' s)rg"ry/ H& o+ #aliga'y/ H& o+ radiot("ra$y PHYSI6A EAM G""ral oo? A!do#ial E&a# R"s$iratory E&a# N")rologi'al "&a# < M"tal stat)s/ Gait/ o"r "&tr"#ity/ P"ri"al s"satio 5 r"C"&"s. P"lvi' E&a# P"lvi' Coor #)s'l" to" Str"ss t"st : 023 diagosti' +or str"ss i' 6otto sa! Z :ti$ t"st IN@ESTIGATIONS 1. Uri" aalysis 5 ')lt)r" %. Urodya#i' st)di"s a. No:ivasiv" #"t(ods4
i. Urofowmetry
ii. @ol)#":+r";)"'y '(art iii. Ultraso)d4 R"sid)al @ol)#"/ Ur"t(ral 'yst/ Div"rti')latio o+ )r"t(ra iv. EMG !y s)r+a'" "l"'trod"s !. Ivasiv" #"t(ods i. Cystometry
,. 9. >. . .
ii. Ur"t(ral Pr"ss)r" Prolo#"try iii. R@ !y 6at("t"r iv. EMG !y ""dl" "l"'trod"s Ultraso)d @6U I@U. Idi'atio4 H"#at)ria/ N")ro$at(i' !ladd"r/ Ut"rovagial st)la. 6ysto)r"t(ros'o$y. Idi'atio4 R"d)'"d !ladd"r 'a$a'ity/ S(ort (& 7%yrs8 o+ )rg"'y 5 +r";)"'y/ P"rsist"t UTI/ Hig( s)s$i'io o+ t)#ors or sto". MRI
UROFOMETRY Nor#al Co ')rv"4 B"ll s(a$"d Nor#al Co rat" 01>#l-s"' Nor#al voidal vol)#" 01>2#l 6YSTOMETRY Idi'atios 1. Pr"vio)s )s)''"ss+)l 'oti"'y s)rg"ry %. Mi&"d i'oti"'" ,. @oidig disord"r 9. N")ro$at(i' !ladd"r
Nor#al @al)"s R"sid)al @ol)#" 0>2#l 1st D"sir" to @oid4 1>2:%22#l Bladd"r 6a$a'ity4 922:22#l D"tr)sor Pr"ss)r" 7Fillig $(as"84 1>'#H%2 D"tr)sor Pr"ss)r" 7@oidig $(as"84 92: 2'#H%2 No l"a?ag" (" 'o)g(ig
MANAGEMENT A. 6ONSER@ATI@E S)''"ss rat" 92:23. Maistay i Str"ss I'. Sto$ s#o?ig/ al'o(ol/ 'a"i". "g"l "&"r'is". Itravagial d"vi'" to s)$$ort !ladd"r "'? 5 )r"t(ra. B. MEDI6A Mild:Mod"rat" Str"ss I'oti"'" Alpha-Aonist
Urg" I'oti"'" Anticholineric !rus
Ps")do"$("dri" P("yl$ro$aola#i"
O&y!)tyi '(lorid" Tolt"rodi" "CA4 I#i$ra#i"
6. SURGI6A [Str"ss I'oti"'"Q 6ol$os)s$"sio
T"sio:+r"" @agial Ta$" 7T@T8
P#$-I%&A'I&$ I%&A'I&$ C$#&ICA !I'$A'$ •
Dysplasia “lesion in which part of the epithelium is replaced by cells showing varying
degrees of atypia” Cervical Intraepithelial Neoplasia (CIN): •
Intraepithelial dysplastic atypia occurring within the metaplastic epithelium of the transformation one!
B"t("sda syst"# AS6US4 Aty$i'al s;)a#o)s '"lls o+ )d"t"r#i"d sigi'a'" •
•
SI4 o grad" s;)a#o)s itra"$it("lia l l"sio
HSI4Hig( grad" s;)a#o)s itra"$it("lia l l"sio
6a'"r4 S;)a#o)s '"ll 'ar'io#a
Origial S;)a#o'ol)#ar \)'tio7OS6\84 T(" )'tio i +"tal li+" !"t"" t(" Strati"d SE o+ t(" vagial ad "'to'"rvi&/ ad t(" 6E o+ t(" "d '"rvi'al 'aal. N" S;)a#o'ol)#ar \)'tio 7NS6\84 T(" )$$"r #a rgi o+
t(" s;)a#o)s #"ta$lasia *o" d"t"r#i"d !y t(" 'ol$os'o$y
Dysplasia " CIN #ystem
• Tras+or#atio ]o" 7T]84 T(" ar"a lyig !"t"" t(" OS6\
Mild dys$lasia
Mod.dys$la sia
S"v"r" dys$lasia
6IN 1
6IN %
6IN ,
• •
•
•
•
6I S
6a' "r
6"rvi'al "o$lasia origiat"s it(i t(" T]. o Ris? HP@ ty$"s 7 ad 118/ ar" asso'iat"d lo: grad" '"rvi'al l"sios 7'odylo#ata a')#iata/ ad 6IN18. Hig( Ris? HP@ ty$"s 71/ 1J/ ,1/,,/or ,>8/ ar" asso'iat"d it( (ig(:grad" '"rvi'al l"sio 76IN%/,8 ad '"rvi'al 'a'"r. HP@ 1 is t(" ty$" )iv"rsally d"t"'t"d it( gr"at"st +r";)"'y i (ig( grad" l"sio ad '"rvi'al 'a'"r/ >23 o+ S66/ ,23 o+ Ad" 'ar'io#a/ ad i ov"r J23 o+ $r"ivasiv" l"sios At l"ast ,>3o+ $ati"ts it( 6IN, ill d"v"lo$ ivasiv" 'a'"r it(i 12y"ars/ ("r"as lo"r grad"s #ay s$ota"o)sly r"gr"ss.
'creenin o+ asymptomatic women
ad t(" NS6\
#is* +actors +or Cer,ical Cancer
1. P"rsist"t HP@ i+"'tio it( (ig( ris? ty$"s %. Yo)g ag" at rst 'oit)s7%2yr8 ,. M)lti$l" s"&)al $art"rs 9. S"&)al $art"r it( #)lti$l" s"&)al $art"rs >. Yo)g ag" at rst $r"ga'y . Hig( $arity . o"r so'io"'oo#i' stat)s J. S#o?ig . Oral 'otra'"$tiv"s )s" 12.G"ital arts 11.E&og"o)s-"dog"o)s i##)os)$$r"ssio
Papanicolaou 'mear •
•
•
•
•
Bot( t(" "d '"rvi'al 'aal ad t(" "'to'"rvi& s(o)ld !" sa#$l"d (" ta?ig t(" Pa$ s#"ar I US / t(" A6OG (as r"'o##"d"d t(at all o#"/ o'" t("y (av" !"'o#" s"&)ally a'tiv"/ s(o)ld )d"rgo a a)al Pa$ s#"ar/ t(" %:> y"ars +olloig to or t(r"" or#al Pa$ s#"ars I A)stralia/ o'" s"&)ally a'tiv" till t(" ag" o+ > y"ar/ ro)ti" s#"ar "v"ry % y"ars T(" +als" "gativ" rat" +or Pa$ s#"ar +or (ig( grad" l"sios is %23 N" t"'(ologi"s 7T(i $r"$/ A)to6yt" PREP8 ar" a)to#at"d li;)id !as"d slid" $r"$aratio syst"#s to d"'r"as" t(" +als" "gativ" rat"
Colposcopy • T(" 'ol$os'o$" is a
•
1. %.
,. 9. >. .
st"r"os'o$i' !io')lar #i'ros'o$" o+ lo #agi'atio/ )s)ally 12& to 92&. Idi'atios +or 'ol$os'o$y4 A!or#al '"rvi'al s#"ar A!or#al digs o ad)'tiv" s'r""ig t"sts s)'( as HP@ t"stig ad '"rvi'ogra$(y/ $arti')larly i 'as"s o+ AS6US I+ t(" '"rvi& is 'lii'ally a!or#al or s)s$i'io)s o a?"d "y" "&a#iatio A!or#al or )"&$lai"d IM! or P6B P"rsist"t vagial dis'(arg" P"rsoal (istory o+ i )t"ro DES "&$os)r"/ v)lvar or vagial "o$lasia
$/#$ Colposcopy
^ A 'o#$l"t" #"di'al (istory ad g""ral "&a#iatio s(o)ld !" $"r+or#"d ^ A 'lii'al ad s$"')l)# "&a#iatio o+ t(" '"rvi&/ vagia ad v)lva s(o)ld !" $"r+or#"d ^ A ,3 to >3a'"ti' a'id sol)tio is li!"rally a$$li"d to t(" '"rvi& )sig soa?"d sa$ :T(" a!or#al digs ar" a'"to(it" "$it("li)# ad a!or#al vas')lar $att"rs 7#osai'is# ad $)'t)atio8 ^ )golKs iodi" a$$li'atio to t(" '"rvi& is 'all"d s(ill"rKs t"st :Nor#al "'to'"rvi& ad vagial s;)a#o)s "$it("li)# 'otais gly'og" ad stais #a(ogay:!ro ^ :Nor#al 'ol)#ar ad s;)a#o)s #"ta$lasia ad "o$lasti' "$it("li)# do ot 'otai
gly'og"/ ad a$$"ar #)stard y"llo ^ Satis+a'tory 6ol$os'o$i' E&a#iatio4 I+ t(" " S6\ ad t(" "tir" T] ar" s"" $,aluation o+ a patient with an abnormal Pap smear
Ay $ati"t it( a grossly a!or#al '"rvi& s(o)ld (av" a $)'( !io$sy $"r+or#"d r"gardl"ss o+ t(" r"s)lts o+ Pa$ s#"ar ^ Pati"ts it( AS6US +o)d i t("ir s#"ar #ay (av" a r"$"at s#"ar i #ot(s or HP@ t"stig ^ A!o)t :123 o+ $ati"ts it( a AS6US s#"ar ill (av" (ig(: grad" 6IN o 'ol$os'o$y/ 23 o+ t("s" 'a !" d"t"'t"d !y HP@ t"stig +or (ig(:ris? ty$"s ^ T(" 'ol$os'o$i' (all#ar? o+ 6IN is a ar"a o+ s(ar$ly d"li"at"d a'"to(it" "$it("il)#/ or-ad a!or#al vas')lar $att"r4 $)'t)atio ad #osai'is#
•
I+ 'ol$os'o$i' "&a#iatio is satis+a'tory/ $)'( !io$sy +ro# t(" s)s$i'io)s ar"a it( "d '"rvi'al ')r"ttag" s$"'i#" ^ Diagosti' 'o" !io$sy o+ t(" '"rvi& is idi'at"d i+4 1. 'ol$os'o$i' "&a#iatio is )satis+a'tory %. Edo'"rvi'al ')r"ttigs s(o a (ig(:grad" l"sio ,. Pa$ s#"ar s(os a (ig(:grad" l"sio t(at is ot 'or#"d o $)'( !io$sy 9. Pa$ s#"ar idi'at"s Ad"o'ar'io#a i sit) >. Mi'roivasio is $r"s"t o $)'( !io$sy
^ Mi'ro ivasiv" 'ar'io#a4 "&tr"#"ly irr"g)lar $)'at" ad #osai' $att"rs ar" +o)d
"reatment o+ intraepithelial neoplasia CI% •
•
o grad" l"sios 76IN18 r"$"at s#"ar i #ot( it"rval )til or#al t(" !a'? to t(" or#al s'r""ig $rogra# Hig( grad" l"sios 76IN %/,84
9. El"'tro'oag)latio/ R";)ir"s g""ral a"st("sia/ '"rvi'al st"osis #ay o'')r/ s)''"ss rat"s )$ to 3.
1. oo$ E&'isio o+ T(" Tras+or#atio ]o" 7ET]8/r"lativ"ly '("a$/ it 'a !" $"r+or#"d o a o)t$ati"t !asis )d"r lo'al a"st("sia/ ad tiss)" is o!tai"d +or (istologi' "val)atio.
>. 6"rvi'al 'oi*atio4 7'old ?i+" or las"r8 :#aily diagosti' !)t it #ay !" )s"d +or tr"at#"t/ ')r" rat"s ar" as (ig( as it( (yst"r"'to#y +or (ig( grad" l"sios.
%. ASER/ d"str)'tio o+ t(" T] !y 6O% las"r/ a!latio 'a !" $"r+or#"d as a o)t$ati"t $ro'"d)r" it( lo'al aa"st("sia/ "&$"siv".
:Maor 'o#$li'atios4 Bl""dig/ i+"'tio/ '"rvi'al st"osis ad i'o#$"t"'".
,. 6ryos)rg"ry/ r"lativ"ly $ail"ss o)t$ati"t $ro'"d)r" it(o)t aa"st("sia/ '("a$/ (ig( +ail)r" rat" +or larg" l"sios/ 'o$io)s vagial dis'(arg" +or s"v"ral ""?s.
^ Si#$l" (yst"r"'to#y is rar"ly "'"ssary/ it #ay !" a$$li'a!l" (" st"rili*atio is d"sir"d i a $ati"t it( 6IN III or (" t("r" is 'o'o#itat )t"ri" or ad"&al dis"as".
C$#&ICA CA%C$# •
•
• •
•
orldid"/ '"rvi'al 'a'"r is t(" #ost 'o##o 'a)s" o+ d"at( +ro# 'a'"r i o#". I d"v"lo$"d 'o)tri"s/ r"g)lar s'r""ig it( Pa$ s#"ar (as #ar?"dly d"'r"as"d t(" i'id"'" o+ t(" dis"as". I US/ '"rvi'al 'a'"r o ra?s oly "l"v"t( a#og 'a'"rs i o#". T(" #"a ag" +or '"rvi'al 'a'"r is >1.9 y"ars/ it( t(" )#!"r o+ $ati"ts +airly "v"ly divid"d !"t"" t(" ag" gro)$s ,2 to , ad 2 to y"ars T(" #ost 'o##o ty$" is S66 )$ to J23/ ad"o'ar'io#a ad ad"os;)a#o)s a''o)t +or %23 to %>3/ ot("r '"ll ty$"s ar" rar".
'ymptoms
Physical 0ndins
1. A!or#al vagial !l""dig is t(" #ost 'o##o $r"s"tig sy#$to#. %. Post'oital !l""dig i s"&)ally a'tiv" o#"/ IMB/ ad PMB ,. Asy#$to#ati' )til ;)it" adva'"d i o#" (o ar" ot s"&)ally a'tiv" 7)li?" "do#"trial 'a'"r (o !l""d "arly8 9. P"rsist"t vagial dis'(arg"/ $"lvi' $ai/ l"g s"llig/ ad )riary +r";)"'y ar" )s)ally s"" it( adva'"d dis"as" >. @"si'o:vagial-r"'to:vagial sy#$to#s
1. Us)ally or#al g""ral "&a#iatio %. I adva'"d dis"as"/ "larg"d ig)ial or s)$ra'lavi')lar ly#$( od"s/ "d"#a o+ t(" l"gs/ as'it"s/ $l")ral ")sio or ("$ato#"galy. ,. T(" Pa$ s#"ar #ay !" or#al i )$ to >23 o+ 'as"s 7+als": "gativ" rat"8 9. P"lvi' "&a#iatio i "arly dis"as" #ay !" or#al/ "s$"'ially i+ t(" l"sio is "do'"rvi'al. >. @isi!l" dis"as" #ay !"/ )l'"rativ"/ "&o$(yti' or"'roti'
C$#&ICA CA%C$# Pattern o+ spread
In,estiations
1.Dir"'t ivasio ito t(" '"rvi'al stro#a/ 'or$)s/ vagia/ ad $ara#"tri)#
1. %. ,. 9. >. .
%. y#$(ati' $"r#"atio ad #"tastasis
6B6/ FT/ FT 6("st :ray P"lvi':a!do#ial 6T S'a Bio$sy o+ t(" l"sio 6ystos'o$y ad $ro'tos'o$y +or 'lii'al stagig PET S'a 7$ositro:"#issio to#ogra$(y8 " t"'(i;)" (as t(" $ot"tial #or" a'')rat"ly to d"li"at" t(" "&t"t o+ dis"as" at t(" $ri#ary sit" ad i ly#$( od"s.
,. H"#atog"o)s diss"#iatio "reatment 'tae IA ( 1icro in,asi,e carcinoma)
'tae 2
#adiation "herapy
^ A $r"o$"rativ" diagosis 'a !" #ad" oly o t(" !asis o+ a 'o" !io$sy o+ t(" '"rvi&
May !" tr"at"d !y "it("r radi'al (yst"r"'to#y ad !ilat"ral $"lvi' ly#$(ad""'to#y or radiatio t("ra$y.
•
Stag" 1A1 4
^ T(" r"s)lts o+ tr"at#"t !y "it("r #"t(od ar" si#ilar.
^ Total a!do#ial - vagial (yst"r"'to#y ^ 6o" !io$sy alo" #ay s)L'" i+ t(" $ati"t d"sir"s to $r"s"rv" ("r +"rtility/ as log as t(" 'o" #argis ar" +r"" o+ dis"as" ad t(" "do'"rvi'al ')r"ttig ar"
^ T(" advatag"s o+ s)rg"ry is t(at t(" ovari"s #ay !" s$ar"d i yo)g o#"/ s)rgi'al stagig #ay !" 'arri"d o)t/ ad '(roi' radiatio t("ra$y #ay !" avoid"d. ^ Radi'al Hyst"r"'to#y4 R"#oval o+ t(" )t"r)s alog it( t(" ada'"t $ortios o+
For $ati"ts it( stag" 1!%/ #ost '"t"rs )s" $ri#ary '("#o radiatio/ )sig ""?ly 'is$lati as t(" radiatio s"siti*"r • T("ra$y )s)ally !"gis it( "&t"ral radiatio to s(ri? t(" '"tral t)#or ad s)!s";)"t itra'avitary t("ra$y. • E&t"ral radiot("ra$y #ay also !" )s"d $osto$"rativ"ly +or $ati"ts it( ly#$( od" #"ts/ or iad";)at" s)rgi'al #argis • T(" additio o+ '("#ot("ra$y to radiot("ra$y (as !"" s(o to i#$rov" s)rvival.
"gativ".
t(" vagia/ 'ardial liga#"ts / )t"rosa'ral liga#"ts/ ad !ladd"r $illars.
•
^ Modi"d radi'al (yst"r"'to#y ad $"lvi' ly#$( od" diss"'tio.
^ T(" #ost 'o##o 'o#$li'atio o+ Rad-Hys is !ladd"r dys+)'tio/ 13 to %3 (av" $"r#a"t dys+)'tio.
•
^ I+ '(ild!"arig is d"sir"d/ larg": 'o" !io$sy or radi'al tra'("l"'to#y ad $"lvi' ly#$( od" diss"'tio #ay !" o"r"d
^ T(" #ost s"rio)s 'o#$li'atio o+ Rad-Hys is )r"t"ri' st)la or stri't)r"/ (i'( o'')rs i 13 to %3 o+ 'as"s
•
Stag" 1A%4
^ o"r li#! ly#$(od"#a/ 1>3 to %23 d)" to $"lvi' ly#$(ad""'to#y
C$#&ICA CA%C$# Complications o+ radiotherapy Acute
Chronic
•
Stag" IIa it( #ii#al ivolv"#"t o+ t(" vagial +ori&/ radi'al s)rg"ry or '("#o radiatio #ay !" "#$loy"d. Stag" IIa to stag" I@a4 P"lvi' '("#o radiatio is t(" tr"at#"t o+ '(oi'" Stag" I@! Palliativ" radiot("ra$y or $alliativ" '("#ot("ra$y
1. A')t" 'ystitis4 ("#at)ria/ )rg"'y ad +r";)"'y. %. Pro'tosig#oiditis4 #ai+"st"d as t""s#)s / diarr("a/ ad $assag" o+ !lood ad #)')s i t(" stool ,. Et"ritis4 #ai+"st"d !y a)s"a/ vo#itig/ diarr("a/ ad 'oli'?y a!do#ial $ai 9. Bo" #arro d"$r"ssio
•
Radiatio Et"ro$at(y4 1. Pro'tosig#oiditis4 $"lvi' $ai/ t""s#)s/ diarr("a/ ad r"'tal !l""dig %. Ul'"ratio4 #ai+"st"d !y r"'tal !l""dig ad t""s#)s ,. R"'tovagial st)la4 #ai+"st"d !y $assag" o+ stool t(ro)g( t(" vagia 9. R"'t)# or sig#oid st"osis #ai+"st"d !y $rogr"ssiv"
•
@agial va)lt "'rosis4 asso'iat"d it( s"v"r" $ai ad t"d"r"ss o+ t(" vagial va)lt ad a $ro+)s" dis'(arg". •
Urologi' I)ri"s4 1. H"#orr(agi' 'ystitis (i'( #ay ""d +r";)"t !lood tras+)sio ad )riary div"rsio %. @"si'ovagial st)la #ai+"st"d !y t(" 'ostat
larg" !o"l o!str)'tio
l"a?ag" o+ )ri" d"#ostra!l" !y 'ystos'o$y
>. S#all !o"l i)ry )s)ally $r"s"t it( 'ra#$ig
,. Ur"t"rovagial st)la (i'( is #ai+"st"d !y
a!do#ial $ai ad vo#itig it( alt"ratig diarr("a
'ostat l"a?ag" o+ )ri" ad is d"#ostra!l" !y I@U
ad 'osti$atio
9. Ur"t"ri' st"osis (i'( is #ai+"st"d !y $rogr"ssiv" (ydro"$(rosis.
#ecurrent or 1etastatic !isease
Pronosis
•
• •
•
6("#ot("ra$y4 t(" ""'tiv""ss is li#it"d/ t(" #ost a'tiv" dr)g is t(" 'is$lati P"lvi' "&"t"ratio4 R"s"rv"d +or $ati"ts (o (av" '"tral r"')rr"'" +olloig irradiatio.
•
Progosis is dir"'tly r"lat"d to 'lii'al stag" it( (ig("r stag" / t(" +r";)"'y o+ odal #"ts "s'alat"/ ad t(" >:y"ar s)rvival rat" di#ii s("s. Ad"o'ar'io#a ad ad"os;)a#o)s 'ar'io#a (av" a
• Total "&"t"ratio ivolv"s r"#oval o+ t(" $"lvi'
•
•
• • •
• • •
• • •
vis'"ra/ i'l)dig t(" )t"r)s/ t)!"s/ ovari"s/ !ladd"r ad r"'t)# Radiot("ra$y i+ t(" iitial dis"as" tr"at"d it( s)rg"ry alo"
so#"(at lo"r >:y"ar s)rvival rat" t(a do S66/ stag" +or stag"
PHYSIOOGI6A 6HANGES IN 6OAGUATION 5 FIBRINOOYTI6S SYSTEMS IN PREGNAN6Y 6oag)latio syst"# 4 I'r"as" i l"v"ls o+ 'oag)latio +a'tors/ – T(" r"s)lt o+ t("s" '(ag"s is (y$"r'oag)la!l" #aily !riog" ad +a'tor @II/ @III/ I ad < +ro# t(" stat" i $r"ga'y !"giig o+ t(" s"'od tri#"st"r. – T(" !""t o+ t("s" '(ag"s is $rot"'tio o+ Fi!riolyti' syst"# 4 I(i!itio o+ t(" syst"#/ d)" to i'r"as" i #ot("r +ro# s"v"r" (a"#orr(ag" a+t"r d"liv"ry t(" l"v"ls o+ $las#iog" i(i!itors. – T(" ris? o+ t("s" '(ag"s is t(" i'r"as"d ris? o+ Plat"l"t 'o)t 4 No '(ag" t(ro#!o"#!olis# Ati'oag)lat syst"# 4 _ l"v"ls o+ ati:t(ro#!i III/ o '(ag" i t(" l"v"ls o+ $rot"i 6 5 S DISSEMINATED INTRA@AS6UAR 6OAGUOPATHY MAIN 6AUSES IN DIAGNOSIS MANAGEMENT PREGNAN6Y Pla'"tal a!r)$tio • 6lii'al o!s"rvatio Is"rtio o+ at l"ast % larg" i+)sio li"s < • Pr""'la#$sia 5 S"d at l"ast %2#l o+ !lood +or 'ross:#at'(ig – @agial !l""dig/ oo*ig +ro# "'la#$sia v""$)'t)r" sit"s 5 s)rgi'al i'isios. 5 'oag)latio $rol"/ ad r";)"st at l"ast )its o+ !lood 5 9 )its o+ FFP. Edoto&i' s(o'? < – History o+ ay o+ t(" a!ov" ris? +a'tors. s"$ti' a!ortio/ (ol" !lood 'lottig ti#" < $rolog"d 6orr"'t (y$ovola"#ia < !y C)ids 5 (ol" • • '(orioa#ioitis 7 Nor#al >:12 #i)t"s8 !lood ad $)"r$"ral 6orr"'t 'oag)latio disord"r < !y FFP • 6oag)latio $rol" 4 • s"$sis %:- $lat"l"t tras+)sio oly idi'at"d i – Plat"l"t 'o)t < r"d)'"d 7Nor#al A#ioti' C)id $r"s"'" o+ a'tiv" !l""dig i+ $lat"l"t 'o)t is 1>2/222 < ,>2/2228 "#!olis# l"ss t(a >2/222 / ad i+ o a'tiv" !l""dig/ i+ – Fi!riog" l"v"l < r"d)'"d 7 Nor#al %:9 Prolog"d s(o'? $lat"l"t 'o)t l"ss t(a %2/222. g#-8 Prolog"d r"t"tio E#$ty t(" )t"r)s as ra$idly as $ossi!l" < !y • – APTT < $rolog"d 7Nor#al ,>:9, o+ d"ad +"t)s < d"liv"ry or D56. s"'ods8 %- DI6 is alays a %ry $("o#"o to a #iss"d a!ortio or – PT < $rolog"d 7Nor#al 12:19 s"'ods8 )d"rlyig sti#)l)s/ ad is )s)ally s"l+:li#itig i+ IUFD +or 0> ""?s – TT < $rolog"d 7Nor#al 12 s"'ods8
–
FDPs l"v"ls < i'r"as"d
t(" sti#)l)s $rod)'ig it is r"#ov"d < t("r"+or" t(" )t"r)s s(o)ld !" "#$ti"d as ra$idly as $ossi!l"
THROMBOEMBOISM RIS FA6TORS • Pr"ga'y < (y$"r'oag)lat" stat" . • Mat"ral ag" 0 ,> y"ars. • Parity 0 9 • O!"sity 0 J2 ?g. • 6a"sar"a s"'tio/ $arti')larly "#"rg"'y 6.S • Pr"vio)s (istory o+ t(ro#!o"#!olis# Vt(" ris? o+ r"')rr"'" o+ t(ro#!o"#!olis# is 1%3/ 5 t(" #aority o'')r a+t"r d"liv"ry . • Prolog"d (os$ital stay. • Fa#ily (istory o+ t(ro#!o"#!olis#. • T(ro#!o$(ilia i". 6og"ital d"'i"'y o+ atit(ro#!i III/ $rot"i 6 or $rot"i S/ 5 $r"s"'" o+ +a'tor @ l"id". • Ati < 'ardioli$i sydro#" or $r"s"'" o+ l)$)s i(i!itor • 6ardia' dis"as" < s)'( as valv)lar $rost("sis or atrial !rillatio. • Si'?l" '"ll dis"as". • Gross vari'os" v"is. • Blood gro)$s ot("r t(a O • S)$$r"ssio o+ la'tatio it( "strog"
DIAGNOSIS D@T 1: S&4 Pai 5 s"llig i t(" l"g %: Sigs4 ↑t"#$ o+ t(" l"g/ t"d"r 'al+ #)s'l"s/ a di"r"'" o+ 0%'# i t(" 'ir')#+"r"'" at id"ti'al sit"s o+ l"gs/ ad =v" Ho#as sig. Vi >23 o+ $ati"ts t("r" ar" o 'lii'al sy#$to#s 5 sigs r"+"ra!l" to t(" li#!s 5 $)l#oary "#!olis# #ay !" t(" 1st idi'atio o+ t(ro#!o"#!olis# . VOv"r J23 o+ D@T ar" l"+t:sid"d. ,:Iv"stigatios 4 I. Do$$l"r U-S < Noivasiv"/ sa+"/ a'')rat" i >3/ #or" a'')rat" i+ D@T a!ov" t(" ?"" d)" to a!s"'" o+ 'ollat"rals t(a i+ D@T !"lo t(" ?"" d)" to $r"s"'" o+ 'ollat"rals. II. As'"dig v"ogra$(y < 6otraidi'at"d i t(" 1st tri#"st"r/ ad #ay!" idi'at"d a+t"r t(at i+ Do$$l"r U-S is ot i+or#ativ".
PE VT("r" #ay !" 7>238 or #ay !" ot 7>238 $rior 'lii'al "vid"'" o+ D@T. 1. S&4 S)dd" os"t o+ dys$o"a/ '("st $ai/ 'o)g( 5 (a"#o$tysis/ ad s)dd" 'olla$s" i #assiv" PE %. Sigs4 6yaosis/ ra$id !r"at(ig 5 )g)lar v"is dist"tio. ,. Iv"stigatios4 • 6R4 May !" ("l$+)l i". 6osolidatio/ i+ar'tio 5 "l"vat"d ("#idia$(rag# o a"'t"d sid"/ !)t 'a !" totally or#al. • E6G4 Us)ally or#al "&'"$t (" t(" "#!ol)s is larg". • R"s$iratory al?alosis ad lo P'o% : d)" to (y$o&ia ` (y$"rv"tilatio it( !loig o o+ 6O% ad r"s$iratory al?alosis. • @"tilatio 5 $"r+)sio l)g s'a • P)l#oary agiogra$(y.
ANTI6OAGUANTS HMH HEPARIN ORA ARFARIN Z Hig( #ol"')lar "ig(t ("$ari T(" dos" is %.>:> #g-ti'" daily Moitor"d !y It"ratioal Nor#ali*"d • Rar"ly )s"d 7 i+ MH is ot Ratio i". INR 7(i'( s(o)ld !" aro)d availa!l" 8. % 8 5 !y PT 7(i'( s(o)ld !" %:%.> • Giv" !y I.@ ro)t". T(" t("ra$")ti' ti#"s o+ 'otrol.8 dos" is 12/222 )its !ol)s dos" / MOA4 I(i!itio o+ t(" syt("sis o+ @it: +ollo"d !y %9/222 )its - day/ d"$"d"t +a'tors4 II/ @II/ I 5 . giv" via i+)sio $)#$. Disadvatag"s o+ ar+ari ar"4 • Moitor"d t("ra$")ti' dos" 71#g-?g-day %&-day8 !y APTT s(o)ld !" % ti#"s 1. Bl""dig o+ 'otrol. %. T"ratog"i' : i+ giv" i 1st tri#"st"r • Moitor #ait"a'" 792#g-#l 1&-day8 5 $ro$(yla'ti' 7%2:92#g-#l 1&-day8 d)rig t(" $"riod o+ orgaog""sis 'o* dos" !y $las#a ("$ari l"v"l s(o)ld !" 2.%:2.9 )its-#l. • T(" a'tio o+ t("ra$")ti' ("$ari is i(i!itio o+ t(ro#!i 5 +a'tors I/ / I 5 ar+ari 'ross t(" $la'"ta4 '(odrodys$lasia $)'tata/ '"r"!ral II. (a"#orr(ag"/ 'al'i'atio 5 • H"$ari DONT 'ross t(" $la'"tal !arri"r 5 so 'a !" )s"d sa+"ly d)rig #i'ro'"$(aly. $r"ga'y ,. F"tal 5 N"oatal '"r"!ral • T(" sid" ""'t is !l""dig. (a"#orr(ag" i+ giv" a+t"r , ""?s. • I+ !l""dig o'')r/ sto$ t(" tr"at#"t/ ad i $ra'ti'" t(is is "o)g(. Rar"ly i+ 9. E"'t ot "asily or ra$idly r"v"rs"d !l""dig ot sto$$"d/ giv" s$"'i' atidot" i". Prota#i" s)l$(at". as ar+ari disa$$"ars +ro# t(" T(" advatag"s o+ ("$ari < 'o#$ar"d to ar+ari : ar"4: 'ir')latio i , days. 1. Do"s ot 'ross t(" $la'"ta • I 'as" o+ !l""dig/ atidot" is FFP. %. S#all dos" $ro$(yla&is: o (a"#orr(agi' (a*ard VN"it("r ("$ari or ar+ari ar" ,. Easily ad ra$idly r"v"rs"d as ("$ari disa$$"ars +ro# t(" 'ir')latio i "&'r"t"d i !r"ast #il?/ so t(at t("y ar" (o)rs. sa+" to !" )s"d d)rig la'tatio. T(" disadvatag"s4: 1. Ost"o$orosis i+ giv" +or #or" t(a #ot(s %. T(ro#!o'yto$"ia. MH HEPARIN o #ol"')lar "ig(t ("$ari 7MH8 ".g Eo&a$ari sodi)# 76l"&a"8. • T(" $r"+"rr"d ty$" )s"d o. • Giv" !y S.6 ro)t". T(" t("ra$")ti' dos" is % #g-?g-day/ giv" i to divid"d dos"s.
MEDI6A TREATMENT OF THROMBOEMBOISM A6UTE PHASE T("ra$")ti' dos" o+ ("$ari. Eit("r MH or HMH. MHKs d)ratio o+ a')t" $(as" t("ra$y % < , #ot(s. MH 76l"&a"8 HMH T(" t("ra$")ti' dos" is % #g-?g-day/ giv" i to T(" t("ra$")ti' dos" is 12/222 )its !ol)s dos"/ +ollo"d !y divid"d dos"s %9/222 )its - day/ giv" via i+)sio $)#$. ONG TERM THERAPY Eit("r MH 7S-68 ("$ari or Oral ar+ari : I+ t(ro#!o"#!olis# o'')rs d)rig $r"ga'y < t(" !"st a+t"r a')t" $(as" t("ra$y +or %:, #ot(s/ is to giv" S-6 ("$ari i t(" #ait"a'" dos" +or t(" r"st o+ $r"ga'y 7 i ord"r to avoi d sid" ""'ts o+ ar+ari d)rig $r"ga'y8 5 +or 1% ""?s $ost$art)# o+ "it("r S-6 ("$ari or ar+ari. : I+ t(ro#!o"#!olis# o'')rs a+t"r d"liv"ry < S-6 ("$ari i t("ra$")ti' dos" +or 9 ""?s/ t(" "it("r S-6 ("$ari i #ait"a'" dos" or oral ar+ari / +or , #ot(s. HEPARIN ARFARIN Giv" !y S6 ro)t". T(" !"st is MH/ i+ ot availa!l"/ HMH. Giv" orally. Dos" o+ MH 76l"&a"8 92#g- 1&-day. HMH >222IU %&-day. Dos" is %.>:>#g %&-day Moitor"d !y $las#a ("$ari l"v"l s(o)ld !" !"t"" 2.%:2.9 )its-#l. VMoitorig o+ #ait"a'" or $ro$(yla'ti' dos" o+ S6 ("$ari !y APTT is o+ o val)"/ 'o* #ait"a'" 5 $ro$(yla'ti' dos" do"sKt _ l"v"l o+ 'oag)latio +a'tors 5 so do"sKt 'a)s" $rologatio o+ 'lottig ti#".
1. %. ,. 9.
6OUNSEING AFTER AN ATTA6 OF THROMBOEMBO DURING PREGNAN6Y E&$lai t(" ris? o+ r"')rr"'" i +)t)r" $r"ga'i"s< (i'( is a!o)t 1% 3 E&$lai t(" ""d +or $ro$(yla'ti' ati'oag)latts i +)t)r" $r"ga'i"s Avoid t(" )s" o+ 'o#!i"d 'otra'"$tiv" $ill. 6osid"r s'r""ig +or t(ro#!o$(ilia < i a!s"'" o+ ot("r ris? +a'tors POI6Y OF PROPHYAIS
No (&. Did ':s"'tio. it( 1 ris? +a'tor. 1 (& o+ D@T No ris? +a'tor.
D"liv"ry
1? $ost$art)#
D"liv"ry 1 (& o+ D@T. Ot("r ris? +a'tor 7".g. ad#itt"d to (os$ital8
Ad#issio
D"liv"ry
? $ost$art)# ?s $ost$art)#
H& o+ %D@T or 1PE or ati'ardioli$i or l)$)s i(i!itors $r"s"'" or 'ardia' Pr"gat D"liv"ry %#ot(s idi'atio +or $ro$(yla'ti' $ost$art)# ati'oag)lats 7"g AF/ valv)lar $rost("sis8 VT(" $oli'y o+ $ro$(yla'ti' ati'oag)lat d)rig $r"ga'y i $r"vio)s (istory o+ $)l#oary "#!olis# or D@T or t(ro#!o$(ilia is !y MH < o'" daily t(ro)g(o)t $r"ga'y )$ to 1% (o)rs !"+or" d"liv"ry . VT(" $oli'y o+ $ro$(yla'ti' ati'oag)lat d)rig $r"ga'y i 'ardia' idi'atio 4 ar+ari i t(" 1st tri#"st"r 5 )$ to , ""?s ad t(" !y HMH/ I.@/ 222 )its-(rs )$ to 1% (o)rs !"+or" d"liv"ry. 3S-6 ("$ari is ot ""'tiv" i $r"v"tio o+ 'ardia' t(ro#!osis/ ad so ar+ari giv" i t(" 1st tri#"st"r i s$it" o+ itKs ?o t"ratog"i' ""'ts. 6ASSIFI6ATION
DIABETES IN PREGNAN6Y DIABETOGENI6 DEFINITIONS
PRESENTATION
Dia!"t"s #"llit)s ty$" I ::: is)li d"$"d"t 7"tosis: $ro"8 Dia!"t"s #"llit)s ty$" II::: • o:is)li d"$"d"t 7"tosis:r"sistat8 I#$air"d Gl)'os" Tol"ra'" • ad G"statioal Dia!"t"s 7IGT8 S6REENING (y. ,23 (av" o" o+ t(" • A!ov" ris? +a'tors Not all DM/ IGT/ (av" • $"rsist"t gl)'os)ria >23 o+ $r"gat o#" • (av" gl)'os)ria at so#" ti#" •
EFFE6TS OF PREGNAN6Y Is)li r"sista'" DM Fastig v"o)s gl)'os" • I'r"as"d li$olysis 'o'"tratio 0 J.2 ##ol-l ad % (rs 7> g# load 8 0 11.2 ##ol-l Alt"r"d #at"ral 7or8 o" o+ t(" a!ov" = Sy#$to#s gl)'o"og""sis IGT Fastig J.22 ##ol-l/ !)t % • (r 7> g# load8 7.2:12.8
• • •
• • • • • • • •
MATERNA O!st"tri'4 Poly(ydra#ios/ • $r":"'la#$sia 712:1>38 Dia!"ti' E#"rg"'i"s4 • Hy$ogly'a"#ia/ "toa'idosis/ Dia!"ti' 'o#a @as')lar 5 Ed:Orgas4 • R"al/ O$(t(al#i'/ P"ri$("ral vas')lar N")rologi'4 P"ri$("ral • ")ro$at(y GI dist)r!a'"
:Sy#$to#s :Ris? +a'tors 7(& 5 "&a#iatio8 :Blood t"sts:: s'r""ig
RIS FA6TORS Ag" 0 ,2 Fa#ily (istory o+ DM Past (istory o+4 Dia!"t"s i a $r"vio)s $r"ga'y/ U"&$lai"d IUFD/ N"oatal d"at(/ 6og"ital a!or#aliti"s/ R"')rr"t a!ortios/ arg" !a!i"s 0 2 t( '"til" O!"sity HTN i #)lti$ara Poly(ydra#ios R"')rr"t i+"'tios4 Uriary/ F)gal Sigi'at Gly'os)ria
6OMPI6ATIONS FETA 718 Ma'roso#ia 5 Tra)#ati' d"liv"ry 7,23 i s""#igly 'otroll"d8 7%8 D"lay"d orga #at)rity 7RDS8 ti#"s 7,8 6og"ital #al+or#atios4 • 6ardiovas')lar4 Tras$ositio o+ gr"at v"ss"ls/ @SD/ ASD/ Aorti' 'oar'tatio • 6"tral N"rvo)s syst"#4 A"'"$(aly/ Ho lo$ros"'"$(aly/ E'"$(alo'"l" • S?"l"tal 5 s$ial : 6a)dal r"gr"ssio • G"ito)riary : R"al ag""sis/ )r"t"ral d)$li'tio • Gastroit"stial : aal atr"sia VV Not"4 (" a to:v"ss"l 'ord is +o)d/ s)s$"'t a (ig( i'id"'" o+
NEONATA Hy$ogly'a"# ia RDS Hy$o'al'a"# ia Poly'yt(a"#i a
•
I+"'tios4 Uriary
'og"ital ao#ali"s 798 Itra)t"ri" +"tal D"at( adva'"d DM8
7>8 Grot( r"stri'tio 7i
MANAGEMENT • •
Start i $r"'o'"$tio ti#" S$"'i' d)rig $r"ga'y SPE6IFI6
Di"t4 1 & t. 7$o)ds 8 = ,22 6AORIES 6ar!o(ydrat"s 23 Fat %23 Prot"i %23 Is)li4 < R"gi#"t A V , ti#"s sol.:it( #"als = lt. Ev"ig Or : R"gi#"t B V % ty$"s 7s(ort 5 it"r#"diat"8 Ti'" Daily Dos" 7daily8 t. 7?g8 & 2. rst & 2. s"'od & 2.J t(ird %-, i A.M. %-, 1t = 1-, s(ort 1-, i P.M. 1-% 1t = b s(ort.
6ONTRO 6otrol 4 Fastig >.2 ##ol-1 • % (rs P.P. .2 ##ol-1 • Ad)st#"t (" "'"ssary • Gly'osylat"d H! A1' 7r"tros$"'tiv"8 • F"tal "ll !"ig4 AFP 1:1J ?s • D"tail"d s'a 1:%2 ?s • Bio$(ysi'al assay +ro# %J ?s • F"tal t. 5 grot( to ""?ly 7, rd8 • D"liv"ry4 : Ti#ig d"$"ds o4 7Aro)d ,J ?s8 Mat"ral +a'tors • Bio'("#i'al 'otrol • F"tal stat)s • : M"t(od ::: S6S i ay #"di'al or o!st"tri' 'o#$li'atio. VVIs)li dos" ad)st"d o (o)rly !asis it( 'alori' r";)ir"#"ts itrav"o)sly.
!#U4' I% P#$4%A%C5 $pidemioloy
I $r"ga'y/ it is "sti#at"d t(at "a'( o#a ta?"s 1:, dr)gs !"sid" vita#i s)$$l"#"ts or iro
1aternal Pharmaco*inetics
6(ag"s i !ody C)id vol)#". 6(ag"s i 6@S $ara#"t"rs. 6(ag"s i
etal pharmaco*inetics
Plas#a !idig $rot"is di"r +ro# #at"ral so +r"" +ra'tios o+ !asi' dr)gs ar" "l"vat"d. iv"r "&$r"ss"s
Placental pharmaco*inetics
Blood Co t(ro)g( t(" $la'"ta 7#at"ral sid"8 i'r"as"s d)rig g"statio 7>2 #l-#i at 12 ""?s o+ $r"ga'y to 22 #l-#i at ,J ""?s8
A!o)t 1-, o+ o#" i t(" U ta?" dr)gs at l"ast o'" d)rig $r"ga'y. Oly 3 ta?" a dr)g d)rig t(" rst tri#"st"r. T("r" (as !"" a 'osid"ra!l" r"d)'tio i dr)gs )s"d i $r"ga'y si'" t(" #id:12s 000 S"l+:ad#iist"r"d dr)gs +ro# 93 to 3
$)l#oary +)'tios. Alt"ratio i gastri' a'tivity. 6(ag"s i s"r)# !idig $rot"i 'o'"tratios. Alt"ratio i ?id"y +)'tio
!ru trans+er
Most dr)gs (av" a #ol"')lar "ig(t !"lo 1222 Daltos. Dr)gs l"ss t(a 122o Daltos 'ross t(" $la'"ta7l"ss t(a 22 Daltos 'ross "asily8 Mai d"t"r#iat o+ t(" dr)g 'o'"tratio i t(" E#!ryo-F"t)s is t(" #ot("rKs !lood 'o'"tratio. Ot("r +a'tors4 0i$id sol)!ility ad $rot"i !idig. 0 D"gr"" o+ ioi*atio at $(ysiologi' $H. 0$la'"tal !lood Co ad s)r+a'" ar"a availa!l" +or tras+"r.
#"ta!oli*ig "*y#"s/ !)t 'a$a'ity l"ss t(a t(" #ot("r. Dr)gs tras+"rr"d a'ross t(" $la'"ta )d"rgo 1 st $ass ("$ati' ""'t t(ro)g( t(" +"tal liv"r. F"tal ?id"ys ar" still i##at)r". F"tal )ri" "t"rs a#ioti' C)id (i'( #ay !" sallo"d !y t(" +"t)s.
6o#$o)ds t(at alt"r !lood Co alt"r #at"ral dr)g dis$ositio ad $la'"tal tras+"r. Pla'"tal #"ta!olis# 7d"al?ylatio/ (ydro&ylatio/ d"#"t(ylatio8 a"'ts dr)gs tras+"r a'ross t(" $la'"ta. At t"r#/ t(" s)r+a'" ar"a o+ t(" $la'"ta is at its #a&i#)# ad "arly all s)!sta'"s 'a r"a'( t(" +"t)s.
T(" $ro'"ss"s t(at gov"r t(" $assag" Ty$" o+ ""'ts o t(" +"t)s4 Bar?"r (y$ot("sis4 o+ a dr)g ito #il? ar" si#ilar to T"ratog""'ity: r"adily d"t"'t"d at/ T(" thri+ty phenotype (y$ot("sis $la'"tal 'oditio4 or s(ortly a+t"r/ !irt( 7t(alido#id"8. says t(at r"d)'"d +"tal grot( is strogly asso'iat"d it( a )#!"r og t"r# lat"'y: 7 DES: i'r"as"d Mat"ral s"r)# 'o'"tratio is o+ '(roi' 'oditios lat"r i li+". ris? o+ vagial ad"o'ar'io#a a+t"r t(" #ai d"t"r#iat. T(is i'r"as"d s)s'"$ti!ility r"s)lts $)!"rty/ or a!or#aliti"s i T(" #il? $H is slig(tly a'idi' +ro# ada$tatios #ad" !y t(" +"t)s t"sti')lar +)'tio ad s"#" i 'o#$ariso to s"r)# $H i a "viro#"t li#it"d i its $rod)'tio8. so "a? !as"s 'o)ld !"'o#" s)$$ly o+ )tri"ts. T("s" '(roi' I#$air"d it"ll"'t)al or so'ial tra$$"d i #il? 7 io tra$$ig 8. 'oditios i'l)d" 'oroary ("art d"v"lo$#"t 7"&$os)r" to dis"as"/ stro?"/ dia!"t"s/ ad $("o!ar!ito" alt"rs $rogra##ig (y$"rt"sio o+ !rai8 Pr"dis$ositio to #"ta!oli' dis"as"s 7Bar?"r (y$ot("sis4 lo !irt( "ig(t is asso'iat"d it( i'r"as"d ris? o+ dia!"t"s/ (y$"rt"sio ad ("art dis"as" i ad)lt(ood8. "eratoenesis
1al+ormations
/ranoenesis
It is d""d as str)'t)ral or +)'tioal 7".g. r"al +ail)r"8 dysg""sis o+ t(" +"tal orgas. Ty$i'al #ai+"statios i'l)d"4 0'og"ital #al+or#atios it( varyig s"v"rity. 0IUGR. 06ar'iog""sis. 0+"tal d"#is". I ()#a/ t(" 'riti'al ti#" +or dr)g: id)'"d 'og"ital #al+or#atios is i t(" rst tri#"st"r. Dr)g:id)'"d to&i'ity 'a o'')r at ay ti#" d)rig g"statio.
T(" ov"rall i'id"'" o+4 0 Maor 'og"ital #al+or#atios is aro)d 7%:,83 0#ior #al+or#atios is 3 It (as !"" "sti#at"d t(at4 0%>3 ar" d)" to g""ti' or '(ro#oso#al a!or#aliti"s 0123 d)" to "viro#"tal 'a)s"s i'l)dig dr)gs. 0>3 o+ )?o "tiology. T(" $art $lay"d !y dr)gs is $ro!a!ly s#all.
T(" 'riti'al ti#" +or dr)g:id)'"d 'og"ital #al+or#atios is )s)ally t(" $"riod o+ orgaog""sis 00a!o)t %2 to >> days a+t"r 'o'"$tio. 00a!o)t ,9 to days 7>:12 ""?s8 a+t"r t(" rst day o+ t(" last #"str)al $"riod. It"r+"r"'" i t(is $ro'"ss 'a)s"s a t"ratog"i' ""'t. I+ a dr)g is giv" a+t"r t(is ti#" it ill ot $rod)'" a #aor aato#i'al d"+"'t/ !)t #or" o+ a +)'tioal o".
Prenancy #is* Cateories
T(" dr)gs ar" 'lassi"d a''ordig to t("ir ris? +a'tor 'at"gory/ ad t(" d"itios +or "a'( 'at"gory ar" )s"d !y t(" Food ad Dr)g Ad#iistratio 7FDA8 Cateory A •
•
18
%8 ,8 98
6otroll"d st)di"s i o#" +ail to d"#ostrat" a ris? to t(" +"t)s i t(" rst tri#"st"r/ t("r" is o "vid"'" o+ a ris? i lat"r tri#"st"rs/ ad a r"#ot" $ossi!ility o+ +"tal (ar# T(" oly +" #"di'atios 'lassi"d as 'at"gory A ar"4 Ea'( o+ t(" vita#is (" )s"d i t(" r"'o##"d"d dos"s 7RDA8 "vot(yro&i" Ati"#"ti' do&yla#i" El"'trolyt"s $otassi)# 'itrat"/ $otassi)# '(lorid"/ ad $otassi)#
Cateory •
•
•
Ai#al r"$rod)'tio st)di"s (av" +ail"d to d"#ostrat" a ris? to t(" +"t)s ad t("r" ar" o ad";)at" ad "ll: 'otroll"d st)di"s i $r"gat o#" OR Ai#al st)di"s (av" s(o a adv"rs" ""'t/ !)t ad";)at" ad "ll: 'otroll"d st)di"s i $r"gat o#" (av" +ail"d to d"#ostrat" a ris? to t(" +"t)s i ay tri#"st"r The classical example is paracetamol
Cateory C •
•
Ai#al r"$rod)'tio st)di"s (av" s(o a adv"rs" ""'t o t(" +"t)s ad t("r" ar" o ad";)at" ad "ll:'otroll"d st)di"s i ()#as/ !)t $ot"tial !""ts #ay arrat )s" o+ t(" dr)g i $r"gat o#" d"s$it" $ot"tial ris?s These drugs should only be given if the potential benet justies the potential risk to the fetus
Cateory ! •
•
•
T("r" is $ositiv" "vid"'" o+ ()#a +"tal ris? !as"d o adv"rs" r"a'tio data +ro# iv"stigatioal or #ar?"tig "&$"ri"'" or st)di"s i ()#as/ !)t $ot"tial !""ts #ay arrat )s" o+ t(" dr)g i $r"gat o#" d"s$it" $ot"tial ris?s T(" !""ts +ro# )s" i $r"gat o#" #ay !" a''"$ta!l"/ as i+ t(" dr)g is ""d"d i a li+": t(r"at"ig sit)atio or +or s"rio)s dis"as"s +or (i'( sa+"r dr)gs ar" i""'tiv" or 'aot !" )s"d E&a#$l"s i'l)d" A6E i(i!itors ad dia*"$a#
Cateory 6 •
St)di"s i ai#als or ()#as (av" d"#ostrat"d +"tal a!or#aliti"s or t("r" is "vid"'" o+ +"tal ris? !as"d o ()#a "&$"ri"'"/ ad t(" ris? o+ t(" )s" o+ t(" dr)g i $r"gat o#" 'l"arly o)t"ig(s ay $ossi!l" !""t
These drugs are contraindicated in women who are or may become pregnant! • NEE EE "E#$%&E T'EM!! • Examples include statins and misoprostol •
gl)'oat"
!iethylstilbesterol (!$')
&itamin A analoues
•
•
•
•
•
Syt("ti' ost"roidal "strog" t(at as rst syt("si*"d i 1,J/ ad ')rr"tly it is 'lassi"d as 6at"gory dr)g It as $r"s'ri!"d d)rig 192:12 to $r"v"t #is'arriag"s i (ig( ris? $r"ga'i"s !y i'r"asig t(" l"v"l o+ "strog" ad $rog"st"ro" syt("sis !y t(" $la'"ta I 11/ it as dis'ov"r"d t(at o#" !"t"" 1:%2 y"ars old d"v"lo$"d vagial ad"o'ar'io#a/ t(at as li?"d to t("ir itra)t"ri" +"tal "&$os)r" A$$ro&i#at"ly 1 i 1222 $r"ga'i"s "r" "&$os"d/ ad >3 o+ (i'( r"s)lt"d i girls it( vagial ad '"rvi'al 'ar'io#as as "ll as )t"ri" ao#ali"s Mal" os$rig (ad a!or#al g"italia ad s$"r# d"+"'ts
• • •
• •
•
T(" #ost 'o##o is isotretinoin, )s"d +or t(" tr"at#"t o+ a'" 6lassi"d as 'at"gory T(" t"ratog"i' ""'ts o+ r"tioids o ai#als "r" ?o +or y"ars !"+or" t("ir 'lii'al )s" T(" 'riti'al "&$os)r" ti#" is !"t"" ,:> ""?s o+ $r"ga'y Contracepti,e measures are o+ at least one month be+ore7 durin treatment7 and no prenancy +or 8 years a+ter a course o+ the dru
F"tal a!or#aliti"s (av" ot !"" asso'iat"d it( to$i'al r"tioids !)t it is advis"d to avoid t("ir )s" i $r"ga'y
• • •
T"ratog"i' ""'ts ar" s"" i )$ to %>3 o+ !a!i"s >23 o+ a"'t"d '(ildr" (av" a I !"lo J> It as a$$ro&i#at"ly r"'ord"d t(at !"t"" 1J% ad 1J4 o o
o
())*+,)) malformed children -))*+))) spontaneous abortions .)))*-))) elective abortions
T(" "#!ryo$at(y i'l)d"s4
• o o o o o
$N# defects $raniofacial defects $ardiovascular defects Thymic defects Miscellaneous defects
"halidomide • • • •
It is o log"r )s"d as a ati"#"ti' It as )s"d i t(" $ast !y $r"gat o#" i t(" 1 st tri#"st"r (" t("y start (avig a)s"a ad vo#itig T(" #"'(ais# o+ a'tio is t(o)g(t to !" $artly d)" to atiagiog""sis F"tal "&$os)r" 'a)s"d (ig( rat"s o+ a!or#aliti"s 7%2:,238 t(at i'l)d"4 o o o o
•
#evere limb shortening defects /phocomelia0 1oss of hearing2 facial paralysis2 anotia2 microtia enal malformations $ongenital heart disease
It is o )s"d +or ot("r dis"as"s/ s)'( as dr)g:r"sistat #)lti$l" #y"lo#a/ ')ta"o)s l)$)s "ryt("#atosis/ "ryt("#a odos)# l"$ros)#/ B"('"tKs dis"as"/ ad a$osi sar'o#a 7'ar" #)st !" ""d"d i+ t(" $ati"t is a o#a i r"$rod)'tiv" ag" or li?"s to !"'o#" $r"gat8
Antibiotics
Class o+ 1edication
Cateory
Ati!ioti's
A*it(ro#y'i A*tr"oa#
Cateory C
Cateory !
• •
Gentamycin
Ba'itra'i Cephalosporin 6(lora#$("i'ol s 6larit(ro#y'i 6lav)laat" Da$so" 6lida#y'i Erythromycin Et(a#!)tol I#i$""#: M"ro$""# 'iliastati M"troida*ol" Isoia*id Nitrofurantoin i"*olid Penicillins Pyra*ia#id" Quinolones** Poly#y&i B S)l!a'ta# Ri+a#$i Ta*o!a'ta# S$"'tio#y'i @a'o#y'i S)l+oa#id"s
)ii" Streptomycin Tetracyclines
Trimethoprim
33 Althouh in cateory C7 i,e concern +or fuoro9uinoloneinduced +etal cartilae damae7 as most obstetricians a,oid their use in prenancy
• •
• •
T("y ar" t(" #ost 'o##oly $r"s'ri!"d dr)gs i $r"ga'y T(" sa+"st !"ig "enicillins 7B8 ad $ephalosporins 7B8 Trimethoprim 768 is a t("or"ti'al t"ratog" as it is a +oli' a'id atagoist 3minoglycosides 'a 'a)s" ototo&i'ity 7".g./ gentamyicn 768 ad streptomycin 7D88 Erythromycin 768 is $ro!a!ly sa+"/ !)t ot )s"d +ro# t(" start Tetracyclines 7D84 < #afe during the rst +4 weeks of pregnancy Minimal e5ect on bone but after 67 weeks of gestation2 discoloration of the teeth and enamel hypoplasia occur < Maternal hepatotoxicity in the form of acute fatty liver2 leading to death in some cases where pregnant women were treated with large doses < "regnancy is not terminated if the women was found to take them
<
• Tri#"t(o$ri# 76-D8 is a t("or"ti'al t"ratog" as it is a • • •
•
+oli' a'id atagoist T(" a#iogly'osid"s7D8 'a 'a)s" ototo&i'ity Eryt(ro#y'i 768 is $ro!a!ly sa+" M"troida*ol" 7B8 Is a t"ratog" i ai#als !)t t("r" is o "vid"'" o o+ t"ratog"i'ity i ()#as ad its !""t i s"rio)s aa"ro!i' s"$sis $ro!a!ly o)t"ig(s ay ris?s 6i$roCo&a'i 768 o R"s)lts idi'at" t(at #ay a"'t oits/ so 'a)tio ad s)gg"st t(" ""d +or #or" st)di"s
•
•
•
6(lora#$("i'ol 768 S(o)ld !" avoid"d i lat" $r"ga'y ad d)rig o la!o)r !"'a)s" o+ t(" $ot"tial +or t(" cgr"y sydro#" i t(" "!or i+at Nitro+)ratoi 7B8 o May !" ad#iist"r"d i $r"ga'y/ !)t s(o)ld !" avoid"d "ar t"r# #ay $r"dis$os" +"tal ("#olyti' a"#ia @a'o#y'i 7B8 Possi!l" +"tal ototo&i' ""'t ad s(o)ld !" o avoid"d )l"ss !""t o)t"ig(s $ot"tial ris?
Anti+unals •
•
Gris"o+)lvi 768 Is a ?o t"ratog" i la!oratory ai#als o o Has !" d"#ostrat"d to 'ross t(" ()#a $la'"ta o Is 'otraidi'at"d d)rig $r"ga'y o Pr"ga'y s(o)ld !" avoid"d +or 1 #ot( a+t"r tr"at#"t M" s(o)ld ot att"#$t to +at("r '(ildr" it(i o #ot(s o+ tr"at#"t "to'oa*ol" 768 I(i!its $la'"tal #i'roso#al aro#atas" ad o 'yto'(ro#" P9>2 o S(o)ld !" avoid"d d)rig $r"ga'y as t("r" is ot "o)g( i+or#atio to 'or# its sa+"ty
• Tria*ol"s:C)'oa*ol" ad itra'oa*ol" 768
I+ tr"at#"t o+ t("s" 'oditios is 'lii'ally idi'at"d/ ot("r sa+"r ati+)gal ag"ts s(o)ld !" )s"d • T"r!ia" 7B8 o A$$rov"d +or t(" tr"at#"t o+ o'(o#y'osis ad it is "sti#at"d t(at 9 #illio $ati"ts orldid" (av" !"" tr"at"d it( oral t"r!ia" Avoid as t(" adv"rs":""'ts $rol" o+ oral o t"r!ia" i $r"ga'y is li#it"d o
T("r" is o o!sta'l" i givig to$i'al ati+)gal ag"ts/ !)t syst"#i' oral #"di'atios ar" avoid"d
Class o+ 1edication
Cateory
Cateory C
Anti+unals
Amphotericin Clotrimaole
Caspo+uni ;etoconaole n %ystatin luconaole "erconaole 4riseo+ul,in
Antimalarial aents •
•
Atova;)o"-Prog)ail 768 No +"tal (ar# i $r"gat rats ad ra!!its o o Prog)ail is 'osid"r"d to !" t(" l"ast to&i' o o#" ta?ig t(" dr)g "it("r alo" or i 'o#!iatio s(o)ld !" s)$$l"#"t"d it( FA S(o)ld !" )s"d it( 'a)tio i t(" rst tri#"st"r o
•
6(loro;)i" 768 At (ig( dos"s/ it is "#!ryo to&i' ad t"ratog"i' o i rats o 6(loro;)i" s(o)ld ot !" it(("ld d)rig $r"ga'y !"'a)s" t(" ris? o+ 'o#li'atios +ro# #alarial i+"'tio i $r"ga'y is i'r"as"d Sa+" to !" !r"ast+""d o 768 Hydro&y'(loro;)i"/ M"Co;)i"/ Pri#a;)i"/ Pyri#"t(a#i"/ Da$so"/ D.Halo+atri"
Anti,iral drus •
•
A'y'lovir 7B8 Not +od to !" t"ratog"i' i $r"gat #i'"/ rats o ad ra!!its Pro!a!ly sa+" i $r"ga'y ad !r"ast+""dig o A#atidi" 768 o Dos":r"lat"d t"ratog"i'ity i rats at dos"s ";)ival"t to t(" ()#a dos" o No +"tal (ar# as o!s"rv"d i $r"gat ra!!its Birt( d"+"'ts (av" !"" o!s"rv"d i ()#as !)t o t(" data ar" v"ry li#it"d
•
•
Ati:r"troviral ag"ts A#$r"avir 768/ Idiavir 768/ N"lavir 7B-68/ o Ritoavir 7B-68 ad Sa;)iavir 7B-68 ar" $rot"as" i(i!itors )s"d +or t(" tr"at#"t o+ HI@ i+"'tio o No "vid"'" o+ t"ratog"i'ity (as !"" o!s"rv"d i ai#als 7"&'"$tios o+ Idiavir8 o B""t o)t"ig( ris?s ]idov)di" 7+or HI@ $ositiv"8 'at"gory 6/ #)st !" giv" +or t(" $r"gat o#a i+ s(" is HI@=v"
o
Avoid d)rig la'tatio
Anticoaulants
•
•
•
It is 'otraidi'at"d i $r"ga'y/ as it 'ross"s t(" $la'"ta ad #ay 'a)s" !l""dig i t(" +"t)s Its )s" i $r"ga'y is 'o##oly asso'iat"d i it( s$ota"o)s a!ortios/ still!irt(/ "oatal d"at(/ ad $r"t"r# !irt( 6o)#aris 7s)'( as ar+ari8 ar" also t"ratog"s t(" i'id"'" o+ !irt( d"+"'ts i i+ats "&$os"d to ar+ari in utero a$$"ars to !" aro)d >3/ alt(o)g( (ig("r g)r"s 7)$ to ,238 (av" !"" r"$ort"d i so#" st)di"s ar+ari ad#iistratio i t(" s"'od ad t(ird tri#"st"rs is #)'( l"ss 'o##oly asso'iat"d it( !irt( d"+"'ts/ ad (" t("y do o'')r/ ar" di"r"t +ro# +"tal ar+ari sydro#". T(" #ost 'o##o 'og"ital a!or#aliti"s asso'iat"d it( ar+ari )s" i lat" $r"ga'y
etal
•
•
A?a dys#or$(is# d)" to ar+ari/ ar+ari "#!ryo$at(y/ or DiSala sydro#" It o'')rs (" ar+ari 7or aot("r 9:(ydro&y'o)#ari d"rivativ"8 is giv" d)rig t(" 0rst trimester$arti')larly !"t"" t(" si&t( ad it( ""?s o+ $r"ga'y Associated conditions include: 'ypoplasia of nasal bridge o o laryngomalacia o "ectus carinatum o $ongenital heart defects o entriculomegaly o 3genesis of the corpus callosum o #tippled epiphyses Telebrachydactyly o
•
• •
•
•
Asso'iat"d it( asal (y$o$lasia ad '(odrodys$lasia i t(" rst tri#"st"r 6NS a!or#aliti"s i lat"r $r"ga'y Hig( i'i'"'" o+ ("#orr(agi' 'o#$li'atios toard t(" "d o+ $r"ga'y N"oatal ("#orr(ag" is diL')lt to $r"v"t !"'a)s" o+ t(" i##at)r" "*y#"s i +"tal liv"r ad lo stor"s o+ vita#i R"'"t st)dy dos"s 0>#g (ad sigi'atly #or" +"tal 'o#$li'atios id"$"d"t o+ t(" #at"ral INR
ar" '"tral "rvo)s syst"# disord"rs/ i'l)dig s$asti'ity/ s"i*)r"s/ ad "y" d"+"'ts
o
8rowth retardation
Anticoaulants Heparin (UH 1
Fast:a'tig ati'oag)lat it( a (ig( !idig aLity +or atit(ro#!i III Us"d i t(" $ro$(yla&is ad tr"at#"t o+ @TE ad PE asso'iat"d it( $r"ga'y/ (i'( !rigs v"ry (ig( #ortality to t(" o#" i+ l"+t )tr"at"d • Sa+" d)rig $r"ga'y as it do"sKt 'ross t(" $la'"ta • T(" #ost sigi'at sid" ""'t is ("$ari:id)'"d t(ro#!o'yto$"ia/ i additio to "l"vatio o+ a#iotras+"ras"/ (y$"r?al"#ia/ ad ost"o$orosis i '(roi' )s" • Do"s ot 'ross t(" $la'"ta !)t #ay 'a)s" #at"ral ost"o$orosis ad HIT • •
Cytoto=ic drus •
•
•
6y'lo$(os$(a#id" 7D8 ad '(lora#!)'il 7D8/ ar" t"ratog"i' ad 'otraidi'at"d i $r"ga'y M"t(otr"&at" 78 s(o)ld !" dis'oti)"d at l"ast , #ot(s $rior to 'o'"$tio ad FA 7>#g8 giv" $r": 'o'"$t)ally A*at(io$ri" 7D8 6)rr"t "vid"'" o idi'at"s t(at #at"ral )s" is ot asso'iat"d t( a i'r"as"d ris? o+ i#$air"d +"tal i##)ity/ IUGR/
Anticon,ulsants
Class o+ 1edication
Cateory Cateory C
Ati'ov)lsats Mag"si)# Et(os)&a#id" s)l+at" Ga!a$"ti a#otrigi" "v"tira'"ta# O&'ar!a*"$i" To$ira#at" ]oisa#id" o o o o o
Cateory ! Carbamazepine
6loa*"$a# Diazepam Phenytoin
Pri#ido" Valproic aci
All t(" ati'ov)lsats 'ross t(" $la'"ta/ ad t(" + o)r $ri'i$al ati:"$il"$ti' dr)gs ar" o+ 'at"gory D/ ad so/ #ost o+ t("# ar" t"ratog"i' Ba'?gro)d ris? ,3 Utr"at"d "$il"$ti' 93 1 dr)g 3 % or #or" dr)gs 1>3 @al = 6ar! = P("ytoi >23
•
$r"#at)rity ad 'og"ital a!or#aliti"s 6oCi'tig o i+or#atio r"gardig !r"ast: +""dig 6y'los$ori 7D8 o B""ts o)t"ig(s ris?/ so )s" it( 'a)tio
It is alloa!l" to $r"s'ri!" o" dr)g/ as a o$ti#al tr"at#"t ""d"d to sto$ t(" ts rat("r t(a t(" r";)ir"d dr)g l"v"ls/ as (avig a t is #or" dag"ro)s to t(" #ot("r ad !a!y t(a t(" t"ratog"i' ""'t. So/ t(is is a 'lassi'al "&a#$l" o+ o)t"ig(ig t(" !""ts ov"r t(" ris?s o+ t"rato"g""sis / (i'( t(" #ot("r #)st !" aar" o+ Folat" (as to !" giv" to $r"v"t ")ral t)!" d"+"'ts 7>#g-day8
Anti-infammatory drus •
• •
•
As$iri ad NSAIDS do ot $rod)'" str)'t)ral d"+"'ts !)t #ay i'r"as" t(" ris? o+ "oatal ("#orr(ag" 7t("y ar" 'osid"r"d i 'at"gory 6/ !)t (" )s"d i l arg" dos"s or +or $rolog"d d)ratio/ t("y ill !" i 'at"gory D8 NSAIDS #ay also l"ad to oligo(ydra#ios via ""'ts o t(" +"tal ?id"y So#" ar" $r"s'ri!"d i "arly $r"ga'y i $ati"ts it( (istory o+ ati$(os$(oli$id sydro#"/ r"')rr"t #is'arriag"s/ or !a!i"s it( IUGR T("y ar" )s)ally avoid"d i t(" last tri#"st"r as t("y #ay 'a)s" $r"#at)r" 'los)r" o+ t(" d)'t)s art"rios)s/ it( 'os";)"t "oatal $ri#ary (y$"rt"sio
Cardio,ascular drus
•
•
6O:% i(i!itors o F"tal 6O:% i(i!itors 'a !" r"s$osi!l" +or "oatal '(roi' r"al +ail)r" o Mt"ral )ag" s(o)ld !" avoid"d )tl +)rt("r st)di"s 'or# t(" sa+"ty o+ t(is gro)$ o+ dr)gs 6ol'(i'i" 7D8 Giv" aro)d 'o'"$tio #ay r"s)lt i a o i'r"as"d +r";)"'y o+ triso#y %1 !y 'a)sig '(ro#oso#al o:dys'tio F"tal ?aryoty$ig is r"'o##"d"d o o It is r"'o##"d"d t(at 'ol'(i'i" ig"stio !y "it("r $ar"t !" dis'oti)"d , #ot(s !"+or" 'o'"$tio
Class o+ 1edication
Cateory
6ardiovas')lar dr)gs
!ethylopa
Cateory C
A'"ta*ola#id" Hydro'(lorot(ia*id Calcium"channel bloc#ers " 6loidi" Digo&i Es#olol Fl"'aiid" Hydrala*i" Isosor!id"s
Cateory ! $abetalol
%CE inhibitors %mioarone %&'s Spironolactone
M"to$rolol Mio&idil Nitrogly'"ri Nitro$r)ssid" Pra*osi Pro$aolol T"ra*osi
At"olol
Cardio,ascular drus •
•
•
I+ t(" tr"at#"t o+ (y$"rt"sio is r";)ir"d !"+or" %J ""?s/ !ethylopa 7B8 s(o)ld !" t(" rst dr)g o+ '(oi'" T("r" is 'o'"r +or )s" o+ !"ta: !lo'?"rs i t(" % d ad , rd tri#"st"rs giv" r"$orts o+ itra)t"ri" grot( r"stri'tios/ alt(o)g( labetalol (as t(" #ost sa+"ty data o+ t(" 'lass 6al'i)# '(a"l !lo'?"rs #aily
•
•
B"ta:adr""rgi' atagoists 768 o Sa+"ty i $r"ga'y is ot so "ll "sta!lis("d G)id"li"s o+ t(" ISSHP do ot o r"'o##"d t(" )s" o+ oral !"ta: adr""rgi' atagoists +or #ild (y$"rt"sio i $r"ga'y Agiot"sio 'ov"rtig "*y#" i(i!itors 7D8 o Hav" !"" asso'iat"d it( a. Prolog"d r"al +ail)r" ad
•
•
6al'i)# '(a"l !lo'?"r 768 o Sa+" to )s"/ 'a)tio it( MgSO% S$iroola'to" 7D8 Ati:adrog"i' ""'ts o "r" o!s"rv"d i "&$os"d #al" ai#al +"t)s"s i o" st)dy Is 'otraidi'at"d i o $r"ga'y
)s"d +or s"v"r" $r":"'la#$ti' to&"#ia 7PET8 •
Spironolactone , amioarone, an %CE inhibitors ne(er prescribe) o
(y$ot"sio i t(" "!or !. D"'r"as"d s?)ll ossi'atio / (y$o'alvaria/ ad r"al t)!)lar dysg""sis '. IUGR/ oligo(ydro#ios/ PDA Is ot t(o)g(t to $rod)'" str)'t)ral #al+or#atios/ so it is a''"$ta!l" to '"as" tr"at#"t "arly i $r"ga'y ad ot "'"ssarily $r"'o'"$tio
•
A#iodaro" 7D8 6a r"a'( t(" +"t)s !y o tras$la'"tal $assag" ad id)'" +"tal (y$ot(yroidis# No:v"r!al "arig o Disa!ility Sydro#" o S(o)ld !" avoid"d d)rig t(" 1st tri#"st"r o+ $r"ga'y
$ndocrine drus • •
•
Is)li is $r"+"rr"d ov"r oral (y$ogly'"#i' ag"ts May o#" ar" ta?ig $rog"st"ros i t(" % d tri#"st"r 6orti'ost"roids ar" r"lativ"ly sa+"/ !)t t("y ar" ot $r"s'ri!"d/ "v" i+ t(" o#a is !r"ast:+""dig
Class o+ 1edication
Hor#o"s
Cateory Cateory C
A'ar!os" Adr"al D"s#o$r"ssi (or#o"s 6al'itoi nsulin Gli$i*id" !etformin Gly!)rid" So#atostati M"latoi Troglita*o" R"$agliid" @aso$r"ssi Rosiglita*o" !icronize Tol!)ta#id"
Cateory !
M"t(i#a*ol" Pro$ylt(io)ra'il Ta#o&i+" Hydro&y$rog"st :"ro"
Cateory 6 Danazol
Estrog"s Iodid"1,1 ")$rolid" Mi+"$risto" T"stost"ro"
Pro+estero ne
$ndocrine drus •
Oral (y$ogly'"#i' dr)gs S)$(oyl)r"as 7D8 (av" !"" r"$ort"d as dir"'t o 'a)s" o+ "oatal (y$ogly'"#ia o T("r" is o r# "vid"'" t(at t("s" dr)gs ar" t"ratog"i'
•
6orti'ost"roids 768 Do ot a$$"ar to giv" ris" to ay s"rio)s $ro!l"#s o Trasi"t s)$$r"ssio o+ t(" +"tal HPAA (as !"" o r"$ort"d o May a"'t grot( lat"r i li+"
•
Prog"stog"s 7D8 6a #as')lii*" t(" +"#al" +"t)s o No "vid"'" t(is o'')rs it( t(" s#all a#o)t i o t(" 6O6P
•
Daa*ol 78 R"$orts s)gg"st virili*atio o+ t(" "&t"ral g"italia o+ o +"#al" +"t)s"s S(o)ld !" avoid"d i $r"ga'y o
•
6as"s o+ neonatal withdrawal syndrome 7)s)ally s"l+: li#it"d8 (av" !"" d"s'ri!"d i i+ats '(roi'ally "&$os"d to !"*odia*"$i"s i )t"ro I+ )s"d i $r"ga'y/ t(os" !"*odia*"$i"s it( a !"tt"r ad log"r sa+"ty r"'ord/ s)'( as iazepam or chloriazepoie / ar" r"'o##"d"d ov"r $ot"tially #or" (ar#+)l !"*odia*"$i"s/ s)'( as alprazolam or triazolam Usig t(" lo"st ""'tiv" dos" +or t(" s(ort"st $"riod o+ ti#" #ii#i*"s t(" ris?s to t(" )!or '(ild
"ran9uiliers antidepressants •
•
I t(" Uit"d Stat"s/ t(" FDA (as 'at"gori*"d benodiaepines into cateories ! or 6 d)" to $ot"tial (ar# to t(" +"t)s/ ''#Is into cateory C/ ad ithium into ! t(at is ot 'o##oly )s"d T("ir )s" !y "&$"'tat #ot("rs s(ortly !"+or" t(" d"liv"ry #ay r"s)lt i a foppy in+ant syndrome / it( t(" "!ors s)"rig +ro# (y$otoia/ (y$ot("r#ia/ l"t(argy/ ad !r"at(ig ad +""dig diL')lti"s
Class o+ medication
Cateory
Antidepressants> uproprion antipsychotics> uspirone an=iolytics ?olpidem
ronchial Asthma
•
•
Cateory C Aripipraole Chlorpromai ne Cloapine Haloperidol /lanapine @uetiapine #isperidone
Cateory ! ''#Is "CAs "hioridaine ?iprasidone
Cateory 6
Alpraolam /ther Chlordiaepo=ide !? Clonaepam !iaepam ithium oraepam 1idaolam /=aepam
Tr"at as o:$r"gat/ d"s$it" o+ t(" sid" ""'ts o+ dr)gs/ as a ast(#a atta'? 7stat)s ast(#ati')s8 'a !" v"ry s"rio)s to t(" #ot("r ad !a!y I g""ral/ r"s$iratory dr)gs ar" "it("r ito 'at"gory B or 6/ ad so ar" r"lativ"ly sa+" d)rig $r"ga'y
•
•
Class o+ 1edication
Cateory
Cateory C
#espiratory drus
Acetylcysteine udesonide Cromolyn sodium Ipratropium 1ontelu*ast ?a0rlu*ast
Albuterol Corticosteroids (inhaled) !e=tromethorphan 4uai+enesin 'almeterol "heophylline
'ummary
T(" d"'isio to )s" ay $ot"tially (ar#+)l dr)g i $r"ga'y s(o)ld !" #ad" o a 'as":!y:'as" !asis T("r" s(o)ld !" t(oro)g( 'o)s"lig it( t(" $ati"t Ea'( 'as" is a idivid)ali*"d 'as"e B"+or" $r"s'ri!ig ay dr)g/ 'osid"ratio #)st !" giv" to ay (ar#+)l ""'ts o t(" +"t)s. Ho"v"r/ o (ar# #)st 'o#" to t(" #ot("r or t(" !a!y !"'a)s" a dis"as" is iad";)at"ly tr"at"d To #ii#i*" t(" +"tal ris?s/ t(" lo"st ""'tiv" dos" s(o)ld !" )s"d It is ot a s(a#" t(at yo) doKt ?o "&a'tly t(" $ossi!l" sid" ""'ts/ s"ar'( +or t("#e To $r"v"t ay #isi+or#atio a!o)t t(" t"ratog"i'ity o+ '"rtai dr)gs ""$ alays )$:to:dat" it( t(" dr)gs i+or#atio/ "s$"'ially t(ro)g( t(" t"ratog":i+or#atio s"rvi'"
• • • • • •
MENORRHAGIA •
It is t(" #ost 'o##o gy"'ologi'al 'as" s"" i t(" 'lii'. • It is t(" #ost 'o##o 'a)s" o+ a"#ia i d"v"lo$"d 'o)tri"s. • Ad t(" %d 'o##o 'a)s" o+ iro d"'i"'y a"#ia a+t"r $oor di"t i t(" d"v"lo$ig 'o)tri"s. – S)!"'tiv"4 Prolog"d or ("avy R"g)lar #"str)al !l""dig. – O!"'tiv"4 #"str)al !lood loss #or" t(a J2 #l 7#or" a'')rat"8/ !)t ot )s"d i $ra'ti'" / )st i r"s"ar'("s8 T(yroid4 (y$ot(yroidis#. V Nor#al #"str)al !lood loss rag" +ro# %2 : J2 #l it( av"rag" o+ ,> #l. 6oag)latio disord"r4 ITP/ @D/ l")?"#ia... Adva'"d liv"r dis"as"s. Dr)gs4 ar+ari/ H"$ari/
SYSTEMI6 PATHOOGY
6AUSES OF MENORRHAGIA
PE@I6 PATHOOGI6
DYSFUN6TIONA UTERINE BEEDING
Fi!roid 7s)!#)'osal8. Edo#"triosis. Ad"o#yosis. 6(roi' PID. 6o$$"r r"l"asig IU6D. Edo#"trial (y$"r$lasia ad #aliga'y. Ovaria t)#ors Estrog"
DYSFUN6TIONA UTERINE BEEDING FA6TORS OF BEEDING AMONG MENSES ETIOOGY 1: PG E% ad PG F%f. 1. Edo#"trial dys+)'tio 7Ov)latory DUB84 %: Fi!riolyti' syst"#. : PGKs i#!ala'" 7d"' PGF%a 4 i' PGE% ratio8. ,: Blood @"ss"ls o+ t(" "do#"tri)#. : I'r"as"d !riolyti' a'tivity. : I""'tiv" 'otra'tio o+ #yo#"trial v"ss"ls. T(" #ost i#$ortat is $rostagladi r"l"as" ad %. Hy$ot(ala#i' < Pit)itary < Ovaria (or#oal Fi!riolyti' syst"# à ay dist)r!a'" i t("# à a&is4 7Aov)latory DUB8 !l""dig. : Most 'o##o ag" at $r"s"tatio is l"ss t(a Dist)r!a'" i $rostagladi r"l"as" s)'( as i+ %2 ad #or" t(a 92. PGE% i'r"as"d 7it is a vasodilator8 ill l"ad to !l""dig ad i'r"as"d PG F%f (i'( ill 'a)s" s$as#odi' or $ri#ary dys#"orr("a. Also/ i+ too #)'( !riolyti' syst"# a'tivity à #"orr(agia. HISTORY PHYSI6A EAM IN@ESTIGATION : 6o#$lait4 Ass"ss t(" a#o)t o+ !lood : G""ral "&a#iatio4 : 6B64 H! ad $lat"l"ts. loss. G""ral 'oditio 7do"s s(" : P"lvi' )ltraso)d4 Ut"r)s si*"/ s(a$"/ : Asso'iat"d Gy"'ologi'al $ro!l"#4 loo? $al" or otW8/ @itals/ #ass"s/ ad "do#"trial t(i'?"ss. Ad"&ia 6og"stiv" dys#"orr("a/ d""$ "ig(t/ T(yroid/ y#$( : 6"rvi'al s#"ar. dys$ar")ia/ '(roi' $"lvi' $ai/ $r"ss)r" od"s 7a&illary ad : OL'" !io$sy4 Pi$"ll"/ Nova? sy#$to#s/ ad vagial dis'(arg". ig)ial8/ Br"ast/ A!do#" : Hyst"ros'o$y ad "do#"trial !io$sy4 : Gy"'ologi'al 5 M"str)al H&4 ast '& 7P"lvia!do#ial #assMadatory s#"ar/ $r"vio)s gya" s)rg"ry/ as'it"s8. +or o#" old"r t(a 92 y"ars. 'otra'"$tio/ IMB/ ad P6B. : P"lvi' "&a#iatio4 : Ot("rs/ a''ordig to t(" s)s$"'t"d $ro!l"#. : M"di'al H&4 T(yroid sy#$to#s/ S$"')l)# "&a#iatio/ H"#atologi'al disord"rs Bi#a)al "&a#iatio. : M"di'atios4 T(" $r"vio)s 9 dr)gs. : Pr"vio)s iv"stigatios ad tr"at#"t. DEFINITION M"orr(agia i t(" a!s"'" o+ orgai' 7$"lvi'/ syst"#i'8 $at(ology. Is a diagosis o+ "&'l)sio.
TREATMENT ESS THAN %2 YEARS OD M"orr(agia is a 'o##o 'a)s" o+ Gy 'lii' visit i t""ag"r/ #aily d)" to DUB. 7d"lay"d #at)ratio o+ HPO a&is8 Tr"at#"t is si#$l" ad +or s(ort d)ratio 7+" #ot(s8 till t(" (or#oal a&is !"'o#"s #at)r". i"s o+ #aag"#"t4 a8 R"ass)ra'" ad "&$laatio. !8 6orr"'tio o+ a"#ia i+ $r"s"t. '8 M"di'al tr"at#"t. NON:HORMONA HORMONA ANTI: ANTI: PROGESTOGENS 6OMBINED O6P DANA]O GRH ANAOG PROSTAGANDIN FIBRINOYTI6S Most 'o##oly : 1ta! daily +or : It is a adrog" : ,.>#g IM "rane=amic acid4 %orethisterone )s"d. : , 'a$s)l" daily/ %1 days/ +ro# aalog)" 71:f< #ot(ly/ +or 9 and +ro# day 1 to day 1edo=yproest day >. "t(iyl #ot(s. 1e+enamic acid > o+ t(" 'y'l". erone acetate. : _ #"str)al t"stost"ro"8. : _ M"str)al (Ponstan): : _ #"str)al : Most 'o##o !lood loss !y : Also !lood loss !y J2: : Is t(" #ost !lood loss !y >23. dr)g )s"d +or >23. ati"strog"ti' 5 1223. 'o##o dr)g : Mai S-E4 a)s"a DUB. : "ss ati$rog"strog"i'. : D"$r"ssio o+ t(" )s"d !y ad vo#itig/ h : > #g ti'" daily/ 'o##oly )s"d : D"$r"ssio o+ t(" HPO: a&is adol"s'"t %>3 o+ $ati"ts +ro# day > to day d)" to its sid" HPO: a&is ad (as a M"o$a)sals&. +"#al" +or sto$ it !"'a)s" o+ %> o+ t(" 'y'l". ""'ts. dir"'t s)$$r"ssiv" : Maor ris?4 dys#"orr("a as t("s" sid" ""'ts. : _ #"str)al : Mior S-E4 ""'t o Ost"o$orosis i+ "ll. : Rar"ly/ it #ay !lood loss !y Na)s"a/ "do#"tri)#. )s"d #or" t(a : , 'a$s)l"s daily/ 'a)s" '"r"!ral %>3. vo#itig/ : _ #"str)al !lood #ot(s. +ro# day 1 to day t(ro#!osis/ so it is : No s"rio)s S-E. ("ada'("/ loss !y J2 < 1223. > o+ t(" 'y'l". 'otraidi'at"d i : Sa+" to )s". : S-E4 VAlt(o)g(/ t("s" irrita!ility/ ↑i : _ #"str)al $ati"t it( ris? Hoars""ss o+ dr)gs ar" "ig(t... !lood loss !y +a'tors +or voi'". "&tr"#"ly : Maor sid" %>3. t(ro#!o"#!olis#. Hirs)tis# ad ""'tiv"/ !)t t("y ""'ts4 HT/ :S-E4 gastritis/ ar" o #or" )s"d t(ro#!o"#!olis a'". gastri' )l'"r. oadays d)" to ↑#)s'l" #ass. #/ t("ir s"rio)s sid" 'ardiovas')lar 6lit"ro#"galy. ""'ts. Br"ast atro$(y. Hy$oo"strog"i'
M"o$a)sal s&.
BETEEN %2 5 92 YEARS OF AGE To li"s o+ #aag"#"t4 AQ M"di'al4 sa#" as +or t(" t""ag"rs. BQ e,onorestrol releasin IUC! (1irena) à t("y d"sir" 'otra'"$tio v"ry ""'tiv". : %2 #'g o+ l"voorg"strol daily. : It d"'r"as"s #"str)al !lood loss !y J2<2 3. : h,23 o+ o#" ar" a#"orr(o"i' a+t"r o" y"ar o+ is"rtio. : It d"'r"as"s t(" i'id"'" o+ PID. : Do"sKt i'r"as" ris? o+ "'to$i' $r"ga'y. : Sid" ""'ts4 !r"a?t(ro)g( !l""dig 5 s$ottig +or t(" rst ,: #ot(s a+t"r is"rtio.
ABO@E THE AGE OF 92 T(r"" li"s o+ #aag"#"t4 AQ M"di'al4 Sa#"/ ot O6P. BQ Mir"a4 Sa+"ly )s"d. 6Q S)rg"ry4 18 $ndometrial resection and ablation 4 : Day 'as" s)rg"ry )d"r GA. : S(ort stay i (os$ital/ ra$id r"'ov"ry. : 6)r" rat" o+ 2
POST6OITA BEEDING D"+4 Bl""dig d)rig or a+t"r 'oit)s. c6"rvi'al E'tro$io T(" 'a)s" is al#ost alays '"rvi'al4: It is or#al/ $(ysiologi'al/ it is ot a )l'"r. : 6"rvi'al "'tro$io/ t(" 'o##o"st 'a)s". : O'')rs i (ig( "strog"i' stat"4 Pr"ga'y or 6O6P )s"rs. : 6"rvi'al )l'"r/ '"rvi'itis. : T(" "strog" ill 'a)s" ov"rgrot( o+ t(" 'ol)#ar : 6"rvi'al $oly$s. "$it("li)# o+ t(" "do'"rvi& ito "'to'"rvi& à $ost'oital : 6"rvi'al 'a'"r. !l""dig. Ho to diagos"W : 6-64 P6B ad "&'"ssiv" #)'oid s"'r"tios. : History : I #"o$a)s"/ t("r" ill !" iv"rsio 7t(" strati"d lay"r : E&a#iatio4 G""ral ad $"lvi'/ s$"')l)#. o+ t(" "'to'"rvi& ill #ov" iards8. Tr"at#"t4 S(o)ld !" dir"'t"d toard t(" 'a)s" Pa$ : D)rig $r"ga'y 6os"rvativ" tr"at#"t/ a+t"r d"liv"ry s#"ar is #adatory !"+or" tr"at#"t. it )s)ally i#$rov"s s$ota"o)sly. : I+ o 6O6P/ sto$ it/ r"ass"ss agai.
INTRODU6TION
E6TOPI6 PREGNAN6Y 6AUSES
6OMPI6ATION
D"+4 Pr"ga'y t(at is i#$lat"d o)tsid" t(" )t"ri" 'avity T(" i'id"'" oadays is tri$l" t(" $r"vio)sly stat"d as 2.,3
•
• • •
SITES T)!"s >3/ Rt. 0 : >>3 a#$)lla : %>3 Ist(#i' 6"rvi&/ R)d. Hor Ovari"s P"rito"al < A!do#ial
Ay d"lay i ov)# $assag" )til i#$latatio stag". • T)!al a!or#aliti"s4 Div"rti')la"/ Fals" $assag"s/ Edosal$igitis ART • Edo'ri" disord"rs4 D"lay"d • ov)latio/ Estrog"-Prog"st"ro" Ratio. 6otra'"$tiv" +ail)r"4 Mii$ill 79: • 38/ IU6D79:38/ T)!al s)rg"ry 7lig./ 'ostr.8 Prior (istory 712:%23 R"')rr"'"8 • Pat(ology4 PID/ Edo#"triosis • Ot("rs •
:T)!al a!ortio : a!sor$tio i t)!" : I'o#$l"t" t)!al a!ortio : T)!al !lood #ol" : T)!al r)$t)r" : itra$"rito"al !l""dig : Broad liga#"ts MANAGEMENT : I.@. li" 7id" !or"8 : Blood/ H!/ gro)$/ 'ross: #at'(ig : O'" diagos"d ` la$arato#y la$aros'o$y • E&$r"ssio • Sal$igosto#y • Sal$ig"'to#y
DIAGNOSIS PRESENTATIONS : Sil"t 238
SYMPTOMS A#"orr("a 7:12 ?s8 Sy#$to#s o+ $r"ga'y A!do#ial $ai 7384 G""ralis"d 79>38/ Uilat"ral 7,>38/ S(o)ld"r ti$ 7%>38 A!or#al )t"ri" !l""dig 7>38 Ay +or# Sy'o$al s& 7,>38 Ad"&al t"d"r"ss 738 Ad"&al #ass 7238 Ut"ri" si*"4 Nor#al 7238 : to J ?s %>3 D56 ')r"ttigs4 :Proli+"rativ"/ s"'r"tory : Arias:st"lla $("o#"o
IN@ESTIGATIONS : Pr"ga'y t"st S"r)# j(6G 'orr"lat"s "ll it( tro$(o!last6"ll • #ass. E'to$i' rar"ly r)$t)r"s (" '"ll #ass is s#all or • j(6G l"v"ls ar" lo. I or#al $r"ga'y val)"s/ s"r)# j(6G 0 1>22 • #l)-#/ #)st s"" g"statioal sa' I or#al $r"ga'y/ (6G @al)"s do)!l"s "v"ry • %.% days. It do"sKt o'')r i "'to$i' $r"ga'y. : Blood H!/ gro)$ig : Trasvagial Ultraso)d4 Itra)t"ri" sa'4 : Ps")do sa' 712:%238 • : Tr)" sa' 7Yol? sa' F. Pol"s8 Ad"&ial #ass 72384 : Sa' it( +"t)s or o • +"t)s : E'(og"i' #ass 7DD&. 6.8 Fl)ids i P.O.D4 : i J23 o+ R)$t)r"d "'to$i's •
•
: I %23 o+ or#al $r"ga'y VV I+ G"st sa' 0 %2 ## or 7>: ?8/ #)st s"" yol? sa' 5 +"tal $ol". i+ ot s""/ s)s$"'t "it("r "'to$i' or !lig(t"d ov)# : a$aros'o$y
A')t" a$$"di'itis
No s& o+ $r"ga'y • UTI
$%!/1$"#IA CA#CI%/1A 1alinant lesions o+ the body o+ uterus • •
Body o+ )t"r)s 'o#$os"d o+ , lay"rs 7"do#"tri)#/ #yo#"tri)#/ s"rosa8 Myo#"tri)# o S#oot( #)s'l" o Maligat4 "io#yosar'o#a
•
Edo#"tri)# Glads = Stro#a o Glads4 Ad"o'ar'io#a o Stro#a4 Edo#"trial stro#al sar'o#a o Glads = Stro#a4 Ut"ri" o 'ar'io#sar'o#a-MMMR 7#i&"d #aligat M)ll"ria t)#or8
$%!/1$"#IA A!$%/CA#CI%/1A •
Dis"as" o+ #"o$a)s" • P"a? i'id"'" 1.>3 i $ost#"o$a)sal o#" • T("r" is #ar?"d g"ogra$(i'al ad ra'ial variatio i t(" i'id"'"/ v"ry 'o##o i "st"r 'o)tri"s • Most 'o##o
$tioloy
Patholoy
•
Estrog":d"$"d"t "o$lasia
Estrog":id"$"d"t "o$lasia
• Yo)g"r/ $"ri#"o$a)sal
•
• •
•
Nor#ally/ "do#"tri)# is "&$os"d to "strog" i t(" 1 st (al+ o+ t(" #"str)al 'y'l" ad $rog"st"ro" i t(" % d (al+ Estrog" is !ad/ Prog"st"ro" is $rot"'tiv" (" "do#"tri)# "&$os"d to "strog" ad ot o$$os"d !y Prog"st"ro"/ ill l"ad to "do#"trial (y$"r$lasia ad 'ar'io#a 6O6P 5 $rog"st"ro" (av"
• •
• •
o#" History o+ '(roi' "strog" "&$os)r" T)#ors iitially "do#"trial (y$"r$lasia/ $rogr"ss to 'ar'io#a "ll di"r"tiat"d Favo)ra!l" $rogosis
•
•
Not asso'iat"d it( "do#"trial (y$"r$lasia Old"r/ $ost#"o$a)sal/ t(i o#" "ss di"r"tiat"d
gy"'ologi'al 'a'"r i t(" US 7o!"sity8/ rar" i \a$a ad 6(ia • E#igrat \a$a"s" i A#"ri'a gai"d si#ilar rat"s to t(os" o+ A#"ri'as. So/ t("r"Ks eoraphical ad racial +a'tors
$rot"'tiv" ""'t agaist "do#"trial 6A • T(is 'a (a$$" i4 1. O!"sity 7$"ri$("ral 'ov"rsio o+ adrog"s ito "strog"8 %. N)lli$aro)s 7)ov)latio8 ,. Estrog" HRT 9. Estrog" s"'r"tig ovaria t)#or >. Fa#ilial4 HNP66 y'( Sydro#" 7ovaria/ 'olo/ "do#"trial 'a'"r8
• • • •
Most 'o##o ty$" o+ "do#"trial 'a'"r4 Edo#"trioid ad"o'ar'io#a 7J238 Ot("r ty$"s4 #)'io)s 'a/ 'l"ar '"ll 'a/ s;)a#o)s 'a/ $a$illary s"ro)s 'a S;)a#o)s '"ll i ad"o'ar'io#a4ad"os;)#o)s 'a S#all gro)$ o+ "do#"trial 'a r"s"#!l"s ovaria 'a4 Pa$illary s"ro)s 5 'l"ar '"ll 'a Eld"rly 7028/ t(i o o Not "strog" r"lat"d o Adva'"d stag" at $r"s"tatio
6o##o"st is t(" 1 st ty$" 7"strog" r"lat"d8
$%!/1$"#IA A!$%/CA#CI%/1A
$%!/1$"#IA 'A#C/1A
'pread
!ianosis
•
• • •
• 6"rvi'al s#"ar • Trasvagial U-S
•
Dir"'t ivasio y#$(ati' Blood 7rar"ly8
Presentation •
Post#"o$a)sal !l""dig o Oly i 123 J>34 atro$(i' d"r#atitis o All PMB s(o)ld do !io$sy o
Edo#"trial t(i'?"ss o+ $ost#"o$a)sal o#" is 9## o I+ 09##/ do !io$sy Bio$sy4 !y (yst"ros'o$y-D56 I+ stagig 'or#"d 'ar'io#a/ do stagig iv"stigatio4 6B6/ FT/ FT/ 6R/ $"lvi' MRI o
• •
Pronosis
•
Rar"/ v"ry aggr"ssiv" Pai 5 !l""dig % y"ar s)vival
$I15/'A#C/1A • • • • •
Most aris" +ro# or#al "do#"tri)# May aris" +ro# !roid tras+or#atio A!or#al !l""dig/ $"lvi' $ai S(o)ld !" s)s$"'t"d i ra$idly "larg" !roidl"sios ?""$ "largig a+t"r #"o$a)s" Diagosis #ad" a+t"r (yst"r"'to#y !y
• •
Pr"#"o$a)sal4 IMB/ irr"g)lar $"riods Pai 7lat" $r"s"tatio/ t)#or (as ivad"d lo'ally 'o#$r"ssig $"lvi' $l"&)s ad "rv"s8
Physical sins • • • •
Rar"ly s)gg"st diagosis Ut"ri" "larg"#"t Pal$a!l" N 7groi/ s)$ra'lavi')lar8 @agial od)l" 7i adva'"d stag"8
• • • •
Stag" Grad" Myo#"trial ivasio Ag" Yo)g4 "d#"triod ty$" 7good o $&8 Eld"rly4 s"ro)s 7!ad $&8 o
•
(istologi'al "&a#iatio Ad)vat radit("ra$y ad '("#ot("ra$y is ;)"stioa!l"/ ot #)'( !""t
'tain
Stag" 14 'o"d to !ody o+ )t"r)s Stag" %4 ivolv"#"t o+ '"rvi& Stag" ,4 ovari"s 5 t)!"s Stag" 94 M"tastasis
"reatment
Stag" 1 5% 7o !ad $rogosti' +a'tor84 Hyst"r"'to#y = BSO =-: N diss"'tio Stag" 1 5 % 7it( !ad $rogosti' +a'tor84 ad)vat '("#ot("ra$y Stag" , 5 9 7diss"#iatio84 'o#!iatio radiot("ra$y/ '("#ot("ra$y/ (or#oal t("ra$y
Ed#"trial 'a )s)ally $r"s"t i "arly stag" > y"ar s)rvival rat" is 23
ENDOMETRIOSIS D"+4 Pr"s"'" o+ "do#"trial glads ad stro#a o)tsid" t(" "do#"trial 'avity ad alls.
D"$osits $roli+"rat" d)rig t(" #"str)al 'y'l"/ !r"a? do 5 !l""d/ 'a)sig lo'al iCa##atory r"a'tio. Fi!rosis 5 distortio o+ t(" tiss)" a"'t"d it( d"s" s'arrig. B"ig. EPIDEMIOOGY O@ER@IE SITES Dis"as" o+ r"$rod)'tiv" ag" Hor#o" d"$"dat Mor" 'o##oly i t(" d"$"dat • • gro)$ R"s$ods to "strog" $art o+ t(" $"lvis • < Ovari"s 7%-, o+ o#"8 A"'t >:1>3 o+ o#" • R"gr"ss a+t"r #"o$a)s"/ oo$("r"'to#y • < Broad liga#"t Diagos"d i %2:,23 o+ ad d)rig $r"ga'y • < P"rito"al s)r+a'" o+ 6)l:d":sa' o#" iv"stigat"d +or ETIOOGY ad )t"rosa'ral liga#"ts i+"rtility U?o • < R"'tovagial s"$t)# Mor" i o#" (os" rst • • T("ori"s < R"'tosig#oid 'olo d"gr"" r"lativ" (av" t(" < R"trograd" #"str)atio < Distat ad la$arato#y s'ars dis"as" < 6o"lo#i' "$it("li)# tras+or#atio O+t" diagos"d i'id"tally • < y#$(ati' ad vas')lar s$r"ad Hig( so'ial 'lass o#" i • < G""ti' ad i##)ologi' +a'tors t("ir t(irti"s ad i+"rtil"e 6a !" diagos"d i ay ty$" • o+ o#" ad all ag" gro)$s PATHOOGY HISTOPATHOOGY Gross A'tiv" "do#"trial glads ad stro#a • • < H"#orr(agi' v"si'l" Fr"" Blood ll"d 'ysti' l"sios • < Pa$)l" ad lat"r od)l" Fi!rosis it( glads oly o stro#a • E'los"d Ad("sio +or#atio • < (it" od)l"s or Catt""d !roti' s'ar H"al"d • Ovaria "do#"trio#a is a "'los"d ("#orr(agi' 'yst o+ varia!l" si*"s
SYMPTOMS A''ordig to sit" No r"latio !"t"" "&t"t o+ t(" dis"as" ad s"v"rity o+ t(" sy#$to#s • O+t" dis'ov"r"d i'id"tally • FEMAE Dys#"orr("a/ o"r a!do#ial ad $"lvi' $ai/ D ys$ar")ia/ A''id"t to "do#"trioti' 'yst/ REPRODU6TI@E o !a'? $ai/ I+"rtility/ M"str)al i rr"g)larity TRA6T URINARY TRA6T 6y'li'al (a"#at)ria - dys)ria/ Ur"t"ri' o!str)'tio GIT Dys'("*ia/ 6y'li'al r"'tal !l""dig/ It"stial o!str)'tio SURGI6A S6AR 5 6y'li'al $ai ad !l""dig UMBII6US UNGS 6y'li'al (a"#o$tysis/ Ha"#o$")#ot(ora& 6NI6A FINDINGS IN@ESTIGATIONS DD& DIAGNOSIS O+t" N"gativ" 6a 1%> o+t" All 'a)s"s o+ '(roi' $"lvi' Dir"'t vis)ali*atio o+ t(" • • • • S)gg"st"d !y "l"vat"d $ai l"sio • < a$aras'o$y < T(i'?"ig ad od)larity • Ultrasoogra$(y +or A')t" 'oditios • < a$arato#y o+ )t"rosa'ral . ovaria 'yst < E'to$i' $r"ga'y < T"d"r"ss i POD MRI < A')t" PID Histo$at(ology to 'or# • • < Ovaria #ass- #ass"s < 6o#$li'at"d ovaria 'yst t(" diagosis < Fi&"d r"trov"rt"d )t"r)s < A')t" a$$"di'itis ad < T"d"r od)l" i t(" ot("r s)rgi'al '"rvi&/ )#!ili')s or s'ar "#"rg"'i"s •
TREATMENT NSAIDS PSEUDO: PREGNAN6Y
: 6o#!i"d O6P 'oti)o)s : 6y'li'al WW o+ li#it"d val)" Sid" ""'t : Syt("ti' $rog"stog"s4 M"dro&y$rog"st"ro" a'"tat" ad dydrog"st"ro" (ig( dos"s 'oti)o)s Sid" ""'t : "voorg"str"l:r"l"asig syst"# r"d)'"s dys#"orr(o"a ad r"gr"ss POD i#$lats PSEUDO: < Daa*ol adrog" d"rivativ" : #ot(s MENOPAUSE < G"strio"/ adrog" d"rivativ" Bot( dr)gs (av" adrog"i' sid" ""'ts < GRH agoists : M"o$a)sal sy#$to#s/ Ost"o$orosis W Add !a'? t("ra$y SURGERY 6ONSER@ATI@E Yo)g $ati"t/ o#" s""?ig $r"ga'y/ 'ysts 0,'# i dia#"t"r S)rgi'al "&'isio/ as"r HYSTERE6TOMY 5 Radi'al-D"itiv" s)rg"ry BSO FA6TORS TO 6HOOSE TREATMENT ENDOMETRIOSIS 5 INFERTIITY 6"rtaity o+ diagosis Ovaria +)'tio • • S"v"rity o+ sy#$to#s • • T)!al +)'tio E&t"t o+ t(" dis"as" 6oital +)'tio • • F"rtility S$"r# +)'tio • • Ag" Early $r"ga'y +ail)r" • • Da#ag" to ot("r orgas •
ADENOMYOSIS Edo#"trial glads d""$ it(i t(" #yo#"tri)# U?o "tiology • Di"r"t ty$" o+ $ati"t ad $r"s"tatio • RIS FA6TORS TREATMENT M)lti$aro)s o#" Id)'" a#"orr("a : s& r"')r o'" tr"at#"t is sto$$"d. • at" t(irti"s or "arly +orti"s Hyst"r"'to#y is t(" oly d"itiv" tr"at#"t • S"v"r" s$as#odi' dys#"orr("a M"orr(agia B)l?y )t"r)s Diagosis o+t" (istologi'al o "&a#iatio o+ (yst"r"'to#y sa#$l" •
• • • • • •
$"A 4#/<"H A ''$''1$%" /bstetric Care /becti,e
etal rowth
"he normal +etal rowth pattern
•
D"'r"as" t(" #at"ral ad $"riatal #or!idity ad #ortality
•
•
Ho to a'(i"v" t("s" o!"'tiv"s 1. Early 'or#atio o+ dat"s %. D"t"'tio o+ 'og"ital #al+or#atios ,. D"t"'tig +"tal (y$o&ia 9. D"t"'tig a!or#al +"tal grot(
F"tal grot( is d"$"d"t o g""ti'/ $la'"tal ad #at"ral +a'tors. F"tal grot( r"stri'tio is t(" s"'od l"adig 'a)s" o+ $"riatal #or!idity ad #ortality.
'mall +or estational ae •
S#all +or g"statioal ag" is d""d as a +"tal !irt( "ig(t !"lo t(" 12t( '"til" +or t(" stat"d g"statioal ag". • T(" i'id"'" o+ SGA +"t)s"s is >:123
1-, o+ t(" "v"t)al !irt( is r"a'("d !y %J ""?s /b !y ,1 ""?s / %-, !y ,9 ""?s
Constitutionally 'mall etus •
U+ort)at"ly/ it 'a !" 'o'l)d"d t(at a +"t)s is 'ostit)tioally s#all oly a+t"r $at(ologi' $ro'"ss"s (av" !"" "&'l)d"d. • T("r"+or"/ id"ti'atio o+ a 'ostit)tioally s#all i+at is )s)ally #ad" i r"tros$"'t/ a+t"r t(" i+at is !or
1. %. ,. 9. >. .
D"t"r#iats o+ +"tal grot( ar" #)lti: +a'torial 4 Ra'" G"ogra$(i'al ar"a S"& 7M0F8 Mat"ral ag" Mat"ral "ig(t ad ("ig(t So'io"'oo#i' stat)s
Assesin +etal rowth 2.History
8.$=amination
1. Mot("rKs ag" %. A'')ra'y o+ MP dat" ,. I+"'tios d)rig $r"ga'y 9. M)lti$l" $r"ga'y
G""ral "&a#iatio O!st"tri' "&a#iatio Uterine +undal ht
Uterus sie
>. At"atal 'ar" ad visits . S)$$l"#"ts . Past o!s. History J. Past #"di'al (istory . Dr)g (istory 12.Fa#ily (istory 11.So'io"'oo#i' (istory
•
O!taiig s"rial )t"ri" +)dal ("ig(t • #"as)r"#"ts. • T(" cM'doalds r)l" i $r"ga'y is • a ro)g( d"t"r#iatio o+ +"tal ag" i ""?s
Eval)atig t(" si*" o+ t(" )t"r)s !y $"lvi' "&a#iatio i t(" rst tri#"st"r ad s)!s";)"t at"atal visits Ut"ri" si*" Misl"adig i4 F)ll !ladd"r/ o!"sity/ d""$ #ass"s/ )t"ri" !roids 5#)lti$l" $r"ga'y
Assesin +etal rowth .In,estiation: U>' Uses o+ U'
!ianosis and Con0rmation o+ &iability
!etermination o+ 4A and assessment o+ +etal sie and rowth
1. Diagosis ad 'or#atio o+ via!ility i "arly $r"ga'y %. D"t"r#iatio o+ g"statioal ag" ad ass"ss#"t o+ +"tal si*" ,. Itra)t"ri" or E'to$i' $r"ga'y. 9. M)lti$l" $r"ga'y >. Diagosis o+ +"tal a!or#aliti"s . Pla'"tal lo'ali*atio . Ass"ss#"t o+ +"tal "ll: !"ig
D"t"'tio o+ 4
a. !. '. d.
6ro:R)#$ l"gt( Bi$ari"tal dia#"t"r H"ad 'ir')#+"r"'" A!do#ial 'ir')#+"r"'" ". F"#oral l"gt(
G"statioal sa' 79:> ?s8 Yol? sa' 7> ?s8 E#!ryo 7>: ?s8 @isi!l" ("art !"at 7 ?s8.
U$ to 1, ?s 4 : 6ro:R)#$ "gt( 76R8 +ro# 1 to %9 ?s 4 : H"ad 'ir')#+"r"'" 7H68 : Bi$ari"tal Dia#"t"r 7BPD8 : F"#)r l"gt( 7F8
a.Crown-#ump enth (C#) • • • •
Fro# 6ro to 6o''y& 7R)#$8 7logit)dial a&is8. A'')rat" )$ to 19 ?s 71st TM8. It is t(" #ost a'')rat" $ara#"t"r. Provid"s a'')ra'y o+ =-: > days +ro# t(" GA.
.In,estiation: U>' b. i-parietal !iameter (P!) • T(" trasv"rs" idt( o+ t(" ("ad at its
• • •
id"st 7t(" dista'" !"t"" t(" $ari"tal !o"s "#i"'" o+ t(" s?)ll8. A'')rat" )$ to 1:%9 ?s. Provid"s a'')ra'y o+ =-: days. It is a"'t"d !y t(" s(a$" o+ t(" ("ad.
•
Not a"'t"d !y t(" s(a$" o+ t(" ("ad.
c.Head circum+erence (HC)
.In,estiation: U>' d. emur lenth () • •
e.Abdominal circum+erence (AC)
B"tt"r t(a BPD i a'')ra'y ad ti#ig. A'')rat" oly (" t(" i#ag" s(os to !l)t"d "ds o+ t(" +"#)r.
It is t(" #ost a'')rat" sigl" $r"di'tor o+ +"tal "ig(t.
• •
IU4#
Is .. Fail)r" o+ t(" +"t)s to a'(i"v" its grot( $ot"tial Tr)" or Fals"W •
All SGA i+ats ar" IUGR Fals" •
All IUGR i+ats ar" SGA
It is #ad" at t(" id"st $oits i t(" a!do#". It is t(" #ost a'')rat" sigl" $r"di'tor o+ +"tal "ig(t.
IU4# and '4A
Incidence • • • •
, : 12 3 o+ all $r"ga'i"s. %2 3 o+ still!ors ar" grot( r"tard"d. : % 3 (av" aato#i' ad-or g""ti' a!or#aliti"s. P"riatal #ortality is J : 12 ti#"s (ig("r +or t("s" +"t)s"s.
Fals" Classi0cation o+ IU4#
1aternal causes
•
Physioloical
Patholoical
M)lti$l" $r"ga'y
1. D"'r"as" Ut"ro$la'"tal !lood Co4
•
•
•
Sy##"tri'al grot( r"stri'tio4 +"t)s (os" "tir" !ody is $ro$ortioally s#all. I'id"'" 4 %2 3 Asy##"tri'al grot( r"stri'tio4 D"'r"as" i s)!')ta"o)s +at ad a!do#ial 'ir')#+"r"'" it( r"lativ" s$arig o+ ("ad 'ir')#+"r"'" ad +"#)r l"gt(. I'id"'" 4 J2 3
: S(ort stat)r" : Yo)g"r or old"r ag" 71> ad 09>8 : o so'io"'oo#i' 'lass : Pri#i$arity : Grad #)lti$arity : o $r"ga'y "ig(t : Pr"vio)s (-o $r"t"r# IUGR !a!y
•
Pr" "'la#$sia "'la#$sia • '(roi' r"ovas')lar dis"as" • 6(roi' (y$"rt"sio %. Mat"ral #al)tritio ,. Mat"ral (y$o&"#ia : H"#oglo!io$at(i"s : Hig( altit)d"s 9. Dr)gs : 6igar"tt"s/ al'o(ol/ ("roi/ 'o'ai" : T"ratog"s/ ati#"ta!olit"s ad t("ra$")ti' ag"ts s)'( as tri#"t(adio"/ ar+ari/ $("ytoi : 6(roi' ill"ss 7 DM/ r"al +ail)r"/ 'yaoti' ("art dis"as"
"t'.8
etal causes Physioloical
Placental Causes Patholoical
•
Pla'"tal is)L'i"'y 7 #ost
: G""ti' Fa'tors4 : Ra'"/ "t(i'ity/ atioality : s"& 7#al" "ig( 1>2 :%22 g# #or" +"#al" 8 : $arity 7$ri#i$aro)s/ "ig( l"ss t(a s)!s";)"t si!ligs8
•
G""ti' disord"rs 7A'(odro$lasia/ R)ss"ll : silv"r sy.8 • 6(ro#oso#al ao#ali"s4 : 6(ro#oso#al d"l"tios
• o o o
: triso#i"s 1,/1J 5 %1 o
•
6og"ital #al+or#atios4 "g4 A"'"$(aly/ GI atr"sia/ $ott"rKs sydro#"/ ad $a'r"ati' ag""sis.
•
i#$ i ,rd tri#"st"r8 Aato#i' $ro!l"#s4 M)lti$l" i+ar'ts A!"rrat 'ord is"rtios U#!ili'al vas')lar t(ro#!osis 5 ("#agio#as Pr"#at)r" Pr"#at)r" $la'"tal s"$aratio S#all Pla'"ta
•
F"tal 6ardiovas')lar ao#ali"s 6og"ital I+"'tios4#aily TOR6H i+"'tios. • I!or "rror o+ #"ta!olis#4 : Trasi"t Trasi"t "oatal dia!"t"s
: Gala'tos"#ia : PU !ianosis o+ IU4# • • •
History P(ysi'al "&a#iatio Iv"stigatios
•
U>'
• •
•
•
•
A!do#ial 'ir')#+"r"'" is t(" sigl" #ost ""'tiv" $ara#"t"r +or $r"di'tig +"tal "ig(t !"'a)s" itKs r"d)'"d i !ot( sy##"tri'al 5 Asy##"tri'al IUGR . I t(" $r"s"'" o+ or#al ("ad ad +"#)r #"as)r"#"ts/ a!do#ial 'ir')#+"r"'" 7A68 #"as)r"#"ts o+ l"ss t(a % stadard d"viatios !"lo
Asy##"tri'al grot( r"stri'tio4 BPD is or#al i t(" ,rd tri#"st"r / ("r"as ratio o+ H6-A6 is a!or#al . Sy##"tri'al grot( r"stri'tio 4 H6-A6 #ay !" or#al . a#ioti' C)id vol)#"s 7 oligo(ydra#ios is asso'iat"d it( IUGR8 . U#!ili'al art"ry 5 +"tal art"ry do$$lar ass"ss#"ts 4 i'r"as"d r"sista'" is asso'iat"d it( a gr"at"r ris? o+ IUGR as $r"ga'y $rogr"ss"s. $rogr"ss"s.
t(" #"a a$$"ar to !" a r"asoa!l" ')t o to 'osid"r a +"t)s asy##"tri'.
Complications o+ IU4# Antenatal Complications
Intrapartum complications:
•
• • •
• • • •
M"ta!oli' '(ag"s 7a'idosis/..8. Oligo(ydra#ios 7J238 A!or#al +"tal ("art $att"rs. A!or#al Do$$l"r st)di"s. Itra )t"ri" +"tal d"at(.
•
%eonatal complications
1: r"lat"d to (y$o&ia %: #"ta!oli'4 A!or#al 6TG. ad a'idosis4 F"tal d"at(. a: M"'oi)# stai"d a: #"'oi)# (y$ogly'"#ia li;)or. I'r"as"d i'id"'" as$iratio. !: o+ istr)#"tal ad !: $"rsist"t +"tal (y$o'al'a"#ia 'a"sar"a d"liv"ri"s. 'ir')latio. ': (y$ot("r#ia ': (y$o&i' is'("#i' d: "'"$(alo$at(y (y$"rvis'o'ity
,: r"lat"d to t(" "tiology4 a: '(ro#oso#al a!. !: i+"'tio. ': 'og"ital ao#ali"s.
sydro#" 1anaement Principles Pre-prenancy
!urin prenancy (Ante-partum)
•
• •
•
Modi+y li+"styl" (a!its. D"t"'t ad tr"at #"di'al disord"rs.
R"g)lar at"atal 'ar". S"rial +"tal grot( ass"ss#"t. • S"rial +"tal "ll!"ig ass"ss#"t 1:Bio$(ysi'al $rol" %:6o#$)t"ri*"d 6TG ,:U#!li'al art"ry Do$$l"r d"liv"ry. • Ti#ig o+ d"liv"ry. • Mod" o+ d"liv"ry.
1ode o+ deli,ery
Ti#" 5 Mod" o+ d"liv"ry gov"r"d !y4
•
6"sar"a d"liv"ry it(o)t a trial o+ la!or4 1. i t(" $r"s"'" o+ "vid"'" o+ +"tal distr"ss
• • • • • • •
#at"ral ag" $ast o!s. History g"statioal ag" +"tal "ll !"ig stat)s o+ '"rvi& availa!ility o+ dir"'t #oitorig d)rig la!or. la!or. E&4 s'al$ PH sa#$lig.
%. +or traditioal o!st"tri'al idi'atios +or '"sar"a d"liv"ry • Id)'tio o+ la!or 'oti)o)s ("art rat" #oitorig ad s'al$ $H #oitorig o$ti#i*" s)''"ss o+ vagial d"liv"ry
I#/I!' •
Fi!roids7"io#yo#as re9uency 8 ar" "ll: • It is t(" 'ir')#s'ri!"d 'o##o"st !"ig )t"ri" t)#or o+ t(" t)#ors +"#al" g"ital • Aris" +ro# t(" tra't ov"rgrot( o+ B"ig $r"s"t i • s#oot( #)s'l" ad at l"ast %23 o+ 6T i t(" )t"r)s o#" ov"r t(" • T("y ar" #oo'loal ag" o+ ,>
#ace •
•
Ae
"io#yo#as o'')r • #or" 'o##oly i !la'? o#" t(a (it" o#"/ it( a !la'?:to:(it" ratio o+ ,:41 I 6a)'asia/ !)t ot !la'? o#" it • is asso'iat"d it(
"io#yo# as o'')r #ost 'o##oly i o#" old"r t(a ,2 y"ars B)t t("y #ay o'')r
Anatomy •
Mostly o'')r i t(" +)d)s ad !ody o+ t(" )t"r)s oly ,3 o'')r i t(" '"rvi& • T("y #ay !" solitary/ #)lti$" or di)s" >3 ar" itra#)ral o o S)!s"rosal- "&o$(yti'/ t("y 'a !"'o#" $"d)')lat"d
$roli+"ratio o+ s#oot( #)s'l" '"lls (i'( also 'otais so#" !ro)s 6T "l"#"ts
• T(" $"a? ag" o+
i'id"'" o+ sy#$to#s is !"t"" ,>:9> y"ars
)lli$arity or r"lativ" i+"rtility
i F o+ ay ag"
o
Hormonal eDects
1ortality>1orbidity
In+ertility
•
•
•
Grot( #ay !" r"lat"d to "strog" sti#)latio o Bot( "strog" ad $rog"sti r"'"$tors ar" $r"s"t i !roids El"vat"d "strog"s o l"v"ls #y 'a)s" !roid "larg"#"t. D)rig t(" 1st tri#"st"r o+ $r"ga'y/ 1>:,23 o+ !roids #ay "larg" t(" s(ri? I $)"r$"ri)#. So#" !roids #ay d"'r"as" i si*" d)rig $r"ga'y Fi!roids Fi!roids #ay s(ri? o a+t"r #"o$a)s". So#" r"grot( #ay o'')r it( (or#oal t("ra$y
Clinical details
1alinant '(ag" to
!"'o#" a sar'o#a o T(" tr)" i'id"'" o+ #aligat tras+or#atio is diL')lt to d"t"r#i" !"'a)s" l"io#yo#as ar" 'o##o/ ("r"as #aligat l"io#yosar'o#as ar" rar" ad 'a aris" d" ovo T(" i'id"'" o+ o #aligat d"g""ratio is l"ss t(a 1.23 ad (as !"" "sti#at"d to !" as lo as 2.%3
o
May o'')r as a r"s)lt o+ o Narroig o+ t(" ist(#i' $ortio o+ t(" +allo$ia t)!" Or as a r"s)lt o+ o it"r+"r"'" it( i#$latatio/ "s$"'ially it"r+"r"'" 'a)s"d !y s)!#)'osal !roids
Rar"ly/ t("y #ay o'')r i t(" !road liga#"t S)!#)'osals)!"do#"trial !roids ar" t(" l"ast 'o##o. T("y 'a $r"s"t as !roid $oly$
Complications durin prenancy
1. S$o S$ota ta" "o) o)ss #is'arriag" %. IUGR ,. Pr":t Pr":t"r "r# # la!o)r la!o)r 9. Ut"ri Ut"ri" " dys?i dys?i"si "siaai"rtia d)rig la!o)r >. O!str) O!str)'ti 'tio o o+ t(" t(" !irt( !irt( 'aal . PPH . Hydro Hydro"$ "$(r (rosis osis
• • • •
Most o#" it( !roids ar" asy#$to#ati' Oly 12:%23 o+ $t r";)ir" t&t Sy#$to#s o+ !roids ar" r"lat"d to t(" 7lo'atio/ si*" ad t(" k o+ t(" t)#ors8 Sy#$to#s #ay i'l)d" t(" +olloig
2.leedin
8.Pressure
.Pain
•
1. O !ladd"r Fr";)"'y/ )rg"'y =-: o i'oti"'" %. O t(" 'olo 6osti$atio o DiL')lt d"+"'atio o o R"'tal $ai ,. A!do#ial 'ra#$ig r"s)lts +ro# $r"ss)r" o t(" s#all !o"l 9. G""rali*"d $"lvi' 5- lo"r a!do#ial dis'o#+ort #ay !" $r"s"t
•
•
M"orr(agia o I'r"as"d a#o)t 5 d)ratio o+ Co Is t(" #ost 'o##o sy#$to# o May r"s)lt i s"v"r" a"#ia ad 'a !" li+" t(r"at"ig/ alt(o)g( t(is is rar" Us)ally r"s)lts +ro# t(" "rosio o+ o a s)!#)'osal !roid ito t(" "do#"trial 'avity Rar"ly/ dilat"d v"is o t(" s)r+a'" o+ a s)!s"rosal $"d)')lat"d !roid 'a 'a)s" s)dd" #assiv" itra$"rito"al !l""dig
• •
o#" #ay "&$"ri"'" a!do#ial 'ra#$ig Pai )s)ally is +"lt d)rig #"str)atio "ss o+t"/ $ai o'')rs it"r#"str)ally
E./thers •
•
Rar" 'a)s"s o+ s"'odary $oly'yt("#ia/ ')r"d it( (yst"r"'to#y ar" r"$ort"d I+"rtility ad-or 'o#$li'atios o+ $r"ga'y #ay o'')r. S)!#)'osal !roids #ay a"'t +"rtility
Complicated 0broids
1. %. ,. 9.
Torsio o+ t(" $"di'l" H"#orr(ag" I+"'tio 7)s)ally at t(" ti$ o+ t(" !roid $oly$8 Hyali" d"g""ratio4 $r"s"t to so#" d"gr"" i #ost #od"rat" o to larg" !roids It !"'o#"s $ai+)l/ "larg"d ad so+t o >. 6ysti' d"g""ratio
. R"d d"g""ratio 7"'ro!iosis8 O'')r ty$i'ally i $r"ga'y o Is d)" to i+ar'tio o+ t(" '"t"r o+ t(" t)#or d)rig #id: o $r"ga'y 6(ara't"risti'ally/ t(" !roid s)dd"ly "larg"s ad is o $ai+)l 5 t"d"r o It 'a !" #ista?" it( PA- a')t" a!do#ial "#"rg"'y o I $r"ga'y it is tr"at"d 'os"rvativ"ly . 6al'i'atio o Us)ally s"" i $ost:#"o$a)sal ad-or $"d)')lat"d !roid
J. Maligat '(ag"
In,estiations
U>' appearance
"reatment
• •
• T(" #ost +r";)"t is t(at o+ a
1. 6os"rvativ" T(" t)#or is s#all ad asy#$to#ati' o i $r"ga'y N"ar #"o$a)s" ad asy#$to#ati' o %. M"di'al 7HRH aalog)"s8/ s(ort t"r# o 6otra:idi'atio +or s)rg"ry o Ad)'t to s)rg"ry i a larg" !roids ,. S)rg"ry Sy#$to#ati' !roids o Ra$idly groig !roids o Diagosis is i do)!t o i?"ly to 'o#$li'at" +)t)r" $r"ga'y o 9. E#!oli*atio
U-S is t(" $r"+"rr"d #"t(od I so#" $t/ MRI $rovid"s additioal i+or#atio • T(" rol" o+ 6T is li#it"d o 6al'i'atios #ay !" #or" visi!l" o 6T s'as t(a o 'ov"tioal radiogra$(s !"'a)s" o+ t(" s)$"rior 'otrast di"r"tiatio it( 6T
• •
•
• •
•
'o'"tri'/ solid/ (y$o"'(oi' #as T(is a$$"ara'" r"s)lts +ro# t(" $r"vailig #)s'l" T("s" solid #ass"s a!sor! so)d av"s ad/ t("r"+or"/ 'a)s" a varia!l" a#o)t o+ a'o)sti' s(adoig @aria!l" d"gr"" o+ "'(og"i'ity/ d"$"dig o t(" a#o)t o+ !ro)s tiss)" ad-or 'al'i'atio Fi!roids #ay (av" a"'(oi' 'o#$o"ts r"s)ltig +ro# "'rosis Fi!roids i t(" lo"r )t"ri" s"g#"t #ay o!str)'t t(" )t"ri" 'aal/ 'a)sig C)id to a'')#)lat" i t(" "do#"trial 'aal T(" "'(og"i' "do#"trial stria" #ay !" dis$la'"d !y a !roid. 6al'i'atios ar" (y$"r"'(oi'/ it( s(ar$ a'o)sti'
Hysterectomy is t(" d"itiv" t&t 1yomectomy i o#" (o ar"
s)!+"rtil"- t(os" (o r"+)s" (yst"r"'to#y
s(adoig. Di)s" l"io#yo#atosis GENITA PROAPSE G"ital $rola$s" is t(" doard d"s'"t o+ t(" )t"r)s ad -or t(" vagia toards or t(ro)g( t(" itroit)s O'')rr i a!o)t 12:,23 o+ #)lti$aro)s o#" ad i %3 o+ )lli$aro)s o#" . TYPES PE@I6 SUPPORT ETIOOGY 5 PATHOPHYSIO PRE@ENTION UTERINE @AGINA UTERUS "a?"ig o+ ad da#ag" to t(" G"ital s)$$ortig str)'t)r"s o+ t(" $"lvi' $rola$s" is a 1st d"gr""4 6ysto'"l"4 Prola$s" i8 Trasv"rs" Z orgas4 $r"v"ta!l" 6ardial Z D"s'"t o+ t(" o+ t(" )$$"r %-, o+ 1. 6(ild!irt(4 7#ost i#$8 dis"as" Ma'?"rodtKs '"rvi& it(i t(" at"rior vagial I'r"asig $arity/ $rolog"d la!o)r/ 1. Pr"v"tio '"rvi'al t(" vagia. all ad t(" !"arig do !"+or" +)ll '"rvi'al d)rig liga#"ts. %d d"gr""4 !ladd"r. dilatatio ad diL')lt istr)#"tal '(ild!irt(4 ii8 Ut"rosa'ral D"s'"t o+ t(" Ur"t(ro'"l"4 d"liv"ri"s. Good la!or liga#"ts '"rvi& t(r) t(" Prola$s" o+ t(" %. 6(roi' "l"vatio i itra: #aag"#"t/ iii8 P)!o'"rvi'al itroit)s. lo"st 1-, o+ t(" a!do#ial $r"ss)r"4 O!"sity/ $ostatal $"lvi' liga#"ts ,rd d"gr"" at"rior vagial s#o?ig/ '(roi' 'o)g(/ '(roi' Coor "&"r'is"s/ all ad t(" 7Pro'id"tia84 'osti$/ ("avy li+tig at or?/ a!d +a#ily $laig. DoKt giv" )r"t(ra. D"s'"t o+ t(" #ass"s ad as'it"s . %. Avoidig ↑ '"rvi& ad t(" R"'to'"l"4 Prola$s" s)$$ort to t(" ,. M"o$a)s"4 "a?"ss o+ t(" $"lvi' )t"r)s/ i" !road (ol" )t"r)s o+ t(" $ost"rior itra:a!d s)$$ort d)" to _ 'ollag" ad liga#"ts/ ro)d t(ro)g( t(" vagial all ad $r"ss)r" "a?"ss o+ t(" 'o"'tiv" tiss)" liga#"ts ad t(" itroit)s. t(" r"'t)#. O!"sity / 9. P"lvi' s)rg"ry 4 l"vator ai Et"ro'"l"4 Tr)" s#o?ig/ A!d vagial (yst"r"'to#y ` #)s'l"s '(roi' 'o)g( ("ria o+ t(" $o)'( @a)lt $rola$s" ad '(roi' o+ Do)glas t(ro)g( @AGINA
t(" $ost"rior vagial +ori& : #ay 'otai !o"l or o#"t)#. @a)lt $rola$s"4 Iv"rsio o+ t(" vagial a$"& (i'( o'')r a+t"r a!do#ial or vagial (yst"r"'to#y.
P"lvi' Coor #)s'l"s 7t(" l"vator ai #)s'l"s c#aily ad t(" s)$"r'ial ad d""$ trasv"rs" $"ri"al #)s'l"s8 ad !y t(" $"lvi' Coor +as'ia.
6o#$os)s$"sio ` R"'to'"l" ad "t"ro'"l". >. 6og"ital $rola$s"d : 'og"ital _ a#o)t o+ 'ollag" ad "a?"ss o+ 'o"'tiv" tiss)" o+ t(" $"lvi' s)$$ort. For t(" $rola$s" i %3 o+ )lli$aro)s o#" . . Ra'ial variatio . 6o##o i 6a)'asia o#" / l"ss 'o##o i Asias / ad rar" i Bla'?s . @ariatio i t(" a#o)t o+ 'ollag" ad 'o"'tiv" tiss)" i t(" $"lvi' s)$$ort.
'osti$atio ,. Pr"v"tio $ost#"o$a )sal4 Bala'"d di"t/ "&"r'is"/ 'al'i)# 5 !y t(" i'r"as"d )s" o+ HRT.
DIAGNOSIS EAMINATION DD&4 : Is$"'tio o+ t(" v)lva it( 'o)g( ad • At"rior straiig < d"#ostrat" s"v"r" $rola$s" ad vagial all • A +""lig o+ so#"t(ig 'o#ig do !"lo or a l)#$ #ay d"#ostrat" str"ss i'oti"'" $rola$s"4 7$rovid"d t(" !ladd"r is +)ll8 it(i t(" vagia or $rotr)dig +ro# t(" itroit)s : DD&4 6og"ital : S$"')l)# "&a#iatio <"it("r dorsal Gart"rKs 'yst/ ors" at t(" "d o+ t(" day/ ↑o stadig ad $ositio 7Bivalv"8 or l"+t lat"ral $ositio i'l)sio d"r#oid 'o)g(ig/ ad _ !y lyig do. 7Si#s8. 'yst 5 )r"t(ral : Ot("r s&/ d"$"ds o t(" orga (i'( $rola$s"d ito : R"'tal "&a#iatio : di"r"tiat" !"t"" div"rti')l)#. t(" vagia. r"'to'"l" 7g"r go"s t(r) it8 +ro# • Ut"ri" • Ut"ri" $rola$s"4 o !a'?a'(" : '"tral/ ors" at "t"ro'"l" 7g"r go"s (ig( )$8 . $rola$s"4 t(" "d o+ t(" day/ ↑o stadig ad _ !y lyig DD&4 larg" do. IN@ESTIGATIONS4 '"rvi'al or • 6ysto'"l"4 Uriary s&/ $t (as to r"d)'" t(" 'ysto'"l" : MSU +or aalysis ad ')lt)r". "do#"trial to "#$ty ("r !ladd"r. : R"al )ltraso)d ad I@U i 'as"s o+ $oly$ 5 '(roi' • R"'to'"l"4 6osti$atio/ i'o#$l"t" r"'tal $ro'id"tia ad s"v"r" 'ysto'"l" to "&'l)d" )t"ri" iv"rsio "va')atio ad t(" $ati"t (as to r"d)'" t(" (ydro)r"t"r 5 (ydro"$(rosis. r"'to'"l" digitally to "#$ty ("r r"'t)#. : 6ysto#"try i 'as"s o+ i'oti"'"/ to "&'l)d" )rg" i'oti"'" • Pro'id"tia4 Ul'"r/ !lood stai"d or $)r)l"t vagial dis'(arg". 6oital $ro!l"#s : )'o#+orta!l" or diL')lt it"r'o)rs" < i )t"ri" ad vagial $rola$s". MANAGEMENT 6ONSER@ATI@E TREATMENT4 PESSARY INDI6ATIONS TYPES SIDE EFFE6TS 5 THEIR MANAGEMENT : Pati"t )t +or s)rg"ry . @agial i+"'tio ad dis'(arg"/ )l'"ratio ad !l""dig. • Rig $"ssary < : Pati"t r"+)s"s s)rg"ry . 'o##oly )s"d : D)rig $r"ga'y ad a+t"r d"liv"ry . Pr"'a)tios4 $"ssary. : D)rig aitig ti#" +or s)rg"ry. Us" sili'o $"ssary. • S("l+ $"ssary < : As a t("ra$")ti' t"st to 'or# t(at 6(ag" t(" $"ssary y"arly or "arli"r i+ i+"'tio or rar"ly )s"d HISTORY S& d"$"ds o t(" sit"/ ty$" 5 d"gr"" o+ t(" $rola$s"d.
s)rg"ry #ay ("l$.
)l'"ratio o'')rr"d. Us" o+ vagial "strog" 'r"a# i #"o$a)sal $ati"ts.
SURGI6A TREATMENT PRE:OPERATI@E ASSESSMENT TYPE OF SURGERY Ai#s o+ s)rg"ry4 6orr"'t $rola$s"/ #aitai D"$"ds o4 1. Ty$" o+ $rola$s"d/ %. Ag" ad $arity o+ t(" $ati"t UTERINE @AGINA EFORT 'oti"'" ad $r"s"rv" 'oital +)'tio. i. @agial (yst"r"'to#y
• •
R"')rr"'" o'')r i a!o)t %2:%>3 Ev" it( "&$"rt s)rg"ry ad good $osto$"rativ" 'ar"/ r"')rr"'" 'a o'')r/ "s$ i t(" $r"s"'" o+ o!"sity/ s#o?ig ad 'osti$atio.
,. At"rior ad $ost"rior r"$air.
vagia.
iii. Sa'ro(yst"ro$"&y I $ati"ts (o 'o#$l"t" t(" +a#ily ad is( to 'os"rv" t(" )t"r)s
4$'"A"I/%A !IA $"$' 1$I"U' (4!1) Classi0cation
•
•
Dia!"t"s #"llit)s ty$" I ::: is)li d"$"d"t 7"tosis:$ro"8 • Dia!"t"s #"llit)s ty$" II::: o: is)li d"$"d"t 7"tosis: r"sistat8 • I#$air"d Gl)'os" Tol"ra'" ad G"statioal Dia!"t"s 7IGT8 !iabetoenic $Dects o+ Prenancy • • •
Is)li r"sista'" I'r"as"d li$olysis Alt"r"d #at"ral
•
DM Fastig v"o)s gl)'os" 'o'"tratio 0 J.2 ##ol-l ad % (rs 7> g# load 8 0 11.2 ##ol-l 7or8 o" o+ t(" a!ov" = Sy#$to#s IGT Fastig J.22 ##ol-l/ !)t % (r 7> g# load8 7.2:12.8
How do diabetic pt present • • •
Sy#$to#s Ris? +a'tors 7 (istory 5 "&a#iatio8 Blood t"sts::s'r""ig
'creenin • • •
,23 (av" o" o+ t(" A!ov" ris? +a'tors Not all DM/ IGT/ (av" $"rsist"t gl)'os)ria >23 o+ $r"gat o#" (av" gl)'os)ria at so#" ti#"
Fasting
Normal
.J-G.K
Hours 8
.J L
And
Or
K.J-2J.K
K.JL
gl)'o"og""sis
#is* actors
DM/ IGT/ #)st !" s)s$"'t"d i Pr"gat o#" it( 1. Ag" 0 ,2 %. Fa#ily (istory o+ DM ,. Past (istory o+4 : Dia!"t"s i a $r"vio)s $r"ga'y
9. >. . .
O!"sity Hy$"rt"sio i #)lti$ara Poly(ydra#ios R"')rr"t i+"'tios4Uriary/ F)gal J. Sigi'at Gly'os)ria
: U"&$lai"d I.U.F.D./ N"oatal d"at( : 6og"ital a!or#aliti"s : R"')rr"t a!ortios : arg" !a!i"s 0 2 t( '"til" #is* +actors
Complications
Complications 1aternal •
/bstetric
etal •
: Poly(ydra#ios : $r":"'la#$sia 712: 1>38 •
!iabetic $merencies
: Hy$ogly'a"#ia : "toa'idosis
%eurol oic
: P"ri$("ral ")ro$at(y : Gastroit"stial dist)r!a'" •
In+ecti ons
(2) 1acrosomia "raumatic deli,ery
6"tral N"rvo)s syst"#
7,23 i s""#igly 'otroll"d8
: A"'"$(aly
cord is found2 suspect a high incidence of congenital anomalies
: Holo$ros"'"$(aly
(E) Intrauterine +etal !eath
(8) !elayed oran maturity (#!') = () Conenital mal+ormations:
: E'"$(alo'"l" S?"l"tal 5 s$ial
VV Note9 when a two*vessel
() 4rowth restriction 7i
adva'"d DM8
: Dia!"ti' 'o#a •
- Uriary
6ardiovas')lar 4 • Tras$ositio o+ gr"at
&ascular $nd-/rans
:R"al
• • •
: O$(t(al#i'
v"ss"ls @"tri')lar s"$tal d"+"'t Aorti' 'oar'tatio Artial s"$tal d"+"'t
:6a)dal r"gr"ssio G"ito)riary : R"al ag""sis : )r"t"ral d)$li'tio Gastroit"stial
: P"ri$("ral vas')lar
: aal atr"sia Complications (%eonatal)
Principles o+ manaement:
• • •
•
Hy$ogly'a"#ia RDS Hy$o'al'a"#ia
'tart in preconception time 'peci0c durin prenancy 'peci0c •
Control
•
Poly'yt(a"#ia
!iet:
Control :
2 =
• •
Carbohydrates
JO
• •
Fastig >.2 ##ol-1 % (rs P.P. .2 ##ol-1 Ad)st#"t (" "'"ssary Gly'osylat"d H! A1' 7r"tros$"'tiv"8
at
8JO
etal well bein:
Protein
8JO
AFP 1:1J ?s D"tail"d s'a 1:%2 ?s Bio$(ysi'al assay +ro# %J ?s • F"tal t. 5 grot( to ""?ly 7, rd8 • !eli,ery4 • •
Insulin: #eiment A M lnt. $,enin
3 times sol.-with meals
: Ti#ig d"$"ds o4 7Aro)d ,J ?s8
/r
Mat"ral +a'tors Bio'("#i'al 'otrol F"tal stat)s • : M"t(od ::: S6S i ay #"di'al or o!st"tri' 'o#$li'atio. •
- #eiment intermediate)
3 8 types (short
"wice !aily !ose (daily) N wt. (*) = J. 0rst = J.G second
•
VVIs)li dos" ad)st"d o (o)rly !asis it( 'alori' r";)ir"#"ts itrav"o)sly.
= J.Q third 8> in A.1.
8> 2nt M 2> short
2> in P.1.
2>8 2nt M R short.
4$'"A"I/%A "#/PH/A'"IC %$/PA'IA
Classi0cation o+ 4"%
4enetics o+ 4"%
$%I4%
1AI4%A%"
Hydatidi+or# #ol"
1. Ivasiv" #ol" %. 6(orio'ar'io#a ,. Pla'"tal:sit" tro$(o!lasti' t)#or
1. 6o#$l"t" #ol" %. Partial #ol"
6o#$l"t" #ol"4 t(" #aority o+ HM ar" 'o#$l"t" #ol"s ad (av" a 9 ?aryoty$"/ !ot( '(ro#oso#"s ar" $at"rally d"riv"d/ r"s)lt +ro# +"rtili*atio o+ a "#$ty ov)# !y a (a$loid s$"r# Partial #ol"4 t(" ?aryoty$" is )s)ally a tri$loid/ o+t" Y/ t(" r"#aiig l"sios ar" or YY 6(orio'ar'io#a4 )s)ally a")$loidy or $oly$loidy ty$i'al +or aa$lasti' 'ar'io#a
H5!A"I/#1 1/$ (H1) Clinical +eatures
!ianosis
Complete
@agial !l""dig4 t(" #ost 'o##o $r"s"tig sy#$to#/ o'')rs i 3o+ 'as"s E&'"ssiv" )t"ri" si*"4 larg" +or dat" is o" o+ t(" 'lassi' sigs/ o'')rs i >23 o+ 'as"s To&"#ia4 PET is o!s"rv"d i %3/ )s)ally d"v"lo$s "arly i t(" $r"ga'y Hy$"r"#"sis Gravidar)#4 O'')rs i %>3 o+ 'as"s
Partial
Hy$"rt(yroidis#4 'lii'ally "vid"t (y$"rt(yroidis# is o!s"rv"d i 3 Tro$(o!lasti' E#!oli*atio4 r"s$iratory distr"ss d"v"lo$s i a$$ro&i#at"ly %3 T("'a l)t"i ovaria 'ysts4 $ro#i"t 'ysts 0'# d"v"lo$ i >23 o+ 'as"s o"r a!do#ial $ai/ "&$)lsio o+ v"si'l"s
Pati"ts it( Partial HM )s)ally do ot (av" t(" 'lii'al +"at)r"s o+ 'o#$l"t" HM I g""ral/ t("s" $ati"ts $r"s"t it( sigs ad sy#$to#s o+ i'o#$l"t" or #iss"d a!ortio T(" diagosis #ay !" #ad" oly a+t"r (istologi' r"vi" o+ t(" ')r"ttig
Ultrasoogra$(y is a r"lia!l" ad s"sitiv" t"'(i;)" o+ 6o#$l"t" HM/ cSo stor# $att"r S"r)# B:H6G (ig("r t(a or#al $r"ga'y val)"s 6("st l# Blood t"sts4 FB6/ BGRH/ 6oag)latio $rol"/ FT/ FT
H5!A"I/#1 1/$ (H1)
FEATURES
PARTIA HM
6OMPETE HM
aryoty$"
Most 'o##oly /
Most 'o##oly 9/ or 9/Y
Or /Y PATHOOGY F"t)s
:
A#io/ +"tal RB6Ks
:
@illo)s "d"#a
@aria!l"/ +o'al
Tro$(o!lasti' $roli+"ratio Fo'al/ slig(t to #od"rat"
Di)s" Di)s"/ slig(t to s"v"r"
ollow up
T(" B:H6G radioi##)oassay is t(" #ost r"lia!l" assay availa!l" +or t(" #aag"#"t o+ $ati"ts it( GTN Folloig #olar "va')atio or (yst"r"'to#y / $ati"ts s(o)ld !" +ollo"d !y ""?ly d"t"r#iatio o+ B:H6G l"v"ls )til t("s" ar" or#al +or , 'os"')tiv" ""?s ad t(" !y #ot(ly d"t"r#iatio )til t(" l"v"ls ar" or#al +or 'os"')tiv" #ot(s
6ONTRA6EPTION
6INI6A PRESENTATION Diagosis
Miss"d a!ortio
Molar g"statio
Ut"ri" si*"
S#all +or dat"
>23 larg" +or dat"
T("'a l)t"i 'ysts
Rar"
1>:%>3
Post #olar #aligat
>3
:%23
E'o)rag" to )s" ""'tiv" 'otra'"$tio d)rig t(" "tir" it"rval o+ +ollo:)$. Itra)t"ri" d"vi'" s(o)ld ot !" is"rt"d )til t(" $ati"t a'(i"v"s a or#al B:(6G l"v"l I+ t(" $ati"t do"s ot d"sir" s)rgi'al st"rili*atio/ t(" '(oi'" is "it("r (or#oal 'otra'"$tio or !arri"r #"t(ods
s";)"la
"reatment 'UC"I/% CU#$""A4$
T(" $r"+"rr"d #"t(od o+ "va')atio / r"gardl"ss o+ )t"ri" si*" i $ati"ts (o d"sir" to $r"s"rv" +"rtility/ it ivolv"s t(" +olloig st"$s4 1. O&yto'i i+)sio: i t(" OR !"+or" t(" $ro'"d)r" %. 6"rvi'al dilatatio t(" S)'tio ')r"ttag" +ollo"d !y g"tl" s(ar$ ')r"ttag" ,. T(" s$"'i#"s o s)'tio ad s(ar$ ')r"ttag" s(o)ld !" s)!#itt"d s"$arat"ly +or $at(ology
H5'"$#$C"/15
I+ t(" $ati"t d"sir"s s)rgi'al st"rili*atio/ a (yst"r"'to#y #ay !" $"r+or#"d it( #ol" in situ. T(" ovari"s #ay !" $r"s"rv"d "v" t(o)g( t("'a l)t"i 'ysts ar" $r"s"t
P#/PH5AC"IC CH$1/"H$#AP5
6otrov"rsial Not idi'at"d i $ati"ts it( #olar $r"ga'y !"'a)s" 23 (av" s$ota"o)s r"#issios #ay !" )s"+)l i t(" #aag"#"t o+ (ig(:ris? 'o#$l"t" HM/ "s$"'ially (" (or#oal +ollo:)$ is )availa!l" or )r"lia!l"
1AI4%A%" 4"% %on-metastatic disease
1etastatic disease
I4/ stain
o'ally ivasiv" GTN M"tastati' GTN o'')rs i d"v"lo$s i 1>3 o+ 93 o+ $ati"ts a+t"r $ati"ts a+t"r "va')atio "va')atio o+ a 'o#$l"t" o+ a 'o#$l"t" #ol" ad #ol" ad i+r";)"t a+t"r i+r";)"tly a+t"r ot("r ot("r $r"ga'i"s g"statios M"tastasis is )s)ally T(" tro$(o!lasti' t)#or asso'iat"d it( #ay $"r+orat" t(ro)g( '(orio'ar'io#a t(" #yo#"tri)#/ 'a)sig Tro$(o!lasti' t)#or itra$"rito"al !l""dig/ $"r+)s"d !y a "tor? o+ or "rod" ito )t"ri" +ragil" ("#orr(agi' v"ss"ls/ 'a)sig v"ss"ls ("#orr(ag" Sy#$to#s o+ #"ts #ay A+t"r #olar "va')atio/ r"s)lt +ro# s$ota"o)s $"rsist"t GTN #ay !l""dig at #"tastati' "&(i!it +"at)r"s o+ "it("r sit"s HM or '(orio'ar'io#a R"lativ" i'id"'" o+ A+t"r o#olar $r"ga'y 'o##o #"tastati' sit"s / $"rsist"t GTN alays (as t(" +"at)r"s o+ )g J23 iv"r 123 '(orio'ar'io#a s
@agi a
,23
P"lvi s
%23
Brai
123
Bo" l/ ?id" y/ s$l""
>3
Ot("r
>3
RE@ISED FIGO S6ORING SYSTEM FIGO S'or" 9
2
Ag" 7y"ars8
,
0,
HM
A!ortio
At"'"d"t $r"ga'y $r"ga'y
1
%
T"r#
It"rval +ro# id"& Pr"ga'y7#ot(s8 01%
9
9:
:1%
Pr"tr"at#"t (6G l"v"l 7#IU-#l8 122/222 0122/222 arg"st t)#or si*" M"tastati' sit" Brai/ liv"r N)#!"r o+ #"ts J 0J Pr"vio)s +ail"d '("#o dr)g % or #or"
1222
1222:12/222
,:9'# l)g/ vagia 2
012/222:
> s$l""/ ?id"y
GI
1:9
9: sigl"
T(" total s'or" +or a $ati"t is o!tai"d !y addig t("
idivid)al s'or"s+or "a'( $rogosti' +a'tor Total s'or" 2: lo ris?/ or #or" (ig( ris? / FIGO STAGING FOR GTN Stag" I4 $ati"ts it( $"rsist"tly "l"vat"d (G6 l"v"ls a d t)#or 'o"d to t(" )t"ri" 'or$)s Stag" II4 Pati"ts it( #"tastasis to t(" vagia or $"lvis Stag" III4 $ati"ts it( $)l#oary #"tastasis it( or it(o)t )t"ri"/ vagial.or $"lvi' ivolv"#"t Stag" I@4 Pati"ts it( adva'"d dis"as" ad ivolv"#"t o+ t(" !rai/ liv"r/ ?id"ys/ or GIT !ianostic e,aluation
1. %. ,. 9.
A 'o#$l"t" (istory ad "&a#iatio M"as)r"#"t o+ t(" s"r)# (6G val)" H"$ati'/ t(yroid ad r"al +)'tio t"sts 6o#$l"t" !lood 'o)t
1etastatic wor*-up
1. %. ,. 9.
A '("st :Ray 6T s'a o+ t(" a!do#" ad $"lvis 6T or MRI s'a o+ t(" ("ad M"as)r"#"t o+ 6SF (6G l"v"l i+ ay #"tastati' dis"as" is $r"s"t ad t(" ("ad 6T is "gativ" >. S"l"'tiv" agiogra$(y o+ a!do#ial ad $"lvi' orgas i+ idi'at"d 1AI4%A%" 4"%
!ianosis o+ post H1 trophoblastic neoplasia
1. Plat"a) o+ (6G lasts +or +o)r #"as)r"#"t ov"r a $"riod o+ , ""?s or log"r/ i." +or days 1/ /19 ad %1 %. A ris" i (6G l"v"l +or t(r"" ""?ly 'os"')tiv" #"as)r"#"ts or log"r/ ov"r a $"riod o+ at l"ast to ""?s or #or"/ i." o day 1/ad 19 ,. Histologi'al diagosis o+ '(orio'ar'io#a (" (6G l"v"l r"#ais "l"vat"d +or #ot(s or #or" 1anaement %onmetastatic ('tae I)
Chemotherapy: Sigl" ag"t
'tae II and III
'("#ot("ra$y is t(" $r"+"rr"d tr"at#"t i $ati"ts it( stag" I dis"as" (o d"sir" to r"tai +"rtility
Hysterectomy Plus Chemotherapy: i+ t(" $ati"t o
log"r is("s to $r"s"rv" +"rtility/ (yst"r"'to#y it( ad)vat sigl" ag"t '("#ot("ra$y Protocol +or treatment o+ stae I 4"%
Initial : MT:FA i+ r"sistat/ sit'( to
A't:D or (yst"r"'to#y it( ad)vat '("#ot("ra$y #esistant: 6o#!iatio '("#ot("ra$y or (yst"r"'to#y it( ad)vat '("#o/ lo'al )t"ri" r"s"'tio ollow-up hC4: ""?ly )til or#al +or , ?/ t(" #ot(ly )til or#al +or 1% #o Contraception: 1% 'os"')tiv" #o o+ or#al (6G val)"s E-ecti(e contraception urin+ the entire inter(al of hormonal follo."up
'tae I&
ow ris* $ati"ts ar"
tr"at"d it( $ri#ary sigl":ag"t '("#ot("ra$y/ ad t(" Hih ris* $ati"ts ar" #aag"d it( $ri#ary 'o#!iatio '("#ot("ra$y
Protocol +or treatment o+ stae I& 4"%
Protocol +or treatment o+ stae II and III 4"%
/< #I';: Initial: MT:FA i+
r"sistat / sit'( to A't:D
#esistant to both:
6o#!iatio '("#ot("ra$y
Hih ris* Initial: 6o#!iatio
'("#ot("ra$y #esistant: S"'od:li" 'o#!iatio '("#ot("ra$y
/ollo. up an contraception are the same as in sta+e
All $ati"ts it( stag" I@ dis"as" s(o)ld !" tr"at"d it( $ri#ary 'o#!iatio '("#ot("ra$y ad t(" s"l"'tiv" )s" o+ radiatio t("ra$y ad s)rg"ry Initial: 'rain
6o#!iatio '("#ot("ra$y/ (ol":("ad irradiatio 6raioto#y to #aag" 'o#$li'atios R"s"'tio to #aag" 'o#$li'atios $i(er #esistant: S"'od:li" 'o#!iatio '("#ot("ra$y7 H"$ati' art"rial i+)sio ollow-up hC4 ""?ly )til or#al +or ,?/ t(" #ot(ly )til or#al +or %9#o Contraception Util t("r" (av" !"" %9 'os"')tiv" #o o+ or#al (6G
1AI4%A%" 4"% ("reatment-Chemotherapy) 'inle aent
Combination
1. !ethotreate 0 Us)ally giv" as a daily dos" +or > 'os"')tiv" days or "v"ry ot("r day +or J days/ alt"ratig it( +olii' a'id r"s')" 7asso'iat"d it( l"ss !o" #arro/ GIT/ ad liv"r to&i'ity 8 %. %ctinomycin D0 Giv" +or > 'os"')tiv" days or "v"ry ot("r ""? as a sigl" dos"
$1A-C/ #eimen +or patients with 4"% Course 2($1A)
1AC III : M"t(otr"&at":FA/ A't:D/ ad 6y'lo$(os$(a#id" !uration o+ treatment :
S"r)# (6G is #"as)r"d ""?ly a+t"r "a'( 'o)rs" o+ '("#ot("ra$y Ad";)at" r"s$os" is d""d as a +allig t(" (6G l"v"l !y 1log a+t"r a 'o)rs" o+ '("#ot("ra$y Sigl" ad 6o#!iatio '("#ot("ra$y s(o)ld !" giv" as o+t" as to&i'ity $"r#its )til t(" $ati"t a'(i"v"s t(r"" Eto$osid"/ Day 2 'os"')tiv" or#al (6G l"v"ls A'tio#y'i D ad Folii' A+t"r or#al (6G l"v"ls ar" attai"d/ at l"ast to a dditioal a'id %9(r a+t"r start o+ 'o)rs"s o+ '("#ot("ra$y ar" )d"rta?" to r"d)'" t(" ris? MT o+ r"la$s" 'econdary "umors: ")?"#ia/ 'olo 'a'"r/ #"lao#a ad Course 8 (C/) !r"ast 'a'"r @i'risti" ad Day 3 ertility outcome: No "vid"'" t(at $ati"ts it( GTN +ollo"d !y 6y'lo$(os$(a#id" '("#ot("ra$y (av" a adv"rs" $r"ga'y o)t'o#"
Eto$osid"/ Day 1 A'tio#y'i D ad M"t(otr"&at"
'or# or#al g"statio/ (istologi'al r"vi" o+ t(" $l a'"ta/ (6G #"as)r"#"t ""?s a+t"r 'o#$l"tio o+ t(" $r"ga'y to "&'l)d" o'')lt GTN CH/#I/CA#CI%/1A
Hig(ly #aligat t)#or it( a $r"dis$ositio to
PAC$%"A 'I"$ "#/PH/A'"IC "U1/# (P'"")
PSTT is a v"ry rar" ad )i;)" +or# o+ GTN/ r"$r"s"t a
(a"#atog"o)s s$r"ad Follos HM i ,:3 o+ 'as"s T(" orgas #ost +r";)"tly a"'t"d !y #"ts ar"/ l)g/ lo"r g"ital tra't/ !rai/ liv"r /?id"y ad GIT So#" 'as"s #ai+"st"d !y itra$"rito"al !l""dig s"'oday to r)$t)r" liv"r or r)$t)r"d t("'a l)t"i 'yst Pati"ts it( $)l#oary #"ts #ay $r"s"t it( (a"#o$tysis or r"s$ +ail)r" 6NS #"ts $r"s"ts it( ")rologi' sigs r"s)ltig +ro# s$ota"o)s !l""dig >23 o+ 'as"s +ollo HM Tr"at#"t it( EMA6O
GESTATIONA HTN BP r"adig m 192-2 ##Hg +or t(" rst ti#" a+t"r %2 ""?s o+ $r"ga'y ^ No $rot"i)ria ^ BP r"t)rs to or#al it(i 1% ""?s $ost$art)# 7i+ t(" BP "l"vatio $"rsists/ t(" o#a is diagos"d as (avig '(roi' (y$"rt"sio8 ^ Fial d& is oly
"o$lasti' tras+or#atio o+ it"r#"diat" tro$(o!lasti' '"lls PSTT 'a o'')r a+t"r a or#al $r"ga'y/ a!ortio/ t"r# d"liv"ry/ "'to$i' $r"ga'y or #olar $r"ga'y 6(ara't"ri*"d !y lo B:(6G l"v"ls/ "&$r"ssio o+ HP is i'"ras"d o (istologi' s"'tio ad as "ll as i t(" s"r)# Diagosis is 'or#"d !y dilatatio ad ')r"ttag" ad (yst"r"'to#y Most 'as"s ar" 'o"d to t(" )t"r)s !)t #"ts (as !"" r"$ort"d S)rg"ry is t(" $ri#ary tr"at#"t o+ '(oi'" Good $rogosis is ati'i$at"d i 'as"s lo'ali*"d to t(" )t"r)s/ it( distat #"ts or d"lay"d tr"at#"t t(" o)t'o#" is dis#al
HYPERTENSI@E DISORDERS IN PREGNAN6Y PREGNAN6Y:INDU6ED HTN PREGNAN6Y:AGGRA@ATED HTN PRE:E6AMPSIA E6AMPSIA Mild $r":"'la#$sia 6NS D"v"lo$#"t o+ PE or ^ BP m 192-2 ##Hg a+t"r ivolv"#"t "'la#$sia i $r":"&istig %2 ""?sK g"statio it( t(" (y$"rt"sio d"t"'t"d !y a ^ Prot"i)ria m 1= !y )ri" o'')rr"'" o+ +)rt("r i'r"as" o+ di$sti'? or a total $rot"i 'ov)lsios t(at 0 ,2 ##Hg i SBP or 01> l"v"l m ,22 #g-%9 (o)rs 'aot !" ##Hg i DBP : Pr":"'la#$sia 'a d"v"lo$ attri!)t"d to or !"+or" t(" %2 ""? o+ ot("r 'a)s"s N" os"t $rot"i)ria o+ g"statio i (ydatidi+or# 0,22 #g-%9 (o)rs i #ol" ad i t(" $r"s"'" o+ (y$"rt"siv" o#" !)t l)$)s ati'oag)lat it( o $rot"i)ria !"+or" %2 ""?s g"statio S"v"r" $r":"'la#$sia or ^ BP m 12 ##Hg systoli' A s)dd" i'r"as" i
6HRONI6 HTN ITH PREGNAN6Y Hy$"rt"sio is $r"s"t !"+or" $r"ga'y or d"t"'t"d !"+or" %2 ""?s Or Hy$"rt"sio rst diagos"d a+t"r %2 ""?s g"statio ad $"rsist"d a+t"r 1% ""?s $ost$art)#
#ad" $ost$art)# ^ May "v" !" asso'iat"d it( a i'r"as"d !irt( "ig(t
or 112 ##Hg diastoli' ^ Prot"i)ria m %= !y )ri" di$sti'? or a total $rot"i l"v"l o+ % g#-%9 (o)rs
$rot"i)ria or a dro$ i $lat"l"t 'o)t to 122/222-##, it( HTN ad $rot"i)ria !"+or" %2? g"statio
PREDISPOSING FA6TORS n Ag"4 PG%2/ all o#" 0 ,> n Parity4 PG (av" do)!l" i'id"'" n o"r so'io:"'oo#i' stat)s n G""ti' $r"dis$ositio4 R"'"ssiv" trait n O!st"tri' 'o#$li'atios4 #)lti$l" ad #olar $r"ga'y/ +"tal ("#olyti' dis"as"s 7(ydro$s +"talis8/ $oly(ydra#ios n E&istig #"di'al 'oditios4 '(r BP/ r" D/ DM/ SE/ ati$(os$(oli$id AS. n Pr"vio)s PE. T(" r"')rr"'" rat" +or PE it( t(" sa#" #al" $art"r is h %23/ ad )s)ally !"'o#"s a$$ar"t at lat"r g"statio t(a i t(" rst $r"ga'y n O!"sity4 9.,3 +or a o#" it( a !ody #ass id"& 1.J ?g-#% to 1,.,3 +or t(os" 0 ,> ?g-#%
FA6TORS THAT _ PET Prolog"d "&$os)r" to $at"ral Ag S#o?ig/ !)t i+ PE o'')rs t(" $"riatal #ortality tri$l"s Pla'"ta $r"via
PRE:E6AMPSIA 6AUSE 7UNNON8
THEORIES 7I8 D"+"'tiv" tro$(o!lasti' ivasio o+ t(" s$iral art"ri"s 7II8 I##)ologi' +a'tor 7III8 I'r"as"d $r"ssor r"s$os"s 7I@8 Prostagladis i#!ala'" 7@8 G""ti' $r"dis$ositio Is'("#ia 'o)ld !" d)" to4 : Ud"rlyig vas')lar '(ag"s 7HTNFail)r" o+ $(ysio '(gs o+ s$iral art"ri"s8 : I'r"as"d #yo#"trial r"sista'" o+ t(" #yo#"trial v"ss"ls/ (i'( 'o)ld !" r"lat"d to a ("ig(t""d #yo#"trial t"sio $rod)'"d !y t(" larg" +"t)s i a $ri#i$aro)s o#"/ !y tis/ or !y $oly(ydra#ios T(" $oorly $"r+)s"d tro$(o!last r"l"as" c+a'tor (i'( "t"rs #at"ral 'ir')latio ad 'a)s"s "dot("lial dys+)'tio ` I#!ala'" !"t"" di"r"t 'lass"s o+ lo'ally
PATHOPHYSIOOGY @ASOSPASM E&'"ss D"'r"as"d $rod)'tio$rod)'tio-s"siti s"sitivity to vity to vaso'ostri'tors vasodilators n Agiot"si II n Prosta'y'li n S"rotoi n Nitri' o&id" n Edot("li INTRA@AS6UAR 6OAGUATION n Plat"l"t a'tivatio n T(ro#!o'yto$"ia n R"d)'"d $rod)'tio o+ ati:t(ro#!i
ORGAN HYPOPERFUSION n id"y4 _ GFR/ $rot"i)ria/ (y$"r)ri'a"#ia/ olig)ria n iv"r4 SGOT/ SGPT/ "$igastri' $ai n Brai4 vis)al s'oto#ata d)" to o''i$ital lo!" is'("#ia/ ("ada'("/ 'ov)lsios 7"'la#$sia8
PASMA @OUME 6ONTRA6TION R"distri!)tio o+ C)id +ro# t(" itra: vas')lar to it"rstitial C)id s$a'"s so t(at total E6F vol)#" r"#ais
Sti#)latio o+ t(" #at"ral i##)" syst"# !y t(" "arly 'o'"$t)s ` Prod)'" !lo'?ig A! to atig"i' sit"s o t(" $la'"ta/ t()s $r"v"tig t(" r""'tio o+ t(" +"t)s ad $la'"ta. Hy$oi##)" r"s$os" r"s)lts i da#ag" o+ t(" $la'"ta ad s)!s";)"t PE. PE l"ss 'o##o i $r"vio)sly sti#)lat"d i##)ity 'oditios as4
PRE:E6AMPSIA DIAGNOSIS INDI6ATIONS OF SE@ERITY OF INDI6ATIONS TO TERMINATE PREGNAN6Y PRE:E6AMPSIA IN PRE:E6AMPSIA HISTORY IN@ESTIGATION n Pr"s"'" o+ sy#$to#s MATERNA FA6TORS FETA FA6TORS : P"rsist"t ("ada'(" or n P"rsoal (& n 6o#$l"t"d , ""?s n O!vio)s IUGR n 6B64 ↑ P6@ ad ot("r '"r"!ral or vis)al n Past (& n A!or#al liv"r- r"al n t(ro#!o'yto$"ia dist)r!a'"s n M"str)al (& +)'tios Oligo(ydra#ios n SGOT/ SGPT4 : P"rsist"t "$igastri' $ai n O!st"tri' (& El"vat"d liv"r "*y#"s n S"v"r" $r""'la#$sia/ IUFD n 6o#$laits ad n 6r"atii" 'l"ara'"/ n Diastoli' BP m 112 ##Hg "'la#$sia r"gardl"ss o+ n Pr"s"'" o+ n Prot"i)ria o+ %= or #or" !y (& o+ $r"s"t s"r)# 'r"atii"/ )ri' t(" g"statioal ag" 'og"ital +"tal )ri" di$sti'? or a total $rot"i $r"ga'y a'id/ total $rot"i i ^ I s"l"'t"d 'as"s o+ #al+or#atios i'o#$ati!l" )ri"/ ad !lood )r"a4 l"v"l o+ m% g#-lit"r i a %9:(o)r s"v"r" PET/ ("r" t(" )ri" sa#$lig "&$"rtis" ad it( li+" PHYSI6A EAM i#$air"d n A!or#al la! digs ";)i$#"t ar" availa!l"/ n 6oag)latio $rol"4 n Hy$"rt"sio n O!vio)s +"tal grot( "&$"'tat #aag"#"t PT/ PTT/ 'lot. ad n Ed"#a r"stri'tio #ay !" )d"rta?" +or !l""d. ti#" → i DI6. n O!st"tri' "&a# n N")rologi'al ""'ts4 +"tal idi'atios Fi!riog" ad FDP to ^ S'oto#ata/ (y$"rr"C"&ia diagos" DI6 ^ E'la#$ti' 'ov)lsios n F"tal S)rv"illa'" MANAGEMENT 6ON@USION ANTIHYPERTENSI@ TIMING OF DEI@ERY FUIDS END:ORGAN 6OMPI6ATIONS PROPHYAIS ES Mag"si)# s)l$(at" n Hydrala*i" n O'" t(" d& o+ 6ar"+) n 6os)#$tio 'oag)lo$at(y4 Ad#iist"r 7MgSO98 n Ni+"di$i" s"v"r" $r""'la#$sia l. $lat"l"ts-FFP oly i+ 'lii'al !l""dig. Blo'?s ")ro#)s')lar n a!"talol (as !"" 6olloid n Itra'raial ("#orr(ag"4S"v"r" 'od)'tio t(ro)g( n Sodi)# "sta!lis("d/ s. ("ada'(" i t(" $ost $art)# it( $r"h or !lo'?ig t(" r"l"as" o+ itro$r)ssid" t"r#iatio o+ "'la#$sia. 6T s'a a'"tyl'(oli" at NM\. $r"ga'y !"'o#"s R&4 6o#!i"d o!st"tri' ad ")ro i ,p To&i'ity4 N")roto&i'ity #adatory a+t"r (os$ 7oss o+ $at"llar r"C"&8 / $ati"t sta!ili*atio n S)! 'a$s)lar ("#ato#a4S"v"r" R"s$ d"$r"ssio 7RR n Mod" o+ d"liv"ry "$igastri' $ai=("$ato#"galy. US. 1%-#i8/ 6ardia' to&i'ity d"$"ds )$o R&46orr"'t 'oag)lo$at(y. I+ liv"r r)$t)r"/ 7'ardia' arr"st8 ("t("r4 T(" o#a tras+)sio = liv"r s)rg"ry. n Atidot"4 6al'i)# is i la!or/ T(" n HEP sydro#"4 A!or#al vas')lar
gl)'oat"
$rogr"ss o+ la!or/ T(" '"rvi& is t +or id)'tio.
to"/ vasos$as# ad 'oag)latio d"+"'ts. R&4D"liv"ry r"gardl"ss GA. St"roids. Plat"l"ts oly i+ %2?-#l. 6s"'tio i $lat"l"ts 0>2?-#l.
6INI6A FEATURES n Pr"#oitory $(as" n Toi' $(as" n 6loi' $(as" n 6o#a
E6AMPSIA MANAGEMENT EMERGEN6Y TREATMENT MONITORING DURING HOSPITA STAY 1. 6l"ar airay $assag"s n 6los" o!s"rvatio4 %. A$$ly a o&yg" #as? ^ Ev"ry ,2 #i)t"s ass"ss $)ls"/ BP ad r"s$iratory rat" ,. Prot"'t t(" $ati"t +ro# (ar# d)rig ^ Maitai a C)id !ala'" '(art #oitorig C)id ita?" s"i*)r"s ad )riary o)t$)t 9. 6otrol 'ov)lsios it( MgSO9 n i#it I@ C)id ad#iistratio )l"ss "&'"ssiv" !lood loss >. 6otrol (ig( BP to avoid +atal n I+ 'ov)lsios o'')r d"s$it" MgSO9 t("ra$y4 'o#$li'atios ^ 6T s'a s(o)ld !" $"r+or#"d . D"liv"r +"t)s n I+ s"v"r" r"s$iratory is)L'i"'y o'')rs4 . Avoid di)r"ti's ad (y$"ros#oti' ^ I6U ad#issio ad v"tilatio ag"ts ^ M"as)rig !lood gas"s ad !lood $H l"v"ls J. 6los" o!s"rvatio
HISTORY n Past (istory4 ^ Hy$"rt"sio tr"at"d !"+or" $r"ga'y it( vario)s ati(y$"rt"siv" #"di'atio ^ R"al $ro!l"#s n O!st"tri' (istory4 ^ Hy$"rt"sio d)rig $r"vio)s $r"ga'i"s ^ Pr"vio)s s)$"ri#$os"d $r":"'la#$sia ^ Pr"vio)s IUFD/ IUGR ad a!ortios n Fa#ily (istory o+ (y$"rt"sio
6HRONI6 HYPERTENSION DIAGNOSIS EAM n Hy$"rt"sio4 Pr"s"tig !"+or" %2 ""?sK g"statio n 6ardia' "larg"#"t4 May !" $r"s"t n Ed"#a4 O'')rs (" $r": "'la#$sia or ("art +ail)r" o'')rs as a 'o#$li'atio o+ (y$"rt"sio
IN@ESTIGATIONS n Uri" aalysis4 Prot"i)ria idi'at"s o'')rr"'" o+ s)$"ri#$os"d $r": "'la#$sia n R"al +)'tio4 S"r)# 'r"atii"/ )ri' a'id ad BUN n F)d)s "&a#iatio4 6(ag"s idi'atig '(roi' (y$"rt"sio
MANAGEMENT ANTIHYPERTENSI@E THERAPY : Ati(y$"rt"siv" t("ra$y r"'o##"d"d (" SBP 0 12:12 ad D BP 0 12>:112/ as s)'( tr"at#"t d"'r"as"s t(" #at"ral '"r"!ral ad 'ardiovas')lar 'o#$li'atios. : I a')t" 'otrol o+ s"v"r" HTN/ t(" o!"'tiv" o+ t("ra$y is a grad)al r"d)'tio o+ !lood $r"ss)r" to a l"v"l o+ a!o)t 192: 1>2 - 2:122 ##Hg BP s(o)ld !" ass"ss"d "v"ry 1> #i)t"s iitially/ o'" t(" !lood $r"ss)r" is sta!ili*"d t(" it"rval 'a !" l"gt(""d to ,2 #i)t"s : o"rig t(" !lood $r"ss)r" ra$idly ov"r #i)t"s ` a!r)$t ad $ro+o)d _ i BP ` _ 'ardia' o)t$)t to t(" )t"r)s it( $ossi!l" +"tal (y$o&ia. 6oti)o)s +"tal ("art rat" #oitorig s(o)ld !" $"r+or#"d d)rig iitial t("ra$y to d"t"'t s)'( ""'t ad allo "arly r"#"dial a'tio HYDRAA]INE 7@asodilator8/ NIFEDIPINE 76a 6(a"l Blo'?"r8/ ABETOO 7B"ta:!lo'?"r8 : #ost 'o##oly )s"d. n a!"talol s(o)ld !" avoid"d i ast(#a. At"olol/ A6E i(i!itor/ ARB ad di)r"ti's s(o)ld !" avoid"d n Di)r"ti's ar" ot r"'o##"d"d n Agiot"si 'ov"rtig "*y#" i(i!itors ar" 'otraidi'at"d it( $r"ga'y n T"r#iatio i+4 ^ F"tal #at)rity r"a'("d ^ F"tal distr"ss ad s"v"r" IUGR ^ Additioal 'o#$li'atios o'')r 7s"v"r" $r""'la#$sia/ a!r)$tio $la'"ta"8
INDI6ATION (" d"liv"ry is sa+"r to #ot("r 5 +"t)s t(a 'oti)atio o+ $r"ga'y. 1. Postdat" %. Pr":"'la#$sia ,. PROM 9. 6(orioa#ioitis >. IUGR . IUFD . F"tal ao#ali"s J. DM . A!r)$tio $la'"ta 12. R( isoi##)i'atio
INDU6TION OF ABOR Idi'at"d i 12:%23 6ONTRAINDI6ATION ABSOUTE REATI@E 1. Pla'"ta $r"via 1. S"v"r" $r": %. Pr"vio)s %6-S/ $r"vio)s 1 d)" to "'la#$sia r"')rr"t 'a)s"/ $r"vio)s 'lassi'al %. Br""'( 6-S $r"s"tatio. ,. A!or#al at"atal 6TG ,. M)lti$l" $r"ga'y 9. Trasv"rs"-o!li;)" li" 9. Grad #)lti$ara >. A!sol)t" 'otra't"d $"lvis >. Polydroa#ios . A'tiv" g"ital ("r$"s i+"'tio. . Pr"s"tig $art . T)#or o'')$i"s $"lvis a!ov" $"lvi' il"t. J. 6"rvi'al 'ar'io#a . S)''"ss+)l $"lvi' Coor r"$air 5 s)''"ss+)l s)rgi'al r& o+ str"ss i'oti"'".
6OMPI6ATION 1. Hy$"rsti#)latio ` +"tal distr"ss 5 )t"ri" r)$t)r". %. Fail"d id)'tio ` i'r"as"d i'id"'" o+ 6-S. ,. Prolog"d la!o)r ` istr)#"tal d"liv"ry 5 PPH. 9. Mor" $ai+)l ` #or" aalg"sia >. Pr"#at)rity . I+"'tio
Bis(o$ S'or"4 Ass"ss '"rvi'al 'oditio 5 statio o+ t(" ("ad/ i ord"r to '(oos" t(" !"st #"t(od +or id)'tio. Total s'or" 1,. BISHOP S6ORE 2 1 % , 6"rvi'al dilatatio 6los"d 1:%'# ,:9'# 0>'# 6"rvi'al l"gt( 0%'# %:1'# 1:2.>'# 2.>'# 6"rvi'al 'osist"'y Fir# M"di) So+t # 6"rvi'al $ositio Post"rio 6"tra At"rior r l Statio o+ t(" ("ad :, :% :1:2 B"lo is'(ial s$i" Bis(o$ s'or" < )+avora!l" '"rvi&. Bis(o$ s'or" or #or" < +avora!l" '"rvi&
METHOD OF INDU6TION Not r"a'( ""'tiv" 'otra'tios Bis( o$
@agial
Bis( o$ 0
Arti'ial R)$t)r" o+ M"#!ra"
O&yto'i
Idi'at"d i+ ""'tiv" )t"ri" 'otra'tios ot o!tai"d a+t"r 1:% ( o+ AROM. 6o#$li'atios4 1. Ut"ri" (y$"rsti#)latio ` Ut"ri" r)$t)r" 5 F"tal Distr"ss %. Hy$ot"sio i+ giv" I@ !ol)s dos". ,. N"oatal a)di'" < i+ total o&yto'i 0%2 )its. 9. at"r ito&i'atio < i+ total a#t o+ C)ids 01.> ` 'o+)sio/ 'ov)lsio/ 'o#a/ d"at(. Ho giv"4 Start %#U-#i/ do)!l" t(" dos" "v"ry ,2#i. N"v"r "&'""d ,%#U-#i 7#)lti$ara8 5 9#U-#i 7$ri#i$ara8. VE"'tiv" )t"ri" 'otra'tios4 ,:9 'otra'tios/ "a'( lastig >2:2s"'ods i 12#i)t"s. (" ""'tiv" 'otra'tios r"a'(/ ?""$ lo"st ""'tiv" dos". •
PGE% 7Prosti8 < #ost 'o##oly )s"d. PGE1 7Miso$rostol8 • @agial PGE% $"ssory ,#g or Itra'"rvi'al PGE1 g"l 2.>#g • Dos" 'a !" r"$"at"d "v"ry 9:( +or a #a& dos" o+ ,dos"s i %9(. • Mai 'o#$li'atio4 Ut"ri" (y$"rsti#)latio ` Ut"ri" r)$t)r" 5 F"tal Distr"ss. • I+ '"rvi& r"#ais )+avora!l" d"s$it" #a& dos" o+ PG 7,dos"s-%9(8/ r":"val)at" $t 5 i+ t("r"Ks o )rg"t idi'atio +or
Id)'"s la!or !y • ↑PG r"l"as" +ro# +"tal #"#! 5 d"'id)a/ 5 !y #"'(ai'al d"s'"t o+ +"tal ("ad • ↑o&yto'i +ro# $ost"rior $it)itary 7F"rg)so r"C"&8 6o#$li'atios4 6ord $rola$s"d/ $la'"tal
MANAGEMENT OF PATIENTS FOR INDU6TION OF ABOR BEFORE INDU6TION DURING INDU6TION 1. 6o)s"lig 5 "&$laatio. 1. Good s"l"'tio o+ #"t(od o+ id)'tio 7Bis(o$ s'or"8 %. H& < Ass"ss GA 5 R-O 'otraidi'atios o+ id)'tio. %. Pro$"r dos" o+ PG or O&yto'i. ,. O!st"tri's "&a# < Ass"ss li"/ $r"s"tatio/ ,. Moitorig o+ la!or < F"tal "ll!"ig/ )t"ri" a'tivity/ $rogr"ss "gag"#"t. o+ la!or 5 #at"ral "ll!"ig. 9. @agial "&a#4 Ass"ss Bis(o$ s'or" 5 $"lvi' 9. Ad";)at" $ai r"li"+ < B"st "$id)ral ad";)a'y. >. Ultraso)d4 Ass"ss +"tal ag"/ "ll!"ig/ a#t o+ li;)or 5 $la'"tal sit". . 6TG4 Ass"ss +"tal "ll!"ig. TREATMENT OF HYPERSTIMUATION 5 FETA DISTRESS 0.%> ` 6oti)" vagial d"liv"ry F"tal distr"ss .%:.%> ` R"$"at $H a+t"r ,2#i Sto$ o&yto'i. .% ` E#"rg"'y ':s"'tio Giv" o&yg" !y #as?. at"ral d"')!it)s. Ra$id i+)sio or#al Ut"ri" P"rsist (y$"rsti#)latio
F"tal s'al$ F"tal distr"ss $"rsist !lood
T"r!)tali" Hy$"rsti#)latio $"rsist 2.%>#g !ol)s
E#"rg"' y 6:
PROONGED PREGNAN6Y Post:dat" $r"ga'y4 6oti)atio o+ $r"ga'y !"yod 92 'o#$l"t"d ""?s Post:t"r# $r"ga'y4 6oti)atio o+ $r"ga'y !"yod 9% 'o#$l"t"d ""?s I'id"'" >:123 $r"ga'i"s. ETIOOGY Maority o+ 'a)s" < o )d"rlyig 'a)s" i.". $(ysiologi'al 'oti)atio o+ t(" $r"ga'y. E&tr"#"ly rar" 'as"s #ay !" d)" to a"'"$(aly/ +"tal adr"al (y$o$lasia or to $la'"tal s)l$(atas" "*y#" d"'i"'y. RISS AQ Pla'"tal is)L'i"'y 5 (y$o&ia (i'( l"ads to4 1. I'r"as"d $"riatal #ortality 7PNM8 %. M"'oi)# as$iratio sydro#" ,. Oligo(ydroa#ios 5 'ord 'o#$r"ssio BQ I'r"as"d +"tal "ig(t 5 ossi'atio o+ s?)ll it( d"'r"as"d #o)ldig/ (i'( l"ads to4 1. Prolog"d la!o)r ad +ail)r" to $rogr"ss (i'( l"ads to ↑i'id"'" o+ 6-S. %. S(o)ld"r dysto'ia < it( its "oatal 5 #at"ral ris?s. a8 Mat"ral ris?s < vagial 5 '"rvi'al la'"ratios 5 r)$t)r" )t"r)s !8 N"oatal ris?s4 "oatal as$(y&ia 5 d"at(/ '"rvi'al 'ord i)ry/ !ra'(ial $l"&)s i)ry 7"r!Ks $alsy i 6>56/ ?l)#$?Ks $alsy i 6J5T1/ $(r"i' "rv" i)ry i 698/ 'lavi')lar 5 ()#"ral +ra't)r"s. MANAGEMENT BEFORE DEI@ERY DEI@ERY 1. 6o)s"lig 5 "&$laatio4 "&$lai ris?s o t(" +"t)s. 1. I )'o#$li'at"d $ostdat" $r"ga'y/ $t s(o)ld !" %. H& < +or a'')rat" ass"ss#"t o+ GA ad to "&'l)d" 6-I +or d"liv"r"d at 91?s = ,:days. id)'tio. %. M"t(od o+ d"liv"ry "it("r id)'tio o+ la!o)r 7#"t(od o+ ,. O!st"tri' "&a#4 Ass"ss li"/ $r"s"tatio 5 "gag"#"t. id)'tio d"$"ds o Bis(o$ s'or"8 or !y 6-S i+ t("r" is 6-I 9. @agial "&a#4 Ass"ss Bis(o$ s'or" 5 $"lvi' ad";)a'y. +or id)'tio. >. Ultraso)d4 at 92.91 5 9% ?s/ to ass"ss a#t o+ li;)or/ ,. I+ d"liv"ry !y id)'tio o+ la!o)r/ a s"ior o!st"tri'ia +"tal "ll!"ig 5 J. s(o)ld att"d d"liv"ry d)" to ris? o+ s(o)ld"r dysto'ia ad a . 6TG4 "v"ry ,days a+t"r 92?s/ to ass"ss +"tal "ll!"ig. $"diatri'ia s(o)ld att"d d)" to ris? o+ #"'oi)# as$iratio. ASSESSMENT OF GA
ANTENATA METHODS 1. First day o+ MP < r"lia!l" i >23 o+ $r"ga'i"s. %. Ultraso)d < !"st is 6R !"t"" :1,?s/ t(" BPD 5 F !"t"" 1,: %?s 5 t(" BPD 5 F a+t"r %?s. ,. 6lii'al < os"t o+ "arly $r"ga'y s&/ "arly !i#a)al "&a#/ ;)i'?"ig 5 s"rial +)dal ("ig(t. INFERTIITY INTRODU6TION D"+4 Ivol)tary +ail)r" to 'o'"iv" it(i 1% #ot(s o+ 'o##"'ig r"g)lar )$rot"'t"d it"r'o)rs". 7Old d"itio it(i %9 #ot(s8 Pri#ary I+"rtility4 No $r"vio)s $r"ga'y • S"'odary I+"rtility4 it( $r"vio)s $r"ga'y 7 (at"v"r t(" • o)t'o#"8
POSTNATA METHODS 1. D)!oit* s'or" < i'l)d" a ass"ss#"t o+ t(" $(ysi'al 5 ")rologi'al +"at)r"s o+ t(" "!or. %. Farr s'or" < (i'( i'l)d" a ass"ss#"t o+ t(" $(ysi'al +"at)r"s o+ t(" "!or.
PHYSIOOGY 6o'"$tio r";)ir"s 4 Oo'yt"/ s$"r#/ at o$ti#al stag" • N""ds tras$ortatio • A r"'"$tiv" $la'" +or i#$latatio • Ita't Mal" ad F"#al" r"$rod)'tiv" syst"#s •
I'id"'"4 12:1>3 o+ #arri"d 'o)$l"s • A!o)t >3 o+ 'o)$l"s 'o'"iv" !y 1% #ot(s/ • A!o)t J>3 o+ 'o)$l"s 'o'"iv" !y %9 #ot(s. •
•
• • • • • •
POSSIBE 6AUSES OF INFERTIITY FEMAE MAE Ov)latory +ail)r" +a'tor4 7aov)latio8 6oital +a'tor4 7$sy'(ologi'al or Hig( '"tr"s : (y$ot(ala#i':$it)itary a&is orgai'8 T(yroid S$"r#atog""sis $ro!l"#4 Adr"al A*os$"r#ia/ oligos$"r#ia Ovaria : P6O7%238/ $r"#at)r" +ail)r"7 0,2IU-8 D)'t)s $ro!l"#4 A*os$"r#ia d)" G""ti' 5 6(ro#oso#al to o!str)'tio 7i+"'tio8 T)!al +a'tor4 PID/T.B Ut"ri" +a'tor4 As("r#aKs/ 'og"ital ao#aly. 6"rvi'al +a'tor4 i+"'tio/ i##)ologi'al Edo#"triosis4 6oital +a'tor4 a$ar)ia/ dys$ar)ia/ vagiis#)s Psy'(oso#ati'4 W N")ro(or#o"s
IDIOPATHI6 A!o)t 1>:,23 o+ I+"rtility. It is a d"itio !y "&'l)sio/ ad t(at d"$"ds o t(" stadard iv"stigatios )s"d. 7Ov)latory/ T)!al/ Mal"8
INFERTIITY OR UP HISTORY EAM Mal"4 Ag"/ (istory o+ #)#$s/ o'')$atio/ dr)gs/ '("#i'al/ Mal"4 "&a#.vas d"+"r"'" :si*" o+ t"sti'l"s / • irradiatio/ ("ria o$"ratios/ vari'o'"l" vari'o'"l"/ "do'ri" stig#ata F"#al"4 Ag"/ #"str)al 'y'l" 7r"g)larity8 : $r"vio)s $r"ga'i"s/ F"#al"4 B.P : T(yroid : gala'torr(o"a < • • A!ortios ad TOP/ gala'torr(o"a : 1p-%p : 'otra'"$tios / (irs)tis#. A!do#ial ad $"lvi' "&a# Hirs)tis#. g"italia 7E&t"ral 5 It"ral8 Bot(4 6oital (istory4: S.T.D : $ast #"d 5 s)rgi'al (&/ s#o?ig ad • ta?ig dr)gs SPE6IA IN@ESTIGATIONS O@UATION 6ER@I6A FA6TOR TUBA 5 UTERINE MAE FA6TOR OTHERS FA6TORS 1. B.B.T.'(art4 : 6& s'or" 7a#o)t/ 76IIA/ FERTII]ATION/ S"#" aalysis4 !y 6B6 Bi$(asi' a i'r"as" s$i!ar?"it/ +"rig/ os8 TRANSPORT8 'oit)s it"rr)$t)s or Uri" aalysis o+ 2.>6/ $rog"st"ro" : 6"rvi'al #)')s alt"ratio4 : T)!al is)qatio #ast)r!atio a+t"r S.T.D < ""'t t(i:'l"ar:at"ry<"lasti' 7R)!iKs t"st8 o!sol"t" a!sti"'" o+ ,:> days : 6(la#ydia %. 6& #)')s 7s)!"'tiv"8 oadays d"liv"r"d it(i % (o)rs R)!"lla tit"r alt"ratio4 : Elasti'ity 7s$i!ar?"it8 : Hyst"rosal$igogra#4 to la!. TFT Mitt"ls'(#"r* $ai : F"rig 7ar!ori*atio or )sig radioo$a;)" at"r S?)ll & ray ,. Hor#oal assay4 'rystalli*atio8 o+ Na6l d)" sol)!l"/ o G.A Nor#al val)"s4 !y HO 6T S'a S. $rog"st"ro" d%1 to )o$$os"d a'tio o+ : a$aras'o$y = 'rit"ria ray '("st. 7%2:,2#ol-8/ "strog" M"t(yl"" !l)" dy" t"st4 @ol)#"4 0%#l : S. $rola'ti : P.6.T47$ost 'oital t"st84 )d"r G.A/ '("'?s +or li;)i'atio i %2: ,2 %2g-#l $ositiv" i+4 #or" t(a >:12 "do#"triosis ad D56 #i)t"s S. FSH ad H rst s$"r# i 7H.P.F8 aliv" i t(" sa#" sittig D"sity4 0%2:%>2 Mil-#l days o+ $"riod +orard $rogr"ssiv" #otility 7(" do" i l)t"al Motility4 0 >23 +orard 9. Edo#"trial !io$sy a+t"r :1% (o)rs o+ s"&)al $(as"8 #otility it(i % (. :d %1: s"'r"tory it"r'o)rs" at ti#" o+ : Hyst"ros'o$y : i Mor$(o4 0 ,23 or#al "do#"tri)#. i.".T.B ov)latio. R"$"at , ti#"s i+ As("#aKs syd. +or#s >. U.S.S : #oitorig N"gativ" 7rog ti#ig/ 'og"ital ao#aly to o+ +olli'l"s 1J:%% ##/ '"rvi'al (ostility d)" W vis)ali*" t(" )t"ri" S"#ial C)id 23 o+ d1%1%## ati!odi"s/ s"v"r" oligo or 'avity 7)sig 6O% or "a')lat"4 %, +ro# . a$aras'o$y : a*os$"r#ia8 gly'"i" sol)tio8 s"#ial v"si'l"s la$arato#y : : 6ross (ostility t"st : Hy:'o:sy 7+r)'tos"8/ 1, +ro# •
i'id"tal digs . H $"a? 7H (o#" ?its84 %( lat"r ov)latio o'')r J. Pr"ga'y
7r"#"r t"st8 i+ P.6.T is 7(yst"rosal$igo: $rostat" 7*i' 5 a'id $(.8 "gativ" 'otrast:soagra$(y8 I a*os$"r#ia = : Atis$"r# ati!ody titr" : )sig E'(ovist oligos$"r#ia4 (or#oal ad MAR 7 #i&"d FSH/H/ $rola'ti 5 aggl)tiatio r"a'tio8 ?aryoty$ig INFERTIITY MANAGEMENT INDU6TION OF O@UATION TUBA FA6TORS 6ER@I6A FA6TOR AQ F"rtility ag"ts4 S"l"'tiv" i#$rov" '"rvi'al s'or"4 Tr"at • • Oral ag"ts4 23 id)'" ov)latio/ !)t 23 $r"ga'y Hyst"rosal$igogra i+"'tio/ 6ryo'a)t"ry/ • :I 'as"s o+ (y$"r$rola'tia"#ia 4 # Estrog" Bro#o'ri$ti" 7"rgot al?aloids/ do$a#i" agoist8 S)rg"ry4 i##)ologi'al : W • • is)rid" 1&1 #i'ros)rg"ry4 a+t"r 'orti'ost"roids +or t(" #al" 6a!"rgoli"7Dosti"&8 1#g ""?ly +allo$os'o$y4 d)rig t(" l)t"al $(as" o+ :6lo#i$("" 'itrat" 7'lo#id84 >2#g %22#g 7d% : d8/ +or • Sal$igolysis/ +"#al" /Mal" )s" o+ 'odo# 'y'l"s. It is oral 'y'li'al/ syt("ti'/ ost"roidal/ "a? +or #ot(s sal$igosto#y/ "strog" it( ati"strog"i' a'tivity "&'isio 5 SIUI ad SI@F • :Ta#o&i+" 4 12:92#g 7d% : d8 +or 'y'l"s/ i P6O r"aasto#. 7s)''"ss :6y'lo+"il 4 %22#g!.d +or 12 days +ro# 12:9238 I P6OS 4#"t+or#i 7oral is)li s"siti*"rs8 Ut"ri" ao#ali"s4 • Sid" ""'ts4 ovaria 'ysts/ tis >3/ (air loss/ GIT/ rar"ly Myo#"'to#y +or (y$"rsti#)latio sydro#" 7OHSS8 !roids M"tro$lasy i '"rtai I"'ta!l" ag"ts • 'as"s Goadotro$(i t("ra$y4 )riary "&tra'ts/ o r"'o#!iat [email protected] $rogra# • : HMG4 7FSH=H8 7H)#"go:$"rgoal8 i"'tios 1:, ENDOMETRIOSIS MAE FA6TOR
a#$)l"s daily or "v"ry ot("r day till +olli')lar #at)ratio/ a!o)t >:12 i"'tios : FSH4 oly 7#"trodi8 i P.6.O : H.6.G4 7$r"gyl/$ro+asi8 : >222 : 12222 )it a+t"r +olli')lar #at)ratio : to r"l"as" oo'yt" : .H.R.H:a4 : 7 B)ss"rli:]olad"&:s)$"r+a't:D"'a$"$tyl 8 'oti)o)s 7asal or s.'. 9: ti#"s daily or d"$ot IM8 to d"$l"t" "dog"o)s FSH/H : .H.R.H:a4 : $)lsatil" i+)sio "v"ry 2 #i)t"s/ 1>)g : .H.R.H.atagoist Sid" ""'ts4 #)lti$l" $r"ga'y %>3 : (y$"rsti#)latio sydro#" 7i+ s"v"r"8 :as'itis/ larg" ovaria 'ysts/ (ydrot(ora&/ t(ro#!o"#!oli' dis"as"/ #)ltiorga +ail)r" B: S)rgi'al4 Ovaria drillig/ "dg" r"s"'tio7o!sol"t"8 O$tios o+ tr"at#"t4 Oral +"rtility ag"ts ` I"'ta!l"s ` SIUI/SI@F •
• • •
Daa*ol/ HRH a tr"at#"t 7#"di'al8 6os"rvativ" s)rg"ry4 [email protected]. $rogra#
Tr"at#"t dir"'t"d toards 'a)s". Advi'"4 sto$ s#o?ig ad al'o(ol/ avoid tig(t )d"r"ar/ ta?" r"g)lar 'old !at(s/ i#$rov"#"ts i 'oital $ra'ti'". Psy'(ologi'al t("ra$y4 +or s"&)al dys+)'tio I s"v"r" oligos$"r#ia ad a*oos$"r#ia/ '("'? +or ?aryoty$" 7li"+"lt"rKs sydro#"/ t"sti')lar atro$(y8 (MG +or (y$ot(ala#i': $it)itary +ail)r". Bro#o'ri$ti" +or (y$"r$rola'ti"#ia. S)rgi'al tr"at#"t i vas"'to#y r"v"rsal. @ari'o'"l" ligatio i vari'o'"l". ART4 SIUI/I6SI 7!y TESE or MESA8
ARTI ARTIFI FI6I 6IA A INSEM NSEMIINATI NATION ON •
Arti'ial is"#iatio 7AI8 • AIH4 itravagial/ itra'"rvi'al ad $"ri'"rvi'al/ itra)t"ri"/ itra$"rito"al • AIH7DI8 • IUI ad SIUI • T(" #ostly )s"d oadays4 is SIUI 7sti#)lat"d itra)t"ri" is"#iatio4 : Pro$"r s"l"'tio o+ t(" 'as"s : 6otroll"d ovaria sti#)latio : Pr"$aratio o+ s"#" : Ti#ig o+ is"#iatio
ASSISTED REPRODU6TION TE6HNIUES 7ART8 I@F = ET ET 7EM 7EMB BRYO @ARIANTS OF I@F TRANSFER8 TRANSFER8 U$ to ,>3 'o)ld G.I.F.T4 Ga#"t" itra +allo$ia o tras+"r 7idi'at"d4 )"&$lai"d !""t +ro# i+"rtil" i+"rtility/ oligos$"r#ia/ 'o)$l"s "do#"triosis. 76.I.t)!al da#ag"8 6adidat"s4 T)!al Pro'"d)r"4 Pro'"d)r"4 a$aras'o$y at ov)latio : o +a'tor / "do#"triosis r"tri"v" oo'y't" #i& it( $r"$ar"d / oligos$"r#ia s"#" : d"$osit !ot( i t)!" /)"&$lai"d i+"rtility ].I.F.T o It is "&$"siv"/ r";)ir"s so$(isti'at"d o SU]I s)!*oal i"'tio la!. +a'iliti"s/ (ig(ly o I6SI itra'yto$las#i' s$"r# s$"r# i"'tio i"'tio s?ill"d #"di'al/ PESA $"r')ta"o)s "$ididy#al s$"r# o )rsig/ s'i"ti' ad as$iratio t"'(. $"rso"l MESA o o TESE OUT6OMES OF I@F PREGNAN6IES %>3 ris? o+ #is'arriag" %:>3 ris? o+ "'to$i's/ ("t"rotro$i' ("t"rotro$i' $r"ga'y %>3 ris? o+ #)lti$l" $r"ga'y I'r"as" ris? o+ $r"#at)rity/ lo !irt( t/ 6s
RESUTS OF I@F
E.T 718 : 123 '(a'" o+ sigl" $r"ga'y E.T 7,8 : %>:,23 '(a'" o+ sigl" $r"ga'y. >3 tis/ 13tri$l"ts EL'i"'y4 %>:,>3 +or "a'( 'y'l" : Ta?" (o#" !a!y 1>:%23 A''ordig to t(" i+"rtility +a'tor ad t(" '"tr"
RISS OF I@F Psy'(ologi'al tra)#a i+ +ail"d 7OHSS8 ovaria (y$"rsti#)latio sydro#" M)lti$l" $r"ga'y
INSTRUMENTS 18 Si#s S$"')l)#. Us"s4 for visualising fistula fistulae e (abnormal holes or connections) and
prolapse (protrusion) of the rectum rectum or orbladder bladder into into the
vagina
Us"s4 P"lvi' "&a#s.
%8 Bivalv" s$"')l)# To ta?" Pa$ s#"ar. To ta?" 'o" 5 $)'( !io$sy.
,8 6)r"tt" Dilatio 5 ')r"ttag". Eva')atio 5 ')r"ttag".
GANDS4 ADENO6AR6INOMA ENDOMETRIU
STROMA4 ENDOMETRIA STROMA GANDS = STROMA4 MMT EIOMYOSAR6OMA
MYOMETRIUM OTHERS INTRODU6TION P"a? i'id"'" is at ag" o+ 1 y"ars >3 o'')r i $ost#"o$a)sal o#" Oly >3 o'')r !"+or" ag" o+ 92 T("r" is #ar?"d #ar?"d g"ogra$(i'al ad ra'ial variatio i t(" i'id"'"
PATHOOGY Grot( is )s)ally ad"o'ar'io#a Ad"o:a'at(o#aad"os;)a#o)s t)#ors S"ro)s $a$illary-
ENDOMETRIA 6AR6INOMA ETIOOGY 6INI6A PRESENTATION E&'"ssiv" )o$$os"d "strog" PMB sti#)latio o+ t(" "do#"tri)# It"r#"str)al Increase !l""dig-irr"g)lar O!"sity/ N)lli$arity/ at" $"riods #"o$a)s"/ P6O/ Estog": H"avy r"g)lar s"'r"tig ovaria t)#ors/ $"riods Uo$$os"d "strog" t("ra$y/ at"ry Fa#ily (istory o+ !r"ast/ ovary/ dis'(arg"-o"siv" 'olo/ "do#"trial t)#ors/ DM Pai !ecrease ENDOMETRIA BIOPSY O66P/ Prog"st"ro" Prog"st"ro" SHOUD BE DONE IN A PATIENTS ITH PMB DIAGNOSIS Alays iv"stigat" PMB/ 'oti)o)s or irr"g)lar !l""dig !"+or" ass)#ig !"ig 'a)s" +or t(" !l""dig 6"rvi'al s#"ar T@S
PROGNOSIS Stag" Grad" Myo#"trial ivasio Ag" T)#or si*" T)#or Ass"ss#"t o+ t("s"
PHYSI6A FINDINGS Rar"ly s)gg"st t(" diagosis Ut"ri" "larg"#"t Pal$a!l" ly#$( od" i t(" groi. S)$ra'lavi'l". @agial od)l"
TREATMENT o ris? stag" I4 TAH/ BSO Hig( ris?4 $osto$"rativ" radiot("ra$y Stag" II4 TAH/BSO= radiot("ra$y-radi'al (yst"r"'to#y
'l"ar '"ll Grad" 1 ` grad" , S$r"ad4 Dir"'t ivasio/ y#$(ati'/ Blood
Edo#"trial !io$sy Hyst"ros'o$y =')r"ttag" I+ 'or#"d/ 6B6/FT/URINE/ MRI.6R
+a'tors r";)ir" la$aroto#y ad (istology 7s)rgi'al $at(ologi'al stagig8
Stag" III -I@4 idivid)ali*"d .rar"ly s)rg"ry )s)ally '("#o/ radiot("ra$y ad (or#oal Follo )$ R"')rr"'" )s)ally it(i % R"')rr"'" y"ars 7238 Ov"rall > y"ar s)rvival is 23
FIGO STAGING Stag" 1 6o"d to t(" !ody o+ )t"r)s Stag" % Ivolv" lv"#"t o+ '"rvi& Stag" , E&t"sio i ito ad"&a"/vagia or $ositiv" .N Stag"9 Distat #"ts
ENDOMETRIA SAR6OMA Edo#"trial stro#al sar'o#a Maligat #i&"d #)ll"ria t)#ors 7'ar'iosar'o#a8 Mor" i !la'?. Pr"vio)s $"lvi' irradiatio Pr"s"t it( !l""dig ad $ai Poor $rogosis
EIOMYOSAR6OMA >:123 May aris" +ro# tras+or#atio o+ !ro#yo#a 72.%38 Mostly aris" +ro# or#al #yo#"tri)# P"a? i'id"'" is 12 y"ars old"r t(a !ro#yo#a Pr"s"t it( a!or#al !l""dig ad $"lvi' $ai ad t loss S(o)ld !" s)s$"'t"d i ra$idly "largig !roids I J23/diagosis is #ad" a+t"r (yst"r"'to#y Id"ally s(o)ld !" tr"at"d !y TAH/ BSO/ as(ig ad +)ll stagig Ad)vat radiot("ra$y or '("#ot("ra$yW
BASI6 6ON6EPTS
PRESENTATION Part o+ t(" +"t)s o'')$yig t(" lo"r s"g#"t o+ t(" )t"r)s 6"$(ali' 7H"ad/ >38/ Br""'( 7B)tto'?s/ ,:938/ S(o)ld"r/ 6ord/ 6o#$o)d. Mal$r"s"tatio is ay $r"s"tatio ot("r t(a '"$(ali'. IE R"latio o+ logit)dial a&is o+ +"t)s to t(" #ot("rKs logit)dial a&is ogit)dial 738 Trasv"rs" O!li;)"
STATION R"latio !"t"" t(" lo"st !oy $art o+ t(" $r"s"tig $art to t(" i#agiary li" !"t"" to is'(ial s$i"s :,/ :%/ :1/ 2/ =1/ =%/ =, [i+ a!ov" li"4 :v"/ i+ !"lo li"4 =v"Q Ass"ss"d t(ro)g( vagial "&a#. ENGAGEMENT Passag" o+ t(" id"st dia#"t"r o+ t(" $r"s"tig $art t(ro)g( t(" $"lvi' il"t. I+ % g"rs ""d"d to $al$at" +"tal ("ad i $"lvi' gri$4 Egag"d. VP"lvi' il"t4 U$$"r !ord"r o+ sy#$(ysis $)!is 7at8/ sa'ral $ro#otory 7$ost8/ il"o$"'ti"al li" o+ ilia' 'r"st 7lat"ral8.
POSITION R"latio !"t"" t(" do#iator 7!oy lad#ar? o+ t(" +"t)s8 to t(" it"ral $"lvis. J4 At"riorly 7l"+t/ rig(t/ dir"'t8/ Post"riorly 7l"+t/ rig(t/ dir"'t8/ Trasv"rs" 7l"+t/ rig(t8 Most 'o##o4 "+t o''i$ito:at"rior. Mal$ositio is ay $ositio ot("r t(a o''i$ito at"rior. VBoy lad#ar?s4 @"rt"&4 O''i$ital Fa'"4 M"tal Bro4 Frotal S(o)ld"r4 S'a$)la Br""'(4 Sa'r)#
FETA ATTITUDE R"latio o+ +"t)s $arts to "a'( ot("r "ll:C"&"d 7or#ally8/ E&t"d"d
BREE6H PRESENTATION 6AUSES DIAGNOSIS Mat"ral 6a)s"s4 N)lli$arity/ Old ag"/ Fi!roid/ H&4 S)!'ostal $ai 7'o* +"tal ("ad8 Poly(ydroa#ios/ oligo(ydroa#ios/ Bi'or)at" A!d "&a#4 "o$old #a")v"r :,.>?g A+t"r d"liv"ry o+ !)tto'?s/ ` 18 E$isioto#y S)$"rior to vagial !r""'( 0,?s GA. Good $"lvi#"try 7roo#y %8 ""$ +"tal !a'? at"rior d"liv"ry. $"lvis8. F"tal ("ad C"&"d/ Br""'( ty$" A+t"r a$$"ara'" o+ s'a$)la ` ,8 Rotat" 2 to Fra? or 6o#$l"t". E&$"ri"'"d d"liv"r at"rior s(o)ld"r 5 vi'" v"rsa. o!st"tri'ia. A"t("tist 7E$id)ral8/ No A+t"r visi!l" (air li" ` 98 Eit("r iv"r$ool DEFINITION B)tto'?s o'')$yig lo"r s"g#"t o+ )t"r)s. 6o##o"st #al$r"s"tatio. 6o##o"st 'a)s" is $r"#at)rity.
ot("r idi'atios +or 6:s"'tio/ M)lti$aro)s/ Nor#al la!or $rogr"ss/ U'o#$li'at"d $r"ga'y.
#a")v"r/ or Ma)ri'"a):S#"lli":@"it #a")v"r or +or'"$s d"liv"ry.
FA6E 5 BRO PRESENTATIONS FA6E @agial E&a#4 Nos"/ '(""?s/ #o)t(. 6o##oly #isdiagos"d as !r""'(. TYPES MENTO:ANTERIOR
Pr"s"tig dia#"t"r4 .>'#. MENTO: POSTERIOR
MANAGEMENT I+ +)lly dilat"d ` Allo vagial d"liv"ry. I+ ot +)lly dilat"d ` 6a a)g#"t la!or it( o&yto'i. 6OMMON NOTES N"v"r att"#$t to 'ov"rt +a'" to v"rt"&. N"v"r a$$ly va'))#. 6a )s" +or'"$s. 6a a)g#"t it( syto'io. arg" "$isioto#y. I+ +)lly dilat"d ` 6: s"'tio. I+ ot +)lly dilat"d ` Moitor +or 'ov"rsio ito v"rt"& $r"s"tatio. I+ +"t)s d"ad `
6AUSES Grad #)lti$aro)s N"'? s"llig 7'ysti' (ygro#a/ goit"r "t'8 A"'"$(aly
SHOUDER PRESENTATION BRO Trasv"rs" or o!li;)" li". @agial "&a#4 Or!ital A!d E&a#4 H"ad i o" Ca? 5 !)tto'? ridg"s 5 os". i aot("r. No vagial "&a# till R-O $r"via. 6AUSES Pla'"ta $r"via/ Pr"#at)rity/ Poly(ydroa#ios/ M)lti$l" $r"ga'y/ A!or#al )t"r)s/ Fi!roid/ 6"rvi'al 'a'"r/ 6otra't"d $"lvis/ R"la&"d a! all. MANAGEMENT4 6:s"'tio Pr"s"tig dia#"t"r4 1,'#. 6:s"'tio. N"v"r vagial d"liv"ry.
Pr"s"tig dia#"t"r4 1,'#.
6raioto#y.
DEFINITION U#!ili'al 'ord as t(" $r"s"tig $art/ !"lo ay $art o+ t(" +"t)s. 6o* ill:ttig $r"s"tig $art ito lo"r s"g#"t o+ )t"r)s ` 'ord 'a go ito s$a'" !"lo $r"s"tig $art #aily (" +ootlig !r""'( or AROM.
UMBII6A 6ORD PROAPSE RIS FA6TORS 6ONSEUEN6ES M)lti$arity 6ord 'o#$r"ssio 5 Pr"#at)rity @asos$as# ` 6)ttig Ma'roso#ia !lood +ro# +"t)s ` F"tal Br""'( distr"ss. Poly(ydroa#ios O)t'o#" d"$"ds o GA 5 d)ratio o+ 'o#$r"ssio.
MANAGEMENT E#"rg"'y 6:s"'tio @agial d"liv"ry oly i+ d"liv"ry is i##i"t 7(" vagial ;)i'?"r t(a ':s"'tio4 +)lly dilat"d 5 $r"s"tig $art v"ry lo8 (il" aitig +or 6:s"'tio : Fill !ladd"r it( 1 : P)s( $r"s"tig $art )$ : Tr"d"l"!)rg $ositio
ESSENTIA HYPERTENSION 6ASSIFI6ATION A''ordig to S"v"rity4 AQ Mild BQ S"v"r" 7012-1128 A''ordig to 6o#$li'atios AQ U'o#$li'at"d BQ 6o#$li'at"d. Ay o+ t(" +olloig4 6ardio#yo$at(y Ag" 092 D)ratio o+ HTN 01>yrs R"al dis"as" DM/
MATERNA RIS S)$"ri#$os"d PET. A!r)$tio. 6"r"!ral ("#orr(ag" E&a'"r!atio o+ HTN R"al +ail)r" 6og"stiv" ("art +ail)r".
FETA RIS IUGR. IUFD. Pr"#at)rity. PNMM dir"'tly r"lat"d to HTN s"v"rity.
6T dis"as" or 'oar'tatio o+ aorta Pr"vio)s (& o+ $"riatal loss. MANAGEMENT PRENATA ANTENATA DURING ABOR POSTNATA Ass"ss 'a)s" 5 s"v"rity. Mild )'o#$li'at"d HTN/ sto$ dr)gs 5 O!s"rv" BP. O!s"rv" BP "s$ 9J( oo? +or ris? +a'tors. o!s"rv" ,#ot(s. I+ BP stay"d #ild/ Stri't C)id 'otrol. $ost$art)#. R"vi" dr)gs. doKt giv" dr)gs. 6oti)" AHD i+ ta?ig O!s"rv" +or $)l# "d"#a. Esta!lis( !as"li" < 6B6/ I+ BP 012-112/ giv" dr)gs. t("#. O!s"rv" +or (y$"rt"siv" )ri" aalysis/ %9( )ri" O!s"rv" +"tal grot( 7IUGR-IUFD8 6oti)o)s +"tal ("art "'"$(alo$at(y. 'oll"'tio t"st/ FT/ E'(o/ O!s"rv" #at"ral 'oditio. #oitorig. R"ass"ss 'ardia' 5 r"al E6G/ 6R. No idi'atio to id)'" la!or !"+or" +7&8. 91?s. 6ARDIA6 DISEASES Pr"di'tors 7NYHA F)'tioal 6lassi'atio8 k Ris? o+ 6o#$li'at"s 13 o+ $r"ga'i"s. $r"di'tors 'o#$li'atios 6o#$li'atios d)rig $r"ga'y4 HF/ 6ardia' dys+7&8 < EF02 or 92 2 ,3 arr(yt(#ia/ stro?" 5 d"at(. 1 ,23 Pr"s"'" o+ $)l# HTN Ass"ss#"t !"+or" $r"ga'y is "ss"tial. % 23 Pr"s"'" o+ 'yaosis 7lo H! sat)ratio8 6a !" 'og"ital/ r(")#ati' 5 is'("#i'. Pr"s"'" o+ aorti' or #itral valv" st"osis H& o+ 6HF/ arr(yt(#ia or TIA MANAGEMENT PRENATA ANTENATA DURING ABOR 6lassi+y $ati"ts 7$r"di'tors o+ Moitor sigs 5 s& o+ HF. Avoid $ai 'o* $ai ↑EF ` a')t" HF. Avoid 'o#$li'atios8. S"rial E'(o. (y$ot"sio. Iv"stigatios. S"rial +"tal #oitorig. "+t lat"ral $ositio it( o&yg" #as?. R"vi" dr)gs. 6oti)o)s sat)ratio #oitorig. Giv" $r"di'tios 7sa+" to go t(r) S(ort" %d stag" la!or 7istr)#"talW8. $r"ga'yW8 Pro$(yla'ti' ati!ioti's. 6ar"+)l C)id t("ra$y. 6oti)o)s 6TG. 6oti)o)s E6G.
HYPERTHYROIDISM O@ER@IE MANAGEMENT >3 'as"s d)" to Grav"s. >23 (av" =v" +a#ily (&. 6ar!i#a*ol" 5 PTU ar" #ost 'o##oly )s"d dr)gs. 6lii'al $i't)r" si#ilar to o:$r"gat. Bot( 'ross $la'"ta/ to a l"ss"r "&t"t do"s PTU/ so "v" i Most dis'ri#iatory +"at)r"s i $r"ga'y ar" "ig(t #od"rat" dos"s #ay 'a)s" +"tal (y$ot(yroidis#. loss/ tr"#or 5 lid lag. Bot( ot t"ratog"i'. T(ryoto&i'osis )s)ally i#$rov"s i $r"ga'y as ot("r j !lo'?"rs )s"d i t(yroid 'risis. T(yroid"'to#y rar"ly a)toi##)". idi'at"d i $r"ga'y. E&a'"r!atios #ay o'')r "s$ i 1st tri#"st"r 7f s)!)it Radioiodi" 'otraidi'at"d i $r"ga'y 7also 9#ot(s o+ j(6G r"s"#!l"s TSH8 !"+or"8 5 d)rig la'tatio. T(yroto&i'osis asso'iat"d it( i+"rtility/ r"')rr"t 6("'? +or "oatal 5 +"tal t(yroto&i'osis. $r"ga'y loss/ IUGR/ $r"t"r# la!or/ (ig("r PNMM. HYPOTHYROIDISM O@ER@IE MANAGEMENT 6o##o"r t(a t(yroto&i'osis. Asso'iat"d it( ot("r a)toi##)" li?" DM 5 $"ri'io)s T(yro&i" s)$$l"#"ts ar" t(" a"#ia. oly r"$la'"#"t t("ra$y. 6lii'al $i't)r" si#ilar to o:$r"gat. 6ross"s $la'"ta !)t oly v"ry Most dis'ri#iatory +"at)r" ar" 'old itol"ra'"/ slo $)ls" 5 d"lay"d r"la& o+ t"do littl" a#o)t ill r"a'( +"t)s/ so r"C"&"s. +"t)s ot at ris? o+ d"v Pr"ga'y its"l+ (as o ""'t o (y$ot(yroidis#. (y$"rt(yroidis#. Asso'iat"d it( i+"rtility/ #is'arriag"s/ a"#ia/ +"tal loss/ IUGR 5 PET. Asso'iatio !- )tr"at"d (y$ot(yroidis# 5 r")'"d I 5 ")rod"v d"lay i os$rig. EPIEPSY O@ER@IE MANAGEMENT Most 'as"s ar" idio$at(i' ad o )d"rlyig 'a)s". T(" lo"st ""'tiv" dos". Try it( 1 dr)g 5 giv" +)ll dos" o+ +oli' ,23 +a#ilial. a'id >#g. All ty$"s o+ s"i*)r"s 'a o'')r i $r"ga'y. Try sto$$ig AED/ i+ s(" is t +r"" +or 0%yrs. Most AED ar" t"ratog"i'. D"tail"d ao#aly s'a at aro)d %o? g"statio. I #aority o+ 'as"s/ +r";)"'y o+ s"i*)r" ar" ot @it s)$$l"#"t +or t(" last 9?s o+ $r"ga'y +or $ts ta?ig alt"r"d !y $r"ga'y. val$roi' a'id. Ris? o+ s"i*)r"s ar" (ig("st i $"ri$"rt)# $"riod. Avoid $ai 5 log 'o)rs" o+ la!or. >:123 ris? o+ tras#ittig "$il"$sy. Maor #al+or#atios 'a)s"d !y AED ar" NTD/ oro+a'ial d"+"'ts 5 T(" +"t)s is r"lativ"ly r"sistat to s(ort "$isod"s o+ 'og"ital ("art d"+"'ts. (y$o&ia. Mior #al+or#atios ar" dys#or$(i' +"at)r"s/ (y$"rt"loris#/
(y$o$lasti' ails 5 digits. 1$%/PAU'$ •
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o'')rs s"'odary to a g""ti'ally $rogra##"d loss o+ ovaria +olli'l"s D""d as t(" '"ssatio o+ #"str)al $"riods #"o$a)s" o'')rs at a #"a ag" o+ >1.9 y"ars i or#al o#"
$pidemioloy
"he menopausal transition •
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variatio i #"str)al 'y'l" l"gt( 70 days di"r"t +ro# or#al #"str)al 'y'l" l"gt(/ (i'( is %1 to ,> days8 m% s?i$$"d 'y'l"s ad a it"rval o+ a#"orr("a m2 days "l"vat"d s"r)# FSH 'o'"tratio 6"ssatio #"str)al $"riod 7ot r"'ogi*"d )til a+t"r 1% #ot(s o+ a#"orr("a8.
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Perimenopause aro)d t(" #"o$a)s"/ ad !"gis
it( t(" #"o$a)sal trasitio ad "ds 1% #ot(s a+t"r t(" last #"str)al $"riod 1enopause M"o$a)s" is d""d !y 1% #ot(s o+ a#"orr("a a+t"r t(" al #"str)al $"riod. It r"C"'ts 'o#$l"t"/ or "ar 'o#$l"t"/ ovaria +olli')lar d"$l"tio ad a!s"'" o+ ovaria "strog" s"'r"tio. Postmenopause is d""d as 7"arly8 t(" rst v" y"ars a+t"r t(" al #"str)al $"riod. It is '(ara't"ri*"d !y +)rt("r ad 'o#$l"t" da#$"ig o+ ovaria +)'tio ad a''"l"rat"d !o" loss #ay o#" i t(is stag" 'oti)" to (av" (ot Cas("s. 7lat"8 !"gis v" y"ars a+t"r t(" al #"str)al $"riod ad "ds it( d"at(
$ndocrinoloy
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Alt(o)g( t(" av"rag" ag" at #"o$a)s" is a$$ro&i#at"ly >1 y"ars/ +or > $"r'"t o+ o#"/ it o'')rs a+t"r ag" >> 7lat" #"o$a)s"8/ ad +or aot("r > $"r'"t/ !"t"" ag"s 92 to 9> y"ars 7"arly #"o$a)s"8. M"o$a)s" o'')rrig $rior to ag" 92 y"ars is 'osid"r"d to !" $r"#at)r" ovaria +ail)r"
• T(" ag" o+ #"o$a)s" is
r"d)'"d !y a!o)t to y"ars i o#" (o s#o?" • T("r" is also a t"d"'y +or o#" (o (av" "v"r (ad '(ildr" ad +or t(os" it( #or" r"g)lar 'y'l"s to (av" a "arli"r ag" o+ #"o$a)s" • Ot("r +a'tors t(at #ay !" i#$ortat i'l)d"4 1. A +a#ily (istory o+ "arly #"o$a)s" %. A (istory o+ ty$" 1 dia!"t"s #"llit)s ,. T(" $r"s"'" o+ a variat o+ +or# gala'tos":1: $(os$(at" )ridyl tras+"ras" 9. S(ort"r 'y'l" l"gt( d)rig adol"s'"'" 7(i'( is also a $r"di'tor o+ (ig("r !asal FSH8.
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M"str)al 'y'l" ad (or#o" $att"rs !"gi to '(ag" #ay y"ars $rior to #"o$a)s". I t(" lat" r"$rod)'tiv" y"ars/ $rior to t(" #"o$a)sal trasitio/ #"str)al 'y'l"s ar" ov)latory/ !)t +olli')lar $(as" l"gt( !"gis to s(ort". I t(" "arly #"o$a)sal trasitio/ o#" !"gi to "&$"ri"'" so#" #"str)al irr"g)larity. D)rig t(is stag"/ i(i!i B 'o'"tratios +all d)" to a d"'li" i +olli')lar )#!"r/ ad as a r"s)lt/ s"r)# FSH l"v"ls !"gi to ris"/ it( r"lativ" $r"s"rvatio o+ "stradiol s"'r"tio 7or#al or (ig( "stradiol l"v"ls8/ !)t it( lo l)t"al $(as" $rog"st"ro" 'o'"tratios . T(" $r"s"rvatio o+ "stradiol s"'r"tio a$$"ars to !" d)" to a i'r"as" i aro#atas" a'tivity. I t(" lat" #"o$a)sal trasitio/ 'y'l" varia!ility i'r"as"s. Hig( FSH ad lo "stradiol val)"s #ay !" s)gg"stiv" o+ #"o$a)s"/ A+t"r #"o$a)s"/ (" ovaria +olli'l"s ar" d"$l"t"d/ t(" ovary o log"r s"'r"t"s "stradiol. Ho"v"r/ it 'oti)"s to $rod)'" ad s"'r"t" adrog"s )d"r t(" 'oti)"d sti#)latio o+ H
Clinical 1ani+estations 2.leedin patterns
8.Hot fushes
. !epression and mood chanes
•
•
•
6(roi' aov)latio ad Prog"st"ro" d"'i"'y i t(is trasitio $"riod #ay l"ad to log $"riods o+ )o$$os"d "strog" "&$os)r" ad t("r"+or" aov)latory !l""dig ad "do#"trial (y$"r$lasia. Oligo#"orr("a 7irr"g)lar 'y'l"s8 +or si& or #or" #ot(s/ or a "$isod" o+ ("avy dys+)'tioal !l""dig. Irr"g)lar or ("avy !l""dig d)rig t(" #"o$a)sal trasitio #ay !" tr"at"d it( lo: dos" oral 'otra'"$tiv"s or it"r#itt"t $rog"sti t("ra$y
E.'leep disturbance •
A distr"ssig +"at)r" o+ (ot Cas("s is t(at t("y ar" o+t" asso'iat"d it( aro)sal +ro# sl""$. I additio/ $ri#ary sl""$ disord"rs ar" 'o##o i t(is $o$)latio/ "v" i t(" a!s"'" o+ (ot Cas("s.
Clinical 1ani+estations
• T(" #ost 'o##o a')t"
• Hot C)s("s ty$i'ally '(ag" d)rig !"gi as t(" s)dd" #"o$a)s" is t(" (ot s"satio o+ ("at C)s(/ (i'( o'')rs i )$ '"t"r"d o t(" )$$"r to > $"r'"t o+ o#" '("st ad +a'" t(at i so#" ')lt)r"s/ !)t oly ra$idly !"'o#"s a!o)t %2 $"r'"t o+ t("s" g""rali*"d. o#" s""? #"di'al • T(" s"satio o+ ("at att"tio +or tr"at#"t o+ lasts +ro# to to +o)r t("ir Cas("s. #i)t"s/ is o+t" • As ot"d a!ov"/ (ot asso'iat"d it( $ro+)s" C)s("s ar" #ost 'o##o $"rs$iratio ad i t(" lat" #"o$a)sal o''asioally $al$itatios/ trasitio ad "arly ad is o+t" +ollo"d !y $ost#"o$a)sal $"riods '(ills ad s(iv"rig/ ad so#"ti#"s a +""lig o+ • T("y ar" s"l+:li#it"d/ a&i"ty. )s)ally r"solvig it(o)t • Hot C)s("s )s)ally o'')r tr"at#"t it(i o" to v" y"ars/ alt(o)g( so#" s"v"ral ti#"s $"r day/ o#" ill 'oti)" to alt(o)g( t(" rag" #ay (av" (ot C)s("s )til !" +ro# oly o" or to a+t"r ag" 2. "a'( day to as #ay as o" $"r (o)r d)rig t(" • T(" $r"val"'" o+ day ad ig(t. Hot vaso#otor sy#$to#s is Cas("s ar" $arti')larly ;)it" varia!l" a'ross 'o##o at ig(t. ')lt)r"s
•
Ho"v"r/ a sigi'at asso'iatio !"t"" t(" #"o$a)sal trasitio ad ris? +or d"$r"ssio s""#s a$$ar"t ov"rall. • I t(" larg"st $ros$"'tiv" 'o(ort st)dy to dat"/ t(" St)dy o+ o#"s H"alt( A'ross t(" Natio 7SAN8 r"$ort"d t(at o#" i "arly $"ri#"o$a)s" (ad a (ig("r rat" o+ #ood sy#$to#s 719. to 1J.9 $"r'"t8 t(a $r"#"o$a)sal o#" 7J to 1% $"r'"t8 • T("s" #ood sy#$to#s $ri#arily "r" irrita!ility/ "rvo)s"ss/ ad +r";)"t #ood '(ag"s/ !)t ot +""lig !l)"/ ad "r" #or" 'o##o i o#" it( lo"r "d)'atioal attai#"t. • S"v"ral st)di"s (av" r"$ort"d t(at a $rior (istory o+ d"$r"ssio or PMS is a strog $r"di'tor o+ d"$r"ssiv" r"')rr"'" d)rig t(" #"o$a)sal trasitio .
.4enitourinary symptoms a.&ainal dryness
b.'e=ual dys+unction
c.Urinary symptoms
• T(" "$it("lial liig o+ t(" vagia ad
• Estrog" d"'i"'y )r"t(ra ar" v"ry s"sitiv" to "strog"/ l"ads to a d"'r"as" i ad "strog" d"'i"'y l"ads to !lood Co to t(" t(iig o+ t(" vagial "$it("li)#. vagia ad v)lva. T(is T(is r"s)lts i vagial atro$(y d"'r"as" is a #aor 7atro$(i' vagiitis8 'a)s" o+ d"'r"as"d vagial l)!ri'atio ad • 'a)sig sy#$to#s o+ vagial dry"ss/ s"&)al dys+)'tio i it'(ig ad o+t"/ dys$ar")ia. #"o$a)sal o#" • T(" $r"val"'" o+ vagial dry"ss • T(is ")ro$at(y as a!o)t 9 $"r'"t o+ o#" a$$"ars to !" • O "&a#/ t(" vagia ty$i'ally 'o#$l"t"ly r"v"rsi!l" a$$"ars $al"/ it( la'? o+ t(" or#al it( "strog" r)ga" ad o+t" (as visi!l" !lood r"$la'"#"t t("ra$y v"ss"ls or $"t"'(ial ("#orr(ag"s. T(" '"rvi& also 'a • @agial $H/ (i'( is )s)ally 9.> i atro$(y ad !"'o#" t(" r"$rod)'tiv" y"ars/ i'r"as"s to C)s( it( t(" to$ o+ t(" .2 to .> rag" i t(" vagial va)lt. $ost#"o$a)sal o#" ot ta?ig • T(" "lasti'ity o+ t(" "strog". T(" i'r"as" i $H ad vagial atro$(y #ay l"ad to i#$air"d vagial all #ay $rot"'tio agaist vagial ad )riary d"'r"as" ad t(" tra't i+"'tio "tir" vagia 'a !"'o#" s(ort"r or arro"r.
•
o "strog" $rod)'tio a+t"r t(" #"o$a)s" r"s)lts i atro$(y o+ t(" s)$"r'ial ad it"r#"diat" lay"rs o+ t(" )r"t(ral "$it("li)# it( s)!s";)"t atro$(i' )r"t(ritis/ di#iis("d )r"t(ral #)'osal s"al/ loss o+ 'o#$lia'"/ ad irritatio t("s" '(ag"s $r"dis$os" to !ot( str"ss ad )rg" )riary i'oti"'". • T(" $r"val"'" o+ i'oti"'" i'r"as"s it( ag". It (as ot !"" "sta!lis("d/ (o"v"r/ t(at t(" +r";)"'y o+ )riary i'oti"'" i'r"as"s a'ross t(" #"o$a)sal trasitio • Alt(o)g( data ar" 'oCi'tig/ syst"#i' "strog" t("ra$y do"s ot a$$"ar to !" ""'tiv" +or t(" tr"at#"t o+ )riary i'oti"'". • R"')rr"t )riary tra't i+"'tios ar" also a $ro!l"# +or #ay $ost#"o$a)sal o#". I additio to "$it("lial atro$(y/ "strog" d"'i"'y 'a i'r"as" vagial $H ad al t"r t(" vagial Cora/ '(ag"s (i'( #ay $r"dis$os" to )riary tra't i+"'tio
./thers •
reast pain Br"ast $ai ad t"d"r"ss ar" 'o##o i t("
•
"arly #"o$a)sal trasitio/ !)t !"gi to di#iis( i t(" lat" #"o$a)sal trasitio 1enstrual miraines M"str)al #igrai"s ar" #igrai"
•
alance I#$air"d !ala'" i $ost#"o$a)sal
o#" #ay !" a '"tral ""'t o+ "strog" d"'i"'y .Pro!l"#s it( !ala'" #ay $lay a #aor rol" i t(" i'id"'" o+ +or"ar# +ra't)r"s i
("ada'("s t(at 'l)st"r aro)d t(" os"t o+ "a'( #"str)al $"riod. I #ay o#"/ t("s" ("ada'("s ors" i +r";)"'y ad it"sity d)rig t(" #"o$a)sal trasitio . • '*in chanes T(" 'ollag" 'ot"t o+ t(" s?i ad !o"s is r"d)'"d !y "strog" d"'i"'y. D"'r"as"d ')ta"o)s 'ollag" #ay l"ad to i'r"as"d agig ad ri?lig o+ t(" s?i. T(" 'ollag" '(ag"s #ay !" #ii#i*"d it( "strog". • Soint pain Alt(o)g( t(" $r"val"'" is ot ?o/ so#" o#" "&$"ri"'" di)s" oit $ai d)rig t(" #"o$a)sal trasitio ad $ost#"o$a)sal $"riod
o#". T(" i'id"'" o+ 6oll"s +ra't)r"s i'r"as"s #ar?"dly i o#" at ag" >2 !)t r"#ais sta!l" i #" )$ to t(" ag" o+ J2. A #"'(ais# ot("r t(a ost"o$orosis #)st !" ivo?"d to "&$lai t(is o!s"rvatio !"'a)s" ost"o$orosis o'')rs grad)ally. • T(" +ra't)r" is )s)ally 'a)s"d !y +allig o a o)tstr"t'("d (ad. T(" rol" o+ "strog" t("ra$y o +alls is dis')ss"d "ls"("r".
on-term issues
!ianosis
Hormone #eplacement "herapy (H#")
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•
•
one loss Bo" loss
!"gis $rior to #"o$a)s". T(" a)al rat"s o+ loss d)rig t("s" $(as"s "r" a$$ro&i#at"ly 1.J to %., $"r'"t i t(" s$i" ad 1.2 to 1.9 $"r'"t i t(" (i$. Hig("r !ody #ass id"& as asso'iat"d it( slo"r !o" loss "t(i'ity (ad o ""'t. •
M"o$a)s" is d""d 'lii'ally as 1% #ot(s o+ a#"orr("a i a o#a ov"r ag" 9> i t(" a!s"'" o+ ot("r !iologi'al or $(ysiologi'al 'a)s"s. • T(" !"st a$$roa'( to diagosig t(" #"o$a)sal trasitio is a logit)dial ass"ss#"t o+ #"str)al 'y'l" (istory ad #"o$a)sal sy#$to#s 7vaso#otor C)s("s/ #ood '(ag"s/ sl""$ dist)r!a'"s8. • !iDerential dianosis Hy$"rt(yroidis# s(o)ld alays !" 'osid"r"d i t(" di"r"tial diagosis $r"ga'y/ (y$"r$rola'ti"#ia. • Aty$i'al (ot Cas("s ad ig(t s"ats #ay !" d)" to ot("r disord"rs/ s)'( as #"di'atios/ 'ar'ioid/ $("o'(ro#o'yto#a/ or )d"rlyig #aliga'y.
Cardio,ascular disease • !ementia 'ummary recommendations
Post#"o$a)sal (or#o" t("ra$y is ')rr"tly r"'o##"d"d s(ort:t"r# +or t(" #aag"#"t o+ #od"rat" to s"v"r" vaso#otor C)s("s. og:t"r# )s" +or $r"v"tio o+ dis"as" is o log"r r"'o##"d"d
Hormone preparations •
•
6o#!i"d/ 'oti)o)s 'o)gat"d "strog"s ".g. 72.%> #g8 ad #"dro&y$rog"st"ro"a'"tat" 7MPA %.> #g8. U:o$$os"d "strog"s 7i
•
•
• •
•
Most $ost#"o$a)sal o#"/ it( t(" E6EPTIONo+ o#" it( !r"ast 'a'"r or ?o 'ardiovas')lar dis"as"/ (o (av" sy#$to#s o+ vagial atro$(y ad-or vaso#otor ista!ility ar" good 'adidat"s +or "strog" t("ra$y 7+or t(" s(ort"st d)ratio $ossi!l" d"$"dig )$o sy#$to#s8. &asomotor instability For $ost#"o$a)sal o#" it( #od"rat":to:s"v"r" vaso#otor sy#$to#s 7ad o (istory o+ !r"ast 'a'"r or 'ardiovas')lar dis"as"8/ s(ort:t"r# "strog" t("ra$y as t(" tr"at#"t o+ '(oi'" Uroenital atrophy it( t(" "&'"$tio o+ o#" it( !r"ast 'a'"r/ al#ost all $ost#"o$a)sal o#" ar" 'adidat"s +or vagial "strog". /steoporosis " ')rr"tly do ot 'osid"r "strog" to !" a rst:li" t("ra$y +or ost"o$orosis. T("r"+or"/ t(" #aag"#"t o+ o#" (o '(oos" ot to or 'aot ta?" "strog" is t(" sa#" as +or ot("r $ost#"o$a)sal o#". Cardio,ascular disease pre,ention Estrog" is NO log"r idi'at"d +or t(" $r"v"tio o+ 6HD i $ost#"o$a)sal o#". T(" !"st #"as o+ $ri#ary ad s"'odary $r"v"tio o+ 'ardiovas')lar dis"as" ivolv"s att"tio to ris? +a'tors s)'( as s#o?ig/ (y$"rt"sio/ dysli$id"#ia/ ad dia!"t"s #"llit)s
•
(yst"r"'to#is"d $ati"ts 8 Oral $r"$aratios / lo'al / i"'ta!l"s / vagial $r"$aratios ad i#$lats
Uses • Tr"at s(ort t"r# #"o$a)sal •
sy#$to#s Dis"as" $r"v"tio
!isease pre,ention • • •
Coronary heart disease /steoporosis !ementia
Androen replacement
•
•
• T(" ?o d"'r"as" i ovaria adrog"
I ("alt(y o#" it( premature ovarian failure/ " 'oti)"
t("ir (or#o" t("ra$y )til t("ir lat" 92s or ag" >2 y"ars. At t(at $oit/ t(" sa#" dis')ssio o+ $ot"tial ris?s ad !""ts o+ $ost#"o$a)sal (or#o" t("ra$y s(o)ld ta?" $la'"
Alt(o)g( o#" it( !r"ast 'a'"r o+t" "&$"ri"'" early menopause d)" to ad)vat '("#ot("ra$y/ ad #ay (av" vaso#otor sy#$to#s d)" to ta#o&i+" t("ra$y/ "strog" t("ra$y s(o)ld NOT !" $r"s'ri!"d. • T(" "$id"#iologi' data ad 'lii'al trial data (av" !"" i'osist"t/ !)t t(" i'r"as"d ris? o+ !r"ast 'a'"r r"')rr"'" it( "strog" t("ra$y i o" trial 7HABITS8/ is o+ gr"at 'o'"r. " t("r"+or" do ot r"'o##"d "strog" +or o#" it( a $"rsoal (istory o+ !r"ast 'a'"r.
$rod)'tio rat"s ad s"r)# adrog" 'o'"tratios (as 'a)s"d 'o'"r t(at #"o$a)s" #ig(t !" asso'iat"d it( a d"'li" i li!ido. A ag":asso'iat"d d"'li" i s"&)al d"sir" (as !"" o!s"rv"d i !ot( #" ad o#". Ho"v"r/ it is )'l"ar ("t("r t(" d"'li" i li!ido i o#" is ag": or #"o$a)s": r"lat"d/ si'" st)di"s i o#" (av" ot s(o a sigi'at 'orr"latio !"t"" li!ido ad t(" s"r)# "stradiol or t"stost"ro" 'o'"tratio
MUTIPE GESTATIONS EPIDEMIOOGY H"lliKs r)l"4 1 i J2 :1 $r"ga'i"s 23 ar" Di*ygoti' 7di'(orioi' ad dia#ioti'8 923 ar" Moo*ygoti' 7o" i %>2 !irt(s/ 'ostat orldid"8 : 123 7di'(orioi' ad dia#ioti'8 : %23 7#oo'(orioi' ad dia#ioti'8 : 123 7#oo'(orioi' ad #ooa#ioti'8
DEFINITION 5 TYPES Ay $r"ga'y i (i'( to or #or" +"t)s"s "&ist si#)lta"o)sly Ty$"s • Di*ygoti' 7di'(orioi' ad dia#ioti'8/ 7+rat"ral8 • Moo*ygoti' 2:% (r ` di'(orioi' ad dia#ioti' 9:J d ` #oo'(orioi' ad dia#ioti' I'id"'" vari"s it(4 Et(i' gro)$ 7Bla'?s #or"8/ :1% days ` #oo'(orioi' ad Mat"ral ag" 7Old"r #or"8/ Parity 7M)lti #or"8/ #ooa#ioti' 01%t( day ` 'ooi"d 7Sia#"s"8 tis/ Fa#ily H&/ 6OH/ 12 ad %23 it( 66 5 (MG r"s. 7Oly i 142/222 7t(or'o$ag)s is t(" di*ygoti' tis8 'o##o"st8 6HORIONI6ITY UNIUE 6OMPI6ATIONS ITH IN MONO6HORIONI6 DETERMINATION Ultraso)d cTIN:TIN TRANSFUSION cA6ARDIA6 TIN : ,23 o+ tis ill !" o+ SYNDR 7TTTS8 di"r"t s"& O" !a!y ill giv" !lood to To groig +"t)s"s !)t oly : %,3 ill (av" #oo'(orioi' t(" ot("r !a!y t(ro)g( a o" ("art !"atig $la'"ta A@ aasto#osis. 6a)s"4 ivig '"lls i t(" : %3 ill (av" sa#" s"&/ d"+or#"d !a!y is s)stai"d !y di'(orioi' $la'"tas/ !)t t(" ("alt(y tiKs 'ir')latio. di"r"t !lood gro)$ig : %23 (av" sa#" s"&/ di'(orioi' $la'"tas/ ad id"ti'al !lood gro)$ig t(at ill r";)ir" HA or DNA P6R aalysis
cFETUS PAPYRA6EOUS F"t)s i a #)lti:g"statio $r"ga'y di"s i:)t"ro 5 t(" $artially-'o#$l"t"ly a!sor!"d !y t(" #ot("r or ti. ZTi "#!oli*atio 7vais(ig8 sydro#"
PREGNAN6Y 6OMPI6ATIONS Hy$"r"#"sis gravidar)# Hy$"rt"siv" dis"as"/ 9& #or" 'o##o t(a sigl"tos G"statioal dia!"t"s Aa"#ia Hydra#ios i 1%3/ $ri#arily i #oo*ygoti' tis R"C)&/ a! dis'o#+ort/ !a'? $ai/ l"g s"llig/ !ladd"r s& ad (a"#orr(oids. APH 7PP ad A!r)$tio/ as larg"r $la'"tal ar"a ad PET8 T(ro#!o"#!oli' dis"as"4 a$$ro$riat" $ro$(yla&is
ad R&
PRESENTATIONS Fo)r $ri'i$al 'o#!iatios o+ $r"s"tatios 6"$(ali'-'"$(ali' 23 6"$(ali'-!r""'( %23 Br""'(-'"$(ali' 123 Br""'(-!r""'( 123 First to/ #ay o!st"tri'ias ill allo vagial d"liv"ry it( t(" sa#" 'otraidi'atios as +or sigl"to $r"ga'i"s T(" sa#" a$$li"s +or trial o+ vagial d"liv"ry i t(" $r"s"'" o+ a $r"vio)s lo"r s"g#"t 6a"sar"a S"'tio 6o#$li'atio A!ortio 71%:1%?8 Pr"#at)r" la!or 7%9: ,%?8 IUGR F"tal d"+"'ts
Sigl"to 13 13
Di'(or h %3 >3
>3 13
123 %3
INDI6ATIONS FOR EE6TI@E 6: SE6TION : Mal$r"s"tatio o+ t(" rst ti : S"'od ti larg"r t(a t(" rst : Evid"'" o+ IUGR i o" or !ot( tis : Moo'(orioi' tis : History o+ +"rtility tr"at#"t A"st("ti'4 E$id)ral
a!o)r #aag"#"t4 I@ li"/ D"liv"ry i t("atr"/ Ti 6TG #a'(i" % r"s)s'itatio troll"ys/ % o!st"tri'ias/ % $a"diatri'ias/ I+or# S6BU PPH4 I@ li"/ Blood gro)$"d ad sav"d/ O&yto'i i+)sio +olloig d"liv"ry
DIAGNOSIS OF MUTIPE PREGNAN6IES Si*" ad (or#o"s Diagosis o+ #)lti$l" g"statios History/ "&a#iatio 79'# larg"r t(a &18 ad iv"stigatios
Moo'(or h 1%3 123
%23 J3 FOI6UAR 6YST
DEATH OF ONE FETUS IN A TIN NON:NEOPASTI6 PREGNAN6Y. FUN6TIONA 6YST Di'(orioi' < Pr"t"r# la!or Moo'(orioi' < Hy$ot"sio ` D"at( - Hadi'a$ o+ t(" ot("r.
6ORPUS UTEA 6YST GRANUOSA:THE6A UTEA POY6YSTI6 ENDOMETRIOTI6
Do"sKt l"ad to DI6 as r"adily as sigl"to. EPITHEIA
O@ARIAN
ABOR MANAGEMENT
GERM 6ORD
BENIGN BORDERIN E
MU6INOU SEROUS ENDOMETRIOI 6EAR 6E 7MESONEPHROI
FOI6UAR 6YST : Us)ally l"ss t(a > '# : B"ig ad asy#$to#ati' : T(i all/ 'otai 'l"ar C)id : R"s'a i 9 ""?s : I+ "larg" or sy#$to#ati'/ 'osid"r s)rg"ry
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O@ARIAN NEOPASM NON:NEOPASTI6 FUN6TIONA 6YST 6ORPUS UTEA 6YST GRANUOSA:THE6A UTEIN 6YST E&'"ssiv" !l""dig ito 'or$)s - i #olar $r"ga'y or $art l)t")# o+ (y$"rsti#)latio 6yst ll"d it( !lood sydro#" D)" to "&'"ssiv" D"lay"d $"riod = $ai goadotro$(i Us)ally t(" +olloig $"riod is ("avy PRIMARY O@ARIAN TUMORS AQ EPITHEIA
B"ig Bord"rli"4 E$it("lial t)#ors it( o ivasio o+ !as"#"t #"#!ra" 1>3 o+ "$it("lial t)#ors/ #ostly s"ro)s ad stag" 1 72:J>38. 12 y"ar s)rvival is >3. at" r"')rr"'". E&t"siv" (istologi'al s"'tioig is "ss"tial to "&'l)d" ivasio. Maligat MU6INOUS SEROUS ENDOMETRIOD : arg" t)#ors. Most 'o##o : F" 'as"s aris" i M)ltilo')lar ll"d it( - 6otai 'l"ar C)id "do#"triosis #)'i O+t" !ilat"ral. : ,23 'o"&ist it( : I+ r)$t)r"d ` Aro)d ag" o+ $ri#ary "do#"trial $s")do#y&o#a #"o$a)s" 'a'"r $"rito"i Maligat ty$" is t(" 'o##o"st ovaria 'a'"r
POY6YSTI6 O@ARY ENDOMETRIOTI6 6YST
-
BRENNER : Us)ally !"ig.o'')r i r"$rod)'tiv" li+" : May !" asso'iat"d it( "do#"trial (y$"r$lasia : May 'o"&ist it( #)'io)s 'ystad"o#a
6EAR 6E ZMESONEPHROID : Asso'iat"d it( "do#"triosis i %>3 : orst $rogosis
O@ARIAN NEOPASM PRIMARY O@ARIAN TUMORS BQ GERM 6E TUMORS BENIGN DERMOID 6YST Z BENIGN 6YSTI6 TERATOMA : %>3 o+ all ovaria "o$las# : 6otai tiss)" d"riv"d +ro# to or #or" g"r# '"ll lay"rs : Uilo')lar 'yst. May 'otai t""t(/ !o" / 'artilag"/ "rv"s/ (air/ t(yroid/.. Tiss)"s : Al#ost alays !"ig. Maligat '(ag"s #ay o'')r i ay 'o#$o"t : O'')r at ay ag". P"a? is %2:,2 y"ars. : Bilat"ral i %23
MAIGNANT Rar". ,3 o+ ovaria 'a'"rs SOID TERATOMA P"a? i'id"'" i s"'od d"'ad"
NON: GESTATIONA 6HORIO6AR6INO MA : S"'r"t" H6G : May !" 'o#$o"t o+ solid t"rato#a
YO SA6 Z ENDODERMA SINUS - Hig(ly #aligat.
A"'t yo)g ag" : Partly solid. S"'r"t" al$(a +"to: $rot"i
DYSGERMINOMA
: Most 'o##o. Hig(ly #aligat : Us)ally s$r"ad !y ly#$(ati's : @"ry radios"sitiv" : O'')r i yo)g o#". May aris" i goadal dysg""sis
6Q GERM 6ORD Z GONADA STROMA Z SE 6ORD TUMORS GRANUOSA THE6A 6E TUMOR ANDROGEN:SE6RETING TUMORS FIBROMA : Mod"rat" to larg" si*" : Adro!lasto#a : Solid t)#or : Solid/ as "larg" #ay (av" 'ysti' : S"rtoli:l"ydig : May !" asso'iat"d it( #"igsK s$a'"s : Gyadro!lasto#a sydro#" : Y"llo tig" o ')t s)r+a'" 6a)s" virili*atio : T"d to (av" log $"di'l" : T("'o#a is !"ig/ !)t gra)losa is #aligat : O'')r at ay ag" .>23 $ost#"o$a)sal : S"'r"t" "strog" : Us)ally stag" 1. at" r"')rr"'" SE6ONDARY Z METASTATI6 O@ARIAN TUMORS Alays !ilat"ral. Fro# #)'i s"'r"tig t)#ors/ sto#a'( ad 'olo 7r)?"!"rg t)#ors8 May !" s"'odary to !r"ast
MAIGNANT EPITHEIA O@ARIAN TUMORS ETIOOGY PRESENTATION PHYSI6A FINDINGS Ris? Fa'tors4 B"ig4 Sil"t dis"as" < >3 N)lli$arity/ Fa#ily : Us)ally #o!il". )l"ss larg" or $r"s"t at adva'"d (istory/ F"rtility 'o#$li'at"d stag" dr)gs : D"r#oid 'yst at"rior to !ladd"r Sy#$to#s o+ Prot"'tiv" Fa'tors4 ^ Maligat4 a!do#ial N)#!"r o+ : Bilat"ral ivolv"#"t $r"ga'i"s/ O66P/ Sy#$to#s o+ distat : As'it"s T)!al ligatio. : Hard d"$osit i $"lvis #"tastas"s : "g "d"#a G""ral #alais"/ : Sigs o+ !o"l o!str)'tio o+ )r"t"ri' "ig(t loss o!str Hor#oal $rod)'tio 6OMPI6ATION O@ARIAN TUMOR IN PREGNAN6Y IN@ESTIGATION • Torsio • Fo)d i'id"tally • Uss -6T s'a : 'o##o it( d"r#oid-!ro#a • 6or$)s l)t"al-d"r#oid • T)#or #ar?"rs7 'a1%>/6EA/ : S"v"r" a!do#ial $ai-vo#ittig H6G/al$(a FP %3 ar" #aligat • • R)$t)r" • Ur"a ad "l"'trolyt" • I+ dis'ov"r "arly ad $"rsist / • Ha"#orr(ag" • FT s)rg"ry aro)d 1 ""?s • I#$a'tio • I+ 'o#$li'at"d/ o$"rat" i##"diat"ly • 6("st ray • i+"'tio • As'iti' ta$ • 6al')lat" ris* malinancy inde=. FIGO STAGING RIS MAIGNAN6Y INDE Stag" Grot( li#it"d to o" or !ot( ovari"s 6A 1%> "sti#atio 1 Stag" Grot( li#it"d to o" or !ot( ovari"s it( M"o$a)sal stat)s % $"lvi' "&t"sio $r" #"o$a)sal s'or" 1 Stag" T)#or ivolvig o"-!ot( ovari"s it( $ost #"o$a)sal s'or" , , $"rito"al i#$lats o)tsid" $"lvis-$ositiv" Ultraso)d s'or" r"tro$"rito"al or ig)ial od"s. M)lti lo')lar/ solid ar"as/ !ilat"ral/ as'itis/ itra a! #"ts. i+ 2 or 1 s'or" 1 i+ %:> s'or" , INTRODU6TION : id" vari"ty o+ t)#ors : %>3 o+ +"#al" g"ital tra't t)#ors : I U./ t(" #ost 'o##o $"lvi' 'a'"r : orst $rogosis o+ all +"#al" g"ital tra't 'a'"rs : i+" ti#" ris? is 13 : S$r"ad !y lo'al s$r"ad/ ly#$(ati' ad rar"ly !y !lood
Stag" 9
Grot( ivolvig o" or !ot( ovari"s it( distat #"ts.
MAIGNANT EPITHEIA O@ARIAN TUMORS MANAGEMENT SURGI6A PRIMARY INTER@A DEBUING SE6OND OO SURGERY : Pri#ary 'ytor"d)'tio : Alt"rativ" to $ri#ary s)rg"ry : Ass"ss r"s$os" to : TAH/ BSO/ OMETE6TOMY/ #"di'ally )t '("#ot("ra$y ASHINGS/ BOE SURGERY larg" as'itis : Pla +)t)r" : O$ti#al d"!)l?ig4 l"ss s"v"r" #al)tritio #aag"#"t t(a % '# r"sid)al t)#ors : , 'y'l"s o+ '("#ot("ra$y FB6/ U5E
FOO UP Ho aggr"ssiv"W. T(r"" #ot(ly +or o" y"ar t(" si& #ot(ly t(" y"arly History/ "&a#iatio ad 6A1%> I#agig i+ r"')rr"'" is s)s$"'t"d 'lii'ally or !y 6A1%>
PAIATI@E SURGERY : R"#oval o+ it"stial o!str)'tio : S)rvival is v"ry $oor : )ality o+ li+" 'osid"ratios
S6REENING i+" ti#" ris? is 13 >3 o+ t)#ors ar" g""ti' History o+ !r"ast 'a'"r i'r"as"s ris? !y +a'tor o+ % History o+ 'a ovary i'r"as"s t(" ris? !y +a'tor o+ , O" rst d"gr"" r"lativ" a"'t"d4 ris? %.3 % rst d"gr"" r"lativ"s a"'t"d 4 ris? is 1,3 4 ris? is >23 I+ BR6A1 #)tatio 'arri"r Pro!l"#s 4 : o $r":'a'"ro)s stag" : )?o at)ral 'o)rs" T@S AND 6A1%> ON YEARY BASIS ONGOING STUDY TO E@AUATE THIS.
PE@I6 INFAMMATORY DISEASE Edo#"tritis PATHOOGY EPIDEMIOOGY 6INI6A FEATURES o"r a! $ai ad No s$"'i'/ la'? o o I'id"'" varia!l" Sal$igitis • I+"'tio as'"d to t"d"r"ss s"sitivity ad 12:1,3/ Oo$(oritis t(" )t"r)s r"s)ltig i D""$ dys$ar)"a s$"'i'ity o )d"r"sti#at"d/ "do#"tritis it( Para#"tritis Positiv" $r"di'tiv" o i'r"asig A!or#al vagial or o $las#a '"ll iltratio P"ritoitis Ag"/ t""s val)" o+ 'lii'al '"rvi'al dis'(arg" T)!"s/ #)'osal • T)!"s/ DD& diagosis is >:23 S"&)al a'tivity/ o 6"rvi'al "&'itatio iCa##atio it( UTI as 'o#$ar"d to "arly 'oit)s/ ad ad"&al s"llig/ r"d"ss ad Early la$aros'o$y #)lti$l" $art"rs/ t"d"r"ss d"'iliatio/ $oly#or$( $r"ga'y E&'"ss o+ B6 i o o+t" $ro'""d"d !y F"v"r 0,Jp6 o iltratio o+ t(" 'o#$li'atio/ t(" vagia $r"s"t STD 7'(la#ydia/ G68 o Ad"&al #ass i s)!#)'osa/ "&)dat" E'to$i' i lo"r g"ital it( %dary ivasio lls t(" l)#"/ %23 o+ 'as"s $r"ga'y tra't i+"'tio also it( aa"ro!"s ad("sios ad s$r"ad Rais"d ESR/ B6/ o A$$"di'itis/ Edo#"trial !io$sy o 6otra'"$tio to t(" s"rosal s)r+a'"/ 6RP div"rti')litis ot r"'o##"d"d $)s +ro# t(" #!ria PillsW Prot"'tiv" o E&'"ss o+ 6o#$li'at"d as ro)ti" • Ovari"s ad IU6D 6) r"l"asig↑ ")?o'yt"s ")?o'yt"s i t(" ovaria t)#or iv"stigatio +or#atio o+ t)!o: vagia ris? Ot("r 'a)s"s o+ ovaria a!s'"ss or G""ral sy#$to#s o Barri"r $rot"'tiv" lo"r a! $ai #ass d"$"d o s"v"rity Parity >3 ar" )lli$aro)s 6OMPI6ATIONS IN@ESTIGATIONS TREATMENT T)!oovaria T )!oovaria 6B6/ 6RP/ Uri" Mild 'as"s 4 A#!)latory S"v"r" 'as"s4 Ad#ite I@ '"$(alos$ori = Ati!ioti' #"tro till %9 (/ a!s'"ss/ aalysis ad ')lt)r" Do&y'y'li" %&-day-19d Idi'atios to Ad#it4 i#$rov"#"t ` oral $oly#i'ro!ial/ H@S/ Edo'"rvi'al = #"troida*ol" S)rgi'al "#"rg"'y do&y'y'li" ad >23 !ilat"ral sa! %&-day->d 'aot !" "&'l)d"d/ #"troida*ol" T)!al da#ag"/ T)!al USS/ ad"&al #ass or 7i+ G6 s)s$"'t"d add 6lii'ally s"v"r" i+"rtility ad a!s'"ss 'i$roCo&o'i" 'i$roCo&o'i" sigl" dis"as"/ T)!oovaria 6lida#y'i" +)t)r" "'to$i'. a$aros'o$y i+ t("r" dos"8 a!s'"ss/ PID i OCo&o'i"= Fit*:H)g(:6)rtis is do)!t a!o)t $r"ga'y/ a'? o+ #"troida*ol" sydr diagosis or o Or r"s$os" to oral 6lida#y'i" R"i+"'tio is R"i+"'tio i#$rov"#"t a+t"r OCo&o'i" = t("ra$y/ Itol"ra'" to %>3 %9:9J (o)rs o+ $ro$"r
6(roi' PID/ ad("sios/ $"lvi' $ai/ dys$ar)"a/ dys#"orr("a
tr"at#"t B(6G
#"troida*ol"
oral t("ra$y
S)$$ortiv" t("ra$y
NOTES VTUBER6UOSIS POSTPARTUM HEMORRHAGE D"+14 Ay !lood loss 0>22# 7vagial8 ad 01222# 7'a"saria8 +olloig oto+i#$rovig o ati!ioti' Pati"ts Rar" d"liv"ry. 7Blood loss "sti#atio ia'')rat"8 D"+%4 123t("ra$y dro$ o+s(o)ld P6@. 7D"$"ds o ti#ig o+ t"st a+t"r os"t8 (av" la$aros'o$y O+t" s"'odary to $)l#oary D"+,4 Ay !l""dig (i'( r"s)lt i t(" sigs 5 s& o+ ("#odya#i' ista!ility. ista!ility l oss r"s$os" di"r +ro# $$l < "s$ IU6D #ay !" l"+t i sit) i o#" TB . 7Blood loss a"#ia/ PET/ 'ardia' dis"as"s/ d"(ydratio8 IN6IDENit( 6E #ild PID !)tHs(o)ld EMOST!" ATI6 ME6H TYPE May $r"s"t as $"lvi: RIS FA6TORS r"#ov"d s"v"rt(" 'as"s T(" l"adig Atit"r#/ "sti#at"d !lood Co to Pri#ary 7Early8a!do#ial PPH4 Pr"vio)s PPH • a'"ratio • #ass T)!oovaria T )!oovaria a!s'"ss #ay !" Syst"#i' sy#$to#s/ 'a)s" o+ t(" )t"r)s >22:J22#-#i. 12:1>3 E&'"ssiv" !lood loss • A!r)$tio#"str)al • Istr)#"tal #at"ral drai"do+ 6ardia' o)t$)t. a!do#ially/ it(i %9( o+ d"liv"ry dist)r!a'"/ a#"orr(o"a/ d"liv"ry • R"tai"d #ortality. la$a$oros'o$i' Nat)ral ("#ostati' #"'(4 7"s$ 1st (8. i+"rtility or USS g)id"d • GA $la'"ta O'')r i 93 o+ 18 6otra'tio 5 r"tra'tio o+ S"'odary 7at"8 as$iratio o $"lvi' 'oll"'tio Tr"at"d !y• atit)!"r')lo)s atit)!"r Fail)r" ')lo)s to • HTN disord"rs Tr"at"d d"liv"ri"s. #yo#"trial !"rs PPH4 E&'"ssiv" !lood $rogr"ss • Id)'tio 5 %8 Hy$"r'oag)la!l" stat" i lat" loss !"t"" %9(: d)rig %d A)g#"tatio o+ $r"ga'y ?s $ost$art)# stag" la!or ,8 It"grity o+ t(" g"ital tra't 7"s$ %d ?8 • Pla'"ta a''r"ta ETIOOGY Bl""dig #ostly +ro# "do#"trial s$iral art"rial art"riol"s 5 d"'id)al v"is t(at s)$$li"d 5 drai it"rvillo)s s$a'"s o+ $la'"ta. 6a)s"s o+ $ri#ary PPH4 18 To" To" %8 Tra)#a ,8 Tiss)" 98 T(ro#!osis >8 Ut"ri" Iv"rsio TONE 7ATONY/ 7ATONY/ >:J238 TRAUMA TISSUE THROMBOSIS UTERINE IN@ERSION Fail)r" o+ 'otra'tio 5 r"tra'tio o+ @as')lar @as')lar !"ds i : R"t"tio o+ Pr""&ist"t4 Pr""&ist"t4 ITP/ \)st a+t"r %d stag" stag" #yo#"trial #)s'l" !"rs. g"ital tra't ar" $art o+ TTP. TTP. o+ la!or/ d)" to Pr"dis$osig +a'tors4 "gorg"d d)rig $la'"ta. A';)ir"d4 )t"ri" atoy/ '"rvi& 18 Ut"r)s ov"rdist"tio < M)lti$l" $r"ga'y. >23 'as"s o+ 1: A!r)$tio 7"a? is o$" 5 $la'"ta g"statio/ GA/ Poly(ydroa#ios. 18 a'"ratio i %dary PPH. AF8 atta'("d. %8 Prolog"d la!or ` +atig)". '"rvi& 5 vagia < %: HEP 7lo Plt8 I"&$"ri"'"d do' ,8 Dr)gs < Halog" a"st/ itrat"/ NSAID/ s$ota"o)s: I'o#$l"t" ,: S"$sis ` DI6 "&"rt +)dal
MgSO9/ Ni+"di$i". 98 Pla'"ta $r"via : _'ot"t o+ #)s')lat)r" o+ t(" all. >8 Ba't"rial to&is < '(orioa#ioitis/ "do#"tritis 5 s"$ti'"#ia. 8 Fi!roid "s$ itra#)ral. 8 Grad #)lti$ara 0> J8 Pr"'i$ito)s la!or 8 A!r)$tio "s$ 'o'"al"d 'o* it"rstitial i t"rstitial !l""dig. 6INI6A MANIFESTATION H"avy vagial !l""dig _ BP ↑HR _ RB6 'o)t 7H't8 S"llig 5 $ai i tiss)"s i t(" vagial 5 $"ri"al ar"a.
istr)#"tal#ai$)latio o+ +"t)s- GA$r"'i$ito)s la!or. %8 Ut"ri" r)$t)r" ` itra$"rito"al !l""dig. ,8 H"#ato#a < $"ri"al/ vagial or !road liga#"t ("#ato#a. 6OMPI6ATION
9: Dil)tioal 'oag)lao$at(y >: A#ioti' C)id "#!olis# < itravas')lar i+)sio o+ s#all a#t o+ AF.
$r"ss)r" $r"ss)r" (il" $)ll )#!ili'al 'ord !"+or" 'o#$l"t" $la'"tal s"$aratio. Iv"rsio ` Tra'tio o+ $"rito"al str)'t)r" ` @asovagal @asovagal r"s$os" ` @asodilatio ` Hy$ovol"#i' s(o'?.
DD& OF 6AUSES
H&4 As? ris? +a'tors + a'tors o+ )t"ri" atoy 5 'oag)lo$at(y. 'oag)lo$at(y. E&a#4 So+t !oggy 5 larg" )t"r)s it( $ro+)s" vagial !l""digW Atoy. Brig(t r"d !l""dig !9 s"$aratio o+ $la'"taW Tra)#a. A!do#ial - vagial #ass i'r"asig i si*"W H"#ato#a. Bl""dig s"v"r"/ !rig(t r"d/ o 'lots !)t )t"r)s 'otra'ts "llW 6oag)lo$at(y. 6oag)lo$at(y. 6)$$ig o+ +)d)s or o:$al$a!l" +)d)sW Ut"ri" iv"rsio. F"v"r 5 t"d"r"ssW Edo#yo#"tritis. I+ o 'a)s" id"ti"d ` Ma)al "&$loratio o+ g"ital tra't. MANAGEMENT OF PRIMARY POSTPARTUM HEMORRHAGE Id"ti'atio o+ t(os" at ris? o+ PPH. Start $ro$(yla'ti' #"as)r"s d)rig la!or to #ii#i*" #at"ral #ortality. #ortality. 1. 6B6 < H! 5 Plt 7'orr"'t a"#ia i+ $r"s"t8. %. Blood ty$ig 5 A! s'r""ig 7#at'( %:)its !lood8 ,. Is"rt larg" !or" I@ li". ROUTES OF MANAGEMENT RESUS6ITATION E@AUATE SURGI6A PROGNOSIS O&yg" !y #as?. Moitor $)ls"/ BP/ 1. a$aroto#y to drai D"$"ds o % larg" !or" I@ li"s. 6"tral v"o)s li". Uri" o)t$)t/ +r"" !lood 5 is$"'t ay 'a)s" o+ PPH/ Dra !lood < 6B6/ 'oag)latio s'r""/ )r"a/ 'r"atii"/ !lood gas"s/ l"v"l i)ry 5 r"$air. d)ratio/ "l"'trolyt". o+ 'os'io)s"ss. %. Ut"ri" art"ry ligatio a#o)t o+ I##"diat" C)id r"$la'"#"t it( NS or R. Ord"r r"g)lar 6BS ,. It"ral ilia' 7i+"rior !lood loss 5
A"#ia Hy$ot"sio 5 (y$ovol)#i' s(o'? R"al +ail)r" Ris?s o+ !lood tras+ S)rg"ry 'o#$li'atios 5 s"$sis S(""(a sydr @"o)s @"o)s t(ro#!osis 5 "#!oli' ""'ts 7'o* o+ s)rg"ry/ !"d r"st 5 (y$"r'oag)la!l" stat"8
s"$aratio o+ a''r"ta or $r"'r"ta.
Tras+)s" Tras+)s" RB6 as availa!l" 5 a$$ro$riat". a$$ro$riat". 'o)ts 5 (y$ogastri'8 art"ry ""'tiv""ss FFP i+ a!or#al 'oag)latio t"st r"s)lts 5 sit"s oo*ig. 'oag)latio t"sts ligatio. o+ r&. 6ryo$r"'i$itat" i+ a!or#al 'oag)latio t"sts ot to g)id" !lood 9. Total (yst"r"'to#y Pro#$t d& 5 'orr"'t"d it( FFP. 'o#$o"t >. S"l"'tiv" art"rial r&. Plt 'o'"trat"s i+ $lt 'o)t >2&12- 5 !l""dig t("ra$y. "#!oli*atio 'oti)"s. MANAGEMENT OF UNDERYING 6AUSE TONE TRAUMA TISSUE 6OAGUOPA 6OAGUOPATHY THY Ass"ss )t"ri" si*" 5 to". 6"rvi'al 5 vagial R"#ov"d "v" i+ !l""dig sto$$"d 6or# !y ris? +a'tors 5 Bi#a)al < "&$r"ss 'lots/ la'"ratios ` a!sor!a!l" it( )s" o+ )r"trotoi's. a!or#al 'oag)latio sti#)lat" )t"ri" 'oti)o)s stit'(. Di')lt it(o)t GA. t"st. 'otra'tios. arg" lo"r g"ital tra't/ R"s)s'itat" ad";)at"ly. Ma)al FFP4 1U1g !riog" E#$ty !ladd"r. )sta!l" !road lig 5 "&$lor". 6ryo$r"'i$itat"4@III/ 6ryo$r"'i$itat"4@III/ iII 5 Ut"ri" art"ry ligatio/ r"tro$"rito"al r"tro$"rito"al ("#ato#a @agial (ad i sit) to _ !riog". s"l"'tiv" art"rial ` i'isio/ drai/ ligatio/ dis'o#+ort/ i+&/ tra)#a. Plt 'o'"trat"4 1) ↑%2: "#!oli*atio or s)!total$a'?ig. Ad("r"tW 6)r"ttag". %>? $lt. total (yst"r"'to#y. Ut"r)s r)$t)r" ` s)!-TAH. Pa'?"d RB64 1U ↑1g-d Ut"rotoi' dr)gs.
SE6ONDARY POSTPARTUM HEMORRHAGE ETIOOGY RIS FA6TORS R"tai"d $rod)'ts o+ 'o'"$tio 7RPO68 < 6:s"'tio #ost 'o##o 'a)s" o+ %dary PPH Prolog"d ROM I+"'tio < o+t" %dary to RPO6. 1:,3 a+t"r Prolog"d la!or it( #)lti$l" "&a#s. s$ota"o)s vagial d"liv"ry. Most 'o##o Ma)al r"#oval o+ $la'"ta 'a)s" o+ $ostatal #or!idity !"t"" day%: Mot("rKs ag" at "&tr"#"s 12. o so'io"'o stat)s a'"ratios < i'l)d"s "$isioto#y Mat"ral a"#ia Tra)#a < R)$t)r" o+ v)lval ("#ato#a It"ral +"tal #oitorig Pr":"&istig )t"ri" dis"as" < Fi!roids S"v"r" #"'oi)# staiig i li;)or Ot("rs 7rar"8 < Blood disord"rs/ 6ar'io#a o+ Prolog"d s)rg"ry '"rvi&. ASSESSMENT IN@ESTIGATIONS MANAGEMENT D& o!tai"d 'lii'ally. 6ross#at'( %:9)its o+ !lood i+ Maistays4 B"d r"st 5 I@ ati!ioti' [H&4 6ra#$y a! $aiW Passag" o+ !its o+ $la'"taW #ar?"d !l""dig. t("ra$y. S& o+ i+&. D)ratio o+ la!or. S#oot(W 6oag)latio $rol" as idi'at"d. 6)r"ttag" ot $"r+or#"d o)ti"ly Istr)#"talW Pla'"ta 'o#$l"t"W 6o#$li'atioWQ S$"')l)# "&a# < '("'? stat)s 7ris? o+ )t"r)s $"r+oratio8 E&a#4 6("'? t"#$/ HR/ BP. o+ '"rvi'al os 5 o!tai No o&yto'i. Ass"ss )t"ri" si*". arg"r t(a a$$ro$riat"W "do'"rvi'al sa!. G"tl" digital "va')atio o+ )t"r)s Ass"ss 'lii'al sigs o+ !lood loss. Esti#at" total US < #ay !" )s"d i+ RPO6 )d"r GA $"r+or#"d it( ati!ioti' !lood loss. s)s$"'t"d. Blood 'lots #ay 'ov"rag". Esta!lis( I@ li" as idi'at"d. r"s"#!l" RPO6. Iro s)$$l"#"t i+ H! lo. O&yg" via +a'" #as? as idi'at"d. 6B6 O@ER@IE 6o##oly $r"s"ts as $rolog"d or "&'"ssiv" !l""dig o'" o#a (as r"t)r"d (o#" a+t"r %9(:?s $ost$art)#. Most 'o##oly at %d ?. %dary to slo)g(ig o+ "s'(ar o $la'"tal sit" : ↑a#t o+ !l""dig. E&t"t o+ !l""dig l"ss t(a $ri#ary PPH.
DYSPASIA D"+4 "sio i (i'( $art o+ t(" "$it("li)# is r"$la'"d !y '"lls s(oig varyig d"gr"" o+ aty$ia.
PREIN@ASI@E 6ER@I6A DISEASE 6"rvi'al Itra"$it("lial N"o$lasia 76IN8 BETHESDA SYSTEM Syst"# Itra"$it("lial dys$lasti' aty$ia o'')rrig A6SUS SI HSI 6AN6ER it(i t(" #"ta$lasti' "$it("li)# o+ t(" tras+or#atio *o". Mild Mod"rJ S"v"r" 6IN 6a'"r OS6\ < Origial s;)a#o'ol)#ar )'tio.
dys$lasia
dys$lasi a 6IN %
dys$las ia 6IN ,
NS6\ < N" s;)a#o'ol)#ar )'tio T] < Tras+o#atio *o" < ar"a !"t"" OS6\ 5 NS6\. 6IN 1 O@ER@IE RIS FA6TORS 6"rvi'al "o$lasia origiat"s it(i T]. • P"rsist"t HP@ i+& o+ (ig( ris? ty$"s. o ris? HP@ 7ty$"s 5 118 ar" asso'iat"d it( lo:grad" • Yo)g ag" at rst 'oit)s '"rvi'al l"sios 7'odylo#a a')#iata ad 6IN18 • M)lti$l" s"&)al $art"rs. S"& $art"r it( #)lti$l" s"& Hig( ris? HP@ 7ty$" 1/ 1J/ ,1/ ,, or ,>8 asso'iat"d it( $art"rs. (ig(:grad" '"rvi'al l"sio 76IN%/, ad 6a'"r8. Yo)g ag" at rst $r"ga'y. • HP@ ty$" 1 is t(" ty$" )iv"rsally d"t"'t"d it( t(" • M)lti$arity. gr"at"st +r";)"'y i (ig( grad" l"sio 5 '"rvi'al 'a. >23 • o so'io"'o stat)s S66/ ,23 ad"o'a/ 5 0J23 $r"ivasiv" l"sios. AT l"ast ,>3 $t it( 6IN, ill d"v ivasiv" 'a it(i 12yrs / • S#o?ig 5 O6P • G"ital arts ("r"as lo"r grad"s #ay s$ota"o)sly r"gr"ss. • E&og"o)s - "dog"o)s i##)os)$$r"sio S6REENING PAP SMEAR 6OPOS6OPY B"+or" 6ol$os'o$y Bot( t(" "d St"r"os'o$i' !io')lar #i'ros'o$" o+ lo 6o#$l"t" (& ad g""ral "&a#. '"rvi'al 'aal ad #agi'atio/ )s)ally 12& to 92&. ^ A 'lii'al ad s$"')l)# "&a#iatio o+ t(" '"rvi&/ t(" "'to'"rvi& vagia s(o)ld !" sa#$l"d Idi'atios +or 'ol$os'o$y4 ad v)lva. (" ta?ig t(" Pa$ : A!or#al '"rvi'al s#"ar ^ A ,3 to >3a'"ti' a'id sol)tio is li!"rally a$$li"d to s#"ar : A!or#al digs o ad)'tiv" t(" ^ T(" +als" "gativ" s'r""ig t"sts 7HP@ t"stig ad '"rvi& )sig soa?"d sa$ rat" +or Pa$ s#"ar '"rvi'ogra$(y8 : T(" a!or#al digs ar" a'"to(it" "$it("li)# 5 +or (ig( grad" :I+ t(" '"rvi& is 'lii'ally a!or#al or a!or#al vas')lar $att"rs 7#osai'is# ad l"sios is %23 s)s$i'io)s o a?"d "y" "&a#. $)'t)atio8 ^ N" a)to#at"d : U"&$lai"d IMB or P6B ^ )golKs iodi" a$$li'atio to t(" '"rvi& is 'all"d li;)id !as"d slid" : P"rsist"t vagial dis'(arg" s(ill"rKs t"st $r"$aratio syst"#s : P"rsoal (istory o+ i )t"ro DES "&$os)r"/ :Nor#al "'to'"rvi& ad vagial s;)a#o)s "$it("li)# to d"'r"as" t(" +als" v)lvar or vagial "o$lasia. 'otais gly'og" ad stais #a(ogay:!ro "gativ" rat" ^ Nor#al 'ol)#ar ad s;)a#o)s #"ta$lasia ad "o$lasti' "$it("li)# do ot 'otai gly'og"/ ad a$$"ar #)stard y"llo ^ Satis+a'tory 6ol$os'o$i' E&a#iatio4 I+ t(" " S6\ 5 "tir" T] ar" s"".
E@AUATION FOR ABNORMA PAP SMEAR • Ay $ati"t it( a grossly a!or#al '"rvi& s(o)ld (av" a $)'( !io$sy $"r+or#"d r"gardl"ss o+ t(" r"s)lts o+ Pa$ s#"ar ^ Pati"ts it( AS6US +o)d i t("ir s#"ar #ay (av" a r"$"at s#"ar i #ot(s or HP@ t"stig ^ A!o)t :123 o+ $ati"ts it( a AS6US s#"ar ill (av" (ig(:grad" 6IN o 'ol$os'o$y/ 23 o+ t("s" 'a !" d"t"'t"d !y HP@ t"stig +or (ig(:ris? ty$"s ^ T(" 'ol$os'o$i' (all#ar? o+ 6IN is a ar"a o+ s(ar$ly d"li"at"d a'"to(it" "$it("il)#/ or-ad a!or#al vas')lar $att"r4 $)'t)atio ad #osai'is# ^ Mi'ro ivasiv" 'ar'io#a4 "&tr"#"ly irr"g)lar $)'at" ad #osai' $att"rs ar" +o)d. • I+ 'ol$os'o$i' "&a#iatio is satis+a'tory/ $)'( !io$sy +ro# t(" s)s$i'io)s ar"a it( "d '"rvi'al ')r"ttag" s$"'i#". ^ Diagosti' 'o" !io$sy o+ t(" '"rvi& is idi'at"d i+4 : 'ol$os'o$i' "&a#iatio is )satis+a'tory : Edo'"rvi'al ')r"ttigs s(o a (ig(:grad" l"sio : Pa$ s#"ar s(os a (ig(:grad" l"sio t(at is ot 'or#"d o $)'( !io$sy : Pa$ s#"ar idi'at"s Ad" 'ar'io#a i sit) : Mi'roivasio is $r"s"t o $)'( !io$sy TREATMENT OF ABNORMA INTRAEPITHEIA NEOPASIA 6IN • o Grad" "sios 76IN18 : R"$"at s#"ar i #ot( it"rval )til or#al t(" !a'? to t(" or#al s'r""ig $rogra#. • Hig( grad" l"sios 76IN %/,84 1. oo$ E&'isio o+ T(" Tras+or#atio ]o" 7ET]8/ r"lativ"ly '("a$/ it 'a !" $"r+or#"d o a o)t$ati"t !asis )d"r lo'al a"st("sia/ ad tiss)" is o!tai"d +or (istologi' "val)atio. %. ASER/ d"str)'tio o+ t(" T] !y 6O% las"r/ a!latio 'a !" $"r+or#"d as a o)t$ati"t $ro'"d)r" it( lo'al aa"st("sia/ "&$"siv". ,. 6ryos)rg"ry/ r"lativ"ly $ail"ss o)t$ati"t $ro'"d)r" it(o)t aa"st("sia/ '("a$/ (ig( +ail)r" rat" +or larg" l "sios/ 'o$io)s vagial dis'(arg" +or s"v"ral ""?s. 9. El"'tro'oag)latio/ R";)ir"s g""ral a"st("sia/ '"rvi'al st"osis #ay o'')r/ s)''"ss rat"s )$ to 3. >. 6"rvi'al 'oi*atio4 7'old ?i+" or las"r8 :#aily diagosti' !)t it #ay !" )s"d +or tr"at#"t/ ')r" rat"s ar" as (ig( as it( (yst"r"'to#y +or (ig( grad" l "sios. :Maor 'o#$li'atios4 Bl""dig/ i+"'tio/ '"rvi'al st"osis ad i'o#$"t"'". ^ Si#$l" (yst"r"'to#y is rar"ly "'"ssary/ it #ay !" a$$li'a!l" (" st"rili*atio is d"sir"d i a $ati"t it( 6IN III or (" t("r" is 'o'o#itat )t"ri" or ad"&al dis"as".
6ER@I6A 6AN6ER SYMPTOMS FINDINGS IN@ESTIGATIONS A!or#al vagial !l""dig is Us)ally or#al g""ral 6B6/ FT/ FT t(" #ost 'o##o "&a#. 6R/ P"lvi: $r"s"tig s&. I adva'"d dis"as"/ a!do#ial 6T Post'oital !l""dig i "larg"d ig)ial or B& o+ l"sio s"&)ally a'tiv" o#"/ IMB/ s)$ra'lavi')lar N/ "d"#a o+ 6ystos'o$y 5 PMB. t(" l"gs/ as'it"s/ $l")ral $ro'tos'o$y +or Asy#$to#ati' )til ;)it" ")sio/ ("$ato#"galy. 'lii'al stagig. adva'"d i o#" (o ar" Pa$ s#"ar #ay !" or#al i PET s'a to ot s"&)ally a'tiv". )$ to >23 o+ 'as"s 7+als" d"li"at" t(" P"rsist"t vagial dis'(arg"/ "gativ"8 "&t"t o+ dis"as" $"lvi' $ai/ l"g s"llig 5 P"lvi' "&a# i "arly dis"as" at t(" $ri#ary sit" )riary +r";)"'y ar" #ay !" or#al/ "s$ i+ l"sio ad i N. )s)ally s"" i adva'"d is "do'"rvi'al. dis"as". @isi!l" dis"as" #ay !" @"si'o:vagial 5 )l'"rativ"/ "&o$(yt' or r"'tovagial s&. "'roti'. TREATMENT IA1 < Total a!do#ial - vagial (yst"r"'to#y. : 6o" !& alo" #ay s)L'" i+ $t ats to $r"s"rv" +"rtility/ as log as 'o" #argis +r"" +ro# dis"as" 5 "do'"rvi'al ')r"ttig :v". IA% < Modi"d radi'al (yst"r"'to#y ad $"lvi' N diss"'tio. : I+ ats '(ild!"arig/ larg" 'o" !io$sy or radi'al tra'("l"'to#y 5 $"lvi' N diss"'tio ar" o"r"d. a8 Radi'al Hyst"r"'to#y 5 Bilat"ral $"lvi' ly#$(ad""'to#y < R"#ov"s )t"r)s/ ada'"t $ortios o+ vagia/ 'ardial liga#"ts/ )t"rosa'ral liga#"ts 5 !ladd"r $illars. S$ar"s ovari"s/ 'a s)rgi'ally stag"/ $r"v"t '(roi' radiatio. Most 'o##o 'o#$li'atio4 Bladd"r dys+)'tio/ 1:%3 $"r#a"t. Most s"rio)s 'o#$li'atio4 )r"t"ri' st)la or stri't)r" 1:%3. o"r li#! ly#$(o"d"#a 1>:%23. !8 Radiatio T("ra$y < B"gis !y "&t"ral radiatio to s(ri? '"tral t)#or 5 'avitary l"sio. Also do" $osto$ +or $t it( N #"ts/ or iad";)at" s)rgi'al #argis. Additio o+ '("#o to radiot("ra$y i#$rov"s s)rvival. IIA it( #ii#al ivolv"#"t o+ vagial +ori& : Radi'al s)rg"ry or '("#o radiatio. IIA < I@A < P"lvi' '("#o is t(" r& o+ '(oi'". Palliativ" radio or '("#ot("ra$y.
INTRODU6TION orldid"/ '"rvi'al 'a is t(" #ost 'o##o 'a)s" o+ 'a'"r d"at( i o#". M"a ag" +or '"rvi'al 'a is >1.9yrs/ it( t(" )#!"r o+ $t "v"ly divid"d !"t"" ag" gro)$s ,2:, ad 2:. Most 'o##o ty$" is S66 7J238/ ad"o'ar'io#a 5 ad"o;)a#o)s a''o)t +or %2:%>3/ ot("rs ar" rar". PATTERN OF SPREAD 1. Dir"'t ivasio ito '"rvi'al stro#a/ 'or$)s/ vagia ad $ara#"tri)#. %. y#$at(i' $"r#"atio 5 #"ts. ,. H"#atog"o)s diss"#iatio.
Stag" IA
Stag" IB
Stag" II Stag" I@B R"')rr" t or
6("#ot("ra$y < i#it"d ""'tiv""ss. Most a'tiv" dr)g is 'is$lasti. P"lvi' "&"t"ratio < R"#oval o+ $"lvi' vis'"ra 7)t"r)s/ t)!"s/ ovari"s/ !ladd"r/ r"'t)#8 : For $t (o (av"
M"ts
'"tral r"')rr"'" +olloig irradiatio. Radiot("ra$y i+ iitial dis"as" tr"at"d !y s)rg"ry oly. PROGNOSIS Dir"'tly r"lat"d to 'lii'al stagig. it( (ig("r stag"/ odal #"ts "s'alat"/ 5 >yr s)rvival di#iis("s. 6OMPI6ATIONS OF RADIOTHERAPY • • • •
A6UTE A')t" 'ystitis < H"#at)ria/ )rg"'y/ +r";)"'y. Pro'tosig#oiditis < T""s#)s/ diarr("a/ $assag" o+ !lood 5 #)')s i stool. Et"ritis < Na)s"a/ vo#it/ diarr("a/ 'oli'?y a! $ai. BM d"$r"ssio.
•
• •
6HRONI6 Radiatio "t"ro$at(y4 Pro'tosig#oiditis 7$"lvi' $ai/ t""s#)s/ diarr("a/ r"'tal !l""dig8/ )l'"ratio 7r"'tal !l""dig 5 t""s#)s8/ r"'tovagial st)la 7stool t(r) vagia8/ R"'t)# or sig#oid st"osis 7$rogr"ssiv" larg" !o"l o!str8/ S#all !o"l i)ry 7'ra#$ig a! $ai/ vo#it/ diarr("a8 @agial va)lt "'rosis : S"v"r" $ai i vagial va)lt 5 $ro+)s" dis'(arg". Urologi' i)ry4 H"#orr(agi' 'ystitis/ @"si'ovagial 5 Ur"t"rovagial st)la 7'ostat )ri" l"a?ag"8/ Ur"t"ri' st"osis 7(ydro"$(rosis8
P#$1A"U#$ #UP"U#$ / 1$1#A%$ (P#/1) !e0nitions
$tioloy
Clinical presentation
•
• •
•
Pr"#at)r" r)$t)r" 7PROM8 d"ot"s s$ota"o)s r)$t)r" o+ +"tal #"#!ra"s !"+or" t(" os"t o+ la!or. • T(is 'a o'')r at t"r# 7PROM8 or $r"t"r# 7PPROM8. • Pr"t"r# $r"#at)r" r)$t)r" o+ #"#!ra" 7PP#/184 :;*
VIt (as !"" s)gg"st"d t(at t(" t"r# $r"t"r# PROM 7PPROM8 s(o)ld !" )s"d to d"" t(os" $ati"ts (o ar" $r"t"r# it( r)$t)r"d #"#!ra"s/ ("t("r or ot t("y (av" 'otra'tios.
Ascendin I+"'tio 7vagial '"rvi'al8
A!or#al #"#!ra" 7d"'i"t 'ollag" • ad #i"rals è "a?"ss8 • I'o#$"t"t '"rvi& • N)tritioal d"'i"'i"s o+ 'o$$"r/ as'or!i' a'id. • S#o?ig • 6osid"r 'a)s"s o+ $r"t"r# la!or • a. #)lti$l" g"statio. !. o so'io"'oo#i' 'lass. '. Et(i'ity.."t'
S)dd" G)s( o+ 'l"ar vagial C)id R)l" o)t 4 E$isodi' )riary o i'oti"'" o ")'orr("a o loss o+ t(" #)')s $l)g sy#$to#s s)gg"stiv" o+ 6(orioa#ioitis W
1ethod o+ dianosis (In,estiations) •
N"v"r do a digital vagial "&a# o a $ati"t (o is ot i la!or/ ("t("r $r"t"r# or t"r# 1. St"ril" S$"')l)# "&a#
!irect ,isualiation o+ li9uor Poolig
Hig( @agial Sa! 7H@S8 à ass"ss 6(orioa#ioitis Nitra*i" F"rig St"ril" / ot oly to $r"v"t i+"'tio !)t !'o* yo) #ay ta?" t(" sa! +ro# t(" s$"')l)# ad g"t a +als" $ositiv"
D& o+ PPROM ivolv"s rst e=aminin the abdomen 7ass"ss t(" li" / $ositio / "as" o+ "&a#iatio à#ay idi'at" oligo(ydra#ios 8
B'o* " #ay +a'" a 'as" t(at " s)s$"'t PPROM !)t " doKt s"" t(" li;)or "&. 4 a$$"ar i t(" a!do#ial "&a# 7s#all +or GA o +)dal ("ig(t "t' 8 'e,ere oliohydramnios
etal head closin the cer,i=
à #ai$)lat"
t(" ("ad ad s""
i+ li;)or 'o#"s o)t a!o)t ot("r DD& +or t(" G)s( o+ C)id 7U. i'oti"'" / l")'orr("a /loss o+ t(" '"rvi'al #)'o)s $l)g 8 "hereFs %o rupture o+ membranes
1ethod o+ dianosis (In,estiations) 2. 'terile 'peculum e=am !irect ,isualiation o+ li9uor
à ill
%itraine blue test
à t(i?
alse Positi,es
6"rvi'al #)')s Blood @agial i+"'tio 7B@8 S"#"
ern li*e
e positi,e
6"rvi'al #)')s Blood Uri"
ern and %itraine "ests
1. Is"rt s$"')l)# +or sa#$l" 'oll"'tio/ avoid t(" )s" o+ l)!ri'at. %. 6oll"'t vagial s"'r"tio +ro# t(" $ost"rior vagial $ool it( to 'otto st"ril" sa!s. Do ot to)'( t(" #)')s $l)g i t(" '"rvi&. Do ot 'ota#iat" t(" s$"'i#" it( sali"-?o(. ,. A+t"r 'oll"'tio/ i##"diat"ly r)! t(" sa! agaist a glass slid"/ 'r"atig a v"ry t(i s#"ar/ do ot a$$ly a 'ov"rsli$. 9. Allo slid" to dry +or >:12 #i)t"s. als >. Usig a #i'ros'o$"/ "&a#i" t(" dri"d s#"ar )d"r 12 $o"r it(o)t a 'ov"r sli$. . I+ $r"s"t/ sali" i t(" a#ioti' C)id 'rystalli*"s to +or# a +"r:li?" $att"r.
1.T"ar o a %:, '# $i"'" o+ Nitra*i" $a$"r. %.A$$ly C)id 'oll"'t"d +ro# t(" vagial $ool dir"'tly to t(" $a$"r. ,.A !l)" 'olor '(ag" is 'osist"t it( a#ioti' C)id $H o+ :.>. T(" Nitra*i" $a$"r 'otai"r i'l)d"s a '(art o+ 'olor '(ag" ad $H. 8.U>' •
• •
ass"ss g"statioal ag" / +"tal grot( ad "ll!"ig Ass"ss a#ioti' C)id vol)#". r)l" o)t +"tal ao#ali"s
Sali"
Complications
Chorioamnionitis
1. D"$"ds o +"tal ag"/ d)ratio ad li;)or vol)#" li+t %. Prolog"d PPROM n 6(orioa#ioitis d"v"lo$#"t ad "oatal i+"'tios ,. Pr"#at)rity r"lat"d 'o#$li'atios 7RDS / PDA / I@H / NE6/ ROP / BPD / 6P 8 9. Oligo(ydra#ios 4 i+ 0%9 ""?s #ay l"ad to $)l#oary (y$o$lasia >. Positioal (y$o$lasia.
S)s$"'t 6(orioa#ioitis i t(" $r"s"'" o+ ay '(ag" 7rat("r t(a a!sol)t" val)"s8 o+4
S)s$"'t 6(orioa#ioitis n #at"ral +"v"r ad Ut"ri" t"d"r"ss i a 'or#"d 'as" o+ PROM ad it(o)t UTI or URI
i+ gra# stai $ositiv" $ro#$t d"liv"ry 7ot "'"ssarily 6S8 REGARDESS o+ G"statioal Ag"
Maag"#"t 4 @agial ')lt)r"s / I@ Ati!ioti's ad $ro#$t d"liv"ry 7ot "'"ssarily 6S8
1. P)ls" rat" %. T"#$"rat)r" #or" t(a ,J 7)"&$lai"d8 ,. T"s" or t"d"r )t"r)s 9. 6olor or s#"ll o+ vagial s"'r"tios V >. F"tal ("art rat". Maag"#"t 4 ta?" @agial gra# stai ad ')lt)r"s / giv" I@ Ati!ioti's
D""$ i+"'tio / 7i t(" )t"r)s (i'( is i t(" a!do#ial 'avity / ot "&$os"d to t(" o#"t)# or ot("r d"+"s" #"'(ais#s ad t(" i##)" syst"# 8 So it 'o)ld $)t t(" #ot("r ad t(" +"t)s at ris? o+ s"$sis
Ay '(ag" o+ #at"ral HR / T"#$ / T"s" t"d"r )t"r)s
B6 6RP #ay !" (ig( or lo / so doKt 'o)t o t("# as "ll as t(" vagial dis'(arg" 7 #ay ot !" $r"s"t8 1anaement •
t(" #ai $ri'i$l" o+ t(" #aag"#"t o)ld !" 'os"rvativ" !ala'ig !"t"" $r"#at)rity ad i+"'tio 7Ul"ss t("r"Ks idi'atios to t"r#iat" $r"g8
•
Mai ris? is $r"#at)rity
Ad#it ad giv" •
First loo? i+ " (av" ay idi'atio to t"r#iat" t(" $r"ga'y 4 1.6(orioa#ioitis %.S"v"r" oligo(ydra#ios ,.6og"ital ao#ali"s
• •
Ati!ioti' )s" is r"'o##"d"d 7Eryt(ro#y'i ad M"troida*ol"8 !)t it #ay ot $r"v"t +"tal i+"'tioV also #ay #as? 6(orioa#ioitis.
W
P#$"$#1 I#"H •
A !irt( t(at o'')rs !"+or" ,
'ini0cance
Pathoenesis
• To'olyti's 4 s(ort t"r# )s" •
oly St"roids4 B"ta#"t(aso"
Blood do"sKt r"a'( t(" +"tal l)g so " #ay +a'" 'as"s o+ 'og"ital $")#oia d"s$it" A!& )s"
•
'o#$l"t"d ""?s o+ g"statio. S)!'lassi'atios o+ PTB ar" varia!ly ad i'osist"tly d""d as4 at" $r"t"r# ,9 to , ""?s
•
•
Mod"rat"ly $r"t"r# ,% to ,9 ""?s @"ry $r"t"r# ,% ""?s E&tr"#"ly $r"t"r# %J ""?s •
PTB 'a also !" d""d !y !irt( "ig(t 7B84 o !irt( "ig(t 7B8 B l"ss t(a %>22 g
•
Ta?" tog"t("r it( its s";)"la"/ PTB is !y +ar t(" l"adig 'a)s" o+ i+at #ortality i t(" Uit"d Stat"s. PTB is also a #aor d"t"r#iat o+ s(ort: ad log:t"r# #or!idity i i+ats ad '(ildr". IN6IDEN6E I t(" Uit"d Stat"s/ 1%.J $"r'"t o+ !irt(s i %22 o'')rr"d $r"t"r# ad ,. $"r'"t "r" l"ss t(a ,9 ""?s o+ g"statio
•
•
•
6lii'al ad la!oratory A$$ro&i#at"ly 2 to J2 $"r'"t o+ PTBs "vid"'" s)gg"st t(at a o'')r s$ota"o)sly. )#!"r o+ $at(og"i' $r"t"r# la!or 7PT8 $ro'"ss"s 'a l"ad to a al a''o)ts +or EJ to J 'o##o $at(ay t(at r"s)lts $"r'"t o+ all PTBs i $r"t"r# la!or ad d"liv"ry. ad $r"t"r# $r"#at)r" r)$t)r" o+ #"#!ra"s 7PPROM8 a''o)ts +or 8J to J T(" +o)r $ri#ary $ro'"ss"s $"r'"t. ar"4 T(" r"#aiig 8J to J $"r'"t o+ PTBs 1. A'tivatio o+ t(" #at"ral ar" d)" to or +"tal (y$ot(ala#i': it"rv"tio +or $it)itary:adr"al a&is #at"ral or +"tal %. I+"'tio $ro!l"#s ,. D"'id)al ("#orr(ag" 9. Pat(ologi'al )t"ri" dist"tio
@"ry lo !irt( "ig(t 7@B8 B l"ss t(a 1>22 g E&tr"#"ly lo !irt( "ig(t 7EB8 B l"ss t(a 1222 g #I'; AC"/#7 CI%ICA 1A%I$'"A"I/%' A%! !IA4%/'I' AC"/#' • •
•
PT is o" o+ t(" #ost 'o##o r"asos +or (os$itali*atio o+ $r"gat o#". I o" syst"#ati' r"vi"/ a$$ro&i#at"ly ,2 $"r'"t o+ $r"t"r# la!ors s$ota"o)sly r"solv"d. Sigs ad sy#$to#s o+ "arly PT i'l)d"
•
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Ut"ri" 'otra'tios ar" a or#al dig at all stag"s o+ $r"ga'y/ t("r"!y addig to t(" '(all"g" o+ distig)is(ig tr)" +ro# +als" la!or. T(" +r";)"'y o+ 'otra'tios i'r"as"s it( g"statioal ag"/ t(" )#!"r o+ +"t)s"s/ ad at ig(t. T(" diagosis o+ PT is g""rally !as"d )$o 'lii'al 'rit"ria o+ r"g)lar $ai+)l )t"ri" 'otra'tios a''o#$ai"d !y '"rvi'al
#"str)al:li?" 'ra#$ig/ 'ostat lo !a'? a'("/ #ild )t"ri" 'otra'tios at i+r";)"t ad-or irr"g)lar it"rvals/ ad !loody s(o. Ho"v"r/ t("s" sigs ad sy#$to#s ar" o: s$"'i' ad o+t" ot"d i o#" (os" $r"ga'i"s go to t"r#. •
Iitial "val)atio o+ o#" it( s)s$"'t"d PT s(o)ld d"t"r#i"4 1. T(" $r"s"'" ad +r";)"'y o+ )t"ri" 'otra'tios %. ("t("r t("r" is )t"ri" !l""dig ,. ("t("r t(" +"tal #"#!ra"s (av" r)$t)r"d 9. G"statioal ag" >. F"tal "ll:!"ig
Physical e=amination •
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T(" )t"r)s is "&a#i"d to ass"ss r#"ss/ t"d"r"ss/ +"tal si*"/ ad +"tal $ositio. A st"ril" s$"')l)# "&a#iatio is $"r+or#"d to r)l" o)t r)$t)r"d #"#!ra"s/ to vis)ally "&a#i" t(" vagia ad '"rvi& O!tai s$"'i#"s +or la!oratory t"stig . A digital "&a#iatio to ass"ss '"rvi'al dilatatio ad "a'"#"t is $"r+or#"d a+t"r $la'"ta $r"via ad PPROM (av" !"" "&'l)d"d
dilatio ad-or "a'"#"t. S$"'i' 'rit"ria/ (i'( "r" iitiall y d"v"lo$"d to s"l"'t s)!"'ts i r"s"ar'( s"ttigs/ i'l)d" $"rsist"t )t"ri" 'otra'tios 7+o)r "v"ry %2 #i)t"s or "ig(t "v"ry 2 #i)t"s8 it( do')#"t"d '"rvi'al '(ag" or '"rvi'al "a'"#"t o+ at l"ast J2 $"r'"t/ or '"rvi'al dilatatio gr"at"r t(a % '#. Digital '"rvi'al "&a#iatio (as li#it"d r"$rod)'i!ility !"t"" "&a#i"rs/ "s$"'ially (" '(ag"s ar" ot $roo)'"d t("r"+or"/ so#" '"t"rs "val)at" t(" '"rvi& via trasvagial )ltraso)d to 'or# t(" diagosis A s(ort '"rvi& (as !"" vario)sly d""d as a '"rvi'al l"gt( l"ss t(a %.2 '#/ %.> '#/ or ,.2 '#. ab tests •
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Uri" ')lt)r"/ si'" !a't"ri)ria ad $y"lo"$(ritis ar" asso'iat"d it( PTB. R"'tovagial gro)$ B str"$to'o''al ')lt)r"/ to d"t"r#i" ""d +or ati!ioti' $ro$(yla&is. T"sts +or goorr("a ad '(la#ydia. T"stig +or goorr("a ad '(la#ydia #ay !" o#itt"d i+ $r"vio)sly $"r+or#"d/ t(" r"s)lts "r" "gativ"/ ad t(" $ati"t is ot at (ig( ris? o+ a';)irig s"&)ally tras#itt"d i+"'tios.
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F"tal !ro"'ti 7+FN8/a sa! +or +FN o all sy#$to#ati' $ati"ts 'osid"r"d at (ig( ris? +or PTB. P"r+or# trasvagial soogra$(i' #"as)r"#"t o+ '"rvi'al l"gt(. " oly s"d t(" sa! to t(" la!oratory +or FFN d"t"r#iatio i+ t(" '"rvi'al l"gt( is %2 to ,2 ## Giv" t(" li? !"t"" 'o'ai" )s" ad $la'"tal a!r)$tio/ $"r+or# dr)g t"stig i $ati"ts it( ris? +a'tors +or dr)g a!)s"
"#IA4$ A'$! UP/% C$#&ICA $%4"H
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6"rvi'al l"gt( 0,2 ## T("s" o#" ar" at lo ris? o+ PTB/ R"gardl"ss o+ +FN r"s)lt. Dis'(arg" t(" $ati"ts (o#" a+t"r a o!s"rvatioal $"riod o+ +o)r to si& (o)rs d)rig (i'( 'or# +"tal "ll:!"ig E&'l)d" t(" $r"s"'" o+ a a')t" $r"'i$itatig "v"t 7"g/ a a!r)$tio or ov"rt i+"'tio8/ Follo:)$ i o" to to ""?s 6"rvi'al l"gt( %2 to ,2 ## PTB is #or" li?"ly i o#" it( '"rvi'"s %2 to ,2 ## t(a i o#" it( log"r '"rvi'"s/ !)t #ost o#" i t(is gro)$ do ot d"liv"r $r"t"r#. T("r"+or"/ s"d t(" sa! +or +FN t"stig i t(is s)!gro)$ o+ o#". I+ t(" t"st is $ositiv" 7l"v"l gr"at"r t(a >2 g-#8/ t(" a'tiv"ly #aag" t(" $r"ga'y to $r"v"t #or!idity asso'iat"d it( PTB. 6"rvi'al l"gt( %2 ## .T("s" o#" ar" at (ig( ris? o+ PTB r"gardl"ss o+ +FN r"s)lt. T("r"+or"/ " do ot s"d t("ir sa!s +or +FN t"stig to t(" la!oratory ad a'tiv"ly #aag" t("# to $r"v"t #or!idity asso'iat"d it( PTB.
1A%A4$1$%" / 1$%
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Hos$itali*" o#" diagos"d it( PT at l"ss t(a ,9 ""?s o+ g"statio ad iitiat" t(" +olloig tr"at#"ts4 At"atal gl)'o'orti'oids to r"d)'" "oatal #or!idity ad #ortality asso'iat"d it( PTB A$$ro$riat" ati!ioti's +or GBS '("#o$ro$(yla&is To'olyti' dr)gs +or )$ to 9J (o)rs to d"lay d"liv"ry so t(at gl)'o'orti'oids giv" to t(" #ot("r 'a a'(i"v" t("ir #a&i#)# ""'t. A$$ro$riat" ati!ioti's to o#" it( $ositiv" )ri" ')lt)r" r"s)lts or $ositiv" t"sts +or goorr("a or '(la#ydia.
1A%A4$1$%" / A'51P"/1A"IC 1$% A" HI4H #I'; / P" • •
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It"rv"tios to $r"v"t PTB g""rally (av" ot !"" s)''"ss+)l/ it( so#" "&'"$tios 7"g/ s)$$l"#"tal proesterone8. o#" it( ris? +a'tors +or PTB ar" so#"ti#"s +ollo"d it( s"rial )ltraso)d #"as)r"#"t o+ '"rvi'al l"gt(. A '"rvi'al l"gt( m,> ## is g""rally 'osid"r"d or#al ad r"ass)rig as '"rvi'al l"gt( d"'r"as"s !"lo ,> ##/ t(" ris? o+ PTB i'r"as"s " #aag" asy#$to#ati' $ati"ts at (ig( ris? o+ PTB si#ilar to t(" ay " #aag" sy#$to#ati' $ati"ts/ !)t it( a (ig("r '"rvi'al l"gt( t(r"s(old +or it"rv"tio. T(is #ii#i*"s o v"rtr"at#"t o+ (ig( ris? asy#$to#ati' $ati"ts ad )d"rtr"at#"t o+ sy#$to#ati' $ati"ts. S)rv"illa'" it( s"rial '"rvi'al l"gt( #"as)r"#"ts is !"g) at %% ""?s. 6"rvi'al l"gt( m,> ## : T(" ris? o+ PTB is lo. S"" t("s" $ati"ts i ro)ti" +ollo:)$ i o" to to ""?s.
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6"rvi'al l"gt( %> to ,9 ## : o!tai a +FN 'o'"tratio. I+ t(" t"st is $ositiv" 7l"v"l gr"at"r t(a >2 g-#8/ t(" a'tiv"ly #aag" t(" $r"ga'y to $r"v"t #or!idity asso'iat"d it( PTB. 6"rvi'al l"gt( %> ## : T(" ris? o+ PTB is i'r"as"d. " a'tiv"ly #aag" t(" $r"ga'y to $r"v"t #or!idity asso'iat"d it( PTB/ as d"s'ri!"d a!ov".
P#$1A"U#$ #UP"U#$ / 1$1#A%$ (P#/1) •
R"+"rs to
$tioloy #
/utcome
#"#!ra" r)$t)r" !"+or" t(" os"t o+ )t"ri" 'otra'tios $r"t"r# PROM 7PPROM8 is t(" t"r# )s"d (" t(" $r"ga'y is l"ss t(a , 'o#$l"t"d ""?s o+ g"statio. PPROM o'')rs i , $"r'"t o+ $r"ga'i"s ad is r"s$osi!l" +or/ or asso'iat"d it(/ a$$ro&i#at"ly o": t(ird o+ $r"t"r# !irt(s. I #aag"#"t o+ PPROM/ Poits o+ 'ot"tio i'l)d"4 •
1. E&$"'tat #aag"#"t v"rs)s it"rv"tio %. Us" o+ to'olyti's ,. D)ratio o+ ad#iistratio o+ ati!ioti' $ro$(yla&is 9. Ti#ig o+ ad#iistratio o+ at"atal gl)'o'orti'oids >. M"t(ods o+ t"stig +or #at"ral-+"tal i+"'tio . Ti#ig o+ d"liv"ry.
T(" $at(og""sis o+ PPROM is ot 'o#$l"t"ly )d"rstood. T("r" ar" #)lti$l" "tiologi"s/ #"'(ai'al ad $(ysiologi'al/ t(at $ro!a!ly s(ar" a al 'o##o $at(ay l"adig to #"#!ra" r)$t)r". Ris? +a'tors +or PPROM • ar" si#ilar to t(os" +or $r"t"r# la!or A (istory o+ PPROM i a $r"vio)s $r"ga'y G"ital tra't i+"'tio At"$art)# !l""dig 6igar"tt" s#o?ig (av" a $arti')larly strog asso'iatio it( PPROM Alt(o)g( a s#all rado#i*"d trial s)gg"st"d •
1. %. ,. 9. >.
,itamin C
s)$$l"#"tatio #ig(t lo"r t(" ris? o+ PPROM / a larg"r rado#i*"d trial i (i'( !ot( vita#i 6 ad E "r" giv" r"+)t"d t(is dig ad s)gg"st"d t(" ris? o+ PPROM #ay a't)ally !" i'r"as"d it( atio&idat s)$$l"#"tatio .
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A$$ro&i#at"ly o":t(ird o+ o#" it( PPROM d"v"lo$ $ot"tially s"rio)s i+"'tios/ s)'( as itraa#ioti' i+"'tio 7'(orioa#ioitis8/ "do#"tritis/ or s"$ti'"#ia. Edo#"tritis is #or" 'o##o a+t"r '"sar"a t(a vagial d"liv"ry. T(" +"t)s ad "oat" ar" at gr"at"r ris? o+ PPROM:r"lat"d #or!idity ad #ortality t(a t(" #ot("r. T(" #aority o+ $r"ga'i"s it( PPROM d"liv"r $r"t"r# ad it(i o" ""? o+ #"#!ra" r)$t)r". Pr"t"r# i+ats ar" "s$"'ially v)l"ra!l" to a vari"ty o+ $ro!l"#s/ s)'( as (yali" #"#!ra" dis"as"/ itrav"tri')lar ("#orr(ag"/ $"riv"tri')lar l")?o#ala'ia ad ot("r ")rologi' s";)"la"/ i+"'tio 7"g/ s"$sis/ $")#oia/ #"igitis8/ ad "'roti*ig "t"ro'olitis. T(" rat"s o+ t("s" #or!iditi"s vary it( g"statioal ag" ad ar" (ig("r i t(" s"ttig o+ '(orioa#ioitis
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PPROM is also asso'iat"d it( i'r"as"d ris?s o+ a!r)$tio $la'"ta" ad $rola$s" o+ t(" )#!ili'al 'ord. F"tal #al$r"s"tatio is 'o##o/ giv" t(" $r"t"r# g"statioal ag" ad t(" +r";)"t o'')rr"'" o+ r"d)'"d a#ioti' C)id vol)#". T(" ris? o+ 'ord $rola$s" is "s$"'ially (ig( 711 $"r'"t i o" st)dy8 i t(" s"ttig o+ !ot( ov"rt"& +"tal $r"s"tatio ad PPROM. Early/ s"v"r"/ $rolog"d oligo(ydra#ios 'a !" asso'iat"d it( $)l#oary (y$o$lasia/ +a'ial d"+or#atio/ ad ort(o$"di' a!or#aliti"s. S)'( 'o#$li'atios ar" #ost li?"ly (" #"#!ra" r)$t)r" o'')rs at l"ss t(a %, ""?s o+ g"statio.
# +or Pre-term birth
2. 'tress Sigl" o#"/ o so'io"'oo#i' stat)s/ A&i"ty/
. In+ection S"&)ally tras#itt"d i+"'tios/
D"$r"ssio/ i+" "v"ts 7divor'"/ s"$aratio/ d"at(8A!do#ial s)rg"ry d)rig $r"ga'y 8. /ccupational +atiue U$rig(t $ost)r"/ Us" o+ id)strial #a'(i"s/ P(ysi'al "&"rtio/ M"tal or "viro#"tal str"ss . $=cessi,e or impaired uterine distention M)lti$l" g"statioPoly(ydra#iosUt"ri" ao#alyUt"ri" l"io#yo#aDi"t(ylstil!"strol E. Cer,ical +actors History o+ s"'od tri#"st"r a!ortioHistory o+ '"rvi'al s)rg"ryPr"#at)r" '"rvi'al dilatatio or "a'"#"t
Py"lo"$(ritis/ a$$"di'itis/ $")#oia/ Syst"#i' i+"'tio/ Ba't"ri)ria/ P"riodotal dis"as" . Placental patholoy Pla'"ta $r"via/ A!r)$tio/ @agial !l""dig G. 1iscellaneous Pr"vio)s $r"t"r# d"liv"ry/ S)!sta'" a!)s"/ S#o?igMat"ral ag" 71J or 0928/ A+ri'a: A#"ri'a ra'"/ Poor )tritio ad lo !ody #ass id"&/ Iad";)at" $r"atal 'ar"/ A"#ia 7("#oglo!i 12 g-d8E&'"ssiv" )t"ri" 'otra'tility/ o l"v"l o+ "d)'atioal a'(i"v"#"t/ G"oty$" Q. etal +actors 6og"ital ao#aly/ Grot( r"stri'tio
Clinical 1ani+estation !=
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History T(" 'lassi' 'lii'al $r"s"tatio o+ PPROM is a s)dd" g)s( o+ 'l"ar or $al" y"llo C)id +ro# t(" vagia. Ho"v"r/ #ay o#" d"s'ri!" it"r#itt"t or 'ostat l"a?ig o+ s#all a#o)ts o+ C)id or )st a s"satio o+ "t"ss it(i t(" vagia or o t(" $"ri")#. A 'lii'al (istory s)gg"stiv" o+ PPROM s(o)ld !" 'or#"d !y vis)al is$"'tio or la!oratory t"sts to "&'l)d" ot("r 'a)s"s o+ vagial-$"ri"al "t"ss/ s)'( as )riary i'oti"'"/ vagial dis'(arg"/ ad $"rs$iratio. P(ysi'al "&a#iatio T(" !"st #"t(od o+ 'or#ig t(" diagosis o+ PPROM is dir"'t o!s"rvatio o+ a#ioti' C)id 'o#ig o)t o+ t(" '"rvi'al 'aal or $oolig i t(" vagial +ori&. I+ a#ioti' C)id is ot i##"diat"ly visi!l"/ t(" o#a 'a !" as?"d to $)s( o ("r +)d)s/ @alsalva/ or 'o)g( to $rovo?" l"a?ag" o+ a#i oti' C)id +ro# t(" '"rvi'al os. Digital "&a#iatio s(o)ld !" avoid"d !"'a)s" it #ay d"'r"as" t(" lat"'y $"riod 7i"/ ti#" +ro# r)$t)r" o+ #"#!ra"s to d"liv"ry8 ad i'r"as" t(" ris? o + itra)t"ri" i+"'tio Nitra*i" ad +"r t"sts I+ PROM is ot o!vio)s a+t"r vis)al is$"'tio/ t(" diagosis 'a !" 'or#"d !y t"stig t(" $H o+ t(" vagial C)id/ (i'( is "asily a''o#$lis("d it( itra*i" $a$"r. A#ioti' C)id )s)ally (as a $H rag" o+ .2 to ., 'o#$ar"d to t(" or#ally a'idi' vagial $H o+ ,.J to9. Fals":"gativ" ad +als":$ositiv" itra*i" t"sts r"s)lts o'')r i )$ to > $"r'"t o+ 'as"s.
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Fals" "gativ" t"sts r"s)lts 'a o'')r (" l"a?ig is it"r#itt"t or t(" a#ioti' C)id is dil)t"d !y ot("r vagial C)ids. Fals" $ositiv" r"s)lts 'a !" d)" to t(" $r"s"'" o+ al?ali" C)ids i t(" vagia/ s)'( as !lood/ s"#ial C)id/ or soa$. I additio/ t(" $H o+ )ri" 'a !" "l"vat"d to "ar J.2 i+ i+"'t"d it( Prot")s s$"'i"s. I t(" Uit"d igdo#/ a a!sor!"t $ad 7A#ioS"s"8 t(at '(ag"s 'olor at $H 0 >.% is )s"d as a $aty li"r ad #ar?"t"d to $r"gat o#". I a st)dy o+ 1> $r"gat o#"/ t(" s"sitivity ad s$"'i'ity o+ t(is d"vi'" +or diagosis o+ #"#!ra" r)$t)r" "r" J ad > $"r'"t/ r"s$"'tiv"ly Ultrasoogra$(y Ultraso)d "&a#iatio #ay !" o+ val)" i t(" diagosis o+ PPROM. Fi+ty to 2 $"r'"t o+ o#" it( PPROM (av" lo a#ioti' C)id vol)#" o iitial soogra$(y . A #ild r"d)'tio o+ a#ioti' C)id vol)#" #ay (av" #ay "tiologi"s. O t(" ot("r (ad/ t(" dig o+ a(ydra#ios or s"v"r" oligo(ydra#ios/ 'o#!i"d it( a '(ara't"risti' (istory/ is (ig(ly s)gg"stiv" o+ r)$t)r" o+ #"#!ra"s/ alt(o)g( r"al ag""sis/ o!str)'tiv" )ro$at(y/ or s"v"r" )t"ro:$la'"tal is)L'i"'y also 'a 'a)s" #ar?"d r"d)'tios i a#ioti' C)id vol)#". Istillatio o+ idigo 'ar#i" O":(al+ (o)r lat"r/ t(" ta#$o is r"#ov"d ad "&a#i"d +o r !l)" staiig/ (i'( idi'at"s l"a?ag" o+ a#ioti' C)id.
1anaement
T(" #aag"#"t o+ $r"ga'i"s 'o#$li'at"d !y PPROM is !as"d )$o 'osid"ratio o+ s"v"ral +a'tors/ (i'( ar" ass"ss"d )$o $r"s"tatio G"statioal ag"
Initial e,aluation •
E&$"ditio)s d"liv"ry o+ o#" it( PPROM is idi'at"d i+ itra)t"ri" i+"'tio/ a!r)$tio $la'"ta"/ r"$"titiv"
1. %. ,. 9.
Availa!ility o+ "oatal it"siv" 'ar" Pr"s"'" or a!s"'" o+ #at"ral-+"tal i+"'tio Pr"s"'" or a!s"'" o+ la!or F"tal $r"s"tatio 7Br""'( ad trasv"rs" li"s ar" )sta!l" ad #ay i'r"as" t(" ris? +or 'ord $rola$s"8 >. F"tal ("art rat" 7FHR8 tra'ig $att"r . i?"li(ood o+ +"tal l)g #at)rity . 6"rvi'al stat)s 7!y vis)al/ ot digital/ is$"'tio )l"ss id)'tio is $la"d or t(" o#a is i la!or8
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FHR d"'"l"ratios/ or a (ig( ris? o+ 'ord $rola$s" is $r"s"t or s)s$"'t"d I "a'( o+ t("s" 'oditios/ +"tal "ll: !"ig 'a d"t"riorat" it( "&$"'tat #aag"#"t/ ad t("r" ar" o t("ra$")ti' it"rv"tios availa!l" ot("r t(a d"liv"ry.
/ur simpli0ed alorithm +or manaement o+ other women with PP#/1 is shown in the • • • • • •
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Antenatal lucocorticoids Antibiotics "reatment o+ o,ert in+ections "ocolysis Hospitaliation "issue sealants 7A ,ariety o+ tissue sealants (e7 0brin lue7 elatin spone) ha,e shown some success in stoppin lea*ae in case reports. %either the sa+ety nor the eTcacy o+ these sealants has been established ). 'upplemental proesterone ("here is no e,idence that administration o+ supplemental proesterone has any bene0cial eDects in women with PP#/1 8
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Mat"ral s)rv"illa'" F"tal s)rv"illa'" Ti#ig o+ d"liv"ry G"statioal ag" ,9 ""?s I g""ral/ $r"#at)rity is t(" gr"at"st ris? to t(" +"t)s it( PPROM. As dis')ss"d a!ov"/ " ad#ii st"r a 'o)rs" o+ at"atal gl)'o'orti'oids/ $ro$(yla'ti' ati!ioti's +or s"v" days/ ad to'olyti's +or 9J (o)rs/ as idi'at"d. G"statioal ag" gr"at"r t(a ,9 ""?s M"t(od o+ d"liv"ry 6"sar"a d"liv"ry is $"r+or#"d +or stadard idi'atios ot("ris" la!or is id)'"d. Favora!l" 6"rvi& vs U+avora!l" '"rvi&
P#$"$#1 A/U# 1A%A4$1$%" Principles o+ manaement
"ocolytic aents
Contraindications to "ocolysis
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Iitial ass"ss#"t #)st • uids ill dilatatio ad t(" statio i#$rov" >2 3 o+ 'as"s. ad at)r" o+ t(" '?@= $r"s"tig $art.V By t(" i(i!itio o+ t(" ADH Id"ti+y tr"ata!l" 'a)s"s r"l"as"d +ro# t(" $ost 7s)'( as a )riary tra't or $it)tary glad +ro# t(" vagial i+"'tio8 sa#" sit" ("r" o&yto'i is S(o)ld !" $la'"d i t(" r"l"as"d.. lateral decubitus position / #oitor"d +or t(" • It is a''"$ta!l" to $r"s"'" 5 +r";)"'y o+ ad#iist"r antibiotics Ato )t"ri" a'tivity 5 '"rvi'al $ati"ts (o ar" i '(ag"s.. $r"t"r# la!or 7a :day 'igh vaginal swab.7B 'o)rs" o+ a#$i'illi str"$/ Ur"a$las#a/ ad-or "ryt(ro#y'i8.. My'o$las#a/Gard"r"lla VVall"rgyà )s" vagialis8V 'lida#y'i or Blood s)gar/ 6B6/ s"r)# va'o#y'i .. "l"'trolyt"s l"v"l/ To pre(ent the )rialysis/ ad )ri" pro+ression of a silent ')lt)r" ad s"sitivity. infection to clinical amnionitis
Tocolytic therapy à
i+ t(" $ati"t do"sKt r"s$od to !"d r"st 5 (ydratio
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Used to reduce and stop uterine Contraction .
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" )s" t("# +or 9J:% (o)rs V.. 18'orti'ost"roids or? %8i 'as"s " doKt (av" good NI6U +a'iliti"s )til " tras+"r t(" $t. to aot("r (os$ital.
• To'olyti's ar" routinely used at less than ,7 weeks gestation i+ t("r"
ar" o 'otraidi'atios to tr"at#"t. • Tr"at#"t is idivid)ali*"d +ro# ,9:, ""?s.
1. %. ,. 9. >. .
S"v"r" PET S"v"r" APH IUGR 6(orioa#ioitis F"tal ao#ali"s 6ardia' disord"rs/ Arr(yt(#ias. . T(yroto&i'osis. "ocolytic aents 2. 8.
1anesium sul+ate Calcium channel bloc*er (ni+edipine) . 'ympathomimetic aents (ritodrine / terbutaline) E. Prostalandin inhibitors (indomethacin) 45 Atosiban
"/C/5"IC A4$%"'
. 'ympathomimetic aents • •
Action
'ide eDects
%otes
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D"'r"as" itra'"ll)lar 6a
1. F"tal ad #at"ral ta'(y'ardia. %. Hy$ot"sio. ,. Rar"ly '("st $ai. 9. Hy$"rgly'"#ia. >. Hy$"r?al"#ia. . Rig(t ("art +ail)r"
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Dos" 'otrol !y #at"ral r"s$os" ad $)ls"
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6o#$"t"s it( 6a=% +or "try ito t(" '"ll à d"'r"as" +r"" itra'"ll)lar 6a
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Hig("r dos"s ar" r";)ir"d 71 g# 9 (o)rly orally8 'o#$ar"d to "'la#$sia Us"+)l i s"l"'t"d 'as"s s)'( as dia!"t"s/ ("art dis"as"s Stri't s"r)# l"v"ls s(o)ld !" o!s"rv"d It is )s"d as a itrav"o)s #"di'atio to (alt $r"#at)r" la!o)r..
Ritodri" (ydro'(lorid" Sal!)ta#ol
1'/E
r"s$iratory d"$r"ssio ad 'ardia' 'od)'tio d"+"'t.
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Atosiban
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O&yto'i atagoist
P4 synthetase inhibitors
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It $r"v"ts 'ov"rsio o+ ara'(idoi' a'id ito
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I+ $rolog"d )s"4 a. Oligo(ydra#ios.
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Ca channel bloc*ers •
PG
Ido#"t(a'i As$iri Fl)+"a#i' a'id •
Ni+"di$i"
i+"di$i" i(i!it slo iard o+ 'al'i)# ios d)rig t(" s"'od $(as" o+ a'tio $ot"tial o+ )t"ri" s#oot( #)s'l" '"ll.
!. Pr"#at)r" 'los)r" o+ d)'t)s art"rios)s7May l"ad to "oatal PHTN 5 6F8 '. Plat"l"t dys+y'tio. Has #ii#al sid" ""'t 4 a. !. '. d.
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H"ada'(" Fl)s(ig (y$ot"sio ta'(y'ardia
Ai#al st)di"s s(o"d +"tal a'idosis
Is tocolytic therapy eDecti,eB • • • •
Fail"d to d"'r"as" $r"t"r# i'id"'" i larg" $o$)latio st)di"s. %t did prolong gestation2 decreased B# 2 improved neonatal survival C increased birth weightD
Us" a+t"r ,9 ""?s is li#it"d. All ag"ts d"lay"d la!o)r !y % (o)rs i J23 o+ tr"at"d $ati"ts
#ole o+ 4lucocorticoids
'ur+actant
un maturity
>' ratio
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R"d)'"s t(" #ortality/ RDS 5 I@H .. • Its r"'o##"d"d )s" )$ to ,9 ""?s. • Dos" 'osists o+ 4 VV% dos"s o+ 1% #g o+ betamethasone(!e,elopmen t o+ C%')/ IM %9 (o)rs a$art or
VV 9 dos"s o+ #g o+ de=amethasone/ IM/ 1% (o)rs a$art.
SO /It (as !ot(
P(os$(oli$ids i. P(os$(otidyl < l"'it(i ii. P(os$(otidyl: iositol iii. P(os$(otidyl: gly'"rol • Prot"is • 6ar!o(ydrat" • Salts ad ")tral li$ids • It is $rod)'"d !y $")#o'yt"s ty$" II 7$roli+"rat"s at %9 ""?s ad +)'tio !y
F"tal l)gs ar" #at)r" i+4 18P(os$(atidylgly'"rol is $r"s"t i a#ioti' C)id
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or •
%8 "'it(i< s$(igo#y"li 7-S8 ratio is 0 %
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0% idi'at"s l)g #at)rity. "'it(i i'r"as"s +ro# ,> ""?s oard (il" s$(ygo#yli" r"#ais 'ostat a+t"r ,> ""?s M"as)r"d !y li;)id '(ro#atogra$(y. %3 o+ i+at it( -S0% d"v"lo$ RDS Blood ad #"'oi)# #ay r"d)'" t(" -S ratio !)t (as o ""'t o PG d"t"'tio.
$ro$(yla'ti' ad t("ra$")ti' )s".
,9 ""?8
PRETERM BIRTH ETIOOGY 6INI6A FEATURES 18 I+"'tio < #ostly s)!'lii'al 1. 6ra#$ig lo"r a! $ai i+& o+ '(oriod"'id)al s$a'" t(at starts irr"g)lar 5 it( %8 Ov"rdist"sio o+ )t"r)s < ti#" ↑i +r"; 5 it"sity 5 $oly(ydro#ios/ #)lti$l" !"'o#"s #or" r"g)lar. $r"ga'y %. o !a'? a'(" ,8 @as')lar 7$la'"tal ,. Bloody vagial dis'(arg" a!or#aliti"s8 98 It"r')rr"t ill"ss < $y"lo"$(ritis/ $")#oia. By "it("r dir"'t s$r"ad or idir"'t '("#i'al trigg"rs "g "doto&is. >8 6"rvi'al "a?"ss 8 Idio$at(i' < "s$ i #ild $r"t"r# !irt(s 8 Iatrog"i' MANAGEMENT IN@ESTIGATIONS 1. Ad#it at l"ast %9( 1. St"ril" s$"')l)# "&a# < a#ioti' C)id $oolig %. A''ordig to GA %. Trasvagial USS < ass"s '"rvi'al dilatio. ,9?s < at"atal st"roids 7giv" i % dos"s 1%( a$art8 Nor#al '"rvi& h,.>'# i l"gt(. ,. Pro$(yla'ti' ati!ioti's 7"ryt(ro#y'i )til ')lt)r" idi'at"s ,. @agial sa! +or GBS ot("ris"8 9. Urialysis 5 ')lt)r" 7UTI #ai 'a)s" o+ $r"t"r# 9. To'olyti's < +or 9J( )til st"roids or?s or till tras+"r to a (os$ la!or8 it( good NI6U +a'ility . +"tal !ro"'ti 7+FN8 (" to as?W : '"rvi'al l"gt( 0,.>'#5 ot i la!or < o ""d : '"rvi'al l"gt( %>'# 5 i la!or < o ""d : %.> '"rvi'al l"gt( ,.>'# < ""d +FN 6ASSIFI6ATION GESTATIONA AGE BIRTH EIGHT Mild $r"t"r# o !irt( "ig(t4 %.>?g • at" $r"t"r#4 ,9:,t( ? @"ry lo !irt( "ig(t4 • Mod"rat" $r"t"r#4 ,%: 1.>?g ,,rd ? E&tr"#"ly lo !irt( "ig(t4 1?g • @"ry $r"t"r#4 %J:,1st ? • E&tr"#"ly $r"t"r#4 %9: %t( ?
cBra&to:Hi'?s 'otra'tio Z Fals" a!or Z Pra'ti'" 6otra'tios : S$oradi' )t"ri" 'otra'tios t(at start a ro)d ""?s/ to aid !ody i its $r"$aratio i !irt(. I+r";)"t/ irr"g)lar/ oly #ild 'ra#$ig.
7Pr"t"r# la!or ↑$rogr"ssiv"ly 5 !"'o#"s #or" it"s" 5 r"g)lar it( ti#"8
PREMATURE RUPTURE OF MEMBRANE A#iorr("&is 7s$ota"o)s r)$t)r" o+ #"#!ra"s8 !"+or" t(" os"t o+ )t"ri" 'otra'tios. Pr"t"r# PROM 7PPROM8 < $r"t"r# 7, ?s8 it( r)$t)r"d #"#!ra"/ it( or it(o)t 'otra'tios. RIS FA6TOR H 5 PE AB TESTS 6ONSIDERATIONS H& o+ $r"vio)s H&4 @agial loss o+ C)id P)l# Maag"#"t d"$"ds a o R-O "$isodi' )riary i'oti"'"/ l")?orr("a or #at)ratio lot to GA at ti#" o+ #"#! PPROM loss o+ '"rvi'al #)')s $l)g. st)di"s. r)$t)r". @agial 5 '"rvi'al o PE4 Poolig o+ a#ioti' C)id i $ost"rior vagial Gra# stai 5 Also ;)atity o+ r"#aiig i+& +ori&. ')lt)r". a#ioti' C)id. o At"$art)# !l""dig 6or# !y4 o 6igar"tt" s#o?ig 18 NItra*i" $a$"r 7al?ali ` !l)"8 A#ioti' C)id id"& 7AFI84 (av" a $arti')larly %8 Mi'ros'o$i' "&a# 7+"rig8 @"rti'al a&is o+ a#ioti' strog asso'iatio St"ril" vagial s$"')l)#. C)id $r"s"t i +o)r it( PPROM VNo digital vagial "&a#ee ;)adrats. A!or#al is A!or#al #"#! o USS4 R-O +"tal ao#ali"s/ ass"ss GA 5 a#ioti' >'#. $(ysiology C)id vol)#". I'o#$"t"t '"rvi& o N)tritioal o d"'i"'i"s MANAGEMENT GA %9 ?s 7Pr": %9?s 0 GA 0 ,?s 7Pr"t"r# PROM8 GA ,?s or via!l" PROM8 #or" 7PROM8 Ris? o+ d"v o+ AQ 6os"rvativ" E&$"'tat Maag"#"t : To 'oti)" $r"ga'y )til t(" l)g $rol" is Id)'" la!or $)l#oary #at)r". Diagos" '(orioa#ioitis at a "arly stag" to #ii#i*" +"tal 5 #at"ral ris?s. a+t"r :1%( (y$o$lasia < d)" c6(orioa#ioitis < Mat"ral t"#$ 0,Jp6 it( o ot("r sit"s o+ i+&/ +"tal ta'(y/ i+ o to +"tal 'rodig t"d"r )t"r)s/ )t"ri" irrita!ility o NST. Pr"s"'" o+ !a't"ria !y Gra#-')lt)r". s$ota"o)s it( t(ora'i' A#$i'illi-"ryt(ro#y'i $rologs it"rval o+ d"liv"ry i $t it( PPROM. 'otra'tios
'o#$r"ssio/ r"stri'tio o+ +"tal !r"at(ig ad dist)r!a'"s o+ $)l# C)id $rod)'tio 5 Co. Positioal s?"l"tal a!or#ality "g tali$"s ";)iovar)s.
(" diagos"d/ a#$i'illi = g"ta#y'i a+t"r ta?" "o)g( ')lt)r"s. T(" id)'" la!or. 6:s"'tio i+ '"rvi& )+avora!l"/ +"tal ivolv"#"t or $r"s"'" o+ a'tiv" g"ital ("r$"s. BQ To'olyti' T("ra$y < To gai ti#" +or $)l# #at)ratio. Us)''"ss+)l i+ it( i+"'tio. 6Q 6ortist"roids Us" : Giv" to $t it( PPROM oly )$ to ,% ?s GA. DQ O)t$ati"t Maag"#"t 6a 'osid"r a+t"r i$ati"t o!s"rv +or %:,d it(o)t ay "vid"'" o+ i+&. R)l"s o+ "ligi!ility4 Pt r"lia!l"/ +)lly i+or#"d o+ ris?s/ $r"$ar"d to $arti'i$at" i ("r o 'ar". F"t)s v"rt"&. 6"rvi& 'los"d. R"stri't $(ysi'al a'tivity. No 'oit)s. Moitor t"#$ at l"ast 9&-d. R)s( to (os$ i+ 0,.Jp6. S"" ""?ly to #"as)r" t"#$/ NST a+t"r %J?/ "val)at" !as"li" +"tal ("art rat" 5 AFI. 6otraidi'at"d i oligo(ydra#ios.
o'')r.
P#//%4$! P#$4%A%C5
D"itios
#I';'
Post dat" $r"ga'y4 'oti)atio o+ $r"ga'y !"yod 92 'o#$l"t"d ""?s
Pla'"tal is)L'i"'y ad (y$o&ia
I'r"as"d +"tal t/ ossi'atio o+ s?)ll 5 d"'r"as"d #o)ldig
Post t"r# $r"ga'y4 'oti)atio o+ $r"ga'y !"yod 9% 'o#$l"t"d ""?s
1. I'r"as"d $"riatal #ortality4 Do)!l"d +or "a'( ""? a+t"r 9% ""?s %. M"'oi)# as$iratio sydro#" ,. Oligo(ydro#ios 9. 6ord 'o#$r"ssio
1. Prolog"d la!o)r ad +ail)r" to $rogr"ss4 i'r"as" i'id"'" o+ 6-S %. S(o)ld"r dysto'ia4 Mat"ral ris?s4 vagial 5 '"rvi'al la'"ratios 5 r)$t)r" )t"r)s N"oatal ris?s4 i. N"oatal as$(y&ia 5 d"at( ii. 6"rvi'al 'ord i)ry iii. Bra'(ial $l"&)s i)ry4 P(r"i' N. i)ry 769 i)ry8/ Er!Ks $alsy 76>56 i)ry8/ l)#$?Ks $alsy 76J 5 T18 iv. 6lavi')lar 5 ()#"ral +ra't)r"s
I'id"'" >:123 o+ $r"ga'i"s A"tiology •
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I #aority o+ 'as"s t("r" is o )d"rlyig 'a)s" 7itKs a $(ysiologi'al 'oti)atio o+ $r"ga'y8 E&tr"#"ly rar"/ d)" to i. A"'"$(aly ii. F"tal adr"al (y$o$lasia
iii.
Pla'"tal s)l$(atas" "*y#" d"'i"'y
How to manae pt in Post-date Post-term prenancy
Assesment o+ 4A:
e+ore deli,ery
!urin deli,ery
A.At"atal #"t(ods
1. 6o)s"llig ad "&$laatio E&$lai t(" ris? o+ $ost:dat" ad $ost t"r# o t(" +"t)s %. History For a'')rat" ass"ss#"t o+ GA To "&'l)d" 'otraidi'atios +or id)'tio ,. O!s "&a# To ass"ss li"/ $r"s"tatio ad "gag"#"t 9. @agial "&a# To ass"ss Bis(o$ s'or" ad $"lvi' ad";)a'y >. U-S 7at 92/ 91 ad 9% ""?s8 To ass"ss a#o)t o+ li;)or/ +"tal "ll!"ig ad t . 6TG 7"v"ry , days a+t"r 92 ""?s8 To ass"ss +"tal "ll!"ig
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1. 1st day MP 7r"lia!l" i >23 o+ $r"ga'y8
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U'o#$li'at"d $ost:dat" $r"ga'y4 d"liv"r at 92=,: days M"t(od o+ d"liv"ry4 a. Id)'tio o+ la!o)r 7d"$"ds o Bis(o$ s'or"8 !. 6-S i+ t("r"Ks 'otraidi'atio +or id)'tio I+ d"liv"ry !y id)'tio o+ la!o)r/ s"ior o!s7ris? o+ s(o)ld"r dysto'ia8 ad $a"d7ris? o+ #"'oi)# as$iratio8 s(o)ld att"d t(" d"liv"ry.
%. U-S4 6R 7:1, ""?s8/ BPD 5 F 71,: % ""?s 5 0% ""?s8 ,.6lii'al4 i. ii. iii. iv.
"arly $r"ga'y sy#$to#s "arly !i#a)al "&a# ;)i'?"ig s"rial +)dal (t
B.Postatal #"t(ods 1. D)!oit s'or"4 ass"ss#"t o+ $(ysi'al ad ")rologi'al +"at)r"s o+ t(" "!or
%. Farr s'or"4 ass"ss#"t o+ $(ysi'al +"at)r"s o+ t(" "!or
PUERPERIUM PHYSIOOGI6 6HANGES DURING PUEPERIUM T(" $"riod +olloig d"liv"ry o+ t(" !a!y ad $la'"ta to a!o)t :J ""?s $ost$art)#. D)rig t(at t(" r"$rod)'tiv" orgas ad t(" #at"ral $(ysiology r"t)r toard t(" o:$r"gat stat)s. O6A UTERUS
Ut"ri" ivol)tio. Str)'t)r" : a)tolysis o+ "&'"ss #)s'l" !"rs : o!lit"ratio 5 t(ro#!osis o+ !lood v"ss"ls/ t(" d"g""ratio 5 tras+or#atio ito "lasti' tiss)" : s"$aratio o+ t(" d"'id)a
co'(ia Bloodstai"d )t"ri" dis'(arg" t(at is 'o#$os"d o+ '"rvi'al #)'o)s/ vagial tras)dat"/ ad $rod)'ts o+ "'rosis ad slo)g(ig o+ t(" s)$"r'ial lay"r o+ t(" d"'id)a
: o'(ia r)!ra 7r"d84 'osists #aily o+ !lood ad : r"d)'"d 71?g a+t"r d"liv"ry → 2:122g "d o+ $)"r$"ri)#8 d"'id)a. It lasts +or > days. : o'(ia s"rosa 7$al"84 d)" to r"lativ" ↓ i RB6s ad $r"do#ia'" o+ l")?o'yt"s. It lasts +or > days. Si*" : o'(ia al!a 7(it"84 'osists #aily o+ l")?o'yt"s : a+t"r d"liv"ry t(" l"gt( o+ t(" )t"r)s is %2 '# ad +"lt at t(" l"v"l ad #)')s. It lasts +or > days. o+ )#!ili')s : a+t"r o" ""? it is #iday !"t"" )#!ili')s ad sy#$(ysis $)!is : P"rsist"'" o+ r"d lo'(ia #"as s)!ivol)tio. : a+t"r % ""?s it is at t(" l"v"l o+ sy#$(ysis : O"siv" lo'(ia #"as i+"'tio. : !y t(" "d o+ t(" t( ""? it is .> '# log : I s"v"r" i+"'tio it( s"$ti'a"#ia/ lo'(ia i s s'aty ad ot o"siv" Ut"ri" liga#"ts : ar" ivol)t"d : T(" $"riod o+ ti#" t(" lo'(ia 'a last vari"s/ S)!ivol)tio $r"dis$os"s to $rola$s" ad r"trov"rsio. alt(o)g( it av"rag"s a$$ro&i#at"ly > ""?s. : O+t"/ o#" "&$"ri"'" a i'r"as" i t(" Edo#"trial liig ra$idly r"g""rat"s/ so t(at !y t(" t( day t(" a#o)t o+ !l""dig at :19 days s"'odary to t(" "do#"trial glads ill !" "vid"t. By t(" 1t( day/ t(" slo)g(ig o+ t(" "s'(ar o t(" $la'"tal sit". "do#"tri)# is r"stor"d t(ro)g(o)t t(" )t"r)s/ "&'"$t at t(" $la'"tal sit". "ig(t
T(" 'otra'tios o+ t(" art"rial s#oot( #)s'l" ad 'o#$r"ssio o+ t(" v"ss"ls !y 'otra'tio o+ t(" #yo#"tri)# r"s)lt i (o#"ostasis. T(" si*" o+ t(" $la'"tal !"d d"'r"as"s !y (al+/ ad t(" '(ag"s i t(" $la'"tal !"d r"s)lt i t(" ;)atity ad ;)ality o+ t(" lo'(ia t(at is "&$"ri"'"d.
PUERPERIUM PHYSIOOGI6 6HANGES DURING PUEPERIUM O6A 6ER@I O@ARIES PERINEUM T(" '"rvi& !"gis to ra$idly r"v"rt T(" r"s)#$tio o+ or#al T(" $"ri")# (as !"" str"t'("d ad to a o:$r"gat stat" 7l"ss +)'tio !y t(" ovari"s is (ig(ly tra)#ati*"d/ ad so#"ti#"s tor or ')t/ d)rig "lasti'/ #or" r#8 !)t it "v"r varia!l" ad is gr"atly iC)"'"d t(" $ro'"ss o+ la!or ad d"liv"ry. T(" soll" ad r"t)rs to t(" )lli$aro)s stat". !y !r"ast+""dig t(" i+at. "gorg"d v)lva ra$idly r"solv"s/ ad s"llig ad By t(" "d o+ t(" rst ""?/ t(" T(" o#a (o !r"ast+""ds ("r "gorg"#"t ar" 'o#$l"t"ly go" it(i 1:% "&t"ral os is 'los"d to t(" "&t"t i+at (as a log"r $"riod o+ ""?s. t(at a g"r 'o)ld ot !" "asily a#"orr("a ad aov)latio Most o+ t(" #)s'l" to" is r"gai"d !y ""?s/ itrod)'"d. t(a t(" #ot("r (o '(oos"s to it( #or" i#$rov"#"t ov"r t(" +olloig +" By t(" "d o+ t(" s"'od ""? t(" !ottl":+""d. #ot(s. T(" #)s'l" to" #ay or #ay ot r"t)r to it"ral os s(o)ld !" 'los"d. Mot("r (o do"s ot !r"ast+""d or#al/ d"$"dig o t(" "&t"t o+ i)ry #ay ov)lat" as "arly as % days a+t"r d"liv"ry. @AGINA ABDOMINA A Most o#" (av" a #"str)al I t(" rst +" days t(" str"'("d T(" a!do#ial all r"#ais so+t ad $oorly to"d $"riod !y 1% ""?s t(" #"a vagia is s#oot( 5 "d"#ato)s/ +or #ay ""?s. T(" r"t)r to a $r"$r"gat stat" ti#" to rst #"s"s is : ""?s. d"$"ds gr"atly o "&"r'is" !)t !y t(" "d o+ t(" t(ird ""? r)ga" !"gi to a$$"ar/ !)t "v"r 'o#$l"t"ly r"t)r to its $r": $r"gat si*"
EIGHT D"'r"as"d d)" to : "va')atio o+ )t"ri" 'ot"t. : #or" C)ids loss t(ro)g( )ri" ad s"at
TEMPERATURE A r"a'tioary i'r"as" #ay o'')r +olloig diL')lt d"liv"ry/ !)t it do"s ot "&'""d ,J6 ad dro$s it(i %9 (rs. A slig(t ris" #ay o'')r i t(" ,rd day d)" to !r"ast "gorg"#"t.
PHYSIOOGI6 6HANGES DURING PUERPERIUM GENERA BREAST BOE BOOD 6(ag"s t(at $r"$ar" t(" #ot("r +or T"d"'y to I'r"as" !r"ast+""dig o'')r t(ro)g(o)t 'osti$at" 'oag)la!ility o+ $r"ga'y4 6a)s"s 4 !lood 'oti)" : a'tog""sis is trigg"r"d iitially : Atoy o+ !o"l d)rig t(" rst % !y t(" d"liv"ry o+ $la'"ta : a&ity o+ a! ad ""?s d"s$it" o+ : Fallig l"v"l o+ Estrog" ad $"ri")# d"'r"as" i a Prog"st"ro" : Aaro&ia )#!"r o+ : 6oti)" $r"s"'" o+ PR : oss o+ C)ids 'oag)latio +a'tor : I+ #ot("r is ot la'tatig/ t(" : F"ar o+ "va')atio4 T(is #ay i'r"as" Pai +ro# str"t'("d i'id"'" o+ PE Prola'ti l"v"l ↓ ad r"t)r to $"ri")#/ $rola$s" ad D@T. or#al it(i %:, ""?s : 6olostr)# s"'r"t"d d)rig t(" rst ("#orr(oid/ or aal H! 'o'"tratio ss)r" t"ds to +all i t(" , days rst %:, days URINE c6ol)str)# : y"llois(/ (ig( $rot"i 'o'"tratio 7IgA8/ $rot"'ts agaist I'r"as" i )ri" $rod)'tio !y t(" %d: 9t( day i+"'tio/ r"$la'"d !y #il? at t(" R"t"tio o+ )ri" is ot )'o##o ,rd:9t( day $ost$art)# 6a)s"s4 : Atoy o+ !ladd"r "'? : Egorg"#"t o+ t(" !r"ast : a&ity o+ a! : arg" ad $ai+)l !r"ast : 6o#$r"ssio o+ )r"t(ra !y v)lval "d"#a B)t/ s)'?lig r"li"v" t(" dis'o#+ort or ("#ato#a S)'?lig → PR 7#il? s"'r"tio8 = O&yto&i 7#il? ""'tio8
6ARDIO@AS6UAR : I##"diat"ly +olloig d"liv"ry/ t("r" is #ar?"d i'r"as" i $"ri$("ral vas')lar r"sista'" d)" to t(" r"#oval o+ t(" lo:$r"ss)r" )t"ro: $la'"tal 'ir')latory s()t : T(" 'ardia' o)t$)t ad $las#a vol)#" grad)ally r"t)r to or#al d)rig t(" rst to ""?s o+ $)"r$"ri)# : P)ls" is or#al !)t #ay i'r"as" i+ t("r" is i+"'tio or ("#orr(ag"
PATHOOGI6 6HANGES DURING PUERPERIUM POST PARTUM HEMORRHAGE PSY6HOOGI6A It is a "&'"ssiv" 70>22 # at vagial ad 01222 # at POSTPARTUM BUES '"sar"a8 !lood loss a+t"r d"liv"ry. 6o#$li'at"s >23 o+ d"liv"ri"s First %9 ( à $ri#ary Mild/ trasi"t/ s"l+:li#it"d disord"r. U$ to ""?s à s"'odary Mood sigs/ it( '(ag" i a$$"tit" ad sl""$. First % ""?s a+t"r d"liv"ry/ o+t" r"solv"s !y $ost$art)# day 12. No $(ar#a'ot("ra$y is idi'at"d. PRIMARY SE6ONDARY POSTPARTUM DEPRESSION 6a)s"s4 6a)s"s4 : 6o#$li'at"s >3 o+ $r"ga'i"s 18 Ut"ri" atoy 18 R"tai"d $rod)'ts o+ : S&4 Sad"ss/ +atig)"/ '(ag"s i sl""$ig ad "atig Ris? Fa'tors4 'o'"$tio $att"rs/ r"d)'"d li!ido/ 'ryig "$isod"s/ a&i"ty/ ad '(orioa#iioitis/ #)lti$l" Maag"#"t4 irrita!ility. g"statios/ #a'roso#i' H"avy !l""digàI@ i+)sio : Us)ally i t(" rst +" #ot(s/ ad #ay last )$ to s"v"ral +"t)s/ !roid. #ot(s or "v" a y"ar. ad :#at'( o+ !lood. R&4 Massag" ad !i#a)al : Tr"at#"t is r"'o##"d"d +or :1% #ot(s !"yod Syto'io 7syt("ti' 'o#$r"ssio/ t(" r"#issio o+ sy#$to#s. o&yto'i8. o&yto'i i+)sio/ POSTPARTUM PSY6HOSIS E&a#iatio )d"r "rgo#"tri/ $rostagladi F% a"st("sia. Rar" !)t s"rio)s. I+ !l""dig $"rsists d"s$it" Eva')atio o+ t(" )t"r)s. S&4 R"stl"ss agitatio/ 'o+)sio/ d"l)sios/ (all)'iatio/ )t"ri" 'otra'tio/ s)s$"'t Ati!ioti's giv" i+ $la'"tal t(o)g(ts o+ s"l+ (ar#. %8 G"ital tra't tra)#a tiss)" is +o)d/ "v" it(o)t Rar"ly $r"s"ts !"+or" t(" ,rd $ost$art)# day !)t 6"rvi'al ad vagial "vid"'" o+ ov"rt i+"'tio. )s)ally do"s so !"+or" 9 ""?s. la'"ratios I+ !lood loss is ot "&'"ssiv"/ R"'ov"ry o'')rs ov"r 9: ""?s. )s" $"lvi' US to "&'l)d" Pati"t s(o)ld !" r"+"rr"d )rg"tly to a $sy'(atrist ad r"tai"d $rod)'ts. ill )s)ally r";)ir" ad#issio to a $sy'(iatri' )it. %8 Edo#"tritis Pat(o$(ysiology ,8 Bl""dig disord"rs Poorly )d"rstood/ !)t #ay !" d)" to ra$id '(ag"s i "strog"/ $rog"srto" ad $rola'ti i $ost$art)# $ati"ts. Str"ss : R"s$osi!iliti"s o+ '(ild r"arig Post$art)# t(yroid dys+)'tio 7$sy'(iatri' disord"rs8. S"" i (ig("r rat"s i $ati"ts it( (istory o+
d"$r"ssio or ot("r #"tal ill"ss"s.
PATHOOGI6 ENDO6RINE SHEEHANKS SYNDROME At"rior $it)itary glad "larg"s d)rig $r"ga'y d)" to a i'r"as" i t(" si*" ad t(" )#!"r o+ $rola'ti s"'r"tig '"lls I+ sigi'at ("#orr(ag" o'')r d)rig t(" $"ri$art)# $"riod/ is'("#i' "'rosis o+ t(" glad ill (a$$". F)ll 'lii'al $i't)r" a$$ar"t a+t"r >3 d"str)'tio 18 ↓ PR → Fail"d la'tatio %8 ↓ FSH 5 H → Aov)latio 5 %dary a#"orr("a ,8 Hy$ot(yroidis# → Brady/ 'old itol"ra'"/ 'osti$ 98 ↓ A6TH → Hy$ot"sio 5 ↓ "ig(t R&4 R"$la'"#"t t("ra$y :'ortiso" 5 t(yro&i" +or li+". :HMG +or id)'tio o+ ov)latio i+ $r"ga'y is d"sir"d. POSTPARTUM THYROIDITIS Trasi"t d"str)'tiv" iCa##atio o+ T(yroid glad o'')rig it(i t(" 1 st y"ar a+t"r d"liv"ry. B"li"v"d to r"s)lt +ro# #odi+ to t(" i##)" syst"# "'"ssary i $r"ga'y. %$(as"s4 18 T(yroto&i'osis %8 Hy$ot(yroidis# T(" $ro'"ss is or#ally s"l+:li#itig/ !)t (" 'ov"tioal ati!odi"s ar" +o)d t("r" is a (ig( '(a'" o+ t(is $ro'""dig to $"r#a"t (y$ot(yroidis#. POSTPARTUM GRA@EKS DISEASE "ss 'o##o t(a PPT. Si#ilar to Grav"Ks dis"as" i ot("r s"ttigs. A)toi##)" A! agaist TSH r"'"$tors →
6HANGES DURING PUERPERIUM NEURO < OBSTETRI6 PASY BADDER PROBEMS O" or !ot( o+ t(" lo"r VUriary r"t"tio/ voidig diL')lty/ li#!s #ay d"v"lo$ sigs 5 ad !ladd"r ov"r:dist"sio ar" s& o+ #otor ad-or s"sory 'o##o. ")ro$at(y +olloig VT(" !a!ys "&it #ay (av" tra)#ati*"d d"liv"ry. it l"adig to t"#$orary $aralysis. 6a)s"s4 Voss o+ !ladd"r s"satio d)" to 1: 6o#$r"ssio or r"gioal a"st("sia. str"t'(ig o+ t(" VS"llig ad $ai i t(" $"ri"al ar"a. l)#!osa'ral $l"&)s as it VPsy'(ologi'al 7+"ar8 +a'tors 'ross"s t(" sa'roilia' oit d)rig d"'"t o+ t(" +"tal Ov"r:dist"tio ill l"ad to 4 ("ad. 1. Da#$" !ladd"r s"satio/ r"d"r it %: H"riatio o+ t(" (y$o:'otra'til" ad l"ad to !ro)s l)#!osa'ral dis's 79->8 r"$la'"#"t o+ s#oot( #)s'l". #ay also o'')r i t(" %. Ov"r Co i'oti"'". "&agg"rat"d lit(oto#y $ositio ad d)rig Its i#$ortat to )riat" it(i :J( o+ istr)#"tal d"liv"ry. d"liv"ry. T(is ↓ rat" o+ UTI ad $r"v"t ay F"at)r"s4 S'iati' $ai/ da#ag" ad !l""dig t(at 'a (a$$" )ilat"ral +oot dro$/ (" !ladd"r g"ts ov"rly +)ll. (y$oa"st("sia/ #)s'l" I+ t(" +"#al" didKt )riat" d)rig t(is astig. $"riod/ " is"rt a 'at("t"r. :Most 'as"s r"solv" s$ota"o)sly i a #att"r o+ days or ""?s/ or #aag"d ort(o$a"di'ally. URINARY IN6ONTINEN6E @agial d"liv"ry strogly i#$li'at"d i t(" d"v"lo$#"t o+ str"ss i'oti"'".
E&'"ss $rod)'tio o+ t(yroid (or#o"s. N""ds tr"at#"t/ li?" ay ot("r grav"Ks dis"as".
: D"liv"ry "a?"s #)s'l"s aro)d t(" !ladd"r ad $"lvis/ (i'( #a?"s it (ard"r to 'otrol (" )ri" starts. : Hor#oal '(ag"s
PATHOOGI6 6HANGES DURING PUERPERIUM BOE FUN6TION DISORDERS THROMBOEMBOISM PUERPERA PYREIA 6ONSTIPATION V T(" ris? o+ t(ro#!o"#!oli' D"+4 T"#$"rat)r" o+ ,J °6 or (ig("r o dis"as" ris"s > +old d)rig It is a 'o##o $ro!l"# d)rig $)"r$"ri)# ay to o+ t(" rst 12 days $r"ga'y $"riods. $ost$art)#/ "&'l)siv" o+ t(" rst %9( V T(" #aority o+ d"at(s o'')r i T("r" ar" t(r"" #ai 'a)s"s4 #"as)r"d orally !y a stadard t(" $)"r$"ri)# ad ar" #or" t"'(i;)" 1. It"rr)$tio o+ or#al di"t/ d"(ydratio 'o##o a+t"r 'a"sar"a s"'tio. d)rig la!or. V I+ D@T or $)l#oary "#!olis# is 6a)s"s o+ $yr"&ia4 %. F"ar o+ "va')atio d)" to $ai +ro# s)s$"'t"d/ a +)ll ati'oag)lat s)t)r"d $"ri")#/ $rola$s"d ("#orr(oid/ V G"ital tra't i+"'tio )$$"r tra't t("ra$y s(o)ld !" 'o##"'"d 5 a 7!)l?y t"d"r )t"r)s8 / or $"ri"al aal ss)r"s. !ilat"ral v"ogra# or l)g s'a ,. Atoy o+ it"stial/ a!do#ial/ $"ri"al i+"'tio oly s(o)ld !" 'arri"d o)t it(i %9 < #)s'l"s. V UTI. 9J (o)rs. Maag"#"t4 V Br"ast i+"'tios ".g. #astitis. VAd";)at" C)id ita?" ad i'r"as" i !"r V R"s$ tra't i+"'tio : #or" 'o##o ita?". a+t"r a"st("sia. VStool so+t""r 7la&ativ"s8 i+ "'"ssary. V T(ro#!o$(l"!itis ad d""$ v"i a&ativ"s4 la't)los"/ is$ag()la t(ro#!osis. ANA IN6ONTINEN6E 5 FE6A URGEN6Y V o)d i+"'tios A"#ia. I'oti"'" o+ stool ad Cat)s ar" +r";)"t V No:$)"r$"ral r"lat"d 'a)s"s ".g. 'o#$li'atios o+ '(ild!irt(. a$$"di'itis. Aal i'oti"'" is asso'iat"d it(4 : Aal s$(i't"r da#ag" "s$"'ially o$"rativ" d"liv"ry. : Folloig r"$air o+ t(ird or +o)rt( d"gr"" t"ar. : Stool i#$a'tio. : D"v o+ t(" aovagial or r"'tovagial st)la. : P"lvi' Coor dys+)'tio
PUERPERA INFE6TIONS I+"'tios ar" a#og t(" #ost $ro#i"t $)"r$"ral 'o#$li'atios. F"v"r r"#ais t(" (all#ar? o+ $)"r$"ral i+"'tio/ ad t(" $ati"t it( +"v"r 'a !" ass)#"d to (av" g"ital i+"'tio )til $rov" ot("ris". ENDOMETRITIS MASTITIS URINARY TRA6T INFE6TION D"+4 I+"'tio o+ t(" "do#"tri)# or D"+4 ICa##atio o+ t(" #a##ary glad %:9 3 o+ o#" d"v UTI d"'id)a/ it( "&t"sio ito t(" 6o)ld !" 4 $ost$art)#. #yo#"tri)# ad $ara#"trial tiss)"s. : 6og"stiv" #astitis 7!r"ast "gorg"#"t8. 6a)s"s4 Bladd"r ad t(" lo"r d rd Us)ally d"v"lo$s o t(" % or , : I+"'tio)s #astitis )riary tra't r"#ais $ost$art)#. Bot( ar" #or" 'o##o i Pri#igravidas. (y$otoi'/ 6at("t"ri*atio/ Birt( Etiology4 PROM 0 %9 (o)rs/ 6"sar"a I+"'tio)s #astitis ad !r"ast a!s'"ss ar" tra)#a/ 6od)'tio a"st("sia/ s"'tio/ 6(orioa#ioitis/ E&'"ssiv" )'o##o 'o#$li'atios o+ t(" !r"ast+""dig. Fr";)"t $"lvi' "&a#. )#!"r o+ digital $"lvi' "&a#/ Al#ost '"rtaily o'')r as a r"s)lt o+ tra)#a to 6o##o"st #-o4 E.'oli ad Prolog"d la!or 0 1% (o)r/ o t(" i$$l" ad t(" s)!s";)"t itrod)'tio o+ Prot")s s$$. so'io"'oo#i' stat)s/ To&"#ia/ t(" Orgais#s +ro# t(" i+atKs ostrils. itra)t"ri" #oitorig d"vi'"s/ Pr": Most 'o##o #-o4 Sta$( a)r")s. Sig 5 s&4 Dys)ria/ Fr";)"'y/ "&istig vagiitis ad '"rvi'itis. oi $ai i+ $y"lo"$(ritis/ Ba't"riologi'al digs4 Aa"ro!i' R&4 isolatio. 6"as" !r"ast +""dig +ro# Syst"#i' s&/ May !" str"$/ Gra# "gativ" 'oli+or#s/ a"'t"d !r"ast. E&$r"ssio o+ #il?. 6)lt)r" 5 asy#$to#ati' ad r"'ogi*"d Ba't"roid s$$./ A"ro!i' str"$/ s"sitivity. Fl)'lo&a'illi 'o##"'"d (il" o ro)ti" #id:str"a# )ri" 6(la#ydia ad My'o$las#a 7diL')lt to aaitig s"sitivity r"s)lt. 123 it( !r"ast 7MSU8 sa#$l". ')lt)r"8 a!'"ss ""d s)rgi'al i'isio 5 draiag". 7$"r+or#"d o all $ati"ts (o INFE6TIOUS 6ONGESTI@E DD&4 UTI/ A')t" $y"lo"$(ritis/ o"r (av" !"" 'at("t"ri*"d i Us)ally o'')r o t(" la!or8 g"ital tra't i+"'tio/ o)d i+"'tio/ 1 ? or #or" a+t"r d"liv"ry. %d or ,rd $ost$art)# E&a#4 Rais"d t"#$"rat)r"/ At"l"'tasis/ P")#oia/ Us)ally o" !r"ast is day. T(ro#!o$(l"!itis/ Mastitis/ S)$ra:$)!i' ad-or r"al agl" ivolv"d. Br"ast soll"/ A$$"di'itis. t"d"r"ss. T"d"r/ r"d"ss/ t"d"r/ t"s" ad Maag"#"t4 Iv"stigatio4 MSU/ (it" '"ll ar#. Ad#it/ Eva')atio o+ r"tai"d $rod)'ts soll" ad (ot. 'o)t/ Nitrit"s ad l")'o'yt"s Pt is +"!ril" ad T"#$ #ay !" #ildly o+ 'o'"$tio )d"r ati!ioti's 'ov"r/ o di$sti'?. a$$"ars ill. "l"vat"d. Par"t"ral !road:s$"'tr)# ati!ioti's/
)s)ally sto$$"d o'" t(" $ati"t is a+"!ril" +or %9:9J (o)rs/ tol"ratig a r"g)lar di"t/ ad a#!)latig it(o)t diL')lty.
P)r)l"t dis'(arg" #ay !" $r"s"t.
A&illary ad"o$at(y 'a !" s"".
R&4 Broad:s$"'tr)# ati!ioti's )til t(" r"s)lts o+ ')lt)r" ad s"sitivity ar" ?o/ t(" !" s$"'i'. B"d r"st. Hig( C)id/ lig(t solid di"t.
PU$#P$#IU1 !e0nition
Physioloical chanes durin puerperium
• T(" $"riod +olloig d"liv"ry o+ t(" !a!y ad $la'"ta to
ocal chanes
4eneral chanes
1. %. ,. 9.
1. "ig(t %. T"#$"rat) r" ,. Bo"l (a!it
• •
a!o)t :J ""?s $ost$art)#. D)rig t(at t(" r"$rod)'tiv" orgas ad t(" #at"ral $(ysiology r"t)r toard t(" o:$r"gat stat)s Fa#ily s)$$ort
Ut"r)s 6"rvi& @agia Ovari"s
>. P"ri")# . A!do#ial all . Br"ast
9. Blood >. Uri" . 6@S
ocal physioloical chanes 2.Uterine In,olution Structure
A)tolysis / "*y#ati' dig"stio o+ t(" 'yto$las# o!lit"ratio 5 t(ro#!osis o+ !lood v"ss"ls/ t(" d"g""ratio 5 tras+or#atio ito "lasti' tiss)". s"$aratio o+ t(" d"'id)a 6ei+ht : r"d)'"d +ro# 1222g# :a+t"r d"liv"ry: ito 2:122g# !y t(" "d o+ $)"r$"ri)#
it(i % to , days $ost$art)#/ t(" r"#aiig d"'id)a !"'o#" di"r"tiat"d ito to lay"rs4 1. S)$"r'ial lay"r ` !"'o#"s "'roti' ` slo)g(s o as vagial dis'(arg" lochia
%. Basal lay"r 7ada'"t to t(" #yo#"tri)#8 ` !"'o#"s " "do#"tri)# •
Size
•
a+t"r d"liv"ry t(" l"gt( o+ t("
T(" "do#"trial liig ra$idly r"g""rat"s/ so t(at !y t(" t(
ochia ochia is the bloodstained uterine discharge that is composed of cervical mucous2 vaginal transudate2 and products of necrosis and sloughing of the supercial layer of the decidua
: 1ochia rubra /red09 'osists #aily o+ !lood ad d"'id)a. It lasts +or > days. : 1ochia serosa /pale09 d)" to r"lativ" d"'r"as" i RB6s ad $r"do#ia'" o+ l")?o'yt"s. It
)t"r)s is %2 '# ad +"lt at t(" l"v"l o+ )#!ili')s. • a+t"r o" ""? it is #iday !"t"" )#!ili')s ad sy#$(ysis $)!is. • a+t"r % ""?s it is at t(" l"v"l o+ sy#$(ysis. • !y t(" "d o+ t(" t( ""? it is .> '# log 7terine li+aments : ar" ivol)t"d ad s)!ivol)tio $r"dis$os"s to $rola$s" ad r"trov"rsio
•
day t(" "do#"trial glads ill !" "vid"t. By t(" 1t( day/ t(" "do#"tri)# is r"stor"d t(ro)g(o)t t(" )t"r)s/ "&'"$t at t(" $la'"tal sit". T(" 'otra'tios o+ t(" art"rial s#oot( #)s'l" ad 'o#$r"ssio o+ t(" v"ss"ls !y 'otra'tio o+ t(" #yo#"tri)# r"s)lt i (o#"ostasis. T(" si*" o+ t(" $la'"tal !"d d"'r"as"s !y (al+.
lasts +or > days. : 1ochia alba /white09 'osists #aily o+ l")?o'yt"s ad #)')s. It lasts +or > days. •
P"rsist"'" o+ r"d lo'(ia #"as s)!ivol)tio 7arr"st"d ivoltio8 • O"siv" lo'(ia #"as i+"'tio / it #ay !" a''o#$ai"d !y $yr"&ia ad t"d"r )t"r)s. : I s"v"r" i+"'tio it( s"$ti'a"#ia/ lo'(ia is s'aty ad ot o"siv". •
•
T(" $"riod o+ ti#" t(" lo'(ia 'a last vari"s/ alt(o)g( it av"rag"s a$$ro&i#at"ly > ""?s O+t"/ o#" "&$"ri"'" a i'r"as" i t(" a#o)t o+ !l""dig at :19 days s"'odary to t(" slo)g(ig o+ t(" "s'(ar o t(" $la'"tal sit"
ocal physioloical chanes 8.Cer,ical chanes
E./,aries
.Perineum
• T(" '"rvi& !"gis to ra$idly
r"v"rt to a o:$r"gat stat" 7l"ss "lasti'/ #or" r#8 !)t it "v"r r"t)rs to t(" )lli$aro)s stat". • &efore childbirth2 the os is a s#all/ r"g)lar/ oval o$"ig. 3fter childbirth2 the orice is a trasv"rs" slit. • T(" "&t"ral os o+ t(" '"rvi& 'otra'ts sloly ad is arro"d !y t(" end o+ the 0rst ""? to t(" "&t"t t(at a g"r 'o)ld ot !" "asily itrod)'"d. • By t(" "d o+ t(" second wee* t(" it"ral os s(o)ld !" 'los"d.
T(" r"s)#$tio o+ or#al +)'tio !y t(" ovari"s is (ig(ly varia!l" ad is gr"atly iC)"'"d !y !r"ast+""dig t(" i+at. T(" o#a (o !r"ast+""ds ("r i+at (as a log"r $"riod o+ a#"orr("a ad aov)latio t(a t(" #ot("r (o '(oos"s to !ottl":+""d. T(" #ot("r (o do"s ot !r"ast+""d #ay ov)lat" as "arly as % days a+t"r d"liv"ry. Most o#" (av" a #"str)al $"riod !y 1% ""?s t(" #"a ti#" to rst #"s"s is : ""?s
I t(" !r"ast+""dig o#a/ t(" r"s)#$tio o+ #"s"s is (ig(ly varia!l" ad d"$"ds o a )#!"r o+ +a'tors/ i'l)dig (o #)'( ad (o o+t" t(" !a!y is +"d ad ("t("r t(" !a!ys +ood is s)$$l"#"t"d it( +or#)la. T(" d"lay i t(" r"t)r to or#al ovaria +)'tio i t(" la'tatig #ot("r is 'a)s"d !y t(" s)$$r"ssio o+ .&ainal chanes ov)latio d)" to t(" "l"vatio i $rola'ti. Hal+ to t(r"" I t(" rst +" days t(" str"'("d +o)rt(s o+ o#" (o !r"ast+""d r"t)r to $"riods it(i , ""?s o+ d"liv"ry. vagia is s#oot( 5 "d"#ato)s/ !)t !y t(" "d o+ t(" t(ird ""? T(" la'tatioal a#"orr("a #"t(od is J3 ""'tiv" +or r)ga" !"gi to a$$"ar/ !)t "v"r )$ to #ot(s i+4 'o#$l"t"ly r"t)r to its $r": $r"gat si*". • T(" #ot("r is ot #"str)atig • T(" #ot("r is )rsig 0 % to , ti#"s $"r ig(t/ ad m "v"ry 9 (o)rs d)rig t(" day it(o)t ot("r s)$$l"#"tatio. • T(" !a!y is #ot(s old
• T(" $"ri")# (as !""
str"t'("d ad tra)#ati*"d/ ad so#"ti#"s tor or ')t/ d)rig t(" $ro'"ss o+ la!or ad d"liv"ry. T(" soll" ad "gorg"d v)lva ra$idly r"solv"s/ ad s"llig ad "gorg"#"t ar" 'o#$l"t"ly go" it(i 1:% ""?s. • Most o+ t(" #)s'l" to" is r"gai"d !y ""?s/ it( #or" i#$rov"#"t ov"r t(" +olloig +" #ot(s. T(" #)s'l" to" #ay or #ay ot r"t)r to or#al/ d"$"dig o t(" "&t"t o+ i)ry .Abdominal wall
T(" a!do#ial all r"#ais so+t ad $oorly to"d +or #ay ""?s. T(" r"t)r to a $r"$r"gat stat" d"$"ds gr"atly o "&"r'is"
4eneral physioloical chanes 2.
8."emperature
D"'r"as"d d)" to
T(" '(ag"s to t(" !r"ast A r"a'tioary i'r"as" #ay o'')r +olloig t(at $r"$ar" t(" #ot("r +or diL')lt d"liv"ry/ !)t it !r"ast+""dig o'')r do"s ot "&'""d ,J6 ad t(ro)g(o)t $r"ga'y dro$s it(i %9 (o)rs • A slig(t ris" #ay o'')r i • a'tog""sis is trigg"r"d t(" ,rd day d)" to !r"ast iitially !y t(" d"liv"ry o+ "gorg"#"t $la'"ta .Urine • At d"liv"ry/ t(" a!r)$t/ larg" d"'r"as" i • I'r"as" i )ri" $rog"st"ro" ad $rod)'tio !y t(" %d:9t( "strog" l"v"ls l"ads to day i'r"as"d $rod)'tio o+ • R"t"tio o+ )ri" is ot al$(a:la'tal!)#i ` )'o##o sti#)lat"s la'tos" • 6a)s"s4 syt(as"` i'r"as"d #il? 1. Atoy o+ !ladd"r "'? la'tos" %. a&ity o+ a!do#" • 6oti)" $r"s"'" o+ ,. 6o#$r"ssio o+ )r"t(ra !y Prola'ti v)lval "d"#a or • I+ t(" #ot("r is ot ("#ato#a la'tatig/ t(" Prola'ti l"v"l d"'r"as"s ad r"t)r to or#al it(i %:, ""?s.
: "va')atio o+ )t"ri" 'ot"t. : #or" C)ids loss t(ro)g( )ri" ad s"at. E.owel chanes
T("r"Ks t"d"'y to 'osti$at" 6a)s"s 4 1. Atoy o+ t(" it"sti" %. a&ity o+ a!do#" ad $"ri")# ,. A"ro&ia 9. oss o+ C)ids >. F"ar o+ "va')atio $ai +ro# str"t'("d $"ri")#/$rola$s" ("#orr(oid/ or aal ss)r"
.reast chanes
•
.lood chanes
G.Cardio,ascular chanes
•
•
")?o'ytosis o'')rs d)rig ad a+t"r la!or )$ to
•
6olostr)# y"llo:'olor"d li;)id s"'r"t"d !y t(" !r"asts t(at 'otais #i"rals/ $rot"i/ +at/ ati!odi"s/ 'o#$l"#"t/ #a'ro$(ag"s/ ly#$(o'yt"s/ lyso*y#"s/ la'to+"rri/ ad la'to$"ro&idas". It is s"'r"t"d d)rig t(" rst ,: > days. • Egorg"#"t o+ t(" !r"ast it( #il? is 'o##o o days % to , $ost$art)# • O+t" $ai+)l • O+t" a''o#$ai"d !y trasi"t t"#$"rat)r" "l"vatio • s)'?lig r"li"v" t(" dis'o#+ort. S)'?lig o&yto'i ME '"ll 'otra'tio ad #il? "&$)lsio.
I##"di"t"ly +olloig d"liv"ry/ t("r" is #ar?"d i'r"as"
,2/222- I'r"as" 'oag)la!ility o+ !lood 'oti)" d)rig t(" rst % ""?s d"s$it" o+ d"'r"as" i a )#!"r o+ 'oag)latio +a'tor i'id"'" o+ PE ad D@T • T(is #ay i'r"as" i'id"'" • H"#oglo!i 'o'"tratio t"ds to +all i t(" rst %:, days
i $"ri$("ral vas')lar r"sista'" d)" to t(" r"#oval o+ t(" lo:$r"ss)r" )t"ro:$la'"tal 'ir')latory s()t r"t)r to • T(" 'ardia' o)t$)t ad $las#a vol)#" grad)ally r"t)r or#al d)rig t(" rst to ""?s o+ $)"r$"ri)# • P)ls" is or#al !)t #ay i'r"as" i+ t("r" is i+"'tio or ("#orr(ag"
•
1anaement 2. /bse /bser, r,at ation ion • P)ls"/ T/ BP • Br"ast/ lo'(ia/ )ri"
o)t$)t/ !o"l #otio 8. #est #est and and $=erc $=ercise ise • R"st i !"d +or % days • •
a+t"r )'o#$li'at"d vagial d"liv"ry 6o#$li'at"d- o$"ratio ""ds a +" days log"r Mov"#"t i ad o)tsid" t(" !"d ar" advis"d to #ii#i*"d t(" ris? o+ D@T
Problems in the puerperium . !iet
. Care Care o+ the the blad bladder der
•
1. Pati" Pati"t t is "'o) "'o)rag rag"d "d to #i't)rat" +r";)"tly %. I+ r"t" r"t"tio tio $r"s" $r"s"t/ t/ 'at("t"r is a$$li"d )d"r as"$ti' 'oditio
Food ri'( i $rot"is/ vita#is/ #i"ral ad C)id
E. Care Care o+ the the brea breast st • as( t(" i$$l" ad
ar"ola it( ar# at"r ad soa$ !"+or" ad a+t"r "a'( +""d . oca ocall Asept Aseptic ic • T(" v)lva ad $"ri)"#
ar" as("d it( atis"$ti' lotio a+t"r "a'( #i't)ratio ad d"+"'atio • T("/ )s" st"ril" v)lval $ad • Add lo'al ati!ioti' i+ $"ri"al stit'( is $r"s"t
G. Care Care o+ the bowel bowel • U$ta?" o+ v"g"ta!l"s ar" •
(ig(ly advisa!l" to $r"v"t 'osti$atio S)L'i"t C)id ita?" ad t(" )s" o+ gly'"ri" s)$$ositori"s i+ ""d"d
2. Post Postpa part rtum um hemorrhae. 8. %eurol %euroloi oical cal Problems Problems.. . Psycho Psycholo loical ical problems. E. $ndocr $ndocrine ine proble problems. ms.
>. Mis'"l Mis'"lla la"o) "o)ss $ro!l $ro!l"#s "#s.. . P)"r$ P)"r$"ra "rall Pyr"&i Pyr"&ia a5 S"$sis. . I+" I+"'t 'tio ios s.. J. P"lvi "lvi'' s"$t s"$ti' i' t(ro#!o$(li!itis. . T(ro T(ro#! #!o" o"#! #!oli olis# s#
P/'"-PA#"U1 H$1/##HA4$ •
It is a "&'"ssiv" !lood loss a+t"r d"liv"ry First %9 ($ri#ary
Primary PPH
'econdary PPH
1anaement
1.Ut"ri" atoy
,.R"tai"d $rod)'ts o+ 'o'"$tio
1. H"avy H"avy !l"" !l""di dig/ g/ I@ i+)sio ad :#at'( o+ !lood. %. Syto' Syto'io io 7syt("t 7syt("ti' i' o&yto'i8. ,. E&a#ia E&a#iatio tio )d"r )d"r a"st("sia. 9. Eva')a Eva')atio tio o+ t(" )t"r )t"r)s. )s. >. Ati!i Ati!ioti oti's 's giv" giv" i+ $la'"tal tiss)" is +o)d/ "v" it(o)t "vid"'" o+ ov"rt i+"'tio
:R.F4 :R.F4 '(orioa#iioitis/ #)lti$l" g"statios/ 1. #a'roso#i' +"t)s/ !roid.%. :Trt4 #assag" ad !i#a)al 'o#$r"ssio/ ,. t(" o&yto'i i+)sio/ "rgo#"tri/ $rostagladi F%f
U$ to ""?ss"'odary 0>22 # at vagial d"liv"ry ad 01222 # at '"sar"a d"liv"ry.
%. G"ital tra't tra)#a
:i+ !lood !lood loss loss is ot "&'"siv" "&'"siv"// :Asso :Asso'ia 'iat"d t"d #or #or" " it( s"'odary PPH. :)s" :)s" $"lvi' $"lvi' US US to "&'l) "&'l)d" d" r"tai"d $rod)'ts. 9.Ot("rs Edo#"tritis / !l""dig disord"rs.
:'"rvi'al ad vagial la'"ratios.
P'5CH//4ICA P#/$1' Postpartum l lues • •
•
Postpartum !e !epression.
6o#$li'at"s >23 • o+ d"liv"ri"s • Mild/ trasi"t/ s"l+:li#it"d disord"r. Mood sigs/ it( •
'o#$li'at"s J:1>3 o+ $r"ga'i"s sy#$to#s i'l)d" sad"ss/ +atig)"/ '(ag"s i sl""$ig ad "atig $att"rs/ r"d)'"d li!ido/ 'ryig "$isod"s/ a&i"ty/ ad irrita!ility. )s)ally i t(" rst +" #ot(s/ ad
Postpartum Ps Psychosis
Pathophysioloy
• •
•
Rar" !)t s"rio)s. Sy#$to#s i'l)d" r"stl"ss agitatio/ 'o+)sio/ d"l)sios/ (all)'iatio/ t(o)g(ts o+ s"l+ (ar#.
Poorly )d"rtood/ !)t #ay !" d)" to ra$id '(ag"s i "strog"/ $rog"st"ro" $rog"st"ro" ad $rola'ti i $ost$art)# $ati"ts.
• •
•
'(ag" i a$$"tit" ad sl""$. First ""? a+t"r d"liv"ry. o+t" r"solv"s !y $ost$art)# day 12. No $(ar#a'ot("ra$y is idi'at"d.
#ay last )$ to s"v"ral #ot(s or "v" a y"ar.
•
Rar"ly $r"s"ts !"+or" t(" ,d $ost$art)# day "#$A"1$%" !)t )s)ally do"s so !"+or" 9 ""?s. P(ar#a'ologi' it"rv"tio is ty$i'ally • R"'ov"ry R"'ov"ry o'')rs ov"r 9: r";)ir"d4 ""?s • T(" $ati"t s(o)ld !" 1. Atid" Atid"$r $r"ss "ssat atss r"+"rr"d )rg"tly to a %. A&ioly A&iolyti' ti' ag"ts ag"ts $sy'(atrist ad ill ,. El"'tro'o El"'tro'ov)lsi v)lsiv" v" t("ra$y t("ra$y )s)ally r";i)r" 9. Mot("r Mot("r s(o)ld s(o)ld !" 'o:#aag 'o:#aag"d "d it( it( ad#issio to a a $sy'(iatrist $sy'(atri' )it.
• •
Str"ss R"s$osi!iliti"s R"s$osi!iliti"s o+ '(ild r"arig • Post$art)# t(yroid dys+)'tio 7$sy'(iatri' disord"rs8. • T("s" $sy'(ologi'al disord"rs ar" s"" i (ig("r rat"s i $ati"ts it( (istory o+ d"$r"ssio or ot("r #"tal ill"s"s.
$%!/C#I%$ !I'/#!$#' 'heehanFs syndrome
Postpartum "hyroiditis
Postpartum 4ra,eFs disease
At"rior Pit)itary glad "larg"s d)rig $r"ga'y d)" to a i'r"as" i t(" si*" ad t(" )#!"r o+ $rola'ti s"'r"tig '"lls
Trasi"t d"str)'tiv" • Trasi"t
•
I+ sigi'at ("#orr(ag" o'')r d)rig t(" $"ri$art)# $"riod is'("#i' "'rosis o+ t(" glad ill (a$$". T(" +)ll $i't)r" is s"" it( d"str)'tio o+ >3 o+ t(" glad 1.D"'r"as"d $rola'ti4 'a)s"s Fail"d Fail"d a'tatio 7'o##oly t(" rst sy#$to#8. %. D"'r"as"d FSH 5 H4 'a)s"s aov)latio 5 s"'odary a#"orr("a ,. Hy$ot(yroidis#4 'a)s"s !rady'ardia / 'old itol"ra'"/ 'osti$atio/ 9. D"'r"as"d A6TH4 'a)s"s (y$ot"sio 5 loss o+ "ig(t
"ss 'o##o t(a PPT. • Si#ilar to Grav"Ks dis"as" i ot("r s"ttigs. • A)toi##)" ati!odi"s agaist TSH r"'"$tors l"adig to "&'"ss $rod)'tio o+ t(yroid (or#o"s . • N""ds tr"at#"t/ li?" ay ot("r grav"Ks dis"as". or#ally s"l+: • T(" $ro'"ss is or#ally li#itig/ !)t (" 'ov"tioal ati!odi"s ar" +o)d t("r" is a (ig( '(a'" o+ t(is $ro'""dig to
iCa##atio o+ T(yroid glad o'')rig it(i t(" 1st y"ar a+t"r d"liv"ry. • it is !"li"v"d to r"s)lt +ro# t(" #odi'atios to t(" i##)" syst"# "'"ssary i $r"ga'y • % $(as"s 1. T(yroto&i'osis. %. Hy$ot(yroidis#.
$"r#a"t (y$ot(yroidis#.
"reatment
REPA6EMENT THERAPY THERAPY :'ortiso" 5 t(yro&i" +or li+". :HMG +or id)'tio o+ ov)latio IF $r"ga'y is d"sir"d.
%$U#//4ICA P#/$1'
A!!$# U%C"I/% P#/$1'
/<$ /<$ U%C"I U%C"I/% /% !I'/ !I'/#!$ #!$# #
"hromb "hromboem oembol bolism ism
/bstetric palsy
ladder problems
Constipation
• T(" ris? o+
6oditio !y (i'( o" or !ot( o+ t(" lo"r li#!s #ay d"v"lo$ sigs 5 sy#$to#s o+ #otor ad-or s"sory ")ro$at(y +olloig d"liv"ry.
Uriary r"t"tio/ voidig diL')lty/ ad !ladd"r ov"r: dist"sio ar" 'o##o.
•
:May !" d)" to4 1: 'o#$r"ssio or str"t'(ig o+ t(" l)#!osa'ral $l"&)s as it 'ross"s t(" sa'roilia' oit d)rig d"'"t o+ t(" +"tal ("ad. % :H"riatio o+ t(" l)#!osa'ral dis's 79->8
VT(" !a!ys "&it #ay (av" tra)#ati*"d it l"adig to t"#$orary $aralysis. Vloss o+ !ladd"r s"satio d)" to r"gioal a"st("sia. VS"llig ad $ai i t(" $"ri"al ar"a. V$sy'(ologi'al 7+"ar8 +a'tors Ov"r:dist"tio Ov"r:dist"tio ill l"ad to 4 1. da#$" !ladd"r s"satio/ r"d"r it (y$o:'otra'til" ad
It is a 'o##o $ro!l"# d)rig $)"r$"ri)# $"riods. t(r"" #ai 'a)s"s4 • T("r" ar" t(r"" 1. It"rr)$ It"rr)$tio tio o+ or#al or#al di"t/ d"(ydratio d)rig la!or. la!or. %. F"ar o+ "va' "va')at )atio io d)" d)" to $ai +ro# s)t)r"d $"ri")#/ $rola$s"d ("#orr(oid/ aal ss)r"s. ,. Atoy Atoy o+ it" it"sti stial/ al/ a!do#ial/ $"ri"al #)s'l"s. • Maag"#"t4 1. ad";)a ad";)at" t" C)id C)id ita? ita?" " ad i'r"as" i !"r ita?". %. stool stool so+t so+t"" ""rr 7la&at 7la&ativ" iv"s8 s8 i+ "'"ssary. ,. a&ati a&ativ"s v"s4la' 4la't)l t)los" os"// is$ag()la Anal incontinence and +ecal urency
•
•
t(ro#!o"#!oli' dis"as" ris"s > +old d)rig $r"ga'y T(" #aority o+ d"at(s o'')r i t(" $)"r$"ri)# ad ar" #or" 'o##o a+t"r 'a"sar"a s"'tio. I+ D@T or $)l#oary "#!olis# is s)s$"'t"d/ a +)ll ati'oag)lat t("ra$y s(o)ld !" 'o##"'"d 5 a !ilat"ral v"ogra# or l)g s'a s(o)ld !" 'arri"d o)t it(i %9 < 9J (o)rs
#ay also o'')r i t(" "&agg"rat"d lit(oto#y $ositio ad d)rig istr)#"tal d"liv"ry. F"at)r"s i'l)d"4 :s'iati' $ai. :)ilat"ral +oot dro$. :(y$oa"st("sia. :#)s'l" astig. :Most 'as"s r"solv" s$ota"o)sly i a #att"r o+ days or ""?s/ or Maag"d ort(o$a"di'ally.
l"ad to !ro)s r"$la'"#"t o+ s#oot( #)s'l".
•
%. Ov"r Co i'oti"'".Its i#$ortat to )riat" it(i 78 to 7J8 (o)rs o+ d"liv"ry.
•
• T(is d"'r"as" rat" o+ UTI
•
ad $r"v"t ay da#ag" ad !l""dig t(at 'a (a$$" (" yo)r !ladd"r g"ts ov"rly +)ll. I+ t(" +"#al" didKt )riat" d)rig t(is $"riod/ " is"rt a 'at("t"r.
1. %. ,. 9. >.
I'oti"'" o+ stool ad Cat)s ar" +r";)"t 'o#$li'atios o+ '(ild!irt(. Aal i'oti"'" is asso'iat"d it(4 Aal s$(i't"r da#ag" "s$"'ially o$"rativ" d"liv"ry. +olloig r"$air o+ t(ird or +o)rt( d"gr"" t"ar. Stool i#$a'tio. D"v"lo$#"t o+ t(" aovagial or r"'tovagial st)la. P"lvi' Coor dys+)'tio
Urinary incontinence
@agial d"liv"ry strogly i#$li'at"d i t(" d"v"lo$#"t o+ str"ss i'oti"'". VD"liv"ry "a?""d #)s'l"s aro)d t(" !ladd"r ad $"lvis/ (i'( #a?" it (ard"r to 'otrol (" )ri" starts. VHor#oal '(ag"s
Puerperal pyre=ia
PU$#P$#A I%$C"I/%'
•
$)"r$"ral $yr"&ia is d""d as a t"#$"rat)r" o+ ,Ju or (ig("r o ay to o+ t(" rst 12 days $ost$art)#/ "&'l)siv" o+ t(" rst %9( #"as)r"d orally !y a stadard t"'(i;)" 'a)s"s ".g. a$$"di'itis.
•
6a)s"s • 1. g"ital tra't i+"'tio )$$"r tra't 7!)l?y t"d"r )t"r)s8 / or $"ri"al i+"'tio oly • %. )riary tra't i+"'tio. ,. Br"ast i+"'tios ".g. #astitis. 9. r"s$iratory tra't i+"'tio : t(is is #or" 'o##o a+t"r a"st("sia. >. t(ro#!o$(l"!itis ad d""$ v"i t(ro#!osis. . o)d i+"'tios A"#ia. • o:$)"r$"ral r"lat"d
I+"'tios ar" a#og t(" #ost $ro#i"t $)"r$"ral 'o#$li'atios . F"v"r r"#ais t(" (all#ar? o+ $)"r$"ral i+"'tio / ad t(" $ati"t it( +"v"r 'a !" ass)#"d to (av" g"ital i+"'tio )til $rov" ot("ris". 1. Edo#"tritis %. Mastitis ,. UTI
PU$#P$#A I%$C"I/%' 2.$ndometritis •
•
Edo#"tritis is a i+"'tio o+ t(" "do#"tri)# or d"'id)a/ it( "&t"sio ito t(" #yo#"tri)# ad $ara#"trial tiss)"s . Us)ally d"v"lo$s o t(" %d or ,rd $ost$art)# day .
'in symptoms
!iDerential dianosis
•
1. %. ,. 9. >. . . J. .
• •
$tioloy
1. %. ,. 9. >. . . J. .
PROM 0 %9 (o)rs 6"sar"a s"'tio 6(orioa#ioitis E&'"ssiv" )#!"r o+ digital $"lvi' "&a#iatio Prolog"d la!or 0 1% (o)r o so'io"'oo#i' stat)s . To&"#ia . itra)t"ri" #oitorig d"vi'"s . $r":"&istig vagiitis ad
•
Body t"#$. 0,J' i to o''asio ( a$art or o'" 0,J.> o"r a!do#ial $ai 6(ag" i o'(ia 4 #or" $ro+)s"/ Fo)l s#"llig or $)r)l"t ")?o'ytosis (i'( #ay !" diL')lt to it"rr)$t !"'a)s" o+ t(" $(ysiologi'al l")?o'ytosis s"" $ost$art)#
In,estiations (act.0ndins)
Aa"ro!i' str"$to'o''i .
Uriary tra't i+"'tio. A')t" $y"lo"$(ritis. o"r g"ital tra't i+"'tio. o)d i+"'tio. At"l"'tasis. P")#oia. T(ro#!o$(l"!itis. Mastitis. A$$"di'itis
1anaement
1. Ad#it to (os$ital. %. Eva')atio o+ r"tai"d $rod)'ts o+ 'o'"$tio )d"r ati!ioti's 'ov"r. ,. Par"t"ral !road:s$"'tr)# ati!ioti's/ )s)ally sto$$"d o'" t(" $ati"t is a+"!ril" +or %9:9J (o)rs/ tol"ratig a r"g)lar di"t/ ad a#!)latig
'"rvi'itis
1. %. ,. 9.
Gra# "gativ" 'oli+or#s Ba't"roid s$$. A"ro!i' str"$to'o''i 6(la#ydia ad My'o$las#a 7diL')lt to ')lt)r"8
it(o)t diL')lty.
PU$#P$#A I%$C"I/%' 8.1astitis
.Urinary tract in+ection
!e0nition
Incidence
$=amination
• •
•
A$$ro&i#at"ly %:9 3 o+ o#" d"v"lo$ UTI $ost$art)# . • D)rig ad Folloig d"liv"ry4 1. t(" !ladd"r ad t(" lo"r )riary tra't r"#ais so#"(at (y$otoi' . %. 6at("t"ri*atio . ,. Birt( tra)#a . 9. 6od)'tio a"st("sia >. Fr";)"t $"lvi' "&a#iatio • T(" 'o##o"st orgais#s ar" E.'oli ad $rot")s s$$.
:Rais"d t"#$"rat)r".
'in 'ymptoms
1anaement
1. %. ,. 9.
1. Broad:s$"'tr)# ati!ioti's )til t(" r"s)lts o+ ')lt)r" ad s"sitivity ar" ?o/ t(" !" s$"'i' . %. B"d r"st . ,. Hig( C)id/ lig(t solid di"t .
• •
ICa##atio o+ t(" #a##ary glad 6o)ld !" 4 a. 6og"stiv" #astitis 7 !r"ast "gorg"#"t8. !. I+"'tio)s #astitis Bot( ar" #or" 'o##o i Pri#igravidas I+"'tio)s #astitis ad !r"ast a!s'"ss ar" )'o##o 'o#$li'atios o+ t(" !r"ast+""dig .
"reatment
1. isolatio o+ t(" #ot("r 5 !a!y %. '"asig !r"ast +""dig +ro# a"'t"d !r"ast. ,. E&$r"ssio o+ #il? "it("r #a)ally or !y "l"'tri' $)#$. 9. #i'ro!iologi'al ')lt)r" 5 s"sitivity o+ a sa#$l" o+ #il?. >. C)'lo&a'illi 'a !" 'o##"'"d (il" aaitig s"sitivity r"s)lt.
Dys)ria. Fr";)"'y o+ #i't)ritio. oi $ai i+ $y"lo"$(ritis o'')rs. Syst"#i' sy#$to#s s)'( as $yr"&ia ad ta'(y'ardia. >. May !" asy#$to#ati' ad r"'ogi*"d o ro)ti" #id:str"a#
:S)$ra:$)!i' ad-or r"al agl" t"d"r"ss . In,estiation
:MSU. :(it" '"ll 'o)t. :Nitrit"s ad l")'o'yt"s o di$sti'?.
. 123 o+ o#a it( #astitis d"v"lo$ !r"ast a!'"ss (i'( ""d s)rgi'al i'isio 5 draiag" )d"r g""ral a"st("sia.
)ri" 7MSU8 sa#$l". . 7T(is s(o)ld !" $"r+or#"d o all $ati"ts (o (av" !"" 'at("t"ri*"d i la!or8
RHESUS ISOIMMUNI]ATION FETOMATERNA HEMORRHAGE "a?ag" o+ R(=v" +"tal '"lls i R(:v" #at"ral 'ir')latio d)rig $r"ga'y E&a#$l"s4 S$ota"o)s a!ortio/ Id)'"d a!ortio/ APH/ E.6.@/ 6ordo'"t"sis/ 6@S/ a#io'"t"sis/ S"v"r" $r""'la#$sia/ E'to$i' $r"ga'y/ 6a"sar"a s"'tio/ Ma)al r"#oval o+
1: I+ ABO is i'o#$ati!l"4 RB6 "asily d"stroy"d/ so ot r"a'(ig "o)g( i##)ologi'al 'o#$o"t to 'a)s" ati!ody r"s$os" ad r"a'tio %: I+ ABO is 'o#$ati!l"4 R( =v" +"tal '"lls à r"#ai i 'ir')latio 7li+" s$a8 )til r"#ov"d !y R.E.S à d"stroy"d à li!"ratig
Mild 6as"s4 F"tal RB6 d"str)'tio +ro# IgG ati D à aa"#ia It 'o#$"satig ta?"s ti#"4 ("#o$oi"sis à "&'"ss o+ à 1st $r"ga'y!ilir)!i. is al#ost alays ot )'o)gat"d a"'t"d4 S"v"r" 6as"s4 13 d)rigd"str)'tio la!o)r or ,rd stag"RB6 à s"v"r" E&'"ssiv" o+ +"tal 123 #ot(s a+t"r d"liv"ry a"#ia Hy$o&ia à Tiss)" à 6ardia' - 'ir')latory ad1>3 !y t(" %d $r"ga'y +ail)r" à G""rali*"d "d"#a à H"art Fail)r" à As'it"s :àItra)t"ri" F"tal D"at( it( "&'"ssiv" )'o)gat"d !ilir)!i 0,12:,>2 #ol- à Pass"s BBB à ?"ri't"r)s à $"r#a"t ")ro ad #"tal disord"rs. FETA 5 NEONATA EFFE6TS : Ha"#olyti' aa"#ia o+ "!or H! 19:1Jg-dl : I't"r)s gravis "oator)# H! 12:19g-dl
Fa'tors A"'t D"v o+ R("s)s ati!odi"s4 1: I!or a!ility to r"s$od %: Prot"'tio i+ ABO i'o#$ati!l"112 ,: Str"gt( o+ R( Ag sti#)l)s 76D"R18 9: @ol)#" o+ l"a?ig +"ta !lood 72.%>#l8 IgM 7 days8 do"sKt 'ross $la'"ta/ t(" IgG %1 days : 'ross"s $la'"ta8
INTRODU6TION R("s)s +a'tor4 Aggl)tiog" 76/D/E8 #aily D 6/D/E do#iat atig" d/" r"'"ssiv" atig" : R( =v" a!o)t J>3 7(o#o*ygo)s DD,>3 or ("t"ro*ygo)s Dd >23
MANAGEMENT A8 Pro$(yla&is 1: Pr"v"tio o+ R("s)s isoi##)i*atio4 Ati D 7R(oD IgG8 Stadard dos" +or 0%2/ ad b stadard dos" +or %2""?s. Giv" it(i %( o+ t(" i'id"t. SD4 I.M. i"'tio4 >22 i) 122 )g# 7U8 : ")trali*" >#l 79#l = 1#l8 122+"tal '"lls SD i USA ,22)g#1>22i) : ")trali*" 1>#l
: R( "gativ" a!o)t 1>3. I'id"'" o+ R( :v" i +ar "ast is a!o)t 13 E&a#$l"s o+ R( +a'tor4 76D"R18 / 76d"r8 7'DER%8 Ot("r syst"#s4 ?"ll:ati?"ll/ l)t("r/ D)y/ "t' . Itrod)'tio o+ +or"ig $rot"i 7Ag8 à $rod)'tio o+ A! to ")trali*" t(" Ag. I ABO ad ot("r o R(: i'o#$ati!ility4 It )s)ally 'a)s"s #ild a"#ia/ #aily as t("r" is o itra$art)# !oostig . I R("s)s isoi##)i*atio4 #aily 7D8/ !)t 6/E 'a $rod)'" ati!odi"s. l"i(a)"r:B"t?" t"'(i;)" 7a'id "l)tio t"st84 M"as)r" a#o)t o+ +"to:#at"ral (a"#orr(ag". I+ 2.1: 2.%>#l o+ +"tal !lood l"a?s 7'riti'al vol)#"8 t(is ill $rod)'" isoi##)i*atio r"$r"s"t"d !y > +"tal '"lls i >2 lo $o"r #i'ros'o$i' "ld o+ $"ri$("ral #at"ral !lood. So 1#l is r"$r"s"t"d !y %2 +"tal '"lls
:B t"st i+ larg" a#o)t o+ l"a?ig à aot("r SD i+ #ot("r is R( :v"/ !a!y R( =v" it( o isoi##)i*atio 7'("'?"d !y idir"'t or dir"'t 'oo#!Ks t"st8 %: A.P ad#iistratio o+ ati D SD at %J or at %J ad , ill r"d)'" R( isoi##)i*atio B8 1: Ati!ody S'r""ig4 +or all $r"gat o#" i AN6 +or irr"g)lar ati!odi"s 7#aily +or R("s)s N"gativ" o#"8 t(" start at %2/ ad "v"ry 9 ""?s %: Maag"#"t +olloig d"t"'tio o+ R( ati!odi"s : S(o)ld !" tr"at"d i s$"'iali*"d '"t"rs : )atitativ" #"as)r"s o+ ati!odi"s = ()s!ad g"oty$" : R"$"at titratio 7idir"'t 'oo#!Ks/ d"t"'tig o+ ati!odi"s8 tit"r or s$"'i' "*y#"s +or ati!odi"s IU : A#io'"t"sis o'" "'"ssary : O!st"tri'al #aag"#"t !as"d o ti#ig o+ I.U tras:+)sio 7No 'ordo'"t"sis = +"tos'o$y8 v"rs)s d"liv"ry ,: A#io'"t"sis4 s(o)ld !" $"r+or#"d )d"r )ltraso)d g)ida'" i+ tit"r 0 11 2.>:1 )g# 0 %.>:> I.U : ti#ig4 1st a#io'"t"sis 12 ""?s !"+or" $r"vio)s IUFD : Start +ro# %2:%% ""?s/ %:9 ""?ly or #or" +r";)"t i+ ""d"d : A#ioti' C)id aalysis4 s$"'tro$(oto#"try4 o$ti'al d"sity at t(" ("ig(t o+ o$ti'al d"sity d"viatio at av" l"gt( 9>2 M.
IU tras+)sio 7'ordo'"t"sis/ i t(" $ast itra$"rito"al tras+)sio8 v"rs)s d"liv"ry o+ t(" !a!y4 : Usig ilyKs '(art : Pr"di'tio '(art 7)""a ')rv"8 : (it""ldKs a'tio li" :Alt"rativ"ly +ollo )$ it( do$$l"r st)dy +or t(" +"tal #iddl" '"r"!ral art"ry. Progosis d"$"ds o4 O!st"tri' (&/ $at"ral g"oty$"/ #at"ral (istory 7!lood
tras+)sio/ ati!ody titr"8 a#io'"t"sis r"s)lts. D"liv"ry4 @agial v"rs)s 6s It"siv" $las#a$(or"sis4 (" s"v"r" 'as"s ati'i$at"d/ )sig 'otio)s Co '"ll s"$arator/ as "arly as 1% Postatal #aag"#"t4 +or t(" "oat" : dir"'t 'oo#!Ks t"st/ Blood gro)$/ R( ty$"/ H!/ !ilir)!i . : Mild 'as"s4 $(otot("ra$y/ 'orr"'tio o+ a'idosis : S"v"r" 'as"s 4"&'(ag" tras+)sio
SMA FOR GESTATIONA AGE INTRODU6TION : F"tal grot( is d"$"d"t o g""ti'/ $la'"tal ad #at"ral +a'tors. : F"tal grot( r"stri'tio is t(" s"'od l"adig 'a)s" o+ $"riatal #or!idity ad #ortality. ASSESSING FETA GROTH HISTORY PHYSI6A EAM USES OF UTRASOUND : Mot("rKs ag" a8 G""ral E&a# : Diagosis ad 'or#atio : A'')ra'y o+ MP !8 O!st"tri'al E&a# o+ via!ility i "arly $r"ga'y dat" Ut"ri" F)dal H"ig(t : D"t"r#iatio o+ g"statioal
FETA @IABIITY D"t"'tio o+ 4 G"statioal sa' 79: >?s8
: I+"'tios d)rig $r"ga'y : M)lti$l" $r"ga'y : AN6 ad visits/ S)$$l"#"ts : Past o!s. H&/ Past M"d H&/ Dr)g H&/ Fa#ily H&/ So'io"'oo#i' H&.
: O!taiig s"rial )t"ri" +)dal ("ig(t ag" ad ass"ss#"t o+ +"tal #"as)r"#"ts. si*" : T(" cM'doalds r)l" i $r"ga'y is a : Itra)t"ri" or E'to$i' ro)g( d"t"r#iatio o+ +"tal ag" i ""?s $r"ga'y. Ut"r)s si*"4 !y $"lvi' "&a#iatio i t(" : M)lti$l" $r"ga'y rst tri#"st"r ad s)!s";)"t at"atal : Diagosis o+ +"tal visits. a!or#aliti"s Misl"adig i4 F)ll !ladd"r/ o!"sity/ d""$ : Pla'"tal lo'ali*atio #ass"s/ )t"ri" !roids 5 #)lti$l" : Ass"ss#"t o+ +"tal "ll: $r"ga'y !"ig DETERMINATION OF GA AND ASSESSMENT OF GROTH UP TO 1,TH EES GA FROM 1 < %9 EES GA 6RON:RUMP ENGTH BIPARIETA DIAMETER HEAD 6IR6UMFEREN6E FEMUR ENGTH 76R8 7BPD8 7H68 7F8 Fro# 6ro to Not a"'t"d !y t(" : B"tt"r t(a BPD T(" trasv"rs" idt( s(a$" o+ t(" ("ad. i a'')ra'y ad 6o''y& 7R)#$8 o+ t(" ("ad at its ti#ig. 7logit)dial a&is8. id"st 7t(" dista'" : A'')rat" oly A'')rat" )$ to 19 !"t"" t(" $ari"tal (" t(" i#ag" !o"s "#i"'" o+ ?s 71st TM8. s(os to !l)t"d t(" s?)ll8. It is t(" #ost "ds o+ t(" +"#)r. A'')rat" )$ to1:%9 a'')rat" ?s. $ara#"t"r. A'')ra'y o+ =-: A'')ra'y o+ =-: > days. days +ro# t(" GA. It is a"'t"d !y t(" s(a$" o+ t(" ("ad.
Yol? sa' 7>?s8 E#!ryo 7>:?s8 @isi!l" ("art !"at 7?s8.
ABDOMINA 6IR6UMFEREN6E 7A68 Mad" at t(" id"st $oits i t(" a!do#". Most a'')rat" sigl" $r"di'tor o+ +"tal "ig(t.
SMA FOR GESTATIONA AGE 7SGA8 S#all +or g"statioal ag" is d""d as a +"tal !irt( "ig(t !"lo t(" 12 t( '"til" +or t(" stat"d g"statioal ag". T(" i'id"'" o+ SGA +"t)s"s is >:123 6ONSTITUTIONA SGA
PREMATURITY 71238 INTRAUTERINE GROTH
SYMMETRI6A IUGR ASYMMETRI6A IUGR
AQ 6ONSTITUTIONAY SMA FETUS U+ort)at"ly/ it 'a !" 'o'l)d"d t(at a +"t)s is 'ostit)tioally s#all oly a+t"r $at(ologi' $ro'"ss"s (av" !"" "&'l)d"d. T("r"+or"/ id"ti'atio o+ a 'ostit)tioally s#all i+at is )s)ally #ad" i r"tros$"'t/ a+t"r t(" i+at is !or. 6a)s"s 7M)lti+a'torial84 Ra'"/ G"ogra$(i'al ar"a/ S"& 7M0F8/ Mat"ral ag"/ Mat"ral "ig(t ad ("ig(t/ So'io"'oo#i' stat)s
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BQ INTRA:UTERINE GROTH RESTRI6TION Fail)r" o+ t(" +"t)s to a'(i"v" its grot( $ot"tial IN6IDEN6E TYPES , : 12 3 o+ all $r"ga'i"s. • Sy##"tri'al grot( r"stri'tio4 +"t)s (os" "tir" !ody is %2 3 o+ still!ors ar" grot( r"tard"d. $ro$ortioally s#all. 7%238 : % 3 (av" aato#i' ad-or g""ti' • Asy##"tri'al grot( r"stri'tio4 D"'r"as" i s)!')ta"o)s +at ad a!do#ial 'ir')#+"r"'" it( r"lativ" s$arig o + ("ad 'ir')#+"r"'" a!or#aliti"s. ad +"#)r l"gt(. 7J238 P"riatal #ortality is J : 12 ti#"s (ig("r +or t("s" +"t)s"s. 6AUSES OF IUGR MATERNA MATERNA FETA FETA PATHOOGI6A PA6ENTA 6AUSES PHYSIOOGI6A PATHOOGI6A 6AUSES PHYSIOOGI6A 6AUSES 6AUSE 6AUSES M)lti$l" $r"ga'y • _ Ut"ro$la'"tal • G""ti' disord"rs • Pla'"tal • G""ti' Fa'tors4 !lood Co4 7A'(odro$lasia/ is)L'i"'y S(ort stat)r" • Ra'"/ "t(i'ity/ : PET-"'la#$sia R)ss"ll : silv"r syd8 7#ost i#$ i ,rd Yo)g"r or old"r atioality tri#"st"r8 ag" 71> ad 09>8 : '(roi' r"ovas')lar • 6(ro#oso#al • s"& 7#al" "ig( ao#ali"s4 Aato#i' o so'io"'oo#i' dis"as" • 1>2 :%22 g# : 6(roi' HTN : 6(ro#oso#al d"l"tios $ro!l"#s4 'lass #or" t(a : Triso#i"s 1,/1J 5 %1 : M)lti$l" i+ar'ts Pri#i$arity • Mat"ral #al)tritio +"#al"8 : A!"rrat 'ord • Mat"ral (y$o&"#ia • 6og"ital Grad #)lti$arity • Parity is"rtios : H"#oglo!io$at(i"s #al+or#atios4 o $r"ga'y 7$ri#i$aro)s/ : U#!ili'al : Hig( altit)d"s E&4 A"'"$(aly/ GI "ig(t "ig( l"ss t(a vas')lar t(ro#!osis atr"sia/ Pott"rKs • Dr)gs Pr"vio)s (-o s)!s";)"t sydro#"/ ad 5 ("#agio#as $r"t"r# IUGR !a!y : 6igar"tt"s/ al'o(ol/ si!ligs8 $a'r"ati' ag""sis. : Pr"#at)r" ("roi/ 'o'ai" $la'"tal s"$aratio : T"ratog"s/ • F"tal 6ardiovas')lar : S#all Pla'"ta ati#"ta!olit"s ad ao#ali"s t("ra$")ti' ag"ts s)'( • 6og"ital I+&4 as tri#"t(adio"/ #aily TOR6H. ar+ari/ $("ytoi. • I!or "rror o+ #"ta!olis#4 • 6(roi' ill"ss 7DM/ r"al +ail)r"/ 'yaoti' : Trasi"t "oatal ("art dis"as" "t'.8 dia!"t"s
: Gala'tos"#ia : PU DIAGNOSIS • History/ P(ysi'al "&a#iatio/ Iv"stigatios • Ultraso)d • A!do#ial 'ir')#+"r"'" is t(" sigl" #ost ""'tiv" $ara#"t"r +or $r"di'tig +"tal "ig(t !"'a)s" itKs r"d)'"d i !ot( sy##"tri'al 5 Asy##"tri'al IUGR . I t(" $r"s"'" o+ or#al ("ad ad +"#)r #"as)r"#"ts/ a!do#ial 'ir')#+"r"'" 7A68 #"as)r"#"ts o+ l"ss t(a % stadard d"viatios !"lo t(" #"a a$$"ar to !" a r"asoa!l" ')to to 'osid"r a +"t)s asy##"tri'. 6OMPI6ATIONS ANTENATA NEONATA 1: R"lat"d to (y$o&ia ad • M"ta!oli' '(ag"s a'idosis4 7a'idosis "t'8. a: M"'oi)# as$iratio. • Oligo(ydra#ios !: P"rsist"t +"tal 7J238 'ir')latio. • A!or#al +"tal ': Hy$o&i' is'("#i' ("art $att"rs. "'"$(alo$at(y. • A!or#al Do$$l"r %: M"ta!oli'4 Hy$ogly'"#ia/ st)di"s. Hy$o6a/ Hy$ot("r#ia/ • IUFD Hy$"rvis'o'ity sydro#" INTRAPARTUM ,: R"lat"d to t(" "tiology4 • A!or#al 6TG. a: 6(ro#oso#al • F"tal d"at(. a!or#aliti"s. • M"'oi)# stai"d !: I+"'tio. li;)or. ': 6og"ital ao#ali"s. • ↑i'id"'" o+ istr)#"tal ad 'a"sar"a d"liv"ri"s.
Asy##"tri'al grot( r"stri'tio 4 BPD is or#al i t(" , rd tri#"st"r / ("r"as ratio o+ H6-A6 is a!or#al . • Sy##"tri'al grot( r"stri'tio 4 H6-A6 #ay !" or#al . • A#ioti' C)id vol)#"s 7 oligo(ydra#ios is asso'iat"d it( IUGR8 . U#!ili'al art"ry 5 +"tal art"ry do$$lar ass"ss#"ts 4 i'r"as"d r"sista'" is asso'iat"d it( a gr"at"r ris? o+ IUGR as $r"ga'y $rogr"ss"s. •
PRE:PREGNAN6Y Modi+y li+"styl" (a!its. • D"t"'t ad tr"at #"di'al disord"rs. •
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MANAGEMENT ANTEPARTUM R"g)lar at"atal 'ar". S"rial +"tal grot( ass"ss#"t. S"rial +"tal "ll!"ig ass"ss#"t 1: Bio$(ysi'al $rol" %: 6o#$)t"ri*"d 6TG ,: U#!ili'al art"ry Do$$l"r Ti#ig o+ d"liv"ry. Mod" o+ d"liv"ry.
Ti#" 5 Mod" o+ d"liv"ry gov"r"d !y4 Mat"ral ag"/ Past o!s. History/ GA/ F"tal "ll !"ig/ Stat)s o+ '"rvi&/ Availa!ility o+ dir"'t #oitorig d)rig la!or 7E&4 s'al$ PH sa#$lig8. Mod" o+ D"liv"ry 6"sar"a d"liv"ry it(o)t a trial o+ la!or4 1. i t(" $r"s"'" o+ "vid"'" o+ +"tal distr"ss %. +or traditioal o!st"tri'al idi'atios +or '"sar"a d"liv"ry
Id)'tio o+ la!or 6oti)o)s ("art rat" #oitorig ad s'al$ $H #oitorig o$ti#i*" s)''"ss o+ vagial d"liv"ry
SHOUDER DYSTO6IA Ris? Fa'tors
D"+4 DiL')lt 6lii'al Mai+"statios d"liv"ry o+ t(" 2. etal macrosomia F"tal s(o)ld"r +ails to d"liv"r s(o)ld"r. a+t"r d"liv"ry o+ +"tal ("ad 8. 1aternal !1 Arr"st o+ or#al d"s$it" ro)ti" #a")v"rs. ,. Ot("rs4 la!or a+t"r t(" : At"$art)#4 O!"sity/ M)lti$arity/ I#$a'tio o+ +"tal s(o)ld"r d"liv"ry o+ t(" ("ad !"(id $)!i' sy#$(ysis. Post:t"r# g"statios/ S(ort !y t(" i#$a'tio o+ cT)rtl" sig4 R"tra'tio o+ stat)r"/ Pr"vio)s (& o+ at"rior s(o)ld"r +"tal ("ad ito $"ri")# #a'roso#ia/ Pr"vio)s (& o+ agaist sy#$(ysis a+t"r its d"liv"ry ad !"+or" s(o)ld"r dysto'ia $)!is. t(" s(o)ld"rs 'a !" : Itra$art)#4 a!or id)'tio/ Post"rior s(o)ld"r d"liv"r"d. "$id)ral aalg"sia/ Prolog"d #ay also !" la!or/ O$"rativ" vagial d"liv"ry o!str)'t"d !y sa'ral $ro#otory. 6o#$li'atios Pr"ga'i"s at Ris? F"tal ris?s Mat"ral ris?s 6aot a'')rat"ly $r"di't 7>23 it(o)t ris? +a'tors8 : As$(y&ia G"ital tra't tra)#a : Birt( tra)#a4 Bra'(ial A6OG r"'o##"ds 6S +or EF ≥>?g i $l"&)s i)ri"s 7Er!Ks 5 ↑ ris? o+ PPH oDM #ot("rs ad ≥9.>?g i DM l)#$?"Ks8/ Fr& ()#"r)s 5 Ut"ri" r)$t)r" #ot("rs. 'lavi'l" : D"at(
H$P$#
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HUMAN H4 6all +or Help.PAPIOMA@IRUS 7HP@8 O@ER@IE PRE@AEN6E 5 TRANSMISSION T("r" ar" a!o)t %22 HP@ g"oty$"s/ ,2 • 6o##o viral STI it( a $4 Eval)at" +or $pisiotomy to 92 ty$"s o+ HP@ ar" ty$i'ally "sti#at"d %2 #illio i+"'t"d tras#itt"d t(ro)g( s"&)al 'ota't ad "$isioto#y. $"rsos i t(" US ad > #illio Midli" i+"'t t(" aog"ital r"gio. " 'as"s "v"ry y"ar. F7&84 Fa'ilitat"s d"liv"ry o+ $ost"rior T(" #ost 'lii'ally "vid"t r"s)lts o+ • A!o)t >3 o+ s"&)ally a'tiv" i+"'tio it( ()#a $a$illo#avir)s ad)lts ill !" i+"'t"d so#"ti#" i 4 es Z 7HP@8 ar" condyloma acuminata or1c#obertFs t("ir 1aneu,re li+". . enital warts HP@ 'al"gs. o'')r • Tras#issio Hy$"rC"&io/ a!d)'tio 5 "&t"ral rotatio o+ o+ #at"ral Maority o+ g"ital arts ar" 'a)s"d !y "v" (" t("r" ar" o visi!l" F7&84 Straig(t"s #at"ral lordosis/ r"#ov" sa'ral $ro#otory as HP@ ty$"s ad 11 (i'( (av" littl" l"sios 7lat"t8. o!str/ o$" $"lvis to #a& di#"sio/ il"t ito $la" o'og"i' $ot"tial. D)rig$"lvi' $r"ga'y/ 'odylo#ata •
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6INI6A PRESENTATION Mostly asy#$to#ati' o visi!l" l"sios 7lat"t i+"'tio8. 6(ara't"ri*"d !y r"adily visi!l" arty grot(s 7 condylomata acuminata8 o t(" v)lva/ vagia/ '"rvi&/ )r"t(ra/ ad $"riaal ar"a/ t(at 'a !" $r)riti' or 'a)s" !l""dig. HP@ i+"'tio )s)ally 'l"ars s$ota"o)sly it(i % y"ars/ !)t r"')rr"'"s ar" 'o##o.
HP@ ty$"s 1 ad 1J #ay 'a)s" Cat #ay i'r"as" i )#!"r ad si*"/ Pressure Z 1aanti 4 S)$ra$)!i' T"'(i;)" +ro# arts ad (av" !""Pli?"d it( t(" (o"v"r/ tras#issio d"v o+ '"rvi'al 'a. Dir"'t s)$ra$)!i' $r"ss)r" #ot("r to i+at is v"ry rar". agaist +"tal at"rior DIAGNOSIS TREATMENT s(o)ld"r to dislodg" +ro# )d"r sy#$(ysis $)!is. 6lii'al "&a# Provid"r:a$$li"d to$i'al t("ra$i"s i'l)d"4 $odo$(ylli r"si 123 to %>3 i ti't)r" o+ !"*oi ad tri'(loroa'"ti' a'id 7T6A8 or Bio$sy o+ t(" l"sio 7)'"rtai o+ $4l"sios #ubin Et"r Z Ma")vr"s !i'(lora'"ti' a'id 7B6A8 J23 to 23. diagosis or +or t(at ar" 5
#4 R"l"as" o+ $ost"rior s(o)ld"r Z Sac9uemier 1aneu,re $ati"t
Had is"rt"d ito vagia/ ad t(" $ost"rior ar# is gras$"d ad $)ll"d r"s)ltig d"liv"ry i $ost"rior s(o)ld"r 5 dis$la'"#"t o+ at"rior 4as*in All-ours
P)t $ati"t o all +o)rs 7?"":'("st $ositio8 ad r"$"at ast R"sorts4 ]ava"lli Ma")vr"4 R"$la'" ("ad !a'? ito $"lvis 5 d"liv"r 6S.
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O@ER@IE STD 'a)s"d !y t(" HS@ ty$" I or ty$" %. HS@:1 is #ost 'o##oly asso'iat"d it( oral l"sios 7'old sor"s8/ !)t a!o)t ,23 o+ $ri#ary GH is d)" to HS@:1. HS@:% is t(" 'a)s" o+ 23 o+ $ri#ary GH ad >3 o+ r"')rr"t GH. 6(ara't"ri*"d !y r"$"at"d "r)$tios o+ s#all/ $ai+)l !list"rs o t(" g"itals/ aro)d t(" r"'t)#/ or 'ov"rig ada'"t ar"as o+ s?i 7enital ulcer8.
HERPES SIMPE @IRUS 7HS@8 PRE@AEN6E TRANSMISSION G"ital ("r$"s 7GH8 is t(" @ir)s "t"rs !ody t(r) #ost $r"val"t STD i t(" #)'osa or #i'roa!rasios US. i t(" s?i ad +ollos t(" s"sory "rv"s to t(" Alt(o)g( oly a!o)t >3 o+ dorsal s$ial gaglio o#" r"$ort a (istory o+ ("r" it r"#ais dor#at g"ital ("r$"s i+"'tio/ )til r"a'tivat"d. as #ay as %>3 to ,23 Tras#issio o'')rs (av" ati!odi"s o s"rologi' t"stig t(ro)g( iti#at" g"ital/ 7asy#$to#ati'8. oral or aal 'ota't. Tras#issio +ro# a A i+"'t"d #ot("r 'a i+"'t"d #al" to (is tras#it t(" vir)s to ("r +"#al" $art"r is #or" i+at d)rig d"liv"ry li?"ly t(a +ro# a r"s)ltig i sigi'at +"tal i+"'t"d +"#al" to ("r #ortality ad #or!idity. #al" $art"r.
6OMPI6ATION Psy'(o distr"ss. 7'o)s"lig8 N")ro ivolv"#"t 7as"$ti' #"igitis/ trasv"rs" #y"litis or a)too#i' ")ro$at(y8. H"r$"s ?"ratitis 7'or"al s'arrig ad !lid"ss8. ↑ris? o+ HI@ i+"'tio N"oatal ("r$"s 7v"rti'al tras#issio8
PRIMARY Ty$i'ally asy#$to#ati' Pr"s"ts )$ to , ""?s a+t"r a';)isitio B"gis it( C)li?" sy#$to#s 7#alais"/ #yalgias/ a)s"a/ diarr("a/ ad +"v"r8. @)lvar !)rig ad $r)rit)s +ollo"d !y #)lti$l" !ilat"ral v"si'l"s t(at a$$"ar "&t ad )s)ally r"#ai ita't +or %9 to , (o)rs !"+or" "volvig ito $ai+)l g"ital )l'"rs. Ig)ial ad"o$at(y/ dys)ria ad a')t" )riary r"t"tio #ay o'')r. R";)ir" a #"a o+ 12 to %% days to ("al/ it( o s'arrig. DIAGNOSIS 6lii'al diagosis @iral ')lt)r" +ro# v"si')lar C)id 7t(" gold stadard lo s"sitivity8 DNA P6R assays +or HS@ 7"&$"ri#"tal8 A T*a'? s#"ar 7'ytology8 Ty$": s$"'i' ati!odi"s +or HS@:1 ad HS@:% IgG 7diagos" t(" $ri#ary i+"'tio ad t(" s"roty$" o+ t(" 'a)sativ" orgais#8.
RE6URRENT (" t(" vir)s !"'o#"s r"a'tivat"d ad trav"ls do t(" s"sory "rv" to t(" #)'o"$it("lial s)r+a'". 6a o'')r as +r";)"t as 1: &-yr. Trigg"r +a'tors i'l)d" +"v"r/ #"s"s/ "#o str"ss/ or lo'al tra)#a. Us)ally o'')r i t(" sa#" ar"a/ )ilat"ral/ #ay !" l"ss $ai+)l t(a t(os" o+ t(" rst "$isod" !)t 'a still !" )'o#+orta!l". Syst"#i' s& ar" )'o##o it( r"')rr"'"s. By t(" :t( day/ #ost l"sios ar" ("al"d it(o)t s'arrig. TREATMENT T(" goals o+ tr"at#"t +or GH ar" s& r"li"+/ a''"l"ratio o+ l"sio ("alig/ ad a _ i +r";)"'y o+ r"')rr"'"s. Ativiral : a'y'lovir/ +a#'i'lovir/ ad vala'y'lovir ar" sa+" ad ""'tiv" +or tr"atig $ri#ary ad "$isodi' o)t!r"a?s/ ad s)$$r"ssiv" t("ra$y +or $ati"ts it( '(roi' dis"as".
NEONATA J>3 o+ 'as"s o'')r d)rig !irt(/ >3 ar" i+"'t"d i )t"ro/ ad123 o+ 'as"s ar" a';)ir"d $ostatally. Ris? o+ tras#issio to t(" "!or is ,2:>3 i 'as"s ("r" t(" #ot("r a';)ir"d a $ri#ary i+"'tio i t(" ,rd tri#"st"r o+ $r"ga'y/ ris? o+ tras#issio !y a #ot("r it( "&istig ati!odi"s +or !ot( HS@:1 ad HS@:% is a!o)t 1:,3. N"oatal ("r$"s #ay ta?" t(r"" +or#s4 18 !isseminated 7it( t(" (ig( #or!idity ad #ortality d"s$it" a$$ro$riat" tr"at#"t8 %8 C%' oly 7(ig( #or!idity/ so#" #ortality d"s$it" tr"at#"t8 ,8 '*in>$ye>1outh ivolv"#"t oly 7lo #or!idity ad al#ost o #ortality it( tr"at#"t8
MANAGEMENT FOR NEONATA HERPES A'y'lovir #ay !" ad#iist"r"d orally to $r"gat o#" it( #ild or #od"rat" o)t!r"a?s/ !)t +or $ri#ary i+"'tios or s"v"r" r"')rr"t o)t!r"a?s/ I@ t("ra$y s(o)ld !" ad#iist"r"d. At t(" os"t o+ la!or/ all o#" s(o)ld !" ;)"stio"d 'ar"+)lly a!o)t sy#$to#s o+ g"ital ("r$"s/ ad s(o)ld !" "&a#i"d 'ar"+)lly +or ("r$"ti' l"sios. Pati"ts it( ty$i'al $rodro#al sy#$to#s or a'tiv" l"sios i la!or s(o)ld !" d"liv"r"d !y '"sar"a s"'tio. Pr"v"tig is diL')lt !"'a)s" 2:J23 o+ aqi't"d
No tr"at#"t 'o#$l"t"ly "radi'at"s vir)s. Ed)'atio ad s)$$ortiv" 'o)s"lig.
"!ors ar" !or to #ot("rs it( o (& o+ $rior i+"'tio or sigs or s& at or aro)d t(" ti#" o+ d"liv"ry.
INTRODU6TION o Most 'o##o !a't"rial STI i US. o O!ligat" itra'"ll)lar !a't"ria t(at gros i vitro oly i tiss)" ')lt)r". I+"'ts 'ol)#ar "$it("li)# o+ o "do'"rvi&/ )r"t(ra/ "do#"tri)#/ +allo$ia t)!"s 5 r"'t)#. No va''i". Ati!odi"s do"sKt o $rot"'t agaist r"i+"'tio. RISS For $r"gat o#"4 Pr"t"r# la!or/ 6(orioa#ioitis/ Post$art)# "do#"tritis. ,23 )tr"at"d '(la#ydial '"rvi'itis $rogr"ss to PID. For i+at4 N"oatal 'o)tivitis 5 $")#oia
6HAMYDIA TRA6HOMATIS 6INI6A FEATURES H& 4 Most 723 o#" = >23 #"8 ar" asy#$to#ati'e M)'o$)r)l"t '"rvi'itis or #)'o$)s o A')t" )r"t(ritis it( dys)r"a !)t o #ii#al +r";)"'y 5 )rg"'y 5 "gativ" )ri" ')lt)r". E&a#iatio4 M)'o$)r)l"t '"rvi'al dis'(arg" 5 6"rvi'al Eryt("#a a! t"sts Tiss)" ')lt)r" : "&$"siv" o Atig" t"sts o DNA (y!ridi*atio 5 )'l"i' a'id o a#$li'atio t"sts NAATs 7P6R or ligas" '(ai r"a'tio8
S6REENING S"l"'tiv" s'r""ig. • All s"&)ally a'tiv" +"#al" %yrs • All o#" it( ris? +a'tors 7)#arri"d/ #)lti$l" s"&)al $art"rs/ i'osist"t )s" o+ !arri"r 'otra'"$tio/ $r"vio)s (& o+ STI/ $r"gat8 DNA a#$li'atio t"st TREATMENT 1. Pr"s)#$tiv" tr"at#"t it( a$$ro$riat" ati!ioti's o A*it(ro#y'i 1g orally sigl" dos"/ or Do&y'y'li" 122#g %&-day +or a o ""? o Pr"gatW A#o&i'illi or "ryt(ro#y'i %. Tr"at all s"&)al 'ota'ts it(i t(" $ast 2 days o+ diagosis. PDPT. ,. T"stig +or ot("r STI 9. A!sti"'" +ro# s"&)al 'ota't +or days a+t"r startig tr"at#"t.
GONORRHEA INTRODU6TION SIGNS 5 SYMPTOMS o Gra# "gativ" di$lo'o'')s N"iss"ria o Asy#$to#ati' 7Most o#"/ !)t >3 Goorr("a #"8 I+"'ts ')!oidal 5 'ol)#ar I'r"as"d vagial dis'(arg" it( o o "$it("li)# i "do'"rvi'al 5 )r"t(ral lo"r a!-$"lvi' $ai. #)'osa. Dys)r"a it( )r"t(ral dis'(arg". o Also r"'tal 5 aso$(aryg"al #)')s o Pro'titis it( r"'tal !l""dig/ o #"#!. dis'(arg"/ $ai. o 6oi+"'tio it( 6(la#ydia 5 Edo'"rvi'al #)'o$)r)l"t o Tri'(o#oas. dis'(arg" 5 'ota't !l""dig. No va''i"s. o M)'o$)r)l"t )r"t(ral dis'(arg". o 1>3 )tr"at"d goo'o''al '"rvi'al o o P"lvi' t"d"r"ss it( '"rvi'al i+& $rogr"ss to PID. "&'itatio. RISS TREATMENT GUIDEINES To $r"gat o#"4 Pr"t"r# 1. Tr"at#"t it( a$$ro$riat" ati!ioti's. la!or 5 d"liv"ry/ %. Si#)lta"o)s tr"at#"t +or '(la#ydia '(orioa#ioitis/ $ost$art)# 71g a*it(ro#y'i i sigl" oral dos"8 "do#"tritis. ,. Tr"at#"t o+ all s"&)al 'ota'ts it(i 2days To i+ats4 N"oatal !"+or" diagosis. 'o)'tivitis 7o$(t(al#ia 9. A!sti"'" +ro# s"&)al a'tivity +or days. "oator)#8. >. T"stig +or ot("r STIs. . 6o)s"llig r"gardig log:t"r# 'o#$li'atios4 6(roi' $"lvi' $ai/ t)!al i+"'tio/ s)!+"rtility.
DIAGNOSTI6 TESTS Gra# staiig4 Gra# 23 s"sitiv". 6)lt)r"4 T(ay"r:Marti or o Trasgro #"dia. S"sitiv" 5 s$"'i' !)t ta?"s ti#". o N)'l"i' a'id a#$li'atio t"sts 7NAATs84 P6R 5 6R. Mor" "&$"siv" !)t ra$id 5 (ig( s"sitivity 5 s$"'i'ity. N)'l"i' a'id (y!ridi*atio t"sts o TREATMENT Sigl" oral dos" o+ '"&i#"/ or o Sigl" IM dos" o+ '"+tria&o"/ or o Sigl" IM dos" o+ s$"'tio#y'i/ o or o Sigl" oral dos" o+ 'i$roCo&a'i/ or Sigl" dos" o+ oral 7A#$i'illi %g o or A#o&y'illi 1g8 = Pro!"i'id %g Pr"gatW P"i'illi 5 '"$(alos$ori ar" sa+"e o
o
o
o
INTRODU6TION Tr"$o"#a $allid)#/ #otil" aa"ro!i' s$iro'("t". 6a !" "radi'at"d/ y"t 'a r"i+"'t. S$r"ad4 STD or 6og"ital
o o
o
SYPHIIS DIAGNOSIS History ad $(ysi'al "&a#iatio a! iv"stigatios4 Blood t"sts No:s$"'i' < @DR/ ra$id $las#a r"agi t"st Tr"$o"#a:s$"'i' < TPHA/ FTA: A!s Dar?:"ld #i'ros'o$y
PRIMARY SYPHIIS o
o
o
1st stag" a+t"r i+&. A$$"ar %:,?s a+t"r 'ota't. c6(a'r" : Fir#/ $ail"ss/ o:it'(y )l'"rs it( roll"d "dg"s #ost 'o##oly o v)lva/ vagia or '"rvi&. S$ota"o)sly disa$$"ar.
SE6ONDARY SYPHIIS o o o
o
%:, #ot(s a+t"r 'ota't Syst"#i' s$(iro'("t"#ia. F"v"r/ #alais"/ g""ral ad"o$at(y/ #a')lo$a$)lar s?i ras( c#o"y s$ots. Broad "&o$(yti' "&'r"s'"'"s c'odylo#a lata o v)lva. S$ota"o)sly disa$$"ar.
TREATMENT Mod" o+ d"liv"ry4 @agial d"liv"ry 6:s"'tio oly +or o!st"tri' idi'atios. STD Pr"v"tio4 Avoid #)lti$l" s"&)al $art"rs/ o $ro#ot" )s" o+ !arri"r 'otra'"$tiv"s. Tr"at#"t4 B"*at(i" $"i'illi 7G8 i $r"ga'y o o All"rgyW F)ll $"i'illi dos" it( oral d"s"siti*atio r"gi#" )d"r 'otroll"d 'oditios. ATENT TERTIARY SYPHIIS SYPHIIS A!s"'" o+ s& N"'roti'/ )l'"rativ" od)l"s o or $(ysi'al cg)##a digs. o S& d"$"d"t o (i'( orga a"'t"d. 6@S4 Aortitis/ sa'')lar a")rys# 6NS4 M"igitis/ Ta!"s dorsalis/ D"#"tia/ Ata&ia MSS4 Ost"itis o
6ONGENITA SYPHIIS Tras#issio4 Tras$la'"tal $assag" +ro# #ot("r to +"t)s d)rig d"liv"ry. Or/ at !irt(. Birt( o)t'o#"s i 'og"ital sy$(ilis4 o !irt( "ig(t/ $r"#at)rity/ 'og"ital ao#aly/ #i s'arriag" or d"at( o+ !a!y. Early Mai+"statio 7% yrs8 at" Mai+"statio 70% yrs8 No:i##)" (ydro$s/ cH)t'(iso t""t( #a'"rat"d s?i/ a"#ia/ c#)l!"rry #olars t(ro#!o'yto$"ia/ csa!"r s(is ("$atos$l"o#"galy. csaddl" os" F"tal d"at( rat"s (ig( < Jt( "rv" d"a+"ss.
P"riatal #ortality rat" >23. Pla'"ta ty$i'ally larg" 5 "d"#ato)s.
@DR FTA:A!s Dar? "ld 6SF
Pri#ar y : = =
S"'oda ry = = =
at" T"rtiar t y = = = = = = = i+ 6NS ivolv" d
&A4I%A !I'CHA#4$ %/#1A &A4I%A !I'CHA#4$ •
Dis'(arg" is 'o##o to all o#" ad ("l$s vagias stay ("alt(y !y r"g)larly C)s(ig t("# o)t ad #aitaiig t("ir $H. • A or#al vagial dis'(arg" 'osists o+ a!o)t a t"as$oo 79 #illilit"rs8 a day t(at is (it" or tras$ar"t/ t(i'? to t(i/ ad odorl • T(is is +or#"d !y t(" or#al !a't"ria ad C)ids t(" vagial '"lls $)t o. T(" dis'(arg" 'a !" #or" oti'"a!l" at di"r"t ti#"s o+ t(" #ot( d"$"dig o ov)latio/ #"str)al Co/ s"&)al a'tivity ad !irt( 'otrol.
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It is ot )'o##o +or t(" or#al dis'(arg" to !" dar?/ !ro or dis'olor"d a day or to +olloig t(" #"str)al $"riod. • T(" +olloig sit)atios 'a i'r"as" t(" a#o)t o+ or#al vagial dis'(arg"4 1:E#otioal str"ss %:Ov)latio 7t(" $rod)'tio ad r"l"as" o+ a "gg +ro# yo)r ovary i t(" #iddl" o+ yo)r #"str)al 'y'l"8 ,:Pr"ga'y 9:S"&)al "&'it"#"t
A%/#1A &A4I%A !I'CHA#4$
Yo)r vagial dis'(arg" #ig(t !" a sig o+ a i+"'tio i+ it4
Here are some *ey ways to determine i+ your ,ainal dischare is normal or i+ you ha,e cause +or concern:
Nor#al 6olo)r
6l"ar or (itis( dis'(arg" 7#ay !" y"llois( (" dri"d8
Y"llo or gr""is( dis'(arg"/ or dis'(arg" t(at s)dd"ly '(ag"s 'olor
S'"t
Mild s'"t or o" at all
A strog/ +o)l/ so#"ti#"s s(y odor/ or a s)dd" '(ag" i odor
T"&t)r"
6a vary +ro# $ast" li?" ad so#"(at sti'?y to 'l"ar ad str"t'(y/ d"$"dig o ("r" yo)
6l)#$y or l)#$y dis'(arg"/ it( 'ottag" '(""s" li?"
1:6a)s"s it'(ig %:6a)s"s s"llig ,:Has a !ad odor 9:Is gr""/ y"llo/ or gray i 'olor >:oo?s +oa#y or li?" 'ottag" '(""s"
6a)s" +or 'o'"r
ar" i yo)r 'y'l" ad ("t("r yo) ar" aro)s"d @ol)#"
A%/#1A &A4I%A !I'CHA#4$
May !" d)" to4
t"&t)r"
6a vary +ro# v"ry littl" to ;)it" a S)dd" '(ag"s i vol)#"/ lot 7$arti')larly (" ov)latig or $arti')larly i+ ot("r sy#$to#s aro)s"d8 ar" $r"s"t
2. Atrophic ,ainitis 7s"" i
o#" (o (av" go" t(ro)g( #"o$a)s" ad (av" lo "strog" l"v"ls8 8. acterial ,ainosis (&) :: Ba't"ria t(at or#ally liv" i t(" vagia ov"rgro/ 'a)sig a gr"y dis'(arg" ad s(y odor t(at ors" a+t"r s"&)al it"r'o)rs". B@ is )s)ally ot s"&)ally tras#itt"d. . Cer,ical or ,ainal cancer
7rar"ly a 'a)s" o+ "&'"ss dis'(arg"8 E. Chlamydia . !es9uamati,e ,ainitis ad lichen planus . orotten tampon or +orein body G. 4onorrhea Q. Ot("r in+ections and se=ually transmitted diseases K. "richomoniasis 2J. &ainal yeast in+ection 22. Alleric reactions7Cer,ical polyp7Cer,icitis7 4enital
CA%!I!A &A4I%I"I'
'o##o vagial i+"'tio i
#is* +actors
Clinical Presentation
t(" Uit"d Stat"s. •
$tioloy • T(" "tiologi' ag"t is a
y"ast 7+)gi8 orgais#/ )s)ally 6adida al!i'as. • T(" orgais# is a 'o##o i(a!itat o+ t(" !o"l ad $"riaal r"gio • T(irty $"r'"t o+ o#" #ay (av" vagial 'oloi*atio ad (av" o sy#$to#s o+ i+"'tio.
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Contracepti,e practices 7".g./ !irt(
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Aot("r r"aso +or a r"+ra'tory #oilial i+"'tio #ay !"
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Pati"ts it( #oilial vagiitis '(ara't"risti'ally 'o#$lai o+ a thic*7
'otrol $ills ad vagial s$"r#i'id"s/ (i'( compromised immune white dischare and iC)"'" vagial $H8 status it( r"')rr"t e=treme ,ul,ar Us" o+ systemic pruritus. T(" v)lva #ay #oilial vagiitis/ a HI@ steroids/ (i'( iC)"'" t"st is idi'at"d/ alog !" r"d ad soll"/ t(" i##)" syst"# it( a +astig s"r)# ss)r"s #ay o'')r Us" o+ antibiotics/ (i'( gl)'os" l"v"l. • Sy#$to#s #ay r"')r ad alt"rs t(" #i'ro!iology o+ • T("r" (as !"" a r"'"t !" #ost $ro#i"t )st t(" vagia %>3 to 23 i'r"as" i t(" )#!"r o+ !"+or" #"s"s or i o+ o#" r"$ort y"ast i+"'tios 'a)s"d !y o: asso'iatio it( i+"'tios a+t"r ati!ioti' al!i'as s$"'i"s. U$ to it"r'o)rs" )s". Ay ati!ioti'/ %23 o+ i+"'tios #ay!" • Y"ast i+"'tios #ay $arti')larly a !road: 'a)s"d !y orgais#s o'')r #or" +r";)"tly s$"'tr)# ag"t/ #ay $lay s)'( as 6adida tro$i'alis d)rig $r"ga'y a 'a)sativ" rol". ad Tor)lo$sis gla!rata. • Pati"ts it( i+"'tios "iht clothin7 panty T("s" orgais#s #ay !" 'a)s"d !y 6. tro$i'alis hose7 and bathin r"sistat to stadard ad T gla!rata #ay (av" suits 7y"ast t(riv"s i a tr"at#"t r"gi#"s a aty$i'al $r"s"tatio. dar?/ ar#/ #oist Irritatio #ay !" "viro#"t8 $ara#o)t/ it( littl" Undianosed or dis'(arg" or $r)rit)s. uncontrolled diabetes mellitus
!ianosis •
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Diagosis is #ad" !y (istory/ $(ysi'al "&a#iatio/ ad #i'ros'o$i' "&a#iatio o+ t(" vagial dis'(arg" i sali" ad 123 OH. O "&a#iatio/ "&'oriatios o+ t(" v)lva #ay !" oti'"a!l" t(" v)lva
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I+"'tio it( 6. tro$i'alis ad T gla!rata #ay ot !" asso'iat"d it( t(" 'lassi' dis'(arg" dis'(arg" #ay !" (it":gray ad t(i. • k@agial $H #ay !" or#al or slig(tly #or" !asi' t(a
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"t #o)t #i'ros'o$i' "&a#iatio r"v"als (y$(a" or $s")do(y$(a" it( !)ddig y"ast i >23 to 23 o+ o#" it( y"ast i+"'tios. 6)lt)r"s ar" ot "'"ssary to #a?" t(" diagosis "&'"$t i so#" 'as"s o+ r"')rr"t i+"'tios.
ad vagia #ay !" "ryt("#ato)s/ it( $at'("s o+ ad("r"t 'ottag" '(""s":li?" dis'(arg". 6adidal i+"'tios o+ t(" v)lva ar" '(ara't"ri*"d !y 'lassi' sat"llit" l"sios.
or#al 79.2 to 9.8.
CA%!I!A &A4I%I"I' "reatment •
May ag"ts ar" availa!l" +or t(" tr"at#"t o+ v)lvovagial 'adidiasis. T("s" i'l)d" to$i'al ag"ts/ (i'( #ay !" availa!l" ov"r t(" 'o)t"r 7OT68 or !y $r"s'ri$tio/ ad oral ag"ts/ (i'( ar" availa!l" !y $r"s'ri$tio oly.
1. Anti+unal intra,ainal aents ar" ad#iist"r"d as s)$$ositori"s or 'r"a#s. T("s" dr)gs ar" availa!l" i t(r"" r"gi#"s4 a sigl" dos"/ ,:day 'o)rs"/ or :day 'o)rs". Ag"ts i'l)d" !)to'oa*ol"/ 'lotri#a*ol"/ #i'oa*ol"/ tio'oa*ol"/ ad t"r'oa*ol". OT6 r"gi#"s s(o)ld !" )s"d oly !y o#" (o (av" !"" diagos"d it( a y"ast i+"'tio i t(" $ast ad ar" "&$"ri"'ig id"ti'al sy#$to#s.
Chronic yeast in+ection 8. /ral Aents: ;etoconaole7 luconaole
Fl)'oa*ol" is availa!l" as a sigl":dos" 71>2 #g8 tr"at#"t +or )'o#$li'at"d vagial 'adidiasis. :"to'oa*ol" is )s"d ""'tiv"ly +or t(" tr"at#"t o+ '(roi' ad r"')rr"t 'adidiasis a >3 i'id"'" o+ ("$atoto&i'ity li#its #or" id"s$r"ad )s". T(" dosig s'("d)l" is %22 #g ti'" a day +or > days/ t(" 122 to %22 #g daily +or #ot(s ,. oric acid capsules itravagially/ 22 #g +or 19 days/ #ay !" ""'tiv".
7>3 o+ o#"8. I #ost 'as"s/ o "&a'"r!atig +a'tor 'a !" +o)d (o"v"r/ t(" +olloig $ossi!iliti"s s(o)ld !" 'osid"r"d 1:ailure to complete a +ull course o+ therapy. %:HI& in+ection. R"'al'itrat 'adidiasis #ay !" a $r"s"tig sy#$to# i o#" it( HI@ i+"'tio. HI@ t"stig s(o)ld !" 'osid"r"d ad o"r"d to t(" $ati"t. ,:Chronic antibiotic therapy . 9:In+ection with a resistant oranism s)'( as 6. tro$i'alis or T gla!rata. >:'e=ual transmission +rom the male partner.
-Alleric reaction to partnerVs semen or a
,ainal spermicide.
:!iabetes. Pati"ts s(o)ld (av" a +astig s"r)# gl)'os" l"v"l i+ t("y (av" r"')rr"t i+"'tios.
"#ICH/1/%A' &A4I%AI'
Tri'(o#oas vagialis vagiitis 7tri'(o#oiasis8 is t(" t(ird #ost 'o##o vagiitis/ a''o)tig +or %>3 o+ 'as"s. $tioloy •
tri'(o#oad 'a !" r"'ov"r"d +ro# 23 to J23 o+ t(" #al" $art"rs o+ t(" i+"'t"d $ati"t t("r"+or"/ Tri'(o#oas vagiitis is a STD. • kT(is i+"'tio is t(" #ost $r"val"t oviral STD i t(" Uit"d Stat"s 7@a d"r Pol/ %22>/ %228. Uli?" ot("r STDs/ its i'id"'" a$$"ars to i'r"as" it( ag" i so#" st)di"s. Tri'(o#oiasis is #or" 'o##oly diagos"d i o#" !"'a)s" #ost #" ar" asy#$to#ati'. Ho"v"r/ )$ to 2 $"r'"t o+ #al" $art"rs o+ o#" it( vagial tri'(o#oiasis ill (av" tri'(o#oads i t("ir )riary tra't.
• T(is $arasit" is )s)ally a #ar?"r o+ (ig(:ris? s"&)al
!"(avior/ ad 'o:i+"'tio it( ot("r s"&)ally tras#itt"d $at(og"s is 'o##o/ "s$"'ially N"iss"ria goorr(o"a". Tri'(o#oas vagialis (as $r"dil"'tio +or s;)a#o)s "$it("li)#/ ad l"sios #ay i'r"as" a''"ssi!ility to ot("r s"&)ally tras#itt"d s$"'i"s. @"rti'al tras#issio d)rig !irt( is $ossi!l" ad #ay $"rsist +or a y"ar.
"#ICH/1/%A' &A4I%AI' Clinical presentation
!ianosis
• Tri'(o#oas vagiitis is a #)lti+o'al i+"'tio ivolvig
•
t(" vagial "$it("li)#/ S?"" glads/ Bart(oli glads/ ad )r"t(ra. No sy#$to#s #ay !" ot"d i )$ to o":(al+ o+ o#" it( tri'(o#oiasis. Ho"v"r/ i t(os" it( 'o#$laits/ vagial dis'(arg" is ty$i'ally d"s'ri!"d as +o)l/ t(i/ ad y"llo or gr"". Additioally/ dys)ria/ dys$ar")ia/ v)lvar $r)rit)s/ ad $ai #ay !" ot"d. At ti#"s/ sy#$to#atology ad $(ysi'al digs ar" id"ti'al to t(os" o+ a')t" $"lvi' iCa##atory dis"as".
•
•
aboratory tests
1:T(" vagial $H is )s)ally !"t"" >.2 ad .2.
•
%:Sali" "t #o)t o+ t(" vagial dis'(arg" r"v"als )#"ro)s l")?o'yt"s ad t(" (ig(ly #otil"/ Cag"llat"d tri'(o#oads 7as #ay as >3 o+ 'as"s8. ,:6)lt)r"s ar" ot )s)ally "'"ssary to #a?" t(" diagosis. T("y s(o)ld !" o!tai"d (" t(" diagosis is s)s$"'t"d !)t 'aot !" 'or#"d !y "t #o)t "&a#iatio.
•
9:Pa$ s#"ars #ay !" $ositiv" i as #ay as >3 o+ 'as"s. Positiv" Pa$ s#"ars s(o)ld !" 'or#"d !y "t #o)t "&a#iatio !"'a)s" o+ t(" (ig( +al s":$ositiv" rat".
•
I')!atio it( T vaginalis r";)ir"s , days to 9 ""?s/ ad t(" vagia/ )r"t(ra/ "do'"rvi&/ ad !ladd"r 'a !" i+"'t"d/ s)'( 'oloi*atio #ay $"rsist +or #ot(s or y"ars i so#" o#". it( tri'(o#oiasis/ t(" v)lva #ay !" "ryt("#ato)s/ "d"#ato)s/ ad "&'oriat"d. T(" vagia 'otais t(" a!ov":d"s'ri!"d dis'(arg"/ ad s)!"$it("lial ("#orr(ag"s or stra!"rry s$ots #ay !" s"" o t(" vagia ad '"rvi&. Tri'(o#oiasis is ty$i'ally diagos"d !y #i'ros'o$i' id"ti'atio o+ $arasit"s i a sali" $r"$aratio o+ t(" dis'(arg". Tri'(o#oads ar" at"riorly Cag"llat"d/ ad t("r"+or" #o!il"/ aa"ro!i' $roto*oa. T("y ar" oval ad slig(tly larg"r t(a a (it" !lood '"ll 7B68. Tri'(o#oads !"'o#" l"ss #otil" it( 'oolig/ ad slid"s s(o)ld !" r"ad it(i %2 #i)t"s. Is$"'tio o+ a sali" $r"$aratio is (ig(ly s$"'i'/ y"t s"sitivity is ot as (ig( as (o$"d 72 to 2 $"r'"t8. I additio to #i'ros'o$y/ vagial $H is o+t" "l"vat"d T(" #ost s"sitiv" diagosti' t"'(i;)" is ')lt)r"/ (i'( is i#$ra'ti'al !"'a)s" s$"'ial #"dia 7Dia#od #"dia8 is r";)ir"d ad +" la!oratori"s ar" ";)i$$"d. Mor"ov"r/ )'l"i' a'id a#$li'atio t"sts 7NAAT8 +or tri'(o#oal DNA ar" s"sitiv" ad s$"'i'/ !)t ot id"ly availa!l". Alt"rativ"ly/ t(" OSOM Tri'(o#oas Ra$id T"st 7G"*y#"/ 6a#!ridg"/ MA8 is a i##)o'(ro#atogra$(i' assay/ (i'( (as JJ $"r'"t s"sitivity ad $"r'"t s$"'i'ity. It is availa!l" +or oL'" )s"/ ad r"s)lts ar" availa!l" i 12 #i)t"s 7H)$$"rt/ %22>8. Tri'(o#oads #ay also !" ot"d o Pa$ s#"ar s'r""ig ad s"sitivity a$$ro&i#at"s 2 $"r'"t. o#" it( tri'(o#oal i+"'tio s(o)ld !" t"st"d +or ot("r s"&)ally tras#itt"d i+"'tios. Additioally/ s"&)al 'ota't7s8 s(o)ld !" "val)at"d or r"+"rr"d +or "val)atio
"#ICH/1/%A' &A4I%AI' "reatment •
B"'a)s" Tri'(o#oas is s"&)ally tras#itt"d/ both partners reuire therapy %>3 o+ o#" ill !" r"i+"'t"d i+ t("ir $art"r do"s ot r"'"iv" tr"at#"t. A:@agial t("ra$y alo" is i""'tiv" !"'a)s" o+ t(" #)lti$l" sit"s o+ i+"'tio/ ad systemic agents are necessary . B:I+ !ot( $art"rs ar" tr"at"d si#)lta"o)sly/ ')r" rat"s o+ 23 ar" a'(i"v"d it( tr"at#"t it( metronidaFole. Pati"ts s(o)ld !" ar"d t(at a dis)lra#:li?" r"a'tio #ay o'')r ad t(at t("y s(o)ld a!stai +ro# al'o(ol )s" d)rig tr"at#"t. 1:T(" preferred regimen is %g i o" dos" !"'a)s" o+ "as" o+ 'o#$lia'". As #ay as 123 o+ $ati"ts #ay "&$"ri"'" vo#itig. %:A alt"rativ" r"gi#" is >22 #g ti'" daily +or days. 6:esistant cases #ay r";)ir" tr"at#"t it( itrav"o)s #"troida*ol". B"'a)s" r"sista'" is rar"/ ot("r 'a)s"s/ s)'( as o'o#$lia'" o+ t(" $ati"t or $art"r/ s(o)ld !" 'osid"r"d. D:M"troida*ol" is contraindicated for use during the rst trimester of pregnancy . A+t"r t(is ti#"/ it 'a !" )s"d to tr"at Tri'(o#oas i+"'tios. E:I+"'t"d $ati"ts s(o)ld !" s'r"""d +or ot("r STDs. AC"$#IA &A4I%/'I' &acterial vaginosis is t("
$tioloy
#is* +actors
#ost 'o##o vagial i+"'tio i t(" Uit"d Stat"s today. I t(" $ast/ !a't"rial vagiitis as ?o as os$"'i' vagiitis ad Gard"r"lla vagiitis.
•
Ba't"rial vagiosis is a $oly#i'ro!ial 'lii'al sydro#" 'a)s"d !y a ov"rgrot( o+ a vari"ty o+ !a't"rial s$"'i"s/ $arti')larly aa"ro!"s/ o+t" +o)d or#ally i t(" vagia. Orgais#s #ost o+t" ivolv"d i'l)d" Ba't"roid"s/ P"$tostr"$to'o'')s/ Gard"r"lla vagialis/ ad My'o$las#a (o#iis. • T(" aa"ro!i' !a't"ria $rod)'" "*y#"s t(at !r"a? do $"$tid"s to a#io a'ids ad a#i"s/ r"s)ltig i 'o#$o)ds asso'iat"d it( t(" dis'(arg" ad odor '(ara't"risti' o+ t(is i+"'tio.
• T(is 'oditio is ot 'osid"r"d !y t(" 6"t"rs
+or Dis"as" 6otrol ad Pr"v"tio 76D68 'os"s)s gro)$ to !" a s"&)ally tras#itt"d dis"as" 7STD8/ ad it is s"" i o#" it(o)t $r"vio)s s"&)al "&$"ri"'". May ris? +a'tors/ (o"v"r/ ar" asso'iat"d it( s"&)al a'tivity/ ad a i'r"as"d ris? o+ a';)irig STDs (as !"" r"$ort"d i a"'t"d o#" 1:Oral s"& %:Do)'(ig ,:Bla'? ra'" 9:6igar"tt" s#o?ig >:S"& d)rig #"s"s :Itra)t"ri" d"vi'" :Early ag" o+ s"&)al it"r'o)rs" J:N" or #)lti$l" s"&)al $art"rs :S"&)al a'tivity it( ot("r o#"
AC"$#IA &A4I%/'I' Clinical presentation
!ianosis
•
•
Fi+ty $"r'"t o+ o#" it( !a't"rial vagiosis ar" asy#$to#ati'. I sy#$to#ati' $ati"ts/ t(" #ost 'o##o $r"s"tatio is a #alodoro)s/ gray dis'(arg".
• T(r"" o+ t(" +olloig +o)r 'rit"ria #)st !" $r"s"t4
A:T(" vagial $H is g""rally !"t"" >.2 ad >.>. B:"t #o)t $r"$aratios it( sali" r"v"al a 6UE 6E !a'?gro)d it( #ii#al or o l")?o'yt"s/ a a!)da'" o+ !a't"ria/ ad t(" '(ara't"risti' 'l)" '"lls. T(" 'l)" '"lls ar" s;)a#o)s '"lls i (i'( 'o''o!a'illary !a't"ria (av" o!s')r"d t(" s(ar$ !ord"rs ad 'yto$las#. 6:A$$li'atio o+ 123 OH to t(" "t #o)t s$"'i#" $rod)'"s a s(y odor/ idi'atig a $ositiv" HIFF t"st. D:A gray/ (o#og"o)s/ #alodoro)s dis'(arg" is $r"s"t
"reatment
T("ra$y is !as"d o t(" )s" o+ ag"ts it( aa"ro!i' a'tivity ad ivolv"s !ot( to$i'al ad syst"#i' ag"ts. T(" 'o#!iatio a$$"ars to !" 23 ""'tiv" A-&ainal preparations:
1:Itravagial %3 'lida#y'i 'r"a# is )s"d at !"dti#" +or days. %:Itravagial #"troida*ol" is a$$li"d o'" a day +or > days. -/ral reimens:
1:M"troida*ol" #ay !" ad#iist"r"d to ays4 >22 #g ti'" daily +or days or a sigl"/ %:g dos". %:6lida#y'i/ ,22 #g ti'" daily +or days 7#ay !" asso'iat"d it( diarr("a/ "s$"'ially 6lostridi)# diL'il"8 C-'e=ual partners should be treated in cases o+ repeated episodes o+ bacterial ,ainosis. #outine treatment o+ partners has not been shown to impro,e cure rates or lower rein+ection rates. !-"reatment durin prenancy is criticalW data suest an associa tion o+ ad,erse maternal and +etal outcomes with bacterial ,ainosis.
1:6lida#y'i #ay !" )s"d t(ro)g(o)t $r"ga'y. %:M"troida*ol" #ay !" )s"d a+t"r t(" rst tri#"st"r. $-Patients with recurrences should be screened +or '"!s
P#$&$%"I/%
To ("l$ $r"v"t ad tr"at vagial dis'(arg"4 1:;eep your enital area clean and dry.
%:!o not douche . (il" #ay o#" +""l 'l"a"r i+ t("y do)'(" a+t"r #"str)atio or it"r'o)rs"/ it #ay a't)ally ors" vagial dis'(arg" !"'a)s" it r"#ov"s ("alt(y !a't"ria liig t(" vagia t(at ar" t("r" to $rot"'t yo) +ro# i+"'tio. It 'a also l"ad to i+"'tio i t(" )t"r)s ad +allo$ia t)!"s/ ad is "v"r r"'o##"d"d. ,:Use an o,er-the-counter yeast in+ection treatment cream or ,ainal suppository7 i+ you *now that you ha,e a yeast in+ection.
9:$at yourt with li,e cultures or ta*e actobacillus acidophilus tablets when you are on antibiotics to avoid a y"ast
i+"'tio.
>:Use condoms to avoid 'at'(ig or s$r"adig s"&)ally tras#itt"d dis"as"s.
I+ t(" dis'(arg" is 'a)s"d !y a s"&)ally tras#itt"d dis"as"/ yo)r se=ual
:A,oid usin +eminine hyiene s$rays/ +ragra'"s/ or $od"rs i t(" g"ital ar"a.
"v" i+ t("y (av" o sy#$to#s. Fail)r" o+ $art"rs to a''"$t tr"at#"t 'a 'a)s" t(" i+"'tio to ?""$ 'o#ig !a'? ad #ay l"ad to $"lvi' iCa##atory dis"as" or i+"rtility.
kYo) t(i? t(at yo)r dis'(arg" #ay !" r"lat"d to a #"di'atio.
6all yo)r do'tor rig(taay i+4
kYo)r sy#$to#s ors" or last log"r t(a 1 ""? d"s$it" (o#" 'ar" #"as)r"s.
:A,oid wearin e=tremely tiht-0ttin pants or shorts / (i'( #ay
partner (or partners) must be treated as well7
'a)s" irritatio. J:
)d"r"ar #ad" o+ sil? or ylo/ !"'a)s" t("s" #at"rials ar" ot v"ry a!sor!"t ad r"stri't air Co. T(is 'a i'r"as" s"atig i t(" g"ital ar"a/ (i'( 'a 'a)s" irritatio. :Use pads ad ot ta#$os. 12:;eep your blood suar le,els under ood control
i+ yo) (av" dia!"t"s
kYo)r dis'(arg" is asso'iat"d it( +"v"r or $ai i yo)r $"lvis or a!do#". kYo) (av" !"" "&$os"d to a s"&)al $art"r it( goorr("a/ '(la#ydia/ or ot("r s"&)ally tras#itt"d dis"as".
Also 'all i+4 kA '(ild (o (as ot r"a'("d $)!"rty (as vagial dis'(arg".
kYo) ar" 'o'"r"d t(at yo) #ay (av" a s"&)ally tras#itt"d dis"as" or yo) ar" )s)r" o+ $ossi!l" "&$os)r".
kYo) (av" !list"rs or ot("r l"sios o yo)r vagia or v)lva 7"&t"rior g"italia8.
kYo) (av" !)rig it( )riatio or ot("r )riary kYo) (av" i'r"as"d t(irst or sy#$to#s :: yo) #ay (av" a a$$"tit"/ )"&$lai"d "ig(t )riary tra't i+"'tio. loss/ i'r"as"d )riary +r";)"'y/ or +atig)" <: t("s" #ay !" sigs o+ dia!"t"s