Infertility
Definition: failure to conceive after one year of regular, unprotected intercourse. |
Etiology: males 40% - abnormal spermatogenesis. Females - anovulatory cycles or ovarian dysfunction = 30%, congenital or acquired disorders. |
DX: hysterosalpingography to evaluate tubal patency or abnormalities. |
Management: 1. Clomiphene — induces ovulation. 2. If amenorrhea or oligomenorrhea, correct endocrine problems. 3. In vitro fertilization |
Uncomplicated Pregnancy Physical Exam
Ladin’s sign |
Uterus softening after 6 weeks |
Hegar’s sign |
Uterine isthmus softening after 6-8 weeks |
Piskacek’s sign |
Palpable lateral bulge or softening of uterine Cronus 7-8 weeks |
Goodell’s sign |
Cervical softening due to increased vascularization, 4-5 weeks |
Chadwick’s sign |
Bluish coloration of cervix and vulva, 8-12 weeks |
Fetal Heart tones |
10-12 weeks, normal = 120-160 bpm |
Pelvic Ultrasound |
Fetus detected 5-6 weeks |
Fetal Movement |
16-20 weeks |
Fundal Height Measurement
12 weeks |
Above pubic symphysis |
16 weeks |
Midway between pubis and umbilicus |
20 weeks |
At umbilicus |
38 weeks |
2-3 cm below diploid process |
Prenatal Care
Estimated Date of Delivery (Naegle’s Rule) : 1st day of LMP + 7 days - 3 months |
Blood pressure |
Blood type & Rh |
CBC |
UA (glucose & protein) |
Random glucose |
HBsAg — hepatitis surfaced antigen, measures acute or chronic |
HIV |
Syphilis |
Rubella Titer |
Sickle cell and cystic fibrosis screen |
PAP smear |
Rh Alloimmunization
Rh(D) negative women carry Rh(D) positive fetus —> exposure to fetal blood mixing D-positive RBCs |
Causes maternal alloimmunization and maternal anti-Rh(D) IgG antibodies |
Subsequent pregnancies —> antibodies may cross placental and attack fetal RBCs = hemolysis of fetal RBCs |
If mother is Rh(D) negative and father is Rh(D) positive, 50% chance |
Anti-D Rh immunoglobulin (RhoGAM) 300 micrograms given @ 28 weeks, within 72 hours of delivery of Rh(D) positive baby, AND after any potential mixing of blood (spontaneous abortion, ectopic pregnancy, amniocentesis, etc.) |
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First Trimester Screening: Weeks 1-12
Free beta-hCG |
Abnormally high or low may indicate chromosomal abnormalities |
PAPP-A |
Serum pregnancy-associated plasma protein-A — Low with fetal Down syndrome |
Nuchal translucency US |
10-12 weeks — trisomies 13, 18, and 21. Increased thickness = abnormal, offer chorionic billows sampling or amniocentesis. |
Fetal US |
10-12 weeks , transvaginal can detect at 5-6 weeks after LMP |
Uterine size and gestation |
If abnormal, offer CVS or amniocentesis |
CVS |
10-13 weeks if abnormalities or if at increased risk of abnormalities (>35 yo) |
Second trimester screening: Weeks 13-27
Triple screening @ 15-20 weeks |
Alpha-feta protein: if high, indicates open neural tube defects / spina bifida. Beta-hCG: high = Down syndrome/ trisomy 21, low = trisomy 18. Unconjugated Estriol: often low in trisomy 21 and 18. |
Gestational Diabetes @ 24-28 weeks |
1 hour & 3 hours abnormal = >140 |
Third Trimester Screening: Weeks 27-birth
Repeat antibody titers |
In RH(D) negative, antibody negative —> give RhoGAM 300 micrograms @ 28 weeks |
Hemoglobin & Hematocrit |
35 weeks |
Group B Streptococcus |
36 0/7 to 37 6/7 weeks, if positive —> prophylactic abx during labor w/in 4 hours of delivery with IV PCN G 5 million units, then 2.5 million units every 4 hours. Second line = Ampicillin, Cefazolin, Clindamycin, Vancomycin |
Biophysical Profile |
Fetal breathing, fetal tones, amniotic fluid levels, NST, and gross fetal movements (2 points each) |
Non-stress testing |
Reactive Test: >/= 2 accelerations of fetal HR >/= 15 bpm from baseline lasting 15 seconds over 20 minutes — fetal well being, repeat weekly-biweekly. Nonreactive test: No fetal HR accelerations or </= 15 bpm lasting < 15 s— indicates sleeping, immature, or compromised fetus —> vibratory stimulus to wake or contraction stress test. |
Contraction Stress Testing |
Negative test: No late decelerations in presence of 3 contractions in 10 minutes = fetal well being. Positive CST: repetitive late deceleration following >/= 50% of contraction = worrisome, hospitalize for fetal monitoring or delivery. |
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Intra Partum (onset of labor-delivery of placenta)
Braxton Hicks |
Spontaneous uterine contractions late in pregnancy not associated with cervical dilation |
Lightening |
Fetal head descending into the pelvis causing a change in abdomen’s shape and sensation |
Ruptured Membranes |
Sudden gush of liquid or constant leakage of fluid |
Bloody Show |
Passage of blood-tinged cervical mucus late in pregnancy, occurs with cervix is thinning (effacement) |
True Labor |
Contractions of uterine fundus with radiation to lower back & abdomen. Regular + painful contraction of uterus causes cervical dilation and fetus expulsion |
Cardinal Movements of labor
Engagement |
When the fetal presenting part enters the pelvic inlet |
Descent |
Passage of the head into pelvis (lightening) |
Flexion |
Flexion of head to allow smallest diameter to present to pelvis |
Internal Rotation |
Fetal vertex moves from occiput transverse position to position where the Sagittarius suture is parallel to the anteroposterior diameter of pelvis |
Extension |
Vertex extends as it passes beneath the pubic symphysis |
External Rotation |
Fetus externally rotates after the head is delivered so that the shoulder can be delivered |
Expulsion |
Of fetus and placenta |
Stages of Labor
Stage 1: Onset of labor (true contractions-cervical dilation @ 10 cm |
Latent phase: cervix effacement with gradual cervical dilation. Active Phase: rapid cervical dilation (begins @ 3-4 cm) |
Stage 2: full dilation-delivery of fetus |
Passive Phase: complete cervical dilation to active maternal expulsive efforts. Active phase: from active maternal expulsive efforts-delivery of fetus. |
Stage 3: postpartum until delivery of placenta (0-30 mins) |
Signs of placental separation: 1. Gush of blood. 2. Lengthening of umbilical cord. 3. Anterior-caphalad movement of uterine fundus (becomes globular and firm) after placenta detaches. |
Stage 4: after delivery |
Mother is assessed for complications, 1-2 hours after |
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