O.
G 01 OBSTETRICS
❖ Elderly primigravida >35 years is high risk of:
- Abortion
- Hyperemesis gravidarum
- Preterm labor
- Preeclampsia
- Placenta abruption
- Congenital malformation
- Breast cancer
- Worsening of HTN, DM, CHF
❖ Grand multiparty ≥5
- Abortion
- Preterm labor
- Anemia
- Pendulous abdomen
- Malpresentation
- Non engagement
- Preeclampsia
- Abruption placenta
- Placenta praevia
- DM
❖ Cause of high MSAFP:
- Dating error
- Open neural tube defect
- Ventral wall defect
- Twin pregnancy
- Placenta bleeding
- Renal disease
- Sacrococcygeal Teratoma
❖ Ectopic pregnancy
- Previous ectopic pregnancy (the strongest RF)
- Adhesions of the fallopian tube: PID, previous pelvic surgery
- IUD, progesterone only pills
- smoking
- Old age
- Black race
- IVF or Clomiphene citrate use
- Structural problem: T shaped uterus, Fibroid, Tumor
O.G 01 OBSTETRICS
❖ Recurrent Abortion (3 or more successive abortion)
- Chromosomal abnormalities (the mc cause in 1st trimester)
- Cervical incompetence (the mc cause in 2nd trimester)
- Immunological (APAS, SLE, anti-sperm antibody …)
- Anomalies of uterus, asherman’s syndrome, endometriosis, pelvic tumors
- Inherited thrombophilia (Factor V leiden, protein S or C deficiency … )
- low progesterone, hypo-hyperthyroidism, hyperprolactinemia, PCOS
- Drugs (quinine)
- Uncontrolled HTN or DM
- Increased maternal age
- Rh isoimmunisation
- Maternal hypoxia, smoking, alcohol
- Trauma, infection, malnutrition
❖ Molar pregnancy
- Previous molar pregnancy
- Race (Asian and Indian)
- Nulliparity
- Smoking
- extreme age <20 or >35
- OCP
❖ Multiple pregnancy
- Personal or familial history
- Race Black > white
- Increased maternal age
- Increased parity
- Increased Height and weight
- Drugs (clomiphene citrate, Gonadotrophins)
- Sudden stop of OCP
Complication
- Hyperemesis gravidarum
- Preterm labor, PROM
- Placenta praevia, placenta abruption
- Pyelonephritis
- Polyhydramnios, uterine atony
- DIC
- Arm or cord prolapse, obstructed labor
O.G 01 OBSTETRICS
❖ Bacteriuria complication
- UTI, pyelonephritis
- Anemia
- HTN
- sepsis
- Preterm labor, IUGR, low birth weight
❖ Gestational DM
- History of impaired GTT, P/F History of gestational DM
- Age >35
- Obesity
- Delivery of babies ≥ 4kg
- Previous malformed babies/ unexplained prenatal death
Complications
- Intrauterine death, neonatal death, abortion, preterm labor
- Congenital malformation (heart anomalies, sacral agenesis)
- IUGR, Macrosomia (50%)
- Risk of developing obesity and T2DM later in infant
- Preeclampsia
- Polyhydramnios
- UTI
- C/S, PPH
- Defective lactation
- Maternal T2DM
❖ Preeclampsia
- Age <20 or >35
- Primigravida
• Smoking reduce the risk
- Family history
of PET by 50%
- Maternal (HTN, DM, CKD, SLE, APAS)
• Obesity and multiparty
- Baby of new partner
are not a RF
- African female
❖ Early preeclampsia before 20 weeks
- Molar pregnancy, Multiple pregnancy
- Polyhydramnios
- Hydrops fetalis
- APAS
O.G 01 OBSTETRICS
❖ Preeclampsia Complications
- Preterm labor
- Abruption placenta
- DIC and thrombophilia
- IUGR
- Liver, renal, lung, heart failure
- Intracranial hemorrhage
- Chronic HTN later
❖ Macrosomia
- Male sex
- Obese mother
- Multiparty
- Maternal DM
- Post-term
- History of macrosomia
❖ IUGR
- Multiple gestation
- Congenital and chromosomal abnormalities
- Maternal DM
- Smoking, alcoholism, cocaine
❖ DIC
- Abruption placenta
- Acute fatty liver of pregnancy
- Amniotic fluids embolism
- IUFD <20w
- Missed abortion >20w
- Severe preeclampsia
- Shock
❖ Placenta praevia
- Multigravida > primigravida
- Age >35 • DM and HTN are not RF
- Multiple pregnancy • PP associated with:
- Previous (C/S, D&C, placenta praevia) - placenta accreta, increta...
- Smoking, cocaine - transvers lie
- congenital anomalies
O.G 01 OBSTETRICS
❖ Placenta abruption
- Eclampsia, Preeclampsia, HTN (MC cause)
- Multiparty
- Multiple gestation
- Polyhydramnios
- Increased maternal age
- Maternal disease (DM, SLE, APAS)
- Smoking, alcohol, cocaine
❖ Placenta Accreta
- Previous uterine surgery
- Placenta praevia
- Age >35
- Multiparty
❖ Indications of Induction of labor
- APH at term
- IUFD, IUGR
- Maternal DM at 39, mild preeclampsia at 37, sever preeclampsia at 32
- Pregnancy reach 42
- Ruptured membrane >34
❖ Preterm labor
- Previous preterm birth
- Preeclampsia
- Maternal heart, Kidney, liver disease
- Infection (UTI, Bacteriuria, Chorioamnionitis, bacterial vaginosis)
- Uterine anatomical anomalies
- Cervical incompetence
- Low maternal BMI
- Increased maternal age
- Black race
- DES exposure
- Polyhydramnios
- Placenta praevia, abruption, insufficiency
- PROM
O.G 01 OBSTETRICS
❖ PROM
- Infection (MC)
- APH
- Cervical incompetence
- Low social class
- Polyhydramnios
- Smoking
❖ Post term
- Dating error (MC)
- Nulliparous or Nulligravida
- High maternal BMI
- Fetal anomalies (hypopituitarism, anencephaly, adrenal hypoplasia)
❖ Malpresentation
- Multiparty
- Multiple gestation
- Poly-oligohydramnios
- Placenta praevia
- Uterine anomalies
- Prematurity
- Hydrocephalus
❖ Instrumental vaginal delivery
indications Contraindications
nd
- Prolonged 2 stage of labor - Before full dilatation to 10 cm
- Fetal distress - Before ROM
- Maternal cardiac, pulmonary, - Before engagement of head
neurological disease - Before uterine contractions
- Deliver the head in breech - Before 34 week (risk ICH)
presentation - Unknown fetal position
- Deliver the head in C/S - Non vertex presentation is CI for
- Rotate the fetus Vacuum
O.G 01 OBSTETRICS
❖ Uterine atony
- Idiopathic
- Anemia, APH, Multiparty, Prolonged labor, excessive sedation, use of
anesthesia, infection
- Polyhydramnios, multiple gestation
- Retained placenta
- Full bladder or rectum
❖ Amniotic fluid embolism
- Multipara
- Male fetus
- Oxytocin use
- Amniotomy
- Short labor
❖ Hydrops fetalis
- Rh isoimmunisation
- Idiopathic
- TORCH (Parvovirus B19 is mc)
- Cardiac disease
- Chromosomal (Turner and down)
- Maternal DM, HTN, severe anemia
❖ Cesarean Section
- Previous C/S (mc cause)
- Cephalopelvic disproportion (mc cause in primigravida)
- Non-vertex presentation in multiple pregnancy
- Maternal HIV without HAART therapy
- Malpresentation (cord prolapse, brow/ shoulder presentation)
- Birth canal HSV
- Placenta accreta, placenta praevia
- Macrosomia
- Birth canal obstruction
- Conjoined twins
- Maternal death
- Uterine rupture
- Fetal distress
O.G 01 OBSTETRICS
❖ Puerperal sepsis
- Retained placenta
- Maternal disease (anemia, DM, malnutrition, APH, PPH)
- Prolonged labor
- PROM
- Vaginal laceration
❖ Premature ovarian failure
- Idiopathic
- Turner (the MC cause of primary ovarian failure)
- Trisomies 18, 13
- Metabolic (17 a hydroxylase deficiency)
- Immunological (DiGeorge, Addison)
- Infection (Mumps)
- Chemo-Radiotherapy
- Smoking
❖ Hormone replacement therapy complications
- DVT/PE
- Endometrial hyperplasia/cancer (but not combined type)
- CAD
❖ Hirsutism
- Familial, After menopause, pregnancy
- High androgen production
- Pituitary cause (Cushing, Acromegaly, Prolactinoma)
- Hypothyroidism
- Adrenal gland (CAH, Cushing)
- Ovarian (PCOS, Virilizing tumor, hyperplasia, Theca lutein cyst)
- Liver disease
- Obesity
- Steroids, Danazol, phenytoin, Cyclosporine
❖ Candida vaginitis (estrogen dependent)
- Pregnancy
- DM, steroid therapy, Broad-spectrum antibiotic use OCP and low
- High dose estrogen estrogen are
- High vaginal acidity not a RF
- Hot weather and tight clothing
O.G 01 OBSTETRICS
❖ Bacterial vaginosis
- Start sex at early age or multiple partners (decrease vaginal acidity)
- Excessive vaginal douching
- IUD
❖ Infection
Bacterial vaginosis Candida vaginitis Trichomonas
vaginitis
st nd
1 MC 2 MC 3rd MC
Anaerobic (Gardnerella Candida monilial (+) Trichomonas
vaginalis) vaginalis (-)
High PH >4.5 Normal PH 3.5-4.5 High PH 5.5-6.5
Fishy odor, white or Odorless, white, thick, Yellow, Offensive
gray discharge, no scanty discharge, frothy discharge,
pruritus pruritus and pruritus and
Dyspareunia Dyspareunia
Metronidazole/ Miconazole/Itraconazole/ Metronidazole/
clindamycin Clotrimazole Tinidazole
Alkaline douching
+ whiff test (KOH) result KOH show + culture
fishy odor, + clue cells pseudohyphae
❖ Contraception
Method Failure rate %
Coitus interruptus >25
Breastfeeding for the first 6 month 1
Male condom 3-14
Female condom/ Vaginal diaphragm 15-25
Bilateral vasectomy 0.1
Tubal ligation 3
Injectable progesterone 0.3
Implantable progesterone 0.2-1
Copper IUD <2
COC 1
Progesterone only pills 7
O.G 01 OBSTETRICS
❖ Combined oral contraceptives
Absolute CI Relative CI
- Smoker > 35 years (>15 cigg/day) - Smoker > 35 years (<15 cigg/day)
- HTN stage 2 - HTN stage 1
- Migraine + focal symptoms - Migraine >35 years
- Severe cirrhosis - Mild cirrhosis
- Liver tumor (adenoma or hepatoma) - Medication interfere with OCP
- Breast/endometrial cancer - Currently symptomatic
- DM + retino-nephro-neuropathy gallbladder disease
- Puerperal period < 6 weeks - History of OCP-related
- History of venous thromboembolism cholestasis
- Complicated Valvular heart disease - SLE, APAS
- IHD/ CVA
❖ Invasive cervical carcinoma
- HPV (16, 18, 31, 33, 35)
- Early sex <20 years (the most important)
- Pregnancy at early age
- Multiple partner
- Multiparty
- STD’s
- Immunodeficiency
- Lake of vitamins A, C, E, B9
- Long using for COC
- Smoking
- DES exposure
❖ Endometrial carcinoma (unopposed estrogen)
- Age 55-70
- Chronic liver disease Protective factors:
- DM, HTN, obesity
- Genetic factor - Early childbearing
- High socio-economic class - Multiparty
- Hyperestrogenism - OCP
- Jewish race and white race - smoking
- Nulliparity and low parity
- Pelvic radiotherapy
- Tamoxifen therapy
O.G 01 OBSTETRICS
❖ Fibroid
- Nulliparity, Low parity
- Black women
- Factors that decrease the risk: smoking, OCP, progesterone
❖ Endometriosis
- Familial
- Hyperestrogenism Protective factors:
- Delayed marriage and fertility - Multiparty
- Cervical obstruction - OCP
- Hysterosalpingography - smoking
- Curettage
- Low parity, High sicio-economic class, Japanese women
❖ Ovarian cancer
- Nulliparity
- Infertility
- First pregnancy at >30 years
- Early menarche and late menopause
- Ovulatory inducers
- Obesity
- Familial history of breast or ovarian cancer
- Radiotherapy
- BRCA1 and BRCA2 gene mutation
