GYN-OBS Lecture 1

Yosor Fiesal- IMLE

LANGE 12th edition
• #1 >> In girls, the first event of puberty is thelarche, the development
of breasts.
• #2 >> Thelarche is then followed by pubarche, the development of
axillary and pubic hair.
• #3 >> Finally there is menarche, the first menstrual period.
Menstrual cycle
Cyclic changes in Cervix
• The mucosa of the uterine cervix does not undergo cyclic
desquamation, but there are regular changes in the cervical mucus.
Estrogen:
• makes the mucus much thinner and more alkaline, changes that
promote the survival and transport of sperm.
• The mucus is thinnest at the time of ovulation, and its elasticity, or
spinnbarkeit (stretchability), increases so that by midcycle a drop can
be stretched into a long, thin thread that may be 8–12 cm or more in
length. In addition, it dries in an arborizing, fernlike pattern when a
thin layer is spread on a slide
Progesterone:
• makes it thick, tenacious, and cellular. After ovulation and during
pregnancy, it becomes thick and fails to form the fern pattern.
Indicators of Ovulation:
• Rise in the basal body temperature
• A rise in urinary LH occurs during the rise in circulating LH that causes ovulation
(Kits using dipsticks or simple color tests for detection of urinary LH are available
for home use)
• Ovulation normally occurs about 9 hours after the peak of the LH surge at
midcycle
• ovum lives 72 hours after it is extruded from the follicle but probably is
fertilizable for less than half this time
• Some sperm can survive in the female genital tract and produce fertilization for
up to 120 hours before ovulation, but the most fertile period is clearly the 48
hours before ovulation
Normal Pregnancy
• Naegele’s rule: estimated due date (EDD) may be estimated by adding 7 days to first day of the last menstrual
period and subtracting 3 months plus 1 year
• 1st trimester: week 1- end of week 12
• 2nd : week 13- week 26
• 3rd : week 27- end of pregnancy

Clinical Findings:
• Hyperemesis gravidarum: extreme form of nausea and vomiting, characterized by dehydration, weight loss (up
to 5%), ketonuria. Tx with oral pyridoxine 10 - 30mg 3 to 4 times a day if mild w/o dehydration
• Montgomery’s tubercles (portion of the areolar glands visible on the skin surface, Breast engorgement,)
• Fetal movement (quickening): 18–20 weeks’ in primiparous, 14 weeks’ in multiparous
• Skin changes: 1. CHLOASMA: skin darkening of the forehead, bridge of the nose, or cheek bones. after 16
weeks’ gestation. Chloasma is exacerbated by sunlight
2. LINEA NIGRA: darkening of nipples and lower midline from the umbilicus to pubis (linea nigra)
3. STRIAE: breast, abdomen appear as irregular scars. Appear late in pregnancy and caused by
collagen separation.
4. SPIDER TELANGIECTASIA: elevated plasma estrogen. vascular stellate skin lesions and palmar
erythema
• Pelvic organ changes:
1. CHADWICK’S SIGN: Congestion of pelvic vasculature causes bluish discoloration of the vagina
and the cervix
2. HEGAR’S SIGN: widening and softening of the body or isthmus of the uterus (6 -8 weeks)
3. PELVIC LIGAMENTS: relaxation of the sacroiliac and pubic symphysis (due to relaxin hormone
produced from the corpus luteum)
4. LEUKORRHEA: vaginal discharge, containing epithelial cells and mucous
• Braxton Hick’s contractions: —Painless uterine contractions, begin at 28 weeks, disappear with
walking, exercise, or hydration, and do not cause cervical dilation
 Imaging
• Sac is seen 4-5 weeks
• Sac diameter > 25 mm must have embryo
• Sac: regular, well-defined, double ring, echo lucent
• To assess for viability, cardiac activity should be noted
by transvaginal ultrasound when the fetal pole
measures 7 mm, which corresponds to a gestational
age of 6.0–6.5 weeks
• Using transabdominal ultrasound, cardiac activity
should be noted when the fetal pole corresponds
with a gestational age of 8 weeks
IUGR:
• Most common cause 70% is constitutional (maternal body dimension)
• Most common pathological cause: hypertension

LGA:
Fall 2017
Which maternal factor is the most common cause of IUGR?

(1)Maternal chronic hypertension

(2)Maternal vascular disease
(3)Maternal small body dimensions
(4)Maternal malnutrition
(5)Maternal smoking
January 2021
A 38-week-pregnant woman had a fetus with a US weight of 4600 gr.
Which of the following variables is the most likely to explain this
situation?

(1) TORCH-congenital infection

(2)Gestational age
(3)Placental insufficiency
(4)Gestational diabetes (correct)
(5)Smoking
Maternal Physiology
Cardiovascular:

• Heart rotates on its long axis in a left-upward

• Heart size increases by 12%
• 50% elevation in plasma volume
• Hypervolemia of pregnancy compensates for maternal blood loss at delivery,
which averages 500–600 mL for vaginal and 1000 mL for caesarean delivery

• Cardiac output increases 40% (7 L instead of 5 L)

• Stroke volume increases 25–30% (SV = EDV – ESV)
• The resting maternal heart rate, 15 beats/min more than the nonpregnant rate
(tachycardia) 15% rise in HR
Blood Pressure:

• Systemic arterial pressure declines slightly during pregnancy, reaching a nadir at

24–28 weeks
• Pulse pressure widens , fall of diastolic> systolic
• Supine hypotensive sx (hypotension, bradycardia, syncope), occurs in 10%, in 3rd
trimester, supine position reduces CO and arterial pressure by compression of
vena cava by gravid uterus with reduction of venous return. ** Shifting gravida to
R/L recumbent position will alleviate caval compression.
• Venous pressure increases in lower extremities (varicose vein)
• Peripheral vascular resistance decreases (hormonal effect> NO, prostacyclin,
adenosine)
• Uterine blood flow 800 ml/min (x4 of nonpregnant)
• Renal blood flow >400 ml/min of nonpregnant
• Breast blood flow increases 200 ml/min
Pulmonary:

• Diaphragm elevated 4 cm (enlarged uterus)

• Increased tidal volume 35-50%
• Decreased residual volume 20%
• Decreased total lung capacity 5%
• Decreased PaCO2 (hyperventilation) 27-32 mm Hg
• Respiratory alkalosis

• Increased levels of progesterone (works on CNS receptors)appear to have a

critical role in the hyperventilation of pregnancy, which develops early in the first
trimester
Renal system:

• length of the kidneys increases by 1–1.5 cm

• renal calyces and pelvis are dilated
• Renal plasma flow increases 50–85% above nonpregnant values
• Rise in glomerular filtration rate (GFR) 50%, therefore decreased creatinine
• Urinary flow and sodium excretion rates in late pregnancy are increased 2-
fold in lateral recumbency compared with the supine position.
• Bladder vascularity increases and muscle tone decreases, which increases
bladder capacity up to 1500 mL (normal bladder capacity 400-600 ml)
Gastrointestinal:

• Stomach pushed upward

• Appendix is displaced superiorly in the right flank area
• Ptyalism: salivation
• Epulis: hypertrophic gums and hyperemic

• GERD-Reflux affects 30-80% of women (52% in 1st trimester. 24% in 2nd vs. 8.8%in 3rd )
• Greater production of gastrin > increases stomach volume and acidity of gastric
secretions
• ** The underlying predisposition to reflux in pregnancy is related to hormone-mediated
relaxation of the lower esophageal sphincter - PROGESTERONE

• Esophageal peristalsis is decreased

• Slower emptying of gallbladder (progesterone, and estrogen increases cholesterol)
Hematology:

• RBCs: mass expands 33% (Hb, Hct decrease slightly) → red cell mass expands during
pregnancy, there is a greater increase in plasma volume. This leads to overall dilutional
effect on hemoglobin. Thus, pregnancy results in decreased hemoglobin counts.
(ANEMIA)
• WBCs: total blood leukocyte count increases (5000-12000), During labor 20000-25000
• Platelets: increased production of PLTs (thrombocytopoiesis), accompanied by
progressive platelet consumption (REMEMBER) (so static or slightly decrease< 150000
in 6% of pregnant)
• Clotting factors: Fibrinogen (factor I) and factor VIII levels increase markedly
Factors VII, IX, X, XII increase to a lesser extent (XI, XIII not changed)
Fibrinolytic activity is depressed –decreased
Metabolism:

• Nails become brittle and can show horizontal grooves (Beau’s lines).
• Thickening of the hair during pregnancy is caused by an increased number of follicles in anagen (growth)
phase, ends 1–5 months postpartum with the onset of the telogen (resting) phase, Normal hair growth
returns within 12 months
• The average weight gain during pregnancy is 12.5 kg
• Circulatory Function: A. Uteroplacental Circulation: uterine blood flow near term is 500–700 mL/min,
85% of uterine blood flow goes to
cotyledons, blood flow in placenta is 400– 500 mL/min
B. Fetoplacental Circulation: total umbilical blood flow of 350–400 mL/min
LABOR & DELIVERY
1st Stage:

• 1.LATENT: <20 hours in nullipara, <14 hrs in multipara (0-4 cm)

• 2. ACTIVE: beginning at 3-5 cm of dilation to 10 cm, rate cervical dilation >> 1.2
cm/hr nullipara, 1.5 cm/hr multipara
• Arrest of (latent) dilation: >2 hrs w/o cervical change in the presence of normal
contraction
• Protraction (slow-rate): nullipara< 1.2 cm/hr, multipara < 1.5 cm/hr

• Active phase arrest: > 6 cm dilated with ruptured membrane who fail to progress
despite at least 4 hrs of adequate contractions, or 6 hrs of oxytocin
2nd Stage:
• Cardinal movements of fetus take place
• Descent of the fetus is evaluated by measuring the relationship of the bony
portion of the fetal head to the level of maternal ischial spines (station)
• 30 minutes to 3 hours in primigravid women and from 5–30 min in multigravida
women

Cardinal movements ( E-DFI-EEE):

• Engagement, Descent, Flexion, Internal rotation, Extension, External rotation,
Expulsion
• Anesthesia affects 2nd stage (prolongation) (‫)שאלה משוחזרת‬

• Protracted 2nd stage: > 2hrs in nullipara w/o anesthesia

> 3 hrs in nullipara with regional anesthesia
> 1 hr in multi w/o anesthesia
> 2 hrs in multi with anesthesia

• Arrest of labor: cervical exam > 6 cm with membrane rupture and 1 of the
following:
1. > 4hrs of adequate contractions
2. > 6 hrs of inadequate contraction and no cervical change
Contraindication regional anesthesia: ‫משוחזר‬
1. Valvular heart disease
2. Infection, bacteremia
3. Coagulopathy
4. Hypovolemia
5. Progressive neurologic disease
6. Patient refusal
3rd Stage:
• Placenta separates within 30 min
• Signs >> 1. fresh show of blood appears from the vagina
2. umbilical cord lengthens outside the vagina
3. fundus of the uterus rises up
4. uterus becomes firm and globular
• Mt 3rd stage: →uterine massage, oxytocin (PPH)
→prophylactically administration uterotonic agents
→Timely cord clamping (delayed 30-60 sec, prevents anemia,
increases Hb level, improves iron stores)
→controlled traction of the cord
Fall 2019
A 24 year old primigravida at 40 weeks gestation in the delivery room
progressed from 6 cm cervical dilatation to 9 cm within 2 hours. What
is your Dx?
(1)Normal labor progression
(2)Prolonged latent phase
(3)Protracted active phase
(4)Active phase arrest
(5)Arrest of descent
 Induction and Augmentation of Labor
 Induction of labor is the process of initiating
labor by artificial means
 Augmentation is the artificial stimulation of
labor that has begun spontaneously

 Evaluation of the cervical status in terms of

effacement and softening is important in
predicting success of induction and is highly
recommended before any elective induction

 Induction should be done in response to

specific indications, should not be done
electively <39 weeks gestational age.

 BISHOP >>>>
Fall 2019
Which of the following cases has a Bishop score above 7?

(1)Soft cervical consistency, posterior cervix, 2 cm dilated, 50% effaced, and fetal
head position -1
(2)Soft cervical consistency, posterior cervix, 2 cm dilated, 50% effaced, and fetal
head position -2
(3)Stiff cervical consistency, posterior cervix, 3 cm dilated, 50% effaced, and fetal
head position -2
(4)Soft cervical consistency, middle cervix, 3 cm dilated, 70% effaced, and fetal
head position -2 (correct_
(5)Stiff cervical consistency, middle cervix, 2 cm dilated, 80% effaced, and fetal
head position -2
INDICATIONS OF INDUCTION CONTRAINDICATIONS

Maternal:
1. Preeclampsia, eclampsia Absolute: 1. Contracted pelvis
2. HELLP 2. Placenta previa
3. Previous classical CS
3. Diabetes
4. Myomectomy entering the endometrial cavity
5. Transverse lie
• Fetal: 1. Post-term Relative: 1. Breech
2. Fetal abnormality 2. Previous CS with low transverse uterine scar
3. Chorioamnionitis
4. PROM
5. Placental insufficiency
6. Oligohydramnios
7. IUGR, fetal demise
8. Multiple gestation
OPERATIVE DELIVERY
Forceps indications:
• Non-reassuring fetal heart rate pattern
• Shortening of 2nd stage of labor for maternal reasons
• Prolonged 2nd stage of labor not due to dystocia (nulliparous patient, a prolonged second stage is defined as >3
hours with a regional anesthetic or >2 hours without a regional anesthetic. In a multiparous patient, more than 2
hours with a regional anesthetic or more than 1 hour without a regional anesthetic)
• Delivery of aftercoming head in a breech presentation

Requirement:
1. Complete cervical dilatation
2. Ruptured membranes
3. Fetal head engaged with the fetal head position known
4. Empty bladder
5. No evidence of cephalopelvic disproportion

Complications: Maternal trauma (episitomy, laceration), Facial and brachial plexus palsies,
Cephalohematoma, ICH, seizure
REMEMBER→ GOOD FOR BREECH
VACUUM indications:
• Non-reassuring fetal heart rate pattern
• Shortening of the second stage of labor for maternal reasons
• Prolonged second stage of labor

Contraindications:
• Face presentation
• Breech presentation Retinal hemorrhage 50%
• True cephalopelvic disproportion Cephalohematoma 6%
Subgleal hematoma 50/10000 0.5%
• Congenital anomalies of the fetal head (hydrocephalus)
• Gestational age < 34 weeks
• Unengaged fetal head
• Fetal demineralization disorder (osteogenesis imperfecta)
• Fetal weight > 4000 g (relative)
Spring 2018
Which of the following is an absolute contraindication for vacuum
assisted delivery?
(1)Vaginal tear on previous delivery
(2)Maternal HBV infection
(3)Fetal estimated weight above 4000 gr
(4)Premature labor at 33 weeks of gestation
(5)Occiput posterior presentation
Caesarean section indications:
• Repeat CS
• Cephalopelvic disproportion/ dystocia
• Abnormal lie/ malpresentation
• Fetal HR tracing abnormalities
• Other: placenta previa, preeclampsia-eclampsia, placental abruption, twins, active genital
herpes infection

➢Trial of labor after CS (TOLAC): 1. 1 prior low-transverse CS

2. Who present in labor
3. Non-recurring conditions: breech, abnormal FHR,
placenta previa in previous pregnancy
4. Prior vaginal delivery
➢Pts who NOT candidates for TOLAC: women with a prior classical (vertical) uterine incision or
prior myomectomy
➢If a trial of labor is to be conducted, Prostaglandins for cervical ripening must be avoided, and
oxytocin must be used in a judicious and conservative fashion, if at all.
The most common complications that result from caesarean section are postpartum
hemorrhage, endometritis, and wound infection.
February 2022
Which of the following women is the most suitable candidate for trial
of labor after cesarean section (TOLAC)?
1. A woman with a history of a cesarean section with a vertical
incision
2. A woman in active labor with breech presentation
3. A woman on her 40th week of pregnancy, with the cord as the
leading part
4. A woman on her 39th week of pregnancy, who had a cesarean
section due to placenta previa
Fall 2019
A 33-year-old woman, 38 weeks gestation, G3P2, presented to the delivery room during
active labor. Her first delivery was spontaneous vaginal delivery with no complications, her
2nd delivery was C-section due to placenta previa. Which mode of delivery would you
recommend her now?
(1)Vaginal delivery is optional if the C-section was with a classical incision
(2)A vaginal delivery trial is possible if the prior C-section was with a low horizontal incision
(3)A prior C-section due to placenta previa is a contraindication for vaginal delivery in any
incision type
(4)Given her obstetric history, the chance for successful vaginal delivery is very poor, thus
trial of labor after cesarean (TOLAC) is not recommended
(5)Considering the fact that the patient already in active labor, an emergency C-section is
indicated.
Summer 2021
.Which of the following is the most common complication of a cesarean
section?
A. Wound infection
B. Uterine rupture
C. Bladder injury
D. DVT