Who is responsible for infertility? 40-65% female, 20-40% male, 15-20% idiopathic Define infertility <35yo inability to conceive after 1 year >35yo inability to conceive after 6mo Secondary Infertility Have conceived in the past, but currently cannot. Hx Questions for 27yo c/o inability to conceive LMP? characteristics of menses..regularity, flow, STIs, PID, PAP smears ROS-->thyroid disease, hirsuitism, pelvic or abd pain, Fam Hx--> infertility, birth defects, mutations, retardation, fragil X Life style-->occupation, exercise, stress, smoking EtOH PE findings for infertility Incomplete secondary sex characteristics Turner syndrome appearance (hypogonadism) Tenderness of the pouch of Douglas (PID endometriosis) Adenexal masses Hyper Evaluation of filopian tubes and pelvis structure? U/S hysterosalpingography Male Infertility approach considerations Seman analysis--90% normal seaman excludes male as cause for infertility Hypothalamic or pituitary tumor Drugs affecting the CNS Klinefelter's syndorm Prolactomas Anabolic steroid use Male Sperm Issues (MMAAL sperm) Motility issues--sperm antibodies, obstruction, infection Morphology issues--cryptochidism, toxins, varicocele Acidic sperm--ejac dysfunction, abscess of vas defrense Azzoospermia--genetic endo infection Low volume--hypogonad, ejac dysfunction The probability of achieving a pregnancy in menstrual cycles is... fecundity Braxton Hicks Contractions are <answer> shorter in duration than labor not as intense as real labor not associated with cervical dilation active labor begins when cervix is dilated 4 cm </answer> Initial prenatal visit includes... H&P-->Gp status, GYN Hx, Fam Hx, Chronic conditions Labs-->type and screen/CBC/UA/STI/HIV/Hep B Pt. Education EDD Estimated Delivery Date Three months back from the start of the LMP + 7 days <question> Normal time for a single gestation? Multiple gestations? </question> 40 weeks 35 weeks Pregnancy catagoires A--safe in humans B--safe in animals, but unknown in humans C--risk/benefit? X--not safe Prenatal care should include regular updates on... BP Weight (normal is 25-35lbs or 3-4lbs/month) Fundal height FHR Uterine palpation Fetal presentation (Leupold maneuvers) U/A PE finding consistent with pregnancy Increased uterine size 1cm/wk after 4 wks gestation Chadwick sign--blueish discoloration of vagina Hegar sign--softening of the cervix Fuller and tender breasts areolar darkens increased visibility of breast veins Fetal heart sounds at 10-12 weeks gestation Stages of labor 1st--time of regular contractions to 10cm dilation two phases latent (up to 4 cm dilation) active (4cm-10cm) 2nd--time of full dilation to expulsion of fetus 3rd--expulsion of fetus to expulsion of placenta Goal of Intrapartum Fetal Surveillance Recognize changes in fetal oxygenation which may result in complications--asses fetal stress Internal monitoring More specific--can tell us if contractions are adequate to cause cervical dilation can measure the intrauterine pressure Cardiovascular changes during normal pregnancy heart displaced up and out normal second heart sound systolic end murmur Diastolic murmur--->BAD Increased CO 30-50% (1/5 of CO goes to placenta increasing the risk of postpartum bleeding) Respiratory Changes in pregnancy increased total O2 consumption by 20% compensated respiratory alkalosis Hematologic changes in pregnancy increased plasma volume increased RBCs increased coagulation factors-->doubled risk for thromboembolism 5x the risk during peurperium (approx 6-8wks postpartum) Endocrine changes during pregnancy Euthryroid-- -gland enlargement -placental Hcg-->stimulation of T4 Estrogen-->hepatic synthesis of TBG-->increased levels of total T3 and T4 Thyroid is working normally, but other hormones are affecting serum levels Description of the fetus during labor Stations--0=presenting part is level with ischial spine (-) values are superior to ischial spines (+) values are inferior to ischial spines Placenta Previa defined placental location near the cervical os Placenta previa signs and symptoms, risk factors, Dx, Tx painless bleeding in 3rd trimester Dx-->transvag US RF-->smoking, previous placenta previa, advanced age, multiparty, cocaine use, prior cesarean or other uterine surgery Tx-->cesarean Placental abruption defined abnormal preseperation of the placenta placental abruption signs and symptoms, risk factors, Tx & complications of SS-->vag bleeding with PAIN RF-->HTN, preecclampsia, multiple gestation, smoking, cocaine use, multiparty, PRIOR abruption Tx--immediate delivery MC cause of coagulopathy in pregnancy Preeclampsia HTN proteninura or platelet <100K, creatinine 2x, AST or ALT 2x, pulmonary edema Eclampsia preeclampsia + seizures Gestational diabetes risk factors Hx of gestational diabetes AA, Pacific islander, native american, hispanic american, asian Fam Hx of diabetes in 1st degree relative BMI >30 previous delivery of baby >9lbs glycosuria at 1st prenatal visit PCOS, current use of glucocoticoids Gestational diabetes effects on newborn baby produces high insulin in response to high sugar from mother, when born the transfer of sugar to baby ceases and the newborn experiences a transient hypoglycemic episode b/c of the insulin overload additionally it cause babies to be born with large heads and overall heavier babies as the unused glucose in converted to fat Routine glucose testing is done when.. 24-28 weeks gestation w/o risk factors fasting not required--ingest 50g and check after 1 hour 3 hour glucose test if inital is >140 need two abnormals for Dx Other complications of GDM macrosomia excessive weight gain for mom shoulder dystocia need for cesarean preeclampsia HELLP syndrome Hemolysis Elevated Liver enzymes Low Platelet counts occurs in 4-12% or pts with preeclampsia Tx platelet transfusions, delivery Schistocytes Risk Factors for HELLP Hx of preeclampsia or ecclampsia FHx of HELLP nulliparity multigestations >35yo HTN DM Vascular, connective tissue, antiphospholipid AA & obesity Threatened abortion... bleeding with a viable pregnancy Missed abortion.. nonviable intrauterin gestation less than 20 weeks with the cervical os closed Incomplete abortion intrauterine gestation less than 20 weeks with the os open and some tissue already passed Inevitable abortion... cervix is open but no tissue has passed Complete spontaneous abortion.. passage of all tissue and an empty uterus Septic abortion... is abortion with retained products f conception with symptoms and signs of infection Suspected abortion work up US HCG levels (should be doubeling every 48 hours with an intrauterine fetus) Five Cardinal Movements of Labor Flexion Descent Internal rotation Extension External rotation <question> Post Partum Hemorrhage PPH primary vs secondary MC cause Risk factors Tx </question> primary 1st 24 hours after delivery secondary after 24 hours MC cause--uterine atony Occurs in 1-5% of deliveries Risk factors-->prolonger labor, augmented labor, Hx of PPH, episiotomy, operative delivery Oxytocin 10-40 units/L of saline