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
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
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
Normal time for a single gestation?
Multiple gestations?
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
Post Partum Hemorrhage PPH
primary vs secondary
MC cause
Risk factors
Tx
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