Abnormalities of early pregnancy  �Problems of pregnancy

Dr Sanaa abujilban RN,RM,PhD

Objectives

• At the end of this lecture the students will be able to:
• consider the causes and diagnosis of the common presenting symptoms in early pregnancy of vaginal bleeding, abdominal pain and vomiting
• Emphasize the need for midwives to be able to offer support and care for mothers during pregnancy
• Provide an overview of problems of pregnancy
• Describe the role of the midwife in relation to the identification, assessment and management of the more common disorders of pregnancy
• Consider the needs of both parents for continuing support when disorder has been diagnosed

Abnormalities of early pregnancy

1. Bleeding in early pregnancy
1. Spontaneous miscarrige
2. Ectopic pregnancy
3. Trophoblastic disease (abnormal growth of cells inside a woman's uterus)
4. Others (cervical ectropion, polyps, carcinoma, infection)
2. Nausea and vomiting in early pregnancy
3. Abdominal pain in early pregnancy
4. Induced abortion

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I. Bleeding in pregnancy

• Vaginal bleeding during pregnancy is abnormal
• Occurred in up to 25% of pregnancies
• Cause concern to the mother
• Viewed seriously by the midwife

Assessment of bleeding

1. When it occurs
2. How much the amount
3. Color of blood
4. Associated with any pain
5. Reoccurrence
6. Assessment of fetal condition
7. Ultrasound:
1. before 20 wks: viability
2. Late in pregnancy: heart sound and fetal movement

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Signs and Symptoms of Hypovolemic Shock

Types of bleeding in the first 20 wks

1. Implantation bleeding
2. Cervical eversion (ectropion)
3. Cervical polyps
4. Carcinoma of the cervix
5. Cervical intraepithelial neoplasia (اورام)
6. Lower genital tract infection
7. Spontaneous miscarriage
8. Induced abortion
9. Recurrent miscarriage
10. Ectopic pregnancy
11. Gestational trophoblastic disease

1. Implantation bleeding

• Small vaginal bleeding with implantation
• Around the expected time of menstruation
• May be mistaken with a period

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2. Cervical ectropion (eversion)

• Not cervical erosion (uterine cells)
• It is a physiological response during pregnancy
• Caused by high level of estrogen
• Physiology: proliferation of columnar epithelium causes cells to spread and cover squamous epithelium vagina
• It increase the (S&S)
1. vaginal discharge and
2. may be bloodstained
3. May be bleeding after intercourse
• Disappear during puerperium
• No need for treatment

Cervical ectropion

3. Cervical polyps

• small., pedunculated growth attached to cervix
• May bleed during pregnancy
• No need for treatment if the bleeding is little
• need treatment:
• Profuse bleeding or
• malignancy

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4. Carcinoma of the cervix

• 1 in 6000 live births
• The screening test used is the Papanicolaou smear (Pap smear)

4. Carcinoma of the cervix

• Risk factors:
1. Human papillomavirus (HPV) (most common: type 16)
2. Sexual behavior: early age, many partners, unprotected sex, a multi-partner’s partner,
3. Smoking: twice incidence; because of weakening of the immune system, changes in DNA
4. Pregnancy: early 1^st pregnancy have higher risk
5. Social class: manual social class have higher risks

• Signs:
• Bleeding with vaginal discharge
• Investigation:
• Pap smear
• Colposcopy (view of the cervix, vagina and vulva)
• biopsies

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• Treatment:
• Laser treatment,
• Cryotherapy العلاج بالتبريد
• Cone biopsy: may cause hemorrhage and miscarriage

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5. Cervical intraepithelial neoplasia

• Precursor (antecedent) to invasive cancer
• Diagnosed by colposcopy following referral for abnormal Papanicolaou smear (Pap smear)
• Asymtomatic
• Treatment deferred until after the pregnancy
• Vaccine for HPV 16,18 is available, but not to be given for pregnant woman
• Regular smear tests are recommended every 3 years (age 25-49)

6. Lower genital tract infection

• Cervisites (inflammatory changes of the cervix)
• It will Cause increase discharge and bleeding
• Screening for chlamydia and urinary PCR (PCR used to detect gonorrhea and chlamydia, and may be performed on first-catch urine) samples should be included for women with bleeding

7. miscarriage:� Types of spontaneous miscarriage

• Threatened
• Inevitable
• Incomplete
• Complete
• Silent or delayed (missed)
• Septic abortion

9. Cervical incompetence; as a cause of Recurrent miscarriage

• Painless dilatation of the cervix in the 2^nd or early 3^rd trimesters
• Causes:
• unclear
• Trauma to the cervix
• Cone biopsy
• Congenital weakness of the cervix
• Treatment: cervical cerclage at 14 weeks in the internal os; and removed at 38 weeks

Complications of Miscarriage

• Hemorrhage
• Infection
• Isoimmunization
• Powerlessness or Anxiety

10. Ectopic pregnancy: �Cervical pregnancy

• Rare
• Potentially fatal
• Result in massive hemorrhage

11. Gestational trophoplastic disease

• Includes:
1. Benign hydatidiform mole
2. Malignant chorio-carcinoma

a. Hydatidiform mole

• Chorionic villi proliferate and become avas-cular
• Found in the cavity of the uterus
• Rarely, in the tubes
• Incidents is 1.5 in 1000 pregnancies

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a. Hydatidiform mole

• Incident increase
• with history of mole pregnancy
• Maternal age (less than 20 and more than 40 years)
• Asian woman

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a. Hydatidiform mole:�types

• 1. complete
• 2. Partial

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a. Hydatidiform mole:�1. complete

• One sperm with empty ovum
• 46 chromosomes
• (sperm reduplicates)
• Contains no evidence of embryo, cord or membranes
• Death occurs before placenta circulation
• Chorionic villi alter to form clear, hydropic vesicles, hang in clusters form small pedicles looks like grapes
• The clusters May be not visible or few centimeters

a. Hydatidiform mole:�1. complete

• The mole may penetrating beyond the site of implantation
• The myometrium and veins may involved
• May cause rupture of uterus and massive bleeding

a. Hydatidiform mole:�2. partial

• evidence of embryo, cord or membranes is present as death happened 8-9 wks
• 69 Chromosomes (one ovum with 2 sperms)

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a. Hydatidiform mole, �clinical features

• Exaggerated signs of pregnancy (6-8 wks)
• Bleeding or a bloodstained vaginal discharge
• Light pink or brown vaginal discharge when the vesicle ruptured
• Vesicle passed from the vagina
• Anemia from bleeding
• Hyperemesis gravidarum
• Hyperthyroidism
• early pre-eclampsia

a. Hydatidiform mole, �clinical features

• On palpation:
• Large uterus than expected
• Not contracted uterus: doughy or elastic
• No fetal parts or movement
• No fetal heart sounds
• Ultrasound confirmed diagnosis
• Higher than normal HCG levels

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a. Hydatidiform mole, �treatment

• The aim is to Remove all trophoplast tissue
• some times aborted spontaneously
• Vaccum aspiration or dilatation and curettage
• 10% of the mole does not die completely
• Women need
• Follow up for 2 years: after 6-8 weeks HCG level should disappear from urine and not rise again
• Avoid pregnancy for the follow up period
• No IUD (cause infection and proliferation) or oral contraceptives
• Explanation and support

b. Choriocarcinoma �a malignant, trophoblastic cancer, usually of the placenta.

• Malignant neoplasm as a consequence of molar pregnancy
• The growth invades the myometrium
• Cause sever hemorrhage
• May develop lung, hepatic, and cerebral metastases
• May occur after:
• normal pregnancy,
• termination of pregnancy,
• ectopic pregnancy
• it can be treated effectively with
• methotrexate.
• Dacti-nomycin is added to the regimen if metastasis occurs.

Anti-D in early pregnancy

• All the women who Rh is –ve and
• have abortion,
• ectopic pregnancy or
• mole pregnancy

II. Nausea and vomiting in early pregnancy

• Common in 4-10 wks and resolving before 20 wks

Hyperemesis gravidarum

• Excessive nausea and vomiting
• Affecting 0.3- 3% of all pregnant
• Causes:
• Unknown cause
• May due to
• Endocrine (abnormality of thyroid),
• gastrointestinal and
• psychological factors
• High levels of estrogen and HCG is related; Occur with
• multiple pregnancy,
• mole pregnancy (high hormones)
• Infection with Helico-bacter pylori (implicated in gastric ulcers)
• History of hyperemesis

Hyperemesis gravidarum:� Associated with

• Weight loss >5 %
• Ketosis
• Dehydration
• Electrolyte imbalance
• Thiamine (vitamin B₁ ) deficiency

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Hyperemesis gravidarum�signs

• Persistent sever nausea and vomiting
• Unable to retain food or fluid
• Distressed
• Need admission

Hyperemesis gravidarum�signs

• Dryness and inelasticity of the skin
• May jaundice (indicate hepatic involvement)
• Rapid pulse, low BP,
• dry tongue
• Acetone smell breath (sign of ketosis)
• (dehydration)
• Elevated of hematocrit,
• electrolyte imbalance and
• ketonuria

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Hyperemesis gravidarum�Treatment

• Keep NPO
• IVF
• IV vitamin supplements (vit. B6)
• Rest in a single room
• Mild sedative if agitated
• Give antihistamines (to sleep)
• If not treated may cause death (renal and hepatic dysfunction)
• May need termination of pregnancy

III. Abdominal pain in early pregnancy

• Common presenting symptom with:
• Miscarriage
• Ectopic pregnancy

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III. Abdominal pain in early pregnancy

• Other causes:
1. Retroversion of the uterus
2. Fibroids (leio-myomas)
3. Ovarian cysts
4. UTI
5. Uro-lithia-sis (renal colic)
6. Appendicitis
7. cholecystitis

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1. Retroversion of the uterus

• Angle between the long axis of the uterus and the long axis of the vagina is >180°
• Causes no problem and corrected with the advance of pregnancy
• In-carceration (to put in jail):
• If the retro-verted uterus fails to rise out of the pelvic cavity by the 14^th week, it is said to be incarcerted

1. Retroversion of the uterus: Incarceration effect

• Uterus confined within the pelvis
• Pressure of the uterus causes:
• Abdominal discomfort
• Pelvic fullness
• Low abdominal and back pain

1. Retroversion of the uterus�Incarceration effect

• elongation of the urethra causes:
• Frequency of urination
• Dysuria
• Paradoxical incontinence (overflow incontinence) (associated with overdistention of the bladder)
• compression of the bladder neck causes Urinary retention
• urine stasis causes Infections
• Treatment: Need indwelling catheter

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2. Fibroids

• Firm benign tumor
• Muscular and fibrous tissue
• during pregnancy: become more vascular and edematous
• If the fibroid occludes its own venous drainage it causes red degeneration (central necrosis)
• red degeneration;
• Signs: severe abdominal pain, tenderness, low-grade fever
• Treatment: U/S, rest and analgesia

Types of Fibroids

3. Ovarian cysts

• Incidence; 1 in 80 to 1 in 300
• Most of it are Benign cysts
• 2 - 5 % malignant

3. ovarian cysts

3. Ovarian cysts

3. ovarian cysts

• is any collection of fluid, surrounded by a very thin wall, within an ovary.
• An ovarian cyst can be
• as small as a pea, or
• larger than an orange.
• Dependent on hormonal influences associated with menstrual cycle

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3. Ovarian cysts

• Functional ovarian cysts:  forms on the surface of a woman's ovaryFunctional ovarian cysts:  forms on the surface of a woman's ovary  during or after ovulation.
• follicular cysts (mature graafian follicle failing to rupture)
• corpus luteum cysts (increase of fluid in the corpus luteum)
• Most common; Dermoid cysts: germ cell tumors (contain hair, bone, …)

3. Ovarian cysts: �diagnosis

• Asymptomatic dignosed by palpation or U/S
• Symptoms arise from complication like
• torsion ( التواء)(not common) or
• rupture of the cyst
• Symptoms
• Pain
• Nausea
• Vomiting
• tenderness

3. Ovarian cysts:�management

• If Asymptomatic and less than 10 cm; left and monitored by U/S
• Lapratomy in the mid trimester (16 wks) if
• cyst > 10 cm
• Enlarging

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4. Urinary tract infection

• Common during pregnancy
• Become ascending and cause pyelonephritis (1-2%)
• Features; fever, loin tenderness and frequency of urine
• Treatment;
• in patient,
• IV antibiotic,
• fluids and
• analgesia

5. Urinary Tract Stones �(Uro-li-thiasis)

• Renal calculi cause Renal colic
• Incidence .03-.5 %
• Sudden onsent abdominal pain
• Associated with UTI and haematuria
• U/S; unilateral hydronephrosis or calcified area
• Management:
• Need admission, IVF, antibiotic and analgesia
• May need surgery

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6. Appendicitis

• Incidence; 1/1000 of pregnant or non-pregnant
• Mortality is higher during pregnancy
• Pain; less well localized and less obvious
• Increase incidence of perforation (15-20 %), peritonitis and sepsis
• Need early referral and surgical intervention

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7. cholecystitis

• Incidence 1 in 1000
• Pain;
• sudden right upper quadrant or epigastric
• Nausea, vomiting and fever
• Diagnosis;
• clinical features,
• biochemical tests and U/S
• Treatment; antibiotic, analgesia and fluids
• Surgery;
• done if associated with pancreatitis or recurrent
• deferred until puerperium over

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IV. Induced abortion

• Definition:
• Termination of pregnancy before 24 weeks gestation
• Reasons for induced abortion:
1. Injury to the physical and mental health of the woman
2. Risk to the woman’s life
3. Abnormal infant (physical or mental)

IV. Induced abortion�methods

1. Surgical termination;
1. 1^st trimester
• Vaccum aspirtion; suction currete
• Dilatation and curettage
2. 2^nd trimester
• Dilatation and evacuation (D&E); using forceps,

IV. Induced abortion�methods

2. Medical termination

• If less than 63 days :
• mifepristone and prostaglandins
• In 2^nd trimester:
• give extra-uterine prostaglandine then oxytocin
• Rest in a separate room
• Prophylactic antibiotics
• Anti-D for all –ve Rh women
• Analgesia
• Privacy and support

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dilation and curettage

Dilation and curettage: definition

• Surgical procedure in which the
• cervix is dilated and
• a suction curette is inserted to scrape the uterine walls and remove uterine content

Dilation and curettage: �indications

1. for the diagnosis of gynecological conditions leading to 'abnormal uterine bleeding
2. to resolve abnormal uterine bleeding
3. to remove the excess uterine lining in women who have conditions such as polycystic ovary syndrome
4. postpartum retained placenta
5. to remove retained tissue in the case of a missedin the case of a missed or incomplete miscarriage;

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Dilation and curettage: �indications

• as a method of abortion that is now uncommon.

The World Health OrganizationThe World Health Organization recommends D&C as a method of surgical abortion only when manual vacuum aspiration is unavailable

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Dilation and curettage:�Pre operative care:

• Full history
• General and pelvic examination
• Education about
• Analgesics and anesthesia
• explanations, answers any questions or concern
• Prepares the woman for surgery

Dilation and curettage: �Post- operative care:

• Oxytocin is given
• Methergine
• Prostaglandin
• Antibiotics
• Analgesics

Dilation and curettage:� Post-oparetive care:

• Transfusion therapy may be needed
• Rh negative women given anti D
• Psychosocial aspects: loss of pregnancy
• Seeing the products of conception
• Make decision about final disposition of fetal remains

Dilation and curettage: �Follow up care at home

• Discharged when:
• stable V/S,
• minimal vaginal bleeding,
• recovered

Dilation and curettage: �Follow up care at home

• At home:
• Rest
• Iron supplement
• Teaching about: cramping, bleeding, sexual activity, family planning
• Support group
• Personal hygiene: Perineal cleaning, shower not bath, no coitus for 2 wks
• Teach about S/S of infection
• Food: high protein, iron, Vit C, fiber, fluid
• Grieve loss

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Dilation and curettage:�Complications

• may arise from
1. infection,
2. adverse reaction to general anesthesia
3. instrumentation itself, as the procedure is performed blindly (without the use of any imaging technique such as ultrasound itself, as the procedure is performed blindly (without the use of any imaging technique such as ultrasound or hysteroscopy).

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Dilation and curettage:�Complications

1. uterine perforation.
2. Infection
3. Asherman's syndrome (is intrauterine adhesions, 30.9% in women, may cause ectopic pregnancyAsherman's syndrome (is intrauterine adhesions, 30.9% in women, may cause ectopic pregnancy, miscarriageAsherman's syndrome (is intrauterine adhesions, 30.9% in women, may cause ectopic pregnancy, miscarriage, placenta previaAsherman's syndrome (is intrauterine adhesions, 30.9% in women, may cause ectopic pregnancy, miscarriage, placenta previa and placenta accreta)

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Problems of pregnancy

Problem of pregnancy

• Life threatening ones
• rare
• increasing age is a concern (increase malignancy, placenta previa, obesity)
• Need for regular antenatal checks

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The midwife role

• Accurate health history
• Physical examination (general and specific)
• Record
• Referral when needed
• Care and support
• Explain the situation for mother and family

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Problem of pregnancy

• I. abdominal pain
• II. Antepartum hemorrhage (APH)
• III. Jaundice in pregnancy
• IX. Skin disorders
• X. Disorders of amniotic fluid
• XI. Obesity

1. abdominal pain

Abdominal pain: definition

• Abdominal pain is pain and discomfort that occurs in the abdomen
• Abdominal pain can be
• mild or
• severe,

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Abdominal pain: definition

• it may be:
• continuous or
• come and go.
• Abdominal pain can be:
• short-lived (acute) or
• occur over weeks and months (chronic).

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Type of pain arising from reproductive organs

• Pain is usually felt in the middle of the lower abdomen.
• Ovary: Pain that is felt more to the side can be more typical of a pain coming from the ovary.
• dysmenorrhoea.
• DDyspareunia
• endometriosis,
• fibroids,
• pelvic inflammatory disease,
• ovarian cysts

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Management

• History:
• questions regarding menstrual periods,
• passing of urine and bowel movements.
• symptoms such as fever, nausea and vomiting.
• questions about a person's
• emotional life-
• family,
• home,
• work
• and sex life.

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Management

• Physical examination:
• abdomen and may
• examine internally (vaginal, rectal)
• Investigations:
• urine sample,
• If vaginal discharge are present take some vaginal swabs.
• ultrasound of abdomen and pelvis.

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Abdominal pain in pregnancy

• Common complaint
• Midwife need to distinguish between:
• physiologic and
• pathologic abdominal pain

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Causes of Abdominal pain in pregnancy

• Physiological:
1. Heart burn
2. Constipation
3. Braxton hicks contraction
4. Mal-presenting fetus
5. Round ligament pain
6. Severe uterine torsion (twisting)

Causes of Abdominal pain in pregnancy

• pathological
• Spontaneous miscarriage
• Leiomyoma
• Ectopic pregnancy
• Hyperemesis gravidarum
• Preterm labor

Causes of Abdominal pain in pregnancy

• Pathological: (cont.)
• Chorioamnionitis
• Ovarian pathology
• Placental abruption
• Spontaneous uterine rupture
• Abdominal pregnancy
• Trauma to abdomen
• Sever pre-eclampsia
• Acute fatty liver of pregnancy

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Causes of Abdominal pain in pregnancy

• Appendicitis
• Acute cholestasis/ cholelithiasis
• Gastro-oesophageal reflux
• Peptic ulcer disease
• Acute pancreatitis
• Urinary tract pathology
• Inflammatory bowel disease
• Intestinal obstruction

Causes of Abdominal pain in pregnancy

• Rectus haematoma (an accumulation of blood in the sheath of the rectus abdominis muscle)
• Sickle cell crisis
• Porphyria (disorders of certain enzymesPorphyria (disorders of certain enzymes in the heme bio-synthetic pathway )
• Malaria
• Arteriovenous haematoma
• Tuberculosis
• Malignant disease
• Psychological causes

1. Uterine fibroid degeneration

• In early pregnancy (20-22 wks)
• fibroid increased in size during pregnancy
• Cause recurrent pain for 4-7 days, nausea, vomiting, pyrexia
• Problem: Central core necrosis (cause by pregnancy pressure)
• Management: reassurance, rest, analgesia
• Possible rupture of uterus

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2. Severe uterine torsion

• Uterus rotation to the right >90 degree
• Pain in late pregnancy
• Predisposing Factors: fibroid, malformation of uterus, mass, hx of surgery
• Management:
• bed rest,
• positioning,
• analgesia,
• monitor fetus,
• may need laparotomy or manual correction

3. Pelvic girdle pain/ symphysis pubis dysfunction

• Abnormal relaxation of pelvic ligaments which cause increase mobility in the joint
• Caused by: relaxin, genetic factors
• S& S; pubic pain, backache, muscle pain
• Management:
• reassurance,
• rest on firm mattress,
• panty girdle,
• referral,
• post natal physiotherapy

I. Abdominal pain: role of the midwife

• Health history
• Physical examination
• Recorded of the results
• Referral and management

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Abdominal pain: role of the midwife

• Treatment depend on:
• the cause and
• woman and fetal condition
• Care and support
• Psychological support
• Provide information (informed decision, less fear)

II. Antepartum hemorrhage (APH)

• Bleeding from the genital tract in late pregnancy, after the 24^th week of gestation and before the onset of labor

APH: Effects on the fetus

• Increase fetal mortality and morbidity
• Still birth
• Neonatal death
• Hypoxia cause sever neurological damage

APH : Effects on the mother

• Shock
• Disseminated intravascular coagulation (DIC)
• Maternal death
• Perminent ill health

Types of antepartum hemorrhage

• Incidental
• Placenta praevia
• Placenta abruption

Causes of bleeding in late pregnancy

• Unclassified bleeding
• Marginal (Bleeding from the edge of a normally implanted placenta)
• Show
• Cervisitis (an inflammation of the uterine cervix)
• Trauma

Causes of bleeding in late pregnancy cont.

Unclassified bleeding cont.

• Valvovaginal varicosites
• Genital tumor
• Genital infections
• Hematuria
• Vasa praevia (fetal vessels crossing or running in close proximity to the inner cervical os)

1. Vasa previa

• A fetal blood vessel lies over the os in front of presenting part

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APH: Assessment of physical condition

• Maternal condition: check for:
• Pallor or breathlessness
• Assess emotional status
• History of events and amount of blood loss
• V/S: Pulse rate, respiratory rate, blood pressure and temperature
• Assess the amount of blood loss
• Gentle abdominal examination to asses labor
• No vaginal examination
• No rectal examination
• No suppositories
• No enema

APH: Assessment of physical condition

• Fetal condition: check for:
• Fetal movement count
• Fetal heart rate
• Ultrasound

Factors assist in the diagnosis of APH

1. Location of placenta
2. Pain: precede bleeding, continuous or intermittent
3. Onset of bleeding: associated with what (eg. Coitus)
4. Amount of visible blood loss: some may be in utero
5. Color of blood: bright red or darker

Factors assist in the diagnosis of APH

6. Degree of shock:
7. Consistency of abdomen: soft or tense and board-like
8. Tenderness of the abdomen: pain with palpation
9. Lie, presentation and engagement: normal according to GA or not
10. Audibility of the fetal heart:
11. Ultrasound scan: placenta site

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Supportive treatment of APH

1. Emotional reassurance
2. Fluid replacement
3. Plasma expander (crystalloids (N/S, RL, D5W) and colloids (Gelofusine)
4. Whole blood if needed
5. Analgesia
6. If at home: transfer to hospital

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III. Jaundice in pregnancy

1. Intra-hepatic cholestasis of pregnancy
2. Acute fatty liver
3. Gall bladder disease
4. Viral hepatitis

1. Intra-hepatic cholestasis of pregnancy

• Idiopathic condition (unknown)
• Pathophysiology: bile metabolism bio-chemistry alteration (sensitivity to estrogen),
• may affect placental flow
• Usually in the third trimester
• Resolve after birth spontaneously (9% recurrent)
• Prevalence: 7 in 1000

Intra-hepatic cholestasis of pregnancy

• S&S; pruritus at night , fatigue, insomnia, mild jaundice; may have fever, nausea, vomiting and abdominal pain
• Causes; unknown, genetic, geographic, and environmental
• Management: anti-pruritic agents, anti-histamines, hygiene, vitamin k (problem with absorption), psychological care, fetal well being

2. Acute fatty liver of pregnancy

• Rare condition (1 in 7000 to 1 in 13000),
• obese women,
• low reoccurrence
• Unknown cause
• Fatal for mother and baby if not treated

Acute fatty liver of pregnancy

• S&S; headache, vomiting, malaise, sever abdominal pain, jaundice, drowsiness, tender liver but not enlarged, increased liver enzymes, signs of renal Failure and hypoglycemia
• Dx; U/S and CT scan (fatty infiltration)
• Management:
• fresh frozen plasma,
• termination of pregnancy,
• preferred vaginal birth,
• no epidural anesthesia

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3. Gall bladder disease (stones)

• Diagnosis:
• history,
• U/S
• Management;
• analgesia,
• hydration,
• naso-gastric suction,
• antibiotic
• Avoid surgery if possible

4. Viral hepatitis

• Most common cause of jaundice (hepatitis A,B,C)
• Affect 1 in 1000 pregnancies
• S&S;
• may be asymptomatic or flu like signs, nausea, vomiting, anorexia, pain, mild diarrhea, jaundice, malaise, rare fever
• Hepatitis B:
• C/S does not prevent infection of baby
• Vaccination of the baby
• Breast feeding is not contraindicated

Skin disorders

1. Physiologic pruritis (over abdomen); need assurance and calamine lotion
2. Pemphigoid gestationis (herpes gestationis)
• Causes:
• Unknown cause
• Autoimmune response to paternal antigens
• Pregnancy hormones
• S&S; itching, burning, rash, blisters
• Management; skin biopsy, steroids, hygiene, high vitamin diet
• May be recurrent in subsequent pregnancy, ovulation time and menstruation time

Disorders of amniotic fluid

• Hydramnios
• oligohydramnios

Hydramnios

• With diabetic patients
• Unknown cause: high glucose level increase water
• Complications:
• Placenta abruption
• Uterine dysfunction
• Post partum hemorrhage
• premature labor

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Oligohydramnios

• Associated with anomaly of urinary tract: renal agenesis or obstruction of tract
• Complications:
• Potter syndrome flat nose, recessed chin, low set ears
• Limb abnormalities
• Pulmonary hypoplasia
• Fetal growth restriction
• Treatment:
• Amnioinfusion (RL)