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Anti natal care, Anaemia, 20230413_021546, talk about gestational HTN --…
Anti natal care
Antinital care visits
First before 12 weeks
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examine thyroid lymph nodes breast age 15 40 hight more 152 weight BMI 19 29 blood pressure diastolic more 90 refer fundal height
Tests urine glucose blood diseases TEST HIV . SYPHILIS IF NOT DONE and check for asymptomatic bacteriurua OGTT .NOW AND 22 WK ...RH
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Risk grading ... IMMUNISATION . tetanus for tetanus neonatorum . education part about supplements. Immunization.. visits.
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Second 13 to 15 weeks
Examine and risk grading and add iron supplementation and refer for obestetrician for anomaly and US if no available do fundal hight
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Sexith 36.38 wk
As usual but add appointment at 40 weeks and secondary care and check fetus presentation and counselling
Complications
HTN
PIH HYPERTENSION
PIH
If blood pressure more than 140 over 90 into occasions tow 4 haours a part
After 20 weeks
And no signs of preeclampsia as proteinuria and no signs of severe preeclampsia such as headache hepatic injury pulmonary oedema blurred vision
Mild up to 149 /99. Just do full lab especially protein urea and call obestetrician
Moderate up to 159/109.full lab especially protein urea and call obestetrician.. start treatment oral labetalol
Severe more than 160/110.. stabilise the patient and they give intravenous hydralazine and then refer the patient as emergency referral
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HIGH RISK PTN
any high risk patient receive aspirin 75 milligram FROM 12 to 34 weeks AND Calcium 2 gram slowly slowly intravenous to prevent preeclampsia
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Preeclampsia
Preeclampsia BP more than 140 / 90 IN TWO occasions 4 hours apart with proteinuria after 20 weeks
IF BEFORE 20 WEEKS IT'S CALLED pre-eclampsia superimposed chronic hypertension
Mild. Up to 149/99 no symptoms and no treatment
Moderate up to 159/109 .. look for severe preeclampsia symptoms such as pulmonary oedema low platelets blurred vision renal problems headache hepatic injury or severe elevated blood pressure more 160/110 .. then treat it with labitalol THEN REFER THE PATIENT
SEVERE MORE 160/110.. treat with intravenous hydralazine and mgsulfate AND THEN REFER THE PATIENT AS EMERGENCY
Eclampsia
Eclampsia it is preeclampsia plus CNs symptoms such as convulsion
Treatment with oxygen and maintain a way and intravenous salin 1 mg/kg/h
treat with intravenous hydralazine plus mg sulfate or ca to prevent eclampsia if no mg sulfate give diazepam and if respiratory arrest or absent deep reflexes due to mg sulfate give calcium gluconate AND THEN REFER THE PATIENT AS EMERGENCY CASE
GENERAL INFO
we have to do screen for hypertension and glucose booking and at all visits mandatory
folic acid should be used before conception three months 12 weeks 600 microgram and after 12 weeks to delivery we should use 5 mg
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GDM
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PRECONCEPTION CARE OF DM PATIENT
Control HEA1C less 7
life style modification and exercise
start insulin and replace oral agents
start folic acid 3 months before pregnancy
assis renal creatine GFR if less s than 90 refer
assess retinal control
hypertension MNG
no drug contraindicated as ACE Statin ARBS
start aspirin from 12 weeks to 34 weeks
assess complications of DM
and do TSH tests
Antinatal care of DM pregnant
Ultrasound
Periodic measurements of FBS
And all of preconception care measures
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Glycaemic target
Premeal less t than 5.3
post meal less than 6.7
FBS 5 -7
If uncontrolled pre meal give intermediate acting insulin
If uncontrolled post meal give short acting insulin
If uncontrolled both then give short acting and intermediate acting answering
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Screening
Fbs at booking for all woman
FBS less then 5.1 before risks assessment
If high risk do o g t t now
If low risks do OGTG after 22 to 24 weeks
FBS 5.1- 6.9 it is GDM
FBs more than 7 Go for
More than 12 weeks it is GDM
Less than 12 weeks it is overt and should be referred
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Thyroid
Test as TSH and if it is abnormal refer the pregnant woman
TSH is high WITH normal T4 it is subclinical hypo and needs thyroxine once daily
TSH is high with low T4 it is overt hypo and needs two additional dose
TSH is high in known-case of hypo increase the dose two additional doses
You must and you have to take treatment for 4-6 weeks then reinvestigate TSH هام
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Any hypo thyroid patient notice no menstruation or signs of pregnancy should notify their doctor to increase the dose of treatment
Symptoms of hyper thyroidia three more sweetened heat and tolerance must weakness by what movement decrease exercise hypertension
If hyper after postnatal you may take propranolol for symptoms
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UTI
Two types dysuria and pylonephritis /Cystitis is dysuria only and treatment with nitrofurantoin 100 mg twice for 7 days
But it is contra inducated in G6PD so we can use amoxicillin 500 mg 3 times a day for 7 days and continue 14 days if culture is positive
Or cephalaxin 2 times aday for 7 days
Pylonephritis is dysuria with fever and treated with ultrasound culture iv antibiotic and must be referred
Asymptomatic bacteria
May lead to preterm labour and pylonephritis . So treatment with nitrofurantoin 100 mg bud for 7 days and repeat culture after one week . Or cephalaxin 3 times aday for 7 days
Any pregnant woman should do screening for UTI by urin analysis
Vaginal discharge
Vagina discharge.. firstly take full history and then examine by inspection.. swap .. palpate of abdomen
If abdominal tenderness.and foul smell. so maybe chorea amniocentestits
If without abdominal pain so maybe
Candida.. white discharge with no odour and treatment with clotrimoxazol 500 mg vagina suppository 1 dose
Bacterial vaginosis . White discharge with fishy order and treatment with metronidazole twice for 7 days
Trichomonas vaginalis yellow discharge and offensive ....treatment with one dose 2 gram of metronidazole and treat the partner or metronidazole twice for 7 days
Infectious dieases
Hiv... Any woman should do Eliza at booking
If negative so the pregnant is negative
If positive then do again Elisa . If again positive then the pregnant is positive
If in conclusive do pCR
If positive she can be pregnant and breastfeeding but with IGM injection
Syphilis any woman should do VDRL at booking and if positive so do TpHA to confirm
It is important to treat the patient immediately and referred urgently to protect the mother and foetus
Varicella chicken pox
Vaccine should be taken 3 months before conception
It is transmitted by contact direct or droplet infection
Incubation period is 1-3 weeks. So rash will be appear after 3 weeks
But if it is confirm it contact you should take IGM injection immediately before symptoms appear
It may lead to increase a bortion if infection after first trimester
Diagnosis of contact
Do IGg titr if positive then reassure the patient if negative so give IGM injection in pregnancy immediately before symptoms appear and refer the patient.. if rash appear then give a cyclovir even she is pregnant
Vaccine can be taken with breastfeeding
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Risk grading
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Obstetrics
Previous hemorrhage or anaemia or surgery or anomaly or infertility . history of diseases in recent pregnancy..last menstruation
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Immunisation
Every pregnant should take five doses of tetanus immunisation and rubella immunisation if she doesn't take rubella before pregnancy she should take it after delivery immediately or take it during the pregnancy with caution because it is recommended to be taken before pregnancy three months
Supplementation
Folic acid 600 mico till 12 weeks
and 5 mg after 12 week
standard dose of iron is 150 mg one does daily
calcium and aspirin to prevent preeclampsia and vitamin d
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Pregnancy bleeding
Firstly you have to determine if it is in shock or nor boy rabbit evaluation and rabbit brief history
And then determine early pregnancy or late pregnancy
Early bleeding pregnancy means before 22 weeks
Causes of early bleeding in pregnancy 6666 .... ectopic pregnancy and this is a associated with shock or threatened abortion or complete abortion or in available abortion or incomplete abortion or ruptured uterus or molar body
If no shock please do vaginal examination to determine the type of abortion
Ectopic pregnancy shock with abdominal pain
Molar body grips like projections with heavey bleeding
Threatened abortion minimal bleeding with closed cervix with a light bleeding
Complete abortion close the cervix with history of bleeding
Incomplete abortion open cervix with bleeding now with partial exclusion of products of conception
Inevitable abortion open cervix with bleeding now with no products of conception
Light bleeding means that cloth takes 5 minutes or more to be soaked
All cases must be stabilised by ABCD and then repair as emergency case
وبالتالي كده ببساطه في الاسابيع قبل الاثنين وعشرين لو الم في البطن مع نزيف شديد مع شوك على طول ده اكتبك ولو اي نوع ثاني يبقى بص على باقي الانواع عن طريق الفحص
Late pregnancy bleeding after 22 weeks
As early bleeding pregnancy do a rapid evaluation and take history to determine if it is in shock or not
Causes of late bleeding pregnancy..3333 rapture uterus..placenta abruption..placenta previe ..
In ruptured uterus the foetus is dead and no movement
In previe the foetus is normally movement but fatal presentation is abnormal
In abruption the foetus has decreasing blood flow so it is decreased movement and distress
All three types will be presented with shock and abdominal pain with bleeding
Management.. as early bleeding but do not do vaginal examination.. and all those keep in mind the shock. And refer all cases as emergency referral
DANGER signs
How to look for danger signs .. 1_preeclampsia so search for headache blurring vision oedema convulsion 2_DVT so search for calf muscles tender or leg swelling 3_pneumonia so search for difficult breathing 4_vagina bleeding or severe abdominal pain 5_fever 6_shock
Abortion is before 22 weeks so it is found early pregnancy
ER CASES تجميعات
Emergency cases in pregnancy..1/vaginal bleeding 2/convulsion or unconsciousness 3/high grade fever 4/abdominal pain 5/
So bleeding are early pregnancy or late pregnancy or postpartum
Causes of postpartum bleeding..1. utetin atony 2_tear of cervix and vagina 3 _retainef placenta 4_inverted uterus 5_trauma لاتنساها ف
الجميع
Early pregnancy bleeding.. abortion all types.. uterin rapture.. chorioamnionitis...trauma this is before 22 week
Late pregnancy bleeding..trauma .. delivery.. placenta previe or placenta abruption or uterin rapture
Causes of abdominal pain in pregnancy.. ovarian cyst ..appendicitis... ectopic pregnancy ...pre-terme labour ...rupture the utetus .. abruption placenta .. chorioamnionitis
Causes of convulsion... eclampsia or fever during septic shock
Causes of fever.. during a pregnancy pylonephritis..pneumonia..chorioamnionitis.. septic abortion.
Cause of fever after birth...endometritis epicially after CS ...menengitis...pelvic abscess .. ovarian abscess.... .. .. peritonitis. Breast engorgement mastitis breast abscess.. pneumonia
Unconscious or convulsion in pregnancy.. examine BP for eclampsia or examine temperature for fever shock
Management of all emergency cases firstly.. take brief history and examination including blood pressure and vital signs... Secondly call for help.. 3/ check for shock.. if shock please pleeeease call for help 😀 check the cause if bleeding early late or after .or if fever during the pregnancy or after birth or because of trauma ....
When management the shock don't forget to do cross match before infusion of intravenous fluids.. and catheterization and oxygen by nasal mask and after stabilisation do emergency referral
Immunisation
Vaccines to be given in pregnancy
Don't forget to take five doses tetanus immunisation
Hepatitis b . Influenza.. meningococcal. Yes take them before pregnancy or even during the pregnancy or even after pregnancy
MMR and varicella . Take them before pregnancy 3 months or after delivery
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Anaemia
Anaemia means haemoglobin level less than 11 and the duration of treatment is 4 weeks and the haemoglobin should raise 2 g in 1 month and if there are no improvements you should check for diet and interactionn with other medications and for compliance with medications and side effects of the medication such as vomiting or diarrhoea which decrease the absorption of the iron
Mild animal haemoglobin level from 10 to 10.9 and the treatment is iron supplementation 150 mg a daily with folic acid once a daily
Moderate anaemia haemoglobin level from 7 to 10 and the treatment is 3 times iron supplementation 200 mg and one time folic acid and reinvestigate after 1 month and if the gestational age more than 34 weeks you should refer this case as urgent referral because of exhi expectedcomplications before delivery
Severe anaemia when haemoglobin level less than 7 and this case should be referred immediately as emergency referral
Every woman should do haemoglobin level 6 weeks after delivery if haemoglobin level lower than 11 she should take iron supplementation for 3 to 6 months
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Postpartum hypertension
If new case.. assis the treatment because it's me be due to medications such as increasing saline or NSIADS or ergots
Then take full history and examination and ensure it is not HEELP S OR preeclampsia
Drugs as in non-pregnant women
No methyldopa in ttt because of postnatal depression
Pp HTN after preeclampsia
Advise the patient if she experienced any signs of severe preeclampsia seek ER
But mostly the symptoms AND BP will resolve by itself after 12 weeks PP
If pp hypertension post PIH
Stop medications after 3 weeks and review after 6 weeks and the target of blood pressure is less than 140/90 ..If needs anti HTN treatment refer him
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talk about gestational HTN -- chronic hypertension-- eclampsia and PRE eclampsia
definition FULL and types and treatment of each type
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