Q. Which of the signs listed below enable an accurate diagnosis of pregnancy in the second trimester?

A. Increased volume of the uterus

B. Objectifying perception and active fetal movements

C. Palpation of fetal parts

D. Softening of the cervix

E. Listening of the fetal heart using cardiotocography

Which of the following statements are false regarding the changes at the level of the cardiovascular system during pregnancy?

A. Cardiac output gradually declines.

B. Cardiac output rise.

C. Increasing volume expansion.

D. Decreased volume expansion.

E. Ejection decreases after 30 SA.

Q. Which of the hematological modifications listed below are found in a normal pregnancy?

A. Decreased leukocytes B. Increased number of leukocytes C. Hypercoagulability D. Normocoagulabilitity E. Hemodilution with decreased red blood cell count

• Metabolism and Emotional Effects:
• Altered metabolism of catecholamines, steroid hormones, and the endorphin system can lead to:
• Sleep disturbances
• Fatigue
• Emotional lability
• Character disorders
• Postpartum Depression:
• Potential risk of occurrence
• First Trimester Symptoms:
• Central origin of morning sickness and vomiting
• State of drowsiness
• Vagotonia in the neurovegetative system
• Second Trimester Mood:
• Possible states of good mood and euphoria
• Third Trimester Changes:
• Depressive manifestations
• Chronic fatigue
• Sympatotony in the neurovegetative system

• Parathyroid: Experiences hypertrophy leading to increased parathormone concentration, resulting in hypercalcemia. The placenta acts as a calcium pump.
• Adrenal Hormones: Maternal cortisol rises, impacting total and free calcium levels. Maternal total calcium decreases due to decreased albumin, but the proportion of free ionized active calcium remains constant due to Parathyroid Hormone (PTH).
• Vascular Changes: Vascularization increases substantially from the start of pregnancy, leading to hypertrophy.
• Gonadotropic Hormones: Serum levels, especially LH, decrease due to prolactin inhibition. Cyclic secretion ceases, leaving only continuous basal secretion.
• Prolactin: Serum levels increase progressively, losing pulsatile characteristics. Prepares the mammary gland and supports the yellow gestational body.
• TSH (Thyroid Stimulating Hormone): Levels do not rise during pregnancy.
• Growth Hormone (GH): Alongside hPL (human placental lactogen) and prolactin, it forms the lactogenic hormone complex.
• Melanocyte Stimulating Hormone (MSH): Secretion doesn't seem to be altered.
• Oxytocin: Plays an essential role in myometrial action during labor and supports uterine dynamics.
• Pancreas: Carbohydrate metabolism is influenced early on by increased estrogen and progesterone, leading to beta-pancreatic hyperplasia.
• Placenta: Functions as an endocrine gland, synthesizing hormones that reach both maternal and fetal circulation. Cytotrophoblast and Syncytiotrophoblast: Synthesize various neurohormones resembling hypothalamic and pituitary functions, releasing hormones like hG, HPL, TSH-like substances.

• Basal Metabolism: Increases by 10-20%, leading to decreased alkaline reserve and a propensity towards acidosis.
• Carbohydrate Metabolism: Influenced by hormones from the pancreas, adrenal, pituitary, and placenta, highlighting changes in carbohydrate metabolism. Glycemia generally remains within normal limits, necessitating an oral hyperglycemia test if blood sugar changes occur (hyperglycemia).
• Lipid Metabolism: Lipemia escalates due to increased HPL and chorionic GH, affecting lipid storage and lipolysis.
• Protein Metabolism: Essential for fetal growth and development, requiring a high-protein diet (1.5 g/kg/day). Total serum protein levels decrease to 55-60 g/l, impacting the albumin-globulin ratio.
• Water and Electrolyte Metabolism: Total water increases up to 7 liters during term pregnancy, mostly in extracellular water. Plasma volume rises until 7 months, followed by a decrease, causing reduced hematocrit. Water retention occurs during pregnancy, while Na, Cl, and K values remain unchanged.
• Phosphor-Calcium Metabolism: Calcium and phosphatemia decrease by 10%, causing an increase in calcium concentration and "physiological hyperparathyroidism."
• Magnesium Metabolism: Low serum Mg levels may contribute to miscarriage or preterm delivery.
• Iron Metabolism: Fetal reliance on maternal iron reserves increases iron needs in pregnant women. Hemoglobin decreases due to hemodilution; values below 11 g% indicate anemia during pregnancy.

• Gastroesophageal Reflux Disease (GERD): Attributed to heightened intra-abdominal pressure and progesterone's effects, including decreased sphincter tone and delayed gastric emptying.
• Increased Gallstones: Progesterone leads to heightened gallbladder stasis, causing a rise in gallstone occurrence.
• Constipation and Hemorrhoids: Progesterone contributes to decreased GI motility, resulting in constipation and the development of hemorrhoids.
• Gingival Hypertrophy and Pregnancy Gingivitis: Hormonal factors like estrogens cause edema and bleeding, while progesterone enlarges the periodontal space.
• Dental Cavities: Elevated calcium transfer from mother to fetus may lead to increased dental cavities.

• The FDA classifies medicines for use during pregnancy into specific groups.
• Group A: Believed safe based on human research. (Note: Such drugs are rare.)
• Group B: Considered safe in studies not involving humans.
• Group C: Uncertainty remains; safety isn't confirmed.
• Group D: There's evidence suggesting potential harm.
• Group X: Definitely unsafe during pregnancy.
• These meds have shown harmful effects in both animals and people.
• The negative impacts clearly surpass any potential benefits.

• The use of certain substances is advised against during pregnancy.
• Potential effects on brain development are noted.
• Limited information available on the potential risks and safety.

F ❌

• X-rays, CT scans:
• Small doses → no harm.
• Harm threshold → unclear.
• 8 to 15 weeks, high doses → microcephaly, growth restriction, intellectual challenges.
• Scans → use lead shields for fetus protection.

• Methylmercury in fish/seafood.
• Cooking → doesn't remove.
• Mothers → usually unaffected.
• Fetus's brain → sensitive to mercury.
• Effects → developmental delays.
• Severe cases → blindness, deafness, cerebral palsy.
• Canned tuna = mercury-tested, considered safe.

• Determined by measuring the depth of fluid pockets (in centimeters). 📷
• Measurements taken in all four abdominal quadrants.
• Typically considered normal when the range is around 10 to 15 cm.
• Oligohydramnios indicated by measurements < 5 cm. 📷
• Polyhydramnios occurs when measurements > 24 cm. 📷

• rarely employed test to assess the safety of a vaginal delivery.
• Involves monitoring fetal heart rate following oxytocin or nipple stimulation.
• Late heart rate decelerations 📷 can signal hypoxia → C-section due to an inability to tolerate labor.

• Utilizes Doppler ultrasound technology.
• Assesses flow velocity and direction.
• Normal flow maintains a continuous forward direction.
• Abnormalities include absent or reversed diastolic flow. 📷
• Absence of end-diastolic flow velocity (AEDV).
• Reversal of end-diastolic flow velocity (REDV) indicates impending fetal demise.

⇒ Typically necessitates urgent delivery.

A. When the first fetus is in breech and the second is in cephalic presentation, there is a risk for locking phenomena during vaginal delivery, and the cesarean section is preferred.

B. If both fetuses are in cephalic presentation, there is a risk of collision, and if this occurs after the onset of labor, the cesarean section is the correct choice.

C. When the first fetus is in breech and the second is in cephalic presentation, there is a risk for compaction during vaginal delivery.

D. If the second fetus is in transverse lie, the cesarean section is not mandatory.

E. The acute fetal distress of only one fetus doesn't mean that a vaginal delivery is not possible.

A. The incidence of multiple pregnancy increased in the last two decades, also due to widespread assisted reproductive techniques. B. The monochorionic twin pregnancy implies two separate placentas. C. Conjoined twins are the result of early separation of a unique embryo in the first 3 days. D. The positive diagnosis of a twin pregnancy is definitive only at the end of the first trimester due to vanishing twin phenomena, which is possible during the first weeks of a multiple pregnancy. E. Dizygotic twin pregnancy is always bichorionic

A. Preeclampsia is less frequent in multiple pregnancies when compared with singleton pregnancies. B. Preterm deliveries are more frequent with twin pregnancies. C. Iron-deficiency anemia is more frequent in singleton pregnancies than in twin pregnancies. D. The fourth stage of labor after the vaginal delivery of twins is characterized by a lower risk of bleeding due to the usually smaller size of the fetuses. E. Hemorrhage is more frequent after vaginal delivery of twins.

• It refers to the loss of a viable uterine pregnancy before 20 weeks, sometimes occurring in the second trimester, but mainly in the first trimester (before 12 weeks).
• It is often recognized through declining serial hCG levels or via US
• Clinically, it manifests as vaginal bleeding + pelvic cramping
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💬
• Pelvic abdominal pain caused by uterine contractions
• Metrorrhagia (uterine bleeding between menstrual periods)
• Changes in the cervix
• Valve examination - ovular fragments can be revealed at the external cervical orifice
• Vaginal examination - estimates the volume of the uterus in relation to the gestational age, the consistency of the uterus (usually the uterus is contracted).

Risk factors:

• Classics
• Maternal age exceeding 35 years.
• Previous pregnancy loss.
• Smoking and alcohol use.
• Maternal health conditions such as infections, diabetes, and obesity, Thyroid-related issues, Thrombophilias.

DDx for Bleeding:

• other 1st Trimester causes Ectopic pregnancy (EP) Hydatidiform mole
• Gyn causes Uterine fibroids Cervical polyp Cervical erosions Dysfunctional bleeding Ovarian tumors

• Hemorrhagic complications: These can range from heavy bleeding to severe hemorrhage and even septic shock in some cases.
• Infectious complications: Miscarriages can lead to infections such as endometritis (inflammation of the inner lining of the uterus), salpingitis (inflammation of the fallopian tubes), and pelviperitonitis (inflammation of the pelvic peritoneum).
• Late complications:
• Pelvic inflammatory disease (PID): An infection that can affect the female reproductive organs, including the uterus, fallopian tubes, and ovaries. PID can lead to chronic pelvic pain and infertility if left untreated.
• Infertility: Recurrent miscarriages or complications from miscarriages can sometimes result in infertility, making it difficult for a woman to conceive in the future.
• Depression: Miscarriages can have a significant emotional impact on individuals, leading to feelings of grief, sadness, and depression.

Pregnancy OUTSIDE uterus & endometrium

⇒ Most common: Fallopian tube → Ampulla

80% ampulla, 10% isthmus, 5% fimbriae

Other locations: 📷

• Fallopian tube damage
• A history of previous ectopic pregnancy.
• Tubal blockage or obstruction.
• Tubal ligation (although pregnancy is rare).
• Prior tubal surgery related to tumors.
• Pelvic inflammatory disease.
• The use of IUDs

Overall: lower risk of pregnancy with IUDs → However, if pregnancy does occur, there's a heightened risk of it being ectopic.

• others:
• infertility treatments
• structural (fibroids, adhesions, anatomical abnormalities)
• smoking (not alcohol!)

Q. Causes of ectopic pregnancy may be: A. Prior tubal surgeries B. Alcohol abuse C. Intestinal inflammatory disease D. Ovarian pathologies E. Infertility treatment

• symptoms typically appear in the first trimester.
• These symptoms may include:
• Vaginal bleeding.
• Abdominal pain, which can sometimes resemble appendicitis.
• Abnormal human chorionic gonadotropin (hCG) levels based on gestational dates.
• Ectopic pregnancies often exhibit smaller-than-expected increases in hCG levels ⇒ An increase of less than 35% in hCG levels over 48 hours may suggest an ectopic pregnancy.
• Normally, hCG should double every 72 hours.
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💬 others
• Fever: Detected in approximately 20% of patients, with temperatures exceeding 38.0°C.
• Abdominal Pain: Occurs in 90% of cases, can be continuous or colicky in nature.
• Tenderness: Noted during bimanual examination and cervical motion tenderness.
• Menstrual Cycle Abnormalities: Presence of amenorrhea followed by scant bleeding that is darker in appearance.
• Pregnancy Signs
• Subjective Pregnancy Signs: Nausea, vomiting, and breast tension are common.
• Gynecological Examination: Presence of signs indicative of pregnancy.
• Chadwick's Sign: Bluish discoloration of the cervix and vagina due to pelvic vasculature engorgement, typically visible from the 6th week of gestation (WG).
• Hegar's Sign: Softening of the cervical isthmus observed between 6-8 WG.
• Uterine Volume: Enlarged uterus noted, but the volume is smaller compared to the duration of amenorrhea.
• Adnexal Mass: Palpable in 50% of cases. Additionally, in half of the patients, a mass attributable to the corpus luteum may be palpated on the side opposite the ectopic pregnancy.
• Peritoneal Irritation: Signs indicative of irritation in the peritoneal cavity.

Clinical Signs:

1. Laffont sign: Pelvic abdominal pain radiating into the shoulder.
2. Ody sign: Pain in the anterior fundus of the vaginal sac, especially during urination.
3. Proust sign: Violent pain on palpation of the vaginal sac, in the backside, known as "Douglas' scream."
4. Mondor sign: A floating sensation of the uterus (due to hemoperitoneum).

In case of rupture of an ectopic pregnancy, there can be an acute abdomen with intensified pain and abdominal relaxation.

Culdocentesis: 📷 Culdocentesis is a diagnostic procedure where the bottom of the pouch of Douglas (cul-de-sac) is punctured, and the characteristics of the aspirated fluid are examined. If the aspirate contains uncoagulated, non-coagulable blood or clots, it confirms the diagnosis of hemoperitoneum, which can be indicative of a ruptured ectopic pregnancy.

TVUS: 📷

1. Transvaginal Ultrasound (TVUS): While TVUS is a valuable diagnostic tool, it may sometimes be non-diagnostic if the pregnancy is too small to localize, or if a spontaneous abortion has occurred.
2. Follow hCG Levels: Human chorionic gonadotropin (hCG) levels are monitored. They are typically measured every 48 hours.
3. Falling hCG Levels: If hCG levels are falling, it indicates a nonviable pregnancy. This could be indicative of a miscarriage.
4. Slowly Rising hCG Levels: If hCG levels are rising slowly, it suggests the possibility of an ectopic pregnancy.
5. Repeat TVUS: A repeat transvaginal ultrasound may be performed to identify whether the pregnancy is intrauterine or ectopic.

• A rare form of pregnancy.
• Associated with trophoblastic placental neoplasms.
• Typically benign → molar pregnancies.
• In rare instances, it may be malignant (see types)

• Detachment = Prior to delivery
• Blood loss from maternal circulation

→ no blood to fetus

→ contraction of uterus (triggered by bleeding)

⇒ life-threatening condition for both fetus and mother

1. 🔂 previous PD
2. 🤰🏼 maternal disorders
• 😷 pre-existing placental RF (HT, pre-eclampisa,vasoconstrictor[smoking, cocaine])
• 👛 uterus d. (structural, C-section)
3. 🚗 Trauma
4. ⬇️ rapid decrompression (twin)

Q. Regarding the diagnosis of premature detachment of a normally situated placenta (abruptio placentae), the symptoms found in the obstetrical syndrome may include:

A. Pain B. Relaxed uterus C. The disappearance of fetal movements or altered fetal heart rate D. Vaginal bleeding (not necessarily in all cases) E. Lowering of the fundus of the uterus

• Fetal distress → might lead to demise
• Maternal
• Hypovolemic shock (maternal)
• DIC
• Cortical necrosis
• lack of blood flow leading to kidney cortex damage → Acute kidney failure • Linked to decreased blood supply and clotting disorders • Commonly linked with placenta detachment
• Symptoms include:
• ARF and Absence of urination (anuria)
• Flank pain
• Blood in urine (possibly macroscopic)

• US ⇒📷 retroplacental hematoma (but not reliable)
• +- MRI
• Other: coagulation markers, renal markers, hepatic markers, fetal heart mornitoring

Sexton's Classification:

• Depending on the detached placental surface:
• Stage I: Detachment of 1/6 of the placental surface.
• Stage II: Detachment of up to 50% of the placental surface.
• Stage III: Detachment of over 50%.

Page's Classification:

• Based on severity (bleeding, contraction, FHB, coagulat.):
• Stage 0: Infraclinical (subclinical) hematoma recognized post-delivery.
• Stage I: Characterized by an irritable uterus with slight contraction and general stability, ↓bleeding, FHB present
• Stage II: Features a contracted uterus, without shock, but friable blood clots (more bleeding), FHB altered
• Stage III: Defined by uteroplacental apoplexy (Couvelaire syndrome 📷), a state of shock, and potential coagulation disorders, FHB undetectable

❤️ Fetal HR monitoring

• Definition: Placenta goes before baby
• Location: Near or at cervical opening
• Attachment: Lower section of womb

• Normal: Positioned >2 cm away from cervix
• Complete: Fully covering cervical opening
• Partial: Covers part of the cervix
• Marginal: Reaches cervix edge
• Low: Border within 2 cm of opening

• history of:
• Placenta previa
• Cesarean delivery
• past pregnancy
• uterine operations

→ Alkalosis? / Hypokalemia?

→ Ketones (urinary)?

Thiamine def. → Wernicke’s encephalopathy (but few cases reported only)

↓

Etiology: Anti-insulin factors produced by placenta and high maternal cortisol levels create increased peripheral insulin resistance, leading to GDM and/or exacerbating pre-existing DM.

a. Abortion b. Postterm delivery (→ preterm) c. Amniosis (→ poly) d. Macrosomy e. Postpartum hemorrhagic complications

>30% over Target values?

Targets: Fasting < 95 1hr postprandial <140 2h postprandial <120

↓

- no ⇒ Diet + Exercise

+ yes ⇒ Insulin (+- Metformine)

• Diabetes typically resolves after childbirth.
• However, there is an elevated risk of developing DM2 following delivery.

⇒ Screening for postpartum diabetes is recommended with a 2-hour glucose tolerance test (GTT) conducted 6-12 weeks after giving birth.

• During pregnancy, women with normal blood pressure levels often experience a reduction in blood pressure, predominantly at the end of the first trimester. This decline is attributed to significantly increased vasodilation, a compensatory mechanism for the increased plasma volume associated with pregnancy.
• The decrease in blood pressure is notable, generally falling by 5 to 10 mm Hg, and this reduced level is maintained throughout the pregnancy until the onset of the third trimester.
• As the third trimester progresses, blood pressure typically begins to return to the levels noted pre-pregnancy. This pattern is consistent with the physiological changes and demands of late pregnancy on the maternal cardiovascular system.
• For women with pre-existing chronic hypertension, the blood pressure pattern during pregnancy mirrors this general trend. However, around 33% of these women will experience a normalization of their blood pressure during pregnancy, while another 33% will continue to have unchanged blood pressure readings. The remaining third are at an increased risk of developing preeclampsia, a serious hypertensive disorder of pregnancy characterized by high blood pressure and often a significant amount of protein in the urine.

1. Chronic HT → BEFORE 20w + PERSISTS >12w postpartum
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💬
a. Essential Hypertension: This includes women who enter pregnancy while already on antihypertensive therapy, and the cause remains unknown. They typically have lower systolic (sBP) and/or diastolic blood pressure (dBP).
b. Secondary Hypertension: This type may have identifiable causes, such as:
• Chronic kidney disease (e.g., glomerulonephritis, reflux nephropathy, and adult polycystic kidney disease).
• Renal artery stenosis.
• Systemic diseases with renal involvement (e.g., diabetes mellitus, systemic lupus erythematosus).
• Endocrine disorders (e.g., pheochromocytoma, Cushing's syndrome, primary hyperaldosteronism, hyperthyroidism, hypothyroidism, hyperparathyroidism, acromegaly).
• Coarctation of the aorta.
• Certain medications and substances (e.g., decongestants, steroids, licorice, cocaine, methamphetamines).
2. Gestational HT → AFTER 20w + RESOLVES <12w postpartum

• proteins (urinary)
• CBC, Renal (incl. uric acid) + liver markers (incl. coagulation)

🥮 PLACENTAL ABNORMALITY (abnormal invasion/transformation of spiral aa. 📷+ other factors) ⇒ ↓PERFUSION (placental)⇒ release circulation substances ⇒ MATERNAL endothelial dysfunct. = VASOSPASM + COAGULATION ⇒ Endorgan-failure (incl. kidney)

Development of systemic features of preeclampsia after 20 weeks gestation in a woman with pre-existing hypertension

‣

DGx?

👉🏽

Serology (IgM + IgG) +- IgG-avidity + PCR(amniocent/cordocent)

Virus can be detect in:

• Pharynx: 7d before until 7 days after rash
• Blood: 7d before until day of rash
• Stool: 4d before until 4d after rash (in children w/ subclinical infection)

→ Most contagious from: day of rash until 7d after

⇒ Infection = lifelong immunity

Q. What part of pregnancy has the highest malformation risk for rubella infection?

a. 3rd trimester b. After 20 gestational weeks c. 1st trimester d. 2nd trimester e. 1 month before birth

Routine First Pregnancy Visit: rubella, chickenpox, and syphilis

• Rubella: Detection of antibodies
• Chickenpox (Varicella): Identification of antibodies
• Syphilis: Using tests RPR/VDRL

Further Tests Depending on Medical Practice

• Toxoplasmosis, Herpes Simplex Virus (HSV), Parvovirus B19, Cytomegalovirus (CMV)

Hormonal Effects on the Urinary System

• Progesterone leading to slowed urine flow
• Softening of muscles in the urinary system

Potential Urinary Conditions During Pregnancy

• Silent urinary infections, bladder infections, or kidney infections

Most common bacteria: E. coli 🥇 Others: S. saprophyticus, GBS, enterococcus

B, C