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A Practical Guide to First Trimester of Pregnancy
Mala Arora, Alok Sharma
CHAPTER 1:
Physiological Changes
INTRODUCTION
GENITAL SYSTEM
Uterus
Uterine Signs
Cervix
Vagina
External Genitalia
Ovaries
Breast
GASTROINTESTINAL SYSTEM
URINARY SYSTEM
CARDIOVASCULAR SYSTEM
MUSCULOSKELETAL SYSTEM
CENTRAL NERVOUS SYSTEM
CUTANEOUS CHANGES
WEIGHT
OSMOREGULATION
METABOLISM
ENDOCRINE SYSTEM
EMBRYONAL AND FETAL DEVELOPMENT
CHAPTER 2:
Dating and Chorionicity
INTRODUCTION
TERMINOLOGY
DATING OF EARLY PREGNANCY
Gestational Sac
Rules for Gestational Sac Measurement
Crown-rump Length
Rules for Crown-rump Length Measurement
Biparietal Diameter
CHORIONICITY
ZYGOSITY (Fig. 12)
Dizygotic Twins
Monozygotic Twins (Fig. 13)
Complications in Monochorionic Twins
CHAPTER 3:
The Booking Visit
INTRODUCTION
ORGANIZATIONAL ISSUES
FOCUSED ANTENATAL CARE
Goals of Antenatal Care
Core Components of Basic Antenatal Care Visit
HISTORY
PHYSICAL EXAMINATION
Weight and Height
Blood Pressure
Pelvic Examination
LABORATORY SCREENING
Universal Tests
Hemoglobin/Hematocrit
Platelet Count
Hemoglobin Electrophoresis
ABO/Rh (D) Type and Antibody Screen
Blood Sugar
Syphilis Screening
Hepatitis B Virus
HIV Serology
Thyroid Status
Urine for Asymptomatic Bacteriuria
Rubella IgG
Selective Tests
Infectious Diseases
PAP Screening
ULTRASOUND SCREENING
SCREENING FOR ANEUPLOIDY
COUNSELING ABOUT LIFESTYLE ISSUES
Nutrition and Nutritional Supplements
Working and Travel During Pregnancy
Alcohol and Smoking
Sex and Sexuality
Exercise in Pregnancy
Prescribed Medicines
MANAGEMENT OF SYMPTOMS AT THE FIRST VISIT
Nausea and Vomiting
Heartburn
Constipation
Vaginal Discharge
REFERENCES
FURTHER READING
CHAPTER 4:
Diet Counseling
INTRODUCTION
NUTRITIONAL STATUS
Weight Gain in Pregnancy
Assessment of Nutritional Status
Preconceptional Counseling
DIET AND FEEDING PATTERN
Healthy Diet during Pregnancy
Calories
Complex Carbohydrates
Protein
Fat
Fiber
Iron
Salt
Fluids
Vegetables
Grains and Legumes
Essential Minerals and Vitamins for Pregnant Women
Minerals
Vitamins
Maintaining a Vegetarian Diet
ENERGY NEEDS OF PREGNANCY— JUST A LITTLE MORE FOOD
FOODS TO AVOID DURING PREGNANCY
COMMON AILMENTS IN PREGNANCY AFFECTING NUTRITION
Morning Sickness
Heartburn and Indigestion
Medications
NUTRITIONAL RISK FACTORS IN PREGNANCY
CHAPTER 5:
Nausea and Vomiting
INTRODUCTION
CAUSES
Psychological
Gastrointestinal Tract Dysfunction
Hormonal
DIFFERENTIAL DIAGNOSIS AND EVALUATION
Laboratory Tests
Maternal and Fetal Outcomes
TREATMENT
Nonpharmacological Therapy
Dietary Modification
Emotional Support
Ginger
Acupressure
Transcutaneous Nerve Stimulation
Pharmacologic Therapy
Pyridoxine (Vitamin B6) and Doxylamine
Antiemetics
Antihistamines and Anticholinergic
Motility Drugs
Corticosteroids
Supportive Treatment
Intravenous Fluids
Enteral or Parenteral Nutrition
CHAPTER 6:
Hyperemesis Gravidarum
INTRODUCTION
RISK FACTORS FOR HYPEREMESIS GRAVIDARUM
COMPLICATIONS
Maternal
Fetal
EVALUATION AND DIAGNOSIS
Identification of Other Causes
Assessment of Severity
Investigations
DIFFERENTIAL DIAGNOSIS
MANAGEMENT
Principles of Management
Parenteral Fluids
Antiemetics
Corticosteroids
Vitamin Supplementation
DIETARY AND LIFESTYLE ADVICE
TOTAL PARENTERAL NUTRITION
THROMBOPROPHYLAXIS
PSYCHOLOGICAL SUPPORT
ALTERNATIVE THERAPY
Ginger
Acupuncture
Acupressure
CONCLUSION
CHAPTER 7:
First Trimester Screening
INTRODUCTION
SCREENING FOR FETAL ANEUPLOIDIES
Nasal Bone
Requirements for Accurate Nasal Bone Measurements10
Free Beta Human Chorionic Gonadotropin
Pregnancy-associated Plasma Protein A
SCREENING FOR FETAL STRUCTURAL ABNORMALITIES
SCREENING FOR PREECLAMPSIA
SCREENING FOR SMALL FOR GESTATIONAL AGE FETUSES
SCREENING FOR PRETERM DELIVERY
SCREENING FOR MISCARRIAGE AND STILLBIRTH
CONCLUSION
CHAPTER 8:
Invasive Procedures
INTRODUCTION
INDICATIONS FOR PRENATAL DIAGNOSIS IN FIRST TRIMESTER
Indications for Chorionic Villous Samples
RECOMMENDATIONS BEFORE PRENATAL PROCEDURES IN FIRST TRIMESTER
METHODS OF INVASIVE PRENATAL DIAGNOSIS IN FIRST TRIMESTER
Chorionic Villous Sampling
Procedure and Approach
Transabdominal Chorionic Villous Sampling
Transcervical Chorionic Villous Sampling
Complications of Chorionic Villous Sampling
Transvaginal Chorionic Villous Sampling
Comparison of Various Approaches of Invasive Prenatal Diagnostic Techniques
Transabdominal Chorionic Villous Sampling versus Second Trimester Amniocentesis
Transabdominal versus Transcervical Chorionic Villous Sampling
Early Amniocentesis versus Transabdominal Chorionic Villous Sampling
Coelocentesis
Technique of Coelocentesis
MULTIPLE PREGNANCY AND SELECTIVE FETAL REDUCTION
Timing, Technique, and Outcome
Complications
Weighing Risks Versus Benefits
CHAPTER 9:
Vaccination
INTRODUCTION
IMMUNIZATION DURING PREGNANCY
ATTENUATED VIRUS VACCINE
Measles-Mumps-Rubella Vaccine
Polio Vaccine
Yellow Fever
Varicella
Influenza
INACTIVATED OR ASSEMBLED VIRUS VACCINE
Hepatitis A
Hepatitis B
Human Papilloma Virus Vaccine
Rabies
LIVE ATTENUATED BACTERIAL VACCINE
Bacillus Calmette–Guérin Vaccine
INACTIVATED BACTERIAL VACCINE
Pneumococcal Polysaccharide Vaccine
Meningococcal Conjugate Vaccine
Typhoid
Anthrax
TOXOIDS
Tetanus
IMMUNOGLOBULINS
Hepatitis B
Rabies
Tetanus
Varicella
Hepatitis A
NEW DEVELOPMENTS
MEDICOLEGAL AND ETHICAL CONSIDERATIONS
CONCLUSION
CHAPTER 10:
Supportive Drug Use
INTRODUCTION
HUMAN CHORIONIC GONADOTROPIN
PROGESTERONE
Route of Administration
Oral Route
Intramuscular Route
Vaginal Route
Duration of Administration
DOCOSOHEXANOIC ACID
FOLIC ACID
ASPIRIN
HEPARIN
ANTIOXIDANTS
AYURVEDIC OR HERBAL PREPARATIONS
CHAPTER 11:
Prescription Writing
INTRODUCTION
STAGES OF DEVELOPMENT IN RELEVANCE TO TERATOGENECITY
Implantation Phase
Embryonic Phase
Fetal Phase
PRINCIPLES OF PRESCRIBING IN PREGNANCY
DEFINING PREGNANCY RISK
REPRODUCTIVE HEALTH NEEDS OF WOMEN ON TERATOGENIC MEDICATIONS
Identifying Teratogens
Assessing Fertility Intentions
Preconception Counseling and Pregnancy Testing
Prescribing for Women who are Pregnant or Desiring Pregnancy
Improving Providers' Ability to Address Women's Reproductive Health Needs
EFFECTS OF PREGNANCY ON DOSE REQUIREMENT OF DRUGS
Total Body Water Changes
Total Drug Concentration
Free Drug Concentration
Serum Protein
Liver Metabolism
Renal Clearance
MONITORING THERAPEUTIC LEVELS IN PREGNANCY
PASSAGE OF DRUGS TO FETUS AND CATEGORY OF DRUGS
SAFE AND UNSAFE DRUGS
CHAPTER 12:
Effect of Tobacco, Substance Misuse and Alcohol Abuse
INTRODUCTION
IMPACT ON CHILDREN
SPECIFIC SUBSTANCE ABUSE IN PREGNANCY
Alcohol
Public Health Concerns
Smoking/Tobacco Consumption
Cannabis
Cocaine/Crack Cocaine
Opioids
CHAPTER 13:
Travel Guidelines
INTRODUCTION
TRAVEL DURING PREGNANCY
Preparation for Travel during Pregnancy
Traveling By Air during Pregnancy
The Effects of Barometric Pressure on Pregnancy
Seat and Exercise
Seat Belts
Food Choices
Fear of Decreased Oxygen
Deep Venous Thrombosis
Precautions for Prevention of DVT
Airline Policy
Traveling By Car during Pregnancy
Car Travel (as a Passenger)
Wearing the Seat Belt
Car Travel (as a Driver)
Traveling By Bus
Traveling By Train
Appropriate Luggage
Time Management
Choice of Lower Berth
Movement
Washroom Visits
Sea Travel
International Travel
Vaccination against Communicable Diseases for the Pregnant Traveler
Prophylaxis against Malaria
Travel Insurance
CHAPTER 14:
Role of Exercise and Bed Rest
INTRODUCTION
CURRENT EVIDENCE ON BED REST IN PREGNANCY
RISKS OF SEDENTARY LIFE STYLE IN PREGNANCY
BARRIERS TO EXERCISE DURING PREGNANCY8
HISTORICAL PERSPECTIVE
PSYCHOLOGICAL AND PHYSICAL BENEFITS
MATERNAL EXERCISE AND PERINATAL AND FETAL OUTCOME
THERMOREGULATORY SYSTEM IN PREGNANCY
PRECAUTIONS DURING EXERCISE
TYPES OF EXERCISES
COCHRANE REVIEW OF EXERCISE DURING PREGNANCY
CONCLUSION
CHAPTER 15:
Pain Abdomen
INTRODUCTION
CAUSES
PRESENTATION
Acute Pain
Subacute/Chronic Pain
DIFFERENTIAL DIAGNOSIS
DIAGNOSIS
Accurate History
Physical Examination
Investigations
MANAGEMENT
Physiological Causes
Round Ligament Pain
Ovarian Pain
Pathological Causes
Obstetric Causes
Gynecological Causes
Surgical and Medical Causes
Very Rare Causes of Acute Abdomen during Pregnancy
CONCLUSION
CHAPTER 16:
Ectopic Pregnancy
INTRODUCTION
DIAGNOSIS AND LABORATORY STUDIES
Blood (ABO and Rh Type)
Beta-human Chorionic Gonadotropin
Prognostic Evaluation of Serial Beta-human Chorionic Gonadotropin Assay
Progesterone
Other Novel Serum Markers
Imaging Studies
Ultrasonography
Transvaginal Color Doppler Sonography
DIAGNOSTIC PROCEDURES
Dilatation and Curettage
Culdocentesis
Laparoscopy/Laparotomy
SCREENING FOR ECTOPIC PREGNANCY
RISK FACTORS
DIFFERENTIAL DIAGNOSIS
Obstetric Causes
Gynecological Causes
Nongynecological Diseases
MANAGEMENT CHOICES
Catastrophic Presentation
Subacute Presentation
Clinical Prediction Tools
Expectant Management
Medical Management
Systemic Therapy
Methotrexate Therapy
Direct Injection in Sac
Surgical Therapy
Indications for Surgical Therapy
Advantages of Laparoscopic Surgery
Complications due to Laparoscopic Surgery
Indications for Laparotomy
Salpingectomy
Salpingostomy
Fimbrial Evacuation
Partial Salpingectomy
Follow-up
Contraception
UNUSUAL LOCATIONS
Cervical Pregnancy
Abdominal Pregnancy
Ovarian Pregnancy
Caesarean Scar Pregnancy
Other Rare Sites of Ectopic Pregnancy
Prognosis
CHAPTER 17:
Gestational Trophoblastic Disease
INTRODUCTION
HYDATIDIFORM MOLE
Complete Hydatidiform Mole
Partial Hydatidiform Mole
INVASIVE MOLE
CHORIOCARCINOMA
PLACENTAL SITE TROPHOBLASTIC TUMOR
INCIDENCE
CYTOGENETICS OF HYDATIDIFORM MOLE
Monospermic Homozygous
Dispermic Diploidy Heterozygous
PRESENTATION OF MOLAR PREGNANCY
Classic Features of Molar Pregnancy
Rarer Presentations
Very Rare Presentation
DIAGNOSIS OF HYDATIDIFORM MOLE
Ultrasonography
Human Chorionic Gonadotropin
INVESTIGATIONS
COMPLICATIONS
TREATMENT
Evacuation of Molar Pregnancy
Time of Evacuation
Before Evacuation
Method
Prognosis
FOLLOW-UP AFTER MOLAR PREGNANCY
Serum hCG Assay
Chest X ray
Pelvic Examination
Contraception
CHEMOPROPHYLAXIS
INDICATIONS FOR THERAPY
POST-MOLAR GESTATIONAL TROPHOBLASTIC NEOPLASIA
Criteria for Diagnosis of Post-Molar Gestational Trophoblastic Neoplasia
Metastatic Work-up in Gestational Trophoblastic Neoplasia
FIGO STAGING OF GESTATIONAL TROPHOBLASTIC NEOPLASIA
RISK SCORING
TREATMENT OF LOW RISK GESTATIONAL TROPHOBLASTIC NEOPLASIA
Single Agent Chemotherapy Schedules
Monitoring During Chemotherapy
Length of Therapy
TREATMENT OF HIGH RISK GESTATIONAL TROPHOBLASTIC NEOPLASIA
MANAGEMENT OF PLACENTAL SITE TROPHOBLASTIC TUMOR
POST-THERAPY PREGNANCY
RECURRENT MOLAR PREGNANCIES
CHAPTER 18:
HIV Positive Mother
INTRODUCTION
HIV AND PREGNANCY
Factors Affecting Mother to Child Transmission
Maternal Viral Load
Maternal Immune Depletion
Genital Tract Infection
Nutritional Deficiencies
Drug Use
Cigarette Smoking
Unprotected Sexual Intercourse
Opportunistic and Coexisting Infection
Intrapartum Events
Breast Feeding
Recommendation for Screening of HIV in Pregnant Women
Indication of Repeat Testing
Confirmatory Tests
GENERAL PRINCIPLES REGARDING USE OF ANTIRETROVIRAL THERAPY IN PREGNANCY
Initial Evaluation
Indication for Treatment
Antiretroviral Therapy
Antiretroviral Prophylaxis
Drugs and Duration of Antiretroviral Prophylaxis
Drug with Transplacental Passage Indicated
Contraindicated Drugs
ANTIRETROVIRAL PROTOCOLS
ANTENATAL CARE FOR HIV POSITIVE WOMEN
Investigations
SPECIAL CONSIDERATIONS FOR OPPORTUNISTIC INFECTION PROPHYLAXIS DURING PREGNANCY
CHAPTER 19:
TORCH Infection
INTRODUCTION
INCIDENCE
PATHOGENESIS
SPECTRUM OF FETAL AFFECTION WITH TORCH INFECTIONS DURING PREGNANCY
SCREENING
DIAGNOSIS
Serology
Isolation of the Parasite
Tests to Establish Specificity
Ultrasonographic Parameters of Fetal Infection
MANAGEMENT
CONCLUSION
CHAPTER 20:
Medical Disorders
INTRODUCTION
DIABETES MELLITUS
Management
Preconception Care
Insulin Requirement in Patients with Pregestational Diabetes
Newer Insulin Analogs in Pregnancy
Oral Hypoglycemic Agents
CHRONIC HYPERTENSION
THYROID DISORDERS
ANEMIA
Maternal Risks
Fetal and Neonatal Complications
SICKLE CELL ANEMIA
Prenatal Care
Indications for Blood Transfusion during Pregnancy with Sickle Cell Disease
THALASSEMIA
β-Thalassemia
THROMBOCYTOPENIA
Immune Thrombocytopenic Purpura
HEART DISEASES
Open Heart Surgery
ASTHMA
Mild Intermittent Asthma
Persistent Asthma
Asthma Exacerbations during Pregnancy
SYSTEMIC LUPUS ERYTHEMATOSUS
TUBERCULOSIS
CHAPTER 21:
Vaginal Discharge
INTRODUCTION
PHYSIOLOGICAL DISCHARGE
NORMAL FLORA
ABNORMAL DISCHARGE
CAUSES
DIFFERENTIAL DIAGNOSIS
INVESTIGATIONS
Implications of These Infections and Their Management
PRACTICE POINTS
CHAPTER 22:
Breast Diseases
INTRODUCTION
PHYSIOLOGICAL CHANGES OF BREAST DURING FIRST TRIMESTER OF PREGNANCY
IMAGING OF BREAST IN PREGNANCY
Ultrasound
Mammograms
Magnetic Resonance Imaging
EFFECT OF PREGNANCY ON DISEASES PRE-EXISTING IN BREAST
Fibroadenoma
Growth of Fibroadenoma
Infarction in Fibroadenoma
Secretory Hyperplasia or Lactational Change in Fibroadenoma
BENIGN DISEASES CLOSELY RELATED TO PHYSIOLOGICAL CHANGE
Gestational and Secretory Hyperplasia
Spontaneous Bloody Nipple Discharge
Gigantomastia
Granulomatous Mastitis
Benign Neoplasia of the Breast
Lactating Adenoma
MALIGNANT TUMORS
Pregnancy Associated Breast Carcinoma
Pregnancy-related Burkitt Lymphoma of the Breast
CHAPTER 23:
Associated Gynecological Conditions
INTRODUCTION
VAGINITIS
CERVICAL INCOMPETENCE
FIBROIDS
PELVIC INFLAMMATORY DISEASE
TUBO-OVARIAN ABSCESS
PROLAPSE
CERVICAL CARCINOMA IN SITU AND CARCINOMA
SEXUALLY TRANSMITTED DISEASES
OVARIAN CYSTS AND ADNEXAL MASSES
ADNEXAL TORSION
VESICOVAGINAL FISTULA
CONGENITAL ANOMALIES OF THE UTERUS
CHAPTER 24:
Recurrent First Trimester Pregnancy Loss
INTRODUCTION
ETIOLOGY
Risk Factors
Genetic Factors
Recurrent Aneuploidy
Structural Chromosomal Abnormality
Mendelian and Polygenic Factors
Management
Uterine Anomalies
Immunological Causes
Autoimmune Abnormalities
Alloimmune Abnormalities
Infectious Causes
Endocrine and Metabolic Disorders
Diabetes Mellitus
Thyroid Dysfunction
Low Progesterone Levels and Luteal Phase Defects
Polycystic Ovarian Syndrome and Obesity
Inherited Thrombophilia
Lifestyle and Environmental Factors
Psychological Cause
CHAPTER 25:
In Vitro Fertilization Conception
INTRODUCTION
Dating
Ultrasound: Normal Landmarks
Missed Abortion
Ectopic Pregnancy
Trisomy Screening
Multiple Gestation
Progesterone Support
CHAPTER 26:
Twin Pregnancy
INTRODUCTION
INCIDENCE AND EPIDEMIOLOGY
ZYGOSITY AND CHORIONICITY
Classification of Twins by Zygosity
Monozygotic Twins
Dizygotic Twins
Zygosity
Classification of Twins by Chorionicity and Amnionicity
BEST NONINVASIVE DIAGNOSTIC MODALITY—THE ULTRASOUND
TWIN REVERSED ARTERIAL PERFUSION SYNDROME AND ACARDIAC TWIN
VANISHING TWIN SYNDROME
Fetal Morbidity and Mortality
Work-up
Antenatal Care in Vanishing Twin
SURVIVAL OF THE EARLY TWIN PREGNANCY AND COMPLICATIONS
PRENATAL DIAGNOSIS
Aneuploidy Screening
Fetal Sampling Technique: Chronic Villous Sampling or Amniocentesis?
MANAGEMENT OF MULTIPLE PREGNANCIES
Dichorionic-diamniotic Twin Gestations
Monochorionic-diamniotic Twin Gestations
Monochorionic-monoamniotic Twin Pregnancies
FOCUS ON NUTRITION IN FIRST TRIMESTER OF TWIN PREGNANCY
KEY POINTS FOR CLINICAL PRACTICE
CHAPTER 27:
Surgery and Anesthesia
INTRODUCTION
SURGERIES PERFORMED DURING THE FIRST TRIMESTER
Gynecological Surgeries
Nongynecological Surgeries
ANATOMICAL AND PHYSIOLOGICAL CHANGES IN PREGNANCY
MATERNAL SAFETY DURING NONOBSTETRIC SURGERY IN PREGNANCY
Alteration in Laboratory Values
Use of Imaging Technique
Medications During Pregnancy
IMAGING TECHNIQUES
Ultrasound
Risk of Ionizing Radiation
Computed Tomography
Magnetic Resonance Imaging
Nuclear Medicine
Cholangiography
PRINCIPLES OF GENERAL SURGERY IN FIRST TRIMESTER OF PREGNANCY
LAPAROSCOPIC SURGERY DURING PREGNANCY
DIAGNOSTIC LAPAROSCOPY
LAPAROSCOPY VERSUS LAPAROTOMY
NONGYNECOLOGICAL SURGERIES
Acute Cholecystitis
Acute Appendicitis
Laparoscopic Appendectomy
Intestinal Obstruction
Breast Cancer Surgery in Pregnancy
GYNECOLOGICAL SURGERIES IN PREGNANCY
Adnexal Masses
Adnexal Torsion
Ovarian Torsion During Pregnancy
Red Degeneration of Fibroid
POST OPERATIVE CARE
ANESTHETIC CONSIDERATIONS
Maternal Safety
Cardiovascular Changes
Aortocaval Compression
Respiratory Changes
Gastrointestinal Changes
Altered Pharmacokinetics/Pharmacodynamics of Drugs
Fetal Safety
Prevention of Fetal Asphyxia
Drugs and Teratogenicity
Prevention of Preterm Labour/Fetal Monitoring
Laparoscopic Surgery
Deep Venous Thrombosis Prophylaxis
Analgesia
CONCLUSION
CHAPTER 28:
Laparoscopic Surgery
INTRODUCTION
ADVANTAGES OF LAPAROSCOPY IN PREGNANCY
PRECAUTIONS TO BE OBSERVED FOR LAPAROSCOPIC SURGERY IN PREGNANCY
Use of Diagnostic Modalities
Diagnostic Laproscopy
Patient Selection
Laparoscopy and Trimester of Pregnancy
Patient Positioning
Initial Port Placement
Insufflation Pressure
Intraoperative CO2 Monitoring
Venous Thromboembolic Prophylaxis
Safety of Laparoscopic Surgery
Perioperative Care
LAPAROSCOPIC MANAGEMENT OF SURGICAL DISEASE DURING PREGNANCY
Gallbladder Disease
Choledocholithiasis
Appendectomy
Adrenal, Kidney, and Spleen Removal
Adnexal Mass
Torsion
Ectopic Pregnancy
Interstitial or Cornual Ectopic Pregnancy
Abdominal Ectopic Pregnancy
Cesarean Scar Ectopic Pregnancy
Prevention of Ectopic Pregnancy
Abdominal Pregnancy
Rudimentary Horn Pregnancy
Ovarian Pregnancy
Cervical Pregnancy
Molar Ectopic Pregnancy
Heterotopic Pregnancy
Management of Patients with Ectopic Pregnancy with Massive Hemoperitoneum
CONCLUSION
CHAPTER 29:
Sexual Behavior
INTRODUCTION
PHYSIOLOGY
EFFECT OF PREGNANCY ON SEXUAL ACTIVITY
CONCERNS ASSOCIATED WITH SEXUAL INTERCOURSE DURING PREGNANCY
Miscarriage
Preterm Labor
Proposed Mechanism of Induction of Labor
Preterm Premature Rupture of Membrane
Antepartum Hemorrhage in Placenta Previa
Venous Air Embolism
RESUMPTION OF SEXUAL INTERCOURSE DURING THE POSTNATAL PERIOD
ROLE OF HEALTH CARE PROVIDER
CONCLUSION
CHAPTER 30:
Vaginal Bleeding
GENERAL CONSIDERATION
ETIOLOGICAL FACTORS
CLINICAL HISTORY TAKING AND EXAMINATION
Epidemiological
Menstrual History
Obstetric History
Drug Intake
Gynecological Causes
CLINICAL EXAMINATION
General Condition
Gynecological Examination
INVESTIGATIONS
ELISA Urine Test
Serial Ultrasound Scans
Complete Blood Count
Serial Beta-human Chorionic Gonadotropin
Serum Progesterone
Other Investigations
IMAGING
Ultrasonogram
Transabdominal Versus Transvaginal Scan
Prognostic Signs of Intrauterine Pregnancy
Dysfunctional Uterine Bleeding and Molar Pregnancy
Ectopic Pregnancy
Magnetic Resonance Imaging
Other Investigations
Dilatation and Curettage
Culdocentesis
Laparoscopy
MANAGEMENT
CONCLUSION
CHAPTER 31:
Sepsis
INTRODUCTION
DEFINITION
CAUSATIVE ORGANISMS
CAUSES OF SEPSIS IN THE FIRST TRIMESTER
CLINICAL FEATURES
Symptoms9
Signs
RISK ASSESSMENT FOR SEPSIS
Low Risk
High Risk
SIGNS OF CRITICAL ILLNESS9
Physiological
Signs of Sympathetic Activation
Signs of Systemic Inflammation
Sign of Organ Hypoperfusion
Biochemical
Metabolic Acidosis
Common Sequence of Organ Failure (Fig. 2)10
INVESTIGATIONS
PRINCIPLES OF MANAGEMENT
TREATMENT
SURVIVING SEPSIS CAMPAIGN GUIDELINES FOR MANAGEMENT OF SEPSIS AND SEPTIC SHOCK 200811
PROGNOSIS OR OUTCOME WITH SEPSIS
PREVENTION OF SEPSIS
CONCLUSION
CHAPTER 32:
Termination of Pregnancy
INTRODUCTION
INDIAN STATISTICS FOR TERMINATION OF PREGNANCY
METHODS
Surgical Procedures
Vacuum Aspiration
Dilatation and Curettage
Dilatation and Evacuation
Complications of Surgical Medical Termination of Pregnancy
Immediate Complications
Delayed Complications
Late Complications
Medical Abortion
Complications of Medical Abortion
Persistent Gestational Sac
Continuing Pregnancy
Hemorrhage
Infection
Undiagnosed Ectopic Pregnancy
CHAPTER 33:
Medico Legal Aspects Termination of Pregnancy
INTRODUCTION
WHO CAN TERMINATE FIRST TRIMESTER PREGNANCY?
Section 2(D) of the Act
INDICATIONS FOR MEDICAL TERMINATION OF PREGNANCY
CONSENT
OPINION
PLACE WHERE FIRST TRIMESTER PREGNANCY CAN BE TERMINATED
Conditions Which Need to be Satisfied
Registration of Center
Suspension or Cancellation of Registration
RECORD KEEPING
How to Maintain Record (custody of Forms)
Maintenance of Admission Register (Form III)
Reporting and Record Maintenance in Emergency
In Case of MTP done to Save the Life of Woman (Under Section-5)
Preservation of Record
Offences and Penalties
WORDS OF CAUTION
ANNEXURES:
PRACTICAL TIPS for ULTRASOUND
Indications
Gestational Sac
Ultrasound Appearance (TVS) of 4 Weeks Gestational Sac
Ultrasound Appearance (TVS) of 5 Weeks Gestational Sac
Double Decidual Sign
Gestation Sac measurement
Abnormal Gestational Scan
Major Criteria
Minor Criteria
Yolk Sac
Yolk Sac Measurement (Table 1)
Yolk Sac Findings Implying Poor Outcome
Assigning Gestational Age and Crown Rump Length Measurement
Pitfalls
CRL and Pregnancy Outcome
Assigning Gestational Age
Guideline for Fixing Gestational Age
Pregnancy Dating with First Trimester Ultrasound
Measurements
Typical Measurements
Placenta
Fetal Heart Rate
Predictive Value of Fetal Heart rate
No Cardiac Activity
Poor Prognostic Signs in First Trimester Ultrasound
Multiple Pregnancy
How Many Embryos/Fetus?
Zygosity
Conjoined Twins
Discordant Twins
Vanishing Twins
Demise of Co-twin
Chorionic Peak Sign
Triplet Pregnancy
Selective Reduction in Multiple Fetal Pregnancy
First Trimester Bleeding Per Vaginum
Early Pregnancy Failure
Causes of Bleeding in Early Pregnancy (Figure 1)
Empty Gestational Sac
Factors Affecting Prognosis
Color Doppler in First Trimester Bleeding
Corpus Luteal Cysts
Differential Diagnosis
Cervical Measurements
Screening for Cervical Incompetence
Dynamic Cervical Incompetence
Cervical Cerclage
Amniotic Sheet
Vesicular Mole
Ultrasound Appearance (Figures 2–6)
Hyaditiform Moles: Complete
Ectopic Pregnancy
Sites of Ectopic Pregnancy (Figure 1)
Sonographic Findings by Transvaginal Sonography (Figure 2 and 3)
Negative Signs
False Negative Signs
Indirect Positive Signs
Direct Positive Signs
Tubal Abortion
Cul de Sac
TVS in Diagnosis and Management of Ectopic Pregnancy
Beta HCG Correlation
Pseudogestational Sac (Figure 4)
Tubal Ring Sign
Uncommon Ectopic Sites
Fetal Hydrops
Nuchal Translucency
First Trimester Nuchal Translucency
Image and Measurement
Pathophysiology of Increased Fetal NT
Major Cardiac Defects
Body Stalk Anomalies
Diaphragmatic Hernia
Exomphalos
Megacystis
Screening for Aneuploidy
Advantages to 1st Trimester Screening
Disadvantages to 1st Trimester Screening
Approaches to Screening
Trisomy 18
Trisomy 21
Nasal Bone
Examination of Nasal Bone
Nasal Bone Sonography: Criteria
Nasal Bone –Aneuploidy
Maxillary Triangle
Fetal Facial Angle
Intracranial Translucency
Absent Intracranial translucency and open spina bifida
Ductus Venosus
Abnormal Flow in Ductus Venosus and Chromosomal Defects
Tricuspid Regurgitation
Uterine Anomaly and Adnexal Masses
Documentation of First Trimester Ultrasound
INDEX
TOC
Index
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