Obstetrics & Gynecology
The Female Reproductive System Mesonephric ducts – also known as Wolffian ducts, differentiates into male genital tract
Mesonephric ducts – differentiates in the presence of testis-determining factor, Y chromosome & testosterone
Paramesonephric ducts – also known as mullerian ducts
Paramesonephric ducts – differentiates into female internal genital tract in absence of anti-mullerian hormone
Cervix – derived from Mullerian ducts extending from isthmus of the uterus to upper portion of the vagina
Gartner’s duct – functionless remnant of paroophoron, may develop later as cyst in walls of vagina & uterus
Internal iliac artery – AKA hypogastric artery, main arterial supply of the perineum & pelvic organs
Submucosal layer – absent in fallopian tubes
Basal – layer of the deciduas which becomes a new source of endometrium
50 cm – average length of normal umbilical cord
7.0 – normal pH of amniotic fluid
Hematosalpinx – accumulation of blood due to obstruction at the fimbriated end of the oviduct
Amnion nodosum – small, firm, white, gray or yellow nodules present on fetal surface
Fertilization & Implantation
Morula – enters the uterine cavity about 3 days after fertilization
Blastocyst – fluid faccumulated between cells of the morula
Implantation – takes place 6 to 7 days after fertilization
Trophoblast – outer wall; forerunner of the fetal membranes & placenta
Embyoblast – inner cell mass; inner surface of the vesicle, where embryo, umbilical cord & amnion are derived
Apposition – 1st step of implantation
Human placenta – described as hemochorial or 21st hemochorioendothelial
Decidualization – change that occurs in the endometrium in response to blastocyst implantation
Nitabuch’s fibrinoid – located in the immediate maternofetal junction zone & is the site of placental separation
Fetal membranes – made up of 3 distinct layes : amnion, chorion leave & deciduas capsularis
A chimera – is an individual whose cells originated from more than 1 fertilized ovum
Hormonal
Progesterone – its thermogenic effect is the rise in basal body temperature during ovulatory period
Progesterone – hormone that stimulates development of breast alveoli (alveolar component)
Progesterone
- ↓ tone of LES
- ↓ broncho-motor tone : ↑ airway conductance, ↓ total pulmonary resistance - ↑ VC, TV & RR, ↓ FRC
- ↓ responsiveness to CCK - prone to UTI
Estrogen – hormone responsible for ductal development of the mammary gland
Pregnancy considered diabetogenic – due to human placental lactogen that has anti-insulin effect
Corpus luteum – principal site of progesterone production during early stage of pregnancy by establishement
Signs
Chadwick’s sign – vaginal mucosa becomes congested & violaceous, bluish to purplish; 6th week (presumptive) Hegar’s sign – softening of the uterine isthmus observed by the 6th to 8th week of pregnancy (probable) Goodell’s sign – cyanosis & softening of the cervix due to increased vascularity of the cervical tissue;
occur as early as 4th week (probable)
Spalding’s sign – overlapping of the fetal skull due to liquefaction of the brain
Robert’s sign – demonstration of gas bubbles in the fetus
Kustner’s sign – dermoid floats upward in the abdomen, elongating the ovarian pedicle & causing them to lie
anterior & superior to the uterus, in contrast to other ovarian tumors w/c are found posterior to the uterus
Syndrome
Asherman syndrome – post-traumatic / post-curettage intrauterine adhesions or synechiae w/ oligomenorrhea/
amenorrhea & infertility
Sheehan syndrome – postpartum pituitary necrosis
Simmond syndrome – pituitary hemorrhage not related to pregnancy
Meig’s syndrome – association of fibroma w/ ascites & hydrothorax w/c resolve after removal of tumor
Weeks AOG
7th to 11th week – most accurate assignment of AOG by UTZ obtained by measuring Crown-Rump Length
8th week – FHT identified by ultrasound
10th – 12th week – FHT identified by doppler
16th – 18th week – quickening (multigravida)
18th week – FHT identified by stethoscope
18th – 20th week – quickening (primigravida)
20th week – ballotment
28th week – highest peak of cardiac load (dilutional anemia)
38th week – engagement of the fetal head usually occurs
History & Physical Examination
Menstrual age – AOG based on the number of days elapsed from the 1st day of the last menstrual period
Viability – beyond 20th week of pregnancy or the stage of abortion
Postmaturity – fetus beyond 42 weeks
Spina bifida – has been associated with the use of sodium valproate (anticonvulsant)
12 weeks AOG – uterus first rises above the pelvic brim to become an abdominal organ
Xiphoid process – the anatomical landmark on the maternal abdomen consistent w/ gestational age of 36 wks
Internal examination – during the latent phase of the 1st stage of labor, IE is best done every 2 hours to determine cervical dilatation
Speculum exam on 20 weeks AOG – will show the color of the cervix
Embryonic cardiac activity – always present when the embryo measures at least 5 mm
Just after a uterine contraction – best time to take the fetal heart beat during labor
Bishop’s scoring – includes cervical effacement, cervical dilation & fetal station
Fetal presentation – not included in Bishop’s scoring
fetal thorax in face presentation
McDonald’s rule : AOG in weeks = D x (8/7)
Johnson’s rule : Fetal weight (grams) = (FH – n) x 155; 11 (above), 12 (below)
Anatomic & Physiologic Changes during Pregnancy
Uterine enlargement during pregnancy – mainly due to hypertrophy of existing muscles
↑ vascularity – responsible for softening of the cervix during pregnancy
Prolonged gastric emptying time - GIT change considered physiologic during pregnancy
Changes seen on urinary tract - ↑ in size, dilatation of ureters, elevation of bladder trigone
Physiologic urinary changes during pregnancy - ↓ BUN; ↑ GFR , ↑ renal plasma flow (not ↑ serum crea)
Elevation of diaphragm – dyspnea develops during the later part of pregnancy
Heart burn – felt during pregnancy due to esophageal reflux
11 kg (24 lbs) – average maternal weight gain during pregnancy (2, 11, 11 lbs)
300 – recommended daily caloric intake during pregnancy
4 cm - upward displacement of the diaphragm
Physiologic hydroureter of pregnancy – more pronounced & frequent on the right side
6 to 7 mg/day – RDA iron requirement
Hypervolemia of pregnancy – change during pregnancy that protects woman from blood loss during delivery
Pregnancy
Presumptive symptoms
- nausea with or without vomiting - disturbances in urination
- fatigue
- perception of fetal movement - breast symptoms
Presumptive signs
- cessation of menstruation - anatomical breast changes - skin pigmentation changes
chloasma or melasma – mask of pregnancy linea nigra
striae gravidarum spider telangiectasia - thermal signs
Probable evidences
- enlargement of the abdomen
- changes in the size, shape & consistency of the uterus - anatomical changes in the cervix
- Braxton-Hicks contractions
: painless, irregular contractions w/c may be palpable or visible : more perceivable towards the 28th week
- physical outlining of the fetus - positive results of endocrine tests Positive signs
- identification of fetal heart action
-perception of active fetal movement by the examiner - recognition of embryo or fetus by ultrasound
The Passages
True or Anatomic Conjugate
True or anatomic conjugate
- distance between the upper margin of the inner border of the symphysis pubis to the midpoint of sacral promontory
- it averages 11 cm & is measured indirectly by subtracting 1.2 cm from the diagonal conjugate
11 cm – average diameter of true conjugate
Obstetric Conjugate
Obstetric conjugate
- distance between the midpoint of the inner surface of the symphysis pubis to the midpoint of sacral promontory
- it measures 10 cm and is obtained by subtracting 1.5 to 2 cm from the diagonal conjugate or by radiopelvimetry
Obstetric conjugate – shortest diameter of the pelvic inlet
Diagonal Conjugate
Diagonal conjugate
- distance between the lower border of the symphysis pubis to the midpoint of the sacral promontory - measures about 12 cm
- the only anteroposterior diameter that can be measured clinically
Diagonal conjugate – the only diameter of the pelvic inlet that can be measured clinically
Diagonal conjugate - distance between lower border of symphisis pubis & sacral promontory
Midpelvic Plane
Midpelvic plane
- extends from the lower margin of the symphysis pubis through the level of the ischial spines to the tip of sacrum
- clinical assessment of midpelvis is not possible
Transverse diameter of midpelvis – distance between the ischial spines
Midpelvis – may be considered if the ischial spines are prominent, pelvic sidewalls are convergent, sacrum is flat
Midpelvis definitely contracted – if the interspinous diameter is < 8 cm by x-ray pelvimetry
Midpelvis – likely to be contracted if the sum of the IIs & PSP is < 13.5 cm
Pelvic Inlet
Pelvic inlet – bounded laterally by linea terminalis
Pelvic inlet – clinically, it may be considered contracted if the sacral promontory can easily be reached
Contracted inlet – results in failure of engagement
Pelvic Outlet
Pelvic outlet
- consists of 2 triangular planes sharing a common base fromed by a line joining the 2 ischial tuberosities
Posterior saggital diameter of the outlet – normally measures 10 cm
The Passenger
Fetal attitude – posture or habitus; relation of the fetal parts to one another
Fetal lie – relation of the long axis of the fetus to the long axis of the maternal abdomen 1. Longitudinal lie
- long axis of the fetus parallels the longitudinal axis of the uterus
2. Transverse lie
- the fetus lies in the transverse or one of the oblique diameters of the uterus
- potentially serious because when the membranes rupture, cord prolapsed commonly follows - shoulder is the presenting part
Fetal presentation – portion of the body of the fetus that is either foremost w/in the birth canal or in closest
proximity to it
1. Cephalic presentation
- full flexion ordinarily achieved because the occipital condyles are located near the posterior aspect of the skull
- 4 varieties depending upon the relation of the head to the thorax:
a. vertex (occiput)
– triangular posterior fontanel as the presenting part
b. sinciput (military attitude)
– diamond shaped anterior fontanel (bregma) is presenting
c. brow
– head partially extended & the occipitomental plane being the longest anteroposterior diameter is presenting; only transient & almost always converted into face presentation by extension & does not advance through the pelvis unless the head is extremely small
d. face
– submentobregmatic or tracheobregmatic is presenting as the anteroposterior
diameter
- vaginal delivery may result in injury to the cervical spinal cord
2. Breech presentation
- considered when the fetus presents w/ the buttocks toward the pelvis & bitrochanteric diameter presents
a. frank breech
surfaces of the body, the feet lie in proximity to the head
b. complete breech
- thighs are flexed over the abdomen, the legs flexed upon the thighs & the feet present at the level of the buttocks
c. incomplete breech
- when 1 or both thighs are extended so that the feet & legs are below the level of the buttocks
- when 1 leg is completely extended & the other leg is flexed, it is a single footling; when both legs are extended below the level of buttocks, it is a double footling
- possibility of compression of a prolapsed of a prolapsed cord or a cord
entangled around the extremities as the breech fills the pelvis is an anticipated complication
2. Shoulder presentation
- shoulder or acromnion is usually presenting into the pelvic inlet in transverse lie & the Bisacromial diameter
3. Compound presentation
- the fetal hand or foot proplapses alongside the presenting vertex or breech
- causes are conditions that prevent complete occlusion of the pelvic inlet by the presenting Part
- combination of hand w/ vertex or breech tends to resolve spontaneously as labor advances - combination of foot & fetal head tends to be complicated by a cord prolapsed
Fetal position
- relationship of the chosen portion of the fetal presenting part in reference to one of the 4 quadrants or to the transverse diameter of the maternal birth canal
O (occiput) : vertex presentation F (frontum) : brow presentation
M (mentum or chin) : face presentation S (sacrum) : breech presentation
Ac (acromion or scapula) : shoulder presentation Leopold’s Maneuver Fundal grip Umbilical grip Pwalik’s grip Pelvic grip Presentation
Fetus is in longitudinal – if the presentation is cephalic, frank breech & complete breech
In cephalic presentation – the presenting part is posterior fontanel
In a transverse lie – the presentin part is usually the fetal shoulder
Complete breech – if the thighs are flexed over the abdomen & the legs are flexed over the thighs
In a vertex position – with the anterior fontanel in the direction of the symphysis pubis, the position is
occiput posterior
Sequence of events – flexion, internal rotation, extension, external rotation
With flexion of fetal head – the occipitofrontal diameter is replaced by suboccipitobregmatic diameter
Cephalic presentation – the usual fetal presentation due to the piriform shape of the uterus
Parturition
- action of giving birth to an offspring or a process of birthing
- starts from the retreat from pregnancy maintenance to delivery of fetus, expulsion of placenta & subsequent return to non-pregnant state
- phase 0 : uterine quiescence
prelude to parturition; time of contractile tranquility & cervical rigidity observe from before before implantation until late in gestation at about 35-38 weeks
- phase 1 : preparation for labor
ripening of cervix, ↑ frequency of painless contractions, development of lower uterine segment & ↑ responsiveness of myometrium to stimuli
Lightening – few weeks prior to active labor, fundic height decreases to some degree & this experience described by the mother as “the baby dropped”
- results in formation of LUS allowing fetal head to descent & reduction in the amount of amniotic fluid volume
- phase 2 : process of labor
period of active uterine contractions, brings about cervical effacement & dilatation, fetal descent & ultimately delivery of the conceptus; divided into 3 stages of active labor
Labor
- corresponds to phase 2 of parturition
- physiologic process during which products of conception
(fetus, membranes, umbilical cord & placenta) are expelled outside the uterus
- onset of labor characterized as regular, painful uterine contractions resulting in progressive
- 3 stages of labor:
1st stage – cervical effacement & dilatation up to full cervical dilatation 2nd stage – full cervical dilatation & ends w/ fetal expulsion
3rd stage – delivery of fetus & ends w/ placental separation & expulsion
- active phase:
Acceleration phase Phase of maximum slope Deceleration phase
Bloody show – made up of a small amount of blood-tinged mucus from vagina which represents
extruded plug of mucus filled up the cervical canal throughout the pregnancy - dependable sign of impending onset of active labor provided no rectal nor vaginal examination has been performed in the preceding 48 hours
Characteristics of uterine contractions during labor:
- uterine contractions of labor are painful - contractions become more frequent
- uterine contractions are involuntary & independent of any extrauterine control - uterine activity enhanced by mechanical stretching of the cervix
False Labor
- irregular uterine contractions - shorter duration
- discomfort confined to the lower abdomen and groin - commonly observed in later pregnancy & in parous women
- often stops spontaneously but may proceed rapidly to effective contractions of true labor
True Labor
- regular uterine contractions - longer in duration
- discomfort commences in the fundal region & then radiates over the uterus & lower back
Effacement
- synonymous to “obliteration” or “taking up” of the cervix
-shortening of cervical canal from a length of about 4 cms by vaginal examination to a circular orifice with paper-thin edges
- phase 3 : puerperium
recovery period which terminates in uterine involution & restored fertility uterine involution takes about 4-6 weeks
Uterine contraction of labor – initiated by progesterone withdrawal
1st stage of labor – ends at full cervical dilatation
1st stage of labor – bathing, eating & going to CR are allowed
8 hours – average duration of the 1st stage of labor in primigravidas Descent – 1st requisite for normal spontaneous delivery
Softening of the cervix during phase 1 of parturition – due to collagen breakdown
Active descent - takes place during slope of dilatation
Active descent – takes place during pelvic phase
Latent phase of labor in nulliparas – considered prolonged if it lasts for more than 20 hours
Secondary arrest of dilatation among nulliparas – if there is no change in cervix for more than 2 hours
At crowning – best time to do an episiotomy
Uterus becomes globular – earliest sign of placental separation
Bilateral depressions – permanent change characteristic of a parous cervix
During pueperium – the lower uterine segment is converted into isthmus
Meconium aspiration – most feared complication of postterm pregnancy
Compression of cord – a complication of oligohydramnios in postterm pregnancy
In collision – the twins compete for entry into the pelvic inlet
Interlocking of twins – associated w/ breech cephalic
PGE2 & PGF2a – applied directly to the cervix or intravaginal suppositories to effect cervical softening &
facilitate induction of labor
Mechanism of Labor
7 Discrete cardinal movements:
1. Engagement
2. Descent – the most significant mechanism 3. Flexion
4. Internal rotation 5. Extension
6. External rotation or restitution 7. Expulsion
Biparietal diameter – widest diameter of presenting part
Inability of the head to engage by 38 weeks AOG – early sign of cephalopelvic disproportion
Station 0 – the fetal head is at the bony ischial spines
Descent – downward passage of the presenting part through the pelvis
Synclitism – the sagittal suture is midway between the symphysis & sacral promontory
Asynclitism – describes the fetal head that is directed anteriorly towards the symphisis or posteriorly towards
the promontory
Progressive dilatation – true indicator of labor
Preterm Labor
SGA – weight less than 10th percentile AGA – weight between 10th & 19th percentile LGA – weight > 90th percentile
Fetal growth restriction or intrauterine growth restriction – for fetus whose weight is below 10th percentile of gestatiotal age
Biochemical markers of preterm labor – fetal fibronectin release, salivary estriol, sonographic findings
Transvaginal UTZ (preterm delivery) - ↓ length, funneling (V & U-shaped patterns, (+) stress test
MacDonald’s procedure – purse-string suturing of the cervix using non-absorbable suture material
Post Maturity Syndrome
Post maturity syndrome - ↓ subcutaneous fats, wrinkled skin, long hair & nails, greenish staining of skin
Post maturity syndrome – old man’s fascies, desquamating skin w/ absence of vernix caseosa
Engagement
Engagement – passage of the widest diameter of the presenting part to a level below the plane of pelvic inlet
Engagement – mechanism by which the BPD of fetal head passes through the pelvic inlet
Delivery
Normal delivery w/ outlet forceps extraction under epidural anesthesia - preferred mode of delivery of px w/
Bishop Scoring System for Assessment of Inducibility
Score Dilatation (cm) Effacement (%) Station Cervical Consistency Cervical Position
0 closed 0-30 -3 Firm Posterior
1 1-2 40-50 -2 Medium Midposition
2 3-4 60-70 -1,0 Soft Anterior
3 > 5 >80 +1, +2 --- ---
Bishop score of 4 or less - identifies an unfavorable cevix, and may be an indication for cervical ripening
Bishop score of 9 – conveys a high likelihood for a successful induction
Bishop scoring – done on postterm pregnancy to evaluate ripeness or inducibility of the cervix
Management of 3rd Stage of Labor
Signs of placental separation:
1. Calkin’s sign – earliest sign; change in the shape of the uterus from discoid to globular as it contracts 2. Gush of blood from vagina
3. Lengthening of the cord
4. Uterus rises in the abdomen as the placenta descends to the LUS or vagina & displaces the uterus upwards
Mechanism of Placental Extrusion
Schultze mechanism
- usual type of placental separation is the one that occurs initially at the central portion of
the placenta & the retroplacental hematoma formed pushes the placenta toward the uterine cavity & the rest of the placenta follows
- what presents at the vulva is the glistening amnion over the placental surface while the hematoma is w/in the inverted sac or escapes after placental extrusion
Duncan mechanism
- separation occurs first at the periphery hence the blood collected between the membranes & uterine wall excapes into the vagina
- the placenta descends to the vagina sideways & the maternal surface is the first to appear at the vulva Lacerations of the Vagina & Perineum
1st degree – involves the fourchette, perineal skin, vaginal mucosa but not the underlying fascia & muscle
2nd degree – involves the fascia & muscle of the perineal body but not the anal sphincter
3rd degree – extends from vaginal mucosa, perineal skin & fascia up to the anal sphincter but not the rectal
Mucosa
4th degree – extension up to the rectal mucosa; rectal mucosa is repaired 1st before the vaginal mucosa 3 Types of Fetal Heart Rate Pattern
Early deceleration
- occurs w/ the onset of contraction & return to baseline at the end of contraction w/ nadir occurring at the peak of each contraction
Late deceleration
- occurs after the onset of contraction (usually at the peak) & return to baseline after the contraction w/ nadir occurring after the peak of the contraction
- connotes uteroplacental insufficiency
Variable deceleration
- most common type
- occurs before, during or after or even without contraction - due to cord compression & cessation of umbilical blood flow Cesarean Section
Types of Abdominal Incision
1. Median Infraumbilical Longitudinal Incision
2. Transverse Suprapubic (Pfannensteil/Bikini) Incision - more difficult but is stronger & w/ less dehiscence
Types of Uterine Incision
1. Classical Cesarean Section
- longitudinal incision above the lower uterine segment - rarely done due to strong tendency to rupture
2. Low Segment Incision
- preferred method due to low tendency to rupture a. Low Transverse (Kerr Incision)
- preferred due to only moderate dissection of the bladder, however, offers little space for extension
- ↓ blood loss & adhesions, faster & easier to repair b. Low Longitidinal Incision (Kronig Technique)
- more bladder dissection but can be extended
Post-cesarean endomyometritis – most common postoperative complication of cesarean delivery
Placenta acreta – most frequent indication for post-cesarean hysterectomy
Postpartum
At 6 weeks postpartum – the uterus weighs approximately 70 g
After pains – produced by uterine contractions
Placental tissues – not a component of lochia (deciduas, bacteria, epithelial cells)
Postpartum Hemorrhage
Postpartum hemorrhage – occurs within 24 hours after delivery
Postpartum hemorrhage – blood loss >500 mL in normal vaginal delivery
Postpartum hemorrhage – blood loss >1000 mL in cesarean delivery
Postpartum hemorrhage - ↓ in postpartum hematocrit level >10% of the prenatal value
Late Postpartum Hemorrhage
Late postpartum hemorrhage – when it occurs 24 hours to 6 weeks after delivery
Uterine Atony
Uterine atony - most common cause of postpartum hemorrhage
Placental implantation site - source of bleeding in uterine atony
Uterine atony – most common reason for hysterectomy after vaginal delivery
PROM
Preterm premature rupture of membrane – occurs before 37 weeks gestation
Premature rupture of membrane – most often associated w/ inlet contraction
Premature rupture of membrane – in most cases, it is diagnosed based on history
Intrapartum Management
Transcervical amnioinfusion – infusion of sterile NSS warmed at 37 C by bolus or continuously through cervix during labor
Puerperium
Puerperal infection following delivery – primarily involves the placental implantation
Ampicillin + gentamycin – standard combination therapy w/ favorable response of 95 % of puerperal infection
Cesarean section
Cesarean section – best done in cases of footling breech presentation, transverse lie, hydrocephalic baby
Epidural anesthesia – usually causes uterine dysfunction
Disadvantage of a low transverse as compared to classical cs – greater risk of injury of uterine arteries
Complications during Pregnancy
Pulmonary hypertension – has the greatest risk for maternal mortality during preganancy
↓ uteroplacental perfusion - Increased perinatal morbidity & mortality in hypertensive pregnancies is a
result of this change in the placenta
Doppler velocimetry – diminished blood flow in the placental bed in hypertensive pregnancies best
demonstrated by this method
Assisted vaginal delivery under epidural block – preferred method of delivery for a gravidocardiac w/
aortic stenosis
Mitral valve prolapse – cardiac lesion that has the best prognosis during pregnancy
Urinary tract dilatation – further aggravated at 21 weeks AOG due to mechanical compression of the ureter
by the enlarging uterus
Acute pyelonephritis – most common serious medical complication of pregnancy
HELLP
Fetal alcohol syndrome – condition associated w/ characteristic facial abnormalities, mental retardation &
small for gestational age babies
Vaginal lacerations and/or hematoma – maternal birth trauma assoc. w/ fetal macrosomia during childbirth
Chronic alcoholism – can result to craniofacial abnormalities: narrow eye width, ptosis, thin upper lip
Chronic fetal asphyxia in utero – highly considered if there is at least 1 fetal breathing movement in 30 min.
Intrapartum Assessment
Causes of fetal bradycardia
- hypoxia & acidosis - complete heart block
- drugs (beta adrenergic blockers) - hypothermia
Maternal fever from abortion-amnionitis – most common cause of fetal tachycardia
Mammary, Lactation & Breastfeeding
Human milk – does not contain Vit. K; contains secretory IgA; contains epidermal growth factor
Not true of human milk – has a high iron concentration
Mastitis – a parenchymatous infection of mammary gland; breasts are hard & reddened; Staphylococcus aureus
is the most common agent Not true of mastitis – often bilateral
Gestational Diabetes
Screening for DM during pregnancy – not done in case of intrauterine growth retardation (family hx of DM,
previous malformed infant, polyhydramnios)
Placental insulinase - not considered a diabetogenic hormone (placental lactogen, estrogen, progesterone)
24 – 28 weeks AOG – screening for gestational diabetes
Gestational diabetes - ↑ incidence of congenital anomalies, macrosomia, growth restriction, delayed lung
Maturation
Macrosomia in infant of diabetic mother – thought to be a direct consequence of fetal hyperinsulinemia
Diagnostic evaluation
Baseline ultrasound for fetal aging – best performed on the 1st trimester
Crown-rump length – during the 1st trimester, this is the most accurate means of assessing gestational age Non-stress test – evaluates alertness of the fetal CNS by observing fetal heart rate response to fetal movement
Negative contraction stress test – interpreted as a normal utero-placental perfusion
Ferning – due to the presence of saline in the amniotic fluid
Non-Stress Test NST
- based on the premise that the heart rate of the fetus that is not acidotic or neurologically depressed will temporarily accelerate w/ fetal movements
- loss of reactivity may be associated w/ fetal sleep cylces, acidosis or CNS depression
- initiated at 32 weeks AOG on a weekly basis or earlier & more frequent in very high risk situations - FHR accelerations that peak at least 15 bpm above the baseline lasting for 15 seconds, at least 2 or more accelerations in a 20 minute period
Contraction Stress Test
Contraction Stress Test (CST)
- goal is to identify a fetus at risk for compromise by observing the fetus in the presence of stress - the 1st 30 minutes is recorded to assess FHR baseline, to identify presence or absence of periodic change and to determine if there is spontaneous uterine activity
- negative test
: 3 uterine contractions in a 10 minute period w/o late decelerations;
average baseline variability & accelerations of FHR w/ fetal movements
- positive test
: persistent late decelerations or late decelerations in more than half of contractions; minimal or absent variability
- suspicious
: late deceleration occurring in less than half of the uterine contractions
- hyperstimulation
: contractions occurring more often than every 2 minutes or lasting longer than 90 seconds Biophysical Profile (BPP)
1. NST – if all 4 ultrasound components are normal, may be omitted
2. Fetal Breathing Movement (FBM) – 1 or more episodes of rhythmic fetal breathing movements of 30 seconds or more within 30 minutes
3. Fetal Movement (FM) – 3 or more discrete body or limb movements within 30 minutes
4. Fetal Tone (FT) – 1 or more espisodes of extension of a fetal extremity w/ return to flexion or opening & closing of hand w/in 30 minutes
5. Amniotic Fluid Volume – single vertical pocket > 2cm or AFI >5cm 10/10 – 8/10 : reassuring
6/10 : equivocal < 4/10 : non-reassuring Pain
Somatic pain – conveyed primarily via pudendal nerves to dorsal nerve roots S2 to S4
Somatic pain – pain that represents stretching of the vagina & perenium during descent of the fetus
Visceral pain – pain caused by dilatation & effacement of the cervix during uterine contractions
Prophylaxis & Maneuver
Left uterine displacement – prophylaxis of vena caval compression
Ritgen maneuver – done to allow fetal head extension
Internal podalic version of the 2nd twin – often done in transverse lie
Pharmacology
FDA Category A – controlled studies show no adequate risk
FDA Category B – animal findings show risk but human findings do not
FDA Category C – human studies are lacking 5 animal studies are either positive or negative for fetal risk;
FDA Category D – positive evidence of risk; if the drug is needed in a life-threatening situation or for a serious
disease for which safer drugs cannot be used or are ineffective
FDA Category X - studies in animals or human beings have demonstrated fetal abnormalities or there is evidence
of fetal risk based on human experience or both & the risk of the use of the drug in pregnant women clearly outweighs any possible benefit
Delayed gastric emptying time & motility – absorption of a weakly acid drug is ↑ in the stomach
↑ lipid solubility – placental drug transfer is ↑
Drugs
Hydralazine – when given IV will have its onset of action in 10 – 20 min.
Thrombocytopenia – neonatal effect of hydralazine
Chronic HPN in pregnant women – may be documented by doing fundoscopic examination, chest x-ray & ECG
ACE Inhibitors – antihypertensive considered unsafe during pregnancy (Captopril)
Trimethoprim – an antimicrobial agent that should be used w/ caution among pregnant women
Heparin – recommended anticoagulant for pregnant women because it hardly crosses the placental membrane
Chloroquine – of the anti-malarial drugs, this can be given to pregnant women
Retinol or retinoid – proven teratogen in doses of 15 – 75 mg/kg/day & has been found to produce
malformations of the brain, cardiovascular system & limb
Paracetamol – analgesic-antipyretic of choice for pregnant women
Dexamethasone – given in premature labor to improve fetal lung maturity
6 mg IM/IV every 12 hours for 4 doses – dose of dexamethasone given for premature labor
Ampicillin – antibiotic of choice for premature rupture of membrane prepartum
Contraception
Injectable hormonal contraceptives – prevent pregnancy by inhibiting ovulation, preventing endometrial
maturation & producing thick cellular cervical mucus
Effect of progestin implant – may lasts for 60 months
↓ incidence of PID – non-contraceptive benefits of oral contraceptive pills
Oral contraceptive pills – absoulutely contraindicated in the presence of impaired liver function
Woman gaining weight excessively w/ pill – should be advised to shift to lower dose pill
Missed taking 3 tablets of pill – should stop the pack, wait for bleeding & start another pack
Progestin only – breastfeeding mothers who want to take pills are best given w/ this one
Billing’s method – prevents pregnancy by having no contact in the presence of peak of wetness
Nonoxynol 9 – a spermicidal agent; can destroy sperm cell membrane; duration of action is only 1 hour
Not true of Nonoxynol 9 – can change the quality of cervical mucus
Progestasert – type of IUD producing endometrial atrophy
Copper T 380A – type of IUD that can be used for a duration of 10 years
Progesterone laden IUD – inhibits sperm migration by making the cervical mucus thick; suppression of
endometrium; production of prostaglandin w/ subsequent inflammatory response
IUD – best inserted nearing the end of a normal menstrual cycle
Irving’s – method of tubal ligation least likely to fail
Vasectomy – sexual contact may be allowed after 15 – 20 ejaculations
Direct abortion
- immediate purpose of the procedure is to destroy the human fetus at any stage after its conception or to expel it when it is not yet viable
Indirect abortion
- the direct, immediate purpose of the procedure is to treat the mother, the death of the fetus is an incidental & secondary result that would have been avoided if possible
Therapeutic abortion
- termination of pregnancy done to save the life of the mother
Threatened abortion
- presence of bloody vaginal discharge, closed cervix & uterine enlargement in the 1st half of pregnancy - pain may be rhythmic, crampy or may be persistent low back pain
Inevitable abortion
- gross rupture of the bag of water in the presence of cervical dilatation w/o passage of products of conception or the fetus often signals that abortion is certain
Incomplete abortion
- when part of the placenta or portions of the products of conception is expelled in the presence of an open cervix & bleeding
Missed abortion
- when there is embryonal or fetal demise but no expulsion of the product of conception & instead
there is retention for 8 weeks or more
Habitual abortion or recurrent pregnancy loss
- recurrent abortion
- usually defined as 3 or more losses in a row
Habitual abortion – diagnosis based on history
Placenta Previa
Placenta previa – condition wherein the placenta is implanted in the lower uterine segment
Fundal portion – normal implantation of the placenta
Cervical internal os – basis for the categorizing placenta previa
1. Total placenta previa – cervical os covered completely by placenta 2. Partial placenta previa – internal os partially covered by placenta
3. Marginal placenta previa – edge of placenta is 2 cm away from the internal os
4. Low-lying placenta – placenta implanted in the lower uterine segment such that the placental edge does not reach the internal os but is in close proximity to it
Factors that influence the occurrence of placenta previa
- multiparity
- multiplr induced abortions - previous cesarean section - puerperal endo metritis - large placenta
- advancing maternal age
Defective vascularization of the deciduas – appears to be a major contributing factor to the development
of placenta previa
Painless vaginal bleeding – classic symptom of placenta previa occurring during 3rd trimester
- uterus is soft, easily palpable, non-tender, non –contractile - placental souffle
- Transabdominal sonography
: false positive - urinary bladder distension
: false negative – position of fetal head obscuring the region to cervix & failure to scan the Lateral uterine walls
- Transvaginal sonography : gold standard
Placenta increta – villi invade myometrium
Placenta percreta – villi penetrate serosal surface of myometrium
Rupture of fetal blood vessels crossing internal os (vasa previa) - can be a differential dx for placenta previa
Placenta Accreta
Placenta accreta – any placental implantation wherein there is abnormal adherence to uterine wall as a result
of partial or total absence of the deciduas basalis & imperfect development of Nitabuch’s layer Placenta accreta – strongly associated w/ placenta previa; this association is due to the thin, poorly formed
deciduas of the lower uterine segment w/c offers little resistance to deeper invasion by the trophoblast
Placenta accreta – when placental villi are attached to the myometrium
Abruptio placenta
Abruptio placenta
- separation of a normally implanted placenta before the birth of the fetus - diagnosis commonly made in the 3rd trimester
Predisposing factors
- maternal hypertension - maternal cigarette smoking - PROM
- choioamnionitis
- severe fetal growth restriction - advanced maternal age & parity… As to extent:
1. Partial - a part has separated
2. Total - the whole placenta has separted
As to onset:
1. Acute abruptio - sudden onset of signs & symptoms
2. Chronic abruptio - shows hemorrhage w/ retroplacental hematoma formation being arrested completely w/o delivery
As to type of bleeding:
1. External - bleeding passes between the membranes & the blood escapes through the cervix 2. Concealed – bleeding is not seen externally but is retained between the detached placenta & the
uterus or may extravasate into the amniotic cavity
3. Marginal sinus rupture – placental separation is limited to the margin w/ minimal bleeding but w/o uterine tenderness & pain
Formation of decidual hematoma – main pathology
Abruptio placenta – initiated by bleeding in the deciduas basalis splitting the layers & leaving a thin layer
adherent to the myometrium causing separation, compression & destruction of placental function adjacent to it
Retroplacental hematomas – composed predominantly of maternal blood, but in some cases there may be
Signs & symptoms
- vaginal bleeding : hallmark of abruption placenta; only 10% present w/ concealed hemorrhage - abdominal pain
- uterine tenderness & uterine hypertonus - fetal distress
- idiopathic preterm labor - dead fetus
Diagnosis - abnormal fetal heart tones, signs of labor, unexplained bleeding, ultrasonically visualized liquid
or dark area behind the placenta, portwine colored amniotic fluid during amniocentesis, decreasing serial hematocrit & retinal detachment
Couvelaire uterus (uterine apoplexy)
- severe form of abruptio in which the entire uterus may undergo bluish, purple or copper discoloration due to blood extravasation into the myometrium & into the uterine serosa
Serum CA 125 – can be used as a marker for abruption
Abnormalities of Amniotic Fluid
Hydramnios – amniotic fluid > 2000 mL at any time of gestation
Hydramnios - clinical correlates: GIT abnormalities, anencephaly / spina bifida, DM, erythroblastosis fetalis
Hydramnios – AFI > 24 cm
Amniotic fluid index (AFI) – summation of the largest vertical pockets of 4 quadrants of uterus
Oligohydramnios – paucity of amniotic fluid at term (<500mL)
Oligohydramnios - clinical correlates: IUGR, dysmaturity syndrome,
Renal agenesis & obstruction of urinary tract Oligohydramnios – AFI < 4 cm
Hypertensive Diseases in Pregnancy
Gestational hypertension – hypertension w/o proteinuria occurring after 20 weeks gestation or postpartum
Pre-eclampsia
- presence of hypertension & proteinuria occurring after 20th week of gestation except in extensive trophoblastic proliferation
- HELLP Syndrome (hemolysis, elevated liver enzymes, low platelet count)
Severe preeclampsia – systolic BP of 160 mm Hg, proteinuria, oliguria, severe headache or visual disturbances
Pulmonary edema or cyanosis; IUGR
Eclampsia – presence of convulsions in a woman w/ underlying pre-eclampsia
MgSO4 – drug of choice to control convulsion
Hydralazine, calcium channel blocker, beta blocker – to control hypertension
Superimposed pre-eclampsia
- increased diastolic or systolic blood pressure over baseline hypertensive readings accompanied by Proteinuria & signs & symptoms of end-organ dysfunction
Spiral arteries – in preeclampsia, the initial lesion was thought to occur in the implantation site involving
these arteries; consequence: impaired uteroplacental perfusion, vasoconstriction, placental ischemia
EDCF, Thromboxane, TXA2 – vasoactive substances increased in preeclampsia
Prostacyclin – not increased in preeclampsia
Changes observed in preeclampsia – hemoconcentration, ↑ afterload, ↓ GFR, ↓ or absent pregnancy-induced
hypervolemia; ↑ destruction of erythrocytes; alterations in coagulation mechanism
Impaired myocardial contractility – not observed in preeclampsia
Multiple pregnancy, family hx of HPN & fetal hydrops – predispose to the development of preeclampsia
Multiparity – not a predisposing factor in the development of preeclampsia
↑ urine protein – manifestation of a worsening preeclampsia
Vascular endothelial injury – indicated by elevation of fibronectin in women w/ preeclampsia
In preeclamptic pregnancies – endovascular trophoblasts invade the arterioles in the deciduas, myometrium &
serosa
Age of the mother – does bot govern the decision to deliver a preeclamptic pregnancy (severity of the disease,
fetal status & nursery capabilities)
Facial edema – not of prognostic value in severe preeclampsia (worsening proteinuria, ↑ liver enzymes,
epigastric pain
Periportal hemorrhagic necrosis – pathognomonic lesion in eclampsia
Periportal hemorrhagic necrosis – may explain the elevation of liver enzymes
Acute atherosis – pathognominc lesion shown in placental bed biopsies of hypertensive women
Acute atherosis – characterized by prominent lipid-rich foam cells in the uteroplacental vessels
ACE Inhibitors – NOT recommended during pregnancy due to fetal side effects like defective skull ossifications,
oligohydramnios & neonatal anuria Intrauterine Growth Retardation
IUGR
- previous undergrown infant in multipara - slowing in fundal measurement (<1cm/week) - slowing of maternal weight gain or girth increase - presence of maternal disease or addictive habits
Type I (Symmetric IUGR)
- insult early in gestation w/ equal ↓ in HC, weight & length such as chromosomal anomalies - ↑ morbidity, lower BW, late catch up
Type II (Asymmetric IUGR)
- insult of later onset such as maternal disease - parents w/ characteristic “sparing of the head” Ectopic Pregnancy
Oviduct - most common site
Ampullary followed by isthmic – most common site
Heterotropic pregnancy – simultaneous intrauterine & ectopic pregnancies
High risk factors
- tubal corrective surgery - tubal sterilization
- previous ectopic pregnancy - intrauterine device
- documented tubal pathology
Pregnancy at the isthmic segment – tubal rupture occurs during the early weeks of the 1st trimester Pregnancy at the interstitial segment – associated w/ late tubal rupture
Secondary abdominal pregnancy - can arise from tubal abortion
Ampullary – mostly the progression of ectopic pregnancy is abortion
Lithopedion – calcified conceptus
Classic triad – abdominal pain, vaginal bleeding & amenorrhea (about 6 weeks)
Transvaginal ultrasound – early diagnosis of ectopic pregnancy (echogenic fluid in the cul-de-sac)
Laparoscopy - gold standard in the diagnosis of ectopic pregnancy
Culdocentesis - inserting a long, large needle (gauge 16-18) through an adequately exposed posterior vaginal
fornix into the Pouch of Douglas
Methotrexate – medical treatment; folic acid antagonist, for rapid absorption of placental tissue
- Indications:
1. pregnancy < 6 weeks 2. tubal mass < 3.5 cm 3. non-viable fetus
4. serum b-hCG < 15,000 mIU/mL
RU 486 – competes for progesterone binding sites
Chorioamnionitis
Chorioamnionitis – fever > 38 C, tachycardia (fetal & maternal), maternal leukocytosis (at least 2 criteria)
Uterine Prolapse
Uterine prolapsed
- due to injury to endopelvic fascia, cardinal & uterosacral ligaments & pelvic floor (levator ani muscles) - due to ↑ pressure/tension on pelvic musculature such as in chronic constipation, tumors, chronic Respiratory disease (asthma, COPD), multiparity, old age, sacral nerve disorders
Classification
- 1st degree : prolapse into the upper barrel of the vagina - 2nd degree : prolapsed through vaginal barrel into introitus
- 3rd degree or total : prolapsed out through the intriotus w/c predisposes to dryness & thickening of vaginal epithelium & stasis ulcers
Gynecology
Fallopian tube – initial focus of genital TB in majority of cases
Chlamydia infection – most common STD in men
Chlamydia infection – common cause of infertility
Syphilis – does not present w/ abnormal vaginal discharge
PID – least likely to occur among menstruating women below 25
Lower abdominal pain – most frequent symptom of acute PID
Laparoscopy – gold standard in the diagnosis of acute PID
Partial Mole
Partial mole – 69 XXX or 69 XXY
Partial mole - only some chorionic villi are swollen
Partial mole - fetal tissues are present such as amniotic membrane, cord, or even rarely a full-term fetus
Partial mole – may be diagnosed as missed abortion
Complete Mole
Complete mole – 46 X or 46 XY
Complete mole - all placental villi are swollen
Complete mole - ↑ hCG (>100,000 U/L) in association w/ vaginal bleeding & uterine enlargement
Hydatidiform Mole
- 3 morphologic characteristics: (1) mass of vesicles (distended villi) that appear as large, grapelike dilations (2) loss of fetal blood vessels, which are either diminished or absent from the villi
(3) hyperplasia of the syncytiotrophoblast & cytotrophoblast
- ultrasound: “snowstorm appearance”
Serial hCG titer determination - monitoring for malignant degeneration of H-mole
Serial hCG titer determination – 1 week after evacuation, then every 2 weeks until titers became normal
for 3 consecutive determinations, then monthly for 6 months, every 2 months for next 6 months Medical complications of H-mole – anemia, toxemia, hyperthyroidism & respiratory insufficiency
Suction curettage – preferred method of molar evacuation regardless of uterine size
Methotrexate or Actinomycin (alternative) – chemotherapeutic agent commonly used
Endometriosis
Endometriosis – presence & growth of endometrial glands & stroma in an aberrant or heterotropic location
(outside the uterus)
Endometriomas – endometriosis implants in the ovaries, usually hemorrhagic appearing as chocolate cysts
Adenomyosis
Adenomyosis – growth of endometrial glands & stroma in the uterine myometrium at a depth of at least
2.5 mm from the basalis layer of the endometrium Choriocarcinoma
Choriocarcinoma – pure epithelial tumor composed of syncytiotrophoblasttic & cytotrophoblastic cells
Chemotherapy – principal mode of treatment for gestational trophoblastic neoplasia
Cysts & Tumors
Fibroma – most common benign solid tumor of the vulva
Fibroma – most common benign, solid ovarian tumor
Leiomyoma – most frequent pelvic tumor
Endometrial carcinoma – most common malignancy of the genital tract
Ovarian carcinoma – 2nd most common (endometrial > ovarian > cervix)
Inclusion cyst – most common vaginal cyst, usually in posterior or lateral walls of lower 3rd of vagina
Nabothian cyst – translucent or opaque-white retention cysts occurring where a tunnel or cleft was covered by
squamous metaplasia; considred a normal feature of adult cervix, no treatment needed Follicular cyst – most frequent cystic structure in normal ovary
Corpus luteum cyst – triad: delayed menses followed by spotting, unilateral pelvic pain & a small tender
adnexal mass
Theca lutein cysts – almost always bilateral w/ moderate to massive enlargement due to excessive
Benign cystic teratoma
- dermoid cyst, mature teratoma
- most common slow-growing ovarian tumor usually in prepubertal & teenage girls - contains elements from all 3 germ layers
- torsion : most common complication
- rupture : most serious due to chemical peritonitis
Epithelial Stromal Tumors
- serous (most common), psammoma bdies, high grade, worse prognosis
- clear cell (mesonephroid) : glycogen rich cells, “hobnail cells” (nuclei protrude into glandular lumen)
Dysgerminoma – most common malignant germ cell tumor, analogous to seminoma in the male testis, most
radiosensitive, curable
Granulosa cell tumors – Call-Exner Bodies (eosinophilic bodies surrounded by granulose cells, primarily
estrogenic) Sexually Transmitted Infection
Herpes simplex virus – multiple, painful, superficial, vulvar vesicles & dysuria, febrile, w/ lymphadenopathy
Herpes simplex virus – resides in the dorsal root ganlia of S2 to S4 during the latent phase
Type 1 & type 2 HSV – induce the same lesion in the skin / mucous membrane
Primary herpes genitalis infection – majority of primary infection is subclinical
Lymphogranuloma venereum – chronic infection of lymphatic tissue caused by Chlamydia trachomatis
Chancroid – painful, tender, genital ulcers
Chancroid – ulcer is excavated w/ purulent base & ragged irregular edges
Primary syphilis – often characterized w/ appearance of hard chancre at the site of entry of spirochetes
Other Infections
Donovanosis – painless, beefy-red vulvar ulcer, clusters of dark-staining bacteria w/ safety pin appearance
of large mononuclear cells
Staphylococcus aureus – etiologic agent recovered from almost all pxs w/ toxic shock syndrome
True about lactation period mastitis – nose & throat of the NB are the sources of infection
Genital TB
Fallopian tube – initial focus of genital TB in majority of cases
Infertility – most common initial symptom of genital TB
Endometrium – the most accessible tissue w/ high frequency of involvement in investigating pelvic TB
Rifampicin – generalized petechiae & purpura
Ethambutol - bacteriostatic
Laboratory
hCG level – peaks at approx. 10 to 14 weeks & rarely exceed levels of 100,000 mIU/mL
Tumor Markers
CA 125 – epithelial ovarian tumors
Serum LDH – dysgerminoma
Alpha Feto Protein – endodermal sinus tumor
hCG – chriocarcinoma
Medications
Acyclovir – given for acute & recurrent HSV infection because it inhibits DNA synthesis of the virus
Clindamycin + gentamycin : drug comination appropriate for PID after hysteroscopic removal of
submucous myoma
Clindamycin + gentamycin : same drug also given for tubo-ovarian abscess
Asherman syndrome – complication of dilatation & curettage
Antepartum assessment prodecureevaluating alertness of fetal CNS by observing fetal heart response to fetal movement – nonstress test
Variable deceleration – most common deceleration pattern encountered during labor attributed to umbilical cord compression
Start ocp after an abortion of less than 12 weeks AOG – start immediately
27 year Old woman w/ IUD consults for amenorrhea of 6 weeks duration, positive pregnancy test – remove IUD to prevent abortion
Most common cause of abortion early in gestation – chromosomal abnormalities
2nd degree uterine proplaspse – considered prolapse through the vaginal barrel to the region of the introitus Most common benign solid tumor of the vulva – lipoma
Increased severity of dysmenorrheal 2 years ago, presence of endometrial glands and stroma 3.5 mm from the basalis layer – adenomyosis
Most common endometrial finding in woman w/ post menopausal bleeding – endotrial atrophy Best way to diagnose endometriosis – laparoscopy
Vaginal carcinoma exposed to DES in utero – adenocarcinoma
Violin string sign of Fitz-Hugh-Curtis syndrome indicates presence of adhesions between liver & diaphragm (seen in PID) Complications from the use of ovulation drugs include – ovarian hyperstimulation syndrome
Key indicator of arousal in men – penile erection
Term used to prolonged uterine bleeding occurring at irregular intervals – menometrorrhagia
Most likely to develop PID – an 18 year old sexually active monogamous female w/ polygamous partner Considered a relative emergency in a teenager w/ amenorrhea – imporforate hymen
Dysfunctional uterine bleeding is frequently associated w/ - anovulation Bleeding associated w/ OCP – breakthrough or withdrawal bleeding Withdrawal bleeding – anticipated
Most sensitive to radiation therapy – dysgerminoma Most common initial manif of pelvic TB – infertility
Initiating event in cervical carcinogenesis – infection w/ high risk type of HPV 16 & 18 types of HPV – commonly
A woman just delivered complaint w/ intermitted crampy umbilical pain almost similar to labor pains – tonic contractions of the uterus
Positive evidence of pregnancy - active fetal movements perceived by the examiner
Unicellular parasite, sexually transmitted & inhabits the vagina & lower urinary tract esp. skene’s ducts in females – trichomonas vaginalis
G8P7 (5-2-1-6) – one pregnancy ended in non-viable delivery Should be Delivered by a classical CS at term – transverse lie
Dx of sdenomyosis made certain by – presence of endometrial stroma & glands in myometrium Pregnant prev diagnose w/ myoma uteri complained of severe hypogastric pain – carneous Most common in non-pregnant – hyaline
Bleeding excessive in flow & duration occurring at regular intervals – menorrhgia Menstruation more than twice a month, less than 20 days – polymenorrhea E coli – most common cause of uti in pregnancy
21 year old, 2 months pregnant px suspected to have Acute bacterial cystitis may be treated empirically – amoxicillin Trimethoprimsulfamethoxazole – avoided during 1st trimester
??????? – 3rd trimester causing kernicterus
Chlamydia not pregnant – give doxy or tetracycline
Bartholin’s duct – open at the lateral margins of the vaginal orifice 20 weeks aog, uterine fundus palpable at the level of umbilucs Midway between umbilicus & sp – 16 wks aog
2fbs below umbilicus – 18 wks
Increase vaginal discharge during pregnancy is due to increase mucus formation of cervical glkands in response to high levels of estrogen
Modified BPP – fetal heart tone AFI + NST – fetal respiration AFI
