Case and Learning Objectives

Learning Objectives

1. Cause of Morning Sickness in Pregnant Women and Hyperemesis Gravidarum

Nausea and vomiting in pregnancy is also known as morning sickness which lasts for 16
to 20 weeks of pregnancy (1st trimester). Pathophysiology of nausea and vomiting
during early pregnancy is unknown, although metabolic, endocrine, GI, and psychologic
factors probably all play a role. Estrogen may contribute because estrogen levels are
elevated in patients with hyperemesis gravidarum.
Hyperemesis gravidarum is persistent, severe pregnancy-induced vomiting that causes
significant dehydration, often with electrolyte abnormalities, ketosis, and weight loss.
Treatment is with temporary suspension oral intake and with IV fluids, antiemetic if
needed, and vitamin and electrolyte repletion.

2. Causes and Pathophysiology of Nausea and Vomiting

The vomiting center can be activated directly by irritants or indirectly following
input from 4 principal areas: gastrointestinal tract, cerebral cortex and thalamus,
vestibular region, and chemoreceptor trigger zone (CRTZ). The CRTZ is closest
in proximity, lying between the medulla and the floor of the fourth ventricle.
Unlike other brain centers, it is not protected by the blood-brain barrier. This is to
say that the endothelium of its capillaries is not tightly joined or surrounded by
glial cells and is permeated easily by irritants regardless of their lipid solubility or
molecular size.
Vomiting is caused by noxious
stimulation of the vomiting center
directly or indirectly via 1 or more of 4
additional sites: the GI tract, the
vestibular system, the chemoreceptor
trigger zone, and higher centers in the
cortex and thalamus. Once receptors
are activated, neural pathways lead to
the vomiting center, where emesis is
initiated. Neural traffic originating in the GI tract travels along afferent fibers of
cranial nerves IX (glossopharyngeal) and X (vagal). Antiemetic targets for drug
interventions are predicated on their ability to block the illustrated receptor sites.
Receptor illustrated along with their conventional ligands are as follows: H 1
histamine, M1 acetylcholine, 5-HT3 serotonin, DA2 dopamine, NK1 (neurokinin)
substance P, and mu/kappa opioids. Transmitter mediators in the cerebral cortex
and thalamus are poorly understood, although cortical cannabinoid (CB1)
pathways have been characterized.
Some Causes of Nausea and Vomiting During Early Pregnancy

Cause Suggestive Findings Diagnostic Approach

Obstetric

Mild, intermittent
symptoms at varying
Morning sickness
times throughout the day,
(uncomplicated Diagnosis of exclusion
primarily during the 1st
nausea and
trimester
vomiting)
Normal vital signs and
physical examination

Frequent, persistent
nausea and vomiting with Urine ketones, serum
inability to maintain electrolytes, Mg, BUN,
adequate oral intake of creatinine
Hyperemesis
fluids, food, or both If the condition persists,
gravidarum
Usually, signs of possibly liver function tests,
dehydration (eg, pelvic ultrasonography
tachycardia, dry mouth,
thirst), weight loss

Larger-than-expected
uterine size, absent fetal
heart sounds and BP measurement, quantitative
movement hCG, pelvic ultrasonography,
Hydatidiform mole
Sometimes elevated BP, biopsy
vaginal bleeding,
grapelike tissue from the
cervix
 Cause Suggestive Findings Diagnostic Approach

Nonobstetric

Acute, not chronic; usually

accompanied by diarrhea
Gastroenteritis Normal (benign) abdomen Clinical evaluation

(soft, nontender, not

distended)

Acute, usually in patients

who have had abdominal
surgery Abdominal imaging with flat and

Colicky pain, with upright x-rays, ultrasonography,

Bowel obstruction obstipation and distended, and possibly CT (if x-ray and

tympanitic abdomen ultrasound results are

May be caused by or equivocal)

occur in patients with

appendicitis

Urinary frequency,
urgency, or hesitancy, Urinalysis and culture
UTI or pyelonephritis
with or without flank pain
and fever

hCG = human chorionic gonadotropin.

3. Physiology of Pregnancy!
Gestational age or menstrual age: 28 days = 40 weeks = 91⁄3 months from first
day of the last menstrual period. Due date can be calculated using “Nagele’s
rule” = (day) + 7, (month) – 3  40 weeks.
Untuk menilai usia kehamilan / gestational age dapat menggunakan 3 cara yaitu
berdasarkan HPHT (hari pertama haid terakhir), pemeriksaan USG trimester 1
(14 minggu pertama), dan juga dengan Ballard score.
Kehamilan sendiri terdiri atas 3 trimester yaitu trimester 1 adalah usia 0 – 14
bula, kemudian trimester ke-2 adalah usia 14 – 28 bulan dan trimester ke-3
adalah usia 28 bulan sampai bayi lahir. Bayi yang lahir preterm adalah mereka
yang lahir dengan usia kehamilan <37 minggu (bayi premature). Kelahiran aterm
 adalah kelahiran pada usia kehamilan 37 – 42 minggu. Pada usia >42 minggu
dikatakan postterm.

4. Changes in Pregnant Women (Cervix, Systemic, Uterus, Breast, etc.)

Changes during pregnancy Explanation

Systemic changes
Volume homeostasis Total blood volume is increased during
pregnancy 30%
Most marked expansion occurs in extracellular
volume with some increase in intracellular water
Contributing factors include:
 Increase sodium retention
 Decrease in plasma osmotic pressure
 Decrease in thirst threshold
 Resetting of osmotate
 Decrease in plasma oncotic pressure
Blood Blood volume expansion increases rapidly in the
2nd trimester, and plateaus at about the 30th week
Increased estrogen production by the placenta
stimulates the renin-angiotensin system, which,
in turn leads to higher circulating levels of
aldosterone that promotes renal Na+ reabsorption
and water retention.
Progesterone also participates in plasma
expansion through poorly understood mechanism
HCG and progesterone promote erythropoiesis
resulting increase in red cell mass by 30%
This is why iron supplementation is necessary
during pregnancy
Cardiovascular system Heart slightly shift in position (left-upward
displacement)
 Enlarging uterus  diaphragm  displace
upward result in decreased systemic vascular
resistance  increase CO 6L/min
Heart rate increase (10 – 20%)
Stroke volume increase (10%)
Cardiac output increase (30 – 50%)
Mean arterial blood pressure decrease (10%)
Peripheral resistance decrease (35%)
Respiratory changes
Urinary tract and renal
function
Alimentary tract
Reproductive organs
Endocrinological changes

5. USG Findings in Pregnancy (As a Criteria to Define the Embryo’s Age)

6. Embryology of Placenta

7. Positive, Probable, and Presumptive Criteria of Pregnancy

Presumptive signs and symptoms
 Amenorrhea (cessation of menstruation)
 Nausea and Vomiting (morning sickness)
 Frequent urination
 Breast changes start with a slight, temporary enlargement of the breasts,
causing a sensation of weight, fullness, and mild tingling
 Quickening id the first perception of fetal movement within the uterus and
will be felt after 18 weeks (16 weeks in multigravida)
 Skin changes (striae gravidarum) / stretch marks noted on the abdomen
and/or buttocks caused by increased production or sensitivity to ACTH
during pregnancy, not just weight gain
  Linea nigra is a black line in the midline of the abdomen that may run from
the sternum or umbilicus to the symphysis pubis (develops in the 3 rd
month); it may be a probable sign if the patient has never been pregnant
 Chloasma / Mask of Pregnancy is a bronze type of facial coloration seen
more on dark-haired women
 Fingernails marked thinning and softening by the 6th week
 Fatigue or weakness during the 1st trimester

Probable signs and symptoms

 Uterine changes
o Position: 12th week the
uterus rises above the
symphysis pubis and should
reach the xiphoid process
by the 36th week of
pregnancy
o Size: increases in width and
length app 5 times its
normal size increases from 60 grams to 1000 grams
 Abdominal enlargement corresponds to changes that occur in the uterus,
as the uterus grows, the abdomen gets larger
 Cervical changes: formation of a mucous plug due to hyperplasia of the
cervical glands as a result of increased hormones to seal the cervix of the
pregnant uterus and to protect it from contamination by bacteria in the
vagina
 Persistent temperature elevation spanning over 3 weeks since ovulation is
noted
 Fetal palpation

Positive signs and symptoms

 Fetal heart sounds that begins beating by the 24th day following
conception, audible with a Doppler by 10 weeks of pregnancy and with a
fetoscope after 16th week. Normal fetal heart rate is 120 to 160 bpm.
  Ultrasound scanning of the fetus can be identified after 4 th week after
conception and fetal parts begin to appear by the 10th week of gestation
 Palpation of the entire fetus is a positive sign after 24th week of pregnancy
of the woman is not obese
 Palpation of fetal movements elicited after 24 weeks of pregnancy
 X-ray will identify the entire fetal skeleton by the 12th week, not
recommended test for identifying pregnancy since body radiation may
lead to genetic or gonadal alterations
 Actual delivery of an infant

8. GnPnAn Definition
G = Gravida (number of pregnancies)
P = Para (number of births of viable offspring)
A = Abortus (number of abortions)
Nullgravida  no pregnancies
Primigravida  1 pregnancy
Secundigravida  2 pregnancies

9. Combine Oral Contraceptives (Mechanism of Action, Side Effect, Contents)

10. Things to do when miss dose of COC happens

11. Goodell and Chadwick Sign? Blue Tinge Tissue?

12. Doppler Foetal Heart Rate *kapan kedengeran detak jantung bayi*

13. Definition of Spotting and Menstruation

In a menstrual period, there is a heavy flow of blood and can last for an average
of 3 to 5 days, whereas in spotting, the discharge of blood is sporadic or
irregular. Spotting may occur between menstrual cycles or as part of the
menstrual cycle, however it can be an indication of pregnancy or an underlying
condition. The blood or fluid that is discharged through the vagina is more often
than not very minimal and at times can only be droplets of blood. The color of
blood may appear as dark brown or light pink.
Pregnancy
Spotting may be an indication that a woman is pregnant, or if a woman is indeed
pregnant, it can also mean that there is a possible problem with the pregnancy:
a. Heavy bleeding in the vagina 1st to 2nd month of pregnancy may be an
indication of ectopic pregnancy or it may lead to a miscarriage.
b. If bleeding occurs after the 2nd month of pregnancy, it may be a sign
that there is a problem with the placenta.

Medicines
Attributable to medicines e.g. birth control pills. Women who have just started
taking the pills, light bleeding between their periods may be experienced in the
first 2 – 3 months. For women who have already been taking the pills on a
regular basis, they may encounter bleeding as well if they missed their usual
time of taking the pill.

Ovulation
Ovulation occurs from day-7 to day-22 of the menstrual cycle. Women may
experience spotting in the middle of their menstrual cycle.

Health Conditions

 Infections – STIs may cause abnormal bleeding, sometimes after

douching and intercourse.
 Pelvic Inflammatory Disease – spotting or bleeding may occur to
women with PID, infection or inflammation of the reproductive organs
such as ovaries, uterus, and fallopian tubes.
 Uterine Fibroids – tumours that grow in uterus.
 PCOS – interferes with the regular ovulation.
 Intrauterine Device (IUD) – have increased chances of irregular bleeding
or heavy bleeding.
 Cancers – ovarian or cervical cancer as well as tumour in the vagina may
have bleeding in between periods.
 Stress and Anxiety
Women under emotional stress or anxiety may also experience bleeding or
spotting.

Others
Other causes that may need immediate attention are:

 Sexual abuse or assault

 Foreign object in the vagina
 Polyps (growths on the cervix)

14. Specificity and Sensitivity of Test Pack

15. Signs of Pregnancy (PISKACEK’S Sign, HAEGAR’S Sign, etc.)

16. Cyst in pregnancy? Is it normal? When will it disappear?

17. Is it possible to had menstrual cycle when pregnant?

a. Vaginal bleeding during early pregnancy
Occurs in 20 to 30% of confirmed pregnancies during the 20 weeks of
gestation; about half of these cases end in spontaneous abortion. Vaginal
bleeding is also associated with other adverse pregnancy outcomes such as
low birth weight, preterm births, stillbirth, and perinatal death.

Cause Suggestive Findings Diagnostic Approach

Obstetric disorders
Vaginal bleeding, abdominal pain (often
sudden, localized, and constant, not crampy), or Quantitative β-hCG
both measurement

Ectopic Closed cervical os CBC

pregnancy
Sometimes a palpable, tender adnexal mass Blood typing

Possible hemodynamic instability if ectopic Pelvic ultrasonography

pregnancy is ruptured
Vaginal bleeding with or without crampy
Threatened Evaluation as for ectopic
abdominal pain
abortion pregnancy
Cause Suggestive Findings Diagnostic Approach
Closed cervical os, nontender adnexa

Most common during the first 12 wk of

pregnancy
Crampy abdominal pain, vaginal bleeding

Inevitable Open cervical os (dilated cervix) Evaluation as for ectopic

abortion pregnancy
Products of conception often seen or felt
through os
Vaginal bleeding, abdominal pain

Incomplete Open or closed cervical os Evaluation as for ectopic

abortion pregnancy
Products of conception often seen or felt
through os
Mild vaginal bleeding at presentation but
usually a history of significant vaginal bleeding
Complete immediately preceding visit; some abdominal Evaluation as for ectopic
abortion pain pregnancy

Closed cervical os, small and contracted uterus

Fever, chills, continuous abdominal pain,
vaginal bleeding, purulent vaginal discharge
Evaluation as for ectopic
Usually, apparent history of recent induced
Septic abortion pregnancy plus cervical
abortion or instrumentation of the uterus (often
cultures
illegal or self-induced)

Open cervical os
Vaginal bleeding, symptoms of early pregnancy
(nausea, fatigue, breast tenderness) that
Evaluation as for ectopic
Missed abortion decrease with time
pregnancy
Closed cervical os
Gestational Larger-than-expected uterine size, often
Evaluation as for ectopic
trophoblastic elevated BP, severe vomiting, sometimes
pregnancy
disease passage of grapelike tissue
Localized abdominal pain, vaginal bleeding
Ruptured corpus Evaluation as for ectopic
luteum cyst Most common during the first 12 wk of pregnancy
pregnancy
Nonobstetric disorders
Apparent from history (eg, laceration of the Clinical evaluation
Trauma
cervix or vagina due to instrumentation or
Cause Suggestive Findings Diagnostic Approach
abuse, sometimes a complication of chorionic Questions about possible
villus sampling or amniocentesis) domestic violence if
appropriate
Only spotting or scant bleeding with vaginal
Diagnosis of exclusion
discharge
Vaginitis
Cervical cultures
Sometimes dyspareunia, pelvic pain, or both
Only spotting or scant bleeding
Diagnosis of exclusion
Cervicitis
Sometimes cervical motion tenderness,
Cervical cultures
abdominal pain, or both
Clinical evaluation
Scant bleeding, no pain
Cervical polyps
Obstetric follow-up for
(usually benign)
Polypoid mass protruding from cervix further evaluation and
removal
β-hCG =β subunit of human chorionic gonadotropin.

b. Vaginal bleeding during late pregnancy

More than 20 weeks of gestation, but before birth occurs in 3 to 4% of
pregnancies. Some disorders can cause substantial blood loss, occasionally
enough to cause hemorrhagic shock or disseminated intravascular
coagulation.

Cause Suggestive Findings Diagnostic Approach

Passage of blood-tinged mucus plug, not
active bleeding

Labor Painful, regular uterine contractions with Diagnosis of exclusion

cervical dilation and effacement

Normal fetal and maternal signs

Painful, tender uterus, often tense with
contractions

Dark or clotted blood Clinical suspicion

Abruptio
placentae Sometimes maternal hypotension Often, ultrasonography, although it
is not very sensitive
Signs of fetal distress (eg, bradycardia or
prolonged deceleration, repetitive late
decelerations, sinusoidal pattern)
Cause Suggestive Findings Diagnostic Approach
Sometimes suspected based on
Sudden onset of painless vaginal bleeding findings during routine screening
Placenta
with bright red blood and minimal or no ultrasonography
previa
uterine tenderness
Transvaginal ultrasonography
Sometimes suspected based on
Painless vaginal bleeding with fetal findings during routine screening
instability but normal maternal signs ultrasonography
Vasa previa
Often, symptoms of labor Transvaginal ultrasonography with
color Doppler studies
Severe abdominal pain, tenderness,
cessation of contractions, often loss of
Clinical suspicion, usually history
uterine tone
Uterine of prior uterine surgery
rupture
Mild to moderate vaginal bleeding
Laparotomy
Fetal bradycardia or loss of heart sounds

18. USG in pregnancy (crown rump, biparietal distance)

19. Effect of Contraceptives Pills and Mefenamic Acid on Pregnancy

20. Teratogen Associated with Human Malformation! Teratogen / Teratogenesis

21. Foetal Development!

22. Process of Fertilization until 8th Week of Pregnancy