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MEDICAL CONDITIONS COMPLICATING PREGNANCY
DIABETES MELLITUS
DEFINITION OF TERMS <ul><li>OVERT DIABETES </li></ul><ul><li>- those known to have diabetes mellitus </li></ul><ul><li>bef...
CLASSIFICATION DURING PREGNANCY <ul><li>CLASS  ONSET  FBS  2-HR PP GL  THERAPY </li></ul><ul><li>A1  Gestational  <105 mg/...
CLASSIFICATION DURING PREGNANCY <ul><li>CLASS  AGE/ONSET  DURATION  VASCULAR  THERAPY </li></ul><ul><li>(Years)  DISEASE <...
GESTATIONAL DIABETES <ul><li>carbohydrate intolerance of variable severity with onset or first recognition during pregnanc...
<ul><li>A 23 yr old markedly obese primigravida at 12 weeks gestation seeks consultation for her first prenatal check-up. ...
WHO to screen ?
GDM - SCREENING <ul><li>RISK FACTORS </li></ul><ul><li>Age over 30 </li></ul><ul><li>Family Hx of DM </li></ul><ul><li>Pri...
WHEN to screen ?
RECOMMENDED SCREENING STRATEGY BASED ON RISK ASSESSMENT FOR DETECTING GDM <ul><li>LOW RISK </li></ul><ul><li>Blood glucose...
RECOMMENDED SCREENING STRATEGY BASED ON RISK ASSESSMENT FOR DETECTING GDM <ul><li>AVERAGE RISK </li></ul><ul><li>Perform b...
RECOMMENDED SCREENING STRATEGY BASED ON RISK ASSESSMENT FOR DETECTING GDM <ul><li>HIGH RISK </li></ul><ul><li>Perform bloo...
HOW to screen ?
GDM - SCREENING <ul><li>50-g GLUCOSE CHALLENGE TEST </li></ul><ul><li>> 140 mg/dl or > 130 mg/dl  </li></ul><ul><li>–  pro...
GDM - SCREENING <ul><li>100-gm ORAL GLUCOSE TOLERANCE TEST (OGTT) </li></ul><ul><li>TIME  NDDG  CARPENTER & COUSTAN </li><...
<ul><li>A 23 yr old markedly obese primigravida at 12 weeks gestation seeks consultation for her first prenatal check-up. ...
GDM - ADVERSE EFFECTS <ul><li>MACROSOMIA </li></ul><ul><li>Excessive fat deposition on shoulders/trunk </li></ul><ul><li>P...
MACROSOMIA Pathogenesis
<ul><li>Fetal effects of persistent maternal fasting hyperglycemia include: </li></ul><ul><li>A.  macrosomia </li></ul><ul...
GDM - MANAGEMENT <ul><li>Type A1 – diet alone </li></ul><ul><li>Type A2 – diet + insulin </li></ul><ul><li>DIET </li></ul>...
<ul><li>Recommended postpartum follow-up for patients with gestational diabetes consists of: </li></ul><ul><li>A.  daily b...
GDM - PROGNOSIS <ul><li>50% risk of developing overt DM w/in 20 yrs </li></ul><ul><li>Evaluate with 75-gm OGTT – 6-12 wks ...
<ul><li>Recommended postpartum follow-up for patients with gestational diabetes consists of: </li></ul><ul><li>A.  daily b...
OVERT DIABETES <ul><li>Pregestational diabetes </li></ul><ul><li>Known diabetics before pregnancy </li></ul>
<ul><li>The diagnosis of overt diabetes is most probable in the gravida with which of the ff OGTT results (Fasting-1hr-2hr...
OVERT DIABETES <ul><li>DIAGNOSIS DURING PREGNANCY </li></ul><ul><li>RBS >200 mg/dl + Sx: polyuria, polydipsia, wt loss </l...
<ul><li>The diagnosis of overt diabetes is most probable in the gravida with which of the ff OGTT results (Fasting-1hr-2hr...
OVERT DIABETES <ul><li>EFFECTS ON FETUS </li></ul><ul><li>ABORTION – poor glycemic control </li></ul><ul><li>HbA1c > 12% <...
OVERT DIABETES <ul><li>EFFECTS ON FETUS </li></ul><ul><li>UNEXPLAINED FETAL DEATH </li></ul><ul><li>HYDRAMNIOS </li></ul><...
OVERT DIABETES <ul><li>EFFECTS ON FETUS </li></ul><ul><li>HYPOCALCEMIA </li></ul><ul><li>HYPOBILIRUBINEMIA </li></ul><ul><...
OVERT DIABETES <ul><li>EFFECTS ON MOTHER </li></ul><ul><li>DIABETIC NEPHROPATHY </li></ul><ul><li>inc. when HbA1c > 10% </...
OVERT DIABETES <ul><li>EFFECTS ON MOTHER </li></ul><ul><li>PREECLAMPSIA </li></ul><ul><li>not related to glucose control <...
OVERT DIABETES MANAGEMENT <ul><li>PRECONCEPTION </li></ul><ul><li>HbA1c – expresses an ave. of circulating  </li></ul><ul>...
OVERT DIABETES MANAGEMENT <ul><li>PREGNANCY </li></ul><ul><li>Blood glucose monitoring </li></ul><ul><li>Precise fetal age...
PULMONARY DISORDERS
NORMAL CHANGES IN PREGNANCY
PULMONARY TUBERCULOSIS
TUBERCULOSIS <ul><li>Organism:  Mycobacterium tuberculosis </li></ul><ul><li>DIAGNOSIS </li></ul><ul><li>Symptoms:  cough ...
TUBERCULOSIS <ul><li>DIAGNOSIS </li></ul><ul><li>Lab: Chest Xray  </li></ul><ul><li>cavitations </li></ul><ul><li>mediasti...
<ul><li>Recommended initial treatment of active tuberculosis during pregnancy is: </li></ul><ul><li>A.  INH, Ethambutol, R...
TUBERCULOSIS <ul><li>MANAGEMENT </li></ul><ul><li>Isoniazid + Rifampicin + Ethambutol for a minimum of 9 months  (WHO: + P...
<ul><li>Recommended initial treatment of active tuberculosis during pregnancy is: </li></ul><ul><li>A.  INH, Ethambutol, R...
URINARY TRACT DISORDERS
<ul><li>Which of the ff laboratory values is not normal during pregnancy and suggests an underlying renal disease: </li></...
NORMAL CHANGES IN PREGNANCY <ul><li>Increased renal size </li></ul><ul><li>Dilatation of pelves, calyces and ureters </li>...
DIAGNOSTIC TESTS <ul><li>Urinalysis </li></ul><ul><li>glucosuria </li></ul><ul><li>orthostatic proteinuria </li></ul><ul><...
<ul><li>Which of the ff laboratory values is not normal during pregnancy and suggests an underlying renal disease: </li></...
URINARY TRACT INFECTION
<ul><li>Acute Uncomplicated Cystitis is most likely in this case: </li></ul><ul><li>A.  A 26-year-old G1P0 with fever,  </...
URINARY TRACT INFECTIONS <ul><li>ASYMPTOMATIC BACTERIURIA </li></ul><ul><li>DIAGNOSIS </li></ul><ul><li>Clean-voided speci...
URINARY TRACT INFECTION <ul><li>CYSTITIS AND URETHRITIS </li></ul><ul><li>DIAGNOSIS </li></ul><ul><li>Symptoms: dysuria </...
URINARY TRACT INFECTION <ul><li>ACUTE PYELONEPHRITIS </li></ul><ul><li>Leading cause of septic shock during pregnancy (end...
URINARY TRACT INFECTION <ul><li>ACUTE PYELONEPHRITIS </li></ul><ul><li>DIAGNOSIS </li></ul><ul><li>Symptoms:  fever </li><...
URINARY TRACT INFECTION <ul><li>ACUTE PYELONEPHRITIS </li></ul><ul><li>MANAGEMENT </li></ul><ul><li>Hospitalization </li><...
URINARY TRACT INFECTION <ul><li>ACUTE PYELONEPHRITIS </li></ul><ul><li>MANAGEMENT </li></ul><ul><li>Antimicrobial therapy ...
<ul><li>Acute Uncomplicated Cystitis is most likely in this case: </li></ul><ul><li>A.  A 26-year-old G1P0 with fever, </l...
THYROID DISORDERS
NORMAL CHANGES IN PREGNANCY <ul><li>Moderate thyroid enlargement </li></ul><ul><li>- glandular hpl and vascularity </li></...
HYPERTHYROIDISM <ul><li>DIAGNOSIS: </li></ul><ul><li>Tachycardia </li></ul><ul><li>Thyromegaly </li></ul><ul><li>Failure t...
GRAVE’S DISEASE <ul><li>Most common cause of thyrotoxicosis in pregnancy </li></ul><ul><li>Autoimmune process associated w...
<ul><li>A 37 yr old G2P1 12 weeks gestation presents for her first prenatal check-up.  She had been diagnosed with Grave’s...
GRAVE’S DISEASE <ul><li>MANAGEMENT </li></ul><ul><li>Medical </li></ul><ul><li>Propylthyouracil / Methimazole </li></ul><u...
<ul><li>A 37 yr old G2P1 12 weeks gestation presents for her first prenatal check-up.  She had been diagnosed with Grave’s...
GRAVE’S DISEASE <ul><li>MANAGEMENT </li></ul><ul><li>Surgical – Subtotal Thyroidectomy </li></ul><ul><li>after thyrotoxico...
GRAVE’S DISEASE <ul><li>EFFECT ON PREGNANCY </li></ul><ul><li>Higher incidence of preeclampsia </li></ul><ul><li>heart fai...
HYPOTHYROIDISM <ul><li>DIAGNOSIS </li></ul><ul><li>Absence of normal rise in serum thyroxine </li></ul><ul><li>Increased t...
HYPOTHYROIDISM <ul><li>EFFECT ON PREGNANCY </li></ul><ul><li>Inc. incidence of abortion, SB, LBW </li></ul><ul><li>preecla...
HYPOTHYROIDISM <ul><li>EFFECT ON NEONATE </li></ul><ul><li>Usually healthy </li></ul><ul><li>Simple Colloid goiter w/o hyp...
HYPOTHYROIDISM <ul><li>MANAGEMENT </li></ul><ul><li>Thyroid hormones </li></ul><ul><li>dose adjusted so that serum thyrotr...
<ul><li>Thyroid function tests showing an elevated serum thyrotropin, normal serum thyroxine and normal triiodothyronine i...
PUERPERAL INFECTION
10 days post cesarean section, a 23 yr old primipara complains of fever of  3 days duration associated with hypogastric pa...
PUERPERAL MORBIDITY <ul><li>temperature 38 C or higher, the temperature to occur on any 2 of the 1 st  10 days postpartum,...
Differential Diagnosis of Puerperal Fever <ul><li>Genital tract infection </li></ul><ul><li>Respiratory complications </li...
Respiratory Complications <ul><li>-  seen within the 1 st  24 hours </li></ul><ul><li>-  in women delivered by cesarean se...
Pyelonephritis <ul><li>SSx:  bacteriuria / pyuria </li></ul><ul><li>costovertebral angle tenderness </li></ul><ul><li>spik...
Breast Engorgement <ul><li>15 % of all postpartum women </li></ul><ul><li>Fever rarely goes > 39 C </li></ul><ul><li>Fever...
Thrombophlebitis <ul><li>SSx:  </li></ul><ul><li>painful swollen leg </li></ul><ul><li>calf / femoral angle tenderness </l...
Uterine Infection <ul><li>Infection involving the decidua, myometrium and parametrial tissues </li></ul><ul><li>Metritis w...
Uterine Infection <ul><li>The  route   of   delivery  is the single most significant risk factor for the development of po...
Risk Factors for Metritis <ul><li>Prolonged labor </li></ul><ul><li>Prolonged membrane rupture </li></ul><ul><li>Multiple ...
Bacteria Responsible for Genital Tract Infections <ul><li>Aerobes </li></ul><ul><li>Grp A, B and D streptococci </li></ul>...
Clinical Course <ul><li>Fever </li></ul><ul><li>Chills </li></ul><ul><li>Abdominal pain / tenderness </li></ul><ul><li>Fou...
Treatment <ul><li>BROAD SPECTRUM ANTIBIOTICS </li></ul><ul><li>Clindamycin + Gentamycin </li></ul><ul><li>most widely stud...
Causes of Persistent Fever Despite Antibiotic Rx <ul><li>Wound infection </li></ul><ul><li>Peritonitis </li></ul><ul><li>P...
Wound Infection <ul><li>3 – 5% post C/S </li></ul><ul><li>2% - with prophylactic antibiotics </li></ul><ul><li>SSx:  fever...
Risk Factors for Wound Infection <ul><li>Obesity </li></ul><ul><li>Diabetes </li></ul><ul><li>Corticosteroid therapy </li>...
Peritonitis <ul><li>Route: lymphatics </li></ul><ul><li>SSx:  severe abdominal pain </li></ul><ul><li>bowel distension – i...
Parametrial Phlegmon <ul><li>Dx: parametrial induration </li></ul><ul><li>unilateral </li></ul><ul><li>uterus fixed on  </...
Pelvic Abscess <ul><li>Dx:  fluctuant broad ligament mass </li></ul><ul><li>Rx:  Drainage </li></ul><ul><li>Colpotomy </li...
Septic Thrombophlebitis <ul><li>Route:  hematogenous </li></ul><ul><li>Pathogenesis: </li></ul><ul><li>placental site infe...
Infections of Perineum, Vagina and Cervix <ul><li>Rx:  Drainage </li></ul><ul><li>Antibiotics </li></ul><ul><li>Analgesics...
10 days post cesarean section, a 23 yr old primipara complains of fever of  3 days duration associated with hypogastric pa...
<ul><li>Please visit: </li></ul><ul><li>http://crisbertcualteros.page.tl </li></ul>
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Medical Complications In Pregnancy

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Transcript of "Medical Complications In Pregnancy"

  1. 1. MEDICAL CONDITIONS COMPLICATING PREGNANCY
  2. 2. DIABETES MELLITUS
  3. 3. DEFINITION OF TERMS <ul><li>OVERT DIABETES </li></ul><ul><li>- those known to have diabetes mellitus </li></ul><ul><li>before pregnancy </li></ul><ul><li>GESTATIONAL DIABETES </li></ul><ul><li>- those diagnosed during pregnancy </li></ul>
  4. 4. CLASSIFICATION DURING PREGNANCY <ul><li>CLASS ONSET FBS 2-HR PP GL THERAPY </li></ul><ul><li>A1 Gestational <105 mg/dl <120 mg/dl Diet </li></ul><ul><li>A2 Gestational >105 mg/dl >120 mg/dl Insulin </li></ul>
  5. 5. CLASSIFICATION DURING PREGNANCY <ul><li>CLASS AGE/ONSET DURATION VASCULAR THERAPY </li></ul><ul><li>(Years) DISEASE </li></ul><ul><li>B Over 20 < 10 None Insulin </li></ul><ul><li>C 10 – 19 10 – 19 None Insulin </li></ul><ul><li>D Before 10 > 20 Benign Insulin </li></ul><ul><li>Retinopathy </li></ul><ul><li>F Any Any Nephropathy Insulin </li></ul><ul><li>R Any Any Proliferative Insulin </li></ul><ul><li>Retinopathy </li></ul><ul><li>H Any Any Heart Insulin </li></ul>
  6. 6. GESTATIONAL DIABETES <ul><li>carbohydrate intolerance of variable severity with onset or first recognition during pregnancy </li></ul><ul><li>disorder of late gestation </li></ul><ul><li>disorder induced by pregnancy: </li></ul><ul><li>from exagerrated physiological changes </li></ul><ul><li>in glucose metabolism </li></ul><ul><li>Type 2 DM unmasked during pregnancy </li></ul>
  7. 7. <ul><li>A 23 yr old markedly obese primigravida at 12 weeks gestation seeks consultation for her first prenatal check-up. She denies any family history of diabetes mellitus. As part of prenatal work-up, you would: </li></ul><ul><li>A. take a 50 gm glucose challenge test as soon as possible </li></ul><ul><li>B. order for 50 gm glucose challenge test at 24-28 weeks </li></ul><ul><li>C. take a 100 gm oral glucose tolerance test as soon as possible </li></ul><ul><li>D. order for a 100 gm oral glucose tolerance test at 24-28 weeks </li></ul>
  8. 8. WHO to screen ?
  9. 9. GDM - SCREENING <ul><li>RISK FACTORS </li></ul><ul><li>Age over 30 </li></ul><ul><li>Family Hx of DM </li></ul><ul><li>Prior macrosomic, malformed or stillborn infant </li></ul><ul><li>Obesity </li></ul><ul><li>Hypertension </li></ul><ul><li>Glucosuria </li></ul>
  10. 10. WHEN to screen ?
  11. 11. RECOMMENDED SCREENING STRATEGY BASED ON RISK ASSESSMENT FOR DETECTING GDM <ul><li>LOW RISK </li></ul><ul><li>Blood glucose testing not routinely required if all of the ff characteristics are present: </li></ul><ul><li>Member of ethnic grp w/ low prevalence of GDM </li></ul><ul><li>No known DM in 1 st degree relative </li></ul><ul><li>Age less than 25 yrs </li></ul><ul><li>Weight normal before pregnancy </li></ul><ul><li>No Hx of abnormal glucose metabolism </li></ul><ul><li>No Hx of poor obstetrical outcome </li></ul>
  12. 12. RECOMMENDED SCREENING STRATEGY BASED ON RISK ASSESSMENT FOR DETECTING GDM <ul><li>AVERAGE RISK </li></ul><ul><li>Perform blood glucose testing at 24-28 wks: </li></ul><ul><li>Hispanic </li></ul><ul><li>African </li></ul><ul><li>Native American </li></ul><ul><li>South or East Asian origin </li></ul>
  13. 13. RECOMMENDED SCREENING STRATEGY BASED ON RISK ASSESSMENT FOR DETECTING GDM <ul><li>HIGH RISK </li></ul><ul><li>Perform blood glucose testing as soon as feasible . If normal, repeat at 24-28 wks or at any time pt has SSx suggestive of hyperglycemia: </li></ul><ul><li>Marked obesity </li></ul><ul><li>Strong family Hx of type 2 DM </li></ul><ul><li>Prior gestational diabetes </li></ul><ul><li>Glucosuria </li></ul>
  14. 14. HOW to screen ?
  15. 15. GDM - SCREENING <ul><li>50-g GLUCOSE CHALLENGE TEST </li></ul><ul><li>> 140 mg/dl or > 130 mg/dl </li></ul><ul><li>– proceed to 100 gm 3 Hr Oral Glucose Tolerance Test </li></ul>
  16. 16. GDM - SCREENING <ul><li>100-gm ORAL GLUCOSE TOLERANCE TEST (OGTT) </li></ul><ul><li>TIME NDDG CARPENTER & COUSTAN </li></ul><ul><li>(1979) (1989) </li></ul><ul><li>Fasting 105 95 </li></ul><ul><li>1 hour 190 180 </li></ul><ul><li>2 hours 165 155 </li></ul><ul><li>3 hours 145 140 </li></ul><ul><li>GDM is dxed with 2 or > abn values. </li></ul>
  17. 17. <ul><li>A 23 yr old markedly obese primigravida at 12 weeks gestation seeks consultation for her first prenatal check-up. She denies any family history of diabetes mellitus. As part of prenatal work-up, you would: </li></ul><ul><li>A. take a 50 gm glucose challenge test as soon as possible </li></ul><ul><li>B. order for 50 gm glucose challenge test at 24-28 weeks </li></ul><ul><li>C. take a 100 gm oral glucose tolerance test as soon as possible </li></ul><ul><li>D. order for a 100 gm oral glucose tolerance test at 24-28 weeks </li></ul>
  18. 18. GDM - ADVERSE EFFECTS <ul><li>MACROSOMIA </li></ul><ul><li>Excessive fat deposition on shoulders/trunk </li></ul><ul><li>Predisposes to shoulder dystocia </li></ul><ul><li>Maternal hyperglycemia  transfer of excess glucose to fetus  stimulate fetal insulin secretion which is a potent growth factor </li></ul><ul><li>HYPOGLYCEMIA at birth </li></ul>
  19. 19. MACROSOMIA Pathogenesis
  20. 20. <ul><li>Fetal effects of persistent maternal fasting hyperglycemia include: </li></ul><ul><li>A. macrosomia </li></ul><ul><li>B. postterm pregnancy </li></ul><ul><li>C. oligohydramnios </li></ul><ul><li>D. hypoglycemia </li></ul>
  21. 21. GDM - MANAGEMENT <ul><li>Type A1 – diet alone </li></ul><ul><li>Type A2 – diet + insulin </li></ul><ul><li>DIET </li></ul><ul><li>Goals: 1. to provide the necessary nutrients for </li></ul><ul><li>mother and fetus </li></ul><ul><li>2. to control glucose levels </li></ul><ul><li>3. to prevent starvation ketosis </li></ul><ul><li>EXERCISE </li></ul><ul><li>upper body cardiovascular training </li></ul>
  22. 22. <ul><li>Recommended postpartum follow-up for patients with gestational diabetes consists of: </li></ul><ul><li>A. daily blood sugar monitoring </li></ul><ul><li>B. fasting blood sugar on day of discharge </li></ul><ul><li>C. 50 gm glucose challenge test 1 week postpartum </li></ul><ul><li>D. 75 gm oral glucose tolerance test 6 weeks postpartum </li></ul>
  23. 23. GDM - PROGNOSIS <ul><li>50% risk of developing overt DM w/in 20 yrs </li></ul><ul><li>Evaluate with 75-gm OGTT – 6-12 wks pp </li></ul><ul><li>TIME NO DIABETES IMPAIRED DIABETES </li></ul><ul><li>GL. TOL. </li></ul><ul><li>Fasting < 115 < 140 >/= 140 </li></ul><ul><li>½, 1, 1-½ All < 200 1 value >/= 200 1 value >/=200 </li></ul><ul><li>2 hr < 140 140 – 199 >/= 200 </li></ul><ul><li>If 75-g OGTT is normal – take FBS yearly </li></ul>
  24. 24. <ul><li>Recommended postpartum follow-up for patients with gestational diabetes consists of: </li></ul><ul><li>A. daily blood sugar monitoring </li></ul><ul><li>B. fasting blood sugar on day of discharge </li></ul><ul><li>C. 50 gm glucose challenge test 1 week postpartum </li></ul><ul><li>D. 75 gm oral glucose tolerance test 6 weeks postpartum </li></ul>
  25. 25. OVERT DIABETES <ul><li>Pregestational diabetes </li></ul><ul><li>Known diabetics before pregnancy </li></ul>
  26. 26. <ul><li>The diagnosis of overt diabetes is most probable in the gravida with which of the ff OGTT results (Fasting-1hr-2hr-3hr post glucose load – mg/dl): </li></ul><ul><li>A. 100 – 190 – 170 – 130 </li></ul><ul><li>B. 90 – 195 – 140 – 120 </li></ul><ul><li>C. 95 - 180 - 155 - 140 </li></ul><ul><li>D. 130 - 170 - 160 - 135 </li></ul>
  27. 27. OVERT DIABETES <ul><li>DIAGNOSIS DURING PREGNANCY </li></ul><ul><li>RBS >200 mg/dl + Sx: polyuria, polydipsia, wt loss </li></ul><ul><li>Fasting glucose > 125 mg/dl </li></ul><ul><li>Strong likelihood in pts with: </li></ul><ul><li>strong family Hx of DM </li></ul><ul><li>previous large infants </li></ul><ul><li>persistent glucosuria </li></ul><ul><li>unexplained fetal losses </li></ul>
  28. 28. <ul><li>The diagnosis of overt diabetes is most probable in the gravida with which of the ff OGTT results (Fasting-1hr-2hr-3hr post glucose load – mg/dl): </li></ul><ul><li>A. 100 – 190 – 170 – 130 </li></ul><ul><li>B. 90 – 195 – 140 – 120 </li></ul><ul><li>C. 95 - 180 - 155 - 140 </li></ul><ul><li>D. 130 - 170 - 160 - 135 </li></ul>
  29. 29. OVERT DIABETES <ul><li>EFFECTS ON FETUS </li></ul><ul><li>ABORTION – poor glycemic control </li></ul><ul><li>HbA1c > 12% </li></ul><ul><li>persistent pre-prandial glucose level > 120 mg/dl </li></ul><ul><li>MALFORMATIONS </li></ul><ul><li>Type 1 – 5-10% incidence </li></ul><ul><li>from poorly controlled DM preconceptionally and in early pregnancy </li></ul>
  30. 30. OVERT DIABETES <ul><li>EFFECTS ON FETUS </li></ul><ul><li>UNEXPLAINED FETAL DEATH </li></ul><ul><li>HYDRAMNIOS </li></ul><ul><li>from fetal polyuria </li></ul><ul><li>RESPIRATORY DISTRESS </li></ul><ul><li>from prematurity </li></ul><ul><li>HYPOGLYCEMIA </li></ul><ul><li>from hyperplasia of fetal B-islet cells </li></ul>
  31. 31. OVERT DIABETES <ul><li>EFFECTS ON FETUS </li></ul><ul><li>HYPOCALCEMIA </li></ul><ul><li>HYPOBILIRUBINEMIA </li></ul><ul><li>prematurity </li></ul><ul><li>polycythemia with hemolysis </li></ul><ul><li>CARDIAC HYPERTROPHY </li></ul><ul><li>INHERITANCE OF DM </li></ul><ul><li>Diabetic Mother – 1-3% risk </li></ul><ul><li>Diabetic Father – 6% </li></ul><ul><li>Diabetic Father and Mother – 20 % risk </li></ul>
  32. 32. OVERT DIABETES <ul><li>EFFECTS ON MOTHER </li></ul><ul><li>DIABETIC NEPHROPATHY </li></ul><ul><li>inc. when HbA1c > 10% </li></ul><ul><li>microalbuminuria  overt proteinuria </li></ul><ul><li> HPN  end-stage renal dse </li></ul><ul><li>DIABETIC RETINOPATHY </li></ul><ul><li>after 7 yrs – 50% chance of dev. </li></ul><ul><li>after 20 yrs – 90% </li></ul><ul><li>DIABETIC NEUROPATHY </li></ul>
  33. 33. OVERT DIABETES <ul><li>EFFECTS ON MOTHER </li></ul><ul><li>PREECLAMPSIA </li></ul><ul><li>not related to glucose control </li></ul><ul><li>KETOACIDOSIS </li></ul><ul><li>result of: hyperemesis gravidarum </li></ul><ul><li>use of B sympathomimetic drugs </li></ul><ul><li>(tocolytics) </li></ul><ul><li>infections </li></ul><ul><li>use of corticosteroids </li></ul><ul><li>INFECTIONS – 80% </li></ul>
  34. 34. OVERT DIABETES MANAGEMENT <ul><li>PRECONCEPTION </li></ul><ul><li>HbA1c – expresses an ave. of circulating </li></ul><ul><li>glucose for the past 4-6 wks </li></ul><ul><li>- assess metabolic control </li></ul><ul><li>- > 10% - inc. risk for malformations </li></ul><ul><li>Folate – 400 ug/day </li></ul><ul><li>- to decrease neural tube defects </li></ul>
  35. 35. OVERT DIABETES MANAGEMENT <ul><li>PREGNANCY </li></ul><ul><li>Blood glucose monitoring </li></ul><ul><li>Precise fetal age determination </li></ul><ul><li>LMP, FH, FHT, U/S </li></ul><ul><li>Well established EDC – to assess accurately </li></ul><ul><li>macrosomia, hydramnios, FGR </li></ul><ul><li>Diet </li></ul><ul><li>Insulin </li></ul>
  36. 36. PULMONARY DISORDERS
  37. 37. NORMAL CHANGES IN PREGNANCY
  38. 38. PULMONARY TUBERCULOSIS
  39. 39. TUBERCULOSIS <ul><li>Organism: Mycobacterium tuberculosis </li></ul><ul><li>DIAGNOSIS </li></ul><ul><li>Symptoms: cough w/ minimal sputum </li></ul><ul><li>low-grade fever </li></ul><ul><li>hemoptysis </li></ul><ul><li>weight loss </li></ul>
  40. 40. TUBERCULOSIS <ul><li>DIAGNOSIS </li></ul><ul><li>Lab: Chest Xray </li></ul><ul><li>cavitations </li></ul><ul><li>mediastinal lymphadenopathy </li></ul><ul><li>extent of dse may be masked by lung compression </li></ul><ul><li>Sputum exam – acid-fast bacilli </li></ul>
  41. 41. <ul><li>Recommended initial treatment of active tuberculosis during pregnancy is: </li></ul><ul><li>A. INH, Ethambutol, Rifampin </li></ul><ul><li>B. INH, Ethambutol, Pyrazinamide, Rifampin </li></ul><ul><li>C. INH, Rifampin, Streptomycin </li></ul><ul><li>D. INH only </li></ul>
  42. 42. TUBERCULOSIS <ul><li>MANAGEMENT </li></ul><ul><li>Isoniazid + Rifampicin + Ethambutol for a minimum of 9 months (WHO: + Purazinamide x 6 months) </li></ul><ul><li>EFFECT ON PREGNANCY </li></ul><ul><li>Preterm delivery </li></ul><ul><li>Low birthweight </li></ul><ul><li>Perinatal death </li></ul><ul><li>Neonatal tuberculosis – rare, fatal </li></ul><ul><li>Route: hematogenous </li></ul><ul><li>aspiration of inf secretion at del unlikely if Rxed </li></ul>
  43. 43. <ul><li>Recommended initial treatment of active tuberculosis during pregnancy is: </li></ul><ul><li>A. INH, Ethambutol, Rifampin </li></ul><ul><li>B. INH, Ethambutol, Pyrazinamide, Rifampin </li></ul><ul><li>C. INH, Rifampin, Streptomycin </li></ul><ul><li>D. INH only </li></ul>
  44. 44. URINARY TRACT DISORDERS
  45. 45. <ul><li>Which of the ff laboratory values is not normal during pregnancy and suggests an underlying renal disease: </li></ul><ul><ul><ul><li>A. Urinalysis: glucose + </li></ul></ul></ul><ul><ul><ul><li>B. mild right hydronephrosis on ultrasound </li></ul></ul></ul><ul><ul><ul><li>C. serum creatinine – 1.2 mg/dl </li></ul></ul></ul><ul><ul><ul><li>D. Urinalysis: protein - trace </li></ul></ul></ul>
  46. 46. NORMAL CHANGES IN PREGNANCY <ul><li>Increased renal size </li></ul><ul><li>Dilatation of pelves, calyces and ureters </li></ul><ul><li>- not to be mistaken for obstructive uropathy </li></ul><ul><li>- predispose to serious upper urinary tract infections </li></ul><ul><li>Increased GFR and RPF </li></ul><ul><li>- Serum creatinine and urea nitrogen decrease </li></ul>
  47. 47. DIAGNOSTIC TESTS <ul><li>Urinalysis </li></ul><ul><li>glucosuria </li></ul><ul><li>orthostatic proteinuria </li></ul><ul><li>Serum creatinine </li></ul><ul><li>> 0.9 mg/dl – suspect intrinsic renal dse </li></ul><ul><li>Ultrasonography </li></ul><ul><li>Intravenous pyelography </li></ul><ul><li>if indicated, one-shot pyelogram </li></ul><ul><li>Cystoscopy </li></ul><ul><li>Renal Biopsy (?) </li></ul>
  48. 48. <ul><li>Which of the ff laboratory values is not normal during pregnancy and suggests an underlying renal disease: </li></ul><ul><ul><ul><li>A. Urinalysis: glucose + </li></ul></ul></ul><ul><ul><ul><li>B. mild right hydronephrosis on ultrasound </li></ul></ul></ul><ul><ul><ul><li>C. serum creatinine – 1.2 mg/dl </li></ul></ul></ul><ul><ul><ul><li>D. Urinalysis: protein - trace </li></ul></ul></ul>
  49. 49. URINARY TRACT INFECTION
  50. 50. <ul><li>Acute Uncomplicated Cystitis is most likely in this case: </li></ul><ul><li>A. A 26-year-old G1P0 with fever, </li></ul><ul><li>dysuria and flank pains </li></ul><ul><li>B. A 35-year-old G3P2 with hematuria </li></ul><ul><li>and colicky right flank pain </li></ul><ul><li>C. An 18-year-old G3P0020 with </li></ul><ul><li>dysuria, urinary frequency & yellow- </li></ul><ul><li>green vaginal discharge </li></ul><ul><li>D. A 28-year-old G2P1 with dysuria and </li></ul><ul><li>urinary urgency </li></ul>
  51. 51. URINARY TRACT INFECTIONS <ul><li>ASYMPTOMATIC BACTERIURIA </li></ul><ul><li>DIAGNOSIS </li></ul><ul><li>Clean-voided specimen containing >100,000 org/ml </li></ul><ul><li>MANAGEMENT </li></ul><ul><li>Nitrofurantoin (or Ampicillin, Amoxycillin, Cephalosporin) </li></ul><ul><li>If untreated, 25% develop acute Sxtic infection. </li></ul>
  52. 52. URINARY TRACT INFECTION <ul><li>CYSTITIS AND URETHRITIS </li></ul><ul><li>DIAGNOSIS </li></ul><ul><li>Symptoms: dysuria </li></ul><ul><li>urgency </li></ul><ul><li>urinary frequency </li></ul><ul><li>Lab: UA – pyuria, bacteriuria, hematuria </li></ul><ul><li>MANAGEMENT </li></ul><ul><li>Ampicillin (or Sulfonamides,Nitrofurantoin, Cephalosporin) </li></ul>
  53. 53. URINARY TRACT INFECTION <ul><li>ACUTE PYELONEPHRITIS </li></ul><ul><li>Leading cause of septic shock during pregnancy (endotoxemia) </li></ul><ul><li>More common after mid-pregnancy </li></ul><ul><li>Uslly right-sided </li></ul><ul><li>Uslly an ascending infection from lower UTI </li></ul>
  54. 54. URINARY TRACT INFECTION <ul><li>ACUTE PYELONEPHRITIS </li></ul><ul><li>DIAGNOSIS </li></ul><ul><li>Symptoms: fever </li></ul><ul><li>shaking chills </li></ul><ul><li>aching pain – lumbar areas </li></ul><ul><li>P.E.: costovertebral angle tenderness </li></ul><ul><li>Lab: UA – leukocytes in clumps </li></ul><ul><li>Urine culture – E. coli 77% </li></ul><ul><li>Klebsiella pneumoniae 11% </li></ul><ul><li>Enterobacter / Proteus 4% </li></ul>
  55. 55. URINARY TRACT INFECTION <ul><li>ACUTE PYELONEPHRITIS </li></ul><ul><li>MANAGEMENT </li></ul><ul><li>Hospitalization </li></ul><ul><li>Urine and blood cultures </li></ul><ul><li>CBC, Serum creatinine, and electrolytes </li></ul><ul><li>Rpt in 48 hrs </li></ul><ul><li>Chest Xray – if w/ dypnea or tachypnea </li></ul><ul><li>Monitor V/S, urine output (FBC) </li></ul><ul><li>IV crystalloid to establish UO to 30 ml/hr or > </li></ul>
  56. 56. URINARY TRACT INFECTION <ul><li>ACUTE PYELONEPHRITIS </li></ul><ul><li>MANAGEMENT </li></ul><ul><li>Antimicrobial therapy </li></ul><ul><li>Ampicillin + Gentamycin </li></ul><ul><li>or Cephalosporins </li></ul><ul><li>Intravenous </li></ul><ul><li>Change to po when afebrile – 7-10 days </li></ul><ul><li>Urine culture 1-2 wks after completion of Rx </li></ul><ul><li>30-40% - recurrent infection </li></ul>
  57. 57. <ul><li>Acute Uncomplicated Cystitis is most likely in this case: </li></ul><ul><li>A. A 26-year-old G1P0 with fever, </li></ul><ul><li>dysuria and flank pains </li></ul><ul><li>B. A 35-year-old G3P2 with hematuria </li></ul><ul><li>and colicky right flank pain </li></ul><ul><li>C. An 18-year-old G3P0020 with </li></ul><ul><li>dysuria, urinary frequency & yellow- </li></ul><ul><li>green vaginal discharge </li></ul><ul><li>D. A 28-year-old G2P1 with dysuria and </li></ul><ul><li>urinary urgency </li></ul>
  58. 58. THYROID DISORDERS
  59. 59. NORMAL CHANGES IN PREGNANCY <ul><li>Moderate thyroid enlargement </li></ul><ul><li>- glandular hpl and vascularity </li></ul><ul><li>Inc. uptake of radioiodine by maternal thyroid </li></ul><ul><li>Inc. total serum thyroxine and triiodothyronine </li></ul><ul><li>Inc. thyroid binding globulin </li></ul>
  60. 60. HYPERTHYROIDISM <ul><li>DIAGNOSIS: </li></ul><ul><li>Tachycardia </li></ul><ul><li>Thyromegaly </li></ul><ul><li>Failure to gain weight despite normal or increased food intake </li></ul><ul><li>Marked elevation of plasma thyroxine </li></ul><ul><li>Elevated sleeping pulse rate </li></ul><ul><li>exophthalmos </li></ul>
  61. 61. GRAVE’S DISEASE <ul><li>Most common cause of thyrotoxicosis in pregnancy </li></ul><ul><li>Autoimmune process associated with thyroid stimulating antibodies </li></ul><ul><li>Autoantibodies mimic thyrotropin and stimulate thyroid function </li></ul>
  62. 62. <ul><li>A 37 yr old G2P1 12 weeks gestation presents for her first prenatal check-up. She had been diagnosed with Grave’s disease and maintained on propylthiouracil. Currently, she is euthyroid. Which of the ff statements is appropriate in counseling this patient: </li></ul><ul><li>She must discontinue PTU because it is associated with leukopenia. </li></ul><ul><li>Infants born to mothers on PTU may develop goiter and be clinically hypothyroid. </li></ul><ul><li>PTU does not cross the placenta. </li></ul><ul><li>Thyroid storm is a common complication in pregnant women with Graves disease. </li></ul>
  63. 63. GRAVE’S DISEASE <ul><li>MANAGEMENT </li></ul><ul><li>Medical </li></ul><ul><li>Propylthyouracil / Methimazole </li></ul><ul><li>readily cross placenta & induce </li></ul><ul><li>fetal hypothyroidism & goiter </li></ul><ul><li>dose depends on total serum </li></ul><ul><li>thyroxine level which should </li></ul><ul><li>be in upper N range for preg </li></ul>
  64. 64. <ul><li>A 37 yr old G2P1 12 weeks gestation presents for her first prenatal check-up. She had been diagnosed with Grave’s disease and maintained on propylthiouracil. Currently, she is euthyroid. Which of the ff statements is appropriate in counseling this patient: </li></ul><ul><li>She must discontinue PTU because it is associated with leukopenia. </li></ul><ul><li>Infants born to mothers on PTU may develop goiter and be clinically hypothyroid. </li></ul><ul><li>PTU does not cross the placenta. </li></ul><ul><li>Thyroid storm is a common complication in pregnant women with Graves disease. </li></ul>
  65. 65. GRAVE’S DISEASE <ul><li>MANAGEMENT </li></ul><ul><li>Surgical – Subtotal Thyroidectomy </li></ul><ul><li>after thyrotoxicosis is under control or pt nearly euthyroid </li></ul><ul><li>done in 2 nd tri or early 3 rd tri </li></ul><ul><li>elective </li></ul><ul><li>Indications: </li></ul><ul><li>1. women who cannot adhere to </li></ul><ul><li>medical Rx </li></ul><ul><li>2. women in whom drug therapy is toxic </li></ul>
  66. 66. GRAVE’S DISEASE <ul><li>EFFECT ON PREGNANCY </li></ul><ul><li>Higher incidence of preeclampsia </li></ul><ul><li>heart failure </li></ul><ul><li>EFFECT ON NEONATE </li></ul><ul><li>Neonatal thyrotoxicosis </li></ul><ul><li>fr transplacental passage of maternal thyroid stimulating ab </li></ul>
  67. 67. HYPOTHYROIDISM <ul><li>DIAGNOSIS </li></ul><ul><li>Absence of normal rise in serum thyroxine </li></ul><ul><li>Increased thyrotropin level </li></ul><ul><li>Uncommon in pregnancy because associated with infertility </li></ul>
  68. 68. HYPOTHYROIDISM <ul><li>EFFECT ON PREGNANCY </li></ul><ul><li>Inc. incidence of abortion, SB, LBW </li></ul><ul><li>preeclampsia </li></ul><ul><li>placental abruption </li></ul>
  69. 69. HYPOTHYROIDISM <ul><li>EFFECT ON NEONATE </li></ul><ul><li>Usually healthy </li></ul><ul><li>Simple Colloid goiter w/o hypothyroidism – no effect </li></ul><ul><li>Severe hypothyroidism sec. to maternal radioiodine Rx during pregn  destruction of fetal thyroid  cretinism </li></ul>
  70. 70. HYPOTHYROIDISM <ul><li>MANAGEMENT </li></ul><ul><li>Thyroid hormones </li></ul><ul><li>dose adjusted so that serum thyrotropin level is w/in N range </li></ul>
  71. 71. <ul><li>Thyroid function tests showing an elevated serum thyrotropin, normal serum thyroxine and normal triiodothyronine in an asymptomatic woman at 14 weeks gestation is diagnostic of: </li></ul><ul><ul><ul><li>A. Hypothyroidism </li></ul></ul></ul><ul><ul><ul><li>B. Hyperthyroidism </li></ul></ul></ul><ul><ul><ul><li>C. Subclinical hypothyroidism </li></ul></ul></ul><ul><ul><ul><li>D. Subclinical hyperthyroidism </li></ul></ul></ul>
  72. 72. PUERPERAL INFECTION
  73. 73. 10 days post cesarean section, a 23 yr old primipara complains of fever of 3 days duration associated with hypogastric pain. Temp – 40 C. Breasts are slightly tender. Pelvic exam shows tenderness over the area of the uterus and parametria. The most likely consideration is: A. Breast engorgement B. Acute pyelonephritis C. Metritis with pelvic cellulitis D. Septic pelvic thrombophlebitis
  74. 74. PUERPERAL MORBIDITY <ul><li>temperature 38 C or higher, the temperature to occur on any 2 of the 1 st 10 days postpartum, exclusive of the first 24 hrs, and to be taken by mouth by a standard technique at least 4x daily </li></ul><ul><li>JOINT COMMITTEE ON MATERNAL WELFARE </li></ul>
  75. 75. Differential Diagnosis of Puerperal Fever <ul><li>Genital tract infection </li></ul><ul><li>Respiratory complications </li></ul><ul><li>Pyelonephritis </li></ul><ul><li>Breast Engorgement </li></ul><ul><li>Bacterial Mastitis </li></ul><ul><li>Thrombophlebitis </li></ul><ul><li>Incisional wound abscess </li></ul>
  76. 76. Respiratory Complications <ul><li>- seen within the 1 st 24 hours </li></ul><ul><li>- in women delivered by cesarean section </li></ul><ul><li>- use of general anesthesia </li></ul><ul><li>Atelectasis </li></ul><ul><li>Aspiration pneumonia </li></ul><ul><li>Bacterial pneumonia </li></ul>
  77. 77. Pyelonephritis <ul><li>SSx: bacteriuria / pyuria </li></ul><ul><li>costovertebral angle tenderness </li></ul><ul><li>spiking temperature </li></ul><ul><li>Clinical Dx: Urinalysis </li></ul><ul><li>U/S </li></ul><ul><li>Rx: Antibiotics </li></ul>
  78. 78. Breast Engorgement <ul><li>15 % of all postpartum women </li></ul><ul><li>Fever rarely goes > 39 C </li></ul><ul><li>Fever – not longer than 24 hrs </li></ul>
  79. 79. Thrombophlebitis <ul><li>SSx: </li></ul><ul><li>painful swollen leg </li></ul><ul><li>calf / femoral angle tenderness </li></ul><ul><li>Mgt: Heparin </li></ul>
  80. 80. Uterine Infection <ul><li>Infection involving the decidua, myometrium and parametrial tissues </li></ul><ul><li>Metritis with Pelvic </li></ul><ul><li>Cellulitis </li></ul>
  81. 81. Uterine Infection <ul><li>The route of delivery is the single most significant risk factor for the development of postpartum uterine infection. </li></ul><ul><li>Incidence of Metritis: </li></ul><ul><li>ff C/S 13 – 50% </li></ul><ul><li>ff vaginal delivery 1.3 – 2.6% </li></ul>
  82. 82. Risk Factors for Metritis <ul><li>Prolonged labor </li></ul><ul><li>Prolonged membrane rupture </li></ul><ul><li>Multiple cervical examination </li></ul><ul><li>Use of internal fetal monitoring </li></ul><ul><li>Intraamniotic infection </li></ul><ul><li>Bacterial colonization of lower genital tract </li></ul><ul><li>Group B streptococcus Mycoplasma hominis </li></ul><ul><li>Chlamydia trachomatis Gardnerella vaginalis </li></ul>
  83. 83. Bacteria Responsible for Genital Tract Infections <ul><li>Aerobes </li></ul><ul><li>Grp A, B and D streptococci </li></ul><ul><li>Enterococcus </li></ul><ul><li>Gram (-) bacteria – E. coli, Klebsiella and Proteus sp </li></ul><ul><li>Staphylococcus aureus </li></ul><ul><li>Gardnerella vaginalis </li></ul><ul><li>Anaerobes </li></ul><ul><li>Peptococcus sp Clostridium sp </li></ul><ul><li>Peptostreptococcus sp Fusobacterium sp </li></ul><ul><li>Bacteroides fragilis Mobiluncus sp </li></ul><ul><li>Others </li></ul><ul><li>Mycoplasma sp Chlamydia trachomatis Neisseria gonorrhea </li></ul>
  84. 84. Clinical Course <ul><li>Fever </li></ul><ul><li>Chills </li></ul><ul><li>Abdominal pain / tenderness </li></ul><ul><li>Foul-smelling lochia </li></ul><ul><li>B hemolytic streptococci – scanty odorless lochia </li></ul><ul><li>Leukocytosis – 15,000 – 30,000/cu mm </li></ul>
  85. 85. Treatment <ul><li>BROAD SPECTRUM ANTIBIOTICS </li></ul><ul><li>Clindamycin + Gentamycin </li></ul><ul><li>most widely studied regimen </li></ul><ul><li>90 – 97% efficacy </li></ul><ul><li>plus ampicillin – if enterococcal infection suspected </li></ul><ul><li>Aztreonam – if with renal insufficiency </li></ul>
  86. 86. Causes of Persistent Fever Despite Antibiotic Rx <ul><li>Wound infection </li></ul><ul><li>Peritonitis </li></ul><ul><li>Parametrial phlegmon </li></ul><ul><li>Pelvic abscess </li></ul><ul><li>Septic Thrombophlebitis </li></ul>
  87. 87. Wound Infection <ul><li>3 – 5% post C/S </li></ul><ul><li>2% - with prophylactic antibiotics </li></ul><ul><li>SSx: fever </li></ul><ul><li>erythema, wound discharges </li></ul><ul><li>Rx: antibiotics </li></ul><ul><li>surgical drainage </li></ul>
  88. 88. Risk Factors for Wound Infection <ul><li>Obesity </li></ul><ul><li>Diabetes </li></ul><ul><li>Corticosteroid therapy </li></ul><ul><li>Immunosuppression </li></ul><ul><li>Anemia </li></ul><ul><li>Poor hemostasis with hematoma formation </li></ul>
  89. 89. Peritonitis <ul><li>Route: lymphatics </li></ul><ul><li>SSx: severe abdominal pain </li></ul><ul><li>bowel distension – ileus </li></ul><ul><li>Rx: antibiotics </li></ul><ul><li>fluid and electrolyte replacement </li></ul><ul><li>decompression </li></ul><ul><li>surgery – bowel lesion </li></ul><ul><li>uterine incisional necrosis </li></ul>
  90. 90. Parametrial Phlegmon <ul><li>Dx: parametrial induration </li></ul><ul><li>unilateral </li></ul><ul><li>uterus fixed on </li></ul><ul><li>one side </li></ul><ul><li>Rx: antibiotics </li></ul><ul><li>surgery – uterine incisional necrosis </li></ul>
  91. 91. Pelvic Abscess <ul><li>Dx: fluctuant broad ligament mass </li></ul><ul><li>Rx: Drainage </li></ul><ul><li>Colpotomy </li></ul>
  92. 92. Septic Thrombophlebitis <ul><li>Route: hematogenous </li></ul><ul><li>Pathogenesis: </li></ul><ul><li>placental site infection  </li></ul><ul><li>thrombosed myometrial vs </li></ul><ul><li>SSx: enigmatic fever </li></ul><ul><li>lower abd’l / flank pain </li></ul><ul><li>tender mass beyond the cornu </li></ul>
  93. 93. Infections of Perineum, Vagina and Cervix <ul><li>Rx: Drainage </li></ul><ul><li>Antibiotics </li></ul><ul><li>Analgesics </li></ul><ul><li>Foleybag catheter </li></ul><ul><li>Repair </li></ul>
  94. 94. 10 days post cesarean section, a 23 yr old primipara complains of fever of 3 days duration associated with hypogastric pain. Temp – 40 C. Breasts are slightly tender. Pelvic exam shows tenderness over the area of the uterus and parametria. The most likely consideration is: A. Breast engorgement B. Acute pyelonephritis C. Metritis with pelvic cellulitis D. Septic pelvic thrombophlebitis
  95. 95. <ul><li>Please visit: </li></ul><ul><li>http://crisbertcualteros.page.tl </li></ul>
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