1. The document discusses physiological changes that occur during pregnancy including increased blood volume, cardiac output, and oxygen demand as well as changes in the gastrointestinal, cardiovascular and renal systems.
2. Fetal monitoring involves monitoring the fetal heart rate and uterine contractions to assess fetal well-being and response to stress. Fetal heart rate patterns including tachycardia, bradycardia, accelerations and decelerations are described.
3. Appendicitis is discussed as the most common nonobstetric surgical condition during pregnancy. Risks of appendicitis increase during pregnancy due to lymphoid hyperplasia in the appendix.
Anatomical & physiological changes in pregnancy & their clinical implications...alka mukherjee
• Women undergo several changes during pregnancy, including cardiovascular, hematologic, metabolic, renal, and respiratory changes that provide adequate nutrition and gas exchange for the developing fetus.
• Progesterone and estrogen levels rise continually through pregnancy, together with blood sugar, breathing rate, and cardiac output.
• The body’s posture changes during pregnancy to accommodate the growing fetus and the mother will experience weight gain.
• Breasts grow and change in preparation for lactation once the infant is born. Once lactation begins, the woman’s breasts swell significantly and can feel achy, lumpy, and
heavy (engorgement). This is relieved by nursing the infant.
• Plasma and blood volume increase over the course of the pregnancy and lead to changes in heart rate and blood pressure. Women may also have a higher risk of blood clots, especially in the weeks following labor.
• During pregnancy, both protein metabolism and carbohydrate metabolism are affected. One kilogram of extra protein is deposited, with half going to the fetus and placenta, and another half going to uterine contractile proteins, breast glandular tissue, plasma protein, and hemoglobin.
• Circulatory Changes
• Plasma and blood volume slowly increase by 40–50% over the course of the pregnancy (due to increased aldosterone) to accommodate the changes, resulting in an increase in heart rate (15 beats/min more than usual), stroke volume, and cardiac output. Cardiac output increases by about 50%, primarily during the first trimester.
• The systemic vascular resistance also drops due to the smooth muscle relaxation and overall vasodilation caused by elevated progesterone, leading to a fall in blood pressure. Diastolic blood pressure consequently decreases between 12–26 weeks, and increases again to pre-pregnancy levels by 36 weeks.
• Edema (swelling) of the feet is common during pregnancy, partly because the enlarging uterus compresses veins and lymphatic drainage from the legs.
• The platelet count tends to fall progressively during normal pregnancy, although it usually remains within normal limits. In a proportion of women (5–10%), the count will reach levels of 100–150 × 109 cells/l by term and this occurs in the absence of any pathological process. In practice, therefore, a woman is not considered to be thrombocytopenic in pregnancy until the platelet count is less than 100 × 109 cells/l.
• Pregnancy causes a two- to three-fold increase in the requirement for iron, not only for haemoglobin synthesis but also for for the foetus and the production of certain enzymes. There is a 10- to 20-fold increase in folate requirements and a two-fold increase in the requirement for vitamin B12.
Changes in the coagulation system during pregnancy produce a physiological hypercoagulable state (in preparation for haemostasis following delivery).
Anatomical & Physiological changes in Pregnancy, all the changes in balance, posture, stance, renal system, cardiovascular system, musculoskeletal system, Pulmonary system changes are described in this ppt. Thank You for choosing this.
Detailed account of the various changes that occur in maternal anatomy, physiology, and metabolism of pregnant women. These physiological changes are often very precise, and deviations of physiological responses can be a prelude to possible disease/infectious states. In this second part of Labor, we will examine the various systems of the human body,its altered states during pregnancy, and how those changes affect the woman preparing for delivery. Special care is imperative in properly determining the needs of an expecting mother, so developing an intimate, trusting relationship between the mother and fully understanding her physiological output will lead to the best chances of a successful delivery.
obstetric and gyneacology; Changes in pregnancy, cardiovascular changes, respiratory changes, endocrine changes, gastrointestinal changes, related organ changes in pregnancy. hormonal changes during pregnancy.
Anatomical & physiological changes in pregnancy & their clinical implications...alka mukherjee
• Women undergo several changes during pregnancy, including cardiovascular, hematologic, metabolic, renal, and respiratory changes that provide adequate nutrition and gas exchange for the developing fetus.
• Progesterone and estrogen levels rise continually through pregnancy, together with blood sugar, breathing rate, and cardiac output.
• The body’s posture changes during pregnancy to accommodate the growing fetus and the mother will experience weight gain.
• Breasts grow and change in preparation for lactation once the infant is born. Once lactation begins, the woman’s breasts swell significantly and can feel achy, lumpy, and
heavy (engorgement). This is relieved by nursing the infant.
• Plasma and blood volume increase over the course of the pregnancy and lead to changes in heart rate and blood pressure. Women may also have a higher risk of blood clots, especially in the weeks following labor.
• During pregnancy, both protein metabolism and carbohydrate metabolism are affected. One kilogram of extra protein is deposited, with half going to the fetus and placenta, and another half going to uterine contractile proteins, breast glandular tissue, plasma protein, and hemoglobin.
• Circulatory Changes
• Plasma and blood volume slowly increase by 40–50% over the course of the pregnancy (due to increased aldosterone) to accommodate the changes, resulting in an increase in heart rate (15 beats/min more than usual), stroke volume, and cardiac output. Cardiac output increases by about 50%, primarily during the first trimester.
• The systemic vascular resistance also drops due to the smooth muscle relaxation and overall vasodilation caused by elevated progesterone, leading to a fall in blood pressure. Diastolic blood pressure consequently decreases between 12–26 weeks, and increases again to pre-pregnancy levels by 36 weeks.
• Edema (swelling) of the feet is common during pregnancy, partly because the enlarging uterus compresses veins and lymphatic drainage from the legs.
• The platelet count tends to fall progressively during normal pregnancy, although it usually remains within normal limits. In a proportion of women (5–10%), the count will reach levels of 100–150 × 109 cells/l by term and this occurs in the absence of any pathological process. In practice, therefore, a woman is not considered to be thrombocytopenic in pregnancy until the platelet count is less than 100 × 109 cells/l.
• Pregnancy causes a two- to three-fold increase in the requirement for iron, not only for haemoglobin synthesis but also for for the foetus and the production of certain enzymes. There is a 10- to 20-fold increase in folate requirements and a two-fold increase in the requirement for vitamin B12.
Changes in the coagulation system during pregnancy produce a physiological hypercoagulable state (in preparation for haemostasis following delivery).
Anatomical & Physiological changes in Pregnancy, all the changes in balance, posture, stance, renal system, cardiovascular system, musculoskeletal system, Pulmonary system changes are described in this ppt. Thank You for choosing this.
Detailed account of the various changes that occur in maternal anatomy, physiology, and metabolism of pregnant women. These physiological changes are often very precise, and deviations of physiological responses can be a prelude to possible disease/infectious states. In this second part of Labor, we will examine the various systems of the human body,its altered states during pregnancy, and how those changes affect the woman preparing for delivery. Special care is imperative in properly determining the needs of an expecting mother, so developing an intimate, trusting relationship between the mother and fully understanding her physiological output will lead to the best chances of a successful delivery.
obstetric and gyneacology; Changes in pregnancy, cardiovascular changes, respiratory changes, endocrine changes, gastrointestinal changes, related organ changes in pregnancy. hormonal changes during pregnancy.
Prof. Mridul Panditrao's Peri-operative MANAGEMENT OF Patients for LaparoscopyProf. Mridul Panditrao
Prof. Panditrao takes you in the detailed discussion about the historical aspects, problems, altered physiology, preparation of and Anesthetic/ peri-operative management of the patients for various laparoscopic surgical procedures
Antenatal care is the clinical examination, observation, and follow up of the mother and fetus during pregnancy, for the purpose of obtaining the best possible health for the mother and child.
Hallux valgus contiene; definición, etiología, anatomía, características, diagnóstico, tratamento, cirugía, anatomía patológica y sus características. De igual forma, incluye los factores desencadenantes, clasificación roger mann y sus complicaciones.
Assessment and management of pregnancy (antenatal) ppt.pptxMeenakshiJohn1
In this assessment and management describe about the reproductive health ,disorder of reproductive health and about pre conception ,genetic counseling and the physiological changes in the reproductive system of pregnant women .briefly knowledge about hematological changes and also the changes of cardiovascular system during pregnancy . the important role of endocrine gland during pregnancy .thyroid and the important role of a hormones and their maintenance .and their minor ailments in pregnancy or discomforts of pregnancy .sign and symptoms of pregnancy
physiological changes during pregnancy
effect of pregnancy on physiological functions during pregnancy
cardiovascular, respiratory and hormonal changes
Shifa Riaz
gynecology
obstetrics
females
Maternal physiological changes in pregnancy are the adaptations during pregnancy that a woman's body undergoes to accommodate the growing embryo or fetus. ... The pregnant woman and the placenta also produce many other hormones that have a broad range of effects during the pregnancy.
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
The Gram stain is a fundamental technique in microbiology used to classify bacteria based on their cell wall structure. It provides a quick and simple method to distinguish between Gram-positive and Gram-negative bacteria, which have different susceptibilities to antibiotics
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Novas diretrizes da OMS para os cuidados perinatais de mais qualidade
The pregnant patient
1. Santa Rosa Hospital
Sheila Sustache de Leon MD
Enero 2012
THE PREGNANT PATIENT
Santa Rosa Hospital
Sheila M. Sustache de Leon MD
Feb/ 2012
2. • Full term delivery at 37 week
of gestation.
• 12% of live births are
premature.
• 65% of all perinatal morbidity
and mortality is associated
with premature delivery.
5. • Exerts pressure on the anterior abdominal wall.
– Displaces the intestine superiorly and laterally.
• Change the relationship between the abdominal visceral
organs.
• In upright position
– The uterus is supported by the anterior abdominal
wall.
– Usually undergoes a dextrorotation because of the
presence of the rectosigmoid on the left.
• In supine position
– Uterine weight falls on the spinal column.
– Compression of the surrounding great vessels.
– Especially the flaccid IVA
6.
7. • Electrical change in the myometrium
– Resting membrane potential of the uterine
myocyte ranges from -40 to -60 mV.
– Early in gestation
• -60mV
• Irregular electrical activity (slow waves)
– Near term
• -40 mV
8. • Rhythmic alteration in the membrane
potential lead to an action potential at the top
of slow waves.
Entry Ca2+
Voltage sensitive
Ca2+ channel
Allow interaction
actin-myosin
Electromechanical
coupling
Uterine
contraction
9. • Second trimester
– Irregular contraction can be palpated though the
abdominal wall (Braxton hicks contractions)
• Irregular in intensity
• Infrequent
• Unpredictable
• Non-rhythmic
• More uncomfortable than painful)
• They do not increase in intensity, or frequency
10. http://www.medhelp.org
• Small increase uterine pressure up to 80 mmHg.
•Increase gap junctions results in rapid and efficient
conduction of the action potential uterine smooth
muscle.
•Resulting coordinated
•Dilatation of cervix and delivery of the baby.
11. Stimulates uterine
activity
Down regulates uterine
activity
Estrogen (opposing the action of
progesterone)
Progesterone (block Ca2+ flux
thought cell membrane)
Oxytocin ( secreted from posterior
pituitary. Stimulate Ca2+ across
myometrial plasma membrane and
distinct receptor myometrium and
other reproductive tissues.)
PGE₂, PGFα (favor activation of
the uterine musculature, onset uterine
contraction. Raise local [Ca2+] by
increasing release from intracellular
store. )
IL-1, IL-6 (produced locally by
placental tissue and act in concert with
other stimulatory factor)
13. • The delaying or inhibition of labor stopping of
contraction during premature labor.
– Intervention is directed at decreasing the uterine
smooth muscle activity thought inhibition of the
muscle contraction.
– Tocolytic treatment may result in the delay of delivery
by aprox. 48 hrs, which allows for the administration
of steroids to promote fetal lung maturation.
• Decrease risk of respiratory distress syndrome and
multiorgan failure in the preterm neonate.
14. • Magnesium sulfate
– First line tocolytic agent
– High intracellular [Mg] inhibits Ca2+ entry
myometrial cells interfering with actin-myosin
coupling. Also increase the sensitivity of K+
channels favoring hyperpolarization and uterine
relaxation.
– Range 4 and 9 mg/dL
15. • Prostaglandins
– Prostaglandin synthetase inhibitors specially
AINES are use to stop premature labor.
• Indomethacin
– Recomendated in Nonobstetric surgery.
– Preoperative dose 50mg-100 mg PO
– Postoperative 50 mg PO q 6 hrs for 48hrs.
– Intraabdominal surgery preterm pregnant
» Two doses of betamethasone 12mg 24hrs or four doses of
dexamethasone 6 mg 12 hrs
» Ideally beginning 48 hrs prior to surgery.
16. • Β adrenergic agonists
– Stimulation of uterine β2 receptor leads to activation
of adenylate cyclase and an increse in intracellular
cyclic adenosine monophosphate (cAMP)
concentration.
– Activation of cAMP dependent protin kinase A inhibits
myosin light chain phosphorylation and actin myosin
coupling.
– Protein Kinase A activity is also associate with increase
Ca2+ effux, decrease Ca2+ influx, and increases K+
conductance.
17. • Calcium channel blockers
– Inhibits entry of calcium though voltage
dependent Ca2+ channels.
• Nifedipine
– Abolish uterine activity and prevent delivery with minimal
toxicity or side effects.
18. • The maternal physiologic homeostasis adapts in
order to promote a physiologic environment the
benefits the development and growth of the
fetus.
19. • Progesterone levels increase
– Is a smooth muscle relaxant that play a major role
in assuring relaxation of the uterine smooth
muscle to prevent premature delivery.
– In addition vascular, gastrointestinal and
urogenital smooth muscle relaxes.
20. • Plasma volume increase by up 50% and RBC
volumen by 20 % to 30%.
– This increase in intravascular (blood) volumen
leads to a 50% increase in cardiac output (CO).
• Marked venous and arterial vasodilatation. The
vasodilatation is facilitated by a decrease in
vasoconstrictor sensitivity and an increase in the
production of nitric oxide and prostacyclin.
21. – Common clinical signs and symptoms associated
with this increase in CO and associated
vasodilatation include:
• Decrease exercise tolerance
• Mild peripheral edema
• Spider angiomata
• Complains of stuffy sinuse
• Increase in lower extremity varicosities
• hemorrhoids
22. • To increase O2 delivery to the fetus and
remove the increased supply of CO2 produced
by the fetus.
– Hyperventilates
– Maternal O2 metabolism increases by 20% - 30%
and functional reserve capacity decrease.
23. • When intubation is needed, there significantly
less time to establish an airway and assure
continued oxygenation.
• Is common to have sensation of SOB,
specifically in the second and third trimester.
24. • The lower esophageal
sphincter tone gradually
decreases.
– Nausea and vomiting of
pregnancy is a common
occurrence affecting
between 50% and 90%
of all women.
25. • The gallbladder empties more slowly during
pregnancy and undergoes a gradual increase
in residual volume, both during fasting and
after meals.
– Motility and volumes return to normal as early as
2 weeks after pregnancy.
26. • Prolonged small bowel transit time and
decreased colonic emptying work to maximize
nutrient and water absorption.
– Contribute to the constipation reported by 38% of
pregnant women.
27. • Abdominal pain
– Round ligament pain is described as an aching,
dragging pain.
• Typically unilateral
• Provoked by physical activity or even turning while sleeping.
• Common occurrence third trimester
– Pain in the hypochondrium.
• Can result from uterine pressure on the lower ribs.
• Px describes a very localizated, sharp, nonradiating pain.
• That more often is on R+ compare to the L+ upper cuadrant.
28. • Hemoglobin concentrations may drop to 10
mg/dl.
• Hematocrit values may go as low as 30%.
• Pregnancy may be associated with an increase
in the WBC count.
– Up to levels of 13,000 cell/mL.
– Intrapartum and immediate postpartum (<24 hrs)
counts may be as high as 25,000 WBC/mL
29. • Platelet count may slightly decrease as the
pregnancy progresses.
– Up 8% of pregnancy
– The most common cause is gestational
thrombocytopenia.
• Typically asymptomatic
• Recover to normal levels a few weeks following the
delivery.
30. • Renal blood flow and glomerular filtration rate
increase by over 50%.
• Creatinine levels decrease appropriately, resulting
in normal levels of 0.5 to 0.6 mg/mL.
• Serum alkaline phosphatase levels gradually
increase.
– Because of production of an alkaline phosphatase
isozyme by the placenta.
• Albumin levels may be lower.
– Associated with the increase in plasma volumen and
osmotic pressure may be decreased.
31. • In almost all clinical presentations, the risks of
misdiagnosis by avoiding the proper imaging
tests are greater compared to the risks of
sequelae from ionizing radiation to the fetus.
32. • Ionizing radiation
– Fetal effects of ionizing radiation depend on the dose
absorbed by the fetal tissue and the stage of fetal
development during exposure.
– The roentgen is a common unit of exposure.
• Produce 0.26 milicoulomb/kg of air or 2 billon ion pairs/ cm³ of
exposed air.
– One gray (Gy) is strictly defined as the deposition of 1.0
joule of energy/kg of tissue.
– One rad is 1% of 1 Gy.
33. – In is a misconception to assume that the radiation
absorbed by the mother is the same as the
absorbed by the fetus.
– Dosing of radiation to the uterus and conceptus
can vary several fold based on abdominal wall
depth and the anteverted or retroverted position
of the uterus.
– DNA damage may be repaired of may result in cell
death, rapid cell growth, abnormal cell growth or
genetic mutation.
34. Radiation dosing to the conceptus an
uterus from selected radiographic
examinations.
Examination DOSE (mrad)
Routine Chest x- ray 0.5-1.0
Abdominal flat plate 140
Intravenous pyelogram 78
CT, chest (uterus shielded, not
exposed)
16-23
CT, abdomen (uterus shielded,
not exposed)
150-190
CT, pelvis 2,000
35. • Growth impairment of organs occurs of the
population of cells cannot be replaced or
damage occurs to a small population of
progenitor cells at a vital stage of
development.
36. – The outcome of radiation exposure depends on
the absorbed dose and the stage of development
during exposure.
• Potential death early in gestation.
• Teratogenesis during organogenesis (4 to 10 weeks of
gestation).
• Growth retardation at later gestational stages.
37. • Lethal Effects
– Multicellular embryo, before the blastocyst stage
is most sensitive to the lethal effects of radiation
but resistant to teratogenesis if it survives.
– More than 50% of all human pregnancies abort.
• Determining the lethal dose of radiation at this stage is
difficult.
– Significant radiation exposure in the first 2 weeks
of human development.
• 3 and 4 weeks of results in loss of the pregnancy.
38. • Teratogenic effects
– Occurs during early organogenesis.
– Correspond to weeks 2 to 8 in human
development (4 to 10 of gestation).
– A significantly higher rate after exposure to
radiation in pregnancy have been report:
• Microcephaly, pigmentary changes in the retina,
hydrocephalus, and optic nerve atrophy.
– Exposure less than 5 rads does not increase the
risk for birth defects.
• 5 to 10 rads = teratogenicity
• Greater than 10 rads = serious risk to the fetus.
39. • Intrauterine Growth restriction
– Result from radiation induced cellular depletion.
– Example: children exposed in utero to the
Japanese atomic blasts.
• 1,500 m from center of the explosion
– Exposed to over 25 rads
– 2 a 3 cm shorter, 3 kg lighter head circumference 1 cm smaller
than normal (17 y/o)
40. • Oncogenic potential
– The correlation between childhood cancer and in
utero exposure to radiation has been reported.
• Ultrasound
– Ultrasonography use high frecuency, no ionizing,
acoustic radiation to create images.
– Audible sound range = 20 to 20,000 vibration/seg
• Ultrasonography use frecuencies of 1 millon to 10 millons
vibrations/seg
– Not been shown to produce fetal damage or harmful
effect.
41. • Rapid compression and decompression of
tissue by sound wave. Cause tissue damage.
– Conversion of mechanical energy to thermal
energy.
– Especially at the bone soft tissue interface, could
lead to local hypertermia.
• CAVITATION could cause microscopic bubbles already
present in tissue to grow size because of absorption of
surrounding diffused gases.
42. • MRI
– Use no ionizing radiation and relies on the magnetic
properties of tissue to create images.
– Four magnetic fields interact during an MRI
examination to create the image.
• Intrinsic magnetic field (2)
• Extrinsic magnetic field (2)
– Present danger to the developing fetus.
• Charged particles and molecules moving in a strong
magnetic field create an electroestatic potential difference
and anormal RBC can alter their shape and create a charge
when moving within an electric field.
• Can induce visual light flashes because of magnetic effects
on the photoreceptors in the eye, and heat can be generated
during the application of radiofrequencies.
43.
44. – Elective examination of pregnant women by MRI postponed
until after the first trimester and completion of organogenesis.
• Is not absolutely contraindicated.
• Medication in pregnancy
– Medications contraindicated in pregnancy include but are not
limited:
• Coumarin derivatives
• Isotretinoin
• Metrotrexate
• Diethylstibestrol
• Thalidomide
• Angiotensin converting enzyme (ACE) inhibitors
• ACE antagonist
• Tetracycline
• Quinolones
– The risks to the fetus may be less compared to the risk to the
mother when not using the proper medication.
45. Fetal monitoring
• Fetal heart rate (FHR) Indirect assessment of fetal
well being.
• Can be monitored externally using Doppler
device that is placed on the maternal abdomen.
• Uterine activity is monitored by using a
tocodynometer, also applied to the maternal
abdomen.
• Response to altered uterine-placental perfusion
or decrease O2 content in maternal blood.
46.
47.
48. • FHR interpretation
– Fetal tachicardia ≥ 10 min ↑ 160 bpm
– Fetal bradycardia ≤ 10 min ↓110 bpm
– Acceleration
• Increase in the FHR of at least 15 bpm fpr at least 15
seconds.
• Normal findings in second half of pregnancy.
• Occur as a result of increased sympathetic and
decrease parasympathetic stimulation with fetal
movement.
49. – Deceleration
• Usually accur intrapartum and related to the uterine
contractions ( periodic decelerations).
• Classification:
– Early
» Simultaneous with the contraction.
» Uniform, gradual drops in the FHR that mirror the uterine
contraction and reflect an increased vagal tone from a
transient increase in intracraneal pressure.
50. – Late
» Starting when the contraction is in progress and
recovering after the contraction is over.
» Poor uterine perfusion or decrease O2
• Causes: Hypotension; IVC compression, blood loss or
regional anesthesia.
– Variable
» Variable in relation to the contraction.
» Result from umbilical cord compression by uterine
contraction.
– Isolated variable
» Inadequate recovery between contractions.
» Intervention may be indicate.
51.
52. • Appendicitis affect 250,000 patient every year
in the US.
• Is the most common nonobstetric indication
for operation during pregnancy
– Average incidence if 1 in 1,500 deliveries.
• Variation in signs and symtoms of appendicitis
during pregnancy (see table).
53. • Appendiceal lumen obstruction
– Lymphoid hyperplasia
– Feacaliths
– Parasites
– Foreign bodies
– Crohn disease
– Metastatic cancer
– Carcinoid syndrome
• Appendiceal lumen obstruction leads to an
increase in intraluminal pressure by blocking the
normal egress of mocus.
– Progressive obstruction of venous outflow followed by
capillary and arterial thrombosis leads to mucosal
ulceration, trasmural wall necrosis and perforation.
54.
55. First trimester Second
trimester
Third trimester
SIGNS AND
SYMPTOMS
% % %
R+ LQ pain 100 50 14
R+ UQ pain 0 17 57
Guarding
(muscle spasm)
80 50 43
Nausea and
vomiting
53 60 23
Tenderness on
rectal
examination
60 17 0
Perforation rate 20 49 70
56. • PE:
– Tenderness RLQ
– Rebound & Guarding (peritoneal signs)
– Rovsing sign
• palpation of the LLQ results in more pain in the RLQ
– Dumphy’s sign
• increased abdominal pain with coughing
– Psoas sign (retroperitoneal retroccal appendix)
• passively extending the thigh of a patient lying on their
side with knees extend
– Obturator sign (Pelvic appendix)
• pain when there is flexion and internal rotation of the
hip
– Rectal examination tenderness (Cul-de-sac)
– Low grade fever
57. • Laboratory
– WBC
• 2nd &3rd Trimester: 6,000-16,000
• Absolute number: not reliable
• Differential: levels of band cells can be reliable
indication of infection.
– U/A
• mild pyuria or mild hematuria: 20%
• {extraluminal irritation of the ureter, not UTI}.
• mild proteinuria
58.
59. • A delay in diagnosis occurred in 18% of
patients in the second trimester.
– In third trimester a delay was the rule.
• Delay in operation with a high rate of
perforation.
– 49% in the second trimester
– 70% in the thrid
60. • Perforated appendicitis presents a greater infectious
risk.
– Large uterus interferes with proper omental migration
throughout the abdominal cavity and prevents the walling
off the inflammatory process.
– Increase vacularity of abdomen
– Greater lymphatic drainage allows rapid dissemination of
infection.
• Perforated appendicitis in pregnancy rapidly leads to
diffuse peritonitis, premature labor and fetal loss.
– Rate of preterm labor and fetal loss 26 % to 66 %
compared with 0% to 5 % for uncomplicated appendicitis.
64. 26-year-old woman in 11th week of pregnancy with right lower quadrant
pain and clinical suspicion of appendicitis
65. • Reduce
insufflations
pressures of 8 to
12 mm Hg.
– Decrease fetal
morbidity and
mortality.
• Use open Hasson
technique of
trocar placement
under direct
visualization
rather than blind
insufflations with
a Veress needle.
67. Guidelines for laparoscopic surgery during pregnancy
1. Defer operative intervention until the second trimester, when the fetal risk is
lower, whenever possible.
2. Pneumatic compression devices must be used because of he enhancement of
lower venous stasis with pneumoperitoneum and pregnancy induced
hypercoagulable state.
3. Fetal and uterine status, as well as maternal end-tidal CO2 and arterial blood
gases, should be monitored.
4. Use fluroscopy selectively and protect th uterus with lead shield if
intraoperative cholangiography is possible.
5. Given enlarged gravid uterus, abdominal access should be obtained using open
technique.
6. Dependent positioning should be used to shift the uterus off the inferior vena
cava.
Pneumoperitoneum pressures should be minimized and not allowed to exceed 15
mm Hg.
7. Obstetric consultation should be obtained before operation.
68. • Acute cholecystitis in the second most
common general surgery diagnosis during
pregnancy.
• Progesterone induced relaxation of the
gallbladder combined with estrogen induced
supersaturation of bile predispose to gallstone
formation.
69. • The risk for development of gallstones is
related to the number of pregnancies,
doubling after two pregnancies and nearly
quadrupling after four.
• Incidence of acute cholecystitis during
pregnancy is relatively low 1 to 8 in 10,000
pregnancies (0.01% to 0.08%).
70. • Symptoms of cystic duct obstruction:
– Crampy RUQ or epigastric pain after a meal can
last several minutes to hours.
• May radiate to the back
• Nausea
• Vomiting
– Tenderness on palpation of the RUQ=acute
cholecystitis
72. • Dx
– History
– PE
– Ultrasonography 97% accurate
• Gallbladder wall thickening
• Pericholecystic fluid
• Pain on palpation with the ultrasound transducer
• Sonographic Murphy sign (is confirmatory of
inflamation)
73. • Management
– Maintained on IV hydratation
– Treated with antibiotic for signs of infection.
– A low fat diet
– The surgery was reserved for those with persistent
symptoms, severe toxicity, sepsis, peritonitis or
obstructive jaundice.
• Complication of gallstones
– Choledocholithiasis
– pancreatitis
74. • Laparoscopic cholecystectomy
– Is a safe and reliable modality
– Removing the diseased gallbladder eliminates the
potential for recurence
– The minimal uterine retraction need with
laparoscopic.
– Access to the RUQ should decrease the risk for
preterm labor.
75. – The incidence of premature uterine contraction with
laparoscopic cholecystectomy has been reported at 0% to
21%.
• Usually well controled with tocolytics.
• Spontaneous abortion ranging from 0% to 7%.
• Open cholecystectomy
– Rate of premature labor ranges from 0% to 40%.
– Spontaneous abortion or premature birth rate of up to
22%.
– Second trimester is the optimal time.
• Organogenesis is complete
• Gravid uterus is not yet large enough to impinge on the operating
field.
76. • Choledocholithiasis
– A bilirubin above 1.5 mg/dL, a dilatad common bile
duct or gallstone pancreatitis.
– Endoscopic retrograde cholangiopancreatograpy
(ERCP) can be performed safely in pregnancy.
• Scatter radiation on the order of 4 mrads during whole
examination.
• Evaluation of the biliary tree, stone retrieval, and
sphincteroctomy can be performed.
– Other methods avoid radiation:
• Endoscopic ultrasonogaphy
• Endoscopic papillotomy under ultrasonographic control
• Magnetic resonance cholangiography
77. • 1 in every 68,000 deliveries.
• Adhesions remain the most common cause of
intestinal obstruction in gravid patient.
• Volvulus is much more common complication.
78. Cause of intestinal obstruction complication
pregnancy and the puerperium in 66 patients.
# and %
Adhesions 39 (59%)
Volvulus 15 (23%)
Sigmoid 7
Cecal 3
midgut 3
Volvulus around vitellointestinal band 2
Intussusception 3 (5%)
Hernia 2 (3%)
Carcinoma 1 (1%)
Appendicitis 1 (1%)
Idiopathic 5 (8%)
79. • Obstruction during pregnancy classically presents
during three peak periods.
– The first peak
• The 4 a 5 months of gestation as the uterus becomes an
intra abdominal organ stretching any previously formed
adhesions.
– The second peak
• during the 8 a 9 months, when the fetal head descends into
the pelvis, decreases the uterine size.
– The third peak
• After delivery as the sudden decrease in uterine size
drastically change the association of adhesions to
surrounding bowel.
80. • Presentation and Dx
– Abdominal pain and vomiting
– Proximal small bowel obstruction
• Results in short period between vomiting episodes with poorly
localized, crampy upper abdominal pain.
– Colonic obstruction
• Present with less frequent feculent vomiting and lower abdominal
pain.
– Tachycardia and hypotension are also late signs suggesting
bowel compromise and shock.
– Labs
• Significant leukocytosis can occur with necrosis and bowel
strangulation.
81. • Rx
– Serial films every 4 to 6 hrs usually show
progressive changes confirming the dx.
82.
83.
84. Reference
• Nature Reviews Molecular Cell Biology 4. Review: MRI: volumetric imaging for vital imaging and atlas
construction. http://www.nature.com/focus/cellbioimaging/content/images/nrm1195_f1.html .SS10–
SS16. 2003.
• American Academy of Family Physicians. Clinical Interpretations of Fetal Monitor Patterns and the
Detailed Implications Regarding Fetal Health: May 1, 1999.
• Appendicitis in Pregnancy: Methods. http://www.medscape.com/viewarticle/549510_4
• Acute appendicit is: Pregnancy complicates this diagnosis
• http://www.jaapa.com/acute-appendicitis-pregnancy-complicates-this-diagnosis/article/130146/
• Lodewijk P. Cobben. MRI for Clinically Suspected Appendicitis During Pregnancy. September 2004 vol.
183 no. 3 671-675 http://www.ajronline.org/content/183/3/671.full
• Stavros Zarkadas. LAPAROSCOPIC APPROACH IN ACUTE ABDOMINAL PROCESSES DURING
PREGNANCY.
http://www.laparoscopyhospital.com/laparoscopy_for_acute_abdomen_in_pregnancy.html
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