INTRINSIC PATHWAY

ENDOTHELIAL DAMAGE-------------------------------------------SEPTIC
ABORTION CHORIOAMNIONITIS
I
CONTACT ACTIVATION
I
XII
I
XI
I
IX
I
VIII PLATELET FACTOR 3CA ++
I
XV PF3
I
II----------------------------THROMBIN
FIBRINOGEN ------------------I--------------FIBRIN (CLOT)

EXTRINSINC PATHWAY
TISSUE INJURY-------------------ABRUPTIO PLACENTA, AMNIOTIC FLUID,
EMBOLISM RETAINED DEAD FETUS
I
THROMBOPLASTIN
I
VII
I
XV PF3 CA ++
I
II-------------------------------THROMBIN
FIBRINOGEN------------------------FIBRIN CLOT

HYPERTENSIVE DESEASE IN PREGNANCY

Classification
1. PIH
1.1 Transient gestational hypertension
1.2 Pre-eclampsia
A. mild
b. severe
2. Pregnancy aggravated hypertension
2.1 superimposed pre-eclampsia
2.2 superimposed eclampsia
3. Chronic or coincidental hypertension

Definition:
Hypertension: is diagnosed when blood pressure is at least 140mmhf systolic or
90 mmHg diastolic
Or an increase of 30/15 mmHg over baseline values
Proteinuria – urinary protein of at least 300 mg /24 hrs. Urine sample or at least
1000mg/ random sample of urine taken 6 hrs. Apart.
 Pathologic edema – is presence of pretibial/ pitting edema after 12 hrs. of bed
rest or weight gain of 5 lbs/week.
Pre-eclampsia- presence of hypertension plus proteinuria and or edema occurring
after the 20th week of gestation except in the case of extensive trophoblastic
proliferation. Classified as severe in the presence one or more of the following
signs and symptoms:
1. BP 160/110
2. Proteinuria 4 gram daily
3. Oliguria
4. Severe headache visual disturbance attributed to cerebral edema.
5. Pulmonary Edema
6. IUGR
7. Abd. Pain epigastric pain RUQ
8. HELLP SYNDROME (hemolysis, elevated liver enzymes, caused by
hepatocellular necrosis low platelet count (thrombocytopenia)

Eclampsia- presence of convulsion in woman with underlying pre-eclampsia

Chronic coincidental hypertension – BP 140/90 mmhg or greater detected
before 20th weeks of gestation persist long after delivery
Superimposed coincidental hypertension on pre-existing chronic HPN-
characterized by an increase of at least 15mmhg diastolic or 30 mmhg systolic.
Risk factors in the future development of pre-eclampsia
1. nulliparity 6-7 x more prone to develop PIH than multipara
2. Hereditary
3. Chronic HPN predisposes gravidas
4. Hyperplacentosis states (multifetal, DM, H-MOLE ANF FETAL HYDROPS)
5. Low socio economic status, poor protein or calcium in diet.

Clinical disease
Management principle

Prevent convulsion control HPN

DELIVERY
DRUG OPTION DRUG OPTION
COVERING FACTORS
Mgso4 hydralazine AOG
Diazepam b blockers (labetalol)
Severity of disease
Phenytoin’s calcium channel blocker
fetal status
Barbiturates dioxide
maternal status
Diaz oxide methyldopa
nursery capacity

IMMEDIATE DELIVERY
ECLAMPSIA
>34 WEEKS MATURE LUNGS
> 34 WEEKS IMMATURE LUNGS STERIODS
> 34 WEEKS (PROM, IUGR 5%, ABRUPTIO PLACENTA, FETAL
COMPROMISE)
DELIVERY OPTION
-PROSTGLANDIN
-AMNIOTOMY
-OXYTOCIN
-CESAREAN SECTION

INFLAMTION OF THE PLACENTA, MEMBRANE AND CORD

CHORIO AMNIONITIS- inflammation in the decidua and membrane
- Indicates an ascending intrauterine infection
FUNITIS- inflammation of cord
TORCH INFECTION- Toxoplasmosis,rubella,cytomegalo virus and herpes
simplex virus produce placental lesions like dysmaturity and focal villitis.
Abnormalities of membrane
1. amnion nodosum
-elevated amniotic nodule less than 5 mm in diameter .

2. Amnion Bands
- cause fetal anomalies such as digital or limb constriction or
amputation,craniofacial defects and club feet

Abnormalities of fetal cord

- 50-70 cm normal
- Long cord – obstructon or wrapping of infant neck
- Short cord – dystocia restriction of fetal descent
- False knot- produce complex structures upon itself and of no clinical
ssignificant
 - True knot- if cord is long, produce fetal demise irreversible cord
obstruction.

ABNORMALITIES OF AMNIOTIC FLUID

HYDRAMNIOS –excessive amount (2000 ml or more) of amniotic fluid

Usually suspected after 7 months pregnancy and large for AOG.

OLIGOHYDRAMNIOS- Decrease amount of amniotic fluid

MECONIUM IN AMNIOTIC FLUID

GESTATIONAL TROPOBLAST DISEASE – H-MOLE

- General term for proliferative abnormalities of the trophoblast the most
benign is the H-mole and most malignant is choriocarcinoma.
GENETICS OF H-MOLE
1. COMPLETE H-MOLE
Fertilization of egg whose nucleus has been lost or inactivated and single sperm
with 23 sets of chromosomes which then duplicates to 46xx or fertilization of egg
by 2 spermatozoa resulting in either 46xy or 46xx.
2. PARTIAL H-MOLE
Karyo type is either normal,trisomic or triploid. Risk of malignancy is low.
PARTIAL H-MOLE CHROMOSOMES

PARTIAL H MOLE CHROMOSOMES

COMPLETE H-MOLE
PARTIAL H-MOLE
 PATHOLOGY

Complete mole incomplete mole

Embryotic or fetal tissue - +
Villous stromal edema diffused localized
Trophoblastic hyperplasia diffused localized
Villous outline regular irregular
Villous stromal blood vessel - +
Karyotype diploid triploid or
tetraploid

ETIOLOGY
High risk factors:
1. Nourishing status, social economy.
2. Age:over 35 and 40 years old;
Below 20 years old.
3. hydatidiform mole history:
if a patient has the history of 1 or 2 times hydatidiform
mole,then the morbidity of the hydatidiform mole when pregnant again is 1%
and 15~20% respectively.
Clinical characteristics
Complete mole Incomplete Mole
Uterus is large for date Uterus is small for date
Content expelled 10-16 wks. Expelled 10-26 wks.
Toxemia occurs early if ever Normal signs and symptoms of
pregnancy
HCG titer is higher Not too high
No evidence of fetus by utz There maybe evidence of fetus
Proceed to carcinoma rare
Easily diagnosed before content Diagnosis made after expulsion of
expelled content of uterus

Diagnosis of H-mole
1. Clinical signs and symptoms
2. Ultrasonography
3. Beta HCG Titer(1000IU/L on the 100th day from LMP
4 .other test
- Chest x ray lung metastasis shows cannon ball lesion or exudates
- UTZ pulse detector to rule fetus alive
- Amniocentesis negative amniotic fluid diagnose Hmole
- Hysterogram or amniogram(honeycomb pattern)
- Hysteroscopy through cervix

Treatment of H-mole
1. Replacement of blood loss
2. Combating infection if prevent
3. Termination of pregnancy
-suction curettage
-hysterectomy
4. Prophylactic chemotherapy before and after hysterectomy
5. Follow up for 1-2 yrs
-HCG titer every 2 weeks for 6 months
-chest x ray every 3 months for 1 yr.
- Combination of Oral contraceptive pills
Hyperemesis Gravidarum (Excessive Vomiting in Pregnancy)
What is Hyperemesis Gravidarum? is the condition which a woman suffers from
excessive vomiting during pregnancy. They usually throw up so often that they
can’t even digest the amount of food and fluid. It can lead to dehydration, weight
loss and electrolyte imbalance.

Causes of Hyperemesis Gravidarum

Is not entirely clear. Hormonal changes in pregnancy, changes in gut motility and
functioning as well as psychological factors have been implicated in manifestation
of excessive vomiting in pregnancy. It is very common to have nausea and
vomiting during the first 3 months of pregnancy.

Few reasons that can cause hyperemesis gravidarum are listed below:
1. Rapid increase in blood level of a hormone that is released by placenta called as
human chorionic gonadotropin
2. Family history of Hyperemesis Gravidarum (Mother, sister also suffer the same
manefestatation)
2. Multipregnancy,primigravida and unplanned pregnancies
3. Molar Pregnancy
4.Acidosis due to starvation

Complication:
Dehydration
Alkalosis
Electrocyte imbalance
Weight loss

Fetus is usually unaffected

but risk of low birth weight and prematurity is there.

Signs and Symptoms

1. Persistent Vomiting (Vomiting is more than 6 times)
2. Loss of weight (5 pounds or more)
3. Dehydration (urine is dark yellow not able to urinate for long periods)
3.Constipation(not able to take any food or fluid for 24 hrs. or longer)
4.Weakness and headache
5.Unusual salivating
6.Low Blood pressure
7.High pulse rate
Test for HEG
1. CBC- use to evaluate your overall health and detect a wide range of disorder
including anemia, infection or leukemia

2. Urine ketones- if you’re cells don’t get enough glucose your’ e body burns fats
for energy. High ketones indicate diabetic (ketoacidosis)

3. Serum Electrolyte-can help to determine whether there’s am electrolyte

imbalance in the body. Electrolytes are salts and minerals, such as sodium,
potassium, chloride and bicarbonate which found in blood.

Electrolytes normal range

Men- 8.8-10.0mg/dl
Women- 9.0-10.5 mg/dl
Pregnant- 8.1-9.5 mg/dl

4. Test of functioning of Liver

-ALT test
Alanine transaminase when liver cells damage they release ALT
-Albumin test
Test for protein made by your liver, helps keeps fluid in your bloodstream so it
doesn’t leak into other tissue
-ALP alkaline phosphates
ALP is enzymes found in liver bones kidney and digestive system. Can indicate
liver disease or bone disorder

5. Ultrasound to check if carrying twins

HCG level in twin pregnancy have 30-50% higher HCG than singleton pregnancy.

6. Ultrasound to check Hydatidiform mole

Increase placental mass in the setting of molar or multiple gestations has been
associated with higher risk of hyperemesis gravidarum

7.Thyroid Functioning Test (TSH,FT4)

HCG has thyroid stimulating activity that influences thyroid function. excessive
HCG secretion may cause hyperthyroidism in patients with hyperemesis
gravidarum.

8. Urine Culture
Test for UTI can be associated in nausea and vomiting.