MIDWIFERY DISORDERS

Gestational Diabetes Mellitus (GDM)

✅ Definition:
Gestational Diabetes Mellitus (GDM) is glucose intolerance first diagnosed during pregnancy, leading to high blood sugar levels, usually resolving after delivery.

✅ Causes & Risk Factors:

• Insulin resistance due to placental hormones (hPL, cortisol, estrogen, progesterone).
• Obesity, polycystic ovary syndrome (PCOS), family history of diabetes.
• History of macrosomia (>4 kg baby) or previous GDM.

✅ Signs & Symptoms:

• Polyuria (excess urination), polydipsia (excess thirst), polyphagia (excess hunger).
• Unexplained weight loss, recurrent infections (UTI, vaginal candidiasis).
• Excessive amniotic fluid (polyhydramnios) due to fetal hyperglycemia.

✅ Diagnosis:

• Oral Glucose Tolerance Test (OGTT) at 24–28 weeks:
  • Fasting glucose ≥92 mg/dL.
  • 1-hour glucose ≥180 mg/dL.
  • 2-hour glucose ≥153 mg/dL.

✅ Medical Management:

• Diet control (low glycemic index foods).
• Exercise (at least 30 minutes daily).
• Insulin therapy if blood sugar remains high.
• Frequent fetal monitoring (NST, BPP, Doppler).

✅ Nursing Management:

• Monitor blood glucose levels.
• Educate on diabetic diet & self-monitoring of glucose.
• Assess fetal growth (ultrasound for macrosomia).
• Monitor for complications (preeclampsia, stillbirth).

✅ Complications:

• Macrosomia (large baby) → Shoulder dystocia risk.
• Neonatal hypoglycemia after birth.
• Increased risk of Type 2 Diabetes in mother.

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Gestational Hypertension (GH)

✅ Definition:
Gestational hypertension is new-onset hypertension (BP ≥140/90 mmHg) after 20 weeks of gestation without proteinuria or organ damage.

✅ Causes & Risk Factors:

• First pregnancy, multiple pregnancies (twins/triplets).
• Obesity, family history of hypertension.
• History of chronic hypertension or preeclampsia.

✅ Signs & Symptoms:

• Elevated BP (>140/90 mmHg on 2 occasions, 4 hours apart).
• No proteinuria or organ dysfunction.
• Mild headaches, occasional dizziness.

✅ Medical Management:

• Antihypertensive drugs (Methyldopa, Labetalol, Nifedipine).
• Fetal growth monitoring (USG, Doppler flow studies).
• Regular BP monitoring.

✅ Nursing Management:

• Monitor BP, educate on self-monitoring.
• Encourage rest, left lateral position.
• Assess for signs of preeclampsia (proteinuria, headache, visual disturbances).

✅ Complications:

• Progression to preeclampsia.
• Intrauterine Growth Restriction (IUGR).
• Preterm birth due to placental insufficiency.

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Polyhydramnios (Excess Amniotic Fluid)

✅ Definition:
Polyhydramnios is excessive amniotic fluid (>25 cm AFI or single pocket >8 cm).

✅ Causes & Risk Factors:

• Gestational Diabetes (Fetal hyperglycemia → Polyuria).
• Fetal anomalies (Esophageal atresia, anencephaly, neural tube defects).
• Multiple pregnancies (Twin-to-twin transfusion syndrome).

✅ Signs & Symptoms:

• Large-for-gestational age uterus.
• Breathlessness due to uterine pressure.
• Preterm labour due to overdistension of uterus.

✅ Medical Management:

• Amnioreduction (Drain excess fluid via amniocentesis).
• Indomethacin (to reduce fetal urine production).
• Monitor for preterm labour & fetal distress.

✅ Nursing Management:

• Monitor uterine size, AFI via ultrasound.
• Assess for signs of preterm labour (contractions, rupture of membranes).
• Prepare for emergency delivery if fetal distress occurs.

✅ Complications:

• Preterm birth, placental abruption, cord prolapse.
• Postpartum hemorrhage (PPH) due to uterine atony.

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Oligohydramnios (Low Amniotic Fluid)

✅ Definition:
Oligohydramnios is amniotic fluid deficiency (AFI <5 cm or single pocket <2 cm).

✅ Causes & Risk Factors:

• Fetal renal abnormalities (renal agenesis, Potter syndrome).
• Post-term pregnancy (>42 weeks).
• Rupture of membranes (PROM, PPROM).

✅ Signs & Symptoms:

• Small-for-gestational-age uterus.
• Decreased fetal movements.
• Oligohydramnios on ultrasound.

✅ Medical Management:

• Amnioinfusion (intrauterine fluid administration).
• Hydration therapy (IV fluids).
• Fetal monitoring (NST, Doppler).

✅ Nursing Management:

• Monitor fetal heart rate, movements.
• Encourage maternal hydration.
• Educate on preterm labour risks.

✅ Complications:

• Fetal distress (cord compression, meconium aspiration).
• Pulmonary hypoplasia if severe.

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Pre-eclampsia

✅ Definition:
Pre-eclampsia is gestational hypertension with proteinuria (>300 mg/day) or organ dysfunction.

✅ Signs & Symptoms:

• Severe hypertension (>160/110 mmHg).
• Proteinuria.
• Edema (face, hands).
• Headache, blurred vision, epigastric pain.

✅ Medical Management:

• Antihypertensives (Labetalol, Nifedipine).
• Magnesium sulfate (to prevent seizures).
• Deliver baby if severe (>34 weeks).

✅ Nursing Management:

• Monitor BP, proteinuria, reflexes (hyperreflexia = risk of seizure).
• Bed rest, left lateral position.
• Educate on warning signs (headache, vision changes).

✅ Complications:

• Eclampsia (Seizures).
• HELLP Syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets).
• Preterm birth, placental abruption.

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Eclampsia

✅ Definition:
Eclampsia is severe preeclampsia with generalized seizures.

✅ Signs & Symptoms:

• Convulsions (tonic-clonic seizures).
• Severe headache, blurred vision.
• Pulmonary edema, respiratory distress.

✅ Medical Management:

• Magnesium sulfate (IV loading dose + maintenance).
• Control BP (Labetalol, Hydralazine).
• Immediate delivery if stable.

✅ Nursing Management:

• Monitor BP, reflexes, respiratory rate (for magnesium toxicity).
• Prevent aspiration (lateral position, suction ready).
• Provide emotional support to the mother and family.

✅ Complications:

• Maternal coma, intracranial hemorrhage.
• Fetal hypoxia, stillbirth.

Preterm Labour (PTL)

✅ Definition:
Preterm labour is the onset of labour before 37 weeks of gestation, leading to cervical dilation and uterine contractions.

✅ Causes & Risk Factors:

• Previous preterm birth, multiple pregnancies (twins/triplets).
• Infections (UTI, bacterial vaginosis, chorioamnionitis).
• Placental abnormalities (abruption, previa).
• Short cervix, cervical incompetence.
• Smoking, drug abuse, stress, poor nutrition.

✅ Signs & Symptoms:

• Uterine contractions (≥4 contractions in 20 minutes).
• Cervical dilation >3 cm before 37 weeks.
• Lower back pain, pelvic pressure.
• Vaginal bleeding or watery discharge.

✅ Diagnosis:

• Fetal Fibronectin Test (fFN): Predicts risk of preterm birth.
• Transvaginal Ultrasound (TVS): Assesses cervical length (<2.5 cm = high risk).
• CTG (Cardiotocography): Monitors contractions.

✅ Medical Management:

• Tocolytics (Nifedipine, Indomethacin) to delay labour.
• Corticosteroids (Betamethasone) to enhance fetal lung maturity.
• Magnesium sulfate for neuroprotection (<32 weeks).
• Antibiotics if infection is suspected.

✅ Nursing Management:

• Monitor fetal heart rate and uterine contractions.
• Encourage hydration (dehydration triggers contractions).
• Educate about warning signs (bleeding, fluid leakage, pain).

✅ Complications:

• Neonatal respiratory distress syndrome (RDS).
• Sepsis, low birth weight, feeding difficulties.

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Premature Labour

✅ Definition:
Premature labour is labour occurring between 34–37 weeks, leading to early birth but without significant prematurity complications.

✅ Key Differences Between Preterm & Premature Labour:

Feature	Preterm Labour (<37 weeks)	Premature Labour (34–37 weeks)
Fetal Lung Maturity	Incomplete	Partially matured
Neonatal Complications	Higher risk	Lower risk
Management	Tocolytics, steroids	Minimal intervention unless distress present

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Post-Maturity & Post-Term Pregnancy

✅ Definition:

• Post-maturity refers to a pregnancy that continues beyond 42 weeks.
• Post-term pregnancy is a pregnancy lasting >40 weeks.

✅ Causes & Risk Factors:

• Unknown in most cases.
• Previous post-term pregnancy.
• Placental aging, fetal anencephaly.

✅ Signs & Symptoms:

• Decreased fetal movements (due to reduced amniotic fluid).
• Dry, peeling skin on the fetus (post-maturity syndrome).
• Meconium-stained amniotic fluid (risk of aspiration).

✅ Medical Management:

• Induction of labour (Oxytocin, Prostaglandins).
• Fetal monitoring (NST, Doppler ultrasound).
• C-section if fetal distress present.

✅ Nursing Management:

• Monitor amniotic fluid index (AFI).
• Assess for signs of fetal distress.
• Prepare for emergency delivery if needed.

✅ Complications:

• Meconium aspiration syndrome (MAS).
• Placental insufficiency → Fetal hypoxia.
• Macrosomia → Shoulder dystocia risk.

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Prolapsed Umbilical Cord

✅ Definition:
A prolapsed umbilical cord occurs when the umbilical cord slips past the fetal presenting part and exits through the cervix before the baby, leading to cord compression and fetal hypoxia.

✅ Causes & Risk Factors:

• Polyhydramnios (excess fluid causes cord slip).
• Premature rupture of membranes (PROM).
• Multiple gestations, breech presentation.

✅ Signs & Symptoms:

• Sudden fetal bradycardia (<110 bpm).
• Palpable umbilical cord in the vagina.
• Mother reports feeling a “loop” of cord.

✅ Emergency Management:

• Trendelenburg/knee-chest position to reduce pressure.
• Manual elevation of the presenting part to relieve compression.
• Immediate C-section delivery.

✅ Complications:

• Stillbirth due to cord occlusion.
• Fetal hypoxia → Brain damage.

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Pre-Labour Rupture of Membranes (PROM)

✅ Definition:

• PROM: Rupture of membranes before labour onset but after 37 weeks.
• PPROM (Preterm PROM): Rupture of membranes before 37 weeks.

✅ Causes & Risk Factors:

• Infections (chorioamnionitis, UTIs).
• Multiple gestation, previous PROM history.
• Trauma, smoking, poor nutrition.

✅ Signs & Symptoms:

• Gush of clear or greenish fluid from the vagina.
• Amniotic fluid pooling in the vagina.
• No contractions initially.

✅ Diagnosis:

• Nitrazine test (pH test for amniotic fluid).
• Fern test (crystallization pattern under microscope).

✅ Medical Management:

• If >37 weeks: Induce labour.
• If <34 weeks: Corticosteroids, antibiotics, bed rest.
• Monitor for infection (chorioamnionitis signs: fever, foul-smelling discharge).

✅ Nursing Management:

• Monitor fetal heart rate & maternal temperature.
• Educate on hygiene to prevent infection.

✅ Complications:

• Chorioamnionitis, neonatal sepsis, preterm birth.

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Intrauterine Death (IUD)

✅ Definition:
Intrauterine death (IUD) is fetal death after 20 weeks but before birth.

✅ Causes & Risk Factors:

• Placental abruption, cord accidents.
• Severe preeclampsia, gestational diabetes.
• Congenital anomalies, infections (TORCH).

✅ Signs & Symptoms:

• Absence of fetal movements.
• No fetal heart activity on Doppler.
• Reduction in fundal height.

✅ Management:

• Confirm with ultrasound.
• Induction of labour if no spontaneous delivery.
• Emotional support, bereavement counseling.

✅ Complications:

• DIC (Disseminated Intravascular Coagulation) if prolonged retention.

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Antepartum Hemorrhage (APH)

✅ Definition:
APH is bleeding from the genital tract after 20 weeks but before delivery.

✅ Types & Causes:

Type	Cause	Clinical Features
Placenta Previa	Placenta covers cervix	Painless bright red bleeding
Placental Abruption	Premature separation of placenta	Painful, dark bleeding + fetal distress
Vasa Previa	Fetal vessels cross cervix	Sudden bleeding, fetal distress

✅ Management:

• Monitor BP, fetal heart rate.
• Immediate C-section if severe bleeding.
• Transfusion if hemorrhage is excessive.

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Types of Abortion

Type	Features	Management
Threatened Abortion	Bleeding, closed cervix	Bed rest, progesterone
Inevitable Abortion	Bleeding, open cervix	Misoprostol, D&C
Incomplete Abortion	Retained products	D&C, IV fluids
Complete Abortion	Full expulsion	Supportive care
Missed Abortion	No fetal heartbeat	Induction
Septic Abortion	Infection, fever	IV antibiotics, evacuation

Introduction to Gestational Trophoblastic Diseases (GTD)

✅ Definition:
Gestational Trophoblastic Diseases (GTD) are a group of rare pregnancy-related disorders originating from abnormal trophoblastic proliferation in the placenta. These conditions range from benign (Hydatidiform Mole) to malignant (Choriocarcinoma, Placental Site Trophoblastic Tumor).

✅ Types of GTD:

1. Hydatidiform Mole (Molar Pregnancy) – Complete & Partial Mole.
2. Persistent Gestational Trophoblastic Neoplasia (GTN).
3. Choriocarcinoma.
4. Placental Site Trophoblastic Tumor (PSTT).
5. Epithelioid Trophoblastic Tumor (ETT).

✅ Risk Factors:

• Extremes of maternal age (<20 or >35 years).
• Previous molar pregnancy.
• Asian ethnicity (higher incidence).
• Nutritional deficiencies (low vitamin A, folic acid).

✅ Clinical Importance:

• Early detection prevents complications like hemorrhage, GTN, and metastasis.
• β-hCG monitoring is essential for diagnosis and follow-up.

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Hydatidiform Mole (Molar Pregnancy)

✅ Definition:
A Hydatidiform Mole is an abnormal pregnancy with excessive trophoblastic growth and cystic degeneration of chorionic villi.

✅ Types of Hydatidiform Mole:

Type	Genetic Composition	Fetal Development	Risk of Malignancy
Complete Mole	Diploid (46, XX or 46, XY, paternal origin)	No fetal development	Higher risk of Choriocarcinoma (~15%).
Partial Mole	Triploid (69, XXX / 69, XXY / 69, XYY)	Fetal tissue present but non-viable	Lower malignancy risk (~5%).

✅ Causes & Pathophysiology:

• Abnormal fertilization of an empty ovum (Complete Mole) or duplication of paternal chromosomes (Partial Mole).
• Results in excessive trophoblastic proliferation and high β-hCG levels.

✅ Signs & Symptoms:

• Excessive nausea & vomiting (Hyperemesis Gravidarum).
• Painless vaginal bleeding (grape-like vesicles).
• Uterus larger than gestational age.
• Absent fetal heart sounds.

✅ Diagnosis:

• Ultrasound:
  • Complete Mole: “Snowstorm” or “Grape-like” appearance.
  • Partial Mole: Abnormal fetus with hydropic placenta.
• Serum β-hCG: Excessively high (>100,000 mIU/mL).
• Histopathology: Confirms molar tissue.

✅ Medical Management:

• Suction & Evacuation (D&C).
• Monitor β-hCG weekly until undetectable, then monthly for 6 months.
• Contraception for 6–12 months (to prevent pregnancy confusion with GTN).

✅ Nursing Management:

• Monitor for heavy bleeding, infection, and anemia.
• Educate about β-hCG monitoring compliance.
• Provide emotional support (risk of malignancy concern).

✅ Complications:

• Persistent Gestational Trophoblastic Neoplasia (GTN).
• Choriocarcinoma (if malignant transformation occurs).
• Uterine rupture if mismanaged.

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Persistent Gestational Trophoblastic Neoplasia (GTN)

✅ Definition:
GTN is a condition where trophoblastic tissue persists after molar pregnancy evacuation, leading to invasive growth or metastasis.

✅ Causes & Risk Factors:

• Invasive mole (~15% of complete moles).
• Choriocarcinoma (~4% of moles).

✅ Signs & Symptoms:

• Persistent β-hCG elevation post-mole evacuation.
• Continuous vaginal bleeding.
• Pelvic pain, uterine enlargement.

✅ Diagnosis:

• β-hCG plateau or increase.
• Ultrasound/MRI: Invasive uterine mass.

✅ Management:

• Methotrexate (first-line chemotherapy).
• Hysterectomy if severe invasive disease.

✅ Nursing Management:

• Monitor for chemotherapy side effects (bone marrow suppression).
• Educate on contraception (avoid pregnancy during treatment).

✅ Complications:

• Metastasis to lungs, brain, liver.
• Choriocarcinoma formation.

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Choriocarcinoma

✅ Definition:
A highly malignant and aggressive trophoblastic cancer following a molar pregnancy, normal pregnancy, or abortion.

✅ Causes & Risk Factors:

• 50% occur after molar pregnancy.
• 25% after miscarriage or ectopic pregnancy.
• 25% after normal pregnancy.

✅ Signs & Symptoms:

• Persistent vaginal bleeding post-pregnancy.
• Pelvic pain, enlarged uterus.
• Metastatic symptoms (cough, hemoptysis if lung metastasis).

✅ Diagnosis:

• Persistent or rising β-hCG levels.
• Ultrasound: Uterine mass.
• Chest X-ray/CT scan (metastasis screening).

✅ Medical Management:

• Single-agent chemotherapy (Methotrexate) for low risk.
• Multi-agent chemotherapy (EMA-CO: Etoposide, Methotrexate, Actinomycin D, Cyclophosphamide, Vincristine) for high risk.
• Hysterectomy if resistant.

✅ Nursing Management:

• Monitor β-hCG levels & chemotherapy side effects.
• Emotional support & fertility counseling.

✅ Complications:

• Lung metastases (most common site).
• Brain metastases (causes seizures, neurological deficits).

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Placental Site Trophoblastic Tumor (PSTT)

✅ Definition:
A rare slow-growing GTN arising from intermediate trophoblasts.

✅ Signs & Symptoms:

• Irregular postpartum bleeding (weeks to months).
• Low but persistent β-hCG levels.

✅ Management:

• Hysterectomy (not sensitive to chemotherapy).

✅ Complications:

• Delayed diagnosis due to low β-hCG.

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Clinical and Competitive Exam Importance

Aspect	Clinical Relevance
Complete vs. Partial Mole	Complete Mole has higher risk of GTN
Choriocarcinoma Metastases	Most common site → Lungs
GTN Treatment	Methotrexate (first-line chemotherapy)
β-hCG Monitoring	Persistent elevation suggests malignancy
Post-Molar Pregnancy Care	Contraception for 6–12 months

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Exam-Oriented Questions

✅ What is the characteristic ultrasound finding in a complete mole?
👉 “Snowstorm” appearance.

✅ Which GTD has the highest metastatic potential?
👉 Choriocarcinoma.

✅ What is the first-line chemotherapy for GTN?
👉 Methotrexate.

✅ Which GTD arises from intermediate trophoblasts?
👉 Placental Site Trophoblastic Tumor (PSTT).

✅ What is the definitive diagnosis for GTD?
👉 Histopathology (tissue examination).

Fetal Distress

✅ Definition:
Fetal distress is a condition where the fetus does not receive adequate oxygen, leading to hypoxia and acidosis. It is commonly detected during labour using fetal heart rate (FHR) monitoring and biophysical tests.

✅ Causes & Risk Factors:

1. Placental Insufficiency:
   • Hypertension, preeclampsia, diabetes.
   • Post-term pregnancy (aging placenta).
2. Umbilical Cord Abnormalities:
   • Cord compression, prolapsed cord, nuchal cord.
3. Maternal Factors:
   • Anemia, hypoxia, infections, drug use (smoking, opioids).
4. Uterine Hyperstimulation:
   • Excessive oxytocin use.
5. Amniotic Fluid Abnormalities:
   • Polyhydramnios, oligohydramnios.

✅ Signs & Symptoms:

1. Fetal Heart Rate (FHR) Abnormalities:
   • Tachycardia (>160 bpm) or bradycardia (<110 bpm).
   • Late decelerations (decreased FHR after contractions).
   • Variable decelerations (due to cord compression).
2. Decreased Fetal Movements:
   • Less than 10 movements in 2 hours.
3. Meconium-Stained Amniotic Fluid:
   • Indicates fetal hypoxia (risk of meconium aspiration).

✅ Diagnosis:

• Non-Stress Test (NST): Identifies FHR variability.
• Cardiotocography (CTG): Detects accelerations and decelerations.
• Biophysical Profile (BPP): Fetal breathing, movement, tone, amniotic fluid.
• Fetal Scalp Blood Sampling (if needed): pH <7.2 suggests hypoxia.

✅ Medical Management:

• Left lateral position (improves uteroplacental perfusion).
• Oxygen therapy for mother (8–10 L/min via mask).
• IV fluids to improve circulation.
• Stop oxytocin if uterine hyperstimulation is present.
• Immediate delivery (C-section) if severe distress.

✅ Nursing Management:

• Monitor fetal heart rate continuously.
• Assess for fetal movements (kick count method).
• Ensure proper hydration and oxygenation of the mother.
• Prepare for emergency delivery if needed.

✅ Complications:

• Stillbirth, neonatal asphyxia.
• Hypoxic-ischemic encephalopathy (HIE).

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Multiple Pregnancy

✅ Definition:
Multiple pregnancy occurs when more than one fetus develops simultaneously in the uterus.

✅ Types of Twins:

Type	Number of Placentas & Amniotic Sacs	Origin
Dizygotic (Fraternal)	2 placentas, 2 amniotic sacs (Diamniotic-Dichorionic).	2 separate fertilized eggs.
Monozygotic (Identical)	Depends on timing of division: – Dichorionic-Diamniotic (before Day 3). – Monochorionic-Diamniotic (Day 4–8). – Monochorionic-Monoamniotic (Day 9–12). – Conjoined twins (after Day 13).	Single fertilized egg splits.

✅ Causes & Risk Factors:

• Family history (especially dizygotic twins).
• Assisted reproductive techniques (IVF, ovulation induction).
• Advanced maternal age, parity (>35 years, >3 pregnancies).
• African ethnicity (higher incidence of twins).

✅ Signs & Symptoms:

• Excessive weight gain (more than expected for gestational age).
• Fundal height larger than expected.
• Increased nausea, vomiting (hyperemesis gravidarum).
• Fetal movements felt at multiple locations.

✅ Diagnosis:

• Ultrasound (Best method):
  • First Trimester: Confirms number of fetuses, chorionicity.
  • Second Trimester: Checks for growth discordance, twin-to-twin transfusion syndrome (TTTS).
• Elevated β-hCG and Alpha-Fetoprotein (AFP).

✅ Medical Management:

• Frequent antenatal monitoring (every 2 weeks after 24 weeks).
• Iron & folic acid supplementation (higher risk of anemia).
• Monitor for complications (TTTS, preterm labour, preeclampsia).
• Delivery planning:
  • Dichorionic twins: 38 weeks.
  • Monochorionic twins: 36 weeks.
  • Monoamniotic twins: 32–34 weeks (C-section recommended).

✅ Nursing Management:

• Monitor fetal growth via ultrasound.
• Assess for complications (polyhydramnios, preeclampsia, preterm labour).
• Prepare for C-section if required.

✅ Complications:

• Preterm labour (most common, >50% cases).
• Twin-to-twin transfusion syndrome (TTTS) in monochorionic twins.
• Cord entanglement in monoamniotic twins.

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Ectopic Pregnancy

✅ Definition:
Ectopic pregnancy occurs when a fertilized ovum implants outside the uterine cavity, most commonly in the fallopian tube (tubal pregnancy ~95%).

✅ Sites of Ectopic Pregnancy:

Site	Incidence	Clinical Risk
Tubal (Ampullary, Isthmic, Fimbrial)	95%	Rupture, internal bleeding.
Ovarian	1%	Rare, can mimic ovarian cyst.
Abdominal	1%	Can grow to term but high maternal risk.
Cervical	1%	Severe hemorrhage risk.

✅ Causes & Risk Factors:

• Pelvic inflammatory disease (PID).
• Previous tubal surgery, ectopic history.
• Endometriosis, IUD use.
• IVF, assisted reproductive techniques.

✅ Signs & Symptoms:

1. Classical Triad:
   • Amenorrhea (missed period).
   • Lower abdominal pain.
   • Vaginal bleeding (spotting).
2. Ruptured Ectopic Pregnancy Symptoms:
   • Severe abdominal pain, shoulder tip pain (diaphragmatic irritation).
   • Hypotension, tachycardia (shock due to hemorrhage).

✅ Diagnosis:

• Serum β-hCG: Slower rise compared to normal pregnancy.
• Transvaginal Ultrasound (TVS): No intrauterine sac, adnexal mass.
• Culdocentesis: Checks for blood in peritoneal cavity.

✅ Medical Management (Unruptured Ectopic):

• Methotrexate (if β-hCG <5000 mIU/mL, sac <3.5 cm).
• Monitor β-hCG levels until undetectable.

✅ Surgical Management (Ruptured Ectopic or Large Sac):

• Salpingectomy (removal of affected tube).
• Laparoscopy preferred, laparotomy if unstable.

✅ Nursing Management:

• Monitor vital signs, signs of internal bleeding.
• Post-operative care after laparoscopy.
• Educate on future fertility risks.

✅ Complications:

• Hemorrhagic shock, death if untreated.
• Infertility due to tubal damage.

Postpartum Hemorrhage (PPH)

✅ Definition:
PPH is excessive bleeding after childbirth, defined as:

• Blood loss >500 mL after vaginal delivery.
• Blood loss >1000 mL after C-section.
• Severe PPH: Blood loss >1500–2000 mL.

✅ Types of PPH:

Type	Timing	Cause
Primary (Early) PPH	Within 24 hours after delivery	Uterine atony, retained placenta, trauma, coagulopathy.
Secondary (Late) PPH	24 hours to 6 weeks postpartum	Retained products of conception, infection, subinvolution.

✅ Causes (4 T’s of PPH):

Cause	Description
Tone (Uterine Atony – 70%)	Uterus fails to contract, leading to continuous bleeding.
Tissue (Retained Placenta – 10%)	Fragments of placenta remain in the uterus.
Trauma (Genital Tract Injury – 20%)	Perineal tears, episiotomy, uterine rupture.
Thrombin (Coagulopathy – 1%)	Clotting disorders (DIC, HELLP Syndrome).

✅ Risk Factors:

• Multiple gestation, polyhydramnios (overdistension of uterus).
• Prolonged or rapid labour.
• Grand multiparity (>5 pregnancies).
• Previous PPH history.

✅ Signs & Symptoms:

• Heavy vaginal bleeding (soaking pads in <15 minutes).
• Soft, boggy uterus (uterine atony).
• Hypotension, tachycardia (shock signs).
• Pale, sweaty, dizziness, altered consciousness.

✅ Diagnosis:

• Clinical assessment (visual blood loss estimation).
• Ultrasound (detects retained placenta).
• CBC, coagulation profile (check for anemia & clotting disorders).

✅ Medical Management:

1. Uterine Massage – Stimulates contraction.
2. Uterotonics (1st line treatment):
   • Oxytocin (10 IU IM or IV).
   • Misoprostol (800 mcg per rectum).
   • Carboprost (Hemabate) for atonic PPH (contraindicated in asthma).
3. Blood transfusion if Hb <7 g/dL.
4. Monitor urine output (to assess shock).

✅ Surgical Management:

• Manual removal of placenta (if retained fragments).
• Balloon tamponade (Bakri Balloon) to compress bleeding vessels.
• B-Lynch suture (if uterotonics fail).
• Hysterectomy (last resort for uncontrolled bleeding).

✅ Nursing Management:

• Monitor vital signs, uterine tone, and vaginal bleeding.
• Encourage breastfeeding (stimulates oxytocin).
• Assess for signs of hypovolemic shock (cold extremities, low BP).

✅ Complications:

• Hypovolemic shock, DIC (coagulation failure).
• Sheehan’s Syndrome (pituitary necrosis → lactation failure).

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Retained Placenta

✅ Definition:
The placenta is considered retained if it is not expelled within 30 minutes after delivery.

✅ Types of Retained Placenta:

Type	Cause	Clinical Relevance
Placenta Adherens	Weak uterine contractions	Most common, responds to uterotonics.
Trapped Placenta	Cervix closes before expulsion	Requires manual removal.
Placenta Accreta	Placenta abnormally attached to the myometrium	High risk of hemorrhage.
Placenta Increta	Placenta invades myometrium	Partial penetration, severe bleeding.
Placenta Percreta	Placenta invades uterine serosa	May require hysterectomy.

✅ Causes & Risk Factors:

• Previous C-section or uterine surgery (scarring).
• Placenta previa (low-lying placenta).
• Multiple pregnancies.

✅ Signs & Symptoms:

• Failure of placenta to deliver within 30 minutes.
• Continuous bleeding despite a firm uterus.
• Severe postpartum hemorrhage if placenta is invasive (accreta, increta, percreta).

✅ Diagnosis:

• Ultrasound (detects retained fragments).
• MRI (if placenta accreta is suspected).

✅ Medical Management:

• Uterotonics (Oxytocin, Misoprostol) to aid placental expulsion.
• Controlled cord traction (Brandt-Andrews maneuver).

✅ Surgical Management:

• Manual Removal of Placenta (MRP) under anesthesia.
• Dilation & Curettage (D&C) for retained products.
• Hysterectomy (if placenta percreta).

✅ Nursing Management:

• Monitor for signs of excessive bleeding.
• Administer uterotonics to prevent atony.
• Support emotional well-being (especially if hysterectomy is performed).

✅ Complications:

• Severe PPH, sepsis, uterine rupture.

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Subinvolution of the Uterus

✅ Definition:
Subinvolution is the delayed return of the uterus to its pre-pregnancy size after childbirth.

✅ Causes & Risk Factors:

• Retained placental fragments.
• Uterine infection (endometritis).
• Uterine atony.
• Grand multiparity (weakened uterine muscles).

✅ Signs & Symptoms:

• Uterus remains enlarged (>10 cm at 2 weeks postpartum).
• Prolonged lochia rubra (heavy, persistent bleeding).
• Soft, boggy uterus on palpation.
• Foul-smelling lochia (if infection is present).

✅ Diagnosis:

• Ultrasound (detects retained fragments, clots).
• CBC (WBC count for infection signs).

✅ Medical Management:

1. Uterotonics (to enhance involution):
   • Oxytocin, Methylergonovine (Methergine).
2. Antibiotics if infection is present.
3. D&C if retained placenta is suspected.

✅ Nursing Management:

• Monitor fundal height and consistency.
• Encourage frequent breastfeeding (stimulates oxytocin).
• Educate mother on normal vs. abnormal lochia changes.

✅ Complications:

• Prolonged bleeding → Anemia, secondary PPH.
• Infection → Endometritis, septicemia.

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Clinical and Competitive Exam Importance

Aspect	Clinical Relevance
PPH Management	Oxytocin is first-line treatment.
Placenta Accreta Risk	High in previous C-section patients.
Subinvolution Complication	Can cause secondary PPH.
Retained Placenta	Needs manual removal if bleeding persists.

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Exam-Oriented Questions

✅ What is the most common cause of PPH?
👉 Uterine atony.

✅ What is the drug of choice for postpartum hemorrhage?
👉 Oxytocin.

✅ How is placenta accreta diagnosed antenatally?
👉 Ultrasound or MRI.

✅ What is the most dangerous form of placenta retention?
👉 Placenta percreta.

✅ Which sign indicates subinvolution of the uterus?
👉 Persistent lochia rubra beyond 2 weeks.

Puerperal Pyrexia

✅ Definition:
Puerperal pyrexia is maternal fever (≥38°C or 100.4°F) occurring within the first 6 weeks postpartum.

✅ Causes & Risk Factors:

• Infections (Endometritis, UTI, Mastitis, Wound Infection).
• Prolonged labour (↑ risk of infection).
• Retained placenta or blood clots.
• Poor hygiene, immunosuppression.

✅ Signs & Symptoms:

• Fever >38°C (100.4°F) for two consecutive days.
• Chills, sweating, malaise, headache.
• Foul-smelling lochia (endometritis sign).

✅ Diagnosis:

• CBC (↑ WBC count indicates infection).
• Blood & urine cultures (for sepsis or UTI).
• Pelvic ultrasound (to check for retained placenta).

✅ Medical Management:

• IV antibiotics (Ampicillin + Gentamicin for endometritis).
• Antipyretics (Paracetamol) for fever.
• Surgical evacuation if retained products.

✅ Nursing Management:

• Monitor temperature, HR, BP, lochia.
• Encourage hydration & proper perineal hygiene.
• Early ambulation to prevent infection.

✅ Complications:

• Progression to puerperal sepsis.
• Uterine rupture or DIC (if untreated).

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Puerperal Sepsis

✅ Definition:
Puerperal sepsis is a life-threatening infection of the genital tract occurring within 42 days postpartum, leading to septicemia or organ failure.

✅ Common Causative Organisms:

• Group A Streptococcus (Streptococcus pyogenes).
• Escherichia coli, Staphylococcus aureus.
• Anaerobes (Bacteroides, Clostridium species).

✅ Causes & Risk Factors:

• Prolonged rupture of membranes (>18 hours).
• Retained placenta, postpartum hemorrhage (PPH).
• Unhygienic delivery, multiple vaginal exams.
• Unsterile episiotomy or C-section wounds.

✅ Signs & Symptoms:

• High fever (≥38.5°C), chills, rigors.
• Tachycardia, tachypnea, low BP (septic shock signs).
• Severe lower abdominal pain, foul-smelling lochia.

✅ Diagnosis:

• Blood cultures (bacteremia confirmation).
• CBC (↑ WBC count, neutrophilia).
• Pelvic ultrasound (to rule out retained placenta).

✅ Medical Management:

• IV broad-spectrum antibiotics (Clindamycin + Gentamicin).
• Fluids & vasopressors for septic shock.
• Surgical removal of retained tissue if needed.

✅ Nursing Management:

• Monitor vital signs, urine output (for sepsis).
• Strict aseptic technique for perineal care.
• Encourage breastfeeding to promote immunity.

✅ Complications:

• Septic shock, DIC, multiple organ failure.

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Inversion of the Uterus

✅ Definition:
Uterine inversion is a rare but life-threatening condition where the uterus turns inside out and protrudes through the cervix.

✅ Types:

• Incomplete: Uterus partially inverted inside cervix.
• Complete: Uterus completely prolapses outside the vagina.
• Prolapsed: Uterus extends outside the introitus.
• Total: Uterus, cervix, and vagina all evert.

✅ Causes & Risk Factors:

• Excessive traction on the umbilical cord.
• Fundal pressure during third-stage management.
• Short umbilical cord.
• Uterine atony, placenta accreta.

✅ Signs & Symptoms:

• Sudden severe lower abdominal pain.
• Mass protruding from vagina.
• Severe postpartum hemorrhage (shock signs).

✅ Diagnosis:

• Clinical examination (soft, absent uterus on palpation).
• Ultrasound confirms inversion if not visible.

✅ Medical Management:

• Immediate uterine replacement (Johnson’s maneuver).
• Tocolytics (Nitroglycerin, Terbutaline) to relax uterus.
• Uterotonics (Oxytocin, Misoprostol) after repositioning.

✅ Surgical Management:

• Huntington’s or Haultain’s operation if manual correction fails.
• Hysterectomy (last resort if irreducible).

✅ Nursing Management:

• Monitor for hypovolemic shock.
• Avoid pulling on the umbilical cord.
• Encourage fluid intake post-reduction.

✅ Complications:

• Severe hemorrhage, uterine rupture, death.

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Perineal Trauma & Perineal Tear

✅ Definition:
Perineal trauma refers to injuries to the perineum during childbirth, either spontaneous (perineal tears) or surgical (episiotomy).

✅ Types of Perineal Tears:

Degree	Structures Involved
First-degree	Skin & vaginal mucosa.
Second-degree	Perineal muscles but NOT anal sphincter.
Third-degree	Anal sphincter involved (but rectal mucosa intact).
Fourth-degree	Full-thickness tear involving rectal mucosa.

✅ Causes & Risk Factors:

• Macrosomia (baby >4 kg).
• Instrumental delivery (forceps, vacuum).
• Prolonged or rapid second stage of labour.

✅ Medical Management:

• Suturing under local anesthesia.
• Antibiotics if infection risk (3rd- & 4th-degree tears).
• Pain relief (NSAIDs, warm sitz baths).

✅ Nursing Management:

• Proper perineal hygiene & sitz baths.
• Pelvic floor exercises (Kegels).
• Monitor for infection, wound dehiscence.

✅ Complications:

• Perineal pain, dyspareunia, fecal incontinence.

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Episiotomy

✅ Definition:
Episiotomy is a surgical incision of the perineum to enlarge the vaginal opening during childbirth.

✅ Types of Episiotomy:

Type	Incision Direction	Advantages & Disadvantages
Midline (Median)	Straight cut from vaginal opening to perineum.	Less pain, easier repair, but higher risk of 4th-degree tear.
Mediolateral	Cut at a 45° angle from vaginal opening.	Lower risk of rectal tear but more pain & difficult healing.

✅ Indications for Episiotomy:

• Fetal distress (to expedite delivery).
• Instrumental delivery (forceps, vacuum).
• Rigid perineum (to prevent spontaneous deep tear).
• Macrosomic baby (>4 kg).

✅ Medical Management:

• Suturing with absorbable stitches (Vicryl).
• Pain relief (ice packs, analgesics).
• Antibiotics if signs of infection.

✅ Nursing Management:

• Perineal care & hygiene.
• Educate on pain relief (sitz bath, cold packs).
• Monitor for signs of infection or hematoma.

✅ Complications:

• Perineal hematoma, wound dehiscence, infection.

Toxemia of Pregnancy (Hypertensive Disorders of Pregnancy)

✅ Definition:
Toxemia of pregnancy refers to hypertensive disorders occurring during pregnancy, including preeclampsia, eclampsia, and HELLP syndrome. These conditions cause multisystem complications and may lead to maternal and fetal morbidity/mortality.

✅ Classification of Hypertensive Disorders in Pregnancy:

Condition	BP Criteria	Additional Features
Gestational Hypertension	≥140/90 mmHg after 20 weeks	No proteinuria, resolves postpartum.
Preeclampsia	≥140/90 mmHg + Proteinuria	Edema, headache, visual disturbances.
Severe Preeclampsia	≥160/110 mmHg	Proteinuria, oliguria, pulmonary edema.
Eclampsia	Preeclampsia + Seizures	Life-threatening, requires emergency management.
HELLP Syndrome	Hemolysis, Elevated Liver enzymes, Low Platelets	Right upper quadrant pain, DIC risk.

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1.1. Preeclampsia

✅ Definition:
Preeclampsia is hypertension (≥140/90 mmHg) after 20 weeks of gestation with proteinuria (>300 mg/24 hrs) and/or organ dysfunction.

✅ Causes & Risk Factors:

• First pregnancy, multiple gestation.
• Chronic hypertension, diabetes, obesity.
• History of preeclampsia in a previous pregnancy.

✅ Signs & Symptoms:

• High BP (≥140/90 mmHg).
• Proteinuria (foamy urine, >300 mg/day).
• Swelling (face, hands, legs – non-dependent edema).
• Severe headache, blurred vision, right upper quadrant pain (liver involvement).

✅ Diagnosis:

• BP monitoring & urine protein tests.
• Serum creatinine & liver enzymes (AST, ALT elevated in HELLP).
• Fetal ultrasound for growth restriction.

✅ Management:

Treatment	Dosage	Purpose
Methyldopa	250–500 mg PO TID	First-line antihypertensive.
Labetalol	20 mg IV bolus	BP control, preferred in emergencies.
Nifedipine	10 mg PO	Acute BP reduction.
Magnesium Sulfate	4-6 g IV over 15 min, then 1-2 g/hr infusion	Prevents eclampsia (seizures).

✅ Nursing Care:

• Monitor BP, urine output, and deep tendon reflexes (for MgSO₄ toxicity).
• Watch for HELLP syndrome (severe epigastric pain, liver damage).
• Prepare for emergency delivery if worsening symptoms.

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1.2. Eclampsia

✅ Definition:
Eclampsia is preeclampsia + seizures, requiring immediate treatment to prevent maternal and fetal death.

✅ Signs & Symptoms:

• Seizures (tonic-clonic convulsions).
• Severe hypertension (>160/110 mmHg).
• Unconsciousness, fetal distress.

✅ Emergency Management:

1. Prevent injury (left lateral position, airway maintenance).
2. Administer Magnesium Sulfate (4-6 g IV bolus, then 1-2 g/hr).
3. Control BP with Labetalol/Hydralazine.
4. Prepare for emergency C-section if fetal distress.

✅ Complications:

• Maternal: Pulmonary edema, DIC, stroke, renal failure.
• Fetal: Growth restriction, prematurity, stillbirth.

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1.3. HELLP Syndrome

✅ Definition:
HELLP Syndrome is a severe form of preeclampsia with:

• Hemolysis (anemia, low RBC count).
• Elevated Liver enzymes (AST, ALT).
• Low Platelets (<100,000).

✅ Signs & Symptoms:

• Right upper quadrant pain (liver involvement).
• Severe nausea, vomiting, jaundice.
• Uncontrolled bleeding (low platelets).

✅ Management:

• Immediate delivery (C-section if maternal instability).
• Blood transfusion (if platelet count <50,000).
• Magnesium sulfate (to prevent seizures).

✅ Nursing Care:

• Monitor liver function tests & coagulation profile.
• Watch for DIC (uncontrolled bleeding).
• Prepare for ICU admission in severe cases.

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2. TORCH Infections

✅ Definition:
TORCH infections are a group of congenital infections that can cross the placenta and cause fetal complications.

✅ TORCH Acronym:

Infection	Causative Agent	Fetal Effects
Toxoplasmosis	Toxoplasma gondii (protozoan)	Hydrocephalus, chorioretinitis, cerebral calcifications.
Other (Syphilis, Varicella, Parvovirus)	Treponema pallidum, Varicella-Zoster virus, Parvovirus B19	Congenital syphilis (saddle nose, Hutchinson’s teeth), hydrops fetalis.
Rubella	Rubella virus	Congenital rubella syndrome (deafness, cataracts, PDA).
Cytomegalovirus (CMV)	Cytomegalovirus (Herpes family)	Microcephaly, sensorineural hearing loss.
Herpes Simplex Virus (HSV)	HSV-1, HSV-2	Neonatal herpes, encephalitis, skin vesicles.

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2.1. Toxoplasmosis

✅ Transmission:

• Eating undercooked meat.
• Exposure to cat feces.

✅ Signs & Symptoms in Newborns:

• Hydrocephalus (excessive cerebrospinal fluid).
• Chorioretinitis (eye inflammation).
• Intracranial calcifications.

✅ Management:

• Spiramycin (for maternal infection).
• Pyrimethamine + Sulfadiazine + Folinic acid (for fetal infection).

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2.2. Rubella

✅ Transmission:

• Respiratory droplets (crosses placenta in 1st trimester).

✅ Signs & Symptoms (Congenital Rubella Syndrome):

• Deafness, cataracts, heart defects (PDA).

✅ Prevention:

• MMR vaccine (before pregnancy, not during pregnancy).

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2.3. Cytomegalovirus (CMV)

✅ Transmission:

• Body fluids (urine, saliva, breast milk, blood).

✅ Signs & Symptoms in Newborns:

• Microcephaly, hepatosplenomegaly, hearing loss.

✅ Management:

• Ganciclovir (for severe cases).

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2.4. Syphilis

✅ Transmission:

• Transplacental spread from an infected mother.

✅ Signs & Symptoms (Congenital Syphilis):

• Early signs: Rash, nasal discharge (snuffles), hepatosplenomegaly.
• Late signs: Hutchinson’s teeth, saddle nose, deafness.

✅ Management:

• Penicillin G (IM injection).

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2.5. Herpes Simplex Virus (HSV)

✅ Transmission:

• Direct contact with genital lesions (during vaginal birth).

✅ Signs & Symptoms in Newborns:

• Skin vesicles, encephalitis, organ failure.

✅ Management:

• Acyclovir (IV) for neonatal herpes.
• C-section if active genital lesions present.