ENDOCRINE DISORDERS

IN PREGNANCY
• Hipertiroidism/ tirotoksikosis
Etiology :
- Graves desease
- Multinodular
- Tiroiditis
Epidemiology :
1,5 %
• Pathofisiology
B lymphocyte  TSH-R antibody  thyroid gland receptor  Thyroid cell
s proliferation
• Risk factor
Genetic, imun, hyperemesis gravidarum
• Diagnosis
Tachycardia, pulse ↑, tiromegali , exophtalmus,doesn’t increase weight

Tioamida, iodide, thyroidectomy

• Gestational diabetes
Etiology
- Destruction of beta pancreatic cells related to immune response
- Insulin resistant
- Genetic mutation in pancreatic beta cells function
- Pancreatic desease
Epidemiology
World : 15%
• Pathophysiology
Estrogen, progesterone, cortisol, HPL  insulin resistant effect

• Diagnosis
Urination frequency ↑., thirsty, hungry, weight ↓, blurred vision.

• Nutrition therapy, exercise, weight management, drugs therapy : i

nsulin, metformin, sulfonylurea
KELAINAN DALAM
LAMANYA USIA
KEHAMILAN
(PRETERM & POSTTERM) 4
◦ Length of Pregnancy is divided into several, among others:
◦ 1) Premature is a pregnancy that is less than 37 weeks old. Babies born in late pregnancy are
accompanied by LBW (low birth weight).
◦ 2) Post matur is a long-term pregnancy of more than 42 weeks. This pregnancy is usually an
abnormal pregnancy.
1. Premature Understanding
◦ Premature labor that lasts at 20-37 weeks' gestation
◦ Risk factors: More than half of pregnant women who give birth
prematurely are known to have no risk factors for preterm labor.
◦ a. Demographic factors
◦ b. Public health
◦ c. Work
◦ d. The condition of the uterus
◦ e. Obstetric factors
2. ETIOLOGY
◦ a. Maternal Factors
◦ Toksenia, hypertension, malnutrition / chronic diseases, such as
premature birth diabetes mellitus is associated with conditions in
which the uterus is unable to withstand the fetus, for example at
premature separation, placental release and infarction of the
placenta
◦ b. Fetal Factor
◦ Chromosomal abnormalities (eg anthosomal trisomes), multiple
fetuses, radiation injuries
3. SIGNS AND SYMPTOMS
◦ signs of preterm delivery, ie
◦ a. Cramps like when it comes to the moon or pain in the back.
◦ b. Abdominal cramps, with or without diarrhea.
◦ c. Regular uterine contractions are ten minutes or less apart and
this contraction does not have to hurt.
◦ d. Feeling depressed in the lower abdomen, feels heavy or like a
baby pushing down.
◦ e. out of water or other fluids from the vagina.
HANDLING PREMATURE LABOR
◦ The principle of handling premature labor is: ah:
◦ a. Try to stop the contractions of the uterus / birth delay
◦ b. Labor continues and prepare for further treatment.
◦ c. Efforts to stop uterine contractions may be drugs or tocolytic only briefly,
but it is important to administer corticosteroids, this intervention aims to
delay birth until the baby is mature enough to be born (37 weeks)
Delay in pregnancy if:
◦ a. 37 weeks pregnancy
◦ b. The opening of the cervix is less than 3 cm
◦ c. There is no active amnionitis, pre-eclampsia or bleeding.
◦ d. There is no fetal distress.
POSTMATUR
1. Understanding
◦ Mature post pregnancy is a pregnancy lasting longer than 42
weeks, calculated on the basis of the naegle formula, with an
average menstrual cycle of 28 days. In addition there is also a
calculated 42 weeks of HPHT and some are also calculated 42
weeks. PARTUS is called the postmaturus or serotonus partus
and the baby is called postmaturity or serotonin.
2. Etiology
◦ The etiology is definitely not known. But there is a cause factor is
a hormonal factor, iS progesterone levels do not fall quickly even
though the pregnancy has been enough months, so the uterine
sensitivity to oxytocin is reduced. Another factor is the hereditary
factor, because postmaturity is often encountered in a particular
family.
Signs of a postmature baby:
◦ a) Usually heavier than a mature baby
◦ b) Bone and sutura head harder than the baby matur
◦ c) Hair lanugo lost or very less
◦ d) Vernix caseosa in the body less
◦ e) Long nails
◦ f) Hair head rather thick
Influence on mother and fetus
◦ Against the mother
◦ Postmatur delivery may cause dystocia because
◦ a) Uncoordinated uterine action
◦ b) Large fetus
◦ c) Head molasses are less
◦ d) So often found old partus, misplaced, uterine inertia, shoulder dystocia,
and postpartum hemorrhage. This will increase morbidity and mortality
rates.
◦ To the fetus
◦ The number of fetal or infant deaths in 42 weeks 'pregnancies is 3 times
greater than 40 weeks' gestation, because postmaturity will add harm to the
fetus. The effect of postmaturity on the fetus varies
Management
◦ a) After the pregnancy age of more than 40-42 weeks is
important is the fetal monitoring as well as possible.
◦ b) In the absence of signs of placental insufficiency, spontaneous
labor can be awaited with strict supervision.
◦ c) Collaborate with an obstetrician or referral physician.
 BLOOD
INCOMPATIBILITY IN
PREGNANCY
Defenition :
When a woman and her unborn baby carry different Rhesus (Rh) protein factors, their condition is called Rh
incompatibility. It occurs when a woman is Rh-negative and her baby is Rh-positive. The Rh factor is a specific
protein found on the surface of your red blood cells.

Ina < 1 %

Afrika5 %
Kaukasia15 %
◦ Antigenically foreign fetal RBCs enter the maternal circulation
◦ IgG antibodies are formed
◦ Cross back across the placenta
◦ Sensitise fetal RBCs to haemolysis
◦ Causes fetal anaemia
◦ Increases bilirubin in amniotic fluid
◦ And can cause fetal hydrops
◦ Which is high output cardiac failure
Other causes of RBC isoimmunisation:
◦ Incompatible blood transfusion

◦ Sensitisation of Rh Neg baby at birth from an Rh positive mother

Patofisiology
Treatment of Blood Group Incompatibilities
◦ Neonatal phototherapy
◦ Neonatal exchange transfusion
◦ Pre term delivery (after steroids)
◦ Intrauterine transfusion
◦ To umbilical or hepatic veins
◦ To the peritoneal cavity
◦ Maternal immune suppression
 OBSTETRICAL
SURGERY
an procedure to help / overcome the problems that occurs during the delivery process.
Episiotomy
◦ Definition
A surgically planned incision on the perineum and the
posterior vaginal wall during the second stage of
labour.
◦ Purpose
◦ To enlarge the vaginal introitus
◦ To facilitate easy & safe delivery
◦ To minimize rupture of the perineal muscles & facia.
◦ To reduce stress on fetal head.
Cunam Extraction
◦ Definition
an act of help childbirth in which a fetus were born with a pull with cunam / forceps mounted on his head.
◦ Indication:
◦ Mom : Eclampsia/pre-eclampsia, asthma, rupture uteri, etc
◦ Baby : fetal distress
◦ Contra indication
◦ Premature
◦ Cephalopelvic dislocation
◦ Requirements
◦ Aterm
◦ The baby can be delivered normally
◦ Cervix fully opened
◦ Engaged fetal head
◦ The water had broke
◦ Complications:
◦ Mom : bleeding, ripping the birth canal, a fistula,
fracture the bones of the pelvis, infection
◦ Baby : forceps bruise on the head, the bones of the
skull fracture, bleeding intracranial, from nervous facial,
asphyxia / suffocated, until the death of the fetus
◦ Procedures:
◦ Preliminary application mode.
◦ Inserting the left blade using the left hand, into the mother’s left sacral cavity, to grab the left parietal bone of the child (Quartet
rule of Dennen).
◦ Inserting the right blade using the right hand, into the mother’s right sacral cavity, to grab the right parietal bone of the child
(Quartet rule of Dennen).
◦ Closing and locking the forceps blades.
◦ Digital checking for correct positioning, followed by a first trial traction. Correct positioning if necessary.
◦ Holding the forceps in position for definitive traction.
◦ Biparietal position of the forceps on the child’s head.
◦ After preliminary episiotomy, and with good contractions, the forceps are pulled steeply down until the neck hairline appears,
then slowly upwards to complete delivery of the head (see arrows). The child is delivered manually afterwards.
Vacuum Extraction
◦ Definition ◦ Contraindication
◦ An act of help childbirth in which a fetus born with ◦ Cephalopelvic disproportion
extraction use negative pressure with a vacuum ◦ ruptura uteri
(negative-pressure vacuum an extractor) installed in
his head. ◦ the mother may not straining due to heart disease,
preeclampsia, asthma, etc.
◦ Indication
◦ Requirements
◦ The need to help accelerate stage two of childbirth,
because if late it could jeopardize the state of ◦ Aterm
mother and / or fetus. ◦ The baby can be delivered normally
◦ Cervix fully opened
◦ Engaged fetal head
◦ The water had broke
◦ Mom has to strain
◦ Delivery with vacuum extraction :
◦ after the cup is attached to the baby’s vertex (or hip /
buttock in breech presentation), the negative pressure is
increased, then the extractor is pulled according to the
rhythm of the mother’s contractions.
◦ Prior episiotomy might be required.
◦ The direction of traction, as in normal vaginal or
forceps delivery, is first slightly downward, then
forward and then slowly upward, following the
curvature of the pelvis.
◦ When one hand is pulling, the other hand should help
to suspend the mother’s perineal region to prevent
further perineal rupture.
Sectio Caesarea
◦ Definition
◦ An act of help childbirth in which a fetus was born through a
incision is on the wall the stomach and the lining of the uterus.
◦ Requirements
◦ The uterus intact so in sectio cesarea, the uterus will be incised)
◦ Weight of the fetus is over 500 grams.
◦ Indication
◦ the state of being precluded a fetus was born per
vaginam, and / or a state of emergency that
requires terminations pregnancy / childbirth
immediately, that is waiting for progress childbirth
per vaginam physiologically.
◦ Mother: pelvic narrow absolute, tumors n the birth
canal that may cause obstruction, stenosis of
cervical / the vagina, placenta previa, disproportion
cephalopelvic, ruptura uteri.
◦ fetus: abnormality position, prolapse umbilical cord,
fetal distress.
◦ Generally sectio cesarea was not done at the state of
a dead fetus, mother shock / severe anemia who
have not handled, or on the fetus withmajor
congenital abnormality.
◦ General procedures
◦ vertical midline incision of the skin between the umbilicus and
the pubic symphisis, followed with layer-by-layer separation of
the subcutaneous fat, muscle, fascia and peritoneum of the
abdominal wall.
◦ After the gravid uterus is exposed, the peritoneal sheet between
the anterior wall of the uterus and the upper / posterior wall of
the urinary bladder is identified and cut, and then separated.
The lower midline region of the anterior uterine wall is then cut
with a small sharp incision.
◦ Through the small incision, the uterine wall is divided further
laterally using the operator’s fingers. The amniotic membrane is
then cut to gain access to the uterine cavity.
◦ Delivery of the baby and the placenta.
◦ Closing repair of the uterine wall, using double / two-layer
sutures recommended. The bleeding in the uterine cavity must
be controlled first before these repairs.
◦ Closing repair of the peritoneum, followed with layer-by-layer
closure of the abdominal wall.
◦ Complication
◦ mother: infection, postpartum bleeding.
◦ fetus: depression the arrangement of the CNS of a
fetus caused by defendants use of anesthesia ( fetal
narcosis ) .
 DYSTOCIA

Second part: abnormalities of birth

canal
 Pelvic contraction
• Birth canal
– bony canal
– soft canal
• abnormal bony canal: pelvic contraction
– any contraction of the pelvic diameters that dimini
shes the capacity of the pelvis can creat dystocia d
uring labor
 Classification
I. Contraction of the pelvic inlet
II. contraction of the midpelvis and pelvic outle
t
III. general contraction of the pelvis
IV. pelvic deformities
 I. Contracted pelvic inlet
• Anteroposterior d<10cm
• diagonal conjugate d<11.5cm
• external conjugate d<18cm
– simple flat pelvis
– rickets flat pelvis
II. contraction of the midpelvis and pelvic
outlet
contraction of the midpelvis
– Midpelvis: from inferior margin of the symphysis p
ubis through the ischial spines,touches the sacrum
near the junction of the 4th and 5th vertebrae
– contraction: interischial spinous diameter is smalle
r than 8cm(spines are prominent, the pelvic side
walls converge or the sacrosciatic notch is narrow)
 Contracted pelvic outlet
Contracted pelvic outlet
– Defination: diminition of the interischial tuberous
diameter to 8cm or less.
– 2 triangles:
• baseof both: interischial tuberous diameter
• anterior triangle
• posterior triangle
III. General contraction of the pelvi
s
•2cm or more shorter than normal

IV. Pelvic deformities

•osteomalacic pelvis
•obliquely contracted pelvis
 Effects on mather and fetus
• MOTHER:Inlet
– Malpresentation and malposition
– prolonged labor
– insufficient uterine contraction
• midpelvis and outlet
– persistant occipitotransverse or occipitoposterior p
osition
– fistula formation
– intrapartum infection
– threatening rupture or rupture
 fetus
• PROM
• Prolapse
• Distress (HI,IVH)
• Death
• Injury
• Infecion
 Soft birth canal
• Lower segment of uterus
• cervix
• vaginal
 Fetal malposition
• Occipitoanterior position 90%
• malposition 10%
• abnormal cephalic posion 6-7%
• breech presentation 3-4%
• others
Persistant occipitoposterior (transverse) po
sition
• Causes
– abnormal pelvis:transverse narrowing of the midp
elvis
– flexion not well
– hypotonic uterine dysfunction
 Breech presentation
• Incidence
– breech presentation is common remote from term.
– 3-4% of singleton deliveries
• Position
– LSA, LST LSP. RSA, RST, RAP
 Causes
• Uterine relaxation
• limited uterine cavity
• fetal head obstructed
 classification
• Frank breech p
– the lower extremities are flexed at the hips and extende
d at the knees, and thus the feet lie in close proximity to
the head.
– It appears most commonly
• complete breech p
– differs in that one or both knees are flexed.
• Incomplete breech p
– one or both hips are not flexed and one or both feet or k
nees lie below the breech, that is, a foot or knee is lower
most in the birth canal.
Incomplete breech presentation
 Effects
• Maternal
– greater frequency of operative delivery
– higher maternal morbidity and slightly higher mor
tality
– PROM
– secondary hypotonic uterine dysfunction
– puerperium infection
– postpartum haemorrhage
– laceration of cervix
 Effects
• Fetus
– PROM
– cord prolapse
– fetal distress even death
– newborn asphyxia
– brachial plexus injury
– IVH
Face presentation
Compound presentation
 HIGH-RISK
PREGNANCY THAT
MUST BE REFERRED
◦ Chorionamniotic

is an inflamationof the fetal membranes (amnion and chorion) due to a bacterial infection. It
typically results from bacteria ascending from the vagina into the uterus and is most often
associated with prolonged labor.
◦ Solutio Plasenta

Abruptio placentae is defined as the premature separation of the placenta from

the uterus.
◦ Plasenta Previa

condition in which the placenta is implanted near the outlet of the

uterus, so that at the time of delivery the placenta precedes the
baby