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SIGNS AND SYMPTOMS + DDs OF PREGNA Symptoms: Amenorrhea, nausea and vomiting, breast tenderness and tingling, urinary frequtenncoytedanadt about urgency "quickening" (perception of first movement 18th week), weight gain. Signs (in Weeks from Last Menstrual Period): Breast changes (enlargement, vascular engorgement, colostrum) start to occur very early in pregnancy and continue until the postpartum period. Cyanosis of the vagina and cervical portion and softening of the cervix occur in about the 7th week. Softening of the cervico-uterine junction takes place in the 8th week, and generalized enlargement and diffuse softening of the corpus occurs after the 8th week. When a woman's abdomen will start to enlarge depends on her body habitus but typically starts in the 16th week. The uterine fundus is palpable above the pubic symphysis by 12-15 weeks from the last menstrual period and reaches the umbilicus by 20-22 weeks. Fetal heart tones can be heard by Doppler at 10-12 weeks of gestation. Differential Diagnosis: The non-pregnant uterus enlarged by myomas can be confused with the gravid uterus, but it is usually very firm and irregular. An ovarian tumor may be found midline, displacing the non-pregnant uterus to the side or posteriorly. Ultrasonography and a pregnancy test will provide accurate diagnosis in these circumstances. AIMS OF ANTENATAL CONSULTATIONS ••• • Screening for and management of pathologies: hypertension, anaemia, TORCH infections particularly Rubella, malaria, syphilis, urinary tract infection, HIV infection, malnutrition, vitamin and micronutrient deficiencies, etc. ❖ Screening for and management of obstetric complications: uterine scar, abnormal presentation, premature rupture of membranes, multiple pregnancy, metrorrhagia, etc. Routine prevention of maternal and neonatal tetanus, anaemia, mother-to-child HIV transmission, malaria (in endemic areas), etc. Devising a birth plan; counselling; preparation for the birth. • Pregnant women vaccinated against tetanus in childhood or • adolescence should receive at least 2 doses of tetanus vaccine (TT) before giving birth: • The first dose should be administered at 27 weeks of pregnancy. The second dose should be administered at least 4 weeks after the first dose and ideally at least 2 weeks before the due date to maximize the maternal antibody response and passive antibody transfer to the infant. Third dose is given at least 6 months after TT2 or during the next pregnancy. Fourth dose is given after 1 year after TT3 or during another pregnancy. Fifth dose is given 1 year after TT4 or during another pregnancy. Once administered, these 5 doses confer lifelong protection. EONATAL TETANUS TYPHOID FEVER IN PREGNANCY Typhoid fever can cause major complications both for the mother (gastrointestinal perforation, peritonitis, and septicemia) and the fetus (spontaneous abortion, preterm birth, intrauterine death). •• Admit to inpatient department. •• In the absence of drug resistance, go for Cap-amoxil Ospamox (amoxicillin) 1gm, 1 cap/tab PO x TDS for 14 days •• In cases of drug resistance or severe infection, go for • ••• Inj- Rocephin / Oxidil (ceftriaxone) 2-4 gm IV x OD for 10 to lz days. Supportive care for other complaints. Fever persists 4 to 5 days after starting treatment, even wher treatment is effective. It is essential to treat the fever and t( monitor for maternal and foetal complications. VOMITING OF PREGNANCY & HYPEREMESIS GRAVIDARUM Hyperemesis gravidarum: •.• Persistent, severe vomiting. •.11 Weight loss, dehydration, hypokalemia. May have transient elevation of liver enzymes. Appears related to high or rising serum HCG. ❖ • More common with multi-fetal pregnancies hydatidiform mole. Management: A. Mild Nausea and Vomiting of Pregnancy In most instances, only reassurance and dietary advice are required. Ask the patient to take care of diet i.e. Eat small frequent meals, eat when hungry, avoid fatty and spicy foods and emetogenic foods and smell, eliminate pills with iron, increase consumption of carbonated drinks, use herbal teas like peppermint and ginger and frozen desserts. Because of possible teratogenicity, drugs used during the first half of pregnancy should be restricted to those of major importance to life and health. Tab- Femiroz/ Pregnova (doxylamine + pyridoxine) 10/10mg, 2 tab PO x OD at bed time "OR" * Tab- Navidoxine (meclizine + pyridoxine) 25/50mg, 1 tab PO x OD at night bed time. • Antiemetics, antihistamines, and antispasmodics are generally unnecessary to treat nausea of pregnancy. B. Hyperemesis Gravidarum • With more severe nausea and vomiting, it may become necessary to hospitalize the patient. In this case, a private room with limited activity is preferred. * It is recommended to give nothing by mouth until the patient is improving, and maintain hydration and electrolyte balance by giving appropriate parenteral fluids and vitamin supplements as indicated. • lnj / Syp- Phenergan (promethazine) 25mg orally, rectally, or IV x QID "OR" • Inj/ Tab- Maxolon / Metomide (metoclopramide) 5-10 mg orally or IV x QID "OR" • inj / Tab- Onset (ondansetron) 4-8 mg orally or IV x TDS. • As soon as possible, the patient should be placed on a dry diet consisting of six small feedings daily. • Antiemetics may be continued orally as needed. * After in-patient stabilization, the patient can be maintainer at home even if she requires intravenous fluids in addition tl her oral intake. When to Refer • Patient does not respond to first-line outpatient management. • There is concern for other Pathology (i.e. hydatidiform mole).