Monday, April 27, 2009



The lists adverse drugs consist of: Name of drugs; Trimester adverse [T1 is first trimester, T2 is second, T3 is third, T-all is all trimester] respectively; Effect [E];and Indications [I].

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ACE [Angiotensin-converting enzyme]inhibitor; T-all especially second and third; E: Renal damage; I: Essential hypertension.
Aminopterin; T1; E: Multiple gross anomalies .
Amphetamines: T-all; E: Suspected abnormal developmental patterns, decreased school performance I: Narcolepsy.
Androgens; T2, T3; E: Masculinization of female fetus; I: Osteoporosis, aging.
Anti depressants, tricyclic; T3; E: Neonatal withdrawal symptoms have been reported in a few cases with clomipramine, desipramine, and imipramine; I: Antihistamine,antidepressant.
Barbiturate; T-all; E: Chronic use can lead to neonatal dependence; I: Sedation, anti-convulsants.
Busulfan; T-all; E: Various congenital malformations, low birth weight; I: Chronic myelogenous leukemia.
Carbamazepine; T1; E: Neural tube defects; I: Partial and tonic-clonic seizures, mania
Chlorpropamide; T-all; E: Prolonged symptomatic neonatal hypoglycemia; I: Diabetes mellitus.
Clomipramine; T3; E: Neonatal lethargy, hypotonia, cyanosis, hypothermia; I: Antidepressants.
Cyclophosphamide; T1; E: Various congenital malformation; I: Rheumatoid arthritis.
Cytarabine; T1, T2; E: Various congenital malformation; I: Acute myelogenous leukemia.
Diazepam; T-all; E: Chronic use may lead to neonatal dependence; I: Sedations, spasmolytics.
Diethylstilbestrol; T-all; E: Vaginal adenosis, clear cell vaginal adeno-carcinoma; I: Postcoital contraceptives.
Etretinate; T-all; E: High risk of multiple congenital malformation; I: Vitamin A analogs.
Iodide; T-all; E: Congenital goiter, hypothyroidism; I: Antithyroid agents.
Isotretinoin; T-all: E: Extremely high risk of CNS [central nervous system], face ear, and other malformations; I: Severe cystic acne.
Lithium; T1; E: Ebstein’s anomaly or cardiac anomaly; I: Anti manic-depressive.
Methotrexate: T1: E: Multiple congenital malformations; I: Rheumatoid artrhitis.
Methylthiouracil: T-all: E: Hypothyroidism; I: Cancer chemotherapy.
Metronidazole; T1: May be mutagenic [from animal studies; there is no evidence for mutagenic or teratogenic effects in humans]; I: Amebiasis, trichomoniasis.
Misoprostol; T1; E: Mobius sequence, cramping abdominal pain, and stimulate uterine contraction may induce abortion; I: Peptic ulcer.
Penicillamine: T1; E: Cutis laxa [loose skin], other congenital malformations; I: Severe rheumatoid arthritis.
Phencyclidine: T-all; E: Abnormal neurologic examination, poor suck reflex and feeding; I: General anasthetics.
Phenytoin; T-all; E: Fetal hydantoin syndrome, congenital malformations, spina bifida [spinal column malformation]; I: Partial and generalized tonic-clonic seizures.
Propylthiouracil; T-all; E: Congenital goiter; I: Thyrotoxicosis.
Sterptomycin; T-all; E: Eighth nerve toxicity, deafness; I: Tuberculosis.
Tamoxifen; T-all; E: Increased risk of spontaneous abortion or fetal damage; I: Breast cancer, chemo-prevention breast cancer.
Tetracycline; T-all; E: Discoloration and defects of teeth and altered bone growth; I: Broadspectrum bacteriostatic and antibiotics.
Thalidomide; T1: E: Phocomelia [shortened or absent long bones of the limbs] and many internal malformations ; I: Multiple myeloma, lupus erythematosus.
Trimethadione; T-all; E: Multiple congenital anomalies; I: Anti seizure, sedation.
Valproic acid; T-all; E: Neural tube defects, cardiac and limb malformations; I: Against absence [prevention] seizures, migraine.
Warfarin; T1; E: hypoplastic nasal bridge, chondrodysplasia; T2, E: CNS malformations; T3, E: Risk of bleeding. Discontinue use one month before delivery; I: Anticoagulants.

Source: Bertram G. Katzung, MD, PhD. Basic and Clinical Pharmacology, McGraw-Hill,California, 2007, p 975-76.

Note: The writer adds Indication [I] to the list of the source for "warning" the physicians and the patients ; for treatment of patients as indicated the above list of drugs are contra-indicated for pregnant women, particularly in trimester concern. Please be careful.

Good luck,have a nice treatments of diseases have been indicated!!!

Sunday, April 26, 2009



The role of medical pharmacology, which is often defined as science of substances used to prevent, diagnose, and treat disease. Toxicology is the branch of pharmacology which deals with the undesirable effects of chemicals on living systems, from individual cells to complex ecosystems.

Drug therapy in pregnancy, most of drugs transfer from the maternal to the fetal circulation may be influenced by maternal, placental and fetal factors. Many therapeutics drugs given during pregnancy, therefore, are “potentially” teratogenic or fetotoxic.
Defining a teratogen: To be considered teratogenic, a candidate substance or process should:
1. Result in a characteristic set of malformations, indicating selectivity for certain target organs.
2. Exert its effects at a particular stage of fetal development, during a limited time period of organogenesis of the target organs;
3. Show a dose dependent incidence. Some drugs with known teratogenic or other adverse effects in pregnancy are listed.

The widely cited Food and Drug Administration system for teratogenic potential is an attempt to quantify teratogenic risk from A [safe] to X [definite human teratogenic risk]. The teratogenic drug actions, for example, Thalidomide is an example of a drug that may profoundly affect the development of the limbs after only brief exposure. This exposure, however, must be at a critical time in the dependent of the limbs. The thalidomide risk occurs during the fourth through the seventh weeks of gestation because it is during this time that arms and legs develop.
The fetotoxic drugs are a general name of undiserable effects on fetus during pregnancy.

Counceling women about teratogenic risk:
Since thalidomide disaster, medicine has been practiced as if every drug were a potential human teratogen when, in fact, fewer than 30 such drugs have been identified, with hundreds of agents proved safe for the unborn. Owing to high levels of anxiety among pregnant women, every year many thousands of women need counseling about fetal exposure to drugs, chemical and radiation. Clinicians who wish to provide such counsel to pregnant women must ensure that their information is up to date evidence-based and that the woman understands that the baseline teratogenic risk in pregnancy [the risk of a neonatal abnormality in the absence of any known teratogenic exposure] is about 3 %.

Thursday, April 23, 2009



What is labor?

Picture: Cardinal movements of labor: A.Engagement; B.flexion;C.descent and internal rotation; D. and E. extension; F. external rotation
Source: F.John Bourgeois et al. Obstetrics and Gynecology Recall, Philadelphia, 2008, p 62

Labor is the process by which the products of conception are normally delivered. Regular uterine contraction that cause progressive effacement and dilatation of the cervix and lead to expulsion of the fetus and placenta from the uterus.
What is effacement?
Effacement is shortening of the cervix and thinning the cervical wall caused by the pressure of the fetus’s head as it descend into the birth canal during labor.
What are the stages of normal labor?
1.The first stage is the period from the onset of labor contraction to full dilatation of the cervix; this stage ends with complete [10 cm] dilatation of the cervix. This stage is by far the longest. The average duration of the first stage is about 15 hours for the primigravidas and about 8 hours for the multiparas. However the first stage of labor may be less than one hour or more than 24 hours.
What conditions may slow progress in the active phase of labor?
Uterine dysfunction, fetal mal-position, cephalo-pelvic disproportion [CPD]
2.The second stage is the period from the full dilatation of cervix to the delivery of the fetus.. The second stage duration of primigravidas is about 30 minutes to 2 hours; multiparas varies from a few minutes to 45 minutes [average].
Spontaneous delivery of the fetus presenting by the vertex is divided into 3 phase:
· Delivery of the head;
· Delivery of the shoulders;
· Delivery of the body and legs.
What are the mechanisms or cardinal movement of labor ?
Engagement: Generally occurs in late pregnancy or onset of labor.
Flexion of fetal neck toward chest, good flexion is noted in majority of cases.
Descent is usually slowly progressive, depends on pelvic architecture relationships.
Internal rotation takes place during descent. Vertex usually rotates to the transverse. It next rotate to the anterior or posterior to pass the ischial spines, whereupon, when vertex reaches the perineum, rotation from a posterior position usually follows.
Extension: Follows distention of perineum by vertex. Head concomitantly stems beneath the symphysis [pubic arch]. Extension is complete with delivery of the head.
External rotation or restitution: Following delivery, head normally rotates to the position it originally occupied at engagement. Next the shoulders descend [in a path similar to that traced by the head]. They rotate anterior-posteriorly for delivery. Then the body and the legs of the baby is delivery next.
3.The third stage of labor
or placental stage is the period from the birth of the infant to
the delivery of the placenta, including recovery of the placenta and the hour
How long does the third stage of labor last? It is about 30 minutes.
What are the stages of placental delivery? Separation of the placenta from the uterine
wall. Expulsion from the vagina.
Why is the placenta examined after delivery? To ascertain its complete removal from the uterine cavity
How is uterine hemostasis achieved after delivery of the placenta? Vasoconstriction by myometria contraction.
How can uterine contractions after delivery of the placenta be stimulated? Agents such as Oxytocin [generic, Pitocin]10 units/ml for IM injection and uterine massage.
What type of lacerations may require repair?
· First-degree laceration involves the vaginal mucosa or perineal skin.
· Second-degree laceration extends into the sub-mucosal tissue of the vagina or perineum with or without involvement of the muscles of the perineal body.
· Third-degree laceration involves the anal sphincter.
· Fourth-degree laceration involves the rectal mucosa.



Picture: Fetal circulation: The upper end of the inferior vena cava opens directly into the left atrium through the oval foramen [see inset] aswell as into the right right atrium; left atrium; right ventricle; left ventricle; ductus arteriosus; ductus venosus; foramen ovale [oval foramen];S.V.C. is superior vena cava;I.V.C. is inferior vena cava.

There are 3 stages of fetal nutrition:
1. Absorption. Minimal quantities of tube and uterine fluid are taken in by the fertilized ovum during the 3-4 days prior to nidation [implantation].

Picture: Diagramatic section of a portion of the placenta.

Source: George H.Bell et al.Physiology and Biochemistry.London,1956, p 984-985.

2. Histotrophic transfer. Strategic and waste materials are passed between the early embryo and decidua for 3 months before the establishment of an effective fetal circulation
3. Hematotrophic transfer. Anabolic and catabolic products traverse the placental barrier between the fetal and maternal circulations by both active and passive processes. If the mother does not receive sufficient food, the fetus draws on the maternal tissues. The birth weight of the infant is not, therefore, governed by the mother’s diet unless is severe under-nutrition.
Hematopoiesis: [the forming and development of blood cells] begins in the liver, spleen, and mesonephros about the second month, although clumps of blood cells may be seen in the yolk sac during the first 1-2 months of fetal life. Fetal blood is slightly more saturated with oxygen than maternal blood.


Environmental changes occurring in the abrupt transition from intrauterine life to an independent existence necessitate certain circulatory adaptations in the newborn. These include diversion of blood flow through the lungs, closure of the arterial duct [ductus arteriosus] and oval foramen [foramen ovale] , and obliteration of the vein duct [ductus venosus] and umbilical vessels.
Infant circulation has 3 phases
The pre-delivery phase, in which the fetus depends upon the placenta;
The intermediate phase , which begins immediately after delivery with the
infant‘s first breath;
The adult phase, which is normally completed during the first few months of life.The ductus arteriosus usually is obliterated in the early postnatal period.Obliteration of the oval foramen is usually complete in 6-8 weeks, with fusion of its valve to the left inter-atrial septum. The foramen may remain patent in some individuals, however, with few or no symptoms.The obliterated ductus venosus from the liver to the vena cava becomes the ligamentum venosum.The occluded umblical vein becomes the ligamentum teres of the liver

Wednesday, April 22, 2009



Picture: Diagrammatic section of a portion of the placenta.
The villi are looked like tree with branches, the intervillous space are filled with mother's blood, red and blue in color.

Placental production of hormones necessary for the continuation of pregnancy.
Human chorionic gonadotropin [HCG] is produced from the first week after implantation, and is secreted into the mother circulation [but not the fetal circulation].The HCG aids in the maintenance of the corpus luteum of pregnancy and is the basis for the Aschheim-Zondek and Friedman pregnancy tests.

Estrogens are bound to serum albumin in the maternal circulation and there for metabolized slowly.
Progesteron on the other hand, is unbound and is metabolized rapidly.
Corticoids are held in relatively inactive form by a plasma protein.Thus, although the titer of hydroxyl-corticosteroids is high during pregnancy.

Placental transfer across the placental barrier by different processes:
Diffusion: Substances required for the growth of fetal life and the elimination of its waste products are handled largely by diffusion across the placental barrier. Included in these group are oxygen, water, electrolytes, water soluble vitamin [B-Complex and C] traverse the plasma easily, Vitamin A, D, E and K also pass the placenta, CO2 [carbon dioxyde] and urea. Substances of low molecular weight [less than 1000]diffuse across the placenta with ease. Large molecules [with molecular weight more than 1000] such as blood proteins will not pass the placental by diffusion.
Selective transfer: Enzymatic processes, often involving slight energy exchange, supply many fetal nutritional needs. Glucose, amino acids, calcium, phosphorus, iron cross the placenta by this means. Essential amino acids are transferred more rapidly than polypeptides.
Pinocytosis: The particles are carried across the cell virtually intact to be released on the other side, whereupon they promptly gain access to the fetal circulation. Complex proteins, small amounts of fat, and perhaps immune bodies may traverse the placenta in this way.
Leakage through defects: Trophoblastic endothelial junctions may “leak” small amounts of plasma and blood cells. Maternal and fetal blood may mix as a result of the defects.

FETAL NUTRITION [next topic]



What organs and functions to ensure delivery of a healthy infant?

Placenta has the functions to produce the hormone for control of pregnancy, transfer of food materials and waste products, transfer of blood and oxygen for the survival of fetus, between mother and fetus.
The umbilical cord with umbilical artery and vein which connect the placenta and fetal circulation

Picture: Relationships of stuctures in the uterus at the end the 7th week of pregnancy.On the top of the picture is decidua basalis which is the site of future development of placenta, in the center is the embryo.

Following fertilization, the ovum develops into the embryonic blastocyst. About 3-4 days are required for the blastocyst to reach the uterus. Normally, the blastocyst implants on the 5th or 6th day after entry into the uterus, most commonly in the decidua lining the anterior or posterior wall of the fundus. The site of implantation immediately heals over.

Three decidual areas may be recognized::
Decidua capsularis [reflexa], or that portion of the uterine mucosa immediately overlying the embryo;
Decidua basalis, beneath the embryo;
Decidua parietalis, the remainder of the uterine lining.
The decidua capsularis disappears as the embryo increases in size to fill the uterine cavity. The decidua basalis is the site of future development of the placenta. The vascularized tufts are now referred to as villi. In the decidua basalis under the developing embryo there is stage a great dilatation of the maternal blood vessels, the chorionic villi, grow into them by erosion of the decidua. This penetration of the villi aided by obliteration of small arteries of the decidua causing necrosis and the formation of a large spaces in the decidua which fill with maternal blood. As the villi are soon invaded by mesoderm carrying fetal blood vessels the fetal and maternal circulations are brought very close to one another and in this way the placenta is formed.
The mature placenta is a blue-red, rounded, flattened, meaty organ about 15-20 cm in diameter and 3 cm thick. It weights 400-600 gm.
The umbilical cord extends from the fetal surface of the placenta to the umbilicus of the fetus; the fetal membranes arise from the placenta at its margin. The fetal portion of the placenta is composed of numerous functional units called villi. These are branched terminals of the fetal circulation, and provide for transfer of metabolic products. The villous surface, which is exposed to maternal blood, may be as much as 160 feet square. The fetal capillary system within the villi is almost 30 miles long. Most villi are free within the intervillous spaces, but an occasional anchor villus attaches the placenta to the decidua basalis. The fetal surface of the placenta is covered by amniotic membrane and is smooth and shiny. The umbilical cord vessels course over the fetal surface before entering the placenta.

The umbilical cord is a gray, soft, coiled, easily compressible structure which connects fetus with the placenta. It averages 50 cm in length and 2 cm in diameter and is covered by a thin layer of stratified squamous epithelium which is comparable to fetal skin .Usually, the cord contains 2 arteries which carry deoxygenated blood from the fetus, and one vein, which supplies the fetus with oxygenated blood.

Friday, April 17, 2009



The EDC , or estimated date of delivery, cannot be precisely stated. It has become traditional to calculate the EDC from Nagele’s rule:

Add 7 days to the first day of the last menstrual period [LMP]; subtract 3 months; add one year. EDC = [LMP + 7 days]- 3 months + 1 year].
For example
, if the first day of the LMP was June 4, 2008, the EDC will be: [date 4+7=11 ] [months 6-3 =3 ] [years 2008+1=2009] =
11 03 2009 or EDC is March 11 2009.
Nagele’s rule is based on a 28-days menstrual cycle, with the expectation that ovulation occurred on 14th day. The pregnancy in women lasts about 10 lunar months or 40 weeks or 280 days.
Only 4 % of patients will deliver on the EDC after a spontaneous labor. Almost pregnancies will deliver during the period extending from
2 weeks before through 2 weeks after the EDC.



When should return visits be scheduled and what should each visit include?
· Every 4 weeks until 28 weeks. Screening: Urinary tract infection, proteinuria, preterm labor, gestational diabetes, and fetal well-being .

· Every 2 weeks until 36 weeks. Screening: All of the above plus fetal growth. At 36 weeks, screening for reproductive infections: Chlamydia, gonorrhea and group hemolytic streptococcus.
· Every week until 41 weeks. Screening: All of the above, fetal well-being.
How is maternal condition evaluated at each visit?
· Blood pressure: Actual and any change or trend
· Weight: Actual and trend
· Symptoms: Headache, vision, pain, nausea, vomiting, bleeding, dysuria, loss of fluid, and uterus contractions.
· Vaginal examination if indicated.
How is fetal condition evaluated at each visit?
Fundus [the top upper part of the womb] of uterine height [to access growth]: Actual and trend
Fetal heart rate
Presenting part
Fetal activity or movement
Amniotic fluid if indicated.
What are the height of fundus on abdominal wall?
Duration of pregnancy as indicated by the height of the fundus::
The fundus [top of the womb] is palpable just above symphysis [pubic arch] at 8-10 weeks
It is halfway between symphysis and the umbilicus at 16 weeks
At the level with umbilicus at 20-22 weeks
At the halfway of umbilicus and epigastrium [mid-top of abdominal wall] at 28 weeks
Highest level
near epigastrium at 36 weeks.
About one inch below the highest level at 40 weeks.
What are the length and weight of fetal or infant growth during pregnancy?

Table : Fetal growth by weeks,
length and weight
[weeks]…....length: cm….gm
Oregon, 1971, p 68-69.

Weight control during pregnancy:
What is the recommended total weight gain during pregnancy?
Approximately 12 kg
For under weight women, slightly more;
For overweight women, less.

Thursday, April 16, 2009



Name of Vitamin Daily
Folic acid.................5 mg
Thiamin ................10 mg
Niacin-amide.......150 mg
Riboflavin..............10 mg
Ascorbic acid.......150 mg
Vitamin B12..........10 micrograms
These vitamins can be put in capsule and intake once or twice daily.
Source: Cecil and Loeb. A Textbook of Medicine. Philadelphia, 1959, p 566.

The effects and roles of basic formula for treatment and prevention of diseases:
Folic acid [vitamin B 9] is an important member of the vitamin B complex. Folic acid can prevent and treat macro-cytic [cellular] anemia of pregnancy, infancy and early childhood.
Thiamin or vitamin B1 can treat and prevent beriberi the “dry type” with polyneuritis and “wet type” with acute cardiac disease, edema and serous effusions.
Niacin-amide [vitaminB3] can treat and prevent pellagra a non-contagious clinical syndrome affecting the skin, glossitis [inflammation of tongue], alimentary tract and nervous system. Niacin can treat and prevent hyper-cholesterol and atherosclerosis generally and particularly in prevent placenta sclerosis and necrosis as the cause of placenta insufficiency..
Riboflavin [vitamin B2] can treat and prevent cheilitis or angular stomatitis [inflammation of lips] associated with transverse fissures in the corners of the mouth.
Ascorbic acid is concern fundamentally with the formation of intercellular substances, including the collagen of fibrous tissue structures, the matrices of bone, cartilage, and dentin, and all non epithelial cement substance , including of vascular endothelium. It is also an important factor in determining resistance to infection.It treat and prevent scurvy where gums become spongy and bleed easily, the teeth become loose and fragile.In scurvy bone formation is stop, atrophy and bone fragility.
Vitamin B12 is effective for treatment of pernicious anemia, neuritis of extremities, tropical sprue [syndromes of impaired absorption and motility of small intestine] and non-tropical sprue in relapse.

Tuesday, April 14, 2009



Picture: Ensure delivery of a Wishing, Hoping, Dreaming and healthy infant.
Say it with flower in the basket

Before this topic the writer had described: Making pregnancy saver, including the treatment and prevention of abortion, those related to help the couples to ensure mother’s health and delivery of a healthy infant which are the indirect prevent of abortion.

If the Couples who wish children get pregnant after succeed treatment of infertility, preference male or female birth; the physician and the midwife must do special care for the pregnant women. Because the infant in the womb of the couples are the Wishing, Hoping and Dreaming children, they are more value than the infant of pregnant women as usual.

What is the problem?
All the pregnant women will get prenatal care as usual.
The question: Are special care for the Wishing, Hoping and Dreaming infant in the womb of the couples? Yes. There are special care!
The detail of the answer of this question or this problem will describe in the following writing :

Problem solving.

Prenatal care: What are the goals of prenatal care?
1. Ensure mother’s health.
2. Ensure delivery of a healthy infant.
3. Anticipate problems.
4. Diagnose problems early.
. Philadelphia, 2008, p 43.
A thorough medical history and physical examination early in pregnancy provide the ground work for the diagnosis and treatment of disorders which may compromise the pregnancy. Knowing the patient’s general health problems permits the obstetrician to interpret the developing symptomatic sign correctly and treat complications promptly.
Good antenatal and prenatal care are preventive medicine of a high order
In obstetric practice the history and physical findings are usually recorded on an outline form of the checklist type. However, in this writing only a few items will describe.

What are the recommended daily allowances in pregnancy?
Increase daily caloric intake by approximately 300 Calories per day; for example: if the woman weight 60 kg the calories intake is about 1800 Calories, with additional 300 Calories, the daily allowance becomes 2100 Calories.
Protein: Recommended daily allowances added for pregnancy is 10 gm, f.e if the weight 60 kg, the daily need is about 60 gm, and the daily allowance becomes 70 gm.
Vitamins: Deficiency diseases frequently occur in patients with true pernicious anemia or in women who are pregnant; thus a group of diseases may be operating simultaneously in the patient such as pregnancy or lactation. One of the basic formulas in treating mixed deficiency employed is :

Vitamin .............daily
Folic acid................ 5 mg
Thiamin................ 10 mg
Niacin-amide...... 150 mg
Riboflavin............. 10 mg
Ascorbic acid...... 150 mg
Vitamin B12......... 10 micrograM
These vitamins can be put in capsule and intake once or twice daily.
Source: Cecil and Loeb. A Textbook of Medicine. Philadelphia, 1959, p 566.

Another needs are vitamin A 20 000 IU daily and E 50 mg daily.
The chief functions of vitamin A are the growth and maintenance of epithelial and epidermal tissues, in process of ovulation for normal fertility and in function of vision. Vitamin E is important role in implantation of fertilize ovum. Administration of vitamin E [alpha tocopherol] during the first half of gestation permits normal embryo development and parturition. The improvement in function of red blood cells by alpha tocopherol serves as the basis for bioassay for vitamin E activity. A sparing effect of vitamin E upon hormone action particularly insulin and sex hormones. This is considered a result of vitamin E existing an antioxidant or sparing action upon the hormone metabolism.
Source: Philip B. Hawk et al. Practical Physiological Chemistry, New York, 1954, 13th Edition, p 1268-69.

To administer the basic formula, vitamin A and E as described above doses are parts of special care for Wishing, Hoping and Dreaming infant in the womb of the couples. The writer helps and treats the all his patient pregnant women with these method or administration and it seems is good results until today. The writer suggests or asks the college physician or midwife to apply these treatment as an input to help and treat the pregnant women.

Vitamin D allowances 400 IU. daily.
Calcium allowances 1.5 gm daily
Phosphorus allowances 1.5 gm daily
Iron allowances 20 mg daily
Magnesium allowances 450 mg daily
Iodine allowances 125 microgram daily.

The daily allowances are described above as a key to ensure the health of mothers and infants in their wombs.

Visits and examinations:

Monday, April 6, 2009



Many abortions can be prevented by study and treatment of maternal disorders before pregnancy, early obstetric care, with adequate treatment of maternal diabetes, hypertension, etc; and by protection of pregnant women from hazards to health in industry, from exposure to rubella or other infection, trauma , diet deficiencies etc

Picture:On the right side, Cerclage of the cervix [Shirodcar] with incompetent os [hole of cervix] in pregnant woman

On the left side: correction of cervical incompetence in the non-pregnat woman

Prevention of abortion in this writing consist of direct prevention and indirect prevention.
1. Direct prevention is to anticipate potential problems in the period of pregnancy.
2. The indirect prevention is to anticipate better health of mothers and infants in the
period of pregnancy.

The direct prevention is to anticipate potential problems by answer the question:
What are danger signals or general warning signs should the patients be aware of during pregnancy? The patients require to report promptly any sign the following below:
Vaginal bleeding: In the first trimester, bleeding can indicate pending miscarriage [abortion] or ectopic pregnancy. In the second and third trimester, bleeding may indicate placenta previa, placental abruption, or labor.
Abdominal and pelvic pain or cramp may indicate uterus contraction before abortion.
Swelling of face or fingers, severe headache, or blurry vision may indicate hypertension or pre-eclampsia.
Markedly reduced urine output or dysuria, chills, or fever may indicate pyelonephritis [kidney infection] or other infection.
Fluid leaking from the vagina could indicate premature of the membranes.
Decreased fetal movement may indicate fetal compromise.

Plan of action to solve the danger signals or general warning signs:
Vaginal bleeding: If there is the sign of bleeding, administer vitamin K , Phytonadione IM 10 mg/ml, vitamin K 5 mg/tablet per oral 3 times daily, vitamin C 1000 mg /tablet once daily and Adona AC-17 [carbazochrome sodium sulfonate], 10 mg/tablet 3 times daily. Prevention of bleeding for pregnant women administer: vitamin K 5 mg once per week, vitamin C 250 mg once daily, and calcium lactate tablet 500 mg once daily.
Abdominal and pelvic pain or cramp: Administer antispasmodic drugs such as Hyoscyne-N-buthylbromide injection S.C. 20 mg/ml, followed by tablet 10 mg 3 times daily, combine with Papaverine 40mg/tablet 3 times daily.
Swelling of face or fingers, headache and blurry vision and reduce urine output: It need examination of blood pressure, detect edema and laboratory urine examination. If there are hypertension [blood pressure more than 140/90 systole/diastole], edema and protein-uria, these are the sign of pre-eclampsia.

Treatment of hypertension, administer Captopril 25 mg/tablet twice daily or Amlodipine [Norvasc ] 5 mg /tablet once daily.

Treatment edema, administer Chlorothiazide [Diuril] tablet 250 mg twice daily, or Furosemide [Lasix] 40 mg/tablet twice daily.

Prevention of convulsion and coma, administer sedative Phenobarbital 60 mg/tablet oral 3 times daily and anticonvulsant Magnesium sulfate may be given I.V.,20 mg of aqueous solution injected slowly and repeated hourly to prevent or control seizures. Diet with higher protein intake than normal pregnant women.

If there is infection administer antibiotic such as Clindamycin 150-300 mg per oral every 8 hours.
Fluid leaking from vagina could indicate rupture of fetal membrane may be caused by incompetent cervical os [hole] of pregnant women. Treatment with Cervical Cerclage [Shirodkar Operation]. The placement, snug tie, and fixation of a nonabsorbable Mersilene or comparable strand, ribbon or band beneath the mucosa and peri-cervical fascia at the cervico-uterine junction may be done during the pregnant state for correction of cervical incompetence. The physician must then decide whether to release the ligature during labor for vaginal delivery or to perform cesarean section near term.
Decrease fetal movement may indicate fetal compromise. Administer neuromuscular vitamin Neurodex or Neurobion which consists of vitamin B1: 100 mg, B6: 200 mg and B12: 200 microgram, the combination of these vitamins are indicated for polyneuritis, asthenia , paresis, neuralgia , fatigue and treatment of nausea and vomiting during pregnancy.
Vitamin E 100 mg/tablet per oral once daily is indicated for infertility, habitual
abortion, muscle dystrophy, intermittent claudication [cramp of muscle] and pain
in the muscle which limited the contraction or movement of the muscle...

Thursday, April 2, 2009



Picture: Upper at right side is a product of complete
abortion, and uterus on the left side.
Lower at right side is an incomplete
abortion, the placenta is still left in the cavity
of uterus on the left side, usually with blood bleeding.
Source: Ralph C.Benson. OBSTETRICS AND GYNECOLOGY, Oregon,
USA,1971, p 254.

What is an abortion?
Abortion is the termination of pregnancy before the fetus becomes viable. Viability is usually reached at 20 weeks and later of pregnancy, when the embryo [infant] weight more than 500 gts; with proper care in neonatal period, the infant may survive.

Abortion may occur before the 16th week; about 75 % of abortions occur before the 16th week; of these, 75 % occur before the 8th week. The relative incidence of abortion is highest in early adulthood and just prior to the menopause. About 12 % of all pregnancies terminate in spontaneous abortion.
What are the categories of abortion?
1. Spontaneous abortion [miscarriage]: pregnancy loss before 20 weeks gestational age.
2. Complete abortion: abortion with complete expulsion of all products of conception [POC].
3. Incomplete abortion: abortion without complete expulsion of all POC ;fetal or placental components remain in the uterus.
4. Threatened abortion: bleeding from the uterus [as seen on visualization of cervical os [hole] without cervical dilatation and with or without contraction before 20 weeks gestational age; no expulsion of POC.
5. Inevitable abortion: bleeding from the uterus with cervical dilatation with or without perceived contractions before 20 weeks’ gestational age; no expulsion of POC.
6. Missed abortion: fetal death before 20 weeks’ gestational age without expulsion of POC.
7. Recurrent abortion: three or more consecutive spontaneous abortion.
8. Induced abortion: Legal abortion, pregnancy termination by medical or surgical means for therapeutic or elective reason; illegal or criminal abortion against the law in a few countries.

What is the cause of abortion?
A. Ovular factors:
First trimester: Congenital absence of the embryo is common. Cleavage defects of the ovum, absence the chorionic cavity, and a hypoplastic trophoblast are found occasionally, many pregnancies are expelled so early that deficiencies such as hydatidiform mole cannot be determined accurately.
Second trimester: The major fetal causes of abortion are syphilis [in developing countries], shallow circumstanced implantation of the placenta. Erythroblastosis and other fetal anomalies are less frequently responsible.
B.Maternal Factors:
Indirect trauma
: Abortion may be induced by electric shock [lightning or power-line contact].
Direct trauma: Concussion of the lower abdomen after the 4th month may injure the uterus, causing placental separation. Abdominal surgery may excite uterine irritability and induce abortion.
Infections:Rubella, syphilis, brucellosis, or toxoplasmosis increases the likelihood of abortion.
Diet: Avitaminosis C and B-complex, or severely deficient protein or caloric intake.
Endocrine: Maternal hypothyroidism , diabetes mellitus .
Toxic: Lead poisoning, drug substances such as chloroquine, aminopterin, methotrexate and anesthetic gases.
Uterocervical: Incompetence of the cervix as a result of previous pregnancies and lacerations cause second trimester abortion.

Symptoms and signs of abortion:
Abortion is classified clinically as [1] complete, [2] incomplete or inevitable, [3] missed, [4] threatened abortion.
Complete abortion:All products of conception [POC] is expelled. When complete abortion is impending, the symptoms of pregnancy often disappear and sudden bleeding begins, followed by cramping. When the entire conception has been expelled, pain ceases but slight spotting persists.
Incomplete or inevitable: In incomplete abortion portions of the conception have already passed; in inevitable abortion, , evacuation of part or all of the conception is momentarily impending. Bleeding and cramps do not subside. Abortion is inevitable when 2 or more of the following are noted [Brown]: [1]moderate effacement of the cervix, [2] cervical dilatation more than 2 cm, [3] rupture of the membranes, [4] bleeding for more than 7 days, [5] persistence of cramps despite narcotics, [6] signs of termination of pregnancy. Fever and generalized pelvic discomfort indicate infection. Retained tissue is evidenced by a stopper tissue in cervix and enlarged, boggy uterus.
Missed: In missed abortion the pregnancy has been terminated for at least one month but the conception has not been expelled. Symptoms of pregnancy disappear. There is a brownish vaginal discharge but no vaginal bleeding. Pain and tenderness are not present. The cervix is semi-firm, the uterus becomes smaller and irregularly softened, the adnexa are normal.
In threatened abortion the viable gestation is in jeopardy but the pregnancy continues. Bleeding or cramping in early pregnancy, and closed cervix, without cervical dilatation, no expulsion of products of conception.

Laboratory findings:
, the Friedman and Aschhem-Zondek pregnancy tests are negative or equi- vocally positive.
Hormones: [1] Chorionic gonadotropin is produced by the cytotrophoblast. It is present in the urine in diminished amounts in failing pregnancy; absent after pregnancy ceases. [2] Estrogen: A falling blood or urine estrogen titer may signify impending abortion. [3] Progesterone: during first trimester the principal source of progesterone is the corpus luteum. Thereafter, the principal source is the chorioplacental system. Pregnanediol [the major catabolite of progesterone] drops precipitously in abortion.
Blood : If significant bleeding has occurred, blood studies will show anemia. If infection is present, the white blood count will be elevated [12-20 thousand].The serum Friedman test is usually negative.


Hemorrhage is a major cause of maternal death. Infection [septic abortion] is most common after criminally induced abortion, death results from salpingitis, peritonitis, and septicemia or septic emboli. Infertility may result from tuba uterine occlusion .Perforation of the uterus, accompanied by injury to the bowel and bladder, hemorrhage, infection and fistula formation, may occur during dilatation and curettage because of the soft and vaguely outlined uterine wall.


Successful management of abortion depends upon early diagnosis. Every patient should recipe a general physical [including pelvic] examination, and a complete history should be taken. Laboratory studies should include cultures of cervical mucus to determine pathogens in case of infection, antibiotic sensitivity tests, blood typing and cross-matching, and a complete blood count.
Emergency measures: If abortion has occurred after the first trimester, the patient should be hospitalized. In all cases, give oxytocin
1 ml/500 ml of 5 % dextrose in water I.V., or 0.5 ml I.M. every 30 minutes for 2-4 doses, to contract the uterus and limit blood loss and aid in the expulsion of clots and tissues. Ergonovine [Ergotrate] should be given only if the diagnosis of complete abortion is certain. Give anti-shock therapy, include blood replacement, to prevent collapse after hemorrhage.
Specific measures: Endocrine therapy has theoretical value in about 15 % of abortion, due to maternal hormonal deficiencies. Progestogen therapy, such as dydrogesterone [Duphaston] 10-20 mg orally daily is reasonable for patients who are threatening to abort but not for patients who are aborting.
What is the treatment of missed abortion? There are 2 option: [1] Prostaglandin Dinoprostone [Cervidil] vaginal: 20 mg suppositories .It is approved for inducing abortion in the second trimester of pregnancy, for missed abortion, for benign hydatidiform mole, and for ripening of the cervix for induction of labor in patients at or near term.Dinoprostone stimulate the contraction of the uterus throughout pregnancy. [2] Dilatation of the cervix and curettage of the endometrial cavity [D and C].
General measures: Place the patient at bed rest and give sedatives to allay uterine irritability and limit bleeding. Coitus and douched are contraindicated.
Surgical measures: [1] Dilatation and curettage for possible retained tissue. Start an oxytocin [Pitocin] intravenous drip prior to surgery to avoid uterine perforation. [2] Uterine packing to control bleeding and promote separation and evacuation of fragments. Remove packing in 6-8 hours to allow drainage.
What are potential treatments for recurrent pregnancy loss?
Supplemental progesteron or clomiphene citrate for luteal phase defect.Treatment of infection ,if present.Aspirin or subcutaneous heparin for antiphospholipid syndrome.Surgery to correct uterine abnormalities. Vitamin E [Evion] 100 mg/tablet once daily.Vitamin A 20 000 IU/tablet daily
Treatment of complications: [1] Uterine perforation, observe for signs of intraperitonial bleeding, rupture of the bowel or bladder, or peritonitis. Exploratory laparotomy may be necessary. [2] Pelvic thrombophlebitis and septic emboli are critical sequel. Consider antibiotics, anticoagulants, and ligation of the internal iliac veins and vena cava.