PCC geremew final _124211 power point pre

ppt

1. DEBRE BERHAN UNIVERSITY
ASRAT WELDEYES HEALTH SCIENCE CAMPUS
SCHOOL OF NURSING AND MIDWIFERY
DEPARTMENT OF MIDWIFERY
PCC for 3
rd
year Midwife students
Geremew Kindie (MSc)
February ,2016 E.C

2. Preconception care

3. Objectives
•At the end of this class, you will be able to:
Define pre conception care
Explain the aim of pre-conception care
List and discuss components of pre conception care
Discus barriers of preconception care

4. Brain storming
What is Pre-conception care?
What are the target groups for Pre-conception
care?

5. Definition
Pre-conception care(PCC)is the provision of
biomedical, behavioraland socialhealth
interventions to women and couples before conception
occur.
It aims at improving their health status, and reducing
behaviors,individualand environmental factors
that contribute to poor maternal and child health
outcomes in both the short and long term.

6. Con….
•Interconception care -is defined as care provided
between delivery and the beginning of the woman’s
next pregnancy
•During the Interconception period, intensive
interventions are provided to women who have
had a previous pregnancy that ended in an
adverse outcome (i.e., fetal loss, PTB, LBW, birth
defects, or infant death)
•Hence Interconception care typically refers to
enhanced interventions after an adverse
pregnancy outcome
Eg: giving folate for a mother with previous NTD

7. Why PCC?

8. Why ?
A.Human health status in adulthood is dictated by micro
and macro-environmental conditions around the time of
conception
the first prenatal visit may be too late to address modifiable
behaviors.
since as many as 30 % of pregnant women begin traditional
prenatal care in the second trimester
Therefore:-preconception care is more important than prenatal
care for prevention of congenital anomalies

9. Preconception intervention is more important than prenatal
intervention; important fetal development happens prior the
woman’s first prenatal visit

10. B. asignificant contribution to adverse pregnancy outcome
is related to congenital anomalies, PTB, and LBW
increase neonatal and infant mortality
Up to 35% of pregnancies among women with untreated
gonococcalinfections result in LBW and PTB, and up to 10%
result in perinatal death
FGM increases the risk of NM by15% to 55%
Perinatal deaths are 50% higher among children born to
mothers under 20 years of age compared to mothers aged 20–
29 years
Women with epilepsy are at increased risk of having babies
with congenital anomalies

11. Con…
Violence against girls and women results in adverse
physical, psychologicaland reproductiveconsequences,
as well as increased risk for PTBand LBWinfants
In the absence of interventions, rates of HIV
transmission from mother to child are between 15 and
45%
Eliminating smoking before or during pregnancy could
avoid 5–7% of preterm related deaths and 23–24% of
cases of sudden infant death syndrome

12. Con…
C. Almost half of pregnancies are unplanned (50% in US)
In Ethiopia
•28% of pregnancies are unintended(AleneM et al, 2020)
•20.4%, of adults are overweight (KassieAM et al , 2020)
•22% of reproductive aged women are thin (BMI <18.5), while
8% are overweight or obese (EDHS, 2016).
•Globally, In 2016, more than 1.9 billion adults, 18 years and older,
were overweight.Of these over 650 million were obese.

13. D. Increasing the proportion of women who delay
childbearing or get pregnant with significant medical
conditions
E. surveys reveal that 84% of reproductive-age women
have had a health care visit within a year, which suggests
significant opportunity to provide PCC

14. Magnitude of maternal and neonatal death
An estimated 2.8 million pregnant women and
newborns die every year, or 1 every 11 seconds,
mostly of preventable causes(according UNICEF,
(WHO,2019).
•Around 80% maternal deaths are due to five direct
maternal cause
Hemorrhage, Hypertension, Sepsis, Unsafe
abortion and Obstructed labor

15. SDG 3 by 2030, MMR should be <70 per 100,000 live
births, and no country should have a MMR more than
140 per 100,000 live births.
Early identification and treatment as well prevention of
pre-existing medical conditions that are aggravated
during pregnancy, such as anemia, malaria,
HIV/AIDS/STIs, DM.
Most pregnancies are unintended
Early prenatal care is not enough

17. Importance of PCC
Improve nutritional status of adolescents and women
Promote family planning
Promote healthy behavior and reduce risk taking behavior.
Reduce rate too-early and too-frequent pregnancies and
abortions;
Improve maternal & neonatal health outcomes and reduce
mortality

18. Goals of PCC
Isto improve pregnancy outcomes and women's
healthin general through prevention of disease and
management of risk factors that affect pregnancy
outcome and the health of future generations.
PCC should be provided to all reproductive age
individuals.
PCC is given by Primary care providers& Coordination
b/n clinicians

19. Con…
The goals of preconception care are to
•Identify potential risks to the mother, fetus,
and pregnancy.
•Educate the individual about these risks,
options for intervention and management for
risk reduction, and reproductive alternatives.
•Initiate interventions to provide optimum
maternal, fetal, and pregnancy outcomes.
Interventions include motivational
counseling, disease optimization, and
specialist referral.

20. Opportunities for preconception counseling:
•After a negative pregnancy test
•Following poor pregnancy outcome
•Contraception counseling
•Evaluation for sexually transmitted disease or vaginal
infection
•Anytime a woman of childbearing age presents for a
periodic health examination(postnatal visit).

21. Barriers to PCC
Ignorance about importance of good health habits prior to
conception ( avoidance of alcohol conception, taking folic acid etc).
Lack of awareness about how to integrate PCC with
ongoing primary care
Risk factors for adverse outcome that cannot be modified
(eg, maternal age or genetic history)
Financial issues (e.g., lack of health insurance, non-
reimbursable services for screening tests )

22. Con…
High rate of unintended pregnancy
Limited access to health services
Most females do not schedule a PCC visit
Lack of provider knowledge and training about
essential components of PCC across all
specialties

23. Elements/ components of PCC
Risk
assessm
ent
•Reproductive history;
•Environmental hazards and toxins;
•Medications that are known teratogens;
•Nutrition, folic acid intake, and weight
•family history;
•substance
Education
& Health
promotion
•nutrition, adequate rest, good hygiene, family planning and
exclusive breastfeeding, and immunization and other disease
prevention ...
Medical
&psychos
ocial
interventi
on
•involved in the prevention, diagnosis, and treatment of disease
•psychotherapy and relapse prevention, stressmanagement

24. Risk assessment
•The key task in identifying risks to the woman and her
pregnancy is to obtain a thorough history.
•Preconception health care tool
•Patient education and medical interventions can be
initiated based on this information.

25. Con…
Guidelines generally targeted the following areas for
preconception risk assessment :-
•Chronic medical problems ( including obesity and mental
health issue)
•Medications known to be teratogens
•Reproductive history (gynecologic and obstetric histories)
•Genetic risks and conditions and family history
•Substance use ( alcohol, nicotine containing product)

26. Con…
•Infectious disease and vaccination
•Nutrition (type of diet and intake, vitamins, supplements)
and weight management
•Physical activity, exercise routine
•Environmental hazards and toxins ( eg, occupational
hazards, travel, pets)
•Social and mental health concern (eg, depression, social
support, IPV)
•Major surgical procedures

27. Areas addressed by the PCC package
WHO, 2013: Areas to be addressed by the preconception care package

28. Reproductive health plan
•Reproductive life plan –a “set of personal goals
regarding the conscious decision about whether or not to
bear children”
•Would you like to be pregnant in the near future?
•To insure that more pregnancies are wanted, planned, and as
healthy as possible
N
O
Yes
Preconception counselingContraception advice

29. Con…
when developing or discussing a reproductive life
plan; these include :-
the desire or lack of desire to have children
parental ages
maternal health and coexisting medical conditions
the desired number of children and anticipated spacing of
children
risk tolerance, such as for genetic or medical/obstetric
complications
life context (age, school career, partner readiness for
childbearing).

30. Con…
•Reproductive planning helps to prevent unintended
pregnancy,age-related infertility and fetal teratogen
exposure.
•It may also improve health and pregnancy outcomes.
•Offer appropriate contraception advice for those not
desiring pregnancy or until chronic medical conditions
are stabilized.

31. PRECONCEPTION HEALTH
COUNSELING

32. Objectives
At the end of this class ,you will be able to:
Provide preconception counseling for a women in terms
of age, weight, medical diseases
Explain the effect of this risks (age, weight, medical
diseases)
Provide screening and management for this risks ((age,
weight, medical diseases))

33. Age
Teen pregnancy (15 to 19 years)
•↑risk for
•anemia, preterm delivery, and instrumental delivery
•STI
•↑ mental health problems (depression, substance abuse,
and posttraumatic stress disorder (PTSD)
•Mostly pregnancy is unplanned & unwanted –has a
negative impact on the physical, emotional, educational,
& economic condition
Advanced maternal age (> 35)
•↑ pregnancy risks that include infertility, developing a chronic
medical disease (gestational diabetes, preeclampsia), fetal
chromosomal abnormality, and stillbirth, spontaneous abortion
•↑maternal mortality : 2 x (35-39 yrs), 5 X (≥ 40 years) that of
women aged 25 to 29 years

34. Effects of advancing woman's age on fertility and
pregnancy
FERTILITY
•Advancing age is associated with prolongation in the
average time for achieving conception.
oFecundability( the probability of achieving a pregnancy in
one menstrual cycle) begins to decline significantly in the
early 30s (about age 32), with a more rapid decline a few
years later (about age 37)
oFecundity:-is the probability that a single menstrual cycle
will result in a live birth
oFertilityrefers to the capacity to conceive and produce
offspring
oInfertility is the inability to conceive after 1 years of
unprotected coitus.
oInfertility refers to a state in which the capacity for fertility is
diminished, but not necessarily absent. For this reason, the term
subfertilityis often used instead of infertility
oSterility is the inability to produce offspring.

35. oSubfertility in older women is primarily related to the
oovarian factors:-poor quality of aging oocytes
(chromosomal abnormalities, morphologic abnormalities,
functional abnormalities), decreased ovarian reserve (fewer
oocytes)
•Advancing age loss of viable oocytes ( depletion of ovarian
reserve + genetic abnormality in the remaining like mitochondrial
deletions )decreased fertility/ increased miscarriage/Infertility
oIn addition to ovarian factors older women have had more
opportunity to acquire medical and surgical conditions, such
as endometriosis, pelvic infection, endometrial polyps, and
leiomyoma, which can impair fertility through a variety of
mechanisms
oLifestyle factors may also play a role. Older women may
have lower coital frequency than younger women and are
more likely to be obese

36. Female Age (years) Infertility
•20–29 8.0%
•30–34 14.6%
•35–39 21.9%
•40–44 28.7%

37. •Spontaneous abortion
•Older women experience an increase rate of spontaneous abortion primarily
result from a decline in oocyte quality
•Ectopic pregnancy
•Maternal age ≥35 years is associated with a four-to eight-fold increased
risk of ectopic pregnancy compared with younger women
Maternal age
Spontaneous
abortions
(percentage)
Ectopic
pregnancies
(percentage)
Stillbirths
rate/1000
2-19 13.3 2.0 5.0
20-24 11.1 1.5 4.2
25-29 11.9 1.6 4.0
30-34 15.0 2.8 4.4
35-39 24.6 4.0 5.0
40-44 51.0 5.8 6.7
>=45 93.4 7.0 8.2

38. •Chromosomal abnormalities
•Karyotype analysis from spontaneous abortions, pregnancy
terminations, genetic amniocenteses, and live born and
stillborn infants shows a steady increase in the risk of
aneuploidy as a woman ages
•Age-related errors appear to increase the risk of
nondisjunction leading to unequal chromosome products
at completion of division.

39. •Congenital malformations
•The risk of having a child with a congenital anomaly may
increase with increasing maternal age.
•several analyses have suggested that the risk of non-
chromosomal anomalies also increases as women age.
•Cardiac anomalies, in particular, seem to increase with
maternal age independent of aneuploidy
•the rates of major congenital anomalies for offspring of
women <35, 35 to 39, and ≥40 years of age were 1.7, 2.8,
and 2.9 percent, respectively

40. •Effects of coexisting medical conditions
•prevalence of medical and surgical illnesses, such as cancer;
cardiovascular, renal, and obesity increases with advancing
age.
•The two most common medical problems complicating
pregnancy are hypertensionand diabetes( which are
increased in older women, especially those who are
overweight)
•The incidence of preeclampsia is 3 to 4 %; this increases to
5 to 10 % in women over age 40 and is as high as 35 % in
women over age 50
•The incidence of gestational diabetes is 3 %, rising to 7 to
12 % in women over age 40, and 20 % in women over age
50
•Preexisting diabetes is associated with increased risks of
congenital anomalies, perinatal mortality, and perinatal
morbidity

42. For the fetus, maternal age-related risks primarily
stem from:
(1)indicated preterm delivery for maternal complications (
HTN, DM)
(2) spontaneous preterm birth,
(3) fetal growth disorders related to chronic maternal disease
or multifetal gestation,
(4) fetal aneuploidy, and
(5) pregnancies resulting from assisted reproductive
technology
NB:-Women should be aware of these risks and the
consequences of delaying conception until they are
over 35 years of age

43. Body Mass Index (BMI)
•The BMI, also known as the Queteletindex, used to
classify obesity .
•The National Institutes of Health classifies adults
according to BMI as follows:
•normal= 18.5 to 24.9 kg/m2,
•Underweight = < 18.5 kg/m2
•overweight = 25 to 29.9 kg/m2, and
•obese = ≥30 kg/m2.
•Obesity is further divided into:
•class 1 is 30 to 34.9kg/m2,
•class 2 is 35 to 39.9 kg/m2, and
•class 3 is ≥40 kg/m2
•Class 3 obesity is often referred to as morbid obesity, and
super-morbid obesity describes a BMI ≥50 kg/m2

44. Overweight and Obesity
•Abnormal maternal weight is an increasingly common
complication in developed and developing countries
and affects an increasing number of women of
reproductive age.
•65% of Americans are overweight [BMI ≥25 kg/m2]
or obese (BMI ≥30 kg/m2)
•Maternal obesity has become a global issue associated
with obstetric, surgical, and anestheticrisks .
•Obesity increased risk for type 2 DM, HTN, heart
disease

45. •Obstetrics risks include:-miscarriage, congenital
anomalies, HTN, GDM, macrosomia, induction rate &
its failure, CS rate, prolonged labor, instrumental
delivery
•Anesthetic complications:-difficult epidural and spinal
anesthesia placement, failed or difficult intubation
•Surgery risks:-high wound infections(23% vs7%)
•Maternal obesity is a key predictor of childhood obesity
and metabolic complications in adulthood.

47. Underweight
•Pre-pregnancy underweight and insufficient gestational
weight gain have been considered as individual risk
factors for the occurrence of miscarriage, PTB,
intrauterine growth restriction(IUGR)
•Maternal weight gain correlates with fetal weight gain
and is, therefore, closely monitored
•It also associated with increased odds of receiving
fertility treatment and increase multiple pregnancy

48. Screening and management of
chronic medical diseases
(chronic Medical history)

49. Diabetes Mellitus
•It is defined as abnormal metabolism of carbohydrates
which results in elevated blood glucose level.
•Classification
•Pre-gestational Diabetes Mellitus or overt DM (Type I or
Type II)
•Gestational Diabetes Mellitus (GDM): a carbohydrate
intolerance resulting in hyperglycemia of variable severity
with onset or first recognition during pregnancy.

50. Con…
•Pre-gestational DM (overt): is diagnosed if one or more
of the following criteria are met:
2-hour plasma glucose 200 mg/dL(11.1 mmol/L) following a 75
g oral glucose load,
Random plasma glucose 200 mg/dL(11.1 mmol/L) in the
presence of classic signs and symptoms such as polydipsia,
polyuria, and unexplained weight loss.
fasting glucose level >125 mg/dL
glycosylated hemoglobin (HbA1c) level of ≥6.5%

51. NB:-Glycatedhemoglobin (A1C) values:-which reflect the average
blood glucose concentration over the previous 8 to 12 weeks, are
useful in evaluating a woman's glycemic control before conception
and throughout pregnancy

52. Complication of pre-gestational DM
fetal and neonatal complications
•congenital malformations (2-4x than those with out DM)
-strongly related to the degree of hyperglycemia.
•Maternal diabetes may change genes involved in signaling and
metabolic pathways essential for normal embryonic development
(folate metabolism, oxidative stress, apoptosis and proliferation)
•glucose concentration causes embryopathy(dysmorphogenesis),
resulting from apoptosis as well as abnormal cellular proliferation and
differentiation in developing organ.
•Cardiovascular, central nervous system and skeletal system are targeted
of this process.

53. Encephalocele:-Herniation of the
brain and/or meninges through a
defect in the skull
SpinaBifida:-Defects in the
closure of the spinal column
Exposure of the spinal cord
Anencephaly:-deficient development of the
vault of the skull and brain tissue
hydrocephalus:-Excessive accumulation of
cerebrospinal fluid

54. •Preterm delivery
•High risk of medically and obstetrically indicated PTB and
spontaneous PTB compared to those with out diabetes
•macrosomia(newborn weight ≥ 4000gm)
•Maternal transfer of glucose leading to fetal hyperinsulinemiaand
subsequent effect of insulin on target tissue to promote growth and
store excess nutrients as adipose tissue.
•growth restriction (in women with vascular or renal disease)
•Perinatal mortality
•Neonatal hypoglycemia and other metabolic abnormalities
•Long term impacts in offspring health
Macrosomicbaby (5.3kg)

55. obstetric complications
•spontaneous abortion (2-3 fold higher)
•Due to frequency of dysmorphogenesis, toxic effect of
hyperglycemia & maternal vascular disease utero-placental
insufficiency
•Preeclampsia and gestational hypertension (3-4 fold higher
)
•Polyhydramnios
•Cesarean birth
Maternal complication
Hypoglycemia
Diabetic retinopathy
Diabetic nephropathy
Neuropathy
Cardiovascular disease

56. Preconception evaluation and management
•It requires multidisciplinary approach (internist,
obstetrician, nutritionist, etc).
•PCC should include:-
Counseling about the impact of glycemic status on maternal-
fetal outcome
•Inform about risks of miscarriage, congenital malformation,
preeclampsia and perinatal mortality with poor glycemic control and
unplanned pregnancy.
•Discuss and provide effective contraceptive to avoid unplanned
pregnancy until glucose control is achieved

57. Helping patients achieve good glucose control, with
HGA1C in the normal range safely achievable
•Encourage regular exercise and weight control, diet
Target glucose level
•Fasting capillary blood glucose: 80 -110 mg/dL.
•2 hrcapillary postprandial blood glucose: < 155 mg/dL
Target HGA1C level (<6.5% )-Measure monthly until
satisfactory control is achieved
Give folic acid supplementation, 4 mg daily before
conception until 12 weeks of gestation to minimize
risk of congenital anomalies
Patients with diabetes should be encouraged to allow
a minimum of three to six months to achieve optimal
glucose control before trying to conceive, if glucose
levels are not already well controlled.

58. Evaluate and treat diabetic complications before pregnancy
(hypertension, retinopathy, nephropathy, neuropathy and
cardiovascular disease).
•Measure and optimize thyroid hormone levels in women with type 1
diabetes
•(Although thyroid disease not caused by diabetes, autoimmune thyroid
dysfunction is frequently associated with type 1 diabetes; hypothyroidism
more common than hyperthyroidism)
Adjusting medications (eganti HTN drug, oral anti-
hyperglycemic agents) as needed for fetal safety
Long-acting reversible contraception methods are generally
most effective at preventing unplanned pregnancy

59. Con…
Pregnancy is not recommended in the presence of
:-
•Ischemic heart disease, active proliferative retinopathy
(untreated), severe renal insufficiency (serum creatinine
> 2.0 mg/dLor heavy proteinuria (>2g/24hr.)), and if
HgbA1c >10%
•Proliferative retinopathy during pregnancy has
substantial risk of visual loss. It should be treated before
pregnancy

60. Hypertension
•Hypertension is one of the common medical
complications of pregnancy and form one member
of the deadly triad, along with hemorrhageand
infection
Definition
•Normal blood pressure –SBP <120 mmHg and DBP
<80 mmHg
Hypertension:
•SBP ≥140 mmHg or DBP ≥ 90 mmHg or both in two
occasions taken 4-6 hours apart
•SBP ≥160 mmHg and/ or DBP ≥ 110 mmHg single
measurement

61. •Hypertension may be pre-existingor appears for the
first time during pregnancy.
•Effective management play a significant role in the
outcome of pregnancy, both for the mother and the
baby

62. Hypertensive
disorders in
pregnancy
<20 wks.
Gestation
Chronic
HTN
≥20 wks.
Gestation
Preeclampsia
/Eclampsia
Gestation
al HTN
Superimposed
Preeclampsia

63. •HTN raises
•The risk of CV disease, stroke, renal failure, peripheral arterial
disease, and mortality
•It has also adverse effect on maternal and perinatal outcome
•Rates of these complications positively correlate with the
severity and duration of pre-pregnancy HTN

64. Preconceptional Counseling
•Women with chronic HTN ideally undergo counseling before
pregnancy
•Ascertain hypertension duration, degree of blood pressure
control, and current therapy
•General health, daily activities, and dietary habits also are assessed

65. Con…
•Provide effective contraception
•poorly controlled hypertension is considered a
contraindication for pregnancy
•ACOG recommended initiating 81mg of aspirin
between 12 and 28 weeks’ gestation and continuing
therapy until delivery for these at-risk gravidas.

66. •Medication adjustment
During pregnancy:
•Angiotensin-converting enzyme inhibitors (ACE-I) are
contraindicated
•It cause ACE-I fetopathy (like fetal hypotension and renal
hypoperfusion, with subsequent ischemia and anuria )
•Reduced perfusion can result in fetal-growth restriction and,
oligohydramniosmay lead to pulmonary hypoplasia and limb
contructure
•Methyldopa, labetaloland hydralazineare the drugs of choice
during pregnancy
•Antenatal contact should be more frequent

67. Thyroid disorders
•Maternal and fetal thyroid function are intimately related,
and drugs that affect the maternal thyroid affect the fetal
gland
•Both high (Uncontrolled thyrotoxicosis )and low
(untreated hypothyroidism )maternal thyroid function
associated with adverse pregnancy outcomes
•Throughout pregnancy, maternal thyroxine(T4) is
transferred to the fetus
•Maternal thyroxineis important for normal fetal brain
development, especially before the onset of fetal thyroid gland
function

68. Hyperthyroidism (thyrotoxicosis)
•clinically
•tachycardia, heat intolerance, sweeting, anxiety exophthalmos, and
failure to gain weight despite adequate food intake
•confirmed by lab investigation,
•suppressed TSH,
•elevated free T4and/orT3
•Have to be stabilize before pregnancy

69. Complications in untreated hyperthyroidism
•Maternal: Miscarriage, preterm delivery, preeclampsia,
congestive cardiac failure, placental abruption, thyroid storm and
infection.
•Fetal/Neonatal: IUGR, prematurity, stillbirth, hyperthyroidism,
hypothyroidism, increased perinatal morbidity and mortality.

70. •Thyrotoxicosis controlled by thionamidedrugs:-
-Propylthiouracil(PTU) in 1
st
Tm
-Methimazole (MMI) after 1
st
Tm
•Radioactive iodine-used for treatment of thyroid cancer
and thyrotoxicosis and for diagnostic thyroid scanning
•postpone conception for 6-12 months following treatment
•It may cause severe or irreversible fetal and neonatal hypothyroidism,
which can lead to decreased mental capacity and delayed skeletal
maturation
•Refer to/consult for better treatment

71. Hypothyroidism
•Overt or symptomatic (clinical) hypothyroidism
•nonspecific clinical findings include fatigue, constipation, cold
intolerance, muscle cramps, and weight gain. Other findings are
edema, dry skin, hair loss
•confirmed by an abnormally
•high serum TSH level and
•low T4 level
•Subclinical hypothyroidismis defined by an
•elevated serum TSH level but
•normal serum T4 concentration

72. •Untreated hypothyroidism in early pregnancy has
risk of
•abortion, stillbirth and prematurity and deficient intellectual
development of the child.
•risk of preeclampsia and anemia
•Cause:
•Iodine deficiency(most common)
•Hashimoto thyroiditis (characterized by glandular
destruction from autoantibodies, particularly anti-TPO
(thyroid peroxidase) antibodies),
•Radio-ablative Rx, Type 1 diabetes

73. Con…
Treatment
•ACOG recommends oral replacement therapy
for overt hypothyroidism beginning with
levothyroxinein doses of 1 to 2 μg/kg/d or
approximately 100 μgdaily
•Women with hypothyroidism require increased doses of
thyroxin early and throughout pregnancy; this is
especially important during the first trimester

74. SEIZURE DISORDERS
•Seizures are the most prevalent neurological condition
encountered in pregnancy.
•CDC reported that 3 million adults in 2015 had active
epilepsy
•The major pregnancy-related risks to women with
epilepsy are fetal malformations and convulsions

75. •Epilepsy risk of pregnancy complications
•miscarriage, hemorrhage, placental abruption, PTB, HTN
disorders ,IUGR and CS, higher maternal death rate
•children of epileptic mothers have a 10 % risk of developing a
seizure disorder
•Seizure control is a priority to avoid its attendant
morbidity and mortality

76. •Anti-epileptic drugs(AED) risk of congenital disorder
NTD, skeletal, cardiac, facial abnormalities, cleft palate
•E.g(Phenytoin and phenobarbital increase the major malformation rate 2 to 3
fold above baseline &Valproate is a particularly potent teratogen, raises the
malformation risk four-to eightfold)
•Because they folate absorption and lowers serum folate
•(All anticonvulsants interfere with folic acid metabolism, Folic acid deficiency
has been associated with NTD and other congenital d/ors)
•A high daily dose or a combination 2 or 3 drugs increases the risk of
malformations.
•Make risk benefit analysis with continuing Vsdiscontinuation of AEDs
during pregnancy

78. •AAN recommends consideration of anti-seizure
medication discontinuation before pregnancy in suitable
candidates
•These include women who satisfy the following criteria:
Have been seizure-free for 2 to 5 years,
Display a single seizure type,
Have a normal neurological examination and normal
intelligence, and
Show electroencephalogram results that have normalized with
treatment

79. •Preconception counseling includes
•Education and counseling
-Medication adjustments/change
-initiate monotherapy(if possible) replacing polytherapy
-High dose folic acid before conception and during
pregnancy (4-5mg/day)
-Close serum monitoring is required during pregnancy

80. Iron deficiency Anemia (IDA)
•WHO has used the following hemoglobin thresholds to
define anemia in adolescents
•Defined as a hemoglobin level of <12 g/dLfor girls (12 years
and older), or <13 g/dLfor boys (15 years and older)
•For Pregnant adolescents and women: hemoglobin <11 g/dL
(1
st
and 3
rd
TM) and < 10.5 g/dl (2
nd
TM) (pregnant)

81. •Prevalence is higher in women of childbearing age,
children, and individuals living in low-and middle-
income countries
•The major causes of iron deficiency are
•dietary intake, reduced absorption, and blood loss .
•Menstrual blood losses account for approximately 1 mg of iron loss per
day

82. Whom to screen:-
●Risk factor-based screening:
Review of risk factors for IDA at least annually during
adolescence, especially for dietary iron intake, heavy
menstrual blood loss, or history or symptoms of IDA
Laboratory screening for any adolescent if any major risk
factors are identified.
AND
●Universal screening for females, on one occasion
In adolescent females in whom no risk factors are identified,
we suggest laboratory screening (regardless of risk factors)
at least every five years, starting at age 12

83. Ironis required for hemoglobin production, fetal and placental
tissue production/ development and to expand the maternal red
cell mass
•Pregnancy is associated with iron requirements, and iron
deficiency is common, especially in individuals who are
not iron replete before the pregnancy
•IDA risk of maternal death, PTB, LBW

84. TREATMENT
For patients with a presumptive diagnosis IDA, we
suggest each of the following steps:
A.trial of treatment with oral iron supplements
Ferrous fumarate–324 or 325 mg tablet (contains 106 mg
elemental iron per tablet)
Ferrous gluconate
•240 mg tablet (contains 27 mg elemental iron per tablet)
•324 mg tablet (contains 38 mg elemental iron per tablet)
•325 mg tablet (contains 36 mg elemental iron per tablet)
Ferrous sulfate-325 mg tablet (contains 65 mg elemental iron
per tablet)

85. For adolescents with iron deficiency ferrous sulfateis
recommended (providing 65 to 130 mgelemental iron ,
typically one to two tablets once daily, for at least 3months),
because it was effective and generally well tolerated.
To enhance absorption of iron instruct women to
•Take iron when eating meat/vitamin—rich foods (fruit and vegetables)
•Avoid tea, coffee, and milk at the same time when taking iron

86. B. Dietary counseling to improve iron intake
•Dietary sources of iron are found in meat, grains, fruits, and
vegetables
C. Measures to evaluate and treat any underlying cause of
the blood loss
•any underlying cause should be treated to ensure appropriate
response to iron therapy and prevent recurrence (eg. Those
with heavy menstrual bleeding should have guidance on
options available to control bleeding)
D. Follow-up monitoring to ensure response to the
supplementation, which also helps to confirm the diagnosis
of iron deficiency
•CBC, with hemoglobin, hematocrit should be checked four
weeks after initiation of iron therapy to assess clinical
improvement and therapeutic efficacy

87. Lifestyle habits
•Exposure to tobacco, alcohol, and illicit drugs can be
harmful to both the mother and fetus
Alcohol
•Ethyl alcohol or ethanol is a potent teratogen (it freely
crosses the placenta)
•that causes a fetal syndrome characterized by growth restriction,
facial abnormalities, and central nervous system dysfunction
•The spectrum of alcohol-related fetal defects known as fetal
alcohol syndrome.
•For every child with the syndrome, many more are born
with neurobehavioral deficits from alcohol exposure

88. –no exact dose-response relationship between the amount
of alcohol consumed during the prenatal period and the
extent of damage caused by alcohol in the infant

89. A baby born with FAS has a face that looks different from
those of other babies
In children with FAS, symptoms can include:
•"Developmental delays" –they take longer to do things than other
children the same age can do, such as walking and talking
•Being more active than normal
•Having weak, floppy muscles
•Having problems with learning, hearing, and seeing
In teenagers and adults with FAS, symptoms might include
problems with:
•Thinking and memory
•Paying attention and concentrating
•Getting along with other people

90. •There is no known safe level of alcohol consumption
during pregnancy.
Despite the well-reported adverse effects of
drinking during pregnancy, the practice continues.
•No exact dose-response relationship has been
established between the amount of consumption and
the severity of the complications to the infant.
•Alcohol-related birth defects include cardiac and renal
anomalies, orthopedicproblems, and abnormalities of
the eyes and ears
•NB :-no amount of alcohol can be considered safe in
pregnancy (ACOG,CDC)

91. •Clearly, alcohol consumption during pregnancy is a
major public health issue.
•It should not be assumed that most women will quit
drinking during pregnancy.
•The recommendation for abstinence should be
emphasized to any woman contemplating pregnancy.

92. •Preconception counseling has been shown to lead to
an increased rate of cessation of drinking prior to
pregnancy.

93. Tobacco
•Cigarette smoking is the leading preventable cause of
perinatal mortality
•There are many potential teratogens in cigarette smoke,
including
•nicotine, carbon monoxide, cadmium, lead, and hydrocarbons
•Which are responsible for adverse pregnancy outcomes such as:
•Abortion, preterm birth, IUGR, infant death, stillbirth, LBW
•increases the risk of infertility, placental abruption, placenta previa and
premature membrane rupture\
•In addition to being fetotoxic, many of these substances have
vasoactive effects or reduce oxygen levels

94. •Cigarette smoking and exposure to second-hand smoke have been
associated with up to a 1.5-fold risk for orofacialclefts
•All forms of nicotine cross the placenta
•NB:-Therefore, smoking cessation should be strongly encouraged
and counseling includes avoidance of secondhand smoke prior to
conception
Five A’s of Smoking Cessation

95. •Women who stop smoking early in pregnancy
generally have neonates with normal birth weights
(Cliver,1995).
•Cigarette smoking has also been linked to sub fertility
and spontaneous abortions, to an increased risk for
placenta previaand placental abruption, and to
preterm delivery.
•Smoking cessation should be achieved prior to
conception.

96. Drugs of Abuse (substance abuse)
Cocaine
•It is CNS stimulant, most adverse outcomes result from
its
•Vasoconstrictiveand hypertensive effects
•Serious potential maternal complications are
•cerebrovascular hemorrhage, myocardial damage, and
placental abruption.
•Cocaine use is also associated with fetal-growth restriction and
preterm delivery.
•Children exposed as fetuses have risks for behavioral
abnormalities and cognitive impairments

97. Marijuana
•Transferred across placenta and breast milk,
•Produce 5x the amount of carbon monoxide in cigarette
smoking
•Alter fetal oxygenation
•Associated with preterm delivery, deficits in problem-
solving skills, decreased attention span
NB:-women who are pregnant or contemplating
pregnancy should avoid marijuana use.

98. Opioids (narcotic)
•opioid refers to natural and synthetic substances with
morphine-like activity (morphine, codeine, heroin,
methadone, and buprenorphine)
•Heroin addiction is associated with adverse pregnancy
outcomes from the effects of repeated narcotic
withdrawal on the fetus and placenta.
•These include PTB, placental abruption, IUGR, and fetal
death.
•Neonatal narcotic withdrawal, called the neonatal
abstinence syndrome, may manifest in 40 to 90 percent of
exposed newborns

99. Caffeine
•Caffeine is metabolized slowly in pregnancy and
passes readily through the placenta to the fetus
•Moderate caffeine intake is common during
pregnancy, however, women who are pregnant or
trying to become pregnant should limit their
caffeine intake to no more than 200 mg/day
•Moderate consumption of coffee has not been
associated with any fetal risks
•Consumption of > five cups of coffee a day has
been shown to be associated with a slightly
increased risk of spontaneous abortion,
preterm birthin some studies
•the risk increased with increasing caffeine dose
•Other sources of caffeine include teas, hot cocoa,
chocolate, energy drinks, coffee ice cream

100. MEDICATION DURING PREGNANCY

101. •The Food and Drug Administration (FDA) estimates
that less than 1 percent of all birth defects are
caused by medications.

102. •Although only a relatively small number of medications
have proven to have harmful effects, there is significant
concern surrounding medication use in pregnancy.
•Examples of medications considered teratogenicare
shown in in the following .

104. The Food and Drug Administration
Classification System
•The system for evaluating drug safety in pregnancy
was developed in 1979.
•It was designed to provide therapeutic guidance by
using five categories—A, B, C, D, or X,

105. •Category A: Studies in pregnant women have not
shown an increased risk for fetal abnormalities if
administered during the first (second, third, or all)
trimester(s) of pregnancy, and the possibility of fetal
harm appears remote.

106. •Category B
Animal studies have shown an adverse effect, but
adequate and well-controlled studies in pregnant
women have failed to demonstrate a risk to the fetus
during the first trimester of pregnancy, and there is
no evidence of a risk in later trimesters.

107. Category C:
•Animal reproduction studies have shown that this
medication is teratogenic(or embryocidalor has
other adverse effect), and there are no adequate and
well-controlled studies in pregnant women.

108. •Category D: This medication can cause fetal harm
when administered to a pregnant woman. If this drug
is used during pregnancy or if a woman becomes
pregnant while taking this medication, she should be
explained of the potential hazard to the fetus.

109. •Category X: This medication is contraindicated in
women who are or may become pregnant.
•It may cause fetal harm.
If this drug is used during pregnancy or if a woman
becomes pregnant while taking this medication, she
should be apprised of the potential hazard to the fetus.

110. Vaccine preventable diseases
and vaccines
•Hepatitis B virus,
•Human papillomavirus
•Rubella and Varicella
•Tetanus & influenza

111. Hepatitis B virus
•The virus is transmitted by parenteral route, sexual
contact, vertical transmission and rarely through
breast milk.
•The risk of transmission to fetus ranges from 10% in
first trimester to as high as 90% in third trimester.
•HBV is not teratogenic.
•All pregnant women should be screened for HBV
infection at first antenatal visit.
•HBV infection can be prevented by vaccination and
the recombinant vaccine is safe in pregnancy (3
doses at 0, 1 and 6 months).

112. •All infants born to HBsAgpositive mothers should
receive :-
•Active immunization with HB vaccine (0.5 mL) and HBIG
(0.5ML)(HBV fighting antibodies) within 12 hrsof birth
•This is very effective (85–95%) to protect the infant
from HBV infection.
•Breastfeeding is not contraindicated.

113. Human Papillomavirus (HPV)
•HPV: Sexual transmitted virus that cause cervical cancer
•Cervical cancer is the most common female cancer
worldwide
•The overall HPV prevalence was 40 % in females aged 14
to 59 years.
•Prevalence is highest in younger women

114. HPV types: there are many types, but the most common
cause of disease are:
HPV 16 & 18 cause~ 70% of cervical cancer, and
types 31, 33, 45, 52, and 58 cause an additional 20
percent
HPV 6 & 11 cause 90 % of genital warts.
HPV vaccines reduce cervical cancer risk

115. •Threedifferent vaccines, which vary in the number of
HPV types they contain and target, have been clinically
developed, although not all are available in all locations
•QuadrivalentHPV vaccine (Gardasil) targets HPV types 6,
11, 16, and 18.
•9-valent vaccine (Gardasil 9) targets (6, 11, 16, and 18) as
well as types 31, 33, 45, 52, and 58.(most available)
•Bivalent vaccine (Cervarix) targets HPV types 16 and 18

116. •HPV vaccine is recommended at 11 to 12 years. It can
be administered starting at 9 years of age, and catch-up
vaccination is recommended for females aged 13 to 26
years who have not been previously vaccinated or who
have not completed the vaccine series
•In resource-limited settings WHO recommends that the
primary target of HPV vaccination programs be females
aged 9 to 14 years

117. Immunization schedule depends on the age of the
patient at vaccine initiation
•Individuals initiating the vaccine series before 15
years of age
•Two doses of HPV vaccine should be given at 0 and at 6 to 12
months. (antibody titers for HPV vaccine types were higher among females aged 9 to 14 years who
received two vaccine doses compared with females aged 16 to 26 years who received three vaccine doses)
•Individuals initiating the vaccine series at 15 years of
age or older
•Three doses of HPV vaccine should be given at 0, 1 to 2
(typically 2), and 6 months. (because of the lower immunologic
response to HPV vaccination in this population)
•Immunocompromisedpatients
•Three doses of HPV vaccine should be given at 0, 1 to 2, and
6 months regardless of age

118. Rubella virus
•Rubella or German measles is transmitted by
respiratory droplet exposure
•Fetal infection is by trans-placental route
throughout pregnancy.
•Risk of major anomalies when this infection occurs in
first, second and third month is approximately 60%,
25% and 10%, respectively
•The virus predominantly affects the fetus and is
extremely teratogenicif contracted within the first
trimester.

119. •There is increased chance of
•abortion, stillbirth and congenitally malformed baby.
•Multisystem abnormalities are seen following congenital
rubella infection.
•Congenital rubella syndrome (CRS) predominantly include
•Congenital deafness
•cardiac (septaldefects, PDA)
•hematologic (anemia, thrombocytopenia)
•liver and spleen (enlargement, jaundice)
•ophthalmic (cataracts, retinopathy, cloudy cornea)
•bone (osteopathy) and
•chromosomal abnormalities

120. •Vaccine(live attenuated rubellavirus (MMR
(Measel,Mump,Rubella)))=> prior to pregnancy only
(preferably during 11–13 years)
•pregnancy should be prevented within three
months by contraceptive.
NB: Active vaccination(live attenuated
vaccine) is not recommended in pregnant
women

121. Influenza virus
•Influenza is an acute respiratory illness caused by
influenza A or B viruses that occurs in outbreaks and
epidemics worldwide, mainly during the winter season
•Infection can be transmitted through sneezing and
coughing
•Effect on pregnancy
•miscarriage, preterm labor, PROM, pneumonia, ARDS, renal
failure, DIC and death.
•Severity of illness are high in pregnancy.
•Increased incidence of congenital malformation
(anencephaly) when the infection occurred in the first
trimester
•Influenza (inactivated) vaccine is safe in pregnancy and
also with breastfeeding
•During influenza season, all pregnant women should be
given the inactivated vaccine (IM).

122. Chickenpox (Varicella zoster virus)
•Transmitted by:-
•infected secretions in the nasopharyngeal mucosa by
droplets onto the conjunctivalor nasal/oral mucosa.
•Direct contact with vesicular fluids that contain virus
•Does cross the placenta and may cause congenital or
neonatal chickenpox
•Congenital varicella syndrome (CVS) is
characterized by:
•Hypoplasia of limb, psychomotor retardation, IUGR,
chorioretinalscarring, cataracts, microcephaly and
cutaneous scarring.
•The risk of congenital malformation is nearly absent
when maternal infection occurs after 20 weeks.

123. •The Advisory Committee on Immunization Practices
recommends that all women of child-bearing age be
assessed prior to conception for evidence of varicella
immunity by either :
•A history of previous vaccination
•Prior varicella infection
•Laboratory evidence of immunity

124. •PRE-EXPOSURE PROPHYLAXIS —VARIVAX, a live
attenuated varicella vaccine, is recommended (2 doses four
to eight weeks apart) to prevent varicella-related morbidity
and mortality
Avoid becoming pregnant for one month after
immunization
•Varicella zoster immunoglobulin (VZIG) should be
given to exposed non-immune patients as it reduces the
morbidity.
•Administered ideally within 72 hours postexposurebut may be
used up to 120 hours (5 days) postexposure

125. •Postexposureprophylaxis is not needed among women
who were immunized with varicella vaccinein the past
•VZIG should also be given to newborn exposed within 5
days of delivery.
•Oral acyclovir, valacycloviris safe in pregnancy and
reduce the duration of illness when given within 24 hours
of the rash. However, it cannot prevent congenital
infection

126. Tetanus and diphtheria
Tetanus is a nervous system disorder characterized by muscle
spasms that is caused by the toxin-producing anaerobe bacteria
Clostridium tetani, which is found in the soil
Diphtheria is an acute respiratory or cutaneous illness caused
by Corynebacteriumdiphtheriae
Td vaccine contains tetanus toxoid and reduced diphtheria toxoid (0.5
mL IM)
•Protection for both mother and neonate

127. •After three doses, almost everyone is
initially immune
•Levels of antibody diminish with time. Booster doses of
tetanus toxoid, reduced diphtheria toxoid are necessary
every 10 years throughout life
•Safe during pregnancy
Visit Interval Antigen
1 0 as early as possible Td1
2 At least 4 week after Td1Td2
3 At least 6 month after Td3
4 At least 1 year after Td3Td4
5 At least 1 year after Td4Td5

128. •Genetic disorders
•Neural Tube Defects

129. Objectives
At the end of this class, you will be able to:-
Discuss types of Genetic disorders
Explain Neural Tube Defects

130. Family history/genetic screening
Genetic disorder is an inherited medical condition caused
by a DNA abnormality.
Screening disease that could be transferred genetically
before and during pregnancy has vital role for better
pregnancy outcomes.
3% of live born infants will have a major congenital
anomaly; about half of these anomalies are due to:-
a genetic cause—a chromosome abnormality, single-gene
mutation, or polygenic/ multifactorial inheritance

131. •The time to screen appropriate populations for genetic
disease-carrier status and multifactorial congenital
malformations or familial diseases with major genetic
components is before pregnancy.
•If patients screen positive, referral for genetic
counseling is indicated, and consideration of additional
preconception options may be warranted including
•donor egg or sperm, prenatal genetic testing after conception,
or adoption

132. •Certain diseases may be related to race/ethnicity or
geographic origin
•Patients of African, Asian, or Mediterranean descent should be
screened for the various heritable hemoglobinopathies(sickle
cell disease, α-and β-thalassemia)
•Patients of Jewish and French-Canadian heritage should be
screened for Tay-Sachs disease, Canavan disease, and cystic
fibrosis
•In the United States, it has been suggested that cystic
fibrosis screening be offered to all couples planning a
pregnancy or seeking prenatal testing.

133. •Obstetricians/gynecologists should attempt to take a thorough
personal and family history to determine:-
•whether a woman, her partner, or a relative has a heritable disorder,
birth defect, mental retardation, or psychiatric disorder that may
increase their risk of having an affected offspring.
•The clinician should inquire into the health status of
•First-degree relatives (siblings, parents, offspring)
•Second-degree relatives (nephews, nieces, aunts, uncles,
grandparents), and
•Third-degree relatives (first cousins, especially maternal).
•A positive family history of a genetic disorder may warrant
referral to a clinical geneticist or genetic counselor who can
accurately assess the risk of having an affected offspring and
review genetic screening and testing options.

134. A gene is the basic physical and functional unit of heredity.
Types of Genetic disorders
1.Single gene defect; sickle cell disease/thalassemia, cystic fibrosis
2.Chromosome disorders:it can be numerical and structural
e.gDown syndrome (Trisomy 21) a total of 47 chromosomes per cell
Turner syndrome, one of the X chromosomes is missing or
partially missing.
Noted Typically, a baby is born with 46 chromosomes.

135. 3)Multi-gene defects(Multifactorial and Polygenic):
Heart disease,
High blood pressure,
Alzheimer's disease,
Diabetes,
Cancer, and.
Obesity
Genetic disorders are not curable but can only be
prevented.
There is no treatment that will prevent embryos from
having chromosome abnormalities

136. Hemoglobinopathies
•Normal hemoglobin: two pairs of polypeptide chains
•Two alphaand two beta (HbA(α2 β2))
Hemoglobinopathies: genetic synthesis disorders
within the polypeptide chains of globin fraction (result
abnormal production or structure of the hemoglobin
molecule)
Two type:-
Sickle cell disease (inherited structural abnormality
involving primarily the β chain of HbA)
Thalassemias(inherited defect in the synthesis and
production of globin in otherwise normal HbA/ reduced
synthesis of alpha-or beta-globin chains)

137. Sickle cell Hemoglobinopathies(SCA)
•It is the structural abnormalities of hemoglobin
•Hemolytic anemia and microvascularobstruction by red
blood cell agglutination
•Sickle cells have a life span of 5–10 days compared to normal
RBCs of 120 days (cells have got shorter life span and are more
fragile).
•Increased destruction leads to hemolysis, anemia and jaundice.
•Accumulate iron and become iron overloadeddespite having
microcytic anemia

139. •Characterized by “sickle cell crisis,”
•Hemolytic crisis : It is due to hemolysis with rapidly
developing anemia along with jaundice.
•Painful (vaso-occlusive) crisis: It is due to vascular occlusion
of the various organs by capillary thrombosis resulting in
infarction and ischemia.
•Organs commonly affected due to vaso-occlusion and infarction are:
bones(osteonecrosis), kidney(renal medulla), hepatosplenomegaly,
lung(infarction) and heart(failure), neurologic(seizures, stroke) and
super added infections are high

140. •Women with SA have an increased risk for:-
•spontaneous abortion,
•preterm labor,
•preeclampsia, PPH, infection
•stillbirth, fetal growth restriction,
•prematurity, and low birth weight.
•Increased maternal morbidity is due to infection (UTIs),
cerebrovascular accident and sickle cell crisis.
•Maternal death is increased up to 25% due to pulmonary
infarction, acute chest syndrome, congestive heart failure and
embolism.

141. •Increased risk for urinary tract infections
•secondary to increased levels of free iron in the urine
•Screening of the father of the fetus is offered, to
identify disease/trait
Father XX
Mother Xx
•XX-normal
•Xx-carrier
•xx-disease
X x
XXX Xx
XXX Xx

142. •If both parents are trait/carriers the fetus will have
25% chance of disease
•Father Xx
•Mother Xx
•XX-normal
•Xx-carrier
•xx-disease
X x
XXX Xx
xXx xx
X-dominant
x-recessive

143. Preconceptional counseling:
•Prenatal identification of homozygous state of the
disorder is an indication for early termination of the
pregnancy, if the parents desire.
•Unless these women need specialized care during
pregnancy and management needs multidisciplinary team
approach.
•women with sickle-cell hemoglobinopathiesrequire close
prenatal observation.
•Prenatal folic acid supplementation with 4 mg daily is needed
to support rapid red blood cell turnover.

144. •Prophylactic booster or exchange blood transfusion may be
given (the objective of transfusion is to keep the hematocrit
value above 25%, and concentration of Hbunder 60%)
•Infection (pneumococcal) or appearance of unusual symptoms
necessitates hospitalization.
•Penicillin prophylaxis is given to all patients with SCD as they
are at risk of infection withS. pneumoniaeand H. influenzae
•CDC recommends specific vaccination for those with
sickle-cell disease (polyvalent pneumococcal,
Haemophilusinfluenzaetype B, and meningococcal
vaccines)

145. Thalassemia
•It is commonly found genetic disorders of the blood.
The basic defect is a reduced rate of globin chain
synthesis (reduced synthesis of alpha-or beta-globin
chains,)
As a result, the red cells being formed with an inadequate
oxygen-carrying protein (haemoglobin) content.
•May result varying degrees of ineffective erythropoiesis,
hemolysis, and anemia
•Severe forms may require blood transfusions or a donor
stem-cell(bone marrow) transplant.

146. Thalassemiasare classified according to the globin
that is deficient. :-
•α-thalassemia (impaired production or instability of α-
globin)
•β-thalassemia (impaired production or instability of β-
globin)

147. Cystic fibrosis
A hereditary disorder affecting the exocrine glands( produce
mucus, sweat and digestive juices)
Damages the lungs and digestive system
Exocrine gland ductal obstruction develops from thick, viscid
secretions.
In the lung, submucosalglandular ducts are affected
Sweat gland abnormalities are the basis for the diagnostic
sweat test, characterized by elevated sodium, potassium, and
chloride levels in sweat

148. •lung involvement is common place and is usually the
cause of death.
•Bronchial gland hypertrophy with mucous plugging and
small-airway obstruction leads to subsequent infection
that ultimately causes chronic bronchitis and
bronchiectasis.

149. Symptoms of CF
Very salty-tasting skin.
Persistent coughing, .
Frequent lung infections including pneumonia
Wheezing or shortness of breath.
Poor growth or weight gain in spite of a good appetite.
Women with clinical cystic fibrosis are sub fertile
because of tenacious cervical mucus

150. •Pre-pregnancy counseling is imperative.
•Women who choose to become pregnant require close
surveillance for development of superimposed infection
and heart failure.
•Serial pulmonary function testing assists management
and estimates prognosis.
•Emphasisis placed on bronchodilator therapy, and
infection control
•β-Adrenergic bronchodilators help control airway
constriction

151. Neural-Tube Defects (NTDs)
•The incidence of NTDs is 0.9 per 1000 live births, and
they are second only to cardiac anomalies as the most
frequent structural fetal malformation.
•NTDs arebirth defects of the brain, spine, or spinal
cord
•The cause is not clear but may berelated to genetics,
maternal nutrition (including folic acid deficiency)
during pregnancy. DM,anti-seizure medicines..
•Preconception folic acid therapy significantly reduced the
risk for a recurrent NTD by 72 %.

152. Folic acid supplementation
For all women of childbearing
•No history of NTD:
•0.4 mg/day (400mcg) ……………. ACOG,CDC
•0.4mg/day (400mcg) –0.8 mg/day (800mcg)… USPSTF
•Prior infant with NTD:
•4 mg/d (4000mcg) or 5 mg/day (5000 mcg) and advised to increase
their food intake of folate

153. occupational hazards and environmental toxins
Gender-based violence (GBV)
PCC delivery strategies

154. Objectives
At the end of this class, the student will be able to :-
•Describe occupational hazards and environmental
toxins during preconception
•Discuss Gender-based violence (GBV)
•Explain PCC delivery strategies

155. Occupational Hazards and Environmental
Exposures
•Occupational hazards should be identified.
•If a patient works in a laboratory with chemicals or in
agriculture around a lot of pesticides, she should be
advised to identify potential reproductive toxins and
limit her exposure

156. •For example,
•pesticideshave been associated with impaired cognitive
development and fetal growth and increased risk of childhood
cancers.
•BisphenolA (BPA) is a chemical primarily used in the
manufacturing of various plasticsand has been associated with
recurrent miscarriages and aggression and hyperactivity in girls.
•High-dose ionizing radiation-during gestation causes
microcephaly and mental retardation in children

157. •Excess exposure to methyl mercury or lead is associated
with neurodevelopmental disorders
•Mercuryin high levels may harm an unborn baby or young
child’s developing nervous system.
•For this reason pregnant and nursing women should avoid shark,
swordfish, king mackerel, and tile fish
•In occupational settings, federal standards mandate that women
should not work in areas where air lead concentrations can reach
50 μg/cm because this can result in blood concentrations above
25 to 30 μg/dL
•lead concentrations in blood should not exceed 25 μg/dLin
women of reproductive age
•Ideally, the maternal blood lead level should be less than 10
μg/dLto ensure that a child begins life with minimal lead
exposure.

158. •Patients whose occupations require heavy physical
exercise or excess stress should be informed that they may
need to decrease such activity later in pregnancy because
both have been associated with an increased risk of PTB
and reduced fetal growth
•Activities to avoid
Heavy lifting
Standing for long time
Holding breath when working
out
Any exercise that compromise
the balance
Jumping

159. Gender-based violence (GBV)
•Sex:
Biologicalandphysiologicalattributesofthatidentifya
personasmaleorfemale
•Gender:
Sociallyconstructedrolesascribedtomenandwomen
•Referstotheroles,activitiesandresponsibilities
assignedtomenandwomeningivensociety,
culture,communityortime

160. Sex VsGender

161. •GBV is a general term
for any harmful act that
is perpetrated against a
person’s will
•that can result in sexual,
psychological, or
physical harm and
suffering of women
•It is a global pandemic
that affects 1 in 3 women
in their lifetime.
•Such
physical/psychological/sexual
violence can be perpetrated by
an intimate partner within a
relationship, by other family
members, by acquaintances, or
by the general community

163. •Violence against women could be domestic at home or
outside(at school, on the road, workplace…)
•Violence among women can be in several forms
i.Sexual violence: -Any sexual act performed on an
individual without their consent. It can take the form of
rape or sexual assault.
ii.Physical violence: -This includes causing injury or
harm to the body by, for example, hitting, kicking or
beating, pushing, hurting with a weapon/object.

164. iii. Emotional and psychological violence:-any act which
causes psychological harm to an individual. for example,
humiliating, defamation, verbal insult or harassment.
v. Socio economic violence:-: Causing/or attempting to
cause an individual to become financially dependent on
another person.

165. Intimate partner violence(IPV)
•IPV: It embraces physical, sexual,
psychological/emotional, as well as economic abuse by a
current or previous intimate partner
•Pregnancy can exacerbate interpersonal problems and is a
time of elevated risk from an abusive partner
•IPV is associated with greater risk for several pregnancy-
related complications that include :-
•HTN, vaginal bleeding, hyperemesis, PTB, and LBW neonates
•Because IPV can escalate during pregnancy, even to the
point of homicide, the preconceptional period provides an
ideal time for screening and intervention

166. •With all types of violence against woman, there are serious
and potentially life threatening outcomes

167. Clinical assessments of IPV
The WHO does not recommend universal screening
for VAW rather raise the topic with women who have
injuriesor conditions that suspect may be related to
violence like:-
•On-going stress, anxiety or depression; substance misuse
•Thoughts, plans or acts of self-harm or (attempted) suicide
•Repeated STIs
•Unwanted pregnancies
•Often misses health-care appointments

168. •ACOGrecommends that all patients should be screened
during:-
•annual examinations, family planning, and preconception
visits, and
•screening for pregnant women should take place at various
times throughout the pregnancy, including the initial prenatal
visit, at least once per trimester, and the postpartum checkup
•As well, the United States Preventive Services Task Force
(USPSTF) and the American Nurses Association (ANA)
also recommend to screening all women of
childbearing age for IPV and providing services for
those who screen positive

169. 1.Help women feel welcome, safe and free to talk
•Help women feel comfortable speaking freely about any
personal issue, including violence.
•Assure every woman that her visit will be confidential.
2.If you suspect violence ask about it
•To explore whether a client is experiencing partner
violence and to support her disclosure of violence, you
can first approach the topic indirectly. for example:
•“Many women experience problems with their husband or
partner or someone else they live with.”
•“I have seen women with problems like yours who have been
having trouble at home.”
NB: Do not ask such questions when a woman’s partner or
anyone else is present or when privacy cannot be ensured.

170. Follow it up with more direct questions
•“Are you afraid of your husband (or partner)?” ” If yes,
“Could you tell me why you are afraid?”
•“Has your husband (or partner) or someone else at home ever
threatened to hurt you or physically harm you in some way? If
so, when has this happened?”
•“Does your husband (or partner) or someone at home bully
you or insult you or try to control you?”
•“Has your husband (or partner) forced you into sex or forced
you to have any sexual contact you did not want?”
you suspect a violence, but if she doesn’t disclose it
•Do not pressurize the person, and give her time to decide what
she wants to tell you.
•Inform the person about services that are available if she
chooses to use them.
•Offer information on the effects of violence on survivor’s
health and their children’s health.
•Offer the person a follow-up visit.

171. 3. First-line support –it provides practical care and
responds to a survivor’s emotional, physical, safety and
support needs, without intruding on her privacy
-has 5 tasks “ LIVES”
•Listen –closely with empathy, and non judgmental

172. •Inquire about needs and concerns-Assess and respond
to her various needs and concerns.
•She may let you know about physical needs, emotional needs,
or economic needs, her safety concerns, or social support that
she needs.
•Validate -Show her that you understand and believe her
•Enhance safety-Discuss a plan to protect her from
further harm if violence occurs again
•Support:-Support her by helping her connect to
information, services and social support.

173. 4.Provide appropriate care –either direct service delivery
or referral
•This involves direct service delivery (e.g. counseling,..),
•Referral for services we don’t provide advocacy and
support.

174. When IPV is screened ?
•Health care professionals can screen woman they
come to
Reproductive health/Family planning
Initial prenatal visit and at least once in each
trimester
Postpartum checkup
Emergency department and whenever depressed

175. Preconception care
delivery strategies

176. Objectives
At the end of this session ,you will be able to:
•Discuss opportunities for delivery and
integrating PCC services

177. Preconception care delivery strategies
•Interventions that are implemented in various settings
particularly in low-income countries face the challenge of
a lack of standardization across the line of
•service delivery, community outreach, and organizational
policies.
•To ensure sustainability and to be as efficient as possible
at meeting health care outcomes, the measure of
integration with existing health care systems and within
other delivery platform is vital.
•As a result, existing systems are strengthened and
improved further, sparking positive development in the
form of viable healthcare networks in such communities

178. Opportunities for delivery and integrating PCC services
A.Delivery within the education system
School health and reproductive health education programs
•Information and services must be made available to
adolescents to educate them on their sexuality and protect
themselves from unwanted pregnancies, STIs, or risks of
infertility
•All females should be counseled about eating disorders,
and the risks to fertility and future pregnancies it might
have.

179. •The reproductive and sexual health program should be
integrated as a vital component of the school curricula
and must be tested upon to emphasize its importance.
•Adolescents should be guided as to:-
•how to make responsible decisions concerning their sexual
lives
•how to practice safe sex, and how to prevent unwanted
pregnancies.

180. B. Delivery within health system
Primary-level health workers (e.g. community health
workers(CHWs))
•CHWs can be trained to offer guidance and increase
awareness regarding STIs, to assess maternal health and
nutrition status in order to improve postpartum outcomes.
•Folic acid, iron and micronutrient supplementations may
also be distributed.

181. •They can also provide information about family planning,
vaccinations or immunizations, proper growth monitoring,
nutrition for neonates and control of common diseases can
be implemented.
•Health education that is a vital part of PCC and health
promotion, but which may be impractical to distribute
effectively in most clinical settings, especially in busy
health clinics with large patient to doctor ratios can utilize
CHWs to increase awareness levels.

182. Pre-marital counseling and screening
•Pre-marital counseling and screening allows couples to test
for the presence of infectious diseases such as HIV/ AIDS,
Hepatitis B, syphilis or for genetic diseases to ensure
proper care is taken before a pregnancy is planned
•Such services should be available at all clinics/outreach
clinics and doctors should make patients aware that this is
a necessary and important step to take before starting a
family.
post-natal care
Take advantage of other health visits

183. C Other platforms
Community support groups
•Community-based programs that provide pre-conception
services will provide directly to the specific needs of the
particular community.
•Members of support groups are usually facing similar
issues and can benefit greatly from the shared experiences,
advice and health support of the other participants.
•Key issues of the community such as a high rate of teenage
pregnancies or poor family planning services can also be
targeted and interventions can then be tailored and
implemented accordingly

184. Mass media campaigns/ Social marketing
•Many of the interventions can be delivered through health
facilities but to reach a larger audience mass mobile text
messages or radio announcements may also be used where
applicable.
•Mass campaigns regarding
•immunization programs,family planning, safer sexual practices,
especially using condoms to prevent STIs, a healthy image of
utilizing pre-conception care at local health facilities.

185. •A challenge faced in developing countries is that many
at-risk young adults are illiterate, or have poor exposure
to educational programs therefore
•mass media may be a very useful tool for effectively
transmitting basic health messages to such a population.
•It can also be an instrument for changing behavioral
stereotypes, pre-formed attitudes, myths and
misconceptions regarding reproductive health

186. Con…
Workplace programs
•Educational workshops may be conducted that are
mandatory in workplace venues where men and
women both need to attend sessions on sexual
health/STI’s, smoking cessation, and other health-
related topics.

187. Con…
Food fortification
•Food fortification is the practice of adding
micronutrients to processed foods for an increase in
the micronutrient status of a population and a
decrease in deficiencies and related programs.
•A very cost-effective program, the addition of folic
acid to enrich flour, rice and pasta takes advantage
of existing technologies and local distribution
networks.

188. STI

189. Objectives
At the end of this session ,you will be able to:
Discuss syndromicmanagement of STI
Identify causative agent of each STI
ExplainComplications of STI

190. Sexual transmitted disease

191. Sexual transmitted disease…
Risk factors
Blood transfusion
Organ transplantation
Misuse of alcohol or use of recreational drugs
Multiple sexual partners
Breaking skin
Inconsistent condom use

192. STI diagnostic approaches
Diagnostic approaches
Etiologic
identifying the causative
agent(s) using laboratory and
giving treatment targeting to
the pathogen identified
Advantages
Avoids over treatment
Can be used to screen
asymptomatic patients
Challenges
requires skilled personnel
and sophisticated lab
equipment.
Lab tests are expensive, time
consuming and results
may not be reliable
Clinical
Uses clinical experience to
identify symptoms which are
typical for a specific STI, then
giving treatment targeted, to
the suspected pathogen(s)
Saves time for patients
• Reduces lab expenses
Requires high clinical skill
• Mixed infections often
overlooked
• Doesn’t identify
asymptomatic STIs
SyndromicIdentification of
clinical syndrome and giving
treatment targeting all the
locally known pathogens
which
can cause the syndrome
Complete STI care
• Simple, rapid and
inexpensive
• Patients treated for
possible
mixed, infections
• Curtails unnecessary
referral t
Risk of over-treatment
• Asymptomatic infections
are missed

193. Sexual transmitted disease…
A syndrome is simply a group of symptoms a patient
complains about and the clinical signs one can observe
during examination of the patient.
Syndromicmanagement of STI
•It is problem oriented (it responds to the patient’s symptoms).
•It is highly sensitive and does not miss mixed infections.
•Uses flow charts that guide the health worker through logical
steps.
•Provides opportunity and time for education and counseling.
•It enables all trained first line health care providers to diagnose
STI syndromes and treat patients on the spot, without waiting
for laboratory results.
•It will help to offer treatment on the initial visit which is an
important step to stop the spread of the disease.

194. STI Syndromes
The commonly encountered STI syndromes
include:
1)Urethral discharge
2)Vaginal discharge
3)Genital ulcer in men and women
4)Lower abdomen pain in women
5)Scrotal swelling
6)Inguinal Bubo
7)Neonatal conjunctivitis

195. Syndromic Flow Chart
A flow chart, also known as algorithm, is a diagram
(map) representing steps to be taken through a
process of decision making.
Can be used at any time in all types of health
facilities.

196. Cont…
Each flow-chart is made up of a series of three
steps.
The clinical problem: patient’s complains/
presenting symptoms.
Problem Box
The decision to be made: this is the box, which
requires further information, which the health care
provider finds out by taking a history or examining
the patient.

197. Cont…
A decision to make usually by answering Yesor
Noto a question
Decision box
The action to be taken (what you need to do):
This is the box that instructs the service provider
on what action to take.
Action box

198. Example of syndromic management
flowchart

199. Cont…
Steps in Syndromic STI Case Management
1.History taking and examination.
2.Syndromic diagnosis and treatment, using flow
charts.
3.Education and counseling on HIV testing and safer
sex, including condom promotion and provision.
4.Management of sexual partners.
5.Recording and reporting

200. History taking and physical examination
Things to consider during Hx&PE
The environment
•Confidentiality and privacy
The service provider
•understands and respects them and wants to listen
The patient’s basic needs
•The patient may be concerned or embarrassed
NotedCommunication skills necessary for establishing
rapport

201. 1.
•Urethral discharge is the presence of abnormal
secretions from the distal part of the urethra and
it is the characteristic manifestation of urethritis.
•Urethral discharge is one of the commonest
sexually transmitted infections among men in our
country
Causative agents
•UD can be caused by many different causative micro-
organisms
•N.gonorrhea& C.trachomatisare most common causes (81%
and 36.8%,resp., 2014 EPHI)
•Some of the other causative micro-organisms are mycoplasma
genitalium, Trichomonasvaginalis, and Ureaplasma
urealyticum.

202. •Clinical presentations
Burning sensation (dysuria)during urination,
increased urgency and frequency of urination
with itching sensation of the urethra
urethral discharge (amount and nature of the
discharge vary according to the causative agents
and other factors like prior treatments with
antibiotics)
The urethritis caused by N. gonorrhea has usually an acute onset with profuse
and purulent dischargeand the one caused by C. trachomatis has sub-acute
onset with scant mucopurulent discharge.
•Complications
•Disseminated gonococci syndrome
•Urethral stricture
•Infertility
•Enhanced transmission of HIV ( five fold)

203. Urethral discharge

205. Treatment:
•Pharmacologic Treatment should target gonorrhea and
chlamydial infections.
•First line (preferred)
•Ceftriaxone 250mg IM stat plusAzithromycin 1gm postat
•Alternative
•Ciprofloxacin, 500mg PO stat/Spectinomycin2 gmIM stat
PLUS
•Doxycycline 100 mg pobid for 7 days/Tetracycline 500 mg po
QID for 7 days/Erythromycin 500 mg poQID for 7 days in
cases of contraindications for Tetracycline (e.g. for children
and pregnancy)
NB: Patients should be advised to return if symptoms
persist for 7days after the initiation of treatment.

206. TREATMENT OF PERSISTENT/RECURRENT URETHRITIS
SYNDROME
•Re-treat with initial regimen
•If non-compliant or re-exposure occurs ,re-treat with the initial
regimen with due emphasis on drug compliance and/or partner
management.
•Cover Mycoplasmagenitaliumand Trichomonasvaginalis
•If compliant with the initial regimen and re-exposure can be
excluded, the recommended drug for persistent or recurrent urethral
discharge syndrome in Ethiopia is:
•Metronidazole 2 gmpo. stat/Tinidazole1gm poonce for 3 days
(Avoid Alcohol!) PLUS
•Azithromycin 1 g orally in a single dose (only if not used during the
initial episode to address doxycycline resistant M.genitalium)
•Referral: Despite all these treatments, if symptoms still
persist the patient should be referred for further work-up.

208. Genital Ulcer Syndrome

209. •Commonly genital ulcer is caused by bacteria and
viruses.
•Genital ulcer facilitates transmission of HIV more than
other sexually transmitted infections because it
disrupts continuity of skins and mucous membranes
significantly
ETIOLOGY OF GENITAL ULCER SYNDROME
•There are different kinds of bacteria and viruses which
cause genital ulcer.
•Some of the common etiologies of genital ulcer
syndrome are:
•Herpes simplex virus (HSV-1and HSV-2)
•Treponemapallidum(syphilis)
•Haemophiliusducreyia(chancroid)
•Chlamydia trachomatis serovar L1, L2 & L3 (LGV)

210. •GUS has different kinds of clinical manifestations due to
different causatives
Common clinical manifestations of genital ulcer are:
•Constitutional symptoms such as Fever, headache, malaise and
muscular pain
•Recurrent painful vesicles and irritations
•Shallow and non-indurated tender ulcers
•Painless indurated (hardened) ulcer (Chancre)
•Regional lymphadenopathy
•Common sites in male are glance penis, prepuce and penile
shaft
•Common sites in women are vulva, perineum, vagina and cervix
and can cause occasionally severe vulvo-vaginitis and
necrotizing cervicitis

211. Genital Ulcer Syndrome flow chart

212. Treatment
Non pharmacologic: Prevent secondary infection by local
cleaning
•Pharmacologic
I.Treatment for non vesicular genital ulcer
•Benzathinepenicillin G, 2.4 million units IM single dose OR
Doxycycline, 100 mg P.O. BID for 14 days (for penicillin allergy) PLUS
•Ciprofloxacin 500 mg pobid for 3 days /OR Erythromycin 500 mg po
qidfor 7 days PLUS
•Acyclovir400mg TID orally for 10 days (or 200 mg five times per day of
10 day)
II. Treatment for vesicular, multiple or recurrent genital ulcer
•Acyclovir200 mg five times per day for 10 days Or Acyclovir 400 mg
TID for 7 days
N.B. There is no medically proven role for topical acyclovir, its
use is discouraged.

213. III. Treatment of recurrent infectionepisodes:
Treatment should be initiated immediately after onset of
symptoms.
•Non pharmacologic:
Local care: Keep affected area clean and dry
•Pharmacologic
•Acyclovir 400 mg P.O. TID for 5 to 7 days,
IV. Suppressive treatment: recommended for patients
with 6 recurrences or more per year
•Acyclovir, 400mg P.O. BID for 1 year
N.B. The need for continued suppressive therapy should
be reassessed.

215. •Abnormal vaginal discharge in terms of quantity, color or odor could be most
commonly as a result of vaginal infections.
•But it is a poor indicator of cervicitis, especially in young girls because a large
proportion of them are asymptomatic.
•The most common causes of vaginal discharge are:-
1.Neisseria gonorrhoeae
2.Chlamydia trachomatis
3.Trichomonasvaginalis
4.Gardnerellavaginalis
5.Candida albicans
N.B: 1-3 are sexually acquired, whereas 4 and 5 are endogenous infection
•Bacterialvaginosis(Gardnerellavaginalis)istheleadingcauseofvaginal
dischargeinEthiopiafollowedbyCandidiasis,Trichomoniasis,Gonococcaland
Chylamydiacervicitisinthatorder

217. Risk Assessment
•While vaginal discharge is highly indicative of vaginal infection, it is
poorly predictive of cervical infection with gonorrhea and/or
chlamydia.
•The flowchart may become more predictive of cervical infection if a
number of risk factors indicative of cervical infection are included.

Age less than 25 years
Having multiple sexual partner in the last three months
Having new partner in the last three months
Ever traded sex
Note:The presence of one or more risk suggest cervicitis
•Premature rupture of membrane
• Pre -term labour
• Infertility
• Chronic pelvic pain, PID

220. Complications
PID Chorioamnionitis
Peritonitis and intra-
abdominal abscess
PROM and Preterm
labour in pregnant
women
Post-partum
endometritis
Chronic pelvic pain
Low birth weight
Adhesions and
intestinal obstruction
Ectopic pregnancy
Infertility

221. PID -Ascending infection of the uterus, fallopian tubes, ovaries,
& peritoneum
•PID is frequently poly-microbial.
•The commonest pathogens associated with PID, which are
transmitted sexually, are C. trachomatis and N. gonorrhoea.
•Other causes which may or may not be transmitted sexually
include:
•Mycoplasma genitalium
•Bacteroidesspecies
•E. coli
•H. influenza
•Streptococcus

222. CLINICAL MANIFESTATION
The commonest manifestations of pelvic inflammatory
diseases include
•Lower abdominal pain
•Abnormal vaginal discharge
•Inter-menstrual or post coital bleeding
•Dysuria
•Backache
•Fever, nausea and vomiting
•Cervical excitation tenderness
•Adnexal tenderness
•Rebound tenderness
•Adnexal mass

223. •Peritonitis and intra-abdominal abscess
•Adhesion and intestinal obstruction
•Ectopic pregnancy
•Infertility
•Chronic pelvic pain

225. Treatment
For Outpatient
Ceftriaxone250 mg IM stat
/Spectinomycin 2gm IMstat
Plus Azithromycin1gm po
stat/Doxycycline 100 mg
po bid for 14 days Plus
Metronidazole500 mg po
bid for 14 days.
Admit if there is no
improvement within 72
hours.
For Inpatient
Ceftriaxone 250 mg
IM/IV/Spectinomycin 2
gm IMbid Plus
Azithromycin 1gm po
daily /Doxycycline 100
mg po bid for 14 days
Plus
Metronidazole 500 mg
po bid for 14 days

226. Cont…
Note:
For inpatient PID, ceftriaxone, spectinomycin or
azithromycin should continue for 24hrs after the patient
remain clinically improved, after which doxycycline and
metronidazole should continue for a total of 14 days.

227. Indication for Inpatient Treatment
The diagnosis is uncertain The patient is pregnant
Pelvic abscess is
suspected
PID in HIV patients
Surgical emergencies such
as appendicitis and
ectopic pregnancy cannot
be excluded
The patient is unable
to follow or tolerate
an outpatient regimen
Severe illness precludes
management on an
outpatient basis
Patient has failed to
respond to outpatient
therapy.

228. Causes depend on the age of patients
• C.trachomatis& N.gonorrheaare
common causes in patients younger
than 35 years
• Scrotal swelling in patients older than
35 years is commonly caused by
gram negative bacteria & TB
Other causes of scrotal swelling
-testicular torsion
-Trauma
-Tumor
-incarcerated inguinal hernia

229. CLINICAL MANIFESTATIONS OF SCROTAL SWELLING
•Scrotal swelling can manifest itself with different signs
and symptoms. Some of the signs and symptoms of
scrotal swelling are:
•Pain and swelling of the scrotum
•Tender and hot scrotum on palpation
•Edema and erythema of the scrotum
•Dysuria
•Sometimes frequency and urethral discharge can be there
•It is important to exclude other causes of scrotal swelling
like testicular torsion, trauma, and incarcerated inguinal
hernia as they may require urgent referral for proper
surgical evaluation and management.

230. Take history and examine
Swelling/pain
confirmed?
Testis rotated or
elevated, or
history of trauma?
Treat GC & CT
•Educate on RR
•Promote & provide condoms
•partner(s) management
•Offer HIV testing
•Recording and reporting
•Review in 7 days or earlier if
necessary, if worse, refer
No
•Reassure patient/educate
•Promote and provide condoms
•Analgesics
No
Refer immediately
for surgical opinion
complains of scrotal swelling/pain
Yes
Yes

231. •
•Epididymitis
•Infertility
•Impotence

232. Treatment
•The preferedregimen is Ceftriaxone 250mg IM stat
plus Azithromycin 1gm postat
Alternative
•Ciprofloxacin, 500mg PO stat/Spectinomycin2 gmIM
stat PLUS
•Doxycycline 100 mg pobid for 7 days/Tetracycline 500
mg poQID for 7 days/Erythromycin 500 mg poQID for
7 days in cases of contraindications for Tetracycline
(e.g. for children and pregnancy)

233. 6. Inguinal Bubo Syndrome
Inguinal bubo is defined as swelling of inguinal lymph
nodes as a result of STIs.
It should be remembered that infections on the
lower extremities or in the perineum could
produce swelling of the inguinal lymph nodes.

234. Etiology
The common causes of inguinal and femoral bubo
are:
Chlamydia trachomatis (L1, L2 and L3)
Klebsiella granulomatis (Donovanosis)
Treponema pallidum
Haemophilus Ducreyi

235. Clinical Manifestations
Constitutional symptoms of fever, headache and
pain.
Tender unilateral or bilateral lymphadenopathy
forms a classical “groove sign” in the inguinal area.
Fluctuant abscess formation which forma coalesce
mass (bubo).
Some time concomitantly occur with genital ulcer.

237. Treatment
Ciprofloxacin 500mg po BID for 3 days Plus
Doxycycline 100 mg po BID for 14 days
/Erythromycin 500mg po QID for 14 days.
If patient have genital ulcer, add Acyclovir 400mg
po TID for 10 days OR 200mg five times per day for
10 days).

238. Cont…
Sometimes, T. Pallidum can causes inguinal
lymphadenopathy. However, unlike other causes, it
doesn’t cause necrosis and abscess collection in
the lymph nodes.
In conditions where the clinical examination
doesn't reveal a fluctuant bubo, syphilis should be
additionally considered and treated accordingly.
Note: Surgical incisions are contraindicated;
aspirate pus with hypodermic needle through the
health skin.

239. Complications
Fistula or sinus formation Extensive scarring
Extensive ulceration of
genitalia
Multiple draining
sinus
Retroperitoneal
lymphadenopathy
Chronic untreated LGV
may result in lymphatic
obstruction, elephantiasis
of the genitalia
Rarely hematogenous
dissemination to lung,
liver, spleen and bone

240. 7.Neonatal Conjunctivitis
Neonatal conjunctivitis (Ophthalmia neonatorum)
is an ocular redness, swelling and discharge occurring
in infants less than 4 weeks of age.
The neonates get the infections from their infected
mothers.
Neonatal conjunctivitis due to sterile chemical
irritants can be resolved by itself within 48 hours
without any intervention.

241. Etiology
Itcanbeduetoinfectionsorirritantchemicals.
Someofthecommonpathogenicagentsare:
N. Gonorrhea
C. Trachomatis
S. Pneumoniae
H. Influenzae
S. Aureus
The commonest irritant chemical that causes neonatal
conjunctivitis is silver nitrate solution, which is applied
to the eye of the neonate for prophylactic purposes.

242. Risk factors
Maternal infection with STI
Exposure of the infant to infectious organisms
Inadequacy of ocular prophylaxis immediately
after birth
Premature rupture of membrane
Ocular trauma during delivery
Mechanical ventilation and
Prematurity

243. Clinical Presentation
Red and edematous conjunctiva
Edematous/swollen eye lid
Discharge which can be sometimes purulent

244. Treatment
Ceftriaxone 50mg/kg IM stat maximum dose
125mg/ Spectinomycin 25 mg/kg IM stat maximum
dose 75mg plus
Erythromycin 50mg/kg orally in four divided doses
for 14 days.
Note: TTC is used as prophylaxis for neonatal
conjunctivitis but note for treatment.

246. Prevention
Wiping the baby’s both eyes with dry and clean
cotton cloth as soon as the baby is born.
Apply 1% Silver Nitrate solution or 1%
Tetracyclineeye ointment into the infant’s eyes;
other options: 0.5% Erythromycinointment or
2.5% povidone Iodine solution.
Properly open the eye of the infant and place the
ointment on the lower conjunctival sacs and avoid
placing on the eye lids.

247. Summary of syndromes
SYNDROME MOST COMMON CAUSE
Urethral Discharge Gonorrhea, Chlamydia
Vaginal Discharge Vaginitis(Trichomoniasis, Candidiasis)
Cervicitis (Gonorrhea, Chlamydia)
Genital Ulcer Syphilis, Chancroid, Herpes
Lower Abdominal PainGonorrhea, Chlamydia, Mixed
anaerobes
Scrotal Swelling Gonorrhea and Chlamydia
Inguinal Bubo LGV and Chancroid
Neonatal ConjunctivitisGonorrhea and Chlamydia

248. Written Assignment (10%)
1.TORCH and preconception care –G1
2.HIV/AIDS and preconception care_G2
3.Psycho-social assessment for PCC clients-G3
Reading Assignment
Chromosomal abnormalities (down syndrome,
turner syndrome….)

249. References
•Williams obstetrics , 26
th
edition
•Gabbeobstetrics, 7
th
edition
•DC Dutta’sobstetrics, 8
th
edition
•Up to date
•Standard treatment guidelines for general
hospitals , fourth edition, 2021

250. Thank you