Gall bladder disease :

-Pregnancy increase gallstone formation (cholithasis) - no risk for developing acute cholecystitis. - Diagnosis by

- previous history 2-an ultrasound scan of the hepatobiliary tract. - treatment relief of biliary colic by analgesia, hydration, nasogastric suction and antibiotics. - surgery in pregnancy should be avoided.

Viral hepatitis - hepatitis A, B and C in pregnancy. -Hepatitis D, E and G described in medical literature but their relevance to pregnancy is not yet known. الإطلاع على الجدول

Skin disorders - women suffer from physiological pruritus in pregnancy, over the abdomen as it grows and stretches. -use calamine lotion is often helpful. - pruritus a symptom of a disease as

1- OC 2-pemphigoid gestationalis 3- an auto-immune disease of pregnancy

- blisters develop over the body as the pregnancy progresses. -Women with pre-existing skin conditions such as eczema and psoriasis advised to use steroid creams and nut oil derivatives, which may adversely affect the fetus.

Abnormalities of the amniotic fluid -The amount of liquor present in a pregnancy can be estimated by measuring ‘pools’ of liquor around the fetus with ultrasound scanning. - the amniotic fluid volume (AFV),The single deepest pool . an amniotic fluid index (AFI),measuring the liquor in each of four quadrants around the fetus abnormalities of amniotic fluid: hydramnios (or polyhydramnios) and oligohydramnios

Hydramnios excess of amniotic fluid in the amniotic sac Hydramnios excess of amniotic fluid in the amniotic sac. Causes and predisposing factors include: twin to twin transfusion syndrome maternal diabetes fetal anemia maternal alloimmunization

syphilis/parvovirus infection) fetal malformation such as oesophageal atresia, open neural tube defect, anencephaly a fetal and placental tumour (rare). -in many cases the cause is unknown.

Types Chronic hydramnios -This is gradual in onset, usually starting from about the 30th week of pregnancy. - It is the most common type. Acute hydramnios -This is very rare. - It usually occurs at about 20 weeks and develops very suddenly. - The uterine size reaches the xiphisternum in about 3 or 4 days. -Acute hydramnios is frequently associated with monozygotic twins or severe fetal malformation.

Diagnosis -The woman c.c breathlessness and discomfort. - acute hydramnios 1-severe abdominal pain. - exacerbation of symptoms associated with pregnancy, such as indigestion, heartburn and constipation. - Oedema and varicosities of the vulva and lower limbs may also be present

Abdominal examination -On inspection, the uterus is larger than expected for the period of gestation -globular in shape. The abdominal skin appears stretched and shiny, with marked striae gravidarum and superficial blood vessels. -On palpation, the uterus feels tense and it is difficult to feel the fetal parts, but the

fetus may be balloted between the two hands. A fluid thrill may be elicited by placing a hand on one side of the abdomen and tapping the other side with the fingers. -Ultrasonic scanning is used to confirm the diagnosis of hydramnios and may also reveal a multiple pregnancy or fetal malformation. -Auscultation of the fetal heart may be difficult due to the hydramnios.

Complications maternal ureteric obstruction and urinary tract infection unstable lie and malpresentation cord presentation and prolapse prelabour (and often preterm) rupture of the membranes placental abruption when the membranes rupture preterm labour increased incidence of caesarean section postpartum haemorrhage increased perinatal mortality rate.

Management -according to 1- the condition of the woman and fetus 2- the cause of the hydramnios 3- degree of the hydramnios 4- the stage of pregnancy. 5-The presence of fetal malformation in choosing the mode and timing of birth.

- If there is a gross malformation present, labour may be induced. -Should the fetus have an operable condition, such as oesophageal atresia, transfer will be arranged to a neonatal surgical unit. -Mild hydramnios is managed by: 1-Regular ultrasound scans will reveal whether or not the hydramnios is progressive.

-Some cases of idiopathic hydramnios resolve spontaneously as pregnancy progresses. - an upright position will help to relieve any dyspnoea - antacids can be taken to relieve heartburn and nausea. If the discomfort from the swollen uterus is severe, then therapeutic amniocentesis, or amnioreduction, may be considered

Risk o amnioreduction 1- infection may be introduced 2-or the onset of labour starts. No more than 500 ml of amniotic fluid should be withdrawn at any one time. the fluid will rapidly accumulate again and the procedure may need to be repeated.

Acute hydramnios managed by 1- amnio-reduction has a poor prognosis for the fetus. 2-Labour may need to be induced in late pregnancy if the woman's symptoms become worse. 3-The lie must be corrected if it is not longitudinal 4- the membranes ruptured cautiously, allowing the amniotic fluid to drain out slowly

why AROM should be done slowly : @ avoid altering the lie @ to prevent cord prolapse @ placental abruption is also a risk if the uterus suddenly diminishes in size. - midwife should be prepared for the possibility of postpartum haemorrhage. - The baby should be examined for malformations at birth and the patency of the oesophagus is ascertained by passing a nasogastric tube.