1. Organization of the teaching - gynecology and obstetrics Lecture for 5 th year general medicine course and dentist medicine course

3. Contents lecture's lecture's practice – (obstetrics hall, small gynecology procedures, department of risk pregnancy, department of gynecology surgery, ultrasound laboratory, phantom exercise) practice – (obstetrics hall, small gynecology procedures, department of risk pregnancy, department of gynecology surgery, ultrasound laboratory, phantom exercise) seminar's seminar's practice before SE practice before SE night duty (14-22; 22-6) night duty (14-22; 22-6) Synopsis of the choice lecture: www.gyne.cz

4. State examination two credits (winter and summer term) two credits (winter and summer term) 14 th days practice at the department of G&O 14 th days practice at the department of G&O test from G&O test from G&O practice part (CTG, HSG, phantom, obstetrical examination, gynecological examination) practice part (CTG, HSG, phantom, obstetrical examination, gynecological examination) assay (deadline – 4/2005) assay (deadline – 4/2005)

5. Basic literature

6. Possible literature

8. „Virtual guide of the Department of G&O“

9. Obstetrics part of the clinic

10. Entry for students

11. Outpatient and gynecology department

12. Lecture hall

14. Practice cabinet

15. Library with the PC

16. Ultrasound laboratory

17. Department of gynecology surgery

18. Department of intensive care

19. Endoscopic operating hall

20. Delivery hall

21. Woman life cycles newborn period newborn period childhood childhood puberty puberty adolescence adolescence fertile age fertile age climacterium climacterium senium (old age) senium (old age)

22. Cycles of woman organism Ovarian cycle maturation of the foliculus maturation of the foliculus ovulation ovulation corpus luteum corpus luteum corpus albicans corpus albicans

23. Cycles of woman organism Uterine cycle proliferative phase (picture 1.) proliferative phase (picture 1.) secretory phase (picture 2.) secretory phase (picture 2.) uterine cervix changes (cervical becomes thin through ovulation because of estrogen peak, than thick because of progesterone) uterine cervix changes (cervical becomes thin through ovulation because of estrogen peak, than thick because of progesterone) menstruation 28/5 menstruation 28/5

24. Picture 1.

25. Picture 2.

26. Cycles of woman organism Vaginal cycle in proliferative phase oesinophile cells exist (influence of estrogens) in proliferative phase oesinophile cells exist (influence of estrogens) in secretory phase intermedial cells + leucocytes exist (influence of progestin's) in secretory phase intermedial cells + leucocytes exist (influence of progestin's) acidity of vaginal secret acidity of vaginal secret

27. Cycles of woman organism Fallopian tube and breast cycle increased motility of tube in first phase increased motility of tube in first phase enlargement of the breast, edema, breast pain, increasing sensitivity at the end of the cycle enlargement of the breast, edema, breast pain, increasing sensitivity at the end of the cycle

28. Physiology of female reproduction system Menstruation – periodic discharge of the blood, tissue, fluid and endometrial debris from the uterus, the mean blood loss is 30 ml Menstruation – periodic discharge of the blood, tissue, fluid and endometrial debris from the uterus, the mean blood loss is 30 ml Menarche – girl's first menstrual period – average 12,5 years Menarche – girl's first menstrual period – average 12,5 years Menopause – last women menstrual period – average 50 years Menopause – last women menstrual period – average 50 years

29. Physiology of female reproduction system II. Menstrual cycle – LMP, 28/5, light, mild, heavy Menstrual cycle – LMP, 28/5, light, mild, heavy The ovarian follicle – liquor folliculi, oocyte, granulosa cells, theca externa, theca interna, size before ovulation (14th day of the cycle) from 15 to 20 mm The ovarian follicle – liquor folliculi, oocyte, granulosa cells, theca externa, theca interna, size before ovulation (14th day of the cycle) from 15 to 20 mm Follicular – proliferative phase (ovulation) Follicular – proliferative phase (ovulation) Luteal – secretory phase (corpus luteum) Luteal – secretory phase (corpus luteum)

30. Sexual and reproductive health Puberty from first signs of sexual development till menarche P1 – prepuberty – 9-10 yrs P1 – prepuberty – 9-10 yrs P2 – early puberty – 10-11 yrs (start of hormone secretion) P2 – early puberty – 10-11 yrs (start of hormone secretion) P3 – thelarche 10-11 yrs, pubarche 11-12 yrs P3 – thelarche 10-11 yrs, pubarche 11-12 yrs P4 – breast fully developed P4 – breast fully developed P5 – menarche – yrs 12,6 P5 – menarche – yrs 12,6

31. Sexual and reproductive health Adolescence from menarche till stabilization of ovulatory cycles duration 2,5 years duration 2,5 years after that fertile period after that fertile period

32. Perinatology Independent scientific discipline

33. Screening test in pregnancy screening interview screening interview weight weight Rh factor, HB Rh factor, HB urine protein and sugar urine protein and sugar BP BP cytology cytology AFP, hCG, E3 AFP, hCG, E3 Rh antibody Rh antibody

34. Abnormal pregnancy pathological pregnancy pathological pregnancy risk gravidity risk gravidity pregnancy with increased probability of perinatal morbidity and mortality pregnancy with increased probability of perinatal morbidity and mortality

35. Risk factors lack of antenatal care Social – unmarried woman, smoking, drugs, alcohol, low education, low social class, poor diet, age Social – unmarried woman, smoking, drugs, alcohol, low education, low social class, poor diet, age Biological – obesity, small height, breech presentation, twins, disease of mother (DM, Rh incompatibility, cardiopathy, nephritis, hypertension, hepatitis) Biological – obesity, small height, breech presentation, twins, disease of mother (DM, Rh incompatibility, cardiopathy, nephritis, hypertension, hepatitis)

36. Risk factors leading to prematurity previous termination of pregnancy previous termination of pregnancy twins twins preeclampsia preeclampsia hepatitis hepatitis zoonosis zoonosis uterine malformation uterine malformation social risk's social risk's

37. Antenatal visit The first visit ideally at 8-10 weeks gestation, monthly until 28 weeks, fortnightly until 36 weeks, weekly until delivery

38. History DM DM tuberculosis tuberculosis hypertension hypertension past obstetrics history past obstetrics history allergies allergies LMP LMP first movements first movements

39. Examination, investigation palpation, colposcopy, cytology, breast palpation, colposcopy, cytology, breast urine (sugar, protein, bacilluria) urine (sugar, protein, bacilluria) blood (Hb, red cell, ABO and rhesus group) blood (Hb, red cell, ABO and rhesus group) screening test for syphilis (RRR) screening test for syphilis (RRR) test for Australian antigen test for Australian antigen rubella antibodies rubella antibodies anti HIV antibodies anti HIV antibodies

40. Special visit 16 th week AFP, hCG and E3 AFP, hCG and E3 Ultrasound examination: Ultrasound examination:  to establish gestational age accurately  to exclude major abnormalities of the fetus  to diagnose multiple pregnancy  localization of the placenta

41. Psychoprofylaxis mother craft mother craft relaxation classes relaxation classes books available books available Social welfare Social welfare iron (300 μg a day) iron (300 μg a day) iodine 100 mg a day iodine 100 mg a day folic acid 500μg a day folic acid 500μg a day vitamin supplementation vitamin supplementation

42. Psychoprofylaxis II. smoking - premature delivery, small babies smoking - premature delivery, small babies alcohol – is cell poison, alcohol syndrome of fetus (short nose, low bridge, small eyes, mental retardation) alcohol – is cell poison, alcohol syndrome of fetus (short nose, low bridge, small eyes, mental retardation) intercourse – no restriction in normal G intercourse – no restriction in normal G exercise – walking, swimming exercise – walking, swimming cloth – brassieres are not required, shoes – flat heels, comfortable dress cloth – brassieres are not required, shoes – flat heels, comfortable dress bathing – not hot water, better shower bathing – not hot water, better shower

43. Vital statistics

44. Birth rates Crude birth rate is the number of live birth per 1000 total population (includes men, children and women) is the number of live birth per 1000 total population (includes men, children and women) General fertility rate is the number of live births per 1000 women between 15 and 44 is the number of live births per 1000 women between 15 and 44

45. Obstetrical statistics Stillbirth (SB) child delivered after 24th week of pregnancy that did not show any sign of life + birth weight is greater than 500 grams or less than 500 grams but not alive 24 hours child delivered after 24th week of pregnancy that did not show any sign of life + birth weight is greater than 500 grams or less than 500 grams but not alive 24 hours Stillbirth rate (SBR) is defined as the number of stillbirth per 1000 total birth (still and live) is defined as the number of stillbirth per 1000 total birth (still and live)

46. Obstetrical statistics II. Early neonatal death (END) is defined as the number of infants dying in the 7 days after delivery per 1000 live birth is defined as the number of infants dying in the 7 days after delivery per 1000 live birth Perinatal mortality rate (PMR) number of stillbirth + early neonatal death per 1000 total birth number of stillbirth + early neonatal death per 1000 total birth Rectified perinatal mortality number of dead babies above 1000 g number of dead babies above 1000 g

47. PMR PMR END SBR ‰

48. Priority of PMR END ≤2000g END ≥2000g SA SBR ≥2000g ‰

49. Causes of perinatal death Ante partum unknown in 25% unknown in 25% congenital abnormality 30% congenital abnormality 30% hypoxia (torsion of umbilicus, placental abruption, eclampsia, vasa praevia etc.) hypoxia (torsion of umbilicus, placental abruption, eclampsia, vasa praevia etc.) Neonatal death 80% due to preterm labour, babies born before 26th week have chance to survive 40% 80% due to preterm labour, babies born before 26th week have chance to survive 40%

50. Perinatal morbidity disorders of child development in perinatal period malformation - (genetic, infectious, toxic) – sensoric (deafness); motoric (children's brain paralysis); mental (slight brain dysfunction) malformation - (genetic, infectious, toxic) – sensoric (deafness); motoric (children's brain paralysis); mental (slight brain dysfunction) cause - prematurity, prolonged labour, mechanical damage, chronic hypoxia, late solution of acute hypoxia, mother's disease – DM, preeclampsia cause - prematurity, prolonged labour, mechanical damage, chronic hypoxia, late solution of acute hypoxia, mother's disease – DM, preeclampsia

51. Maternal mortality means death connected to gravidity, labour till 60 day's after the labour the number is 0,04 per 1000 total birth the number is 0,04 per 1000 total birth A. Specific risk – preeclampsia (I.), haemorrhage (II.), shock, uterine rupture (III.), puerperal infection (IV.), thrombosis (V.), connection with abortion (VI.) A. Specific risk – preeclampsia (I.), haemorrhage (II.), shock, uterine rupture (III.), puerperal infection (IV.), thrombosis (V.), connection with abortion (VI.) B. Unspecific risk – internal medicine (I.), surgical disease (II.) B. Unspecific risk – internal medicine (I.), surgical disease (II.) C. Death without relation to G C. Death without relation to G

52. Maternal mortality MM complete MM rectified Number of death women per 100 000 total birth in Czech Republic

53. MM in Czech Republic 1997 (0,08) Decrease of maternal mortality due to: control of infection control of infection blood transfusion blood transfusion advances in anesthesia and resuscitation advances in anesthesia and resuscitation improvement in the health and nutrition improvement in the health and nutrition prevention of disease in gravidity prevention of disease in gravidity Detailed analysis of any maternal mortality (Annual Report on Maternal Deaths).

54. MM - notes Hypertensive disease of pregnancy – deaths from eclampsia and preeclampsia can be avoided i n 75% (early admission to hospital, nutrition, control of BP) Hypertensive disease of pregnancy – deaths from eclampsia and preeclampsia can be avoided i n 75% (early admission to hospital, nutrition, control of BP) Pulmonary embolism – prevention in puerperium, right checking of puls rate, heparinisation (LMWH), early mobilization, therapy of thrombophlebitis, decrease of cesarean section rate, no estrogen's in lactation inhibition Pulmonary embolism – prevention in puerperium, right checking of puls rate, heparinisation (LMWH), early mobilization, therapy of thrombophlebitis, decrease of cesarean section rate, no estrogen's in lactation inhibition

55. MM - notes Amniotic fluid embolism – sudden collapse, strong contraction's, dyspnoe, cyanosis, blood stained sputum – treatment oxygen, steroid's, correction of coagulopathy Amniotic fluid embolism – sudden collapse, strong contraction's, dyspnoe, cyanosis, blood stained sputum – treatment oxygen, steroid's, correction of coagulopathy Hemorrhage – placental abruption, placenta praevia, coagulopathy, postpartum atonia, uterine rupture, risk of home birth Hemorrhage – placental abruption, placenta praevia, coagulopathy, postpartum atonia, uterine rupture, risk of home birth Cesarean section – death's from associated and undercurrent condition's (cardiac disease) Cesarean section – death's from associated and undercurrent condition's (cardiac disease)