fisiologi kehamilan,persalinan, dan nifas
TRANSCRIPT
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1st LOFertilization Implantation and
Placentation
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Fertilization
Fertilization occur when sperma meet ovum.
It happen in ampulla Tuba fallopii.
Sperma will come into the ovum by releasing
akrosom enzyme thet can
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Trofoblastik cell
will cover inner
cell mass
Dinding2 sel trofoblas yg masuk ke
endometrium luruh, mmbntuk
synsitium multinukleus
yg akan mnjadi plasenta janin
Blastokista akan
ditanam di desidua
Blastokista akan
ditanam di desidua
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embentukan Ruang mnion
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2nd LO
Anatomy and Physiology changes
in Pregnancy
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1. Cardiovaskular System
1) CARDIAC OUTPUT
The total blood volume increases by about40% above nonpregnant levels, with wide
individual variations. The disproportionate increase in plasma
volume compared to the red cell volumeresults in hemodilution with a decreased
hematocrit reading, sometimes referred to asphysiologic anemia of pregnancy
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Cardiac output rises by the 10th week of
gestation; it reaches about 40% above
nonpregnant levels by 20 to 24 weeks, after
which there is little change
For any given level of exercise, oxygen
consumption is higher in pregnant than in
nonpregnant women
2) INTRAVASCULAR PRESSURES
Systolic pressure falls only slightly during
pregnancy, whereas diastolic pressure
decreases more markedly; this decrease
begins in the first trimester, reaches its nadirin midpregnancy, and returns toward
nonpregnant levels by term
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3) MECHANICAL CIRCULATORY EFFECTS OF THE
GRAVID UTERUS
supine hypotensive syndrome
The venous compression by the gravid
uterus elevates pressure in veins that drain
the legs and pelvic organs, thereby
exacerbating varicose veins in the legs and
vulva and causing hemorrhoids
Because of venous compression, the rate of
blood flow in the lower veins is also
markedly reduced, causing a predisposition
to thrombosis
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4)REGIONAL BLOOD FLOW
Two of the major increases (those to
the kidney and to the skin) serve
purposes of elimination: the kidney of
waste material and the skin of heat
When maternal cardiac output falls,
blood flow to the brain, kidneys, and
heart is supported by a redistribution of
cardiac output, which shunts bloodaway from the uteroplacental
circulation
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5) CONTROL OF
CARDIOVASCULAR CHANGES
A unifying hypothesissuggests that the changes in
circulating steroid hormones
in combination with changesin production of vasodilatory
prostaglandins, atrial
natriuretic peptide, nitric
oxide, and aldosterone affect
venous distensibility and
arterial tone
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6) OXYGEN-CARRYING CAPACITY OF
BLOOD
Plasma volume expands
proportionately more than red
blood cell volume, leading to a fallin hematocrit
Despite the relatively low
"optimal" hematocrit, thearteriovenous oxygen difference in
pregnancy is below nonpregnant
levels.
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B. RESPIRATORY SYSTEM
The major respiratory changes in
pregnancy involve three factors:
the mechanical effects of the
enlarging uterus, the increasedtotal body oxygen consumption,
and the respiratory stimulant
effects of progesterone
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1) RESPIRATORY MECHANICS IN PREGNANCY
As pregnancy progresses, the enlarging uterus
elevates the resting position of the
diaphragm. This results in less negative
intrathoracic pressure and a decreased
resting lung volume, that is, a decrease in
functional residual capacity (FRC)
These characteristics-reduced FRC with
unimpaired VC-are analogous to those seen
in a pneumoperitoneum and contrast with
those seen in severe obesity or abdominalbinding, where the elevation of the
diaphragm is accompanied by decreased
excursion of the respiratory muscles
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2) OXYGEN CONSUMPTION AND
VENTILATION
Total body oxygen consumption
increases about 15% to 20% inpregnancy
pregnancy, the elevations in
both cardiac output and alveolar
ventilation are greater than
those required to meet the
increased oxygen consumption
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The rise in minute ventilation
reflects an approximate 40%
increase in tidal volume at term;
Such increased respiratory
sensitivity to CO2 is characteristic of
pregnancy and probably accounts
for the hyperventilation of
pregnancy
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In summary
both at rest and with exercise, minute
ventilation and, to a lesser extent, oxygen
consumption are increased during
pregnancy over the nonpregnant control
values.
The respiratory stimulating effect of
progesterone is probably responsible for
the disproportionate increase in minuteventilation over oxygen consumption
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3)ALVEOLAR-ARTERIAL GRADIENT
AND ARTERIAL BLOOD GASMEASUREMENTS
Pregnancy is characterized byhyperventilation (the arterial
PCO2 falls to a level of 27 to 32
mm Hg) and associatedrespiratory alkalosis
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C. RENAL PHYSIOLOGY
The urinary collecting system, including the
calyces, renal pelves, and ureters, undergoes
marked dilation in pregnancy, as is readily
seen on intravenous urograms. It begins in the
1st trimester, is present in 90% of women at
term, and may persist until the 12th to 16th
postpartum week.
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2) FLUID VOLUMES
The maternal extracellular volume,
which consists of intravascular and
interstitial components, increases
throughout pregnancy, leading, ineffect, to a state of physiologic
extracellular hypervolemia. The
intravascular volume, which consistsof plasma and red cell components,
increases approximately 50% during
pregnancy
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3) RENIN-ANGIOTENSIN SYSTEM IN PREGNANCY
Plasma concentrations of renin, renin substrate,
and angiotensin I and II are increased. Reninlevels remain elevated throughout pregnancy.
4) HOMEOSTASIS OF MATERNAL ENERGY
SUBSTRATES
The metabolic regulation of energy substrates,
including glucose, amino acids, fatty acids, and
ketone bodies, is complex and interrelated
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5)INSULIN EFFECTS AND GLUCOSE METABOLISM
In pregnancy, the insulin response to glucose
stimulation is augmented
Glycogen synthesis and storage by the liver
increases, and gluconeogenesis is inhibited
After early pregnancy, insulin resistance
emerges, so glucose tolerance is impaired. Thefall in serum glucose for a given dose of insulin is
reduced compared with the response in earlier
pregnancy
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A variety of humoral factors have been suggested
to account for the anti-insulin environment of the
latter part of pregnancy. Perhaps the mostimportant is human placental lactogen (hPL)
6)LIPID METABOLISM
During the second half of pregnancy, however,
probably as a result of rising hPL levels, lipolysis is
augmented, and the plasma concentration of free
fatty acids after an overnight fast is elevated. In the context of maternal lipid metabolism, the
most dramatic lipid change in pregnancy is the rise
in fasting triglyceride concentration
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D. Tractus Digestivus
Intestine move to lateral and top
Motility of intestine and secret of gastes ( as
hidrochlorid and peptine) go down causing
vomite and constipation
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F. Glandula mammae
Enlargement of sinus and ductus cause of
esterogen
Accumulating of lipid cause of progesteron
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G. Reproductive system
1) Uterus
Increasing volume and enlargement of uterus and hypertrofi of
miometrium
Accumulation of sheaf tissue and elastine increase its stregh
Placenta make a rough sign at uterus Itsmus hypertropy and longer formed hergar sign
Dextrorotation of uterus
Formed a sign upper and lower segmen caused by Contraction of uterus
called phycology retraction ring
Sporadic contraction at trisemster 2 called Braxton Hix contraction
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G. Reproductive system
2) Serviks
More soft and bluish after one month
Collagen are syntesized and formed by collagenase to prevent weakness of
its
3) Vagina
Formed chadwick sign
ovarium
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3rd LO
ANC and PNC
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b ckground
Maternal Mortality Rate (MMR)
because (60-80%) is bleeding, obstructedlabor, sepsis, high blood pressure It canactually be anticipated
One way to MMR with ANC(Antenatal Care)
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Antenatal Care a program planned by health workers
1. Observation Kehamilanaman
2. Education Ibu Hamil Persalinanaman
3. Medical treatment Deteksidini
(kelainan obstetri)
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Determine the health status of themother and fetus.
Determine the gestational age of the
fetus.
Initiated plans to continue obstetriccare.
Ensuring the safety and health of thepregnancy, both the mother and baby
Formulate a list of risk factors
Main purpose of
the ANC
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Antenatal care early or first visit
complete history
routine inspection
Assessment of risk factors
Next antenatal care.
On the first visit if found to be a risk factor of routinehistory taking and examination then be evaluated
during the next visit
Components of Antenatal Care
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Examination schedule (gestational age of HPHT):
- Up to 28 weeks (7 Months): 4 weeks. Once- 28-36 weeks (7-9 months): 2 weeks.Once- > 36 weeks: 1 week..Twice
except...
If found abnormalities / risk facto
need medical treatment needmore frequent inspection and int
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Obstetric examination
General inspectionFront chloasma gravidarum, edema +/-Eyes conjungtiva anemic +/-, sclera
jaundice +/-Mouth gums and teethNeck JVP, enlargement of the thyroid glandand lymph +/Mammary shapes, symmetrical,enlargement, nipple widened, areolahyperpigmentation, vascular, glandulartissue hyperplasia
Abdomen enlarged , pigmentation of linea alba andstriae,+/- scarring, motion +/- childrenVulva perineum, varices +/-, flour albus +/- anus hemorrhoids +/-,Limbs varices +/-, +/- edema (pretibial, ankle,
instep), scarring +/-
f h
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examination of theAbdomen(LEOPOLD)
Leopold I :Examiner stands facing the patient, and then with both
hands touching with fingers to determine the height ofthe fundus and what part of the child contained in the
fundus
Leopold II :The position is still the same, move the h
side. Determine where there is a child's b
gives the biggest hurdle then look for smare located in conflict
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Leopold III :
Wearing one hand only, Handle bottoming section and
determine whether they can be shaken to determinewhat is at the bottom and whether it has / has not been
held in check by the pelvic
Leopold IV :Examiner position facing the patient's legs, wit
hands specify what the bottom and whether thi
has been entered into the PAP and how the ent
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42
Fetal Heart Sounds
(auscultation)
Fetal heart sounds
can already be
heard at week 20 in
80 percent of
women
At week 21, the
sound of the fetal
heart was heard at95 percen
at week
all pregwome
S i l
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SpecialExamination
Imaging
Resonance
Magnetic
Amniocentesis
Cordosintesis Fetoscopy
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rovide exclusive
breastfeeding
Not give cow's milk
Breastfeeding
counseling ..
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4Th LO
Labor and Delivery
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Labor
Childbirth is the period from the onset of
regular uterine contractions until expulsion of
the placenta.
Uterus contraction -> effacement and dilatation
of servic -> push the baby out.
Needs huge energy, so its called labor (hard
work)
b
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Labor
Signs of labour , theres painful uterine contractions accompaniedby any one of the following:
1) ruptured membranes,
2) bloody "show,"
3) complete cervical effacement.
True labor?
Stages of labor:
First stage: Dilatation
Second stage: Delivery
Third stage: Placental
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First Stage of Labor (cont)
Active Labor.
These phase ischaracterized bydilatation of cervixuntil its complete.
Nulipara = 1,2 cm/hr,Multipara 1,5 cm/hour
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The curve
The first stage is divided into a relativelyflat
latent phase and a rapidlyprogressive active
phase.
In the active phase, there are three identifiable
component parts that include an acceleration
phase, a linear phase of maximum slope, and a
deceleration phase.
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The second Stage of Labor
This stage begins when cervical dilatation is completeand ends with fetal delivery.
The median duration is about 50 minutes for nulliparasand about 20 minutes for multiparas, but it can be highly
variable .
In a woman of higher parity with a previously dilatedvagina and perineum, two or three expulsive efforts afterfull cervical dilatation may suffice to complete delivery.
Conversely, in a woman with a contracted pelvis or alarge fetus or with impaired expulsive efforts fromconduction analgesia or sedation, the second stage maybecome abnormally long
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Mechanism of Labor
It is thus of paramount importance to know the
fetal position within the uterine cavity at the
onset of labor. The position of the fetus with
respect to the birth canal is critical to the routeof delivery.
Fetal orientation relative to the maternal pelvis
is described in terms of fetal lie, presentation,attitude, and position.
Mechanism of Labor
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Mechanism of Labor
LIE, PRESENTATION, ATTITUDE,
AND POSITION. Fetal Lie. The lie is the relation
of the long axis of the fetus tothat of the mother, and is
either longitudinal or transverse.
Fetal Presentation. Thepresenting part is that portion
of the fetal body that is eitherforemost within the birth canalor in closest proximity to it. Itcan be felt through the cervixon vaginal examination (VT).
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Mechanism of Labor
Position = Fetal Attitude or Posture. Inthe later months of pregnancy the fetusassumes a characteristic posturedescribed as attitude or habitus (flexion,extension)
Fetal Position. Position refers to therelationship of an arbitrarily chosenportion of the fetal presenting part to theright or left side of the maternal birthcanal.
The fetal occiput, chin (mentum), andsacrum are the determining points invertex, face, and breech presentations,respectively
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Mechanism of Labor
Longitudinal lie.Cephalic presentation.Differences in attitude
of the fetal body in
A) vertex, B) sinciput,
C) brow, and D) face
presentations.
L b
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Labor
Longitudinal lie. Vertexpresentation.
A. Left occiput anterior(LOA).
B. Left occiput posterior(LOP)
C. Right occiputposterior (ROP).
D. Right occiputtransverse (ROT)
E. Right occiput
anterior (ROA)
A
DC
BB
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CARDINAL MOVEMENT
The cardinal movements oflabor are engagement,
descent, flexion, internal
rotation, extension, externalrotation, and expulsion
During labor, these
movements are sequentialbut also show great
temporal overlap.
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1. Engagement
The fetal head may engage during the
last few weeks of pregnancy or not
until after the commencement of
labor. In many multiparous and some
nulliparous women, the fetal head is
freely movable above the pelvic inlet
at the onset of labor. In thiscircumstance, the head is sometimes
referred to as "floating."
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Labor
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Labor
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2. Descent
Descent is brought about by one or more of four forces:
1) pressure of the amnionic fluid,
2) direct pressure of the fundus upon the breech with contractions,
3) bearing down efforts of maternal abdominal muscles, and
4) extension and straightening of the fetal body.
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3. Flexion
As soon as the descending head meets
resistance, whether from the cervix, walls of
the pelvis, or pelvic floor, flexion of the head
normally results.
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4. Internal Rotation
This movement consists of a turning of thehead in such a manner that the occiput
gradually moves toward the symphysispubis anteriorly from its original positionor, less commonly, posteriorly toward the
hollow of the sacrum. Internal rotation is essential for the
completion of labor, except when the fetusis unusually small.
When the head fails to turn until reaching
the pelvic floor, it typically rotates duringthe next one or two contractions inmultiparas. In nulliparas, rotation usuallyoccurs during the next three to fivecontractions.
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5. Extension
. When the head presses upon the
pelvic floor, however, two forcescome into play. The first, exerted bythe uterus, acts more posteriorly, and
the second, supplied by the resistantpelvic floor and the symphysis, actsmore anteriorly.
The resultant vector is in thedirection of the vulvar opening,
thereby causing head extension. Thisbrings the base of the occiput intodirect contact with the inferiormargin of the symphysis pubis
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6. External Rotation
The delivered head next undergoes restitution. If theocciput was originally directed toward the left, it
rotates toward the left ischial tuberosity; if it was
originally directed toward the right, the occiput
rotates to the right.
Restitution of the head to the oblique position isfollowed by completion of external rotation to the
transverse position, movement that corresponds to
rotation of the fetal body, serving to bring its
bisacromial diameter into relation with the
anteroposterior diameter of the pelvic outlet.
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7. Expulsion
Almost immediately after external rotation, theanterior shoulder appears under the symphysis
pubis, and the perineum soon becomes
distended by the posterior shoulder.
After delivery of the shoulders, the rest of the
body quickly passes.
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5Th LO
PUERPERIUM
CHANGES THAT OCCUR DURING THE
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CHANGES THAT OCCUR DURING THE
PUERPERIUM
Is recovery period after childbirth whichlasted for 6 weeks.
1. Uterine
Soon after postpartum, the rest of deciduadifferentiate into:
Stratum superficial
Basale stratum Involution autolysis and necrosis of
decidua superficial
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Involution will produce lokhia (duh) which is
contain eritrocyt, leukocyt, epitel cells,
decidua cells, and bactery.
Type of lokhia:
Lokhia rubra
Lokhia serosa
Lokhia alba
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2. Cervix
Ostium cervix smaller but could not return asusual.
Ostium cervix externum widen as lip.
3. Urinary tract
Diuresis for 2-5 days
Decreased sensitivity of VU
4 Peritoneum and abdominal wall
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4. Peritoneum and abdominal wall
Broad and round ligament become loose, and
need long time to be recovered.Striae gravidarum ( during pregnancy)
become striae alba
5. Blood and Circulation
Leukocytosis, granulocytosis, trombocytosis.
CO increased in the first 48 hours, and will be
as usual in 2 weeks.
6 Weight loss
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6. Weight loss
Become as usual in 6 month post partum.
Due to: Diuresis
Uterine changes
7. Mamae
The first two days will produce colostrum, and
the next day produce ASI.
Due to: estrogen & progesteron prolactin
& oxytocin ASI produced
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6Th LO
Drugs in Pregnant
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7Th LOPrevention, Promote, and
Management of complicationwhi le pregnant, in labor , and
during postpartum per iod
Preventive promotive and
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Preventive, promotive, and
management complication1. Pregnant
- ANC
2. In Labor
- Partograf
3. Postpartum
- Active management in stage 3 of labour
- post partum Observation at least until one week
after labor
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1. Preeclampsia
1. Dietry and Lifestyle Modification
2. Antihypertensive Drugs
3. Antioxidants
f f
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Dietary and life style modification
1. Low-Salt Diet.
One of the earliest research efforts to prevent
preeclampsia was salt restriction
a sodium-restricted diet was ineffective in
preventing preeclampsia
2. Calcium Supplementation
women with low dietary calcium intake were at
significantly increased risk for gestational
hypertension
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3. Fish Oil Supplementation
supplementation with these fatty acids would
prevent inflammatory-mediate atherogenesis, it
was not a quantum leap to posit that they
might also prevent preeclampsia
4. Exercise
the protective effects of physical activity on
preeclampsia
Dietary and life style modification co
h d
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Anti hypertension drugs
women given diuretics had a decreasedincidence of edema and hypertension but not
of preeclampsia.
chronic hypertension are at high risk for
preeclampsia
i id
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Antioxidants
imbalance between oxidant and antioxidantactivity may play an important role in the
pathogenesis of preeclampsia
vitamins C, D, and Emight decrease such
oxidation
7 E l i
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7. Expulsion
Almost immediately after external rotation, theanterior shoulder appears under the symphysis
pubis, and the perineum soon becomes
distended by the posterior shoulder.
After delivery of the shoulders, the rest of the
body quickly passes.