Disorder Of Preg Pharm Phys Of Parturition Lactation

The most likely diagnosis for this patient is preeclampsia. Preeclampsia is a pregnancy complication characterized by high blood pressure and damage to organs, often the liver and kidneys. The persistent headaches, swelling of the legs and face, and proteinuria are all classic symptoms of preeclampsia. Eclampsia is a severe form of preeclampsia characterized by seizures, which the patient does not have. Gestational trophoblastic disease is a rare condition that involves abnormal growth of cells in the uterus, and nephrotic syndrome is a kidney disorder that typically presents with edema and proteinuria, but not hypertension.

Based on the given information, the most likely condition present in this individual is ectopic pregnancy. Ectopic pregnancy refers to the implantation of a fertilized egg outside of the uterus, most commonly in the fallopian tubes. The symptoms of lower abdominal pain, vaginal bleeding, and passing a cast of tissue are consistent with an ectopic pregnancy. The presence of a soft, tender mass in the right adnexa and pouch of Douglas on physical examination further supports this diagnosis. Therefore, ectopic pregnancy is the most likely condition in this case.

The most likely diagnosis in this case is a threatened abortion. A threatened abortion refers to vaginal bleeding and lower abdominal pain during the first half of pregnancy, while the cervix remains closed and the fetus is still alive. In this scenario, the patient is 16 weeks pregnant, has a closed internal cervical os, and has been healthy throughout the pregnancy. These findings suggest that the pregnancy is still viable and there is a chance that it may continue without any further complications.

The presence of three X chromosomes (69XXX) suggests that this lesion is likely to be a form of triploidy, a chromosomal abnormality characterized by the presence of an extra set of chromosomes. In this case, one set of chromosomes is maternal, and two sets are paternal. This abnormality can lead to the rapid enlargement of the uterus, as seen in the pregnant woman described in the question.

Patient presentation — Women with an acute abruption classically present with the abrupt onset of vaginal bleeding, mild to moderate ABDOMINAL AND/OR BACK PAIN, and uterine contractions. Back pain is prominent when the placenta is on the posterior wall of the uterus. The UTERUS IS OFTEN FIRM, AND MAY BE RIGID AND TENDER.
Contractions are usually high frequency and low amplitude, but a contraction pattern typical of labor is also possible and labor may proceed rapidly.
VAGINAL BLEEDING ranges from mild and clinically insignificant to severe and life-threatening. Blood loss may be underestimated because bleeding may be retained behind the placenta and thus difficult to quantify. The amount of vaginal bleeding correlates poorly with the degree of placental separation and does not serve as a useful marker of impending fetal or maternal risk. Maternal hypotension and fetal heart rate (FHR) abnormalities, however, suggest clinically significant separation that could result in fetal death and severe maternal morbidity. When placental separation exceeds 50 percent, acute disseminated intravascular coagulation and fetal death are common.
In 10 to 20 percent of placental abruptions, patients present with only preterm labor, and no or scant vaginal bleeding. In these cases, termed ‘concealed abruption,’ all or most of the blood is trapped between the fetal membranes and decidua, rather than escaping through the cervix and vagina. Therefore, in pregnant women with abdominal pain and uterine contractions, even a small amount of vaginal bleeding should prompt close maternal and fetal evaluation for placental abruption. In other cases, a small concealed abruption may be asymptomatic and only recognized as an incidental finding on an ultrasound.
Occasionally, the signs and symptoms of abruption develop after rapid uterine decompression, such as after uncontrolled rupture of membranes in the setting of polyhydramnios or after delivery of a first twin. Signs and symptoms of abruption also may occur after maternal abdominal trauma or a motor vehicle crash. In these cases, placental abruption generally presents within 24 hours of the precipitating event and tends to be severe. The clinical presentation and obstetrical evaluation of pregnant trauma victims are described in detail separately. (See "Trauma in pregnancy", section on 'Evaluation and management'.)
Laboratory findings — The degree of MATERNAL HEMORRHAGE correlates with the degree of hematological abnormality; fibrinogen levels have the best correlation with severity of bleeding. Initial fibrinogen values of ≤200 mg/dL are reported to have 100 percent positive predictive value for severe postpartum hemorrhage, while levels of ≥400 mg/dL have a negative predictive value of 79 percent. Mild separation/hemorrhage may not be associated with any abnormalities of commonly used tests of hemostasis.
Severe abruption can lead to disseminated intravascular coagulation (DIC). DIC occurs in 10 to 20 percent of severe abruptions with death of the fetus.

The patient's symptoms of unilateral right leg swelling, distended superficial veins, warm and tender leg, and calf pain when the foot is passively dorsiflexed are consistent with deep venous thrombosis (DVT). DVT is a blood clot that forms in a deep vein, commonly in the leg. The patient's history of pregnancy, pelvic inflammatory disease, and miscarriages may increase her risk for developing DVT. Lymphedema and elephantiasis typically present with bilateral leg swelling and are less likely given the patient's symptoms. Cellulitis would present with redness, warmth, and swelling of the skin, but would not typically cause distended superficial veins.

Gravida: a woman who is or has been pregnant
Nulligravid: never pregnant
Primigravid: currently pregnant for first time
Primipara: a woman once delivered of a fetus beyond 20 weeks gestation
Multipara: delivered > 2 pregnancy beyond 20 weeks
Numerical designation:
PARA 2-1-0-3 
2 term deliveries
1 preterm
0 abortuses
3 living children

Patient presentation — Women with an acute abruption classically present with the abrupt onset of vaginal bleeding, mild to moderate ABDOMINAL AND/OR BACK PAIN, and uterine contractions. Back pain is prominent when the placenta is on the posterior wall of the uterus. The UTERUS IS OFTEN FIRM, AND MAY BE RIGID AND TENDER.
Contractions are usually high frequency and low amplitude, but a contraction pattern typical of labor is also possible and labor may proceed rapidly.
VAGINAL BLEEDING ranges from mild and clinically insignificant to severe and life-threatening. Blood loss may be underestimated because bleeding may be retained behind the placenta and thus difficult to quantify. The amount of vaginal bleeding correlates poorly with the degree of placental separation and does not serve as a useful marker of impending fetal or maternal risk. Maternal hypotension and fetal heart rate (FHR) abnormalities, however, suggest clinically significant separation that could result in fetal death and severe maternal morbidity. When placental separation exceeds 50 percent, acute disseminated intravascular coagulation and fetal death are common.
In 10 to 20 percent of placental abruptions, patients present with only preterm labor, and no or scant vaginal bleeding. In these cases, termed ‘concealed abruption,’ all or most of the blood is trapped between the fetal membranes and decidua, rather than escaping through the cervix and vagina. Therefore, in pregnant women with abdominal pain and uterine contractions, even a small amount of vaginal bleeding should prompt close maternal and fetal evaluation for placental abruption. In other cases, a small concealed abruption may be asymptomatic and only recognized as an incidental finding on an ultrasound.
Occasionally, the signs and symptoms of abruption develop after rapid uterine decompression, such as after uncontrolled rupture of membranes in the setting of polyhydramnios or after delivery of a first twin. Signs and symptoms of abruption also may occur after maternal abdominal trauma or a motor vehicle crash. In these cases, placental abruption generally presents within 24 hours of the precipitating event and tends to be severe. The clinical presentation and obstetrical evaluation of pregnant trauma victims are described in detail separately. (See "Trauma in pregnancy", section on 'Evaluation and management'.)
Laboratory findings — The degree of MATERNAL HEMORRHAGE correlates with the degree of hematological abnormality; fibrinogen levels have the best correlation with severity of bleeding. Initial fibrinogen values of ≤200 mg/dL are reported to have 100 percent positive predictive value for severe postpartum hemorrhage, while levels of ≥400 mg/dL have a negative predictive value of 79 percent. Mild separation/hemorrhage may not be associated with any abnormalities of commonly used tests of hemostasis.
Severe abruption can lead to disseminated intravascular coagulation (DIC). DIC occurs in 10 to 20 percent of severe abruptions with death of the fetus.

PLACENTA PREVIA should be suspected in any woman beyond 20 weeks of gestation who presents with ****painless vaginal bleeding.***** For women who have not had a second trimester ultrasound examination, antepartum bleeding after 20 weeks of gestation should prompt sonographic determination of placental location before digital vaginal examination is performed because palpation of the placenta can cause severe hemorrhage.
Placenta previa refers to the presence of placental tissue that extends over or lies proximate to the internal cervical os. Sequelae include the potential for severe bleeding and preterm birth, as well as the need for cesarean delivery.
PATHOPHYSIOLOGY — Placental bleeding is thought to occur when gradual changes in the cervix and lower uterine segment apply shearing forces to the inelastic placental attachment site, resulting in partial detachment. Vaginal examination or coitus can also disrupt the intervillous space and cause bleeding. Bleeding is primarily maternal, but fetal bleeding can occur if a fetal vessel is disrupted.

Gravida: a woman who is or has been pregnant
Nulligravid: never pregnant
Primigravid: currently pregnant for first time
Primipara: a woman once delivered of a fetus beyond 20 weeks gestation
Multipara: delivered > 2 pregnancy beyond 20 weeks
Numerical designation:
PARA 2-1-0-3 
2 term deliveries
1 preterm
0 abortuses
3 living children

ERGONOVINE has a medical use in obstetrics to facilitate delivery of the placenta and to prevent bleeding after childbirth by causing smooth muscle tissue in the blood vessel walls to narrow, thereby reducing blood flow. It is usually combined with oxytocin (Syntocinon) as syntometrine.
It can induce spasm of the coronary arteries. It is used to diagnose Variant (Prinzmetal's) angina.
While it acts at alpha-adrenergic, dopaminergic, and serotonin receptors (the 5-HT2 receptor), it exerts on the uterus (and other smooth muscles) a powerful stimulant effect not clearly associated with a specific receptor type.
ERGONOVINE is an ergoline (and lysergamide) derivative, and one of the primary ergot and morning glory alkaloids . It is chemically similar to lysergic acid diethylamide (LSD), ergine, and lysergic acid.

The naturally occurring prostaglandin E2 (PGE2) is known in medicine as DINOPROSTONE. It has important effects in labour (softens cervix and causes uterine contraction) and also stimulates osteoblasts to release factors that stimulate bone resorption by osteoclasts. PGE2 is also the prostaglandin that ultimately induces fever.
Like other prostaglandins, dinoprostone can be used as an abortifacient. It is a direct vasodilator, relaxing smooth muscles, and it inhibits the release of noradrenaline from sympathetic nerve terminals. It does not inhibit platelet aggregation, where PGI2 does.

It works by binding and activating the prostaglandin E2 receptor (PGE2)

Dexamethasone is the most likely drug that was administered in this case. Dexamethasone is a corticosteroid that is commonly used to accelerate maturation of the fetal lungs in cases of premature rupture of membranes. By promoting lung maturation, it helps to decrease the risk of neonatal respiratory distress syndrome. The other options, such as Progesterone, Ethinyl estradiol, Ergonovine, Dinoprostone, and Fludrocortisone, are not typically used for this purpose.

The therapeutic efficacy of oxytocin, in this case, is most likely mediated by the activation of the phosphoinositide hydrolysis signaling pathway. Oxytocin is a hormone that plays a crucial role in inducing labor and promoting uterine contractions. Phosphoinositide hydrolysis is a signaling pathway that involves the breakdown of phosphoinositides into inositol trisphosphate (IP3) and diacylglycerol (DAG). IP3 then binds to receptors on the endoplasmic reticulum, releasing calcium ions into the cytoplasm, which ultimately leads to smooth muscle contraction. Therefore, the activation of the phosphoinositide hydrolysis pathway is likely responsible for the therapeutic effect of oxytocin in inducing labor.

During stage 3 of labor, the placenta separates at the spongy layer of the decidua basalis. This layer is located in the uterus and provides a rich blood supply to the placenta. As the placenta detaches, the spongy layer is where the separation occurs. This allows for the safe removal of the placenta without causing excessive bleeding or damage to the uterus.