Current symptoms

-          Pelvic pain (location, duration, character, quality, triggering and relieving factors)

-          abnormal vaginal bleeding (quantity, duration, relation to the menstrual cycle)

-   Vaginal discharge (color, odor, consistency), irritation, or both

gonadotropin-releasing hormone (GnRH)

LUTEINIZING RELEASING HORMON

secreted by Hypothalamus

 regulates the release of the gonadotropins luteinizing hormone (LH) and follicle-stimulating hormone (FSH) from specialized cells (gonadotropes) in the anterior pituitary gland.

[image]Menstrual Cycle

.  Average duration of menses is 5 (± 2) days. Blood loss  is usually greatest on the 2nd day.  Menstrual blood does not usually clot

is 28 days (usual range, about 25 to 36 days

maximal and intermenstrual intervals are longest in the years immediately after menarche and immediately before menopause, when ovulation occurs less regularly.

The menstrual cycle begins and ends with the first day of menses (day 1). 

Follicular phase: 

In the 1^st half of the follicular phase, the primary event is growth of recruited follicles.  During the 2^nd half of the follicular phase, the follicle selected for ovulation matures and accumulates hormone-secreting granulose cells

Ovulatory phase

Ovulation occurs.  Estradiol levels usually peak as the ovulatory phase begins

Luteal phase

The follicle is transformed into a corpus luteum.  The length of this phase is the most constant, averaging 14 days, after which the corpus luteum degenerates.  The corpus luteum secretes primarily progesterone in increasing quantities.  Progesterone stimulates development of the secretory endometrium, which is necessary for embryonic implantation.  Because progesterone is thermogenic, basal body temperature increases by 0.5⁰C for the duration of this phase.

HEAVY BLEEDING

Qi deficiency;

blood heat;

empty heat;

Liver & Kidney Yin deficiency;

blood stasis

SCANTY BLEEDING

: blood deficiency;

cold in the uterus;

Liver blood stasis

Mense-Brownish Blood

empty cold

MENSE- SCARLET RED

EMPTY HEAT

Clotted with darkdull clot

blood stasis;

cold in the uterust

Clotted with dark but fresh-looking clots

HEAT

Small dark clots but blood not dark

cold in the uterus

LARGE CLOTS

BLOOD STASIS

PURPLISH

FULL COLD

WATERY

BLOOD OR YIN DEF

STICKY

DAMPNESS OR DAMPHEAT IN UTERUS

ALWAYS EARLY MENSE

:

Qi deficiency

blood heat

 empty heat

Liver & Kidney Yin deficiency

ALWAYS LATE

BLOOD DEF

LV BLOOD STASIS

COLD IN UTERUS

IRREGULAR MENSE

LV QI STAG

LV BLOOD STASIS

SP DEF

KI DEF

STARTING OR ENDING WITH BROWN DISCHARGE

LV BLOOD STASIS

MID CYCLE BLEEDING

DAMP HEAT

QI DEF

LV & KI YIN DEF

AMENORRHEA

BLOOD DEF

BLOOD STASIS

COLD IN UTERUS

HESITANT START

BLOOD STASIS

PELVIC PAIN

Related to mense

-dysmenorrhea, sharp or crampy pain before or at onset of mense, often w/ ha, nausea, constipation, or urinary frequency

-endomitriosis, pain before and during early menses, often with dysmenorrhea, dyspareunia, or painful defecation, later uterine retroversion, tenderness

-mittelschemez, sudden onset severe, sharp pain, most intense @ onset, 1-2 days, light spotting, midcycle, caused by ruptured follicular cyst, inducing mild peritoneal irritation

PID

infection of upper female genital tract:

the cervix, uterus, fallopian tube and ovaries, maybe absecess

Pelvic pain-unrelated to mense, 

 Gradual onset of pelvic pain, mucopurulent cervical discharge

Sometimes fever, dysuria, dyspareunia

Typically, marked cervical motion tenderness and adnexal tenderness

RUPTURED ETOPIC PREG

Pelvic Pain, unrelated to mense

Sudden onset of localized, constant (not crampy) pain, often with vaginal bleeding and sometimes syncope or hemorrhagic shock; Closed cervical os; Sometimes acute abdominal distention or tender adnexal mass

b-hCG quantitative test

UTERINE OR OVARIAN CANCER

Gradual onset of pain, vaginal discharge (which precedes bleeding), abnormal vaginal bleeding (eg, postmenopausal bleeding, premenopausal recurrent metrorrhagia); Rarely, a palpable pelvic mass

vaginal bleeding

Treatment: hemorrhagic shock is treated.  Women with iron deficiency anemia may require supplemental oral iron.  Hormones, usually oral contraceptives, are used to treat dysfunctional uterine bleeding

abnormal vaginl bleeding includes:

-mense that are prolonged-menorrhagia

- excessive-menorrhagia or hypermenorrhia

-too frequent-polymenorrhagia

- metrorrhagia, bleeding b/w mense, not related to mense

-postmenopausal bleeding 

Uterine bleeding – CAM

EXCESSIVE HEAT

Ren 3, Sp 10, Sp 1, Liv 8

Affection of external heat: LI 11

Excessive Ht fire: Ht 8

Excessive Liv fire: Liv 3

      Sudden onset of profuse or prolonged continuous vaginal bleeding in deep red color

·         Fidgets

·         Insomnia

·         Dizziness

T: red with yellow coat

P: rapid

uterine bleeding CAM

QI DEFICIENC

·         Sudden profuse bleeding or continuous scanty bleeding marked by light red and thin blood

·         Lassitude

·         Shortness of breath

·         Apathy

·         Anorexia

T: pale

P: thready, weak 

mid cycle bleeding, GIO

Liv & KD Yin deficiency with empty heat

Scanty, scarlet red blood, dizziness, tinnitus, night sweating, backache, five-palm heat, malar flush  T: red w/o coating  P: floating, empty

(Mid-cycle bleeding GIO)

Damp heat

May be heavy or scanty, sticky blood, vaginal discharge    

T: sticky yellow coating   

P: slippery, rapid

Mid-cycle bleeding  - GIO

Blood stasis

Pain, scanty blood, dark blood with dark clots

 T: purple tongue   P: wiry

(Mid-cycle bleeding  - GIO)

Sp & KD Yang deficiency

Profuse, dilute bright red blood 

T: pale and swollen tongue   P: deep, weak

periods that stop and start

-Blood stasis in the uterus

-Cold in the uterus, painful, stringy d clots, scanty periods, abdo pain alleviated by heat

-Liver Qi stagnation

Periods that return after menopause

 Liv & KD Yin deficiency with empty heat, scanty in volume, fresh red blood

Liv Qi stagnation turned in Liv fire,  Heavy period, dark red blood with red clots 

   T: red tongue with redder sides and yellow coating   P: wiry, rapid

Spleen Qi deficiency, Heavy period, dilute bright-red blood 

T: pale   P: empty

,Toxic heat in the uterus, Bloody vaginal discharge with offensive odor, five color vaginal discharge 

T: red tongue with sticky yellow coat and red spots   P: rapid, overflowing

Toxic heat in the uterus

VAGINAL ITCHING AND DISCHARGE

Vaginal itching, discharge, or both result from infectious or noninfectious inflammation of the vaginal mucosa, often with inflammation of the vulva.  

Candidal Infection

Clinical evaluation plus:

Vaginal pH < 4.5; Yeast or hyphae identified on a wet mount or KOH preparation; Sometimes culture

vaginal discharge-resembles cottage cheese and adheres to vaginal wall

vulva and vaginal irritation,

edema,

pruritis

Bacterial Vaginosis

Malodorous (fishy), thin, gray vaginal discharge with pruritus and irritation;

Erythema and edema uncommon

Trichomonal infection

STD- trichomonas vaginalis

Yellow-green, frothy vaginal discharge, often with soreness, erythema, and edema of the vulva and vagina

Sometimes dysuria and dyspareunia; Sometimes punctate, red “strawberry” spots on the vaginal walls or cervix; Mild cervical motion tenderness often detected during bimanual examination

(Vaginal Discharge - SHANG HAI)

This condition is attributed either to a depletion of Qi and blood, or dampness and heat moving into the lower jiao where they disrupt the Girdle, penetrating and conception channels.

     Qi and blood deficiency: white, thin discharge, fatigue in the limbs and dizziness

Dampness and heat: yellow or red discharge, palpitations, dryness in the mouth

Morbid Leukorrhea (CAM)

SP DEF

sp unable to hold fluid

-    Profuse thick, white or light yellow vaginal discharge w/o smell

-    Pale / sallow complexion

-    Lassitude

-    Poor appetite

-    Loose stools

-    Edema in the lower limbs

T: pale with white sticky coat              P: slow, weak

pt:    GB 26, Ren 6, UB 30, Sp 9, St 36

Method: reinforcing, moxa

Morbid Leukorrhea (CAM)

KID DEF

 kid yang xu causing DAI and Ren Meridian dysfunction

-    Profuse and continuous discharge of thin and transparent whites discharge

-    Sever soreness of the low back

-    Cold sensation in the lower abdomen

-    Frequent and excessive urine

-    Loose stools

T: pale with thin coat            P: deep

pt:  UB 23, Ren 4, KD 12, GB 26, KD 7

Method: reinforcing, moxa

Morbid Leukorrhea (CAM)

Damp Heat 

sp qi def----> damp--->heat

Lv qi stag--->dampheat

Ren 3, UB 32, Sp 6, Liv 3

 Itching in the vulva: Liv 5

Reddish leukorrhea: Sp 10

Excessive heat: LI 11

Method: reduce

_{Five colour vaginal discharge}

This may be watery like rice soup, like bloody water or like pus, usually with an offensive odor, 

white, red, green, yellow, dk brown

Vaginal itching (GIO)

AMENORRHEA

Anovulatory amenorrhea:  The most common causes involve a disruption of the hypothalamic-pituitary ovarian axis.  Causes include hypothalamic dysfunction; pituitary dysfunction; premature ovarian failure; endocrine disorders that cause androgen excess.  Anovulatory amenorrhea is usually secondary but may be primary if ovulation never begins

Ovulatory amenorrhea: The most common causes include chromosomal abnormalities; other congenital anatomic genital abnormalities that obstruct menstrual flow

The absence of menstruation can be primary or secondary.  Primary amenorrhea is failure of menses to occur by age 16 or 2 years after the onset of puberty or about age 14 in girls who have not gone through puberty.  Secondary amenorrhea is cessation of menses after they have begun; evaluation of amenorrhea is usually done if menses are absent for > 6 months.

(Amenorrhea – SHANG HAI

The cause of amenorrhea are dried and stagnant blood.

.       Dried blood (exhaustion of Kidney Qi, insufficient blood in the uterus, deficiency in the penetrating and conception channels): gaunt appearance, dry skin, lassitude and occasionally low fever, night sweats, dizziness and palpitations

Stagnant blood: pain and distension in the lower abdomen, congestion in the chest, pain in the flanks or abdominal lumps, scaly skin

DYSMENORRHEA

It is uterine pain around the time of menses.  Pain may occur with menses or precede menses by 1 to 3 days.  Pain tends to peak 24 h after onset of menses and subside after 2 to 3 days.  It is usually sharp but may be cramping, throbbing, or a dull, constant ache; it may radiate to the legs.

1.       Primary dysmenorrhea: Pain is thought to result from uterine contractions and ischemia.  Contributing factors may include passage of menstrual tissue through the cervix, a narrow cervical os, a malpositioned uterus, lack of exercise, and anxiety about menses. It occurs almost invariably in ovulatory cycles.   W/I 2 YRS OF MENSE

2.       Secondary dysmenorrhea: symptoms are due to pelvic abnormalities.  Common causes include endometriosis; uterine adenomyosis, fibroids ,  ONSET LATER

(Dysmenorrhea – CAM)

EXCESS

·         Pain in the lower abdomen (start before menstruation)

·         Retarded, scanty and dark purple menses with clots

·         Distending pain in the lower abdomen (alleviated by passing out of the clots) (KD 14, St 28)

·         Distension in the hypochondriac region and breast

T: purplish tongue with purple spots on its edge

P: deep and string-taut

·         Pain and cold feeling in the lower abdomen referring to the waist and back (alleviated by warmth) (St 29, St 27)

·         Scanty dark red menses with clots

T: sticky and white tongue coating

P: deep, string-taut

(Dysmenorrhea – CAM)

Deficiency

                          Ren 4, UB 20, UB 23, St 36, Sp 6             

                                Method: reinforcing, moxa

·         Dull pain appearing by the end of or after menstruation

·         Alleviated by warmth and pressure

·         Pink, scanty and thin menses

·         Aversion to cold

·         Cold extremities

·         Pale complexion

P: thready, weak

PREMENSTRUAL SYNDROME (PMS)

PMS appears to be caused by multiple endocrine factors.  The symptoms occur 7 to 10 days before menses begin and usually ending a few hours after onset of menses.

Signs and symptoms (type and intensity of symptoms vary from woman to woman and from cycle to cycle)

·         The most common symptoms are irritability, anxiety, agitation, anger, insomnia, difficulty concentrating, lethargy, depression, and severe fatigue

·         Fluid retention causes edema, transient weight gain, and breast fullness and pain

·         Pelvic heaviness or pressure and backache may occur  

·         Some women (younger ones) have dysmenorrheal when menses begins

·         Headache, vertigo, paresthesias of the extremities, syncope, palpitations, constipation, nausea, vomiting, and changes in appetite

Premenstrual dysphoric disorders (PMDD)

Mood is markedly depressed, and anxiety, irritability, and emotional lability are pronounced. Suicidal thoughts may be present. Interest in daily activities is greatly decreased. Symptoms are severe enough to interfere with routine daily activities or overall functioning

For PMDD to be diagnosed, women must have ≥ 5 of the following symptoms for most of the week before menses and at least one symptom must be from the first 4:

·         Feelings of sadness, hopelessness, or self-depreciation

·         A tense (on edge) feeling or anxiety

·         Emotional lability with frequent tearfulness

·         Irritability or anger that persists, leading to increased interpersonal conflicts

·         Loss of interest in daily activities, possibly causing withdrawal

·         Decreased concentration

·         Fatigue, lethargy, or lack of energy

·         Changes in eating habits, including bingeing

·         Insomnia or hyperinsomnia

·         Feelings of being overwhelmed or out of control

·         Physical symptoms associated with PMS

MENOPAUSE

Menopause is physiologic or iatrogenic cessation of menses (amenorrhea) due to decreasing ovarian function.

Treatment

·         Avoidance of triggers and stress

·         Exercise and relaxation techniques 

Signs and symptoms (perimenopausal changes in menstruation usually begin during a woman’s 40s)

·         Vasomotor: hot flushes and sweating and usually begin before menses stop

·         Neuropsychiatric: Neuropsychiatric changes (eg, poor concentration, memory loss, depression, anxiety) may accompany menopause but are not directly related to decreased estrogen.

·         Genital: decreased estrogen leads to vaginal and vulvar dryness and thinning, which may result in inflammation of the vaginal mucosa

·         Other: risk of osteoporosis increases because estrogen is decreased, increasing bone resorption by osteoclasts

Menopausal Syndrome (GIO)

ENDOMETRIOSIS

Endometriosis is a noncancerous disorder in which functioning endometrial tissue is implanted outside the uterine cavity. 

The most widely accepted hypothesis is that endometrial cells are transported from the uterine cavity and subsequently become implanted at ectopic sites

·         Pelvic pain, pelvic mass, alteration of menses, and infertility are typical

·         Large intestine: Pain during defecation, abdominal bloating, or rectal bleeding during menses
Bladder: Dysuria, hematuria, suprapubic pain (particularly during urination), or a combination

·         Ovaries: Formation of an endometrioma which occasionally ruptures or leaks, causing acute abdominal pain and peritoneal signs

·         Adnexal structures: Formation of adnexal adhesions, resulting in a pelvic mass

·         Extrapelvic structures: Vague abdominal pain (sometimes)

UTERINE FIBROIDS

Uterine fibroids are benign uterine tumors of smooth muscle origin. Fibroids frequently cause abnormal vaginal bleeding, pelvic pain and pressure, urinary and intestinal symptoms, and pregnancy complications.

·         Fibroids can cause menorrhagia or menometrorrhagia

·         If fibroids grow, degenerate, or hemorrhage or if pedunculated fibroids twist, severe acute or chronic pressure or pain can result

Fibroids may prevent pregnancy; during pregnancy, they may cause recurrent spontaneous abortion, premature contractions, or abnormal presentation or make cesarean delivery necessary

(Heavy periods - GIO)

MASTALGIA (BREAST PAIN)

Mastalgia (breast pain) is common and can be localized or diffuse and unilateral or bilateral.  Localized breast pain is usually caused by a focal disorder that causes a lump.  Diffuse, bilateral pain may be caused by fibrocystic changes or, uncommonly, diffuse, bilateral mastitis.  The most common causes are hormonal changes that cause breast tissue proliferation; large, pendulous breasts that stretch Cooper’s ligaments

Infertility

SPERM DISORDERS

Sperm disorders include defects in quality or quantity of sperm produced and defects in sperm emission.

Other causes: Men with microdeletions affecting the Y chromosome can develop oligospermia via various mechanisms, depending on the specific deletion.

Diagnosis: semen analysis; genetic testing

Treatment: clomiphene; assisted reproductive technique

OVULATORY DYSFUNCTION

Ovulatory dysfunction is abnormal, irregular, or absent ovulation. Menses are often irregular or absent.  Chronic ovulatory dysfunction in premenopausal women is most commonly caused by polycystic ovary syndrome.

Signs and symptoms: menses are absent, irregular

Diagnosis: BBT monitoring; measurement of urinary or serum hormones or ultrasonography

Treatment:

·         Clomiphere

·         Possibly metformin if body mass index is >35

·         Gonadotropins if clomiphene is ineffective

TUBAL DYSFUNCTION AND PELVIC LESIONS

Tubal dysfunction is fallopian tube obstruction or epithelial dysfunction that impairs zygote motility; pelvic lesions are structural abnormalities that can impede fertilization or implantation.

Diagnosis: hysterosalpingography; laparoscopy or sonohysterography

Treatment: Laparoscopy or hysteroscopy to restore patency

1.       Tubal dysfunction can result from:

a.       PID

b.       Use of an intrauterine device

c.        Rptured appendix

d.       Lower abdominal surgery leading to pelvic adhesions

e.        Inflammatory disorders

f.         Ectopic pregnancy

2.       Pelvic lesions that can impede fertility include

a.       Intrauterine adhesions (Asherman’s syndrome)

b.       Fibroids obstructing the fallopian tubes or distorting the uterine cavity

c.        Certain malformations

d.       Pelvic adhesions

UNEXPLAINED INFERTILITY

I

nfertility is considered unexplained when semen in the man and ovulation and fallopian tubes in the woman are normal

Controlled ovarian hyperstimulation (COH) may be use and it is to induce ovulation of > 1 oocyte.  COH involves:

·         Giving,clomiphere with human chorionic gonadotropin (hCG) to trigger ovulation, for up to 3 menstrual cycles

·         Intrauterine insemination within 2 days of hCG administration

·         If pregnancy does not result, other assisted reproductive techniques

In vitro fertilization (IVF)

The procedure involves the following

a.       Controlled ovarian hyperstimulation: Clomiphene plus gonadotropins or gonadotropins alone can be used. A gonadotropin-releasing hormone (GnRH) agonist or antagonist is often given to prevent premature ovulation. After sufficient follicular growth, human chorionic gonadotropin (hCG) is given to induce final follicular maturation and ovulation.

b.       Oocyte retrieval: oocytes are retrieved about 34 hours after hCG is given

c.        Fertilization

d.       Embryo culture: after sperm are added, the oocytes are cultured for about 2 to 5 days

                          e.  Embryo transfer: The number of embryos transferred is determined by the woman's age and likelihood        of response to IVF. Other embryos may be frozen in liquid nitrogen for transfer in a subsequent cycle

Gamete intrafallopian tube transfer (GIFT):

  GIFT is an alternative to IVF but is used infrequently, typically for women with unexplained infertility or with normal tubal function plus endometriosis.

Intracytoplasmic sperm injection

This technique is useful when other techniques are not successful or are unlikely to be so or when a severe sperm disorder is present.

 (Infertility, GIO)

    Ectopic pregnancy

 Risk factors for ectopic pregnancy include

 ·         History of sexually transmitted disease or pelvic inflammatory   disease

·         Cigarette smoking

·         Use of intrauterine device

            ·         Age > 35

            ·         Previous abdominal surgery (especially tubal surgery)

            ·         Use of fertility drugs or assisted reproductive techniques

            ·         Previous ectopic pregnancy (the most important)

            ·         Multiple sex partners 

                         Douching

Abdominal or pelvic pain, which is often sudden, localized, and constant (not crampy), with or without vaginal bleeding; Closed cervical os

No fetal heart sounds; Possibly hemodynamic instability if ectopic pregnancy has ruptured

Quantitative β-hCG measurement

CBC; Blood type and Rh typing

Pelvic ultrasonography

Spontaneous abortion 

Risk factors for spontaneous abortion include

·         Age > 35

·         History of spontaneous abortion

·         Cigarette smoking

·         Drugs (eg, cocaine, alcohol, high doses of caffeine)

·         Uterine abnormalities (eg, leiomyoma, adhesions)

Crampy, diffuse abdominal pain, often with vaginal bleeding; Open or closed cervical os depending on the type of abortion 

Quantitative β-hCG measurement

CBC; Blood type and Rh typing

Pelvic ultrasonography

Adnexal (ovarian) torsion

Sudden onset of localized pelvic pain, which may be colicky and often mild if torsion spontaneously resolves; Often, nausea, vomiting

Evaluation as for ectopic pregnancy plus Doppler ultrasonography

Threatened abortion

vaginal bleeding

Vaginal bleeding with or without crampy abdominal pain

Closed cervical os, nontender adnexa; Most common during the first 12 wk of pregnancy

Septic abortion

vaginal bleeding

Fever, chills, continuous abdominal pain, vaginal bleeding, purulent vaginal discharge; Usually, apparent history of recent induced abortion or instrumentation of the uterus (often illegal or self-induced); Open cervical os

NAUSEA AND VOMITING DURING EARLY PREGNANCY

Hyperemesis Gravidarum

Frequent, persistent nausea and vomiting with inability to maintain adequate oral intake of fluids, food, or both; Usually, signs of dehydration (eg, tachycardia, dry mouth, thirst), weight loss

Urine ketones, serum electrolytes, Mg, BUN, creatinine; If the condition persists, possibly liver function tests, pelvic ultrasonography

Hydatidiform mole

nausea vomiting during early preg

Larger-than-expected uterine size, absent fetal heart sounds and movement; Sometimes elevated BP, vaginal bleeding, grapelike tissue from the cervix

(SHANG HAI)

NAUSEA AND VOMITTING

When a woman becomes pregnant the blood in the uterus which no longer passes from the body during menstruation may become turbid and join with fire in the stomach and liver, rebelling upward.  Alternatively, phlegm and dampness may obstruct the stomach such that the Qi of that organ does not properly descend, causing stomach upset.

1.       Fire in Liver and Stomach: pain in the flanks, depressed feeling in the chest, belching and sighing in discomfort

2.  Phlegm and dampness obstructing the stomach: feeling of fullness in the chest, obstruction in the stomach, food seems tasteless  T: white, greasy tongue coating

Nausea and vomiting – CAM

Sp and St deficiency

nausea vomitting- CAM

Disharmony between liver and stomach

LOWER EXTREMITY EDEMA DURING LATE PREGNANCY

DVT

Risk factors for DVT include:

·         Venous insufficiency

·         Trauma

·         Hypercoagulability disorder

·         Thrombotic disorders

·         Cigarette smoking

·         Immobility

·         Cancer

LOWER EXTREMITY EDEMA DURING LATE PREGNANCY

PRECLAMPSIA

Hypertension and proteinuria, with or without significant nondependent edema (eg, in face or hands), which, when present, is not red, warm, or tender; Sometimes presence of risk factors for preeclampsia; When preeclampsia is severe, possibly additional symptoms of headache; pain in the right upper quadrant, epigastric region, or both; and visual disturbances; Possibly papilledema, visual field deficits, and lung crackles (in addition to edema), detected during physical examination

Risk factors for preeclampsia include:

·         Chronic hypertension

·         Personal or family history of preeclampsia

·         Age < 17 or > 35

·         First pregnancy

·         Multifetal pregnancy

·         Diabetes

·         Vascular disorders

·         Hydatidiform mole

·         Abnormal maternal serum screening results

PREECLAMPSIA AND ECLAMPSIA

Preeclampsia is new-onset hypertension and proteinuria after 20 wk gestation.

Eclampsia is unexplained generalized seizures in patients with preeclampsia

                ·         Preeclampsia may be asymptomatic or may cause edema or           excessive weight gain

·         Nondependent edema, such as facial or hand swelling (the patient's ring may no longer fit her finger), is more specific than dependent edema

·         Reflex reactivity may be increased, indicating neuromuscular irritability

·         Petechiae may develop, as may other signs of bleeding

·         Severe preeclampsia may cause organ damage:  manifestations may include headache, visual disturbances, confusion, epigastric or right upper quadrant abdominal pain (reflecting hepatic ischemia or capsular distention), nausea, vomiting, dyspnea (reflecting pulmonary edema or acute respiratory distress syndrome [ARDS]), stroke (rarely), and oliguria (reflecting decreased plasma volume or ischemic acute tubular necrosis).

HYPERTENSIVE DISORDER IN PREGO

·         Chronic hypertension is identified if hypertension precedes pregnancy, is present at < 20 wk gestation, or persists for > 6 wk (usually > 12 wk) postpartum.  Chronic hypertension may be masked during early pregnancy by the physiologic decrease in BP.

·         Gestational hypertension is hypertension without proteinuria or other findings of preeclampsia; it first occurs at > 20 wk gestation in women known not to have hypertension before pregnancy and resolves by 12 wk (usually by 6 wk) postpartum.

·         Preeclampsia superimposed on chronic hypertension is diagnosed when a woman with hypertension develops new-onset proteinuria after 20 wk gestation.

Preeclampsia is diagnosed in women who have known hypertension and proteinuria if BP increases to ≥ 160 mmHg systolic or ≥ 110 mmHg diastolic in the last half of pregnancy even if they do not have proteinuria, particularly if the increase is accompanied by symptoms, increased liver enzymes (aminotransferases), or thrombocytopenia

Eclampsia - GIO

Threatened miscarriage (GIO)

Habitual miscarriage (GIO)

PROLONGED LABOR (CAM)

QI AND BLOOD DEF

PROLONGED LABOR (CAM)

QI AND BLOOD STAG

(INSUFFICIENT LACTATION - CAM)

QI AND BLOOD DEF

(INSUFFICIENT LACTATION - CAM)

Liver qi stag

·         Absence of milk secretion after delivery

·         Distending pain in breast

·         Mental depression

·         Chest distress and hypochondriac pain

·         Epigastric distension

·         Loss of appetite

T: pink

P: string-taut

(SHANG HAI- Insufficent Lactation)