15: Obsteric Complication

Question 0

Chadwick sign

Answer 0

Week 8-12
sign of pregnancy
Vaginal mucosa discolorationn- dark bluish or purplish red and congested

Question 1

Perception of fetal movement

Answer 1

Btw 16-20 wks

Question 2

Uterine changes- pregnancy

Answer 2

12 weeks: uterus palpable at symphysis pubis
20 weeks: uterus palpable at umbilicus
-After wk 20, the fungal height measured in cm from the pubis should approximate the gestational age in weeks

Question 3

Hegar’s sign

Answer 3

6-8 weeks of pregnancy
-softening of the lower uterine segment at junction with Cervix (Goodell’s sign). On bimanual palpation cervix may seem to separate from fundus.

Question 4

Braxton Hicks contractions

Answer 4

• begins at 12th week

- painless palpable uterine contractions at irregular intervals occurring throughout pregnancy

Question 5

Ballottement

Answer 5

• Bimanual exam at 16-20th week

- tap on cervix with a finger-> cervix floats up and down to tap the finger back

Question 6

Fetal heart sound

Answer 6

• Doppler: 6-10 weeks

- Fetoscope/ Stethoscope: 17-19 weeks

Question 7

Bleeding in early pregnancy

Answer 7

• Abortion
• Ectopic pregnancy
• Normal implantation of ovum

Question 8

Bleeding in late pregnancy

Answer 8

• Cervical: erosion, polyps, rarely carcinoma
• Vaginal: varicosities, lacerations
• Placental: abruptio placenta, placenta previa, vasa previa
• *Never perform a digital or speculum exam until US rules out placenta previa

Question 9

Abruptio placentae

Answer 9

• Painful late-trimester vaginal bleeding with a normal placed placenta
• External bleeding (MC)
• Internal bleeding: increase in fundal height*

Question 10

Classification of Abruptio placenta

Answer 10

0: asx
1: mild vaginal bleeding, slight tender uterus
2: moderate bleeding/ tenderness, maternal tachycardia with orthostatic HTN, fetal distress
3: Heavy bleeding, painful tetanic uterus, maternal shock, coagulopathy, fetal death
* *DIC is one of the most feared complication

Question 11

Abruptio placenta- investigations

Answer 11

• Kleihauer-Betke test: determine the volume of fetal blood transfused into the maternal circulation
• Nonstress test & BPP (Biophysical profile)

Question 12

Abruptio P- initial management

Answer 12

• External fetal monitoring
• Fluid resuscitation
• Blood transfusion
• Correct coagulopathy- fresh frozen plasma

Question 13

Abruptio P- management

Answer 13

• 36wks with controlled bleeding: Vaginal delivery

- Maternal or fetal jeopardy: Emergency cesarean section

Question 14

Placenta Previa

Answer 14

• Implantation of the placenta over or near the internal os of the cervix
• Painless vaginal bleeding 28-32wks
• DO NOT PERFORM vaginal and rectal exams-> might cause uncontrollable bleeding

Question 15

P previa- types

Answer 15

• Total
• Partial
• Marginal
• Low-lying

Question 16

P Previa- imaging

Answer 16

• Transabdominal ultrasonography
• Transperineal
• Transvaginal
• MRI

Question 17

Vasa previa

Answer 17

-fetal vessels cross in close proximity of the inner cervical os
-Velamentous insertion
Triad
-Membrane rupture
-Painless vaginal bleeding
-Fetal bradycardia

Question 18

Vasa previa- rx

Answer 18

-Cesarean delivery after confirming fetal lung maturity (Lecithin Sphingomyelin ratio of 2**)

Question 19

HTN in pregnancy- categories

Answer 19

1: Chronic HTN
2: Preeclampsia-eclampsia
3: Preeclampsia superimposed on chronic HTN
4: Gestational HTN

Question 20

Chronic HTN- info

Answer 20

BP over 140/90

1: before pregnancy or before 20wks gestation
2: after 20wks gestation and persists after 12wks post partum

Question 21

Chronic HTN- rx

Answer 21

Rx started if SBP is greater than 160 or DBP is greater than 100
-Methyldopa
-Nifedipine
-Hydralazine
Sodium nitroprusside (only postpartum)
-Labetalol and Propranolol (NOT: atenolol, nadolol, metoprolol- accumulate in breast milk)
**Do NOT use ACE inhibitor and ARBs

Question 22

Gestational HTN

Answer 22

• BP of 140/90 or greater than the first time during pregnancy
• No proteinuria
• BP returns tot normal less than 12wks postpartum

Question 23

Preeclampsia/Eclampsia

Answer 23

• BP 140/90 or greater after 20wks gestation with proteinuria**
• Always ask about past hx of preeclampsia since it RECURS**
• Eclampsia: seizures that cannot be attributed to other causes

Question 24

Preeclampsia superimposed on chronic HTN

Answer 24

1: New onset proteinuria 2: A sudden increase in proteinuria or BP, or a platelet count of less than 100,000, in a woman with HTN and proteinuria before 20wks gestation

Question 25

Severe preeclampsia (1 of following)

Answer 25

1: 160/110 or higher on 2 occasions at least 6hrs apart 2: Proteinuria of >5g/24hr collection or >3+ on 2 random urine samples at least 4hrs apart 3: Pulmonary edema or cyanosis 4: Oliguria (<400mL in 24hr) 5: Persistent headaches 6: Epigastric pain or impaired liver fx 7: Thrombocytopenia 8: Oligohydramnios, decreased fetal growth, or placental abruption

Question 26

HELLP syndrome

Answer 26

H: Hemolysis EL: Elevated Liver enzymes LP: Low Platelet count

Question 27

Seizure- Rx, Px

Answer 27

- ABC: airway, breathing, circulation | - Magnesium sulfate (PreventionOC)** to all severe preeclampsia

Question 28

Abnormal labor- cc

Answer 28

A: Mechanical dystocia -narrow pelvis: android or platypelloid shape of pelvis -abnormal fetal lie -fetal macrosomia, hydrocephalus, encephalocele, cystic hygroma B: Functional dystocia -reduced frequency or intensity of uterine contractions C: Iatrogenic -oversedation

Question 29

Abnormal labor- rx

Answer 29

- those who in passive phase: rest for several hrs - High dose oxytocin (goal: 7 contraction per 15mins) - Low dose oxytocin (goal: 3-5 contractions per 10mins) - Dinoprostone & Misoprostol (**contraindicated for a scarred uterus for labor induction) - Amniotomy (artificial rupture of membranes- ARM) - Delivery (Cesarean section or Operative vaginal delivery)