3- Abnormal Pregnancy III & IV Flashcards by Colleen Cahill

Preterm labor is the most common cause of perinatal morbidity/ mortality, and can lead to long-term neuro impairment. How is preterm labor defined?

Regular contractions between 20 - 37 weeks resulting in cervical changes

How well did you know this?

Not at all

Perfectly

Pt presents with menstrual-like cramps, low/ dull backache, abd/ pelvic pressure, abd cramping, vaginal discharge, and painless uterine contractions. What are you concerned for?

Preterm labor

How well did you know this?

Not at all

Perfectly

What is included as part of preterm labor eval aside from digital cervical exam, UA C+S +/- NST?

R/o ROM

US for cervical length

GBS culture

How well did you know this?

Not at all

Perfectly

What diagnostic test is used as a predictive value for preterm labor?

Fetal fibronectin (fFN) = “glue like” glycoprotein

Present @ term, but NOT @ 22-35 wks

(none = (-) predictive value, (+) = (+) predictive value)

How well did you know this?

Not at all

Perfectly

What criteria must be met for a diagnosis of preterm labor?

Uterine contractions ≥ 4 q 20 min or ≥ 8 in 60 min PLUS

cervical dilation ≥ 3cm or
cervical length < 20mm on TVUS or
cervical length 20-30mm on TVUS + (+) fFN

How well did you know this?

Not at all

Perfectly

What is the management for preterm labor?

Hospitalize if < 34 weeks

+ betamethasone, tocolytic drugs, GBS abx, mg sulfate (neuroprotection)

How well did you know this?

Not at all

Perfectly

What tocolytic agents are used in the management of preterm labor?

In-pt: Terbutaline, Mg Sulfate

Out-pt: Nifepidine, Indomethacin

How well did you know this?

Not at all

Perfectly

What is defined as placental location close to or over the internal cervical os and is the leading cause of 3rd trimester bleeding?

Placenta previa

How well did you know this?

Not at all

Perfectly

What is a specific RF for placenta previa?

Hx of prior c-section or uterine surgery

How well did you know this?

Not at all

Perfectly

What are the 4 degrees of placenta previa?

Complete- internal os completely covered

Partial- internal os partially covered

Marginal- edge of placenta at margin of internal os

Low-lying- placenta < 2cm from internal os

How well did you know this?

Not at all

Perfectly

Pt presents with mod-severe acute painless vaginal bleeding in the late 2nd or 3rd trimester. What are you concerned for?

Placenta previa

How well did you know this?

Not at all

Perfectly

How is placenta previa diagnosed?

Start w/ transabdominal US

Confirm w/ TVUS

How well did you know this?

Not at all

Perfectly

If placenta previa is detected in the 2nd trimester, what pt education can be provided?

Most resolve by 32-35 wks due to placental migration

(unless complete placenta previa)

How well did you know this?

Not at all

Perfectly

What should you NEVER do on a known placenta previa pt?

Bimanual/ cervix exam

How well did you know this?

Not at all

Perfectly

What is the management for placenta previa if presenting w/ spontaneous labor or hemorrhage?

Immediation c-section

How well did you know this?

Not at all

Perfectly

What is the management for placenta previa if preterm w/o active bleeding?

Observe (home > hospital) until c-section @ 37-38 wks

Corticosteroids if < 37 wks, RhoGAM if Rh (-)

How well did you know this?

Not at all

Perfectly

What complications are a/w placenta previa? (4)

Increased risk of:

preterm delivery/ perinatal death
placenta accreta (too deep/ firm into uterine wall)
placenta increta (into uterine muscle)
placenta percreta (through uterine muscle layers, most dangerous)

How well did you know this?

Not at all

Perfectly

What is defined as abnormal premature separation of an otherwise normally implanted placenta that can cause 2nd/ 3rd trimester bleeding or hemorrhage?

Abruptio placentae

How well did you know this?

Not at all

Perfectly

What are the types of placental abruption?

Marginal, partial, complete

(complete a/w increased risk of fetal death)

How well did you know this?

Not at all

Perfectly

What is the greatest RF for placental abruption?

Abdominal trauma

(displaces uterus → detaches placenta)

How well did you know this?

Not at all

Perfectly

What is the most common presentation of placental abruption?

Hemorrhage and abd pain

(others: fetal distress, rigid abd, irritable uterus, DIC)

How well did you know this?

Not at all

Perfectly

What is included in the management of a placental abruption? (4)

Expectant if marginal

Tx shock/ stabilize hemodynamically

C-section if fetal distress

Corticosteroids if < 37 wks

How well did you know this?

Not at all

Perfectly

What is defined as fetal blood vessels running unsupported through the membranes over the cervix and under the presenting fetal part and what is the problem w/ this condition?

Vasa previa

Membranes rupture → fetal blood supply vessels rupture → rapid fetal blood loss/ death

How well did you know this?

Not at all

Perfectly

Multiple gestation pregnancies, 2nd trimester/ low-lying placentas, bi-lobed/ accessory lobed placentas, and IVF pregnancies are RF for what condition?

Vasa previa

How well did you know this?

Not at all

Perfectly

Pt presents w/ vaginal bleeding w/ ROM and changes in fetal heart rate. What are you concerned for and what is used for confirmation of dx?

Vasa previa Dx w/ color doppler US

What is the management for vasa previa?

Hospitalize if 3rd trimester Corticosteroids b/w 28-32 wks Pelvic rest C-section @ 35 wks

How is premature rupture of membranes (PROM) defined?

Spontaneous rupture of membranes before the onset of labor

90% of women **at term** will go into spontaneous labor w/i 24 hrs of PROM. If spontaneous labor does not ensue, there is increased risk of what?

Chorioamnionitis (infection of chorion/ amnion/ both)

What complications are a/w PROM? (4)

Preterm labor Cord prolapse Placental abruption Intrauterine infection

Preterm premature rupture of membranes (PPROM) is defined as PROM that occurs when?

Before 37 wks gestation

Neonatal infection, necrotizing enterocoloitis, RDS (respiratory distress), neuro/ neuromuscular dysfunction are complications a/w what?

PROM (before 37 wks)

If PPROM occurs \< 26 weeks gestation, what are associated risks? (2)

Fetal pulmonary hyperplasia Limb positioning defects

What RFs are a/w PPROM? (3)

Smoking (x2), prior PROM, polyhydraminos

What tests are used to confirm membrane rupture?

Nitrazine paper (pH) FERN test

What should be avoided if suspicion for PROM?

Vaginal exams (limit risk of infection)

What is included in the management for PROM if chorioamnionitis is present?

Prompt delivery, regardless of gestational age

What is included in the management for PROM if chorioamnionitis is NOT present?

Hospitalization for induction of labor

What is included in the management for PPROM if chorioamnionitis is NOT present?

\> 34 weeks → induce labor 24-34 weeks → hospitalize, steroids, abx, Mg

What is the outcome for PROM?

Typical labor and delivery course

What is the typical outcome for PPROM?

**Spontaneous labor w/i 1 week** ↑ risk of neuro- developmental impairment Continue pregnancy @ home w/ close f/u (rare)

How is postterm pregnancy defined?

Pregnancy lasting ≥ 42 weeks gestation

What problems are a/w postterm pregnancy?

Stillbirth (≥ 41 weeks = increased risk) Fetal dysmaturity syndrome- malnutrition

What is the #1 cause of postterm pregnancy?

Inaccurate estimation of gestational age (must accurately date pregnancy- 1st trimester US most accurate)

Stillbirth, shoulder dystocia, fetal injury, oligohydraminos, and meconium aspiration are fetal complications of what?

Postterm pregnancy

Trauma, hemorrhage, and labor abnormalities are maternal complications a/w what?

Postterm pregnancy

What is included in management for postterm pregnancy?

Induction of labor @ 41 completed weeks Expectant management if refuse induction (serial NST/ BPP)

What abnormal labor patterns can be the cause of intrapartum complications?

Protraction disorder- labor is progressing at a slower pace than expected Arrest disorder- complete cessation in progress of labor

What is the management for abnormal labor patterns?

Observation, augmentation, operative vaginal delivery, c-section

What are the types of breech presentations?

Frank- feet near head Complete- legs crossed Incomplete- one/ both feet extended

How is a breech presentation detected/ confirmed?

Cervical exam → US

What are the preferred methods of management for breech presentation?

External cephalic version (ECV) @ 36 weeks C-section b/w 39-41 weeks (vaginal delivery not preferred/ rarely performed)

Transverse lie occurs when the head and butt of the baby are horizontal. What is the management?

ECV or C-section (no possibility for vaginal delivery because no presenting part)

Cephalopelvic disproportion arises from what 2 factors?

Diminished pelvic size or excessive fetal size (or both)

What is the most common cause of cephalopelvic disproportion?

Contraction of mid-pelvis during 2nd stage of labor

What is defined as descension of the umbilical cord alongside or beyond the fetal presenting part?

Cord prolapse- rare obstetric emergency

In addition to visualization or palpation of umbilical cord adhead of presenting, how is umbilical cord prolapse diagnosed?

Abrupt onset of: - severe, prolonged fetal bradycardia - mod-severe variable decelerations

What is the management for umbilical cord prolapse?

Trendelenburg, immediate C-section

What is defined as the inability to deliver the shoulders after the head of the baby has delivered?

Shoulder dystocia

Why is shoulder dystocia considered to be an acute obstretric emergency?

May cause fetal damage (brachial plexus injury)/ death

What is the management for shoulder dystocia?

McRoberts maneuver

What is defined as an adverse response of the fetus to the stress of labor contractions and is usually reflected in the interpretation of the fetal heart rate (reassuring vs nonreassuring)?

Fetal intolerance to labor

What is the goal in management of fetal intolerance to labor?

Recognize changes in fetal oxygenation that could result in serious complications

What fetal HR parameteres for decelerations are followed for consideration of fetal intolerance to labor? (N = 110-160 +/- 6-25 bpm, accelerations N)

**Early**: top of contraction, due to **head compression** **Variable**: before end of contraction, due to **cord compression** **Late**: after full contraction, due to **uteroplacental insufficiency**

What is included in the management for fetal intolerance to labor? (7)

Repositioning of pt D/c pitocin Correct maternal hypotension Admin O2 to mother Tocolysis Amnioinfusion Prepare for C-section

What does VBAC stand for?

Vaginal birth after cesarean

What does TOLAC stand for?

Trial of labor after cesarean

What does PRCD stand for?

Planned repeat cesarean delivery

What is the greatest maternal risk a/w VBAC?

Uterine rupture

What is the greatest fetal risk a/w TOLAC?

Perinatal/ neonatal mortality

How much delivery-associated blood loss is considered postpartum hemorrhage (PPH) for vaginal and C-section?

Vaginal \> 500mL C-section \> 1000mL

What is the most common cause of PPH?

Uterine atony

What complications are a/w PPH? (5)

RDS Coagulopathy Shock Loss of fertility Pituitary necrosis (Sheehan syndrome)

What criteria are used for diagnosis of PPH?

Cumulative blood loss ≥ 1000mL Bleeding a/w s+s of hypovolemia w/i 24 hrs of birth regardless of delivery route S+s of blood loss

How do you differentiate between primary vs secondary PPH?

Primary (early): w/i 24 hrs after delivery Secondary (late, delayed): 24 hrs - 12 weeks after delivery

What are the tx goals of PPH? (4)

Prevent hypoperfusion of vital organs w/ adequate circulation Adequate tissue oxygenation Reverse/ prevent coagulopathy Eliminate obstetric cause of PPH

3- Abnormal Pregnancy III & IV Flashcards

(75 cards)