Late pregnancy complications

Question 1

What is Umbilical Cord Prolapse?

Answer 1

cord extends beyond the presenting part of the fetus and protrudes into the vagina

Question 2

What is a prolapsed umbilical cord susceptible to?

Answer 2

Umbilical vein occlusion and umbilical artery vasospasm: reduce fetal oxygenation

Question 3

How does umbilical cord prolapse present?

Answer 3

Sudden onset fetal bradycardia or variable decelerations with a palpable umbilical cord on vaginal exam

Question 4

What is a prolapsed umbilical cord associated with?

Answer 4

Amniotomy or spontaneous rupture of membranes

Question 5

How do you treat a prolapsed umbilical cord?

Answer 5

manual elevation of the presenting fetal part to prevent compression and emergency C-section

Question 6

What are risk factors for preterm labor?

Answer 6

Premature rupture of membranes
Multiple gestation
Previous history of preterm labor
Placental abruption
Maternal factors
-Uterine anatomical abnormalities
-infections: Choriamnionitis
-Preeclampsia
-intraabdominal surgery

Question 7

What are common symptoms of preterm labor?

Answer 7

Contractions: abd pain, lower back pain, pelvic pain
dilation of the cervix
Betwen 20 weeks and 36 weeks 6 days

Question 8

What should the fetus be evaluated for in preterm labor?

Answer 8

Weight
Gestation age
present part: Cephalic vs breech

Question 9

What are situations where preterm delivery should not be stopped with tocolytics?

Answer 9

Maternal severe HTN: eclampsia/preeclampsia
Maternal cardiac disease
Maternal cervical dilation >4cm
maternal hemorrhage: Abruptio placenta, DIC
Fetal Death
Choramnionitis

Question 10

What are indications to stop preterm delivery?

Answer 10

24-33 weeks EGA, 600-2500 grams

Question 11

What are indications proceed with preterm delivery?

Answer 11

34-37 weeks EGA, >2,500 grams

Question 12

What are you treatments for preterm delivery?

Answer 12

Corticosteroids
Tocolytics
Terbutaline

Question 13

What Corticosteroid is commonly used in preterm delivery?

Answer 13

Betamethasone

Question 14

Why are corticosteroids used in preterm delivery?

Answer 14

to mature the fetus’s lungs and reduce the risk of respiratory distress syndrome and neonatal mortality

Question 15

What should be given after steroids in preterm delivery?

Answer 15

Tocolytic to allow time for the steroids to work

Question 16

What do Tocolytics do in premature delivery?

Answer 16

Slow the progression of cervical dilation by decreasing uterine contraction

Question 17

What is the preferred Tocolytic drug class?

Answer 17

CCBs: prevent Ca influx and inhibit release of intracellular ca from the SR

Question 18

What is the mechanism of Terbutaline?

Answer 18

Beta-adrenergic receptor agonist

Question 19

How does Terbutaline work in premature delivery?

Answer 19

temporarily stops contractions in a laboring patient with a nonreassuring fetal heart tracing

Question 20

When is Prelabor Rupture of Membranes (PROM) the biggest problem?

Answer 20

When the fetus is preterm or with prolonged rupture of membranes

Question 21

What does “Prolonged” rupture of membranes mean?

Answer 21

labor starts >24 hours after rupture

Question 22

What are complications associated with Prelabor rupture of membranes (PROM)?

Answer 22

Preterm labor
cord prolapse
placental abruption
chorioamnionitis

Question 23

What are common symptoms of Prelabor Rupture of Membranes (PROM)?

Answer 23

Hx of gush fluid from the vagina which should be sampled with sterile speculum examination

Question 24

What can confirm the gush fluid from the vaginia is amniotic fluid?

Answer 24

Fluid in the posterior fornix
Fluid turns nitrazine paper blue: pH is more basic
When placed on slide and air dried: ferning pattern
Amniotic fluid index may be low

Question 25

If there is PROM and Chorioamnionitis what do you do next?

Answer 25

Deliver immediately

Question 26

If there is PROM without chorioamnionitis and the fetus is at term what do you do?

Answer 26

Wait 6-12 hours for spontaneous delivery then induce labor

Question 27

What antibiotic is given to help decrease the risk of developing Chorioamnionitis?

Answer 27

Ampicillin and 1 dose of Azithromycin

Question 28

What antibiotic is given to help decrease the risk of developing Chorioamnionitis if the patient has a low risk penicillin allergy?

Answer 28

Cefazolin and 1 dose of azithromycin

Question 29

What antibiotic is given to help decrease the risk of developing Chorioamnionitis if the patient has a high risk penicillin allergy?

Answer 29

Clindamycin and 1 dose of azithromycin

Question 30

What is Chorioamnionitis ("Triple I")?

Answer 30

Intrauterine Infection and/or Inflammation

Question 31

What pathogens are commonly associated with Chorioamnionitis?

Answer 31

Ureaplasma, Mycoplasma, Gardnerella Vaginalis or GBS

Question 32

What are common risk factors for Chorioamnionitis?

Answer 32

Prolonged labor PROM Multiple digital vaginal exams Cervical Insufficiency Invasive testing Internal fetal monitoring STD

Question 33

How is Chorioamnionitis diagnoses?

Answer 33

1 Measurement of fever >39.0C or 2 measurements of Fever 38.0-38.9C 30 minutes apart without another clear source + 1 or more of the following -Fetal Tachycardia -Maternal leukocytosis -Purulent Cervical fluid

Question 34

How do you treat Chorioamnionitis?

Answer 34

Immediate delivery + abx

Question 35

What Abx are given for chorioamnionitis with Vaginal delivery?

Answer 35

Ampicillin and Gentamicin

Question 36

What abx are given for chorioamnionitis with C-Section?

Answer 36

Ampicillin and gentamicin + Clindamycin (anerobic coverage)

Question 37

What is Placenta Previa?

Answer 37

Abnormal implantation of the placenta over the internal cervical os

Question 38

What are common risk factors for Placenta Previa?

Answer 38

Previous C-section Previous uterine surgery Multiple Gestations Previous Placenta previa

Question 39

How does Placenta Previa present?

Answer 39

Painless vaginal bleeding: 3rd trimester

Question 40

How is Placenta Previa diagnosed?

Answer 40

Transabdominal US: done first transvaginal US: confirmatory test

Question 41

When do you treat placenta previa?

Answer 41

large-volume bleeding or a drop in Hct

Question 42

How do you treat placenta previa?

Answer 42

Strict pelvic rest: nothing put into vagina Immediate C-section if indicated

Question 43

What are indications for immediate c-sections in placenta previa?

Answer 43

Severe hemorrhage or fetal distress

Question 44

What is a Velamaentous Umbilical cord?

Answer 44

Umbilical vessels lack the protective layer of wharton jelly close to the placental insertion leaving vessels susceptible to rupture and compression

Question 45

How does Velamentous Umbilical Cord present?

Answer 45

Spontaneous rupture of membranes with heavy vaginal bleeding from torn umbilical vessels crossing the cervical os

Question 46

What happens if you do not treat a velamentous umbilical cord?

Answer 46

rapid fetal exsanguination and death

Question 47

How do you treat a velamentous umbilical cord with Vasa Previa?

Answer 47

Emergency C-Section

Question 48

What are the subtypes of the Placenta Accreta Spectrum (PAS)?

Answer 48

Placenta accreta, increta and percreta: when the placenta abnormally adheres to different areas of the uterus

Question 49

What is Placenta Accreta?

Answer 49

Placenta adheres to the superficial uterine wall

Question 50

What is Placenta Increta?

Answer 50

Placenta attaches to the myometrium

Question 51

What is placenta percreta?

Answer 51

Placenta invaded into uterine serosa, bladder wall or rectal wall

Question 52

What happens if a placenta cannot detach from the uterine wall after delivery of the fetus?

Answer 52

Catastrophic Hemorrhage and shock

Question 53

What is often required by patients on the Placenta Accrets Spectrum (PAS)?

Answer 53

hysterectomy

Question 54

What is Placental Abruption?

Answer 54

Premature separation of the placenta from the uterus resulting in tearing of the placental blood vessels and hemorrhaging into the separated space

Question 55

What are potential complications of Placental Abruption?

Answer 55

Premature delivery Uterine tetany DIC Hypovolemic shock

Question 56

What are common precipitating factors for placental abruption?

Answer 56

Maternal HTN Prior placental abruption Maternal cocaine use/smoking during pregnancy Maternal external trauma

Question 57

How does Placental Abruption present?

Answer 57

Third-trimester vaginal bleeding severe abdominal pain contractions possible fetal distress

Question 58

What are indications for C-Section in Placental Abruption?

Answer 58

Uncontrollable maternal hemorrhage Rapidly expanding concealed hemorrhage Fetal Distress Rapid placental separation

Question 59

What are indications for vaginal delivery in placental abruption?

Answer 59

Placental separation is limited Fetal heart tracing is reassuring separation is extensive and fetus is dead

Question 60

Who is uterine rupture life-threatening to?

Answer 60

Both fetus and mother

Question 61

What are common risk factors for Uterine Rupture?

Answer 61

Previous c-section: Classical (longitudinal) has higher risk Trauma: car accidents most common Uterine myomectomy Uterine Overdistention: Poyhydramnios, multiple gestation Placenta Percreta

Question 62

What are symptoms of uterine rupture?

Answer 62

Sudden onset extreme abdominal pain abnormal bump in abdomen No uterine contractions Loss of fetal station: fetus withdrew into abdomen

Question 63

How is uterine rupture treated?

Answer 63

Immediate laparotomy with delivery of the fetus followed by repair or the uterus or hysterectomy

Question 64

What will be done in future pregnancies for a patient with history of uterine rupture?

Answer 64

Scheduled C-Section at 36 weeks

Question 65

When does Rh Incompatibility occur?

Answer 65

Rh (-) mother and Rh (+) baby: usually not an issue in first pregnancy

Question 66

What does Rh incompatibility lead to?

Answer 66

Hemolytic Disease of the newborn

Question 67

What does Hemolytic Disease of the newborn lead to?

Answer 67

Fetal anemia and extramedullary production of RBC increased heme and bilirubin from hemolysis possible Erythroblastosis fetalis: high CO CHF

Question 68

If unsensitized when is Rhogam administered?

Answer 68

28 weeks if indicated

Question 69

What does it mean if a patient is Rh (-) without ab?

Answer 69

They are unsensitized

Question 70

What does it mean if a patient is Rh (-) with antibodies?

Answer 70

they are sensitized

Question 71

What are some common examples where fetal blood cells may cross the placenta into the mother's blood and sensitize?

Answer 71

Amniocentesis Abortion Vaginal Bleed Placental Abruption Delivery

Question 72

When is the prenatal Ab screening for Rh ab performed?

Answer 72

First prenatal visit and again at 28 weeks

Question 73

When is Rhogam given if indicated?

Answer 73

28 weeks if they are Rh (-) and unsensitized, then again at delivery if the baby is Rh(+)