Nageles Rule
Subtract 3 mo from LMP and add 7 days for EDC
Parity
delieveries; FPAL - full term (>37w), preterm (20-36), abortion (<20) and living children #
Fetal heart tones can be heard at
10-12 w
Quickening
First awareness of fetal movements (18-20w in nullip and earlier (14-16) in multiparous woman)
Trimesters
1: week 1-12
2: week 13-27
3: week 28-40
Screening: first trimester
nuchal US, PAPP-A and b-HCG detects 82-87% of trisomy 21s
abn US, elevated b-HCG and dec PAPP-A
if positive, can offer chorionic villus sampling (CVS) or amniocentesis
*10-13 wks
Screening: second trimester
unconjugated estriol, AFP, inhibin A
abn low estriol/AFP and high inhibin A = trisomy 21/genetic dx
high AFP = NTD (can detect 75-85% open defects
*amnio also performed in 2nd trimester - 15-18wks
lower risk of abortion but later test if abortion desired
Screening: third trimester
NST, BPP
NST
normal if two accels (hr inc >15bpm) for 15 sec when tested for 20 min w no decels
abn: decels
BPP - biophysical profile
five parameters (2pts ea; total 10pts) NST amniotic fluid level gross fetal movt fetal tone fetal breathing
Ectopic preg
MC in fallopian tube
risks=prev ectopic, saplingitis, abd/tubal surg, IUD, and assisted repro
serum levels of hCG double q 48h - if less think ectopic
transvag US makes dx in 90% (should see gestation when hCG>1500)
Ectopic treatement
Methotrexate can treat 80% (serum hCG <3.5cm, hemodynamically stable, compliant pt)
laparoscopy
Gestational trophoblastic disease (GTD)
complete/partial hydatidiform moles; placental site invasive moles; trophoblastic tumors; choriocarcinomas
Treat tumors with chemo; rad and surg PRN
Hydatidiform moles
Bengin form of GTD.
Complete: MC. empty egg. “grapelike vesciles” or “snowstorm pattern” on US. 20% progress to malignancy.
partial: fetus present but nonviable. 100,000)
Complications of gestational DM
maternal: preeclampsia, hyperacceleration of DM comps, traumatic birth/dystocia, risk of DM post-birth
fetal: macrosomia, prematurity, fetal demise, and delayed fetal lung maturity
gestational DM screening
24-28 weeks with glucose challenge test at 1 hour. if abn, need 3 hr OGTT
test high risk (prev lg infant, >25 yo, glucosuria, fam hx DM, non-wt ethnicity) also in 1st tri
Gestational DM tx
oral agents not useful
need insulin if fasting >105 or 2hr PP >120
tx of chronic htn in preg and preg-induced htn (after 20 wks)
monthly US for growth retardation, serial BPs and urine protein, weekly NST in 3rd tri
Meds only if severe - methyldopa is drug of choice; labetalol is alternative
classic triad of preeclampsia
HTN, edema and proteinuria (edema not nec for dx)
risk if extremes of gae, multigestation, DM, chronic HTN
Eclampsia is seizures
pre/eclampsia
> 20 wks; can occur 6 wks post-partum
HELLP syndrome
pre-eclampsia with Hemolysis, Elevated Liver enzymes and Low Platelets
Rho-Gam
admin routinely at 28-29 wks to all Rh-neg moms. Given again following delivery if baby is Rh-pos.
also given after ectopic, spon/ther abortions, CVS, amniocentesis, trauma
MCC third tri bleeding
abruptio placentae
first stage of labor
onset of reg contractions to full dilatation
6-20h nullip; 2-14 multip
second stage of labor
full dilatation to delivery
30min to 3h nulip; 5-60min multip
third stage of labor
separation and delivery of placenta; 5 min
fourth stage
first hour after delivery - assess tears, lacs, hemorrhage
early decels
mirror contractions; often head compression prior to second stage
variable decels
no pattern; usu cord compression; benign if mild/infreq
late decels
bad; need delivery; denote uteroplacental insufficiency
APGAR score
Activity, Pulse, Grimace, Appearance, Respiration
0,1, or 2 pts each
Activity- absent, arms/legs flexed, active movt
P - absent, 100
G- no response, grimace, coughs/pulls away
A- Blue/pale, agrocyanosis, pink all over
R- absent, slow/irreg, good/crying
Endometritis
usu post- CSec or PROM fever, uterine tenderness, leukocytosis tx with clindamycin plus gentamicin - add ampicillin if no response in 24h add metronidazole if septic tx til afebrile x 24h
