OB Flashcards
(119 cards)
1
Q
Transient HTN in pregnancy
A
BP > 140/>80 Only need 1 to make a diagnosis Timing: non-sustained Nothing on UA No alarm symptoms No treatment F/u: just bring in a log
2
Q
Chronic HTN in pregnancy
A
BP >140/>80
Timing: sustained and before 20 weeks during 2 separate measurements taken at least 4 hrs apart
Nothing on UA
No alarm symptoms
Tx: alpha-methyldopa, labetalol, hydralazine, nifedipine
F/u: close monitoring of UA, US, and more frequent visits
**HTN increases the risk of superimposed preeclampsia, abruptio placentae, fetal growth restriction, preterm labor, and stillbirth
3
Q
Gestational HTN in pregnancy
A
BP >140/>80
Timing: sustained and after 20 weeks
Nothing on UA
No alarm symptoms
Tx: alpha-methyldopa, labetalol, hydralazine, nifedipine
F/u: close monitoring of UA, US, and more frequent visits
CAN PROGRESS TO PREECLAMPSIA
4
Q
Mild Preeclampsia (PEC)
A
BP > 140/>90
Timing: sustained and after 20 weeks
UA: >300 mg/24 hr protein, >0.3 protein/cr ratio, or dipstick >1+
No alarm symptoms
Tx: >37 –> deliver; <37 –> wait
F/u: more frequent visits (weekly), continually screen for alarm sx and worsening of proteinuria
Diagnosis of HTN in preeclampsia: >140/>90 on 2 occasions >4 hours apart.
Diagnosis of proteinuria in preeclampsia: urine dipstick has a high false-pos and high false-neg rate during pregnancy –> confirm with either urine protein/creatinine ratio or 24 hour collection for total protein (gold standard)
5
Q
Severe Preeclampsia (SPEC)
A
BP > 160/>110
Timing: sustained and after 20 weeks
UA: >5 g/dL
+ Alarm Sx (pulm edema, platelet count <100k, transaminitis, cr >1.1, headaches or visual changes
Acute pulmonary edema: generalized arterial vasospasm –> increased vascular resistance and high cardiac after load; other contributing factors: decreased renal function, decreased serum albumin, and endothelial damage leading to increased capillary permeability
Tx:
Meds that acutely lower BP to decrease stroke risk: hydralazine IV, labetalol IV, nifedipine PO [labetalol is a non-selective beta blocker and can dec HR in someone who is brady. hydralazine is a vasodilator. nifedipine is an oral med that would not help someone who is having emesis. alpha-methyldopa treats chronic HTN]
Give Mg to prevent or treat eclamptic seizures and deliver (usually by vaginal and induced) regardless of age
Leading cause of fetal and maternal morbidity and mortality. Pathophys involves abnormal placental development and function which puts the fetus at risk for chronic uteroplacental insufficiency –> fetal growth restriction/low birth weight
6
Q
Eclampsia
A
BP doesn't matter Timing: sustained and after 20 weeks UA doesn't matter \+ Active Seizures Tx: Give Mg and deliver (usually by C/S)
7
Q
HELLP syndrome
A
Severe features: dec plt’s, inc LFT’s, RUQ pain (caused by swelling of the liver causing stretch of glisson’s capsule as blood flow decreases to the liver) elevated creatinine (> 1.1 or doubling), pulmonary edema, HA, vision changes, BP >160/>110
Tx: Give Mg and deliver (usually by C/S) if 34+ weeks or with deteriorating maternal or fetal status
Thought to result from abnormal placentation, triggering systemic inflammation and activation of the coagulation system and complement cascade. Circulating platelets are rapidly consumed, and microangiopathic hemolytic anemia (MAHA) is particularly detrimental to the liver.
8
Q
Dangers of Magnesium
A
Must check for dec DTR’s in patients as dec DTR’s is a sign of dec resp drive –> mom stops breathing if magnesium is continued
Ca = antidote to dec DTR’s
Mg is excreted renally so pts with renal insufficiency are susceptible to Mg toxicity
9
Q
False Labor vs Latent Labor vs Active Labor
A
False: mild irregular contractions that cause no cervical change (e.g. braxton Hicks contractions)
Latent: reg contractions with inc freq and intensity that cause gradual cervical change
Labor: regular, painful uterine contractions that cause cervical change
10
Q
Spontaneous Abortion
A
Pregnancy loss < 20 weeks
Tx: expectant, medical induction, suction curettage if infection or hemodynamic instability
11
Q
Antepartum fetal surveillance
A
NST: external FHR monitoring for 20-40 minutes. Normal = reactive = 2+ accelerations
Biophysical profile: NST + amniotic fluid volume, fetal breathing movement, fetal movement, fetal tone. Reassuring = 8+. Equivocal = 6 pts. Abnormal = <6.
12
Q
Suspected Appendicitis in Pregnancy
A
Sx: N, V, RLQ pain
US with graded compression technique
Noncompression and dilation of the appendix are diagnostic
13
Q
Acquired Hypogonadotropic Hypogonadism
A
Low FSH and estrogen levels due to loss of pulsatile GnRH secretions precipitated by caloric deficiency or chronic illness. Causes irregular menses and infertility.
14
Q
Abortion, Preterm, Term, and Post dates
A
Abortion: 0-20/24
Preterm: 24-32
Term: 37-42
Post dates: 42+
15
Q
Definitions: ROM, PROM, PPROM, Duration of Labor once ROM
A
ROM: term and there are contractions that start the rupture
PROM: term, no contractions
PPROM: preterm rupture of membranes without preterm labor, no contractions
Duration of labor once ROM should last less than 18 hours
If longer –> Prolonged ROM
16
Q
ROM
A
Types: spontaneously, artificially, pathologically (infection like GBS, vaginal flora, or STI)
Characterize: clear, meconium-stained, bloody
Dx: Speculum exam: will see pooling (not all fluid exits immediately) Nitralazine blue test Ferning US: oligohydramnios
Tx: Deliver if term or below the age of abortion
If between, must weigh risks (ascending infection) and benefits (maturation) - the younger the more benefit to staying in, the older the less benefit to staying in
17
Q
pROM
A
Usually caused by infection (GBS) Definition: term, no contractions Dx: Clinically. Also check GBS status Tx: Deliver If GBS+ or don't know, give ampicillin If GBS-, wait
18
Q
ppROM
A
Usually caused by infection (GBS)
Definition: preterm, no contractions
Dx: Clinically. Also check GBS status.
Tx: must weigh risks and benefits of keeping baby in
If baby > 34, deliver
If baby < 24, deliver –> abortion
In between: give steroids for fetal lung maturation
May lead to prolonged ROM
19
Q
Prolonged ROM
A
Usually caused by infection due to entrance of vaginal flora into mom (GBS)
Definition: ROM for 18+ hours
Tx: Deliver. Also check GBS status
If GBS+ or don’t know, give ampicillin
If GBS-, wait –> f/u endometritis and chorioamnionitis
20
Q
Endometritis and Chorioamnionitis
A
Infection of endometrium (uterus) or chorioamnionitis (sac)
Path: Vaginal flora ascends into mom’s sterile uterus. Risk increases the longer mom is open.
If baby is still in, bacteria infect the sac –> chorioamnionitis
If baby is delivered, bacteria infect mom’s uterus –> endometritis
Presentation: mom has prolonged ROM, operative bag delivery, CS, prolonged labor
mom gets fever or becomes toxic
Dx: presence of maternal fever and one or more of the following: uterine tenderness, maternal or fetal tachy, malodorous amniotic fluid, purulent vaginal discharge
DO NOT GET VAGINAL CX (will not help you). Rule out other infections - UA, CXR, BxCx
Tx: administer antibiotics: Ampicillin, Gentamicin, and Clindamycin (gram neg and anaerobes)
followed by delivery to reduce the risk of life-threatening neonatal infection and maternal complications.
CHORIO IS NOT AN INDICATION FOR CS. Give oxytocin to accelerate labor
21
Q
Preterm Labor
A
Path: Idiopathic, Risk factors: preterm in prior pregnancy*, cervical surgery like cone biopsy (use TVUS to assess cervix length), cigarette smoking, young maternal age, multiple gestations, pROM, uterine anatomical defects
Definition: preterm, + Ctx AND cervical change
Dx: Clinically
Tx: based on GA
> 34, deliver
< 20, deliver –> abortion
In between: give steroids and tocolytics for fetal lung maturity (you cannot stop labor once it starts - can only delay); if <32 weeks should also receive magnesium sulfate for fetal neuroprotection
Some exceptions: eclampsia, fetal demise, placental problems, etc
Used to do amniocentesis to check lecithin:sphingomyelin ratio for fetal lung maturity but it’s not done anymore
A short cervix (<2 cm without a history of preterm birth or <2.5cm with a history of preterm birth) on TVUS during the 2nd trimester is a strong predictor for preterm delivery. Progesterone maintains uterine quiescence and protects the amniotic membranes against premature rupture. Supplement with exogenous progesterone
Pts with short cervices and no history of preterm delivery should be offered vaginal progesterone
Pts with hx of preterm delivery receive intramuscular progesterone and undergo serial TVUS for measurements
22
Q
Post dates
A
Dilemma is usually a question of how many weeks the baby actually is (if mom comes in for first prenatal visit in the third trimester, EDD can be actually +/- 3 weeks via US)
Path: baby can end up macrosomic –> increased risk for shoulder dystocia
Or dysmaturity –> can lead to fetal demise
Definition: >40 weeks by conception or >42 weeks by dates
Dx: clinically
Tx: how sure you are of dates and mom’s cervical position
If sure and cervix is favorable –> induction
If sure and cervix is unfavorable –> CS
If not sure, regardless of cervix, do NST and US to do BPP. If BPP good, stay in. If BPP bad, get out
Post date babies are at risk of uteroplacental insufficiency
Potential complications of post dates/post partum:
Fetal - oligohydramnios (aging cervix may have decreased fetal perfusion, resulting in decreased renal perfusion and decreased urinary output from the fetus), meconium aspiration, stillbirth, macrosomia, convulsions
Maternal - CS, infection, PPH, perineal trauma
23
Q
Multiple Gestations (twins)
A
Hints: baby is too big for dates, AFP is high on quad screen
Vocabulary:
zygote = # of fertilizations
chorion = # of placentas
amnion = # of sacs
- Look at gender
Diff genders: dizygotic, dichorionic, diamniotic
Risks: preterm labor - for every 1 gestation, deliver 4 weeks early; malpresentation (breech birth –> CS); post partum hemorrhage
Same genders: can either be one fertilized zygote that split very early or 2 separate fertilizations resulting in same gender - will not be able to know until babies are out.
Look at the number of placentas:
If 2, monozygotic, dichorionic, diamniotic (zygote split day 0-3 tubal phase)
Added Risks: identical twins - cannot tell until they come out of the womb
If 1, look at septum and number of sacs
+ septum, 2 sacs –> monozygotic, monochorionic, diamniotic (zygote split day 4-8 blastocyst phase)
Added Risks: twin-twin transfusions (since they share the same placenta; smaller twin does better due to less bilirubin)
no septum, 1 sac –> monozygotic, monochorionic, monoamniotic
Added Risks: conjoined twins (can be surgically repaired if no major organs shared), cord entanglement (can potentially cause problems with delivery, leading to CS)
If the zygote split day 9-12 –> non conjoined twins
If the zygote split > day 12 –> conjoined twins
24
Q
ABO incompatibility
A
ABO incompatibility generally occurs in a group O mom with a group A or B baby (A and B are found in food and bacteria in the environment which can induce various degrees of antibody production in group O moms)
However, ABO incompatibility causes less severe hemolytic dz of the newborn than does Rh(D) incompatibility. Affected infants are usually asymptomatic at birth with absent or mild anemia and develop neonatal jaundice, which is usually successfully treated with phototherapy.
25
Post Partum Hemorrhage
Definition:
- 500 cc blood loss in vaginal delivery
- 1000 cc blood loss in CS
PE uterus:
- Absent = Uterine Inversion --> manually put back in place or use tocolytics to quiet uterus down then use uterine tonics to contract back down
- Boggy = Uterine Atony (most common cause of PPH) --> massage uterus from the outside to get it to contract down or start meds like oxytocin
- Firm = Retained Placenta --> D&C, may require hysterectomy
- Normal = Vaginal Laceration --> sutures
If laceration not found, think about DIC
If cause is not found or ongoing PPH despite intervention, treat like GI bleed: place 2 large bore IV's (18 gauge or larger, AC or higher), bolus IV fluids, type and cross, transfuse as needed, call surgeon, could try IV estrogen
Surgery options: uterine artery ligation (OB) or internal iliac ligation, uterine artery embolization (IR), total abdominal hysterectomy (OB)
CS --> uterine artery ligation
Vag --> uterine artery embolization
Complications: Sheehan syndrome, pituitary apoplexy
26
Uterine Atony
Most common cause of PPH
RF's: prolonged labor, induction of labor, operative vaginal delivery, fetal weight > 8.8lbs
Path: atonic uterus, occurs when uterus is tired either in the setting of prolonged labor or if oxytocin or tocolytics were given during delivery and were now stopped
Presentation: PPH and "boggy/soft" uterus that is enlarged ("above the umbilicus")
Dx: clinical
Tx: uterine massage to stimulate uterus to contract; or use oxytocin if used before in labor; or use Methergine (methylergonovine) or Hemabate (carboprost - prostaglandin); or do surgery
27
Uterine Inversion
Path: uterus "births itself", contracts so hard that it goes through the cervix; may occur during a delivery with oxytocin or with traction when pulling out the placenta
Presentation: PPH and absent uterus
Dx: clinical. Speculum exam: can see uterus inverted into the vagina
Tx: manually; or use tocolytics to calm it down, get it into place, then turn on oxytocin to get it back down to the right place; or do surgery
If placenta is still attached to the uterus, it should not be removed until after the uterus is replaced due to risk of massive hemorrhage
28
Vaginal laceration
Path: tear in cervix and/or vagina; can occur in precipitous deliveries, macrosomic babies, and episiotomy
Presentation: PPH and normal uterus
Dx: clinical. Speculum exam: look for lacerations on cervix and vagina
Tx: Hold pressure and/or suture close. Use anesthetics first.
29
Retained Placenta
Path: Placenta burrows deeply during pregnancy (more common in multiparous women, prior CS, hx of D&C, advanced maternal age). During delivery, there is an accessory lobe that causes a placental tear as the front half is delivered, leaving behind a piece. Depth of invasion of the piece gives it its name.
Types:
1. Placenta accreta (only in the endometrium where it's supposed to be, only a lil deeper)
2. Placenta increta (through the endometrium into the myometrium)
3. Placenta percreta (all the way through)
Presentation: PPH and firm uterus
Dx: look at placenta - do the BV go to the edge? Normal placenta delivery BV should not reach all the way to the edge. If there is a piece left behind the BV's will travel all the way to the edge.
Tx: get remaining part out --> manually or D&C, if not do hysterectomy.
Track beta-HCG levels in serum to 1. make sure the placenta is out (b-HCG reaches 0) and 2. dec risk for chorioamnionitis
30
DIC
Fibrin clots everywhere they're not supposed to be and no where where they're supposed to be
Clots cause shearing of RBC's
Labs: Low plts, low hgb, presence of schistocytes, low fibrinogen, elevated INR (clotting factors being used)
Tx: Give plts, packed RBC's (for low hgb), cryoprecipitate (for low fibrinogen), FFP (replace clotting factors)
**Pregnancy = hypercoagulable state. Fibrinogen should normally be elevated to prevent PPH. If fibrinogen is within normal limits during delivery, suspect DIC.
31
Types of Abortions
1. Missed
- no vaginal bleeding
- closed os
- no fetal cardiac activity or empty sac w/o a fetal pole (e.g. no embryo)
baby is dead but mom doesn't know
2. Threatened
- vaginal bleeding
- closed os
- fetal cardiac activity
- can potentially revert back to intrauterine pregnancy if put on bed rest but once abortion advances past threatened, it cannot go back
3. Inevitable
- vaginal bleeding
- dilated os
- baby is dead
- products of conception may be seen or felt at or above the os
4. Incomplete
- vaginal bleeding
- dilated os
- some products of conception expelled and some remain
5. Complete
- vaginal bleeding or none
- closed os
- products completely expelled
** serial beta-hCG levels normally increase until the end of the first trimester; decreasing beta-hCG levels indicate a demise and exclude a normal pregnancy
Medical management:
Misoprostol
Oxytocin to induce delivery of dead baby ex) missed abortion
D&C
Rh- moms still need to be given Rhogam if there's potential baby may be Rh+
32
Infertility in women age >35
Inability to conceive after 6 months of unprotected intercourse
Can occur due to diminished ovarian reserve, characterized by regular menstrual cycles and decreased oocyte number and quality.
33
Placenta Previa
Placenta implants over the internal cervical os
RFs: previous, previous CS, multiparity, advanced maternal age (>35)
At risk for antepartum bleeding which is typically painless and occurs with or without contractions on the tocodynamometer.
Usually diagnosed during routine antenatal US. Pelvic rest is recommended for duration of pregnancy as intercourse can cause contractions and bleeding
Pts diagnosed antenatally undergo CS at 36-37 wks to avoid risks associated with labor and to minimize prematurity complications
Intercourse, digital cervical exam, vaginal delivery, and labor and expectant management are contraindicated due to risk of hemorrhage
34
NST
Non-stress test (no contractions)
Looking at FHR: good = consistent variability that stays same; accelerations; not brady or tachy (<110. <160)
Accelerations:
good = 2 in 20 min or a rise in 15 over 15 sec or rise in 10 over 10 sec
>32 wks = 15/15
<32 wks = 10/10
Good variability and good accels = reassuring NST
Presentation: high risk mom, or decreased FM
Nonreactive NST = no accelerations - can be associated with fetal sleep cycle (can last as long as 40 min - extend NST to ensure fetal activity outside of sleep is captured), fetal hypoxia from placental insufficiency
Tx:
Reassuring NST = reassurance (leave dec FM mom alone, high risk mom comes in next week)
Nonreassuring NST = repeat with vibroacoustic stimulation and reinterpret
35
BPP
Biophysical profile (no contractions)
Done if there is a failed NST with vibroacoustic stimulation
5 components: 0-2 pts each
1. NST
2. AFI - divide mom into 4 quadrants. get maximum depth of each quadrant and sum together. normal: >5. reassuring = 8-25. pathologic values: <5 (oligo - usually problem with kidneys), >5 (poly - usually problem with gut)
3. Baby breathing
4. Baby moving
5. Baby tone
Tx:
8-10 = reassurance
0-2 = fetal demise (emergency CS)
Between: use GA to decide
36
CST
Contraction stress test (used when there are adequate contractions - 3 in 10 min, 200mV each)
Usually done in the setting of labor, NOT induced due to failed BPP
Looking at decels and presence/absence of brady
Presentation: mom is in labor or failed BPP
--
Variable decel = Cord compression (decels and contractions don't match) or oligohydramnios
--> intermittent variable decels (occurring with <50% of contractions) are well tolerated by the fetus
--> persistent variable decels (occurring with >50% of contractions) may impede fetal-placental blood flow; may be alleviated by maternal repositioning and if that fails, amnioinfusion
Early decel = Head compression (decals and contractions match)
Accel = Ok
Late decel = Placental insufficiency (decels start after contractions peak) --> delivery (usually emergency CS)
Sinusoidal = Anemia
37
3rd Trimester Bleeding
Normal:
- Cervical lesions like a polyp or cervicitis
- Cervical dilation
- Bloody show (blood tinged ROM)
Regardless of normal or abnormal 3rd trimester bleeding, must investigate anyway
- mom's vital signs
- mom's hgb
- consider DIC: plts, coags
- pelvic PE
- baby: NST/CST to check for FHR
- baby: US
3rd trimester bleeding can either be painful or painless
Painless: comes from Placenta; it is baby's blood - mom doesn't feel baby --> Previa
Painful: comes from mom's uterus tearing; it is mom's blood - mom feels it -->NOT Previa
```
4 diseases:
Placenta Previa
Vasa Previa
Uterine Rupture
Placental Abruption
```
38
Placenta Previa
- placenta implants across the os
- as cervix dilates and gets bigger, the placenta gets torn and baby's blood comes out
Presentation:
- occurs most commonly in multi-gravid woman and in multiple gestations
- painless bleeding in 3rd trimester usually when contractions begin and cervix begins to dilate
Dx:
- US: transverse lie (shoulder presentation)
- NST/CST: fetal distress
Types:
- Marginal (a little bit, not even midline)
- Partial (makes it to midline)
- Complete (spans entire os)
Tx:
Urgent CS
39
Vasa Previa
- Placenta is on one side of the uterus, an accessory lobe on the other side, with vessels running in between them over the os. Another RF: multiple gestations
- when os dilates, the connection between the 2 tears and baby loses blood
- Vs Placenta Accreta: in placenta accreta, the placenta has been birthed so you can see that the BV run to the edge. In vasa previa, the placenta has not been birthed yet so you cannot look at it although if you could you would see that the BV run to the edge as well
Presentation:
- painless bleeding in 3rd trimester
- Vs placenta previa: rapid deterioration of the fetal heart tracing
Dx:
- US although most likely will not show anything
- NST/CST showing fetal distress
Tx:
- urgent CS
40
Uterine Rupture
- occurs commonly in moms who've had a previous CS (uterine scar) who are now attempting a vaginal birth
- force of contractions can rip the uterus apart
- baby takes path of least resistance --> into the peritoneum instead of the vagina unless there is a membrane blocking baby into the peritoneum
- can also occur when powering the delivery with oxytocin --> uterus bursts and baby goes into the peritoneum
Presentation: painFUL bleeding in the 3rd trimester (although this process has to happen with contractions (so mom is already in pain))
--> loss of fetal station as baby is birthed into the peritoneum - can no longer tell where baby is - no palpable fetal presenting part, presence of abdominally palpable fetal parts
Dx: none --> go straight to tx
Tx: laparotomy
41
Placental Abruption
- Path: some insult like severe HTN, cocaine use, or decel injury from MVA rips placenta off and mom starts to lose blood
2 types:
- COMPLETE = placenta rips off the endometrium lining; usually a piece stays on; now mom's blood is coming out
- CONCEALED = placenta rips in the middle and stays connected on the 2 ends; contains the blood coming out from mom in a pocket; dangerous bc you can't see it
Presentation:
- painFUL bleeding, FHR abnormalities, abd/back pain
Dx:
US
NST/CST
Also keep an eye out on mom's vital signs, hgb, and mentation (mom can lose a lot of blood)
Tx:
CS
Complications: DIC, hypovolemic shock
for baby - hypoxia, preterm delivery
42
C-Section
Many variations, many techniques
2 main types:
1. Slow controlled planned elective CS - mom wants to save aesthetics
2 cuts: bikini cut and low transverse incision on the uterus
2. Crash section
2 cuts: vertical incision from xyphoid to pubis and in the uterus
3 categories: elective, urgent, and emergent
Elective procedures: mom's desire, known breach birth
Urgent procedures: due to complication or disease - prolonged or arrest of labor, eclampsia
Emergent procedures: maternal hemodynamic instability, fetal distress (profound brady, loss of variability, late decels)
Risks:
- VBAC
- scar
- permanent sterilization with b/l tubal ligation
VBAC:
- What type of CS did she have? What is her risk of attempting vaginal birth?
- Low risk: If mom has had <2 CS and all were low transverse cuts. Can attempt vaginal delivery. If successful --> VBAC (best outcome). If failed --> TOLAC (trial of labor after CS) --> unplanned CS (worst outcome)
- High risk: anything else. --> planned CS (intermediate outcome)
43
Vacuum Delivery
| Forceps Delivery
Either labor is taking too long (arrest of descent) or baby is doing poorly
--> fetal distress or prolonged/arrest of labor
Have to go in through the vagina so it is only useful if baby is almost out --> must have full effacement of the cervix and must be at least 2+ station
Risk:
Vacuum delivery: denuding vagina (very painful) (vacuum only supposed to go on baby's head but if some of mom's vagina gets caught) - do not do vacuum delivery on preterm babies
Forceps delivery: cephalohematomas and Bell's palsy
If 2+ station or more, do instrumental
If higher than 2+, do CS
44
Epiosiotomy (Lacerations)
To avoid the creation of an uncontrolled laceration
Indicated when baby is macrosomic or vagina is small (nulliparous mom) or to prevent a bigger baby from developing shoulder dystocia
Risk: you're creating a laceration, postpartum hemorrhage
2 types:
1. Medial (most common in US) - easy to re-suture; more painful and risk of laceration extending to grade 4
2. Medial-lateral (most common outside US) - less painful, harder to repair (heals poor-er), but no risk of laceration extension (grade 4)
```
Grades:
Grade 1 laceration: involves vagina only
Grade 2: extends into perineal body
Grade 3: into the anus and sphincter
Grade 4: invades through the anal mucosa --> risk of recto-vaginal fistula.
```
45
Cerclage
Used to preserve incompetent cervix (RF's: repeated STI's, PID, repeated D&C's, multiple second trimester losses)
Usually done at wk 14
Remove around wk 36
Risk:
- Insertion: needle pokes the amniotic sac --> ROM - babies generally don't progress
- Cervical laceration/rupture: leaving the suture in too long or forgetting to take it out
46
Anesthesia
Opiates:
- Can be used anytime
- Avoid in latent phase of stage I labor bc they can cause prolonged latent phase
- Avoid in very late stages of delivery bc baby can get it - can cause resp distress and baby may need naloxone
Epidural
- Great pain reliever
- Needle in mom's back - doesn't go through subdural space - should not see any CSF (not like a LP)
- Requires tocometer since mom can't feel her contractions and mom needs a coach to tell her when to push
- Risk: infuse lidocaine into subdural space --> cardiac collapse (anesthetizing all of sympathetic nerve fibers) --> blood redistribution to the LE and venous pooling from --> potential hypotension and death
Local anesthetics:
Cervical block prevents pain of stage 1 (cervical dilation). However baby is close by so there is risk of fetal bradycardia. If fetal bradycardia occurs after cervical block, this does not signify fetal distress-->CS like fetal brady would usually do so just wait and baby's HR should go back up.
Pudendal nerve block prevents pain of stage 2. Easier to do than cervical block. Risk: miss the nerve and mom is still in pain.
47
GBS
For mom, GBS is benign normal flora of her vagina
For baby, GBS can be devastating --> pROM, preterm delivery, chorioamnionitis; pneumonia/sepsis after baby is born
Presentation:
1. Mom has prenatal care: asymptomatic screen - UA at wk 10, re-screen at wk 35-36. Treat during delivery if positive at any time even if treated at wk 10.
2. Mom has not had prenatal care (immigrant, travel) - healthy delivery --> toxic baby
Dx:
1. UA and UxCx
2. Clinically: toxic baby
3. + RF even if mom does not have positive screen: any previous history of pos GBS, prolonged ROM, intrapartum fever
Tx: Ampicillin
Cefazolin (2nd gen) if pcn allergy
Clindamycin if severe pcn allergy
Vancomycin (last resort)
Exception to treating: no previous GBS history and normal delivery; mom getting planned CS and has not had ROM or contractions does not need intrapartum antibiotics
48
Hep B
Vertical transmission by blood: mom = chronic carrier state
Avoid transmission by avoiding maternal/fetal blood mixing
HepB itself cannot cross the placenta; antibodies can, but the virus itself cannot unless there is blood mixing
Presentation: asymptomatic hep B screen at wk 10
Tx: CS to avoid mixing blood
Give baby hep B IVIG and hep B vaccine at delivery
Ideally would also want to vaccinate mom before she gets pregnant
Dx:
+ any antigens = infected
+ eAg = infectious
+ sAB = immune through vaccination or exposure
+ cAB and + sAB = immune through exposure
49
HIV
The lower the CD4 count, the higher the risk of opportunistic infections
The higher the viral load, the higher the risk of infection
HIV itself cannot cross the placenta; antibodies can, but the virus itself cannot unless there is blood mixing
Presentation:
1. asymptomatic HIV screen at wk 10 + prenatal care
2. no/unknown prenatal care status
caveat: confirmatory test takes longer than delivery to come back; so if unsure of HIV status you have to treat anyway
Dx:
1. ELIZA - looking for antibodies
2. Western blot confirmatory test
3. VL, CD4 of mom
Tx: HAART - 2 NRTI's and 1 NNRTI or 1 PI+ritonavir
```
2 NRTI's:
tenofovir and emtricitebine - pregnancy class B
zidovudine and lamivudine - pregnancy class C
```
NNRTI: neviraprine (class C)
PI: atazanavir + ritonavir (class B)
Common combo pill: tenofovir, emtricitebine, efavirenz. CANNOT be used in pregnancy bc efavirenz = teratogen.
At delivery 3 options:
1. VL <1000 (undetectable) and mom is on HAART --> can deliver vaginally
2. VL >1000 or mom is not on HAART --> CS
3. Status unknown and mom presents at delivery --> give her AZT
50
TORCH infections
Toxo, Other (syphillis), Rubella, CMV, HSV
51
Toxo
Parasite: T. gondii found in cat feces, undercooked meat, cysts in soil
Presentation:
Mom experiences a mono-like illness (fever, malaise, anterior cervical lymphadenopathy, hepatosplenomegaly)
Baby: brain calcifications, ventriculomegaly, seizure disorder
Dx: Toxo Ab labs done in 1st trimester (but not universally done)
+ Toxo Ab = reassurance
- Toxo Ab = counsel on avoidance
52
Syphillis
STI spirochete T. pallidum
```
Presentation:
1': painless chancre on genitals
2': contagious targetoid lesions on palms and soles
EL/LL: + test but no symptoms
3': neurosyphillis
```
Dx:
1': darkfield microscopy (body has not had time to make antibodies)
2': RPR (screening test); FTA-abs (confirmatory test)
EL/LL: same as 2' but no lesions, just screening asymptomatically
3': CSF studies - VDRL (not as good as RPR, positive in more things) or RPR
```
Tx:
All forms = penicillin
Allergic to penicillin = still get penicillin desensitization
1', 2', EL = IM dose x 1
LL = IM dose weekly for 3 weeks
3' = IV dose q4h for 7-10 days
```
F/u after transmission:
1st trimester --> dead baby
2nd/3rd trimester --> deformities: Snuffles (rhinorrhea), Saber Shins, Saddle nose, HutchinsonS teeth
53
Rubella
Problem = 1' viremia (mom contracts it for the 1st time when pregnant)
Presentation:
1. + prenatal care but never vaccinated --> avoidance of virus
2. - prenatal care and not vaccinated
* *MMR = live attenuated virus; mom should get vaccine at least 3 months prior to getting pregnant. if given to mom after she becomes pregnant you're basically giving baby congenital rubella
```
Congenital rubella:
Blueberry muffin baby (petechiae and purpura over the baby)
Cataracts
Congenital heart defects
Deafness
```
F/u after transmission:
1st trimester: IUGR or abortion
Tx: Mom needs to practice avoidance - stay away from sick ppl and kids too young to have completed their MMR series
give MMR vaccine in preconception care before pregnancy begins
54
CMV
dsDNA virus
| Pt presents with toxo-like symptoms
55
HSV
Problem = 1' viremia which causes the congenital defects
whereas 2' reactivation puts baby at risk of getting infected
Presentation:
Mom: painful burning prodrome and eruption of vesicles on an erythematous base
Dx: (not necessary if clinically sure)
PCR for the virus from a scrapping of the ulcer
NOT Tzank prep
Tx: valcyclovir or acyclovir to mom to reduce the lesions whether its 1' or 2' viremia.
CS: Because baby is at risk of getting infected when going through the birth canal with lesions
F/u:
Congenital HSV: IUGR, preterm delivery, blindness
56
Long Acting Reversible Contraceptives
Most effective form of birth control for women who can get pregnant but do not want to
2 types:
1. IUD: 2 major forms - hormonal and copper. Copper = longest acting, 10 years, no hormones, may increase menstrual bleeding. Hormonal = 5 years, contains estrogen and progesterone, inc DVT risk, dec or stop bleeding altogether
2. Non-IUD: Explanon, Implanon. Placed under the skin. Good for about 3 years.
57
Non Reversible Contraceptives
Male: vasectomy
Female:
B/l tubal ligation - can be done during a C section - irreversible but not always 100% effective; risk for ectopic pregnancy
Total abdominal hysterectomy - not done routinely but if there is another reason for hysterectomy then 2 birds with 1 stone
58
Injections, Patches, Rings, OCP's, Mini-pill (order of decreasing effectiveness)
Injections:
Depo-Provera - lasts 3 months.
Patches: E&P
Ortho-Evra - lasts 1 month. Risk of falling out.
Highest risk of DVT/PE. ***
Rings: E&P
Nuva-Ring - lasts 1 month. Vaginally inserted - risk of falling out
OCP's: E&P
Good for use in pathologic states like dysfunctional uterine bleeding, chorioamnionitis, gestational trophoblastic disease, molar pregnancies where long-term sterilization is not desired.
Requires daily compliance.
Mini-pill: P only
Reduces DVT risk.
Requires daily compliance down to the hour.
59
DVT risk
1. Any contraceptive form containing estrogen (not just OCP's)
2. Smoker
3. age > 35
60
Barrier contraceptives
Condoms (males) and Diaphragms (females)
Barrier methods --> the only contraceptives to provide STI protection. ***
Recommended to be used in addition to long acting reversible contraceptives.
Condoms are used at the time of intercourse.
Diaphragms must be inserted ahead of time.
Female condom
61
Spermicide, Sponges, Caps
Provide no STI protection and not good at preventing pregnancy bc there is no barrier. Can be used in addition to barrier method.
62
Levonorgestrel (morning after pill)
If used within 72 hours after intercourse can prevent pregnancy
It is not an abortifacient - will not harm a current pregnancy
63
Ectopic Pregnancy
Due to early implantation due to stricture or PID - something has scarred the fallopian tube that sperm can get in but fertilized zygote cannot get out
Occurs most commonly at the ampulla of the fallopian tube
Presentation: + UPT + vag bleeding or amenorrhea, abd pain
1. Look at TVUS
If you see intrauterine pregnancy, could be molar pregnancy (snowstorm pattern), normal pregnancy, or abortion
If you see ectopic pregnancy, look at U/S and serum b-hcg - has there been rupture?
+ rupture --> salpingectomy
- rupture --> salpingostomy
medical therapy with methotrexate +/- leucovorin can be used if b-hcg <5,000, GA fetus<3.5cm, no fetal heart tones, mom should not have been on folate. AKA very early in preg. methotrexate is the most fertility sparing but is the most limited
If you don't see anything on TVUS, look at serum b-hcg
(discriminatory zone: 1500-2000)
If > 1500 or 2000, you should be able to see a intrauterine pregnancy and if you don't, there is an ectopic and treat like so
If < she should come back in 48 hours and repeat the b-hcg
If it doubles, it is an intrauterine pregnancy and you're good
If it fails to double, it is ectopic.
---
Types: tubal (most common), ovarian, abdominal, cervical, cornual/interstitial
RF's: previous, pelvic/tubal surgery, PID, uterine abnormalities (eg bicornuate heart shaped uterus)
Presence of fluid in the posterior cul-de-sac in the setting of ectopic pregnancy suggests blood in the pelvis - emergency surgical exploration is required in a pt with hemoperitoneum and unstable vital signs
64
Intrahepatic cholestasis of pregnancy
Elevated bilirubin and transaminases
| Generalized pruritis
65
Acute fatty liver of pregnancy
N, V, abd pain, jaundice
most often occurs in T3 or in the post partum period
transaminitis, elevated bilirubin, elevated alk phos, leukocytosis, hypoglycemia, AKI
66
Maternal hypertensive crisis
BP > 160/110 for > 15 min. First line tx: control the BP with IV hydralazine, IV labetalol, or PO nifedipine.
67
Asymptomatic bacteriuria
Asymptomatic pt grows > 100k colony-forming units/mL of a single organism, most commonly E coli. Due to increased risk of pyelo during pregnancy, all pts should be screened for asymptomatic bacteriuria during their first prenatal visit and be treated as indicated
First line tx: amoxicillin-clavulanate, cephalexin, nitrofurantoin
68
Disorders of the active stage of labor: protraction and arrest
Active stage of labor = when the cervix is 6cm dilated - 10 cm dilated
Protraction: cervical change that is slower than expected +/- adequate contractions. Tx: oxytocin
Arrest: no cervical change for 4 hours with adequate contractions or no cervical change for 6 hours with inadequate contractions. Tx: CS
Adequate contractions = contractions generating 200+ MVU in a 10 min interval
69
Gestational DM
Goal blood glucose levels:
Fasting: < 95
1 hr post prandial: < 140
2 hr post prandial: <120
Tx: 1st line = dietary modifications (evenly distributed carb, protein, and fat intake over 3 meals and 2-4 snacks daily). If fails, move to 2nd line
2nd line = insulin, metformin, glyburide
70
Shoulder dystocia
Obstetric emergency
Anterior shoulder gets stuck behind the pubic symphysis and the shoulders are unable to be delivered with routine gentle traction.
RF's: fetal macrosomia, maternal obesity, excessive pregnancy weight gain, gestational diabetes, post-term pregnancy
Management:
Breathe, do not push
Elevate legs into McRoberts position (sharp hip flexion while supine)
Call for help
Apply suprapubic pressure on the anterior shoulder (downward and laterally to release the shoulder)
enLarge vaginal opening with episiotomy to facilitate extra maneuvers
Maneuvers: if McRoberts fails --> Woods corkscrew or Rubin maneuver, Gaskin maneuver, Zavanelli maneuver
Complications: humerus fracture, clavicle fracture, erb-duchenne palsy (waiters tip), klumpke palsy (claw hand), perinatal asphyxia
Klumpke palsy can sometimes involve the sympathetic chains (C8/T1) and cause Horner's syndrome (anhydrosis, ptosis, miosis)
Duchenne palsy: gentle massage and PT to prevent contractures. Prognosis depends on whether damage resulted from mild nerve stretching or compression as opposed to severe rupture or avulsion. Up to 80% of patients have spontaneous recovery within 3 months.
Complications in mom: femoral nerve damage (can occur during delivery as a result of hyper flexion of the thigh - McRoberts - numbness over the anterior and medial thigh, inability to extend the leg or flex the thigh, diminished patellar reflexes)
71
Septic abortion
Medical emergency - requires prompt tx with broad-spectrum antibiotics and surgical evacuation of the uterus (e.g. suction curettage)
Most commonly occurs after an unsterile and/or incomplete procedure for an elective abortion
Presents with fever, heavy vag bleeding, purulent discharge, and boggy uterine tenderness
Pelvic US: retained POC, thick endometrial stripe
72
Contraindications to combined hormonal contraceptives
- migraine with aura
- > 15 cigs/day and age >35
- stage 2 HTN (>160/100)
- hx of venous thromboembolic dz
- hx of stroke or ischemic heart dz
- breast cancer (E&P may have proliferative effect on breast tissue, esp concerning in hormonal receptor-positive breast cancer - BRCA2 carriers tend to have ER-positive breast cancer)
- cirrhosis and liver cancer
- major surgery with prolonged immobilization
- <3 weeks postpartum
73
Normal physiological changes during pregnancy
Inc GFR and renal size, dec BUN and serum cr
--> inc in CO and renal blood flow due to progesterone, with inc renal excretion
Urinary frequency, nocturia
--> inc urine output and sodium excretion
Mild hyponatremia
--> hormones reset threshold to inc ADH release from pituitary
Dilutional anemia
--> inc plasma volume and RBC mass
Prothrombotic state
--> hormone mediated dec in total protein S antigen and activity; inc in fibrinogen and coag factors
Inc CO and HR
--> inc BV, dec SVR
Chronic resp alkalosis with metabolic compensation: inc in PaO2 and dec in PaCO2
--> progesterone directly stimulates central resp centers to inc TV and minute ventilation
74
Hyperemesis gravidarum
Occurs early in pregnancy and presents with significant vomiting leading to volume depletion and hypochloremic metabolic alkalosis (increased bicarb), hypokalemia, elevated serum aminotransferases
Differentiate from typical nausea and vomiting of pregnancy by the presence of ketones on UA (ketonuria occurs due to prolonged hypoglycemia and resultant ketoacidosis), lab abnormalities, and changes in volume status.
RF's: multiple gestations, hydatidiform mole, hx of esophageal reflux
Complication: Wernicke encephalopathy - thiamine deficiency. Presenting symptoms include encephalopathy, oculomotor dysfunction, and gait ataxia
75
SLE in pregnancy
Pregnancy and the postpartum period are associated with an increased risk for SLE flares, particularly in pts with a hx of lupus nephritis.
Other RF's: discontinuation of hydroxychloroquine and active dz prior to conception.
Sx: HTN, edema, joint pain, malar rash, UA with proteinuria and RBC casts
SLE is associated with an increased risk for obstetrical complications, including preeclampsia, preterm birth, CS, fetal growth restriction, and fetal demise.
76
Postpartum thyroiditis
Autoimmune inflammation and destruction of the thyroid within a year of delivery
Causes transient hyperthyroid symptoms followed by a self-limited hypothyroid state
77
Pituitary apoplexy
Spontaneous hemorrhage into the pituitary, occurs most commonly in pts with a pituitary adenoma
Typical symptoms include acute headache, visual field defects, and decreased visual acuity
78
Sheehan syndrome
Postpartum ischemic necrosis of the ant pit
Potentially life-threatening complication of PPH
Presentation: lactation failure (prolactin deficiency), hypotension and anorexia/wt loss (secondary adrenal insufficiency)
79
Postpartum urinary retention
Due to bladder atony which is temporary and reversible
RF's: nulliparity, prolonged labor, perineal injury (episiotomy, laceration), regional analgesia (reduces sensory and motor impulses of the sacral spinal cord which suppresses the micturition reflex and decreases detrusor tone --> bladder atony), CS, instrumental vaginal delivery
Presentation: inability to void, sensation of bladder fullness, dribbling of urine or small-volume voids
Suspect when pt is unable to void by 6 hr after vaginal delivery or 6 hours after removal of an indwelling catheter after CS
Tx: analgesics, encourage ambulation, urinary catheterization
Urethral catheterization (more accurate than bladder US) confirms retention when it produces >150mL of urine
80
AFP screening
AFP = protein produced by the fetal yolk sac, liver, and GI tract
Measured at 15-20 weeks gestation (optimally at 16-18 wks) to screen for fetal anomalies
Primarily used to screen for open neural tube defects (e.g. anencephaly, open spina bifida).
Increased AFP: open neural tube defects, ventral wall defects (e.g. omphalocele, gastroschisis), multiple gestation
--> US eval of fetal anatomy & clarification of # of fetuses
Decreased AFP: aneuploidies (trisomy 18, 21)
Should also send for acetylcholinesterase (elevated in open neural tube defects)
81
Breast engorgement
Can occur at any point during breast feeding but commonly occurs 3-5 days after delivery, when colostrum is replaced by milk and milk production is robust
Sx: bilateral, symmetric breast fullness, tenderness, warmth; no fever
Tx: cool compresses, acetaminophen, NSAIDs
82
Mastitis
Unilateral breast pain with an isolated firm, tender, erythematous area accompanied by fever
Complication: breast abscess
Vs plugged ducts: presents with same sx except the fever
83
Lochia
vaginal discahrge containing blood and mucus, normal up to 6-8 weeks postpartum.
Heavy bleeding that soaks >2 pads/hr is considered excessive
84
Amniotic fluid embolism
Sudden hypoxemic respiratory failure, hypotensive shock, DIC
Pathogenesis: amniotic fluid entering into the maternal circulation during labor/delivery/immeidate post part period
85
Pubic symphysis diastasis
Physiologic widening (diastasis) of the pubic symphysis to facilitate vaginal delivery - due to increased levels of progesterone and relaxin
RF's: fetal macrosomia, forceps-assisted vaginal delivery, and multiparty
Presentation: suprapubic pain that radiates to the back or hips; exacerbated by weight-bearing, walking, or position changes.
Dx: point tenderness to palpation over the pubic symphysis and sometimes a waddling gait; no neurologic deficits
Management: conservative (pelvic support, physical therapy)
Pts usually recover within the first 4 weeks postpartum
86
Thyroid effects in Pregnancy
Estrogen induces an increase in serum TBG (thyroxine-binding globulin) levels, requiring an increase in the amount of thyroid hormone needed to saturate the binding sites. Thyroxine production is also increases due to the stimulatory effects of hCG on TSH receptors --> total thyroid hormone levels increase
Patients with preexisting hypothyroidism are unable to increase thyroxine production appropriately and are at risk for worsening hypothyroid state and adverse fetal and maternal effects.
Pts on stable dose of thyroid replacement soul have their dose inc by approx 30% at the time the pregnancy is detected.
87
Inflammatory breast carcinoma
Diffuse breast erythema, warmth, pain, edema with peak d'orange appearance (superficial dimpling, fine pitting)
Aggressive form, may be metastatic on initial presentation
Dx: mammo, US
Confirm: tissue biopsy
88
Quadruple screen
Genetic screening test performed in the 2nd trimester
AFP, estriol, b-hCG, inhibin A
Down's: low AFP, low estriol, high b-hCG, high inhibin A
Trisomy 18: low AFP, low estriol, low b-hCG, normal inhibin A
Neural tube or abdominal wall defect: high AFP, normal b-hCG, normal estriol, normal inhibin A
A thorough TVUS should be performed to evaluate fetal anatomy and measure growth
Amniocentesis is recommended for confirmation of abn quad screen - but it is invasive and should be guided by US to determine the best site for needle insertion (assess amniotic fluid, fetal and placenta position)
89
Triple screen (first trimester screening test)
Done in the first trimester
b-hCG, PAPP, nuchal translucency
Trisomy 18: low b-hCG, low PAPP, enlarged nuchal translucency
Trisomy 21: high b-hCG, low PAPP, enlarged nuchal translucency
90
Cell-free fetal DNA testing
non invasive, highly sensitive and specific screening test for fetal aneuploidy
Can be ordered at 10+ weeks gestation; abn results can be confirmed by CVS at 10-12 weeks or amniocentesis at 15-20 weeks
91
Contraindicated drugs in pregnancy
Fluoroquinolones - fetal cartilage abnormalities
| TMP-SMX - congenital malformations in the 1st trimester and inc risk of neonatal kernicterus in the 3rd trimester
92
Intrauterine fetal demise (Stillbirth)
fetal death >20 weeks
RF's: nulliparity, obesity, HTN, DM
Presentation: decreased or absent fetal movement
Inability to find FHR by doppler is not diagnostic and can be due to fetal malpresentation or maternal obesity. Diagnosis must be confirmed by absence of fetal cardiac activity on transabdominal US
Evaluation: fetal autopsy, fetal karyotype, placental exam, maternal lab testing for fetomaternal hemorrhage and antiphospholipid antibody syndrome
Delivery can be delayed to allow time for parental acceptance of the diagnosis, however retention of the fetus for several weeks can lead to coagulopathy
93
Hep C in Pregnancy
Incidence of vertical transmission of HCV infection is 2-5%. All pts with chronic hep C, including pregnant women, should be immunized against hep A and B if not already immune - acute viral hepatitis can be life threatening esp in a pt with pre-existing chronic hepatitis. Hep A and B are both safe in pregnancy
94
Antiphospholipid syndrome
Vascular thrombosis (TIA, stroke, DVT) and/or pregnancy complication (recurrent miscarriage) plus at least 1 of the following antibodies: anti-cardiolipin antibody, lupus anticoagulant, anti-beta2-glycoprotein antibody
Management: chronic anticoagulation with warfarin, heparin
95
Septic pelvic thrombophlebitis
Postoperative or postpartum infected thrombosis of the deep pelvic or ovarian veins --> lower quadrant tenderness
Pts have persistent fever unresponsive to antibiotics. Endometritis is the most common cause of puerperal fever so endometritis is usually suspected first but when it doesn't respond to antibiotics, think of septic pelvic thrombophlebitis
RF's: CS, chorioamnionitis/endometritis, hypercoagulable state of pregnancy, pelvic venous stasis and dilation, endothelial damage from infection and/or trauma during delivery
Tx includes anticoagulation and broad-spectrum antibiotics
96
Pregnancy in a perimenopausal woman
Presentation: insomnia, fatigue, weight gain, amenorrhea, and an enlarged uterus
Evaluate with hCG
97
Infertility
Workup: Start with counseling, then male problems (erections, sperm quality/count, etc). If negative, look for women problems:
- Mucous workup: Most of the time cervical mucous is inhospitable (hard and kills things). Around ovulation, mucous should turn soft and less inhospitable --> Tell couple to have sex around ovulation, then take mucous sample. Smush test: <6cm, no sperm, neg Fern (reaction to estrogen) --> hostile mucous --> tx with estrogen or artificial insemination prob with intrauterine injection
>6cm, + sperm, + Fern --> normal mucous
- Assess ovulations:
If female is anovulatory, you can push her into ovulation with clomiphene (disinhibits GnRH) or pergonal (basically FSH, LH)
History: anovulation (PCOS), etc
Take basal temp - at ovulation there is a spike in temperature and if no pregnancy, temp goes back to normal. If there is pregnancy, it stays up.
Do endometrial biopsy in day 14-28 - should see secretory uterus - prob not necessary since it's pretty invasive
Progesterone level, urinary LH level should be elevated in day 14-28
If ovulating well, it is not ovulation that is the problem, it is an anatomical problem
- Anatomy:
Hysterosalpingogram for visualization of female parts
Anatomical defects make implantation difficult: bicornate uterus, stricture, fibroids
+ bad anatomy --> cannot implant or cannot get zygote through tubes --> surgery (like tuboplasty), artificial insemination
If normal anatomy --> endometriosis --> diagnostic lap --> + ablation, OCP's, estrogen
- --> unexplained fertility --> adoption, surrogate, or artificial insemination
98
Fetal position vs presentation
Fetal presentation: lowest part of the fetus in the maternal pelvis (ex: vertex, face, breech)
Fetal position: relationship of the fetal presenting part to the maternal pelvis
optimal position: occiput anterior
deviations: occiput transverse, occiput posterior
--> can cause cephalopelvic disproportion and arrest of the second stage of labor (3+ hrs in nulliparous woman, 2+ hrs in multiparous woman)
99
Contraindications to breastfeeding
- active untreated TB
- maternal HIV infection
- herpetic breast lesions
- active varicella infection
- chemo or radiation therapy
- active substance abuse
infant: galactosemia
100
Postpartum period normal findings and routine care
Normal: transient rigors/chills, peripheral edema, lochia rubra, uterine contraction and involution, breast engorgement
Routine care: rooming-in/lactation support, serial exam for uterine atony/bleeding, perineal care, voiding trial, pain management
101
Lactational mastitis
Due to inadequate milk duct drainage due to poor latch, pumping breast milk instead of direct breastfeeding, weaning, cracked or clogged nipple pore, etc
Bacteria are transmitted from the infant's nasopharynx or the mother's skin via the nipple, ad multiply in stagnant milk. Staph aureus is the most common offending organism
Presentation: fever, unilateral breast erythema/warmth/pain, lymphadenopathy
Tx: analgesics, breastfeeding, and antibiotics against Staph aureus
Complications of untreated mastitis: breast abscess - localized erythema/pain, fever, malaise - along with a fluctuant, tender, palpable mass.
Needle aspiration of a breast abscess, usually under US guidance, and antibiotics for the surrounding mastitis are first-line treatments. Continued breastfeeding is recommended for continued milk drainage.
102
External cephalic version
Maneuver to convert a breech into a vertex presentation for delivery. Performed between 37 weeks and the onset of labor --> reduces rate of CS.
Contraindications:
- indications for CS regardless of fetal lie (eg failure to progress, non-reassuring fetal status)
- placental abnormalities
- oligohydramnios
- ruptured membranes
- hyperextended fetal head
- fetal or uterine anomaly
- multiple gestation
103
Internal podalic version
Performed in twin delivery to convert the second twin from a transverse/oblique presentation to a breech presentation for subsequent delivery
104
Vaccines during pregnancy
Safe:
- immunoglobulins (like Rho(D) immunoglobulin)
- toxoids (eg tetanus toxoid)
- inactivated vaccines (Tdap, inactivated influenza)
Indicated for high risk patients (HIV, immunocompromised, splenectomy):
- hep B
- hep A
- pneumococcus
- Hflu
- meningococcus
- varicella-zoster IG
Contraindicated:
- HPV
- MMR
- live attenuated influenza
- varicella
105
Alloimmunization
anti-D immune globulin is first administered at 28 weeks and repeated within 72 hours of delivery
anti-D antibody titers > 1:8 = alloimmunized ie sensitized
A standard dose of 300 nanograms at 28 wks can usually prevent alloimmunization, but ~50% of Rh-negative women will need a higher dose AFTER delivery - esp if there was placental abruption or procedures.
The Kleihauer-Betke (KB) test is commonly used to determine the dose. RBC's from maternal circulation are fixed on a slide, the slide is exposed to an acidic solution and adult hemoglobin lyses, leaving "ghost" cells. The dose of anti-D immune globulin is calculated from the percentage of remaining fetal hemoglobin.
106
Most accurate way to determine EGA
US dating with fetal crown-rump measurement in the first trimester
107
Fetal growth restriction
US EFW <10th percentile for GA
2 types: symmetric and asymmetric
Symmetric: onset is 1st trimester, etiology is chromosomal abnormalities or congenital infection, clinical features: global growth lag
Asymmetric: onset is 2nd/3rd trimester, etiology is utero-placental insufficiency (HTN, cocaine, tobacco, alcohol) or maternal malnutrition, clinical features: head-sparing growth lag
108
Neonatal thyrotoxicosis
Infants born to women with Graves' disease are at risk for thyrotoxicosis due to passage of maternal TSH receptor antibodies across the placenta. Affected infants are irritable, tachycardic, and gain weight poorly
Tx: methimazole + beta-blocker are given to symptomatic patients until the condition self-resolves over a few weeks to months
109
Hyperandrogenism in Pregnancy
- Luteoma: yellow or yellow-brown masses (often with areas of hemorrhage) of large lutein cells, solid ovarian masses on US (50% are b/l), regress spontaneously after delivery; high risk of fetal virilization
- Theca luteum cyst: b/l ovarian cysts on US, associated with molar pregnancy and multiple gestation, regress spontaneously after delivery; low risk of fetal virilization
- Krukenberg tumor: metastases from primary GI cancer, b/l solid ovarian masses on US; high risk of fetal virilization
Management: clinical monitoring and US eval of masses; sx regress spontaneously after delivery
110
Rheumatic heart disease in pregnancy
Rheumatic mitral stenosis is an insidious progressive disease, and physiologic and hemodynamic changes during pregnancy can precipitate symptoms in previously asymptomatic patients. The development of new atrial fibrillation can further increase transmitral gradient and left atrial pressure, with dramatic worsening of pulmonary congestion and pulmonary edema.
111
Role of hCG in pregnancy
Hormone secreted by the syncytiotrophoblast
Responsible for preserving the corpus luteum during early pregnancy in order to maintain progesterone secretion until the placenta is able to produce progesterone on its own
Production begins about 8 days after fertilization, and the levels of hCG double every 48 hrs until they peak at 6-8 weeks gestation
112
Lithium exposure in pregnancy
1st trimester exposure: increased risk of cardiac malformations like septal defects and Ebstein's anomaly
2nd/3rd trimester exposure: goiter and transient neonatal neuromuscular dysfunction
Pts who are pregnant should be weaned off
113
Isotretinoin in pregnancy
Associated with many congenital abnormalities including craniofacial dysmorphism, heart defects, and deafness
Cannot be taken by women of reproductive age unless 2 effective forms of contraception have been used for at least 1 month prior to initiating treatment. Contraception must be continued during treatment and for 1 month after isotretinoin is discontinued
114
Fetal hydantoin syndrome
Exposure to anticonvulsant medications during fetal development, most commonly associated meds are phenytoin and carbamazepine
Presentation: midfacial hypoplasia, microcephaly, cleft lip and palate, digital hypoplasia, hirsutism, developmental delay, excess hair
115
Fetal alcohol syndrome
Midfacial hypoplasia, microcephaly, stunted growth, CNS damage causing hyperactivity or MR or learning disability
Cleft palate and excess hair are not typical
116
Pseudocyesis
A form of somatization
Non psychotic woman presents with signs and symptoms of early pregnancy (e.g. amenorrhea, morning sickness, abd distension, breast enlargement) and the belief that she is pregnant.
Likely occurs when the somatization of stress affects the hypothalamic-pituitary-ovarian axis and causes early pregnancy symptoms or when bodily changes are misinterpreted. The belief is often strong enough that the pt misinterprets negative home pregnancy tests as being positive. Because pseudocyesis is a form of somatization, management requires psychiatric evaluation and treatment.
Risk factors: history of infertility and prior pregnancy loss
117
Valproic Acid Exposure in Pregnancy
increased risk for neural tube defects, hydrocephalus and craniofacial malformations
118
Poorly controlled diabetes in pregnancy
Women with poorly controlled diabetes immediately prior to conception and during organogenesis have a four- to eight-fold risk of having a fetus with a structural anomaly. The majority of lesions involve the central nervous system (neural tube defects) and the cardiovascular system. Genitourinary and limb defects have also been reported. Although caudal regression malformation occurs at an increased incidence in individuals with diabetes, this condition is very rare.
119
DM in pregnancy
screening: 1 hr gtt - do not need to be fasting: give 50g
>140 go to 3 hr gtt
>200 = diagnostic - don't need to do 3 hr gtt --> treat as indicated
3 hour gtt - need to be fasting
95/180/155/140
2+ abnormal numbers = diagnostic
post-prandial cut offs:
1 hr - 140
2 hr - 120
babies are at risk of hypoglycemia, hypokalemia, hypercalcemia
early screening (1st visit instead of 24-28 wks): prior LGA, prior gDM, DM in first degree relative
