OB Flashcards
1
Q
Anticoagulation in Pregnancy
A
Preconception = Warfarin During pregnancy = LMWH Last few weeks of preg = UFH Stop anticoagulation at onset of labor and during delivery Postpartum = Warfarin
Warfarin also ok in 2nd/3rd trimester if pt is high risk (eg. has mechanical valves)
2
Q
Medical CIs to Pregnancy (6) –> must terminate pregnancy if have these
A
EF <40% Previous peripartum cardiomyopathy CHF class III-IV Severe obstructive lesions Eisenmenger syndrome (severe Pulm HTN) Unstable aortic dilation >40mm
3
Q
First Trimester Routine Tests (9)
A
CBC Type and cross (test for Rh; if Rh (-) = get Rh Ab titer) UA/urine cx Pap smear Chlamydia/gonorrhea Hep B HIV Rubella Syphilis
4
Q
Third Trimester Routine Tests (4)
A
DM –> 24-28 wk
Anemia –> 24-28 wk
Indirect Coombs test (for anti-D Abs in Rh - moms) –> 28 wk
GBS screening (vaginal and rectal cx) –> 35-37 wks
5
Q
Trisomy 21 - Quad Screen Results
A
“HIgh”
↓ AFP
↓ Estriol
↑ hCG
↑ Inhibin A
FOR ↓ AFP DO AMNIOCENTESIS TO GET KARYOTYPE
6
Q
Trisomy 18 - Quad Screen Results
A
“HEA is low”
↓ AFP
↓ Estriol
↓ hCG
N Inhibin A
7
Q
Trisomy 13 - Quad Screen Results
A
“AFPatau is high” - looks like NTD/multiple gestations/ventral wall defect
↑ AFP
N Estriol
N hCG
N Inhibin A
FOR ↑ AFP DO AMNIOCENTESIS TO GET AMNIOTIC FLUID AFP AND ACH-ESTERASE ACTIVITY (increased AF-AFP = open NTD)
8
Q
Evaluation of Gestational DM (weeks 24-28)
A
1 hr 50g OGTT (gluc. load test) –> POSITIVE is ≥ 140mg/dL –> confirm (+) test w/ 3 hr 100g OGTT (glu. tolerance test)
NEED 2 ABNORMAL POSTGLUCOSE LOAD MEASUREMENTS FOR DX (so either fasting, 1 hr, 2 hr or 3 hr)
9
Q
GBS (AKA: Strep Agalactiae) Tx in mom
A
Immediate tx w/ amoxocillin or cephalexin THEN
Intrapartum IV PCN G as ppx (if PCN allergic = IV clindamycin or IV erythromycin) –> give 4 hrs before delivery
10
Q
RFs for Abruptio Placenta (5)
Complication of Abruptio Placenta
A
HTN (chronic, preeclampsia, eclampsia) Trauma Cocaine use Smoking during pregnancy Previous abruption
Complication = DIC
11
Q
sudden PAINLESS vaginal bleeding
h/o trauma, coitus, pelvic exam
A
Placenta Previa
12
Q
RFs for Placenta Previa (4)
Complication
A
Previous placenta previa
Previous C-section/ uterine surgery
Fibroids
Multiparity
Complication = placenta accreta/iincreta/percreta
13
Q
Tx for Abruption Placenta and Placenta Previa
A
Emergency C-section (if pt/mom unstable) Vaginal delivery (if pt/mom stable and greater than 36 wks; can do in placenta previa if placenta is >2 cm from internal os)
14
Q
Painful vaginal bleeding w/ previous h/o uterine scar
Assc. w/ placenta previa, prior C-section
A
Placenta Accreta, Increta, Percreta
15
Q
Tx for Placenta Accreta, Increta, Percreta
A
Cesarean Hysterectomy
16
Q
Triad:
- rupture of membranes
- painless vaginal bleeding
- fetal tachycardia then bradycardia (sinusoidal pattern)
Mom stable
A
Vasa Previa
17
Q
Tx for Vasa Previa
Complication
A
Emergency C-section
Fetal exsanguination and death
18
Q
sudden onset vaginal bleeding and abdominal pain loss of electronic fetal HR NO uterine contractions abnormal bump in abdomen recession of fetal head during labor
A
Uterine Rupture
- abnormal bump in abdomen = fetal part coming out of tear in uterus (“irregular mobile mass in RUQ”)
- placental abruption has uterine contractions and they’re painful
19
Q
RFs for Uterine Rupture (5)
A
previous C-section uterine myomectomy (for fibroids) placenta percreta excessive oxytocin grand multiparity
20
Q
Tx for Uterine Rupture
A
Immediate laparotomy and delivery
May need hysterectomy for uncontrolled bleeding
21
Q
causes of vaginal bleeding in 1st trimester
A
ectopic preg
spon. abortion
subchorionic hematoma
22
Q
vaginal bleeding in 1st trimester OR
incidental finding in U/S (crescent, hypoechoic lesions adjacent to gestational sac)
A
subchorionic hematoma
23
Q
Tx for subchorionic hematoma
Complications
A
Expectant management
Complications: spon. abortion abruptio placenta preterm PROM preterm delivery
24
Q
How GBS dx in 1st trimester?
A
w/ clean catch urine cx
at 35-37 wks = rectovaginal cx
25
vertical transmission of GBS causes what in neonate?
PNA and sepsis (50% mortality rate)
GBS meningitis NOT related to vertical transmission (it's a hospital acq'd infxn)
26
When do you give GBS ABX ppx in moms?
Previous BABY (NOT MOM) w/ GBS sepsis
If GBS status unknown + have any of these:
- maternal fever
- rupture of membranes ≥ 18 hrs
- preterm delivery (< 37 wks)
27
When do you NOT give GBS ABX ppx in moms?
If pt getting planned C-section w/o ROM (even if cx +)
| Negative cx during this pregnancy (+ cx in prev preg doesn't matter)
28
preg mom in SOUTH AMERICA handling cat feces or litter boxes OR drinking raw goat milk OR eating raw meat
Mild mononucleosis-like syndrome
Toxoplasmosis (Toxoplasma gondii)
DX: IgM (active infxn) or IgG (past infxn, protective) levels
29
if have maternal Varicella, what's the tx in MOM vs NEONATE?
```
MOM= PO acyclovir + VZIG
NEONATE = VZIG
```
30
Tx of congenital Varicella in neonate?
IV acyclovir + VZIG
31
Postexposure Varicella PPX if have previous h/o chickenpox or evidence of immunity (varicella Abs)
Nothing - observe
32
Postexposure Varicella PPX if have NO previous h/o chickenpox or evidence of immunity ( NO varicella Abs) AND Immunocompromised
IVIG
33
Postexposure Varicella PPX if have NO previous h/o chickenpox or evidence of immunity ( NO varicella Abs) AND Immunocompetent
Varicella vaccine
34
Postexposure PPX for Rubella in preg woman
None available
35
What do you do if preg woman has negative IgG titers for Rubella during 1st trimester routine screening?
Nothing --> have to wait until after delivery to give her Rubella vaccine (b/c it's live vaccine)
36
how is CMV (HHV 5) transmitted?
via body fluids
Avoid transfusion w/ CMV positive blood
37
Tx for CMV + neonate
ganciclovir or foscarnet
38
Does ganciclovir cure CMV infxn?
NO! It just stops viral shedding and prevents hearing loss
39
How is HSV transmitted to baby from mom?
via contact w/ active maternal genital lesions
40
Active genital herpes in preg woman is indication for?
C-section
41
Tx for mom w/ active HSV
Acyclovir
42
How is HSV in preg pt Dx?
HSV cx from vesicle/ulcer OR HSV PCR
43
acute, symmetric arthralgias/arthritis
red, lacy rash on trunk and extremities
flulike sxs
Parvovirus B19 in preg pt
44
Dx of parvovirus B19 in preg pt (Immunocompromised vs Immunocompetent)
```
Immunocompromised = NAAT for B19 DNA
Immunocompetent = B19 IgM Abs
```
45
Dx of parvovirus B19 in fetus
PCR analysis of amniotic fld for B19 DNA
46
how do you monitor a fetus w/ parvovirus B19 infxn
do serial U/S for hydrops fetalis
47
when do HIV + preg pts need antiretroviral therapy?
all the time REGARDLESS of CD4 count, RNA load, gestational age
48
Recommended HIV therapy in preg pt? What should you avoid?
```
use zidovudine + lamivudine + protease inh
AVOID Efavirenz (NNRTI) --> avoid before 8 wks gestation; can use after 8 wks gestation --> if pt already on Efavirenz before preg continue it during preg even during first 8 wks
```
49
Indication for C-section in HIV preg pt?
viral load > 1000 at time of delivery
50
What does baby of HIV preg pt get? and for how long?
zidovudine during delivery and for 6 wks postpartum
51
Can HIV + mom breastfeed?
NO (breast milk transmits virus)
52
Does C-section prevent vertical transmission of syphilis?
NO (b/c infxn happens through placenta before birth)
53
Tx for syphilis + mom (assume primary/secondary stage)
Benzathine PCN IM x 1
| If PCN allergic = desensitize
54
Tx for congenital syphilis
Aqueous PCN G IV q8-12h x 10 days
55
Next step after + VDRL test in preg pt?
FTA-ABS (NOT PCN --> start after confirmation)
56
How does neonate get HBV infxn?
gets it from mom who has primary infxn in 3rd trimester OR from ingestion of infected genital secretions during vaginal delivery
57
Tx for preg pt w/ Hep B infxn
get tx for Hep B + vaccine
58
If mom + for Hep B, what tx do you give neonate?
HBIG + vaccine (w/in 12 hrs of delivery)
59
PPX for preg pt w/ (-) HBsAg BUT RFs for Hep B infxn
Vaccine during preg
60
Hep B Postexposure PPX for preg pt
HBIG + vaccine
61
Do infants who acquire acute Hep B go on to develop chronic hep B?
YES!
90% infants develop chronic Hep B
(acute to chronic transformation is based on age; high age = decreased chance of chronic transformation)
In ADULTS --> 90% w/ acute Hep B recover and ONLY 5% or less get chronic Hep B
62
What is the standard does of RhoGAM?
300 micrograms (increase dose if have severe hemorrhage)
Protection from RhoGAM is dose dependent
63
When do you give RhoGAM?
any time mom bleeds during preg, during 28 wks gestation and after delivery (if baby Rh +)
64
When is pt considered sensitized to Rh Abs?
if titer is more than 1:4
titer < 1:16 = no tx
titer > 1:16 = serial amniocentesis to evaluate for fetal anemia and hydrops fetalis
65
Can you give RhoGAM to sensitized pts?
NO
66
What is Kleihauer -Betke test?
Helps determine RhoGAM dose req'd
Determines incidence and size of fetal transplacental hemorrhage (in test, mom's RBCs turn pale and fetus RBCs remain unstained)
67
H/o elevated BP before preg OR before 20 wks gestation OR beyond 12 wks postpartum
Chronic HTN
68
Elevated BP after 20 wks gestation and returns to normal baseline by 6 wks postpartum
Gestational HTN
69
Mild Preeclampsia (occurs in 3rd trimester) Criteria (3)
BP >140/90
Proteinuria 1+/2+; >300mg (24 hr urine); protein:Cr ratio ≥ 0.3
Edema (hands, feet, face)
70
Severe Preeclampsia (occurs in 3rd trimester) Criteria (3)
BP >160/110
Proteinuria 3+/4+; >5g (24 hr urine)
Warning signs
71
Warning signs of Severe Preeclampsia
Headache
Epigastric pain
Vision changes
Pulmonary edema (from ↑ SVR, ↑ cap. perme., ↓ albumin)
Oliguria
↓ PLTs, ↑ LFTs, ↑ Cr (> 1.1) = signs of HELLP
NOTE: In preg, ↑ GFR = ↓ Cr so if see ↑ Cr = bad
72
HIGH RFs for Preeclampsia
```
previous preeclampsia
CKD
chronic HTN
DM
multiple gestations
autoimmune disease
```
High risk pts should receive low dose Aspirin to prevent preeclampsia (start at 12 wks gestation)
73
MILD RFs for Preeclampsia
obesity
nulliparity
advanced maternal age
74
Preeclampsia features + tonic-clonic seizures
Eclampsia
75
Goal BP for Preeclampsia/Eclampsia Tx
140-150/90-100
76
MDXs for MAINTENANCE THERAPY for BP Control in Preeclampsia/Eclampsia
"Hypetensive Moms Love Nifedipine"
First line = Methyldopa, Labetalol
Second line = nifedipine (slow onset; sedative at high doses)
77
MDXs for ACUTE BP Control in SEVERE Preeclampsia/ Eclampsia
IV hydralazine or labetalol
78
MDX for Seizure management in Eclampsia
IV MgSO4
79
Signs of MgSO4 toxicity (3)
Tx
respiratory depression
loss of DTRs
cardiac arrest
Tx: stop Mg and give calcium gluconate
80
ABSOLUTE TX for SEVERE Preeclampsia or Eclampsia (at any gestational age)
Delivery (≥ 34 wks if severe preeclampsia; ≥ 37 wks if mild preeclampsia)
81
Who gets HELLP syndrome? and when?
Preeclamptic pts get HELLP
In 3rd trimester OR 2 days after delivery
82
TX for HELLP
Immediate delivery (regardless of gestational age)
- IV MgSO4 for seizure ppx
- IV corticosteroids when PLTs < 100,000 (keep giving until PLTs > 100,000)
- -> needed for lung maturation if <36 wks gestation
- PLT transfusion if PLTs <20,000 (if C-section being performed, transfuse if PLTs < 50,000)
- BP ≥160/110 = IV hydralazine
83
Most dangerous cardiac D in preg pt
Peripartum cardiomyopathy (EF < 45%)
#2 = Eisenmenger syndrome
84
When do you get peripartum cardiomyopathy?
SXs
Last month of preg to 5 months postpartum
SXs: SOB, edema, palpitations, fatigue
85
5 yr mortality rate in peripartum cardiomyopathy
50%
LV dysfxn reversible and short term (if doesn't improve need cardiac transplant)
86
Tx for peripartum cardiomyopathy
Same as dilated cardiomyopathy
| - ACE-inh, ARBs, B-blockers, spirinolactone, diuretics, digoxin
87
Pts with DVT/PE in prev preg or h/o underlying thrombophilic condition get PPX w/ what?
LMWH throughout preg AND warfarin 6 wks postpartum
88
Maternal thyroid changes in 1st trimester of preg
↓ TSH (best initial screening test)
↑ Total T4 (b/c of ↑ TBG) --> preferred over free T4
N Free T4
89
HYPERthyroidism in preg causes what?
IUGR
| still birth
90
HYPOthyroidism in preg causes what?
Intellectual deficits
| Miscarriage
91
Hormone replacement (T4) in pts w/ HYPOthyroidism during preg
INCREASE dose of thyroid hormones by 25-30%
92
Drug of choice for symptomatic HYPERthyroidism
B-blockers
1st trimester: PTU
2nd/3rd trimester: methimazole
CI in preg = radioactive iodine
93
Neonatal thyrotoxicosis - Definition AND SXs
maternal anti-TSH receptor Abs bind to fetal TSH receptors = increased TH release
SXs:
- fetal tachycardia
- goiter
- growth restriction
- poor feeding
- warm, moist skin
94
TX for Neonatal thyrotoxicosis
Resolves spont in 3 mo after mom's Abs gone
95
Target glucose levels for preg pt w/ Gestational DM
FBS ≤ 95
1 hr after meal ≤ 140
2 hr after meal ≤ 120
96
Tx of gestational DM
First line: diet and exercise
Second line: Insulin (can use metformin and glyburide as well); d/c insulin after delivery
Order 2 hr 75g OGTT 6-12 weeks postpartum to determine if DM resolved
97
When do you start weekly NSTs and AFI (via U/S and BPP) in pt with gestational DM?
32 weeks
27 weeks if pt has poor glycemic control or small vessel disease present
98
Insulin requirements during preg
Increased during preg
Decrease after preg (Pts w/ DM I/II require 1/2 of their pregnancy insulin in postpartum period)
During delivery, give 5% dextrose in water + insulin drip
Turn off insulin infusion after delivery --> maintain gluc levels w/ sliding scale insulin
99
Target delivery gestational age in pts w/ gestational DM
39 wks (after this, induce labor)
100
Indication for C-section in pt w/ gestational DM
fetus >4500 g
101
L/S ratio of fetal lung maturity
>2.5
102
Complication of Appendicitis in 1st, 2nd and 3rd Trimester?
1st: abortion (1/3 of pts)
2nd: premature delivery (14% pts)
3rd: If appendix PERFORATED --> fetal death, abscess formation and pylephlebitis (infectious thrombosis of portal veins)
103
```
Intractable noctural pruritus on palms/soles w/out rash
common in European women
Associated w/ multiple pregnancies
Increased bile acids
Increased LFTs
Jaundice
```
Intrahepatic Cholestasis of Pregnancy
104
Tx of Intrahepatic cholestasis of preg
Complication
ursodeoxycholic acid or cholestyramine for sxs relief
delivery at 37 wks
Complication: risk of intrauterine demise
105
Tx of asymptomatic bacteriuria or acute cystitis during preg
First line: PO nitrofurantoin x 7 days (repeat cx 1 wk after tx)
Second line: Cephalexin or amoxocillin
Don't use bactrim in 1st or 3rd trimester
106
Complications of asymptomatic bacteriuria/ acute cystitis/ pyelonephritis during preg
preterm birth
low birth weight
ARDS
107
Tx of pyelonephritis during preg
Hospitalize, IVFs, IV ceftriaxone, tocolysis
- -> after afebrile for 48 hrs, switch to PO ABXs for 10-14 days
- -> after tx completion, pt gets daily ppx w/ either PO nitrofurantoin or cephalexin
- -> ppx continued until 6 wks postpartum
108
Safe vs unsafe SSRIs in pregnancy
SAFE: sertraline, fluoxetine
UNSAFE: paroxetine
109
focal pruritus (eg. abd); no rash
no increase in bile acids
mild increased in LFTs
Pregnancy Induced Skin Changes
TX: expectant management, oatmeal baths, UV light, antihistamines
110
pruritic, red papules that begin w/in abd striae and spread to extremities
face, palms/soles, periumbilical region spared
happens in 3rd semester or postpartum
Polymorphic Eruption of Pregnancy
111
disseminated eczematous or papular rash in pts w/ h/o atopy (eg. seasonal allergies, atopic dermatitis)
Atopic Eruption of Pregnancy
112
Acute Fatty Liver of Pregnancy
Happens in 3rd trimester or postpartum
```
RUQ pain
N/V
malaise
↑ LFTs, ↑ bilirubin
↓ glucose
possible DIC
Risk of hepatic coma
```
113
Tx of acute fatty liver of pregnancy
Prognosis
IVFs
Glucose
FFP (no Vit K b/c liver not working)
Prognosis: If pt survives, liver dysfxn will resolve on its own
114
red plaques surrounded by sterile pustules that spread outward in flexural regions
no itching
Pustular Psoriasis of Pregnancy (Impetigo Herpetiformis)
115
get pruritus then truncal rash
periumbilical urticarial papules and plaques that develop into bullae and vesicles
rash spreads over entire body but spares mucous membranes
Pemphigoid Gestationis (Herpes Gestationis)
In 2nd/3rd trimester
Autoimmune disorder
116
Dx and Tx of Pemphigoid Gestationis
DX: clinical but can be confirmed w/ skin bx
TX:
high potency topical steroids (triamcinolone)
antihistamines
117
Prognosis and complications of Pemphigoid Gestationis
Prognosis:
Resolves after delivery but increased risk of recurrence w/ subsequent pregn
Complications:
prematurity
IUGR
neonatal Pemphigoid Gestationis
118
woman w/ strong desire to be pregnant comes w/ all sxs of pregnancy but U/S is normal and preg test is (-)
Pseudocyesis
Need psych evaluation and tx
119
```
pt w/ ≥ 2 first trimester abortions
thromboses
assoc w/ SLE
false + VDRL/RPR
↓ PLTs
↑ PTT
N PT and INR
```
Antiphospholipid Syndrome
Abs = anticardiolipin and lupus anticoagulant
120
Dx of Antiphospholipid Syndrome
Initial test: Mixing study (PTT doesn't correct b/c of Ab)
| Most specific: Russell viper venom test (prolonged)
121
Tx for Antiphospholipid Syndrome
Asymptomatic Ab found = no tx
| DVT/PE = Heparin
122
PLTs 70,000 to 150,000
no h/o thrombocytopenia
no assco w/ fetal thrombocytopenia
Gestational Thrombocytopenia
resolves after delivery (reevaluate postpartum to ensure resolution)
123
Gradually worsening headache (worse w/ awakening and Valsalva like maneuvers - cough, sneeze)
focal deficits (hemiparesis)
seizures
confusion
Assoc w/ pregnancy, combined OCPs, malignancy, infxn, head trauma
Cerebral Venous Sinus Thrombosis
Life threatening --> formation of bld clot in dural sinuses which drain CSF and venous bld from brain = signs of increased ICP
124
Dx of Cerebral Venous Sinus Thrombosis
MRI brain w/ magnetic resonance venography
125
Tx for Cerebral Venous Sinus Thrombosis
CI
LMWH
No increased risk of brain hemorrhage w/ this tx
CI: labor induction CI b/c it increases ICP and risk of intracranial hemorrhage
126
MDXs for medical abortion
```
PO mifepristone (progesterone antagonist)
PO misoprostol (prostaglandin E1 analogue)
```
127
U/S Finding:
no products of conception
cervix closed
Complete Abortion
TX: f/u w/ B-hCG
128
U/S Finding:
some products of conception present
cervix closed
Incomplete Abortion
TX: D&C
129
U/S Finding:
products of conception present
cervix dilated
intrauterine bleeding
Inevitable Abortion
TX:
medical induction (if pt stable and minor bleeding) OR
D&C (if pt unstable and actively bleeding)
130
U/S Finding:
products of conception present
cervix NOT dilated
intrauterine bleeding
Threatened Abortion
TX: bed rest (no hospitalization req'd)
131
U/S Finding:
Fetus dead but in uterus
cervix closed
no bleeding
Missed Abortion
TX: medical induction or D&C
132
```
U/S Finding:
retained products of conception
increased vascularity
echogenic material in cavity
thick endometrial stripe
```
Septic Abortion
TX: D&C + IV levofloxacin + metronidazole
133
fever
chills
lower abd pain
bloody or purulent foul-smelling vaginal d/c
boggy and tender uterus w/ dilated cervix
Septic Abortion
RF: h/o elective abortion in non-sterile setting (not hospital)
134
Complication of fetal demise and management
DIC
After dx of fetal demise, get coagulation profile --> if values are low-normal, suspect coagulopathy = DELIVER ASAP
If values normal, wait or induce labor
135
When can you see intrauterine pregnancy on transvaginal vs abdominal U/S (at what B-hCG levels)?
Transvaginal U/S --> B-hCG >1500
| Abdominal U/S --> B-hCG >6500
136
```
amenorrhea
U/L lower abd pain or pelvic pain
vaginal bleeding
adnexal mass
hypotension, tachycardia, abd rigidity/guarding
```
Ectopic Pregnancy
Signs of rupture = hypotension, tachycardia, abd rigidity/guarding
137
what is B-hCG is <1500, how do you manage?
wait 48-72 hrs and measure B-hCG again (appropriate rise is ≥ 35% every 48 hrs)
B-hCG decreased = failed preg (f/u hCG until it's zero)
B-hCG increased appropriately = do transvaginal U/S when it's > 1500
B-hCG increased inappropriately= D&C
--> (-) chorionic villi = ectopic
--> (+) chorionic villi = failed intrauterine preg
138
Management if pt has B-hCG <1500 but signs of ruptured ectopic preg
Laparatomy (don't wait for B-hCG to be > 1500)
139
Tx for unruptured ectopic preg
methotrexate OR laparoscopy
140
RFs for cervical insufficiency
```
h/o preterm birth
h/o 2nd trimester abortion
h/o cervical surgery (LEEP or cone bx)
h/o deep cervical laceration
uterine abn (septate uterus, bicornuate uterus)
DES exposure
```
141
Cervical insufficiency management
Elective cerclage placement --> weeks 14-16 (esp. w/ h/o previous unexplained miscarriages)
Urgent cerclage ONLY AFTER labor and chorioamnionitis ruled out AND there is cervical dilation
Remove cerclage --> weeks 36-37 (after lung maturity)
142
preg woman w/ NO previous h/o preterm birth is found to have short cervix (≤ 2 cm) in 2nd trimester U/S--> what to do?
get serial transvaginal U/S during 2nd trimester to keep eye on cervical length and to evaluate for cervical dilation
can also give vaginal progesterone to prevent preterm birth
143
preg woman w/ previous h/o preterm birth is found to have short cervix --> what to do?
elective cerclage placement
144
Pt at 28 wks gestation has contractions and cervical dilation
preterm labor
145
pt at 28 wks gestation has painless cervical dilation but NO contractions or signs of labor
cervical insufficiency/ incompetence
146
tools used to assess for risk of preterm birth
U/S for cervical length AND fetal fibronectin (if + = increased risk of birth in next 2 wks)
147
Preterm labor management in following gestational wks:
1) 24-33 wks
2) 34- 36 6/7 days
3) 37 wks
1) betamethasone, tocolytics; if pt also <32 wks then give MgSO4 (for protection against cerebral palsy)
2) betamethasone
3) deliver
148
Examples of tocolytics (4)
- Indomethacin (use only if <32 wks gestation)
- MgSO4 (CI in myesthenia gravis)
- CCBs (eg. nifedipine)
- Terbutaline (beta adrenergic receptor agonist) --> can cause pulm edema
149
Causes of symmetric IUGR (all body parts decreased in measurement)
IUGR means weight <2500 g
Fetal causes (early in preg) --> intrinsic factors
- aneuploidy
- infection (eg. TORCH)
- structural anomalies (eg. CHD, NTD)
150
Causes of asymmetric IUGR (abd small, head normal)
Maternal or placental causes (late in preg) --> extrinsic factors
- preeclampsia/ HTN
- DM
- tobacco, alcohol, drug use
- SLE, antiphospholipid sydrome
- malnutrition
- placental abruption/ infarction
151
Next step if suspect macrosomia
U/S
152
Indication for C-section in macrosomia
weight >4500g in DM pt OR
| weight >5000 in non-diabetic pt
153
Definition and causes of oligohydraminos
Defn: AFI <5cm
Causes:
- renal anomalies (Potter's syndrome)
- NSAIDs (decrease renal bld flow = oliguria)
- uteroplacental insufficiency
- preeclampsia
- abruptio placenta
154
Definition and causes of polyhydraminos
Defn: AFI ≥ 24cm
Causes:
- esophageal/duodenal atresia
- anencephaly (abn fetal swallowing)
- congenital infxn (eg. parvovirus)
- DM
- multiple gestation
155
- pooling of clear amniotic fld in posterior fornix
- fld is nitrazine positive
- fld is ferning positive
Premature Rupture of Membranes (PROM)
156
what to do if Biophysical Profile is abnormal (score <4)?
Do contraction stress test
- -> give oxytocin and measure fetal heart strip
- -> helps to identify uteroplacental dysfxn
157
Complication of PROM
Chorioamnionitis
158
SXs of Chorioamnionitis
```
Maternal fever and tachycardia
uterine tenderness
increased WBCs
fetal tachycardia
foul odor of amniotic fld
```
159
Tx of Chorioamnionitis
Get cervical cx
IV ABXs (ampicillin + gentimicin)
Deliver baby
160
Stages of Labor and Normal Duration of Each Stage
Stage 1 (latent phase - effacement): 0-6cm dilation
- -> Primipara: <20 hrs
- -> Multipara: <14 hrs
Stage 1 (active phase - dilation): 6-10cm dilation
- -> Primipara: >1.2 cm/hr
- -> Multipara: >1.5 cm/hr
Stage 2 (descent): delivery of baby
- -> Primipara: <3 hrs (w/ epidural = <4 hrs)
- -> Multipara: <2 hrs (w/ epidural = <3 hrs)
```
Stage 3 (expulsion): delivery of placenta
--> <30 min
```
161
Dx and Tx of Prolonged Latent Phase
no cervical change in 20 hrs (primipara) or 14 hrs (multipara); common cause = analgesia
Tx: rest and hydration
162
Dx of Prolonged Active Phase
cervical dilation of less than <1.2cm/hr (primipara) or <1.5cm/hr (multipara)
163
Dx of Arrest of Active Phase
no cervical change in ≥ 2 hrs despite adequate contractions
164
Tx of Prolonged/Arrest of Active Phase
If contractions NOT adequate --> give IV oxytocin
If contractions TOO many --> morphine sedation
If contractions adequate and still no dilation --> Emergency C-section
165
Dx of Arrest of Second Stage
No delivery w/in 3 hrs (primipara) or 2 hrs (multipara) after full cervical dilation; cause = 3 P's --> power, passenger, pelvis
166
Tx of Arrest of Second Stage
fetal head engaged --> try forceps or vacuum
| fetal head NOT engaged --> Emergency C-section
167
Dx and Tx of Arrest of Third Stage
no delivery of placenta w/in 30 min
Tx: IV oxytocin --> if it fails, try manual extraction --> worst case = hysterectomy
168
MDXs that Induce Labor
Dinoprostone (prostaglandin E2 analog)
Misoprostol (prostaglandin E1 analog)
SE of both MDXs = bronchospasm so don't give to asthma pts
169
MDXs that Augment Labor
Oxytocin
Amniotomy (artificial ROM)
Foley Balloon
170
Tx for Umbilical Cord Prolapse
Immediate C- section
171
Dx and Cause of Early Decelerations
Gradual decreases in FHR beginning and ending simultaneously w/ contractions
Fetal head compression
http://www.rahulgladwin.com/noteblog/obgyn/early-decelerations.png
172
Dx and Cause of Variable Decelerations
Abrupt decreases in FHR that are UNRELATED w/ contractions
Umbilical cord compression
Indicate fetal acidosis
http://www.rahulgladwin.com/noteblog/obgyn/variable-decelerations.png
173
Two Categories of Variable Decelerations and Tx
Severe variable decelerations --> accompany ≥ 50% contractions
--->TX: O2, change maternal position, amnioinfusion
Intermittent variable decelerations --> accompany <50% contractions
--->TX: nothing
174
Dx and Cause of Late Decelerations
Decrease in FHR AFTER contraction started
Uteroplacental insufficiency
Indicate fetal acidosis
http://www.rahulgladwin.com/noteblog/obgyn/late-decelerations.png
175
Tx for Non-reassuring Fetal Tracings
D/c MDXs (eg. oxytocin)
IVFs
O2
Change mom's position (left lateral)
If nothing above works --> prepare for delivery
176
PPX for woman w/ previous h/o genital herpes
Acyclovir at 36 wks gestation
177
Optimum time for External Cephalic Version
37 wks gestation (if doesn't work --> C-section)
Before 37 wks, do nothing --> baby will move own it's own to cephalic position
178
MCC of postpartum hemorrhage
Uterine atony (enlarged, boggy uterus)
179
Tx for Uterine Atony
```
Uterine massage AND
Uterotonic agents:
--> oxytocin
--> misoprostol (HTN is NOT CI)
--> methylergonovine (causes vasospasm); CI = HTN and scleroderma
--> carboplast (prostaglandin F2 alpha analog); CI = HTN
Intrauterine balloon tamponade
Uterine A embolization
Hysterectomy
```
180
2 other common causes of postpartum hemorrhage
Lacerations (see enlarging hematoma)
Retained products of conception/ placenta (tx w/ manual extraction or uterine curretage)
181
lower abdominal pain
round mass protruding through cervix
can't palpate uterine fundus
hemorrhagic shock
Uterine Inversion
182
Tx of Uterine Inversion
- IVFs
- manual replacement of uterus (need relaxed uterus so stop oxytocin) --> if doesn't work give uterine relaxants (NG, terbutaline) and try again
- laparotomy (if manual replacement fails)
- placental removal and uterotonic drugs after uterus replacement
183
postpartum mom develops:
- sudden SOB
- hypotension
- tachypnea
- chest pain
- DIC
Amniotic Fld Embolism
TX: CPR
184
Postpartum mom who had postpartum hemorrhage presents w/:
- inability to breastfeed (no breast milk produced)
- amenorrhea
- loss of pubic hair
- weight gain
- fatigue
- hypotension, hypo Na+
Sheehan Syndrome (ischemic necrosis of anterior pituitary)
185
Tx for Sheehan Syndrome
Estrogen and progesterone replacement
| Thyroid and adrenal hormone supplementation
186
Postpartum Contraception in breastfeeding mom
Doesn't need contraception till 3 mo after delivery
DO NOT use combined OCPs b/c they decrease lactation
Progestin ALONE safe during breastfeeding
187
CIs to breastfeeding
```
HIV
active TB
active herpes lesions on breast
Galactosemia in baby
active substance use
receiving chemo
```
188
breastfeeding decreases risks of which cancers?
breast and ovarian
189
```
Postpartum period:
high fever
uterine tenderness
foul smelling lochia
purulent vaginal d/c
tachycardia
```
Endometritis (polymicrobial infxn)
190
RFs for Endometritis
C-section
PROM
many vaginal exams
191
TX of Endometritis
IV gentimicin + clindamycin
| Continue until pt afebrile for ≥ 24 hrs
192
Postpartum period:
Persistent fever even w/ ABXs
H/o prolonged labor
Septic Thrombophlebitis
193
Tx for Septic Thrombophlebitis
IV Heparin x 7-10 d
194
Postpartum period:
U/L breast tenderness
Breast erythema and edema
H/o nipple cracking and trauma
Infectious mastitis
Cause: S. aureus from baby's mouth
195
Tx for Infectious mastitis
PO oxacillin or dicloxacillin or cephalexin
Continue breastfeeding
If ABXs don't help or get breast induration/fluctuant mass = breast abscess (get U/S and then I&D)
196
```
Postpartum period:
Low grade fever
B/L breast tenderness
Breasts warm to touch
H/o baby not feeding well
```
Breast engorgement
197
Tx for Breast engorgement
NSAIDs
Cold compresses
Breast pumping
198
Physiologic Changes in Pregnancy - CARDIOLOGY
↑ CO
| ↓ SVR
199
Physiologic Changes in Pregnancy - PULMONOLOGY
↓ total lung capacity (b/c of diaphragm elevation)
| ↑ minute ventilation (from ↑ tidal volume) = compensated Resp. Alkalosis
200
Physiologic Changes in Pregnancy - GI
Morning sickness
GERD b/c stomach pushed by uterus
Constipation
201
severe, persistent vomiting
ketosis, dehydration
weight loss ≥ 5% of pre-preg weight
Hyperemesis Gravidarum
RFs: Previous hyperemesis gravidarum, molar pregnancy, multiple gestations
TX: IVFs, electrolyte replacement, antiemetics
202
Physiologic Changes in Pregnancy - ENDOCRINE
↑ TBG (↑ total T3/T4, N free T3/T4)
↓ TSH
↑ estrogen
203
Physiologic Changes in Pregnancy - RENAL
↑ risk of pyelonephritis (b/c uterus compresses ureters)
| ↑ GFR (b/c of ↑ plasma volume) = ↓ BUN/Cr
204
Physiologic Changes in Pregnancy - HEMATOLOGY
Dilutional anemia (b/c of ↑ plasma volume)
- 1st/3rd semester: Hg 11
- 2nd semester: Hg 10.5
```
↑ RBCs
↑ WBCs (from preg stress and labor)
↓ PLTs
↑ Coagulation factors
N PT/PTT/INR/bleeding times
↑ ESR
↑ Alkaline phosphotase
```
