OB Flashcards
(83 cards)
1
Q
Discriminatory zone
A
b-hCG 1500-2000 - 5 weeks
when gestational sac should be visible on TVUS
2
Q
Naegele’s rule
A
1st day of LMP + 7 days - 3 mo + 1 yr
3
Q
Gs and Ps
A
G - number pregnancies P - number of births -F - term births -P - preterm births less than 37 wks -A - abortions before 20 weeks -L - living children
4
Q
Physiologic changes in pregnancy
A
BMR increases 10-20% - need 100-300 more calories/day
Plasma volume increases 30-50%, RBC mass increases 20-30%
- > physiologic anemia
- > systolic murmur, S3
Cardiac output increases 30-50%
BP decreases in early pregnancy -> nadir at 24-26 wks, return to normal by term
Relaxation of the lower esophageal sphincter -> GERD
Increase GFR -> decreased BUN and Cr
Increased procoagulation factors -> hypercoaguable state through first few weeks postpartum
5
Q
Age of viability
A
24 weeks
6
Q
Wt gain in pregnancy - Underweight - BMI less than 18.5 Normal Overweight (BMI 25-29.9) Obese (BMI >30)
A
Under - 28-40
Normal - 25-35
Overwt - 15-25
Obese - 11-20
7
Q
Chorionic villus samping
A
10-13 weeks
8
Q
Quad screen, amniocentesis
A
15-20 weeks
9
Q
Screen for gestational diabetes
A
24-28 weeks
10
Q
Administer anti-D immune globulin in Rh(D) negative
A
28 weeks
Or anytime risk fetomaternal hemorrhage
11
Q
Screen for group B strep
A
35-37 weeks
12
Q
Check for lung maturity
A
Lecithin-Splingomyelin ratio >2:1
13
Q
Fetal alcohol syndrome
A
Dysmorphic facial features: short palpebral fissures, smooth philtrum, thin vermillion border
growth retardation
CNS abnormalities: microcephaly, intellectual deficits, behavioral problems, Learning disabilities (MC cause), impaired executive functioning
14
Q
Hyperemesis gravidarum
A
N/V severe enough to cause wt loss of more than 5% of prepregnancy wt, dehydration, ketosis, and/or abnormal labs
Vitals: Weight, HR, orthostatic blood pressure
-tachycardia and hypotensive with dehydration
Labs:
hypokalemic, hypochloremic, metabolic alkalosis
Ketonuria
U/S: r/o gestational trophoblastic disease and multiple gestation -> higher level of hormones
Tx: IVF Electrolyte and thiamine repletion Antiemetics NG tube feeds, parenteral nutrition
15
Q
Infant complications in pre-gestational diabetes
A
Spontaneous abortion/stillbirth Macrosomia Neonatal hypoglycemia Congenital malformations -cardiac defects -caudal regression syndrome - sacral agenesis
16
Q
Maternal complications in pre-gestational diabetes
A
Preeclampsia
Polyhydramnios
DKA
Worsening of retinopathy, nephropathy
17
Q
Management of pre-gestational diabetes
A
HgbA1c, urine protein:Cr, ECG, dilated eye exam
Insulin
DM diet - monitor glucose
2nd trimester: US and fetal echo
3rd trimester: fetal surveillance, US: look for macrosomia
Consider C/S if EFW more than 4500g
Induction at 39-40 weeks
18
Q
Infant complications in gestational diabetes
A
still birth
macrosomia
neonatal hypoglycemia
19
Q
Maternal complications in gestational diabetes
A
preeclampsia
polyhydramnios
20
Q
Management of A1 diabetes in pregnancy
A
diet/exercise 3rd trimester US consider C/S if EFW more than 4500 g Induction at 40-41 weeks Post partum OGTT - 2 hour, 75 g
21
Q
Management of A2 diabetes in pregnancy
A
Insulin 3rd trimester fetal surveillance, US Consider C/S if EFW more than 4500 g Induction at 39 weeks Post partum OGTT
22
Q
Asx bacteriuria in pregnancy
A
screen of Ucx at first visit
treat positive Ucx -PO: nitrofurantoin (MC) amoxicillin Cephalexin Fosfomycin
Repeat Ucx 1 week after completion
23
Q
Cystitis in pregnancy
A
S/S:
Dysuria, frequency, urgency
Suprapubic pain
Hematuria
UA: bacteriuria, pyuria, leukocyte esterase, nitrate
+ UCx
-PO: nitrofurantoin (MC) amoxicillin Cephalexin Fosfomycin
Repeat Ucx 1 week after completion
24
Q
Pyelonephritis in pregnancy
A
Risk: progesterone -> smooth muscle relaxation -> dilation of ureters
S/S: Dysuria, frequency, urgency Suprapubic pain Hematuria Fever/chills N/V Flank pain CVA tenderness Pulmonary edema -> SOB
UA: bacteriuria, pyruia, leukocyte esterase, nitrite, WBC casts
Positive UCx
Tx: Admit IV Abx: ampicillin + gentamicin Ceftriaxone Meropenem Pip-tazo
Suppresive therapy remainder of pregnancy
Complications: Preterm birth Sepsis -> septic shock ARDS Maternal death
25
HELLP syndrome
Hemolysis, elevated liver enzymes, low platelets
pre-eclampsia + RUQ pain + bleeding
26
Amniotic fluid embolism
Amniotic fluid enters maternal circulation -> CV collapse, possible death
```
Features:
Hypotension - cardiogenic shock
Respiratory failure
Unresponsiveness
Excessive/prolonged bleeding (DIC)
(looks like PE with DIC)
```
Occurs during Labor and delivery or a immediately postpartum
Dx of exclusion
Tx: ACLS protocols
27
Toxoplasmosis
Historical clues:
Infant findings:
Historical clues:
- exposure to cat feces
- ingestion of undercooked meat
Infant findings:
- chorioretinitis
- intracranial calcifications (diffuse)
- hydrocephalus (big head)
Tx: spiramycin
After 18 weeks: Pyrimethamine + sulfadiazine + folinic acid
pre-pregnancy infection offers immunity if reinfected during pregnancy
28
CMV
Historical clues:
Infant findings:
Historical clues: mono-like illness in mom
Infant findings:
- sensorineural hearing loss
- intracranial calcifications (periventricular)
- Microcephaly (small head)
MC congenital infection
No immunity from prior infection
29
Rubella
Historical clues:
Infant findings:
Historical clues:
Maternal infection - mild fever and rash - starts in and face and spreads to trunk/extremities
ppx - MMR virus - contraindicated 1 mo prior to conception and during pregnancy
Infant findings:
- sensorineural hearing loss
- cataracts
- patent ductus arteriosus
- pulmonary artery stenosis
- "blue berry muffin" rash
30
Parvovirus B19
Historical clues:
Infant findings:
Historical clues:
Maternal infection - fever and "slapped cheek" rash; arthritis
Infant findings:
- severe anemia
- cardiac failure
- hydrops fetalis
tx:
Serial U/S
Intrauterine blood transfusion
Prior infection offers immunity
31
Listeriosis
Historical clues:
Infant findings:
Historical clues: deli meats; mom infection - flu-like illness
Infant findings:
- granulomatous infantiseptica - rash, (widespread internal abscesses)
- stillbirth
Dx: blood culture
Tx: ampicillin + gentamicin
or TMP-SMX
32
Early manifestations of congenital syphilis
First two years of life
```
Hepatomegaly, elevated LFTs
Disseminated maculopapular rash involving soles
Blood tinged nasal secretions - snuffles
Meningitis
Skeletal abnormalities of long bones
```
33
Late manifestations of congenital syphilis
After first two years of life
Interstitial keratitis --> corneal scarring -> blindness
Sensorineural hearing loss
Facial abnormalities- frontal bossing, saddle nose
Hutchinson teeth - notching up teeth
Perforation of hard palate
Anterior bowing of tibia - saber shins
34
Varicella-zoster virus - maternal vs fetal vs neonatal infection
Maternal infection: chickenpox rash, pneumona
```
Fetal infection:
scarring of kin in dermatomal pattern
CNS abnormalities
Chorioretinitis
Limb hypoplasia
```
neonatal infection:
chickenpox rash, disseminated disease
-high mortality - 30%
Tx:
Maternal exposure - varicella IG
Maternal infection - acyclovir, +PNA -> hospitalize
Maternal infection around delivery -> acyclovir + VZV IG to infant
Neonatal infection -> acyclovir
35
HSV neonatal infection
```
vesicular skin rash
Conjunctivitis
meningoencephalitis
Disseminated disease - sepsis, hepatitis, pneumonia
Untreated mortality 80%
```
36
Group B strep
Vertical transmission -> sepsis, PNA, meningitis
Screen 35-37 weeks
Intrapartum ppx:
PCN G or ampicillin
allergy minor - cefazolin
risk of anaphylaxis - clindamycin insensitive, vancomycin if resistant
37
Ectopic pregnancy
```
Features:
Amenorrhea
vaginal bleeding
Ipsilateral abdominal pain
Referred pain to shoulder
urge to defecate - d/t pooling of blood in Pouch of Douglas
Dizziness, LOC
Abdominal tenderness
Adnexal mass
Rebound tenderness, guarding - if ruptures
```
Stable - methotrexate, monitor bhCG to zero
Unstable - ABCs, immediate surgical management
38
Cervical insufficiency
Painless cervical dilation -> 2nd trimester loss
Dx: exam and U/S - cervical length less than 25 mm
Tx: cerclage
Associated with: Ehler's danlos, previous trauma, LEEP
39
Intrauterine fetal demise (IUFD)
after 20 weeks
```
Causes:
Fetal chromosome abnormality or congenital anomalies
Abnormal placenta or umbilical cord
Placental abruption
Rh alloimmunization
Congenital infections
Maternal complications - HTN, DM
idiopathic
```
Tx:
Expectant management
D&E
Induce labor - misoprostol, oxytocin
Risk DIC if wait
40
Intrauterine growth restriction (IUGR)
Fetal wt less than 10th percentile for GSA
```
Causes:
Chromosomal/ congenital
Multiple gestations
TORCH infections
Placental abnormalities
low uteroplacental blood flow - HTN, DM, SLE
Low pre-pregnancy BMI
Poor wt gain during pregnancy
smoking - esp 3rd trimester
Cocaine use
Teratogens
```
Symmetric - entire body small - early insult
Asymmetric - small abd, normal head - late insult
Dx: U/S
Tx: serial U/S
Fetal surveillance
early delivery
41
Macrosomia
EFW > 4500g
```
Risk:
Advanced maternal age
Hi prepregnancy BMI
Excessive weight gain
Post term
Maternal diabetes
```
Dx: U/S
```
Complications:
Shoulder dystocia, birth trauma
Postpartum hemorrhage
C/S
Future increased risk of metabolic syndrome
```
Tx: C/S if EFW >5000 g (or >4500 g in DM pt)
42
Causes of oligohydramnios
less than 5 cm amniotic fluid index
Placental insufficiency
Obstructed urine flow - posterior urethral valves-males
B/L renal agensis -> Potter sequence
Tx: amnio infusion
43
Potter Sequence
"POTTER"
```
Pulmonary hypoplasia
Oligohydramnios
Twisted skin (wrinkled skin)
Twisted face (facial deformities)
Extremities (limb deformities)
Renal agenesis
```
44
Causes of polyhydramnios
>24 cm amniotic fluid index
```
esophageal/duodenal atresia
Anencephaly
Multiple gestation
Uncontrolled maternal diabetes
Congenital infections - parvovirus B19
Fetal anemia d/t RH alloimmunization
```
Tx: amnioreduction
Indomethacin (decrease renal a. flow)
-risk early PDA, limit to short term use, not in 3r trimester
45
Accelerations - fetal heart rate tracing
Increases of heart rate of more than 15 bpm for more than 15 seconds
46
Normal (reactive) nonstress test
At least 2 accelerations in 20 minutes - 15x15
| if less than 32 weeks - 10x10
47
Biophysical profile
```
Nonstress test
Amniotic fluid volume
Fetal breathing
Fetal movement
Fetal tone - flexion and extension
```
score 2 if normal, 0 if abnormal
total of 8-10 reassuring
48
Early deceleration
mirrors contraction - nadir with nadir
head compression
49
Variable deceleration
V shaped
no relationship to contraction
umbilical cord compression
50
Late deceleration
U shaped
FHR nadir after contraction nadir
uteroplacental insufficiency
Fetal hypoxia
51
Sinusoidal pattern to FHR
severe fetal anemia
52
management of non-reassuring FHR tracing
administer maternal O2, turn to left lateral decubitus
DC oxytocin, consider correction of hyperstimulation (tocolytic)
IVF bolus
Sterile vaginal exam - check for cord prolapse
Consider immediate delivery - C/S
53
Twin to twin transfusion syndrome
complication of monochorionic twin pregnancies
Vascular anastomoses link the fetal circulations -> blood from one twin flows to the other twin
Donor twin - anemia, growth restriction, oligohydramnios
Recipient twin: polycythemia, volume overload, heart failure, polyhydramnios
54
Erythroblastosis fetalis
Rh(D) negative mom with IgG antibodies against Rh(D)
Ab cross placenta, attack fetal RBCs -> hemolytic disease of fetus
55
Hydatidiform mole (molar pregnancy)
S/S:
Amenorrhea, positive pregnancy test, S/S of pregnancy
Vaginal bleeding
Pelvic pain/pressure
Uterine size does not match gestational age
Hyperemesis gravidarum
hyperthyroidism - hCG activates TSH receptor
preeclampsia before 20 weeks
passage of tissue with grapelike appearance
Dx:
Quant hCG
US: snowstorm - abnormal or absent fetus
-Theca-lutein ovarian cysts
Tx: D&C
follow hCG to zero
Wait at least 6 months before trying to conceive- to detect recurrence
56
Choriocarcinoma
Malignant form after gestational trophoblastic disease
- half arise from complete moles
- SBAs, ectopic pregnancy, normal pregnancies
Mets: lung (MC), vagina, brain, liver
Presentation:
Recent pregnancy
Persistent brown, bloody discharge
Pulmonary sxs - SOB, cough, hemoptysis
```
Dx:
pelvic exam
Quant hCG - extremely high
US: uterine mass with areas of necrosis and hemorrhage
CXR
```
Tx: methotrexate
+/- surgery
Follow hCG levels to zero
Wait at least one year before attempting to conceive
57
Placenta previa
```
Risk factors:
Increasing maternal age
Multiparity
Multiple gestations
History of uterine surgery
History of C-section
```
Presentation:
Painless vaginal bleeding late in pregnancy
Dx: US before pelvic exam - risk massive hemorrhage
```
Tx:
Asx - pelvic rest, serial u/s, C/S 36-37 weeks
Bleeding previa:
-resuscitation - IVF, blood transfusion
-FHR monitoring
-glucocorticoids to promote lung maturity
-inpatient bed rest if bleeding resolves
-if continues or abnormal FHTs -> C/S
```
58
Vasa previa
Unprotected fetal vessels overlie cervical os
Ruptured membranes -> compression or laceration of fetal vessels -> fetal hypoxia or hemorrhage/exsanguination
Dx: US
Suspect if ROM followed by bleeding and nonreassuring FHT
Tx: C/S 34-35 wks
59
Placental abruption
```
risk factors:
Prior abruption
Hypertension
Trauma
Smoking
Cocaine
```
Features:
Sudden onset, painful vaginal bleeding late pregnancy
contractions
Fetal distress - bradycardia, late/prolonged decels
DIC possible complication
Dx: US, clinical
tx: emergent C/S
60
Test to confirm ruptured membranes
Sterile speculum exam - pooling fluid in posterior vaginal vault
Nitrazine paper test - blue in amniotic fluid
Microscopy - ferning pattern
Amnisure
US: low amniotic fluid volume
61
Management of PROM less than 34 weeks
Admit
Betamethasone or dexamethasone for fetal lung maturity
Abx:
IV ampicillin 2g q6hr + gentamicin 250 mg q6 hr x 48 hours
PO amox 250 q8hr + azithromycin 233 mg q8 hr x5 days
62
Management of PROM greater than 34 weeks, or evidence of infection
induce labor - oxytocin
63
Complications of premature rupture of membranes
Chorioamninitis if greater than 18 hrs
cord prolapse
placental abruption
preterm labor
64
Preterm labor
less than 37 weeks
Contractions -> cervical changes
```
Less than 34 weeks:
Admit
Corticosteroids for lung development
Consider tocolysis
Mag sulfate for neuroprotection under 32 weeks
+/- PCN for GBS
```
over 34 weeks: allow labor
```
Risk:
Placental abruption
PROM
Prior preterm birth
Multiple gestations
UTI/STI
uterine abnormality
cervical insufficiency
```
65
Chorioamnionitis
Infection of fetal membranes, placenta, and amniotic fluid
```
Risk factors:
PROM longer than 18 hrs
Prolonged labor
Multiple cervical exams
Meconium fluid
Internal monitors
```
Dx: clinical
```
Features:
Maternal fever
Maternal/fetal tachycardia (fetal >160)
Uterine tenderness
Purulent amniotic fluid
```
Tx:
IV ampicillin + gentamycin
Delivery
66
Methods to induce labor
Cervical ripening - mechanical cervical dilators, misoprostol (PGE1),
-dinoprostone (PGE2) -> tachysystole - too strong contractions, fetal distress
IV oxytocin - stop if tachysystole
Amniotomy - risk cord prolapse
Membrane stripping
Nipple stimulation
67
Signs of placental separation
Sudden gush of blood
Lengthening of the umbilical cord
uterus rises to anterior abdominal wall
Uterus becomes firmer and more globular in shape
68
1st stage of labor
latent phase - onset of regular contractions to 6 cm
-nulliparous - less than 20 hours
-multiparous - less than 14 hrs
management of protraction/arrest: expectant mgmt, amniotomy +/- oxytocin
Active phase - 6 cm to 10 cm
management of protraction -> oxytocin; arrest -> C/S
69
2nd stage of labor
10 cm -> delivery
Nulliparous 3 hrs or less
Multiparous 2 hrs or less
+1 hr if epidural
Protraction/arrest:
expectant mgmt, oxytocin, operative vaginal delivery, rotation of fetal occiput, C/S
70
3rd stage of labor
delivery of infant to delivery of placenta
less than 30 min
-otherwise manual removal
71
adequate uterine contractions
200 montevideo units or more
add amplitude of each contraction in 10 minutes
72
labor arrest vs protraction
labor protraction - slower than normal
Labor arrest - not progressing at all
no cervical change in patient 6 cm + and ruptured membranes despite:
-at least four hours of adequate contractions or
-at least six hours of inadequate contractions + oxytocin
73
Cardinal movements of labor
```
Engagement
Descent
Flexion - chin to chest
Internal rotation (towards midline)
Extension - of head
External rotation
Expulsion
```
74
Uterine rupture
Risk:
Prior uterine surgery (C/S)
Labor induction/augmentation
```
Features:
Fetal bradycardia (less than 110)
Maternal abdominal pain - constant
Loss of fetal station
Change in shape of uterus
Maternal tachycardia and hypotension
```
Tx:
emergent C/S with repair or hysterectomy
75
Management of shoulder dystocia
suprapubic pressure
McRoberts maneuver - hyperflex legs
Delivery of posterior arm/shoulder - Barnum's maneuver
Rubin manuever - rock shoulders side to side
Wood maneuver - rotate posterior shoulder 180 degress may release it
Intentional fracture of clavicle
Zavanelli maneuver - last resort - push back in with STAT C/S
76
Indication for C/S
```
Arrested labor
Abnormal fetal heart tracing
Malpresentation - breech
prior C/S
Abnormal placentation - previa, accreta, increta, percreta
Acute placental abruption
uterine rupture
multiple gestation
suspected fetal macrosomia
HIV load >1000, active HSV lesions
prior vaginal delivery with 4th degree tear
```
77
Postpartum hemorrhage definition
500 ml vaginal
| 1000 ml c/s
78
Causes of postpartum hemorrhage
```
Uterine atony (MC) - open spiral arteries
Retained placental tissue
Placenta accreta/increta/percreta
genital lacerations
uterine rupture
coagulopathy
```
79
Uterine atony
```
Risk:
overdistended uterus
chorioamnioitis
induced/augmented labor
prolonged labor
```
Presentation:
bleeding continues after placenta delivered
Big, soft, "boggy" uterus
Tx:
fundal or bimanual massage
Exam uterus for placental fragments or large blood clots
Uterotonic agent: oxytocin, methylergonovine (contra in HTN), carboprost (contra in asthma), misoprostol, dinoprostone
IVF, blood
Consider uterine artery ligation or hysterectomy
Intrauterine balloon to tamponade
80
Sheehan syndrome
massive postpartum hemorrhage -> hypotension -> underperfusion of pituitary gland -> pituitary necrosis -> hypopituitarism
S/S of deficiencies in:
FSH/LH - amenorrhea, breast atrophy, loss of pubic/axillary hair
ACTH - hypotn, hyponatremia
TSH - fatigue, cold intolerance, wt gain, constipation, dry skin
Prolactin - failure to lactate
GH - decrease in lean body mass
81
Postpartum endometritis
```
Risk factors:
C/S
Chorioamnionitis
Prolonged labor/PROM
multiple cervical exams
internal monitoring
manual removal of placenta
```
```
Features:
fever
tachycardia
urterine tenderness
Foul-smelling lochia
```
Dx: clinical
Tx: ampicillin + gentamicin +/- clindamycin (anaerobic coverage)
82
Contraindications to breastfeeding
```
HIV infections
Drug or alcohol abuse
Active TB
active herpes on breast
chemotherpay
Infant with galactosemia
```
83
mastitis
S. aureus (MC)
```
Features:
tender, erythematous, swollen area
fever
myalgias
malaise
```
Dx: clinical
US r/o breast abscess
```
Tx:
continue breastfeeding/pumping
Abx:
dicloxacillin - antystaph
if MRSA suspected - clindamycin, TMP-SMX, vancomycin
```
If abscess - I&D
