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OB Flashcards

1
Q

What is the difference between an embryo, fetus, and infant?

A
  • embryos exist from fertilization to 8 weeks gestation
  • from 8 weeks to birth the products of conception are referred to as a fetus
  • infants are children less than 1 year old
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2
Q

How is amenorrhea defined?

A
  • no menses for 3 months in someone with regular menses

- no menses for 6 months in someone with irregular menses

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3
Q

What defines the first, second, and third trimesters?

A
  • the first trimester is from LMP to 14 weeks
  • the second trimester is from 14 to 28 weeks
  • the third trimester is from 28 weeks until delivery
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4
Q

How can you quickly estimate the due date?

A

LMP - 3 months + 7 days

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5
Q

What is a previable fetus and how is birth of a previable fetus managed?

A

a previable fetus is one born at less than 25 weeks gestation

  • before 22 weeks resuscitation is not attempted
  • between 22-25 weeks, the decision is made on a case-by-case basis after discussing risks and benefits with parents
  • after 25 weeks, resuscitation is always initiated
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6
Q

What is considered a preterm birth? What is considered a post-term birth?

A
  • preterm is birth before 37 weeks gestation

- post-term is birth after 42 weeks gestation

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7
Q

What are the Gs and Ps for a woman who is currently pregnant, has had 2 abortions, had two children born at term, and a set of twins born preterm?

A

G6P2124

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8
Q

Describe each of the following signs of pregnancy and when they are seen:

  • Goodell sign
  • Landin sign
  • Chadwick sign
  • Telangiectasias/Palmar Erythema
  • Chloasma
  • Linea Nigra
A
  • Goodell sign: softening of the cervix felt at 4 weeks
  • Landin sign: softening of the midline uterus at 6 weeks
  • Chadwick sign: blue discoloration of the vagina and cervix at 6-8 weeks
  • Telangiectasias/Palmar Erythema: first trimester
  • Chloasma: the mask of pregnancy with hyperpigmentation of the face which worsens with sun exposure at 16 weeks
  • Linea Nigra: hyperpigmentation extending from the xiphoid to the pubic symphysis seen in the second trimester
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9
Q

What is the first sign of pregnancy seen on physical exam?

A

Goodell sign, a softening of the cervix, which can be felt as early as 4 weeks gestation

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10
Q

What is chloasma?

A

also referred to as the mask of pregnancy, it is a hyperpigmentation of the face, worse with sun exposure, that is first seen around 16 weeks gestation

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11
Q

How should B-hCG levels change throughout the course of early pregnancy?

A
  • the level should double approximately every 2 days for the first 4 weeks
  • a level of 1500, seen around 5-6 weeks, suggests a gestational sac should be visible on ultrasound
  • it should then peak around 10 weeks gestation
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12
Q

What are the first two steps in confirming pregnancy?

A

get a B-hCG level then perform an ultrasound to confirm an intrauterine pregnancy

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13
Q

At what point in pregnancy should a gestational and yolk sac be visible?

A

when B-hCG levels reach 1500 IU/mL

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14
Q

How do the following cardiac parameters change during pregnancy:

  • blood volume
  • hematocrit
  • systemic vascular resistance
  • heart rate
  • cardiac output
A
  • blood volume: increases
  • hematocrit: decreases
  • systemic vascular resistance: decreases
  • heart rate: increases
  • cardiac output: increases
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15
Q

How do the following respiratory parameters change during pregnancy:

  • residual volume
  • FEV1/FVC
  • tidal volume
  • respiratory rate
  • minute ventilation
  • PaCO2
A
  • residual volume: decreased (upward pressure on diaphragm)
  • FEV1/FVC: unchanged
  • tidal volume: increased
  • respiratory rate: unchanged
  • minute ventilation: increased
  • PaCO2: decreased
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16
Q

What are three common physiologic GI side effects of pregnancy and what causes these?

A
  • morning sickness caused by increased estrogen and progesterone
  • reflux caused by progesterone-induced LES relaxation
  • constipation caused by reduced colonic motility
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17
Q

How do the following renal parameters change during pregnancy:

  • GFR
  • creatinine
  • BUN/Cr
  • kidney volume
A
  • GFR: increases (greater blood volume and decreased SVR improves perfusion)
  • creatinine: decreases (secondary to increased GFR)
  • BUN/Cr: decreases
  • kidney volume: increases due to increased vascular volume, increased interstitial volume, and dilation of renal pelvises
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18
Q

How do the following hematologic parameters change during pregnancy:

  • WBC
  • platelet count
  • hematocrit
  • PT
  • PTT
  • INR
  • fibrinogen
  • coagulability
A
  • WBC: increased
  • platelet count: decreased
  • hematocrit: decreased
  • PT: unchanged
  • PTT: unchanged
  • INR: unchanged
  • fibrinogen: increased
  • coagulability: increased
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19
Q

At what point should thrombocytopenia be investigated during pregnancy?

A

once platelet count is less than 80K

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20
Q

Describe the five options and timing of genetic testing available in the prenatal period.

A
  • in the first trimester, between 9-13 weeks, a combined test of maternal B-hCG, maternal PAPP-A, and nuchal translucency can be performed as a screening tool
  • in the first trimester, after 10 weeks, cell-free fetal DNA testing can be performed as a screening tool
  • in the second trimester, between 15-20 weeks, a triple or quad screen can be performed with MSAFP, B-hCG, estriol, and (for the quad) inhibin A
  • CVS is a confirmatory test performed at 10-13 weeks
  • amniocentesis is a confirmatory test performed at 15-17 weeks
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21
Q

What routine prenatal testing is performed in each of the trimesters?

A
  • in the first trimester, a dating ultrasound, pap smear, and G/C are performed along with routine blood tests
  • in the second trimester, a routine ultrasound for anatomy is performed at 18-20 weeks
  • in the third trimester a 1-hr GTT is performed at 24-28 weeks; a CBC for anemia at 27 weeks; and G/C, STD, and GBS testing at 36 weeks
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22
Q

When is glucose challenge testing performed during pregnancy?

A

at the end of the second trimester between 24-28 weeks gestation

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23
Q

What testing should be performed at 36 weeks gestation?

A

G/C, GBS culture, STD testing if patient was positive during pregnancy or has risk factors

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24
Q

What are Braxton-Hicks contractions and how should they be managed?

A

they are contractions that do not lead to cervical dilation; if they become regular or persist, the cervix should be checked to rule out preterm labor

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25
Q

When can CVS and amniocentesis be performed?

A
  • CVS from 10-13 weeks

- amniocentesis from 15-17 weeks

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26
Q

What is the “combined test” during pregnancy?

A

it is a combination of maternal B-hCG, maternal PAPP-A, and nuchal translucency which serves as a screening for trisomy 21 and is performed at 9-13 weeks gestation

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27
Q

What is cell free DNA testing during pregnancy?

A

it is a screening test for aneuploidy that is performed in women over 35 after 10 weeks gestation

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28
Q

What are the triple and quad screening?

A
  • triple is MSAFP, B-hCG, and estriol
  • quad is the same plus inhibin A
  • both are done between 15-18 weeks gestation
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29
Q

What does elevated maternal serum AFP indicate?

A

a dating error, neural tube defect, or abdominal wall defect

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30
Q

When should routine fetal US for anatomy be performed?

A

between 18-20 weeks of gestation

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31
Q

What is non stress testing, why is it performed, and how are the results interpreted?

A
  • it is a noninvasive evaluation of the fetus in utero using fetal heart rate tracing
  • a reactive test is defined by at least two accelerations within 30 minutes and this indicates adequate fetal oxygenation
  • a nonreactive test does not necessarily indicate inadequate oxygenation however as the child may be sleeping
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32
Q

How is a fetal heart acceleration defined?

A

it is a more than 15 bpm abrupt increase in fetal heart rate that peaks within at least 30 seconds

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33
Q

How is the biophysical profile scored?

A

each category is worth 2 points and a score of 4 or less indicates fetal compromise:

  • NST
  • Amniotic fluid index: one pocket at least 2 cm in height
  • Fetal breathing: at least 1 episode lasting 30 seconds
  • Fetal movement: at least 4 counts
  • Fetal muscle tone: at least 1 flexion and extension
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34
Q

What is a normal fetal heart rate? How are bradycardia and tachycardia defined?

A
  • normal is 110-160
  • bradycardia is a baseline (>10 minutes) less than 110
  • tachycardia is a baseline (>10 minutes) more than 110
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35
Q

What causes variable, late, and early decelerations on fetal monitoring? Which is most serious?

A

V - Cord compression
E - Head compression
A - Okay!
L - Placental Insufficiency (most serious)

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36
Q

What are early decelerations?

A
  • a decrease in HR that mirrors a contraction

- caused by head compression

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37
Q

What are late decelerations?

A
  • a decrease in HR that comes after a contraction starts

- it is caused by placental insufficiency and fetal hypoxia

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38
Q

What are variable decelerations?

A
  • decreases in HR that have no association with contractions

- caused by umbilical cord compression, which raises peripheral resistance and BP, triggering a reflexive bradycardia

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39
Q

What is meant by “lightening”?

A

this is a physiologic change that occurs before labor and describes fetal descent into the pelvic brim

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40
Q

What is meant by “bloody show”?

A

this is a physiologic change that occurs before labor and describe passage of blood-tinged mucus from the vagina that is released with cervical effacement

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41
Q

What do each of the following parts of labor involve:

  • stage 1
  • latent phase
  • active phase
  • stage 2
  • stage 3
A
  • stage 1: onset of labor to full cervical dilation
  • latent phase: onset of labor to 6cm dilated
  • active phase: 6cm dilated to full dilation
  • stage 2: full dilation to child birth
  • stage 3: child birth to delivery of placenta
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42
Q

What are the seven steps of stage 2 labor?

A
  • engagement
  • descent
  • flexion
  • internal rotation
  • extension
  • external rotation
  • expulsion
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43
Q

Describe three methods of inducing labor and their mechanism of action.

A
  • prostaglandin E2 is used for cervical ripening
  • oxytocin is used for augmentation of uterine contractions
  • amniotomy promotes engagement and effacement
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44
Q

Describe the following for ectopic pregnancy:

  • risk factors
  • presentation
  • diagnosis
  • most likely location
  • management
A
  • risk factors include prior ectopic, PID, IUD, and IVF
  • it presents with pelvic pain and vaginal bleeding; patients may be hemodynamically compromised if it ruptures
  • diagnosis is made with B-hCG and an ultrasound to identify the extrauterine pregnancy
  • it most commonly occurs in the ampulla of the fallopian tube
  • if it ruptures, patients require surgery, but if it has yet to rupture, patients can attempt medical management with methotrexate first (with some exceptions)
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45
Q

Describe the management of ectopic pregnancy.

A
  • start by getting a B-hCG and US to make the diagnosis
  • for ruptured ectopics, patients need hemodynamic support and surgery
  • for unruptured ectopics less than 3.5 cm with no heartbeat and no other contraindications, methotrexate can be used for medical management
  • after MTX, patients should have B-hCG monitored; if a decrease of 15% is not seen by day 7, an additional dose of MTX can be given
  • surgery is indicated in these patients after 2 failed attempts at medical management
  • in all patients, continue to follow B-hCG level to 0
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46
Q

Which patients with ectopic pregnancy are candidates for methotrexate?

A

must meet all of the following criteria:

  • unruptured ectopic and hemodynamically stable
  • no pre-existing immunodeficiency or liver disease
  • ectopic is less than 3.5cm and without heart beat
  • not breastfeeding or with a co-existing viable pregnancy
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47
Q

What is the most common cause of spontaneous abortion? What are other potential causes?

A
  • the most common is chromosomal abnormality
  • other causes include anatomic abnormalities, uncontrolled thyroid dysfunction or DM, SLE and antiphospholipid syndrome, infections, and trauma
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48
Q

What testing should be done at the time of suspect spontaneous abortion?

A
  • get a CBC to evaluate blood loss
  • get a blood type and Rh screen
  • do an ultrasound and perform a digital exam
49
Q

Describe each of the following:

  • threatened abortion
  • inevitable abortion
  • incomplete abortion
  • complete abortion
  • missed abortion
A
  • threatened abortion: bleeding but products of conception are intact and the os is closed
  • inevitable abortion: bleeding with open os; products of conception still intact
  • incomplete abortion: bleeding with open os and some products of conception found
  • complete abortion: no products of conception found and os has closed
  • missed abortion: products of conception present, os is closed, but fetus has died
50
Q

How are the various types of spontaneous abortion treated?

A
  • threatened: bed and pelvic rest
  • inevitable: medical or D/C
  • incomplete: medical or D/C
  • complete: office follow up
  • missed: medical or D/C
  • septic: D/C and IV antibiotics
51
Q

What is the management of septic abortion?

A
  • perform a D/C to evacuate the uterine contents

- give IV antibiotics: cefoxitin plus doxy or clinda plus gentamycin

52
Q

What medication is used for medical abortion?

A

misoprostol, a PGE1 analog

53
Q

What role do methotrexate, mifepristone, and misoprostol play in pregnancy?

A
  • methotrexate is used for termination of ectopic pregnancies
  • mifepristone is used in combination with misoprostol for spontaneous or elective abortion of intrauterine pregnancy
54
Q

How is recurrent fetal loss defined?

A

as more than 3 consecutive miscarriages

55
Q

What are the four major complications of multiple gestations?

A
  • premature labor and delivery
  • spontaneous abortion of one fetus
  • placental abruption
  • anemia
56
Q

What are the risk factors for preterm labor?

A
  • PROM
  • multiple gestations
  • previous history of preterm labor
  • placental abruption
  • chorioamnionitis
  • pre-eclampsia
  • uterine anatomical abnormalities
57
Q

How is preterm labor managed?

A
  • 34-37 weeks: give betamethasone and deliver
  • 32-34 weeks: give betamethasone and CCB for tocolysis
  • < 32 weeks: give betamethasone, magnesium, and indomethacin for tocolysis
58
Q

What are the two major tocolytics and what are their side effects?

A
  • calcium channel blockers cause headache, flushing, and dizziness
  • terbutaline causes palpitations and hypotension
59
Q

How is rupture of membranes diagnosed?

A
  • should do an exam, looking for fluid in the posterior fornix
  • do a nitrazine test, which should turn the paper blue
  • plate the fluid and look for ferning
  • perform an ultrasound to look for decreased amniotic fluid volume
60
Q

What is prolonged rupture of membranes?

A

rupture of membranes more than 24 hours before delivery

61
Q

Prelabor rupture of membranes is associated with what four complications?

A
  • preterm labor
  • cord prolapse
  • placental abruption
  • chorioamnionitis
62
Q

What is prelabor rupture of membranes? How is it further classified, diagnosed, and managed?

A
  • prelabor rupture of membranes is that which occurs before the onset of labor
  • it can be classified as preterm if occurring before 37 weeks gestation and as prolonged if occurring more than 24 hours before the onset of labor
  • it is diagnosed by finding fluid in the posterior fornix that is nitrazine blue positive, displays ferning, and is accompanied by a low amniotic fluid index
  • the first step in management is to avoid multiple digital exams to reduce the rate of infection
  • if the fetus is term, wait 6-12 hours for spontaneous labor and then induce
  • if the fetus is preterm, give betamethasone, tocolytics, ampicillin, and azithromycin
63
Q

Which antibiotics are used as prophylaxis in those with prolonged or preterm premature rupture of membranes?

A
  • ampicillin and azithromycin are preferred
  • for low risk penicillin allergy, use cefazolin and azithromycin
  • for high risk penicillin allergy, use clindamycin and azithromycin
64
Q

Describe the etiology, presentation, and treatment of chorioamnionitis.

A
  • it is most often polymicrobial, involving vaginal flora
  • it presents with maternal fever and leukocytosis, maternal and fetal tachycardia, and uterine tenderness
  • it is managed with delivery and antibiotics
  • give ampicillin and gentamicin for vaginal delivery and add clindamycin for c-section
65
Q

What antibiotics are used for chorioamnionitis prophylaxis and for treatment?

A
  • prophylaxis: first-line is ampicillin and azithromycin (switch ampicillin to cefazolin or clindamycin for PCN allergy)
  • treatment: use ampicillin and gentamicin for vaginal delivery; add clindamycin for c-section
66
Q

Describe the presentation and management of placenta previa.

A
  • it presents as painless third trimester bleeding
  • digital exams are contraindicated so start with a transabdominal ultrasound followed by a transvaginal ultrasound
  • in most cases treatment is strict pelvic rest with nothing in the vagina and scheduled c-section for 36-38 weeks
  • immediate c-section is indicated for severe hemorrhage, fetal distress, and unstoppable labor (>4 cm cervical dilation)
67
Q

What is a velamentous umbilical cord?

A

one in which the umbilical vessels lack the protective layer of Wharton jelly close to the placental insertion

68
Q

Describe the presentation and treatment of vasa previa.

A
  • patients present with heavy vaginal bleeding at the time of rupture of membranes
  • all patients should undergo emergent c-section
69
Q

Describe the presentation and treatment of umbilical cord prolapse.

A
  • it present with sudden onset fetal bradycardia or variable decelerations and a palpable umbilical cord on vaginal exam
  • treatment involves manually elevating the presenting part followed by emergent c-section
70
Q

What are the three different types of placental invasion?

A
  • accreta: attaches to the superficial uterine wall
  • increta: inserts into the myometrium
  • percreta: penetrates into the uterine serosa
71
Q

Describe the presentation and management of placental invasion.

A
  • presents with difficulty delivery the placenta and significant postpartum hemorrhage
  • patients often require hysterectomy to control the bleeding
72
Q

Describe the risk factors, presentation, diagnosis and treatment of placental abruption.

A
  • risk factors include maternal hypertension, cocaine use, and smoking; external trauma; and prior abruption
  • presents with painful third-trimester bleeding
  • differential includes placenta previa so delay digital exam until transabdominal ultrasound has been performed
  • vaginal delivery is indicated for limited placental separation and a reassuring fetal heart tracing or if fetal demise has already occurred
  • c-section is indicated for uncontrollable hemorrhage, fetal distress, or rapid placental separation
73
Q

Describe the risk factors, presentation, and management of uterine rupture.

A
  • risk increases with uterine over distention, placenta percreta, prior uterine surgery, and trauma
  • presents with sudden onset of extreme pain and loss of fetal station
  • treat with immediate laparotomy for delivery and uterine repair
74
Q

How should delivery be managed if patients have a history of classical cesarean or uterine rupture?

A

these patients are always delivered via c-section at 36 weeks

75
Q

How does Rh incompatibility manifest in a sensitized woman?

A

during subsequent pregnancies, antibody production leads to fetal anemia, hepatosplenomegaly from extramedullary hematopoiesis, elevated bilirubin levels, and erythroblastosis fetalis

76
Q

How is Rh incompatibility managed during pregnancy?

A
  • Rh antibody screening is done during the initial prenatal visit and a Rh antibody titer is then done for Rh- women
  • RhoGAM is then given routinely to unsensitized Rh- women at 28 weeks gestation, the time of delivery or abortion, and any time procedures or vaginal bleeding occur
77
Q

What does a Rh antibody titer greater than 1:8 indicate in terms of management?

A
  • that is a titer which is likely to cause significant fetal anemia so monitoring is necessary
  • greater than 1:32, however, suggests severe anemia and an amniocentesis should be performed
78
Q

How is IUGR defined and what are the two types?

A
  • IUGR is defined as a weight in the bottom 10%
  • symmetric is that in which the brain is proportional to the rest of the body; it occurs before 20 weeks and is caused by intrinsic factors like genetic issues or fetal infection
  • asymmetric is that in which brain size is not decreased; it occurs; it usually presents after 20 weeks and is caused by extrinsic factors like utter-placental insufficiency
79
Q

What is the most common preventable cause of IUGR in the US?

A

smoking

80
Q

How are IUGR and macrosomia defined?

A
  • IUGR is weight less than the tenth percentile

- macrosomia is weight greater than 4,500g

81
Q

Describe the diagnosis, potential complications, and treatment of macrosomia.

A
  • the diagnosis is suggested by a fundal height more than 3 cm the gestational age and should be confirmed with an ultrasound
  • complications include birth injury including shoulder dystocia, hypoglycemia, and low apgar scores
  • labor should be induced if the fetus’ lungs are mature before reaching 4500g
  • otherwise, c-section is indicated for weight more than 4500g in diabetic mothers and more than 5000g in all others
82
Q

What is suggested weight gain during pregnancy?

A
  • for BMI < 18.5: 28-40 pounds
  • for BMI 18.5-24.9: 25-35 pounds
  • for BMI 25-29.9: 15-25 pounds
  • for BMI > 30: 10-20 pounds
83
Q

How should hyperemesis gravidarum be managed?

A
  1. avoidance of triggers, ginger, B6
  2. antihistamines, doxylamine and diphenhydramine
  3. metoclopramide
  4. ondansetron
84
Q

When do we screen for asymptomatic bacteriuria and how is it treated in pregnancy?

A
  • screen between 12-16 weeks go gestation

- treat with nitrofurantoin, amoxicillin, or cephalexin

85
Q

Why is trimethoprim-sulfamethoxazole avoided during pregnancy?

A

because it is a folic acid antagonist

86
Q

How are asymptomatic bacteriuria, acute cystitis, and acute pyelonephritis treated in pregnancy?

A
  • asymptomatic bacteriuria: nitrofurantoin, amoxicillin, or cephalexin
  • acute cystitis: nitrofurantoin
  • pyelonephritis: hospitalize, start IV ceftriaxone, and gather urine cultures monthly
87
Q

Describe the workup for pulmonary embolism in pregnancy.

A
  • if leg symptoms are present, get a doppler and if this is positive, treat for PE
  • if leg symptoms are absent or dopplers are negative, get a CXR
  • if CXR is normal, get a V/Q scan (preferred diagnostic tool)
  • if CXR is abnormal or V/Q is indeterminate, get a CTA
88
Q

What is the best diagnostic test for PE in pregnancy? How should it be treated?

A
  • V/Q scan is the best diagnostic test but CTA should follow if it is indeterminate
  • treat with low-molecular weight heparin; stop 24 hours prior to delivery if scheduled; resume 6 hours after vaginal delivery and 12 after c-section
  • continue LMWH for 6 weeks postpartum
89
Q

What is the only aspect of cervical cancer screening and diagnosis that differs during pregnancy?

A

in pregnant patients, endocervical curettage is contraindicated; everything else is unchanged

90
Q

What is polymorphic eruption of pregnancy, also known as papule and plaques of pregnancy?

A
  • a pruritic rash that presents as erythematous papule within striae that spread outward to form urticarial plaques and spares the face, palms, and soles
  • it is usually seen after 35 weeks gestation or in the postpartum period
  • treat with topical corticosteroids for pruritus but it is self-limited and benign
91
Q

Describe the presentation, diagnosis, and treatment of cholestasis of pregnancy.

A
  • presents as pruritus in the absence of rash, predominately in the palms and soles that is worse at night
  • labs demonstrate elevated bile acids to confirm the diagnosis
  • treat with ursodeoxycholic acid and induction of labor at term
92
Q

Describe the presentation, diagnosis, and treatment of acute fatty liver of pregnancy.

A
  • presents with nausea, vomiting, abdominal pain, malaise, anorexia, and jaundice
  • LFTs and WBC counts may be elevated with depressed platelet count similar to HELLP; however, signs of hepatic insufficiency and coagulation abnormalities help distinguish it
  • liver biopsy is the gold standard but this is rarely done for diagnosis
  • treat with immediate induction of labor
93
Q

What differentiates chronic hypertension in pregnancy from gestational hypertension?

A
  • chronic hypertension is that which exists prior to pregnancy or before 20 weeks of gestation
  • gestational hypertension is that which arises after 20 weeks gestation
94
Q

What are the three agents used to control hypertension during pregnancy?

A

labetalol, nifedipine, and methyldopa

95
Q

How are pre-eclampsia and pre-eclampsia with severe features defined?

A
  • pre-eclampsia is defined as blood pressure greater than 140/90 with greater than 300mg protein in 24-hour catch
  • pre-eclampsia with severe features does not require proteinuria but instead has BP greater than 160/110, visual disturbance, RUQ pain, altered mental status, creatinine greater than 1.1, or pulmonary edema
96
Q

How is pre-eclampsia managed?

A
  • without severe features, term babies can be delivered and preterm should be given betamethasone and magnesium sulfate
  • for severe features, start with magnesium sulfate for seizure prophylaxis and labetalol or hydralazine for blood pressure control, then deliver at 34 weeks
97
Q

What is eclampsia and how is it treated?

A
  • it is defined as preeclampsia with at least one tonic-clonic seizure
  • stabilize the mother, deliver the baby, control BP with hydralazine, and give magnesium for seizure control
98
Q

What is HELLP and how is it treated?

A
  • it is a syndrome of HTN, hemolysis, elevated liver enzymes, and low platelet counts
  • treatment is the same as for eclampsia: hydralazine, magnesium, and delivery of the baby
99
Q

What complications are associated with gestational diabetes and diabetes in pregnancy?

A
  • pre-eclampsia
  • preterm labor
  • spontaneous abortion
  • infection
  • post-partum hemorrhage
  • heart and neural tube defects
  • macrosomia and brith injury
  • neonatal hypoglycemia
100
Q

Those with diabetes prior to pregnancy should undergo what additional evaluations once pregnant?

A
  • ECG
  • 24-hour urine creatinine and protein
  • HbA1c
  • ophthalmological exam
101
Q

What causes neonatal hypoglycemia in infants with diabetic mothers?

A

these babies produce increased insulin because they live in an environment of hyperglycemia; at birth insulin remains high despite withdrawal of the mother’s glucose levels and hypoglycemia results

102
Q

What causes gestational diabetes?

A

human placental lactose which shares structure with insulin and decreases maternal insulin sensitivity

103
Q

What is considered a positive glucose challenge? What follow up test should pregnant women undergo and what is considered a positive?

A
  • a positive test is glucose greater than 130 at one hour
  • these patients should then undergo a three hour glucose tolerance test
  • the GTT is positive if two or more values are elevated
104
Q

How is gestational diabetes treated?

A
  • never recommend weight loss
  • instead, first line therapy is a diabetic diet and exercise
  • insulin is the gold standard if this fails, but metformin and glyburide are safe alternatives
105
Q

What thyroid related molecules cross the placenta?

A
  • TRH and immunoglobulins against the TSH receptor

- TSH and free T4 do NOT

106
Q

What physiologic changes in thyroid function are expected during pregnancy?

A
  • an increase in serum TBG increases the total amount of circulating thyroxine but does not alter free levels
  • B-hCG stimulates the TSH receptor
107
Q

How is hyperthyroidism treated during pregnancy?

A
  • use PTU in the first trimester

- switch to methimazole for the second and third

108
Q

Define arrest of cervical dilation and arrest of descent.

A
  • arrest of cervical dilation is defined by failure to dilate after 2 hours during the active phase of stage 1 labor
  • arrest of descent is defined by failure of the fetal head to move down into the birth canal with 1 hour of pushing
109
Q

What is prolonged latent stage and how is it treated?

A
  • defined as a latent stage lasting more than 20 hours in primipara or 14 hours in multipara
  • treatment is rest and hydration as most will convert to spontaneous delivery
110
Q

What is protracted cervical dilation and how is it treated?

A
  • defined as failure of the cervix to dilate more than 1cm in nulliparous patients or more than 1.2-1.5cm in multiparous women during the active phase of stage 1 labor
  • if the cause is cephalopelvic disproportion, the treatment is c-section
  • if the cause is weak contractions (<200MVU/10min), oxytocin should be given
111
Q

What is the difference between a frank, complete, and footling breech?

A
  • frank is when the hips are flexed and the knees are extended
  • complete is when the hips and knees are both flexed
  • footling is when the fetus has at least one foot first
112
Q

How is malpresentation diagnosed and managed?

A
  • the Leopold maneuvers and vaginal exam are used to screen for malpresentation
  • diagnosis must be confirmed by ultrasound
  • then offer external cephalic version starting at 37 weeks
113
Q

Describe the most common etiology, presentation, and treatment for uterine inversion.

A
  • most often secondary to excessive umbilical cord traction and fundal pressure during stage 3 labor
  • presents with pain, vaginal bleeding, and a smooth round mass protruding through the cervix
  • treatment begins by stopping all uterotonic drugs and attempting to manually reposition the uterus; if needed, uterine relaxing agents like terbutaline, nitroglycerine, and magnesium can be used to help with repositioning
  • if all else fails, perform a laparotomy to reposition it
114
Q

How is lactational mastitis treated?

A
  • give antibiotics: dicloxacillin or cephalexin
  • use cold compresses and anti-inflammatories
  • continue breast feeding
115
Q

How is postpartum hemorrhage defined?

A

more than 1L of blood loss or bleeding with signs and symptoms of hypovolemia in the first 24-hours post-partum

116
Q

What are the most common etiologies for postpartum hemorrhage?

A
  • uterine atony, usually secondary to over distention, anesthesia, or prolonged labor
  • may also be due to retained placenta or coagulopathy
117
Q

How is postpartum hemorrhage managed?

A
  • start with exam to ensure there is no uterine rupture or retained placenta
  • then perform bimanual compression and massage
  • can use oxytocin if needed to augment uterine tone
118
Q

What are the benefits of breast feeding?

A
  • enhances infant GI function
  • decreases risk of infant infection
  • increases rate of maternal recovery
  • reduces maternal and neonatal stress
  • improves rate of maternal weight loss
  • reduces risk of maternal DM, cardiovascular disease, and breast, ovarian, and endometrial cancer
119
Q

What are six contraindications to breast feeding?

A
  • maternal HIV/HTLV-1
  • maternal active TB
  • maternal herpes lesion on breast
  • maternal use of cytotoxic medications
  • maternal substance use disorder
  • fetal galactosemia

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