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1

Define 3 stages of labor

Labor - cervical changes and regular uterine contractions (firm, every 2-3 min, last up to 60 sec, nl intensity > 40 mm Hg and nl sum total of >200 montevideo units in 10 min interval)

1st stage - onset until full cervical dilation
A. latent - cervix effaces (thins) until dilation of 6 cm
- can be up to 20 hours in nulli, 14 hrs in multip
* if prolonged - NOT an indication for C-section, give pitocin

B. active - more rapid dilation until 10 cm; 1.2 cm/hr in nulli, 1.5 cm/hr in multip
* arrest of active phase if ROM with no progress for 4 hours (w ctx) or 6 hrs (w/out ctx) --> amniotomy, then C-section

2nd stage - 10 cm to delivery of baby
- 3 hours - nulli w epidural
- 2 hours - nulli w/out epi
- 2 hours - multip w epidural
- 1 hour - multip w/out epi
*MCC of arrested second stage is fetal malposition (optimal is occiput anterior); manage with operative vaginal delivery (forceps / vacuum)

3rd stage - delivery until placenta is delivered
- less than 30 min (if longer, try manual extraction)
- bloody show, uterus becomes firm and globular and rises in abdomen, and umbilical cord lengthens

2

Fetal heart rate monitoring - categories

Fetal heart rate monitoring

Category I - reassuring --> normal baseline and variability, no late or variable decelerations, reactive (2 accelerations of 15+ bpm that last for 15 seconds over a 20 min period)

Category II - represents majority; concerning but not ominous eg tachycardia w/out decelerations
- if minimal variability (non-reactive) - scalp stimulation should induce an acceleration (indicates normal umbilical cord pH >7.2)
- if nonreassuring - fetal scalp electrode to directly measure FHR

Category III - ominous - indicates hypoxia or acidosis e.g. absent baseline variability + recurrent late or variable decelerations, or sinusoidal HR pattern (indicates fetal anemia), or prolonged bradycardia
*indication for C-section if intrauterine resuscitation maneuvers do not work

3

When to do C-section
Cardinal movements of labor

NO trial of labor with:
- active herpes
- prior classical C-section with vertical incision
- prior abdominal myomectomy with uterine cavity entry
- placenta previa
- vasa previa
- HIV with viral load >1000
- transverse lie / breech presentation

Cardinal movements of labor - engagement, descent, flexion, internal rotation, extension, external rotation

4

Fetal orientation
1. Lie
2. Presentation
3. Posture / attitude
4. Position

Fetal orientation - can do Leopold maneuvers or U/S to determine

1. Lie - transverse, longitudinal, or oblique

2. Presentation
A. Long - cephalic (compound, face, brow, vertex, ideal) or breech (complete, frank, footlong)
B. Transverse - shoulder presents --> C-section
C. Incomplete - leg coming out

3. Posture / attitude - fetus folds so back is convex, arms crossed, necks flexed

4. Position - relationship of fetus to R or L side
- Vertex - occiput anterior e.g. ROA, OA, LOA ideal, malposition is OT or OP
- Face - chin --> must be mentum anterior for NSVD
- Breech - sacrum

*mentum posterior of cephalic face presentation --> will NOT deliver vaginally

5

Bishop score - components

Bishop score - >8 --> cervix favorable for spontaneous and induced labor

1. Dilation - how open the internal os of the cervix is
- 10 cm is fully dilated

2. Effacement - length of the cervix from internal to external os (normal is ~4 cm)
- 2 cm is 50% effaced
- as thin as lower uterine segment is 100% effacted

3. Station - relation of fetal head to ischial spines of pelvis
- level of pelvic outlet is +3 station

4. Consistency of cervix - firm, medium soft

5. Position of cervix - posterior, middle, anterior

*labor - cervix goes to soft and anterior

6

Differential and workup for anemia in pregnancy
1. Microcytic
2. Macrocytic
3. Normocytic

Anemia in pregnancy - Hb < 11 in 1st and 3rd trimesters, 10.5 g/dL in 2nd trimester (<12 in nonpregnant women)

1. Microcytic
A. iron deficiency - therapeutic trial of iron, recheck Hb in 3 weeks
- then evaluation iron stores, Hb electrophoresis

B. Hemoglobinopathies - do Hb electrophoresis
- B thalassemia minor - elevated HbA2 and HbF--> prophylactic folate
- A thalassemia - trait is normal eletrophoresis, ferritin; can have HbH or HbBart's
- sickle cell trait (50% HbS) vs disease (almost 99% HbS)

2. Macrocytic - vitamin B12 and folate deficiency --> MCC is folate

3. Normocytic
A. G6PD deficiency - triggered by nitrofurantoin, sulfa drugs --> jaundice, fatigue, bilirubinuria

B. HELLP - hemolysis, elevated liver enzymes, low platelets

C. Consider bone marrow process (leukemia) if other cell lines eg WBC, platelets also decreased
- do bone marrow bx

D. Anemia of pregnancy - increased demands for iron due to fetus need and expanded maternal blood volume (increase in plasma >> increase in RBC)

7

Uterine inversion
1. Risk factors
2. Etiology
3. What to do if it happens

Uterine inversion - need to deliver placenta within 30 min in 3rd stage of labor

1. Risk factors - placenta implanted in fundus, placenta accreta

2. Etiology - massive hemorrhage bc uterine atony --> myometrial fibers do not exert tourniquet on spiral arteries --> placental bed pours out blood

3. What to do if it happens - fluid resuscitation
- reduce the uterus
- if initial attempt is unsuccessful, use relaxation agents (halothane, terbutaline, mag sulfate) then try again to reduce the uterus
- then give uterotonic agents (e.g. oxytocin) to prevent it from coming out again
- if unsuccessful, laparotomy

8

Shoulder dystocia
1. Risk factors
2. Management
3. Complications

Shoulder dystocia - impaction of anterior shoulder behind symphysis pubis
*cannot be predicted or prevented in majority of cases

1. Risk factors - prior shoulder dystocia, fetal macrosomia, maternal gestational diabetes, maternal obesity, prolonged 2nd stage labor
- "turtle sign" - head retracts towards perineum

2. Mgmt - need to deliver < 5 min to avoid compression of umbilical cord
A. Maneuvers
- McRoberts (flex maternal thighs to straighten the sacrum and rotate symphysis pubis)
- apply suprapubic pressure (move fetal shoulder from AP to oblique plane)
B. Episiotomy
C. Fracturing fetal clavicle
D. Put infants head back in pelvis and C-section

3. Neonatal complications - 90% cases have none
- fractured clavicle or humerus (decreased Moro, intact biceps/grasp reflexes); hypoxia
- Erb palsy (C5-C6) --> Affects deltoid, infraspinatus --> arm internally rotated, pronated "waiter's tip sign"; most spontaneously recover
- Klumke Palsy (C8-T1) --> "claw hand" with absent grasp (intact Moro/biceps reflexes), Horner's syndrome
- maternal complication - PPH, vaginal lacerations

9

Umbilical cord prolapse
1. Risk factors
2. Management
3. Neonatal complications

*DDx for fetal bradycardia

Umbilical cord prolapse - cord protrudes through cervical os

1. Risk factors - unengaged fetal head (-3, -2, -1 station), footlong breech, transverse fetal lie
*engagement - largest diameter of fetal head has negotiated pelvic inlet (0 station)
*do not do AROM with unengaged presentation

2. Management -
- digital exam for cord through cervical os (pulsating)
- elevate the presenting part (trendelenberg)
- immediate C-section

3. Neonatal complications - sustained fetal bradycardia post AROM (<110 bpm for >10 min) --> take maternal pulse first to differentiate fetal pulse from mom's
- improve maternal 02 (100% face mask)
- place patient on side to move uterus from great vessels --> improve blood return
- IVF bolus
- stop oxytocin

*DDx for fetal brady --> cord prolapse, uterine rupture, uterine hyperstimulation 2/2 misoprostol

10

Uterine atony

1. Risk factors
2. Management
3. DDx

Uterine atony - myometrium does not contract to cut off uterine spiral arteries supplying placental bed "boggy uterus" --> MCC of early PPH (>500 cc blood loss in NSVD and >1000 cc in C-section)
*can exsanguinate in 10-15 min!

1. Risk factors
- magnesium sulfate (for preeclampsia)
- rapid OR prolonged labor/delivery
- prolonged oxytocin stimulation (hyponatermia, hypotension, tachysystole)
- chorioamnionitis
- high parity
- uterine overdistension (macrosomia, multis, hydramnios)

2. Management
- ABCs
- palpate uterine fundus --> if boggy --> oxytocin and bimanual massage
- uterotonic agents --> rectal misoprostol / Cytotec, ergot alkaloid eg Methergine (c/i in HTN), prostaglandin F2ef eg carboprost / Hemabate (c/i in asthma)
- if bleeding continues --> large bore IVs, foleys, blood; Bakri balloon, OR for embolization/ligation of uterine arteries or compression stitches (B-lynch) or hysterectomy

3. DDx - if there is PPH but uterus is firm --> Suspect laceration to genital tract

11

Postpartum hemorrhage - causes
1. Early
2. Late

PPH

1. Early PPH - <24 hours
- MCC is uterine atony
- genital tract laceration
- uterine inversion
- placenta accreta, increta, percreta (can do MRI to dx)
- retained placenta
- coagulopathy

2. Late - >24 hours
- subinvolution of placental state (~2 weeks PP) --> eschar falls off and leads to bleeding; give uterotonic agent
- uterine atony 2/2 retained products conception --> uterine cramping bleeding --> D and C
- infection eg endometritis - uterine fundal tenderness, fever, foul smelling lochia

12

Serum screening in pregnancy - first and second trimester

1. DDx elevated msAFP
2. DDx decreased msAFP
3. Serum levels associated with:
A. Trisomy 21
B. Trisomy 18
C. Trisomy 13
4. Mgmt

Serum screening: >2 MOM are considered elevated
- first trimester in weeks 11 - 14: PAPPA, bhCG, nuchal translucency
- second trimester screening in weeks 15-20:
---- triple screen - msAFP, estriol, bHCG
---- quad screen - msAFP, estriol, bHCG, inhibin A

1. DDx elevated msAFP - underestimating gestational age (MCC), multis, defects of skin, abd wall, or neural tube; olighydramnios, cystic hygroma, decreased maternal weight, fetal demise

2. DDx decreased msAFP - overestimation of gestational age (MCC), trisomies, molar pregnancy, increased maternal weight

3. Serum levels associated with:
A. Trisomy 21 - ↓ PAPPA, ↑ bhCG, ↑ Inhibin A, ↓ AFP, ↓ estriol
B. Trisomy 18 - ↓ PAPPA, ↓ bhCG, ↓ Inhibin A, ↓ AFP, ↓ estriol
C. Trisomy 13 (holoprosencephaly, cleft lip, polydacyly, club foot) - results are variable and not generally reported

4. Mgmt - do U/S to determine correct gestational age, look for multis or NT defects, exclude fetal demise

13

Twins
1. Monozygotic - timing of division and chorion/amnion
2. Dizygotic
3. Maternal complication
4. Neonatal complications

Twins
1. Monozygotic - timing of division and amnion (innermost placenta), chorion (outer membrane)
A. first 72 hours ie 3 days (morula) --> dichorionic / diamniotic
B. Days 4-8 (blastocyst) --> monochorionic / diamniotic
C. Days 8-12 (implanted) --> monochorionic / monoamniotic
D. After day 13 --> conjoined twins

2. Dizygotic - fertilization of two eggs by two sperms
- incidence ↑ with maternal age, fertility tx
- dichorionic / diamniotic

3. Maternal complication - preeclampsia, GDM, anemia, DVT, PPH, and C-section more common

4. Neonatal complications - preterm delivery, stillbirth, placenta previa
- twin-twin transfusion syndrome (TTTS - one twin has polyhydramnios, polycythemia and other has IUGR, oligohydramnios --> need laser ablation)

14

HSV infections
1. Primary infection
2. Nonprimary first episode infection
3. Recurrent infection
4. Mgmt in pregnant women with HSV
5. Neonatal herpes

HSV infections - HSV1 (labialis) and 2 (genitals) --> dx via PCR

1. Primary infection - no HSV Ab
- clinical: asx, local sx (burning, herpetic lesions), systemic sx (malaise, fever, n/v), can have urinary retention 2/2 lumbosacral neuropathy
- lesions last ~ 2 weeks

2. Nonprimary first episode infection - first infection HSV2 in pt who has IgG HSV1
- milder sx and less duration than primary

3. Recurrent infection - no systemic sx, lesions last ~9 days, usually with decreasing recurrence over time
- can also have asymptomatic viral shedding

4. Mgmt in pregnant women with HSV - offer oral acyclovir at 36 wks for pt with first episode or recurrence
- no lesions or prodromal sx --> NSVD
- lesions or burning/itching/tingling --> offer C-section

5. Neonatal herpes - encephalitis, herpetic lesions of eyes/skin/mucosa, or asx
- transmission MC due to asx viral shedding during primary or nonprimary first episode at term (mother has no HSV hx)

15

Antepartum bleeding
Risk factors, clinical presentation, and mgmt for:
1. Placenta previa
2. Placental abruption
3. Vasa previa

Antepartum bleeding - vaginal bleeding post 20 weeks gestation

1. Placenta previa - placenta < 2 cm from cervical os
A. Risk factors - multis, prior C-section, prior D and C, prior previa
- previa increases risk of placenta accreta
B. Clinical - postcoital spotting, painless vaginal bleeding
C. Mgmt - if preterm, pelvic rest and repeat TVUS at term; if there is still previa at term --> pelvic rest, C-section @ 34-37 weeks

2. Placental abruption - placenta detaches from uterus
A. Risk factors - HTN, prior abruption, short cord, trauma (eg MVA), cocaine use, submucosal leiomyomata, hydramnios, smoking, PPROM
B. Clinical - painful vaginal bleeding, Couvelaire uterus (bleed into myometrium), firm tender uterus
- blood clot adherent to placenta, can lead to coagulopathy (DIC) 2/2 hypofibrinogenemia
C. Mgmt - clinical diagnosis, US to r/o previa
- C-section, unless there is fetal demise --> vaginal delivery

3. Vasa previa - umbilical vessels cross internal os in front of fetal presenting part
A. Risk factors - velamentous cord insertion, placenta with accessory lobes, IVF babies, or multis
B. Clinical - sinusoidal FHR (due to fetal anemia) --> fetus can exsanguinate on ROM (abrupt sustained fetal bradycardia)
C. Mgmt -
- diagnose via color Doppler US (middle cerebral artery peak systolic velocity)
- Apt test for fetal nucleated RBCs (determine fetal vs maternal hemorrhage)
- C-section prior to ROM (~35 weeks gestation)

16

Ectopic pregnancy
1. Risk factors
2. Clinical
3. Mgmt

Ectopic pregnancy - embryo implants not in uterine lining, MC in fallopian tube ampulla

1. Risk factors - prior ectopic, IVF, IUD, prior tubal sx (adhesions), PID, endometriosis, DES-exposed, smoking

2. Clinical - triad: amenorrhea, unilateral pelvic or lower abdominal pain, irregular vaginal bleeding
- palpable tender adnexal mass
- bHCG does not increase appropriately (2x) after 48 hrs
- if ruptured - hypotensive, tachycardic, peritoneal, fever

3. Mgmt - do US (need bHCG > 2000 to visualize IUP)
A. If unruptured -- methotrexate
B. If ruptured (erodes through tissue --> hemorrhage from exposed vessels) -- pelvic US, stabilize (ABCs), and OR for ex lap to coagulate bleeding and resect ectopic
C. if stable and r/o ectopic -- can follow bHCG (should double every 48 hrs)

17

Spontaneous abortion
1. Risk factors
2. Clinical
3. Mgmt


Spontaneous abortion i.e. miscarriage - pregnancy that ends prior to 20 weeks gestation
- can be complete, incomplete (partial expulsion), inevitable (no expulsion but bleeding), threatened (normal but bleeding), or missed (no expulsion and not bleeding)

1. Risk factors -
- first trimester - due to abnormal chromosomes (most commonly autosomal trisomies due to failures in maternal gametogenesis)
- second trimester - due to infection, anatomic defects, exposure to teratogens, trauma

2. Clinical - vaginal bleeding, cramping, abdominal pain, decreased symptoms of pregnancy

3. Mgmt - give Rhogam if mom is Rh (-), use Kleihauer - Betke test to see how many fetal nucleated RBCs are to dose the rhogam
- threatened (normal pregnancy with bleeding) - pelvic rest
- incomplete, inevitable, missed - medical (misoprostol) or surgical (D and C or Dand E or inducing labor with pitocin and PGEs)
*need to r/o preterm labor and incompetent cervix in second trimester since they can lead to abortions

for patients w recurrent abortions --> check AP Ab (tx - aspirin + heparin), SLE, thyroid, DM, karyotypes

18

Incompetent cervix (cervical insufficiency)
1. Risk factors
2. Clinical
3. Mgmt

Cervical incompetence - painless dilation and effacement of the cervix, MC in 2nd trimester
*preterm labor is d,e with ctx

1. Risk factors - surgery e.g. D and C, LEEP, conization; uterine anomalies, DES exposure, hx of cervical lacerations with vaginal delivery

2. Clinical - lower abdominal cramping or contractions
- vaginal bleeding --> amniotic sac bulging through cervix --> exposure to vaginal flora --> fever / infection, vaginal discharge, ROM
* "funneled lower uterine segment" on U/S

3. Mgmt - do TVUS to look at cervix
- normal cervix and no hx PTL --> routine prenatal care
- short cervix (<2.5 cm) and no hx PTL --> vaginal progesterone
- normal cervix and hx PTL --> serial TVUS (q2wks) until 24 wks
- short cervix (<2 cm) and hx PTL --> cerclage at 12-14 weeks, serial TVUS (q2 wks) until 24 wks
* give betamethasone from 24 - 37 weeks

19

DDx for abdominal pain in pregnancy
A. Timing
B. Clinical
C. Mgmt

DDx for abdominal pain in pregnancy:

1. Appendicitis - any time, in RUQ (NOT RLQ), tx is surgery regardless of gestational age + abx

2. Cholecystitis - after 1st trim, RUQ dx via U/S, tx is surgery

3. Ovarian torsion - ~14 weeks or after delivery, acute onset n/v and colicky pain, see complex adnexal mass w/out Doppler flow on US
- tx - lap detorsion, cystectomy, or oophorectomy if necrosis

4. Ectopic - in 1st trim, u/l pelvic pain and spotting, track bHCG (<2x ↑ in 48 hrs), tx is methotrexate or sx

5. Ruptured corpus luteum (secretes E and P to maximize endometrial implantation) - in 1st trim, sudden onset lower abdominal pain + peritoneal signs
- U/S and laparoscopy show hemoperitoneum (pelvic free fluid)
- tx - hemostasis, cystectomy; need progesterone supplement if excised before 10 weeks gestation
*more common in bleeding d/o (vW, heparin)

6. Placental abruption - in 2nd and 3rd trims, crampy midline uterine tenderness and vaginal bleeding; tx - delivery

20

DDx for pruritus in pregnancy - clinical, mgmt
1. ICO
2. PUPPP

DDx for pruritus in pregnancy

1. Intrahepatic cholestasis of pregnancy (ICP) - generalized mild pruritus without lesions, worse at night
A. Clinical - in 3rd trimester, clinical dx of exclusion
- extremities (palms and soles) >> trunk
- normal labs initially but after several days of symptoms --> v high LFTs, ALP, Tbili - need to r/o viral hepatitis
- increased risk fetal demise with higher bile acid levels
B. Mgmt - 1st line is antihistamines, topical emollients, then ursodeoxycholic acid, delivery once fetal maturity achieved

2. Pruritic urticarial papules and plaques of pregnancy (PUPPP)
A. Clinical - pruritus and erythematous papules, begins on abdomen and spreads to thighs
- no lab abnormalities
B. Mgmt - topical steroids and antihistamines
- no adverse fetal/maternal outcomes

21

DDx for pruritus in pregnancy - clinical, mgmt
3. Pemphigoid gestationis
4. Acute fatty liver of pregnancy

3. Pemphigoid gestationis - pruritus followed by extensive patches of cutaneous erythema and then vesicles / bullae
A. Clinical - in 2nd trimester, autoimmune (IgG)
- limbs >> trunk
B. Mgmt - oral corticosteroids

4. AFLP - microvesicular steatosis
A. Clinical - RUQ pain, persistent nausea / vomiting, anorexia, progressive jaundice
- develops over weeks late in third trimester
- increased LFTs, Bili, clotting times
- decreased glucose, cholesterol, albumin, fibrinogen
- can lead to fulminant liver failure (hepatic encephalopathy)
B. Mgmt - delivery! high fetal mortality

22

Hypertensive diseases of pregnancy - define, clinical, mgmt
1. Gestational HTN
2. Chronic HTN
3. Superimposed preeclampsia

Hypertensive diseases of pregnancy - risk for maternal PPH, GDMA, placental abruption; for fetal IUGR, PTL, oligohydramnios

1. Gestational HTN - HTN w/out proteinuria at >20 weeks for at least 4 hours
- risk for IUGR, placental abruption
- deliver at 37 weeks

2. Chronic HTN - BP of 140/90 before pregnancy or <20 weeks, persisting more than 12 weeks postpartum
- antiHTN
- deliver 38-39 weeks

3. Superimposed preeclampsia - patient with chronic HTN that develops preeclampsia - new onset uncontrollable HTN, new onset proteinuria, or severe features

23

Hypertensive diseases of pregnancy - define, clinical, mgmt
4. Eclampsia
5. HELLP
6. PRES

4. Eclampsia - preeclampsia + seizures
- most commonly occur in 3rd trimester just prior to delivery, labor, or 24 hrs postpartum
- seizures can cause posterior shoulder dislocation, death due to intracerebral hemorrhage
- tx - delivery via c-section
- give mag sulfate and monitor for side effects at >8 (1st sign is hyporeflexia, also pulm edema, somnolence, muscle paralysis) --> give calcium gluconate to counteract
- give IV labetalol to control HTN
*can get hypermagnesemia with renal insufficiency (lower dose with higher Cr - so monitor urine output)

5. HELLP - microangiopathic hemolytic anemia, elevated LFTs, low platelets; affects up to 1/5 women with preeclampsia
- n/v, RUQ pain (due to liver capsule distension)
- LFTs up to 1000s, patelets <100K
- due to abnormal placentation --> systemic inflammation --> activates coagulation / complement cascades
- tx - delivery, mag sulfate, antiHTNs

6. PRES - posterior reversible encephalopathy syndrome
- headache, seizures, visual disturbances
- dx via clinical and MRI (Vasogenic edema 2/2 breakdown of BBB)
- tx - antiHTN, antiepileptics, ICU dispo

24

Hypertensive diseases of pregnancy

Preeclampsia
A. Pathophys
B. Definition - severe features
C. Risk factors
D. Mgmt
i. Stable
ii. Severe features
iii. HTN emergency

Preeclampsia

A. Pathophys - to arterial vasospasm and endothelial damage --> hypoxemia, ↑ SVR, ↓ intravascular volume 2/2 third spacing, ↓ oncotic pressure
- typically presents in late third trimester

B. Definition - HTN >140/90 measured 2x 6 hours apart AND 1 of the following:
- new onset proteinuria (>300 mg over 24 hours or urine protein:cr >0.3) at 20+ weeks gestation

OR severe features:
- thrombocytopenia (plt <100K)
- ↑ LFTs (2x nl) or persistent RUQ pain
- AKI (Cr > 1 .1)
- pulmonary edema (sudden onset DOE, crackles, hypoxia)
- new onset visual or cerebral disturbance (headache, hyperreflexia)

C. Risk factors - nulliparity, young or old, black, prior preeclampsia or family hx, chronic HTN or CKD, antiphospholipid syndrome, DM, multis
*obesity is risk factor for gestational HTN and PEC

D. Mgmt
i. Stable, uncomplicated - expectant mgmt (dont need antiHTN), deliver at 37 weeks
ii. Severe features -
<34 weeks - mag sulfate, corticosteroids (betamethasone) over 24 hrs, assess status
>34 weeks - mag sulfate and deliver
iii. HTN emergency (SP>160 or DP>110 for 15+min) or severe features - give IV labetelol, IV hydralazine (if bradycardic and HTN), or oral nifedipine to lower BP and avoid stroke; improve oxygenation
*alpha methyldopa used to treat chronic HTN (slower onset)

25

Preterm labor (vs cervical insufficiency)
1. Risk factors
2. Assessing risk
3. Management
4. Tocolytics and side effects

Preterm labor - cervical change (2 cm dilated, 80% effaced) with contractions between 20 and 37 weeks
*vs cervical insufficiency which is painless dilation

1. Risk factors - *hx of prior*, PPROM, multis, hx cervical cone biopsy, cocaine, trauma, pyelo, gonococcal cervicitis, uterine anomalies (bicornuate), placental abruption

2. Assessing risk
- fetal fibronectin (after 20 weeks) - if negative, no delivery in the next week
- TVUS to look at cervical length measurement - <25 mm = increased risk

3. Management - if no c/i --> pts at >34 weeks can be managed expectantly
- steroids (betamethasone) for <34 weeks --> tocolytics, which extend gestation by 48 hrs so you can give 2 doses steroids
- 17OHprogesterone from 16 to 36 weeks in high risk women with prior PTL
- penicillin if GBS (+)
- mag sulfate (Ca2+ competitive antagonist, membrane stabilizer) for fetal neuroprotection for <32 weeks --> hyporeflexia, flushing, HA, diplopia, respiratory depression

4. Tocolytics - decreased Ca2+ --> fewer uterine smooth muscle contractions
A. ritodrine, terbutaline (B2 agonists) - smooth muscle relaxation but can cause anxiety, hyperglycemia, hypokalemia, hypotension tachycardia, pulm edema; c/i in diabetes and terbutaline dangerous if given >48 hrs
B. nifedipine (CCB) - headache, flushing, dizziness; c/i at > 34 weeks bc risk of maternal hypotension
C. indomethacin (NSAID blocks PGE -> decreased Ca) - c/i >34 weeks bc it closes DA and can cause fetal renal failure (--> oligohydramnios --> cord compression --> FHR variable decels)

26

PPROM
1. Diagnosis tests for ROM
2. Risk factors
3. Management - based on GA (34 wks)
4. Complication - chorioamnionitis

PPROM - Preterm premature ROM prior to onset of labor at <37 weeks; prolonged if >18 hours

1. Diagnosis - gush of fluid from vagina with constant leakage
- pooling of amniotic fluid on speculum exam
- positive nitrazine test (alkaline changes of vaginal fluid)
- positive fern test (cervical mucus ferns under microscope)
- US shows oligohydramnios (single deepest pocket < 2 cm)
- Amnisure - tests placental alpha macrogolobulin 1
- tampon test - seeing if dye injected in amniotic fluid leaks into vagina

2. Risk factors - primary risk factor is genital tract infection (eg BV)
- also prior PPROM, smoking, conization, multis, hydramnios, placental abruption
- can lead to olighydramnios --> cord compression --> variable decels on FHR

3. Management - depends on gestational age
A. <34 weeks -
- no signs of infection --> abx, steroids, observe
- signs of infections --> abx, steroids, Mag (if <32), and deliver

B. > 34 weeks - delivery esp with fetal lung maturity (phosphatidyl glycerol in vaginal fluid)
- abx - ampicillin, erythromycin to prolong latency period

4. Chorioamnionitis --> maternal fever and 1+: fetal or maternal tachycardia, maternal WBC, uterine fundal tenderness, and/or malodorous vaginal discharge
- baby can be septic (pale, lethargic, high temp)
- tx - IV amp and gent and induce labor regardless of gestational age

27

Congenital intrauterine infections incl presentation, treatment:
1. Parvovirus
2. CMV
3. Toxo
4. Rubella

Congenital intrauterine infections (part of TORCHeS)

1. Parvovirus - fetal aplastic anemia (sinusoidal FHR), hydrops fetalis (excess fluid in 2+ fetal body cavities; caused by parvovirus), hydramnios
- mgmt - intrauterine transfusion, delivery

2. CMV - DNA virus, 90% of congenital CMV is asymptomatic but it is the MC congenital infection in the USA, MCC of retardation and deafness due to viral infection
- hydrops fetalis in first trimester
- microcephaly, periventricular calcifications, sensorineural hearing loss, chorioretinitis, seizures, blueberry muffin rash
- no treatment - prevent! frequent handwashing

3. Toxoplasma - CNS protozoa
- triad (hydrocephalus, intracranial calcifications, chorioretinitis) + ventriculomegaly, IUGR, deafness
- use PCR to diagnose (not serology)
- prevent with pyrimethamine, sulfadiazine
- transmitted via undercooked meats or oocytes from feces of cats

4. Rubella - triad (sensorineural deafness, cataracts, cardiac defects eg patent DA) + microcephaly, purpura / blueberry muffin rash, IUGR, jaundice
- immunize, live attenuated vaccine (give postpartum)
- increased transmission in 1st trimester

28

IUGR
1. Risk factors

2. Etiology
A. Asymmetric
B. Symmetric

3. Presentation at birth

4. Mgmt

IUGR - birthweight <10th percentile for gestational age (small and sick)

1. Risk factors -
A. maternal - smoking/cocaine, HTN, cardiac/renal/pulm dz, anemia
B. uterine/placenta - abruption, previa, infection
C. fetal - Multis, aneuploidy, congenital syndromes, structural abnormalities, infection

2. Etiology
A. asymmetric (abdominal circ and femur length are low, head circ normal) --> later insults eg HTN, maternal malnutrition, Factor V leiden mutation
B. symmetric - all are low --> early insults eg chromosomal abnormalities, congenital infection

3. Presentation - loose peeling skin, wide anterior fontanel, thin umbilical cord
- high morbidity e.g. NRDS, necrotizing enterocolitis, meconium aspiration syndrome (respiratory distress), hypothermia
- IUGR babies at risk for developing DMII, obesity, COPD, CVD, stroke as an adult

3. Mgmt - twice weekly NSTs / AFI or weekly BPPs
- reversed end diastolic doppler flow from umbilical artery --> associated with stillbirth w/in 48 hrs
- steroids if <34 weeks, mag sulfate if <32 weeks
- at birth --> send placenta for histopathology, neonatal urine tox screen

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Postpartum Endomyometritis
1. Risk factors
2. Presentation
3. Mgmt

Endomyometritis - infection of decidua, myometrium, and parametrial tissues due to ascension of polymicrobial bacteria from normal vaginal flora (MC is staph aureus and strep)

1. Risk factors - C-section (MC), chorioamnionitis, GBS, numerous vaginal exams, operative vaginal delivery, long labor, low SES, multis, young maternal age, chlamydia, manual extraction of placenta

2. Presentation - fever over 100.4F (MCC of fever in woman post C-section) usually on POD2
- uterine fundal tenderness
- purulent foul-smelling lochia

3. Mgmt - IV gentamicin and clindamycin until pt afebrile >24 hours; add amp if GBS infection, infection persists
- if fever does not improve after 2-3 days --> do CT to r/o abscess, infected hematoma, or septic pelvic thrombophlebitis
- if fever is due to wound infection --> open wound

30

Diabetes in pregnancy
1. Pregestational diabetes
A. Fetal risks
B. Maternal risks
C. Mgmt

1. Pregestational diabetes - hyperglycemia existing prior to pregnancy; accounts for 10% diabetes in pregnancy

A. Fetal risks - congenital anomalies (cardiac, skeletal, NTD), growth restriction (IUGR), fetal macrosomia (less likely), miscarriage, prematurity

B. Maternal risks - diabetic retinopathy, worsening nephropathy (if already existing), and HTN --> preeclampsia

C. Mgmt - target <105 fasting glucose
- glycemic control during labor to avoid neonatal hypoglycemia after birth
- C-section if big baby to avoid shoulder dystocia