✅ObGyn Labor & Delivery Flashcards
(208 cards)
1
Q
What are the 4 main inquries pts should be asked when coming in for L&D checks?
A
- Vaginal bleeding?
- Leakage of Fluid?
- Contractions?
- Fetal mvmnt?
2
Q
Which 4 drugs can you give to treat HTN in pregnant patients?
A
Mothers Loathe Nefarious HTN
Methyldopa / Labetalol > Nifedipine / Hydralazine
3
Q
CP of Edward’s Trisomy 18 - 6
A
- Prominent Occiput
- Micrognathia (small jaw & mouth)
- Overlapping Fingers
- Absent Palmar creases
- VSD
- Rocker-bottom feet
These pts die within 1st month of life
5
Q
Explain what Pseudocyesis is
A
Somatization of stress –> activates [hypothalamic-pituitary-ovarian] axis –> early pregnancy sx without there actually being a baby in utero = nonpsychotic woman who mentally AND PHYSICALLY presents like she’s pregnant (may even misinterpret a pregnancy test!)
US and clinic pregnany test will be negative
6
Q
Risk factors for Pseudocyesis - 2
A
- infertility hx
- prior abortion
7
Q
Neonatal Abstinence Syndrome
Classic Signs-4 ; What drug usually causes this?
A
STTD
- Sneezes a lot
- Tremors w/sweating
- Tachypnea w/HIGH PITCHED CRY
- Diarrhea
From intrauterine exposure to Opiates (i.e. Heroin/Methadone)!
8
Q
s/s of intrauterine cocaine exposure - 3
A
- Excessive sucking
- Jitteriness
- Hyperactive Moro reflex
9
Q
Postpartum depression affects women during what time periods? What 2 methods are used to screen for this?
A
within 1st year > first 3 mo ;
- [PHQ2 –(if both +)–> PHQ9]
- Edinburgh Postnatal Depression Scale
Screen prenatal, postnatal and well child
10
Q
Starting with [Day 0 Fertilization], describe the process of Implantation (9 steps)
A
11
Q
Give brief descriptions that differentiate Postpartum
Blues vs Depression vs Psychosis
A
- Blues = onsets after birth, peaking at postpartum day 5 and subsiding PPD14, worst w/lactation
- Depression = onset right after birth - 12 months later. Traditional s/s. Previous Depression hx is RF
- Psychosis = RARE but onsets IMMEDIATELY after birth
12
Q
What are 5 ways to determine if a pt truly has Leakage of Amniotic Fluid?
A
- Amnisure immunoassay (detects placental ⍺-microglublin1)
- POOL test (there’s pool of fluid in vaginal vault)
- NITRAZINE test (fluid turns blue when placed on nitrazine paper since amniotic fluid is alkaline)
- FERN test (fern-like estrogen crystals under microscopy)
- US to determine fluid quantity
13
Q
Rupture of Membranes ≥ ___ hours is a risk factor for intraamniotic infection & neonatal sepsis. ; When is Rupture of Membranes too early?
occurs when chorioamniotic membrane ruptures before labor
A
18 ; 1 hour before labor
- Do not confuse this with PPROM (Preterm Premature Rupture Of Membrane)*
- Chorioamnionitis Tx = Abx –> Delivery*
14
Q
What constitutes an infant as “Full Term”?
A
37 - 42WG
15
Q
1st trimester is ___ weeks gestation
What are the 3 biggest questions to ask during history taking for these patients? Why?
A
< 14 weeks
- NV? - asking because this is treatable
- Vaginal Bleeding?
- Cramping?
16
Q
What are the 2 clinical features for diagnosing ACTIVE labor?
A
Labor = LAPD
- Strong Contractions every 3-5 min
- Cervix Dilation > 6 cm, growing at 1-2 cm/hr and effaced
Fetal Heart Tracing is IRRELEVANT to diagnosing active labor
17
Q
What is the normal Fetal Heart Rate and variability on a NST?
A
110 - 160/min (w/variability of 6-25)
Normal Fetus’ should have a reactive NST
19
Q
For Antepartum patients, their NST (Non Stress Test) should be reactive
What is the Fetal Heart Tracing criteria for this?-4 Does this happen in pts in labor?
A
reactive = appropriate [fetal cerebral oxygenation]
- within a 20 min period there are
- at least two HR acclerations that are
- 15 bpm over baseline
- 1.5 small boxes long (15 sec)
THIS IS NOT REQUIRED FOR PTS IN LABOR
20
Q
Criteria for PreEclampsia is Gestational HTN + [Proteinuria or End Organ Damage]
How do you clinically diagnose Gestational HTN? - 6
A
- NO previous HTN
- ≥ 20 WG (2nd trimester)
- Systolic > 140
- Diastolic > 90
- At least 2 readings taken > 6 hrs apart
- BP taken in seated or semi-reclined position
FYI: PreEclampsia can still occur superimposed on Chronic HTN
21
Q
Criteria for PreEclampsia is Gestational HTN + [Proteinuria or End Organ Damage]
How do you clinically diagnose Proteinuria for pregnant women - 4
A
- ≥300 mg protein on 24 hr urine
OR
- ≥ 30 mg/dL on dipstick
OR - At least 1+ on dipstick
OR
-
Protein:Creatinine ratio > 0.3
* Must occur at least 2 times at least 6 hours apart*
22
Q
Criteria for PreEclampsia is Gestational HTN + Proteinuria
Which demographic are at greater risk for this?
A
Af American Women
greater risk of having PreEclampsia, it being severe and suffering placental abruptio and Eclampsia
23
Q
What are the 4 major causes of Postpartum Hemorrhage? - 4
A
The 4 T’s!
Tone (Uterine aTony)
Trauma (Perineal vs Cervix lacerations vs Uterine inversion/prolapse)
Tissue (retinaed/invasive placental tissue)
Thrombin (rare bleeding DO)
24
Q
When is [RhoGam AntiRhD] administered to Rh NEGATIVE pregnant women? - 7
A
DO THIS FOR ALL Rh NEGATIVE mothers
- 50mcg 1st trimester if uterine bleeding and/or spontaneous abortion occurs
- 300mcg at 28 WG
- 300 mcg within 3 days after delivery
- give with any episodes of vaginal bleeding (if indicated)
- give with External Cephalic Version
- give with Hydatidiform Mole dx
- give if Ectopic Pregnancy occurs
26
Q
When are pts screened for Group B Strep via vaginal and rectal swab?
A
35-37 WG
results are valid for 5 weeks
27
Q
Why is prematurity a risk factor for breech presentation? ; What’s a way to convert a breech into cephalic?
A
25% of fetuses ≤28WG are naturally breeched, but will flip over into cephalic position by 37 WG; External Cephalic Version (can only be done ≥37 WG)
28
What is an Internal Podalic Version?
Performed in twin deliveries to convert 2nd twin from transverse presentation --\> breech presentation for subsequent delivery
29
External Cephalic Version can only be done at __ weeks gestation!!
What are the contraindications to External Cephalic Version? - 7
≥ 37 WG
1. There are vaginal delivery ctd and C/S (CSection) is indicated instead
2. Placental demise (previa or abruptio)
3. Oligohydraminos
4. Rupture Of Membrane
5. Hyperextended fetal head
6. Fetal/Uterine anomaly
7. Multiple Gestation
31
What is Intrauterine Fetal Demise (IUFD)? ; Dx?-3
fetal death ≥ 20WG BUT before onset of labor;
1. No fetal cardiac activity on US
2. No fetal heart tones on Doppler
3. No/minimal subjective fetal mvmnt
*This commonly occurs in uncomplicated pregnancies*
32
What is the management for Intrauterine Fetal Demise? - 3;
What complication can arise from IUFD?
*Main causes: Anencephaly, Potter sequence, etc.*
1. If ≥ 28WG = Spontaneous Vaginal Delivery regardless of fetal lie
2. **If 24-27 WG = Induced Vaginal Delivery *_regardless of fetal lie_* when Mom's ready but before 28 WG**
3. If 20-23WG = Dilate and Curettage
## Footnote
* keeping fetus in there too long (\> 28 WG) can --\> coagulopathy*
* \* fetal death \< 20WG = spontaneous abortion \**
33
What are the risk factors for Intrauterine Fetal Demise? - 3
1. **SMOKING** intrapartum! (can also --\> *asymmetric* IUGR)
2. IUGR
3. abnormal fetal karyotype
34
AFP is a protein made by the \_\_-3. It is obtained in pregnant women at ___ weeks gestation
What does an elevated AFP indicate in a pregnant woman?-3
[Fetal Yolk Sac]/Liver/GI tract ; 15-20WG via Quad BUAD screen
1. Fetal Open Neutral Tube Defects (open spina bifida, anencephaly)
2. Fetal Abd Wall defect (Gastroschisis, Omphalocele)
3. Multiple gestation simulatenously (twins)
*If ⬆︎AFP --\> GET ANATOMY US!*
35
Which vaccines should be given to pregnant women **during their pregnancy**? - 5
1. Tdap (27-36WG)
2. Flu inactivated
3. RhoD (28WG)
4. Hep A killed - if HepC positive
5. Hep B killed - if HepC positive
36
Which vaccines can be given to pregnant women **AFTER delivery (since they're contraindicated for intrapartum)**? - 3
1. HPV
2. MMR
3. Varicella
37
When is a hgb electrophoresis screen indicated in a pregnant woman?
Pt has anemia during pregnancy ([hgb \< 11] + [MCV \< 80])
## Footnote
Non-Pregnant female normal hgb = 12-16
38
What are the risk factors for Placenta Accreta - 4 ; dx?
1. prior c/s (csection)
2. prior D&C (dilation and curettage)
3. Myomectomy
4. Maternal age \> 35
Dx = Intraplacental villous lakes on antenatal US
39
CP for Placental Abruptio - 3
## Footnote
*Risk factors = HTN, cocaine and smoking*
1. **PAINNNFFULLL antepartum vaginal bleeding (which can --\> hypovolemic shock, [DIC-from decidual bleeding releasing tissue factor 7] and fetal demise)**
2. Distended firm uterus
3. abd AND/OR back pain
## Footnote
*etx: HTN of maternal decidual vessels --\> rupture --\> premature detachment of placenta from endometrium*
40
What is Vasa Previa MOD?
fetal vessels traverse the amniotic membranes over the internal cervical os --\> antepartum bleeding and FHR abnormalitites **after** ROM (rupture of membrane)
41
CP for Uterine Inversion? - 3
1. Smooth mass protruding from cervix or vagina
2. postpartum hemorrrhage
3. severe abd pain
## Footnote
*results from inversion/collapse and prolapse of uterine fundus thru cervix or vagina*
42
What are the 4 major causes of Postpartum Hemorrhage? - 4
The 4 T's!
**T**one (Uterine aTony)
**T**rauma (Perineal vs Cervix lacerations vs Uterine inversion/prolapse)
**T**issue (retinaed/invasive placental tissue)
**T**hrombin (rare bleeding DO)
44
Major causes of Antepartum Hemorrhage - 4
## Footnote
*Antepartum = right before childbirth*
1. Placental abruptio (**PAINFUL** Anterpartum hemorrhaging)
2. Placenta accreta (occurs during placental removal)
3. Placental previa
4. Vasa Previa
45
What are the risk factors for Uterine Inversion? - 4
1. Nulliparity
2. LGA
3. Placenta Accreta (RF: prior c/s, myomectomy, D&C)
4. Precipitous (rapid) Labor & Delivery
## Footnote
*results from inversion/collapse and prolapse of uterine fundus thru cervix or vagina when too much traction is applied to cord before placental separation*
46
A pt with precipitous vaginal delivery has just had a uterine inversion with prolapse and postpartum hemorrhage
After giving fluids for loss of blood, what's the ultimate tx for this? - 3
1st: **Replace the Uterus first**
2nd: AND THEN remove placenta if still attached
3rd: Give Uterotonics (oxytocin/misoprstol) to ⬇︎ postpartum hemorrhage
47
Differentiate the following spontaneous abortions:
Inevitable abortion
Threatened abortion
Missed abortion
Complete abortion
*spontaneous abortion = occurs \< 20 WG*
1. INEVITABLE = vaginal bleeding \< 20 WG **with cervical os dilated** --\>abortion will *inevitably* happen soon
2. THREATENED = early vaginal bleeding \< 20 WG **with cervical os closed** is clearly a threat to a STILL LIVING FETUS
3. MISSED = Fetal death **with cervical os closed**...which is why we *Missed* it - (pt will have pregnancy sx that just suddenly disappear out of nowhere)
4. COMPLETE = ALL PRODUCTS OF CONCEPTION COMPLETELY EXPEL AND THEN CERVIX CLOSES BACK UP
## Footnote
*spontaneous = occurs \< 20 WG*
48
Spontaneous abortions (unprovoked pregnancy loss \< 20 WG) are usually a result of \_\_\_\_
what are the other 2 less common causes?
**chromosomal abnormalities**
2. tertogen exposure
3. mullerian anomalies (uterine septum)
* In comparison to IUFD, which etx is mostly unknown!*
49
What are the options for Mngmt of Spontaneous Abortion - 4
1. **Expectant**: Watchful Waiting for products of conception to expel naturally in 2-6 weeks
2. **Surgical**: [Dilitation & Curettage (D&C) (cant be done during infection)] or [Manual Vacuum Aspiration]
3. **Medical**: 800mcg Vaginal Misoprostol - takes up to 2 weeks for expel
## Footnote
*ALL REQUIRE 1 WEEK FOLLOW UP*
50
Major causes of 1st trimester bleeding - 3
1. Spontaneous Abortion (inevitable vs threatened)
2. Acute cervicitis (cervix will have discharge)
3. Molar Pregnancy
51
What is Cervical insufficiency
2nd trimester **PAINLESS** Cervical Dilation that --\> Spontaneous abortion (\< 20WG) or IUFD ( ≥ 20WG)
52
CP for septic abortion - 3
1. Fever
2. malodorous purulent vaginal discharge
3. Large, Boggy tender uterus --\> lower abd pain
## Footnote
*usually comes from unsterile/incomplete elective abortion*
53
What would ultrasound reveal for septic abortion
irregularly thickened endometrial stripe with active blood flow
54
Septic Abortion can --\> Peritonitis, Sepsis and Death
How do you manage it? - 3
1. broad abx x 2 days
2. Dilation & Curettage
3. IVF
55
In the context of Ob/Gyn, what is Methotrexate typically used for? - 2
1. Ectopic pregnancy
2. Gestational Trophoblastic Neoplasia
56
A pregnant pt who looks like they're in active labor stage 1B but has a baby tht regressed from 0 station to -3 Station should concern you for \_\_\_\_
Uterine rupture!
## Footnote
* "Full thickness disruption of the uterine wall"*
* bigest RF = pre-existing uterine scars (c/s, myomectomy)*
57
What is a Nuchal Cord
when loop of umbilical cord wraps around fetus' neck --\> recurrent variable decelerations but **is not clinically significant**
58
What are the effects of Amphetamine use during pregnancy? - 6
1. IUGR
2. Intrauterine fetal demise
3. preeclampsia
4. Placenta abruptio
5. Preterm delivery
6. Maternal death!
59
Risk factors for Cervical Insufficiency - 2
1. DES intrauterine exposure--\> congenital abnormalities
2. cervical surgery
60
Gastroschisis is associated with ___ trimester use of which drug?
1st trimester use of **NSAIDs**
61
What are the risk factors for Polyhydraminos? - 2
## Footnote
*Polyhydraminos ( ≥24 cm AFI) is a risk factor for Placenta Abruptio*
1. Maternal DM - poorly controlled
2. swallowing fetal anomalieis (esophageal atresia)
62
How many pounds are pts underweight (BMI \< 18.5) advised to gain?
~35 lbs
63
Hyperemesis Gravidarum is a normal part of pregnancy
When is it expected to resolve?
by 20WG
## Footnote
*BE SURE TO WATCH OUT FOR THIAMINE DEFICIENCY SX IN THESE PTS!*
64
name the possible sequelae of Gestational HTN? - 7
## Footnote
*Remember: can ONLY be diagnosed in ≥ 20 WG*
1. IUGR asymmetrically
2. Preterm delivery
3. Oligohydraminos (AFI ≤5 cm)
4. Perinatal mortality
5. Placental Abruptio
6. Preeclampsia superimposed
7. c/s
65
Risk factors for Placenta Previa - 3
## Footnote
***PAINLESS** Antepartum Vaginal Bleeding with unaffected FHT since bleeding is all maternal*
1. c/s
2. Multiparity
3. Smoking
## Footnote
***PAINLESS** Antepartum Vaginal Bleeding with ONLY maternal vitals changing*
*"previews are painless :-)"*
66
When is Placenta Previa typically diagnosed? ; What are the things that are contraindicated because of Placenta Previa? - 4
20 WG via routine US;
1. Coitus
2. Digital examination
3. Vaginal delivery
4. External cephalic version
*sometimes previa (and other malpresentations) spontaneously resolves by 3rd trimester due to growth of lower uterine segment and/or placental growth toward fundus. but other wise schedule c/s for 37 WG*
67
Placenta Previa and Vasa Previa both present as **PAINLESS** Antepartum Vaginal bleeding
What is the differentiating factor? - 2
1. Since Vasa Previa involves destruction of **fetal** blood vessels it --\> deterioration of FHT (bradycardia, decelerations), while Placenta Previa is all maternal bleeding only so FHT is NOT affected.
2. Vasa Previa occurs only after amniotomy is done
68
What is a Cerclage procedure?
Using a suture or synthetic tape to reinforce the cervix in 2nd trimester pts who have cervical length ≤ 2cm per transVaginal US (or 2.5 if preterm hx present) or risk for PPROM
69
What does the Biophysical Profile (BPP) consist of? - 2 ; What is the breakdown of the results?
**NonStress Test**
+
[**US assessment** of Amniotic Fluid/Fetal mvmnt/Fetal tone/Fetal breathing - *each given 2 points if nml and 0 if not*]
Normal= 8,10 (repeat BPP in 1 wk) / Equivocal=6 (repeat BPP in 24 hrs) / Abnml=0,2,4
*this (and alternative Contraction Stress Test) are performed in high risk fetal demise pregnancies to assess for fetal hypoxia*
70
What is Doppler US of the umbilical artery used for?
evaluates for fetoplacental vascular insufficiency in IUGR pts (\< 10th%tile)
71
What is the dx for Hydatidiform mole gestation? - 2
1. **"Snowstorm with grapes" on ultrasound**
2. **HHIIGH LEVELS OF bHCG (\> 100,000)**
## Footnote
*Most of the time this is caused by sperm implanting an EMPTY ovum*
72
Asymmetric IUGR is typically caused by \_\_\_\_-3 while **Symmetric** IUGR is caused by \_\_\_-2
## Footnote
*Symmetric = Head AND Abd are growth restricted while in Asymmetric it's mostly just Abd*
Maternal HTN, Maternal DM, Smoking (these cause IUGR in the 2nd & 3rd trimester);
1. **Congenital chromosome abnormality**
2. **Congenital infxns of 1st trimester (toxo, CMV) = RARE**
73
What is "Precipitous" labor? ; What's the greatest risk factor for Precipitous labor?
Fast delivery that occurs within **3 hours** of contraction onset ; Multipartiy
## Footnote
*Precipitous labor is NOT affected by Oxytocin induction and is usually spontaneous. It may cause Uterine prolapse!*
74
What effects does Tachysystole have on the fetus - 4
## Footnote
*Tachysystole: ≥6 ctx in 10 min period*
1. **Usually none**
2. ⬆︎ risk for c/s
3. ⬆︎risk for NICU
4. ⬇︎umbilical cord pH due to hypoxemia
75
What are the effects of Oxytocin toxicity? - 3
1. **hypOtension** (⬇︎ BP)
2. **hypOnatremia** (oxytocin cross reacts with POST pit ADH receptors)
3. Tachysystole ( ≥6 ctx in 10 min)
## Footnote
*tx: 3% Hypertonic saline*
76
What is the Kleihauer Betke test
Determines the dose of [Rhogam Anti-D] needed after delivering an Rh+ fetus to an Rh- mother. Can confirm or exclude fetomaternal hemorrhage
77
Mg Sulfate is 1st line for Eclampsia px
What are the alternatives for Eclampsia px? - 2
1. Diazepam
2. Phenytoin
78
Normal Fetal Heart Rate is 110-160 bpm
What could Fetal Tachycardia indicate? - 6
1. Infxn chorioamnionitis (will include maternal fever)
2. Hypoxia
3. Anemia
4. Maternal Hyperthyroidism
5. Placenta Abruptio
6. Meds (terbutaline)
79
Fetal Heart Tracing like this indicates what dx?
Fetal Anemia
## Footnote
*Sinusoidal Fetal Heart Tracing*
80
What is the **FIRST** thing you should look at when seeing a pregnant patient? Why is this?
Blood Pressure! ; RULE OUT PREECLAMPSIA
81
*Criteria for PreEclampsia is **Gestational HTN** + [**Proteinuria or End Organ Damage]***
How do you clinically diagnose _SEVERE_ PreEclampsia? - 9
**PreEclampsia** --\> **SEVERE PreEclampsia** --\> **HELLP** and at anytime, **Eclampsia** is possible
ANY **ONE** OF THE FOLLOWING:
1. Systolic \> 160
2. Diastolic \> 110
3. **refractory** HA
4. scotoma vision changes
5. Pulmonary Edema (from ⬇︎albumin)
6. RUQ OR Epigastric pain
7. Doubling of LFTs
8. Platelets \< 100K
9. Cr \> 1.1 or doubled from baseline
*although not in criteria, can also include Hyperreflexia*
82
*Criteria for PreEclampsia is **Gestational HTN** + [**Proteinuria or End Organ Damage]***
How does the Liver play a role in SEVERE PreEclampsia?
*PreEclampsia --\> SEVERE PreEclampsia --\> HELLP and at anytime, Eclampsia is possible*
Centrilobular necrosis, hematoma formation and portal capillary thrombi all --\> Distension of the [**Glisson's Hepatic Capsule**] --\> RUQ OR Epigastric abd pain = SEVERE PreEclampsia
83
What are the major s/s of Magnesium Toxicity - 2
## Footnote
*Risk Factor = Renal Insufficiency*
1. **Neuro** depression (Somnolence, ⬇︎ Deep tendon reflexes, Visual disturbances, Paralysis)
2. **Respiratory** depression
## Footnote
* Risk Factor = Renal Insufficiency since it's renal excreted!!*
* Tx for Mg Toxicity = Ca+Gluconate*
84
A **Non**reactive NonStress test is one without \_\_\_\_\_. What does a **non**reative NonStress test indicate? - 2
Accelerations ;
1. poor [fetal cerebral oxygenation] OR
2. fetal sleep (20 min duration) - be sure to extend NST to at least 40 min to catch this!
***Non**reactive NonStress test should be f/b BioPhysical Profiles to assess for necessary intervention*
85
*A pregnant pt has Graves' disease*
What medication is recommended to treat this in the 1st trimester? What about the 2nd and 3rd trimester?
PTU ; Methimazole
86
[T or F] You should be alarmed if a fetus of 14 Weeks Gestation has no accelerations (**non**reactive stress test) on Fetal Heart Tracing
Why or Why not?
FALSE!
Fetal heart accelerations are a sign of good [fetal cerebral perfusion] and therefore neuro development, and neuro development doesn't fully develop until 28 WG
87
What is Pubic Symphsis Diastasis? ; What is the clinical presentation of this after a traumatic delivery?
Physiological widening of pelvis by progesterone and relaxin to facilitate vaginal delivery ; **Postpartum** **suprapubic TTP pain that radiates to the Back and/or Hips**
## Footnote
*worst with weight bearing, walking or position change and resolves by 4 weeks PostPartum*
88
After vaginal delivery, pt is now numb over her Anterior and Medial thigh
What happened?
Prolonged Hyperflexion of thigh for vaginal delivery (McRoberts maneuver) can --\> Femoral n compression --\>
1. Anterior & Medial thigh numbness
2. ⬇︎thigh flexion
3. ⬇︎patellar reflexes
89
In the context of labor and delivery, how do retroperitoneal hematomas form? ; What is the CP?-3
damage to internal iLiac artery during delivery ;
1. Palpable mass
2. Hemodynamic instability
3. Fever
90
Sciatica etx ; Clinical Presentation - 3
"Having Sciatica makes you break **LAWS**"
* [**L**ower Back pain w/radiation down POST thigh --\> lateral foot]
* **A**nkle jerk reflex ABSENT
* **W**eak Hip Extension
* [**S**1 n PosteroLateral compression at L4-5 or L5-S1]
91
Gestational sacs normally implant in the \_\_\_\_\_
Describe a Cornual Interstitial ectopic pregnancy
upper uterine fundus ;
implantation in outer "cornual" areas of uterus
*dx = trans**Vaginal** US // tx = MTX or surgery if severe*
92
Name the major risk factors for Ectopic Pregnacy - 6
1. previous ectopic
2. previous Pelvic
3. previous Tubal surgery
4. PID
5. Bicornuate heart shaped uterus (causes cornual interstitial ectopic pregnancy)
6. In Vitro Fertilization (causes cornual intersitital ectopic pregnancy)
## Footnote
*tx = MTX or surgery if severe*
93
Hyperemesis Gravidarum is a normal part of pregnancy that resolves by **20 WG**
What are the risk factors for getting this? - 3
1. Multiple Gestation
2. GERD hx
3. Hydatidiform Mole (note: elevated βHCG can stimulate thyroid and --\> thyrotoxicosis of hyperemesis!)
## Footnote
*HG is usually unresponsive to PO antiemetics, and can cause Thiamine Deficiency*
94
What are the potential CP for Hydatidiform Mole? - 5
1. **HEAVY vaginal bleeding**
2. Hyperemesis Gravidarum
3. Severe Preeclampsia
4. Hyperthyroidism
5. Uterus larger than expected gestational age **but with regular countour**
## Footnote
"Snowstorm with grapes" and/or [Theca lutein ovarian multiseptated cyst from excess bHCG] on ultrasound
HHIIGH LEVELS OF bHCG (\> 100,000)
*Most of the time this is caused by sperm implanting an EMPTY ovum*
95
Preeclampsia is typically diagnosed ____ weeks gestation. What is the exception to the rule?
≥ 20WG! ; Preeclampsia is a complication of Hydatidiform mole which may occur \< 20WG
96
What are the primary components for the Mechanisms of Disease in Preeclampsia? - 3
**Ab complex mediated endovascular damage --\>**
1. Hemolytic Anemia
2. Platelet aggregation from ⬆︎Thromboxane
3. Vascular constriction pervasively from ⬆︎Thromboxane
97
PPROM = Preterm Premature Rupture Of Membranes (which occurs **before** 37 WG)
How do you manage PPROM when it occurs ≥ 34WG?
*Complications = Chorioamnionitis/Endometritis/Cord Prolapse/Placenta Abruptio*
98
PPROM = Preterm Premature Rupture Of Membranes **before** 37 WG
How do you manage PPROM when it occurs \< 34WG?
**if baby not compromised, fetal surveillance until 34 WG and then deliver!**
*Complications = Chorioamnionitis/Endometritis/Cord Prolapse/Placenta Abruptio*
99
PPROM = Preterm Premature Rupture Of Membranes **before** 37 WG
What are px meds for PPROM? - 2
1. Progesterone (vaginal or IM after 1st trimester)
2. Cerclage
## Footnote
*Complications = Chorioamnionitis/Endometritis/Cord Prolapse/Placenta Abruptio*
100
The First Trimester Combined Test analyzes risk for ____ and ___ by measuring what 3 things?
If abnormal, how should this test be followed up? - 2
analyzes risk for Trisomy 21 or [Edward's Trisomy 18] by measuring **BUS**
1. **β**HCG
2. **U**S analyzing fetal nuchal translucency
3. **S**erum plasma maternal protein A
if abnormal, f/u with
1st: [cell free fetal DNA test (cffDNA)] at ≥ 10WG *(this should come before First Trimester Combined Test if pt is high-risk for aneuploidy)* then if cffDNA still abnml...
2nd: fetal karyotyping **[via amniocentesis if ≥ 14WG]** or [Chorionic Villus Sampling if ≤ 13WG]
101
What is the purpose of Chorionic Villus Sampling? ; What is the differnece between this and amniocentesis?
determines fetal karyotyping via placental biopsy
both CVS and amniocentesis can be used for fetal karyotyping **but only amniocentesis can be used in \> 13 WG pts**
102
Hyperandrogenism (Hirsutism/Acne) during pregnancy is a **benign** condition that is caused by \_\_\_\_\_-2 ; Dx? ; Tx?
[luteoma ovarian *mass*] or [theca luteal ovarian *cyst*(comes from ⬆︎⬆︎⬆︎βHCG Hydatidiform mole)];
Dx = US ;
Tx = **Watchful Waiting** since it typically resolves after delivery (but watch for mass effect on the kidneys and inform pt that this ⬆︎virilizaiton risk)
103
Krukenberg tumors present like Luteomas, in that they both cause Female Hirsutism
Where do Krukenberg tumors come from?
they are Metastasis from GI CA
104
What is the classic presentation for Uterine rupture? ; What are the risk factors? - 2
**recession of fetal station** after sudden abd pain
*any prior uterine scars*
1. prior c/s
2. prior myomectomy (usually for fibroids)
105
Prolonged Rupture of Membranes ≥ ___ hours is a risk factor IntraAmniotic Infection & neonatal sepsis
What is the dx criteria for IAI (IntraAmniotic Infection)? - 2
18
**Maternal Fever**
+
≥ 1 of:
1. Uterine tenderness
2. Tachycardia (maternal or fetal)
3. malodorous amniotic fluid
4. purulent vaginal discharge
* Chorioamnionitis Tx = Abx --\> Delivery*
106
Why is it rare for Women to get PID after the ___ trimester
1st; cervical mucus and decidua seals off the uterus from pathogens during pregnancy
107
Physically describe Uterine Atony - 3
1. soft (it's lost its tone)
2. boggy
3. enlarged above the umbilicus
## Footnote
*this also could indicate retained blood clots or septic abortion*
108
Methylergonovine MOA ; Indication?
UteroTonic --\>
1. uterine contraction
2. vasoconstriction (ctd in HTN pts)
3. smooth m constriction
Indication = When Uterine massage AND oxytocin have failed to stop postpartum hemorrhage 2/2 uterine atony
109
Although most commonly associated with Alcoholism, why are pregnant pts also at risk for developing Wernicke Encephalopathy from Thiamine deficiency?
Hyperemesis Gravidarum = severe NV that --\> dehydration, wt loss from **hypoglycemia** and **thiamine deficiency/Wernicke Encephalopathy** which can --\> Spontaneous Abortion!
## Footnote
*Tx = Glucose WITH Thiamine B1 supplement*
110
CP for Acute Fatty Liver of Pregnancy - 3 ; When does this occur?
**3rd** trimester
1. NV
2. hypOglycemia
3. ⬆︎LFTs
*linked to [fetal long chaing dehydrogenase fatty acid dysfunction] . Can look like Hyperemesis Gravidarum but occurs 3rd and not 1st!*
111
Full term infant = 37- 42WG
How do you manage Preterm Labor 34 to 36+6 WG - 2
***P**regnant **B**itches*
112
Full term infant = 37 -42WG
How do you manage Preterm Labor 32 to 33+6 WG - 3
***P****regnant **B**itches **T**ake*
113
Full term infant = 37 - 42WG
How do you manage Preterm Labor \< 32WG - 4
***P**regnant **B**itches **T**ake **M**oney*
114
Name the main Toco**lytics** - 5
1. Mg (⬇︎ Ca+ needed for uterine ctx)
2. Indomethacin (⬇︎Prostaglandin as a COX inhbiitor)
3. Nifedipine (Ca+ Channel Blocker)
4. Terbutaline (Relaxes Uterus as B2 agonist)
5. Atosiban (Uterus Oxytocin R Blocker)
115
What factors indicate ⬆︎ risk for possible Preterm labor? - 4
## Footnote
*Full Term delivery = 37 - 42WG*
1st best indicator: **PRIOR PRETERM DELIVERY = STRONGEST INDICATOR**
2nd best: Shortened cervix ≤ 2cm per transVaginal US (or 2.5 if preterm hx present) - hx of cold knife conization?
3rd best: + Fetal Fibronectin BUT ONLY BETWEEN 20-37WG
4th best: Circumstantial (Smoking, multiple gestation, IVF, obesity)
116
What are the absolute contraindications to breastfeeding? - 7
1. Maternal HIV
2. Active HSV breast lesions
3. Active untreated TB
4. Active Varicella
5. Active Substance use
6. On Chemoradiation
7. Infants with galactosemia
## Footnote
*Hep B pts can breastfeed as long as baby receives HepB Immunoglobulin and vaccination*
117
What is lochia
postpartum uterine/vaginal discharge **that's normal**
118
Because of ____ and \_\_\_\_, immediate postpartum urinary retention is expected. When does this become pathologic (bladder atony)?
Regional anesthesia and [Pudendal n palsy 2/2 pelvic floor injury] ; if urinary retention is **\> 6 hours** after delivery then = Bladder Atony
## Footnote
Tx = ambulation f/b catheterization until resolves spontaneously
119
name the most common causes of uterine size-date discrepancy in pregnant patients - 5
1. **INCORRECT DATING**
2. Multiple gestation
3. Hydatidiform Mole
4. Leiomyomata uterine Fibroids (irregular contour)
5. Polyhydraminos (only in 2nd & 3rd trimester and is uniform)
120
False labor occurs as a result of Braxton Hicks contractions and causes NO CERVICAL CHANGE
Compare the **Timing** / **Strength** / **Cervix status** of contractions occuring in False Labor to True Labor
Uterine Contractions...
FALSE = irregular + weak + NO CERVICAL CHANGE
True = [Regular with **increasing frequency**] + [**increasing in strength**] + cervical change
121
Risk factors for pt having preterm delivery? - 6
1. prior Preterm delivery
2. \> 40 yo
3. multiple gestation
4. Gestational HTN
5. Amphetamine use
6. Cocaine
***P**regnant **B**itches **T**ake **M**oney*
122
A: **Potters Sequence** etx
B: Clinical Presentation - 6
A: [Fetal **R**enal Agenesis bilaterally / Dysfunction] --\> Oligohydraminos (No Amniotic Fluid)
B: **POTTER**
**P**ulm hypOplasia
**O**ligohydraminos
**T**wisted Face
**T**wisted and shortened Limbs
**E**ars set low
**R**enal agenesis = cause
123
CP for Type 2 Osteogenesis Imperfecta - 4 ; etx?
1. **Thoracic cavity hypOplasia**
2. Multiple fractures
3. Short femur
4. DOA (Lethal-Stillborn)
AUTO DOM Type 1 Collagen Defect
Type 1=mild / Type2=perinatal fatal / Type 3-9=mod
124
Amniotic Band Sequence CP - 3
1. limb defects
2. craniofacial defects
3. abd wall defects
## Footnote
*NON-LETHAL :-)*
125
How does pregnancy affect Renal function? ; Why is this important?
Pregnancy ⬆︎Renal blood flow AND Glomerular basement membrane permeability in 1st trimester --\> ⬆︎GFR --\> ⬇︎BUN and Creatinine levels. and then this plateaus by midpregnancy
Important because renally excreted drugs will be excreted faster than usual
126
What changes to Hematocrit occur during pregnancy? Why is this helpful?
Hct ⬇︎ because Plasma volume ⬆︎ more than the RBC mass --\> mild ⬇︎in hgb concentration and = **dilutional anemia**
Helpful because it protects Mom in case of Postpartum Hemorrhage (⬆︎hypercoaguability during pregnancy also helps with this)
127
Pregnant Women are known to be hypercoagulable in order to decrease effects of PostPartum hemorrhage
What biochemical changes occur to make them hypercoagluable? - 4
1. ⬆︎fibrinogen (never should be nml in pregnancy. If so, could indicate DIC)
2. ⬆︎vWF (impt for platelet adhesion & stabilizes Factor 8)
3. ⬆︎**resistance** to [activated Protein **C**] (Protein **C** **C**uts [proteolysis] factors 5 and 8 in half but requires Protein S to do it)
4. ⬇︎Protein S (helps activated Protein C)
128
In a pregnant pt who has chronic HTN (HTN prior to 20 WG), what goals for blood pressure should be set?
*Less than Stage 1*
Systolic \< 140
Diastolic \< 90
129
Shoulder Dystocia = inability to deliver neonatal shoulders
What is the biggest risk factor for Shoulder Dystocia? ; Why is Shoulder Dystocia so dangerous for newborns? - 3
Fetal Macrosomia \> 4.5 kg ;
1. Brachial plexus injury
2. Fracture of clavicle or humerus
3. hypoxic brain death
tx = **BE CALM** mnemonic
130
In a pregnant pt who hasn't felt fetal mvmnt in 2 days, and dopper reveals no heart tones, what should be next step in management, **NST** or **Transabdominal Ultrasound**? Why?
Transabd US; NST uses same technology as doppler and just plots the fetal heart tones. If doppler was neg, so will NST
## Footnote
*IUFD is confirmed by absence of cardiac activity **ON ULTRASOUND***
131
What is the work up for a Fetus that just underwent IntraUterine Fetal Demise? - 3
IUFD = fetal death ≥ 20WG BUT before onset of labor;
1. Autopsy
2. Placenta/Umbilical Cord/Amniotic Membranes exam
3. Karotype genetic studies
132
What is the work up for a Mother that just underwent IntraUterine Fetal Demise? - 3
IUFD = fetal death ≥ 20WG BUT before onset of labor;
1. Kleihaurer Betke to assess for fetomaternal hemorrhage
2. Antiphospholipid Ab levels (causes recurrent pregnancy loss)
3. Coagulation studies
133
Septic Pelvic Thrombophlebitis CP - 2
1. **Refractory to abx** postpartum Fever with no obvious source (blood, urine, spinal)
2. B/L lower quadrant TTP (since it usually occurs in deep pelvic or ovarian veins)
## Footnote
*This is a dx of exclusion! Always consider Endometritis first in postpartum pts with fever*
134
What is the Prenatal Maternal Quad Serum screening? When is this obtained?
Measures 4 chemical markers for fetal anomalies and down syndrome- 81% accuracy (QUAD = **BUAD**):
1. **β**HCG⬆︎
2. **U**nconjugated EsTriol⬇︎
3. **A**FP⬇︎
4. **D**imeric inhibin A⬆︎ - *only in QUAD screen*
Performed 15 -20WG
*Be sure to f/u abnml results with cell free fetal DNA test and US*
135
What are the Quad BUAD results (obtained 15-20WG) for Edward's Trisomy 18?
⬇︎βHCG
⬇︎**U**nconjugated EsTriol
⬇︎**A**FP
NML **D**imeric inhibin A
136
Name the causes of Variable Decelerations on Fetal Heart Tracing
**Umbilical Cord Compression (consider cord prolapse, oligohydramnios or nuchal cord as etx)**
137
A pregnant pt is having recurrent Variable decelerations with more than 50% of her contractions
tx? - 2
**L lateral decubitius Maternal repositioning** --\> **amnioinfusion** if that doesn't work
## Footnote
(⬇︎umbilical cord compression)
138
What is 1st line tx for gestational DM? - 2; What's used if this doesn't work? -2
1st: Exercise and Diet change
2nd: Insulin or PO DM drugs (metformin, glyburide)
* Wt loss during pregnancy is **NOT** a good idea since it ⬆︎risk for IUGR*
139
When should women be screened for Gestational DM?
24 - 28WG
140
Shoulder Dystocia = inability to deliver neonatal shoulders
What is the management for this? - 6
**BE CALM**
1. **B**reathe, stop pushing and lower head of bed
2. **E**levate and flex hips against abd (McRoberts position)
3. **C**all for help (anesthesiologist/2nd physician/nurses)
4. **A**pply suprapubic pressure downward & laterally to release ANT shoulder
5. **L**argen's vaginal opening (episiotomy)
6. **M**aneuvers (see image)
141
What are the most common dangerous activities for pregnant women? - 4
1. Contact sports (basketball/hockey/soccer)
2. High Fall Risk (skiing/gymnastics/horseback riding)
3. Scuba diving
4. Hot yoga
## Footnote
*30 min of moderate exercise/day is actually recommended for pregnant pts unless ctd (see image)*
142
What is a normal Lactate DeHydrogenase (LDH)?
\< 190 U/L
143
Systemic Lupus Erythematosus in pregnant pts complicates the picture of diagnosing preeclampsia since they both present very similarly
How can you differentiate the two? - 4
1. pt will have more classic s/s of SLE (RASH OR PAIN)
2. RBC cast = SLE
3. ⬆︎ ANA = SLE
4. ⬇︎Complement = SLE
## Footnote
*Beware: SLE can look like Preeclampsia!*
144
Systemic Lupus Erythematosus in pregnant pts complicates the picture of diagnosing preeclampsia since they both present very similarly
What are the ⬆︎ risk associated with having SLE during pregnancy? - 5
1. preeclampsia (smh naturally)
2. preterm
3. c/s
4. IUGR
5. fetal demise
## Footnote
*Beware: SLE can look like Preeclampsia!*
145
Full term infant = 37- 42WG
What are the Fetal complications involved with Late term (41-42WG) and Post term ( \> 42WG) pregnancies? - 5
1. **STILLBIRTH** 2/2 UteroPlacental insufficiency
2. Oligohydramnios (UteroPlacenta insufficiency ⬇︎fetal urine output)
3. Macrosomia
4. Meconium aspiration
5. Convulsions
## Footnote
*Maternal complications = infxn, postpartum hemorrhage, c/s*
146
What are the common side effects of the Medroxyprogesterone depot injection contraception? - 4
1. prolonged menstrual bleeding during 1st 6 months
2. weight gain!
3. breast tenderness
4. ⬇︎bone mineral density
## Footnote
*50% of women have amenorrhea after using for a year*
147
When is the First Trimester Combined Test administered?
analyzes risk for Trisomy 21 or [Edward's Trisomy 18] by measuring **BUS**
9-13WG
148
Gestational sacs normally implant in the \_\_\_\_\_
What is the "typical" triad for Ectopic Pregnancy? - 3
upper uterine fundus ;
## Footnote
VAL had an ectopic the other day!
1. **V**aginal bleeding/spotting
2. **Adnexal Tenderness** **(if implanted in tube)**
3. **L**ower abd pain
*dx = trans**V****aginal** US / tx = MTX or [surgery if severe]*
149
IUFD = fetal death ≥ 20WG but before onset of labor
What is *usually* the cause of IntraUterine Fetal Demise?
**UNKNOWN!!**
## Footnote
*This commonly occurs in uncomplicated pregnancies and could be maternal/placental/fetal origin*
150
Endometriosis is defined as \_\_\_\_\_\_
What are the possible findings for Endometriosis? - 4
Endometriosis = endometrial glands and stroma outside the Endometrium
1. **Gun Powder burn lesions**
2. ADHESIONS --\> immobile uterus
3. Chocolate fluid
4. Nodules flesh or dark colored
*# of implants does NOT correlate with sx intensity and these pts can be asx!*
Dx = **Laparoscopy** to biopsy & remove endometriotic lesions
151
How does thyroid dysfunction affect pregnancy? - 2
Both hypO and HYPERthyroidism ⬆︎risk for infertility and recurrent pregnancy loss
152
CP for Endometriosis - 5
## Footnote
*Homogenous cystic ovarian mass*
The 3 Ds and AI!
1. **D**ysmenorrhea
2. **D**yspareunia - implants in posterior cul-de-sac
3. **D**yschezia (painful defecation) - implants in posterior cul-de-sac
OR
**(4) ASX** (tx not indicated if so) - otherwise tx = NSAIDs or combined OCPs
(5) Infertility of unknown origin
* Findings: Gun Powder Burn lesions, ADHESIONS--\>immobile uterus, Chocolate fluid*
* Dx = Laparoscopy to biopsy & remove endometriotic lesions*
153
tx for Endometriosis - 5
## Footnote
*Homogenous cystic ovarian mass*
1. observation if asx
2. NSAIDs **1st**
3. Contraceptive (OCP/IUD progesterone)
4. Leuprolide (GnRH agonist that ⬇︎Endometrial gland estrogen stimulation)
5. Hysterectomy with oophorectomy
## Footnote
* Findings: Gun Powder Burn lesions, Adhesions, Chocolate fluid*
* Dx = Laparoscopy to biopsy endometriotic lesions*
154
25% of fetuses ≤ 28WG are naturally breeched, but flip into cephalic/vertex position by 37WG
What are the 2 dx for disovering breech presentation?
1st: fetal presenting part is not palpable
2nd / **CONFIRMATION IS DONE BY TRANSABDOMINAL US**
155
Name the things that make vaginal delivery contraindicated - 4
1. Breech
2. Placenta Previa
3. Active HSV lesion
4. Prior **classical** c/s
156
Full term infant = 37- 42WG
Most Tocolytics are not used in managing Preterm Labor 34 to 36+6 WG
Why specifically is Nifedipine not used?
***P**regnant **B**itches*
Maternal hypOtension with reflex tachycardia
157
Full term infant = 37- 42WG
Most Tocolytics are not used in managing Preterm Labor 34 to 36+6 WG
Why specifically is Indomethicin not used? - 2
***P**regnant **B**itches*
1. Premature closure of ductus arteriosus
2. Oligohydramnios
158
Full term infant = 37- 42WG
Most Tocolytics are not used in managing Preterm Labor 34 to 36+6 WG
Why specifically is Mg not used?
***P**regnant **B**itches*
It's a **weak tocolytic** so it doesn't actually help with slowing contractions down in preterm delivery
159
Amniotic Fluid Index for Oligohydramnios
≤ 5cm
160
Amniotic Fluid Index for Polyhydramnios
≥ 24cm
## Footnote
RF = Maternal DM, congenital swallowing malformation
Polyhydramnios can --\> placenta Abruptio
161
Erby's palsy of an infant is a common complication of shoulder dystocia
Impingement of which nerves causes the *self-limited* Erb's Palsy? - 3
1. C**5** --\> deltoid and infraspinatus muscle weakness
2. C**6** --\> bicep muscle weakness
3. C**7** --\> enables predominance of opposing muscles
## Footnote
tx = 3 month self limited, but give massage and Physical Therapy to prevent contractures
162
What are the sx of Breast Engorgement-4 ; When does this usually occur?
1. b/l Breast Fullness
2. b/l Breast Tenderness
3. b/l Breast warmth
4. No Fever
Usually occurs 3 days postpartum when colostrum is replaced with milk, but can occur anytime during breastfeeding
*Tx = BREASTFEED, Cool compress, APAP, NSAIDS*
163
How can you differentiate Breast Engorgement from Mastitis? ; How can you differentiate Breast Engorgement from Plugged Ducts?
* Breast Engorgement is BL without fever and Mastitis is uL WITH FEVER (Breast abscess is Mastitis with fluctuance)
* Breast Engorgement is BL and Plugged Ducts is uL
164
Etx of Sheehan Syndrome ; What are the main signs and symptoms of Sheehan Syndrome?-5
ischemic necrosis of ANT Pituitary 2/2 massive postpartum hemorrhage ;
FLAT PiG
1. FSH/LH ⬇︎ --\> **Amenorrhea** (remember, postpartum women should resume menses after 10 wks)
2. ACTH ⬇︎ --\> **⬇︎Na+ which causes ⬇︎BP**
3. TSH⬇︎ --\> **Fatigue/hypOthyroidism**
4. Prolactin⬇︎ --\> **LACTATION FAILURE (1ST SIGN OF SHEEHAN!)**
5. GH⬇︎ --\> **Anorexia**
165
Early Postpartum period had several physiological processes that can be mistaken for pathology
Name them-5 (so you can avoid overdiagnosing!)
1. Shivering (due to thermal imbalance)
2. Uterus contracts to become firm with fundus around umbilicus area
3. Bloody Lochia x 3 days postpartum eventually becoming white/yellow in 3 wks (comes from shedding of residual uterine decidua)
4. Breast Engorgement
5. Peripheral Edema
166
How do Prostaglandins "ripen" the cervix during induction?
degenerates cervical connective tissue --\> softens and effaces cervix for induction
## Footnote
*ex: misoprostol, dinoprostone*
167
Biophysical Profile and Contraction Stress Test can either or be used to assess for fetal hypoxia in high risk pregnancies
How do you perform a Contraction Stress Test?-2 ; What are the contraindications?
1. Give Oxytocin to induce contractions and watch fetal heart tracing OR
2. Nipple Stimulate until 3 contractions every 10 min occur
CTX = any ctx to labor itself (as both of these can --\> active labor) - ex: placenta previa, prior myomectomy
168
How do you manage SEVERE Preeclampsia when it occurs ≥ 34WG?
*It's the same as PPROM!*
169
How do you manage SEVERE Preeclampsia when it occurs \< 34WG? - 2
*It's the same as PPROM! Evaluate Fetal well-being first*
170
CP for Ovarian Torsion - 3
1. **Palpable adnexal mass**
2. abrupt uL pelvic pain
3. NV
171
What are the complications for the fetus when exposed to acute uteroplacental insufficiency (i.e. abruptio placenta) and chronic uteroplacental inusufficinecy (i.e. preeclampsia)?
**ACUTE** uteroplacental insufficiency --\> fetal hypoxic brain injury
vs
**Chronic** uteroplacental insufficiency--\> asymmetric IUGR /SGA & oligohydramnios
172
Clinical criteria for Arrest of "Active Labor Stage 1B" - 2 ; Tx?
Occurs once pt reaches *Active* Labor ( ≥6cm dilated) and...
1. No cervical dilation for ≥4 hours despite [adequate contractions: ≥200 MonteVideoUnit q10 min]
OR
2. No cervical dilation for ≥6 hours despite inadequate contractions
* Tx = c/s*
173
Clinical criteria for "Labor Protraction" of Active Labor Stage 1B - 2
Occurs once pt reaches *Active* Labor ( ≥6cm dilated) and...
1. slower than 1-2 cm/hr dilation
2. +/- inadequate contractions
*Tx = oxytocin*
174
Epidural Anesthesia causes hypOtension in \_\_\_% of pregnant pts when given during Active Labor
What is the mechanism for this?
10%
## Footnote
Sympathetic nerve fibers are anesthetized --\> vasoDilation --\> venous pooling --\> ⬇︎venous return --\> ⬇︎Cardiac Output
*Prevent this by giving IVF prior to epidural, L lateral decubits position and vasopressors if needed*
175
What is the antidote for Magnesium Toxicity?
## Footnote
*Risk Factor for Mg toxicity = Renal Insufficiency*
Ca+Gluconate
## Footnote
*Risk Factor for Mg toxicity = Renal Insufficiency since it's renal excreted!!*
176
What are the **common** side effects of Magnesium administration? - 3
1. HA
2. Flushed
3. Nausea
177
What is the most common cause of postpartum fever? When does this fever usually present? Tx?
**ENDOMETRITIS** ; \> 24 hours postpartum ; [Clindamycin + Gentamicin]
## Footnote
*You do NOT need cx for this dx!*
178
Abx for Lactational mastitis?
Dicloxacillin
## Footnote
*covers MSSA and GASP*
179
A placenta is close to the internal cervical os
How far away does the placenta have to be from the cervical os to NOT be considered placenta previa
\>2 cm away from os
180
Why is it normal for pregnant patients to have a systolic ejection murmur
⬆︎Stroke volume during *early* pregnancy --\> ⬆︎Cardiac Ouput AND ⬆︎HR during *late* pregnancy --\> even more ⬆︎Cardiac Output
## Footnote
*Also, Volume expansion can --\> peripheral edema and their body compensates by ⬇︎BP*
181
How does pregnancy affect the respiratory system? - 2
Progesterone ⬆︎tidal volume for more O2 (pt takes deeper breaths) --\> physiologic hyperventilation and this --\> physiologic respiratory alkalosis (PaCO2 27-32) - eventually kidneys compensate by dumping HCO3
+
enlarging uterus ⬇︎ functional residual capacity
Both cause pregnancy dyspnea
182
What is often the cause of Early Decelerations on Fetal Heart Tracing
**Head Compression** of Fetus
## Footnote
*these occur WITH contractions and no tx is required*
183
Clinical Criteria for Arrest of Labor Stage 2 - 2
*Occurs once pt is **P**ushing and dilated to 10 cm but has **insufficient fetal descent after**:*
1. ≥ 3 hours if nulliparous OR
2. ≥ 2 hours if multiparous
184
What are the causes of Labor Stage 2 ? - 3
1. **FETAL MALPOSITION** (occiput faces transverse or posterior instead of Anterior) --\> cephalopelvic disproportion
2. Cephalopelvic disproportion
3. Inadequate contractions (possibly from maternal exhaustion)
## Footnote
RF: Maternal obesity, DM
185
What is the difference between fetal Malpresentation and Malposition?
Malpresentation = lowest part of the fetus in pelvis is NOT the vertex (i.e. face, breech)
vs
Malposition = relationship of the fetal presenting part to the pelvis (occiput anterior vs transverse vs posterior)
186
Shoulder Dystocia can cause multiple neonatal sequelae
What are they? - 5
187
Shoulder Dystocia can cause multiple neonatal sequelae. **Klumpe Palsy** is one of those possible sequelae
What is it caused by specifically? - 2
Impingement (or avulsion) of
1. cervical fibers at **C8** and **T1 --\>** L hand paralysis (klumpke claw)
2. sympathetic fibers running along **C8** and **T1** --\> Horner Syndrome = poorer outcome if present
188
What all labs should be ordered for the Initial prenatal visit? - 11
1. RhD type and antibody screen
2. CBC Hgb studies
3. HIV
4. RPR syphillis
5. HepB surface antigen
6. Rubella immunity
7. Varicella immunity
8. Chlamydia PCR
9. Urine cx CLEAN CATCH
10. Urine protein
11. Pap test (if indicated)
189
What all labs should be ordered for the 24-28WG prenatal visit? - 3
1. Hgb & Hct
2. Oral Glucose Challenge Test 1 hr - 50gram load (if positive confirm with 3 hr 100gm load)
3. Antibody screen if pt RhD negative
## Footnote
*After 1st trimester, placenta secretes hormones that ⬆︎maternal physiologic insulin resistance so that baby gets more sugar. But if maternal pancreas cant overcome this resistance by secreting more insulin it can --\> gestational DM*
190
Why are some women at risk for developing gestational DM after the 1st trimester?
After 1st trimester, placenta secretes hormones that ⬆︎maternal physiologic insulin resistance so that baby gets more sugar. But if maternal pancreas cant overcome this resistance by secreting more insulin it can --\> gestational DM
## Footnote
*Dx = Oral Glucose Tolerance Test*
191
When is a NST indicated? - 2
1. 32-34WG in high risk pregnancies OR
2. ⬇︎fetal movements
## Footnote
*the most common cause of NONreactive NST is fetal sleep cycle so be sure to allow at least 40 min testing and use vibroacoustic stimulation to wake them up!*
192
What is the most accurate method of determining gestational age?
**FIRST** trimester US with crown to rump length (since there is minimal variability of fetuses when they first start off)
193
After the ____ is used as the most accurate method to determine gestational age, what can be used as secondary? - 6
**FIRST trimester US is most accurate**
1. fundal height if \> 20WG
2. fetal abd cirucumference
3. fetal biparietal diameter
4. fetal femur length
5. fetal head circumference
6. LMP
194
Dx for Ovarian Torsion
**Pelvic US** revealing adnexal mass with absent Doppler flow
195
A Woman comes in with c/o breast engorgement (BL tender, swollen, firm) after she elected to not breast feed
How do you induce Lactation suppresion? - 3
1. NSAIDs for pain/inflammation
2. COMFORTABLE Bra that **avoids nipple stimulation**
3. Cool Compress to breast
## Footnote
*Engorgement in and of itself eventually --\> Lactation suppresion on its own due to negative feedback! do NOT breast bind as this causes mastitis. Don't use drugs to treat this.*
196
Ovarian Torsion is more common amongst \_\_\_\_\_[pre/post] menopausal women
**PRE**menopausal
## Footnote
*Untreated ovarian torsion --\> sepsis, chronic pelvic pain and infertility*
197
What is Culdocentesis? ; What is it used for?
centesis of intraperitoneal fluid thru the cul-de-sac via vaginal aspiration ; No longer used and has been replaced by US for identifying pelvic free fluid
198
How do you diagnose Endometriosis?
**LAPORASCOPY** to biopsy & remove endometriotic lesions
## Footnote
*1st, treat empirically with NSAIDs tho*
199
What is the MOST IMPORTANT intervention for preventing vertical HIV transmission from Mom to baby? ; What are 2 other less important methods?
**Triple Antiretroviral therapy** (2 NRTI + 1 NNRTI or 1 PI)
## Footnote
*Also, c/s if viral load is \> 1000 and Zidovudine given to neonate for ≥6 wks after birth are also good but not most important*
200
What is the precaution in a pregnant woman with Graves' disease?
Mom's **Thyroid stimulating Ab** (anti-TSH R Ab) can cross the placenta and stimulate the baby's thyroid gland --\> Thyrotoxicosis
## Footnote
Baby's tx = methimazole + Beta Blcoker
201
[T or F] Thyroid hormones (T4 and T3) can NOT cross the placenta during pregnancy
TRUE! - only the thyroid stimuating Ab can cross and that's only during 3rd trimester
202
What's the only maternal Antibody that has the ability to cross the placenta? ; why does it do this?
Ig**G**; protects neonate for first 3 months of life
203
CP for Amniotic Fluid Embolism - 4
1. ARDS (intubate and ventilate them STAT!)
2. Cardiogenic shock
3. Seizures/Coma
4. DIC
## Footnote
*RF = Multiparity, Advanced maternal age, Placental demise and c/s*
204
Fetal Hydantoin Syndrome results from intrapartum usage of ____ or \_\_\_\_\_
Describe the CP of the baby for this - 5
phenytoin, carbamazepine
1. microcephaly --\> developmentally delay
2. midfacial hypoplasia
3. cleft lip and palate
4. digital hypoplasia
5. hirsutism
205
How does Peripartum Cardiomyopathy present? ; When during the pregnancy does this present?
**Rapid** Heart Failure (SOB, cough, pedal edema) ; \> 36WG
206
What type of shoulder dislocation are Violent Muscle Contractions associated with
POSTERIOR
207
Mode of inheritance for Hemophilia A
X-linked recessive
208
What's the time limit for pregnant women in Latent labor Stage 1A if they're nulliparous? ; What about if they're multiparous?
*Labor = (LA)PD*
## Footnote
**1A: L**atent phase = Strong Contractions q3-5 min **(should be ≤20 hrs for nulliparous pts and 14 hrs for multiparous pts)**
**1B:** **A**CTIVE phase = Cervix is now 6 cm Dilated, [growing @ 1-2 cm/hr] and effacing
**2** : **P**ushing Time! since Cervix is now 10 cm FULLY DILATED (should be ≤3 hrs for nulliparous and 2 hrs for multiparous)
**3 : D**elivery of Baby! and then Deliver Placenta
209
What's the time limit for pregnant women in Labor Stage 2 if they're nulliparous? ; What about if they're multiparous?
*Labor = (LA)PD*
## Footnote
**1A: L**atent phase = Strong Contractions q3-5 min (should be ≤20 hrs for nulliparous pts and 14 hrs for multiparous pts)
**1B:** **A**CTIVE phase = Cervix is now 6 cm Dilated, [growing @ 1-2 cm/hr] and effacing
**2** : **P**ushing Time! since Cervix is now 10 cm FULLY DILATED **(should be ≤3 hrs for nulliparous and 2 hrs for multiparous)**
**3 : D**elivery of Baby! and then Deliver Placenta
210
What's the time limit for pregnant women in Labor Stage 3?
*Labor = (LA)PD*
## Footnote
**1A: L**atent phase = Strong Contractions q3-5 min (should be ≤20 hrs for nulliparous pts and 14 hrs for multiparous pts)
**1B:** **A**CTIVE phase = Cervix is now 6 cm Dilated, [growing @ 1-2 cm/hr] and effacing
**2** : **P**ushing Time! since Cervix is now 10 cm FULLY DILATED (≤3 hrs for nulliparous and 2 hrs for multiparous)
**3 : D**elivery of Baby! and then Deliver Placenta **(≤30 min)**
211
What are the stages of Labor?
*Labor = (LA)PD*
**1A: L**atent phase = Strong Contractions q3-5 min (should be ≤20 hrs for nulliparous pts and 14 hrs for multiparous pts)
**1B:** **A**CTIVE phase = Cervix is now 6 cm Dilated, [growing @ 1-2 cm/hr] and effacing
**2** : **P**ushing Time! since Cervix is now 10 cm FULLY DILATED (≤3 hrs for nulliparous and 2 hrs for multiparous)
**3 : D**elivery of Baby! and then Deliver Placenta **(≤30 min)**
https://www.youtube.com/watch?annotation\_id=annotation\_563008&feature=iv&src\_vid=Xath6kOf0NE&v=ZDP\_ewMDxCo
212
Why is there no use in getting a D-dimer in a pregant woman for DVT workup?
D-dimer is already **naturally elevated** in pregnant woman due to their physiological ⬆︎ fibrinogen
213
What is the disadvantage of using Progestin only OCP for contraceptive?
You have to take it every day **DOWN TO THE EXACT HOUR** or it will fail! = compliance issues
