OBGYN Lectures Flashcards
1
Q
Lecture 1 : Menarche
A
time of the first menstrual cycle in life
2
Q
Hypermenorrhea (menorrhagia)
A
prolonged or excessively heavy uterine bleeding with normal periodicity
3
Q
Metrorrhagia
A
uterine bleeding at irregular intervals (abnormal periodicity)
4
Q
Menometrorrhagia
A
prolonged or excessive uterine bleeding occurring irregularly
5
Q
Polymenorrhea
A
menstrual intervals <21 days
6
Q
Oligomenorrhea
A
menstrual intervals >35 days
7
Q
Menopause
A
no menstruation in 12 consecutive months
8
Q
What is the estimated duration of pregnancy from the 1st day of the Last Menstrual Period (LMP)?
A
40 weeks or 280 days from the 1st day of the LMP.
9
Q
What rule is used to estimate the due date for a pregnancy?
A
Naegele’s rule.
10
Q
What is Naegele’s rule for calculating the Estimated Date of Delivery (EDD)?
A
Add 9 months and 7 days to the first day of the last menstrual period (LMP), or subtract 3 months and add 7 days.
11
Q
How does Naegele’s rule account for menstrual cycles?
A
It assumes a 28-day cycle but can accommodate cycles between 21-35 days.
12
Q
What is important about the first day of the cycle in determining the Estimated Date of Delivery (EDD)?
A
The first day of the cycle must be accurate.
13
Q
What can be used in the first trimester to help confirm the Estimated Date of Delivery (EDD)?
A
A first trimester ultrasound using CRL (Crown-Rump Length) measurement.
14
Q
What is the definition of a miscarriage?
A
A miscarriage is the spontaneous end of a pregnancy before 24 completed weeks of gestation, with no vital signs, and fetal weight <500g.
15
Q
What is a “threatened” miscarriage?
A
In a threatened miscarriage, the patient experiences contractions and/or bleeding, but the embryo/fetus remains inside the uterus with the cervical os closed. The patient is at risk of miscarriage.
16
Q
What characterizes an “inevitable” miscarriage?
A
An inevitable miscarriage is when the cervical os begins to open.
17
Q
What is a “complete” miscarriage?
A
A complete miscarriage occurs when all products of conception have been expelled from the uterus.
18
Q
What is an “incomplete” miscarriage?
A
An incomplete miscarriage is when only some products of conception have been expelled, with tissue remaining in the uterus.
19
Q
What is a “missed” (silent) miscarriage?
A
A missed miscarriage occurs when the embryo or fetus is no longer alive, but there are no physical signs of miscarriage.
20
Q
What is a “septic” miscarriage?
A
A septic miscarriage occurs when tissue from a missed or incomplete miscarriage becomes infected.
21
Q
What is “recurrent” (habitual) abortion?
A
Recurrent abortion is defined as having more than 2 consecutive miscarriages.
22
Q
What is an ectopic pregnancy?
A
An ectopic pregnancy is a complication of pregnancy where the embryo implants outside the uterine cavity.
23
Q
What is a tubal pregnancy?
A
A tubal pregnancy is a type of ectopic pregnancy where the embryo implants in the fallopian tube.
24
Q
What are the locations within the fallopian tube where an ectopic pregnancy can occur?
A
The locations include the fimbrial, ampullar, isthmic, and interstitial regions of the fallopian tube.
25
Where can an ectopic pregnancy occur outside of the fallopian tube?
Ectopic pregnancies can also occur in the abdomen, ovary, or cervix.
26
What is a heterotopic pregnancy?
A heterotopic pregnancy is when there is a simultaneous intrauterine and ectopic pregnancy.
27
What are the key uterine ligaments in the female pelvis?
The uterine ligaments include the broad ligament, round ligament, cardinal ligament, uterosacral ligament, and pubo-vesical (pubo-cervical) ligament.
28
What is the anatomical significance of the phrase "bridge over water" in the female pelvis?
The phrase "bridge over water" refers to the topography of the ureter as it passes underneath the uterine artery.
29
Which arteries are major vessels in the female pelvis?
Major arteries include the common iliac artery, internal iliac artery, uterine artery, inferior vesical artery, medial vesical artery, vaginal artery, umbilical artery (medial umbilical ligament), and medial rectal artery.
30
Which artery in the female pelvis forms an anastomosis with branches of the external iliac artery?
The uterine artery forms anastomoses with branches of the external iliac artery.
31
What is the true conjugate diameter of the pelvic inlet?
The true conjugate diameter is the distance between the midpoint of the sacral promontory and the superior border of the pubic symphysis, measuring approximately 12.5 cm.
32
What is the obstetric conjugate diameter?
The obstetric conjugate diameter is the distance between the midpoint of the sacral promontory and the nearest point on the posterior surface of the pubic symphysis, measuring about 11.5 cm.
33
What is the diagonal conjugate diameter?
34
What are the transverse and oblique diameters of the pelvic inlet?
The transverse diameter refers to the widest horizontal distance across the pelvic inlet, while the oblique diameter is the distance from one iliac to the opposite sacroiliac joint.
35
What does "gravida" refer to in obstetric terminology?
Gravida refers to the total number of pregnancies a woman has had, regardless of outcome.
36
What does "parity" refer to in obstetric terminology?
Parity refers to the number of pregnancies that have reached 20 weeks of gestation or more, regardless of the outcome.
37
How is gestational age defined?
Gestational age is the number of completed weeks from the first day of the last menstrual period (LMP).
38
What defines each trimester of pregnancy?
1. First trimester: <12 weeks (embryo)
2. Second trimester: 12-24 weeks (fetus)
3. Third trimester: 24-40 weeks
39
What is considered a miscarriage?
A miscarriage is the spontaneous end of a pregnancy before 24 weeks of gestation.
40
What criteria define a birth?
A birth is defined as occurring at 24 weeks or later, with a weight of 500 grams or more, and involves a viable fetus.
41
What is a preterm birth?
A preterm birth occurs between 24 and 37 weeks of gestation, with the fetus weighing 500 grams or showing signs of life.
42
What is a stillbirth?
A stillbirth is the birth of a newborn after the age of viability (>24 weeks) with no vital functions at birth.
43
What is a postterm birth (postmaturity)?
A postterm birth, or postmaturity, occurs when the fetus has not yet been born after 42 weeks of gestation.
44
What does "lie" refer to in obstetric terms?
Lie refers to the relationship of the long axis of the fetus to the long axis of the uterus, and can be longitudinal, oblique, or transverse.
45
What are the types of fetal presentation?
Fetal presentation describes which anatomical part of the fetus is closest to the pelvic inlet just before birth: cephalic, breech, or shoulder presentation. Specific types include vertex, deflected vertex, brow, and face presentations.
46
What does "position" refer to in obstetric terms?
Position refers to the relationship of the denominator of the presenting part to the inlet of the maternal pelvis, such as occipito-anterior.
47
What is "engagement" in obstetrics?
Engagement occurs when the widest part of the presenting part of the fetus (usually the head) has successfully passed through the true pelvic inlet.
48
What does "station" refer to in obstetric terms?
Station refers to the position of the presenting part of the fetus in relation to the ischial spines of the maternal pelvis, measured in centimeters from 1/5 (above the spines) to 5/5 (below the spines).
49
What is a "malposition" in obstetrics?
Malposition refers to an abnormal position of the fetal presenting part relative to the maternal pelvis, which may complicate labor.
50
What are key aspects to examine when assessing external genitalia?
Examine vulva, Bartholin glands, hair distributions, skin, size of the clitoris, and any evidence of trauma.
51
What is the purpose of using a Cusco speculum during an examination?
The Cusco speculum is used to visualize the vaginal mucosa, assess discharge, and check vaginal pH.
52
What should be done to ensure comfort and accuracy when using a speculum?
Ensure muscle relaxation and apply a lubricant to facilitate insertion and examination.
53
What can be assessed during a bimanual examination?
The bimanual examination evaluates the size, shape, symmetry, mobility, position, and consistency of the uterus.
54
What does "version" refer to in relation to the uterus?
Version refers to the position of the uterus relative to the vaginal axis, such as anteverted or retroverted.
55
What does "flexion" refer to in relation to the uterus?
Flexion refers to the position of the uterine fundus relative to the vaginal axis, such as retroflexed.
56
What is the purpose of a rectal or recto-vaginal examination?
To assess conditions like cervical cancer or cul-de-sac endometriosis.
57
What does an ultrasound of the uterus typically evaluate?
An ultrasound evaluates the size, shape, and endometrium of the uterus, as well as the adnexa (ovaries and fallopian tubes).
58
What is colposcopy used for?
Colposcopy is used to closely examine the cervix, vagina, and vulva for signs of disease.
59
What areas are assessed during the abdominal portion of a pelvic examination?
The abdomen is examined for any abnormalities or signs related to the pelvic organs.
60
What is examined during the assessment of the external genitalia?
The vulva and Bartholin glands are assessed, including hair distribution, skin condition, size of the clitoris, and any evidence of trauma.
61
What tool is used in a speculum examination?
A Cusco speculum is used for the examination.
62
What areas are evaluated during a speculum examination?
The vaginal mucosa, discharge, pH, vaginal wall relaxation, and the presence of uterine prolapse or descensus are evaluated.
63
What procedure involves examining the cervix under magnification?
Colposcopy.
64
What is assessed during a bimanual examination of the uterus?
The uterus is assessed for size, shape, symmetry, mobility, position, and consistency.
65
What is uterine version?
Uterine version refers to the position of the uterus relative to the vaginal axis, such as being anteverted.
66
What is uterine flexion?
Uterine flexion refers to the position of the uterine fundus relative to the vaginal axis, such as being retroflected.
67
What conditions can be evaluated with a rectal or recto-vaginal examination?
Cervical cancer and cul-de-sac endometriosis can be evaluated during a rectal or recto-vaginal examination.
68
What can be assessed through ultrasound in a pelvic examination?
The ultrasound can assess the size and shape of the uterus, the endometrium, and the adnexa.
69
What are the key methods for cervical cancer screening?
Cytology-based screening and HPV screening.
70
What is a limitation of cytology-based cervical cancer screening?
It is subjective and has a lower sensitivity (70-80%).
71
What system is used for interpreting cytology-based cervical cancer screening results?
The Bethesda system (Papanicolau).
72
What are the two main types of cytology-based screening for cervical cancer?
Conventional smear and liquid-based cytology.
73
At what age is HPV screening recommended?
HPV screening is recommended for women above 30 years of age.
74
Why is HPV screening not commonly recommended for women under 30 years of age?
There is a high prevalence of transient HPV infection in women under 30.
75
What type of sample can be used for HPV screening?
A self-obtained sample.
76
What is an HPV co-test?
An HPV co-test is a screening method that combines HPV testing with cytology.
77
When is screening for STDs recommended during a pelvic exam?
Screening for STDs is recommended when symptoms are present or before IVF procedures.
78
What are the possible Papanicolau (Pap smear) results in cytology-based screening?
P0, P1, P2, P3, P4, P5.
79
What is the Bethesda system used for in cytology-based screening?
The Bethesda system (updated in 1988, 1991, 2001, 2014) is used for specimen adequacy, general categorization, interpretation, and suggestions for review schedule, sampling, and co-test.
80
What does ASC-US, ASC-H, LSIL, and HSIL stand for in the Bethesda system?
ASC-US: Atypical Squamous Cells of Undetermined Significance
ASC-H: Atypical Squamous Cells, cannot exclude HSIL
LSIL: Low-Grade Squamous Intraepithelial Lesion
HSIL: High-Grade Squamous Intraepithelial Lesion
81
What are AGC, AGC-NOS, and AIS in the context of cervical cytology?
AGC: Atypical Glandular Cells
AGC-NOS: Atypical Glandular Cells Not Otherwise Specified
AIS: Adenocarcinoma in Situ
82
What does the cervical index C2111 represent?
C2111 is a specific cervical index used for assessing cervical effacement and dilatation, though the exact values are not specified in the image.
83
What is cervical effacement and dilatation?
Cervical effacement refers to the thinning of the cervix, while dilatation refers to the opening of the cervix during labor.
84
What is the Bishop score used for in cervical assessment?
The Bishop score assesses cervical readiness for labor based on consistency, effacement, dilatation, and the fetal head's station.
85
What are the components of the Bishop score?
Consistency (firm, medium, soft)
Effacement (%)
Dilatation (cm)
Station (head position relative to the ischial spine)
86
What is the cervical index C2111 used for?
The cervical index C2111 is used to assess cervical favorability for labor, evaluating factors such as position, consistency, effacement, dilation, and station of the fetal head.
87
What mnemonic is used to remember the components of the cervical index assessment?
Mnemonic: BISHOP
B: (unknown)
I: Effacement
S: Station
H: Hard or soft (consistency)
O: Opening
P: Presenting part
88
What are the scoring components of the Bishop score?
Position: Posterior (0), Mid (1), Anterior (2-3)
Consistency: Firm (0), Medium (1), Soft (2-3)
Effacement: 0-30% (0), 40-50% (1), 60-70% (2), >80% (3)
Dilation: Closed (0), 1-2 cm (1), 3-4 cm (2), >5 cm (3)
Station: -3 (0), -2 (1), -1 (2), >0 (3)
89
What is the purpose of palpating the uterine fundus?
Palpating the uterine fundus helps compare the fundal height with anatomical landmarks like the symphysis, umbilicus, and xiphisternum to assess fetal growth and gestational age.
90
Where is the uterine fundus typically located at 24 weeks of gestation?
At 24 weeks, the uterine fundus is usually at the level of the umbilicus.
91
How is the symphysial-fundal height measured, and what is the normal growth rate?
The symphysial-fundal height is measured from the symphysis pubis to the top of the uterus. At 20 weeks, it is about 20 cm, and it grows approximately +1 cm per week.
92
What are Leopold maneuvers?
Leopold maneuvers are a series of abdominal palpation techniques used to determine fetal position, presentation, and engagement in the uterus.
93
What is the typical length of the menstrual cycle?
The menstrual cycle typically lasts between 21 and 35 days.
94
Which system regulates the menstrual cycle?
The hypothalamus-pituitary-ovarian axis regulates the menstrual cycle.
95
How do positive and negative feedback mechanisms play a role in the menstrual cycle?
Positive and negative feedback mechanisms regulate hormone levels, such as estrogen and progesterone, throughout the menstrual cycle.
96
When does the follicular phase of the menstrual cycle begin?
The follicular phase begins with the onset of menses (menstruation).
97
What is the luteal phase of the menstrual cycle, and how long does it last?
The luteal phase follows ovulation and typically lasts 14 days.
98
How is body temperature used in menstrual cycle diagnostics?
Body temperature is measured to detect ovulation, as it typically rises slightly after ovulation due to increased progesterone levels.
99
What is hormone cytology, and how is it used in cycle diagnostics?
Hormone cytology involves examining a vaginal smear to assess hormone levels and the stages of the menstrual cycle.
100
How does cervical mucus change during ovulation?
During ovulation, cervical mucus becomes more distensible and shows arborization (ferning pattern) when dried, indicating fertility.
101
What is the purpose of an endometrial biopsy in cycle diagnostics?
An endometrial biopsy (curettage) is used to assess the health and readiness of the endometrium, particularly for diagnosing cycle abnormalities or infertility.
102
What role does ultrasound (US) play in diagnosing the menstrual cycle?
Endometrial ultrasound is used to evaluate the thickness and structure of the endometrium during different phases of the menstrual cycle.
103
What is folliculometry, and how is it used in cycle diagnostics?
Folliculometry is the process of using ultrasound to track the growth and development of ovarian follicles, helping to assess ovulation.
104
What clinical signs can indicate ovulation?
Clinical signs of ovulation include breast tenderness, midcycle pain (mittelschmerz), midcycle spotting, and postovulatory stress.
105
Which hormone tests are important for diagnosing the menstrual cycle, particularly in the context of infertility?
Hormone tests for baseline hormone levels, luteinizing hormone (LH), and progesterone (P) are important for diagnosing cycle issues related to infertility.
106
Why are cycle diagnostics significant in cases of infertility?
Cycle diagnostics help determine if ovulation is occurring normally and whether the endometrium and hormonal environment are conducive to conception, which is crucial for addressing infertility.
107
What is the significance of screening in the prevention of cervical cancer?
Screening can prevent cervical cancer by detecting Cervical Intraepithelial Neoplasia (CIN) before it progresses to cancer, as it is a multi-year transformation process.
108
What are the components of cervical cancer screening?
Cervical cancer screening includes:
Colposcopic examination
Exfoliative oncocytology (Pap smear)
HPV screening (especially in cases of suspected cytology or viral infection)
109
When is HPV screening recommended in cervical cancer screening?
HPV screening is recommended when cytology is suspicious or there is a suspected viral infection (e.g., coliocytosis).
110
What test provides a definitive diagnosis in cervical cancer screening?
A histological examination provides a definitive diagnosis in cervical cancer screening.
111
What does "Secunder prevention" refer to in the context of precancerous lesions?
It refers to preventive measures taken after the initial detection of precancerous lesions.
112
How are precancerous lesions assigned according to the involvement of layers of the epithelium?
The lesions are assigned as CIN I, CIN II, or CIN III based on the extent of epithelial layer involvement.
113
What is CIN I (low grade SIL)?
CIN I is a condition where the basal one third of the epidermis is affected.
114
What is CIN II (high grade SIL)?
CIN II is a condition where two thirds of the epithelium is affected.
115
What is CIN III (high grade SIL)?
CIN III is a condition where atrial epithelial cells can also be observed in the superficial third of the epithelium.
116
What is colposcopy?
Colposcopy is a diagnostic procedure to visually examine the surface of the cervix, vagina, and vulva using a magnifying device.
117
How does the application of acetic acid solution and Lugol solution help during a colposcopy?
They help to visualize the abnormal epithelium on the surface of the cervix.
118
How is the cervical surface divided during a colposcopy?
The cervical surface is divided into three concentric zones (A, B, C) and examined clockwise to the appropriate zone.
119
What is the purpose of a pelvic examination in the context of cervical cancer?
Cervical cancer screening
120
What are the types of cytology-based screening methods for cervical cancer?
Conventional smear and liquid-based cytology
121
What is the sensitivity of cytology-based cervical cancer screening?
Subjective, with a lower sensitivity of 70-80%
122
What is the Bethesda system (Papanicolaou) used for?
It is used for classifying cervical cytology results.
123
When is HPV screening recommended?
For individuals above 30 years of age
124
What is HPV co-testing?
It is a combined screening method for both HPV and cytology.
125
When else might a pelvic examination be conducted besides cervical cancer screening?
Screening for STDs, evaluating symptoms, or before IVF procedures.
126
What controls the menstrual cycle?
The hypothalamus and the hypophysis (pituitary gland).
127
What does the hypothalamus release to regulate the menstrual cycle?
GnRH (Gonadotropin-Releasing Hormone)
128
What is the role of GnRH in the menstrual cycle?
GnRH stimulates the anterior part of the hypophysis (pituitary gland) to release FSH (Follicle-Stimulating Hormone) and LH (Luteinizing Hormone).
129
How is GnRH typically released?
GnRH is normally released in pulses, and the frequency of these pulses determines the production of FSH and LH.
130
What is the median length of a menstrual cycle?
28 days from the first day of one period to the first day of the next.
131
At what age does menarche typically occur?
Around 12 years of age.
132
Between what ages does menopause typically occur?
Usually between 45 and 55 years of age.
133
What are the two main cycles included in the menstrual cycle?
The ovarian cycle and the uterine cycle.
134
What phases do the ovaries alternate between during the menstrual cycle?
The luteal and follicular phases
135
What happens to the follicles during the menstrual cycle?
Follicles begin developing, and one or more become dominant while the others die.
136
When does ovulation occur in relation to the LH surge?
Ovulation occurs about 10–12 hours after the LH surge.
137
What happens to the dominant follicle after ovulation?
It transforms into a corpus luteum.
138
What happens to the corpus luteum if implantation does not occur within 14 days?
The corpus luteum degenerates, causing a sharp drop in levels of both progesterone and estrogen.
139
What is the first part of the menstrual cycle called?
The follicular phase
140
What does rising FSH level stimulate in the ovarian follicles?
It stimulates folliculogenesis (the development of ovarian follicles).
141
What determines which follicle will continue to maturity?
The dominant follicle, which has the most FSH receptors.
142
What role does LH play in follicular development?
LH stimulates further development of the ovarian follicle.
143
What is a matured follicle called and what does it contain?
A matured follicle is called an antral follicle, and it contains the ovum.
144
What do the theca cells secrete in response to LH?
Theca cells secrete androstenedione.
145
What is the role of granulosa cells in follicular maturation?
Granulosa cells have FSH receptors and convert androstenedione to estrogen using the aromatase enzyme.
146
How does estrogen affect FSH and LH production?
Estrogen inhibits further production of FSH and LH through negative feedback.
147
How do rising estrogen levels affect the hypophysis?
Rising estrogen levels make the hypophysis (pituitary gland) more responsive to GnRH.
148
How does increased estrogen level influence FSH and LH secretion?
Increased estrogen levels signal for more FSH and LH secretion (positive feedback).
149
When does the peak of FSH and LH occur in relation to ovulation?
The peak of FSH and LH occurs before ovulation and leads to the rupture of the antral follicle.
150
When does ovulation occur after the LH peak?
Ovulation occurs approximately 12 hours after the LH peak.
151
What role does LH play in ovulation and corpus luteum formation?
LH initiates ovulation around day 14 and stimulates the formation of the corpus luteum.
152
What does the corpus luteum produce and release following further stimulation by LH?
The corpus luteum produces and releases estrogen, progesterone, and inhibin, which inhibits further secretion of LH.
153
How does the mature egg compare in size to other human cells?
The mature egg is the largest human cell, about 0.1 mm in size.
154
What is the luteal phase of the ovarian cycle and how does it correspond to the uterine cycle?
The luteal phase is the final phase of the ovarian cycle and corresponds to the secretory phase of the uterine cycle.
155
What role do FSH and LH play during the luteal phase?
FSH and LH cause the formation of the corpus luteum, which produces progesterone.
156
How does progesterone affect estrogen production during the luteal phase?
Progesterone induces the production of estrogen.
157
How do progesterone and estrogen levels affect FSH and LH production?
Progesterone and estrogen suppress the production of FSH and LH, which are necessary to maintain the corpus luteum.
158
What happens to FSH and LH levels during the luteal phase and what is the result?
FSH and LH levels fall quickly, leading to the atrophy of the corpus luteum.
159
What triggers menstruation in the luteal phase?
Falling levels of progesterone lead to menstruation.
160
How long does the luteal phase typically last?
The luteal phase typically lasts approximately two weeks.
161
What marks the beginning of the menstrual cycle?
Menstruation marks the first phase of the cycle.
162
What initiates menstruation?
Menstruation is initiated by falling levels of estrogen and progesterone and the release of prostaglandins, which lead to the constriction of spiral arteries.
163
What happens to the blood supply to the endometrium during menstruation?
The blood supply to the endometrium is broken, leading to the superficial layer of the endometrium (stratum functionalis) becoming deprived of oxygen.
164
What happens to the endometrial layers during menstruation?
The superficial layer (stratum functionalis) is lost, leaving only the stratum basalis in place.
165
How long does menstruation typically last?
Menstruation typically continues for 2–6 days.
166
What is the usual volume of blood loss during menstruation?
The usual blood loss is around 30–60 milliliters.
167
What is the second phase of the menstrual cycle?
The second phase is the proliferative phase, which overlaps with the last days of the follicular phase.
168
What role does estradiol play in the proliferative phase?
Estradiol, secreted by ovarian follicles, initiates the formation of a new layer of endometrium with spiral arterioles.
169
How does increased estrogen affect cervical mucus?
Increased estrogen levels cause cervical mucus to become less viscous and have a higher pH.
170
Why does cervical mucus change during the proliferative phase?
The change in cervical mucus increases the chances of fertilization.
171
How can cervical mucus be detected during the proliferative phase?
The cervical mucus can be detected as a vaginal discharge.
172
What is the final phase of the uterine cycle, and how does it correspond to the ovarian cycle?
The final phase is the secretory phase, which corresponds to the luteal phase of the ovarian cycle.
173
What effect does progesterone have on the endometrium during the secretory phase?
Progesterone makes the endometrium receptive to the implantation of a blastocyst.
174
What is secreted during the secretory phase, and what happens to the cervical mucus?
Glycogen, lipids, and proteins are secreted, and the cervical mucus thickens.
175
How does progesterone affect blood flow and muscle contractility during the secretory phase?
Progesterone increases blood flow to the endometrial layer, reduces the contractility of the myometrium, and raises basal body temperature.
176
What does the Cervical Index help determine?
The Cervical Index helps determine the length of the cervix and its dilation at different levels (external, middle, internal cervical canal). It is measured during a bimanual vaginal examination.
177
What are the stages of cervical effacement and dilatation shown in the diagram?
1. Not effaced, not dilated
2. Fully effaced, 1 cm dilated
3. Fully effaced, fully dilated to 10 cm
178
What is the Bishop Score used for?
The Bishop Score is a pre-labor scoring system used to predict whether induction of labor will be required and to determine the optimal method of labor induction.
179
What cervical factors are considered in the Bishop Score?
The Bishop Score assesses cervical position, consistency, effacement percentage, dilation, and station (head position).
180
What is the score range for cervical effacement in the Bishop Score?
0: 0-30% effacement
1: 40-50% effacement
2: 60-70% effacement
3: >80% effacement
181
What is the score range for cervical dilation in the Bishop Score?
0: Closed (0 cm)
1: 1-2 cm
2: 3-4 cm
3: >5 cm
182
How is the station of the fetal head scored in the Bishop Score?
0: -3 station
1: -2 station
2: -1 station
3: 0 station
183
What is the mnemonic used to assess cervical favorability in cervical assessment?
The mnemonic is "BISHOP":
B: Cervical position
I: Effacement
S: Station (head position)
H: Hard or soft (consistency)
O: Opening (dilation)
P: Presenting part
184
What is the Cervical Index (C2111) used for?
The Cervical Index (C2111) is used to assess cervical favorability during labor preparation.
185
What is palpated during abdominal palpation to assess fetal growth?
The uterine fundus is palpated during abdominal palpation.
186
What anatomical landmarks are used to compare the position of the uterine fundus during palpation?
The symphysis, umbilicus, and xyphisternum are used as landmarks, and the unit of measurement is fingers.
187
At how many weeks of pregnancy does the uterine fundus typically reach the umbilicus?
The uterine fundus typically reaches the umbilicus at 24 weeks of pregnancy.
188
How is the symphysial-fundal height measured, and what is the unit of measurement?
The symphysial-fundal height is measured in centimeters (cm), typically corresponding to the number of weeks of pregnancy.
189
What is the typical symphysial-fundal height at 20 weeks of pregnancy?
At 20 weeks, the symphysial-fundal height is approximately 20 cm.
190
How much does the symphysial-fundal height increase after 20 weeks of pregnancy?
The symphysial-fundal height increases by approximately 1 cm per week after 20 weeks.
191
What are Leopold maneuvers used for?
Leopold maneuvers are used to determine the position and presentation of the fetus by abdominal palpation.
192
Demonstrate Leopold maneuver
193
Week 2 : What occurs during fertilization?
During fertilization, a sperm cell fuses with a secondary oocyte, forming a zygote.
194
What is the 4-cell stage in embryonic development?
The 4-cell stage occurs after several divisions of the zygote, resulting in four distinct cells.
195
What is the morula?
The morula is a solid ball of cells (blastomeres) formed from the division of a fertilized egg.
196
What is the blastocyst?
A blastocyst is a structure formed after the morula stage, containing an inner cell mass and a fluid-filled cavity, ready for implantation.
197
At what stage does implantation occur, and where does it happen?
Implantation occurs at the blastocyst stage, and it happens when the blastocyst embeds into the uterine lining.
198
What is zona hatching?
Zona hatching is the process where the blastocyst breaks free from the zona pellucida before implantation.
199
What happens after the blastocyst implants in the uterine wall?
After implantation, the cell mass differentiates into the epiblast and hypoblast, and the bilaminar disc is formed.
200
What key development occurs by day 10?
By day 10, the mesoderm forms, creating the three germ layers: ectoderm, mesoderm, and endoderm.
201
What is the significance of the mesoderm spreading?
The spreading of the mesoderm leads to the formation of various tissues and organs, including the heart and muscles.
202
What forms around day 23 of embryonic development?
Around day 23, the amniotic sac grows, surrounding the developing embryo for protection.
203
Week 3: What happens to morbidity and mortality rates during pregnancy compared to before and after?
Morbidity and mortality rates during pregnancy are much higher—twice as high—compared to before and after pregnancy, applying to both the mother and the fetus.
204
What can be done to lower the increased risk of morbidity and mortality during pregnancy?
Using scientific research and evidence-based practices can help optimize circumstances to lower morbidity and mortality risks during pregnancy. This is the goal of antenatal care.
205
What are the basic aims of antenatal care?
To ensure optimal maternal health
To detect and treat disorders to ensure a healthy mother and infant
206
How can optimal maternal health and infant well-being be achieved through antenatal care?
Initial health and medical history assessment
Screening tests
Educational support
Regular check-ups to monitor both mother and fetus
207
Timing of antenatal visits: How often are they scheduled until 28 weeks?
Monthly until 28 weeks.
208
Timing of antenatal visits: How often are they scheduled at 12 weeks?
At 12 weeks, the visit is scheduled according to screening exams.
209
Timing of antenatal visits: How often are they scheduled at 18 weeks?
At 18 weeks, the visit is scheduled according to screening exams.
210
Timing of antenatal visits: How often are they scheduled from 28 weeks to 36 weeks?
2-weekly until 36 weeks.
211
Timing of antenatal visits: How often are they scheduled from 36 weeks until delivery?
Weekly until delivery.
212
What immunizations are recommended during preconception care?
Rubella (MMR), Varicella, and possibly Influenza, pertussis (Di-Per-Te, DTeP).
213
What supplementation is recommended for primary prevention of neural tube defects (NTDs) during preconception care?
Folic acid (0.4 – 0.8 – 3 – 5 mg) and Iodine.
214
What supplementation is recommended for primary prevention of neural tube defects (NTDs) during preconception care?
Folic acid (0.4 – 0.8 – 3 – 5 mg) and Iodine.
215
What immunizations are recommended during preconception care?
Rubella (MMR), Varicella, and possibly Influenza, pertussis (Di-Per-Te, DTeP).
216
What supplementation is recommended for primary prevention of neural tube defects (NTDs) during preconception care?
Folic acid (0.4 – 0.8 – 3 – 5 mg) and Iodine.
217
What aspects of maternal health should be optimized during preconception care?
Diabetes mellitus, Hypertension, and Epilepsy.
218
What are the potential effects of smoking during pregnancy?
IUGR (Intrauterine Growth Restriction), perinatal mortality, and childhood neurodevelopment issues.
219
What are the effects of carbon monoxide (CO) exposure during pregnancy?
It causes placental changes.
220
How does alcohol use during pregnancy affect the fetus?
It is dose dependent and can cause Fetal Alcohol Syndrome (FAS), which includes IUGR, facial abnormalities, joint issues, and cardiac defects.
221
What are the risks associated with illicit drug use during pregnancy?
IUGR, intrauterine death (IUD), and preterm birth.
222
What are routine screening tests in pregnancy?
Haematological investigations for anaemia and haemoglobinopathies, blood group and antibodies for Rhesus disease prevention.
223
What infections are screened for during pregnancy?
Rubella, varicella, syphilis, hepatitis B and C, HIV, and GBS (Group B Streptococcus).
224
What screening is done for maternal disorders during pregnancy?
Screening for diabetes (GDM, GTT by history or universal), and urinary tract infections.
225
What tests are used to detect fetal anomalies?
Nuchal translucency, second trimester ultrasound, invasive diagnostic testing, and NIPT (Non-Invasive Prenatal Testing).
226
What dietary advice is typically given during antenatal education?
Nutritional guidance tailored to support the health of both mother and baby, including balanced intake of essential nutrients.
227
What exercise recommendations are commonly provided in antenatal education?
Safe, moderate physical activity that is appropriate for pregnancy and helps maintain overall health and well-being.
228
What is advised about coitus during antenatal education?
Guidance on safe sexual practices during pregnancy, considering individual health and any potential risks.
229
What methods are used for fetal surveillance in a low-risk pregnancy?
Observing fetal movements, checking fetal heartbeat using a Pinard stethoscope or hand-held Doppler, and checking growth through fundal height measurement.
230
What is the primary concern for fetal surveillance in a high-risk pregnancy?
Risk to the fetus mainly arises from suspected or confirmed placental insufficiency.
231
What conditions contribute to a high-risk pregnancy requiring more complex fetal surveillance?
Insulin-dependent diabetes mellitus (IDDM), twins, and Rhesus disease.
232
How is blood flow in the umbilical artery assessed?
Using Doppler ultrasound.
233
What does an increased difference between systolic and diastolic velocity in the umbilical artery indicate?
Increased placental vascular resistance.
234
What is the impact of using umbilical artery (UA) Doppler in high-risk pregnancies?
It has strong evidence of improving perinatal statistics.
235
Which other vessels can be assessed during a fetal Doppler examination?
Middle cerebral artery, descending aorta, ductus venosus, umbilical vein, and maternal uterine artery.
236
What fetal growth patterns are associated with no increased risk?
Normal, constitutionally small, and constitutionally large.
237
What fetal growth patterns are associated with increased risk?
Asymmetrically small, symmetrically small, and pathologically large (macrosomia).
238
What is considered a normal amniotic fluid volume?
500-1000 ml, with an Amniotic Fluid Index (AFI) of 70-200 mm and a single deepest pocket (SDP) of 20-80 mm.
239
What defines oligohydramnios?
AFI < 70 mm and SDP < 20 mm, indicating increased risk.
240
What defines polyhydramnios?
AFI > 200 mm and SDP > 80 mm, indicating increased risk.
241
What is antenatal cardiotocography (CTG) also known as?
NST (non-stress test).
242
What characterizes a normal antenatal CTG (reactive NST)?
Presence of accelerations, baseline variability > 5 bpm, and FHR between 110-160 bpm.
243
What indicates a non-reassuring (nonreactive) antenatal CTG?
No accelerations and reduced variability (< 5 bpm), requiring further tests such as Doppler or CST.
244
What indicates a pathological CTG?
Abnormal NST with repeated decelerations, bradycardia, and may require delivery if appropriate.
245
What components are included in a biophysical profile?
1. NST (Non-Stress Test), 2. Fetal movement (by ultrasound), 3. Fetal tone (by ultrasound, flexion-extension cycle), 4. Fetal breathing movement (by ultrasound), 5. Amniotic fluid (SDP > 20 mm).
246
What is the scoring system for a biophysical profile?
The scoring system ranges from 0 to 10.
247
Why might a biophysical profile be considered time-consuming?
Due to the comprehensive nature of the test, MBP (Modified Biophysical Profile) or Doppler may be used as alternatives.
248
What should be considered when planning an intervention for fetal risk?
Prepare for delivery by determining the timing and method (e.g., induction of labor (IOL) or cesarean section (CS)) based on the degree of fetal risk.
249
What is the recommendation for maternal steroids if the pregnancy is very preterm (< 34 weeks)?
Consider the benefit of administering maternal steroids to enhance fetal lung maturity.
250
When is immediate delivery indicated?
Immediate delivery is indicated with an abnormal NST or red flag (REDF) findings on Doppler.
251
What are the key aspects in assessing early pregnancy?
Defining the pregnancy location (intrauterine or extrauterine), measuring the gestational sac diameter (MSD), evaluating the embryo’s crown-rump length (CRL), and identifying the yolk sac.
252
What defines a missed abortion?
A missed abortion is a nonviable intrauterine pregnancy retained within the uterus without spontaneous abortion.
253
How is a nonviable pregnancy identified?
If it is an ectopic pregnancy, or if intrauterine with no embryo or yolk sac in a >25 mm MSD gestational sac, or if there is no fetal heartbeat in an embryo with >7 mm CRL.
254
How should a missed abortion diagnosis be confirmed?
The diagnosis should be confirmed by a subsequent examination, preferably by another examiner, before making the final decision to terminate the pregnancy.
255
What are the purposes of a first trimester fetal ultrasound scan?
To confirm viability, establish gestational age accurately based on fetal measurements, determine the number of fetuses and assess chorionicity and amnionicity in multiple pregnancies, detect gross fetal abnormalities, and assess for chromosomal anomalies.
256
When is the optimal time for a first trimester fetal ultrasound examination?
Between gestational weeks 11 and 13+6 days.
257
What is the main measurement for assessing fetal size at gestational weeks 11-13+6 days?
Crown-Rump Length (CRL), measured from the vertex to the last coccyx.
258
What is the optimal measurement for nuchal translucency (NT) at this stage?
NT should be under 3 mm.
259
What should be visible when measuring nuchal translucency?
The nasal bone, upper palate, translucent diencephalon, and nuchal membrane.
260
What is the required position of the fetus for accurate measurements?
The fetus should be in a horizontal plane, midsagittal section, and in a neutral position, not hyperflexed or hyperextended, and surrounded by amniotic fluid.
261
How is the presence of the nasal bone assessed in the first trimester scan?
The nasal bone should be checked for presence or absence in the scan.
262
What anatomical structures should be assessed between gestational weeks 11-13+6 days?
Cranium and brain (shape of skull, midline falx, interhemispheric fissure, normal choroid plexuses),
neck (hygroma colli or mass),
spine (longitudinal and axial views, intact skin),
thorax (homogeneous lungs),
heart (levocardia, normal anatomy),
abdomen (stomach, bladder),
abdominal wall (intact, physiological umbilical hernia until week 12),
extremities (three segments of four limbs),
amniotic fluid (subjective assessment),
placenta (location, hemorrhage, mass),
and other structures (abnormal structures intrauterine or around the uterus).
263
When is amniocentesis typically performed and what are its advantages and disadvantages?
Amniocentesis is usually performed between gestational weeks 16-20.
Advantages include high accuracy (99%) in detecting chromosomal anomalies, certain metabolic diseases, neural tube defects, and some inherited diseases. The disadvantage is a miscarriage risk of about 1%.
264
When is chorionic villous sampling (CVS) indicated and what are the reasons for its use?
CVS is performed before gestational week 15.
It is indicated in cases of high nuchal translucency (NT), other abnormal ultrasound findings, family history of chromosomal abnormalities or genetic defects, known carrier status for certain genetic diseases, or advanced maternal age (over 35 years).
265
When is the optimal time for a mid-trimester routine ultrasound scan?
Between gestational weeks 18-22
266
What are the main purposes of a mid-trimester routine ultrasound scan?
To provide accurate diagnostic information for optimized antenatal care, perform fetal measurements to detect growth abnormalities, and identify congenital malformations.
267
What is the significance of performing a mid-trimester ultrasound scan in relation to pregnancy management?
It allows time for subsequent examinations and decisions, as per Hungarian law, possible to end the pregnancy until the 24th gestational week if necessary.
268
What anatomical structures should be assessed in the head during a mid-trimester ultrasound scan?
Intact cranium, cavum septi pellucidi, midline falx, thalami, cerebral ventricles, cerebellum, and cisterna magna.
269
What are the key features to check for in the face and neck?
Both orbits present, median facial profile, nose, nostrils, mouth, intact upper lip (to exclude cleft lip), and absence of masses (e.g., cystic hygroma).
270
What should be evaluated in the chest and heart during the scan?
Normal shape/size of chest and lungs,
presence of heart activity,
four-chamber view of the heart,
detection of congenital cardiac anomalies,
septal defects, hypoplastic left heart syndrome,
persistent truncus arteriosus, echogenic intracardiac foci (EIF), aortic and pulmonary outflow tracts,
left ventricular outflow tract view (5-chamber view), right ventricular outflow tract view (3VV), three-vessel and trachea view (3VT), and no evidence of diaphragmatic hernia.
271
What abdominal structures should be assessed?
Stomach in normal position (left side), non-dilated bowel, both kidneys and bladder present (renal pelves size), cord insertion site, and exclusion of ventral wall defects like omphalocele or gastroschisis.
272
What skeletal features should be checked?
No spinal defects (e.g., spina bifida, sacral agenesis) or masses, arms and hands present with normal relationships, and legs and feet present with normal relationships.
273
What should be evaluated regarding the placenta?
Position and relationship with the internal cervical os, no masses (e.g., multiple cysts, hemorrhage, chorioangioma), and checking for an accessory lobe.
274
What should be assessed regarding the umbilical cord?
Ensure a three-vessel cord.
275
When should twin pregnancies ideally be dated using ultrasound?
When the crown-rump length (CRL) measurement is between 45 and 84 mm, typically at 11 + 0 to 13 + 6 weeks of gestation.
276
How should gestational age be estimated in spontaneously conceived twin pregnancies?
Use the larger of the two CRLs to estimate gestational age.
277
What are the roles of ultrasound in managing twin pregnancies?
Screening for aneuploidy and structural abnormalities, diagnosing and managing discordant twin pregnancies, fetal reduction or selective termination, screening for preterm birth, and screening, diagnosing, and managing fetal growth restriction (FGR).
278
When should chorionicity be determined in a twin pregnancy, and what methods are used?
Chorionicity should be determined before 13 + 6 weeks of gestation using membrane thickness at the site of insertion, identifying the T-sign or lambda sign, and the number of placental masses.
279
When is amnionicity determined in a twin pregnancy?
Amnionicity is determined at the same time as chorionicity.
280
How do chorionicity and amnionicity affect the management of a multiple pregnancy?
They determine the management plan, including monitoring and potential interventions. The types are:
DCDA (Dichorionic-Diamniotic)
MCDA (Monochorionic-Diamniotic)
MCMA (Monochorionic-Monoamniotic)
281
What is the purpose of cervical assessment in predicting preterm birth?
To assess the risk of preterm delivery in both asymptomatic and symptomatic patients, regardless of their risk status.
282
What cervical length measurement is considered at increased risk for preterm birth?
A cervical length < 25 mm at 18-23 weeks.
283
What position should the patient be in for cervical assessment, and why?
The patient should be in the gynecological position with an empty bladder for better visualization.
284
What type of ultrasound is preferred for cervical assessment and why?
Transvaginal ultrasound is preferred because it provides better visualization.
285
What sonographic parameters are used for estimating gestational age and assessing fetal size?
Biparietal diameter (BPD): Measured in a cross-sectional view of the fetal head at the level of the thalami.
Head circumference (HC).
Abdominal circumference (AC): Measured in a transverse section of the fetal abdomen, as circular as possible, with the umbilical vein at the level of the portal sinus, stomach bubble visualized, and kidneys not visible.
Femur diaphysis length (FDL): Measured as the longest axis of the ossified diaphysis.
286
How is estimated fetal weight (EFW) used in assessing fetal well-being?
EFW helps identify abnormalities in fetal size and detect potential growth problems.
287
How can amniotic fluid be assessed?
Amniotic fluid volume can be estimated subjectively or using quantitative sonographic measurements such as the deepest pocket or amniotic fluid index (AFI).
Conditions include polyhydramnios, oligohydramnios, and anhydramnios.
288
What is the typical presentation of fetal movements in a normal fetus?
Normal fetuses usually have a relaxed position and show regular movements.
289
Is the biophysical profile a routine part of fetal well-being examination?
No, the biophysical profile is not part of the routine examination.
290
What is the role of Doppler ultrasound in fetal well-being assessment?
Doppler ultrasound is used to examine fetoplacental blood flow, which is crucial for assessing fetal well-being.
291
What are the commonly used Doppler indices, and how are they calculated?
Pulsatility Index (PI) = (Peak Systolic Velocity (PSV) - End-diastolic Velocity (EDV)) / Time-Averaged Max Velocity (TAMX).
Resistance Index (RI) = (PSV - EDV) / PSV.
292
What does the Doppler measurement of the mid-cerebral artery (MCA) indicate?
The MCA Pulsatility Index (PI) and Resistance Index (RI) can be used for non-invasive detection of fetal anemia.
293
How is the Doppler measurement of the umbilical artery used in fetal assessment?
The Umbilical Artery Resistance Index (RI) and Pulsatility Index (PI) help assess placental blood flow and potential fetal distress.
294
What is the significance of the Ductus Venosus flow in Doppler ultrasound?
The Ductus Venosus flow assessment helps evaluate fetal hemodynamics and cardiac function.
295
What does the Cerebroplacental Doppler Ratio (CPR) reflect and how is it calculated?
The CPR reflects arterial redistribution during fetal hypoxemia and is calculated as the ratio of MCA-PI to Umbilical Artery PI.
It amplifies the effects of abnormal hemodynamics and correlates more closely with fetal oxygen levels.
296
How is real-time color Doppler ultrasound used in the first trimester for pre-eclampsia screening?
It is used to measure Doppler velocimetry in the uterine artery at the cervicocorporeal junction.
Measurements are taken transabdominally or transvaginally, with values reported independently for the right and left uterine arteries, and the presence of notching (NOTCH) noted.
297
What is the normal flow pattern in the uterine artery in a non-gravid state and early pregnancy?
In a non-gravid state and early pregnancy, the flow is characterized by high pulsatility with high systolic flow and low diastolic flow.
Resistance to blood flow generally decreases during gestation.
298
What does abnormal resistance in the uterine artery indicate, and how is it related to pre-eclampsia and IUGR?
Abnormally high resistance in the uterine artery can persist in pre-eclampsia and intrauterine growth restriction (IUGR).
299
What is the role of low-dose aspirin in the context of pre-eclampsia?
Low-dose aspirin significantly decreases the risk of developing early pre-eclampsia when administered starting at the time of first-trimester screening.
300
What are the key developmental stages in embryogenesis and organogenesis during the first trimester (day 14-70)?
Day 14-70: Morula, blastocyst, embryoblast, trophoblast formation.
~15 days: Germ plates formation.
~25 days: Neural tube and heart tube development.
~30 days: Pulsating heart tube and limb buds.
~40 days: Development of brain, ears, and eyes.
~50 days: Formation of fingers, external genitalia, and four-chambered heart.
~60 days: Development of pronephros (primitive kidneys).
~70 days: Differentiation of male and female external genitalia.
301
How does a potentially teratogenic insult impact development?
The consequences depend on the specific developmental processes that are ongoing at the time of exposure.
302
What is the definition of teratogens?
Teratogens are agents that may cause harm to the fetus during pregnancy. In a narrower sense, they cause fetal abnormalities, while in a wider sense, they can lead to miscarriage, intrauterine growth restriction (IUGR), and postnatal conditions such as behavioral problems and malignancies.
303
What are the types of teratogenic effects?
Direct: Physical effects such as vasoconstrictors, vasodilators, and hypoxic effects.
Indirect: Chemical effects such as pyrogens and biological effects.
304
What factors determine the embryologic consequences of cell death due to a teratogenic effect?
The consequences depend on:
The number and location of dead cells.
The potential for regeneration.
The type of cells affected:
Omnipotent cells (morula-blastocyst, Day 1-7).
Pluripotent cells (from the formation of the embryoblast, Day 8-14).
Differentiated cells (neurons, muscle cells, connective tissue, epithelium) in the neighborhood (after Day 14).
305
What are the consequences of teratogen effects if exposure occurs between Day 1-14?
Embryos: Miscarriage.
Embryo Continues: Development may continue undisturbed.
"Rule of All or Nothing": Either results in miscarriage or no effect if the embryo survives.
306
What are the potential outcomes of teratogen exposure after Day 14?
Malformation: Structural abnormalities.
Multiple Malformations: Syndrome with multiple related abnormalities.
307
What are the consequences of teratogen effects after Day 70?
No Abnormality: Typically no structural abnormality.
Fetopathy: May develop, which refers to a disease or abnormality affecting the fetus.
308
What are the clinical consequences of embryopathy?
Embryopathy involves malformations resulting from teratogenic effects.
309
What conditions are associated with fetopathy, where malformations are not present?
Anemia: Due to Rhesus incompatibility or infections.
Edemas and Hydrops: Excess fluid accumulation.
Myocarditis: Inflammation of the heart.
Intrauterine Growth Restriction (IUGR): Poor fetal growth.
Hepatitis and Ascites: Liver inflammation and fluid in the abdomen.
Meningitis, Meningoencephalitis, Ventriculomegaly, Hydrocephalus: Infections and conditions affecting the brain and cerebrospinal fluid.
Hyperinsulinemia and Macrosomia: Excess insulin leading to larger-than-average fetal size.
310
What are the effects of temperature and fevers as physical teratogens?
Elevated temperatures and fevers can be teratogenic, potentially leading to developmental abnormalities in the fetus.
311
What is the impact of irradiation as a physical teratogen?
Ionizing Radiation: 5-10 rad is considered teratogenic.
Diagnostic X-rays: Typically below this threshold and are not usually teratogenic.
Therapeutic Irradiation: In the first half of pregnancy is an indication for considering termination due to high risk.
312
What are the potential effects of mechanical impact as a physical teratogen?
Mechanical impacts can cause steric changes, isolated amniotic rupture, and adhesions. These are rare but possible complications.
313
What are the effects of consuming certain fish as a chemical teratogen?
Fish like swordfish, mackerel, and shark accumulate mercury, which can cause brain damage, and loss of hearing and sight in the fetus.
314
What are the teratogenic effects of poisons found in certain cleaning substances?
Organic ammonium derivatives in some cleaning substances can cause neural tube defects.
315
How are drugs categorized as chemical teratogens?
Drugs are categorized by the FDA into different categories based on their potential teratogenic effects, with specific guidelines for their use during pregnancy.
316
What was the historical impact of thalidomide (Contergan) on fetal risk?
Thalidomide (Contergan) had a 75-100% fetal risk, causing severe malformations.
317
Which substances are associated with a risk greater than 10% for teratogenic effects?
Isotretinoin (Roaccutan)
Aconumor, Dicumarol (Syncumar, Warfarin)
Penicillamine
Etritinate, Acitretin
Chemotherapeutic drugs
Phenytoin, Valproic acid
318
What are the potential fetal consequences of biological teratogens?
Congenital Anomaly: Structural abnormalities present at birth.
Embryopathy: Developmental issues occurring early in pregnancy.
Fetopathy: Fetal disease without malformations.
Miscarriage and Premature Labor: Pregnancy loss or early delivery.
Connatal Infection: Infections occurring during or around the time of birth.
319
When does the fetal immune response develop, and what are its implications for infections?
The fetal immune response develops by 9-15 weeks of gestation. Before this time, only embryopathy or miscarriage can occur due to infections.
320
Which infections pose a significant risk to the fetus?
Rubella
Cytomegalovirus Infection
Toxoplasmosis
Parvovirus B19 Infection
Chickenpox
Hepatitis B
Herpes
HIV Infection
Syphilis
321
What is the difference between teratologic counseling and prenatal diagnosis?
Teratologic Counseling: Provides an estimated risk percentage of teratogenic exposure based on history and potential exposure, but does not offer specific fetal condition assessment.
Prenatal Diagnosis: Uses methods such as ultrasound and amniocentesis (e.g., CMV PCR) to assess the fetal condition. If a positive diagnosis is found, pregnancy can be terminated on maternal request, even if initial risk estimates were below 10%.
322
Week 2 cont: At what stage of development does the embryo reach 3 cm in length?
Around 60 days (Carnegie stage 23).
323
What is the volume of the embryo at around 45 days after conception?
Approximately 1 ml.
324
Which key organs are depicted in green in the embryo diagrams?
The brain.
325
What percentage of embryo volume does the neural tube occupy around 15-30 days after conception?
The neural tube occupies around 1-10% of embryo volume during this period.
326
How does the liver's volume percentage change during the embryo’s development from 7 to 60 days?
The liver starts to occupy a larger percentage of the embryo's volume after 30 days and stabilizes around 60 days.
327
What happens to the embryo’s volume after 30 days?
The embryo's volume rapidly increases after 30 days, reaching up to 3 ml by 60 days.
328
What anatomical structure is depicted by a neural tube in the graph?
The neural tube is part of the early nervous system development, eventually forming the brain and spinal cord.
329
At what stage of development can external anatomical features, such as the limbs, be distinctly observed?
Distinct limb buds can be observed by Carnegie stages 17-20 (around 40-50 days).
330
What is the significance of the "Carnegie stage" mentioned in the embryonic timeline?
Carnegie stages refer to a standardized system of embryo development stages based on size and morphological features, used to track early development.
331
How is the embryo volume typically measured as depicted in the graph?
The embryo volume is measured in microliters (μl) during the early stages and increases to milliliters (ml) as development progresses.
332
Week 4: What is parturition?
Parturition is the birth process.
333
Define labour.
Labour involves coordinated, effective uterine contractions, effacement and dilation of the cervix, and expulsion of the products of conceptus.
334
What is the definition of delivery?
Delivery refers to the expulsion of the products of conceptus, which includes the fetus and the placenta.
335
What is vaginal delivery?
Vaginal delivery is the natural endpoint of the second stage of labour, where the baby is delivered through the birth canal.
336
What is a Caesarean delivery?
Caesarean delivery is when the baby is born through an incision in the abdominal wall and uterus.
337
What is gestational age?
Gestational age refers to the number of completed weeks from the first day of the last menstrual period (LMP).
338
What are the durations of the three trimesters?
1st trimester: Less than 12 weeks (embryo stage)
2nd trimester: 12 to 24 weeks (fetus stage)
3rd trimester: 24 to 40 weeks
339
What is a miscarriage?
A miscarriage is the spontaneous end of pregnancy before 24 weeks of gestation.
340
At what gestational age is a birth considered preterm?
Preterm birth occurs between 24 and 37 weeks, with a viable fetus weighing at least 500 grams and showing signs of life.
341
What is the definition of a stillbirth?
A stillbirth is the birth of a newborn after 24 weeks of gestation with no vital functions at birth.
342
What is a postterm birth (postmaturity)?
A postterm birth occurs when the fetus has not been born after 42 weeks of gestation.
343
What are the inhibiting factors of the myometrium?
Inhibiting factors of the myometrium include:
Neural: sympathetic tone
Hormonal: progesterone
Enzymatic: oxytocinase
344
What are the activating factors of the myometrium?
Activating factors of the myometrium include:
Prostaglandins
Oxytocin
Oestrogen
Uterus distension
Increased sympathetic tone
Cortisol (from the fetal adrenal gland)
345
What is the role of cortisol in the onset of labor?
Cortisol from the fetal adrenal gland increases and contributes to the onset of labor.
346
How does the oestrogen-progesterone ratio affect labor?
Increased oestrogen levels relative to progesterone lead to the onset of labor by promoting uterine contractions and cervical ripening.
347
What role do prostaglandins play in labor?
Prostaglandins promote cervical ripening and help initiate uterine contractions.
348
How does oestrogen sensitize the uterus during labor?
Oestrogen increases the uterus's sensitivity to oxytocin, enhancing uterine contractions.
349
What is the significance of cervix ripening in labor?
Cervix ripening is the softening and thinning of the cervix, which is essential for dilation and the progression of labor.
350
What role does oxytocin play in labor?
Oxytocin stimulates uterine contractions and helps maintain the rhythm and strength of labor.
351
What is the difference between false labor and true labor?
False labor: Irregular contractions that do not result in cervical dilation.
True labor: Regular contractions that lead to cervical effacement and dilation, marking the actual onset of labor.
352
What is lightening in the context of premonitory symptoms of labor?
Lightening is when the baby drops or descends into the pelvis, leading to a feeling of relief in the upper abdomen for the mother.
353
What is the descent of the fundus?
Descent of the fundus refers to the lowering of the top of the uterus (fundus) as the baby moves lower into the pelvis before labor.
354
How does the amount of amniotic fluid change as labor approaches?
There is a reduction in amniotic fluid as the body prepares for labor.
355
How does abdominal distension change before labor?
Abdominal distension decreases as the baby descends lower into the pelvis, reducing pressure on the diaphragm and making the mother feel more comfortable.
356
What does it mean when the woman feels more comfortable before labor?
As the baby drops lower, the mother often feels relief from previous discomforts, such as difficulty breathing, and experiences less pressure on the upper abdomen.
357
What are uterine contractions like in the premonitory phase of labor?
Uterine contractions are irregular and ineffective in the premonitory phase, often referred to as "false labor" or Braxton Hicks contractions.
358
What is a key symptom of the onset of labor involving uterine contractions?
Painful uterine contractions are a key symptom of the onset of labor.
359
What is a show in the context of labor?
A show refers to the passage of a mucous plug, often with some blood (blood show), indicating that the cervix is beginning to dilate and efface.
360
What does rupture of the membranes mean in labor?
Rupture of the membranes, often called "water breaking," refers to the breaking of the amniotic sac, releasing amniotic fluid, signaling that labor may start soon or has already started.
361
What changes occur to the cervix during the onset of labor?
The cervix shortens (effacement) and dilates (opens) as labor begins, preparing for the baby's passage through the birth canal.
362
First stage of labor
Dilatation
363
Second stage of labor
Fetus born
364
Third stage of labor
Placenta and membranes are delivered
365
Fourth stage of labor
Postplacentar period
366
First stage of labor
From the onset of regular, painful contractions until full cervical dilatation (i.e., the cervix is no longer palpable)
367
Latent phase of the First stage
Effacement and dilatation to 3 cm
368
Active phase of the First stage
Dilatation from 3 cm to 10 cm (full dilatation)
369
Second stage of labor
From full dilatation to delivery of the fetus
370
Passive phase of the Second stage
Descent of the head
371
Active phase of the Second stage
Pushing
372
Third stage of labor
From the delivery of the newborn to the delivery of the placenta and membranes
373
Increasing frequency, intensity, duration of contractions
Up to 1 in 2 minutes, lasting 1 minute
374
Effect of contractions on myometrial cells
Contractions cause shortening of myometrial cells
375
Formation associated with uterine activity
Formation of the lower uterine segment
376
Effects of uterine contractions on the cervix
Effacement and dilatation of the cervix
377
378
379
380
381
382
Lie
Relationship of the long axis of the fetus to the long axis of the uterus
383
Types of fetal lie
Longitudinal, oblique, transverse
384
Define Presentation term
Which anatomical part of the fetus is closest to the pelvic inlet just before birth
385
Types of fetal presentation
Cephalic, breech, shoulder
386
Types of cephalic presentation
Vertex, deflected vertex, brow, face
387
Define Position
Relationship of the denominator of the presenting part to the inlet of the maternal pelvis (e.g., occipito-anterior)
388
Define term Malposition
Incorrect relationship of the presenting part to the maternal pelvis
389
Term Engagement
Widest part of the presenting part of the fetus (head) has passed successfully through the true pelvic inlet
390
Term Station
In 1/5 to 5/5 (compared to the pelvic brim)
391
Term Lie
Longitudinal, transverse, oblique
392
Cephalic presentation types
Vertex, brow, face
393
Breech presentation
Podalic (breech)
394
Breech presentation
Podalic (breech)
395
Fetal positions
LOT, ROT, LOA, ROA, LOP, ROP
396
Flexion head movement
The chin of the fetus moves toward the chest
397
Term Internal rotation
The fetus rotates to align with the pelvic canal
398
Term Extension
The fetal head emerges with the face and chin first
399
Term Restitution
The fetal head returns to the original position, aligning with the back
400
Term External rotation
The fetal head rotates to the side to face the maternal thighs
401
Descent of the head
Essential for delivery, assessed by observing the station of the head
402
Sequence of movements of head
Results from the 90-degree difference between the longest diameter of the pelvic inlet and outlet
403
Delivery of the anterior shoulder
The anterior shoulder emerges from under the symphysis pubis
404
Delivery of the posterior shoulder
The posterior shoulder is delivered as the fetus rotates
405
Delivery of the trunk with the arms
The trunk and arms follow the shoulders as the fetus is guided out
406
Delivery of the lower limbs
The lower limbs are delivered last, completing the birth process
407
Duration of the third stage
From the delivery of the baby until the delivery of the placenta and membranes (5-10 minutes on average)
408
Contractions during the third stage
Contractions are continuing
409
Placental separation
Placenta shears off the uterine wall
410
Expulsion of the placenta
Expelled to the lower uterine segment, then to the vagina; gentle traction on the cord may help
411
Handling the umbilical cord
Never pull the cord before separation!
412
Signs of placental separation
Lengthening of the cord, elevation of the fundus and becoming hard and globular, trickling of fresh blood
413
Active management of the third stage
May reduce blood loss
414
Oxytocin in the third stage
10 IU Oxytocin may be given
415
Controlled cord traction
Applied after signs of placental separation are seen
416
Brandt-Andrews technique
: A method used in controlled cord traction during the third stage of labor
417
Active management of 3rd stage
May reduce blood loss
• 10 IU Oxytocin may be given
• After signs of placental separation seen, controlled cord traction
applied
• Brandt-Andrews technique
418
Postplacentar period
check
General condition
• Temperature
• P., RR.,
• Breathing
• Uterine fundus, consistentia
• Abdominal palpability
• Urinary bladder
• Vaginal bleeding
• Condition of the perineum, vulva, vagina (haematoma?)
419
progress in labor check
Dilatation
• Assessed by vaginal examination
• 1 cm/hr is expected
• Descent (relevant only in the presence of ruptured membranes)
• By external exam: 5 to 0 fifth of the head is palpable above the pelvic brim
• Vaginal exam: station -... -3,-2,-1, 0,+1,+2, etc. cm to the level of the ischial
spine
420
Delay in progress in labour
Can be both symptom and risk
• Cephalopelvic disproportion
• Large fetus
• Small pelvis (pelvic inlet)
• vaginal delivery impossible
• Inefficient uterine activity (uterine inertia)
• Hypertonic- rare as primary, but can be sign of abruption
• Hypotonic – common, no severe risk initially, but infection, fetal distress can develop,
and it may become untreatable, if not recognized in time
421
Fetal surveillance
Low-risk pregnancy:
–Observing fetal movements
–Checking fetal heartbeat
Pinard stethoscope
Hand-held Doppler
• –Checking growth: fundal height
422
Fetal Doppler examination
•Strong evidence of improving perinatal statistics by using UA Doppler
in high-risk pregnancies (only)
•Other vessels can be involved
–Middle cerebral artery
–Descending aorta
–Ductus venosus
–Umbilical vein
–Maternal uterine artery
423
Biophysical profile
1.NST
2.Fetal movement (by US)
3.Fetal tone (by US, flexion-extension cycle)
4.Fetal breathing movement (by US)
5.Amniotic fluid (SDP > 20 mm)
• –Scoring system 0 –10
• –Time consuming MBP, Doppler
424
Definition of power in labor
Power refers to the force generated by the contraction of the uterine myometrium
425
How is uterine activity assessed?
By maternal observation, palpation of the fundus, or external tocodynamometry
426
How is contraction force measured directly?
By using internal manometry or pressure transducers to measure intrauterine pressure
427
Criteria for adequate uterine activity
There is no specific criteria for adequate uterine activity
428
General guideline for adequate labor
3-5 contractions in a 10-minute period is considered adequate labor
429
Fetal variables that can affect labor
Fetal size
• Fetal Lie – longitudinal, transverse or oblique
• Fetal presentation – vertex, breech, shoulder, compound (vertex and hand),
and funic (umbilical cord).
• Attitude – degree of flexion or extension of the fetal head
• Position
• Station – degree of descent of the presenting part of the fetus, measured in
centimeters from the ischial spines
• Number of fetuses
• Presence of fetal anomalies – hydrocephalus, sacrococcygeal teratoma
430
Fetal size
One of the variables that can affect labor progress
431
Fetal size
One of the variables that can affect labor progress
432
Fetal lie
Longitudinal, transverse, or oblique
433
Fetal presentation
Vertex, breech, shoulder, compound (vertex and hand), funic (umbilical cord)
434
Fetal attitude
Degree of flexion or extension of the fetal head
435
Fetal position
Orientation of the presenting part relative to the maternal pelvis
436
Station
Degree of descent of the presenting part, measured in centimeters from the ischial spines
437
Number of fetuses
Multiple fetuses can affect labor progress
438
Presence of fetal anomalies
Conditions like hydrocephalus or sacrococcygeal teratoma may impact delivery
439
Passage
Passage = Pelvis
• Consists of the bony pelvis and soft tissues of the birth canal (cervix,
pelvic floor musculature)
• Small pelvic outlet can result in cephalopelvic disproportion
• Bony pelvis can be measured by pelvimetry but it not accurate and
thus has been replaced by a clinical trial of labor
440
441
Symptoms and signs of the onset of labour
Painful uterine contractions
• A show: mucous show, blood show
• Rupture of the membranes
• Shortening and dilatation of the cervix
442
443
444
Labour- Second stage
Interval between full cervical dilation to delivery of the infant.
• Characterized by descent of the presenting part through the maternal pelvis and
expulsion of the fetus.
• Indications of second stage:
• Increased maternal show
• Pelvic/rectal pressure
• Mother has active role of pushing to aid in fetal descent
• Examining the fetal head during the second stage may become
difficult due to molding
• Molding is the alteration of the fetal cranial bones to each other as a
result of compressive forces of the maternal bony pelvis.
• Caput is the localized edematous area on the fetal scalp caused by
pressure on the scalp by the cervix.
• PrimiG – 0.5-3 h; mulitG 0-30min
445
Labour- Third stage
The time from fetal delivery to delivery of the placenta
• Three signs of placental separation:
• Lengthening of umbilical cord
• Gush of blood
• Fundus becomes globular and more anteverted against
abdominal hand
Placenta is delivered using one hand on umbilical cord with
gentle downward traction. Other hand on abdomen
supporting the uterine fundus.
• Risk factor for aggressive traction is uterine inversion.
• Obstetrical emergency!!
• Normal duration between 0-30 min for both PrimiG and
MultiG
446
Signs of separation of the placenta
Lengthening of the cord
• Elevation of the fundus and becoming hard and globular
• Trickling of fresh blood
447
Labour- Fourth stage
• Refers to the time from delivery of the placenta to 2 hours
immediately postpartum
• Blood pressure, uterine blood loss and pulse rate must be monitor
closely ~ 15 minutes
• High risk for postpartum hemorrhage from:
• Uterine atony, retained placental fragments, unrepaired lacerations of
vagina, cervix or perineum.
• Occult bleeding may occur – vaginal hematoma
• Be suspicious with increased heart rat, pelvic pain or decreased BP
448
Cardinal Movements of Labour
Engagement
• Passage of the widest diameter fetal presenting part below the plane
of the pelvic inlet
• The head is said to be engaged if the leading edge is at the level of the
ishial spines.
Descent
• Refers to the downward passage of the presenting part through the
bony pelvis
• Not steady process
• Greatest at deceleration phase of first stage and during 2nd stage of
labour
Flexion
• Occurs passively as the head descends
due to the shape of the bony pelvis.
• Partial flexion occurs naturally but
complete flexion usually occurs only in
the labor process
• Complete flexion places the fetal head in
optimal smallest diameter to fit through
the pelvis
Internal rotation
• Rotation of the fetal head from occiput
transverse to occiput either in anterior or
posterior position
• Occurs passively due to the shape of the
bony pelvis
Extension
• Occurs when the fetus has descended
to the level of the vaginal introitus
(Crowning)
• When occiput is just past the level of
the symphysis, the angle of the birth
canal changes to upward position
Restitution
• The head turns back to
be in line with its
normal relationship to
the shoulders
External rotation
• Shoulders rotate also to
the longest diameter of
the pelvic outlet, the
sagittal one, before they
are delivered
• This results in further
rotation of the head,
facing to the maternal
thigh
Expulsion
• Delivery of the fetus
• After delivery of the fetal head, descent and intraabdominal pressure
by mother brings shoulder to the level of the symphysis
• Downward traction allows release of the shoulder and the fetus is
delivered.
449
Indications
Maternal Benefit – Shorten the 2nd stage of labor, decrease the
amount of pushing
Ie: maternal cardiac conditions (Eisenmenger’s, pulmonary HTN) or history of
aneurysm/stroke
Concern for immediate/potential fetal compromise
Ie: Prolonged terminal bradycardia
Prolonged 2nd stage
Nulliparous = No progress for 3 hrs w/epidural or 2 hours w/o epidural
Multiparous = No progress for 2 hrs w/epidural or 1 hr w/o epidural
450
Need To Know Before Attempting an
Operative Delivery + Contraindications
Presentation
(Cephalic/Breech)
Position (i.e. occiput
posterior, sacrum anterior)
Lie (longitudinal, oblique,
transverse)
Station
Presence of asyncliticism
Clinical pelvimetry
Anesthesia?
Contraindications
GA < 34 weeks (contraindication for vacuum due to risk of fetal IVH)
Known bone demineralization condition (e.g. osteogenesis
imperfecta) or bleeding disorder, ie: VWD)
Fetal head unengaged
Position of fetal head unknown
451
Vacuum-Assisted Vaginal Delivery
Do not apply rocking
motion or torque, only
steady traction in the line
of the birth canal
Stop after: three “popoffs”
of vacuum, > 20
minutes elapsed, three
pulls with no progress
452
Fetal risks VAVD
453
Fetal risks VAVD
454
Type of Forceps Delivery
455
Forceps-Assisted Vaginal Delivery definitions + risks
Identify & apply blades
Place instrument in
front of pelvis with tip
pointing up & pelvic
curve forward
Apply left blade, guided
by right hand, then right
blade with left hand
Lock blades
Should articulate with
ease
Risks:
Maternal Risks
Perineal Injury (extension of
episiotomy)
Vaginal and Cervical lacerations
Postpartum hemorrhage
Fetal Risks
Intracranial hemorrhage
Cephalic hematoma
Facial / Brachial palsy
Injury to the soft tissues of face &
forehead
Skull fracture
456
Using both forceps and vacuum
Highest risk for injury is for combined forceps/vacuum extraction or
cesarean delivery after failed operative delivery
The weight of available evidence is against multiple efforts with
different instruments
457
Cervical insufficiency - Terminology + clinical diagnosis
•Cervical insufficiency (CI): Inability of cervix to
retain pregnancy in absence of contractions or
labor
•Clinical diagnosis
• Short cervix: Cervical length (CL) <10th percentile
for gestational age
○ Sonographic observation;
458
Cervical insufficiency – Clinical issues
• US more sensitive to cervical shortening than manual
exam at < 32 weeks
• Most patients at risk for CI can be safely monitored with
serial TVUS examinations
• Look for preterm labor/infection if CL↓
• Progesterone administration is an ongoing area of
investigation regarding optimal dose and route
• Cervical cerclage limited to 2nd-trimester pregnancies,
usually before viability
• Cerclage potentially harmful in multiple gestations
459
Assesment of Amniotic Fluid Index - AFI
Determination of the
amniotic fluid index, with
measurement of the
deepest vertical pocket in
each of the four quadrants
of the uterus.
460
Umbilical artery velocimetry
461
Umbilical artery velocimetry
462
Fetal descending aorta velocimetry
463
Fetal surveillance
Low-risk pregnancy:
– Observing fetal movements
– Checking fetal heartbeats
Pinard stethoscope
Hand-held Doppler
• –Checking growth: fundal height
464
Fetal assessment during labour
Aim: to detect conditions leading to asphyxia in time in order to perform
operative delivery in compensated fetuses preventing them from severe hypoxy
or stillbirth
• Detecting fetal heartbeats
• NST, CTG: intrauterine fetal surveillance
• FTT, OTT: check the reserv capacity of the placenta
• Fetal scalp vein sampling
• Fetal scalp stimulation test
• Fetal pulsoxymetry
• STAN (fetalis distress)
465
Basics of cardiotocography
Autonomic adjustment balanced by SIMP és PSIMP nervous system
• Used for fetal surveillance
• Medulla oblongata: cardiorespiratoric centre
• Autonomous nervous system is sensitive to hypoxy and replies with a
fetal heartbeat change
• External, indirect, non-invasive
• Internal direct
• Triggered by fetal ECG R wave
• Intrauterine pressure measurement
• Assessment: subjective
466
Intrapartum CTG
Continous or intermittent
• Aim: to detect signs of hypoxy in time
• Mirror of fetal cardiac answers for effects on the fetus
• Objective assessment
• Absolute indications:
maternal: previous CS, preeclampsia, post-term pregnancy, preterm rupture
of the membranes, induction of labour, bleeding
fetal: IUGR, preterm labour, oligohydramnios, abnormal fetal Doppler,
multiple gestations, meconium stained amniotic fluid, breech presentation
During labour: Oxytocin administration, EDA, vaginal bleeding, fever,
meconium
467
468
Basics of CTG
- Baseline
- Variability
Baseline
average of fetal heartbeats in one unit of time (10 minutes)
normal range: 120- 160/min
1. Baseline tachycardia: >10min, FHR over 160/min (moderate,
severe)
2. Baseline bradycardia: > 10min, FHR under 120/min (moderate,
severe)
Variability
Reflects the integrity of autonomous nervous system of the fetus.
Change in the FHR in one minute= Oscillation
1. Frequency: the frequency of baseline crossing heartbeat changes in
one minute
2. Amplitude: the difference between teh highest and the lowest FHR
in one minute
Normal range: 5-25 beats/min
469
CTG Acceleration
Acceleration
Temporary increase in the fetal heartbeats with at
least 15 bpm lasting at least 15 seconds and turning
back to the baseline in 2 minutes
1. Long term acceleration: >2 min, but < 10min
2. Baseline change: >10min increase in FHR
(tachycardia)
470
CTG Deceleration
Deceleration
Temporary decrease in the fetal heartbeats with at least 10 bpm lasting at least 15
seconds and turning back to the baseline in 2 minutes.
1. Sporadic
2. Periodic
a. Early: deepest point (nadir) is at the same time with the peak of the contraction; caused
by vagal reflex due to intracranial pressure increase
b. Late: the onset of fetal heartbeat change is delyed regrding the peak of the contraction;
caused by abnormal fetomaternal circulation, decreased placental reserve.
c. Variable: declerations are different in onset and shape and deepest point; caused by
umbilical cord compression
Long term deceleration: >2 min, < 10 min
Baseline change: >10 min
471
Classification of CTG findings
• Normal: all 3 FHR descriptor (frequency, variability, deceleration) are
reassuring.
The presence of sporadic accelerations refer to the intrauterine
well-being of the fetus.
• Suspicious: one of the 3 descriptors is non-reassuring while the two others
are reassuring.
The patient should lay on her left side, body temperature and BP check,
hydration
• Abnormal:
• one or more abnormal CTG pattern or the presence of at least two non-reassuring
patterns should refer to fetal hypoxy
• If all 3 descriptors are non reassuring or variability is totally missing or bradycardia is
longer than 3 minutes
472
Placenta functions
Proper work of the placenta is essential
• 3 main roles:
o Endocrine protection
o Sufficient nutrients
oAssure of fetal oxygenization
• Intrauterine assessment: checkup and monitoring all of these factors
473
Factors leading to fetal distress
Praeplacental (maternal):
• Insufficient maternal O2 uptake eg. disease of the lungs
• Insufficient maternal O2 transport eg. anemia, shock, tetanic
contraction of the uterus, polyhydramnios
Placental:
• Infarcts eg.:PE, hypertension, post-term
• Increased vessel resistance eg. multiple gestation, polyhydramnios
• Change of the placental membrane eg. preeclapmsia
• Missing placental function eg. placental abruption, placenta previa
Postplacental (fetal):
• Insufficient O2 uptake eg. fever, anemia
• Insufficient O2 forward eg. Umbilcal cord prolapse, knot in cord
• Increased need for O2 eg. Multiple gestations, infection, macrosomy
Acute or chronic
474
Normal labour
Continous decrease in the oxygenisation
of the fetus within physiological ranges
• Decrease of oxygenistaion: temporary
occlusion of placental vessels during
contractions, decrease in the uterine
volume, decreasing the area between
the placenta and the uterus
(detachment), maternal metabolic
acidosis
• Physiological process + abnormal event=
worsening fetal oxygenisation
Graph ib pp, check
475
476
Hypoxaemia
Hypoxaemia: initial step of fetal lack of O2.
• Fetal O2 saturation decreases, CO2 pressure increases (respiratoric
acidosis)
• O2 supply for tissues is enough
• Activity of the fetus decreases.
• This equilibrium can be maintained for days-weeks.
477
Change in fetal circulation labor
• Hypoxy: worsening lack of O2 which affects the tissues as well.
Oxidative procedures and anaerob glycolysis triggers sympathetic
tones as a reply for fetal stress and ends up in increased BP, HR, VPM.
Fetal circulation is getting centralized: circulation of fetal brain, heart
and adrenal glands become prioritzed with vasoconstriction on
peripheral organs. Decreased fetal movements and oligohydramnios
are accompanied by increased fetal bowel peristalsis presenting
meconium in the amniotic fluid. It can be maintained only for hours.
Bradycardia - ”rebound tachycardia”
Hypoxy + hypercapnia + acidosis = ASPHYXIA
478
Fetal asphyxia
Fetal asphyxia: severe lack of O2, aerob to anaerob switch.
Glycolysis produces lactate acid, H+ produced, pH decreases
acidosis
Severe metabolic acidosis: fetal arterial pH < 7
As blood redistribution collapses oxyigen gap is increasing
Brain damage depending on senisitivity of the cells
Severe asphyxia: fetal death or in case of livebirth sevree ischaemic
encephalopathy
Prevention: urgent c-section
479
Fetal assessment during labor
Aim: to detect conditions leading to asphyxia in time in order to perform
operative delivery in compensated fetuses preventing them from severe hypoxy
or stillbirth
• Detecting fetal heartbeats
• NST, CTG: intrauterine fetal surveillance
• FTT, OTT: check the reserve capacity of the placenta
• Fetal scalp vein sampling
• Fetal scalp stimulation test
• Fetal pulsoxymetry
• STAN (fetalis distress)
480
Meconium
- Definition
- Consist of what
- Causes
Sticky, black-green-yellow, odorless
• Present in fetal bowels from the 3rd month
• Consist of: epidermal cells, secretions, fetal hair, fetal sebum,
bowel enzimes, amniotic fluid
• Colour: biliar secretions
• Causes: fetal maturity, fetal demise, atonic or paralized anal
sphincter
• Sterile but in the lungs it can trigger citokines and other
vasoactive agents: MAS: Meconium Aspiration Syndrome!
• Indirect sign of fetal hypoxy
• Part of adaptative procedures, refers to fetal state indirectly
• Rare in preterm fetuses
481
Pathway of meconium appearing in the amniofic fluid and consequences
Meconium
• Stress caused by asphyxia or infection
• Vagal nerve stimulation, sympathetic tone increase
• Increased peristalsis, anal sphincter tone decreases
• Meconium appears in amniotic fluid
• Colour: varies depending on part of bowel section from where it derivates,
„pea puree”: its is from higher bowel segments
• Fetal breathing movemnets or first breath after labour can facilitate it into the lungs: MAS
Meconium in the amniotic fluid
• Higher risk for infections
• Higher risk for Chorioamnionitis
• Decreases phagocytosis made by neutrophil granulocytes
• Meconium alone is never an indication for immediate termination of
a labour
• Meconium in the amniotic fluid + abnormal CTG
Intrauterine fetal risk – termination of pregancy
482
What does panel A of the image depict regarding human embryonic development?
Panel A shows the growth of the human embryo during the first two months of development, depicting the lengths of embryos at various Carnegie stages (7 to 23), ranging from 3 mm to 3 cm.
483
According to panel B, how does the volume of the human embryo change over the first two months?
Panel B shows that the embryo volume increases exponentially, from less than 1 microliter at Carnegie stage 7 (around day 15) to approximately 3 milliliters by Carnegie stage 23 (around day 60).
484
What does panel C show regarding the volume distribution of different organs during early embryonic development?
Panel C depicts the percentage of embryo volume made up by the liver, neural tube, metanephros, and notochord across Carnegie stages.
The liver shows a substantial increase, the neural tube remains relatively constant, the metanephros grows slightly, and the notochord decreases over time.
485
What does panel A (bottom) show in terms of visual development during early embryonic growth?
Panel A (bottom) provides a photograph of a human embryo at a later Carnegie stage, showing detailed anatomical features like the limbs, head, and general body shape.
486
What is highlighted in green in panel C, and what is its significance?
In panel C, the brain (highlighted in green) is shown in a 3D reconstruction, signifying its relative size and importance during early development, with emphasis on its prominent growth.
487
What do panels D and E reveal about embryonic cross-sections?
Panels D and E display cross-sectional images of the human embryo, showing anatomical structures like the spine and brain in detailed views using imaging technology.
Panel D shows a transverse section, while panel E provides a more detailed look at spinal and brain development.
488
What does panel A of the image illustrate regarding the human embryo between stages 17 and 20?
Panel A shows the positioning of various organs in the human embryo between stages 17 (42-44 days) and stage 20 (51-53 days).
It highlights the cervical, thoracic, lumbar, sacral, and coccygeal regions, as well as the positioning of organs like the gonads and metanephros as the spine develops.
489
What does panel B indicate about the relative positions of the gonads, metanephros, and IMA in relation to the spine during early embryonic development?
Panel B shows the positions of the gonads, metanephros, and inferior mesenteric artery (IMA) relative to specific vertebrae at different stages of development (stages 16, 17, and 20).
It indicates that as the embryo develops, these organs shift in relation to the spine, moving upwards along the vertebral column.
490
What does the graph in panel C represent regarding embryonic organ position?
The graph in panel C represents the changes in relative position of the gonads, metanephros, and IMA over time during stages 16-23.
It shows the dynamics of their positioning along the vertebral column (Th1 to Co1), with notable shifts in positioning for the gonads and metanephros.
491
What steps are involved in generating 3D reconstructions of human embryos according to the bottom panel?
The process involves four main steps:
1. Obtaining original data (digitized sections from staining and image acquisition).
2. Generating 3D reconstructions through segmentation and 3D surface generation.
3. Data analysis, including morphometry, topography, and heterochrony studies.
4. Storing results in a contents database for aligned sections, reconstructions, and analysis.
492
What is the purpose of the contents database shown in the bottom panel?
The contents database stores aligned sections, 3D reconstructions, and data from morphometry and topography analyses.
It facilitates access to the developmental overviews, chronological data, and other detailed embryo development information for research and educational purposes.
493
494
What do the graphs represent in terms of hCG levels during early pregnancy?
The graphs show normal values of hCG (intact + β-subunits) during early pregnancy, with different percentiles (P5, median, and P95) tracked from 3 to 18 weeks.
The first graph highlights the rapid rise in hCG levels between 4-7 weeks, peaking around 9-12 weeks before declining.
495
What is the significance of the hCG level of 1800 MIU/ml in early pregnancy?
The second graph indicates that a gestational sac becomes visible at around 1800 MIU/ml of hCG, which typically occurs between the 4th and 5th week of pregnancy.
496
In early pregnancy, how do hCG levels change between weeks 3 and 7?
During weeks 3 to 7, hCG levels increase rapidly, with the 95th percentile (P95) rising steeply, while the median and P5 levels also show a sharp incline during this period.
497
What happens to hCG levels after week 8 of pregnancy according to the graphs?
After week 8, hCG levels peak and then begin to decline around weeks 9 to 12, stabilizing at lower levels from weeks 14 to 18.
498
Why is the range of hCG values from weeks 3 to 6 significant in the context of early pregnancy?
The range of hCG values during weeks 3 to 6 is crucial for monitoring the viability of pregnancy, as it is during this time that hCG levels rise rapidly, and the visibility of the gestational sac is used to confirm the pregnancy's progression.
499
What is the first svidence of pregnancy on ultrasound
Gestational sac, completely embedded blastocyst 14 days post conception.
500
Gestational sac measurement growth rate
In early pregnancy 1mm/day
501
Yolk sac characteristics
502
Amnion characteristics in pregnancy
503
Heartbeat characteristic in pregnancy, using which mode
504
Practical rules early pregnancy regarding:
- Transvaginal ultrasound
- Abdominal ultrasound
For different measurements
505
Estimate timing of EDD or Due date
506
CRL criteria
507
Dating by HC and FL
508
Estimating of weight
509
3rd trimester GA assignment
510
Physiologic Changes in Pregnancy
Maternal Adaptation
511
Risk assement for pregnancy complications
PREECLAMPSIA
• GESTATIONAL DIABETES
• MISCARRIAGE
• STILLBIRTH
• FETAL GROWTH RESTRICTION
• FETAL MACROSOMIA
• PRETERM BIRTH
512
Physiologic changes
in pregnancy
1. Immune system
2. Myometral hypertrophy
3. Uterine contractility and blood flow
4. Cardiovascular system
5. Respiratory system
6. GI system
7. Renal function
8. Metabolism and endocrine
9.hematology system
513
Immune system changes during pregnancy
In the placenta, the embryotic trophoblast forms the surface where the
fetal and maternal antigens meet. These cells do not express HLA antigens
protecting the fetus against the maternal immune system as the Tlymphocytes
won’t attack the trophoblast cells.
• The highly similar maternal and paternal HLA antigens are unfavorable for
the pregnancy.
This diversity allows identifying the pregnancy by the
immune system.
• The basis of the maternal immune regulation which helps to maintain the pregnancy is
the altered cytokine production and the decreased NK (natural killer)-cell activity.
• During a physiological pregnancy, the NK-cell activity is low.
• The Th1 (mediates T-, and NK cell activity) and Th2 (mediates humoral immune response)
cytokine ratio shifts towards Th2 and the immunglobulin production increases.
Symptoms of autoimmune diseases with Th1 activity are mostly relieved, but there is a potential
relapse after the delivery.
• The2 (like IL-10) cytokine predominance is favorable, but Th1 (like IFNγ, TNFα, TNFß)
cytokine predominance is unfavorable for fetal development.
• The immunosuppressive effect of the progesterone hormone is also important.
514
Myometral hypertrophy changes during pregnancy
The volume of the myometrium continuously increases during the pregnancy.
• Its content by the end of the pregnancy is appr. 5-20 liter and the capacity is 500-
1000 times higher.
• Mostly smooth muscle hypertrophy is detectable, formation of a new muscle cell
is insignificant.
• There is an elevated number of muscles and vessels detectable in the pelvis.
• The thickness of the uterine wall also decreases during pregnancy.
• The uterus emerges from the lower pelvis by the end of the first trimester, in
standing position it leans anteriorly, in resting it leans towards the spine.
515
Myometral hypertrophy changes during pregnancy
The volume of the myometrium continuously increases during the pregnancy.
• Its content by the end of the pregnancy is appr. 5-20 liter and the capacity is 500-
1000 times higher.
• Mostly smooth muscle hypertrophy is detectable, formation of a new muscle cell
is insignificant.
• There is an elevated number of muscles and vessels detectable in the pelvis.
• The thickness of the uterine wall also decreases during pregnancy.
• The uterus emerges from the lower pelvis by the end of the first trimester, in
standing position it leans anteriorly, in resting it leans towards the spine.
516
Uterine contractility and blood flow changes during pregnancy
Even in the first trimester, there are contractions, which the mother usually
does not experience.
• In the second trimester, there are sporadic contractions, so-called BraxtonHicks
contractions.
• The blood supply of the uterus comes from the uterine and ovarian
arteries, the blood flow of this area could be 650 ml/sec at the end of the
pregnancy.
• The most important regulators are the catecholamines, the angiotensin II
and nitroxide systems.
• The effect of angiotensin II. system is important in preeclampsia (ACE
inhibitors)
517
Cardiovascupar system changes during pregnancy
The cardiac output elevates already in the first trimester. It reaches its
maximum (30-40%) around the 28th week.
• The heart rate decreases, it could be 85-100/min.
• The consistency of blood is also altered: the volume of plasma
increases 40%, the number of blood cells increases 20-30%, This is
the physiological haemodilution.
• The blood pressure initially decreases. Elevated blood pressure always
needs further investigations.
518
Respiratory system changes during pregnancy
The ventilatory minute volume increases.
• At the end of the pregnancy, the movement of the diaphragm is less
due to the elevated intraabdominal pressure. The respiratory
movements are mostly provided by the costal muscles so the
respiratory rate increases.
• During the delivery the pCO2 level decreases, there is a higher risk
for respiratory alkalosis.
519
Gastrointestinal system changes during pregnancy
• During the weeks of the pregnancy, the intraabdominal pressure
increases.
• During the first few weeks, nausea and vomiting are frequent due to
the elevated gastric pressure and reduced motility caused by
progesterone.
• Vomiting rarely can be severe (hyperemesis gravidarium)
• Heartburn is common just like obstipation and haemmorhoids.
520
Renal function changes during pregnancy
The renal blood flow increases 50% during pregnancy.
• The glucose resorption slightly decreases which leads to temporary
pregnancy glucosuria.
• There is a mild pyelectasia.
• Mild proteinuria
• Due to the elevated pressure on the urinary bladder, the frequency of
urination and the residual urine volume increase.
521
The metabolism and endocrine system changes during pregnancy
The basic metabolism increases 20%.
• The initial weight gain is due to the increased fluid capacity, but fat and
protein storage is detectable (appr. 10-15 kg).
• The carbon-hydrate metabolism shift to diabetic, there is an increased
tendency for ketosis, insulin secretion, and insulin resistance.
• The serum albumin level decreases. Protein intake is important.
• The level of lipids, cholesterin, triglyceride HDL/LDL ratio, and fat storage
increases.
• The thyroid gland intakes less iodin, but its size and vascularisation
increase.
522
Haematological changes during pregnancy
The blood volume increases up to 40% during pregnancy.
• Hemoglobin and hematocrit concentration decreases (relative iron
insufficiency) just like the viscosity of blood.
• Leukocytosis is detectable.
• Hemostatic factors: the fibrinogen level increases by 50%, the other
factors not so significantly.
There is a mild decrease in thrombocyte
number. D-dimer elevates.
523
Risk assesment pregnancy
• I. General risk factors
1. Maternal age ›40 or ‹18 years
2. Gestational age beyond 14 weeks at the first visit
3. Number of previous pregnancies over 4
4. Socioeconomic background
• II. Maternal diseases known before or detected during pregnancy
5. Regular alcohol, drug consumption or smoking
6. HIV, hepatitis B, C, syphilis, tuberculosis
7. BMI ‹18 or ›30
8. Chronic hypertension, cardiovascular disease
9. Endocrine disorders (diabetes, hypo-, hyperthyreosis, PCO)
10. Chronic gastrointestinal, liver, lung, kidney disorders
11. Diseases of the nervous system or psychiatric disorders
12. Haematologic, autoimmune diseases, antiphospholipid sy, thrmboembolism
13. Malignancies
14. Genetic disorders in the family
15. Multiple pregnancies
16.Haemorrhage during the present pregnancy
• IiI. Complications in previous pregnancies or deliveries
17. Surgeries on the uterus (previous cesarean delivery, cone biopsy, etc.)
18. Preterm delivery
19. Preeclampsia, HELLP syndrome
20. Rh isoimmunisation
21. Intrauteroine growth restriction IUGR
22. Gestational diabetes
23. Birthewight from the previous pregnancies› 4500 g
24. Perinatal mortality with known or unknown causes
524
Tests to be performed in 1st semester
Complete blood cell count – CBC (Hgb, Htc, RBCs, WBCs,
platelets), creatinine, GFR, GOT,GPT, bilirubin, glucose
• Urinalysis (heme, albumin, leukocyte esterase, nitrite,
glucose, UBG, hydrogen ions, specific gravity, sediment)
• Hepatitis B sAg
• Syphilis screening (VDRL, Wassermann)
• Blood group, antibodies
• Ultrasound screening (11-13 wks)
• Genetic counselling (› 37 years and specific risk factors)
• Odontology
525
Tests to be performed in 2nd and 3rd trimemster
Ultrasound screening between 18-22 weeks
• Oral glucose tolerance test - OGTT (75 g glucose
120 min) between 24-28 weeks
• CBC, urinalysis between 24-28 weeks
• Ultrasound screening between 30-32 weeks
• CBC, antibody screening, urinalysis, se creatinine,
eGFR, sebi, sGOT, sGPT between 36-37 weeks
• CTG 38, 39, 40 weeks
526
Differences between screening and diagnostic test
527
Ultrasound screening times
11-13 weeks
18-22 weeks
30-32 weeks
528
Risks assesment for pregnancy complications
Preeclampsia
• Gestational diabetes
• Miscarriage
• Stillbirth
• Fetal Growth Restriction
• Fetal Macrosomia
• Preterm Birth
• Placental pathologies
529
530
Screening for fetal malformations
1. Spina bifida : 11-13 weeks, 18-22 weeks
2. Fetal chrkmosomal aneuploidies
3. Trisomy 21: nuchal translucency measurement, individual risk calculation for trisomy 21,18,13
4. Nasal bone, facial angle
5. Ductus venous flow
6. Tricuspid flow
7. Amniocentesis, chorion biopsy
531
1st trimester combined test and
2nd trimester biochemical screening
532
1st trimester combined test and
2nd trimester biochemical screening
533
Markers suggestive of aneuploidies in 2nd trimester
534
NIPT
535
Carrier screening
536
Carrier screening
537
ECS
538
ECS
