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Obstetric Complications Flashcards

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1
Q

The terms ________ have been used to describe the

inability of the uterine cervix to retain a pregnancy to viability in the absence of contractions or labor.

A

“cervical insufficiency” and “cervical incompetency”

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2
Q

Etiology of cervical insufficiency

A

rapid forceful cervical dilation associated with
second trimester abortion procedures, cervical laceration from rapid delivery, injury from deep cervical conization, or congenital weakness from diethylstilbestrol (DES) exposure

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3
Q

Studies show the benefit of _____ with a history of 1 or more unexplained second-trimester pregnancy losses.

A

elective cervical cerclage

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4
Q

Elective cerclage placement at ______’ gestation is appropriate after sonographic demonstration for fetal normality.

A

13–14 weeks

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5
Q

Emergency or urgent cerclage may be considered with sonographic evidence of cervical insufficiency after ________

A

ruling out labor and chorioamnionitis.

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6
Q

Cerclage should be considered if cervical length is ______by vaginal sonography
prior to 24 weeks and prior preterm birth at_______gestation.

A

<25 mm

<34 weeks

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7
Q

_______ places a removable suture in the cervix. The benefit is that vaginal delivery can be allowed to take place, avoiding a cesarean.

A

McDonald cerclage

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8
Q

Cerclage removal should take place at _____, after fetal lung maturity has taken place but before the usual onset of spontaneous labor that could result in avulsion of
the suture.

A

36–37 weeks

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9
Q

______utilizes a submucosal placement of the suture that is buried beneath the mucosa and left in place. Cesarean delivery is performed at term.

A

Shirodkar cerclage

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10
Q

______twins are most common. Identifiable risk factors include by race, geography, family history, or ovulation induction

A

Dizygotic twins

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11
Q

Risk of twinning is up to 10% with ____ and up to 30% with ______

A

clomiphene citrate

human menopausal gonadotropin.

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12
Q

Cx of Twin pregnancy

A 
nutritional anemias (iron and folate), preeclampsia,
preterm labor (50%), malpresentation (50%), cesarean delivery (50%), and postpartum
hemorrhage.
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13
Q

Dizygotic twins arise from multiple ovulation with 2 zygotes. They are always _______

A

dichorionic,

diamnionic.

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14
Q

Monozygotic twins arise from one zygote. Chorionicity and amnionicity vary according to the ________

A

duration of time from fertilization to cleavage

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15
Q

Up to 72 hours (separation up to the morula stage), the twins are _______This is the lowest risk of all monozygotic twins.

A

dichorionic, diamnionic. There are 2 placentas and 2 sacs.

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16
Q

Between 4 and 8 days (separation at the blastocyst stage), the twins are___________

A

monochorionic, diamnionic. There is 1 placenta and 2 sacs

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17
Q

A specific additional complication is

________ which develops in 15% of mono-di twins

A

twin–twin transfusion,

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18
Q

Between 9 and 12 days (splitting of the embryonic disk), the twins are _______

A

monochorionic, monoamnionic. There is only 1 placenta and 1 sac

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19
Q

After 12 days,_______ result. Most often this condition is lethal.

A

conjoined twins

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20
Q

In twin gestation,

Route of delivery is based on presentation in labor—

______if both are cephalic presentation (50%); ________if first twin in noncephalic presentation;

A

vaginal delivery

cesarean delivery

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21
Q

route of delivery is controversial if ________

A

first twin is cephalic and second twin is noncephalic.

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22
Q

A pregnant woman has developed antibodies to foreign red blood cells (RBCs), most commonly against those of her current or previous fetus(es), but also caused by transfusion of mismatched blood

A

ALLOIMMUNIZATION

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23
Q

Hemolytic disease of the newborn (HDN) is a continuum ranging from _________

A

hyperbilirubinemia to erythroblastosis fetalis

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24
Q

______ is caused by maternal antibodies crossing

into the fetal circulation and targeting antigen-positive fetal RBCs, resulting in hemolysis.

A

HDN

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25
RF for Alloimmunization
Other pregnancy-related risk factors are amniocentesis, ectopic pregnancy, D&C, abruptio placenta, and placenta previa
26
______ decreases the risk of maternal alloimmunization from foreign RBCs. Naturally occurring anti-A and anti-B antibodies rapidly lyse foreign RBCs before maternal lymphocytes are stimulated to produce active antibodies
ABO incompatibility
27
Reqts for dx of alloimmunization ``` 1 2 3 4 5 ```
• Mother must be antigen negative. • Fetus must be antigen positive, which means the father of the pregnancy must also be antigen positive. • Adequate fetal RBCs must cross over into the maternal circulation to stimulate her lymphocytes to produce antibodies to the fetal RBC antigens. • Antibodies must be associated with HDN. • A significant titer of maternal antibodies must be present to cross over into the fetal circulation and lead to fetal RBC hemolysi
28
In alloimmunization, Fetal risk is present only if 1 2 3 4
(1) atypical antibodies are detected in the mother’s circulation, (2) antibodies are associated with HDN, (3) antibodies are present at a significant titer (>1:8), and (4) the father of the baby (FOB) is RBC antigen positive
29
``` In alloimmunization,No fetal risk is present if 1 2 3 4 ```
(1) the AAT is negative, (2) antibodies are present but are NOT associated with HDN, (3) antibody titer is <1:8, or (4) the FOB is RBC antigen negative
30
Assess the degree of fetal risk if the fetus is RBC antigen positive or if fetal blood typing is impossible. This can be done by 1 2 3 4
serial amniocentesis, PUBS, or ultrasound Doppler
31
Amniotic fluid bilirubin indirectly indicates fetal hemolysis because bilirubin accumulates as a byproduct of RBC lysis. The bilirubin is plotted on a_______
Liley graph
32
______ directly measures fetal hematocrit and degree of anemia.
PUBS
33
Alloimmunization: _____is the procedure of choice since it is non-invasive and has a high correlation with fetal anemia
Doppler MCA ultrasound
34
When to intervene in Alloimmunization:
Intervene if there is severe anemia. This is diagnosed when amniotic fluid bilirubin is in Liley zone III or PUBS shows fetal hematocrit to be ≤25% or MCA flow is elevated
35
Tx of Alloimmunization: * _______ is performed if gestational age is <34 weeks. * _______is performed if gestational age is >34 weeks
Intrauterine intravascular transfusion Delivery
36
______ is pooled anti-D IgG passive antibodies that are given IM to a pregnant woman when there is significant risk of fetal RBCs passing into her circulation
RhoGAM
37
``` RhoGAM is routinely given to 1 2 3 4 ```
Rh(D)-negative mothers at 28 weeks, and within 72 h of chorionic villus sampling (CVS), amniocentesis, or D&C.
38
300 mcg of RhoGAM will neutralize_______
15 ml of fetal RBCs or 30 mL of fetal whole blood
39
________ is a qualitative screening test for detecting significant feto-maternal hemorrhage (>10 mL).
Rosette test
40
______ quantitates the volume of fetal RBCs in the maternal circulation by differential staining of fetal and maternal RBCs on a peripheral smear.
Kleihauer-Betke test
41
______ is the most common cause of perinatal morbidity and mortality
Preterm delivery
42
Criteria for PTL
• Gestational age—pregnancy duration >20 weeks, but <37 weeks • Uterine contractions—at least 3 contractions in 30 min • Cervical change—serial examinations show a change in dilation or effacement, or a single examination shows cervical dilation of >2 cm
43
RF for PTL
prior preterm birth (PTB), short transvaginal (TV) cervical length (<25 mm), PROM, multiple gestation, uterine anomaly
44
Other RF for PTL
low maternal pre-pregnancy weight, smoking, substance abuse, and short inter-pregnancy interval (<18 months)
45
All gravidas should be screened: • History: _______ • Sonographic cervical length: ______
previous PTB prior to 24 weeks
46
Mx of PTL –________ if cervical length >25 mm with prior spontaneous PTB –_________ if cervical length <25 mm before 24 weeks with prior PTB – ________ if cervical length <20 mm before 24 weeks but no prior PTB
Weekly IM 17-hydroxy progesterone caproate (17-0H-P) Weekly IM 17 -OH-P plus cervical cerclage placement Daily vaginal progesterone
47
_______is a protein matrix produced by fetal cells that acts as a biological glue binding the trophoblast to the maternal decidua.
Fetal Fibronectin (fFN):
48
Importance of FFN
It “leaks” into the vagina if PTB is likely and can be measured with a rapid test using a vaginal swab
49
Pre-req for FFN Tests
Prerequisites for testing: gestation 22-35 weeks, cervical dilation <3 cm, and membranes intact
50
How to interpret FFN tests
main value of the test is a negative, since the chance of PTB in the next 2 weeks is <1%. With a positive result, the likelihood of PTB is 50%
51
_________may reduce the severity and risk of cerebral palsy in surviving very preterm neonates
Matemal IV MgSo4
52
______ is recommended for pregnant women with gestational age 23–34 weeks of gestation who are at risk of preterm delivery within 7 days
A single course of corticosteroids
53
Advanatges of pts with PTL given CS
lower severity, frequency, or both of respiratory distress syndrome, intracranial hemorrhage, necrotizing enterocolitis and death
54
These are conditions under which stopping labor is either dangerous for mother and baby or futile: Obstetric
severe abruptio placenta, ruptured membranes, chorioamnionitis.
55
These are conditions under which stopping labor is either dangerous for mother and baby or futile: Fetal conditions—
lethal anomaly (anencephaly, renal agenesis), fetal demise or jeopardy (repetitive late decelerations).
56
These are conditions under which stopping labor is either dangerous for mother and baby or futile: Maternal conditions—
eclampsia, severe preeclampsia, advanced cervical dilation
57
Importance of tocolytic agents for PTL
(1) administration of maternal IM betamethasone to enhance fetal pulmonary surfactant and (2) transportation of mother and fetus in utero to a facility with neonatal intensive care
58
Oral tocolytic agents are no more effective than placebo
Magnesium sulfate b-Adrenergic agonists include terbutaline Calcium-channel blockers Prostaglandin synthetase inhibitors
59
What tocolytic ______is a competitive inhibitor of calcium. Clinical monitoring is based on decreasing but maintaining detectable deep tendon reflexes
MgSO4
60
SE of MgSO4
Side effects include muscle weakness, respiratory depression, and pulmonary edema
61
SE of MgSO4 Tx
Magnesium overdose is treated with IV calcium gluconate.
62
Contraindications of MgSO4
Contraindications include renal insufficiency and myasthenia gravis.
63
______ Tocolytic effect depends on the b2-adrenergic | receptor myometrial activity
b-Adrenergic agonists include terbutaline.
64
_____decrease smooth muscle contractility by decreasing prostaglandin production (e.g., indomethacin).
Prostaglandin synthetase inhibitors
65
Prostaglandin synthetase inhibitors SE
Side effects include oligohydramnios, in utero ductus arteriosus closure, and neonatal necrotizing enterocolitis
66
Contraindications Prostaglandin synthetase inhibitors SE _________
include gestational age >32 weeks.
67
Mx of PTL * Confirm labor using the 3 criteria listed earlier. * Rule out contraindications to tocolysis using criteria listed above. * Initiate IV hydration with _______ * Start IV MgSo4 for ______
isotonic fluids. fetal neuroprotection (if <32 weeks) at least 4 hours before anticipated birth
68
Mx of PTL * Start tocolytic therapy with ______, _______, ____for no longer than 48 hours to allow for antenatal steroid effect. * Obtain cervical and urine cultures before giving IV penicillin G (or erythromycin) for ______ * Administer maternal IM betamethasone to stimulate ________
terbutaline, nifedipine or indomethacin (if <32 weeks) group B b Streptococcus sepsis prophylaxis. fetal type II pneumocyte surfactant production if gestational age is <34 weeks.
69
Rupture of the fetal membranes before the onset of labor, whether at term or preterm
PROM
70
PROM RF
Ascending infection from the lower genital tract is the most common risk factor for PROM. Other risk factors are local membrane defects and cigarette smoking
71
PROM UTZ
Oligohydramnios is seen on ultrasound examination.
72
Dx of PROM PROM is diagnosed by sterile speculum examination meeting the following criteria: * __________—clear, watery amniotic fluid is seen in the posterior vaginal fornix * _______—the fluid turns pH-sensitive paper blue * ________—the fluid displays a ferning pattern when allowed to air dry on a microscope glass slide
Pooling positive Nitrazine positive Fern positive
73
Chorioamnionitis is diagnosed clinically with all the following criteria needed: 1 2 3
• Maternal fever and uterine tenderness in the presence of confirmed PROM in the absence of a URI or UTI
74
Mx of PROM * If uterine contractions occur, __________ * If chorioamnionitis is present, _________
tocolysis is contraindicated. obtain cervical cultures, start broad-spectrum therapeutic IV antibiotics, and initiate prompt delivery.
75
PROM If no infection is present, management will be based on gestational age as follows: – Before viability (<23 weeks), outcome is dismal. Either induce labor or manage patient with bed rest at home. Risk of __________ is high.
fetal pulmonary hypoplasia
76
PROM If no infection is present, management will be based on gestational age as follows: With preterm viability (23 0/7–33 6/7 weeks), conservative management.
Hospitalize the patient at bed rest, administer IM betamethasone to enhance fetal lung maturity if <34 weeks, obtain cervical cultures, and start a 7-day course of prophylactic ampicillin and erythromycin
77
PROM If no infection is present, management will be based on gestational age as follows: At term (≥34 weeks), initiate prompt delivery. If vaginal delivery is expected, ________
use oxytocin or prostaglandins as indicated. Otherwise, perform cesarean delivery
78
The most precise definition is a pregnancy that continues for ≥40 weeks or ≥280 days postconception. This includes 6% of all pregnancies
POSTTERM PREGNANCY
79
Generally, _____of patients deliver by 40 weeks, ______ by 41 weeks, and ______ by 42 weeks.
50% 75% 90%
80
The most common cause of true postdates cases are _______
idiopathic
81
Post term: It does occur more commonly in _______ with ______
young primigravidas and rarely with placental sulfatase deficiency
82
Pregnancies with ______ are the longest pregnancies reported.
anencephalic fetuses
83
Post term What syndrome In a minority of patients, placental function declines as infarction and aging lead to placental scarring and loss of subcutaneous tissue. This reduction of metabolic and respiratory support to the fetus can lead to the asphyxia that is responsible for the increased perinatal morbidity and mortality
Dysmaturity syndrome
84
Mx of Post term pregnancy is based on:
Confidence in dates. | Favorableness of the cervix
85
Favorableness of the cervix is assessed by?
The Bishop score is a numerical expression of how favorable the cervix is and the likelihood of successful labia induction.
86
How to interpret the BISHOP score – Favorable cervix is dilated, effaced, soft, and anterior to mid position. Bishop score______ – Unfavorable cervix is closed, not effaced, long, firm, and posterior. Bishop score is________
is >8. <5.
87
Mx of postterm pregnancy: Dates sure, favorable cervix.
Induce labor with IV oxytocin and artificial | rupture of membranes.
88
Mx of postterm pregnancy: Dates sure, unfavorable cervix
Management could be aggressive, with cervical ripening initiated with vaginal or cervical prostaglandin E2 followed by IV oxytocin. Or management could be conservative with twice weekly NSTs and AFIs awaiting spontaneous labor.
89
Mx of postterm pregnancy: Dates unsure,
Dates unsure. Management is conservative. Perform twice weekly NSTs and AFIs to ensure fetal well-being and await spontaneous labor. If fetal jeopardy is identified, delivery should be expedited
90
Mx of Post term pregnancy ______ may be helpful to prevent umbilical cord compression; okay to perform it. ________ makes no difference in preventing MAS; do not routinely perform. ________ is only indicated if the neonate is depressed; perform selectively.
Amnioinfusion Suctioning of fetal nose and pharynx Laryngoscopic visualization of vocal cords

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