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Obstetric Complications Flashcards

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1
Q

When is preterm birth?

A
  • Birth after 20 weeks gestation and before 36 6/7 weeks
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2
Q

How is diagnosis of preterm birth done?

A
  • Uterine contractions accompanied with cervical change or cervical dilation of 2 cm and/or 80% effaced
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3
Q

What causes preterm labor?

A
  • Spontaneous
  • Multiple gestations
  • Preterm premature rupture of membranes (PPROM)
  • Pregnancy associated hypertension
  • Cervical incompetence or uterine anomalies
  • Antepartum hemorrhage
  • IUGR
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4
Q

What are some socioeconomic factors that cause PTL?

A
  • African American’s twice as likely as Caucasians
  • Decrease access to prenatal care
  • High stress levels
  • Poor nutrition
  • Questionable genetic differences
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5
Q

What are some medical and obstetrical factors that cause PTL?

A
  • Previous history of PTL
  • History of second trimester abortion
  • Repeated spontaneous first trimester abortions
  • Bleeding in the first trimester
  • UTI/genital tract infections
  • Multiple gestation
  • Uterine anomalies
  • Polyhydramnios
  • Incompetent cervix
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6
Q

What are some infections that may cause PTL?

A
  • Bacterial vaginosis
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7
Q

What is done to help reduce PTL due to bacterial vaginosis?

A
  • Treatment for group B strep, gonorrhea, and chlamydia
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8
Q

How does the length of the cervix affect PTL?

A
  • Relative risk of PTL increases as cervical length decreases
  • Checked via ultrasound
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9
Q

What is a screening tool used to check cervical length?

A
  • Fetal fibronectin (FFN)
  • Released from the basement of the fetal membranes
  • Released in response to disruption of the membranes as with uterine activity, cervical shortening, or infection
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10
Q

When does the placental-vascular pathway begin?

A
  • At time of implantation
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11
Q

What is seen at the level of the placental-decidual-myometrial interface?

A
  • Immunologic component
  • Vascular component
  • Low resistance connection of spiral arteries
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12
Q

What could alteration to any of the components see at the level of the placental-decidual-myometrial interface do?

A
  • May result in poor fetal growth which is a risk factor for PTL as well as growth restriction and preeclampsia
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13
Q

What is the stress-strain pathway?

A
  • Mental and physical stress are thought to induce a stress response that increases the release of cortisol and catecholamines
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14
Q

What does cortisol do?

A
  • Released from adrenals
  • Stimulates early placental corticotropin-releasing hormone (CRH) gene expression and increased CRH levels are known to assist in labor at term
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15
Q

How do catecholamines affect PTL?

A
  • Affect blood flow and can cause uterine contractions
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16
Q

What is the uterine stretch pathway?

A
  • Uterine stretches as a result of increasing volume

- If the uterus gets to a “full term” size, then contractions may begin

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17
Q

What must be present for the diagnosis of PTL?

A
  • Uterine contractions

- Cervical change or cervical dilation of 2 cm or greater AND/OR 80% effacement

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18
Q

What are the symptoms of PTL?

A
  • Menstrual like cramping
  • Low/dull backache
  • Pelvic pressure
  • Increase in discharge/blood discharge
  • Uterine contractions
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19
Q

What is done to look for PTL?

A
  • Initial assessment done with cervical exam to assess dilation, effacement and fetal presenting part
  • Evaluate for any underlying correctable problems such as infections
  • External monitoring for uterine activity and fetal heart rate
  • Reevaluate the cervix and during that hour oral or IV hydrate
  • Cultures are taken
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20
Q

What is done once a diagnosis has been made?

A
  • CBC
  • UA
  • Urine culture
  • Obtain an ultrasound
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21
Q

What is the management of PTL?

A
  • If diagnosed 2 cm and/or 80% effaced or made cervical change then begin tocolysis (if gestational age is less than 34 weeks and no contraindication)
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22
Q

What does magnesium sulfate do?

A
  • Acts on the cellular level and competes with calcium for entry into the cell at the time of depolarization
  • May have a role in neuroprotection or prevention of cerebral palsy
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23
Q

How much magnesium sulfate is given?

A
  • 6g load IV and then 3g/hour maintenance
  • Therapeutic range is 5.5-7 mg/dL
  • Continue until both doses of steroids are given
  • Titrate down if uterine activity decreases
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24
Q

What are some maternal side effects of magnesium sulfate?

A
  • Feeling of warmth and flushing
  • Nausea and vomiting
  • Respiratory depression
  • Cardiac conduction defects and arrest at high serum levels
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25
What are some neonate side effect of magnesium sulfate?
- Loss of muscle tone - Drowsiness - Lower Apgar scores
26
What is nifedipine?
- An oral agent effective in suppressing preterm labor | - Minimal maternal and neonatal side effects
27
What does nifedipine do?
- Inhibits slow, inward current of calcium during the second phase of the action potential
28
What side effects are seen with nifedipine?
- Headache - Cutaneous flushing - Hypotension - Tachycardia
29
What do prostaglandin synthetase inhibitors do?
- Inhibit prostaglandin production that induce myometrial contractions
30
What is the most common prostaglandin synthetase inhibitor?
- Indomethacin which can be given orally - Can result in oligohydramnios - Can cause the premature closure of fetal ductus arteriosus and result in primary hypertension and heart failure
31
What are infants that are exposed to indomethacin at a higher rate of?
- Necrotizing enterocolitis | - Intracranial hemorrhage
32
What is the biggest risk with PTL?
- Fetal lung maturation
33
What is used for fetal lung maturation?
- Glucocorticoids which reduces mortality and incidence of RDS and intraventricular hemorrhage
34
When are glucocorticoids given?
- Given between 24 and 34 weeks gestation
35
How are glucocorticoids given?
- Either two doses of 12mg betamethasone given 24 hours apart or 4 doses of dexamethasone given every 12 hours
36
How long do the effects of glucocorticoids last?
- 7 days
37
What is the lower limit of viability?
- 22?-24 weeks or 500 grams
38
What should be done for a preterm infant?
- Continuous fetal monitoring and act quickly on abnormal patterns as premature infants have less reserves
39
What is the delivery method if there is vertex presentation?
- Vaginal is preferred | - Some recommend c section due to low birth weight
40
What is the delivery method if there is breech presentation?
- Increased risk of cord prolapse or compression as well as head entrapment with vaginal delivery therefore most will c-section
41
What are some prevention methods of PTL?
- IM progesterone - Vaginal progesterone (used in women with short cervix) - Pessary-Arabian pessary (used in women with short cervix)
42
What are some risk factors for PPROM?
- History of preterm premature rupture of membranes - Vaginal/cervical infections - Second and third trimester bleeding - Incompetent/short cervix - Low BMI - Lower socioeconomic status - Smoking and illicit drug use - Nutritional deficiencies
43
How is the diagnosis of PROM made?
- Based on history - Loss of fluid - Confirmation of amniotic fluid in vagina - Confirmed with a sterile speculum
44
Why do you not check the cervix of a presumed ruptured preterm patient?
- Increases the risk of infection especially during the prolonged latency before delivery
45
What are the three tests to confirm PROM?
- Pooling - Nitrazine paper (turns blue) - Ferning - May also use ultrasound to evaluate amniotic fluid volume to aid in diagnosis
46
What are some causes of false positives in nitrazine results?
- Urine - Semen - Cervical mucous - Blood - Vaginitis
47
What are some causes of false negatives in nitrazine results?
- Remote PROM with no remaining fluid | - Minimal leakage
48
What are some maternal risks with management of PPROM?
- Endomyometritis - Sepsis - Failed induction due to unfavorable cervix
49
What does management of PPROM depend on?
- Gestational age at time of rupture (if less than 24 weeks, may lead to pulmonary hypoplasia) - Amniotic fluid index (any value less than 5 cm is considered or no 2 cm deepest vertical pocket = oligohydramnios) - Fetal status - Maternal status
50
What is the goal of conservative management of PPROM?
- Continue pregnancy until lung profile is mature | - Usually will deliver around 34 weeks due to benefits of delivering outweighing the risks
51
What is monitored for and how is it diagnosed?
- Monitor for signs of chorioamnionitis - Diagnosed by maternal temperature greater than 100.,4 - Fetal or maternal tachycardia - Tender uterus - Foul smelling amniotic fluid/purulent discharge
52
What antibiotic use is recommended in management of PPROM?
- 48 hour course of IV ampicillin and erythromycin/azithromycin followed by 5 days of amoxil and erythromycin
53
What tocolytic use is recommended in management of PPROM?
- No recommendation can be made for or against - Can be used if no evidence of chorioamnionitis - Use mainly to get steroids on board
54
What steroid use is recommended in management of PPROM?
- Use up to 34 weeks of gestation to reduce the risk of RDS
55
What is the outpatient management in PPROM?
- No real place for outpatient management | - May manage in cases of extreme prematurity until reaches viability
56
What is intrauterine growth restriction?
- When the birth weight of a newborn is below 10% for a given gestational age
57
What are growth restricted fetuses at risk for?
- Meconium aspiration - Hypoxia - Stillbirth - Polycythemia - Hypoglycemia - Cognitive delay - Adult onset conditions like HTN, DM, CAD, stroke
58
What are some causes of IUGR?
- Poor nutritional intake/low maternal body weight - Cigarette smoking - Drug abuse - Alcoholism - Cyanotic heart disease - Pulmonary insufficiency - Antiphospholipid syndrome - Collagen vascular disease/autoimmune disorders - Teratogen exposure
59
What are some placental causes of IUGR?
- Insufficient substrate transfer through placenta as well as defective trophoblast invasion - Conditions that may result in placental insufficiency like HTN, renal disease, placenta or cord abnormalities, preexisting diabetes
60
What are some fetal causes of IUGR?
- Infectious diseases (listeria, TORCH) - Congenital anomalies/genetic disorders - Multiple gestations - Chromosomal abnormalities
61
How is IUGR diagnosed?
- Physical exam --> fundal height - Ultrasound --> biometry - Direct studies --> amniocentesis or percutaneous umbilical blood sampling - Doppler studies
62
How is IUGR managed pre-pregnancy?
- Optimizing disease processes | - I.E. blood sugar control in diabetes, control of HTN
63
How is IUGR managed in antepartum?
- Decrease any modifying factors --> improve nutrition, stop smoking - Goal is to deliver before fetal compromise but after fetal lung maturity
64
What is monitored in antepartum?
- Non-stress test twice weekly - Biophysical profile - Doppler studies of umbilical artery
65
What is post term pregnancy?
- Pregnancy that continues past 42 weeks
66
What is seen in post term pregnancy?
- Perinatal mortality is 2-3x higher | - Postmaturity syndrome
67
What is postmaturity syndrome?
- Related to aging and infarction of the placenta | - Loss of subcutaneous fat, long fingernails, dry and peeling skin and abundant hair
68
What are some etiologies of postterm pregnancy?
- Usure due dates - Fetal adrenal hypoplasia - Anencephalic fetuses - Placental sulfatase deficiency - Extra-uterine pregnancy
69
What is the management of a postterm pregnancy?
- In 41st week: begin antenatal testing to include twice weekly NST and biophysical profile - In 42nd week: induction of labor - Induction of labor at 41 weeks is preferred
70
What is intrauterine fetal demise?
- Fetal death after 20 weeks gestation but before onset of labor
71
What are some causes of IUFD?
- Most are unknown (50%)
72
How is IUFD diagnosed?
- Suspect if patient complains of absence of fetal movements or if unable to Doppler fetal heart tones - Confirm by ultrasound with lack of fetal activity and absence of fetal cardiac activity
73
What is the follow up on an IUFD?
- TORCH titers - Parvovirus studies - Listeria cultures - Anticardiolipin antibodies - Hereditary thrombophilias - Fetal chromosome studies - Fetal autopsy

Endo/Repro (31 decks)

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