Obstetrics Flashcards
1
Q
Signs of pregnancy
A
amenorrhea breast engorgement/tenderness fatigue nausea/vomiting quickening (movement)
2
Q
Signs of early pregnancy
A
Goodell sign- softening of the cervix
Chadwick sign- dark- bluish red discoloration of the vaginal mucosa
Hegar and Ladin signs: softening of uterus
Chloasma: skin hyperpigmentation on the face, often in sun-exposed areas
Linea nigra: skin hyperpigmentation along the midling of the anterior abdominal wall
3
Q
When does betaHCG become detectable in theurine? in the serum?
A
urine: 2 weeks after fertilization
serum 1 week after fertilization
4
Q
when does a pregnancy show up on ultrasound?
A
5 weeks
5
Q
when does fetal cardiac activity become perceptible on Doppler?
A
10-12 weeks
6
Q
gestational age-
A
measured from 1st day of LMP
inaccurate if the cycle isn’t 14 days
can be estimated with US
7
Q
embryonic age
A
measured from fertilization
how old is the age of the embryo?
8
Q
Naegele’s rule for calculating due date
A
1st day of LMP \+ 7 days -3 months \+ 1 year = expected date of delivery
9
Q
G and P
A
G:# of pregnancies
P:# of births: 20 weeks
A:# of abortions
10
Q
nulligravida
A
never been pregnant
11
Q
nullipara
A
never given birth
12
Q
primigravida
A
currently in 1st pregnancy
13
Q
primipara
A
has had 1 birth
14
Q
multipara
A
has had >2 births
15
Q
age of viability
A
24 weeks
16
Q
preterm
A
17
Q
term birth
A
37 w 0 d - 41w 6 d
18
Q
postterm
A
> 42 weeks
19
Q
maternal physiology SU260
A
Basal metabolic rate increases 10-20% plasma volume increases 30-50%, RBC volume increases 20-30% systolic Ejection flow mumur S3 cardiac output inreases 30-50%
blood pressure decreases in early pregnancy- nadir at 24-26 weeks, return to prepregnancy levels by term
relaxation of the lower esophageal sphincter - GERD
increased GFR- decreased BUN and Creatinine
increased procoagulation factors- hypercoagulable state
20
Q
sensitive and specific diagnostic lab test for chronic pancreatitis
A
low fecal elastase
21
Q
How many extra kcal does a woman need during pregnancy?
A
women need an extra 100-300kcal/day to meet increased metabolic needs (rate increases by 10-20%)
22
Q
What is the recommended weight gain during pregnancy for someone who is Underweight (BMI
A
28-40 pounds
23
Q
What is the recommended weight gain during pregnancy for someone who is normal weight (BMI
A
25-35 pounds
24
Q
What is the recommended weight gain during pregnancy for someone who is overweight ((BMI 25-29.9)?
A
15-25 pounds
25
What is the recommended weight gain during pregnancy for someone who is obese (BMI>30)
11-20 pounds
26
What supplements should pregnant women take?
folic acid prevents NTD
extra if on antiseizure meds
iron
avoid vitamin A in excess
27
what should pregnant women avoid eating?
deli meats (listeriosis)
fish high in mercury (CNS damage)
- shark
- swordfish
- king mackerel
- tilefish
28
how big is the uterus during pregnancy?
6-8 wks-lemon
8-10 wks- orange
10-12 wks- grapefruit
12 weeks- at the pubis
16 weeks- halfway
20 weeks- umbilicus
from 20-32 weeks the distance from the pubis approximates the age of the uterus
29
What should you do at every prenatal visit?
weight
BP
gestational age
FHTs
fetal movement (especially after 16weeks)
fetal presentation (in the 3rd trimester- cephalic or breech)
30
Leopold's maneuvers
sonogram is more accurate
31
What should you accomplish in the 1st prenatal visit?
```
CBC
type and screen
Pap
chlamydia
UA and urine culture
rubella titer
syphilis
HIV
hepatitis B
```
32
What should you accomplish at 18-20 weeks?
ultrasound
33
What should you accomplish at 10-13 weeks?
chorionic villus sampling
34
What should you accomplish at 15-20 weeks?
quadruple screen, amniocentesis
35
What should you accomplish at 24-28 weeks?
screen for gestational diabetes
1hr 50g glucose challenge
if abnormal,
3hr 100g glucose tolerance test
36
What should you accomplish at 28 weeks?
administer anti-D immune globulin if RhD negative to prevent formation of antibodies against the fetus
37
What should you do in the 3rd trimester?
CBC, chlamydia, syphilis, HIV
38
What should you do at 35-37 weeks?
screen for group B streptococcus
39
increased AFP
neural tube defects
abdominal wall defects
-gastroschisis
-omphalocele
```
multiple gestations
incorrect dating (most common cause for a quad screen to be abnormal)
```
40
decreased AFP, decreased estriol, increased hCG, increased inhibin
Trisomy 21 (down)
41
decreased AFP, decreased estriol, decreased hCG
Trisomy 18 (Edward)
42
```
Quadruple screen:
what does it measure?
what conditions does it look for?
when do you do it?
is it diagnostic?
```
```
1. maternal serum levels of
AFP
Estriol
hCG
inhibin
```
2. Conditions:
chromosomal abnormalities
NTDs
abdominal wall defects
3. timing:
15-20 weeks
4. not diagnostic
43
```
chorionic villus sampling:
what does it measure?
what conditions does it look for?
when do you do it?
what are the disadvantages?
```
1. sample of chorionic villi obtained for fetal karyotyping and other genetic testing
2. looking for chromosomal abnormalities genetic diseases
3. timing: 10-13 weeks
4. risk of fetal loss, bleeding, infection, ROM, fetomaternal hemorrhage
44
```
amniocentesis:
what does it measure?
what conditions does it look for?
when do you do it?
what are the disadvantages?
```
1. sample of amniotic fluid obtained for fetal karyotyping and other testing
2. chromosomal abnormalities
genetic diseases blood type
NTDs (acetylcholinesterase will be detected)
lecithin:sphingomylelin ratio greater than 2:1 indicates fetal lung maturity
3. 15-20 weeks
```
4. risk of fetal loss
fetal injury
bleeding
infection
amniotic fluid leakage
fetomaternal hemorrhage
```
45
Cell-free fetal DNA testing
fetal nucleic acids from maternal blood tested for
fetal sex
blood type
certain genetic diseases
aneuploidy screening
46
when do you screen a pregnant lady for syphilis?
1st visit and 3rd trimester
47
when do you perform quadruple screen?
15-20 weeks
48
when do you screen for gestational diabetes?
24-48 weeks
49
When do we administer anti-D immunoglobulin (RhoGAM) if Rh negative?
28 weeks, after delivery, risk of fetomaternal hemorrhage
50
When do we screen for GBS?
35-37 weeks
51
n/v in pregnancy
high levels of HCG, usually resolves around 16 weeks
Treat:
1. lifestyle modifications- bland foods, eating slowly, small frequent meals
2. pharmacotherapy- pyridoxing (B6) + doxylamine
3. diphenhydramine, promethazine, ondansetron
52
hyperemesis gravidarum
n/v severe enough to cause weightloss >5% of pre-pregnancy weight, dehydration, ketosis, or abnormal labs
Work-up:
Vitals: weight, HR, orthostatic blood pressure
Labs: serum electrolytes, UA
US: rule out gestational trophoblastic disease and multiple gestation (higher levels of hormones)
```
Management:
IV fluids
electrolyte and thiamine repletion
antiemetics
NG tube feeds, parenteral nutrition
```
53
Gestational diabetes
arises during pregnancy but then resolves postpartum
54
Human placental lactogen
decreases insulin sensitivity so that glucose will go to the embryo. an exaggerated response will lead to diabetes
55
gestational diabetes
```
RF:
family history
obesity
PCOS
HTN
age>25
previous baby >9 pounds
```
screening preformed at 24-28 weeks gestation
check fasting level, then give
50 gram 1hr oral glucose tolerance test (check in 1 hour)
100 gram 3hr oral glucose tolerance test (measured at 0, 1, 2, 3 hours): if 2/4 readings are above normal then diagnose
```
complications:
fetal macrosomia
neonatal hypoglycemia
pre-eclampsia
polyhydramnios
stillbirth
```
management:
diabetic diet
insulin
A1 diabetics: controlled with diet and exercise
A2 diabetics: insulin- regulated and needs fetal surveillance starting at 32-34 weeks
US in 3rd trimester to look for fetal macrosomia
-offer c/s if the fetus is >4500 g
risk of shoulder dystocia is high
possible early delivery
postpartum diabetes screening
-2hr 75g oral glucose tolerance test
56
Pregestational diabetics
diabetes before pregnancy
```
complications:
fetal macrosomia
neonatal hypoglycemia
pre-eclampsia
polyhydramnias
```
congenital malformations
- cardiac defects
- caudal regression syndrome- sacral defects (high glucose even early in pregnancy when everything is forming)
stillbirth
DKA
worsening of diabetic retinopathy and nephropathy
```
Tests to order at baseline:
HbA1C
Urine protein:Cr
EKG
Dilated eye exam
```
```
Management:
Glycemic control
-insulin
-diabetic diet
-blood glucose monitoring
```
```
2nd trimester US and fetal echo
3rd trimester fetal survaillance
3rd trimester US, looking for macrosomia
-offer C/S if fetus >4500 g
deliver by 39-40 weeks
```
57
UTI in pregnancy
cystitis (lower tract)
pyelonephritis (higher)
preterm birth
sepsis
ARDS
maternal death
58
Asymptomatic bacteriuria (ASB)
screen for ASB with urine culture at 1st prenatal visit
treat during pregnancy to prevent progression to cystitis and pyelonephritis
- nitrofurantoin
- amoxicillin
- cephalexin
- fosfomycin
- TMP-SMX
Repeat urine culture 1 week after completion of antibiotic therapy
If still positive on urine culture after 2 rounds of antibiotics, give suppressive therapy
-nitrofurantoin for the remainder of the pregnancy
objective: avoid development of pyelonephritis
59
Symptoms of cystitis
```
Dysuria
Frequency
Urgency
Suprapubic pain
Hematuria
```
60
Urinalysis findings that support UTI
bacteriuria
pyuria (WBCs)
leukocyte esterase
nitrite
61
Pyelonephritis symptoms
```
symptoms of cystitis
fever/chills
nausea/vomiting
flank pain
CVA tenderness
pulmonary edema leading to SOB
```
UA and urine cx
- bacteriuria
- pyuria (WBCs)
- leukocyte esterase
- nitrite
- WBC casts
```
treatment:
admission
IV abx (empirically then tailor)
-ampicillin + gentamicin
-ceftriaxone
-meropenem
-piperacillin-tazobactam
```
continue the patient on oral antibiotics for the rest of pregnancy
62
points to know about chronic hypertension
HTN existing before pregnancy
ACEI are teratogenic
-renal and cardiac malformations
methyldopa (central- acting alpha 2 agonist) and
labetalol (combined alpha adrenergic blocker) are safe during pregnancy
nifedipine
63
Gestational hypertension
new onset HTN after 20 weeks gestation, resolves postpartum
>140/90
after 20wks gestation
not associated with proteinuria
close monitoring for progression, no meds
64
pre-eclampsia
new onset HTN (>140/90 after 20 weeks GA)
+proteinuria (>300mg/24 hrs)
+signs of end-organ dysfunction (thrombocytopenia, renal insufficiency, elevated LFTs, pulmonary edema, HA, visual disturbances, seizure)
abnormal development of placental blood vessels
placental ischemia
inflammatory response
widespread endothelial dysfunction
```
risk factors:
history of pre-eclampsia
extremes of age
nulliparity
chronic HTN
diabetes
multiple gestations
hydatidiform moles
```
65
Preeclampsia with severe features
preeclampsia and end-organ dysfunction or BP> 160/110 mmHg
pre-e= new onset HTN (>140/90 after 20 weeks GA)
+proteinuria (>300mg/24 hrs)
+signs of end-organ dysfunction (thrombocytopenia, renal insufficiency, elevated LFTs, pulmonary edema, HA, visual disturbances, seizure)
66
HELLP syndrome
hemolysis
elevated liver enzymes
low platelets
67
eclampsia
eclampsia=
seizure in a patient with pre-e
pre-e=
new onset HTN (>140/90 after 20 weeks GA)
+proteinuria (>300mg/24 hrs)
+signs of end-organ dysfunction (thrombocytopenia, renal insufficiency, elevated LFTs, pulmonary edema, HA, visual disturbances, seizure)
Treatment: magnesium sulfate
68
Management of pre-eclampsia with severe features
lower BP: hydralazine, labetalol, nifedipine
seizure prophylaxis:magnesium sulfate
watch for magnesium toxicity:
- loss of DTRs
- respiratory suppression
- CV collapse
Calcium gluconate is the reversal agent
Definitive treatment is delivery
69
Deep venous thrombosis
Lower extremity
- pain
- swelling
- erythema
- warmth
Left side>right side
shortness of breath (PE)
DVT:
-compression US
-Doppler US
PE:
-CT or MRI of chest
Management:
1. anticoagulate with heparin or LMWH
-warfarin is contraindicated during pregnancy
-continue anticoagulation until labor begins or 24 hours prior to planned delivery
2. bridge to warfarin after delivery (safe while breast feeding)
continue anticoagulation for >6 weeks postpartum
3. counsel patient to avoid using estrogen- containing contraceptives in the future because of the increased risk of VTE
70
Amniotic fluid embolism
Amniotic fluid enters maternal circulation leading to cardiovascular collapse and possibly death
```
H and P:
hypotension (cardiogenic shock)
respiratory failure
unresponsiveness
excessive/prolonged bleeding (DIC)
```
This usually occurs during labor and delivery or immediately postpartum
Treatment: follow ACLS protocols
71
TORCHeS
```
Toxoplasmosis
Other (parvovirus B19, VZV, Listeria)
Rubella
CMV
HIV/HSV
e
Syphilis
```
```
common effects:
growth retardation
intellectual disability
hepatosplenomegaly
miscarriage
stillbirth
```
72
Toxoplasmosis
Toxoplasmosis gondii
cat feces
undercooked meat
```
primary infection during pregnancy:
-mononucleosis-like illess
-congenital infection
chorioretinitis
hydrocephalus
intracranial calcifications
```
diagnosis:
serology
PCR of amniotic fluid
Treatment:
spiramycin
pyrimethamine + sulfadiazine
73
Parvovirus B 19
children: erythema infectiosum (fifth disease)
adults: arthritis
fetus: severe anemia, hydrops fetalis (fluid accumulating in multiple parts of the body)
diagnosis:
- serology
- PCR of amniotic fluid
management:
serial ultrasounds
intrauterine blood transfusion to fetus
74
VZV
Maternal infection
- chickenpox rash
- PNA
Congenital infection
- skin scarring
- CNS abnormalities
- eye abnormalities
- limb hypoplasia
Neonatal infection (transfer during delivery
- chickenpox rash
- disseminated disease, which can lead to high mortality rate
If mom has not had chickenpox and also has not been immunized against chickenpox, confirm unimmunized status with IgG titer
avoid anyone who has chickenpox if titers are neg
avoid varicella vaccine during pregnancy because it contains live attenuated virus
If a susceptible patient is exposed to varicella during pregnancy, give immune globulin as prophylaxis
Diagnosis:
clinical, tzanck smear, DFA, PCR PCR of amniotic fluid
Treatment:
acyclovir
neonatal prophylaxis with varicella immune globulin
75
Listeriosis
Listeria monocytogenes
Classically acquired from deli meats
flu-like symptoms in mother
```
fetus can get
granulomatosis infantiseptica
-skin rash
-widespread abscesses in internal organs
-stillborn
```
Diagnosis in mother is made with blood culture
Treatment- ampicillin
76
Rubella
Children: mild fever, rash
Congenital: cataracts, PDA, sensorineural deafness
-blueberry muffin rash due to extramedullary hematopoeisis
Check mom's rubella titer at 1st visit
MMR vaccine contraindicated during pregnancy
77
CMV
```
mononucleosis-like syndrome
fetal infection
-jaundice
-hepatosplenomegaly
-sensorineural hearing loss
```
diagnosis: serology
PCR of amniotic fluid
prevent with good hand hygiene
no treatment
78
HIV/HSV
transmission during labor/deliver
screen at 1st trimester for everyone
screen at 3rd trimester is mother is at high risk
Antiretroviral therapy
- include zidovudine (AZT)
- avoid efaviranz (teratogenic)
intrapartum zidovudine
deliver by c-section
Neonatal zidovudine prophylaxis after delivery
avoid breastfeeding (HIV is a contraindication)
79
HSV
```
vesicular skin rash
conjunctivitis
PNA
meningoencephalitis
disseminated disease
```
suppressive therapy with acyclovir starting at 36 weeks
if active lesions or prodrome at time of delivery, then c-section
80
What are the features of congenital syphilis?
early manifestations (onset during first 2 years of life)
- hepatosplenomegaly, elevated LFTs
- rash followed by desquamated hands and feet
- snuffles (blood-tinged nasal secretions)
- skeletal abnormalities
late manifestations (onset after the first 2 years of life)
- frontal bossing
- interstitial keratitis
- hutchinson teeth
- saddle-nose deformity
- perforation of the hard palate
- saber shins
-neonatal death
Screen with RPR or VDRL at 1st visit, 3rd trimester, and at delivery
Confirm the diagnosis with FTA-ABS or MHA-TP
Treatment:
Benzathine penicillin G
all: desensitize then give PCN
81
GBS
```
s. agalactiae
vertical transmission leading to neonatal
-meningitis
-PNA
-sepsis
```
intrapartum prophylaxis:
PCN G to prevent transmission to infant
Who should receive intrapartum prophylaxis against GBS:
1. Positive GBS screen during current pregnancy by rectovaginal culture at 35-37 weeks
2. GBS baceteriuria during current pregnancy
3. Previous infant with early onset GBS
4. unknown screening result + one of the following:
- intrapartum fever
- prolonged rupture of membranes
- preterm labor
82
Gonorrhea and chlamydia
Cervicitis
Urethritis
Disseminated gonoccocal infection
RF:
Age
83
chorioretinitis + hydrocephalus + intracranial calcifications
toxoplasma gondii
84
hydrops fetalis
parvovirus B19
85
PDA+ cataracts + deafness
rubella
86
saddle nose, snuffles, Hutchinson teeth, saber shings
syphilis
87
HIV management during pregnancy
```
HAART (Avoid efavirenz)
intrapartum zidocudine
c-section
neonatal prophylaxis
counsel against breastfeeding
```
88
Who should get GBS prophylaxis?
```
positive GBS screen this pregnancy
GBS bacteriuria this pregnancy
previos infant with early- onset GBS
unknown screening result +1 of the following
-intrapartum fever
-prolonged ROM
-preterm labor
```
89
Risk factors for ectopic pregnancy
```
prior ectopic pregnancy
tubal surgery
PID
smoking
infertility
IUD
```
90
Presentation of ectopic pregnancy
```
amenorrhea
vaginal bleeding
abdominal pain
referred shoulder pain
urge to defecate
dizziness
LOC
peritoneal signs
-rebound tenderness, guarding
```
91
at what level of bHCG will you see IUP on TVUS?
>1500
92
What should you do with a stable patient whose TVUS doesn't show anything, and quantitative serum HCG is
repeat hcg in 48-72 hours
the hcg should double every 48 hours in a normal IUP
if the level falls, suspect some kind of failed pregnancy, and follow it all the way down to zerop
if it rises inappropriately, follow with D and C
- no chorionic villi- ectopic pregnancy, follow with treatment
- chorionic villa- failed IUP
93
Ectopic pregnancy treatment:
options
who is eligible for medical management?
resuscitation if the patient is unstable, then surgery
- salpingostomy
- salpingectomy
Methotrexate
- folic acid antagonist
- inhibits dihydrofolate reductase
patient must be stable, with normal renal and liver function to be eligible for medical management
HCG
94
Spontaneous abortion
pregnancy loss
95
Threatened abortion
bleeding
closed cervix
no POC
expectant management
96
inevitable abortion
bleeding
open cervix
no POC
D and C, misoprostal, or expectant mgmt
97
incomplete abortion
bleeding
open cervix
some POC
D and C, misoprostal, or expectant management
98
complete abortion
bleeding
closed cervix
passage of POC
no management
99
missed abortion
no bleeding
closed cervix
no passage of POC
D and C, misoprostal, expectant management
100
septic abortion
+/- bleeding
open or closed cervix
+/- passage of POC
D and C, broad-spectrum antibiotics
101
cervical insufficiency
painless cervical dilatation leading to 2nd trimester (unlike inevitable abortion which leads to painful dilatation)
pregnancy loss
uterine anomalies
ED
trauma
diagnosis: US
management: placement of cerclage
102
intrauterine fetal demise
```
pregnancy loss after 20 weeks
causes:
fetal chromosomal abnormalities or congenital anomalies
abnormalities of the placenta or umbilical cord
placental abruption
Rh alloimmunization
congenital infections
maternal complications (HTN, DM)
idiopathic
```
cessation of fetal movement
absent fetal heart tones (FHT)
ultrasound- no fetal cardiac activity
management:
expectant management
dilation and evacuation (D and E)
induction of labor: misoprostol (PGE1), mifepristone, oxytocin
103
intrauterine fetal demise
```
pregnancy loss after 20 weeks
causes:
fetal chromosomal abnormalities or congenital anomalies
abnormalities of the placenta or umbilical cord
placental abruption
Rh alloimmunization
congenital infections
maternal complications (HTN, DM)
idiopathic
```
cessation of fetal movement
absent fetal heart tones (FHT)
ultrasound- no fetal cardiac activity
management:
expectant management
dilation and evacuation (D and E)
induction of labor: misoprostol (PGE1), mifepristone, oxytocin
104
fetal heart tones, with bleeding before 20 weeks gestation, no passage of POC, closed cervix
threatened abortion
105
spontaneous abortion complicated by intrauterine infection
septic abortion
106
passage of some POC and open cervix
incomplete abortion
107
passage of all POC and closed cervix
complete abortion
108
bleeding before 20 weeks gestation + cramping + passage of POC + open cervix
inevitable abortion
109
intrauterine growth restriction
fetal weight
110
Amniotic fluid index
5-24cm: normal
| 24cm: polyhydramnios
111
Amniotic fluid index
5-24cm: normal
| 24cm: polyhydramnios
112
Potter sequence
bilateral renal agenesis: decreased urine production: oligohydramnios: pulmonary hypoplasia and structural abnormalities
```
POTTER
Pulmonary hypoplasia
Oligohydramnios
Twisted skin (wrinkled skin)
Twisted face (facial deformities)
Extremities (limb deformities)
Renal agenesis
```
Management:
amnioinfusion
113
Polyhydramnios
```
esophageal/duodenal atresia
anencephaly
multiple gestation
uncontrolled maternal diabetes
congenital infections (parvovirus B19)
fetal anemia due to Rh alloimmunization
```
Management:
Amnioreduction
Indomethacin
114
Polyhydramnios
esophageal/duodenal atresia
anencephaly
multiple gestation
uncontrolled maternal diabetes
115
Dizygotic (fraternal)
2 eggs fertilized by 2 sperm
116
Twin-twin transfusion syndrome
- possible complication of monochorionic twin pregnancies
- vascular anastomoses link the fetal circulations- blood from one twin flows to the other
- donor twin: anemia, growth restriction, oligohydramnios
- recipient twin: polycythemia, volume overload, heart failure, polyhydramnios
117
signs of multiple gestation
rapid weight gain
size>dates
increased hCG and AFP
auscultation of >1 FHT
diagnosis: ultrasound
management: serial ultrasounds to monitor growth,
fetal surveillance, possible early delivery
118
abnormal placentation
normal placenta is high
lower uterine segment- placenta overlies internal cervical os
```
RF:
increasing maternal age
multiparity
multiple gestation
uterine surgery
history of C/S
```
Presentation:
painless vaginal bleeding in the 2nd half of pregnancy
Dx: US
It is important to US before digital exam to avoid perfing
management:
1. pelvic rest
2. US, deliver at 36 wks by C/S to avoid complications
```
active bleeding:
Resuscitation- IVF, blood transfusion
Fetal HR monitoring
Corticosteroids
Bedrest, try to monitor the pregnancy and buy more time
C/S
```
119
placenta previa and history of CS are risk factors for...
placenta accreta: abnormal adherence to myometrium
placenta increta: invasion of placenta into myometrium
placenta percreta: penetration of placenta through uterus
diagnosis: us
may not be discovered until after delivery when the placenta can't be delivered
Treatment:
C/S
hysterectomy
120
Vasa previa
fetal vessels overlie cervical os
risk of compression or rupture of fetal vessels with ROM- hypoxia, hemorrhage
presents with bleeding after rupture of fetal membranes, especially if there are nonreassuring fetal heart tones
diagnosis: US
121
Abruptio placentae; placental abruption
hematoma and fetal hypoxia
DIC in mom
```
Risk factors:
prior placental abruption
hypertension
trauma
smoking
cocaine use
```
Sudden onset painful vaginal bleeding in 2nd half of pregnancy
contractions
abnormal FHT
DIC
Diagnosis:
ultrasound
clinical
Treatment:
emergency C-section
122
Premature rupture of membranes (PROM)
membranes rupture before labor
presentation: a woman who's water has broken but she is not having contractions
Confirm diagnosis with sterile speculum exam- pool of fluid in the posterior vault
nitrazine paper test
microscopy: ferning pattern of fluid
Amnisure
US: volume
```
complications:
infection
cord prolapse
placental abruption
preterm labor
```
management: if >34 weeks; induce labor (oxytocin)
infection: induce labor
if 24-34 weeks gestation and risk of preterm delivery, give corticosteroids- betamethasone, dexamethasone,deliver over 48 hours to induce type 2 pneymocytes
123
Preterm labor
34 weeks, let labor proceed
124
Tocolytics
magnesium sulfate
indomethacin
nifedipine
terbutaline- selective b2 agonist that causes bronchiodilitation of the lungs, making it useful for asthma
125
Gestational trophoblastic disease
| cytotrophoblasts and syncytiotrophoblasts
cytotrophoblasts make up chorionic villi
syncytiotrophoblasts secrete hCG
hydatidiform mole- benign, some extra hcg
invasive mole
choriocarcinoma- malignant, a lot of extra hcg
RF:
prior molar pregnancy
extremes of age
126
which has a higher rate of association with choriocarcinoma?
complete mole (2.5%)
127
How does molar pregnancy present?
```
amenorrhea
+pregnancy test
si/sx of pregnancy
vaginal bleeding
abnormal uterine size
hyperemesis gravidarum from elevated levels of HCG
```
hyperthyroidism (common alpha subunits)
very early pre-eclampsia (
128
Invasive mole
more common with complete moles
invade the uterine wall
may lead to uterine rupture/ hemorrhage
129
Choriocarcinoma
metastatic malignant form of trophoblastic disease
```
RF:
complete hydatidiform mole
miscarriage
normal pregnancy
ectopic pregnancy
spontaneous occurence
```
```
mets:
lung
vagina
brain
liver
other organs
```
h and p:
- enlarged uterus
- hyperthyroidism
- elevated hCG
- vaginal bleeding
- persistent, bloody brown discharge
- theca-lutein ovarian cysts, developing in response to high levels of HCG
- pulmonary symptoms
```
workup:
check quantitative hCG level:
extremely high
pelvic exam looking for mets
ultrasound
-uterine mass with areas of necrosis and hemorrhage
```
Chest xray:
mets to lung?
```
Treatment:
chemotherapy
+ methotrexate
surgery, depending on stage
follow hCG levels down to zero
wait 1 year before pregnancy
```
130
RhD incompatibility
mother has blood type that is RhD neg when fetus is positive
RhD woman develops IgG abs against RhD + fetus
in subsequent pregnancies, anti-D antibodies cross the placenta and attack fetal RBCs- hemolytic disease of the fetus and newborn (erythroblastosis fetalis)
this can lead to hydrops fetalis
type and screen for RhD abs at initial visit
If she is RhD negative, prevent sensitization with RhoGAM (anti-D immune globulin) at 28 weeks, at delivery, and when there is any risk of fetomaternal hemorrhage
If the patient is RhD negative with anti-D antibodies, then confirm the presence of antibodies with indirect Coombs test
Then test the paternal blood type. If he is RhD negative there should be no risk to the fetus.
If the dad is +/- and mom is -/- then test fetal blood type (fetal cell free DNA, amniocentesis)
And then, if the fetus is RhD positive you have a potential problem
Follow maternal titers. If they get higher than 116 then worry about fetal anemia- test:
MCA doppler US
fetal blood sampling
If you detect severe anemia,
- intrauterine blood transfusion
- delivery
131
When do we give RHOgam?
28wks GA
w/in 3 d of delivery
any risk of fetomaternal hemorrhage- abortion, amniocentesis, placental abruption, bleeding placenta previa
132
Antibiotics to avoid in pregnancy
fluoroquinolones
tetracyclines
aminoglycosides
sulfonamides
133
Indications for fetal nonstress test
increasd risk of fetal demise:
diabetes
HTN
Fetal growth restriction
Continue if the NST is normal
If you have an abnormal NST move on to biophysical progile
134
Biphysical profile
1. nonstress test
2. amniotic fluid volume
3. fetal breathing
4. fetal movement
5. fetal tone
2 points for each if normal
0 if abnormal
8-10 points total is reassuring
135
normal FHR
110-160 BPM with beat to beat variabioligy (oscillations of 5-10 BPM around baseline)
accelerations of at least 15 beats per minute for at least 15 seconds
136
nonstress test
20 minutes of monitoring, at least 2 accelerations of 15 BPM above baseline each lasting at least 15 seconds, in 20 minutes
Continue if the NST is normal
If you have an abnormal NST move on to biophysical progile
137
Contraction stress test
Oxytocin to induce contractions
watch fetal heart rate
look for decelerations
138
Early deceleration
fetal heart rate and contraction mirror each other
head compression
139
Variable deceleration
abrupt decrease in fetal heart rate with rapid return to baseline, not necessarily in relation to the contraction
looks like a V
occuring during umbilical cord compression
140
late deceleration
gentle down and up with a slow return to baseline
utero-placental insufficiency and fetal hypoxia
141
Sinusoidal pattern on nonstress test
severe fetal anemia
142
Management of non-reassuring fetal heart rate tracing
- Administer maternal O2, turn to left lateral decubitus position
- Discontinue oxytocin, consider correction of hyperstimulation if needed, with a tocolytic
- IV fluid bolus
- Sterile vaginal exam (check for cord prolapse)
- consider need for immediate delivery
143
Cervical dilation
how dilated is the cervix?
cm
how far apart are the fingers?
144
Cervical effacement
thinning of the cervix
| cervix gets thinner and thinner until 100% effaced
145
Fetal station
position of fetal head in relation to the fetal spines
-3
-2
-1
0 - ischial spine level
+1
+2
+3
146
Braxton Hicks contractions
sporadic, irregular contractions
that do not cause cervical dilation
"false labor"
147
1st stage of labor
latent phase- onset of regular ctx, until 6cm dilation
up to 20 hours in a nulliparous woman
up to 14 hours in a multiparous woman
active phase, 6cm to full dilation
nulliparous- 1.2 cm/hr
multiparous- 1.5cm/hr
148
Second stage of labor
from full dilation to delivery of infant
multiparous- 2 hours
nulliparous- 3 hours
this is when the mother is actually pushing
149
3rd stage of labor
begins with delivery of the infant
ends with delivery of placenta
usually lasts 30 minutes
150
things to evaluate when labor has stopped
```
power
passenger (size, etc)
passage (cephalopelvic disproportion?
```
adequate uterine contractions:
>5 contractions in 10 minutes
>200 Montevideo units
151
Montevideo units- power
look at the contractions occurring within a 10 minute window
peaks minus baseline
>200 is considered adequate
152
signs of placental separation
sudden gush of blood
lengthening of the umbilical cord
uterus rises to the anterior abdominal wall
uterus becomes firmer and more globular in shape
153
Cardinal movements of labor
```
1. engagement
fetal head drops below pelvic inlet
2. descent
drops downward
3. flexion
chin to chest
4. internal rotation
rotation towards the midline
5. extension
chin away from chest as the fetus moves through the vaginal introitus
6. external rotation
head out facing one side
7. expulsion
delivery of the body
```
154
Inducing labor- reasons to do so
- postterm pregnancy (>42 weeks)
- chorioamnionitis
- premature ROM
- pre-eclampsia with severe features
- maternal diabetes
155
Bishop score
- dilation
- effacement
- fetal station
- cervical consistency
- cervical position
low bishop score suggests low likelihood of a successful induction
156
Medications used to induce labor
Prostaglandins (misoprotol -PGE1 or dinoprostone- PGE2)
These help ripen cervix and produce contractions
main concern is that they cause hyperstimulation of uterus and tachysystole- give vaginally so that you can stop when there's enough
157
Oxytocin
causes contractions, doesn't ripen the cervix, so start with prostaglandins
given IV
short half-life
titrate until you get the contraction pattern you want
158
Amniotomy
augments labor that has stalled
159
Cesarean delivery
incision in the uterus (hysterotomy) in order to deliver the infant
can be classified based on where the incision is made
low transverse preferred- less bleeding, less risk in future pregnancies
vertical- more exposure, easy to get baby out
160
indications for C/S
1. arrest of labor
2. malpresentation
A-frank butt
B complete- cannonball
C- footling- cord at risk
3. non-reassuring fetal heart rate tracing
4. prior cesarean delivery
5. abnormal placentation (eg placenta previa)
6. placental abruption
7. uterine rupture
8. multiple gestation
9. suspected fatal macrosomia
10. certain maternal infections (HIV, HSV) to prevent transmission
avoid if you can, since vaginal deliveries have fewer complications
161
complications of c-section
1. postpartum hemorrhage
2. infections
3. damage to ureters, bladders, or other organs
4. transient tachypnea of the newborn
5. wound complications
6. post-op DVT/PE
Future pregnancies:
1. placenta previa
2. placental invasion
3. uterine rupture
162
chorioamnionitis
rupture or membrane and ascending infection
```
RF:prolonged rupture of membranes
prolonged labor
multiple cervical exams
meconium fluid
internal monitors (FSE, IUPC)
```
```
Clinical features:
maternal fever
maternal and fetal tachycardia
uterine tenderness
purulent amniotic fluid
```
treatment:
IV broad-spectrum abx
(ampicillin+ gentamicin)
definitive treatment is delivery
163
uterine rupture
weakness 2/2 prior c/sectin
induced or augmented labor
```
signs and symptoms:
fetal bradycardia
maternal abdominal pain (constant)
loss of fetal station
change in shape of uterus
maternal tachycardia and hypotension
```
management:
emergent C-section
surgical repair of uterus or hysterectomy
164
Shoulder dystocia
```
anterior shoulder gets stuck behind the pubic symphisys
management:
suprapubic pressure
mcrobert's maneuver (opens the pelvis)
delivery of posterior arm/shoulder
Rubin and wood maneuvers
intentional fracture of clavicle
Zavanelli maneuver (push the infant in and perform stat C-section)
```
complications:
Erb-Duchenne Palsy
165
postpartum hemorrhage
EBL> 500mL (SVD)
EBL> 1000 mL (C/S)
usually encountered within minutes of delivery
166
what are the causes of postpartum hemorrhage
uterine atony (MCC), soft boggy uterus, overdistended uterus, induced or augmented labor
retained placental tissue
genital lacerations
placenta accreta/increta/percreta
uterine rupture
coagulopathy
management:
fundal or bimanual massage
examine uterus for placental fragments or large blood clots
uterotonic agent
-oxytocin
-methylergonocine (contraindicated in HTN)
-carbaprost (contraindicated in asthma bc it can cause bronchospasm)
IV fluid/blood, assess need for surgery or transfusion as you go
167
How old does a child have to be before a diagnosis of enuresis is made
5yo
168
Newborn care
cord is clamped and cut
secretions are suctioned
baby is dried and stimulated
stimulation and oxygen in the air should prompt the baby to start breathing
169
APGAR
Acitivity (muscle tone):
0-limp
1- moderate movement
2-active movement
Pulse
0-no pulse
1- 100 BPM
Grimace (response to stimulation)
0-none
1-grimace, whimpering
2- strong cry
Appearance (skin color)
0-blue
1-pink with blue extremities
2- pink
Respirations
0-none
1-irregular breathing
2-regulat breathing
Normal: 7-10
Calculate at 1 and 5 minutes after birth
170
What changes does mom experience post- partum?
1. birth canal returns to non-pregnant state. There is a risk of urinary incontinence and pelvic organ prolapse
2. diuersis of expanded plasma volume
3. lactational amenorrhea
171
postpartum blues
vs
MDD with peripartum onset
Postpartum blues
| mild, self- limited depressive symptoms, starting in the first few days after delivery, lasting
172
Postpartum psychosis
hallucinations and delusions
| risk of suicide and infanticide
173
postpartum endometritis
"metritis"
polymicrobial
```
RF:
cesarean delivery
chorioamnionitis
prolonged labor
prolonged ROM
multiple cervical exams
internal monitoring
manual removal of placenta
```
```
Clinical features:
fever
tachycardia
uterine tenderness
foul-smelling lochia
```
Diagnosis: clinical
Treatment: gentamicin + clindamycin
174
Breastfeeding
```
appropriate nutrition
immunological factors
maturation of GI tract
decreased SIDS
maternal recovery and weight loss
```
decreased maternal breast and ovarian cancer
cheaper than formula
175
Contraindications to breastfeeding
```
HIV infection
Drug or alcohol abuse
Active tb
Active herpes infection on breast
Certain medications (chemotherapy)
Infant with galactosemia
```
176
Mastitis
mcc s. aureus
fever and malaise, painful swelling
treat with breastfeeding or pumping
Ultasound to look for abscess, which is a possible complication
Anti-staphylococcal penicillin like docloxacillin
If you suspect MRSA then use (recent hospitalization, recent abx use, abscess, serious infection)
- clindamycin
- TMP-SMX
- vancomycin
If there is an abscess then you need to I and D it
