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Flashcards in Obstetrics Deck (176):
1

Signs of pregnancy

amenorrhea
breast engorgement/tenderness
fatigue
nausea/vomiting
quickening (movement)

2

Signs of early pregnancy

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

When does betaHCG become detectable in theurine? in the serum?

urine: 2 weeks after fertilization
serum 1 week after fertilization

4

when does a pregnancy show up on ultrasound?

5 weeks

5

when does fetal cardiac activity become perceptible on Doppler?

10-12 weeks

6

gestational age-

measured from 1st day of LMP
inaccurate if the cycle isn't 14 days

can be estimated with US

7

embryonic age

measured from fertilization
how old is the age of the embryo?

8

Naegele's rule for calculating due date

1st day of LMP
+ 7 days
-3 months
+ 1 year
= expected date of delivery

9

G and P

G:# of pregnancies
P:# of births: 20 weeks
A:# of abortions

10

nulligravida

never been pregnant

11

nullipara

never given birth

12

primigravida

currently in 1st pregnancy

13

primipara

has had 1 birth

14

multipara

has had >2 births

15

age of viability

24 weeks

16

preterm

17

term birth

37 w 0 d - 41w 6 d

18

postterm

>42 weeks

19

maternal physiology SU260

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

sensitive and specific diagnostic lab test for chronic pancreatitis

low fecal elastase

21

How many extra kcal does a woman need during pregnancy?

women need an extra 100-300kcal/day to meet increased metabolic needs (rate increases by 10-20%)

22

What is the recommended weight gain during pregnancy for someone who is Underweight (BMI

28-40 pounds

23

What is the recommended weight gain during pregnancy for someone who is normal weight (BMI

25-35 pounds

24

What is the recommended weight gain during pregnancy for someone who is overweight ((BMI 25-29.9)?

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

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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