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Obstetrics Flashcards

1
Q

Gestational age (GA)

A

From day of last menstrual petiod

  • Fundal height: umbil-20wks +2-3cm/wk
  • Fetal heart tones: 10-12wks
  • Appreciat fetal mvt: 17-18wks
  • US: CRL 6-12wks; BPD/FL/AC 13wks; measur of GA most reliable in 1st trim
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2
Q

Diagnosis of pregnancy

A

Beta-hCG: by placenta; peak at 100K by 10wksGA
↓2nd trim
Double every 48h in early pgncy; ectopic if abNl doubling

US: confirm intraUt pgncy
Gestational sac on transvag US, by 5wksGA + B-hCG 1000-1500

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3
Q

Normal physiology of pregnancy

A

↑ then ↓: renal flow
↓ then ↑: BP
↑ then plateaus: GFR, SV, TV
↑: weight, HR, CO, periph venal distens*, bld volume, fibrinogen, gastric emptying time
↓: periph vasc resist, expirat reserve, Ht, sphincter tone
Unchanged: RR, vital capac, e-

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4
Q

Prenatal care (weight, nutrition, exercise)

A

-Weight gain: 1-1.5kg/mo
-Prepgncy BMI: 19.8-26 w/ gain of 11-16kg
-Nutrition: add 100-300kcal/d; add 500/day if breastfd
Folic ac 0.4mg/d; Iron 30mg/d; Calcium 1000mg/d; VitD 400IU/d; VitB12 2ug/d
-Exercise: moderate 30min/d

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5
Q

Prenatal diagnostic testing

A

Wks 0-28: /4wks
Wks 29-35: /2wks
Wks 36-birth: /1wk

CBC, ABO, Rh, UA+Cx, rubella, HBV, syphilis, gono/chlam, TB, HIV, Pap smear, HCV, varicella, …

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6
Q

Quad screening

A

MSAFP, estriol, B-hCG, inhibin A

MSAFP >2.5xNl ass w/ neural tub def, abdo wall def, multi gestat*, incorrect date, fetal death, placent abNl

MSAFP <0.5xNl ass w/ trisomy 21/18, fetal demise, incorrect date

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7
Q

Pregnancy-associated plasma protein A

A

Recomm at 9-14wks
PAPP-A + nuchal transp + free B-hCG detect trisomy 21/18

  • Screen of pgnt women (>35yo)
  • Available before CVS + less invasive
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8
Q

Chorionic villus sampling vs Amniocentesis

A

CVS: 10-12wks; transcerv/transabdo apirat of placental T.; genetic dg; earlier GA; ↑R fetal loss; limb defect if <9wks

Amniocentesis: 15-20wks; transabdo aspirat of amniot fluid; genetic dg; PROM; chorioamnionitis; fetal-maternal hge

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9
Q

Cell-free fetal DNA

A

10wks
Fetal DNA from bld of mother
Noninvasive
Limited bcz low concentration of DNA in mom

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10
Q

Amniocentesis (indications)

A

In women >35yo
If abNl quad screen
In Rh-sensitized pgncy
Eval fetal lung maturity (L/S ≥2.5)

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11
Q

Toxoplasmosis congenital infection

A 
Transplacental
Hydroceph, intracran calcif, chorioret, ring les* (MRI)
Dg: serology
ttt: pyrimethamine + sulfadiazine
Prophyl: spiramycin in 3rd trim
Prev: avoid cat feces
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12
Q

Rubella congenital infection

A

Transplacental (1st trim)
Blueb muff rash, cataract, mental retard, hear loss, PDA
Dg: serology
ttt: sympt
Prevent: immunize before pgncy; vaccin mom if ⊖ serol

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13
Q

CMV congenital infection

A 
Transplacental
Petechial rash, periventric calcif
Dg: urin Cx, PCR of amniot fluid
Postpartum ganciclovir
No prevention
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14
Q

HSV congenital infection

A 
Intrapartum if active les*
Skin, eye, mouth; life-treat CNS/systemic
Dg: serology
ttt: acyclovir
Prevent: C-section if active les*
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15
Q

HIV congenital infection

A

In utero, at delivery, via breast milk
Often asympt; failure to thrive; bact inf; up/low resp ds
Dg: ELISA, Western blot
ttt: HAART (mom); prophyl AZT (baby)
Prevent: AZT or nevirapine in pgnt W; C-section if viral >1000; No breastfeed

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16
Q

Syphilis congenital infection

A 
Intrapartum, transplacental
Maculopap rash, LNpathy, HMG, snuffles, osteitis, late congen (saber shins, saddle nose, CNS, Hutchinson teeth, deafness)
Dg: dark-field, VDRL/RPR, FTA-ABS
ttt: penicillin
Prevent: penicillin if pgnt W is ⊕
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17
Q

Spontaneous abortion (RF)

A

<20wks; esp 1st trim
-Chrom abNl: 1st/2nd/3rd trim
-Maternal fact: inherited thrombophilias, immuno, anatomic, endocrino, other (trauma/↑age/inf/diet)
-Environm: tobacco, alcoh, caffeine, toxin, drug, radiat*
-Fetal fact: anatom malfo
-Recurr SAB: ≥2 consecut or 3SAB/1y; for cause, karyotype parents, hypercoag labs mom, uterin anatom
(<12wks esp chrom abNl) (12-20wks esp hypercoag)

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18
Q

Spontaneous abortion (types)

A 
Complete
Threatened
Incomplete
Inevitable
Missed
Septic
Intrauterine fetal demise
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19
Q

Spontaneous abortion (dg, ttt)

A

Nonviable pgncy: gestat sac >25mm w/o fetal pole of card activ
Clinic, speculum, US, serum B-hCG
US
Give RhoGAM if mom Rh⊖

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20
Q

Elective termination of pregnancy

A

Depend on GA and ptt
-First (90%): medical mngmt (mifepristone, misoprostol, methotrexate) up to 59d; surgical mngmt (MUA, D&C) up to 13wks

-Second (10%): obstetric mngmt (induct* labor w/ prostagl, oxytocin); surgical mngmt (D&E) up to 13-24wks

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21
Q

Normal obstetric examination

A

Leopold maneuvers: fetal lie + presentation

Cervical exam: dilat*, effacem, consist, station of fetal head relative to ischial spines, …
Sterile speculum exam if ROM suspected

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22
Q

Stages of labor

A

1st latent: 3-4cm dilation, 6-11h (primip), 4-8h (multip), prolong w/ excess sedation
1st active: 4-10cm dilation, 4-6h (primip), 2-3h (multip), prolong w/ cephalopelvic disprop

2nd: 10cm to deliv of NN, 0.5-3h (primip), 5-30min (multip), NN through all cardinal mvts
3rd: deliv of NN to deliv placenta, 0-30min (primip/multip), uterus contr + hemostasis

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23
Q

Recommendations for fetal heart rate monitoring

A

Electrode to fetal scalp or external monit Doppler US

  • Ptts w/o complic: 1st stage /30min; 2nd stage /15min
  • Ptts w/ complic: 1st stage /15min; 2nd stage /5min
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24
Q

Components of fetal heart rate evaluation

A

Rate (110-160bpm):

  • Brady (<110): congen heart malfo, severe hypox
  • Tachy (>160): hypox, mom fever, fetal anemia

Variability (6-25bpm):
-Absent (sev fet distress); minimal (<6; fet hypox, sleep, opioid); marked (>25; fel hypox, before ↓variab); sinusoidal (serious fet anem)

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25
FHR: accelerations vs decelerations
Accelerations (↑>15 beats abov baseline in <30sec): reassuring Decelerations: - Early (gradual ↓FHR to nadir in >30sec, then baseline): head compress by Ut contrac (Nl) - Late (gradual ↓FHR to nadir in >30sec, then baseline): begins after end of Ut contrac, uteroplac insuff + fet hypoxemia - Variable (abrupt ↓FHR 15 below baseline for ≥15sec + <2min, to nadir in <30sec): umbil cord compress
26
Antepartum fetal surveillance
``` In pgncy w/ ↑R of antepart fet demise Tests at 32-34wks -Fetal mvt assessment -Nonstress test -Contraction stress test -Biophysical profile -Amniotic fluid index -Modified biophysical profile -Umbilical artery Doppler velocimetry ```
27
Obstetric analgesia and anesthesia
- Visceral pain (T10-L1): ut contrac + cerv dilat* - Somatic pain (pudend N, S2-S4): press on vagina+perineum Absolute CI to regional anesthesia: maternal: refract hypoTN, coagulop, LMWH in 12h, unttt bacteremia, ↑ICP
28
Hyperemesis gravidarum (PE)
``` Persist vomit (#morning sickn that is wks 4-16) Acute starvat*; ↓weight (≥5% of preprgncy) ``` Esp first pgncy, multiple gest, molar pgncy ↑B-hCG, ↑estradiol
29
Hyperemesis gravidarum (dg, ttt)
Dg: B-hCG; US; R/o molar pgncy Ketones, Na, K, metab alkal, liv enz, bili, amyl/lipa ttt: VitB6, doxylamine, promethazine/dimenhydrinate If sev: metoclopra, ondenset, prochlorpera, promethaz If dehydr: IV fluids, nutrit supplem, dimenhydrinate
30
Diabetes in pregnancy
-Gestational DM: during pgncy >50% dev glu intol +/- DM2 later in life; always screen -Pregestational: before pgncy If RF for DM, screen w/ HbA1c or fasting glu
31
Gestational diabetes mellitus (PE, dg)
Usual dg 24-28wks Asympt; may have edema, polyhydram, large infant (>90th percentile) Dg: 1-h 50g glu chall test at 24-28wks (abNl if ≥140) Confirm w/ 3-h 100g glu toler test (3h >140)
32
Gestational diabetes mellitus (ttt)
ADA diet, regular exo, strict glu monito (4/d) Tight glu control Insulin if diet insuff (+ intrapartum insulin+dextrose) Periodic US + NST (fetal growth/health) If poor glyc control, induce labor 39-40wks
33
Pregestational diabetes
Poorly controlled DM: ↑R congen malfo, fetal loss, mater/fet morbi ttt mom: assess end-org damage + strict glu control (fastin ≤95 and 2-h postprand <120) ttt fetus: 16-24wks (quad screen, US); 32-34wks (NST, CST, BPP, US); deliv-postpart (IV insulin and glu/h in labor, early deliv if RF, C-sect* if >4500g, breastfeed)
34
Maternal complications of pregestational DM
``` DKA or hyperosm nonketotic coma Preeclampsia or eclampsia C-section Preterm labor Infection Polyhydramnios Postpartum hge Maternal mortality ```
35
Fetal complications of pregestational DM
``` Macrosomia or IUGR Cardiac and renal defects Neural tube defects Hypocalcemia Polycythemia Hyperbilirubinemia Hypoglycemia from hyperinsulinemia RDS Birth injury Perinatal mortality ```
36
Gestational and chronic hypertension
- Gestat HTN: at >20wks; proteinuria (<300); 25% dev preeclamp - Chronic HTN: at <20wks and before concept*; till >12wks postpart; 33% dev preeclamp ttt: close monitor BP Antihypertens (methyldopa, labetalol, nifedipine) !!! No ACEIs or diuretics
37
Preeclampsia and eclampsia
- Preeclam: new HTN (SBP≥140 or DBP≥90) + proteinuria (>300/d) at >20wks - Eclam: new grand mal seiz + preeclam -HELLP sd: Hemolyt anem, ↑LFTs, ↓plts Vasospasm → hge + org necros; poor pg
38
Preeclampsia and eclampsia (PE, complications)
- Mild: asymp; edema - Severe: BP>160/110; proteinuria (>5g/d) or oliguria; headac, somnol, blurred vis*, scotom, RUQ pain, HELLP - Eclampsia: same as severe preeclam + seiz Compl: prematur, fet distress, stillbirth, plac abrupt, seiz, DIC, cereb hge, retin detach, hypox enceph, thromboemb, fet/mat death
39
Preeclampsia and eclampsia (ttt)
Only cure: delivery - Preecla: near term (induct*); far term (bed rest); labetal/hydral; continuous MgSulfate; seiz prophyl - Sev preecla: same + induct* or C-section -Eclam: !ABC; Mg; IV diazepam (if seiz); monito baby; contr BP; limit fluids+Foley; delivery if no seiz !Seiz: antep/intrap/postpart till 48h
40
UTI and pyelonephritis during pregnancy
Asympt bacteriuria then UTI/pyelon if unttt Persist unttt, ↑R for preterm labor, low birth weight, perinatal mortality Dg: ⊕Cx (esp E coli) ttt: asympt (3-7d nitrofur, cephalexin, amoxiclav) Follow Cx at 1wk Pyelon: admit, IV fluids, IV C3G, AB for rest of pgncy
41
Antepartum hemorrhage
Bleeding at >20wks Esp placental abrupt* and placenta previa Other: placenta accreta, ruptured uterus, genit tract les*, trauma !cervical cancer, cerv/vagin les*, fetal bleeding
42
Placental abruption (RF, PE, dg, comlications)
Premature separat* of placenta RF: HTN, trauma, tobacco/cocaine, previous abr, ... Painful dark bleed, uter hypertonicity, fetal distress Dg: clinic, TA/TV US (retroplac clot; r/o previa) Compl: hgic shock; DIC; recurr; fetal hypoxia
43
Placental abruption (ttt)
Mild: stabilize ptt w/ hospit, IV, fetal monito, bed rest Mod-sev: immed delivery (vag if mom/baby stable; C-section if 1 in distress)
44
Placenta previa (RF, PE)
AbNl implantat*: total (covers os); marginal (margin of os); low lying (close to os) RF: prior C-sec; multipar; adv age; multip gest; prior previa Painless bright red bleed, stops in 1-2h; +/- contract* No fetal distress
45
Placenta previa (dg, complications, ttt)
Dg: TA/TV US (abNl posit*) Compl: ↑R placenta accreta; vasa previa; preterm; PROM; IUGR; congen anomal; recurr ttt: NO vag exam; stabilize ptt; tocolytics; serial US; betamethasone (28-32wks, lung matur) C-sect*: if labor, life-threat bld, fet distress, ⊕lung matur, 36wks GA
46
Vasa previa (RF, PE, dg)
Velamentous umb cord insert* +/or bilobed placenta RF: multi gest, IVF, 1 umb artery, plac previa, low-lying plac Painless bleed at rupture of membranes + fet bradycard Dg: TV US w/ Doppler
47
Vasa previa (complications, ttt)
Compl: fetal exsanguinat* ttt: acute bld = emerg C-sect* If dg before bld: steroids at 28-32wks, hospit 30-32wks, close monito + C-sect* at 35wks
48
Ectopic pregnancy (PE, #dg)
Esp tubal Abdo pain + vag bleed; or asympt Ass w/ causes of scarring (Hx of PID, pelv surg, DES, endometriosis) #dg: abort*, ov tors*, PID, ruptured ov cyst
49
Ectopic pregnancy (dg, complications, ttt)
Dg: W of reprod-age + abdo pain = ruptured ectop pgncy until proven otherwise ⊕pgncy test, TV US (empty ut), serial B-hCG w/o doubling Complic: tubal rupture, hemoperitoneum ttt: methotrexate (if small + unruptured); surg is rupt or unstable (salpingectomy/salpingostomy w/ evacuat*)
50
Intrauterine growth restriction (RF, dg, complications)
EFW < 10th percentile for GA RF: mat system ds w/ uteroplac insuff (An, HTN, ut inf); mat subst abuse; plac previa; multi gest Dg: US (serial fundal height measur + EFW) Compl: ↑perinatal morbi/morta
51
Intrauterine growth restriction (ttt)
Underl cause If near term, give steroids (48h before delivery) Fetal monito w/ NST, CST, BPP, umbil art Doppler
52
Fetal macrosomia
Birth weight > 95th percentile Sequela of gest diabetes Prenatal dg imprecise Compl: ↑R should dystocia (brach plex injury + Erb-Duchenne palsy) ttt: C-sect* if >5000g + no DM or if >4500g + DM
53
Polyhydramnios
AFI ≥25; asympt Nl pgncy; fetal chromosom dev abNl Causes: mat DM; multi gestat*; isoimmuniz; pulm abNl; fet anomalies; tw-twin transfu sd Dg: fundal height > expect; US (fet anom); gluc; Rh ttt: underl cause Compl: preterm labor; fet malpresent; cord prolapse
54
Oligohydramnios
AFI <5; asympt or IUGR/fet distress Causes: fet urin tract abNl; chron uteroplac insuff; ROM Dg: US ttt: r/o inaccur gest date; ttt underl cause Compl: ass w/ ↑x40 perinat morta; MSK abNl; pulm hypopl; umbil cord compress*; IUGR
55
Rhesus isoimmunization (RF, dg, ttt)
Fetal RBCs leak to mat bld (Rh⊖) → mat form anti-Rh IgG → Ab cross plac + fet hemolysis (2nd pgncy) ↑R w/ prev SAB or TAB or delivery w/o RhoGAM Dg: monito sensitized Rh⊖ moms w/ serial US + amniocent ttt: sev (preterm deliv when lungs mature) +/- intraut bld transfu (if low fet Ht)
56
Rhesus isoimmunization (prevention, complications)
Prev: if mom Rh⊖ + dad ⊕/unk, give RhoGAM If bb ⊕, give mom RhoGAM If mom ⊖ and abort, Hx ectop pgncy, amniocent, vag bld, plac prev/abrup → type + screen + prev pgncy for 1y Compl: hydrops fetalis if bb Hb <7; fet hypox + acidosis, kernict, prematur, death
57
Gestational trophoblastic disease (benign vs malignant)
-Benign: complete (sperm+empty ov; 46XX; no fet tiss) or incomplete (Nl ov+2 sperm; 69XXY; fet tiss) molar pgncy -Malign: molar pgncy progr to invasive mole or choriocarcinoma W/ complic: pulm or CNS meta, trophobl pulm emboli
58
Gestational trophoblastic disease (PE, dg)
1st trim ut bleed; hyperem gravid; preecl/ecl <24wks; ↑ut size RF: <20 or >40yo; def folate or B-carotene Dg: no heartbeat; large ovaries; grapelike molar in vagina ↑↑B-hCG (>100K); US (snowstorm, no gest sac/fetus); CXR (lung meta)
59
Gestational trophoblastic disease (ttt)
Evacuate uterus + follow B-hCG/week Malign: methotrexate or dactinomycin (chemoth) Residual: hysterectomy Meta: chemoth + irradiation
60
Multiple gestations
Monozy (ident) or dizygot (fratern) Rapid ut growth; excess ↑weight; palpat* of ≥3 large fet parts Dg: US; B-hCG; human plac lactogen; MSAFP (all ↑) ttt: surveill for IUGR Compl: hospit ↑x6; ↑R plac prev + C-sect*; tw-twin transfu sd; IUGR; preterm; ↑R congen malfo
61
Shoulder dystocia
RF: obes, DM, macrosomic bb, Hx of prior dystocia Dg: prolong 2nd stage of labor, recoil of perineum, No spontan restitut* ttt: HELPER (Help reposit*, Episiotomy, Leg elevat*, Pressure suprapub, Enter vagina+rotation, Reach fetal arm
62
Failure to progess with labor/delivery (dg, complications)
Ass w/ chorioamnionitis, occiput post posit*, nullipar, ↑birth weight - 1st stage: fail adequate progr cervic chang - 2nd stage: arrest fetal descent Compl: chorioamnionitis, fet inf, permanent injury, postpart hge, lacerat*
63
Failure to progess with labor/delivery (ttt)
- 1st stage: latent (parenteral analgesia, oxytocin, amniotomy, cervical ripening); active (amniotomy, oxytocin, C-sect*) - 2nd stage: observ w/ ↓epidural rate and oxytocin; assisted vagin deliv (forceps/vacuum); C-sect*
64
Rupture of membranes (4 types)
- Spontan: after or at onset of labor - Premat: >1h before onset of labor - Preterm premat: <37wks gest - Prolong: >18h before deliv
65
Rupture of membranes (dg, ttt, complications)
Dg: sterile spec exam; nitrazine paper test (blue); fern test; US No digit vag exam (if no plan for labor) Monito fetal HR, mat T*C, WBCs, ut tendern ttt: dep on GA+lung matur (rest or induct*) AB (prophyl or ttt); CS (betameth or dexameth x48h Compl: perterm, chorioamnionitis, plac abrupt*, cord prolapse
66
Preterm labor (RF, PE)
``` Labor betw/ 20-37wks gestat* #1 cause of neonat morbi/morta ``` RF: multi gest; inf; PROM; ut anomalies; prev preterm; polyhydram; plac abrupt; poor mat nutrit*; low SES PE: cramps, low back pain, pelv press, new vag disch/bld
67
Preterm labor (dg)
Dg: regular ut contrac (≥3 each 30sec over 30min) AND concurr cerv chang at <37wks - CI tocolysis: inf, nonreassu fet test, plac abrupt - Sterile spec: r/o PROM - US: r/o anomalies, verigy GA, fet present, fluid volume - Cx chlam/gororr/GBS; UA, ur Cx
68
Preterm labor (ttt, complications)
ttt: hydrat* + bed rest; tocolyt unless CI; steroids; GBS prophyl (peni/ampic) Compl: RDS; intravent hge; PDA; necrot enterocolitis; retinopathy; bronchopulm dyspl; death
69
Fetal malpresentation
Other than vertex RF: premat; prior breech deliv; ut anomal; poly/oligohydr; multi gest; PPROM; hydroceph; anenceph; plac previa ``` Esp breech (LE/butt) ttt: 75% chang by wk38; external vers*; C-sect* ```
70
Indications for cesarean section
- Mat fact: prior C-sec; activ gen herpes; cerv carcinoma; mat trauma; HIV - Fet + mat fact: cephalopelvic disprop; plac previa/abrupt; failed vag deliv; postterm pgncy - Fet fact: malposit*; distress; cord compr/prolap; erythroblastosis fetalis (Rh incomp)
71
Episiotomy
Median or mediolateral Compl: extens* to anal sphinct or rectum; bleed; inf; dyspareunia; rectovag fistula; mat death
72
Postpartum hemorrhage (complications, ttt)
>500mL for vag deliv or >1000mL for C-sect* Before, during, after deliv of placenta Compl: acute bld loss (fatal); chronic loss (anemia, ↑R inf); Sheehan sd ttt: if severe, uter art emboliz
73
Uterine atony
RF: ut overdist (multi gest, macrosom, polyhydr); exhausted myomet (prolong labor, oxytocin); ut inf; condit* interfer w/ contrac (anesth, myoma, MgSO4) Dg: soft enlarg boggy ut; #1 cause of postpart hge ttt: biman ut massage; oxytocin; methergine if no HTN; PGF2a
74
Genital tract trauma
RF: precipit labor; operat vag deliv; large bb; inadeq episiot repair Dg: manual/visual inspect* of lacerat* >2cm; postpart hge ttt: surg repair
75
Retained placental tissue
RF: plac accr/incr/percreta/previa; ut leiomyoma; preterm deliv; previous C-sec/curett Dg: manual/visual inspect* of cotyled; US ttt: manual removal; curettage w/ suct*
76
Postpartum infections (PE, RF)
≥38*C for ≥2 of the first 10 days postpart (w/o first 24h) Ut tendern, malodor lochia RF for endometritis: emerg C-sec; PROM; prolong labor; multi intrapart vag exams; intraut manip; deliv; low SES; young W; prolong rupt membr; bact coloniz; CS
77
Postpartum infections (ttt, complications)
ttt: broad AB IV (clinda/genta) until afeb x48h; add ampi if complic Compl: septic pelvic thrombophlebitis (abdo/back pain; fev up to 41*C; bld Cx; CT (absc); ttt w/ broad AB and anticoag heparin x7-10d)
78
Sheehan syndrome (postpartum pituitary necrosis)
Massive obstet hge/shock → pituit ischem + necros → ant pit insuff (#1 in adult W) PE: esp failure to lactate (↓ prolact); other sympt Dg: provocative hormo test, MRI of hypoth/pitui (r/o other cause) ttt: replac all def hormo
79
7 W's of postpartum fever (10 days)
``` Womb (endometritis) Wind (atelectasis, pneumonia) Water (UTI) Walk (DVT, PE) Wound (incision, episiotomy) Weaning (breast engorgement, abscess, mastitis) Wonder drugs (drug fever) ```
80
Lactation and breastfeeding
In pgncy: ↑estro+progest → brst hypertrop + inhib prolact After deliv: ↓hormo, prolac stimul alveol epith cells (↑milk) Periodic suckling: ↑prolact/oxytocin → milk eject* Colostrum: prot, fat, secret IgA, minerals In 1wk: mature milk w/ prot, fat, lactose, water
81
Lactation and breastfeeding (benefits, CI)
↓ incid of allergies ↓ incid of early URIs and GI inf Facilit mom-bb bonding Maternal weight loss CI: HIV; active HBV and HCV; medic (tetracyc, chloramph)

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