Phillips - Pregnancy Flashcards

Question

What are the benefits of breastfeeding for the mother?

Answer 1

- _Natural contraception_ as long as mom is fully breastfeeding, even for months post-partum 1. Will not ovulate until starts supplementing, & PRL levels go down in intermediary periods - _Weight loss_ - Some evidence it _protects against breast cancer_ - _Bonding_

Answer 2

- _Pregnancy_: level of prolactin INC 10-20x - _Delivery_: progestin, estrogen levels drop, and INH of PRL hormone removed -\> milk production begins - FUNCTION: promotes _casein mRNA_ transcription 1. May stimulate syn of _alpha-lactalbumin_, the regulatory protein of the lactose synthetase enzyme system 2. INC mammary gland _lipoprotein lipase_ activity 3. Regulates milk production via osmotic balance at the membrane - Levels DEC as nursing becomes established, but _nursing itself stimulates episodic production of PRL_ to keep process of milk production going

Answer 3

- Produced by post pit; _contracts smooth mm layer of band-like cells surrounding the alveoli_ to squeeze the newly produced milk into the duct system (out from the alveoli) - _INC maternal GI mobility and nutrient absorption_ so she can make the most of breast feeding (promotes nutrition) - Necessary for milk ejection reflex, or **let-down**, in _response to suckling_ - _Anti-stress effect_: increase bonding (can relax and enjoy nursing)

Answer 4

- Colostrum from breast in first few days of nursing, NOT breast milk -\> _low vol, high nutritional content_ 1. Perfect for immature gut of newborn b/c simple in construction and low-volume - CONTENTS: 1. Very rich in proteins, Vit A, and NaCl 2. Lower amts of carbs, lipids, and potassium than mature milk (simpler formulation) 3. Growth factors (stimulate devo of the gut), anti-microbial factors, Ab's of passive immunity

Answer 5

- _Glucose_ is the major substrate for breast milk - Glucose, amino acids, and minerals delivered to the milk from maternal circulation - _Lipid content rises throughout nursing episode_: the longer the baby nurses, the higher the lipid content in the breast milk 1. Protein stays the same - _Maternal diet variation causes NO variation_ in milk components (or their concentrations)

Answer 6

- Nursing itself _INC blood flow to the breast by 20-40%_ so more nutrition can get directly to the breast and into breast milk - Maternal cardiac output goes up, and vasodilation occurs from oxytocin

Answer 7

- Breast milk is _present by mid-pregnancy_: women don’t lactate or leak breast milk until baby is born - Progesterone drops at delivery, and PRL (from pit gland) increases -\> milk production - Breast engorgement: 2 days postpartum

Answer 8

- Release from post pituitary gland causes breast _myoepithelial cells to contract_ and release milk 1. Causes uterus muscle cells to contract too, involuting uterus, and _reducing bleeding_ as the mother nurses - Released through a _somatosensory pathway_ initiated by neonatal suckling -\> breastfeeding begets milk production (when they stop feeding, milk production stops) - _Remember_: pitocin (oxytocin) given to women in labor to help augment their contraction pattern

Answer 9

- Breast feeding coalition -\> OB's now educate the patients that _breastfeeding is expected_ 1. No longer say, "would you like to breastfeed or bottle feed;" expectation is breastfeeding - Educate family members in spite of potential (-) comments or feedback: _want mom to feel comfortable breastfeeding_ - Provide support for new moms: teams of lactation consultants -\> has worked!

Answer 10

- BARRIERS: stigma, fear, pressure to bottle feed, esp. with young women that are eager to get back to school or work - EDUCATION: _baby benefits_ from improved neonate nutrition, protection against obesity, some infections, allergies and asthma, BONDING 1. _Benefits to mom_ include convenience, weight loss, protection against breast cancer, and BONDING 2. _Requires support_- antepartum by doctors (Not “are you breast or bottle feeding?” like it is an even choice; but. “Breast feeding is best for the baby, so I assume you are breast feeding.”) 3. _Lactation nurses_ postpartum: in hospital and beyond

Answer 11

- Postpartum hemorrhage rarely results in hypovolemic shock and necrosis of pituitary (if vascular system not supported, for example) - Immediate result will be no prolactin production 1. First clue to dx is not able to breast feed - Very rare phenomenon now because we do so much to prevent and treat post-partum hemorrhage

Answer 12

- NO medication to suppress breast milk production - Good bra, breast binders, do not stimulate breast, and cycle of stimulation will break and production will cease - Bromocriptine was used in the past, but not anymore because terrible side effects, including stroke

Answer 13

- _Mastitis_: commonly caused by S aureus, Strep, or H. influenza -\> introduced via baby’s mouth (baby giving it to mom) 1. Treat with antibiotics: Dicloxicillin 2. Continue breast feeding 3. Can be painful, so treat with some pain meds (Tylenol, in particular) - Occasionally an _abscess_ results that requires surgical drainage (may cause pain) 1. Patient will feel ill, and have fever 2. Usually S. aureus via baby’s mouth

Answer 14

- Occurs in the **ampulla** of the fallopian tube - **Completes meiosis II**, & zona pellucida becomes impenetrable so no other sperm can get in 1. Fails in polyploidy (69 chrom organism) - Pro-nuclei of sperm & oocyte fuse: 23 -\> 46 chrom - Cleavage of cells is rapid to form a **morula**, or mulberry-shaped embryo (12 or so cells via mitosis) 1. **Blastocyst**: morula cavitates -\> inner cell mass (fetus) and outer layer (trophoblast and placenta)

Answer 15

- _Day 4_: morula enters the uterus, and cavitates, becoming blastocyst (day 5) 1. Trophoectoderm becomes the outer cell mass, and is destined to be the placenta 2. Inner cell mass destined to be the fetus - _Day 8-9_ post-fertilization: blastocyst actually implants

Answer 16

- _Human blastocyst_: can see the blastoceal cavity from the outside (area a little thinner, with mass-like appearance) 1. Inner cell mass: will become fetus 2. Outer cell mass: will become trophoblasts

Answer 17

- Embryo travels to the uterine cavity day 5-6, and implantation occurs _day 8-9_ - Endometrium _glycogen, lipid-rich_: decidualization process promoted by **progesterone** produced by corpus luteum to nourish new embryo 1. Oftentimes, removal of an ovary will result in miscarriage b/c not enough progesterone - **Trophoblastic cells** invade decidua: act much like cancer cells, _attaching embryo to the endometrium_ 1. Invades so entire embryo can be nourished; uterine surface folds back over developing embryo - **hCG** produced by trophoblastic cells can be detected via blood testing

Answer 18

- Based on first day of last menstrual period (**LMP**) b/c easier to establish than date of conception 1. Assumes idealized 28-day menstrual cycle - Due date always an estimate (**EDD**): normal 40 wks +/- 2 wks (or 40 wks gestational age) 1. _Count back 3 mos from LMP and add 7 days_: ex., LMP is May 10 -\> EDD is February 17 2. +/- 2 weeks is considered term, or normal - This is important for potential EXPOSURES

Answer 19

- Due date is _September 13th_ - _She should be reassured_ -\> embryo was likely just at an implantation stage where a teratogen would have no effect on organ development - You can’t give her any guarantees, but you can certainly give her some advice - _NOTE_: Accutane is the exception to problems with teratogen exposure in very early fetal development because may hang around a bit longer because it is a fat-soluble vitamin (A)

Answer 20

- First: 0-14 weeks - Second: 14-28 - Third: 28-40 1. 40 weeks is due date, but normal +/- 2 wks on either side

Answer 21

Unborn, regardless of gestational age

Answer 22

- When organs forming: _2-8 wks after fertilization_ (4-10 weeks from LMP) - Important for thinking about potential exposures and birth defects, i.e., from meds or environmental exposures - Depends on precise ultrasound dating

Answer 23

- Medical term: by law, **\<20 wks or \< 500 grams** (pre-viable pregnancy loss that can be first or second term) - _Spontaneous_: miscarriage - _Induced_: medical/surgical procedure

Answer 24

- Viability: **\> 23 weeks gestation** - Variable based on place of delivery - Few miracle babies born at 21-22 weeks, but 23 weeks and above considered for possibility of viability - _No C-section if patient is \<23 weeks_ b/c viability chance is practically 0

Answer 25

- _Preterm_: \<37 weeks gestation - _Late term_: \>41 weeks - _Post-term_: \>42 weeks 1. Start to worry about adverse consequences after this date

Answer 26

- Pregnant now, one term birth, no preterm births, one abortion (not sure if spontaneous or induced), one living child - Gravid: pregnant - Parity: had a baby (dead or alive at birth)

Answer 27

- Pregnant now, one term birth, no pre-term births or abortions, two children living at home (twins) - Gravid: pregnant - Parity: had a baby (dead or alive at birth)

Answer 28

- To help achieve as good a maternal and infant outcome as possible - Promote good health for mom and baby through the pregnancy - _Screening_ for and managing any complications that may develop during pregnancy or immediately post-op - Identify needs for care beyond normal OB care: pts may have a number of _other medical issues_

Answer 29

- _Missed menses_: the way many young women find out they are pregnant - _Nausea/vomiting_: not sure why this happens; AM sickness generally happens early in pregnancy, but can continue throughout (meds to tx this) - _Breast tenderness_: part of early symptomatology - _Perceives fetal movement_: primigravida 18 weeks; G2 or greater 16 weeks (i.e., if you have had more than one child, and you know what to look for) 1. NOT possible to feel this @ 8 wks b/c there are specific times when fetal movement is *actually perceptible*

Answer 30

- URINE detects: **\>25** mIU/mL -\> _5-6 wks gestation_ (just missed a period); RELIABLE - SERUM detects: **\>5** mIU/ml -\> _3 wks LMP_ -\> prior to pt knowing she's pregnant (b4 missed menses) 1. Level **doubles e/48 hrs** in early pregnancy, and peaks at 10-12 weeks 2. Used to monitor in vitro fertilization - This hCG pattern critical for OB b/c they might be trying to _determine if the pregnancy is a healthy one_ (reassuring that pregnancy is a healthy one, even if mom is having lots of cramping, bleeding)

Answer 31

- Uterus soft (a little enlarged) at 6-7 wks gestation - Cervix is bluish (blood engorgement) - Can tell is enlarged at 7-8 weeks, and sometimes earlier, depending on the habitus - Hear _fetal heart tones_ w/battery operated Doppler at _10 weeks from LMP_ (depending on pt habitus) - Used to rely on physical exam to diagnose early pregnancy before HCG levels and US to help

Answer 32

- Pelvic brim: 12 weeks -\> should be able to feel the uterus abdominally 1. Umbilicus: 20 weeks 2. Beyond 20 wks: +1cm from pubic bone to fundus each week of gestation - In general, in spite of patient’s habitus, uterus for the most part grows in a predictable fashion - Msmt in cm should be approx to wk of gestation -\> important to be able to document normal growth

Answer 33

- TRANSVAGINAL: _3-4 wks_ gestation, hCG 1000-2000 mIU/mL (much earlier than abdominal) 1. If \< this, won’t see anything on transvaginal US, but this doesn’t mean she’s not pregnant - ABDOMINAL: _5-6 wks_ post-LMP, cardiac activity 1. HcG is 4000-5000 mIU/mL - Earlier these are performed, the more accurate they are for dating - IMAGE: fetal pole at 7 o’clock, normal gestational sac surrounded by thickened endometrium (7 wks, so would be able to see fetal heart beat at this gestation as well)

Answer 34

- _Ultrasound_: could be transvaginal or transabdominal - Yolk sac = YS - Fetal pole = FP -\> inner and outer cell mass sitting at lining of uterus

Answer 35

- She is too early to detect pregnancy on US - Look again when hCG is over 2000

Answer 36

- **Screen for adverse history that predisposes to problems for maternal and fetal outcome** - Questionnaire or face to face: usually both - LMP and contraception use - _Meds_, esp. any that may cause birth defects - _Previous pregnancy hx_: if she has had pregnancy losses -\> spontaneous abortions or pre-term deliveries may put patient at-risk for more of these - Medical: diabetes, HTN, heart disease AND sx hx - _Hx of infectious diseases_: may have adverse fetal outcome if during pregnancy - _Genetic history_: previous child with birth defects or family history of cystic fibrosis or sickle cell - PE, labs, US (dating, # of fetuses; assess for birth defects at later date) - Referrals if indications, or to high-risk OB

Answer 37

- _CBC_: anemia, thrombocytopenia - _Urine culture_: look for asymptomatic bacteriuria to prevent pyelonephritis during pregnancy 1. Culture \>10⁵ of identifiable organism tx with AB; test cure later in pregnancy to ensure pt adherence to regimen and infection is gone - _Blood group_: Rh and Ab screen - _Infectious disease profile_ -\> test for infections that put fetus/neonate at risk: 1. Syphilis 2. Hepatitis B and C 3. Chlamydia and Gonorrhea 4. HIV is an opt-in - NOTE: make pt aware of the tests you are doing

Answer 38

- _Genetic screening_ via questionnaire + might offer screenings for the following depending on pt answers: 1. Chromosome abnormalities: trisomy 21 2. Carriership of single gene disorders, incl. sickle cell disease 3. _Cystic fibrosis, hemoglobinopathies (sickle cell, thalassemia), spinal muscular atrophy (SMA) type 1_ should be offered to all patients - _HIV_: can opt out - _PAP smear_: guideline dependent

Answer 39

- Typing and matching blood critical because some _fetal blood may make it into maternal circulation_ in pregnancy -\> want to prevent antibody response - **Rh factor** is most common type of Ag/Ab rxn in pregnancy -\> _anti-D Ab_ can be made by Rh- mom to Rh+ fetal RBCs (ALLO-IMMUNIZATION) 1. 85% of pop Rh+: D/D or D/d (auto dom) 2. 15% Rh-: d/d - Ab to Rh factor is **IgG**, and can pass freely to the placenta, and into fetal circulation 1. Ab-Ag complexes form on fetal RBCs, and they are lysed in liver, spleen, bone marrow, and macros -\> fetus _at risk for anemia_ and high output heart failure

Answer 40

- If this is a new partner and he is Rh-, there is nothing to be concerned about - If he is Rh+, repeat the titer in one month. If \>1;32, fetus may be at risk -\> _8x original value_, meaning mom mounting an immune response to fetal blood 1. If amnestic (remembered) response like this, _ultrasound + fetal cord sampling_ so we can know how severely the baby is being affected 2. _Intrauterine transfusions_ can be performed if fetus is pre-viable or baby can be delivered early if pregnancy is further along (transfused after birth, in this case) - She may have been sensitized when she had her miscarriage, or maybe she didn’t get enough Rhogam

Answer 41

- _Ultrasound_: will eventually show signs of heart failure 1. Edema 2. Hydrops: can have swelling of entire fetus 3. Fetal tachycardia, impending demise - _Fetal cord sampling_: can be used to diagnose fetal anemia

Answer 42

- It is too late - Mom has already mounted an immune response, and the whole point of Rhogam is to prevent this

Answer 43

- Give Rhogam at 28 weeks gestation to help protect against fetal-maternal exchange that may happen at delivery - These moms would have a (-) titer at prenatal screening; if they had a titer, it would be too late to admin Rhogam

Answer 44

- One option may be donor sperm because there will be fetal risk with every pregnancy in which baby is Rh+ - Happens earlier and earlier with subsequent pregnancies at risk - _NOTE_: ABO incompatibility can also cause fetal anemia and jaundice (O- moms), but this is much more mild than the anti-D rxn

Answer 45

- _Folic acid_ prior to, and throughout pregnancy to prevent fetal birth defects - _Multivitamin_: this may not be as important for some affluent populations; chewable forms okay - _Diet_: INC fluids b/c blood volume expanded by 40-50%, avoid sushi, and improve diet

Answer 46

- _Early for dating_: more accurate LMP the earlier you do this - _18-20 wks_: to detect birth defects -\> best time to do this b/c should be able to see 4 chambers of the heart, determine septal/vessel defects, look at limbs/digits pretty, facial structures, intracranial findings and sex - _Add'l US only for indications_: uterus small, large, and other concerns, i.e., may need another US to rule out restriction or too large a baby

Answer 47

- **28 wks**: 1-hr post glucola (50gm load) serum glu screen for _gestational diabetes_ 1. _Rhogam_ if Rh(-): MAb to Rh (D) Ag; prevents mom’s immune response by “tagging” fetal RBCs that get into mom’s bloodstream - **36 wks**: repeat _STI screen_ (CDC recommends for high-risk pops) -\> HIV, Hep B/C, RPR (syphilis), GC + chlamydia (if previously + and tx, and high-risk) 1. Culture for _group B streptococcus_: if (+), tx during labor w/penicillin to prevent neonatal disease (baby could die soon after birth from sepsis, meningitis, pneumonia if no tx) a. \>50% of Memphis pts + for GBS

Answer 48

- Discuss with the neonatal team -\> baby will get Ig at birth - RARELY trans-placental transmission - Baby will also get vaccinated early

Answer 49

- Rapid HIV is drawn, and if (+), AZT is begun 1. If HIV rapid is (+) and pt refuses AZT intrapartum, her wishes must be respected - REMEMBER: if in high risk population, re-screen for HIV, Hep B, syphilis at 36 weeks

Answer 50

- Every 4 weeks from first visit to 28 weeks - Every 2 weeks from 28-36 weeks - Every week from 36 weeks until delivery - _Monitoring_: BP, complaints, FHTs (fetal heart tones), fundal height - _Education_: preterm labor signs/symptoms, diet, exercise, breast feeding benefits, contraceptive plans, delivery plan

Answer 51

- _Contractions_: get closer together, more regular, and more painful as time goes on 1. If this happens far from labor, patient needs to come in to be evaluated for pre-term labor 2. Aches, pains normal in pregnancy; labor = regular ontractions + cervical changes - _Ruptured membranes, or bleeding_: should prompt presentation for care

Answer 52

- We don't really know: 1. Fetal _cortisol rises_, but fetuses that don't have this rise are still born 2. INC in plasma _PG's_ + changes in _estrogen:progesterone ratio (both fall)_ near due date, but no consistent swings/sways - Iatrogenic PG's will induce labor, but how they work is still kind of a mystery

Answer 53

Latent and active

Answer 54

- From "not in labor" to **4 cm** from contractions (but there is debate about this; can be up to 5-6 cm) - _Contractions become regular, painful, and cervical dilation_ picks up 1. Contractions don't always mean labor: Braxton-Hicks contractions - May be 18 hrs in primigravida, or very rapid in multigravidas

Answer 55

- _Rapid cervical change_ because contractions much more regular, intense (**\>4cm**) - From this moment (4-5cm) to delivery of infant 1. 0.8 cm/hr in a primigravida or 1.3cm/hr in a multiparous patient (much more rapid)

Answer 56

- _Thinning of the surface of the cervix_ during dilatation - IMAGE: may be able to get one finger in at stage 2 1. Bit of guess work for stage 4: helpful to have same OB monitor pregnancy b/c they can see the change in cervical dilation/initiation of the labor process

Answer 57

- Idealized labor curve - Some things have to be evaluated and treated during labor in some cases

Answer 58

- She is admitted - Pitocin for labor augmentation, if necessary

Answer 59

- **Stage 1**: 4 cm (5 or 6 cm) to completely dilated 1. _Contractions drive this process_: not much the pt can do to affect an INC/DEC in this time - **Stage 2**: completely dilated to delivery of baby 1. Requires maternal effort: pushing (valsalva maneuvers) - **Stage 3**: delivery of baby to delivery of placenta - _NOTE_: she mentioned a fourth stage in podcast in which the uterus involutes, but said it is a bit of an afterthought people don't really talk about

Answer 60

- _X-linked_ mutation in androgen receptor; 46 XY 1. May be complete or partial 2. Prenatal diagnosis possible - Present at puberty with amenorrhea (older brother could not be affected, but younger sister could be) 1. _No pubic or axillary hair_ - _HIGH testosterone_ level -\> aromatase converts to estrogen, so female habitus - No uterus (AMH), cervix, tubes, or upper vagina on US - _40-50% risk for gonadoblastoma_ -\> testes

Answer 61

- 46 XY; autosomal recessive - Female or ambiguous external genitalia and male internal genitalia 1. No chest hair and male chest devo + fused labial folds 2. No uterus -\> testes produced AMH, and now have risk of gonadoblastoma (seminoma)

Answer 62

- _Mosaic karyotype_: 45X, 46 XY - Presents with ambiguous genitalia: level of ambiguity depends on level of functioning testis 1. No F pubertal devo, and may have virilization at puberty 2. Usually raised as female - Short stature, web-necked, wide-spaced nipples: like Turner + male pseudohermaphroditism - _Streak gonad on one side; testis on the other_ (needs to be removed bc gonadoblastoma risk) 1. Unicornuate uterus and fallopian tube

Answer 63

- Very common: **25%** of all pregnancies end in loss 1. _Most sporadic_, with NO recurrence risk -\> after first one, couple should be reassured they will have live birth on next pregnancy - _Earlier in pregnancy = higher risk for loss_ 1. Once a heart beat is seen on ultrasound, the chance of a successful pregnancy is \>90%

Answer 64

- Most **chromosomal abnormalities** -\> earlier miscarriages 1. 50-60% in first trimester 2. 15-20% in second 3. 5-6% in third (or stillbirths) - 1/500 in alive-born - Most common type of chromosome abnormality is _aneuploidy_: trisomy 16 (NOT born alive), trisomy 21 - Single most common abnormality: _45,X_ -\> can be born alive, but a common cause of sporadic losses

Answer 65

- Usually caused by the same event: 1. Insufficient cervix 2. Uterine anomalies: T-shaped (DES) or other birth defects of uterus itself (treated w/surgery, but C-section needed if uterine scarring) 3. Ab syndromes: Ab recognizes placenta as foreign, and attacks it, leading to scarring and vasculitis 4. Parent a carrier of a balanced translocation, and passes unbalanced complement to fetus

Answer 66

- Cervical integrity compromised, usually causing _2nd trimester losses_ (may cause recurrent losses) 1. Can be dx'd during early pregnancy if, on US or digital exam, cervix noted to be opening up - Hallmark is **painless**: no associated contractions 1. Pressure in vagina, presents for care, then spontaneously delivers fetus - Tx: **cerclage** placed during 1st trimester -\> stitch around cervix to hold it closed, hold up pregnancy (see attached image) - This is a pretty common phenomenon

Answer 67

- TX with heparin subcu throughout pregnancy to prevent clot formation, and produce successful pregnancy

Answer 68

- Prenatal diagnosis - Pre-implantation genetic diagnosis (**PGD**): allows only healthy, chromosomally normal embryos to be implanted in an IVF procedure

Answer 69

- 25% - Bleeding and cramping during this time is worrisome

Answer 70

- _Ultrasound_: best way to reassure mom everything is normal 1. Trans-abdominal can detect gestational sac when hCG level is 2000 mIu 2. Transvaginal can detect gestational sac when hCG level is 1000 mIu - _Hormone levels_: progesterone \>5 is reassuring for a normal early IUP (intrauterine pregnancy) 1. HcG levels should double every 48 hours in a normal IUP - Oftentimes bring pts back to check hCG levels, and then to look for sac on US

Answer 71

- _Chromosome abnormalities_: less likely than first trimester losses - _MDA_: mullerian duct abnormalities - _Insufficient cervix_ (incompetent cervix): painless dilation, no contractions (image attached) 1. May deliver at home or come to the hospital with spotting or feeling pressure 2. Cervix found to be advanced dilation

Answer 72

- This is a _sporadic loss_: no reason to evaluate for recurrent losses

Answer 73

- Sounds like _insufficient cervix_, and a CERCLAGE should be considered with next pregnancy

Answer 74

- _Chromosomal_: associated with INC maternal age 1. Trisomy 21, 18, 13 2. Down's screen option in 1st, 2nd trimester - _Single gene_: sickle cell, CF, spinomuscular atrophy -\> part of routine care to offer screening - _Structural_: usually sporadic or assoc w/a teratogen (i.e., alcohol or Dilantin) -\> picked up on US 1. All women should have US at 18-20 wks to confirm dates and look for birth defects

Answer 75

- Normal US in first trimester - Some birth defects can be detected this early

Answer 76

- _Anencephaly_: large orbits on right side, and no fetal head - Can also see INC thickening in a line down the back of the fetus 1. _Cystic nuchal translucency_: an abnormality indicating that birth defects might be present

Answer 77

- _Cystic nuchal translucency_: lg space b/t skin and remainder of tissue indicative of possible birth defects, including: 1. Aneuploidy: abnormal # of chromosomes in a cell 2. Cardiac defects 3. Neural tube defects (NTD) - Unsure what this actually is: may be lymphatics

Answer 78

- Routine care at 18-20 wks - Dating by msmts of biparietal diameter, femur length, humerus length, head circumference, and abdominal circumference 1. Create a composite to allow us to best date the pregnancy - Scan for birth defects - Could be done at OB, radiology, or perinatology

Answer 79

- Normal anatomy of fetal head at 18 wks in _biparietal diameter view_ (BPD) - Cerebral falx going left to right down midline, and evidence of ventricles on either side - _Line measures the cerebellum_, and shows normal size -\> banana, crescent-shaped organ in the back of the head, where the calipers are making their measurements

Answer 80

- _Ventriculomegaly_: hydrocephalus - _Abnormal BPD_: can still see the falx, but don’t get the integrity of white and grey matter 1. Huge ventricle; choroid plexus dangling in it - Size of skull may not be big, but _intracranial findings abnormal_, and brain tissue pushed and compressed against fetal skull

Answer 81

- _Gastroschisis_: ventral wall hernia (1/10,000) - Allows gut to exteriorize: happens prematurely, and can be detected prenatally via US

Answer 82

- _Gastroschisis on US_ at 20 wks - Something sitting out from the fetus: lumen with fluid spaces in it -\> bright spaces probably ischemic areas in the gut after it has been compressed - Usually, these kids do very well, but may have to have some gut resected if it was strangulated in utero

Answer 83

- Cleft palate: easier to pick-up on 3D US - In general, 2D the best for routine evaluation 1. The exception is cleft lip and palate because you can see 3D structures so well, particularly in the face

Answer 84

- Advanced reproductive technologies like _IVF, or gonadotropin-induced_ pregnancies 1. Can result in many more than 2 babies, and is a serious issue for the repro endocrinology community - Associated with _advanced maternal age,_ and we’re seeing more older mothers

Answer 85

- 1/30 pregnancies start out as twin gestation 1. 1 will then not survive in some, so rate turns out to be _1/76 live gestations_ - 1/3 are monozygotic (identical) and _2/3 are dizygotic (fraternal)_: separate eggs fertilized by separate sperm

Answer 86

- DIZYGOTIC: black race 1. Maternal family history 2. Very young maternal age, or advanced maternal age - MONOZYGOTIC: sporadic!!! 1. Only risk factor is IVF -\> occasionally, a single gestation will divide after being implanted as an IVF

Answer 87

- _Monozygotic_: one egg and sperm, but conception splits in early development 1. One, shared placenta - _Dizygotic_: two eggs (superovulation), and both are fertilized 1. Always are dichorionic/diamniotic 2. Separate placentas

Answer 88

- Chorionicity depends on when the split happened - _Di/Di_: separate chorionic and amniotic sacs, but share one placenta -\> still some communication (never totally separate) 1. Cleavage days 1-3 - _Mono/Di_: one, large chorionic sac, but two smaller amniotic sacs, sharing same placenta 1. Cleavage days 4-8 (implantation typically occurs during this time) - _Mono/Mono_: chorionic and amniotic sacs shared 1. Cleavage days 8-13 2. Must be DELIVERED EARLY to prevent cord entrapment - _Conjoined_: often times not compatible with life, but sometimes one or both can survive 1. Cleavage days 13-15

Answer 89

- _Lambda sign_: V and very thick membrane, which suggests this is a Di/Di gestation - US helps diagnose chorionicity: most likely would be diagnosed as dizygotic twins

Answer 90

- _Prematurity_: most common complication; average age of delivery is 36 wks 1. Some very premature and have problems as a result: CP (cerebral palsy), blindness, MR (mental retardation) - _Birth defects_: more common in twins, especially limb abnormalities and NTD’s - _Need for C-section_: oftentimes, but not always -\> depends on the presentation 1. Depends on presenting fetus; if 1st is coming headfirst, then vaginal is fine, but if coming legs or butt first, then C-section is better - _Maternal diabetes_: more risk with twin gestations - _Maternal hemorrhage_: more likely with twins

Answer 91

- _Cord entanglement and death_ are common - These patients are hospitalized at viability (at UT), and monitored in hospital to ensure code entanglement isn’t occurring - Can pick up signs of distress via fetal heart tones - Delivery at 32-34 weeks gestation

Answer 92

- _Twin-to-twin transfusion_: one twin often dies in utero or after delivery - Timing crucial bc risk of death with either twin due to shifts of blood from one fetus to the other via placental circulation 1. _Recipient is likely to survive_, even though s/he has more problems (e.g., polycythemia) - _Effort made to treat this with laser_ (laparoscope inside the uterus) by ablating communicating vessels -\> high risk of miscarriage/fetal death, but can be used in *extreme circumstances*

Answer 93

- _Vertex_: 95% of the time (normal) - _Malpresentation_ (something other than the head presenting): 5% 1. In general, all require C-section: breech, foot, face, arm - _Cord prolapse_: obstetrical emergency, and need to deliver ASAP via cesarean because cord can be compressed with presenting part, leading to fetal anoxia or death - _Placenta previa_

Answer 94

- **Intrauterine growth restriction** (IUGR): high morbidity and mortality 1. Dx w/serial ultrasound when fetal growth \<10th percentile (fundal height) 2. Early delivery or extensive monitoring with US and listening to fetal heart tones - **Symmetrical**: all msmts equally small, and have been since the beginning; usually chromosomal abnormalities - **Asymmetrical**: "head sparing" -\> apparent as the pregnancy progresses b/c some vascular accident or insufficiency occurring, and all fetal efforts being made to spare brain and head 1. _Smoking, sickle cell, diabetes_ with vascular disease: not enough O₂/nutrition is getting to the fetus (_placental insufficiency_) 3. Head may measure more or less normal for gestational age, but everything else small

Answer 95

- _Smoking, sickle cell, diabetes_ w/vascular disease: not enough O2/nutrition is getting to the fetus (placental insufficiency) - "Head sparing" -\> all fetal efforts being made to spare brain and head

Answer 96

- **Maternal diabetes**: glu moves freely across the placenta, and babies become macrosomic (\>4500) 1. _\>4500 gms_ (macrosomic) delivered via C-section if mom diabetic 2. _At-risk for birth injury_: shoulder dystocia (OB emergency: head out, rest of baby too big to deliver), stuck in birth canal, death in delivery 3. _Neonatal complications_: hypoglycemia, polycythemia, hypoCa²⁺, hyperbilirubinemia in nursery when mom has uncontrolled diabetes (every effort to keep this in control with insulin during pregnancy, IV insulin drips in delivery) - _Other causes_: some birth defects, like Beckwith-Weideman syndrome -\> 10-11 lbs, and C-section indicated, auto dom, and often predicted based on mom or dad having it - Weights can be estimated by US and a delivery plan (vaginal delivery versus CD) can be made

Answer 97

- These are OB emergencies: 1. Placenta previa 2. Placental abruption 3. Labor 4. Vaso previa 5. Trauma - Have to think of these things when mom presents with bleeding in 3rd trimester

Answer 98

- **Placenta previa**: placenta overlying cervical os, and in the way of baby coming through cervix (3rd trimester bleeding) 1. Usually, a zygote embryo will implant on ant or post surface high in the endometrial fundus 2. If drops lower in uterine cavity, may implant lower, closer to cervix -\> placenta previa 3. When cervix opens naturally, in preparation for labor, little rip in plate defining vessels from uterus to placental surface for oxygenation can tear and bleed -\> maternal blood - _Risk factors_: previous previa 1. Multiparous: uterine cavity might be quite big, and egg will search for awhile, then nearly drop out of cervix before implanting low 2. Previous cesarean: can cause scarring and mixed signals, making mom more prone - _Presentation_: painless bleeding -\> wake up in pool of blood, or bleed in toilet 1. May be hemorrhage: telltale signs of great deal of bleeding -\> may require transfusion 2. Not having contractions 3. Can be quite serious - _Tx_: requires C-section; rarely, fetal anemia

Answer 99

- **Placental separation from uterine wall** in 3rd trimester that prevents oxygenation of fetus, and presents as bleeding (can be severe) 1. Severity of abruption: % of detachment - **Risk factors**: previous abruption, smoking 1. _Hypertensive disorders_: vasculopathy can cause fragile vessels, & spike in HTN episode may cause hemorrhage and abruption 2. _Cocaine use_: BP goes up very high, and pt will have essentially what looks like a stroke -\> hemorrhagic bleed causing separation - **Presentation**: _PAIN_, tetanic contractions (one right after the other, and can feel on uterine palpation), bleeding (unless concealed) 1. _Fetal distress_: late decelerations after freq contractions, indicating fetus getting poorly oxygenated during contractions (attached image; also flat HR instead of variation) 2. _DIC in mom_: clot consumptive, and chews up clotting factors in maternal system -\> need to deliver (and get out products of conception) and replace clotting factors with blood (pt would receive fibrinogen, cryoprecipitate, platelets, and blood, as needed)

Answer 100

- OB cx in which fetal blood vessels cross or run near external orifice of the uterus (os; lengthened across and through the membranes) 1. Placenta on ant surface of uterus - Vessels at-risk of rupture when the supporting membranes rupture during contractions b/c they are unsupported by the umbilical cord or placental tissue -\> _fetus can exsanguinate_ (blood is fetal) - Very rare; presents with 3rd trimester bleeding - _C-section immediately_ due to fetal distress - Do NOT perform physical exam until you have done imaging

Answer 101

- US for localization of the placenta - Do NOT do physical exam until you have done imaging

Answer 102

You should ask and screen for drug use

Answer 103

About 2% of reported pregnancies

Answer 104

- 9% of all pregnancy-related deaths - Most common cause of death in first trimester - Hemorrhage

Answer 105

- _History of Chlamydia, GC, or PID_: can lead to sub-acute scarring (patient may not even know she had this, but still have tubal disease as a result) - _Tubal ligation_: possible one sperm could get through and fertilize egg distal to ligation site - _Previous ectopic pregnancy_: this means you have tubal disease - _IVF pregnancy_: eggs introduced into uterus with catheter -\> may travel retrograde to tube or corneal portion of the uterus - _Endometriosis_ - _Previous tubal re-anastomosis_: scarring can prevent egg fertilized in ampulla from traveling to the uterus

Answer 106

- Any one that is not in the uterine cavity: ovary, tube, cervix, abdomen - Ampullary and interstitial portions of tubes most common

Answer 107

- Pt usually presents w/_irregular bleeding and some pain_ -\> pregnancy test (even urine) will be positive 1. May not be acute abdomen, but rather just spotting 2. _7-8 wks gestation_ (LMP) - Ultrasound will reveal an empty uterus - Ectopic in _interstitial or corneal segment of tube may be diagnosed later_ b/c more room to grow before causing symptoms (more dangerous) 1. May present at 12 weeks; if it should rupture at this stage, in this portion of the uterus, pt may bleed out very rapidly

Answer 108

- Ectopic pregnancy - Early IUP - Spontaneous or complete abortion

Answer 109

- Type & cross for blood products, and to the OR if: 1. Blood in abdomen + positive pregnancy test 2. Acute abdomen 3. Tachycardia, hypotension: signs, symptoms of blood loss (hemodynamically unstable) 4. Anemia - This is very rare these days

Answer 110

- Be patient, but counsel pt about signs of rupture: can be rapid; pt should return for pain, dizziness - Draw quantitative hCG levels and progesterone 1. _Progesterone \<5 likely a failed pregnancy, ectopic, or spontaneous abortion (SAB)_ 2. Progesterone \>5, but nothing on US, may be early pregnancy - _Quantitative hcg levels should double in 48 hrs_: can do serial levels if no dx on first visit (stable, progesterone \>5), and need to monitor 1. hCG based on LMP, last US, evidence of IUP

Answer 111

- Dx: failed pregnancy (may or may not be in uterus) - _Curette the uterus, and send to pathology_ 1. If products of conception (membranes, placental tissue): SAB 2. If no products: ectopic - If no evidence of pregnancy in uterus, and still have hCG levels that are slightly rising, even without finding of mass on US, you can make the diagnosis this is likely ectopic pregnancy

Answer 112

- _Ectopic pregnancy_ in isthmic portion of fallopian tube - Can easily be removed with ligatures or cautery via laparoscopy - US also attached here showing mass with fluid-filled areas (darker) on left + some placental/tubal tissue (imaging can be hard to see)

Answer 113

Ultrasound ## Footnote - If US shows empty uterus, and hCG is 3100, further evaluation is necessary - If 48 hrs later, her hCG is 2900 and bleeding has decreased, this is possibly an ectopic pregnancy and we should still follow her 1. Rule out failed IUP: evacuate uterus to look for villi

Answer 114

- Surgical treatment is the standard 1. _Stable patient_: laparoscopy 2. _Unstable patient_: may need laparotomy to get in, find bleeding, stop it, and remove pregnancy and all of the blood inside the abdomen - Patients may need a transfusion - Post-resection in attached image: cautery, ligatures, tube removal to isthmus via laparoscope

Answer 115

- _Medical mgmt_: if mass \<5 cm, including hematoma that sometimes surrounds ectopic pregnancy 1. If no cardiac activity: sometimes fetus thrives in this envo and heartbeat is detectable on US in the tube - _Methotrexate_: capacity to kill rapidly growing cells, i.e., trophoblastic cells (dose to kill cells, and stop growth) 1. Needs f/u with HCG levels to see if effective - _Patient must be reliable_, and return if any pain or concerns occur - Also depends on what the patient may want - Becoming more and more popular as we pick these up earlier, prior to rupture

Answer 116

- Advise pt of recurrence risk: **7%** - Almost invariably, other tube is damaged, which can lead to infertility -\> may need to move towards IVF as a method, rather than via natural pregnancy - _MTX may have advantage over removing tube_ to help promote healthy pregnancy next time around - If tube greatly damaged, and the other one is normal, _may be advantage to removing damaged tube_ and hoping healthy tube works just fine

Answer 117

- Usually 1 or 2 embryos are transferred to uterine cavity at the 4-8 cell stage - Can result in embryo being pushed into the tube

Answer 118

- 1 IUP and 1 ectopic possible 1/10,000 (VERY rare) - When naturally occurring

Answer 119

- _Mass \<5 cm_, including hematoma that sometimes surrounds ectopic pregnancy - _No cardiac activity_: sometimes fetus thrives in this environment and heartbeat is detectable on US in the tube - _Pt must be reliable_: need f/u hCG levels to determine if effective, and pt should return if any pain or concerns - Depends on what the patient may want

Phillips - Pregnancy Flashcards

(144 cards)