Pregnancy, Childbirth & Puerperium Flashcards
(157 cards)
1
Q
Clinical Manifestation:
- Painful third-trimester vaginal bleeding
- hypertonic uterus
A
Abruptio placentae (placental abruption)
2
Q
What are the common risk factors for placental abruption?
A
- maternal hypertension
- smoking
- cocaine
These things can cause placental hypoperfusion and hemorrhage in the decidua basalis.
3
Q
Define preeclampsia.
A
New-onset hypertension AND proteinuria OR end-organ damage at >/= 20 weeks gestation.
proteinuria= >/=300 mg/24hr, protein/creatinine ratio >/= 0.3, or dipstick of >/=1+
end-organ damage= severe headache, persistent right upper quadrant or epigastric pain, renal insufficiency, pulmonary edema
4
Q
What are signs of end-organ damage in preeclampsia?
A
- severe headache
- right upper gastric or epigastric pain
- renal insufficiency
- pulmonary edema
5
Q
What is considered elevated blood pressure or hypertension in a pregnant woman?
A
systolic BP >/= 140 mmHg
diastolic BP >/=90 mmHg
6
Q
What are the severe features of preeclampsia?
A
- BP >/= 160mmHg systolic or 110 mmHg diastolic on 2 occasions greater than 4 hours apart on bed rest
- Thrombocytopenia 1.1mg/dL OR doubling of serum creatinine
- Elevated transaminases
- Pulmonary edema
- New-onset visual or cerebral symptoms
7
Q
Treatment:
Hypertensive emergency in pregnancy
A
- Labetalol IV
- Hydralazine IV
- Nifedipine PO
- Magnesium sulfate to prevent seizures if patient is preeclamptic
Hypertensive emergency= systolic BP >/= 160 mmHg and/or diastolic BP >/= 110 mmHg persisting for >/= 15 minutes
8
Q
Treatment:
Seizure protection in preeclamptic patients
A
magnesium sulfate
9
Q
Definition:
Threatened abortion
A
Threatened abortion is characterized by any hemorrhage occurring before the 20th week of gestation with a live fetus and a closed cervix.
10
Q
Treatment:
Threatened abortion
A
Reassurance and outpatient follow up is standard of care for threatened abortion.
Note, you can suggest that patients take bed rest and abstain from sex in case a complete abortion occurs, but there is no evidence to support these are preventative measures.
11
Q
Pathophysiology:
Klumpke palsy
A
Injury to the 8th cervical and 1st thoracic nerve resulting in hand paralysis and ipsilateral Horner syndrome (miosis & ptosis).
12
Q
What is a rare, but potentially permanent complication of shoulder dystocia?
A
Klumpke palsy “claw hand”
Other complications of shoulder dystocia include: fractured clavicle, fractured humerus, Erb-Duchenne palsy & perinatal asphyxia.
13
Q
Diagnosis:
- vaginal bleeding
- fluid discharge
- lower abdominal cramps
- dilated cervix
- products of conception visualized through cervix
A
Inevitable abortion
14
Q
What is the work-up for decreased fetal movement?
A
- Nonstress test (NST)
- Contraction stress test (CST)
- Biophysical profile
Do #2 & 3 if one is nonreactive. Also contraction stress test should only be done when there are no contraindications to labor.
15
Q
How should a patient with a normal contraction stress test be managed?
A
Repeat antepartum fetal testing in 1 week
A normal CST indicates that fetal compromise is unlikely.
16
Q
Diagnosis:
- sudden onset of abdominal pain
- fetal heart rate abnormalities
- recession of the fetal station during active labor
A
uterine rupture
17
Q
What are some risk factors for uterine rupture.
A
- pre-existing uterine scar
2. abdominal trauma
18
Q
Diagnosis:
Intrauterine fetal demise (IUFD)
A
ultrasonography
19
Q
When should an autopsy be performed on a stillborn fetus?
A
Autopsy of the fetus and placenta should be performed in all cases of stillbirth with the permission of the parents.
20
Q
Treatment:
Preterm premature rupture of membranes (PPROM)
A
- Penicillin prophylaxis if maternal GBS status is unknown
- Delivery is recommended for babies >34 weeks with PPROM; the risks of continued expectant management outweight the risks of prematurity at this point
21
Q
What are the two most common causes of hyperandrogenism in pregnancy?
A
- Luteoma
2. Theca luteum cysts
22
Q
Diagnosis:
- new onset hirsutism and acne in a pregnant woman
- solid mass on ultrasound
A
Luteoma
These can induce virilization in female fetuses!
23
Q
Diagnosis:
- new onset hirsutism and acne in a pregnant woman
- bilateral ovarian cysts on ultrasound
A
Theca leuteum cyst
24
Q
Treatment (maternal):
Luteoma
A
no maternal treatment warranted
25
Treatment (maternal):
Theca luteum cysts
1. Ususally, no maternal treatment warranted
| 2. Suction curettage if the underlying cause is molar pregnancy
26
Diagnosis:
grand-mal seizures in the setting of preeclampsia
Eclampsia
27
Treatment:
Eclampsia
Magnesium sulfate
28
Treatment:
preeclampsia-eclampsia syndrome
1. stabilize the patient
2. initiate seizure and stroke treatment as indicated
3. proceed with delivery
29
What complications are associated with pregnancy for women with a current or previous diagnosis of anorexia nervosa?
1. Intrauterine growth retardation
2. hyperemesis gravidarum
3. miscarriage
4. premature birth
5. cesarean delivery
6. postpartum depression
7. osteoporosis (maternal)
30
What is the earliest sign of magnesium sulfate toxicity?
Depression of the deep tendon reflexes
The second sign of magnesium toxicity is respiratory depression.
31
Treatment:
Magnesium sulfate toxicity
1. Stop Magnesium sulfate
| 2. Replace w/ calcium gluconate
32
Diagnosis:
Painless third-trimester vaginal bleeding
Placenta previa
33
What causes early decelerations?
Fetal head compression followed by a vagal response
34
Fetal heart traces showing variability and late deceleration indicate what risks?
1. hypoxemia
| 2. acidosis
35
What are the physiological effects of pregnancy on the pulmonary system?
1. Increased Tidal Volume
2. Increased Minute Ventilation
3. Increased PaO2
4. Chronic compensated respiratory alkalosis
36
Pathology:
normal hyperventilation of pregnancy
elevated progesterone > stimulation of the medullary respiratory center in the brain > increased tidal volume and minute ventilation
37
Diagnosis:
stillborn baby with
1. limb deformities
2. growth retardation
3. multiple fractures
4. blue sclerae
Type I Osteogenesis Imperfecta
38
What is the genetic inheritance associated with osteogenesis imperfecta?
Autosomal dominant
39
Pathogenesis:
Osteogenesis imperfecta
mutation in type I collagen
40
Clinical Manifestations:
Severe type II Osteogenesis imperfecta
These babies have multiple intrauterine or perinatal fractures and typically die in utero.
41
Diagnosis:
Urine Analysis in Glomerulonephritis
1. Protein?
2. Blood?
1. proteinuria
2. hematuria
3. RBC casts
42
Diagnosis:
Systemic Lupus Erythematosus in pregnancy
1. massive proteinuria
2. malar rash
3. strongly positive ANA titer
4. hypertension
43
What is the one absolute infant contraindication to breastfeeding?
Galactosemia
44
What are the maternal contraindications to breastfeeding?
1. Active, untreated tuberculosis
2. Maternal HIV infection
3. Herpetic breast lesions
4. Varicella infection
45
Management:
Patient with symptoms of hyperemesis gravidarum and newly detected pregnancy
Pelvic ultrasonogram
Patients with multi-fetal gestation and molar pregnancy are at increased risk for hyperemesis gravidarum.
46
Diagnosis:
Hyperemesis gravidarum
1. severe, persistent nausea and vomiting
2. >5% loss of pre-pregnancy weight
3. dehydration
4. malnourishment
5. No other explanation
47
Diagnosis:
gestational trophoblastic disease on ultrasound
large abnormal placenta (" central heterogeneous mass with numerous cystic spaces and no fetal pole")
48
Diagnosis:
1. Bilateral ovarian enlargement
2. Ovarian cyst formation
Gestational trophoblastic disease
1. Ovarian enlargement is due to hyper stimulation
2. Ovarian cysts are also called theca lutein cysts
49
Treatment:
5 week pregnant female with acne currently controlled with isotretinoin
STOP isotretinoin!
50
How does lithium affect pregnancy?
Lithium is associated with congenital heart disease, especially Epstein's anomaly.
Epstein's anomaly= displacement of the septal and posterior tricuspid leaflet towards the apex of the heart.
51
Are inhaled corticosteroids safe during pregnancy?
Yes.
52
Treatment:
Pregnant woman inadvertently vaccinated for rubella
Routine pregnant care
Wild-type rubella has been associated with birth defects, but there are no cases associated with vaccination. Nonetheless, pregnant women should NOT receive live vaccines directly before or during pregnancy as a precaution.
53
Diagnosis:
Placental abruption
1. sudden vaginal bleeding (~80% of cases)
2. abdominal pain
3. hypertonic, tender uterus
4. uterine contractions
The absence of blood on pelvic exam DOES NOT rule out this condition.
54
What is an important risk factor for placental abruption?
Hypertension during pregnancy
55
Treatment:
Placental abruption with rapid maternal or fetal deterioration
Emergency cesarean delivery
56
At what lecithin/sphingomyelin ratio is prematurity a major concern?
L/S
57
Definition:
rupture of fetal membranes before onset of labor
Premature rupture of membranes (PROM)
58
Defintion:
rupture of fetal membranes before onset of labor in a preterm baby
Preterm premature rupture of membranes (PROM)
59
Treatment:
PPROM at (???)
Steroids
60
Mechanism of Action:
Steroid in PPROM
Steroids enhance fetal lung maturity
61
What is the most important complication of PPROM?
pulmonary hypoplasia
62
Diagnosis:
1. painless antepartum hemorrhage
2. sudden fetal deterioration after ROM
Vasa previa
63
Clinical Manifestation (maternal):
Vasa previa
1. abdominal examination= WNL
2. vital signs=WNL
The bleeding originates from the fetus, not the mother.
64
Diagnosis:
1. antepartum hemorrhage
2. tachycardia then bradycardia then sinusoidal pattern on fetal heart rate monitor
Vasa previa
65
What is a common side effect of epidural anesthesia?
Hypotension
66
Pathophysiology:
Hypotension after epidural anesthesia
1. anesthesia causes a sympathetic blockade
2. blood is redistributed to the lower extremities
3. blood pools in the venous system because of the sympathetic blockade
67
Diagnosis:
Uterine atony
1. soft, boggy, poorly contracted uterus
| 2. uterus remaining at the level of the umbilicus postpartum
68
What is the most common cause of postpartum hemorrhage within 24 hours of labor?
Uterine atony is responsible of 80% of all postpartum hemorrhage cases occurring within 24 hours of delivery.
69
Treatment:
Uterine atony
1. bimanual uterine massage
2. fluid resuscitation
3. uterotonic agents (eg, oxytocin, methylergonovine or carboprost infusion)
4. blood transfusion as needed
70
How do you manage PPROM when the fetus has been found to have a severe congenital anomaly incompatible with life?
You should allow the patient to proceed with labor.
71
Diagnosis:
10 week pregnant patient reports
1. pain and uterine contractions that eventually subsided
2. closed cervix on examination
3. empty uterus
complete abortion
72
Which vaccinations, covering sexually transmitted infections, must every pregnant woman receive regardless of risk factors?
1. Syphilis (eg rapid plasma reagin RPR)
2. HIV
3. Hepatitis B
73
Screening for these three sexually transmitted infections is done in pregnant women IF they have risk factors...
1. Chlamydia
2. Gonorrhea
3. Hepatitis C
74
When should anti-D immune globulin be given to Rh (D)-negative women?
1. Between 28-32 weeks gestation
| 2. after delivery of Rh positive baby
75
Treatment:
preterm labor + repetitive late decelerations
emergency cesarean section
76
What are the indications for emergent caesarian section with newfound placenta previa?
1. active, uncontrolled antepartum hemorrhage
2. unstable vital signs
3. unreassuring fetal heart rates
REGARDLESS OF GESTATIONAL AGE
77
List the risk factors for maternal cervical insufficiency/incompetent cervix.
1. Hx of maternal obstetrical trauma (including cervical LEEP or cone biopsy)
2. DES exposure
3. multiple gestation
4. Hx of preterm birth
5. Hx of second trimester pregnancy loss
78
Diagnosis:
Gold standard method for evaluating cervical incompetence in pregnancy
Transvaginal ultrasound
79
What cervical length is considered a short cervix?
cervical length
80
Treatment:
Oligohydramnios in a late-term or post-term pregnancy
delivery
81
Diagnosis:
Postterm baby whose ultrasound shows low amniotic fluid
oligohydramnios
82
How are babies with placenta previa delivered?
cesarean section
83
Diagnosis:
1. Fever
2. Postpartum uterine tenderness
3. Foul-smelling lochia
Endometritis
84
Definiton:
lochia
post-partum uterine discharge
85
What are the risk factors for endometritis?
1. prolonged ROM
2. prolonged labor
3. operative vaginal delivery
4. caesarian section
86
What organism is typically responsible for postpartum endometritis?
Endometritis is typically a polymicrobial infection (gram positive, gram negative, aerobic and anaerobic organisms).
87
Treatment:
Postpartum endometritis
IV clindamycin and gentamicin
88
Pathogenesis:
Sheehan syndrome
postpartum ischemic necrosis of the anterior pituitary
89
Clinical Manifestation:
Sheehan syndrome
1. Failure of postpartum lactation
2. Anterior pituitary hormone deficiencies (GH, Prl, FSH, LH, TSH, ACTH)
3. Amenorrhea
4. Loss of sexual hair, anorexia, weight loss & lethargy
5. Hyponatremia
***It is very uncommon for these patients to have posterior pituitary hormone deficiencies.
90
Clinical Manifestation:
Endometritis
1. Fever
2. Post-partum uterine tenderness
3. Foul-smelling lochia
91
What are the risk factors for endometritis?
1. prolonged ROM
2. prolonged labor
3. operative vaginal delivery
4. caesarian section
92
What pathogen is the most common cause of endometritis?
Endometritis is most commonly a polymicrobial infection composed of gram positive, gram negative, aerobic and anaerobic organisms.
93
Treatment:
postpartum endometritis
IV clindamycin and gentamicin
94
Clinical Manifestation:
Sheehan syndrome
1. Failure of postpartum lactation
2. Deficiency of other anterior pituitary hormones
*Sheehan syndrome is not often associated with a deficiency in posterior pituitary hormones.
95
Define a missed abortion.
A missed abortion is a form of spontaneous abortion.
1. Intrauterine death before 20 weeks gestational age
2. Complete retained products of conception
3. Closed cervix
96
Clinical manifestation:
Missed abortion
1. Scant to light vaginal discharge
| 2. Loss of pregnancy symptoms
97
How do you diagnose missed abortion?
Pelvic ultrasound
98
Diagnosis:
Down syndrome on maternal quadruple screen
Increased:
Beta-hCG & Inhibin A
Decreased:
Maternal serum alpha-fetoprotein (MSAFP) & Estriol
99
Diagnosis:
Trisomy 18 on maternal quadruple screen
Normal:
Inhibin A
Decreased:
MSAFP, Estriol & beta-hCG
100
Diagnosis:
Open neural tube defects & abdominal wall defects on maternal quadruple screen
Increased:
MSAFP
Normal:
Inhibin A, Estriol & beta-hCG
101
What should be done after an elevation in MSAFP is detected?
Perform an ultrasound to evaluate the fetal anatomy
102
Clinical Manifestation:
1. lightheadedness
2. diffuse abdominal pain
3. adnexal tenderness
4. hemodynamic instability
Ruptured ectopic pregnancy
103
Treatment:
Ruptured ectopic pregnancy
Urgent surgical evaluation
104
Define arrest of labor in the first stage.
Dilation >/= 6 cm with ruptured membranes in the setting of:
1. no cervical change for >/= 4 hours despite adequate contractions OR
2. no cervical change for >/= 6 hours with inadequate contractions
105
What is the next stage of management in a patient who does not fit the criteria for arrest of labor, but lacks signs of fetal distress?
Observation
106
Pathophysiology:
Variable decelerations
umbilical cord compression
107
Definition:
Intermittent variable decelerations
variable decelerations occurring independently of the majority of the contractions
108
Treatment:
Intermittent variable decelerations
No treatment required
109
Definition:
Recurrent variable decelerations
variable decelerations accompanying >/= 50% of contractions
110
Management:
Recurrent variable decelerations
1. evaluation
| 2. maternal intrauterine resuscitative measures
111
Clinical Manifestation:
HELLP syndrome in a pregnant patient
1. RUQ pain
2. Hemolytic anemia
3. Elevated liver enzymes
4. Low platelet count
*HELLP syndrome is a manifestation of severe preeclampsia.
112
Pathophysiology:
Abdominal pain in a pregnant patient with HELLP syndrome
1. the liver begins to swell
| 2. the hepatic capsule (Glisson's capsule) begins to distend, causing pain
113
What is the alternative name for the hepatic capsule?
Glisson's capsule
114
Pathophysiology:
Pulmonary edema in the setting of severe preeclampsia
PE is caused by:
1. Systemic vascular resistance
2. Capillary permeability
3. Pulmonary capillary hydrostatic pressure
4. Decreased albumin
115
Management:
Decreased of imperceptible fetal movement as noted by mother
nonstress test should be performed to document fetal well-being
116
What is the first step in the evaluation of a women of childbearing age with an absence of menses for > 1 month?
Urine pregnancy test
117
Clinical Manifestation:
Depot medroxyprogesterone acetate side effects
1. menstrual irregularities (prolonged bleedign/spotting)
2. amenorrhea after 1 year
3. weight gain
4. nausea
5. breast tenderness
118
True vs. False:
Overt diabetes insipidus is common in patients with Sheehan's syndrome
False, overt diabetes insipidus is uncommon.
119
What is an important risk factor for the development of chorioamnionitis?
prolonged rupture of membranes
120
How do you clinically diagnose chorioamnionitis?
maternal fever AND 1 or more of the following:
1. uterine tenderness
2. maternal or fetal tachycardia
3. malodorous amniotic fluid
4. purulent vaginal discharge
121
Treatment:
Chorioamnionitis
1. Prompt administration of broad spectrum antibiotics
| 2. Delivery
122
Why is it important to proceed with delivery after administering broad spectrum antibiotics in a case of chorioamnionitis?
Delivery will reduce the risk of life-threatening neonatal infection and maternal complications.
123
True vs. False
Chorioamnionitis alone is indication for cesarean delivery
False
124
When is surgical management indicated for patients with spontaneous abortion (miscarriage)?
Surgical management is indicated for hemodynamically unstable patients.
Spontaneous abortion can be managed expectantly, medically or surgically.
125
When is external cephalic version indicated in the diagnosis of breech presentation?
If breech presentation persists after 37 weeks.
126
What is the next step to convert to vertex presentation if external cephalic version fails?
planned cesarean delivery
127
When do you observe breech presentation.
When breech presentation is identified before 37 weeks gestation. Breech presentations often convert to vertex before the 37th week.
128
When is the quadruple screen performed?
second trimester
129
Diagnosis:
1. MSAFP
2. Estriol
3. Beta-hCG
4. Inhibin A
in Trisomy 21
1. MSAFP-decreased
2. Estriol-decreased
3. Beta-hCG-increased
4. Inhibin A-increased
130
Treatment:
Your patient has a low-grade fever, leukocytosis and vaginal discharge in the immediate postpartum period.
No treatment necessary. Low-grade fever, leukocytosis and vaginal discharge are normal findings in the immediate postpartum period. The loch is initially bloody, then serous and finally white to yellow days after delivery.
131
True vs. False
According to the CDC, pregnant women should not receive the influenza vaccination.
False, it is recommended that all pregnant women be vaccinated against influenza without contraindications.
132
Define incomplete abortion.
Incomplete abortion is the partial passage of fetal tissue.
133
Clinical Manifestation:
1. bleeding
2. cramping
3. partial passage of fetal tissue
incomplete abortion
134
Treatment:
Incomplete abortion
1. Expectant management
2. Misoprostol
3. Dilation and Evacuation
135
Pathophysiology:
Low back pain in the third trimester of pregnancy
low back pain in pregnancy is caused by:
1. an increase in lumbar lordosis
2. relaxation of the ligaments supporting the joints of the pelvic girdle
136
What are the most common causes of symmetric growth restriction?
1. fetal anomalies
2. abnormal fetal karyotype
3. early maternal viral infection
137
What are the most common causes of asymmetric growth restriction?
1. maternal vascular disease (i.e. hypertension, diabetes & smoking)
138
Treatment:
Stillbirth in third trimester
1. Vaginal delivery
2. Cesarean delivery
via oxytocin labor induction
139
Clinical Manifestation:
Uterine rupture
1. vaginal bleeding
2. intra-abdominal hemorrhage
3. fetal distress or demise
...in a women with prior cesarean delivery
140
How do you differentiate uterine rupture from placental abruption?
Uterine rupture is associated with:
1. loss of fetal station vaginally
2. palpable fetal parts through the site of rupture
141
When is cesarean delivery indicated in placental abruption?
1. mother is hypotensive and has severe bleeding
2. fetus deteriorates
Laboring patients at term should be allowed to deliver vaginally.
142
Treatment:
Septic abortion
1. broad-spectrum antibiotics
2. surgical evacuation of the uterus
Septic abortion is a medical emergency. After initial treatment patients should be monitored for systemic sepsis.
143
Clinical Manifestation:
False labor
1. Absence of progressive cervical changes
2. Irregular contractions
3. Discomfort relieved by sedation
144
What are the activity recommendations for healthy pregnant women?
Healthy pregnant women should be encouraged to exercise for >/= 30 minutes per day at low or moderate intensity.
Healthy pregnant women should NOT partake in contact sports or activities with high fall risk.
145
Fetal macrosomia is a risk factor for this vaginal delivery complication.
Shoulder dystocia
African-American boys are at a increased risk for fetal macrosomia.
146
Pathophysiology:
Erb-Duchenne palsy
Excessive traction on the neck during a difficult delivery
147
Clinical Manifestation:
Erb-Duchenne palsy
1. "waiter's tip" posture
148
Treatment:
Erb-Duchenne palsy
No treatment needed. Most infants recover arm function spontaneously or within a few months.
149
Treatment:
Preterm labor at
1. Tocolytic agent (calcium channel blockers)
2. Magnesium sulfate for neuroprotection
3. Corticosteroids fo acceleration of fetal lung maturity
150
Define preterm labor
Regular contractions causing cervical dilation and/or effacement at
151
Clinical Manifestation:
Adducted and internally rotated arm after tonic-clonic seizures
posterior shoulder dislocation
152
What is the most noninvasive and highly specific screening test for fetal aneuploidy.
cell-free fetal DNA testing
This testing can be ordered at >/= 10 weeks gestation
153
How can you confirm an abnormal cell-free fetal DNA test?
1. chorionic villus sampling at 10-12 weeks
| 2. amniocentesis at 15-20 weeks
154
True vs. False
PPX cesarean section and induction of labor prevent complications related to shoulder dystocia.
False, these interventions have not been consistently shown to prevent complications related to shoulder dystocia.
155
What is a normal result for a nonusers test?
2 heart rate accelerations
156
How often should a non-stress test be performed in a third trimester pregnancy requiring antepartum fetal surveillance.
Once every week during the third trimester
157
Management:
Patients with intrauterine fetal demise who develop coagulation abnormalities?
Induction of labor without delay
