Pregnancy & Labor

Question 1

Pregnancy Induced Hypertension

Answer 1

Blood pressure increase of
- 30 mm Hg systolic or
- 15 mm Hg diastolic over prepregnancy
values
or

• BP of 140/90 after 20 weeks if previous
  BP is unknown

Question 2

Chronic HTN

Answer 2

• BP > 140/90 before 20 wk gestation
  or
  • Known previous hypertension

Question 3

Pre-Eclampsia

Answer 3

• BP increase as with PIH, plus proteinuria
  and edema
• Proteinuria = 0.1 gm/liter in a random
  specimen or 0.3 gm in a 24 hour specimen
• Edema may manifest as clinical swelling
  or rapid weight gain

Question 4

Severe Pre-Eclampsia

Answer 4

• BP of 160 mm Hg systolic or 110 mm Hg
diastolic
• Proteinuria OF 5 gm or more in 24 hr
• Oliguria (500 ml or less in 24 hr)
• Cerebral or visual disturbances
• Epigastric pain
• Pulmonary edema or cyanosis
• Impaired liver function of unclear etiology
• Thrombocytopenia

HELLP Syndrome
• Hemolysis
• Elevated Liver enzymes
• Low Platelets

Question 5

Eclampsia

Answer 5

• Eclampsia is the presence of seizures
  not attributable to another cause
  • High fetal mortality
  • Significant maternal morbidity

Question 6

Treatment of PIH/Pre-eclampsia

Answer 6

- Delivery is the definitive treatment.
• Delivery is indicated for a woman
– at term with PIH
– preterm with severe disease
– Immediate if oliguria, renal failure, or HELLP syndrome, regardless of fetal gestation

Question 7

Alpha Methyldopa

Answer 7

- Acts as a false neurotransmitter
• Most extensively used antihypertensive
medication in pregnancy
• Fetal safety is well documented
• Watch for orthostatic hypotension

Question 8

Hydralazine

Answer 8

• Vasodilator

• Watch for reflex tachycardia

Question 9

Musculoskeletal change during pregnancy

Answer 9

Lordosis: more curvature of the spine to accommodate the size and weight of the fetus

Question 10

Heigh of Fundus at 20 weeks gestation

Answer 10

at the height of the belly button/umbilicus

Question 11

Morning sickness (time of onset and cause)

Answer 11

• usually beginning about 4-8 weeks until about 14-16 weeks
• This may be related to sensitivity to human chorionic gonadotrophin levels (hCG)
• High levels of progesterone cause smooth muscle relaxation which decreases the tone and motility of the gastrointestinal (GI) system (good for absorbing nutrients, but bad for nausea)

Question 12

“physiologic anemia” of pregnancy

Answer 12

• Aldosterone controls plasma volume increase
• Erythropoetin controls increase of red blood cells
• Plasma volume increase begins earlier than red blood cell volume increase

Question 13

Uterine Phases of Parturition

Answer 13

Phase 0 - Relaxation phase - contractile unresponsiveness
- uses a lot of inhibitors, especially PROGESTERONE

Phase 1 - Preparation for labor
- ESTROGEN

Phase 2 - Processes of labor - three stages of labor
Stimulation: PROTSTGLANDINS AND OXYTOCIN

Phase 3 - Parturient recovery - uterine involution, breast feeding, restoration of fertility

Question 14

Oxytocin

Answer 14

• 9 amino acid peptide synthesized in the HYPOTHALAMUS and released from the POSTERIOR PITUITARY
• Short ½ life, 3 to 6 minutes
• • Important in maintaining uterine contractions postpartum
• Infusions of oxytocin cause contractions and can induce labor

Question 15

Cervical Effacement

Answer 15

• the progressive thinning of the cervix from about 2 cm in thickness to paper thin.
• The cervical substance is drawn upward to become a part of the lower uterine segment.

Question 16

Cervical Dilatation

Answer 16

• The cervix must dilate to 10 centimeters to accommodate the diameter of a full-term fetus’s head

Question 17

3 Stages of Labor

Answer 17

First Stage of Labor

• begins when uterine contractions are of sufficient frequency, intensity and duration to bring about effacement and progressive dilatation of the cervix
• further divided into latent and active phases (acceleration, maximum slope, deceleration)

Second Stage of Labor
- begins when dilatation of the cervix is complete and ends with delivery of the fetus

Third Stage of Labor

• Interval between delivery of fetus to delivery of placenta.
• During this stage the placenta separates and is expelled

Question 18

Seven Cardinal Movements for Delivery

Answer 18

1. Engagement: the BPD descends to the level below the plane of the pelvic inlet
2. Descent: Fastest during Deceleration phase of stage 1
3. Flexion: Flexion of the fetal chin onto the fetal chest occurs passively as the descending head meets resistance
4. Internal Rotation: baby rotates so more “up and down”
5. Extension
6. External Rotation (Restitution)
7. Expulsion

“Every Delivery Feels IckyEEE”

Question 19

Reasons for performing a cesarean delivery

Answer 19

• fetal malpresentation
• nonreassuring fetal heart rate tracing during labor
• arrest of labor

Question 20

Pre-Term Birth & Risk Factors

Answer 20

– Infants delivered <259 days post conception

Major risk factors for preterm birth (but EVERY PREGNANCY IS AT RISK):
– Prior history of preterm birth
– Multifetal gestation
– Bleeding after the 1st trimester
– Low maternal body mass index (BMI)

Initiating Factors:
- Infection
• Vascular – ischemia/hemorrhage
• Stress-nutrition
• Uterine over distension
• Cervical disease
• Progesterone deficiency
• Abnormal allogenic recognition
• Allergy
• Unknown

Question 21

Low birth weight (LBW)

Answer 21

<2,500 gm at birth regardless of gestational age

Question 22

Very low birth weight (VLBW)

Answer 22

<1,500 gm at birth

Question 23

Premature rupture of membranes (PROM)
vs.
Preterm premature rupture of membranes
(PPROM)

Answer 23

PROM: rupture of membranes before the onset of labor

PPROM: rupture of membranes before 37 weeks
gestation, before the onset of labor

Question 24

How to Diagnose Pre-Term Labor

Answer 24

• Fibronectin is a glycoprotein produced by a variety of cell types and is thought to have a role in intracellular adhesion in relation to maintenance of adhesion of the
  placenta to the decidua.
• Fetal fibronectin detected in cervical secretions may signal impending preterm birth; however, there is a
  significant false positive rate.
• The ABSENCE of fetal fibronectin in cervical secretions is more useful clinically because these patients can be potentially treated less agressively.

Question 25

Maternal Indications for Preterm

Delivery

Answer 25

• Preeclampsia
  • Renal disease
  • Cardiac disease

Question 26

Fetal Indications for Preterm Delivery

Answer 26

Unfavorable intrauterine environment where
risks of in utero damage or stillbirth are
more significant than the risks of
prematurity, e.g.
– Intrauterine growth restriction
– Poorly controlled maternal diabetes mellitus
– Placenta previa
– Placental abruption

Question 27

Antenatal Corticosteroids reduce the risk of:

Answer 27

• respiratory distress syndrome
  – intraventricular hemorrhage
  – necrotizing enterocolitis
  – patent ductus arteriosus