Week 8 pt 2

Question 1

Recurrent abortions: List and describe some causes

Answer 1

1) Uterine causes: septum, leiomyoma, incompetent cervix
2) Chromosomal abnormalities with one or both partners resulting in nonviable embryos
3) Lupus
4) Endocrine: thyroid (+/-), under-treated DM, PCOS, luteal phase defect
5) Thrombophilias: especially factor V Leiden
6) Antiphospholipid syndrome
7) Maternal Infections, especially TORCH infections (Toxoplasmosis, Other agents, Rubella, Cytomegalovirus, Herpes Simplex)

Question 2

Describe incompetent cervix

Answer 2

-Cervical length of less than 2 cm and/or internal cervical os open 1 cm or greater is diagnostic
-Causes around 25% of second trimester losses
-Often diagnosed “after the fact” after a second trimester loss
-On speculum exam open os may be visible
-“Funneling” of the cervix may be noted on US

Question 3

List some risks for incompetent cervix

Answer 3

-Congenital uterine or cervical anomaly
-Previous obstetric trauma
-Previous mechanical dilation
-D&C
-Termination of pregnancy (TOP)
-Hysteroscopy
-Treatments for CIN
-Cold Knife Cone procedures, LEEP procedures

Question 4

What is the Tx for incompetent cervix? Define this procedure and when it has a better outcome

Answer 4

1) A procedure in which the cervical opening is closed with sutures or with a band
2) Better if done before membranes are visible

Question 5

Define and describe macrosomia. How common is it and how can you predict it?

Answer 5

1) Macrosomia= Birth weight of 4000-4500 Grams (8lbs13 – 9lbs15)
-Can only be diagnosed after the baby is born
2) Approximately 10% of babies
3) Difficult to assess accurately antenatally
Abdominal circumference greater than 35cm on ultrasound very predictive of baby weighing > 8lbs 13oz
+ clinical palpation (Leopold maneuvers)

Question 6

List some risk factors for macrosomia

Answer 6

Genetics, specific gene disorders, male sex, hx of previous macrosomic pregnancy, DM, pregnancy weight gain, >40wks gestational age

Question 7

Describe the following in macrosomia:
1) Neonatal injury
2) Neonatal morbidity
3) Maternal injury
4) C. Section

Answer 7

1) Brachial plexus, hematomas, fractured clavicles
2) Especially if mom diagnosed or UNDIAGNOSED diabetic, shoulder dystocia
3) Cervical and vaginal laceration; postpartum hemorrhage
4) Cesarean Section with inherent increased risk due to surgery and anesthesia

Question 8

Describe assessing for macrosomia

Answer 8

1) Watch via fundal height
-If 3-4 cm larger than expected, assess by ultrasound and may need to re-evaluate for diabetes
-Clinical findings may be combined with ultrasound to diagnose macrosomia.
-The real value of u/s is its ability to rule out macrosomia.
2) Macrosomic babies significantly more likely to be stillborn so you should begin closer surveillance (NST, biophysical profile)

Question 9

Describe the delivery of babies with macrosomia

Answer 9

1) Must be delivered by someone experienced and comfortable with delivering a baby with shoulder dystocia
2) Must be delivered in a setting where an emergency C-Section is an option
3) Offer c-section if estimated fetal weight > 5000g in women w/o DM (4500g in women w/ DM)

Question 10

What do macrosomia babies have a risk of long-term?

Answer 10

Increased risk of being overweight or obese in later life

Question 11

Intrauterine Growth Restriction (IUGR):
1) What is this relatively dependent on?
2) What is it associated with? Give examples

Answer 11

1) Good dates for the pregnancy.
Much more difficult to evaluate if late entry to care
2) Chronic maternal conditions:
-Preeclampsia, pregestational DM, poor nutrition, drug use, multifetal pregnancy, poor placental location, congenital infection or anomalies
-Viral infections (rubella, varicella, CMV, malaria, syphilis)
-Intrauterine infections cause 5-10% of IUGR cases

Question 12

IUGR may be asymmetrical (nearly normal head, little body); when is this usually seen?
When is symmetrical seen?

Answer 12

1) Placental issues, maternal hypertension, nutritional deficiencies
2) More frequent with congenital anomalies or early infection, particularly the TORCH infections

Question 13

What is a risk with IGUR? Explain

Answer 13

1) IUGR associated with increased perinatal mortality
-Must weigh risk of prematurity against risk of continued pregnancy in an environment hostile to the fetus

Question 14

Describe how to mange IUGR

Answer 14

1) Must maintain strenuous antenatal surveillance
-Ultrasound
-Fetal biometry measurements repeated every 3-4 weeks
-Fetal surveillance with fetal movement counting, nonstress testing, biophysical profiles, umbilical artery
-Doppler studies
2) Many IUGR babies do not tolerate labor = C-section

Question 15

Intrauterine Fetal Demise (IUFD): What is it? How prevalent is it?

Answer 15

Stillbirth; 0.5-1% of pregnancies overall

Question 16

When is there an increased risk of Intrauterine Fetal Demise (IUFD)?

Answer 16

A variety of medical and obstetric complications of pregnancy:
1) Abruption
2) Congenital abnormalities
3) Infection
4) Post term pregnancy (past 42 weeks)

Question 17

Describe how to Dx fetal demise

Answer 17

-Possible vaginal bleeding/cramping
-Confirmed by absence of fetal heart tones or cardiac motion on ultrasound
-Absence of fetal movement (later in pregnancy)
-Confirm by ultrasound, not fetal monitor
-Lack of uterine growth (fundal height LOWER than expected for gestational age)
-Confirmed with serially falling hCG and u/s documentation

Question 18

Describe the definition of fetal death

Answer 18

1) Each state has its own wording about what constitutes a fetal death; in Tennessee, a fetal death is the death of a fetus weighing 350 or more grams.
-Deaths occurring before that weight would be considered spontaneous abortions.
2) Fetal deaths must be reported for statistical purposes.

Question 19

What are some causes of fetal death?

Answer 19

1) Many, many times there is no obvious cause
2) Causes, if present, may be: Maternal, fetal, or complications of pregnancy (such as infection, injury, or consequence of drug use) or of chronic disease (uncontrolled DM, uncontrolled hyperthyroidism, etc.)

Question 20

Describe the risk of DIC with fetal death

Answer 20

Rare incidence of DIC associated with waiting—increased risk if:
fetus withheld for five weeks or longer,
with abruption,
with uterine perforation,
or with eclampsia

Question 21

Describe the Tx of fetal death

Answer 21

1) Expectant management
2) Some recommend obtaining baseline coagulation labs
3) Most women will go into labor within 2 weeks time
4) Rare incidence of DIC associated with waiting—increased risk if:
fetus withheld for five weeks or longer,
with abruption,
with uterine perforation,
or with eclampsia
5) Best treatment is delivery (usually with an induction)

Question 22

Describe pregnancies before 24 wks

Answer 22

In pregnancies before 24 weeks, inadequate amniotic fluid generally prevents normal development of the alveoli within the fetal lungs.
Then, when they are born, they are impossible to ventilate

This is why pregnancies before 24 weeks are not considered viable

Question 23

What do PROM and PPROM have in common?

Answer 23

Both are “water breaking” in the absence of uterine contractions
-Can be a sudden gush or small, gradual leak of amniotic fluid
-It is not always like the movies…

Question 24

List causes of PROM and PPROM

Answer 24

-Infection (including BV)
-Doubled risk in women who smoke
-Previous PROM (two-fold risk)
-Polyhydramnios (excess amniotic fluid)
-Multiple gestation
-Premature cervical dilation

Question 25

Diagnosing PROM/PPROM: What should you perform?

Answer 25

1) Abdominal exam 2) Sterile speculum exam + obtain cultures 3) NO digital exam (unless in active labor)

Question 26

Diagnosing PROM/PPROM: What are the 4 tests? Describe each

Answer 26

1) Nitrazine test- uses pH to distinguish amniotic fluid from urine and vaginal secretion Amniotic fluid pH >7.1 so nitrazine impregnated paper turns dark blue 2) Amnisure test- more accurate than nitrazine but $$$ 3) Fern test- amniotic fluid placed on a slide and dries in room air which then resembles the leaves of a fern plant Considered to be more indicative of ruptured membranes than the nitrazine test 4) Ultrasound: Ample amniotic fluid around the fetus?

Question 27

Describe the Tx of PROM and PPROM

Answer 27

1) Heavily dependent on gestational age PROM >37wks gestation (term) = spontaneous labor in 90% of women w/in 24hrs PROM at term = induce labor (usually with oxytocin infusion) to reduce risk of chorioamnionitis (infection) 2) Must weigh risks against benefits according to gestational age and presence/absence of infection 3) If very preterm and no signs of infection, may try to delay to get steroids

Question 28

Describe how to manage PROM/ PPROM chronologically between term and preterm

Answer 28

Question 29

Describe how to manage PROM/ PPROM chronologically between preterm and less than 24 weeks

Answer 29

Question 30

20-30% of preterm birth is due to ___________________ for a variety of complications (i.e., pre/eclampsia)

Answer 30

deliberate intervention

Question 31

Define preterm labor

Answer 31

1) Regular contractions (occurring every 10 minutes or less, with each contraction lasting at least 30 seconds) + cervical changes (softening, effacement, dilation) 2) Occurring before 37 weeks gestation

Question 32

What is the term used to describe contractions that do not meet the criteria for preterm labor?

Answer 32

Preterm contractions

Question 33

Give some risk factors for preterm labor

Answer 33

Maternal age <18 years or >40 years PROM or PPROM Low maternal pre pregnancy weight Smoking Substance abuse Lack of prenatal care Short interpregnancy interval Short cervical length UTI or genital tract infection Multiple gestation Prior preterm birth

Question 34

List some maternal complications (medical or obstetric) of preterm labor

Answer 34

1) Activation of maternal/fetal HPA axis 2) Inflammation/infection 3) Hemorrhage 4) Pathologic uterine distention (Preterm labor may be secondary to these pathogenic processes)

Question 35

Give some uterine causes of preterm labor

Answer 35

-Leiomyomas -Uterine septum -Bicornuate uterus -Cervical incompetence natural or surgical -Cervical length -Exposure to diethylstilbestrol (DES)

Question 36

Give some infectious causes of preterm labor

Answer 36

Chorioamnionitis (E. coli and GBS are most common causes) Bacterial vaginitis In pregnancy, treatment with topical metronidazole (Metrogel) or Clindamycin is preferable to oral Flagyl. Some clinicians defer treatment until after 12 weeks (organogenesis) Asymptomatic bacteriuria Acute pyelonephritis Cervical/vaginal colonization

Question 37

Give some fetal causes of preterm labor

Answer 37

Intrauterine fetal death Intrauterine growth retardation Congenital anomalies Abnormal placentation Polyhydramnios Multiple gestation Macrosomia

Question 38

List and describe some factors improving outcomes of preterm labor

Answer 38

NICU management of preterm infants Corticosteroids administered to a mother at immediate risk for preterm birth Decreased incidence of respiratory distress syndrome, intraventricular hemorrhage Medications to stop contractions in a women in preterm labor Tocolytic therapy Magnesium sulfate administered prior to preterm birth Decreased incidence of cerebral palsy GBS prophylaxis in women in preterm labor or PPROM

Question 39

True or false: Despite improved prenatal care and screening, rates of preterm labor and preterm delivery have not declined

Answer 39

True

Question 40

Perinatal survival has improved in babies_____ gestational weeks; minimal improvement in survival in babies below this

Answer 40

>27

Question 41

List some S/Sx of preterm labor

Answer 41

Menstrual-like cramps Low, dull backache Abdominal pressure Pelvic pressure Abdominal cramping (with or without diarrhea) Increase or change in vaginal discharge (mucous, watery, light bloody discharge) Uterine contractions, often painless

Question 42

Preterm labor assessment; describe: 1) Uterine monitoring 2) Fetal fibronectin testing 3) Cervical eval

Answer 42

1) Uterine monitoring Tocodynamometer (external fetal monitor) 2) Fetal fibronectin testing—negative test is reassuring that labor/delivery will not occur within 7-14 days. 3) Cervical evaluation Serial speculum evaluation to assess cervical dilation and effacement (esp if suspicion of fetal membrane rupture)

Question 43

Preterm labor assessment; describe: 1) Ultrasound 2) Urinalysis 3) Cultures 4) Amniocentesis

Answer 43

1) Ultrasound to assess gestational age of the fetus, amniotic fluid volume, fetal presentation, placental location 2) Urinalysis: for UTIs and such 3) Cultures of cervix and urine (incl. GBS, G/C) 4) Amniocentesis: not always done

Question 44

How do you Tx preterm labor?

Answer 44

Aggressively treat any confirmed or suspected infections Reverse dehydration Left lateral decubitus position rest Treat earlier gestations more aggressively +GBS  intrapartum abx prophylaxis

Question 45

Preterm labor Tx: When do you use tocolysis? What abt steroids?

Answer 45

Typically, do NOT start tocolysis after 35 to 36 weeks (or if + infection) From 24 to 34 weeks, steroids have been shown to hasten lung maturity in the fetus (single dose)

Question 46

List some preterm labor Tx contraindications

Answer 46

1) Heavy vaginal bleeding suggestive of placental disruption Placental abruption 2) Fetus with significant anomalies 3) Intrauterine infection 4) Advanced labor 5) Maternal contraindications (cardiac, or severe side effects to the tocolytics)

Question 47

Third Trimester Bleeding: What Hx should you get?

Answer 47

Personal or FH of bleeding with procedures? No recent Pap test with a history of cervical dysplasia? Hemorrhoids? Acute cystitis?

Question 48

Third Trimester Bleeding: What PE should you do?

Answer 48

Significant changes not seen until blood loss < 10-15% of total blood volume Auscultate FHR IV access if bleeding is heavy, patient unstable; obtain type and cross Inspection for petechiae or bruising Abdominal exam NO bimanual pelvic exam until placental position confirmed by ultrasound

Question 49

Third Trimester Bleeding: 1) What should you do if bleeding is heavy, patient unstable; obtain type and cross? 2) What should you not do until placental position confirmed by ultrasound?

Answer 49

1) IV access 2) NO bimanual pelvic exam

Question 50

Third Trimester Bleeding: How common is it?

Answer 50

4-5% of all pregnancies A leading cause of maternal and fetal morbidity and mortality

Question 51

Third Trimester Bleeding: List the causes

Answer 51

Two most common causes: Placenta previa Placental abruption Other important causes include: Cervical change Preterm labor Uterine rupture

Question 52

Placenta Previa: 1) What is it? Is it painful? How much blood? 2) What is it assoc. with?

Answer 52

1) Placenta is covering or partially covering the cervical os Bleeding is bright red and PAINLESS. May be small amount or can bleed to death 2) Associated with an increase in preterm birth and perinatal mortality and morbidity

Question 53

Placenta Previa: 1) How is it usually found? 2) Does it resolve on its own? Explain

Answer 53

1) Usually known due to ultrasound TVUS more accurate than abdominal u/s 2) If placenta is low early in pregnancy, it may resolve by 32-35 weeks You need to recheck closer to term *Complete rarely resolves spontaneously

Question 54

List some risk factors for placenta previa

Answer 54

Placenta previa in prior pregnancy Prior c/s or other uterine surgery Multiparty Advanced maternal age Cocaine use Smoking

Question 55

What is required for placenta previa mgmt if fetus is premature and bleeding is not heavy enough to warrant immediate delivery?

Answer 55

Close observation Frequent BP measurements Fluid administration Bed rest Administration of steroids for fetal lung maturity Single dose of betamethasone between 34 0/7- 36 6/7 if at risk for preterm birth within 7 days

Question 56

Placenta previa: First bleeding episode usually ceases in __________hrs if not severe enough to require delivery

Answer 56

1-2hrs

Question 57

Describe placenta previa mortality

Answer 57

Maternal mortality now <1%, was 25-30% Fetal mortality now <10%, was 60-70%

Question 58

Define and describe vasa previa

Answer 58

Amnion with vessels is in front of the presenting part -If the vessel ruptures, the baby can bleed to death. -50% mortality rate -Apt test to differentiate maternal blood from fetal blood

Question 59

Define the 3 types of placental abruption: 1) Marginal 2) Partial 3) Complete

Answer 59

1) Separation limited to the edge of the placenta 2) Part of the placenta starts to come away from the uterus, bleeding and pain increases 3) The placenta comes entirely free from the uterine wall. Can be obvious, with copious blood, or can be concealed, with the blood trapped behind the placenta

Question 60

About half of all placental __________ are “mild” with no fetal distress (half are moderate to severe)

Answer 60

abruptions

Question 61

List the risks of placental abruption

Answer 61

Maternal chronic HTN Preeclampsia Multiple gestation Abdominal trauma Maternal smoking (doubles the risk) Substance abuse, particularly stimulants like cocaine Maternal age over 40 Sudden uterine decompression History of abruption Increased AFP

Question 62

Describe abd pain and the uterus in placental abruption

Answer 62

Can be hyperactive contractions, or constant tightening. -Uterus VERY firm to touch. Does NOT completely relax between contractions.

Question 63

Non-reassuring fetal heart rate can be a manifestation of what?

Answer 63

Placental abruption

Question 64

Non-reassuring fetal heart rate in placental abruption: 1) What is it seen as? 2) How is Dx confirmed?

Answer 64

1) Typically see deep, long, decelerations of the fetal heart rate as baby’s oxygen supply is depleted 2) Diagnosis suspected by exam can be confirmed by bedside ultrasound if baby’s condition permits

Question 65

Describe the Tx of placental abruption

Answer 65

1) If the abruption is due to trauma and is not enlarging, particularly if the baby is premature and not exhibiting signs of distress, patient/baby can be observed -Small abruptions are not at all uncommon after trauma…can be admitted and watched 2) Abruption in labor generally results in a c-section unless the baby is nearly delivered, and the abruption is very marginal…can go from marginal to complete VERY quickly 3) Delivery often by c-section

Question 66

Couvelaire Uterus: 1) How can it be seen? What is it? 2) What is a complication? How is this managed?

Answer 66

1) Can be visualized with c-section for abruption Blood trapped behind the placenta has been absorbed by the myometrium 2) Can make it impossible for the uterus to contract after delivery, can be life-threatening; may require hysterectomy to control bleeding after delivery

Question 67

Placental Abruption: What are some findings with DIC (close assoc.)?

Answer 67

Reduced fibrinogen Increased fibrin degradation products (FDP) Decreased platelet count Increased PTT

Question 68

Placental Abruption: What are some PE findings with DIC?

Answer 68

Petechiae, epistaxis, bleeding gums, blood in the Foley bag, bleeding around IV site If post c-section, bleeding from the incision as well as vaginally If vaginal delivery, marked vaginal bleeding

Question 69

List some malpresentations of baby

Answer 69

Breech Face Brow Shoulder Compound presentations

Question 70

List the risk factors for breech babies

Answer 70

-Prematurity: many babies don’t “flip” before 32 weeks Most likely reason -Multiple fetuses -Polyhydramnios: too big of a swimming pool -Oligohydramnios: not enough pool to swim around -Too roomy uterus: after many pregnancies -Hydrocephaly -Anencephaly -Uterine abnormalities (i.e., fibroids in the lower uterus) -Placenta previa -Nuchal cord (especially if multiple loops)

Question 71

What are some Complications of Breech Presentations?

Answer 71

1) Perinatal morbidity and mortality from difficult birth 2) Possible perineal trauma from difficult birth 3) Possible low birth weight due to prematurity 4) Prolapsed cord 5) Placenta previa (if the cause of the breech) 6) Fetal anomalies

Question 72

Define Face, brow, shoulder, compound malpresentations

Answer 72

1) Face: Can palpate face during vaginal exam Mentum anterior (chin facing anterior and is presenting part of the face) only face presentation that will allow for vaginal delivery 2) Brow: Must convert to vertex or face to deliver vaginally 3) Shoulder: Delivered via c section 4) Compound: Fetal extremity + vertex or breech presentation

Question 73

Post term pregnancy: 1) Who is it more common in? 2) What must you start bc of incr. risk in baby?

Answer 73

1) Primips and in women who delivered post term before 2) Must start fetal assessment (kick counts, non-stress tests, ultrasound evaluation of amniotic fluid)

Question 74

Describe the following risks of post term pregnancy: 1) Macrosomia 2) Shoulder dystocia 3) Meconium aspiration syndrome (MAS)

Answer 74

1) > 4,500g = macrosomia 2) Impaction of the anterior fetal shoulder behind the symphysis pubis during vaginal delivery causing a brachial plexus injury 2) MAS can cause severe respiratory distress

Question 75

Define the following risks of post term pregnancy: 1) Dysmaturity syndrome 2) Oligohydramnios

Answer 75

1) Infants with characteristics resembling chronic growth restriction 2) Decreased amniotic fluid; if >36 weeks, indication for delivery

Question 76

Post Term Pregnancy: Induction of labor is appropriate if what?

Answer 76

1) The cervix is favorable AND if the patient prefers such management -Cervical ripening agents (intracervical or intravaginal preparation of prostaglandin, misoprostol)