19. Obstetrical Complications Flashcards
Preterm Labor PTL, preterm birth is birth after 20 weeks, before 36 6/7 weeks, dx is uterine contractions with cervical change or cervical dilation of 2cm and or 80% effacement, usually spontaneous, or d/t multiple gestations, PPROM, cervical incompetence, AA* 2x more likely than whites, high stress, poor nutrition, prevention via infection, placental vascular, psychosocial stress/work strain and uterine?
Stretch
Bacterial vaginosis is assoc with preterm delivery - treat group B strep, gonorrhea, chlamydia w abx during preg to prevent PTL, RR for PTL increases as cervical length decreases, so length of 3.5cm has RR2.4, cervical length of 2.5cm has RR for PTL of 6.2, ultrasound and fetal what is used to screen for cervical shortening?
Fetal fibronectin (FFN)
Placental vascular pathway begins at time of implantation includes immunologic component, vascular component, low resistance connection of sprial arteries, alteration of any of these can result in PTL. Stress-strain pathway causes release of corticol and catecholamines, which causes CRH expression and assists in labor and affects blood flow causing uterine contractions, respectively, so stress reduction and what is the only modifiers of this pathway?
Good nutrition
Uterine stretch pathway is due to increased volume, risk factor in polyhydramnios and multiple gestations. PTL occurs between 20 and 37 weeks, must have *** uterine contractions and cervical change or cervical dilation of 2cm or greated and or ?
80% effacement
*Sx: cramping, low/dull back pain, pelvic pressure, increase in discharge.bloody and uterine contractions
Eval for PTL is done with cervical exam, looking for underlying correctable problems like infection, external FHR monitoring and reevaluate cervix- hydration and bed rest will resolve contractions in 20%, cultures of what should be taken, and abx given to treat infection if cultures are positive?
Group B strep, ureaplasma, mycoplasma ,gardnerella, gonorrhea, chlamydia
If PTL is diagnosed, the start tocolytics (if gestation age less than 34 weeks and no contraindications): magnesium sulfate, nifedipine, indomethicin, Mag Sulfate is drug of choice and given IV, allows for neuroprotection against cerebral palsy- given if less than 32 weeks, SE include flushing, N/V, resp distress| neotate: loss muscle tone, drowsiness and lower?
apgar scores
Nifedipine is the ORAL agent effective in suppressing PTL, minimal SE: HA, flsuhing, hypotentsion, tachycardia, inhibits inward current of Ca during second phase of action potention, may replace mag sulfate as drug of choice. What tocolytic inhibits PGE production which induce myometrial contraction, used short term, given orrally or rectally, can result in oligohydramnios, can cause premature closure of fetal ductus arteriosus, increased risk of necrotizing enterocolitis, intracranial hemorrhage?
Indometicin (PG synthetase inhibitor)
*nsaids used to decrease uterine activity- not primary tx for PTL
Glucocorticoids are need to mature premature fetal lung*, reduces mortality and incidence of RDS, given between 24-34 weeks, 2 doses of betamethaasone or 4 doses of decamethasone … *a single course of betamethasone is recommended for pregnant women between 34 and 36 weeks of gestation at risk of preterm birth within 7 days and who have not received previous?
antenatal corticosteroids
Prevention of PTL is unknown, some think progesterone IM given weekly 16-36 weeks, vaginal progesterone, or pessary-arabin pessary- used in women with short cervix - a ring! Premature rupture of the membranes before the onset of labor at any gestational age is the definition for?
Premature rupture of membranes PROM
*unknown etiology
Dx of PROM includes hx of loss of fluid and confirmation of amniotic fluid in vagina, **DONOT check cervix of assumed ruptureed preterm pt- increases risk for infection- rupture confirmed using sterile speculum.. COnfirmation of PROM has 3 tests, pooling, fening and ?
nitrazine paper will turn blue
sometimes US
intact amniotic sace provides a barrier to infection (chorioamnionitis-inc PTL30%), risks of PROM include endomyometritis, sepsis, failded induction due to unfavorable cervix…Management: 1) gestation age less than 24 weeks could lead to pulmonary hypoplasia 2) amniotic fluid index- <5cm is oligo and no fluid is anhydramnios, 3) fetal status and 4) what should be considered for management?
Maternal status
Goal of PROM is to continue pregnancy until lung profile is mature, most deliver at 34 weeks- ***monitor for chorioamnionitis which is dx via maternal temp >100.4, fetal/mom tachycardia, tender uterus, fould smelling amniotic fluid or purulent discharge, 48 hours of IV ampicillin and erythromycin is used post PROM, tocolytics may be used to get steroids on board- which are used up to 34 weeks to?
reduce risk of RDS
***NO outpatient, once PROM- hospital bound til 34 weeks
Intrauterine growth restriction (IUGR) is birth weight below 10% given for gestational age, SGA is birth weight lower extreme of normal, growth restricted fetuses are at risk for meconium aspiration, hypoxia, stillbirth, polycythemia, hypoglycemia, cognitive delay- 3 main categories: maternal, placental and fetal, maternal causes of IUGR include poor nutrition, cigarettes, drugs, alcohol, pulm insufficiency, antiphospholipid sundrome
MEOW
Placental causes of IUGR include conditions resulting in placental insufficiency such as HTN, renal disease, placental or cord abnormalities such as velamentous cord, preexisiting DM, also commonly caused due to insufficient substrate transfer through placenta as well as defective trophoblast?
invasion
fetal causes of IUGR include inadequate or altered substrate, such as intrauterine infections, listeriosis, TORCH, congenital anomalies, multiple gestations, chromosomal abnormalities.. Dx of IUGR via PE- fundal height, US: biometru, Direct studies not used, and what is always used?
Doppler Studies
