Obstetrics and gynecology Flashcards
Hemodilution during pregnancy
With normal pregnancy, blood volume increases, which results in a concomitant hemodilution. Although red blood cell (RBC) mass increases 17 % during pregnancy, plasma volume increases more 45%, resulting in a relative anemia. This results in a physiologically lowered hemoglobin (Hb) level, hematocrit (Hct) value, and RBC count, but it has no effect on the mean corpuscular volume (Mcv).
anemia defined as a value less than the fifth percentile is a hemoglobin level of 11 g/dL or less in the first trimester, 10.5 g/dL or less in the second trimester, and 11 g/dL or less in the third trimester.
Normal hb is 12 for women
What murmur is ok to hear in a pregnant woman?
Systolic murmur; diastolic murmur is NOT ok
What does increased minute ventilation during pregnancy cause?
a compensated respiratory alkalosis (pco2 decrease and hco3 decrease and ph normal)
PFT in normal pregnancy?
Inspiratory capacity increases by 15% during the third trimester because of increases in tidal volume and inspiratory reserve volume. The respiratory rate does not change during pregnancy, but the TV is increased which increases the minute ventilation, which is responsible for the respiratory alkalosis in pregnancy. Functional residual capacity (erv +rv) is reduced to 80% of the non-pregnant volume by term. These combined lead to subjective shortness of breath during pregnancy.
Pulmonary edema in pregnancy
What drug can cause it?
Plasma osmolality is decreased during pregnancy which increases the susceptibility to pulmonary edema. Common causes of acute pulmonary edema in pregnancy include tocolytic use, cardiac disease, fluid overload and preeclampsia.
Magnesium sulfate (used as a tocolytic to stop uterine contractions)
Cardiovascular changes in pregnancy
The cardiac output increases up to 33% due to increases in both the heart rate and stroke volume. The SVR falls during pregnancy. Up to 95% of women will have a systolic murmur due to the increased volume.
Right hydronephrosis (distention of the renal calyces and pelvis with urine as a result of obstruction of the outflow of urine distal to the renal pelvis)
Some degree of dilation in the ureters and renal pelvis occurs in the majority of pregnant women. The dilation is unequal (R > L) due to cushioning provided by the sigmoid colon to the left ureter and from greater compression of the right ureter due to dextrorotation (clockwise) of the uterus. The right ovarian vein complex, which is remarkably dilated during pregnancy, lies obliquely over the right ureter and may contribute significantly to right ureteral dilatation. High levels of progesterone likely have some effect but estrogen has no effect on the smooth muscle of the ureter
Thyroid in pregnancy
Thyroid binding globulin (TBG) is increased due to increased circulating estrogens with a concomitant increase in the total thyroxine. Free thyroxine (T4) remains relatively constant. Total triiodothyroxine (T3) levels also increase in pregnancy while free T3 levels do not change. In a pregnant patient without iodine deficiency, the thyroid gland may increase in size up to 10%.
ultrasound reveals heterogeneous cystic tissue in the uterus (snowstorm pattern)
This patient’s presentation is classic for a molar pregnancy (A molar pregnancy starts when an egg is fertilized, but instead of a normal, viable pregnancy resulting, the placenta develops into an abnormal mass of cysts). Beta-hCG levels in normal pregnancy do not reach one million. A chest x-ray would be the most appropriate step, as the lungs are the most common site of metastatic disease in patients with gestational trophoblastic disease. Though a repeat quantitative Beta-hCG will be required on a weekly basis, an immediate post-operative value will be of little clinical utility.
Recommendations concerning weight gain in pregnancy
The recommendations are: underweight (BMI 30 kg/m2) total weight gain 11 - 20 pounds.
When does fetal organ formation occur?
3-10 week estimated gestational age
Mom brother has sickle cell disease. odds that this couple will have a child with sickle cell anemia, if the carrier rate for sickle cell disease in the African American population is 1/10?
Sickle cell anemia is an autosomal recessive condition that occurs in 1/500 births in the African-American population. The carrier state, or sickle-cell trait, is found in approximately 1/10 African-Americans. Since the patient’s brother is affected, both of their parents have to be carriers. Each time two carrier parents for an autosomal recessive condition conceive there is a 1/4 chance of having either an affected or an unaffected child and a 1/2 chance of having a child who is a carrier. Since the patient is unaffected, she has a 1/3 chance of not being a carrier and a 2/3 chance of being a carrier. The patient’s husband has a 1/10 chance of being a carrier (the general population risk for African-Americans). Thus, the chance that this couple will have a child with sickle cell anemia is: 2/3 X 1/10 X 1/4 = 1/60.
African American couple preconception counsel
Screening for carriers of both alpha and beta thalassemia is possible by evaluation of red cell indices. Although solubility tests for hemoglobin S or sickle cell preparations can be used for screening, hemoglobin electrophoresis is definitive and preferable because other hemoglobinopathies can also be detected including hemoglobin C trait and thalassemia minor. Although sickle cells can be identified on a blood smear in individuals with sickle cell disease, the cells may be absent in individuals with milder types of sickle cell disease and even in some individuals with severe sickle cell disease. Evaluation of a peripheral smear is not useful in detecting carriers for sickle cell disease.
Jewish decent genetic disorders (4)
Fanconi anemia (rare inherited bone marrow failure), Tay-Sachs disease (rare inherited disorder that progressively destroys nerve cells (neurons) in the brain and spinal cord), Cystic Fibrosis, and Niemann-Pick disease (lipid storage disorder that results from the deficiency of a lysosomal enzyme, acid sphingomyelinase) are all autosomal recessive conditions that occur at an increased incidence in Jews of Ashkenazi descent. The Beta thalassemia is seen mainly in Mediterranean populations.
Valproic acid effects on fetus
Valproic acid is associated with an increased risk for neural tube defects (specifically lumbar meningomyelocele), hydrocephalus (fluid build up in brain) and craniofacial malformations.
Fetal ultrasound examination at approximately 16 to 18 weeks gestation is recommended to detect neural tube defects.
diabetes immediately prior to conception and during organogenesis effect
Women with poorly controlled diabetes immediately prior to conception and during organogenesis have a four- to eight-fold risk of having a fetus with a structural anomaly. The majority of lesions involve the central nervous system (neural tube defects) and the cardiovascular system. Genitourinary and limb defects have also been reported. Although caudal regression malformation occurs at an increased incidence in individuals with diabetes, this condition is very rare.
Chorionic villi sampling
CVS is generally performed at 10-12 weeks gestation. The procedure involves sampling of the chorionic frondosum, which contains the most mitotically active villi in the placenta. CVS can be performed using a transabdominal or transcervical approach. The sampled placental tissue may be analyzed for fetal chromosomal abnormalities, biochemical, or DNA-based studies including testing for the mutations associated with cystic fibrosis
Highest detection rate for trisomy 21
All of the tests screen for trisomy 21 and trisomy 18. Cell-free DNA screening has a trisomy 21 detection rate of over 99% at a 0.2% false-positive rate. The other options may also be used to screen for trisomy 21. Detection rates provided at a 5% false positive screen rate.
- First trimester combined test: first trimester nuchal translucency, PAPP-A (pregnancy associated plasma protein A) and Beta-hCG – 85% Detection Rate
- Triple screen: second trimester AFP (alpha fetoprotein), Beta-hCG, uE3 (unconjugated estriol) – 69% Detection Rate
- Quad screen: (second trimester Triple screen + inhibin A) – 81% Detection Rate
- Sequential screen: (first trimester NT and PAPP-A + second trimester quad screen) – 93% Detection Rate
- Serum integrated screen, when unable to obtain nuchal translucency: (first trimester PAPP-A + second trimester quad screen) – 85-88% Detection Rate
risk of fetal loss associated with CVS
The risk of fetal loss associated with CVS is approximately 1% and is not related to her prior miscarriage Hx
Most common syndrome of inherited mental retardation?
Fragile X syndrome is the most common form of inherited mental retardation. The syndrome occurs in approximately 1 in 3,600 males and 1 in 4,000 to 6,000 females. Down syndrome is genetic but the majority of cases are not inherited.
This patient has three values on the three-hour glucose tolerance test that were abnormal.
Begin a diabetic diet and blood glucose monitoring
Initial management should include teaching the patient how to monitor her blood glucose levels at home on a schedule that would include a fasting blood sugar and one- or two-hour post-prandial values after all three meals, daily. Goals for blood sugar management would be to maintain blood sugars when fasting below 90 and one- and two-hour post-meal values below 120. A repeat glucose tolerance test would not add any value, as an abnormal test has already been documented. Oral hypoglycemic agents and insulin are not indicated at this time, as the patient may achieve adequate glucose levels with diet modification alone. Gestational diabetes varies in prevalence. The prevalence rate in the United States has varied from 1.4 to 14% in various studies. Risk factors for gestational diabetes include: a previous large baby (greater than 9 lb), a history of abnormal glucose tolerance, pre-pregnancy weight of 110% or more of ideal body weight, and member of an ethnic group with a higher than normal rate of type 2 diabetes, such as American Indian or Hispanic descent.
Gestational diabetes
Intrauterine growth restriction is typically seen in women with pre-existing diabetes and not with gestational diabetes. Shoulder dystocia, metabolic disturbances, preeclampsia, polyhydramnios and fetal macrosomia are all associated risks of gestational diabetes.
Folic acid intake
In 1991, the Centers for Disease Control and Prevention recommended that all women with a previous pregnancy complicated by a fetal neural tube defect ingest 4 mg of folic acid daily before conception and through the first trimester. In one analysis, this dose of folic acid in women at high risk reduced the incidence of neural tube defects by 85%. According to ACOG, tThe recommended dose for non-high risk patients is at least 0.4-.8 mg/day.
Maternal serum alpha fetoprotein
Ninety to ninety-five percent of cases of elevated MSAFP are caused by conditions other than neural tube defects including under-estimation of gestational age, fetal demise, multiple gestation, ventral wall defects and a tumor or liver disease in the patient. Incorrect dating, specifically under-estimation of gestational age, is the most common explanation for an elevated MSAFP. The next appropriate step in the management of this patient is to obtain an ultrasound to assess the gestational age, viability, rule out multiple gestation as well as a fetal structural abnormality.
Increased unchallenged translucency, want to rule out chromosomal abnormalities
Amniocentesis is a diagnostic test that may detect Down syndrome as well as other chromosomal abnormalities. Cell-free DNA testing detects over 99% of cases of Down syndrome. The first trimester screen, which consists of a nuchal translucency and maternal serum PAPP-A and beta-hCG, yields an 85% detection rate for Down syndrome. The NT is the measurement of the fluid collection at the back of the fetal neck in the first trimester. A thickened NT may be associated with fetal chromosomal and structural abnormalities as well as a number of genetic syndromes
Ibuprofen, warfarin in pregnancy
Ibuprofen is safe to take until around 32 weeks gestation, when premature closure of the ductus arteriosis is a risk. While heparin is safe during pregnancy, warfarin has known teratogenic effects and should not be given. If continued anticoagulation is necessary, low molecular weight heparin is the drug of choice.
Braxton hicks vs true labor
Braxton Hicks contractions are characterized as short in duration, less intense than true labor, and the discomfort as being in the lower abdomen and groin areas. True labor is defined by strong, regular uterine contractions that result in progressive cervical dilation and effacement.
Group b strep: previous pregnancy, current group b, regular gbs screen
Cultures for group B streptococcus are not required in women who have group B streptococcal bacteriuria during the current pregnancy or who have previously given birth to a neonate with early-onset group B streptococcal disease because these women should receive intrapartum antibiotic prophylaxis. Universal screening with a recto-vaginal culture at 35–37 weeks of gestation is recommended for all women who do not have an indication for intrapartum antibiotic prophylaxis. All women with positive cultures for group B streptococci should receive intrapartum antibiotic in labor unless a cesarean delivery is performed before onset of labor in a woman with intact amniotic membranes.
What to do when pt present for early labor?
The initial evaluation of patients presenting to the hospital for labor includes a review of the prenatal records with special focus on the antenatal complications and dating criteria, a focused history and a targeted physical examination to include maternal vital signs and fetal heart rate, and abdominal and pelvic examination. A speculum exam with a nitrazine test to confirm rupture of membranes is indicated if the patient’s history suggests this, or if a patient is uncertain as to whether she has experienced leakage of amniotic fluid. Performing a fetal ultrasound is not a routine part of an assessment in a patient who may be in early labor. A prenatal ultrasound may be used in cases to determine fetal presentation, estimated fetal weight, placental location or amniotic fluid volume
Fetal hr can’t be found externally
If the fetal heart rate cannot be confirmed using external methods, then the most reliable way to document fetal well-being is to apply a fetal scalp electrode. Putting in an epidural without confirming fetal status might be dangerous. Although ultrasound will provide information regarding the fetal heart rate, it is not practical to use this to monitor the fetus continuously while the epidural is placed. An intrauterine pressure catheter will provide information about the strength and frequency of the patient’s contractions, but will not provide information regarding the fetal status.
Intrauterine pressure catheter risks
If an intrauterine pressure catheter is placed, and a significant amount of vaginal bleeding is noted, the possibility of placenta separation or uterine perforation should be considered. Take it out and observe for fetal demise And then replace it if fetal tracing is reassuring
Causes of early, late and variable decelerations?
Variable decelerations are typically caused by cord compression and are the most common decelerations seen in labor. Placental insufficiency is usually associated with late decelerations ( oxygen deprivation). Head compression typically causes early decelerations.
Umbilical cord prolapse, what to do
Although fetal surveillance is reassuring, the most appropriate management is to continue to elevate the fetal head with a hand in the patient’s vagina and call for assistance to perform a Cesarean delivery. It is important
to elevate the fetal head in an attempt to avoid compression of the umbilical cord. Once an umbilical cord prolapse is diagnosed, expeditious arrangements should be made to perform a cesarean section. It is not appropriate to replace the umbilical cord into the uterus or allow the patient to continue to labor or perform a forceps-assisted vaginal delivery.
slightly flattened nasal bridge. Her ears are small and slightly rotated. What is the most appropriate next step
A flattened nasal bridge, small size and small rotated, cup-shaped ears may be associated with Down syndrome and should prompt a survey looking specifically for other features seen with Down syndrome that include sandal gap toes, hypotonia, a protruding tongue, short broad hands, Simian creases, epicanthic folds, and oblique palpebral fissures.
Prevent newborn from experiencing meconium aspiration after amniotomy( artificial rupture of membrane)
Meconium aspiration syndrome occurs in up to 10% of infants who have been exposed to meconium-stained amniotic fluid. It is associated with significant morbidity and mortality. all infants with meconium-stained amniotic fluid should not routinely receive suctioning at the perineum. If meconium is present and the newborn is depressed, the clinician should intubate the trachea and suction meconium or other aspirated material from beneath the glottis. If the newborn is vigorous, defined as having strong respiratory efforts, good muscle tone, and a heart rate greater than 100 beats per minute, there is no evidence that tracheal suctioning is necessary. Injury to the vocal cords is more likely to occur when attempting to intubate a vigorous newborn. Routine prophylactic amnioinfusion for meconium-stained amniotic fluid is not recommended as there is no definitive benefit.
Diabetes type 1 vs gestational diabetes
Diabetes
Small babies are more common with type 1 diabetes than with gestational diabetes, and the blood sugar level of all newborns of diabetic mothers should be monitored closely after delivery, as they are at increased risk for developing hypoglycemia. Macrosomic (large) infants are typically associated with gestational diabetes.
Infants born to diabetic mothers are at increased risk for developing hypoglycemia, polycythemia, hyperbilirubinemia, hypocalcemia and respiratory distress. Thrombocytopenia is not a risk.
Diabetics also have increased risk for polyhydramnios, congenital malformations (cardiovascular, neural tube defects, and caudal regression syndrome), preterm birth and hypertensive complications. Her diabetes does place her at an increased for twins.
inflammation of the fetal membranes (amnion and chorion) due to a bacterial infection. It typically results from bacteria ascending into the uterus from the vagina and is most often associated with prolonged labor. —chorioamnionitis
fetal tachycardia may be in response to the maternal fever. Fetal tachycardia coupled with minimal variability is a warning sign that the infant may be septic. A septic infant will typically appear pale, lethargic and have a high temperature.
twin A is large and plethoric, and twin B is small and pale. The risks of each?
This case is suggestive of twin-twin transfusion syndrome (TTTS). Polycythemia is a common complication for the plethoric twin. TTTS is a complication of monochorionic pregnancies. It is characterized by an imbalance in the blood flow through communicating vessels across a shared placenta leading to under perfusion of the donor twin, which becomes anemic and over perfusion of the recipient, which becomes polycythemic. The donor twin often develops IUGR (intrauterine growth restriction)and oligohydramnios, and the recipient experiences volume overload and polyhydramnios that may lead to heart failure and hydrops.
Mother treated with meperidine (Demerol) , Hx of marijuana, baby born no respiratory effort
You should give positive pressure ventilation and prepare to intubate the infant, if necessary. Any history of substance abuse may be a relative contraindication to the use of naloxone (Narcan) because the mother may have used narcotics during the pregnancy and administration of naloxone to the infant can cause life-threatening withdrawal. Stimulation may not be sufficient for this infant. Suction will not necessarily stimulate a respiratory effort.
Hiv positive mom
A usual protocol is to start AZT (zidovudine) immediately after delivery. HIV testing begins at 24 hours. Breastfeeding not encouraged
Positive pressure ventilation
The sniffing position (tilting the neonate’s head back and lifting the chin) is the correct position for application of positive pressure ventilation in a newborn infant. It is important to also secure the mask to the infant’s face and to observe an initial chest rise. A recommended rate of oxygen flow is 10 L/minute.
Apgar score
Heart rate, Respiratory rate, Reflex, Activity (muscle tone), Color
2,1,0; good score is 10
Postpartum hemorrhage
Management
Postpartum hemorrhage (PPH) is an obstetrical emergency that can follow vaginal or Cesarean delivery. Uterine atony is the most common cause of PPH and occurs in one in every twenty deliveries. The most common definition of PPH is an estimated blood loss of greater than or equal to 500 ml after vaginal birth, or greater than or equal to 1000 ml after Cesarean delivery.
Risk factors for uterine atony include precipitous (high risk) labor, multiparity, general anesthesia, oxytocin use in labor, prolonged labor, macrosomia, hydramnios, twins and chorioamnionitis.
first steps in the management of postpartum hemorrhage are to make sure the uterus is well-contracted, there is no retained placental tissue and to look for lacerations
Uterotonics (oxytocin, misoprostol etc), then uterine packing or Bakri balloon, then surgical treatment (uterine artery ligation, uterine artery embolization, hysterectomy)
Sheehan syndrome
Sheehan Syndrome is a rare occurrence. When a patient experiences a significant blood loss, this can result in anterior pituitary necrosis, which may lead to loss of gonadotropin, thyroid-stimulating hormone (TSH) and adrenocorticotropic hormone (ACTH) production, as they are all produced by the anterior pituitary. Signs and symptoms of Sheehan syndrome may include slow mental function, weight gain, fatigue, difficulty staying warm, no milk production, hypotension and amenorrhea. Sheehan’s syndrome frequently goes unnoticed for many years after the inciting delivery. Treatment includes estrogen and progesterone replacement and supplementation with thyroid and adrenal hormones.
Greatest risk for Puerperal infection
Endometritis can be found in less than 3% of vaginal births and this is contrasted by a 5-10 times higher incidence after Cesarean deliveries. Factors related to increased rates of infection with a vaginal birth include prolonged labor, prolonged rupture of membranes, multiple vaginal examinations, internal fetal monitoring, removal of the placenta manually and low socioeconomic status.
Postpartum fever
The most common cause of postpartum fever is endometritis. The differential diagnosis includes urinary tract infection, lower genital tract infection, wound infections, pulmonary infections, thrombophlebitis, and mastitis. Uterine fundal tenderness is commonly observed in patients with endometritis.
Endometritis
Bacterial isolates related to postpartum endometritis are usually polymicrobial resulting in a mix of aerobes and anaerobes in the genital tract. The most causative agents are Staphylococcus aureus and Streptococcus.
Postpartum blues vs depression
Postpartum depression is a common condition estimated to affect approximately 10-15% of women and often begins within two weeks to six months after delivery. Signs and symptoms of depression which last for less than two weeks are called postpartum blues; it occurs in 40-85% of women in the immediate postpartum period. It is a mild disorder that is usually self-limited.
In addition to the more common symptoms of depression, the postpartum patient may manifest a sense of incapability of loving her family and manifest ambivalence toward her infant–pp depression
most significant risk factor for developing postpartum depression is the patient’s prior history of depression.
Breastfeeding
Benefits to the mother include increased uterine contraction due to oxytocin release during milk let down and decreased blood loss. Breastfeeding is associated with a decreased incidence of ovarian cancer. Some studies have reported a decreased incidence of breast cancer. Breast milk is a major source of Immunoglobulin A which is associated with a decrease of newborn’s gastrointestinal infections.
Breastfeeding positions
Although the side lying position is a good one for breastfeeding, it is important for mother and baby to be belly-to-belly in order for the infant to be in a good position to latch on appropriately, taking a large part of the areola into its mouth
Breast and pregnancy hormones
Estrogen-mammary gland/lobule growth
Progesterone- alveoli hyper trophy
Prolactin-milk production (inhibited by estrogen and progesterone—inhibitory influence of progesterone on the production of alpha-lactalbumin by the rough endoplasmic reticulum. The increased alpha-lactalbumin serves to stimulate lactose synthase and ultimately to increase milk lactose.)
Oxytocin - milk let down and uterine
fever and a red tender wedge-shaped area on the outer quadrant of her left breast
classic picture of mastitis that is usually caused by streptococcus bacteria from the baby’s mouth. Mastitis is easily treated with antibiotics. The initial choice of antimicrobial is influenced by the current experience with staphylococcal infections at the institution. Most are community-acquired organisms, and even staphylococcal infections are usually sensitive to penicillin or a cephalosporin. If the infection persists, an abscess may ensue which would require incision and drainage. However, this patient’s presentation is that of simple mastitis. There is no need for the mother to stop breastfeeding because of the mastitis.
Breastfeeding hospital policies
Hospital policies that promote breastfeeding include getting the baby on the breast within a half hour of delivery and rooming-in for the baby to ensure frequent breastfeeding on demand (i.e. unlimited access).
sore nipples, burning pain in the breasts, which is worse when feeding. The tips of the nipples are pink and shiny with peeling at the periphery
This presentation is classic for candidiasis and should prompt an inspection of the baby’s oral cavity. Candida of the nipple is associated with severe discomfort and pain. Localized candida of the nipple may be treated with an antifungal, topical medication such as clotrimazole or miconazole cream. The treatment plan may include a topical antibiotic ointment because nipple fissures can concurrently present with candida of the nipples, and S. aureus is significantly associated with nipple fissures. Either a triple antibiotic ointment or mupirocin can be prescribed. A topical steroid cream can be used to facilitate healing for cases in which the nipples that are very red and inflamed. Every treatment regimen must include the simultaneous treatment of the mother and baby. Oral nystatin is the most common treatment for the baby, followed by oral fluconazole.
Signs that a baby is getting sufficient milk
3-4 stools in 24 hours, six wet diapers in 24 hours, weight gain and sounds of swallowing.
Engorgement of breast relief
Engorgement commonly occurs when milk comes in. Strategies that may help include frequent nursing (every 1.5 -2 hours), taking a warm shower or warm compresses to enhance milk flow, massaging the breast and hand expressing some milk to soften the breast, wearing a good support bra and using an analgesic 20 minutes before breastfeeding.
Differential dx for 1st trimester vaginal bleeding
Spontaneous abortion
Viable, intrauterine pregnancy (nml implantation bleeding or sub chorionic hemorrhage)
Ectopic pregnancy
Ectopic pregnancy dx
Inappropriately rising Beta-hCG levels (less than 50% increase in 48 hours) or levels that either do not fall following diagnostic dilation and curettage would be consistent with the diagnosis of ectopic pregnancy. Alternatively, a fetal pole (thickening of margin of yolk sac) must be visualized outside the uterus on ultrasound. The patient would need a Beta-hCG level over the discriminatory zone (1500-2000, the level where an intrauterine pregnancy can be seen on ultrasound) with an empty uterus. The level commonly used is 2000 mIU/ml.
progesterone level is within expected range for a normal pregnancy (>25 ng/ml suggests healthy pregnancy)
Risk factor for ectopic pregnancy
tenfold increase risk for ectopic pregnancy in women with a prior history of ectopic pregnancy. Age between 35 and 44 years old is associated with a threefold increase in ectopic pregnancy.
Ruptured ectopic pregnancy
How to dx it?
Her vital signs ( high p, high rr, low bp) , examination ( rebound and voluntary guarding, free fluid in the cup de sac )and anemia are consistent with an intra-abdominal bleed. Exploratory laparoscopy/laparotomy is indicated at this point. Conservative management with observation, serial examinations or repeat Beta-hCG testing could be dangerous in a patient suspected of having a ruptured ectopic pregnancy. Medical management (methotrexate) is not used in a patient with an acute surgical abdomen
Signs of hypovolemia (tachycardia, hypotension) with peritoneal signs (rebound, guarding and severe abdominal tenderness) and a positive pregnancy test lead to the diagnosis of ruptured ectopic pregnancy.
Mifepristone
Mifepristone is a progestin receptor antagonist and can be used as emergency contraception to prevent ovulation and blocks the action of progesterone which is needed to maintain pregnancy.
Certain conditions must be met prior to initiating methotrexate therapy for treatment of an ectopic pregnancy.
These include: hemodynamic stability; non-ruptured ectopic pregnancy; size of ectopic mass
increasing lower abdominal pain, nausea, scant bleeding, and fever; rebound tenderness and abdominal guarding, uterus soft and slightly tender; d and c performed two days ago
Perforated uterus
Cause majority of 1T spontaneous abortion
Other causes
approximately 50 to 60 percent of embryos and early fetuses that are spontaneously aborted contain form of chromosomal abnormalities.
Environmental factors, such as smoking, alcohol and radiation are causes of spontaneous abortion
Most common abnormal karyotype encountered in spontaneous abortuses
Autosomal trisomy is accounting for approximately 40-50% of cases.
Diseases assoc with early pregnancy loss
Systemic diseases such as diabetes mellitus, chronic renal disease and lupus are associated with early pregnancy loss. In women with insulin-dependent diabetes, the rates of spontaneous abortion and major congenital malformations are both increased.
This patient is actively bleeding and is anemic.
She, therefore, requires immediate surgical treatment consisting of dilation and suction curettage. Although clinicians increasingly utilize both expectant management and various drug regimens to treat spontaneous abortion, a prerequisite for either is that the patient is hemodynamically stable and reliable for follow-up care.
Pts have options for early pregnancy loss
Patients experiencing early pregnancy loss can safely consider several different treatments, including expectant management, medical treatment to assist with expulsion of the pregnancy or surgical evacuation. Provided the patient is hemodynamically stable and reliable for follow-up, expectant management is appropriate therapy. At the gestational age described, expectant management portends no increase in risk of either hemorrhage or infection compared with surgical or medical evacuation. Regardless of method chosen, the patient’s blood type should be checked and rhogam administered as indicated.
Hx of uncomplicated spontaneous losses
incompetent cervix and should have a cervical cerclage at 14 weeks. A positive fetal fibronectin does not indicate incompetent cervix and is used later in pregnancy as a negative predictor of preterm delivery. Pregnancy loss in the late second trimester is not usually related to genetic abnormality of the conceptus and most clinicians delay placement of a cerclage until after the first trimester, given the high background prevalence of first trimester pregnancy wastage
prior first trimester surgical abortion
Neither controlled trials nor surveillance data support the contention that a single, prior first trimester surgical abortion increases the risk of subsequent first trimester pregnancy loss.
Lisinopril in pregnancy
angiotensin converting enzyme inhibitors, such as Lisinopril, beyond the first trimester of pregnancy has been associated with oligohydramnios, fetal growth retardation and neonatal renal failure, hypotension, pulmonary hypoplasia, joint contractures and death. Amitriptyline is used in pregnancy to treat migraine headaches.
Hiv positive mom
The baseline transmission rate of HIV to newborns can be reduced from about 25% to 2% with the HAART (highly active antiretroviral therapy) protocol antepartum and continuing through delivery with intravenous zidovudine in labor and zidovudine treatment for the neonate. Cesarean section prior to labor can reduce this rate to 2% (although the benefit is less clear in women with viral loads).
Asthma in pregnancy
Asthma generally worsens in 40% of pregnant patients. One of the indications for moving to the next line of treatment includes the need to use beta agonists more than twice a week. The appropriate choice for her treatment would be inhaled corticosteroids or cromolyn sodium. Theophylline would be used in more refractory patients. Subcutaneous terbutaline and systemic corticosteroids would be used in acute cases. Zafirlukast, a leukotriene receptor antagonist, is not effective for acute disease.
Syphyllis in pregnancy
rapid plasma reagin test (RPR) positive (titer = 32); fluorescent treponemal antibody absorption test (FTA-ABS) is positive
fluorescent treponemal antibody absorption test (FTA-ABS) confirms the diagnosis. The transmission rates for primary and secondary disease are approximately 50-80%. There are no proven alternatives to penicillin therapy during pregnancy and penicillin G is the therapy of choice to treat syphilis in pregnancy. Women with a history of penicillin allergy can be skin tested to confirm the risk of immunoglobulin E (IgE)-mediated anaphylaxis. If skin tests are reactive, penicillin desensitization is recommended and is followed by intramuscular benzathine penicillin G treatment.
Screening for gestational diabetes
Screening should be performed between 24 and 28 weeks in those women not known to have glucose intolerance earlier in pregnancy. This evaluation can be done in two steps: a 50-g oral glucose challenge test is followed by a diagnostic 100-g oral glucose tolerance test (OGTT) if initial results exceed a predetermined plasma glucose concentration. Patients at low risk are not routinely screened. For those patients of average risk screening is performed at 24-28 weeks while those at high risk (severe obesity and strong family history) screening should be done as soon as feasible.
Pulmonary hypertension
Among women with cardiac disease, patients with pulmonary hypertension are among the highest risk for mortality during pregnancy, a 25-50% risk for death. Management of labor and delivery is particularly problematic. These women are at greatest risk when there is diminished venous return and right ventricular filling which is associated with most maternal deaths. Similar mortality rates are seen in aortic coarctation with valve involvement and Marfan syndrome with aortic involvement.
Systolic ejection murmur with a click, palpitations, intermittent chest pains
Most women with mitral valve prolapse are asymptomatic and diagnosed by routine physical examination or as an incidental finding at echocardiography. A small percentage of women with symptoms have anxiety, palpitations, atypical chest pain, and syncope. For women who are symptomatic, b-blocking drugs are given to decrease sympathetic tone, relieve chest pain and palpitations, and reduce the risk of life-threatening arrhythmias.
Pneumonia
typical symptoms include cough, dyspnea, sputum production, and pleuritic chest pain. Mild upper respiratory symptoms and malaise usually precede these symptoms, and mild leukocytosis is usually present. Chest radiography is essential for diagnosis, although radiographic appearance does not accurately predict the etiology of the pneumonia
Microcytic anemia
This patient has alpha thalassemia trait characterized by mild anemia, microcytic and hypochromic anemia and a normal hemoglobin electrophoresis. She denies blood loss therefore acute blood loss is unlikely and her serum ferritin is normal ruling out iron deficiency anemia. Hemoglobin H disease and beta thalassemia are characterized by moderate to severe anemia. Beta-thalassemia would have hemoglobin F as well as hemoglobin A2 on hemoglobin electrophoresis.
Obesity in pregnancy
Increased maternal morbidity results from obesity and includes chronic hypertension, gestational diabetes, preeclampsia, fetal macrosomia, as well as higher rates of Cesarean delivery and postpartum complications. This patient’s BMI is approximately 38 so she is a class II and has over a 7-fold increase risk for preeclampsia and a 3-fold risk for hypertension.
Lupus in pregnancy
Clinical manifestations include malaise, fever, arthritis, rash, pleuro-pericarditis, photosensitivity, anemia, and cognitive dysfunction. A significant number of patients have renal involvement. There is no cure and complete remissions are rare. Mild disease may be disabling because of pain and fatigue. Nonsteroidal anti-inflammatory drugs are used to treat arthralgia and serositis. Severe disease is best treated with corticosteroids.
classic depression
most commonly used antidepressants are the selective serotonin reuptake inhibitors (SSRIs). One SSRI, paroxetine (Paxil) has been changed to a category D drug because of the increased risk of fetal cardiac malformations and persistent pulmonary hypertension. Other SSRI compounds, fluoxetine, sertraline, and citalopram have not been reported to cause early pregnancy loss or birth defects in animals or in human
Pruritis gravidarum
pruritus gravidarum, a common pregnancy-related skin condition that is a mild variant of intrahepatic cholestasis of pregnancy. There is retention of bile salt, and as serum levels increase they are deposited in the dermis. This, in turn, causes pruritus. The skin lesions are secondary to scratching and excoriation. Antihistamines and topical emollients may provide some relief and should be used initially. Ursodeoxycholic acid relieves pruritus and lowers serum enzyme levels. Another agent reported to relieve the itching is the opioid antagonist naltrexone
fever, nausea, vomiting, and mid-abdominal pain for the last 24 hours, no appetite, temperature 102.0°F (38.9°C).Abdominal examination reveals decreased bowel sounds and tenderness more pronounced on the right than the left
The diagnosis is made based on clinical findings and graded compression ultrasonography that is sensitive and specific especially before 35 weeks gestation. This noninvasive procedure should be considered first in working up suspected acute appendicitis.
Magnesium sulfate
In addition to discontinuing the magnesium sulfate, she needs a dose of calcium gluconate to restore her respiratory function. The classic signs of magnesium toxicity include muscle weakness and loss of deep tendon reflexes, nausea, and respiratory depression. If magnesium is given in high doses, cardiac arrest is possible.
At a magnesium level of 11 mEq/L, respiratory depression is most likely to occur. The therapeutic magnesium level is between 4-7 mEq/L. Seizures are prevented by the use of magnesium. Loss of deep tendon reflexes occurs at a level of 7-10 mEq/L. Cardiac arrest may occur at a level of 15 mEq/L.
Used for eclampsia also
Preeclampsia
Risk factors
Regardless of disease severity, the only definitive therapy for preeclampsia is delivery of the fetus and placenta. This solution can occasionally be delayed in the setting of stable disease (mild or severe) when it occurs at an extremely early gestational age. Fluid management must be monitored closely in this person. Magnesium sulfate is the mainstay of therapy during labor and for 24 hours postpartum to lower the seizure threshold in women with severe disease.
It is related to race, ethnicity and genetic predisposition. Environmental factors are also likely to play a role. Other risk factors for preeclampsia include a previous history of the disease, chronic hypertension, multifetal pregnancy and molar pregnancy. In addition, patients at extremes of maternal age or with diabetes, chronic renal disease, antiphospholipid antibody syndrome, vascular or connective tissue disease or triploidy are at increased risk for developing preeclampsia
Contraindications to expectant delivery when preeclampsia with severe features
Thrombocytopenia
HELLP syndrome
HELLP syndrome is a disease process in the spectrum of severe preeclampsia. The acronym stands for “hemolysis, elevated liver enzymes, low platelets” and can lead to swelling of the liver capsule and possibly liver rupture. It may or may not be accompanied by right upper quadrant pain. It is possible to only have thrombocytopenia and elevated transaminases without clear hemolysis (elevated bilirubin and anemia), especially if a diagnosis is made early.
Placenta abruption
tachysystole on tocometer and evidence of fetal anemia (tachycardia and sinusoidal heart rate pattern) on the heart rate tracing. Hypertension and preeclampsia are risk factors for abruption
Antihypertensives in pregnancy
indicated for blood pressures persistently greater than 160 systolic and 105 diastolic. First-line agents include hydralazine (a direct vasodilator) 5 mg IV followed by 5-10 mg doses IV at 20-minute intervals (maximum dose = 40 mg); or labetalol (combined alpha & beta-adrenergic antagonist) 10-20 mg IV followed by 20 mg, then 40 mg, then 80 mg IV every 10 minutes (maximum dose = 220 mg). The goal is not a normal blood pressure, but to reduce the diastolic blood pressure into a safe range of 90-100 mmHg to prevent maternal stroke or abruption, without compromising uterine perfusion.
Rh neg mom and rh pos baby, refuse rho gham, risk of isoimmunization (forming Ab to baby)
The risk of isoimmunization is 2% antepartum, 7% after full term delivery, and 7% with subsequent pregnancy so less than 20% total. While 75% of all gravidas have evidence of transplacental hemorrhage during pregnancy or immediately after delivery, 60% of these patients have
Noninvasive technique to detect fetal anemia
Noninvasive diagnosis of fetal anemia can be performed with Doppler ultrasonography. The use of middle cerebral artery peak systolic velocity in the management of fetuses at risk for anemia because of red cell alloimmunization (immune response to foreign antigens after exposure to genetically different cells or tissues) has emerged as the best test for the noninvasive diagnosis of fetal anemia. All the other listed tests are for assessment of fetal well-being and non-specific to detect fetal anemia.
Immune hydrops fetalis is most often a complication of a severe form of Rh incompatibility
Fetal hydrops is easily diagnosed on ultrasound. It develops in the presence of decreased hepatic protein production. It is defined as a collection of fluid in two or more body cavities, such as ascites, pericardial and/or pleural fluid and scalp edema. On occasion, when extramedullary hematopoiesis is extensive, there will be evidence of hepatosplenomegaly. Placentomegaly (placental edema) and polyhydramnios are also seen on ultrasound
Rhogam
Thirty (30) cc of fetal blood is neutralized by the 300 micrograms dose of RhoGAM. At 28-weeks gestation, 300 micrograms of Rh-immune globulin is routinely administered after testing for sensitization with an indirect Coombs’ test. Administration is given following amniocentesis at any gestational age.
The current recommendations for Rh-negative women without evidence of Rh immunization is prophylactically at 28-weeks gestation (after an indirect Coombs’ test), and within 72 hours of delivering an Rh-positive baby, following spontaneous or induced abortion, following antepartum hemorrhage and following amniocentesis or chorionic villus sampling. If the father of the fetus is known to be Rh-negative, RhoGAM is not necessary since the fetus will be Rh-negative and not at risk for hemolytic disease.
