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EndoRepro 2 Exam 1 > Clin: Obstetric Complications - Wootton > Flashcards

Clin: Obstetric Complications - Wootton Flashcards

1
Q

birth that occurs after 20 weeks, but before 36.6 weeks gestation

A

preterm birth

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2
Q

uterine contractions accompanied with cervical change or cervical dilation 2cm and/or 80% effaced

A

labor

- preterm if 20-36 weeks

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3
Q

what is the leading cause of infant mortality?

A

preterm labor

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4
Q

what are the risk factors for PTL?

A
  • african american
  • decreased access to prenatal care
  • high stress levels, poor nutrition
  • previous hx of PTL
  • bleeding in first trimester (inflammatory response)
  • UTI/genital tract infections
  • polyhydramnios (AFI greater than 20)
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5
Q

what are the four main causes of PTL?

A
  1. infection
  2. placental-vascular
  3. psychosocial stress and work strain
  4. uterine stretch (polyhydramnios, multiple babies)
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6
Q

what infections are associated with preterm delivery? (4)

A
  • bacterial vaginosis
  • GBS
  • gonorrhea/chlamydia (link b/w infection and progressive changes in cervical length)
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7
Q

when is it important to use US for routine screening of cervical length?

A

with hx of PTL or cervical procedure (LEEP or CKC)

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8
Q

what is another screening tool for cervical length?

A

fetal fibronectin (FFN)

  • released from basement membrane of fetal membranes
  • released in response to disruption of membranes as with uterine activity, cervical shortening, or infection
  • negative predictive value is GOOD, positive predictive value is LOW
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9
Q

alteration of what 3 factors may result in poor fetal growth?
- risk factors for PTL as well as growth restriction and preeclampsia

A
  • immunologic
  • vascular
  • low resistance connection of spiral arteries
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10
Q

cortisol stimulates early placental corticotrophin-releasing hormone (CRH) gene expression and increased CRH levels are known to do what?

A

assist in labor at term

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11
Q

what hormone class affects blood flow and causes uterine contractions?

A

catecholamines

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12
Q

what are the two main risk factors for uterine stretch?

A
  • polyhydramnios

- multiple gestations

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13
Q

what two factors must be present in order to dx PTL?

A
  1. uterine contractions

2. cervical change, cervical dilation of 2cm or greater and/or 80% effacement

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14
Q

what are the sx of PTL?

A

menstrual like cramping, low/dull backache, pelvic pressure, increase in discharge/bloody discharge and uterine contractions

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15
Q

hydration and bedrest can help resolve what in 20% of patients?

A

contractions

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16
Q

what is the management of PTL?

A
  • GBS culture (give penicillin if needed)
  • CBC, UA, urine culture
  • US (for fetal presentation, growth, amniotic fluid volume, rule out congenital anomalies)
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17
Q

what meds can be given in PTL?

A
  • MgSO4
  • nifedipine
  • prostaglandin synthetase inhibitors (indomethacin - only if < 32 weeks)
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18
Q

what is the drug of choice (arguably) in US?

A

MgSO4

  • acts on cellular level, competes with calcium for entry into the cell
  • may offer prevention against cerebral palsy
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19
Q

what are the side effects of MgSO4 on mom?

A
  • warmth, flushing
  • NV
  • respiratory depression
  • cardiac conduction defects and arrest at high serum levels
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20
Q

what are the side effects of MgSO4 on baby?

A
  • loss of muscle tone
  • drowsiness
  • lower APGAR scores (worse on premature infants)
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21
Q

oral agent effective in suppressing preterm labor

  • minimal maternal and fetal side effects (HA, flushing, hypotension, tachycardia)
  • inhibits slow, inward current of calcium during the second phase of action potential
  • may replace MgSO4 as drug of choice
A

nifedipine

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22
Q

inhibits prostaglandin production that induce myometrial contractions
- used on short term basis (mostly for extreme prematurity)

A

prostaglandin synthetase inhibitors

- indomethacin most commonly used (orally or rectally)

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23
Q

what are the side effects of indomethacin?

A

can result in oligohydramnois (decreases fetal renal function)

  • can cause premature closure of fetal ductus arteriosus -> result in pulmonary HTN and heart failure
  • infants exposed to indomethacin are at greater risk of necrotizing enterocolitis, intracranial hemorrhage
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24
Q

used to mature the fetal lung

  • reduces motality and incidence of RDS and intraventricular hemorrhage
  • given between 24 and 34 weeks
  • either 2 doses of betamethasone, or 4 doses dexamethasone q 12 hrs
A

glucocorticoids

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25
Q

what is the rescue dose of corticosteroids?

A

single course of betamethasone is recommended for pregnant women between 34 and 37 weeks gestation, at risk of preterm birth within 7 days, and who have not received a previous course of antenatal corticosteroids

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26
Q

what is the recommended delivery method for preterm infants?

A

if vertex -> vaginal

if breech -> c-section (d/t increased risk of cord prolapse)

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27
Q

what is the most recent intervention to prevent PTL?

A

progesterone (IM) given 16-36 weeks

  • vaginal progesterone used in women with shortened cervix
  • arabin pessary (a little donut-shaped thing that keeps the cervix closed)
28
Q

why should you not check the cervix of a presumed ruptured PRETERM patient?

A

it increases the risk of infection, especially with the prolonged latency before delivery

29
Q

how do you confirm PPROM?

A

sterile speculum

  • look for pooling (around cervix)
  • nitrazine paper (turns blue)
  • ferning on microscopy sample
30
Q

what can cause a false positive on nitrazine paper?

A
  • urine
  • semen*
  • cervical mucous
  • blood
  • vaginitis
31
Q

what can cause a false negative on nitrazine paper?

A
  • remote PROM with no remaining fluid

- minimal leakage

32
Q

what does an intact amnoitic sac provide a barrier to?

A

infection!

- prevents chorioamnionitis (associated with 30% of preterm deliveries)

33
Q

what are the maternal risks of PPROM?

A
  • endomyometritis (infection of uterus postpartum)
  • sepsis
  • failed induction due to unfavorable cervix
34
Q

what 4 factors influence management of PPROM?

A
  1. gestational age at time of rupture
  2. amniotic fluid index
  3. fetal status
  4. maternal status
35
Q

what is the concern if ROM occurs before 24 weeks?

A

pulmonary hypoplasia and fetal structural abnormalities from position

36
Q

what is the concern if amniotic fluid index is less than 5cm?

A

considered oligohydramnios -> lungs won’t develop properly

37
Q

what is the expectant management of PPROM?

A

goal is to continue pregnancy until lung profile is mature

  • most deliver at 34 weeks regardless of fetal lung maturity
  • must monitor for signs/sx of chorioamnionitis
38
Q

how is dx of chorioamnionitis made?

A
  • maternal temp > 100.4
  • fetal or maternal tachycardia
  • tender uterus
  • foul smelling amniotic fluid/purulent discharge
39
Q

what is abx regimen for PPROM?

A

48 hr course IV ampicillin and erythromycin/azythromycin followed by 5 days of amox and erythromycin
- attempt to prolong latency

40
Q

when does ACOOG recommend using steroids?

A

up to 34 weeks to reduce risk of RDS

41
Q

when the birth weight of a newborn is below the 10% for a given gestational age

A

IUGR

42
Q

birth weight at the lower extreme of a normal birth weight distribution

A

small for gestational age (SGA)

43
Q

what are growth restricted fetuses at risk for?

A
  • meconium aspiration
  • hypoxia
  • still birth
  • polycythemia
  • hypoglycemia
  • cognitive delay
44
Q
  • poor nutritional intake/low maternal body weight
  • cigarette smoking
  • drug abuse
  • alcoholism
  • cyanotic heart dz
  • pulmonary insufficiency
  • antiphospholipid syndrome
  • hereditary thrombophilias
  • collagen vascular disease/autoimmune
A

maternal causes of IUGR

45
Q

insufficuent substrate transfer through placenta as well as defective trophoblast invasion

A

placental causes of IUGR

46
Q

what conditions can result in placental insufficiency?

A
  • HTN
  • renal dz
  • placental or cord abnormalities (vilamentous cord)
  • pre-existing diabetes
47
Q
  • inadequate or altered substrate
  • intrauterine infections
  • listeriosis
  • TORCH (toxoplasmosis, rubella, CMV, herpes, syphillis)
  • multiple gestations
A

fetal causes of IUGR

48
Q

what should always be performed to diagnose IUGR?

A
  • *doppler study**
  • checks flow of blood to see if adequate amount is getting to baby
  • also do US, PE for fundal height, amniocentesis, cord blood sampling
49
Q

what is the primary screeing tool of IUGR?

A

fundal height measurement

50
Q

what should you do if fundal height lags more than 3cm behind gestational age?

A

order US

51
Q

what is measured on US to get fetal weight?

A
  • biparietal diameter (BPD)
  • head circumference
  • abd circumference
  • head-abd circumference
  • femoral length
  • amniotic fluid volume
  • fetal weight
52
Q

what is the management of IUGR?

A
  • NST twice weekly
  • biophysical profile
  • doppler studies of umbilical artery
53
Q

patient in lateral tilt position, FHR monitored with external transducer

  • tracing observed for FHR accelerations that peak at least 15bpm above baseline and last 15 seconds
  • may be necessary to continue tracing for 40 minutes or longer to take into account variations of fetal sleep-wake cycle
A

nonstress testing (NST)

54
Q

if you suspect IUGR, and US confirms, >38-39 weeks?

A

> 38-39 weeks -> DELIVER

55
Q

you suspect IUGR, and US confirms, but <38-39 weeks:

  • if antenatal testing normal?
  • if antenatal testing abnormal?
A
  • if normal -> continue pregnancy

- if abnormal -> DELIVER

56
Q

why do you need to monitor neonatal blood glucose and respiratory status after delivery of IUGR infant?

A
  • blood glucose: neonates have less hepatic glycogen stores

- respiratory status: RDS more common

57
Q

what are IUGR infants more at risk for developing?

A

adult onset diabetes, HTN, CAD

58
Q

what is postmaturity syndrome?

A

related to aging and infarction of the placenta

- loss of subcutaneous fat, long fingernails, dry and peeling skin and abundant hair loss

59
Q

if not affected by placental insufficiency, what are post-term pregnancies at risk for developing?

A

fetal macrosomia (>4500g)

  • abnormal labor
  • shoulder dystocia
60
Q

what can cause post-term pregnancy?

A
  • unsure dates
  • fetal adrenal hypoplasia
  • anencephalic fetuses (neural tube defect missing part of brain, skull and scalp)
  • placental sulfatase def (x-link dz prevents conversion of sulfated estrogen precursors)
  • extrauterine pregnancy
61
Q

what is management of post-term pregnancy in the 41st week?

A
  • begin antenatal testing to include twice weekly NST and BPP
  • if testing abnormal or oligohydramnios -> INDUCE

induction in 41st week is preferred plan

62
Q

what is management of post-term pregnancy in the 42nd week?

A

INDUCE

63
Q

fetal death after 20 weeks gestation, but before the onset of labor

A

intrauterine fetal demise (IUFD)

  • most cases unknown etiology (>50%)
  • HTN/diabetes/SLE/thyroid
  • cholestasis of pregnancy
  • umbilical cord abnormalities
64
Q

what is the management of IUFD?

A
  • watch: up to 28 weeks gestation, spontaneous labor will occur within 2-3 weeks of fetal demise
  • induce: most will require cervical ripening
  • monitor coagulopathy: at risk of disseminated intravascular coagulopathy -> collect CBC, fibrinogen, PT/PTT
65
Q

what should you search for after IUFD?

A
  • TORCH titers
  • parvovirus studies
  • listeria cultures
  • anticardiolipin Ab
  • fetal xsome studies
  • fetal autopsy

EndoRepro 2 Exam 1 (25 decks)

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