Complicated Pregnancy Flashcards
what is a spontaneous abortion (miscarriage)?
pregnancy terminating before 20 weeks
what is abortus?
fetus lost before 20 weeks, less than 500g or 25cm
how are spontaneous abortions defined?
whether any or all products of conception have passed and whether or not cervix is dilated
what is a threatened abortion?
bleeding with or w/out cramping with a closed cervix
what is an inevitable abortion?
bleeding with or without cramping with dilation of cervix
what is a complete abortion?
all products have been expelled
what is a missed abortion?
embryo/fetus dies but products of conception (POC) are retained
what is an incomplete abortion?
some portion of POCs remain in the uterus
what is a habitual abortion?
3 or more abortions in succession
sx’s of abortion?
bleeding, cramping, abd pain, decreased pregnancy sx’s
PE for abortion?
vitals to r/o shock, febrile illness, pelvic exam
labs for abortion?
quantitative B-hcg, CBC, blood type and screen
what does US for abortion assess?
assess fetal viability and placentation
tx for abortion?
stabilize if hypotensive
monitor bleeding and for signs of infection
send tissue to pathology to assess for POC
+/- D&C or prostaglandins (e.g. misoprostol)
RhoGAM for Rh-negative pts
when do 2nd trimester abortions occur?
12-20 weeks gestation
causes of 2nd trimester abortions?
infection, maternal uterine or cervical anatomic defects
maternal systemic disease, exposure to fetotoxic agents, trauma, PTL and incompetent cervix
D&C vs D&E (dilation and evacuation) as tx for 2nd trimester abortions?
16-24 weeks: either D&E or induction of labor
what is incompetent cervix? when does it occur?
cervical insufficiency, painless dilation and effacement of cervix (in 2nd trimester)
what is exposed in incompetent cervix? risk of?
fetal membranes exposed to vaginal flora and risk of increased trauma (infection, vaginal discharge, ROM)
what can incompetent cervix cause?
2nd trimester losses
what are the risk factors for incompetent cervix?
cervical surgery or trauma, uterine anomalies, hx of DES exposure
dx of incompetent cervix?
noted on routine exam, US, or in setting of bleeding, vaginal discharge, or ROM
tx of incompetent cervix? (HINT: cerclage, previable, viable)
cerclage: suture placed vaginally around the cervix at cervical-vaginal junction or at the internal os (want to get close to cervix)
previable: expectant management and elective termination
viable: betamethasone, strict bed rest, tocolysis if preterm contractions
what does betamethasone help the fetus with?
helps fetal lung maturity
when is emergent cerclage a tx?
in previable pregnancy and incompetent cervix
when is elective cerclage a tx?
if incompetent cervix suspected in previous pregnancy loss
placed b/w 12-14 weeks, removed b/w 36-38 weeks
when is trans abdominal cerclage a tx?
if both type of vaginal cerclage have failed (emergent and elective)
- placed at level of internal os
- PT MUST DELIVER VIA C/S
what is an ectopic pregnancy? most common where?
pregnancy that implants outside the uterus
M/C in the Fallopian tube
what increases likelihood of ectopic pregnancy?
assisted fertility, STIs, PID,
if pt is pregnant and present with vaginal bleeding and abdominal pain, what should you assess for?
ectopic pregnancy
rupture ectopic pregnancy is what type of emergency? can lead to what?
TRUE EMERGENCY
can lead to rapid hemorrhage, shock, and even death
Ectopic Pregnancy risk factors?
hx of STIs or PID, tubal surgery, endometriosis, current use of exogenous hormones, in vitro fertilization, use of IUD
most common sx’s of ectopic pregnancy?
unilateral pelvic/abdominal pain and vaginal bleeding
PE of ectopic pregnancy?
adnexal mass, uterus small for GA, bleeding from cervix
what is the B-Hcg level like in ectopic pregnancy?
does not rise appropriately - doesn’t double
dx of ectopic pregnancy? what should B-hCG levels be in ectopic pregnancy?
serial B-hCG and Transvaginal US
B-hCG levels fail to double
what does transvaginal US show for ectopic pregnancy?
adnexal mass, extrauterine pregnancy, RING OF FIRE!
signs of ruptured ectopic pregnancy?
hypotensive, unresponsive, peritoneal irritation secondary to hemoperitoneum
what is the tx of RUPTURED ectopic pregnancy?
stabilize pt first with 2 large bore IVs with fluid, blood, pressers
EXPLORATORY LAPAROTOMY
RhoGAM if mom is Rh negative
what does exploratory laparotomy do for tx of rupture ectopic pregnancy?
controls bleeding and removes ectopic pregnancy (salpingostomy or salpingectomy)
what is the tx of UNRUPTURED ectopic pregnancy?
METHOTREXATE!!!
RhoGAM if Rh negative
Laparotomy if pt prefers surgery
what are the indications to use methotrexate for tx of UNRUPTURED ectopic pregnancy?
hemodynamically stable, early gestation <4cm without FH, B-hCG <5,000, no fetal tones
when do you repeat B-hCG levels when treating unruptured ectopic pregnancy?
repeat B-hCG levels on day 4 and 7 - should fall by 15%
-b/w dat 1 and day 4, levels may go up
when do you give second dose of methotrexate for tx of unruptured ectopic pregnancy?
if B-hCG does not fall by 15%
what is heterotopic pregnancy?
Rare co-existence of intrauterine with ectopic pregnancy
heterotopic pregnancy most common with what pregnancies?
assisted pregnancies
visualization of true intrauterine pregnancy with heterotypic pregnancy doesn’t exclude what?
ectopic pregnancy
Rh negative women don’t have what antibody?
anti-D
if woman is Rh negative and losses baby or delivers baby, what can happen with Rh positive blood from fetus?
Rh positive blood from fetus or placenta pass retrograde into maternal system causing “sensitization”
what is gestational trophoblastic disease?
diverse group of interrelated disease resulting in abnormal proliferation of placental tissue
types of gestational trophoblastic disease? (HINT: 4)
Molar pregnancies (benign) - M/C
Persistent/invasive moles
Choriocarcinoma
Placental site trophoblastic tumors (very rare)
what is the most common gestational trophoblastic disease?
molar pregnancies (benign)
what develops in gestational trophoblastic disease? what can the neoplasms produce? what is a tumor marker for efficacy of tx? extremely sensitive to what tx?
Maternal tumors result from abnormal fetal tissue
Neoplasms able to produce hCG - tumor marker and tool for measuring efficacy of tx
Extremely sensitive to chemotherapy - most curable
what are hydatidiform moles? types?
molar pregnancies
types:
- complete (M/C)
- partial
what is a COMPLETE molar pregnancy?
molar degeneration with no associated fetus
what is a PARTIAL molar pregnancy?
molar degeneration in association with an abnormal fetus
molar pregnancy risk factors?
teenager, AMA
prior hx of GTD
Nulliparity, Infertility, or OCP use
***Diet low in beta-carotene, folic acid, and animal fat
Smoking
what features are present in a PARTIAL molar pregnancy? (fetus, amnion/fetal RBCs, villous edema, trophoblastic proliferations, dx, uterine size)
fetus: abnormal fetus
amnion/fetal RBCs: present
villous edema: focal
trophoblastic proliferation: focal, flight-mod
dx: MAB
Uterine size: small uterine size of GA
what features are present in a COMPLETE molar pregnancy? (fetus, amnion/fetal RBCs, villous edema, trophoblastic proliferations, dx, uterine size)
fetus: none
amnion/fetal RBCs: none
villous edema: diffuse
trophoblastic proliferations: difuse, slight to severe
dx: molar gestation
uterine size: large uterine size for GA
when is dx made for molar pregnancies?
in 1st trimester
sx’s for molar pregnancies?
Irregular or heavy vaginal bleeding
-symptoms attributed to high hCG levels (hyperemesis, preeclampsia, hyperthyroidism)
what are hCG levels like in molar pregnancies?
HCG levels will rise incorrectly or be abnormally high when compared to pregnancy size
what is pathognomonic for molar pregnancy?
preeclampsia occurring prior to 20 weeks in absence of chronic HTN
physical exam for molar pregnancy?
Preeclampsia, hyperthyroidism, uterine size greater than GA,
US for molar pregnancy?
Molar tissue identified as diffuse mixed echogenic pattern replacing the placenta
***cluster of grape-like molar clusters extruding from cervix
what is the main tx for molar pregnancy?
immediate removal of uterine contents by suction D&C
if mom has pre-eclampsia and molar pregnancy how do you tx? what about if hCG-induced hyperthyroidism?
use antihypertensives to decrease risk of maternal stroke for pre-eclampsia
use BB’s to prevent thyroid storm
what is an alternate therapy for tx of molar pregnancies if woman has completed child bearing?
hysterectomy
follow-up for molar pregnancies?
Serial hCG titers
- weekly until negative for 3 weeks
- average time to normalization 14 weeks for complete and 8 weeks for partial (compared to 2 to 4 normally)
plateau or rise in hCG or presence of hCG greater than 6 months after suction D&C tx for molar pregnancy means what?
persistent/invasive disease
how long should pregnancy be prevented after tx of molar pregnancy and how?
for 1 year with OCPs
if woman with previous molar pregnancy gets pregnant again how is she monitored?
with early US and hCG levels to exclude recurrent disease
who can get malignant GTDs?
Persistent/invasive moles (75%)
also choriocarcinoma, but less common
50% of cases of malignant GTD occurs when?
months to years after a molar pregnancy
malignant GTD classifications?
Nonmetastatic - disease confined to uterus
Metastatic - progressed beyond uterus
what is good prognosis for metastatic malignant GTDs?
short duration (<4 months)
serum hCG < 40,000
no mets to brain or liver, no significant prior chemo
what is poor prognosis for metastatic malignant GTDs?
Long duration (>4 months)
Serum hCG >40, 000
Metastases to brain or liver
Unsuccessful prior chemotherapy
GTD following term pregnancy
persistent/invasive mole occurs most commonly when?
after molar pregnancy
Dx of persistent/invasive mole? characterized by? where can proliferation go to? do they metastasize? do they spontaneous regress?
hCG level plateau or rise, pelvic u/s may show one or more intrauterine masses with high vascular flow
Characterized by penetration of large, swollen (hydropic) villi and trophoblasts into myometrium
Proliferation can go to uterine vasculature
Rarely metastasize
Capable of spontaneous regression
tx of persistent/invasive mole?
usually single agent chemo with Methotrexate or actinomycin-D
follow-up for persistent/invasive mole?
Serial hCG and reliable contraception
what is a choriocarcinoma?
RARE malignant necrotizing tumor (type of GTD)
Pure epithelial tumor invade uterine wall/vasculature causing destruction of tissue, necrosis and potentially severe hemorrhage
are choriocarcinomas metastatic?
yes, often metastatic and spread thru blood
what is one of the leading causes of cancer of women in Africa?
choriocarcinoma
dx of choriocarcinomas?
irregular uterine bleeding or signs of metastatic disease
need hCG levels, pelvic US, CXR, CT or MRI of chest, abdomen/pelvis, brain
what are hCG levels like in choriocarcinomas?
VERY HIGH -> 100,000’s
tx for choriocarcinomas?
chemotherapy - single or multiagent
what are placental site trophoblastic tumors (PSTT)?
Extremely rare tumors that arise from placental implantation site
dx of placental site trophoblastic tumors (PSTT)?
irregular bleeding, enlarged uterus, chronic LOW hCG levels
histology shows absence of villi
tx for placental site trophoblastic tumors (PSTT)?
NOT sensitive to chemo
HYSTERECTOMY!!! - followed my multi agent chemo to prevent recurrence
what is complete placenta previa?
placenta completely covers the internal os
what is partial placenta previa?
placenta covers a portion of the internal os
what is marginal placenta previa?
the edge of the placenta reaches the margin of the os
what is low-lying placenta?
placenta implanted in lower uterine segment in close proximity to os
what is vasa previa?
rare, a fetal vessel may lie over the cervix
placenta previa results from what events?
events that prevent normal progressive development of the lower uterine segment
risk factors for placenta previa?
prior C-section or uterine surgery (myomectomy)
erythroblastosis
smoking
AMA
what fetal complications are associated with placenta previa?
Preterm delivery, PPROM (preterm-premature ROM), IUGR (IU growth restriction), malpresentation, vasa previa, congenital abnormalities
what is placenta accreta? caused inability of placenta to what? can result in what?
abnormal invasion of placenta into the uterine wall
causes inability of placenta to properly separate from uterine wall after delivery of fetus
can result in profuse hemorrhage, shock, and significant maternal morbidity and mortality
what is accreta?
superficial invasion of placenta into myometrium
what is increta?
placenta invades myometrium
what is percreta?
placenta invades through myometrium into uterine serosa
5% of placenta previa’s complicated by what?
associated placenta accreta
sx’s of placenta previa?
3rd trimester sudden onset PAINLESS bleeding - sentinel bleed
NO ABD PAIN
70% of women with placenta previa have recurrent bleeding event, which means what?
ACTION REQUIRED!!!
what is C/I in placenta previa?
VAGINAL EXAM -> WILL DISRUPT PLACENTA!!!
dx of placenta previa?
Pelvic US
tx for placenta previa?
pelvic rest (no intercourse)!!!
+/- bed rest
C-section at 36-37 weeks after lung maturity confirmed by amnio
what is placental abruption? results in what? when do 50% occur?
Premature separation of normally implanted placenta from uterine wall
Results in hemorrhage between uterine wall and placenta
50% occur before labor and after 30wks
large placental abruptions may result in what?
premature delivery, uterine tetany, DIC and hypovolemic shock
what is the MOST COMMON CAUSE of placental abruption?
maternal HTN
precipitating factors of placental abruption?
trauma, MVA, sudden uterine volume loss, delivery of 1st twin, ROM w/ polyhydramnios, PPROM
what is a concealed hemorrhage with placental abruption?
bleeding confined within uterine cavity (in 20%)
what is a revealed or external hemorrhage with placental abruption?
blood dissects downward toward cervix (in 80%)
fetal mortality rate with placental abruption? how do they die?
Fetal mortality from 30-80%
-Hypoxia
what is the classic presentation of placental abruption?
3rd trimester vaginal bleeding associated with SEVERE abdominal pain and/or frequent, strong ctx
PE for placental abruption?
vaginal bleeding, firm and tender uterus (rigid uterus)
type of contraction in placental abruption?
tetanic contractions
fetal heart rate in placental abruption?
recurrent late decals in fetus (bradycardia) -> hypoxia
dx of placental abruption?
clinical and/or US
Concealed bleeding: btw placenta and myometrium í thrombocytopenia and PAIN
classic sign at c-section for placental abruption?
Couvelaire uterus (blood from abruption penetrates uterine musculature)
tx for placental abruption?
hospitalize and stabilize pt, IV access
continuous EFM (fetal heart monitoring)
prepare for future hemorrhage - anti-shock measures (large-bore IV, LR, cross-matched blood)
prepare for preterm delivery (use betamethasone before 34 weeks +/- tocolysis)
vag delivery preferred if safe
deliver if bleeding is life threatening or fetal testing non-reassuring
what is premature rupture of membranes (PROM)?
Rupture of membranes before the onset of labor
what is preterm rupture of membranes?
Rupture of membranes before week 37
what is PPROM?
pre-term premature rupture of membranes
what is prolonged ROM?
Rupture of membranes lasting longer than 18hr before delivery
without intervention most women will go into labor when with ROM?
50% within 24hrs, 75% within 48hrs
what is the most common cern with PROM?
chorioamnionitis
risk of what increases with length of PROM (prolonged PROM)?
risk of infection
if ROM occurs after 36 weeks labor is what?
induced/augmented
what does ACOG recommend with PROM?
immediate induction
what is gestational HTN? what is their BP? who does it occur in?
HTN WITHOUT proteinuria develops after 20 wks and blood pressure levels return to normal postpartum
Systolic BP≥140 mmHg or diastolic BP≥90 mmHg
occurs in women with previously normal BP
what is preeclampsia? what is proteinuria defined as?
HTN WITH proteinuria that occur after 20 wks in woman with previously normal BP
Proteinuria is defined as urinary excretion of ≥0.3 g protein in a 24-hour urine specimen
maternal complications of preeclampsia?
Seizure, cerebral hemorrhage, DIC and thrombocytopenia, renal failure, hepatic rupture or failure, pulmonary edema, uteroplacental insufficiency, placental abruption, increased premature deliveries and c/s
fetal complications of preeclampsia?
Premature birth, intrapartum fetal distress, stillbirth, asymmetric or symmetric SGA fetus
RF’s for preeclampsia?
chronic HTN, chronic renal disease, collagen vascular disease (SLE)
DM, AA, maternal age <20 or >35
nulliparity, multiple gestation, abnormal placentation, prior PEC
New paternity, female relative with PEC, mother-in-law with PEC (risk here is related to dad, so if different dad, might not get it)
what is the ultimate treatment for preeclampsia?
DELIVERY - do vaginal delivery if mom is stable (safer!!!)
induction of labor is tx of choice for preeclampsia in who?
Term, unstable preterm, or pregnancies with evidence of fetal lung maturity - attempt vaginal delivery
tx for preeclampsia in stable preterm pts?
Bed rest, expectant management, betamethasone (promote lung maturity)
what med is given to mom w/preeclampsia during labor, delivery, and for 12-24hrs postpartum? for what?
Mag sulfate for seizure ppx
what does Mag sulfate do to labor induction process?
slows the labor induction process, so if stable, give Mag sulfate once active labor has started
what do you give pt for magnesium toxicity?
calcium gluconate
when is Mag sulfate given for preeclampsia?
during labor, delivery, and for 12-24hrs postpartum
what is superimposed preeclampsia?
New-onset proteinuria in a woman with CHTN, a sudden increase in proteinuria if already present in early gestation, a sudden increase in HTN, or development of HELLP syndrome
what women may have superimposed PEC?
Women with CHTN who develop HA, scotoma, or epigastric pain
how do you control chronic HTN in superimposed PEC?
labetalol or nifedipine
how do you treat superimposed PEC?
like PEc
stable -> manage expectantly
unstable -> mag sulfate and deliver
when is preeclampsia considered severe? (HINT: criteria)
Preeclampsia is considered severe if one or more of the following criteria are present:
- BP ≥160 mmHg systolic or ≥110 mmHg diastolic on 2 occasions at least 6 hours apart while the patient is on bed rest
- Proteinuria of ≥5 g in a 24-hour urine specimen or ≥3+ on two random urine samples collected at least 4 hours apart
- Oliguria of less than 500 mL in 24 hours
- Cerebral or visual disturbances
- Pulmonary edema or cyanosis (occurs quickly)
- Epigastric or right upper-quadrant pain
- Impaired liver function (LFTs double or triple)
- Thrombocytopenia
- Fetal growth restriction (Sign that BP is affecting the baby)
severe pre-eclampsia can quickly turn into what?
eclampsia
what is eclampsia?
New-onset grand mal seizures in a woman with preeclampsia
tx for eclampsia?
- Seizure management
- BP control -> carvedilol or hydralazine
- Prophylaxis against further convulsions
- Mag sulfate from time of dx thru 12-24 hrs postpartum
when should delivery be initiate in eclampsia?
after eclamptic pt has been stabilized and convulsions have been controlled
what is common in fetal heart rate with eclampsia? tx?
deceleration - tx by stabilizing mother
If get mom to stop seizing -> fetal HR should come back up -> then do delivery
what is HELLP syndrome?
hemolytic anemia, elevated liver enzymes (AST/ALT), low platelets (thrombocytopenia <100,000)
what may pts with HELLP syndrome develop?
DIC or hepatic rupture
characterization of hemolytic anemia with HELLP syndrome/
shistocytes on peripheral blood smear, elevated LDH, elevated total bilirubin
50% of pts with acute fatty liver of pregnancy will also have?
HTN and proteinuria
dx of acute fatty liver of pregnancy?
Differentiate from HELLP via labs showing elevated ammonia, BS<50, reduced fibrinogen and antithrombin III
tx of acute fatty liver of pregnancy?
mostly supportive, liver transplant prn, occasionally spontaneous resolution
when does gestational diabetes first manifest?
during pregnancy
pathophysiology of GDM?
Human placental lactogen and other hormones produced by placenta act as anti-insulin agents
when is GDM apparent and why then?
Hormones increase in volume with size and function of placenta, thus not usually apparent until late 2nd or early 3rd trimester
increased risk of what with GDM?
***Fetal macrosomia
Birth injuries
Neonatal hypoglycemia
Hypocalcemia, hyperbilirubinemia, polycythemia
once have GDM is the risk of developing T2DM after delivery high?
YES!!!!
when do you screen for GDM? test when?
b/w 24-28 weeks - test at 28 weeks
what are risk factors for GDM? when do you screen pts with these risk factors?
AA, Hispanic, Asian, Native American
AMA
Obesity
fam hx of DM
previous infant weighing >4,000g
Previous stillborn infant
if woman starting BMI >30 what do you want to do at 1st visit?
glucola - glucose challenge test with glucola drink
what is the GDM screening?
glucose loading test (GLT) and glucose tolerance test (GTT)
what is the glucose loading test? when to proceed to GTT?
50g oral glucose loading dose and check serum glucose 1hr later
> 140mg/dL proceed to GTT
what is the glucose tolerance test?
DIAGNOSTIC!!!
-Fasting serum glucose
-100g oral glucose loading dose
-Serum glucose at 1, 2, and 3hrs after oral dose
-Elevation of 2 or more values = GDM
-Fasting >95mg/dL, 1 hr >180mg/dL, 2 hr
>155mg/dL, 3 hr >140mg/dL
GDM tx
diet of 2,200 cal/day (start with diet first)
QID blood sugar testing - take fasting in the morning and 2hr post-meals
Exercise (walking)
if >25-30% of BS values elevated, start INSULIN or PO hypoglycemic agent
true GDM often has what fasting values and postprandial values?
normal fasting values with elevated postprandial values
what are the 2 most common White Classifications for GDM?
Class A1 - GDM; diet controlled
Class A2: GDM; med controlled
if pregnant women in GDM A2 class (on insulin), how do you monitor the fetus?
NST or BPP weekly or bi-weekly starting b/w 32 and 36 weeks
fetal monitoring with US for GDM used for what and when?
for estimated fetal weight b/w 34-37 weeks (b/c of macrosomia)
GDM A1 class and delivery management?
random BS on admission
-if normal, no intervention needed
when do you do induction of labor for GDM? what do you use to maintain BS <120?
at 39 weeks for GDM A2
-Dextrose and insulin drips used to maintain BS <120 mg/dL
if baby of GDM mom weighs >4,000g what is there an increased risk of and what should you avoid?
increased risk of shoulder dystocia
avoid forceps and vacuum
if baby of GDM mom weights >4,500g what should you offer them?
elective C-section delivery
GDM follow-up?
Screen at postpartum visit and yearly thereafter
- Fasting serum blood glucose or 75g 2hr GTT
- Don’t screen immediately post-partum -> do at 6 week follow up
infants of pts with GDM at increased risk of what?
childhood obesity and T2DM
important maternal complication of pregestational DM?
end organ involvement - cardiac, renal, ophthalmic, peripheral vascular, peripheral neuropathy, GI disturbance
fetal complication of pregestation DM?
Macrosomia - traumatic delivery, shoulder dystocia, erbs palsy (nerve damage to arm as a result of hyperextension of neck)
Congenital malformations
Delayed organ maturity
intrauterine fetal demise
what is shoulder dystocia?
Difficulty delivering shoulders after the head of the fetus is delivered
what is stuck in shoulder dystocia?
shoulder bone stuck against pubic bone
what is a common RF for shoulder dystocia?
prolonged 2nd stage of labor
fetal complications of shoulder dystocia?
- Fractures of humerus or clavicle
- Brachial plexus nerve injuries (Erb’s palsy)
- Phrenic nerve palsy
- Hypoxic brain injury
- Death
when is dx of shoulder dystocia made?
when routine obstetric maneuvers fail to deliver the fetus
preparation for shoulder dystocia?
Pt in dorsal lithotomy position, adequate anesthesia, experienced staff, episiotomy prn
will episiotomy help with shoulder dystocia?
not unless trying to get hands in there b/c it is really a bone against bone problem so cutting tissue doesn’t help
what is a sign of shoulder dystocia?
turtle sign
what kind of emergency is shoulder dystocia?
Obstetric emergency!
if shoulder dystocia what is the max time to deliver baby and if go over that time what can happen?
max time is 5 min and if go over then brain death of baby
what are the maneuvers to help with shoulder dystocia?
McRoberts maneuver
Suprapubic pressure
Rubin maneuver
Wood’s corkscrew
what is the McRoberts maneuver for shoulder dystocia?
Sharp flexion of maternal hips to decrease inclination of pelvis and increase AP diameter
Take legs and pull them all the way up to the shoulders
how does suprapubic pressure help with shoulder dystocia? done in conjunction with what maneuver?
Pressure directed at an oblique angle to dislodge anterior shoulder from behind pubic symphysis
Typically done in conjunction with McRoberts
what is the Rubin maneuver for shoulder dystocia?
Place pressure on shoulder and push toward anterior chest wall to decrease bisacromial diameter and free impacted shoulder
Have to put hands ALL the way in -> need to turn shoulder -> NOT just head
what is the wood’s corkscrew for shoulder dystocia?
Apply pressure behind posterior shoulder to rotate infant
other ways to help with shoulder dystocia?
delivery of posterior arm/shouder, fracture fetal clavicle, cut maternal pubic symphysis, Zavanelli maneuver (last line)
when is cutting of the maternal pubic symphysis done for shoulder dystocia?
ONLY IN TRUE EMERGENCY AND DONE IN AFRICA
what is the last line maneuver for shoulder dystocia?
Zavanelli maneuver - putting baby’s head back into pelvic and performing C-section
what is postpartum Hemorrhage (PPH)?
Blood loss >500mL for vaginal delivery and >1,000mL for cesarean delivery
typical blood loss for vagina and c-section?
vagina - 200-300mL
c-section - 800mL
what is early PPH and late/delayed PPH?
Hemorrhage within 1st 24hr - early PPH
Hemorrhage >24hrs - late or delayed PPH
tx of postpartum hemorrhage (PPH)?
Simultaneously investigate cause, start fluid resuscitations, prepare for blood transfusion
blood loss of >2-3L in PPH, may cause pt to develop what? what do you give to treat?
pt may develop consumptive coagulopathy (DIC) - give coagulation factors and platelets
what is Sheehan syndrome?
pituitary infarct d/t PPH
risk factors of PPH?
abnormal placentation, trauma during labor and delivery, uterine atony, coagulation defects
what defines prolonged FHR deceleration?
<110 for longer than 2 mins
etiologies of FHR decelerations?
preuterine, uteroplacental, or postplacental
preuterine etiologies of FHR decelerations?
any event leading to maternal hypotension or hypoxia
seizure, PE, MI
uteroplacental etiologies of FHR decelerations?
abruption, infarction, hemorrhaging previa, uterine hyperstimulation
post placental etiologies of FHR decelerations?
cord prolapse, cord compression, rupture of fetal vessel
tx of FHR decelerations?
reposition mother and O2 via face mask
manage cause
how do you manage cause for FHR decelerations?
- Ephedrine and IVF for maternal hypotension
- Stop oxytocin or tocolytic for uterine hyperstimulation
- C/S for cord prolapse or previa
what is the GREATEST RISK of C-section?
infection or thrombotic events
most common indication for primary C-section?
failure to progress (failure of 3 P’s)
2hrs without cervical change in the setting of adequate uterine contractions in active phase of labor
most common indication for C-section?
previous C-section
maternal indications for C-section
maternal disease (active genital herpes, HIV, cervical ca)
prior uterine surgery (c/s, full-thickness myomectomy)
prior uterine rupture
obstruction of birth canal (fibroids, ovarian tumor)
fetal indications for C-section
non reassuring FHR
cord prolapse
malpresentation (breech, transverse, brow)
multiple gestations
fetal anomalies (hydrocephalus, osteogenesis imperfecta)
what fetal malpresentation need c-section?
breech, transverse, brow
placental indications for C-section
previa, vasa previa, abruption
preparation for C-section?
IV fluids (lactated ringers)
IV abx (cefazolin)
anesthesia
Foley catheter (empty bladder)
local prep (shave, betadine)
what abx is added to cefazolin when doing c-section?
azithromycin when done laboring b/c prevents ascending infections
how are monozygotic (identical) twins made?
Fertilized ovum divides into 2 separate ova
how are dizygotic (fraternal) twins made?
Ovulation produces 2 ova and both are fertilized
what are dizygotic twins?
fraternal twins
what are monozygotic twins?
identical twins
what is a complication of multiple gestation?
Monochorionic (one placenta), diamnionic (two amniotic sacs) twins often have placental vascular communications and can develop twin- to-twin transfusion syndrome (TTTS)
Basically one twin is stealing from the other -> has bad effects for both babies
dx of multiple gestations?
US
Rapid uterine growth, excess maternal weight gain, palpation of 3 or more large fetal parts
what levels are elevated in multiple gestations?
Levels of hCG, human placental lactogen, maternal serum α-fetoprotein all elevated for GA
what does multiple gestations require d/t increased complications?
consultation and co-management with MFM
what is the principle issue with multiple gestations?
mode of delivery
