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Question 1

What is preterm delivery defined as?

Answer 1

Contractions that cause cervical change before 37 weeks of gestation

Question 2

What are the some that can precipitatepreterm delivery?

Answer 2

-previous preterm delivery (recurrence of 17-37%)-infection-uterine overdistention (polyhydramnions, multiple gestations)-vaginal bleeding secondary to placenta previa or abruption

Question 3

What are the risk factors for preterm delivery?

Answer 3

-Non-white race-low socioeconiic status-low BMI-Smoking or cocaine use-DES exposure

Question 4

What is the leading cause ofneonatal morbidity and mortality in developed countries?

Answer 4

Preterm delivery.Accounts for 60-80% of neonatal deaths not related to congenital anomalies

Question 5

What is fetal fibronectin?

Answer 5

Fetal fibronectin is a protein that’s believed to help keep the amniotic sac “glued” to the lining of the uterus.Fetal fibronectin is often present in vaginal discharge before week 22 of pregnancy. Fetal fibronectin also begins to break down and can be detected in vaginal discharge toward the end of pregnancy and can be used as an indication that labor in ineminent

Question 6

What is the main goal of management of preterm labor?

Answer 6

Maintain a pregnancy long enough to ensure lung maturity via corticosteroid administration via tocolytic therpay, such as magnesium sulfate

Question 7

What things can reduce the risk of a preterm delivery?

Answer 7

-•Weekly 17-alpha-hydroxyprogesterone injections between 16 and 36 weeks (40% reduction)-•Tobacco cessation, improving nutritional status, treating infections

Question 8

How does premature rupture of fetal membranes correlate to the inevitabilty of labor?

Answer 8

If PPROM occurs prior to 26 weeks, 50% will enter labor within 1 week, whileif PPROM occurs between 28-34 weeks, 50% will enter labor within 24 hrs while 80-90% will enter labor within 1 week

Question 9

Risk factors for PPROM

Question 10

pPROM is associated with significantly increased morbidity in both the mother and the fetus. How?

Answer 10

It can lead to preterm delivery and the sequelae associated with that, as well increased risk of chorioamnionitis andplacental abruption, as well as:umbilical cord prolapse and Potter sequence as a consequence of oligohydramnios

Question 11

How should the evaulation of a woman with suspected pPROM begin?

Answer 11

You want to look for signs of infection like a febrile state or fundus pain on examination, which might be indications to go ahead and induce labor via C-section. If the mother appears stable, depending on the gestation period, different options must be advised.

Question 12

How can ruptured membranes be confirmed?

Answer 12

A Nitrazine test-This test involves putting a drop of fluid obtained from the vagina onto paper strips containing Nitrazine dye. The strips change color depending on the pH of the fluid. The strips will turn blue if the pH is greater than 6.0. A blue strip means it’s more likely the membranes have ruptured. ORFern testing to look for cervical fluid crystallization

Question 13

What should be done if membranes rupture after 34 weeks?

Answer 13

usually just proceed with delivery. May give tocolytics to add steroids

Question 14

What should be done if membranes rupture before 24 weeks?

Answer 14

Must advise the pt on the risks of birthing a child with effects of oligohydramnios, including Potter sequence or cerebral palsy or can offer termnation of the pregnancyIf pPROM occurs between 24-34 weeks, typically the pt. will be admitted, tocolytics will be given and birth will be allowed to commense

Question 15

Is preeclampsia more common in first or subsequent pregnancies?

Answer 15

First

Question 16

What are the risk factors for preeclampsia?

Answer 16

¨Nulliparous,multifetal gestation,obesity, chronic HTN, DM, renal diseaseSLE, thrombophiliafamily history of preeclampsia,molar pregnancy

Question 17

Describe HELLP syndrome

Answer 17

HELLP usually begins during the third trimester; rare cases have been reported as early as 21 weeks gestation. Often, a woman who develops HELLP syndrome has already been followed up forpregnancy-induced hypertension(gestational hypertension), or is suspected to developpre-eclampsia(high blood pressure andproteinuria). Up to 8% of all cases occur after delivery

Question 18

How might HELLP syndrome present?

Answer 18

Women with HELLP syndrome often “do not look very sick.”Early symptoms can include:In 90% of cases, eitherepigastricpain described as “heartburn” orright upper quadrant pain develops.In 90% of cases,malaiseoccurs.In 50% of cases, nausea or vomiting happen.Gradual but marked onset ofheadaches(30%), blurred vision, andparesthesia(tingling in the extremities) can occur.Edemamay occur, but its absence does not exclude HELLP syndrome.Arterial hypertensionis a diagnostic requirement, but may be mild. Rupture of the liver capsule and a resultanthematomamay occur.If a woman has aseizureorcoma, the condition has progressed into full-blowneclampsia.

Question 19

How can the seizures of eclampsia be prevented?

Answer 19

Magnesium sulfate is treatment of choice

Question 20

What isAcute fatty liver of pregnancy (AFLP)?

Answer 20

A serious complication unique to pregnancy first described by Sheehan in 1940.It is characterized by microvesicular steatosis in the liver

Question 21

What causes AFLP?

Answer 21

The foremost cause of AFLP is thought to be due to a mitochondrial dysfunction in the oxidation of fatty acids leading to an accumulation in hepatocytes. The infiltration of fatty acids causes acute liver insufficiency, which leads to most of the symptoms that present in this condition.

Question 22

What pt pop are more at risk for AFLP?

Answer 22

There does not appear to be a predilection for any geographical area or race. It appears to occur more commonly in primiparous women than multiparous women

Question 23

Women who develop AFLP are more likely to have a heterozygous ________ deficiency.

Answer 23

long-chain 3-hydroxyacyl-coenzyme A dehydrogenase (LCHAD)

Question 24

What does LCHAD do?

Answer 24

LCHAD is found on the mitochondrial membrane and is involved in the beta oxidation of long-chain fatty acids.

Question 25

So why would LCHAD deficiency present in pregnancy?

Answer 25

This gene mutation is recessive; therefore, outside of pregnancy under normal physiological conditions, women have normal fatty acid oxidation. However, if the fetus is homozygous for this mutation, it will be unable to oxidize fatty acids. These acids are passed to the mother, who, because of diminished enzyme function, cannot metabolize the additional fatty acids. This results in hepatic strain leading to the development of AFLP, which can be relieved by delivery of the infant

Question 26

How might AFLP present?

Answer 26

Clinical presentation of acute fatty liver of pregnancy (AFLP) is nonspecific, and the patient can present with the following complaints:MalaiseAltered mental statusJaundiceHypoglycemiaNausea and vomiting (70%); this may present for the first time in the third trimesterRight upper-quadrant and epigastric pain (50-80%)Upper gastrointestinal hemorrhageAcute renal failureInfectionPancreatitisFulminant liver failure with hepatic encephalopathy

Question 27

NOTE:Women with hepatic and gastrointestinal disease in pregnancy may have atypical symptoms in AFLP

Question 28

Note about the presence of jaundice in pregnancy

Answer 28

Jaundice: Hyperbilirubinemia resulting in jaundice is rarely encountered in patients with severe preeclampsia. When jaundice is present in pregnancy, AFLP should be high on the differential.

Question 29

What labs suggest that AFLP may be occurring?

Answer 29

-elevated LFTsHepatic injury results in decreased gluconeogenesis and, therefore, hypoglycemia ensues.Liver detoxification is also affected, resulting in elevated levels of blood ammonia, especially late in the disease course.In addition, laboratory findings may be consistent with disseminated intravascular coagulation (DIC), specifically, prolongation of prothrombin time, low fibrinogen, and low antithrombin levels. This results in a clinical picture similar to DIC; however, in AFLP, the values are abnormal, not due to consumption of the clotting factors but rather to decreased production by the damaged liver.Bilirubin levels are elevated. This elevation is primarily the conjugated form, with levels exceeding 5 mg/dL. This can result in jaundice, which is rarely seen in patients with other forms of pregnancy-related hepatic injury, including preeclampsia.Some patients may develop pancreatitis, which can result in elevated amylase, lipase, and increased blood sugars.As the maternal kidneys become affected, blood creatine and uric acid can become elevated, leading to metabolic acidosis.

Question 30

Whatis the only treatment for acute fatty liver of pregnancy (AFLP) once the diagnosis has been made?

Answer 30

Delivery of the fetus,regardless of gestational age,

Question 31

Postpartum depression can be assessed via what scale?

Answer 31

Edinburgh Depression Scale•Greater than 10% of women have depression within the first 3 months pp

Question 32

What is lochia?

Answer 32

Normalvaginal bleeding/discharge that can persist for 3-8 weeks pp.NOTE:Occasionally a heavy bleed can occur at day 7-14 pp. Eschar at placental site sheds

Question 33

What is the biggest concern (other than self harm) with PP Depression?

Answer 33

Lack of bonding with baby at a critical time

Question 34

How do different hormones affect the breast during late pregnancy to prepare for pp. lactation?

Answer 34

•Progesterone influences the growth in size of alveoli and lobes•Estrogen stimulates the milk duct system to grow and differentiate•Prolactin causes differentiation of the alveoli and ductal structures•Human placental lactogen (HPL) produced by the placenta, causes breast, nipple, and areola growth

Question 35

What are the benefits of breastfeeding to a neonate?

Question 36

What are the benefits of breastfeeding to a mother?

Answer 36

It promotes maternal weight loss and may protect against breast cancer

Question 37

What prevents lactation during pregnancy even as prolactin levels icnrease drastically?

Answer 37

progesterone. As birth occurs, progesterone lowers and prolactin can induce transcription of casein mRNA

Question 38

What are the actions of prolactin during breastfeeding mediated by?

Answer 38

may stimulate synthesis of alpha-lactalbumin, the regulatory protein of the lactose synthetase enzyme system;and increases lipoprotein lipase activity in the mammary gland

Question 39

T or F.Prolactin levels decrease as nursing becomes established

Answer 39

T.

Question 40

What hormone promotes maternal-neonate bonding?

Answer 40

oxytocin

Question 41

What is colostrum?

Answer 41

The product of the first few days of nursing, described as low volume, high nutritional content: perfect for the immature gut of the newborn

Question 42

What is the composition of colostrum?

Answer 42

Colostrum is very rich in proteins, vitamin A, and sodium chloride and contains lower amounts of carbohydrates, lipids, and potassium than mature milk.•Contains growth factors (stimulate the development of the gut), antimicrobial factors, the antibodies of passive immunity.

Question 43

What is the major substrate for breast milk?

Answer 43

glucose