Endo Repro Last Flashcards

1
Q

Early pregnancy loss, ectopic and Rh isoimmunization

A

Ok

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2
Q

First trimester

A

First day of last period (FDLMP)-13+6 weeks

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3
Q

Second trimester

A

14-27+6 weeks

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4
Q

Third trimester

A

28-42

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5
Q

Estimate date of confinement

A

40 weeks after FDLMP

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6
Q

Abortion

A

<20 weeks

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7
Q

Preterm delivery

A

20-36+6 weeks

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8
Q

Full term

A

37-42 weeks

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9
Q

Postdates

A

> 42 weeks

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10
Q

What percent of pregnant women have vagina bleeding in early preg

A

40%

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11
Q

What d if girl present with vaginal bleeding

A

Pregnancy test

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12
Q

What is a negative hCG

A

<5 mIU/L

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13
Q

HCG level at time of expected menstruation

A

100 IU/L

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14
Q

HCG ___ every __ days

A

Doubles

2

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15
Q

What hCG level can we see gestational sac? :Discriminatory level”

A

1500-2000 mIU/L

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16
Q

Fetal pole seen what hCG

A

5200, 5 weeks

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17
Q

What is abnormal rise in hCG of less then 53% in 48 hours

A

Abnormal IUP or ectopic

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18
Q

Spontaneous abortion percent

A

10-15%

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19
Q

Biochemical pregnancy

A

Refers to the presence of hCG 7-10 days after ovulation but in whom menstruation occurs when expected
-when both clincial biochemical pregnancies are considered evidence suggests that 50% of all conventions end in abortions

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20
Q

Abortus

A

Loss before 20 weeks or less than 500 grams

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21
Q

Most common cause of first trimester SAB

A

Chromosomal abnormalities
45 CO most common abnormality
Trisomy 16 most commontrisomy

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22
Q

Threatened abortion

A

Vaginal bleeding and closed cervic

25-50% result in lsos

Treatment is expected management

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23
Q

Inevitable abortion

A

Vaginal bleeding and the cervic is partially dilated

Loss inevitable

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24
Q

Incomplete abortion

A

Vaginal bleeding, cramping lower abdominal pain with dilated cervix

Passage of some but not all products

Treat with suction D and C

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25
Q

Complete abortion

A

Passage of all with closed cervic

With resolution of pain, bleeding and pregnancy symptoms

No treatment needed

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26
Q

Missed abortion

A

Fetus has expired and remains int he uterus

Usually no symptoms

Coagulation problems may develop, check fibrinogen levels weekly until SAB occurs or proceed with suction D and C

Expectant management vs misoprostol vs D and C

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27
Q

Septic abortion

A

Fever, uterine and cervical motion tenderness, purulent discharge, hemorrhage, and renal failure

Retained infected products

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28
Q

Treat septic abortion

A

IV antibiotics and D and C

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29
Q

Blighted ovum

A

Anembryonic gestation

Gestational sac to large to not have embryo >25 mm

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30
Q

Induced or elective abortion

A

Roe v wade 1971

Suction D and C is most common in first trimester

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31
Q

Anembryoinc gestation (blighted ovum)

A

Fertilized egg develops a placenta but no embryo

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32
Q

How see anembryonic gestation

A

US reveals empty gestational sac

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33
Q

Treat anembryonic gestation

A

Expectant management

Medical management -misoprostol

D and C

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34
Q

Suction D and C

A

Uses suction to remove products of conception

Surgical D and C is a more successful primary therapy then medical or expectant management

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35
Q

Recurrent abortions

A

Defined as three successive SAB

Excluding ectopic and molar pregnancies

1% of pregnant women

Often no identifiable cause can be found

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36
Q

Recurrent abortions: infection

A

Mycoplasma, chlamydia, listeria, or toxoplasmosis rarely identified

Can be treated with antibiotics

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37
Q

Recurrent abortions: smoking and etoh

A

Increase SABS

4 fold increase risk. If smoke 20 cigarettes a day and consume 7 alcoholic beverages per week

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38
Q

Recurrent abortions: medical disorders

A

DM, Hypothyroidism, SLE< antiphospholipid ab syndrome and hypercoagulability sources

Factor V Leiden defiency, antithrombin III, protein C and S, prothrombin G20210A, ANA, anticardiolipin antibody, methylene tetrahydrofolate reductase

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39
Q

Recurrent abortion maternal age

A

> 40 lots 56%

Increase with maternal age

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40
Q

Recurrent abnortions: uterine abnormalities

A

Congenital anomalies (DES)

Submucosal fibroids, uterine septum

Intrauterine synechiae (asherman)

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41
Q

Recurrent abortion: cervical incompetence

A

Second trimester loss

Painless dilation and delivery

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42
Q

Risk factors cervical incompetenance

A

Uterine anomalies,previous trauma, and history of conization

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43
Q

Treat cervical incompetence

A

Cervical circulate

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44
Q

Recurrent abortions chromosomal abnormalities

A

45 XO most common

Trisomy 16 most common trisomy

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45
Q

Recurrent abortio karyotype gets

A

Recommended for both parents bc 3% chance that one parent is an asymptomatic carrier of a genetically balanced chromosomal translocation

Detect balanced reciprocal or robertsonian translocations that could be passed on

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46
Q

Recurrent abortions antiphospholipid syndrome

A

Most common

Has been associated with recurrent fetal loss, preeclampsia, venous and arterial thromboembolism and stroke

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47
Q

Tests for immunological factors

A

Lupus anticoagulant

Anticardiolipin antibodies IggIgm
Anti B2 glycoproteins 1 antibodies iggigm

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48
Q

Treat immunological

A

Prophylactic dose of heparin and low dose asprin

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49
Q

Ectopic pregnancy

A

Fallopian tubes, abdomen, cervix, ovary, uterine cornua

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50
Q

% ectopic

A

1.5%

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51
Q

How ectopic pregnancy happen

A

Trophoblastic implant into the mucosa of the Fallopian tube and rapidly erode through to underlying blood vessels
-if the bleeding is extensive it can create a pressure necrosis of the overlying tubal serosa resulting in acute rupture and significant hemoperitoneum

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52
Q

Leading cause maternal death 1st trimester

A

Ectopic pregnancy

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53
Q

Natural vs art locations

A

Natural-tubal

Art-some tubal more ampullae and cornual
Also get ovarian /abdominal (heterotopic more), more cervical

But both most tubal

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54
Q

Risk factors ectopic pregnancy

A

History tubal infection (G or chlamydia)

Previous ectopic

Previous tubal reconstructive surgery or sterilizaiotns

DES

IUD preg

IVF or ART
Smoking

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55
Q

Differential ectopic

A

Threatened or incomplete abortion

Ruptured hemorrhagic corpus luteum cyst

Acute PID

Adnexal torsion

Degenerating leiomyoma

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56
Q

Nongynecological ectopic pregnancy

A

Acute appendicitis

Pyelonephritis, renal calculi

Pancreatitis

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57
Q

Triad ectopic pregnancy

A

Prior missed menses

Vaginal bleeding

Lower abdominal pain

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58
Q

Ectopic pregnancy signs

A

Usually 1 visit before diagnosis
-follow hcg and TVUS

Ab pain, spotting, bleeding

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59
Q

PE ectopic: possible

A

Uterus soft and normal size

May not feel any adnexal mass

US-thickened endometrial stripe (arias Stella reaction)
Rarely do you see the ectopic preg)

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60
Q

Symptoms probable ectopic pregnancy

A

Lower ab pain vag spotting

Abdominal adnexal tenderness or cervical motion tenderness

US-variable amounts of fluid in cul de sac

May see ectopic

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61
Q

Acutely ruptured ectopic pregnancy

A

Severe abdominal pain and dizziness from intraperitoneal preg

Distended and acute tender abdomen , cervical motion tenderness, sign of hemodynamically instability

US-empty uterus with free fluid

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62
Q

Hcg Doubles every 48 hours

A

Indicates a normal IUP
Some 66%

Slowest is 53%

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63
Q

<53% rise in hCG

A

Consistent with ectopic pregnancy or nonviable IUP

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64
Q

Can an ectopic pregnancy have normal rising HcG

A

Yup

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65
Q

Falling hCG

A

Most likely blighted ovum, spontaneously resolving ectopic ,abnormal pregnancy

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66
Q

Discriminatory zone

A

1500-2000 IU/L should see an intrauterine great sac

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67
Q

What see with transvaginal US

A

IUP

Extrauterine preg

Nondiagnostic-follows with hCG a

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68
Q

When repeat US

A

Hcg in discriminatory zone

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69
Q

Manage ectopic preg

A

Methotrexate-folic acid antagonist whihc inhibits DNA synthesis and cell replication

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70
Q

Follow up methotrexate

A

Check hCG levels day 4 and 7

-if 15% continue to follow weekly until negative

If plateau or fall slow, give another dose

Increase-surgical intervention

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71
Q

What avoid when on methotrexate

A

Folate containing vitamins

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72
Q

Success rate methotrexate

A

70-90%

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73
Q

Absolute contraindications methotrexate

A

IUP, breastfeeding, immunodeficiency, alcoholism, liver disease, hepatic renal failure

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74
Q

Relative contraindicatiosn mtx

A

Gestational sac>3.5 cm
Embryonic cardiac motion
HCG>6000

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75
Q

Expectant management

A

Stable and symptoms are resolving

Follow hCG and give strong ectopicprecaution

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76
Q

A lot of ectopic with hCG< 1000

A

Not rupture and resolve spontaneously

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77
Q

Laparotomy

A

Preferred for hemodynamically unstable

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78
Q

Laparoscopy

A

Stable patient

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79
Q

Salpingectomy

A

Entire Fallopian tube when damage

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80
Q

Salpingostomy

A

Incision is made parallel to the axis of the tube over the site of implantation and incision is left open to heal by secondary intention

Most studies reveal salpingostomy results in better long term tubal fcuntion

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81
Q

Salpingostomy

A

Incision is sutured

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82
Q

What do after surgery

A

Repeat hCG 3-7 days post op

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83
Q

Salpingostomy risk

A

20% risk residual trophoblastic tissue

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84
Q

Thesis isoimmunization

A

Rh negative women with RH positive fetus

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85
Q

Rh complex

A

C,D,E,c,d,e

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86
Q

> 905 of cases of Rh isoimmunization

A

Antibodies to D antigens

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87
Q

Who most common Rh D negative

A

Caucasion>african American> Asian an Native American

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88
Q

Rh sensitization

A

IgM initially then igg that cross placenta and into fetus

Bind fetal rbc and hemolysis

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89
Q

Mild hemolysis

A

Fine bc increase erythropoietin

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90
Q

Severe hemolysis

A

Resulting in hydrops fetalis from congestive heart failure and intrauterine fetal deat

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91
Q

RhoGAM

A

Prophylactic Rh immune globulin prevent maternal production of antibodies

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92
Q

Fetomaternal hemorrhage that can lead to isoimmunization

A

Most commonly occur during routine uncomplicated vaginal deliveries

Factors that can increase the volume of fetomaternal hemorrhage
-c section, placenta previa or abrupton and manual extraction of placenta

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93
Q

1-2% of Rh isoimmunization occur in the antepartum period

A

Abortion, abdominal trauma, ectopic preg, obstetrical procedures

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94
Q

Prevent rh isoimmunization

A

Rhogam decrease availability to RHD to maternal immune system

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95
Q

Prevent Rh isoimmunization

A

More than 1 dose in some populations

-do kleinhauer-betke test which identifies fetal rbc in maternal blood and will determine if rhogam is necessary

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96
Q

All pregnant women wha test

A

ABO blood group, Rh D type and antibody screen

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97
Q

What is women rh neg and anti d antibody tigers are positive (sensitized)

A

Test father for antigen status
If he is rhd negative, no further workup or treatment is necessary bc the fetus will be rh negative

If positive for rh d

  • homozygous, all with be rh +
  • heterozygous-50% will be

Fetal rhd status determined by cell free fetal DNA in maternal plasma or invasively with the fetal antigen testing

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98
Q

Maternal rh antibody tigers

A

Screening tool to estimate the severity of fetal hemolysis in rh disease

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99
Q

Titers less than 1:8

A

Usually indicate the fetus is not in serious jeopardize

Recheck titers in 4 weeks

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100
Q

Titers>1:16

A

Further evaluation

Detailed US to detect hydrops and Doppler studies of the idle cerebral artery

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101
Q

US fetal hydrops

A

Ascites, pleural effusion, pericardial effusion, skin scalp edema, polyhydramnios

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102
Q

US isoimmunization

A

Doppler assessment of peak systolic velocity in the fetal mca most valuable

Do ever 1-2 weeks from 18-35

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103
Q

Fetal MCA

A

Value peak systolic velocity >1.5 MOM for gestational age

Predictive of moderate to severe fetal anemia
Need to proceed with percutaneous umbilical blood sampling to assess true hemoglobin concentration

Intrauterine transfusion if indicated

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104
Q

Amniotic fluid in isoimmunization

A

Before MCA Doppler

Find bilirubin analysis with spectral analysts 450nm which correlated with cord blood hemoglobin of newborn at birth

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105
Q

Issue of amniotic fluid spectrophotometer in isoimmunization

A

Amniocentesis can increase the severity of fetomaternal transfusion and worsen the disease

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106
Q

Manage severe fetal anemia: what is it

A

HCT below 30% or 2 Sd below mean for gestational age

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107
Q

Teat severe fetal anemia

A

Intrauterine transfusions between 18-35 weeks

Use group O Rh neg packed rbc

  • <20 weeks intraperitoneal transfusion
  • IV transfusion into umbilical vein are preferred secondary to therapeutic effects are more rapid and reliable
  • repeat transfusion 1-3 weeks
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108
Q

Survival rate after transfusion

A

85%

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109
Q

Antepartum testing

A

Twice weekly non stress test or biophysical profiles

Serial growth scans q 3-4 weeks

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110
Q

After 35 weeks

A

The risk of intrauterine transfusions may be greater then that of a preterm 35 week
Consider delivery and transfuse

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111
Q

Each subsequent pregnancy after the first affected pregnancy is likely to manifest more severe fetal/neonatal hemolytic disease and at an earlier gestation
-90% risk of hydrops

A

Ok

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112
Q

Visit by all patient who are considering pregnancy

A

Risk assessment(smoking cessation, etoh ,illicit drugs)

Health promotion (nutrition, folic acid, weight)

Medical intervention(DM management)

Psycosocial intervention (stress reduced, 10% are abused during preg)

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113
Q

When start folic acid

A

At least 1 month before

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114
Q

Why manage glucose

A

SAB, morbidity, fetal malformation, fetal macrosomia, IUFD

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115
Q

G1p1002

A

Given birth 1 set of twins both alive

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116
Q

G4p1123

A

One term infant, one set of preterm twins and 1 miscarriage and 1 ectopic

2 living kids

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117
Q

Systolic murmur, splitting and S3, palmar erythema, spider angiomatosis, linea nigra, striae gravidarum, Chadwick’s sign

A

Normal in preg

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118
Q

What get for prenatal labs at 1st visit

A

Cbc, type and screen rubella immunity (cavvinate post partum if not0, syphilis, hepatitis B surface ag, HIV, cervical cytology and gonorrhea, DM, urine culture

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119
Q

Albumin, calcium, glucose, cr, protein, na, urea nitrogen, folic acid blood

A

Decrease

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120
Q

Fibrinogen

A

Increase

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121
Q

Urine

A

Cr no chance, protein increase, cr clearance decreased

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122
Q

Amy last

A

Increased

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123
Q

Alt ast

A

No chance

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124
Q

Hematocrit, leukocyte factors 7-10

A

Increase

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125
Q

Platelets hemoglobin

A

Decrease

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126
Q

Gestational ae

A

Number of weeks elapsed since first day of LMP and date of delivery

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127
Q

Serum hcg value preg

A

<5 no
Above 25 positive
100-time of next menses

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128
Q

First 20 days hcg

A

Doubles every 2 days

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129
Q

When see gestational sac

A

5 weeks, hcg 15000-2000

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130
Q

Fetal pole when seen

A

6 weeks, hcg 5200

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131
Q

Cardiac activity

A

7 weeks, 17500

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132
Q

Naegels rule

A

LMP minus 3 months and add 7 days-but only in 28 day cycle ppl

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133
Q

How use US to determine date of delivery

A

Crown rump length (CRL) between 6-11 weeks can determine due date within 7 days
At 12-20 weeks measuring femur length, biparietal diameter and abdominal circumference can determine due date within 10 days
Third trimester due date can be off up to +/- 3 weeks

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134
Q

How PE estimate exam

A

Size of uterus

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135
Q

Who needs genetic counseling

A

Over 35
Previous child.family history of birth defects or known genetic disorder

Previous birth mental retarded

Previous dead baby

Multiple fetal lossses

Abnormal serum marker

Consanguinity

Maternal conditions

Exposure to teratogens

Abnormal US

Genetic disorder

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136
Q

Down’s syndrome

A

Meiosis nondisjucntion 47 chromosome extra 21

If have a Down’s syndrome have 1% cance of another

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137
Q

Chromosomal studies (karyotype) on couples after 3 or more spontaneous abortions

A

3-5% will have balanced translocation

Should get counseling on having kid with an unbalanced translocation and therefore be offered prenatal diagnosis (chorionic villus sampling/amniocentesis)

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138
Q

Most common class of spontaneous abortion

A

Autosomal trisomy (16)

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139
Q

Most common single chromosomal abnormality in SAB

A

45 xo

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140
Q

AD dosirders

A

Tuberous sclerosis, neurofibromatosis, achondroplasia, craniofacial synstosis, adult onset POCS, muscular dystrophy

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141
Q

AR

A

Ray sachs, sickle cell, alpha and beta thalassemia, cystic fibrosis

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142
Q

Who is offered CF screen

A

1/25 ppl carry the AR tait

15% undiagnosed

All preg women

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143
Q

Sex linked

A

Duchene muscular dystrophy, fragile x

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144
Q

Fragile x

A

Most common inherited mental retardation

Second most common mental retardation a fter Down’s syndrome

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145
Q

How get x linked disorder

A

No male male transmission
Unaffected females carry

Effect males

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146
Q

Multifactorial inherited

A

Cleft lips, heart defects, pylorus stenosus, neural tube

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147
Q

Neural tube defects

A

Folic acid

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148
Q

When screen and uploads

A

1st and 2nd

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149
Q

1st trimester screening

A

Maternal age, fetal nuchal translucency (NT) thickness (echo free area at back of neck between 10 and 14 weeks-high thickness chromosomal and congenital abnormalities)

Hcg

Pregnancy associated plasma protein a PAPPA

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150
Q

Elevated bhcg and low pappa

A

Down’s syndrome

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151
Q

Increased nuchal translucency

A

Also downs

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152
Q

Second trimester triple screen

A

Bhcg, estriol, alpha fetoprotein

Detect trisomy 21

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153
Q

Second trimester quadruple screen

A

Bhcg, estriol, afp, inhibiton a

Trisomy 21

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154
Q

Combined 1st and 2nd trimester screening

A

Report results after 2nd trimester

Improve detection rate

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155
Q

Cell free fetal dna

A

9-10 weeks

Tests cell free fetal dna, thought to be from apoptosis of trophoblastic cells that have entered the maternal circulation

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156
Q

What cell free dna good for

A

Trisomy 21

Trisomy 18
Trisomy 13
Sex chromosome

NOT NEURAL FETAL DEFECTS LIKE NT

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157
Q

Who cell cell free dna

A

High risk

-old, prior trisomy preg, family history chromosomal abnormalities, US abnormal, positive fist trimester screen

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158
Q

If positive

A

Anniocenteisis or Chorionis villi sampling

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159
Q

Amniocentesis

A

16-20 weeks

.3% miscarriage

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160
Q

Chorionic villi sampling

A

11 weeks

1% miscarriage

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161
Q

Teratology

A

Study abnormal fetal development

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162
Q

Thalidomide

A

Phocomelia

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163
Q

Pregnancy and lactation labeling rule

A

PLLR

Removed letters changed content and format for information to assist health care provides in assessing benefit vs risk

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164
Q

PLRR

A

Pregnancy subsections 8.1-preg
Pregnancy subsection 8.1 breastfeeding

Females and male reproductive potential 8.3

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165
Q

Fetal susceptibility to teratology

A

Genetic make up of mom and fetus and environment

Multifactorial

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166
Q

Low dose

A

Fine

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167
Q

Intermediate dose

A

Organ malformation

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168
Q

High dose

A

Abortion

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169
Q

Most vulnerable time

A

17-56 days during organogenesis

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170
Q

4 th month and after

A

Growth delay and not malformation

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171
Q

Organogenesis

A

Malformation

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172
Q

Most common teratogen

A

Alcohol

Fetal alcohol syndrome

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173
Q

Antianxiety

A

Meprobamate or chlordiazepoxide

Congenital anomalies

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174
Q

Antineopalstic

A

Aminopterin and methotrexate are both folic acid antagonists

=before 40 lethal

Later UIGR, craniofacial, mental retard

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175
Q

FAS

A

Growth restriction

Facial abnormalities(low ears, smoot philitrum, thin upper lip, short palpebral tissues, flat midface)

CNS dysfunction
-microcephalic, mental retardation and behavior disorders

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176
Q

Alkalyating

A

Iugr, fetal death, cleft lip, microphthalmia, limb reduction, poorly developed external genetalia

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177
Q

Anticoagulatnts

A

Coumadin cross placenta, heparin doesnt

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178
Q

Coumadin

A

SAB, IUGR, CNS mental retardation, stillbirth, craniofacial features, fetal warfarin syndrome

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179
Q

Anticonvulsants

A

Usually epileptic women benefits of seizure prevention weighed against teratogenicity of the drug

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180
Q

Diphenylhydantoin

A

Fetal hydantoin syndrome

-craniofacial , limb reduction, FHS, mental defiency, cardiovascular anomalies

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181
Q

Valproic acid

A

Spina bifida

Cardiac, skeleton, craniofacial abnormalities

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182
Q

Carbamazepine

A

Spina bifida, craniofacial defects, fingernail hypoplasia

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183
Q

Phenobarbital

A

Neonatal withdrawal and neonatal hemorrhage

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184
Q

Estrogen and progesterone

A

Masculinization of female external genetalia

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185
Q

DES

A

Treat threatened abortion

Risk cervical and uterine issue

Cancer

Male-testicular abnormalities, infertility and malignancy

T uterus

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186
Q

Retinoids

A

CNS
CVD
Craniofacial defects

SAB, congenital malformations 50%

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187
Q

Tobacco smoke

A

low birth weight IUGR

SAB, fetal death, neonatal death and prematurity

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188
Q

Illicit drugs

A

Opiate-experience withdrawal

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189
Q

Infectious agents virus bacteria

A

Congenital malformations, growth restriction, fetal death, mental retardation

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190
Q

CMV

A

Proposes, depressed nasal bridge, triangular mouth

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191
Q

Radiation

A

Dose dependent
2-6 weeks

Before 2 lethal or none

Less than 5 rads of exposure no risk

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192
Q

How deal with n/v

A
Small frequent meals
Avoid greasy fried food
Room temp soda and saltnines
Acupuncture
Medes
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193
Q

Heartburn

A

From relaxation of esophageal sphincter by progesterone

-donut lie down after meals, elevate head of bed, small frequent meals, antacids, H2O blockers

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194
Q

Constipation

A

Decrease in colonic activity

Increase water, fiber, fruits, and vegetables, stool softened

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195
Q

Hemorrhoids

A

Increase in venous pressure in rectum

Rest, sti bath, stool softener, elevat legs, avoid cnstipation

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196
Q

Leg crams

A

Last half preg, calves at night

Massage stretch

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197
Q

Backache

A

Avoid weight gain, exercise/stretch, comfortable shoes, pillows, heat massage

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198
Q

How often go to doctor

A

Every 4 weeks until 28 then ever 2 weeks tilll 36 and weekly until delivery

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199
Q

What get at routine visit

A

Bp, weight, urine protein, uterine size, fetal heart rate (Doppler)

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200
Q

Quickening

A

First sensation of miovement 20 weeks

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201
Q

Near term

A

Evaluate fetal lie and fetal position

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202
Q

20 weeks

A

Fetal survey ultrasound

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203
Q

28 weeks

A

Gestational diabetes and repeat hemoglobin and hematocrit

Rhogam injection to Rh negative patients

Tdap give between 27-36 weeks

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204
Q

35 week

A

Screening for group b step carrier with vaginal culture-treat in labor if positive

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205
Q

Kick counting

A

Monitor how often

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206
Q

Nonstress test

A

Reactive-2 accelerations of at least 15 beats above baseline lasting at least 15 seconds during 20 minutes of monitoring

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207
Q

Contractions tress test

A

Give oxytocin to establish at least 3 contractions in a 10 min period. If late decelerations are noted with the majority of contractions the test is positive and delivery is warranted

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208
Q

8-10

A

Reassuring

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209
Q

6

A

Deliver if at term

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210
Q

4 or less

A

Onreassuring consider delivery

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211
Q

Still birth reactive non stress test

A

2/1000

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212
Q

Negative contraction stress test still birth

A

.3/1000

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213
Q

Biophysical profile

A

.8/1000

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214
Q

Normal labor and delivery

A

Gynecoid

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215
Q

Gynecoid

A

Round at inlet

Wide transverse diameter
Wide suprapubic arch

Head into the occiput anterior position

Good for deliver

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216
Q

Android

A

Males and 30% females

Wides transverse diameter closer to scrum

Prominent ischial spines

Narrow pubic arch

Fetal head to occiput posterior position
Arrest of descent common
Bar prognosis for delivery

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217
Q

Anthropoid

A

Ape pelvis 20%

Larger AP then transverse Creasy long narrow oval with narrow pubic arch

Fetal head anterioposterior diameter

Usually in OP position

Good delivery

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218
Q

Platypelloid

A

Flat gynecoid pelvis 3% of females

Short AP and wide transverse diameter

Wide bispinous diameter
Wide suprapubic arch

Fetal head has to engage in transverse diameter

Poor prognosis for delivery

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219
Q

Diagonal conjugate

A

Inferior pubic symphysis to sacral promontory

>11.5 ok

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220
Q

Obstetric conjugate

A

Diagonal-2 cm

Narrowest fixed distance through which the fetal head must pass through during a vaginal delivery

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221
Q

What palpate

A

Sacral and iscial spine

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222
Q

Pelvic outlet

A

Measure ischial tuberosities and pubic arch

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223
Q

Iscial tuberosities distance between

A

8.5 cm distance ok

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224
Q

Infrapubic angle

A

Place thumb next to each inferior pubic ramus and estimate the angle at which they meet
>90 good

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225
Q

Radiographically MRI CT

A

Rare only do if history or clincial indication of pelvic abnormalities or pelvic trauma

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226
Q

Initial evaluation

A

Review prenatal records, identify complications, confirm gestational age, review labs, history, PE

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227
Q

Focused history

A

Frequency contractions, loss fluid, vaginal bleeding

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228
Q

Fetal lie

A

Reference to maternal spine

Longitudinal, transverse, oblique

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229
Q

Fetal presentation

A

Vertex, breech, transverse, or compound

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230
Q

Leopoldo maneuver

A
  1. Palpate fundus
  2. Palpate or spine and fetal small parts
  3. Palpate what is presenting in the pelvis with suprapubic palpation
  4. Palpate for cephalic prominence
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231
Q

Dilation

A

Check at internal os

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232
Q

Effacement

A

Thinning cervix occurs and is reported as % change in length

Normal 3-5 cm
Thick 100% effaced

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233
Q

Station

A

Degree of descent of the presenting part of fetus
Measured in cm from presenting part to ischial spines
When the bony portion of the head reaches the level of the ischial spines the station is zero

-5 to 5 cm

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234
Q

First stage labor

A

Onset labor to complete cervical dilation

Latent and active

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235
Q

Second stage

A

Complete cervical dilation to delivery

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236
Q

Third stage

A

Delivery of infant to delivery of placenta

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237
Q

Fourth stage

A

Delivery of placenta to stabilization of patient

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238
Q

Phases of first stage

A

Latent active

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239
Q

Latent

A

Onset of labor and slow cervical dilation

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240
Q

Active

A

Faster rate of dilation and usually begins when cervix is dilated to 4 cm

Admit for labor

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241
Q

Duration 1st stage primiparas and multiparas

A

6-18 hrs

2-10 hours

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242
Q

Rate cervical dilation primiparas and multiparas

A

1.5 cm per hour

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243
Q

When may patient ambulated

A

Head engaged and reassuring monitoring is noted

I in bed be left lateral recumbent

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244
Q

Fluids

A

IV to hydrate give meds if need

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245
Q

Labs

A

Cbc and t ands

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246
Q

Maternal monitoring

A

Vitals q 1-2 hours

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247
Q

External fetal monitoring

A

Continuous

Intermittent if uncomplicated or complicated differs

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248
Q

Monitor uncomplicated

A

Q 30 min in active phase of first stage

Q 15 min in second stage of labor

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249
Q

Monitoring if complicated

A

Q15 min in active phase

Q15 min during the second stage

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250
Q

How get most accurate tracing

A

Internal monitoring

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251
Q

How get uterine activity

A

External tocodynamometer

Internal pressure catheter

Can get strength of contractions and help xyytocin augmentation

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252
Q

Vaginal exam

A

Active phase q2 hrs record dilation, effacement, station

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253
Q

Amniotomy

A

Augment labor, allows assessment of meconium status

Risk cord prolapse, prolonged rupture is associated with chorioamnionitis

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254
Q

Second stage

A

Descent of the presenting part through the maternal pelvis and culminates in delivery

Increase in bloody show and desire to bear down with contractions

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255
Q

Duration second stage

A

Primiparas without epidural 2 hours
With 3 hours

Multiparas without epidural 1 hour
Multiparas 2 hours

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256
Q

Engagement

A

Presenting part at zero station

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257
Q

Descent

A

Brought about by the force of uterine contractions and maternal valsava efforts

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258
Q

Flexion

A

OA baby’s chin to chest thus changing the presenting part from occipitofrontl to the smaller suboccipitobregmativ

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259
Q

Internal rotation

A

At ischial spines

Fetal head enters pelvis int ransverse diameter, rotates so the occiput turns anteriorly or posteriorly toward the pubic symphysis

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260
Q

Extension

A

Crowning occurs when the largest diameter of the fetal head is encircled by the vaginal introitus
+5
Head is born by rapid extension

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261
Q

External rotation

A

Delivered head now returns to its original positiona t the time fo engagement to align itself with the fetal back and shoulders

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262
Q

Expulsion

A

Anterior shoulder then delivers under the pubic symphysis, followed by the posterior shoulder and the remainder of the body

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263
Q

Maternal position second stage

A

Avoid supine

Dorsal lithotomy

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264
Q

Bearing down second stage

A

With each contraction, the mother should hold her breath and bear down with expulsion efforts

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265
Q

2nd stage fetal monitoring

A

Continuous
Q15 with no risk factors
Q5 minutes during seconds tage with risk

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266
Q

Vaginal exam 2nd stage

A

Access descent and confirm position

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267
Q

Delivery head

A

2 nurses and physician
Antiseptic soap vulva
Episiotomy
Facilitate with modified rotten maneuver
Head out bulb suction oral cavity and use index finger to assess nuchal cord
-if loose can manually reduce over the infants head if tight clamp and cut

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268
Q

How deliver shoulder

A

Anterior shoulder with gentle downward traction on fetal head

Posterior shoulder by elevating the head

Support head, bulb suction, dry and stimulate

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269
Q

Cord

A

Clamp x2 and cut

Obtain cord blood specimen

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270
Q

Deliver placenta

A

Third stage then inspec and repair

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271
Q

Indications episiotomy

A

Likelihood of spontaneous laceration seems high

To expedite delivery by enlarging the vaginal outlet

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272
Q

Midline episiotomy

A

Common
Risk of extension 3rd or 4th degree

Less postpartum pain

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273
Q

Meidolateral episotomy

A

Greater blood loss
More difficult to repair
More postpartum pain
Increase risk of dyspareunia

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274
Q

Rotten maneuver

A

Fingers of the right hand are used to extend the head while counterpressure is applied to the occiput by the left hand to allow for a more controlled delivery

Or just support perineum

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275
Q

FIRST DEGREE LACERATION

A

SUPERFICIAL LACERATION INVOLVING THE VAGINAL MUCOSA AND OR PERINEAL SKIN

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276
Q

SECOND DEGREE

A

LACERATION EXTENDING INTO THE MSUCLES OF THE PERINEAL BODY BUT DOES NOT INVOLVE THE ANAL SPHINCTER

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277
Q

THIRD DEGREE

A

LACERATION EXTENDS INTO OR COMPLETELY through the anal sphincter but not into the rectal UC osa

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278
Q

Fourth degree

A

Involves the rectal mucosa

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279
Q

Third stage

A

Interval between delivery of the infant and delivery of placenta

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280
Q

Retained placenta

A

Placenta not delivered in 30 minutes

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281
Q

Signs placental separation

A

Gush of blood from vagina

Lengthening of umbilical cord

Fundus of uterus rises up

Change in shape of the uterine fundus from discoid to globular

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282
Q

What do

A

Apply counter pessure between symphysis and fundus

Do not pull cord until classic signs noted

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283
Q

Inappropriate pulling cord

A

Uterine inversion

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284
Q

Fourth stage

A

Monitor patient
Vitals
Uterine fundal checks and assess for vaginal bleeding

Postpartum hemorrhage commonl occurs during this time
-uterine stony, retained placenta, unprepared vaginal or cervical laceration

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285
Q

Cervical ripening

A

Do before labor

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286
Q

Augmentation

A

Artificial stimulation of labor which already began

Vs induction of labor

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287
Q

Indication induction

A

Abruptio placenta, chorioamnionitis, fetal demise, preeclampsia, eclampsia, gestational HTN, prom, postterm pregnancy, maternal medical conditions, fetal compromise

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288
Q

Contraindications induction

A
Unstable fetal
Acute fetal distress
Placenta previa or vasa previa
Previous classical c section or transfundal uterin surgery
HIV high viral load, active herpes
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289
Q

Bishop score

A

Cervical dilation, cervical effacement, station, cervical consistency cervical position

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290
Q

Biochip<6

A

Unfavorable

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291
Q

Bishop>8

A

Probability of vaginal delivery after labor induction is similar to that of spontaneous labor

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292
Q

Cervical dinoprostone

A

E2 vaginal insert

Not in previous c section

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293
Q

Misoprostol cytotoxicity

A

E1
Oral or vaginal
Can’t be removed
Not in previous c section

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294
Q

Mechanical dilators

A

Foley bulb catheter

Laminara japonicum

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295
Q

Pitocin infusion

A

Synthetic oxytocin stimulate contraction
IV
Induction and augmentation

In normal saline IV and stopped if fetal distress
1-30 mu/min

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296
Q

Uterine tachysystole

A

More than 5 contractions in 10 min

Side effect

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297
Q

Antidiuretic effect

A

Pitocin ADH has effect can lead to increase water reabsorption
-convulsion and coma

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298
Q

Uterine muscle fatigue

A

Prolonged pitocin increase risk

-post partum hemorrhage secondary to uterine stony

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299
Q

Obstetric anesthesia

A

Pain relied sage for baby

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300
Q

Maternal mortality due to anesthesia

A

1:500000

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301
Q

Uterine blood flow

A

Blood flow to uterus may decrease To uterus with anesthesia from hypotension

Need adequate hydration

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302
Q

What do if hypotension anesthesia

A

Vasopressor

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303
Q

Pain uterine contractions

A

Visceral pain t10-t12 through l1

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304
Q

Perineum pain

A

Somatic s2-4

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305
Q

Regional anesthesia

A

Low of pain below t10

Epidural, spinal

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306
Q

Local

A

Perineum, pudendal block

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307
Q

Early labor anesthesia

A

Morphine, fentanyl, meperidine nalbuphine

Not for labor pain women work bc moa is sedation

Opoids cross placenta

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308
Q

Regional

A

T8-t10 and below

Local anesthesia and narcotic

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309
Q

Epidural

A

Most effective catheter in epidural space l2-l3 , l3-l4, l4-L5 then placed over needle

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310
Q

Spinal

A

Single shot analgesia which provide excellen pain relief for limited procedures

Limited use in labor since a single shot

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311
Q

Regional ae

A

Hypotension , spinal HA, fever, spinal hematoma, abscess

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312
Q

Contraindications regional

A

Coagulopathy, heparin within 12 horus, bacteremia, ICP, skin infection

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313
Q

Local

A

1-2% lidocaine for 20-40 min

Before episiotomy or laceration repair

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314
Q

AE local

A

Hypotension, seizures, cardiac arrhythmias

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315
Q

Pudendal ae

A

Intravascular injection, hematoma infection

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316
Q

General

A

Propofol

Loss of consciousness need airway management
16 fold increase maternal mortality

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317
Q

All inhaled anesthetics

A

Cross placenta and associated with neonatal respiratory depression

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318
Q

When do general

A

Emergent cases

Regional anesthesia

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319
Q

Fetal heart rate monitoring

A

To look for for patterns that may be frequently associated with delivery of infant with poor outcomes

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320
Q

For benefit

A

No increase operative deliveries and c section no change in neuro damage

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321
Q

Who do for

A

Reassurance

Would have to get nurse

Still goor warning of potential problems

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322
Q

External monitoring vs internal

A

Internal Rome accurate

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323
Q

External

A

Doppler US< pressure sensiiive tacodynanmometer

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324
Q

Doppler US

A

On maternal abdomen overlying fetal heart

Records reflected sound waves fromt he fetal heart back to transducer

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325
Q

Pressure sensitive tocosynanmometer transducer

A

Detects and records contractions

Useful for measuring the frequency of contractions but not the strength

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326
Q

Internal

A

Fetal scalp electrode

Intrauterine pressure catheter

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327
Q

Fetal scalp electrode

A

R wave peaks of the fetal echocardiogram

Maternal and fetal movement will not alter the quality of signal
Rare cases of fetal pustules

Not for HIV

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328
Q

Intrauterine pressure catheter

A

Soft plastic catheter placed transcervically

Gives precsise measurement of the intensity of uterine contractions in millimeters of mercury

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329
Q

What does internal require

A

Membranes to be ruptured

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330
Q

Fetal oxygen reserve is only enough to meet its metabolic needs for ___

A

1-2 min

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331
Q

When is blood flow from maternal circulation stopped

A

Every contraction

Can tolerate without hypoxia bc adequate oxygen exchange occurs still between contractions

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332
Q

A fetus who is marginal

A

Can’t tolerate stress of contractions and will become hypoxic

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333
Q

Hypoxia in fetus

A

Chemoreceptors and baroreceptors in the peripheral arterial circulation of the fetus influence the FHR by giving rise in contraction related or periodic FHR changes

Anaerobic metabolism, Peruvian and lactic acid and fetal acidosis

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334
Q

PH fetal scal normal and acidosis

A

7.25-7.3

<7.2

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335
Q

How do uterine contractions effect HR

A

Blood flow ceases
Increase or decrease

Decrease

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336
Q

Normal uterine activity

A

5 contractions or less in 10 minutes over 30 minutes

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337
Q

Tachysystole

A

> 5 in 10 min over 30 min

Presence or absence FHR decelerations

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338
Q

How measure contractions

A

Peak to peak

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339
Q

Normal contractions

A

3 in 8 minutes

Occurring 2-3 mintues

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340
Q

MVU

A

> 200 Montevideo units (sum of the contractions in a 10 minute period) for at least 2 hours

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341
Q

Baseline FHR

A

Increments of 5 bpm during 10 minute

Assess between contractions

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342
Q

Normal

A

110-160 bpm

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343
Q

Tachycardia

A

Baseline>160 bpm

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344
Q

Bradycardia

A

<110 bpm

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345
Q

Tachycardia

A

> 160

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346
Q

Bradycardia

A

<110

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347
Q

Causes tachycardia

A
Fetal hypoxia
Meds-oxytocin
Arrhythmias
Prematurity
Maternal fever
Fetal infection-chorioamnionitis most common cause1
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348
Q

Bradycardia

A

Fetal hypoxia, obstetric anesthesia, pitocin, maternal hypotension, prolapsed or prolonged compression of the umbilical cord, heart block

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349
Q

Chemoreceptors tachycardia

A

In response to hypoxia

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350
Q

Baroreceptors

A

Vagus in response to changes in fetal bp

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351
Q

Absent

A

Amplitude undetected

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352
Q

Minimal

A

<5 bpm

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353
Q

Moderate

A

6-25 bpm

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354
Q

Marked

A

Amplitude>25 bpm

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355
Q

Decreased variability

A

Indicators of fetal stress
Persistent late decelerations

Hypoxia and acidemia
-lack of oxygen and the build up acid in the fetus depresses the fetal heart rate and cns

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356
Q

Decreased variability

A

Prematurity, sleep, maternal fever, fetal tachycardia, fetal congenital anomalies, maternal hyperthyroidism, drugs

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357
Q

Accelerations

A

Abrupt increase in the FhR and is a normal reassuring response
>32 weeks HE>15 bpm above baseline for 15 sec or more
<32 weeks HR>10 bpm above baseline for 10 sec or more

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358
Q

Prolonged acceleration

A

> 2 min

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359
Q

Change in baseline

A

If acceleration lasts >10 min

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360
Q

Cause accelerations

A

Spontaneous fetal movement

Vaginal exam

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361
Q

Deceleratiosn

A

FHR decreases in response to uterine contractions

Early, variable, late

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362
Q

Early deccelerations

A

Head compression-fetal autonomic response to increased ICP caused by transient compression of the fetal head

Not associated with fetal distress

The nadir of the deceleration occurs at the same time as the peak fo the contraction and thi s. Amirror image

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363
Q

Cause early deceleration

A

Pressure on fetal skull increase ICP->decrease cerebral blood flow->activates central vagus nerve-> produces decrase in HR->recovering occurring as pressure is relieved

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364
Q

Variable decelerations

A

Secondary to umbilical cord compression
Abrupt decrease in FHR-can occur before, during or after contraction starts

Decrease in FHR >15 bpm lasting >15 sec and <2 min in duration

Onset depth and duration an vary with successive uterine contractions

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365
Q

Variable decelerations abuse

A

Cord compression

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366
Q

Slight cord compression

A

Obstruct umbilical vein which returns re oxygenated blood to fetal heart

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367
Q

Response to cord comrpession

A
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368
Q

Shoulder

A

Slight fhr decrase followed by major drop

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369
Q

Late decelerations

A

Uterine placental insuffiency

Most ominous deceleration-repetitive late decelerations usually indicate fetal metabolis acidosis and low arterial pH

Nadir of the deceleration occcurs after the pea of contraction

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370
Q

Cause late deceleration

A

Excessiveuterine activity

Maternal supne hypotension

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371
Q

Prolonged deceleration

A

Decrease in FHR from baseline that is >15 bpm >2 min but <10 min

Disruption of oxygen transfer from the environment to the fetus at one or more points along the oxygen pathways

Maternal pushing

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372
Q

Change in baseline prolonged decelaeration

A

> 10 min

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373
Q

Sinusoidal pattern

A

Smooth sine wave like undulating pattern in fhr

Fetal anemia

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374
Q

Category 1

A

Baseline 110-160 bpm

Moderate variability no late or variable decelerations

May have acccelerations and early decelerations

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375
Q

Tracing category 1

A

Normal

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376
Q

Manage category 1

A

Intermittent CEFM

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377
Q

Category II

A

Intermittent: variable decelerations <50% of contractions

Recurrent variable decelerations >50% of contractions

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378
Q

Category II intermittent

A

Normal outcome

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379
Q

Category II recurrent variable

A

Umbilical cord compression with acidemia impending

Moderate variability and or accelerations suggest fetus is not acidemia

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380
Q

Manage intermittent category II

A

No intervention required

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381
Q

Treat recurrent category II

A

Alleviate cord comrpession repositioning amnoiinfusion

Modify pushing efforts push with every other ctx

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382
Q

Amnioinfusion

A

Instillation of normal saline can alleviate cord compression
250-1000 cc infused 15 cc/min

Continuous infusion of 100-200 cc/hour

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383
Q

How infuse amnioinfusion

A

Transcervical IUPC

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384
Q

Category iI

A

Minimal or absent variability

Recurrent late decelerations

Prolonged decelerations

Tachycardia, bradycardia
Variable late or prolonged decelerations occurring with maternal pushing efforts

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385
Q

Etiology category II

A

Fetal sleep, meds, acidemia, UPI:hypotension, tachysystole, maternal hypoxia

Rapid fetal descent , cord comrpession, tachysystole

Prematurity , chorioamnionitis, epidural , cord prolapse, cord comrpession UPI

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386
Q

Manage categor II

A

Promote fetal oxygenation

Decrease oxytocin

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387
Q

Tachysystole category II

A

Spontaneous labor, induction or augmentation

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388
Q

Goals tachysystole

A

Reduce uterine activity

Lateral positioning, IV bolus, decrease oxytocin, tocolytic (tertbutaline)

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389
Q

Absent baseline variability(recurrent late decelerations, recurrent variable decelerations, bradycardia0

Sinusoidal pattern

A

Increased risk of fetal acidemia

Increased risk of hypoxemia and acidemia

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390
Q

Manage

A

Prepare for delivery

Fetal scalp stimulation

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391
Q

Fetal scalp stimulation

A

Poke it with finder

If an acceleration of 15 bpm lasting 15 seconds occurs the fetal pH value almost always is 7.33 or greater

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392
Q

How fetal scalp stimulation show difference between fetal sleep from acidosis

A

When teal tracing shows reduced variability but no decelerations

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393
Q

Category III

A

How many minutes is standard of care to deliver this infant

Idk

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394
Q

Operative delivery with category II tracing

A

Get consent, get team, assess transit time and location for operative deliver, ensure IV access, review labs, assemble neonatal resuscitation personnel

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395
Q

Normal FHR good?

A

98% fetal wellbeing

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396
Q

Does electronic fetal monitoring result in reduction of cerebral palsy

A

False positive >99%

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397
Q

Abnormal patterns or non reassuring FHR can occur into e absence of fetal distress

A

False positive rate is 80%

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398
Q

Do most patient sithe nonreassuring FHR give birth to healthy infants

A

Yup

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399
Q

Watch end for reading

A

Please

400
Q

Medical conditions in pregnancy

A

Ok

401
Q

Geational DM

A

7% get glucose intolerance

402
Q

Screen GDM when

A

24-48 weeks
50 gm on hour glucose challenge (>130-140 abnormal)
May perform an earlier screen if risk

403
Q

If abnormal 50 gm one hour oral gloat glucose challenge (>130-140)

A

Follow 3 hour 100 gm oral load glucose tolerance test

-fail three hour with 2 or more abnormal values

404
Q

Risk factors for development of GDM

A

Obesity, history, family history DM, glucose intolerance

405
Q

Maternal complications

A

Increase risk of gestational HTN
Increase risk preeclampsia
Greater risk of c delivery
Increase risk Dm later in life

406
Q

Fetal complication GDM

A

Macrosomia, neonatal hypoglycemia, hyperbilirubinemia, operate delivery, shoulder dystocia, birth trauma

407
Q

Antepartum management

A

Diabetic teaching, blood glucose monitoring, fetal testing, US for fetal weight get c section is over 4500 gm

408
Q

When can u wait for spontaneous labor or estimated due date

A

Testing, growth, glycemic control are good

409
Q

Diet controlled

A

No treat

410
Q

Medication control intrapartum

A

Hourly glucose monitoring
Need between 80-120

Continuous fetal monitoring in labor

411
Q

Increasing glycosylated hemoglobin levels HgBA1C in period of embryogenesis, sixfold increase risk of congenital anomalies

A

Birth defects

412
Q

Maternal complications

A

Worsening nephropathy and retinopathy, increased risk of developing preeclampsia, greater risk of diabetic ketoacidosis

413
Q

Fetal complications

A

Increase risk of spontaneous abortions, anatomic birth defects, fetal growth restriction and prematurity

414
Q

White classification

A

Class a1 and a2

415
Q

A1

A

Gestational diabetes, diet controlled

416
Q

A2

A

Gestational diabetes; insulin or oral meds controlled

417
Q

What want fasting glucose

A

Less than 95 mg/dl

418
Q

Two hour postprandial

A

Less than 120

419
Q

Exercise after meals

A

Half an hour

420
Q

Antepartum maternal evaluation

A

Renal-24 hour urine collections every trimester

Cardiac ekg

Ophthalmic detailed eye exam in first trimester

Glycemic control (dail finger stick blood glucose and hgba1c0

421
Q

Fetal evaluation antepartum

A

Early dating US

Detailed fetal anatomy US and echo

Biochemical testing for congenital malformations in first trimester 11-13 weeks or quad screen at 16-21 weeks

Fetal growth US every 2-4 weeks

Fetal testing every weeks tarting 32 weeks

422
Q

Postpartum management

A

Insulin requirements drop significantly after delivery of placenta

Insulin dependent patients typically require about 2/3 of pregnancy dose of insulin

GDM frequently do not need further treatment

With GDM-need 2 hour glucose tolerance 6 to 12 weeks postpartum to look for preexisting disease

423
Q

Hyperthyroidms

A

Similar to preg so hard to see symtpoms

424
Q

Diagnose hyperthyroidism

A

T4 up and TSH down

425
Q

Treat maternal hyperthyroidism

A

Radioactive iodine contraindicated

PTU and methimazole in 2 or 3 (aplasia cutis in 1st)

PTU-liver toxicity so only 1st

426
Q

Fetal effects hyperthyroidism

A

Meds cross placenta and fetal hypothyroid an goiter an come

Risk of prematurity, IUGR, preeclampsia and stillbirth

427
Q

Thyroid storm trigger

A

Infection, labor, c secretion, noncompliance with medication

428
Q

Symptoms thyroid storm

A

Hyperthermia, tachycardia, perspiration, high output cardiac failure,

429
Q

Maternal mortality thyroid storm

A

25%

430
Q

Treat thyroid storm

A

Beta blockers-propranolol

Sodium iodide

PTU

Dexamththasone

Replace fluid
Bring t down

431
Q

Hypothyroidism

A

Normal preg

432
Q

Untreated hypothyroidism

A

Spontaneous abortion, preeclampsia, abruption, low birth weight infants, still birth, lower intelligence leees (cretinism)

433
Q

Treat hypothyroidism

A

Levothyroxine

Monitor tsh and free t3/t4

434
Q

Neonatal thyrotoxicosis

A

Due to transplacental transfer of thyroid stimulating antibodies

Transient

Mortality 16%

435
Q

Neonatal hypothyroidism

A

Defiency results in generalized development retardation causes
-thyroid dysgenesis
Inborn error of thyroid function
Drug induced

436
Q

Rheumatic heart disease

A

Mitral stenosis

High risk of developing heart failure, subacute bacterial endocarditis and thromboembolic disease

437
Q

Congenital heart disease

A

Atrial and ventricular septal defects, primary pulmonary htn, t of fallout, transposition of great vessels
-if corrected in childhood no consequences

438
Q

Primary pulmonary htn

A

Contraindications to pregnancy due to decompensation during pregnancy and a high mortality rate, epidural anesthesia is preferred and vaginal delivery ma be an option for these patients

439
Q

Cardiac arrhythmias

A

Most frequently supraventricular tachycardia
Benign
A fib.flutter more worrisome for underlying cardiac disease

440
Q

Postpartum cardiomyopathy

A

No underlying cardiac disease
Develops typically within last weeks of pregnancy or within 6 months postpartum
Women with preeclampsia, htn and poor nutrition

441
Q

Mortality rate postpartum cardiomyopathy

A

10%

442
Q

Prenatal manage cardiac disease

A

Co managed with cardiologist!!!!!

Ekg, echo, avoid na, left lateral position, no strenuous, prevent anemia, avoid infection, fetal echo

443
Q

Delivery cardiac disease

A

Vaginalis unless obstetric indications

Antibiotic prophylaxis for endocarditis in high risk patients

Acute cardiac decompensation with congestive heart failure is managed as a medical emergency

444
Q

Immune idiopathic thrombocytopenia

A

Immunoglobulins attach to maternal platelets

445
Q

Treat immune idiopathic thrombocytopenia

A
Begun after platelets from to 50000
Prednisone
IV immunoglobulin if severe 
Platelet transfusion
Splectomy
446
Q

Baby risk immune idiopathic thrombocytopenia

A

Neonatal thrombocytopenia can occur due to placental transfer of antiplatelet antibodies

447
Q

SLE

A

1/3 improve 1/3 same , 1/3 worse

448
Q

Treat sle flares

A

Prednisone

449
Q

Fetal complications sle

A

Preterm delivery restrictions
Still birth
Miscarriage

450
Q

10% risk for neonatal lupus passive transfer of anti ro.ssa or anti la/SBS

A

SLE

451
Q

Antiphospholipid syndrome

A

Presence of lupus anticoagulatn and or anticardiolipin antibody

Associated with arterial or venous thrombosis

452
Q

Pregnancy complications antiphospholipid syndrome

A

Increase risk of miscarriage

Risk for developing preeclampsia

Fetal growth restriction

453
Q

Treated during pregnancy with heparin/low olecular weight heparin and low dose asprin

A

If history of thrombosis-full anticoagulation

454
Q

Acute renal failure

A

Due to rpeexisting renal disease or pregnancy induced

455
Q

Three types acute renal failure

A

Pre renal renal post renal

456
Q

Pre renal

A

Acute blood or fluid loss

457
Q

Renal

A

Usually preexisting disease or hypercoagulable state

458
Q

Post renal

A

Rare, urologic obstructive lesions

459
Q

What do if renal pro

A

Urine output, BUN:Cr, fractional excretion of Na, uring osmolality

Cvs study-in labor need swan gang catheter

Urologic-foley catheter, renal us to diagnose obstructive source

460
Q

Treat pre renal

A

Retort volume

Electrolytes, diuretic, flus restriction, hemodialysis

461
Q

Post renal treat

A

Mechanics to remove the obstruction

Left lateral position, urethral catheter, possible surgical intervention to remove stone

462
Q

Chronic renal failure

A

Bad outcome

Cr>1.5-2 worsens prognosis

463
Q

Treat chronic renal failrue

A

Monitor renal function with 24 hour urine collections for protein and cr clearance , manage htn, fetal surveillance with growth us and nonstress tests/biophysical profiles

464
Q

Post renal transplant

A

Not recommended
May lose graft function or experience rejection; best candidates are 1-2 years post transplant with stable cr and proteinuria without severe htn

465
Q

Fetal complications post renal

A

Steroid induced adrenal and hepatic insuffiency, prematurity, intrauterine growth restriction

466
Q

Asymptomatic bacteriuria

A

More likely to lead to cystitis and pyelonephritis in pregnant women

From urinary stasis and glucosuria

467
Q

Initial asymptomatic bacteriuria

A

Urine culture at initial prenatal visit

468
Q

Most common Asymptomatic Bacteruria

A

E. coli

469
Q

Treat asymptomatic bacteriuria

A

Antibiotic (3 or more if recurrent)

470
Q

Pyelonephritis signs

A

Fever, costovertebral tender, malaise, WBC up

471
Q

Issue pyelonephritis

A

Increase uterine activity and preterm labor

Result in adult respiratory distress syndrome

472
Q

Treat pyelonephritis

A
IV hydration
Antibiotics
Antipyretic
Tocolytics 
Suppression remainder pregnancy
473
Q

N/v in pred

A

8-12 weeks not known why

474
Q

Treat n/v preg

A

Symptomatic

475
Q

Hyperemeis gravidarum

A

Persistent nausea and vomiting >5% loss of pre preg weight, ketonuria, dehydration

476
Q

Who get hyperemesis gravidarum

A

Occurs more frequently in first pregnancy, multiple pregnancies, trophblastic disease

477
Q

Treatment hyperemesis gravidarum

A

Outpatient management fails then may need hospitalization for IV fluids, electrolytes, glucose, vitamins and Anti-emetic

Severe-may need nasogastric feeding or parental nutrition

478
Q

Gerd common how treat

A

Small meals, avoid lying down after meals, elevate head when sleeping, antacids, H2O blocs

479
Q

Peptic ulcer

A

Preg may improve

Diagnose symptoms, and only endoscopy if severe or signs of gi bleeding

480
Q

Treat peptic ulcer

A

No caffeine, alchol tobacco, spicy foods

Antacids, H2O blockers/proton pump
Treat H pylori

481
Q

Mendelsons syndrome

A

Acid aspiration syndrome

Preg women get from delayed gastric emptying and icnreased intrabadominal intra gastris pressure

482
Q

Treat mendelsons

A

Supplemental o2, maintain airway, treat for acute respiratory failure

483
Q

Prevent mendelsons

A

Decrease acid ins tomach

Do not feed in labor

484
Q

Ibd

A

Fine in pred, IC more active

If bowel disease active at time of conception may increase miscarriage

485
Q

Treat ibd preg

A

Acute exacerbation is same as non preg

486
Q

Intrahepatic cholestasis of pregnancy

A

Cholestasis and pruritis is second half ofpregnancy

487
Q

ICP associated

A

Can recur with each pregnancy

Association with oral contraceptives and multiple gestation

Benign course for maternal consequences

Increase risk of meconium strained amniotic fluid and fetal demise

488
Q

Symptoms ICP

A

Itching without abdominal pain r rash

Labs reveal elevated serum bile acids and occasionally elevated liver enzymes

489
Q

Treat icp

A

Local treatment cold baths, bicarbonate washes

Use ursodeocycholic acid

Fetal surveillance and delivery at early term

490
Q

Acute fatty liver of pregnancy

A

Scary!
Diffuse fatty infiltration of liver resulting in hepatic failure

1 per 14000 pregnancies

491
Q

Symptoms scute fatty liver

A

Ab pain, nv, jaundice , irritability, polydipsia/pseudodiabetes insipidus, HTN.proteinuria in 50% of cases

492
Q

Lab finding acute fatty liver

A

Increase prothrombin time and partial thrombophlebitis time, elevated bilirubin, ammonia and uric acid and elevation of liver transaminase

493
Q

Treat acute fatty liver

A

Termination pregnancy

Supportive care-IV fluids with 10% glucose, FFP and cryoprecipitate

494
Q

Maternal fetal mortality acute fatty liver

A

Yup both about 10-20%

495
Q

If survive acute fatty liver

A

Full recovery

496
Q

Anemia

A

Physiology decreas in hgb/hematocrit during pregnancy

Hematocrit less than 30% or a HgB concentration less than 10 g/dL

497
Q

Most common reason for iron defiency

A

Screened at initial prenatal visit and again 26-28 weeks

Treat iron supplementation-oral or IV

498
Q

Preg is hypercoagulably

A

5 fold increase in venous thrombosis and greatest risk is fist 5 weeks postpartum

499
Q

Superficial thrombophlebitis

A

Most common in patients with varicose gains, obesity and little physical activity

Most common in calf, will not result in pulmonary emboli

500
Q

Symptoms hpercoagulable

A

Most common in patients with varicose veins, obesityand littlen physical activity

Most common in calf, will not result in pulmonary emboli

501
Q

Symptoms hypercoagulable state

A

Swelling, ternderness

502
Q

Treat pregnancy hypercoagulable

A

Bed rest , pain medication, local heat, no need for anticoagulants, wear support hose

503
Q

Dvt

A

1/2000 antepartum 1/700 antepartum

504
Q

Symptoms dvt

A

More common in the left leg than the right

Pain in the calf with dorsiflexion

May also have dulla Che, tingling or pain with walking

505
Q

Diagnose dvt

A

50% asymptomatic

compression US with Doppler

MRI suspect pelvic thrombosis

506
Q

Treat dvt

A

Anticoagulation

Low molecular weight or unfractioned heparin
-PTT values with heparin and factor Xa values with lovenox

Coumadin for 6 weeks postpartum nut not during preg

507
Q

Pulmonary embolism

A

Maternal mortliaity -80% untreated treated 1%

From dvt

508
Q

Symptoms pulmonary embolism

A

Pleuritic chest pain, shortness of air, air hunger, palpitations, hemoptysis

509
Q

Signs pulmonary embolism

A

Tachypnea, tachycardia, low grade fever, pleural friction rub, chest splinting, pulmonary rales, accentuated pulmonic valve second heart sound

510
Q

Pulmonary embolism

A

Ekg, chest x ray, arterial blood gas, ventilation perfusion scan, helical computed tomography

511
Q

Treat pulmonary embolism

A

Anticoagulation

512
Q

Thrombophlebitis work up for dvt or pulmonary emboli

A

Lupus anticoagulatnts, anticardiolipin antibody, factor v Leiden, protein c and s, antithrombin III, prothrombin G20210A

513
Q

All patients with history of thromboembolism need what

A

Prophylactic anticoagulant

514
Q

Asthma

A

Most common pregn pulmonary disease!

1.3 better 1.3 same 1/2 worse

515
Q

Severe asthma problem

A

Miscarriage, preeclampsia, intrauterine fetal demise, intrauterine fetal growth restriction, preterm delivery

516
Q

Treat asthma

A
Mile-SABA
Mild persistence-low dose inhaled CS
Moderate persistent0saily inhaled corticosteroid combined with long acting inhaled beta agonist
Severe persistent-add systemic CS
Maternal monitoring
517
Q

Fetal monitoring asthma

A

Serial growth US, NST.biophyscial profiles, deliver for fetal growth restriction or maternal deterioration

518
Q

Labor and delivery asthma

A

Stress dose of IV steroids if using daily inhaled or high potency oral for more than 3 weeks

519
Q

Tension HA

A

Most common

Give acetaminophen

520
Q

Migraines

A

Highes prevenalce in childbearing years

Improve preg
Neurology can be helpful

521
Q

Multiple sclerosis

A

Diagnose at 30

Fewer and less severe pregnancy but may exacerbate post partum

Increased risk LBW, C section

522
Q

Seizure rate in preg

A

Not alter

523
Q

Treat seizure

A

If seizure fre 2 years propr to conception may stop

Monotherapy at lowest dose

524
Q

Med for seizure

A

Alt eratogen

525
Q

Valproate

A

Noooooooooooo

526
Q

Most common preg ant seizure

A

Dilatin phenobarbital

527
Q

What give women on anti epileptics

A

1-4 mg of folic acid

528
Q

Anti epileptic complications preg

A

Preeclampsia, placental abruption, hyperemesis, premature labor, intrauterine fetal demise, congenital cleft lip and palate and cardiac anomalies

529
Q

Depression

A

Arise and recur postpartum in 10%

530
Q

Risk factors post partum depression

A

Personal or family history depression
History of abuse
Drug use
History of personality disorder

531
Q

Treat post partum depression and anxiety

A

Counseling

Antidepressants -not 1st trimester and if 3rd may get neonatal withdrawal

532
Q

Post partum depression

A

70-80% from hormonal fluctuations get maternal blues

10-15 depression

533
Q

Treat post partum

A

Counseling an medication

534
Q

Risk post partum depression

A

Depression during pregnancy

Younger women

535
Q

Operative

A

Non spontaneous

Vaginal forceps assisted, vacuum extracted /c section

536
Q

Operative vaginal delivery

A

Direct traction with vacuum extractor or forceps

537
Q

Maternal indications for operative vaginal

A

Maternal exhaustion/lack of expulsion effort

Inability to have expulsive effort
-spinal cord injuries, neuromuscular disorders

Need to avoid maternal expulsive efforts-certain cardiac conditions, cerebrovascular disease

538
Q

Fetal indications for operative vaginal delivery

A

Non reassuring fetal status (bradycardia, repetitive heart rate decelerations)

539
Q

Other indications operative vaginal delivery

A

Prolonged second stage of labor
Nulliparous>2 hours without regional anesthesia or>3 hours with regional anesthesia

Multiparous >1 hour without regional anesthsia or> 2 hours with regional anesthesia

540
Q

Prerequisites for maternal vaginal delivery

A

Adequate analgesia, lithotomy position, bladder empty, verbal or written consent

541
Q

Fetal prerequisites for operative vaginal delivery

A

Vertex presentation, fetal head must be engaged (biparietal diameter at 0 station), position fothe fetal head must be known with certainty, station fo hte fetal head must be> 2

542
Q

Ureteroplacentla criteria prerequisites for operative vaginal delivery

A

Cervix fully dilated, membranes ruptured, no placenta previa

543
Q

Outlet operative vaginal delivery

A

Scalp visible without labia separation

Fetal skull reached the pelvic floor

Sagittal suture is in the anteroposterior diameter or right or left occiput anterior or posterior position
Fetal AED at perineum

Rotation not exceed 45 degrees

544
Q

Low operative vaginal delivery

A

Leading potent of the fetal head is at +2 station or more and is not on the pelvic floor

545
Q

Midpelvis and high forceps operative vaginal delivery

A

Fetal skill is above +2

Not ever indicated today

546
Q

If you aren’t positive of position

A

Don’t do forceps

547
Q

If they don’t articulations easily-reapply. If they still don’t articulate well

A

Don’t apply

548
Q

Always

A

Make sure no vaginalis tissues or the cervic are caught in the forceps

Blades should dit the fetal head evenly, should lie against the fetal head so that they cover the space between the orbits and ears

549
Q

Traction is applied into e plane of least resistance and follows the pelvic cord-if not come early

A

Stop

550
Q

Maternal complications forceps

A

Lacration of vagina/cervic, episiotomy extension, pelvic hematoma, urethral and bladder injuries, uterine rupture

551
Q

Fetal complications forceps

A

Facial laceration, forcep marks, brachial plexus injur, skull fracture, intracranial hemorrhage, seizures

552
Q

Vacuum

A

Indications requirements exactly same

Advantage-little maternal analgesia

553
Q

Contraindications vacuum

A

Gestational age less than 34 weeks

Suspected fetal coagulation disorder
Suspected fetal macrosomia

Breech

554
Q

How do vacuum assisted vaginal delivery

A

Applied to fetal head with a mechanical pump

Steady traction

No rocking or torque on the device

No rocking or torque on the device

Incidence of serious complication is about 5%

555
Q

3 checks for forceps

A

No material tissue trapped int he cup, cup should be placed int he midline of the sagittal suture, the vacuum port of the suction cup should point toward hte occiput

556
Q

What o with vacuum between contractions

A

Release suction

557
Q

How many pop offs ok

A

No more than 2

558
Q

How long can we vacuum

A

No mroe than 20 minutes

559
Q

Can u turn or twist device

A

No

560
Q

Complication vacuum vs forceps

A

More failures deliveries

Fewer perineal injuries

Icnreased incidence of delta cephalohematoma

More scalp lacerations and bruising

561
Q

C section

A

Delivery of a fetus through a surgical incision of the anterior uterine wall

Rate is climbing

562
Q

Fetal indication c sectio

A

Nnonreassuring fetal heart rate

Reach presentation/transverse presentation
Very low birth weight

Active herpes

Immune theomocytopenia purpura

Congenital anomalies

563
Q

Maternal fetal indications c section

A

Cephalopelvic disproportion

Failure to progress
Placental abruption

Placenta previa

564
Q

Maternal indications c section

A

Obstructive benign and malignant tumors

Large vulvar condyloma

Abdominal cervical cerclage

Prior vaginal colporrhaphy

Conjoined twins

Maternal requires

565
Q

Intraoperative complications c section

A

Uterine artery lacerations, bladder injuries, urethral injures, GI injury, uterine atony, placenta accretion, c hysterectomy

566
Q

Post op complications c sectio

A

Nendoyometritis

Wound-infection, separation, dehiscence

Urinary complications, ileus diarrhea, thromboembolic disorders (pulmonary emboli/dvt), septic pelvic thrombophlebitis

567
Q

Preterm labor

A

After 20 weeks before 37

568
Q

Diagnose preterm labor

A

Uterine contractions with cervical change or cervical dilation of 2 cm and/or 80% effaced

569
Q

Leading cause of infant mortality

A

Prematurity

570
Q

Socioeconomic factors PTL

A
African Americans 
Decreased access prenatal care
High stress
Poor nutrition
Genetics
571
Q

Medical obstetric PTL risk

A
Previous
History 
SAB
Bleeding 1st trimester
UTI/genital infections
Multiple gestation
Polyhydramnios, 
Incompetent cervix
572
Q

Pathways to prevent PTL

A

Infection
Placental-vascular
Psychosocial
Uterine stretch

573
Q

Infection

A

Bacterial vaginosis
Group B strep
Gonorrhea, chlamydia

574
Q

Treat infection

A

Antibiotics,

575
Q

Link between infection and what that is a risk for preterm

A

Cervical length

576
Q

Cervical length 3.5 cm or up RR 2.4

Cervical length 2.5 cm RR 6.2

A

Relative risk of PTL increases as cervical length decreases

577
Q

How assess cervical length

A

US

Fetal fibronectin (FFN)-released from the BM of the fetal membranes

Released in response to disruption of the membranes as with uterine activity, cervical shortening or infection

578
Q

Placental vascular pathway

A

Immunologic component
Vascular component
Low resistance connection of spiral arteries

579
Q

Stress strain pathway

A

Mental and physical stress increase cortisol and catecholamines

580
Q

Cortisol

A

From adrenal

Stimulates early placental CRH known to help in labor

581
Q

Catecholamines

A

Affect blood flow an can cause uterine contractions

582
Q

How treat stress strain

A

Nutrition and stress reduction

583
Q

Risk factors for uterin stretch

A

Polyhydramnios

Multiple gestation

584
Q

Symptoms PTL

A

Cramps, backache, pelvic pressure, increase in discharge/bloody discharge, uterine contractions

585
Q

What do when present

A

Initial-cervical exam to see dilation, effacement and fetal presentation

Look for correctable prob like infection

External monitoring for uterine activity and fetal HR

Oral or IV hydrate

Reevaluate cervic in an hour

Culture for groups strep and gonorrhea and chlamydia (once diagnosis CBC, urinalysis and urine culture)
US

586
Q

Hydrationa d bed rest

A

Works 1/5

587
Q

I f 2 cm an or80 % effaced or made cervical change what do

A

Tocolysis

Mg sulfate

Nifedipine

Prostagladin synthase inhibitors

588
Q

Mg sulfate

A

Yes
Competes with ca for entry into the cell at time of depolarization

IV

NEUROPROTECTIVE (cerebral palsy, )

If less Han 32 weeks

589
Q

AE MG sulfate mom

A
Feeling of warmth and flushing 
NV 
Respiratory depression
-seen with serum levels 12-15
Cardiac conduction
590
Q

AE fetal mg sulfate

A

Loss of msucle tone, drowsiness, low APGARs

591
Q

Nifedipine

A

Oral suppress preterm labor

Minimal side effects

Inhibits slow, inwar current of ca during the second phase of the action potential

592
Q

Prostagladin synthetase inhibtiors

A

Inhibits prostagladin production that induce myometrial contractions

Used on a short term basis

Indomethacin-oral orrectal

593
Q

AE indomethacin

A

Oligohydramnios, preterm closure of fetal ductus arteriosus and cause pulmonary HTN

594
Q

Indomethacin fetal risk

A

Necrotizing enterocolitis and intracranial hemorrhage

595
Q

NSADIS

A

Can decrease uterine activity

Not for primary tratment

When not meet diagnosis preterm labor or after discontinuing mg to decrease prostagladin procuction

596
Q

When give glucocorticoids for fetal lung maturation

A

24-34 weeks gestation

Effects last 7 days

597
Q

Pregnant women between 34 0/7 weeks and 36 6/7 weeks at risk preterm within 7 days and no antenatal corticosteroids

A

Single course of betamethasone

598
Q

Vertex presentation PTL

A

Vaginal delivery preferred

-some recommended c section for very low birt weight

599
Q

If breech presentation

A

Increased risk of cord prolapse of compression as well s head entrapment with vaginal delivery therefore most will c section

600
Q

Prevent PTL

A

Progesterone IM

Women with previous PTL/PPROM
Smooth msucle relaxant is the thorny

601
Q

Vaginal progesterone

A

Used in women with shortened cervix <2.5

602
Q

Pessary Arabian pessary

A

Women with short cervix

603
Q

PROM

A

Rupture before labor onset at any gestational age

604
Q

Risk factor PROM

A

Vaginal/cervical infections
Abdominal membranes
Incompetent cervix
Nutritional defiencies

605
Q

Diagnose PROM

A

History! Loss of fluid and amniotic fluid in vagina

606
Q

Why not check cervix of PROM presumed

A

Infection

607
Q

How confirm rupture

A

Sterile speculum

608
Q

3 tests to confirm PROM

A

Pooling
Nitrazine paper
Ferning

609
Q

False positive nitrazine

A

Urine, semen, cervical mucous, blood, vaginitis

610
Q

False negative nitrazine

A

Remote PROM with no remaining fluid

Minimal leak

611
Q

Intact amniotic sac

A

Barrier to infection preventing chirioamniotitis

612
Q

Maternal risk PPROM

A

Endomyometritis
Sepsis
Failed induction due to unfavorable cervix

613
Q

PROM less than 24 weeks

A

Pulmonary hypoplasia and structural abnormalities from position

614
Q

Amniotic fluid index less than 5

A

Oligohydramnios and no fluid is called anhydramnios

615
Q

Conservative management PPROM

A

Continue preg until lung mature
Assess lung maturity with vaginal poor of amniotic fluid

Most deliver at 34 weeks

616
Q

When do most PPROM deliver

A

34 weeks

617
Q

Diagnose PROM

A

Maternal temp 100.4
Fetal maternal tachycardia
Tender uterus
Foul smelling amniotic fluid/purulent discharge

618
Q

Antibiotic PPROM

A

IV ampicillin and erythromycin 48 hours

Amoxicillin and erythromycin and amoxicillin 5 days

619
Q

Tocolytic PPROM

A

Sure

620
Q

Steroids PPROM

A

Reduce risk RDS up to 34 weeks

621
Q

When type I pneumocytes ok

A

24 weeks start making surfactant

622
Q

How tel FLM

A

Phosphatidylinositol and phosphatidylglycerol from amniocentesis

623
Q

L/S ration

A

Greater than 2 is mature

Lecthicin increase rapidly after 35 weeks

624
Q

What is phosphatidylglycerol is present

A

Mature lungs

625
Q

Rapid test FLM

A

Lamellar body number density assessment

2 hours (6-12 for amniocentesis)

More sensitive and predictive

626
Q

IUGR

A

Below the 10% for a given gestational age

627
Q

Causes IUGR

A

Maternal, placental, fetal

628
Q

Maternal IUGR

A
Poor nutritional intake/maternal low body weight 
Smoking
Drug abuse
Alcoholism
Cyanosis heart disease
Pulmonary insuffiency
Antiphospholipid syndrome
Hereditary theomvophilias
Collagen vascular disease
629
Q

Placental IUGR

A

Insufficient substrate transfer through placenta as well defective trophoblast invasion

630
Q

Conditions that may result in placental insuffiency

A

HTN, renal disease, placental or cord abnormalities such as velamentous cord, diabetes

631
Q

Fetal IUGR

A

Inadequate substrate
-TORCH
Congenital anomalies, multiple gestations, chromosomal abnormalities

632
Q

Diagnose IUGR

A

PE fundal height

US biometry

Amniocentesis, percutaneous umbilical blood sampling

Doppler studies

633
Q

Diagnose IUGR

A

Serial fundal measurement is primary screening tool

634
Q

What do if fundal height lags more than 3 cm behind the gestational age then order an

A

US

635
Q

US is routinely for high risk conditions that predispose to IUGR

A

HTN, renal disease, diabetes, drug abuse, antiphospholipid syndrome, lupus

636
Q

Pre pregnancy IUGR prevent

A

Optimize disease processes

637
Q

Antepartum manage IUGR

A

Decrease modifying factors-improve nutrition, sop smoking, bed rest

Deliver before fetal compromise but after fetal lung maturity monitor:
Non stress test twice weekly, biophysical profile, Doppler studies of umbilical artery

638
Q

Nonstress test

A

Patient lateral tilt position, the fetal heart rate is monitored with an external transducer. The tracing is observed for fetal heart rate accelerations that peak at least 15 beats per minute above the baseline and last 15 seconds from baseline to baseline. It may be necessary to continue the tracing for 40 min

639
Q

When omit nonstress test

A

All four US components normal

640
Q

Fetal breathing movements

A

One or more episodes of rhythmis fetal breathing movements of 30 seconds or more within 30 mintues

641
Q

Fetal movement

A

Three or more discrete body or limb movements within 30 minutes

642
Q

Fetal tone

A

One or more episodes of extension of a fetal extremity with return to flexion or opening or closing of a hand

643
Q

Amniotic fluid volume

A

A single vertical pocket of amniotic fluid exceeding 2 cm is considered evidence of adequate

644
Q

Each 5 components given score

A

2

645
Q

Composite score

A

8-10

646
Q

6

A

Equivocal

647
Q

4

A

Abnormal

648
Q

Doppler study umbilical artery

A

Vascular impedance

Umbilical flow velocity waveform of normally growing fetuses is characterized by high velocity diastolic flow, whereas with intrauterine growth restriction, there is a dimunition of umbilical artery diastolic flow

649
Q

What do is suspect IUGR

A

US-if ok no intervention

US-abnormal intervene

650
Q

US IUFR and greater than 38-39 weeks

A

Deliver

651
Q

US IUFR less than 38-39 weeks

A

Antenatal testing normal-continue pregnancy

Antenatal testing abnormal -delivery

652
Q

Antenatal testing normal

A

Continue preg

653
Q

Antenatal testing not normal

A

Deliver

654
Q

C secretion with IUGR

A

May benefit

Will need continuous fetal monitor

655
Q

After birth IUGR

A

Monitor neonatal blood glucose bc these neonates have less hepatic glycogen stores

Monitor respiratory status as respiratory distress syndrome is more common

656
Q

Prognosis IUGR

A

Greater risk DM, HTN, atherosclerosis as adults

657
Q

Post term preg

A

Over 42 weeks 10% with a 2-3x high perinatal mortality

658
Q

Postmaturity syndrome

A

Related to aging and infarction of the placenta

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

659
Q

Post term also at risk with what

A

Macrosomia, abnormal labor, shoulder dystocia and c section

660
Q

Postterm pregnancy etiology

A

Unsure dates, fetal adrenal hypoplasia, anencephalic fetuses, placental sulfatase defiency, extra uterine pregnancy

661
Q

41st week

A

Begin antenatal testing to include twice weekly NST and biophysical profile
If testing abnormal or oligohydramnios induce labor (AFI lesss than 5 cm)

662
Q

42 week

A

Induction of labor

Induction of labor at 41 weeks preferred plan

663
Q

IUFD

A

Intrauterine fetal demise

Fetal death after 2 weeks but before onset of labor

664
Q

Most causes IUFD

A

Unknown

665
Q

Diagnose IUFD

A

Suspect if patient complains of absence of fetal movements or if unable to Doppler fetal tones

Confirm by US with lack of fetal activity and absence of fetal cardiac activity

666
Q

IUFD watchful expectancy

A

Only up till 28 weeks gestation, spontaneous labor will occur in 2-3 weeks of fetal demise

667
Q

Manage IUFD

A

Most will require cervical ripeningwith prostagladin/laminaria/misoprostol/oxytocin

668
Q

Manage IUFG monitoring of coagulopathy

A

Patients with IUFD are at risk of disseminated intravascular coagulopathy: need to follow complete blood count, fibrinogen level, PT/PTT/INR

669
Q

Laminaria

A

Open up cervix

670
Q

Follow up IUFD

A

Look for cause TORCH, parvovirus, listeria, anticardiolipin……

671
Q

IUFD and future preg

A

Greater risk reoccurrence

672
Q

HTN pregnancy

A

10%

673
Q

Maternal risk HTN

A

MI, cardiac failure, cerebral vascular accident, renal failure, hepatic failure

674
Q

Fetal complications HTN

A

Fetal growth restriction, preterm birth, placental abruption, stillbirth, neonatal dearth

675
Q

Normal bp

A

<120/8-

676
Q

Stage I

A

Systolic 130-129 or

Diastolic between 80-89

677
Q

Stage 2

A

Systolic at least 140 or diastolic at least 90 mmHg

678
Q

Chronic

A

Present before or during 1st half of preg

679
Q

Gestational htn

A

After 20 weeks

680
Q

Preeclampsia

A

Occurs after 20 weeks gestation and coexists with proteinuria

681
Q

Eclampsia

A

New onset seizure activity associated with preeclampsia

682
Q

Superimposed preeclampsia

A

Transposed onto chronic HTN

683
Q

Evaluate chronic HTN

A

Rule out causes

Look for maternal end organ damage
-CBC, glucose, complete metabolic profile, 24 hour urine collection for total protein, EKG

Assess fetal wellbeing
-US, screening , growth US monthly after 28 weeks, antepartum fetal testing to begin 32-34 weeks gestation

684
Q

Mild HTN (less than 160/110)

A

Initiate antihypertensive if reach threshold

Visit every 2-4 weeks until 34-36 weeks and then weekly

Antepartum fetal monitoring
Deliver 39-40 weeks

685
Q

Severe HTN (greater than 160/110)

A

Methyldopa, labetalol, nifedipine

686
Q

When associated with renal disease

A

24 hr urine collection

687
Q

Antepartum fetal surveillance

A

Growth US every 3-4 weeks

Nonstress tests and or biophysical profiles

688
Q

Severe htn when deliver

A

38 weeks

689
Q

HTN without preeclampsia

A

After 20 weeks gestation

48-72 hrs after delivery
Resolves by 12 weeks

690
Q

Diagnose preeclampsia

A

HTN, proteinuria, edema

691
Q

Symptoms preeclampsia

A

Scoroma, blurred vision, epigastric and/or right upper quadrant pain, HA

692
Q

Risk preeclampsia

A
<20 >35
Primigravid
Multiple gestation
DM
Thyroid
HTN chronic
Collagen vascular disease
Antiphospholipid syndrome
Highest of it
693
Q

Bran preeclampsia

A

Cerebral edema

694
Q

Heart preeclampsia

A

Absence of normal intravascular volume expansion

reduction in circulating blood volume

695
Q

Lungs preeclampsia

A

Noncardiogenic pulmonary edema

-changes in colloid osmotic pressure, capillary endothelial integrity, and intravascular hydrostatic vessels

696
Q

Liver preeclampsia

A

Sinusoidal fibrin depositio in periportal areas with surrounding hemorrhage and portal capillary thrombi

Subscapularis hematoma-> liver rupture

Stretching of glisson’s capsule results in right upper quadrant pain

697
Q

Kidney preeclampsia

A

Swelling and enlargement of glomerular capillary endothelial cells

Narrowing of capillary lumen

698
Q

Eyes preeclampsia

A

Retinal vasospasm

Retinal edema

699
Q

Mild preeclampsia

A

Proteinuria >300 mg/24 hr uring but less than 5 gm/24 hr or single specimen uring protein: cr ration of .3 mg/dL

Asymptomatic

700
Q

Severe preeclampsia

A

Proteinuria 5gm/24 hr or 3+ protein on two random urine dips at least 4 hours apart

Oliguria from renal insuffiency

Symptomatic-cerebral or visual, pulmonary edema, epigastric or right upper quadrant pain, elevated liver enzymes, thrombocytopenia

701
Q

Oliguria

A

Renal insuffiency

702
Q

What do if have preeclampsia

A

HISTORY of htn or renal disease

Address HA, ab pain, n/vom vaginal bleeding, vision

703
Q

PE finding preeclampsia

A

Brisk reflexes, clonus, edema

704
Q

Lab finding preeclampsia

A

Increased hematocrit, LD, ALT AST, uric acid

Thrombocytopenia (low paltelet0

705
Q

Manage severe preeclampsia les than 37 weeks

A

Bed rest, 1 BPP or twice NST weekly antepartum testing
Fetal growth US every 3-4 weeks
Office visits and laboratory evaluation
Possible hospitalization

706
Q

Manage severe preeclampsia 37-40 weeks

A

If favorable cervix induction

If unfavorable cervix use a cervical ripening agent to begin induction

707
Q

Manage immediate severe features preeclampsia

A

Immediate hospitalization, delivery if greater than 34weeks

Hydralazine, labetalol, nifedipine

If less than 37 weeks administer corticosteroids and work towards delivery as long as patient and fetus are stable

708
Q

Intrapartum management

A

Vaginal delivery

Cervical ripening agents and pitocin as necessary

Mg sulfate for seizure prophylaxis

Pain management as with delivery useless thrombocytopenia then may not be able to receive an epidural

709
Q

Mg sulfate

A

Loading dose for preeclampsia 4 gm

Maintenance dose 2 gm/hr

Therapeutic value 5-9 mg/dL

710
Q

Why not give mg sulfate over 7-8 mg/dL

A

Loss patellar reflexes, respiratory paralysis, cardiac arrest

711
Q

How revers mg sulfate

A

Calcium glucoronate

712
Q

Fluid restriction with mg sulfate

A

Prevent overload

713
Q

Eclampsia

A

1-3 per 1000 patients

Most seizures 1-2 min and 24 hours before delivery

714
Q

What do eclampsia

A

Protect airway is first

715
Q

First line treatment eclampsia

A

Mg sulfate

716
Q

Persistent aclampsia

A

Lorazepam

717
Q

HELLP

A

Hemolysis, elevated liver , low platelets

Severe preeclampsia patients and 50 % eclampsia

718
Q

Symptoms HELLP

A

Right upper quad pain, epigastric pain, n/v , HTN, proteinuria

719
Q

Prevent eclampsia

A

Asprin

720
Q

Relaxation uterus

A

Increase cAMP

721
Q

Contraction uterus

A

Increase intracellular Ca

Promote interaction of actin and myosin causing uterine contractions

722
Q

Two segments of the uterus during labor

A

Upper segment-actively contracts and retracts to expel the fetus the lower segment-along with cervic becomes thinner and passive

723
Q

Cervix change in labor

A

Soft pliable, dilateble structure

-these structural changes from collagenous is, incrase in hyaluronic acid, decrease in dermatan sulfate which favors increased water content

724
Q

Labor

A

Regular uterine contraction of sufficient intensity, frequency, and duration to bring about demonstratable effacement and dilation of the cervix

725
Q

First stage of labor

A

Onset of contractions to full dilation of cervix

726
Q

Second stage

A

Full dilation of cervix to delivery of the infant

727
Q

Third stage

A

Delivery of the infant to delivery of placenta

728
Q

Latent phase

A

Cervical softening and effacement occurs with minimal dilation

729
Q

Active phase

A

Starts when cervix is dilated to 4 cm

This phase of labor includes both cervical dilation and ultimately, descent of the presenting fetal part

Acceleration phase

Deceleration phase

730
Q

Protraction of a phase of labor

A

Slower than normal

731
Q

Arrest disorder of labor

A

Complete cessation of progress

732
Q

An arrested latent phase

A

Labor has not begun

733
Q

Dysfunctional labor

A

Rates of dilation and descent exceed times of normal labor

734
Q

Normal limits of latent phase for nulliparous and multiparous

A

Up to 20 hrs

Up to 14 hrs

735
Q

Prolonged latent phase effect

A

Little

736
Q

Etiology of prolonged latent phase

A

Without substantial cervical change
Excessive use of sedatives or analgesics
Fetal malposition

737
Q

Manage abnormal latent phase

A

Rest

Morphine

738
Q

Normal limits of fetal descent nulliparous and multiparous

A

Nulliparous 1 cm/hr

Multiparous 2 cm/hr

739
Q

Protraction of fetal descent (active phase)

A

Less then what is expected

740
Q

No change in descent has occurred in 1 hr

A

Arrest has occurred

741
Q

Risk of perinatal mortality latent vs active phase

A

No increased risk

742
Q

Etiology of active phase abnormalities

A

Inadequate uterine activity
Cephalopelvc disportion
Fetal malposition
Anesthesia

743
Q

Dystocia

A

Difficult labor/dysfunctional labor

744
Q

Three P of active phase of labor

A

Power, passenger, passage

745
Q

When not make a diagnosis of dystocia

A

Not be made before an adequate trial of labor has been tried

746
Q

Augmentation

A

Refers to stimulation of uterine contraction when spontaneous contraction have failed to result in progressice cervical dilation or descent of the fetus

747
Q

When consider augmenting

A

Contractions less than 3-10 minute period and or intensity is less then 25 mmHg

748
Q

What give for protraction

A

Oxytocin

After look at maternal pelvis, fetal position, station, maternal and fetal status

749
Q

Intrauterine pressure catheter for assessing 3P of active phase

A

Soft plastic catheter placed transcervically

Gives precise measurement of the intensity of the uterine contractions in mmHg

750
Q

IUPC requires what

A

Membranes to be ruptured

751
Q

Benefits. IUPC

A

Augment labor, allows assessment of meconium status

752
Q

Risk IUPC

A

Cord prolapse, prolonged rupture is associated with chorioamnionitis

753
Q

Minimal effective uterine activity

A

3 contractions in a 10 minutes period averaging 25 mmHg abover baseline

754
Q

Montevideo units (MVU)

A

Calculated by measuring the peaks of contractions in mmHg in a 10 min period

755
Q

> 200 MVU

A

For at least2 hours

756
Q

Before c section

A

Document adequate contractions at least for 4 hours

757
Q

Pitocin

A

FDA approved medicine for labor stimulation

758
Q

MOA pitocin

A

Stimulates uterine contractions

Increase intracellular Ca in

759
Q

When is uterus most sensitive to pitocin

A

20-40 weeks

760
Q

How long for pitocin to take effect

A

20-30 min

761
Q

Cephalopelvic disproportion

A

Disparity between the size of the maternal pelvis and the fetal head that preculdes vaginalis delivery

CPD causes a failure of descent and sometimes engagement of the head

Nulliparous women who present in labor wth an unengaged head indicate an increased likelihood of CPD

762
Q

Gynecoid and anthropoid pelvis have good prognosis for delivery

A

Pubis are how>90
Ischial tuberosity>8.5
Diagonal conjugate>11.5
Prominence of ischial spines

763
Q

Presentation other than ___ are abnormal in labro

A

Vertex occiput anterior (OA

764
Q

How get to OA

A

Fetal head enters and engage the maternal pelvis in occipitotransverse position then rotated to OA

765
Q

What if no go to AO

A

Rotate to OP or stay OT

766
Q

Macrosomia, shoulder dystocia, fetal anomalies

A

Also dystocia

767
Q

Persistent OT

A

No rotate to OA

Caused by CPD, android or platypelloid pelvis, relaxed pelvic flood (epidural

768
Q

Transverse arrest of descent

A

Persistent OT position with arrest of descent for a period of 1 hr or more

769
Q

Why arrest OT

A

Deflection positions the occipitofrontal diameter 11 cm becomes presenting diameter

+1 +2 stations

770
Q

Occipitofrontal

A

11 cm

Head deflected

Seen in OT and OP

771
Q

Manage OT if pelvis adequate, infant not macrosomia and contractions are inadequate

A

Oxytocin

Rotation manuallly or keilland forceps

772
Q

Manage OT if pelvis inadequate or infant macrosomia

A

C section

773
Q

Persistent OP position

A

Most go to OA in labor

OP labor usually normal if not may have prolonged second stage , more back discomfort

774
Q

Manage OP

A

Prolonged labor in second stage

Delivery of head often occurs spontaneously

Or operative vaginal delivery -vacuum or forceps

775
Q

Macrosomia

A

Over 4500 g

Account for 1.5% of births

776
Q

Large for gestational age

A

Birth weight equal to or greater then 90% for a given gestational age

777
Q

How diagnostic macrosomia

A

US imprescise

778
Q

Hydrocephalus

A

May cause enlargement of the head that makes vaginal delivery impossible

Usually see with US

779
Q

Fetal ascites or enlargement of fetal organs (liver) can result in a dystocia secondary to enlarged fetal abdomen

A

Immune. Hydrops Rh isoimmunization is most common

Nonimmune hydrops-caused by congenital infections, chromosomal abnormalities or fetal arrhythmias

780
Q

Locked twins

A

Baby a breech, baby b vertex

781
Q

3 p

A

Power passage passenger

782
Q

LGA

A

Birth weight >90% for gestational age

783
Q

Macrosomia

A

> 4500 grams

784
Q

Risk factors for macrosomia

A

Maternal diabetes, previous history, maternal pre preg obesity, weight gain, mulitparity, male fetus, >40 weeks, maternal birth weight, maternal height, maternal age <17 years , +50 g glucose screen with a negative 3 hr

785
Q

Maternal morbidity with macrosomia

A

C section

Post partum hemorrhage and significant vaginal lacerations

786
Q

Fetal morbidity and mortality

A

Shoulder dystocia, fracture clavicle, damage to nerves of brachial plexus (c5, c6) resulting in era duschenne , brachial plexus injuries are rare and majority resolve without any permanent injury

787
Q

Brachial plexus injuries and macrosomia

A

Increase 21x

788
Q

Err duschenne

A

Upper arm palsy

Most common brachial plexus injury

C5 c6

789
Q

Klumpke

A

Lower arm palsy

Damage c8-t1

790
Q

Paralysis entire arm

A

All four nerve roots

791
Q

> 5000 grams non diabetic

>4500 grams diabetic

A

C section

792
Q

Shoulder dystocia

A

Delivery that requires additional obstetric maneuvers following failure of gentle downward traction on the fetal head to effect delivery of the shoulders

793
Q

Cause of shoulder dystocia

A

Impaction of the anterior fetal shoulder behind the maternal pubic symphysis or the impaction of the post shoulder on the sacral promontory

794
Q

Turtle sign

A

Retraction of the delivered fetal head against the maternal perineum

795
Q

Antepartum risk factors shoulder dystocia

A
Fetal macrosomia
Maternal diabetes
Obesity
Post term gestation
Short stature
Previous history macrosomia
Previous history of shoulder dystocia
796
Q

During labor risk for shoulder dystocia

A

Labor induction
Epidural analgesia
Prolonged labor
Operative vaginal deliveries

797
Q

Neonatal risk shoulder dystocia

A

Erbs most common, klumpke, fractured clavicle or humerus, hypoxic, death

798
Q

Mcroberts maneuver

A

Hyperflexion and abduction of the maternal hips

799
Q

Suprapubic pressure

A

May dislodge the impacted anterior shoulder

Do not apply fundal pressure

800
Q

Zavanelli maneuver for shoulder dystocia

A

Cephalic replacement, last resort, poor prognosis significant risk of fetal morbidity and mortality

801
Q

Rubin maneuver shoulder dystocia

A

Place pressure on an accessible shoulder to push it toward the anterior chest wall fo the fetus to decrease the bisacrominal diameter and free the impacted shoulder

802
Q

Woods corkscrew maneuver

A

Apply pressure behind the posterior to rotate the infant and dislodge he anterior shoulder

803
Q

Zavanelli maneuver

A

Last resort

Fetal head manually returned to its prostitution position

Slowly replaced int he vagina by steady upward pressure

Delivery is by emergent c section

804
Q

What do with shoudler dystocia

A

Obstetric emergency
Call for help, team

Can NOT be predicted or prevented and most accurate in absence of macrosomia

805
Q

Predict shoulder dystonia

A

Can’t

806
Q

Initial maneuver shoulder dystocia

A

Mcroberts and suprapubic

807
Q

Dizygotic twins

A

Two separate ova are fertilized by two separate sperm

Distinct pregnancies coexisting in same uterus

Each have own amnion, chorion and placenta

808
Q

Monozygotic twins

A

Arise from cleavage of a single fertilized ovum at various stages during embryogenesis

Arrangement of fetal membranes and placentas will depend on the time at which hte embryo divides

809
Q

Time of cleavage

A
Scab
0-3 dichorionic dimniotic
4-8 days monochorionic diamniotic
9-12 monochorionic, monoamniotic
>13 days conjoined twins
810
Q

Most monozygotic twins are what

A

Monochorionic diamniotic

811
Q

Most serious

A

Monochorionic monoamniotic

Not separating amnions
Cord entanglement , mortality 50-80%

812
Q

Craniopagus

A

Joined at the cranium

813
Q

Thoracopagus

A

Joined chest wall most common

814
Q

Ischiopagus

A

Joined at the coccyx and sacrum

815
Q

Dizygotic twins influence

A

2x more likely after 35

Familyhistory

Most spontaneous twins dizygotic

816
Q

When suggest multiple gestations

A

HCG higher than normal
Uterus palpated larger
Pregnancy has occured after ovulation induction or in vitro fertilization

Confirmwith US

817
Q

Increased risk of what with monozygotic

A
Congenital anomalies 
Weight discordance
Twin twin transfusion syndrome 
Neurologic sequelae
Preterm delivery
Fetal demise
818
Q

Determination of zygomatic is the most important step after after diagnosing twins

A

Diagnosing

819
Q

Dizygotic

A

Different fetal gender

Visualization of a thick amnion chorion septum

Peak or inverted V sign at the bae of the septum

820
Q

Monozygotic

A

Dividing membrane is fairly thin

821
Q

If US is not definitive in determining zygomatic

A

Inspect placenta after delivery

DNA analysis

822
Q

Conjoined twins

A

Cleavage occurs 13-15 days
1 in 70,000 deliveries (ratio of females to males is 3:10
Mortality rates 50%
C section
Advancement of imaging allows mapping of shared organs and more successful surgical separation procedures
Elective termination if cardiac or cerebral fusion is identified

823
Q

Interplacental vascular anastomoses

A

90% occur in monochorionic twins

Most common type is arterial arterial followed by arterial-venous and then venous venous

Vascular communications between the 2 fetuses through the placenta can cause several problems
-abortion polyhydramnios, TTTS, fetal malformations

824
Q

Twin twin transfusion

A

Results secondary to uncompensated arterial-venous anastomoses in a monochorionic placenta
-which leads to a net transfer of blood flow going from one twin to the other

825
Q

Fetal complications donor twin

A

Hypovolemia, hypotension, anemia, oligohydramnios, growth restriction

826
Q

Recipient twin TSS

A

Hyperbole is, polyhydramnios rhomboids, HTN, polycythemia, edema, and cardiomegaly , congestive heart failure

827
Q

Baby bad twin twin transfusion

A

Both twins are at risk of demise bc of heart failure

828
Q

Diagnose TTTS

A

US

829
Q

Donor twinUS

A

Smaller stuck appearance

Oligohydramnios

830
Q

Recipient twin US

A

Larger
Polyhydramnios
Ascites

831
Q

Treat TTTS

A

Serial amniocentesis with amniotic fluid reduction

Laser photocoagulation of the anastomoses vessels on the placenta

832
Q

Fetal malformations arterial to arterial anastomosesarterial blood flow fromt he donor twin enters the arterial circulation of hte recipient twin

The reversed blood flow may cause thrombosis within critical organs or atresia due to trophoblastic embolization

A

Recipient twin being perfused in a reverse direction with poorly oxygenated blood fails to develop normally. It is known as acardiac twin (ACARDIAC)

833
Q

ACARDIAC twin

A

Fully formed lower extremities

No anatomic structures cephalic of the abdomen

834
Q

Umbilical cord abnormalities

A

Primarily associated with monochorionic twins

Absence of umbilical artery

Velamentous umbilical cord insertions occur more frequently

835
Q

Absence of umbilical artery

A

Associated with renal agenesis

836
Q

Retained dead fetus syndrome

A

Incidence of single fetal death in utero up to 5%

If gestation is 20 weeks or greater retained dead fetus syndrome can develop

  • disseminated intravascular coagulopathy in the mother
  • check platelets and fibrinogen levels weekly
837
Q

Vanishing twin syndrome

A

Vanishing twin syndrome if gestation is <12 weeks and dead fetus reabsorbed

838
Q

Maternal polyhydramnios

A

Polyhydramnios anemia, HTN, preeclampsia, gestational diabetes, preterm labro, c section, postpartum hemorrhage, uterine atony

839
Q

Fetal complications of multiple gestations

A

Prematurity, malpresentaiton, placental previa, placental abruption, PROM, umbilical cord prolapse, IUGR, congenital, incrase perinatal morbidity and mortality

840
Q

Manage first and second trimester

A

2 week office visits

US cervical length assessments

841
Q

Third trimester

A

Cervical length of less than 25 mm at 24-28 weeks doubled the risk for premature birth in twins

Serial US to check for intrauterine growth q 4-6 weeks begin at 24 weeks.

Looking for discordant fetal growth
—defined by a 20% reduction in fetal weight of the smallest fetus compared with the largest
Antepartum testing testing (NSTs or weekly BPPs)
Often patients will be placed on bed rest

842
Q

Monoamniotic twins should be delivered 32 weeks

A

Secondary to increase risk for lethal cord entanglement

Hospitalization at 26 weeks, antenatal steroids, and fetal heart rate monitoring several times daily

843
Q

Most twins deliver when

A

35-36 weeks

844
Q

If no complications when deliver twins

A

38 weeks

845
Q

What have before intrapartum management

A

Delivery room equipped for c section

Large IV bore needle, blood products

Capability to monitor fetal heart rates
Anesthesiology

US to determine precise presentations of the twins

Two pediatricians/NICU personnel one for each Abby

Nurses

846
Q

Vertex vertex presentations

A

Presenting twin is designated twin a and secondtwin b

After delivery 1st cord clamped and cut
Vaginal exam to assess station of second
-second twin is at increased risk of cor prolapse, placental abruption and malpresentation

Careful attention to fetal monitoring is necessary

After seen twin delivers obtain cord samples and deliver placenta

Be prepared for hemorrhage

847
Q

Vertex transverse and vertex breech are usually delivered by

A

C section

848
Q

Breech breech and breech vertex twins are delivered

A

C section

849
Q

High perinatal mortality in singletons

A

Secondary to prematurity and congenital anomalies
RDS, intracranial hemorrhage

Birth asphyxia-second twin 2 x the perinatal mortality then the first born twin and are 4x more likely then first to die from birth trauma complications

850
Q

Stillbirths

A

2x more frequently then in singletones

851
Q

Cerebral palsy

A

Most in twins

852
Q

Size twins

A

Shorter and lighter until 4 years old

853
Q

Triplets quadruples

A

ART,

854
Q

Prematurity increases

A

As number of fetus grow

855
Q

Deliver triplets

A

C section

856
Q

Fetal malpresentation most common

A

Breech

857
Q

Breech

A

Fetal butt or lower extremities presents into the maternal pelvis

858
Q

Most common factor for breech

A

Prematurity

859
Q

Diagnoseis breech

A

US, Leopoldo, pelvic exam

860
Q

Frank

A

Most common presentation
Thighs flexed
Lower extremities are extended at knees

861
Q

Complete breech

A

Thighs are flexed

Lower extremities are flexed

862
Q

Incomplete breech

A

1 or both thighs are extended

1 or both feet are below the bout

863
Q

External cephalic versio

A

Applying pressure to moms abdomen to turn the fetus in either a forward or backward somersault to achieve a vertex presentation

864
Q

Who gets ECV

A

36 weeks

865
Q

Contraindication ECV

A

Placental previa
Non reassuring fetal monitoring
Oligohydramnios
Previous uterine surgery that is contraindication for vaginal delivery

866
Q

Where do ECV

A

Hospital equipped for c section

867
Q

Prepare for ECV

A
NPO 7 hrs
IV access
Continuous monitor NST BPP
Confirmbreech with US
Consider tocolytics
868
Q

Vaginal delivery breech

A
Frank or complete
>37 weeks
2500-4000 grams
Fetal head flexed
Adequate maternal pelvis
No maternal or fetal contraindications for vag
Anesthesia
869
Q

Standard care breech

A

All c section

870
Q

Assisted breech vaginal delivery: two hands

A

NO aggressive traction can cause deflection of the fetal vertex and increase risk of head entrapment or nuchal arm entrapment

871
Q

Assisted breech vaginal delivery: after spontaneous expulsion to scapula one hand

A

YES external rotation of each thigh combined with opposite rotation of the fetal pelvis restyles in flexion of the knee and delivery on the leg

872
Q

Wrap towel around fetus for better traction

A

When scapula appears under the symphysis.

The operator reache over the left shoudler , sweeps the arm across the chest and delivers the arm

873
Q

Delivery head breech

A

Gentle traction maintain cephalic flexion by applying pressure on fetal maxilla NOT fetal mandible

874
Q

Forceps for breech

A

Piper forceps

875
Q

Breech presentation delivery

A

C section preferred esp pre term

Don’t want fetal asphyxia

876
Q

Outcomes breech

A

Perinatal mortality higher than forvertex fetuses

Lethal congenital anomalies, prematurity, birth trauma and asphyxia are common

877
Q

Brown presentation

A

Presenting part of the fetus is between the facial orbits and anterior fontanelle

  • presenting diameter is the supraoccipitomental diameter
  • frontal bones are te point of designation
878
Q

Brow presentation change before birth

A

Usually to a face presentation through extension or vertex presentation throug flexion

879
Q

Persistent brow

A

Vaginal delivery impossible CSECTION

880
Q

Persistent brow

A

C section

881
Q

Brown supraoccipitoental diameter vs vertex

A
  1. 5

9. 5

882
Q

Face presntation

A

Fulle xtension of the fetal head and neck with occiput against upper back

883
Q

Incidence face

A

1.500
Can be seen in frequently with fetal malformations
-anencephaly is seenin 1/3 of face presentation

884
Q

Fetal chin is chosen as point of definition for face

A

Most present mentum anterior and can deliver vaginally

Can NOT deliver vaginally menum posterior presentation
-will need to proceed with c section

885
Q

Face trachelobregmatic diameter face vs vertex

A

12.6 cm

9,5 cm

886
Q

Face

A

C section

887
Q

Compound presentations

A

Fetal extremity found prolapsed alongside the presenting fetal part (head)

Premature

888
Q

Compound presentation with failureto progress, cord prolapse, non reassuring fetal status

A

C section

889
Q

Initial evaluation antepartum hemorrhage if bleeding profusely

A

Knowledgeable team for hemodynamically stability and correct cause

2 large bore IV

Access vitals, bleeding, mental status

890
Q

What history for antepartum hemorrhage

A

Known bleeding disorders, liver disease, anatomic abnormalities, and abnormal placentation

891
Q

Labs for profuse post partum hemorrhage

A

CBC and coagulation profile
Serial H and H
Type and crosmatch

892
Q

Type and crossmatch 4 units of blood

A

PRBC

893
Q

When can you do a digital exam

A

Avoid until placenta previa has been ruled out by US

894
Q

Sterile speculum exam

A

Genital lacerations or cervical lesions

895
Q

Digital exam

A

Cervical dilation

896
Q

How assess entire situation

A

US-placenta location, rsetnation of fetus

Amount of bleeding, maternal status, gestational age, continuous electronic fetal monitoring

897
Q

Vaginal bleeding before 20 weeks cause

A

Abortion ectopic clot

898
Q

Vaginal bleeding after 20 weeks upper genital tract

A

Placental abruption
Placenta previa
Uterine rupture
Vasa previa

899
Q

Vaginal bleeding lower genital tract

A
Bloody show labor
Cervical polyps
Infection
Trauma
Cancer vulvar varicosities
Blood dyscrasia
900
Q

Placenta previa

A

Implantation of placenta over cervical os

Most common placental prob

901
Q

Presentation placenta previa

A

Painless vaginal bleeding

902
Q

Risk factors placenta previa

A

Maternal age >35
Multiparity geation
Cocaine smoking

Prior previa, previous c section

903
Q

Marginal placenta previa

A

Edge of the placenta extending to the margin of cervical os

But does not cover the os

904
Q

Partial placenta previa

A

Partial occlusion of the cervical os by the placenta

905
Q

Complete placenta previa

A

Cervical os completely covered by the placenta

Most serious type and is associated with greater blood loss

906
Q

Classic presentation placenta previa

A

Painless bleeding at 30 weeks

907
Q

How diagnose placenta previa

A

US

908
Q

What do if have since 4-5% have is at 24 weeks

A

Repeat US at 30 weeks

909
Q

Do msot placenta previa resolve

A

90% by 32-25 weeks by placental migration

910
Q

Which previa least likely to resolve

A

Third trimester

911
Q

Manage preterm preg with placenta previa

A

Fetal maturation is goal

Manage in hospital and bed rest and if bleeding stops cn go home but 70% recur bleed

912
Q

Placenta previa. 36-37 weeks

A

C section if fetal lung maturity

913
Q

If unstoppable labor and placenta previa, fetal distress, or hemorrhage

A

C section immediately regardless of gestational age

914
Q

How stabilize patient with placenta previa

A

Hospitalize, IV access
2 large bore needles if bleeding profuse
H/H type and cross
PT PTT fibrinogen
RH neg-kleihauer-betke test, give rhogam if need

915
Q

How prepare for catastrophic hemorrhage

A

Serial blood draws , NPO statins, type and cross 4 units

916
Q

Placenta previa prepare for preterm delivery

A

Prior to 34 weeks give antenatal steroids (betamethasone) tocolysis can be used in stable

917
Q

Placenta accretion

A

Abnormal firm attachment to the superficial lining of the myometrium
Most common

918
Q

Placenta incretins

A

Invades myometrium

919
Q

Placenta percreta

A

Through the myometrium into the uterin serosa

Least common

920
Q

Previa without prior uterine surgery

Incidence of accreta is 4%

A

Ok

921
Q

Risk factors

A

Previous c section

C hysterectomy

922
Q

Placenta abruption

A

Premature separation of the normally implanted placenta

Most common third trimester bldeeding

Painful bleeding, uterine tenderness, uterine hyperactivity, and fetal distress and/or death

923
Q

Symptoms placenta abruption

A

Painful bleeding, uterine tenderness, uterine hyperactivity, fetal distress and /or death

924
Q

Risk factors placental abruption

A

Maternal HTN*
Cocain
Blunt trauma
Polyhydramnios and multiparity

Previous abruption

925
Q

Diagnose placenta abruption

A

Painful vaginal bleeding, uterine tenderness and uterine hyperactivity and fetal distress or death

US can detect, but better for previa

926
Q

Manage placenta abruption

A

Monitor fetal and maternal condition s

927
Q

If both stable

A

Vaginal delivery—rapid delivery often ensues after abruption

If remote from vaginal delivery with signs of fetal distress or uncontrolled bleeding proceed with c section

928
Q

Abruption os mst common cause of DIC in pregnancy
Results from the release of thrombophlebitis from the disrupted placenta and subplacental decidua causing consumptive coagulopathy

DIC occurs in 20%

A

Ok

929
Q

Stabilize placenta abruption patien

A

HostpiatIV access
2 large bore 16 guage if bleeding profusely
H/H type and cross
PT PTT fibrinogen, platelets
RH neg consider kleihauer Bette test, give rhogam if indicated

930
Q

Prepare for catastrophic hemorrhage

A

Serial blood draws
NPO status
Type and cross 4 units

931
Q

Prepare for preterm delivery

A

Prior to 34 weeks give antenatal steroids

Tocolysis can be used to stabilize

932
Q

Couvelaire uteris with placenta abruption

A

Extravasation of blood into the uterus

Causing red and purpl discoloration of the serosa

933
Q

Uterine rupture

A

Complete separation of the uterine musculature through all layers

934
Q

Cause uterine rupture

A

Spontaneous, traumatic ,associated ith previous uterine scar

935
Q

Uterine rupture sequelae

A

Fetal mortality or permanent neurologic sequelae

936
Q

Risk factors uterine rupture

A

Prior uterine incision

Injudicious use of oxytocin
Trauma
External cehoali version
Multiparity

937
Q

Diagnose uterine rupture

A

Rupture associated with sudden onset of intense abdominal pain vaginal bleeding
Abnormal fetal heart rate pattern of cessation of fetal heart tones

Regression
Fetal parts may be easily palpable on abdominal exam

938
Q

Manage uterine rupture

A

Immediate laparotomy and delivery of fetus
If feasible repair ruptured site
If large rupture may have to do c section

939
Q

Uterine rupture and future preg

A

C section

Recurrence rate! Upper segment recurrent more common than lower though

940
Q

Fetal bleeding in 3rd trimester causes

A

Rupture fetal vessel secondary to velamentous insertion of umbilical cord

941
Q

Most common cause of third trimester bleeding

A

Rupture of fetal vessel

942
Q

How does cord insert

A

At a distance away from the placenta and its vessels must transverse between the chorion and amnion without the protective Wharton’s jelly

943
Q

Vasa previa

A

Unprotected vessels pass over the cervical os

944
Q

Signs vessel rupture

A

Acute vaginal bleeding with a change in fetal heart rate .

945
Q

What do if rupture

A

Diagnose rapidly and proceed to delivery

946
Q

Define postpartum hemorrhage

A

> 500 cc following vaginal birth

>1000 cc following a c section

947
Q

Primary postpartum hemorrhage

A

In first 24 horus

Secondary to uterine atony

948
Q

Secondary postpartum hemorrhages

A

24 hours to 12 weeks

Can occur with subinvolution of the uterus, sloughing of the Escher or retained products

949
Q

Can core than half of all maternal deaths occur in_

A

24 hours

950
Q

Leading cause of maternal death worldwide

A

Postpartum hemorrhage

951
Q

Etiology primary postpartum hemorrhage

A

Uterine atony
Retained placenta espicially accreta
Defects in coagulation
Uterine inversion

952
Q

Secondary etiology

A

Subinvolution of placental site
Retained products of conception
Infection
Inherited coagulation defects

953
Q

Risk factors postpartum hemorrhages

A
Prolonged labor
Augmented labor
Precipitous laborhistory of postpartum hemorrhages
Placental abruption
Placental previa
Vag delivery
954
Q

Uterine atony post partum hemorrhages

A

Immediately preceding or after delivery of placenta

Most PPH are due to it
Excessive blood loss most commonly result when the uterus fails to contract after delivery of placenta. Palpation-boggy uterus

955
Q

Risk factor uterine atony

A

Enlargement of the uterus
Abnormal labor
Conditions which interfere with contraction of the uterus
-leiomyoma and mg sulfate

956
Q

Effects hemostasis after separation of the placenta is dependent on what

A

The myometrium to comrpession the severed vessels(spiral arterioles and decidua veins)

957
Q

Manage uterine atony

A

Bimanual massage uterus

Oxytocin, methylergovinins, hemabate, dinoprostone, misoprostol

Uterine packing or large volume balloon catheter

Interventional radiology

Surgical measure/hysterectomy

958
Q

Bimanual massage

A

Confirms diagnosis
Boggy!

Massage of the uterine corpus can dismiss bleeding, expel blood clots and allow time for other measured to be implemented

959
Q

Uterine packing

A

4 inch gauze layer back and forth from one course to other using sponge stick

Large volume balloon

960
Q

Interventional radiology

A

Patient has stable vitals and persistent bleeding may be a candidate for arterial embolization

961
Q

Surgery

A

Is last resort, if patient desires future fertility may try to lighten uterine arteries
If unstable proceed with total abdominal hysterectomy

962
Q

Second most common cause of postpartum hemorrhage

A

Trauma during delivery

963
Q

What do if genital tract trauma

A

Inspect for vaginal, perineal, periurethral and cervical lacerations

Repair surgical

964
Q

Retained placenta

A

Most of secondary PPH have it
-bleeding is secondary to inability of uterus to maintain a contraction and involuted normally around the placental tissue

965
Q

Risk factor retained placenta PPH

A

Previous c section, leiomyoma, prior d and c, and accessory placenta lobe

966
Q

Treatment retained placenta

A

Manual removal if bleeding is profuse

+/- uterine curettage with or without US guidance be careful not to perforate

967
Q

Uterine inversion

A

Top of fundus descends into the vagina and sometimes through the cervix
-if occurs before placenta is delivered DO NOT remove placenta until inversion is corrected

968
Q

Iatrogenic uterine inversion

A

Improper management of third stage

969
Q

Uterine inversionsymptom

A

Copiousbleeding and hypovolemia shock

970
Q

Treat postpartum hemorrhroage

A

Anesthesiologist
Manually replace the uterus
Once replaced start oxytocin to cause the uterus to contract
Rarely paratotomy

971
Q

Amniotic fluid embolism

A

80% mortality rare

Caused by infusion of amniotic fluid into maternal circulation

972
Q

Characterization amniotic fluid embolism

A

Respiratory distress, intense bronchospasm, cyanosis, cardiovascular collapse, hemorrhage, coma

973
Q

Treat amniotic fluid embolism

A

Respiratory support, correct the hypovolemia shock and replace coagulation factors

974
Q

Von williebrans

A

Inherited coagulopathy with prolonged bleeding times

Factor VIII defiency

975
Q

Treat Von williebrand

A

Factor VIII concentrate or cryoprecipitate

976
Q

Idiopathic thrombocytopenia

A

Platelets function abnormally and have a shortened life span

Causes thrombocytopenia an tendency to bleed

Circulating antiplatelet antibodies of igg type can occasionally cross placenta resulting in fetal and neonatal thrombocytopenia

977
Q

Treat idiopathic thrombocytopenia

A

Require platelet concentration infusions

978
Q

Puerperal sepsis

A

Following delivery women can develop a febrile morbidity

979
Q

Febrile morbidity

A

Temps100.4 or higher that occurs for more than 2 consequetive days during first 10 postpartum das

980
Q

Most fevers

A

Endometriosis

981
Q

After delivery , the pH of the vagina becomes more alkaline

A
982
Q

Alkaline pH after birth

A

Favors growth of aerobic organisms

About 48 hours after delivery the endometrial and placental remnants produce a favorable intrauterine environment for the production of anaerobic bacteria

983
Q

Most organisms that cause peurperal infection

A

Anaerobic organisms

Cocci, (peprostrep, peptococcus, streptococcus)

Mixed with abcteriodes fragilis

Aerobic-e coli

984
Q

Predisposing factors for puerperal sepsis

A

Poor nutrition and hygiene

Anemia

PROM

Prolonged rupture of membranes

Prolonged labor

985
Q

Clinical features peurperal sepsis

A

Postpartum fever and increasing uterine tenderness on postpartum day 2 OT 3 are the key clinical findings
-purulent lochia, child, malaise, anorexia

986
Q

Diagnose peurperal sepsis

A

Careful history and physical

Extreapelvic causes of fever should be excluded

987
Q

Treat peurperal sepsis

A

Antibiotic treatment
Anaerobic coverage since more scommon

Ampicillin and gentamicin
Major pathogen resistant to this is bacteriodes fragilis, which is sensitive to clindamycin

988
Q

Septic pelvic thrombophlebitis

A

Physiologic conditions for the pathogesis of thrombosis

Endothelial damage, venous stasis, hypercoagulable state of preg

989
Q

Ovarian vein thrombophlebitis

A

Fever and ab pain within 1 week after delivery or surgery

990
Q

Clincial ovarian vein thrombophlebitis

A

Fever, abdominal pain, localized to the side of the affected vein

991
Q

How see ovarian vein thrombophlebitis

A

Ovarian vein on radiography

992
Q

Deep septic pelvic vein theombophlebitis

A

Unlocalized fever int he first few days that is non responsive to antibiotcs

993
Q

Clincial deep septic pelvic vein theombophlebitis

A

So not appear CLINCIALLY ill

994
Q

See deep septic pelvic vein theombophlebitis

A

No radiographically evidence of thrombosis

Diagnosis of exclusion

995
Q

Treat septic pelvic theombophlebitis

A

Anticoagulation is though to prevent further thrombosis
Unfractioned heparin or low molecular weight heparin

Discontinue after resolution of fever x 48 hrs

996
Q

If ovarian vein thrombosis is seen radiographicallytrat

A

Anticoagulatnts 6 weeks

Repeat imaging to evaluate for persistence