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OB/GYN > Midterm > Flashcards

Midterm Flashcards

1
Q

Blood volume changes

A

-increase by 50%

4L to 5.5 L

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2
Q

RBC changes

A
  • RBC volume increases only about 25% which results in a dilutional anemia
  • blood flows faster due to lower viscosity
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3
Q

cardiac output changes

A

increases 40% mostly due to increases in stroke volume and not so much heart rate

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4
Q

vasculature changes

A
  • decreased systemic vascular resistance resulting in systolic decrease 5 points and diastolic decrease 10 points
  • gravid uterus can compress vena cava resulting in supine and orthostatic hypotension, varicose veins, edema, and hemorrhoids
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5
Q

heart sound findings

A

normal to find systolic ejection murmur and S3

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6
Q

regional blood flow changes

A

-increased flow to kidneys and uterus

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7
Q

respiratory changes

A
  • increase in oxygen consumption and minute ventilation (tidal volume x RR)
  • tidal volume increased more than respiratory rate
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8
Q

metabolic acidosis

A
  • increase in minute ventilation exceeds oxygen consumption leading to respiratory alkalosis and hyperoxemia
  • leads to metabolic acidosis
  • decreased bicarb on labs is normal
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9
Q

dyspnea of pregnancy

A
  • lower CO2 trigger to breathe

- can feel short of breath often which is normal

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10
Q

gastrointestinal changes

A

changes mediated by progesterone

  • increased appetite, food cravings
  • increased cholesterol concentration
  • increases colon transport time
  • decreased gallbladder emptying time
  • nausea, decreased swallowing
  • decreased gastric and lower esophageal sphincter tone
  • bleeding gums
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11
Q

renal changes

A
  • increased urine outflow
  • can overwhelm absorption ability
  • can find protein in urine
  • ureters are dilated due to decreased peristalsis from progesterone and effect of fetal head on ureter
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12
Q

metabolic changes

A
  • increased insulin resistance, serum triglycerides, lipolysis
  • increased cortisol
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13
Q

endocrine changes

A
  • pregnant women create ketones in 4-6 hrs versus a normal 2 days and need to eat 300-500 more cal/day (esp. fat/protein)
  • increase in aldosterone where lack of can lead to preeclampsia
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14
Q

hematological changes

A
  • platelet numbers stay stable
  • clotting factors increase
  • iron stores decrease due to increase RBC production
  • WBC not reliable indicator of infection if pregnant
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15
Q

weight changes

A
  • frequently weight loss in 1st semester due to N/V
  • by 20 wks nearly all have reached or passed baseline weight
  • expected gain 1#/wk after 20 weeks
  • if not expected weight loss after delivery then retaining fluid somewhere
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16
Q

oxygen transport to fetus

A
  • want large surface area and decreased thickness to increase O2 diffusion across placenta
  • hemochorial placenta is most efficient at O2 delivery but has increased blood loss when placenta delivers
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17
Q

placenta versus lungs

A
  • placenta receives 60% CO and lungs receive 100%
  • placenta metabolically active and uses 30% O2 delivered, lungs use <5%
  • V/Q mismatch in placenta is normal and pathologic in lungs
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18
Q

fetal compensation for O2

A
  • CO enhanced at a rate 10X greater than an adult
  • hemoglobin is higher
  • blood with higher O2 saturation is shunted to essential vascular beds
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19
Q

fetal hemoglobin

A

contains a gamma chain that does not allow it to respond to DPG and decrease O2 affinity, therefore fetal hemoglobin has higher O2 affinity

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20
Q

fetal circulation

A
  • placenta acts as small intestine, kidneys, lung

- blood in IVC has 2 different streams with minimal mixing

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21
Q

fetal circulation after birth

A
  • increase in systemic pressure causes foramen ovale to close
  • ductus arteriosus becomes the ligamentum arteriosum
  • ductus venosus becomes ligamentum venosum
  • left umbilical vein becomes ligamentum teres
  • umbilical arteries become lateral umbilical ligaments
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22
Q

immunological changes in pregnancy

A
  • can become septic easier

- viral, bacterial, and fungal infections are more severe

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23
Q

goals of prenatal care

A
  • reduce maternal and fetal morbidity/mortality
  • reproductive life planning
  • promote lifelong health behaviors
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24
Q

individual care model

A
  • 1 patient per 1 MD

- majority of practices

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25
Q

group care model

A
  • multiple patients with similar due dates grouped together
  • social aspect due to being able to relate to each other
  • experienced with pregnancy can help new to pregnancy
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26
Q

Complete history

A
  • medical and surgical
  • OB and gyn
  • meds/allergies (may need to modify Rx)
  • family/genetic (inheritable disease)
  • substance abuse (all get urine drug screen)
  • psychosocial
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27
Q

physical exam (initial Ob visit)

A
  • be aware of the normal abnormal

- identify problem list for months long management

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28
Q

ascertainment of gestational age

A
  • determines gestational milestones

- by history using LMP, 1st positive pregnancy test

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29
Q

initial sonogram

A
  • earliest sonogram with a viable fetus is most accurate
  • 1st trimester ultrasound accurate within 1 week +/-
  • 2nd trimester ultrasound accurate within 2 weeks +/-
  • 3rd trimester ultrasound accurate within 3 weeks +/-
  • determine viability, gestational age, and location of pregnancy
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30
Q

goals of initial OB visit

A
  • generate problem list to manage throughout pregnancy
  • encourage healthy behaviors
  • discuss reproductive life planning
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31
Q

prenatal CBC

A
  • screen for anemia (typically Fe deficient)

- thrombocytopenia (establish baseline)

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32
Q

prenatal blood type and antibody screen

A

-screen for isoimmunization (Rh)

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33
Q

prenatal rubella screen

A
  • susceptibility, postpartum immunization

- rubella is teratogenic

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34
Q

prenatal RPR

A
  • screen and treat congenital syphilis
  • tested three times
  • syphilis teratogenic
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35
Q

prenatal Hep B screen

A

post exposure prophylaxis at delivery for baby

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36
Q

prenatal HIV screen

A
  • screen and treat to decrease risk of vertical transmission

- baby has 25% chance of contracting without treatment

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37
Q

prenatal gonorrhea/chlamydia

A

neonatal ophthalmia

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38
Q

screen for malformation

A
  • nutritional (folate needed for DNA synthesis)
  • genetic
  • vascular
  • medical
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39
Q

deformation - mechanical fetal anomalies

A
  • fibroids
  • amniotic band syndrome
  • potter sequence (no fluid around body)
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40
Q

teratogenesis fetal anomalies

A
  • chemical
  • radiation
  • infectious disease
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41
Q

serum screen for aneuploidy

A
  • quad screen
  • cell free DNA screen (chromosome count/sequence) (typically for high risk due to cost)
  • ultrasound 18 weeks (screening test)
  • fetal echo 22 weeks (screening test)
  • amniocentesis (diagnostic test)
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42
Q

prenatal visit schedule

A

4-28 weeks: every 4 weeks
28-36 weeks: every 2 weeks
36-40 weeks: every week
40+ weeks: 1-3 times/weeks

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43
Q

8 week visit

A
  • assess and manage common 1st trimester symptoms (fatigue, nausea)
  • bleeding? (not normal 1st trimester)
  • assess viability
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44
Q

12 week visit

A
  • follow up prenatal labs
  • typically peak of nausea, fatigue subsiding
  • assess viability and reassure loss is rare after 1st trimester (1-2%)
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45
Q

16 week visit

A
  • can typically determine gender
  • most 1st trimester symptoms resolved
  • check fundal height (should be halfway between pubic symphysis and umbilicus)
  • check fetal heart tones and movement
  • aneuploidy screen
  • fetal anatomy screen
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46
Q

20 week visit

A
  • follow up on aneuploidy screen and any consultations
  • most women feel fetal movement by now
  • assess weight gain
  • discuss feeding and encourage breast feeding
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47
Q

24 week visit

A
  • fetal movement reliable felt
  • weight gain should be 1 lb/week
  • watch BP and protein (preeclampsia can occur 24+ weeks)
  • evaluate/counsel preterm labor symptoms (cramping, pressure, bleeding, leaking)
  • fundal height in cm nearly same as weeks +/- 2
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48
Q

28 week visit

A
  • discuss 3rd trimester symptoms (heart burn, back/feet pain, mild/moderate edema, lightheaded)
  • glucose tolerance test
  • rhogam if Rh negative
  • constant pelvic pressure is normal, pressure that comes and goes could be contraction
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49
Q

30, 32, 34 week visits

A
  • baby should be head down by week 34

- post partum birth control counseling

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50
Q

36 week visit

A
  • vaginal/rectal swab for group B strep and urine PCR for gonorrhea/chlamydia
  • discuss term labor symptoms (cramping, pressure, bleeding, leaking)
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51
Q

37-40 week visits

A
  • check cervix upon request if symptomatic or if induction indicated
  • spontaneous is typically better than induction
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52
Q

40+ week visit

A
  • being seen twice per week
  • test baby for well being
  • most go in to labor 40-41 weeks and if not give induction date
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53
Q

APGAR

A

helps determine if resuscitation is needed after delivery

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54
Q

intrauterine apgar

A
  • correlates well with degree of acidemia
  • done at weeks 32 and later
  • score 10 = pH >7.20
  • score 0 = pH <7.2
  • low amniotic fluid indicates chronic asphyxia and is always abnormal
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55
Q

nonstress test (fetal cardiotocography)

A
  • tests for presence of neurocardiac reflexes which require non-acidotic CNS
  • reactive = at least 2 accelerations (15 bpm x 15 sec) over a 20 minute period = normal
  • nonreactive = hypoxemia
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56
Q

contraction stress test

A

-tests the fetuses ability to oxygenate during contractions

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57
Q

uterine artery velocimetry

A
  • pregnant uterine artery is always maximally dilated
  • useful for predicting fetal demise, particularly with fetal growth restriction
  • absent and reversed end diastolic flow associated with fetal demise within a week
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58
Q

arrest of dilation

A

no cervical change in 2 hours

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59
Q

arrest of descent

A
  • no delivery after 3 hours if nulliparous
  • no delivery after 2 hours if parous
  • add 1 hour if epidural present
60
Q

stages of labor

A

-pre labor: (braxton-hicks) contractions thin cervix and prepare it for labor
-1st stage: cervix thins and dilates to 10 cm
0-4 cm early labor
5-8 cm active labor
8-10 cm transition
-2nd stage: pushing until baby born
-3rd stage: contractions to expel placenta
-4th stage: breastfeeding established and contractions so uterus will shrink

61
Q

cardinal movements of labor

A

Every Darn Fetus Is Extremely Eager to Exit

Engagement
Descent
Flexion
Internal rotation
Extension
External rotation
Expulsion
62
Q

pelvic inlet

A
  • smallest diameter is antero-posterior
  • widest diameter is transverse
  • failure at this phase (engagement) typically occurs before complete dilation
63
Q

mid pelvis

A
  • smallest diameter is transverse
  • widest diameter is antero-posterior
  • descent, then flexion, then internal rotation must occur to get through
  • failure at this stage is deep transverse arrest (no forceps used)
64
Q

pelvic outlet

A
  • all diameters generally wide enough
  • fetus usually enters OA
  • head then delivers through extension
  • shoulders deliver through external rotation
  • rest of body undergoes expulsion
  • difficulty at this point may be assisted with vacuum/forceps
65
Q

gynecoid pelvis

A
  • 50%
  • most common in Caucasian
  • round, cylindric shape and wide pubic arch
  • good prognosis for vaginal birth
66
Q

anthropoid pelvis

A
  • 25% white, 50% nonwhite
  • long, narrow oval shape
  • anteroposterior diameter is longer than transverse
  • narrow pubic arch
  • fetus may be born OP
  • more favorable for vaginal birth, but not perfect
67
Q

android pelvis

A
  • 30%
  • common in PCOS
  • heart or triangular shaped
  • narrow diameters and narrow pubic arch
  • poor prognosis for vaginal birth
68
Q

platypelloid pelvis

A
  • 3%
  • flattened, wide short oval
  • transverse wide but AP diameter short
  • wide pubic arch
  • poor prognosis for vaginal birth
69
Q

lie

A
  • orientation of the fetal spine relative to maternal spine
  • cephalic 95%
  • breech 4%
  • oblique & transverse 1% (not compatible with vaginal delivery)
70
Q

presentation

A
  • part of the fetoplacental unit closest to the cervix

- cephalic, breech, back, hand/arm, compound, placenta, cord

71
Q

attitude

A
  • degree of flexion of the fetal head (longitudinal lie)
  • vertex and face will fit (well flexed/hyperextended)
  • military and brow won’t fit
72
Q

dilation

A
  • how open the cervix is

- fully dilated 10 cm

73
Q

effacement

A

-how “flat” the cervix is

74
Q

station

A
  • how low the fetus is in the pelvis
  • superior to ischial spine = negative station
  • inferior to ischial spine = positive station = 2nd stage labor
75
Q

position

A
  • the relationship between a designated part of the fetus and maternal pelvis
  • OA is most favorable
76
Q

baseline HR and pacemakers

A
  • intrinsic rate 160 but predominance of vagal tone results in typical 140s rate
  • AV junctional pacer rate 90
  • idioventricular rate 60
77
Q

bradycardia and causes

A
  • rate <110

- hypoglycemia, hypothermia, hypotension, heart block/defect

78
Q

tachycardia and causes

A
  • rate >160
  • more worrisome than bradycardia
  • fever/infection, hyperthyroidism, arrhythmia, stimulants, acidemia
79
Q

variations from baseline

A
  • general rule all variations from baseline are reflexes designed to maintain homeostasis, particularly oxygen delivery
  • can’t manage vascular beds, can only manage HR
80
Q

variability

A
  • increases in HR due to increase in O2 demand via sympathetic nervous system
  • implies intact CNS
81
Q

absent variability

A
  • sleep (no more than 45 minutes)
  • meds (opioids, mag)
  • CNS injury (diagnosis of exclusion)
82
Q

amplitude range classification

A
  • absent: undetectable (possible CNS injury)
  • minimal: undetectable to equal to or less than 5 BPM (possible CNS injury)
  • moderate: 6-25 BPM (normal)
  • marked: >25 BPM (unknown clinical significance)
83
Q

accelerations

A
  • reflex increase in HR due in increased O2 demand and implies intact CNS
  • less than 32 weeks, increase HR 10 BPM for 10 seconds
  • 32 weeks and greater, increase HR 15 BPM for 15 seconds
84
Q

Early decelerations

A
  • start with initiation of contraction, bottom out at contraction peak, and end with contraction
  • thought to be vagal response
  • not associated with hypoxemia/acidemia
85
Q

variable decelerations

A
  • hypoxemic event
  • > 15 BPM drop reaching peak in <30 seconds
  • lasting at least 15 seconds but no more than 2 minutes
  • possibly due to cord occlusion
  • can result in secondary hypoxemia
86
Q

late decelerations

A
  • hypoxemic event
  • symmetric, gradual decrease in HR
  • onset at peak of contraction, nadir at contraction termination, termination after contraction ends
  • during contraction lactic acidosis occurs
87
Q

reestablish oxygen pathway

A
  • correct maternal physiologic abnormalities
  • examine cord
  • maternal repositioning
  • IV bolus
  • amnionfusion
  • O2
88
Q

FHR category I

A
  • baseline rate 110-160 BPM
  • baseline variability moderate
  • late/variable decelerations absent
  • early decelerations present or absent
89
Q

FHR category II

A

doesn’t fit into category I or III but need to monitor

90
Q

FHR Category III

A
  • increased presence of acidemia (have 60-90 minutes before onset)
  • absent variability and any of the following
  • recurrent late decelerations, recurrent variable decelerations, bradycardia, sinusoidal pattern
91
Q

neonatal resuscitation

A
  • suction mouth/airway
  • stimulate breathing with rubbing
  • pulse <60 = compressions
  • pulse 60-100 = stimulate
  • pulse >100 = good
92
Q

vacuum assisted delivery

A
  • amount of traction limited by suction, too much acceleration results in pop-off
  • if more than 3 pop-offs without progress then attempts abandoned
  • preferred to C-section
93
Q

cesarean

A
  • low transverse hysterotomy best healing and lowest rupture risk
  • pfannensteil most common laparotomy
94
Q

fetal survival by week

A
  • 23 weeks 20-30%
  • better survival at 26 weeks
  • 34 weeks = low complication
  • 37 weeks = home with mom
95
Q

preterm labor causes

A
  • # 1 risk factor is preterm in previous pregnancy
  • infection
  • vascular disorder
  • decidual senescence
  • uterine overdistension
  • decline in progesterone activity
  • cervical disease
  • breakdown of maternal fetal tolerance
  • stress
96
Q

signs of preterm labor

A
  • pelvic or lower abdominal pressure
  • constant low, dull backache
  • mild abdominal cramps or regular consistent contractions
  • change in vaginal discharge
  • blood vaginal discharge is a late but specific sign
97
Q

fetal fibronectin

A
  • negative = just contraction

- positive = delivery likelihood in 2 weeks 50%

98
Q

preterm labor prevention

A

progesterone

99
Q

preterm labor management

A
  • celestone steroid injection for lung development (#1 intervention)
  • PCN/ampicillin for GBP
  • Mag to prevent contractions
100
Q

premature rupture of membranes diagnosis

A

Has to be before 37 weeks

  1. visualize fluid with speculum
  2. amniotic pH approximately 7
  3. fern test (not all fluid will fern)
101
Q

premature rupture of membranes complications

A
  • # 1 complication = labor
  • chorioamnionitis (no matter fetal age have to deliver if mom infected)
  • if little fluid physical deformities
  • cord prolapse
102
Q

preterm rupture of membranes management

A
  • similar management to preterm labor if <34 weeks
  • check temp/vitals/contractions/ABD pain
  • regular contractions = short delivery
103
Q

antepartum hemorrhage causes

A
  • labor/PPROM = #1 reason
  • placenta previa
  • placental abruption
  • uterine rupture
  • vasa previa
104
Q

placenta previa

A
  • placenta covers the cervix and must have C-section (36 weeks for most)
  • diagnosis with sonogram
  • painless bleeding
105
Q

placental abruption

A

-painful bleeding

106
Q

placental abruption risk factors

A
  • HTN
  • age >35
  • multiple births
  • smoking
  • cocaine
  • ABD trauma (watch for 24 hours)
107
Q

placental abruption class 1

A
  • 0-10% separation
  • minimal bleeding/pain
  • normal vitals, coags, fetal heart tones

-if <34 weeks consider expectant management and steroids; gentle induction

108
Q

placental abruption class 2

A
  • 10-40% separation
  • minimal to moderate bleeding
  • normal vitals
  • pain/contractions
  • normal coags
  • abnormal fetal heart rate tracings
  • cesarean immediate
109
Q

placental abruption class 3

A
  • 50% or greater separation
  • 1 liter blood loss
  • hypotension
  • hypertonic uterus
  • DIC
  • fetal demise
  • resuscitation, avoid c-section, induce labor, prepare for massive post partum hemorrhage
110
Q

uterine rupture

A
  • risk factors: uterine scarring, obstructed labor, uterine trauma
  • prolonged decelerations
  • can be stitched back together, but usually hysterectomy performed
111
Q

vasa previa

A
  • fetal vessels go over cervix
  • can’t tell fetal blood from maternal
  • C-section
112
Q

post partum hemorrhage

A
  • # 1 cause of maternal death
  • 70% uterine atony
  • 10% retained placenta
  • 20% lacerations/uterine rupture
  • <1% coagulopathy
113
Q

post partum hemorrhage risk factors

A
  • distended uterus (large baby, multiples)
  • infection
  • mag
  • fibroids
  • long labor
114
Q

uterine atony Rx treatment

A
  • prostaglandin
  • ergot alkaloid
  • TXA
115
Q

uterine atony surgical treatment

A
  • intrauterine balloon (24 hrs)
  • stitch compression (few weeks)
  • ligate uterine artery
  • hysterectomy
  • ligate internal iliac
  • embolize uterine artery
116
Q

retained placental tissue

A
  • visualize with ultrasound
  • treat with D and C
  • bleeding can start week or two later
117
Q

morbidly adherent placenta

A
  • risk factor uterine trauma

- standard treatment hysterectomy

118
Q

genital tract trauma

A
  • perineal laceration
  • cervical laceration (not common)
  • hematoma

-risk factors: macrosomia, episiotomy, forceps and vacuum delivery

119
Q

uterine inversion

A

huge vagal response

120
Q

shoulder dystocia

A
  • Erb’s palsy
  • anoxic injury
  • risk factors: macrosomia, gestational diabetes, forceps use
121
Q

pre-eclampsia

A

blood pressure >140/90 with at least 300 mg protein without end organ damage

122
Q

pre-eclampsia with severe features

A

BP>160/110 or with end organ damage

123
Q

superimposed pre-eclampsia

A
  • worsening HTN, interval development of proteinuria, development of severe features
  • systolic increase 30 points
  • diastolic increase 15 points
124
Q

signs of end organ damage

A
  • headaches (seizure warning)
  • scotoma, vision changes (seizure warning)
  • hyperreflexes
  • seizure
  • cerebral edema
  • stroke
  • death
125
Q

liver end organ damage

A
  • microangiopathic hepatitis
  • HELLP syndrome
  • stretching Glisson’s capsule (RUQ pain)
  • subcapsular hematoma
  • liver rupture
  • acute fatty liver of pregnancy (hypoglycemia)
126
Q

renal end organ damage

A
  • proteinuria
  • azotemia (elevated BUN and creatinine)
  • oliguria/anuria
127
Q

cardiopulmonary end organ damage

A
  • HTN
  • left ventricular failure
  • pulmonary edema
  • peripheral edema
128
Q

hematologic end organ damage

A
  • thrombocytopenia
  • hemolysis
  • DIC
129
Q

uteroplacental end organ damage

A
  • chronic HTN leads to placental vascular disease and infarction
  • acute HTN leads to abruption
  • fetal growth restriction
  • oligohydraminos
  • fetal demise
130
Q

intrapartum pre-eclampsia management

A
  • mag for severe

- steroids for <34 weeks

131
Q

acute HTN emergency

A
  • BP >160/110 for >15 minutes
  • labetalol and hydralazine
  • goal is BP <160/110
132
Q

eclamptic seizure phases

A
  1. facial automatisms
  2. tonic/clonic seizures
  3. post-ictal

don’t abolish the seizure with benzos, give mag

133
Q

isoimmunization

A

-Rh negative mother and Rh positive fetus

134
Q

fetal hydrops

A
  • liver and high output cardiac failure secondary to severe anemia
  • ascites, pleural effusion, pericardial effusion, skin edema
135
Q

isoimmunization surveillance

A
  • referral at antibody titer > 1:8
  • kell always gets referral
  • check blood viscosity as hemoglobin proxy (decreased = anemia)
136
Q

isoimmunization prevention

A
  • RhoGam (dose good for 12 weeks)

- give with any vaginal bleeding, at 28 weeks, and at delivery if baby Rh positive

137
Q

fetal growth restriction

A
  • potential harbinger of fetal demise
  • risk factors: radiation, drugs, alcohol, multiples, placental infarction, aneuploidy
  • food intake <1000 cal/day for growth restriction
138
Q

fetal growth restriction diagnosis

A
  • typically diagnosed by fundal height

- some may need serial ultrasounds

139
Q

post maturity syndrome

A
  • thin
  • reduced subQ fat
  • low BG
140
Q

Breech presentation

A
  • Frank can deliver vaginally, complete/incomplete cant
  • complications
    1. cord prolapse
    2. head entrapment
    3. nuchal arm
    4. head deflexion and spinal cord injury
    5. hypoxemia
141
Q

vaginal breech delivery requirements

A
  1. frank breech
  2. flexed head
  3. normal size
  4. experienced provider
  5. capacity for emergency c-section

2nd twin smaller than 1st

142
Q

multiples

A

more likely after age 35

143
Q

multiples complications

A
  • increased pre-eclampsia
  • increased hyperemesis
  • increased gestational diabetes
  • increased low back/pelvic pain
144
Q

monochorionic/diamniotic

A
  • twins vessels can join

- twin twin transfusion syndrome

145
Q

monochorionic/monoamniotic

A

-cords can get tangled up

OB/GYN (2 decks)

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