OB Flashcards
Post partum hemorrhage definition
> 500 ccs if vaginal;
>1000 ccs if c-section
What is the Pomeroy technique?
Tubal ligation involving removal or a part of the uterine tube
What is the Parkland method?
The Parkland procedure involves tying two non-absorbable ligatures around the fallopian tube in its proximal to middle segment and then cutting out the tubal segment between the ligatures. The end result is similar to the Pomeroy method of tubal ligation.
Post partum hemorrhage and absent uterus on physical exam, dx?
Uterine inversion
Manage with surgery
Post partum hemorrhage and boggy, soft uterus on physical exam, dx?
Uterine atony
Post partum hemorrhage and firm placenta on physical exam, dx?
Retained placenta
Manage with surgery
Post partum hemorrhage and normal-feeling uterus on physical exam, dx?
Vaginal laceration
Post partum hemorrhage, never forget this dx in your differential:
DIC
What is the management for unexplained post partum hemorrhage?
Surgery to ligate arteries and possible TAH
What is the pathology behind uterine atony?
Uterus cannot contract down, usually a product of:
a prolonged labor,
a labor that used pitocin;
a labor that used tocolytics (anti-contraction meds)
What is an absolute contraindication for the use of MgSO4?
Myasthenia gravis bc MgSO4 is a myosin light chain inhibitor
What tocolytic should not be used in conjunction with MgSO4?
Nifedipine (Procardia, Adalat), a Ca channel blocker
Also contraindicated in cardiac disease
What is the management of uterine atony?
- Massage
- Methergen or Pitocin if massage does not work
- PGF-2 alpha
- go to surgery if bleeding does not stop
How is the diagnosis of uterine atony made?
Clinically;
Pt presents with PPH and boggy uterus on physical exam
What is the pathology of uterine inversion?
Uterus births itself and there is a defect in the myometrium, which falls into the uterine lumen, pushing the uterus into the birth canal
How is the diagnosis of uterine inversion made?
Clinically;
Speculum reveals uterus
What is the management of uterine inversion?
Transvagial surgery to tack down the fornices of the uterus;
Can give pitocin if bleeding continues
What conditions predispose vaginal lacerations?
Precipitous births;
Macrosomal births
What are the causes of retained placenta?
- Burrows too deeply, or
- Accessory lobe
- -> placenta tears during birth
T/F: Placenta blood vessels never go to the surface of the placenta
True
What is the management of retained placenta?
- D&C, then
- TAH
Follow-up with beta-quant to rule out choriocarcinoma later
What is placenta accreta?
Retained placenta at the layer of the endometrium
What is placenta increta?
Retained placenta burrows into myometrium
What is placenta percreta?
Retained placenta burrows to serosa
What is the pathology of DIC-PPH?
Placental contents get into blood stream –> fibrin clots consume platelets and clotting factors
How does a patient with PPH-DIC present?
PPH that won’t stop, no other cause found, plus oozing from IV sites
What is the management of PPH-DIC?
- Get a DIC panel
- -Plts low
- -clotting factors low
- -PT/PTT high
- -fibrinogen low
- -shistocytes on smear - Give FFP, transfuse platelets and blood
What is the pathology behind gestational diabetes?
Insulin insensitivity
What are the risk factors for gestational diabetes?
- Preconception obesity
- > 1lb/wk weight gain
- Advanced maternal age
How do you diagnose gestational diabetes?
Asymptomatic screen with 1 hr glucose tolerance test;
confirm with 3 hour gTT
How does the gTT work?
Give non-fasting patient 50g glucose load: \+ if >/= 140 If +, give fasting patient 100g glucose load and check fasting, 1h, 2h and 3h: \+ if: fasting >/= 125 1h >/= 180 2h >/= 155 3h >/= 140
Gestational diabetes is any two + tests from the above
What is the management of gestational diabetes?
Basal-bolus insulin
When in pregnancy does hemoglobin reach a nadir?
28-30 weeks because of gain of fluid volume
What is the definition of third trimester anemia?
Asymptomatic screen CBC that shows H/H
What is the pathology behind isoimmunization?
Isoimmunization - when Rh (-) mom has Rh (+) kid.
Aka, mom has no Rh antigen.
Blood mixes during delivery or procedure, and mom makes antibodies to baby. IgM cant cross placenta, but IgG can, which can cause anemia or fetal death
How is Rh status evaluated and managed?
- Asymptomatic screen in beginning of pregnancy to find out if mom if Rh + or -
- If mom is Rh -, does she have antibodies to Rh?
- If she is Rh (-) with no Ab –> give Rhogam at 28 weeks and then within 72 hrs of delivery or procedure
- If she is Rh (-) with Ab –> too late –> get transcranial Doppler to evaluate risk for fetal anemia
What are the Rh subtypes?
Lewis - won’t kill baby
Duffy - will kill baby
Kal - will kill baby
Titers >1:8 sufficient
What is the management of fetal anemia?
If > 34 weeks, deliver;
If
How is fetal anemia diagnosed?
- Transcranial Doppler; then
2. PUBS (needle into umbilical vein), if Hct
When can mom’s and baby’s blood mix?
- D&C
- PPH
- Normal vaginal delivery
- Third trimester bleeding
What is a reactive NST?
2 or more accelerations in 20 minutes, each lasting at least 15 seconds
How high is the beta-quant if a fetus can be seen on u/s?
At least 1500
What is the effect of pregnancy on the renal system?
GFR increases, +50% by week 24
What are the cardiovascular effects of pregnancy?
HR up
BP down (vasodilated bc of increased estrogen)
CO up up up
What are the pulmonary effects of pregnancy?
TV up
Minute volume up
What is the effect of pregnancy on albumin?
Down bc of increased plasma volume
What are the effects of pregnancy on the thyroid?
thyroid-binding protein up;
effective circulating T4 down
What labs are drawn at the first OB visit?
CBC Rh factor type and screen U/A and culture RPR/VDRL Heb B Ag HIV GC/chlam cervical swab pap smear
What is a normal Hgb at the start of pregnancy?
13-15
What is a normal Hgb at 28 weeks?
10
What are the test results for trisomy 18?
low MSAFP;
low estriol;
low inhibin A;
low b-hCG
What are the test results with trisomy 21?
low MSAFP;
low estriol;
high inhibin A;
high b-hCG
What is the treatment for asymptomatic bacteriuria?
Nitrofurantoin (same for cystitis)
What is the treatment for pyelonephritis?
IV ceftriaxone;
if no improvement, u/s
What are the acceptable treatments for chronic HTN in pregnancy?
Alpha-methyldopa;
Hydralazine;
Metoprolol
What is the management of hyperthyroidism in pregnancy?
PTU; surgery if 2nd semester
What is the management of hypothyroidism in pregnancy?
give thyroid
What is the latent phase of stage I labor?
Beginning of contractions to 4 cm
20 hrs for first time delivery
14 for multip
What is the active stage of stage I labor?
4cm - fully dilated or 10;
about 4 hours;
1.2 cm/hr for primi;
1.5 cm/hr for multi
What is stage II labor?
10cm –> delivery
What is stage III labor?
delivery fetus –> delivery placenta
What are the cervical changes in labor?
- Dilation
- Effacement
- Softening
- Position
* *breakages of disulfide bonds and collagen mediated by prostaglandin E2, stimulated by engagement of fetal head or balloon**
What is station -2?
Fetal head has engaged the cervix
What is station -1?
Fetus has entered the vagina
What is station +2?
Fetal head is at opening of vagina
What are the two ways of assessing fetal position?
- u/s, or
2. Leopold maneuver
What is frank breech?
Knees are extended, butt facing down
What is complete breech?
Baby indian style, butt facing down
What is incomplete breech?
Baby’s knees partially extended, butt facing down
What is footling breech?
One leg extended, baby is feet first
What is transverse lie?
Baby’s back is pointing down, perpendicular to mom
What is the management for breech?
Can try external version
What are the cardinal movements of labor?
Engagement - at cervix Descent Flexion - upper 2/3 vagina Internal Rotation - upper 2/3 vagina Extension External Rotation Expulsion
What does the Bishop score measure?
How favorable vaginal delivery is, and how soon it will come
What is a common cause for prolonged labor?
Giving analgesics too soon
Manage by waiting out the effect of the analgesic
What is the initial management for prolonged latent labor?
Measure uterine contractions (IUPC) They should be > 3/30 min and > 40 mmHG ...can then insert balloon ...if balloon fails, c-section can always augment with pitocin
What is the management of arrested active phase labor?
Pitocin, give it 2 hrs, then c-section
What is prolonged second stage labor?
> 3 hrs epidural or > 2 hours no epidural
In what station can vacuum or forceps be used?
Station 1 or 2
If 0 –> go to c-section
What is the only reason for prolonged third stage labor?
Power (contractions)
Manage with massage, or pitocin, or manual manipulation
How do you manage transient HTN?
> 140/>90 before 20 weeks. Nothing seen on u/a because no time to damage kidneys, keep a log
How do you manage chronic HTN?
> 140/90 before 20 weeks:
alpha-methyldopa;
hydralazine;
metoprolol
What is the pathology of pre-eclampsia?
Placental contents released into blood stream, causing vasoconstriction
What is mild pre-eclampsia?
u/a has 140/>90;
What is severe pre-eclampsia?
Sustained >160/>90 after 20 weeks;
>5g/dL protein - full on nephrotic symptoms;
1+ alarm symptoms
How is mild pre-eclampsia managed?
If >36 weeks, Mag and deliver;
If baby shows any signs of clinical worsening, and is
How is severe pre-eclampsia managed?
Mag and deliver via c/s
What is eclampsia?
If mom has a seizure during pregnancy with no hx of seizures;
BP and u/a don’t matter,
What is HELLP syndrome?
Hemolysis
Elevated Liver enzymes
Low Platelets
How is HELLP syndrome managed?
Mag and deliver
What are the alarm symptoms of pre-eclampsia?
Hemoconcentration especially in the presence of edema (third spacing) - patient is losing protein in urine –> Hgb appears higher;
Epigastric abdominal pain - swelling of the liver - Gleason’s capsule stretching;
Headaches, vision changes - sign of vasospasm;
Gets labs - CBC, LFT, U/A
What is the goal of u/s?
Assess IUP, fetal age, fetal well-being
What is the goal of transcranial Doppler?
Generally used after 20 weeks, used to assess fetal anemia (can measure increased flow through the cranium, which is a compensatory mechanism for anemia)
What is the goal of amniocentesis?
Can only be done in 2nd trimester and later (>16 weeks);
AFP, genetic material,
risk of loss is 1:200;
If in beginning of 2nd trim - for genetic material;
If >36 weeks, can assess lecithin:sphingomyelin ratio
What is the goal of chorionic villous sampling?
6-12 weeks, risk of loss is 1/150;
can do genetic screens and karyotypes
What is the goal of PUBS?
Percutanous Umbilical Blood Sampling
>20 weeks;
only done later on to test for fetal anemia if transfusion is needed;
Risk of loss is 1:30
What anti-emetics do you prescribe for hyperemesis gravidarium?
Doxylamine
Promethazine
Metaclopromide
Ondansetron
What is the pathology behind the premature rupture of membranes?
Ascending infection
What is the risk of prolonged ROM?
Group B strep infection –> prophylaxis with amoxicillin
What is the risk with a post-date baby?
Macrosomia –> shoulder distocia
What is included in the BPP?
NST + AFI with U/S
What is the management of a non-reactive NST?
vibroacoustic stimulation, repeat NST
What is the next step in management of babies that failed repeat NST after vibroacoustic stimulation?
BPP
reassuring 8-10 score;
if 0-2, fetal demise imminent or occurred –> deliver;
If >36 weeks and iffy, deliver (pitocin or c/s);
What is the management of a
Contraction stress test = give pitocin, watch for DECELERATIONS;
if late decels or bradycardia –> deliver;
If reassuring –> grow baby, admit mom, +/1 steroids
