OB Flashcards
Name 9 conditions all associated with breech presentation
1) prematurity; 2) multip gest; 3) genetic disorders; 4) polyhydramnios; 5) hydrocephaly; 6) anencephaly; 7) placenta previa; 8) uterine anomalies; 9) uterine fibroids
Name 6 conditions associated with increased incidence of shoulder dystocia
1) fetal macrosomia; 2) maternal obesity; 3) DM; 4) postterm pregnancy; 5) prior should dystocia delivery; 6) prolonged second stage of labor
What qualifies as prolonged 2nd stage?
gt 3 hours (nulli)
gt 2 hours (multi)
What qualifies as prolonged latent phase?
gt 20 hrs (nulli)
gt 14 hrs (multi)
What qualifies as prolonged active phase?
slower than 1.5 cm/hr (nulli)
slower than 1.2 cm/hr (multi)
What qualifies as arrest of active phase
4 hrs of adequate ctx (200 mV in 10 mins)
or
6 hrs of all type
What is the most common type of breech (and the next two?)
Frank breech then footling, then complete
When is the fetus at greatest teratogenic risk?
Weeks 3-8
There is no increase seen in fetal anomalies or pregnancy losses with ionizing radiation exposure less than ___. Fetus is at greatest risk of exposure brown __ and __ weeks
5 rads; 8-15 weeks
Smoking increases the risk of these 5 serious complications
1) placental abruption; 2) placenta previa; 3) fetal growth; 4) preeclampsia; 5) infxn
Name 5 tocolytics
1) nifedipine; 2) terbutaline; 3) ritodrine; 4) magnesium sulfate; 5) indomethacin
Which two tocolytics are contraindicated in diabetic pts? Which one in myasthenia gravis?
terbutaline and ritodrine (terbutaline is no longer used to stop preterm labor in anyone); magnesium sulfate
___ (a tocolytic) is contraindicated at 33 weeks due to risk of premature __ closure.
Indomethacin; ductus arteriosus (also associated with oligohydramnios)
How does magnesium sulfate work as a tocolytic? Beta adrenergic agents? CCB? NSAIDs?
by competing with calcium entry into cells; increasing cAMP thereby decreasing free calcium; CCBs prevent calcium entry into muscle cells by inhibiting ca transport; NSAIDs block PG production
Name 3 side effects of magnesium sulfate and the order in which they appear. What is the antidote?
1) loss of DTR; 2) respiratory depression (12-15mg/dl); 3) cardiac depression (gt 15mg/dl)
calcium
Name 2 bad side effect associated with nifedipine.
fetal hypoxia and decreased uteroplacental blood flow
In addition to increasing pulmonary maturity and reducing the incidence of RDS in the newborn, betamethasone from 24-34 wks has been associated with a decrease in __ and __.
intracerebral hemorrhage; necrotizing enterocolitis
___ is an extracellular matrix protein that acts as an adhesive btwn the fetal membranes and the underlying decidua. Its presence in the cervical mucus btwn __ and __ weeks is thought to indicate a disruption to the __. It has a strong positive/negative predictive value only
fibronectin; 22-34 (it is normally found in cervical secretions in first half of preg); maternal-fetal interface; negative (if you have negative you have a 99/100 chance of not delivering in the next 14 days)
During delivery a fibrinogen is checked; what do you expect to see
fibrinogen should go up
if a pregnant woman is hypotensive, what is the first thing you do?
turn her on her left side (ivc compression)
what happens to a pregnant woman in regard to clotting?
clotting increases
what pulmonary function test gets worse (decreases) in pregnancy?
FRC
what is the expected change in hemoglobin in pregnancy?
blood volume increases but hgb (concentration) falls; normal is to nadir at 10
what happens to the tidal volume in pregnancy?
increases
what is the expected change in creatinine in pregnancy?
goes down
How do you treat GERD in a pregnant woman?
PPI
prior to pregnancy what vaccines should mom receive? What vaccine can mom NOT get once pregnant?
influenza, hep B, MMRV; MMRV
What vitamin should a woman who wants to get pregnant be on?
folic acid
Mom has HTN and wants to get pregnant. What do you put her on?
alpha methyl dopa (hydralazine, labetalol, nifedipine)
Mom is Rh-antigen positive, what do you put her on?
nothing
Pt has diabetes and wants to get pregnant, what do you do?
switch to insulin
What are the followup periods for pregnancy?
q4w until 28 wks, q2w until 36 wks, q1w until delivery
What is the quad screen for down syndrome?
increased: bHCG, inhibin
decreased: AFP, estriol
What is sequential screening?
1st then 2nd trimester screens - more unnecessary testing, more abortion advantage
What is combine screening?
1st and 2nd trimester screens at once - less unnecessary testing, less room for intervention
Nuchal translucency screen - when and for what?
1st tri screening for aneuploidy and spina bifida
What age is considered increased risk for aneuploidy? (AMA age)
35
Rh ? mom, Rh+ baby, Rh Ab-, what do you do?
Rhogam at 28 wks and w/in 72 hrs from delivery
How do you screen for gestational diabetes?
1 hr glucose tolerance test - 50g, sugar should be less than 140
For 3hr glucose tolerance test, what are the four glucose levels to look for?
give 100g; fasting gt 95 1 hr gt 180 2hr gt 155 3hr gt 140 (need 2/4 to be positive)
What constitutes anemia in a pregnant woman?
hgb lt 10; hct lt 30
Rh ? mom, Rh + baby, what do you do?
check mom for antibodies
How do you test to confirm a pregnancy?
ultrasound
How do you treat fetal anemia?
PUBS and transfuse (PUBS = percutaneous umbilical cord sampling)
When do you get an amniocentesis? What can it show? What is the risk of loss?
16-20 wks; AFP, genetics, fetal lung maturity, assess for infxn; 0.5%
How do you screen for fetal anemia? How do you confirm?
transcranial doppler (highly sensitive); PUBS
When do you perform chorionic villous sampling? What can it show? What is the risk of loss?
10-13 wks; genetics, karyotyping; 1-3%
Which is more invasive, CVS or amniocentesis?
CVS
What medication can you use in pregnancy for hyperthyroid?
PTU
A pregnant woman has n/v so bad that she has electrolyte abnormalities, next step?
IV hydration (THEN work it up)
A woman gets pregnant and has hypothyroid, what do you do with her synthroid?
increase it (thyroid binding proteins are increasing) - trend TSH q4wks (instead of q12)
Who do you tx when you find a positive UTI without symptoms?
pregnant women only
Cystitis in pregnant woman, what do you give?
amoxicillin (nitrofurantoin if penicillin allergic) x 7d (complicated UTI!)
How do you diagnose diabetes BEFORE she gets pregnant?
A1c or 2 hr glucose tolerance test
Who do you screen with urinalysis?
pregnant women!
The thyroid has to come out. When is it safe for thyroidectomy?
2nd trimester
How do you tx pyelonephritis in a pregnant woman?
ceftriaxone - if no improvement after 3 days, U/S looking for abscess
Pregnant pt with epilepsy - what can you give to prevent seizures? What can you give to abort seizures?
levetiracetam or lamotrigine; phenobarbital or benzos (ok in late pregnancy)
folate for all women on AEDs looking to get pregnant!
Latent phase of pregnancy is __ to __ and should take no longer than __ (nulli) or __ (multi)
0cm to 6cm; 20 hrs; 14 hrs
Active phase of pregnancy is __ to __ and should take no longer than __ (nulli) or __ (multi), __ (max)
6cm to 10cm; 1.2cm/hr; 1.5 cm/hr; 5hrs
What is the beginning and end of stage 1 of labor
0cm w/contractions to 10 cm max dilation
What defines stage II of labor? How long should it take?
delivery of fetus - from max dilation 10 cm to fetus out; 3 hrs (nulli) or 2hrs (multi); add one hour for epidural
Breech birth + external version fails, whats next?
C section
Define stage III of labor. How long should it take?
delivery of placenta, from fetus out to placenta out; less than 30 minutes
Fetal station is the number of centimeters from the __
ischial spine
We can simulate head engagement with?
cervical ripening balloon (CRB)
If prolonged latent phase, how can you tx?
augmentation of labor (balloon, oxytocin, misoprostol, amniotomy)
Mom has been pushing for 3 hrs since maximum dilation, baby is still at station -1, next step?
assess for progress/descent of fetal head - if not progressing offer cesarean (this is how to tx prolonged 2nd stage with negative station)
Baby’s head can be seen just at the vaginal opening, but it’s been going for 4 hours (maternal exhaustion). Next step?
vacuum or forceps (this is how to tx prolonged 2nd stage with positive station)
Define arrest of active phase. How do you tx?
4hrs of adequate ctx (gt 200 mV) or 6 hrs all comer. If decreased frequency or adequacy, oxytocin; everything else: C/S
What is considered adequate frequency of contractions in labor?
3 ctx in 10 mins = good; less than 3 in 30 mins is bad (this tells you nothing about the power of the ctx)
What are the 3 ways to tx prolonged stage 3 of labor?
1st: uterine massage; 2nd: oxytocin; 3rd: manual extraction
Mom has a fever after delivering baby 6 hrs ago, placenta out came 5.5 hours ago, diagnosis and next step?
endometritis - antibiotics (gentamicin + ampicillin)
Mom has had ROM and she’s been laboring for 20 hours. She’s progressing, just slowly - diagnosis and next step?
prolonged ROM (gt 18 hrs!); give GBS ppx (ampicillin) - watch out for endometritis and chorioamnionitis
A woman at 20 gestational weeks has a rush of fluid, her membranes are ruptures, diagnosis and next step?
previable PPROM - counsel on expectant mgmt vs delivery; counsel on risk of infxn
Mom has a rush of fluid, she is at 38 wks, but not contracting, diagnosis and next step?
PROM (premature rupture of membranes); GBS ppx if indicated; induce labor
A woman at 30 wks has a rush of fluid, her membranes are ruptured. Diagnosis and next step?
PPROM (preterm premature ROM); steroids for fetal lung maturity (betamethasone) and antibiotics for latency
Infxn is usually cause for PPROM
How do you treat PPROM?
gt 34 weeks = deliver
24-34 wks = cortiocosteroids
lt 24 wks = nonviable
What does premature in PROM mean?
absent contractions
Name 4 ways to confirm ROM
1) speculum shows pooling of fluid; 2) nitrazine test turns blue; 3) fern sign on a glass slide; 4) can also do U/S for AFI (shows oligo)
A woman at 38 wks has a rush of fluid, her membranes are ruptured, next step?
Deliver!
Mom has contractions at 28 wks, but there is no cervical change, and then they stop, diagnosis?
Braxton hicks (ctx, but not labor)
At 42 wks mom still hasn’t delivered; what do you do? What is called when baby is gt 42 wks? Name 5 fetal risks
induction of labor, if that fails C/S; post dates; 1) macrosomia; 2) shoulder dystocia; 3) meconium aspiration; 4) fetal demise; 5) oligohydramnios
Mom has ct. at 28 wks. There are cervical changes, diagnosis and next step?
Preterm labor; give mag sulfate (for neuroprotection); give steroids (for lung maturation) and can also give tocolytics (just really to get mom to a tertiary center)
Name 6 causes of preterm labor
1) idiopathic; 2) smoking; 3) young maternal age; 4) preterm mom; 5) anatomical (short cervical length); 6) multiple gestations (twins)
Proteinuria in pregnancy + HTN, diagnosis?
pre-eclampsia (look for severe features)
Pregnant woman seizing who does not have epilepsy, next step?
Mag, benzos, and deliver (eclampsia)
BP gt 160/110 in pregnancy, no HTN at baseline, diagnosis?
gestational HTN vs preeclampsia - look for proteinuria
Name 7 alarm sxs that earn you preeclampsia with severe features
1) decreased plts; 2) increased LFTs; 3) RUQ abdominal pain; 4) increase creatinine (gt 1.1 or 2x baseline); 5) pulmonary edema; 6) HA/vision changes; 7) BP gt 160/110
Why might you get RUQ abd pain and increased LFTs with preeclampsia?
There is a stretch of glisson’s capsule leading to decreased blood flow to the liver, leading to increased LFTs; pain is due to inflammation and stretching of the capsule around the liver
HA, vision change, HTN in pregnancy, diagnosis and next step?
pre eclampsia with severe features; tx with Mag and deliver
RUQ pain and HTN in a pregnant woman, diagnosis?
Pre-E
How do you tx Pre-E without severe features? With severe features? Eclampsia?
antenatal testing, deliver at 37 wks if stable; Mag + BP monitor + deliver urgently (induce); Mag + deliver emergently (section)
You get a lab question about a delivery: INR is elevated, plts are low, fibrinogen is low/normal and hub is low. Likely dx?
DIC
How do you tx Pre-E without severe features and gt 37 wks
deliver
You get a lab question about a pregnant woman, AST and ALT are up, the plts are down, the hgb is low, dx and next step?
HELLP; Mag and deliver emergently (section)
What is the primary risk factor for preterm ROM? Name 3 other risk factors
genital tract infxn (especially assoc w/bacterial vaginosis); smoking, previous premature ROM, shortened cervical length
Variable decelerations are a result of ___, which is frequently caused by a lack of ___.
cord compression; lack of amniotic fluid (can be seen with oligohydramnios or PPROM)
In some cases of preterm ROM, amniocentesis may be performed to detect intra-amniotic infxn. A low __ is an indication of infxn. The presence of __ has the lowest predictive value for the dx of chorioamnionitis
amniotic fluid glucose; amniotic leukocytes
What can be administered weekly (starting btwn 16-20 wks to 36 wks) to reduce the risk of premature labor?
17-alpha-hydroxyprogesterone
Prostaglandins are used for cervical ripening and are contraindicated in pts with previous hx of __ b/c of increased risk of uterine rupture
cesarean delivery
Name 5 initial measures to tx fetal hypo perfusion (late decels)
1) change in maternal position to left lateral position (which increases perfusion to uterus); 2) maternal supplemental oxygenation; 3) tx of maternal hypotension; 4) discontinuation of oxytocin; 5) intrauterine resuscitation w/tocolytics and IV fluids
Amnioinfusion may be used in pts with __
variable decelerations
What is the most common cause of post partum hemorrhage?
uterine atony
Name 4 of 9 risk factors of uterine atony
1) precipitous labor; 2) multiparity; 3) general anesthesia; 4) oxytocin use in labor; 5) prolonged labor; 6) macrosomia; 7) hydramnios; 8) twins; 9) chorioamnionitis
Factors that lead to a __ are risk factors for uterine inversion. Name 4. But what is the most common risk factor?
over distended uterus; 1) grand multiparity; 2) multiple gestation; 3) polyhydramnios; 4) macrosomia;
excessive (iatrogenic) traction on the umbilical cord
Name 3 risk factors for genital tract lacerations
1) precipitous labor; 2) macrosomia; 3) instrument assisted delivery or manipulative delivery (i.e. breech extraction)
Name 4 uterotonics (used to increase contractions and decrease uterine bleeding).
1) methergine (methylergonovine); 2) prostaglandins (cervidil = dinoprostone = PGE2; hemabate = carboprost = prostaglandin F2alpha); 3) misoprostol (PGE1); 4) oxytocin
Which uterotonic should be withheld in pts with HTN and/or preeclampsia? Asthma?
methergine; hemabate (carboprost, PGF2alpha)
A risk factor for placenta accreta is ___.
multiple prior c sections
Name 4 risk factors associated with retained placenta
1) prior cesarean delivery; 2) uterine leiomyomas; 3) prior uterine curettage; 4) succenturiate lobe of placenta (smaller accessory placental lobe separate from the main disc of the placenta)
When is a B lynch suture used?
it is a uterine compression suture used in mgmt of unresponsive uterine atony (requires laparoscopic surgery)
What is the risk for mono/mono twins?
cord entanglement/accident
For conjoined twins, when did the eggs split?
greater than day 12
Name 4 risks of ALL multiple gestations
1) preterm; 2) malpresentation; 3) C/S; 4) PPH
Identical twins, 2 placentas, 2 sacs - when did the egg split?
Day 0-3
monochorion diamnion split 4-8
What added risk does monozygotic, mono-chor, and di-amniotic have?
twin-twin transfusion
Which baby does better in twin-twin transfusion?
the transfuser (the little one) - the acceptor has polycythemia which can result in bilirubinemia
What added risk does mono-zy, mono-chor, mono-amnio have?
coinjoined twins, cord entanglement
Post partum hemorrhage and nonpalpable uterus, dx?
uterine inversion
PPH that cannot be controlled with meds, next step?
surgery - ligate arteries
When do you do a hysterectomy in the setting of PPH?
severe instability or failure of all other options
How do you tx uterine inversion?
replace funds with pressure - may need to relax uterus (tocolytics)
Placenta has vessels to the edge, next step?
suspected retained placenta - U/S
PPH and a firm uterus, next step?
U/S for retained placenta
PPH and a boggy uterus, dx?
uterine atony
What is the goal accelerations you are looking for?
15x15, 2 in 20 (before wk 32 its 10x10)
Mom can’t feel baby kicking, no accelerations on NST, next step?
vibroacoustic stim test
Biophysical profile lt 4, next step?
deliver
Variable decels, what’s the likely dx? Early decels? Late decels?
cord compression; head compressions; uteroplacental insufficiency
Mom can’t feel baby kicking, next step?
NST - accelerations are good
Vessels run to the edge of placenta surface over cervical os, dx?
vasa previa
What do you do for a uterine rupture?
Emergent c/section
How do you diagnose an abruption?
clinically and u/s
Baby is in a transverse lie, question about bleeding, dx?
placenta previa
MVA and 3rd tri bleeding, dx?
placental abruption
Cocaine, HTN, and 3rd tri bleeding, dx?
placental abruption
Painless 3rd tri bleeding, dx?
placenta previa
Contractions, lots of pain, contractions stop, uterus is no longer firm, dx?
Uterine rupture (also look for detail about loss of fetal station in stem)
Rh-Ag-Neg mom, Rh-Ag-Neg dad, what’s risk to baby?
None
Rh-Ag-Neg mom, Rh-Ag-Pos daad, what’s the risk?
Mom will prime against the NEXT baby
Rh-Ag-Pos mom, Rh-Ag-Pos dad, what’s the risk?
None (mom is Ag+ so she can never develop Ab)
Rh-Ag-Neg mom, Rh-Ag-Pos dad, mom’s first pregnancy, what do you do?
Rh-immune globulin (Rhogam) at week 28 and within 72 hours of delivery
When do you deliver a fetus with fetal anemia?
Transcranial doppler screen is positive and GA is gt 32 wks
When do you PUBS and transfuse fetal anemia
transcranial doppler screen is positive and GA is lt 32 wks
List the tx for group B strep
Ampicillin, cefazolin (if pen allergic), clinda (if pen anaphylaxis), vanco (if can’t tolerate any of above)
Who gets intrapartum antibiotics for group B strep (3 groups)?
If GBS positive ever. Prolonged ROM, intrapartum fever
Hep B core ANTIBODY means what?
They’ve been exposed (unsure if active infxn or immune - look for Hep B surface antibody)
Hep B positive mom, what do you do for baby?
IVIG and vaccine at birth (no evidence C/S reduces vertical transmission)
Mom giving birth, HIV positive, next step?
AZT during birth
Tx for late latent syphilis? Tertiary syphilis? Secondary syphilis? Primary syphilis? Early latent syphilis?
penicillin IM qwk x 3; penicillin IV x 7-10 days; penicillin IM x 1; penicillin IM x 1; penicillin IM x 1
When it’s not clinical, make the diagnosis of HSV using ___.
PCR (never the tzanck prep)
What test do you use to diagnose primary syphilis? Tertiary syphilis? secondary syphilis?
Darkfield microscopy (pick “gram stain”); CSF VDRL; RPR to FTL-antibodies
Painful prodrome, vesicles on an erythematous base suggests?
HSV
Tx of tertiary syphilis in a pregnant woman allergic to penicillin?
Penicillin IV x 7-10 days (give it anyways! desensitize)
Tx for herpes simplex virus in a pregnant woman?
(Val)-acyclovir
What is a risk of vacuum suction delivery?
fetal: cephalohematoma
maternal: catching vagina in suction can cause vaginal trauma
What’s wrong with opiates for pain control in labor?
They go to baby
Cephalohematoma = ?
Complication of vacuum delivery, hemorrhage beneath periosteum (will not cross suture line)
Why/when do you cerclage?
Dx of cervical insufficiency; usually placed in second tri
Station +2, fetal distress, what do you use?
forceps or vacuum
When do you undo the cerclage?
by 36 wks, or if labor begins
What do you need if you do epidural?
tocodynamometer (she can’t feel ctx anymore)
What is female surgical contraception? Male?
tubal ligation; vasectomy
What are two major contraindications to OCPs?
gt 35 yo and smoking (increased risk of DVTs!)
What is the emergency contraception for condom failure/rape?
Plan B = levonorgestrel, or ella = ulipristal, or copper IUD
Postpartum fever day 0, 1-2, 2-3, 4-5, 5-6, 7-21
0: atelectasis
1-2: UTI
2-3: endometritis (risk factors c/s after prolonged ROM and prolonged labor)
4-5: wound infxn
5-6: septic thrombophlebitis or pelvic abscess (pelvic mass)
7-21: infectious mastitis
How do you manage a pt with septic thrombophlebitis?
IV heparin for 7-10 days, keeping PTT values at 1.5-2x baseline
Postterm pregnancies are associated with these 4 things
1) placental sulfatase deficiency; 2) fetal adrenal hypoplasia; 3) anencephaly; 4) inaccurate or unknown dates
Define postterm pregnancy; define late term
postterm: gt/= 42 0/7
late-term: 41 0/7 to 41 6/7
Fetus is born and is withered, meconium stained, long nailed, fragile, and has an associated small placenta. What is this called and who do you see it in?
Dysmaturity; postterm pregnancies
The systolic/diastolic (S/D) ratio of the umbilical artery is determined by __. An increase in the S/D ratio reflects increased __. It is a common finding in __ fetuses.
doppler u/s; vascular resistance; IUGR
increased S/D associated with increased rate of perinatal morbidity and mortality
IUGR is a significant risk factor for the subsequent development of diseases as an adult such as these 6
1) CV disease; 2) chronic HTN; 3) stroke; 4) chronic obstructive lung disease; 5) type 2 DM; 6) obesity
(asthma, cardiomyopathy, and type 1 DM are not associated with IUGR)
Macrosomia is defined as a fetus greater than ___. A fetus with biparietal diameter greater than __, could benefit from a C/S
4000 grams; 12 cm
What complication is less likely to occur with a vacuum then with forceps delivery?
maternal laceration
External cephalic versions and internal versions are contraindicated in ___. Instead, if baby is breech, do a __.
active labor; c/s
What are the four signs of placental separation?
1) gush of blood; 2) lengthening of the cord; 3) globular-shaped uterus; 4) uterus rising to the anterior abdominal wall
Hyperemesis gravidarum is a severe persistent form of n/v of pregnancy that results in __, __, and __. Name 3 risk factors.
weight loss of gt 5% pre pregnancy weight; electrolyte abnormalities; ketonuria
1) multiple gestation; 2) hydatidiform mole; 3) hx of esophageal reflux
(HG is typically unresponsive to anti-emetics
Name 7 contraindications to external cephalic version
1) indications for C/S delivery regardless of fetal lie; 2) placental abnormalities (prevue or abrupt); 3) oligo; 4) ROM; 5) hyperextended fetal head; 6) fetal or uterine anomaly; 7) multiple gestation
Name 5 risk factors of postpartum endometritis. What’s the tx?
1) C/S; 2) chorioamnionitis; 3) group B strep colonization; 4) prolonged ROM; 5) operative vaginal delivery;
clinda + gentamicin
Which antibiotic is given for lactation mastitis?
dicloxacillin
To dx proteinuria for preeclampsia, you need a __ or __.
urine protein to cretatinine ratio of gt/= 0.3 or a 24-hr urine collection for total protein of gt 300mg
Name 6 contraindications to breast feeding
1) active untreated TB; 2) maternal HIV infxn; 3) herpetic breast lesions; 4) active varicella infxn; 5) chemo or RT; 6) active substance abuse
