OB Block 2 Cram Flashcards

1
Q

When is the first pregnancy visit needed and when are f/us needed?

How is the obstetric conjugate estimated?

A

Fist: 10-12wks EGA
Until 27wks: q4wks
28-36wks: q2wks
+36wks: q2wk

Inferior pubic symphisis to sacral promontory:
Diagonal conjugate - 2.5cm= +10cm

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2
Q

Preferred pelvis types for vaginal delivery?

Midpelvis is measured at ? and during labor are called ?

A

Gynecoid*
Anthropoid

Ischial spine
Stations

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3
Q

Mid pelvis and ischial spine make up ? labor start point?

Why is the interspinous diameter important?

A

Station 0
Above= neg numbers
Below= pos numbers

Obstructed/arrested labor point

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4
Q

When would GA be adjusted to an US date?

What are the two layers of the Double Decidua Sign and the importance?

A

<9wks old w/ >5d difference
9-14wk old w/ >1wk difference

D Parietalis
D Capsularis
First/earliest sign of intrauterine pregnancy

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5
Q

What is TORCH

What are the Others?

A

Toxoplasmosis Other Rubella
CMV HSV

Coxsackie Chicken C/G
HIV HTV HBV
GBS TB Bacteriuria Zika Syphilis

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6
Q

What are the RNA viruses in this block?

What are the DNA viruses?

A

Rubella HIV (retrovirus)

CMV HSV Varicella HBV

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7
Q

Toxoplasmosis infection can lead to ? in the baby

How is this type of infection Tx

A

Microcephaly

Spiramycin- PT only
Pyrimethamin Sulfa w/ FA- PT and baby

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8
Q

When does a CMV infection become a possibility?

How is a Dx made but w/ ? cautious info?

A

Mono-like
Hydrops IUGR CNS abnormality on US

Serology- IgM x 2yrs

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9
Q

When are pregnant PTs not screened for GBS?

What are the risk-factor strategies?

A

GBS bacteriuria this pregnancy
Previously infected infant

FBIRD
Fever 
Bacteriuria
Infected infant
Ruptured +18hrs
Delivered <37wks
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10
Q

When is intrapartum prophylaxis indicated for GBS

A
BUIC
Bacturemia
Unknown (DRNF)
Infected infant
Culture pos
DRNF
Delivered <37wks
Ruptured >18hrs
NAAT Pos
Fever >100.4
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11
Q

When is intrapartum GBS prophylaxis not needed?

A

Previous pregnancy w/ +culture
Planned c-section
Neg vag/rectal cultures during this pregnancy

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12
Q

When are pregnant PTs screened for bacteriuria?

What ABX are used for empiric Tx?

What can this progress into and how is it Tx?

A

All PTs at new OB appt w/ UA and culture

Nitro Amox Amp w/ Test of Cure after completion of ABX

Leading cause of septic shock during pregnancy:
Pyelonephritis Tx InPt w/ IV ABX

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13
Q

Pregnant PTs need to be cautious and not exceed daily limits of ? vitamins?

Why is it recommended to be on folic acid prior to conception?

How much is recommended?

A

Iron Zinc Selenium
A B6 C D

NT closes on day 28

400-800mcg/day ideally 12wks prior

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14
Q

When would PTs be recommended to increase daily folate to 4mg?

What meds are c/i during pregnancy?

A

Valproate/Carbamazepine
Hx of NTD
T1DM
BMI >35

100 IS CAT
>100mg/day ASA Isotretinoin Sulfonamides Coumadin ACEIs Tetracyclines

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15
Q

What is the leading cause of preventable developmental disabilities?

What are the discriminating features of FAS?

A

FAS

Flat midface
Indistinct philtrum
Thin upper lip
Short fissures/nose

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16
Q

When/why would sex need to be avoided during pregnancy?

What dental issue is linked to increased risk of preterm labor?

A

Miscarriage risk/hx
Placenta previa
Premature labor

Peridontal dz

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17
Q

When are domestic violence screenings conducted?

When to screen for depression or behavioral health w/ ? questionnaire?

A

First prenatal visit
One/trimester
Post-partum visits

Once during perinatal period
Edinburgh post-natal depression

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18
Q

When is breast feeding c/i?

What are the emergent return criteria for PTs >20wks EGA?

A

HIV Lithium Dependence Active TB

Contractions q3-5min
Membrane rupture
Vaginal bleeding

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19
Q

What criteria need to be met for an elective delivery to be considered?

What may be the first test ordered at the first prenatal appointment?

A

FHTs in past 30wks
US dating supports
HCG at 36wks prior
Not before 39wks

hCG confirmation test

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20
Q

What is the quick time frame milestones for prenatal care by week?

A
FQAFGRO
10: Doppler FHT
18: quickening
18-20: anatomy scan
20: fundal height at umbilicus
24-28: GTT
28: Rhogam if M-/F+
36: GBS
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21
Q

How quickly does hCG increase during pregnancy

What is seen on TVUS to correlate to hCGs for viability

What would be seen and indicative of demise?

A

Doubles every 2.2 days

Sac- 5wks, 1500
Pol- 5wks, 5200
Cardiac- 7wks, 17,500

Gestational sac w/out yolk
No FCM
CRL >5mm

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22
Q

What are the 6 types of abortions and the criteria of each

A

Threat: <20wks w/ bleeding and closed os

Inevitable: bleeding w/ dilated os, non-viable

InComp: Bleeding, dilated and passage of tissue

Comp: Os closed after passage of tissue

Missed: demise yet retained

Recurrent: +3 SpAbs in succession

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23
Q

Fetus feels mother’s stress until ? age

How are EPL’s managed?

A

22wks

Threat: reassure
InComp: Type/Cross, evacuate
Missed: US, manage w/ Misoprostol

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24
Q

What are 5 things conducted at routine prenatal visits?

How far should the fundus advance above umbilicus after 20wks and what indicates need for US?

A

BP/Weight
Fundal height
Fetal cardiac activity
Fetal movements

1cm per week
>3cm discrepancy

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25
How much weight gain is expected? When/how many calorie increases are needed? How many calories are needed when breast feeding?
1st-T: 3-6lbs After 20wks: 1lb/wk Total: 25-35lbs for PTs w/ BMI 18.5-24.9 Avg: 27.5lbs/12.5kgs 3-400kcal/day= 1lb/wk during 2-3rd-T 500kcal/day
26
How much weight gain is normal for PTs w/ BMI <18.5 How much is normal if BMI is >30?
28-40lbs 11-20lbs
27
Pregnancy criteria for edema When/how are fetal kick counts conducted
>+1 after 12hrs bed rest 5lb inc in 1wk After 28wks in LLR: >10/hr, norm >10 in 30min If less, drink glucose, reassess x 1hr <10 after 2hrs, LnD w/ Dec Fetal Movement
28
# Define Rh Alloimmunization What is the name of this response
Rh- mother carries Rh+ baby Delivery= Rh+ mother, now dangerous to second Rh+ baby, IgGs cross and destroy fetal RBCs= hemolysis/hydrop Anamnestic
29
How is fetal-maternal hemorrhage qualitative/screened and quantified? When is quant test used?
Qual/Screen: RBC rossette screen Quant: Kleihauer Betke test- citric acid dissolves maternal cells, Eosin stain remaining fetal cells Need for higher dose of Rhogam, >30cc blood loss
30
What is a "dose" of Rhogam When/what prenatal genetic screening is conducted?
300mg IM to cover 30cc of fetal-maternal hemorrhage 20wk US and serum markers for all PTs
31
What d/o is the primary target for fetal aneuploidy screening? Define Triple and Quad Screening done in 2nd-T
Tri-21 Triple at 13-16wks: AFp hCG Uncon Estradiol Quad at 15-20wks: triple + Inhibin A
32
What fetal aneuploidy screening is done during 1st-T ``` Tri-13= ? Tri-18= ? ``` All pregnant PTs in US are screened for ?
Age NT bhCG PAPP-A Patau Edwards Cystic Fibrosis
33
What is the earliest screening option avail for detecting Tri-21 Being able to identify ? structure dec risk/likelihood?
US w/ marker Nasal bone
34
Triple screening for Tri-21 has better positive predictive value in ? PTs What would MSAFP, Estriol, bhCG, Inhibin results look like for Tri 13, 18 or 21
Older PTs 13: all depends 18: all dec 21: dec M/E, inc b/i
35
What are the indications to do a cffDNA test?
+35y/o at delivery Prior 13 18 21 issues Robertsonian translocation carrier Any abnormal aneuploidy result
36
What are the indications for PTs to have amniocentesis of CVS procedures? Pros/Cons of amnio or CVS
>35y/o at delivery (>32 w/ twins) Pos serum marker Abnormal US Carrier/chrome abnormality Amnio: 16-20wks test w/ 2wk culture CVS: Earlier/faster dx but no NTD info <9wks risk jaw/limb abnormalities
37
When does antenatal testing begin? What is the use and normal response for Electronic Fetal Monitorin
32-34wks q7days High risk- 26-28wks Assess fetal well being in high risk pregnancy w/ external monitors- inc of HR w/ movement
38
What is the first line tool for fetal surveillance and how is it performed?
Non-stress test | 20min w/ PT in LLSupine- measures fetal HR as indicator of well being
39
What is a 'normal' NST result What NST results are categorized as 'moderate' reassuring Fetal heart rate monitoring with NST is essentially ? monitoring?
Reactive Inc 10bpm x 10sec <31wks Inc 15bpm x 15sec >32wks Low risk of fetal acidosis Fetal brain monitoring
40
When are NSTs most predictive? What could be 4 causes of a non-reactive NST test?
Normal, high false-+ rate Hypoxemia Maternal sedative/opioid Cardiac/neuro abnormality Sleep-wake cycles
41
What is done during NSTs if fetal sleep cycle is occurring? Define Contraction Stress test and the value of it's results
Artificial larynx applied max of 3x to reduce testing time to 15min Nipple/oxytocin release stimulates contractions; High negative predictive value + test= high fetal death risk
42
Amniotic fluid is similar to ? fluid and starts production at ? By __wks, fetal kidneys are the main contributor to amniotic fluid production
Extra cellular fluid 8-11wks 18wks- renal anomaly would present as oligohydramnios early in pregnancy
43
# Define AFI and it's value What results are high, norm or low What are the the two methods to measure the AFI
Amniotic fluid index- assesses volume and used to assess fetal health High: >24cm Norm: 5-24cm Low: <5cm Sum of 4 quadrants Deepest pocket of 2x2cm
44
# Define BPP How is is measured and what does it include
Biophysical Profile- NST + US ``` Score of 0 if: NST- 0-1 acceleration Breathing- <30sec Movement- < 3 movements Tone- 0 exten/flexion AFI- 2cm or less at deepest pockets ```
45
What is the modified method to acquire BPP that is equivocal to traditional BPP What are the BPP scores indicative of
AFI + acoustic NST 10: rpt weekly; PT is DM/Post-partum repeat biweekly 8: dec AFT- deliver 6: repeat, still 6 or less- deliver 4: repeat same day, 6 or less- deliver 2: near certain asphyxia- deliver
46
How do BPP scores correlate to fetal pH? What form of surveillance is utilized if suspected IUGR is present?
8-10: normal and reassuring 6: retest or deliver 4 or less: not reassuring, eval and consider delivery Doppler of UA
47
What is considered normal or unfavorable Doppler UA US results What unique situation can arise from these results?
Norm: dec vascular resistance as GA inc Quantified w/ S:D ratio, if increased- possible steroids for pre-labor prep if 23-34wks
48
When is Quad screening used? When are NT defects screened for?
If Triple Screen was abnormal, screening only, not Dx 1st-T w/ US 2nd-T w/ Triple/Quad screen
49
Where is MSAFP produced? How/why does it become detectable and what does it signify
Yolk sac/Fetal GI and liver Defected fetal skin allows MSAFP to leak into amniotic fluid and become detectable in serum Anencephaly Spina Bifida
50
What is the next step if higher than normal levels of MSAFP are detected? This follow up step is preferred because ?
Eval w/ Sonography/US DxToC for NTDs
51
When are pregnant PTs screened for Tri-21 Where is the genetic error leading to CF?
All screened during prenatal care prior to 20wks Auto recessive mutation on CFTR within Chrom-7
52
What are the screening recommendations for Tay Sachs? What screening tests are done for high or low risk ethnicity groups?
If both have risks/Hx One is high risk or both are carriers ``` Molecular test (DNA base mutation analysis)- high Hexosaminidase A serum levels- low ```
53
How does Tay Sachs cause damage to baby How are amniocentesis procedures conducted if more than one fetus is present?
Undigested milk builds and damages Brain Liver Eyes Kidney Indigo carmine dye injected to guarantee two samples from two different sacs
54
Indications to do amniocentesis Indications to do CMV Indications to do Cordocentesis
Alloimmunization Dx Fetal lung assessment Infections Genetic d/o Karyotype Genetic anaylsis MC fetal anemia assessment Assess/Tx platelet alloimmunization Karytotype results earlier than CMV/Amnio
55
What S/Sx for Dx pregnancy is not reliable until after 10 days Define Chadwick sign Define Hegar sign Define Goodell's
Amneorrhea Red/blue cervix Softening of isthmus Softening of cervix
56
# Define Cholasma Uterus is too big for pelvis by ? wk and shifts ?
Mask of pregnancy 13wks, to R
57
# Define Braxton Hicks contractions Vasodilation allows for inc maternal/fetal flow is due to ?
Non-rhythmic contraction between 5-25mmHg w/out cervical changes Estradiol
58
What causes cervical ripening near the end of pregnancy? What is the purpose and contents of the mucus plug?
Inc water content IgA/IgG, cytokines to prevent infections
59
What causes cervical mucus to get thicker farther into pregnancy? What prevents further ovulation during pregnancy?
Progesterone- inc thickness, dec ferning Corpus luteum secretes Progesterone x 7wks
60
# Define Theca Lutein Cysts Where does Relaxin get made and what for
Exagerated follicle stimulation due to inc hCG and: Trophoblastic dz Eclampsia/Hyperthyroid Placentomegaly Luteum Decidua Placenta for CT remodeling
61
Candidiasis infection increase during 2nd/3rd-T due to? What effects do Estrogen and Progesterone have on breasts during pregnancy
Inc lactic acid- pH 3.5-6 Inc glycogen stores E stims fat deposition, ductal growth P stims ampullary hypertrophy, secretory maturation
62
Endocrine changes during pregnancy inc changes to : Pituitary Thyroid ParaThyroid Pancreas Adrenals
Pit: inc size d/t estrogen Thy: hCG has similar affect as thyroid hormones PT: hyperplasis d/t PTH production and inc Ca needs Pan: hyperplasia= inc insulin resistance Ad: Inc cortisol d/t estrogen resulting in striae
63
What part of endocrine system is not needed to maintain pregnancy? What is progesterones role in pregnancy?
Pituitary Dec smooth muscle tone, naturally produced tocolytic
64
# Define Linea Nigra Chloasma is AKA and defined as ?
Dark brown pigmentation Melasma gravidarum- irregular brown patches on face/neck
65
# Define Angiomas Define Palmar Erythema
Telangiectasias- vascular spiders on face/neck/upper chest/arms Inc estrogen/cutaneous blood flow due to inc metabolism
66
Why do pregnant PTs have pitting edema in LEs? In a normal pregnancy, what is a normal metabolic state due to carbs?
Inc venous pressure secondary to partial VC occlusion Dec interstitial colloid osmotic pressures Fasting hypo/post-prandial hyperglycemia w/ hyperinsulinemia
67
Why does placenta express ghrelin? Why do maternal T4 levels inc? When is fetal thyroid development begin and what demand is created?
Role in fetal growth and cell proliferation Maintain maternal euthryoid and transfer to fetus 2nd half of pregnancy, inc iodide
68
Why does maternal levels of Vit D3 increase? Why does maternal Hct/Hgb decrease during pregnancy?
Facilitates Ca absorption from diet to fetal bone development Induced hypervolemia- plasma and RBC expansion
69
What blood work results can be used as a marker of bacterial infection? Why do overall levels of WBCs increase during pregnancy?
Inc procalcitonin during 3rd-T/early post-partum Estrogen/Cortisol
70
What happens to CO during pregnancy? What would be seen on EKG? What would be seen on CXR?
Inc CO= Dec SVR + Inc HR LAD w/ inc Preload Larger silhouette
71
What would be heard on cardiac exam in pregnant PTs When/why would PTs experience Sx HOTN when laying down?
Exaggerated S1 split Louder S1/S2 Compression of aorta/dec preload LLR recommended, also reduces IVC occlusion
72
What are the roles of prostaglandins in pregnancy? What CV lab result may be useful in pre/eclampsia pathogenesis?
Vascular tone BP Na balance ``` Ratio of PGI2:thromboxane Inc endothelin (constrictor) ```
73
How is morning sickness Tx How is hyperemesis gravidarum present and Tx
Small meals w/ B6 and Doxylamine/Phenothiazine >5% Weight loss E+ imbalance Ketosis Admit fluids/nutrition
74
What can be used for N/V during pregnancy What antiemetics can be used in pregnancy?
Ginger B6 Doxlamine Meclizine Diphenhydramine Metoclopramide Cat B: Serotonin antagonists- Ondansetron (long Qt, Serotonin syndrome) Cat C: Promethazine Prochlorperazine Chlorpromazine
75
# Define Epulis Gravidarum and its AKA Define Intrahepatic Cholestasis
AKA- pyogenic granuloma Inc vascularity/swelling of gums Dec emptying/inc saturation leading to retained bile salts
76
How much proteinuria should be expected? What type of memory issues may present?
>150mg/day 3rd-T dec verbal recall and processing speeds
77
What type of optic shifts occur? What is the first and second MC form of Pica seen during pregnancy What is believe to be the cause of Pica
Krukenberg spindles- brown/red opacities on posterior cornea Amylophagia- MC Pagophagia Fe deficiency
78
Pregnancy induced GERD is due to relaxing of LES, how is it Tx Why is constipation common in pregnancy and how is it Tx
1st- small meals, raise bed, avoid fatty/tomato/coffee 1st meds: tums Persistent- endoscopy Progestone slows GI motility Colace
79
Round ligament pain usually occurs ? and is on ? side What meds can be used for back pain during pregnancy?
2nd trimester R>L Tylenol Cyclobenzaprine Baclofen
80
# Define IUFD Define PTL Define Macrosomia
Death >20wks Labor prior to 37wks >4kg
81
# Define LBW Define VLBW Define ELBW
1.5-2.5kg 1-1.49kg 0.5-0.99kg
82
Criteria for IUGR AMA is ? age Adolsecent age is ?
<10th percentile due to genetic/environmental restraints 35 or older at delivery <20 at delivery
83
What is the MC 1st-T procedure done while PTs are pregnant? What needs to be monitored if surgery is needed?
Laparoscopy FHTs before and after surgery
84
Obesity in pregnancy can produce ? trifecta of a syndrome? How is asthma during pregnancy managed? How does this factor into delivery?
DM2 Dyslipidemia HTN SABA and CCS If used >3wks, stress dose during delivery
85
What is the leading cause of pregnancy related deaths? What DVT screening test is not reliable during pregnancy? What anti-thrombic meds are used?
PEs D-dimer LMWH- Lovenox No coumdin
86
When is gestational diabetes screened for? How is this Dx
24-28wks Step 1: GCT; 50g w/out fasting, draw in 1hr 140 or higher= OGTT Step 2: Fasting gluose, 100g, if two or more are at/over= Dx Fast: 95mg 1hr: 180mg 2hr; 155mg
87
Glucose levels at ? during any gestational age is Dx and over ? is overt When is follow up needed after delivery?
92-126 >126- overt 6-12wks Q3yrs
88
What is the goal for diabetes in pregnancy? What meds can be given to help control gestatational diabetes```` Insulin is only used if ?
Euglycemia during organogenesis Glyburide Metformin Fasting glucose persistently >95
89
Why is gestational diabetes so dangerous? What endocrine hormone at high levels may increase risk of multiple gestations?
Maternal progressing to Overt Diabetes w/in 20yrs FSH
90
# Define Superfetation Define Superfecuntation
Second conception in woman already pregnant Second ovum fertilized during same cycle but different coitus/male
91
What happens during TTT 80% of EPLs occur ?
Donor: Oligo Anemic Restricted Recipient: Polycythemia Overloaded Polyhydra First 12wks
92
If PT has SpAb, exam must be done and what are indications? What is the preferred method to visually assess PT? What is the next step if this preferred method is unclear?
CRL +7mm w/out heart Sac +25mm w/out embryo TVUS w/ M-mode Serial b-hCG: Inc: ectopic Dec: complete SpAb
93
Ectopic means implantation ? What is the MC site of ectopic implantation What are the two biggest RFs for ectopic?
Anywhere but endometrial lining Ampulla 6-8wks post LMP Prior ectopic SurgHx on fallopian tube
94
Ectopic Triad What is the next step once an extra-uterine pregnancy is Dx
Amenorrhea Ab pain Vaginal bleeding Immediate laparotomy
95
# Define Heterotopic pregnancy How are ectopic pregnancies Tx non-surgically and when does the Tx work best
IUP and ectopic at same time Methotrexate- best if ASx, motivated and compliant
96
# Define GTD What are the two types When is this more common
Gestational Trophoblastic Dz Hydatidiform- + villi Malignant neoplasm- - villi Hx Extremes of age
97
Define GTD- Complete Molar
Empty ovum- only paternal, no maternal chromosomes Grape clusters w/ hCG >100K Associated w/ Theca-Lutein cysts and risk of GTNeoplasia 1st-T bleeding Hyperemesis gravidum Preeclampsia
98
Define GTD- Partial Molar
Normal ovum w/ extra paternal haploid set: 69XXX/69XXY Non-viable fetus Lower risk of GTN than complete molar
99
What are the 4 types of GTN
Invasive- MC after hydatidiform Choriocarcinoma- MC after SpAb/pregnancy; metastatic, associated w/ theca-lutein cysts Placenta site trophoblast- chemo resistant Epitheloid trophoblast- low hCG, chemo resistant and commonly metastatic
100
What is the MC presentation of GTN What is pathognomonic for molar pregnancy?
Irregular uterine bleeding w/ failure of uterine returning to regular size (subinvolution) Pre-eclampsia w/out chronic HTN
101
Other than GTDz, where else did we see Theca Lutein cysts? How are hydatidiform moles Tx
Hyperthecosis D and C Serial hCG until non-detectable Monthly x 6mon
102
How are GTNs Tx What is the MC cause and other causes of fetal anemia?
Chemo Hysterectomy if chemo resistant MC- alloimmunization B19 Thalassemia Fetal/Maternal hemorrhage
103
How is fetal anemia detected? What is the whole goal of Rhogam?
Fetal blood sample Doppler eval of cerebral artery Prevent maternal sensitization
104
How is maternal/fetal hemorrhage tested for? Define Hydrops fetalis
Quant- KB test: detects fetal blood cells in maternal circulation Edema overload of fetus from serous fluids
105
How is Hydrops Dx What usually accompanies this Dx
Two of: Pericardial Pleural or Ascites or One effusion and anasarca Placentamegoly and polydydraminos
106
Non-immune hydrops usually occurs in ? PTs What is the MC infectious cause?
45XO Turners ParvoB19
107
Criteria for mild/sev Polyhydramnios Criteria for Oligohydramnios
Mild: AFI 25-29.9 Sev: AFI 35cm or more AFT <5cm or deepest pcoket <2cm
108
When would an aminioinfusion be conducted to Tx Oligo? What are the 3 phases of fetal growth?
For FHR Dcells, suggest cord compressions 1: Wk 1-16, 5g/day , hyperplasia 2: Wk 17-32wks, 15-20g/day hyperplasia/trophy 3: 33+wks, fat/glycogen accumulation, hypertrophy
109
# Define Barker Hypothesis of IUGR What are the two types of IUGR
Fetal adversity impacts adult-ness Symetric: proportionate Asymmetric: abdominal growth lags behind head
110
What can cause a symmetric growth restriction What causes Asymmetric growth restriction
Early pregnancy dec cell number/size: chemical viral mal-development Later pregnancy w/ placental insufficiency from maternal HTN- dec glucose dec cell size, N number AKA Brain sparing
111
Placental abnormalities can cause ? part of fetal development to accelerate? How is IUGR managed
Inc stress= inc adrenal GCS release, advanced lung maturation Suspect: fundal growth lag >3cm ID: serial US Modify: improve nutrition/stressors Preempt: deliver if lung mature
112
What is the ACOG criteria for macrosomia hCG resembles ? endocrine hormone Placenta produces TSH and ?
Born 4500g or more TSH hCT
113
MC form of pregnancy hyperthyroid and how is it Tx? MC form of pregnancy hypothyroid and how is it Tx?
Graves- dec TSH, Inc FT4 Tx: PTU (1st-T) or Methimazole (2nd-T) Hashimotos- Inc TSH, Dec FT4 Tx: Levothyroxine
114
What is added to seizure d/o Tx w/ lowest possible dose of anti-seizure med? If PT has seizure, ? PE finding is indicative of poor fetal outcome?
Vit K, Folic acid Hyperthermia
115
What is a normal LFT change during pregnancy What is HELLP Syndrome for?
Inc ALPs Hemolysis Elevated Liver enzyme Low Platelets
116
How does intrahepatic cholestasis present What would be seen on lab results How is it Tx What sequelae can occur?
Pruritis, Jaundice Inc Bile acid, Bilirubin, ALP Tx: Antihistamine, emollient Ursodeoxycholic acid Inc reoccurrence in future pregnancy/OCP use
117
How does AFLP present? What is seen on labs? How is it Tx?
Pain HTN N/V Jaundice Proteinuria Hypoglycemia Inc Bili Ammonia Uric acid Transaminase Dec Glucose Coags Delivery and maternal support
118
What is SIGECAPS
Sleep Interest Guilt Energy Concentration Appetite Psychmotor Suicide
119
# Define PUPPP How does it present How is it Tx
AKA Polymorphic Eruption of Pregnancy Urticarial plaques in white striae on abdomen/thighs but sparing the umbilicus Tx: PO antihistamines, emollients and topical CCS
120
# Define Pemphigoid Gestationis How is this one different?
Erythematous, pruritic papules/vesicles on abdomen and extremities Involves umbilicus and endangers fetus
121
What are cardiac indications a PT needs to have C-section
``` Dilated AA/root >4cm Recent MI Acute sev CHF Warfarin in past 2wks Severe Sx aortic stenosis Emergency valve replacement after delivery ```
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Criteria for Chronic HTN Dx What can we not give these PTs?
Pre-pregnancy HTN Dx >140/90 prior to 20wks or, After 12wks post-partum ACEI/ARBs
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How is mild HTN <160/<105 Tx Criteria for Chronic HTN w/ Superimposed Proteinuria
No meds CHTN w/ new preoteinuria >300mg prior to 20wks Tx as pre-eclampsia
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Criteria for Gestational HTN Preeclampsia can be Dx if HTN and ? other exists
>140/>90 after 20wks w/out proteinuria and, Resolves <12wks postpartum ``` Proteinuria 300 or more Renal insufficiency Cr>1.1 Thrombocytopenia <100K Pulmonary edema Cerebral Sxs- HA Vision Convulsion Liver involvement- 2x transaminase ```
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What is the name of a visual disturbance that can precede eclampsia What is the definitive Tx for pre-eclampsia
HA or Scotomata Delivery, preferred vaginal
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What is used for first seizure prophylaxis for PTs w/ severe pre-eclampsia What meds can be used to Tx BP Fetal lungs need to mature until ? and ? can be used to help them mature
MgSulfate Hydralazine Labetalol 34wks w/ CCS
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Criteria for Eclampsia How is it Tx
Pre-eclampsia w/ seizure, tonic clonic ABCs IVFs MgSlft and diazepam Hydralazine and Labetalol Definitive- delivery
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# Define Preterm labor What PE finding would be a reassuring finding for these PTs
Regular uterine contractions w/ cervical changes 20-37wks No cervical changes in 2hrs
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What can be used to Dx preterm labor What cervical lengths are used for preterm Dx
Fetal fibronectin and Cervical length High neg value in Sx PTs += preterm delivery >30mm- low risk 20-30mm- check FFN <20mm- big preterm birth risk
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How is preterm labor managed if PT is <34wks
Bed rest/hydrate Betamethason IM 24-32wks- Indomethacin, MgSO4 32-34wks- Nife/Terbutaline 17-OHP- prevent preterm birth
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What PT populations would benefit from receiving progestogens to prevent preterm birth Don't use tocolytics if pregnancy is older than ? and offer benefits for how long?
Singletons + prior SPTB Singletons - prior SPTB but cervical length <20mm or less at 24wks or less >34wks 48hrs
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What are the tocolytics available for use?
MgSO4 Indomethacin- prostaglandin inhibitors Nifedipine- CCBs Terbutaline- B-agonist to relax uterus (not for DM/respiratory conditions)
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What needs to be monitored in PTs receiving MgSulfate? This needs to be avoided in PTs w/ ? NSAIDs use= no ? production ASA use= no ? production?
Dec DTRs, precedes respiratory depression Tx w/ Ca Gluconate M Gravis N: arachadonic acid A: cyclooxygenase
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What is the potential s/e of using NSAIDs during labor? When does ACOG recommend CCS for lung maturity What two are avail for use
Monitor amniotic fluid w/ US for possible Oligohydramnios 23-34 wks if delivery <7days Rpt at 34wks if previous dose was 7 or more days ago Betameth 12mg IM q24hrs Dexameth 6mg IM q12hrs
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What triggers the start of labor? What is the only FDA approved drug to prevent recurrent preterm birth
Progesterone withdrawal 17 OHP-C
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# Define Cervical insufficiency How can this be Tx/managed
Incompetent cervix dilates and prolapses during 2nd-T Loss of fetus Cerclage- sutures to strengthen Recommended if prior preterm delivery <34wks, cervix is <25mm long and prior to <24wks EGA
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Measurement indications to cerclage What Tx/prevention is growing in favor of cerclage procedure? What is the single most identifiable factor of preterm labor?
<15mm <25mm and <24wks Progesterone if short cervix w/out Hx of preterm delivery PROM- premature rupture of membranes, rupture prior to onset of labor
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# Define PPROM What can occur if this happens prior to week 24?
Preterm Premature Rupture of Membranes Ruptured membrane before labor and <37wks Lung hypoplasia
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What tests can be done in attempt to Dx SROM? During PPROM, what considerations are taken during Dx
Ferning- arborization of d/c Amnisure- proteins in fluid Nitrazine- alkalinity of fluid No fingers Sterile speculum Dec of AFI
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What can lead to false-pos of ferning test? What can cause false-pos on Nitrazine test?
Mucus/blood presence + test= blue BV Soap Blood Urine Mucus Semen
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How are PTs w/ PROM and >37wks managed? How are PTs w/ PPROM managed?
Pitocin FHR Steroids if 23-34wks Empiric ABX Tocolytics if ABX/Steroids
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What can be done for post-term pregnancy's to induce labor starting at 41wks What is done at 42wks?
PgE Membrane stripping Surveillance- Movement AFI NST Induction
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Algorithm for post-term pregnancy management
41 0/7wks- UnComp- Surveillance Stripping Induction Complication- HTN, Oligo- induce 42 0/7-42 6/7- induce
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Baby being born forehead first is called ? If the top of their head is leading the way, what is it called?
Sinciput Vertex
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What are the two fontanelle shapes and names Leopolds are only assessments, what is the name of manually repositioning a baby?
Triangle- occiput, posterior Diamond- bregma, anterior Extracephalic version
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# Define Engaged What is the textbook definition
Fetal presenting part passes through pelvic inlet Can be before/during labor Mechanism of biparietal dameter- transverse diamter of occiput presentation- passes pelvic inlet
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What is the MC birthing presentation What does it mean if during birth the occiput posterior (diamond ant, triangle post) is seen first?
Left occiput anterior- triangle top right, diamond bottom left, face down/left Arrest of descent
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What are the 3 types of breech presentation Preferred imaging modality for pelvimetry?
Frank- hip flex, knee ext Complete: hip flex, 1+ knee flex Incomplete- 1+ hip unflexed CT
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What AP, Inlet Transverse of Midpelvic diameters are needed for vaginal delivery External cephalic version is not attempted prior to ? and can try w/ epidural if at ?
A: 10.5cm I: 12cm M: 10cm 36wks 39wks
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What are the 3 types of breech births
Spontaneous- whole fetus expelled w/out aid Partial- expelled to umbilucs, remainder delivered w/ outside efforts Total- entire fetus removed by OB
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What are the 4 phases of labor
Quiescence- cervical softening Activation- cervical ripening Stimulation- 3 stages: contractions dilation expulsion Involution- repair, feeding Conception 1 Initiation 2 Onset 3 Delivery 4 Fertility
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Events of Phase 1 Events of Phase 2
36wks, prodrom of Braxton Hicks w/ cervical softening Uterus awakens, baby drops to inlet- lightening, cervical ripens
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What are the 3 stages of Phase 3? What is Phase 4 AKA and what med can be given to augment it
1: cervical effacement/dilation 2: descent of fetus 3: placenta delivery Puerperium- Oxytocin
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How long after delivery does it take for ovulation to resume but what does this depend on? What events mark the onset of labor
4-6wks, breast feeding Sudden onset contractions or, Bloody show
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What is the criteria of labor to be admitted to LnD? What is the sequence of labor transition?
Dilated 3cm or more w/ uterine regular contraction Exception- SROM Prodromal Latent Active
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? is a severe form of pre-eclampsia What is the best predictor of low risk for a preterm delivery?
HELLP - FFN test
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What indicates fetal lung maturity? Four types of head flexion
Lecithin>Sphingomyelin Poor Moderate Advanced Complete*
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What is the timing of contractions during different phases of labor What is criteria for normal
Latent- 10min Active- q3-5min x 30-90sec 5 contractions or less in 10min, averaged over 30min
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Why is labor painful How much does the cervix dilate during Phase 3 stages?
Hypoxia to endometrium Compression of nerve ganglia Cervical/peritoneum stretching 1: 0-3cm 2: 3-5cm (delivery 4-6hrs)
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What are the 3 stages of Phase 3 When are mothers at highest risk for post-partum hemorrhage
Onset Descent Afterbirth 6hrs after stage 3
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What is the difference in cervical dilation between Primi and Multiparis No admitting to labor unit unless
Primi- 1.2cm/hr Multi- 1.5cm/hr Clear Dx of labor- Dilation Contraction quality- regular, painful w/ one of: complete effacement, membrane rupture, bloody show
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Why would Oxytocin be given during active labor? How often are vaginal exams conducted for cervical changes?
Dilation <1cm/hr in 1st stage No descent x 1hr in 2nd stage q1hr for first 2-3hrs Then q2hrs
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What are the 4 components of a cervical check When do these no longer need to be done?
Dilation Effacement Station Position- 4cm/80%/-1/vertex Once infant is vertex
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Infant head is 'crowing' at station ? Define Precipitous Labor and when is this seen?
Station 5 Delivery <3hrs Cocaine use
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# Define Labor Dystocia What is a common and correctable cause What are the 4 potential components
Dysfunctional labor Insufficient uterine activity ``` 4 Ps: Power: Abnormal forces Passage: Abnormal pelvis Passenger: Fetal abnormality Psyche: stage 2 w/ pushing ```
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What is the MC cause of dystocia and subsequent need for c-sections? Most of these causes arise from ?
Cephalopelvic disproportion Malposition
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Latent phase is considered prolonged if it lasts ? in Primi or Multi Define Protraction criteria of Nulli, Multi
Null/Primi- >20hrs Multi- >14hrs Null: <1.2cm/hr, <1cm descent/hr Multi: <1.5cm/hr, <2descent/hr
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# Define protraction arrest When is dystocia suspected What is the next step?
Dilation: 2hrs of no cervical changes Descent: 1hr w/ no descent Inadequate/absent cervical changes w/in 2hrs of admission Amniotomy, recheck in 2hrs Little/no change- IU monitor
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Uterine contractions are measured in ? units If these contractions are too weak during a prolonged active phase, what is added
Mentevideo: Sum of contraction amplitudes in 10min Adequate= 200-250 Oxytocin if <200 in 10min
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Montevideo units are measured w/ ? device Installing this device also allows for ?
Trancervical Intrauterine Pressure Catheter (TIPC), must have ruptured membrane Route for amnio infusion
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# Define Labor Induction Define Labor Augmentation
Stimulation of contraction before spontaneous onset of labor/ROM including ripening Enhancement of spontaneous but inadequate contractions due to failed cervical dilation/fetal descent
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What items are considered when inducing labor What scoring system is used to measure cervical remodeling?
``` Fetal maturity Quickening US (1st-T) EGA LMP Size ``` Bishop- 4 or less, not favorable and indication for ripening 9- high likelihood for successful induction
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When is the method of induction 'stripping' started What are mechanical methods of dilation? What meds can be used?
Weekly starting at 37wks Laminaria Foley Balloon E1- Misoprostol E2- Vervidil
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What med is the only FDA approved drug for induction/augmentation of labor? Define Amniotomy
Oxytocin Active Labor augmentation, allows rush of fluid Keep hand to assess for cord entrapment No walking x 30min
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Maternal indication for induction Fetoplacental indications for induction Maternal indications for augmentation
Preeclampsia HDz DM ``` Prolonged Abnormal fetal test IUGR Rh incompatible PROM Fetal abnormality Chorioamnionitis ``` Abnormal labor Prolonged latent/active phases
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What are maternal c/is to induction or augmentation
Maternal- Absolute: contracted pelvis Relative: Classic c-section Oversdistended uterus Prior uterine surgery
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What are fetoplacental c/is to induction/augmentation
Premature w/out lung maturity Acute distress Abnormal presentation
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When are prostglandins the initial agent of choice for labor initiation? Where is Oxytocin released from and what stimulates the release
Low Bishops PostPit, distended birth canal, mammary stimulation
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S/e of Pitocin use How can you tell if the fetus is tolerating the drug?
Tachysystole- >5 cxn in 10min W/in 1min of each other Any lasting longer than 2min + Accel and - Dcell
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If PTs develops Tachysystole, how is it managed Moderate variability in fetal HR is defined as ?
D/c med Put PT on L side, do cervical exam to r/o cord entrapment O2, 250mcg Terbutaline Amplitude 6-25bpm
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# Define fetal acceleration When is is defined as prolonged acceleration What if it is prolonged past the time frame for 'prolonged'
+32wks: +15bpm x 15sec, less than 2min -32wks: +10bpm x 10sec, less than 2min Lasts 2min-10min Baseline change
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What is the name of the electronic fetal heart rate monitor allowing for internal or external monitoring What does it NOT assess?
Tocodynamometer Contraction strength from external monitoring
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Acronym for fetal A-cell/D-cell Which ones require intervention
``` VEAL CHOP Variable Cord compression Early decl Head compression Accel Okay Late decell Placental insuff. ``` Variable/Late
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What will be seen on baby EKG that is OK and no intervention Late Decell looks like What does cord compression produce on baby ekg
Early Dcell: Mom and baby HR mirror each other Not mirror image Shoulders
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What are reassuring patterns on baby EKG Preferred head flexion position for delivery
HR 110-160 No late/variable D-cells Moderate 6-25 bpm A-cell >32: 15x15 <32 10x10 Suboccipitobregmatic diameter, shortest of fetal head, w/ complete flexion