OB Block 2 Cram Flashcards
When is the first pregnancy visit needed and when are f/us needed?
How is the obstetric conjugate estimated?
Fist: 10-12wks EGA
Until 27wks: q4wks
28-36wks: q2wks
+36wks: q2wk
Inferior pubic symphisis to sacral promontory:
Diagonal conjugate - 2.5cm= +10cm
Preferred pelvis types for vaginal delivery?
Midpelvis is measured at ? and during labor are called ?
Gynecoid*
Anthropoid
Ischial spine
Stations
Mid pelvis and ischial spine make up ? labor start point?
Why is the interspinous diameter important?
Station 0
Above= neg numbers
Below= pos numbers
Obstructed/arrested labor point
When would GA be adjusted to an US date?
What are the two layers of the Double Decidua Sign and the importance?
<9wks old w/ >5d difference
9-14wk old w/ >1wk difference
D Parietalis
D Capsularis
First/earliest sign of intrauterine pregnancy
What is TORCH
What are the Others?
Toxoplasmosis Other Rubella
CMV HSV
Coxsackie Chicken C/G
HIV HTV HBV
GBS TB Bacteriuria Zika Syphilis
What are the RNA viruses in this block?
What are the DNA viruses?
Rubella HIV (retrovirus)
CMV HSV Varicella HBV
Toxoplasmosis infection can lead to ? in the baby
How is this type of infection Tx
Microcephaly
Spiramycin- PT only
Pyrimethamin Sulfa w/ FA- PT and baby
When does a CMV infection become a possibility?
How is a Dx made but w/ ? cautious info?
Mono-like
Hydrops IUGR CNS abnormality on US
Serology- IgM x 2yrs
When are pregnant PTs not screened for GBS?
What are the risk-factor strategies?
GBS bacteriuria this pregnancy
Previously infected infant
FBIRD Fever Bacteriuria Infected infant Ruptured +18hrs Delivered <37wks
When is intrapartum prophylaxis indicated for GBS
BUIC Bacturemia Unknown (DRNF) Infected infant Culture pos
DRNF Delivered <37wks Ruptured >18hrs NAAT Pos Fever >100.4
When is intrapartum GBS prophylaxis not needed?
Previous pregnancy w/ +culture
Planned c-section
Neg vag/rectal cultures during this pregnancy
When are pregnant PTs screened for bacteriuria?
What ABX are used for empiric Tx?
What can this progress into and how is it Tx?
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
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?
Iron Zinc Selenium
A B6 C D
NT closes on day 28
400-800mcg/day ideally 12wks prior
When would PTs be recommended to increase daily folate to 4mg?
What meds are c/i during pregnancy?
Valproate/Carbamazepine
Hx of NTD
T1DM
BMI >35
100 IS CAT
>100mg/day ASA Isotretinoin Sulfonamides Coumadin ACEIs Tetracyclines
What is the leading cause of preventable developmental disabilities?
What are the discriminating features of FAS?
FAS
Flat midface
Indistinct philtrum
Thin upper lip
Short fissures/nose
When/why would sex need to be avoided during pregnancy?
What dental issue is linked to increased risk of preterm labor?
Miscarriage risk/hx
Placenta previa
Premature labor
Peridontal dz
When are domestic violence screenings conducted?
When to screen for depression or behavioral health w/ ? questionnaire?
First prenatal visit
One/trimester
Post-partum visits
Once during perinatal period
Edinburgh post-natal depression
When is breast feeding c/i?
What are the emergent return criteria for PTs >20wks EGA?
HIV Lithium Dependence Active TB
Contractions q3-5min
Membrane rupture
Vaginal bleeding
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?
FHTs in past 30wks
US dating supports
HCG at 36wks prior
Not before 39wks
hCG confirmation test
What is the quick time frame milestones for prenatal care by week?
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
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?
Doubles every 2.2 days
Sac- 5wks, 1500
Pol- 5wks, 5200
Cardiac- 7wks, 17,500
Gestational sac w/out yolk
No FCM
CRL >5mm
What are the 6 types of abortions and the criteria of each
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
Fetus feels mother’s stress until ? age
How are EPL’s managed?
22wks
Threat: reassure
InComp: Type/Cross, evacuate
Missed: US, manage w/ Misoprostol
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?
BP/Weight
Fundal height
Fetal cardiac activity
Fetal movements
1cm per week
>3cm discrepancy
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
How much weight gain is normal for PTs w/ BMI <18.5
How much is normal if BMI is >30?
28-40lbs
11-20lbs
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
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
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
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
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
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
What is the earliest screening option avail for detecting Tri-21
Being able to identify ? structure dec risk/likelihood?
US w/ marker
Nasal bone
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
Define Cholasma
Uterus is too big for pelvis by ? wk and shifts ?
Mask of pregnancy
13wks, to R
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
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
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
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
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
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
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
Define Linea Nigra
Chloasma is AKA and defined as ?
Dark brown pigmentation
Melasma gravidarum- irregular brown patches on face/neck
Define Angiomas
Define Palmar Erythema
Telangiectasias- vascular spiders on face/neck/upper chest/arms
Inc estrogen/cutaneous blood flow due to inc metabolism
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
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
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
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
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
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
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)
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
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
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
How much proteinuria should be expected?
What type of memory issues may present?
> 150mg/day
3rd-T dec verbal recall and processing speeds
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
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
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
Define IUFD
Define PTL
Define Macrosomia
Death >20wks
Labor prior to 37wks
> 4kg
Define LBW
Define VLBW
Define ELBW
1.5-2.5kg
1-1.49kg
0.5-0.99kg
Criteria for IUGR
AMA is ? age
Adolsecent age is ?
<10th percentile due to genetic/environmental restraints
35 or older at delivery
<20 at delivery
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
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
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
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
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
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
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
Define Superfetation
Define Superfecuntation
Second conception in woman already pregnant
Second ovum fertilized during same cycle but different coitus/male
What happens during TTT
80% of EPLs occur ?
Donor: Oligo Anemic Restricted
Recipient: Polycythemia Overloaded Polyhydra
First 12wks
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
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
Ectopic Triad
What is the next step once an extra-uterine pregnancy is Dx
Amenorrhea Ab pain Vaginal bleeding
Immediate laparotomy
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
Define GTD
What are the two types
When is this more common
Gestational Trophoblastic Dz
Hydatidiform- + villi
Malignant neoplasm- - villi
Hx
Extremes of age
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
Define GTD- Partial Molar
Normal ovum w/ extra paternal haploid set: 69XXX/69XXY
Non-viable fetus
Lower risk of GTN than complete molar
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
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
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
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
How is fetal anemia detected?
What is the whole goal of Rhogam?
Fetal blood sample
Doppler eval of cerebral artery
Prevent maternal sensitization
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
How is Hydrops Dx
What usually accompanies this Dx
Two of:
Pericardial Pleural or Ascites
or
One effusion and anasarca
Placentamegoly and polydydraminos
Non-immune hydrops usually occurs in ? PTs
What is the MC infectious cause?
45XO Turners
ParvoB19
Criteria for mild/sev Polyhydramnios
Criteria for Oligohydramnios
Mild: AFI 25-29.9
Sev: AFI 35cm or more
AFT <5cm or deepest pcoket <2cm
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
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
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
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
What is the ACOG criteria for macrosomia
hCG resembles ? endocrine hormone
Placenta produces TSH and ?
Born 4500g or more
TSH
hCT
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
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
What is a normal LFT change during pregnancy
What is HELLP Syndrome for?
Inc ALPs
Hemolysis
Elevated Liver enzyme
Low Platelets
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
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
What is SIGECAPS
Sleep Interest Guilt Energy Concentration Appetite Psychmotor Suicide
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
Define Pemphigoid Gestationis
How is this one different?
Erythematous, pruritic papules/vesicles on abdomen and extremities
Involves umbilicus and endangers fetus
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
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
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
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
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
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
Criteria for Eclampsia
How is it Tx
Pre-eclampsia w/ seizure, tonic clonic
ABCs IVFs
MgSlft and diazepam
Hydralazine and Labetalol
Definitive- delivery
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
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
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
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
What are the tocolytics available for use?
MgSO4
Indomethacin- prostaglandin inhibitors
Nifedipine- CCBs
Terbutaline- B-agonist to relax uterus (not for DM/respiratory conditions)
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
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
What triggers the start of labor?
What is the only FDA approved drug to prevent recurrent preterm birth
Progesterone withdrawal
17 OHP-C
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
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
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
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
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
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
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
Algorithm for post-term pregnancy management
41 0/7wks-
UnComp- Surveillance Stripping Induction
Complication- HTN, Oligo- induce
42 0/7-42 6/7- induce
Baby being born forehead first is called ?
If the top of their head is leading the way, what is it called?
Sinciput
Vertex
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
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
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
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
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
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
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
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
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
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
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
? is a severe form of pre-eclampsia
What is the best predictor of low risk for a preterm delivery?
HELLP
- FFN test
What indicates fetal lung maturity?
Four types of head flexion
Lecithin>Sphingomyelin
Poor Moderate Advanced Complete*
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
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)
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
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
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
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
Infant head is ‘crowing’ at station ?
Define Precipitous Labor and when is this seen?
Station 5
Delivery <3hrs
Cocaine use
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
What is the MC cause of dystocia and subsequent need for c-sections?
Most of these causes arise from ?
Cephalopelvic disproportion
Malposition
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
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
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
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
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
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
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
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
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
What are maternal c/is to induction or augmentation
Maternal-
Absolute: contracted pelvis
Relative:
Classic c-section Oversdistended uterus
Prior uterine surgery
What are fetoplacental c/is to induction/augmentation
Premature w/out lung maturity
Acute distress
Abnormal presentation
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
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
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
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
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
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
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
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
