OB/GYN Flashcards
H/o DVT rules out what contraception options?
anything containing combination of estrogen and progestin
Define typical use effectiveness and perfect use effectiveness
Typical use effectiveness- overall effectiveness in actual use when forgetfulness and misuse occur
Perfect use effectiveness- efficacy when used correctly, consistently and reliably
What is the yuppie method?
OCP regimen consisting of 2 tablets of 100-120 mug of ethinyl estradiol and 500-600 mug of levonorgosterol at time zero and 2 tablets after 12 hrs
What is plan B?
Levonorgestrel 0.75 mg PO at time 0 and the same dose after 12 hrs (method used within 72 hours of unprotected sex)
Plan B one-step
levonergosterol 1.5 mg taken as one pill
What is the most effective contraception to protects against STDs?
male condoms; this is the second most common form of contraception used
What are the disadvantages with a vaginal diaphragm?
it must be fitted by a physician; placed 1-2 hours before sex and left in 8 hours afterwards
There is an increased rate of UTIs and increased risk of ulceration of the vagina with prolonged use
Cervical caps are limited in use because women with ____ should not use them.
abnormal cervical cytology; due to fear of traumatizing the cervix
What is the function of the progestin and estrogen in OCPS?
progestin- thickens the cervical mucous and inhibits ovulation
Estrogen- maintain the endometrium, prevent unscheduled bleeding, and prevent follicular development
What risks are involved with OCPs (primarily due to estrogen)?
Venous thromboembolism
Stroke in pts with migraines with aura
MI in heavy smokers (>15 cigarettes per day) and who are 35 or older
What are the non-contraception benefits of OCPs?
Decreased risk of ovarian, colon, or endometrial cancer
Shortened duration of menses
Decreased bleeding during menses
Improved pain from dysmenorrhea and endometriosis
Decreased abnormal uterine bleeding
Improving acnes
T/F: Depot (DMPA) is just as effective as LARCs.
F- depot has a higher pregnancy rate than LARC
What medication is in the contraceptive patch?
norelgestromin and ethinyl estradiol
What medication is in the contraceptive arm implant?
etonogestrel
What is the time period after stopping contraception needed to regain fertility?
Pills, patches, rings- 2 weeks
Injectables-9-10 months
postpill amenorrhea may persist for ____ amount of time
6 months
How long can the IUDs be in place for?
Cooper T380A- 10 yrs
Mirena- 5 years
Skyla- 3 years
Liletta- 3 yrs
What are the non contraceptive uses for levonorgestrel IUDs?
tx pts with menorrhagia, dysmenorrhea, and pain due to endometriosis, and adenomyosis
What risks are there with IUD insertion?
uterine perforation in 1:1000
transient increase in upper GU infection (1:1000) due to endometrial contamination
Contraindication to IUD insertion
current pregnancy, current STD, PID currently or within the past 3 months, unexplained vaginal bleeding, malignant gestational trophoblastic disease, untreated cervical cancer, untreated endometrial cancer, uterine fibroids distorting the endometrial cavity, current breast cancer (for levonorgestrel IUDs), anatomical distortions of the uterine cavity, known pelvic TB, allergy to IUD component, Wilson’s dx (Copper IUD)
What are the forms of emergency contraception?
Progestin Plan B, Plan B One-Step, ulipristal are the three most common forms. Also includes the copper IUD and the Yuzpe method
True/false – there are no medical conditions were the risk of emergency contraception outweighs the benefits.
True-woman with cardiovascular disease, migraines, liver disease, or who are breast-feeding may use emergency contraception.
What is the major side effect of emergency contraception?
Nausea and vomiting
When is emergency contraception contra indicated?
In women with suspected or known pregnancy, are those with abnormal vaginal bleeding
What effect does Depot have on bones in adolescence?
Depot Is associated with the loss of bone mineral density particularly in adolescence. If it is the best type of contraception for the patient, the loss and bone mineral density should not discourage the use of the agent.
True/false – oral contraceptives decrease the risk of benign breast disease
True
OCPs may cause a slight increase in ____ and ______.
Risk of breast cancer and incidence of gallstones
What birth control method is best suited for breast-feeding females?
Progestin only pill- e.g. Minipill
What birth control method is best suited for patients with sickle cell disease or epilepsy?
Injectables like Depot
What form of contraception may lead to more bleeding or dysmenorrhea?
Copper IUD
Of the three most common causes of infectious vaginal discharge, which etiology is not inflammatory?
Bacterial vaginosis
What is the treatment of bacterial vaginosis?
Antibiotic therapy targeting anaerobes such as metronidazole are clindamycin
What are the diagnostic criteria for a bacterial vaginosis?
Three out of four Amsel’s criteria are indicative of bacterial vaginosis: 1. Homogeneous gray white discharge 2. Vaginal pH greater than 4.5
3. Positive whiff test 4. Clue cells on wet mount
Gram stain is considered the gold standard for diagnosis, but is rarely used.
Bacterial vaginosis is associated with what genital tract infections and pregnancy complications?
Endometriosis, PID, preterm delivery, and preterm premature rupture of membranes
What STD can survive for up to six hours on a wet surface?
Trichomonas vaginalis
What is the most common symptom associated with trichomoniasis?
Profuse frothy Yellow– Green to gray vaginal discharge or vaginal irritation
What can cause trichomonads on a wet mount to have decreased movement?
If the wet mount is cold or there are excess leukocytes present
What is the treatment for trichomoniasis?
A fairly high dose of metronidazole (2 g) as a one time dose, with the partner treated as well.
Why is vaginal metronidazole not effective in the treatment of trichomoniasis?
Vaginal metronidazole results in low therapeutic levels of the drug in the urethra or Skene’s glands were trichomonads may reside
In a healthy vagina what prevents the growth of fungus?
The native lactobacilli; this explains why anabiotic therapy may result in Candida overgrowth
Typical presentation: intense vulvar or vaginal burning, irritation and swelling
Candidal vaginitis
Candidal vaginitis treatment
Oral fluconazole/Diflucan or topical imidazoles such as Terconazole/terazol, miconazole/ Monistat, and clotrimazole/ lotrimin
What are the most common side effects with metronidazole?
G.I. including nausea, abdominal discomfort, bloating or diarrhea
Which forms of vaginitis are associated with alkaline pH and positive whiff test?
Bacterial vaginosis and trichomoniasis
Uncomplicated cystitis treatment
Three day course of trimethoprim/sulfa (Bactrium)
If a patient with UTI symptoms has a urine culture that demonstrates no growth of organisms, but symptoms persist what is the most likely diagnosis?
Urethritis often caused by chlamydia, candidalvulvovaginitis, or urethral syndrome
What is urethral syndrome?
Recurrent episodes of urgency and dysuria caused by urethral inflammation of unknown cause; Urine cultures are persistently negative
Gross hematuria should raise the suspicion of _____
Nephrolithiasis
True/False – fever is common with a UTI
False- fever is uncommon unless there is upper urinary tract/kidney involvement
What is the definition of bacteriuria?
More than 100,000 colony forming units per milliliter of a single uropathogen obtained from a midstream voided clean catch urine culture
If the patient is symptomatic, as few as 1000 colony forming units per milliliter may be significant.
On a catheterized patient, 10,000 colony forming units per milliliter is considered bacteriuria
What is the most common form of UTI?
Simple cystitis
List the antibiotics that are effective in treating simple cystitis
(Trimethoprim/sulfa) Bactrim, nitrofurantoin, ciprofloxacin, norfloxacin, fosfomycin
What are the three most common causes of urethritis?
Chlamydia, gonorrhea, trichomoniasis
How should urethritis be diagnosed?
Gram stain and culture of the urethra for gonococcus and chlamydia, with confirmatory nucleic acid amplification testing (NAAT)
Urethritis treatment
Empiric treatment for chlamydia with doxycycline; if gonorrhea is suspected, intramuscular ceftriaxone with oral doxycycline is usually curative. If treating a pregnant woman azithromycin should be substituted for doxycycline
Typical presentation: nausea, vomiting, fever, chills, flank pain
Pyleonephritis
Mild Pyelonephritis in non pregnant woman treatment
Oral Bactrim or a fluroquinolone for 14 day course; women should be re-examined within 48 to 72 hours
When should a woman with Pyelonephritis be hospitalized?
Those who are not beginning to clinically improved, are more toxic, unable to take oral medications, pregnant, or immunocompromise should be hospitalized and treated with IV anabiotics
Treatment of pyleonephritis in a hospitalized patient
Treatment and patience bad enough to warrant hospitalization – IV anabiotic’s such as ampicillin and gentamicin, third generation cephalosporin such as ceftriaxone, fluroquinolones, the carbapenems, or piperacillin – tazobactam
Management of a pregnant patient following resolution of fever and symptoms from acute Pyelonephritis
Suppressive antibiotic therapy for the remainder of the pregnancy– Such as nitrofurantoin Macrocrystals 100 mg once daily
Upper UTIs increase the risk of _____ in pregnant women
septicemia, kidney dysfunction, or preterm labor
Asymptomatic bacteriuria has a high incidence in women with ______
Sickle cell trait
What is the hCG threshold at which a intrauterine pregnancy should be seen with transvaginal sonography?
1500 to 2000 mIU/mL
In a normal pregnancy what should happen to the hCG levels in 48 hours?
Follow up hCG at 48 hours should rise at least by 66%. If the follow up hCG does not rise by 66% particularly if it rises by only 20% then the patient most likely has an abnormal pregnancy
True/false – a subnormal rise in hCG indicates that an abnormal pregnancy exist outside of the uterus
False – a subnormal rise in hCG does not indicate whether the abnormal pregnancy is in the uterus or the tube
Following a complete abortion what should happen to the hCG levels?
HCG level should be cut in half every 48 to 72 hours
Following a complete abortion what does a hCG plateau indicate?
If the hCG level plateaus rather than falling, then the patient has residual pregnancy tissue
True/false – spontaneous abortions are more common in older patients.
True
What is the most common identifiable cause for spontaneous abortion?
Chromosomal abnormality of the embryo
Define. Threatened abortion
Pregnancy with vaginal spotting during the first half of pregnancy; this does not delineate the viability of the pregnancy
Define: inevitable abortion
Cramping, bleeding, and cervical dilation without passage of tissue in a pregnancy less than 20 weeks
Define: incomplete abortion
Cramping, vaginal bleeding, and open cervical os, and some passage of tissue per vagina with remaining tissue in utero in a pregnancy less than 20 weeks. The cervix remains open and the uterus continues to contract
Define: completed abortion
A pregnancy less than 20 weeks in which all the products of conception have passed and the cervix is generally closed. Because all of the tissue has been passed, the uterus no longer contracts, and the cervix closes
Define: missed abortion
My pregnancy less than 20 weeks with embryonic demise no symptoms such as a bleeding or cramping
What percentage of threatened abortions result in viable intrauterine pregnancy?
50%
A single progesterone level more than ____ almost always indicates a normal intrauterine gestation
25 ng/mL
A single progesterone level less than ____usually correlates with a non-viable gestation
5ng/mL
True/false –Abnormal hCG rise or single progesterone less than five means a non-viable pregnancy is diagnosed; however, it is still unclear whether the patient has a spontaneous abortion ectopic pregnancy
True
When a non-viable pregnancy is diagnosed either by abnormal rising hCG or a single progesterone less than five, what is the next step in distinguishing miscarriage from ectopic pregnancy?
Most physicians perform a uterine curettage; if chorionic villi are present the patient had a miscarriage. If chorionic villi are absent the patient had an ectopic pregnancy.
What is the treatment for small ectopic pregnancies?
Asymptomatic, small (less than 3.5 cm) ectopic pregnancies are ideal candidates for intramuscular methotrexate
What is the management of a non-viable intrauterine pregnancy?
Manage expectantly, surgically via dilation and curettage or medically with vaginal misoprostol
Rh negative women with ____, _____, or ______ should receive RhoGAM to prevent isoimmunization
Threatened abortion, spontaneous abortion, or ectopic pregnancy
How can an inevitable abortion be differentiated from an incompetent cervix?
With an insufficient cervix, the cervix opens spontaneously without uterine contractions. However, in inevitable abortion uterine contractions lead to cervical dilation.
Incompetent cervix treatment
Cerclage – a surgical suture at the level of the internal cervical os
Missed or incomplete abortion treatment
Expectant management for passage of tissue, medical management with mifepristone misoprostol, and surgical management with dilation and curettage of the uterus for immediate definitive treatment
What is the primary complication of retained tissue from an incomplete abortion?
Bleeding and infection
Management of a patient with threatened abortion, hypotension/volume depletion, severe abdominal/pelvic pain or adnexal mass
Consider a laparoscopy or laparotomy due to high possibility of ectopic pregnancy
Management of a patient with threatened abortion, HCG more than 1500, no interuterine pregnancy seen on transvaginal ultrasound
Consider a laparoscopy
Management of a patient with threatened abortion, hCG less than 1500
Ultrasound is optional and repeat hCG in 48 hours
Management of a patient with threatened abortion, no acute signs of ectopic pregnancy, hCG less than 1500, Repeat hCG reveals abnormal rise
Diagnosis: probable non-viable pregnancy; uterine curettage – chorionic villi seen versus no villi seen
No villi seen -diagnosis ectopic pregnancy; consider methotrexate
Chorionic villi seen- diagnosis miscarriage
Typical presentation: vaginal spotting, absence of fetal heart tones, size greater than dates, and markedly elevated hCG levels
Molar pregnancy
Molar pregnancy treatment
Uterine suction curettage; patients followed with weekly hCG levels because sometimes gestational trophoblastic disease persist after evacuation of the molar pregnancy. In this case chemotherapy is used.
Incompetent cervix risk factors
Cervical conization, congenital (short cervix or collagen disorder), trauma to the cervix, prolonged second stage of labor, and uterine overdistention as with a multiple gestation pregnancy
List the two most common causes of antepartum bleeding
Placenta previa and placenta abruption
What is the most common cause of a first trimester miscarriage?
Fetal karyotypic abnormality
True/false – enlarged uterus does not exclude the diagnosis of an ectopic pregnancy
True – hCG has an affect on the uterus regardless if the pregnancy is interuterine or ectopic
Define: heterotopic pregnancy
When both and interuterine pregnancy and an act topic pregnancy exist at the same time; risk 1:10,000
this is why the proof of an interuterine pregnancy decreases the likelihood of an ectopic pregnancy
Management of a patient with hCG more than 1500, no intrauterine pregnancy seen on transvaginal ultrasound
The risk of extra uterine pregnancy is high but it is not 100%. Therefore, laparoscopy is indicated and not methotrexate
What is the location of the majority of ectopic pregnancies?
97% involve the Fallopian tube
What is the most common reason for maternal mortality in the first 20 weeks of pregnancy?
Hemorrhage from ectopic gestation
Typical presentation: abdominal pain, amenorrhea of 4 to 6 weeks, irregular vaginal spotting
Ectopic pregnancy
Typical presentation: acute worsening of Abdominal pain, syncope, shoulder pain, tachycardia, hypertension, orthostasis, hemoperitoneum
Ruptured ectopic pregnancy
Risk factors for ectopic pregnancy
Salpingitis particularly with chlamydia, tubal adhesive disease, infertility, progesterone secreting IUD, tubal surgery, prior ectopic pregnancy, ovulation induction, congenital abnormalities of the tube, assisted reproductive technology
Which is more sensitive transvaginal sonography or trans abdominal sonography?
Transvaginal sonography – can detect pregnancies as early as 5.5 to 6 weeks
Define: pseudo gestational sac
irregularly shaped fluid collection in the midline of the uterine cavity seen in some ectopic pregnancies
Distinguished from a normal gestational sack because these or eccentrically located and have a decidual sign
When is a salpingectomy performed for ectopic pregnancies?
Gestations too large for conservative therapy, when rupture has occurred, or for those women who do not want future fertility.
During a salpingostomy, why is the incision on the tube not reapproximated?
Suturing may lead to structure formation
Follow up after salpingostomy
There is a 10 to 15% chance of persistent ectopic pregnancy. Therefore, serial hCG levels should be followed
When is methotrexate used for ectopic pregnancy?
Ectopic Pregnancy is less than 3.5 cm in diameter, without fetal cardiac activity, and hCG levels less than 5000
Following one dose of methotrexate, what should be done if the hCG level does not fall?
Methotrexate leads to resolution in 85 to 90% of cases. However, a second dose is required if the hCG level does not fall
Hypotension, worsening or persistent pain, or a falling hematocrit after methotrexate treatment may indicate what?
Tubal rupture which will necessitate surgery
What is indicated when hCG levels plateau in the first eight weeks of pregnancy?
An abnormal pregnancy – may be either a miscarriage or an ectopic pregnancy
True/false – spotting and lower abdominal pain can be a normal occurrence in pregnancy especially very early in the first trimester
True
Define: latent phase of labor
The initial part of labor where the cervix mainly effaces/thins rather than dilates. Cervical dilation less than 6 cm
Define: active phase of labor
The portion of labor were dilation occurs more rapidly; cervix is more than 6 cm dilated
Define: arrest of active phase of labor
No progress in the active phase of labor with ruptured membranes for four hours with adequate contractions, or six hours of inadequate contractions
What are the stages of labor?
First stage: onset of labor through the complete dilation of cervix
Second stage: complete cervical dilation through the delivery of infant
Third stage: delivery of infant through delivery of placenta
Define: normal fetal heart rate, fetal bradycardia, fetal tachycardia
Normal: between 110 and 160 bpm
Fetal bradycardia: baseline less than 110 bpm
Fetal tachycardia: heart rate exceeding 160 bpm
What are the three types of Decelerations?
Early: mirror image of uterine contraction due to compression of fetal head
Late: Deceleration offset following the uterine contraction that indicate fetal hypoxia
Variable: abrupt jagged dips below the baseline caused by cord compression
Define: acceleration
Episodes of the fetal heart rate increasing above the baseline for at least 15 bpm and last for at least 15 seconds
Normal labor parameters in a nullipara Woman
Latent phase: less than or equal to 18 to 20 hours
Active phase: continued progress
Second stage of labor: less than or equal to three hours or less than or equal to four hours if epidural used
Third stage of labor: less than or equal to 30 minutes
Normal labor parameters a multipara woman
Latent phase: less than or equal to 14 hours
Active phase: continued progress
Second stage of labor: less than or equal to two hours or less than or equal to three hours if epidural used
Third stage of labor: less than or equal to 30 minutes
When an abnormal labor is diagnosed what three categories should be considered?
Powers, pelvis, and passenger
When it is determined that the power is the issue, what is the treatment?
Oxytocin
Define: clinically adequate uterine contractions
Contractions every 2 to 3 minutes, firm on palpation, and lasting for at least 40 to 60 seconds
How can the adequacy of the powers be assessed?
Internal ureter catheters can evaluate the adequacy of the powers. One common assessment tool is to examine a 10 minute window and add each contraction’s rise above baseline (each mm Hg rise is called a Montevideo unit); 200 Montevideo units is commonly accepted as an adequate uterine contraction pattern.
What are the most common decelerations?
Variable
What can late decelerations occurring in more than 50% of uterine contractions indicate?
Fetal acidemia
When late decelerations occur together with decreased variability, then _____ is strongly suspected.
Acidosis
Define: category I, category II, and category III fetal heart rate patterns
Category I: Reassuring – normal baseline and variability, no late or variable decelerations
Category II: needs watching – may have some aspect that is concerning but not Ominous; for example Fetal tachycardia without decelerations
Category III: ominous and indicates a high likelihood of severe fetal hypoxia or acidosis– examples include absent baseline variability with recurrent late or variable decelerations or bradycardia, or sinusoidal heart pattern (this requires prompt delivery if no improvement)
Management of arrest disorder (no change in active phase of labor for four hours)
Assess three Ps; if adequate contractions for four hours with rupture of membranes and cervix is dilated more than 6 cm OR inadequate contractions for six hours with rupture of membranes and cervix dilated more than 6 cm–> c-section
If the above criteria are not met, give oxytocin and reassess
What are the two most common reasons for a C-section?
Labor dystocia in 34% of cases and an abnormal fetal heart rate in 23% of cases
How does the safety of a C-section compare to vaginal delivery?
C-section has a higher overall severe morbidity or mortality rate, and a 3.5 fold increase risk of mortality
Management of category III tracings
Require prompt intervention – if prompt interuterine resuscitation maneuvers are not curative, imminent delivery is prudent
What conditions are associated with category III tracings?
these tracings are associated with low pH, hypoxia, and encephalopathy, and cerebral palsy
Most fetal heart rate tracings fall in which category?
II – which can span from reassuring fetal heart rate tracing versus a tracing that is worrisome
Scalp stimulation inducing ____ highly correlates to a normal umbilical cord pH (greater than or equal to 7.2).
An acceleration
What are the 6 causes for prolonged decelerations?
Tachysystole, hypotension, rapid cervical dilation, umbilical cord prolapse, placental abruption, uterine rupture
Define: prolonged decelerations
Decelerations lasting between 2 and 10 minutes
Define tachysystole. What is the intervention?
More than 5 contractions per 10 minutes averaged over 30 minutes; decrease or stop oxytocin, or administer beta-mimetic agent
If hypotension following anesthesia or epidural causes prolong decelerations, how should this be managed?
IV fluid bolus, or administer vasopressor agents such as ephedrine
If rapid cervical dilation is causing prolonged decelerations, how should this be managed?
Positional changes and observation
Management of umbilical cord prolapse
Elevate presenting part and emergency C-section
If placental abruption is causing prolonged decelerations, how should this be managed?
Support BP, stabilize patient, consider C-section if progressive
If uterine rupture is causing prolonged decelerations, how should this be managed?
Emergency C-section
True/false – IV oxytocin aids in cervical dilation, and enhances contraction strength and/or frequency
False – IV oxytocin does not affect cervical dilation. It does however enhance contraction strength and/or frequency
Define: anthropoid pelvis
A pelvis with an anterioposterior diameter greater than the transverse diameter with prominent ischial spines and a narrow anterior segment, which predisposes to the persistent fetal occiput posterior position
Define: station
Refers to the relationship of the presenting bony part of the fetal head in relation to the ischial spines, and not the pelvic inlet
Define: engagement
Refers to the relationship of the widest diameter of the presenting part and its location with reference to the pelvic inlet
Define bloody show
Loss of the cervical mucus plug; a sign of impending labor
Delivery before 39 weeks gestation is associated with an increased risk of neonatal complications including…
Increased incidence of NICU admission, respiratory difficulties, sepsis, hyperbilirubinemia, Ventilator use, and hospital stay exceeding five days
Management of prolonged latent phase of labor
Observation and Oxytocin
Management of repetitive deep variable decelerations
Amnioinfusion
What is the most common abnormal karyotype encountered in spontaneous abortions?
Autosomal trisomy
What can be given for pregnancy is less than 32 weeks for Neuroprotection?
Magnesium sulfate
A single examination revealing _________ and _______ in a nulliparous woman would be sufficient to diagnose preterm labor.
2 cm dilation and 80% effacement
Explain what a positive and negative result on fetal fibronectin indicates.
A positive result indicates risk of preterm birth whereas a negative result is strongly associated with no delivery within one week
Treatment for Preterm labor
Intramuscular antenatal steroids to enhance fetal pulmonary maturity in a pregnancy less than 34 weeks
Tocolysis unless there is a contraindication such as inter-amniotic infection or severe preeclampsia
IV antibiotics such as penicillin in the case that delivery cannot be prolonged to help reduce the likelihood of GBS sepsis
Magnesium sulfate in pregnancies less than 31 weeks and six days for neurodevelopment, Reducing cases of cerebral palsy in preterm infant
Define: preterm labor
Cervical change associated with uterine contractions prior to 37 weeks and after 20 weeks
What are the four most common tocolysis agents used?
Indomethacin, nifidepine, terbutaline, ritodrine
Cervical length of less than ____ millimeters results in an increased risk of preterm delivery
25
Define: late preterm gestation
Delivery that occurs between 34w0d and 36w6d
This category comprises most preterm deliveries
What is the most significant risk factor for preterm delivery?
History of a prior spontaneous preterm birth
Symptoms of preterm labor
Uterine contractions, abdominal tightening, pelvic pressure, increased vaginal discharge
What is the most serious side effect of nifidipine?
Pulmonary Edema
What is a complication of indomethacin?
Closure of the ductus arteriosus, leading to severe neonatal pulmonary hypertension; oligohydramnios may also be seen
If a patient who previously entered preterm labor was given one course of corticosteroids, and 7 to 14 days afterwards reenters preterm labor (before 34 weeks), what is the management?
One additional rescue course of corticosteroids: repeat rescue doses are contraindicated
Risk factors for preterm labor
Preterm premature rupture of membranes, multiple gestations, previous preterm labor and birth, hydramnios, uterine anomaly, history of cervical cone biopsy, cocaine abuse, African-American race, abdominal trauma, pyleonephritis, abdominal surgery in pregnancy
What can be used to reduce the incidence of preterm birth in women at high-risk?
Weekly 17 alpha hydroxyprogesteronecaprotate (makena) from 16 to 36 weeks
Contraindication for nifidepine use
Hypotension
Side effects terbutaline and ritodrine
Pulmonary edema, increased pulse pressure, hyperglycemia, hypokalemia, and tachycardia
Which is more strongly associated with preterm delivery, gonococcal cervicitis or chlamydial cervicitis?
Gonococcal
Why is tocolysis contraindicated in suspected placental abruption?
If given, it would increase the chance of hemorrhage and mothers after delivery because it will be more difficult to get the uterus to contract on itself, since tocolytics also act as uterine relaxants
What might cause a sudden worsening in the frequency and/or severity of variable decelerations?
Oligohydramnios, rupture of membranes, or dissent of the fetal head, such as in labor, so that I nuchal cord may tighten
What is the most common cause of neonatal morbidity in a preterm infant?
Respiratory distress syndrome
Mekena used weekly from week 16 to 36 in women with history of prior spontaneous preterm birth decreases the risk of preterm birth by ____
1/3rd
What is the most common cause of preterm labor?
Idiopathic
What tocolytic agents are contraindicated in diabetic patients?
Terbutaline and ritodrine
What are the long-term complications of salpingitis?
Infertility, topic pregnancy, chronic pelvic pain
What most commonly causes salpingitis?
Pathogenic bacteria of the endocervix that accends to the tubes
The pain of salpingitis occurs _____
Around the time of menses
When does the ascending infection leading to salpingitis occur?
At the time of menses during endometrial break down
What is included in the differential diagnosis of Salpingitis?
Pyleonephritis, appendicitis, Cholecystitis, diverticulitis, pancreatitis, ovarian torsion, gastroenteritis
Why is a pelvic alter sound typically performed on patients with suspected PID?
Tubo-ovarian abscesses are difficult to diagnose on physical exam and can present without fever; a pelvic ultrasound is used to assess for tubo-ovarian abscess
Define: Fitzhugh Curtis
Perihepatitis caused by purulent tubal discharge which ascends to the right upper quadrant area.
Define: Mucopurulent cervicitis
Yellow exudative discharge arising from the endocervix with 10 or more PMNs per high-powered field on microscopy
Define pelvic inflammatory disease
Synonymous with salpingitis or infection of the fallopian tube
Define: tubo – ovarian abscess
Collection of Purulent material around the distal tube and ovary
Gonoccocal and chlamydial organisms have a propensity for _____ cells
Columnar cells of the endocervix
What is the most common organism implicated in mucopurulent cervical discharge?
Trichomonas
What are the Gram stain findings from cervical discharge caused by gonorrhea?
Intracellular gram-negative diplococci
What is the treatment of gonococcal disease?
Ceftriaxone 125 to 215 mg IM and because of the frequency of coexisting chlamydial infection, Azithromycin 1 g or orally or doxycycline 100 milligrams orally b.i.d. for 7 to 10 days
If the Gram stain of the cervical discharge is negative, what should be done?
Antimicrobial therapy directed at chlamydia should be used
Other than sampling the endocervix directly, what is another diagnostic approach to confirming infection with gonococcus or chlamydia?
Urine nucleic acid amplification test (NAAT)
Describe the arthritis associated with gonococcus.
Usually involves the large joints and is classically migratory
What is the most common cause of septic arthritis in young women?
Gonorrhea
What is a possible skin finding and disseminated gonorrhea?
Irruption of painful pustules with an erythematous base on the skin
Classic presentation: young, nulliparous female complaining of lower abdominal or pelvic pain and vaginal discharge; fever and nausea and vomiting may be present; cervix is inflamed and patient complains of dyspareunia
PID
How is PID diagnosed?
Clinically – abdominal tenderness, cervical motion tenderness, and/or adnexal tenderness
True/false – most episodes of PID are asymptomatic or have mild symptoms.
True
Mucopurulent cervicitis with exacerbation of symptoms during and after menstruation is classically caused by _____
Gonorrhea
Findings highly suggestive of PID
Endometrial biopsy showing endometritis or transvaginal ultrasound or MRI showing thickened or fluid filled tubes
When the diagnosis of PID is in doubt, what is the best method for confirmation?
Laparoscopy-look for discharge from the fimbria
What are the criteria for outpatient management of PID?
Low-grade fever, tolerance of oral medication, and the absence of peritoneal signs. The woman must also be compliant. The patient should be reevaluated in 48 hours for improvement.
What are the criteria for inpatient management of P ID?
Failure of outpatient therapy after 48 hours, pregnancy, extremes of age, cannot tolerate oral medications, Surgical emergencies cannot be ruled out, tubo-ovarian abscess, Severe illness, upper peritoneal signs, fever greater than 102°F
What is the outpatient regimen for PID treatment?
IM ceftriaxone 250 mg as a single injection and oral doxycycline 100 mg twice a day for 14 days, with or without metronidazole twice a day for 14 days
What is the inpatient regimen for treatment of PID?
IV cefotetan 2 g IV every 12 hours and oral or IV doxycycline 100 mg twice daily to continue 24 hours after clinical improvement, then discharge on doxycycline 100 mg twice daily for 14 days
If be patient with P ID does not improve within 48 to 72 hours, what should be considered?
Laparoscopy to assess the disease
What is the treatment of Tubo-ovarian abscess?
This disorder generally has anaerobic predominance and is treated with clindamycin or metronidazole. Unlike other abscesses these do not require surgical drainage
The risk of infertility due to tuple damage is directly related to…
The number of episodes of PID
____ form of contraception places the patient had a greater risk for PID, whereas ____ form of contraception decreases the risk of PID.
IUD; oral contraceptive agents (progestin thickens the cervical mucus)
What are the two most common organisms involved in PID?
Gonorrhea and trichomonas
What is considered the gold standard for diagnosing Salpingitis?
Laparoscopy
What imaging modality is most helpful when appendicitis is suspected?
CT
Actinomyces involvement in PID is more common with _____
IUDs
True/false – Nulliparity is associated with an increased risk of PID.
True
Which is most commonly associated with mucopurulent cervical discharge, gonorrhea or chlamydia?
Chlamydia is more common than gonorrhea
Which work causes pharyngitis associated with world sex, chlamydia or gonorrhea?
Gonorrhea. Chlamydia is not a common causes because it lacks the pili the gonorrhea has that allows it to adhere to the surface of the columnar epithelium at the back of the throat
What is the most common reason for hysterectomy in the US?
Symptomatic uterine fibroids
What is the most common symptom of uterine Leiomyomata?
Menorrhagia
What medical treatments are available for uterine fibroids?
NSAIDs, Provera, gonadotropin releasing hormone agonist ( causes temporary shrinkage of fibroids after three months of therapy; after therapy has stopped, fibroids will regrow), Levonorgestrel IUD, selective progesterone receptor antagonist, or oral contraceptives.
What are the various types of uterine fibroid based on their location?
Subserosal, intramural, submucosal, cervical, prolapsed
Define: carneous degeneration
Changes of the fibroid due to rapid growth; the center of the fibroid becomes red, causing pain; this is also known as red degeneration
What is the most common tumors of the pelvis?
Uterine fibroids
What causes menorrhagia in women with fibroids?
May be due to an increased endometrial surface area or the disruption of hemostatic mechanisms during menses
Leiomyomata rarely degenerate into leiomyosarcomas. What are some signs of this progression?
Rapid growth such as an increase of more than six weeks gestational size in one year
Fibroids causing labor like uterine contraction pain indicate what?
That a submucosal fibroid has prolapsed through the cervix
Physical exam findings: irregular, midline, firm, nontender mass that moves contiguously with the cervix
Uterine fibroid; this presentation is approximately 95% accurate and most of the time ultrasound is used to confirm the diagnosis
What is the best conservative treatment option for submucosal fibroid’s?
Hysteroscopic resection
What is the procedure of choice for women with symptomatic fibroids who desire pregnancy?
Myomectomy; is not indicated in women who have uterine fibroids unless there have been pregnancy complications due to the fibroids in the past
Explain the technique of uterine artery embolization.
Both uterine arteries are catheterized and infused with embolization particles that preferentially float to the fibroid vessels. Fibroid infarction and subsequent hyalinization and fibrosis results
Uterine artery embolization should not be used in women who want to be pregnant in the future because…
There is an increased risk of placentation abnormalities
What are the Contra indications for uterine artery embolization?
Pregnancy, suspected gynecologic malignancy, history of PID, or renal failure
What type of fibroid is most likely to be associated with recurrent abortions?
Submucosal because of their affect on the uterine cavity- changes in the contours of the endometrium and insufficient vasculature
Impingement of the ureters is most likely to occur with what type of fibroids?
Subserosal
Extensive myomectomies sometimes necessitate cesarean delivery because of…
Risk of uterine rupture
What is the best treatment for leiomyosarcoma?
The diagnosis and treatment is surgical – laparoscopy with possible hysterectomy
What are the best ways to diagnose Leiomyosarcoma?
MRI usually reveals a large heterogenous mass in the uterus with areas of both hyper and hypo enhancement; percutaneous biopsy or even better surgical resection and pathologic examination are the best ways to assess for Leiomyosarcoma
How is endometrial cancer staged?
Surgically
What are the risk factors for endometrial cancer?
Obesity, diabetes, hypertension, prior anovulation, late menopause, Unopposed estrogen replacement therapy and nulliparity
What are the initial diagnostic test acceptable for assessing for endometrial cancer?
Endometrial biopsy or transvaginal ultrasound
What is the most common cause of postmenopausal bleeding?
Atrophic endometrium– Friable tissue of the endometrium or vagina due to low estrogen levels causes postmenopausal bleeding
Define endometrial stripe:
Transvaginal sonographic assessment of the endometrial thickness; a thickness greater than 4 mm is abnormal in a post menopausal woman
Define: type one endometrial cancer
Typical endometrioid cell type which is estrogen dependent, occurring in the perimenopausal or early menopause patient with the classic risk factors of unopposed estrogen. This type of cancer is typically lower grade and not as aggressive
Define: type two endometrial cancer
Usually an aggressive disease with cell types of papillary serous or clear-cell, and is estrogen independent/ER negative. These cancers involve late menopausal women, thin patients, are those with regular menses
Complex hyperplasia with atypia is associated with endometrial carcinoma in __% to ___% of cases
30-50
Women over the age of ____ with abnormal uterine bleeding should have assessment for endometrial cancer and those women Younger than this with ____ should also be considered for a diagnostic procedure.
40 to 45
Risk factors
What is the most common female genital tract malignancy?
Endometrial carcinoma
Women with Lynch syndrome or an increased risk of developing…
Colon cancer, ovarian cancer, and type one endometrial cancer
What is the inheritance of Lynch syndrome?
Autosomal dominant disorder associated with mutations of one of the mismatch repair genes
True/false – smoking increases a patient’s risk for endometrial cancer.
Force – smoking is associated with the lower estrogenic state which would therefore also decrease a patient’s risk for endometrial cancer
And a woman with normal endometrial sampling and continued postmenopausal bleeding, what should be done?
Further investigation such as a hysteroscopy
What is the most common source of fever on the first postpartum day after a csection, especially if done under general anesthesia?
The lungs
What conditions are associated with breech presentation of the infant?
Prematurity, multiple gestation, genetic disorders, polyhydramnios, hydrocephaly, anencephaly, placenta previa, uterine anomalies and uterine fibroids
What conditions are associated with an increased incidence of shoulder dystocia?
Fetal macrosomia, maternal obesity, diabetes mellitus, post term pregnancy, a prior delivery complicated by a shoulder dystocia, and a prolonged second stage of labor
True/false –Ambulation is contraindicated in the presence of a nonreassuring fetal heart tracing’s
True
What are the different categories a breech presentation? What is the most common type of breech?
Frank breech – the buttocks is the presenting part
Complete breech –
Incomplete breech – footling breech
Frank breach is the most common type
True/false – SSRIs are safe during breast-feeding
True – the drug is passed through breastmilk but there is not a detectable amount of drug in the baby’s serum
What is caused by third trimester use of SSRIs?
Abnormal muscle movement/extraparametal signs and withdraw symptoms, which may include agitation, abnormally increased or decreased muscle tone, tremor, sleepiness, severe difficulty breathing and difficulty in feeding.
What are the symptoms of postpartum blues?
Postpartum blues occur within 2 to 3 days postpartum and resolve within two weeks. Symptoms include insomnia, easy crying, depression, poor concentration, irritability or labile affect and anxiety. Symptoms often last a few hours per day and they are mild and transient.
What is the biggest risk factor for the development of postpartum depression?
A history of depression whether that be major depression or postpartum depression
What is the typical rate of progression in the active phase of labor?
1 cm dilation per hour; multiparous women 1-2 cm/h
What is contained in fresh frozen plasma?
Fibrinogen, clotting factors five and eight
Classic presentation: abdominal pain, bleeding, uterine hypertonus and fetal distress
Placental abruption
What are the risk factors for placental abruption?
Smoking, cocaine use, chronic hypertension, trauma, prolonged premature rupture of membranes, and prior history of abruption
Classic presentation: vaginal bleeding, fever, dilated cervix
Septic abortion
What is the treatment of septic abortion?
Uterine evacuation and broad-spectrum antibiotics
What is the treatment for antiphospholipid antibody syndrome causing a recurrent pregnancy loss?
Aspirin plus heparin
____ is increased in women undergoing medical abortion versus surgical abortion.
Blood loss
What are the surgical treatment options for endometriosis?
The definitive treatment is hysterectomy/BSO. In young patients, in order to preserve fertility laser ablation is preferred.
How can anorexia nervosa cause amenorrhea?
Significant weight loss may cause hypothalamic pituitary dysfunction- lack of the normal pulsatile secretion of GnRH leads to a decrease stimulation of the pituitary gland to produce FSH and LH. This leads to anovulation and amenorrhea.
How does hormone replacement therapy affect cholesterol profiles?
Decrease LDL and increase HDL- increase triglycerides and increase LDL catabolism, as well as lipoprotein receptor numbers activity therefore causing decreased LDL levels
What is the normal sequence of sexual maturation in puberty for females?
Breast-feeding/thelarche, then hair growth/adrenarche, a growth spurt, and then menarche
What bodyweight is needed before menses begins?
85 to 106 pounds
What is the treatment of Kallmann syndrome?
Pulsatile GnRH therapy
Define: true precocious puberty
diagnosis of exclusion were the sex steroids are increased by the hypothalamic-pituitary-gonadal axis with increased pulsatile GnRH secretion
Explain the reason for postpartum hair loss/ telogen effluvium.
High estrogen levels during pregnancy increase the synchrony of hair growth. Therefore hair grows in the same phase and is shed at the same time. This can affect 40 to 50% of women postpartum. This can result in significant postpartum hair loss at 1 to 5 months postpartum, with three months after delivery being the most common time.
Classic presentation: rapid onset of acne, hirsutism, amenorrhea, clitoral hypertrophy and deepening of the voice, unilateral adnexal mass
Sertoli Leydig cell tumor
Define: hyperthecosis
A more severe form of polycystic ovarian syndrome; it is associated with virilization due to the high androstenedione production and testosterone levels. In addition to Temporel balding, other signs of virilization include clitoral enlargement and deepening of the voice.
When should mammography screening begin? What is the screening schedule?
ACOG recommends women beginning at the age of 40 to receive annual mammogram
What are the risk factors of osteoporosis?
FH, age > 50, female, small framed, petite and thin women, heavy alcohol use
What is the best way to prevent osteoporosis?
regular weight bearing exercise 3-4 times per week
Physiologic dyspnea is present in __% of women by the 3rd trimester.
75
What respiratory physiologic changes are seen in pregnancy?
Inspiratory capacity increases by 15% during the third trimester b/c of increase in tidal volume and inspiratory reserve volume. The respiratory rate is unchanged, but because TV increases, minute ventilation increases as well. This causes a respiratory alkalosis. FRC is reduced to 80% of the non pregnant volume by term. Combined, these effects lead to subjective SOB.
What are the common causes of acute pulmonary edema in pregnancy?
tocolytic use, cardiac disease, fluid overload and pre-E
What change in CO is seen in pregnancy?
increase by 33% CO due to increase in HR and Stroke volume
Explain why some degree of dilation of the ureters and renal pelvis is seen in pregnancy.
The uterus causes compression which is asymmetrical due to the cushioning of the L ureter by the sigmoid colon and the dextrorotation of the uterus.. Also the R ovarian vein complex dilates in pregnancy and lays obliquely over the R ureter.
Explain the effects of pregnancy on the thyroid.
TBG increases due to estrogens with a concomitant increase in total thyroxine. Free T4 remains relatively constant. Total T3 increase while free T3 levels do not change.
What is the most common location of metastatic disease in patients with gestational trophoblastic disease?
the lungs
What are the recommendations for weight gain in pregnancy?
Underweight–> 28-40 lbs
normal weight–> 25-35 lbs
Overweight–>15-25 lbs
Obese–> 11-20 lbs
What autosomal recessive diseases are more common in Jews of Ashkenazi descent?
Fanconi anemia, Tay-sachs, CF, and Niemann-Pick
What are the teratogenic effects of valproic acid?
increased risk of NTD, hydrocephalus and craniofacial malformations
What are the effects of uncontrolled diabetes during conception and organogenesis?
4-8 fold increase in fetal structural anomalies- majority involving the CNS (like NTD) and cardiovascular system
What screening test has the highest detection rate for Trisomy 21?
Cell-free DNA
What is the risk of fetal loss with chorionic villus sampling?
1%; not related to miscarriage history
What is the most common form of mental retardation?
Fragile X syndrome
Define: twin-twin transfusion syndrome
complication of monochorionic pregnancies characterized by an imbalance in th blood flow communicating vessels across a shared placenta, leading to undwrperfusion of the donor twin. The donor twin becomes anemic and the recipient becomes polycythemia. The donor ten often develops IUGR and oligohydramnios and the recipient experiences volume overload and polyhydramnios that may lead to heart failure and hydrops
What are the risk to infants born to diabetic mothers?
increased risk of developing hypoglycemia, polycythemia, hyperbilirubinemia, hypocalcemia, and RDS.
Management of an infant born to a HIV+ mom
start zidovudine immediately after delivery; HIV testing begins at 24 hours
What are signs that a baby that is breastfed is getting enough milk?
3-4 stools in 24 hours, six wet diapers in 24 hours, weight gain and sounds of swallowing
T/F- Prostaglandins are contraindicated in patients with h/o csection
T- increased risk of uterine rupture
What conditions are associated with post-term pregnancies?
placental sulfatase deficiency, fetal adrenal hypoplasia, anencephaly and inaccurate or unknown dates. Macrosomia, olgio, meconium aspiration , uteroplacental insufficiency and dysmaturity
What is the most common cause of sepsis in pregnancy?
pyleonehritis
A woman with pulmonary hypertension has a __% mortality rate during pregnancy.
25%
Define: fetal hydrops
collection of fluid in at least 2 body cavities
300 micrograms of RhoGAM neutralizes __cc of fetal blood or __cc of fetal RBCs
30
15
What ultrasound markers are suggestive of dizygotic twins?
dividing membrane thickness greater than 2mm, twin peal (lambda) sign, different feta genders and two separate placentas (anterior and posterior)
The twin infant death rate is __ times higher than singletones
5
Twin-twin transfusion syndrome occurs most often in what type of twins?
monochorionic, diamniotic
Define: superfecundation
fertilization of two different ova at two separate acts of intercourse in the same cycle
What is the most common aneuploidy encountered in abortuses?
Trisomy 16
What gestational age is the fetus most susceptible to developing intellectual disability with sufficient doses of radiation?
8-15 weeks
What are the ultrasound criteria for a missed abortion?
Crown-rump length > 7 mm with no cardiac activity
What is the most reliable way to date a pregnancy in the first trimester?
ultrasound measurement of crown-rump length
A fetal head greater than __cm could benefit from c-section.
12
Macrosomia is defined as greater than ____ grams.
4000
Chorionic villi sampling is done at __ weeks and amniocentesis is done at ___ weeks
10-12
after 15
Define: advanced maternal age
Age 35 or greater at estimated time of delivery
Fundal height at the level of the umbilicus corresponds to ____ weeks gestational age
20
What defines anemia in pregnancy?
Hemoglobin less than 10.5
Explain the cardiovascular physiologic changes in pregnancy.
Cardiac output increases due to an increase in heart rate and stroke volume. Plasma volume increases by 50%; systemic vascular resistance decreases; mean arterial pressure is unchanged or slightly lowered
Explain the respiratory physiologic changes in pregnancy.
Respiratory rate unchanged; tidal volume increased; minute ventilation increased; ventilation exceeds needs causing primary respiratory alkalosis
What are the physiologic changes and arterial blood gases in pregnancy?
PH is increased, PCO2 is decreased, HCO3 is decreased. Primary respiratory alkalosis and partial metabolic compensation
What are the renal physiologic changes in pregnancy?
GFR is increased by 50% (reason for glucosuria); serum creatinine is decreased due to increased clearance; ureteral caliper dilated
Describe the hematologic physiologic changes in pregnancy.
Hemoglobin is decreased slightly; platelets are decreased slightly; leukocyte count is slightly increased; physiologic anemia due to plasma volume increased more than red blood cell mass
Describe the gastrointestinal physiologic changes in pregnancy.
Delayed stomach emptying, decreased lower esophageal sphincter tone, decreased gut motility
Cystic fibrosis gene frequency is ___ in Caucasian patients
1:40
Define: asymptomatic bacteriuria
Urine culture of 100,000 CFU per milliliter or more of a pure pathogen of a midstream voided specimen
The fundal height in centimeters corresponds to the gestational age from ___ to ___ weeks.
20-34
What is a reasonable approach in a patient with a history of abruption in a prior pregnancy?
Induction at or slightly before the time of abruption with the fetal loss if at term is a reasonable approach to avoid repeat abruption
What are the ramifications of anti-Lewis antibodies?
Anti-Lewis antibodies do not cause hemolytic disease of the newborn; these antibodies are IgM and do not cross the placenta
If a worrisome antibody is identified from a positive comes test, the tighter should be evaluated. In general, fetal risk is not great unless the titer is ____ or higher.
1:8
How can chronic carrier status versus active hepatitis be differentiated?
Chronic carriers have normal LFTs versus active hepatitis with elevated LFTs
Management of an infant born to a mother with positive hepatitis B surface antigen.
When born should receive hepatitis B immune globulin to protect against immediate exposure and then the active hepatitis B vaccine for lifelong immunity
What can result from hepatitis B infections in infants?
Often this infection leads to cirrhosis and hepatocellular carcinoma
What are the recommendations for the TdaP vaccine in pregnancy?
This vaccine is a killed vaccine and is therefore safe in pregnancy. It should be given between 28 and 36 weeks regardless of whether it has been given in prior pregnancies.
Define: chronic hypertension
Blood pressure is greater than 140/90 before pregnancy or at less than 20 weeks, or persisting more than 12 weeks postpartum
Define: gestational hypertension
Hypertension at greater than 20 weeks persisting for at least four hours
Define:preeclampsia
Blood pressure greater than 140 systolic or 90 diastolic measured twice six hours apart with the new onset of proteinuria usually at 20 weeks or greater. Proteinuria equals greater than 300 mg over 24 hours or a urine protein to creatinine ratio of 0.3 or greater
In the absence of proteinuria, hypertension and any one of the following findings may suffice: thrombocytopenia, impaired liver function test, renal insufficiency he, pulmonary edema, cerebral disturbances, or visual impairment
Define: posterior reversible encephalopathy syndrome
Syndrome consisting of headache, encephalopathy, seizures, cortical visual disturbances diagnosed with clinical features and MRI showing enhancement in the posterior parietal areas
Treatment of posterior reversible encephalopathy syndrome
Antihypertensives, antiepileptics, and intensive care unit monitoring
Define: severe feature of preeclampsia
Vasospasm associated with preeclampsia of such extent that maternal end organs are threatened; usually necessitating delivery of the baby regardless of gestational age
Severe features: systolic greater than or equal to 160, diastolic greater than or equal to 110, platelets less than 100,000, impaired LFTs (2X normal), severe persistent epigastric pain, RUQ pain, progressive renal insufficiency (Cr less than or equal to 1.1), pulmonary edema, New onset cerebral or visual disturbances
Define: superimpose preeclampsia
Development of preeclampsia in a patient with chronic hypertension often diagnosed by an increase in blood pressure and/or new onset proteinuria
What risks to the pregnancy does chronic hypertension and bows?
IUGR, fetal demise, placental abruption, Preeclampsia
True/false – eclampsia can occur without elevated blood pressure or proteinuria
True
What are they hematologic changes seen in preeclampsia?
Vasospasm leads to an increase of systemic vascular resistance, decreased intravascular volume, and decreased oncotic pressure. Vasospasm and endothelial damage result in leakage of serum between the endothelial cells and cause local hypoxemia of tissue
What are the complications of preeclampsia?
Placental abruption, eclampsia, coagulopathies, renal failure, hepatic subcapsular hematoma, hepatic rupture, Uteroplacental insufficiency, Fetal growth restriction, poor Apgar scores, and fetal acidosis
Where are the rest factors for preeclampsia?
Nuliparity, extremes of age, African-American, personal history of severe preeclampsia, family history of preeclampsia, chronic hypertension, chronic renal disease, obesity, antiphospholipid syndrome, diabetes, and multifetal gestation
Management of just stational hypertension or preeclampsia without severe features
Deliver at 37 weeks 0 days; magnesium sulfate use is individualized
How should a mother with gestational hypertension or preeclampsia without severe features be assessed?
- Check for symptoms
- check blood pressure two times per week,
- check platelet count, LFT, and creatinine 1 time per week
- Check serial ultrasound for fetal growth
- BPP once a week for fetal well-being
Where is the assessment of a mother with chronic hypertension?
- Check blood pressure and urine protein at prenatal visits
- Serial ultrasounds to assess for fetal growth
- BPP starting at 30 to 32 weeks
Management of chronic hypertension
Delivery at 38 to 39 weeks
What is the management of preeclampsia with severe features at or greater than 34 weeks?
Administer magnesium sulfate and deliver
Who is the management of preeclampsia with severe features at less than 34 weeks?
Give corticosteroids magnesium sulfate and assess the maternal and fetal stability.
If the maternal/field status is stable, wait at least 48 hours than deliver with magnesium sulfate.
With greater prematurity, if delivery is delayed, Monitor carefully and reassess daily in a tertiary care center.
If fetal or maternal status is unstable, deliver immediately with magnesium sulfate.
What circumstances in preeclampsia with severe features necessitate delivery regardless of gestational age?
Uncontrollable severe hypertension despite max meds, eclampsia, pulmonary Edema, abruption, DIC, nonreassuring fetal status
Management of acutely elevated blood pressure in pregnancy
Use IV labetalol, IV hydralazine, or oral nifidepine immediately and reassess 20 minutes later; escalate dose or alternate agent to bring the BP to a safe level
_____ maybe elevate the blood pressure and postpartum preeclampsia and patients and should be avoided.
NSAIDs
When is the greatest risk for eclampsia to occur?
Just prior to delivery, during labor, and within the first 24 hours postpartum
What monitoring is needed for a patient on magnesium?
Monitor urine output, respiratory depression, dyspnea, abolition of the deep tendon reflexes
What can be done to reduce the reoccurrence of preeclampsia?
Low-dose aspirin started in the late first trimester may slightly reduce the reoccurrence of preeclampsia. Women who have had one or more pregnancies complicated by severe features at less than 34 weeks are candidates.
Women with preeclampsia have an increased risk of ______ later in life.
Cardiovascular disease
What is the most common cause of maternal death due to eclampsia?
Intracerebral hemorrhage
What are the two most common acute complications of preterm premature rupture of membranes?
Infection and labor
Define: preterm premature rupture of membranes
Rupture of membranes prior to 37 weeks and before the onset of labor
When PPROM has been detected causes should be looked into. Test should include:
Urine culture, assay for chlamydia and gonorrhea, fetal weight, fetal presentation, and amniotic fluid volume, GBS cultures
Approximately ____% of patients with PPROM will go into labor within 48 hours and ____% within one week.
50
90
What are the complications of preterm delivery?
Respiratory distress syndrome, chorioamnionitis, placental abruption, necrotizing enterocolitis
What are signs and symptoms of Chorioamnionitis?
Maternal fever, maternal tachycardia, uterine tenderness ,malodorous vaginal discharge, fetal tachycardia is an early sign
What is the treatment of PPROM?
Prior to 34 weeks steroids are given in the absence of overt infection. Broad-spectrum antibiotics therapy, usually ampicillin and erythromycin, initially IV for 48 hours and then orally for five days to complete a seven day course. Antibiotics have been shown to delay the delivery and decrease the incidence of chorioamnionitis. If the risk of infection is thought to be less than the risk of prematurity, patients are placed on bed rest and expectantly managed.
If membranes reseal – discharge home
If before 22 weeks corticosteroids and anabiotic’s are not recommended; patient should be given informed consent about the risk of pulmonary hypoplasia and outcomes
After 34 to 35 weeks – the treatment is usually delivery
In ____% patients with PPROM resealing of membranes may occur demonstrated by absence of the fluid leakage, several negative speculum examinations and normal amniotic fluid volume.
10
What are the risk factors for PPROM?
Lower social economic status, sexually transmitted diseases, cigarette smoking, cervical conization, emergency cerclage, multiple gestations, hydramnios, placental abruption
What can be given in pregnancies before 32 weeks for Neuroprotection?
Magnesium sulfate
What is the most accurate method to confirm an intra-amniotic infection?
Amniocentesis revealing organisms on Gram stain
______ may induce chorioamnionitis without rupture of membranes due to transplacental spread.
Listeria
What is the treatment for chorioamnionitis?
Broad-spectrum antibiotics such as IV ampicillin and gentamicin and labor should be induced
What are the prenatal wrist factors for shoulder dystocia in order of significance?
- prior shoulder dystocia
- fetal macrosomia
- maternal gestational diabetes
Define: shoulder dystocia
Inability of the fetal shoulders to deliver spontaneously, usually due to the impaction of the anterior shoulder behind the maternal symphysis pubis
Define: McRoberts maneuver
The maternal thighs are sharply flexed against the maternal abdomen to straighten the sacrum relative to the lumbar spine and rotate the symphysis pubis anteriorly toward the maternal head
Define: erb palsy
A brachioplexus injury involving the C5 – C6 nerve roots which may result from the downward traction of the anterior shoulder; the baby usually has weakness of the deltoid and infraspinatus muscles as well as the flexor muscles of the forearm. The arm often hangs limply by the side and is internally rotated
What are The maternal complications of shoulder dystocia?
Postpartum hemorrhage and vaginal/perineal lacerations
___% of the time, brachioplexus injury will improve with physical therapy
80
True/false-artificial rupture of membranes should be avoided with an unengaged fetal part
True – this increases the likelihood of umbilical cord prolapse
What situations predispose to cord prolapse?
Transverse fetal lie, footling breach presentation, unengaged fetal part
What is the first step in the evaluation of the fetal bradycardia in the face of rupture of membranes?
Vaginal exam to assess for the umbilical cord
Management of cord prolapse
Place the patient in Trendelenburg position, physician should keep his or her hand in the vagina to elevate the presenting part, emergent C-section
Define: engagement
The largest transverse diameter of the fetal head has negotiated the bony pelvic inlet
Define: fetal bradycardia
Baseline fetal heart rate less than 110 for greater than 10 minutes
Management of fetal bradycardia
Confirm fetal heart rate versus maternal heart rate, vaginal examination to assess for cord prolapse, Placement of the patient on her side to improve blood return to the heart, intravenous fluid bolus if the patient is possibly volume depleted, administration of 100% oxygen by facemask, and stopping oxytocin if it has been given
And women with prior C-section, uterine rupture made manifest as _____
Fetal bradycardia
Why does epidural administration lead to hypotension in the mother?
The epidural cause a sympathetic blockade leading to vasodilation
What is the treatment for hypotension caused by an epidural?
Intravenous fluids and a vasopressor of agents such as ephedrine if late decelerations persist
What is the most common cause of uterine inversion?
undue traction of the cord before placenta detachment
What are the 4 signs of placental detachment?
Gus of blood, lengthening of the cord, globular and firm shape of the uterus, and the uterus rises up to the anterior abdominal wall
What is the difference between active management and physiologic management of the third stage of labor?
Active- maneuvers that attempt to facilitate the 3rd stage of labor
Physiologic- no interventions are done until the natural separation of the placenta
What is the function of delayed cord clamping?
Delayed cord clamping of 30-60 seconds is beneficial for the preterm infant due to increasing total iron stores and hemoglobin levels, and decreasing the risk of intraventricular hemorrhage. delayed cord clamping in a term infant also improves the iron stores but may lead to a higher risk of hyperbilirubinemia
What is the explanation for hypercoaugable states in pregnancy?
venous stasis and mechanical obstruction by the uterus; high estrogen also increase coagulation factors particularly fibrinogen
Tx for confirmed PE in pregnancy
Full IV anticoagulation for 5-7 days then switched to subcutaneous therapy to maintain aPTT at 1.5 to 2.5 times control for at least 3 months after the acute event. After 3 months, either full heparinization or prophylactic heparization doses can be utilized for the remainder of the pregnancy and for 6 weeks postpartum
Both unfractioned and LMWH are safe to use in pregnancy because they do not cross the placenta
What is the tx for antiphospholipid syndrome in pregnancy?
aspirin and heparin
What hypercoaguable states in pregnancy need prophylactic anticoagulation?
homozygogus FVL or a previous h/o VTE
DVT is associated with PE in __% of untreated cases
40
signs and symptoms of DVT
deep leg pain, linear cords palpated along the calf, tenderness and swelling in the lower extremity, 2 cm difference in leg circumference; the examination is normal in 50% of cases
What is the tx for DVT?
anticoagulation with bed rest and elevation of involved extremity
Anticoagulation the same as PE: Full IV anticoagulation for 5-7 days then switched to subcutaneous therapy to maintain aPTT at 1.5 to 2.5 times control for at least 3 months after the acute event. After 3 months, either full heparinization or prophylactic heparization doses can be utilized for the remainder of the pregnancy and for 6 weeks postpartum
When is the most common time for amniotic fluid embolism to occur?
during labor or immediately postpartum
Explain the mechanism of amniotic fluid embolism.
amniotic fluid enters the maternal circulation and subsequently causes obstruction and vasoconstriction of the pulmonary vessels due to fetal debris and vasoactive substances in the fluid
What are risk factors for amniotic fluid embolism?
c-section, instrumental vaginal delivery, induction of labor, traumatic delivery, placental abruption, placental accreta, advanced maternal age, grandmultipartiy
What is the tx for amniotic fluid embolism?
supportive and immediate delivery if there is rapid maternal or fetal decompensation
What is the most common cause of maternal mortality?
embolism of all types, followed by CV and infections
hypercoaguable state of pregnancy persists for __ weeks postpartum
6
What is the most common side effect of long-term heparin in pregnancy?
osteoporosis- thought to be due to overactive osteoclasts
A PO2 of less than ___ is abnormal in a pregnant woman.
80
What is the anatomical problem of genuine stress incontinence (GSUI)?
the bladder neck is below the abdominal cavity
Tx of GSUI
initially pelvic floor exercises (kegel exercises). If these are unsuccessful, then pessary or surgical tx is considered
