OB lecture (Part 1 to slide 102) Flashcards
what is antepartum? intrapartum? postpartum?
before birth, prenatal
childbirth, labor and delivery
postnatal period until 6wks following delivery
TPAL stand for?
term
preterm
abortion
living children
what is considered a preterm infant?
born prior to 37wk gestation
what is considered a fetus?
9th wk of pregnancy –> birth
What is Nagele’s rule?
add 7 days to LMP and subtract 3 mo’s
what is gestational age?
age of fetus calculated from 1st day of LMP including 2wks when women is not pregnant
how long does pregnancy last? (EDC)
280 days, 40 wks
what is 1st, 2nd, and 3rd trimester?
1-12wks gestation
13-28wks
29-40wks
what skin changes can pregnant women get?
Melasma = mask of pregnancy >16wk
linea nigra –> darkening at midline btwn pubis and umbilicus
striae
what respiratory changes can pregnant women get?
incr. tidal volume and PO2
decr. expiratory reserve volume and PCO2
what cardiac changes during pregnancy?
incr. CO and SV
decr. systemic vascular resistance
effects of pregnancy on kidneys?
increased GFR
preconception counseling includes:
wt. management, substance use/abuse, folic acid supplementation, manage existing comorbidities
how much folic acid should you recommend?
0.4mg low risk
4mg high risk
Most prenatal vitamins contain 1mg
when soon can home pregnancy tests come out positive?
by the time of missed menses +/- 1wk
HCG level ~25
how long does HCG rise exponentially?
for 10wks then plateus
how often should beta-HCG double?
every 48hrs in normal pregnancy
2 hormones responsible for most pregnancy sxs in 1st trimester?
beta-HCG and progesterone
PE findings during pregnancy
systolic ejection murmur, Chadwick’s sign (bluish cervix), Hegar’s sign (soft uterine isthmus), Goodell’s sign (soft cervix)
routine labs/diagnostic at initial OB visit
CBC Blood type and Rh Antibody screen Rubella immunity Syphilis testing Hepatitis B antigen testing HIV UA C&S Chlamydia/gonorrhea cultures Pap smear U/S (5-6wk fetal heart activity)
when does genetic screening occur?
11-13wk gestation
what are you looking for on U/S in regards to genetic screening during 1st trimester?
nuchal translucency (assoc w/ Down Syndrome)
fetal nasal bone
what genetic screening can be done during 2nd trimester?
Quad screen: AFP, HCG, estriol, inhibin-A
incr. AFP: neural tube defects, multiple gestation
abn. levels all 4 tests: trisomy 18 or 21
what are some invasive diagnostic tests and when are they performed?
amniocentesis (2nd trimester) 15-20wk gestation
chorionic villus sampling (1st tri) 10-12wk
frequency of prenatal visits?
Initial visit ~ 6 – 8w after LMP
Monthly until 28w gestation
Bimonthly 28w – 36w gestation
Wkly 36w until delivery
what is included in a routine prenatal care visit for mom?
wt. gain 1.5-3lbs 1st trimester, 0.8lb/wk during 2nd trimester and beyond
total wt. gain 25-35lbs
BP, edema, UA (proteinuria and glucosuria)
when can you measure fetal heart tones and what is the bpm?
10-12w
120-160bpm
how do you detect fetal movement?
begins around 18-20wk for 1st pregnancy using “count to 10” method –> 10 FM’s over 2hrs
at 12wk where do you measure the fundal ht? at 20wks?
12w –> pubic symphysis
20w –> umbilicus
when do you perform Group B strep screen?
35-37w
how do you dx gestational dm?
screen at 24-8w
50g 1hr glucose challenge test
value >130 = 3h GTT
need 2 or more abn. results
when do you perform Rh antibody screening? and what is the tx?
26-28w gestation
if negative –> RhoGAM at 28w
If women are Group B strep (+) what is the tx?
intrapartm IV abx if vaginal delivery: Ampicillin or Clinda w/ PCN allergy
T or F: most women in labor prior to GBS screen require empirical abx therapy?
FALSE. all women!
what are some dietary recommendations?
calories –> 350 additional per day
protein –> 1g/kg/day
iron –> 30mg/day
Calcium–> 250mg/day
carbs–> 175g/day
Folic acid –> 0.4mg/day
Vit D –> 600IU/day
fish w/ low mercury content
caffeine –> <200mg/day
what foods should women avoid in pregnancy?
unpasteurized dairy products or undercooked meats
what exercise should women avoid during pregnancy >20w gestation?
any exercise on the back bc it can decr. blood flow to etus by compressing IVC
vaccines in pregnancy?
update Tdap and inactive influenza
avoid ALL live vaccines
what is effacement?
Thinning or shortening of the length of the cervix
Normal length is > 2.5cm
what is complete dilation?
10cm dilation and 100% effacement
diameter of cervical os in cm
Process of labor: what is station?
Degree of descent of the presenting part in the birth canal in relationship to the ischial spines
(+ or -)
what are the 3P’s of labor?
power: uterine contractions
passenger: size, position attitude of presentation
pelvis/passage: bony and soft tissue of maternal pelvis
Characteristics of first stage of labor:
latent phase: 1st regular contractions to 3-4cm dilation
active phase: ends w/complete dilation
how is hypocontractile uterine activity (power) measured? what is the solution?
external tocometry or internal pressure catheter (IUPC)
solution –> augment labor w/pitocin
what is cephalopelvic disporportion? solution?
non-gynecoid pelvis, previous injury or illness causing contracted pelvis
solution = abd. delivery
what is an abortion?
loss of pregnancy prior to 20w gestation d/t chromosomal abnormalities or teratogens
what is the MC complication in early pregnancy?
abortion (80% in 1st trimester)
what is a threatened abortion? inevitable abortion?
threatened–> vaginal bleeding w/a closed cervix
inevitable –> vaginal bleeding w/open cervix
what is a missed abortion?
pregnancy is retained despite death of the fetus
what are some RF’s for complicated pregnancy abortion?
Advanced maternal age, prior spontaneous abortion, multigravity, alcohol, illicit drug use, smoking
physical exam/labs for a complicated pregnancy abortion?
Blood w/in vagina, open vs. closed cervix
CBC
βHCG quant
Transvaginal u/s (heart tone, fetal pole, yolk sac)
blood type and RH
Tx for complicated pregnancy abortion?
expectant management –> pregnancy test 2wks later
surg = dilation and curettage
medical = misoprostol
80mcg per vagina, repeat U/s 24h later, preg test 2w later
Tx for septic abortion
hospitalization for IV abx = cefoxitin (+) doxycycline
medical options for elective abortion?
day 1 - Mifepristone 200mg
24-48hr later = Misoprostol 800mcg buccaly
ONLY up to 70 days gestation
surgical elective abortion options?
suction curettage: 1st trimester pregnancy
dilation and evacuation: 2nd trimester, laminaria placed w/in endocervix 24-48h prior to procedure
surgical abortion complications:
hemorrhage, uterine perforation, infx/retained products, death, postabortal pregnancy
tx–> methergine and D&C
RF’s for ectopic pregnancy
prior ectopic, previous tubal surgery, hx of PID
clinical presentation of ectopic pregnancy
pelvic/abd pain, vag bleeding, orthostatic s/s
Diagnostic/labs for ectopic pregnancy?
CBC, βhCG, CMP, LFT’s, Rh factor, blood type, BUN, Cr
Transvaginal u/s
medical tx for ectopic pregnancy?
administer RhoGAM in Rh (-) women
Methotrexate IM
parameters for dosing methotrexate IM in ectopic pregnancy?
inhibits DNA synthesis and fetal cells
HCG < 5,000, no cardiac activity, sac <4cm
repeat HCG on days 4 and 7 ( >15% HCG decline)
contraindications to methotrexate?
Renal / liver / pulmonary compromise, at risk for loss to follow up, breastfeeding, heterotopic pregnancy, immunodeficiency
surgical tx options for ectopic pregnancy?
administer RhoGAM if (-)
laparoscopy vs. laparotomy
indicated: hemodynamically unstable, impending or active rupture, methotrexate failure, heterotopic pregnancy
what is Gestational Trophoblastic Disease?
Abn. proliferation of trophoblastic tissue (epithelium) of the placenta 2/2 abn. fertilization
maternal tumor arises from gestational tissue
what are the 4 types of gestational trophoblastic dz?
Hydatiform Mole = MC (80%)
Invasive Mole
Placental site nodule
Choriocarcinoma
what is complete and partial hydatiform mole (molar pregnancy)
complete: no chromosomes or 2 copies of paternal
partial: 2:1 paternal vs. maternal DNA
clinical presentation of gestational trophoblastic dz?
Abn. uterine bleeding/Amenorrhea Uterine size greater than dates Absent fetal heart tones Hyperemesis Pre-eclampsia “like” sx prior to 20w
what will you see on U/S for gestational trophoblastic dz?
“snow storm” or “grape-like clusters” w/in endometrium
uterine is enlarged
Tx for hydatiform mole?
D&C to evacuate contents of uterus, pelvic rest for 4-6 wk, close monitoring of hCG levels for 6-12 mo’s, avoid pregnancy 12mo’s
what is placental abruption?
Premature separation of a normally implanted placenta after 20th wk gestation d/t rupture of maternal vessels
clinical presentation of placental vaginal bleeding:
Abrupt PAINFUL vaginal bleeding
Abd/back pain
Contractions
tx for placental abruption?
closely monitor hemodynamic status, continuous fetal monitoring, expectant management in stable mom’s only
unstable –> C-section
what is placenta previa?
An abnormal location of the placenta over, or in close proximity to, the internal cervical os
(unknown etiology)
RF’s for placenta previa?
Prior c- section
Multiple gestation
Prior Hx of previa
Advanced maternal age
clinical presentation for placenta previa?
PAINLESS vaginal bleeding after 20wk gestation
what is a low-lying placenta previa?
located near but not directly adjacent to internal os?
dx for placenta previa?
U/S
Never perform cervical exam bc hemorrhage can occur
Tx fo placenta previa?
asx. –> avoid intercourse, decr. physical activity, may resolve w/advanced gestational age
sx. –> admit to hospital, C-section
what is the MC cause for pre-term delivery?
premature rupture of membranes (before onset of uterine contractions
what is pre-PROM?
Rupture of membranes before 37w gestation without the presence of uterine contractions
RF’s for premature rupture of membranes?
genital tract infx (BV), smoking, previous pre-term delivery
Dx for premature rupture of membranes:
Speculum exam reveals amniotic fluid coming out of the cervical os or pooling of fluid in the vaginal fornix
Sample vaginal fluid and look for “ferning” under microscope
high concentration (+) alpha-fetoprotein
vaginal fluid pH is 7.0-7.3
Tx for premature rupture of membranes?
corticosteroids to promote lung maturity < 34w
If GBS status unknown administer abx prophylaxis
Expectant management until delivery
what is the etiology of post-partum hemorrhage?
uterine atony (#1): lack of effect contractions following delivery
trauma, coagulopathy
PE for post-partum hemorrhage?
Tachycardia
Oliguria
↓O2 saturation
Hypotension
tx for post-partum hemorrhage
Uterine massage IV hydration Oxytocin/misoprostol/methergine Blood transfusion Surgery
