OB operations, 3rd Trimester Labs, Isoimmunization, Postpartum Bleeding

Question 1

C-section indications

Answer 1

elective= bikini cut. Indications = fetal distress (breech, non reassuring CST), maternal factors = preeclampsia, eclampsia

Question 2

C-section risks

Answer 2

VBAC increases risk of uterine rupture, there’s a scar

Question 3

C-section benefits

Answer 3

Can do BTL

Question 4

Forceps/vacuum delivery indications?

Answer 4

Prolonged stage 2 (with baby at station 1 or 2) with cervical effacement

Question 5

Forceps/vacuum delivery risks

Answer 5

Cephalohematoma, bell’s palsy, can denude mom if vaginal tissue isn’t cleared.

Question 6

Episiotomy indications

Answer 6

Nulliparous mom, macrosomic baby, prolonged labor.

Question 7

Two types of episiotomy

Answer 7

Medial - hurts, heals, can go grade IV

Lateral - hurts, doesn’t heal well, no potential for stage IV

Question 8

Grades 1-4?

Answer 8

Grade 1, tear into vagina
Grade 2, tear into vagina and perineal body
Grade 3, tear into sphincter
Grade 4, tear into anal mucosea

Question 9

Risks of episiotomy?

Answer 9

Can cause postpartum hemorrhage.

Question 10

Cervical Cerclage indications? Technique

Answer 10

Recurrent second trimester losses. Suture around cervix, tighten.

Question 11

When to perform cerclage and when to remove?

Answer 11

Insert in weeks 12-16, remove at 35-36.

Question 12

Risk of cerclage?

Answer 12

ppROM if membranes are hit, cervical rupture

Question 13

Is fetal bradycardia okay with anesthesia?

Answer 13

Yes, reassure

Question 14

What blocks to do in stage I and II

Answer 14

Paracervical block for stage I, pudendal block for stage II

Question 15

Gestational DM pathogenesis

Answer 15

Insulin insensitivity

Question 16

Risk factors for gestational DM

Answer 16

Preconception obesity, 1lb/week weight gain, advanced maternal age

Question 17

How to diagnose gestational DM?

Answer 17

Screen with 1 hour GTT, confirm with 3 hr GTT. Can’t use A1C because there was no diabetes to begin with.

Question 18

1 hr gtt, technique and numbers

Answer 18

50g glucose, positive if greater than 140mg/dl

Question 19

3 hour gtt technique and numbers

Answer 19

100g glucose, positive if fasting over 95mg/dl
1hr over 180
2 hours over 155
3 hours over 140
Need two of above

Question 20

How to treat gestational DM

Answer 20

Insulin basal bolus qHs and qAc, no role for orals.

Question 21

When is nadir hemoglobin during pregnancy?

Answer 21

28-30 weeks, usually iron deficiency anemia

Question 22

How to diagnose anemia

Answer 22

Hgb less than 10
Hct less than 30
Decreased MCV, decreased Ferritin

Question 23

Isoimmunization pathogenesis

Answer 23

Rh - mom and rh + baby. First pregnancy IgM generated, second pregnancy igg can cross and cause anemia and death

Question 24

Three types of antibody subtypes and outcomes

Answer 24

Lewis - baby lives
Duffy- baby dies
Kal- Kills baby
Titers must be greater than 1:8 (so 1:16, 1:36)

Question 25

Algorithm for determining fetal isoimmunization safety during pregnancy?

Answer 25

Check Rh ab titers. If positive, check to see if baby is anemic with transcranial doppler. If not, stop, if yes, ask if baby can be delivered. If baby greater than 34 weeks then deliver. If baby younger than 34 weeks, then transfuse.

Question 26

How to assess fetal anemia?

Answer 26

Transcranial doppler is best initial test

PUBS (percutaneous umbilical vein blood sampling)– risk of fetal loss. If HCT is less than 35% then transfuse.

Question 27

Definition of postpartum hemorrhage?

Answer 27

More than 500ml vaginal

More than 1L c/s

Question 28

How to diagnose etiology of postpartum hemorrhage?

Four types and treatments?

Answer 28

Check uterus for tone
Absent uterus? Then inversion, go to surgery
Boggy uterus? Then atony, give pitocin
Firm uterus? Then retained placenta, go to surgery
Normal uterus? Then laceration or DIC. Suture or give products.

Question 29

How to treat PPH if unexplained?

Answer 29

Ligate uterine arteries or perform hysterectomy.

Question 30

Pathogenesis of uterine atony

Answer 30

Uterus can’t contract, most common.

Question 31

Causes of uterine atony

Answer 31

Prologed labor, d/c’d pitocin, use of tocolytics, mag

Question 32

How to treat uterine atony?

Answer 32

uterine massage or pitocin, methergine, pgf2a

Question 33

Pathogenesis of uterine inversion

Answer 33

Uterus births itself due to defect in myometrium, then inverts into vagina

Question 34

How to treat uterine inversion

Answer 34

Transvaginal tacking – tack fornices then give pitocin

Question 35

What causes vaginal lacs?

Answer 35

Big baby, precipitous birth, episiotomy

Question 36

Pathogenesis of retained placenta

Answer 36

Burrowed deeply or accessory lobe, placenta tears and bleeds firmly

Question 37

How to diagnose retained placenta?

Answer 37

Look at blood vessels, if they go to edge then retained (should end before edge)

Question 38

How to treat and follow up retained placenta

Answer 38

First do a D and C, then maybe total abdominal hysterectomy.

Follow up with beta hcg quant to check for choriocarcinoma

Question 39

DIC pathogenesis

Answer 39

Placental contents enter circulation, fibrin clots cause massive consumption of platelets and factors.

Question 40

How to diagnose DIC

Answer 40

Increased PT PTT, decreased fibrinogen, decreased platelets, schistocytes on smear