OB (part 1)-Exam 3 Flashcards

Question

Pregnancy: Serum Progesterone * Not what? * Unless levels are what?

Answer 1

* Not a sensitive evaluation of pregnancy * Unless levels are low and then ectopic/miscarriage should be suspected

Answer 2

* Amenorrhea * Nausea, vomiting, food aversions * Breast tenderness (Mastodynia) and tingling * Fatigue (first trimester, improves second, may return third) * Heartburn * Urinary frequency * Increased lability of mood/emotions

Answer 3

Leukorrhea, increase in vaginal discharge containing epithelial cells and cervical mucous Breast changes may start early and continue to postpartum * Enlargement * Vascular engorgement * Nipple darkening * Colostrum

Answer 4

* Blue discoloration or increased vascularity/congestion of vaginal mucosa -> Chadwick’s sign, * Softening of cervix at or after 4 weeks -> Goodell’s sign * Softening of the uterus at cervical junction at 6 weeks -> Hegar’s sign

Answer 5

* Chloasma: “mask of pregnancy”, darkening of the forehead, bridge of the nose or cheek bones. Usually after 16 weeks; exacerbated by sunlight * Spider telangiectasia: result from elevated plasma estrogen. Vascular stellate skin lesions and palmar erythema

Answer 6

* Linea nigra: Melanocyte-stimulating hormone increases, causing darkening of the nipples and the lower midline from the umbilicus to the pubis. Lightens slightly after delivery * Striae: Stretch marks. Breast and abdomen. Appears red, glossy skin that become scar-like. Appear late in pregnancy. Caused by abnormal collagen formation or separation

Answer 7

* Dizygotic or fraternal twins; fertilization of two separate ova; MOST COMMON; frequency varies by races and ethnic groups * Monozygotic or identical twins; single fertilized ovum that then divides 1/250 births * Quadruplets, may arise from one to four ova

Answer 8

* Race (AA women 3.5%, Caucasian women 3%; Hispanic, Asian and Native American lower rates than both) * Advancing maternal age; fourfold increase between 15-37yo * Multiparous * Heredity, more maternal side; Mother twin 1/58; father twin 1/116 pregnancies

Answer 9

* Increased fundal height * Detection of multiple heart beats * **Ultrasound**

Answer 10

* Increased risk spontaneous abortion (0.9 singleton compared 7.3 multifetal) * Congenital malformations * Low birth weight * Malpresentation * Placenta previa * Abruptio placentae * PROM * Prematurity * Umbilical cord prolapse * IUGR * Increased perinatal morbidity and mortality, increases with the number of fetuses

Answer 11

* Anemia * Hydramnios * Hypertension * Premature labor * Postpartum uterine atony * Postpartum hemorrhage * Preeclampsia * Cesarean delivery

Answer 12

* Fetal reduction * Increased US; 2-4 weeks * Delivery between 34-38 weeks

Answer 13

* Initial Visit, usually 6-12 weeks gestation * Monthly until week 28 * Biweekly 28-36 * Weekly until delivery

Answer 14

Occurs at any point between 6-12 weeks gestation Confirmation of pregnancy (usually with US) Calculate Estimated Due Date (EDD) * Add 7 days to LMP, subtract 3 months, add one year to the first day of LMP (Naegele’s Rule)

Answer 15

Past pregnancies, complications, outcomes and other risk factors Counseling: * Nutrition, weight gain, Immunizations, Lifestyle modifications, exposures * Exercise: 150 minutes/week moderate physical activity, muscle-strengthening 2 days week.

Answer 16

* Screen for domestic violence * Full Physical and Pelvic Exams * Prenatal Testing (Aneuploidy (trisomy, monosomy), sickle cell disease, cystic fibrosis, Tay-Sachs disease) * Prenatal vitamins; 30-60mg Iron, 0.4 mg Folic Acid

Answer 17

* Blood type and Rh typing (ABO/Rh) and antibody * CBC (hemoglobin, hematocrit, and platelets) * Syphilis * Rubella titer (if negative, give after birth) * Hepatitis B surface antigen * HIV test * Varicella

Answer 18

* Screening Gonorrhea, Chlamydia, trichomonas, candida, BV * UA with Culture * If at least 21 years old, cervical CA screening * If hx of gestational diabetes or obese, 50g glucose challenge test (GCT) * If hx of preeclampsia – initiate aspirin

Answer 19

* Screening- Will not begin until at least 10 weeks * Noninvasive prenatal testing (NIPT) - cell free DNA analysis of fetal cells in mothers’ circulation- must be at least 10 weeks * First-trimester combined test (Fetal aneuploidy screening for extra or missing chromosomes; Trisomy 13, 18, 21)

Answer 20

US for nuchal translucency: measures thickness back of fetus’s neck, abnormal measurement means increased risk of Down syndrome (trisomy 21) Serum levels of PAPP-A (pregnancy-associated plasma protein A) and free beta subunit hCG * Detection rate of Trisomy 18 (Edwards Syndrome) is 85-87% with false positive rate <5%

Answer 21

Chorionic villus sampling: tissue sample from the placenta, usually about 10-13 weeks, higher risk of miscarriage than Amniocentesis, but able to do earlier if results would alter course of pregnancy.

Answer 22

A small hypoechoic space in the posterior fetal neck is a normal finding in all first trimester fetuses, excessive enlargement is associated with an increased risk of Down syndrome, as well as other fetal abnormalities

Answer 23

* For prenatal diagnosis of genetic disorders (e.g. Down’s Syndrome) * Small samples of the placenta are obtained for chromosome or DNA analysis * Same information as amniocentesis but faster

Answer 24

* Transcervical or transabdominal * Carries a significantly increased risk of fetal loss compared to second trimester amniocentesis. Safer than early amniocentesis * Typically done 10-13 weeks of gestation

Answer 25

* Pneumococcal * Meningococal * Hepatitis A, B * Inactivated polio * Inactivated influenza--should be given, ok any trimester * RSV * Tdap

Answer 26

* RSV @ 32-36 weeks gestation – can protect infant for up to 6 months * Tdap—should be given at 27-36 weeks REGARDLESS of prior immunization hx (there is some passive antibody transfer to infant). All persons with close contact to infant should also be immunized.

Answer 27

* Measles/mumps/rubella * Polio * Varicella

Answer 28

HPV Vaccine. No adverse outcomes have been described but not recommended. If found to be pregnant during series, remaining doses given after pregnancy

Answer 29

Check Rh(D) and antibody typing at first prenatal visit, at 28 weeks, and at delivery Rh factor protein on red blood cells, testing MOTHER only If Mother is Rh -, after exposure to Rh + blood, antibodies are made to attack the Rh + blood cells. * Exposure: labor and birth, amniocentesis, CVS, bleeding during pregnancy, attempts to manually turn fetus from breech presentation, trauma to the abdomen during pregnancy

Answer 30

Can cause fetal hydrops or hemolytic anemia (erythroblastosis fetalis), or to neonate (erythroblasosis neonatorum) and death Rh immune globulin (Rhogam) 300 mcg IM at: * 28 weeks gestation OR 72 hours of delivery OR Any procedure at risk of blood exposure (isoimmunization) such as amniocentesis, CVS * AND any episode of vaginal bleeding (at 13 weeks interval)

Answer 31

* Alcohol, tobacco, drugs, herbal substances * Unpasteurized milk and foods made unpasteurized milk * Raw and undercooked seafood, eggs, meat * Refrigerated pate, meat spreads, and smoked salmon * Hot dogs, luncheon meats and cold cuts unless served steaming hot * Seafood high in mercury: tilefish, shark swordfish, and king mackerel

Answer 32

omega-3 fatty acids and DHEA may enhance brain development and should be encouraged, 8-12 oz/week fish lower in mercury: salmon, shrimp, pollock, tuna (light canned), tilapia, catfish, and cod

Answer 33

* Encourage continue current exercise programs or initiate light exercise. Do not start strenuous exercise routines. * Do not exercise until exhaustion or breathlessness, do not lie flat on back during 3rd trimester

Answer 34

* Psychological benefits * Reduces risk of excessive gestational wt gain, gestational DM, preeclampsia, preterm birth, varicose veins, DVT * May reduce length of labor and complications with delivery

Answer 35

Every Visit: * Vital signs, BP and Weight * Fundal height * Fetal heart rate (FHR) * Fetal position and activity * UA for bacteria, glucose and protein

Answer 36

* Audible with doppler 10-12 weeks * 10-18 weeks, found along midline lower abdomen (DO NOT PANIC IF IT TAKES A MINUTE TO FIND THIS) * After 18 weeks, depends on fetal position, best heard over back or chest * 110-160 bpm * Should vary 10-15 bpm per second. More variable after 32-34 weeks due to increased fetal activity

Answer 37

* “Quickening” is sensation of fetal movement. Felt 18-24 weeks * “Kick counts” after 28 weeks is assessed routinely

Answer 38

* Perception of at least 10 FMs during 12 hours of normal maternal activity * Perception of least 10 FMs over two hours when the mother is at rest and focused on counting * Perception of at least 4 FMs in one hour when the mother is at rest and focused on counting

Answer 39

Non-Stress Test: external transducer monitors fetal heart rate in response to fetal activity * **Reassuring if ≥2 HR accelerations (15bpm above baseline and lasting 15 seconds) in 20 minutes**

Answer 40

* Maternal Triple screen. Includes alpha-fetoprotein (AFP), hCG, estriol. * Maternal “quad screen” for aneuploidy if first trimester screening not done. Adds Inhibin A and evaluates for everything as in Triple screen + abdominal wall defects

Answer 41

* Diagnostic: Amniocentesis as indicated and requested for aneuploidy * Fetal US (20 weeks) to determine pregnancy dating and evaluate fetal anatomy * Physical defects in the brain, spine, facial features, abdomen, heart, limbs * Cervical length measurement (mean = 3.6cm; >2.5cm is normal) can identify women at risk for preterm birth. Not always done

Answer 42

* Technique for withdrawing amniotic fluid from the uterine cavity using a needle via a transabdominal approach * Technically possible after 11 weeks gestation. (Procedures performed before 15 weeks are associated with higher fetal loss and complication rates) * Most common indications are prenatal genetic studies and assessment of fetal lung maturity

Answer 43

* Performed with abnormal 1st semester Combined test or Triple/Quad test to look for some genetic or NTD conditions * Higher chance of miscarriage if done <15 weeks

Answer 44

* US for fetal size and growth if fundal height is 3cm < expected gestational height * US every 2-6 weeks for multi-fetal pregnancies for discordant growth * If initial antibody screen for anti-Rh(D) negative, repeat antibody test at 28 weeks. Result is not required before Rh(D) immune globulin is administered. * 28-32 weeks, CBC for anemia

Answer 45

50-g glucose load and a 1-hour post load venous blood glucose test (@28w) * Abnormal is >=140. Abnormal test followed with a 3-hour glucose tolerance test for diagnosis with check of serum or plasma

Answer 46

* Fetal position determined * Now discuss preterm labor or rupture of membranes at each visit * Maternal perception of fetal movement * Nonstress tests and biophysical profiles performed if medically indicated * Air travel is appropriate up to 36 weeks gestation

Answer 47

* Repeat blood tests for syphilis and HIV (depending on state laws) and urine nucleic acid amplification. * Gonorrhea and Chlamydia for at-risk patients * Screening for group B streptococcal colonization (Neonate risks: pneumonia, meningitis, sepsis) * Leopold Maneuvers (External Cephalic Version) can begin now and assessed systematically

Answer 48

* Cervical examination * Induction if cervix is favorable (2 cm or more dilated, 50% or more effaced, vertex at -1 station, soft cervix, midposition); also considered if cervix not favorable at this time. * Induction at 42 weeks regardless of cervical examination findings

Answer 49

* FHR detectable 10-12 weeks midline lower abdomen * Fetal movement (Quickening) 18-24 weeks (earlier for multiparous) * Braxton Hick’s contractions are painless, felt as tightening or pressure, begin approx. 28 weeks and increase in regularity. DISAPPEAR with walking exercise, or hydration, NO CERVICAL DILATION. * Avoid cat litter and wear gloves when gardening

Answer 50

* It is ok to get hair dyed * Caffeine should be <200mg (not proven harmful if over 200mg -300 mg) * Ok to take a bath, keep temp about 98. Hot tub and sauna limited less than 10 minutes. Goal is to keep body temp <102. * Vibrio bacteria from seafood, Listeria from cheese, Botulism from honey

Answer 51

* Preterm infant: born between 20 and 36 6/7 weeks (259 days) * Term infant: 37 and 40 6/7 weeks gestation (280 days) * Late term: 41 0/7 to 41 6/7 weeks * Post term: 42 weeks and beyond

Answer 52

* Nulliparous – No pregnancies * Uniparous or Primiparous or Para 1 – Pregnant once and first baby delivered * Multiparous- Had babies before * Could be vaginal or cesarean

Answer 53

* Gravidity: the number of times a woman has been pregnant, whether she delivered or not, including the present pregnancy * Parity is the number of viable/live births

Answer 54

(G)TPAL * “T” or “F” – (full) term births (after 37 weeks) * “P” – premature births * “A” – abortions/ectopic (elective and spontaneous) * “L” – living children * Multiples count as one birth

Answer 55

* G2P2 * G4P3A1 * G1P1 * G4 P1113

Answer 56

Contractions + Cervical Change Six P’s: * Parity * Passenger (baby) * Passage (pelvis) * Powers (contractions) * Position * Psyche

Answer 57

* Powers: strength, duration and frequency of uterine contractions. We want to see: * Passenger (fetus) * Pelvis: is it adequate for delivery?

Answer 58

* Occur every 2-3 minutes * Firm on palpation * Last 40-60 sec

Answer 59

* Estimation of clinical weight * Evaluation of fetal lie (longitudinal, transverse or oblique) * Presentation (vertex or breech) * Station – descending into pelvis * Number of fetuses

Answer 60

* Progress of descent of the presenting part during labor is the best test of pelvic adequacy * Consider C-section if pelvis is not adequate

Answer 61

Induction = stimulation of uterine contractions Indications * Continuing the pregnancy carries greater maternal or fetal risk than intervention to deliver * There is no contraindication to vaginal birth * 41 weeks gestation

Answer 62

* Prior classical uterine incision * Active genital herpes infection * Placenta previa * Umbilical cord prolapse * Transverse fetal lie * Cervix is not well prepared (i.e. softened and partially effaced).

Answer 63

* Membrane stripping: pulling away sac * Cervical ripening * Oxytocin * Amniotomy * Others (anecdotal evidence): nipple stimulation, intercourse, spicy food

Answer 64

Prostaglandins * Misoprostol (Cytotec) 25mcg intravaginally q3-6hrs * Dinoprostone (Cervidil) 10mg; insert is left in place until active labor begins, or for 12 hours

Answer 65

* Artificial rupture of membranes * Note clarity of fluid and presence of meconium * Monitor FHR before and immediately after * Risk of umbilical cord prolapse

Answer 66

* Cervical dilation: Described in centimeters dilation * One finger = 1 cm * Two Fingers = 2 cm * Dilates to 10cm

Answer 67

* Degree to which the cervix has thinned * Expressed as a percent of thinning from uneffaced state

Answer 68

Described the relative level of the presenting part to the level of the ischial spine

Answer 69

First stage: * Early/latent phase * Active phase Second stage: Birth Third stage: Delivery of placenta Fourth stage: Recovery

Answer 70

* Prior to onset of labor, fetal head settles into the brim of the pelvis (or at onset in multiparous women) * Time from onset of painful contractions resulting in cervical changes to complete cervical dilation

Answer 71

Latent phase (dilation < 4cm; ≤ 18-20 hrs) * Softening and effacement of the cervix with minimal dilatation * Mild, irregular contractions * Release of mucous plug, may have small amount of blood-tinged mucous ”bloody show” * Can last from hours to days. Often shorter with subsequent deliveries

Answer 72

Active phase (normal dilation occurs at a rate of ≥1.2 cm/hr) * Begins when the cervix is 6 cm dilated in the presence of regular occurring contractions * Accelerated rate of cervical dilatation from 6cm to 10 cm, approximately 1 cm per hour * Descent of the fetal presenting part begins, progresses at rapid rate at end of active phase * Contractions stronger, closer together, regular * Lasts 4-8 hours on average

Answer 73

* IV access and Foley obtained * Patient may ambulate. * If in bed, left lateral recumbent position should be encouraged (ensure uteroplacental perfusion) * Avoid oral fluids (decreased gastric emptying), hydrate with IV fluid

Answer 74

* Maternal monitoring: HR, BP, RR, temp every 1-2 hours, urine output * Analgesia * Fetal monitoring every 30 minutes active stage in patient’s with no significant risk (or electronic monitor tracings reviewed) * Uterine contractions every 30 minutes by palpation or continuously along with FHR for high risk

Answer 75

**A baseline fetal heart rate of 120 to 160 bpm** * **Absence of late or variable FHR decelerations (after contractions)** * Moderate FHR variability (6 to 25 bpm) * Age appropriate FHR accelerations

Answer 76

* Absent/minimal variability with decelerations or bradycardia * Recurrent late or variable decelerations * Bradycardia – FHR < 110 BPM

Answer 77

* Abnormal fetal heart rates that may not be reassuring and signal distress * Confused with birth asphyxia (baby does not have adequate amounts of oxygen before, during, or after labor; maternal low oxygen, cord compression) * Detection with FHR monitor

Answer 78

Findings: * Fetal tachycardia or bradycardia * Repetitive variable decelerations * Low biophysical profile (NST and US) * Late decelerations Risks: anemia, oligohydramnios, pregnancy induced HTN (PIH), post-term pregnancies, intrauterine growth retardation (IUGR), Meconium-stained amniotic fluid (can block airways)

Answer 79

## Footnote V = VERY BAD

Answer 80

Anemia, oligohydramnios, pregnancy induced HTN (PIH), post-term pregnancies, intrauterine growth retardation (IUGR), Meconium-stained amniotic fluid (can block airways)

Answer 81

Treatment: intrauterine resuscitation; prevent any unnecessary procedures * Change mother’s position * Ensure mother well-hydrated * Ensure mother has adequate oxygen * Correct maternal hypotension * Amnioinfusion (alleviate cord compression) * Tocolysis * IV dextrose * Cesarean section

Answer 82

* Nonpharmacological approaches * Epidural block via infusion pump * Spinal anesthesia (single injection of sufentanil and lasts only 90 mins) * Combined spinal-epidural * Local block (pudendal) * General anesthesia

Answer 83

Protracted (slow to progress) * ≥20 hrs for the nullipara * ≥14 hrs for the multiparous woman

Answer 84

Protracted * Cervical dilation <1.5cm over two hours (1.2 cm/hr for nulliparous; <1.5 cm/hr for the multiparous woman) Arrested * Cervix that ceases to dilate after reaching ≥ 6cm or no progressive dilation in 6 hrs following oxytocin administration

Answer 85

Oxytocin is initiated in either protracted phases; +/- amniotomy

Answer 86

Time from complete cervical dilation to expulsion of the fetus * 30 minutes to 3 hours primigravid, 5 min to 30 minutes multigravid

Answer 87

Cardinal Movements of the baby (Passenger) enable it to adapt to the maternal pelvis: * Engagement (prior to labor) * Flexion * Descent * Internal rotation * Extension * External rotation * Expulsion

Answer 88

* Cord is clamped (usually 15-20 seconds, can be delayed 30-60 seconds with child below introitus to increase hemoglobin levels and greater iron stores in first several months of life. Premature infants decreased need for blood transfusion and lower incidence of necrotizing enterocolitis and intraventricular hemorrhage) * Epidural is usually turned down, (not off) in the 2nd stage

Answer 89

Engagement: * Presenting part is at the pelvic inlet * Occurs late in pregnancy, about 2 weeks prior to delivery in primigravida; Multiparous usually occurs with onset of labor Descent: * Presenting part passing through pelvis. * Brought about by force of uterine contractions, maternal bearing down (Valsalva), if upright, gravity * Continues until fetus delivered; all other cardinal movement superimposed.

Answer 90

Flexion: * During descent, resistance from the cervix, walls of the pelvis, and pelvic floor cause further flexion of the cervical spine (chin to chest) * Lessens the presenting diameter Internal Rotation: * Occiput turns anteriorly toward the symphysis pubis

Answer 91

* Fetus has descended to the introitus and then deflexes * Vaginal outlet is directed upward and forward, extension must occur before the head can pass through * As the head continues to descend, there is bulging of the perineum followed by “crowning” (largest diameter of the fetal head is encircled by the vulvar ring. Sensation called “ring of fire”

Answer 92

External Rotation (Restitution): * Delivered head returns to original position at time of engagement to align itself with the back and shoulders (passive rotation) Expulsion: * Following external rotation of head, anterior shoulder delivers under they symphysis pubis, then the posterior shoulder, and then the body of the child

Answer 93

Protracted * >3 hours in nulliparas (4 hours when epidural analgesia is used) * >2 hour in multiparas (3 hours when epidural analgesia is used) Arrested * diagnosed after one hour if there is no descent, despite good maternal pushing efforts

Answer 94

Oxytocin may be initiated or c/section considered Prolonging second stage worsens maternal and fetal outcomes * Maternal: Infection, exhaustion, uterine atony * Fetal: Meconium aspiration

Answer 95

Forceps (make up <1.1% of all deliveries) * In deliveries <36 weeks gestation * Less likely to cause injury Suction (make up even less) * Higher rates of vaginal delivery failure

Answer 96

* Both carry higher rates of vaginal tears, thrombophlebitis, urinary and anal incontinence * Both carry higher risks to the fetus due to skin/skull injuries

Answer 97

* Clear airway with suction if obvious obstruction * APGAR score at 1 and 5 minutes * Clamp and cut cord * Dry, warm on mothers chest (warmed blankets); Kangaroo Care – encourage immediate bonding.

Answer 98

After delivery of the head, anterior shoulder gets impacted on pubic symphysis Risk Factors: * Macrosomia (DM, genetic determinants, multiparity, postterm gestation); over 4500g. * Previous Hx shoulder dystocia * Multigestational * Excessive maternal weight gain * Dysfunctional labor patterns: protracted active phase of first-stage, protracted second-stage * Size of maternal pelvis in relation to size of fetus * Assisted vaginal delivery (forceps or vacuum) ## Footnote Occurs approximately 1% of vaginal deliveries

Answer 99

* Attempt maneuvers to displace the anterior shoulder from behind the symphysis pubis; McRoberts maneuver, suprapubic pressure, internal rotation, or removal of the posterior arm * If maneuvers unsuccessful, one of both clavicles are fracture

Answer 100

* Fetal hypoxia with or without permanent neurologic damage; Hypoxic ischemic encephalopathy * Damage to brachial plexus * Clavicle fracture * Fetal Death

Answer 101

* Postpartum hemorrhage * Rectovaginal fistula * Symphyseal separation * Third- or fourth-degree episiotomy tear * Uterine rupture

Answer 102

* Occurs when cord wraps 360 degrees around neck of fetus * 10-29% of occurrence, increases with advanced maternal age * Degree of complications arise based on degree of tightness of the wrap * From slower flow to strangulation * Facial “duskiness” and sometimes petechia are usually apparent

Answer 103

Risk factors: * Artificial rupture of membranes * Footling breech Fetal bradycardia (always eval for cord prolapse) “Ropelike” cord w/pulsations felt on vaginal digital exam

Answer 104

US with doppler is gold standard to diagnose (93% sensitive) Fetal heart monitoring looking for decelerations (89% sensitive) Clinical management: * Depends upon number of involved nuchal loops (more loops = sooner delivery), the amniotic fluid index, the gestational age, the fetal growth and stress index during labor. * Digitally elevate the presenting part and emergent c-section

Answer 105

Time from expulsion of the fetus and cord clamping to expulsion of the placenta Separation of the placenta occurs within 2-10 minutes Signs of placental separation: * Fresh show of blood from the vagina * Umbilical cord lengthens outside the vagina * Fundus of the uterus rises up * Uterus becomes firm and globular (fundal massage)

Answer 106

Only when these signs have appeared, may attempt traction on the cord Examine placenta to ensure its complete removal Give oxytocin 20U IM/IV while doing uterine massage * May decrease uterine bleeding originating from the placental implantation site.

Answer 107

* Recovery and observation * Close observation of the patient; BP, pulse, uterine blood loss monitored closely * Postpartum hemorrhage commonly occurs during this time (usually from uterine relaxation, retained placental fragments, unrepaired lacerations)

Answer 108

* Signs of hypovolemia may manifest as increase in pulse rate out of proportion to any decrease in BP * Vaginal tears or episiotomy should be repaired now.