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Clinical Medicine 5 > OB (part 2)- Exam 3 > Flashcards

OB (part 2)- Exam 3 Flashcards

1
Q

Vaginal Tears
* What is first and second degree tear?

A
  • First-degree tear: The least severe of tears, this small injury involves the first layer of tissue around the vagina and perineal area.
  • Second-degree tear:The most commonly seen tear during childbirth. The tear is slightly bigger here, extending deeper through the skin into the muscular tissue of the vagina and perineum.
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2
Q

Vaginal Tears
* What is third and fourth tear?

A
  • Third-degree tear:Tear extends from your vagina to your anus. This type of tear involves injury to the skin and muscular tissue of the perineal area, as well as damage to the anal sphincter muscles.
  • Fourth-degree tear: The least common type of tear during childbirth. Extending from the vagina, through the perineal area and anal sphincter muscles and into the rectum, this injury is the most severe type of tear
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3
Q

Postpartum Care
* Monitor what?
* What is postpartum infections? What are the 7 Ws?

A
  • Monitor for hemorrhage: blood loss in excess 500 mL immediate post partum
  • Postpartum infection: fever of 100.4 on two or more times during first 10 days postpartum, exclusive of first 24 hours.
  • 7 Ws: Womb, Wound, Wind (atelectasis, pneumonia), Water (UTI), Wonder drug (drug allergy), Walk (thrombophlebitis), Woman’s breast (Mastitis)
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4
Q

Postpartum Care
* What type of counseling?
* What will after with BP after birth?
* What type of resources?
* What will change shape?

A
  • Contraceptive Counseling
  • Postpartum Hypertension; pregnancy induced HTN will usually return to normotensive range within a few days of delivery.
  • Breast feeding and resources
  • Cervical os changes in shape post vaginal delivery
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5
Q

Metritis
* what is it?
* Aka what?
* Ascending infection from where?
* MC infection after what?

A
  • Infection of the uterine cavity and adjacent tissue
  • AKA: endomyometritis, endometritis, metritis with cellulitis
  • Ascending infection from the lower genital tract
  • Most common infection after C/Section
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6
Q

Metritis
* How do you dx it?
* How do you tx it?

A

Dx: Fever (post-op day 1 or 2) and uterine tenderness

Tx: IV ABX until patient is asymptomatic and afebrile for 24 hours
* Clindamycin(900 mg every eight hours) plus gentamicin(1.5 mg/kg every eight hours)
* Add ampicillinor vancomycin if patient has not improved in 48-72 hours

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7
Q

What is Puerperium?

A

period following delivery to 6 weeks post partum

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8
Q

Puerperium:
* What happens to Maternal reproductive organs and physiology?
* Uterus size?
* What happens to the cervix?
* What regains their former tone?

A
  • Maternal reproductive organs and physiology return toward pre-pregnancy state
  • Uterus decreased from about 1000g at delivery to 100 to 200 g at 3 weeks
  • Cervix loses its elasticity and regains firmness
  • Supportive tissues of the pelvic floor gradually regain their former tone
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9
Q

Puerperium
* What happens to cardiovascular?
* Psych changes?
* Menstrual flow usually returns when?

A
  • Cardiovascular: immediately following delivery, marked increase in peripheral vascular resistance, cardiac output and plasma volume return to normal during first 2 weeks
  • Psychosocial changes: “postpartum blues”, “baby blues”, emotional and hormonal factors.
  • Menstrual flow usually returns 6-8 weeks, ovulation may not occur for several months, particularly in nursing mothers, contraception emphasized
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10
Q

Postpartum Care: postpartum blues
* Either who?
* _
* Which gender is most common?
* Starts when?

A
  • Either parent
  • Transient
  • 50-80% of women
  • Starting 2-3 days after delivery and remitting within a few days to 2-3 weeks
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11
Q

Postpartum Care
* What is postpartum depression?
* What is postpartum psychosis?

A

Postpartum Depression
* Major depressive disorder occurring in the first postdelivery weeks.

Postpartum psychosis- life threatening
* Sudden onset usually within the first 2 weeks postpartum
* 5% risk of suicide/ 4% risk of infanticide

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12
Q

Postpartum Care
* Follow up when?
* What counseling?

A
  • Follow up in 6 weeks
  • Newborn care counseling
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13
Q

⭐️

Postpartum Changes
* What happens to the discharge? What are the different types? (3)

A

Lochia: postpartum discharge, very heavy for 2-3 days, lasts for several weeks
* Lochia rubra – menses like bleeding
* Lochia serosa – less blood
* Lochia alba – whitish discharge

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14
Q

⭐️

Postpartum Changes
* Perineum txt?

A
  • Oral analgesics (NSAIDS)
  • Ice packs
  • Topical anesthetics
  • Sitz baths 24 hours after delivery
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15
Q

⭐️

Postpartum Period
* What happens to the breast? What is the txt?

A

Breast engorgement – takes 2-3 days for milk to come in after engorgement
* Ice packs
* Analgesia
* Supportive undergarment
* Discourage manual expression of milk if lactation suppression is desired

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16
Q

⭐️

Postpartum Period
* What happens to the milk?
* Breasting is recommended how?

A
  • Colostrum: small amounts, first few days and nutrient dense; slowly replaced by milk
  • Breastfeeding is recommended exclusively for 6 months (AAP and WHO), and supplement with breast milk for 2 years.
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17
Q

LY

A
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18
Q

⭐️

Drugs in Breastmilk
* What are the safe drugs?(5)

A

Alpha/Beta blockers, CCBs, ACEI, HCTZ (may reduce milk supply)

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19
Q

⭐️

Drugs in Breastmilk
* What are the drugs that are bad?

A
  • Retinoid
  • Valproic acid ⭐️
  • Antineoplastics/cancer (pump and dump 15 days)
  • HIV Antiviral
  • HIV is contraindicated to breastfeeding in the US
  • Amiodarone (if used >5 days)
  • Immunosuppressants
  • Antibiotics (Doxycycline, ciprofloxacin, gentamicin)
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20
Q

⭐️

Postpartum Period: Contaception
* What may inhibit milk supply?
* What is the only safe option? When do you start it?
* IUD?

A

Combined oral contraceptives may inhibit milk supply

Progestin only preparations are “safe” for breastfeeding
* Initiate at 6 weeks if breastfeeding exclusively
* Initiate at 3 weeks if not breastfeeding exclusively

Initiate at 3 weeks if not breast feeding (any method)

IUD 4-6 weeks postpartum

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21
Q

⭐️

Postpartum Period
When do patients start sexual activity?
* What might need to be necessary for sex?
* Initiate what prior to intercouse?
What happens with weightloss?

A

Sexual activity
* Can resume as soon as the patient is comfortable (general advice is 6 weeks)
* External lubrication may be necessary
* Initiate contraception prior to intercourse

Weight loss
2 lbs per month will not affect lactation

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22
Q

⭐️

Threatened Abortion
* What is it?
* What are the sxs?

A
  • Vaginal bleeding without tissue passage through a closed cervical os during first 20 weeks.
    * 50% proceed to spontaneous abortion
  • Sx: suprapubic discomfort, mild cramps, pelvic pressure, persistent low backache.
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23
Q

⭐️

Threatened Abortion
* Must be differentiated from what?
* What is the tx?
* Single pregnancy loss does not what?

A
  • Must be differentiated from implantation bleeding (bleeding at time of expected menses); 1/4 women have bleeding in early gestation
  • Tx: No proven treatment; Observation; Tylenol for discomfort-> NSAIDs?
  • Single pregnancy loss does not significantly increase risk of future pregnancy loss
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24
Q
A
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25
Q

⭐️

Spontaneous Abortion (Stillbirth)
* What is it?
* Occurs when usually?
* Usually frome what?

A
  • Spontaneous expulsion of fetus prior to 20 weeks gestation (miscarriage) and is most common complication of pregnancy
  • 80% occur within the first 12 weeks
  • 50% result from chromosomal defects (fetus wouldn’t have been viable anyway)

20% of pregnancies terminate in spontaneous abortion

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26
Q

⭐️

Spontaneous Abortion (Stillbirth)
* What are other causes besides chromosomal defects?

A

15% infections, medical disorders (DM, obesity, thyroid disease, SLE), substance abuse (esp. cocaine and tobacco), medications
* Trauma seldom causes first-trimester miscarriage
* Major abdominal trauma can cause fetal loss, more likely as pregnancy advances
* Dietary deficiency of one nutrient or moderate deficiency of all does not appear to increase risk (hyperemesis gravidarum)

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27
Q

⭐️

Inevitable/Incomplete abortion:
* What is it?
* What are the sxs?

A
  • Cervix is dilated some products of conception remain. Tissue may remain entirely in the uterus or partially extrude through the cervix
  • SSX: Mild cramping. Bleeding, may persistent and excessive
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28
Q

⭐️

Inevitable/Incomplete abortion:
* What is the txt?

A
  • Products lying loosely in cervical canal can be easily extracted. Prompt removal to stop bleeding and decrease risk infection
  • With incomplete expulsion: curettage, expectant management or misoprostol (last two not options in clinically unstable women or those with infection)
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29
Q

⭐️

What is complete abortion?

A

Products of conception passed. Cervix closed. May have spotting.

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30
Q

⭐️

Missed Abortion
* What is it?
* What disappears?
* What are the lab findings? (4)

A

Pregnancy ceases to develop and symptoms of pregnancy disappear

Laboratory Findings:
* Low or falling levels hCG
* CBC if bleeding heavy
* Rh Type, give Rh(D) immune globulin if Rh-negative
* Tissue recovered should be sent to pathology, may be sent for genetic analysis

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31
Q

⭐️

Missed Abortion
* What does the transvaginal US?
* What is the txt?

A

Transvaginal Ultrasound:
* Crown-rump length of 7 mm or more and no heartbeat
* Mean sac diameter of 25 mm or more and no embryo

Treatment:
* Surgical or medical evacuation;
* Expectant observation; underperforms medical or surgical evac, 15-50% failure

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32
Q

⭐️

Inevitable Abortion
* What is it?
* Rupture may be what?

A
  • Preterm premature rupture of membranes (PPROM) at a previable gestational age (<22 weeks)
  • Rupture may be spontaneous or may follow invasive procedure such as amniocentesis or fetal surgery
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33
Q

⭐️

Inevitable Abortion
* What are the risks? (3)
* Confirmation with what?

A
  • Risks: prior PPROM, prior second-trimester delivery, tobacco use
  • Confirmation with STERILE speculum exam; pooling; amnionic fluid will fern on a microscope slide or have pH>7; oligohydramnios on sonography
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34
Q

⭐️

Inevitable Abortion
* What is the txt for iatrogenic and first trimester?

A
  • Iatrogenic: higher in uterus, may self seal; amniopatch
  • First trimester: almost always followed by uterine contractions or infection; termination is typical
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35
Q

⭐️

Inevitable Abortion
* What is the txt for second trimester?

A
  • If no pain, fever, or bleeding, fluid may have collected previously between amnion and chorion, Observation is reasonable; recheck 48 hours, if no additional amniotic fluid, resume ambulation and pelvic rest at home
  • 40-50% deliver within first week, average 2 weeks; High risk chorioamnionitis, endometritis, sepsis, placental abruption, retained placenta, if bleeding cramping, fever MUST EVACUATE UTERUS
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36
Q

⭐️

Pregnancy Termination (Therapeutic)
* Another term?
* how far along can you have this?
* What are the two medications? What do they do?

A
  • Induced abortion
  • Within 9 weeks of LMP, medical termination is an option
  • Mifepristone: antiprogesteronal steroids that works by blocking the activity of progesterone, thereby ending pregnancy
  • Methotrexate: Methotrexate interferes with the growth of the placenta, which allows it to separate from the endometrium (type of chemotherapy - antifolate)
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37
Q

⭐️

Pregnancy Termination (Therapeutic)
* First trimester and early second trimester, what are the options?
* In second trimester, what is the option?

A
  • First trimester and early second trimester, D&C with conception products removed via suction or sharp curette
  • In second trimester, destructive grasping forceps may be used
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38
Q

Ectopic Pregnancy
* What happens?
* Where are many of them?

A

Fertilized ovum implants outside the endometrial cavity
* >95% in the fallopian tube (tubal pregnancy)
* endocervical canal (cervical pregnancy)
* ovary (ovarian pregnancy)
* Scar from prior cesarean (cesarean scar pregnancy)
* In peritoneal cavity (abdominal pregnancy

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39
Q

Ectopic Pregnancy
* Leading cause of what?
* What are risk factors?(4)

A
  • Leading cause of pregnancy-related death in the first trimester; 4-10% of all pregnancy-related deaths
  • Risk Factors: PID (damage, obstruction adhesions), Assisted Reproductive Technology (ART), Smoking, 5% of IUD pregnancies are ectopic but IUD does not elevate risk, use of clomiphene, advanced maternal age
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40
Q

Ectopic Pregnancy
* What does it increase the risk of?
* What are the sxs?

A

Risk: Spontaneous rupture; occurs 6-16 weeks depending on location.

Symptoms:
Pelvic or abdominal pain in almost 100% cases
* Abnormal uterine bleeding 75% cases; light spotting to heavy
* Amenorrhea; approximately half of women with ectopic pregnancies have some bleeding at the time of their expected menses and may not realize they are pregnant
* Syncope, dizziness, lightheadedness; raises suspicion for intra-abdominal bleeding from a ruptured ectopic pregnancy. Kehr sign

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41
Q

Ectopic Pregnancy
* What does the exam show?
* what does the lab show?

A

Exam:
* Tenderness, adnexal mass, uterine changes, HEMODYNAMIC INSTABILITY

Lab: Hematocrit, quantitative beta-hCG, progesterone
* Progesterone level <5 ng/mL has 100% specificity for identifying an abnormal pregnancy, but does not identify location (>20 normal pregnancy, 5-20 equivocal)

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42
Q

Ectopic Pregnancy
* How do you dx it?

A
  • Transvaginal Ultrasound: location or “pregnancy of unknown location” (may not see anything until hCG is ~2000)
  • Beta-hCG rises slower than with normal pregnancy
  • Progesterone level <5 ng/ml
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43
Q

Ectopic Pregnancy
* What is the txt?

A

Expectant: asymptomatic, lower starting hCG levels and evidence ectopic pregnancy is spontaneously resolving (decreasing hCG levels). 88% will experience resolution with expectant management.

Medical management: with an antifolate; i.e., Methotrexate (MTX)
* Hemodynamically stable with confirmed ectopic pregnancy
* Cannot use if embryonic cardiac motion, gestational sac larger than 3.5cm, of hCG>5000
* Expect 15% decrease from day 4 to day 7 after MTX

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44
Q

Ectopic Pregnancy
* What is the surgical txt?
* What is the emergency txt?

A

Surgical Treatment
* MAINSTAY of treatment for ectopic pregnancy; despite declining rates of surgical management, remains most definitive treatment
* Laparoscopy standard approach

Emergency treatment
* Request blood products immediately
* Deteriorate quickly
* Rh (D) immunoglobulin given to any Rh-negative mother with diagnosis

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45
Q

Heterotopic Pregnancy
* What is it?
* How is the extopic pregnancy treated with?
* What in instable patient?
* What is contraindicated?

A
  • Concurrent of ectopic and intrauterine pregnancies
  • Ectopic pregnancy is treated with Laparoscopy and Salpingectomy/salpingotomy
  • Laparotomy in instable patients
  • Methotrexate is contraindicated
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46
Q

Abruptio placentae
* What is it?
* What are the risk factors?

A

Premature separation of the placenta

Risk factors:
* Maternal Hypertension (Most common)
* Previous placental abruption (10% after one, 25% after two)
* Trauma
* Polyhydramnios with decompression
* Premature rupture of membranes
* Short umbilical cord
* Cocaine and/or Tobacco use
* Folate deficiency

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47
Q

Abruptio placentae
* What is the clinical presentation?

A

Clinical Presentation: PAINFUL VAGINAL BLEEDING (80%), uterine tenderness (66%), Fetal distress (60%), uterine hyperactivity and increased tone (34%), fetal demise (15%).

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48
Q

Abruptio placentae
* how do you dx it?
* What can be elevated?

A
  • Largely clinical
  • US may only detect 2%; may exclude placenta previa
  • Elevated 2nd trimester AFP associated with increased risk of abruption
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49
Q

Abruptio placentae
* What is the txt?

A
  • Maternal hemodynamic monitoring, may be rapid deterioration
  • Fetal monitoring, may be rapid deterioration
  • Serial evaluation of hematocrit and coagulation profile
  • Blood products on hand + Rhogam
  • Delivery is definitive (via C/S)
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50
Q

Abruptio placentae
* What are the fetus and maternal fetal risks?
* What does it cause?

A
  • Fetus at significant risk of hypoxia and death
  • Perinatal mortality rate 35%; 15% of third-trimester stillbirths
  • MOST COMMON CAUSE of DIC in pregnancy
  • Hypovolemic shock and acute renal failure
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51
Q

⭐️

Placenta Previa
* What is the clinical presentation?

A
  • 70% present with painless vaginal bleeding; mean 30 weeks
  • 20% have contractions with bleeding
  • 10% incidental finding on US
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52
Q

⭐️

Placenta previa:
* What are the risk factors? (5)

A
  • Prior c/section or scars on uterus
  • Multiparity
  • Increasing maternal age
  • Prior placenta previa (4-8% risk)
  • Multiple gestation
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53
Q

⭐️

Placenta Previa
* What is it?
* What are the classifications? (4)

A

Placental location close to or completely covering the cervical os

Classified as:
* Complete: the entire cervical os is covered
* Partial: margin of the placenta extends across part, but not all, of the internal cervical os
* Marginal: edge of the placenta lies adjacent to the internal os
* Low lying: placenta is located near but not adjacent to the internal os

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54
Q

⭐️

Placenta Previa
* how do you dx it?
* What is contraindicated?

A
  • US, transvaginal almost 100% accurate, transabdominal 95%
  • 4-6% of patients have some degree of placenta previa on US before 20 weeks; upward migration of placenta, 90% resolve by third trimester
  • If dx in second trimester, repeat US 30-32 weeks
  • Partial and low-lying placenta previa often resolve by 32-35 weeks
  • DIGITAL EXAM IS CONTRAINDICATED prior to US due to the risk of hemorrhage
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55
Q

⭐️

Placenta Previa
* What is the txt?

A
  • Goal to obtain fetal maturity via amniocentesis without compromising mother’s health
  • If bleeding is excess, Cesarean delivery regardless of gestational age
  • If bleeding not profuse or repetitive, expectant management; 70% will have recurrent bleeding and require delivery before 36 weeks
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56
Q

Premature Rupture of Membranes (PROM)
* What is it?
* What are the RFs? (4)

A

Rupture of the amniotic sac before labor begins
* Before 37 weeks it is Preterm PROM (PPROM)

Etiology and Risk factors
* Vaginal and cervical infections
* Abnormal membrane physiology
* Incompetent cervix or multiple gestation
* Nutritional deficiencies

8-10% of pregnancies

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57
Q

Premature Rupture of Membranes (PROM)
* how do you dx it?

A
  • Vaginal loss of fluid and confirmation of amniotic fluid in the vagina; nitrazine paper or ferning on slide
  • Sterile vaginal exam
  • US to assess fetal anomalies, assess gestational age and amniotic fluid level
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58
Q

Premature Rupture of Membranes (PROM)
* how do you txt it?

A
  • Risks of preterm delivery vs risks of infection and sepsis
  • PPROM: Conservative expectant management while watching for signs of infection; gram stain of amniotic fluid
  • PROM 36 weeks or later, induce labor if no spontaneous contractions 6-12 hours
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59
Q

PROM and PPROM
* What is amniotic fluid for? (2)
* What are the major risks of PROM? (3)

A

Amniotic fluid
* Protects against infection, trauma and cord prolapse
* Allows for fetal movement and breathing

Major Risks of PROM
* Intrauterine infection (chorioamnionitis)
* Cord prolapse
* Placental abruption – premature detachment from uterine wall

60
Q

Preterm Labor and Delivery
* What is preterm labor?
* What is perterm delivery?
* Spontaneous with what? (2)
* What is the most common risk factor?

A
  • Preterm Labor: presence of regular uterine contractions associated with w/cervical changes prior to 37 weeks
  • Preterm Delivery: delivery before 37 weeks
  • Spontaneous: 40-50% with intact membranes & 25-40% with preterm rupture of membranes
  • Multigestation is the most common risk factor
61
Q

Preterm Labor and Delivery
* What are the effects of preterm delivery? (4)

A
  • Bronchopulmonary dysplasia
  • Visual or hearing impairment
  • Developmental delays
  • Cerebral palsy
62
Q

Prediction of Preterm Labor: Fetal fibronectin
* What is fFN?
* When it is released?
* Rise may be associated with what?

A
  • fFN a “trophoblast glue” binds the uterine-placental and decidual-fetal membrane
  • It is released into cervicovaginal secretions when the cellular matrix of these structures is disrupted
  • Rise may be associated with increased risk of birth between 22 and 34 weeks

Test secretions for this trophoblastic glue. - if its not present – unlikely to go into preterm laborr.

63
Q

Prediction of Preterm Labor: Cervical length
* Measured by what?
* Cervical length ≤20mm before 25weeks requires what?
* Weekly IM injections of what?
* No intervention has been proven beneficial in who?

A
  • Measured by transvaginal u/s between 16 and 28 weeks
  • Cervical length ≤20mm before 25weeks requires vaginal progesterone supplementation
  • Weekly IM injections of progesterone from 16-20 weeks through 36 weeks (also if documented hx of preterm birth)
  • No intervention has been proven beneficial in multiple gestations with a short cervical length, monitoring is not recommended in this population
64
Q

Incompetent Cervix: “Silent” cervical dilation
* What is it?
* What are the risk factors?

A
  • Cervical dilation and effacement before week 24 without contractions, vaginal bleeding, ruptured membranes or infection
    * Once dilated to 4 cm, active uterine contractions or rupture of membranes may occur
  • Risk factors: Congenital disorders of collagen synthesis, hx cone bx, hx deep cervical laceration (vaginal or cesarean), Prior excessive or rapid dilation with instruments, Mullerian duct defects, >=2 prior fetal losses during 2nd trimester, multiple gestations
65
Q

Incompetent Cervix:“Silent” cervical dilation
* how do you dx it? (3)

A
  • Pelvic exam; eval cervix, see if amniotic sac has begun to protrude (Prolapsed fetal membranes)
  • Transvaginal US to evaluate length of cervix and membrane protruding
  • Lab: may do amniocentesis to rule out infection of the amniotic sac and fluid (chorioamnionitis)
66
Q

Incompetent Cervix: “Silent” cervical dilation
* What is the txt?

A
  • Cerclage for a viable IU pregnancy less than 24 weeks, purse-string suture around cervix. May be done before week 14 prophylactically for patients with hx of premature birth. Suture removed last month of pregnancy, before labor
  • Progesterone supplementation in second and third trimester
67
Q

Preterm Labor and Delivery: Tocolytics
* Delay how much?
* What is the goal?
* What are the examples? (3)

A
  • 2-7 day delay
  • Goal is to allow time for administration of corticosteroids for fetal lung maturity
  • Magnesium sulfate, terbutaline or nifedipine
68
Q

Preterm Labor and Delivery
* What are the contraindications? (5)

A
  • Advanced labor – not going to stop it
  • Mature fetus
  • Intrauterine infxn
  • Significant vaginal bleeding
  • Severe preeclampsia
69
Q

Management of PPROM

A
70
Q

Assessment of fetal lung maturity
* When does pul system develop?
* Not indicated if what?
* No assessment before when?

A
  • Pulmonary system is among the last of the fetal organ systems to mature
  • Not indicated if delaying delivery will place the mother or fetus at significant risk
  • No assessment before 32 weeks because we are assuming prematurity
71
Q

Assessment of fetal lung maturity
* Indicated before what?
* Amniotic fluid is obtained by what?
* Testing for what?

A
  • Indicated before elective deliveries that are, or may be, less than 39 weeks of gestation
  • Amniotic fluid is obtained by amniocentesis or, in women with ruptured membranes, from fluid pooled in the posterior vaginal fornix
  • Testing for components of fetal lung secretions in amniotic fluid (surfactant)
72
Q

Corticosteroids for Fetal Lung Maturity
* What is the MOA?
* Indicated when?

A
  • Accelerate development of alveolar cells responsible for the production and secretion of surfactant
  • Induce enzymes that stimulate synthesis and release of surfactant
  • Indicated between 23-34 weeks gestation
73
Q

Corticosteroids for Fetal Lung Maturity
* What are the two examples?

A
  • Betamethasone (two doses of 12 mg given IM 24 hours apart)
  • Dexamethasone (four doses of 6 mg given IM 12 hours apart)
74
Q

Corticosteroids for Fetal Lung Maturity
* Administer to who?
* Avoid when and why?

A

Administered at 23 to 34 if increased risk of preterm delivery within the next seven days

Avoid after 34 weeks of gestation
* Low risk of severe respiratory morbidity
* Lack of consistent evidence of corticosteroid efficacy
* Theoretic potential for long-term harm following late exposure

75
Q

Corticosteroids for Fetal Lung Maturity
* Administered to all women at high risk for what?

A

Administered to all women at high risk for preterm delivery unless “impending” delivery (birth expected within an hour or two) is anticipated

76
Q

Breech presentation
* What is it?
* When can this be common?

A
  • Fetal buttocks or lower extremities present into the maternal pelvis
  • Prior to 28 weeks, about 25% of fetuses are in breech presentation, most resolve by 34 weeks
77
Q

Breech presentation
* What are the etiologies? (4)

A
  • Major factor is prematurity
  • 20-30% low birth weight
  • Fetal structural anomalies (such as hydrocephalus) restrict ability to present as vertex 6%
  • Other: uterine anomalies (bicornuate uterus), multiple gestation, placenta previa, hydramnios, contracted maternal pelvis, pelvic tumors
78
Q

Breech
* What are the different presentations? (3)

A
  • Complete (25%): both thighs flexed, one or both knees flexed (squat position)
  • Incomplete/footling (10%): one or both thigs extended, one or both knees or feet lying below the buttocks
  • Frank (65%): both thighs flexed and both lower extremities are extended at knee
79
Q

How do you dx breech?(3)

A
  • Leopold examination (aka external cephalic version)
  • Ultrasound
  • Vaginal exam in labor
80
Q

Breech
* What is the txt?

A
  • Exclude fetal and uterine anomalies: Ultrasound
  • External cephalic version (ECV) at 37 weeks: manually converts breech fetus to vertex, about 60% successful; 2% may revert to breech (lessen by waiting to 37 weeks)
  • Vaginal delivery depends on “experience of the health-care provider”, presentation, facility, maternal anatomy and health; Standard of care is cesarean section
  • If unable to perform cesarean, assisted breech delivery
81
Q

What is External Cephalic Version?

A
82
Q

Cesarean Delivery
* What are the indications?

A
  • Dystocia 30%
  • Repeat cesarean 25-30%
  • Breech presentation 10-15%
  • Fetal distress 10-15%
  • Absolute indication “classical” cesarean delivery incision through myometrium of the uterus
  • Complications from placenta previa
83
Q

What are the different types of C-section incisions?(5)

A
84
Q
  • What is TOLAC AND VBAC?
  • Who are appropriate candidates? (4)
A
85
Q

VBAC
* What are the contraindications to VBAC? (4)

A
  • Prior classical or T-shaped uterine incision
  • Previous uterine rupture
  • Medical or obstetrical complications that preclude vaginal birth (eg, placenta previa/breech presentation)
  • Inability to perform emergency cesarean delivery due to factors related to the facility, including availability of the surgical, anesthesia, or nursing staff
86
Q

Postpartum Hemorrhage
* What is it?
* May occur when?
* Leading cause of what?

A
  • ANY Blood loss at time of vaginal or c/s delivery CAUSING signs and symptoms of hypovolemia; or 10% decrease in hematocrit
  • May occur immediately postpartum or slowly over the first 24 hours
  • Leading cause of maternal mortality worldwide
87
Q

TEST

Postpartum Hemorrhage
* What are the causes?

A

* Uterine atony (75-80%)
* Genital tract trauma
* Retained placental tissue
* Low placental implantation
* Uterine inversion
* Coagulation disorders
* Abruptio placentae
* Amniotic fluid embolism
* Retained dead fetus

88
Q

Postpartum Hemorrhage
* How do you dx it?

A

Dx: Identification of cause with systematic approach:
* Palpate the uterus to determine presence or absence uterine atony
* Inspect vagina and cervix for lacerations
* Uterine inversion or pelvic hematoma
* Manual exploration of the uterine cavity (gloved hand)
* If not cause of bleeding found; coagulopathy

89
Q

Postpartum Hemorrhage
* How do you tx it?

A
  • Treat underlying cause
  • Stop source of bleeding
  • Atony: Oxytocin to increase uterine tone, bimanual compression and massage; IR intervention with thrombolytics, hysterectomy or ligation of the uterine arteries.
  • Remove retained products of conception
  • Uterine inversion; rapid shock, volume expansion, replace uterus after separated placenta completely removed
  • Thrombocytopenia: platelets
90
Q

Postpartum Hemorrhage
* What is placenta accreta, increta and percreta?

A

Placenta accreta: abnormal adherence of the placenta to the superficial lining of the uterus (doesn’t separate easily)

Placenta increta: placental penetration into the uterine muscle

Placenta percreta: complete invasion of the placenta through the uterine muscle

91
Q

Disseminated Intravascular Coagulation (DIC)
* Disruption of what?
* What is it?
* Widespread clotting causes what?

A

Disruption of hemostasis
* Systemic activation of blood coagulation, results in generation and deposition of fibrin and formation of microvascular thrombi in the small blood vessels through the body (thrombosis) and activation of plasmin (fibrinolysis and hemorrhage), eventually leading to multiple organ dysfunction
* Widespread clotting depletes the platelets and clotting factors that are needed to control bleeding, excessive bleeding often occurs

92
Q

Disseminated Intravascular Coagulation (DIC)
* What are the obstertical DIC causes?

A
  • Acute peripartum hemorrhage (uterine atony, cervical and vaginal lacerations, uterine rupture
  • Placental abruption
  • Preeclampsia/eclampsia/HELLP
  • Retained stillbirth
  • Septic abortion and intrauterine infection
  • Amniotic fluid embolism
  • Acute fatty liver of pregnancy
93
Q

DIC
* What is the txt?(3)

A
  • Prompt diagnosis and treatment of causative problem
  • Stop bleeding: Administer whole blood
  • Antibiotics: Broad Spectrum
  • Evacuation of the uterus
94
Q

TEST

HELLP Syndrome
* What is it?
* Occurs in who more often?
* What is the only proper way to treat it?

A

(H) Hemolysis, (EL) Elevated Liver Enzymes, (LP) thrombocytopenia

Occurs in 4 – 12% of patients with preeclampsia or eclampsia (risk factor)

Delivery is the only proper way to treat HELLP syndrome
* Also, correct coagulopathy

95
Q

Gestational Trophoblastic Neoplasia
* What is it?
* More likely in who?

A

Spectrum of disorders benign or malignant, nonmetastatic or metastatic; arising from abnormal placental (trophoblastic) proliferation
* More likely age >35 and in smokers
* 80-90% benign course, dx remitting spontaneously

96
Q

Gestational Trophoblastic Neoplasia
* What is chorioadenoma and choriocarcinoma?

A
  • Chorioadenoma: invasive mole, can metastasize
  • Choriocarcinoma (20%): frankly malignant, metastatic
97
Q

Gestational Trophoblastic Neoplasia
* What is Hydatidiform Mole?
* What are the two types?

A

Hydatidiform Mole: Benign but tissue can embolize to lungs

2 types
* Complete Mole: An abnormal pregnancy when sperm fertilizes an egg that does not contain any genetic material. Molar pregnancy. (46XX). Most common and is paternal in origin.
* Incomplete or Partial Mole: normal egg fertilized by two sperms (69XXY)-> Focal trophoblastic proliferation

98
Q

Gestational Trophoblastic Neoplasia
* What is the clinical presentation?(3)

A
  • Uterine size mismatch (larger/double) to dates on exam
  • Bleeding and absence of fetal heart tone.
99
Q

Gestational Trophoblastic Neoplasia
* What are the labs?
* What is the imaging?

A

Lab:
* High serum beta-hCG (high normal to millions), higher levels in complete mole

Imaging:
* Dx confirmed by US, “cluster of grapes” or “Snowstorm”
* CXR to r/o pulmonary metastases

100
Q

Gestational Trophoblastic Neoplasia
* What is the txt?

A
  • Evacuation and sharp curettage of uterine cavity, regardless of duration of pregnancy
  • Weekly serum beta-hcg; should fall to normal within 12-16 weeks;
  • Initiate chemo if beta-hcg plateaus or rises: Methotrexate or Actinomycin D
101
Q

Gestational Trophoblastic Neoplasia
* What do you need to educate the patient on?

A
102
Q

Gestational Trophoblastic Neoplasia: Chorioadenoma/Invasive Mole
* What is it? In who? What is the txt?

A
  • Locally invasive; may penetrate the entire myometrium, rupture through the uterus, and result in hemorrhage into the broad ligament or peritoneal cavity
  • 5-10% of molar pregnancies, usually those with persistent beta-hcg levels after molar evacuation
  • Treatment: Chemotherapy, Hysterectomy
103
Q

Gestational Trophoblastic Neoplasia
* What does choriocarcinoma present with? How do you dx and tx it?

A
  • Presents with symptoms of metastatic disease; hemoptysis, cough, dyspnea, headaches, dizzy spells, “blacking out”, acute abdomen, neurologic signs
  • Dx: Beta-hCG, CT abdomen, pelvis, brain; LP for early detection brain mets
  • TX: Chemotherapy
104
Q

TEST

Gestational Diabetes
* What happens in normal pregnancy?
* GDM believed to be what?

A
  • Normal pregnancy, insulin sensitivity decreases to ensure a steady stream of glucose delivery to the fetus
  • GDM believed to be exaggeration of the pregnancy-induced physiologic change; alternatively, pregnancy may unmask an underlying propensity for glucose intolerance and that it will declare itself in the future
105
Q

TEST

Gestational Diabetes
* 50% of GDM will have diagnosis of what?
* What are the risks?

A
  • 50% of GDM will have diagnosis of DM in their lifetime
  • Risk: excessive fetal growth, increased maternal and perinatal morbidity; increased risk shoulder dystocia; increased cesarean delivery and preeclampsia (both overt DM and GDM)
106
Q

TEST

Gestational Diabetes
* What is the screening (how it is done and when)?

A
107
Q

TEST

A

Diagnosis is made if 2 of the 4 values are increased

108
Q

TEST

Gestational Diabetes
* What is the txt?
* What is the patient educaiton?

A
  • Diet and exercise is usually sufficient
  • Insulin is the only approved treatment
  • If insulin cannot be used, metformin next line
  • Patient education: Nutrition counseling and Pregnancy Risks
109
Q

TEST

Gestational Diabetes
* What are the risks associated with GDM? (3)
* Consider induction in who?

A

Risks associated with GDM:
* Macrosomia (>4500 g)
* Shoulder dystocia
* Increased risk for c-section

Consider induction in well controlled patients w/o complications at 38 to 39 wks

110
Q

TEST

Gestational Diabetes
* Consider C-section if what?
* Recurrence of what?

A
  • Consider C-section if estimated fetal weight >4500g
  • Recurrence of gestational diabetes in 60%-90% of subsequent pregnancies
111
Q

Hypertension Disorders in Pregnancy
* Severe HTN increases mother’s risks of what?
* Fetus and neonate increased risk from complications from what?

A
  • Severe HTN increases mother’s risks MI, cardiac failure, CVA and renal failure
  • Fetus and neonate increased risk from complications from poor placental insufficiency, fetal growth restriction, preterm birth, placental abruption, stillbirth, and neonatal death
112
Q

⭐️

Hypertension Disorders in Pregnancy
* What is chronic HTN?
* What is gestational HTN?
* What is preeclampsia?

A
  • Chronic HTN – before 20 weeks gestation
  • Gestational hypertension (aka Pregnancy Induced HTN): elevated blood pressure diagnosed for the first-time during pregnancy at or beyond 20 weeks, without proteinuria
  • Preeclampsia is onset of hypertension, proteinuria or other sequelae, typically after 20 weeks, usually third trimester.
113
Q

Gestational HTN
* Usually occurs when?
* How do you dx it?

A

Usually occurs near term

Dx:
* Elevated BP on 2 occasions 4 hours apart in previously normotensive woman at 20 weeks or more gestation and no proteinuria
* Mild SBP >=140 or DBP >=90 (watch)
* Severe SBP >=160 or DBP >=110 (treat)
* Lab: hepatic transaminases, Creatinine, hematocrit and platelets, and a UA

114
Q

Gestational HTN
* What can you tx with severe BP?(3)

A

Severe SBP >=160 or DBP >=110 (treat)
* Methyldopa, Labetalol or Nifedipine

115
Q

Gestational HTN
* What are the complications?

A
  • Over 25% will develop preeclampsia
  • Mild gestational HTN not at increased risk of preterm birth, abruption or stillbirth
  • Severe: at risk of all of the above.
116
Q

Gestational HTN
* What is the monitoring plan?

A
  • Baseline US for fetal weight and amniotic fluid index as well as NST (and biophysical profile (BPP) if NST is nonreactive,
  • Repeat US every 3 weeks
  • Weekly NST (and BPP if indicated)
  • Daily fetal kick counts
  • Twice weekly maternal BP
  • Evaluation of proteinuria each visit
  • Weekly CBC, liver enzymes, serum creatinine
  • Delivery at 37 weeks. If any complication (i.e., preeclampsia), delivery at 34 weeks
117
Q

Gestational HTN:
* What is the prognosis?

A
  • Most experience normalization of BP 2 weeks after delivery
  • 20% will have persistently elevated BP after 12 weeks and meet dx criteria for chronic hypertension
  • Recurrence 46.8% in subsequent pregnancies
118
Q

Gestational HTN
* What are the drugs you avoid?

A

ACEI, ARB

119
Q

⭐️

Preeclampsia
* Occurs when?
* What are the risks?

A
  • Occurs at or after 20 weeks gestation
  • Risks: Nulliparous, >35 years of age, hx previous preeclampsia, Chronic HTN, chronic renal dx, hx thrombophilia, multifetal pregnancy, IVF, DM, obesity, SLE
120
Q

⭐️

Preeclampsia
* Classified how?

A

Without severe features:
* fewer complaints, DBP <110, Platelet count over 100,000/mcL, fetal testing reassuring

With severe features:
* symptoms dramatic and persistent, HA, vision changes, SBP >160/110; thrombocytopenia (<100,000)
* may progress to DIC; HELLP (Hemolysis, elevated liver enzymes, low platelets)is advanced severe preeclampsia

121
Q

⭐️

Preeclampsia:
* What is needed in order to dx it?

A
122
Q

⭐️

Preeclampsia
* What are the complications?(3)

A
  • Intrauterine growth restriction (IUGR)
  • Placental abruption
  • Maternal pulmonary edema
123
Q

⭐️

What is eclampsia?

A

occurrence of seizure in setting of preeclampsia; manifestation of severe neuro involvement

124
Q

⭐️

Preeclampsia
* What is the txt?

A

Low-dose Aspirin 81mg starting at 12-28 weeks for at risk

Initial eval in hospital, delivery if indicated
* Home management for pts without severe features if stable, reliable, and rapid access to hospital
* Induce labor or C/S at 37 weeks

125
Q

⭐️

Preeclampsia txt: With severe features
* What is the cure?
* What is given and why?
* Stabilize what?

A

Delivery is cure and usually indicated

Magnesium sulfate IV 4-6g load over 15-20 minutes, then 2-3g/h; continues for 24 hours postpartum to prevent seizures especially if there are clinical signs of hyperreflexia
* Therapeutic serum level of Magnesium is 4-6mg/ml

Stabilize Blood pressure: goal to get SBP <160 and DBP<110
* Labetalol, hydralazine, nifedipine

126
Q

⭐️

Preeclampsia txt: With severe features
* What is given for the lungs?
* Hospitalization and close monitoring where?

A
  • Corticosteroids for fetal lung development (If less than 34 weeks)
  • Hospitalization and close monitoring in tertiary center if able to stabilize mother and allow for further fetal development until 34 weeks in absence of life-threatening conditions for mother or fetus.
127
Q

⭐️

Preeclampsia
* When must you deliver immediately regardless of fetal age?

A
  • Eclampsia
  • Pulmonary edema
  • DIC
  • Uncontrollable severe hypertension
  • Abruptio placenta
  • Nonviable fetus <23-24 weeks
  • Intrauterine fetal demise
  • Nonreassuring fetal status
128
Q

⭐️

Preeclampsia
* What situations can you consider delaying birth for 48 hours?

A
  • Persistent symptoms
  • HELLP syndrome
  • Fetal growth restriction that is less than 5th percentile
  • Severe oligohydramnios
  • Reversed end-diastolic flow in umbilical artery doppler studies
  • PPROM
  • Significant renal dysfunction
129
Q

⭐️

Eclampsia
* What is it?
* When does it occur?
* What is the txt?

A
  • Presence of convulsions in a woman with preeclampsia that is not explained by another neurologic disorder
  • Usually occur within 24 hours of delivery
  • Tx: Seizure precautions + delivery of fetus + Magnesium + Hydralazine/Labetalol/Nifedipine
130
Q

Sheehan Syndrome
* What is it?

A

Postpartum anterior pituitary necrosis stemming from excessive post-partum bleeding, hypovolemia and shock.
* Higher prevalence in developing countries who have not benefited inpractical and scientific advances of maternal care

131
Q

Sheehan Syndrome
* What happens to the pituitary?
* What is the first sign? What happens later?

A

Pituitary is not able to produce hormones
* 1st sign – absence of lactation (agalactorrhea)
* Later -> amenorrhea or oligomenorrhea, hot flashes and decreased sex drive, hypothyroidism symptoms, adrenal insufficiency (hyponatremia, anemia and hypoglycemia).

132
Q

Sheehan Syndrome
* May present as what?
* Sxs can become what?

A

May present as pan-hypopituitarism or as selective loss of pituitary function
* Symptoms can become evident months to years after initial shock.

133
Q

Sheehan Syndrome
* how do you dx it?

A

Anterior pituitary hormones (FSH, LH, GH, PRL, ACTH, TSH)
* GH tends to be the first one affected, TSH is last.

Should also evaluate the secondary effects (CBC/BMP, TSH, FSH, LH, prolactin, estrogen, cortisol)

134
Q

Sheehan Syndrome
* What is the txt?

A

Lifelong replacement of affected hormones
* TSH – levothyroxine
* Cortisol – prednisone
* Gonadotropin
* If uterus present -> estrogen and progesterone
* If uterus absent -> estrogen
* GH – refer to endocrinologist

135
Q

Sheehan Syndrome
* What are the worst complications?

A

Worst complications: Addisonian crisis and Myxedema coma leading to death

136
Q

Psychological Trauma in Pregnancy
* Who?
* Violence does not have to be what? What is a strong coefficient?

A

Nearly 20% of women experience violence during pregnancy
* Adolescents and unintended pregnancies have unequally higher prevalence

Violence does not have to be physical (verbal/emotional, manipulative, financial)
* Credit score is a strong coefficient to intimate partner violence (IPV)

137
Q

Psychological Trauma in Pregnancy
* 1 in 5 women who experience IPV later develop what? What are they at higher risk for?
* Who should be screened during perinatal and postnatal periods?

A

1 in 5 women who experience IPV later develop PTSD during pregnancy
* Women with PTSD are at higher risk for pre-term delivery, low birthweight and postpartum depression/anxiety
* ASD/PTSD should be screened during perinatal and postnatal periods

138
Q

Postpartum Psychiatric Disorders
* Postpartum phenomenology is characterized by what?

A

Postpartum phenomenology is characterized by a range of emotions from transient mood lability, irritability, and weepiness, to marked agitation, delusions, confusion, and delirium leading to maternity or postpartum blues, puerperal or postnatal depression, or postpartum psychosis.

139
Q

Postpartum Psychiatric Disorders
* Link noted to decrease in what?
* What drops during birth? How does this affect things?

A

Link noted to decrease in gonadal steroids in postpartum period
* Progesterone drops in second stage of labor, estrogen drops with expulsion of placenta
* Estrogen affects monoaminergic system which directly affects serotonin (affective symptoms) and dopamine (psychotic symptoms)

140
Q

Postpartum Psychiatric Disorders
* What are the risk factors?

A

Primigravida; unmarried mother; cesarean sections; family hx or personal hx of psychiatric disorders or IPV

141
Q

Postpartum Psychiatric Disorders: Postpartum blues
* Frequent what?
* Experienced by who?
* Sxs occur when?
* Sxs do not do what?
* What is the txt?

A
  • Frequent crying episodes, irritability, confusion, and anxiety
  • Experienced by most mothers (~85%) to some extent with higher incidence in developed countries (lack of family support)
  • Symptoms arise within 10 days and peak at 3-5 days post childbirth
  • Symptoms do not interfere with social or occupation functioning
  • Treatment is supportive and if symptoms persist >2 weeks, high alert should be placed to identify postpartum depression
142
Q

Postpartum Psychiatric Disorders: Postnatal depression
* What are RFs?
* Negative thoughts about what? Other sxs?

A
  • Personal Hx of depression raises incidence by 25%, where past PD in previous pregnancies increases risk by 50%.
  • Negative thoughts are typically related to the newborn
  • Pervasive depressed mood, disturbances of sleep and appetite, low energy, anxiety, and suicidal ideation
143
Q

Postpartum Psychiatric Disorders
* Sxs appear when?
* txt?

A
  • Symptoms appear within a few days to weeks, but generally 2-3 months after childbirth
  • Pharmacotherapy is reserved for moderate symptoms or postpartum psychosis
144
Q

Postpartum Psychiatric Disorders: Postpartum psychosis
* appears when?
* What are major risk factors?

A
  • Typically appears within 2 weeks of delivery, at most 3 months after childbirth
  • Past Hx of psychosis or Bipolar d/o are major risk factors
145
Q

Postpartum Psychiatric Disorders: Postpartum psychosis
* What are the sxs?
* Should be regarded as what? Why?

A

Typical Sxs: elation, lability of mood, rambling speech, disorganized behavior/hyperactivity, and hallucinations or delusions (persecution)
* Delusions revolve around the infant, especially that the infant is possessed, has special powers, is divine, or is dead

Should be regarded as psychiatric emergency
* Infanticide and suicide are observed in 4% and 5% respectively, therefore enquiring about suicidal and infanticidal thoughts is crucial during the assessment

146
Q

Postpartum Psychiatric Disorders
* how do you dx it?
* What do you need to exclude?

A
  • May utilize “Edinburgh Postnatal Depression Scale,” and the “Mood Disorder Questionnaire” to improve awareness
  • Exclude organic etiology: Sheehan
147
Q

Postpartum Psychiatric Disorders
* What is the txt?

A

Psychotherapy (CBT)

Pharmacotherapy (most will spill into breastmilk)
* Psychotropics: fluoxetine, sertraline, paroxetine, and nortriptyline
* Atypical antipsychotics or lithium in postpartum psychosis: Valproic acid or carbamazepine may be used

Electroconvulsive therapy

Clinical Medicine 5 (10 decks)

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