OB Proper (Abnormal) Flashcards
Abortion in the 1st Trim
Common causes
80% of abortion in the first 12 weeks.
Usually fetal cause (aneuploidy)
2nd most common: Monosomy X
Termination of pregnancy prior to 20 weeks gestation, or fetal weight <500g
Abortion
Abortion in the second trim
Maternal causes usually Uterine abnormalities (septate uterus) Uterine duplication Uterine myoma Cervical incompetence
Risk factors associated with abortion
1) Infection: TORCH
2) Chronic maternal illness
3) Thyroid autoantibodies
4) DM
5) Progesterone deficiency
6) Tobacco, Alcohol, Caffeine
7) Radiation
How much caffiene is associated with abortion
> 500mg/day.
What type of abortion?
Retrochoreal hemorrhage on utz, closed cervix
Threatened
What type of abortion?
Absent heart sounds
Uterine size incompatible with AOG
(+) bleeding
Inevitable
What type of abortion?
(+) retained products
(+) hemorrhagic shock
Incomplete
What type of abortion?
Empty gestational sac in blighted ovum
Closed cervix
Absent bleeding
Missed
What type of abortion?
Empty uterus, no bleeding
Incompatible uterine size
Complete
When does one do D&C for abortions?
Inevitable, Incomplete, Missed
Causes of Recurrent Pregnancy Loss
Genetic
Balanced translocation
Causes of Recurrent Pregnancy Loss
Hormonal and metabolic
Luteal phase defect
PCOS
DM
Hypothyroidism
Causes of Recurrent Pregnancy Loss
Infections
Toxoplasma gondii
Listeria monocytogenes
Causes of Recurrent Pregnancy Loss
Uterine abnormalities
Septate uterus Bicornuate uterus Incompetent cervix Asherman syndrome Submucous myoma
What is Asherman Syndrome?
Aka Fritsch syndrome, condition characterized by adhesions and fibrosis of the endometrium, associated with congenital defects, previous D&C, abortion
Causes of Recurrent Pregnancy Loss
Thrombophilia & Autoimmune disorders?
Factor V Leiden
APAS
What is an Incompetent cervix?
Common cause of pregnancy loss or preterm labor in the late second trim
Defined as cervical dilation of at least 1cm, with cervical length <2cm.
Tx: McDonald Cerclage, Shirodkar cerclage
Risk factors: previous incompetent cerclage, hx of conization, DES exposure, uterine anomalies
When does ovulation resume after an abortion?
after 2 weeks
GTD
Karyotype of Incomplete mole? Complete?
Incomplete: 69, XXY, extra paternal set
Complete: 46, XX, paternally derived chromosomes
GTD
Hydropic villi with severe trophoblastic hyperplasia
Size large for age
Theca Lutein cyst in 25% of cases
Complete Mole
GTD
Focal hydropic villi, minimal trophoblasts, size equals date, slightly elevated HCG
Incomplete/partial mole
UTZ differences between complete and partial mole?
Complete: snow storm pattern
Incomplete: Swiss cheese pattern
Treatment of hydatidiform moles
Suction D&C
Hysterectomy if >35 yo and undesirous of future pregnancy
HCG measurements every 2 weeks until with 3 consecutive negative values
OCPs for 1 year
GTN prophylaxis (controversial)
Signs of very high HCG (>100,000)
Pre-eclampsia before 20 weeks AOG
Hyperemesis gravidarum
Thyrotoxicosis
Presence of Theca Lutein cysts
Components of the WHO Prognostic scoring for GTD
Age Antecedent Pregnancy Interval months from index event Pretreatment HCG Largest tumor size Sites of metastasis Number of metastasis Previous failed chemotherapy / chemoprophylaxis
GTN
Most common GTN
Very sensitive to chemotherapy
Invasive mole
GTN
Primarily secretes prolactin and gonadotropins
PSTT
GTN
Extremely malignant form of chorionic epithelium
Choriocarcinoma
Treatment of GTN II:7 and below
Single agent: Methotrexate or Actinomycin D
Treatment of GTN III:8 and above
EMA-CO
Ectopic Pregnancy
Most recognized risk factor
Hx of PID
Ectopic Pregnancy
Rupture timings of different types?
Ampulla: 8-12 weeks
Isthmus: 6-8 weeks
Interstitial: 16 weeks
Ectopic Pregnancy
Best Predictor of resorption
HCG < 1000 at time of diagnosis
Ectopic Pregnancy
Greatest risk factor
Documented tubal pathology & Previous ectopic pregnancy
Ectopic triad
Amenorrhea
Vaginal bleeding
Abdominal pain (most common)
Signs of Unruptured Ectopic Pregnancy
Cervical motion tenderness
Unilateral adnexal tenderness
Signs of Ruptured Ectopic pregnancy
Hypotension, tachycardia
Peritoneal signs
HCG level when a gestational sac is expected
1500
Presumptive evidence of ectopic pregnancy esp if with TV-UTZ w/o evidence of sac
Serum level of progesterone for normal pregnancies
> 25ng/L
If <5ng/L, consider ectopic pregnancy
Gold standard for diagnosis of ectopic pregnancy
laparoscopy
Medical Management of Ectopic Pregnancy
Requisites
Methotrexate 50mg/m2 IM
1) < 3.5 cm
3) Absence of fetal cardiac act
4) B-HCG < 1500
5) Unruptured
Surgical Management of Ectopic pregnancy
ExLap with salpingiectomy
1) Severely damaged tube
2) Recurrent ectopic preg
3) Uncontrolled hemorrhage
4) Desire for sterility
Best indicator for the success of medical management
BHCG levels before treatment, best if <1000.
14% failure rate at 5000-10000.
Late Pregnancy Bleeding
Third Trimester Bleeding Postpartum Hemorrhage (PPH)
Painful Causes of 3rd trim bleeding? Painless? Non-obstetric causes?
Painless: placenta previa, vasa previa
Painful: uterine rupture, abruptio placenta (most common)
Non-obstetric: cervical polyp, vaginal lesions
Risk factors for Placenta Previa
Multiparity
Increased maternal age
Mult. abortions
Previous CS
Bleeding due to the velamentous insertion of the umbilical cord
Vasa previa
Tx: expectant management up to 37th week, emergency CS
Cause of bleeding in placenta previa vs. vasa previa
PP: Avulsion of anchoring villi of a low implanted placenta - maternal blood
VP: vessels may pass over the cervical OS and rupture - fetal blood
Key pathophysiologic feature of Abruptio Placenta
Hemorrhage into the Decidua basalis
Major risk factors for abruptio
Pre-eclampsia
Short umbilical cord
Trauma
Cig. smoking, alcohol, advanced age
Management of Abruptio
Diagnostic: UTZ - retroplacental clots, Amniotomy - bloody amniotic fluid
Fetus alive: CS under GA
Fetus dead, patient not in DIC: Vaginal delivery under pudendal block
Fetus dead, patient in DIC: CS under GA
Complications of Abruptio
1) Couvelaire uterus - uterine apoplexy
2) Acute renal failure
3) DIC
Most common cause of uterine rupture
Previous CS scar
Other causes: Oxytocin stimulation during labor
Tx of Uterine rupture
Repair of rupture
Hysterectomy
PPH
4 major causes
Tone: Abnormal uterine contractility
Tissue: Retained products of conception
Trauma: Genital tract trauma
Thrombin: Abnormalities of coagulation
PPH
Abnormal Uterine Contractility
High yield card
Overdistended uterus (mult. gest, polyhydramnios, macrosomia) Uterine muscle fatigue (prolonged, augmented labor) Chorioamnionitis Uterine distortion (placenta previa, myoma) Uterine relaxants (B-mimetics, MgSO4, anesthesia)
PPH
Retained products of Conception
High yield card
Accreta (placenta adherent to myometrium)
Increta (placenta invades myometrium)
Percreta (placenta perforates past the myometrium)
Risk factors: scarred uterus, previa, multiparity
Retained products of conception: Manual placental removal, succinturiate lobe
PPH
Genital tract trauma
High yield card
Cervical/vaginal laceration (precipitous delivery, macrosomia, dystocia, operative delivery, forceps, episiotomy) Extension of CS (deep engagement, malposition, malpresentation) Uterine rupture (Scarred uterus) Uterine inversion (fundal placenta, grand multiparity, excessive traction on the umbilical cord)
PPH
Coagulation abnormalities
High yield card
Preexisting clotting anomalies (Hemophilia, von Willebrands disease, etc) Acquired in pregnancy (Sepsis) DIC (IUFD) HELLP (Hemorrhage/Pre-eclampsia) APAS
Postpartum Hemorrhage
Definitions
SVD
CS
SVD > 500cc
CS > 1000cc
Management of Uterine atony
Conservative measures: Uterotonics (oxytocin, methylergonovine) Uterine massage Ice pack Hemostatics with blood volume replacement
Non-surgical procedures:
Bimanual compression
Balloon tamponade, uterine packing
Surgical procedures:
B-Lynch
Uterine artery ligation
Hysterectomy
Placenta accreta pathophysiology
Partial or total absence of the decidua basalis
Imperfect development of the fibrinoid layer (Nitabuch layer)
Tx: Blood replacement
Prompt hysterectomy OR Uterine packing with methotrexate injection
Puerperal hematoma
Risk factors:
Tx:
Nulliparity
Episiotomy
Forceps
Tx: Incision and Drainage
Pathognomic finding of amniotic fluid embolism
Detection of squamous cells or fetal debris in the central pulmonary circ.
AFE is characterized by abrupt onset hypotension, DOB, and DIC
Differentiate PROM, PPROM, Prolonged PROM
PROM: >37weeks AOG, ROM 1 hour before labor
PPROM: PROM 18hours before onset of labor
Management of PROM, PPROM, PPPROM
PROM: Labor induction, GBS prophylaxis
PPROM: Steroids if <34 weeks, expectant management, GBS prophylaxis
Indications for Delivery: PPPROM, PPROM
Active labor Chorioamnionitis Non-reassuring testing IUFD Significant vaginal bleeding Increased concern for cord prolapse
Organisms Associated with preterm labor
Ureaplasma urealyticum, Mycoplasma hominis, Gardnerella vaginalis, peptostreptococci, and Bacteroides species
Biochemical markers of Preterm labor
Fetal fibronectin (FFn): >50ng/mL Salivary estriol: >2.3ng/mL
Clinical diagnosis of preterm labor
1 uterine contraction in 10 minutes with duration of 30 seconds or more
4 contractions in 20 minutes
Regular uterine contractions 5-8 minutes apart with:
- progressive cervical change
- cervical dilatation of 2 cm
- cervical effacement >80%
What cervical UTZ findings suggest preterm labor
Cervical length <35mm (williams)
Funneling (bulging of the membranes into the endocervical canal and protruding at least 25 percent of the entire cervical length)
Tocolytics for controlling preterm labor
1) MgSO4 (Williams - not of use)
- blocks calcium influx by competing at the receptor binding sites
2) Nifedipine
3) Terbutaline, Ritodrine
4) Indomethacin
Dosing of Steroids for Fetal Lung maturity
Betamethasone 2 doses q24
Dexamethasone 4 doses q12
Other benefits of Corticosteroids for premature infants
Decreased RDS
Decreased IVH
Fetal lung maturity assessment
Surfactant-albumin ratio > 55
Lecithin-sphingomyelin ratio > 2
Post term Pregnancy
Definition
42 completed weeks or more, or >294 days since 1st day of LNMP.
Differentiate macrosomia and Dysmaturity syndrome
Macrosomia:
Placental fxn continued
Healthy, large fetus
Increased incidence of dystocia
Dysmaturity
Placental insufficiency
Dry parchment like skin, wasted, malnourished, meconium stained, increased alertness
Increased acidosis, oligohydramnios, cord compression, asphyxiation, and meconium aspiration
Breech
Type of breech with highest incidence of cord prolapse
Incomplete / Footling
20-24% incidence
Breech
Most common type of breech, lowest incidence of cord prolapse
Frank breech
Cord Prolapse risks Cephalic Frank Complete Footling
Cephalic 0.4%
Frank 0.5%
Complete 5%
Footling 15%
Methods of vaginal delivery
SBD - no traction/support
Partial breech extraction - unassisted up to umbilicus
Total breech extraction - entire body extracted
Maneuvers for breech
Delivery of posterior shoulder
Lovesets
Maneuvers for breech
Preferred delivery method for the aftercoming head
Pipers forceps
Maneuvers for breech
Index and middle finger placed on fetal maxilla to maintain flexion, then traction with other hand
Mauriceau
Maneuvers for breech
aka Breech decomposition
Frank breech converted to footling
Pinard’s
Maneuvers for breech
Used for persistent fetal back
legs grasped and body is swung over abdomen
Prague maneuver
