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OB Proper (Abnormal) Flashcards

0
Q

Abortion in the 1st Trim

Common causes

A

80% of abortion in the first 12 weeks.
Usually fetal cause (aneuploidy)
2nd most common: Monosomy X

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1
Q

Termination of pregnancy prior to 20 weeks gestation, or fetal weight <500g

A

Abortion

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2
Q

Abortion in the second trim

A 
Maternal causes usually
Uterine abnormalities (septate uterus)
Uterine duplication
Uterine myoma
Cervical incompetence
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3
Q

Risk factors associated with abortion

A

1) Infection: TORCH
2) Chronic maternal illness
3) Thyroid autoantibodies
4) DM
5) Progesterone deficiency
6) Tobacco, Alcohol, Caffeine
7) Radiation

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4
Q

How much caffiene is associated with abortion

A

> 500mg/day.

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5
Q

What type of abortion?

Retrochoreal hemorrhage on utz, closed cervix

A

Threatened

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6
Q

What type of abortion?
Absent heart sounds
Uterine size incompatible with AOG
(+) bleeding

A

Inevitable

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7
Q

What type of abortion?
(+) retained products
(+) hemorrhagic shock

A

Incomplete

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8
Q

What type of abortion?
Empty gestational sac in blighted ovum
Closed cervix
Absent bleeding

A

Missed

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9
Q

What type of abortion?
Empty uterus, no bleeding
Incompatible uterine size

A

Complete

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10
Q

When does one do D&C for abortions?

A

Inevitable, Incomplete, Missed

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11
Q

Causes of Recurrent Pregnancy Loss

Genetic

A

Balanced translocation

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12
Q

Causes of Recurrent Pregnancy Loss

Hormonal and metabolic

A

Luteal phase defect
PCOS
DM
Hypothyroidism

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13
Q

Causes of Recurrent Pregnancy Loss

Infections

A

Toxoplasma gondii

Listeria monocytogenes

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14
Q

Causes of Recurrent Pregnancy Loss

Uterine abnormalities

A 
Septate uterus
Bicornuate uterus
Incompetent cervix
Asherman syndrome
Submucous myoma
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15
Q

What is Asherman Syndrome?

A

Aka Fritsch syndrome, condition characterized by adhesions and fibrosis of the endometrium, associated with congenital defects, previous D&C, abortion

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16
Q

Causes of Recurrent Pregnancy Loss

Thrombophilia & Autoimmune disorders?

A

Factor V Leiden

APAS

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17
Q

What is an Incompetent cervix?

A

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

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18
Q

When does ovulation resume after an abortion?

A

after 2 weeks

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19
Q

GTD

Karyotype of Incomplete mole? Complete?

A

Incomplete: 69, XXY, extra paternal set
Complete: 46, XX, paternally derived chromosomes

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20
Q

GTD
Hydropic villi with severe trophoblastic hyperplasia
Size large for age
Theca Lutein cyst in 25% of cases

A

Complete Mole

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21
Q

GTD

Focal hydropic villi, minimal trophoblasts, size equals date, slightly elevated HCG

A

Incomplete/partial mole

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22
Q

UTZ differences between complete and partial mole?

A

Complete: snow storm pattern
Incomplete: Swiss cheese pattern

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23
Q

Treatment of hydatidiform moles

A

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)

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24
Signs of very high HCG (>100,000)
Pre-eclampsia before 20 weeks AOG Hyperemesis gravidarum Thyrotoxicosis Presence of Theca Lutein cysts
25
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 ```
26
GTN Most common GTN Very sensitive to chemotherapy
Invasive mole
27
GTN | Primarily secretes prolactin and gonadotropins
PSTT
28
GTN | Extremely malignant form of chorionic epithelium
Choriocarcinoma
29
Treatment of GTN II:7 and below
Single agent: Methotrexate or Actinomycin D
30
Treatment of GTN III:8 and above
EMA-CO
32
Ectopic Pregnancy | Most recognized risk factor
Hx of PID
33
Ectopic Pregnancy | Rupture timings of different types?
Ampulla: 8-12 weeks Isthmus: 6-8 weeks Interstitial: 16 weeks
34
Ectopic Pregnancy | Best Predictor of resorption
HCG < 1000 at time of diagnosis
35
Ectopic Pregnancy | Greatest risk factor
Documented tubal pathology & Previous ectopic pregnancy
36
Ectopic triad
Amenorrhea Vaginal bleeding Abdominal pain (most common)
37
Signs of Unruptured Ectopic Pregnancy
Cervical motion tenderness | Unilateral adnexal tenderness
38
Signs of Ruptured Ectopic pregnancy
Hypotension, tachycardia | Peritoneal signs
39
HCG level when a gestational sac is expected
1500 | Presumptive evidence of ectopic pregnancy esp if with TV-UTZ w/o evidence of sac
40
Serum level of progesterone for normal pregnancies
>25ng/L | If <5ng/L, consider ectopic pregnancy
41
Gold standard for diagnosis of ectopic pregnancy
laparoscopy
42
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
43
Surgical Management of Ectopic pregnancy
ExLap with salpingiectomy 1) Severely damaged tube 2) Recurrent ectopic preg 3) Uncontrolled hemorrhage 4) Desire for sterility
44
Best indicator for the success of medical management
BHCG levels before treatment, best if <1000. | 14% failure rate at 5000-10000.
45
Late Pregnancy Bleeding
``` Third Trimester Bleeding Postpartum Hemorrhage (PPH) ```
46
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
47
Risk factors for Placenta Previa
Multiparity Increased maternal age Mult. abortions Previous CS
48
Bleeding due to the velamentous insertion of the umbilical cord
Vasa previa | Tx: expectant management up to 37th week, emergency CS
49
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
50
Key pathophysiologic feature of Abruptio Placenta
Hemorrhage into the Decidua basalis
51
Major risk factors for abruptio
Pre-eclampsia Short umbilical cord Trauma Cig. smoking, alcohol, advanced age
52
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
53
Complications of Abruptio
1) Couvelaire uterus - uterine apoplexy 2) Acute renal failure 3) DIC
54
Most common cause of uterine rupture
Previous CS scar | Other causes: Oxytocin stimulation during labor
55
Tx of Uterine rupture
Repair of rupture | Hysterectomy
56
PPH | 4 major causes
Tone: Abnormal uterine contractility Tissue: Retained products of conception Trauma: Genital tract trauma Thrombin: Abnormalities of coagulation
57
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) ```
58
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
59
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) ```
60
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 ```
61
Postpartum Hemorrhage Definitions SVD CS
SVD > 500cc | CS > 1000cc
62
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
63
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
64
Puerperal hematoma Risk factors: Tx:
Nulliparity Episiotomy Forceps Tx: Incision and Drainage
65
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
66
Differentiate PROM, PPROM, Prolonged PROM
PROM: >37weeks AOG, ROM 1 hour before labor PPROM: PROM 18hours before onset of labor
67
Management of PROM, PPROM, PPPROM
PROM: Labor induction, GBS prophylaxis PPROM: Steroids if <34 weeks, expectant management, GBS prophylaxis
68
Indications for Delivery: PPPROM, PPROM
``` Active labor Chorioamnionitis Non-reassuring testing IUFD Significant vaginal bleeding Increased concern for cord prolapse ```
69
Organisms Associated with preterm labor
Ureaplasma urealyticum, Mycoplasma hominis, Gardnerella vaginalis, peptostreptococci, and Bacteroides species
70
Biochemical markers of Preterm labor
``` Fetal fibronectin (FFn): >50ng/mL Salivary estriol: >2.3ng/mL ```
71
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%
72
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)
73
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
74
Dosing of Steroids for Fetal Lung maturity
Betamethasone 2 doses q24 | Dexamethasone 4 doses q12
75
Other benefits of Corticosteroids for premature infants
Decreased RDS | Decreased IVH
76
Fetal lung maturity assessment
Surfactant-albumin ratio > 55 | Lecithin-sphingomyelin ratio > 2
77
Post term Pregnancy | Definition
42 completed weeks or more, or >294 days since 1st day of LNMP.
78
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
79
Breech | Type of breech with highest incidence of cord prolapse
Incomplete / Footling | 20-24% incidence
80
Breech | Most common type of breech, lowest incidence of cord prolapse
Frank breech
81
``` Cord Prolapse risks Cephalic Frank Complete Footling ```
Cephalic 0.4% Frank 0.5% Complete 5% Footling 15%
82
Methods of vaginal delivery
SBD - no traction/support Partial breech extraction - unassisted up to umbilicus Total breech extraction - entire body extracted
83
Maneuvers for breech | Delivery of posterior shoulder
Lovesets
84
Maneuvers for breech | Preferred delivery method for the aftercoming head
Pipers forceps
85
Maneuvers for breech | Index and middle finger placed on fetal maxilla to maintain flexion, then traction with other hand
Mauriceau
86
Maneuvers for breech aka Breech decomposition Frank breech converted to footling
Pinard's
87
Maneuvers for breech Used for persistent fetal back legs grasped and body is swung over abdomen
Prague maneuver

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