OB Stepup Flashcards
how is sgestational age calculated
first day of LMP + 7 days
minus 3 months+1 year
when can teratogens cause abnormal organ function
between 2 and 12 weeks
when is surfactant produced
26 weeks
CV changes in mom during pregnancy
CO increases 40%
systolic murmur from CO
inc O2 demand
dec BP
Resp changes in mom during pregnancy
decreased in RV, FRC, and ERV
O2 consumption increases 20%
tidal volum einc 40%
pCO2 decreases because of increased minute ventilation stimulated by progesterone
Renal changes in mom during pregnancy
increased RBF and GFR
dec DUN and Cr
Inc renal loss HCO3 to compensate for respiratory alkalosis
endocrine changes in mom during pregnancy
nondiabetic hyperinsulinemia with assoc mild glucose intolerance
production human placental lactogen contributes to glucose intolerance
fasting TG increase
cortisol increases
TBG and total T4 increase
TSH decreases slightly during early pregnancy
heme changes during pregnnacy
hypercoagulable state
increased RBC production
Hct dec from inc blood volume
GI changes during pregnancy
increased salivation
decreased gastric motility
ideal weight gain for pregnant women BMI
28-40
ideal weight gain for pregnant women BMI
25-35
ideal weight gain for pregnant women BMI >26
15-25
caffeine increases risk for what during pregnancy
increased risk spontaneous abortion
why limit fish during pregnancy
methylmercury contamination
daily caloric intake during pregnancy
2500 kcal
screening labs at first visit of pregnancy
CBC blood Ab and Rh testing pap smear Gon/chalmydia testing UA RPR or VDRL rubella Ab Hep BsAg HIV screening
when do you do the quad screen
16-18 weeks
when do you do US dating for age and fetal anomalies
18-20 weeks
when is the gestational DM test
24-28 weeks
when do you do GBS sreening
32-37 weeks
Why to do amniocentesis
abnormal quad screen
women >35 years
risk Rh sensitization
0.5% risk spont abortion
when do you perform amniocentesis (date)
16 weeks
measures amniotic AFP and can do karyotype
at what date do you do chorionic villus samlping
transabdominal or transcervical aspiration of tissue 9-12 weeks gestation
detects chromosomal abnormalities
indications for chorionic villus sampling
early detection of chromosomal abnormalities in higher risk patients
when is percutaneous umbilical blood sampling
blood sampling from umbilical vein after 18 weeks gestation to look for chromosomal defects, fetal infection and Rh sensitization
What are leopold maneuvers
external abdominal exam to determine fetal presentation
what do you measure for full integrated test in 1st trimester
PAPP-A and NT
labs in downs for full integrated test
dec PAPP-A and icnreased nucal translucency
labs for downs in quad screen
dec AFP
dec estriol
inc hCG
inc Inhibin A
labs for edwards in quad screen
dec AFP
very dec estriol
very dec hCG
normal inhibin A
labs for patau trisomy 13 in quad screen
normal AFP
normal estriol
normal hCG
normal inhibin A
labs for patau trisomy 13 on full integrated test
very dec PAPP-A and increased nuchal translucency
labs for edwards on full integrated test
very dec PAPP-A and increased nuchal transluceny
high levels maternal AFP between 16-18 weeks assoc with
neural tube defects or multiple gestations
low levels maternal AFP between 16-18 weeks assoc with
trisomy 21 and 18
risk factors gestational DM
>25 years old obesity prior polyhydramnios recurrent abortions prior stillbirth prior macrosomia HTN african or pacific islander corticosteroid use PCOS
what should fasting glucose be in pregnancy
new onset DM in first trimester
nongestational!!!
pregnant patient failing non pharmacologic methods to control gesttational DM
insulin
what is normal 1 hr glucose tolerance test
give 50g glucose 1 hour later should be
3 hr glucose tolerance test
carbo load 3 days
fasting glucose measured
100 g given then measure at 1 2 and 3 hours
abnormal is fasting >95 1 hr >180 2 hr >150 3 hr >140 Need 2 of the above values to be considered gestational DM
when to check gestational DM
24-28 weeks
complications gestational DM
macrosomia polyhydramnios delayed pulmonary maturity uteroplacental insufficiency IUGR delayed neurologica maturity fetal RDS hypoglycemia hypoCa
Dx for DM I
anti insulin and anti islet cell Ab
in mom with DM and is pregnant do what in third trimester
give corticosteroids for fetal lung maturation
fetal cardiac anomalies associated with maternal DM
transposition tetralogy neural tube defects sacral agenesis renal agenesis polyhydramnios macrosomia IUGR intrauterine fetal demise
what is preeclampsia
pregnancy induced HTN with proteinuria and edema after 20 weeks gestation
risk factors preeclampsia
HTN nulliparity prior Hx preeclampsia multiple gestation vascular disease chronici HTN or renal disease DM obesity african american heritage
signs Sx preeclampsia
edema in hands and face rapid weight gain HA epigastric pain visual disturbances hyperreflexia BP >140/90
UA in preeclampsia
2+ proteinuria on dipstick
>300 mg protein/24 hr
CBC preeclampsia
dec platelets
normal or inc Cr
increased aLT AST
dec GFR
cure for preeclampsia
delivery
which BP meds do you not use in preeclampsia
ACEI or ARB
want to maintain what BP in preeclampsia
90
what meds do you use in severe preeclampsia
labetalol
IV MgSO4 for seizure proph
continue postpartum
Rx for preexisting HTN in pregnant women
lavetalol or methyldopa
long acting CCB as sexond agent
Complications preeclampsia
eclampsia, seizure, stroke, IUGR, pulmonary edema, maternal organ dysfunction, oligohydramnios, preterm delivery, hemolysis, elevated liver enzymes, low platelets, abruptio placenta, renal insufficiency, encephalopathy, DIC
what is eclampsia
maternal seizures that can be fatal
Signs Sx eclampsia
HA
scotoma visual disturbances, upper abdominal pain preceding seizures
Tx exlampsia
delivery
MgSO4 and IV diazepam for seizure
O2 and BP control with labetolol and hydralazine
continue MgSO4 for post 48 hours
anticonvulsants with pregnancy
kept on meds but supplemented with folate
what is associated with severe maternal asthma
preeclampsia, spontaneous abortion, intrauterine fetal demise and IUGR
Tx mild persistent asthma in pregnangy
short acting Beta agonist and low dose inhaled corticosteroid
Tx mod persistent asthma in pregnangy
med dos inhaled corticosteroid or low dose + long acting beta
Tx severe persistent asthma
high dose inhaled corticosteroid plus long acting beta
complications maternal asthma
increased risk preeclampsia, spontaneous abortion, Intrauterine fetal death
IUGR
Tx hyperemesis gravidarum
avoidance large meals
adequate hydration
pyridoxine and doxylamine
what causes morning sickness
increase hCG or imbalance P and E
Dx DVT in pregnancy
doppler and US studies
Tx DVT in pregnangy
IV heparin to maintain PTT 2x normal or LMWH to keep anti-factor Xa levels within 0.5-1.2 4 hours post infection
DVT in pregnancy, discharged on
LMWH
try to discontinue 24-36 hrs prior to delivery
why not use warfarin in pregnancy
teratogenic
but can use breast feeding
how long are anticoagulants continued post partum if patient had DVT during pregnancy
6 weeks
and wait at least 6 hours since delivery to prevent severe hemorrhage
Tx UTI in pregnancy
amox
nitrofurantoin
cephalexin x3-7 days
why not use fluoroquinolones in pregancy
teratogenic
fetal effects from maternal marijuana
IUGR and prematurity
fetal risks of maternal cocaine use
abruptio placentae IUGR prematurity facial abnormalities delayed intelectual development fetal demise
fetal risks of ethanol use during pregnancy
fetal alcohol syndrome- mental retardation, IUGR, sensory and motor neuropathy, facial abnormalities
psontaneous abortion
Intrauterine fetal demise
fetal risks of maternal use of opioids
prematurity, IUGR meconium aspiration, neonatal infecitons, narcotic withdrawl
fetal risks of maternal use of stimulants
IUGR congenital heart defects, cleft palate
fetal risks of maternal use of tobaccco
spont abortion prematurity IUGR intrauterine fetal demise impaired intellectual development higher risk neonatal respiratory infections
maternal risk factors for using tobacco during pregnancy
abruptio placentae, placenta previa, PROM
fetal risks of maternal use of hallucinogens
developmental delays
ACEI teratogenic effects
renal abnormalities and decreased skull ossification
Aminoglycoside teratogenicity
CN VIII damage (hearing) skel abnormalities, renal defects
carbamazapine teratogenicity
facial abnrmalities, IUGR, mental retardation, CV abnormalities
neural tube defects
DES teratogenicity
vaginal and cervical cancer later in life
fluoroquinolone teratogenicity
cartilage abnormalities
phenobarbital teratogenicity
neonatal withdrawal
phenytoin teratogenicity
facial abnormalities, IUGR, mental retardation, CV abnormalities
retinoids teratogenicity
CNS abnormalities, CV abnormalities, facial abnormalities, spont abortion
sulfonamides teratogenicity
kernicterus
tetracycline teratogenicity
skeletal abnormalities, limb abnormalities, teeth discoloration
thalidomide teratogenicity
limb abnormalities
valproic acid teratogenicity
neural tube defects
facial abnormalites
CV abnormalities
skeletal issues
warfarin is assoc with what teratogenic effect
dandy walker malformation
TORCH
toxo other: varicella, parvo, GBS, Chlamydia, gonn Rubella, rubeola, RPR Cytomegalovirus Herpes/hepatitisB, HIV
congenital toxo signs
hydrocephalus, intracranial calcifications, chorioretinitis, microcephaly
seizures
spont abortion
Dx toxo in pregnancy
amniotic fluid PCR for toxo and srum Ab sscreening
Tx for toxo infection in mom
pyrimethamine, sulfadiazine, folinic acid
avoid gardening, raw meat, cat litter and unpasteurized milk
congenital rubella
blueberry muffin baby
IUGR, deafness, CV abrnomalities, vision isssues, CNS problems, hepatitis
screeningmaternal rubella
early prenatal IgG screening
if mom contracts rubella during pregnancy
no Tx and no benefit from Ig
fetal effects of rubeola (measles) infection
increased risk prematurity
IUGR
spont abortion
high risk neonatal death if transmission occurs
Dx rubeola or measles in pregnancy how
IgM or IgG Ab in mom after rash develops
Tx if mom has rubeola during pregnancy
Ig to mom
not vaccine because live attenuated
Fetal risks of maternal syphilis infection
neonatal anemia, deafness, HSM, pneumonia, hepatitis, osteodystophy, rash and hand foot desquamation
25% death
Dx maternal syphilis infection
early prenatal RPR or VDRL screen
confirm with FTA-ABS
Tx maternal syphilis infection
penicillin for mom and baby if needed
effcts of CMV infection on fetus
IUGR, chorioretinits, CNS problems
mental retardation, vision issues, deafness, hydrocephalus, seizures, HSM
Dx of CMS infection during pregnancy
mono like illness
IgM screening or PCR of baby in first few weeks
Tx for CMV infection in pregnany
no Tx
gangciclovir after once baby is born
good hygiene reduces transmission
fetal effects of maternal herpes infection
increased risk prematurity
IUGR and spont abortion
high risk death
CNS problems
Tx for herpes maternal infection
delivery by C section to avoid transmission
acyclovir maybe in infants
What happens with HIV during pregnancy
viral transmission, and rapid progression to AIDs
Tx maternal HIv infection
AZT to reduce vertical transmission
continue antiretroviral regimen
no efavirenz, didanosine, stavudine or nevirapine
risks with maternal hep B infection
inc risk prematuiry, IUGR and neonatal death if they get acute disease
how to screen for hep B in pregnancy
prenatal surface Ag screening
Tx maternal hep B infection during pregnancy
vaccination
neonate gets vaccine and Ig shortly after birth
Tx gonorrhea or chlamydia in neonate from mom
erythromycin
can give to mom during pregnancy
fetal risks of maternal varicella zoster infection
prematurity, encephalitis, pneumonia IUGR
CNS problems
limb problems, blindness
high risk neonatal death with transmission
Dx maternal variceela zoster infection
IgG screening with no known Hx of disease prenatally
IgM and IgG in infants can confirm
Tx for varicella zoster infection during pregnancy
varicella Ig to nonimmune mom
and to neonate if active infection
vaccine is contraindicated during pregnancy
fetal risks of maternal GBS infection
respiratory distress, pneumonia, meningitis, sepsis
when to screen for maternal GBS
after 34 weeks gestation
Tx for GBS in mo during pregnancy
IV beta lactams or clinda during labor or in infected neonates
fetal effects of maternal parvo virus
decreased RBC produciton
hemolytic anemia
hydrops fetalis
screening parvo
IgM Av or PCR viral DNA in neonate
Tx maternal parvo B 19 infection
monitor fetal Hb by PUBS and give transfusion if severe anemia
where is most common place ectopic
ampulla of fallopian tube
risk factors for ectopic
PID or STDs gyn surgery prior ectopic multiple partners smoking
sign ectopic
pain, nausea, amenorrhea, scant vaginal bleeding
peritoneal signs and tachy if ruptured
how does bhCG increase in pregnanc
double every 48 hours
bhCG that is not doubling in the right amount of time
suspicious for ectopic
most common cause vaginal bleeding in early pregnancy
ectopic
spont abortion
physiologic bleeding
uterine-cervical pathology
when to do transvaginal US to look for ecotpic
when bhCG>6500 and 1500
Tx unruptured ectopic
MTX to abort pregnancy
Tx ruptured ecoptic
IV hydration and surfical excision with attempts to preserve fallopian tube
complications ectopic
fetal death,
severe maternal hemorrhage
increased risk for future ectopics, infertility, Rh sensitization, maternal death
cause of first trimester spont abortion
chromosomal abnormalities, especially trisomies
causes of second trimester spont abortions
infection, cervical incompetence, uterine abnormalities, hypercoagulable, poor maternal health or drug use
risk factors for spont abortions
increased maternal age multiple prior births prior spont abortion uterine abnormalities smoking alcohol NSAIDs cocaine excessive caffeine use maternal inections low folate autoimmune- antiphospholipid!
signs of threatened abortion
uterine bleedingin initial 20 weeks
closed cervical os, no uterine contents expelled
US show viable fetus
need bed rest
signs of missed abortion
some uterine bleeding can be with pain
closed os
no expelled contents
US shows nonviable intrauterine fetus
Tx of missed abortion
expectant
misoprostol or D&C
give Rhogam
Signs inevitable abortion
uterine bleeding in inital 20 weeks with pain
open cervical os with no contents expelled
US shows viable fetus and cervix is dilated
Tx of inevitable abortion
expectant
misoprostol or D&C
give rhogam
Signs incomplete abortion
uterine bleeding in inital 20 weeks
open os and some uterine contents expelled
Tx incomplete abortion
misoprostol or D&C
give rhogam
what to give for complete abortion
rhogam
when is intrauterine fetal demise
fetal death after 20 weeks and before onset labor
what can cause intraunterine fetal demise
placental or cord abnormalities from maternal CV or heme conditions maternal HTN infection poor maternal health fetal congenital abnormalities
US of intrauterine fetal demise
nonviable intrauterine fetus with no heart activity
Tx of intrauterine fetal demise
oxytocin, misoprostol (PGE1) or PGE2
dialtion and evactuation
complications intrauterine fetal demise
DIC if retained for a while
definition of IUGR
fetal growth that lags behind gestational age
symmetric IUGR
overall decrease in size
likely from congenital infection, chromosomal abnormality or maternal drug use
asymmetric IUGR
majority
decreased abdominal size with preserved head and extremities
happens late in pregnancy
caused from multiple gestation or poor maternal health or placental insufficiency
fundal height in IUGR
when does fundal height equal gestational age
20 weeks and on
Tx IUGR
follow with US
nutritional supp and mom O2 therapy
maybe bedrest
delivery should be induced if fetal growth slows further
give corticosteroids to increase lung maturation
some causes of oligohydramnios
IUGR, fetal stress, fetal renal abnormalities, poor fetal health
second trimester oligohydramnios
renal problems
maternal cause like preeclampsia, renal disease, HTN
or placental thormbosis
third trimester oligohydramnios
assoc with PROM, preeclampsia, abruptio placentae or idiopathic cause
US of oligohydramnios Dx
amniotic fluid index
Tx oligohydramnios
expectant. may need to induce
hydraiton and bed rest
complications oligohydramnios
spon abortion
intrauterine fetal demise
abnomral limb, facies of lungs
abnormal abdominal development all from compression
polyhydramnios Dx criteria
> 25 cm amniotic fluid index
causes of polyhydramnios
insufficient swallowing of fluid(esophageal atresia)
infecreased fetal urination from maternal DM
multiple gestation
fetal anemia, chrom abnormalities
Tx polyhydramnios
32 weeks amnioreduction only
complications polyhydramnios
preterm labor
PROM
fetal malpresentation
maternal respiratory compromise
what is PROM
spontaneous rupture of amniotic sac with spillage of fluid before onset of labor
risk factors for PROM
vaginal or cervical infection, cervical incompetence, poor maternal nurtrion, prior PROM
labs to Dx PROM
microscopic exam of vaginal fluid will show ferning
vaginal fluid will turn nitrazine paper blue
Need to send for culture to Dx possible infection
imaging for PROM
US to assess volume and fetal position
why not do bimanual if patient has PROM
risk of infection
Tx for PROM
Tx for PROM 32-34 weeks
amniotic analysis for lung maturation
if mature induce labor
corticosteroids and antibiotics if not mature yet
Tx PROM >34 weeks
antibiotics and delivery is induced
how to assess fetal lung maturity
Lecithin and sphingomyelin levels L:S should be >2 in presence of phophatidylglycerol which suggests maturation
what is preterm labor
labor before 37 weeks
risk factors preterm labor
multiple gestation, PROM, infection, placenta previa, abruptio placentae, previous preterm labor, polydydramnios, cervical imcompetence, poor nutrition, stressful environment, smoking, substance abuse, lower socioeconomic statu
signs Sx preterm labor
constant low back pain and conractions
what to order in preterm labor
UA vaginal and cervical cultures to check for infection
do US to assess amniotic fluid and fetal well being and confirm gestational age
Tx preterm labor
hospitalization, hydration and acitivy restriction
tocolytics for 48 hours – with MgSO4, terbutaline, indomethacin or nifedipine
glucocorticoids for 48 hours
empiric ampicillin if delivery is immenent of suspect infection
Tx preterm labor >34 weeks
active management if indication for delivery
empiric ampicillin
what cervical length by US has greater risk preterm birth
What is placenta previa
implantation of placenta near cervical os assoc with vaginal bleeding
what is low implantation placenta previa
in lower uterus but does not affect cervical os until dilation
what is partial placental previa
placenta partially covers os
what is complete placental previa
placenta completely covers os
risk factors placenta previa
muliparity, increased maternal age, prior previa, prior cesarean section!!!!
multiple gestation, fibroids, Hx ablation and smoking
painless vaginal bleeding in third trimester
placenta previa
Dx placenta previa
US
Tx placenta previa
bed rest
rhogram for Rh- moms with any bleeding
tocolytics can be used
do C section
most common causes of vaginal bleeding after 20 weeks gestation
placenta previa and placenta abruption
complications plcaenta previa
severe hemorrhage, IUGR, malpresentation, PROM, vasa previa(fetal exsanguination)
maternal death in 1%
painless vaginal bleeding in 3rd trimester
do NOT do what
steril vaginal examination
need to rule out placenta previa
risk factors abruptio placentae
HTN prior abruption trauma tobacco use cocaine PROM mutiple gestation multiparity
signs of abruptio placentae
painful vaginal bleeding in 3rd trimester, back pain, abdominal pain, pelvic tenderness, increased uterine tone, hypotension
US of abruptio placentae
inconsistently shows separation of placenta from uterus
Tx abruptio placentae
bed rest
C section for hemodynamic instability
transfusion usually required
complications abruptio placentae
DIC, severe hemorrhage that increases risk maternal death, fetal demise and increased abruption in future pregnancies
monozygotic twins
division zygote resulting in identical fetuses
may or maynot share same amnion or chorion
dizygotic twins
fertilization of more than one egg by different sperm
fraternal twins
separate amnions
twins create increased risk for what during pregnancy
HTN DM preeclampsia and preterm
fetal malpresenationa, previa, abruptiom PROM, IUGR, birth trauma, CO and RDS
what is twin twin transfusion syndrome
umbilical cords are fused and one twin is inadequately perfused causing more complications
average delivery time for twin
36 weeks
pregnancy visits for twins
biweekly or weekly starting at 24 weeks
when do you start fetal non stress tests for twins
36 weeks
twins and having preterm labor
tocolytics
when can you attempt vaginal delivery of twins
Vertex vertex
or vertex-breech sometimes
normal fetal HR
120-160
position for fetal non stress test
L lateral decubitus
normal reactive NST for fetal wellbeing
2+ 15 bpm accelerations lasting at least 15 seconds each within 20 minutes
what to do if nonreactive NST
biophysical profile
what is a biophysical profile to assess fetal well being
NST repeat with US US measures amniotic fluid index fetal breathing rate fetal mvoement fetal tone
total points for biophysical profile
- 8-10 is normal
what is used to assess uteroplacental dysfunction
contractions tress test
fetal HR monitored with fetal scalp electrode
reassuring signs of fetal HR
beat to beat variability
long term HR variability
occasional HR acclerations
decelerations
fetal head compression, umbilical cord compression of fetal hypoxia
when do you perform fetal scalp blood sampling
consistentlyabnormal fetal heart rate tracing
dec pH and hypoxemia and inc lactate indicate fetal distress
braxton hicks contractions
false contractions
early decelerations
begin and end with uterine contractions
head compression
late decelerations
begin after initiation of uterine contraction and end after contraction finishes
cause of late decelerations
uteroplacental insufficiency, maternal venous compression
maternal hypotension
abruptio placentae
fetal hypoxia
Tx for late decelerations
test fetal blood for hypoxia or acidosis
recurrent late declerations promt delivery
variable decelerations
inconsistent onset duration and degree
cause of variable decelerations
umbilical cord compression
Tx for variable decelerations
change in mother position
Stage 1 labor begins and ends with what
latent is the start of uterine contractions until 6 cm dilated and complete effacement
active phase is 6 cm to 10 cm dilation
deceleration phase is transition into 2nd stage
Stage 2 labor what happens
full dilation until delivery
Stage 3 labor what happens
delivery of neonate until placental delivery
Stage 4 labor is what
initial postpartum hour
progression of cervical dilation in active phase 1 for nulliparous
1.2 cm/hr
progression of cervical dilation in active phase 1 for multiparous
1.5cm/hr
management stage 1 labor
monitor fetal heart rate and uterine contractions
assess progressions of cervical change periodically
how long is stage 1 labor in nulliparous
how long is stage 1 labor in multiparous
management of stage 2 labor
monitor fetal heart rate and movenet through birth canal
how long is stage 2 labor in nulliparous
how long is stage 2 labor in multiparous
management of stage 3 labor
uterine massage and examination of placenta to confirm no intrauterine remnatns
how long is stage 3 labor for nulli and multiparous
0-30 minutes
managemnet stage 4 labor
monitor maternal pulse and BP
look for signs of hemorrhage
how long is stage 4 labor for nulliparous and multiparous
1 hr
what can you induce labor with
oxytocin or misoprostol
indicatoins to induce labor
maternal preeclampsia, DM, stalled stage of labor, chorioamnionitis
fetal: prolonged pregnancy, IUGR, PROM, congenital defects
contraindications to induce labor
prior uterine surgery, fetal lung immaturity, malpresentation, acute fetal distress, active genital herpes, vasa previa
what is bishop score measuring
likelihood of vaginal delivery following induction
face presentation of fetus
full hyperextension of neck
brow presentation of fetus
partial hyperextenion
frank breech
hips flexed and knees extended- 75%
complete breech
hips and knees flexed
footling breech
one or both legs extended
risk factors for malpresentation
prematurity, multiple gestation,polyhydramnios, uterine anomaly placenta previa
complications malpresentation
cord prolapse, head entrapment, fetal hypoxia, abruptio placentae, birth trauma
vertical C section
vertical incision through anterior muscle protion
“classic”
when fetus is in transverese position or adhesions and fibroids prevent acess
do it if hysterectomy after delivery
if cervical cancer
or if postmorten delivery
low transverse C section
transverse incision in lower uterine segment
decreased risk uterine rupture, bleeding, bowel adhesions, and infection
more common
when can you do VBAC, what type of C section did they have
transverse
cannot do with vertical
what is colostrum
early breast milk rich in proteins, fat and minerals
has IgA
components of apgar
color heart rate response to stimulation muscle tone respirations
when does the red lochia discharge after birth stop in mom
by 10th day
when does mensturation return in non nursing moms
6-8 weeks
what causes the most substantial volume of postpartum bleeding
retaiend placental tissue
what blood loss in delivery is abnormal
> 500 mL in 24 hours if vaginal
>1000 in 24 hours if c sextion
major cause of postpartume bleeding
uterine atony
workup for postpartum bleeding
US to look for retained tissue
Tx for postpartum bleeding
uterine massage and oxytocin administration dec hemorrhage surgical repair of lacerations D&C if retained tissue hysterectomy for refractory cases
What is hydatidiform mole
benign neoplasm of trophoblastic cells that become malignant
complete mole
46 XX or 46 XY
derived from father
empty egg with 2 sperm
what is incomplete mole
69 XXY or 69XYY
fertilization of egg by 2 sperm
assoc with abnormal fetus
risk factors for hydatidiform mole
low socioeconomic status, extremes of age, Hx prior molar pregnancy, asian, smoking
signs of molar pregnancy
heavy or irregular painless bleedingi n 1st and 2nd trimester
hyperemesis gravidarum
dizziness
anxiety
large fundal height for gestational age
grape like vesicles in vagina and no heart tones
preeclampsia in first half of pregnancy
suspect molar pregnancy
labs in molar pregnancy
bhCG is very high
US in molar pregnancy
snowstorm pattern without presence of gestational sac
Tx molar pregnancy
D&C to remove neoplasm
follow bchCG for 1 year
avoid pregnancy 6 mo-1 year
complications molar pregnancy
malignant gestational trophoblastic neoplasm
choriocarcinoma
choriocarcinoma
malignant trophoblastic neoplasm that arises from hydatidiform moles or following abortion, ectopic or normal pregnancy
signs choriocarcinoma
vaginal bleeding, possible hemoptysis, dyspnea, HA, dizziness or rectal bleeding, enlarged uterus with bleeding from cervical os
labs in choriocarcinoma
increase bhCG
US in choriocarcinoma
uterine mass with mix hemorrhagic and necrotic areas, possible parametrial invasion
CT detects mets
treatment choriocarcinoma
hysterectomy if limited to uterus chemo if want to maintain fetility do chemo alone follow bhCG avoid pregnancy 1 year after therapy
complications choriocarcinoma
mets to lungs, brain, liver, kidneys and GI tract
good prognosis unless brain or liver mets
