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step 3 Ob/Gyn > ✅ObGyn Labor & Delivery > Flashcards

✅ObGyn Labor & Delivery Flashcards

1
Q

What are the 4 main inquries pts should be asked when coming in for L&D checks?

A
  1. Vaginal bleeding?
  2. Leakage of Fluid?
  3. Contractions?
  4. Fetal mvmnt?
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2
Q

Which 4 drugs can you give to treat HTN in pregnant patients?

A

Mothers Loathe Nefarious HTN

Methyldopa / Labetalol > Nifedipine / Hydralazine

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3
Q

CP of Edward’s Trisomy 18 - 6

A
  1. Prominent Occiput
  2. Micrognathia (small jaw & mouth)
  3. Overlapping Fingers
  4. Absent Palmar creases
  5. VSD
  6. Rocker-bottom feet

These pts die within 1st month of life

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5
Q

Explain what Pseudocyesis is

A

Somatization of stress –> activates [hypothalamic-pituitary-ovarian] axis –> early pregnancy sx without there actually being a baby in utero = nonpsychotic woman who mentally AND PHYSICALLY presents like she’s pregnant (may even misinterpret a pregnancy test!)

US and clinic pregnany test will be negative

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6
Q

Risk factors for Pseudocyesis - 2

A
  1. infertility hx
  2. prior abortion
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7
Q

Neonatal Abstinence Syndrome

Classic Signs-4 ; What drug usually causes this?

A

STTD

  1. Sneezes a lot
  2. Tremors w/sweating
  3. Tachypnea w/HIGH PITCHED CRY
  4. Diarrhea

From intrauterine exposure to Opiates (i.e. Heroin/Methadone)!

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8
Q

s/s of intrauterine cocaine exposure - 3

A
  1. Excessive sucking
  2. Jitteriness
  3. Hyperactive Moro reflex
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9
Q

Postpartum depression affects women during what time periods? What 2 methods are used to screen for this?

A

within 1st year > first 3 mo ;

  1. [PHQ2 –(if both +)–> PHQ9]
  2. Edinburgh Postnatal Depression Scale

Screen prenatal, postnatal and well child

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10
Q

Starting with [Day 0 Fertilization], describe the process of Implantation (9 steps)

A
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11
Q

Give brief descriptions that differentiate Postpartum

Blues vs Depression vs Psychosis

A
  • Blues = onsets after birth, peaking at postpartum day 5 and subsiding PPD14, worst w/lactation
  • Depression = onset right after birth - 12 months later. Traditional s/s. Previous Depression hx is RF
  • Psychosis = RARE but onsets IMMEDIATELY after birth
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12
Q

What are 5 ways to determine if a pt truly has Leakage of Amniotic Fluid?

A
  1. Amnisure immunoassay (detects placental ⍺-microglublin1)
  2. POOL test (there’s pool of fluid in vaginal vault)
  3. NITRAZINE test (fluid turns blue when placed on nitrazine paper since amniotic fluid is alkaline)
  4. FERN test (fern-like estrogen crystals under microscopy)
  5. US to determine fluid quantity
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13
Q

Rupture of Membranes ≥ ___ hours is a risk factor for intraamniotic infection & neonatal sepsis. ; When is Rupture of Membranes too early?

occurs when chorioamniotic membrane ruptures before labor

A

18 ; 1 hour before labor

  • Do not confuse this with PPROM (Preterm Premature Rupture Of Membrane)*
  • Chorioamnionitis Tx = Abx –> Delivery*
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14
Q

What constitutes an infant as “Full Term”?

A

37 - 42WG

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15
Q

1st trimester is ___ weeks gestation

What are the 3 biggest questions to ask during history taking for these patients? Why?

A

< 14 weeks

  1. NV? - asking because this is treatable
  2. Vaginal Bleeding?
  3. Cramping?
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16
Q

What are the 2 clinical features for diagnosing ACTIVE labor?

A

Labor = LAPD

  1. Strong Contractions every 3-5 min
  2. Cervix Dilation > 6 cm, growing at 1-2 cm/hr and effaced

Fetal Heart Tracing is IRRELEVANT to diagnosing active labor

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17
Q

What is the normal Fetal Heart Rate and variability on a NST?

A

110 - 160/min (w/variability of 6-25)

Normal Fetus’ should have a reactive NST

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19
Q

For Antepartum patients, their NST (Non Stress Test) should be reactive

What is the Fetal Heart Tracing criteria for this?-4 Does this happen in pts in labor?

A

reactive = appropriate [fetal cerebral oxygenation]

  1. within a 20 min period there are
  2. at least two HR acclerations that are
  3. 15 bpm over baseline
  4. 1.5 small boxes long (15 sec)

THIS IS NOT REQUIRED FOR PTS IN LABOR

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20
Q

Criteria for PreEclampsia is Gestational HTN + [Proteinuria or End Organ Damage]

How do you clinically diagnose Gestational HTN? - 6

A
  1. NO previous HTN
  2. ≥ 20 WG (2nd trimester)
  3. Systolic > 140
  4. Diastolic > 90
  5. At least 2 readings taken > 6 hrs apart
  6. BP taken in seated or semi-reclined position

FYI: PreEclampsia can still occur superimposed on Chronic HTN

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21
Q

Criteria for PreEclampsia is Gestational HTN + [Proteinuria or End Organ Damage]

How do you clinically diagnose Proteinuria for pregnant women - 4

A
  1. ≥300 mg protein on 24 hr urine

OR

  1. ≥ 30 mg/dL on dipstick
    OR
  2. At least 1+ on dipstick

OR

  1. Protein:Creatinine ratio > 0.3
    * Must occur at least 2 times at least 6 hours apart*
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22
Q

Criteria for PreEclampsia is Gestational HTN + Proteinuria

Which demographic are at greater risk for this?

A

Af American Women

greater risk of having PreEclampsia, it being severe and suffering placental abruptio and Eclampsia

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23
Q

What are the 4 major causes of Postpartum Hemorrhage? - 4

A

The 4 T’s!

Tone (Uterine aTony)

Trauma (Perineal vs Cervix lacerations vs Uterine inversion/prolapse)

Tissue (retinaed/invasive placental tissue)

Thrombin (rare bleeding DO)

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24
Q

When is [RhoGam AntiRhD] administered to Rh NEGATIVE pregnant women? - 7

A

DO THIS FOR ALL Rh NEGATIVE mothers

  1. 50mcg 1st trimester if uterine bleeding and/or spontaneous abortion occurs
  2. 300mcg at 28 WG
  3. 300 mcg within 3 days after delivery
  4. give with any episodes of vaginal bleeding (if indicated)
  5. give with External Cephalic Version
  6. give with Hydatidiform Mole dx
  7. give if Ectopic Pregnancy occurs
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26
Q

When are pts screened for Group B Strep via vaginal and rectal swab?

A

35-37 WG

results are valid for 5 weeks

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27
Q

Why is prematurity a risk factor for breech presentation? ; What’s a way to convert a breech into cephalic?

A

25% of fetuses ≤28WG are naturally breeched, but will flip over into cephalic position by 37 WG; External Cephalic Version (can only be done ≥37 WG)

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28
Q

What is an Internal Podalic Version?

A

Performed in twin deliveries to convert 2nd twin from transverse presentation –> breech presentation for subsequent delivery

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29
Q

External Cephalic Version can only be done at __ weeks gestation!!

What are the contraindications to External Cephalic Version? - 7

A

≥ 37 WG

  1. There are vaginal delivery ctd and C/S (CSection) is indicated instead
  2. Placental demise (previa or abruptio)
  3. Oligohydraminos
  4. Rupture Of Membrane
  5. Hyperextended fetal head
  6. Fetal/Uterine anomaly
  7. Multiple Gestation
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31
Q

What is Intrauterine Fetal Demise (IUFD)? ; Dx?-3

A

fetal death ≥ 20WG BUT before onset of labor;

  1. No fetal cardiac activity on US
  2. No fetal heart tones on Doppler
  3. No/minimal subjective fetal mvmnt

This commonly occurs in uncomplicated pregnancies

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32
Q

What is the management for Intrauterine Fetal Demise? - 3;

What complication can arise from IUFD?

Main causes: Anencephaly, Potter sequence, etc.

A
  1. If ≥ 28WG = Spontaneous Vaginal Delivery regardless of fetal lie
  2. If 24-27 WG = Induced Vaginal Delivery regardless of fetal lie when Mom’s ready but before 28 WG
  3. If 20-23WG = Dilate and Curettage

  • keeping fetus in there too long (> 28 WG) can –> coagulopathy*
  • * fetal death < 20WG = spontaneous abortion **
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33
Q

What are the risk factors for Intrauterine Fetal Demise? - 3

A
  1. SMOKING intrapartum! (can also –> asymmetric IUGR)
  2. IUGR
  3. abnormal fetal karyotype
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34
Q

AFP is a protein made by the __-3. It is obtained in pregnant women at ___ weeks gestation

What does an elevated AFP indicate in a pregnant woman?-3

A

[Fetal Yolk Sac]/Liver/GI tract ; 15-20WG via Quad BUAD screen

  1. Fetal Open Neutral Tube Defects (open spina bifida, anencephaly)
  2. Fetal Abd Wall defect (Gastroschisis, Omphalocele)
  3. Multiple gestation simulatenously (twins)

If ⬆︎AFP –> GET ANATOMY US!

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35
Q

Which vaccines should be given to pregnant women during their pregnancy? - 5

A
  1. Tdap (27-36WG)
  2. Flu inactivated
  3. RhoD (28WG)
  4. Hep A killed - if HepC positive
  5. Hep B killed - if HepC positive
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36
Q

Which vaccines can be given to pregnant women AFTER delivery (since they’re contraindicated for intrapartum)? - 3

A
  1. HPV
  2. MMR
  3. Varicella
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37
Q

When is a hgb electrophoresis screen indicated in a pregnant woman?

A

Pt has anemia during pregnancy ([hgb < 11] + [MCV < 80])

Non-Pregnant female normal hgb = 12-16

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38
Q

What are the risk factors for Placenta Accreta - 4 ; dx?

A
  1. prior c/s (csection)
  2. prior D&C (dilation and curettage)
  3. Myomectomy
  4. Maternal age > 35

Dx = Intraplacental villous lakes on antenatal US

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39
Q

CP for Placental Abruptio - 3

Risk factors = HTN, cocaine and smoking

A
  1. PAINNNFFULLL antepartum vaginal bleeding (which can –> hypovolemic shock, [DIC-from decidual bleeding releasing tissue factor 7] and fetal demise)
  2. Distended firm uterus
  3. abd AND/OR back pain

etx: HTN of maternal decidual vessels –> rupture –> premature detachment of placenta from endometrium

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40
Q

What is Vasa Previa MOD?

A

fetal vessels traverse the amniotic membranes over the internal cervical os –> antepartum bleeding and FHR abnormalitites after ROM (rupture of membrane)

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41
Q

CP for Uterine Inversion? - 3

A
  1. Smooth mass protruding from cervix or vagina
  2. postpartum hemorrrhage
  3. severe abd pain

results from inversion/collapse and prolapse of uterine fundus thru cervix or vagina

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42
Q

What are the 4 major causes of Postpartum Hemorrhage? - 4

A

The 4 T’s!

Tone (Uterine aTony)

Trauma (Perineal vs Cervix lacerations vs Uterine inversion/prolapse)

Tissue (retinaed/invasive placental tissue)

Thrombin (rare bleeding DO)

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44
Q

Major causes of Antepartum Hemorrhage - 4

Antepartum = right before childbirth

A
  1. Placental abruptio (PAINFUL Anterpartum hemorrhaging)
  2. Placenta accreta (occurs during placental removal)
  3. Placental previa
  4. Vasa Previa
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45
Q

What are the risk factors for Uterine Inversion? - 4

A
  1. Nulliparity
  2. LGA
  3. Placenta Accreta (RF: prior c/s, myomectomy, D&C)
  4. Precipitous (rapid) Labor & Delivery

results from inversion/collapse and prolapse of uterine fundus thru cervix or vagina when too much traction is applied to cord before placental separation

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46
Q

A pt with precipitous vaginal delivery has just had a uterine inversion with prolapse and postpartum hemorrhage

After giving fluids for loss of blood, what’s the ultimate tx for this? - 3

A

1st: Replace the Uterus first
2nd: AND THEN remove placenta if still attached
3rd: Give Uterotonics (oxytocin/misoprstol) to ⬇︎ postpartum hemorrhage

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47
Q

Differentiate the following spontaneous abortions:

Inevitable abortion

Threatened abortion

Missed abortion

Complete abortion

spontaneous abortion = occurs < 20 WG

A
  1. INEVITABLE = vaginal bleeding < 20 WG with cervical os dilated –>abortion will inevitably happen soon
  2. THREATENED = early vaginal bleeding < 20 WG with cervical os closed is clearly a threat to a STILL LIVING FETUS
  3. MISSED = Fetal death with cervical os closed…which is why we Missed it - (pt will have pregnancy sx that just suddenly disappear out of nowhere)
  4. COMPLETE = ALL PRODUCTS OF CONCEPTION COMPLETELY EXPEL AND THEN CERVIX CLOSES BACK UP

spontaneous = occurs < 20 WG

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48
Q

Spontaneous abortions (unprovoked pregnancy loss < 20 WG) are usually a result of ____

what are the other 2 less common causes?

A

chromosomal abnormalities

  1. tertogen exposure
  2. mullerian anomalies (uterine septum)
    * In comparison to IUFD, which etx is mostly unknown!*
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49
Q

What are the options for Mngmt of Spontaneous Abortion - 4

A
  1. Expectant: Watchful Waiting for products of conception to expel naturally in 2-6 weeks
  2. Surgical: [Dilitation & Curettage (D&C) (cant be done during infection)] or [Manual Vacuum Aspiration]
  3. Medical: 800mcg Vaginal Misoprostol - takes up to 2 weeks for expel

ALL REQUIRE 1 WEEK FOLLOW UP

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50
Q

Major causes of 1st trimester bleeding - 3

A
  1. Spontaneous Abortion (inevitable vs threatened)
  2. Acute cervicitis (cervix will have discharge)
  3. Molar Pregnancy
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51
Q

What is Cervical insufficiency

A

2nd trimester PAINLESS Cervical Dilation that –> Spontaneous abortion (< 20WG) or IUFD ( ≥ 20WG)

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52
Q

CP for septic abortion - 3

A
  1. Fever
  2. malodorous purulent vaginal discharge
  3. Large, Boggy tender uterus –> lower abd pain

usually comes from unsterile/incomplete elective abortion

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53
Q

What would ultrasound reveal for septic abortion

A

irregularly thickened endometrial stripe with active blood flow

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54
Q

Septic Abortion can –> Peritonitis, Sepsis and Death

How do you manage it? - 3

A
  1. broad abx x 2 days
  2. Dilation & Curettage
  3. IVF
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55
Q

In the context of Ob/Gyn, what is Methotrexate typically used for? - 2

A
  1. Ectopic pregnancy
  2. Gestational Trophoblastic Neoplasia
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56
Q

A pregnant pt who looks like they’re in active labor stage 1B but has a baby tht regressed from 0 station to -3 Station should concern you for ____

A

Uterine rupture!

  • “Full thickness disruption of the uterine wall”*
  • bigest RF = pre-existing uterine scars (c/s, myomectomy)*
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57
Q

What is a Nuchal Cord

A

when loop of umbilical cord wraps around fetus’ neck –> recurrent variable decelerations but is not clinically significant

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58
Q

What are the effects of Amphetamine use during pregnancy? - 6

A
  1. IUGR
  2. Intrauterine fetal demise
  3. preeclampsia
  4. Placenta abruptio
  5. Preterm delivery
  6. Maternal death!
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59
Q

Risk factors for Cervical Insufficiency - 2

A
  1. DES intrauterine exposure–> congenital abnormalities
  2. cervical surgery
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60
Q

Gastroschisis is associated with ___ trimester use of which drug?

A

1st trimester use of NSAIDs

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61
Q

What are the risk factors for Polyhydraminos? - 2

Polyhydraminos ( ≥24 cm AFI) is a risk factor for Placenta Abruptio

A
  1. Maternal DM - poorly controlled
  2. swallowing fetal anomalieis (esophageal atresia)
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62
Q

How many pounds are pts underweight (BMI < 18.5) advised to gain?

A

~35 lbs

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63
Q

Hyperemesis Gravidarum is a normal part of pregnancy

When is it expected to resolve?

A

by 20WG

BE SURE TO WATCH OUT FOR THIAMINE DEFICIENCY SX IN THESE PTS!

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64
Q

name the possible sequelae of Gestational HTN? - 7

Remember: can ONLY be diagnosed in ≥ 20 WG

A
  1. IUGR asymmetrically
  2. Preterm delivery
  3. Oligohydraminos (AFI ≤5 cm)
  4. Perinatal mortality
  5. Placental Abruptio
  6. Preeclampsia superimposed
  7. c/s
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65
Q

Risk factors for Placenta Previa - 3

PAINLESS Antepartum Vaginal Bleeding with unaffected FHT since bleeding is all maternal

A
  1. c/s
  2. Multiparity
  3. Smoking

PAINLESS Antepartum Vaginal Bleeding with ONLY maternal vitals changing

“previews are painless :-)”

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66
Q

When is Placenta Previa typically diagnosed? ; What are the things that are contraindicated because of Placenta Previa? - 4

A

20 WG via routine US;

  1. Coitus
  2. Digital examination
  3. Vaginal delivery
  4. External cephalic version

sometimes previa (and other malpresentations) spontaneously resolves by 3rd trimester due to growth of lower uterine segment and/or placental growth toward fundus. but other wise schedule c/s for 37 WG

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67
Q

Placenta Previa and Vasa Previa both present as PAINLESS Antepartum Vaginal bleeding

What is the differentiating factor? - 2

A
  1. Since Vasa Previa involves destruction of fetal blood vessels it –> deterioration of FHT (bradycardia, decelerations), while Placenta Previa is all maternal bleeding only so FHT is NOT affected.
  2. Vasa Previa occurs only after amniotomy is done
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68
Q

What is a Cerclage procedure?

A

Using a suture or synthetic tape to reinforce the cervix in 2nd trimester pts who have cervical length ≤ 2cm per transVaginal US (or 2.5 if preterm hx present) or risk for PPROM

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69
Q

What does the Biophysical Profile (BPP) consist of? - 2 ; What is the breakdown of the results?

A

NonStress Test

+

[US assessment of Amniotic Fluid/Fetal mvmnt/Fetal tone/Fetal breathing - each given 2 points if nml and 0 if not]

Normal= 8,10 (repeat BPP in 1 wk) / Equivocal=6 (repeat BPP in 24 hrs) / Abnml=0,2,4

this (and alternative Contraction Stress Test) are performed in high risk fetal demise pregnancies to assess for fetal hypoxia

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70
Q

What is Doppler US of the umbilical artery used for?

A

evaluates for fetoplacental vascular insufficiency in IUGR pts (< 10th%tile)

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71
Q

What is the dx for Hydatidiform mole gestation? - 2

A
  1. “Snowstorm with grapes” on ultrasound
  2. HHIIGH LEVELS OF bHCG (> 100,000)

Most of the time this is caused by sperm implanting an EMPTY ovum

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72
Q

Asymmetric IUGR is typically caused by ____-3 while Symmetric IUGR is caused by ___-2

Symmetric = Head AND Abd are growth restricted while in Asymmetric it’s mostly just Abd

A

Maternal HTN, Maternal DM, Smoking (these cause IUGR in the 2nd & 3rd trimester);

  1. Congenital chromosome abnormality
  2. Congenital infxns of 1st trimester (toxo, CMV) = RARE
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73
Q

What is “Precipitous” labor? ; What’s the greatest risk factor for Precipitous labor?

A

Fast delivery that occurs within 3 hours of contraction onset ; Multipartiy

Precipitous labor is NOT affected by Oxytocin induction and is usually spontaneous. It may cause Uterine prolapse!

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74
Q

What effects does Tachysystole have on the fetus - 4

Tachysystole: ≥6 ctx in 10 min period

A
  1. Usually none
  2. ⬆︎ risk for c/s
  3. ⬆︎risk for NICU
  4. ⬇︎umbilical cord pH due to hypoxemia
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75
Q

What are the effects of Oxytocin toxicity? - 3

A
  1. hypOtension (⬇︎ BP)
  2. hypOnatremia (oxytocin cross reacts with POST pit ADH receptors)
  3. Tachysystole ( ≥6 ctx in 10 min)

tx: 3% Hypertonic saline

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76
Q

What is the Kleihauer Betke test

A

Determines the dose of [Rhogam Anti-D] needed after delivering an Rh+ fetus to an Rh- mother. Can confirm or exclude fetomaternal hemorrhage

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77
Q

Mg Sulfate is 1st line for Eclampsia px

What are the alternatives for Eclampsia px? - 2

A
  1. Diazepam
  2. Phenytoin
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78
Q

Normal Fetal Heart Rate is 110-160 bpm

What could Fetal Tachycardia indicate? - 6

A
  1. Infxn chorioamnionitis (will include maternal fever)
  2. Hypoxia
  3. Anemia
  4. Maternal Hyperthyroidism
  5. Placenta Abruptio
  6. Meds (terbutaline)
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79
Q

Fetal Heart Tracing like this indicates what dx?

A

Fetal Anemia

Sinusoidal Fetal Heart Tracing

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80
Q

What is the FIRST thing you should look at when seeing a pregnant patient? Why is this?

A

Blood Pressure! ; RULE OUT PREECLAMPSIA

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81
Q

Criteria for PreEclampsia is Gestational HTN + [Proteinuria or End Organ Damage]

How do you clinically diagnose SEVERE PreEclampsia? - 9

A

PreEclampsia –> SEVERE PreEclampsia –> HELLP and at anytime, Eclampsia is possible

ANY ONE OF THE FOLLOWING:

  1. Systolic > 160
  2. Diastolic > 110
  3. refractory HA
  4. scotoma vision changes
  5. Pulmonary Edema (from ⬇︎albumin)
  6. RUQ OR Epigastric pain
  7. Doubling of LFTs
  8. Platelets < 100K
  9. Cr > 1.1 or doubled from baseline

although not in criteria, can also include Hyperreflexia

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82
Q

Criteria for PreEclampsia is Gestational HTN + [Proteinuria or End Organ Damage]

How does the Liver play a role in SEVERE PreEclampsia?

A

PreEclampsia –> SEVERE PreEclampsia –> HELLP and at anytime, Eclampsia is possible

Centrilobular necrosis, hematoma formation and portal capillary thrombi all –> Distension of the [Glisson’s Hepatic Capsule] –> RUQ OR Epigastric abd pain = SEVERE PreEclampsia

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83
Q

What are the major s/s of Magnesium Toxicity - 2

Risk Factor = Renal Insufficiency

A
  1. Neuro depression (Somnolence, ⬇︎ Deep tendon reflexes, Visual disturbances, Paralysis)
  2. Respiratory depression

  • Risk Factor = Renal Insufficiency since it’s renal excreted!!*
  • Tx for Mg Toxicity = Ca+Gluconate*
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84
Q

A Nonreactive NonStress test is one without _____. What does a nonreative NonStress test indicate? - 2

A

Accelerations ;

  1. poor [fetal cerebral oxygenation] OR
  2. fetal sleep (20 min duration) - be sure to extend NST to at least 40 min to catch this!

Nonreactive NonStress test should be f/b BioPhysical Profiles to assess for necessary intervention

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85
Q

A pregnant pt has Graves’ disease

What medication is recommended to treat this in the 1st trimester? What about the 2nd and 3rd trimester?

A

PTU ; Methimazole

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86
Q

[T or F] You should be alarmed if a fetus of 14 Weeks Gestation has no accelerations (nonreactive stress test) on Fetal Heart Tracing

Why or Why not?

A

FALSE!

Fetal heart accelerations are a sign of good [fetal cerebral perfusion] and therefore neuro development, and neuro development doesn’t fully develop until 28 WG

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87
Q

What is Pubic Symphsis Diastasis? ; What is the clinical presentation of this after a traumatic delivery?

A

Physiological widening of pelvis by progesterone and relaxin to facilitate vaginal delivery ; Postpartum suprapubic TTP pain that radiates to the Back and/or Hips

worst with weight bearing, walking or position change and resolves by 4 weeks PostPartum

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88
Q

After vaginal delivery, pt is now numb over her Anterior and Medial thigh

What happened?

A

Prolonged Hyperflexion of thigh for vaginal delivery (McRoberts maneuver) can –> Femoral n compression –>

  1. Anterior & Medial thigh numbness
  2. ⬇︎thigh flexion
  3. ⬇︎patellar reflexes
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89
Q

In the context of labor and delivery, how do retroperitoneal hematomas form? ; What is the CP?-3

A

damage to internal iLiac artery during delivery ;

  1. Palpable mass
  2. Hemodynamic instability
  3. Fever
90
Q

Sciatica etx ; Clinical Presentation - 3

A

“Having Sciatica makes you break LAWS”

  • [Lower Back pain w/radiation down POST thigh –> lateral foot]
  • Ankle jerk reflex ABSENT
  • Weak Hip Extension
  • [S1 n PosteroLateral compression at L4-5 or L5-S1]
91
Q

Gestational sacs normally implant in the _____

Describe a Cornual Interstitial ectopic pregnancy

A

upper uterine fundus ;

implantation in outer “cornual” areas of uterus

dx = transVaginal US // tx = MTX or surgery if severe

92
Q

Name the major risk factors for Ectopic Pregnacy - 6

A
  1. previous ectopic
  2. previous Pelvic
  3. previous Tubal surgery
  4. PID
  5. Bicornuate heart shaped uterus (causes cornual interstitial ectopic pregnancy)
  6. In Vitro Fertilization (causes cornual intersitital ectopic pregnancy)

tx = MTX or surgery if severe

93
Q

Hyperemesis Gravidarum is a normal part of pregnancy that resolves by 20 WG

What are the risk factors for getting this? - 3

A
  1. Multiple Gestation
  2. GERD hx
  3. Hydatidiform Mole (note: elevated βHCG can stimulate thyroid and –> thyrotoxicosis of hyperemesis!)

HG is usually unresponsive to PO antiemetics, and can cause Thiamine Deficiency

94
Q

What are the potential CP for Hydatidiform Mole? - 5

A
  1. HEAVY vaginal bleeding
  2. Hyperemesis Gravidarum
  3. Severe Preeclampsia
  4. Hyperthyroidism
  5. Uterus larger than expected gestational age but with regular countour

“Snowstorm with grapes” and/or [Theca lutein ovarian multiseptated cyst from excess bHCG] on ultrasound

HHIIGH LEVELS OF bHCG (> 100,000)

Most of the time this is caused by sperm implanting an EMPTY ovum

95
Q

Preeclampsia is typically diagnosed ____ weeks gestation. What is the exception to the rule?

A

≥ 20WG! ; Preeclampsia is a complication of Hydatidiform mole which may occur < 20WG

96
Q

What are the primary components for the Mechanisms of Disease in Preeclampsia? - 3

A

Ab complex mediated endovascular damage –>

  1. Hemolytic Anemia
  2. Platelet aggregation from ⬆︎Thromboxane
  3. Vascular constriction pervasively from ⬆︎Thromboxane
97
Q

PPROM = Preterm Premature Rupture Of Membranes (which occurs before 37 WG)

How do you manage PPROM when it occurs ≥ 34WG?

A

Complications = Chorioamnionitis/Endometritis/Cord Prolapse/Placenta Abruptio

98
Q

PPROM = Preterm Premature Rupture Of Membranes before 37 WG

How do you manage PPROM when it occurs < 34WG?

A

if baby not compromised, fetal surveillance until 34 WG and then deliver!

Complications = Chorioamnionitis/Endometritis/Cord Prolapse/Placenta Abruptio

99
Q

PPROM = Preterm Premature Rupture Of Membranes before 37 WG

What are px meds for PPROM? - 2

A
  1. Progesterone (vaginal or IM after 1st trimester)
  2. Cerclage

Complications = Chorioamnionitis/Endometritis/Cord Prolapse/Placenta Abruptio

100
Q

The First Trimester Combined Test analyzes risk for ____ and ___ by measuring what 3 things?

If abnormal, how should this test be followed up? - 2

A

analyzes risk for Trisomy 21 or [Edward’s Trisomy 18] by measuring BUS

  1. βHCG
  2. US analyzing fetal nuchal translucency
  3. Serum plasma maternal protein A

if abnormal, f/u with

1st: [cell free fetal DNA test (cffDNA)] at ≥ 10WG (this should come before First Trimester Combined Test if pt is high-risk for aneuploidy) then if cffDNA still abnml…
2nd: fetal karyotyping [via amniocentesis if ≥ 14WG] or [Chorionic Villus Sampling if ≤ 13WG]

101
Q

What is the purpose of Chorionic Villus Sampling? ; What is the differnece between this and amniocentesis?

A

determines fetal karyotyping via placental biopsy

both CVS and amniocentesis can be used for fetal karyotyping but only amniocentesis can be used in > 13 WG pts

102
Q

Hyperandrogenism (Hirsutism/Acne) during pregnancy is a benign condition that is caused by _____-2 ; Dx? ; Tx?

A

[luteoma ovarian mass] or [theca luteal ovarian cyst(comes from ⬆︎⬆︎⬆︎βHCG Hydatidiform mole)];

Dx = US ;

Tx = Watchful Waiting since it typically resolves after delivery (but watch for mass effect on the kidneys and inform pt that this ⬆︎virilizaiton risk)

103
Q

Krukenberg tumors present like Luteomas, in that they both cause Female Hirsutism

Where do Krukenberg tumors come from?

A

they are Metastasis from GI CA

104
Q

What is the classic presentation for Uterine rupture? ; What are the risk factors? - 2

A

recession of fetal station after sudden abd pain

any prior uterine scars

  1. prior c/s
  2. prior myomectomy (usually for fibroids)
105
Q

Prolonged Rupture of Membranes ≥ ___ hours is a risk factor IntraAmniotic Infection & neonatal sepsis

What is the dx criteria for IAI (IntraAmniotic Infection)? - 2

A

18

Maternal Fever

+

≥ 1 of:

  1. Uterine tenderness
  2. Tachycardia (maternal or fetal)
  3. malodorous amniotic fluid
  4. purulent vaginal discharge
    * Chorioamnionitis Tx = Abx –> Delivery*
106
Q

Why is it rare for Women to get PID after the ___ trimester

A

1st; cervical mucus and decidua seals off the uterus from pathogens during pregnancy

107
Q

Physically describe Uterine Atony - 3

A
  1. soft (it’s lost its tone)
  2. boggy
  3. enlarged above the umbilicus

this also could indicate retained blood clots or septic abortion

108
Q

Methylergonovine MOA ; Indication?

A

UteroTonic –>

  1. uterine contraction
  2. vasoconstriction (ctd in HTN pts)
  3. smooth m constriction

Indication = When Uterine massage AND oxytocin have failed to stop postpartum hemorrhage 2/2 uterine atony

109
Q

Although most commonly associated with Alcoholism, why are pregnant pts also at risk for developing Wernicke Encephalopathy from Thiamine deficiency?

A

Hyperemesis Gravidarum = severe NV that –> dehydration, wt loss from hypoglycemia and thiamine deficiency/Wernicke Encephalopathy which can –> Spontaneous Abortion!

Tx = Glucose WITH Thiamine B1 supplement

110
Q

CP for Acute Fatty Liver of Pregnancy - 3 ; When does this occur?

A

3rd trimester

  1. NV
  2. hypOglycemia
  3. ⬆︎LFTs

linked to [fetal long chaing dehydrogenase fatty acid dysfunction] . Can look like Hyperemesis Gravidarum but occurs 3rd and not 1st!

111
Q

Full term infant = 37- 42WG

How do you manage Preterm Labor 34 to 36+6 WG - 2

A

Pregnant Bitches

112
Q

Full term infant = 37 -42WG

How do you manage Preterm Labor 32 to 33+6 WG - 3

A

Pregnant Bitches Take

113
Q

Full term infant = 37 - 42WG

How do you manage Preterm Labor < 32WG - 4

A

Pregnant Bitches Take Money

114
Q

Name the main Tocolytics - 5

A
  1. Mg (⬇︎ Ca+ needed for uterine ctx)
  2. Indomethacin (⬇︎Prostaglandin as a COX inhbiitor)
  3. Nifedipine (Ca+ Channel Blocker)
  4. Terbutaline (Relaxes Uterus as B2 agonist)
  5. Atosiban (Uterus Oxytocin R Blocker)
115
Q

What factors indicate ⬆︎ risk for possible Preterm labor? - 4

Full Term delivery = 37 - 42WG

A

1st best indicator: PRIOR PRETERM DELIVERY = STRONGEST INDICATOR

2nd best: Shortened cervix ≤ 2cm per transVaginal US (or 2.5 if preterm hx present) - hx of cold knife conization?

3rd best: + Fetal Fibronectin BUT ONLY BETWEEN 20-37WG

4th best: Circumstantial (Smoking, multiple gestation, IVF, obesity)

116
Q

What are the absolute contraindications to breastfeeding? - 7

A
  1. Maternal HIV
  2. Active HSV breast lesions
  3. Active untreated TB
  4. Active Varicella
  5. Active Substance use
  6. On Chemoradiation
  7. Infants with galactosemia

Hep B pts can breastfeed as long as baby receives HepB Immunoglobulin and vaccination

117
Q

What is lochia

A

postpartum uterine/vaginal discharge that’s normal

118
Q

Because of ____ and ____, immediate postpartum urinary retention is expected. When does this become pathologic (bladder atony)?

A

Regional anesthesia and [Pudendal n palsy 2/2 pelvic floor injury] ; if urinary retention is > 6 hours after delivery then = Bladder Atony

Tx = ambulation f/b catheterization until resolves spontaneously

119
Q

name the most common causes of uterine size-date discrepancy in pregnant patients - 5

A
  1. INCORRECT DATING
  2. Multiple gestation
  3. Hydatidiform Mole
  4. Leiomyomata uterine Fibroids (irregular contour)
  5. Polyhydraminos (only in 2nd & 3rd trimester and is uniform)
120
Q

False labor occurs as a result of Braxton Hicks contractions and causes NO CERVICAL CHANGE

Compare the Timing / Strength / Cervix status of contractions occuring in False Labor to True Labor

A

Uterine Contractions…

FALSE = irregular + weak + NO CERVICAL CHANGE

True = [Regular with increasing frequency] + [increasing in strength] + cervical change

121
Q

Risk factors for pt having preterm delivery? - 6

A
  1. prior Preterm delivery
  2. > 40 yo
  3. multiple gestation
  4. Gestational HTN
  5. Amphetamine use
  6. Cocaine

Pregnant Bitches Take Money

122
Q

A: Potters Sequence etx

B: Clinical Presentation - 6

A

A: [Fetal Renal Agenesis bilaterally / Dysfunction] –> Oligohydraminos (No Amniotic Fluid)

B: POTTER

Pulm hypOplasia

Oligohydraminos

Twisted Face

Twisted and shortened Limbs

Ears set low

Renal agenesis = cause

123
Q

CP for Type 2 Osteogenesis Imperfecta - 4 ; etx?

A
  1. Thoracic cavity hypOplasia
  2. Multiple fractures
  3. Short femur
  4. DOA (Lethal-Stillborn)

AUTO DOM Type 1 Collagen Defect

Type 1=mild / Type2=perinatal fatal / Type 3-9=mod

124
Q

Amniotic Band Sequence CP - 3

A
  1. limb defects
  2. craniofacial defects
  3. abd wall defects

NON-LETHAL :-)

125
Q

How does pregnancy affect Renal function? ; Why is this important?

A

Pregnancy ⬆︎Renal blood flow AND Glomerular basement membrane permeability in 1st trimester –> ⬆︎GFR –> ⬇︎BUN and Creatinine levels. and then this plateaus by midpregnancy

Important because renally excreted drugs will be excreted faster than usual

126
Q

What changes to Hematocrit occur during pregnancy? Why is this helpful?

A

Hct ⬇︎ because Plasma volume ⬆︎ more than the RBC mass –> mild ⬇︎in hgb concentration and = dilutional anemia

Helpful because it protects Mom in case of Postpartum Hemorrhage (⬆︎hypercoaguability during pregnancy also helps with this)

127
Q

Pregnant Women are known to be hypercoagulable in order to decrease effects of PostPartum hemorrhage

What biochemical changes occur to make them hypercoagluable? - 4

A
  1. ⬆︎fibrinogen (never should be nml in pregnancy. If so, could indicate DIC)
  2. ⬆︎vWF (impt for platelet adhesion & stabilizes Factor 8)
  3. ⬆︎resistance to [activated Protein C] (Protein C Cuts [proteolysis] factors 5 and 8 in half but requires Protein S to do it)
  4. ⬇︎Protein S (helps activated Protein C)
128
Q

In a pregnant pt who has chronic HTN (HTN prior to 20 WG), what goals for blood pressure should be set?

A

Less than Stage 1

Systolic < 140

Diastolic < 90

129
Q

Shoulder Dystocia = inability to deliver neonatal shoulders

What is the biggest risk factor for Shoulder Dystocia? ; Why is Shoulder Dystocia so dangerous for newborns? - 3

A

Fetal Macrosomia > 4.5 kg ;

  1. Brachial plexus injury
  2. Fracture of clavicle or humerus
  3. hypoxic brain death

tx = BE CALM mnemonic

130
Q

In a pregnant pt who hasn’t felt fetal mvmnt in 2 days, and dopper reveals no heart tones, what should be next step in management, NST or Transabdominal Ultrasound? Why?

A

Transabd US; NST uses same technology as doppler and just plots the fetal heart tones. If doppler was neg, so will NST

IUFD is confirmed by absence of cardiac activity ON ULTRASOUND

131
Q

What is the work up for a Fetus that just underwent IntraUterine Fetal Demise? - 3

A

IUFD = fetal death ≥ 20WG BUT before onset of labor;

  1. Autopsy
  2. Placenta/Umbilical Cord/Amniotic Membranes exam
  3. Karotype genetic studies
132
Q

What is the work up for a Mother that just underwent IntraUterine Fetal Demise? - 3

A

IUFD = fetal death ≥ 20WG BUT before onset of labor;

  1. Kleihaurer Betke to assess for fetomaternal hemorrhage
  2. Antiphospholipid Ab levels (causes recurrent pregnancy loss)
  3. Coagulation studies
133
Q

Septic Pelvic Thrombophlebitis CP - 2

A
  1. Refractory to abx postpartum Fever with no obvious source (blood, urine, spinal)
  2. B/L lower quadrant TTP (since it usually occurs in deep pelvic or ovarian veins)

This is a dx of exclusion! Always consider Endometritis first in postpartum pts with fever

134
Q

What is the Prenatal Maternal Quad Serum screening? When is this obtained?

A

Measures 4 chemical markers for fetal anomalies and down syndrome- 81% accuracy (QUAD = BUAD):

  1. βHCG⬆︎
  2. Unconjugated EsTriol⬇︎
  3. AFP⬇︎
  4. Dimeric inhibin A⬆︎ - only in QUAD screen

Performed 15 -20WG

Be sure to f/u abnml results with cell free fetal DNA test and US

135
Q

What are the Quad BUAD results (obtained 15-20WG) for Edward’s Trisomy 18?

A

⬇︎βHCG

⬇︎Unconjugated EsTriol

⬇︎AFP

NML Dimeric inhibin A

136
Q

Name the causes of Variable Decelerations on Fetal Heart Tracing

A

Umbilical Cord Compression (consider cord prolapse, oligohydramnios or nuchal cord as etx)

137
Q

A pregnant pt is having recurrent Variable decelerations with more than 50% of her contractions

tx? - 2

A

L lateral decubitius Maternal repositioning –> amnioinfusion if that doesn’t work

(⬇︎umbilical cord compression)

138
Q

What is 1st line tx for gestational DM? - 2; What’s used if this doesn’t work? -2

A

1st: Exercise and Diet change
2nd: Insulin or PO DM drugs (metformin, glyburide)
* Wt loss during pregnancy is NOT a good idea since it ⬆︎risk for IUGR*

139
Q

When should women be screened for Gestational DM?

A

24 - 28WG

140
Q

Shoulder Dystocia = inability to deliver neonatal shoulders

What is the management for this? - 6

A

BE CALM

  1. Breathe, stop pushing and lower head of bed
  2. Elevate and flex hips against abd (McRoberts position)
  3. Call for help (anesthesiologist/2nd physician/nurses)
  4. Apply suprapubic pressure downward & laterally to release ANT shoulder
  5. Largen’s vaginal opening (episiotomy)
  6. Maneuvers (see image)
141
Q

What are the most common dangerous activities for pregnant women? - 4

A
  1. Contact sports (basketball/hockey/soccer)
  2. High Fall Risk (skiing/gymnastics/horseback riding)
  3. Scuba diving
  4. Hot yoga

30 min of moderate exercise/day is actually recommended for pregnant pts unless ctd (see image)

142
Q

What is a normal Lactate DeHydrogenase (LDH)?

A

< 190 U/L

143
Q

Systemic Lupus Erythematosus in pregnant pts complicates the picture of diagnosing preeclampsia since they both present very similarly

How can you differentiate the two? - 4

A
  1. pt will have more classic s/s of SLE (RASH OR PAIN)
  2. RBC cast = SLE
  3. ⬆︎ ANA = SLE
  4. ⬇︎Complement = SLE

Beware: SLE can look like Preeclampsia!

144
Q

Systemic Lupus Erythematosus in pregnant pts complicates the picture of diagnosing preeclampsia since they both present very similarly

What are the ⬆︎ risk associated with having SLE during pregnancy? - 5

A
  1. preeclampsia (smh naturally)
  2. preterm
  3. c/s
  4. IUGR
  5. fetal demise

Beware: SLE can look like Preeclampsia!

145
Q

Full term infant = 37- 42WG

What are the Fetal complications involved with Late term (41-42WG) and Post term ( > 42WG) pregnancies? - 5

A
  1. STILLBIRTH 2/2 UteroPlacental insufficiency
  2. Oligohydramnios (UteroPlacenta insufficiency ⬇︎fetal urine output)
  3. Macrosomia
  4. Meconium aspiration
  5. Convulsions

Maternal complications = infxn, postpartum hemorrhage, c/s

146
Q

What are the common side effects of the Medroxyprogesterone depot injection contraception? - 4

A
  1. prolonged menstrual bleeding during 1st 6 months
  2. weight gain!
  3. breast tenderness
  4. ⬇︎bone mineral density

50% of women have amenorrhea after using for a year

147
Q

When is the First Trimester Combined Test administered?

A

analyzes risk for Trisomy 21 or [Edward’s Trisomy 18] by measuring BUS

9-13WG

148
Q

Gestational sacs normally implant in the _____

What is the “typical” triad for Ectopic Pregnancy? - 3

A

upper uterine fundus ;

VAL had an ectopic the other day!

  1. Vaginal bleeding/spotting
  2. Adnexal Tenderness (if implanted in tube)
  3. Lower abd pain

dx = transVaginal US / tx = MTX or [surgery if severe]

149
Q

IUFD = fetal death ≥ 20WG but before onset of labor

What is usually the cause of IntraUterine Fetal Demise?

A

UNKNOWN!!

This commonly occurs in uncomplicated pregnancies and could be maternal/placental/fetal origin

150
Q

Endometriosis is defined as ______

What are the possible findings for Endometriosis? - 4

A

Endometriosis = endometrial glands and stroma outside the Endometrium

  1. Gun Powder burn lesions
  2. ADHESIONS –> immobile uterus
  3. Chocolate fluid
  4. Nodules flesh or dark colored

# of implants does NOT correlate with sx intensity and these pts can be asx!

Dx = Laparoscopy to biopsy & remove endometriotic lesions

151
Q

How does thyroid dysfunction affect pregnancy? - 2

A

Both hypO and HYPERthyroidism ⬆︎risk for infertility and recurrent pregnancy loss

152
Q

CP for Endometriosis - 5

Homogenous cystic ovarian mass

A

The 3 Ds and AI!

  1. Dysmenorrhea
  2. Dyspareunia - implants in posterior cul-de-sac
  3. Dyschezia (painful defecation) - implants in posterior cul-de-sac

OR

(4) ASX (tx not indicated if so) - otherwise tx = NSAIDs or combined OCPs

(5) Infertility of unknown origin
* Findings: Gun Powder Burn lesions, ADHESIONS–>immobile uterus, Chocolate fluid*
* Dx = ​Laparoscopy to biopsy & remove endometriotic lesions*

153
Q

tx for Endometriosis - 5

Homogenous cystic ovarian mass

A
  1. observation if asx
  2. NSAIDs 1st
  3. Contraceptive (OCP/IUD progesterone)
  4. Leuprolide (GnRH agonist that ⬇︎Endometrial gland estrogen stimulation)
  5. Hysterectomy with oophorectomy

  • Findings: Gun Powder Burn lesions, Adhesions, Chocolate fluid*
  • Dx = Laparoscopy to biopsy endometriotic lesions*
154
Q

25% of fetuses ≤ 28WG are naturally breeched, but flip into cephalic/vertex position by 37WG

What are the 2 dx for disovering breech presentation?

A

1st: fetal presenting part is not palpable

2nd / CONFIRMATION IS DONE BY TRANSABDOMINAL US

155
Q

Name the things that make vaginal delivery contraindicated - 4

A
  1. Breech
  2. Placenta Previa
  3. Active HSV lesion
  4. Prior classical c/s
156
Q

Full term infant = 37- 42WG

Most Tocolytics are not used in managing Preterm Labor 34 to 36+6 WG

Why specifically is Nifedipine not used?

A

Pregnant Bitches

Maternal hypOtension with reflex tachycardia​

157
Q

Full term infant = 37- 42WG

Most Tocolytics are not used in managing Preterm Labor 34 to 36+6 WG

Why specifically is Indomethicin not used? - 2

A

Pregnant Bitches

  1. Premature closure of ductus arteriosus
  2. Oligohydramnios
158
Q

Full term infant = 37- 42WG

Most Tocolytics are not used in managing Preterm Labor 34 to 36+6 WG

Why specifically is Mg not used?

A

Pregnant Bitches

It’s a weak tocolytic so it doesn’t actually help with slowing contractions down in preterm delivery

159
Q

Amniotic Fluid Index for Oligohydramnios

A

≤ 5cm

160
Q

Amniotic Fluid Index for Polyhydramnios

A

≥ 24cm

RF = Maternal DM, congenital swallowing malformation

Polyhydramnios can –> placenta Abruptio

161
Q

Erby’s palsy of an infant is a common complication of shoulder dystocia

Impingement of which nerves causes the self-limited Erb’s Palsy? - 3

A
  1. C5 –> deltoid and infraspinatus muscle weakness
  2. C6 –> bicep muscle weakness
  3. C7 –> enables predominance of opposing muscles

tx = 3 month self limited, but give massage and Physical Therapy to prevent contractures

162
Q

What are the sx of Breast Engorgement-4 ; When does this usually occur?

A
  1. b/l Breast Fullness
  2. b/l Breast Tenderness
  3. b/l Breast warmth
  4. No Fever

Usually occurs 3 days postpartum when colostrum is replaced with milk, but can occur anytime during breastfeeding

Tx = BREASTFEED, Cool compress, APAP, NSAIDS

163
Q

How can you differentiate Breast Engorgement from Mastitis? ; How can you differentiate Breast Engorgement from Plugged Ducts?

A
  • Breast Engorgement is BL without fever and Mastitis is uL WITH FEVER (Breast abscess is Mastitis with fluctuance)
  • Breast Engorgement is BL and Plugged Ducts is uL
164
Q

Etx of Sheehan Syndrome ; What are the main signs and symptoms of Sheehan Syndrome?-5

A

ischemic necrosis of ANT Pituitary 2/2 massive postpartum hemorrhage ;

FLAT PiG

  1. FSH/LH ⬇︎ –> Amenorrhea (remember, postpartum women should resume menses after 10 wks)
  2. ACTH ⬇︎ –> ⬇︎Na+ which causes ⬇︎BP
  3. TSH⬇︎ –> Fatigue/hypOthyroidism
  4. Prolactin⬇︎ –> LACTATION FAILURE (1ST SIGN OF SHEEHAN!)
  5. GH⬇︎ –> Anorexia
165
Q

Early Postpartum period had several physiological processes that can be mistaken for pathology

Name them-5 (so you can avoid overdiagnosing!)

A
  1. Shivering (due to thermal imbalance)
  2. Uterus contracts to become firm with fundus around umbilicus area
  3. Bloody Lochia x 3 days postpartum eventually becoming white/yellow in 3 wks (comes from shedding of residual uterine decidua)
  4. Breast Engorgement
  5. Peripheral Edema
166
Q

How do Prostaglandins “ripen” the cervix during induction?

A

degenerates cervical connective tissue –> softens and effaces cervix for induction

ex: misoprostol, dinoprostone

167
Q

Biophysical Profile and Contraction Stress Test can either or be used to assess for fetal hypoxia in high risk pregnancies

How do you perform a Contraction Stress Test?-2 ; What are the contraindications?

A
  1. Give Oxytocin to induce contractions and watch fetal heart tracing OR
  2. Nipple Stimulate until 3 contractions every 10 min occur

CTX = any ctx to labor itself (as both of these can –> active labor) - ex: placenta previa, prior myomectomy

168
Q

How do you manage SEVERE Preeclampsia when it occurs ≥ 34WG?

A

It’s the same as PPROM!

169
Q

How do you manage SEVERE Preeclampsia when it occurs < 34WG? - 2

A

It’s the same as PPROM! Evaluate Fetal well-being first

170
Q

CP for Ovarian Torsion - 3

A
  1. Palpable adnexal mass
  2. abrupt uL pelvic pain
  3. NV
171
Q

What are the complications for the fetus when exposed to acute uteroplacental insufficiency (i.e. abruptio placenta) and chronic uteroplacental inusufficinecy (i.e. preeclampsia)?

A

ACUTE uteroplacental insufficiency –> fetal hypoxic brain injury

vs

Chronic uteroplacental insufficiency–> asymmetric IUGR /SGA & oligohydramnios

172
Q

Clinical criteria for Arrest of “Active Labor Stage 1B” - 2 ; Tx?

A

Occurs once pt reaches Active Labor ( ≥6cm dilated) and…

  1. No cervical dilation for ≥4 hours despite [adequate contractions: ≥200 MonteVideoUnit q10 min]

OR

  1. No cervical dilation for ≥6 hours despite inadequate contractions
    * Tx = c/s*
173
Q

Clinical criteria for “Labor Protraction” of Active Labor Stage 1B - 2

A

Occurs once pt reaches Active Labor ( ≥6cm dilated) and…

  1. slower than 1-2 cm/hr dilation
  2. +/- inadequate contractions

Tx = oxytocin

174
Q

Epidural Anesthesia causes hypOtension in ___% of pregnant pts when given during Active Labor

What is the mechanism for this?

A

10%

Sympathetic nerve fibers are anesthetized –> vasoDilation –> venous pooling –> ⬇︎venous return –> ⬇︎Cardiac Output

Prevent this by giving IVF prior to epidural, L lateral decubits position and vasopressors if needed

175
Q

What is the antidote for Magnesium Toxicity?

Risk Factor for Mg toxicity = Renal Insufficiency

A

Ca+Gluconate

Risk Factor for Mg toxicity = Renal Insufficiency since it’s renal excreted!!

176
Q

What are the common side effects of Magnesium administration? - 3

A
  1. HA
  2. Flushed
  3. Nausea
177
Q

What is the most common cause of postpartum fever? When does this fever usually present? Tx?

A

ENDOMETRITIS ; > 24 hours postpartum ; [Clindamycin + Gentamicin]

You do NOT need cx for this dx!

178
Q

Abx for Lactational mastitis?

A

Dicloxacillin

covers MSSA and GASP

179
Q

A placenta is close to the internal cervical os

How far away does the placenta have to be from the cervical os to NOT be considered placenta previa

A

>2 cm away from os

180
Q

Why is it normal for pregnant patients to have a systolic ejection murmur

A

⬆︎Stroke volume during early pregnancy –> ⬆︎Cardiac Ouput AND ⬆︎HR during late pregnancy –> even more ⬆︎Cardiac Output

Also, Volume expansion can –> peripheral edema and their body compensates by ⬇︎BP

181
Q

How does pregnancy affect the respiratory system? - 2

A

Progesterone ⬆︎tidal volume for more O2 (pt takes deeper breaths) –> physiologic hyperventilation and this –> physiologic respiratory alkalosis (PaCO2 27-32) - eventually kidneys compensate by dumping HCO3

+

enlarging uterus ⬇︎ functional residual capacity

Both cause pregnancy dyspnea

182
Q

What is often the cause of Early Decelerations on Fetal Heart Tracing

A

Head Compression of Fetus

these occur WITH contractions and no tx is required

183
Q

Clinical Criteria for Arrest of Labor Stage 2 - 2

A

Occurs once pt is Pushing and dilated to 10 cm but has insufficient fetal descent after:

  1. ≥ 3 hours if nulliparous OR
  2. ≥ 2 hours if multiparous
184
Q

What are the causes of Labor Stage 2 ? - 3

A
  1. FETAL MALPOSITION (occiput faces transverse or posterior instead of Anterior) –> cephalopelvic disproportion
  2. Cephalopelvic disproportion
  3. Inadequate contractions (possibly from maternal exhaustion)

RF: Maternal obesity, DM

185
Q

What is the difference between fetal Malpresentation and Malposition?

A

Malpresentation = lowest part of the fetus in pelvis is NOT the vertex (i.e. face, breech)

vs

Malposition = relationship of the fetal presenting part to the pelvis (occiput anterior vs transverse vs posterior)

186
Q

Shoulder Dystocia can cause multiple neonatal sequelae

What are they? - 5

A
187
Q

Shoulder Dystocia can cause multiple neonatal sequelae. Klumpe Palsy is one of those possible sequelae

What is it caused by specifically? - 2

A

Impingement (or avulsion) of

  1. cervical fibers at C8 and T1 –> L hand paralysis (klumpke claw)
  2. sympathetic fibers running along C8 and T1 –> Horner Syndrome = poorer outcome if present
188
Q

What all labs should be ordered for the Initial prenatal visit? - 11

A
  1. RhD type and antibody screen
  2. CBC Hgb studies
  3. HIV
  4. RPR syphillis
  5. HepB surface antigen
  6. Rubella immunity
  7. Varicella immunity
  8. Chlamydia PCR
  9. Urine cx CLEAN CATCH
  10. Urine protein
  11. Pap test (if indicated)
189
Q

What all labs should be ordered for the 24-28WG prenatal visit? - 3

A
  1. Hgb & Hct
  2. Oral Glucose Challenge Test 1 hr - 50gram load (if positive confirm with 3 hr 100gm load)
  3. Antibody screen if pt RhD negative

After 1st trimester, placenta secretes hormones that ⬆︎maternal physiologic insulin resistance so that baby gets more sugar. But if maternal pancreas cant overcome this resistance by secreting more insulin it can –> gestational DM

190
Q

Why are some women at risk for developing gestational DM after the 1st trimester?

A

After 1st trimester, placenta secretes hormones that ⬆︎maternal physiologic insulin resistance so that baby gets more sugar. But if maternal pancreas cant overcome this resistance by secreting more insulin it can –> gestational DM

Dx = Oral Glucose Tolerance Test

191
Q

When is a NST indicated? - 2

A
  1. 32-34WG in high risk pregnancies OR
  2. ⬇︎fetal movements

the most common cause of NONreactive NST is fetal sleep cycle so be sure to allow at least 40 min testing and use vibroacoustic stimulation to wake them up!

192
Q

What is the most accurate method of determining gestational age?

A

FIRST trimester US with crown to rump length (since there is minimal variability of fetuses when they first start off)

193
Q

After the ____ is used as the most accurate method to determine gestational age, what can be used as secondary? - 6

A

FIRST trimester US is most accurate

  1. fundal height if > 20WG
  2. fetal abd cirucumference
  3. fetal biparietal diameter
  4. fetal femur length
  5. fetal head circumference
  6. LMP
194
Q

Dx for Ovarian Torsion

A

Pelvic US revealing adnexal mass with absent Doppler flow

195
Q

A Woman comes in with c/o breast engorgement (BL tender, swollen, firm) after she elected to not breast feed

How do you induce Lactation suppresion? - 3

A
  1. NSAIDs for pain/inflammation
  2. COMFORTABLE Bra that avoids nipple stimulation
  3. Cool Compress to breast

Engorgement in and of itself eventually –> Lactation suppresion on its own due to negative feedback! do NOT breast bind as this causes mastitis. Don’t use drugs to treat this.

196
Q

Ovarian Torsion is more common amongst _____[pre/post] menopausal women

A

PREmenopausal

Untreated ovarian torsion –> sepsis, chronic pelvic pain and infertility

197
Q

What is Culdocentesis? ; What is it used for?

A

centesis of intraperitoneal fluid thru the cul-de-sac via vaginal aspiration ; No longer used and has been replaced by US for identifying pelvic free fluid

198
Q

How do you diagnose Endometriosis?

A

​LAPORASCOPY to biopsy & remove endometriotic lesions

1st, treat empirically with NSAIDs tho

199
Q

What is the MOST IMPORTANT intervention for preventing vertical HIV transmission from Mom to baby? ; What are 2 other less important methods?

A

Triple Antiretroviral therapy (2 NRTI + 1 NNRTI or 1 PI)

Also, c/s if viral load is > 1000 and Zidovudine given to neonate for ≥6 wks after birth are also good but not most important

200
Q

What is the precaution in a pregnant woman with Graves’ disease?

A

Mom’s Thyroid stimulating Ab (anti-TSH R Ab) can cross the placenta and stimulate the baby’s thyroid gland –> Thyrotoxicosis

Baby’s tx = methimazole + Beta Blcoker

201
Q

[T or F] Thyroid hormones (T4 and T3) can NOT cross the placenta during pregnancy

A

TRUE! - only the thyroid stimuating Ab can cross and that’s only during 3rd trimester

202
Q

What’s the only maternal Antibody that has the ability to cross the placenta? ; why does it do this?

A

IgG; protects neonate for first 3 months of life

203
Q

CP for Amniotic Fluid Embolism - 4

A
  1. ARDS (intubate and ventilate them STAT!)
  2. Cardiogenic shock
  3. Seizures/Coma
  4. DIC

RF = Multiparity, Advanced maternal age, Placental demise and c/s

204
Q

Fetal Hydantoin Syndrome results from intrapartum usage of ____ or _____

Describe the CP of the baby for this - 5

A

phenytoin, carbamazepine

  1. microcephaly –> developmentally delay
  2. midfacial hypoplasia
  3. cleft lip and palate
  4. digital hypoplasia
  5. hirsutism
205
Q

How does Peripartum Cardiomyopathy present? ; When during the pregnancy does this present?

A

Rapid Heart Failure (SOB, cough, pedal edema) ; > 36WG

206
Q

What type of shoulder dislocation are Violent Muscle Contractions associated with

A

POSTERIOR

207
Q

Mode of inheritance for Hemophilia A

A

X-linked recessive

208
Q

What’s the time limit for pregnant women in Latent labor Stage 1A if they’re nulliparous? ; What about if they’re multiparous?

A

Labor = (LA)PD

1A: Latent phase = Strong Contractions q3-5 min (should be ≤20 hrs for nulliparous pts and 14 hrs for multiparous pts)

1B: ACTIVE phase = Cervix is now 6 cm Dilated, [growing @ 1-2 cm/hr] and effacing

2 : Pushing Time! since Cervix is now 10 cm FULLY DILATED (should be ≤3 hrs for nulliparous and 2 hrs for multiparous)

3 : Delivery of Baby! and then Deliver Placenta

209
Q

What’s the time limit for pregnant women in Labor Stage 2 if they’re nulliparous? ; What about if they’re multiparous?

A

Labor = (LA)PD

1A: Latent phase = Strong Contractions q3-5 min (should be ≤20 hrs for nulliparous pts and 14 hrs for multiparous pts)

1B: ACTIVE phase = Cervix is now 6 cm Dilated, [growing @ 1-2 cm/hr] and effacing

2 : Pushing Time! since Cervix is now 10 cm FULLY DILATED (should be ≤3 hrs for nulliparous and 2 hrs for multiparous)

3 : Delivery of Baby! and then Deliver Placenta

210
Q

What’s the time limit for pregnant women in Labor Stage 3?

A

Labor = (LA)PD

1A: Latent phase = Strong Contractions q3-5 min (should be ≤20 hrs for nulliparous pts and 14 hrs for multiparous pts)

1B: ACTIVE phase = Cervix is now 6 cm Dilated, [growing @ 1-2 cm/hr] and effacing

2 : Pushing Time! since Cervix is now 10 cm FULLY DILATED (≤3 hrs for nulliparous and 2 hrs for multiparous)

3 : Delivery of Baby! and then Deliver Placenta (≤30 min)

211
Q

What are the stages of Labor?

A

Labor = (LA)PD

1A: Latent phase = Strong Contractions q3-5 min (should be ≤20 hrs for nulliparous pts and 14 hrs for multiparous pts)

1B: ACTIVE phase = Cervix is now 6 cm Dilated, [growing @ 1-2 cm/hr] and effacing

2 : Pushing Time! since Cervix is now 10 cm FULLY DILATED (≤3 hrs for nulliparous and 2 hrs for multiparous)

3 : Delivery of Baby! and then Deliver Placenta (≤30 min)

https://www.youtube.com/watch?annotation_id=annotation_563008&feature=iv&src_vid=Xath6kOf0NE&v=ZDP_ewMDxCo

212
Q

Why is there no use in getting a D-dimer in a pregant woman for DVT workup?

A

D-dimer is already naturally elevated in pregnant woman due to their physiological ⬆︎ fibrinogen

213
Q

What is the disadvantage of using Progestin only OCP for contraceptive?

A

You have to take it every day DOWN TO THE EXACT HOUR or it will fail! = compliance issues

step 3 Ob/Gyn (2 decks)

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