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Obstetrics > Obstetric and Pregnancy Disorders > Flashcards

Obstetric and Pregnancy Disorders Flashcards

1
Q

What is the presentation of ectopic pregnancy?

A
  • Unilateral lower abdominal or pelvic pain
  • Vaginal bleeding
  • If ruptured, pt can be hypotensive with peritoneal irritation
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2
Q

How is ectopic pregnancy diagnosed?

A
  • Beta-HCG confirms the presence of a pregnancy.
  • Ultrasound is used to locate the site of implantation.
  • Laparoscopy is an invasive test used to visualize the ectopic pregnancy; it is done if surgery is chosen as the treatment method.
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3
Q

What is the treatment for stable pts with ectopic pregnancy with ruptured membranes? What about unstable pts?

A

Stable pts with ruptured membranes should be sent to surgery.

Unstable pts (low BP, high HR) should be stabilized with IV fluids, blood products and dopamine and then sent to surgery immediately.

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4
Q

Where is the most common location for ectopic pregnancy?

A

Ampulla of the fallopian tube

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5
Q

What is the medical treatment for ectopic pregnancy? What tests are done first?

A

Medical treatment should begin with baseline exams such as:

  • CBC to monitor for anemia
  • Blood type/screen
  • Transaminases to detect changes indicating hepatotoxicity from the medications (e.g. methotrexate)
  • Beta-HCG to assess for success of treatment via a decrease in beta-HCG

After these are obtained, methotrexate is given.

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6
Q

What is the next step after the first dose of methotrexate is given for ectopic pregnancy?

A

4-7 days after methotrexate is given, obtain the beta-HCG level.

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7
Q

If methotrexate is given for ectopic pregnancy, what is done if there is a >15% drop in beta-HCG?

A

Continue to observe for side effects; no other treatment is necessary. Follow beta-HCG weekly until it reaches zero.

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8
Q

If methotrexate is given for ectopic pregnancy, what is done if there is a

A

Give a second dose of methotrexate and measure beta-HCG again.

  • If there is >15% drop in beta-HCG, continue to observe for side effects. Follow beta-HCG weekly until it reaches zero.
  • If there are persistently high beta-HCG levels, surgery is needed.
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9
Q

What is the exclusion criteria for methotrexate?

A
  • Immunodeficiency
  • Noncompliant pts
  • Liver disease
  • Ectopic is 3.5 cm or larger
  • Fetal heartbeat auscultated
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10
Q

What is the surgery for ectopic pregnancy?

A

Surgery is done to try and preserve the fallopian tube by cutting a hole in it via salpingostomy. However, removal of the whole fallopian tube via salpingectomy my be necessary.

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11
Q

What is abortion?

A

A pregnancy that ends before 20 weeks or a fetus less than 500 grams. Almost 80% of spontaneous abortions occur prior to 12 weeks gestation.

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12
Q

What are the causes / risk factors of abortions?

A

Chromosomal abnormalities in the fetus account for 60-80% of spontaneous abortions.

Maternal factors include:

  • Anatomic abnormalities
  • Infections (STDs)
  • Immunological factors (antiphospholipid syndrome)
  • Endocrine factors (uncontrolled hyperthyroidism or diabetes)
  • Malnutrition
  • Trauma
  • Rh isoimmunization
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13
Q

What is the presentation of abortion?

A
  • Cramping abdominal pain
  • Vaginal bleeding
  • May be stable or unstable, depending on the amount of blood loss
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14
Q

What diagnostic tests are done for abortion?

A
  • CBC to evaluate blood loss and need for transfusion
  • Blood type and Rh screen
  • Ultrasound to distinguish between the types of abortion
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15
Q

For complete abortion, what are the findings? What is the treatment?

A

No products of conception found.

Follow up in the office.

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16
Q

For incomplete abortion, what are the findings? What is the treatment?

A

Some products of conception found.

Dilation and curettage; medical Rx.

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17
Q

For inevitable abortion, what are the findings? What is the treatment?

A

Products of conception intact, but dilation of the cervix and intrauterine bleeding are present.

D&C and medical Rx.

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18
Q

For threatened abortion, what are the findings? What is the treatment?

A

Products of conception intact with intrauterine bleeding, but NO dilation of the cervix.

Bed rest, pelvic rest.

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19
Q

For missed abortion, what are the findings? What is the treatment?

A

Death of the fetus, but all products of conception present in the uterus.

D&C, medical Rx.

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20
Q

For septic abortion, what are the findings? What is the treatment?

A

Infection of the uterus and the surrounding areas.

D&C and IV abx such as levofloxacin and metronidazole.

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21
Q

What is the medical treatment for abortion?

A

Induction of labor via drugs that help open and expulse the fetus, e.g. misoprostol (a prostaglandin E1 analog).

*Also, rhoGAM should be given to Rh negative mothers.

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22
Q

What is the presentation of multiple gestations?

A
  • Exponential growth of the uterus.
  • Rapid weight gain by the mother.
  • Elevated beta-HCG and MSAFP (levels higher than expected for estimated gestational age is the first clue to multiple gestation).
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23
Q

What is the diagnostic test for multiple gestations?

A

Ultrasound

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24
Q

What are the complications of multiple gestations?

A
  • Spontaneous abortion of one fetus
  • Premature labor and delivery
  • Placenta previa
  • Anemia
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25
Q

What are the risk factors for preterm labor?

A
  • Premature rupture of membranes
  • Multiple gestation
  • Previous history of preterm labor
  • Placental abruption
  • Maternal factors
    • Uterine anatomical abnormalities
    • Infections (chorioamnionitis)
    • Preeclampsia
    • Intraabdominal surgery
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26
Q

What is the presentation of preterm labor?

A
  • Contractions (abdominal pain, lower back pain, or pelvic pain)
  • Dilation of the cervix
  • Occurs between 20-37 weeks
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27
Q

How should the fetus be examined in suspected preterm labor?

A

The fetus should be evaluated for weight, gestational age, and the presenting part (cephalic vs breech).

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28
Q

What class of drugs are used to stop preterm labor?

A

Tocolytics

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29
Q

In which circumstances should preterm labor not be stopped with tocolytics and instead delivery should occur?

A
  • Maternal HTN (preeclampsia/eclampsia)
  • Maternal cardiac disease
  • Maternal cervical dilation
  • Maternal hemorrhage (abruptio placenta, DIC)
  • Fetal death
  • Chorioamnionitis

*When any of these are present, deliver the fetus.

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30
Q

If preterm labor is occurring (contractions and cervical dilation), at what gestational age and size do you stop delivery? What drugs are used?

A

Stop delivery if:

  • EGA 24-33 weeks
  • Weight 600-2500 grams

Give betamethasone and tocolytics

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31
Q

If preterm labor is occurring (contractions and cervical dilation), at what gestational age and size do you induce delivery?

A

Deliver if:

  • EGA 34-37 weeks
  • Weight > 2,500 grams
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32
Q

Why are corticosteroids used when stopping preterm labor?

A

Pt should be given betamethasone, a corticosteroid used to mature the fetal lungs. The effects begin within 24 hours, peak at 48 hours, and persist for 7 days. Corticosteroids decrease the risk of respiratory distress syndrome and neonatal mortality.

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33
Q

How do tocolytics work? What drugs are used as tocolytics?

A

When steroids are administered, a tocolytic should follow to allow time for steroids to work. Tocolytics slow progression of cervical dilation by decreasing uterine contractions.

Magnesium sulfate is the most commonly used tocolytic. It decreases uterine tone and contractions. Side effects include flushing, headaches, diplopia, and fatigue.

CCBs can be used. Side effects include headache, flushing and dizziness.

Terbutaline, a B-agonist, causes myometrial relaxation. Maternal effects may include increase in heart rate leading to palpitations and hypotension.

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34
Q

How does premature rupture of membranes (PROM) present?

A

Gush of fluid from the vagina

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35
Q

How is PROM diagnosed?

A

Sterile speculum examination should confirm the fluid as amniotic fluid:

  • Fluid is present in the posterior fornix.
  • Fluid turns the nitrazine paper blue.
  • When placed on the slide and allowed to air dry, fluid has ferning patterns.
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36
Q

When in the pregnancy can PROM occur? When does it become a big problem?

A

PROM can happen at any time throughout the pregnancy.

It becomes the biggest problem when the fetus is preterm or prolonged rupture of the membranes. Prolonged means that labor starts more than 24 hours before delivery.

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37
Q

What are the four possible complications of prolonged rupture of membranes?

A
  • Preterm labor
  • Cord prolapse
  • Placental abruption
  • Chorioamnionitis
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38
Q

What two factors does treatment of PROM depend on?

A

Treatment of PROM depends on the fetus’s GA and the presence of chorioamnionitis.

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39
Q

What is the treatment of PROM with chorioamnionitis?

A

Deliver now

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40
Q

What is the treatment of PROM in a term fetus without chorioamnionitis?

A

Wait 6-12 hours for spontaneous delivery. If it doesn’t happen, induce labor.

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41
Q

What is the first step in management in all third trimester bleeding?

A

Transabdominal ultrasound

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42
Q

When is digital vaginal exam indicated in third trimester bleeding?

A

Never, as it may lead to increased separation between placenta and uterus, resulting in severe hemorrhage.

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43
Q

What is the treatment of PROM in a preterm fetus without chorioamnionitis?

A

Treat with betamethasone (to mature fetal lungs), tocolytics (to decrease contractions), ampicillin, and one dose of azithromycin (to decrease risk of developing chorioamnionitis while waiting for steroids to begin working).

If the pt is penicillin allergic with low risk for anaphylaxis, use cefazolin instead of ampicillin. If high risk for anaphylaxis, use clindamycin.

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44
Q

When can placenta previa occur?

A

Third trimester

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45
Q

What increases the risk of placenta previa?

A
  • Previous cesarean deliveries
  • Previous uterine surgery
  • Multiple gestations
  • Previous placenta previa
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46
Q

What are the risk factors for ectopic pregnancy?

A
  • Previous ectopic pregnancy (strongest RF)
  • Pelvic inflammatory disease
  • Intrauterine devices
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47
Q

What is the presentation of placenta previa?

A
  • Painless vaginal bleeding

- It may be detected on routine ultrasound before 28 weeks, but usually does not cause bleeding until 28 weeks.

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48
Q

What is the diagnostic test for placenta previa?

A

Transabdominal ultrasound

*Do not do transvaginal US for the same reason you don’t do DVE in third trimester bleeding–it is dangerous and can separate the placenta farther from the uterus.

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49
Q

Describe placental positioning in complete placenta previa

A

Complete covering of the internal cervical os

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50
Q

Describe placental positioning in partial placenta previa

A

Partial covering of the internal cervical os, covering more than in marginal PP.

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51
Q

Describe placental positioning in marginal placenta previa

A

Placenta is adjacent to the internal os

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52
Q

Describe placental positioning in low-lying placenta previa

A

Placenta is implanted in the lower segment of the uterus but not covering the internal os (more than 0 cm but less than 2 cm away).

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53
Q

Describe placental positioning in vasa previa

A

Fetal vessel is present over the cervical os.

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54
Q

When is placenta previa treated?

A

PP is treated when there is large-volume bleeding or a drop in hematocrit.

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55
Q

What is the treatment of placenta previa?

A

Treatment is strict pelvic rest with nothing inserted into the vagina e.g. intercourse.

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56
Q

What are the indications for immediate cesarean delivery? How do you prepare for life-threatening bleeding in cesarean delivery?

A

Indications for cesarean:

  • Unstoppable labor (cervix dilated > 4 cm)
  • Severe hemorrhage
  • Fetal distress

Prepare for life-threatening bleeding by type and screen of blood, CBC, and PT.

*Preterm fetuses should be prepared for delivery with betamethasone to mature the lungs.

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57
Q

What is placental invasion? What is the presentation? When does it become a problem?

A

Placental invasion is abnormal adherence of the placenta to different areas of the uterine wall. Patients are generally Asymptomatic unless invasion into the bladder or rectum results in hematuria or rectal bleeding.

This becomes a problem when the placenta must detach from the uterus after the fetus is born. Often it cannot be seen on ultrasound, but does result in a significant amount of postpartum hemorrhage.

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58
Q

What are the three types of placental invasion? Define them

A

Placenta accreta: abnormally adheres to the superficial uterine wall.
Placenta increta: attaches to the myometrium.
Placenta percreta: invades the uterine serosa, bladder wall, or rectal wall.

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59
Q

What happens if the placenta cannot detach from the uterine wall after delivery of the fetus? What is the treatment?

A

The result is catastrophic hemorrhage and shock.

Pts often require hysterectomy.

60
Q

What is placental abruption? When can it occur?

A

Premature separation of the placenta from the uterus. This results in tearing of the placental blood vessels and hemorrhaging into the separated space. This can occur before, during, or after labor.

61
Q

In placental abruption, what are the complications if the separation is large enough and life-threatening bleeding occurs?

A
  • Premature delivery
  • Uterine tetany
  • DIC
  • Hypovolemic shock

*If the degree of separation is very small with minor hemorrhage, there may be no clinical signs or symptoms.

62
Q

What are the precipitating factors of placental abruption?

A
  • Maternal HTN (chronic, preeclampsia, eclampsia)
  • Maternal cocaine use
  • Maternal external trauma
  • Maternal smoking during pregnancy
  • Previous placental abruption
62
Q

What is the presentation of placental abruption?

A
  • Third trimester vaginal bleeding
  • Severe abdominal pain
  • Contractions
  • Possible fetal distress
63
Q

How is placental abruption diagnosed? How is it differentiated from placenta previa?

A

Transabdominal ultrasound is used, as in PP, though the abruption may not be seen.

Placental abruption presents with painFUL vaginal bleeding, while placenta previa presents with painLESS vaginal bleeding.

64
Q

Describe the two types of placental abruption. Which has more serious complications?

A

Concealed abruption - blood is within the uterine cavity; placenta is more likely to be attached; complications are more serious

External abruption - blood drains through the cervix; placenta more likely to be partially detached

65
Q

What are the serious complications of concealed abruption?

A
  • DIC
  • Uterine tetany
  • Sheehan syndrome (postpartum hypopituitarism)
  • Fetal hypoxia
  • Fetal death
66
Q

What are the indications for cesarean delivery in placental abruption?

A
  • Uncontrollable maternal hemorrhage
  • Rapidly expanding concealed hemorrhage
  • Rapid placental separation
  • Fetal distress
67
Q

What are the indications for vaginal delivery in placental abruption?

A
  • Placental separation is limited
  • Separation is extensive and the fetus is dead
  • Fetal heart tracing is assuring
68
Q

When does uterine rupture usually occur? What are the risk factors?

A

It usually occurs during labor. The risk factors are:

  • Previous cesarean deliveries: both types, but higher risk in classical (longitudinal) than low transverse
  • Trauma, most commonly MVA
  • Uterine myomectomy
  • Uterine overdistension, e.g. polyhydramnios, multiple gestations
  • Placenta percreta
69
Q

What is the presentation of uterine rupture?

A
  • Sudden onset of severe abdominal pain
  • Abnormal hump in abdomen
  • No uterine contractions
  • Regression of fetus: the fetus was moving toward delivery, but is no longer in the canal because it withdrew into the abdomen
70
Q

What is the treatment of uterine rupture?

A

Immediate laparotomy with delivery of the fetus. Repair of the uterus or hysterectomy will follow.*

*If repair of the uterus is done, all subsequent pregnancies will be delivered via cesarean birth at 36 weeks.

71
Q

Can a cesarean delivery be done for uterine rupture?

A

No, because the baby may not be inside the uterus, but rather floating in the abdomen.

72
Q

What causes hemolytic disease of the newborn?

A

Antibodies of a Rh negative mother attack the fetal blood cells of her second Rh positive baby. This is not a problem in the first Rh positive baby or any Rh negative babies.

73
Q

What are the complications of hemolytic disease of the newborn?

A
  • Fetal anemia
  • Extramedullary production of RBCs (liver and spleen)
  • Elevated heme and bilirubin; bilirubin can be neurotoxic

These effects can lead to erythroblastosis fetalis, characterized by high fetal cardiac output (CHF).

74
Q

What is done at the initial prenatal visit for Rh incompatibility?

A
  • Antibody screen is done to see if the mother is Rh- or Rh+
  • Antibody titer is done to see how many antibodies to Rh+ blood the mother has. Pts who are Rh- but have no antibodies are “unsensitized.” Pts who are Rh- and have antibodies to Rh are “sensitized.”
75
Q

For unsensitized pts, RhoGAM is given any time fetal blood cells may cross the placenta, which may happen in what scenarios?

A
  • Amniocentesis
  • Abortion
  • Vaginal bleeding
  • Placental abruption
  • Delivery
76
Q

When should prenatal antibody screening be done?

A

Prenatal antibody screening at 28 and 35 weeks. Pts who continue to be unsensitized at 28 weeks should receive RhoGAM prophylaxis. At delivery, if the baby is Rh positive, the mother should be given RhoGAM again.

77
Q

If a pregnant pt already has antibodies to Rh+ blood on the initial visit, what test needs to be done? How does it determine if they are sensitized?

A

An antibody titer needs to be done via the indirect antiglobulin test. The pt is sensitized if the titer level is > 1:4.

78
Q

If you do the indirect antiglobulin test on an Rh- pt and the titer level is

A

For titer level

79
Q

If the antibody titer reaches 1:16 on a pregnant woman and amniocentesis is done, what do you do if fetal cells show medium bilirubin level? What if bilirubin level is high?

A

Medium bilirubin level: Repeat amniocentesis in 1-2 weeks.

High bilirubin level: This means the fetus is probably anemic. Do a percutaneous umbilical blood sample to measure fetal hematocrit.

80
Q

If a Rh+ fetus of a Rh- mother has an elevated bilirubin level and low hematocrit is evident after percutaneous umbilical blood sample, what do you do?

A

Perform an intrauterine transfusion

81
Q

What is gestational HTN? What is the treatment?

A

BP > 140/90 that starts after 20 weeks gestation.

Treat only during pregnancy with methyldopa, labetalol, or nifedipine.

82
Q

What is preeclampsia? What are the risk factors?

A

Preeclampsia is HTN, edema and proteinuria during pregnancy.

The risk factors are chronic HTN and renal disease.

83
Q

Describe mild preeclampsia in terms of:

  • Blood pressure
  • Proteinuria
  • Edema
  • Mental status changes
  • Vision changes
  • Impaired liver function
A

Mild preeclampsia:

  • Blood pressure: >140/90
  • Proteinuria: Dipstick 1+ to 2+, or 24-hr >300 mg
  • Edema: Hands, feet, face
  • Mental status changes: None
  • Vision changes: None
  • Impaired liver function: None
84
Q

Describe severe preeclampsia in terms of:

  • Blood pressure
  • Proteinuria
  • Edema
  • Mental status changes
  • Vision changes
  • Impaired liver function
A

Severe preeclampsia:

  • Blood pressure: >160/100
  • Proteinuria: Dipstick +3 or more, or 24-hr >5 grams
  • Edema: Generalized
  • Mental status changes: Yes
  • Vision changes: Yes
  • Impaired liver function: Yes
85
Q

What is the treatment of mild preeclampsia if the pregnancy is at term? What if it is preterm?

A

Term: Induce delivery

Preterm: Betamethasone (lung maturation) and magnesium sulfate (seizure prophylaxis)

86
Q

What is the treatment of severe preeclampsia if the pregnancy is at term? What if it is preterm?

A
  1. Prevent eclampsia with magnesium sulfate
  2. Control BP with hydralazine
  3. Deliver if term; give betamethasone if preterm
87
Q

What is eclampsia? What is the treatment?

A

Eclampsia: a tonic-clonic seizure in a pt with preeclampsia.

Treatment:

  1. Stabilize the mother with magnesium sulfate (seizure control) and hydralazine (BP control)
  2. Deliver the baby
88
Q

What is HELLP syndrome? What is the treatment?

A

A complication of preeclampsia characterized by:

  • Hemolysis
  • Elevated Liver enzymes
  • Low Platelets

The treatment is the same for eclampsia:

  1. Stabilize the mother with magnesium sulfate (seizure control) and hydralazine (BP control)
  2. Deliver the baby
89
Q

Does pregestational diabetes refer to having type 1 or type 2 diabetes before becoming pregnant?

A

Both

90
Q

What are the maternal complications of pregestational diabetes?

A
  • Four times more likely to have preeclampsia
  • Two times more likely to have a spontaneous abortion
  • Increased rate of infection
  • Increased postpartum hemorrhage
  • Preterm labor
91
Q

What are the fetal complications of pregestational diabetes?

A
  • Increase in congenital anomalies (heart and neural tube defects)
  • Macrosomia
    • Shoulder dystocia: the shoulder gets stuck under the pubic symphysis during delivery (a complication of macrosomia)
92
Q

In addition to the usual prenatal tests, what tests should be done for a pregnant pt with pregestational diabetes?

A
  • EKG
  • 24-hr urine for baseline renal function (creatinine clearance, protein)
  • Hb A1C
  • Ophthalmological exam for baseline eye function and assessing the condition of the retina
93
Q

For type 1 and type 2 pregestational diabetes, what is the treatment? What is the route of administration?

A

Insulin is used for both.

Type 1: NPH is given via insulin pump
Type 2: NPH and lispro are given subcutaneously

94
Q

Describe fetal testing in pregestational diabetes at 32-36 weeks and at >36 weeks

A

32-36 weeks: Weekly nonstress test (NST) for fetal well-being; ultrasound for fetal size.

> 36 weeks: Twice-weekly testing: one NST for fetal well-being; one biophysical profile (BPP) for amount of fluid and fetal well-being

95
Q

Describe fetal testing in pregestational diabetes at 37 weeks and at 38-39 weeks

A

37 weeks: Lethicin/sphingomyelin ratio to assess fetal lung maturity; if fetal lungs are mature, deliver the fetus.

38-39 weeks (if pt refuses (L/S ratio): No test, just induce labor.

96
Q

What are the maternal complications of gestational diabetes?

A
  • Preterm birth

- The mother is 4-10 times more likely to develop type 2 diabetes after delivery.

97
Q

What are the fetal complications of gestational diabetes?

A
  • Preterm birth
  • Macrosomia with associated birth injuries e.g. Shoulder dystocia
  • Neonatal hypoglycemia: There is an excess of fetal insulin secondary to living in a hyperglycemic environment. When the fetus leaves this environment, the excess insulin causes the glucose level to drop.
98
Q

When do you screen for gestational diabetes? What is the testing for it?

A

Screen for GD at 24-28 weeks.

Testing:

  1. Glucose load test: Nonfasting of 50g glucose, measure serum level in one hour; if > 140 mg/dL, do glucose tolerance test.
  2. Glucose tolerance test: Nonfasting ingestion of 100g glucose with three serum measurements at 1, 2, and 3 hours; if any are elevated, GD is confirmed.
99
Q

What is the treatment of gestational diabetes?

A

Diabetic diet and exercise are first-line. If these fail to control blood sugar levels adequately (fasting >95 and one hour postprandial >140), medication is indicated. Treatment with insulin is given with:

  • Aspart before meals
  • NPH before bed

For pts who refuse insulin, both metformin and glyburide may be both safe and effective. If glycemic control is not achieved with oral agents, however, insulin must be used.

100
Q

Is telling a pregnant woman with GD to lose weight sound advice for treatment?

A

No, especially if they are on insulin.

101
Q

How is intrauterine growth restriction (IUGR) defined?

A

The fetus weighs in the bottom 10% for their GA.

102
Q

Describe the two types of IUGR, symmetric and asymmetric.

A

Symmetric: brain is in proportion with the rest of the body; occurs before 20 weeks GA.

Asymmetric: brain weight is not decreased; abdomen is smaller than the head; occurs after 20 weeks.

103
Q

What are the causes of IUGR?

A
  • Chromosomal abnormalities
  • Neural tube defects
  • Infections
  • Multiple gestations
  • Maternal HTN or renal disease
  • Maternal malnutrition
  • Maternal substance abuse (smoking is the #1 preventable cause in the United States)
104
Q

What is the diagnostic test for IUGR?

A

Ultrasound is done to confirm the GA and fetal weight.

105
Q

What are the complications of IUGR?

A
  • Premature labor
  • Stillbirth
  • Fetal hypoxia
  • Lower IQ
  • Seizures
  • Mental retardation
106
Q

What is the treatment of IUGR?

A

There is no treatment other than to try to prevent it:

  • Stop smoking
  • Prevent maternal infection with immunizations
107
Q

How is macrosomia defined?

A

Fetus has estimated birth weight > 4500 grams.

108
Q

What are the risk factors of macrosomia?

A
  • Maternal diabetes or obesity
  • Advanced maternal age
  • Postterm pregnancy
109
Q

How is macrosomia diagnosed?

A

Typically, the fundal height in cm should equal the GA in weeks. In macrosomia, the fundal height will be greater than the GA by 3 (e.g. fundal height is 31 cm at 28 weeks). If this is the case, ultrasound confirms the gestational weight by:

  • Femur length
  • Abdominal circumference
  • Head diameter
110
Q

What are the complications of macrosomia?

A
  • Birth injuries e.g. shoulder dystocia
  • Low Apgar score
  • Hypoglycemia
111
Q

What is the treatment of macrosomia?

A
  • Induction of labor should be considered if the lungs are mature BEFORE the fetus is above 4500g in weight.
  • Cesarean delivery is indicated if the fetus is above 4500g in weight.
112
Q

If a pregnant pt already has antibodies to Rh+ blood on the initial visit, what test needs to be done? How does it determine if they are sensitized?

A

An antibody titer needs to be done via the indirect antiglobulin test. The pt is sensitized if the titer level is > 1:4.

113
Q

If you do the indirect antiglobulin test on an Rh- pt and the titer level is

A

For titer level

114
Q

If the antibody titer reaches 1:16 on a pregnant woman and amniocentesis is done, what do you do if fetal cells show medium bilirubin level? What if bilirubin level is high?

A

Medium bilirubin level: Repeat amniocentesis in 1-2 weeks.

High bilirubin level: This means the fetus is probably anemic. Do a percutaneous umbilical blood sample to measure fetal hematocrit.

115
Q

If a Rh+ fetus of a Rh- mother has an elevated bilirubin level and low hematocrit is evident after percutaneous umbilical blood sample, what do you do?

A

Perform an intrauterine transfusion

116
Q

What is gestational HTN? What is the treatment?

A

BP > 140/90 that starts after 20 weeks gestation.

Treat only during pregnancy with methyldopa, labetalol, or nifedipine.

117
Q

What is preeclampsia? What are the risk factors?

A

Preeclampsia is HTN, edema and proteinuria during pregnancy.

The risk factors are chronic HTN and renal disease.

118
Q

Describe mild preeclampsia in terms of:

  • Blood pressure
  • Proteinuria
  • Edema
  • Mental status changes
  • Vision changes
  • Impaired liver function
A

Mild preeclampsia:

  • Blood pressure: >140/90
  • Proteinuria: Dipstick 1+ to 2+, or 24-hr >300 mg
  • Edema: Hands, feet, face
  • Mental status changes: None
  • Vision changes: None
  • Impaired liver function: None
119
Q

Describe severe preeclampsia in terms of:

  • Blood pressure
  • Proteinuria
  • Edema
  • Mental status changes
  • Vision changes
  • Impaired liver function
A

Severe preeclampsia:

  • Blood pressure: >160/100
  • Proteinuria: Dipstick +3 or more, or 24-hr >5 grams
  • Edema: Generalized
  • Mental status changes: Yes
  • Vision changes: Yes
  • Impaired liver function: Yes
120
Q

What is the treatment of mild preeclampsia if the pregnancy is at term? What if it is preterm?

A

Term: Induce delivery

Preterm: Betamethasone (lung maturation) and magnesium sulfate (seizure prophylaxis)

121
Q

What is the treatment of severe preeclampsia if the pregnancy is at term? What if it is preterm?

A
  1. Prevent eclampsia with magnesium sulfate
  2. Control BP with hydralazine
  3. Deliver if term; give betamethasone if preterm
122
Q

What is eclampsia? What is the treatment?

A

Eclampsia: a tonic-clonic seizure in a pt with preeclampsia.

Treatment:

  1. Stabilize the mother with magnesium sulfate (seizure control) and hydralazine (BP control)
  2. Deliver the baby
123
Q

What is HELLP syndrome? What is the treatment?

A

A complication of preeclampsia characterized by:

  • Hemolysis
  • Elevated Liver enzymes
  • Low Platelets

The treatment is the same for eclampsia:

  1. Stabilize the mother with magnesium sulfate (seizure control) and hydralazine (BP control)
  2. Deliver the baby
124
Q

Does pregestational diabetes refer to having type 1 or type 2 diabetes before becoming pregnant?

A

Both

125
Q

What are the maternal complications of pregestational diabetes?

A
  • Preterm labor
  • Four times more likely to have preeclampsia
  • Two times more likely to have a spontaneous abortion
  • Increased rate of infection
  • Increased postpartum hemorrhage
126
Q

What are the fetal complications of pregestational diabetes?

A
  • Preterm birth
  • Increase in congenital anomalies (heart and neural tube defects)
  • Macrosomia
    • Shoulder dystocia: the shoulder gets stuck under the pubic symphysis during delivery (a complication of macrosomia)
127
Q

In addition to the usual prenatal tests, what tests should be done for a pregnant pt with pregestational diabetes?

A
  • EKG
  • 24-hr urine for baseline renal function (creatinine clearance, protein)
  • Hb A1C
  • Ophthalmological exam for baseline eye function and assessing the condition of the retina
128
Q

For type 1 and type 2 pregestational diabetes, what is the treatment? What is the route of administration?

A

Insulin is used for both.

Type 1: NPH is given via insulin pump
Type 2: NPH and lispro are given subcutaneously

129
Q

Describe fetal testing in pregestational diabetes at 32-36 weeks and at >36 weeks

A

32-36 weeks: Weekly nonstress test (NST) for fetal well-being; ultrasound for fetal size.

> 36 weeks: Twice-weekly testing: one NST for fetal well-being; one biophysical profile (BPP) for amount of fluid and fetal well-being

130
Q

Describe fetal testing in pregestational diabetes at 37 weeks and at 38-39 weeks

A

37 weeks: Lethicin/sphingomyelin ratio to assess fetal lung maturity; if fetal lungs are mature, deliver the fetus.

38-39 weeks (if pt refuses (L/S ratio): No test, just induce labor.

131
Q

What are the maternal complications of gestational diabetes?

A
  • Preterm labor

- The mother is 4-10 times more likely to develop type 2 diabetes after delivery.

132
Q

What are the fetal complications of gestational diabetes?

A
  • Preterm birth
  • Macrosomia with associated birth injuries e.g. Shoulder dystocia
  • Neonatal hypoglycemia: There is an excess of fetal insulin secondary to living in a hyperglycemic environment. When the fetus leaves this environment, the excess insulin causes the glucose level to drop.
133
Q

When do you screen for gestational diabetes? What is the testing for GD?

A

GD is routinely screened for between 24 and 28 weeks GA.

Testing:

  1. Glucose load test: Nonfasting ingestion of 50g glucose with serum measurement at one hour; if serum glucose > 140 mg/dL, then do glucose tolerance test.
  2. Glucose tolerance test: Nonfasting ingestion of 100g glucose with three serum measurements at one, two, and three hours; if any of the measurements are elevated, GD is confirmed.
134
Q

What is the treatment of gestational diabetes?

A

Diet and exercise are first-line. If this fails (fasting glucose > 95 or one hour postprandial glucose > 140), medication is indicated.

Treatment with insulin should be given with NPH before bed and Aspart before meals. For pts who refuse insulin, both metformin and glyburide may be safe and effective. If oral agents don’t work, insulin should be used.

135
Q

How is intrauterine growth restriction (IUGR) defined?

A

Fetuses with IUGR weigh in the bottom 10% for their GA.

136
Q

Describe the two types of IUGR, symmetric and asymmetric

A

Symmetric: Brain in proportion to the rest of the body; occurs before 20 weeks GA.

Asymmetric: Brain weight not decreased; abdomen is smaller than the head; occurs after 20 weeks.

137
Q

What are the causes of IUGR?

A
  • Chromosomal abnormalities
  • Neural tube defects
  • Infections
  • Multiple gestations
  • Maternal HTN or renal disease
  • Maternal malnutrition
  • Maternal substance abuse (smoking is #1 preventable cause in the US)
138
Q

How is IUGR diagnosed?

A

Ultrasound is done to confirm the GA and fetal weight.

139
Q

What are the complications of IUGR?

A
  • Premature labor
  • Stillbirth
  • Fetal hypoxia
  • Lower IQ
  • Seizures
  • Mental retardation
140
Q

What is the treatment of IUGR?

A

No treatment other than to prevent it:

  • Quit smoking
  • Prevent maternal infection with immunizations
141
Q

How is macrosomia defined? What are the risk factors?

A

Macrosomia is estimated birth weight > 4500g.

Risk factors:

  • Maternal diabetes or obesity
  • Advanced maternal age
  • Postterm pregnancy
142
Q

How is macrosomia diagnosed?

A

On physical exam, normally the fundal height in cm equals the GA in weeks. In macrosomia, the fundal height is at least 3 cm greater than the GA in weeks. Ultrasound is done if macrosomia is suspected after comparing fundal height to GA.

US confirms the estimated gestational weight by:

  • Femur length
  • Abdominal circumference
  • Head diameter
143
Q

What are the complications of macrosomia?

A
  • Birth injuries, e.g. shoulder dystocia
  • Low Apgar scores
  • Hypoglycemia
144
Q

What is the treatment of macrosomia?

A
  • Induction of labor should be considered if the lungs are mature BEFORE the fetus is above 4500 g in weight.
  • Cesarean delivery is indicated if the fetus is above 4500 g in weight.

Obstetrics (3 decks)

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