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Endo/Repro > Obstetric Complications > Flashcards

Obstetric Complications Flashcards

1
Q

When is preterm birth?

A
  • Birth after 20 weeks gestation and before 36 6/7 weeks
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2
Q

How is diagnosis of preterm birth done?

A
  • Uterine contractions accompanied with cervical change or cervical dilation of 2 cm and/or 80% effaced
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3
Q

What causes preterm labor?

A
  • Spontaneous
  • Multiple gestations
  • Preterm premature rupture of membranes (PPROM)
  • Pregnancy associated hypertension
  • Cervical incompetence or uterine anomalies
  • Antepartum hemorrhage
  • IUGR
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4
Q

What are some socioeconomic factors that cause PTL?

A
  • African American’s twice as likely as Caucasians
  • Decrease access to prenatal care
  • High stress levels
  • Poor nutrition
  • Questionable genetic differences
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5
Q

What are some medical and obstetrical factors that cause PTL?

A
  • Previous history of PTL
  • History of second trimester abortion
  • Repeated spontaneous first trimester abortions
  • Bleeding in the first trimester
  • UTI/genital tract infections
  • Multiple gestation
  • Uterine anomalies
  • Polyhydramnios
  • Incompetent cervix
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6
Q

What are some infections that may cause PTL?

A
  • Bacterial vaginosis
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7
Q

What is done to help reduce PTL due to bacterial vaginosis?

A
  • Treatment for group B strep, gonorrhea, and chlamydia
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8
Q

How does the length of the cervix affect PTL?

A
  • Relative risk of PTL increases as cervical length decreases
  • Checked via ultrasound
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9
Q

What is a screening tool used to check cervical length?

A
  • Fetal fibronectin (FFN)
  • Released from the basement of the fetal membranes
  • Released in response to disruption of the membranes as with uterine activity, cervical shortening, or infection
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10
Q

When does the placental-vascular pathway begin?

A
  • At time of implantation
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11
Q

What is seen at the level of the placental-decidual-myometrial interface?

A
  • Immunologic component
  • Vascular component
  • Low resistance connection of spiral arteries
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12
Q

What could alteration to any of the components see at the level of the placental-decidual-myometrial interface do?

A
  • May result in poor fetal growth which is a risk factor for PTL as well as growth restriction and preeclampsia
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13
Q

What is the stress-strain pathway?

A
  • Mental and physical stress are thought to induce a stress response that increases the release of cortisol and catecholamines
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14
Q

What does cortisol do?

A
  • Released from adrenals
  • Stimulates early placental corticotropin-releasing hormone (CRH) gene expression and increased CRH levels are known to assist in labor at term
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15
Q

How do catecholamines affect PTL?

A
  • Affect blood flow and can cause uterine contractions
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16
Q

What is the uterine stretch pathway?

A
  • Uterine stretches as a result of increasing volume

- If the uterus gets to a “full term” size, then contractions may begin

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17
Q

What must be present for the diagnosis of PTL?

A
  • Uterine contractions

- Cervical change or cervical dilation of 2 cm or greater AND/OR 80% effacement

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18
Q

What are the symptoms of PTL?

A
  • Menstrual like cramping
  • Low/dull backache
  • Pelvic pressure
  • Increase in discharge/blood discharge
  • Uterine contractions
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19
Q

What is done to look for PTL?

A
  • Initial assessment done with cervical exam to assess dilation, effacement and fetal presenting part
  • Evaluate for any underlying correctable problems such as infections
  • External monitoring for uterine activity and fetal heart rate
  • Reevaluate the cervix and during that hour oral or IV hydrate
  • Cultures are taken
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20
Q

What is done once a diagnosis has been made?

A
  • CBC
  • UA
  • Urine culture
  • Obtain an ultrasound
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21
Q

What is the management of PTL?

A
  • If diagnosed 2 cm and/or 80% effaced or made cervical change then begin tocolysis (if gestational age is less than 34 weeks and no contraindication)
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22
Q

What does magnesium sulfate do?

A
  • Acts on the cellular level and competes with calcium for entry into the cell at the time of depolarization
  • May have a role in neuroprotection or prevention of cerebral palsy
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23
Q

How much magnesium sulfate is given?

A
  • 6g load IV and then 3g/hour maintenance
  • Therapeutic range is 5.5-7 mg/dL
  • Continue until both doses of steroids are given
  • Titrate down if uterine activity decreases
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24
Q

What are some maternal side effects of magnesium sulfate?

A
  • Feeling of warmth and flushing
  • Nausea and vomiting
  • Respiratory depression
  • Cardiac conduction defects and arrest at high serum levels
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25
Q

What are some neonate side effect of magnesium sulfate?

A
  • Loss of muscle tone
  • Drowsiness
  • Lower Apgar scores
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26
Q

What is nifedipine?

A
  • An oral agent effective in suppressing preterm labor

- Minimal maternal and neonatal side effects

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27
Q

What does nifedipine do?

A
  • Inhibits slow, inward current of calcium during the second phase of the action potential
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28
Q

What side effects are seen with nifedipine?

A
  • Headache
  • Cutaneous flushing
  • Hypotension
  • Tachycardia
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29
Q

What do prostaglandin synthetase inhibitors do?

A
  • Inhibit prostaglandin production that induce myometrial contractions
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30
Q

What is the most common prostaglandin synthetase inhibitor?

A
  • Indomethacin which can be given orally
  • Can result in oligohydramnios
  • Can cause the premature closure of fetal ductus arteriosus and result in primary hypertension and heart failure
31
Q

What are infants that are exposed to indomethacin at a higher rate of?

A
  • Necrotizing enterocolitis

- Intracranial hemorrhage

32
Q

What is the biggest risk with PTL?

A
  • Fetal lung maturation
33
Q

What is used for fetal lung maturation?

A
  • Glucocorticoids which reduces mortality and incidence of RDS and intraventricular hemorrhage
34
Q

When are glucocorticoids given?

A
  • Given between 24 and 34 weeks gestation
35
Q

How are glucocorticoids given?

A
  • Either two doses of 12mg betamethasone given 24 hours apart or 4 doses of dexamethasone given every 12 hours
36
Q

How long do the effects of glucocorticoids last?

A
  • 7 days
37
Q

What is the lower limit of viability?

A
  • 22?-24 weeks or 500 grams
38
Q

What should be done for a preterm infant?

A
  • Continuous fetal monitoring and act quickly on abnormal patterns as premature infants have less reserves
39
Q

What is the delivery method if there is vertex presentation?

A
  • Vaginal is preferred

- Some recommend c section due to low birth weight

40
Q

What is the delivery method if there is breech presentation?

A
  • Increased risk of cord prolapse or compression as well as head entrapment with vaginal delivery therefore most will c-section
41
Q

What are some prevention methods of PTL?

A
  • IM progesterone
  • Vaginal progesterone (used in women with short cervix)
  • Pessary-Arabian pessary (used in women with short cervix)
42
Q

What are some risk factors for PPROM?

A
  • History of preterm premature rupture of membranes
  • Vaginal/cervical infections
  • Second and third trimester bleeding
  • Incompetent/short cervix
  • Low BMI
  • Lower socioeconomic status
  • Smoking and illicit drug use
  • Nutritional deficiencies
43
Q

How is the diagnosis of PROM made?

A
  • Based on history
  • Loss of fluid
  • Confirmation of amniotic fluid in vagina
  • Confirmed with a sterile speculum
44
Q

Why do you not check the cervix of a presumed ruptured preterm patient?

A
  • Increases the risk of infection especially during the prolonged latency before delivery
45
Q

What are the three tests to confirm PROM?

A
  • Pooling
  • Nitrazine paper (turns blue)
  • Ferning
  • May also use ultrasound to evaluate amniotic fluid volume to aid in diagnosis
46
Q

What are some causes of false positives in nitrazine results?

A
  • Urine
  • Semen
  • Cervical mucous
  • Blood
  • Vaginitis
47
Q

What are some causes of false negatives in nitrazine results?

A
  • Remote PROM with no remaining fluid

- Minimal leakage

48
Q

What are some maternal risks with management of PPROM?

A
  • Endomyometritis
  • Sepsis
  • Failed induction due to unfavorable cervix
49
Q

What does management of PPROM depend on?

A
  • Gestational age at time of rupture (if less than 24 weeks, may lead to pulmonary hypoplasia)
  • Amniotic fluid index (any value less than 5 cm is considered or no 2 cm deepest vertical pocket = oligohydramnios)
  • Fetal status
  • Maternal status
50
Q

What is the goal of conservative management of PPROM?

A
  • Continue pregnancy until lung profile is mature

- Usually will deliver around 34 weeks due to benefits of delivering outweighing the risks

51
Q

What is monitored for and how is it diagnosed?

A
  • Monitor for signs of chorioamnionitis
  • Diagnosed by maternal temperature greater than 100.,4
  • Fetal or maternal tachycardia
  • Tender uterus
  • Foul smelling amniotic fluid/purulent discharge
52
Q

What antibiotic use is recommended in management of PPROM?

A
  • 48 hour course of IV ampicillin and erythromycin/azithromycin followed by 5 days of amoxil and erythromycin
53
Q

What tocolytic use is recommended in management of PPROM?

A
  • No recommendation can be made for or against
  • Can be used if no evidence of chorioamnionitis
  • Use mainly to get steroids on board
54
Q

What steroid use is recommended in management of PPROM?

A
  • Use up to 34 weeks of gestation to reduce the risk of RDS
55
Q

What is the outpatient management in PPROM?

A
  • No real place for outpatient management

- May manage in cases of extreme prematurity until reaches viability

56
Q

What is intrauterine growth restriction?

A
  • When the birth weight of a newborn is below 10% for a given gestational age
57
Q

What are growth restricted fetuses at risk for?

A
  • Meconium aspiration
  • Hypoxia
  • Stillbirth
  • Polycythemia
  • Hypoglycemia
  • Cognitive delay
  • Adult onset conditions like HTN, DM, CAD, stroke
58
Q

What are some causes of IUGR?

A
  • Poor nutritional intake/low maternal body weight
  • Cigarette smoking
  • Drug abuse
  • Alcoholism
  • Cyanotic heart disease
  • Pulmonary insufficiency
  • Antiphospholipid syndrome
  • Collagen vascular disease/autoimmune disorders
  • Teratogen exposure
59
Q

What are some placental causes of IUGR?

A
  • Insufficient substrate transfer through placenta as well as defective trophoblast invasion
  • Conditions that may result in placental insufficiency like HTN, renal disease, placenta or cord abnormalities, preexisting diabetes
60
Q

What are some fetal causes of IUGR?

A
  • Infectious diseases (listeria, TORCH)
  • Congenital anomalies/genetic disorders
  • Multiple gestations
  • Chromosomal abnormalities
61
Q

How is IUGR diagnosed?

A
  • Physical exam –> fundal height
  • Ultrasound –> biometry
  • Direct studies –> amniocentesis or percutaneous umbilical blood sampling
  • Doppler studies
62
Q

How is IUGR managed pre-pregnancy?

A
  • Optimizing disease processes

- I.E. blood sugar control in diabetes, control of HTN

63
Q

How is IUGR managed in antepartum?

A
  • Decrease any modifying factors –> improve nutrition, stop smoking
  • Goal is to deliver before fetal compromise but after fetal lung maturity
64
Q

What is monitored in antepartum?

A
  • Non-stress test twice weekly
  • Biophysical profile
  • Doppler studies of umbilical artery
65
Q

What is post term pregnancy?

A
  • Pregnancy that continues past 42 weeks
66
Q

What is seen in post term pregnancy?

A
  • Perinatal mortality is 2-3x higher

- Postmaturity syndrome

67
Q

What is postmaturity syndrome?

A
  • Related to aging and infarction of the placenta

- Loss of subcutaneous fat, long fingernails, dry and peeling skin and abundant hair

68
Q

What are some etiologies of postterm pregnancy?

A
  • Usure due dates
  • Fetal adrenal hypoplasia
  • Anencephalic fetuses
  • Placental sulfatase deficiency
  • Extra-uterine pregnancy
69
Q

What is the management of a postterm pregnancy?

A
  • In 41st week: begin antenatal testing to include twice weekly NST and biophysical profile
  • In 42nd week: induction of labor
  • Induction of labor at 41 weeks is preferred
70
Q

What is intrauterine fetal demise?

A
  • Fetal death after 20 weeks gestation but before onset of labor
71
Q

What are some causes of IUFD?

A
  • Most are unknown (50%)
72
Q

How is IUFD diagnosed?

A
  • Suspect if patient complains of absence of fetal movements or if unable to Doppler fetal heart tones
  • Confirm by ultrasound with lack of fetal activity and absence of fetal cardiac activity
73
Q

What is the follow up on an IUFD?

A
  • TORCH titers
  • Parvovirus studies
  • Listeria cultures
  • Anticardiolipin antibodies
  • Hereditary thrombophilias
  • Fetal chromosome studies
  • Fetal autopsy

Endo/Repro (31 decks)

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