Obstetrical Complications Flashcards by erin flaherty

Preterm birth is defined as what?

Birth that occurs after 20 weeks but before 36 weeks and 6/7 days completed weeks of gestation

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The diagnosis of preterm labor is defined as what events?

Uterine contractions accompanied with cervical change

Cervical dilation of 2cm and/or 80% effaced

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Which ethnicity is 2x more likely to experience pre-term labor?

African Americans 2x more likely than Caucasians

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What 4 pathways are aimed at when preventing PTL?

Infection (cervical)
Placental-vascular
Psychosocial stress and work strain
Uterine stretch

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What infections are associated with PTL?

bacterial vaginosis

group B strep

gonorrhea and chlamydia

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There is a link between infection and progressive changes in cervical length and how is this related to preterm labor?

Risk of PTL ↑ as cervical length ↓

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What are 2 screening tools that can be used to assess cervical length and to better predict risk of PTL?

Ultrasound for routine screening of cervical length
Fetal fibronectin (FFN) released from BM’s of fetal membranes in response to disruption of the membranes as w/ uterine activity, cervical shortening or infection

*negative predictive value is good; positive predictive value is low.

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Alterations of any of the components of the placental-vascular pathway (immunologic component, vascular component, or low resistance connection of spiral arteries) is a risk factor for what?

results in poor fetal growth which is a risk factor for PTL as well as growth restriction and preeclampsia

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Mental and physical stress are thought to induce a stress response that increases the release of what 2 things?

What is the effect of these 2 products?

Cortisol and catecholamines

Cortisol: released from the adrenal glands; stimulates early placental corticotrophin-releasing hormone (CRH) gene expression and increased CRH levels are known to assist in labor at term

Catecholamines: affect blood flow and can cause uterine contractions

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The uterine stretch pathway in PTL is a risk factor in what women?

polyhydramnios
multiple gestations

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What is the evaluation for PTL when a patient presents with any of the symptoms?

initial assessment done with cervical exam to assess dilation, effacement, and fetal presenting part

evaluate for any underlying correctable problems such as infection

external monitoring for uterine activity and fetal heart rate

reevaluate the cervix (usually at an hour) and during that hour oral or IV hydrate

cultures should be taken for GBS

also obtain an US

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How is group B strep usually treated?

Antibiotics, typically penicillin, are given empirically to treat for GBS and usually discontinued if culture negative

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Once you diagnose a patient with either 2 cm and/or 80% effacement or having made cervical change, what should you do next?

begin tocolysis (if gestational age is less than 34 weeks and there are no contraindications)

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What are 3 tocolytic agents Whooten discussed?

Magnesium sulfate

Nifedipine

Prostaglandin Synthetase Inhibitors (indomethicin)

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What is the MOA of magnesium sulfate?

it acts on the cellular level and competes with calcium for entry into the cell at the time of depolarization

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What have some recent studies suggested about magnesium sulfate?

it may be more important in the role of neuroprotection

may offer prevention against cerebral palsy

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What are the maternal side effects of magnesium sulfate?

feeling of warmth or flushing

nausea and vomiting

respiratory depression

cardiac conduction defects and arrest at high serum levels

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What are the side effects in the neonate when mother is given magnesium sulfate?

loss of muscle tone

drowsiness

lower Apgar scores

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What is Nifedipine

side effects

MOA

an oral agent effective in suppressing preterm labor

minimal maternal and fetal side effects

MOA: inhibits slow, inward current of calcium during the second phase of the action potential

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What is the MOA of prostaglandin synthetase inhibitors?

What are the AEs of indomethacin?

they inhibit prostaglandin production that induce myometrial contractions

can cause oligohydramnios (decreases fetal renal function)

can cause premature closure of fetal ductus arteriosis and result in pulmonary hypertension and heart failure

infants exposed are at greater risk of necrotizing enterocolitis, intracranial hemorrhage

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Which tocolytic used for PTL is only used on a short-term basis (mostly for extreme prematurity)?

Indomethacin

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What are NSAIDs (Ibuprofen) used for in regards to PTL?

Used to ↓ uterine activity
NOT used for primary treatment of preterm labor

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Glucocorticoids are given for fetal lung maturation between what weeks?

Between 24 weeks and 34 weeks gestation

A single course of betamethasone is recommended for pregnant women between which weeks of gestation if at risk of PTL within 7 days and who have no received a previous corse of antenatal corticosteroids?

Between 34 0/7 week and 36 6/7 weeks of gestation

What are some of the preventative measures being used for PTL?

- **IM progesterone (Makena)** given **weekly** from **16-36 weeks** in women w/ prior hx of spontaneous PTL/PPROM - **Vaginal progesterone** used in women w/ **shortened** cervix (\<2.5 cm) - **Pessary** **(Arabin pessary)** used in women w/ **shortened** cervix

Diagnosis of premature rupture of membranes (PROM) is based on what; confirmed how?

- **History!** ---\> loss of fluid + confirmation of amniotic fluid in vagina - **Rupture** is confirmed using a **sterile speculum (AmniSure Test)**

What should you never do when assessing a presumed ruptured **_preterm_** patient?

Do **NOT** check the cervix ---\> ↑ risk of **infection** especially w/ prolonged latency before delivery

What are 3 tests that can be done to confirm PROM?

- **Pooling** - **Nitrazine paper** (**turns blue**) - **Ferning**

What could cause a false negative nitrazine result?

remote PROM with no remaining fluid minimal leakage

What are the Maternal risks of PPROM?

endomyometritis (infection of uterus postpartum) sepsis failed induction due to infavorable cervix

Management of PPROM depends on what 4 factors?

1. **Gestational age** at time of **rupture:** if **\<24 wks** may lead to **pulmonary hypoplasia** 2. **Amniotic fluid index**: any value **\<5cm** is considered **oligohydramnios** 3. **Fetal status** 4. **Maternal status**

What is the goal of management for PPROM?

**Continue** the **pregnancy** until **lung profile** is **mature**

Regardless of fetal lung maturity, most women with PPROM will deliver at how many weeks gestation?

**34 weeks**

While managing woman with PPROM you must monitor for signs/sx's of chorioamnionitis, which include what?

- **Maternal temp \>100.4 °F** - **Fetal** or **maternal tachycardia** - **Tender uterus** - **Foul smelling amniotic fluid/purulent discharge**

ACOG recommends using what drugs to attempt to prolong latency period of woman with PPROM?

- **48 hour course** of **IV Ampicillin** and **Erythromycin/Azithromycin** - Followed by **5 days** of **Amoxil** and **Erythromycin**

What is the ACOG recommendation for use of steroids in patient with PPROM?

Use **up to 34 weeks** of gestation to ↓ risk of **RDS**

What is the definition of intrauterine growth restriction (IUGR)?

when the estimated fetal weight or abdominal circumference of a newborn is below 10% for a given gestational age

What is the definition of small for gestational age (SGA)?

birth weight at the lower extreme of normal birth weight distribution

What are the placental causes of IUGR?

insufficient substrate transfer through placenta as well as defective trophoblast invasion

What are some conditions which may result in placental insufficiency?

hypertension renal disease placental or cord abnormalities such as velamentous cord insertion preexisting diabetes

What are the fetal causes of IUGR?

infectious disease such as intrauterine infections, listeriosis, or TORCH infections congenital anomalies/genetic disorders multiple gestations chromosomal abnormalities

What is the primary screening tool used to assess/diagnose intrauterine growth restriction?

Serial **fundal height** measurements

If fundal height lags more than how many cm behind gestational age do you then order an ultrasound to assess intrauterine growth restriction?

Lags **more** than **3cm** behind gestational age

How do you manage IUGR antepartum?

decrease any modifying factors: improve nutrition, stop smoking goal: deliver before fetal compromise but after fetal lung maturity Monitor: non-stress test twice weekly, biophysical profile, doppler studies of umbilical artery

if you suspect IUGR and you perform an ultrasound, how would you manage: Normal ultrasound? Ultrasound that shows IUGR between 3rd and 10th percentile with normal dopplers? ultrasound shows IUGR less than 3rd percentile? Ultrasound shows absent or reverse umbilical flow?

Normal: no intervention ultrasound shows IUGR between 3rd and 10th percentile with normal dopplers: deliver between 38-39 weeks ultrasound shows IUGR less than 3rd percentile: recommended to deliver at 37 weeks earlier delivery is indicated in cases of absent or reverse umbilical flow

What is considered a normal doppler study of the umbilical artery? What is considered to be a finding of a doppler study of the umbilical artery in a patient with IUGR?

normal: the umbilical flow velocity waveform of normally growing fetuses is characterized by high-velocity diastolic flow IUGR: there is a diminution of umbilical artery diastolic flow

What 2 things should be monitored after birth of a fetus that was subjected to IUGR?

- Neonatal **blood glucose** because these neonates have **less hepatic glycogen stores** - Monitor **respiratory status** as **RDS** is **more common**

babies born with IUGR are at greater risk for adult onset what?

diabetes, HTN, and CAD

What is the definition of a post-term pregnancy?

a pregnancy that continues past 42 weeks

What is postmaturity syndrome?

related to aging and infarction of the placenta loss of subcutaneous fat, long fingernails, dry and peeling skin, and abundant hair

if not affected by placental insufficiency, what are post-term pregnancies at risk for?

fetal macrosomia (greater than 4500 g) abnormal labor shoulder dystocia c-section

what are some of the etiologies of post-term pregnancies?

unsure dates, fetal adrenal hypoplasia, anencephalic fetuses, placental sulfatase deficiency, and extra-uterine pregnancy

How should you manage post-term pregancies?

in the 41st week: begin antenatal testing to include twice weekly NST and biophysical profile; if abnormal or oligohydramnios then induce labor in the 42nd week: induction of labor

what is intrauterine fetal demise (IUFD)?

fetal death after 20 weeks gestation but before the onset of labor

how do you manage IUFD?

watchful expectancy: only up till 28 weeks gestation, spontaneous labor will occur within 2-3 weeks of fetal demise induction of labor: most will require cervical ripening with prostaglandin/laminaria/misoprostol/oxytocin monitoring of coagulopathy: patients with IUFD are at risk of DIC; need to follow CBC, fibrinogen level, PT/PTT/INR