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ENRP II > Obstetrical complications > Flashcards

Obstetrical complications Flashcards

1
Q

what is preterm labor

A

preterm birth/labor is defined as birth that occurs after 20 weeks gestation but before 37 weeks

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2
Q

diagnosis of preterm labor is _ _ accompanied with _ _ or cervical dilation of _ cm and _% effaced

A

uterine contractions

cervical change

OR

cervical dilation of 2cm and or 80% effaced

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3
Q

prematurity is the leading cause of infant _

A

mortality

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4
Q

what causes a preterm labor?

A

spontaneous is the most common reason

multiple gestations

preterm premature rupture of membranes

hypertension in pregnancy

cervical incompetence , uterine anomalies- fibroids, T shaped, bicornate (cant support baby)

antepartum hemorrhage

intrauterine growth restriction

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5
Q

_ are twice as likely as caucasions to have a preterm birth

A

blacks

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6
Q

what socioeconomic factors can lead to PTL

A

high stress, no access to prenatal care, poor nutrition, genetic differences?

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7
Q

what are some medical/OB risk factors for preterm labor

A

history of PTL
history of second trimester abortion
repeated spontaenous first trimester abortions
bleeding in the first trimester
infections
multiple babies in the sac
polyhradminos - more pressure on cervic
incompentent cervic

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8
Q

prevention of PTL is aimed at what 4 main pathways

A
  1. infection (cervical)
  2. placental-vascular
  3. psychosocial stress
  4. unterine stretch
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9
Q

what infections do we want to treat to assess the infection cervical pathway to stop PTL

A

bacterial vaginosis (clue cell)

group B step infections (antibiotics)

gonorrhea and chlamydia

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10
Q

there is a link between infection and progressive changes in the cervical _

A

length

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11
Q

cervical _ is a predictor for preterm birth risk

A

length

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12
Q

the relative risk of PTL increases as cervical length _

A

decreases

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13
Q

the relative risk of 2.4 for PTL in a cervical length of _

A

3.5

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14
Q

the relative risk of 6.2 for PTL in cervical length of

A

2.5

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15
Q

how can you routinely screen for cervical length

A

ulatrasound ( this is inmportant in someone with history of PTL or cold knife conization procedures)

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16
Q

what screening tool can we use to determine cervical length

A

fetal fibronectin (FFN)

this is released from the basement membrane of fetal membranes in times of disruption of membranes, cervical shortening, infection, or uterine activity

has good negative predictive value

positive predictive value is low because it could be indicating something else going on

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17
Q

the placental-vascular pathway begins at the time of _

A

implantation

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18
Q

the placental-vascular pathway is at the level of the _ _ _ interface

A

placental-decidual-myometrial interface

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19
Q

what components make up the placental vascular pathway

A

immunologic component- preeclampsia

vascular component- invasion

lower resistance connection of spiral arteries-inefficient connection

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20
Q

alteration in any of the components of the placental-decidual-myometrial interface (immunologic component, spiral artery connection, vascular component) may result in poor fetal _ which is a risk factor for _ as well as growth restriction and preeclampsia

A

growth

PTL

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21
Q

mental and pyschial stress are thought to induce a stress response that increases release of _ and _

A

cortisol and catecholamines

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22
Q

cortisol is released from _ _ and stimulates early placent _ _ homrone gene expression which assits in labor at term

A

adernal gland

corticotrophin release hormone

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23
Q

catecholamines affect _ _ and can cause uterine _

A

blood flow

uterine contractions

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24
Q

how can you midfy the stress-strain pathway

A

stress reduction and good nutrition

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25
Q

what causes uterine stretch in the uterine stretch pathway

A

increasing volume: polyhydraminos and multiple gestations

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26
Q

symptoms of PTL

A

mesutral like cramping, backache, increase in discharge/blood discharge and uterine contractions

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27
Q

how do you evaluate PTL

A
  1. cervical exam to assess dilation, effacement, and fetal presenting part
  2. evaluate for correctable problems like infection
  3. monitor uterine activity and fetal heart rate
  4. reevlauate cervix and hydrate the patient
  5. take cultures for group B strep and empircally treat and LABS cbc, urinalysis
  6. obtain ultrasound to determine fetal presentation, growth, amniotic fluid, and to rule our congenital anomalies
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28
Q

hydration and rest will resolve _ in about 20% of patients in PTL

A

contractions

but will not stop labor!

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29
Q

what infection should be have cultures taken when a person is admitted for PTL

A

group B strep

need to give them penicillin to emprically treat

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30
Q

how do you manage PTL

A

begin tocolysis if gestational age is less than 34 weeks

get magnesium sulfate
nifedipine
and prostaglandin synthetase inhibitors (idomethicin)

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31
Q

how does magnesium sulfate work

A

it competes for calcium for entry into the cell at the time of depolarization

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32
Q

theraputic serum levels of magnesium sulfate

A

5.5-7.0 mg/dL

given intravenously, can titrate down

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33
Q

continue magnesium sulfate therapy until recieved both doses of _

A

steroids

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34
Q

magnesium sulfate is important in _

A

neuroprotection against cerebral palsy

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35
Q

magnesium sulfate is given when patient is at risk for delivering within _ days. and is currently given if less than _ weeks

A

7 days of delivering

less than 32 weeks gestation

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36
Q

side effects of magnesium (maternal)

A

feeling warm
N/V
respiratory depression at levels of 12
cardiac arrest at levels greater than 30

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37
Q

side effects of magnesium sulfate (neonate)

A

loww of muscle tone
drowsiness
lower apgar score

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38
Q

what is nifedepinde?

A

an oral tocolytic to supress preterm labor

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39
Q

MOA of nifedipine

A

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

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40
Q

side effects of nidedipine (baby and mom)

A

hypotension
tachycardia
headache

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41
Q

what is a prostaglandin synthetase inhibitor - ideomethacin

A

a pgf2a inhibitor that inhibits prostaglandin production that induces myometrial contractions

it is only used on short term basis (extreme prematurity)

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42
Q

indomethacin can be given _ or _

A

orally or rectally

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43
Q

indomethacin can result in _ and can cause premature closure of fetal _ _ and result in pulmonary hypertension and heart failure

A

oligohydraminos

ductus arteriosis

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44
Q

infants exposed to indomethacin are greater risk of _ and _

A

necrotizing enterocolitis and intracranial hemorrhage

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45
Q

_ are used to mature premature fetal lungs

A

glucocorticoids (betamethasone and dexmethasone)

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46
Q

glucorticoids are given between _ and _ weeks gestation

A

24 and 34

47
Q

glucorticoids reduce mortality and incidence of _

A

respiratory distress syndrome, NEC, IVH (intraventricular hemorrhage)

48
Q

how is betamethasone and dexmathasone given and how long do they last

A

betamethasone : 2 doses given 24 hours apart

dexamathasome: 4 doses 12 hours apart

7 days effects last

49
Q

a single course of _ is recommended for pregnant women between 34 and 37 weeks of gestation at risk of preterm birth within 7 days and who have not recieved a course of antenatal corticosteroids

A

betamethasone

50
Q

the lowewr limit of viability is _ weeks or _ grams

A

24 weeks and 500 grams

51
Q

how do you deliver a preterm baby in vertex position

A

vaginal delivery is proffered

52
Q

how do you deliver a preterm baby thats in the breeched postion

A

C section because there is an increased risk cord prolapse or compression or head entrapment in the cervix

53
Q

how can we prevent PTL

A

progesterone IM weekly from 16 weeks to 36 weeks -only used in people with previous history of sponteneous PTL

relaxes the smooth muscle

54
Q

what do we use in women with a shortned cervix

A

vaginal progesterone

or pessary-arabian

55
Q

what is premature rupture of membranes (PROM)

A

premature rupture of membranes before the onest of labor at any gestational age

56
Q

what are the risk factors for PROM

A

history of PROM

infections

short/incompentent cervix

smoking

nutritional def.

second and third trimester bleeding

57
Q

how do you diagnose PROM

A

based on history
- loss of fluid
- -confirmation of amniotic fluid in vagina

58
Q

why should you not cehck the cervic of a presumed ruptured preterm patient

A

it increases the risk of infection

59
Q

PROM rupture is confirmed with?

A

sterile speculum

60
Q

what test detect amniotic fluid

A

amnisure- detects PAMG-1 in amniotic fluid

can be done at any age

not affected by urine, semen, infection, or small amount of blood

cannot use if recent intercourse, digital vaginal exam of significant blood

61
Q

what 3 tests confirm PROM

A

pooling
nitrazine paper (will turn blue)
ferning

ultrasound amniotic fluid volume to aid in fiagnosis

62
Q

what can cause a false positive on nitrazine test

A

urine, semen, cervical mucus, blood, vaginitis

63
Q

what can cause a false negative on nitrazine paper

A

remote PROM with no remainng fluid

minimal leakage

64
Q

an intact amniotic sac provides a barrier to infection: specifically what infection

A

chorioamnionitis

when is an infection of hte membranes and fetus

65
Q

PPROM (premature premature rupture of membranes ) is associated with about 30% of preterm _

A

labors

66
Q

what are some risks that PPROM can cause in the mother

A

endomymetritis

sepsis

failed induction due to an unfavorable cervix

67
Q

management of PPROM depends on what?

A
  1. gestational age at time of rupture
  2. amniotic fluid index
  3. fetal status
  4. maternal status
68
Q

if the gestational age is less than 24 weeks and there is PPROM this may lead to?

A

pulmonary hypoplasia and fetal structural abnormalities

69
Q

if the amniotic fluid index is a value less than 5 or no _cm deepest vertical pocket is found this is called _

A

oligohydraminos

no fluid is anhydramnios

70
Q

when there is PPROM we put them in inpatient care and try to continue pregnancy until lung profile is mature and deliver them at _ weeks

A

34 (regardless of fetal lung maturity, could be earlier if there is an a infection)

71
Q

in a patient with PPROM you must monitor for chorioamniotis: what are the symptoms of this

A

maternal temperature greater than 100.4

fetal or maternal tachycardia

tender uterus

foul smelling amniotic fluid/purulent discharge

72
Q

what should you conservatively give someone with PPROM

A

antibiotcs to prolong the latency period until delivery (decrease their chances of getting an an infection) - ampicillin and erythromycin/azithromycin followed by 5 days of amoxicilin and erythromycin

tocolytics if there are contractions to delay labor and get steroid onboard

steroids up to 34 weeks to reduce risk of RDS

no real place for them to be in outpatient management

73
Q

if lamellar bodies are present, l/s ratio is greater than 2 and phosphatidylglycerol is present what does this mean?

A

the lungs are mature

74
Q

what is intrauterine fetal growth restriction

A

when the fetal weight or abnominal circumference of a newborn is below 10% for any gestational age

75
Q

what is SGA (small for gestational age)

A

birth waeight at the lower extreme of normal birth weight distribution (after delivery)

76
Q

growth restricted fetuses are at risk for?

A

meconium aspiration
hypoxis
polycythemia
hypoglycemia
adult onset of conditons like hypertension, diabetes, CAD, stroke

77
Q

intrauterine growth restriction can be caused by 3 main categories:

A
  1. maternal
  2. placental
  3. fetal
78
Q

what are some maternal causes of IUGR

A

poor nutritional intake/low maternal body weight

smoking

alchoholism

antiphospholipid syndrome **

teratogen exposure

collage vascular disease/autoimmune disorders

79
Q

placental causes of IUGR

A

defective trophoblast invasion

insufficent substrate transfer

giving placental insufficency: due to renal disease, HTN, velamtonous cord, preexisting diabetes

80
Q

fetal causes of IUGR

A

infections: TORCH
toxoplasmosis
other infections
rubella
cytomegalovirus
herpes

also listeriosis

chromosomal abnormalities, congeital anomalies, multiple gestations (fight for room to grow)

81
Q

toxoplasmosis can cause _ in the infant

A

hydrocephalus

82
Q

how do you diagnose IUGR

physical exam
ultrasound
direct studies
other

A

physical exam: fundal height

ultrasound: biometry

direct studies: amniocentesis

other: doppler studies

83
Q

in IUGR serial _ _ measurements is a primary screening tool

A

fundal height

(from the top of the uterus to the pubic bone)

84
Q

if the fundal height lags more than _ cm behind gestational age then order an _

A

3cm

ultrasound

85
Q

ultrasound is used routeinly for high risk conditions that predisopse to IUGR like?

A

HTN, renal disease, diabetes, drug use, Antiphospholipid syndrome, lupus

86
Q

what measurements are we taking during ultrasound to diagnose IUGR

A

biparietal diameter
head cicumference
abdonimal circmference
head-abdominal circumference
femoral length
femoral length to abdominal circumference ratio
amniotic fluid volume
fetal weight
umbilical and uterine artery doppler

87
Q

how do you manage IUGR pre-pregnancy?

A

optimize disease process control (like if they were diabetic or have HTN control these diseases)

88
Q

how do you manage IUGR during pregnancy

A

decrease any modifying factors like stop smoking; and improve nutrition

89
Q

what is the goal with managing IUGR

A

to deliver before fetal compromise byt after fetal lung maturity

90
Q

what do you monitor in a baby with IUGR during pregnancy

A

non-stress test twice weekly

biophysical profile

doppler studies of umbilical artery

91
Q

what is a nonstress test?

A

testing the babies heart rate with an external transducer while the mom is in a left lateral recombent position. a good stress test is 15bpm accelerations lasting at least 15 seconds. It usually takes about 20 minutes.

92
Q

what does the biophysical profile contain

A

NST (which can be omitted if the other 4 portions are normal)

fetal breathing movements

fetal movements

fetal tone

amniotic fluid volume - greater than 2cm

score of 8-10 is normal
uses ultraasound
30 minutes long

93
Q

doppler study of the umbilican artery in IUGR

A

depicts any vascular inmpedence in a fetus

shows umbilical flow velocity, waveform is usually high velocity diastolic flow

in IUGR there is a decrease in umbilical artery diastolic flow (can be absent or reversed)

  • if flow is reversed this is not a good sign and mortality is high
94
Q

if you suspect IUGR and the ultrasound is normal what do you do?

if the ultrasound shows IUGR between 3rd and 10th percentile with normal dopplers what do you do?

if the ultrasound shows IUGR less than 3rd percentile what should you do

early delivery is indicated in cases of ?

A

no intervention

deliver between 38-39 weeks

deliver at 37 weeks

absent/reverse umbilical flow

you can use corticosteroids for lung maturity if less than 37 weeks

95
Q

is IUGR an indication for c-section?

A

no but some fetuses may have less reserve and tolerance for laboe, monitor them!

96
Q

after birth you should monitor a IUGR neonate for what?

A

monitor blood glucoase- because they have less hepatic glycogen stores

monitor respiratory statius - RDS is very common

97
Q

what is a post term pregnancy?

A

this is a pregnancy that continues past 42 weeks

occurs in about 10% of pregnancies

98
Q

post term pregnancies have a higher perinatal mortility rate and can lead to _ syndrome

A

postmaturity

99
Q

what is post maturity syndrome?

A

this is when the placenta ages and infarcts which leads to fat loss, long fingernails, abundant hair, and dry peeling skin in a baby

100
Q

in a post term pregnanct is not complicated by placental insufficeincy the fetus is at risk for _, there could be abnormal _, shoulder dystocia, and c-section

A

macrosomia (greater than 4500 grams)

abnormal labor

101
Q

why do post-term pregnancies occur

A

unsure dates, fetal adrenal hypoplasia, anecephalic features (need normal structures to have a functional labor)
placental sulfatase deficiency
extrauterine pregnancy

102
Q

what is placental sulfatase deficinecy

A

an x linked disease that prevents conversion of sulfated estrogen precursors

103
Q

at 41 weeks in post partum pregnancy you should do what

A

begin fetal testing with NST twice weekly and biophysical profile

if any testing is abnormal or there is no amniotic fluid you should induce labor

104
Q

at 42 weeks in a post term pregnancy you should

A

just induce labor

105
Q

induction of labor at _ weeks is the preferred plan on care in a post-term pregnancy

A

41

106
Q

what is intrauterine fetal demise

A

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

107
Q

what causes an intrauterine fetal demise

A

most of the time the cause is unknown

could be : HTN, diabetes, cholestasis of pregnancy, umbilical cord accident
infections, hemorrhage, antiphopholipid antibodies
thrombophilias

108
Q

diagnosis if IUFD

A

complains of absence of fetal movements, no doppler fetal heart tones

109
Q

confirm IUFD by?

A

ultrasound with lack of fetal acivity and absence of fetal cardiac activity

110
Q

you can watch IUFD up until _ weeks because spontaneous delivery will usually occur within 3 weeks of fetal demise

A

28

111
Q

you can induce labor in IUFD and this will require cervical ripening with prostaglandins, _, misprostol, oxytocin

A

laminaria

112
Q

patients with IUFD are at high risk for _ and need to follow complete blood count, fibrinogen levels, and PT/PTT/INR

A

disseminated intravascular coagulopathy

113
Q

follow up of IUFD includes?

A

TORCH titers
fetal chromosome studies and fetal autopsy which must be consentede to
listeria cultures
anticardiolipin antibodies

(susbequent pregnancies are at a greater risk for IUFD so antenatal testing should be done)

ENRP II (25 decks)

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