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NRS 251 D: Emergency, Surgery, Geriatrics, Peds, OB > Obstetrics > Flashcards

Obstetrics Flashcards

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1
Q

Stages of Pregnancy & Birth

A
  • -Pregnancy: 1st trimester (weeks 1-12), 2nd Trimester (weeks 13-28), 3rd trimester (weeks 29- birth)
  • -Birth: Preterm (< 37 weeks), term (37-42 weeks), post-term ( >42 weeks)
  • **Notes: at 37 weeks the fetal lungs have fully developed so baby won’t need respiratory assistance; at 42 weeks the placenta begins to age out & breakdown → impairs the fetal circulation and oxygenation
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2
Q

Diagnosis of Pregnancy

A
  • Serum B-hCG: definitive test, can detect pregnancy 5 days after conception
  • Urine B-hCG: can detect pregnancy 14 days after conception
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3
Q

Physical Exam for Uncomplicated Pregnancies and the different signs

A
  • -Height, weight, & BMI at EVERY visit (recommended weight gain of 25-35 lbs if normal BMI)
  • -Systems to examine: thyroid, CV, respiratory, abdomen, breast, GYN
  • -Auscultation: fetal heart tones best heard after 10 weeks by Doppler (normal = 120-160)
  • -Ladin’s Sign: Uterus softening after 6 weeks
  • -Hegar’s Sign: uterine isthmus softening after 6-8 weeks
  • -Piskacek’s Sign: palpable lateral or softening of uterine cornus after 7-8 weeks
  • -Goodell’s Sign: cervical softening due to increased vascularization after 4-5 weeks
  • -Chadwick’s Sign: bluish coloration of the cervix & vulva after 8-12 weeks
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4
Q

Ladin’s Sign

A
  • Ladin’s Sign: Uterus softening after 6 weeks
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5
Q

Hegar’s Sign

A
  • -Hegar’s Sign: uterine isthmus softening after 6-8 weeks
  • On the surface of the uterus, about midway between the apex and base, is a slight constriction, known as the isthmus
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6
Q

Piskacek’s Sign

A

Piskacek’s Sign: palpable lateral or softening of uterine cornus after 7-8 weeks

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7
Q

Goodell’s Sign

A

Goodell’s Sign: cervical softening due to increased vascularization after 4-5 weeks

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8
Q

Chadwick’s Sign

A

Chadwick’s Sign: bluish coloration of the cervix & vulva after 8-12 weeks

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9
Q

Diagnostics that can be used during pregnancy

A
  • -Pelvis US: detects fetys ~5-6 weeks
  • -Non-Stress Test (NST): assess whether the intrauterine environment is supportive of the baby’s health; woman lies down with 2 monitors attached to her abdomen that monitor baby’s heartbeat & maternal contractions for 20 minutes; Reactive if fetal HR is 110-160 with moderate variability & 2+ heart rate accelerations (> 15bpm from baseline lasting > 15 seconds); if non reactive (BAD), try to stimulate baby with food or vibro-acoustic stimulator
  • -Contraction Stress Test: non-stress test while mother is having contractions; Positive (bad) when baby is compromised 99% of the time but high false positive rate
  • -Amniotic Fluid Index (AFI): US measurement of the fluid surrounding the baby; measurements of fluid taken in 4 quadrants of abdomen & added together; normal 6-24
  • -Estimated Fetal Weight (EFW): indicated if risk for IUGR (intrauterine growth restriction), not an accurate predictor for macrosomia
  • -Biophysical Profile (BPP): 5 parameters: NST, fetal breathing movements, fetal movement, fetal tone, amniotic fluid volume; 8/10 is a reassuring score, 4/10 = non reassuring → delivery wanted.
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10
Q

Fundal Height Measurements

A
  • -Number of cm = # weeks GA +/- 2 cm
  • -Milestones: 12 weeks→ fundus at symphysis pubis, 20 weeks→ fundus at umbilicus.
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11
Q

Estimated Delivery Date

A
  • -Naegele’s Rule: 1st day of LMP + 7 days - 3 months ( then change the year)
  • -Other methods: SNLP (sure normal last menstrual period), pregnancy wheel (40 weeks from 1st day of LMP), US (most accurate in 1st trimester as fetuses vary in size in 2nd/3rd trimester)
  • **Notes: dating is important because we want to track fetal growth, educate the mother throughout the pregnancy, and determine what tests are needed at particular times.
    *
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12
Q

Types of Genetic Screening in Pregnancy

A
  • “Never Not Making Quality Assessments, Chris!”
  • **Note that these are screenings that tell you low/high risk, NOT definitive.
  • -Non-Invasive Prenatal Testing (NIPT): blood drawn after 10 weeks that measures fetal cell DNA fragments in the mother’s blood; screens for Trisomy 13, 18, & 21, chromosomal sex disorders, & identifies sex of the fetus
    • done 1st tri
  • -Nuchal Translucency US: done at 11-13 weeks; measurement of nuchal fold correlates with risk of Down Syndrome
    • don 1st tri
  • -Maternal Serum Alpha-FetoProtein: done at 14-22 weeks; screens for trisomy 18, 21, neural tube defects
    • done 2nd tri
  • -Quad Screen: done at 15-18 weeks; measurement of AFP, HCG, estriol, & inhibin A; screens for trisomy 18, Down syndrome, neural tube defects (spina bifida), or abdominal wall defects
    • done 2nd tri
  • -Amniocentesis: done at 15-20 weeks; consider if positive results on prenatal screening
  • Chorionic Villus Sampling: done at 11-14 weeks, sample of chorionic villus removed from placenta for testing
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13
Q

How frequently does a preggo need to be seen for an uncomplicated pregnancy?

A

q 4 weeks up to 32 weeks, q 2 weeks 32-36 weeks, q week 36-40 weeks, twice weekly at 41+ weeks, 6 weeks postpartum, for vaginal delivery or 1 week & 8 weeks for C-section delivery.

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14
Q

What is done at the initial prenatal visit?

A
  • Pregnancy confirmation (pregnancy in uterus? Viable embryo?), pregnancy dating, complete Hx & PE, fundal height measurement, fetal heart tones
    • Screening/Test: 1st trimester panel, US (for EDD, dating confirmation by measuring fetal pole), genetic testing (maternal/paternal carrier status, fetal chromosomes)
      *
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15
Q

What is done during the 1st trimester visits?

A
  • Weeks 1-12:
    • -Standard Labs: blood type & Rh, antibody screen, CBC, UA (protein- preeclampsia, glucose- GDM), rubella titer, varicella titer, hepatitis B & C Igg, GC/CT, syphilis RPR/VDRL (at prenatal & 28 weeks), HIV, pap smear
    • -PRN labs: carrier screening for Tay Sachs/Cystic Fibrosis/ Sickle Cell Anemia, genetic screening test, disease specific labs
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16
Q

What is done during the 2nd trimester visits?

A

2nd Trimester: weeks 13-28

  • At 18-20 weeks: US for fetal anatomy survey
  • At 28-35 weeks: 1 hour GTT/ 3 hour GTT (if 1 H is +), CBC, Rh antibodies, Syphilis repeat
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17
Q

What is done during 3rd trimester visits?

A

3rd Trimester: weeks 29-birth

  • After 28 weeks: fetal kick counts (spend 1 hour counting baby’s movements, can stop after 10)
  • At 28-35 weeks: TDaP given (provides pertussis antibodies to fetus)
  • At 35-37 weeks: GBS (group B strep) culture (25% of women are colonized & transmitted vertically → if positive = tx in labor with penicillin or ampicillin IV)
  • After 36 weeks: palpate & US to confirm vertex fetal position
  • After 37 weeks: schedule external rotation for non-vertex fetal position
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18
Q

Physiologic Changes Leading to Labor

A

(Final 4 weeks): fetal lie (spine position), uterine contractions, cervical dilation, cervical effacement (thinning), fetal station (relation to ischial spine)

  • Fetal Lie: by week 36 fetus should be in vertex presentation (longitudinal position) for vaginal delivery
  • Uterine Contractions: uterine muscles tighten & shorten assisting in dilation, effacement, & descent of fetus into birth canal; active labor = contractions q 5 minutes each lasting 1 minute for at least 1 hour.
  • Cervical Dilation: internal cervical os begins to open, measured by cm or finger widths during cervical check; 1 cm - 10 cm (fully dilated)
  • Cervical Effacement; thinning of the cervix leading toward labor; occurs during final week or days of pregnancy; measured in percentages (25%, 50%, 75%, 100% = fully effaced)
  • Fetal Station: fetal head (or presenting part) in relation to the pelvic ischial spines; measured as -3, -2, -1, 0, +1, +2, +3, delivered
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19
Q

Stages of Labor

A

(Avg length of all stages is 8 hours)

  1. Effacement & dilation: latent phase
  2. Active Labor: baby moves through the birth canal
  3. Afterbirth: delivery of the placenta
  4. Recovery
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20
Q

Labor Complications & Indications for C-Section

A

GDM, hypertensive disorder, HSV outbreak, fetal distress, fetal malpresentation, dystocia

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21
Q

Contraction Stress Test

A

Contraction Stress Test: electronic fetal monitoring with uterine contractions during labor

→ Positive (bad): baby’s heart rate decelerations & stays slow after contractions for > ½ contractions

→ Non-reactive Fetal Monitoring: emergency C-section with goal of <30 minutes from decision to delivery

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22
Q

Intrapartum Definitions: Braxton-Hicks Contractions

A

spontaneous uterine contractions late in pregnancy not associated with cervical dilation

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23
Q

Intrapartum Definitions: Lightening

A

fetal head descending into pelvis → change in abd shape & sensation the baby is “lighter”

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24
Q

Intrapartum Definitions: Ruptured Membranes

A

sudden gush of liquid or constant leaking of fluid

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25
Q

Intrapartum Definitions: Bloody Show

A

passage of blood-tinged cervical mucus late in pregnancy that occurs when cervix begins thinning

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26
Q

True Labor

A

contractions of the uterine fundus with radiation to the lower back & abdomen: regular & painful contractions of the uterus → cervical dilation & fetus expulsion

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27
Q

Cardinal Movements of Labor

A
  1. Engagement: fetal presenting part enters the pelvic inlet
  2. Descent: passage of the head into the pelvis (“lightening”)
  3. Flexion: flexion of the head to allow the smallest diameter to present to the pelvis
  4. Internal Rotation: fetal vertex moves from occiput transverse position to a position where the sagittal suture is parallel to the anteroposterior diameter of the pelvis
  5. Extension: vertex extends as it passes beneath the pubic symphysis
  6. External Rotation: fetus externally rotates after the head is delivered so that the shoulder be delivered
  7. Expulsion
  8. “Everybody Does Fart In Extremely Egregious Explosions”
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28
Q

Maternal Assessment PostPartum

A

need to perform assessment within a few hours of birth & 6-8 weeks postpartum

→ BUBBLE-HE(EAT): breasts, uterus, bladder, bowel, lochial (vaginal discharge after birth), episiotomy/lac/incision, Homan’s (for DVT), edema, emotions, attachment, transition

→ Breasts: normal findings include intact tender everted nipples, abnormal = abrasion, bleeding, flat, inverted nips

→ Uterus: measurement of postpartum fundal involution (takes ~ 10 days for uterus to return to prepartum size, can do fundal massage); normal = fundus firm, at or below umbilicus, midline, non-tender, uterine cramping relieved with motrin or vicodin, & decreasing with time; abnormal = boggy fundus, above umbilicus, left or right of midline, tender, & uterine cramping that is hard to control with motrin or vicodin & not decreasing in intensity with time

→ Bladder: normal = voiding regularly (no retention/distension), no bladder infection, diuresis, some stress incontinence; abnormal = inability to void, dysuria

→ Bowel: Normal = fear of bowel movement, hemorrhoids, no BM for 2-3 days PP; abnormal = no BM > 3 days PP

→ Lochia: postpartum vaginal discharge, hemorrhage = 1+ liter, tx by 500mL lost or volume status change; types include lochia rubra (red, day 1-3), lochia serosa (pink, day 3-10), lochia alba (white, days 10-14), normal = lochia rubra x 3 days with small clots, menstrual odor; abnormal = soaking >1 pad per hour with large golf-ball sized clots, foul odor.

→ Episiotomy/Laceration/Incision: normal = not bleeding, stitches/staples intact, no signs of inx, edema resolving; abnormal = bleeding, stitches have come out or loose, sxs of infection, edema not resolving

→ DVT (aka Homan’s): normal = negative Homan’s, lower extremity edema is equal bilaterally, no warm or hot spots; abnormal = positive Homan’s, significantly greater edema on one side (esp left), warm/hot spot behind calf

→ Emotions: assess for PP depression at 6-8 week visit using Edinburgh Postnatal Depression Scale (EPDS) - score > 10 suggest minor or major depression; f/u in 4 weeks to check on tx plan

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29
Q

Helpful vs. Harmful factors for the postpartum maternal state

A
  • Helpful: oxytocin hormone (feelings of joy & love), support & protecting time with newborn, rest & pain relief (ibuprofen), physical support (assist with walking, ADLs, meal prep), emotional support
  • Harmful: sudden hormonal shift with decrease in progesterone (grief, sadness, anxiety, anger), postpartum physical complications, lack of physical & emotional support, separation from baby
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30
Q

Prescribing Meds to Postpartum moms

A
  • Check Lact:Med: reports adverse effects in infants
  • Consider alternative drug with shorter T1/2 or higher protein-binding (if T ½ is < 3 H can time to minimize infant exposure)
  • Radioactive compound or harmful drug: wait 5 half-lives before breastfeeding
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31
Q

Promotion of Maternal/Newborn Attachment

A
  • Attachment: process by which an enduring bond is formed
  • Attachment theory: posits that the bond between infant & primary caregivers is the most important factor in infant/child development
  • Strange Situation Experiment: parent & child alone in room → child explores room without parental participation → stranger enters room/talks to parent/approaches child → parent quietly leaves the room → parent returns & comforts the child; if secure attachment, the child is distressed when mother leaves, avoid when alone with stranger, and happy when mother returns; if resistant attachment, the child resists contact upon parent return; if avoidant attachment, the child has no distress when parent leaves, ok with stranger, little interest with return
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32
Q

Physiology of Breastfeeding

A

prolactin & oxytocin keep the milk factory going (rise & fall in proportion to nipple stimulation), need > 8 feeds per 24 H to maintain prolactin levels; prolactin returns to non-pregnant levels by 7 days post-partum if no breastfeeding or pumping.

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33
Q

Assessment of Breastfeeding

A

LATCH: Latch, Audible swallow, Type of nipples, Comfort of breast/nip, Hold; LATCH score = 0-2 points for each for 10 points total

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34
Q

Benefits of Breastfeeding

A

immunoglobulins, lactoferrin (sequesters free iron, bactericidal), leukocytes (macrophages, lymphocytes, neutrophils), signaling molecules (cytokines increase local production of IgA in infant), oligosaccharides (prebiotics, pathogen deflection)

35
Q

Contraindications for Breastfeeding

A
  • HIV+ (if access to formula),
  • Brucellosis or T-cell lymphotropic virus I or II,
  • active TB (can resume after 2 weeks of tx),
  • HSV lesion on breast (can express milk),
  • varicella infx (give expressed milk while separated from infant 5 days before birth through 2 days pp),
  • infant with galactosemia,
  • HBV/HCV if nips cracked/bleeding
36
Q

How to Suppress Lactation

A

mother should wear a tight fitting bra/sports bra; do not touch or allow water in shower to touch breasts; apply ice packs +/- frozen cabbage leaves to breast, take OTC pain reliever (APAP or IBU), sage tea or capsules; consider bromocriptine in 1st week PP (often used in fetal demise surrogacy, adoption cases)

37
Q

What is Domperidone?

A

medication that can be used to produce lactational breast tissue in parents who didn’t carry infant

38
Q

Contraception & Sexual Activity Postpartum

A
  • -~15% of women are fertile postpartum but ~40% of women don’t attend their 6-8 week PP visit. → discussion regarding contraception is initiated in the 3rd trimester
  • Do NOT use estrogen-progesterone contraception if woman is breastfeeding –
    • it inhibits lactation & gives estrogen to the infants; it also should not be initiated for 1st 3 weeks postpartum if mother is not breastfeeding
  • Progestin oral contraceptives may be initiated immediately; Long-acting reversible contraception (LARCs) may be inserted before hospital discharge or at the 6 week PP visit
  • Sex can be resumed when the woman is comfortable, after the perineum is healed & when bleeding has decreased; it may not be comfortable due to lack of vaginal lubrication d/t low estrogen levels (use lube is OK)
    *
39
Q

Gestational DM: definition, Pathophys, Epidemiology, s/sxs

A
  • Definition: glucose intolerance or DM only present during pregnancy (subsides postpartum)
  • Pathophys:
    • -Pregnancy is a diabetogenic state: increased glucose & insulin production, insulin resistance d/t placcental hormones, mild postprandial hyperglycemia
    • -Glucose transport: by facilitated diffusion, concentration of glucose is 15-20% lower in fetus, maternal insulin doesn’t cross the placenta
    • -Fetal Growth: fetGDM, SAB, hx of infant > 4000g at birth, multiple gestations, obesity, > 25 yo
  • Epidemiology:
    • 80% more common in AA women and more likely to develop complications or disabilities, death rates are 3x higher than in women w/o DM
40
Q

Gestational DM: types, Screening, and Tx

A
  • Types of DM in Pregnancy:
    • -Type I DM: autoimmune, 13%
    • -Type II DM: insulin resistant
    • -Preexisting/Overt: diagnosed during 1st T for the 1st time
    • -GDM: diagnosed during 2nd or 3rd T for 1st time, 87% of DM in pregnancy.
  • Screening:
    • -Fasting blood sugar at 1st prenatal visit for women at high risk OR 1H GGT in 3rd T if low risk
    • -1H glucose tolerance test: if positive (>139) do 3H GTT, if > 190 = GDM
    • -3H glucose tolerance test = gold standard
  • 3H GTT: <95 (fasting), < 180 (1 hour), <155 (at 2 hours), < 140 (at 3 hrs) → 2 elevated values = GDM
  • HbA1C at 1st prenatal visit, if high then dx pre-existing DM; if prediabetic (5.7-6.2) do 2H GGT, if WNL repeat in 3rd T (24-28wks)
  • Tx:
    • GDM type A1 (dietary controlled): healthy diet, 30 minutes daily activity, walking after meals, monitoring glucose QID
    • GDM type A2: if >20% of blood sugars are elevated despite diet & exercise begin medication (insulin= 1st choice, Metformin or Glyburide OK), NST biweekly after 34 weeks, IOL at 39-40 weeks
    • Referral to diabetes educator for nutritional counseling & glucometer education
  • Intrapartum Tx:
    • maintain euglycemia (70-110 mg/dL), prevent maternal hyperglycemia & natal hypoglycemia
  • Encourage breastfeeding after delivery (decreased risk of DM/obesity in baby & DM2 conversion in mom)
41
Q

Postpartum Management of GDM and Complications

A
  • Postpartum Management:
    • -Retest for DM at 6-12 weeks postpartum, FBS yearly, continue healthy diet, 30-60 minutes daily exercise
    • -GDM type A2: stop medication after birth
  • Complications:
    • Spontaneous abortion (SAB), birth defects (cardiac, preeclampsia, fetal organomegaly (liver & heart), polyhydramnios, fetal macrosomia (>8lbs 13oz, 4000g) → should dystocia/operative delivery/birth trauma, C-section, neonatal respiratory problems & metabolic complications (hypoglycemia, hyperbilirubinemia, hypocalcemia), perinatal mortality (20 weeks gestation – 28 days post delivery)
42
Q

Most common medical complication of pregnancy

A

HTN

43
Q

Chronic HTN

A
  • Definition: HTN (140/90 mmHg+) before 20 weeks gestation or prior to pregnancy
  • S/sxs:
    • HA, visual sxs, usually asymptomatic
  • Classifications:
    • -Mild: 140/90+
    • -Moderate: 150/100+
    • -Severe: 160/110 +
  • Dx: BP readings
  • Tx:
    • Mild: monitor q2-4 weeks, q 1 week from 34-36 weeks
    • -Moderate-Severe: medication (labetalol, nifedipine, or methyldopa)
    • **ACEI & ARBs = contraindicated in pregnancy
44
Q

Gestational HTN

A
  • Definition: onset of HTN (140/90+) after 20 weeks gestation . No proteinuria or organ dysfunction
  • S/sxs:
    • asymptomatic
  • Classifications:
    • -Mild: 140/90+
    • -Moderate: 150/100+
    • -Severe: 160/110 +
  • Dx:
    • -Urine Protein: negative
    • -Platelets
    • -LFTs
    • Complications:
    • -Preeclampsia (10-50% of these pts will develop)
  • Tx:
    • Mild: biweekly NST, weekly prenatal visits for BP/labs, EFW (estimated fetal weight) q 3 weeks, induce at 38-39 weeks
    • -severe: medication, induce at 34 weeks for seizure prevention
45
Q

Pre-Eclampsia: Def, Pathophys, risks, Epid, & s/sxs

A
  • Definition:
    • gestation HTN (140/90+) +proteinuria (>300mg in 24H urine) or evidence of organ dysfunction.
  • Pathophys:
    • increased BP → decreased placental perfusion → endothelial cell activation → vasoconstriction + intravascular fluid redistribution + activation of coagulation cascade → decreased organ perfusion.
  • Risks:
    • nulliparity, hx/family hx of preeclampsia, multiple gestation, obesity, maternal age > 40 or < 18, chronic HTN, renal dx, DM, prolonged interpregnancy interval, new partner or limited sperm exposure
  • Epidemiology:
    • 1 of top 4 causes of maternal mortality (with eclampsia), AA women have higher mortality rates, occurs in 7% of all pregnancies
  • S/sxs:
    • -HTN
    • -Proteinuria
    • -severe HA
    • -Visual Disturbances
    • -RUQ or epigastric pain (heartburn)
    • -Edema
    • -N/V
    • -decreased urinary output
46
Q

Pre-Eclampsia: PE, Dx, and Tx

A
  • PE:
    • -DTR: hyperreflexia or clonus
    • -Clonus
  • Dx:
    • *BP ≥140/90 on at least 2 occasions at least 4H apart after 20 weeks’ gestation + 1 of the following:
    • -Proteinuria >300mg in 24H urine
    • -Protein/creatinine ratio ≥0.3
    • -Platelet count <100,000
    • -Serum creatinine >1.1mg/dL
    • -LFTs twice upper limit of normal
    • -Pulmonary edema
    • -Cerebral or visual symptoms
  • Tx:
    • -Mild (<37 weeks): biweekly NST & PN visits with EFW, antenatal steroids (for lung maturation) → dexamethasone
    • -Mild (>37 weeks): induction +/- medication for seizure prevention
    • -Severe (<34 weeks): inpatient management + medication for seizure prevention + antenatal steroids
    • -Severe (>34 weeks): induction + medication for seizure prevention
47
Q

Pre-Eclampsia: HELLP, Induction, and indications for inductions

A
  • HELLP: (Hemolysis, Elevated Liver Enzymes, Low Platelets): antenatal steroids w/ induction of labor after 48 hours + medication for seizure prevention
  • Induction:
    • birth “cures” preeclampsia; need to balance against gestational age, fetal lung maturity, & indications of fetal well-being
  • Indications for Induction:
    • growth restriction, non-reassuring testing, oligohydramnios (low amniotic fluid), placental abruption
48
Q

Eclampsia

A
  • Definition: pre-eclampsia + seizure or coma
  • S/sxs:
    • abrupt onset of tonic-clonic seizures
  • Tx:
    • IV Mag sulfate for seizures and BP stabilization
    • -Induction of labor once mom is stable
    • -IV labetalol or hydralazine for BP control
49
Q

Spontaneous Abortion

A
  • Definition:
    • pregnancy loss occurs spontaneously prior to 20 weeks gestation.
  • Categories:
    • -Early: 1st trimester, most commonly due to chromosomal abnormalities
    • -Late: 12-20 weeks, due to chromosomal abnormalities, uterine anomaly (ex. cervical insufficiency), biochemical changes (infection, hemorrhage, uterine overdistension)
  • Epidemiology:
    • 50-60% of all conceptions end in miscarriage, 15-20% confirmed pregnancies end in miscarriage (risk decreased if cardiac motion seen on US & >10 weeks gestation)
  • Assessment:
    • Vitals, LMP, OB/gyn hx, emotional state (unplanned vs desired pregnancy)
  • Dx:
    • -Labs: hCG, H/H, WBC, Blood type & Rh factor
    • -Transvaginal US: if 1st trimester or early 2nd trimester we need to see uterine contents closer
  • Tx:
    • -Anticipatory guidance & education
    • -See management of specific types
    • -D&C/D&E: IV during procedure, hemorrhage prevention with IV Pitocin; dilation & curettage is done prior to 23 weeks gestation; dilation & evacuation is done after 23 weeks gestation
    • Prior to 23 weeks = D&C
    • After 23 weeks = D&E
50
Q

Threatened Abortion

A
  • Definition: cervical os is closed & fetal cardiac motion is present
    • Only type that is potentially viable
  • S/sxs:
    • vaginal bleeding, cramping
  • PE:
    • Cervical os = CLOSED
  • Dx:
    • U/S: fetal cardiac motion is present!
  • Tx:
    • Supportive care: pain management, pelvic rest (no vaginal penetration) or bed rest (if 2nd trimester)
    • -Cervical cerclage: if cervical dilation is noted & patient is <14 weeks gestation
51
Q

Imminent/Inevitable Abortion

A
  • Definition: cervical os is open & fetal cardiac motion is rarely present
    • Concern that the patient is going through a pregnancy loss & fetus is demised
  • S/sxs:
    • vaginal bleeding, cramping
  • PE:
    • Cervical os = OPEN
  • Dx:
    • Ultrasound: fetal cardiac motion rarely present
  • Tx:
    • Pelvic rest or bed rest
    • -Expectant management: lab work
    • -Misoprostol or D&C: if patient is not expelling the products of conception
    • -Rhogam: if Rh- (patient has experienced mixture of blood products with her own → antibody production)
52
Q

Missed Abortion

A
  • Definition:
    • neither fetus nor placenta are expelled
  • S/sxs:
    • vaginal bleeding, cramping
  • Dx:
    • U/s = no fetal cardiac motion
53
Q

Incomplete Abortion

A
  • Definition: fetus is expelled & placenta remains inside uterus
  • S/sxs:
    • vaginal bleeding, cramping
54
Q

Complete Abortion

A
  • Definition: fetus and placenta are expelled
  • S/sxs:
    • Vaginal bleeding, cramping
  • Dx:
    • beta-hCG = zero
  • Tx:
    • No further care needed if woman is stable
    • -Rhogam: if Rh-
55
Q

Habitual Abortion

A
  • Definition: 3+ consecutive SABs
  • S/sxs:
    • vaginal bleeding, cramping
  • Dx:
    • chromosomal testing
  • Tx:
    • -Determine cause → anatomic vs chromosomal
    • -Cervical cerclage: if cervical insufficiency is diagnosed
56
Q

Ectopic Pregnancy

A
  • Definition:
    • gestational sac is implanted outside of the uterine cavity. 98% in ampulla of fallopian tubes.
  • Risks:
    • prior ectopic (#1), hx tubal surgery, tubal ligation, in utero DES exposure, current IUD use
    • **>50% of women don’t have any risk factors
  • Epidemiology:
    • 2% in general population, causes 10% of maternal mortality, no variation by maternal age or ethnicity
  • S/sxs:
    • -Dull or colicky pelvic pain
    • -Vaginal bleeding
    • -Amenorrhea
    • Ruptured:
      • -shock
      • -lightheadedness
      • -referred pain to shoulder if blood is in the peritoneum
      • *bleeding may not be visible in the vagina
  • PE:
    • Adnexal tenderness
  • Assessment:
    • -Vitals
    • -LMP
    • -OBGYN hx
    • -Emotional status
  • Dx:
    • Labs: serial hCG (q 48H), H/H (hgb & Hct) , WBC, blood type & Rh factor
    • -Transvaginal US: determine location of pregnancy
    • Need to rule out ectopic for every woman who presents in early pregnancy with abdominal pain &/or bleeding
  • Tx:
    • *Goal: prevent rupture & salvage fallopian tube
    • -Early (<4cm): Methotrexate IM
    • -Late: remove surgically & give Methotrexate post-op
    • Management- Ruptured:
      • *Goal: control bleeding & prevent shock
      • -Salpingectomy: remove fallopian tube
  • Complications:
    • intra-abdominal hemorrhage, DIC, death, impaired fertility, risk of recurrence
57
Q

Gestational Trophoblastic (Molar) Pregnancy

A
  • Definition:
    • neoplasm d/t abnormal placental development with trophoblastic tissue proliferation arising from gestational tissue.
  • Types: *egg may or may not contain fetal DNA
    • -Partial molar pregnancy: with fetal DNA
    • -Complete molar pregnancy: without fetal DNA
  • Risks:
    • >40 y.o. or <20 y.o.
  • Epidemiology:
    • 1/2000 pregnancies (rare)
  • S/sxs:
    • Vaginal bleeding
    • -Enlarged uterus
    • -Pelvic discomfort
  • Dx:
    • -Pregnancy test: positive
    • -hCG: >100,000 mlU/mL (abnormally high, way higher than a normal pregnancy)
    • -Transvaginal US: shows abnormal pregnancy in the uterus, mosaicism
  • Tx:
    • -D&C
    • -Methotrexate: if high risk
    • -Follow-Up: follow hCG until 3 normal levels obtained over 8 weeks, then follow for 6 months
  • Complications:
    • uterine cancer
58
Q

Multiple Gestations

A
  • Types:
    • -Diamniotic/dichorionic: 2 ovum + 2 sperm, 2 separate or 1 fused (large) placenta
    • -Diamniotic/monochorionic (identical twins): 1 ovum + 2 sperm, 2 amniotic sacs, 1 placenta
    • -Monoamniotic/monochorionic (identical twins): 1 ovum + 1 sperm, 1 amniotic sack, 1 placenta
    • -Conjoined twins: incomplete division, fetal fusion
  • S/sxs:
    • Increase in severity of N/V during 2nd trimester
    • -Maternal sxs: uterine contractions, abd pain, increase or thinner vaginal discharge or bleeding
      -Fetal well-being: fetal heart tones, US q4-6 weeks after 20 weeks gestation (if monochorionic Q2 weeks)
  • Dx:
    • Transvaginal U/S: confirms location, number, viability, & chorionicity
  • Tx:
    • Average length of twin pregnancy is 36 weeks
    • -US q 4-6 weeks after 20 weeks gestation (if monochorionic q 2 weeks)
      Complications: maternal, fetal & neonatal morbidities
59
Q

Discordant Growth

A
  • Definition: >20% fetal growth difference between larger & smaller fetus
  • Tx:
    • Additional antenatal surveillance initiated
60
Q

Intrauterine Growth Restriction (IUGR)

A
  • Definition:
    • fetal weight is less than 10th percentile of a specific population at a given gestational age.
  • Risks:
    • -Maternal Factors: viral infections (rubella, varicella, cytomegalovirus), maternal medical conditions (GDM, renal insufficiency, autoimmune, HTN), substance abuse, teratogen exposure, genetic disorders, placental/cord complications
  • PE”:
    • Fundal height exam: size < dates by >2cm, limited use in dx but good screening tool
    • Note: small for gestational age (SGA) is used to describe an infant with a birth weight at the lower extreme of the normal birth weight distribution. AKA they are still a normal weight just low.
  • Dx:
    • US: 4 standard measurements-
        1. biparietal diameter (ear to ear),
        1. head circumference (around forehead) ,
        1. abdominal circumference,
        1. femur length
    • -Doppler velocimetry of fetal vessels: fetal placental circulation evaluated in the umbilical artery & is measured by a systolic/diastolic ratio
  • Tx:
    • Goal: identify infants at risk for increased short-term & long-term morbidity & mortality. Deliver healthiest possible infant at the optimal time
  • Management:
    • -Referral to perinatologist for surveillance (especially if monoamniotic/monochorionic or conjoined)
61
Q

Fetal Macrosomia

A
  • Definition: estimated fetal weight >4,000 gm
  • Risks:
    • -Maternal Factors: history of previous macrosomia, preexisting diabetes, body composition, pregnancy weight gain, parity
    • -Fetal Factors: genetic potential, specific gene disorders, male sex
  • PE:
    • Fundal height exam: poor predictor
      • Note: large for gestational age (age) is used to describe an infant with a birth weight >90% for gestational age within population-specific norms
  • Dx:
    • Diagnosis is imprecise & can only be accurately diagnosed at delivery after weighing the infant.
    • Diagnostics:
    • -US: ability to r/o diagnosis but not to rule in
  • Tx:
    • No interventions designed to treat or curb fetal growth in mother’s w/o diabetes
    • C-section delivery planned for estimated fetal weights:
      • >5,000g in women w/o diabetes
      • >4,500g in women w/ diabetes
62
Q

Fetal Malpresentation

A
  • Definition:
    • baby is in an unusual position as the birth approaches. Normal position= cephalic.
    • Determine fetal presentation by 36 weeks (confirm via US).
  • PE:
    • hand on belly to determine position
  • Dx:
    • U/s to confirm position
  • tx:
    • External Version: scheduled at 37 weeks at L&D with US guidance
63
Q

Breech Presentation

A
  • Definition:
    • fetus whose presenting part is the buttocks and/or feet.
  • Risks:
    • developmental dysplasia of the hip, torticollis, mild deformations
  • Epidemiology:
    • occurs in 3-5% of fetuses at term
  • PE:
    • hand on belly to determine position
  • Dx:
    • U/S confirms position
  • Tx:
    • External Version: scheduled at 37 weeks at L&D with US guidance
64
Q

Preterm Birth (Overview): definition, risk factors, categories

A
  • Definition:
    • birth occurring b/w 20 weeks – 36 weeks + 6 days. Age of viability is 24 weeks.
  • Risk Factors:
    • history of preterm birth, short cervix, cervical insufficiency, multiple gestation, infection (UTI, GC/CT, BV, periodontal disease), genetics, smoking, substance abuse, obesity, hispanic & black, teen & advanced maternal age, short inter-pregnancy period
  • Epidemiology:
    • 10% of babies in the US, 30% spontaneously resolve, 50% of patients hospitalized for PTL will deliver at term
  • Categories:
    • Extremely Preterm: <25 weeks
    • -Very Preterm: 25 weeks + 1 day - 31 weeks + 6 days; 2% of all babies born but 50% of all infant deaths
    • -Moderately Preterm: 32 weeks – 33 week + 6 days
  • Late Preterm: 34 weeks – 36 weeks + 6 days; best preterm outcome but still have 3x mortality rate of term baby
65
Q

Preterm Labor

A
  • Definition:
    • onset of regular uterine contractions (labor) before 37 weeks.
  • Epidemiology:
    • 40-50% of preterm births
  • Prevention (hx of previous PTB or short cervix):
    • -Progesterone IM or SQ weekly starting b/w 16-20 weeks until 36 weeks
    • -Cervical cerclage: if cervix <2.5cm on TVUS or in high risk patients (stitching the cervix shut)
  • S.sxs:
    • Uterine contractions: 6+ in 1 hour, lasting 30-60 seconds each
    • -Vaginal bleeding
    • -Intermittent back pain occurring with the contractions
    • -Pelvic pressure
  • PE:
    • Fetal monitoring: assess fetal well-being
    • -Non-stress test: uterine contractions
    • -VS & PE: maternal well-being
  • Sterile speculum exam: to r/o BV and PPROM (looks for amniotic fluid)
  • Dx:
    • Urine culture: to r/o UTI, pyelo, gonorrhea, chlamydia, substance abuse
    • -Group B Strep (GBS) culture
    • -Fetal fibronectin: protein that the baby releases when they are going through labor
    • -US: measure cervical length, presentation, estimated fetal weight
  • Diagnosis:
    • -Cervical dilation 3cm or greater + >80% effacement or presence of fetal fibronectin
    • Preterm labor = uterine contractions (4+ q 2o min or 8+ in 60 min AND:
      • -cervical dilation 3+ cm OR
      • -cervical length < 20mm on TVUS Or
      • -Cervical length 20 to < 30 mm on TVUS and positive fetal fibronectin)
  • Triage:
    • drink 2-3 glasses of water, lie down or get in warm bath, empty your bladder, if sxs continue at rate 6+ per hour call provider
  • Tx:
    • Goal: prevent preterm birth x 48H so underlying conditions may resolve, steroid for lung maturity can work, & woman may be transferred for better care
    • Betamethasone or Dexamethasone IM x 48H: to accelerate fetal lung maturity, can repeat in 7 days
    • Tocolytics: smooth muscle relaxants that decrease uterine contractions; Terbutaline, Mg sulfate, Nifedipine, Indomethacin
    • -Antibiotics: treat infections as needed

Post-Acute Episode Management:

-Pelvic rest: avoid heavy lifting, prolonged standing, intercourse

66
Q

Preterm Premature Rupture of Membranes (PPROM)

A
  • Definition:
    • rupture of the amniotic membranes prior to the onset of labor occurring before 37 weeks.
  • Risks:
    • hx of PPROM, genital tract infection, antepartum bleeding, cigarette smoking
  • Epidemiology:
    • 33% of preterm births, 3% of pregnancies
  • S/sxs:
    • Sudden “gush” of clear fluid from the vagina OR
    • Intermittent constant leaking of small amount of fluid from the vagina
  • PE:
    • -Sterile speculum exam: look for pooling in the vagina, nitrazine strip to look at pH (pH > 6 → paper turns blue which indicates most likely amniotic fluid), fluid sample on microscope slide to look for ferning, amnisure
    • assess for infection & fetal wellbeing
  • Tx:
    • SEND TO L&D
  • Complications:
    • -Risk of placental abruption & cord prolapse
    • -Serious infections: chorioamnionitis, endometritis, septicemia
    • -Preterm birth within 1 week
67
Q

Rh incompatibility

A
  • Definition:
    • occurs when an Rh(D) negative woman carries a Rh(D) positive fetus with exposure to fetal blood mixing of D-positive RBCs → maternal anti-Rh(D) IgG antibodies
  • Pathophys:
    • during subsequent pregnancies if mother carries an Rh(D) positive fetus the antibodies may cross the placenta & attack fetal RBCs → hemolysis of fetal RBCs
    • At risk pregnancy= Rh(D) negative mother + Rh(D) positive father
  • Dx:
    • Antibody screen: done at initial prenatal visit to see if mother is Rh(D)- or Rh(D)+; if Rh(D)- repeat screening at 28 weeks gestation
    • Antibody titers: performed in Rh(D) negative women to determine if unsensitized vs. sensitized (Rh antibodies present)
  • Tx:
    • Anti-D Rh immunoglobulin (RhoGAM): for any Rh(D) negative women; given at 28 weeks’ gestation, within 72H of delivery of Rh(D) positive baby, and after any potential mixing of blood
      • **If mother has already formed Rh antibodies than Rhogam will no longer help

Complications: repetitive miscarriage, fetal anemia, hydrops fetalis, intra-uterine fetal death

68
Q

Substance Abuse in Pregnancy

A
  • Substance abuse is a modifiable factor with significant impact on pregnancy.
  • Types: caffeine, smoking, alcohol, recreational substances, medication safety categorization
  • Tobacco Use s/sxs:
    • growth restriction
    • preterm delivery
    • perinatal mortality
    • SIDS
    • asthma
  • Alcohol Use S/sxs:
    • ***Quantity related***
    • Miscarriage or stillbirth
    • Premature delivery
    • -Fetal alcohol syndrome
    • -Infant death
    • -Behavior problems
    • -Mental deficiencies
    • -Poor growth before/after birth
    • -Changes in structures of the head, eyes, nose, mouth, heart
  • New Drug Safety Categories:
    • Pregnancy: pregnancy exposure risk registry, risk summary, clinical considerations, data
    • -Lactation: risk summary, clinical considerations, data
  • Management:
    • Use motivational interview techniques (pregnancy may be a window of opportunity for intervention as denial is less common)
    • Prenatal substance use support programs
69
Q

Shoulder Dystocia

A
  • Definition:
    • failure of the shoulders to spontaneously traverse the pelvis after delivery of the fetal head due to impaction (anterior shoulder is stuck behind the mother’s pubic bone).
  • Risks:
    • macrosomic infants of diabetes, post-term pregnancy, multiparity, maternal obesity, advanced maternal age, prolonged 2nd stage of labor, forceps delivery, epidural
  • S.sxs:
    • Turtle sign: baby retracts head (like turtle retracting into its shell)
    • Red, puffy face
  • Complications:
    • Fetal: brachial plexus injuries, Erb’s palsy, Klumpke’s paralysis, cerebral palsy, Erb-Duchenne palsy, clavicular fx, fetal asphyxia
    • -Maternal: perineal or vaginal tears, postpartum hemorrhage, uterine rupture
  • Prevention:
    • C-Section delivery indicated if fetus is >4500g in mother with DM or >5000g in nondiabetic mother
  • Tx:
    • Obstetric emergency
    • 1st line = McRoberts maneuver: non manipulative, hyperflexion & abduction of the mother’s hips towards the abdomen +/- extending episiotomy
    • Delivery of posterior arm to allow for rotational maneuver
    • Woods corkscrew maneuver: manipulative, rotation of fetal shoulders 180 degrees
    • Zavanelli maneuver: push fetal head back in & go to C-section
70
Q

Placenta Previa: Definition, Types, S/sxs, PE

A
  • Definition:
    • a condition in which the placenta is attached close to or covering the internal cervical os
  • Types:
    • Marginal: placenta is adjacent to the cervical os (2.5 cm or closer), “low lying placenta”
    • -Partial: placenta is partially over the cervical os
    • Total: placenta completely covering cervical os
  • S/sxs:
    • Painless 3rd trimester vaginal bleeding (as cervix dilates)
    • Absence of abdominal pain or uterine contractions
    • May be provoked by uterine contractions, examination, or intercourse
    • ***All women >20 weeks who present with bleeding should be presumed to have placenta previa until proven otherwise.
  • PE:
    • Avoid vaginal exams or sterile speculum (may cause separation resulting in severe hemorrhage)
    • Soft, nontender uterus
71
Q

Placenta Previa: Dx & Tx

A
  • Dx:
    • A definitive diagnosis must be avoided in asymptomatic patients before 3rd trimester because cases of placenta previa identified early in pregnancy will resolve as pregnancy advances (watchful waiting).
    • Transvaginal US: allows location of placenta in relation to internal cervical os with great precision; ~20 weeks this formal US is performed & placenta location commented on; follow-up US at 28-32 weeks, then at 36 weeks (each trimester)
    • Transabdominal US: less reliable → use if TVUS not available
  • Tx:
    • L&D: vital signs, 2 large bore IVs, Hgb/HCT, Type & screen, cross-match for 4 units, Rhogam (if Rh negative mom), fetal monitoring, then evaluate for placenta previa once stabilized
    • Betamethasone: to enhance fetal lung maturity if <34 weeks’ gestation
    • Beta mimetic drugs & Mg: to decrease uterine contractions, used with success
    • Hospitalization: for 48H post-bleed
    • Home management: if asymptomatic (no bleeding or pain), watchful waiting
    • *If patient has a 2nd bleed, she will be hospitalized until she delivers
    • C-Section: all women with placenta within 2 cm of cervix as documented by 3rd trimester TVUS
    • Vaginal delivery: an asymptomatic woman whose placenta >2cm from cervical os
72
Q

Placenta Previa: Causes of Bleeding, Postpartum complications, and Risk Reduction for Hemorrhage

A
  • Causes of Bleeding:
    • development of the lower uterine segment, effacement of the cervix, pre-labor uterine contractions, intercourse
  • Postpartum Complications:
    • PP hemorrhage can occur with low lying placenta d/t lower uterine segment atony
    • With anterior placenta, need to quickly clamp umbilical cord as excessive blood loss could occur
    • Oxytocin, methergine, hemabate, & Misoprostol used to control bleeding
  • Risk Reduction for Hemorrhage:
    • bedrest or reduced activity, avoid intercourse, education
73
Q

Vasa Previa

A
  • Definition:
    • fetal vessels run through the fetal membranes & pass over the cervix → risk for rupture with consequent fetal exsanguination
  • Risks:
    • placenta previa or lower lying placenta identified during 2nd T US (60%), in vitro pregnancy, multiple gestation
  • Types:
    1. Velamentous cord insertion between the umbilical cord & placenta, fetal vessels that run freely within the amniotic membranes overlie the cervix or are in close proximity to it
    2. Placenta contains a succenturiate lobe or is multilobed & fetal vessels that connect the 2 placental lobes course over or near the cervix
  • S/sxs:
    • Rupture of membranes
    • -Painless vaginal bleeding
    • -Fetal distress: bradycardia
  • Dx:
    • TVUS: during 2nd trimester (less effective if done in 3rd trimester); color pulsed wave Doppler showing rate consistent with fetal heart rate
    • No standardized criteria for how close the fetal vessels must be to the internal os to constitute a vasa previa. Threshold of 2cm has been proposed.
  • Tx:
    • If diagnosed in the 2nd trimester → 20% resolve by delivery.
    • -Betamethasone: at 28-32 weeks in case of preterm labor to mature the fetal lungs
    • Cervical length testing: starting at 30 weeks, if cervix >2.5cm in length then the patient can remain out of the hospital
    • Antenatal hospitalization: at 30-34 weeks’ gestation with delivery at 34-37 weeks’ gestation via C-section
    • Fetal Lung Maturity Evaluation (amniocentesis) not recommended
    • *Goal: deliver before rupture of membranes while minimizing impact of prematurity
  1. 2.
74
Q

Placenta Abruption

A
  • Definition:
    • premature separation of a normally sited placenta before birth, but >20 weeks’ gestation.
  • Pathophys:
    • strongly associated with PPROM (Preterm Premature Rupture of Membranes) in both causal & consequential manner (possibly linking abruption to placental dysfunction & IUGR)
  • Risks:
    • previous placental abruption (5-17% recurrence), cocaine abuse (10% risk in 3rd T), cigarette smoking (vasoconstriction), maternal parity, chronic HTN or preeclampsia (5 fold increase), PPROM, rapid uterine decompression, uterine malformation/fibroids, trauma
  • Epidemiology:
    • peaks at 24-26 weeks’ gestation, causes fetal death in 1/420 deliveries, 10% of all preterm births are due to abruption
  • S/sxs:
    • Preterm labor
    • -Painful 3rd trimester vaginal bleeding
    • -Severe abdominal pain
    • -Uterine tenderness deferred to shoulder pain
    • -Dark blood (port-wine) amniotic fluid
    • -Increased uterine tone
    • -Tachycardia, anemia, shock
  • PE:
    • tender, rigid uterus
    • do NOT perform pelvic exam
  • Dx:
    • Subchorionic: between placenta & membranes
    • -Retroplacental: between the placenta & myometrium
    • -Preplacental: between the placenta & the amniotic sac
  • Tx:
    • Management- Mild Symptoms:
      • -Betamethasone for <32 weeks
      • -Closely monitor
      • -Quantify blood loss (QBL)
      • -Type & Crossmatch 2 units of blood
      • -Alert NICU
    • Management- Moderate Symptoms:
      • -IV access-anticipate central line
      • -O2 at 10L per mask
      • -Frequent VS
      • -Continuously monitor fetus
      • -Blood products/MTP
      • -Anticipate C-Section
      • -Manage pain
75
Q

Umbilical Cord Prolapse

A
  • Definition:
    • umbilical lies beside or below the presenting part of the fetus and protrudes into the vagina → reduced fetal oxygenation
  • Causes:
    • AROM (artificial rupture of membranes), SROM (spontaneous ROM)
  • Risks:
    • fetal malpresentation (breech or transverse lie), fetal anomalies, IUGR, preterm labor, multiple gestation, PROM, polyhydramnios (overproduction of amniotic fluid → extreme aqueous environment), membranes rupture with high presenting part
  • S/sxs:
    • Sudden onset of severe, prolonged fetal bradycardia or variable decelerations after a previously normal tracing
    • Prolapsed cord visualize through vaginal opening
  • Tx:
    • Once the cord is out of the uterus or vagina, the fetal blood and oxygen supply can be blocked because of drop in temperature, spasm of blood vessels, and compression between pelvic brim & presenting part
    • Transfer to hospital: call 911
    • Position:
      • knee to chest, Trendelenburg (use gravity to reduce compression)
    • vaginal exam
      • If fully dilated → deliver the baby; if not dilated C-section needed
      • Place fingers on either side of cord to relieve pressure on cord, but do not actually handle cord because a vasospasm can occur
76
Q

Uterine Rupture

A
  • Definition:
    • a symptomatic disruption and separation of the layers of the uterus or previous scar. May result in extrusion of the fetus or fetal parts into the peritoneal cavity
  • Risks:
    • uterine scars (C/S), prior uterine rupture, abortion, instrumentation or uterine perforation, Grand Multips, uterine over distension (macrosomia, twins, polyhydramnios, fetal presentation- transverse)
  • S/sxs of Fetus:
    • Category 2 or Category 3 tracing
    • -An abrupt decrease in fetal HR, late variable decelerations or bradycardia
  • S/sxs of Mom:
    • Abdominal pain: sudden onset ripping, tearing sensation that is independent of contractions
    • -Decreased or absent uterine contractions
    • -Loss of fetal station or no fetal descent
    • -Palpable fetal parts in maternal abdomen
    • -Vaginal bleeding: bright red
    • -Shock: hypotension, bradycardia
  • Tx:
    • Life-threatening to mother and fetus.
    • Transfer to hospital: call 911
    • -D/C any medications such as oxytocin
    • -Get patient to the OR
    • -If fully dilated then can attempt to deliver vaginally
    • -IV-Fluid bolus
    • -Oxygen at 10L per mask
    • -Anticipate giving blood products
    • -Place woman on left or right side
    • -Monitor baby continuously
77
Q

Sepsis 1 Screen vs Medicaid/Medicare OB Sepsis Screening

A
  • SEPSIS 1 Screen:
    • *2+ of SIRS Criteria
    • -Temp >38.3C or <36C
    • -HR >90 beats/min
    • -RR >20 bpm
    • -WBC >12,000 mm or <4,000 mm OR >10% immature neutrophils (bands)
  • Center for Medicaid & Medicare OB Screen:
    • *2+ of SIRS Criteria
    • -Temp >38C or <36C
    • -HR >110 beats/min
    • -RR >24 bpm
    • -WBC >15,000 mm or <4,000 mm OR >10% immature neutrophils (bands)
    • -Altered mental status
  • Risks for Sepsis in pregnancy:
    • advanced maternal age, obesity, DM, placental abruption, placental abnormalities, ART, emerging infectious diseases
78
Q

Labor Dystocia

A
  • Definition:
    • baby doesn’t exit the pelvis during childbirth d/t being physically blocked, despite the uterus contracting normally.
  • Causes:
    • macrosomia, malpresentation, small pelvis, problems with birth canal (narrow vagina)
  • Categories:
    • Problems of power: uterine contraction
    • -Problems of passenger: presentation, size (macrosomia), position of fetus
    • -Problems of passage: uterus or soft
  • Complications:
    • Fetus: not enough oxygen
    • -Mother: infection, uterine rupture, postpartum bleeding
79
Q

Cesarean Delivery

A
  • Definition:
    • use of surgery for delivery of the fetus
  • Epidemiology:
    • ~32% of deliveries in the U.S.
  • Reasons for C-Section:
    • dystocia, failure to progress to labor (most common), breech presentation, fetal distress
  • Low transverse uterine incision: decreased blood loss, ease of repair, lower likelihood of rupture
  • Prophylactic antibiotic: up to 60 minutes prior to making the initial incision; IV Cefazolin
    • Thromboprophylaxis
80
Q

Incompetent Cervix

A
  • Definition: a weakening of the cervix which causes premature shortening or dilation & miscarriage- causes recurrent 2nd trimester miscarriages.
  • Causes:
    • past trauma to cervix (surgery, D&C), previous deliveries, genetic anomalies
  • S/sxs:
    • Vaginal bleeding
  • PE:
    • Cervical length <25mm (<2.5cm) before 24 weeks
  • Dx:
    • TVUS: funneling of the cervix
    • Usually diagnosed after 2nd or 3rd T miscarriage occurs but can be detected on routine prenatal US
  • Tx:
    • Cervical cerclage: placing purse-string sutures in the cervix to draw it closed at 14-16 weeks, removed at 36 weeks to allow for delivery
81
Q

What does GPTAL stand for in OB?

A

Gravid (pregnancies), Para (births), Term, abortion, living

82
Q

2 hour GTT

A
83
Q

3 Hour GTT

A
84
Q

Fetal Heart Rate Changes

A

NRS 251 D: Emergency, Surgery, Geriatrics, Peds, OB (9 decks)

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