Obstetrics Flashcards
Diagnosis
Present with
- first-trimester vaginal bleeding
- uterine size greater than gestational age
- markedly elevated β-hCG levels (eg, >100,000 mIU/mL)
- ultrasound with a “snowstorm” appearance and no fetus
Complete hydatidiform moles
Treatment is suction curettage
Due to the risk of malignant transformation (choriocarcinoma), patients are followed with serial monitoring until the hCG level is undetectable
Diagnosis, may present with:
- intense abdominal pain
- vaginal bleeding
- fetal heart rate tracing abnormalities (recurrent variable and late decelerations)
- Loss of fetal station
- Fetal parts palpable abdominally (irregular protuberance).
Uterine rupture
tx: emergency Laprotomy and C-section
Hx of prior uterine surgery (eg, cesarean delivery) increases risk of uterine rupture (s/t a disruption of the uterine wall from contractions)
may have a palpable,** irregular abdominal mass **(ie, protruding fetal parts) and fetal decelerations
Maternal vitamin D deficiency is associated with fetal ___
growth restriction
Acute cervicitis presents with mucopurulent discharge, and a friable cervix. In pregnancy, it can cause what symptom not associated with the fetus?
postcoital bleeding
Empirically treat with ceftriaxone and azithromycin
To cover Chlamydia trachomatis & Neisseria gonorrhoeae.
FYI: threatened abortion has bleeding originating from the uterus (bleeding from the endocervical canal on examination) not cervix.
Diagnosis
Presents with painful vaginal bleeding, cramping, and a dilated cervix, often with products of conception visualized at the os.
inevitable abortion
Pregnant patients with von Willebrand disease (vWD) are at increased risk for what?
postpartum hemorrhage
Maternal sickle cell disease can cause uteroplacental insufficiency which may present with
* decreased fetal movement
* oligohydramnios (ie, amniotic fluid index ≤5 cm)
* Fetal
* Preterm birth
* Spontaneous abortion
* Abruptio placentae
s/t vasoocclusion that can result in placental infarction and ischemia
Fetal growth restriction
Diagnosis
Present with:
* decreased fetal movement
* oligohydramnios
* abnormal anatomical ultrasound findings (hydrops fetalis, microcephaly)
Fetal congenital infections
Diagnosis
Increases the risk of obstetric complications such as,
* gestational diabetes
* fetal macrosomia
* uterine size-greater-than-dates discrepancy
Maternal obesity
What type of diabetes mellitus can cause uteroplacental insufficiency, fetal growth restriction, and oligohydramnios?
Prepregnancy
Diagnosis
Can cause fetal macrosomia and polyhydramnios (ie, amniotic fluid index ≥24 cm).
Gestational diabetes mellitus
However,** pregnancy-induced hyperglycemia** (an** abnormal glucose challenge test** + a normal glucose tolerance test) does not cause significant changes.
In Rh(D)-negative women (aka no + sign in blood type) with a negative coombs test require a anti-D immunoglobulin at 28-32 weeks gestation.
Other indications include (4–8):
Antepartum prophylaxis is not indicated if the father is Rh(D) negative.
Ectopic Pregnancy
Threatened abortion
<72 hours after delivery of Rh(D)-positive infant
<72 hours after spontaneous abortion
Hydatidiform mole
Chorionic villus sampling, amniocentesis
Abdominal trauma
2nd- & 3rd-trimester bleeding
Because Fetomaternal blood mixing and maternal anti-D antibody production can cause Rh(D) alloimmunization
Intramuscular ____ is used for medical treatment of some ectopic pregnancies (no fetal cardiac motion, small size).
methotrexate
What procedure is indicated for patients with acute cervical insufficiency?
(ie, painless cervical dilation at <24 weeks gestation)
Cervical cerclage
What medication is used for fetal neuroprotection (ie, cerebral palsy risk reduction) for fetuses at risk for preterm birth at <32 weeks gestation?
Magnesium sulfate
Also used for seizure prophylaxis/treatment for patients with preeclampsia/eclampsia.
Patients with systemic lupus erythematosus have an increased risk of passive placental transfer of maternal anti-SSA (Ro) and anti-SSB (La) antibodies to fetus resulting in what fetal complication?
Fetal atrioventricular block (persistent bradycardia, decreased fetal movement) → Cardiomyopathy →Hydropsfetalis
Neonatal lupus
Pts with decreased fetal movement requires additional testing (eg, biophysical profile, fetal growth ultrasound) and possible delivery
A fetal sleep cycle can present with minimal or absent variability and decreased frequency of accelerations; however, what remains normal?
Baseline fetal heart rate remains normal
(110-160/min)
Diagnosis
Presents with fever, uterine tenderness, and fetal tachycardia (on fetal heart rate tracing)
Intraamniotic infection
Diagnosis:
Morbidly adherent placental attachment to the myometrium rather than decidua basalis
ultrasound revealing a low-lying placenta, myometrial thinning, and numerous placental lacunae
Placenta Accreta
Management planned cesarean hysterectomy/ emergency hysterectomy
Postpartum diagnosis: adherent placenta, postpartum hemorrhage
Fetal hydantoin syndrome presents with
* microcephaly
* wide anterior fontanelle
* cleft lip and palate
* distal phalange hypoplasia
It results from in utero exposure to what medication?
Antiepileptics
(phenytoin, carbamazepine)
What teratogen causes
* fetal renal failure
* oligohydramnios
* pulmonary hypoplasia
* growth restriction
* limb defects (ie, Potter sequence)
lisinopril (and other angiotensin-converting enzyme inhibitors)
Diagnosis
It’s use causes microcephaly and midfacial hypoplasia
Fetal alcohol syndrome
Routine prenatal laboratory tests for
24-28 weeks gestation?
2
Indirect Coombs (if Rh– for Rhogam)
1-hr 50-g Glucose Tolerance Test
if 1hr GTT abn do 3hr test
Routine prenatal laboratory test for
36-38 weeks gestation?
Group B Streptococcus rectovaginal culture
Initial prenatal visit laboratory test:
* Rh(D) type & antibody screen (indirect coombs)
* Urine culture
* Urine dipstick for protein
* Rubella & varicella immunity
* HIV, VDRL/RPR, HBsAg, anti-HCV Ab
* Chlamydia PCR (if risk factors are present)
* (if screening indicated) _____
- Hemoglobin/hematocrit, MCV, ferritin
Pap test
Nerves affected?
Delivery c/b shoulder Dystocia
“Claw Hand”
Absent Grasp Reflex
C8-T1
Klumpke palsy
Hold the eight’s (ape’s) claw
Nerves affect?
“waiter’s tip” posture
Intact grasp reflex
Moro reflexes: decr/absent
C5-C6
(5, 6 give a tip)
Erb-Duchenne palsy (mcc)
unlike Klumpke palsy which has absent grasp reflex
Preterm Prelabor ROM
management at <34 weeks
without infection or fetal/maternal compromise
5
betamethasone (corticosteroid)
Ampicillin + Azithro
Fetal monitoring
Expectant management
Magnesium (if <32w)
no Nifedipine bc ROM has occurred already
Preterm Prelabor ROM
management at <34 weeks
with Infection or fetal/maternal compromise
4
Delivery
Betamethasone
Ampicillin + Gentamicin
Magnesium (if <32w)
Diagnosis
Nitrazine-positive fluid and a closed cervix (ie, prior to labor onset) at <37 weeks
preterm prelabor rupture of membranes (PPROM)
prolonged or excessive ____ administration can cause severe hyponatremia, cerebral edema, and generalized tonic-clonic seizures.
oxytocin
Diagnosis
presents with:
* RUQ pain, N/V
* HTN
* Anemia
* Elevated liver enzymes
* Thrombocytopenia
* ± Proteinuria
HELLP Syndrome
(Hemolysis, Elevated LFTs, Low Platelets)
Tx: Delivery, Magnesium (seizure ppx), Hydralazine (antihypertensive)
Complications: Abruptio placentae, Subcapsular liver hematoma/distention (ie, blood pooling beneath the hepatic capsule), Acute renal failure, Pulmonary edema, DIC
Symptoms of what toxicity?
neuromuscular depression
* decreased respiratory effort/apnea
* Decreased deep tendon reflexes
* muscle paralysis
* somnolence.
Magnesium
diagnosis
A polymicrobial infection characterized by fever >24 hours postpartum, purulent lochia, and uterine tenderness.
Postpartum endometritis
Tx: clindamycin + gentamicin
Risk factors: prolonged rupture of membranes, operative vaginal delivery, prolonged labor, & cesarean delivery.
The treatment of choice for pyelonephritis during pregnancy?
Ceftriaxone (must be IV)
a third-generation cephalosporin that covers the most common cause of pyelonephritis, gram-negative E coli.
A dual-therapy regimen that covers the most common bacterial causes of acute cervicitis, Neisseria gonorrhoeae (gram-negative cocci) and Chlamydia trachomatis (atypical organism).
Ceftriaxone + doxycycline
Diagnosis
Head sparing growth lag
s/t Uteroplacental insufficiency or Maternal malnutrition
Assymetric Fetal Growth Restriction
Diagnosis
Head sparing growth lag
s/t Uteroplacental insufficiency or Maternal malnutrition
UP Insufficiency s/t maternal HTN, sickle cell, etc.
Assymetric Fetal Growth Restriction
Fetal growth restriction (FGR) is characterized by estimated fetal weight <10th percentile or birth weight <3rd percentile
Global growth lag
s/t Chromosomal abnormalities or Congenital infection
Stmetric Fetal Growth Restriction
FGR is characterized by estimated fetal weight <10th percentile or birth weight <3rd percentile
DIagnosis
Presents with generalized pruritus, hyperbilirubinemia, and elevated transaminases due to impaired bile acid flow.
Intrahepatic cholestasis of pregnancy
Tx: ursodeoxycholic acid
In Pre-Eclampsia w/ severe features, severe HTN increases maternal risk of stroke, pulmonary edema, and MI;
fetal risks include abruptio placentae & IUFD.
Acute antihypertensive therapy with one of what 3 meds is required?
hydralazine, labetalol, or nifedipine
Inadequate maternal folate intake is a major risk factor for fetal neural tube defects like what?
Anencephaly
Diagnosed by fetal u/s, shows absent cerebrum, a calvarial defect, an abnormal cerebellum or brainstem, and polyhydramnios
The following are complications of what maternal illness?
- Fetal growth restriction ± oligohydramnios
- Preterm delivery
- Intrauterine fetal demise
- Perinatal mortality
Obstetric HTN
Chronic hypertension is prepregnancy hypertension **or **hypertension recognized at <20 weeks gestation
Common causes of uterine size–dates discrepancies:
* Incorrect pregnancy dating
* large uterine leiomyoma (ie, fibroid)
* Multiple Gestations
* Rh alloimmunization can cause hydrops fetalis
Name 4 other causes
- Polyhydraminos (GI atresias/anencephaly/infection)
- Molar Pregnancy
- gestational diabetes mellitus
- Macrosomia
causes of Polyhydramnios (AFI ≥24 cm)
- Multiple gestation
- Diabetes mellitus
- Idiopathic (mcc)
List 4 more
Polyhydramnios: amniotic fluid index ≥24 cm or a deepest vertical pocket of ≥8 cm
s/t an imbalance of fluid production (fetal urination) and removal (fetal swallowing).
Esophageal/duodenal atresia
TE Fisula
Anencephaly
Congenital infection
Complications of Polyhydraminos
Preterm labor
Preterm prelabor ROM
List 3 more
Fetal malpresentation (eg, breech)
Umbilical cord prolapse
postpartum uterine atony
Causes of Oligohydramnios (AFI <5 cm)
- Preeclampsia
- Abruptio placentae
- NSAIDs
List 2 more
Uteroplacental insufficiency
Renal anomalies
Complications of Oligohydraminos
Preterm delivery
List 2 more
Meconium aspiration
Umbilical cord compression
Management of Polyhydraminos
Most patients are asymptomatic.
Management is based on severity, maternal symptoms, and gestational age
Severe/Symptomatic polyhydramnios at preterm gestation →
amnioreduction (ie, amniotic fluid removal by amniocentesis)
Mild/Asymptomatic polyhydramnios at term gestation → expectant management
After 20 weeks gestation, fundal height in centimeters should directly correlate to gestational age in weeks with a small variation (eg, ±2-3 cm)
A uterine size–dates discrepancy requires further evaluation with what to measure fetal growth and amniotic fluid volume?
ultrasound
Diagnosis
Second-trimester quadruple screening
MSAFP: ↓
β-hCG: ↓
Estriol: ↓
Inhibin A: normal
MSAFP = maternal serum α-fetoprotein
Trisomy 18 (Edward’s syndrome)
diaphragmatic hernia, rocker-bottom feet ± clenched hands with overlapping fingers
small jaw (micrognathia), low set ears, heart disease, omphalocele, myeloiningocele
Diagnosis
Second-trimester quadruple screening
MSAFP: ↓
β-hCG: ↑
Estriol: ↓
Inhibin A: ↑
Trisomy 21 (Down Syndrome)
advanced maternal age is a risk factor
Risk ↑ for alzheimers, AML/ALL
flat facies, single palmar crease, epicanthal folds, thickened nuchal fold
ASD/VSD, duodenal atresia, esophageal atresia
Hirschsprung (missing nerve cells in colon – delayed passage of meconium)
Diagnosis
Second-trimester quadruple screening
MSAFP: ↑
β-hCG: normal
Estriol: normal
Inhibin A: normal
Neural tube or abdominal wall defect
Multiple-gestation pregnancies are associated with isolated elevated AFP
The quadruple marker test (Quad screen) is performed in the second trimester (13 – 26 weeks gestation).
It screens for congenital defects and what else?
A positive screening results require confirmation via what?
Fetal aneuploidy (chromosome abnormalities)
Confirmed via amniocentesis for karyotyping.
A fetal anatomy ultrasound also done to screen for fetal anomalies
Diagnosis
Normal Quad Screen
* Microcephaly
* Holoprocephaly (one central eye)
* cleft lip/palate (medial)
* Polydactyly
* Cutis Aplasia (focal or widespread absence of the skin)
* Heart/Kidney disease
Trisomy 13 (Patau syndrome)
IUFD or death by 1 year
Myelomeningocele (ie, spina bifida) is a neural tube defect (NTD) due to what deficiency
folate
Prolonged and early-onset oligohydramnios’ most significant sequela is what?
Pulmonary hypoplasia (ie, neonatal respiratory syndrome)
Additional complications include flat facies and limb deformities (Potter sequence)
amniotic fluid is required for fetal lung development
Describe the pathophysiology of the Potter Sequence
Urinary tract anomaly (ex: renal agenesis) or PPROM <26 weeks → severe olygohydraminos → Fetal Compression → Potter Sequence (Flat Face, Lung Hypoplasia, Limb deformities)
Duodenal atresia is commonly associated with what 2 syndromes?
Bc these syndrome present w/ multiple congenital anomalies, the presence of duodenal atresia requires evaluation for other malformations.
Down syndrome (VSD/ASD, Hirschsprung’s, single palmar crease, duodenal atresia)
&
VACTERL (vertebral defects, anal/duodenal atresia, cardiac defects, tracheo-esophageal fistula, renal anomalies, and limb abnormalities)
Patients at high risk for preeclampsia (ex: multiple gestations) are prescribed what prophylaxis at 12-28 weeks gestation (but optimally before 16 weeks) for prevention?
low-dose aspirin
What is the most common cause of postpartum hemorrhage (PPH) within 24 hours of delivery?
PPH: estimated blood loss ≥1,000 mL or bleeding with signs/symptoms of hypovolemia.
uterine atony
patient w/ heavy bleeding & blood clots in the lower uterine segment
presents as Enlarged, soft, boggy, poorly contracted uterus
Diagnosis
Presents w/ severe abdominal pain, a smooth mass protruding from the cervix or vagina, and no palpable uterine fundus.
Uterine inversion
can occur due to excessive traction on the umbilical cord with an adherent placenta, causing the uterine fundus to invert and prolapse.
Diagnosis
Trauma due to operative vaginal delivery, particularly forceps-assisted vaginal delivery. Resulting in bleeding/PPH immediate after fetal delivery.
Cervical lacerations
Management of PPH s/t Uterine Atony
6 steps
- Bimanual Massage
- High-dose oxytocin (first-line uterotonic agent)
- If persists, tranexamic acid (antifibrinolytic agent that stops breakdown of blood clots to achieve hemostasis) reduces maternal mortality
- If STILL persists, give second-line uterotonic medications
- If still persists, use intrauterine balloon tamponade
Finally, patients with PPH refractory to medical and minimally invasive techniques require either:
1. uterine artery embolization or
2. Laparotomy (and possible hysterectomy)
2nd line meds: carboprost tromethamine, methylergonovine & misoprostol
Carboprost tromethamine is contraindicated in patients with asthma
Methylergonovine is contraindicated in patients with hypertension (regardless of the pt’s’s current BP)
Dilation and curettage may be indicated for PPH due to what?
retained products of conception
(eg, placenta, membranes)
Due to the high risk for severe complications (eg, maternal sepsis, preterm delivery),
management of Acute Pyelonephritis in Pregnancy is with
hospitalization and which empiric intravenous antibiotic?
Ceftriaxone
Gestational diabetes mellitus
Fetal macrosomia
Cesarean delivery
are complications for ____ in pregnancy?
Excessive weight gain
Fetal growth restriction
Preterm delivery
are complications for ____ in pregnancy?
Inadequate weight gain
Risk factors for a cause of painless second-trimester pregnancy loss include,
- inherited collagen defects (Ehlers-Danlos syndrome)
- prior cervical surgery (cervical conization)
cervical insufficiency
because these conditions cause structural weakness of the cervix.
Typically occurs due to fetal red blood cell destruction (hemolysis).
Risk factors include Rh alloimmunization and intra-utero infection (ex:Parvovirus B19)
fetal anemia
Umbilical cord prolapse is typically associated with an abrupt, prolonged decelerations or ____ as the umbilical cord is compressed with no subsequent decompression
bradycardia
umbilical cord compression s/t transient occlusion of the umbilical vessels, particularly during contractions. FHT would reveal what?
versus umbilical cord prolapse where the umbilical cord is compressed with no subsequent decompression
Variable decelerations
can be, but NOT always, associated w/ contractions
Oxytocin augmentation worsens umbilical cord compression
Next best step in management
In patients with absent variability and recurrent variable decelerations on FHT
cesarean delivery
Fetal head compression causes what on FHT?
They have a slow onset and occur symmetrically with contractions.
early decelerations
