Obstetrics Flashcards by Stephanie Escobar

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

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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

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Maternal vitamin D deficiency is associated with fetal ___

growth restriction

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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.

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Diagnosis

Presents with painful vaginal bleeding, cramping, and a dilated cervix, often with products of conception visualized at the os.

inevitable abortion

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Pregnant patients with von Willebrand disease (vWD) are at increased risk for what?

postpartum hemorrhage

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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

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Diagnosis

Present with:
* decreased fetal movement
* oligohydramnios
* abnormal anatomical ultrasound findings (hydrops fetalis, microcephaly)

Fetal congenital infections

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Diagnosis

Increases the risk of obstetric complications such as,
* gestational diabetes
* fetal macrosomia
* uterine size-greater-than-dates discrepancy

Maternal obesity

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What type of diabetes mellitus can cause uteroplacental insufficiency, fetal growth restriction, and oligohydramnios?

Prepregnancy

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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.

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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

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Intramuscular ____ is used for medical treatment of some ectopic pregnancies (no fetal cardiac motion, small size).

methotrexate

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What procedure is indicated for patients with acute cervical insufficiency?

(ie, painless cervical dilation at <24 weeks gestation)

Cervical cerclage

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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.

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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

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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)

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Diagnosis

Presents with fever, uterine tenderness, and fetal tachycardia (on fetal heart rate tracing)

Intraamniotic infection

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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

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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)

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What teratogen causes
* fetal renal failure
* oligohydramnios
* pulmonary hypoplasia
* growth restriction
* limb defects (ie, Potter sequence)

lisinopril (and other angiotensin-converting enzyme inhibitors)

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Diagnosis

It’s use causes microcephaly and midfacial hypoplasia

Fetal alcohol syndrome

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Routine prenatal laboratory tests for
24-28 weeks gestation?

Indirect Coombs (if Rh– for Rhogam)
1-hr 50-g Glucose Tolerance Test

if 1hr GTT abn do 3hr test

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Routine prenatal laboratory test for
36-38 weeks gestation?

Group B Streptococcus rectovaginal culture

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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) _____ ## Footnote * 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) ## Footnote unlike Klumpke palsy which has absent grasp reflex

Preterm Prelabor ROM management at <34 weeks | **without** infection or fetal/maternal compromise ## Footnote 5

betamethasone (corticosteroid) Ampicillin + Azithro Fetal monitoring Expectant management | Magnesium (if <32w) ## Footnote no Nifedipine bc ROM has occurred already

Preterm Prelabor ROM management at <34 weeks | with Infection or fetal/maternal compromise ## Footnote 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) ## Footnote 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 ## Footnote 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) ## Footnote 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 ## Footnote UP Insufficiency s/t maternal HTN, sickle cell, etc.

Assymetric Fetal Growth Restriction ## Footnote 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 ## Footnote 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 ## Footnote 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 ## Footnote 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 ## Footnote 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 ## Footnote 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 ## Footnote MSAFP = maternal serum α-fetoprotein

Trisomy 18 (Edward's syndrome) ## Footnote 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 ## Footnote 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 ## Footnote **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) ## Footnote 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? ## Footnote 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? ## Footnote 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 ## Footnote 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 ## Footnote 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

1. Bimanual Massage 2. High-dose **oxytocin** (first-line uterotonic agent) 3. If persists, **tranexamic acid** (antifibrinolytic agent that stops breakdown of blood clots to achieve hemostasis) **reduces maternal mortality** 4. If STILL persists, give second-line **uterotonic medications** 5. 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 ## Footnote **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 ## Footnote 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? ## Footnote versus umbilical cord **prolapse** where the umbilical cord is compressed with **no subsequent decompression**

Variable decelerations | can be, but NOT always, associated w/ contractions ## Footnote 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