Obstetrics Flashcards
(133 cards)
1
Q
What does APGAR stand for?
A
- Apperance
- Pulse
- Frimace (reflex irritability)
- Activity
- Respiration
2
Q
When is APGAR given?
A
1 minute after birth and again at 5 minutes
3
Q
What is a normal, low, and critically low APGAR score?
A
- Normal: = to or greater than 7
- Low: 4-6
- Critically low: = to or less than 3
4
Q
What are the APGAR categories for appearance?
A
- 0: blue, pale
- 1: pink body, blue extremities
- 2: pink
5
Q
What are the APGAR categories for pulse?
A
- 0: absent
- 1: below 100 bpm
- 2: over 100 bpm
6
Q
What are the APGAR categories for grimace?
A
- 0: floppy
- 1: minimal response to stimulation
- 2: prompt response to stimulation
7
Q
What are the APGAR categories for activity?
A
- 0: absent
- 1: flexed arms and legs
- 2: active
8
Q
What are the APGAR categories for respiration?
A
- 0: absent
- 2: slow and irregular
- 3: vigorous cry
9
Q
What are dizygotic or fraternal twins?
A
- 2/3 of multiple gestations
- fertilized 2 ova by 2 different sperms
- not the same genetic material
10
Q
What are monozygotic or identical twins?
A
- 1/3 of multiple gestations
- fertilization of 1 ova that splits
- same genetic material
11
Q
How much weight can a patient gain with multiple gestations?
A
37-54 lbs
12
Q
How are multiple gestations diagnosed?
A
US + elevated hCG + AFP
13
Q
What are monochorionic monoamniotic (mo/mo) twins?
A
single placenta, one chorion, one amnion
14
Q
What are monochorionic diamniotic (mo-di) twins?
A
Single placenta, single chorion, two sacks
15
Q
What are dichorionic diamniotic (di-di) twins?
A
two placentae, two chorion, two sacs
16
Q
What are management recommendations for multiple gestations?
A
- 2 prenatal vitamine with iron
- 1 mg folate and 1000 mg of vitamin D daily
- More frequent US & visits
- Sleep on the left side
17
Q
What are the 7 cardinal movements of labor & delivery?
A
- Engagement
- Descent
- Flexion
- Internal rotation
- Extension
- External rotation
- Expulsion
18
Q
What is engagement?
A
fetal head enters into pelvis
19
Q
What is descent?
A
Fetal head descends into pelvis
20
Q
What is flexion?
A
head flexes to smallest diameter to present to the pelvis
21
Q
What is internal rotation?
A
fetal vertex rotates from the transverse position to the anterioposterior position
22
Q
What is extension?
A
vertex extends beyond pubic symphysis
23
Q
What is external rotation?
A
after the head is delivered, baby externally rotates to allow for babys shoulders to pass
24
Q
What is stage 1 of labor?
A
- onset of true regular contractions until full dilation/effacement of cervix
- 10-12 hrs
- latent phase: onset until 2-4 cm dilated
- active phase: extends until >9 cm
- deceleration/transition phase: cervix completes dilation
25
What is stage 3 of labor?
* from delivery of infant until delivery of placenta
25
What is stage 2 of labor?
* time of full dilation until delivery
* 1-2 hours
* early/variable decelerations common
* passive and active phases
26
What are fetal stations?
a measurement of how high ot low the baby is
* -3: above ischial spines
* 0: at ischial spines
* 3: below ischial spines (time to push)
27
What is the first trimester screen and when is it done?
* Plasma hCG, PAPP-A, nuchal translucency
* 11-13 wks
* CVS sampling if indicated
28
What chromosome abnormalities does the 1st trimester sceen look for?
* Downs (21): ↑↑ NT, ↓↓ PAPP-A, ↑ hCG
* Edwards (18): ↑↑ NT, ↓↓ PAPP-A & hCG
* Pataus (13): ↑ NT, ↓↓ PAPP-A & ↓ hCG
29
What is the QUAD screen and when is it done?
* AFP + inhibin-A + estriol + BhCG
* 15-20 weeks
30
What chromosome abormalities does the QUAD screen look for?
* Downs (21): ↑ hCG & ↑ inhibin-A
* Edwards (18): ↓ estriol, ↓↓ hCG
* Pataus (13): ↑ AFP
* Turners (X/0): ↑↑ hCG & inhibin-A
31
What is the MCC of spontanous abortion?
chromosomal abnormalities
32
What is a threatened abortion?
* cervical os: closed
* POC: retained
33
What is an inevitable abortion?
* cervical os: open
* POC: retained
34
What is an incomplete abortion?
* cervical os: open
* POC: some passed
35
What is a complete abortion?
* cervical os: closed
* POC: completly passed
36
What is an ectopic pregnancy?
* implantation anywhere but the endometrium
* MC: fallopian tube
* MCC: occlusion of tube due to adhesions
* typically presents 6-8 weeks after LMP
37
What are risk factors for an ectopic pregnancy?
* strongest RF: previous ectopic
* hx PID, IUD
38
What are symptoms of an ectopic pregnancy?
**Unilateral/lower abd pain + bleeding/spotting + amenorrhea**
* ruptured: severe abdominal or shoulder pain (kehr sign), syncope, hypotension
39
How is an ectopic pregnancy diagnosed?
hCG less than expected
* > 1500 should show up on TVUS
40
How do you treat an ectopic pregnancy?
* hCG < 5000 without fetal activity: methotrexate
* emergent: laparoscopy
* trend BhCG until levels return to normal
41
How is gestational diabeties diagnosed?
GTT screening at 24-28 weeks
* 50g 1 hr glucose test: > 140
* 100g 3 hr test: fasting > 90, 1 hr > 180, 2 hr > 155, 3 hr > 140
42
How is gestational diabeties treated?
* Diet & exercise
* Severe: insulin
* Alt. glyburtide or metformin
* Comp.: polyhydramnios
42
What are symptoms of gestational trophoblastic disease?
painless vaginal bleeding, uterine size greater than gestational age, hyperemesis gravidarum, preclampsia 6-16 weeks
43
What is gestational trophoblastic disease?
neoplasm due to abnormal placental development with trophoblastic tissue proliferation arising from gestational tissue
* 2 types: complete (MC), partial
* complete: empty, no viable fetus
* partial: some fetal tissue + trohoblastic hyperplasia
44
How is gestational trophoblastic disease diagnosed?
* earilest it can be dx: 8 wks
* hCG > 100,000
* US: snowstorm pattern and grapelike vesicles
45
How is gestational trophoblastic disease treated?
* benign/low risk: chemo (methotrexate)
* high risk: chemo + surgery/radiation
* **surgical: suction curettage/hysterectomy**
* Monitor weekly hCG until return to baseline
46
What is cervical insufficiency?
inability of the cervix to retain a pregnancy through the 2nd trimester due to premature cervical dilation in the absense of uterine contractions
47
What are risk factors for cervical insufficency?
**ehlers-donlos syndrome**, cervical trauma during labor/delivery, cervical dilations
48
What are symptoms and physical exam findings of cervical insufficency?
* Sx: ASX or pelvic pressure & vaginal discharge
* PE: soft, effaced, dilated cervix with grossly prolapsed or ruptured membranes
49
How is cervical insufficency diagnosed?
* 2 consecutive 2nd trimester losses or early premature births
* TVUS: cervical length less than 25 mm before 24 wks
50
How is cervical insufficency treated?
cerclage placement at 12-14 weeks
51
52
What is placenta abruptio?
* premature separation of normally implanted placenta from the uterine wall after 20 weeks resulting in hemorrhage
* most occur before labor and after 30 wks
* **MCC of third trimester bleeding**
53
What are risk factors for placenta abruptio?
**HTN**, cocaine, smoking
54
What are symptoms of placenta abruptio?
**3rd trimester painful vaginal bleeding** +/- severe contraction, firm/tender uterus
55
How is placenta abruptio diagnosed?
clinically - **NO VAGINAL EXAM**
56
How is placenta abruptio treated?
stabilize patient, prepare for hemorrhage
* < 34 wks: tocolytics + steriods + bed rest
* > 34 wks: delivery
57
What is placenta previa?
when the placenta attaches low in the uterus
* complete: covers all of interal os
* partial: covers portion of internal os
* marginal: covers edge of internal os
58
What are symptoms of placenta previa?
sudden onset of painless vaginal bleeding after 28 weeks
* absense of abfominal pain ot uterine tenderness
59
How is placenta previa diagnosed?
**NO VAGINAL EXAM**
* transabdominal US: to screen
* TVUS: to confirm
* Kleihaver-betke test for all Rh - women
60
How is placenta previa treated?
strict pelvic rest and bed rest
* planned c-section at 34-37 weeks + hysterectomy
61
What are the guidelines for elective abortions?
>8 weeks gestation: medical abortion
* methotrexate/misoprostol
>12 weeks gestation: surgical abortion
* 4-12 wks: suction curettage (D&C)
* greater than 12 wks: D&E
62
What is preclampsia?
**TRIAD: nondependent edema, HTN, proteinuria**
63
How is preclampsia diagnosed?
**BP >140/90** on 2 seperate occasions after 20 wks **+ proteinuria**
* >300 mg per 24hr collection
* protein:creatinin > 0.3
**OR in the absence of proteinuria**
* thrombocytopenia: platelets < 100,000
* creatinine > 1.1
* RUQ or epigastric pain unresponsive to tx
* pulmonary edema
* visual disturbances/headaches
64
How is preclampsia treated?
**prevent eclampsia + BP control + delivery**
* seizure prophylaxis: magnesium sulfate (monitor patellar reflex - calcium gluconate if mag toxicity)
* BP: hydralazing, labetalol, nifedipine
* >32 wks: deliver w/ induction
* Future pregnancies: low dose ASA
65
What is eclampsia?
**elevated BP + proteinuria + seizures**
66
What are symptoms of eclampsia?
HTN after 20 wks gestation + protinuria + evidence of end-organ dysfunction (visual changes, AMS, pulmonary edema, seizures)
67
How is eclampsia diagnosed?
Control BP + delivery
* magnesium sulfate: 4-6g over 15-20 min followed by 1-2g per hour (monitor patellar reflex)
* BP: hydralazine, contuine for 12-24 hrs after delivery
68
What is HELLP syndrome?
* Hemolytic anemia: bite cells, schistocytes, high lactate & bilirubin, low Hgb
* Elevated Liver enzymes
* Low Platelets: < 100k
69
When to suspect HELLP syndrome?
epigastric pain + headache + HTN
Tx: delivery
70
What is augmentation?
induction of labor, increases contractions
* prostaglandins, oxytocin, mechanical dilation, artifical ROM
71
What induction agent would you give a patient with a Bishop score greater than 6?
Favorable for success of induction
* IV oxytocin, aminotomy (artifical ROM)
72
What induction agent would you give for a patient with a Bishop score less than 6?
Unfavorable for successful induction
* prostaglandin gel or transcervical balloon catheter
73
How is hyperemesis gravidarum diagnosed?
* weight loss of > 5 % of pre-pregnancy body weight
* UA: ketonuria
* hypokalemia, hypochloremic metabolic alkalosis
74
How is hyperemesis gravidarum treated?
* Inital: lifestyle modification
* 1st line: pyridoxine +/- doxylamine
* 2nd line: phenergan, zofran or metoclopramide
75
What is the leading cause of neonatal sepsis?
GBS
76
How is pyelonephritis treated in a pregnant patient?
IV ceftriaxone
77
What is intrahepatic cholestasis?
liver disease that occurs during pregnancy characterized by increased serum bile acids and elevated LFTs
* MC in 3rd trimester
* recurs in 1/2 of pregnancies
78
What are symptoms of intrahepatic cholestasis?
purititis on plams and soles
79
How is intrahepatic cholestasis treated?
ursodexyxholic acid to ↑ hepatic bile flor
* Induce labor at 36-37 weeks gestation
80
How should seizures be managed in pregnancy?
* taper to lowest effective dose
* if no seixure in 2 years, stop meds
* **no depakote or valproic acid**
81
How should DVT be managed in pregnancy?
heparin
82
How should thyroid disorders be managed in pregnancy?
* hyper: PTU (1st trimester), methimazole
* hypo: levothyoxine
83
How should SLE be treated in preganancy?
ASA, heparin, steriods
* **NO methotrexate**
84
What is intraamniotic infection (chorioamnionitis)?
serious complication of pregnancy due to infection or inflammation of the fetal amnion membrane and chorion membrane
* caused by upward migration of vaginal flora
85
What are symptoms of IAI (chorioamionitis)?
fever > 100.4, leukocytosis (>15,000), purulent cervical os fluid, baseline fetal tachycardia
* maternal tachycardia, uterine tenderness, ill/toxic appearing, hypotension, diaphoresis
86
How is IAI (chorioamnionitis) diagnosed?
Clinical
* fever + leukocytosis + fetal tachycardia OR purulent fluid from cervical os
* Confirm: needle aspiration & analysis of amniotic fluid
87
How is IAI treated?
ABX + quick delivery
* IV ampicillin + gentamycin
* + clindamycin or metronidazole if c-section
88
What is the frank breech presentation?
MC
* hips flexed & knees extended
* feet adjacent to head
89
What is complete breech presentaion?
* both hips flexed
* both knees flexed
90
What is incomplete (footling) breech presentation?
* one or both hips not completely flexed
* presenting part may be buttock or one or both feet
91
What is McRoberts maneuver?
* hyperflexion and abduction of maternal hips towars the abdomen without pressure then with suprapubic pressure
* for shoulder dystocia
92
What is Rubin maneuver?
* for shoulder dystocia
* pressure on accessible shoulder towards anterior chest of fetus to decrease diameter
93
What is Woods corkscrew maneuver?
* for shoulder dystocia
* rotation fo the fetal shoulder 180°
94
What is Zavenilli maneuver?
* for a true emergency of shoulder dystocia
* place head back into pelvis and perform c-section
95
What is normal acceleration of fetal heart rate?
* ≥ 32 weeks gestation
* HR peak of ≥ 15 bpm above baseline with a duration of 15sec-2min from onset to return
96
What is reactive accleratino of fetal heart rate?
Two normal accelerations within 20 minutes
97
What is an early deceleration?
* lowest fetal HR at the **SAME TIME** as peak contraction
* due to vagal tone and head compression during contraction
98
What is a variable deceleration?
* ↓ in fetal HR ≥ 15 bpm for 15 sec-2 min
* due to cord entrapment under fetal shoulder
99
What are late decelerations?
* lowest fetal HR **AFTER** the peak of the contraction
* due to uteroplacental insufficency
100
What is category I of fetal distress?
* Normal fetal HR
* normal baseline
* moderate variability
* no late decelerations
101
What is category II of fetal distress?
* indeterminate fetal HR
* anything that doesnt fall into categories I or II and warrents further investigation
102
What is category III of fetal distress?
abnormal fetal HR + atleast 1 of the following
* abseent variability
* recurrent late declerations
* bradycardia
* sinusoidal pattern (fetal anemia)
103
What is VEALCHOP?
* Variable: Cord compression
* Early: Head compression
* Accelerations: Ok
* Late: Placenta insufficency
104
What is premature rupture of membranes (PROM)?
membrane rupture before the onset of labor or refular uterine contraction ≥ 37 weeks
105
What are symptoms and physical exam findings of PROM?
* Sx: sudden gush of clear or pale yellow fluid from the vagina
* PE: pooling of amniotic fluid in vaginal fornix
106
How is PROM diagnosed?
Clinical - **avoid digital exam!**
To confirm:
* **+ nitrazine paper test**
* **microscopic ferning**
* US: absent or very low levels of amniotic fluid
107
How is PROM treated?
Prompt induction of labor with oxytocin
* Complications: IAI or endometritis if prolonged
108
What is preterm premature rupture of membranes (pPROM)?
* membrane rupture before 37 weeks
109
How is pPROM treated?
* 20-36wks: steriods + ABX (ampicillin, erythromycin) + tocolysis + bethamethosone
* daily BPP, NST, aminocentesis
* prompt delivey if sxs of maternal/fetal infection or distress
110
What is preterm labor?
* before 37 weeks gestation
* regular uterine contraction ~5 min apart that occur with cervical dilation, effacement or both
* **MCC of infant morbidity/mortality**
111
112
What are the 4 main causes of preterm labor?
1. pathologic uterine distension: multiple gestation, polyhydramnios
2. blood vessel hemorrahe & abruption: maternal HTN
3. **exaggerated response to inflammation or infection: activation of TNF**
4. premature activation of HPA
113
Howis preterm labor diagnosed?
regular uterine contractions + 1 of the following
* cervical dilation ≥ 3 cm
* cervical length < 20 mm on TVUS
* cervical length 20-29mm on TVUS + positive fetal fibronectin
114
How is preterm labor treated?
* >34 wks: deliver
* <34 wks: ABX + steriods + tocolytics
115
What are tocolysis?
Its Not My Time!
* Indomethacin: before 32 weeks
* Nifedipine: after 32 weeks
* Magnesium sulfate: neuroprotective
* Terbutaline: BBW may cause maternal death and cardiac events
116
How can preterm labor be prevented?
weekly injections of 17 alpha hydrocyprogesterone caproate from 16-36 weeks
117
What is oligohydramnios?
* too little amniotic fluid
* ↑ in perinatal mortality
* AFI < 5 on US
118
How is oligohydramnios treated?
* induce labor
* dilure meconium in amniotic fluid to decrease aspiration risk
119
What is polyhydramnios?
* too much amniotic fluid
* MCC chromosome abnormalities
* AFI > 20-25 on US
* Tx: ROM
120
What is a prolapsed umbilical cord?
* umbilical cord presents outside the cervix before fetus is delivered
* emergency! inhibits blood flow and can lead to fetal demise
* RF: breech position
121
What are symptoms of a prolapsed umbilical cord?
changes on fetal HR tracings, variable late decelerations or prolonged bradycardia
122
How is a prolapsed umbilical cord treated?
* cord decompression (manual)
* **standard: emergent C-section**
* if delay: terbutaline 0.25mg to decrease contractions and alleviate pressure on cord
123
What is endometritis?
infection of the decidua (pregnancy endometrium)
* MC after c-section
* MCC: anaerobic streptococci
124
What are symptoms of endometritis?
* 5-10 days after delivery
* Classic: lower abdominal pain + fever + tachycardia + uterine tenderness
* foul smelling lochia
125
How is endometritis diagnosed?
WBC > 20K, UA
126
How is endometritis treated?
**IV clindamycin + gentamycin **
* may add ampicillin or metro if no response in 24-48 hrs
* suspect septic pelvic thrombophlebitis if no imporvment after 3-5 days (palpable cord-like mass)
* Prophylaxis: ceftazolin within 60min of c-section
127
What is a 1st degree perineal laceration?
involves only the perineal skin
128
What is a second-degree perineal laceration?
involves the perineal body and deeper tissues (bulbospongious muscle, superficial transverse perineal muscle)
129
What is a third-degree perineal laceration?
extends into the capsule and muscle of the rectal sphincter
* 3a <50%
* 3b >50%
* 3c: both external and internal anal sphincter
130
What is a 4th degree perineal laceration?
extends through the spincter and into the rectal mucosa
131
What is a episiotomy?
surgical incision from vaginal opening to anus to assit with vaginal delivery
* reserved for when 3rd/4th degree lacerations are likely
* MC mediolateral
