Obstetrics Flashcards
What does APGAR stand for?
- Apperance
- Pulse
- Frimace (reflex irritability)
- Activity
- Respiration
When is APGAR given?
1 minute after birth and again at 5 minutes
What is a normal, low, and critically low APGAR score?
- Normal: = to or greater than 7
- Low: 4-6
- Critically low: = to or less than 3
What are the APGAR categories for appearance?
- 0: blue, pale
- 1: pink body, blue extremities
- 2: pink
What are the APGAR categories for pulse?
- 0: absent
- 1: below 100 bpm
- 2: over 100 bpm
What are the APGAR categories for grimace?
- 0: floppy
- 1: minimal response to stimulation
- 2: prompt response to stimulation
What are the APGAR categories for activity?
- 0: absent
- 1: flexed arms and legs
- 2: active
What are the APGAR categories for respiration?
- 0: absent
- 2: slow and irregular
- 3: vigorous cry
What are dizygotic or fraternal twins?
- 2/3 of multiple gestations
- fertilized 2 ova by 2 different sperms
- not the same genetic material
What are monozygotic or identical twins?
- 1/3 of multiple gestations
- fertilization of 1 ova that splits
- same genetic material
How much weight can a patient gain with multiple gestations?
37-54 lbs
How are multiple gestations diagnosed?
US + elevated hCG + AFP
What are monochorionic monoamniotic (mo/mo) twins?
single placenta, one chorion, one amnion
What are monochorionic diamniotic (mo-di) twins?
Single placenta, single chorion, two sacks
What are dichorionic diamniotic (di-di) twins?
two placentae, two chorion, two sacs
What are management recommendations for multiple gestations?
- 2 prenatal vitamine with iron
- 1 mg folate and 1000 mg of vitamin D daily
- More frequent US & visits
- Sleep on the left side
What are the 7 cardinal movements of labor & delivery?
- Engagement
- Descent
- Flexion
- Internal rotation
- Extension
- External rotation
- Expulsion
What is engagement?
fetal head enters into pelvis
What is descent?
Fetal head descends into pelvis
What is flexion?
head flexes to smallest diameter to present to the pelvis
What is internal rotation?
fetal vertex rotates from the transverse position to the anterioposterior position
What is extension?
vertex extends beyond pubic symphysis
What is external rotation?
after the head is delivered, baby externally rotates to allow for babys shoulders to pass
What is stage 1 of labor?
- 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
What is stage 3 of labor?
- from delivery of infant until delivery of placenta
What is stage 2 of labor?
- time of full dilation until delivery
- 1-2 hours
- early/variable decelerations common
- passive and active phases
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)
What is the first trimester screen and when is it done?
- Plasma hCG, PAPP-A, nuchal translucency
- 11-13 wks
- CVS sampling if indicated
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
What is the QUAD screen and when is it done?
- AFP + inhibin-A + estriol + BhCG
- 15-20 weeks
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
What is the MCC of spontanous abortion?
chromosomal abnormalities
What is a threatened abortion?
- cervical os: closed
- POC: retained
What is an inevitable abortion?
- cervical os: open
- POC: retained
What is an incomplete abortion?
- cervical os: open
- POC: some passed
What is a complete abortion?
- cervical os: closed
- POC: completly passed
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
What are risk factors for an ectopic pregnancy?
- strongest RF: previous ectopic
- hx PID, IUD
What are symptoms of an ectopic pregnancy?
Unilateral/lower abd pain + bleeding/spotting + amenorrhea
* ruptured: severe abdominal or shoulder pain (kehr sign), syncope, hypotension
How is an ectopic pregnancy diagnosed?
hCG less than expected
* > 1500 should show up on TVUS
How do you treat an ectopic pregnancy?
- hCG < 5000 without fetal activity: methotrexate
- emergent: laparoscopy
- trend BhCG until levels return to normal
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
How is gestational diabeties treated?
- Diet & exercise
- Severe: insulin
- Alt. glyburtide or metformin
- Comp.: polyhydramnios
What are symptoms of gestational trophoblastic disease?
painless vaginal bleeding, uterine size greater than gestational age, hyperemesis gravidarum, preclampsia 6-16 weeks
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
How is gestational trophoblastic disease diagnosed?
- earilest it can be dx: 8 wks
- hCG > 100,000
- US: snowstorm pattern and grapelike vesicles
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
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
What are risk factors for cervical insufficency?
ehlers-donlos syndrome, cervical trauma during labor/delivery, cervical dilations
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
How is cervical insufficency diagnosed?
- 2 consecutive 2nd trimester losses or early premature births
- TVUS: cervical length less than 25 mm before 24 wks
How is cervical insufficency treated?
cerclage placement at 12-14 weeks
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
What are risk factors for placenta abruptio?
HTN, cocaine, smoking
What are symptoms of placenta abruptio?
3rd trimester painful vaginal bleeding +/- severe contraction, firm/tender uterus
How is placenta abruptio diagnosed?
clinically - NO VAGINAL EXAM
How is placenta abruptio treated?
stabilize patient, prepare for hemorrhage
* < 34 wks: tocolytics + steriods + bed rest
* > 34 wks: delivery
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
What are symptoms of placenta previa?
sudden onset of painless vaginal bleeding after 28 weeks
* absense of abfominal pain ot uterine tenderness
How is placenta previa diagnosed?
NO VAGINAL EXAM
* transabdominal US: to screen
* TVUS: to confirm
* Kleihaver-betke test for all Rh - women
How is placenta previa treated?
strict pelvic rest and bed rest
* planned c-section at 34-37 weeks + hysterectomy
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
What is preclampsia?
TRIAD: nondependent edema, HTN, proteinuria
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
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
What is eclampsia?
elevated BP + proteinuria + seizures
What are symptoms of eclampsia?
HTN after 20 wks gestation + protinuria + evidence of end-organ dysfunction (visual changes, AMS, pulmonary edema, seizures)
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
What is HELLP syndrome?
- Hemolytic anemia: bite cells, schistocytes, high lactate & bilirubin, low Hgb
- Elevated Liver enzymes
- Low Platelets: < 100k
When to suspect HELLP syndrome?
epigastric pain + headache + HTN
Tx: delivery
What is augmentation?
induction of labor, increases contractions
* prostaglandins, oxytocin, mechanical dilation, artifical ROM
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)
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
How is hyperemesis gravidarum diagnosed?
- weight loss of > 5 % of pre-pregnancy body weight
- UA: ketonuria
- hypokalemia, hypochloremic metabolic alkalosis
How is hyperemesis gravidarum treated?
- Inital: lifestyle modification
- 1st line: pyridoxine +/- doxylamine
- 2nd line: phenergan, zofran or metoclopramide
What is the leading cause of neonatal sepsis?
GBS
How is pyelonephritis treated in a pregnant patient?
IV ceftriaxone
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
What are symptoms of intrahepatic cholestasis?
purititis on plams and soles
How is intrahepatic cholestasis treated?
ursodexyxholic acid to ↑ hepatic bile flor
* Induce labor at 36-37 weeks gestation
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
How should DVT be managed in pregnancy?
heparin
How should thyroid disorders be managed in pregnancy?
- hyper: PTU (1st trimester), methimazole
- hypo: levothyoxine
How should SLE be treated in preganancy?
ASA, heparin, steriods
* NO methotrexate
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
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
How is IAI (chorioamnionitis) diagnosed?
Clinical
* fever + leukocytosis + fetal tachycardia OR purulent fluid from cervical os
* Confirm: needle aspiration & analysis of amniotic fluid
How is IAI treated?
ABX + quick delivery
* IV ampicillin + gentamycin
* + clindamycin or metronidazole if c-section
What is the frank breech presentation?
MC
* hips flexed & knees extended
* feet adjacent to head
What is complete breech presentaion?
- both hips flexed
- both knees flexed
What is incomplete (footling) breech presentation?
- one or both hips not completely flexed
- presenting part may be buttock or one or both feet
What is McRoberts maneuver?
- hyperflexion and abduction of maternal hips towars the abdomen without pressure then with suprapubic pressure
- for shoulder dystocia
What is Rubin maneuver?
- for shoulder dystocia
- pressure on accessible shoulder towards anterior chest of fetus to decrease diameter
What is Woods corkscrew maneuver?
- for shoulder dystocia
- rotation fo the fetal shoulder 180°
What is Zavenilli maneuver?
- for a true emergency of shoulder dystocia
- place head back into pelvis and perform c-section
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
What is reactive accleratino of fetal heart rate?
Two normal accelerations within 20 minutes
What is an early deceleration?
- lowest fetal HR at the SAME TIME as peak contraction
- due to vagal tone and head compression during contraction
What is a variable deceleration?
- ↓ in fetal HR ≥ 15 bpm for 15 sec-2 min
- due to cord entrapment under fetal shoulder
What are late decelerations?
- lowest fetal HR AFTER the peak of the contraction
- due to uteroplacental insufficency
What is category I of fetal distress?
- Normal fetal HR
- normal baseline
- moderate variability
- no late decelerations
What is category II of fetal distress?
- indeterminate fetal HR
- anything that doesnt fall into categories I or II and warrents further investigation
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)
What is VEALCHOP?
- Variable: Cord compression
- Early: Head compression
- Accelerations: Ok
- Late: Placenta insufficency
What is premature rupture of membranes (PROM)?
membrane rupture before the onset of labor or refular uterine contraction ≥ 37 weeks
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
How is PROM diagnosed?
Clinical - avoid digital exam!
To confirm:
* + nitrazine paper test
* microscopic ferning
* US: absent or very low levels of amniotic fluid
How is PROM treated?
Prompt induction of labor with oxytocin
* Complications: IAI or endometritis if prolonged
What is preterm premature rupture of membranes (pPROM)?
- membrane rupture before 37 weeks
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
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
What are the 4 main causes of preterm labor?
- pathologic uterine distension: multiple gestation, polyhydramnios
- blood vessel hemorrahe & abruption: maternal HTN
- exaggerated response to inflammation or infection: activation of TNF
- premature activation of HPA
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
How is preterm labor treated?
- > 34 wks: deliver
- <34 wks: ABX + steriods + tocolytics
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
How can preterm labor be prevented?
weekly injections of 17 alpha hydrocyprogesterone caproate from 16-36 weeks
What is oligohydramnios?
- too little amniotic fluid
- ↑ in perinatal mortality
- AFI < 5 on US
How is oligohydramnios treated?
- induce labor
- dilure meconium in amniotic fluid to decrease aspiration risk
What is polyhydramnios?
- too much amniotic fluid
- MCC chromosome abnormalities
- AFI > 20-25 on US
- Tx: ROM
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
What are symptoms of a prolapsed umbilical cord?
changes on fetal HR tracings, variable late decelerations or prolonged bradycardia
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
What is endometritis?
infection of the decidua (pregnancy endometrium)
* MC after c-section
* MCC: anaerobic streptococci
What are symptoms of endometritis?
- 5-10 days after delivery
- Classic: lower abdominal pain + fever + tachycardia + uterine tenderness
- foul smelling lochia
How is endometritis diagnosed?
WBC > 20K, UA
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
What is a 1st degree perineal laceration?
involves only the perineal skin
What is a second-degree perineal laceration?
involves the perineal body and deeper tissues (bulbospongious muscle, superficial transverse perineal muscle)
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
What is a 4th degree perineal laceration?
extends through the spincter and into the rectal mucosa
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