Obstetrics Flashcards
Stage of Labour (Include Times)
Stage 1: (1) Latent (infrequent contractions; slow dilation to 3 cm w/ effactment) (2) Active phase (frequent, painful contractions; full dilation up to 10 cm)
Nulliparous: 6-18 hrs
Mult: 2-10 hrs
Stage 2: expulsion
N: 30min-3 hrs
M: 5-30 min
Stage 3: placental expulsion
N: 5-30 minutes
M: 5-30 minutes
What is deemed normal in a non-stress test
Is no less than “02 of 15 for 15 in 20”
ie. 2 accelerations of FHR > 15 bpm from baseline, lasting > 15 seconds in 20 minutes
Note: can drink fluid or nudge fetus if sleeping
DDx Menorrhagia
Disorders of coagulation
Hypothyroidism
Fibroids
Endometrial polyps
Pelvic inflammatory disease
Foreign bodies/ intrauterine devices
Endometriosis
Adenomyosis
Ix Menorrhagia
FBC
Clotting Studies
Thyroid function
High vaginal swab
Cervical Swab
Imaging
U/S (immediately after menstruation)
Hysteroscopy (if U/S unsatisfactory)
Indications for endometrial biopsy include:
1) persistent intermenstrual bleeding
2) women over 35 years who have failed initial treatment
3) abnormal endometrial morphology or thickness on ultrasound.
Myomectomy Fibriod Warnings
Warn (if bleeding excessive)
1) Risk need for blood transfusion
2) Hysterectomy
Causes Anovulation
Physiologic states: Adolescence, perimenopause, lactation, pregnancy.
Pathologic: PCO, CAH, androgen secreting tumors.
Hypothalamic dysfunction: Anorexia nervosa, stress, exercise, weight loss.
Endocrine Dysfunction: Hypothyroidism, Hyperprolactinemia, pituitary disease.
DDx for 1st Trimester Bleed
Spontaneous abortion/miscarriage
Ectopic
Trophoblastic disease
Cervical polyp
Friable cervix
Trauma
Cervical Cancer
Define Abortive Terms:
1) Spontaneous
2) Threatened
3) Incomplete
4) Inevitable
1) spontaneous loss of pregnancy before 20 wks OR expulsion of fetus, or embryo, weighing < 500g
2) uterine bleeding, closed cervix, no products of conception passed
3) Some, but not all products of conception passed
4) Cervix dilated, products not passed
Criteria Methotrexate in Ectopic
Stable Vital signs
No contraindications to drug
unruptured ectopic
no embryonic cardiac activity
ectopic mass < 4 cm
bHCG < 5000 mIU/mL
Tx of Suspected Gon/Chlaymdia
ceftriaxone 250mg IM (gonorrhea)
azithromycin 1 g PO OR doxycycline 100mg BD x 7d (either or for chlaymdia)
RF for Endometriosis
Early menarche
Late menopause
Obesity
Chronic anovulation
Estrogen-secreting ovarian tumors
Ingestion of unopposed estrogen
Hypertension
Diabetes mellitus
Personal or family history of breast or ovarian cancer
RF Placenta Previa
Grand multiparity
Prior cesarean delivery
Prior uterine curettage
Previous placenta previa
Multiple gestation
Smoking
DDx Late Term Bleeding
Late Term = > 20 wks
Life threatening:
Placenta Previa
Placenta Abruptio
Vasa previa
Uterine scar rupture
Non-immediate life threatening
Polyp
Cervicitis/ectropion
Cervical cancer
Vaginal Trauma
Bloody show
RF Placenta Abruptio
Hypertension (chronic and preeclampsia)
Cocaine use
Short umbilical cord
Trauma
Uteroplacental insufficiency
Submucous leiomyomata
Sudden uterine decompression (hydramnios)
Cigarette smoking
Preterm premature rupture of membranes
DDx fluid leaking down leg
Urinary incontience
UTI
PROM
Vaginal DC
Management if PROM is not imminent
Admit to hospital
Daily assessment - pains? unwell? tender?
Betamethasone - 2 doses
Antibiotics- erythromycin 250 mg QDS for 10 days
Vaginal swab for C/S
4-hourly T, P, FH
Daily CTG
Twice weekly FBC, CRP
US - presentation, BPS, liquor, growth
Timely delivery - aim for after 34 weeks
Insufficient evidence to recommend the use of amniocentesis in the diagnosis of intrauterine infection.
RF for Cerivcal Cancer
Early age of coitus
Sexually transmitted diseases
Early childbearing
Low socioeconomic status
Human papillomavirus
HIV infection
Cigarette smoking
Multiple sexual partners
Management of Fetal Bradycardia
Confirm fetal heart rate (vs maternal heart rate)
Vaginal examination to assess for cord prolapse
Positional changes
Oxygen
Intravenous fluid bolus
Discontinue oxytocin
Shoulder Dystocia Complications
Maternal:
soft tissue injuries
anal sphincter damage
postpartum haemorrhage
uterine rupture
symphyseal separation
Neonatal
brachial plexus palsy
clavicle fracture
humeral fracture
fetal acidosis
hypoxic brain injury
RF for Preterm Delivery
Maternal
Lower socioeconomic status
Smoking
Low pre-pregnancy weight <55kg
Maternal age <18 years and > 40
Poor nutrition
Obstetrical
Shortened cervix
Cervical surgery e.g cone biopsy
Previous hx of repeat TOP
Previous second trimester miscarriage
Pregnancy complications
Multiple pregnancy
Infections
Bleeding < 24 weeks
Previous preterm delivery- 17 to 37%
Complications of prematurity for the baby
Neonatal death
Respiratory distress syndrome (RDS)
Necrotising enterocolitis (NEC)
Intraventricular haemorrhage (IVH)
Infection
Jaundice
Hypothermia
Hypoglycaemia
Long-term - developmental delay, cerebral palsy, blindness, deafness, poor educational attainment; bronch-pulmonary dysplasia
Causes of unstable lie
Start at Center
§ Twins or conjoined twins, hydrocephalus, anencephaly
§ Cord: short cord in high uterus
§ Too much or too little liqor
§ Placenta: previa
§ Uterus: bicorniate (feet in one horn, head in other), fibroid
§ Extra-uterine: extra-uterine cyst
§ Bones: osteomalacia (Ricket’s), RTA
§ Muscles: multigravidy with lax muscles (5-6 previous babies)
DDx Polyhydraminous
1) Twins
2) Diabetes
3) Down’s: duodeal atresia (double bubble)
○ Jejunal atresia (random anomaly not associated with Down’s) - triple bubble
4) TOF
5) NTD
Rhesus Disease
Oligohydraminous DDx
Kidney issues (Potter’s sydrome, posterior urethral valves)
Meds: NSAIDs
IUGR: Placental Insufficiency
Ruptured membranes
Late pregnancy
(Fluid peaks 33 wks)
( Induce Term + 10: legality, amniotic fluid becomes thick which baby may aspirate )
Name some Tocolytics
COX inhibitors (indomethacin)
CCB (nifedipine)
Oxytocin antagonist (atosiban)
Ritodrine (B2-agoinst)
Candidates for tocolysis
No contraindication to the drug
No contraindication for prolonging the pregnancy
Fetus is currently healthy
Clear diagnosis of preterm labour
Cervix < 4cm dilated
Gestational age between 24-34 weeks
Contraindications to tocolysis
Severe hemorrhage
Abruption
Severe preeclampsia
Eclampsia
Intrauterine fetal death
Severe intrauterine growth restriction
Pulmonary hypertension
Known intolerance to tocolytics
Fetal maturity
Lethal fetal anomaly
Chorioamnionitis
Ix for PTL
FBC and urineanalysis
Evaluate for maternal infection
Amniocentesis
Assess fetal lung maturity
Ultrasound
Assess AFI
Gestational age and EFW
Transvaginal scan for cervical length
Cervicovaginal swab for FfN test
GBS Risk Factors
What is the Rx
Prenatal
Previous GBS infected baby
GBS bacteriuria during current pregnancy
Intrapartum
Maternal temprerature more than 38 degree C
Gestational age < 37 weeks
Ruptured membranes >18 hours
Rx
penicillin 1st line (benzylpenicillin 3g IV stat dose; followed 1.5 g IV q 4 hours until baby born), ampicillin 2nd line (cefazolin if penicillin allergic)
GBS Prophylaxis
Benzylpenicillin 3g iv stat dose
Followed by 1.5g iv every 4 hours until baby born
If allergy to penicillin
Clindamycin 900 mg iv every 8 hours until delivery
5 basic factors of infertility
Ovulatory (30-40%)
BBT, Mid-luteal Progesterone, LH,FSH
Uterine Hysterosalpinogram (first-line - done days 6-10)
Tubal
Male factor
Peritoneal factor (endometriosis)
DDx Small Baby on Clincial Exam
- Wrong Dates
- Small normal baby
- Congenital defects
- IUGR
DDx IUGR
- Pre-eclampsia
- Smoker
- Isolated IUGR
- Maternal disease
Placental insuffiency
Symmetric vs. Asymetric IUGR
Symmetric = fetal causes (irreversible)
TORCH infections & congenital anomalies (Turner`s, T21, T18, T13)
Asymmetrical = mother causes (reversibe) after 28 wks
Smoking, drug use, alcohol, Maternal disease (SLE, APS, DM 1), Previous IUGR, pre-eclampsia, Chronic HTN (most common cause IUGR)
Mx IUGR
Serial U/S: twice wkly
Umbilical Doppler U/S: < 3 ratio & +ve EDV
MCA Doppler: fetal anemia
1) Indications for Instrumental Delivery
2) Requirements
Prolonged second stage: This includes nulliparous woman with failure to deliver after 2 hours without, and 3 hours with, conduction anesthesia. It also includes multiparous woman with failure to deliver after 1 hour without, and 2 hours with, conduction anesthesia
.
Suspicion of immediate or potential fetal compromise in the second stage of labor.
Management of ASCUS of LSIL smears
ASCUS: 3 consecutive ASCUS -> refer to colposcopy
Ascus + LSIL -> refer to colposcopy
LSIL (= CIN I): 2 consecutive LSIL -> refer to colposcopy
Must have 3 consecutive normal smears at 6 month intervals to go back to routine PAPs schedule (every 3 years under 45 and every 5 years 45-60)
Management of AGUS and HSIL
- If 1 abnormal smear of AGUS or HSIL (= CIN II, CIN III, or CIS), you must refer to colposcopy!!
- must have 2 consecutive normal smears at 6 month intervals, then annual smears for 9 years before going back to routine PAPs schedule.
- treatment options include ablation (ie. cold coagulation) or excision (ie. conization or LETTZ); the latter being able to take biopsy samples for histology. Therefore only use ablation when you are sure there is no risk of invasive carcinoma.
- CIN I and CIN II 4, 4, 2 rule for regress, stay the same, progress
- CIN III 1,6,3 for regress, stay the same, progress
POP advantages and disadvantages
Advantages:
- Useful when patient has conditions predisposing to clots (previous DVT, diabetes, SLE, smoking above 35), and can take if hx of migraine +- aura
- 3rd generation (desorgestral) work mainly by preventing anovulation (90%, compared to 50% in traditional ), whereas tradition work by thickening cervical mucus
- as efficacious as COC when used correctly (99%)
- immediate return to fertility
- can be used immediately post-partum
Disadvantages:
- irregular bleeding (4, 4, 2 have none), weight gain, acne, mood change, bloating
- change in bleeding should b investigated for STI
- need to take it within a 12 hour window for 3rd generation, can’t miss a pill or need contraception for 48 hours and NO PILL FREE INTERVAL
- affected by liver-inducing agents
Drugs to avoid in mom’s breastfeeding
antibiotics: ciprofloxacin, tetracycline, chloramphenicol, sulphonamides
psychiatric drugs: lithium, benzodiazepines
aspirin
carbimazole
sulphonylureas
cytotoxic drugs
amiodarone
Infertility DDx and Workup
DDx Approach
1. Failure to ovulate - excessive exercise, underweight, PCOS, hyperprolactinemia
2. Fallopian tube not patient - endometrosis, infection, adhesions
3. Failure of sperm production: testicular radiotherapy and infection
Ix
- LH/FSH/estradiol - day 2-6
- Progesterone - day 21 or 7 days before menses
- Transvaginal ultrasound - fibroids or PCOS
- Blood: TSH, prolactin, testosterone
Semen sample: 2-3 days abstience and repeat after 6 weeks.
Causes Menorrhagia
Coagulopathies
von Willebrand’s disease
Thrombocytopenia (due to idiopathic thrombocytopenic purpura, hypersplenism, chronic renal failure)
Acute leukemia
Anticoagulants
Advanced liver disease
Neoplasm
Endometrial adenocarcinoma
Uterine sarcoma
Structural lesions
Leiomyomata uteri (fibroids)
Adenomyosis
Polyps
Other
Endometritis
Hypothyroidism
Intrauterine device
Hyperestrogenism
Endometriosis
Indications for continuous EFM
**Fetal **
Intrauterine growth restriction
Oligohydramnios
Abnormal Doppler velocimetry
Preterm labour
Multiple pregnancy
Breech presentation
Rhesus iso-immunisation
Maternal
Previous Caesarean section
Pre-eclampsia
Pregnancy >42 weeks
Prolonged ROM >24 hours
Diabetes
Antepartum haemorrhage
Significant medical condition – eg cardiac
DDx Endometrosis
Differential diagnoses include adhesions, chronic pelvic inflammatory disease, irritable bowel syndrome, musculoskeletal pain, and neuralgia.
Complications of Twins
**Maternal **
Gestational HTN
Gestational Diabetes
Hyperemesis gravidarum
Anemia
C-section
Placental (P’s)
Incr. PROM
Polyhydraminous
PPH
Placenta Previa
Placenta Abruptio
Cord Prolapse
Fetal
Prematurity (most common)
IUGR
Malpresentation
Congenital abnormalities
Twin-to-Twin
Incr. mortality and morbidity
Single fetal demise
DDx Large for Dates
Multiple Gestations
Inaccurate menstrual hx
polyhydraminous
hydatiform mole
adnexal mass
uterine myoma
dystended bladder pushing up uterus
fetal macrosomia
RF for Preeclampsia
Demographic
More common in women < 20 years of age and >35 years of age
Nulliparity (8x risk)
Obstetric
History of previous preeclampsia
Positive family history
Multiple gestations
Blacks
Thrombocytosis
obesity
Molar pregnancy (can develop pre-eclampsia before 20 wks)
Medical
DM
Chronic HTN
Renal Disease
SLE
Management of Pre-eclampsia & Eclampsia
Pre-elampsia
Maternal monitoring
- Admit
- 4 hourly BP
- Regular blood tests
- 24 hour urine collection
○ Urine input/ouput
- Daily medical review
- *Fetal Monitoring**
- Fetal movement
- Daily CTG
- USS
Mom
- FBC (anemia), BUN, Cr, AST/ALT, LDH, uric acid
- LFTs, platelets (think HELLP)
Fetal:
- U/S - look of IUGR
- Look at lycor volume
- Doppler through umbilical artery (incr. resistance will bounce blood off placenta)
_Eclampsia _
Management (worry about mom not baby)
- ABC (establish 2 large bore cannulas)
○ Pulse oximeter, O2
- Restrict IV fluid to 80 ml/hr (can cause pulmonary edeam), like to see 30 ml output/ hr - monitor input and output
- Place mom in LL position
- Prevention: MgSO4 4g over 15 minutes (IV load) then 1-3 g/hr for next 24 hour (prophylactic >160/110 or symptoms of pre-eclampsia then start)
○ Therapeutic range: 2-4 mmol/L (check reflexes)
§ 1 g IV slow (over 3 min) infusion Ca gluconate if too high
- BP: goal 90-110 maternal diastolic
○ If BP 160/110: IV labetalol or IV hydralazine
Post-partum management - Generally improvement after 24 hrs
- Risk of seizures greatest first 24 hrs - therefore continue MgSO4 for 1 day
Causes of Fetal Bradycardia
BRADYCARDIA<110
Gestation > 40 weeks
Cord compression
Congenital heart malformations
Congenital heart block (including SLE)
Drugs eg.benzodiazepines
DDx Fetal Tachycardia
TACHYCARDIA>160
Excessive fetal movement
Maternal anxiety
Gestation <32 weeks
Maternal pyrexia
Fetal infection
Chronic hypoxia
Treatment for Non-reassuring CTG
Maternal position change, Oxygen and iv fluid
Change method of monitoring
Reassess maternal vital signs
Assess cervix for dilation or prolapse
Stop oxytocin if in use
Fetal blood sampling
Tocolysis
Amnioinfusion
Acoustic or scalp stimulation
Plan immediate delivery
Scalp pH monitoring
Above 7.25
Repeat pH in 1 hour if tracing non reassuring
Between 7.20 to 7.25
Repeat pH in 30 minutes if tracing not improved
Below 7.20
Deliver immediately
Complications of Gestational Diabetes
** Maternal complications**
• polyhydramnios - 25%, possibly due to fetal polyuria
• preterm labour - 15%, associated with polyhydramnios
• Diabetes may develop at a later date (>50% of cases)
Neonatal complications
• macrosomia (although diabetes may also cause small for gestational age babies)
• hypoglycaemia
• respiratory distress syndrome: surfactant production is delayed
• polycythaemia: therefore more neonatal jaundice
• If pre-gestational diabetic: malformation rates increase 3-4 fold e.g. sacral agenesis, CNS and CVS malformations (hypertrophic cardiomyopathy)
• stillbirth
• hypomagnesaemia
• hypocalcaemia
RF Placenta Previa
Advancing material age
Multiparity
Multiple gestations
Smoking
Prior caesarian section (10%)
Signs of normal placental delivery
- More globular uterus
- Lengthening of cord
- Gush of blood
RF Placenta Abruptio
Hypertension (greatest risk factor; 40-50% of cases)
Smoking cigarettes
Cocaine addiction; advanced maternal age
Trauma; chorioamnionitis
Premature rupture of membranes
Previous abruptio placentae
Causes of recurrent miscarriages
antiphospholipid syndrome
endocrine disorders: poorly controlled diabetes mellitus/thyroid disorders. Polycystic ovarian syndrome
uterine abnormality: e.g. uterine septum
parental chromosomal abnormalities
smoking
Frequency of progression of endometrial hyperplasia to endometrial cancer
Simple 1%
Complex 3%
Simple with atypia 8%
Complex with atypia 29%
Types of endometrial cancer
Endometrioid 80- 85%
Generally resembles normal proliferation
Adeno-squamous
Papillary Serous 10%
Clear cell 4%
DDx of post- menopausal bleeding (PMB)
Endometrial ca.
Endometrial/cervical polyps
Endometrial hyperplasia
Other gynecological cancers
Exogenous estrogen use (tamoxifen)
Atrophic endometritis/vaginitis
Difference between HSV 1, 2
HSV-1 HSV-2
• Trigeminal ganglia • Lumbo-sacral ganglia
• Can be latent many years • Can be latent many years
• Cold sores • Genital ulcers
• Typically 1/3 of new cases • Typically 2/3 of new genital cases genital cases.
• 5% genital recurrences • 95% genital recurrences
• Causes ocular herpes, • Causes encephalitis
encephalitis, whitlow.
• Does not protect against • Protects against HSV-1
HSV-2
- Function of progesterone in early and late pregnancy?
- Level of progesterone that indicates viable pregnancy
- Early pregnancy - change endothelial lining to make it more favourable for implantation
- Late pregnancy - stabilizes myometrium to prevent preterm labor
2. <5ng/ml - poor outcome; >25 ng/ml viable IUP
Define blighted ovum
Identifiable sac and placental tissue, with no embryo
Causes of Miscariage
Major genetic anomaly
Internal environmental factors - Uterine (anomalies, leiomyomata, incompetent cervix), maternal DES exposure, luteal phase defect, immunologic factors
External environmental factors - Substance use (tobacco, EtOH, cocaine), irradiation, infection, occupational chemical exposure
Advanced maternal age
Diagnosis of Ectopic Pregnancy
Failure of bHCG to double in 48-72 hrs
Low serum progesterone
U/S - transvaginal - gestational sac outside of uterus
Laparascopy - gold standard
Extrauterine signs of EP inlcude - no mass or free fluid, any free fluid, echogenic mass
Complications of D&C for abortion
Bleeding
Perforation
Infection
Incomplete evacuation
Late sequelae : Intrauterine synchaie(asherman’s syndrome), depression/guilt
Risk factors for shoulder dystocia
Antenatal
Macrosomia, maternal DM, maternal obesity, excessive weight gain in pregnancy (>20 kg gain), short pelvic structure, previous shoulder dystocia or big bag
Labour
Oxytocin augmentation, slow progress through first stage of labor, secondary arrest after 8cm/2nd stage, midcavity arrest, need for midcavity assisted delivery
Delivery
Head delivering at the end of contraction, difficulty with delivery of head and chin, retraction of head between contractions
Causes of hirsuitism
Non-androgenic causes
Chronic skin irritation and excess hair growth
Acromegaly
Iatrogenic(drug-induced)hirsutism
Androgenic hirsutism
Polycystic ovarian syndrome
Hyperandrogenic insulin-resistant acanthosis nigricans syndrome
Non-classical congenital adrenal hyperplasia
Cushing’s syndrome
Androgen-secreting tumours
Idiopathic hirsutism
Hirsutism in the presence of normal androgens and ovulatory cycles
Complications of PID
Infertility - Infertility after a single episode is 15% but after 3 episodes increases to 75%
Chronic pelvic pain
Risk of EP - 7 x greater
Chronic tubo-ovarian abscess
What is the rate of fall in pH in umbilical cord with shoulder dystocia?
Umbilical cord pH falls by 0.04 unit/minute.
Delivery should be done within 5 minutes
Permanent injury is progressively more likely with delays above 10 minutes.
Complications of assisted Conception
EP
Multiple gestations
Ovarian hyperstimulation syndrome (resence of multiple luteinized cysts within the ovaries leading to ovarian enlargement and secondary complications incl nausea, bloating, etc)
Infection and/or hemmorhage
No response to treatment
Complications of oxytocin
Uterine hyperstimulation
hypoxia of intervillus space
fetal compromise
abruption
uterine rupture
water toxicity in high doses
Management of Incontience
Management depends on whether urge or stress UI is the predominant picture. If urge incontinence is predominant:
bladder retraining (lasts for a minimum of 6 weeks, the idea is to gradually increase the intervals between voiding)
bladder stabilising drugs: immediate release oxybutynin (an antimuscarinic) is first-line
surgical management: e.g. sacral nerve stimulation
If stress incontinence is predominant:
pelvic floor muscle training (for a minimum of 3 months)
surgical procedures: e.g. retropubic mid-urethral tape procedures
Indications for anti-D immunoglobulin
Anti-D immunoglobulin should be given as soon as possible (but always within 72 hours) in the following situations:
delivery of a Rh +ve infant, whether live or stillborn
any termination of pregnancy
miscarriage if gestation is > 12 weeks
ectopic pregnancy
external cephalic version
antepartum haemorrhage
amniocentesis, chorionic villus sampling, fetal blood sampling
Complications of Rh -ve mom with Rh +ve baby
Affected fetus
oedematous (hydrops fetalis, as liver devoted to RBC production albumin falls)
jaundice, anaemia, hepatosplenomegaly
heart failure
kernicterus
treatment: transfusions, UV phototherapy
contraindications to OCP
Examples of UKMEC 3 (disadvantages generally outweigh the advantages) conditions include
more than 35 years old and smoking less than 15 cigarettes/day
BMI > 35 kg/m^2*
migraine without aura and more than 35 years old
family history of thromboembolic disease in first degree relatives < 45 years
controlled hypertension
immobility e.g. wheel chair use
breast feeding 6 weeks - 6 months postpartum
Examples of UKMEC 4 (represents an unacceptable health risk) conditions include
more than 35 years old and smoking more than 15 cigarettes/day
migraine with aura
history of thromboembolic disease or thrombogenic mutation
history of stroke or ischaemic heart disease
breast feeding < 6 weeks post-partum
uncontrolled hypertension
breast cancer
major surgery with prolonged immobilisation
Cervical Cancer Screening
25-49 years: 3-yearly screening
50-64 years: 5-yearly screening
Factors Associated with Earlier Menopause
Smoking
Nulliparity
Medically treated depression
Toxic chemical exposure
Treatment of childhood cancer with abdominal-pelvic radiation and alkylating agents
Premature, or early, menopause (age < 40 years) has been linked to both familial and non-familial X-chromosome abnormalities.
Most common site of fractures in post menopausal women
Vertebral fractures
Effect of estrogen changes on uterus during menopause
E deficiency results in:
Thin and paler vaginal mucosa.
Moisture content is low.
pH increases (usually pH > 5).
Inflammation and small petechiae.
Loss in superficial cells and an increase of basal and parabasal cells.
UTI (eg, coliform bacteria), as a result of the reduced acidity.
Decrease in lactobacilli, yeast.
Contraindications to Tocolysis
Obstetrics
Severe abruption
Ruptured membranes
Chorioamnionitis
Fetal
Lethal anomaly
Fetal demise
Fetal jeopardy
Maternal
Eclampsia
Severe pre-eclampsia
Advanced dilation
