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STEP2 > Obstetrics > Flashcards

Obstetrics Flashcards

1
Q

Signs of pregnancy

A 
amenorrhea
breast engorgement/tenderness
fatigue
nausea/vomiting
quickening (movement)
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2
Q

Signs of early pregnancy

A

Goodell sign- softening of the cervix

Chadwick sign- dark- bluish red discoloration of the vaginal mucosa

Hegar and Ladin signs: softening of uterus

Chloasma: skin hyperpigmentation on the face, often in sun-exposed areas

Linea nigra: skin hyperpigmentation along the midling of the anterior abdominal wall

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3
Q

When does betaHCG become detectable in theurine? in the serum?

A

urine: 2 weeks after fertilization

serum 1 week after fertilization

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4
Q

when does a pregnancy show up on ultrasound?

A

5 weeks

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5
Q

when does fetal cardiac activity become perceptible on Doppler?

A

10-12 weeks

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6
Q

gestational age-

A

measured from 1st day of LMP
inaccurate if the cycle isn’t 14 days

can be estimated with US

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7
Q

embryonic age

A

measured from fertilization

how old is the age of the embryo?

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8
Q

Naegele’s rule for calculating due date

A 
1st day of LMP 
\+ 7 days
-3 months
\+ 1 year
= expected date of delivery
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9
Q

G and P

A

G:# of pregnancies
P:# of births: 20 weeks
A:# of abortions

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10
Q

nulligravida

A

never been pregnant

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11
Q

nullipara

A

never given birth

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12
Q

primigravida

A

currently in 1st pregnancy

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13
Q

primipara

A

has had 1 birth

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14
Q

multipara

A

has had >2 births

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15
Q

age of viability

A

24 weeks

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16
Q

preterm

A
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17
Q

term birth

A

37 w 0 d - 41w 6 d

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18
Q

postterm

A

> 42 weeks

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19
Q

maternal physiology SU260

A 
Basal metabolic rate increases 10-20%
plasma volume increases 30-50%, RBC volume increases 20-30%
systolic Ejection flow mumur
S3
cardiac output inreases 30-50%

blood pressure decreases in early pregnancy- nadir at 24-26 weeks, return to prepregnancy levels by term

relaxation of the lower esophageal sphincter - GERD

increased GFR- decreased BUN and Creatinine

increased procoagulation factors- hypercoagulable state

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20
Q

sensitive and specific diagnostic lab test for chronic pancreatitis

A

low fecal elastase

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21
Q

How many extra kcal does a woman need during pregnancy?

A

women need an extra 100-300kcal/day to meet increased metabolic needs (rate increases by 10-20%)

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22
Q

What is the recommended weight gain during pregnancy for someone who is Underweight (BMI

A

28-40 pounds

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23
Q

What is the recommended weight gain during pregnancy for someone who is normal weight (BMI

A

25-35 pounds

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24
Q

What is the recommended weight gain during pregnancy for someone who is overweight ((BMI 25-29.9)?

A

15-25 pounds

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25
Q

What is the recommended weight gain during pregnancy for someone who is obese (BMI>30)

A

11-20 pounds

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26
Q

What supplements should pregnant women take?

A

folic acid prevents NTD
extra if on antiseizure meds

iron
avoid vitamin A in excess

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27
Q

what should pregnant women avoid eating?

A

deli meats (listeriosis)

fish high in mercury (CNS damage)

  • shark
  • swordfish
  • king mackerel
  • tilefish
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28
Q

how big is the uterus during pregnancy?

A

6-8 wks-lemon
8-10 wks- orange
10-12 wks- grapefruit

12 weeks- at the pubis
16 weeks- halfway
20 weeks- umbilicus
from 20-32 weeks the distance from the pubis approximates the age of the uterus

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29
Q

What should you do at every prenatal visit?

A

weight
BP
gestational age
FHTs
fetal movement (especially after 16weeks)
fetal presentation (in the 3rd trimester- cephalic or breech)

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30
Q

Leopold’s maneuvers

A

sonogram is more accurate

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31
Q

What should you accomplish in the 1st prenatal visit?

A 
CBC
type and screen
Pap
chlamydia
UA and urine culture
rubella titer
syphilis
HIV
hepatitis B
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32
Q

What should you accomplish at 18-20 weeks?

A

ultrasound

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33
Q

What should you accomplish at 10-13 weeks?

A

chorionic villus sampling

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34
Q

What should you accomplish at 15-20 weeks?

A

quadruple screen, amniocentesis

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35
Q

What should you accomplish at 24-28 weeks?

A

screen for gestational diabetes

1hr 50g glucose challenge

if abnormal,
3hr 100g glucose tolerance test

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36
Q

What should you accomplish at 28 weeks?

A

administer anti-D immune globulin if RhD negative to prevent formation of antibodies against the fetus

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37
Q

What should you do in the 3rd trimester?

A

CBC, chlamydia, syphilis, HIV

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38
Q

What should you do at 35-37 weeks?

A

screen for group B streptococcus

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39
Q

increased AFP

A

neural tube defects
abdominal wall defects
-gastroschisis
-omphalocele

multiple gestations
incorrect dating (most common cause for a quad screen to be abnormal)
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40
Q

decreased AFP, decreased estriol, increased hCG, increased inhibin

A

Trisomy 21 (down)

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41
Q

decreased AFP, decreased estriol, decreased hCG

A

Trisomy 18 (Edward)

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42
Q 
Quadruple screen:
what does it measure?
what conditions does it look for? 
when do you do it?
is it diagnostic?
A 
1. maternal serum levels of 
AFP
Estriol
hCG
inhibin
  1. Conditions:
    chromosomal abnormalities
    NTDs
    abdominal wall defects
  2. timing:
    15-20 weeks
  3. not diagnostic
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43
Q 
chorionic villus sampling:
what does it measure?
what conditions does it look for? 
when do you do it?
what are the disadvantages?
A
  1. sample of chorionic villi obtained for fetal karyotyping and other genetic testing
  2. looking for chromosomal abnormalities genetic diseases
  3. timing: 10-13 weeks
  4. risk of fetal loss, bleeding, infection, ROM, fetomaternal hemorrhage
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44
Q 
amniocentesis:
what does it measure?
what conditions does it look for? 
when do you do it?
what are the disadvantages?
A
  1. sample of amniotic fluid obtained for fetal karyotyping and other testing
  2. chromosomal abnormalities
    genetic diseases blood type
    NTDs (acetylcholinesterase will be detected)
    lecithin:sphingomylelin ratio greater than 2:1 indicates fetal lung maturity
  3. 15-20 weeks
4. risk of fetal loss
fetal injury
bleeding
infection
amniotic fluid leakage
fetomaternal hemorrhage
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45
Q

Cell-free fetal DNA testing

A

fetal nucleic acids from maternal blood tested for

fetal sex
blood type
certain genetic diseases
aneuploidy screening

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46
Q

when do you screen a pregnant lady for syphilis?

A

1st visit and 3rd trimester

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47
Q

when do you perform quadruple screen?

A

15-20 weeks

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48
Q

when do you screen for gestational diabetes?

A

24-48 weeks

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49
Q

When do we administer anti-D immunoglobulin (RhoGAM) if Rh negative?

A

28 weeks, after delivery, risk of fetomaternal hemorrhage

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50
Q

When do we screen for GBS?

A

35-37 weeks

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51
Q

n/v in pregnancy

A

high levels of HCG, usually resolves around 16 weeks

Treat:

  1. lifestyle modifications- bland foods, eating slowly, small frequent meals
  2. pharmacotherapy- pyridoxing (B6) + doxylamine
  3. diphenhydramine, promethazine, ondansetron
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52
Q

hyperemesis gravidarum

A

n/v severe enough to cause weightloss >5% of pre-pregnancy weight, dehydration, ketosis, or abnormal labs

Work-up:
Vitals: weight, HR, orthostatic blood pressure

Labs: serum electrolytes, UA

US: rule out gestational trophoblastic disease and multiple gestation (higher levels of hormones)

Management:
IV fluids
electrolyte and thiamine repletion
antiemetics
NG tube feeds, parenteral nutrition
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53
Q

Gestational diabetes

A

arises during pregnancy but then resolves postpartum

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54
Q

Human placental lactogen

A

decreases insulin sensitivity so that glucose will go to the embryo. an exaggerated response will lead to diabetes

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55
Q

gestational diabetes

A 
RF:
family history
obesity
PCOS
HTN
age>25
previous baby >9 pounds

screening preformed at 24-28 weeks gestation

check fasting level, then give
50 gram 1hr oral glucose tolerance test (check in 1 hour)

100 gram 3hr oral glucose tolerance test (measured at 0, 1, 2, 3 hours): if 2/4 readings are above normal then diagnose

complications:
fetal macrosomia
neonatal hypoglycemia
pre-eclampsia
polyhydramnios
stillbirth

management:
diabetic diet
insulin

A1 diabetics: controlled with diet and exercise

A2 diabetics: insulin- regulated and needs fetal surveillance starting at 32-34 weeks

US in 3rd trimester to look for fetal macrosomia
-offer c/s if the fetus is >4500 g
risk of shoulder dystocia is high

possible early delivery
postpartum diabetes screening
-2hr 75g oral glucose tolerance test

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56
Q

Pregestational diabetics

A

diabetes before pregnancy

complications:
fetal macrosomia
neonatal hypoglycemia
pre-eclampsia
polyhydramnias

congenital malformations

  • cardiac defects
  • caudal regression syndrome- sacral defects (high glucose even early in pregnancy when everything is forming)

stillbirth
DKA
worsening of diabetic retinopathy and nephropathy

Tests to order at baseline:
HbA1C
Urine protein:Cr
EKG
Dilated eye exam
Management:
Glycemic control
-insulin
-diabetic diet
-blood glucose monitoring
2nd trimester US and fetal echo
3rd trimester fetal survaillance
3rd trimester US, looking for macrosomia
-offer C/S if fetus >4500 g
deliver by 39-40 weeks
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57
Q

UTI in pregnancy

A

cystitis (lower tract)
pyelonephritis (higher)

preterm birth
sepsis
ARDS
maternal death

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58
Q

Asymptomatic bacteriuria (ASB)

A

screen for ASB with urine culture at 1st prenatal visit

treat during pregnancy to prevent progression to cystitis and pyelonephritis

  • nitrofurantoin
  • amoxicillin
  • cephalexin
  • fosfomycin
  • TMP-SMX

Repeat urine culture 1 week after completion of antibiotic therapy

If still positive on urine culture after 2 rounds of antibiotics, give suppressive therapy
-nitrofurantoin for the remainder of the pregnancy

objective: avoid development of pyelonephritis

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59
Q

Symptoms of cystitis

A 
Dysuria
Frequency
Urgency
Suprapubic pain
Hematuria
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60
Q

Urinalysis findings that support UTI

A

bacteriuria
pyuria (WBCs)
leukocyte esterase
nitrite

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61
Q

Pyelonephritis symptoms

A 
symptoms of cystitis
fever/chills
nausea/vomiting
flank pain
CVA tenderness
pulmonary edema leading to SOB

UA and urine cx

  • bacteriuria
  • pyuria (WBCs)
  • leukocyte esterase
  • nitrite
  • WBC casts
treatment:
admission
IV abx (empirically then tailor)
-ampicillin + gentamicin
-ceftriaxone
-meropenem
-piperacillin-tazobactam

continue the patient on oral antibiotics for the rest of pregnancy

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62
Q

points to know about chronic hypertension

A

HTN existing before pregnancy
ACEI are teratogenic
-renal and cardiac malformations

methyldopa (central- acting alpha 2 agonist) and
labetalol (combined alpha adrenergic blocker) are safe during pregnancy
nifedipine

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63
Q

Gestational hypertension

A

new onset HTN after 20 weeks gestation, resolves postpartum
>140/90
after 20wks gestation

not associated with proteinuria

close monitoring for progression, no meds

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64
Q

pre-eclampsia

A

new onset HTN (>140/90 after 20 weeks GA)
+proteinuria (>300mg/24 hrs)
+signs of end-organ dysfunction (thrombocytopenia, renal insufficiency, elevated LFTs, pulmonary edema, HA, visual disturbances, seizure)

abnormal development of placental blood vessels

placental ischemia
inflammatory response

widespread endothelial dysfunction

risk factors:
history of pre-eclampsia
extremes of age
nulliparity
chronic HTN
diabetes
multiple gestations
hydatidiform moles
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65
Q

Preeclampsia with severe features

A

preeclampsia and end-organ dysfunction or BP> 160/110 mmHg

pre-e= new onset HTN (>140/90 after 20 weeks GA)
+proteinuria (>300mg/24 hrs)
+signs of end-organ dysfunction (thrombocytopenia, renal insufficiency, elevated LFTs, pulmonary edema, HA, visual disturbances, seizure)

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66
Q

HELLP syndrome

A

hemolysis
elevated liver enzymes
low platelets

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67
Q

eclampsia

A

eclampsia=
seizure in a patient with pre-e

pre-e=
new onset HTN (>140/90 after 20 weeks GA)
+proteinuria (>300mg/24 hrs)
+signs of end-organ dysfunction (thrombocytopenia, renal insufficiency, elevated LFTs, pulmonary edema, HA, visual disturbances, seizure)

Treatment: magnesium sulfate

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68
Q

Management of pre-eclampsia with severe features

A

lower BP: hydralazine, labetalol, nifedipine

seizure prophylaxis:magnesium sulfate

watch for magnesium toxicity:

  • loss of DTRs
  • respiratory suppression
  • CV collapse

Calcium gluconate is the reversal agent

Definitive treatment is delivery

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69
Q

Deep venous thrombosis

A

Lower extremity

  • pain
  • swelling
  • erythema
  • warmth

Left side>right side

shortness of breath (PE)
DVT:
-compression US
-Doppler US

PE:
-CT or MRI of chest

Management:
1. anticoagulate with heparin or LMWH
-warfarin is contraindicated during pregnancy
-continue anticoagulation until labor begins or 24 hours prior to planned delivery
2. bridge to warfarin after delivery (safe while breast feeding)
continue anticoagulation for >6 weeks postpartum
3. counsel patient to avoid using estrogen- containing contraceptives in the future because of the increased risk of VTE

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70
Q

Amniotic fluid embolism

A

Amniotic fluid enters maternal circulation leading to cardiovascular collapse and possibly death

H and P:
hypotension (cardiogenic shock)
respiratory failure
unresponsiveness
excessive/prolonged bleeding (DIC)

This usually occurs during labor and delivery or immediately postpartum

Treatment: follow ACLS protocols

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71
Q

TORCHeS

A 
Toxoplasmosis
Other (parvovirus B19, VZV, Listeria)
Rubella
CMV
HIV/HSV
e
Syphilis
common effects:
growth retardation
intellectual disability
hepatosplenomegaly
miscarriage
stillbirth
72
Q

Toxoplasmosis

A

Toxoplasmosis gondii
cat feces
undercooked meat

primary infection during pregnancy:
-mononucleosis-like illess
-congenital infection
 chorioretinitis
 hydrocephalus
 intracranial calcifications

diagnosis:
serology
PCR of amniotic fluid

Treatment:
spiramycin
pyrimethamine + sulfadiazine

73
Q

Parvovirus B 19

A

children: erythema infectiosum (fifth disease)
adults: arthritis
fetus: severe anemia, hydrops fetalis (fluid accumulating in multiple parts of the body)

diagnosis:

  • serology
  • PCR of amniotic fluid

management:
serial ultrasounds
intrauterine blood transfusion to fetus

74
Q

VZV

A

Maternal infection

  • chickenpox rash
  • PNA

Congenital infection

  • skin scarring
  • CNS abnormalities
  • eye abnormalities
  • limb hypoplasia

Neonatal infection (transfer during delivery

  • chickenpox rash
  • disseminated disease, which can lead to high mortality rate

If mom has not had chickenpox and also has not been immunized against chickenpox, confirm unimmunized status with IgG titer

avoid anyone who has chickenpox if titers are neg

avoid varicella vaccine during pregnancy because it contains live attenuated virus

If a susceptible patient is exposed to varicella during pregnancy, give immune globulin as prophylaxis

Diagnosis:
clinical, tzanck smear, DFA, PCR PCR of amniotic fluid

Treatment:
acyclovir
neonatal prophylaxis with varicella immune globulin

75
Q

Listeriosis

A

Listeria monocytogenes
Classically acquired from deli meats

flu-like symptoms in mother

fetus can get 
granulomatosis infantiseptica
-skin rash
-widespread abscesses in internal organs
-stillborn

Diagnosis in mother is made with blood culture

Treatment- ampicillin

76
Q

Rubella

A

Children: mild fever, rash
Congenital: cataracts, PDA, sensorineural deafness
-blueberry muffin rash due to extramedullary hematopoeisis

Check mom’s rubella titer at 1st visit
MMR vaccine contraindicated during pregnancy

77
Q

CMV

A 
mononucleosis-like syndrome
fetal infection
-jaundice
-hepatosplenomegaly
-sensorineural hearing loss

diagnosis: serology
PCR of amniotic fluid

prevent with good hand hygiene
no treatment

78
Q

HIV/HSV

A

transmission during labor/deliver
screen at 1st trimester for everyone
screen at 3rd trimester is mother is at high risk

Antiretroviral therapy

  • include zidovudine (AZT)
  • avoid efaviranz (teratogenic)

intrapartum zidovudine
deliver by c-section

Neonatal zidovudine prophylaxis after delivery

avoid breastfeeding (HIV is a contraindication)

79
Q

HSV

A 
vesicular skin rash
conjunctivitis
PNA
meningoencephalitis
disseminated disease

suppressive therapy with acyclovir starting at 36 weeks

if active lesions or prodrome at time of delivery, then c-section

80
Q

What are the features of congenital syphilis?

A

early manifestations (onset during first 2 years of life)

  • hepatosplenomegaly, elevated LFTs
  • rash followed by desquamated hands and feet
  • snuffles (blood-tinged nasal secretions)
  • skeletal abnormalities

late manifestations (onset after the first 2 years of life)

  • frontal bossing
  • interstitial keratitis
  • hutchinson teeth
  • saddle-nose deformity
  • perforation of the hard palate
  • saber shins

-neonatal death

Screen with RPR or VDRL at 1st visit, 3rd trimester, and at delivery

Confirm the diagnosis with FTA-ABS or MHA-TP

Treatment:
Benzathine penicillin G

all: desensitize then give PCN

81
Q

GBS

A 
s. agalactiae
vertical transmission leading to neonatal
-meningitis
-PNA
-sepsis

intrapartum prophylaxis:
PCN G to prevent transmission to infant

Who should receive intrapartum prophylaxis against GBS:

  1. Positive GBS screen during current pregnancy by rectovaginal culture at 35-37 weeks
  2. GBS baceteriuria during current pregnancy
  3. Previous infant with early onset GBS
  4. unknown screening result + one of the following:
    - intrapartum fever
    - prolonged rupture of membranes
    - preterm labor
82
Q

Gonorrhea and chlamydia

A

Cervicitis
Urethritis
Disseminated gonoccocal infection

RF:
Age

83
Q

chorioretinitis + hydrocephalus + intracranial calcifications

A

toxoplasma gondii

84
Q

hydrops fetalis

A

parvovirus B19

85
Q

PDA+ cataracts + deafness

A

rubella

86
Q

saddle nose, snuffles, Hutchinson teeth, saber shings

A

syphilis

87
Q

HIV management during pregnancy

A 
HAART (Avoid efavirenz)
intrapartum zidocudine
c-section
neonatal prophylaxis
counsel against breastfeeding
88
Q

Who should get GBS prophylaxis?

A 
positive GBS screen this pregnancy
GBS bacteriuria this pregnancy
previos infant with early- onset GBS
unknown screening result +1 of the following
-intrapartum fever
-prolonged ROM
-preterm labor
89
Q

Risk factors for ectopic pregnancy

A 
prior ectopic pregnancy
tubal surgery
PID
smoking
infertility
IUD
90
Q

Presentation of ectopic pregnancy

A 
amenorrhea
vaginal bleeding
abdominal pain
referred shoulder pain
urge to defecate
dizziness 
LOC
peritoneal signs
-rebound tenderness, guarding
91
Q

at what level of bHCG will you see IUP on TVUS?

A

> 1500

92
Q

What should you do with a stable patient whose TVUS doesn’t show anything, and quantitative serum HCG is

A

repeat hcg in 48-72 hours

the hcg should double every 48 hours in a normal IUP

if the level falls, suspect some kind of failed pregnancy, and follow it all the way down to zerop

if it rises inappropriately, follow with D and C

  • no chorionic villi- ectopic pregnancy, follow with treatment
  • chorionic villa- failed IUP
93
Q

Ectopic pregnancy treatment:

options
who is eligible for medical management?

A

resuscitation if the patient is unstable, then surgery

  • salpingostomy
  • salpingectomy

Methotrexate

  • folic acid antagonist
  • inhibits dihydrofolate reductase

patient must be stable, with normal renal and liver function to be eligible for medical management

HCG

94
Q

Spontaneous abortion

A

pregnancy loss

95
Q

Threatened abortion

A

bleeding
closed cervix
no POC
expectant management

96
Q

inevitable abortion

A

bleeding
open cervix
no POC
D and C, misoprostal, or expectant mgmt

97
Q

incomplete abortion

A

bleeding
open cervix
some POC
D and C, misoprostal, or expectant management

98
Q

complete abortion

A

bleeding
closed cervix
passage of POC
no management

99
Q

missed abortion

A

no bleeding
closed cervix
no passage of POC

D and C, misoprostal, expectant management

100
Q

septic abortion

A

+/- bleeding
open or closed cervix
+/- passage of POC
D and C, broad-spectrum antibiotics

101
Q

cervical insufficiency

A

painless cervical dilatation leading to 2nd trimester (unlike inevitable abortion which leads to painful dilatation)
pregnancy loss

uterine anomalies
ED
trauma

diagnosis: US
management: placement of cerclage

102
Q

intrauterine fetal demise

A 
pregnancy loss after 20 weeks
causes:
fetal chromosomal abnormalities or congenital anomalies
abnormalities of the placenta or umbilical cord
placental abruption 
Rh alloimmunization
congenital infections
maternal complications (HTN, DM)
idiopathic

cessation of fetal movement
absent fetal heart tones (FHT)
ultrasound- no fetal cardiac activity

management:
expectant management
dilation and evacuation (D and E)
induction of labor: misoprostol (PGE1), mifepristone, oxytocin

103
Q

intrauterine fetal demise

A 
pregnancy loss after 20 weeks
causes:
fetal chromosomal abnormalities or congenital anomalies
abnormalities of the placenta or umbilical cord
placental abruption 
Rh alloimmunization
congenital infections
maternal complications (HTN, DM)
idiopathic

cessation of fetal movement
absent fetal heart tones (FHT)
ultrasound- no fetal cardiac activity

management:
expectant management
dilation and evacuation (D and E)
induction of labor: misoprostol (PGE1), mifepristone, oxytocin

104
Q

fetal heart tones, with bleeding before 20 weeks gestation, no passage of POC, closed cervix

A

threatened abortion

105
Q

spontaneous abortion complicated by intrauterine infection

A

septic abortion

106
Q

passage of some POC and open cervix

A

incomplete abortion

107
Q

passage of all POC and closed cervix

A

complete abortion

108
Q

bleeding before 20 weeks gestation + cramping + passage of POC + open cervix

A

inevitable abortion

109
Q

intrauterine growth restriction

A

fetal weight

110
Q

Amniotic fluid index

A

5-24cm: normal

24cm: polyhydramnios

111
Q

Amniotic fluid index

A

5-24cm: normal

24cm: polyhydramnios

112
Q

Potter sequence

A

bilateral renal agenesis: decreased urine production: oligohydramnios: pulmonary hypoplasia and structural abnormalities

POTTER
Pulmonary hypoplasia
Oligohydramnios
Twisted skin (wrinkled skin)
Twisted face (facial deformities)
Extremities (limb deformities)
Renal agenesis

Management:
amnioinfusion

113
Q

Polyhydramnios

A 
esophageal/duodenal atresia
anencephaly
multiple gestation
uncontrolled maternal diabetes
congenital infections (parvovirus B19)
fetal anemia due to Rh alloimmunization

Management:
Amnioreduction
Indomethacin

114
Q

Polyhydramnios

A

esophageal/duodenal atresia
anencephaly
multiple gestation
uncontrolled maternal diabetes

115
Q

Dizygotic (fraternal)

A

2 eggs fertilized by 2 sperm

116
Q

Twin-twin transfusion syndrome

A
  • possible complication of monochorionic twin pregnancies
  • vascular anastomoses link the fetal circulations- blood from one twin flows to the other
  • donor twin: anemia, growth restriction, oligohydramnios
  • recipient twin: polycythemia, volume overload, heart failure, polyhydramnios
117
Q

signs of multiple gestation

A

rapid weight gain
size>dates
increased hCG and AFP
auscultation of >1 FHT

diagnosis: ultrasound

management: serial ultrasounds to monitor growth,
fetal surveillance, possible early delivery

118
Q

abnormal placentation

A

normal placenta is high
lower uterine segment- placenta overlies internal cervical os

RF: 
increasing maternal age
multiparity
multiple gestation
uterine surgery
history of C/S

Presentation:
painless vaginal bleeding in the 2nd half of pregnancy

Dx: US

It is important to US before digital exam to avoid perfing

management:

  1. pelvic rest
  2. US, deliver at 36 wks by C/S to avoid complications
active bleeding:
Resuscitation- IVF, blood transfusion
Fetal HR monitoring
Corticosteroids
Bedrest, try to monitor the pregnancy and buy more time
C/S
119
Q

placenta previa and history of CS are risk factors for…

A

placenta accreta: abnormal adherence to myometrium

placenta increta: invasion of placenta into myometrium

placenta percreta: penetration of placenta through uterus

diagnosis: us
may not be discovered until after delivery when the placenta can’t be delivered

Treatment:
C/S
hysterectomy

120
Q

Vasa previa

A

fetal vessels overlie cervical os
risk of compression or rupture of fetal vessels with ROM- hypoxia, hemorrhage

presents with bleeding after rupture of fetal membranes, especially if there are nonreassuring fetal heart tones

diagnosis: US

121
Q

Abruptio placentae; placental abruption

A

hematoma and fetal hypoxia
DIC in mom

Risk factors:
prior placental abruption
hypertension
trauma
smoking
cocaine use

Sudden onset painful vaginal bleeding in 2nd half of pregnancy
contractions
abnormal FHT
DIC

Diagnosis:
ultrasound
clinical

Treatment:
emergency C-section

122
Q

Premature rupture of membranes (PROM)

A

membranes rupture before labor
presentation: a woman who’s water has broken but she is not having contractions

Confirm diagnosis with sterile speculum exam- pool of fluid in the posterior vault

nitrazine paper test
microscopy: ferning pattern of fluid
Amnisure
US: volume

complications:
infection
cord prolapse
placental abruption
preterm labor

management: if >34 weeks; induce labor (oxytocin)
infection: induce labor

if 24-34 weeks gestation and risk of preterm delivery, give corticosteroids- betamethasone, dexamethasone,deliver over 48 hours to induce type 2 pneymocytes

123
Q

Preterm labor

A

34 weeks, let labor proceed

124
Q

Tocolytics

A

magnesium sulfate
indomethacin
nifedipine
terbutaline- selective b2 agonist that causes bronchiodilitation of the lungs, making it useful for asthma

125
Q

Gestational trophoblastic disease

cytotrophoblasts and syncytiotrophoblasts

A

cytotrophoblasts make up chorionic villi

syncytiotrophoblasts secrete hCG

hydatidiform mole- benign, some extra hcg
invasive mole
choriocarcinoma- malignant, a lot of extra hcg

RF:
prior molar pregnancy
extremes of age

126
Q

which has a higher rate of association with choriocarcinoma?

A

complete mole (2.5%)

127
Q

How does molar pregnancy present?

A 
amenorrhea
\+pregnancy test
si/sx of pregnancy
vaginal bleeding
abnormal uterine size
hyperemesis gravidarum from elevated levels of HCG

hyperthyroidism (common alpha subunits)
very early pre-eclampsia (

128
Q

Invasive mole

A

more common with complete moles
invade the uterine wall
may lead to uterine rupture/ hemorrhage

129
Q

Choriocarcinoma

A

metastatic malignant form of trophoblastic disease

RF:
complete hydatidiform mole
miscarriage
normal pregnancy
ectopic pregnancy
spontaneous occurence
mets:
lung
vagina
brain
liver
other organs

h and p:

  • enlarged uterus
  • hyperthyroidism
  • elevated hCG
  • vaginal bleeding
  • persistent, bloody brown discharge
  • theca-lutein ovarian cysts, developing in response to high levels of HCG
  • pulmonary symptoms
workup:
check quantitative hCG level:
extremely high
pelvic exam looking for mets
ultrasound
-uterine mass with areas of necrosis and hemorrhage

Chest xray:
mets to lung?

Treatment:
chemotherapy 
\+ methotrexate
surgery, depending on stage
follow hCG levels down to zero
wait 1 year before pregnancy
130
Q

RhD incompatibility

A

mother has blood type that is RhD neg when fetus is positive

RhD woman develops IgG abs against RhD + fetus
in subsequent pregnancies, anti-D antibodies cross the placenta and attack fetal RBCs- hemolytic disease of the fetus and newborn (erythroblastosis fetalis)

this can lead to hydrops fetalis

type and screen for RhD abs at initial visit
If she is RhD negative, prevent sensitization with RhoGAM (anti-D immune globulin) at 28 weeks, at delivery, and when there is any risk of fetomaternal hemorrhage

If the patient is RhD negative with anti-D antibodies, then confirm the presence of antibodies with indirect Coombs test

Then test the paternal blood type. If he is RhD negative there should be no risk to the fetus.

If the dad is +/- and mom is -/- then test fetal blood type (fetal cell free DNA, amniocentesis)

And then, if the fetus is RhD positive you have a potential problem
Follow maternal titers. If they get higher than 116 then worry about fetal anemia- test:
MCA doppler US
fetal blood sampling

If you detect severe anemia,

  • intrauterine blood transfusion
  • delivery
131
Q

When do we give RHOgam?

A

28wks GA
w/in 3 d of delivery
any risk of fetomaternal hemorrhage- abortion, amniocentesis, placental abruption, bleeding placenta previa

132
Q

Antibiotics to avoid in pregnancy

A

fluoroquinolones
tetracyclines
aminoglycosides
sulfonamides

133
Q

Indications for fetal nonstress test

A

increasd risk of fetal demise:
diabetes
HTN
Fetal growth restriction

Continue if the NST is normal
If you have an abnormal NST move on to biophysical progile

134
Q

Biphysical profile

A
  1. nonstress test
  2. amniotic fluid volume
  3. fetal breathing
  4. fetal movement
  5. fetal tone

2 points for each if normal
0 if abnormal

8-10 points total is reassuring

135
Q

normal FHR

A

110-160 BPM with beat to beat variabioligy (oscillations of 5-10 BPM around baseline)
accelerations of at least 15 beats per minute for at least 15 seconds

136
Q

nonstress test

A

20 minutes of monitoring, at least 2 accelerations of 15 BPM above baseline each lasting at least 15 seconds, in 20 minutes

Continue if the NST is normal
If you have an abnormal NST move on to biophysical progile

137
Q

Contraction stress test

A

Oxytocin to induce contractions

watch fetal heart rate
look for decelerations

138
Q

Early deceleration

A

fetal heart rate and contraction mirror each other

head compression

139
Q

Variable deceleration

A

abrupt decrease in fetal heart rate with rapid return to baseline, not necessarily in relation to the contraction

looks like a V

occuring during umbilical cord compression

140
Q

late deceleration

A

gentle down and up with a slow return to baseline

utero-placental insufficiency and fetal hypoxia

141
Q

Sinusoidal pattern on nonstress test

A

severe fetal anemia

142
Q

Management of non-reassuring fetal heart rate tracing

A
  • Administer maternal O2, turn to left lateral decubitus position
  • Discontinue oxytocin, consider correction of hyperstimulation if needed, with a tocolytic
  • IV fluid bolus
  • Sterile vaginal exam (check for cord prolapse)
  • consider need for immediate delivery
143
Q

Cervical dilation

A

how dilated is the cervix?
cm
how far apart are the fingers?

144
Q

Cervical effacement

A

thinning of the cervix

cervix gets thinner and thinner until 100% effaced

145
Q

Fetal station

A

position of fetal head in relation to the fetal spines

-3
-2
-1
0 - ischial spine level
+1
+2
+3

146
Q

Braxton Hicks contractions

A

sporadic, irregular contractions
that do not cause cervical dilation

“false labor”

147
Q

1st stage of labor

A

latent phase- onset of regular ctx, until 6cm dilation
up to 20 hours in a nulliparous woman
up to 14 hours in a multiparous woman

active phase, 6cm to full dilation
nulliparous- 1.2 cm/hr
multiparous- 1.5cm/hr

148
Q

Second stage of labor

A

from full dilation to delivery of infant

multiparous- 2 hours
nulliparous- 3 hours

this is when the mother is actually pushing

149
Q

3rd stage of labor

A

begins with delivery of the infant
ends with delivery of placenta

usually lasts 30 minutes

150
Q

things to evaluate when labor has stopped

A 
power
passenger (size, etc)
passage (cephalopelvic disproportion?

adequate uterine contractions:
>5 contractions in 10 minutes
>200 Montevideo units

151
Q

Montevideo units- power

A

look at the contractions occurring within a 10 minute window

peaks minus baseline
>200 is considered adequate

152
Q

signs of placental separation

A

sudden gush of blood
lengthening of the umbilical cord
uterus rises to the anterior abdominal wall
uterus becomes firmer and more globular in shape

153
Q

Cardinal movements of labor

A 
1. engagement
fetal head drops below pelvic inlet
2. descent
drops downward
3. flexion
chin to chest
4. internal rotation
rotation towards the midline
5. extension
chin away from chest as the fetus moves through the vaginal introitus
6. external rotation
head out facing one side
7. expulsion
delivery of the body
154
Q

Inducing labor- reasons to do so

A
  • postterm pregnancy (>42 weeks)
  • chorioamnionitis
  • premature ROM
  • pre-eclampsia with severe features
  • maternal diabetes
155
Q

Bishop score

A
  • dilation
  • effacement
  • fetal station
  • cervical consistency
  • cervical position

low bishop score suggests low likelihood of a successful induction

156
Q

Medications used to induce labor

A

Prostaglandins (misoprotol -PGE1 or dinoprostone- PGE2)

These help ripen cervix and produce contractions

main concern is that they cause hyperstimulation of uterus and tachysystole- give vaginally so that you can stop when there’s enough

157
Q

Oxytocin

A

causes contractions, doesn’t ripen the cervix, so start with prostaglandins

given IV
short half-life
titrate until you get the contraction pattern you want

158
Q

Amniotomy

A

augments labor that has stalled

159
Q

Cesarean delivery

A

incision in the uterus (hysterotomy) in order to deliver the infant

can be classified based on where the incision is made

low transverse preferred- less bleeding, less risk in future pregnancies

vertical- more exposure, easy to get baby out

160
Q

indications for C/S

A
  1. arrest of labor
  2. malpresentation
    A-frank butt
    B complete- cannonball
    C- footling- cord at risk
  3. non-reassuring fetal heart rate tracing
  4. prior cesarean delivery
  5. abnormal placentation (eg placenta previa)
  6. placental abruption
  7. uterine rupture
  8. multiple gestation
  9. suspected fatal macrosomia
  10. certain maternal infections (HIV, HSV) to prevent transmission

avoid if you can, since vaginal deliveries have fewer complications

161
Q

complications of c-section

A
  1. postpartum hemorrhage
  2. infections
  3. damage to ureters, bladders, or other organs
  4. transient tachypnea of the newborn
  5. wound complications
  6. post-op DVT/PE

Future pregnancies:

  1. placenta previa
  2. placental invasion
  3. uterine rupture
162
Q

chorioamnionitis

A

rupture or membrane and ascending infection

RF:prolonged rupture of membranes
prolonged labor
multiple cervical exams
meconium fluid
internal monitors (FSE, IUPC)
Clinical features:
maternal fever
maternal and fetal tachycardia
uterine tenderness
purulent amniotic fluid

treatment:
IV broad-spectrum abx
(ampicillin+ gentamicin)

definitive treatment is delivery

163
Q

uterine rupture

A

weakness 2/2 prior c/sectin
induced or augmented labor

signs and symptoms:
fetal bradycardia
maternal abdominal pain (constant)
loss of fetal station
change in shape of uterus
maternal tachycardia and hypotension

management:
emergent C-section
surgical repair of uterus or hysterectomy

164
Q

Shoulder dystocia

A 
anterior shoulder gets stuck behind the pubic symphisys
management:
suprapubic pressure
mcrobert's maneuver (opens the pelvis)
delivery of posterior arm/shoulder
Rubin and wood maneuvers
intentional fracture of clavicle
Zavanelli maneuver (push the infant in and perform stat C-section)

complications:
Erb-Duchenne Palsy

165
Q

postpartum hemorrhage

A

EBL> 500mL (SVD)
EBL> 1000 mL (C/S)

usually encountered within minutes of delivery

166
Q

what are the causes of postpartum hemorrhage

A

uterine atony (MCC), soft boggy uterus, overdistended uterus, induced or augmented labor

retained placental tissue

genital lacerations

placenta accreta/increta/percreta
uterine rupture
coagulopathy

management:
fundal or bimanual massage
examine uterus for placental fragments or large blood clots
uterotonic agent
-oxytocin
-methylergonocine (contraindicated in HTN)
-carbaprost (contraindicated in asthma bc it can cause bronchospasm)
IV fluid/blood, assess need for surgery or transfusion as you go

167
Q

How old does a child have to be before a diagnosis of enuresis is made

A

5yo

168
Q

Newborn care

A

cord is clamped and cut
secretions are suctioned
baby is dried and stimulated

stimulation and oxygen in the air should prompt the baby to start breathing

169
Q

APGAR

A

Acitivity (muscle tone):
0-limp
1- moderate movement
2-active movement

Pulse
0-no pulse
1- 100 BPM

Grimace (response to stimulation)
0-none
1-grimace, whimpering
2- strong cry

Appearance (skin color)
0-blue
1-pink with blue extremities
2- pink

Respirations
0-none
1-irregular breathing
2-regulat breathing

Normal: 7-10
Calculate at 1 and 5 minutes after birth

170
Q

What changes does mom experience post- partum?

A
  1. birth canal returns to non-pregnant state. There is a risk of urinary incontinence and pelvic organ prolapse
  2. diuersis of expanded plasma volume
  3. lactational amenorrhea
171
Q

postpartum blues

vs

MDD with peripartum onset

A

Postpartum blues

mild, self- limited depressive symptoms, starting in the first few days after delivery, lasting

172
Q

Postpartum psychosis

A

hallucinations and delusions

risk of suicide and infanticide

173
Q

postpartum endometritis

A

“metritis”
polymicrobial

RF:
cesarean delivery
chorioamnionitis
prolonged labor
prolonged ROM
multiple cervical exams
internal monitoring
manual removal of placenta
Clinical features:
fever
tachycardia
uterine tenderness
foul-smelling lochia

Diagnosis: clinical

Treatment: gentamicin + clindamycin

174
Q

Breastfeeding

A 
appropriate nutrition
immunological factors
maturation of GI tract
decreased SIDS
maternal recovery and weight loss

decreased maternal breast and ovarian cancer

cheaper than formula

175
Q

Contraindications to breastfeeding

A 
HIV infection
Drug or alcohol abuse
Active tb
Active herpes infection on breast
Certain medications (chemotherapy)
Infant with galactosemia
176
Q

Mastitis

A

mcc s. aureus
fever and malaise, painful swelling

treat with breastfeeding or pumping

Ultasound to look for abscess, which is a possible complication

Anti-staphylococcal penicillin like docloxacillin

If you suspect MRSA then use (recent hospitalization, recent abx use, abscess, serious infection)

  • clindamycin
  • TMP-SMX
  • vancomycin

If there is an abscess then you need to I and D it

STEP2 (34 decks)

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