Obstetrics Flashcards
Signs of pregnancy
amenorrhea breast engorgement/tenderness fatigue nausea/vomiting quickening (movement)
Signs of early pregnancy
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
When does betaHCG become detectable in theurine? in the serum?
urine: 2 weeks after fertilization
serum 1 week after fertilization
when does a pregnancy show up on ultrasound?
5 weeks
when does fetal cardiac activity become perceptible on Doppler?
10-12 weeks
gestational age-
measured from 1st day of LMP
inaccurate if the cycle isn’t 14 days
can be estimated with US
embryonic age
measured from fertilization
how old is the age of the embryo?
Naegele’s rule for calculating due date
1st day of LMP \+ 7 days -3 months \+ 1 year = expected date of delivery
G and P
G:# of pregnancies
P:# of births: 20 weeks
A:# of abortions
nulligravida
never been pregnant
nullipara
never given birth
primigravida
currently in 1st pregnancy
primipara
has had 1 birth
multipara
has had >2 births
age of viability
24 weeks
preterm
term birth
37 w 0 d - 41w 6 d
postterm
> 42 weeks
maternal physiology SU260
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
sensitive and specific diagnostic lab test for chronic pancreatitis
low fecal elastase
How many extra kcal does a woman need during pregnancy?
women need an extra 100-300kcal/day to meet increased metabolic needs (rate increases by 10-20%)
What is the recommended weight gain during pregnancy for someone who is Underweight (BMI
28-40 pounds
What is the recommended weight gain during pregnancy for someone who is normal weight (BMI
25-35 pounds
What is the recommended weight gain during pregnancy for someone who is overweight ((BMI 25-29.9)?
15-25 pounds
What is the recommended weight gain during pregnancy for someone who is obese (BMI>30)
11-20 pounds
What supplements should pregnant women take?
folic acid prevents NTD
extra if on antiseizure meds
iron
avoid vitamin A in excess
what should pregnant women avoid eating?
deli meats (listeriosis)
fish high in mercury (CNS damage)
- shark
- swordfish
- king mackerel
- tilefish
how big is the uterus during pregnancy?
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
What should you do at every prenatal visit?
weight
BP
gestational age
FHTs
fetal movement (especially after 16weeks)
fetal presentation (in the 3rd trimester- cephalic or breech)
Leopold’s maneuvers
sonogram is more accurate
What should you accomplish in the 1st prenatal visit?
CBC type and screen Pap chlamydia UA and urine culture rubella titer syphilis HIV hepatitis B
What should you accomplish at 18-20 weeks?
ultrasound
What should you accomplish at 10-13 weeks?
chorionic villus sampling
What should you accomplish at 15-20 weeks?
quadruple screen, amniocentesis
What should you accomplish at 24-28 weeks?
screen for gestational diabetes
1hr 50g glucose challenge
if abnormal,
3hr 100g glucose tolerance test
What should you accomplish at 28 weeks?
administer anti-D immune globulin if RhD negative to prevent formation of antibodies against the fetus
What should you do in the 3rd trimester?
CBC, chlamydia, syphilis, HIV
What should you do at 35-37 weeks?
screen for group B streptococcus
increased AFP
neural tube defects
abdominal wall defects
-gastroschisis
-omphalocele
multiple gestations incorrect dating (most common cause for a quad screen to be abnormal)
decreased AFP, decreased estriol, increased hCG, increased inhibin
Trisomy 21 (down)
decreased AFP, decreased estriol, decreased hCG
Trisomy 18 (Edward)
Quadruple screen: what does it measure? what conditions does it look for? when do you do it? is it diagnostic?
1. maternal serum levels of AFP Estriol hCG inhibin
- Conditions:
chromosomal abnormalities
NTDs
abdominal wall defects - timing:
15-20 weeks - not diagnostic
chorionic villus sampling: what does it measure? what conditions does it look for? when do you do it? what are the disadvantages?
- sample of chorionic villi obtained for fetal karyotyping and other genetic testing
- looking for chromosomal abnormalities genetic diseases
- timing: 10-13 weeks
- risk of fetal loss, bleeding, infection, ROM, fetomaternal hemorrhage
amniocentesis: what does it measure? what conditions does it look for? when do you do it? what are the disadvantages?
- sample of amniotic fluid obtained for fetal karyotyping and other testing
- chromosomal abnormalities
genetic diseases blood type
NTDs (acetylcholinesterase will be detected)
lecithin:sphingomylelin ratio greater than 2:1 indicates fetal lung maturity - 15-20 weeks
4. risk of fetal loss fetal injury bleeding infection amniotic fluid leakage fetomaternal hemorrhage
Cell-free fetal DNA testing
fetal nucleic acids from maternal blood tested for
fetal sex
blood type
certain genetic diseases
aneuploidy screening
when do you screen a pregnant lady for syphilis?
1st visit and 3rd trimester
when do you perform quadruple screen?
15-20 weeks
when do you screen for gestational diabetes?
24-48 weeks
When do we administer anti-D immunoglobulin (RhoGAM) if Rh negative?
28 weeks, after delivery, risk of fetomaternal hemorrhage
When do we screen for GBS?
35-37 weeks
n/v in pregnancy
high levels of HCG, usually resolves around 16 weeks
Treat:
- lifestyle modifications- bland foods, eating slowly, small frequent meals
- pharmacotherapy- pyridoxing (B6) + doxylamine
- diphenhydramine, promethazine, ondansetron
hyperemesis gravidarum
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
Gestational diabetes
arises during pregnancy but then resolves postpartum
Human placental lactogen
decreases insulin sensitivity so that glucose will go to the embryo. an exaggerated response will lead to diabetes
gestational diabetes
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
Pregestational diabetics
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
UTI in pregnancy
cystitis (lower tract)
pyelonephritis (higher)
preterm birth
sepsis
ARDS
maternal death
Asymptomatic bacteriuria (ASB)
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
Symptoms of cystitis
Dysuria Frequency Urgency Suprapubic pain Hematuria
Urinalysis findings that support UTI
bacteriuria
pyuria (WBCs)
leukocyte esterase
nitrite
Pyelonephritis symptoms
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
points to know about chronic hypertension
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
Gestational hypertension
new onset HTN after 20 weeks gestation, resolves postpartum
>140/90
after 20wks gestation
not associated with proteinuria
close monitoring for progression, no meds
pre-eclampsia
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
Preeclampsia with severe features
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)
HELLP syndrome
hemolysis
elevated liver enzymes
low platelets
eclampsia
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
Management of pre-eclampsia with severe features
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
Deep venous thrombosis
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
Amniotic fluid embolism
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
TORCHeS
Toxoplasmosis Other (parvovirus B19, VZV, Listeria) Rubella CMV HIV/HSV e Syphilis
common effects: growth retardation intellectual disability hepatosplenomegaly miscarriage stillbirth
Toxoplasmosis
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
Parvovirus B 19
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
VZV
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
Listeriosis
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
Rubella
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
CMV
mononucleosis-like syndrome fetal infection -jaundice -hepatosplenomegaly -sensorineural hearing loss
diagnosis: serology
PCR of amniotic fluid
prevent with good hand hygiene
no treatment
HIV/HSV
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)
HSV
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
What are the features of congenital syphilis?
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
GBS
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:
- Positive GBS screen during current pregnancy by rectovaginal culture at 35-37 weeks
- GBS baceteriuria during current pregnancy
- Previous infant with early onset GBS
- unknown screening result + one of the following:
- intrapartum fever
- prolonged rupture of membranes
- preterm labor
Gonorrhea and chlamydia
Cervicitis
Urethritis
Disseminated gonoccocal infection
RF:
Age
chorioretinitis + hydrocephalus + intracranial calcifications
toxoplasma gondii
hydrops fetalis
parvovirus B19
PDA+ cataracts + deafness
rubella
saddle nose, snuffles, Hutchinson teeth, saber shings
syphilis
HIV management during pregnancy
HAART (Avoid efavirenz) intrapartum zidocudine c-section neonatal prophylaxis counsel against breastfeeding
Who should get GBS prophylaxis?
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
Risk factors for ectopic pregnancy
prior ectopic pregnancy tubal surgery PID smoking infertility IUD
Presentation of ectopic pregnancy
amenorrhea vaginal bleeding abdominal pain referred shoulder pain urge to defecate dizziness LOC peritoneal signs -rebound tenderness, guarding
at what level of bHCG will you see IUP on TVUS?
> 1500
What should you do with a stable patient whose TVUS doesn’t show anything, and quantitative serum HCG is
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
Ectopic pregnancy treatment:
options
who is eligible for medical management?
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
Spontaneous abortion
pregnancy loss
Threatened abortion
bleeding
closed cervix
no POC
expectant management
inevitable abortion
bleeding
open cervix
no POC
D and C, misoprostal, or expectant mgmt
incomplete abortion
bleeding
open cervix
some POC
D and C, misoprostal, or expectant management
complete abortion
bleeding
closed cervix
passage of POC
no management
missed abortion
no bleeding
closed cervix
no passage of POC
D and C, misoprostal, expectant management
septic abortion
+/- bleeding
open or closed cervix
+/- passage of POC
D and C, broad-spectrum antibiotics
cervical insufficiency
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
intrauterine fetal demise
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
intrauterine fetal demise
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
fetal heart tones, with bleeding before 20 weeks gestation, no passage of POC, closed cervix
threatened abortion
spontaneous abortion complicated by intrauterine infection
septic abortion
passage of some POC and open cervix
incomplete abortion
passage of all POC and closed cervix
complete abortion
bleeding before 20 weeks gestation + cramping + passage of POC + open cervix
inevitable abortion
intrauterine growth restriction
fetal weight
Amniotic fluid index
5-24cm: normal
24cm: polyhydramnios
Amniotic fluid index
5-24cm: normal
24cm: polyhydramnios
Potter sequence
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
Polyhydramnios
esophageal/duodenal atresia anencephaly multiple gestation uncontrolled maternal diabetes congenital infections (parvovirus B19) fetal anemia due to Rh alloimmunization
Management:
Amnioreduction
Indomethacin
Polyhydramnios
esophageal/duodenal atresia
anencephaly
multiple gestation
uncontrolled maternal diabetes
Dizygotic (fraternal)
2 eggs fertilized by 2 sperm
Twin-twin transfusion syndrome
- 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
signs of multiple gestation
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
abnormal placentation
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:
- pelvic rest
- 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
placenta previa and history of CS are risk factors for…
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
Vasa previa
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
Abruptio placentae; placental abruption
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
Premature rupture of membranes (PROM)
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
Preterm labor
34 weeks, let labor proceed
Tocolytics
magnesium sulfate
indomethacin
nifedipine
terbutaline- selective b2 agonist that causes bronchiodilitation of the lungs, making it useful for asthma
Gestational trophoblastic disease
cytotrophoblasts and syncytiotrophoblasts
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
which has a higher rate of association with choriocarcinoma?
complete mole (2.5%)
How does molar pregnancy present?
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 (
Invasive mole
more common with complete moles
invade the uterine wall
may lead to uterine rupture/ hemorrhage
Choriocarcinoma
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
RhD incompatibility
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
When do we give RHOgam?
28wks GA
w/in 3 d of delivery
any risk of fetomaternal hemorrhage- abortion, amniocentesis, placental abruption, bleeding placenta previa
Antibiotics to avoid in pregnancy
fluoroquinolones
tetracyclines
aminoglycosides
sulfonamides
Indications for fetal nonstress test
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
Biphysical profile
- nonstress test
- amniotic fluid volume
- fetal breathing
- fetal movement
- fetal tone
2 points for each if normal
0 if abnormal
8-10 points total is reassuring
normal FHR
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
nonstress test
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
Contraction stress test
Oxytocin to induce contractions
watch fetal heart rate
look for decelerations
Early deceleration
fetal heart rate and contraction mirror each other
head compression
Variable deceleration
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
late deceleration
gentle down and up with a slow return to baseline
utero-placental insufficiency and fetal hypoxia
Sinusoidal pattern on nonstress test
severe fetal anemia
Management of non-reassuring fetal heart rate tracing
- 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
Cervical dilation
how dilated is the cervix?
cm
how far apart are the fingers?
Cervical effacement
thinning of the cervix
cervix gets thinner and thinner until 100% effaced
Fetal station
position of fetal head in relation to the fetal spines
-3
-2
-1
0 - ischial spine level
+1
+2
+3
Braxton Hicks contractions
sporadic, irregular contractions
that do not cause cervical dilation
“false labor”
1st stage of labor
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
Second stage of labor
from full dilation to delivery of infant
multiparous- 2 hours
nulliparous- 3 hours
this is when the mother is actually pushing
3rd stage of labor
begins with delivery of the infant
ends with delivery of placenta
usually lasts 30 minutes
things to evaluate when labor has stopped
power passenger (size, etc) passage (cephalopelvic disproportion?
adequate uterine contractions:
>5 contractions in 10 minutes
>200 Montevideo units
Montevideo units- power
look at the contractions occurring within a 10 minute window
peaks minus baseline
>200 is considered adequate
signs of placental separation
sudden gush of blood
lengthening of the umbilical cord
uterus rises to the anterior abdominal wall
uterus becomes firmer and more globular in shape
Cardinal movements of labor
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
Inducing labor- reasons to do so
- postterm pregnancy (>42 weeks)
- chorioamnionitis
- premature ROM
- pre-eclampsia with severe features
- maternal diabetes
Bishop score
- dilation
- effacement
- fetal station
- cervical consistency
- cervical position
low bishop score suggests low likelihood of a successful induction
Medications used to induce labor
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
Oxytocin
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
Amniotomy
augments labor that has stalled
Cesarean delivery
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
indications for C/S
- arrest of labor
- malpresentation
A-frank butt
B complete- cannonball
C- footling- cord at risk - non-reassuring fetal heart rate tracing
- prior cesarean delivery
- abnormal placentation (eg placenta previa)
- placental abruption
- uterine rupture
- multiple gestation
- suspected fatal macrosomia
- certain maternal infections (HIV, HSV) to prevent transmission
avoid if you can, since vaginal deliveries have fewer complications
complications of c-section
- postpartum hemorrhage
- infections
- damage to ureters, bladders, or other organs
- transient tachypnea of the newborn
- wound complications
- post-op DVT/PE
Future pregnancies:
- placenta previa
- placental invasion
- uterine rupture
chorioamnionitis
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
uterine rupture
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
Shoulder dystocia
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
postpartum hemorrhage
EBL> 500mL (SVD)
EBL> 1000 mL (C/S)
usually encountered within minutes of delivery
what are the causes of postpartum hemorrhage
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
How old does a child have to be before a diagnosis of enuresis is made
5yo
Newborn care
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
APGAR
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
What changes does mom experience post- partum?
- birth canal returns to non-pregnant state. There is a risk of urinary incontinence and pelvic organ prolapse
- diuersis of expanded plasma volume
- lactational amenorrhea
postpartum blues
vs
MDD with peripartum onset
Postpartum blues
mild, self- limited depressive symptoms, starting in the first few days after delivery, lasting
Postpartum psychosis
hallucinations and delusions
risk of suicide and infanticide
postpartum endometritis
“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
Breastfeeding
appropriate nutrition immunological factors maturation of GI tract decreased SIDS maternal recovery and weight loss
decreased maternal breast and ovarian cancer
cheaper than formula
Contraindications to breastfeeding
HIV infection Drug or alcohol abuse Active tb Active herpes infection on breast Certain medications (chemotherapy) Infant with galactosemia
Mastitis
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
