Obstetrics Flashcards
developmental age
of weeks and days since fertilization
gestational age
weeks and days since LMP
when can you start hearing fetal heart tones
10-12 weeks
quickening (appreciation of fetal movement) begins around
17-18 weeks at the earliest
US measurement of GA is most reliable during?
1st trimester
standard method to diagnose pregnancy?
B-hCG
B-hCG is produced by the ______ and peaks at ______ by ______ weeks gestation
placenta ; 100,000 ; 10 weeks Gestation
When does BhCG level off
decreases during 2nd trimester and levels off in 3rd trimester
BhCG levels double every _____ during early preg
48 hours
When doubling is abnormal, BhCG can be used to diagnose ________
ectopic pregnancy
A gestational sac is visible on transvag US by ______
five weeks GA
renal flow increases by _____ %
GFR ______ early and then ______
25-50%
increases ; plateus
Average body weight gain in preg?
11- kg or 25lb increase
Excessive weight gain in preg is ____/month
Inadequate weight gain in preg is ____/month
> 1.5 kg
< 1 kg
Eat an additional _____- _____ kcal /day during preg and _____ kcal/day during breastfeeding
100-300 during preg
500 during breastfeeding
folic acid supplementation for all repro age women?
folic acid supplementation for women with a history of neural tube defects in prior pregnancies?
.4mg/day
4mg/day
Complete vegetarians should consume what vitamins during preg?
Vit D: 10ug or 400 IU/day
and Vit B12 2ug/day
Say whether increases or decreases in pregnancy? HR BP SV CO PVD PVR RR Blood volume Hcrit Fibrinogen Electrolytes GI sphincter tone GI emptying time
HR: increases gradually by 20% BP: decreases gradually by 34 weeks then increases to prepreg values SV: increases to max at 19 weeks CO: rises rapidly by 20% then gradual increase PVD: increases to term PVR: decreases to term RR: unchanged Blood volume: 50% increase by 2nd trimester Hcrit: decrease slightly Fibrinogen: increase Electrolytes: no change GI sphincter tone: decrease GI emptying time: increase
Prenatal visit timeline
Weeks 0-28:
Weeks: 29-35:
Weeks 36-birth:
0-28: q 4 weeks
29-35: q 2 weeks
36-birth: q 1 week
Prenatal testing at first visit?
CBC, Rh factor, type and screen.
UA /culture, rubella antibody titer, HbsAg, RPR/VDRL, cervical gonorrhea, chlamydia, PPD, HIV, Pap smear, HCV, varicella
Hba1c/sickle- if indicated
Discuss: tay-sachs, CF screen
9-14 week screens?
offer PAPP-A and nuchal transparency and free B-hCG- CVS
15-22 week screens?
offer maternal serum AFP or Quad screen (AFP, estriol, B-hCG, inhibin A)
18-20 week screen?
US and full anatomic screen
24-28 week screen?
1 hour glucose challenge test for GDM
28-30 week screen?
RhoGAM for Rh (-) women
35-37 week screen?
GBS culture. repeat CBC
34-40 week screen?
chlamydia, gonorrhea, HIV, RPR in high risk patients
Elevated maternal serum AFP is associated with?
open neural tube defects (spina bifida, anencephaly)
abdominal wall defects (gastroschisis, omphalocele)
multiple gestation
incorrect GA
fetal death
placental abnml (abruption)
Low MSAFP is ass with?
Trisomy 21 and 18
Fetal demise
Incorrect gest dating
What will Quad screen show for Trisomy 18?
“Still UNDER age at 18”
low AFP, low estriol, low B-hCG, low Inhibin A
What will Quad screen show for Trisomy 21?
low AFP, high B-hCG, low estriol, high inhibin
Pregnancy associated plasma protein A. PAPP-A and nuchal transparency and B-hCG are recommended when?
week 9-14
PAPP-A, nuchal transparency, B-hCG can detect ____ % cases DS and ____ cases T 18
91% DS
95% T18
Chorionic villus sampling
transcervical or abdominal aspiration of placental tissue offered at 10-12 weeks.
advantages/disadvantages of CVS?
Adv: genetically diagnostic, available at early GA
Dis: 1% risk of fetal loss. cant detect open neural tube defects. CVS at < 9 weeks ass with limb defects
Amniocentesis
transabdominal aspiration of amniotic fluid using US guided needle
adv/disadv of amniocentesis
adv: genetically diagnostic
disadv: PROM, chorioamionitis, fetal maternal hemorrhage
cell free DNA test. when is screening? how? adv/dis?
10 week test. Isolation of fetal DNA obtained from blood sample from mom.
adv: non-invasive
dis: limited due to low concentration of fetal DNA in maternal circulation
When is amniocentesis indicated?
Women > 35 at time of delivery
Conjunction with abnormal quad screen
Rh-sensitized pregnancy to detect fetal blood type or fetal hemolysis
Evaluate fetal lung maturity
How do you evaluate fetal lung maturity with amniocentesis?
Lecithin to Sphingomyelin ratio > 2.5 or presence of phosphatidylglycerol
TORCHeS infections
Toxo Other (parvo, varicella, listeria, TB, malaria, fungi) Rubella CMV HSV, HIV Syphilis
Common sequelae that occur with maternal-fetal infections?
Premature delivery, CNS abnormalities, Anemia, Jaundice, Hepatosplenomegaly, Growth retardation
Teratogenic effects: ACE-Inh
renal tubular dysplasia, neonatal renal failure, oligohydramnios, IUGR, lack of cranial ossification
Teratogenic effects: Alcohol
FAS (> 6 drink/day = 40% risk). growth restriction, mental retardation, midfacial hypoplasia, renal and cardiac defects.
Teratogenic effects: androgens
virilization in females. advanced genital development in males
Teratogenic effects: carbamazepine
neural tube defects, fingernail hypoplasia, microcephaly, developmental delay, IUGR
Teratogenic effects: cocaine
bowel atresia, congen heart, limb, face, GU malformations, microcephaly, IUGR, cerebral infarct
Teratogenic effects: DES (old birth control)
clear cell adenocarcinoma of vagina/cervix, vaginal adenosis, abnml cervix, uterus, testes, possibly infertile
Teratogenic effects: Lead
increase SAB, stillbirth
Teratogenic effects: Lithium
Ebstein anomaly
Teratogenic effects: Methotrexate
SAB
Teratogenic effects: Organic mercury
cerebral atrophy, microcephaly, mental retardation, spasticity, seizures, blindness
Teratogenic effects: Phenytoin
IUGR, mental retardation, cardiac, fingernail hypoplasia, dysmorphic cranial features
Teratogenic effects: Radiation
< .05 no risk. microcephaly/retardation
Teratogenic effects: Streptomycin, kanamycin
hearing loss, CN VIII damage
Teratogenic effects: tetracycline
permanent yellow-brown teeth discoloration. hypoplasia of teeth enamal
Teratogenic effects: thalidomide
bilateral limb issue, cardiac, GI
Teratogenic effects: Trimethadione, paramethadione (anticonvulsants)
cleft lip/palate, cardiac, microcephaly, MR
Teratogenic effects: valproic acid
spina bifida, neural tube, craniofacial
Teratogenic effects: vit A derivative
SAB, thymic agenesis, micropthalmia, cleft lip/palate, MR
Teratogenic effects: warfarin
nasal hypoplasia, stippled bone epiphyses, developmental delay, IUGR, ophthalmologic abnml
SAB
loss of products of conception before 20 weeks. > 80% in first trimester
risk factors for SAB
chromosome abnml
Maternal factors: inherited thrombophilias (Factor V leiden, prothrombin, antithrombin, proteins C/S, methylene tetrahydrofolate reductase)
Immune: antiphospholipid antibodies
Anatomic: uterine/cervix, incompetent cervix, cervical conization or LEEP, DES exposure
Endocrine: DM, hypothyroid, progesterone deficient
Env: tobacco, alcohol, caffeine
recurrent SAB
2 or more consecutive SABs or 3 SABs in 1 year
how to determine possible cause for recurrent SAB?
karyotype both parents, hypercoag work up for mom, evaluate uterine anatomy
likely cause for recurrent SAB < 12 weeks
chromosome abnml
likely cause for recurrent SAB 12-20 week?
hypercoag (SLE, factor V, protein S deficiency)
7 types of SAB?
Complete Threatened Incomplete Inevitable Missed Septic Intrauterine fetal demise
Sign/symp, diagnosis, treatment: complete SAB
S/S: bleeding and cramping stopped. POC expelled
Dx: US w/o POC, closed OS
tx: none
Sign/symp, diagnosis, treatment: threatened
SS: uterine bleeding +/- abd pain (often painless). No expelled POC
Dx: Closed os, intact membranes, +fetal cardiac motion
Tx: pelvic rest for 24-48 hrs, follow up US
Sign/symp, diagnosis, treatment: Incomplete
SS: Partial POC expulsion. bleeding, cramping, visible tissue on exam
Dx: open OS, POC on US
Tx: Manual uterine aspiration (if < 12 weeks D+C or misoprostol or expectant management in inevitable and missed)
Sign/symp, diagnosis, treatment: Inevitable
SS: uterine bleeding and cramps. no POC expulsion.
Dx: open os +/- RM. POC on US
Sign/symp, diagnosis, treatment: Missed
SS: crampy, no bleeding. loss of early preg symptoms
Dx: closed os. no fetal cardiac activity. POC on US
Sign/symp, diagnosis, treatment: Septic
SS: foul smelling discharge, abd pain, fever, cerv motion tenderness +/- POC expulsion
Dx: hypotension, hypothermia, elevated WBC, blood cultures
Tx: MUA, D+C, IV abx
Sign/symp, diagnosis, treatment: Intrauterine fetal demise
SS: absence of fetal cardiac activity > 20 weeks GA
Dx: uterus small for GA, no fetal heart tone or movement on US
Tx: Induce labor, evacute uterus (D+E) to prevent DIC at GA > 16 week
Maternal mortality with septic SAB?
10-15%
Diagnosing SAB in general?
Gestational sac > 25 mm without a fetal pole or absence of fetal heart activity when CRL > 7 on US
fetal pole should be seen at?
6 weeks
fetal cardiac activity at?
6-7 weeks
For SAB, administer RhoGAM if mom is Rh
negative
First term abortion options (>90% of TAB)
- oral mifepristone (progesterone antag) + oral/vaginal misoprostol (PGE2 analogue) (49 days)
- IM/oral methotrexate + oral/vag misoprostol (49 days)
- Vaginal or sublingual or buccal misoprostol (high dose) repeated up to 3 times (59 days GA)
- Surgical management (MUA, D+C with vaccum) (13 weeks)
2nd term abortion (10% TAB)
Induction of labor (prostaglandins, amniotomy, oxytocin)
surgery (D+E)
13-24 weeks depending on state law
If ROM is suspected what should you do?
Conduct a sterile speculum exam
negative station?
fetal head superior to ischial spines
positive station?
fetal head inferior to ischial spines
stages of labor?
- First Stage
a. latent: onset of labor to 3-4 cm dilation. (6-11 for primiparous) (4-8 for multiparous) (prolonged if sedated or hypotonic uterine contractions)
b. active: 4 cm to complete cervical dilation -10cm (4-6 hr primiparouos) (2-3 hour multiparous) (prolonged if cephalopelvic disproportion) - Second: complete cervical dilation to delivery of infant
(.5-3 hr primiparous) ; (5-30 min multiparous) (all cardinal movements of delivery!) - third: delivery of infant to delivery of placenta (0-.5 hour) (uterus contracts and placenta separates to establish homeostasis)
For patients with complications review FHR tracing every _____ min in first stage of labor and every ____ min in 2nd stage
15 min- 1st stage
5 min- 2nd stage
For patients without complications- review FHR tracings q _____ min for first stage and q _____ min for 2nd stage
30 min- 1st stage
15 min - 2nd stage
Fetal accelerations and decelerations
VEAL CHOP
Variable decel: Cord compression
Early decel: head compression
Acceleration: Okay!
Late accel: placental insufficiency
Normal FHR?
110-160 bpm
Causes of FHR < 110 bradycardia
congenital heart malformations, severe hypoxia (2ndary to uterine hyperstimulation, cord prolapse, rapid fetal descent)
FHR > 160 causes
hypoxia, maternal fever, fetal anemia
Absent variability indicates
severe fetal distress
minimal variability (<6 bpm) indicates
fetal hypoxia, opioid effects, magnesium, sleeping
normal variability is?
6-25 bpm
marked variability is? and can indicate?
> 25 bpm. fetal hypoxia, can occur before a decrease in variability
sinusoidal variability?
serious fetal anemia.
pseudosinusoidal pattern can occur with maternal use of what drug?
meperidine (demerol) opioid
Accelerations are defined as?
onset of FHR >15 beats above baseline to a peak in less than 30 seconds.
why are accelerations reassuring?
indicate fetal ability to respond to environment
If patient has active HSV-2 lesions and is in labor what is appropriate action to take?
c-section
What does early decel look like on FHR tracing?
it begins before uterine conraction but nadir occurs around same time as uterine contraction
Early and late decels onset to nadir is > ____ seconds while variable decels onset to nadir is
30, 30
Variable decels last between ____ seconds and ____ mins
15 sec, 2 mins
non-stress test
mother is in lateral tilt position. FHR and uterine contractions monitored.
What is a reactive NST?
normal response: 2 accerlerations >15bpm above baseline (if >32 weeks); 10bpm above baseline (if < 32 weeks). lasting for 15 seconds. Over a 20 min period
Non-reactive NST
insufficient accels over a 40 min period
what do you do if non-reactive NST?
perform BPP
Contraction stress test
FHR is monitored via spontaneous or induced (nipple stimulation of oxytocin) contractions
What is a positive CST?
BAD. Late decels following 50% or more of contractions in 10 min window. Delivery usually warranted
Negative CST?
Good. no late or significant variable decels and at least 3 contractions. in conjunction with normal NST- highly predictive of fetal well-being
Equivocal CST
intermittent late decels OR significant variable decels
BPP measures?
Test the
Baby
MAN
Tone, breathing, movements, amniotic fluid volume, nonstress test.
Uses real time US to score (2) or (0) to the 5 parameters listed above.
8-10: reassuring
6: equivocal
0-4: very worrisome (asphyxia concern. consider delivery)
AFI
amniotic fluid index. sum of measures of deepest cord free amniotic fluid measured in each abdominal quadrant
modified BPP is?
NST + AFI
normal modified BPP is?
reactive NST and AFI > 5cm
When is umbilical artery doppler velocimetry used? why?
IUGR suspected. Because there can be a reduction or even reversal of umbilical artery diastolic flow.
AFI < 5 =
oligohydramnios
Uterine contractions and cervix dilation result in visceral pain from
T10-L1
Descent of fetal head and pressure on vagina and perineum result in
somatic pain (pudendal nerve) S2-S4
Absolute contraindications to regional anesthesia (epidural, spinal, or combo)
Refractory maternal hypotension maternal coagulopathy maternal useof LMWH w/in 12 hours untreated maternal bacteremia skin infection over needle site increased ICP caused by mass lesion
If morning sickness persists after 1st trimester, think?
hyperemesis gravidarum
Hyperemesis gravidarum presentation
persistent vomit, acute starvation ( large ketonuria) and weight loss- usually at least 5% from preg weight
Hyperemesis gravidarum is more common when? What hormones/markers are elevated/implicated in its cause?
First pregnancies, multiple gestations, molar pregnancies
B-hCG and estradiol are implicated in pathophysiology
morning sickness usually starts when?
weeks 4-7 and resolves prior to week 16
first step in diagnosis of hyperemesis gravidarum is to rule out?
molar pregnancy with US +/- B-hCG
What other labs should you get in eval of hyperemesis gravidarum
ketonemia, ketonuria, hyponatremia, hypokalemia, hypochloremic metabolic alkalosis, liver enzymes, serum bili, serum amylast/lipase
Treatment for hyperemesis gravidarum
Vit B6 Doxylamine (antihistamine) PO Promethazine or dimenhydrinate PO or rectal If severe: metoclopramide, ondansetron If dehydrated: IV fluids, IV nutrition,
GDM is usually diagnosed in which trimester?
3rd
GDM will present?
usually asymp. possible edema, polyhydramnios, or a large for GA infant (>90th %)
Diagnosis of GDM
screen with 1 hour 50g glucose challenge at 24-28 weeks.
glucose > 140 is abnormal
How to confirm 1 hour 50g glucose challenge?
3 hour 100g glucose tolerance test showing any of the following:
Fasting: >95
1 hour: >180
2 hour: > 155
3 hour: >140
4 keys to the management of GDM
- ADA diet
- insulin if needed
- US for fetal growth
- NST at 34 weeks if requiring insulin or oral hypoglycemic
Define tight maternal glucose control
fasting < 95
1 hour postprandial <140
2 hour postprandial < 120
how to maintain tight control during delivery?
intrapartum insulin and dextrose
how to monitor fetus when mom has GDM
periodic US and NST to assess growth. Might need to induce labor at 39-40 in patients poorly controlled on insulin or oral hypoglycemic
complications of GDM
> 50% patients go on to develop glucose intolerance and/or typeII DM later in life
When to screen for DM after delivery?
6-12 weeks with a 75g 2 hour GTT and repeat every 3 years if normal
For pregestational diabetes, insulin requirements may increase by?
3X
poorly controlled DM is associated with increased risk of?
congenital malformations
If HbA1c is > _____ investigate for ______
8, congenital abnormalities
If UA before 20 weeks GA shows glycosuria, should you think GDM or pregestational DM?
pregestational DM
Hyperglycemia in 1st trimester suggests?
pre-existing diabetes and should be managed that way
C/s should be considered when EFW is > ____
4500
Gestational htn
idiopathic htn without significant proteinuria < 300mg/L
Develops at > 20 weeks GA
how many patients with gestational htn develop preeclampsia?
25%
chronic htn
present before conception and <20 weeks GA. can persist for >12 week postpartum. 1/3 of patients develop preeclampsia
Classic triad of preeclampsi
hypertension
proteinuria
edema
Appropriate anti-htn for pregnancy?
methyldopa, labetolol, nifedipine
What blood pressure meds are absolutely contraindicated in preg? why?
ACE-Inh: lead to uterine ischemia
Diuretics: aggrevate low plasma volume to point of uterine ischemia
HELLP syndrome
hemolysis
elevated LFTs
low plateletes
Pre-eclampsia
new onset htn with systolic > 140 and diastolic >90 and proteinuria > 300 mg/24 hour occuring at > 20 week GA
eclampsia
new onset grand mal seizure in women with pre-eclampsia
HELLP syndrome
variant of pre-eclampsia with a poor prognosis.
cause is unknown.
risk factors for HELLP syndrome
nulliparity, black, extremes of age (<20, >35), multiple gestation, molar preg, renal disease (SLE or type I DM), family history of preeclampsia or chronic HTN
how does severe pre-eclampsia present and differ from mild preeclampsia?
Mild BP: >140/90 on 2 occasions 6 hours apart
Protein: >300mg/24 hours or 1-2 + urine dips
edema
Severe
BP: > 160/110 on 2 occasions 6 hours apart
Protein >5g/24hours or 3-4 + urine dips or oliguria < 500ml/24 hours
Cerebral changes: HA, somnolence
Visual changes: blurred vision, scotomata (partial loss of vision or blind spot)
Hyperactive reflexes/clonus; RUQ pain; hemolysis; elevated liver enzyme, thrombocytopenia (HELLP)
most common symptoms preceding eclampsia attack?
HA, vision changes, RUQ/epigastric pain
Only cure for eclampsia/preeclampsia is?
delivery of fetus
If patient is close to term with worsening preeclampsia what do you do?
Induce delivery with IV oxytocin, prostaglandin or amniotomy
If progressing preeclampsia and far from term what do you do?
modified bed rest and expectant management
Prevent intrapartum seizures with a continuous _____ drip?
magnesium
What are signs of mag toxicity?
loss of DTRs, respiratory paralysis, coma
how long should you continue magnesium seizure prophylaxis?
24 hours postpartum
Treat magnesium toxicity with?
IV calcium gluconate
What is blood pressure goal for severe preeclampsia? how can you control the BP?
goal <160 systolic
between 90-100 diastolic to maintain fetal blood flow
control with labetolol and/or hydralazine
Treatment for eclampsia
ABCs with supplemental O2
Seizure control with mag
If seizures occur give IV diazepam
Limit fluids (foley catheter for strict Is and Os)
Asymptomatic bacteriuria
+ urine culture on 1st trimester screen (>10^5) colonies
Diagnosis of UTI/Pyelonephritis ?
positive urine culture
treatment for asymptomatic bacteriuria and UTI
3-7 days nitrofurantoin, cephalexin or amox-clavulonate. follow up cuture at 1 week for test of cure
Treatment for pyelo in preg?
admit to hospital, IV fluids, IV 3rd gen cephalosporin, follow up culture
Antepartum hemorrhage
any bleeding that occurs after 20 weeks gestation
most common causes of antepartum hemorrhage?
placental abruption and placenta previa
With third trimester bleeding think anatomically:
vagina: bloody show, trauma
cervix: cancer, cervical or vaginal lesion
placenta: abruption, previa, accreta
fetus: fetal bleeding
Ectopic pregnancies are most common where? can also occur?
tubal.
can also occur abdomen, ovarian, cervical
presentation of ectopic preg
abd pain, vaginal spotting, bleeding. can be asymptomatic
ectopic preg is associated with?
PID, pelvic surg, DES use, endometriosis
differential for ectopic preg
surgical abdomen, abortion, ovarian torsion, PID, ruptured ovarian cyst
Approach women of repro age with abdominal pain as having ______ until proven otherwise
ectopic preg
diagnosis of ectopic preg?
+ pregnancy test, transvaginal US showing empty uterus
confirm with serial B-hCG without appropriate B-hCG doubling
Medical treatment for ectopic preg
methotrexate (sufficient for small, unruptured tubal pregnancies)
Surgical treatments for ectopic preg?
salpingectomy or salpingostomy with evacuation (laparoscopic vs laparotomy)
IUGR defined as
estimated fetal weight less than 10th percentile for GA
Risk factors for IUGR
maternal systemic disease-> uteroplacental insuficiency
intrauterine infection, hypertension, anemia
maternal substance abuse
placenta previa
multiple gestation
diagnosis of IUGR
serial fundal height measurements with US
perfrom US for EFW (estimated fetal weight)
If patient is near due date with IUGR, what medical therapy is indicated?
betamethasone to accelerate fetal lung maturity (need 48 hours prior to delivery)
Fetal macrosomia
Birth weight > 95th %
Tx/management for fetal macrosomia
planned c/s for EFW > 4500g in women with GDM and > 5000g in women w/o GDM
There is an increased risk of _________ leading to brachial plexus injiry as birth weight increases
shoulder dystocia
AFI > 25 on US =
polyhydramnios (can be present in normal pregnancies but also need to consider pathology)
Causes of polyhydramnios include?
Maternal DM Multiple gestation Isoimmunization Pulm abnml (cystic lung malformations) fetal anomaly (duodenal atresia, T-E fistula, anencephaly) twin-twin transfusion
dx and work up for polyhydramnios:
fundal height > than expected on US.
Eval includes US for fetal anomaly, DM screen, Rh screen
Common causes of oligohydramnios
renal agenesis. GU obstruction
oligohydramnios is associated with a ____ X increase in fetal mortality
40 fold
other complications associated with oligohydramnios include:
club foot, facial distortion, pulm hypoplasia, umbilical cord compression, IUGR
Rh isoimmunization
fetal RBCs leak into maternal circulation and maternal anti-Rh IgG antibodies form that can then cross the placenta, leading to hemolysis of fetal Rh RBCs and erythroblastosis fetalis. Occurs only in Rh (-) women
Who is at greatest risk for Rh isoimmunization?
increased risk with previous SAB, TAB or a delivery where RhoGAM wasnt given
Tx for Rh isoimmunization
initiate preterm delivery when fetal lungs are mature (if severe)
prior to delivery- intrauterine blood transfusions canbe given to correct low fetal hcrit
Prevention for Rh isoimmunization
If mom is Rh (-) at 28 weeks and father is Rh (+) or unknown then give RhoGAM (Rh Immune globulin)
If baby is Rh (+) give mom Rhogam when?
postpartum
For women who have abortion, ectopic preg, amniocentesis, vaginal bleeding, placenta previa/placental abruption and are Rh -, you should
give RhoGAM
Type and screen
follow B-hCG and prevent pregnancy for 1 year
Complication of Rh isoimmunization when Hgb is < 7?
hydrops fetalis
What are the 2 types of malignant gestational trophoblastic disease?
invasive moles
choriocarcinoma
complications of malignant gestational trophoblastic disease?
pulmonary or CNS metastases and trophoblastic pulmonary emboli
2 types of benign gestational trophoblastic disease?
Incomplete and Complete molar pregnancies
Compare and contrast incomplete vs complete molar pregnancies according to
Mechanism of fertilization, karyotype and presence of fetal tissue
Complete:
MOF- sperm fertilizes empty ovum
Karyotype- 46, XX
fetal tissue - none
Incomplete:
MOF- 2 sperm fertilize normal ovum
Karyotype- 69, XXY
Fetal Tissue- yes
Presentation of GTD
first trimester uterine bleeding, hyperemesis gravidarum, preeclapsia, eclampsia at < 24 weeks and uterine size greater than dates
Risk factors for GTD
extremes of age < 20, >40. Diet deficient in folate or B-carotene
Physical exam findings in GTD?
no fetal heartbeat
pelvic exam may reveal large ovaries (bilateral theca-lutein cysts)
May be grape-like molar clusters expelling into vaginal canal
What will labs, US, CXR possibly show in women with GTD?
labs: markedly elevated B-hCG (usually > 100,000)
Pelvic US: snowstorm appearance w/o gestational sac
CXR: can show lung mets
Treatment for GTD
evacuate uterus and follow up with weekly B-hCG
Treat malignant diseases with chemo
Treat residual uterine disease with hysterectomy
Diagnosis of shoulder dystocia?
prolonged 2nd stage of labor, recoil of perineum “turtle sign”, lack of spontaneous restitution (turning head to align with shoulders)
Treatment for shoulder dystocia
“HELPER”
Help reposition into lateral position Episiotomy Leg elevated (McRoberts maneuvar) Pressure (suprapubic) Enter vagina and attempt rotation (Woods screw maneuvar) Reach for fetal arm
causes for failure to progress in labor?
chorioamnionitis, occiput posterior, nulliparity, elevated birth weight
Premature ROM definition
Occurs > 1 hour before onset of labor
Premature ROM can be precipitated by?
vaginal or cervical infections, abnormal membrane physiology, cervical incompetence
Preterm premature rupture of membranes (PPROM) definition
ROM occuring before 37 weeks
Prolonged ROM defined as
> 18 hours prior to delivery.
To minimize risk of infection do not perform _______ on women with PROM
digital vaginal exams
Diagnosis of ROM
Sterile speculum exam- pooling of amniotic fluid in vaginal vault
Nitrazine paper test: (+) paper turns blue due to alkaline pH of amniotic fluid
Fern test: (+) - ferning under microscope with dried amniotic fluid
Treatment for PROM in term women?
Check GBS status and fetal presentation. Induce labor or observe for 6 hours and then induce
Treatment for PROM in >34-36 week?
Consider labor induction
Treatment for PROM in <32 weeks?
Expectant management with bed rest. Give abx and antenatal corticocteroids for 48 hours to promote fetal lung maturity
If signs of infection/fetal distress develop with PROM, give?
antibiotics (ampicillin and gentamicin) AND induce labor
Risk factors for preterm labor (20-37 weeks)
multiple gestation, infection, PROM, uterine anomalies, previous preterm labor, polyhydramnios, placental abruption, poor nutrition, low SES
Most patients with preterm labor have/do not have risk factors?
Do not have!
tocolytics
meds used to suppress preterm labor
Diagnosis of preterm labor requires
regular uterine contractions
concurrent cervical change
sterile speculum exam to rule out PROM
US- rule out fetal anomalies, verify GA, assess presentation and amniotic fluid volume
Contraindications to tocolytics
infection, nonreassuring fetal testing, placental abruption
Tocolytic therapy meds include?
B-mimetics, MgSO4, CCBs, prostaglandin inhibitors
Some common complications for neonates born prematurely?
RDS, inttraventricular hemorrhage, PDA, necrotizing enterocolitis, retinopathy of prematurity, bronchopulmonary dysplasia, death
Why is sodium citrate given to mothers for both elective and indicated c/s delivery?
Decrease gastric acidity and prevent acid aspiration syndrome
Post-partum endometritis is characterized by what signs/symptoms?
Fever > 38 within 36 hours
Uterine tenderness
Malodorous lochia
Postpartum hemorrhage is defined as?
> 500 ml for vag delivery
> 1000 ml for c/s
3 of the most common causes for postpartum hemorrhage are?
Uterine atony- most common
Genital tract trauma
Retained placental tissue
Soft enlarged “boggy” uterus indicates?
uterine atony (most common cause of post-partum hemorrhage- 90%)
How to treat uterine atony?
bimanual uterine massage, oxytocin infusion methergine (if patient is NOT HTN) or PGF2
For all post-partum hemorrhage, when bleeding persists after conventional therapy what can be done?
uterine/iliac artery ligation, uterine artery embolization, or hysterectomy
Treatment for suspected postpartum infection- endometritis?
broad spectrum antibiotics (clindamycin, gentamicin) until patients have been afebrile for 48 hour. (add ampicilin if complicated)
Complications of post-partum endometritis?
Septic thrombophlebitis
How does septic thrombophlebitis present?
“picket-fence” fever curve -> hectic fevers with wide swings from normal to as high as 41 C (105.8)
The most common presenting syndrome for Sheehan syndrome is?
Failure to lactate due to decreased prolactin levels
What are the 7W’s of postpartum fever (10 days post-delivery)
Womb (endometritis) Wind (atelectasis, pneumonia) Water (UTI) Walk (DVT, PE) Wound (Incision, episiotomy) Weaning (breast engorgement, abscess, mastitis) Wonder drugs (drug fever)
Colostrum contains ?
protein, fat, ** secretory IgA and minerals
What is the benefit of high IgA levels in Colostrum?
provide passive immunity for infant and protect against enteric bacteria
Symptoms of placental abruption
PAINFUL, dark vaginal bleeding that does not spontaneously cease. Abdominal pain. Uterine hypertonicity. Fetal distress
How to diagnose placental abruption? Is US helpful?
Mostly clinical. US is only 50% sensitive
Management of abruption
expectent management if you can with starting IV, fetal monitoring, type and cross blood, bed rest
If severe- need to deliver
Complications of abruption
hemorrhagic shock. DIC in 10% of patients. fetal hypoxia
risk factors for abruption
htn, cocaine use, tobacco use, trauma, excessive uterine stimulation
risk factors for previa
c-section hx, grand multip, advanced maternal age, multiple gestation, prior hx previa
presentation of placenta previa
PAINLESS, bright red bleeding that often stops in 1-2 hours. usually no fetal distress
diagnosis previa?
US is 95% sensitive.
What should you not do to manage or diagnose previa?
NEVER perform vaginal exam!
How/when should you deliver a baby with placenta previa present?
C/S! Indicated if term baby, lungs are mature, or if life-threatening bleeding or fetal distress
Vasa previa
Fetal vessels cross over cervical os (due to biloped placenta or strangely inserted umbilical vessel in placenta)
Presentation of vasa previa
PAINLESS bleeding at time of ROM and fetal bradycardia
Diagnosis of vasa previa?
Transvaginal US with color doppler showing vessels passing over the interal os
If patient presents with acute bleeding of vasa previa you should?
Deliver by emergency c-section
If patient is diagnosed with vasa previa prior to bleeding what are steps you should take?
Steroids at 28-32 weeks. Hospitalization at 30-32 weeks for close monitoring. Scheduled c-section at 35 weeks.
With intrauterine fetal demise (fetal death > 20 weeks) how do you manage (20-23 weeks) or (>24 weeks)
20-23 weeks: Dilation and evacuation OR vaginal delivery
> 24 weeks: vaginal delivery
A Kleihauer-Betke test can confirm or exclude?
fetomaternal hemorrhage
How do you evaluate fetal demise? (FETAL things)
Fetal: autopsy, exam of placenta, membranes and cord
Karyotype/genetic studies
How do you evaluate for fetal demise (MATERNAL things)
- Kleihauer-Btke test for feto-maternal hemorrhage
- anti-phospholipid antibodies
- coag studies
Particular complication for IUFD that is retained in utero for several weeks?
coagulopathy
Progesterone supplementation is used to prevent recurrence of _____
preterm labor
Contraindicated vaccines in pregnancy
HPV, MMR, Live influenza, Varicella
Recommended vaccines in pregnancy
Tdap
Inactivated influenza
Rho (D) immunoglobulin
pregnant women are at increased risk of what virus during preg? how to manage this?
Influenza. all preg women should get vaccine. they are more likely to get influenza pneumonia.
If a pregnant women was exposed to varicella but did not show immunity (IgG response to it) how do you manage this?
post-exposure prophylaxis with varicella zoster immunoglobulin administration
Diagnosis of chorioamnionitis is based on?
maternal fever and 1 or more of following (uterine tendernesss, maternal/fetal tachy, malodorous amniotic fluid, purulent vaginal discharge , WBC >15,000
Treatment for chorioamnionitis
broad spectrum antibiotics (amp, gent, clinda)
delivery
What should a patient with chorioamnionitis receive to accelerate labor?
oxytocin
Corticosteroids are administered to all patients likely to deliver a preterm infant before ____ weeks
34
Definition of preeclampsia
new onset htn (> 140 or > 90) at > 20 weeks. plus proteinuria and/or end organ damage
What are severe features of pre-eclampsia
> 160, >110 (2X 4 hours apart) thrombocytopenia elevated creatinine elevated transaminases pulmonary edema visual/cerebral symptoms
Management for preeclampsia
without severe features:
with severe features:
without: delivery >37 weeks
with: delivery > 34 weeks
Give mag (seizure prophylaxis) and anti-htn
proteinuria is defined as?
> 300mg/24 hour
protein/creatinine ratio > .3
dipstick > or equal to 1+
Patients with acute fatty liver of pregnancy present with?
nausea, vomit, abd pain, jaundice
What are the anti-htn treatments of choice for pre-eclampsia?
Hydralazine (IV), Labetalol (IV), Nifedipine (PO)
What is a contraindication for giving labetalol?
bradycardia
Reason not to give nifedipine?
emesis
Medication used to treat chonic htn in pregnancy?
methyldopa (limited by its slow onset)
For an SAD, when do you have to treat with suction curettage?
If infection or hemodynamic instability
Can you use oxytocin to stimulate uterine contractions or expel retained products of conception in 1st/2nd trimester?
NO- few oxytocin receptors in uterus during early pregnancy
Largest risk factor for preterm delivery is?
Previous preterm delivery
What should you do starting in 2nd trimester to help prevent preterm delivery?
progesterone
serial cervical length measurements by transvag ultrasound
When do you consider cerclage?
short cervix.
management of PPROM 34-37 weeks?
Antibiotics
+/- steroids
Delivery
Management of PPROM < 34 weeks if signs of infection and fetal compromise are present
Antibiotics
steroids
mag if < 32 weeks
delivery
Management of PPROM < 34 weeks if signs of infection and fetal compromise are NOT present
antibiotics
steroids
fetal surveilance
Purpose of amnioinfusion??
instillation of saline into uterine cavity for treatment of recurrent variable decels for cord compression during labor
Wernicke encephalopathy (thiamine deficiency) is a major complication of?
Hyperemesis gravidarum
Classic presentation of Wernicke encephalopathy?
Encephalopathy
Oculomotor dysfunciton
Gait ataxia
Fetal anemia is associated with what type of fetal heart rate tracing?
Sinusoidal!
What is the first line intervention for reducing cord compression and improve blood flow to placenta?
Maternal repositioning
2nd line intervention for reducing cord compression?
amnioinfusion
Intermittent variable decels occuring with < 50% of contractions are/are not well tolerated by fetus
ARE
Transverse lie invants typically correct before delivery. True/false?
True
When is internal podalic version used?
to facilitate the breech extraction of a malpresenting 2nd twin
Prognosis for erb-Duchenne palsy (waiter tip posture) after brachial plexus injury in setting of shoulder dystocia?
80% of patients have spontaneous recovery within 3 months
Hyperemesis gravidarum can be associated with transient?
hyperthyroidism (thyrotoxicosis of hyperemesis) due to stimulation of the thyroid by elevated hCG levels
Clinical features of mild, mod, severe mag toxicity
Mild: nausea, flushing, HA, hyporeflexia
Mod: areflexia, hypocalcemia, somnolence
Severe: resp paralysis, cardiac arrest
Mag sulfate decreases the risk for ____ in preterm infants
cerebral palsy
Oxytosin can enhance ____ hormone and cause SIADH
ADH
Two major types of fetal growth restriction?
symmetric and asymmetric
Symmetric FGR
is global, proportionate growth lag that includes the head and starts in 1st trimester. most likely to be congenital/chromosomal or 1st trimester TORCH infxn
Asymmetric FGR
Head sparing growth lag that often begins in 2nd/3rd trimester due to placental insufficiency or maternal malnutrition
Reactive NST?
2 or more accels greater thean 15 bpm and > 15 seconds long in 20 min period
Non-reactive NST?
<2 accels or recurrent variable or late decels
Loss of fetal station or retraction of fetal part is pathognomonic for?
Uterine rupture
management for suspected uterine rupture?
Emergency laparotomy
BPP and CST are equivalent/non-equivalent?
equivalent
Women who miss GBS screening at 35-37 weeks ang go into labor should be treated if: (3 things)
< 37 weeks
intrapartum fever
rupture of membranes > 18 hours
Do women who are GBS negative need prophylaxis if they have rupture of membrane > 18 hours?
NO
when should penicillin prophylaxis be given for GBS?
4 hours before delivery
most common cause of an arrested 2nd stage of labor is?
fetal malposition
malpresentation refers to any?
non-vertex presentation (breech)
malposition refers to?
(non-occiput anterior): relationship of presenting fetal part to maternal pelvis (occiput posterior, occiput transverse)
Most common cause of protracted 1st stage of labor?
inadequate contractions
molding of fetal head is suggestive of?
cephalopelvic disproportion
Describe pathophysiology of pulmonary edema in pre-eclampsia/ eclampsia
generalized arterial vasospasm -> increased afterload -> increased pulm cap wedge pressure -> pulm edema
Also decreased albumin, renal function and increased vasc permeability -> pulm edema
amniotic fluid embolism presentation and etiology
sudden hypoxemic resp failure and hypotensive shock. Amniotic fluid enters maternal citculation during delivery.
When should you have suspicion of septic thrombophlebitis
post partum or post pelvic surgery in patient with bilateral low quad tenderness (thrombosis in deep pelvic or ovarian veins). these patients have persistent fever unresponsive to broad spectrum abx and negative blood, urine, urinalysis
Treatment for septic pelvic thrombophlebitis
anticoagulation and broad spec abx
adverse affects of oxytocin
hyponatremia (similar in structure to ADH) hypotension uterine tachysystole (abnml frequent contractions)
Patients with positive syphilis serology should be treated with?
Intramuscular benzathine Penicillin G
An intrauterine fetal demise associated with growth restriction, multiple limb fractures, hypoplastic thoracic cavity is consistent with?
Type II osteogenesis imperfecta (lethal)
autosomal dominant
non-lethal autosomal dominant bone dysplasia that presents with macrocephaly, frontal bossing, midface hypoplasia, genu varum and limb shortening
Achondroplasia
symptomatic pubic symphisis presents as?
suprapubic pain that spreads to the back and hips. exacerbated by weight-bearing, walking, position changes, waddling gait, point tenderness over pubic symphisis
Who should have cerclage
hx of 2nd trimester delivery or short <2.5cm cervical length
DIC is a complication of?
placental abruption
adhesions, powder-burn lesions, flesh colored or dark nodules and chocolate cysts indicate?
endometriosis
Tocolysis is not indicated after _____ weeks because?
risk of therapies exceed those of preterm delivery
In a patient with breech IUFD > 24 weeks, what is the best mode of delivery? why?
Vaginal induction of labor. Do not need c/s for breech IUFD because benefits are typically to protect the fetus. Vag delivery is a more safe option for Mom
What types of fibroids can cause recurrent pregnancy loss?
submucosal and intracavitary
What treatment is required for early decels? why?
NONE. Early = head compression. does not indicate fetal hypoxia.
bladder atony should be suspected when?
patients unable to void by 6 hours after vaginal delivery or 6 hours after removal of indwelling catheter after cesarean delivery
Symptoms of sheehan syndrome
fatigue, weight loss, hypotension, inability to breastfeed
Tocolytic meds include?
nifedipine (CCB) and indomethicin
Nifedipine and Mag together can cause
resp depression and suppressed muscular contractility
A positive fetal fibronectin test is associated with?
preterm delivery
Arrest of active labor occurs when?
no cervical change for >4 hours with adequate contraction or no cervical change >6 hours with inaequate contraction
contractions generating > ______ MVUs in a 10 min interval are considered adequate
200
When is oxytocin indicated for protracted labor?
inadequate contraction strength
When can operative vag delivery be used to manage a protracted second stage of labor?
cervix is completely dilated (10cm)
