Obstetrics Flashcards
Which hormone triggers a surge in LH?
Estrogen during the follicular phase
What does a surge in LH lead to
ovulation
Which medications have placental transmission?
- Acutane
- Antidepressant (sodium valproate)
- Anticonvulsants
- Anticoagulants
- Vitamins ADEC in excess
When would you refer for genetic counseling?
- advanced maternal age
- suspected carriers for gene
- family condition/trait
- recurrent SAB
- unexplained fetal death
- SIDS hx
Carrier tests are available for which conditions?
- Sickle Cell
- Tay Sachs
- Thalassemias
- Cystic Fibrosis
T/F: Tay sachs screening is offered if both parents are Jews
True
What percentage of pregnancies are unplanned?
50%
Define infertility
inability to conceive after 1yr of trying
When should you intervene with an eval and workup for infertility?
If <35yo, wait 1yr;
If >35yo, wait only 6mo
What are the 3 primary causes of infertility?
1- Pelvic factors (PID, adhesions, inflam)
2- Semen defect (amount, motility, morph)
3- Ovulatory defect (progesterone, cycle, luteal phase defect)
What is labs are performed on an infertility workup?
- Fertility awareness edu.
- TSH
- FSH
- Progesterone
- Prolactin
- Semen analysis
When would you perform a hysterosalpingogram w/ infertility?
Checking for potency of tubes or anatomical obstructions
When would you perform laparoscopy w/ infertility?
checking for adhesions and fibroids or cysts
Which are 3 requirements for successful conception?
Egg, sperm, good environment
Where does conception occur?
FIMBRIA OR AMPULLA
How long is the egg viable for, once released?
24hrs
When is hCG produced?
When egg burrows into endometrium
- hCG triggers corpus lute to secrete prog past its normal 14 days
Once implantation occurs, how long does the corpus lute secrete prog for?
12-16th week, until placenta takes over
Why might there be increased hCG on pregnancy test?
- Pregnancy (normal or complicated)
- Ovarian tumor
- Testicular cancer
What is the pattern of hCG increase with pregnancy?
- doubles every 48-72hrs
- peaks at 50-75 days
What timeframe is considered for spontaneous abortion?
loss of fetus before 20 weeks gestation
Describe threatened abortion
spotting/bleeding w/ NO significant cramps/clots
Describe inevitable abortion
- Heavy bleeding, cramps, cervix dilated, ROM, no FHTs
- decrease in hCG
- before wk 10 - natural course
- after wk 10 = D&C
Describe incomplete abortion
Part or all of POC (products of conception) remained in uterus
What are s/sx of incomplete abortion? Next steps?
- bleeding and pain
- monitor for infection/hemorrhage and refer for D&C
Describe complete abortion
all POC expelled
- 2-3wk follow up with provider
Describe missed abortion
Death of embryo or fetus with retained POC
- requires D&C
What is habitual abortion?
3 successive pregnancy losses
- requires referral
What is a septic abortion?
POC infected, may lead to systemic infection
What are s/sx of septic abortion?
- increased bleeding
- malodorous vaginal d/c
- pain
- fever/chills
- leukocytosis
What is a blighted ovum?
- Egg gets fertilized and implants- but does NOT develop
What is the usual cause for an anembryonic pregnancy/blighted ovum?
chromosomal abnormality
What is the presentation of ectopic pregnancy?
bleeding, pain, s/s of pregnancy
How do you dx ectopic pregnancy?
decreasing or low hCG levels and ultrasound
What are the risk of ectopic pregnancy?
- hemorrhage and death
- future infertility
- increased risk of future complications
what occurs when there is an overproduction of placental cells with an abnormally high hCG level?
hydatidiform mole
What is the typical presentation for a molar pregnancy?
- Large for gestational age
- bleeding and pain
- no fetal mvmt.
- more nausea than normal (hCG)
- no FHTs
Presence of a hydatidiform mole increases the risk for developing ________.
Choriocarcinoma
what are the common causes for first trimester SAB?
chromosomal abnorm, reproductive hazards and unknown
What are the common causes for second trimester SAB?
incompetent cervix, uterine septum, trauma
Which criteria help form a “Presumptive” pregnancy dx?
- Amennorhea
- N/V
- Mastodynia
- Quickening (baby moving)
- Urinary freq.
- Wt gain
- Fatigue
- Increase BBT
- Chloasma/linea nigra/darkened areola
Which criteria help form a “Probable” pregnancy dx?
- OTC pregnancy test (pos @ 12-14 days)
- Blood test (pos @ 9-11 days)
- Uterine changes (hegar’s & goodell’s)
- Ballotable mass
- Braxton-Hicks contractions
What is a ddx for probable pregnancy?
- choriocarcinoma, hydatidiform mole, ectopic pregnancy.
- obesity or neoplasm
- muscle spasm
Which findings suggest a definitive “POSITIVE” pregnancy?
FHTs, Ultrasound and X-Ray
What is the role of “relaxin”?
softens tissues and joints, secreted through breastfeeding
What is role of prostaglandins in pregnancy?
Present in amniotic fluid, menstrual blood and semen; ripens cervix and induces contractions
What is the role of progesterone in pregnancy?
- Secreted by CL then placenta
- promotes breast gland growth
- maintains pregnancy
Which form of estrogen is dominant through pregnancy?
E3 - Estriol, 1000x higher while prego
What is the role of prolactin in pregnancy?
Develops alveolar and glandular cells to help promote lactation and produces lactose and lipids
What is the role of oxytocin in pregnancy?
“Contractor hormone”
- secreted from post. pit. to express milk and stimulate the uterus
- induces labor and controls PP hemmorhage
What is piskacek’s sign?
asymmetric enlargement of the body of the pregnant uterus, an indication of pregnancy
What is goodell’s sign?
cervical softening, an indication of pregnancy
What is hegar’s sign?
Uterine isthmus softens. indication of pregnancy
What is chadwick’s sign?
bluish discoloration- increased vascularization of vaginal walls, indicating prengnancy
Which hormone inhibits egg maturation?
Progestin
Which hormone preserves corpus lute?
hCG
How does estrogen influence chloasma + similar conditions?
Estrogen stimulates melanocytes
Why and how is GI tract affected during pregnancy?
Relaxin from placenta causes GI relaxation, slowing food and water digestion
What are montgomery’s tubercles?
small glands around the nipples that secrete oils which lubricate and protect against infection
At what times do breasts become more enlarged w/ modularity and when do they express colostrum?
- nodularity/enlargement by 8wks
- colostrum (rich in Ab/PRO, low in lipids) by 12wks
What are the normal cardiovascular changes with pregnancy?
- CO increases, peaks @ 20-24wks
- BP decreases in 2nd tri
- HR increases by 10-15bpm
- LE edema/neous congestion
Why will pregnant women appear anemic on lab tests?
- Plasma increases more than RBC mass increases;
- Will appear anemic on labwork as there is a RELATIVE decrease in hematocrit and hemoglobin. “Macrocytic anemia” d/t hemodilution
Which respiratory changes are important with pregnancy?
increase in tidal volume and O2 uptake
Which GI condition is common in pregnancy?
cholestasis
Which skin conditions are very common w/ pregnancy?
- spider angiomas and varicosities
- hyperpigmentation
What is the difference between gravid and gravida?
one has an “a”;
- gravid = currently pregnant
- gravida = has been pregnant
Define nulligravida
never been pregnant
Define primigravida
pregnant for the first time
Define para
carried fetus to viability
Define primipara and multipara
carried one fetus and multiple fetuses to viability
Define parturient
woman IN labor
What is post-partum
post-parturient = after labor
What is puerpera?
woman who has just given birth
What is GPA
Gravida-Para-Aborta
What is Naegle’s rule?
due date calculation:
- subtract 3mo from LNMP
- Add 7 days to day of LNMP
- Add year, if appropriate
How much do caloric needs increase/day for a pregnant woman?
200-300kcal
Which are the prenatal vitamins?
Folic acid, Iron, Calcium citrate and Mg malate
Can you have caffeine while pregnant?
Yes, limit to 200mg per day
What are the pregnancy risk factors?
- High BP
- Heart, lung, liver, kidney dz
- STI or UTI
- Diabetes (type 1)
- asthma
- seizure or psychiatric disorders
- hypothyroidism
What is the proposed frequency of visits throughout pregnancy?
1/mo until 28wks
2/mo from 28-36wks
1/wk from 36-40wks
What procedures are performed on an initial prenatal visit?
- Blood and Rh type
- CBC
- Rubella titer
- Syphilis screen (VDRL/RPR)
- Hep/HIV
- Urinalysis
- PAP smear and infection
- Toxoplasmosis
What is the QUAD screen?
Maternal serum screen at 16-18wks:
- AFP
- HCG
- Estriol
- Inhibit A
When is the diabetes screen performed?
24-28wks
When does the uterus become an abdominal organ during pregnancy?
First day of 2nd trimester
What tests are performed on prenatal visits?
- Gestational age
- Wt
- BP
- Urine
- FHR (120-160bpm)
- Fetal presentation
When can you hear FHTs via stethoscope ?
20wks
When can you hear FHTs via doppler?
12wks
At what rate does the uterine fundal height grow?
@ 12/14wks = above pubic bone;
@ 20wks = at umbilicus +1cm for each week
What infection do you test for at 36wks?
Group B strep (GBS)
What are the safest weeks for a pregnant woman to travel?
18-32wks
What is the MC cause of mental disabilities in the US?
Fetal Alcohol Syndrome (FAS)
Which facial features are characterized by FAS?
short eye opening, wide-set eyes, short nose, flat mid face, thin upper lip and small chin
What are the 3 primary characteristics of FAS?
- Characteristic facies
- Growth retardation
- CNS anomalies
Which minerals are important to supplement in pregnancy?
Zinc and Calcium
Which vitamins are important to supplement in pregnancy?
A (only in B-carotene form d/t teratogenic risk), B6 and B12
When would you perform amniocentesis and CVS?
Amnio - ONLY after 16wks
CVS - btw wks 9-12
What is oxytocin challenge aka stress test?
sees how baby reacts to oxytocin via HR monitor
How is biophysical profile test performed and evaluated?
- Uses U/S and Non-stress test to evaluate many parameters
- Scores up to 10, with 4pts or less being ominous
What is MC onset of pre-eclampsia/eclampsia?
3rd Trimester (may be 20wks to 6wks PP)
T/F: Progression of pre/eclampsia may be rapid
True
What is the presentation for pre/eclampsia?
HTN, proteinuria, wt gain, edema, HA, URQ or Epigastric pain
What is anasarca?
Generalized edema (pitting)
What s/sx would signify severe preeclampsia?
anasarca, oliguria, acute retinal hemorrhages, HA, CNS irritability
What is a major complication of preeclampsia?
HELLP
Hemolysis, Elevated Liver enzymes and Low Platelets
What is the most common complication of pregnancy?
gestational diabetes
What are s/sx of GD?
excessive thirst, hunger, fatigue or “not feeling right”
SCREEN @ 24-28wks
What are complications of GD?
SAB, polyhydraminos, preterm, HTN, dystocia, resp. distress, macrosomia
Which type of zygotic twins are riskier?
monozygotic
What are s/sx of preterm labor?
- back pain/pressure
- contractions >4x/hr
- mucoid d/c or ROM
When is “term”?
38wks
What is Franks breech position?
bum is facing outlet in pike position
What are complications of postterm birth?
placental insuff., asphyxia, aspiration of mecon., dystocia
What are red flags with post-date pregnancy?
- less mvmt
- bleeding
- severe HA/visual disturbance
- sudden wt gain
- abd. pain
Which drug while ingested during pregnancy will cause withdrawal s/sx
heroin
which organism is commonly found in soft cheeses, lunch meat and unpasteurized milk?
listeria monocytogenes
Which s/sx occur with toxoplasmosis?
fatigue, muscle pain and lymphadenopathy
Which prominent STIs are communicable in utero?
- Syphilis
- Herpes (HSV)
- CMV (salivary transmission too)
- Mycoplasma
- Hep B
- HIV
Which prominent STIs are communicable via birth canal?
- NG/CT
- GBS
- Herpes (HSV)
- CMV (salivary transmission too)
- HPV
When is HIV communicable?
in utero, delivery and via breastfeeding
What is trademark sign of CMV?
hepatosplenomegaly
Rubella is typically mild, however the congenital form may cause which problems?
deafness, heart dz, dev’t delays
what is lightening?
when the baby drops lower into mother’s pelvis
what is quickening?
first sign of fetal movement
What is “lie” fetopelvic relationship?
relationship of long axis of fetus to long axis of mother (long/transverse/oblique)
What is “presentation” fetopelvic relationship?
part of fetus presenting to pelvic inlet - usually vertex
What is “attitude” fetopelvic relationship?
relationship of fetal parts to each other (flex/ext of head on trunk)
What is “denominator” fetopelvic relationship?
point on PRESENTING part to describe position (i.e. Occiput, mentum or sacrum)
What is most common denominator? Why?
Left occiput anterior d/t liver
What is “position” fetopelvic relationship?
relationship of denominator to the front, back or side of maternal pelvis
What is the order of cardinal movements?
- EDIERAP*
- engagement
- descent, flexion
- internal rotation
- extension
- restitution (90 deg rot.)
- anterior shoulder
- posterior shoulder
How many cm is the cervix dilated in each stage of labor?
Stage 1 = 0-10cm
Stage 2 = 10cm to birth
What are the 3 phases of stage 1 of labor?
Latent
Active
Transition
How are CXNs timed?
start of CXN to start of the next CXN
What is station?
“Zero station” means that the head is at the middle of the pelvis at the line of the sacroiliac spine, increasing numbers indicates head further below pelvis
What is effacement?
thinning of cervical wall
What is the frequency of contractions along all three phases of stage 1 labor?
Latent - 5-20min
Active - 2-4min
Transition - 2-3min
What is the frequency of contractions in stage 2 labor?
2-5min
T/F: Early decels in FHTs are ok, while only late decels are bad.
correct
What is crowning?
“ring of fire” = widest part of fetal head at vulvar ring w/out retraction
With a gush ROM, what should you be wary of?
check for prolapsed cord and monitor FHTs
What is the concern with preterm or prolonged ROM?
increasing risk of infection after 24hr
What is back labor?
baby is in occiput posterior position, fix with counter pressure on sacrum in quadruped position
What is turtle’s sign?
shoulder gets stuck on pubic bone, causes dystocia
What condition may corkscrew procedure cause?
Erb’s palsy
What occurs in stage 3 of labor?
separation and expulsion of placenta
What occurs with separation of placenta?
lengthening of cord, gush of blood and contractions
How do you examine placenta after delivery?
for completeness
- amniotic side is Shiny, Smooth and “Shultz”
- meaty side is dull “Duncan”
what is amniotomy?
artificial rupture of membranes
What is placental abruption?
Subchorionic hematoma displacing placenta from uterine wall, there will be decrease in FHTs, painful
What is placenta previa?
Placenta covers cervical os
S/sx = painless bright red bleeding late in pregnancy, requires c-section
What are the labor laceration classification?
1st- vaginal mucosa/labial skin
2nd- bulbocavernosal muscle
3rd- external anal sphincter
4th- anterior anal wall
What is lochia?
vaginal d/c post partum
What are the types of lochia?
Rubra - active bleeding, red, lasts few days
Serosa - pink w/ serum and WBCs, 5-10days
Alba - whitish brown, RBCs, mucous and tissue debris for up to 6wks
Pt has low back pain, CVA tenderness, fever and nausea post partum. What is their Dx?
UTI
What are 3 depressive states following pregnancy?
I. Baby Blues
II. Depression
III. Psychosis
Describe post partum depression
Mood has effect on ADLs, obsessive thoughts of harming baby or inability to care for baby
Describe post partum psychosis
Manic and severe depressive state, sleep deprives and volatile
- requires management
When should you screen for anemia post partum
4-6wks
What is diastasis recti?
separation of rectus abdomens 2.7cm or greater
What is APGAR?
- Appearance (color)
- Pulse (>100bpm)
- Grimace (flex irritability)
- Activity (mm. tone)
- Respiration
score below 6 suggests neurologic sequelae
What does Ballard assess?
determines actual age using physical assessment
Vernix caseosa and lanugo suggest baby is younger or older?
younger
Foot creases in baby suggest they are ______
older
What are s/sx of perinatal oxygen deprivation?
- decreased LOC/mvmt, poor tone, apnea spells and seizures
+ jittery/weak after 12hrs
+ brain stem/feedingw signs after 24hrs
What is newborn molding?
sutures fold in on each other, CONE HEADS
What is cephalohematoma?
blood btw periosteum and skull; DOES NOT CROSS SUTURE LINES
What is caput succedeneum?
edema of scalp, more diffuse and crosses suture lines; lasts 1-2 days
Why is baby jaundice important to manage?
potential for neuro defecits
When is it normal for babies to get jaundice?
2-4 days after delivery; within 24hrs signifies hemolytic condition (kernicterus)
What precautions should you take with sore nipples while breast feeding?
- avoid soapy water & drying agents
- air dry after feeding
- limit time on that nip
- avoid plastic lined breast pads
What is the causative agent of mastitis?
S. aureus
When is mastitis MC?
within 3 months
What are s/sx of mastitis?
unilateral redness, tenderness, warmth and fever
->Tx with Ab and regular expression
What is TORCH?
refers to a group of maternally acquired communicable diseases
What does TORCH stand for?
Toxoplasmosis Other: • Varicella • Venezuelan equine encephalitis • Mumps • Coxsackie • Parvovirus • HIV Rubella Cytomegalovirus Herpes
