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*PANCE by subspecialty > Obstetrics > Flashcards

Obstetrics Flashcards

1
Q

oligomenorrhea

A

cycle length >35 days -

meaning don’t have period every month

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2
Q

Polymenorrhea

A

cycle length <21 days

meaning > 1 period every month

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3
Q

Hypomenorrhea

A

Scanty menstruation - light flow

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4
Q

Menorrhagia

A

Regular cycles

Excessive flow or duration

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5
Q

Amenorrhea

A

Absence of menses for 6 months

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6
Q

Metorrhagia

A

Uterine bleeding at irregular intervals, particularly between the expected menstrual periods

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7
Q

Menometorrhagia

A

Irregular cycles

Excessive flow or duration

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8
Q

Gestational Age

A

Age in days or weeks from the last menstrual period

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9
Q

First trimester

A

up to 14 weeks GA

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10
Q

Second trimester

A

14-28 weeks GA

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11
Q

Third trimester

A

28 weeks until delivery

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12
Q

Preterm definition

A

24-36 weeks

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13
Q

Term definition

A

37-42 weeks

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14
Q

Post-term

A

Past 42 weeks

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15
Q

Gravidity

A

Number of times a woman has been pregnant

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16
Q

Parity

A

Number of pregnancies that led to birth after 20wks or > 500g infant

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17
Q

G1P1001 = ?

A

1 baby delivered at term

P - - - - 
Term
Preterm
Abortions
Living children
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18
Q

G2P1011 = ?

A

Pregnant two times
One living child delivered at term
One abortion

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19
Q

How does maternal cardiac physiology (CO, SV, pulse, PVR, BP) change when pregnant?

A 
Increased blood volume = 
CO increases by 30-50%
SV increases 10-15%
Pulse increases 15-20 BPM
SEM and S3 gallop common

PVR falls
Fall in BP 2nd semester, return to normal during 3rd trimester

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20
Q

How does maternal respiratory physiology (RR, vital capacity, inspiratory reserve volume, residual volume, TLC, inspiratory capacity, tidal volume) change when pregnant?

A

UNGHANGED: RR, vital capacity, inspiratory reserve volume

Decreased: Functional reserve capacity, expiratory reserve volume, residual volume, TLC (b/c uterus is getting big)

Increased: Inspiratory capacity, tidal volume

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21
Q

How does maternal renal physiology (GFR, Cr, kidney size, bladder) change during pregnancy?

A

Bladder becomes intra-abdominal organ

GFR increases 50%

CrCl increases by 150/200 cc/min

BUN & serum Cr goes down by 25%

Marked increase in renin & angiotensin levels but reduced vascular sensitivity to their HTN-effects

Inc tubular re-ab of Na+ = one of reasons why preggers ppl have edema

Increased glucose excretion

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22
Q

What is done at almost every prenatal visit?

A

H&P

Fetal exam (fetal heart tones, fundal height, fetal presentation (>36 wks)

Urine dip (protein, glucose, leukocytes)

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23
Q

When is maternal cystic fibrosis screening done during pregnancy?

A

First visit (blood test mom)

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24
Q

When is group B strep culture done during pregnancy

A

36 weeks

Also test for STDs at this time - need to know before delivery - including HIV

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25
Q

What labs are drawn during the first prenatal visit?

A 
Labs: 
Hct/hgb 
Rh factor 
Blood type 
Antibody screen 
Pap smear 
Gonorrhea/chlamydia cx 
UA (protein, glucose, ketones) 
Urine culture (treat) 
Cystic fibrosis screen 
Infection screen (rubella, syphilis, hep B, HIV, Tb)
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26
Q

History questions to ask - obstetrical & menstrual

A

H&P:
Biographical (age, race, occupation, marital status)

Obstetrical (GP, deliveries (vaginal, cesarian), complications, infant status, birth weight

Menstrual (LMP, menstrual irregularities)

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27
Q

Pertinent medical history to ask for at prenatal visit

A 
Asthma 
Diabetes 
Hypertension 
Thyroid disease 
Cardiac disease 
Seizures 
Rubella 
Previous surgeries 
STDs 
Allergies 
Medications 
Smoking 
Alcohol 
Drugs
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28
Q

Family history to ask for in prenatal visit

A 
Multiple gestations 
Diabetes 
HTN
Bleeding disorders 
Hereditary disorders 
Mental retardation 
Anesthetic problems
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29
Q

When do you give anti-Rho D immunoglobulin if indicated?

A

28 weeks

Within 72 hours of bleeding

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30
Q

Physical exam components prenatal obstetrics visit

A 
Vitals 
Head &amp; neck 
Heart &amp; lungs 
Back 
Pelvic: 
External genitalia - lesions, bartholins gland 
Vagina - discharge, inflammation 
Cervix - polyps, growth 
Uterus - masses, irregularities, size vs GA 
Adnexa - massed
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31
Q

Questions to ask at every prenatal visit (after first)

A 
Presence of fetal movement 
Vaginal bleeding 
Leakage of fluid 
Contractions/abdominal pain 
Pre-eclampsia sx: HA, visual changes, RUQ pain)
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32
Q

Subsequent prenatal visits 4 MUST do physical exam

A

BP
Urine dip
Fundal height
Fetal heart rate

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33
Q

What is the cfDNA test, what does it screen for and when in pregnancy is it done?

A

Cell-free fetal DNA - sample of maternal blood (non-invasive) - next generation sequencing looking for below diseases

Done at > 10 weeks

Tests for: 
Down syndrome T21 (99% detection) 
Trisomy 13 
Trisomy 18 
Turner syndrome 
Sex chromosome aneuploidies
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34
Q

Quad screen - what is it, when is it done?

A

Done 16-18 wks - test of maternal serum

Labs drawn: 
Unconjugated estriol
B-hcg
Alpha-fetoprotein
Inhibin A

Screening for:
Trisomy 18, 21, neural tube defects

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35
Q

First trimester screen - when is it done, why, what does it test for?

Invasive or noninvasive
Labs values drawn

A

Done at 11-13 weeks
Optional, non-invasive

Combines maternal blood screening tests (B-hcg - increased, PAPP-A- decreased)

with a findings on a fetal US evaluation to identify risk for Down syndrome (T21)

(can also find Edward syndrome (trisomy 18))

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36
Q

Fetal ultrasound findings on the FTS suggestive of Down syndrome

A

Increased nuchal translucency

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37
Q

Quad screen findings associated with Down syndrome

A

UE3 decreased
AFP decreased
B-Hcg increased
Inhibin A increased

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38
Q

Quad screen findings associated with Edwards syndrome

A

All decreased

UE3, AFP, B-Hcg, inhibin A

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39
Q

Quad screen findings associated with NTD

A

Normal uE3
Increased AFP
B-Hcg normal
Inhibin A

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40
Q

When is gestational diabetes tested for and how?

A

24-28 weeks

1-hour 50g glucose tolerance test

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41
Q

Fundal height - where is the height of the uterus at 12 weeks?

A

Pubic symphysis

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42
Q

Fundal height - where is the height of the uterus at 16 weeks?

A

Between pubic symphysis and umbilicus

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43
Q

Fundal height - where is the height of the uterus at 20 weeks?

A

At the level of the umbilicus

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44
Q

Fundal height - where is the height of the uterus at 20-36 weeks?

A

Uterine height correlates with gestational age after 20 weeks

Fundal height in cm should correlate with gestational age +/-3

If it doesn’t match - consider inaccurate dating (most common), multiple gestations, or molar pregnancy

Post 36 weeks, fundal height may not correlate with GA because fetus has started to descend into the pelvis

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45
Q

What are the different forms of fetal surveillance & when are they performed?

A 
Fetal movement counts 
Non-stress tests 
Contraction stress tests 
Biophysical profile &amp; modified 
Doppler ultrasonography

Performed in T3 unless needed earlier
Choice and frequency of testing depends on indication, GA, medical condition, & experience of the practitioner

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46
Q

Non-stress test - what it is and the 4 components

A

The NST evaluates 4 components of fetal heart rate tracing:

  1. Fetal HR (110-160)
  2. Variability
  3. Periodic changes - accel
  4. Periodic changes - decel
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47
Q

Greatest RF for ectopic pregnancy

A

Prior ectopic pregnancy

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48
Q

RF for ectopic pregnancy

A

Prior ectopic (greatest)
PID
Tubal surgery
IUD

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49
Q

Definitive dx for ectopic

A

Pelvic Ultrasound

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50
Q

Ectopic pregnancy clinical presentation, PE, dx, tx

A

Patient with a history of prior ectopic, PID, tubal surgery, IUD

CP: Complaining of vaginal bleeding, abdominal pain,amenorrhea

PE will show adnexal tenderness or unexplained hypotension

Labs will show positive pregnancy test and lower than expected serum beta-hCG levels

Diagnosis is made by ultrasound

Most commonly located in a fallopian tube

Treatment is methotrexate or surgery

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51
Q

Most common location ectopic

A

Fallopian tube

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52
Q

RF for developing rectocele

A

risk factors for development of a rectocele include obesity, vaginal childbirth, pelvic surgery, collagen disorders and advanced age.

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53
Q

Most effective non surgical tx of rectocele

A

Pessary

Can also tx constipation if present

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54
Q

Most common surgical management of rectocele is…

A

a posterior colporrhaphy which has an anatomic cure rate of up to 96%.

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55
Q 
Which of the following drugs is C/I in pregnancy?
Labetalol 
Methyldopa 
Adenosine 
Catopril
A

Angiotensin-converting-enzyme (ACE) inhibitors (e.g. captopril) are category D drugs and are contraindicated in pregnancy. The most serious fetal effects occur when they are taken in the second and third trimester and include oligohydramnios, renal agenesis, fetal skull abnormalities, and increased risk of stillbirth.

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56
Q

Which class of antibiotics is a/w fetal kernicterus if taken in third trimester?

A

Sulfonamides

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57
Q

Bacterial vaginosis

A

Patient will be complainingofmalodorous vaginal discharge

PE will showthin, gray/white discharge
Labs will showpH > 4.5, clue cells
Diagnosis is made byKOHto smear → fishy odor,”whiff test”,AmselCriteria

Most commonly caused byGardnerellavaginalis

Treatment ismetronidazole

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58
Q

Endometriosis pathophysiology

A

CAUSE = RETROGRADE MENSTRUATION

Endometriosis is a benign, estrogen-dependent condition that results in endometrial tissue developing in extrauterine sites.

The most common site for endometrial implantation is the pelvis, with the ovaries, posterior cul-de-sac, and anterior cul-de-sac affected most frequently.

Endometriosis is a disease of women of reproductive age and is rare in postmenopausal women unless they are on estrogen replacement therap

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59
Q

Primary amenorrhea

A

Failure of menses to occur by age 15 despite normal growth of secondary sexual characteristics

Failure of menses to occur by age 13 in the absence of secondary sexual characteristics

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60
Q

Secondary amenorrhea

A

Cessation of menses anytime after menarche has already occurred

(Three + months for women who have regular menses. Six + months for those with irregular menses)

Lab workup:FSH, LH, prolactin, TFTs, testosterone, hCG

Comments: Pregnancy is the most common cause of secondary amenorrhea

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61
Q

Three “D’s” of EnDometriosis

A

Dysmenorrhea (painful period)

Dyspareunia (painful sex)

Dyschezia (painful bowel movement)

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62
Q

PE Endometriosis

A

Often normal, can have localized tenderness or pelvic pain

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63
Q

Diagnosis Endometriosis

A

Definitive diagnosis is laparoscopy

Initial workup is pelvic ultrasound - often times non-diagnostic for endometriosis but rules out other causes of pelvic pain

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64
Q

Management of endometriosis

A

Pain management (NSAIDs), Cessation of menstrual cycle with OCP, Gynecology referral

Surgical management with laparoscopic removal of implants is option - especially for those patients wishing to get pregnant

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65
Q

Ddx endometriosis

A

Mittelsmerz

PID - has BILATERAL adnexal pain, FEVER, CMT, DISCHARGE

Ruptured ovarian cyst - Acute onset unilateral pelvic pain with NAUSEA, VOMITING

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66
Q

What is the most common location of endometrial tissue in endometriosis?

A

Ovaries

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67
Q

Amenorrhea labs

A

FSH, LH, prolactin, TFTs, Testosterone, hCG

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68
Q

What is the most common cause of secondary amenorrhea?

A

Pregnancy

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69
Q

Definition of secondary amenorrhea

A

Cessation of menses anytime after menarche has already occurred

Absence of regular menses for THREE months (women with regular menses) or absence for SIX months in women with irregular menses

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70
Q

Definition of primary amenorrhea

A

Failure of menses to occur by age 15 despite normal growth of secondary sex characteristics

OR

Failure of menses to occur by age 13 in absence of secondary sexual characteristics

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71
Q

Chronic HTN definition

A

High BP outside pregnancy
High BP prior to 20 wks gestation
High BP existing 12 weeks PP

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72
Q

Preeclampsia definition

A

New onset HTN (>140/90, measured twice >4 hours apart) after 20 wks AND…

Proteinuria (1+ dipstick, >300 24hr, or protein/Cr ratio > 0.3) OR…

Thrombocytopenia (plt <100,000), Cr >1.1, LFTs 2x ULN, pulmonary edema, cerebral or visual symptoms

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73
Q

Symptoms of preeclampsia

A

Usually ASYMPTOMATIC - must catch on routine screening

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74
Q

What % of pt with chronic HTN develop preeclampsia in pregnancy and how is it defined?

A

25%

For women with prior chronic HTN with previous proteinuria, preeclampsia is defined as worsening HTN or development of more severe features (RUQ/epi pain = hepatic ischemia, Cr >1.1 or doubling of Cr, pulm edema, plt < 100,000)

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75
Q

Pathophysiology of preeclampsia

A

Vasospasm in various organs (brain, kidneys, lungs, uterus) - cause of vasospasm unknown - how placental vasculature dev early on in pregnancy contributes

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76
Q

Tx preeclampsia

A

Definitive - delivery

Preterm - close monitoring - NST and biophysical profiles - dec activity

Term - deliver fetus - vaginal via IOL

MgSo4 for seizure PPX if delivering the fetus - monitor for toxicity (Mg levels, check reflexes)

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77
Q

HEELP Syndrome def

A

Severe preeclampsia with:

Hemolysis
Elevated liver enzymes
Low platelets

A/w high morbidity - deliver IMMEDIATELY - May occur with or without HTN

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78
Q

RF for HTN diseases in pregnancy

A 
Nulliparity 
Age > 40 
Fam Hx preeclampsia 
Chronic HTN, 
Chronic renal dz
DM 
Multiple gestations 
Hx preeclampsia
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79
Q

Anti HTN drugs safe in pregnancy

A

Short term - IV labetalol, IV hydralazine

Long term - PO labetalol, methyldopa, nifedipine

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80
Q

Are ACEI safe in pregnancy?

A

NO - CONTRAINDICATED- TERATOGENIC

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81
Q

Are diuretics a safe choice of anti- hypertensive?

A

Not used in pregnancy bc dec plasma volume which may be detrimental to fetal growth - same w/Na restriction

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82
Q

What does gestational DM result from?

A

Results from human placental lactogen secreted during pregnancy, which has glucagon-like effects

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83
Q

How is DM screened for and at how many weeks?

A

1 hour GTT —> results > 140 then follow up with 3 hour GTT

Fasting > 95
1 hour > 180
2 hour > 155
3 hour > 140

= gestational DM

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84
Q

Maternal effects of GDM

A 
4x risk preeclampsia 
Inc risk bacterial infections 
Higher rate cesarean delivery 
Inc risk polyhydramnios 
Inc risk birth injury 
Inc lifetime risk of T2DM
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85
Q

Fetal effects of DM

A

Inc risk perinatal death
Macrosomia —> birth injury (shoulder dystocia)

Metabolic derangements —> hypoglycemia, hypocalcemia

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86
Q

What to do differently with moms who have A2 (requires insulin/oral agents) GDM at their OB appointments

A

Have them do glucose control log - check at every prenatal visit

Maintain fasting glucose < 95, and 2 hr post-prandial < 135

If A1 with continued increase in glucose - start PO agent (metformin, glyburide)

If A2 with continued increase in glucose - switch to insulin

Fasting glucose is most important for fetal and maternal effects

At 32-34 weeks - fetal testing (biophysical profile or twice weekly NST with amniotic fluid index), US for growth

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87
Q

What extra testing to moms with A1 (diet-controlled) GDM need during pregnancy?

A

Have them do glucose control log - check at every prenatal visit

Maintain fasting glucose < 95, and 2 hr post-prandial < 135

US for growth at 36-39 weeks

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88
Q

How is delivery approached differently for moms with A2 GDM?

A

Well-controlled: Delivery at 39 weeks to dec risk of still birth

Poorly controlled - deliver as clinically indicated before 39 weeks

Maintain euglycemia during labor (insulin drip for A2)

May offer cesarean delivery (to avoid birth trauma or shoulder dystocia) if fetal weight >4500 g

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89
Q

Risk Factors for shoulder dystocia

A

Maternal: Obesity, multiparity, GDM, AMA (>35YO)

Fetal: Post-term (>42 wk), macrosomia, male

Intrapartum: Prolonged 1st/2nd stage labor, history of shoulder dystocia

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90
Q

Shoulder dystocia management

A 
HELPERR acronym of maneuvers 
Call for Help
Episiotomy
Legs up (McRoberts maneuver) 
Pressure suprapubically 
Enter vagina for shoulder rotation (Woods screw/rubin_ 
Reach for posterior arm 
Return head to vagina for cesarean (Zavanelli maneuver)
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91
Q

Why is shoulder dystocia an obstetric emergency?

A

Because if infant is not delivered quickly, it may suffer neurologic injury/death from hypoxia

92
Q

What is the turtle sign?

A

In shoulder dystocia the turtle sign is when the fetal head emerges and then retracts against the perineum like a turtle head bobbing out then in

93
Q

Complications of shoulder dystocia?

A

Brachial plexus nerv injuries
Fetal humeral/clavicular fracture
Hypoxia
Death

94
Q

Definition of hyperemesis gravidarum

A

Severe vomiting during pregnancy that results in weight loss, dehydration, and metabolic derangements

95
Q

Workup of hyperemesis gravidarum?

A

It is kind of diagnosis of exclusion - you must rule out other causes of vomiting first - molar pregnancy, thyrotoxicosis, GI etiology

96
Q

Treatment hyperemesis gravidarum

A

Vitamin B6 (pyridoxine) with doxylamine (name brand: Unasom - anti-histamine w/ anti-nausea effects, safe in pregnancy)

IV hydration, thiamine & electrolyte replacement, acid-reducing medications (PPI), antiemetics

97
Q

Antiemetics safe in pregnancy

A

Non-pharmacological changes FIRST - avoid triggers, change diet etc…if not resolved move on to pharmacological options:

First try vitamin B6 (pyridoxine) & doxylamine (Unasom) - if doesn’t work, d/c and try:

Other anti-histamines: Diphenhydramine, meclizine, dimenhydrinate (dramamine)

Not resolved, ADD: Metoclopramide (reglan), promethazine (phenergan), prochlorperazine

Not resolved, add odansteron (Zofran)

98
Q

29-year-old G2P1001 at 16 weeks pregnant presents for prenatal care - blood type is A-negative and she has a positive antibody screen - what is the next best step in management?

A

Identify the antibody type - some are dangerous for fetus and some are benign - remember: “Kell kills, Duffy Dies, Lewis Lives” i.e….

Anti-Lewis antibodes = benign
Anti-Kell antibodies = fatal
Anti-D antibodies = fatal
Anti-Duffy antibodies = fatal

They are fatal because they cause hemolytic disease of the newborn when the mother’s immune system attacks the baby because it has recognized something foreign (an antigen on the fetal RBC he/she got from dad)

Woman needs a type & antibody screen for EVERY pregnancy at FIRST prenatal visit

99
Q

What is the next step if you have found that a mother has a type of antibodies to fetal RBC which are harmful to the fetus?

A

Get an antibody titer - the critical titer is usually 1:16 - the antibody titer level which is associated with significant risk of hemolytic disease of the newborn (HDN)

100
Q

What is hemolytic disease of the newborn and how does it occur?

A

It occurs when the mother is Rh negative and the fetus is Rh positive (father is Rh positive, got Rh factor from there)

If the mother is exposed to the fetal blood she can develop antibodies against the foreign Rh factor on the fetal RBC - the antibodies cross the placenta and attack fetal RBC, causing massive hemolysis = fetal anemia = fetal heart failure & death

101
Q

Name 5+ conditions which cause fetal-maternal bleeding (blood mixing) which can lead to “sensitization” (development of maternal antibodies against fetal RBC)?

A 
Chorionic villus sampling
Amniocentesis
Spontaneous/induced abortion
Threatened/incomplete abortion
Ectopic pregnancies
Placental abruption/bleeding placental previa
Vaginal or cesarean delivery
Abdominal trauma
102
Q

Why does hemolytic disease of the newborn happen more frequently with a woman’s second pregnancy and not during her first if she was sensitized during her first pregnancy?

A

Because during the first pregnancy, the maternal Ab against fetal RBC are just developing and the Ab titer levels remain pretty low (less chance of HDN)

During the second pregnancy, the immune system is already primed and ready to go so if it recognizes the D Rh (D) antigen, plasma cells will recognize it immediately and start pumping out tons of antibodies against fetal RBC = massive fetal hemolysis

103
Q

What is the standard management of a D-negative patient with a negative antibody screen?

A

Antibody screen done at first prenatal visit and 28 wks. If D-negative, RhoGAM given at 28 wks & at time of delivery (if baby is D-positive, test in hospital)

104
Q

During what trimester is the risk of sensitization of the mother’s immune system to Rh (D) antigen the highest?

A

Third trimester

105
Q

What is anti-D IgG and when is its use indicated?

A

Anti-D IgG is an antibody (immunoglobulin) against the Rh factor

It is given to mother’s who are NOT sensitized at 28 weeks and 72 hours prior to delivery IF infant is D-positive (test when in hospital for L&D)

(ie immune system has not formed antibodies against Rh factor yet) so that the Anti-D IgG can bind all of the fetal RBC with Rh factor in maternal circulation and hide it from the mother’s immune system it doesn’t recognized it and make antibodies agains it, thereby preventing the possibility of hemolytic disease of the newborn

It is NOT indicated for patients who already have anti-D antibodies and are sensitized

106
Q

What is the management of a sensitized mother who is D-negative?

A
  1. Screen for antibodies. If positive, find out which type.
  2. If anti-D, order a titer level:
    > 1:16 is critical - do amniocentesis
    < 1:16 is stable - antibody titer Q4 wks
  3. Look at results of amnio:
    Fetal cells analyzed for D-status
    Perform MCA doppler (low flow = anemia)
  4. Serial US monitoring for:
    Scan for fetal hydrops (collection of fluid 2+ areas)
    MCA doppler for presence of severe anemia
    Consider fetal RBC transfusion if very premature
  5. Delivery:
    Mildly anemic - delivery at 37 wks
    Moderately/severely anemic - deliver at 32-34 wks
    Steroids to mom to enhance fetal lung maturity
107
Q

What are braxton - hicks contractions?

A

Irregular, non-rhythmic, usually painless contractions that begin at early gestation and increase as term approaches - may make it difficult to distinguish between true and false labor

108
Q

Preterm labor definition

A

GA <37 weeks w/ regular uterine contractions and progressive cervical change

109
Q

Risk factors for preterm labor

A

(BFTP: Definition = GA <37 weeks w/ regular uterine contractions and progressive cervical change)

Prior hx preterm delivery 
Polyhydramnios
Multiple gestations
Substance abuse 
Systemic infection 
Vaginal Infections 
Placental abruption
History of cervical surgery
110
Q

Management of preterm labor

A

Evaluate for causes (infection, abruption etc)
Confirm GA of fetus via US

Look at cervical length (> 30 mm - low risk, <20 mm high risk) & fetal fibronectin assay (from posterior fornix - if negative, 99% predicability for no preterm delivery within 1 week)

Stay hydrated (dec uterine irritability) 
Administer tocolytics
111
Q

What do tocolytic agents do? When are they used? Name some tocolytics

A

Tocolysis is the pharmacologic inhibition of uterine contractions - do NOT dec neonatal morbidity/mortality but buy you some time (2-7d) to give steroids to mom (if 24-34 wks - for fetal lung maturation) and transfer to hospital with NICU (if < 34 wks gestation)

Agents: Magnesium sulfate, nifedipine, Terbutaline

112
Q

What has the administration of corticosteroids shown do decrease the risk of in the fetus

(Remember given to mothers in preterm labor AKA 24-34 wk GA)

A

It has been shown to decrease incidence of respiratory distress syndrome (RDS) and intraventricular hemorrhage

113
Q

Which drug is given for neuroprotection if the mother is at high risk of imminent preterm (GA 24-34 wks) delivery?

A

Magnesium sulfate (at different dosing regimen than if giving for tocolysis)

4gm bolus followed by 1g/hr maintenance

114
Q

What is the most common diagnosis associated with preterm labor?

A

Preterm premature rupture of membranes (PPROM)

115
Q

What is PROM?

A

PROM = premature rupture of membranes AKA rupture of membranes BEFORE the onset of labor

116
Q

What is PPROM?

A

PPROM is preterm (<37 wks) premature rupture of membranes

117
Q

What is prolonged rupture of membranes?

A

ROM > 18 hours

118
Q

What is the etiology of PROM?

A

Vaginal and cervical infections
Incompetent cervix
Nutritional deficiencies

119
Q

What is the most concerning complication(s) of PROM?

A

CHORIOAMNIONITIS!!!
(Infection of the fetal membranes: amnion and chorion)

Premature delivery & associated complications

Placental abruption

120
Q

What is oligohydramnios?

A 
Oligo = few/scanty 
Amnio = fetal membrane 
Hydro = fluid

Therefore oligohydramnios is deficiency of amniotic fluid, which is the opposite of polyhydramnios

121
Q

Management of PROM

A

AVOID VAGINAL EXAMS - they inc risk of chorioamnionitis

Evaluate pt for chorioamnionitis - Fever, WBC count, maternal or fetal tachycardia, uterine tenderness, malodorous vaginal discharge

IF chorioamnionitis - delivery is performed regardless of GA, and broad-spectrum ab are initiated (ampicillin w/ gentamycin)

122
Q

An 18-year old G1P0 at 30 wks gestation presents to triage with complaints of clear amniotic fluid leaking from her vagina - exam positive for pooling, ferning, and nitrazine - cervix is closed on speculum exam. US shows a breech singleton fetus - what is best next step in management?

A

This patient has PPROM and therefore should be admitted to the hospital for steroids (< 34 weeks = dec risk fetal RDS), and given ABX to increase latency period

123
Q

Workup of third trimester bleeding…

A

Get good history (how much blood, ABD trauma?)

Get VITALS - hypotensive, tachycardic? ==> hypovolemic!

Labs: CBC (H/H), Type & Screen, Coags, UA, drug screen

Imaging: Ultrasound to look for placenta previa & to monitor fetal well-being

Use “Apt” test to determine if it is fetal blood or maternal blood –> maternal turns brown, fetal turns pink

124
Q

Ddx third trimester bleeding

A 
Placental abruption 
Placenta previa 
Uterine rupture
Vasa previa/velamentous insertion 
Circumvillate placenta
Extrusion of cervical mucus ("blood show") 
DIC

Cervicitis
Neoplasm

125
Q

What lab value abnormalities would support the diagnosis of DIC in third trimester bleeding?

A

Low platelets
HIGH D-DIMER
Prolonged PT and/or PTT

126
Q

What is the most common cause(s) of third trimester bleeding?

A

Placenta previa

Placental abruption

127
Q

Pregnant woman + Pain + vaginal bleeding = what until proven otherwise?

A

Placental abruption

128
Q

What is placental abruption?

A

Premature separation of the placenta from the uterine wall before delivery of the baby

129
Q

What is vasa previa?

A

Vasa previa is a condition in which fetal blood vessels cross or run near the internal opening of the uterus. These vessels are at risk of rupture when the supporting membranes rupture, as they are unsupported by the umbilical cord or placental tissue.

Risk factors include in vitro fertilization

Think placenta previa is when placenta is over uterine opening, vasa (vein) previa = vessels over uterine opening

130
Q

Whose blood is lost with a ruptured vasa previa?

A

The fetal-placental blood circulation&raquo_space;> maternal blood

131
Q

RF for placental abruption

A 
Trauma (MVA, domestic violence) 
Previous history of abruption 
Preeclampsia, chronic HTN
Substance abuse (cocaine, cigarettes) 
High # parity
132
Q

Diagnosis of placental abruption

A

Via ultrasound will see retroplacental hematoma - supports the diagnosis but not always seen so clinical findings are most important

133
Q

Management of pregnant woman (35 weeks) w/ DIC?

A

Transfuse blood products (PRBCs, platelets, FFP) & expedite a VAGINAL delivery - want to AVOID c-section (major surgery) in setting of DIC

134
Q

CP Placental abruption

A

Vaginal bleeding (minimal to life-threatening)
Constant, severe abd pain
Irritable, tender, hypertonic uterus
Evidence of fetal distress (if severe)
Maternal shock
Disseminated intravascular coagulation (DIC)

135
Q

What percentage of placental abruptions present without vaginal bleeding because the bleeding is concealed?

A

20%!

136
Q

Management of placental abruption

A

Correct shock (IV fluids, pRBC, FFP, CPP, plt)

Maternal oxygen

Expectant management (close obs w/ ability to deliver immediately if necessary)

If fetal distress –> C-section. If not, can try vaginal.

137
Q

What is placental previa? Etiology?

A

Condition in which placenta is implanted in the immediate vicinity of the cervical os

Etiology: Unknown, but a/w IVF PREGNANCIES!!! mulitparity, AMA, previous abortions, previous hx placenta previa, previous c-section

138
Q

Clinical presentation placenta previa

A

PAINLESS bleeding in 2nd-3rd trimester

If pt has not had a 2nd trimester US, DO NOT PERFORM DIGITAL VAGINAL EXAM UNTIL US SHOWS PLACENTAL LOCATION

PAINFUL bleeding = placental abruption
PAINLESS bleeding = placenta previa

139
Q

Diagnosis of placenta previa

A

Transabdominal US (95% accurate). Transvaginal helps further define location if needed.

MRI - good modality to diagnose but costly & limited availability - therefore most useful when placenta accrete is suspected (can see level of tissue invasion of the placenta)

140
Q

US reveals anterior placenta previa in patient with two prior cesarean deliveries - what are you suspicious of?

A

Placenta accreta

141
Q

Which two fetal conditions cause third trimester vaginal bleeding?

A

Vasa previa
When fetal blood vessels cross or run near the internal opening of the uterus. These vessels are at risk of rupture when the supporting membranes rupture, as they are unsupported by the umbilical cord or placental tissue.

Velamentous cord insertion
(fetal vessels insert in the membranes and travel unprotected to the placenta, with no protection from wharton’s helly. THis leaves them susceptible to tearing when the amniotic sac ruptures (Incidence: 1% of singleton’s, 10% of twins)

142
Q

Clinical presentation of vasa previa or velamentous cord insertion

A

Vaginal bleeding WITH fetal distress

143
Q

Management of vasa previa rupture or velamentous cord insertion rupture?

A

Correction of shock and immediate delivery (usually via cesarean section)

144
Q

When is trial of labor after cesarean section (TOLAC) contraindicated?

A

With hx of prior classical cesarean or if pt has classical uterine scar, TOLAC is CONTRAINDICATED

145
Q

What is uterine rupture and what are some risk factors?

A

Disruption of the uterine musculature through all of its layers, usually with part of the fetus protruding through the opening

Risk factors: Prior uterine scar from cesarean delivery = MOST IMPORTANT RISK FACTOR 2/2 scarring of the active, contractile portion of the uterus

Low transverse scar < 1% risk
Can occur in setting of trauma

146
Q

CP uterine rupture

A

Non-reassuring FHT or bradycardia = the MOST suggestive finding of uterine rupture

Sudden cessation of uterine contractions

“Tearing” sensation in the abdomen

Vaginal bleeding

Presenting fetal part moves higher in pelvis

Maternal hypovolemia from concealed hemorrhage

147
Q

Management uterine rupture

A

Immediate laparotomy and delivery

May require a cesarean hysterectomy if uterus cannot be reconstructed

148
Q

What is the “bloody show” and is it dangerous?

A

The “bloody show” is the small amount of bleeding mixed with cervical mucus which often occurs at the onset of labor - it is not dangerous - it is from tearing of a few small vessels as consequence of effacement and dilation of the cervix

149
Q

Complications of uterine rupture

A

Maternal: Hemorrhage, hysterectomy, death
Fetal: Permanent neurologic impairment, cerebral palsy, death

150
Q

Most common cause of postpartum hemorrhage

A

Uterine atony (no tone in uterus after birth - usually contracts & is hard to close off blood vessels & prevent bleeding)

151
Q

Definition of early postpartum hemorrhage

A

During first 24 hours is “early” PPH, past 24 hours to 6 weeks is “late” PPH

Hemorrhage = Excessive bleeding that makes pt symptomatic and/or results in signs of hypovolemia

OR Blood loss > 500 mL in vaginal delivery, >1,000 mL for cesarean delivery

152
Q

Etiology of postpartum hemorrhage

A 
CARPIT 
Coagulation defect
Atony of uterus
Rupture of uterus 
Placenta retained 
Implatation site bleeding
Trauma to genitourinary tract 
OR - the 4 T's of PPH: 
Tissue: Retained placenta 
Trauma: Instrumentation, laceration, episiotomy
Tone: Uterine atony 
Thrombin: Coagulation defects, DIC

Cause of PPH should be sought out immediately

153
Q

Management of PPH

A

Compress & massage the uterus, check for retained placental parts & that uterus is intact (no rupture)

If uterus feels BOGGY and not hard, suspect uterine atony as the etiology of PPH (MCC of PPH) - give dilute oxytocin (= uterine contraction)

Uterine artery ligation, hysterectomy if still bleeding

Standard hypovolemia care: Large bore IV x2, isotonic crystalloids, type & cross, vitals, in & outs

Consider coagulopathy if perrsistent bleeding with above management - uterine packing until FFP and CCP are available - AVOID hysterectomy if coagulopathy (further surgery)

154
Q

Placental attachment disorders:

Placenta acretta vs increta vs percreta

A

Placenta….

Accreta = attaches to myometrium 
Increta = invades into myometrium 
Percreta = penetrates though myometrium
155
Q

Etiology of placental acreta, increta, percreta

A

Placental acreta, increta, percreta are associated with:

Placenta previa
Previous cesarean delivery (inc #, inc risk)
Previous D&C
Grand multiparity (>5 parity)

All of which are associated with hemorrhage in third stage of labor - treatment of choice is hysterectomy

156
Q

Uterine inversion

A

Medical emergency

Etiology: Occurs 2/2 excessive cord traction during placental delivery or abnormal placental implantation - morbidity results from shock and sepsis

Incidence: 1/2200 births

Management: Call for help, administer anesthesia, large-bore IV, Don’t remove placenta until uterus replaced, stop uterotonic medications, give uterine relaxants, try to replace inverted uterus by pushing on the fundus toward the vagina, oxytocin after uterus is restored and anesthesia is stopped

157
Q

Antepartum: Indications for genetic testing

A

Indications
AMA
Pervious child with abnormal karyotype
Known parental chromosome abnormality
Fetal structural abnormality on sonogram
Unexplained intrauterine growth retardation (IUGR)
Abnormal quad screening

Techniques:
FISH, karyotyping

158
Q

What is the targeted weight gain for a woman during her pregnancy? What is the most important dietary supplement she should be taking & why?

A

25-35 lbs
< 15 lb weight gain can cause IUGR
> 40 lb weight gain = inc morbidity

FOLIC ACID!!! –> Prevents neural tube defects - neural tube formed by time of missed period -therefore MUST start supplementing WAY BEFORE that

159
Q

Risk factors for IUGR

A 
Poor nutrition
Substance use - tobacco, drugs, alcohol
Thrombophilia
Preeclampsia 
Chromosomal abnormalities 
Placental infarction/hematoma
Infections
Multiple gestations
160
Q

What dietary supplement is recommended in the second and third trimester?

A

Iron!

Many women develop iron-deficiency anemia during preg due to increased hematopoietic demands of mother and baby

Vegans need to additionally supplement vitamin B12, iron & zinc

161
Q

Why must women limit caffeine intake to 1 cup/day?

A

> 300 mg/day caffeine may increase the risk of spontaneous abortion - risk increases proportionally w/ amount of caffeine ingested

162
Q

In general, no data exists to support that a pregnant woman must decrease the intensity of her exercise or lower her target heart rate - BUT certain scenarios exercise can be dangerous - name three scenarios in which exercise is contraindicated

A 
Evidence of IUGR
Persisten vaginal bleeding
Incompetent cervix 
Risk factors for preterm labor
Rupture of membranes 
Pregnancy-induced HTN, preeclampsia/eclampsia
163
Q

34 wk pregnant woman comes in complaining of leg cramps - management?

A

Leg cramps occur in 50% of pregnant women, especially in T3 - management is stretching the affected muscle groups and massage

164
Q

When is the safest time to travel in pregnancy?

A

T2 - past possible miscarriage complications in T1 and not yet encountered risk of preterm labor of T3

Must attempt to stretch lower extremities and stretch for 10 min every 2 hours to avoid DVTs

No air travel after 35 weeks

If traveling abroad, use usual precautions regarding ingestion of un-purified water and raw foods - appropriate vaccines should be given

165
Q

Which vaccines should be avoided in pregnancy?

A

Any LIVE vaccines - MMR, varicella, oral polio, intranasal influenza

Try not to get pregnant for 4 weeks after getting these vaccines too

Flu vaccine (NOT live nasal mist) is safe at ANY time because benefits outweigh the risks

166
Q

Are immunoglobulins safe in pregnancy? If so when/why are they given?

A

Immunoglobulins are safe in pregnancy and recommended for women exposed to measles, hepatitis A and B, tetanus, varicella, and rabies

167
Q

Risk factors for uterine atony

A

RF FOR ATONY = ATOMY

Anesthesia, amnionitis 
Twins or prolonged pregnancy
Overly long/difficult labor 
Macrosomia, multiparity 
Polyhydramnios

Just think everything too big/too much/lots = uterus cannot contract like it’s supposed to - it was stretched too much by big baby, twins, too much fluid, being stretched out too much before (multiparity), gets tired b/c of long labor & can’t contract etc

168
Q

First stage of labor - beginning to end

A

Begins with onset of uterine contractions of sufficient frequency, intensity, and duration = effacement and dilation of cervix

Ends with cervix is completely dilated to 10 cm

169
Q

What are the two phases of the first stage of labor?

A
  1. Latent phase: begins with onset of labor and ends at 4-6 cm dilation –> Considered prolonged if nulliparous > 20 hrs, multiparous >14 hours
  2. Active phase: rapid dilation - begins at 4-6 cm dilation and ends at 10 cm - classified according to rate of cervical dilation - acceleration phase, phase of maximum slope, deceleration phase
170
Q

When does fetal descent begin?

A

During first stage of labor when cervix is at 7-8cm dilation in nulliparious & becomes more rapid after 8 cm

171
Q

What is the minimal average duration of cervical dilation from 4-10 cm

A

Minimal normal rate of cervical dilation from 4 to 10 cm (active phase of first stage):

  1. 2 cm/hr nulliparous
  2. 5 cm /hr multiparous

If progress during the active phase of first stage is slower than these figures, evaluation for adequacy of uterine contractions, fetal malposition or cephalopelvis disproportion should be done

172
Q

What is the second stage of labor?

A

Fetal expulsion - begins when cervix is fully dilated & ends with the delivery of the fetus

Average time - nulliparous < 2 hrs (3 w/ epidural), multiparous < 1 hours (2 w/ epidural)

173
Q

What is the third stage of labor?

A

Placental separation

Begins immediately after the delivery of the fetus & ends with the delivery of fetal & placental membranes

**Usually < 10 min. If 30 min have passed without placental delivery, manual removal of the placenta may be required

174
Q

What are the three signs of placental separation?

A
  1. Gush of blood from vagina
  2. Umbilical cord lengthening
  3. Fundus of the uterus rises up & becomes firm
175
Q

When does the ROM usually occur spontaneously?

A

It usually occurs in the active phase (cervix >4-6 cm) of first stage of labor

176
Q

How to assess for ROM?

A

+ Pooling in posterior fornix
+ Valsalva = fluid out of os w/ valsalva
+ Ferning = fern pattern on slide (false + w/ blood, semen, trichomonas infection)
+ Nitrazine = Paper turns blue = basic pH of amniotic fluid

Presence of these factors means membranes are probably ruptured & that the fluid noted on exam is probably amniotic fluid

177
Q

Cervical Exam: Dilation - what is it?

A

Describes the size of the opening of the cervix at the external os

178
Q

Cervical Exam: Effacement - what is it?

A

Describes the length of the cervix - usually 3-4 cm- but… with labor the cervix thins out & length is reduced

The cervix is said to be 50% effaced when it’s length has shortened by 50% ( ~2 cm)

When it becomes as thin as the adjacent lower uterine segment, it is 100% effaced

179
Q

Cervical Exam: Station - what is it?

A

Describes the degree of descent of the presenting part in relation to the ischial spines, which are designated at “zero” station

Ranges from -3 to +3. Positive stations describe fetal descent below the ischial spine. Each point on the scale represents 1 cm.

180
Q

Cervical Exam: Consistency

A

Goes from: Firm –> medium –> soft during labor, in preparation for dilation and labor

181
Q

Cervical Exam: Position

A

Describes the location of the cervix with respect to the fetal presenting part - it is classified as:

Posterior - difficult to palpate because it is behind the presenting part, and usually high in the pelvis
Midposition
Anterior - easy to palpate, low in pelvis

During labor, cervical position progresses from posterior to anterior

182
Q

What agent is used for cervical ripening?

A

Vaginal prostaglandins

183
Q

What drug is used to increase strength and frequency of contractions?

A

IV Pitocin

184
Q

Fetal presentation

A

Describes the presenting part of the fetus:

Vertex is head first (posterior fontanelle)
Brow is eyebrows present first
Face is face first - fetal neck sharply extended
Breech is butt first

185
Q

What to do with breech presentation

A

If at 31 weeks (not in labor) recheck at 36 weeks & then attempt external cephalic version if persistently breech . < 34 weeks, malpresentation is common (up to 15%) & not significant - most will spontaneously convert to vertex as term approaches

If at term, most frequent management is to do cesarean section - can try to deliver vaginally if other factors favorable and it is a frank breech (complete/incomplete NOT delivered vaginally!!! = HIGH RISK UMBILICAL CORD PROLAPSE)

186
Q

Risk factors for breech presentation

A

In general think things that make the baby small -

Low birth weight (30% of breeches)
Congenital anomalies (hydrocephalus, anencephaly)
Preterm pregnancy
Multiple gestation

Oligohydramnios, hydramnios
Placenta previa

187
Q

Types of breech presentations

A

Complete - criss crossed legs, knees bent
Incomplete - one leg up, one leg down
Frank - both legs up & extended fully, flexed at hips

NOTE: Complete and incomplete breeches NOT DELIVERED VAGINALLY - HIGH RISK OF UMBILICAL CORD PROLAPSE

188
Q

Cardinal movements of labor

A

Engagement - fetal head thru plane of pelvic inlet (-2)

Descent - fetal head down into pelvis (0)

Flexion - chin to chest of fetus

Internal rotation - turning of fetal head towards pubic symphysis

Extension - after fetal head is at maternal vulva, fetal head extends fully to deliver the rest of the head

Restitution (External rotation) - - fetus turns face forward so that occiput is in line with the spine

Expulsion - delivery of anterior shoulder, then the rest of the fetus

189
Q

Describe different degrees of perineal lacerations

A

First degree: Perineal skin & vaginal mucosa torn, muscle & underlying fascia intact

Second degree: First degree + fascia & muscle of perineal body but NOT the anal sphincter

Third degree: Second degree + involvement of anal sphincter

Fourth degree: Extends thru rectal mucosa to expose the lumen of the rectum

NOTE: Proper repair/closure of 3rd/4th degree is essential to prevent future fecal incontinence and rectovaginal fistula

190
Q

Types of episiotomies & benefits/risk of each

A

NOT standardly performed anymore - in special cases only like shoulder dystocia

Types = midline vs mediolateral

Midline: Most common. Inc risk 4th deg lac
Mediolateral: Causes more bleeding/pain

191
Q

Monitoring during labor

A

Uterine contractions - external vs internal monitors

Fetal heart rate -

192
Q

MCC maternal mortality in western world

A

PPH

193
Q

What is considered a “reactive” fetal heart tracing?

A

15 bpm above the baseline lasting 15 seconds
Need two of these in 20 minutes = indicates well-oxygenated fetus with intact neurological & cardiovascular system

Normal rate: 110-150

194
Q

What are early decelerations and what causes them?

A

Early decels are decelerations in FHR that occur WITH the uterine contraction

They are due to head compression - they are clinically benign and no intervention is necessary

195
Q

What are late decelerations and what causes them?

A

FHR decelerations which occur AFTER the uterine contraction has ended - due to UTEROPLACENTAL INSUFFICIENCY (not enough OXYGEN) - can follow epidural (hypotension) or uterine hyperstimulation

Management: O2, lateral decubitus position, pitocin off, close monitoring

196
Q

Variability of FHR - absent vs mild vs moderate vs marked

What causes decrease in beat to beat variability?

A

Beat to beat FHR variability (BTBV) is the single most important characteristic of the baseline FHR

Absent - amplitude undetectable
Minimal - amplitude 0-5 beats
Moderate = amplitude 6-25 beats
Marked = amplitude > 25 beats

BTBV decreases with: 
Fetal acidemia
Fetal asphyxia 
Maternal acidemia
Drugs (Narcotics, MgSO4, barbiturates) 
Acquired or congenital neurologic abnormality
197
Q

What do you do if you note an abnormal labor pattern?

A

Assess the three P’s:

Power (contractions - adequate?)
Passenger (fetal size & position good for vaginal delivery?)
Pelvis (adequate for normal vaginal delivery?)

198
Q

What does NO beat to beat variability on FH monitoring mean?

A

It means fetal acidosis & the fetus MUST be delivered immediately

199
Q

Episiotomy care

A

Ice pack for first several hours (dec edema/pain)
At 24 hours, moist heat (sitz bath)
Typically well-healed by week 3

200
Q

APGAR components

A

Activity (muscle tone)
Pulse (absent, <100, >100)
Grimace (reflex irritability)
Appearance (skin color - blue, pink body blue ext, pink)
Respirations (absent, slow, vigorous cry)

201
Q

CP & Management Endometritis

A

CP: Fever, fundal tenderness, and foul-smelling lochia - MC 2-3 days postpartum
Management: Broad spectrum abx

202
Q

Risk factors for endometritis

A 
Cesarean delivery 
GBS colonization (leads to 80% greater likelihood) 
Prolonged ROM (>18 hours) 
Prolonged labor 
DIabetes
Multiple cervical exams
Manual extraction of placenta
Chorioamnionitis
Internal monitoring
203
Q

Spontaneous abortion - def, etiology, RF

A

Pregnancy loss < 20 wks gestation. Most are in first trimester due to chromosomal abnormalities. Types of spontaneous abortion include threatened, inevitable, incomplete, complete, missed, septic & recurrent (see other cards to follow)

Etiology:

  1. Chromosomal abnormalities (aneuploidy, triploidy etc)
  2. Unknown
  3. Infections (think STDs)
  4. Anatomic defects (uterine, cervical incompetence, leiomyomas (fibroids), intrauterine adhesions etc)
  5. Endocrine factors (progesterone deficiency, PCOS, uncontrolled diabetes)

RF: AMA, smoking, prior hx spontaneous abortion

204
Q

Threatened abortion

A

Uterine bleeding from a gestation that is <20 wks w/o cervical dilation or passage of tissue

Exam: CLOSED cervical os WITHOUT products of conception or amniotic fluid in endocervical canal

Management: Observation, pelvic rest

205
Q

Inevitable abortion

A

Vaginal bleeding, cramps, and CERVICAL dilation at < 20 weeks conception WITHOUT products of conception

Management: D&C or misoprostol (prostaglandin E1)

206
Q

Incomplete abortion

A

Pass age of some, but not all, products of conception from uterus before 20 wks gestation. Inc risk of ongoing bleeding requiring a blood transfusion and inc risk ascending infection.

Dx: Cramping &Bleeding, enlarged boggy uterus w/ DILATED internal cervical os - POC present in endocervical canal or vagina, w/ POC retained in the uterus seen on US.

Management: Assess HD stability & stabilize
Suction D&C to remove POC from uterus or medical evacuation with misoprostol - ONLY IF STABLE. Karyotype POC if recurrent abortion.

207
Q

Complete abortion

A

Complete passage of POC - cervical os re-closes after the abortion is complete.

Pain has ceased, uterus well-contracted, cervical os may be closed, US shows empty uterus

Management: Observe patient

208
Q

Missed abortion

A

Missed abortion is fetal demise before 20 wks of gestation without expulsion of any POC

The pregnant uterus fails to grow and sx of preg disappear. Intermittent vaginal bleeding/spotting/brown discharge & a closed cervix

B-hcg quant may decline, plateau, or continue to inc

Managemet: Most will spontaneously deliver w/in 2 wks, Risk of incomplete or septic abortion may require a suction D&C. Misoprostol if want medical evacuation of the uterus.

209
Q

Septic abortion

A

More likely with induced abortions
Polymicrobial infection
Can spread from endometrium to peritoneum
Septic shock may occur, esp if all POC are not removed

210
Q

Ddx T1 bleeding

A

Spontaneous abortion
Ectopic pregnancy
Molar pregnancy
Vaginal/cervical lesions/lacerations

211
Q

Ddx T3 bleeding

A

Uterine rupture
Rupture of vasa previa
Placental abruption
Placenta previa

212
Q

Pharmacologic agents for pregnancy termination - T1 vs T2

A

Mifepristone and misoprostol used in T1
Prostaglandins used in T2

Remember M before P in alphabet

Note: Complications for T2 abortions are 4x higher than T1 abortions

213
Q

Surgical methods of pregnancy termination

A

May be used in T1 or T2

Dilation & evacuation - Evacuation is via curettage in T1, (D&C) via other instruments in T2

D&E is the SAFEST form of pregnancy termination in T2 (better than prostaglandins) b/c has decreased maternal mortality compared to PGE induction

Note: Complications for T2 abortions are 4x higher than T1 abortions

214
Q

What form of prostaglandin is contraindicated for pregnancy termination in specific subset of pt with lung disease?

A

PGF2a is contraindicated in asthmatics because it induces smooth muscle contraction

215
Q

MC site of ectopic pregnancy

A

Fallopian tubes (97%) w/ AMPULLA of tubes being mc site inside the tubes

216
Q

Ectopic pregnancy more common in younger women or older women?

A

4x more common in women > 35 YO compared to 15-24 YO group

Note: Ectopic preg is the LEADING cause of pregnancy-related death

217
Q

RF ectopic pregnancy

A 
Prior ectopic pregnancy = #1 RISK FACTOR
PID, STIs
Current IUD use
Septate uterus 
Current smoking
Tubal scarring form prior surgery (sterilization)
DES exposure
218
Q

PE Ectopic

A

Vaginal bleeding
Pelvic pain
Adnexal mass
Si rupture ectopic: Hypotension, tachy, rebound, guarding

219
Q

Ddx ectopic pregnancy

A 
Ovarian torsion
Threatened abortion 
PID
Acute appendicitis
Ruptured ovarian cyst
Tubo-ovarian abscess
Degenerating uterine leiomyoma (fibroid)
220
Q

Dx studies ectopic pregnancy

A

Transvaginal ultrasound = imaging modality of choice for diagnosing ectopic pregnancies

221
Q

Do b-hcg levels correlate with the size of the ectopic pregnancy/potential for rupture?

A

NO

B-hcg also doesn’t correlate with the location of hte ectopic or the GA of the ectopic

222
Q

Management of ectopic pregnancy

A 
Assess hemodynamic stability of pt
Assess if ectopic is ruptured or not
Medical management = methotrexate - for early ectopic
Surgical - if stable - Laparotomy
Surgical - if unstable - Laparoscopy
223
Q

Chadwick’s Sign

A

Bluish discoloration of vagina and cervix during pregnancy

224
Q

Goodell’s Sign

A

Softening and cyanosis of hte cervix at or after 4 weeks

225
Q

During what gestational age is placental abruption most likely to occur?

A

24-28 weeks GA

*PANCE by subspecialty (22 decks)

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