Obstetrics Flashcards
pts OBGYN hx is written how
G# Ptpal
term
premature
abortions (before 20 wks)
living
how often do you check pregnant moms
q 4 weeks undtil 32 weeks
then 2 weeks
then 36 q week
what dx should be done at every check
UA for glucosuria, ketonuria and proteinuria
when should you start doing vaginal exams in OB
at 36 weeks
when would you check fundal height and when FHR
20 wks and 10 wks
fetal HR should be
120-160
can measure from 9-12 weeks onward
common complaints of pregnancy inculde
bleeding gums
prfuse salivation
fatigue
also
variscosities
heartburn
hemorrhoids
first trimester screening includes
PAPPA and free BHCG
ULS for establishing and confirming EDC
What findings in a first trimester screen would indicate potential genetic disorder
low PAPPA and high free HCG
would suggest trisomy 21
dark patched on face associated with pregnancy are known as
malasma or cholasma
when can you do NT
10-13 weeks
screens for trisomies 13,18, adn 21 as well as for Turner
if positive NT then
amnio or CVS
what is the likelihood of detecting trisomy 21 with early screenign
NT plus PAPPA and B hcg can detect 82-87%
first prenatal visit need to order
HIV offered cystic fibrosis, sickle cell
coomb’s for irregualr aB screen
UA BRATS PAP hep B rubella a CBC type and screen syphilis
if that brat is dirty get a Chlamydia and Gonorrhea
in the first trimester you can do these tests
PAPPA Free beta HCG ULS NT CVS
when exactly can you do a CVS
10-13
what tests can you do in second trimester
unconjigated estriol maternal serum AFP inhibin A ULS Amnio
Endometritis classically occurs ___ and is characterized by
2-3 days post-partum and is characterized by fever, foul-smelling lochia, abdominal and pelvic pain, abnormal vaginal bleeding, uterine tenderness and leukocytosis.
management of suspected endometritis
This is an acute bacterial infection of the endometrium commonly caused by Group B strep, S. aureus, E. coli and E. faecalis. The patient should have an ultrasound to rule out retained products of conception. She should be started on intravenous broad-spectrum antibiotics and admitted to the hospital.
risk factors for endometritis include
1 is a c section
PRIM>24 hours
stage 2 of labor >12 hours
increase in internal exams
when can you do a amnio
15-18 weeks
what tests can you do in the thrid trimester
DM gestation 24-28
In unsensitized Rh repeat Ab titers at 28 weeks
GBS 35
Hgb and Hct 35 weeks
NST
BPP
When do you get the results form a CVS
48 hours after
can not detec NT defects through AFP
risk of spontainious abortion is the same as amnio when adjusted for earlier gestational age
trisomy 21 would yield these results in 2nd trimester screen
low unconjugated ertiol
AFP LOW
inhibin A high
NT defects would yield these resutls in second trimester screen
abnormally high AFP
spina bifida and ancephaly
Combining first trimester screen with second trimester screen gets you this % of accuracy for trisomy 21
94-96%
indication for amnio or CVS in clude
> 35
previous child with abnormality
family history of chromosomal abnormality
NT defect risk (Amnio only)
abnormal first trimester or second trimester serum screening
two previous pregnancy losses
abnormal uLS
What is a normal NST
acceleration ins 20 minutes of 15 bpm from baseline heart rate for a duration of 25 seconds and the absence of decelerations
what is the definition of a deceleration
decline in fetal heart rate of 15 bpm or lasting more than 15 second or a slow return to baseline
persistent late deceleration
begin AFTER the peak of the contraction are NONreassuring and warrant intervention
permateres of BPP
gross movement breathing fetal tone amniotic fluid level NST
B- TANG
each parameter contains 2 points with a total of ten and the risk of asphyxia
teenage preganncies have a higher risk of
premature delivery and low fetal birth weight (poor nutritional intake)
the most common MATERNAL complication of multiple gestation are
spontaneous abortion and preterm birth
other problems that occur with greater frequency are preeclampsia and anemia
the most common fetal complications of mutliple gestations are
IUGR cor accidents death of own twin congenital anomalies abnormal or breech presentation placental abruption or placental previa
the most common cause of ectopic pregnancy is
occlusion of the tube secondary to adhesions
most common risk factors for ectopic pregnancy are
previous PID previous abd surgery use of IUD assisted reproduction
most common signs and symptoms of ectopic in order
pain abnormal menstruation tachycardia hypotension pelvic mass dizziness or syncrope shock GI symptoms
Sxs of ruptured ectopic
abdominal or shoulder pain associated with peritonitis
tachycardia
syncope
orthostatic hypotension
hcg in exctopic
less than expected
diagnoses for ectopic
transvaginal ULS dx in 90% of cases
should have IUP ive >1500 hcg
Treatment for ectopic
folic acid analog like methotrexate can be used for treatment in 80% of cases
critera
<3.5 cm bhcg<5000 thrombocytes > 100,000 hemodynamically stable no blood disorders no pulmonary damage no peptic ulcer disease normal renal function normal hepatic function compliant patient and able to return for follow up
surgical treatment for ectopic
involves laparoscopy
laprotomy is reserved for pts with known abdominal adhesions or those that are clinically unstable
factors that increase risk of abortion include
smoking infection maternal systemic disease immunological parameters drug use
diagnsotic studies for spontaious abortion
serial HCG
serum progesterone
serial ultrasonohrapy
high blood pressure during the first 20 weeks of pregancny could be a sign of
mole
dilation and curratage procedure morbidity
uterine perforation or cervical laceration
grape like or snow storm refers to complete or incomplete mole
complete 20% progress to malignancy .
what is a partial hydratiform
fetus present
non viable
rarely progress to malignancy
when would beata hcg indicate a gestational trophoblastic tumor
> 100,000
treatment of hydratiform mole
benign tumors can be treated with chemo
metastatic or high risk tumors can be treated with chemo and radiation and surgery
after evacuation must monito hcg and use contraception for 6 mo to a year
treatment for mole
if don’t desire fertility hysterectomy
if do than curretage
what percentage of pts with gestational diabetes go on to develop DM
50% of those that need insulin therapy will develop DM within five years
reoccurrence of GDM is common in 60-90 % of subsequent pregnancies
what are MATERNAL complications are associated with GDM
preeclampsia
hyperacceleration of general diabetic complications
traumatic birth
should dystocia
what are the fetal complications of GDM
marcosomia
prematurity
fetal demise
delayed fetal lung maturity
clincial features of GDM
patients are usually asymptomatic
RF include previous GDM large for gestation infant obestiy age older than 25 family hx of DM AA Asian Hispanic American indian
diagnostic studies for GDM
obtain random glucose on all pregnant women during the first week of pregnancy to check for preexisting DM
then 24-28 do glucose screening
A1c is NOT recommended for screening
screening for GDM
24-28 weeks administer 50 g of glucose challenege test followed by serum glucose level 1 hour later
if the 1 hour serum glucose value is >130 THEN NEED 3 HOUR
What is the 3 hour glucose test
if 1 hour is over 130 need it
give 100 g glucose load in the morning after an overnight fast serum glucose levels are taken at fasting and then 1, 2, and 3 hours after the glucose load
fasting /<95
1 hour<180
2 hour<155
4 hour <140
what is the management of GDM
careful management of diet and exercise
need to check blood sugars daily after fasting overnight and after each meal
need to review fbg
When would a mom with GDM require insulin
FBG >105 or
2 hour PP> 120
when should you screen women for post partum diabetes if they have GDM
at 6 weeks postpartum visit and at yearly intervals after
labor management of pt with GDM
if glucose is in control and no signs of macrosomia then induction at 40 weeks
if glucose is poorly controlled and there are signs of macrosomia then induction will occur at 38 weeks gestation
to helo avoid GDM moms can
mainatin ideal body weight
preterm labor and delivery is defined as
infant before 37 weeks
MCC of neonatal deaths is
preterm
those that do survive have significant developmental delays
cerebral palsy
and lung disease
RF for preterm labor
smoking cocaine uterine malformations cervical incompetence infection (vaginal group B strep or urinary infection) and low prepregnancy weight
clincial features of preterm labor include
> 4 uterine contractions between 20-36 weeks of gestation and the presence of one or more of the following
cervical dilation >2cm at presentation
cervical dilation of 1 cm or greater on serial examinations cervical effacement at 80%
late symptoms of preterm labor
painless contractions pressure menstrual like cramps watery or bloody discharge low back pain
diagnsotic studies for preterm labor
ultrasonography can be used to exam the lenght of the cervix
normal length is 4 cm
what cervical length increases the risk of a premature delivery
2cm or less at 24 weeks
how do you evaluate cervicovaginal secretions for possible premature delivery
fetal fibronectin
(glycoprotein)
absence means low risk of dilvery in the next 2 weeks
management of premature delivery
IV
anbx for subclincal infection
steroids for fetal lung maturity
tocolytics if indicated
what tocolytics are used
Mag sulfate inhibits myometrial contractions mediated by Ca
side effects of CCB as tocolytics
maternal hypotension and tachycardia
why are beta mimetic adrenergic agents infrequently used and what are they
beta mimetic adrenergic agents are used as tocolytics they include
terbutaline
they are infrequently used because of the potentially ftal maternal heart complications
How do CCB work as tocolytics
they inhibit smooth muscle contraction by decreasing calcium ions intracellularly
—> relaxes uterine muscle
side effects of CCB as tocolytics
maternal hypotension and tachycardia
prevention of preterm labor
for those women with a history of preterm delivery weekly injections of 17 alpha hydroxyprogesterone from 16-36weeks gestation can sometimes reduce the rate of reoccurrent preterm birth
PROM
rupture of the amniotic membrane before the onset of labor or beyond 37 weeks gestation and it occurs approximately 8% of all pregnancies
most women (90%) will go into spontanious labor afterwords
Major risk with PPROM and PROM
infection (chorioamnionitis and endometritis
cord prolapse can also occur with ruptured membranes if the head is not well engaged
when is a digital exam permissible with PPROM
if delivery is imminent
what is the management of PROM
the patietn should be hospitalized and monitored for expectant management
labor induced if it does not occur withhin 18 hours of rupture
management of PPROM
20-36 weeks
if there is no sign of distress pt should be admitted to the hospital for bed rest
when should steroids be administered for a patient in PPROM
before 34 weeks
use of antibiotics in PPROM
have been administered to prevent infection and help prolong pregnancy because thye have been shown to reducinfant mortality
what tests should be done while mom is hospitalized wtih PPROM
NST
BPP
both should be monitored daily
amnio can be performed to check for lung matuirty
if distress–> deliver
management of PIH and chronic HTN
monthly ULS to check for IUGR
Serial BP and urine protein
weekly NST during the third trimester
medication for chronic HTN and PIN
methlydopa
labetelol is the alternative
preeclampsia and eclampsia
triad
HTN
edema
proteinuria but edema is NOT necessary for the dx
most common risk factor for preeclampsia is
nulliparity
other RF for preeclampsia include
multiple gestations
dm
Preexisting renal disease
chronic HTN
what is the difference between mild and severe preeclampsia
BP measurements
mild is >140/90 where severe is 160-180/110 on twooccasions 6 hours apart
if the pt has an increase of 30 S or 15 D then that is also milkd preeclampsia
what is the difference in protein b/w preeclampsia mild and severe
mild is 300 mg/24hrs but less than 5g and hour
severe is >5g in 24 hours
or 4+ urine on dip
uric acid in mild vs severe pre e
mild >4.5
severe much greater than 4.5
liver enzymes would be elevated in severe or mild preeclampsia
severe
what are the symptoms of mild Pre E
hyperreflexia
what re the symptoms of severe pre e
HA Blurred vision scotomas clonus RUQ pain
scotomas
a partial loss of vision or blind spot in an otherwise normal visual field.
complications of pre E
HELLP Abruptio placente renal failure cerebral hemorrhage pulmonary edema disseminated intravascular coagulation
Syphilis may cause
Syphilis may cause stillbirth, late term abortions, transplacental infection and congenital syphilis.
All women should be tested for syphilis during prenatal visits
fetal complications if PRE E
hypoxia
low birth weight
preterm delivery
perinatal death
when do you give Rh immunoglobulin
28 to 29 weeks
after delivery if baby is Rh positive then the mother recieves Rhogam again to protect against subsequent pregnancies
when rhogham is given it helps reduce incidence by 99%
what is the management of mild pre e
inpatient management is magnesium sulfate until 24 hours after birth
outpatient management would be just close f/u
urine output should be monitored as magnesium sulfate is cleared through the kidney which leads to an increase risk of Mg SO4 toxcity
betamethazone prior to 34 weeks
severe pre E ALWAYS DELIVER regardless of age
what is the drug of choice for managing pre e in addition to mg sulfate
hydralizine or labetelol is given for the acute management of high blood pressure
what are the diagnostic studies for Rh incompatibility
routine blood type and cross
Rh factor
coombs test for Ab
Ab titiers of less than 1:16 probably will not adversely affect the pregnancy
in a sensitized pregnancy what do you do
you need to do a coomb’s test
amnio
and ultrasound to follow the developing fetus for evidence of distress or hydrops
what is the maangement of Rh incompatability
rhogam 300mg to Rh negatice nonimmunized 28 weeks of gestation AND within 72 hours of delivering an Rh positive infant
other than the aformentioned when would you give Rhogam
at amnio or possible uterine bleeding
when would you need a larger dose of rhogam
if massive maternal hemorrhage
abrupto placenete happens
after the 20th week
MOST COMMON CAUSE OF THIRD TRIMESTER BLEEDING
what are the risk factors for placental abruption
trauma smoking HTN decrease folic acid alcohol (>14 weeks) cocoaine uterine anomalies high parity previous abruption (recurrence rate os 10% to 17%) and advance maternal age
think party mom with hypertension and not taking vitamins
which one is painless vaginal bleeding
previa
what is the characteristic of pain experienced with placental abruption
searing back pain or uterine cramps
what are the risk factors for placental previa
advanced age
smoking
multiple gestations
previous scarring on endometrium
think old whethered mom with twins smoking on the porch
difference between external abruption and canceled abruptiom
external is more common and less severe
this is where blood escapes from the uterus and vaginal bleeding occurs
with conceled abruption is is more severe because the blood is retained. if the bleeding is canceled back pain uterine or abdominal pain may be the only symptom
what happens to the uterus with placental abruption
it becomes irritable
tender
HYPERtonic
what is used to diagnose placental abruption
not a whole lot apparently
ULS is not routinely reliable
what is the management with abruption
depends on the degree of seperation and the biability of the fetus
blood type
cross and math
coagulation studies are indicated in the unstable patient
need large IV bore line
C-section
placenta previa is more common in
smokers
previous c -section (unlike TOA)
advanced age
high parity
what effects does placenta previa have on the uterus
lower uterus contracts poorly may continue to have blleding after delivery
test of choice for placenta previa
ULTRASOUND (unlike abruption)
management of placent aprevia
watch and wait
may need blood transfusion
if diagnosed prior to 20 weeks 50% migrate
should abstain from vaginal penetration
C section is the preferred method of choice for delivery
what is the first stage of labor and the typical length
usually 6-20 hours in a primiparous woman
in a multiparous woman anywhere from 2-14 hours
usually theis is just defined by the onset of true contractions until the patient is fully dilated
second stage
begins at full dilation and ends with the delivery of the infant
usually 30 minutes to 3 hours with an average of an hour in a primiparous woman
multiparous woman anywhere from 5-60 minutes (average 20 minutes)
thirs stage of labor
delivery of the fetus to the delivery of the placenta
usually under 30 mintues with average being 5
what is the fourth stage of labor
monitoring and laceration/hemorrhage management
bloody show
often precedes labor and is the passage of a small amount of blood tinged mucus
what should you get (diagnostic tests) when a woman is admitted for labor
protein
glucose
hematocrit
when would you use and internal vs external fetal heart rate monitor
external is used when first in labor and that is attached to the abdomen transmitted via sound waves
an internal monitor is attached to the infant’s head and the mom must be at least 2 cm dilated and membranes must be ruptured
transmitted via R waves
early decels
mirror the image of a contraction and denote fetal head compression
Variable decelerations → Cord compression/prolapse
Early decelerations → Head compression
Accelerations → OK
Late decelerations → Placental insufficiency/Problem
often present as a woman approaches second stage and are considered to be benign
when do late decels occur
when the fetal heart rate drops during the SECOND HALF of the contractions
they denote Placental insufficiency
what is the course of action when fetus appears to have late decels
STOP oxytocin
change maternal position
administer oxygen via a face mask
measure fetal scalp
why do you assess the placenta
should have entire placenta membrane and contina three vessels arteries and vein
why would you use oxytocin in the third or fourth stage of labor
to reduce blood loss by stimulating contractions
what does pelvis power passage refer to
common causes of abnormalities
pelvis refers to the cephalopelvic disproportion where the maternal pelvis is not large enough to allow the infant to pass through
power refers to the contractions that are needed to dilate and expel the infant if inadequate sometimes oxytocin (pitocin) is needed to enhance labor
passanger reders to the baby where if it is too big the likelihood of cephalopelvic disproprotion
APGAR
ACTIVITY PULSE GRIMACE APPEARANCE RESPIRATION
ACTIVITY scoring
arms and legs flexed is a 1 and active movement is a 2
pulse scorign APGAR
<100 is a 1 and >100 is a 2
grimace or reflex irritability scoring
grimace is 1
sneezes coughs or pulls away is 2
appearance
pink except extremities is 1 and pink all over is 2
respiration rating
slow and irregular is 1 where good and crying is 2
what is the marker of true dystocia
inability to deliver vaginally after full cervical dilation
if maternal pushing is inadequate
rest or assisted delivery with vacuum extraction or forceps may be used to shorten the second stage
when can you use forcep extractors
only when the head is engaged and the cervix is fully dilated for fetal distress or maternal indications
leading indication for cesarean section
dystocia
if the baby is non vertex presentation you can do
external version with ultrasound guidance can be attempted after 37 weeks
when is VBAC the least successful
when dystocia was the indicator for previous cysarian
risks of cesarian sections
greater likelihood of thromboembolic events
increased bleeding
development of infection
management of c section
prophylactic antibiotics are often used after C section to prevent infection
low transverse incision is usually made because of the decreased blood loss associated with it’s use
recovery time is longer following a c-section and breast feeding may be difficult secondary to abdominal pain
induction of labor-early
with minimal dilation or effacement
initiated with prostaglandin gel applied to the cervix and repeated every 12 hours
this helps soften the cervix and additionally a balloon catheter or laminaria can also be used
later induction of labor
once the cervix is dilated more than 1 cm and there is some effacement pitocin can be given IB
with systemic increases in oxytocin q 3 minutes
what is the name for artifically rupturing the membranes
amniotomy
what decrease in hematocrit constitues as pp hemorrhage
10%
what are the most frequent causes of late pp hemorrhage
occurs more than 24 hours after deivery as is usually because of subinvolution of the uterus
retained products of conception
or
endometriitis
how do you differentiate a subinvoluted uterus
it will feel enlarged and soft on examination and the patient may present with increased bleeding
pain
fever
foul-smelling lochia
management of pp hemorrhage
initial management should be uterine massage and comrpession
establish IV access and prepare blood compoennets
after you have massaged the uterus and established IV access and blood compoennets what should be done to manage pp hemorrhage
use IV oxytocin ergonovine, methylergonovine, or protoglandins
subinvolution of the uterus will often respond to
oral agents that increase uterine contraction like
methylergonovine maleate
ergonovine maleate
antibiotic treatment may also be necessary
endometritis characteristic
commonly presents 2-3 days postpartum \fever higher than 38.3 or 101 and uterine tenderness are highlighy suspicious
other than uterine tenderness and high fever what other symptoms would be concerning for endometritis
adnexal tenderness
peritoneal irritiation
decreased bowel sounds
diagnostic studies for endometritis
WBC commonly more than 20,000
causative bacteria vary wildly but anaerobic steptoccoci
UA should be performed
management of endometritis
should be administered until afebrile for 24 hours
clindamycin plus gentamicin is the first line
what would you add if clindamycin and gentamycin didn’t work for endometritis
ampicillin is the first line if no response in the first 24 to 48 hours
when would you add metronidazole to a pt with endometritis
if sepsis was present
what is lochia
bleeding that occurs after delivery and can represent a sloughing off of decidual tissue
can last for 4-5 weeks pospartum
when does period return for non breast feeding mothers
6-8 weeks
what is common in lactating mothers
atrophic vaginitis
treat with vaginal cream
when does the uterus shrink or involute
2 days after delivery
when does the uterus descend into the pelvic cavity
2 weeks afte
when is the uterus back to its normal size
by 6 weeks
when should a pt be further worked up for PP depression
if they score greater than a 10 on the edinburgh postnatal depression scale
start at the peak of contraction into the second half of the contraction
late
worrisome
placental insufficiency
urgent care
mirror the contraction
early decels
ok
rapid droos of fetal heart rate with variable returnt to baseline
fetal head comrpession
benign
3 hr GTT
FASTING >90
1HR >180
2HR >155
3 HR >140
just need 2 of these
