Obstetrics and Gynecology Flashcards
What is the most common detrimental consequence of prolonged membrane rupture?
Chorioamnionitis
- increasing risk of fetal and maternal sepsis
- this prompts effort to effect delivery immediately
What is chorioamnionitis?
Also known as IAI or intra-amniotic infection. It is an inflammation of the fetal membrances (amnion and chorion) due to a bacterial infection probably from bacteria ascending from the vagina into the uterus.
What is the benefit/significance of antimicrobial therapy in mothers with premature rupture of membrane associated with chorioamnionitis?
antimicrobial therapy had significantly reduces the number of newborns with RDS, NEC, and other adverse outcomes of bacterial sepsis.
What are the available choice of management for preterm ruptured membranes?
Delivery by induction of labor
Expectant management
other ancillary includes: GBS prophylaxis corticosteroids tocolytics for expectant management antimicrobials
What are the available choice of management for preterm labor without rupture of membrane?
almost the same with PROM
Delivery by induction of labor
Expectant management
other ancillary includes: GBS prophylaxis corticosteroids tocolytics for expectant management antimicrobials amniocentesis corticosteroids bed rest
How do you detect infection in amniotic fluid of a preterm labor without rupture of membrane? what are its criteria to diagnose infection?
amniocentesis
criteria for positive infection: elevated leukocyte count low glucose level high IL-6 or positive gram stain results
What is the rationale in administering corticosteroid in a mother undergoing premature labor? What are the corticosteroids of choice?
corticosteroid were found to accelerate lung maturation in fetus.
-it is effective in lowering the incidence of RDS and neonatal mortality
Betamethasone or dexamethasone
What is a cervical pessaries?
It is a medical device used to treat an incompetent or short cervix. Early in pregnancy, a rounf silicone pessary is placed at the opening of the cervix to close it, and then removed later in the pregnancy if the risk of preterm labor has passed.
What is a cervical cerclage?
Also known as cervical stitch. It is a treatment for cervical weakness, when the cervix starts to shorten and open too early during pregnancy causing either a late miscarriage or preterm birth.
what is the significance of tocolytic agents?
Tocolytic agents do not markedly prolonged the gestation but may only delay the delivery up to 48 hrs. This may allow transport to a regional obstetrics center and permit time for corticosteroid therapy to take effect.
Beta-adrenergic agonist (ritodrine), calcium channel blockers or indomethacin are recommended tocolytics that last up to 48 hrs,
What are the drugs used as tocolytics?
B-adrenergic agonists (reduced intracelullar calcium thus preventing activation of myometrial contractile proteins) magnesium sulfates (alter myometric contratility) calcium channel blockers prostaglandin inhibitors (indomethacin) Atosiban (competitive antagonists of oxytocin-induced contractions) NO donors (muscle relaxant)
How do you classify newborn as SGA?
if its birth weight is less than the 10th percentile for gestational age
How do you classify newborn as LGA?
if its birth weight is more than the 90th percentile for gestational age
How do you classify newborn as AGA?
if its birth weight is lbetween 10th and 90th percentile for gestational age
What are the PRESUMPTIVE SIGNS of pregnancy?
meaning signs that are unrelated to fetus and mother
- Amenorrhea
- Breast tenderness
- Nausea and vomiting
- Increased skin pigmentation
- Skin striae
What are the PROBABLE SIGNS of pregnancy?
meaning signs that are related to mother
- Enlargement of the uterus
- Maternal sensation of uterine contractions and fetal movements
- Hegar sign (or the softening of the junction between corpus and cervix)
- Positive urine and serum B-HCG
What are the POSITIVE SIGNS of pregnancy?
meaning signs that are related to fetus
- Fetal heart tones
- Sonographic visualization of fetus
- Perception of fetal movements by examiner
- X-ray showing fetal skeleton
What is the normal duration of pregnancy postconception? from LMP?
266 days or 38 weeks (postconception)
280 days or 40 wks (from LMP)
How do you establish gestational age?
through conception dating, mestrual dating and naegele’s rule
How to use Naegele’s rule?
Get LMP, then minus 3 months and add 7 days from it,
The last few hours of human pregnancy are characterized by?
forceful and painful uterine contractions that effect cervical dilations and cause the fetus to descend through the birth canal
What are the four phases of parturition?
Phase 1-Uterine quiescence and cervical softening
Phase 2 -preparation
Phase 3 -parturition or the clinical stages of labor
Phase 4 - Recovery
What are Braxton-Hicks contractions or false labor contractions?
These are some low intensity myometrial contractions that are felt during the quiescent phase, but they do not normally cause cervical dilatation. These contractions become more common toward the end of pregnancy.
What are the first trimester methods to induce abortion?
Vacuum curettage-Dilation and curettage (D&C)
Medical abortion- Mifepristone and Misoprostol
What are the second trimester methods to induce abortion?
Dilation and Evacuation (D&E)
Labor induction methods (hypertonic solutions like urea or saline, prostaglandins, vaginal pge like disoprostone)
What is the immediate complication of induced abortion using labor induction method at 2nd semester pregnancy?
Retained placenta
What is the most common problem with all PG abortions during 2nd semester?
Retained placenta
What are the immediate complications of dilation and curettage in induced abortion of a 2nd semester pregnancy?
uterine perforation retained tissue hemorrhage infection DIC
How can you ensure of a complete evacuation of pregnancy after abortion?
sonogram (look for retained pregnancy tissues)
What is the limitation of using medical drugs like misoprostol (cytotec), mifepristone (mifiprex), etc?
can only be used in women within first 63 days of amenorrhea
What are other ancillary procedures used in abortion?
prophylactic antibiotics and pain relief
Define spontaneous abortion.
bleeding within 12 weeks of gestation (first trimester)
the most common cause of early pregnancy loss is fetal in origin (chromosomal, mendelian abnormalities, antiphospholipid syndrome)
Majority of early pregnancy loss is caused by what etiology?
chromosomal abnormalities
Followed by:
- mendelian abnormalities (autosomal or x-linked dominant and recessive)
- antiphospholipid syndrome (rare)
What is a missed abortion?
sonogram finding of NONVIABLE pregnancy WITHOUT vaginal bleeding, uterine cramping or cervical dilation.
Mgt: scheduled suction D&C, induce contractions with misoprostol, or conservative management
What is a threatened abortion?
sonogram finding of VIABLE pregnancy WITH vaginal bleeding, but NO cervical dilation.
Mgt: No intervention, pregnancy may continue to term
What is an inevitable abortion?
has VAGINAL BLEEDING, UTERINE CRAMPING, CERVICAL DILATION but NO passage of POC yet.
mgt: emergency suction D&C to prevent further blood loss and anemia
What is an incomplete abortion?
VAGINAL BLEEDING, UTERINE CRAMPING, CERVICAL DILATION with PARTIAL passage of POC.
mgt: emergency suction D&C to prevent further blood loss and anemia
What is a complete abortion?
VAGINAL BLEEDING, UTERINE CRAMPING, CERVICAL DILATION with ALL POC being passed.
mgt:
- confirm with sonogram to ensure no intrauterine debris left
- weekly hCG titers to ensure negative pregnancy and rule out ectopic pregnancy
What is fetal demise?
In-utero death of a fetus after 20 weeks gestation before birth
Antenatal demise-before labor
Intrapartum demise-during onset of labor
What is the most serious consequence of fetal demise to mother?
DIC
What are the presentations to suspect fetal demise?
Fundus less than date (before 20 wks)
Absence of fetal movements (after 20 wks)
What are the risk factors causing fetal demise?
fetal infection maternal trauma over diabetes antiphospholipid syndrome severe maternal isoimmunization fetal aneuploidy
How to confirm diagnosis of fetal demise?
Ultrasound doppler showing ABSENCE OF CARDIAC ACTIVITY/ FETAL HEART BEAT
What is the appropriate management for fetal demise presenting with DIC?
How would you know the presence of DIC?
Immediate delivery and seldective transfusion of blood products
Order laboratory tests like plateletcount, d-dimer, fibrinogen, PTT, aPTT
What is an ectopic pregnancy? common location?
Pregnancy outside the uterine cavity
The most common site is in the distal ampulla of oviduct
What are the risk factors for the occurrence of ectopic pregnancy?
previous pelvic inflammatory diseases that can cause scarring or adhesions that prevent normal migration of zygote into the uterine cavity.
Risk factors are: Infectious (pelvic inflammatory disease) Postsurgical (tuboplasty/ligation) Congenital (DES use) Idiopathic
Classic triad of unruptured ectopic pregnancy? What happens when it ruptures?
Amenorrhea
Vaginal bleeding
Unilateral pelvic abdominal pain
Ruptured ectopic pregnancy symptoms will vary depending on the extent of intraperitoneal bleeding and irritation. Sometimes indicates HYPOTENSION, indicative of hypovolemia
What are the classic signs of unruptured ectopic pregnancy?
Unilateral adnexal and cervical motion TENDERNESS
Uterine enlargement and fever are usually absent
Tachycardia and hypotension (indicates ruptured ectopic pregnancy)
abdominal guarding and rigidity
What diagnostic tests/tools are used to diagnose ectopic pregnancy?
What results from these tests highly suggest of an ectopic pregnancy?
Serum beta-hCG levels
and vaginal sonogram
Failure to see a normal intrauterine gestational sac when the serum beta-hCG titer is >1500 mIU
if less than <1500 mIU and does not reveal IUP, it may suggest possible ectopic. Advise for a repeat serum hcg titer level every 2-3 days until levels exceed 1500 mIU and still no IUP
Management for a ruptured ectopic pregnancy
Exploratory laparotomy
Signs/Symptoms of Rupture: amenorrhea, vaginal bleeding, abdominal pain, hemodynamically unstable
What is the management for threatened abortion?
preferably bed rest and avoid stressful activities
Treatment for hydatidiform mole?
suction curettage
follow-up beta-hCG titer weekly
Management for unruptured ectopic pregnancy?
medical treatment (METHROTREXATE) surgical treatment (LAPAROSCOPY)
Rationale for usage of methotrexate for medical treatment of unruptured ectopic pregnancy?
methotrexate is a folate antagonist that attacks rapidly proliferating tissue including the trophoblastic villi, This is also used in treating cancer that kills rapidly dividing cancer cells.
What are the criteria to use methotrexate for treatment of unruptured ectopic pregnancy?
pregnancy mass <3.5 cm diameter
absence of fetal heart motion
beta-hCG levels <6000 mIU
no history of folic supplementation
if does not meet criteria, proceed to laparoscopy
Limitation of transabdominal ultrasound in obstetrics?
affected by maternal habitus. Not usually used in obese patients.
transvaginal are utilized in first trimester, producing high resolution images that are not influenced by maternal BMI
What is chorionic villus sampling and what is it for?
CVS biopsy is a prenatal test that involves taking a sample of tissue from the placenta villi to test for chromosomal abnormalities and certain genetic problem. the placenta and the fetus have similar genetic make-up.
What is amniocentesis?
direct ultrasound guided aspiration of amniotic fluid containing amniocytes. This is used for neural tube defect screening. It involves biochemical analysis of AF-AFP and acetylcholinesterase.
What is a percutaneous umbilical cord sampling (PUBS) and what is it for?
Ultrasound-guided aspiration of fetal blood from the umbilical vein after 20 wks gestation.
Used to test blood gases, karyotype, IgG and IgM antibodies.
Also used as therapeutic procedure for intrauterine transfusion with fetal anemia.
What is a fetoscopy?
a transabdominal procedure performed with a fiberoptic scope in the operating room after 20 wks under general or regional anesthesia.
Indications: Intrauterine surgery and fetal skin biopsy.
What is a cervical cerclage? purpose?
placing a suture the encircles the cervix to hold the cervical canal from dilating.
It is performed under regional or general anesthesia.
Purpose: Treatment for cervical insufficiency
What is the frequent complication in first trimester of pregnancy?
spontaneous abortion?
What is quickening? lightening?
quickening- maternal awareness of fetal movements detected around 16-20 wks
lightening-descent of the fetal head into the pelvis resulting in easier maternal breathing and pelvic pressure
What are the common pregnancy danger signs?
vaginal bleeding vaginal fluid leakage epigastric pain uterine cramping decreased fetal movements persistent vomiting headaches/visual changes pain with urination chills and fevers
Possible diagnosis for a pregnancy complaint of VAGINAL BLEEDING
early (spontaneous abortion)
later (placental abruptio or previa)
Possible diagnosis for a pregnancy complaint of VAGINAL FLUID LEAKAGE
membrane rupture
urinary incontinence
Possible diagnosis for a pregnancy complaint of EPIGASTRIC PAIN
severe preeclampsia (enlarged liver with proteinuria)
Possible diagnosis for a pregnancy complaint of UTERINE CRAMPING
preterm labor
preterm contractions
Possible diagnosis for a pregnancy complaint of DECREASED FETAL MOVEMENTS
fetal demise/compromise
Possible diagnosis for a pregnancy complaint of PERSISTENT VOMITING
hyperemesis (early)
hepatitis
pyelonephritis
Possible diagnosis for a pregnancy complaint of HEADACHES/VISUAL CHANGES
severe preeclampsia
Possible diagnosis for a pregnancy complaint of SEIZURES
eclampsia
Possible diagnosis for a pregnancy complaint of PAIN WITH URINATION
cystitis
pyelonephritis
Possible diagnosis for a pregnancy complaint of CHILLS AND FEVER
pyelonephritis
chorioamnionitis
What are UNSAFE immunizations or vaccines for pregnant women?
live attenuated vaccines:
Measles, Mumps, Rubella (MMR)
Varicella
Polio (oral)
Yellow Fever
*intramuscular polio (IPV) is inactivated type of vaccine
What are SAFE immunizations or vaccine for pregnant women?
killed or inactivated organisms
Influenza (all pregnant women in flu season) Hepatitis B (pre- and postexposure) Hepatitis A (pre- and postexposure) Pneumococcus (for high risk women) Meningococcus Typhoid
Differential diagnosis of LATE PREGNANCY BLEEDING
can be vaginal, cervical, or placental causes
Cervical erosion, polyps, carcinoma
Vaginal varicosities, laceration
Placental abruptio, previa, accreta, vasa previa
Initial needed work-up for a pregnant who presents with late pregnancy bleeding
Initial management?
CBC
platelets, PTT, aPTT, fibrinogen, d-dimer
type and cross-match
sonogram
Insert IV line with large bore needle (isotonic without desxtrose if mother is unstable)
Insert urinary catheter to monitor urine output
Define abruptio placenta
a normally implanted placenta separates from the uterine wall before delivery of the fetus.
partial or complete.
overt/external or concealed/internal
Risk factors for occurrence of placental abruption
hypertensive cocaine abuse maternal trauma previous placental abruption premature membrane rupture
Management for placental abruption when mother or fetus is jeopardized or unstable?
emergency cesarean delivery
as long as there is jeopardy, do cesarean
Avoid cesarean delivery if the fetus is dead.
Management for placental abruption when mother has heavy bleeding but the bleeding is well controlled or pregnancy is >36 weeks
Perform amniotimy and induce labor. Place external monitor to assess fetal heart rate pattern and contractions.
Avoid cesarean delivery if the fetus is dead.
Complications of severe placental abruptio
hemorrhagic shock with acute tubular necrosis (hypotension)
DIC (release of tissue thromboplastin into the general circulation from disrupted placenta)
Couvelaire uterus (extravasating blood in the myometrial fibers)
Define placenta previa
placenta is imppanted in the lower uterine segment.
common in early pregnancy but most often not associated with bleeding
most likely diagnosis for a late trimester bleeding that is painless
placental previa
Different classifications of placenta previa?
complete/total/central
partial
marginal or low-lying previa
OB triad for placental previa
late trimester bleeding
painless
lower segment placental implantation
What is a possible consequence of a placnta previa implanted in a previous uterine scar? management?
The villi may invade into the deeper layers of the desidua basalis and myometrium resulting to intractable placenta (accreta)
Management:esarean hysterectomy
What do you call to a condition where the villi invade deeper than the superficial layers of decidua basalis?
placental accreta, increta, percreta
Difference between accreta, increta, percreta
accreta invades the deepest layer of the desidua basalis but does not reach the myometrium yet
increta reaches the myometrium
percreta reaches the serosal layer
What is vasa previa?
A condition in which fetal blood vessels cross or run near the internal opening of the uterus.
These vessels are at risk o rupture when the supporting membranes rupture, as they are unsupported by the umbilical cord or placental tissue.
What is the classic triad for vasa previa?
Rupture of membrane,
painless vaginal bleeding,
fetal bradycardia
What is the immediate management for a confirmed vasa previa?
Immediate/emergency cesarean delivery
Rationale: to prevent fetal death secondary to fetal hypovolemia
What is an uterine rupture? What are its risk factors?
Spontaneous tearing of the uterus that may results in the fetus being expelled into the peritoneal cavity
RF are: prior cesarean delivery (incision site) myomectomy excessive oxytoxin stimulation grand multiparity marked uterine distension
Common presentation of a uterine rupture
vaginal bleeding
loss of electronic fetal heart rate signal
loss of station of fetal head (may be expelled to peritoneal cavity)
may occur before or during labor
