Obstetrics and Pregnancy Pearls

Question 1

Define Goodell’s sign.

When?

Answer 1

Softening of the cervix.

Seen in 1st trimester, by 8 weeks

Question 2

Define Chadwick’s sign.

When?

Answer 2

Cervical cyanosis.

Seen in 1st trimester, by 8 weeks

Question 3

Define Hegar’s sign.

When?

Answer 3

Softening of cervicouterine junction.

See in 1st trimester, by 8 weeks

Question 4

When can you hear fetal heart tones?

Answer 4

10-12 weeks

Question 5

When do you tell the mother she can expect to feel her baby move?

Answer 5

18-20 weeks

Question 6

Where do you expect to feel the fundus at 20 weeks?

Answer 6

At the umbilicus.

*It grows ~1cm/wk thereafter

Question 7

When can Leopold maneuvers be done?

Answer 7

20 weeks

Question 8

When should the only required US be done?

Answer 8

18-20 weeks for fetal survey, looks at the anatomy

Question 9

When do you perform the 1hr glucose tolerance test?

Answer 9

At 20 weeks if family hx of DM or pt’s weight >200 lbs

At 28 weeks for routine screening

Question 10

Who is RhoGAM given to and when?

Answer 10

Rh NEGATIVE mothers at 28 weeks, 3rd trimester

Question 11

When can an amniocentesis be performed and on whom?

Answer 11

At 15-20 weeks if family history of chromosomal abnormalities or advanced maternal age

Question 12

How many total prenatal care visits should a woman receive? What is the breakdown?

Answer 12

15 total visits.
Every 4 weeks from 0-28 weeks (first 7 months)
Every 2 weeks from 28-36 weeks (7-9 months)
Every week from 36 weeks to delivery

Question 13

How do you calculate Naegele’s rule?

Answer 13

Subtract 3 months and add 7 days from 1st day of last menstrual period

Question 14

What should be done at every prenatal visit?

Answer 14

BP, weight, fundal height in cm, FHT, fetal movement (starting at 10 weeks), presentation (Leopold maneuver at 20 weeks) and fetal lie.

Question 15

What is the classic presentation of an ectopic pregnancy?

Answer 15

Spotting - dark brown/tarry 
Variety of abdominal/pelvic complaints
Unilateral lower quadrant pain
Low back pain or shoulder pain
Hemodynamic changes in VS - shock - HR

Question 16

What is the age of viability?

Answer 16

24 weeks

Question 17

Spontaneous Abortion

Answer 17

prior to viability - 24 weeks

approx 15% of all pregnancies

Question 18

What are pregnancy losses in the first trimester often due to?

Answer 18

chromosomal abnormalities

Question 19

What are pregnancy losses in the second trimester often due to?

Answer 19

incompetent cervix
infection
uterine abnormalities

Question 20

What signs/symptoms may indicate a spontaneous abortion?

Answer 20

vaginal bleeding of varying degrees
cramping/pelvic pressure
low back pain
rupture of membranes
hemodynamic changes in VS - hemorrhaging - HR

Question 21

What tests would you run if you suspected a spontaneous abortion?

Answer 21

serum hCG, US, CBC, blood type and Rh

Question 22

What are the primary risk factors for PIH?

Answer 22

• HTN
• Renal/Cardiac disease
• DM
• Lupus/autoimmune disease
• Multiple gestation
• Primigravida
• Personal or family hx of PIH or preeclampsia
• Maternal age <14 or >35

Question 23

What are the diagnostic tests of PIH?

Answer 23

BP surveillance
CBC, LFTs, 24hr urine for protein, creatinine clearance
NST

Question 24

What is the primary management of PIH?

Answer 24

Rest at home, if worsening, bed rest in L lateral recumbent position and ongoing fetal surveillance with NST, US and kick counts

Question 25

Preeclampsia S/S

Answer 25

PIH + Proteinuria + Generalized Edema after 20 weeks gestation ***Sudden weight gain *Progression from digital and mild facial edema to generalized edema *Frontal or occipital headaches *Visual disturbances with worsening condition

Question 26

What testing is done for pre-eclampsia?

Answer 26

``` BP surveillance Urine testing Q visit, repeat 24 hr/urine Baseline labs/coag studies NST weekly; biophysical profile **Amniotic fluid must be included Ultrasound ```

Question 27

What is the management of pre-eclampsia?

Answer 27

``` Referral. Strict bedrest, L lateral Fetal surveillance NST US Kick counts Weekly injections with B-methasone for fetal lung maturity ```

Question 28

What are the physical findings in eclampsia?

Answer 28

**PIH + Preeclampsia + Seizure** May have prodromal symptmos of: * Severe, unrelenting headache * Epigastric or RUQ pain which worsens * Visual changes, spotty vision, blurriness, blindness BP consistently > 160/100 Tonic-clonic seizures Oliguria progressing to anuria **Fetal distress in utero**

Question 29

What is the testing for eclampsia?

Answer 29

CBC, LFTs with full chem profile, coag profile 24hr urine for protein creatinine/creatinine clearance Uric acid

Question 30

What is the management of eclampsia?

Answer 30

Refer. Most likely will be hospitalized and delivery encouraged as soon as mother is stable enough. MgS04 to break seizure.

Question 31

What does HELLP stand for?

Answer 31

Hemolysis, Elevated Liver enzymes, Low Platelets

Question 32

What are signs/symptos of HELLP?

Answer 32

``` Pre-eclampsia plus... Nausea w/wo vomiting Jaundice Extreme fatigue Ill-feeling ```

Question 33

What would you expect to find on the physical exam of someone with HELLP syndrome?

Answer 33

* *Hepatosplenomegaly * *RUQ pain/tenderness extending to epigastric area * *Jaundice * *Possible ascites

Question 34

What is the management of someone with HELLP syndrome?

Answer 34

Refer for physician management... hospital, delivery ASAP

Question 35

What would you expect to find on laboratory data with HELLP syndrome?

Answer 35

Thrombocytopenia - <50,000 Reduced clotting factors Severe hemoconcentration Very elevated LFTs - AST and ALT in 100's Proteinuria consistent w/severe preeclampsia

Question 36

What tests should be done if placenta previa?

Answer 36

Ultrasound, CBC, external fetal monitoring

Question 37

How is placenta previa managed?

Answer 37

Hospitalization is often required and vaginal rest.

Question 38

What is premature labor?

Answer 38

Contractions after 20 weeks and before 37 weeks gestation Risk factors: Hx of preterm labor, STI/UTI, multiple gestation, low income, poor weight gain, poor nutrition, drug use/cocaine, smoking, cervical trauma, maternal age <14 or >35

Question 39

What is the management of pre-term labor?

Answer 39

Hospitalization for tocolytic therapy

Question 40

What are signs/symptoms of premature labor?

Answer 40

**Etiology Unknown** Uterine cramping/intermittent or constant; lower back pain; uterine contractions 10-12 minutes (5/hr), vaginal spotting, change in vaginal discharge, cervical effacement or shortening or dilation

Question 41

First Trimester Symptoms

Answer 41

``` 0-12 weeks Amenorrhea N/V Fatigue Breast tenderness Urinary Frequency ```

Question 42

Second Trimester

Answer 42

13-27 weeks Fetal Movement - 18-20 weeks Abdominal discomfort secondary to stretching Change in skin pigmentation *Cholasma - brownish/tan mask-like appearance Syncopal episodes Striae *Fundus palpable at umbilicus @20 weeks, increases by 1 cm per week

Question 43

Third Trimester

Answer 43

28-40 weeks Fetal movement Braxton-Hicks contractions Increased respiratory effort * Lightening may occur 3-4 weeks prior to labor * Loss of mucus plug/bloody show 1 week prior to labor * Braxton-Hicks contractions * Rupture of membrane

Question 44

Fundus

Answer 44

Palpable at umbilicus at 20 weeks, up or down 1 cm/week | IE: at 17 weeks, palpable at 3 cm below umbilicus

Question 45

Triple Screen | When and what's included?

Answer 45

16-20 weeks\ hCG, estriol, alpha-fetoprotein

Question 46

Quad Screen | When and what's included

Answer 46

16-20 weeks hCG, estriol, alpha-fetoprotein, and inhibin A

Question 47

PIH

Answer 47

*Pregnancy Induced HTN *BP >140/90 or rise in systolic >30 or diastolic >15 on at least 2 occasions w/readings 6 hrs apart *Approx 12% of all pregnancies

Question 48

Preeclampsia Physical Exam Findings

Answer 48

*HTN - >140/90 or increase in systolic of 30 or increase of diastolic of 15 from baseline *Proteinuria - Trace to +1 progressing to +2 with worsening condition *Edema - Nondependent edema >1+ progressing to >3-4+ pretibial edema and worsening facial edema *WG - >2 lbs/week or >6 lbs/month, lagging fundal height *Reflexes - WNL progressing to 3-4+ with worsening condition

Question 49

Placenta Previa

Answer 49

* Mal-implantation of placenta in lower uterine segment * Bleeding occurs in late 2nd trimester and often precipitated by vaginal intercourse **PAINLESS** Risk Factors Include: * Previous C-section or uterine surgery * Multiparity * Malpresentation * Hx of previous placenta previa

Question 50

Abruptio Placentae

Answer 50

* Separation of placenta from uterine wall * Contributing factors: Trauma, chronic HTN, preeclampsia/eclampsia, cocaine use, EtoH, smoking, uterine tumor ***SEVERE Abdominal PAIN*** **Immediate transport to ER**

Question 51

Ectopic Pregnancy

Answer 51

Any conceptus that implants and grows outside the uterine cavity Greater risk with: * Previous tubal surgery * Previous ectopic pregnancy * Hx of PID * Using/used an IUD Women with history of infertility are at increased risk 95% occur in fallopian tubes

Question 52

Ectopic Pregnancy | Physical Exam Findings

Answer 52

* Tender adnexa w/possible palpable mass * Positive CMT (cervical motion tenderness) * Uterine enlargement w/Hegar's sign * +Peritoneal signs if rupture occurred and perhaps vaginal bleeding

Question 53

Ectopic Pregnancy | Diagnostic Testing

Answer 53

serum hCG CBC, type, and Rh Ultrasound Other pre-op labs **Refer**

Question 54

Induced/Elective Abortion

Answer 54

* Surgical abortion * vacuum D&C to 12 weeks * D&E 13-22 weeks * hysterotomy/hysterectomy Medical - indicated through 49 days of pregnancy *mifepristone - RU486 *prostaglandin (Misoprostol) - used for NSAID induced ulcers

Question 55

Postpartum Complications

Answer 55

**Pulmonary Embolism** - SOB Postpartum hemorrhage Postpartum depression Mastitis - usually staph - NSAIDs and ice packs Abx if needed - dicloxacillin, cephalexin, clindamycin