PANCE Prep- GYN Flashcards
Uteroplacental insufficiency occurs when the uteroplacental unit is compromised. Initial fetal responses include:
- fetal hypoxia,
- shunting of blood flow to the fetal brain, heart, and adrenal glands, and
- transient repetitive late decelerations of the fetal heart rate
*If hypoxia continues the fetus will eventually switch over to anaerobic glycolysis and develop metabolic acidosis –> lactic acid accumulates and progressive damage to vital organs occurs
A normal fetal HR is ___ and it Usually ___ w/ contractions
110-160bpm
increases w/ contractions
<110= bradycardia >160= tachycardia
___ after contractions are abnormal and can indicate stress
____ to baseline is particular omnious
Decelerations
*indication for “operative intervention” if persistent
Slow recovery to baseline
The most common cause of fetal tachycardia is
- chorioamnionitis
- (aka intra-amniotic infection (IAI)– inflammation of the fetal membranes (amnion and chorion) due to a bacterial infection- E. coli, GBS)
Other causes:
- Maternal fever
- Thyrotoxicosis
- Medication
- Fetal cardiac arrhythmias
Moderate variability in FHR is a reassuring sign that reflects adequate fetal oxygenation and normal brain function
Decreased variability associated with:
- Cardiac or CNS anomalies
- Hypoxia (fetal)
- Acidemia
- Tachycardia (fetal)
- Prematurity
- Depressed CNS (meds)
- Fetal sleep
- Prolonged uterine contraction
(CHATPDFP)
At 32 weeks and beyond, an acceleration has a peak of __bpm or more above baseline, with a duration of __ seconds or more but less than __minutes
Before 32 weeks, an acceleration has a peak of __ bpm or more above baseline, with a duration of __ seconds or more but less than __ minutes
15bpm– 15sec but less than 2 min
10bpm– 10 sec but less than 2 min
Prolonged acceleration lasts __ minutes or more but less than __ minutes
2 min but less than 10 min
*If longer than 10 minutes, it is a baseline change
What are early decelerations
-Associated with uterine contractions –> nadir of the deceleration occurs at the SAME TIME as the peak of the uterine contraction (“Mirror image” of the contraction)
- Usually symmetrical gradual decrease and return
- Result of pressure on the fetal head from the birth canal, digital exam, or forceps application that causes a reflex response through the vagus nerve with acetylcholine release at the fetal SA node
**Physiologic, not a cause of concern
Late decelerations are associated w/
uteroplacental insufficiency, as a result of either decreased uterine perfusion or decreased placental function –> decreased intervillous exchange of oxygen and CO2 and progressive fetal hypoxia and acidemia
What is the most common period fetal HR pattern
variable decelerations
*usually associated w/ umbilical cord compression– often correctable by changes in maternal position to relieve pressure on the umbilical cord
How often do you evaluate a continuous electric monitoring tracing during the active phase of 1st stage labor?
low risk: at least every 30 min
high risk: at least every 15 min
How often do you evaluate a continuous electric monitoring tracing during the 2nd stage labor?
low risk: at least every 15 min
high risk: at least every 5 min
A good reassuring fetal HR strip is indicated by
- long term variability w/ baseline HR 120-160
- accelerations (increase in 15bpm) for at least 15 sec above baseline
- no decelerations
Causes of increase in fetal HR
- fetal movement
- contractions
- sounds or other stimuli like scalp stimulation
*accelerations= good fetal well being
tx of late decelerations
- reposition mom on left (off VC)
- maternal fluid bolus (increase BP) and O2
- decrease pitocin (decrease contractions)
- administer terbutaline to decrease contractions frequency
- C-section
Nonstress test evaluates the fetal heart rate response to fetal activity. It measures the fetal heart rate, patterns, and accelerations, which are monitored with an external transducer for at least 20 minutes. The tracing is observed for fetal heart rate accelerations. Patient asked to note fetal movement by pressing a button on the monitor which causes a notation on the monitor strip
- Results are considered reactive (reassuring) if: ___
- Nonreactive (nonreassuring) tracing is: __
- Reassuring: if 2 or more FHR accelerations occur in a 20 minute period
- Nonreactive: one without sufficient heart rate accelerations in a 40 minute period –> should be followed with further fetal assessment
Define the parts of a cervical exam:
- Dilation
- Effacement
- Station
- Dilation= estimation of the diameter of the cervical opening at the level of the internal os
- Effacement = thinning of the cervix expressed as a percentage of thinning from the perceived uneffaced state
- Station = the level of the fetal presenting part in the birth canal in relation to the ischial spines
*only do every 4 hours
Describe the different stations of a cervical exam
-3 = 3 cm above the ischial spines 0 = at the ischial spines, engaged \+3 = 3 cm below the ischial spines
Reasons for C-section
- Multiple pregnancy (too early, not in good position)
- failure of labor to progress
- concern for baby
- problems w/ placenta
- large baby
- breech presentation
- maternal infection or condition
- prior C section or uterine scar (trail of labor after C section (TOLAC) for women only w/ 1 prior low transverse c section)
- labor dystocia
Absolute contraindications to vaginal delivery
- complete placenta previa
- HSV w/ active genital lesions or prodromal symptoms
- untreated HIV
- previous classic uterine incision or extensive transfundal uterine surgery
Opioid SE when used during labor
- M- myosis
- O- out of it/ drowsy (mom and baby- hard to BF hours after birth)
- Resp. depression (mom and baby)
- P- pneumonia/ aspiration
- H- hypotension
- I- infreq. constipation/urinary retention OR ITCHY
- N- nausea
- E- emesis
What are Braxton-Hicks contractions
spontaneous/irregular uterine contractions late in pregnancy NOT ASSSOCIATED w/ cervical dilation (do not get closer together)
-false labor
Differences between false and true labor
False: irregular contractions that don’t get closer together, contrations stop w/ position change or walking, contractions sometimes get weaker, pain felt only in front usually
True: contractions at regular intervals lasting 30-70 sec, contractions continue despite movement, increase in strength steadily, pain starts in back and moves to front
What is considered premature labor
regular uterine contractions (>4-6/hrs) w/ progressive cervical changes (effacement 2-3cm and dilation 80%+) BEFORE 37 WEEKS GESTATION
*MC cause of perinatal mortality (70%)
Preterm labor medication managment
- Corticosteroids/Bethamethasone- help speed up development of babys lungs, brain, and digestive organs
- most likely to help when given 24-34 weeks - Tocolytics- suppress uterine contractions- can use up to 48 hrs
- (Indomethacin- NSAID, Nifedipine- CCB, Magnesium sulfate), Terbutaline- B2agonist)
Diagnostic tests for premature labor
- Clinically: effacement 2-3cm and dilation 80%+ BEFORE 37 WEEKS GESTATION
- Nitrazine pH paper test: turnbs blue if pH >6.5 (normal vaginal pH 3.8-4.2)
- Fern test: estrogen + amniotic fluid= crystallization
- Presence of fetal fibronectin btwn 20-34weeks
**Must R/O infection: L:S ratio <2:1= fetal lung immaturity
L:S ratio <2:1=
fetal lung immaturity
lecithin–sphingomyelin ratio (a.k.a. L-S or L/S ratio) is a test of fetal amniotic fluid to assess for fetal lung immaturity
Categories of Dystocia
abnormal labor progession
- Power= uterine contraction
- Passenger= presentation size or position of fetus (shoulder dystocia lodged at pubic symphysis +/- ERB’s palsy
- Passage= uterus or soft tissue abnormalities
What is considered post-term pregnancy
41-42 weeks
Situations in which risk of labor induction of vaginal delivery are greater than C section
- prior uterine rupture
- prior C section
- active genital herpes infection
- umbilical cord prolapse
- placenta previa or vasa previa
- transverse fetal lie
Things done when inducing labor
- prostaglandins PO or vaginally to ripen cervix
- Stripping or sweeping amniotic membranes–> may cause body to release PGE
- rupture amnotic sac- can start contractions
- Oxytocin- causes uterus to contract
What are the 7 cardinal movements of labor
- Engagement: fetal presenting part enters pelvic inlet
- Flexion: flexion of head to allow smallest diameter to present to the pelvis
- Descent: head into pelvis
- Internal Rotation: fetal vertex moves from occiput transverse to a position where the sagittal suture is parallel to the anteroposterior diameter of the pelvis
- Extension: vertex extends as it passes beneath pubic symphysis
- External rotation: fetus externally rotates after head is delivered so should can be delivered
- Expulsion
*Every Darn Fetus Is Extremely Eager to Exit
cause of IUGR
Inherited: fetal genetic disorders
Uterus: placental insufficency, multiple gestation
General: maternal malnutrition, smoking, drug use, gestational diabetes
Rubella and other congenital infecton
Describe Rh incompatibility
- Mother is Rh negative and baby is Rh positive
- When blood from the fetus crosses the placenta mother makes antibodies against the Rh factor –> Rh antibodies may destroy some of the fetal RBCs and result in hemolytic anemia
- Rh immunoglobulin (RhIg) given to mothers that are Rh negative
Baby risk for Rh incompatibility
- Hemolytic anemia
- jaundice
- kernicterus
- splenomegaly
- fetal hydrops (fluid accumulation)
How do you prevent Rh alloimmunization
- RhoGAM to mom if Rh-
- given at 28 weeks gestation to prevent Rh sensitization AND at 72 hrs of delivery
OR
after potential blood mixing ( spontaneous abortion, vaginal bleeding, ectopic)
Describe the stages of labor
Stage I: onset to full dilation of cervix 10cm
- Latent: cervix effacement w/ gradual cervical dilation
- Active: rapid cerivcal dilation
Stage II: full cervical dilation until delivery of the fetus
Stage III: postpartum until delivery of placenta
3 signs of placental separation
- Gush of blood
- Lengthening of umbilical cord
- Anterior-cephalad movement of the uterine fundus (becomes globular and firmer) after the placenta detaches
Complications of HTN during pregnancy
- Extra stress of heart, kidneys, and risk for stroke
- Fetal growth restriction (decreased flow of nutrients through placenta)
- Preterm delivery
- Preeclampsia
- Placental abruption
What is transitional (gestational) HTN
HTN w/ no proteinuria after 20 weeks gestation
-resolves 12 weeks post partum
What is preeclampsia
HTN + proteinuria +/- edema after 20 weeks gestation
+/- earlier in multiple gestation or molar pregnancy
What is eclampsia
Preeclampsia + seizure or coma
*life threatening for mother and fetus
Signs/Sx of Preeclampsia
- Edema
- Proteinuria
- HA
- Visual changes/seeing spots
- N/V
- fetal growth restriction
Risk factors for preeclampsia
- 1st pregnancy
- hx of preeclampsia or fhx of preeclampsia
- hx chronic HTN or kidney dz
- 40+ y/o
- Carrying more than 1 baby
- DM, thrombophilia, lupus
- obesity
- IVF
How to dx mild preeclampsia
- BP 140/90 or higher on 2 separate occasions at least 6 hr apart
- Proteinuria >/= 300mg/24 hr or >1+ on dip
How to dx severe preeclampsia
- BP 160/90 or higher
- Proteinuria >/= 5g/24 hr or >3+ dip
- olguria
- thromboyctopenia +/- DIC
- HELLP syndrome
Tx of preeclampsia
- typically managed in hosptial
1. delivery at >/= 37 weeks gestation
2. conservative if <34 weeks–> daily weights, BP, dipstick weekly, bed rest, + steroids to mature lungs
If severe:
- Magnesium sulfate to prevent eclampsia
- Hydralazine or Labetalol to control BP
It is considered Preterm premature rupture of membranes when?
BEFORE 37 weeks gestations
It is considered prolonged rupture of membranes when?
if ruptured greater than 24 hours
Risk factors for gestational diabetes
- Fhx or PMH of gestation DM
- sponatenous abortion
- Hx of infant >4000g at birth
- multiple gestations
- obesity
- age 25+
- AA, Hispanic, Asian, NA
Describe the pathophysiology of gestational diabetes
- Diabetes mellitus that develops in women for the first time during pregnancy
- During pregnancy a woman’s cells naturally become slightly more resistant to insulin’s effects –> change is designed to increase the mother’s blood glucose level to make more nutrients available to the baby
- Mother’s body makes more insulin to keep the blood glucose level normal –> sometimes not enough to keep the blood glucose levels in normal range
How do you dx/screen for gestational diabetes
- Screen at 24-28 weeks gestation w/ 50g oral glucose challenge test (nonfasting)
If ≥140 mg/dL after 1 hour –> perform 3 hour glucose tolerance test - Confirmatory 3 hour 100 g oral glucose tolerance test (Gold standard)
-Performed in the morning after overnight fast
-Positive if (2 or more of the following):
fasting >95 mg/dL,
1 hour > 180 mg/dL,
2 hour > 155 mg/dL,
3 hour > 140 mg/dL
Tx of gestational diabetes
- Insulin tx of choice (doesn’t cross placenta)
- Goal: fasting glucose <95
- Indications: fasting > 105 or postprandial >120
- 0.8 IU/kg 1st trimester, 1.0 IU/kg 2nd trimester, 1.2 IU/kg 3rd trimester
**Check mom for DM 6 weeks postpartum and yearly afterwards
What is HELLP Syndrome
Hemolysis, elevated liver enzymes, and low platelet count– **Medical emergency
- Hemolysis: abnormal peripheral smear, T. bili >1.2, LDH >600 IU/L
- Elevated liver enzymes: SGOT >72 IU/L
- Low platelets: platelets <100,000
*RBCs are damaged or destroyed, blood clotting is impaired, and the liver can bleed internally, causing chest or abdominal pain
What weeks are in each trimester?
1st: 1-12 weeks
2nd: 13-27 weeks
3rd: 28 weeks- birth
What is placenta Previa
abnormal placenta placement on or close to cervical os
can be partial, complete or marginal
What is abruptio placentae
premature separation of placenta from uterine wall after 20 weeks gestation
Bloody vaginal discharge:
I: mild, slight bleeding
II: moderate/partial
III: complete (increased risk to fetus and mom)
What is vasa previa
Fetal vessels traverse the fetal membranes over the cervical os
Clinical manifestation of placenta previa
- PREVIA= sudden onset of PAINLESS bleeding (usually bright red)
- resolves w/in 1-2 hrs
- NO abdominal pain
- Uterus soft and non-tender
Clinical manifestation of abruptio placenta
- ABRUPTIO= ABDOMINAL pain (painful uterine contractions)
- Continuous painful bleeding (dark red)
- Tender and rigid uterus
Clinical manifestations of vasa previa
rupture of membranes–> painless vaginal bleeding
Normal length of gestation
37-42 weeks
Most common birthing position
occiput anterior - head first, face down
Describe APGAR scoring
Usually done at 1 and 5 minutes after birth, repeat at 10 minutes if abnormal -Score from 1-10 ≥7 = normal 4-6 = fairly low ≤3 = critical low
Appearance, Pulse<100=1, Grimace (reflex irritability), Activity (muscle tone), resp.
Risk factors of PROM
- smoking
- STDS
- prior preterm delivery
- multiple gestations
What med controls post delievery uterine bleeding
*Smooth muscle constrictor that acts mostly on the uterus
Methergine
What med • Used to start labor causes uterine contractions and the ripening (effacement or thinning) of the cervix
Cytotec/Misoprostol
What med is used to slow down contractions if hyperstimulated
*Short tern use only, as it can cause maternal heart problems
Terbutaline
*Beta 2 adrenergic receptor agonist
What med is used for reduction of neonatal respiratory morbidity and mortality from preterm delivery
Antenatal corticosteroid therapy
steroid injection given 2 times (12 mg each) 12 or 24 hours apart
Kernicterus if total bili= ___
> 20
Steroids given until ___ for organ maturity
36 weeks and 6 days
Beta hCG doubles every ___ for the first ~__weeks of pregnancy
48-72 hours
12 weeks
Epidural may slow down labor if ___, won’t usually slow down labor if ___
nulliparous
multiparous
Post partum hemorrhage: blood loss ___
> 500 mL
___ can use to predict preterm labor
- 25% PPV, 99% NPV
- If negative, very good predictor that you will not go into labor in the next __ weeks
Fetal fibronectin
2 weeks
Contractions spaced every ___ minutes normal before birth, if faster than this you may have hyperstimulated or sudden change to occurring every __ minutes may be suggestive of abruption
3-4min
1-2 min
describe the components of the uterus
Fundus → muscle
Cervix → rubbery
Lower segment → fibromuscular (Where the c section occurs)
Urine protein:Cr ratio of ___ diagnostic for pre-eclampsia
0.3
70% of DVTs occur in the __ leg
left
→ hard artery pushes against compressible vein on this side
Breastfeeding protects from ovulating to about __- efficacy for ~__ months after birth
95%
6months
No sex for ___ after giving birth
6 weeks
How do you manage pain after delivery
Narcotics or IBU 600mg q6hrs
Not supposed to use stimulatory drugs (Cytotec, Pitocin) on top of each other: space __-
Space 4 hours apart
Stop ___ when methotrexate given for abortion
all vitamins and food with folate
methotrexate a folic acid antagonist and it would defeat the purpose
How do you tx migraines during pregnancy
Benadryl + reglan
Describe Uterus changes during pregnancy
- Ladin’s sign: uterus softening after 6 weeks
- Hegars sign: uterine isthmus softening after 6-8weeks gestation
- Piskaceks sign: palpable lateral bulge or softening of uterine cornus 7-8 weeks gestation
Cervix changes during pregnancy
- Goodells sign: cervical softening due to increased vascularization 4-5 weeks gestation
- Chadwicks sign: bluish coloration of cervix and vulva 8-12 weeks gestation
fetal heart tones can be heard when
10-12weeks (towards end of 1st trimester)
Normal 120-160bpm
When can pelvic US be done
detects fetus ~5-6 weeks
When does fetal movement start
16-20 weeks
Describe where you would expect fundal height to be at the following times 12 weeks 16 weeks 20 weeks 38 weeks
12 weeks: above pubic symphysis
16 weeks: midway between pubis and umbilicus
20 weeks: at the umbilicus**
38 weeks: 2-3cm below xiphoid process
How do you estimate date of delivery (EDD)
Naegeles rule:
1st day of LMP + 7 days - 3 months
ex. LMP: 8/7/16 EDD: 5/14/17
When is the triple screen done
2nd trimester: measured at 15-20 weeks
Alpha-fetoprotein, B-hCG, Estradiol
Describe what the triple screen can reveal
- AFP: LOW, BhCG: HIGH, Estradiol: low = Downs syndrome
- AFP: HIGH, BhCG: N/A, Estradiol: N/A = open neural tube defects ex. spina bifida
- AFP: low, BhCG: low, Estradiol: low = trisomy 18 often stillborn or die w/in 1st yr of life
how much caffeine is safe during pregnancy
1-2 cups caffeine/day
What are the post partum questions
5B's Blues (mood) Breast/bottle feeding Bathroom (bladder/bowel issues) Bottom (healed, check on PE) Birth control
describe the CCHD screening
done at 24 hrs
O2 sat on right hand and either foot
-pass if >95% sat and less than 3% difference btwn the right arm and the other extremity
CCHD screening screens for what main heart defects?
- Tetralogy of Fallot
- total anomalous pulmonary venous retrun
- Transposition of the great arteries
- tricuspid atresia
- Truncus arteriosus
- pulmonary atresia
- hypoplastic left hand syndrome
Describe the pathophysiology of hyperemesis gravidarum
vomiting center oversensitivity to pregnancy hormones
Clinical manifestations of hyperemesis gravidarum
- severe N/V
- weight loss 5% or pre pregnant weight
- acidosis from starvation
- metabolic hypochloremic alkalosis form vomiting
- MC in 1st/2nd trimesters (persists >16 weeks gestation)
Management of hyperemesis gravidarum
- Fluids
- electrolyte repletion
- Multivitamins
- high protein foods/small more frequent meals
- Antiemetics: Pyridoxine (vit. B6) +/- doxylamine 1st line
What is pinkish/brown vaginal bleeding especially postpartum days 4-10 (from the decidual tissue). Usually resolves by 3-4 weeks postpartum
Lochia serosa
Describe BF and menstruation in the postpartum period
breast milk in postpartum day 3-5 bluish/white.
If lactating, mothers may remain anovulatory during that time.
If not breastfeeding, menses may return 6-8 weeks postpartum
Describe the uterus size during the postpartum period
- at level of umbiliuc after delivery
- involution/shrinks after 2 days
- descends into the pelvic cavity ~2 weeks.
- Normal size around 6 weeks postpartum
MC cause of postpartum hemorrhage
uterine atony (uterus unable to contract to stop the bleeding)
initial tx of postpartum hemorrhage
bimanual uterine massage, tx underlying cause, IV access
+/- oxytocin, prostaglandin analogs
A 25 year-old female presents with vulvar pruritus and a thick, white vaginal discharge. Which of the following tests will be most helpful in making the correct diagnosis?
KOH prep is used to assist in the diagnosis of vaginal candidiasis, which presents with vulvar pruritus and white curd like, cheesy vaginal discharge.
On examination of a pregnant patient the physician assistant notes the fundal height is at the level of the umbilicus. This corresponds to what gestational age?
20-22 weeks gestation
A couple presents having not been able to conceive over the past 12 months. Evaluation of the male has been normal. The female has had regular menses. Ovulation can be confirmed with mid-luteal phase measurement of which of the following?
progesterone
A 30 year-old presents with persistent vaginal discharge and vulvar pruritus. The discharge is profuse, frothy, greenish, and foul smelling. pH of the vagina is 6.0. Which of the following is the most likely diagnosis?
Trichomoniasis presents with vulvar pruritus and a profuse, frothy, greenish, foul-smelling vaginal discharge with a pH usually exceeding 5.0.
___ presents with malodorous, gray-white discharge. The pH is typically 5.0-5.5.
Bacterial vaginosis
___ presents with a thick, curd-like discharge and vulvar pruritus.
Vulvovaginal candidiasis
___ presents with sudden, painless, profuse bleeding in the third trimester
Placenta previa
___ presents with a vaginal discharge with a fishy odor and ___ on wet mount exam
-Tx for this is __
Bacterial vaginosis
- clue cells
- metronidazole
Treatment of the patient with Pediculosis pubis consists of which of the following?
Permethrin (Nix) cream- 1% cream/shampoo is used to kill the louse and remove the eggs from the hair shafts.
if a woman has a normal 28-day menstrual cycle what tissue and hormonal phase occurs during the last 14 days?
Secretory luteal phase under the influence of estrogen and progesterone
___ presents with a frothy discharge, irritative symptoms of pruritus, dysuria, and frequency, and you diagnose this with ___
Trichomonas
-the flagellated protozoa are demonstrated on a saline preparation
___ usually present with a white cottage cheese discharge and you diagnose this with ___
Candida infections
- diagnosed by demonstrating hyphae and budding yeast on KOH prep
__ usually presents with vaginal discharge that is grayish and has an unpleasant fishy odor and you diagnose this with ___
Gardnerella vaginalis infections
-Clue cells are seen on normal saline prep
What is the recommended method for screening pregnant women for gestational diabetes?
50 gram glucose load followed by a blood sugar in 1 hour
At the time of ovulation in a normal menstrual cycle, there is a peak in the serum concentration of what hormone?
LH- responsible for ovulation
At ___ weeks, fundal height is midway between the pubic symphysis and umbilicus.
16 weeks
Nägele’s rule is
LMP minus 3 months plus 7 days.
What phase of the female menstrual cycle occurs at the time of elevated estrogen and LH/FSH surge?
Ovulation occurs within 30-36 hours of the LH surge and at the time of elevated estrogen.
