Pregnancy & Child Birth Flashcards
[T or F] Posterior Cul-De-Sac fluid accumulation in a pregnant woman is an abnormal finding
FALSE
(this is a normal finding for preggos along with corpus luteum ovarian cyst UNLESS IT’S IN THE SETTING OF ECTOPIC. THEN IT MEANS HEMOPERITONEUM)
Which CA does breastfeeding reduce - 2
- Breast
- Ovarian
Breastfed infants have a Decreased risk of what conditions - 5
- SinoPulmonary infection (Ear, Lung, GI, UTI)
- Necrotizing Enterocolitis
- Type 1 DM
- CA
- Childhood Obesity
For pts taking OCP
How does Estrogen affect Thyroid function?
Estrogen (OCP, Pregnancy) ⬆︎ T4 binding globulin –> mostly euthyroid state (slight HYPERthyroid sx) and normal TSH
How does fetal hyperglycemia affect newborns? - 3
it –> macrosomia, hypOglycemia, birth malformations
What are the 4 main inquries pts should be asked when coming in for L&D checks?
Can Mom Feel Baby?
Contractions?
Movement from Fetus?
Fluid leak vaginally?
Blood leak vaginally?
Which 4 drugs can you give to treat HTN in pregnant patients?
Mothers Loathe Nefarious HTN
Methyldopa / Labetalol > Nifedipine / Hydralazine
Explain what Pseudocyesis is
Somatization of stress –> activates [hypothalamic-pituitary-ovarian] axis –> early pregnancy sx without there actually being a baby in utero = nonpsychotic woman who mentally AND PHYSICALLY presents like she’s pregnant (may even misinterpret a pregnancy test!)
US and clinic pregnany test will be negative
Risk factors for Pseudocyesis - 2
- infertility hx
- prior abortion
Neonatal Abstinence Syndrome
Classic Signs-4 ; What drug usually causes this?
STTD
- Sneezes a lot
- Tremors w/sweating
- Tachypnea w/HIGH PITCHED CRY
- Diarrhea
From intrauterine exposure to Opiates (i.e. Heroin/Methadone)!
s/s of intrauterine cocaine exposure - 3
- Excessive sucking
- Jitteriness
- Hyperactive Moro reflex
Postpartum depression affects women during what time periods?
________________
What 2 methods are used to screen for this?
[within 1st year > first 3 mo]
________________
- [PHQ2 –(if both +)–> PHQ9]
- Edinburgh Postnatal Depression Scale
Screen prenatal, postnatal and well child
Give brief descriptions that differentiate Postpartum
Blues vs Depression vs Psychosis
- Blues = onsets PPD1, peaking at PPD5 and subsiding PPD14, worst w/lactation
- Depression = can onset between [1 month - 12 months after birth] Traditional s/s. Previous Depression hx is RF
- Psychosis = RARE but onsets IMMEDIATELY after birth
CP of [Edward’s Trisomy 18] - 8
- Prominent Occiput
- [Dysplastic malformed ears]
- Micrognathia (small jaw & mouth)
- VSD
- [shielded chest with wide nipples]
- Overlapping Fingers
- Absent Palmar creases
- Rocker-bottom feet
These pts die within 1st month of life
What are 5 ways to determine if a pt truly has Leakage of Amniotic Fluid?
- Amnisure immunoassay (detects placental ⍺-microglublin1)
- POOL test (there’s pool of fluid in vaginal vault)
- NITRAZINE test (fluid turns blue when placed on nitrazine paper since amniotic fluid is alkaline)
- FERN test (fern-like estrogen crystals under microscopy)
- US to determine fluid quantity (Normal = 6-23 cm AFI)
What are the 2 clinical features for diagnosing ACTIVE labor? -4
Labor = LAPD
- [Strong Contractions every 3-5 min]
- [Cervix Dilation > 6 cm]
- [Cervix growing at 1-2 cm/hr]
- [Cervix effaced]
Fetal Heart Tracing is IRRELEVANT to diagnosing active labor
After the Rupture of Membranes, when is it safe for labor to begin?
[1 - 18 hours after ROM] (no sooner ; no later)
________________
labor starting ≥18H after ROM ➜ chorioamnionitis ➜ neonatal sepsis
________________
- Do not confuse this with PPROM (Preterm Premature Rupture Of Membrane)*
- Chorioamnionitis Tx = Abx –> Delivery*
What constitutes an infant as “Full Term”?
37 - 42WG
For Antepartum patients, their NST (Non Stress Test) should be reactive
What is the Fetal Heart Tracing criteria for this?-4 Does this happen in pts in labor?
reactive = appropriate [fetal cerebral oxygenation]
- within a 20 min period there are
- at least two HR acclerations that are
- 15 bpm over baseline
- 1.5 small boxes long (15 sec)
THIS IS NOT REQUIRED FOR PTS IN LABOR
What is the normal Fetal Heart Rate and variability on a NST?
110 - 160/min (w/variability of 6-25)
Normal Fetus’ should have a reactive NST
Criteria for PreEclampsia is Gestational HTN + [Proteinuria or End Organ Damage]
How do you clinically diagnose Gestational HTN? - 6
- NO previous HTN
- ≥ 20 WG (2nd trimester)
- Systolic > 140
- Diastolic > 90
- At least 2 readings taken > 6 hrs apart
- BP taken in seated or semi-reclined position
FYI: PreEclampsia can still occur superimposed on Chronic HTN
Criteria for PreEclampsia is Gestational HTN + Proteinuria
Which demographic are at greater risk for this?
Af American Women
greater risk of having PreEclampsia, it being severe and suffering placental abruptio and Eclampsia
What are the 4 major causes of Postpartum Hemorrhage? - 4
The 4 T’s!
Tone (Uterine aTony)
Trauma (Perineal vs Cervix lacerations vs Uterine inversion/prolapse)
Tissue (retinaed/invasive placental tissue)
Thrombin (rare bleeding DO)
What is Intrauterine Fetal Demise (IUFD)?
________________
Dx?-3
fetal death ≥ 20WG BUT before onset of labor
________________
- No fetal cardiac activity on US
- No fetal heart tones on Doppler
- No/minimal subjective fetal mvmnt
This commonly occurs in uncomplicated pregnancies
What is the management for Intrauterine Fetal Demise? - 2;
What complication can arise from IUFD?
Main causes: Anencephaly, Potter sequence, etc.
- If ≥24 WG = Induced Vaginal Delivery regardless of fetal lie when Mom’s ready and before 28 WG if possible
- If 20-23WG = Dilate and Curettage
- keeping fetus in there > 28 WG can –> coagulopathy*
- * fetal death < 20WG = spontaneous abortion **
When is [RhoGam AntiRhD] administered to Rh NEGATIVE pregnant women? - 7
DO THIS FOR ALL Rh NEGATIVE mothers
- 50mcg 1st trimester if uterine bleeding and/or spontaneous abortion occurs
- 300mcg at 28 WG
- 300 mcg within 3 days after delivery (MUST adjust with Kleihauer-Betke if fetomaternal hemorrhage /abruptio placentae occurs)
- give with each vaginal bleeding
- give with External Cephalic Version
- give with Hydatidiform Mole
- give with Ectopic Pregnancy
When are pts screened for Group B Strep via vaginal and rectal swab?
35-37 WG
results are valid for 5 weeks
Why is prematurity a risk factor for breech presentation?
________________
What’s a way to convert a breech into cephalic?
25% of fetuses ≤28WG are naturally breeched, but will flip over into cephalic position by 37 WG
________________
External Cephalic Version (can only be done ≥37 WG)
External Cephalic Version can only be done at ⬜ weeks gestation!!
What are the contraindications to External Cephalic Version? - 7
≥ 37 WG
- There are vaginal delivery ctd and C/S (CSection) is indicated instead
- Placental demise (previa or abruptio)
- Oligohydraminos
- Rupture Of Membrane
- Hyperextended fetal head
- Fetal/Uterine anomaly
- Multiple Gestation
CP for Placental Abruptio - 3
Risk factors = HTN, cocaine and smoking
- PAINNNFFULLL antepartum vaginal bleeding (which can –> hypovolemic shock, [DIC-from decidual bleeding releasing tissue factor 7] and fetal demise)
- Distended firm uterus
- abd AND/OR back pain
etx: HTN of maternal decidual vessels –> rupture –> premature detachment of placenta from endometrium
What are the risk factors for Intrauterine Fetal Demise? - 3
- SMOKING intrapartum! (can also –> asymmetric IUGR)
- IUGR
- abnormal fetal karyotype
AFP is a protein made by the (⬜3) It is obtained in pregnant women at ⬜ weeks gestation via ⬜
[Fetal Yolk Sac]/GI/Liver
________________
15-20WG
________________
via Quad BUAD screen
AFP is obtained in pregnant women at 15-20WG
________________
What does an elevated AFP indicate in a pregnant woman?-3
- Fetal Open Neural Tube Defects (open spina bifida, anencephaly)
- Fetal Abd Wall defect (Gastroschisis, Omphalocele)
- Multiple gestation (twins)
If ⬆︎AFP –> GET ANATOMY US!
What is an Internal Podalic Version?
Performed in twin deliveries to convert 2nd twin from transverse presentation –> breech presentation for subsequent delivery
What is Vasa Previa MOD?
fetal vessels traverse the amniotic membranes over the internal cervical os –> antepartum bleeding and FHR abnormalitites after ROM (rupture of membrane)
Which vaccines should be given to pregnant women during their pregnancy? - 5
- Tdap (27-36WG)
- Flu inactivated
- RhoD (28WG)
- Hep A killed - if HepC positive
- Hep B killed - if HepC positive
Which vaccines can be given to pregnant women AFTER delivery (since they’re contraindicated for intrapartum)? - 3
- HPV
- MMR
- Varicella
Spontaneous abortions (unprovoked pregnancy loss < 20 WG) are usually a result of ⬜
what are the other 2 less common causes?
chromosomal abnormalities
- teratogen exposure
- mullerian anomalies (uterine septum)
________________
IUFD etx = mostly unknown
What are the options for Mngmt of Spontaneous Abortion - 4
- Expectant: Watchful Waiting for products of conception to expel naturally in 2-6 weeks
- Surgical: [Dilitation & Curettage (D&C) (cant be done during infection)] or [Manual Vacuum Aspiration]
- Medical: 800mcg Vaginal Misoprostol - takes up to 2 weeks for expel
ALL REQUIRE 1 WEEK FOLLOW UP
When is a hgb electrophoresis screen indicated in a pregnant woman?
Pt has anemia during pregnancy ([hgb < 11] + [MCV < 80])
Non-Pregnant female normal hgb = 12-16
What are the risk factors for Placenta Accreta - 4
________________
dx?
- prior c/s (csection)
- prior D&C (dilation and curettage)
- Myomectomy
- Maternal age > 35
________________
Dx = Intraplacental villous lakes on antenatal US
CP for Uterine Inversion? - 3
- Smooth mass protruding from cervix or vagina
- postpartum hemorrrhage
- severe abd pain
results from inversion/collapse and prolapse of uterine fundus thru cervix or vagina
What are the 4 major causes of Postpartum Hemorrhage? - 4
The 4 T’s!
Tone (Uterine aTony)
Trauma (Perineal vs Cervix lacerations vs Uterine inversion/prolapse)
Tissue (retinaed/invasive placental tissue)
Thrombin (rare bleeding DO)
Major causes of Antepartum Hemorrhage - 3
Antepartum = right before childbirth
- Placental abruptio (PAINFUL Anterpartum hemorrhaging)
- Placental previa
- Vasa Previa
A pregnant pt who looks like they’re in [active labor stage 1B] but has a baby tht regressed from 0 station to -3 Station should concern you for ⬜
Uterine rupture!
- “Full thickness disruption of the uterine wall”*
- biggest RF = pre-existing uterine scars (c/s, myomectomy)*
What are the risk factors for Uterine Inversion? - 4
- Nulliparity
- LGA
- Placenta Accreta (RF: prior c/s, myomectomy, D&C)
- Precipitous (rapid) Labor & Delivery
results from inversion/collapse and prolapse of uterine fundus thru cervix or vagina when too much traction is applied to cord before placental separation
A pt with precipitous vaginal delivery (within 3 hours after contractions start ) has just had a uterine inversion with prolapse and postpartum hemorrhage
After giving fluids for loss of blood, what’s the ultimate tx for [Uterine prolapse] ? - 3
1st: Replace the Uterus first
2nd: AND THEN remove placenta if still attached
3rd: Give Uterotonics (oxytocin/misoprstol) to ⬇︎ postpartum hemorrhage
What is Cervical insufficiency
2nd trimester PAINLESS Cervical Dilation that –> Spontaneous abortion (< 20WG) or IUFD ( ≥ 20WG)
CP for septic abortion - 3
- Fever
- malodorous purulent vaginal discharge
- Large, Boggy tender uterus –> lower abd pain
usually comes from unsterile/incomplete elective abortion
What would ultrasound reveal for septic abortion
irregularly thickened endometrial stripe with active blood flow
What is a Cerclage procedure?
Using a suture or synthetic tape to reinforce the cervix in 2nd trimester pts who have cervical length ≤ 2cm per transVaginal US (or 2.5 if preterm hx present) or risk for PPROM
What does the Biophysical Profile (BPP) consist of? - 2 ; What is the breakdown of the results?
NonStress Test
+
[US assessment of Amniotic Fluid/Fetal mvmnt/Fetal tone/Fetal breathing - each given 2 points if nml and 0 if not]
Normal= 8,10 (repeat BPP in 1 wk) / Equivocal=6 (repeat BPP in 24 hrs) / Abnml=0,2,4
this (and alternative Contraction Stress Test) are performed in high risk fetal demise pregnancies to assess for fetal hypoxia
What is Doppler US of the umbilical artery used for?
evaluates for fetoplacental vascular insufficiency in IUGR pts (< 10th%tile)
What is the dx for Hydatidiform mole gestation? - 2
- “Snowstorm with grapes” on ultrasound
- HHIIGH LEVELS OF bHCG (> 100,000)
Most of the time this is caused by sperm implanting an EMPTY ovum
Septic Abortion can –> Peritonitis, Sepsis and Death
How do you manage it? - 3
- broad abx x 2 days
- Dilation & Curettage
- IVF
In the context of Ob/Gyn, what is Methotrexate typically used for? - 2
- Ectopic pregnancy
- Gestational Trophoblastic Neoplasia
What is a Nuchal Cord
when loop of umbilical cord wraps around fetus’ neck –> recurrent variable decelerations but is not clinically significant
What are the effects of Amphetamine use during pregnancy? - 6
- IUGR
- Intrauterine fetal demise
- preeclampsia
- Placenta abruptio
- Preterm delivery
- Maternal death!
Risk factors for Cervical Insufficiency - 2
- DES intrauterine exposure–> congenital abnormalities
- cervical surgery
Gastroschisis is associated with ⬜ trimester use of which drug?
1st trimester use of NSAIDs
Fetal Heart Tracing like this indicates what dx?
Fetal Anemia
Sinusoidal Fetal Heart Tracing
What are the risk factors for Polyhydraminos? - 2
Polyhydraminos ( ≥24 cm AFI) is a risk factor for Placenta Abruptio
- Maternal DM - poorly controlled
- swallowing fetal anomalieis (esophageal atresia)
Criteria for PreEclampsia is Gestational HTN + [Proteinuria or End Organ Damage]
How does the Liver play a role in SEVERE PreEclampsia?
PreEclampsia –> SEVERE PreEclampsia –> HELLP and at anytime, Eclampsia is possible
Centrilobular necrosis, hematoma formation and portal capillary thrombi all –> Distension of the [Glisson’s Hepatic Capsule] –> RUQ OR Epigastric abd pain = SEVERE PreEclampsia
How many pounds are pts underweight (BMI < 18.5) advised to gain?
35 lbs ([16kg])
Hyperemesis Gravidarum is a normal part of pregnancy
When is it expected to resolve?
by 20WG
BE SURE TO WATCH OUT FOR THIAMINE DEFICIENCY SX IN THESE PTS!
name the possible sequelae of Gestational HTN? - 7
Remember: can ONLY be diagnosed in ≥ 20 WG
- IUGR asymmetrically
- Preterm delivery
- Oligohydraminos (AFI ≤5 cm)
- Perinatal mortality
- Placental Abruptio
- Preeclampsia superimposed
- c/s
Risk factors for Placenta Previa - 3
PAINLESS Antepartum Vaginal Bleeding with unaffected FHT since bleeding is all maternal
- c/s
- Multiparity
- Smoking
PAINLESS Antepartum Vaginal Bleeding with ONLY maternal vitals changing
“previews are painless :-)”
What is Pubic Symphsis Diastasis? ; What is the clinical presentation of this after a traumatic delivery?
Physiological widening of pelvis by progesterone and relaxin to facilitate vaginal delivery ; Postpartum suprapubic TTP pain that radiates to the Back and/or Hips
worst with weight bearing, walking or position change and resolves by 4 weeks PostPartum
After vaginal delivery, pt is now numb over her Anterior and Medial thigh
What happened?
Prolonged Hyperflexion at Hip for vaginal delivery (McRoberts maneuver) can –> Femoral n compression –>
- Anterior & Medial thigh numbness
- ⬇︎hip flexion
- ⬇︎patellar reflexes
When is Placenta Previa typically diagnosed?
________________
What are the things that are contraindicated because of Placenta Previa? - 4
20 WG via routine US
________________
- Coitus
- Digital examination
- Vaginal delivery
- External cephalic version
sometimes previa (and other malpresentations) spontaneously resolves by 3rd trimester due to growth of lower uterine segment and/or placental growth toward fundus. but other wise schedule c/s for 37 WG
Sciatica etx ; Clinical Presentation - 3
“Having Sciatica makes you break LAWS”
- [Lower Back pain w/radiation down POST thigh –> lateral foot]
- Ankle jerk reflex ABSENT
- Weak Hip Extension
- [S1 n PosteroLateral compression at L4-5 or L5-S1]
Gestational sacs normally implant in the _____
Describe a Cornual Interstitial ectopic pregnancy
upper uterine fundus ;
implantation in outer “cornual” areas of uterus
dx = transVaginal US // tx = MTX or surgery if severe
Name the major risk factors for Ectopic Pregnacy - 6
- previous ectopic
- previous Pelvic
- previous Tubal surgery
- PID
- Bicornuate heart shaped uterus (causes cornual interstitial ectopic pregnancy)
- In Vitro Fertilization (causes cornual intersitital ectopic pregnancy)
tx = MTX or surgery if severe
Placenta Previa and Vasa Previa both present as PAINLESS Antepartum Vaginal bleeding
What is the differentiating factor? - 2
- Since Vasa Previa involves destruction of fetal blood vessels it –> deterioration of FHT (bradycardia, decelerations), while Placenta Previa is all maternal bleeding only so FHT is NOT affected.
- Vasa Previa occurs only after amniotomy is done
PPROM = Preterm Premature Rupture Of Membranes (which occurs before 37 WG)
How do you manage PPROM when it occurs ≥ 34WG?
Complications = Chorioamnionitis/Endometritis/Cord Prolapse/Placenta Abruptio
PPROM = Preterm Premature Rupture Of Membranes before 37 WG
How do you manage PPROM when it occurs
if baby not compromised, fetal surveillance until 34 WG and then deliver!
Complications = Chorioamnionitis/Endometritis/Cord Prolapse/Placenta Abruptio
PPROM = Preterm Premature Rupture Of Membranes before 37 WG
________________
What are 2 px therapies for PPROM?
- Progesterone (vaginal or IM after 1st trimester)
- Cerclage
Complications = Chorioamnionitis/Endometritis/Cord Prolapse/Placenta Abruptio
The First Trimester Combined Test analyzes risk for ____ and ___ by measuring what 3 things?
If abnormal, how should this test be followed up? - 2
At 9-13WG analyzes risk for Trisomy 21 or Edward’s Trisomy 18 by measuring the BUM inside the pregnant woman
- βHCG
- US analyzing fetal nuchal translucency
- Maternal protein A serum
if abnormal, f/u with
1st: Fetal Karyotyping obtained via [amniocentesis if ≥ 14WG] or [Chorionic Villus Sampling if ≤ 13WG]
ALTERNATIVE IF MOTHER DECLIENS INVASIVE TESTING: [cell free fetal DNA screen (cffDNA)] (usually used as screen ≥ 10WG) (this should come before First Trimester Combined Test if pt is high-risk for aneuploidy)
Hyperandrogenism (Hirsutism/Acne) during pregnancy is a benign condition that is caused by _____-2 ; Dx? ; Tx?
[luteoma ovarian mass] or [theca luteal ovarian cyst(comes from ⬆︎⬆︎⬆︎βHCG Hydatidiform mole)];
Dx = US ;
Tx = Watchful Waiting since it typically resolves after delivery (but watch for mass effect on the kidneys and inform pt that this ⬆︎virilizaiton risk)
What is the classic presentation for Uterine rupture? ; What are the risk factors? - 2
recession of fetal station after sudden abd pain
any prior uterine scars
- prior c/s
- prior myomectomy (usually for fibroids)
Asymmetric IUGR is typically caused by ____-3 while Symmetric IUGR is caused by ___-2
Symmetric = Head AND Abd are growth restricted while in Asymmetric it’s mostly just Abd
Maternal HTN, Maternal DM, Smoking (these cause IUGR in the 2nd & 3rd trimester);
- Congenital chromosome abnormality
- Congenital infxns of 1st trimester (toxo, CMV) = RARE
What is “Precipitous” labor?
________________
What’s the greatest risk factor for Precipitous labor?
Delivery within 3 hours after contractions start
________________
Multipartiy
Precipitous labor is NOT affected by Oxytocin induction and is usually spontaneous. It may cause Uterine prolapse!
What effects does Tachysystole have on the fetus - 4
Tachysystole: ≥6 ctx in 10 min period
- Usually none
- ⬆︎ risk for c/s
- ⬆︎risk for NICU
- ⬇︎umbilical cord pH due to hypoxemia
What are the effects of Oxytocin toxicity? - 3
- hypOtension (⬇︎ BP)
- hypOnatremia (oxytocin cross reacts with POST pit ADH receptors)
- Tachysystole ( ≥6 ctx in 10 min)
tx: 3% Hypertonic saline
What is the Kleihauer Betke test
Determines the dose of [Rhogam Anti-D] needed after delivering an Rh+ fetus to an Rh- mother. Can confirm or exclude fetomaternal hemorrhage
Full term infant = 37- 42WG
How do you manage Preterm Labor 34 to 36+6 WG - 2
Pregnant Bitches
Full term infant = 37 -42WG
How do you manage Preterm Labor 32 to 33+6 WG - 3
Pregnant Bitches Take
Full term infant = 37 - 42WG
How do you manage Preterm Labor < 32WG - 4
Pregnant Bitches Take Money
Name the main Tocolytics - 5
- Mg (⬇︎ Ca+ needed for uterine ctx)
- Indomethacin (⬇︎Prostaglandin as a COX inhbiitor)
- Nifedipine (Ca+ Channel Blocker)
- Terbutaline (Relaxes Uterus as B2 agonist)
- Atosiban (Uterus Oxytocin R Blocker)
What factors indicate ⬆︎ risk for possible Preterm labor? - 4
Full Term delivery = 37 - 42WG
1st best indicator: PRIOR PRETERM DELIVERY = STRONGEST INDICATOR
2nd best: Shortened cervix ≤ 2cm per transVaginal US (or 2.5 if preterm hx present) - hx of cold knife conization?
3rd best: + Fetal Fibronectin BUT ONLY BETWEEN 20-37WG
4th best: Circumstantial (Smoking, multiple gestation, IVF, obesity)
Mg Sulfate is 1st line for Eclampsia px
What are the alternatives for Eclampsia px? - 2
- Diazepam
- Phenytoin
Normal Fetal Heart Rate is 110-160 bpm
What could Fetal Tachycardia indicate? - 6
- Infxn chorioamnionitis (will include maternal fever)
- Hypoxia
- Anemia
- Maternal Hyperthyroidism
- Placenta Abruptio
- Meds (terbutaline)
What is the FIRST thing you should look at when seeing a pregnant patient? Why is this?
Blood Pressure! ; RULE OUT PREECLAMPSIA
Risk factors for pt having preterm delivery? - 6
- prior Preterm delivery
- > 40 yo
- multiple gestation
- Gestational HTN
- Amphetamine use
- Cocaine
Pregnant Bitches Take Money
What are the major s/s of Magnesium Toxicity - 2
Risk Factor = Renal Insufficiency
- Neuro depression (Somnolence, ⬇︎ Deep tendon reflexes, Visual disturbances, Paralysis)
- Respiratory depression
- Risk Factor = Renal Insufficiency since it’s renal excreted!!*
- Tx for Mg Toxicity = Ca+Gluconate*
Amniotic Band Sequence CP - 3
- limb defects
- craniofacial defects
- abd wall defects
NON-LETHAL :-)
A Nonreactive NonStress test is one without _____. What does a nonreative NonStress test indicate? - 2
Accelerations ;
- poor [fetal cerebral oxygenation] OR
- fetal sleep (20 min duration) - be sure to extend NST to at least 40 min to catch this!
Nonreactive NonStress test should be f/b BioPhysical Profiles to assess for necessary intervention
A pregnant pt has Graves’ disease
What medication is recommended to treat this in the 1st trimester? What about the 2nd and 3rd trimester?
PTU ; Methimazole
[T or F] You should be alarmed if a fetus of 14 Weeks Gestation has no accelerations (nonreactive stress test) on Fetal Heart Tracing
Why or Why not?
FALSE!
Fetal heart accelerations are a sign of good [fetal cerebral perfusion] and therefore neuro development, and neuro development doesn’t fully develop until 28 WG
In the context of labor and delivery, how do retroperitoneal hematomas form? ; What is the CP?-3
damage to internal iLiac artery during delivery ;
- Palpable mass
- Hemodynamic instability
- Fever
Hyperemesis Gravidarum is a normal part of pregnancy that resolves by 20 WG
What are the risk factors for getting this? - 3
- Multiple Gestation
- GERD hx
- Hydatidiform Mole (note: elevated βHCG can stimulate thyroid and –> thyrotoxicosis of hyperemesis!)
HG is usually unresponsive to PO antiemetics, and can cause Thiamine Deficiency
Name the causes of Variable Decelerations on Fetal Heart Tracing
Umbilical Cord
Compression (consider cord prolapse, oligohydramnios or nuchal cord as etx)
VEAL CHOP
A pregnant pt is having recurrent Variable decelerations with more than 50% of her contractions
tx? - 2
L lateral decubitius Maternal repositioning –> amnioinfusion if that doesn’t work
(⬇︎umbilical cord compression)
What are the most common dangerous activities for pregnant women? - 4
- Contact sports (basketball/hockey/soccer)
- High Fall Risk (skiing/gymnastics/horseback riding)
- Scuba diving
- Hot yoga
30 min of moderate exercise/day is actually recommended for pregnant pts unless ctd (see image)
Systemic Lupus Erythematosus in pregnant pts complicates the picture of diagnosing preeclampsia since they both present very similarly
How can you differentiate the two? - 4
- pt will have more classic s/s of SLE (RASH OR PAIN)
- RBC cast = SLE
- ⬆︎ ANA = SLE
- ⬇︎Complement = SLE
Beware: SLE can look like Preeclampsia!
Systemic Lupus Erythematosus in pregnant pts complicates the picture of diagnosing preeclampsia since they both present very similarly
What are the ⬆︎ risk associated with having SLE during pregnancy? - 5
- preeclampsia (smh naturally)
- preterm
- c/s
- IUGR
- fetal demise
Beware: SLE can look like Preeclampsia!
Full term infant = 37- 42WG
What are the Fetal complications involved with Late term (41-42WG) and Post term ( > 42WG) pregnancies? - 5
- STILLBIRTH 2/2 UteroPlacental insufficiency
- Oligohydramnios (UteroPlacenta insufficiency ⬇︎fetal urine output)
- Macrosomia
- Meconium aspiration
- Convulsions
Maternal complications = infxn, postpartum hemorrhage, c/s
When is the First Trimester Combined Test administered?
analyzes risk for Trisomy 21 or [Edward’s Trisomy 18] by measuring BUS
9-13WG
Gestational sacs normally implant in the _____
What is the “typical” triad for Ectopic Pregnancy? - 3
upper uterine fundus ;
VAL had an ectopic the other day!
- Vaginal bleeding/spotting
- Adnexal Tenderness (if implanted in tube)
- Lower abd pain
dx = transVaginal US / tx = MTX or [surgery if severe]
IUFD = fetal death ≥ 20WG but before onset of labor
What is usually the cause of IntraUterine Fetal Demise?
UNKNOWN!!
This commonly occurs in uncomplicated pregnancies and could be maternal/placental/fetal origin
Endometriosis is defined as ______
What are the possible findings for Endometriosis? - 4
Endometriosis = endometrial glands and stroma outside the Endometrium
- Gun Powder burn lesions
- ADHESIONS –> immobile uterus
- Chocolate fluid
- Nodules flesh or dark colored
# of implants does NOT correlate with sx intensity and these pts can be asx!
Dx = Laparoscopy to biopsy & remove endometriotic lesions
CP for Endometriosis - 5
Homogenous cystic ovarian mass
The 3 Ds and All
- Dysmenorrhea
- Dyspareunia - implants in posterior cul-de-sac
- Dyschezia (painful defecation) - implants in posterior cul-de-sac
OR
(4) ASX (tx not indicated if so) - otherwise tx = NSAIDs –> Contraceptives (combined OCP/IUD progesterone)
(5) Infertility of unknown origin
* Findings: Gun Powder Burn lesions, ADHESIONS–>immobile uterus, Chocolate fluid*
* Dx = Laparoscopy to biopsy & remove endometriotic lesions*
tx for Endometriosis - 5
Homogenous cystic ovarian mass
- observation if asx
- NSAIDs 1st
- Contraceptive (OCP/IUD progesterone)
- Leuprolide (GnRH agonist that ⬇︎Endometrial gland estrogen stimulation)
- Hysterectomy with oophorectomy
- Findings: Gun Powder Burn lesions, Adhesions, Chocolate fluid*
- Dx = Laparoscopy to biopsy endometriotic lesions*
What is the purpose of Chorionic Villus Sampling? ; What is the differnece between this and amniocentesis?
determines fetal karyotyping via placental biopsy
both CVS and amniocentesis can be used for fetal karyotyping but only amniocentesis can be used in > 13 WG pts
Full term infant = 37- 42WG
Most Tocolytics are not used in managing Preterm Labor 34 to 36+6 WG
Why specifically is Nifedipine not used?
Pregnant Bitches
Maternal hypOtension with reflex tachycardia
Full term infant = 37- 42WG
Most Tocolytics are not used in managing Preterm Labor 34 to 36+6 WG
Why specifically is Indomethicin not used? - 2
Pregnant Bitches
- Premature closure of ductus arteriosus
- Oligohydramnios
Full term infant = 37- 42WG
Most Tocolytics are not used in managing Preterm Labor 34 to 36+6 WG
Why specifically is Mg not used?
Pregnant Bitches
It’s a weak tocolytic so it doesn’t actually help with slowing contractions down in preterm delivery
Krukenberg tumors present like Luteomas, in that they both cause Female Hirsutism
Where do Krukenberg tumors come from?
they are Metastasis from GI CA
Erby’s palsy of an infant is a common complication of shoulder dystocia
Impingement of which nerves causes the self-limited Erb’s Palsy? - 3
- C5 –> deltoid and infraspinatus muscle weakness
- C6 –> bicep muscle weakness
- C7 –> enables predominance of opposing muscles
tx = 3 month self limited, but give massage and Physical Therapy to prevent contractures
Prolonged Rupture of Membranes ≥ ___ hours is a risk factor IntraAmniotic Infection & neonatal sepsis
What is the dx criteria for IAI (IntraAmniotic Infection)? - 2
18
Maternal Fever
+
≥ 1 of:
- Uterine tenderness
- Tachycardia (maternal or fetal)
- malodorous amniotic fluid
- purulent vaginal discharge
* Chorioamnionitis Tx = Abx –> Delivery*
Why is it rare for Women to get PID after the ___ trimester
1st; cervical mucus and decidua seals off the uterus from pathogens during pregnancy
Physically describe Uterine Atony - 3
- soft (it’s lost its tone)
- boggy
- enlarged above the umbilicus
this also could indicate retained blood clots or septic abortion
Methylergonovine MOA ; Indication?
UteroTonic –>
- uterine contraction
- vasoconstriction (ctd in HTN pts)
- smooth m constriction
Indication = When Uterine massage AND oxytocin have failed to stop postpartum hemorrhage 2/2 uterine atony
Although most commonly associated with Alcoholism, why are pregnant pts also at risk for developing Wernicke Encephalopathy from Thiamine deficiency?
Hyperemesis Gravidarum = severe NV that –> dehydration, wt loss from hypoglycemia and thiamine deficiency/Wernicke Encephalopathy which can –> Spontaneous Abortion!
Tx = Glucose WITH Thiamine B1 supplement
Biophysical Profile and Contraction Stress Test can either or be used to assess for fetal hypoxia in high risk pregnancies
How do you perform a Contraction Stress Test?-2 ; What are the contraindications?
- Give Oxytocin to induce contractions and watch fetal heart tracing OR
- Nipple Stimulate until 3 contractions every 10 min occur
CTX = any ctx to labor itself (as both of these can –> active labor) - ex: placenta previa, prior myomectomy
How do you manage SEVERE Preeclampsia when it occurs ≥ 34WG?
It’s the same as PPROM!
How do you manage SEVERE Preeclampsia when it occurs
It’s the same as PPROM! Evaluate Fetal well-being first
CP for Acute Fatty Liver of Pregnancy - 3 ; When does this occur?
3rd trimester
- NV
- hypOglycemia
- ⬆︎LFTs
linked to [fetal long chaing dehydrogenase fatty acid dysfunction] . Can look like Hyperemesis Gravidarum but occurs 3rd and not 1st!
What are the absolute contraindications to breastfeeding? - 7
- Maternal HIV
- Herpes Simplex breast lesions
- untreated TB
- Varicella active
- Substance use
- Chemoradiation
- Infants with galactosemia
Hep B pts can breastfeed as long as baby receives HepB Immunoglobulin and vaccination
What is lochia
postpartum uterine/vaginal discharge that’s normal
Because of ____ and ____, immediate postpartum urinary retention is expected. When does this become pathologic (bladder atony)?
Regional anesthesia and [Pudendal n palsy 2/2 pelvic floor injury] ; if urinary retention is > 6 hours after delivery then = Bladder Atony
Tx = ambulation f/b catheterization until resolves spontaneously
name the most common causes of uterine size-date discrepancy in pregnant patients - 5
- INCORRECT DATING
- Multiple gestation
- Hydatidiform Mole
- Leiomyomata uterine Fibroids (irregular contour)
- Polyhydraminos (only in 2nd & 3rd trimester and is uniform)
Why is it normal for pregnant patients to have a systolic ejection murmur
⬆︎Stroke volume during early pregnancy –> ⬆︎Cardiac Ouput AND ⬆︎HR during late pregnancy –> even more ⬆︎Cardiac Output
Also, Volume expansion can –> peripheral edema and their body compensates by ⬇︎BP
How does pregnancy affect the respiratory system? - 2
Progesterone ⬆︎tidal volume for more O2 (pt takes deeper breaths) –> physiologic hyperventilation and this –> physiologic respiratory alkalosis (PaCO2 27-32) - eventually kidneys compensate by dumping HCO3
+
enlarging uterus ⬇︎ functional residual capacity
Both cause pregnancy dyspnea
What is often the cause of Early Decelerations on Fetal Heart Tracing
Head Compression of Fetus
these occur WITH contractions and no tx is required
False labor occurs as a result of Braxton Hicks contractions and causes NO CERVICAL CHANGE
Compare the Timing / Strength / Cervix status of contractions occuring in False Labor to True Labor
Uterine Contractions…
FALSE = irregular + weak + NO CERVICAL CHANGE
True = [Regular with increasing frequency] + [increasing in strength] + cervical change
A: Potters Sequence etx
B: Clinical Presentation - 6
A: [Fetal Renal Agenesis bilaterally / Dysfunction] –> Oligohydraminos (No Amniotic Fluid)
B: POTTER
Pulm hypOplasia
Oligohydraminos
Twisted Face
Twisted and shortened Limbs
Ears set low
Renal agenesis = cause
Shoulder Dystocia can cause multiple neonatal sequelae
What are they? - 5
Shoulder Dystocia can cause multiple neonatal sequelae. Klumpe Palsy is one of those possible sequelae
What is it caused by specifically? - 2
Impingement (or avulsion) of
- cervical fibers at C8 and T1 –> L hand paralysis (klumpke claw)
- sympathetic fibers running along C8 and T1 –> Horner Syndrome = poorer outcome if present
What all labs should be ordered for the Initial prenatal visit? - 11
- RhD type and antibody screen
- Hemoglobin and Hematoctrit with MCV
- HIV
- RPR syphillis
- HepBBBB surface antigen
- Rubella immunity
- Varicella immunity
- Chlamydia PCR
- Urine cx CLEAN CATCH
- Urine protein
- Pap test (if indicated)
What all labs should be ordered for the 24-28WG prenatal visit? - 3
- Hgb & Hct
- Oral Glucose Challenge Test 1 hr - 50gram load (if positive confirm with 3 hr 100gm load)
- Antibody screen if pt RhD negative
After 1st trimester, placenta secretes hormones that ⬆︎maternal physiologic insulin resistance so that baby gets more sugar. But if maternal pancreas cant overcome this resistance by secreting more insulin it can –> gestational DM
Why are some women at risk for developing gestational DM after the 1st trimester?
After 1st trimester, placenta secretes hormones that ⬆︎maternal physiologic insulin resistance so that baby gets more sugar. But if maternal pancreas cant overcome this resistance by secreting more insulin it can –> gestational DM
Dx = Oral Glucose Tolerance Test
When is a NST indicated? - 2
- 32-34WG in high risk pregnancies OR
- ⬇︎fetal movements
the most common cause of NONreactive NST is fetal sleep cycle so be sure to allow at least 40 min testing and use vibroacoustic stimulation to wake them up!
CP for Type 2 Osteogenesis Imperfecta - 4 ; etx?
- Thoracic cavity hypOplasia
- Multiple fractures
- Short femur
- DOA (Lethal-Stillborn)
AUTO DOM Type 1 Collagen Defect
Type 1=mild / Type2=perinatal fatal / Type 3-9=mod
How does pregnancy affect Renal function? ; Why is this important?
Pregnancy ⬆︎Renal blood flow AND Glomerular basement membrane permeability in 1st trimester –> ⬆︎GFR –> ⬇︎BUN and Creatinine levels. and then this plateaus by midpregnancy
Important because renally excreted drugs will be excreted faster than usual
What changes to Hematocrit occur during pregnancy? Why is this helpful?
Hct ⬇︎ because Plasma volume ⬆︎ more than the RBC mass –> mild ⬇︎in hgb concentration and = dilutional anemia
Helpful because it protects Mom in case of Postpartum Hemorrhage (⬆︎hypercoaguability during pregnancy also helps with this)
Pregnant Women are known to be hypercoagulable in order to decrease effects of PostPartum hemorrhage
What biochemical changes occur to make them hypercoagluable? - 4
- ⬆︎fibrinogen (never should be nml in pregnancy. If so, could indicate DIC)
- ⬆︎vWF (impt for platelet adhesion & stabilizes Factor 8)
- ⬆︎resistance to [activated Protein C] (Protein C Cuts [proteolysis] factors 5 and 8 in half but requires Protein S to do it)
- ⬇︎Protein S (helps activated Protein C)
In a pregnant pt who has chronic HTN (HTN prior to 20 WG), what goals for blood pressure should be set?
Less than Stage 1
Systolic < 140
Diastolic < 90
How do you diagnose Endometriosis?
LAPORASCOPY to biopsy & remove endometriotic lesions
1st, treat empirically with NSAIDs tho
Shoulder Dystocia = inability to deliver neonatal shoulders
What is the biggest risk factor for Shoulder Dystocia? ; Why is Shoulder Dystocia so dangerous for newborns? - 3
Fetal Macrosomia > 4.5 kg ;
- Brachial plexus injury
- Fracture of clavicle or humerus (RESOLVES SPONTANEOUSLY)
- hypoxic brain death
tx = BE CALM mnemonic