Pregnancy, Childbirth and Puerperium III Flashcards
What is the next step in management after manual replacement of the uterus in a woman with uterine inversion with a retained placenta?
placental removal and uterotonics
uterotonics (e.g. oxytocin, misoprostol) cause uterine contraction, which helps prevent further hemorrhage and recurrence of the prolapse
What is the next step in management for a healthy pregnant woman at 37 weeks gestation that desires a vaginal delivery? Ultrasound reveals the fetus is in a frank breech presentation.
External cephalic version
can be attempted in women with breech pregnancies at > 37 weeks of gestational age if there’s no contraindications to vaginal delivery and the fetus is in good health
What is the next step in management for a mother with post-partum hemorrhage following a forceps-assisted vaginal delivery? The patient is afebrile and the uterus is normal-sized and firm.
Genital tract inspection
genital tract injury is a common cause of PPH after operative vaginal deliveries; other causes of PPH typically result in an enlarged, soft uterus (e.g. atony, retained placental tissue) and/or fever (e.g. endometritis)
What is the next step in management for a pregnant woman at 12 weeks gestation with an abnormally elevated beta-hCG level and increased nuchal thickness on ultrasound?
Chorionic villous sampling (CVS)
this patient has a positive first-trimester combined test; diagnosis is made
What is the next step in management for a pregnant woman at 25 weeks gestation that presents after feeling no fetal movement for the past two days? Fetal heart sounds are not heard on Doppler.
Transabdominal ultrasound
the patient likely has intrauterine fetal demise (fetal death at > 20 weeks), which must be confirmed by the absence of fetal cardiac activity on ultrasound
What is the next step in management for a pregnant woman at 28 weeks gestation with confirmed intrauterine fetal demise? The fetus is in the breech position on ultrasound.
Induced vaginal delivery
vaginal delivery is preferred regardless of fetal position; prior to 24 weeks (e.g. 20-23 weeks), patients may elect to have dilation and evacuation
What is the next step in management for a pregnant woman at 32 weeks gestation that presents with decreased fetal movement? Heart tones are heard by Doppler.
Non-stress test
i.e. recording the fetal heart rate while monit
What is the next step in management for a pregnant woman at 34 weeks gestation that presents with decreased fetal movement? Non-stress testing reveals a normal FHR but is non-reactive despite vibroacoustic stimulation.
biophysical profile or contraction stress test
choice of test depends on resources available and contraindications (e.g. contraction stress test is contraindicated if there are contraindications to labor, such as placenta previa or prior myomectomy)
What is the next step in management for a pregnant woman at 38 weeks gestation with chorioamnionitis after administration of antibiotics? Fetal heart tracing reveals tachycardia but is otherwise reassuring.
Induction of labor
cesarean delivery is reserved for standard obstetric indications (e.g. prior uterine surgeries, breech presentation, non-reassuring fetal heart tracing)
What is the next step in management for a pregnant woman with a blood glucose > 140 mg/dL 1 hour after a 50g oral glucose load?
100g 3-hour glucose challenge
abnormally high glucose levels with the 3-hour challenge confirms the diagnosis of GDM
What is the prophylactic agent of choice for pregnant women who test positive for group B Streptococcus?
Intrapartum penicillin
penicillin administration prior to labor is not beneficial; women with a history of GBS bacteriuria/UTI during current pregnancy or history of an infant with early-onset GBS disease should receive prophylaxis without testing
What is the recommended management for a hemodynamically stable patient with an ectopic pregnancy?
Methotrexate
What is the recommended management for a hemodynamically unstable patient with a suspected ectopic pregnancy?
Surgical exploration
What is the recommended management for a hemodynamically unstable patient with an inevitable abortion?
Suction curettage
expectant and medical management (e.g. misoprostol) are only appropriate for hemodynamically stable patients; additionally the patient should receive Rho(D) immune globulin to prevent isoimmunization
What is the recommended management for a laboring patient with > 6 cm dilation that experiences no further dilation for 4 hours and inadequate contractions?
Cervical examination in 2 hours
arrest of active labor is not diagnosed with inadequate contractions until there is > 6 hours of no cervical change
What is the recommended management for a patient at 28 weeks gestation with the fetus in transverse lie position? The patient desires a vaginal delivery.
Expectant management
most fetuses in transverse lie spontaneously convert to vertex presentation prior to term; persistent malpresentation may require external cephalic version or C-section
What is the recommended management for a patient with arrest of active labor?
Cesarean delivery
differentiated from protraction of active labor by the absence of cervical dilation (versus abnormally slow cervical dilation)
What is the recommended management for a patient with protraction of active labor?
Oxytocin
differentiated from arrest of active labor by the presence of slow cervical dilation (versus no further cervical dilation)
What is the recommended management for a pregnant patient with history of preterm labor and a normal cervix (> 2.5 cm) on TVUS?
IM progesterone with serial cervical length measurements until 24 weeks
What is the recommended management for a pregnant patient with history of preterm labor and a short cervix (
IM progesterone and cerclage with serial cervical length measurements until 24 weeks
What is the recommended management for a pregnant patient with no history of preterm labor and a short cervix (
Vaginal progesterone
progesterone maintains uterine quiesence and protects against premature rupture of membranes
What is the recommended management for a pregnant woman at 28 weeks gestation that presents in labor for a fetus diagnosed with anhydramnios and anencephaly?
Allow spontaneous vaginal delivery
the priority for patients with lethal fetal anomalies (e.g. anecephaly) is to minimize maternal morbidity/mortality; C-section has an increased risk of maternal complications
What is the recommended management for a pregnant woman at 32 weeks gestation with gestational hypertension and a biophysical profile score of 6 at today’s visit?
Repeat biophysical profile in 24 hours
pregnant women with gestational hypertension need weekly BPPs starting at 32 weeks gestation; a BPP of 6/10 is equivocal and should be repeated in 24 hours
What is the recommended management for a pregnant woman at 35 weeks gestation that presents in preterm labor with a fetus in vertex presentation on ultrasound?
Expectant management
betamethasone +/- penicillin may be administered as well
What is the recommended management for a pregnant woman at 35 weeks gestation that presents in preterm labor with the fetus in breech presentation on ultrasound?
Cesarean delivery
betamethasone +/- penicillin may be administered as well
What is the recommended management for a pregnant woman at 37 weeks gestation that presents with placenta previa?
Cesarean delivery
patients diagnosed antenatally should have C-section delivery at 36-37 weeks; vaginal delivery is contraindicated
What is the recommended management for a pregnant woman that is rubella-nonimmune?
Immediate postpartum vaccination (e.g. MMR)
contraindicated during pregnancy but safe during breastfeeding
What is the recommended management for a pregnant woman with a suspected luteoma?
Observation and expectant management
masses typically regress spontaneously after delivery; luteomas are occasionally complicated by ovarian torsion or symptoms related to mass effect (e.g. hydronephrosis)
What is the recommended management for a pregnant woman with a suspected theca luteum cyst secondary to a complete molar pregnancy?
Suction curettage of the hydatidiform mole
theca luteum cysts typically resolve following removal of the hydatidiform mole
What is the recommended management for a woman in the third trimester of pregnancy that presents with lower back pain that radiates down the legs, especially with activity? Physical exam is benign.
reassurance and conservative management
e.g. behavioral modifications, analgesics; back pain occurs due to postural changes, weakened abdominal muscles, and joint/ligament laxity
What is the recommended management for an asymptomatic patient with incidentally discovered endometriosis during an unrelated surgery?
Observation
intraoperative findings may include adhesions, powder-burn lesions, and “chocolate cysts”; asymptomatic patients do not require any treatment
What is the recommended management for patients that present in false labor?
Expectant management
What is the recommended management for patients with PPROM at < 34 weeks gestation and NO signs of infection/fetal compromise?
antibiotics, corticosteroids, and expectant management
e.g. ampicillin, erythromycin, and betamethasone; deliver at 34 weeks gestation or if signs of infection/fetal compromise develop
What is the recommended management for patients with PPROM at < 34 weeks gestation and signs of infection/fetal compromise?
corticosteroids, antibiotics, delivery +/- magnesium
e.g. evidence of chorioamnionitis
What is the recommended management for patients with PPROM at > 34 weeks gestation?
delivery, antibiotics +/- corticosteroids
decreases the incidence of chorioamnionitis
What is the recommended treatment for a patient with suspected postpartum endometritis?
Clindamycin plus gentamicin
postpartum endometritis is a polymicrobrial infection, thus requires broad-spectrum coverage
What is the recommended treatment for a pregnant patient with a penicillin allergy that is diagnosed with syphilis?
IM penicillin (patients need to be desensitized)
penicillin is the treatment of choice for syphilis in pregnancy regardless of drug allergies
What is the recommended treatment for a pregnant woman with antiphospholipid syndrome?
aspirin and LMW heparin
warfarin is contraindicated during pregnancy
What is the recommended treatment for acute cervicitis?
azithromycin and ceftriaxone
provides coverage for both Chlamydia trachomatis and Neisseria gonorrhoeae
What is the recommended treatment for patients with gestational diabetes that continue to have elevated glucose levels despite lifestyle modifications?
insulin or oral medications (e.g. metformin)
What is the recommended treatment for patients with septic abortion?
broad-spectrum antibiotics and suction curettage
medical emergency; urgent treatment required to reduce risk of sepsis
What is the recommended treatment for septic pelvic thrombophlebitis?
anticoagulation and broad-spectrum antibiotics
What is the recommended treatment for symptomatic postpartum pubic symphysis diastasis?
Supportive (e.g. NSAIDs, physical therapy)
typically resolves witin the first 4 weeks postpartum
What is the strongest risk factor for preterm delivery?
preterm delivery in a prior pregnancy
What is the target fasting blood glucose level in patients with gestational diabetes mellitus?
What is the typical prognosis for newborns with Erb-Duchenne or Klumpke palsy secondary to shoulder dystocia?
Spontaneous resolution within 3 months (80%)
rarely surgical intervention is considered for infants with no improvement by age 3 - 6 months
What is the underlying cause of early decelerations on fetal heart tracing?
Fetal head compression
occurs as an autonomic response to alterations in intracranial pressure
What is the underlying cause of late decelerations on fetal heart tracing?
Placental insufficiency
due to transient fetal hypoxia
What is the underlying cause of variable decelerations on fetal heart tracing?
Fetal cord compression
compression causes transient fetal hypertension, triggering a parasympathetic response that slows the heart rate
What is the underlying pathophysiology of hypotension after administration of epidural anesthesia?
vasodilation and venous pooling
sympathetic nerve fibers responsible for vascular tone may be blocked by the anesthesia resulting in vasodilation and venous pooling
What level of proteinuria is required to make a diagnosis of preeclampsia?
≥ 300 mg/day (or a protein/creatinine ratio > 0.3)
What screening test is used to determine if an Rh(D)- pregnant woman has already alloimmunized?
Antibody screen (indirect Coombs test)
detects the presence of any RBC antibodies; Rh(D)- women with a negative antibody screen should receive anti-D immune globulin at 28 - 32 weeks gestation
What type of miscarriage is characterized by no vaginal bleeding and a closed cervical os with no fetal cardiac activity?
Missed abortion
patients are typically asymptomatic or have loss of pregnancy symptoms (e.g. nausea, breast tenderness) with decreasing beta-hCG levels; ultrasound reveals a non-viable pregnancy (e.g. no fetal heartbeat, empty gestational sac)
What type of miscarriage is characterized by vaginal bleeding and a closed cervical os with normal fetal cardiac activity?
Threatened abortion
management is typically expectant with observation and repeat ultrasound
What type of miscarriage is characterized by vaginal bleeding and a dilated cervical os without expulsion of products of conception?
Inevitable abortion
ultrasound typically reveals a nonviable gestation in the lower uterine segment
What type(s) of fibroids are most associated with bulk-related symptoms and irregular uterine enlargement?
subserosal and pedunculated fibroids (leiomyomata)
e.g. constipation, incomplete voiding, pelvic pressure
What type(s) of fibroids are most associated with heavy menstrual bleeding and/or recurrent pregnancy loss?
submucosal and intracavitary fibroids (leiomyomata)
Which TORCH infections are routinely screened for in pregnant women during their first prenatal visit?
rubella and syphilis
other routinely screened infections include HIV, hepatitis B, and Chlamydia trachomatis
Which type(s) of decelerations may be indicative of fetal hypoxia and/or acidosis?
late and recurrent variable decelerations
[…] fetal growth restriction begins in the second/third trimester and is associated with conditions that cause placental insufficiency (e.g. hypertension).
Asymmetric fetal growth restriction begins in the second/third trimester and is associated with conditions that cause placental insufficiency (e.g. hypertension).
characterized by normal growth in vital organs (e.g. brain, heart, placenta) at the expense of less vital organs (e.g. abdominal viscera)
Asymmetric fetal growth restriction begins in the […] trimester and is associated with conditions that cause placental insufficiency (e.g. hypertension).
Asymmetric fetal growth restriction begins in the second/third trimester and is associated with conditions that cause placental insufficiency (e.g. hypertension).
characterized by normal growth in vital organs (e.g. brain, heart, placenta) at the expense of less vital organs (e.g. abdominal viscera)
Asymmetric fetal growth restriction begins in the second/third trimester and is associated with conditions that cause […].
Asymmetric fetal growth restriction begins in the second/third trimester and is associated with conditions that cause placental insufficiency (e.g. hypertension).
characterized by normal growth in vital organs (e.g. brain, heart, placenta) at the expense of less vital organs (e.g. abdominal viscera)
[…] is a blood pressure > 140/90 mmHg before the 20th week of gestation.
Chronic hypertension is a blood pressure > 140/90 mmHg before the 20th week of gestation.
elevated blood pressure must be seen on 2 separate measurements taken at least 4 hours apart
Chronic hypertension is a blood pressure > 140/90 mmHg before the […] week of gestation.
Chronic hypertension is a blood pressure > 140/90 mmHg before the 20th week of gestation.
elevated blood pressure must be seen on 2 separate measurements taken at least 4 hours apart
[…] maternal serum alpha-fetoprotein (AFP) is associated with aneuploidies (e.g. trisomy 18 & 21)
Decreased maternal serum alpha-fetoprotein (AFP) is associated with aneuploidies (e.g. trisomy 18 & 21)
[…] is a blood pressure > 140/90 mmHg after the 20th week of gestation with no proteinuria, pre-existing hypertension, nor end-organ damage.
Gestastional hypertension is a blood pressure > 140/90 mmHg after the 20th week of gestation with no proteinuria, pre-existing hypertension, nor end-organ damage.
[…] refers to normal vaginal discharge containing blood and/or mucus in the postpartum period.
Lochia refers to normal vaginal discharge containing blood and/or mucus in the postpartum period
can occur for up to 2-3 months.
[…] fetal growth restriction begins in the first trimester and is typically caused by chromosomal abnormalities.
Symmetric fetal growth restriction begins in the first trimester and is typically caused by chromosomal abnormalities.
global growth lag that affects fetal organs uniformly; less frequently occurs due to congenital or intrauterine infection
Symmetric fetal growth restriction begins in the […] trimester and is typically caused by chromosomal abnormalities.
Symmetric fetal growth restriction begins in the first trimester and is typically caused by chromosomal abnormalities.
global growth lag that affects fetal organs uniformly; less frequently occurs due to congenital or intrauterine infection
Elevated maternal serum alpha-fetoprotein (AFP) is associated with […] defects, […] defects, and […].
Elevated maternal serum alpha-fetoprotein (AFP) is associated with neural tube defects, abdominal wall defects, and multiple gestation.
typically measured between 15 - 20 weeks and correlated with ultrasound evaluation
[…] maternal serum alpha-fetoprotein (AFP) is associated with neural tube defects, abdominal wall defects, and multiple gestation.
Elevated maternal serum alpha-fetoprotein (AFP) is associated with neural tube defects, abdominal wall defects, and multiple gestation.
typically measured between 15 - 20 weeks and correlated with ultrasound evaluation
