Tuesday, 2-28-Obstetrical complications (Wootton) Flashcards by Kelley Perry

preterm birth is defined as a birth that occurs after __ weeks but before __ completed weeks of gestation. Dx is uterine contractions with cervical change or cervical dilation of __ cm and/or __% effaced

after 20 wks

but before 37

cervical dilation of 2 cm

80% effaced

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Socioeconomic factors for PTL?

Medical and obstetrical factors for PTL?

AA’s 2x more likely as whites, decreased access to prenatal care, high stress, poor nutrition, genetic differences

previous hx of PTL, hx of 2nd tri abortion, repeated spontaneous 1st tri abortions, 1st tri bleeding, UTI/genital tract infx, multiple gestation, uterine anomalies, polyhydramnios, incompetent cervix

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the relative risk of PTL increases as cervical length ___

decreases

increasing use of US for routine screening of cervical length to assess risk

can also do fetal fibronectin for screening (NPV good, PPV low)

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symptoms of PTL?

mentrual-like cramping, low/dull backache, pelvic pressure, increase in discharge/bloody discharge and uterine contractions

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initial assessment of PTL?

cervical exam to assess dilation, effacement, and fetal presenting part

hydration and bed rest will resolve contractions in about 20% pts

also want to evaluate for any underlying correctable problems such as infx

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in management of PTL, what should you culture for?

Group B strep

also think about Ureaplasma, Mycoplasma, and Gardnerella as well as gonorrhea and chlamdyia

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in management of PTL, if there is no response to IV hydration and rest or diagnosed 2 cm and/or 80% effaced, then begin ___ (if gestational age <34 wks and no contraindication)

Tocolytics –> MgSO4, nifedipine, indomethacin

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drug of choice for PTL?

MgSO4

typically 6 gm LOAD IV then a 3 gm/hr continuous maintenance

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side effects (maternal) of MgSO4?

feeling of warmth and flushing
N/V
resp depression –> seen w/serum levels of 12-15 mg/dl
cardiac conduction defects and arrest at high serum levels

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side effects (neonate) of MgSO4?

loss of muscle tone
drowsiness
lower apgar scores

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this oral tocolytic is effective in suppressing PTL, has minimal maternal and fetal side effects, inhibits slow, inward current of Ca during 2nd phase of AP

nifedipine

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most common PG synthetase inhibitor used for PTL? potential complications?

Indomethacin (orally or rectally)

can result in: oligohydramnios (decrease fetal renal function), can cause premature closure of fetal ductus arterioles and result in pulm HTN and heart failure, infants exposed are at greater risk of necrotizing enterocolitis, intracranial hemorrhage

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___ are used for fetal lung maturation.

a single course of __ is recommended for pregnant women between 34 0/7 wks and 36 6/7 wks of gestation at risk of preterm birth within 7 days and who have not received a previous course

glucocorticoids

betamethasone

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the lower limit of viability of a preterm infant is __ weeks or __ gms

23-24 wks or 500 gms

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in labor and delivery of preterm infant, if vertex presentation then a _ delivery is preferred. if breech presentation then a __ delivery is preferred

vertex –> vaginal

breech –> c-section

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risk factors for premature rupture of membranes?

vag/cervical infx
abnormal membranes
incompetent cervix
nutritional deficiencies

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how do you dx premature rupture of membranes?

based on hx –> loss of fluid, confirmation of amniotic fluid in vagina

DO NOT CHECK CERVIX OF PRESUMED RUPTURED PRETERM PT. IT INCREASES RISK OF INFX ESP WITH THE PROLONGED LATENCY BEFORE DELIVERY

Rupture is confirmed using a STERILE SPECULUM

tests for confirm premature rupture of membranes?

pooling
nitrazine paper (turns blue)
ferning

may also use US to evaluate amniotic fluid volume

diagnosis of preterm premature rupture of membranes?

maternal temp >100.4
fetal or maternal tachycardia
tender uterus
foul smelling amniotic fluid/purulent discharge

ACOG recommends abx usage for preterm premature rupture of membranes with:

48 hr course IV ampicillin and erythromycin/azithromycin followed by 5 days of Amoxil and Erythromycin

what fetal lung substances are measured to test for fetal lung maturity and how are they obtained?

lecitin
phosphatidylinositol
phosphatidylglycerol

obtain by amniocentesis

what lecithin/sphingomyelin ratio indicates mature lungs?

L/S ratio >2:1

what test can be done rapidly for fetal lung maturity?

Lamellar body number density assessment (LBND)

__ is defined by when the birth weight of a newborn is below the 10% for a given gestational age

intrauterine growth restriction (IUGR)

methods of IUGR dx?

- Physical exam --> serial fundal height measurement is primary screening tool - US --> biometry - Direct studies (more for cause dx) --> amniocentesis, percutaneous umbilical blood sampling - doppler studies

if you do a fundal height and find that the height lags more than 3 cm behind the gestational age, then order a ___

ultrasound --> used routinely for high risk conditions that predispose to IUGR

pre-pregnancy management of IUGR? Antepartum management of IUGR?

pre: optimizing disease processes, i.e., blood sugar control in diabetes, control of HTN ante: decrease any modifying factors-improve nutrition, stop smoking, bed rest

goal of management of IUGR?

deliver before fetal compromise but after fetal lung maturity

This test for monitoring IUGR is when the pt is in the lateral tilt position and the fetal heart rate is monitored with an external transducer. The tracing is observed for fetal heart rate accelerations that peak at least 15 beats per min above the baseline and last 15 secs from baseline to baseline. It may be necessary to continue the tracing for 40 mins or longer to take into account the variations of fetal sleep-wake cycle

Nonstress testing For monitoring IUGR

This test for monitoring IUGR consists of an non stress test with 4 observations made by real-time ultrasonogaphy. It has the following 5 components: Nonstress test, fetal breathing movements, fetal movement, fetal tone, and amniotic fluid volume

biophysical profile for monitoring IUGR --> each component assigned a score up to 2. Composite score of 8-10 is normal, 6 is equivocal, 4 or less is abnormal

in a doppler study of the umbilical artery, compare velocity diastolic flow through the artery in a normal to an IUGR:

umbilical flow velocity waveform of normally growing fetuses has high-velocity diastolic flow IUGR has diminution of umbilical artery diastolic flow

if you suspect IUGR and US shows IUGR and she is 38-39 weeks along, next step?

deliver

if you suspect IURG and US shows IUGR and she is less than 38-39 weeks along, begin antenatal testing. If antenatal testing is normal, next step? If antenatal testing abnormal, next step?

normal --> continue pregnancy abnormal --> deliver

what is the definitions of post-term pregnancy?

pregnancy that continues past 42 weeks (~10% pregnancies)

management of post term pregnancy?

induction of labor at 41 weeks is preferred plan of care

__ is defined as fetal death after 20 weeks gestation but before the onset of labor (occurs in <1% pregnancies)

intrauterine fetal demise (IUFD)

dx of IUFD? confirmation?

suspect if pt complains of absence of fetal movements or if unable to doppler fetal heart tones confirm by US with lack of fetal activity and absence of fetal cardiac activity

risks associated with post-term pregnancies?

fetal macrosomia (>4500 gms) abnormal labor shoulder dystocia c-section

management of IUFD?

- watchful expectancy - induction of labor - monitoring of coagulopathy

why do you need to monitor for coaguloapathy in mom with IUFD?

pts with IUFD are at risk of DIC --> need to follow CBC, fibrinogen level, PT/PTT/INR

list some causes to search for following an IUFD?

``` TORCH titers parvovirus studies listeria cultures anticardiolipin Abs hereditary thrombophilias fetal chromosome studies fetal autopsy ```