UWise - Objectives 25-29 Flashcards
What methods can be used to confirm rupture of membranes?
- Testing VAGINAL (not cervical) fluid for ferning (false positive with cervical mucus)
- Nitrazine testing
Why should a digital exam be avoided in a patient with suspected PROM?
Risk of introducing bacteria into the uterine cavity and increasing risk for chorioamnionitis
When is tocolysis in the setting of PPROM appropriate?
In an attempt to prolong the interval to delivery to gain time for steroids to obtain maximum benefit for the fetus, although this does not guarantee fetal lung maturity
When do the risks of chorioamnionitis with continuing tocolytics outweigh the benefit of awaiting lung maturity?
Beyond 48 hours
What causes variable decelerations?
Umbilical cord compression as a result of cord wrapped around fetal parts, fetal anomalies, or oligohydramnios (low AFI)
What is a frequent cause of cord compression in the setting of PPROM?
Lack of amniotic fluid
What is indicated in patients with PPROM to prolong the latency period by 5-7 days and reduce the incidence of maternal chorioamnionitis and neonatal sepsis?
Antibiotic therapy with ampicillin and erythromycin
What antibiotics are indicated chorioamnionitis is suspected?
Clindamycin and gentamicin
Most authors agree that the achievement of ___ is the threshold at which the risk of morbidity and mortality of maintaining the pregnancy in utero outweighs the benefits of prolonging the pregnancy. How is this measured?
Fetal lung maturity; positive phosphatidylglycerol or 34 weeks gestational age
___ is seen when ROM occurs before 24 weeks gestation - why?
Pulmonary hypoplasia; the lack of amniotic fluid interferes with the normal intrauterine lung development and breathing process
Pulmonary hypoplasia occurs in ___% of cases of PPROM.
10-20
Neonatal survival with rupture of membranes between 20 and 23 weeks is approximately ___%.
25
___ has been shown to reduce the risk of premature labor from all causes including PPROM. How is it administered?
17 alpha-hydroxyprogesterone; weekly starting between 16-20 weeks until 36 weeks
PROM occurs in approximately ___% of all pregnancies. PPROM between 16-26 weeks is identified in ___% of all pregnancies.
10-25; 1
What is the reported recurrence rate for PPROM when it occurred in the index pregnancy?
32%
In general, delivery is recommended at ___ weeks for women with PPROM.
34
What can cause a false positive nitrazine test?
When semen or blood are present
Abruptio placentae is present in ___% of patients with PPROM.
2-5
What indicates a placental abruption?
Repetitive frequent painful contractions with vaginal bleeding, rapid progression of labor, clot on placenta
How is placental abruption managed in various settings?
- Reassuring fetal and maternal status - expectant
2. Maternal or fetal indications - C-section
What can be used to determine if contractions are adequate?
Intrauterine pressure catheter (IUPC)
Why are prostaglandins contraindicated in patients with a history of previous C-section?
Increased risk of uterine rupture
Prolonged periods of fetal tachycardia are frequently found with ___ and ___.
Maternal fever; chorioamnionitis
True or false - a biophysical profile is not of any value during labor.
True
What FHR tracing is an indication for amnioinfusion?
Repetitive variable decelerations; NOT for recurrent late decelerations
How do variable decelerations appear?
Acute fall in the FHR, with a rapid down slope and a variable recovery phase; they are characteristically variable in duration, intensity, and timing, and may not bear a constant relationship to uterine contractions
What causes early decelerations?
Fetal head compression during uterine contraction, resulting in vagal stimulation and slowing of the heart rate
How do early decelerations appear?
Uniform shape with a slow onset that coincides with the start of the contraction and a slow return to the baseline that coincides with the end of the contraction; characteristic mirror image of the contraction
How does a late deceleration appear?
Symmetric fall in the FHR, beginning at or after the peak of the uterine contraction and returning to baseline only after the contraction has ended
What causes late decelerations?
Uteroplacental insufficiency
How does a true sinusoidal FHR pattern appear?
Regular, smooth, undulating form typical of a sine wave that occurs with a frequency of 2-5 cycles/minute and an amplitude range of 5-15 bpm. It is also characterized by a stable baseline HR of 120-160 bpm and absent beat-to-beat variability
List initial measures to evaluate and treat fetal hypoperfusion.
- Change maternal position to left lateral position, which increases perfusion to the uterus
- Maternal supplemental oxygenation
- Treatment of maternal hypotension
- Discontinuation of oxytocin
- Intrauterine resuscitation with tocolytics and IV fluids
(These should be attempted before proceeding with C-section)
What is the goal of digital scalp stimulation of the fetus?
Elicit an acceleration of 15 bpm amplitude with duration of 15 seconds in order to confirm appropriate acid-base status
If there is a lack of acceleration on digital scalp stimulation, what should be done?
Fetal scalp pH
Vibroacoustic stimulation
Allis clamp test
Late decelerations when viewed as repetitive and/or with decreased variability are an ominous sign - what may this be associated with?
Decreased uterine perfusion or placental function, thus leading to fetal hypoxia and fetal acidemia
What are common causes of uteroplacental insufficiency?
Chronic HTN and postdate pregnancies
What is the most common cause of postpartum hemorrhage?
Uterine atony
List 9 risk factors for uterine atony.
- Precipitous labor
- Multiparity
- General anesthesia
- Oxytocin use in labor
- Prolonged labor
- Macrosomia
- Hydramnios
- Twins
- Chorioamnionitis
List 3 risk factors for genital tract lacerations.
- Precipitous labor
- Macrosomia
- Instrument-assisted delivery or manipulative delivery (ie, breech extraction)
Generally, what increases risk for uterine inversion?
Factors that lead to an over-distended uterus
List 4 factors that lead to an over-distended uterus and increase risk for uterine inversion.
- Grand multiparity (5+ previous pregnancies)
- Multiple gestation
- Polyhydramnios
- Macrosomia
- Abnormal placentation such as accreta
What is the most common cause of uterine inversion?
Excessive (iatrogenic) traction on the umbilical cord during the third stage of delivery
List uterotonic agents used to increase uterine contractions and decrease uterine bleeding.
- Methergine (methylergonovine)
- Prostaglandins
- Oxytocin
MOA - methylergonovine?
Ergot alkaloid (potent smooth muscle constrictor)
Which uterotonic agent is contraindicated in women with hypertension and/or preeclampsia and why?
Methylergonovine; it is also a vasoconstrictive agent
List the prostaglandins used as uterotonics and their brand names.
- Prostaglandin E1 (Misoprostol)
- Prostaglandin E2 (Dinoprost)
- Prostaglandin F2-alpha (Hemabate)
Which prostaglandin is not FDA approved as a uterotonic?
E1 (Misoprostol) - used for cervical ripening and labor induction, also frequently used for uterine atony
How is Dinoprost administered?
Vaginal or rectal suppository that must be stored frozen and thawed to room temperature prior to use
Which prostaglandin is contraindicated in hypotensive patients?
E2 (Dinoprost)
How is Hemabate administered?
IM injection
Hemabate is contraindicated in which patients?
Asthmatics (absolute contraindication in patients with poorly controlled or severe asthma)
MOA - Hemabate?
F2-alpha; potent smooth muscle constrictor with a bronchoconstrictive effect
MOA - oxytocin?
Polypeptide hormone that binds to receptors on the uterine myocytes causing contractions
What is the most common risk factor for uterine inversion?
Excessive (iatrogenic) traction on the umbilical cord during the third stage of delivery
How does uterine inversion present?
With a globular mass at the introitus
Define postpartum hemorrhage.
Bleeding in excess of 500 cc after a vaginal delivery or in excess of 1,000 cc after C-section
After ensuring appropriate backup, establishing IV access, and stabilizing a patient as needed, what are the first steps in management of postpartum hemorrhage?
- Make sure the uterus is well-contracted (firm fundus)
- Make sure there is no retained placental tissue
- Look for lacerations
Although placental abruption and uterine atony are both common, what must be considered in the presence of a low-lying anterior placenta in a patient with a history of multiple cesarean births?
Placenta accreta
A uterine compression suture such as a ___ has been shown to be effective in the management of unresponsive uterine atony.
B-Lynch
Ligation of a number of pelvic vessels can lead to reduction in the vascular pressure in the pelvis, thus controlling hemorrhage, with ligation of ___ and ___ arteries being the most likely to treat hemorrhage.
Uterine; internal iliac (hypogastric)
Ligation of the external iliac artery results in ___ of the leg and, therefore, should not be performed.
External iliac
___ can present for the first time in a patient with delayed postpartum hemorrhage.
Von Willebrand’s Disease
___ is a common complication of prolonged labor, PPROM, and multiple vaginal examinations.
Endometritis
How should endometritis be covered and why?
Ampicillin - GP
Gentamicin - GN
Erythromycin provides good coverage for ___ infections. Vancomycin provides good coverage for ___ and ___. Ciprofloxacin provides excellent coverage for ___, including ___.
Upper respiratory; S. aureus; penicillin-resistant GP bacteria; GN pathogens; pseudomonas
Acute cystitis is a common complication after vaginal delivery and the risk increases with the use of an indwelling catheter. What are the most common causes?
Generally - GN bacteria
75%: E. Coli 8%: P. mirabilis 20%: K. pneumoniae <5%: S. faecalis S. agalactiae
___ is an exaggerated response to the lymphatic and venous congestion associated with lactation.
Breast engorgement
When does milk “let-down” generally occur?
PPD 2 or 3
If the baby is not feeding well, the breast can become engorged, causing ___.
A low-grade fever
DDx - postpartum fever
Endometritis Cystitis Mastitis Breast engorgement (Septic pelvic thrombophlebitis - rare, high fever not responsive to antibiotics, diagnosis of exclusion)
Prior to establishing a diagnosis of surgical site infection, how should a wound showing signs of infection be evaluated?
Open the wound, check for fascial dehiscence, drainage, assessment of the fluid; packing the wound until it has healed from the base of the wound facilitates the healing process
Pregnancy puts women at risk for cholelithiasis and, therefore, ___.
Cholecystitis
What are classic symptoms of cholecystitis?
N/V, dyspepsia, upper abdominal pain after eating fatty foods
Classical findings for endometritis?
Fever, maternal tachycardia, uterine tenderness, no other localizing signs of infection
Presentation of appendicitis?
N/V, anorexia, abdominal pain
How is septic thrombophlebitis treated?
Anticoagulation and antibiotics
Clinical manifestations of cystitis?
Lower abdominal pain, frequency, urgency, dysuria
Clinical findings of mastitis?
Fever, tenderness, induration and erythema of the affected breast
What is the most common source of fever on the first postpartum day, particularly if the patient had general anesthesia?
The lungs - atelectasis may be associated with postpartum fever, aspiration pneumonia should be considered in patients who had general anesthesia
In addition to broad spectrum antibiotics, how should a perineal abscess be managed?
Aggressive debridement of the necrotic areas to prevent further spread of infection. It should extend until vital tissue with good blood supply is encountered. Repair of the defect should be delayed until the infection has completely resolved.
List 3 complications of epidural.
- Spinal headache
- Localized back pain
- Meningitis
A patient’s history of a psychiatric illness and/or depression (situational or spontaneous) is a risk factor for the development of ___.
Postpartum depression
___% of patients with a postpartum psychiatric problem report a prior history.
33
What is one of the most common side effects of fluoxetine (Prozac)?
Insomnia
Significant insomnia may affect ___% of patients taking SSRIs.
20
In addition to sleep disturbances, what is another common side effect of SSRIs?
Sexual dysfunction, such as decreased libido and delayed or absent orgasm
True or false - current recommendations state that SSRI medications can be safely used duration lactation.
True; several studies show that SSRIs are secreted in breast milk; however, no detectable levels of the drug were found in the infants’ serum + no adverse effects were noted in the infants by either their parents or pediatricians following the infants
Third trimester maternal use of SSRIs, including fluoxetine, has been associated with what fetal effects?
Abnormal muscle movements (EPS) and withdrawal symptoms, which may include agitation, abnormally increased or decreased muscle tone, tremor, sleepiness, severe difficulty breathing, and difficultly in feeding. In some newborns, the symptoms subside within hours or days and do not require specific treatment; other newborns may require longer hospital stays.
What is an important first step in diagnosing PMS and PMDD?
Ascertaining the timing of symptoms each month
Symptoms of both PMS and PMDD begin in the ___ phase of the menstrual cycle and resolve shortly after ___.
Luteal (second half); onset of menses
Symptoms of postpartum blues affect 40-80% of women within ___ days postpartum and resolve within ___.
2-3; 2 weeks
List symptoms of postpartum blues.
- Insomnia
- Easy crying
- Depression
- Poor concentration
- Irritability or labile affect
- Anxiety
Symptoms often last a few hours per day and are mild and transient
What is the biggest risk factor for development of PPD?
History of depression (either major or postpartum)
