UWise - Objectives 30-34 Flashcards
Perinatal morbidity and mortality increase beginning at ___ weeks gestation (postterm).
41
How should late term and postterm pregnancies be surveilled?
Non-stress test assess fetal well-being my measuring the FHR response to fetal movement
Amniotic fluid volume assessment (modified BPP)
What is a reactive non-stress test?
2 FHR accelerations of 15 bpm for 15 seconds within 20 minutes
Postterm pregnancies are associated with what 4 situations?
- Placental sulfatase deficiency
- Fetal adrenal hypoplasia
- Anencephaly
- Inaccurate or unknown dates
(Not associated with fetal adrenal hyperplasia, AFP deficiency, renal anomalies, or chromosomal abnormalities)
What are # risks associated with late term and postterm pregnancies?
- Macrosomia
- Oligohydramnios
- Meconium aspiration
- Uteroplacental insufficiency
- Dysmaturity
Define postterm pregnancy.
42 0/7 weeks or more
Define late-term pregnancy.
41 0/7 to 41 6/7 weeks
How should a pregnant patient with irregular menses be accurately dated?
U/S prior to 20 weeks to accurately date the pregnancy
___% of patients with a history of postterm pregnancy will experience prolonged pregnancy with the next gestation.
50
What is amnioinfusion and what is it used for?
Procedure where normal saline is infused into the intrauterine cavity.
Used in the treatment of repetitive variable decelerations, regardless of amniotic fluid meconium status
Why is meconium staining of the amniotic fluid 3-4x more common in the postterm pregnancy?
- Greater length of time in utero allows for activation of a more mature vagal system
- Fetal hypoxia
True or false - based on current literature, routine prophylactic amnioinfusion for meconium-stained amniotic fluid is not recommended.
True
Optimal management for the patient with a favorable cervix at greater than or equal to 41 weeks gestation is ___.
Delivery
Induction of labor in a patient with an unfavorable cervix increases the risk of ___ significantly.
Cesarean delivery
The incidence of infants with dysmaturity approaches 10% when the gestational age exceeds ___ weeks.
43
How do infants with dysmaturity appear?
Withered, meconium stained, long-nailed, fragile, associated small placenta
What are the most common findings in infants with Trisomy 18?
Overlapping fingers, micrognathia, cardiac defects
What are characteristic findings in Trisomy 21?
Facial findings (low set ears, flattened bridge of the nose, almond shaped eyes), cardiac defects (50%)
What is the hallmark of Fragile X syndrome?
Developmental delay not apparent at birth
What are the most commonly used cervical ripening agents?
Prostaglandins applied locally
List the ACOG recommendations for the management of late-term and postterm pregnancy.
- Patient recording fetal kick counts
- Fetal surveillance with one of the following: NST, CST, BPP, delivery for nonreassuring testing or oligohydramnios
- Induce at 42 weeks if the cervix is favorable; use a ripening agent if unfavorable
Which risk factor confers the highest risk of postterm pregnancy? What are other risk factors?
Previous postterm pregnancy (2-4x risk); nulliparity, advanced maternal age, obesity, male fetus, Caucasian women
Alterations in ___ affect the growth and status of the fetus, as well as the placenta.
Uteroplacental perfusion
In the setting of limited fetal growth, what are the next steps in management?
- Amniotic fluid volume
- Umbilical artery Doppler
- Systolic/diastolic ratio
- Non-stress test
In the setting of limited fetal growth, why is an amniotic fluid volume done?
Oligohydramnios is frequently found in growth-restricted pregnancies, presumably due to reduced fetal blood volume, renal blood flow, and urinary output. Chronic hypoxia is responsible for diverting blood flow from the kidney to organs that are more critical during fetal life.
___% of patients with oligohydramnios deliver growth-restricted infants.
90
An increase in the S/D ratio reflects ___, a common finding in IUGR fetuses.
Increased vascular resistance
Once IUGR is detected, what should be done?
Periodic evaluation for evidence of well-being until delivery
- Non-stress test (2x weekly) with at least a weekly AFI
- BPP weekly
- U/S for growth (2 weeks)
In order to accurately confirm gestation age at term, what criteria should be met?
1 of the following:
- Fetal heart tones have been documented for 20 weeks by a non-electronic fetoscope or for 30 weeks by Doppler
- It has been 36 weeks since a positive serum or urine HCG pregnancy test was performed by a reliable laboratory
- U/S of the crown-rump length, obtained at 6-12 weeks, supporting a gestational age of at least 39 weeks
- U/S obtained at 13-20 weeks confirms the gestational age of at least 39 weeks, determined by clinical history and physical exam
The crown-rump length can reliably date a pregnancy within ___ days.
5-7
In general, the causes of polyhydramnios relate to __ and ___.
Amniotic fluid production (abnormalities of the fetal urinary tract) and removal (abnormalities of fetal swallowing and intestinal reabsorption of fluid)
Fetal growth restriction is a significant risk factor for the subsequent development of what diseases as an adult?
CVD, chronic HTN, stroke, chronic obstructive lung disease, DM2, and obesity; also increased risk for cognitive delay in childhood
What is the indication in a fetus with IGUR at 36 weeks with oligohydramnios and abnormal umbilical artery Doppler studies?
Delivery (induction of labor is generally preferred over elective Cesarean)
How is a fetus with enhanced general growth or macrosomia defined?
Birth weight at or above the 90th % for gestational age
Macrosmia can usually be ascribed to one of what three etiologies?
- Enhanced growth potential (50-60%)
- Abnormal maternal glucose homeostasis (35-40%)
- Underestimation of fetal age (5%)
Macrosomic newborns of diabetic mothers experience excess rates of neonatal morbidity, including what?
Birth trauma such as shoulder dystocia and brachial plexus injury; higher rates of severe hypoglycemia; neonatal jaundice; increased fetal demise secondary to neonatal acidosis caused by poor glycemic control
Clinical estimates of fetal weight may be determined via what 2 measurements?
- Leopold’s
2. Measurement of the height of the fundus above the pubic symphysis
What is the most reliable measurement used to date pregnancy in the first trimester?
Crown-rump length
If “fatty appearing tissue” is noted to be coming through the curette during D&C, what should be done and why?
The tissue is consistent with omental tissue and may include segments of bowel. The suction should be turned off and the tissue gently removed from the curette. Laparoscopy will allow closer examination.
Why are uterine fibroids located in the lower uterine segment an indication for C-section?
They may obstruct labor by preventing the fetal head from entering the pelvis.
A fetal head with measurements greater than ___cm could benefit from C-section.
12
Newer form of vacuum extractors lead to a decreased rate of ___.
Maternal lacerations
Fetal and neonatal complications related to vacuum use include what?
Lacerations at the edges of the vacuum cup, particularly if torsion is applied. Torsion may also lead to separation of the fetal scalp from the underlying structures, can cause a cephalohematoma, and places the fetus at risk of jaundice.
What is the most likely complication of a tubal ligation?
Future pregnancy
What is the failure rate associated with surgical sterilization?
1%
Compare the timing of chorionic villus sampling with amniocentesis.
CVS - between 10-12 weeks
Amnio - performed after 15 weeks
Early CVS (<10 weeks) is associated with an increase in ___.
Rare limb abnormalities
Which is more likely to involve multiple attempts - CVS vs. amnio?
CVS
A patient with a history of cervical insufficiency (typically painless cervical dilation before 24 weeks with expulsion of pregnancy in second trimester, in absence of labor or other clear pathology such as infection or ruptured membranes) is a candidate for ___.
Prophylactic cerclage
Who should get a transabdominal cerclage?
Patients who previously failed a transvaginal cerclage
How should a patient be counseled regarding a Depo-Provera injection and bleeding?
Initially, there may be unpredictable bleeding. This usually resolves in 2-3 months. In general, after one year, nearly 50% of users have amenorrhea.
How should a patient be counseled regarding emergency contraceptive pills?
They are not abortifacient, and they have not been shown to cause any teratogenic effect if inadvertently administered during pregnancy. They may be used anytime during a woman’s cycle, but may impact the next cycle, which can be earlier or later with bleeding ranging from light to normal to heavy.
How should emergency contraceptive pills be taken (timing)?
More effective the sooner they are taken after unprotected intercourse; it is recommended that they be started within 72 hours and no later than 120 hours
Who are ideal candidates for progestin-only pills?
Women who have contraindications to combined OC’s - history of thromboembolic disease, an estrogen-sensitive cancer such as breast cancer, women who are lactating, women over age 35 who smoke or women who develop severe nausea with combined OC’s.
Oral contraceptives will decrease a woman’s risk of developing what cancers?
Ovarian and endometrial
Oral contraceptives decrease the risk of what other conditions?
PID, endometriosis, benign breast changes, ectopic pregnancy
What are possible side effects of oral contraceptives?
Slightly higher risk of developing cervical intraepithelial neoplasia; HTN and thromboembolic disorders
The progesterone IUD will decrease a woman’s risk of developing what cancers?
Endometrial cancer
Which contraceptive has been associated with increased ovarian cysts?
Progesterone IUD
Approximately ___% of women who have been sterilized regret having the procedure. What is the strongest predictor of regret?
10; young age at the time of the procedure
What is the effectiveness rate of vasectomy and tubal ligation?
99.8%
Compare the risk of vasectomies vs. tubal ligations.
Vasectomies are performed as an outpatient procedure under local anesthesia vs. tubal ligations are typically performed in the OR under regional or general anesthesia (slightly more risk to the woman)
The patch has significantly higher failure rates when used in women who…
…weigh more than 198 pounds.
How does the patch function as contraception?
Slowly releases ethinyl estradiol and norelgestromin, which establishes steady serum levels for 7 days; apply the patch in a different area each week for 3 weeks, then have a patch-free week during which time she will have a withdrawal bleed
How does the risk for thromboembolism compare between the patch and OC’s?
Higher risk on the patch
How is the copper IUD used as emergency contraception?
Placement can be performed up to 5 days after unprotected intercourse
Presentation of septic abortion?
Fever + bleeding with a dilated cervix
Presentation of threatened abortion?
Vaginal bleeding, positive pregnancy test, closed or uneffaced cervical os
Presentation of missed abortions?
Retention of a nonviable intrauterine pregnancy for an extended period of time (i.e. dead embryo or anembryonic gestation)
Presentation of ectopic pregnancy?
Bleeding, abdominal pain, possible adnexal mass, cervix closed (typically)
How is septic abortion managed?
Broad-spectrum antibiotics and uterine evacuation (medical termination is not the best option because prompt evacuation of the uterus and removal of the infected tissue is indicated)
Medical abortion is associated with increased ___ (complication) than surgical abortion.
Blood loss
When can both medical and surgical abortions be offered?
Before 49 days
How is a medical abortion performed?
Mifepristone (antiprogestin), followed by misoprostol (prostaglandin) to induce uterine contractions to expel the products of conception
What is the efficacy rate of medical abortion?
96%
What is the efficacy rate of manual vacuum aspiration in early pregnancy (<8 weeks)?
Over 99% effective
Complications of pregnancy termination increase with ___.
Increasing gestational age (age, parity, and medical illnesses are not contraindications for manual vacuum aspiration)
True or false - the risk of Asherman’s syndrome increases with each subsequent pregnancy termination.
True
What are risks of medical abortion?
Hemorrhage and failure
What is the next best step in a patient s/p medical termination of pregnancy with heavy bleeding and echogenic material in the uterus on U/S?
D&C
How should post-operative endometritis be managed?
Begin IV antibiotics immediately
While there is no consensus on a specific antibiotic regiment to prevent post-abortal infection, there is a 42% reduction in infection when antibiotics are administered at the time of surgical abortion. What is a commonly accepted regimen?
100 mg doxycycline orally 1 hour prior to the procedure, followed by 200 mg after
