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ENRP > Weeks 2/3 (Exam 1) > Flashcards

Weeks 2/3 (Exam 1) Flashcards

1
Q

Anthropoid pelvis

A

Ape-like, 20% of females
Huge anteroposterior (oval), narrow pubic arch
Fetal head engages only in anteroposterior diameter
Good Px

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2
Q

FHR category 2 indications for promoting fetal oxygenation

A 
Minimal or absent variability
Recurrent late decelerations
Prolonged decelerations
Tach/Brady
Variable, late, or prolonged decelerations with pushes
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3
Q

Side effects of Misoprostol

A

Maternal: Oral: N/V etc, Vag: tachysystole, etc
Fetal: hypoxia from tachysystole or prolonged uterine contraction

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4
Q

Criteria for mild preeclampsia

A

Proteinuria above 300mg/24 hour or a single specimen urine protein:creatine of 0.3mg/dL or urine dipstick reading of 2+
BP above 140-160/90-110 4 hours apart
Asx

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5
Q

What happens in the eyes during preeclampsia?

A

Retinal vasospasm

Retinal edema

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6
Q

Corticosteroid choices to give for fetal lung maturation

A

Betamethasone: 2 IM doses q24h
Dexamethasone: 4 IM doses q12h
Not cortisol, the placental would metabolize (inactivate) it to cortisone

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7
Q

What causes Dystocia (difficult labor)?

A

Power: uterine contractions or maternal expulsive force
Passenger: position, size, presentation of fetus
Passage: maternal pelvic bone contractures

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8
Q

Best (only real) drugs for tocolysis

A

Indomethacin and nifedipine

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9
Q

Fetus acidity

A

normal pH of fetal scalp blood is 7.25 - 7.3

pH less than 7.2 is considered abnormal / acidotic

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10
Q

Treat a breech presentation before it happens

A

External cephalic version: apply pressure to mothers abdomen to somersault it into vertex position
36 week gestations not in labor
Not w/ placental previa, non-reassuring monitoring, oligohydramnios, previous contraindicating surgery

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11
Q

What stimulates lung maturation / surfactant components in amniotic fluid?

A

Fetal cortisol

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12
Q

Most vulnerable stage for teratogenesis

A

Day 17 to day 56 post-conception (organogenesis)

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13
Q

When to give pregnant women Tdap

A

27 - 36 weeks

Coincides with DM screening, Rhogam, repeat Hb/hematocrit at 28 weeks

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14
Q

US findings of monozygotic twins

A

Dividing membrane is fairly thin

if US is not definitive, inspect placenta after delivery or analyze DNA

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15
Q

Most dangerous twin membrane situation

A

9-12 day cleavage, 1 chorion 1 amnion
Dangerous because there are not separating anions
Cord entanglement, net mortality is 50-80%

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16
Q

Antepartum management of a patient carrying twins

A

Trimesters 1/2: 2 week office visits, US cervical length
3: Cervix under 25mm at 24-48 weeks x2 premature risk
Serial US for intrauterine growth q4-6weeks at wk 24
Look for discordant fetal growth: 20% growth difference
Deliver monoamniotic twins at 32 weeks (avoid cord)
Hospitalize at 26 weeks, antenatal steroids, FHR monitor
Deliver at 38 weeks if there aren’t complications

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17
Q

What level of Rh Ab titers require further evaluation?

A

Over 1:16
US for hydrops
doppler studies of MCA for fetal anemia (peak systolic velocity over 1.5 MOM for gestational age? percutaneous umbilical blood sampling to assess true [Hb]

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18
Q

Criteria for threatened abortion

A

Vaginal bleeding and closed cervix
24-50% result in loss
Tx is expected management

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19
Q

IUDs

A 
Copper T (Paragard) - Use w/ Wilsons Dz
Levonorgestrel (Mirena/Liletta, Skyla/Kyleena) - Use w/ Breast cancer
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20
Q

Check baby Station

A

Degree of descent of presenting part of the fetus
cm from presenting part to ischial spines
When bony portion of the head reaches level of ischial spine its zero
-5 to +5

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21
Q

Possible etiologies of FHR patters associated with inadequate O2

A 
Fetal sleep, medications, acidemia
UPI: HPTN, tacysystole, maternal hypoxia
Rapid fetal descent, cord compression, tachysystole
Prematurinty, choriamnionitis
Epidural, cord prolapse
Cord compression, UPI
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22
Q

Mg Sulfate MOA

A

Unknown, competes with Ca at channels, preventing contraction?

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23
Q

Fetal HR category 1

A

BL 110-160, moderate variability, no late or variable decelerations, accelerations and early decelerations maybe
Normal tracing
Goals/management: intermittent or CEFM

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24
Q

Types of internal fetal monitors

A

Fetal Scalp Electrode: Rate computed from R wave peaks (avoid in HIV patients)
Intrauterine pressure Cath: Gives intensity, trans-cervical

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25
Q

Maternal side effects of carboprost

A

HTN, PE (its a strong vasoconstrictor, unlike PGE2)

Reduced body temp (unlike PGE2)

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26
Q

How to treat pre-term labor

A

Mg Sulfate
Nifedipine
PG synthetase inhibitor (indomethacin)

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27
Q

A-A malformation in monozygotic twins

A

Reversed blood flow can make thrombosis in critical organs or artesian from trophoblastic embolism
Recipient twin “Acardiac” (fully formed legs, no anatomic structures above the abdomen)

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28
Q

How does shoulder dystocia occur during delivery?

A

Delivery requiring additional obstetric maneuvers following failure of gently downward traction on fetal head to affect delivery of the shoulders
Caused by impaction of anterior fetal shoulder behind maternal pubic symphysis or impaction of posterior shoulder on sacral promontory

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29
Q

BRCA1 associated cancers

A

Ovary and Fallopian tubes

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30
Q

Most common malpresentation of fetus coming out

A

Breech (buttocks show first)
Associated with prematurity, malformations, multiple pregnancies, uterine malformations (bicornuate)
Dx by Leopold’s maneuver, US, pelvic exam

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31
Q

Manage PPROM

A

Most deliver at 34 weeks regardless
Monitor for chorioamnionitis
Dx by maternal temp above 100.4, fetal or maternal tach, tender uterus, found amniotic fluid/discharge

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32
Q

Indications for C-Section and macrosomia

A

Do it with a baby over 4500g in diabetics

Do it with a baby over 5000g in non-diabetics

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33
Q

Criteria for chronic HTN in pregnancy

A

Present before or recognized during first half of pregnancy

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34
Q

Fetal HR criteria

A

Normal: 110 - 160
Tach: Baseline > 160 bpm
Brady: baseline < 110 bpm

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35
Q

Etiologies of prolonged latent phase of labor 1

A

mostly those who entered labor without cervical change
Excessive sedatives or analgesics
Fetal malposition

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36
Q

What happens in the kidneys during preeclampsia?

A

Swelling and enlargement of glomerular capillary endothelial cells
Narrowing of the capillary lumen

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37
Q

Nifedipine MOA

A

Inhibits slow inward Ca current during AP phase 2

may replace Mg

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38
Q

Types of breech presentation

A

Frank: legs flexed up at hips
Complete: cross-legged
Imcomplete: one or both thighs extended/coming out (cant do vaginal delivery with this one)

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39
Q

Anticoagulant teratogens

A

Coumadin (crosses placenta)

Heparin (does not cross placenta)

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40
Q

US findings of fetal hydrops

A

Ascites, pleural effusion, pericardial effusion, skin or scalp edema, polyhydramnios

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41
Q

Mild maternal HTN management

A

Begin aspirin therapy 81mg qd at 12 weeks until delivery
Initiant anti-HTN if threshold met
Antepartum fetal monitoring
Delivery between 38-39 weeks gestation

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42
Q

Pharmacokinetics of Misoprostol

A

Stable at room temperature

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43
Q

What malformation is associated with face presentations?

A

Anencephaly

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44
Q

Management of shoulder dystocia

A

McRobert’s maneuver: hyper flexion and abduction of maternal hips
Suprapubic pressure: DONT apply fundal pressure
Rotational moves, deliver posterior arm, fracture clavicle
Proctoepisotomy
Zavanelli maneuver (last resort): cephalic replacement, poor Px

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45
Q

Pregnancy test hCG sensitivity

A

Below 5 is -
Above 25 is +
~100 at expected menstrual period

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46
Q

Misoprostol (cytotec)

A

PGE1
Oral or vaginal for labor induction
Cannot be readily removed if there’s concerns
Contraindicated in patients with previous C sections

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47
Q

BMI recommendations for pregnant women

A

Under 19? gain 28-40 lbs
19 - 25? gain 25-35 lb
Over 25? gain 15-25 lb

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48
Q

US findings of dizygotic twins

A

Different fetal gender
Visualize thick amnion-chorion septum
“peak” or “inverted V” sign at base of septum

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49
Q

What do you use to measure fetal heart rate

A

Doppler until 12 weeks, fetoscope 18-20 weeks

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50
Q

Estimate a due date for a normal pregnancy

A

Last menstrual period - 3 mos + 7 days

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51
Q

1st trimester screening tools

A

Maternal age
Fetal nuchal translucency and thickness (10 - 14 weeks)
Maternal b-hCG and plasma protein A (PAPP-A)
Can add nasal bone assessment

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52
Q

Management of severe preeclampsia

A

Hospitalize. Deliver if above 34 weeks gestation
Manage HTN w/ Labetalol, Nifedipine, Hydralazine
Under 37 weeks can give corticosteroids and work toward delivery if mother and fetus are stable

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53
Q

Indications for indomethacin

A

agent of choice for 24-32 weeks tocolysis( Nifedipine is second choice)
Contraindicated after 32 weeks b/c PDA closure

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54
Q

Most common cause of excessive maternal blood loss

A

Uterine Atony: Uterus fails to contract after delivery of placenta
Boggy placenta on palpation

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55
Q

What do you think of when there’s decreased variability in FHR?

A

Possible fetal stress: its ominous if associated with persistent late decelerations
Associated with Hypoxia and acidemia

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56
Q

Transvaginal US findings by week

A

Week 5: Gestational sac: 1500-2k gCG
Week 6: Fetal Pole: 5200 hCG
Week 7: Cardiac activity: 17,500 hCG

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57
Q

What does MHT treat?

A

Vasomotor symptoms and vaginal changes post-menopause

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58
Q

Terbutaline Dosage

A

0.25mg/sec q20-30min until tocolysis
then, q3-4hours
don’t use longer than 48 hours

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59
Q

Turtle sign

A

Retraction of delivered fetal head against maternal perineum

Sign of shoulder dystocia

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60
Q

What do do with finger assessment of nuchal cord

A

Loose: manually reduce over the infants head
Tight: clamp x2 and cut

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61
Q

5 major points of menopause treatment

A

Younger women (up to 59): MHT is acceptable
Vaginal Sx only: Low-Dose topical E
w/Uterus: Progestin + E, W/out just E
E+/-Progestin increases clots, less in 50-59
Increased breast CA within 3-5yr. continuous
Risks and benefits eliminated years after MHT stopped

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62
Q

Prolonged decelerations in FHR

A

decrease from baseline 15bpm or more 2-10 minutes
Disruption of O2 transfer to fetus, common in pushing
Change in baseline if deceleration lasts 10 min+

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63
Q

Sx of preeclampsia

A

HTN + Proteinuria + Edema

Scotomia, blurred vision, epigastric / RUQ pain, HA

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64
Q

management of labor stage 2

A

Maternal position: avoid supine, go dorsal lithotomy
Bearing down (help the contractions)
Fetal monitoring: continuous, q15min w/no risk factors
q5min w/ yes risk factors
Access descent and confirm position

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65
Q

Critical period of teratogenesis with radiation

A

2 - 6 weeks post-conception
before 2 weeks it either kills you or does nothing
Less than 5 rads is fine

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66
Q

Atosiban MOA

A

Blocks oxytocin action for tocolysis but doesn’t work better than placebo lol

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67
Q

Maneuvers for shoulder dystocia

A

Rubin maneuver: pressure accessible shoulder toward anterior chest wall of fetus to decrease bisacrominal diameter and free the impacted shoulder
Wood’s Corkscrew: pressure posterior to rotate infant and dislodge anterior shoulder

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68
Q

Leopold maneuvers

A

Palpate the fundus (fetal head vs butt vs transverse pos)
Palpate for spine and fetal small parts
Palpate presenting parts in pelvis w/ suprapubic palp
Palpate for cephalic prominence (chin, occiput)

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69
Q

Nexplanon

A

Single, Radiopaque rod shaped implant
Etonogestrel (birth control)
3 years
inserted in first 5 days of menses

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70
Q

Criteria for severe preeclampsia

A

Oliguria (less than 500 in 24hr)
Liver enzymes 2x ULN or epigastric pain refractory
Pulmonary edema
Sx: Cerebral or visual disturbances, pulmonary edema, epigastric or RUQ pain, elevated liver enzymes, thrombocytopenia

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71
Q

Complications of pitocin

A 
Uterine tachysystole (5+ contractions/10 min)
Anti-Diuretic: Similar structure to ADH, water intox
Uterine muscle fatigue (non responsiveness)
Prolonged use? risk post party hemorrhage from uterine atony
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72
Q

Magnesium sulfate

A

IV for seizure prevention in preeclampsia
4mg loading dose, 2gm maintenance, monitor
fluid restriction to prevent overload/pulm edema

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73
Q

How to manage a persistent Occipitoposterior baby position

A

Observation of prolonged Labor 2

Operative vaginal delivery with vacuum or forceps

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74
Q

What do you give to an Rh- mother?

A

Rhogam at 28 weeks gestation

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75
Q

Stages of HTN in pregnancy

A
  1. Systolic 130-39 / diastolic 80-89

2. Systolic 140+ / diastolic 90+

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76
Q

RhoGam

A

Anti-D Ig
Decreases RhD availability to maternal immune system
Prevents isoimmunization
Do Kleinhauer-Betke test to ID fetal RBC in maternal blood (tells you if you need to give more)

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77
Q

What do you think of when there are accelerations in FHR?

A

Abrupt increase is normal reassuring response
at or above 32 weeks, HR at or above 15 above baseline for 15 seconds - 2 min
above 32 weeks, Hr 10 or more above baseline for 10 sec - 2 min

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78
Q

Assessing the Passage part of abnormal active phase of labor

A

Cephalopelvic Disproportion (size of maternal pelvis:fetal head that precludes vaginal delivery)

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79
Q

What is the chemical basis of uterine relaxation?

A

Comes about by factors that increase myocyte cAMP

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80
Q

Sinusoidal pattern of FHR

A

Smooth, sine wave-like undulating pattern 3-5/min

Seen w/ fetal anemia

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81
Q

Indomethacin MOA

A

Blocks PGF2a (stimulator of uterine contractions)

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82
Q

Velamentous insertion of umbilical cord

A

Common cause of third trimester bleeding
Cord inserts at distance away from placenta and its vessels must transverse between chorion and amnion without Protein give Wharton’s jelly
If it passes over cervical os its a vasa previa

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83
Q

What happens in the heart during preeclampsia?

A

Absence of normal intravascular volume expansion (third spacing)
Reducting in circulating blood volume

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84
Q

Nifedipine MOA

A

Competes with Ca for cellular entry at depolarization

6gm load IV then 3/hr continuous

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85
Q

Retinoids as teratogens

A 
CNS, CV, and Craniofacial defects
Spontaneous abortions (esp in 1st trimester)
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86
Q

Abnormal presentations of baby coming out

A

anything other than vertex occiput anterior (OA). Usually starts in OT and rotates into OA. Sometimes doesn’t, sometimes rotates into OP

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87
Q

How do persistent occipitoposterior positions occur?

A

Head generally rotates from OT to OA
Even if head rotates to OP initially, the majority will eventually rotate spontaneously during labor to OA
Course of labor in the OP position is usually normal (maybe more back discomfort)

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88
Q

Nature of membranes and time of twin cleavage

A

0-3 days: Dichorionic, diamniotic
4-8: Monochorionic, diamniotic
9-12: monochorionic, monoamniotic
13+: conjoined twins

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89
Q

Nifedipine indication

A

2nd choice agents for 24-32 weeks

1st choice for 32-34 weeks when NSAIDS contraindicated

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90
Q

Abnormal timing of active phase of labor 1

A

No cervical dilation is 2 hours+? arrested
No descent /station change within 1 hr? arrest
Slowing down from normal is protraction

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91
Q

Most common type of placental vascular anastomoses in twins

A

A-A, then A-V, then V-V

Can cause abortion, polyhydramnios, TTTS (A-V), fetal malformations

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92
Q

How do you deliver a breech baby?

A
  1. Allow fetus to deliver the scapulae
  2. ER of each thigh combined with opposite rotation of fetal pelvis = flexion of knee and delivery on the leg.
  3. Wrap a towel around the fetus
  4. When scapulae appears under symphysis, reach over the left shoulder, sweep arm across the chest, deliver arm
  5. Maintain traction on head with maxilla, NOT mandible
    Or, just use piper forceps
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93
Q

Dinoprostone (cervidil)

A

PGE2
Vaginal insert for labor induction
Contraindicated in patients with previous C sections

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94
Q

Slight increase in FHR followed by major drop

A

Called a shoulder, and comes from slight compression of umbilical cord / obstruction of umbilical vein

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95
Q

Pitocin

A

IV oxytocin, stimulates myometrial contractions
Only drug for Iduction AND augmentation
Start at 2 mu and go up by 2 q20-30min

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96
Q

Who is betamethasone recommended for?

A

Pregnant women between 34 0/7 weeks and 36 6/7 weeks gestation at risk of preterm birth within 7 days and have not received previous course of antenatal corticosteroids

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97
Q

Fetal lung maturation

A

starts at 24 weeks

Lecithin, PI, PG measured by amniocentesis (presence of PG considered mature)

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98
Q

Normal limits of latent phase of Labor 1

A

Nulliparous is up to 20 hours

Multiparous is up to 14 hours

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99
Q

Ergot Alkaloid MOA

A

(ethyl-/ergonovine)
Stimulates adrenergic dopaminergic and 5HT receptors
Causes tonic uterine contraction, vasoconstriction

100
Q

What history would indicated need for chromosomal studies for prenatal dx?

A

Couples after 3+ spontaneous abortion

3-5% have balanced translocation

101
Q

Fetal Lie

A

Maternal spine to fetus spine

Determines if infant is longitudinal, transverse, or oblique

102
Q

How to estimate a due date at different periods

A

6-11 weeks: Crown rump length (accurate to 7d)
12-20 weeks: Femur length, pibarietal diameter, abdominal circumference (accurate to 10d)
3rd trimester: can be off up to +/- 3 weeks

103
Q

Pap smear recommendations by age

A 
Nothing under 21
Nothing over 65
Nothing after hysterectomy
21-29 cytology alone q3y
30-65 HPV and cytology contesting q5y
104
Q

Criteria for Preeclampsia

A

occurs after 20 weeks gestation and coexists with proteinuria (eclampsia adds new onset seizure)
Superimposed means transposed onto chronic HTN

105
Q

Anticonvulsant teratogens

A

Dephenylhydantoin: fetal hydantoin syndrome
Craniofacial abnormalities, limb reduction, pre-natal growth restriction, mental deficiency, CV abnormalities
Valproic Acid (spina bifida)
Carbamazepine (tegretol): spina bifida, others

106
Q

Why is placental abruption the most common cause of DIC in pregnancy?

A

Results from release of thromboplastin from disrupted placenta and sub placental decidua, causing consumptive coagulopathy

107
Q

When is fetal movement / kicking first noticed?

A

~20 weeks, should be 10 movements in 2 hours

108
Q

How much pure RBCs raises your hematocrit by how much?

A

1 unit raises Hct by 3%, Hgb by 1g/dL

Type and crossmatch for 4 units for antepartum hemorrhage

109
Q

Post-term pregnancy syndrome

A

past 42 weeks
Related to aging and infarction of placenta
loss of subcutaneous fat, long fingernails, dry and peeling skin, abundant hair

110
Q

Exam findings in preeclapsia

A

Brisk reflexes, clonus, edema
Increased hematocrit, lactate dehydrogenase, transaminases, uric acid
Thrombocytopenia

111
Q

Erythromycin eye ointment

A

prophylaxis for neonatal gonococcal conjunctivitis

Not effective against C Trachomatis (5-14 days after)

112
Q

What happens in the lungs during preeclampsia?

A

Noncardiogenic PULMONARY EDEMA
Changes in colloid osmotic pressure, capillary endothelial integrity and intravascular hydrostatic vessels (leaking vessels)

113
Q

Braxton Hicks contractions

A

False Labor: irregular with no cervical dilation

114
Q

Amnioinfusion

A

giving normal saline can help cord compression
250-1000cc at 15cc/min
Followed by continuous infusion of 100-200cc/hr
infused through transcervical IUPC

115
Q

Smoking and pregnancy

A

Interferes with fetal growth

Spontaneous abortion, fetal death, prematurity

116
Q

hCG rate with pregnancy

A

Doubles every 2.2 days

117
Q

Minimal effective uterine activity

A

3 contractions in a 10 minute period wavering 25mmHg above baseline

118
Q

Diameters of the baby skull

A

Suboccipitobregmatic: flexed
Occipitofrontal: deflexed, occiput is posterior
Supraoccipitomental: Brow presentation, longest
Submentobregmatic: Face presentations
Avg circumference is occipitofrontal. 34.5cm

119
Q

What causes variable deceleration sin FHR?

A

Secondary to umbilical cord compression
Abrupt decrease before during or after contractions start
Decrease 15bpm or more 15 sec - 2 min

120
Q

Cardinal movements of labor

A

Engagement: presenting part at zero station
Descent: contractions and maternal valsalva
Flexion: OA- babys chin to chest, changing presentation from Occipitofrontal to smaller suboccipitobregmatic
IR: At ischial spines, head enters pelvis transverse, rotates occiput ant or post toward pubic symphysis
Extension: crowning is when largest diameter of fetal head encircled by vaginal Introitus. Station +5. Head is born by rapid extension
ER: Head returns to original position during engagement
Expulsion: ant shoulder delivers under pubic symphysis, followed by posterior shoulder and body

121
Q

Most common cause of fetal ascites or enlarged organs (liver)

A

Immune hydros (Rh isoimmunization)

122
Q

Amniocentesis

A

16 - 20 weeks

0.3% miscarriage rate

123
Q

How does dead fetus syndrome happen?

A

Can happen if gestation is 20 weeks+ from disseminated intravascular coagulopathy in the mother
Check platelets and fibrinogen weekly
Big monozygotic problem

124
Q

Pharm management of premature rupture of membranes 24-32 weeks

A

Group B Strep Prophylaxis
Single corticosteroid (lung maturity/surfactant)
Antimicrobials
+ Mg Sulfate (neuroprotection)

125
Q

Cervical changes during labor

A

become pliable due to collagenolysis, increase in hyaluronic acid, decrease in dermatan sulfate (favors increased water content)

126
Q

What causes early FHR decelerations?

A

Secondary to head compression / intracranial P
Not associated with distress
“mirror image” / occurs at same time as peak contraction

127
Q

First line maternal HTN treatments

A

Oral Methyldopa (a2-agonist) and oral labetalol (a/b blocker)

128
Q

Management of mild preeclampsia

A

<37wks: weekly testing, fetal growth US q3-4w etc

37-40: Begin induction at time of dx w/ favorable cervix use cervical ripener if unfavorable.

129
Q

Major forms of post-menopausal estrogen treatment

A

Estradiol
Conjugated estrogens
Esterified estrogens (Na estrone sulf > “ equilin “)
Estropipate (soluble via S, stabile via Piperazine)

130
Q

Check for maternal dilation

A

At level of internal os

Closed to completely dilated at 10 cm

131
Q

Monitor uterine activity, labor stage 1

A

external tocodynamometer, internal pressure catheter (can assess strength of contractions, helps oxytocin / Pitocin augmentation)

132
Q

Chorionic villi sampling

A

11 weeks

1% miscarriage rate

133
Q

What pt cant you give regional anesthesia to during delivery?

A

Thrombocytopenic

134
Q

Fetal side effects of indomethacin

A

Contraction of ductus arterioles and reversible decrease in renal fxn w/ oligohydramnios

135
Q

When to screen for group B strep with vaginal culture of pregnant woman?

A

36 weeks: treat in labor if positive

136
Q

Pharm management of premature rupture of membranes above 34 weeks

A 
Group B Strep prophylaxis
Single corticosteroid (lung maturity/surfactant)
137
Q

Criteria for vaginal delivery of breech presentation

A

Frank or complete breech presentations

Gestation over 37 weeks, weight 2500-4000g, fetal head flexed, good maternal pelvis, prepared OR

138
Q

Management of uterine atony

A

Bimanual massage of uterus (fisting), balloon/gauze packing

Oxytocine, Methylergonovine, 15-methyl-PGF2a, Dinoprostone, Misoprostol

139
Q

Bishop score

A

Cervical dilation, position, consistency, effacement, station
Blow 6 is bad above 8 is good

140
Q

Second line maternal HTN treatments

A

Parenteral Labetalol
Hydralazine (arterial dilator)
Na Nitroprusside (A/V dilator)

141
Q

Testing for Rh- women whose Anti-D ab titers are +

A

Test father: Negative? all kids will be fine
Homozygous+? all kids can be affected
Heterozygous+? half and half. Test fetus.

142
Q

Indomethacin MOA

A

Blocks PGF2a synthesis (stimulator of uterine contraction)

143
Q

Most common class of spontaneous abortion

A

Autosomal trisomies (16 most common)

144
Q

Gestational HTN

A

No signs of preeclampsia

Occurs after 20 weeks gestation or within 48-72 hours after delivery. Resolves by 12 weeks postpartum

145
Q

Android pelvis

A

Classic male type (30% of women)
Widest transverse diameter closer to sacrum
Prominent ischial spines, narrow pubic arch
Fetal head forced in Occiput Posterior (OP) position
Space restricted and descent arrest common. Poor Px.

146
Q

Different outcomes of dead fetus syndrome

A

Below 12 weeks the dead fetus is reabsorbed (vanishing twin syndrome)
Above 12 weeks it shrinks, dehydrates, flattens (fetus papyraceus)

147
Q

Phases of Labor stage 1

A

Latent: early, between onset, slow dilation
Active: faster dilation, usually at 6cm. Admit here

148
Q

What to not do with suspected premature rupture of membranes

A

Dont check the cervix. It risks infection esp with prolonged latency before deliver

149
Q

Palpatory assessment of pelvic delivery vortex

A

Anterior surface of sacrum (usually concave)

Ischial spines to assess prominence

150
Q

Management of a prolonged latent phase of labor 1

A

sleep, morphine (15 to 20 mg)

151
Q

Etiology of post term pregnancy syndrome

A

Unsure dates, fetal adrenal hypoplasia, anencephalic fetuses, placental sulfatase deficiency (X-linked), extra-uterine pregnancy

152
Q

Obstetric conjugate

A

Diagonal conjugate - 2cm

Narrowest fixed distance fetal head passes through

153
Q

What do you first have to assess before giving oxytocin?

A

Maternal pelvis
Fetal position
Station
Maternal and fetal status

154
Q

Complete abortion criteria

A

Passage of all products of conception with closed cervix
Resolution of pain, bleeding, pregnancy sx
No tx needed

155
Q

Cell-Free fetal DNA prenatal testing

A

9-10 weeks
Derived from apoptosis of trophoblast cells in mom blood
Super great at sex chromosome detection
Does not test for neutral open neural fetal defects (continue to evaluate for NTD with AFP or US)
Only order for high risk patients

156
Q

Why do pregnant women get heartburn?

A

Relaxation of esophageal sphincter by progesterone

Don’t lie down right after eating, elevate your head, etc

157
Q

Vertex-Vertex presentation management

A

Deliver first twin, clamp and cut cord
Second twin is at higher risk of cord prolapse, placental abruption, malpresentation
Prepare for postpartum hemorrhage secondary to uterine atony

158
Q

Blighted ovum criteria

A

Anembryonic gestation
Gestional sac too large to not have embryo (>25mm)
Tx w/ expectant and medical (misoprostol) management

159
Q

Management of severe maternal HTN

A

Methyldopa, Labetalol, Nifedipine, etc
Avoid ACE inhibitors and Angiotensin rec blockers!
Increase risk of malformations (renal dysgenesis, calvarial hypoplasia, fetal growth restriction)

160
Q

How to stave off neural tube defects after having a child with one?

A

Take 4mg folic acid before conception (neural tube closure is complete at 28 days post conception)

161
Q

Assessing the Power factor of abnormal active phase of labor

A

Intrauterine pressure catheter

Requires membranes be ruptured (risks cord prolapse, chorioamnionitis)

162
Q

Ritodrine

A

b2-agonist for tocolysis
Causes severe hallucinations
FDA approved but not available lol

163
Q

Montevedeo units

A

Pressure each heartbeat gives (minus the baseline 20 for each) added together over 10 minutes
Should be over 200 for at least 2 hours
Shouldn’t be more than 5 contractions in 10 min

164
Q

Etiologies of active phase abnormalities

A

Inadequate uterine activity
Cephalopelvic disproportion
Fetal Malposition
Anesthesia

165
Q

Nifedipine contraindications

A

Avoid concomitant use with Mg Sulfate: can cause lethal CV collapse

166
Q

Pharmacologic treatment of ectopic pregnancy

A

MTX and restrict folate

Check hCG on days 4 and 7

167
Q

Steroid hormone production cascade in fetuses

A

Late gestation: placental CRH stimulates fetal adrenals to produce DHEA-S and Cortisol
That cortisol stimulates more placental CRH, etc

168
Q

Indomethacin side effects

A

Can cause oligohydramnios, premature DA closure, higher risk of necrotizing enterocolitis, intracranial hemorrhage

169
Q

How does cervical ripening work?

A

Collagen and GAGs broken down by metalloproteinases
Cervix becomes thin (effacement), dilates
Phase 1 well organized and uniform to size 2 less uniform and disorganized

170
Q

Nerve branches that cause obstetric pain

A

Contractions and dilation: T10-12 through L1
Pressure: S2-S4 (pudendal N)
Regional anesthesia hits all below T10

171
Q

Mechanical cervical dilators

A 
Foley bulb catheter (inflate 30-80cc)
Laminara Japonicum (dilation by swelling of laminar rods)
172
Q

Diagnosis of pre-term labor

A

Between 20 and 37 weeks gestation
Uterine contractions
Cervical change/dilation of 2cm+ AND/OR 80% effacement

173
Q

Ways FHR can vary from baseline

A 
Its all about amplitude / peak to trough
Absent: amplitude range undetected
minimal: amp range detectable but at or below 5bpm
moderate: normal: 6-25 bpm
Marked: amplitude range above 25 bpm
174
Q

What causes late decelerations in FHR?

A

Uterine placental insufficiency (UPI)
Most ominous one, repetitive and late decelerations usually indicated fetal metabolic acidosis and low arterial pH
From excessive uterine activity or maternal supine HPTN

175
Q

Antineoplastic teratogens

A

Alkylating agents: Busulfan, chlorambucil, cyclophosphamide

176
Q

Criteria for Inevitable abortion

A

Vaginal bleeding and cervix is partially dilated

Loss is 100%

177
Q

FHR tracing and possible etiology indications for preparing for delivery in FHR Category II

A

Absent baseline variability (recurrent late decelerations, recurrent variable decelerations, Bradycardia) or sinusoidal pattern from increased risk of fetal acidemia or hypoxemia and acidemia

178
Q

Hormonal teratogens

A

Androgenic progestins: masculinization of female external genitalia
DES (T-uterus, others)

179
Q

Nifedipine MOA

A

Ca channel blocker for tocolysis
2nd choice agents for 24-32 weeks
1st choice for 32-34 weeks when NSAIDS contraindicated
Preferable to b-mimetics because fewer adverse effects

180
Q

Fetal scalp stimulation

A

If an acceleration of 15bpm lasting 15 seconds occurs, the fetal pH value is almost always 7.22 or more
Great for differentiating sleep from acidosis when tracing shows reduced variability but no decelerations (category 2)

181
Q

Septic abortion criteria

A 
Fever, uterine and cervical motion tenderness
Purulent discharge and hemorrhage
Retained infected products of conception
Start IV Abx
Proceed with suction D&C
182
Q

Criteria for gestational HTN

A

Recognized after 20 weeks gestation

183
Q

Management of post-term pregnancy

A

wk 41: Run tests 2x/wk, induce labor if necessary

wk 42: induce labor

184
Q

What happens in the brain during preeclampsia?

A

Cerebral edema

Maybe fibrinoid necrosis, thrombosis, micro-infarcts, petechial hemorrhages

185
Q

Management of maternal hyperthyroidism

A

No iodine, use methimazole in 2nd and 3rd trimester or propylthiouracil

186
Q

Platypelloid pelvis

A

Flattened gynecoid, 3% of females
Short AP and Wide transverse, bispinous, suprapubic
Fetal head has to engage in transverse diameter
Poor Px

187
Q

What happens in the liver during preeclampsia?

A

Sinusoidal fibrin deposition in the peri portal areas with surrounding hemorrhage and portal capillary thrombi (sub capsular hematoma, causes liver rupture)
Stretching of glissons capsule (RUQ pain)

188
Q

Terbutaline Indications

A

Second choice after Nifedipine

Between 32-34 weeks when NSAIDs contraindicated

189
Q

Couvelaire uterus

A

Extravasation of blood into uterus

Causes red and purple discoloration of serosa

190
Q

Missed abortion criteria

A

Fetus has expired, remains in uterus
Usually no sx
Coagulation problems maybe, check fibrinogen
Expectant management vs misoprostol vs D&C

191
Q

Check baby effacement

A

Thinning of cervix occurs and is reported as % change in length
Normal cervical length is 3-5cm
Ranch is thick (100% effaced)

192
Q

Adverse effects of Mg Sulfate

A

Maternal: flushing, palpitations, HA, depressed reflexes
Fetal: Muscle relaxation, maybe CNS depression

193
Q

FPAL

A

Full term: 37 - 42 weeks
Pre-term: 20-36 weeks
Abortions
Living

194
Q

Fetal presentation

A

Presenting part to the pelvis

Vertex, breech, transverse or compound (vertex w/ hand)

195
Q

Nonstress test during pregnancy

A

Reactive: 2 accelerations for at least 15 beats above baseline lasting at least 15 seconds during 20 minutes of monitoring

196
Q

Adverse effects of Carboprost

A

Dont induce labor if lungs aren’t mature or cervix is not ripe (causes rupture)
Maternal water intoxication

197
Q

Puerperal sepsis

A

Postpartum fever and increasing uterine tenderness on day 2-3
Managed by Ampacillin and Gentamycin (Bacteroides fragilis is resistant, but sensitive to clindamycin)

198
Q

Most common single chromosomal abnormality

A

45 XO / Turners

199
Q

Normal limits of the active phase of labor 1

A

Cervical dilation: Nulliparous 1.2cm/hr, multi is 1.5

Fetal descent: Nulliparous is 1cm/hr, multiparous is 2

200
Q

Thickened endometrial stripe on US

A

Arias-Stella rxn indicative of possible ectopic pregnancy

201
Q

Rate of cervical dilation

A

Primiparas: 1.2 cm/hour
Multiparas: 1.5 cm/hour

202
Q

Prophylaxis of pre-term birth

A 
vaginal progesterone (women with short cervix)
Pessary-arabin pessary (same)
203
Q

Pharm management of premature rupture of membranes below 24 weeks

A

Dont do Group B Strep prophylaxis

Maybe corticosteroid, maybe antimicrobials

204
Q

Diagonal conjugate

A

Inferior portion of pubic symphysis to sacral promontory

AP diameter of pelvic inlet above 11.5cm is good

205
Q

Types of external fetal monitors

A

Doppler US transducer

Pressure sensitive tocodynanmometer: detects and records contractions (measures frequency, NOT strength)

206
Q

St Anthonys fire

A

Mania, psychosis, gangrene distal parts

From fungus-containing rye (ergot alkaloids)

207
Q

What drug causes fever unresponsive to NSAIDs?

A

Dinoprostone

208
Q

1st trimester screening findings of down’s syndrome

A

Elevated b-HCG and low PAPP-A

209
Q

Duration of labor stage 1

A

Primiparas: ~6 - 18 hours
Multiparas: ~2 - 10 hours

210
Q

Benefits and risks of amniotomy

A

Augments labor and allows assessment of meconium status. BUT, risks cord prolapse, prolonged rupture associated with chorioamnionitis

211
Q

Duration of labor stage 2

A

Primipara: 3 hours w/ epidural and 2 hours w/out
Multipara: 2 hours w/epidural and 1 hour w/out

212
Q

Different managements for different cervical cancers

A

Microinvasive: cold knife cone or hysterectomy
Inv. 1a1: cone or total hysterectomy
Inv. 1a2: modified radical hysterectomy, LN removal
Bulky (1b and IIa): Radical w/LN direction/rads/cisplatin
iib+: external beam rads and cisplatin-based chemo

213
Q

Manage persistent occipitotransverse position

A

pelvis is adequate, infant is not macrosomoc and contractions are inadequate: start oxytocin, rotate manually or with keilland forceps
If pelvis is inadequate or infant deemed to be macroscopic proceed with C section

214
Q

Stages of labor

A
  1. Onset to complete cervical dilation. Latent / Active
  2. Complete dilation to delivery of baby
  3. Delivery of baby to delivery of placenta
  4. Delivery of placenta to stabilization of pt
215
Q

Indications for ergot alkaloids

A

Postpartum uterine tone, decrease bleeding
Augment labor (but dangerous)
Migraine relief

216
Q

Treat TTTS

A

serial amniocentesis with amniotic fluid reduction: can reduce pre-term contractions secondary to uterine distention (polyhydramnios) and maternal Sx
Laser photocoagulation of anastomosis vessels on placenta (done at specialized locations)

217
Q

Criteria that give gynecoid and anthropoid pelvises good Px

A

Public arch greater than 90 degrees
Ischial tuberosity greater than 8.5cm
Diagonal conjugate above 11.5cm
Prominence of ischial spines

218
Q

Terbutaline MOA

A

b2-agonist
Increases cAMP, leads to K-mediated hyperpolarization
Not FDA approved

219
Q

Management of labor stage 1

A

Uncomplicated: monitor q30min active 1, q15min stage 2
Complicated: q15min active 1, q5min stage 2

220
Q

Causes of Downs syndrome

A

95% non-dysjunction

4% unbalanced translocations

221
Q

Incomplete abortion criteria

A

Vaginal bleeding, cramping lower abdominal pain with dilated cervix
Passage of some but not all products of conception
Tx is usually suction and D&C

222
Q

HELLP labs

A

LDH above 600, Liver enzymes 2x ULN, Platelets less than 100k
Immediately deliver this baby. Half eclamptic pt get this

223
Q

FHR tracing and possible etiology indications for reducing uterine activity in FHR Category II

A

Tachysystole from spontaneous labor, induction or augmentation

224
Q

Antiphospholipid Syndrome can cause recurrent spontaneous abortions. How would you treat it?

A

Prophylactic heparin and low dose aspirin

Test for Lupus Anticoagulant, Anti-Cardiolipin, B1-glycoprotein 1 abs

225
Q

How often should pregnant women visit the doctor

A

q4w until 28 weeks
q2w from 28 - 36 weeks
Weekly until delivery

226
Q

How does persistent occipitotransverse position come about?

A

Head fails to rotate and flex into OA position
Can be caused by CPD, altered pelvic architecture, relaxed pelvic floor
Can cause arrest of descent because of deflexion

227
Q

Classical presentation of placenta previa

A

Painless vaginal bleeding

228
Q

Fetal HR category 2

A

Intermittent variable decelerations (<50%): normal, fine
Recurrent variable decelerations (>50%): could be umbilical cord compression w/ impending acidemia. Alleviate it with repositioning, amnioinfusion (first stage), pushing every other contraction

229
Q

Carboprost MOA

A

Synthetic PG-F2a analog
Induces uterine contractions, prolonged duration
Induces abortion (13-20 wks)
Helps postpartum refractory bleeding

230
Q

Anxiolytic of choice during pregnancy

A

Fluoxetine (meprobamate or chlordiazepoxide associated with 4x increase in birth defects)

231
Q

Vaginal examinations during labor stage 1

A 
Active: cervical check q2hrs
Record dilation (cm)/%effaced/station (cm)
232
Q

Second trimester screening tools

A

Triple: b-hCG, estriol, maternal AFP
Do it between 16 and 20 weeks
70% Downs sydrome detection
Quadruple: All that + Inhibin A levels (80%)

233
Q

Assess the pelvic outlet

A

Measure between ischial tuberocities (8.5cm is good)
Infrapubic angle: thumb next to each inferior pubic ramus and estimate angle (above 90 degrees is good)
MRI/CT: like never happens

234
Q

Side effects of too much Mg sulfate

A

Therapeutic value is 5-9mg/dL
Above 9 you get loss of patellar reflexes
Above 12 get respiratory paralysis
Above 30 get cardiac arrest, respiratory compromise
Give Ca Gluconate to reverse

235
Q

What stimulates the amnion so synthesize PGs?

A

Increased Phospholipase A, Prostaglandin H synthase, (Type 2/PGHS-2 Activity)
During pregnancy, this is suppressed by PGDH (prostaglandin dehydrogenase) in the chorion. This falls away during labor

236
Q

Umbilical cord abnormalities found in monozygotic twins

A

Primarily associated with monochorionic twins
Absence of umbilical A.
Velamentous umbilical cord insertions more frequent (can cause growth abormalities)

237
Q

Major forms of post-menopausal Progesterone treatment

A

Alone
MedroxyProgesterone (MPA) (add Conjugated E)
MethylTestosterone (Add Esterified E)

238
Q

Indications for Misoprostol

A

Induce uterine contraction
Maintain PDA
Prevent NSAID ulcers
Off label for cervical ripening, labor, pp hemorrhage, incomplete abortion
Terminate intrauterine pregnancy if <77 days
use in combo with mifepristone for uterine contracts

239
Q

When to get fetal survey US

A

20 weeks

240
Q

Uterus segments during labor

A

Upper: actively contracts and retracts to expel fetus

Lower segment and cervix become thinner and passive

241
Q

Risks associated with macrosomia

A 
Maternal morbidity (c-section, hemorrhage)
Shoulder dystocia, fractured clavicle, damaged brachial plexus (C5-6 gives herb-duschenne paralysis) (Klumpke is C8 and T1)
242
Q

Hepcedrin

A

Treats HER2 cancers

243
Q

Gynecoid pelvis

A

Classic female type (50% of women)
Round at inlet, wide transverse, wide suprapubic arch
Head generally rotates into occiput anterior (OA) position
Good delivery Px

244
Q

Intrauterine growth restriction diagnosis

A

Fundal height lags more than 3cm behind gestational age, then order an ultrasound

245
Q

Mg Sulfate indications

A

Prevents eclamptic seizures, confers neuroprotection (decreased CP risk)
Long-term drug choice for tocolysis (but not really?)

246
Q

Pharm management of premature rupture of membranes at 32-34 weeks

A 
Group B Strep prophylaxis
Single corticosteroid (lung maturity/surfactant)
Antimicrobials to prolong latency
247
Q

Downsides to using NSAIDS (classically indomethacin but now ibuprofen) to close a PDA in a pre-term infant

A

Decreased kidney fxn (oliguria, edema, mild HTN)

Less effective in term infants, btw. Maybe surgery.

ENRP (4 decks)

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