Women's Health Exam 1 Flashcards
1
Q
Non-endocrine tissue in the body that produces estrogen
A
Fat tissue
2
Q
Role of LH and FSH
A
Cause secretion of Estrogen, Progesterone and other hormones from ovaries
Stimulate thecal and follicular cells to mature an egg
3
Q
Roles of estrogen
A
Growth of endometrium
Breast in largement
Induces LH surge
Assists in libido
4
Q
Roles of progesterone
A
Decreases uterine contractility
Promotes breast development and differentiation
Signals lactation as it falls
Maintaining pregnancy
5
Q
Activins
A
Stimulate FSH secretion
Involved in WBC production and embryo development
6
Q
Inhibins
A
Inhibit FSH so we don’t use all out follicles at once
7
Q
Follistatins
A
Inhibit activins
Regulate gonadotropin secretion
8
Q
Relaxin
A
Relaxes pubic symphisis and pelvic joints in pregnancy
Inhibits uterine contractions
Mammary and follicular development
9
Q
Positive feedback on the HPO
A
Estrogen at high levels increases GnRH and LH secretion
Activin promotes gonadotropic cell function
10
Q
Ad===Thelarche
A
Beginning of breast development
First sign of puberty in females
11
Q
Pubarche
A
Onset of pubic and axillary hair, after breasts and before menstruation
12
Q
Day one of a period
A
The first day of bleeding
13
Q
Normal menstrual cycle
A
28 days on average
14
Q
Follicular phase
A
Length varies - getting a new follicle ready
15
Q
Hormones of the follicular phase
A
FSH stimulates a few follicles and then realease inhibin to stop more follicles
One grows and secretes Estrogen
Estrogen causes LH surge, triggering ovulation
16
Q
Typical ovulation day
A
Day 14
17
Q
Mittelschmerz
A
Pain upon ovulation
18
Q
Corpus hemorrhagicum
A
Ruptured follicle fills with blood
19
Q
Luteal phage
A
consistently 14 days
Corpus luteum forms from corpus hemmorrhagicum
20
Q
Hormones of luteal phase
A
FSH drops
Corpus luteum produces estrogen which inhibits LH which is stimulating the corpus luteum
CL scars up if no pregnancy
21
Q
Proliferative phase of the uterus
A
Estrogen forms the stratum functionale about days 5-16 - endometrium growth
Glands are made bu don’t work yet
22
Q
Secretory phase of the uterus
A
About 14 days
CL is formed
Progesterone from the CL decorates the uterus
Glands become coiled and secrete fluid
23
Q
Menstrual phase
A
Loss of blood flow results in the death of the stratum functionale
24
Q
Cervical changes during the menstrual cycle
A
Estrogen makes cervicle mucus thinner and more hospitable to sperm - fern like pattern on slide first half of cycle
Progesterone makes the muscous THICK and impenatrable
25
Cervical ectopy
Caused by opening of cervical opening/unrolling exposing columnar epithelium of the inner cervix
Darker area of tissue - looks like an infection
26
Birth control and cervical ectopy
Stays around longer with birth control
27
Falopian tube cilia and hormones
Estrogen - beat faster
Progesterone - beat slower
28
Muscle and hormones
Progesterone - reduces spasms, relaxes smooth muscle, antagonizes insulin
Estrogen - Improves skeletal muscle contractility
29
Fat skin and Sodium/Water effect of progesterone
Maintains skin
Fat gain in pregnancy
Excretion of sodium and water
30
Cardiovascular changes of pregnancy
Laterally displaced PMI
Supine hypotensive syndrome from uterus compressing IVC
Larger heart and HR increase by 15bpm
Drop in BP w/ increase in volume
May see some murmur, SVT, Left shift, ST depression
31
Pulmonary changes in pregnancy
Congested upper respiratory tract from vasodilation
Higher and wider ribcage
Less dead space in lungs with increased tidal volume
Mild respiratory alkalosis
32
Renal changes during pregnanacy
Transient renal hypertrophy
Dilated ureters, hydronephrosis
Risk of UTI
Increased load on kidneys
Increased GFR
Some leakage of protein and glucose but not to excess
Increased renin
33
GI changes in pregnancy
Increased salivation
Gum hypertrophy
Increased transit times
Slow gallbladder emptying
Increased heartburn
NO worsening dental health is normal
34
Heme/Onc and Fluid changes in pregnancy
Increased in blood volume by 50%
More RBCs
Increased WBCs
More blood clots
Less immune function
35
When is prolactin highest
During pregnancy to help mammary glands develop
36
Thyroid and pregnancy
Increase in production
PTH decreases in 1st trimester and increases in 2 and 3
37
Eye changes in pregnancy
Glaucoma gets better, cornea can thicken
38
Skin changes in pregnancy
Increased skin pigmentation
Linea nigra - black line down midline of abdomen
Melasma - Brown butterfly rash on cheeks
Stretch marks -Red to Brown
39
Other skin changes that may be seen in pregnancy
Spider angiomas
Palmar erythema
Cutis marmorata
Varicosities in legs
Brittle nails
Thickening of hair
40
Metabolic changes in pregnancy
Increased fatigue
Increased appetite, weight, thirst
41
Weight increase during pregnancy
Average increase of 25-35 lbs
Loose about 20 lbs at delivery and thereafeter
42
Calories per day recommended for pregnancy and lactation
300 per day during pregnancy
500 per day during lactation
43
Protein intake recommendation for pregnancy
1g/kg/day
Plus 20 g/d in 2nd half
44
Pregnancy calcium recommendation
1200 mg/d
45
Iron recommendation for pregnancy
60-120 mg/day if defficient
46
Folic acid supplementation in pregnancy
.4 mg/day 1 month before conception and first 3 months
1g/d for insulin dependant diabetics, Valproate, or Carbamazepime
4mg/d if hx of tube defects
47
B6 for pregnancy
Helps with nausea
48
Placenta
Part of the fetus - takes up most of the blood brought to the uterus
Eats into the wall
Uterus needs to contract to prevent bleeding
49
SUbstances that don't cross the placenta
Only very large
Heparin and Insulin
50
Initial evolution of fertilized egg
Zygote, morula, blastocyst
51
Week at which organ development begins
Weeks 5
52
Landmarks at weeks 6-7
Limb buds and heart beat
53
Week 9 landmarks
All essentail organs have begun to form
54
Week 10 landmarks
Fetal heart tones heard on US
End of embryonic period - fetal period begins
55
Lanugo development
Weeks 15-18
56
Weeks 19-22 landmarks
Fetus can hear
Feel movement of fetus
57
Threshold of survivability
Weeks 23-25 some survive
Week 26+ most survive
58
Week 26
Hands and startle reflex
59
Weeks 27-30
Surfactant production begins to occur
60
Mesonephric ducts
Turn into male structures
61
Paramesonephric ducts
Turn into female structures
62
Time of testes descending
About week 28, should be there by week 32
63
Term baby
Born at 37+ weeks
64
Preterm baby
20-37 weeks
65
Abortion baby
ALL pregnancy losses before 20 weeks
66
Living children
Any infant who lives for 30+ days
67
Primipara
Has delivered once AFTER 20 weeks
68
1st trimester
1-14 weeks
69
2nd trimester
15-28
70
3rd trimester
29-42
71
Amount of pregnancies that are unplanned
Up to half
72
Pre-conceptual care
Help modify risk factors before conception to improve pregnancy outcome
73
Presentation of pregnancy
Amenorrhea - May have conception bleeding
Chadwick sign - Bluish red uterus, soft
Breast enlargement and tenderness
Areolar enlargement
74
Fetal movement
May not feel until 20 weeks first time
May feel 16-18 weeks after first time
75
Pregnancy diagnosis
Urine hCG detectable 8-9 days after ovulation, can also detect in blood
76
3 hormones similar to hCG
LH, FSH, TSH
77
How rapidly should hCG increase?
Value doubles every 1.4-2 days
78
95% detection level for hCG
12.3 mIU/mL
79
First US evidence of pregnancy
4-5 weeks
Gestational sack seen
Transvaginal US
80
Yolk sac on US
Seen at 5-6 weeks
COnfirms location in the uterus (r/o ectopic)
Echogenic ring with anechoic center
81
Fetal Pole/Embryo
Seen after 6 weeks, looks like a hole in the muscle
82
Crown Rump length
Measure from head to butt can be done 6-12 weeks
More reliable estimate of age than LMP
Most accurate at 12 weeks
83
Naegele's rule
LMP+7 days-3 months
84
Hx for pregnancy
Prior pregnancies
Contraceptive use/desires
Menses interval
Depression
Abuse
Drug/Alcohol use/Drugs
85
PE for pregnancy
Pap smear over 21
Chlamydia and Gonoirrhea testing
Cervical dilation, length, consistency
Bony pelvic architecture
86
Uterine sizes over time
6 week - Small orange
8 week - Large orange
12 week - Grapefruit
87
When should a Rho gam shot be given
at 28 weeks to negative mothers with positive babies
Also for vaginal bleeding intrapartum
Post delivery of neg mothers with positive babies
88
Kleihauer-Betke
Tests for number of fetal RBCs in circulation, in cases of trauma may need to test and give Rho gam
89
Rh IgG attack rate on fetal RBCs
.3 mg will eradicate 15mL Fetal RBCs (eq. to 30 mL fetal blood)
90
Rubella
MCC of fetal growth restriction
Infection in first trimester can cause abortion
Vaccine needs to be taken 1 month BEFORE getting pregnant
91
Syphillis
T. pallidum
Treat with PCN-G - desensitization recommended if allergic
92
Prenatal counseling recommendations
Prenatal vitamin - 400mcg folic acid and Iron
May work but should not do intense or hazardous work
93
Pregnancy weight gain
25-35 lbs if okay weight
Less if they weigh more
94
Risks associated with obesity while pregnant
Hypertension/Preeclampsia
Gestational diabetes
Macrosomia and C section
95
Additional diet for pregnancy
Increase by 100-300 calories per day
Avoid FISH/SEAFOOD
96
4 risk factors for lead exposure in mothers
Immigrant
Remodeling home with lead
Live near lead source
Contaminated water
97
Air travel and pregnancy
Safe up to 35 weeks
Need to ambulate
98
Dental treatment and pregnancy
Okay to get radiographs
Recommended to have done
99
Caffeine and pregnancy
5+ cups of coffee per day can increase risk
Under 200mg/day is okay
100
Exercise and pregnancy
Do not usually need to limit exercise
Encourage mild to moderate exercise - don't ramp it up
10 lb lifting is the general rule
Don't scuba dive, etc.
101
Smoking and alcohol and pregnancy
Need to avoid including vaping
Binge drinking is especially problematic
102
Breastfeeding recommendations
6 months is preferred
2 years by WHO (also recommedning ofr Africa)
8-12 times daily with 15 minutes per session
Helps with weight loss, child obesity, chronic disease, bonding
103
CI to breastfeeding
HIV
Drug/Alcohol use
Galactosemia
Hep C with broken skin
Active TB
Medications
Undergoing breast cancer tx
Active herpes lesions on breast
104
Pregnancy visit spacing
Every 4 weeks until 28
Every 2 until 36
Every week until delivery
105
Prenatal surveillance
Fetal HR
Height of the fundus
106
Fundus height benchmarks
12 weeks -emerging from bony pelvis
16 weeks - Between pubic symphysis and umbilicus
20 weeks - Fundus at the umbilicus
20-34 - correlates with gest age
+/- 2cm
107
Timing of gestational diabetes screening
24-28 weeks
50 g glucose with test right after
108
Lab tests during pregnancy
CBC at 28 weeks
Syphillis and HIV 28 weeks for high risk
Rh testing 28-29 weeks
Group B strep testing 35-37 weeks
109
Vaccines and pregnancy
Hep A and B
Flu vaccine
Tdap
RSV between 32 and 36 weeks
COVID
110
Tx for nausea and vomiting in pregnancy
Small meals
BRAT diet
Ginger
B6
Prochlorperazine
Metoclopramide
Odansetron
111
Hyperemesis gravidarum
Vomiting severe enough to produce weight loss, electrolyte disturbances, ketosis, dehydration, etc.
112
Tx for back pain in pregnancy
Shoes, maternity belt
Tylenol
Muscle relaxers
113
Hemorrhoid tx in pregnancy
Topical anesthetics
Warm bath
Compression socks for varcosities
114
Tx for heartburn in pregnancy
Antacids
H2 blockers
PPIs
115
Pica in pregnancy
Craving for dirt, ice, starch
Assoc. with iron deficiency
116
Tx for sleep issues with pregnancy
Benadryl and naps
117
Leukorrhea
Increased vaginal discharge during pregnancy - generally not pathologic
118
2 MC congenital abnormalities
Heart and Cleft palate
119
Threshold for downs risk
35years
120
Marker for neural tube defects
Alpha feto protein
May screen 15-18 weeks
Can use a US for it (more common)
121
Down syndrome screening recommendation
Offer to everyone regardless of risk
Screening NOT diagnostic
NUchal translucency and PAPP-A value
122
Second trimester down screening
hCG
AFP
Unconjugated estriol
123
Cell free DNA
Check for genetic abnormalities and gender
99% detection rate
Blood draw at 9-10 weeks
124
Amniocentesis
15-20 weeks
20 cc of fluid
Assess karytype, can be done for comfort
Evaluate for fetal lung maturity
Chance of fetal loss 1 in 300-500
125
Chorionic villus sampling
10-13 weeks
Assess fetal karyotype
Transabdominal or transcervical
126
CI to CVS
Vaginal bleeding
Higher risk of pregnancy loss - 2%
Uterine ante or retro flexion
127
Fetal blood sampling
For fetal anemia
Cord blood sampling
Perfromed at cord insertion
128
s/s of fetal stress
Low HR
Low fetal movement
129
Recommendations for antepartum testing
Every week starting weeks 32-34 (26-28 if high risk)
130
Factors effecting fetal movement
Diminished by increased movement
Sleeping
Placement of the placenta
Should be consistent in its habits
131
Non-stress test
For a baby not moving Measure heartbeat of fetus - should see 2+ accelerations in a 20 minute time span
132
What to do to wake baby up for a nonstress test
Acoustic stimulator up to three times - should have a positive result after
133
Biophysical profile
Score 0 or 2 in five categories
Non stress test
Breathing
Movement
Tone
Amniotic fluid volume (2x2 pocket)
134
BPP interpretation 8
Normal - deliver if abnormal amniotic fluid index
135
BPP interpretation 6
Deliver if over 36 weeks
Repeat within 24 hours
Deliver if still 6 or lower, observe if above 6
136
BPP interpretation 4
Probably asphyxia repeat or deliver
137
BPP interpretation 2
DELIVER!!
138
Doppler velocitrimetry
Looks at fetal blood flow
Umbilical artery - Shows lack of blood to flow to fetus = growth restriction
Middle cerebral artery - Fetal anemia and growth restriction
139
Complete dilation
10cm - max amount
140
Effacement
How thick the cervix is - 0% is 4cm, 100% is no cervix left
141
Braxton Hicks contractions
False contractions - more likely with more pregnancies, dehydration
142
Bishop score favorable for labor
Greater than 8
143
Diagnoses for labor
Water breaking
Ferning
AFI - Amniotic fluid
Nitrazine
144
Vaginal bleeding in labor
A small amount can be okay
145
Tx for group be strep vaginal colonization
PCN
Erythromycin or Clinda for allergies
146
IV pain medication for labor
Usually avoided in later stages of labor to avoid fetal respiratory distress
Epidural anesthesia preferred
147
Where is an epidural given
L3-L4 intercostal space
148
CI to an epidural
Bleeding disorder or recent heparin use
Patient preference
Thrombocytopenia
149
Regional anesthesia
One time dose for C section
Pudendal block - less common for pregnancy today
150
General anesthesia for deliver
Usually only used in emergencies and C sections
Danger of maternal aspiration
151
Bishop score that indicates likely failure of induction and what can be done
Less than 5
Cervical ripening
152
Cervical ripening medication
Prostaglandins - Cervidil or Cytotec Both vaginal, Cytotec is oral as well
Can cause tachysystole, fever, vomiting, diarrhea, uterine rupture
CI - C-section, Hysterotomy, Myomectomy
153
Induction of labor
Pitocin IV infusion that increases over time
Danger of tachysystole and rupture
Stop if fetal distress occurs
154
Manual induction of labor
Balloon catheter or laminaria
More effective with ptosin
Inserted vagnially
Amnio hook to break water
155
Augmentation of labor
Strengthen contractions - Use ptocin
156
Operative vaginal delivery
Forceps or vacuum
Can cause lacerations (forceps - vaginally) (Vaccuum -Perineal)
Use for fetal compromise or if a C section can no longer be done
157
First stage of labor
Onset to complete cervical dilation
1st 6 cms are much slower
158
Second stage of labor
Cervial dilation to fetal expulsion
159
Third stage of labor
Fetal delivery to placental delivery
160
Fourth stage of labor
Placental delivery to one hour postpartum
161
Adequate labor
Over 200 Montevideo unites in 10min as measured by intrauterine catheter
Start ptosin if inadequate
162
Fetal variabilities that affect labor
Fetal size and alignment
163
Vertex
Head first delivery
164
Breech
Butt first delivery
165
Shoulder/compound
Something in front of baby arm
166
Funic
Umbilical cord first - C SECTION!!
167
Direction baby should be looking when born
Down to the floor (posteriorly)
168
Determinationof fetal position in Uterus
Mother lies supine
Leopolds maneuver:
Evaluate fetal lie, weight, position and presentation
Difficult with obesity, multiples, excess amniotic fluid
US is best bet though
169
C-section indication
More than two fetuses
Any non vertex position
5,000+grams
4,500+ grams and diabetic mother
170
Pelvic shapes
Gynecoid - best
Antropoid - Narrow front to back
Android - Triangular
Platypelloid - Narrow side to side
171
Active phase arrest labor
No progression in cervical dilation in 6cm dilated patients despite four hours of adequate contractions or 6 hours of inadequate contraction with augmentation
C-section indicated
172
Prolonged second stage labor
More than 3 hours pushing for nulliparous and 2 hours in multiparous
Indication for C section
173
IUDC
Catheter to measure strength of contractions
174
Umbilical cord prolapse
Emergency if cord get pinched - needs to be propped up manually
Indication for immediate C section while holding baby off the cord
175
Indications of second stage
Pelvic/rectal pressure
Mother has active role in pushing out fetus
176
Molding
Fetal head shaping to shape of pelvis as it works its way out
177
Perineal laceration first degree
Injury to perineal skin and vaginal mucosa only
178
Second degree perineal laceration
Injury to perineal body (space between vagina and rectum)
179
Third degree perineal laceration
Injury through external anal sphincter
180
Fourth degree perineal laceration
Injury through rectal mucosa
181
Episotomy
Intentionally making a perineal laceration
Usually causes problems - not popular
Midline or Mediolateral - more painful to the side
182
Shoulder dystocia
Fetal shoulder impaction on the pubic symphysis
Macrosomia, Diabetes, Obesity, Operative deliver are risk factors
183
Dangers to the fetus in shoulder dystocia
Humerus or clavicle fracture, Brachial plexus injury, Death
184
Management of shoulder dystocia
Episiotomy
Mcroberts maneuver - sharp flexion of maternal hips
Suprapubic pressure
Rubin, Wood's corkscrew - rotate baby
Symphisiotomy
185
Delivery of the placenta
Done with one hand on the umbilical cord with gentle downward traction
186
Uterine inversion
Uterus is pulled out through the vagina
Replace uterus - use NOX or terbutylline to relax so it can go back inside
187
Fourth stage of labor risk and definition
Postpartum hemorrhage - Uterine atony, Lacerations, retained placental fragments
Defines as 500+cc's in a vaginal deliver or 1000+cc's in a c-section
188
Tx for uterine atony
Four Meds
Pitocin, Methergine, Cytotec, Hemabate
189
Engagement
First movement of delivery
Passage of the widest aspect of the fetal presenting part (typically the head) below the plane of the pelvic inlet (level of ischial spines)
190
Descent
Second maneuver of labor
Moving down into the bony pelvis
191
Flexion
Head flexes to fit through the birth canal
192
Internal rotation
Head of baby either rotates from transverse to anterior or posterior position
193
Extesnsion
Head extends out as the baby passes into the vaginal
194
External rotation / Restitution
Head rotates back to its original position prior to internal rotation - aligns with fetal torso
195
Expulsion
Rest of baby comes out
196
7 Cardinal movements of labor
Engagement
Flexion
Descent
Internal rotation
Extension
External rotation/Restitution
Expulsion
197
Normal fetal HR
110-160
198
Fetal bradycardia
Under 110 bpm
May be due to lupus heart block or maternal hypotension
199
Absent fetal HR variability
Absent - worrisome
200
Minimal fetal HR variability
1-5bmp variation
Fetus asleep or inactive
201
Moderate fetal HR variability
5-25bpm variation
Considered normal
202
Marek fetal HR variability
25+ bpm variation
Worrisome
203
Normal acceleration of fetal HR
15bpm for 15s after 32 weeks
10bpm for 10s before 32 weeks
204
Early decelerations
Begin and end with contractions
Result of head compression
No intervention required
205
Late decelerations
Begin at peak of contraction and slowly return to baseline after contraction is finished
Result of compromised bloodflow during contractions - uteroplacental insufficiency
206
Tx for late decelerations
Position, Oxygen, Stop Pitocin, Check cervix, consider C section or assisted vaginal delivery
207
Variable decelerations
V shaped at any time due to cord compression
The deeper and longer, the more concerning
Reposition
Infuse water into the uterus
208
Sinusoidal fetal HR
Most often fetal anemia - always concerning
209
Category I fetal heart tracing
FHR 110-160
Moderate FHR variability
No late or variable decelerations
210
Category II fetal heart tracing
Neither category I or III
211
Category III fetal heart tracing
Absent FHR variability with any of the following
Recurrent late decelerations
Recurrent variable decelerations
Bradycardia
Sinusiodal waveform
212
Contraction stress test
Use pitocin to trigger 3 contractions in ten minutes
Test for poor fetal HR patterns during contractions
Recurrent late decelerations - Positive - Bad
Good looking - Negative test
Equivocal (maybe one deceleration - Wait and see
213
MC site of ectopic pregnancy
Ampulla of fallopian tube
Can also occur in C-section scar (becoming more frequent
214
Risk factors for ectopic pregnancy
Prior
STDs
PID
Endometriosis
IUD
Assistive reproductive technology
215
Presentation of ectopic pregnancy
Vaginal bleeding
Lower abdominal pain
Adnexal mass
Abdominal pain on rupture
Hemodynamic instability
216
beta hCG at which pregnancy should be visible in the uterus
1500-2000mIU/mL
Should be increasing at a steady rate if pregnancy is normal
217
US for ectopic pregnancy
No yolk sac seen in uterus with pseudo gestational sack
Donut sign - thick walls
218
HCg monitoring if you dont see an intrauterine pregnancy
Check every other day
219
Ectopic pregnancy treatment
Methotrexate - Patient needs to be compliant, no fetal cardiac activity, under 3.5 cm, beta hCG under 5000
Check hCG decrease by day 7
Increased abdominal pain afterwards, N/V/D
220
Surgery for ectopic pregnancy
Salpinostomy - open up and remove - creates higher risk of ectopic pregnancy
Salpingectomy - Preferred
221
Complete abortion
Expulsion of all products of conception before 20 weeks - can do analysis of products
222
Incomplete abortion
Not all of the products of conception are expelled
Vaginal bleeding and abdominal cramping
May see protruding POC through cervical os
Curettage, Prostaglandins and removal of tissue for tx
223
Inevitable abortion
No expulsion but vaginal bleeding and dilation of the cervix such that viability is unlikely
Treat with prostaglandins - keep pregnancy if fetal heartbeat
224
Missed abortion
Death of embryo or fetus before 20 weeks with complete retention of products of conception
US shows nonviable pregnancy
Wait to pass or prostaglandins, Curettage, Expectant management
225
Threatened abortion
Any bleeding before 20 weeks
Cervical os closed
Pelvic rest and close monitoring
226
Complete Molar pregnancy
Excessive growth of placenta
Large for dates
2 sets of paternal chromosomes
Very high hcg
Excessive placental tissue
No POC
227
Incomplete molar pregnancy
Two paternal and one half maternal set of chromosomes
Small for dates
Missed abortion
Fetal parts present
228
Diagnostics for Molar pregnancy
Snowstorm appearance on US
Thickened multicystic placenta
Confirm via pathology
Vomiting
preeclampsia before 20 weeks
229
Management of molar pregnancy
CXR for cancer
CBC
Thyroid
EKG
Suction, dilation and curettage
Pitosin to evacuate uterus
Rhogam if Rh negative
Watch for cancer with serial hCG - should decrease - birth control for some time
230
Questions to ask about Antepartum bleeding
Check where it is coming from (could be UTI or hemorrhoids)
Sexual activity - ask
231
Placental abruption
Separation of the placenta either partially or totally from its implantation site
Concealed or revealed
Usually early in pregnancy - monitor
Can cause hypovolemic shock - deliver immediately
232
Revealed placental abruption
Presents with vaginal bleeding
233
Diagnosis of placental abruption
Exclusion diagnosis - pay attention if mother has experienced trauma
234
Couvelaire uterus
Purplr/Blue uterus from blood infiltration
235
Management of placental abruption
Deliver -Vaginal preferred for dead fetus; C-section is quicker with bleed risk
236
Placenta previa
Four Risk Factors
Placenta covering cervix
Increases with age, parity, c-section, smoking
237
Presentation of placenta previa
Painless vaginal bleeding seen after second trimester
238
Diagnosis of placenta previa
Should be excluded in any bleeding patient who presents after the 2nd trimester
Transvaginal US to visualize
NO DIGITAL EXAM ONCE CONFIRMED!!!
239
Point before which previa is unlikely to persist
23 weeks
240
Management for placenta previa
Delivery via C-section as late as possible
Deliver sooner if persistently bleeding
Goal to keep pt pregnant as long as possible
241
Placenta accrete
Abnormally adhered
Accreta - Attached to myometrium
Increta - Attached into myometrium
Percreta - Goes through myometrium
242
Risk factors for placenta accrete syndromes
C section or placenta previa
243
Presentation of pracenta accrete
Found on US
Hard to deliver placenta
Recommended early delivery at 34-36 weeks
May consider leaving placenta insode or hysterectomy -MC
244
Cervical insufficiency
Painless cervical dilation during the second trimester
d/t prior cervical trauma
245
Eval and management of cervical insufficiency
US to confirm
Swab for infection
Trendelenburg psoition
Pelvic rest
Cerclage - stitch in the uterus kept in until week 36
Delivery
246
Tx of cervical insufficiency for next pregnancy
US to measure
Preventative Cerclage - Rescue (wait) or Elective (don't wait)
247
Cerclage
Stitch in the uterus - what Mary Crawley got
248
Preterm birth - 4 reasons
Delivery of infant before 37 weeks
Spontaneous
Idiopathic
Maternal or fetal indication
Twins+
249
Fetal fibronectin and early labor
Sensitive but not specific for preterm labor - can rule it OUT
250
Workup for preterm labor
Tocolysis - Stops contractions for 48 hours max
Administer steroids for fetal development
Nifedipine
Mag Sulfate
Prostaglandin inhibitors
Beta agonists - Terbutaline
251
Management for preterm labor
Steroid for fetal lung maturation
Betamethazone indicated 24-34 weeks
Cerclage to help prevent
Progesterone NOT helpful unless vaginal
252
Reason for magnesium sulfate in preterm labor
Prevents neonatal intercranial hemorrhage weeks 24-32 for at least 12 hours
253
Preterm premature rupture of membranes
Check for pooling, nitrazine swab, ferning of vaginal mucosa to confirm
Risk of cord prolapse - don't send home
254
Managementof preterm premature rupture of membranes
Patient hospitalized for remainder of pregnancy
Corticosteroids for fetal lung maturity
Tocolysis
Ampicillin or Erythromycin can extedn time before delivery
255
Intrauterine growth restriction
Stick with original due date
May be due to alcohol, smoking, young patients, TORCH infections
256
Dangers with IUGR
Stillbirth
Encephalopathy
Palsy
Still monitor even if parents are small
257
Diagnosis for IUGR
Less then 10th percentile overall growth OR less than 10th percentile abdominal circumference is indicative
US
258
Management of IUGR
Amiotic fluid volume management
US for circumference and weight
Umbillical artery doppler monitor
Serial growth scans
Plan for delivery at 38 weeks
259
Fetal death risk factors
Age
AA race
Smoking diabetes
260
Dx and management of fetal death
Usually incidental - US
Plan for delivery
Karyotyping, Autopsy
261
Management for future pregnancies after a fetal death
Control modifiable risk factors
Offer genetic testing
Anatomy scan at 18 weeks growth US at 32 weeks
Begin antepartum surveillance 1-2 weeks prior to when stillbirth happened
Elective induction or C section at 39 weeks
262
Hypertension in pregnancy
Over 140/90 on two occasions at leat 2 hours apart
263
Chronic hypertension and pregnancy
Present before 20 weeks or persistent 12 weeks after delivery is an underlying chronic HTN
ACEIs and Angiotensin receptor agonists are CI
264
Prenatal care for chronic HTN
EKG, Echo (at risk for cardiomyopathy)
Baseline labs
265
Medications for HTN in pregnancy
Labetolol or Calcium channel blockers
Aspirin reduced preeclampsia risk
266
Management for chronic hypertension in pregnancy
Close observation
Deliver early at 37-39 weeks
267
Gestational HTN
After 20 weeks BP becomes 14/90+
Resolves by 12 weeks postpartum
Treat and manage like chronic HTN in pregnancy
268
Preeclampsia
Hypertension and proteinuria after 20 weeks gestation
0.3g+ urine protein on dipstick
Can also present with: Thrombocytopenia, Renal insufficiency, Liver disease, Pulm edema
269
Risk factors for preeclampsia
Young age
First pregnancy
Multifetal
Obesity
Other vascular disorders
270
Dx of preeclampsia
140/90+ BP
Proteinuria dipstick of 2+
300mg or more in a 24 hour urine collection
Could also be with thrombocytopenia
271
Eclampsia
Occurence of generalized convulsion and or coma in the setting of preeclampsia with no other neuro condition
Before, during, or after labor - hold in hospital after birth
272
Preeclampsia superimposed on chronic HTN
Need to have close monitoring of labs and home blood pressure so that it can be caught
273
HELLP
Hemolysis, Elevated Liver Enzymes, and Low Platelet Count
RUQ pain because liver bleeds and distends capsule
Risk of hepatic hematoma and rupture
Indicates SEVERE preeclampsia
274
Tx for preeclampsia
Delivery
Monitor closely if mild
HTN therapy if 160/110 or greater
Labetolol (IV), Hydralazine (IV), or nifedipine (PO) can be used
275
Magnesium sulfate and preeclampsia
To prevent seizure, NOT BP
Continued after delivery until the patient diureses
276
Pregestational diabetes
Check hemoglobin A1c first trimester
A1c over 6.5%
Higher A1c = More fetal anomalies - significant risk over 12%
Fasting glucose over 125, nonfasting over 200
277
Complications of pregestational diabetics
Spontaneous abortion
Preterm birth
IUGR
Cardiac defects
Hydramnios
Macrosomia
278
Neonatal effects of pregestational diabetes
Baby born with overproduction of insulin - hypoglycemia
Hypocalcemia
Diabetes and Obesity later in life
279
Preconception care for diabetes
Glucose 70-110 mg/dL
A1c 7% or lower
Folic acid supplementation
280
First trimester care for DM
Careful glucose monitoring
HGA1c under 6
81 mg Aspirin for preeclampsia prevention
24 hour urine
281
Second and third trimester care for diabetic mothers
US at 18-20 weeks
Fetal echo at 20-24
Antepartum testing at weeks 32-34
Deliver 36-40 weeks
Vaginal or C section delivery
282
Postpartum diabetes management
Insulin may need to be decreased - mom needs more insulin during gestation
283
Gestational diabetes
Commonly recurrence
Diabetes after the first 20 weeks
Ethnic populations are at higher risk
Increased risk of DM later in life
284
Screening for Gestational Diabetes
50g one hour glucose challenge followed by 100g 3 hour test - fasting
285
Limits for 3 hour GTT
Fasting 95
1 hour 180
2 hours 155
3 hours 140
286
Management of rgestational diabetes
Keep fasting BS under 95 and postprandial under 120
Diet modification - 40-20-40 diet
Insulin - First line
Metformin - also good
May consider early induction or not with vaginal delivery depending on size
Same risk factors as pregestational diabetes
287
Postpartum management of gestational diabetes
All should receive a 75g 2 hour OGTT at 6-12 weeks postpartum
288
Vanishing twin
Twin vanishes or is lost before the second trimester
10-40% of all twin pregnancy
289
Diagnosis of multifetal gestation
Uterus larger than expected
Determine chorionicity in the first trimester with US
290
Dichorionic twins
Two separate placentas with a thick 2mm+ dividing membrane
Twin peak sign aka lambda or delta sign
291
Monochorionic twins
Thin under 2mm dividing membrane
T sign on US - right angle relationship between membranes
292
Monoamniotic twins
One amniotic sac - the later the split the more the twins share
High risk of fetal death - deliver 32-24 weeks, steroids at 24-28 weeks with antepartum testing
293
Complications of multifetal pregnancies
Congenital malformations
Spontaneous abortions
Low birth weight
HTN
Size dischordance
294
Twin-Twin Transfusion syndrome
In monochorionic twins
One twin gets all the nutrients, one gives all the nutrients
May be able to ablate vascular abnormalities causing TTTS
May need selective abortions
Harms both twins -One anemic, one congested
295
Weight gain expectation for multifetal pregnancies
37-54lbs. weight gain
296
Labor management for DD twins
38 weeks, can be vaginal - first twin should be vertex!!
297
Labor management for MD or MM twins
Usually C section at 34-37 weeks and 32-34 weeks respectively - first twin should be vertex!!
298
Maternal hypothyroidism
Fetus does not produce own thyroid before 12 weeks
Check TSH every trimester
Cold, Fatigue, Muscle Cramps, Hair loss
MC - Hashimotos thyroiditis
Treat with levothyroxine
299
Screening for maternal depression
Screen for in patients in initial visit and at every visit if at risk
300
Tx for depression during pregnancy
Counselling
SSRI or SNRI are first line
If mother is stable on current antidepressant - don't change
301
Zuranlone
For post partum depression with and SSRI or SNRI
302
Substance abuse among pregnant women
7.2% abused pain relievers
12% Drank
25+% Smoked including marijuana
303
Screen for substance abuse in pregnancy
Try to screen all patients if possible - tend to use for those with risk factors
304
Opioid substitution for pregnancy
Methadone, Suboxone, Subutex
All associated with neonatal withdrawal
Subutex does not cross the placenta as early
305
UTI dx and tx in pregnancy
Always do a urine screen when first presenting as pregnant
Can cause preterm birth
Macrobid or Keflex and recheck urine a week after
306
Suppressive UTI therapy in pregnancy
Macrobid 100mg PO daily
307
Pyelonephritis in pregnancy
Flank pain
Admit w/ IV abx and prophylaxis
Assess for kidney stone
308
Definition of infertility
1 year of unprtected intercourse of reasonable frequency in under 35
6 months for those over 35
309
Primary v. Secondary infertility
Primary no prior pregnancies
Secondary - prior pregnancy
310
How often is reasonable to have sex for fertility
Once every other day
Make sure you're having it during the right time
311
Workup for many pregnancy losses
Do genetic testing to see if there is a problem
Look for uterine septum on US
312
Dx for ovulatory dysfunction
Use menstual hx as a predictor
Ask about mittleschmirtz
TSH, Weight over or under
Basal body temperature
US to look at ovarian reserve
Urine LH sticks
313
Serum progesterone
Check around 21 days for ovulation
Relatively cheap
314
Serum FSH
Predictor of ovarian reserve - less inhibin
Check on day 3 of cycle
Estradiol compensation (elevation) indicates a depleated ovarian reserve
315
Antimullerian hormone testing
Expressed by granulosa cells
Possible role in dominant follicle recruitment
Under 1ng/mL can indicate depleated ovaries
High in PCOS
316
Tx for ovulatory dysfunction
Check hyperprolactinemia
Treat any adenoma
Levothyroxine for hypothyroid
Ovulation induction
317
Clomiphene for ovulation dysfunction
Clomiphene - Estrogen antagonist results in increased FSH given around day 3 of cycle
PO
318
Aromatase inhibitors for ovulation induction
Letrozole
Inhibits estrogen and increases FSH
PO
High BMI and PCOS
319
Gonadotropins
Variety of IM formulations
Expensive
320
COmplications of ovulation induction
Multifetal gestation
Ovarian hyperstimulation syndrome - enlarged ovary with cysts - causing abdominal pain, distention
321
Intrauterine insemination
Sperm washed and concentrated and inserted into the uterus - less expensive than and tried before IVF
322
IVF
Sperm and ova combine seperately and inserted into uterus
323
Tubal and pelvic factors that can lead to infertility
Endometriosis
Surgery such as appendectomy
Pelvic infection
324
Dx for tubal issues
Hyerosalpingogram on days 5-10 - uses radio-opaque medium in uterus
Chromopertubation - Methylene blue for tube patency with laparoscopy
Expensive
325
Tx for tubal and pelvic factors
Cannulation to create patency
Reconstruction post op
Removal if dyfunctional tube causing issues
IVF with removal of adhesions
326
Uterine factors that cause infertility
Polyps, Uterine septum, Fibroids
Dx with US or Hysteroscopy, endometrial biopsy before IUI or IVF
327
Asherman's syndrome
Intrauterine adhesions that can resemble a fetus on US
Form after dilation and curettage
328
Cervical factors that cause infertility
Infection
Thick mucous d/t high estrogen
329
Dx and tx for cervical factors
Postcoital test - how many sperm got through
Bypass with IUI
330
Male hx for infertility
Testosterone use!!
Get a semen analysis
Mumps, ED, Hx of infection
331
Lag time for sperm to be impacted
Takes 3 months for effects to be felt - look at that in hx
332
Semen analysis
Refrain from ejaculation for 2-3 days
Too much sex can reduce sperm count per time
f/u analyze for antisperm antibodies
f/u low volume with urology
333
Tx for low sperm count
IUI - Under 20 million per mL
334
Azoospermia
Congenital absence of vas deferens d/t cystic fibrosis
335
Asthenospermia
Decreased sperm motility
Prolonged abstinence
Infection
Varicocele
IUI to treat
336
Antisperm antibodies
Can be d/t vasectomy, infection, testicular torsion
337
Hormonal evaluation of male infertility
Look for low FSH and or Testosterone
Giving testosterone can actually suppress sperm production
