Women's Health OB Flashcards
APGAR SCORE
Summary of health of newborn: Done @ 1 and 5 mins after birth (AND EVERY 5 MINS AFTER UNTIL THEY ARE > 7)
→ Appearance:
0: CYANOTIC/mottled
1: Cyanotic extremities/pink body
2: Pink extremities and body
→ Pulse:
0: Absent
1: <100
2: >100
→ Grimace:
0: No response to stimulation
1: Grimace with suction/aggressive stim.
2: Cry on stimulation
→ Activity:
0: None
1: Some flexion of extremities
2: Strong cry
→ Respirations:
0: Absent
1: Weak, irregular, slow
2: Strong cry
**7-10 = Normal
**4-6 = moderately depressed (needs further eval)
***0-3 = CRITICAL
Fetal Size/Attitude/Lie
→ Fetal Size:
Fetal Head = Most Critical
CEPHALOPELVIC DISPROPORTION → LABOR DYSTOCIA (difficult/obstructed)
Macrosomia = Birth weight >90th percentile
Associated with shoulder dystocia (fecal shoulders unable to pass below maternal pubic symphysis)
→ Fetal Attitude:
Full flexion = Chin on chest, rounded back with flexed arms, legs
Smallest diameter of the head at pelvic inlet (suboccipitobregmatic diameter)
→ Fetal Lie:
Relationship of fetal cephalocaudal axis (spinal column) to material cephalocaudal axis
LONGITUDINAL (IDEAL): fetal spine lies alone maternal
TRANSVERSE: fetal spine perpendicular to maternal
OBLIQUE: fetus at slight angle
Fetal Presentation Cephalic
Fetal Presentation:
Presenting part of fetus that is entering the pelvic inlet first
** CEPHALIC: HEAD FIRST (ideal)
Vertex = MC/Optimal
Head completely flexed onto chest → occiput (fetal occipital skull) presenting
Brow:
Fetal head partially extended → Sinciput (frontal bone/anterior fontanelle) presenting
Face:
Head hyperextended/ Fetal face from forehead to chin presenting
Fetal Presentation Breech
** Breech Birth:
→ Bottom first
Decreases with increased gestational age:
<28 weeks = 25%, but only 3-4% if full term
DX: Physical exam or US confirmation
TX: External Cephalic Version at or near term followed by a TRIAL of a Vaginal Delivery → CSection if failed
** BREECH: Bottom First
Frank Breech:
HIPS flexed, Knees extended, BOTTOM PRESENT
Complete Breech:
Hips & Knees flexed, BOTTOM PRESENT
Incomplete Breech:
One/Both hips not completely flexed, FEET PRESENT
** BREECH: Shoulder First
Transverse lie, SHOULDERS FIRST
Multiple Gestations
→ Ex.) 13 weeks + fundal height and alpha-fetoprotein > than expected for due date
Twins = 1/80 Births
→ MONOZYGOTIC = Identical
Multiple fetuses by the splitting of ONE ZYGOTE
→ DIZYGOTIC = Fraternal
Multiple fetuses produced by TWO ZYGOTES
→ POLYZYGOTIC
Multiple fetuses produced by TWO or MORE ZYGOTES
Dx:
→ First Screening:
Greater FUNDAL height than expected
EXTRA fetal heart tones
ELEVATED AFP (alpha-fetoprotein)
Tx:
→ Prenatal visits more frequently
→ Manage diet, surveillance of fetal growth and cervical length
Care:
→ INDUCTION for vaginal or c-section > 34
→ Complications: Spontaneous Abortion, Preeclampsia, anemia
1ST STAGE OF LABOR
1st Stage:
Onset of labor to fully dilated (10cm)
Early/Late: 8-12 hrs
Mild contractions every 5-30 mins - Duration ~30 seconds - gradually increase in F, I, D
Cervical Dilated: 0-3 cm
Effacement: 0-30% (cervix stretches and gets thinner)
Spontaneous ROM
Active Phase: 3-5 hrs
Contractions every 3-5 mins - duration >/= 1 min
Cervical Dilation: 3-7cm
Effacement: 80%
Progressive fetal decent
Transition Phase: 30 mins - 2 hrs
Intense contractions every 1.5-2 mins, lasting 60-90 secs
Cervical Dilation 7-10 cm
Effacement: 100%
2ND STAGE OF LABOR
Fully dilated to birth infant = PUSH
Navigating through pelvis by 3 Ps:
Power, Passenger, Passage
POWER:
F, D, I of contractions
PASSENGER: BABY
Fetal Size:
Fetal Attitude
Fetal Lie
Fetal Presentation
Cephalic
Breech
PASSAGE:
Route through bony pelvis
SIZE/TYPE of PELVIS: (4)
GYNECOID: Optimal
Rounded Pelvic Outlet, midpelvis, adequate outlet capacity
ANDROID: Labor Dystocia = Common
Heart shaped PO, decreased midpelvis diameters
ANTHROPOID:
Oval shaped, favorable midpelvis, adequate outlet capacity
PLATYPELLOID: NOT favorable
Oval shaped, decreased midpelvis
CARDINAL MOVEMENTS/Mechanisms of Labor: (6 STEPS)
DESCENT:
Presenting part of fetus reaches pelvic inlet (engagement)
Degree of descent/fetal station, relationship of presenting part to maternal ischial spines
Fetus moved from pelvic inlet (-5 station) down to ischial spines (0 station) to pelvic outlet (+4) to crowning at vaginal opening (+5)
FLEXION:
Fetal chin presses against chest, head meets resistance from pelvic floor
INTERNAL ROTATION:
Fetal shoulders INTERNALLY rotate 45* = widest part of shoulders are in line with the widest part of the pelvis
EXTENSION:
Fetal head passes under symphysis pubis (+4) and moves (+5), emerges from vagina
RESTITUTION/EXT. ROTATION:
Head EXTERNALLY rotates as the shoulders pass through pelvic outlet, under symphysis pubis, turns to align with back
EXPULSION:
Anterior shoulder slips under symphysis pubis, following by posterior shoulder, rest of the body, marks end of second stage
3RD STAGE OF LABOR
Delivery of Placenta
Delivery of placenta, umbilical cord, fetal membranes
Uterus contracts firmly
Placenta separates from uterine wall
4TH STAGE OF LABOR
Physiological adaptation to blood loss, initiation of uterine involution
Where atony can occur
FETAL MONITORING:
Monitoring:
HR and Pattern
Normal HR in newborn: 120-160
Fetal Distress: CONSISTENT DECELERATIONS after a contraction
External Fetal monitor = moms belly
Internal Fetal monitor = electrode on infants head
FETAL HR CHANGES/NST: (4)
ACCELERATIONS: increase in baseline by 15 bpm for 15 secs
Response to fetal movement
REASSURING
EARLY DECELERATIONS: Mirror images of contractions
Fetal head is compressed
Benign
VARIABLE DECELERATIONS: Rapid FHR drop WITH A RETURN TO BASELINE
Cord compression
If severe=worrisome (mild/mod = benign)
LATE DECELERATIONS: FHR drop at the END OF A CONTRACTION
UTEROPLACENTAL INSUFFICIENCY
BAD!
Preg. Physiology Changes - Uterus
→ UTERUS:
Increase size/capacity: Hypertrophy, Hyperplasia, Stretching (20x larger)
Increase strength, distensibility, contractile proteins, number of mitochondria
Increase volume capacity (10ml → 5L)
HEGAR’S SIGN: softens uterine isthmus
Preg. Physiology Changes - Cervix
→ CERVIX:
FORMATION OF MUCUS PLUG: seals endocervical canal
Increased vascularity = Chadwick’s Sign:
PURPLE-BLUE COLOR
Goodell’s Sign: Hyperplasia, softening (increased softening in 3rd trimester)
Preg. Physiology Changes - Placenta
Develops where embryo attaches to uterine wall
Covers 50% of internal uterine surface
Maternal-fetal organ for metabolic, nutrient exchange
Secretes ESTROGEN, PROGESTERONE, RELAXIN, HCG
Preg. Physiology Changes - Vagina
Increased vascularity: blue-purple color
Loosens connective tissue = increased distensibility
LEUKORRHEA:
pH 3.5-6.0 to protect against bacterial infections
Preg. Physiology Changes - Breast
Increased size, weight, nodularity, blood flow, vascular prominence
Areola, nipples are darker due to increased melanocytes
Increased activity of MONTGOMERY TUBERCLES (sebaceous glands)
Estrogen increased growth of lactiferous ducts
Secretion of COLOSTRUM at WEEK 16
Preg Changes - Cards
Hypertrophy, S2/S3 = easily heard with exaggerated split
Increased HR by 15-20
Increased SV, CO
Decreased BP (due to progesterone induced vasodilation)
Supine Hypotensive Syndrome:
Caused by gravid uterus pressing on IVC (left lateral recumbent position optimal for CO, uterine perfusion)
Gravid Uterus elevates pressure veins draining legs, pelvic organs = slowed venous return, dependent edema, varicose veins, hemorrhoids
Preg Changes - Hem
Increased Blood Volume (>1500)
Na/Water retention due to changes in OSMOREGULATION, secretion of vasopressin by Ant. Pituitary, RAAS system
Increased RBC volume with IRON supplementation
Increased volume, oxygen carrying capacity needed for increased basal metabolic rate, need of uterine-placental unit
Plasma > RBC volume → Hemodulation, Decreased Hematocrit
Increased WBC
Increased Clotting Factors (fibrin, fibrinogen) = Hypercoag. State
Preg Changes - Pulm
Increased oxygen consumption, subcostal angle, ant.post. Diameter, tidal volume, min. Ventilation, min. Oxygen uptake
Gravid uterus places upward pressure on diaphragm (elv. 4cm)
Hyperventilation → Res.
Alkalosis (renal compensation → maternal pH 7.4-7.45)
Estrogen-induced edema → nasal congestion, epistaxis
Preg Changes - GI
Estrogen-induced hyperemia = gums bleed
Progesterone induced smooth muscle relaxation, delayed gastric emptying, decreased peristalsis = N/V “ morning sickness”
Decreased gallbladder emptying (increased risk of cholelithiasis)
Ptyalism (increased saliva production)
Constipation, heartburn, GERD
Preg Changes - GU
BLADDER:
1st Tri: pressure on bladder = frequency, nocturia, stress incontinence
2nd Tri: uterus occupies abd. Space = decreased urinary frequency
3rd Tri: Presenting part of descends into pelvis = urinary frequency, nocturia, stress incontinence
Increased GFR = Increased UOp
Increased Kidney size
Dilation of urinary collecting system = Physiologic Hydronephrosis
Urinalysis:
Glycosuria (increased glucose load), Protein excretion increases to do altered prox. Tubule function + increased GFR)
Preg Change - Skin
Hyperpigmentation (due to increased estrogen, increased melanocyte activity)
MELASMA (CHLOASMA) “mask of pregnancy”
LINEA NIGRA (line down abdomen)
Nippes, Areola, Vulva darken
Increased cutaneous blood flow = increased dissipation = pregnancy “glow”
Decreased connective tissue strength due to increased adrenal steroid levels = STRETCH MARKS (Striae Gravidarum)
Estrogen induced Vascular Permeability = Spider Nevi, Angiomas, Palmar Erythema
Preg Changes - MSK
LORDOSIS: abd. Distension + shift in center of gravity
Enlarged uterus = DIASTASIS RECTI (separation of abdominal rectus muscles)
Increased joint mobility/Waddling gait
Due to increased progesterone/relaxin
Widened pubis symphysis
Facilitates baby into pelvis
High bone remodeling/turnover
Preg Changes - ENDO
Increase pituitary gland size = increased intrasellar pressure = increased risk of postpartum infarction (SHEEHAN SYNDROME) in the setting of PP Hem.
Increased PTH (meets cal/ needs of fetal skeleton)
Hypercortisolism:
Increased need for estrogen, cortisol = increased glucocorticoid from adrenal glands = supports fetal somatic reproductive growth
“Diabetogenic State” of pregnancy
Increased need for glucose/insulin production = hypertrophy/hyperplasia of pancreatic beta cells
DECREASED TSH = increased T3/T4 and gland enlarges
Reproductive hormones:
HCG from placenta
Estrogen, progesterone from Corpus Luteum (in 1st/2nd tri) and from Placenta (3rd)
Suppressed FSH, LH due to feedback from estrogen, progesterone, inhibin
DECREASED Oxytocin throughout pregnancy = INCREASED at Labor Onset and POS. FEEDBACK REALLY INCREASED during 2nd (push) stage of labor
Nutritional Needs in Pregnant
Add 300 cals
Expect ~ 25-35 pounds added
11lb (placenta, fetus, fluid), 2lb (uterus), 4lb (INCREASED BLOOD VOLUME), 3lb (breast), 5-10 (maternal reserves)
** 600 mcg FOLIC ACID
RBC synthesis, growth, DECREASED RISK OF NEURAL TUBE DEFECTS
** 1,000-1,300 mg CALCIUM
60g of PROTEIN
27mg IRON = increased RBC
PRENATAL CARE SCHEDULE
→ PRENATAL CARE SCHEDULE:
4-28 weeks = MONTHLY
28-36 weeks = TWICE MONTHLY
>36 weeks = WEEKLY
DIETARY SUPS IN PREG
Prenatal Vitamins
FOLIC ACID
CALCIUM
IRON
VITAMIN A (teratogenic in early preg)
VITAMIN D
6 FINDINGS EVERY PRENATAL VISIT
→ Full physical exam at first visit
→ Every visit after record:
Weight
BP = ACOG HTN >140/90
UA = Glucose and Protein (24 hr protein is gold standard)
Fundal height
Fetal HR → 12 WEEKS = AUDIBLE
Fetal Position → 36 WEEKS = palpable
→ Due Date Expectation = NAEGELE’s RULE
1st day of LMP + 7 days - 3 months + 1 year
1st day of LMP = 1st day of bleeding
FIRST PRENATAL VISIT
** First Visit = 6 weeks after LMP **
HR with US detected around 5-6 weeks (1-2 wks after missed cycle)
HCG
PAP
CHAL/GON CULTURE
CBC
RUBELLA
SYPHILIS
HEP B
FIRST TRIMESTER SCREEN:
FIRST TRIMESTER SCREEN:
→ 11-14 WEEKS:
US for NUCHAL TRANSLUCENCY
PAPP-A and hCG
Low PAPP-A associated with Down Syndrome
Cell Free Fetal DNA
Cell Free Fetal DNA:
→ ~10 WEEKS:
Fetal DNA in Maternal Blood
Trisomies 13, 18, 21
+ tests followed by CVS (Chorionic Villus Sampling) or Amniocentesis
Chorionic Villus Sampling:
Chorionic Villus Sampling:
→ 11-14 WEEKS:
Placental Tissue to test for chromosomal and genetic abnormalities
Quad Screen
→ 16-18 WEEKS:
AFP, HCG, ESTRIOL, Inhibin A
Increased AFP = neural tube/ab. Wall.
Increased hCG + Inhibin + Decreased AFP and Estriol = Down Syndrome
Decreased AFP, hCG, and Estriol = Edwards Syndrome
Amniocentesis DONE PRENATALLY
→ 15-20 WEEKS:
Collect Amn. Fluid to Dx Chromosomal AbnormalitieS
Glucose Challenge Test:
→ 24-28 WEEKS:
75 g 1 hr glucose challenge
If abnormal = Repeat 3 hr
Group B Strep Test:
→ 35-37 WEEKS:
Swab vagina and rectum
SYMPTOMS OF PREGNANCY + DX
SYMPTOMS OF PREGNANCY:
→ AMENORRHEA
→ NAUSEA
→ Increased urinary frequency
→ Breast engorgement
** CHADWICK’s Sign → blue discoloration of the vagina, vulva, cervix
→ Cervical Softening
DX:
Urine Preg. Test (UPT)
Detects hCG or B subunit
Sensitive to 1-2 weeks
Ultrasound:
Most accurate method to detect fetal size
GESTATIONAL SAC = 5 WEEKS
YOLK SAC = 6 weeks
FETAL IMAGE = 6-7 weeks
CARDIAC ACTIVITY = 8 weeks
Found on US by Weeks
GESTATIONAL SAC = 5 WEEKS
YOLK SAC = 6 weeks
FETAL IMAGE = 6-7 weeks
CARDIAC ACTIVITY = 8 weeks
First Trimester Weeks/Visits
FIRST TRIMESTER (week 1-12)
→ Visit every 4 weeks (monthly)
Evaluate for:
Wt changes, BP, PEDAL EDEMA, FUNDAL HEIGHT
Urine dip for GLYCOSURIA and PROTEINURIA
Trace glucose is normal due to increased GFR
Trace PROTEIN is NOT NORMAL (thinking preeclampsia)
CELL FREE FETAL DNA = 10 weeks or greater
Fetal DNA in Maternal Blood
Can confirm with CVS or Amniocentesis
Very sensitive/specific
CHORIONIC VILLUS SAMPLING (CVS) = 10-13 weeks
Small samples of placenta is taken to do genetic testing on (DNA analysis, cyotgenetics)
INDICATIONS:
>35, prior genetic d/o, carriers for genetic d/o, if first US shows congenital anomaly, abn. Aneuploidy screening
RISKS:
Maternal Alloimmunization or Vertical transmission of infx (HIV)
Complications: Misscarrage, AM. Fluid Leakage
Second Trimester Weeks/Visits
SECOND TRIMESTER (WEEKS 13-26)
*** Continue visits every 4 weeks
→ 15-18 weeks: TRIP MARKER SCREEN (hCG, AFP, Estriol) = Neural Tube Defects/Trisomies
→ 16-20 weeks: Amniocentesis IF >35
→ 17 weeks: Movement Documented
→ 24 weeks: GLUCOSE SCREENING
→ 25-28 weeks: Repeat HCT
Third Trimester Weeks/Visits
THIRD TRIMESTER ( week 27-Birth)
** Every 4 weeks UNTIL 28 weeks → Then every 2 weeks until 36 → Then EVERY WEEK **
→ UA, Blood Glucose
→ 28-30: GIVE RHOGAM (if Rh -)
→ 28-32: Pre-gestational diabetes = TWICE WEEKLY NON-STRESS TESTING UNTIL DELIVERY
→ 35-37: GROUP B STREP (strep agalactiae)
→ 36-40 weeks: IF needed cervical chlamydia and gonorrhea
Abortion (+ 5 types)
ABORTION:
- Pathophysiology:
→ Loss of pregnancy before 20 weeks
→ RF: CHROMOSOMAL ABNORMALITIES (MC: Trisomy, Monosomy X)
→ FR from MOM: SMOKING, Previous Abortions, Infx, anatomy, Ashermans, BMI <18.5/>25
TYPES + PRESENTATION:
** VAGINAL BLEEDING + PAIN +/- TISSUE PASSING FROM VAGINA **
→ Spontaneous: <20 weeks
(Fetal HR present in Threatened, Inevitable, and Incomplete → NO FHR = Complete or Missed)
Threatened: VIABLE PREGNANCY
Bloody D/C <20 weeks + CLOSED CERVIX + Retained POC (without passage of tissue)
Inevitable:
OPEN CERVIX + Retained POC (without passage of tissues)
Incomplete:
OPEN CERVIX + some but not all POC passed (may be stuck in os/vagina)
Complete:
CLOSED CERVIX + Complete passage of fetal parts + placenta
MISSED: NON-VIABLE PREG.
Undetected fetus (No heartbeat) before 20 weeks but POC remain
NO BLEEDING
SEPTIC: infx of uterus before or after abortion
→ Medical Abortion (induced)
- Diagnosis:
→ QUANT. B-HCG, CBC, BLOOD TYPE (Must know to give Rhogam or not)
→ Ultrasound
Will show if Cervical Os is open or closed
Will show if the POC have passed - Treatment:
→ EXPECTANT MANAGEMENT <13 weeks (allow for complete abortion to occur)
→ >13 weeks = MEDICAL ABORTION
MISOPROSTOL (prostaglandin) or MIFEPRISTONE (antiprogestin)
→ 1st Trimester = D&C
→ 2nd Trimester = Dilation & Evacuation
→ SURGERY if ineffective/excessive blood loss
Ectopic Pregnancy
- Pathophysiology:
→ Embryo implants outside of the uterus
MC = FALLOPIAN TUBE (Ampulla)
→ MCC: OCCLUSION OF TUBE due to ADHESIONS
RF: HX of ectopic, previous salpingitis (caused by PID), previous abd./tubal surgery, IUD, assisted reproductive, smoking - Patient Presentation:
→ Bleeding + Abdominal Pain + Adnexal Mass in Pregnant Pt - Diagnosis:
→ POSITIVE HCG PREGNANCY TEST (>1,500) BUT NO FETUS IN UTERO
Get serial HCGs (if they are rising but NOT DOUBLING - probs an EP)
→ US = RING OF FIRE SIGN = RING OF VASCULARITY - Treatment:
→ METHOTREXATE (if HCG < 5,000)
Indications = Stable pt, <5,000, Mass<3.5, no fetal heart beat
C/I: Breastfeeding, pulm.ds, immunodef.
FOLIC ACID ANTAGONIST → Inhibits DNA replication
→ Surgery → Laparoscopy Salpingostomy = if ruptured or CI for Methotrexate
** MUST FOLLOW UP ** - PEARLS:
→ RUPTURED: (medical emergency)
SEVERE ADB. or SHOULDER PAIN, peritonitis (guarding), tachycardia, syncope, ortho. HTN
Gestational Diabetes
- Pathophysiology:
→ Pregnant pt with abnormal glucose tolerance
→ MC diagnosed in 2nd or 3rd trimester if it was not clearly present prior to pregnancy
→ RF: Obesity, Hx of impaired glucose tolerance, FHx DM, Maternal age > 30
Given birth to baby >9lb, PCOS, Non-white
→ MC Complication = MACROSOMIA - Patient Presentation:
- Asymptomatic (may have typical DM symptoms)
- Diagnosis:
→ Random Glucose in ALL pregnant women the 1st Prenatal visit!!!!
REPEAT at 24-28 weeks
→ 1 hour Glucose Tolerance Testing @ 24-28 weeks
Non-fasting 50-g glucose challenge test followed by serum glucose level 1 hour later
> 130 → Do 3 hr glucose test
100g 3 Hour Glucose Test: if 2 or more of these levels are positive = Positive Dx
Fasting: 95
1 hr: >180
2 Hr: >155
3 Hr: >140
- Treatment:
→ Daily glucose checks (fasting overnight and after each meal)
→ Insulin if fasting > 105 mg (TX of Choice)
→ GLYBURIDE (Only oral hypoglycemic that DOESN’T CROSS PLACENTA – BUT – Higher risk of Eclampsia)
→ EARLY DELIVERY = C-SECTION AT 38 WEEKS (if child is macrosomic)
→ Weekly fetal HR
GESTATIONAL TROPHOBLASTIC DISEASE (Non-malignant and Malignant)
→ Proliferation of Placental Cells
→ RF: < 20/>35, Previous Molar Preg.
→ Benign (Molar Preg/Hydatidiform Mole)
→ Malignant (Invasive Moles & Choriocarcinoma)
**** EXTREMELY HIGH HCG >100,000 ***
→ MOLAR PREGNANCY: Premalignancy (HYDATIDIFORM MOLE)
COMPLETE MOLE: HUGE HCG >100, 000 + missed periods, + preg. Test, vaginal bleeding, syms of hyperthyroidism, UTERUS is LARGER THAN EXPECTED
“Grape-like” mass or SNOW-STORM on US
INCOMPLETE MOLE: More than usual HCG (not as much as Complete), Uterus is NOT larger than normal, most result in spontaneous abortion
→Malignant
→ INVASIVE MOLE: Derives from benign mole
ALWAYS AFTER MOLAR PREG>
→ CHORIOCARCINOMA: PLACENTAL CANCER occuring in the absence of a molar pregnancy
Can develop after a normal or molar pregnancy
Diagnosis:
→ HCG > 100,000
→ Transvaginal US: “Snowstorm” / “Swiss Cheese” → ECHOGENIC pattern from the abnormal placenta villi and clots
Complete Mole: THECA LUTEIN CYSTS
Incomplete Mole: Fetal Parts may be visible - often Oligohydramnios
→ Invasive and Choriocarcinoma:
Dx made bc HCG Levels PLATEAU
Invasive US = ANECHOIC & high vascular flow
Choriocarcinoma = Single Mass distending the uterus and is HETEROGENEOUS bc it has areas of necrosis and hemorrhage
ORDER Chest X-RAY & CT head, abd., pelvis for Metastases!!!!
Stage 1: ONLY uterus
Stage 2: Tubes, Ovaries, Vagina
Stage 3: LUNGS
Stage 4: Any organs other than lungs or genitals
Treatment:
→ Complete/Incomplete:
UTERINE EVACUATION via SUCTION CURETTAGE
Follow up & measure HCG weekly until gone for 3 weeks then once a month for 6 months (use contraceptives)
HCG rises or plateaus, there may be an invasive mole or choriocarcinoma
→ Choriocarcinoma:
RESECT, METHOTREXATE, CHEMO
0-6 = low risk
>6 = high risk + Chemo (EMA-CO)
** Remission = 3 consecutive undetected HCGs **
Incompetent Cervix
- Pathophysiology:
→ SPONTANEOUS, premature DILATION or SHORTENING of the Cervix during the 2nd or early 3rd trimester (up to 28 weeks)
→ RF: H/o of cervical insufficiency, hx of injury, surgery, colonization, etc. - Patient Presentation:
** RECURRENT 2nd TRI. MISCARRIAGES **
→ PAINLESS dilation (>2cm) and effacement, minimal contractions until 4cm
→ bleeding or vaginal d/c - Diagnosis:
→ Transvaginal US = “Funneling of the cervix”
→ 18-22 weeks = US focuses on abnorm.
→ NORMAL CERVIX LENGTH = 30mm
→ CERVICAL WEAKNESS = <25mm before 24 wks (<2.5cm) - Treatment:
→ CERVICAL CERCLAGE @ 12-14 weeks
Removed @ 36-38 weeks
→ Culture for GBS before inserting + confirm viable pregnancy
Placenta Abruption
- Pathophysiology:
→ Placenta detaches from the Uterus too early >20 weeks causing hemorrhage
→ MCC OF 3rd TRIMESTER BLEEDING
→ RF: Trauma, Smoking, HTN, Preeclampsia, Cocaine - Patient Presentation:
→ PAINFUL 3rd Trimester Bleeding + severe abdominal pain + frequent small contractions + FIRM, TENDER UTERUS - Diagnosis:
→ CLINICAL
BLOOD STAINED AMNIOTIC FLUID
→ US may show Retroplacental Blood Collection - Treatment:
→ DELIVERY = Definitive
Blood type, Crossmatch, Coag. studies + LARGE BORE IV
Corticosteroids as needed = Enhance Fetal Lung Maturity
Placenta Previa (and types)
- Pathophysiology:
→ Placenta lies LOW in the uterus and covers the cervix
→ RF: Prior C-Section, Multiple Gestations, Multiple Induced Abortions, Advanced Maternal Age
→ NORMAL LOCATION: FUNDUS, which is the top, rounded part of the uterus
“Low-Lying” Placenta: Implanted in the lower uterus, NOT extending to the internal os
“Marginal” Previa: EDGE of placenta reaches the margin of the os
“Partial” Previa: Placenta covers PART of the internal os
“Complete” Previa: Placenta completely covers the internal os
VASA PREVIA: Fetal vessel lies over the cervix
** FETAL COMPLICATIONS:
Preterm Delivery, Preterm PROM, IUGR, Vasa Previa, etc.
- Patient Presentation:
→ PAINLESS bleeding after 28 weeks
Thinning of the lower uterus segment in the 3rd trimester
→ No pain or cramping - Diagnosis:
→ Do NOT do VAGINAL Exam (can cause further separation)
→ TRANSVAGINAL ULTRASOUND - Treatment:
→ STRICT PELVIC REST + NO INTERCOURSE
Type and Screen incase the need for transfusion
C-Section = Preferred
If Rh- = Give Rhogam
Hypertension in Pregnacy (Not Pre/Eclampsia)
- Gestational HTN:
→ BP >150/90 after 20 weeks into pregnancy that resolves 12 weeks postpartum
NO PROTEINURIA
-Chronic HTN:
→ BP>140/90 PRIOR TO 20 wks Gestation that persists >6 weeks postpartum
NO PROTEINURIA
→ Monitor every 2-4 weeks and weekly at 34-36 weeks
- Treatment:
→ Gestational = May withhold meds (Hydralazine or Labetalol are safe if needed)
→ Chronic = > 150/100 = TREAT (severe)
Labetalol or Nifedipine
Oral Hydralazine added if needed
Methylodopa (safe alternative, but hard to use)
AVOID ACE/DIURETICS
Rh Incompatibility
- Pathophysiology:
→ Mothers blood type is Rh (-)
→ Risk baby being born with Rh (+) blood which can cause ANTIBODIES AGAINST THE BABY’S BLOOD
** 1st pregnancy = always UNAFFECTED
- Diagnosis:
→ ALL pregnant women: - ABO Blood Group
- RH-D Type
- Indirect Erythrocyte Ab Screen
- Indirect Coombs Test
→ Fetal Monitoring in 2nd Trimester - Treatment:
→ Give RHOGAM at 28 weeks, within 72 hours of delivery AND during any uterine bleeding throughout pregnancy
Or if assumption of abortion
Given if Rh- mom and Father is Rh+ or unknown
RISK: Hydrops Fetalis → large amount of fluid builds up in babies tissues and organs causing extensive swelling (not a good survival rate)
Breech Positioning
- Pathophysiology:
→ Fetus is not head down = “Bottom-first”
→ DECREASED likelihood with increased gestational age - Patient Presentation:
→ 3 Type:
FRANK: MC → Both Hips are Flexed and both knees are extended
COMPLETE: Both hips extended + knees bent
INCOMPLETE: One hip flexed, one extended + knee bent
FOOTLING: both legs and knees extended - Diagnosis:
→ PHYSICAL EXAM
→ US Confirms:
Observe and Repeat US at 37 weeks - Treatment:
→ ECV (external cephalic version) Technique: @ 37 weeks → Head down, pillow under knees, IV TOCOLYTIC, trying to lift breech from pelvis (other practitioner on head)
→ Trial of Vaginal Delivery → if persistent → C-Section
Dystocia
- Pathophysiology: Obstructed Labor
→ Obstruction of Labor
**SHOULDER DYSTOCIA:
Failure of the shoulders to deliver spontaneously after the delivery of the head
→ RF: Macrosoma from Gestational DM, Ab. Positioning, small pelvis
→ Complications: Baby = Hypoxic
Mom = infx, uterine rupture, PP Bleeding
3 Categories:
POWER: uterine contraction
PASSENGER: macrosomia, shoulder dystocia
PASSAGE: uterus or soft tissue abnormalities
- Patient Presentation/DX:
** TURTLE SIGN: HEAD DELIVERS AND SUDDENLY RETRACTS AGAINST PELVIS
→ US = Predicts malpresentation - Treatment:
→ Change Positioning of Mom
→ May require C-Section or Vacuum Extraction (possible surgical symphysiotomy)
**SHOULDER DYSTOCIA:
1st line = NON-MANIPULATIVE MANEUVERS
McRoberts Maneuver = Flexion of maternal hips
2nd line = Manipulative Maneuvers:
Wood’s Corkscrew: Rotation of fetal shoulder 180 degrees
Delivery of posterior arm
3rd = Push fetal head back in and immediate C-Section with Zavanelli Maneuver
Fetal Distress
NORMAL Fetal HR: 120-160
→ >160 for 10 mins = BRADY
→ <120 fro 10 mins = TACHY
NONSTRESS TESTING:
→ Records movement, heartbeat, and contractions
→ GOOD = REACTIVE NST
>2 accelerations in 20 mins
Accels = increase in FHR of at least 15 bpm from baseline, which lasts > 15 seconds
→ BAD = NONREACTIVE NST
No FHR acceleration OR < 15 bpm increasing lasting longer than 15 secs
If this occurs get a contraction stress test
** DECELS = BAD **
CONTRACTION STRESS TEST:
→ Measures fetal response to stress at times of contraction
GOOD = NEGATIVE CST
No late decelerations in the presence of 2 contraction in 10 minutes
BAD = POSITIVE CST
Repetitive late decelerations in the presence of 2 contractions in 10 minutes
APGAR Score:
→ Appearance, Pulse, Grimace, Activity, Respirations
>7 = Normal, <3 = Critically Low
Premature Rupture of Membranes
- Pathophysiology:
→ Rupture of membranes greater than or equal to 37 weeks aka “water broke”
→ RISK = Infection or Cord Prolapse - Patient Presentation:
→ Gush of fluid (clear or pale yellow) from vagina after 37 weeks - Diagnosis:
→ Nitrazine Test: BLUE (elevated pH = > 7.1 = positive amniotic fluid)
→ Microscopic Exam: FERNING
Crystallization of amniotic fluid (+ estrogen) - Treatment:
→ >34 weeks: Induce Labor
→ 32-34 weeks: Collect fluid + check for lung maturity → Induce
→ <32 weeks: STOP contractions + 2 doses of steroid injx → DELIVER
GIVE ABX
Preterm Labor
- Pathophysiology:
→ Born < 37 weeks (Normal = 40)
→ Earlier the baby is born, the greater risk of complications (especially to the respiratory system)
→ Earliest possible with 50% survival rate is 24 weeks
→ RF: Smoking, cocaine, uterine malformations, cervical incompetence, infection, low pregnancy weight - Patient Presentation:
→ Contractions occurring more often than every 10 minutes OR leaking of fluid from the vagina
→ “Coordinated Contractions” every 3 mins (example) - Diagnosis:
→ FETAL FIBRONECTIN: (22-34 weeks)
Differentiates women who are high risk for preterm than others
Used in women with symptoms of preterm labor by measuring the level in secretions form the vaginal/cervix
→ Placental Alpha Microglobulin-1 (PAMG-1) -- Biomarker that identifies PROM
→ Obstetric US:
Short cervix preterm = indesirable
<25mm at or before 24 weeks = Cervical Incompetence = risk of preterm
- Biomarker that identifies PROM
- Treatment:
→ TOCOLYSIS: Delay Delivery
NSAIDS, CCB, Beta Mimetics, or Atosiban
Relax the uterus
GOAL: Delay onset of labor until STEROIDS can be administered <34 weeks
CCBs: NIFEDIPINE and Oxytocin Antagonist can delay delivery by 2-7 days
B2 Agonist delay delivery by 48 hrs
Magnesium Sulfate: DOES NOT WORK (but decreases risk of cerebral palsy)
→ At risk ⇒ Progesterone (if taken during pregnancy) may prevent preterm birth
→ Give steroids < 34 weeks (24-37)
Prolapsed Umbilical Cord
- Pathophysiology: * Emergency *
→ Umbilical cord comes out before the baby
→ Risk: Fetal Hypoxia, Brain Damage, Death
→ RF: Malpresentation and ROM - Patient Presentation/Diagnosis:
→ SUDDEN & SEVERE DECREASE in FHR
Does not immediately resolve
→ On Fetal HR Tracing (NST):
VARIABLE DECELERATIONS - Treatment: EMERGENT C-SECTION
→ Place patient in Knee-Chest Position and MANUALLY ELEVATE the CORD → get to delivery room for emergent delivery
ENDOMETRITIS
- Pathophysiology:
→ Inflammation of the endometrium from bacteria
→ MC infx after childbirth
→ Causes: birth, procedures, IUD, Chlamydia, Gonorrhea
→ Risks: C-section, PROM, Vaginal delivery, D&C, Pelvic exams
→ Acute (Symptoms), Chronic (Asymptomatic)
→ COMPLICATIONS:
Myometritis (bacteria spreads into myometrium) or Parametritis (spreads into parametrium)
Salpingitis or Oophoritis
Chronic can lead to Asherman Syndrome (Intrauterine Adhesions) - Patient Presentation:
→ Fever, Tachy
→ Possible vaginal bleeding (FOUL-smell)
2-3 Days post-c-section, post-abortion - Diagnosis:
→ Clinical
→ Endometrial Biopsy = Helps Diagnosis
→ Histology = Neutrophils in the endometrium - Treatment:
→ AFTER CHILDBIRTH:
CLINDAMYCIN + GENTAMICIN
→ REMAINING PLACENTAL/FETAL TISSUE/POST-ABORTION:
D&C
→ CHLAMYDIA/GONORRHEA:
DOXY + CEFTRIAXONE - PEARLS:
Postpartum Hemorrhage
- Pathophysiology:
→ Significant loss of blood after delivery
Greater than or equal to 1,000mL in the first 24 hours after birth
Decreased Hmt 10%, changes in HR, BP, O2 - # 1 reason for maternal death worldwide *
→ 4 MC Causes: “4 Ts”
Tone: UTERINE ATONY (MC)
Boggy, Enlarged Uterus
Doesn’t contract after to stop clotting
Trauma: Forceps, vacuum, precipitous labor
Tissue: Incomplete separation of placenta from uterine wall or expulsion of placenta isn’t complete
Thrombin: Coagulation D/O
Prevents blood clots from forming naturally (von Willie, eclampsia, placenta abruption, DIC)
DIC = severe preeclampsia, amniotic fluid embolism, placental abruption
- Treatment:
→ Uterine Atony = FUNDAL MASSAGE + (oxytocin IV, misoprostol = helps contract)
→ Genital Trauma = >2cm = Surgically Repaired
→ Retained Placental Tissue = Placenta Accreta
Placenta grows too deeply into uterine wall
Hysterectomy
Normal PP period
→ Last ~ 6 weeks
Immediate: first 24 hrs (acute postanesthetic/post-delivery complications)
Early: extends until first week
Remote: period of time required for the genital organs and return of menses to occur (~6 weeks(
Uterus & Placental PP
→ Uterine Involution:
First week → decreased to size of 12 week gestation & is palpable at pubis symphysis
→ Placental Implantation Site Changes:
Immediate contraction of the placental site to the size less than half the diameter → leads to hemostasis
NORMAL POSTPARTUM DISCHARGE aka LOCHIA RUBRA:
blood, shreds of tissue, and decidua → over 3 days it changes to brown d/c
5th/6th week PP = Lochial secretions stop
Cervix, Vagina, Walls of Pelvic Organs - PP
Cervix gradually closes → by the end of the 1st week it is back down to ~1cm
The vagina returns to its antepartum condition by ~3rd week
OVULATION occurs as early as 27 days after delivery, but average:
70-75 days in non-lactating
6 months in lactating
Changes in the pelvis = widened symphysis and SI Joints
Pelvic floor gradually regain tone
Tearing/overstretching of the muscles can lead to prolapses and hernias
Overdistension of abd. Walls can result in striae, diastasis of the rectus muscles
6-7 of no vigorous exercise
Urinary System PP
Immediate PP = bladder mucosa is edematous and there is an INCREASED BLADDER CAPACITY
Overdistention and incomplete emptying of bladder + residual urine
Urinary stasis until ~ 12 weeks PP
Increase UTI risk if distended
Mild Proteinuria for 1-2 days
Increased GFR until about 8 weeks
Creatinine clearance returns normal ~8 weeks
Management of PP (hospital, activity, diet, sex, bathing)
2-4 days hospitalization PP
RETURN home safely 2 days after normal vaginal delivery
Optimal = 4th day home nurse visit
ACTIVITY = out of bed as soon as tolerated if uncomplicated delivery
Exercise does not compromise lactation of neonate weight gain
Decreases anxiety and PPD
DIET = regular diet is permissible asap
Protein rich food, fruits, veggies, high fluid intake
500kcals per day more than non pregnant/non lactating women
SEX: when bleeding stop and perineum is comfortable
Median time is 6 weeks and normal sex response 12 weeks
Bathing: ASA Ambulatory
Care of Perineum PP
Normal cleaning/showers
Immediately after delivery: cold compresses to decrease edema
Gently cleaned with plain soap once or twice per day and after voiding to keep clean and avoid infection
