Women's Health - OB Flashcards
Gravida and Parity
G = pregnancies P = deliveries
What is advanced maternal age?
AMA > 35 yo
How to report a women with 3 pregnancies, 1 miscarriage, and two living children one of whom was born premature?
G3P2 or G3P1112
What is GTPAL system for reporting female’s obstetric history?
T = term births (after 37 weeks gestation) P = premature births A = abortions L = living children
Nägele’s rule for estimated date of confinement (EDC):
EDC = 1st day of LMP + 7 days – 3 months
Early PE signs of pregnancy
Chadwick’s sign: blueish coloring of vagina and cervix, secondary to increased estrogen
Hegar’s sign: softening of uterus
Things to check on exam visits during pregnancy
baby movement, fundal height, fetal heart rate, U/A and possible vaginal exam
Fundus height at 12 wks, 20 wks, and 36 wks?
12 wks = pubic symphisis
20 wks = umbilicus
36 wks = xiphoid process
How frequent are prenatal exams?
6-28 wks - every 4 wks
28-36 wks - every 2-3 wks
36 wks to delivery - weekly
When can heart sounds be detected on Doppler U/S?
12 wks
Baseline fetal heart rate
120-160 bpm
When should gestational diabetes screen be done?
28 wks
When should culture for beta hemolytic strep be done prenatally?
35 wks
A women whose LMP was on June 6th will have what estimated due date according to Nägele’s rule?
March 13th
When can chronic villus sampling be performed?
10-12 wks
What is quickening and when does it occur?
Quickening is when mother can feel fetal movements for the first time
Typically at 20 weeks though multiparas women may feel a little earlier
What does the biophysical profile done in 3rd trimester test for?
Breathing – 1 or more normal breathing episode
Movement – 2 or more movements
Muscle Tone – 1 episode of extension/flexion
Heart Rate – 1 or more episodes of accelerations of at least 15 bpm fetal heart rate
Amniotic Fluid – 1 or more adequate pockets
U/S is performed throughout pregnancy for many reasons, including…
fetal viability detect presence of more than one fetus placental localization checking amniotic fluid levels position of fetus gestational age/due date weights and size of fetus Detect fetal malformations Biophysical profile in 3rd trimester
What is a chronic villus sampling?
biopsy of placental tissue used to obtain chromosomal info about fetus
Indications of amniocentesis or chronic villus sampling?
FHX of genetic d/o, parent with genetic d/o, abnormal U/S, advanced maternal age
Risk of doing chronic villus sampling
small infection risk
higher miscarriage risk than amniocentesis
When is quad screen done and what does it measure?
15-18 weeks
checks maternal blood for AFP, hCG, estriol, and inhibin-A
Why do quad screen?
offered to all women to eval risk of genetic disorders such as Down Syndrome and other trisomies
What is amniocentesis? When can it be done?
15-18 wks
needle to withdraw amniotic fluid from uterine cavity to eval for genetic disorders
How is gestational diabetes dx’d?
Oral Glucose Challenge at 24-28 weeks
women ingests either 50 or 75 grams of glucose (glucola), an hour later a blood sugar is drawn on the patient and if blood sugar >130 blood is drawn again at 2 hours and if necessary 3 hours
Best method to eval for an abnormal fetal heart
U/S
What are 2 early term pregnancy complications?
Spontaneous abortion (w/i 12 wks) Ectopic pregnancy
Treatment of spontaneous abortion
Bed rest and routine physical exam and U/S
If Rh- woman should be given immunoglobulin
If fetus terminated than contents of uterus must be emptied by D&C
Threatened abortion =
cramping, bloody discharge (spotting), closed cervical os, a small percentage will go on to spontaneous abortion
Inevitable abortion =
Obvious rupture of membranes and leaking of amniotic fluid in the first 12 weeks. If this occurs with cervical dilation this will likely go on to miscarriage.
Complete abortion =
Complete detachment of placenta from the uterus and expulsion of the products of conception. The cervical os will be closed once complete
Incomplete abortion =
Cervical os is open with some portion of the fetus and/or placenta remaining in the uterus.
Missed abortion =
Cervical os is closed and the terminated fetus remains in the uterus. This may go unnoticed for several days or even weeks.
What is the treatment for a missed abortion at 12 weeks?
Contents of uterus must be emptied with D&C, otherwise they will become a reservoir for bacteria
Recurrent abortion =
Usually defined as 3 or more consecutive spontaneous abortions.
Amazingly the prognosis for these women is good as one spontaneous abortion does not increase risk of another
__________ is defined as the implantation of the fertilized egg outside of the uterus.
Ectopic pregnancy
Risk factors for ectopic pregnancy
surgery on fallopian tubes salpingitis pelvic inflammatory disease ectopic pregnancy endometriosis
Clinical presentation of ectopic pregnancy
Pain!!! amenorrhea GI symptoms light headedness abnormal vaginal bleeding
Treatment for ectopic pregnancy
CANNOT go on to birth
Methotrexate given if mass
What are the two categories of gestational trophoblastic disease?
Hydatidiform mole (molar pregnancy) Choriocarcinoma
What type tissue does Gestational trophoblastic disease (GTD) develop in?
placental tissue
Will a patient with GTD be able to deliver a viable fetus?
No; there is either no or very little fetal tissue in the uterus. The patient will undergo a D&C to have the contents of the uterus removed.
Treatment for Choriocarcinoma typically consists of…?
single agent chemo and D&C
Which symptoms will immediately cause you to consider hydatidiform mole (molar pregnancy)?
Vaginal bleeding and significantly elevated BP in first trimester
Preeclampsia
protein urea and elevated blood pressure in the late 2nd or 3rd trimester; precursor for eclampsia
Eclampsia
seizures in a pregnant women with no preexisting disorder
Risk factors for Preeclamspia and Eclampsia
First pregnancy Multiple gestation Obesity Advanced maternal age History of DM, HTN or kidney disease Teenage pregnancy African American
Signs of eclampsia
seizures
oliguria = decreased urine output
muscle aches and pains
BP and urine analysis of eclampsia
UA: protein urea > 5 g/24hr
BP > 140/90
Fetal complications of mother with eclampsia
Preterm delivery
Low birth weight
Death
Treatment of eclampsia
Goal: keep the pregnancy going as long as it is safe and deliver the baby as soon as possible (delivery only treatment)
- Assess risk of delivery vs risk to mother and child of prolonging pregnancy
- Magnesium often given as safe anti-seizure med
- Anti-HTN and steroids may also be given
What test is done at every office visit as a screening for preeclampsia?
UA and BP
What happens if mom is Rh (-) and baby is Rh (+)?
Mom may start creating anti Rh (+) antibodies; concern for her next pregnancy not this one
(this baby’s blood will likely not mix with mother unless trauma)
Treatment of Rh(-) mothers
Prevent production of Rh(+) antibodies:
IM RhoGAM at 28 weeks (99% effective)
Another dose within 72 hrs of trauma, amniocentesis, or delivery
What test is used to determine titers of maternal antibodies?
Coomb’s test
A patient presents to your office in the third trimester of her pregnancy with vaginal bleeding. 3 DDX;s?
Placenta previa
Placental abruption
Preterm labor
Painless third semester bleeding =
placenta previa
What is placenta previa?
placenta implants over cervical os; partial or complete
Treatment of placenta previa
Close monitoring is the first step of treatment
Typically delivered by c-section though marginal ones technically can be done vaginally.
Blood transfusion during pregnancy and after delivery if necessary
Nothing per vagina during pregnancy
Premature detachment of an otherwise normal placenta from the uterine wall
placental abruption
painful vaginal bleeding in 3rd trimester =
placental abruption
Treatment of placental abruption
Delivery is definitive treatment, but this must be weighed against the age of fetus, distress of fetus and mother, and degree of separation
When does preterm labor occur?
20-37 weeks
Risk factors for preterm labor
Multiple gestation (10% of preterm births) Low socioeconomic status Mother > 35 yo Mother with low pre-pregnancy weight Previous premature birth Maternal health issues including DM, HTN Abruptio placentae
Clinical presentation of early labor
Regular contractions 5-8 minutes apart with any of following: cervical changes, cervical dilation > 2 cm, cervical effacement > 80%
Cervical effacement and dilation
Effacement - cervix stretching and thinning
Dilatation - cervix opens
Leading cause of neonatal mortality in the U.S.
preterm labor
Clinical presentation of labor
Pressure
Watery or bloody vaginal discharge
Low back pain
Preterm delivery management
Bed rest
Tocolytics (anti labor/contraction med); Mg most popular
Steroids for fetal lung development
Surgically a cervical cerclage (cervix sewn closed) may benefit an incompetent cervix
Pooling of fluid in the vagina and visualization of fluid leaking from the cervix without any contractions
Premature rupture of membranes
If mother’s cultures are positive or unknown for group B strep, then she and baby must receive what tx?
Penicillin G
Treatment of UTI in pregnant woman
ampicillin, cephalexin, or nitrofurantoin
Treatment course for an infant whose mother is HIV positive?
Anti-retroviral therapy x 6 weeks
What should be done if mother has active herpes infection at delivery?
C-section indicated
Effects of pregnant woman with syphilis
still birth, late term abortions, transplacental infection, congenital syphilis
What should be ruled out with any right-sided abdominal pain in pregnant patient?
appendicitis
- atypical presentation in pregnant women and often overlooked
Infectious complications of pregnancy
Group B strep UTI HIV Genital Herpes Syphilis Cholecystitis Appendicitis
Should a pregnant women who comes in with a unilateral swollen, red, tender breast continue to breast feed. Should the infant receive antibiotics and if so which antibiotic?
Yes, breast feeding is encouraged as breast milk needs to be emptied in order to help clear infection. Little to no risk to infants and they don’t need antibiotics
What is “water breaking?”
amniotic fluid from vagina
What is normal vaginal bleeding of labor?
bloody show; small amount of blood that is passage of mucus plug which was covering cervix
Braxton Hick’s contractions
Begin in 1st trimester; not considered “true” contractions
Irregular
Relieved with change in position
Felt more in pelvis
Describe true contractions
regular intervals last about 60 sec (initially shorter and progress) progress in strength they get closer together felt more in the lower back
4 stages of labor
First stage: true contractions to full dilation of cervix (10cm); longest phase
Second stage: full dilation to delivery; 20min - 2 hours
Third stage: delivery of infant to delivery of placenta; 5-30 minutes
Fourth stage (technically not a stage): assessment and treatment of lacerations, tears or hemorrhage; oxytocin given to help uterus contract
Pathophysiological causes of postpartum hemorrhage
Retained portions of placenta
Cervical or vaginal laceration
Poor involution of uterus
Postpartum hemorrhage treatment
Uterine massage and compression!!
Uterotonic meds including oxytocine, ergonovine, methylgonovine
Fluids/blood transfusion
Consider surgical intervention if bleeding is uncontrollable
Station refers to the relation between the presenting portion of the fetus and the _______.
ischial spine
fetus >4000 grams and associated with maternal diabetes
Macrosomia
Normal positioning of fetus in uterus
vertex; head down
Breech position of fetus in uterus
butt down
Different types of breeches?
Frank breech = hips flexed, knees extended
Complete breech = hips flexed, knees flexed
Footling breech = leg extended with foot down either single or double
What is cord prolapse during labor? What fetal presentation is it most likely?
cord stretched during delivery or compressed between birth canal and fetus; hypoxia is biggest concern
transverse presentation highest risk
Shoulder dystocia
baby’s anterior shoulder gets stuck behind the mother’s pubic bone during delivery
How should macrosomia, shoulder dystocia, breeching, and other problems with delivery be managed?
C-section
How should breeched fetus be managed?
Manually turned with careful monitoring; may need c-section
Indications of C-section
Fetal distress Transverse for breech position Baby’s head too big for mother's hips (Cephalopelvic Disproportion) Repeat C-section Placenta Previa Active genital herpes
What should be done if cervix not dilating during labor?
Cervidil may be used; prostoglandin applied directly to cervix to aid with induction
Complications of C-section
Bleeding
Thromboembolic event
Metritis (uterine wall infection) most common complication
Why are IV antibiotics given before C-section surgery?
to prevent metritis
VBAC =
vaginal birth after cesarean
First visit after labor should be when?
4-6 weeks postpartum
List four things that should be included in a the first postpartum office visit.
Bleeding and/or vaginal discharge
Pelvic pain
Sex and contraception requirements (wait 6-12 wks)
Bowl and bladder function
Breast vs bottle feed
Emotional well being
Fasting glucose if patient had gestational diabetes
How to determine station of fetus?
Station of fetus is the relation between the presenting body part and the ischial spines.
Felt by digital exam and recorded using number line where zero is directly at ischial spines and negative numbers are above and positive numbers are below
Recorded in cm (+2, +1, 0, -1, -2 cm)
