ALSO - Advanced Life Support in Obstetrics
U/S Finding of Early Pregnancy Failure (3 diagnostic criteria)
Mean sac diameter >25 w/o embryo Embryo >=7 without heartbeat Absent embryo w/ heartbeat 11 days after yolk sac seen
Crown-Rump Length
Mesnstral Age * (weeks) = CRL (cm) + 6.5 [*Accurate between 8-13 weeks]
Abruption Severity
Mild: usually noted PP w/ retroplacental clot Severe: symptomatic w/ tender abdomen Severe w/ Fetal Demise: w/ or w/o coagulopathy
Causes of Early Pregnancy Bleeding
Miscarriages (occurs in 15% of clinically recognized pregnancies Ectopic Pregnancy Gestational Trophoblastic Disease Cervical bleeding from causes unrelated to pregnancy Otherwise Uncomplicated Pregnancies
Pulmonary Embolism
Most often PP, mild symptoms of chest pain, dyspnea. Eval: start with venous doppler of LE and CXR. If CXR is abnl do CT. If CXR normal but still suspicious, do VQ>CT. Tx: LMWH is treatment of choice for PE. UFH is an alternative. (Never Warfarin antepartum due to crossing placenta, risk of embryopathy, miscarriage, and stillbirth. Okay PP and is safe with breastfeeding.)
RF of Preeclampsia
Primiparity 1st Degree relative w/ hx of preeclampsia prior hx of preeclamptic pregnancy Chronic HTN Obesity Multiple Gestation Chronic Renal Disease SLE AMA >40 Yo
Tx of Trophoblastic Disease
Prompt evacuation of uterus, serial beta hCG to zero, 1 year of contraception, recurrence can occur. Most can conceive and carry normal pregnancy in future.
PROM (Prolonged ROM)
ROM >=18 hrs If pt is GBS positive or unconfirmed (use RF's, >18 hrs, Temp >100.4) , give abx.
Rh Prophylaxis w/ Miscarriage
Rh-neg women who have 1st Trimester miscarriage should receive 50 mcg of anti-D immune globulin (or full dose)
Post C/S DVT PPx
SCD's for all C/S. Consider adding LMWH based on risk factor (obesity, age, parity, prolonged labor, pre-e, chorioamnioitis)
RF for Preterm Birth
Short cervical length <25mm at 18-25 wks on endovagional U/S Hx of preterm delivery non-hispanic black race
First Color Flow on Doppler (MA)
4 weeks menstrual age
Gestational Sac Visible (MA & hCG level)
4-5 weeks menstrual age, 1500-2000 mIU/mL hCG (discriminatory zone)
Diagnosis of Labor
- Missed menses - PE - Qual or Quant hCG - U/S
Management/Prevention of Preterm Delivery
17 alpha-hydroxyprogesterone 250 mg IM from 16-20 wks through 36 wks gestation - check cervical length via U/S every 2 weeks from 16-22 wks Reduces preterm birth & mortality Consider cerclage for cervical length <25mm
Implantation Site & Decidual Thickening (MA)
3-4 weeks menstrual age
Acute Fatty Liver of Pregnancy
3rd Trimester vomiting, abd pain, anorexia, jaundice and may progress to liver failure, ascites, renal failure, encephalopathy. Dx: hypoglycemia, AST elevated but <500, bilirubin elevated, PT/PTT prolonged
Embryo and Cardiac Activity (MA)
5-6 weeks menstrual age
Yolk Sac (MA)
5-6 weeks menstrual age
Septic abortion
A life-threatening emergency in which the uterus becomes infected following any type of abortion.
RF of Placenta Previa
AMA, chronic HTN, multiparity, multiple gestation, prior C/S, prior uterine curettage, smoking
Invasive Placenta
Accreta - implantation of myometrium (rather than decidua) Increta: invades myometrium Percreta: invades through myometrium (often into bladder) RF: prior C/S, and increases with # of C/S Dx: U/S doppler color flow
Management of Pre-E w/ Severe Features
Admit to hospital & bedrest Goal: prevent seizures, ctrl BP to prevent cerebral hemorrhage Expedite delivery, balancing maternal/fetal
Missed abortion
An abortion in which the products of conception are no longer viable but are retained in the uterus.
Management of Preterm Labor
Antenatal steroids: at 24-34 wks to reduce RDS; betamethasone 2 doses of 12mg IM q24; dexamethasone 4 doses of 6mg IM q12. May repeat steroids to repeat if <33 weeks GA and 14 days from last admin Tocolysis: can delay up to 48 hrs (gives time for management w/ steroids, GBS PPx, mag) Transfer to higher care GBS prophylaxis
Prevention of Preeclampsia
Aspirin has modest benefit, calcium some benefit. Fish oils, Vit D/C/E, salt restriction, bed rest does not prevent preeclampsia. USPSFT: ASA 60-81mg daily for anyone with high risk factors (hx of pre-E, multiple gestation, chronic HTN, antenatal DM, renal disease, SLE) or multiple moderate risk factors (nulliparity, BMI>30, FHx of Pre-E, AA ethnicity, or low SES, AMA >35 Yo)
Initial Steps of Bleeding
Assess Vital Signs & Circulatory Stability 2 Large Bore IVs and start isotonic crystalloid (NS or LR) Estimated Fetal Weight (1 IV bag ~2lbs, estimate by # IV bags) Estimated Gestational Age (by fundal height) Fetal Presentation Region/Quadrant of Tenderness Presence of Uterine Contractions Gentle Speculum Exam is okay. No digital vaginal exams unless placental location known Fetal Monitoring & Toco U/S for placental location, clots, and fetal presentation Labs: CBC, Type & Screen, Antibody Screen, Coag, BUN & Cr, LFTs
Seizure Management
Avoid anticonvulsant polypharmacy. Administer mag sulfate. Seizures are often self-limiting Protect airway.
Mnemonic for Vaginal Breech Delivery
CAREFUL • Check for dilation, presentation, and umbilical cord • Await delivery of fetal umbilicus • Rotate for arms • Enter for Mauriceau-Smellie-Veit maneuver (MSV) • Flex head • (back) Up (sacrum anterior) • Lift baby onto mother
Magnesium sulfate Antidote
Calcium Gluconate 1 g IV over 3 min.
Short Cervical Length
Cervical length <=20 mm at <=24 wks (increase risk of preterm delivery) Tx: Vaginal progesterone 90 mg gel or 200mg cap from dx until 36 wks
Vaccum Assisted Delivery
Contraindicated under 34 weeks due to risk of IVH. Forcep/episiotomy does not improve or worsen fetal outcomes. Consider C/S.
Mnemonic for Concerning Fetal Heart Tracing
DR C BRA V A D O Determine Risks: maternal-fetal context Contractions Baseline Rate Variability Accels Decels: Early, Late, Variable, Prolonged Overall Assessment:
VTE
DVT & PE's. C/S & thrombophilic d/o's is a large risk factor Pt: DVT most often left leg w/ unilateral leg pain and swelling Dx: Venous doppler Tx: anticoag w/ LMWH
Delay Cord Clamping
Decreases IVH and need for transfusions. Hold infant below level of placenta for 1-3 min prior to clamping and cutting of the cord. However, don't delay resuscitation efforts if needed.
Management of Pre-E w/o Severe Features
Expectant Mx before 37 weeks with close monitoring for severe features. Establish baseline CBC, transaminases, Cr, LDH, and uric acid. Antepartum surveillance w/ NST's, AFI, biophysical profiles, and growth U/S every 3-4 weeks. Weekly follow CBC, AST/ALTs. (Uprotein not needed to follow) Plan for delivery at 37 weeks.
Dx of Ectopic Pregnancy
Failure of beta hCG rise (<53% in 48 hrs) Pelvic pain, tubual rupture, intraperitoneal hemorrhage, abdominal and shoulder pain, shock, death Transvaginal U/S: Presence of IU pregnancy R/O ectopic; visualization of gestational sac/embryo outside the uterus, no IU gestational sac w/ beta hCG > 3000-3510; Ectopic = extrauterine echogenic mass w/ fluid Laparoscopy is gold standard.
Management of Placenta Previa
Go to labor & delivery. If premature, transfer to facility w/ NICU. Administration of steroids for fetal lung maturity. Avoid intercourse & tampons (and any foreign obj). Avoid digital exams until placental location confirmed. Follow-up at 32 weeks to see if previa resolved. Follow-up at 36 to plan and decide mode of delivery.
Management of Severe Abruption
Goal of decision to delivery interval at <20 min. Increase risks of fetal mortality or cerebral palsy if >20min. Maintain maternal circulation w/ Uoutpt: >30 mL/hr, Hct >30%. Prep for neonatal resuscitation If fetal demise occurs, vaginal delivery is preferred unless severely bleeding. Check for coagulopathy.
Chronic HTN
HTN BP >=140/90 prior to 20 weeks gestation, no new proteinuria, BP remains elevated beyond 12 weeks PP.
Peripartum Cardiomyopathy
Heart failure develop in last month of pregnancy (or within last 5 months). Presents w/ dyspnea, fatigue, edema DDx: PE, amniotic fluid embolism, PNA Dx: echo Note: avoid ACE-i and excessive diuresis in antepartum period. Counsel risks.
HELLP Syndrome
Hemolysis, Elevated Liver Enzymes, Low Platelets Variable presentation. Commonly RUQ/epigastric pain, N/V, hypertension. Labs: Abn peripheral smear, elevated LDH, >2x nl liver enzymes, platelet ct <100,000. Mx: Give mag, esp when symptomatic or in labor.
Risk Factor of Ectopic Pregnancy
History of ectopics Prior tubal surgery or infection Progestin-only contraception (poor fimbriae motility) IUD Currently Placed IU DES exposure No risk factors.
Antihypertensives for Severe Preeclampsia
Indication: sustained BP >=160mm/>=110 Labetalol Hydralazine Nifedipine (PO med)
Delivery Decision w/ Previa
Known low-lying or marginal previa w/ no bleeding, U/S at 36 weeks. If placenta is >=2 cm from os, expect vaginal delivery. If 1-2cm from os, may attempt vaginal delivery w/ immediate surgical backup available. C/S if U/S indicate complete previa, fetal head not engaged, concerning fetal heart tracing, brisk or persistent bleeding. Regional anesthetic is safe to use.
VTE Prophylaxis
LMWH is drug of choice. Indication: hx of unprovoked DVT/PE or some thrombophilias Duration: Usually continued for 6 wks PP
LEFt Criteria
Left Leg symptoms Edema First trimester at time of symptom present
Placenta Previa Types
Low-Lying: leading age w/ 2-3.5 cm from os Marginal: within 2 cm of os Complete: covers the cervical os
Management of Miscarriage
Majority does not require intervention, unless a risk of infection of bleeding. - Surgical: D&C or MVA - Medical: misoprostol (off-label) - Expectant ~Incomplete AB: expectant & medical are highly successful ~Missed AB: Medical & surgical are more effective ~Expectant management have more outpt visits than those treated with misoprostol ~Those treated medically have more bleeding, but less pain than treated surgically. ~Surgery is assoc w/ more trauma and infection than medically
Dx of Preeclampsia
New onset HTN after 20 wks w/ proteinuria. - HTN: 2 readings of >140/90, 4 hrs apart or 1 reading of >160/110 - Proteinuria: 24 hr urine protein >=300mg; time extrapolated urine protein of >=300mg; protein/Cr ratio of >=0.3; urine dip +1 or more. - Proteinuria not required if new onset HTN w/ any of the following severe features: platelet <100,000, Cr >1.1 or double baseline, transaminases twice normal, pulmonary edema, cerebral or visual symptoms, BP>=160/110
PP Magnesium
New onset HTN w/ cerebral centpoms, preeclampsia w/ severe features.
Drugs for Tocolysis
Nifedipine: loading dose of 30mg then 10-20mg PO q4-6; not for maternal hypotension Terbutaline: useful in triage when pt have tachysystole, fast onset; 0.25 mg SQ q20-30min to 3 doses; Prolonged course may produce pulmonary edema, contraindicated for , heart disease, poorly controlled DM, and thyrotoxicosis Indomethacin: NSAID, not after 32 weeks b/c may closes patent ductus arteriosis; follow AFI. Mag Sulfate: not an effective tocolytic, but may be used. Better for neuroprotection. Contraindicated w/ myasthenia gravis.
PPROM (preterm premature rupture of membranes)
No labor contraction or cervical change, but ROM before term. Gestation age dictates management. If 24-34, use steroids. Abx for 24-32 weeks GA - amp, erythomcin and amox (to prolong latency and decreasing infection). Abx for 32-37, start pending culture. Tocolysis? >= 37 - expedite delivery <34 - transfer to NICU capable hospital, give antenatal steroid, and amp & erythromycin to prolong latent labor
Gestational HTN
Non-proteinuric HTN after 20 wk. (May develop preeclampsia, may be undx'ed chronic HTN, or transient gestation HTN)
Minimal hCG rise in viable IU pregnancy (% in hrs)
Normal IU pregnancy: 53% rise in 48 hrs
Uterine Rupture
Occult dehiscence: enough scar tissue causing a window to open, but not a lot of bleeding due to surrounding scar tissue. Symptomatic Rupture: heavy bleeding RF: U/S, uterine surgery, high levels of oxytocin, labor induction, uterine over-distention, abn placental attachment, etc. Findings: sudden deterioration of FHR pattern (initial sign), vaginal bleeding, sudden onset pain, stair step decrease or cessation of contraction, loss of fetal station, maternal tachycardia or hypotension. Emergent C/S within 18 min has good outcomes
Misoprostol for Tx of AB
Off-label use 600 mcg orally or 600-800 mcg vaginally or bucal Fewer GI side effects via vaginal or buccal route
Eclampsia
Onset of seizures in pt w/ preeclampsia BP may be elevated. May occur before, during, or after delivery.
Presentation of Previa
Painless late second/third trimester bleeding, often provoked by intercourse. May be accompanied w/ preterm contractions. Persistent Malpresentation is suspicious for previa.
Life-Threatening Bleeding in Late Pregnancy (name 4)
Placenta Previa Placental Abruption Uterine Scar Disruption Ruptured vasa previa
Preeclampsia-Eclampsia Spectrum
Preeclampsia w/o or w/ features Preeclampsia superimposed on chronic HTN Eclampsia HELLP syndrome
Magnesium sulfate
Preferred anticonvulsant in preeclampsia. Slows neuromuscular conduction and decreases CNS irritability. No effect on BP. Indicated for women w/ severe features Initial Loading Dose of 4-6g IV over 15-20 min Maintain with continuous infusion of 2g/hr Check mag level if: Uout <30mL/hr, elevated serum Cr, symptoms of mag tox (somnolence, respiratory depression, paralysis, cardiac arrest), loss of DTRs.
Placental abruption
Premature separation of placenta from uterine wall, partial or complete. RF: HTN d/o in pregnancy, abdominal trauma, tobacco, cocaine, stimulants, thrombophilias, chorioamnioitis, oligiohydramios w/ PROM, and hx of abruption. PresentatioN: abdominal or back pain. Vaginal bleeding or bloody amniotic fluid (amount apparent may be misleading)
Vasa previa
Presence of fetal (not placental) blood vessels that cross the internal cervical os and can cause loss of fetal blood. RF: IVF, low-lying placenta Presentation: often found antenatally during U/S. May also palpate vessels on digital exams. Bleeding occurs at time of rupture of membrane. Mx: tests are insensitive or takes too long. If concerned, immediate C/S and immediate bolus of 10-20mL/kg immediately after delivery. Dx: color flow doppler (f/u on 2nd semester U/S if noted earlier)
Preterm Labor Definition
Preterm: ensure good dating; <37 wks = preterm Labor: regular uterine contraction w/ cervical change of effacement (>=80%) and dilation (>=2cm) - Cervical length <20mm is very supportive of dx of labor
ROM Evaluation
Sterile Speculum Exam Pooling/Gushing of Fluid Nitrazine Test Ferning under microscopy
Discontinuation of Anticoagulation
Stop heparin 24 hrs before scheduled induction or C/S or at onset of labor. At theraputic LMWH, wait 24 hrs before epidual. At PPx once-daily LMWH dose, wait for 10-12 hrs. With UFH, follow aPTT to guide decision.
Tx of Ectopic Pregnancy
Surgical: (mainstay) salpingectomy or salpingostomy via opon lap or laparoscopy. Medical: methotrexate (stable, unruptured, <=4cm, beta hCG <5000-10000, no embryonic cardiac activity) Expectant: stable, <3cm, beta hCG <1000 and falling
Evaluation of Pre-E
Symptom Assessment q8hr for H/A, visual change, RUQ/Epigastric/Retrosternal pain/pressure Vital Sign, neuro check, and DTRs q15-60min until stable Monitor I's & O's. Insert foley if needed. Alert physician if <30mL/hr urine output (esp. due to risk of magnesium toxicity) Labs: CBC, transaminases, Cr, Uric acid, LDH, consider blood smear & coag panel. Type & screen in labor.
Dx of Previa
Transvaginal U/S confirmation
Coagulopathy w/ Abruption
Usually not seen w/ live birth. Etio: consumption of factors or DIC. Administer placets, fresh frozen plasma (FFP) before delivery
Threatened abortion
Uterine bleeding at 18 weeks' gestation; no products expelled; cervical os closed.
Mnemonic for FHT Decels
VEAL CHOP MINE Variable Cord Compression Move Patient Early Head Compression Initiate 2ndary Measures Accel Okay Nothing :) Late Placental Insufficiency Emergency Delivery
Delivery Decision for Severe Preeclampsia
Vaginal delivery preferred. C/S indicated for continuous seizures or other emergent signs and symptoms, fetal distress, or unfavorable cervix w/ severe prematurity (<30 wks). Anesthesia: epidural/spinal prefered versus general. General anesthesia is indicated if platelet count <50,000.
Subchorionic Hemorrhage
a bleed between the endometrium and the gestational sac at the edge of the placenta
Complete abortion
all products of conception are expelled
Determining Likelihood of Preterm Delivery
fFN - if negative, very low likely of delivering in 7-14 days; if positive, likely within next 7-10 days. (inaccurate with presence of semen/intercourse, gel/digital vaginal exam & U/S, or blood) Cervical Length: longer (>30 mm) = less likely to deliver; funnel length is not included in cervical length); shorter (<15mm) = likely to deliver
hCG in Spontaneous Abortions
falls over 48 hr period
hCG in Ectopic Pregnancy
hCG does not rise at a doubling rate as in normal pregnancy, but does not fall either. Carefully monitor, assess, and intervene.
Incomplete Abortion
incomplete expulsion of the products of conception
Ectopic Pregnancy
pregnancy outside the uterus, usually fallopian tube Occurs in 1% of pregnancy, but 2nd most common cause of maternal mortality.
GBS PPx
universal screening at 35-37 weeks at time of presentation of PTL. If negative GBS screening at 25 weeks or later does not require PPx. Repeat GBS is indicated if > 5 weeks, but presume positive. In absence of culture, use RF (any 1 = positive): preterm (<37 wks), any GBS bacteriuria, prior birth w/ GBS positive, ROM>18 hrs, or T>100.4. Use Pen G or Ampicillin, Cefazolin (2nd line), use culture & sensitivity to choose clindamycin or erythromycin. Last choice is vancomycin.