OB/GYN L&D

Causes of oligohydramnios?

#1 cause is ROM (thus, always r/o ROM with ferning/nitrazine/pooling etc) Uteroplacental insufficiency from pre-eclampsia, chronic HTN (fetus not getting sufficient nutrients/blood to sustain GFR) Postterm pregnancy Fetal congenital abnormalities (renal agenesis, posterior urethral valves, urethral atresia) Maternal dehydration

Interventions for post-term pregnancies?

-Accurate assessment of dating -Membrane sweeping: associated with decreased risk of late/postterm pregnancies -> sweeps the amniotic sac away from the uterine wall at the level of the cervix or lower uterine segment -Antepartum surveillance: initiate at 41 weeks given increased risk of IUFD after 41 weeks -IOL should be initiated between 41 and 42 weeks of age

Features of a category I FHR tracing?

-Baseline: 110-160 -Moderate variability -No late or variable decelerations -+/- early declerations and accelerations

What are the options for pain management during labor?

-Epidural block: local anesthetic/narcotics infused into epidural space is the most effective method in US IV opioids/opioid agonists/antagonists: primary mechanism of relief is sedation

Treatment options for postpartum hemorrhage?

-Fundal massage - first line -Medical interventions/uterotonics: Pitocin, methergine, hemabate, misoprostol *Pitocin is usually given prophylactically after elivery of infant If maximal medical intervention fails -> bring to OR for D&C to r/o possible retained POC's -Bakri balloon -B-Lynch suture -IR for embolization -Hysterectomy (definitive - only for refractory)

Requirements to be met before considering methotrexate for ectopic pregnancy tx?

-Hemodynamic stability, non-ruptured ectopic pregnancy -size of ectopic mass < 4cm without a fetal HR or <3.5 cm in the presence of a fetal HR, -normal liver enzymes and renal function -normal white cell count -ability of the patient to follow up rapidly if condition changes

Workup for recurrent pregnancy loss?

-KAryotype of both parents and POC from each of the SAB's if possible -Examine maternal anatomy with hysterosalpingogram -Screening tests for hypothyroidism, DM, APA syndrome, hypercoagulability, SLE

Fetal complications of late/post-term pregnancies?

-Macrosomia -> increased operative vaginal delivery, cesarean delivery, shoulder dystocia -Post-maturity syndrome (aging placenta; 10-20% of post-term pregnancies) -> babies have decreased subQ fat, vernix and lanugo -Meconium aspiration syndrome (MAS) -> meconium passage increases with prolonged pregnancies -> severe respiratory distress from mechanical obstruction of airways and chemical pneumonitis -Oligohydramnios: aging placenta -> decreased fetal perfusion -Intrauterine fetal demise (IUFD): increased risk after 41 weeks Convulsions

Medical management options of uterine atony as suspected cause of post-partum hemorrhage

-Methylergonovine maleate (methergine) - uterine protonic that is given IM -Contraindicated in HTN -15-methyl-prostaglandin F2alpha (Hemabate) - given IM; also stimulates uterine contraction; do NOT give to those with asthma -IV oxytocin -Misoprostol

Risk factors for postpartum urinary retention?

-Nulliparity -Prolonged labor -Perineal injury -Regional anesthesia (eg epidural) - reduces sensory and motor impulses of the sacral spinal cord, which suppresses the micturition reflex and decreases detrusor tone (bladder atony) -Cesarean delivery -Instrumental vaginal delivery

Tx of placenta previa?

-Stabilize mom if necessary with IV fluids -Patients diagnosed antenatally undergo cesarean delivery at 36-37 weeks (late preterm/early term) to avoid risks associated with labor and to minimize prematurity complications

Diagnostic criteria of ectopic pregnancy?

1) Fetal pole is visualized outside the uterus on US 2) patient has a beta-hCG level over the discriminatory zone and there is no intrauterine pregnancy seen on US or 3) patient has inappropriately rising beta-hcg level (less than 50% increase in 48 hours) and has levels which do not fall following diagnostic dilation and curettage

Indications for operative delivery?

1) Prolonged or arrested second stage 2) Suspicion of immediate or potential fetal compromise 3) Shortening of the second stage for maternal benefit

What are 5 tests available for antepartum fetal surveillance?

1. Fetal kick count 2. Nonstress test (NST) 3. Biophysical profile (most common modality!) = NST + US evaluation of amniotic fluid, fetal tone, movement, and breathing 4. Contraction stress test (CST) 5. Doppler sonography of the umbilical artery

A woman at 8 weeks GA has a BMI of 45kg/m2. How much weight should she ideally gain in pregnancy?

11-20 lbs!

Why is post-partum contraception important? What are the options for contraception?

15% of non-nursing women are fertile at 6 weeks 50% of women resume sexual intercourse by 6 week f/u appointment If patient is breast-feeding she is partially protected from pregnancy BUT the breastfeeding must be exclusive, be every 3 hours and patient must be amenorrheic Combination estrogen/progesterone avoided while breastfeeding due to fear it may hamper mild production. However, it is safe once milk supply is established. Progesterone-only: mini-pill, nexplanon, progesterone IUD will not affect milk supply If bottle-feeding, they can take any form of contraception, but combination estrogen/progesterone options should be delayed until 2-3 weeks pp to minimize risk of VTE during pp period

Tx of gestational diabetes mellitus?

1st line: dietary modifications 2nd line: insulin (*does NOT cross the placenta), metformin, glyburide

Screening methods for Down syndrome?

1st trimester (a lot of research in last decade): 2 methods - US for nuchal translucency measurement and serum analytes (Pregnancy associated plasma protein A/PAPP-A and free beta-hcg) 2nd trimester: quad screen (MSAFP, hcg, estriol, inhibin A) - most commonly used method

MC cause of spontaneous abortion in the first trimester? 2nd trimester?

1st: Chromosomal abnormalities! Often trisomies 2nd: Maternal systemic disease, abnormal placentation or other anatomic consideration

Management of intrauterine fetal demise/stillbirth?

20-23 weeks: dilation and evacuation OR vaginal delivery >= 24 weeks: vaginal delivery

Beta-hcg level discriminatory zone for US?

2000mIU/mL = the beta-hcg level at which intrauterine pregnancy should be visible on US

Normal rate of contractions in labor?

3 in a 10 minute period

At what point do cervical length measurements become unhelpful for assessing risk of preterm delivery?

30 weeks gestation as the cervix normally begins to efface during the third trimester

When would a patient diagnosed antenatally with placenta previa be planned for cesarean delivery?

36-37 weeks

Therapeutic Mg level?

4-7mEq/L Loss of DTR's occurs at 7-10mEq/L Cardiac arrest may occur at 15

First stage arrest definition?

6cm or greater dilation with membrane rupture and no cervical change for: -4 hour or more of adequate contractions (eg >200 MVU's) OR -6h or more if contractions inadequate

Target diastolic blood pressures when treating pre-eclampsia with severe features with anti-hypertensives?

90-100

Definition of protracted active phase of stage 1 labor?

<1.2cm/hour in nulliparous <1.5cm/hour in multiparous

Definition of short cervix?

<= 2cm without a history of preterm birth or <= 2.5cm without a history of preterm birth

Definition of recurrent pregnancy loss?

> 2 consecutive or >3 spontaneous losses before 20 weeks gestation

Systolic and diastolic blood pressures required for definition of pre-eclampsia with severe features?

>160/110

Definition for prolonged stage 2 labor?

>2 hours for nulliparous (3 hours if epidural) >1 hour for multiparous

Progesterone level suggestive of a healthy pregnancy?

>25ng/mL

Definition of arrest of active phase labor in first stage?

>6cm dilation with membrane rupture and >=4 hours of adequate contractions (>200 MVU) or 6 hours or more if contractions inadequate with no cervical change Pink book is outdated! Given the slowness of the latent phase, latent phase arrest is not a clinical diagnosis.

Why does dehydration cause an increase in preterm (or just generally) contractions?

A dehydrated patient has increased levels of vasopressin/ADH, the octapeptide synthesized in the posterior hypothalamus along with oxytocin. As it differs from oxytocin by only one AA, ADH may bind with oxytocin R's and lead to contractions. *Thus, hydration may decrease number of contracitons

26 yo g2p1 at 33 weeks gestation presents in preterm labor. She has insulin-dependent diabetes and a history of myasthenia gravis. She has regular contractions q3min and fetal heart tones reassuring. Cervix 3cm dilated and 0 station. BP 140/90. Most appropriate tocolytic agent to use in this patient? a) Nifedipine b) Terbutaline c) Mg sulfate d) Indomethacin e) Ritodrine

A! Both terbutaline and ritodrine are contraindicated in diabetes! (may cause hyperglycemia) Mg sulfate is contraindicated in myasthenia gravis Indomethacin is contraindicated at 33 weeks due to risk of premature ductus areteriosus closure

A24 yo g1p1 presents due to not having a menstrual period for 2 months. She gave birth to a healthy boy 8 months ago. She breastfed for a month and has since been formula-feeding. Since the delivery, the patient has received 2 medroxyprogesterone injections for contraception; the last was administered 4 months ago. Over the last 2 weeks, she has begun experiencing breast soreness, weight gain, and increasing fatigue. She requests a different form of contraception for her sxs. Best next step? a) Administer urine pregnancy test b) Advise patient that sxs will improve c) Measure TSH level d) Recommend copper IUD e) Recommend a subdermal progestin implant

A! Depot medroxyprogesterone acetate (DMPA) is administered IM q3 months to prevent pregnancy by inhibiting release of GnRH from the hypothalamus and suppressing ovulation. DMPA causes menstrual irregularities such as prolonged bleeding and/or spotting. About 50% of women have amenorrhea after 1 year of use. Less common side effects include weight gain, fatigue, nausea, and breast tenderness. This patient's sxs could be due to DMPA or pregnancy. Her acute onset, absence of menses for >1month and mistiming of subsequent injection raise suspicion for pregnancy.

Conservative medical management and procedural management have not worked for a case of pph. She is hemodynamically unstable. You decide to take her back to the OR for an ex lap. What is the next best step in management? a) B-Lynch suture b) Hysterectomy

A! B-Lynch suture has been shown to be effective. Do a hysterectomy only if other measures (b-lynch suture, uterine artery ligation, uterine artery ligation, uterine artery embolization by IR) have failed

If someone presents with features of chorioamnionitis following prolonged ROM, in addition to IV antibiotics, what is the next best step in management? a) Administer oxytocin b) Administer tocolytics c) Cesarean delivery d) Expectant management

A! Delivery should be hastened with induction and augmentation by vaginal delivery Cesarean is not indicated for chorio exclusively (you would only do it if the other standard indications for Cesarean were present eg breech presentation, nonreassuring FHT) Expectant management is not recommended due to significant risk of maternal and neonatal complications -Maternal: uterine atony, pph, endometritis -Neonatal: premature birth, infection, encephalopathy, CP, death

Of the following, what factor is most likely associated with postterm pregnancy? a) Placental sulfatase deficiency b) Fetal adrenal hyperplasia c) Fetal alpha-fetoprotein deficiency d) Fetal renal anomalies e) Fetal chromosomal abnormalities

A! Postterm pregnancies are associated with placentla sulfatase deficiency, fetal adrenal hypoplasia, anencephaly and inaccurate or unknown dates

If a patient presents with severe RUQ abdominal pain and meets criteria for HELLP syndrome, which of the following is the most likely cause of the patient's abdominal pain? a) Distension of liver capsule b) Fatty infiltration of the liver

A! Serious liver problems of HELLP syndrome include centrilobular ncrosis, hematoma formation and thrombi in the portal capillary system. These processes can cause liver swelling with distension of the hepatic (Glisson's capsule), resulting in RUQ or epigastric pain.

If a woman presents at 20 weeks gestation with edema, joint pain, a malar rash, HTN and UA with proteinuria and RBC casts, on a background history of SLE that was managed with hydroxychloroquine before stopping it prior to conception, what would you suspect? a) SLE flare b) Pre-eclampsia

A! This is tricky; it can be tough to differentiate between pre-eclampsia and SLE in pregnancy as many of the signs are the same. However, the malar rash, RBC casts, and joint pain are more suggestive of SLE flare c/b nephritis rather than pre-eclampsia. You could further distinguish them by seeing decreased complement levels and increased ANA in SLE

33 yo g2p1 at 29 weeks GA presents with confirmed PPROM. Next best step? a) Ampicillin and erythromycin b) Clindamycin and gentamicin c) Nifedipine d) Terbutaline

A! Tx with ampicillin and erythromycin for PPROM has been shown to increase the latency period by 5-7 days as well as reduce risks of maternal amnionitis and neonatal sepsis. Tocolytics can also prolong latency period for PPROM but generally NOT by 5-7 days

A 40 yo woman G2p1 comes for her first prenatal visit at 10 weeks gestation. Her husband and 3 yo son are healthy but she has a cousin with Down syndrome. Best next step in management? a) Order plasma cell free fetal DNA testing b) Order serum AFP, estriol, beta-hcg, and inhibin A c) Order serum pregnancy-associated plasma protein A level d) Perform chorionic villous sampling e) Perform amniocentesis

A! Women at age >= 35 are at increased risk of fetal aneuploidy and should be offered cell-free fetal DNA testing (cffDNA) of maternal plasma. This test can be performed at >= 10 weeks gestation and has good sensitivity for detecting trisomies, fetal sex, and some sex chromosomal disorders. Abnormal cffDNA results can be confirmed by fetal karyotyping via chorionic villous sampling in the first trimester or amniocentesis in the second trimester Patients who are not high0risk can undergo screening during the first tri with the combined test (PAPPA, Beta-hcg and US nuchal translucency) or second tri with quad screen

What hormone is oxytocin structurally similar to and why does this matter?

ADH! High levels of oxytocin can lead to fluid retention and hyponatremia

Indications for induction of labor?

Abruptio placentae, chorioamnionitis Fetal demise Gestational HTN Pre-eclampsia, eclampsia PROM Post-term pregnancy Maternal medical conditions Fetal compromise

Route of delivery preferred for placental abruption? Previa? Accreta?

Abruption: Vaginal delivery Previa: Cesarean Accreta: Cesarean

Features of a category III fetal heart rate tracing?

Absent baseline variability +ANy of the following: recurrent late decelerations, recurrent variable decelerations, bradycardia OR sinusoidal wave pattern (very ominous and a sign for immediate delivery) Sinusoidal pattern: cycle frequency of 3-5 and persists > 20 minutes

Indications for primary cesarean? (uptodate answer)

Absolute indications: very few but would include complete placenta previa, vasa previa, or cord prolapse Major indications Prelabor: malpresentation, multiple gestation, hypertensive disorders, macrosomia, maternal request In labor: first or second-stage arrest, failed induction, nonreassuring FHR (eg category III tracing)

Management of women in labor with active genital HSV lesions or prodromal sxs (burning/pain)?

Active lesion: Cesarean delivery is indicated here to reduce neonatal HSV infection risk! Pregnant women with a history of genital HSV infection should also receive prophylactic acyclovir or valacyclovir

Intraoperative findings suggestive of incidental endometriosis?

Adhesions, powder-burn lesions, flesh-colored or dark nodules, and collections of chocolate fluid (endometrioma)

If patient is being given IV Mg sulfate for pre-eclampsia with severe features and during the past 2 hours, her respiratory rate decreases to 10 from 20. What should you do next?

Administer calcium gluconate! She likely has signs of Mg toxicity causing respiratory depression! Calcium gluconate can restore respiratory function

Tx of hyperemesis gravidarum?

Admission to hospital Anti-emetics (typically IV) and IV fluids

Nonmodifiable osteoporosis risk factors?

Advanced age Postmenopause Low body weight White or Asian ethnicity Malabsorption disorders Hypercortisolism, hyperthyroidism, hyperparathyroidism Inflammatory disorders (RA) Chronic liver or renal disease

When is indomethacin contraindicated for use as a tocolytic?

After 32 weeks gestation due to risk of premature constriction of ductus arteriosus

Tx of uterine inversion?

Aggressive fluid replacement Manual replacement of the uterus Placental removal and uterotonic drugs AFTER manual uterine replacement (doing so before uterine replacement leads to risk of massive hemorrhage)

Patient in active labor. You are called after experiences SROM. The cervix is completely dilated and the fetal head is occiput anterior at 1+ station. You palpate a long section of umbilical cord in the patient's vagina. Fetal heart tracing is reassuring. What should you do?

Although the fetal heart rate tracing is reassuring, the presence of the umbilical cord in the patient's vagina is concerning for umbilical cord prolapse (obstetric emergency!) -> continue to elevate fetal head with a hand in the patient's vagina and call for assistance to perform a C-section. Elevate the fetal head to avoid compression of the cord.

Chorionicity of dizygotic (non-identical/fraternal) coneptions? What about monozygotic?

Always dichorionic for dizygotic! Monozygotic: either monochorionic or dichorionic placentation, depending on time of division of the zygote

Which of the following signs or sxs of pp depression are most useful to distinguish it from pp blues and normal changes after delivery? a) anhedonia b) crying spells c) ambivalence toward the newborn d) sleeplessness

Ambivalence toward the newborn

Labs to workup antiphospholipid antibody syndrome?

Anticardiolipin and beta-2glycoprotein antibody status PTT Russell viper venom time

How do you treat septic pelvic thrombophlebitis?

Anticoagulation and broad-spectrum antibiotics

Causes of uterine atony?

Anything that overdistends the uterus (review the pathophysiology of this): -macrosomic fetus, multiple gestation, polyhydramnios Anything that exhausts the myometrium: -Rapid labor -Prolonged labor -Oxytocin or PG stimulation -Chorioamnionitis

When should pregnant women be screened for GDM?

At 24-28 weeks gestation Patients with risk factors should be screened earlier in pregnancy and then rescreened at 24-28 weeks if initial screen negative

Where is 0 station?

At the level of the ischial spines

34 yo g1p0 F in a MVA. While in ED, docs order multiple X-rays to evaluate her injuries. At what gestational age would fetus be most susceptible to developing intellectual disability with sufficient doses of radiation? a) 0-7 weeks b) 8-15 weeks c) 16-25 weeks d) 26-30 weeks

B!

Newborn with small body size with microcephaly, hypoplasia of the distal phalanges of the fingers and toes, excess hair and a cleft palate. Further eval of the mother would most likely reveal which of the following: a) Untreated syphilis b) Phenytoin use c) Alcohol abuse

B!

A 29 yo g1p0 at 31 weeks presents with watery discharge from vagina several hours ago. VSS. Best next step? a) Nitrazine testing of mucus swabbed from cervix b) Exam of vaginal fluid for ferning c) Digital exam of cervix d) Determination of AFI e) Non-stress test

B! a) Not test of the cervical mucus because this can be a false positive c) Digital cervical exam contraindicated in suspected ROM due to risk of introducing bacteria and causing chorioamnionitis d) AFI can support dx if oligohydramnios seen but does not confirm e) NST similarly can show variable decels but cannot confirm

26 yo g1p0 LMP 13 weeks ago presents for first prenatal visit. She reports vaginal spotting for the last 2 days. US shows IUP consistent with 11 weeks with no cardiac activity. She denies cramping or abdominal pain. Most important lab test to check for this patient? a) Quantitative beta-hcg b) Maternal blood type c) H&H d) Platelet count e) Progesterone

B! All patients with vaginal bleeding during pregnancy should get their blood type checked! There is a risk of Rh sensitization in Rh negative women with vaginal bleeding so Rhogam would be administered

33yo g2p1 at 16 weeks GA here for f/u prenatal visit. Fundal height is 22cm. MSAFP is 3.0 MoMs (multiples of the median). She has not felt fetal movement. Best next step? a) Repeat MSAFP b) Fetal sonogram c) Biophysical profile d) Fetal Doppler studies e) Amniocentesis

B! In pregnancies with size greater than dates and an elevated MSAFP, you should consider multiple gestation as the etiology. a) this would only delay further workup c and d) These are not indicated or performed at this gestational age Amniocentesis is invasive and would not be utilized prior to performing a fetal survey by US.

A 36 yo G1P0 F presents in active labor. PMH and prenatal course c/b chronic HTN and superimposed pre-eclampsia. She received Mg sulfate for seizure ppx and oxytocin augmentation. Postpartum she has a 1000mL hemorrhage due to uterine atony. Which of the uterotonics is contraindicated in this patient? a) Oxytocin b) Methylergonovine c) Prostaglandin E2 d) Misoprostol

B! Methergine is an ergot alkaloid, which is a potent smooth muscle constrictor -> vasoconstriction. It should be witheld from women with HTN and/or preeclampsia

Patient in early labor. FHR and vitals wnl. However, she complains of increasing discomfort and requests an epidural. External monitoring of fetal HR becomes difficult due to her discomfort. Best next step? a) Place epidural b) Place fetal scalp electrode c) Fetal US to assess HR d) Place an intrauterine pressure catheter (IUPC) e) Recommend a Cesarean delivery

B! Most reliable method of determining fetal status if external methods fail a) it is not safe to place an epidural without knowing fetal status c) While US can give info, it is not practical to do this continuously while epidural is placed

A 38 yo G5p4 woman with history of 4 C-sections is at 36 weeks gestation with a singleton pregnancy. She presents to L&D with complaints of vaginal bleeding for the last hour. 2nd tri US discovered an anterior placenta, which partially covers the cervical os. Denies uterine contractions and abdominal pain. She is at greatest risk for which of the following? a) vasa previa b) placenta accreta c) placental abruption d) uterine rupture e) preterm labor

B! She has a history of 4 C-sections and a low anterior placenta. The scar tissue from the previous surgery prevents proper implantation of the placenta and it subsequently grows into the muscle. Risk of uterine rupture could be 5% in this case, and the risk for accreta approaches 50%

Patient presents at 8 weeks gestation with 2 prior pregnancies ending in spontaneous losses at 19 and 18 weeks respectively. In both cases, her cervix had dilated completely with the amnionic sac bulging into the vagina to the level of the introitus. Normal sonohysterogram several weeks after spontaneous passage each time. Best next step? a) Begin weekly fetal fibronectin testing b) Placement of a cervical cerclage at 14 weeks gestation c) Immediate placement of a cervical cerclage d) Administer prophylactic progesterone

B! She has an incompetent cervix and should have a cerclage at 14 weeks. A positive fetal fibronectin does not indicate incompetent cervix and is used later in pregnancy as a negative predictor of preterm delivery. Typically wait to place cerclage until after first trimester

16 yo F runner presents with hirsutism. Irregular menses since 12. BMI 20, vitals normal. Urine pregnancy test negative. PEx normal. Elevated serum LH, FSH, 17-OH progesterone, testosterone, DHEA-S. Dx? a) Adrenal carcinoma b) Congenital adrenal hyperplasia c) Cushing syndrome d) Germ cell tumor e) PCOS

B! She has non-classic CAH (21-OHase deficiency). Without 21-OHase, 17-OH progesterone (a steroid precursor to cortisol) builds up and cortisol levels drop. This stimulates pituitary ACTH release. The marked increase in 17-OH progesterone is diverted toward adrenal androgen synthesis and leads to hyperandrogenism. In addition, androgen excess impairs hypothalamic sensitivity to progesterone -> increased GnRH, LH, FSH -> increased gonadal steroid production. c) No features of Cushing syndrome (moon facies, buffalo hump, central obesity, HTN, hyperglycemia, hypokalemia) d) typically present with abdominal enlargement, precocious puberty, abnormal vaginal bleeding or pregnancy sxs (beta-hcg increased) e) Need 2+ of 3: oligo-ovulation, clinical/biochemical hyperandrogenemia, and PCOS AND exclusion of other disorders (CAH)

Patient has fever on POD2 from a primary cesarean delivery for arrest of descent. She has uterine tenderness, purulent lochia. Best regimen for treating her condition? a) Ceftriaxone + azithromycin b) Clindamycin + gentamycin c) Dicloxacillin

B! She has postpartum endometritis - common complication of cesarean delivery. Tx should be continued until patient is afebrile for >24 hours

A healthy 28 yo nulliparous woman is scheduled for IOL at 42 weeks. She is at greatest risk for which of the following complications? a) placental abruption b) Oligohydramnios c) polyhydramnios d) Uterine rupture

B! This pregnancy will be post-term As the placenta ages, it has decreased fetal perfusion, resulting in decreased renal perfusion and decreased urinary output from the fetus -> oligohydramnios. The dx of oligohydramnios is an indication for delivery even if antepartum fetal testing is abnormal!

Management for shoulder dystocia (mnemonic)?

BECALM B- breathe, do not push; lower head of the bed E- elevate legs into McRoberts position - sharp hip flexion while in supine position C - Call for help - nurses, anesthesia, pediatricians, another pediatrician A- Apply suprapubic pressure - downward and lateral to release anterior shoulder L - enLarge vaginal opening with episiotomy to facilitate extra maneuvers M - Maneuvers: delivery of posterior arm, pressure against baby's posterior shoulder either anteriorly or posteriorly and anterior rotation (Woods corkscrew or Rubin); Mother on hands and knees ("all fours" or Gaskin maneuver) -Replacement of baby's head to vagina f/b cesarean delivery (Zavanelli maneuver: final resort)

Weight gain recommendations in pregnancy (2009 guidelines)?

BMI < 18.5: gain 28-40lbs Normal weight (18.5-24.9): gain 25-35lbs Overweight (BMI 25-29): gain 15-25lbs Obese (>30): gain 11-20lbs

How do you diagnose gestational diabetes?

Based on glucose challenge tests. The first test with a 50g load is typically performed at 24-28 weeks gestation. It is not abnormal for patients to have glucosuria (and this is not diagnostic for GDM)

How do you distinguish between vasa previa and placenta previa?

Both can present as painless antepartum hemorrhage However, fetal heart tracing will be normal in placenta previa as the bleeding is all maternal. In vasa previa, FHT will rapidly deteriorate as bleeding is of fetal origin

Safest method to suppress lactation after delivery if mother does not desire to breastfeed? a) Bromocriptine b) OCP's c) Breast binding, ice packs, analgesics d) breast expression

Breast binding, ice packs, analgesics a) bromocriptine can cause HTN, stroke, and seizures b) ocp's can increase risk of thromboembolic events

Patient presents 3-5 days postpartum s/p NSVD with symptoms of bilateral, symmetric breast fullness, tenderness, and warmth. Vital signs all wnl. She still reports vaginal bleeding. What should you suspect as the cause for her symptoms?

Breast engorgement! This often happens 3-5 days after delivery, when colostrum is replaced by milk. Although it may occur at any point during breastfeeding due to milk accumulation with inadequate drainage, breast engorgement is especially common early in the postpartum period, when milk production is particularly robust. Sxs of engorgement include b/l, symmetric breast fullness, tenderness and warmth without fever Lochia refers to vaginal discharge containing blood and mucus and is normal up to 6-8 weeks postpartum so this patient is normal

How do you distinguish mastitis vs breast engorgement clinically? How about mastitis vs plugged ducts? Breast abscess?

Breast engorgement: symmetric breast fullness, tenderness, and warmth without fever Mastitis: tenderness/erythema AND fever; breast infection that causes usually unilateral pain with an isolated firm, tender, erythematous area Plugged ducts: firm, tender, and sometimes erythematous area of one breast; NO fever

How commonly does breech presentation occur? What is a major risk factor? What is the most common type of breech presentation?

Breech occurs in 3-4% of women in labor overall, and occurs more frequently in preterm deliveries. Frank breech is the MC type, occurring in 48-73% of cases and the buttocks are the presenting part Complete breech is present in 5-12% of cases and incomplete breech (footling) occurs in 12-38%

23 yo G1P0 lady at 38 weeks gestation presents to L&D with complaint of lower abdominal pain and mild nausea for one day. Fetal kick counts are appropriate. ROS negative. Vitals wnl. FHR 140's, reactive, no decelerations. Tocometer shows irregular contractions every 2-8 minutes. Cervix is firm, long, closed and posterior. Urine dipstick is notable for 1+ glucose. Dx? a) appendicitis b) gestational DM c) Braxton-HIcks contractions d) First stage of labor

C!

Tx of syphilis in pregnant lady with a penicillin allergy? a) Oral doxycycline b) Oral erythromycin c) Desensitization and penicillin

C! While doxycycline may be the next best choice in a nonpregnant patient, it is contraindicated in pregnancy

A 27 yo G2p0 F is dx with an early first trimester spontaneous abortion. She has a hx of DM1, mild chronic HTN and one prior termination fo pregnancy. Most likely cause of this spontaneous abortion? a) prior termination of pregnancy b) Chronic HTN c) Diabetes mellitus d) Intrauterine adhesions

C! Maternal systemic diseases such as lupus, chronic renal failure, and IDDM are all associated with early pregnancy loss Other causes of spontaneous abortion include endocrine abnormalities, immunologic abnormalities, environmental factors

A 28 yo g1 F at 31 weeks gestation presents with complaints of fluid leaking from the vagina. PPROM is diagnosed. The patient has mild uterine tenderness concerning for early chorioamnionitis. An amniocentesis is performed. Which of the following amniotic fluid results is indicative of an intra-amniotic infection? a) Presence of leukocytes b) Low IL-6 c) Amniotic glucose < 20mg/dL d) Elevated bilirubin e) L/S ratio < 2

C! a) Leukocytes have the lowest predictive value for chorioamnionitis b) IL-6 would be increased e) LS ratio <2 indicates immature fetal lung

29 yo at 25 weeks GA presents for routine prenatal care. History of chronic hepatitis C infection acquired 10 years ago. She is married and monogamous with husband who knows about infection. Not immunized against HAV or HBV. Best recommendation? a) Avoid breastfeeding the baby b) Begin tx with IFNalpha and ribavirin c) Obtain HAV and HBV vaccinations now d) Schedule elective cesarean e) Use barrier protection

C! Acute viral hepatitis can be life-threatening, especially in a patient with pre-existing chronic viral hepatitis. Therefore, all patients with chronic HCV should be immunized against HAV and HBV if not already immune. These vaccines are killed and safe to administer during pregnancy. a) Breastfeeding should be encouraged unless maternal blood present (eg nipple injury) b) ribavirin is teratogenic and should be avoided d) C-section not protective; vertical transmission strongly associated with maternal viral load

A 36 yo g2p0 F at 11 weeks gestational age requests a surgical termination of pregnancy. She had a manual vacuum aspiration last year and would like to undergo the same procedure again. History of HTN and diabetes well-controlled on meds. Which is a contraindication for manual vacuum aspiration of this patient? a) age b) parity c) gestational age d) chronic HTN e) diabetes

C! Manual vacuum aspiration is effective 99% of the time but only in early pregnancy (<8 weeks gestation)

A 23 yo G1p1 develops fever on third day after uncomplicated C-section. Only significant finding on exam is moderate breast engorgement and mild uterine fundal tenderness. Most likely dx in this patient? a) UTI b) Mastitis c) Endometritis d) Wound cellulitis

C! Mild uterine tenderness is a common sign in endometritis, and her risk is significantly increased with C-section Endometritis is actually the MC cause of postpartum fever!

19 yo g1p0 at 28 weeks presents to L&D with onset of contractions. Last 40s and q5min. Intact membranes, cervical exam is 3cm dilated and 50% effaced. Most frequent cause? a) dehydration b) fetal anomalies c) Idiopathic d) uterine fibroids e) cervical incompetence

C! Most often idiopathic! Dehydration and uterine distortion (fibroids or structural anomaly) may also be associated with preterm labor. b) fetal anomalies not usually associated with preterm labor e) usually diagnosed earlier in pregnancy

26 yo F call with question about management of hypothyroidism during pregnancy. Wishes to become pregnant soon. TSH 3 months ago 2.0. Well-controlled on stable dose of levothyroxine. Best rec? a) Continue current levothyroxine dose through pregnancy b) Decrease levo dose when patient becomes pregnant c) Increase the levo dose when patient becomes pregnant

C! Patients with pre-existing hypothyroidism are unable to increase thyroxine production appropriately and are at risk for a worsening hypothyroid state and adverse fetal and maternal effects.

22 yo g1p1 delivered her first baby 5 days ago after prolonged labor and subsequent Cesarean delivery for arrest of dilation at 7cm. Fever was noted on POD2. Put on broad-spectrum abx for 48 hours but fevers above 101.3F persist. On exam, breasts have no erythema. abdomen is soft, uterine fundus is firm and nontender. Incision healing without induration or erythema. Normal lochia and UA is normal. No adnexal massess or tenderness. Most likely cause of her fever? a) Endometritis b) Cystitis c) septic pelvic thrombophlebitis d) Ovarian abscess e) Mastitis

C! STP involves thrombosis of the venous system of the pelvis. Dx is often one of exclusion but sometimes a CT scan will reveal thrombosed veins. Tx requires addition of anticoagulation to abx and resolution of fever is rapid.

24 yo g2p1 who underwent elective termination 2 days ago presents to the ED with abdominal and pelvic pain. BP 100/60; HR 100; respiration 16; T102F. PEx reveals diffuse abdominal tenderness and on pelvic exam, marked cervical motion tenderness. In addition to sending a CBC and cultures, best next step in management? a) Obtain beta-hcg level b) Order a hysterosonogram c) Begin IV abx d) Proceed with D&C e) Laparoscopy

C! She likely has post-op endometritis (possibly from introduction of bacteria from D&C). Begin abx immediately. After abx, an US should be obtained to look for POC. If found, the patient would require a repeat D&C b) Hysterosonogram involves saline infusion into uterine cavity with US. This is contraindicated when infxn present

A 23 yo g2p1 F at 36 weeks gestation presents with her 3rd episode of heavy vaginal bleeding. She has known placenta previa confirmed on US. Hct is 29%. FHT is reassuring. She has no contractions or abdominal pain. baby in cephalic presentation. Best next step? a) Tocolysis b) Induction of labor c) Cesarean delivery d) Amniocentesis e) Administer steroids

C! The patient is near term with a 3rd episode of active bleeding from a placenta previa. The next step would be to move towards delivery via C-section. She is not experiencing contractions so tocolysis not needed and would not be used with heavy vaginal bleeding Catastrophic bleeding could occur due to disruption of blood vessels as the cervix dilates if a vaginal delivery is pursued and IOL would be contraindicated. Steroids only if <= 34 weeks GA

23 yo g2p1 at 36 weeks presents with 3rd episode of heavy vaginal bleeding. Normal prenatal labs with known placenta previa. Denies uterine contractions and abdominal pain. BP 100/60; HR 110; afebrile. FHT reassuring. Hct 29%. Pelvic US confirms previa and fetus is cephalic. Best next step? a) Tocolysis b) IOL c) Cesarean delivery d) Amniocentesis e) Administer steroids

C! This is a near term patient with a 3rd episode of active bleeding from previa. Best next step is Cesarean. IOL is contraindicated because catastrophic bleeding could occur due to disruption of blood vessels with cervical dilation.

22 yo g1p0 presents at 8 weeks gestation experiencing heavy vaginal bleeding. BP 94/60, HR 108, RR 20, T37C. Pelvic exam demonstrates brisk bleeding through a dilated cervical os. Hb is 7. Best next step? a) Intravaginal miso b) Oral miso c) dilation and suction currettage d) Endometrial ablation e) expectant care to permit spontaneous abortion

C! This patient is actively bleeding and is anemic. Expectant management and drug regimens can only be used if hemodynamically stable and reliable for f/u care

Pregnant patient at 26 weeks gestation has postcoital musty odor and increased milky, gray-white discharge for the last week. Profuse discharge in the vaginal vault. Pertinent labs: wet mount pH >4.5 and whiff test positive. Microscopic exam reveals clue cells, but no trichomonads or hyphae. Best next step? a) delay treatment until postpartum b) Treat her now and again during albor c) Treat her now d) Treat her and her partner

C! Treatment should not be delayed. She has bacterial vagiosis with gardnerella. Po metronidazole is tx of choice

24 yo g2p1 has a fetus affected by Rh disease. At 30 weeks gestation, the delta OD450 results plot on the Liley curve in Zone 3 indicating severe hemolytic disease. Most appropriate next step in management? a) Immediate cesarean delivery b) Induction of labor c) Intrauterine intravascular fetal transfusion d) Umbilical blood sampling e) Maternal plasmapheresis

C! Values in Zone 3 of the Liley curve indicate presence of severe hemolytic disease with hydrops and fetal death likely within 7-10 days, thus demanding immediate delivery or fetal transfusion. At 30 weeks, the fetus would benefit from more time in utero, so an attempt at transfusion should be made. Intravascular transfusion into the umbilical vein is the preferred method

Cardiovascular changes of pregnancy?

CO increases by 30-50% (mostly in first tri) due to increase in SV maintained by increased HR (pregnancy can cause tachycardia later in course) as SV decreases to near prepregnancy levels by end of third tri SVR decreases during pregnancy (progesterone relaxes SM). It decreases to a nadir at week 24 and then slowly returns to prepreg levels

Describe cardiovascular maternal changes during pregnancy. When does it return to normal?

CO: increased by 30-50% during pregnancy Circulating volume increased by 30% Approximately 1000cc's lost during delivery Large shift from extravascular to intravascular space -> large diuresis Normal CV function: returns 2-3 weeks pp

First-line antibiotics options for pregnant women with asymptomatic bacteriuria?

Cephalexin Amoxicillin-clavulanate Nitrofurantoin Fosfomycin **Fluoroquinolones (bone deformities, arthropathy) is contraindicated in pregnancy **TMP-SMX is safe in 2nd trimester but not safe in 1st due to folic acid metabolism interference or in 3rd due to kernicterus risk

Drugs you can use for GBS if patient is allergic to penicillin?

Cephalosporins Clindamycin Erythromycin vancomycin

Definition of protracted active phase labor?

Cervical dilation > 6cm who are dilating less than 1-2cm/hour +/- inadequate contractions

Cervical insufficiency vs preterm labor?

Cervical insufficiency: cervix is more dilated than what would be expected with level of contractions Both can present with a dilated cervix, vaginal discharge, or ROM

Maternal complications of late/postterm pregnancy?

Cesarean delivery Infection PPH Perineal trauma

Management of active phase labor arrest?

Cesarean section!

Which is more common: gonorrhea or chlamydia? Why would this be important?

Chlamydia is way more common (C for common!) This is important b/c almost all sexually active young adults/teens are screened for chlamydia but not gonorrhea This is also important b/c tx for confirmed gonorrhea also covers chlamydia empirically with azithromycin + ceftriaxone (azithro to cover chlamydia) BUT if only chlamydia is isolated, you do not have to add ceftriaxone for gonorrhea

If pregnant woman presents with prolonged ROM (>= 18 hours), has a fever, diffuse uterine tenderness on exam, has a HR 100 and FHR tracing shows fetal HR of 165 baseline, what should you suspect?

Chorioamnionitis!

Causes of symmetric fetal growth restriction?

Chromosomal abnormalities Congenital infection

Antibiotic regimen for endometritis?

Clindamycin and gentamicin +/- ampicillin? (in contrast to amp and erythromycin for PPROM)

Cause and tx of edema in pregnancy?

Compression IVC and pelvic veins by uterus can lead to increased hydrostatic pressure in the LE's and eventually to edema in the feet and ankles. Tx with lower extremity elevation above the heart

Tx of postpartum urinary retention?

Conservative: analgesia and encourage ambulation Urethral catheterization if conservative fails Reassure patients that retention is usually temporary and reversible

A 32 yo G2P1 F is 20 weeks GA. Prior pregnancy complicated by postpartum endometritis and her son was diagnosed with early-onset neonatal sepsis due to GBS. How should she be managed with regards to GBS during this pregnancy? Should she get cultures?

Cultures are not required in women who have GBS bacteriuria during the current pregnancy or who have previously given birth to a neonate with early-onset GBS disease b/c these women should receive intrapartum antibiotic ppx by default

Patient has HTN during pregnancy. Which of the following is she at greatest risk for? a) Fetal heart defect b) Fetal macrosomia c) Placenta accreta d) Preterm labor e) PPROM

D! HTN in pregnancy leads to increased risk for: Maternal - superimposed pre-eclampsia, pph, gestational diabetes, placentae abruptio, Cesarean Fetal - fetal growth restriction, perinatal mortality, preterm delivery, oligohydramnios The risk for preterm labor and other complications may be linked to the increased SVR and arterial stiffness leading to placental dysfunction. In addition, expedited preterm delivery may be indicated for tx of unstable maternal or fetal complication listed above

A 36 yo G2P1 F presents for her first prenatal visit at 11 weeks gestation. She has a 2-year history of chronic HTN treated with lisinopril and labetalol. In addition, she has hypothyroidism treated with levothyroxine and recurrent herpes, for which she is on chronic acyclovir suppressive therapy. She takes amitriptyline for migraine headaches. Which of her meds is contraindicated in pregnancy? a) Levothyroxine b) Labetalol c) Acyclovir d) Lisinopril e) Amitriptyline

D! ACE inhibitors after the 1st trimester have been associated with oligohydramnios, fetal growth retardation, and neonatal renal failure, hypotension, pulmonary hypoplasia, joint contractures and death

Pregnant woman with nausea/vomiting, RLQ pain with guarding, and leukocytosis with left shift. Best next step? a) CT abdomen b) Diagnostic laparoscopy c) MRI d) US of the abdomen

D! Acute appendicitis of pregnancy may result in ruptured appendix if dx is delayed beyond 24-36 hours. Many of the sxs mimic sxs of pregnancy. Depending on gestational age, the location of pain and tenderness may be higher than expected due to displacement of the appendix upward by the gravid fetus. Ultrasounds should be the first diagnostic test used to confirm the diagnosis of appendicitis in pregnancy. Nonvisualization of the appendix on US does not exclude the diagnosis of acute appendicitis.

29 yo g1p0 at 28 weeks gestation presents with preterm labor. Contractions q2min. VSS. 2cm/50%effaced/-4 station. Fetus with category 1 tracing. Admitted and started on nifedipine and betamethasone. Which medication is also indicated for this patient? a) Terbutaline b) Prostaglandin E1 c) Prostaglandin E2 d) Ampicillin

D! Ampicillin is indicated in this patient because her GBS is unknown (remember, rectovaginal cultures not known until 35-37 weeks) and should be continued until a culture result is negative or her labor stops Nifedipine is a tocolytic used to delay progression of labor to allow for betamethasone to hasten pulm maturation. Both prostaglandins are utertonics Terbutaline is a tocolytic but is not indicated by FDA due to lack of efficacy and side effects

Pregnant lady presents with beta-hCG 1 million and snowstorm pattern on transvaginal uterine US. She complains of a "racing heart". Next best step? a) Repeat beta-hcg b) repeat transvaginal US c) PET scan d) Chest X-ray

D! Classic presentation for molar pregnancy. Lungs are the most common site of metastatic disease in patients with gestational trophoblastic disease.

37 yo g3p3 presents for contraceptive counseling. She requests permanent sterilization. Husband refuses vasectomy. BMI 52, BP 140/80 HR 86. Hx of 3 previous Cesareans. Best method of sterilization? a) Laparoscopic tubal ligation b) Mini-laparotomy with tubal ligation c) Hysterectomy d) Hysteroscopic tubal ligation (Essure) e) Endometrial ablation

D! Essure can be performed in the office and places coils into the fallopian tubes that cause scarring that blocks the tubes. Patients are required to use a back up method of contraception for 3 months following the procedure until a hysterosalpingogram is performed confirming occlusion of the fallopian tubes a and b) While these are common and effective methods, her prior surgical history increases her risk of complications c) Not indicated for sterilization e) used for menorrhagia; not sterilization

24 yo Rh negative g2p1 found at 10 weeks gestation found to have anti-D ab's. You follow her closely and order serial ultrasound examinations. Which of the following fetal US findings would be most explained by Rh disease? a) Meconium b) Fetal bladder obstruction c) Oligohydramnios d) Pericardial effusion e) Placenta previa

D! Fetal hydrops is easily diagnosed on US. It develops in the presence of decreased hepatic protein production. It is defined as a collection of fluid in 2 or more body cavities such as ascites, pericardial and/or pleural fluid and scalp edema. On occasion, when extramedullary hematopoiesis is extensive, there will be evidence of HSM

A 22 yo g2p1 F presents for prenatal care at approximately 10 weeks gestation. Her first pregnancy was c/b PPROM at 28 weeks gestation. Which intervention could reduce risk of PPROM durin g this pregnancy? a) Bedrest b) Placement of cerclage c) Placement of a terbutaline pump d) 17-alphaOH progesterone

D! Reported recurrence rate for PPROM is 32% when it occurred in index pregnancy. Bedrest and tocolytics have not been shown to reduce risk for PPROM and may have detrimental effects to the mother! A cerclage can be used if history of cervical incompetence. progesterone has been shown to decrease the risk of preterm labor.

23 yo g2p1 lmp 6 weeks ago presents with lower abdominal pain and vaginal bleeding. Fever to 102F and cervix is 1cm dilated. Uterus is 8 week size and tender. Urine pregnancy test is positive. Most likely dx? a) Threatened abortion b) Missed abortion c) Normal pregnancy d) Septic abortion e) Ectopic pregnancy

D! She has fever, bleeding and dilated cervix - findings associated with septic abortion a) The cervix would be closed and uneffaced b) retention of nonviable pregnancy for prolonged periods of time c) Normal pregnancy would have a closed cervix

34 yo g4p3 at 36 weeks with a twin gestation in labor. Twin A is breech with EFW of 2800g and twin B is vertex, with EFW of 3200g. Best delivery option for this patient? a) Total breech extraction of twin A, vaginal delivery of B b) ECV for twin A, vaginal delivery of B c) Operative vaginal delivery for twin A and vaginal delivery for twin B d) Cesarean

D! The optimal mode of delivery for twins in which the first twin is breech is cesarean. If first twin is breech, problems such as head entrapment and umbilical cord prolapse can occur. When presenting twin is vertex and 2nd twin is non-vertex, optimal mode of delivery is controversial

A 20 yo g2p1 at 28 weeks presents to l&d q4 min. Febrile to 101F, HR 120, RR18 and BP 110/65. Uterine fundus is tender and the rest of the physical exam is normal. Cervix is dilated 1cm and 50% effaced. Fetus in vertex. Fetal heart tones are in the 150's with a catI tracing. WBC 18000. Best next step? a) Observation b) Tocolysis c) Contraction stress test d) Labor induction e) Cesarean

D! This patient has a fever, tender fundus and leukocytosis suggesting chorioamnionitis. Delivery is warranted here (recall that management of a preterm delivery is a balance between prematurity and infection!) and a FHT is reassuring so no contraindications for labor induction and a Cesarean is not indicated at this time. Tocolytics contraindicated with intra-amniotic infections

A 29 yo g1p0 F presents at 31 weeks gestation with preterm ROM 6 hours ago. VSS stable. Uncomplicated pregnancy. Role of tocolysis in this patient? a) Prevent delivery b) Delay delivery until fetal lung maturity is reached c) Delay delivery for one week d) Delay delivery in order to administer steroids

D! Tocolysis may be given in attempt to gain time for steroids to obtain max benefit for the fetus. Risks of chorioamnionitis with continuing tocolytics beyond 48 hours outweighs the benefit of awaiting lung maturity

A 39 yo G4p1 at 36 weeks presents to L&D. No fetal heart tones noted on Doppler. US confirms fetal demise. Problems during pregnancy include dx of an open neural tube defect, EFW > 90thpercentile, polydhydramnios. Most likely etiology for this fetal demise? a) Uncontrolled HTN b) In-utero viral infection c) Antiphospholipid Antibody syndrome d) Uncontrolled diabetes e) Uncontrolled maternal hyperthyroidism

D! Uncontrolled diabetes during organogenesis is associated with a high rate of birth defects (most commonly spine and heart). Fetuses in utero exposed to high levels of glucose transplacentally have increased growth and polyuria resulting in an increase in the amniotic fluid volume While some viral infxns are also associated with placentomegaly and polyhydramnios, the fetus will have normal or decreased growth depending on the timing of the infection. Severe HTN and APAS increase risk of IUGR and oligohydramnios

A 29 yo G2P1 F at 39w presents in early labor after SROM. 30 min after arrival, she delivers. A globular pale mass appears at the introitus when attempting to deliver the placenta. BP is 90/60. HR 104. Most likely etiology? a) Multiparity b) twin gestation c) Leiomyoma d) Uterine inversion e) Rapid labor

D! Uterine inversion is an uncommon etiology of PPH. Factors that predispose to an over-distended uterus are risk factors for uterine inversion. Grand multiparity, multiple gestation, polyhydramnios, and macrosomia are all risk factors. The most common is excessive (iatrogenic) traction on cord during placental delivery (stage 3)

28 yo F G2P1 presents in active labor at 37 weeks with severe abdominal and back pain. She had a prior cesarean delivery and is scheduled for a repeat cesarean at 39 weeks gestation. BP 90/60, HR 120. PEx shows a palpable irregular protuberance in the lower abdomen and moderate vaginal bleeding. Cervix is 3cm, 80% effaced. A bulging bag is palpated at the cervical os, but there is no presenting fetal part. FHT shows late decels, minimal variability, and fetal tachycardia. Dx? a) Fetomaternal hemorrhage b) Placental abruption c) Cord prolapse d) Uterine rupture

D! Uterine rupture may present with sudden, excruciating abdominal pain. Bleeding may be severe. An abnormal FHT is common due to disruption of the maternal-placental circulation. Distinguishing features include loss of fetal station and presence of abdominally palpable fetal parts. These serve to distinguish it from placental abruption. Cord prolapse occurs after ROM and can cause abrupt onset of persistent fetal variable decelerations or severe bradycardia. On exam, the umbilical cord can be palpated below the cervix in the vagina

Definition of recurrent pregnancy loss? Common causes?

Definition: >= consecutive SAB's Causes: similar to SAB's - chromosomal abnormalities, maternal systemic disease, maternal anatomic defects, infection, antiphospholipid antibody syndrome

Causes of increased Braxton Hicks contractions?

Dehydration - advise patients to drink many (10-14) glasses of water/day Regular contractions (q10 min) should be considered a sign of preterm labor and should be assessed by cervical exam UTI's are another cause

Description of fetal Nonstress test (NST), normal result, and abnormal result?

Description: External FHR monitoring for 20-40 minutes Normal - Reactive: >= 2 accelerations Abnormal - Nonreactive: <2accels; recurrent variable or late decels

Biophysical profile description, normal result, abnormal result?

Description: NST + US assessment of the following: -Amniotic fluid volume -Fetal breathing movement -Fetal movement -Fetal tone 2 points/category if normal and 0 if abnormal (binary system for max of 10/10) Normal: 8-10 Equivocal 6 points Abnormal: 0,2, or 4 points or oligohydramnios

Contraction stress test (CST) description, normal result, abnormal result?

Description: external FHR monitoring during spontaneous or induced (eg oxytocin, nipple stimulation) uterine contractions Normal: no late or recurrent variable decels Abnormal: Late decels with >50% of contractions

What are the 5 components of the cervical exam? What is the Bishop score? What is a good score/bad score?

Dilation, Effacement, Station, cervical consistency, cervical position The bishop score is composed of the 5 components of the cervical exam. A score <= 6 is considered unripe and would be an indication for cervical ripening. A score > 8 is associated with the same probability of vaginal delivery after induction as spontaneous labor

Complications to the donor and recipient twins in twin-twin transfusion syndrome?

Donor: IUGR and oligohydramnios Recipient: Volume overload, polycythemia, heart failure and hydrops

Which of the following non-invasive tests can detect severe fetal anemia? a) Umbilical artery systolic-diastolic ratio b) Biophysical profile c) AFI d) Umbilical artery blood flow e) Middle cerebral artery peak systolic velocity

E!

29 yo g3p0 presents for eval and tx of pregnancy loss. History of 3 early (<14 weeks) pregnancy losses. Parental karyotype is normal. Best next step? a) Prophylactic cerclage with her next pregnancy b) Serial cervical length with her next pregnancy c) 17-OHprogesterone with next pregnancy d) Check for Factor V Leiden mutation e) Check for antiphospholipid antibodies

E! a and b) History not consistent with cervical insufficiency which is dx in 2nd trimester by history, PEx and other diagnostic tests so serial cervical length and cerclage not indicated c) progesterone given for history of preterm birth

Which of the following is associated with betamethasone therapy in the newborn? a) Enhancement of fetal growth b) Increased risk of infection c) Increased incidence of necrotizing enterocolitis d) increased incidence of intracerebral hemorrhage e) Decreased incidence of intracerebral hemorrhage

E! Betamethasone leads to decreased risk of RDS, intracerebral hemorrhage and necrotizing enterocolitis

A 19 yo g2p1 AA woman at 30 weeks presents with preterm ROM. Prenatal course complicated by 2 episodes of BV for which she was treated. Smokes 5 cigarettes a day. Prior pregnancy delivered at 41 weeks after SROM. Sonogram reveals oligohydramnios and cervical length of 30mm. Most likely cause of PPROM in this patient? a) Ethnicity b) Smoking c) Previous PPROM d) Cervical length e) Genital infections

E! Genital tract infections are the primary risk factor for PPROM!!! Especially BV. All the other options are also risk factors. Smoking and prior PPROM increase risk by 2-fold Shortened cervical length is also a risk factor but her length is normal

23 yo g1p0 at 6 weeks undergoes medical termination of pregnancy. 1 day later, she presents to ED with bleeding adn soaking >1pad/hr for 5 hours. BP 110/60; HR 86. On exam, her cervix is 1cm dilated with active bleeding. Hct 29%. Best next step? a) Admit for observation b) Repeat Hct in 6 hours c) Begin transfusion with Onegative blood d) Give additional dose of prostaglandins e) Dilation and curettage

E! Her bleeding is most likely due to retained products of conception, best managed with D&C.

Woman with FHx of ovarian cancer requests contraception. She wants to decrease her risk of gynecologic cancer. Best method of contraception? a) Diaphragms b) Condoms c) Copper IUD d) Progesterone IUD e) Combined OCP's

E! OCP's will decrease a woman's risk of developing ovarian and endometrial cancer. The first developed higher dose OCP's have been linked to a slight increase in breast cancer but not the most recent lower dose pills

A 35 yo g3p3 F presents for contraception. PMHx of Wilson's disease, chronic HTN, and anemia 2/2 menorrhagia. BP 144/96. Best contraceptive option? a) Progestin-only pill b) Low-dose combination contraceptive c) Continuous OCP d) Copper IUD e) Levonorgestrel IUD

E! The levonorgestrel IUD has lower failure rates within 1st year than the Copper IUD. It cases more disruption in menstrual bleeding in the first few months of use but the overall volume of bleeding is decreased long-term and many women become amenorrheic. It is protective against endometrial cancer due to release of progestin. b abd c) C/i due to her poorly controlled HTN a) Higher failure rates d) c/i due to Wilson's disease

DDx for elevated maternal serum AFP screening? DDx for decreased MSAFP?

Elevated: Multiple gestations, abdominal wall defects (gastroschisis, omphalocele), neural tube defects Decreased: Aneuploidies (trisomy 18 and 21)

Postpartum fever differential?

Endometritis, mastitis, cystitis, breast engorgement

Clue cells?

Epithelial cells diffusely coated with bacteria

Tx of spontaneous abortion?

Expectant or medication induction with misoprostol if stable Suction curettage if infection or hemodynamic instability Rho(D) immune globulin required as well to prevent fetomaternal transfusion Pathology examination

17 yo G2P0 F has severe RLQ pain. LNMP was 7 weeks ago. Last night she began having suprapubic pain that awakened her from sleep. Hx of 2 first trimester elective abortions and chlamydia treated 2x. Vital signs are BP 90/60; HR 99; RR 22. On exam, she has rebound and voluntary guarding. She has severe cervical motion tenderness and rectal tenderness. Beta-hcG level is 2500; Hct 24%; UA negative. Right adnexal mass shown on US. Best next step?

Exploratory surgery! Her vital signs, anemia, and peritoneal signs are all suggestive of a rupture ectopic pregnancy leading to an intra-abdominal bleed

Failed induction of labor definition?

Failure to generate regular (q3min) contractions and cervical change after at least 24h of oxytocin administration with AROM if feasible

Target BG levels in gestational diabetes?

Fasting <= 95mg/dL 1hr postprandial <= 140 2hr postprandial <= 120

Vasa previa definition

Fetal blood vessels that cross fetal membranes between fetus and internal cervical os.

Fetal complications of GDM?

Fetal death Fetal macrosomia (OR IUGR!) Polyhydramnios (glucose acts as osmotic diuretic in fetus) Congenital malformations (CV, NTD, and caudal regression syndrome) Preterm birth and hypertensive complications

What are the complications of inadequate maternal weight gain during pregnancy?

Fetal growth restriction Preterm delivery (NOT post-term birth)

Risk factors for shoulder dystocia?

Fetal macrosomia is the primary risk factor Other factors include things that predispose to fetal macrosomia: maternal obesity, diabetes mellitus, postterm pregnancy Also: a prior delivery c/b shoulder dystocia, and a prolonged 2nd stage of labor

Malposition vs malpresentation

Fetal position is the relationship of the fetal presenting part to the maternal pelvis (eg OA is best; OT, OP are malpositions). Malposition can cause cephalopelvic disproportion and arrest of second stage Fetal presentation refers to the lowest part of the fetus in the maternal pelvis.

You are assessing risk of preterm delivery this pregnancy. She has history of preterm delivery. Along with TVUS-CL, what would be your first step in management? What if TVUS-CL shows short cervix? What if it shows normal cervix?

First step in management would be progesterone injections AND TVUS-CL If normal cervix: serial TVUS-CL until 24 weeks (age of viability) If short cervix: cerclage AND serial TVUS-CL until 24 weeks

Thionamide choice in pregnancy?

First trimester: PTU preferred due to risk of aplasia cutis with methimazole 2nd and third trimesters: Methimazole okay

Teratogenic effects of lithium exposure in each trimester?

First- Cardiac defects: Ebstein's anomaly or malformed/inferiorly attached tricuspid valve causing a portion of the RV to become functionally part of the RA (atrialization) Second - goiter Third - Neuromuscular issues

Management of intrauterine fetal demise if mother is at 28 weeks? Does it change if she is 22 weeks?

For >= 24 weeks, vaginal delivery (may be induced) is the preferred delivery route regardless of fetal presentation For 20-23 weeks: both D&E and vaginal delivery are acceptable options

Factors associated with lower ECV success rate?

Frank breech presentation Nulliparity Anterior placenta Decreased amniotic fluid volume (decreased AFI) Obesity Ruptured membranes

Types of breech presentation

Frank: Both hips flexed and both knees extended Complete: Both hips and knees flexed Incomplete: Both hips incompletely flexed. Either feet (footling) or knee (kneeling) can be presenting part

Renal changes in pregnancy?

GFR increases by 50% early in pregnancy and is maintained until delivery Cr and BUN both decrease by 25%

Mechanism for pulmonary edema in severe preeclampsia?

Generalized arterial vasospasm (systemic HTN) -> increased afterload against which the heart is pumping -> increased PCWP 2. Decreased albumin 3. Decreased renal function 4. Increased vascular permeability

Patient at 19 weeks GA has a history of preterm labor. What are your management options for her?

Give progesterone injections and TVUS for cervical length measurements. -If there is a short cervix: can give cerclage and serial TVUS-CL until 24 weeks gestation -Otherwise, serial TVUS-CL until 24 weeks

Mother with history of HIV infection in active labor has viral load >1000 copies. How should you manage her/route of delivery?

Give zidovudine and consider elective cesarean section (shown to reduce perinatal transmission of HIV by 50%)

Routine prenatal labs performed at 35-37 weeks?

Group B strep culture

Vaccines contraindicated during pregnancy?

HPV MMR Live attenuated influenza Varicella These are all live vaccines. This is due to a theoretical risk of causing congenital infection -> congenital rubella, varicella syndromes; neonatal hpv Non-immune mothers should receive these vaccines POST-partum as they are safe for breastfeeding

Which uterotonic is contraindicated if a patient has a history of asthma?

Hemabate or prostaglandin F2-alpha: smooth muscle constrictor, which has a bronchio-constrictive effect

What routine prenatal labs should be performed at 24-28 weeks gestation?

Hemoglobin/hct Antibody screen if Rh(D) negative 50g 1-hour Glucose challenge test (GCT) -> then confirm with a 3-hour 100g GCT

Complications of spontaneous abortion?

Hemorrhage, retained products of conception, septic abortion, uterine perforation, intrauterine adhesions

Tx of APAS?

Heparin AND aspirin

Risk factors for cervical incompetence?

History of cervical surgery, cervical lacerations Uterine anomalies History of DES exposure

Risk factors for ectopic pregnancy?

History of ectopic pregnancy (greatest risk factor) History of tubal surgery History of chlamydial infection If 3 episodes of PID -> ratio of ectopic:uterine pregnancy is 1:3 Endometriosis Congenital uterine malformations Smoking But 50% have no risk factors

Contraindications to estrogen?

History of thromboembolic disease Women who are lactating Women over 35 who smoke Migraine with aura Severe nausea with combined OCP's

What should you suspect in an adolescent who is sexually active, presents with pre-eclampsia with severe features at <20weeks GA and abnormally elevated beta-hcg?

Hydatidiform mole!

Fetal complications of maternal diabetes?

Hypoglycemia, polycythemia, hyperbilirubinemia, hypocalcemia, and respiratory distress

Side effects of pitocin?

Hyponatremia, uterine tachysystole, hypotension (important to prevent pph in the immediate postpartum period)

Management of pregnant patients with history of prior spontaneous preterm delivery?

IM progesterone during the 2nd and 3rd trimesters to minimize risk of recurrence Serial cervical length measurements by transvaginal US during the 2nd trimester Cerclage if short cervix

Tx of chorioamnionitis (be specific)?

IV broad-spectrum antibiotics (ampicillin, gentamicin +/- clindamycin) Antipyretics to reduce maternal fever and in turn improve fetal tachycardia Delivery - be careful here! Cesarean delivery is not indicated for chorioamnionitis exclusively. The best next step would be to accelerate labor with oxytocin

Commonly used regimen for postpartum endometritis?

IV clindamycin and gentamicin

Causes of polyhdramnios?

Idiopathic (2/3 of cases) Maternal diabetes (hyperglycemia in fetus stimulates osmotic diuresis) Neurologic: anencephaly, NMJ disease GI: esophageal and duodenal atresia Twin-twin transfusion syndrome/multiple gestation Chromosomal abnormalities Hydrops fetalis

Tx of endometriosis?

If asymptomatic -> observe! If symptomatic: conservative tx includes NSAIDs, OCPs, or a progesterone IUD (copper has no effect). Leuprolide (a GnRH agonist) treats by suppressing estrogen stimulation of the ectopic endometrial glands Definitive tx: surgical resection with hysterectomy and oophorectomy

Indication for external cephalic version?

If fetus remains persistently in transverse lie or converts to breech at 37 weeks GA Cesarean indicated if ECV fails or is contraindicated (eg oligohydramnios, abnormal fetal heart tracing)

What is an indication for a NST?

If mother detects decreases or cannot detect fetal movements

Why does HTN in pregnancy lead to asymmetric "head-sparing" fetal growth restriction?

In normal fetal development, the fetal abdomen grows exponenetially during the 2nd and 3rd trimesters. Insults such as hypoxemia due to uteroplacental insufficiency at this stage of pregnancy cause fetal blood flow to be redistributed to the vital organs (eg brain) and away from the abdomen, resulting in an asymmetric head sparing growth pattern

Pulmonary changes of pregnancy?

Increase of 30-40% in TV despite decreased TLC due to diaphragm elevation This leads to increased PaO2 and decreased PaCO2 leading to increased increased CO2 gradient between mother and fetus: allows for oxygen delivery to fetus and CO2 removal from fetus

Why does pregnancy cause dyspnea physiologically?

Increased progesterone induces increased tidal volume with a constant RR -> increased minute ventilation. At the same time, the enlarging uterus causes the diaphragm to be elevated, resulting in decreased FRC -> physiologic dyspnea

Fetal and maternal risks of shoulder dystocia?

Infant: brachial plexus injuries, clavicular or humeral fractures, and hypoxic encephalopathy Maternal: 4th degree perineal lacerations and pph

Definition of complete cervical dilation?

Internal os has dilated to 10cm

Tx of preterm ROM?

It depends on the GA of the fetus! Management is a balance between risk of prematurity and risk of infection. <32 weeks: risk of prematurity drives management 32-36 weeks: equal risk >36 weeks: risk of infection > risk of prematurity -Antibiotics recommended in setting of PPROM -Tocolysis (to buy time for steroids) and corticosteroids often given

What is endomyometritis? Risk factors?

It is a polymicrobial infection of the uterine lining that often invades the underlying wall. Increased risk with cesarean section, meconium, chorioamnionitis, and prolonged ROM

When is a NST considered reactive?

It is reactive if in 20 minutes there are at least 2 accelerations of the FHR of >= 15bpm above the baseline and lasting at least 15s each. If <2 accelerations noted, the test is nonreactive and further assessment is required MC cause of a nonreactive NST is a fetal sleep cycle

What is fetal scalp pH used for?

It is used to directly monitor fetal acid-base status if fetal HR tracings

What is the Kleihauer Betke test used for?

It is used to measure the degree of fetomaternal blood transfusion in a Rh- mom after

Why can a large placental abruption lead to DIC?

It leads to release of tissue factor by decidua bleeding!

Why is vaginal delivery contraindicated with placenta previa?

It would require the placenta to detach and be delivered before the fetus, which would deprive the fetus of oxygen + risk of hemorrhage (along with the all of the other complications of delivery)

Prognosis of Erb-Duchenne palsy?

It's pretty good - up to 80% of patients have spontaneous recovery within 3 months

Lab abnormalities in hyperemesis gravidarum?

Ketonuria (order a UA when evaluating!) - occurs due to prolonged hypoglycemia and resultant ketoacidosis Hypokalemic, hypochloremic metabolic alkalosis Hypoglycemia Hemoconcentration

Definition of late-term and postterm pregnancies?

Late-term: 41 - 41w6d Postterm: >= 42 weeks gestation

Tx of persistent variable decelerations?

Likely due to cord compression 1st line would be to reposition the mom! 2nd line would be to consider amnioinfusion - cord compression may result from reduction of amniotic fluid after ROM so infusion of saline into cavity may relieve this

Definition of spontaneous abortion?

Loss of a pregnancy at <20 weeks gestation Spontaneous abortion = miscarriage

Routine problems of pregnancy?

Low back pain - mechanical. tx with gentle massage, heating pads, and Tylenol. Muscle relaxants and narcotics occasionally can be used for severe narcotics Constipation Contraction Dehydration Edema GERD Hemorrhoids Round ligament pain (late 2nd or early 3rd tri - pain in the lower abdomen) - tx with warm compresses or acetaminophen Urinary frequency Varicose veins

Presentation of complete abortion?

Lower abdominal pain and heavy vaginal bleeding with passage of clots at <20 weeks gestation. These sxs worsen until the products of conception, often described as a solid or sack-like bloody white mass are expelled and the symptoms lessen and resolve. Pelvic examination includes a normal size uterus with a CLOSED cervix. US reveals an empty uterus and normal adnexa. +betahCG is common as it often takes 6 weeks for it to become undetectable again

Workup for recurrent spontaneous abortions?

Maternal disease: lupus, diabetes mellitus, thyroid disease Maternal and paternal karyotpes Uterine imaging - hysteroscopy or hysterography

Causes of fetal tachycardia?

Maternal fever Maternal hyperthyroidism Medication use (terbutaline) Placentae abruption

Diagnostic criteria for chorioamnionitis (aka intraamniotic infection or IAI)

Maternal fever (T>= 100.4F) and 1+ of the following: -uterine tenderness -Maternal or fetal tachycardia -WBC's >15000 -Malodorous amniotic fluid -or purulent vaginal discharge

Indications for C-section (blueprints)

Maternal/fetal: cephalopelvic disproportion, failed IOL Maternal: maternal diseases (active HSV, untreated HIV w/ elevated viral load, cervical cancer), prior uterine surgery, prior uterine rupture, obstruction to the birth canal (fibroids, ovarian tumors) Fetal: Nonreassuring fetal testing (bradycardia, absence of FHR variability, scalp pH < 7.20), fetal malpresentations (breech, transverse lie, brow), multiple gestations, fetal anomalies (hydrocephalus, OI) Placental: placenta previa, placenta abruption, vasa previa

Breastfeeding contraindications?

Maternal: Active untreated TB -Maternal HIV infection (NOT HBV, HCV) -Herpetic breast lesions -Acute varicella infection -Chemotherapy or radiation therapy -Active substance abuse Infant: galactosemia

Postnatal HIV infection management?

Maternal: Continue HAART Infant: Zidovudine for >= 6 weeks PLUS serial HIV PCR testing

How do Mg, beta-mimetics, indomethacin, and CCB's work as tocolytics?

Mg: competes with Ca entry into cells to decrease uterine contractions Beta-mimetics: increasing cAMP in the cell, decreasing free Ca Indomethacin: block COX1/2 -> decreasing prostaglandin synthesis CCB's: Block Ca entry into cells by inhibiting transporters

Risk factors for postpartum infection (eg endometritis)?

Mode of delivery: <3% for vaginal births and 5-10x higher after Cesarean For vaginal birth: prolonged labor, prolonged ROM, multiple vaginal exams, internal fetal monitoring, removal of the placenta manually and low SES

What is a Montevideo unit?

Montevideo unit (MVU) = average of baseline variability and multiplying by number of contractions in 10-minute period

Risk factors for hyperemesis gravidarum?

Multiple gestation, hydatidiform mole History of esophageal reflux

What are the classic signs of Mg toxicity?

Muscle weakness and loss of DTR's, nausea, and respiratory depression If in high doses, cardiac arrest is possible

GI changes in pregnancy?

Nausea and vomiting occur in 70% of pregnancies. This has been termed "morning sickness" though it can occur anytime throughout the day. Attributed to elevations in estrogen, progesterone, and hCG Hyperemesis gravidarum = severe form of morning sickness in which women lose > 5% of their prepregnancy weight and go into ketosis Decreased GE sphincter tone -> GERD Decreased large bowel motility -> increased water absorption and constipation

Diagnostic tests to confirm ROM?

Nitrazine paper - amniotic fluid is alkaline with pH > 7.1 -> will appear blue Vaginal secretions have pH of 4.5-6 Ferning - Pattern of arborization when amniotic fluid is placed on a slide and allowed to dry Pooling - Filling of speculum with amniotic fluid

Stage 2 arrest definition?

No progress (descent or rotation) for ->= 4h in nulliparous women with epidural (3h if without epidural) ->= 3h in multiparous women with epidural (2h if without epidural)

Definition of arrest of labor in second stage?

No progress (descent or rotation) for more than 4 hours in nulliparous women with an epidural >3 hours in nulliparous women without an epidural >3hours in multiparous women with an epidural >2 in multiparous without an epidural Basically, 3 and 2 for multip and nullip. Then add 1 to each of those if with an epidural because they won't feel the pressure and it will take longer

Risk factors for uterine inversion?

Nulliparity, fetal macrosomia, placenta accreta, and a rapid labor and delivery Uterine inversion can result from excessive fundal pressure and traction on the umbilical cord before placental separation. It is typically accompanied by hemorrhagic shock and lower abdominal pain

What is primary post-partum hemorrhage? What is the differential?

Occurs in 24 hours after delivery DDx: Uterine atony (80% of cases), placenta accreta, uterine inversions/lacerations, maternal defects in coagulation, retained placenta

AFI definitions of oligohydramnios, normal, and polyhydramnios?

Oligo: <= 5cm Normal: 5-24 Polyhydramnios: >24

Management of protracted active phase labor?

Oxytocin. Amniotomy if fetal head achieves adequate descent

PROM? PPROM? Prolonged ROM?

PROM = Premature ROM = ROM occurring before the onset of labor (contractions + cervical changes) Preterm ROM = ROM occuring before week 37 PPROM = Preterm and Premature ROM Prolonged ROM = Anytime rupture of membranes lasts longer than 18 hours before delivery

Which SSRI should you avoid in pregnancy?

Paroxetine (some data suggesting association with cardiac malformations)

What is internal podalic version used for?

Performed to facilitate breech delivery of a malrepresenting second twin

Diagnostic criteria for hyperemesis gravidarum?

Persistent vomiting accompanied by weight loss exceeding 5% of pre-pregnancy body weight and ketonuria unrelated to other causes

A 30 yo G4P3 F at 24 weeks gestation is found to have an anterior placenta previa. She has a hx of 3 prior Cesarean deliveries. Most likely serious complication that can lead to obstetric hemorrhage? a) Placental abruption b) Uterine dehiscence c) Uterine inversion d) Placenta accreta e) Uterine atony

Placental abruption and uterine atony are both common. But in the presence of low-lying anterior placenta in a patient w/ a history of multiple Cesarean births, placenta accreta must be entertained. Incidence is rising due to number of women with previous Cesarean sections.

Risks of ECV?

Placental abruption, uterine rupture, cesarean section *Also, just a note that you must know maternal type and screen as ECV can cause Rh sensitization in Rh- mothers with Rh+ fetuses

Hematologic changes in pregnancy?

Plasma volume increases by 50% in pregnancy, but RBC volume increases only by 20-30%, leading to a dilutional anemia. WBC count increases to a mean of 10.5 million/mL Hypercoagulable state

Contraindications to expectant management of severe preeclampsia remote from term (<32 weeks)?

Plts < 100k Inability to control BP with max doses of 2 BP meds Non-reassuring fetal surveillance LFT's > 2x normal Eclampsia Persistent CNS sxs and oliguria

Arm held in internal rotation and adduction following an eclamptic seizure?

Posterior shoulder dislocation

What does free fluid in the pelvic cul-de-sac possibly represent?

Potentially ruptured tube from ectopic pregnancy (leading to free blood in that space)

Why does pre-eclampsia put the fetus at risk for SGA status?

Pre-eclampsia is due to an abnormality in placental vasculature formation, leading to abnormally narrow caliber vessels. This leads to CHRONIC uteroplacental insufficiency -> SGA This is opposed to acute uteroplacental insufficiency (eg from placenta abruptio) leading to hypoxic brain injury in the fetus

Describe maternal coagulation changes during pregnancy. When does it return to normal?

Pregnancy is a procoagulant state to protect from hemorrhage at time of delivery Risk of VTE is increased and especially high during pp period. Balance restored at 6-8 weeks pp

Risk factors for breech presentation?

Prematurity, multiple gestation (twins push each other into malpresentation) Genetic disorders Polyhydramnios - room to float around into malpresentation Hydrocephalus, anencephaly Placenta previa, uterine anomalies and uterine fibroids - anomalies in the womb that may displace the fetus

Uses for Mg sulfate?

Prevention of eclamptic seizures Also administered to patients for whom preterm delivery is imminent as it decreases risk for cerebral palsy in premature infants

Tx of cervical insufficiency?

Previable (<24 weeks GA): expectant management/elective termination or place emergent cerclage Viable:betamethasone and managed expectantly

Risk factors for pre-eclampsia?

Previous history of pre-eclampsia - 7x risk Chronic HTN Multifetal pregnancy Molar pregnancy Maternal age > 40yo Chronic renal disease Diabetes Antiphospholipid antibody syndrome Vascular or connective tissue disease

Risk factors for preterm delivery?

Previous history of preterm delivery Multiple gestation History of cervical surgery

Indications for GBS intrapartum ppx?

Prior delivery complicated by neonatal GBS infection GBS bacteriuria or GBS UTI during the current pregnancy (regardless of treatment) GBS-positive rectovaginal culture Unknown GBS status + any of the following: -<37 weeks GA -intrapartum fever -ROM >= 18 hours (prolonged ROM)

Risk factors for uterine rupture?

Prior uterine surgery Induction of labor/prolonged labor Congenital uterine anomalies Fetal macrosomia

Why are pregnant women at increased risk of pyelonephritis, asymptomatic bacteriuria, and cystitis?

Progesterone elevations cause smooth muscle relaxation and ureteral/urethral dilation

What medication has been shown to reduce preterm birth risk? How does it do this? What are its indications?

Progesterone therapy can reduce risk!!!*** -Causes inhibition of cervical ripening, reduction of myometrial contractility, and inflammatory modulation -Indications: history of preterm delivery or short cervix during pregnancy -Can decrease risk of future preterm delivery

What is mifepristone?

Progestin receptor antagonist- can be used as emergency contraception to prevent ovulation and blocks the action of progesterone, which is needed to maintain pregnancy Also used with misoprostol for pregnancy termination

What do you use to ripen the cervix?

Prostaglandin analogues (misoprostol)

Methods of labor induction?

Prostaglandins to ripen the cervix (if Bishop score <=6) + mechanical cervical dilation However, very often done pharmacologically with Oxytocin. Amniotomy (AROM) can also be performed though this is also an augmentation method. Membrane stripping, nipple stimulation

Management of arrest of active phase of labor? How about protracted/prolonged active phase of labor?

Protraction: oxytocin Arrest: Cesarean delivery*** (must know this, high yield)

Patient G5P5 is evaluated for difficult and painful ambulation on ppd1. The patient has no pain while lying down but reports sharp lower midline abdominal pain that radiates down her legs while ambulating. No difficulties voiding or passing flatus. No numbness or foot drop. She had a vaginal delivery of a 4400g infant that was c/b shoulder dystocia relieved by the McRoberts maneuver and suprapubic pressure. Vitals wnl. What should you suspect?

Pubic symphysis diastasis! Risk factors include fetal macrosomia, multiparity, precipitous labor Presents with difficulty ambulating, radiating suprapubic pain, pubic symphysis tenderness, intact neuro function After a traumatic delivery, patients can develop a symptomatic pubic symphysis diastasis.

Intrapartum management of HIV infection?

Rapid HIV testing if not previously performed -Avoid AROM, fetal scalp electrode and instrumentation -If mom not on HAART: Zidovudine -If viral load > 1000 copies: zidovudine and perform C-section

When is universal screening for Group B strep (GBS) performed?

Recto-vaginal culture at 35-37 weeks GA for all women who do not have an indiation for intrapartum antibiotic ppx

Timing of universal screening for GBS infection?

Rectovaginal culture at 35-37 weeks gestation

Routine prenatal lab tests performed at initial prenatal visit?

Rh(D) type, antibody screen Hb/Hct, MCV HIV, VDRL/RPR, HBsAg Rubella and varicella immunity Pap test (if screening indicated) Chlamydia PCR Urine culture, urine protein

What are the commonly used beta-mimetics for tocolyzing preterm labor? What are some other tocolytics?

Ritodrine and terbutaline However, studies have shown they gained an average of only 24-48 h's further gestation over hydration and bed rest alone Magnesium sulfate: decreases uterine tone and contractions by acting as a Ca antagonist and membrane stabilizer CCB's (po nifedipine specifically): Decrease the influx of Ca into smooth muscles cells thereby diminishing uterine contractions Prostaglandin inhibitors (indomethacin) - while showing promising efficacy, it has been associated with a variety of fetal complications (premature constriction of PDA, oligohydramnios) Oxytocin antagonists - investigational

DEXA scan recommendations for routine screening? Who should get it earlier?

Routine screening for women 65yo+ Earlier screening recommended for women with risk factors for osteoporosis (history of fracture, smoking, hyperparathyroidism, prolonged steroid use)

Patient has persistent postpartum fever 5 days after a cesarean delivery for arrest of descent after a prolonged induction of labor. She has been unresponsive to trials of broad-spectrum antibiotic therapy. Negative blood, urine cultures, UA. She has bilateral lower quadrant tenderness. What should you suspect?

Septic pelvic thrombophlebitis (SPT) - a complication associated with either pelvic surgery or the postpartum period. It is a thrombosis of the deep pelvic or ovarian veins that becomes infected. It is a diagnosis of exclusion.

Patient presents with lactation failure, amenorrhea in the weeks following her delivery which was c/b postpartum hemorrhage requiring blood transfusions. She also has persistent hypotension, weight loss, lethargy. What do you suspect?

Sheehan syndrome!

You are assessing a woman for risk of preterm delivery. She has no prior history of preterm delivery. TVUS-CL shows short cervix. What should you do? What would you do if it were a normal cervix?

Short cervix with no prior history: vaginal progesterone Normal with no prior history: routine prenatal care

What are 3 intrapartum obstetric emergencies?

Shoulder dystocia Umbilical cord prolapse (cord vessels compressed) Breech delivery

Modifiable osteoporosis risk factors?

Smoking Excessive alcohol intake Sedentary lifestyle Meds Vitamin D deficiency Estrogen deficiency

What environmental factors are associated with spontaneous abortion?

Smoking, alcohol, radiation

How might you quantify when lochia is excessive?

Soaking >2 pads/hour

DDx of first-trimester bleeding?

Spontaneous abortion Postcoital bleeding Ectopic pregnancy Vaginal or cervical lesions or lacerations Extrusion of molar pregnancies Nonpregnancy causes of bleeding

What are Braxton Hicks contractions?

Spontaneous contractions at term that do not result in cervical dilation/effacement Short in duration, less intense than true labor, and localized to the lower abdomen and groin areas

What are the stages of labor?

Stage 1 - onset of labor to full cervical dilation Latent phase: cervical dilation to 4cm (can happen over a few days) Active phase: >4cm cervical dilation (1.2-1.5 cm/hour dilation; 1.2 if first and 1.5 if multiparous) Stage 2 complete dilation -> delivery of infant Stage 3 - delivery infant to delivery placenta Stage 4 - immediate post-partum period of approximately 2 hours after delivery of placenta

Stillbirth vs miscarriage

Stillbirth (aka intrauterine fetal demise or IUFD) refers to fetal death at >= 20 weeks that occurs prior to expulsion from the mother Miscarriage (or spontaneous abortion) is fetal death at < 20 weeks

Why do you give ampicillin and gentamicin for chorioamnionitis?

Synergy for gram-negative infections! ampicillin busts open the wall for gentamicin to get in. You also need broad-spectrum because chorio (and a lot of pelvic infections such as PID) tends to be polymicrobial

Vaccines recommended for everybody during pregnancy?

Tdap, influenza, Rhogam (Rh negative)

Prenatal management of HIV infection?

Test HIV-1 viral load monthly until undetectable, then q3 months -CD4 count every 3 months -Initiate 3-drug HAART: dual NRTI PLUS NNRTI OR protease inhibitor -Avoid amniocentesis until viral load is undetectable

43 yo G6P5 at 39 weeks becomes disoriented, lightheaded, breathless, and cyanotic 20 min after uncomplicated delivery. She then has a seizure. BP 80/40, HR 110, RR30. O2 sat 75% on facemask. Unconscious woman who is no longer seizing. Generalized purpuric rash and bleeding from IV site. What does she have?

The patient's presentation is concerning for respiratory failure from amniotic fluid embolism. This patient's risk factors include AMA and high gravida (>= 5 live or stillbirths). Amniotic fluid can enter maternal circulation through endocervical veins, placental insertion site or areas of uterine trauma (eg from C-section). This leads to an inflammatory response causing vasospasm, cardiogenic shock, hypoxemic respiratory failure and DIC. Hypoxia can lead to seizures.

US markers suggestive of dizygotic (non-identical) twins?

Thick dividing membrane (>2mm), twin peak (lamda) sign, different fetal genders and 2 separate placentas (anterior and posterior)

What is cervical effacement?

Thinning out of the cervix so that the distance between the internal and external os becomes 0. A non-effaced cervix is usually around 4cm in length

Tx of thyroid storm in pregnancy? What can you not use?

Thioamides (PTU but NOT methimazole depending on the trimester I believe), propranolol, sodium iodide, and dexamethasone Oxygen, digitalis, antipyretics, and fluid replacement may also be indicated. Do NOT use radioactive iodine as it can concentrate in the fetal thyroid and cause congenital hypothyroidism.

What should you do if you place an intrauterine pressure catheter and a significant amount of vaginal bleeding is noted?

This could indicate placental separation or uterine perforation. You should withdraw the catheter, monitor the fetus, and observe for signs of fetal compromise

Retraction of fetal head into the perineum after delivery of head?

This is the turtle sign - a warning sign of shoulder dystocia

Thyroid changes in pregnancy? Total T4, Free T4, TSH

Total T4 - increased Free T4 - Unchanged or mildly increased TSH decreased Beta-hcg stimulates thyroid hormone production in the first trimester. Estrogen stimulates thyroid binding globulin (TBG) production to maintain steady-free T4 levels. The increased beta-hcg and thyroid hormone suppress TSH secretion.

Test required to diagnose stillbirth/intrauterine fetal demise (IUFD)?

Transabdominal US showing absence of fetal cardiac activity (may be initially suspected when Doppler sonography fails to show fetal heart tones and mom reports decreased or absent fetal movement)

Gold standard method for assessing the risk of preterm delivery?

Transvaginal US measurement of cervical length in the 2nd trimester (short cervical length)

Definition of true labor as opposed to false labor?

True labor causes: 1. painful uterine contractions and 2) cervical dilation Spontaneous uterine contractions that occur without cervical dilation are known as Braxton-Hicks contractions

Tx of placental abruption?

Typically emergent cesarean section with appropriate resuscitation, including IV fluids and blood products as needed steroids if <= 34 weeks

Definition of fetal growth restriction?

US estimated weight <10th percentile for gestational age

Mechanism of HTN 2/2 OCP's?

Unclear but possibly due to estrogen-mediated increase in hepatic angiotensinogen synthesis

Risk factors for placetental abruption?

Uncontrolled maternal HTN, maternal cocaine use, and hx of placental abruption -Primarily vascular in etiology

What should you think of if you see difficulty with placental delivery, including cord avulsion and postpartum hemorrhage?

Undiagnosed placenta accreta

Causative organisms in postpartum endometritis?

Usually polymicrobial resulting in a mix of aerobes and anaerobes in the genital tract. Most agents are Staph aureus and streptococcus

Common causes of postpartum hemorrhage?

Uterine atony Vaginal/cervical lacerations Retained products (eg placenta accreta) Maternal coagulopathies

How do beta-mimetics work as tocolytic agents?

Uterine myometrium is composed of SM fibers. The contraction of these fibers is regulated by myosin light chain kinase that is activated by Ca ions through their interaction with calmodulin. Thus, by increasing the level of cAMP, the level of free Ca ions decreases, likely by sequestration in the SR, and uterine contractions may be decreased Conversion of ATP to cAMP is increased by Beta-agonists that bind and activate Beta2 R's on myometrial cells.

What should you suspect if you see intense abdominal pain, abnormal vital signs, loss/retraction of fetal station, abnormal abdominal contour in a pregnant woman with prior C-section?

Uterine rupture at site of past scar!

Placenta accreta definition? How is it usually diagnosed (be specific, what would you see)?

Uterine villi attach directly to the myometrium instead of the decidua It is usually diagnosed by antenatal US findings that include irregularity or absence of the placental-myometrial interface and intraplacental villous lakes.

Causes of asymmetric fetal growth restriction?

Uteroplacental insufficiency Maternal malnutrition

What is the mnemonic for the most common accelerations and decelerations seen on FHR tracings and their causes?

VEAL CHOP Variable decelerations - rapid onset and recovery with no clear relationship to uterine contractions; often caused by Cord compression Early deceleration - slow onset and recovery timed with the uterine contractions; caused by Head compression (benign) Accelerations - Ok! Late decelerations - slow onset and recovery time at or after peak of the uterine contractions; caused by Placental insufficiency

Patient at 19 weeks GA. No history of preterm delivery but has short cervix on TVUS. Best tx option to reduce risk of preterm birth?

Vaginal progesterone!

Definition of acceleration?

Visually apparent abrupt increase (onset to peak <30s) in the FHR At 32 weeks and beyon,d peak of 15bpm above baseline with a duration of 15s or more (but less than 2min) - 15 on 15 Before 32 weeks, 10bpm or more above baseline with a duration of 10s or more but less than 2 minutes from onset to return - 10 on 10

Initial evaluation of a pregnant woman with persistent vomiting?

Weight, orthostatic blood pressures, serum electrolytes, urine ketones and specific gravity US to look for multiple gestation and GTD/GTN

When should you suspect postpartum urinary retention?

When the patient is unable to void by 6 hours after vaginal delivery or 6 hours after removal of an indwelling catheter after Cesarean delivery (along with sxs of overflow incontinence)

General treatment for pre-eclampsia?

Without severe features: delivery at >= 37 weeks With severe features: delivery at >= 34 weeks MgSulfate (seizure ppx) Anti-hypertensives (labetalol, hydralazine first line; can also use nifedipine)

Patient has a non-reactive non-stress test. What should you do next?

You can do either a contraction stress test (CST) or a biophysical profile (BPP). However, CST can induce labor and you should not do it if they have contraindications to labor (eg placenta previa, prior myomectomy)

What should you suspect if you see a pregnant woman with HTN at 34 weeks GA and fetal US reveals biparietal diameter consistent with 32 weeks and abdominal circuference consistent with 27 weeks gestation. Estimated fetal weight at 8th percentile for GA?

You should suspect asymmetric "head-sparing" FGR 2/2 HTN leading to uteroplacental insufficiency

Tx of constipation in pregnancy?

encourage increased po fluids Stool softeners or bulking agents Laxatives- but avoid in 3rd tri due to theoretical risk of PTL

Indications for episiotomy?

impending or ongoing shoulder dystocia

How is a diagnosis of ectopic pregnancy made?

positive beta-hcg test combined with transvaginal US. Ectopic is virtually ruled out if TVUS shows an intrauterine gestational sac in the setting of a positive hcg test. Conversely, ectopic pregnancy is confirmed if the gestational sac is seen at an ectopic site

Risk factors for retained placenta?

prior Cesarean delivery, uterine leiomyomas, prior uterine currettage and succenturiate lobe of placenta