OB-Peds Exam 3

placental abruption

Premature separation of the placenta from the uterine wall after 20 weeks' gestation and before the fetus is delivered; fetal mortality rate of 20%

What is the most common bacterial infection in pregnancy?

UTI- can be mistaken for normal pregnancy symptoms, untreated can cause low birthweight, intrauterine death, preeclampsia, maternal anemia

Postpartal chills

Uncontrolled shaking or chills as a physiologic response to labor and a result of the rapid weight loss at delivery

Incomplete abortion

partial expulsion of some but not all POC before 20 weeks gestation

Risk factors for ectopic pregnancy

pelvic inflammatory disease, IUD, endometriosis, tubal ligation reversal

breast assessment postpartum

days 0-2 breasts feel soft to touch by day 3 begin to feel warm and firm when milk comes in; assess for engorgement, infection, plugged milk ducts (pea sized tender lumps)

Risk factors for uterine rupture

history of cesarean or uterine surgery, no previous vaginal births, augmented or induced labor, multifetal gestation, macrosomia, infection, short period between pregnancies

Multiple gestation increases risk for what?

hospitalization, pulmonary edema, hyperemesis gravidarum, additional tests and fetal surveillance, preterm labor

Gestational Trophoblastic Disease (GTD)

hydatidiform mole (molar pregnancy)- develops from abnormal fertilization such as when 2 sperms fertilize one egg or when either the sperm or egg is missing genetic material; complete mole has no fetal tissue, partial mole has some fetal tissue remaining

Dystocia

long difficult or abnormal labor; related to 5 P's Powers- uterine contractions Passage- pelvic and vaginal structure Passenger- fetus Position- maternal position Psychological- response of the woman

tocolytics suppression of labor

magnesium sulfate, terbutaline, indomethacin, nifedipine

Reasons for scheduled cesarean

malpresentation, previa, previous C/S, multiples, HSV+, HIV+, cardiac disease, extensive condylomatas (HPV)

Daily Fetal Movement Count (DFMC)

maternal assessment of fetal activity; the number of fetal movements within a specified time are counted; want 10 or more movements in 12 hours

Postpartal tachycardia

may result from a complication, prolonged labor, blood loss, temperature elevation, hemorrhage, or infection

Lactating women return of ovulation

menses suppressed dependent on length and amount of BF; not reliable BC

Contraction Stress Test (CST)

nipple stimulation or oxytocin stimulation, evaluates fetal response to stress could inadvertently precipitate labor Negative (normal): no late or variable decells Positive: late or variable decells with > 50% uterine contractions Suspicious/unequivocal: variable or late decells with < 50% of contractions

Inevitable abortion

no expulsion of products of conception, but bleeding and dilation of cervix has occurred and expulsion of POC cannot be halted

Postpartum tempature elevation <100.4

normal due to dehydration and stress

Gestational hypertension

onset of hypertension without proteinuria after 20 weeks gestation

Signs of placenta previa

painless vaginal bleeding in 2nd or 3rd trimester

glucose tolerance test (GTT)

(50 g) negative is BG less than 130-140 after 1 hour retest if positive- 100 g for 3 hours 2 or more of following is positive: -fasting 95 -1 hr 180 -2 hr 155 -3 hr 140

amniotic fluid embolism

(anaphylactoid syndrome of pregnancy) Amniotic fluid containing particles of debris Acute onset of hypotension, hypoxia, cardiovascular collapse, and coagulopathy Maternal mortality to 61% or higher Neonatal outcome is poor

Postpartum weight loss

-about 10-12 lbs lost during childbirth; if normal weight gain during pregnancy, should be back to original weight by 6-8 weeks

Insulin requirements during pregnancy

1st trimester: reduced insulin needs 2nd trimester: gradual increase in insulin needs 3rd trimester: insulin needs double or more immediately drops off and gradually increases- lower needs in breastfeeding moms than baseline

What are the danger zones of pregnancy for women with cardiac issues

20-26 weeks gestation 24-72 hours after delivery

RhoGAM timeline

27-28 weeks in all rh- women, within 72 hours of birth if baby is +

How many wet and dirty diapers should baby have by 4 days old

6 wet, 4 dirty

Return of ovulation in non-lactating women

7-9 weeks, regular period by by 12 weeks

BPP score actions

8-10: no fetal asphyxia, repeat weekly 6: suspected chronic fetal asphyxia: if > 36 weeks deliver, if less repeat in 4-6 hours 4 and under: strongly suspect fetal asphyxia, if > 36 weeks deliver, if less repeat in 4-6 hours for 120 minutes; persistent score under 5 deliver regardless of gestational age

Group B Streptococcus (GBS)

A common bacterium found in the vagina and rectum of healthy women, dangerous to newborns; women are screened universally at 36-37 weeks gestation via vaginal rectal swab. Prophylactic oenecillin is given if status is unknown or if PROM occurs, mom has a fever greater than 100.4

Signs and symptoms of ectopic pregnancy

Abdominal pain, cullen's sign- umbilical bleeding, missed menses, positive pregnancy test, abnormal vaginal bleeding

Placenta accreta/increta/percreta

Abnormal attachment of the placenta to the uterus with different terms used to describe the depth of placental invasion- increta and percreta likely to result in hysterectomy

Velamentous cord insertion

Abnormal insertion of umbilical cord into membranes beyond placental edge, vessels not protected by whartons jelly

feeding cues for hunger

Licking or sucking movements, Lip smacking, Rooting, Hand-to-mouth movements, Sucking on fists, Increased activity, Crying (late sign)

augmentation of labor

Artificial stimulation of uterine contractions after labor has started but not progressed

Severe preeclampsia

BP > 160/110 * 2 while on bedrest Massive proteinuria > 5 g in 24 hours platelet count < 100,000 elevated liver enzymes; epigastric or RUQ pain Progressive renal insufficiency; serum creatinine >1.1 or doubling Pulmonary edema New onset of visual disturbances

Mild preeclampsia

BP of 140/90 * 2 or 15 higher than pre-pregnancy blood pressure proteinuria > 300 mg in 24 hours platelet count < 100,000 elevated liver enzymes new development of serum creatinine >1.1

Testing done during pregnancy for diabetes

Baseline renal function, UA and culture, A1c, non stress test 2 times a week in 3rd trimester

Reasons for urgent cesarean

CPD, dystocia, nonreassuring FHR

HIV/AIDS

Can be transmitted in pregnancy to the baby, risk is reduced if mother complies with antiviral medications and newborn has 4-6 weeks pf post-exposure HIV antiviral medication; testing should occur ASAP in pregnancy, rapid test if status is unknown

postmaturity syndrome

Condition in which a postterm infant shows characteristics indicative of poor placental functioning before birth. Also called dysmaturity syndrome.

Afterpains

Cramping pain after childbirth caused by alternating relaxation and contraction of uterine muscles; usually more mild for first birth; breastfeding causes more severe pain

Lochia rubra

Dark red discharge - 0 to 3 days

Diagnosis and treatment of cervical insufficiency

Diagnosed by OB history of preterm births or late miscarriages; treated by cerclage, bed rest, progesterone, anti inflammatory drugs, and close monitoring of pregnancy

Home management for preeclampsia

Diet: low sodium, daily weight, activity restriction, fetal kick counts, check for proteinuria, possible oral antihypertensive: methyldopa; nifedipine; hydralazine; labetalol, last trimester: NSTs; BPPs; US once or twice a week

Fetal fibronectin (fFN)

Glue like protein that connects amniotic membrane to the lining of the uterus and if detected between 22-37 weeks could signify increased risk of pre-term labor. Negative Result means 99% of women will not give birth in the next 1-2 weeks.

Diagnosis and treatment of placental abruption

Fetal blood in maternal circulation or in vaginal blood- check kleihauer betke, ultrasound, coagulation abnormalities; prepare for emergency C/S, blood transfusion, DIC if 50% or greater abruption,

What is oligo/poly hydramnios associated with

GI system and kidney problems in fetus

Contraindications to breastfeeding

HIV, active TB, certain medications, herpes or hep B lesions of nipples, galactasemia in infant

Hematoligic consideration postpartum

Hct and Hgb drop after delivery due to blood loss, WBC may increase above 15,000 and mask infection, clotting factors increase-risk for DVT

ABO incompatibility

Hemolytic disease that occurs when the mother's blood type is O and the newborn's is A, B, or AB- hemolysis of fetal RBCs Direct coombs tests for maternal antibodies in fetal blood- risk for jaundice Indirect coombs tests for materna; antibodies in maternal blood

Symptoms of eclampsia

Hypertension, proteinuria, edema, convulsions/seizures, coma, death

Treatment of hyperemesis gravidarum

IV fluid for fluid or electrolyte imbalance, antiemetics, Vitamin B6 with doxylamine (unisom), small frequent meals, high protein

management of prolapsed cord

Immediately restore perfusion by lifting presenting part, call for help, stat C/S

Cervical insufficiency

Incompetent cervix, early cervical dilation

Precipitous labor

Labor that lasts 3 hours or less from onset of contractions to time of delivery; risk factors include hypertonic contractions, oxytocin use, multiparous woman

Magnesium toxicity

Mag level Greater than 8 DTRs- sluggish or absent, flaccidity andmuscle weakness CNS depression Respirations < 12 Decrease urine output: less than 30 mLs per hour Chesk pain, EKG changes, Cardiac arrest, Pulmonary edema

Management of severe preeclampsia

Magnesium sulfate per protocol (4-6 g loading doase then 2g/hour) Therapeutic at 4-7 mEq/L

Emergency medications for preeclampsia

Magnesium sulfate, hydralazine, labetalol, nifedipine, calcium gluconate

interventions for postpartum hemorrhage

Massage fundus, Lactated Ringers, Blood administration, Pitocin, methergine, cytotec, hemabate, D&C, Hysterectomy

Complications of precipitous labor

Maternal soft tissue lacerations, amniotic fluid embolism, PPH, Fetal hypoxia, intracranial hemorrhage, bruised face.

Biophysical Profile (BPP)

Method for evaluating fetal status by assessing fetal heart rate NST, breathing movements, gross body movements, muscle tone, and amniotic fluid volume.

Maternal riskfactors for GDB

Obesity, EGWG - Excessive gestational weight gain, Physical Inactivity, Previous Macrosomia, Advanced Maternal Age, Hypertension, Family History of Diabetes, Stressful Lifestyle, Urbanization (more fast food, stress), Previous unexplained IUFD

Risk factors for dystocia

Overweight or short stature, Advanced maternal age, Uterine abnormalities, Malpresentation and position of fetus, Cephalopelvic disproportion (CPD), Uterine overstimulation with oxytocin, Maternal fatigue, dehydration and electrolyte imbalance, and fear, Inappropriate timing of analgesic or anesthetic administration (secondary powers), Abnormal uterine activity

Interventions for PROM and PPROM

PROM- after 37 weeks; estimate risk, determine if infection is present, induce labor PPROM- before 37 weeks; manage conservatively, bedrest, NST and BPP daily, 7 day antibiotics, monitor for early labor, placental abruption, and infection

Lochia serosa

Pinkish/brown, serosanguineous. Lasts day 4-10 postpartum

Complications of pitocin use

Placental abruption, Uterine rupture, Unnecessary cesarean birth, Postpartum hemorrhage, Infection, Fetal hypoxemia and acidemia

Hypothyroidism in pregnancy increases risk for what complications?

Preeclampsia, Placental abruption, Preterm birth, Low birth weight, Stillbirth, Impairments in fetal neurological development

Birth complications associated with diabetes

Preterm delivery, preeclampsia, birth trauma, shoulder dystocia, fractured clavicles, cesarean delivery

HELLP syndrome is associated with increased risk for what complications?

Pulmonary edema, Acute renal failure, Liver hemorrhage or failure, Disseminated intravascular coagulation (DIC), Placental abruption, Acute respiratory distress syndrome (ARDS), Sepsis, Stroke, Fetal and maternal death

What is the leading cause of maternal mortality

Pulmonary embolism

Pregnancy is contraindicated in women who have which cardiac conditions?

Pulmonary hypertension, marfan syndrome, eisenmenger syndrome

systemic lupus erythematosus (SLE)

Recommendations for pregnancy include inactive disease state for at least 6 months depending on the degree of known organ damage; In the pre-steroid era, it was common practice to terminate pregnancy in patients with active SLE Increased risk for PROM, growth restriction, LBW

SPASMS assessment tool for preeclampsia

Significant BP changes Proteinuria Arterioles are affected by vasospasms-edema results Significant laboratory changes Multiple organ systems can be involved Symptoms appear after 20 weeks gestation

Uterine assessment

Should be firm, midline immediately after delivery it will be 5 below-ish; rises back up to 1 above in 6-12 hours; 24 hours after it is at umbilicus and descends by 1 cm per day

Interventions for shoulder dystocia

Stop pushing, mcroberts position, suprapubic pressure, episiotomy, woods corkscrew

Engorgement interventions while bottlefeeding

Supportive bra, avoid stimulation, ice packs or cold cabbage leaves, analgesics, should subside in 24 hours

Magnesium Sulfate considerations

Therapeutic leves are 4-7; need continuous FHR and ctx monitoring, vital signs q15-30 mins; Assess LOC, I&O, urine output, proteinuria, DTR's, headache, visual disturbances, epigastric pain Crash cart, resuscitation equipment at bedside

TORCH infections

Toxoplasmosis Other (Hep B, syphilis, HIV) Rubella Cytomegalovirus Herpes torch infections cross the placenta and cause harm to the fetus

Disseminated Intravascular Coagulation (DIC)

Triggered by preeclampsia, HELLP, sepsis, amniotic fluid embolusm retained fetuc, placental abruption

spinal headache

When spinal fluid leaks through a tiny puncture site decreasing fluid pressure around brain and spinal cord which is described like a "headache like no other"; resolved with laying flat

Lochia alba

Yellowish, white cream color. Lasts approx 11 days-6 weeks postpartum

uterine rupture

a tear in the wall of the uterus, abnormal FHR tracing, loss of fetal station, abdominal pain, shock

Non-stress test (NST)

a test that monitors fetal heart rate in response to stimulation; reactive means normal reactive: 15bpm accells for 15 seconds 2 times in 20 minutes

signs of placental abruption

abdominal pain, bright red painful bleeding, board-like abdomen, uterine tenderness-knife like, fetal heart rate abnormalities- bradycardia and prolonged decells

Dystocia of fetal origin

anomalies, CPD, malposition, malpresentation, multifetal pregnancy

induction of labor

attempt to start the childbirth process artificially by administering a drug to start labor (prostaglandins, oxytocin) or by puncturing the amniotic sac

newborn weight loss

babies lose up to 10% of weight in first few days, should return to BW by 2 weeks

chorioamnionitis

bacterial infection of the amniotic cavity: maternal fever, fetal tachycardia, uterine tenderness, foul smelling amniotic fluid

Prerequisites for vacuum assisted birth

cervix fully dilated, engaged head, vertex presentation, ruptured membranes, no suspicion of CPD

Complications of PROM

chorioamnionitis, prolapsed cord

Twin-to-Twin Transfusion Syndrome (TTTS)

complication of blood supply in monochorionic twins with one twin receiving a deficient amount (the donor) and the other receiving too much (the recipient); fatal in 90% of cases without laser intervention

What to do for suspected PROM

confirm with ferning, pooling or amniosure; obtain sample for lung maturity testing

shoulder dystocia

delayed or difficult birth of the fetal shoulders after the head is born- turtle sign; can result in brachial plexus nerve injury, fractured clavicle, dislocated shoulder, hemorrhage, or rectal injuries

Diagnosis and treatment of molar pregnancy

diagnosed by ultrasound (snowstorm appearance); most will pass spontaneously, suction curettage; avoid pregnancy for 1 year following molar pregnancy

diagnosis and treatment for placenta previa

diagnosed through ultrasound; observation, bedrest, NO vagnial exams, cesarean birth

Diagnosis and treatment of ectopic pregnancy

diagnosed via transvaginal ultrasound; treated with methotrexate (chemical abortive agent), or saplingectomy (incision of fallopian tube and removal of fetal contents)

common postpartum medications

docusate sodium (Colace), bisacodyl (Dulcolax), lidocaine spray, witch hazel pads (Tucks), ibuprofen (Motrin), oxycodone and acetaminophen (Percocet)

Postpartum bradycardia

down to 50 bpm, normal in first 6-10 days due to changes in CO

Magnesium Sulfate education and antidote

educate patient that they will initially feel flushed, hot, sedated, nauseated. Notify if expericing epigastric pain or trouble breathing Calcium gluconate reversal

Engoregement treatment while breastfeeding

feed frequently, warm compress, analgesics, supportive bra

Meconium stained fluid

first stool of infant (meconium) is passed inutero. caused by fetal stress: hypoxia,cord compression, post maturity

polyhydramnios

greater than 2 L of amniotic fluid

HELLP syndrome

hemolysis, elevated liver enzymes, low platelets symptoms: N/V, epigastric pain, RUQ pain, headache, blurred vision, malaise, increased BP Only cure is delivery STAT

Rho (D) Isoimmunization

hemolytic disease of the newborn in which maternal antibodies attack fetal and neonatal RBCs in Rh- moms with Rh+ babies fetus develops RBC deficiency, bilirubin rises, neurologic disease, erythroblastosis (hydrops) fetalis, miscarriage may occur

Triad of symptoms preeclampsia

hypertension, edema and proteinuria

ectopic pregnancy

implantation of the fertilized egg in any site other than the normal uterine location; 95% occur in fallopian tube

placenta previa

implantation of the placenta over the cervical opening or in the lower region of the uterus, complete, marginal, or low-lying

Risk factors for PPROM

infection, history of conization or cerclage, low socioeconomic status, low BMI, nutritional deficiencies, smoking

Postpartum Bladder Assessment

interferes with uterine contraction if bladder is distended

Complications of molar pregnancy

invasive mole- grows into the muscular layer of the uterus; choriocarcinoma- monitor Hcg levels and monitor for carcinoma

LATCH score

latch audible swallowing type of nipple comfort hold

oligohydramnios

less than 300 mL of amniotic fluid

Preeclampsia

pregnancy specific syndrome, hypertension develops after 20 weeks gestation in previously normotensive women, vasospastic systemic disorder categorized as mild or severe; complicates 5-10% of pregnancies

uterine cord prolapse

presenting part compresses umbilical cord- caused by long cord, malpresentation, ROM before the head is engaged

Risk factors for preeclampsia

primigravida (8X risk), obesity, smoking, age extremes, diabetes, preexisting hypertension, vascular or renal disease, previous preeclampsia, family history of hypertension, african american, grand multiparity >5, multiple gestation

Reasons for STAT emergent C/S

prolapsed cord, abruption, fetal bradycardia, eclampsia

Indications for forceps assisted birth

prolonged 2nd stage of labor, maternal exaustion, abnormal FHR tracing, abnormal presentation, arrest of rotation, breech delivery

Signs and symptoms of hyperemesis gravidarum

prolonged vomiting, weight loss, dehydration, electrolyte imbalances, ketosis, malaise, low BP

Betamethasone (Celestone)

promotes fetal lung maturation, administered between 24-34 weeks. give 2 times in 24 hours

Interventions for afterpains

prone position, ambulation, sitz bath, mild analgesic

Intrahepatic cholestasis of pregnancy

pruritus (palms & soles), dark urine, light colored stools, elevated serum bile acids (LFTS), finally jaundice; may cause early meconium treatments: Ursodeoxycholic Acid, Benadryl, Monitor liver function (LFTs), Cool oatmeal baths, baking soda, delivery

Storage of breast milk

room temp for 4 hours, refrigerator for 4 days, freezer for 12 months; use within 24 hours of thawing and don't refreeze

Premature Rupture of Membranes (PROM)

rupture of amniotic sac and leakage of fluid at least 1 hour before the onset of labor

Postpartum BP

should be compared to 1st trimester reading; hypotension could result from hemorrhage, monitor for preeclampsia

Threatened abortion

signs of SAB present with intrauterine bleeding before 20 weeks, without dilation of cervix; fetus still alive and attached to the uterus

Cerclage

suturing of the cervix to prevent it from dilating prematurely during pregnancy, thus decreasing the chance of a spontaneous abortion; prophylactic: done at 12-14 weeks; resuce: done at 16-23 weeks; removed at 36 weeks

Eclampsia

toxemia; Seizure activity or coma in woman diagnosed with preeclampsia; no history of pre-existing pathology; eclamptic seizures before, during or after birth

Signs and symptoms of molar pregnancy

vaginal bleeding, significantly larger uterus than normal for gestational age, absence of fetal heart tones, positive pregnancy test, snowstorm appearance on ultrasound

Preeclamptic headache

visual disturbances

Risk factors for hyperemesis gravidarum

young age, nulliparity, under or overweight, low socioeconomic status, multiple gestation, deficiency in thiamine and vitamin B1, fetus with chromosomal abnormalities