Women's Health PAEA - Obstetrics

PPH during first 24 hr

"EARLY" PPH

PPH btwn 24hr and 6 week after delivery =

"LATE" PPH

congenital infection of CMV

*- intracranial calcifications - chorioretinitis* - microcephaly - intellectual disability and motor retardation - hemolytic anemia - sensorineural deficits

How do you treat PPH

*1*. UTERINE MASSAGE - controls most cases of hemorrhage due to atony. *2*. Start two large-bore IVs and infuse *isotonic crystalloids*. Type and cross blood. Monitor vitals, including ins and outs. *3*. Carefully explore the uterine cavity to ensure that all placental parts have been delivered and that the uterus is intact. *4*. Inspect the cervix and vagina for trauma/lacerations. *5*. If uterus is *boggy, suspect atony*: - Give additional dilute *oxytocin.* - *Methergine*—contraindicated: HTN. - *Carboprost* Prostaglandin F2α—contraindicated: Asthma. - *Misoprostol*. - ↓ uterine pulse pressure: - Uterine artery embolization. - Surgical exploration: Hypogastric artery ligation, uterine artery ligation, ligation of utero-ovarian ligament, uterine compression suture (B-Lynch stitch). - if all else fails --> Hysterectomy. (but make sure no coagulopathy) *6*. Consider coagulopathy if persistent bleeding with above management. Red top tube for clot retraction test. Normal coags if clot forms <8 min. Coagulopathy if no clot >12 min. Uterine packing until fresh frozen plasma and/or cryoprecipitate available. Hysterectomy (additional surgery) should be avoided in setting of coagulopathy.

Types of C section

*1. Low Transverse C Section* (LTC) - horizontal incision made in lower uterine segment - MC type *2. Classic* - vertical incision made in the contractile portion of uterine corpus performed when: - lower uterine segment is not developed (extreme prematurity) - fetus is transverse lie with back down - placenta previa present

What does reactive mean?

*15*bpm *above baseline lasting 15 seconds*; *2x/ 20 min*

How many arteries and veins are in the umblical cord?

*2* arteries, *1* vein normally

What is the RDA of zinc IN PREGNANCY?

*20mg*/day from 15.

your patient got a GCT and her glucose was *>140 but less than 200 (still abnormal)*. what do you want to do?

*3-hr GTT* - done if glucose challenge test is ≥ 140 and < 200: 1. *Unrestricted* diet for 3 days, carbohydrate load prior to test. 2. Fasting for 8-14 hr. 3. Draw fasting glucose level. 4. Give *100-g* glucose load. 5. Draw glucose levels at *1 hr, at 2 hr, and at 3 hr.* 6. Diagnosis of gestational diabetes made if two or more values are equal to or greater than those listed (see table) ----- *95, 180, 155, 140* -- FASTING, 1, 2, 3 - -- PART OF THE 2 STEP APPROACH

A 27-year-old woman at 37 weeks presents with a 2-day history of fever of 101°F (38.3°C), loss of fluid from the vagina, and diffuse abdominal tenderness. What is the most likely diagnosis? What is the gold standard for diagnosis? What is the most common cause? How is it treated?

*Chorioamnionitis* (infection of the amniotic fluid, membranes, placenta or decidua—also known as intra-amniotic infection). - *Amniotic fluid culture is the gold standard for diagnosis.* - *Most common cause is Group B streptococcus.* - It is treated with * IV antibiotics: ampicillin + gentamicin +/− clindamycin.*

How does FSH help distinguish between gonadal failure and hypogonadotropic hypogonadism?

*FSH is high with gonadal failure* [ trying to respond to low levels of estrogen] and low with hypogonadotropic hypogonadism

this stage of labor begins with the onset of uterine contractions of sufficient frequency, intensity, and duration to result in effacement and dilation of the cervix and *ends when the cervix is dilated to 10cm*. What stage is it?

*First stage of labor* ---- consists of 2 stages *1*. Latent: begins with onset of labor and ends at 4-6cm cervical dilation. - Nulliparous: prolonged if >20 hr - Multiparous: prolonged if >14 hr *2.* Active: rapid dilation. *Begins at 4-6cm and ends at 10cm*. Further classified according to rate of cervical dilation [1. acceleration phase 2. phase of maximum slope, and 3. deceleration]

A 26-year-old G2P0010 at 6 weeks by LMP presents to the ED with left-sided abdominal pain and vaginal bleeding. She reports no chest pain, dizziness, or shortness of breath. She had a positive home pregnancy test 2 weeks ago, but has not received prenatal care yet. She was treated for pelvic inflammatory disease 1 year ago. The serum β-hCG is 2000 mIU/mL. What is the next step that will help to confirm or exclude the diagnosis of ectopic pregnancy?

*Transvaginal ultrasound is the modality of choice and should be done next.* - The presence of an intrauterine pregnancy makes the risk of ectopic very low (not zero). - The TVUS may show an empty uterus, an early intrauterine pregnancy, or findings consistent with an ectopic pregnancy.

Criteria for PostPartum Depression/ Major Depression

*Two-week period* of *depressed mood or anhedonia* nearly every day *plus -one- of the following*: 1. Significant weight loss or weight gain without effort (or ↑ or ↓ in appetite). 2. Insomnia or hypersomnia. 3. Psychomotor agitation/ retardation. 4. Fatigue or loss of energy. 5. Feelings of worthlessness/excessive or inappropriate guilt. 6. ↓ ability to concentrate/ think. 7. Recurrent thoughts of suicide/death. ****Classified as postpartum depression if it begins with 3-6months after childbirth**

All vitamins except vitamin ______ are found in mothers milk.

*Vitamin K* - give to newborns to prevent hemorrhagic disease of the newborn Vitamin D: Breast milk alone does not provide infants with an adequate amount of vitamin D, even if mothers are taking vitamins containing vitamin D. Shortly after birth, most infants will need an additional source of vitamin D. To avoid developing a vitamin D deficiency, the American Academy of Pediatrics recommends breastfed and partially breastfed infants be supplemented with 400 IU per day of vitamin D beginning in the first few days of life. Vitamin D supplementation should be continued unless the infant is weaned to at least 1 liter per day (about 1 quart per day) of vitamin D-fortified formula. Any infant who receives <1 liter or 1 quart of formula per day needs an alternative way to get 400 IU/day of vitamin D, such as through vitamin D supplementation.

first trimester screening (FTS)

*also known as combined screening/ FTS*, is performed between *11-13 weeks of pregnancy* and involves an ultrasound and a finger-stick blood test - *screens for downs and trisomy 18* - *nuchal translucency* is measured via U/S [if *increased* --> sign of *downs*] - Maternal serum pregnancy associated plasma protein A (*PAPP-A*) - *free beta hCG* [[ THIS IS DIFFERENT THAN A QUAD SCREEN OBVIOUSLY JUST KNOW THAT BOTH CAN SCREEN FOR DOWNS!!]

neonatal sepsis from GBS <7 days after birth can or cannot be prevented with itnrapartum pphx abx

*can!!!* - results from vertical transmission - *first line for GBS pphx = penicillin* --- *if allergy = cefazolin* ----- if resistant to above = vancomycin

Management of Asymptomatic placenta previa

*if* diagnosed at routine *second trimester US*: - recommend *avoiding intercourse and vigorous exercise* - *repeat US around 28-32* weeks to see if resolves as the lower uterine segment develops *Delivery by c section btwn 36-37*

preexisiting or chronic HTN during preganncy must begin

*prior to pregnancy or before 20 weeks.* - sustained systolic BP of >140 and or diastolic BP >90 documented on more than 1 occasion PRIOR TO THE 20TH WEEK, HTN BEFORE PREGNANCY, OR HTN THAT PERSISTS >12 WEEKS AFTER DELIVERY.

this medical emergency may result form excessive cord traction during placental delivery. Can also be a result of abnormal placental implantation. Morbidity results from shock and sepsis. - 1/2200 deliveries

*uterine inversion* - *if a mass is palpated in the vagina immediately after the placenta delivers --> suspect uterine inversion. * tx: - call for help ("dont remove hand; hop on and go to OR') - give anesthesia - large bore IV - do not remove placenta until uterus has been replaced - stop uterotonic meds and give uterine relaxants - immediately try to replace inverted uterus by pushing on the fundus toward the vagina - oxytocin is given after uterus is restored to normal configuration and anesthesia is stoped.

Glucose Challenge test

- *at 24-28 weeks*: 1. Give *50-g* glucose load (*nonfasting state*). 2. Draw glucose blood level *1 hr later.* - If *≥ 140, a 3-hr glucose tolerance test (GTT) is then required to diagnose GDM.* - *If > 200, patient is diagnosed with GDM type A1 and a diabetic diet* is initiated.

how do you treat lupus in pregn?

- *high dose methyprednisolone in a flare*8 - azathioprine is an immunosuppressant that can be used safely in pregnancy ---- Cyclophosphamide, MTX, and mycophenolate motefil should be avoided or at least not started until after 12 weeks gestation. The risk and benefits should always be out weighed

Complication of pitocin?

- *hypOnatremia* - oxytocin is related structurally and functionally to vasopressin or *ADH*. leads to water intoxication. - hyperstimulation

how do you treat HPV warts in pregnancy?

- *trichloroacetic or bichloroacetic acid* applied weekly for external warts. - *cryotherapy* - *laser* NOT RECOMMENDED IN PREGNANCY - Podophyllin resin - Podofilox - F-fluorouracil - Imiquimod - interferon

management of second trimester pregestational diabetic

- 16-20 weeks: offer quad screen if first trimester genetic screen not performed - *18-20 weeks: targeted US to evaluate for anomalies then US every 4 weeks for growth*

When can a baby's heartbeat be detected with Doppler?

- 8-12 weeks of gestation - Fetal heart starts beating at 22-24 days

How do you manage eclampsia?

- ABCs - r/o other causes: head trauma, cerebral tumors, CVTs, drug ODs, epilepsy, CVAs - *control with MgSO4 (THE ONLY ANTICONVULSANT USED)* - delivery is definitive treatment; expectant management is not appropriate - *control BP with hydralazine or labetalol* - *Calcium gluconate is the antidote for Magnesium Sulfate toxicity.*

The AFI is the sum of amniotic fluid measured in four quadrants of the uterus via the US What are the values?

- AFI 5-25 cm: Adequate. - AFI ≤ 5 cm: Abnormal (oligohydramnios). - AFI ≥ 25 cm: Abnormal (polyhydramnios).

Pharmacologic agents for pregnancy termination

- Abortions in T1 and T2 can be performed with pharmacologic agents. *--- Prostaglandin E 2 (Dinoprostone), E1 (Alprostadil), F2α (carboprost)* - Typically used for T2 pregnancy terminations. - Can be administered orally or vaginally, depending on the type of prostaglandin. - Given every 2-6 hr until uterus evacuated. *Advantages*: Easy to use, can be safely used in women with prior cesarean delivery. *Disadvantages*: Diarrhea, fever. *--- Mifepristone (RU 486) and misoprostol* - Primarily used for T1 abortion. - Antiprogestin mifepristone 200 mg orally is followed by 800 µg buccal or oral misoprotol 24-48 hr later. - Ninety-two percent successful for pregnancy <49 days' gestation (7 weeks). - Seventy-seven percent successful for pregnancy 57-63 days' gestation (8-9 weeks).

Management of pregestational diabetic in third trimester

- Antenatal testing 32-34 weeks or when poor glycemic control - consider amniocentesis for fetal lung maturity and delivery at 37 weeks if poor glycemic control - consider delivery at 38 weeks without fetal lung maturity without amniocentesis if good glycemic control - consider cesarean delivery if estimated fetal weight is >4500g - start insulin drip in labor for glycemic control

assessment of the patient wishing to have induced abortion

- Confirm gestation age. US most reliable method and most commonly used. Definitive LMP date and pelvic exam consistent with suspected dates is acceptable in T1. Adequate dating helps determine legality of the procedure—states usually set gestational age limits. - Blood type and Rh type: If patient is Rh negative, anti-D immunoglobulins should be administered prophylactically. Careful patient counseling should be performed. Some states have mandatory requirements for waiting

If mother has hep B how do you prevent neonatal infection

- Give hep B immunoglobulin to infant upon delivery - give first of three hep B vaccines upon delivery - tell mother she can breast feed *if infant is given prophylaxis* [ most infection is due to ingestion of infected fluid in the peripartum or with breast feeding.]

Short term control of BP meds safe in pregancy

- Hydralazine (a/w lupus like rxn; HA, palpitations; is a vasodilator and is IV or PO) - Labetalol (nonselective alpha and beta blocker; a/w HA and tremor; is IV or PO)

Surgical Methods for pregnancy termination

- May be used in T1 or T2. - Dilation and evacuation (D&E): *T1:* Involves dilation of cervix and suction curettage of uterine contents. Sometimes referred to as dilation and *curettage* (D&C). *T2:* Involves dilation of cervix (osmotic, mechanical, pharmacologic) and *extraction of fetal parts* using various instruments. *--* Advantages: Less emotional stress for patient, avoid hospitalization, greater convenience. *--* Disadvantages: Need technical expertise, trauma to the cervix. Hysterotomy: Rarely performed unless contraindications to other methods.

What HTN meds are safe in pregnancy?

- Methyldopa - Labetalol (CI in asthma) - Hydralazine - Nifedipine (also used for tocolysis in preterm)

CANDIDIA

- PSEUDOHYPHAE ON MICROSCOPY - TOPICAL TX WITH ANTIFUNGALS IS PREFERRED - CAN GIVE PO FLUCONAZOLE

An amniocentesis may be performed to assess fetal lungs for risk of RDS in preterm labor . Fetal lungs are mature if

- Phosphatidylglycerol is present in amniotic fluid - Surfactant-Albumin in amniotic fluid at a ratio >55 - Lecithin-sphingomyelin in amniotic fluid at a ratio >2.

What is misoprostol?

- Prostaglandin PGE1 analog - can be administered Intravaginally or orally - used for cervical ripening and induction - can also be used for first trimester abortions (first trimester 0-~13 weeks)

- 2 week postoperative from repeat c section - swelling around incision site and increased tenderness - no relief w/ pain med - white malodorous drainage from incision - tolerating diet and voiding spontaneously - PE: afebrile, induration at surgical incision site 2cm and erythematous 3cm. Purulent drainage is noted from 1cm opening at right margin *WHAT IS THE MANAGEMENT? WHAT IS GOING ON?*

- Surgical Site Infection - step 1: differentiate superficial or deep - step 2: open wound and probed, evaluate if fascia is intact - step 3: cultures / gram stain should be obtained - step 4: IV antibiotics - step 5: wet to dry packing if superficial // may need debridement if necrotic tissue present (consider necrotizing fasciitis)

How do you determine dilation of the cervix?

- The index finger and or middle fingers are inserted in the cervical opening and are separated as far as the cervix will allow. - The distance (cervical dilation between 2 fingers is estimated)

What can cause false positives in a Nitrazine test?

- Trichomonas Vaginalis - Blood - Semen

PCOS can cause secondary amenorrhea. How do you diagnose PCOS?

- U/S - signs of androgen excess - oligomenorrhea/ secondary amenorrhea - other signs: obesity, acne, hirsutism, acanthosis nigricans, premature pubarche, precocious puberty - *serum testosterone inc* - Labs will show *high LH:FSH* due to *inc abnormal secretion of GnRH* - androgen excess

prenatal diagnosis of CMV

- US can show *microcephaly*, ventriculomegaly, intracranial calcification - PCR detects and quantifies viral DNA in amniotic fluid and fetal blood - confirm infection by measurement of serum IgM and IgG - if maternal primary infection confirm --> invasive prenatal testing with US and amniocentesis; can cause sensineural hearing loss

What agents are used to induce labor?

- Vaginal Prostaglandins are inserted for ripening / softening of cervix - IV pitocin is used to inc strength and frequency of contractions and also reduces maternal blood loss (half life of 5 min) - others: misoprostol; dinoprostone.

One step approach to dg GDM

- administer a *75g*--- *2 hr oral GTT* - *fast at least 8 hours* - draw fasting glucose level - give 75g glucose load - draw glucose at 1 hr and 2 hr - diagnosis of GDM made if one of the three values is elevated NEVER DONE TBH

Anti D immunoglobulins (IgG) (Brand name RhoGam)

- anti D immune globulins are collected from donated human plasma - when a mother is given a dose of anti d *IgG*, the antibodies bind to the fetal RBCs that have the D antigen on them and clear them from the maternal circulation. - the goal is to prevent the mothers immune system from recognizing the presence of the D antigen and forming antibodies against it - *give to D NEGATIVE mothers who have NOT formed antibodies against D antigen* - *NOT* indicated for pts who *already have anti-D antibodies* and *are sensitized* - indicated for patients who might be sensitized to other blood group antigen

Clinical criteria of antiphospholipid syndrome

- arterial and venous thrombosis - pregnancy morbidity: 1. at least one otherwise unexplained fetal death beyond 10 weeks 2. at least one preterm birth before 34 weeks 3. at least 3 consecutive spontaneous abortions before 10 weeks. - puerperium 1. IDA 2. acute blood loss

What helps N/V in pregnant women?

- avoid spicy or fatty foods - eating small, frequent meals - inhaling peppermint oil vapors - drinking ginger teas - *pyridoxine B6*, + antihistamine (*doxylamine*)

What is PGE2 Gel and vaginal insert?

- both contain *dinoprostone (prostaglandin)* - used for cervical ripening in women or at near term. - induction agent.

how do you manage severe pre-eclampsia in the mother who's fetus is preterm?

- close monitoring in hospital and in general deliver by *34 weeks or when maternal or fetal condition is unstable.* - delivery may not be in the best interest of the premature but may be indicated to prevent worsening maternal disease - vaginal delivery is attempted via induction; c section if necessary - start *MgSO4* - administer *steroids for lung maturity*

Management of PPROM

- consider amniotic fluid assessment for fetal lung maturity from vaginal pool specimen - U/S to assess GA, anomalies, presentation, and AFI - monitor for infection, abruption, fetal distress and preterm labor - if *<34wks gestation --> give steroids to decrease incidence of RDS* - give *mag sulfate* for neuroprotection if delivery is thought to be imminent

how do you manage placental abruption?

- correct shock (IV fluids, packed RBCs, FFP, cryoprecipitate, PLTs) - maternal o2 admin - expectant management or delivery: close obs with ability to intervene immediately - if there is fetal distress --> c section

What are some things that may induce DKA in a patient with type 1?

- corticosteroids for lung maturity - beta mimetics (for tocolysis; Terbutaline) - hyperemesis gravidum - infections

complications of uterine rupture

- death for both - hemorrhage for mother - cerebral palsy for fetus - hysterectomy for mother - neuro damage for fetus

Full term fetus; treatment for pre-eclampsia?

- delivery, vaginally is usually attempted via induction of labor; c section delivery for other indications - start MgSO4 for pphx of seizures

Trichomoniasis

- flagellated organisms seen on wet prep; - strawberry cervix - thick yellow-green frothy discharge. - complications: preterm delivery, PPROM - tx: PO metronidazole

What are some mechanical induction methods?

- foley balloon: passed through the internal cervical os into the extra-amniotic space, inflated and rested with traction on the internal os to cause dilation, - Laminaria: organic/synthetic seaweed material that slowly hygroscopically expands when paced in the cervix.

If the antibodies are known to cause harm to the fetus, what is the next step?

- get titers; critical titer occurs if the titer is at risk of HDN (hemolytic disease of the newborn)

Progestin Challenge Test

- give oral progestin for 10 days - if the endometrium has been primed with estrogen from ovaries or peripheral fat then the withdrawal of progestin after 10 days will cause endometrial sloughing *with resultant menses = no pathology* - *no menses --> absence of ovaries, estrogen deficiency or outflow obstruction. (obvious pathology) [d/t very low levels of estrogen]* if theres no menses after the test then the issue is within the ovaries.

how do you manage GDM

- glucose control log - *fasting glucose <95* - *2 hr post prandial (bfast, lunch, dinner) <135* - if *A1 (controlled with diet)* with continued inc in glucose --> start PO hypoglycemic agent (glyburide or metformin) or insulin - if *A2 (taking meds)* with continued inc in glucose, increase the doses of meds - if A2 on PO agent that is not insulin with continued inc in glucose; SWITCH TO INSULIN (duh) - *at 32-34weeks for A2 GDM*: -- fetal testing w BPP or twice weekly NST with AFI -- US for growth in the late third trimester and possibly early trimester as clinically indicated and depending on glycemic control

workup for third trimester bleeding

- history including trauma - vitals: signs of hypovolemia? hypotension? tachycardia? - labs: CBC, coags, type and screen, UA, drugs - US to look for placenta previa as well as fetal well being - determine whether the blood is fetal, mother, both (*APT TEST*)

Endocrine causes of Secondary Amenorrhea

- hypo/hyper thyroidism - diabetes mellitus - hyperandrogenism (neoplasm/ exogenous andoregens)

Puerperium care if episiotomy/laceration repair

- ice pack for first several hours to reduce edema - at 24hr postpartum, moist heat, (eg: via warm sitz baths) can decrease local discomfort - the episiotomy incision is typically well healed and asymptomatic by week 3 of puerperium - may require narcotic meds but NSAIDs or acetaminophen can help

If you suspect a episotomy infection, what should you do?

- look for pain at site, disruption of wound, and a necrotic membrane over wound - *rule out presence of rectovaginal fistula with careful rectovaginal exam* - open, clean and debride the wound to *promote granulation* tissue formation. - sitz bath - reassess for possible closure after granulation tissue has appeared.

laboratory criteria for antiphospholipid syndrome

- lupus anticoagulant - medium to high titers of anticardiolipid anitbody - anti beta glycoprotein - each of these findings must be present in plasma on at least 2 occasions >12 weeks apart

IUD post partum

- may be inserted immediately postpartum (this carries a higher risk of expulsion) or interval insertion 6 weeks postpartum

Combined oral contraceptive post partum

- may reduce the amount of breast milk - very small quantities of the hormones are excreted in the milk

Long term control of BP meds safe in pregnancy

- methyldopa (PO; false neurotransmitter; A/W *postural hypotension*, drowsiness, fluid retention) - nifedipine (PO, CCB a/w edema, dizziness

management of bleeding placenta previa

- most women who present with bleeding due to placenta previa can be managed conservatively and do not require delivery - severe bleeding should be managed by correcting shock and stabilizing; then C section

imperforate hymen; transverse septum

- normal breast and pubic hair - uterus present - *cyclic pelvic pain* due to menstrual blood not having an egress - *hematocolpos (accumulation of menstrual blood from the imperforate hymen.* - can be palpated as a *perirectal mass* on PE [*bulging blue mass at introitus*] - tx is to excise obstruction.

MVP in a pregnant woman

- normally asymptomatic - have a systolic click on PE (as always) - generally safe in pregnancy - consider pphx intrapartum for endocarditis

management of pregestational diabetic in preconception

- optimize glycemic control - HbA1c levels >10% are a/w significant increased risk of congenital malformations - folic acid 0.4mg / day during preconception and early pregnancy to decrease risk of NTDs - baseline 24hr for total protein and creatinine clearance - Ophthalmologic exam - ECG - TSH test

what is superimposed pre-eclampsia?

- pre eclampsia in pts with chronic HTN in pregnancy - defined by new onset of either proteinuria or end organ damage after 20 weeks in a woman with chronic HTN - for women with chronic HTN who have pre-existing proteinuria, superimposed is defined as worsening HTN or development of "severe features" - 25% of patients with chronic HTN in pregnancy develop pre-eclampsia!!

What causes secondary amenorrhea?

- pregnancy (MCC) - hypothalamus - pituitary - ovary - uterus - other: cervical/ endocrine

indications for c section

- prior c section - dystocia or failure to progress in labor - breech presentation - transverse lie - concern for fetal well being - uterine malformations/ scars

Depo-medroxyprosterone post partum

- progesterone containing injection - given every 3 months - should not reduce breath milk production or affect contents.

What can cause dystocia?

- prolonged latent phase - active phase abnormalities: cephalopelvic disproportion, excessive sedation, conduction analgesia, malposition. - protraction disorder: slow rate of cervical dilation or descent - arrest disorder: complete cessation of dilation or descent. [assess: contraction strength, fetal size and position, pelvis]

how do you tx hyperemesis gravidarum

- rule out other causes (molar, thyroidtoxicosis, GI etiology) - *First line: B6 with doxylamine* - IV hydration , thiamine/ electrolyte replacement, acid reducing meds, antiemetics (dramamine) - parenteral nutrition if necessary

pre-eclampsia with severe features

- severe BP elevation *>160/110* !!!!!!! [different from 140/90!!!] - neuro dsfx: HA, Scotoma, AMS - renal abnormality: *serum Cr >1.1 or doubling* [GET CMP!!!] - hepatic abnormality: epigastric or *RUQ pain*, inc *AST/ ALT > twice the normal level or both* [GET LFTS!!] - *Pr:Cr ratio of >0.3 or >300 protein /24hr or +1 protein on dipstick* - pulm edema - thrombocytopenia [GET CO AGS!!!]

When would a pt need an episiotomy?

- shoulder dystocia - operative vaginal deliveries 1. *Midline*: MC, from posterior fourchette. (inc risk of 4th degree perianal laceration) 2. *Mediolateral*: the incision is oblique starting from 5 o clock or 7 o clock position of vagina. *Causes more bleeding and pain*.

Aortic Stenosis in pregnant woman

- similar problems with MS - avoid tachycadia and fluid overload - give abx pphx

management of pregestational diabetic in first trimester

- start individualized insulin regimen - check fasting and 1hr post prandial glucose - viability US - offer first trimester genetic screen (FTS or cfDNA)

You suspect your patient has ruptured membranes. What tests do you want to perform?

- sterile speculum exam to assess for ----- 1. *pooling*: presence of fluid collection in the posterior fornix noted or not. 2. *valsalva*: ask the pt to bear down; see if fluid appears through cervical os opening 3. *ferning*: place a thin later of fluid on slide. View the dried fluid under microscope for a characteristic *ferning pattern* made by the crystallized NaCl in the amniotic fluid (positive ferning). Confirms ROM in 85-95% of cases. 4. *nitrazine*: asses pH. *Amniotic fluid is basic; will turn BLUE* unlike vaginal secretions which are acidic. --> if these are positive then the patient most likely does have ruptured membranes and the fluid is amniotic fluid

How do you treat chlamydia neonatal conjunctivitis?

... erythryomycin?? and Gonnorhea = IM ceftriaxone?

What is in a quad screen?

1) Maternal serum alpha-fetoprotein (*AFP*) - Elevated: assoc w/ open neural tube defects (anencephaly, spina bifida), abd wall defects (gastroschisis, omphalocele), multiple gestation, incorrect gestational dating, fetal death, and placental abnormalities (e.g. placental abruption) - Decreased: assoc w/ trisomy 21 and 18, fetal demise, and inaccurate gestational dating. 2) *inhibin A* - increased in downs 3) *estriol* 4) *B-hCG* - increased in downs *IDEALLY PERFORMED BETWEEN 16-18 WEEKS* remember 4x4=16

First trimester is

1-12 weeks

When can a pt be discharged after vaginal delivery?

1-2 days post delivery if no complications - tell to return to office at 4-6 weeks postpartum for exam

Management of *unsensitized* D neg patient (D negative mother with *negative antibody screen*)

1. *antibody screen should be done at the initial pre natal visit and again at 28 weeks* 2. if antibody screen is *negative, the fetus is presumed to be D positive and one dose of anti-D IgG immune globulin is given to the mother at 28 weeks to prevent development of maternal antibodies.* Anti-D immune globulin lasts for ~12 weeks and the highest risk of sensitization is in T3. 3. At birth, the infants D status is tested. If the infant is D neg, no antibody D is given to the mother. If the infant is positive, anti-D IgG is given to the mother within 72 hours of delivery. *The dose of anti-D IgG is determined by the KB test* 4. administration of Anti-D IgG at 28weeks gestation and within 72 hr of birth reduces sensitization to 0.2%

What are the 3 signs of placental separation?

1. *gush of blood from vagina* 2. *umbilical cord lengthening*; protrudes farther out of vagina 3. *fundus of the uterus* rises up and becomes *firm*

What are the 5 parameters for the cervical exam of pregnancy?

1. Dilation: opening of the cervix at external os (*0-10cm*) 2. Effacement: *length of cervix*. In labor it thins out and softens with the length reducing. When the cervix shortens by 50% (to around 2cm) it is said to be 50% effaced. When the Cervix becomes as thin as the adjacent lower uterine segment it is 100% effaced. 3. Station: *degree of descent* of the presenting part (usually the head) in the relation to ischial spine (0 station.) 4. Consistency: breakdown of collagen bonds in the cervix changes the consistency of the vervix progressively from *firm to medium to soft*, in preparation for dilation and labor 5. Position: location of cervix with respect to presenting part - *posterior, midposition, anterior* - usually progresses from posterior to anterior - Posterior: difficult to palpate because its behind presenting part and is high in the pelvis - Anterior: easy to palpate; low in pelvis

32 weeks visit

1. H&P 2. Fetal exam 3. urine dip

11-13 weeks visit

1. H&p 2. fetal exam: fetal tones 3. *urine dip: protein, glucose, leukocytes* 4. *first trimester screen (FTS) [nuchal translucency, bhcg, papp-a] OR cfDNA (cell free DNA)* - fundal height is usually barely above pubic symphysis

what are the 5 components of the biophysical profile?

1. NST: appropriate variation of fetal heart rate with reactive NST 2. Breathing: *>1 episode* of rhythmic breathing movements of *30 sec or more within 30 min* 3. Movement: *>3* discrete body or limb movements within 30 min 4. Muscle Tone: *>1* episode of extension with return to flexion or opening closing of hand 5. Determination of amniotic fluid volume: single vertical pocket of amniotic fluid measuring *>2cm is considered adequate*. *SCORING:* - Each category is given 0 or 2 points. 0: abnormal, absent, insufficient 2: normal and present as previously defined. - total number of points = 10 - equivocal = 6pts - abnormal <4

4 T's of postpartum hemorrhage

1. Tone (uterine atony) 2. Trauma (cervical, vaginal, perineal; episotomy) 3. Tissue (retained placenta, membranes) 4. Thrombin (coagulopathies; DIC)

what are the two main strategies to decrease vertical transmission of HIV

1. antiretroviral therapy - give maternal IV ZDV (ZIDOVUDINE) intrapartum 2. c section - especially if viral load >1000 copies

What do you do when you get an abnormal quad screen?

1. confirm US dates 2. genetic counseling + targeted US 3. diagnostic procedure such as amniocentesis to obtain fetal cells 4. karyotype analysis MCC of abnormal quad screen: incorrect dates

how do you manage toxoplasmosis

1. confirm diagnosis - seroconversion of IgG and IgM OR >4-fold rise in paired specimen - avidity IgG testing: if high avidity IgG found, infection in the preceding 3-5 months is exluded - PCR for t. gondii in amniotic fluid

week 38 vist

1. h&P 2. Fetal exam - heart, height, presentation** 3. Urine dip 4. Cervical exam (controversial)

First prenatal visit labs

1. h&p 2. Labs - H&h - Rh - blood type and screen - pap smear (if not UTD / and only if over 21yoa) - G+C cx - urine cx - *infection screen: Rubella, syphilis with RPR, Hep B surface antigen, HIV, TB!!!* - *Cystic Fibrosis screen* 3. Hemoglobin electrophoresis as needed 4. Discuss plan for genetic testing

26-*28* weeks visit

1. h&p 2. fetal exam 3. labs: CBC, Ab if Rh NEGATIVE, *GDM screen using 1 hour 50g GTT* (@ 24-28weeks), Urine dip. -- recheck antibody screen/ give anti D immunoglobulin/ *RHO GAM* if indicated (@ 28 weeks)

week 39 visit

1. h&p 2. fetal exam: heart, height, presentation 3. urine dip

week 40 visit

1. h&p 2. fetal exam: heart, height, presentation, urine dip

week 36 visit

1. h&p 2. fetal exam - *FIRST TIME YOU LOOK FOR FETAL PRESENTATION* !!!!!!!!!!!!!!! 3. urine dip 4. *GBS culture* (@35-37 weeks)!!!!!!!!!!!!!!!!!!!!!! 5. *STD panel including HIV* [mandated in some states]

16-20 weeks visit

1. h&p 2. fetal exam: fetal heart and fundal height 3. urine dip: protein, glucose, leukocytes 4. fetal US: anatomy, dating 5. QUAD SCREEN *if FTS or cfDNA NOT selected* [best 14-18wks] 6. Amniocentesis if indicated

Eisenmenger Syndrome 1. What is it? 2. What risks are there in pregnancy? 3. management in Pregnancy?

1. the change of a left to right shunt to right to left 2/3.. extremely dangerous; justifies termination of pregnancy on medical ground. Maternal mortality can be as high as 50% with death usually occurring post partum

what two conditions cause third trimester bleeding from fetal vessel rupture?

1. vasa previa 2. velamentous cord insertion

Leopold Maneuvers

1. what fetal part occupies the fundus? FUNDUS 2. on what side is the fetal back? BACK 3. what fetal part lies over the pelvic inlet? WHATS AT THE PELVIS 4. on which side is the cephalic prominence? WHERE IS THE HEAD

In Parvovirus B19 IgM is produced _________ after infection and persists for 3-6months

10-12 days

Second trimester is

13-27

- PRIMARY AMENORRHEA - 46 XX OR 46 XY - *decreased cortisol levels and adrenal/gonadal sex steroid secretion* - *HTN, Hypernatremia, Hypokalemia due to excess mineral corticoid* - need replacement sex steroids and cortisol - can achieve pregnancy with IVF in XX - *46, XY Breasts Absent, Uterus Absent.* - *46, XX Breast Absent, Uterus Present* [can carry with IVF]

17 alpha hydroxylase deficiency

When can a pt be discharged after c section?

2-3 days post delivery if no complications - tell pt to return in 2 weeks to check incision if needed and 4-6 weeks for postpartum exam like in vaginal delivery.

What is pre term?

20-36 weeks

When is surfactant produced?

28 weeks

Third trimester is

28-40 weeks or term

How much elemental *iron* is needed per day in T2 and T3

30mg

Air travel is not recommended after ____ weeks

35

when should pregn women be screened for GBS

35-37

What is full term?

37-42 weeks

What is the folic acid requirement in pregnancy to prevent NTD?

400ug/day (.4mg) is required. *Ideal if started 6 weeks before pregnancy*.

Your patient had a previous child with NTD, what is needed to prevent?

4mg/ day of folic acid strting 6 weeks prior to conception --> Trimester 1. (increased from the usual .4mg!!!!!)

Folic Acid requirement in pt with sickle cell?

4mg/day to accommodate for rapid cell turnover to prevent NTDs (nonsickle cell pt = .4mg)

β-hCG of 25 will have a positive urine pregnancy test. β-hCG of 1500-2000: IUP detectable with trans vaginal US. β-hCG of ___??___: IUP detectable with *abdominal US*

5000 --- If the quantitative β-hCG is >1500-2000 mIU/mL, and there is no evidence of an IUP, suspect ectopic pregnancy.

When can a postpartum mom start having sex again?

6 weeks.

What is an ideal PREPRANDIAL glucose for a pregestational diabetic woman preconception?

70-100mg/dL

what is brady for a fetus?

<110 caused by: - maternal beta blocker therapy - hypothermia - hypoglycemia - fetal heart block

What is an ideal POSTPRANDIAL glucose for a pregestational diabetic woman preconception?

<140mg/dL and <120mg/dL at 1 and 2 hr respectively

what is pre viable?

<24 weeks

What is an ideal Hba1c for a pregestational diabetic woman preconception?

<6

A transvaginal U/S can visualize a gestational sac when hCG levels are _____ _________

> 1500.

What is tachy for a fetus?

>160 bpm for >10 min caused by: - fetal hypoxia - IU infection - maternal fever - drugs

Trial of Labor After Cesarean (TOLAC)

An attempt to have a vaginal birth after a previous cesarean birth. - a/w small but significant risk of uterine rupture with poor outcome - candidates: one LTC, clinically adequate pelvis, no uterine scars or ruptures previously, physician immediately available to perform emergency CD if needed, availability of anesthesia and personnel for emergent CD (surgical team basically)

- PRIMARY AMENORRHEA - *XY* - *breasts present; uterus absent* - scant/ absent pubic hair. - *testes may be located intra-abdominally or in the inguinal canal and have an increased risk of malignancy* - normal male hormone levels - Remove gonads/testes after puberty to avoid risk of malignancy (gonadoblastoma or dysgerminoma) and to allow for breast development and adequate bone growth. - Estrogen is then given after removal - Raised as females.

Androgen Insensitivity - (Testicular Feminization.)

What is the most thrombogenic of the heritable coagulopathies?

Antithrombin 3

- intrauterine adhesions/scarring can obliterate the endometrial cavity causing secondary amenorrhea - MCC endometrial curettage a/w pregnancy - adhesions may form from myomectomy, metroplasty or C section - confirm dg with hysterosalpingogram (HSG) or hysteroscopy - tx: resection of adhesions. Estrogens to stimulate regrowth of endometrium

Asherman's Syndrome (Uterine cause of 2ndary amenorrhea)

how do you treat chlamydial conjunctivitis?

Azithromycin/ erythromycin PO

Amsel's criteria

BACTERIAL VAGINOSIS: replacement of normal lactobacillus with anaerobic bacteria like *gardnerella vaginalis* or mycoplasma hominis CRITERIA: - *homogenous white discharge* that coats vaginal walls - *clue cells* - vaginal pH *>4.5* - *whiff test (+)*: fishy odor when kOH added to discharge

How often should maternal VS be taken during labor?

BP and pulse should be evaluated and recorded every 10 min

What is the single most important characteristic of the baseline fetal heart rate?

Beat to beat variability - no BTBV = fetal *acidosis* and the fetus *must be delivered immediately*

At the completion of involution, the cervix does not resume its pregravid appearance. Before childbirth the os is _______. After childbirth the os is ____________

Before= os is small, regular, oval opening After= os is a horizontal slit

The _______ passes from the fallopian tube into the uterine cavity where it develops into a blastocyst as it freely floats in the endometrial cavity after conception.

Blastomere

Chadwicks sign

Bluish purple discoloration of the cervix, vagina, and labia during pregnancy as a result of increased vascular congestion. (*appears by 12 weeks!!!!*)

MCC of perinatal infection on the developed world

CMV - day care = mc source of infection - previous infection does not confer immunity

Any pregnant woman suspected of having PNA should undergo

CXR with abdominal shield

Intra-amniotic infection Risk factors: preterm labor, premature rupture of membranes, prolonged rupture of membranes GBSinfection at 18 hrs Rx: *ampicillin+gentamicin*

Chorioamnionitis

Most common medical complication of pregnancy?

Diabetes (pregestational and gestational)

seizure or coma without another cause in patient with pre-eclampsia

ECLAMPSIA - can lead to hemorrhagic stroke / death

how do you screen HIV

ELISA

A 20-year-old G1P1001 presents to the ED with right lower quadrant (RLQ) pain and vaginal spotting. She reports that her menses have been regular, except that she is currently 3 weeks late and her last menstrual period (LMP) was 7 weeks ago. She has a history of pelvic inflammatory disease, and she smokes one pack of cigarettes per day. Review of systems is positive for nausea and vomiting. Physical exam shows blood pressure 100/70, heart rate 90, and temperature 98.8°F (37.1°C). She has RLQ tenderness without rebound or guarding. Pelvic exam shows 5 cc of dark blood in the vault and right adnexal tenderness. Quantitative β-human chorionic gonadotropin (β-hCG) is 3000 mIU/mL. Ultrasonography (US) shows an empty uterus. What is the most likely diagnosis?

Ectopic pregnancy. All reproductive-age women who present with abdominal pain and bleeding should have a β-hCG performed. The quantitative β-hCG is at a level where an intrauterine pregnancy should be visualized in the uterus. Since the uterus is empty, the pregnancy must be in an ectopic location.

Intentional termination performed based on the woman's desire.

Elective termination of pregnancy

What are the cardinal movements of labor?

Engagement ->Descent ->Flexion -> *Internal rotation* -> Extension-> *External rotation* -> Expulsion

This analgesia block begins at the 8th thoracic level and extends to the first sacral dermatome (abdominal delivery) OR from the 10th thoracic level to the 5th sacral dermatome (vaginal delivery). What is it?

Epidural block

Why do patients with Gonadal Dysgenesis have phenotypical external and internal genitalia of a female?

Estrogen is not necessary for mullerian duct development of wolffian duct regression or the internal and external genitalia are phenotypically the same.

Most common heritable thrombophilia?

Factor V Leiden

T or F: mother with breast mastitis or even abscess need to stop breastfeeding.

False - typically in most cases they can continue to breast feed/ pump.

T or F epidural block decreases second stage of labor.

False. it prolongs the second stage of labor. - HAS NO EFFECT ON *FIRST* STAGE OF LABOR.

A 30-year-old G2P1001 at 24 weeks presents with a bright red rash on both of her cheeks that started yesterday. She reports a two-day history of fever of 100.4°F (38°C) and lethargy. On physical exam, she is afebrile and has a fine erythematous, lacelike rash on her arms. What is the most likely diagnosis? What is the risk to the fetus?

Flulike symptoms, slapped cheek rash, and fine reticular rash (erythema infectiosum) are a classic presentation for *parvovirus infection*. The fetus is at risk for aplastic anemia, which can cause *nonimmune hydrops and fetal death.* check for fetal anemia with MCA doppler

Non stress test evaluates what?

Four components of fetal heart tracing 1. Baseline: normally 110-160bpm 2. Variability: beat to beat irregularity and waviness of FHR. Presence reflects intact and mature brain stem and heart 3. Periodic changes: transient accelerations or decelerations. - Early: vaginally mediated; caused by *head* compressions - Variable decelerations: caused by *cord* compressions - Late Decels: reflect hypoxemia / placenta insufficiency 4. Reactivity - Accelerations: *at least two accelerations of at least 15 beats above baseline for 15 sec in a 20 min period reflects fetal well being. (reactive, reassuring)* - lack of/ nonreactive = baby may be asleep ( first try feeding or making mother drink to wake baby) if not reactive after 1-2 hours then further workup is needed. --> also records uterine contractions to help interpret NST

what degree of perineal laceration involves *rectal mucosa* and *exposes the lumen of the rectum*?

Fourth degree.

What should you do after delivery of the placenta?

Fundal massage to help the uterus contract down by increasing oxytocin and decrease the bleeding.

the following are risk factors for what? - age >35 - prior pregnancy involving this dz - FM history of this in a first degree relative - obesity (BMI >30) - previous infant >4000g (8 and 3/4 lbs) - hx of still birth/ child with cardiac defects - race: black, hispanic, native maerican

GDM

Hepatic abnormality a.w *pre-eclampsia* causes epigastric or *right upper quadrant pain* (hepatocellular ischemia and edema that stretches _______?????_______, *↑ aspartate transaminase (AST), alanine transaminase (ALT) ≥ twice the normal level*, or both.

Glisson's capsule

- PRIMARY AMENORRHEA - ovaries are replaced by band of *fibrous tissue called gonadal streak* - due to absence of ovarian follicles there is no synthesis of ovarian steroids. - no estrogen =/= breast development - *FSH and LH are markedly elevated* due to *dec levels of estrogen* - Body is not provided the negative feedback needed to dec FSH and LH levels.

Gonadal Dysgenesis

the number of times a woman has been pregnant regardless of outcome

Gravidity

Hemolysis; elevated liver enzymes; low platelets

HELLP - may occur with OR without HTN

what is gestational HTN

HTN *without proteinuria or other signs of pre eclampsia* - sustained or transient systolic *BP of >140* and or *diastolic >90* that occurs *AFTER 20 WEEKS*

- Secondary Amenorrhea; _______________ - *low levels of gonadotropins*, estrogen, *absent withdrawal bleed with progesterone* - caused by Lesions, Drugs, Stress and Exercise, Weight Loss/ Anorexia, Functional Hypothalmic Amenorrhea (rare)

Hypothalamic

how do you treat neonatal gonococcal conjunctivitis

IV/IM ceftriaxone

During labor, when would you perform a sterile vaginal exam with speculum?

If you suspect - rupture of membranes (water broke!) - preterm labor - bleeding that is suspicious for placenta previa OTHERWISE, a sterile digital Vaginal Exam may be performed. -- keep at a minimum. Every 4 hr in latent phase and every 2 hr in the active phase.

Intentional termination of pregnancy before 20 weeks' gestation.

Induced Abortion (Pregnancy Termination)

Pt with DM in labor should get what for glycemic control?

Insulin Drip.

this reaction may occur with penicillin treatment. - uterine contractions - late decelerations in the fetal heart rate - d/t the dead spirochetes occluding the placental circulation.

Jarisch-Herxheimer --- happens in pregnant women with syphilis

this test detects fetal-maternal hemorrhage in Rh-negative mothers - 300 μg of anti-D immune globulin neutralizes 30 mL of fetal whole blood or 15 mL of Rh-positive RBCs.

Kleihauer-Betke

Cervical contractions that result in cervical change is defined as

Labor

- contraceptive method - 98% effective for up to 6 months if 1. mother is not mestruating 2. mother is nursing >2-3 times a night and more than every 4 hours during the day without supplementation 3. baby is <6 months old

Lactational Amenorrhea Method of Contraception: exclusive breast feeding to prevent ovulation.

Treatment of hypothyroidism in pregnancy

Levothyroxine Replacement - TSH is monitored every 8 weeks after initiation of tx or a change in dosage - TSH is monitored every trimester if no change in med is needed due to INCREASED THYROXINE REQUIREMENTS IN ADVANCING PREGNANCY

Mothers not previously immunized against/not immune to rubella should be vaccinated prior to discharge and not during pregnancy. WHY?

MMR is a live virus

Gestational DM causes ___________ especially when fasting glucose is high.

Macrosomia

what is given for seizure prophylaxis in patients with pre-eclampsia when the decision is made to deliver the fetus or when expectantly managing pt with severe preeclampsia

Mag sulfate --- IT IS NOT A TX FOR HTN

___________ is an option for treatment of an unruptured early ectopic pregnancy. Antimetabolite. Inhibits dihydrofolic acid reductase. *Interferes with DNA synthesis.* Treatment of certain neoplastic diseases, rheumatoid arthritis, psoriasis, and ectopic

Methotrexate (MTX) - must be <3.cm in size - must be hemodynamically stable -bhcg <5000 - NO fetal cardiac activitiy - Laparotomy if patient is hemodynamically unstable: Enter into the peritoneal cavity via a large incision on abdominal wall. Place two large-bore IVs to administer normal saline and type and cross for blood. Most commonly used for hemodynamically unstable patient. Fast access and minimal equipment needed. - Laparoscopy if patient is hemodynamically stable: Entry into peritoneal cavity via small incisions and visualization of abdominal and pelvic organs with a small camera. Can be diagnostic (only visualize) or operative (perform surgical procedures). - Salpingectomy: Removal of the affected fallopian tube. Performed to treat ruptured ectopic or severely damaged tube. - Salpingostomy: Incision on the antimesenteric portion of the tube. Used for unruptured distal tubal ectopic pregnancy. Allows pregnancy to be removed while sparing the tube. Should follow the β-hCG down to zero as some pregnancy tissue may be left behind and continue to grow, which can cause a chronic ectopic

A 30-year-old G2P1001 at 6 weeks presents to the ED with vaginal spotting and right lower quadrant pain. She reports no medical problems, prior surgeries, or substance abuse. She is afebrile with stable vital signs. She is tender in the right lower quadrant without rebound or guarding. Serum β-hCG is 4000 mIU/mL. TVUS shows an empty uterus with a 2.5-cm hyperechoic ring consistent with an ectopic in the right adnexa. There is a small amount of fluid in the cul-de-sac. What is the best treatment for this patient?

Methotrexate. This hemodynamically stable patient has findings consistent with an ectopic pregnancy. With methotrexate, she avoids risks of surgery and can preserve the fallopian tube. *Criteria for use of MTX:* - hemodyanmically stable - ectopic <3.5cm in size - pt reliable for follow up - IUP ruled out - no fetal heart activity - bhCG <5000

- PRIMARY AMENORRHEA - *XX* - *no uterus* - shortened vagina - *normally functioning ovaries; normal female levels* - *normal breast development* - normal axillary and pubic hair - a/w renal and skeletal abnormalities and should be screened with an U/S or MRI - normal endocrine function - do not need supplemental hormones - may need surgery to make vagina functional.

Mullerian Agenesis (Mayer-Rokitansky-Kuster-Hauser Syndrome)

The nonisoimmunized D (Rh) _________ mother whose baby is D *positive* is given 300ug of anti D immune globulin (RHO GAM) within 72 hours of delivery.

NEGATIVE - RhoGAM is one brand of Rh immunoglobulin (RhIg)

When does implantation occur?

On day *5-6 after ovulation* - the blastocyst adheres to the endometrium with the help of adhesion molecules on the secretory endometrial surface. - After attachment, the endometrium proliferates around the blastocyst.

breasts absent, uterus present have no ______________ ___________.

Ovarian Estrogen

Clomiphene citrate is highly effective as the first line treatment for infertility in

PCOS. It can be accompanied with metformin, weight loss, exercise, and exogenous gonadotropins when clomiphene fails.

blood loss >1000 in c section (difficult to quantify)

PPH

blood loss >500mL in vaginal delivery

PPH

TOC of hyperthyroidism in pregnancy

PTU

the number of times a woman has been pregnant that lead to a birth *after 20 weeks* gestation *or an infant >500g*

Parity

what is the TOC of syphilis

Penicillin is the treatment of choice for all stages of syphilis (same as nonpregnant patients) - If patient is penicillin allergic, then she must be desensitized and still treated with penicillin.

- Secondary Amenorrhea; ______________ - caused by Neoplasms at the site of concern OR lesions such as hemorrhage, destruction from anoxia or thrombosis, - may be a/w dec section of other hormones produced/ secreted at the site like ACTH, TSH, LH, FSH (hint hint)! - Sheehan Syndrome - Simmonds Disease

Pituitary!; Hypoestrogenic Amenorrhea

abnormal *implantation of the placenta in the uterus* - *can cause retention* of the placenta after delivery (PPH) and *heavy bleeding*. - 3 types. - a/w placenta previa, previous c section, previous d&c, grand multiparty. What are they?

Placenta Attachment Disorder - *placenta accreta* - *placenta increta* - *placenta percreta* Accreta = Attaches Increta = Invades Percreta = Penetrates

US reveals an anterior placenta previa in patient with two prior c sections. What are you suspicious of?

Placenta accreta

A 28-year-old woman at 35 weeks' gestation is brought in by ambulance following a *car accident*. She is complaining of severe abdominal pain, and on exam she is found to have vaginal bleeding. An US shows a *fundal placenta* and a fetus in the cephalic presentation. What is most likely the cause?

Placental abruption. - PS: Microangiopathic hemolytic anemia seen on maternal blood smear. What is occurring? - *Disseminated intravascular coagulation (DIC).* What is the next step? - Transfuse blood products (PRBCs, platelets, FFP) and expedite a vaginal delivery. Want to avoid major surgery in the setting of DIC.

What causes uteroplacental insufficiency? (the cause of late decels)

Placental insufficiency is linked to blood flow problems. - While maternal blood and vascular disorders can trigger it, medications and lifestyle habits are also possible triggers. - *The most common condition linked to placental insufficiency* *= diabetes.* -- can also follow epidural which induces hypotension**

- Depletion of oocytes resulting in secondary amenorrhea before the age of 40 - idiopathic but can be caused by *radiation or chemo/ autoimmune dz/ fragile x / turner's* - tx: hormone replacement/ bone protection

Premature Ovarian Failure

A 24-year-old G3P1102 at *38 weeks* presents to triage with a complaint of leakage of fluid from the vagina. She reports good fetal movement, no vaginal bleeding, and no contractions. She is afebrile. *Sterile speculum exam* demonstrated a *pool of fluid* in the vagina which is *nitrazine positive* and shows *ferning* on glass slide exam. On exam, her cervix is 1 cm and long. Fetal heart rate (FHR) is reassuring, and no contractions are noted. What is the diagnosis?

Premature rupture of membranes (PROM) is diagnosed when the membranes rupture prior to the onset of labor. Rupture of membranes is *confirmed by the sterile speculum exam*. Based on the cervical exam and the absence of contractions, the patient is not in labor. Considering that the *fetus is term*, the next step should be induction of labor in order to prevent chorioamnionitis.

absence of menses by 16 years old with normal growth and secondary sexual characteristics *OR* absence of menses by age 13 with no secondary sexual characteristics

Primary Amenorrhea

What has an inhibitory effect on *production* of milk?

Progesterone

What oral contraception has no effect on breast milk contents and minimally reduces the mount of breast milk?

Progestin only pill - typically start 2 weeks postpartum - does not release hormone into milk

What stimulates milk production?

Prolactin

MC pruritic dermatosis in pregnancy

Pruritic Urticarial Papules and Plaques of Pregnancy (PUPPP) tx: oral antihistamines and topical steroids are the mainstays

which is more common R or L hydronephrosis in pregnancy?

R

Three or more successive clinically recognized pregnancy losses prior to 20 weeks gestation.

RECURRENT ABORTION (RECURRENT PREGNANCY LOSS—RPL) MANAGEMENT Investigate possible etiologies. Potentially useful tests include: Karyotype of abortus. Parental karyotypes: Balanced translocation in parents may result in unbalanced translocation in the fetus. Sonohysterogram, hysteroscopy: Evaluate uterine cavity. Immunologic workup: Anticardiolipin antibodies and lupus anticoagulant. Thyroid function tests.

this stage of labor is the stage of fetal expulsion. It begins when the cervix is fully dilated and ends with the delivery of the fetus. What stage is it?

Second stage - Nulliparous: <2 hours and 3hr with epidural - Multiparous: <1 hour and 2hr with epidural

absence of menses for >6 months in a woman who previously had normal menses. Usually caused by underlying medical condition.

Secondary Amenorrhea

- Pituitary cell destruction occurs due to *hypotensive episode* during pregnancy (usually due to catastrophic hemorrhage) - leads to secondary ammenorhea - tx: replacement of pituitary hormones - aka pituitary necrosis

Sheehan Syndrome

- similar to sheehan's syndrome - pituitary damage except NOT related to pregnancy like Sheehans'

Simmonds Dz - can cause secondary amenorrhea

Most common procedure for pregnancy termination also Safest surgical pregnancy termination method.

Suction curettage (D&C)

How do you treat toxoplasmosis

Sulfadiazine + pyrimethamine = presumptive tx in late pregnancy - spiramycin - no vaccine

One screening test should be followed by one confirmatory test for this dz. - Screening tests: *Rapid plasma reagin (RPR)* or Venereal Disease Research Laboratory (VDRL) - Confirmatory tests: *Fluorescent treponemal antibody absorption test (FTA-ABS)* or Microhemagglutination assay (MHA-TP) what disease????

Syphilis other --- US findings: Edema, ascites, hydrops, thickened placenta.

T or F: by 1 week postpartum, blood volume has returned to patient's nonpregnant range

TRUE.

-PRIMARY AMENORRHEA 45, x - primary amenorrhea + absent breasts - short stature, webbed neck, short fourth metacarpal and cubitus valgus - cardiac abnormalities like coarctation of aorta/ renal / hypothyroidism - given estrogen and progesterone at puberty to allow secondary sexually characteristics to develop.// may receive growth hormone.

TURNER'S SYNDROME; gonadal dysgenesis

how do you screen for GDM

TWO STEP APPROACH (24-28 wk) 1. glucose challenge test to identify patients at high risk 2. diagnostic test ONE STEP APPROACH [not really done ever] 1. one step diagnostic test; omit screening

Post Delivery causes of fever

The 5 W's + B 1. Wind: Atelectasis, 1-2 days postop 2. Water: Urinary tract infections, 2-3 days postpartum 3. Wound: Surgical site infection—cellulitis, purulence, fluctuant, tenderness; 5-7 days postpartum - Cesarean: Abdominal incision - Vaginal: Episiotomy 4. Walking: Deep vein thrombosis (DVT) and subsequent pulmonary embolus, 4-10 days postpartum 5. Wonder drugs: Drug fever, 7-10 days postpartum + Breast: Engorgement, mastitis, abscess, 3 days-4 weeks postpartum

A 35 year old G4P2012 at 26weeks is diagnosed with anti-Kell antibodies with the titer of 1:32. Amniocentesis shows that the fetus is positive for the Kell antigen. In addition to antenatal testing, what other *testing* is critical for this fetus?

The fetus should be monitored with *middle cerebra artery dopplers which can indicate the severity of the anemia.* -- critical titer 1:16 !

An 18-year-old G1P0 at *30 weeks* presents to triage with complaints of clear fluid leaking from her vagina. *Her exam is positive for pooling, ferning, and nitrazine.* The cervix is visually closed on sterile speculum exam. FHR is reassuring, and no contractions are noted. The US shows a breech singleton fetus. What is the next step in management?

The patient has *preterm* premature rupture of membranes (PPROM). - She should be admitted to the hospital. - *Steroids should be administered to ↓ the risk of RDS in the fetus* - antibiotics should be given to ↑ the latency period.

A 25-year-old G3P1011 presents to the ED with fever, lower abdominal pain, and *foul-smelling discharge*. She *reported having a medical termination of pregnancy 6 days prior.* Her temperature is 101.1°F (38.3°C), blood pressure 110/70, pulse 100, and respiratory rate 18. On physical exam, she appears lethargic and ill. She has lower abdominal tenderness, and sterile speculum exam shows a *copious amount of foul-smelling discharge* in the vagina. Bimanual exam reveals uterine tenderness and no adnexal masses. The cervix is dilated 1 cm and thick. Complete blood count (CBC) shows a *white blood cell count (WBC) of 20K*. US shows a large amount of *heterogenous tissue in the uterus*. What is the most likely diagnosis? What is the best treatment for her condition?

The patient has a *septic abortion* and should receive broad-spectrum IV antibiotics and a D&C. - *Infected POC are present.* - Less likely to occur with spontaneous abortion, and more likely to occur with induced abortion. - The infection is usually polymicrobial. Infection can spread from endometrium, through myometrium, to parametrium and sometimes to peritoneum. - Septic shock may occur.

Intentional termination performed to maintain maternal health.

Therapeutic abortion

When does pregnant woman receive Tdap?

Third Trimester. Begins in *week 28* of pregnancy and lasts until you give birth.

What degree of perianal laceration involves the anal sphincter?

Third degree. (2nd is fascia and muscle BUT NOT ANAL SPHINCTER)

T or F: *cardiac output is higher* in *puerperium than in pregnancy for >48 hours post partum* due to decreased blood flow to the uterus and increased systemic intravascular volume

True

T or F: ACE inhibitors are teratogenic

True

T or F: plasma fibrinogen and ESR are elevated for >1 week postpartum

True - this is normal!

T or False: prophylactic use of antibiotics is recommended during C sections

True! IV cefazolin is commonly used.

T or F: CMV, HBV and HIV are excreted in breast milk?

True. - *Only HIV is a contraindication to breast feeding.* (along with other things like TB, Herpetic breast infection, certain meds etc etc) - HBV isn't contraindicated *if baby got vaccinated* - For CMV, both the *antibodies and antigens* are secreted in breast milk.

T or F: Leukocytosis is common during and after labor?

True. - up to 30,000!

What is a Nitrazine test?

Used to detect the presence of amniotic fluid. (water broke/ ruptured membrane) - Vaginal secretions have a pH of *4.5-5.5 (acid)* and do not affect the Nitrazine strip or swab. - *Amniotic fluid* has a pH of *7-7.5 (basic)* and turns the Nitrazine strip *blue.*

A 37-year-old G6P6006 with a history of asthma and chronic hypertension undergoes a spontaneous vaginal delivery of a 4500-g infant. After the placenta delivers spontaneously, profuse vaginal bleeding was noted from the vagina. Pitocin is given, fundal massage is performed, and large clots are removed from the uterus. No lacerations are noted. Estimated blood loss is 700 cc. What is the most likely cause of the bleeding? What is the next step in management

Uterine atony is the most likely cause for this patient's postpartum hemorrhage. - Prostaglandin F2α(CARBOPROST) (asthma) and methergine (hypertension) are contraindicated due to her medical conditions. - The next best agent is *misoprostol* These drugs INDUCE CONTRACTIONS OPTIONS FOR PPH - oxytocin - carboprost - methergine - misoprostol

Hegar's Sign

Uterine isthmus softening *@6-8 weeks* goodells sign = cervical softening due to inc vascularization ~ 4-5 weeks

varicella zoster post exposure prophyalxis

VZIG (varicella zoster immune globulin) - within 10 days of exposure is indicated for those who are exposed and susceptible

What is preferred in a pregnant woman with cardiovascular dz? vaginal delivery or c section?

Vaginal

how do you confirm HIV

Western blot and or PCR

if herpes lesions or prodromal symptoms are present at the time of labor.......

a c section must be performed to decrease the risk of vertical transmission

Colostrum

a specialized form of milk that delivers essential nutrients and antibodies in a form that the newborn can digest

pregnant woman + bleeding + pain =

abruption until proving otherwise

what is the result of mullerian failure?

absent uterus

Naegele's Rule

add 7 days to LMP, subtract 3 months, add 1 year to find EDD

Patient's older than 35 have an indication for _________ because they have a higher risk of aneuploidy

amniocentesis; karyotyping.

If *IgM POSTITIVE* in parvovorus B19, what should you check for via MCA doppler

anemia

what antibodies threaten the fetus

anti D, anti Kell, anti Duffy "Lewis Lives, Duffy Dies, Kell Kills"

What antibodies pose no threat to the fetus

anti lewis

D negative mother with negative antibody screen: If the infant is positive....

anti-D IgG is given to the mother within 72 hours of delivery.

How do you treat DVT in preg

anticoagulant with unfractionated or LMWH - heparin should be suspended during labor and delivery - ok to convert to warfarin post partum (DO NOT USE DURING PREGNANCY)

what should you not do in shoulder dystocia

apply fundal pressure

What is cephalopelvic disproportion?

been used to describe disparity between the size of the maternal pelvis and fetal head that precludes vaginal delivery - leads to: failure to progress and c section

How do you treat uncomplicated CAP in pregnant woman?

beta lactam (ceftriaxzone, cefotazime, ampicillin-sulbactan) PLUS azithryomycin -- vanc is added for CAP MRSA

what follows a morula?

blastomere

What is breech?

butt first vertex is head first. (MC; head is presenting part)

Pt with DM, estimated fetal weight is >4500g... what should you do?

c section

septate uterus is a congenital malformation of the uterus that

can cause ectopic pregnancy other risk factors for ectopic: - DES exposure - IUDs - current smoking - PID/ tubal scarring - previous ectopic - assisted reproductive technology

pulmonary hypoplasia and PROM

can occur if PROM occurs at *<24weeks d/t oligohydramnios* bc theres like no surfactant (surfactant is produced at 28wks) - low chance of survival

What is the CNS anomaly most specific to DM

caudal regression

first step in management of isoimmunized pregnant patient?

check the paternal erythrocyte antigen status

neonatal conjunctivitis day 5-7

chlamydia MCC of opthalmia neonatorum!!!!!!

fetal hydrops is defined as

collection of fluid in two or more body cavity - scalp edema - pleural effusion - pericardial effusion - ascites

- complete passage of POC - cervical os is closed - *pain has ceased*

complete abortion

- BP *>140/ >90* twice at least 4 hours apart. AND - *proteinuria: 1+ on dipstick* - OR *>300 mg/24hr* - OR *protein/creatinine ratio of >0.3*

criteria for pre-eclampsia in pregnant patients with new onset HTN *without proteinuria*, a new finding of any of the follow is also diagnostic: - *thrombocyotpenia (PLT <100,000)* - *Serum creatinine >1.1 or doubling of serum creatinine* - *LFTs at least twice the normal concentration* - pulm edema - cerebral or visual sx (HA, scotoma)

pre-eclampsia

defined as new onset HTN (140/90) with either proteinuria or end organ damage or both *AFTER 20 WEEKS*. (protein no longer required to diagnose preeclampsia with severe features)

how do you tx preeclampsia?

delivery

What occurs in the third stage of labor?

delivery of the placenta. Usually begins immediately after delivery of fetus. Usually only <10 min long and is considered prolonged if >30min

Bishop Scoring

determines favorable or unfavorable cervix successful or not for vaginal delivery. - score *>6* indicates that probability of vaginal delivery with induction of labor is similar to that of spontaneous delivery.

gestational DM

develops during pregnancy - white classification A1: controlled with diet - white classification A2: requires insulin or oral agents

pregestational DM

diagnosed prior to pregancy

How do you treat mastitis?

dicloxacillin

What does dystocia mean?

difficult labor; characterized by abnormally slow or no progress of labor

In normal pregnancy, total T3 and t4 and Thyroid binding globulin are elevated but free thyroxine levels

do not change. (euthyroid)

women with epilepsy taking anticonvulsants during pregnancy have ____ the general popular risk of fetal malformations and preeclampsia

double think of how anticonvulsants can cause NTDs etc. etc.

nuchal translucency is increased, *PAPP-A is decreased*, free bHCG (FTS) is increased.. what is suspected?

downs

*double bubble* sign of *duodenal atresia* found on US is a marker for

downs syndrome

MC indication for primary c section?

dystocia/ previous c section

ingestion of caffeine >300 mg/day may inc risk of

early spontaneous abortion among nonsmoking women carrying fetuses of normal karyotype. The risk increases according to amount of caffeine ingested.

If hCG is >1500 and there is no evidence of IUP on transvaginal U/S what do you suspect?

ectopic pregnancy

- fever - fundal tenderness - foul smelling lochia - absence of other findings (pyelo, mastitis, PE) - Risk factors: hx of *c section*; multiple vaginal exams, long labor course; *GBS colonization* What is it?

endometritis - infection involving the deciuda which may involve the myometrium and parametrial tissue - typically develops 2-3 days postpartum - Treatment is: *Post cesarean section: Clindamycin + gentamicin* *Post vaginal delivery: Ampicillin + gentamicin*

What is bloody show

extrusion of cervical mucus: *consequence of effacement and dilation* of the cervix with tearing of the small vessels leading to small amount of bleeding that is mixed with cervical mucus. Benign finding. - Often used as a *marker for the onset of labor.*

How do you diagnose pregestational DM?

fasting glucose >126 and random glucose >200

anti ro (SS-A) and anti-La (SS-B) is a.w what?

fetal congenital heart block - a/w lupus

whose blood is lost with ruptured vasa previa?

fetal-placental circulation more than maternal

- young woman has 18-20 week size uterus - negative pregnancy test what is the most likely diagnosis?

fibroid uterus

VEAL CHOPS

for fetal heart tracings // NST

MCC of primary amenorrhea ?

gonadal dysgenesis

neonatal conjunctivitis day 2-5

gonococcal

Pregestational DM causes __________ ____________ especially due to concurrent maternal vascular dz.

growth restriction

posterior arm delivery

hand is inserted into vagina and posterior arm is pulled across chest, delivering posterior arm and shoulder - creates a shorter distance btwn anterior shoulder and axilla, allowing the anterior shoulder to be delivered.

what is the most common single defect of Rubella (GERMAN MEASLES)?

hearing loss - CONGENITAL RUBELLA SYNDROME: cataracts, congenital glaucoma, hearing loss

Hep b should be screened for at *first prenatal* visit *and at delivery* of fetus with

hep B surface antigen (HBsAg)

what causes hyperemesis gravidarum

high levels of hCG, estrogen, progesterone, or a combination - may be psych

cervical length <20mm (especially with funneling) is indicative of high or low risk for preterm labor?

high risk

GDM probably results from ________________ secreted during pregnancy which has large glucagon like effects

human placental lactogen

If IgM POSTITIVE in parvovorus B19, what should you check for via ultrasound

hydrops

Ovarian failure may be due to

hypothalamus not producing GnRH OR ovaries not responding to FSH

Zanvanelli Maneuver

if all other maneuvers fail, the fetal head can be returned to the uterus by reversing the cardinal movements of labor. - at this point a C section should be performed - Maneuvers that do not require direct contact with the fetus should be done first because they have a lower mortality.

How do you manage a *sensitized* D-Negative patient (antibody screen *positive for anti D antibody*)

if the antibody screen at initial prenatal visit is positive and is identified as anti-D 1. check the antibody titer. *Critical titer is 1:16* - If titer remains *stable at <1:16*, the likelihood of hemolytic disease of the newborn is low. Follow the antibody titer every 4 weeks. - If the titer *>1:16 and/or rising, the likelihood of hemolytic disease of the newborn is high. Amniocentesis is done.* 2. Amniocentesis: - fetal cells are analyzed for D status - Historically, amniotic fluid was analyzed by spectral analysis, which measured the light absorbance by bilirubin. *The preferred method is now to perform middle cerebral artery MCA dopplers to assess for anemia* 3. serial US monitoring: - *anatomy scan for hydrops fetalis* - *MCA doppler for presence or severity of anemia.* - consider blood transfusion to fetus if very premature 4. delivery - mild anemia: induction of labor at 37-28wks - severe anemia: deliver at 32-34wk -- most babies>32 weeks to do well in the neonatal ICU -- weigh risk for continued cord blood sampling and transfusions with neonatal risk of preterm delivery - administer steroids to mature lung

What is the problem with isoimmunization?

if the mother is *D negative* and the father is D positive, there may be a chance that the baby is D positive. - these antibodies cross the placenta and attack the fetal RBCs, resulting in significant fetal anemia, resulting in fetal heart failure and death. This disease process is known as HDN. - Sensitization is the development of maternal antibodies against D antigens on fetus RBCs. Sensitization may occur whenever fetal blood enters the maternal circulation. The fetus when sensitization occurred usually suffers no harm because the maternal antibody titers are low. *Subsequent pregnancies with D positive fetus are at risk of HDN bc the mother developed memory cells that quickly produce anti-D antibodies against the fetus*

- PRIMARY AMENORRHEA - breasts present and uterus present What should you suspect?

imperforate hymen, transverse vaginal septum

- passage of some but not all POC from the uterine cavity before 20 weeks - cramping - bleeding (ongoing) - cervical dilation (os is open) - needs D&C

incomplete abortion

________; is a Prostaglandin inhibitor for *<32 weeks*!!! - can cause premature constriction of ductus arteriosus

indomethacin -- is a tocolytic agent

- bleeding - cramps - cervical dilation (open os) - at <20 weeks - tx: with surgical evacuation of the uterus with D&C or medical evacuation with misoprostol

inevitable abortion

dilated cervix is seen with _______________ and _______________ abortions

inevitable and incomplete abortions

what must you do before administration of spinal block? why?

infuse 1 L of *crystalloid solution* to *prevent hypotension*

PGF2A is contraindicated for use for abortion in *asthmatics* because...

it induces smooth muscle contraction (bronchoconstriction!) EXAMPLE: Carboprost is a synthetic prostaglandin analogue of PGF2α with oxytocic properties

What is the recommended daily allowance (RDA) of calcium?

it is increased in pregnancy to *1200mg/day* and may be met adequately with diet alone this is also the same value women 51yoa+

Within 2-3 days post pardum, the remaining decidua becomes differentiated into two layers 1. superficial layer becomes necrotic and sloughs off as vaginal discharge = ___________ 2. basal layer (adjacent to myometrium) becomes new endometrium

lochia

cervical length >30mm is indicative of high or low risk for preterm labor?

low

Antiphospholipid antibodies are commonly seen in pts with

lupus

What should you do for a pt who is A2 during labor?

maintain euglycemia - insulin DRIP

McRoberts maneuver

maternal thighs are sharply flexed against maternal abdomen. Flattens the sacrum and symphysis pubis and may allow the delivery of the fetal shoulder - performed at the same time as suprapubic pressure

Contraction stress test

measures how the fetal heart rate reacts to uterine contractions. - can be performed if the NST is nonreactive/nonreassuring. - often a BPP will be performed instead as a means to evaluate fetal well being. - potentially risky bc of contractions

Which has more fat and carbs-- milk or colostrum?

milk. Milk: comes within the first week postpartum and is protein, fat, carbs (lactose) and water. Colostrum: protein, fat, carbs (lactose), *secretory IgA, and minerals*

how long does a post partum mother continue taking iron supplement?

minimum of 3 months post partum if tolerated

fetal demise before 20 weeks of gestation without expulsion of any POC

missed abortion - most women will spontaneously deliver a missed abortion within 2 weeks - risk of incomplete or septic abortion that may require d&c - concern for coagulopathy if dead fetus is not evacuated, higher risk in t2 ot t3 - needs suction d&c / misoprostol - ((( would need to know os )))

- inc preload to due normal inc in blood volume results in left atrial over load. Inc pressure in the left atrium is transmitted into the lungs resulting in *Pulm HTN* - tachycardia a/w labor and delivery exacerbates the pulm HTN bc of dec filling time. May lead to pulm edema. - 25% of women with this valve abnormality may have cardiac failure for for the first time during pregnancy - fetus is at risk of growth restriction - *peripartum period is most hazardous time* - consider intrapartum pphx for endocarditis

mitral stenosis

What do you suction first upon birth of head?

mouth then nose

2nd mcc of primary amenorrhea?

mullerian agenesis / failure

erythromycin ophthalmic ointment is used as *prophylaxis* against

neonatal gonorrhea conjunctival infection BUT DOES NOT TX THE INFECTION IF OCCURING.

MCC of persistent pyelonephritis despite adequate therapy?

nephrolithiasis

morula

new name for zygote that divided into 16 cells.

D negative mother with negative antibody screen: If the infant is D neg...

no antibody D is given to the mother.

Neonatal sepsis from GBS 1-3 months after birth is or is not preventable with intrapartum pphx abx

not - infection is community or hospital acquired

how do you diagnose gonorrhea/chlamydia in a pregnant woman

nucleic acid PCR -- pre screen should be done at the first prenatal visit - repeat later in pregnancy if high risk or if required by state law

TREATMENT OF CHOICE IN PREGNANCY OF BV

oral metronidazole

What stimulates milk letdown/ ejection?

oxytocin

Blood that accumulates within the uterus postpartum without visible vaginal bleeding can be discovered by

palpable uterine enlargement during the initial few hours postpartum.

How do you determine effacement?

palpate with finger and estimate the length from the internal to external os. (kinda like the width on the side.. ??) . see pic. - When the cervix shortens by 50% (to around 2cm) it is said to be 50% effaced. When the Cervix becomes as thin as the adjacent lower uterine segment it is 100% effaced.

Magnesium Sulfate cannot be used in who?

people with Myasthenia Gravis!!!!!!!

A 32-year-old G2P1001 at 34 weeks is brought to triage after a *motor vehicle accident*. She was a restrained driver who was rear-ended while going 65 miles per hour on the freeway. The airbags were deployed. She has dark-red vaginal bleeding and severe abdominal pain. Her vitals are stable. On exam, her abdomen is firm and tender. FHR shows a baseline of 130, ↓ variability, no accelerations, and late decelerations. Contractions are seen on the monitor. US shows a *fundal grade 2 placenta*. What is the most likely diagnosis?

placenta abruption Risk factors: - Trauma: MVA, domestic violence - Previous Hx of Abruption - Preeclampsia (and chronic HTN) - smoking - cocaine abuse - high parity

condition in which placenta is implanted in the immediate vicinity of the cervical os.

placenta previa *four types* 1. complete 2. partial 3. marginal (one edge of the placenta extends to the edge of the internal cervical os) 4. low lying (within 2 cm of the internal cervical os)

- *painless* vaginal bleeding in second or third trimester - if patient has not had a second trimester US, do NOT perform digital Vaginal Exam until US demonstrates placental location

placenta previa - PAINLESS

- *retroplacental hematoma on US* (not always seen) - clinical findings: *vaginal bleeding, constant abd pain*, irritable, tender and typically *HYPERTONIC uterus*, fetal distress, maternal shock, *DIC*.

placental abruption

varciella infection can cause maternal _____________ in pregnancy

pneumonia!!!!!! - can be datal in to neonate if they develop disseminated dz - if maternal infection 5 days before or after delivery. Give infant ZVIG for passive immunity.

fetus/ mothers with GDM are at risk of oligo or polyhydraminos?

polyhydraminos - also a/w macrosomnia

What does meconium in the amniotic fluid indicate?

possible fetal stress. - can be indicative of *Meconium Aspiration Syndrome*; gets into fetus lungs and cause damage. 1. At birth, presents with respiratory distress and possible pulm HTN 2. MAY need ECMO to improve hypoxia.

Headache that is *worse when upright*, *improved when lying down*. Due to a certain type of analgesic block. - *caffeine and hydration may help* - may occasionally need a *blood patch* performed by anesthesiologist

post spinal puncture headache

often defined as *>500mL of blood loss* for vaginal delivery and *>1000mL for C section*

postpardum hemorrhage.

F-Series prostaglandins should be avoided in who?

pregnant w/ asthma - Function: uterus contractions and bronchoconstriction - carboprost

PROM

premature rupture of membranes

Woods screw manuever

pressure is applied to the anterior surface of the posterior shoulder to rotate the posterior shoulder and "unscrew" the anterior shoulder

Rubin Manuever

pressure is applied tot he most accessible part of the fetal shoulder and rotated toward the chest -v similar to woods screw

PPROM

preterm (<37 weeks) premature rupture of membranes

gestational age <37 weeks with regular uterine contractions and progressive cervical change

preterm labor

Chronic HTN in pregnancy occurs

prior to the 20th week of gestation

most important risk factor for uterine rupture

prior uterine scar from c section - vertical scar is 10% risk (contractile part of uterus) - low transverse is <1% risk --- can also occur in the setting of trauma.

what hormone can be given in a preparation to *decrease risk of preterm birth* in women with a *hx of term singleton preterms* and also a *shortened cervix on US during current pregnancy*

progesterone

the period of confinement between birth and 6 weeks after delivery =

puerperium

What is the APT test

put blood from vagina in tube with KOH. turns brown for maternal.. pink for fetus

what is the most common serious medical complication of pregnancy?

pyleonephritis

how do you tx antiphopholipid syndrome?

ranges from no tx, to daily low-dose aspirin to heparin, depending on the patient past history of thrombosis and pregnancy morbidity

Pt is soaking a pad an hour post delivery What should you suspect?

retained placenta.

ROM

rupture of membranes

Prolonged rupture of membranes

rupture of membranes present for >18hr

chorionic villus sampling

sampling of placental tissue for microscopic and chemical examination to detect fetal abnormalities

Stenosis due to loop electrosurgical excision procedure (LEEP) or cold knife cone may cause __________________ ________________ - tx: cervical dilation

secondary amenorrhea; cervical

In parvovirus B19, IgG presents _________

several days after IgM appears. IgG persists for life and offers natural immunity against subsequent infections.

suprapubic pressure for shoulder dystocia

slightly superior to the symphysis pubis and in the direction of desired shoulder rotation - DIFFERENT FROM FUNDAL PRESSURE

tocolysis is the pharmacologic *inhibition of uterine contractions*. (Indomethacin, nifepidine, mag sulfate, terbutaline) - they have no been proven to prolong pregnancy. - They have no been shown to decrease neonatal M&M but may prolong gestation for 2-7 days to allow time for administration of _____________. - *used in fetus <34 weeks old*

steroids!!!!! and transfer to a facility with a neonatal ICU.

What is Rh or D?

the surface of the human RBC may or may not have "Rho"/ "Rh" antigen. Also referred to as "D" - If a pt with blood type A has Rho antigen, the blood time is A+ - If that person has no Rho antigen, the blood time is A- - half of all antigens on fetal RBCs come from the father and half come from the mother. This means the fetus may have antigens to which the mothers immune system is unfamiliar

What is a decidua?

the thick layer of modified mucous membrane that lines the uterus during pregnancy and is shed with the afterbirth.

- Mag Sulfate - Nifedipine - Ritodrine, Terbutaline - Indomethacin what do these all have in common

they are all tocolytic agents

Why are diuretics not used in pregnancy?

they decrease plasma volume and this may be detrimental to fetal growth. FYI: salt restriction is not recommended for the same reason

Patients with Sheehan syndrome cannot breast feed. WHY?

they have a postpartum pituitary dysfunction due to intrapartum ischemia causing an *absence of prolactin.* (the hormone that stimulates milk production)

- *bleeding* that is *<20 weeks* - *without cervical dilation* - *without passage of tissue* - no passage of tissue/ amniotic fluid in enocervical canal - cervical os *closed*

threatened abortion

Each cell of the preimplantation embryo is _______; each cell can form ALL DIFFERENT types of cells in the embryo

totipotent.

- eating raw meat or undercooked meat - cat feces - usually asymptomatic in mothers - infected fetus clears the infection from organs but localizes to CNS - classic triad of newborn complications 1. chorioretinits 2. intracranial calcifications 3. hydrocephalus - can also cause intellectual disability and vision loss

toxoplasmosis

head delivers then retracts into the perineum

turtle sign - consistent with shoulder dystocia - fetal shoulder is dislodged behind pubic symphysis

When can you use spinal block regional anesthesia?

uncomplicated c section and vaginal delivery

Biophysical Profile (BPP)

uses a real-time ultrasound for visualization of physical and physiological characteristics of a fetus.

- *nonreassuring fetal heart tones or bradycardia: most suggestive* - *sudden cessation of uterine contractions* - tearing sensation in abdomen - presenting fetal part moves higher in the pelvis - vaginal bleeding - maternal hypovolemia from concealed hemorrhage

uterine rupture

disruption of the uterine musculature through all of its layers, usually with part of the fetus protruding through the opening

uterine rupture

- condition in which the unprotected fetal cord vessels pass over the itnernal cervical os, making them susceptible to rupture when membranes are ruptured - prevalence: 1/2500 ... higher with use of fertility tx - vaginal bleeding with fetal distress

vasa previa

what pathophysiologic mechanism causes most of the symptoms of pre-eclampsia?

vasospasm

- fetal vessels insert in the membranes and travel unprotected to the placenta with no protection from wharton's jelly. This leaves them susceptible to tearing when the amniotic sac ruptures - vaginal bleeding with fetal distress

velamentous cord insertion

gold standard for diagnosis of DVT

venography with contrast --- never used --- MC diagnostic tool: compression US/ doppler

Women who do not want to breast feed should.....

wear a sports bra/ binder - bromocriptine used to be used but is NO LONGER RECOMMENDED OR FDA APPROVED BC OF STROKES, MI, SEIZURES ETC.

when are corticosteroids indicated for preterm labor?

when the preterm labor is from *24-34 weeks* - accelerate fetal lung maturity (decreases RDS) and reduce intraventricular hemorrhage

can the hep b vaccine be given during pregnancy?

yes