Ob step2

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Author:
gm1147
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166151
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Ob step2
Updated:
2012-08-15 13:59:21
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OB obstetrics obgyn step2
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kaplan
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  1. Embryo etc stages
    • Embryo - up to 8 weeks
    • Fetus - 8 weeks-birth
    • 1st trim - up to 12 weeks developmental age (14 weeks gestational age)
    • 2nd 12-24
    • 3rd 24-deliver
  2. Nagele rulre
    LMP-3 mo + 7 days = EDD
  3. Signs of pregnancy
    • Goodell sign: softening of cervix at 4 weeks
    • Ladin sign: softening of midline uterus at 6 weeks
    • Chadwick sign: blue vagina and cervix at 6-8 weeks
    • Telangiectasias/palmar erythema during 1st trim
    • Chloasma: hyperpigmentation of face at 16 weeks
    • Linea nigra: hyperpigmentation from xiphoid to pubic during 2nd trim
  4. bHCG levels
    • double every 48 hrs for first 4 weeks.
    • Peak at 10 weeks
    • Drop during 2nd trim
    • inc in 3rd trim
    • Gestational sac seen at 1000-1500 (5 weeks)
  5. Pregancy BP
    • lower
    • Lowest at 24-28wks
  6. Pregnancy renal
    • Inc GFR due to inc plasma volume
    • Dec in BUN/Cr
    • Inc in size of kidney and ureters increases risk of pyelonephritis
  7. Pregnancy hematology
    • Inc plasma volume by 50% - anemia
    • Hypercoagulable with normal PT, PTT, and INR but inc in fibrinogen and venous stasis
  8. First trimester care
    • See ever 4-6weeks
    • 11-14 weeks check age and nuchal
    • Fetal heart sounds at end of 1st trim
  9. 2nd trimester care
    • Triple or quad test at 15-20 weeks
    • Auscultate fetal heart
    • Quickening (feel movements) at 16-20 weeks
    • US for malformations at 18-20 weeks
  10. Triple and quad screens
    • AFP - inc in dating error, NT defect, abdominal wall defect
    • bHCG
    • estriol
    • inhibin A
    • Rest inc sensitivity
  11. Third trimester care
    • every 2-3 weeks then every week after 36 weeks
    • Wk 27: CBC
    • Wk 26-28: Glc load (50g glc, 1hr later, should be lower than 140. If not, do tolerance test with 100g and check at 1,2,3 hrs)
    • Wk 36: Chlamydia, gonorrhea, GBS
    • Cervix exam at 37 weeks
  12. Chorionic villus sampling
    9-12 wks if advanced maternal age or genetic diseases
  13. Amniocentesis
    after 15 weeks if advanced maternal age or genetic diseases
  14. Fetal blood sampling
    Rh isoimmunization or for fetal CBC
  15. Methotrexate
    • Folate R antagonist
    • 15% dec in 4-7d. If not, repeat. If still no dec, surgery
    • Exclusions: done with kids, immunodeficiency, noncompliant, liver disease, 3.5cm or larger, fetal heart rate
  16. Types of abortions
    • Complete: no products of conception on US
    • Incomplete: Some products. D&C
    • Inevitable: products, bleeding, dilated cervix. D&C
    • Threatened: products, bleeding. Bed rest
    • Missed: death with products. D&C
    • Septic: infection. D&C, levofloxacin and metronidazole
  17. Times to allow preterm labor
    • Severe maternal HTN
    • Maternal cardiac disease
    • Cervix >4cm
    • Maternal hemorrhage
    • Fetal death
    • Chorioamnionitis
    • GA is 34-37 weeks and >2500g
  18. Tx for preterm labor
    • Betamethasone - mature lungs (works within 24hrs, peaks at 48hrs, lasts 7days)
    • Tocolytics - Mg sulfate, CCB
  19. PROM tx
    • if chorioamnionitis - deliver now
    • If term, wait 6-12 hours to induce
    • If preterm - betamethasone, tocolytics, ampicillin and gentamicin. Erythro if pen allergy
  20. Placenta previa tx
    • If large bleeding or drop in hematocrit, pelvic rest
    • Immediate Csection if cervix >4cm, severe hemorrhage, fetal distress
  21. Placental invasions
    • Accreta: superficial uterine wall
    • Increta: into myometrium
    • Percreta: serosa, bladder wall, or rectum wall
  22. Placental risks, presentation, abruption complications
    • HTN, prior abruption, cocaine, trauma
    • 3rd trim bleeding, pain, contractions, fetal distress
    • Bleeding, premature delivery, uterine tetany, DIC, hypovolemic shock, Sheehan. External type as less complications since more likely to be partial
  23. Work up for Rh sensitized mom
    • If <1:16, no tx
    • >1:16 amniocentesis at 16-20 weeks
    • If fetal cells Rh+, evaluate fetal bili
    • If low - repeat in 2-3 weeks. Medium 1-2 weeks
    • If high - percutaneous umbilical blood sample for fetal hematocrit
    • If low hematocrit - intrauterine transfusion
  24. Tx of hypertension in pregnancy
    methyldopa, labetalol, or nifedipine
  25. Mild vs severe preeclampsia
    • Mild: >140/90, 1-2+ proteinuria or 24hr >300mg, edema in hands, feet and face
    • Severe: >160/110, 3+ or >5g, generalized edema, mental status change, vision change, impaired liver fxn
  26. Tx of preeclampsia
    • If term - deliver
    • Preterm mild - betamethasone, Mgsulfate for sz ppx
    • svere - mg sulfate, hydralazine, deliver or betamethasone
  27. HELLP
    • HTN
    • Elevated Liver enzymes
    • Low Platelets
    • tx as eclampsia
  28. Risks of pregestational DM
    • preeclampsia
    • abortion
    • infection
    • postpartum hemorrhage
    • congenital anomalies, macrosomia
    • preterm labor
    • Neonatal hypoglycemia
  29. Extra tests for DM pregnancy
    • EKG
    • 24 hr urine for cr an protein
    • HbA1C
    • Ophtho exam
  30. Tx of DM pregnancy
    • Diet and exercise but no weight loss
    • NPH night and aspart premeal
    • No sulfonylureas
  31. IUGR: types, causes, complications
    • symmetric <20wks, asymmetric >20wks
    • chrom, NT defects, infection, twins, HTN or renal disease in mom, smoking
    • Premature, stillbirth, hypoxia, low IQ, sz, retardation
  32. Macrosomia
    • >4500g
    • Fundal height >3cm more than GA
  33. Nonstress test
    • 2 fetal movements, HR accelerations within 20 min
    • If nonreassuring, wake baby up with vibroacoustic stimulation
  34. Biophysical profile
    • Nonstress test
    • 1+ chest expansions in 30 min
    • 3+ movements in 30 min
    • Fetus flexes
    • Amniotic fluic index
    • Each is 2 pts. normal is 8-10pts, <4 is abnormal
  35. Normal fetal heart rate
    • 110-160
    • With accelerations of 15+ above baseline for 15-20 seconds twice within 20 min
  36. Decelerations
    • Early: dec in HR with contractions due to head compression
    • Variable: dec in HR and return to baseline due to umbilical cord compression
    • Late: After contraction started, no return to baseline until contraction ends due to fetal hypoxia
  37. Lightening
    fetal descent to pelvic brim
  38. Stages of labor
    • 1: onset-full dilation. 6-18hrs in primipara, 2-10 in multipara
    • Latent: onset-4 cm. 7hrs, 5hrs
    • Active: 4cm-full. 1cm/hr min, 1.2cm/hr min
    • 2: full dilation-delivery. 30min-3hrs, 5-30min
    • 3: deliver-delivery of placenta. 30 min
  39. Steps of stage 2 labor
    • Engagement - enters pelvis
    • descent
    • flexion
    • internal rotation - at ischial spines, moves sagittal sutures into forward position
    • extension
    • external rotation- ant shoulder first
    • delivery of ant shoulder
    • derlivery of post shoulder
  40. Induction of labor
    • Prostaglandin E2 for cervical ripening. Contraindicated in asthmatics
    • Oxytocin for contractions
    • Amniotomy
  41. Arrest disorders
    • Cervical - no dilation for 2hrs
    • Fetal - no descent for 1 hr
  42. Types of breech and tx
    • Frank - hips flexed, extended knees
    • Complete - flexed hips and knees
    • Footling - one or 2 legs first
    • External rotation after 36 weeks
  43. Shoulder dystocia steps
    • McRoberts: flex moms knees
    • Rubin: push post shoulder twd head to rotate baby
    • Woods: rotate shoulders by pussing post shoulder to back
    • Deliver post arm
    • Fracture fetal clavicle
    • Zavanelli: push back and Csection
  44. Postpartum hemorrhage, types, tx
    • Bleeding >500ml
    • Early is within 24 hours
    • Late is 1d-6 weeks
    • Exam, compression and masage, oxytocin

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