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Trichomoniasis
sx
tx
- Sx: persistent yellow, frothy discharge, external vulvar irritation, no odor, erythematous patches on cervix ("strawberry cervicitis"),
- Microscope: motile ovoid protozoa with flagella
- Tx:
-
Bacterial vaginosis
- Trichomonas
- frothy, yellow-green vaginal discharge with strong odor
- clue cells: characterized by adherent coccobacillary bacteria that obscure the edges of the cells
- Fishy odor: KOH releases amines from the cell
-
Candidiasis
- Yeast vaginitis
- Thick, white clumpy discharge
- Sx: erythema, swelling, intense pruritis
-
Primary herpes
testing limitations
- painful ulcers involving vulva
- fluid filled, open or crusted
- cultures: highly specific, but 10-20% false negative rate
-
Elective cesarean sections:
what GA?
39 weeks
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Anencephaly
- Neural tube defect
- absence of major portion of brain, skull, and scalp
-
Neural tube defects
rates
- 1.4 to 2/1000
- Previous NTD pregnancy: 3-4%
-
Risks of amniocentesis
- Second trimester:
- -1 to 2% risk of amniotic fluid leakage
- -0.5% fetal loss rate
- -transient transvaginal spotting
- -0.1% risk of chorioamnionitis
- -rare risk of cell culture failure
-
Risk of chorionic villus sampling
Performed at GA <9 weeks: fetal limb reduction defects
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Tetracycline
adverse reactions related to pregnancy
- Tetracycline: contraindicated in all three trimesters
- Skeletal abnormalities, staining and hypoplasia of budding fetal teeth, bone hypoplasia, fatal maternal liver decompensation
-
Sulfonamide
- Kernicterus in the newborn (billirubin-induced brain dysfunction)
- Contraindicated during the last 2 to 6 weeks of pregnancy
-
Streptomycin
prolonged tx of TB in pregnancy, streptomycin has been associated with fetal hearing loss
-
Chloramphenicol
- Gray baby syndrome: infants can't metabolize the drug
- toxic levels reached by day 4, can lead to death within 1 to 2 days
-
Monozygotic twinning
rate
- 1 set per 250 births
- unaffected by race, heredity, age, parity, or infertility agents
- Division after formation of embryonic disk will result in conjoined twins
- 20 to 30% have dichorionic placentation
-
Dizygotic twins
dichorionic and diamniotic, regardleses of the sex of the twins
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Single umbilical artery
- Frequency in singletons: 0.7 to 0.8%
- frequency in abortuses: 2.5%
- Frequency in twins: 5%
- Increased incidence in newborns of diabetic mothers
- White > blacks (2:1)
-
Vasa previa
- fetal vessels cross the internal oss
- Increases risk of rupture of membranes to be accompanied by rupture of a fetal vessel, leading to exsanguination
-
Bilateral hydronephrosis and hydroureter in pregnancy
Normal or abnormal?
- Normal!
- Tends to be greater on the right side (due to dextrorotation of the uterus)
-
Urine dipstic in pregnancy
normal findings
- Trace glucosuria: 1 in 6 women
- Trace protein: common in normal pregnancies
- Abnormal: WBCs and blood (infection)
-
Dyspnea in pregnancy
- Often physiologic
- increased tidal lung volume
- increased minute ventilation
- systolic ejection murmur = increased blood flow across the aortic and pulmonic valves
-
Succenturiate placenta
one or more smaller accessory lobes that develop in the membranes at a distance from the main placenta
-
Fenestrated placenta
Rare anomaly where the central portion of the placenta is a rare anomaly where the central portion of the placenta is missing
-
Membranous placenta
- All fetal membranes are covered by villi
- Placenta develops as a thin membranous structure
-
Obstetric conjugate
- The shortest distance between the sacral promontory and the symphysis pubis
- Generally measures 10.5 cm
-
Diagnoal conjugate
Distance from the lower margin of the symphysis to the sacral promontory
-
True conjugate
From the top of the symphysis to the sacral promontory
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Interspinous diameter
- Transverse measurement of the midplane
- generally the smallest diameter of the plevis
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Gynecoid pelvis
- classic female pelvis
- Posterior sagittal diameter of the inlet only slightly shorter than the anterior sagittal diameter
-
Android pelvis
- posterior sagittal diameter at the inlet is much shorter than the anterior sagital diameter
- Limits the use of the posterior space by the fetal head
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Anthropoid pelvis
- Anteroposterior (AP) diameter of the inlet is greater than the transverse diameter
- Oval with large sacrosciatic notches and convergent side walls
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Platypelloid pelvis
- flattened with a short AP and wide trnasverse diameter
- Wide sacrosciatic notches are common
-
Fetal heart tracing:
sinusoidal pattern
Seen in : Rh-isoimmunized fetuses, normal fetuses, associated with maternal medication
-
Fetal heart rate
Saltitory pattern
- episodes of brief and acute hypoxia in the previously normally oxygenated fetus
- Seen during labor; not before
-
Indicators of fetal lung maturity
- Lecithin/sphingomyelin ratio of 2.0:1
- ratio is close to 1 until ~34 weeks
- ratio is predictive of RDS risk
-
Reverse diastolic flow in ubilical artery ultrasound
worrysome: fetal status is deteriorating
-
biophysical profile
- FHR monitoring (nonstress testing)
- amniotic fluid volume:single vertical pocket exceding 2cm
- fetal breathing: one or more episode of fetal breathing movements of 30s or more within 30 min
- fetal body movements: three or more discrete body or limb movements within 30 min
- fetal body tones: one or more episode of extension of fetal extremity with return to flexion, or opening or closing of hand
- Scoring: each gets 0 to 2; normal is 8 to 10, score less than 4 promps delivery
- False-negative rate: 0.1%
- False-positive rate: relatively frequent
- Bad signs: oligohydramnios, spontaneous decelerations
-
Caloric intake in pregnancy
weight gain
- Daily increase of 300kcal is recommended
- Total weight gain: 25 to 35 lb
- T2-T3: normal weight gain is about 1lb/week
-
Round ligament pain
- sharp, exacerbated by movement and exercise
- due to stretching of the ligaments from the gravid uterus
- Right side > left (dextrorotation)
- Tx: local heat and analgesics
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External cephalic version
- fetus with breech presentation is manipulated through the abdominal wall
- If not performed, 80% will remain breach
- Success rate: 60%, better if unengaged breech and normal AFI
-
Bishop score
- Dilation, effacement, station, consistency, position
- more points, more favorable
- Favorable position: anterior
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management of 41 week, 1/0%/-3, posterior and firm cervix?
BPP testing
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Management of 39 weeks, AFI 1.5, unfavorable cervix
- Admit to hospital for cervical ripening and induction of labor
- Oligohydramnios at term should be delivered
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Management of 41 week, decreased fetal movements x24hrs, FHR 180 bpm with absent variability
cervix long/closed/-2
Cesarean section (emergent)
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Management 34 week, decreased fetal movements
Nonstress test
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Expected delivery date
+ 1 year, minus 3 months, + 7 days
-
vaginal delivery + postpartum tubal
or
c/s with tubal
vaginal delivery + postpartum tubal has less risk
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Twin-to-twin transfusion syndrome
- Donor twin: always anemic, due to direct transfer of blood to the recipient
- Recipient twin: polycythemic; may also suffer thromboses secondary to hypertransfusion and subsequent hemoconcentration
- Donor placenta: pale, atrophied
- Recipient placenta: congested and enlarged
- Hydramnios can develop in either twin, but is more frequent in the recipient
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Cervical insufficiency/incompetence
- Dx: presence of painless cervical dilation with a h/o pregnancy loss in the second trimester or early-third-trimester preterm delivery
- Cerclage: 3 or more of the above. NOT for first trimester losses
- Cervical length <25mm or funneling of more than 25% or both is associated with increased risk of preterm delivery
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Complete abortion
expulsion of all fetal and placental tissue from the uterine cavity
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Incomplete abortion
Passage of some but not all placental tissue through the cervix
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Threatened abortion
Uterine bleeding without any cervical dilation
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Missed abortion
Fetal death without expulsion of any fetal or maternal tissue for at least 8 weeks
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Inevitable abortion
Uterine bleeding with cervical dilation without passage of tisseu
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Pre-eclampsia
Dx criteria
- BP >140/90 after 20 weeks GA in women with previously normal BP
- Proteinuria: >300mg on 24hr urine
- Severe preeclampsia: >160/110, proteinuria >5g or 3+, oliguria of <500ml in 24hr, cerebral or visual disturbances, pulmonary edema or cyanosis, RUQ pain, impaired liver function, thrombocytopenia, fetal growth restriction
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Pre-eclampsia risk factors
- Previous pre-eclamptic pregnancies
- Chronic HTN
- Pregestational DM
- Mulitfetal gestations
- Vascular or CT disease
- Nephropathy
- Antiphospholipid syndrome
- obesity
- older age
- AA race
-
Eclapsia
management
- stabilize
- Magnesium - prevent further seizures
- anti-hypertensives
- deliver in timely fashion
-
hydatiform mole
most common symptom
- Vaginal bleeding, enlarged-for-dates uterus
- other sx: hypertension, proteinuria, hyperthyroidism
-
hydatiform moles
tx and follow up
- D&C (if incomplete abortion)
- weekly hCG titers
- check for metastatic disease
-
Hydatiform mole:
Single-agent chemotherapy use after D&C
- Used if levels of hCG remain elevated 8 weeks after evacuation
- 50% of pts who have persistently high hCG will develop malignant sequelae
- metastases: need to use combination chemotherapy
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Culdocentesis
- Removal of fluid from the pelvic cavity via ultrasound guided needle (?)
- Uses: confirm ruptured tubal pregnancy accompanied by hemoperitoneum (as long as it has not clotted)
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Salpingostomy
- can be done via laparoscopic surgery
- parallel incision in the tube, removing the ectopic pregnancy
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Salpingectomy
- often done via laparotomy (or mini laparotomy)
- Removal of tube, or portion of tube that has the pregnancy
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Risks for ectopic pregnancies
- Pelvic inflammatory disease (previous)
- operative procedures on the fallopian tubes
- tubal sterilization (fulgaration > clips, rings)
- DES exposure
- induction of ovulation
- IUD use
-
hyperemesis gravidarum
- intractable vomiting of pregnancy associated with disturbed nutrition:
- weight loss
- ketonuria
- electrolye abnormalities (potassium depletion)
- Jaundice (later finding)
-
Hyperemesis gravidarum treatment
- parenteral fluids and electrolytes
- sedation
- rest, vitamins, antiemetics
-
PROM management:
febrile, contracting regularly, 24 weeks,
- #1: Antibiotics
- steroids, tocolytics... not helpful when delivery is imminent
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Chorioamnionitis
- presence of maternal fever, tachycardia, uterine tenderness
- leukocyte counts are nonspecific
-
history of vaginal bleeding:
first step in evaluating?
- ultrasound, to determine placental location
- Digital exam after the placenta is shown to not be previa
-
When is maternal Rubella infection most dangeroud?
- Risk: teratogenic
- 1st trimester infection: 80% risk to fetus
- 2nd trimester infection: 25% by the end
-
Tx of choice for N. gonorrheae infections in patients allergic to penicillin
-pregnant
-non pregnant
- Pregnant: Spectinomycin, erythromycin
- Non-pregnant: ceftriaxone 250mg IM + Azithromycin 1g PO or Doxycycline 100mg PO BID x 7 days
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Toxoplasmosis
Protozoal infection caused by toxoplasma gondii results from ingestion undercooked or raw meat
-
Appendicitis in pregnancy
- Incidence is unchanged: 1 in 2000
- Dx is more difficult: leukocytosis, nausea, vomiting are common in pregnancy
-
Asymptomatic bacteriuria in pregnancy
incidence?
risk of developing acute infection?
- Prevalence: 2 to 12%
- Higher incidence in black multips with sickle cell trait
- 20 to 40% of women with ASB develop an acute infection during that pregnancy
-
Tx of choice for UTI in pregnant patient?
- Ampicillin and cephalosporins
- Avoid: sulfonamides (disrupt albumin binding to bilirubin), Nitrofurantoin (nausea), tetracyclines (dental staining in the fetus)
-
Heart sound changes in pregnancy
- 90% have systolic ejection murmurs
- 20% have soft diastolic murmur
-
PUPPP
- Pruritic urticarial papules and plaques of pregnancy
- more common in nulliparous women
- T2 and T3
- -Erythematous papules and plaques that are intensely pruritic
- presentation: abdomen first, buttocks, thighs, extremities, sparing the face
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Birth defects in diabetic patients
- incidence of major malformations in women with DM: 5 to 10%
- Cardiac: 38% (VSD, etc.)
- MSK: 15%
- CNS: 10%
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