OB PEDS Exam 3

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OB PEDS Exam 3
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2014-01-17 14:46:25
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OB PEDS
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  1. Premature Rupture of the Membranes (PROM)
    Spontaneous rupture of the fetal membranes before the onset of labor
  2. PPROM
    Premature rupture before 37 weeks
  3. Hydramnios
    • Too much fluid
    • > 2000 cc of fluid
    • Normal is 500-2000cc
  4. UTI can cause...
    PROM and preterm labor
  5. Maternal Assessment
    • Time, amount, color ( of ruptured fluid )
    • Ferning test
    • VS esp temp!
    • monitor for infection,fever and WBC
  6. Fetal Assessment
    • ***HEART RATE***
    • Biophysical profile - how much fluid?
  7. Labor
    Contractions and cervical changes
  8. Preterm Labor
    • Occurs between 20-36 completed weeks
    • 12.7% of all pregnancies
    • RDS biggest problem for fetus - give steroids
  9. Cervicovaginal Fetal Fibonectin (fFn) Swab
    • Indicates that labor is coming within 7 days
    • usually need to be effaced
    • 99% accurate
  10. Dx of preterm labor
    • 20-36 Weeks
    • ** documented uterine contractions (4 in 20 mins or 8 in one hour)
    • Documented cervical changes - 1cm or 80% effaced
  11. How to maintain good uterine blood flow to fetus
    • Left lateral side lying
    • IV
    • labs
    • vaginal cultures
    • urine culture
    • US of cervix
  12. Tocolysis
    • Stopping of contractions
    • use of meds to stop labor; usually used with steroids
    • NOT for dilation > 5cm
    • Pulm edema - most serious complication
  13. Brethine/Terbutaline
    • Tocolytic
    • SE - Tachycardia
    • 2 common meds
    • Smooth muscle relaxant
    • monitor HR
  14. Mag Sulfate
    • Smooth muscle relaxant
    • used for preeclampsia
    • hypotonia
    • loss of DTRs
    • neonatal resp depression
  15. Procardia
    • Vasodilation
    • tachycardia/ HTN
    • tocolytic
  16. Prostaglandin Inhibitors
    • Indocin
    • Can constrict ductus arteriosis, increase risk of NEC and IVH
    • wouldnt give to premature
    • tocolytic
  17. Placenta Previa
    • Placenta is implanted in the lower uterine segment rather than the upper portion
    • 4 types : complete, partial, marginal, low lying
    • NO pain - bright red bleeding (bleed can be concealed)
    • Until PP is ruled out - NO VAGINAL EXAMS
  18. Complete Placenta Previa
    • NO VAGINAL EXAMS
    • C-Section - Cannot deliver vaginally
  19. Abruptio Placentae
    • PAINFUL**
    • Premature separation of placenta
    • severe hemorrhaging  - 10-15% of all prenatal mortality
  20. Couvelaire Uterus
    • Uterus is engorged with blood and turns blue = atony
    • Have to do TAH
  21. Dizygotic
    fraternal twins - 2 zygotes
  22. Monozygotic
    • Identical Twins
    • one ovum
  23. Discordinate Twins
    twin to twin transfusion
  24. Oilgohydramnios
    • Less than normal amounts of amniotic fluid 
    • < 500 cc
    • fetal resp and skeletal abnormalities
    • Think "lower" - Renal Problems
    • reduces cushioning during labor, variable decelerations and fetal head compression
  25. Polyhydramnios
    Think "Higher"  - resp problems
  26. Amniofusion
    • 250mL of warm NSS or lactated ringers then 100-200mL/hr
    • reposition mom to relieve cord compression
  27. Atopic Eczema (Atopic dematitis)
    • Unknown cause 
    • Chronic, relapsing superficial inflammatory skin disorder
    • 80% have associated allergies
  28. Acute Atopic Eczema
    • Flare, common on face, neck and behind knees
    • vesicles, exudate, crusts
  29. Subacute Atopic Eczema
    • Flare starts to heal
    • scaling, excoriation, erythema
  30. Chronic Acute Eczema
    • Multiple relapses
    • darkened skin
    • thickened skin
  31. Pediculosis Capititis (Lice)
    • Wingless bugs that feed on human blood
    • lay eggs in hair - hatch in 8-10 days
    • transmission by contact
    • run away from light
    • toys in trash bags for 2 weeks
  32. Scabies
    • Highly contagious
    • skin to skin transmission
    • preg bugs burrow into skin and lay eggs and feces under skin - hatch in 2-4 days
    • can have scabies for 5-6 wks before symptoms
    • look for linear gray lines
    • dx - scrape test and S/S
  33. Impetigo
    • Highly contagious superficial skin infection caused by a strep or staph infection
    • bacteria enters thru open area
    • honey-colored crust - tell tale sign
    • soak off crusts and apply ointments
    • 24H after medication - no longer contagious
  34. Most common burns by age group
    • Infants - Thermal, Sunburn
    • Toddlers - Stove, candles, curling irons
    • School-age - matches, chemicals
    • Adolescents - fireworks, chemicals, sunburn
  35. Abusive Burns
    "glove and stocking" burn
  36. Superficial partial thickness burn (1st degree)
    • Just epidermis
    • red and painful
    • heals in a few days
    • no scaring
  37. Partial thickness (2nd degree)
    • damages the epidermis and upper layer of the dermis
    • blisters
    • can leave scaring
  38. Full Thickness (3rd degree)
    • Damage epidermis, dermis and may involve underlying tissue (req grafting)
    • can destroy nerves
    • black,brown,deep cherry red, white and gray in color
  39. Parkland Formula
    • Determines how much fluid to give
    • 4mL x Kg x % body area = total 24H fluid replacement in mL
    • 24H starts at the time of burn
  40. Chicken Pox (varicella)
    • Airborne
    • most contagious 1-2 days before rash
    • contagious until lesions crust over
    • can be fatal d/t meningitis complications 
    • usually starts on trunk, face and scalp then spreads out
    • do NOT give kids ASA - causes rye syndrome
  41. Measles (Rubeola)
    • Airborne
    • Contagious 3-5 days before rash and 4 days after rash
    • rash starts at hairline and moves downward and outward
    • preg women at r/o SAB & preterm labor
    • pronomal stage - 3-5 days, fever, conjunctivitis
    • coplic spots - bluish, white, irregular spots in cheek
    • Vit A given
  42. Mumps (Parotitis)
    • Rubulavirus
    • transmitted in resp secretions
    • contagious 1-2 days before swelling and up to 9 days after swelling
    • pain with chewing
    • parotid gland swelling - unilat or bilat
    • sweling peaks around day 3
    • orcitis
  43. Rubella (German Measles)
    • Rubella Virus
    • Transmitted by contact with resp secretions
    • contagious 7 days before and after rash
    • 1st stage - low grade fever, malaise, HA up to 5 days
    • 2nd stage - rash develops - starts in face than down and out
    • after 3 days rash leaves in order it appeared
    • live vaccine
    • pregnant women with rubella in 1st trimester - 85% chance of fetus with congenital rubella
  44. Congenital Rubella
    • Blueberry Muffin spots
    • can be blind/deaf with neurological delays
  45. Erythema Infectiosum (fifth disease)
    • caused by human parvovirus (B19)
    • transmitted in resp secretions
    • contagious prior to rash and no longer contagious after getting rash
    • common 5-14y.o
    • flu-like symptoms
    • slapped cheek appearance
    • lacey rash on trunk and limbs
    • up to 3 weeks to resolve
    • Complications - Aplastic crisis
    • Preg women can SAB
  46. Aplastic Crisis
    • Complication of fifth disease
    • disease like sickle cell 
    • bone marrow stops making RBCs
    • Tx - blood transfusion
  47. Roseola (exathem subitum, 6th disease)
    • herpes virus type 6
    • 6 mths - 2 y.o
    • transmitted from resp secretions of healthy individuals who happen to have the virus
    • not really contagious
    • sudden high fever (105)
    • Pink, maculopapular rash - face, neck and extremities
  48. BUBBLEHE Assessment
    Breast, uterus, bowel, bladder, lochia, episiotomy, Homan and Emotions
  49. Breast Assessment (BUBBLEHE)
    Inspect nipples and palpate for engorgement
  50. Breast Milk
    • 16-28 cals/oz
    • Formula - 20cals/oz
    • prolactin and oxytocin released in late pregnancy
    • colostrum - antibodies
    • transitional milk - not full supply yet
    • mature milk - usually 6-7 days old
    • let down reflex - tingling in nipple
  51. Uterus Assessment
    • Involution - rapid reduction in size of uterus and return to prepregnant state
    • exfoliation allows for healing of placenta site and important part of involution
    • Uterus at level of umbilicus within 6-12 hours of birth and decrease 1 finger breadth per day
  52. Lochia Assessment
    • Bright red at birth
    • Rubra (dark red) - 2-3 days
    • Serosa (pink) - 3-10 days
    • Alba (white) - varies if breastfeeding
    • Clear
  53. Ovulation and menstruation return
    • Varies
    • usually period returns in 6-10 weeks in nonlactating women
    • ovulation returns within 6 months
  54. Vital signs and blood values
    • * Decreased blood volume = bradycardia - 50-70 bpm occur during first 6-10 days
    • WBC - usually elevated 25-30
    • Risk of embolism lasts 6 weeks
    • Temp elevation in first 24h is OK
  55. Taking In/Taking Hold
    Taking IN
    • 1-2 days post delivery
    • passive and dependent
    • food and sleep are major needs
  56. Taking in/Taking Hold
    Taking HOLD
    • 2-3 days post delivery
    • mom ready to resume control
    • focused on baby
  57. Maternal Role Attachment (BAM)
    • Learns mothering behaviors and becomes comfortable 
    • 4 stages - 
    • 1. Anticipatory stage - during preg
    • 2. formal stage - when baby is born
    • 3. Informal Stage - 3-10 mths after delivery
    • 4. Personal Stage - after 3-10 months after delivery
  58. Postpartum Blues
    • Transient period of depression
    • 1st few days after delivery 
    • Usually resolves in 10-14 days
    • Caused By - change in hormone level, physiological adj, unsupported environment, insecurity, fatigue, discomfort and overstimulation
  59. Postpartum Sexual Activity
    • Sleep deprivation, vaginal dryness and lack of time all impact sexual activity 
    • Can usually resume once episiotomy has healed and lochia has stopped
  60. Iron deficiency anemia 
    Causes
    • Poor diet
    • infants who do not consume solids after 6 mths
    • too much milk
    • heavy menstrual bleeding
    • prematurity
    • mom with poor prenatal nutrition
  61. Iron deficiency anemia
     Dx
    • CBC - H&H
    • Serum Ferritin - measures iron stores
    • Serum Iron
  62. Iron deficiency anemia
    Clinical Therapy
    • Iron fortified cereal at 6 months
    • foods high in iron
    • foods high in vit C
    • limit milk if needed
    • iron supplements
  63. Sickle Cell Disease
    • Autosomal recessive
    • 25% chance
    • abnormal hemoglobin (HbS)
    • any condition that increases need for O2 or alters O2 transport = sickled cells = obstruction = ischemia 
    • Sickled RBC lives 10-12 days, normal RBC 120 days
  64. Sickle Cell Crisis
    Precipitating factors
    • fever
    • dehydration
    • altitude
    • extreme temp change
    • emotional distress
    • fatigue
    • alcohol
    • pregnancy
    • excessive exercise
  65. Sickle Cell Disease
    Vaso-occlusive crisis
    • Pain crisis
    • Most common
    • Caused by clumping - ischemia
  66. Sickle Cell Disease
    Splenic Sequestration
    • EMERGENCY
    • Pooling of blood into spleen = hypovolemic shock
  67. Sickle Cell Disease
    Aplastic Crisis
    • EMERGENCY
    • Triggered by viral infection or depletion of folic acid
    • decreased production or increased destruction of RBC
  68. Sickle Cell Complication
    Acute Chest Syndrome
    • Infiltrate on CXR
    • Pain,cough,fever and dyspnea = notify MD
    • EMERGENCY
  69. Hemophilia A
    • Classic hemophilia
    • Most common (85%)
    • Deficiency of clotting factor VIII
    • Mostly affects males
    • X-linked recessive
  70. Hemophilia B
    • Christmas Disease
    • deficiency of clotting factor IX
    • mostly affects males
    • x-linked recessive
  71. Hemophilia Clinical Manifestations
    • Spontaneous Bleeding
    • Hemarthrosis
    • Bruising
    • Hematuria
    • Intracranial Bleeding
  72. Hemophilia Dx
    PTT will be prolonged
  73. Hemophilia Tx
    • Desmopressin (DDAVP) - mild hemophilia A - Stimulates release of factor VIII
    • Factor VIII or IX - Given IV
  74. Developmental Dysplasia of the Hip (DDH)
    • Dislocation present at birth
    • minor hip instability
    • can range to complete dislocation
    • more common in girls
    • cause is unknown - thought to be inutero position
  75. DDH 
    Clinical Manifestations
    • Uneven gluteal folds
    • Undiagnosed - walk with a lump
  76. Allis Sign
    DDH
    • > 4 mths old
    • knees different heights = instability or displaced
  77. DDH
    Ortolani-Barlow
    • Feel or hear clunk or click
    • can only do until 4 months old
  78. DDH
    Clinical Therapy
    • < 6 months old - pavlik harnes
    • > 6 months old - closed reduction and spica cast
  79. Idiopathic Scoliosis
    • Unknown cause
    • most common
    • dx in early teens
  80. Congenital Scoliosis
    • Present at birth
    • Cerebral palsy; muscle dystrophy
  81. Acquired Scoliosis
    Radiation Tx
  82. Scoliosis 
    Clinical Therapy
    • Mild (10-20 degree) - No formal Tx
    • Moderate (20-40) - Brace 23H/day until growth stops
    • Severe (40-50) - Sx - Spinal Fusion
  83. Osteogenesis Imperfecta 
    Brittle Bone Disease
    • Autosomal Dominant
    • Biochemical defect in collagen = brittle bone
    • multiple fx
    • blue sclera
    • short stature
  84. Duchenne Muscular Dystrophy
    • X-linked recessive
    • common in boys
    • muscle fiber degeneration and muscle wasting
    • delayed walking
    • freq falls
    • + Growers maneuver
    • Most end up in wheelchair by 12
  85. Slipped Capital Femoral Epiphysis (SCFE)
    • Seen during prepubertal growth spurt
    • Cause unknown
    • femoral head displaced from neck
  86. Clubfoot
    • Unknown cause
    • congenital
    • foot is twisted out
  87. Postpartum Hemorrhage
    • Early (primary) - 1st 24H after birth
    • Late (secondary) - 24H - 6 weeks after delivery
    • 10% drop in Hgb
    • Occult bleeds - intra-abd - most serious
  88. Early Uterine Atony
    • Lack of uterine muscle tone
    • **slow and steady bleeding - uterus may be filled with 1000cc of blood before spilling onto peri pad**
    • Perform fundal massage and check for clots
  89. Hematomas
    • Collection of blood
    • risk of infection
    • Trauma during delivery
    • vaginal packing - will need foley
  90. Retained placental fragments
    • Commonly occurs when fundus is massaged prior to spontaneous placental seperation - causing partial separation
    • Placenta should detact in 20-30 mins
  91. Reproductive Tract Infections
    • Can occur up to 6 weeks post delivery
    • Endometritis/metritis - limited to uterine lining, spreads easily via lymph and circulatory system
    • Parametritis (pelvic cellulitis) - invaded pelvic area
  92. Puerperal Morbidity
    • Temp increases 38 (100.4)
    • temple that occurs any 2 of he 1st 10 postpartum days
    • exclused 1st 24H - Temp increases physiologically in 1st 24H
  93. METRITIS
    • 1-3% vag; 5-15% c/s
    • **Foul smelling bloody discharge**
    • Uterine tenderness - severe cases
    • fever 101-104 - sepsis
    • Tachycardia - sepsis
  94. Pelvic Cellulitis 
    Parametritis
    • Involves the connective tissue of the broad ligaments or pelvic structures
    • may start with a cervical laceration
    • abscess formation
    • prevention - elevate HOB
  95. Perineal Wound Infections
    • Flora of vaginal canal
    • REEDA
    • localized pain
    • sutures removed, wound left open
    • broad spectrum abx
    • secondary closing of wound - closed after laceration healed and bacteria cleared
  96. Cystitis
    Lower Urinary Tract
    • More uncomfy than sick
    • Symptoms appear 2-3 days after delivery
    • Frequency, urgency, dysuria, nocturia
    • low grade temp possible
    • could evolve to pyleonephritis
  97. Mastitis
    • Infection of the breast connective tissue
    • 5-10% of breastfeeding moms
    • staph aureus
    • often doesnt occur for 2-4 weeks after delivery
    • *frequent breast feeding is key*
  98. Candida Albicans Mastitis
    • Baby has thrush which enters the breast cracks 
    • late onset nipple pain, burning nipples or areola, milk may have yeasty odor
    • *continue breast feeding*
  99. Superficial Vein Disease
    • Tenderness
    • local heat
    • low grade fever
    • palpable cord
  100. DVT
    • Hydramnios, preeclampsia, c/s = increased risk
    • tends to reoccur with each pregnancy
    • homans sign may or may not be positive
  101. Postpartum Psychosis
    • 1-2/1000 patients
    • 1st 3 months
    • with appropriate treatment - 95% improvement
    • Not associated with antenatal depression
  102. Postpartum major mood disorder
    • 4.5-28% of postpartum women
    • highest incidence - 4th week before return of period

    • Tx - SSRIs
    • sertraline is 1st line
    • many anti psychotics are contraindicated with breastfeeding
  103. Metosis
    Cell division
  104. Meiosis
    • Gametes
    • contain only half of the genetic material
  105. Non-disjunction**
    **Chromosomes fail to split and unite properly - can produce an extra chromosome (trisomy) or delete a chromosome (monosomy)**
  106. Conception
    When NUCLEI of egg and sperm unite to form zygote
  107. Implantation
    • Implants into endometrium 7-9 dpo
    • common site of attachment - upper part of the posterior uterine wall
    • semen is loaded with prostaglandins to help sperm travel
  108. Embryonic Stage
    • Starts on day 15 (beginning on the 3rd week after conception)
    • **Tissue differentiates into essential organs, and main external features develop**
    • Kidneys and eyes develop at same time
  109. Fetal Stage
    • End of the 8th week the embryo is sufficiently developed and is called a fetus
    • **every organ system and external structure is present including a beating heart**
  110. 8 Gestational Weeks
    • All body organs developed
    • BEATING, FUNCTIONING HEART**
  111. 24 gestational weeks
    • Considered Viable
    • Respiration begin
  112. 28 gestational weeks
    • Eyes open and close
    • surfactant being formed

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