OB 1

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OB 1
2011-05-12 22:13:05

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  1. Infertility
    • A disease defined by the failure to achieve a successful pregnancy after 12 months or more of regular unprotected intercourse.
    • Earlier evaluation and treatment may be justified based on medical history and physical findings and is warranted after 6 months for women over age 35.
  2. Infertility Incidence
    Estimated 10 to 15 percent of couples in the United States are infertile.
  3. Infertility Etiologies
    • Unexplained (28%)
    • Male factors (24%)
    • Ovarian dysfunction (21%)
    • Tubal factors (14%)
    • Other (13%)
  4. When to evaluate for Infertility
    • After 1 year: 85-90% will succeed in first year
    • Earlier if: Age > 35, Irregular periods suggesting anovulation, History endometriosis or tubal disease, Known male factor
  5. Infertility Evaluation
    • History: Duration, Menstrual cycle (length, pain), Prior surgery, Prior pelvic infection, Past conceptions, Prior evaluation, Family history
    • Exam: Thyroid, Galactorrhea, Uterine & adnexal size & tenderness
  6. Ovulation
    • 25% infertility; 40% female factors
    • Spectrum: oligo-/amenorrhea, DUB, to luteal phase defect
    • Basal body temperature
    • Urine LH
    • Progesterone
    • Ultrasound
  7. Ovarian reserve
    • Time-limited
    • 1 million follicles at birth
    • 400,000 at menarche
    • 400 ovulated
    • 1000 at menopause
  8. Tubes
    • Open
    • Normal
  9. Sperm
    • Count, motility
    • Function
  10. Elevated Prolactin
    • Check medications:
    • Neuroleptics (phenothiazines, haloperidol)
    • SSRIs
    • Anti-HTN (methyldopa, verapamil, reserpine)
    • Metoclopramide (DA-R blocker)
    • H-2 Blockers (cimetidine)
    • MRI
  11. Infertility Male Factor
    • 20% solely responsible
    • 40% contributing
    • Order semen analysis: 2-5 d abstinence prior, Repeat in 1 month if abnormal.
    • Urologic evaluation
    • Anatomy (outflow obstruction/obstruction or absence of vas deferens), infection, varicocele
    • Genetic: Karyotype (15% if azo, 5% if <5-10 mil), Klinefelter’s (XXY) 1/500 azospermia, Y microdeletions 10-15% azo or severe oligo, bilateral absence of vas deferens; CF
  12. Testes
    • Seminiferous tubules: spermatogenesis
    • Leydig cells: testosterone
    • Sertoli cells: ABP to concentrate T and DHT in seminiferous epithelium and epididymis
    • LH: stimulates testosterone synthesis/secretion
    • FSH: increases LH receptor #
  13. Sperm journey
    • Spermatogonia (46) → mitosis → 1° spermatocytes → meiosis → 2° spermatocytes (23) → maturation → spermatid
    • 50 d in seminiferous tubule, 12-21 days epididymis, vas deferens = approx 70 d
  14. Male History for Infertility
    • Injury, surgery, mumps
    • Heat decreases spermatogenesis
    • Marijuana & alcohol depress count/testosterone
    • Cocaine decreases spermatogenesis
  15. Semen Analysis
    • 2-5 days abstinence prior
    • To lab within one hour of collection
    • 2-3 samples before diagnosis secure
    • Round cells: WBC or immature sperm; need stains to differentiate
    • Agglutination: suggests immunologic source or infection
    • Oligospermia: low count
    • Asthenospermia: low motility
    • Teratospermia: low morphology
    • Azospermia: no sperm in ejaculate
    • Hypogonadotropic hypogonadism Kallmann’s
    • Hypergonadotropic hypogonadism
    • Elev. LH: Leydig cell dysfunction
    • Elev. FSH:spermatogenic dysfunction
    • Eugonadotropic vasectomy, CAVD, Epididymal obstruction
    • Low volume, no fructose (seminal vesicle)
    • Retrograde ejaculation: 2%; abnormal function of internal sphincter of urethra; Associated with prostatectomy, LND, spinal cord injury, diabetic neuropathy, meds (alpha blockers)
  16. WHO Criteria for Male Sperm
    • Count >= 15 x 106/mL
    • Motility >40% forward progression
    • Morphology >30% normal, >4% (if Kruger criteria)
    • Volume >1.5 mL
  17. Sperm function tests
    • Sperm penetration assay: penetration of zona-less hamster eggs
    • Human hemizona assay: comparison of patient and fertile control sperm bound to egg halves (hemizona index)
  18. Infertility and Hypothalamus
    • Hypothalamus: Chronic anovulation with estrogen absent
    • Dysfunction: Stress/exercise/nutrition, Pseudocyesis
    • Deficiency: Kallman (anosmia), Idiopathic
  19. Infertility and Infection
    • TB
    • Syphilis
    • Sarcoidosis
  20. Infertility and Tumors
    • Craniopharyngioma
    • Germinoma
    • Hamartoma
    • Teratoma
    • Endodermal sinus tumor
    • Langerhans cell
  21. Chronic anovulation with estrogen present: PCOS
    • Increased frequency of hypothalamic GnRH pulsations
    • Elevated LH/FSH ratio
    • Increased ovarian/adrenal androgens
  22. FSH High
    Indicates anovulation, possibly premature ovarian failure
  23. Biomarkers to evaluate ovarian reserve
    • Day 3 FSH, estradiol
    • Inhibin B (Clomid challenge test)
    • Anti-müllerian hormone: AMH declines with age. AMH predicts ovarian response to fertility drugs
  24. Ultrasound to Evaluate Ovarian Reserve
    • Antral follicle count
    • Ovarian volume
  25. Tubal Patency: Hysterosalpingogram
    • 35% infertility
    • Surgery: Severe 1%/cycle, Mild 5-8%/cycle, Sterilization reversal 8-10%/cycle
    • IVF
  26. Uterine Evaluation
    • HSG or saline infusion sonogram
    • Ultrasound to evaluate for fibroids
  27. Laparoscopy
    • Abnormalities on HSG
    • Pelvic Pain, high suspicion for endometriosis
  28. Infertility and Endometriosis – Possible mechanisms
    • Distorted pelvic anatomy
    • Altered peritoneal function. Peritoneal fluid toxicity to sperm, embryos.
    • Altered hormonal and cell-mediated function
    • Endocrine and ovulatory abnormalities. Anovulation, luteinized unruptured follicle syndrome
    • Impaired implantation
  29. Cervical mucus and sperm transport
    • Cervical mucus from 12 cycles in 10 ovulating women
    • Increase in hydration precedes LH surge (& in many cases rise in E2)
    • Sperm penetration increases with increasing hydration > 97.5%
    • Morphologically abnormal sperm swim slower in cervical mucus
    • Increased head resistance, same flagellar beat frequency
  30. Vaginal lubricants
    • Avoid if possible
    • Canola oil no difference in motility from media
    • KY jelly, olive oil, saliva all decreased sperm motion; only baby oil did not
  31. Spontaneous cycle compared to controlled ovarian stimulation:
    • Use of gonadotropins, opens window
    • Allows recruitment of more than one dominant follicle
    • We can only recruit what the ovary brings that cycle
  32. Endometriosis
    Laparoscopy: diagnostic, pain relief, only modest increase in fertility
  33. Cervical transport
    • should get sticky/stringy as water concentration increases, aids with sperm motility
    • cervical transport is essential: screens out abnormal swimmers, increased head resistance, same flagellar beat frequency
    • no good test
    • daily record of BBT, cervical mucus, intercourse within the fertile window, mucus more predictive than timing to ovulation
  34. Controlled ovarian stimulation
    • Pills: Clomid, Letrozole, Tamoxifen
    • Injections: FSH, LH, hCG
    • Use of gonadotropins: opens window. Allows recruitment of more than one dominant follicle. We can only recruit what the ovary brings that cycle.
  35. Intrauterine Insemination
    • Mild male factor
    • Modest increase in fertility
  36. In vitro fertilization (IVF)
    Intracytoplasmic sperm injection (ICSI). Severe male factor
  37. IVF Consists of:
    • Pituitary suppression
    • Ovarian stimulation
    • Egg Retrieval
    • Fertilization
    • Culture
    • Replacement
    • Allows Third-Party Reproduction: Donor Sperm (IUI), Donor egg (IVF), Donor embryo (IVF), Gestational Carrier (IVF)
  38. Management of ovulatory dysfunction
    • Underlying causes of ovulatory dysfunction, such as thyroid dysfunction, should be corrected if possible. As with men, women who have hyperprolactinemia can be treated with dopaminergic agents, which may restore ovulation. Insulin-sensitizing agents, most commonly metformin (Glucophage), have been shown to increase ovulation and pregnancy rates in patients with PCOS, although these agents are not yet approved by the U.S. Food and Drug Administration (FDA) for the treatment of infertility. Laparoscopic ovarian drilling for ovulation induction also may be considered for patients with PCOS if other treatments are unsuccessful.
    • In most women with ovulatory dysfunction without evident cause or that is not otherwise correctable, the condition can be managed with use of the oral ovulation-inducing agent clomiphene citrate. Clomiphene citrate can be used in patients with PCOS as well, with or without the coadministration of insulin-sensitizing agents. Treatment with clomiphene citrate is ineffective in patients with ovulatory dysfunction caused by hypothalamic amenorrhea, however, because its mechanism of action occurs at the hypothalamus. These patients are more likely to respond to gonadotropin therapy. Women with limited ovarian reserve also are unlikely to benefit from ovulation induction. Currently, only oocyte donation has been proven successful for these patients.
    • Clomiphene citrate is generally well tolerated and effective; 80 percent of appropriately selected patients will ovulate with this treatment. Major risks associated with the use of clomiphene citrate include ovarian hyperstimulation syndrome and twinning. Higher-order multiple gestation is a rare consequence. Generally, a dosage of 50 mg per day is administered starting on day 3 to day 5 of the menstrual cycle and is continued for five days. Documentation of ovulation can be accomplished fairly easily with basal body temperature charting or use of a urinary LH kit. If a dosage of 50 mg per day is insufficient to induce ovulation, it can be increased to 100 mg per day.
    • Higher dosages generally should be managed by a fertility specialist because 100 mg per day is the maximal dosage approved by the FDA. If clomiphene citrate therapy is unsuccessful, additional treatment options include IVF and injectable ovulation-inducing agents such as human menopausal gonadotropin, exogenous FSH, and gonadotropin-releasing hormone.
  39. Management of tubal, uterine, and pelvic disease
    Tubal disease may be treated with tubal reparative surgery, although success rates are generally low and are compromised by increased risk of subsequent ectopic pregnancy. IVF is an alternative, especially in patients with markedly damaged tubes. Patients with endometriosis may benefit from laparoscopic ablation or laparotomy, depending on the severity of disease. Ovulation induction with or without intrauterine insemination and IVF also can be used in these patients.
  40. Management of unexplained or persistent infertility
    Options for patients with unexplained infertility include intrauterine insemination, clomiphene citrate therapy, and intrauterine insemination with either clomiphene citrate or gonadotropin therapy. To date, the benefit of IVF has not been proven in patients with unexplained infertility. IVF may be useful in patients with persistent infertility in whom treatments for specific diagnoses have been unsuccessful.
  41. Third-party reproduction
    • Donor sperm (IUI)
    • Donor egg (IVF)
    • Donor embryo (IVF)
    • Gestational Carrier (IVF)
  42. How long must a couple have been having unprotected sex to be considered infertile?
    • Twelve months If <35
    • 6 months > 35, Irregular periods suggesting anovulation, History endometriosis or tubal disease, Known male factor
  43. How many couples in the U.S. are infertile?
  44. What is the success rate in the first year of attempted conception
  45. What % of infertility is attributes to male factors?
  46. What % is a contributing factors (both)
  47. What are the most common sources of female infertility?
    Ovarian dysfunction (21%), tubal factors (14%)
  48. What is the most common cause of male infertility?
    Testicular failure/dysfunction aka 1° hypogonadism
  49. If this hormone is high, it suggests ovarian failure
  50. When is hysterosalpingography indicated?
    If the initial history and physical examination suggest tubal dysfunction or a uterine abnormality, or if other testing has failed to reveal an etiology
  51. What should components of a PE entail in a female?
    Thyroid, Galactorrhea, Uterine & adnexal size & tenderness
  52. What do you evaluate wrt eggs?
    Ovulation, reserve
  53. What is the diagnostic workup for egg eval?
    • Basal body temperature
    • Urine LH
    • Progesterone
    • Ultrasound
  54. What labs should you order to evaluate ovulation?
    hCG, TSH, Prolactin ,FSH
  55. What medications will elevate prolactin levels?
    • Neuroleptics (phenothiazines, haloperidol)
    • SSRIs
    • Anti-HTN (methyldopa, verapamil, reserpine)
    • Metoclopramide (DA-R blocker)
    • H-2 Blockers (cimetidine)
  56. What imaging study will be used if prolactin is high?
    MRI to check for adenoma
  57. What is wrong with eggs in ovarian insufficiency and what hormone will be elevated?
    They are absent, FSH
  58. What should you think if eggs are present, but patient is amenorrheic with a normal or low FSH?
    PCOS or hypothalamic amenorrhea
  59. What is the diagnostic criteria for PCOS?
    • 2 out of 3:
    • 1. Not ovulating
    • 2. High male hormone
    • 3. Polycystic ovary
  60. What test do you do if PE is normal, FSH is normal or low and anovulation?
    P4 challenge
  61. Is estrogen present in PCOS
    Yes, so is LH/FSH ratio
  62. What are treatment goals for PCOS?
    • Evaluate & Treat Metabolic syndrome
    • Protect uterus
    • Induce ovulation
  63. What hormone is related to hypothalamic amenorrhea?
  64. What is Kallmann?
    Isolated GnRH deficiency with anosmia
  65. Stress, exercise and diet can create dysfunctions in what?
  66. Cardio General Pregnancy Changes
    • Due to uterine enlargement and diaphragmatic elevation the heart rotates in a left upward displacement
    • Apical beat (max intensity) shifts laterally
    • Heart size increases 12%: myocardial mass and volume
    • Hypertrophy of smooth muscle and reduction in collagen content
    • Blood flow increases to uterus, kidneys, skin (dissipates heat), breasts
    • Exercise diverts blood to muscles- women who have a workout regimen can continue, but not a good time to start a rigorous routine for those who haven’t.
    • Sinus tachycardia, sinus bradycardia and isolated atrial and ventricular premature contractions can be normal – so can ST segment depression or T wave flattering
  67. Heme General Pregnancy Changes
    • RBC’s increase in mass by 33%
    • Increase in plasma volume can lead to anemia
    • Iron is used up more → iron deficiency anemia can occur → supplement
    • Increase in WBC’s: mostly PMN’s → may predispose preggers to infection
    • Platelets used and created more→ not pathological significance
    • Circulating clotting factors increase, especially fibrinogen and factor VIII
  68. Pulmonary General Pregnancy Changes
    • Capillary dilation leads to engorgement of nasopharynx, larynx, trachea and bronchi
    • Increased pulmonary blood volume
    • Dead space volume increases because airway musculature relaxes
    • Tidal volume and inspiratory capacity increase
    • Increase in minute ventilation due to rise in tidal volume – more tthan oxygen consumption of maternal tissues → hyperventilation (thought to be due to progesterone and protective for fetus respiratory control)
    • Diaphragm elevated by as much as 4 cm – rib cage is displaced upward
    • Increases angle of ribs and spine
    • Ab muscles have less tone so breathing is more diaphragm dependent
    • Reduction in total lung capacity and functional residual capacity – decreases expiratory reserve and residual volume
    • Peak expiratory rate decreases throughout pregnancy but especially if in supine position.
  69. Renal General Pregnancy Changes
    • Length and weight of kidneys increase during pregnancy
    • Calyces, pelves and ureters become dilated → holds more urine → predisposes women to UTI’s
    • Plasma flow increases during 1st half of pregnancy; decreases in 2nd half
    • During later pregnancy urine flow and sodium excretion rates will vary by maternal position – higher in lateral recumbency
    • Creatinine production unchanged – pregnant woman will excrete 1 g a day
    • Volume of urine excreted a day is unchanged
    • Proteinuria >300 suggests renal disorder
    • Bladder is also pushed upward and flattened → increases frequency
    • Bladder vascularity increases and muscle tone decreases which increases bladder capacity
  70. GI General Pregnancy Changes
    • Gums may bleed more
    • Acid reflux is more common in pregos due to increased acid production and lower sphincter relaxation
  71. Gallbladder General Pregnancy Changes
    Emptying in pregos may be incomplete → increased risk for gallstones
  72. Liver General Pregnancy Changes
    • Morphology unchanged
    • Fall in albumin/globulin ratio mimics liver dz in non-pregos
    • Alkaline phosphatase activity can double
  73. Skin General Pregnancy Changes
    • Hyperpigmentation: melanocyte stimulating hormone and rise in estrogen
    • Linea nigra (linea alba)
    • Melasma (mask of preg, malar region
    • Striae gravidarum (stretch marks) – decreased collagen adhesivesness and increased ground substance formation
    • Spider angiomas, Palmar erythema, Cutis marmorata
    • Nails become brittle and hair thickens
  74. Metabolism General Pregnancy Changes
    • Weight gain due to fetus and increased breast tissue, blood volume and water volume
    • Total body fat increases
    • Insulin resistance→ gestational diabetes in predisposed women
  75. Cardio 1st Trimester 0-12 wks
    • Blood volume expansion starts: triggered by hormones – estrogen stimulates renin-angiotensin system → high levels of aldosterone → renal Na+ reabsorption and water retention
    • Vascular resistance decreases due to hormonal changes
  76. Renal 1st Trimester 0-12 wks
    • Decreased renal vascular resistance → increases plasma flow reaches peak @ end of first tri
    • Increased GFR – reaches peak at end of first tri too
    • Renin activity increases → angiotensin II (does not cause vasoconstriction in preg women) → aldosterone (causes increase in water retention – decreases plasma sodium concentration)
    • Vasopressin should increase as response – if not it can lead to diabetes insipidus like condition → diuresis and hypernatremia
  77. Cardio 2nd Trimester 14-27 wks
    • Blood volume increases rapidly
    • Max cardiac output achieved @ 20-24 weeks : hormonal change and av-shunt effect of the uteroplacental circulation;
    • SV peaks at 12-24 weeks – increases 25-30%. Decreases with supine position
    • HR increases 15%: 15 bpm more than non-pregs and decreased blood viscosity
    • Systolic ejection murmurs can be heard due to CO changes
    • Systemic arterial pressure decline reaches nadir at 24-28 weeks
    • Pulse pressure widens
    • Venous pressure rises in lower extremities: worse supine – can cause edema and varicosities
  78. GI2nd Trimester 14-27 wks
    Intestinal transit times decreased
  79. Heme 2nd Trimester 14-27 wks
    Plasma fibrinogen levels begin to rise
  80. Skin2nd Trimester 14-27 wks
    Striae gravidarum (stretch marks) appear
  81. Cardio 3rd Trimester 28-40 wks
    • Blood volume plateaus
    • CO increases with contractions of labor and at delivery; supine position can reduce CO by compression of the vena cava
    • Blood pressure returns to normal by 36 weeks
    • Delivery associated w/ 40% fall in peripheral vascular resistance; MAP maintained because of rise in CO
  82. GI 3rd Trimester 28-40 wks
    Intestinal transit times decreased
  83. Normal pregnancy
    • 280 days – trimesters
    • First: 0-12 weeks; most miscarriages occur here
    • Tests: early US, good for dating pregnancy if <20 weeks (important for induction), translucency of neck fold is a good indicator for down’s
    • Second: 14-27 weeks; women feel good, sex drive up (women who are carrying male – male partners sex drive will increase)
    • US: 18-20 weeks, looks at every system, organs, limb sizes, sex
    • Family hx of diabetes, glucose tolerance
    • Everyone gets one towards end.
    • Quadruple screen test- Optional test: down’s, twins, spina bifida (positive means more diagnosis needed)
    • Third: 28-40 weeks or delivery
    • Due date is an estimate
    • > 41 weeks can lead to meconium (1st stool) aspiration; more importantly placenta can break down**, more expensive tests needed
  84. Amenorrhea
    1st thing you should do is preg test
  85. Weight gain
    • 1st trimester, should not gain much
    • BMI of 18.5 or less they should gain 28-40
    • BMI 18.5, between 24.9 25-35 lbs
    • BMI 25-29, between 15-25 lb
    • BMI >30, no more than 11 to 20 lbs
  86. Cravings
    • Ice: anemia – blood volume doubles but not necessarily RBCs
    • Iron supplementation
  87. Digestive
    constipation, Give water, high fiber diet, exercise
  88. Breast changes
    tender and enlargement – estrogen and progesterone; pigmentation changes around areola, 12 weeks milk is produced
  89. Pigmentation changes
    • chloasma (mask – nose and cheeks)
    • linea negra (linea alba)
  90. Stretch marks
    genetic- breast, abs, butts, thighs
  91. Bleeding
    gums, veins underneath skin of breasts, cervix (pap can cause!, intercourse, cough…)
  92. Chadwick sign
    cervix becomes blue/purplish due to increased blood volume
  93. Goodel’s sign
    softening of cervix
  94. Hegar’s sign
    softening of isthmus leads to urination frequency
  95. Changes in fetal circulation from the intrauterine state at term to after delivery
    • Umbilical Vein → DuctusVenosus → Inferior Vena Cava → Right Atrium
    • R. atrium → L atrium → aortic arch → systemic capillary beds
    • R. atrium → R. ventricle → pulmonary trunk → aortic arch → systemic cap beds
  96. G and P’s:
    • Gravida: how many times has she been pregnant
    • Para: what has happened in those pregnancies. FPAL (Florida Power And Light)
    • Full term
    • Preterm (20 weeks- 36 weeks and 6 days)
    • A = abortions
    • L = # of living children
  97. Common Pregnancy Concerns and Recommendations
    • Healthy diet: food pyramid
    • Women are receptive to health info
    • Exercise: if they haven’t been exercising then don’t start a big regimen – but walking
    • Increased sex drive: its ok to have sex
  98. Pregnancy and HTN
    • high risk for Pre-eclampsia.
    • Perfusion to placenta: small babies, placenta can stop functioning
    • Meds: make sure its ok for pregs
  99. Pregnancy and Diabetes
    • high risk
    • Most of the time will become insulin dependent
    • LGA (large gestational age): Big baby, hard to out, trauma. Baby can have trouble controlling blood sugar
  100. Pregnancy and Coagulation disorders
    • Hemorrhage
    • Can lead to miscarriages
  101. Pregnancy and UTI
    • pregnant women are susceptible
    • Not the same symptoms, check urine every visit, culture if frequent before pregnancy
    • Pyelonephritis can be an issue
  102. Rh factor
    • type and screen
    • if negative give Rogan anytime there is a significant bleed
    • again at 28 weeks and once baby is born
  103. Surgical history
    • scar tissue
    • Cervix? Could be incompetent
  104. C-section:
    • controversial
    • @ Duke: one, you can have a vaginal birth next time; 2-3 c-section always
  105. Pregnancy and Family hx
    • Htn
    • Diabetes
    • Cancer
  106. Pregnancy and Social history
    • Smoke: #1 cause of pre term labor
    • Drugs: there will be a drug screen done at labor which can get social work involved if in the chart it states a history of drug use. Cocaine (abruption of placenta)
    • Support system: planned?
    • Abuse: increases during pregnancy
    • Seatbelt use: need to use it low
    • Gun safety
  107. Medications
    • Aspirin not used during pregnancy
    • Can take Tylenol NOT Ibuprofen
  108. Management of N/V During Pregnancy
    • Ginger ale, lemonade, salty things
    • Small frequent meals
    • Empty stomach makes it worse
    • B6 vitamins
    • BRAT diet
    • Meds: Zofran, Phenergan (sleepiness), Reglan (h/a)
    • Usually goes away 12-14 weeks
    • Hyperemesis gravida: look into social hx, abuse
  109. Hemolytic disease of the newborn (erythroblastosis fetalis)
    mom is Rh – and baby is Rh + for first pregnancy. Mom is given Rh immune globulin within 72 hours of delivery so she won’t produce anti-Rh, preventing erythroblastosis with her next pregnancy. Immune globulin also administered at 28 weeks
  110. Pregnancy Diagnostics
    • Missed period-Last normal menstrual period
    • Urine Pregnancy Test
    • Serum Pregnancy Test
    • Vaginal Ultrasound
    • Abdominal ultrasound
    • Fetal heart tones with doptone
    • Fetal heart tones with fetoscope
  111. Anticipatory Guidance
    • Normal physiological changes
    • Early Pregnancy: morning sickness
    • Recommend exercise
    • Discomforts of late pregnancy
    • Warning signs
    • Bleeding
    • Decreased Fetal Movement
    • Pre-term Labor
    • Pre-eclampsia
    • Labor
    • Preparation for Breastfeeding, Childbirth, Postpartum, Parenting, Siblings, and Reproductive Health Planning
  112. Healthy Birth Practices
    • Let labor begin on its own
    • Walk, move around and change positions throughout labor
    • Bring a loved one, friend, or doula for continuous labor support
    • Avoid interventions that are not medically necessary
    • Avoid giving birth on your back and follow your body’s urges to push
    • Keep mother and baby together-it’s best for mother and baby and breastfeeding
  113. Postpartum Depression
    • Incidence 10-26%
    • Postpartum psychosis 1-2 per 1000
    • Symptoms: insomnia, exhaustion, excessive sleeping, change in appetite, crying spells, feelings of guilt, sadness, despair, worthlessness, forgetful, difficulty making decisions
    • Risk Factors: Low family income and unemployment, Postpartum blues, Prepregnancy history of depression, Family h/o psychiatric disorder, Marital conflict/lack of support
  114. Breastfeeding
    The top 2 reasons women stop breastfeeding are pain and fear of inadequate supply
  115. Labs
    • 1st Trimester: Blood type and Rh, CBC (anemia, platelets), RPR. HIV. GC/chlamydia, PAP?, Early Glucose Challenge Test
    • 2nd Trimester: AFP/MMS
    • 3rd Trimester: Glucose Challenge Test, CBC, RPR, HIV, GC/chlamydia, Beta Strep
  116. Centering Pregnancy
    Centering Pregnancy provides group prenatal care that is relationship centered, nurturing and transforming relationships among women, their families, and health care professionals. Complete prenatal care is provided in a group setting. Prenatal assessment, education, and support occur in a facilitative environment. The model offers effective and efficient care that is sustainable and can enhance the health of women, their families, health care providers, and communities.
  117. “In utero Apgar
    • Fetal breathing
    • Fetal movement
    • Fetal tone
    • Amniotic Fluid
    • Non Stress Test
  118. Rh
    • Rh immune globulin administered within 72 hours after delivery
    • The antibodies in the immune globulin destroy fetal Rh-positive cells so that the mother will not produce anti-Rh
    • Routine administration of immune globulin at 28th week of pregnancy
  119. Assessing Fetal Lung
    • All tests involve amniotic fluid, which is an indirect assessment of the likelihood of lung maturity; direct studies of fetal pulmonary function are not possible.
    • In term and near term gestations, amniocentesis is used as an assessment of fetal lung maturity. Although only one factor in the final pre-delivery development of the term newborn
    • AmnioStat-FLM: This test looks for the presence of a lung surfactant called phosphatidylglycerol (usually just called PG). This is an agglutination test that uses antibodies to detect PG in amniotic fluid. If PG is present then visible agglutinates (clumps of particles) can be seen and the fetal lungs are considered mature.
    • Lamellar Body Count: In certain cells of the lungs, surfactants are packaged into granules called lamellar bodies and secreted from the cells into the alveoli. This test actually counts the number of lamellar bodies in amniotic fluid. The higher the lamellar body count, the more likely it is that the fetal lungs are mature.
    • Lecithin/Sphingomyelin Ratio: This was the first test of fetal lung maturity ever developed and is more commonly known as the L/S ratio. It's a measure of the ratio of two lung surfactants, lecithin and sphingomyeli, that's determined using a technique known as thin-layer chromatography. Lecithin is the most important lung surfactant and provides the greatest surface tension-lowering properties of all the surfactants. It increases dramatically in the last few weeks of pregnancy. Sphingomyelin is a minor lung surfactant and that amount of it in the lungs stays about the same throughout pregnancy so it serves as a good baseline against which the increasing amount of lecithin can be compared. A ratio that is 2.5 or greater is usually used to indicate lung maturity. Many doctors consider this to be the "best" fetal lung maturity test but that is not true.
    • TDx FLM II: This test measures the ratio of surfactant to albumin and so is sometimes called the S/A ratio.
    • The test relies on a technique known as fluorescence polarization and is the most widely used fetal lung maturity test; unfortunately it will no longer be available to clinical labs at the end of this year because the manufacturer has decided to stop making it. The effect that the loss of this test will have on patients, doctors, and labs remains to be seen!
  120. Leopold maneuvers
    • First maneuver (Upper Pole): stand at woman’s side, facing her head. Keeping the fingers of both examining hands together, palpate gently with the fingertips to determine what part of the fetus is in the upper pole of the uterine fundus
    • Second maneuver (Sides of the maternal abdomen): place one hand on each side of the woman’s abdomen, aiming to capture the body of the fetus between them. Use one hand to steady the uterus and the other to palpate the fetus.
    • Third Maneuver (Lower Pole): Turn and face the woman’s feet. Using the flat palmar surfaces of the fingers of both hands and, at the start, touching the fingertips together, palpate the area just above the symphysis pubis. Note whether the hands diverge with downward pressure or stay together. This tells you whether or not the presenting part of the fetus—head or buttocks—is descending into the pelvic inlet.
    • Fourth Maneuver (Confirmation of the Presenting Part): with your dominant hand, grasp the part of the fetus in the lower pole, and with your nondominant hand, the part of the fetus in the upper pole. With this maneuver, you may be able to distinguish between the head and the buttocks
  121. Smoking
    • Remains the single most important preventable cause of poor birth outcome
    • 20% low birth weight deliveries
    • 8% pre-term births
    • 5% perinatal deaths
  122. Reasons for Reduced Fetal Growth
    • Lower maternal weight gain
    • Vasoconstriction and decreased uterine blood flow
    • Carbon monoxide toxicity
    • Increased cyanide production
  123. Fetal Heart Rate Monitoring
    • Non Stress Test
    • FHR accelerations 15 beats x 15 seconds x2 in 20 minutes
    • Biophysical Profile
    • Labor
  124. Diabetes
    • Who needs a GCT?
    • Risks of Diabetes Mellitus
    • congenital anomalies
    • risk of preterm birth (IUGR, polyhydramnios)
    • Abnormal fetal growth (IUGR, macrosomia)
    • PIH (25% incidence)
  125. Spontaneous abortion
    • A pregnancy that ends spontaneously before the fetus has reached a viable gestational age.
    • WHO: expulsion of fetus or embryo <500 g (20 to 22 weeks)
    • The most common complication of early pregnancy
    • Estimated at 50% of all pregnancies
    • Diagnosed SAB probably half of that or less
    • 80% occur in the first trimester
    • 50% due to chromosomal abnormality
  126. Other factors (maternal, paternal, fetal and immunologic) associated with spontaneous abortion.
    • Maternal age, paternal age
    • Increasing parity
    • Smoking, ETOH, NSAIDs, aspirin, caffeine
    • Submucosal fibroid(s) (harder for successful implantation)
    • Uterine abnormality (septum, bicornuate)
    • Asherman’s (uterine synechiae, Scarring within the uterus- difficult to establish/maintain pregnancy)
    • DM, thyroid, PCOS
    • History of prior SAB
  127. SAB Usual presentation (variable)
    • Amenorrhea
    • Vaginal bleeding
    • Abdominal pain/cramping
  128. Bleeding in the first trimester:
    • Physiologic (implantation)
    • Ectopic pregnancy
    • Impending SAB
    • Cervical polyp
    • Cervical infection (Chlamydia, Trichomonas)
    • Neoplasia
    • Sexual activity (friction, increased vascularity)
  129. Threatened AB
    • Any bleeding in the first half of an intrauterine pregnancy
    • Presumptively called “threatened AB” until another specific diagnosis can be made
    • Bleeding, often painless
    • Closed cervical os and uterine size = EGA (estimated gestational age)
    • 25% of pregnancies, half proceed to SAB
    • Ultrasound needed
    • Fetal cardiac activity at expected EGA a positive sign
    • Placental sign, implantation bleeding at expected OOM (onset of menses)
  130. Inevitable AB
    • Rupture of membranes and/or cervix open, pregnancy loss unavoidable
    • Cervix is dilated, bleeding increasing, cramping
  131. Complete AB
    • All POC spontaneously passed
    • Common prior to 12 weeks
  132. Incomplete AB
    • Partial expulsion of gestational tissue
    • After 12 weeks, incomplete AB more likely
    • ROM (rupture of membranes), fetus passed, but placental tissue retained
    • Cervix open, gestational tissue may be seen in cervix, uterus Bleeding can be severe
  133. Missed AB
    • Retention of a failed IUP for an extended time period
    • Also called blighted ovum, anembryonic pregnancy
    • Physical exam – uterus smaller than expected
    • Uterus DIC can occur in 2nd trimester if missed AB >6 weeks
  134. Recurrent AB
    • More than 2 consecutive or 3 total SAB
    • Recurrent pregnancy loss: 3 or more consecutive SAB
    • Extensive workup to search for cause
  135. Induced AB
    • Termination of an intact pregnancy before the time of viability
    • May be elective or to safeguard the health of the mother
    • Elective: legal, but not medically necessary
    • Therapeutic: necessary for the health of the mother (medical, rape)
  136. SAB Definite US diagnosis
    • Absence of fetal cardiac activity in an embryo with a crown-rump length >5 mm
    • Absence of a fetal pole when mean sac diameter >18 TVS, >25 mm abdominal U/S. Smaller than expected
    • Normal yolk sac and fetal cardiac activity early in pregnancy reassuring. Chance of miscarriage is less likely, but no guarantee
    • Abnormal yolk sac (large, small, irregular, calcified), fetal heart rate <100, large subchorionic hematoma (large collection of blood under the membranes): ominous signs
    • Small subchorionic bleed may not be a problem, generally resolves spontaneously
  137. AB Treatment
    • Threatened: reassurance, pelvic rest
    • Others: Follow serum quant hCG to negative if apparent complete, D & E
    • Medical treatment: misoprostol, mifepristone
    • Expectant management if <13 weeks, stable vital signs, no evidence of infection (This is based on UpToDate, and differs from book, which states regarding watchful waiting of incomplete AB: “Conservative management of these patients significantly increases the risk of infection.” )
  138. Post Abortion Care
    • Rhogam, if Rh negative
    • Methylergonovine maleate, Helps clamp down the uterus
    • Doxycycline for prophylaxis with D & C. Reduce chance of surgical infection
    • Grief counseling
    • Pelvic rest for 2 weeks
    • Custom is to advise no pregnancy for 2 to 3 cycles (no evidence this is beneficial)
    • Contraception if desired
  139. Ectopic Pregnancy
    • Ectopic = out of place
    • Pregnancy implantation outside the uterine cavity
    • Leading cause of pregnancy-related death in the 1st trimester
    • 20/1000 pregnancies 1992
    • Incidence increasing, deaths decreasing
    • No CDC reporting since early 1990s
    • Rates increased during the 20th century, associated with increase in PID
    • Current incidence difficult to estimate
    • 98% fallopian tube
    • Others: cornual (interstitial), cervical, fimbrial, ovarian, abdominal, heterotopic (intrauterine and ectopic at the same time)
    • Unusual locations more common with ART (assistive reproductive technologies)
  140. Ectopic Risk Factors
    • High: Tubal pathology, Previous ectopic, DES, Tubal surgery (reconstructive), but due to underlying tubal damage—depends on Tubal condition, Type of surgery, Surgeon’s expertise.
    • Moderate: Previous infection (PID, chlamydia, GC), especially recurrent, Infertility (probably due to tubal problems), Multiple sexual partners
    • Low: Smoking, Vaginal douching, Age, Early sexual debut, Older age groups (probably cumulative risk factors over time)
    • Other Factors: IVF (previously, now = prevailing rate), Tubal sterilization (Higher in BTL before age 30. Bipolar coagulation more associated with ectopic. Copper IUD and Mirena lowest rate, Progestasert higher than no contraception.
    • 98% fallopian tube
    • Others: cornual (interstitial), cervical, fimbrial, ovarian, abdominal, heterotopic (intrauterine and ectopic at the same time)
    • Intrauterine pregnancy may or may not be viable after correcting ectopic pregnancy
    • Unusual locations more common with ART (assisted reproductive technologies) – fertility treatment.
  141. Ectopic Symptoms
    • Abdominal pain
    • Amenorrhea
    • Vaginal bleeding
    • Sound familiar??
    • BUT: 50% of women are asymptomatic with ectopic pregnancy before tubal rupture
    • Usual pregnancy symptoms
    • Shoulder pain (blood under diaphragm), acute onset
    • Rupture: lightheadedness, shock (intraabdominal bleeding)
    • Urge to defecate (blood in cul-de-sac)
  142. Ectopic Evaluation
    • Exam often unremarkable
    • Orthostatic vitals if ruptured,
    • Occasionally fever
    • Pain to abdominal palpation, rebound
    • Adnexal pain
    • CMT
    • Quantitative serum hCG
    • Ultrasound (transvaginal)
  143. Ectopic Treatment
    • Surgical: Ruptured ectopic, especially if hemodynamically unstable. Laparoscopic surgery the approach of choice. Salpingostomy with healing by secondary intention, best outcomes
    • Methotrexate
    • Expectant management?
  144. Natural history of ectopic pregnancies
    • Tubal rupture: profound hemorrhage, major cause of pregnancy-related maternal mortality in 1st trimester
    • Tubal abortion: expulsion of POC through the fimbria, resulting in tissue regression or reimplantation (abdominal or ovarian)
    • Spontaneous resolution (1955 study 48%)
  145. Gestational Trophoblastic Neoplasia (GTN)
    • A rare variant of pregnancy
    • Hydatidiform mole (complete and partial)
    • Invasive mole (chorioadenoma destruens)
    • Choriocarcinoma
    • Placental-site trophoblastic tumor (PSTT)
    • Clinical Features: Usually benign molar pregnancy. Potential for malignant transformation (choriocarcinoma). Often exaggerated pregnancy symptoms. Now more often diagnosed before clinical manifestations, due to hCG and U/S. hCG is the tumor marker – quantitative counts will be much higher than expected. Highly curable with chemotherapy.
    • Evaluation: hCG, U/S, Workup for metastatic disease
    • Treatment: D & C, Methotrexate, Other chemotherapeutic agents, if malignant or malignant potential. Follow with serial hCGs. Make sure levels return to zero. If they don’t come back or are increasing – could be GTN.
  146. Cervical Insufficiency
    • previously cervical incompetence
    • Painless cervical changes that occur in the second trimester and result in recurrent pregnancy loss
    • Congenital factors: Short cervix (mean 35 mm, preterm birth risk 10-fold higher if cervix 22 mm). Müllerian abnormalities (developmental abnormalities such as bicornuate, unicornuate uteri.) Collagen abnormalities. Familial clustering
    • Trauma (most associated): Cervical laceration (MVA, precipitous delivery), Instrument dilation, Cone biopsy, LEEP (tx for abnormal PAP smears)
    • Elevated serum relaxin: Connective tissue remodeling. Higher in twin pregnancies and pregnancies induced by menotropins
  147. Cervical Insufficiency Clinical Manifestations
    • Vaginal fullness or pressure
    • Vaginal spotting or bleeding
    • Watery, mucousy, or brown vaginal discharge (tinged with old blood)
    • Vague abdominal or back discomfort
    • Late presentations usually – cervix is starting to thin out, something has already happened.
  148. Cervical Insufficiency Diagnosis
    • History of acute, painless 2nd trimester pregnancy loss
    • Clinical findings of premature cervical effacement &/or dilatation (>2 cm)—serial digital exams (previously)
    • TVS: (shortening endocervical canal, “funneling” fetal membranes into endocervix). Wedge shaped appearance of cervix – not normal
  149. Cervical Insufficiency Treatment
    • Bed rest—not proved in RCT, pessary?
    • Progesterone (best), indomethacin
  150. Progesterone for prevention of preterm labor
    • Vaginal progesterone
    • 17 alpha-hydroxy-progesterone caproate (17-OHPC, 17-P) – best evidence. IM injections by healthcare provider, 250 mg weekly for weeks 16-36 (gluteal or arm) 20 doses for complete pregnancy
  151. Prophylactic cerclage
    • ”purse string suture”
    • Medical treatment is much more effective than cerclage
    • Remove prior to labor or c-section
    • Labor with cerclage in place risks uterine rupture or extensive cervical laceration
  152. Twins
    • Two placentas, two amnions, two chorions From either dizygotic twins or monozygotic twins with cleavage of zygote during first 3 days after fertilization
    • One placenta, one chorion, two amnions. Monozygotic twins with cleavage of zygote from the fourth to the eighth day after fertilization
    • One placenta, one chorion, one amnion Monozygotic twins with cleavage of zygote from the eighth to the twelfth day after fertilization)
  153. Monozygotic twinning
    • Division of the fertilized ovum at various times after conception
    • “Identical”
    • Incidence 1/250
    • Risks to fetuses based on when twinning occurs
  154. Dizygotic twinning
    • 2 separate ova are fertilized by 2 separate sperm
    • “Fraternal”—siblings
    • Increased Risk: 2 separate ova are fertilized by 2 separate sperm, “Fraternal”—siblings, Increased with age, parity, Familial factor follows maternal lineage
  155. Multifetal gestation Concerns
    • Preterm labor and delivery
    • IUGR
    • Polyhydramnios
    • Preeclampsia
    • Congenital anomalies
    • Postpartum hemorrhage
    • Placental/umbilical cord accidents
    • Increased risk SAB
  156. Usual Presentation of SAB
    Amenorrhea, Vaginal bleeding, Abdominal pain/cramping
  157. Differential Diagnosis
    Bleeding in the first trimester: Physiologic (implantation), Ectopic pregnancy, Impending SAB, Cervical polyp, Cervical infection, neoplasia
  158. hCG (Human chorionic gonadotropin)
    Can be qualitative (positive or negative), usually on urine; Quantitative on serum
  159. Ultrasound and hCG level
    • Visibility of gestational sac:
    • TVS: as low as 800 IU/L hCG, definitely at 1500 to 2000 IU/L
    • Abdominal: 5000 IU/L
    • TVS:
    • Gestational sac usually visible at 4.5 to 5 weeks
    • Fetal pole with cardiac activity 5.5 to 6 weeks
  160. Sequence of Prenatal Diagnosis
    • Clinical screening (historical, physical, biochemical, sonographic)
    • Initial referral interview (family history, review of medical records, patient education)
    • Discussion of risks, benefits, limitations of available testing options (informed consent)
    • Initial screening (ultrasound)
    • Invasive testing (CVS, amnio, PUBS)
    • Evaluation of test results
    • Perinatal planning
    • Postnatal care
  161. Impact of Prenatal Diagnosis
    • Terminate Pregnancy
    • Continue Pregnancy
    • Antenatal treatment (NTDs)
    • Anticipatory grief
    • Preparation
    • Ancillary counseling
    • Tertiary referral and delivery (timing and method)
    • Adoption
    • Decision for future reproduction
  162. Ethical Considerations
    • Terminations vs. continuation vs. adoption
    • Eugenics: Some believe that testing is available to eliminate certain genetic conditions or groups of people
    • Privacy/confidentiality/discrimination: Who should have access to results?
    • Effective patient and public education
  163. non-directive counseling
    • Nondirective, or client-centered, counseling is the process of skillfully listening to a counselee, encouraging the person to explain bothersome problems, and helping him or her to understand those problems and determine courses of action. This type of counseling focuses on the member, rather than on the counselor as a judge and advisor; hence, it is “client-centered.”
    • It stresses changing the person, instead of dealing only with the immediate problem in the usual manner of directive counseling. The counselor attempts to ask discerning questions, restate ideas, clarify feelings, and attempts to understand why these feelings exist.
    • Counseling procedure in which the counselor is empathetic and does not evaluate or direct (but may clarify) clients' remarks, thus assisting them to accept responsibility for their own problem-solving.
    • The non-directive approach involves presentation of the facts in an unbiased manner, leaving the entire responsibility of decision with the consultee. It supports people in reaching their own decisions, based on their own unique medical and social circumstances.
    • The counselor communicates, enables, explores, encourages, informs, offers choices, discusses, promotes autonomy, is empathetic, non-judgmental, and respectful of the client.
  164. Key factors in genetic screening and teratology counseling.
    • Obtain pregnancy history
    • Obtain family history
    • Provide risk assessment
    • Review risks, benefits, limitations of available prenatal diagnostic options
    • Provide information, support to patient throughout decision-making, testing and result process
    • Maternal conditions: Maternal illnesses increase the risk for birth defects. Some individuals consider maternal conditions to be “teratogenic”. Insulin-Dependent Diabetics, Lupus, Seizure disorders, Substance Abuse
    • Teratogens: An exposure during embryogenesis which has a harmful effect on the developing fetus. Maternal conditions (IDDM), Medications (Valproic Acid, Accutane), Excessive heat, Hypoxia, Recreational drugs (Ethanol, cocaine, tobacco)
  165. Which populations should be tested for hemoglobinopathies
    • African American, Southeast Asian, Mediterranean descent
    • Sickle Cell: parents are carriers—have sickle cell disease or trait
    • ACOG: Individuals of African, Southeast Asian, and Mediterranean descent are at increased risk of being carriers of hemoglobinopathies and should be offered screening tests. If both parents are carriers, genetic counseling should be available. A complete blood count and hemoglobin electrophoresis or HPLC are appropriate screening tests.
  166. Current ACOG recommendations for cystic fibrosis (CF) screening.
    • As a routine part of obstetric care and regardless of ethnicity, all women of reproductive age should be offered preconception and prenatal CF carrier screening.
    • CF screening should be offered to all women of reproductive age, although it is most efficacious in the non-Hispanic white and Ashkenazi Jewish populations.
    • If a patient has been screened previously, the test should not be repeated, but CF screening results should be documented.
    • For routine carrier screening, complete analysis of the CF transmembrane regulator (CFTR) gene by DNA sequencing is not appropriate.
    • Maternal carrier screening is not replaced by newborn screening panels that include CF screening.
    • If a woman with CF wishes to become pregnant, a multidisciplinary team may assist in management of issues regarding pulmonary function, weight gain, infections, and higher risks for diabetes and preterm delivery.
    • When both parents are CF carriers, they should undergo genetic counseling to review prenatal testing and reproductive options.
    • When neither parent is affected by CF, but 1 or both has a family history of CF, CFTR mutation analysis in the affected family member may be identified from medical record review, and the couple should undergo genetic counseling.
    • If a woman's reproductive partner has CF or apparently isolated congenital bilateral absence of the vas deferens, mutation analysis and consultation by a geneticist is recommended.
  167. First Trimester Screening
    • Nuchal translucency screening
    • PAPP-A and Free H-hCG
    • Early amniocentesis
  168. Nuchal Translucency Screening
    • Designed to identify fetuses at-risk for Trisomies 13, 18 & 21.
    • Ultrasound measurement of the Nuchal Translucency (NT) obtained 10-13 6/7 gestational weeks
    • Increased Nuchal Translucency > 3mm = 60% risk of aneuploidy
  169. PAPP-A and Free B-hCG
    • PAPP-A (Pregnancy Associated Plasma Protein-A) produced by placenta.
    • hCG (Human Choriogonadotropin) produced by placenta
    • Up to 80% detection of DS
    • >90% detection of Tri 13 & 18
    • if both PAPP-A and B-hCG are very low MoM = Increased risk for tri 18, triploidy, fetal anomalies or perinatal complications
  170. Advantages of 1st Trimester Screening
    • Provides patients with early risk assessment compared to second trimester screening
    • Patients can opt for earlier prenatal diagnostic procedures.
    • May reduce number of invasive procedures
    • May identify other severe anomalies at time of scan and increased risk of adverse pregnancy outcome
    • Opportunity to estimate gestational age
  171. Limitations of 1st Trimester Screening
    • Accuracy of NT strongly dependant on experience of ultrasonographer
    • Not all women enter prenatal care in time for screening
    • Results of screen may arrive too late for available diagnostic testing (CVS, early amnio)
    • Cost
    • Cannot detect many NTD’s and no ventral wall defects (omphaloceles, gastrochisis)
  172. CVS
    • Performed between 10-12 weeks gestation
    • 1/100-1/150 procedure-related risk for miscarriage
    • Transcervical and transabdominal
    • Detects aneuploidy and single gene conditions
    • Cannot detect ONTDs or evaluate fetal anatomy
    • Limb anomalies and confined placental mosaicism (CPM) associated with procedure (1/3,500 and 1/150, respectively)
  173. Early Amniocentesis
    • Performed between 12-14 weeks gestation
    • Higher risk for miscarriage compared to traditional amniocentesis (amnion/chorion separation)
    • Advantages: Early diagnosis of aneuploidy and ONTD
    • Disadvantages: Increased risk for club foot (1.5%)
    • Low yield of amniocytes, higher risk for culture failure or longer turnaround time
  174. Second Trimester Screening
    Maternal Serum Screening (aka AFP, Triple Screen, Quad Screen)
  175. Maternal Serum Screening (aka AFP, Triple Screen, Quad Screen)
    • Biochemical Screening (maternal blood)
    • AFP (Produced in fetal liver and GI tract of the fetus)
    • hCG (Produced and secreted by the placenta)
    • uE3 (Produced and secreted by fetal adrenals and the placenta)
    • Dimeric Inhibin A (produced and secreted by placenta)
    • Demographic information (i.e., age, weight, gestational age, IDDM status, multiple status, ethnicity)
    • Trisomy 18: 60% (Quad screen does not impact detection rate)
    • Neural Tube defects: 80% (AFP is the only protein which impacts detection rate)
    • Down Syndrome: With traditional triple screen (AFP, hCG, uE3) detects 60%. With Quad screen (AFP, hCG, uE3, DIA) detects 70%
    • Detection of OPEN neural tube defects (80%)
    • Detection of certain aneuploidies: Trisomy 21 (Down syndrome) up to 70%, Trisomy 18 (Edward syndrome) 60%
  176. Advantages of Screening
    • Identifies pts at risk for certain birth defects
    • Identifies incorrectly dated pregnancies (allows for correction of dates if incorrect by 10-14 days)
    • Can alter pregnancy management by improving outcome of fetuses with lumbar & sacral NTDs
    • Allows patients to consider pregnancy management options
    • Identifies multiple pregnancies
    • Can identify fetuses at risk for certain malformations/conditions: Renal agenesis (AFP low or undetectable), GI obstruction, Ventral wall defects (AFP high), IUFD or future demise (any or all values extremely altered)
  177. Disadvantages of MSS
    • Cannot r/o all aneuploidies
    • Cannot eliminate risk for Down syndrome, Trisomy 18 or NTDs
    • Increases maternal/paternal anxiety
  178. Amniocentesis
    • Performed weeks 15 through term
    • 1/200 procedure-related risk for SAB
    • Detects aneuploidy, ONTDs (>98%) and single gene conditions, Rh incompatibility, lung maturity (term)
    • Fetal anatomy can be evaluated at time of amniocentesis
  179. Percutaneous Umbilical Blood Sampling (PUBS)
    • Performed after 16 weeks gestation
    • Ultrasound guidance
    • IM injection of pancuronium bromide to fetus or umbilicus
    • 3-5ml blood aspirated from vein
    • 1/100 procedure-related risk for miscarriage
    • Originally designed to test for conditions that could not be determined by CVS or amnio alone. Currently used to evaluate fetuses at risk for thrombocytopenia, etc and used for management issues (i.e., transfusion)
  180. Fluorescent In Situ Hybridization (FISH)
    • Fluorescent probes used to adhere to centromeric region of chromosomes
    • Allows for a rapid, preliminary result of certain aneuploidy
    • Can identify conditions associated with small deletions of chromosomes (i.e., Prader-Willi syndrome)
  181. Tests to Offer when Screening Shows Increased Risk of Fetal Abnormalities
    • Detailed ultrasound exam: A type of ultrasound exam that can help explain abnormal results and provide more detailed information about the growth and development of the fetus.
    • Amniocentesis: A procedure in which a small amount of amniotic fluid and cells are withdrawn from the sac surrounding the fetus and tested.
    • Chorionic villus sampling (CVS): A procedure in which a small sample of cells from the placenta is tested.
  182. Influenza During Pregnancy
    • Pregnant women generally have a worsened flu course – particularly true with H1N1
    • Vaccination should be universally practiced, inactivated – any trimester with or without preservative
  183. GBS Pregnancy
    • 10-30% of women GBS vaginal/rectal colonization
    • Colonization can be acute/chronic or intermittent
    • GBS bacteruria indicates heavy colonization
    • Neonatal sepsis rate about 1% but GBS sepsis has a 50% case fatality
  184. GBS Infant
    • GBS infections in infant are categorized as “early” or “late”
    • Early: first 6 days of life- 75% of cases, can occur in utero or during birth
    • Risk factors: PTL, PPROM, PROM
    • Late: onset after first week of life, nosocomial or community acquired cases documented
  185. CDC’s recommendations for prenatal GBS cultures
    • Site: vagina and rectum, single swab or two swabs, through anal sphincter
    • Timing: 35 to 37 weeks
    • Collection: NOT by speculum, self collection an option
  186. Asymptomatic Bacteruria and UTIs During Pregnancy
    • 10% of pregnant women have asymptomatic bacteruria
    • Risk doubled with sickle cell
    • One quarter of those will go on to pyelonephritis
    • Most are gm neg –E coli, proteus, Klebsiella
  187. Bacterial Vaginosis
    • Related to sexual activity – not STD
    • Thin, watery, fishy discharge
    • Dx: clue cells on wet prep, basic pH, fishy order with KOH
    • Adverse pregnancy outcomes: Preterm Birth/LBW, Placental/Intraamniotic Infection, Associated with higher risk of preterm delivery, perioperative infection
    • USPSTF says insufficient evidence to recommend routine screen and Rx
    • Pursue and Rx for sxs.
  188. HIV Mom at risk
    • For AIDS pts may be risk if pt has pneumonia
    • For HIV infected, generally does not cause progression though slight CD4 decline may be seen at end of pregnancy
    • With a few exceptions, most meds are available
  189. HIV Baby at risk
    • No rx – 30% vertical transmission
    • AZT alone 6 %, with c/s 3%
    • Optimal Rx -VL undetectable <1%
  190. HIV and Cesarean
    • Most transmission intrapartum
    • Increased risk with ROM >4 hours
  191. Hepatitis B
    • Sort out acute versus chronic infection- check LFTs, Hep B core antibody
    • Transmission to partner: check his surface antigen /antibody status. If both negative, then vaccinate
    • Vertical transmission when mom is a Hep B chronic carrier
    • Usually occurs in labor, <10% infected transplacentally antenatally
    • E antigen suggests increased risk infectivity
    • Give Recombivax, HBIg to neonate after delivery to interrupt transmission, 90% effective
    • Can she have an amniocentesis? Yes, no increased rates of vert transmission have been reported after amniocentesis, defer if Hep B e ag +?
    • Can she breast feed? Yes, after infant receives Hep B vaccine and HBIg
  192. Hepatitis C
    • Screen at risk gravidas currently – HIV pos, IVDU
    • Vertical transmission greatest if viral load > 10^6
    • OK for vag delivery, nursing if nipples not cracked
    • Risk of transmission 2-5%
  193. Syphilis
    • All Ob pts screening with a VDRL, RPR or STS
    • Diagnosis confirmed with a treponemal specific test
    • PCN allergic pts are desensitized
    • Syphilis can cayuse hydrops, stillbirth and congenital syphilis
  194. Management of Genital Herpes During Pregnancy
    • Acyclovir
    • Category C
    • Asymptomatic shedding may still occur
    • No strategy eliminates the risk of neonatal herpes.
  195. Effects of Congenital Rubella
    • Risks of congenital rubella syndrome are GA dependent and cover a wide spectrum of disease and can be transient, permanent and/or progressive, Most common Heart, eye, ear, heart.
    • Live attenuated vaccine: administer post partum to avoid conception. Recommend 3 month delay though no cases of CRS reported after vaccine
    • Ocular Defects: cataracts, microphthalmia, glaucoma, retinitis
    • Heart Defects: patent ductus arteriosus, ventricular septal defect, peripheral pulmonic artery stenosis
    • Hearing Impairment/CNS: sensorineural deafness, mental retardation, meningoencephalitis, progressive rubella panencephalitis, microcephaly
    • Other: growth retardation, radiolucent bone disease, hepatosplenomegaly, hematologic abnormalities, thrombocytopenia, purpura, pneumonitis, endocrine dysfunction, IDDM, thyroiditis
  196. Varicella
    • Order a varicella antibody. In US, 80% of those with no history of Ch Pox have antibodies to Varicella.
    • Plan to vaccinate postnatally. 2 dose regimen. Little data on lactation but generally given
    • Varicella – perinatal exposure: Varicella immune globulin (VZIg) 1 amp / 10kg up to 5 amps given may interrupt transmission.
    • Maternal varicella: Higher case fatality rate – use acyclovir
  197. TORCHES
    • Acronym for infections in pregnancy with teratogenic potential for fetus
    • TOxoplasmosis
    • Rubella
    • Cytomegalovirus
    • HErpes Simplex
  198. Pregnancy Induced Hypertension (PIH)
    • Develops as a consequence of pregnancy and regresses postpartum
    • Hypertension without proteinuria or pathologic edema
    • Preeclampsia
    • Eclampsia
    • Coincidental hypertension: Underlying chronic hypertension that antecedes pregnancy
    • Pregnancy-aggravated hypertension: Underlying hypertension worsened by pregnancy, Superimposed preeclampsia/eclampsia
    • Transient hypertension: Mild hypertension that develops after the mid-trimester that does not compromise pregnancy. Regresses after delivery
  199. Preeclampsia
    • proteinuria and/or pathologic edema (MILD or SEVERE)
    • Hypertension complicates 5% to 7% of all pregnancies
    • Preeclampsia/Eclampsia is responsible for 70% of hypertension in pregnancy
    • Preeclampsia is a major contributor to maternal morbidity and mortality
  200. Preeclampsia Pregnancy Associated Risks
    • multi-fetal gestation
    • hydrops fetalis
    • hydatidiform moles
    • chromosomal anomalies (trisomy 13, triploidy)
    • urinary tract infection
    • structural congenital anomalies
    • gestational diabetes
  201. Preeclampsia preconceptional and/or chronic risk factors
    • Partner related factors
    • first pregnancy with a new partner
    • limited sperm exposure, teenager, donor insemination
    • partner fathering preeclamptic pregnancy with another woman
  202. Maternal-specific risk factors for Preeclampsia
    • first pregnancy
    • personal or family history of preeclampsia
    • age <20 or >40, interval between pregnancy
    • Underlying maternal disorders - (i.e. – chronic HTN, renal disease, diabetes, migraine, RA, lupus, hereditary thrombophilias, etc.)
  203. Severe Preeclampsia Signs and Symptoms
    • HA
    • Hyperreflexia (3+, ankle clonus)
    • Visual changes: photophobia, blurry, blind spots
    • Irritability
    • Epigastric (hepatic) pain of elevated liver enzymes
    • Edema of face, hands, abdomen
    • Oliguria
  204. Eclampsia
    • Proteinuria and/or pathologic edema with convulsions
    • Seizure ® anoxia ® hypoxia ® hypoxemia ® uteroplacental insufficiency, possibly abruptio ® fetal distress ® fetal growth restriction, preterm birth, low birth weight
    • Can lead to maternal and/or fetal death
    • Worse outcomes if occurs before 28 wk, if mother > 25 yr., multigravid, or with pre-existing renal or hypertensive disease
  205. HELLP Syndrome
    • Complication in 10% of severe preeclampsia/eclampsia
    • major factor for maternal morbidity & mortality
    • H = hemolysis
    • E = elevated
    • L = liver enzymes
    • L = low
    • P = platelets
  206. HELLP Classic presentation
    • Primary symptom: Malaise, Fatigue
    • N&V
    • HA
    • RUQ Abd pain
    • Severe ­ BP
    • 3+ protein, 85% of the time
  207. Treatment of Severe Preeclampsia or HELLP Syndrome
    • Antihypertensives: to control blood pressure until delivery
    • Corticosteroids: to improve liver & platelet function, assist with fetal lung maturity
    • Anticonvulsants: magnesium sulfate for seizure prophylaxis
    • Bed rest: improve blood pressure, increase blood flow to placenta
    • Delivery: only cure
  208. Fetal Growth Restriction
    • Weight < 10th percentile for gestational age & gender
    • occurs as a result of a pathologic process that inhibits expression of normal growth potential
  209. Low Birth Weight
    Low birth weight (LBW) is defined as a birth weight of <2,500 g (5 lb, 8 oz).
  210. IUGR Risk factors
    • Chronic vascular diseases – hypertension, diabetes
    • Smoking
    • Fetal abnormalities (trisomy 18)
    • Multifetal gestation
    • Abnormal placentation
    • Poor maternal weight gain or malnutrition/malabsorption
  211. IUGR Diagnosis, Clinical suspicion, Maternal risk factors
    • cardiovascular or renal disease
    • low maternal weight gain
    • vaginal bleeding during pregnancy
    • low pre-pregnancy weight
    • prior delivery of FGR infant
    • prior stillbirth
    • maternal smoking, alcohol, cocaine, or heroin use
    • elevated second trimester MSAFP
    • Clinically size less than dates (< 2cm than expected fundal height)
    • Ultrasound measurements. Serial measurements reinforce diagnosis
  212. IUGR Types
    • Symmetric growth
    • Asymmetric growth - head sparing
  213. IUGR Etiology
    • Genetic factors ( 5%-15%)
    • congenital malformations
    • chromosomal abnormalities (2% -5%)
    • Maternal genetic disorders (PKU)
    • Congenital Infections (< 5%)
    • damage cells during organogenesis
    • Infections leading to FGR
    • 5-10% of FGR due to chronic uterine infection
    • Cytomegalovirus (CMV) Most common infectious cause of FGR
    • Rubella, 40 to 60% of cases
    • Varicella, 40% of fetuses developing in utero varicella infection
    • Others: Toxoplasma, HSV, Listeria, influenza, malaria
    • Placental factors: Placenta previa, placental infarction, single umbilical artery, small placenta,
    • Multiple gestation
  214. IUGR Management
    • Ultrasound for growth assessment
    • Antenatal testing
    • Nonstress testing
    • Biophysical profile –breathing, tone, movement, AFI
    • Umbilical Doppler
  215. Long-term follow-up of FGR
    • High mortality in the first 2 years of life
    • Decreased height and head circumference measurement at 4 years of age
    • Intellectual deficits
  216. Gestational Diabetes Mellitus (GDM)
    • Carbohydrate intolerance induced by pg-insulin resistance and/or not enough insulin
    • 3-5% of all pregnancies (8-10% if Hispanic, African American Pregnancies)
    • ACOG: Screen at 24-28 wks with I hr glucola if: > 25 yo or Family history of DM or Ethnic Risk
    • NML FBS and 2 HR GTT = Not at Risk
    • 2 Abnormals, or FBS > 199, = GDM
  217. Rule of 15’s
    • 15% of prenatal patients have abnormal initial GTT
    • 15% of these will have abnormal 3 hour GTT (= GDM)
    • 15% of there will have diabetes that persists postpartum
  218. GDM Risk Factors
    • > 25 years old
    • Prior GDM or family history of DM
    • Prior macrosomic infant, prior stillbirth
    • BMI greater than or equal to 27
    • Chronic hypertension
    • Glycosuria
    • Obesity
    • Non-white race
  219. Diagnosis of GDM
    • 1 hr. 50 g glucola challenge with cutoff of 140 mg/dL. Usually done at 28 weeks – may be done sooner if indicated by presence of risk factors (obesity, family history, etc.)
    • If abnormal, a 3 hr. 100 g glucola challenge is done – If at least 2 values are abnormal, GDM is diagnosed
  220. White’s Classification
    • A – Abnormal GTT without clinical signs/symptoms of DM. A1 – diet controlled. A2 –insulin controlled.
    • B – Age at onset > 20 yr., duration < 10 yr., no vascular complications.
    • C – Age at onset 10-19 yr. or duration 10-19 yr., no vascular disease.
    • D – Age at onset <10 yr. or duration > 20 yr. or background retinopathy or HTN.
    • F – Nephropathy (>500 mg/24 hr.)
    • H – arteriosclerotic heart disease
    • R – Proliferative retinopathy
    • T – post renal transplant
  221. Treatment for GDM
    • DIET: 2000-2500 ADA diet, 3 meals and 2 snacks, 50-60% carbs, 20% proteins, 25-30% fat, if possible, refer to diabetic nurse educator
    • Blood Glucose Monitor : blood sugar check QID, tight control
    • Exercise
    • If inadequate blood sugar control, insulin 2-3 x/day
    • Consider glyburide, metformin (controversial, not FDA approved, but appears safe & effective)
    • In addition to diet, BS checks, medications
    • NST @ 36 weeks
    • BPP & US to follow size & anomaly scan
    • Deliver at 40 weeks, earlier if EFW near 4000 gm
  222. Treatment for preexisting DM
    • Oral hypoglycemic agents/insulin sensitizers have not been well studied in pregnancy in the setting of preexisting DM (e.g. Type 2)
    • Insulin: Multiple regimens available for flexibility – split dose (e.g. NPH/Regular); “basal-bolus” using analogs (e.g. long acting insulin glargine, short acting insulin aspart & insulin lispro); CSII/pump therapy with short acting analog
  223. Maternal Complications of DM
    • Pre-eclampsia: 4x more likely
    • Bacterial Infection: More likely to have UTI ® pyelonephritis
    • Difficult delivery: macrosomia/shoulder dystocia, More likely to have operative delivery, C-section, forceps, vacuum delivery
    • Polyhydramnios
    • Ketoacidosis
    • Preterm labor
  224. Pregnancy ‘unmasks’ potential IDDM mothers
    • 30-50% develop Type II DM in 10 years
    • 60-100% develop Type II DM in 20 years
  225. Neonatal Complications of DM
    • Macrosomia (2-3x more likely)
    • Birth injury
    • Shoulder dystocia
    • Hypoglycemia
    • Major anomalies (3x more likely) – cardiac, neural tube defect, skeletal
    • Predisposition to DM & obesity
    • Polycythemia
    • Hyperbilirubinemia
    • Neonatal hypoglycemia
    • Perinatal mortality 4x more likely
  226. McRoberts maneuver
    • sharply flex maternal hips
    • apply moderate suprapubic pressure to disimpact the anterior shoulder
    • insert hand to sweep posterior arm across chest & over perineum, using even pressure to avoid fracture
  227. Dangers of Shoulder Dystocia
    • Umbilical cord enlargement
    • Inability of child’s chest to expand properly
    • Severe brain damage or death due to hypoxia or acidosis if delay in delivery
    • Brachial plexus damage
  228. Oligohydramnios
    • too little fluid
    • < 5 cm AFI on ultrasound (total of 4 quadrants), or max pocket < 2 cm x 2 cm
    • Postdates
    • Fetal growth restriction
    • Fetal renal abnormalities
    • Premature rupture of membranes
  229. Polyhydramnios
    • too much fluid
    • > 25 cm AFI on ultrasound
    • > 1000ml at term
    • Diabetes
    • Fetal abnormalities
    • Twins
    • Hydrops
  230. Pregnancy Changes Cardiovascular Anatomic changes
    • Heart rotates in a left upward displacement with uterine enlargement and diaphragmatic elevation.
    • PMI shifts laterally.
    • Heart size increases by 12%
  231. Pregnancy Changes Blood volume
    • hypervolemia
    • Expansion begins early in first trimester, rapid increase in second, and plateaus in third
    • ~50% increase in plasma volume due to cascade of pregnancy hormones
    •  estrogen by placenta → stimulates RAAS which promotes Na+ and water reabsorption
    • Other hormones promote erythropoiesis → 30% increase in RBC mass
    • The resultant hypervolemia compensates for maternal blood loss at delivery
  232. Pregnancy Changes Cardiac output
    • Increases ~40%
    • Heart rate rises ~15%
    • CO increases in labor with painful contractions
    • Multiple gestations have more profound effects
  233. Pregnancy Changes Blood pressure
    • SAP declines slightly with lowest point ~24-48 weeks
    • Pulse pressure widens
    • Venous pressure progressively increases in LEs → edema and varicosities.
    • This results from compression of IVC
  234. Pregnancy Changes Peripheral Vascular resistance
    Decreases in first trimester
  235. Pregnancy Changes Blood flow distribution
    • Uterine blood flow ~ 800ml/min
    • Renal, breast, and skin blood flow increases
  236. Pregnancy Changes Heart murmurs
    • Systolic ejection murmurs
    • Heard in ~90% in pregnancies as a result of increased CO
    • Splitting of S1
    • Continuous murmurs or bruits at LLSB due to mammary artery
    • Normal pregnancy can also be accompanied by sinus tachycardia, sinus bradycardia, and isolated atrial and ventricular premature contractions
  237. Pregnancy Changes Pulmonary system
    • Anatomic changes
    • Prominent pulmonary markings on CXR due to increased pulm blood volume
    • Diaphragm is elevated ~ 4cm
    • Thoracic circumference increases ~6cm
  238. Pregnancy Changes Lung volumes and capacities
    • Hyperventilation, as a result of increased tidal volume, results in mild respiratory alkalosis
    • May be feto-protective to prevent fetus from being exposed to high CO2 tensions
  239. Pregnancy Changes Renal system
    • Anatomic changes
    • Length of kidneys increase by 1/5cm
    • Entire collecting system dilates to contain ~200ml more urine; disappears by postpartum day 4
  240. Pregnancy Changes Renal function
    • Renal plasma flow increases 50-85%, results in:
    • Elevated GFR - peaks by end of 1st trimester and remains high until term
    • Lowers Cr and BUN serum concentrations
    • Decreased renal vascular resistance
    • Renin activity increases in 1st trimester and rises until term
    • Pregnant women are resistant to vasoconstriction effects of angiotensin II and other vasopressors
    • Pregnant women who are unable to sufficiently augment vasopressin secretion (in the presence of vasopressinase produced by placenta) can develop a diabetes insipidus–like condition characterized by massive diuresis and profound hypernatremia
  241. Pregnancy Changes Bladder
    • Displaced upward as uterine enlarges
    • Increased urinary frequency
    • Increased bladder capacity
  242. Pregnancy Changes GI system
    • Anatomic changes
    • Abdominal organs displaced with uterine growth
  243. Pregnancy Changes Oral cavity
    • Increased salivation
    • Hypertrophic gums with easy bleeding, possibly due to increased estrogen
  244. Pregnancy Changes Esophagus and stomach
    • Reflux symptoms in ~80% of women, commonly in 1st trimester
    • Greater production of gastrin → increased stomach volume and acid production
    • Decreased peristalsis
    • Slowed gastric emptying of solid foods
  245. Pregnancy Changes Intestines
    • Decreased transit times (slower) in 2nd and 3rd trimesters, due to progesterone?
    • Can enhance water absorption and predispose to constipation
  246. Pregnancy Changes Gallbladder
    • Slowed/incomplete emptying
    • Increased risk of stone formation
  247. Pregnancy Changes Liver
    • Reduced plasma albumin levels
    • Elevated serum alkaline phosphatase
  248. Pregnancy Changes Hematologic system
    • Pregnancy Changes RBCs
    • Cell mass expansion by 33% → anemia
  249. Pregnancy Changes Iron
    Many women begin pregnancy in an iron-deficient state, making them vulnerable to iron deficiency anemia → supplemental iron
  250. Pregnancy Changes WBCs
    Elevated leukocyte counts
  251. Pregnancy Changes Platelets
    • Pregnancy associated thrombocytopenia during 3rd trimester
    • Pregnancy Changes Clotting factors
    • Circulating levels increase
  252. Pregnancy Changes Skin
    • Anatomic changes
    • Hyperpigmentation → mask of pregnancy
    • Striae gravidarum = ‘stretch marks’ appear in 2nd trimester
    • Spider angiomas, palmar erythema, cutis marmorata, worsening varicosities
    • Nails become brittle, Beau’s lines
    • Thickening of hair, hirsutism
  253. Pregnancy Changes Metabolism
    The maternal appetite and food intake usually increase, although some have a decreased appetite or experience nausea and vomiting. In rare instances, women with pica may crave substances such as clay, cornstarch, soap, or even coal
  254. Pregnancy and STIs
    • Syphilis: Penicillin remains the treatment of choice in pregnancy, secondary to its ability to cross the placenta and treat the fetus
    • For PCN allergic pts: penicillin desensitization is recommended
    • Chlamydia: Treatment usually consists of 7 days of erythromycin or one dose of azithromycin in the pregnant woman
    • Gonorrhea: ceftriaxone is the drug of choice
    • HSV: Oral acyclovir may be used for recurrent outbreaks and should be considered after 36 weeks for prophylaxis against outbreaks at the time of delivery. Cesarean delivery is the route of choice for patients with active lesions. High rate of morbidity and mortality associated with neonatal herpes infection
    • HIV: The goal of prenatal care for HIV-positive pregnant women focuses on appropriately treating maternal disease and minimizing vertical transmission of HIV. Pharmacotherapy varies, but usually consists of regimen of highly active anti-retroviral therapy (HAART) and intrapartum infusion of azidothymidine (AZT). Cesarean delivery is recommended only for patients with high viral load
    • Trichomoniasis: discharge is fetid, foamy, or greenish, or when there are reddish ("strawberry") petechiae on the mucous membranes of the cervix or vagina
    • Candidiasis: vaginal burning and itching and a profuse, caseous, white discharge. Topical miconazole nitrate or nystatin suppositories are the preferred treatment during pregnancy
    • BV: 2-fold increased risk of preterm birth in general
  255. Pregnancy Issues
    • UTI: pregnant women are susceptible. Not the same symptoms, check urine every visit, culture if frequent before pregnancy. Pyelonephritis can be an issue
    • Rh factor: type and screen, if negative give Rogan anytime there is a significant bleed, at 28 weeks and once baby is born
    • Ptyalism: Excessive salivation, strongly associated with severe N/V
    • Varicose veins
    • Joint pain, back pain, and pelvic pressure: Unstable pelvis, tight girdle, belt, bed rest, hospitalization. Improved posture and exercises relieves back pain
    • Leg cramps: Reduce phosphate intake (milk and supplements) and increase Ca intake. Massage, flexing feet, localized heat
    • Breast soreness (mastodynia): Results from physiologic breast engorgement. Relieved by well-fitting bras, temporary ice bags
    • Hand pain: ~5%, periodic numbness and tingling
    • Intercourse: if cramps or spotting follow coitus, it should be proscribed for the time being. Coitus late in pregnancy may initiate labor
    • Bathing: Water does not enter the vagina, bathing or swimming is not contraindicated
    • Douching: May be harmful
    • Dental care: Periodontal disease has been associated with an increased risk of preterm birth
    • Immunizations: Killed virus, toxoid, or recombinant vaccines may be safely administered during pregnancy, and patients should be vaccinated appropriately for both maternal and fetal benefit. Live, attenuated vaccines, including those for varicella, measles, mumps, polio, and rubella, should be given 3 months prior to pregnancy or immediately postpartum. These vaccines are contraindicated in pregnancy secondary to the potential of fetal infection
    • Employment
    • Travel: instruct patients with a history of spontaneous abortion and those who have experienced vaginal bleeding in the course of the present pregnancy to avoid travel to distant places
  256. What is adequate labor?
    • Classically, 3-5 ctx’s in 10 min (seen in 95%)
    • IUPC, 200 to 250 Montevideo units
  257. Fetal variables that influence course of labor
    • Size: macrosomia (4,500 g)
    • Lie: longitudinal axis of fetus to uterus
    • Presentation: vertex, breech, shoulder, compound
    • Position: relationship of presenting part in relation to the pelvis
    • Station: measure of descend through birth canal
  258. True vs False (Braxton Hicks) labor
    Before "true" labor begins, you may have "false" labor pains, also known as Braxton Hicks contractions. These irregular uterine contractions are perfectly normal and may start to occur as early as the second trimester, although they are more common during the third trimester of pregnancy. They are your body's way of getting ready for the "real thing."
  259. What Do Braxton Hicks Contractions Feel Like?
    Braxton Hicks contractions can be described as tightening in the abdomen that comes and goes. These contractions are typically not painful and do not occur at regular intervals. They do not get closer together, do not increase with walking, do not increase in how long they last, and do not feel stronger over time as they do when you are in true labor.
  260. What Do True Labor Contractions Feel Like?
    The way a true labor contraction feels is different for each woman and may feel different from one pregnancy to the next. Labor contractions cause discomfort or a dull ache in your back and/or lower abdomen, along with pressure in the pelvis. Some women may also feel pain in their sides and thighs. Some women describe contractions as strong menstrual cramps, while others describe them as strong waves that feel like diarrhea cramps.
  261. False Labor
    • Contractions are often irregular and do not get closer together
    • Contractions may stop when you walk or rest, or may even stop if you change positions
    • Contractions are usually weak and do not get much stronger. Or they may be strong at first and then get weaker.
    • Contractions are usually only felt in the front of the abdomen or pelvic region
  262. True Labor
    • Contractions come at regular intervals and last about 30-70 seconds. As time goes on, they get closer together.
    • Contractions continue despite movement or changing positions
    • Contractions steadily increase in strength
    • Contractions usually start in the lower back and move to the front of the abdomen
  263. lightening
    • the settling of fetal head into the brim of the pelvis – occurs 2 or more weeks before labor in primigravida women
    • often accompanied by increased pelvic discomfort and urinary frequency
    • several days to weeks before onset of true labor, cervix begins to soften, efface, and dilate
    • With cervical effacement, the mucus plug within the cervical canal may be released
    • the onset of labor is sometimes marked by the passage of a small amount of blood-tinged mucus from the vagina known as bloody show
  264. Fetal Lie
    • Longitudinal axis of fetus to the longitudinal axis of uterus
    • Transverse
    • Oblique
    • Longitudinal
  265. Effacement
    Thinning of the cervix
  266. Station and Presentation
    • Vertex
    • Breach
    • Shoulder
    • Compound
  267. Cardinal movements of labor
    • Engagement: passage of widest diameter of presenting part to the below plane of the pelvis. The head enters the superior straight in the occiput transverse position ~70% of women with gynecoid pelvis. Usually occurs late in pregnancy, commonly last 2 weeks.
    • Descent: downward passage of presenting part through the pelvis. Affected by the forces of labor and thinning of the lower uterine segment. The greater the pelvic resistance or the poorer the contractions the slower the descent.
    • Flexion: passive flexion of fetal head as it descend due to resistance related to body pelvis
    • Internal rotation: rotation of presenting part (usually from transverse to anterior-posterior). Rotation occurs so that the sagittal suture occupies the A-P diameter of the pelvis. Normally begins when the presenting part is at the level of the ischial spines.
    • Extension: brings base of occiput in contact with the inferior margin of the pubic symphysis. Head is delivered by extension. Crowning occurs when the largest diameter of the fetal head is encircled by the vulvar ring. Further extension follows extrusion of the head beyond the introitus.
    • External rotation (restitution): rotation to the correct anatomic position in relation to the fetal torso. Follows delivery of the head. Followed by delivery of the shoulders.
    • Expulsion: delivery of body of fetus
  268. First Stage of Labor
    • The first phase of the first stage of labor is called the latent phase, when contractions are becoming more frequent (usually 5 to 20 minutes apart) and somewhat stronger. However, discomfort is minimal. The cervix dilates (opens approximately three or four centimeters) and effaces (thins out). Some women may not recognize that they are labor if their contractions are mild and irregular.
    • The latent phase is usually the longest and least intense phase of labor. The mother-to-be is usually admitted to the hospital during this phase. Pelvic exams are performed to determine the dilatation of the cervix.
    • The second phase of the first stage (active phase) is signaled by the dilatation of the cervix from 4 to 7 centimeters. Contractions become longer, more severe, and more frequent (usually 3 to 4 minutes apart).
    • The third phase is called transition and is the last phase. During transition, the cervix dilates from 8 to 10 centimeters. Contractions are usually very strong, lasting 60 to 90 seconds and occurring every few minutes. Most women feel the urge to push during this phase.
    • In most cases, the active and transition phases are shorter than the latent phase.
  269. Second Stage of Labor
    The second stage of labor begins when the cervix is completely opened and ends with the delivery of the baby. The second stage is often referred to as the "pushing" stage. During the second stage, the woman becomes actively involved by pushing the baby through the birth canal to the outside world. When the baby's head is visible at the opening of the vagina, it is called "crowning." The second stage is shorter than the first stage, and may take between 30 minutes to two hours for a woman's first pregnancy.
  270. Third Stage of Labor
    After the baby is delivered, the new mother enters the third and final stage of labor - delivery of the placenta (the organ that has nourished the baby inside of the uterus). This stage usually lasts just a few minutes and involves the passage of the placenta out of the uterus and through the vagina.
  271. Initial labor assessment
    • Time of onset and frequency of contractions, status of membranes, any history of bleeding, and any fetal movement.
    • History of allergies, use of medication, and time, amount, and content of last oral intake.
    • Prenatal records with special attention to prenatal laboratory results that impact intrapartum and immediate postpartum management (eg, human immunodeficiency virus [HIV] and hepatitis B status).
    • Maternal vital signs, urinary protein and glucose, and uterine contraction pattern.
    • Fetal heart rate, presentation, and clinical estimated fetal weight.
    • Status of the membranes, cervical dilatation and effacement (unless contraindicated, eg, by placenta previa), and station of the presenting part
    • When a patient is admitted, a hematocrit or hemoglobin measurement should be obtained and a blood clot should be obtained in the event that a cross-match is needed. A blood group, Rh type, and antibody screen should also be done.
  272. Passenger: Fetal variables that influence the course of labor
    • Size - macrosomia (4,500 g)
    • Lie - longitudinal axis of fetus to uterus
    • Presentation - vertex, breech, shoulder, compound
    • Position - relationship of presenting part in relation to the pelvis
    • Station - measure of descend through birth canal
  273. How to assess contractions
    • Qualitatively: Observation of the mother and palpation of the fundus of the uterus. External tocodynamometry (Toco). Number of contractions in an average 10 min window, intensity, and duration of the contractions
    • Quantitatively (most precise): Measurement of intrauterine pressure via internal pressure transducers (IUPC)
    • No evidence that one method is better than the other
    • Mild contractions begin at 15 to 20 minutes apart and last 60 to 90 seconds. The contractions become more regular until they are less than 5 minutes apart. This part of labor is called the Latent Phase
    • When the cervix dilates from 4 to 8 centimeters (called the Active Phase), contractions get stronger and are about 3 minutes apart, lasting about 45 seconds
    • When the cervix dilates from 8 to 10 centimeters contractions are 2 to 3 minutes apart and last about 1 minute
  274. Dystocia of Labor
    • characterized by the slow, abnormal progression of labor
    • leading indication of primary c-section
    • 1 in every 10 birth (U.S.) has had a c-section
    • 60% of ALL c-sections in the US are attributable to the diagnosis of dystocia
    • Abnormal labor that results from abnormalities of: POWER, PASSENGER, or PASSAGE
    • “failure to progress” or “CPD” vague terminology
    • More practical classification: Labor slower than normal (protraction disorder) and Complete cessation of progress (arrest disorder)
  275. Shoulder dystocia
    • Definition: delivery that requires additional maneuvers following failure of gently downward traction on the fetal head to effect delivery of the shoulders
    • Complicates 0.6-1.4% of deliveries
    • Risk Factors: maternal obesity, diabetes, hx of macrosomic infant, current macrosomia, hx of shoulder dystocia
    • Warning Signs: ANTICIPATION is key!!! Prolonged 2nd stage. Recoil of head on perineum (turtle sign). Lack of spontaneous restitution
    • Fetal complications: occur in 4-40% of deliveries complicated by shoulder dystocia. Common injuries include brachial plexus injury, clavicle fracture, and humerus. <10% have permanent injuries. Increased of asphyxia
    • Maternal complications: 11% risk of postpartum hemorrhage, 3.8% risk of 4th degree laceration
    • Treatment: McRobert’s Maneuver - dorsiflexion of hips against abdomen, Episiotomy, Suprapubic pressure, Rubin’s Screw, Wood’s Screw, Delivery of posterior shoulder (fracture of humerus), Zavenilli
  276. Prolonged latent phase
    • The latent phase is abnormally long if it lasts more than 20h in a nulliparous women
    • Causes:
    • Excessive sedation given during or before the end of the latent phase
    • Used of conduction or general anesthesia before active phase of labor
    • Unfavorable cervix
    • Uterine dysfunction (weak/irregular or uncoordinated contractions)
    • Fetopelvic disproportion
  277. Labor slower than normal (protraction disorder)
    • Defined as protracted cervical dilation (slow rate) in active phase of labor and protracted descent of the fetus (rate of descent less than 1cm/h)
    • Causes: multifactorial
    • Fetopelvic disproportion
    • Malpositions of the fetus
    • Improperly administered conduction anesthesia
    • Excessive sedation
    • Obstructive pelvic tumors
  278. Complete cessation of progress (arrest disorder)
    • Two patterns: Secondary arrest of dilatation with no progressive cervical dilation in active phase of labor for 2h or more. Arrest of descent, with descent failing to progress for 1h or more
    • Causes:
    • Fetopelvic disproportion
    • Inadequate uterine contractions
    • Fetal malpositions
    • Inappropriately administered sedation
    • Excessive sedation
    • Arrest disorders in the presence of adequate uterine contractions carry a poor prognosis for vaginal delivery
  279. Risks of prolonged labor.
    • Older
    • Medical issue such as DM, HTN, obesity
    • Macrosomia
    • Prolonged rupture of membranes and/or chorioamnionitis
    • Short maternal stature
    • High station at complete dilation
    • Occiput posterior position
    • Pelvic abnormalities
  280. Complications of prolonged labor
    • Uterine rupture
    • Predisposition to postpartum hemorrhage
    • Decreased uteroplacental perfusion leading to intracranial hemorrhage to fetus and fetal hypoxemia
  281. Episiotomy
    • Most common procedure performed in obstetrics
    • In 2000, 33% of women giving birth had an episiotomy
    • Historically, the purpose has been to facilitate completion of 2nd stage to improve maternal and fetal outcome
    • two recent trials - failed to show any improvement in maternal or fetal outcomes
    • no evidence to support routine use
    • may be associated with higher rates of anal sphincter and rectal injuries
  282. Episiotomy Midline (most common in US)
    • easy to perform and repair
    • less pain postpartum
    • associated with greater risk for extension to include the anal sphincter and rectum (4th degree lacerations)
  283. Episiotomy Mediolateral
    • difficult to repair
    • greater blood loss
    • more discomfort
    • less risk for extensions
  284. Pain Management in Labor
    • Parenteral: most common Fentanyl PCA
    • maternal risk for aspiration and respiratory depression
    • fetal risk for respiratory depression (common need for Narcan at delivery)
    • Regional: epidural offers the most effective pain relief
    • other options spinal or combined spinal epidural
    • less effects on fetus
    • may slow down labor, but DOES NOT increase risks of c-section
  285. Post-term pregnancy
    • pregnancy beyond 42 weeks
    • Most frequent cause: error in dating
    • Most common risk factors: first pregnancy, and prior postterm pregnancy
    • Risks to fetus: stillbirth, meconium aspiration, intrauterine infection, utero-placenta insufficiency (oligo)
    • Risks to mother: increased labor dystocia, perineal injury related to macrosomia, and c-section rate
  286. PTL Management and Antenatal Surveillance
    • Literature is inconsistent regarding both type and frequency
    • Options include: nonstress test (NST), biophysical profile (BPP) or modified BPP (NST and amniotic fluid volume estimation), or contraction stress test (CST).
    • Modified BPP most commonly performed
    • At Duke, testing start after 41-wks if unfavorable cervix for induction
    • Twice weekly
    • Indication for delivery: If favorable cervix - induce labor (risk of failed induction is low). Fetal compromise - non-reassuring NST. Low amniotic fluid (oligohydramnios) - AFI <5 or no vertical pocket measurable >2 cm
  287. Induction of Labor
    • Iatrogenic stimulation of uterine ctx’s to achieve vaginal delivery before onset of spontaneous labor
    • Overall rate has increased to 20.6% of all births in 2002
  288. Induction of Labor Indications (either maternal/fetal, or for logistic)
    • Gestational HTN or PIH
    • Preeclampsia, eclampsia
    • Postterm pregnancy
    • Maternal medical conditions (eg, cHTN, DM)
    • Fetal compromise (eg, growth restriction)
    • PROM, chorioamnionitis
    • Hx of rapid labor, distance from hospital
  289. Induction of Labor Contraindications
    • prior classical c-section
    • active genital herpes
    • placenta or vasa previa
    • umbilical cord prolapse
    • transverse lie
  290. Labor Induction Methods:
    • Cervical Ripening Agents: prostaglandins such as misoprostol (not to use in VBAC)
    • Membrane Stripping: increases prostaglandin release
    • Oxytocin:
    • Mechanical dilation: Foley bulb with or without oxytocin
    • Amniotomy: artificial rupture of membranes (AROM)
  291. Complications of induction of labor
    • Maternal: Uterine inertia and prolonged labor, Tumultuous labor, Premature separation of the placenta, Rupture of placenta, Laceration of cervix, Intrauterine infection, Postpartum hemorrhage
    • Fetal: Risk of prematurity, Physical injury/birth trauma, Cord prolapse, Fetal heart rate abnormalities, Poor apgar score
  292. Bishop Score
    • Best tool to predict likelihood of successful labor induction (resulting in vaginal delivery)
    • Scores greater or equal to 6 are favorable
    • 0-4: 45-50% failure
    • 5-9: 10% failure
    • 10-13: 0% failure
  293. Breech presentation
    • fetal pelvis or lower extremities engage the maternal pelvic inlet
    • Frank breech: hips are flexed with extended knees bilaterally
    • Complete breech: both hips and knees are flexed
    • Footling breech: (single or double foot) – leg(s) are extended below the level of the buttocks
  294. Compound presentation
    • Prolapse of a fetal extremity alongside the presenting part
    • Prolapse of the hand in the cephalic presentation is most common
    • Causes: Fetal prematurity, feto-pelvic disproportion, multiple gestation, grand multiparity, hydramnios
  295. Presentation
    • Vertex malpositions
    • Occiput posterior
    • Occiput transverse
    • Brow presentation
    • Face presentation
  296. PROM
    • rupture of membranes before onset of labor
    • if before 37-wks is referred to as PPROM (preterm premature rupture of membranes)
    • Associated with 25-33% of PTD
    • 50% will enter PTL within 24 hrs
    • 85% will enter PTL within 1 wk
    • intraamniotic infection clinically evident in 13-60%
    • placenta abruption occurs in 4-12%
    • risk for pulmonary hypoplasia (if ROM occurs <26-wks)
  297. PROM Risk Factors
    • intraamniotic infection
    • prior hx (16-32% recurrence rate)
    • lower socioeconomic classes, teens, smokers, hx of STD
    • hx of cervical cerclage
    • uterine overdistention
  298. management of PROM and PPROM
    • >34 wks: proceed with delivery, GBS prophylaxis
    • 32-33 wks: expectant management (unless fetal lung maturity documented), GBS prophylaxis, steroids (no consensus, but recommended), antibiotics to prolong latency (no contraindications)
    • 24 (23)-31 wks: expectant management, GBS prophylaxis, steroids recommended, tocolysis (no consensus), antibiotics to prolong latency (no contraindications)
    • < 24 wks (<23-wk): patient counseling, expectant management, no steroids, no GBS prophylaxis or antibiotics
  299. PTL
    regular ctx’s associated with cervical change before 37-wks
  300. Preterm Delivery
    • Delivery before 37 wks gestation
    • Major determinant of infant mortality in developed countries
    • Leading cause of hospitalization among pregnant women
    • Rate in US has increased progressively from 9 to 12%
    • Affects 12% of all births and 17% of births among African Americans
    • The crisis is particularly acute among African Americans
    • Leading cause of developmental disability in children, including cerebral palsy and mental retardation.
    • Important cause of blindness and chronic lung problems
  301. Cause of Preterm
    • Epidemiological studies have identified potential risk factors
    • Smoking
    • African American
    • Maternal age: youngest and oldest
    • Stressful social factors: poverty, poor housing, crime
    • Underlying biological mechanisms poorly understood
    • It has been recognized that “silent” infections, such as vaginal infections or periodontal gum disease. However, data from treatment of infections may not be effective in preventing preterm delivery. Perhaps the inflammatory response to infection, and not the infection itself, is responsible for preterm delivery
  302. PTL Screening Predictors
    • Physiological measures (home monitoring of uterine contractions) - no benefit
    • Anatomical measures (ultrasonographic measurement of cervical length) - may be predictive
    • Cervical Length: Reliable and reproducible. Numerous studies have confirmed the association of cervical shortening with preterm delivery. However, very variable predictive value
    • Biochemical measures (assessment of fetal fibronectin) - strong negative predictive value between 24-34 wks
  303. Fetal Fibronectin Testing
    • Negative predictive value - 99.2%
    • Positive predictive value - 16.7%
    • FFN testing useful in women with symptoms of PTL to identify those with negative values and a reduced risk of preterm birth, thereby avoiding unnecessary intervention
  304. Prevention of recurrent preterm delivery by 17 alpha-hydroxyprogesterone caproate
    • 17P weakly active, naturally occurring progesterone
    • Synthetic caproate ester virtually inactive when given by mouth, but works as a long-acting progestin when administered IM
  305. Management of PTL: Tocolytic therapy
    • Minimal success
    • NO improvement in perinatal outcomes
    • However, may prolong gestation for 2-7 days to allow administration of steroids for fetal long maturity and maternal transport to a facility with a NICU.
    • Tocolytic Agents (No clear first line treatment)
    • Beta-mimetic - Terbutaline 0.25 mh SQ (cardiac arrhythmias)
    • Magnesium sulfate - 4-6 g bolus, then 2-3 g/hr (pulmonary edema)
    • Calcium channel blockers such as Procardia- 30 g load, then 10-20 mg every 4-6 hrs (maternal hypotension)
    • Prostaglandin synthetase inhibitors such as Indomethacin - 50 mg load rectally, then 25-50 mg every 6 hrs for only 48-hrs (constriction of ductus arteriosus and oligohydramnios)
  306. Causes of Hemorrhage DURING pregnancy
    • Trauma
    • Ectopic pregnancy
    • Placenta previa: Historically presented as painless vaginal bleeding. Now diagnosed by ultrasound
    • Abruptio placenta
  307. Hemorrhage Risk Factors
    • hypertension
    • trauma
    • smoking
    • cocaine use
    • preterm premature rupture of the membranes
    • chorioamnionitis
    • rapid decompression of the uterus
    • thrombophilia
  308. Causes of POSTPARTUM Hemorrhage
    • Uterine rupture: usually associated with previous uterine surgery
    • Uterine inversion: associated with uterine atony, fundal placenta, first baby; not necessarily associated with cord traction, requires replacement, may require uterine relaxing agent, may require laparotomy, shock is out of proportion to blood loss
    • Birth trauma More common with: forceps delivery, vacuum extraction delivery, first baby, large baby, precipitous labor and delivery, episiotomy
    • Retained placenta: retained placental fragments, placenta accreta
  309. Uterine Atony Risk Factors
    • chorioamnionitis
    • over-distended uterus
    • prolonged, augmented or induced labor
    • magnesium sulfate
    • general anesthesia
    • multiparity
    • previous postpartum hemorrhage
    • placenta previa or abruption
    • operative delivery
  310. Uterine Atony Treatment
    • Oxtocics: oxytocin (Pitocin), prostaglandin F2a (Hemabate), misoprostol, methylergonovine (Methergine)
    • bimanual compression
    • Surgical and other therapeutic interventions: curettage, laparotomy, B-lynch suture, uterine artery ligation, progressive uterine devascularization, hypogastric artery ligation, hysterectomy, embolization
  311. Blood Loss
    • 1: 900 mL, 15%
    • 2: 1200-1500 mL, 20-25%, ↑pulse, respiratory rate, orthostatic changes, ↓capillary refill, ↓pulse pressure
    • 3: 1800-2100 mL, 30-35%, marked tachycardia, tachypnea, cold, clammy skin
    • 4: ≥ 2400 mL, ≥ 40%, weak or absent pulse, BP, oliguria, cardiac arrest
  312. Placenta Accreta
    • accreta - 78%: to the myometrium. Adverse outcomes are uncommon
    • increta - 17%: into the myometrium. Commonly results in retained placental parts and postpartum hemorrhage
    • percreta -5%: through the myometrium . Removal of a totally adherent placenta is difficult - Preparation for hysterectomy should begin as soon as the diagnosis is suspected
  313. HELLP syndrome (hemolysis, elevated liver enzymes, low platelet count)
    • HELLP syndrome is a disorder that in some respects mimics AFLP.
    • This liver derangement is a variant of severe preeclampsia or eclampsia.
    • The disorder occurs in the last trimester of pregnancy and is characterized by nausea and vomiting and right upper quadrant pain.
    • Unlike AFLP, liver function is generally preserved as reflected by the normal prothrombin time.
    • Stillbirth occurs frequently (10–15%) if delivery is not prompt; neonatal loss is high (20–25%), usually because of prematurity (see Chapter 19).
    • Corticosteroids may hasten recovery in HELLP syndrome.
    • HELLP syndrome occasionally persists beyond 2–3 days postpartum, in which case it takes on the characteristics of other microangiopathic hemolytic disorders, such as thrombotic thrombocytopenic purpura or hemolytic-uremic syndrome.
    • Plasmapheresis may be required with persistent HELLP syndrome.
  314. Puerperium
    The 6 to 8 week period after birth during which the reproductive tract returns to its normal, nonpregnant state. (Often defined as 42 days)
  315. Lochia
    • Lochia consists of serous exudate, RBCs, WBCs, decidua, epithelial cells & bacteria, Blood, necrotic membrane remnants & decidua shed from uterine cavity--decreases over several weeks
    • Discharge heavy for 2 to 3 days
    • Resolves more rapidly in women who breastfeed
    • Lochia rubra: (red, red brown) first few days postpartum
    • Lochia serosa: (pinkish brown, more watery) lasts for 2-3 weeks
    • Lochia alba: (yellowish-white)
    • If becomes foul smelling or greenish, evaluate for infection source such as foreign body (retained gauze, sponge, etc.)
    • Endometrium usually reestablished by 3 weeks postpartum
  316. Postpartum Cervix
    • Contracts slowly
    • 2-3 cm dilated over first few days
    • < 1 cm dilated at one week postpartum
    • External os never regains pre-pregnant shape
    • Nulliparous ♀: small, smooth, regular opening
    • Parous ♀: large, transverse, stellate slit
  317. Lactogenesis
    • Results from withdrawal of estradiol & progesterone, tactile stimuli cause release of prolactin and oxytocin
    • Progesterone: budding & development of acini at ends of ducts of mammary glands
    • Estradiol: promotes growth & branching of mammary gland ducts
    • After delivery: ↓ opposition of prolactin by steroid hormones (from placenta)
  318. Suppression of lactation
    • Tight bra, binder
    • Heat or ice
    • Avoid breast & nipple stimulation
  319. Involution of the Uterus
    • Uterus weighs 1000g and has a volume of 5000 ml immediately after delivery
    • Nonpregnant weight 60-70g and volume capacity 5 ml
    • Immediately postpartum the uterus should be non-tender, globular & firm
    • Uterine size decreases due to: Delivery of fetus, placenta, amniotic fluid. Loss of hormonal stimulation. Autolysis of intracellular myometrial protein. Lysosomal enzyme.
    • Contraction of the uterus is the major mechanism to prevent hemorrhage
    • By 24 hours after delivery, fundus is near umbilicus
    • One week after delivery, fundus is between symphysis & umbilicus
    • Uterus returns to the pelvis by 2 weeks postpartum
    • Uterus nearly normal size by 6-8 weeks postpartum
    • In many women, the uterus never completely returns to its pre-pregnancy size.
    • Often find the uterus to be enlarged to a 6-8 weeks pregnant size at the 6-8 week postpartum exam
  320. Return of ovarian function postpartum
    • Ovulation suppression is due to high prolactin levels, which remain elevated until approximately 3 weeks after delivery in nonlactating women and 6 weeks in lactating women
    • When not breastfeeding: Ovulation can occur as early as 4 to 5 weeks postpartum if not breastfeeding. Mean time 45 days. 50% of women ovulate by 90 days postpartum. Estrogen levels begin to rise in 2 weeks. Return of menses in 7-9 weeks. Discuss contraceptive methods
    • When breastfeeding: Time to first ovulation dependent on breastfeeding practices. When exclusive with breastfeeding – most women can remain amenorrheic for 6 months and is about 98% effective as contraceptive method. Ovulation suppressed due to prolactin. Estrogen levels low. Hypoestrogenic state due to suppression of ovarian function (like menopause). Loss of vaginal rugation. Vaginal dryness. Menstruation returns as late as 36 months in 70% of breastfeeding mothers.
  321. Endometritis
    • Infection of the uterus
    • More common in cesarean section than vaginal delivery
    • Occurs within 5 days of delivery
    • Polymicrobial: cover for both gram + and - organisms
    • Diagnosis by clinical criteria: fever, uterine tenderness, foul lochia & leukocytosis
    • Prevention: Assure removal of all placenta and associated membranes. Prophylactic antibiotics reduce the rate of endometritis in high-risk patients (C/Section).
  322. Uterine Wound Infections
    • Incidence 2% to 20% of Cesarean births
    • Risk factors include: diabetes, obesity, poor nutrition, immunocompromised, long operative time, emergency surgery
    • Treatment: Drainage, Debridement of devitalized tissue, Antibiotics are not sufficient without drainage.
  323. Postpartum hemorrhage
    Uterine atony the most common cause
  324. Other Causes of Postpartum Hemorrhage
    • Retained placenta: Expulsion incomplete
    • Increased Risk: C/S, Fibroids
    • Placenta accreta: placental villi penetrate the uterine wall
    • Placenta Increta: into the uterine wall
    • Placenta Percreta: complete invasion through uterine muscle
    • Coagulation defects (DIC)
    • Placental abruption
    • Amniotic fluid embolism
    • Severe preeclampsia
  325. Mastitis
    • Commonly caused by coagulase positive S. Aureus
    • Presentation: Sudden onset, Unilateral, Localized swelling & pain/erythema, Feels sick, Fever
    • Treat with antibiotic that covers staph
    • Can be confused with blocked milk duct, which is treated via alternating nursing position.
    • Prevention: Nipple hygiene. Active care of cracks and fissures; lanolin or A&D ointment. Early diagnosis & prompt antibiotic therapy
  326. Breast engorgement
    • Gradual onset
    • Engorgement occurs between 1 & 7 days, with peak symptoms at 3-5 days postpartum. Treat discomforts with good breast support, ice packs (or bag of frozen peas, etc.), some recommend cool cabbage leaves
    • Bilateral
    • Generalized pain & swelling
    • No systemic systems
    • No fever
  327. Episiotomy Essential wound care management
    • Ice for relief of pain & swelling
    • Sitz baths
    • Donut cushions
    • Baths OK (most women prefer showers due to heavy lochia)
  328. Postpartum management
    • Measure vitals frequently while in hospital
    • Examine for: Uterine atony (primary cause of postpartum hemorrhage), Excessive bleeding, Over-distended bladder, Dyspnea/pleuritic pain, Perineal infection
    • Minimal labs needed in uncomplicated delivery
    • immunize as appropriate (RhoGAM, Rubella, Tdap, Hep B all compatible with breastfeeding)
    • Resume normal diet
    • Consider stool softener
    • Physical activity: Early ambulation, slow and easy, stop if painful; don’t drive until off narcotics
    • Baths & showers are OK
    • Iron supplement for hematocrit <30
    • Pelvic rest for 4-6 weeks - abstinence
  329. Complications cesarean
    • C/S infection uncommon
    • Reduced by prophylactic antibiotics
  330. Incision infection risk factors
    • Obesity
    • Diabetes
    • Immunocompromised
    • Anemia
    • Hematomas
  331. Issues related to type of delivery
    • Vaginal: 1-2 day hospital stay, 6-8 week postpartum visit is typical
    • Cesarean section: 3-4 day hospital stay, Often staples are removed prior to discharge, 1-2 week interim visit for incision check, 6-8 week routine postpartum visit
  332. Contraceptive options postpartum
    • Close interconceptional spacing: increased risk of preterm delivery & low birth weight infants.
    • Recommend delay of next pregnancy for 18 months
    • Natural family planning: problematic until cycles reestablished
    • IUD: (expulsion slightly higher, uterine perforation more frequent if done too soon after delivery); may wait til 4-6 weeks
    • Progestin-only: (pills, injection, implants) can be used immediately postpartum (rec by 2 weeks) in non-breastfeeding women
    • Start oral contraceptives once lactation well established because risk of DVTs due to hypercoagulable state in postpartum period
    • Wait for COCPs until 2-4 weeks postpartum (controversial if lactating, but 4 better; must weigh risk of pregnancy)
    • Barrier methods: Diaphragm sometimes problematic due to vaginal tone; must be refit after delivery
    • Condoms sometimes problematic if decreased estrogen
    • Vaginal lubricants such as KY jelly or Astroglide, or estrogen creams can help with vaginal dryness (especially common in breastfeeding women)
    • sterilization
  333. Baby blues
    • Transitory mood disturbance following delivery (within 2 weeks) and usually occurs at the height of hormonal changes
    • Prevalence: 26 – 85% - very common
    • Occurs cross-culturally, but is less noticeable in cultures where emotions are expressed freely and when relatives and friends surround the new mother, offering care and support
    • Risk Factors: Depressive symptoms during pregnancy, Previous episode of depression, Pre-menstrual depression according to self-report
    • Symptoms: Feeling “down in the dumps”; sadness; irritability; crying and anxiety, feeling trapped, sensitivity to criticism, despondence.
    • Severity: Mild.
    • Onset: Symptoms peak about the 4th – 5th day after delivery and typically subside by the 10th day.
    • Treatment: Time – may last a few days to 2-3 weeks. Support of Friends and Family
    • Up to 20% of women who suffer from this disorder will go on to develop depression in the first postpartum year
  334. Postpartum depression
    • Prevalence: 10–20% postpartum. The syndrome is profoundly under diagnosed (< 15%) and often left untreated
    • Risk factors: Marital tension. Highest risk were women whose spouses were rated “low” in caring or who were rated as over-controlling. Financial problems. Low levels of social support. Negative life stress during pregnancy and the postpartum, particularly a move or the loss of a loved one. Difficult infants; temperament/health problems. History of depression or other psychiatric illness, including prior pregnancy-associated depression. (Yet most women with a history of depression do not become depressed). A mother who had postpartum depression. A troubled childhood with little love. Poor self-esteem as an adult – high interpersonal sensitivity. An unsupportive extended family. Women with complications during pregnancy are three times more likely to suffer from postpartum depression.
    • Symptoms: Depressed mood with clear evidence that the symptoms are substantially interfering with functioning.
    • At least four of the following: Appetite disturbance, Sleep disturbance, Agitation or psychomotor retardation, Loss of interest, Loss of libido, Fatigue, Self-deprecation or guilt, Difficulty with concentration, Suicidal ideation, May involve fear of harming infant
    • Severity: Estimates are that half of these suffer from a minor, as opposed to a major, depression – less suicidal ideation, more guilt, agitation, and irritability
    • Onset: the syndrome develops weeks to months after delivery when the patient is not under the routine medical care
    • Treatment: Dependent on severity of symptoms. Support from family & friends. Psychotherapy, antidepressant medication. Professional assessment strongly recommended. Support groups
  335. Postpartum psychosis
    • Psychosis is a severe mental illness characterized by a false reality and can be associated with fear and impulsivity
    • Prevalence: 1 to 2 births per 1000. In one study - ¾ of cases of postpartum psychosis occurred after the birth of the first child
    • Risk factors: Previous episode of psychosis (Especially, postpartum psychosis), Bi-polar affective disorder, Family history of bi-polar affective disorder or postpartum depression., Marital and family problems, Recent stressful life situations, Lack of social supports
    • Symptoms: restless, unable to sleep, irritable, have pressured speech, unusual behavior, obsessional or delusional thinking, or become very withdrawn
    • Severity: severe – a medical emergency
    • Onset: typically within several days to 2-4weeks postpartum. Early onset and lucid intervals may be confused with “baby blues”; 75% of admissions within the first two weeks.
    • Treatment: skilled professional intervention, admission to hospital for delusions and the concern that the woman may harm herself or the infant