-
When is the placenta formed
7-10 weeks
-
Progesterone coming from the corpus luteum accomplishes what
Keeps the endometrium in a receptive state (keeps it ready for implantation)
-
High prolactin will shut down __ axis
Ovarian
-
If FSH is high it is __ failure
Ovarian
-
What is the most common reason a woman might not be ovulating
PCOS
-
Two out of three findings are needed for the diagnosis of PCOS. What are the three findings
Oligo- and or anovulation, hyperandrogenism, US with polycystic ovaries
-
How do oral medications such as Clomid and tamoxifen stimulate ovulation
They trick the brain into thinking there is no estrogen in the body so it stimulates the ovaries into producing more
-
As egg number decreases, there is less feedback from the ovaries, which causes a rise in __
FSH
-
As FSH levels increase, likelihood of pregnancy __
Decreases
-
What is an HSG
Hysterosalpingogram (tests for tubal patency)
-
Why would you do a laparoscopy for an infertile woman
Abnormalities on HSG, pelvic pain, high suspicion for endometriosis
-
What affect do most vaginal lubricants have on sperm motility
Decreased
-
Where does spermatogenesis take place
Seminiferous tubules
-
How many days prior to semen analysis does the man need to stay abstinent
2-5 days
-
How soon should the semen sample make it to the lab for analysis
Within 1 hour
-
Infertility & Endometriosis: Possible mechanisms
Distorted pelvic anatomy; Altered peritoneal fn (peritoneal fluid tox to sperm, embryos); Altered hormonal & cell-mediated fn; Endocrine/ ovulatory abnormalities; impaired implantation
-
What are the two systems that continue to develop throughout pregnancy
Brain and genitalia
-
A union between individuals who are related
Consanguinity
-
Consanguinity increases the risk for __ disorders
Autosomal recessive
-
As a general rule everyone carries __ autosomal recessive genes
5-7
-
What is First trimester screening or “Nuchal Translucency Screening”
Ultrasound measurements of the nuchal translucency obtained 10-13 6/7 gestational weeks. Designed to identify fetuses at risk for Down syndrome, trisomy 13 and trisomy 18
-
What does CVS stand for
chorionic villus sampling, basically a biopsy of placental tissue
-
Ultrasound can identify __% of babies with Down syndrome
50
-
Ultrasound cannot __ all chromosome conditions or birth defects
Rule out
-
Ultrasound an identify __% of babies with any chromosome condition, although those that are detected tend to be the most severe
30
-
A fluid collection in 3 or more body parts
Hydrops
-
The earlier a spontaneous abortion occurs the more likely it was due to __
A chromosomal abnormality
-
What are the three most common trisomic conditions seen in living individuals
Trisomy 13,18 and 21
-
What is the most frequent abnormality related to a chromosome abnormality
Down syndrome
-
What is the most common type of Down syndrome
Trisomy 21
-
There is a positive correlation with the frequency of Down syndrome and __
Maternal age
-
Babies with Down syndrome are more often born to __ mothers
Teenage, and over 35
-
What is the incidence of babies born with Down syndrome to mothers over the age of 45
1 in 40 deliveries
-
What is the incidence of babies born with Down syndrome to mothers over the age of 40
1 in 100 deliveries
-
What is the incidence of babies born with Down syndrome in the general population
1 in 600 deliveries
-
What are some examples of neural tube defects
Anencephaly, spina bifida, and meningomyelocele
-
If a couple has a child with a neural tube defect what is the chance that they will have another child affected with the disease. What if they had 2 children affected with the disease
2-5%, 10% respectively
-
__ screening detects about 85% of all open NTD, and 90% of all anencephalic infants, however it does not detect closed forms of NTDs
Maternal serum AFP
-
When is amniocentesis generally carried out
15-17 weeks
-
What is the underlying risk of amniocentesis when performed at 15 weeks of gestation and beyond
Increased risk of miscarriage
-
How long does the process of karyotyping take place
10-14 days
-
If 1 parent is affected by an autosomal dominant disorder what are the chances that the child will be affected
1 in 2
-
If both parents are affected by an autosomal recessive disorder what is the chance the child will be affected, what is the chance that the child will be a carrier
1 in 4 of being affected, 1 in 2 of being a carrier
-
Nuchal translucency, measured between 11 and 13 6/7 weeks, combined with free b-hcg, and pregnancy associated plasma protein A levels has been found to have 87% sensitivity for detection of __
Trisomy 21
-
In the absence of chromosomal abnormalities an increased nuchal translucency is associeated with an increased risk of __
Structural cardiac abnormalities and skeletal dysplasia
-
What is included in the maternal serum analyte testing (triple screen)
Maternal serum alpha-fetoprotein, beta hCG, and estriol
-
What is added to the triple screen to make it the quad screen in some institutions
Inhibin
-
To which populations should screening for sickle cell disease be offered
Individuals of African/African American descent, those from the Mediterranean basin, the middle east, and India
-
What is the definitive test to determine the carrier status of sickle cell disease
Hemoglobin electrophoresis
-
What two groups have the highest rates of cystic fibrosis
Caucasians and Ashkenazi jews
-
What type of information does a standard US examination provide
Fetal number, presentation, documentation of viability, gestational age, amniotic volume, placental location, fetal biometry, and an anatomic survey
-
When is a specialized US exam performed
When an anomaly is suspected based on history, biochemical abnormalities, or results of either the limited or standard scan
-
When is the typical fetal anatomic survey performed
17-20 weeks
-
When is amniocentesis often performed
15-20 weeks
-
What is the risk of abortion as a result of amniocentesis
1 in 200 to 1 in 450
-
When is chorionic villus sampling performed
10-12 weeks
-
What is the benefit of CVS over amniocentesis
Its availability earlier in pregnancy
-
What are some disadvantages of CVS over amniocentesis
Higher rate of abortion, does not allow diagnosis of neural tube defects
-
What does PUBS stand for
Percutaneous umbilical blood sampling
-
What are some benefits of PUBS
Rapid result turnaround and the ability to perform the procedure in the second and third trimesters
-
Fetal movements associated with __ provide reassurance that the fetus is not acidotic or neurologically depressed
Accelerations of fetal heart rate
-
A reactive and therefore reassuring non-stress test is defined as
2 or more FHR accelerations, at least 15 bpm above baseline and lasting at least 15 seconds within a 20 min period
-
What are high levels of maternal serum AFP associated with
Open neural tube defects
-
__ levels in amniotic fluid appear to be more specific than the AFP test in predicting neural tube defects
Acetylcholinesterase
-
Low levels of AFP in conjunction with estriol and comparatively high levels of hCG have been shoen to be predictive for __
Down syndrome
-
__ is the most common congenital cause of severe mental retardation with an incidence of about 1.3 per 1000 live births
Down syndrome
-
What is the most common consideration in selecting women for diagnostic amniocentesis
Advanced maternal age
-
After __ weeks both amniotic fluid and maternal plasma volume decrease
38
-
If a young female patient is hypertensive and having a seizure she is __ until proven otherwise
Preeclamptic
-
Hypertension with proteinuria and or pathologic edema
Preeclampsia
-
Hypertension without proteinuria or pathologic edema during pregnancy
Pregnancy induced hypertension
-
Hypertension with proteinuria and or pathologic edema with convulsions
Eclampsia
-
Signs and symptoms of preeclampsia
HA, hyperreflexia, visual changes, irritability, epigastric pain, edema of face/hands/abdomen, oliguria
-
What does HELLP stand for
Hemolysis, Elevated Liver enzymes, Low Platelets
-
Primary symptom of HELLP syndrome
Malaise, fatigue
-
Classic presentation of HELLP syndrome
Malaise/fatigue, N/V, HA, RUQ pain, severe elevated BP, 3+ protein/85% of the time
-
Partial or complete detachment of placenta from uterine wall, after 20 weeks gestation
Abruptio Placenta
-
What are some risk factors of abruptio placenta
Cocaine use, maternal hypertension, trauma
-
Placenta previa is __ bleeding
Painless/silent
-
Placenta abruption is __ bleeding
painful
-
When do you screen with 1 hour glucose
At 24-28 weeks in patients >25 or family history of DM or Ethnic risk
-
Risk factors for GDM
> 25 years, prior GDM/family hx, prior big baby/still birth, BMI greater than or equal to 27, chronic hypertension, glycosuria
-
What is the biggest complication of GDM
Big babies that don’t want to come out (macrosomia/shoulder dystocia)
-
What are the birth traumas associated with macrosomia
Brachial plexus injury, clavicular injury, facial nerve injury
-
Risk factors for fetal growth restriction
CVD (hypertension), smoking, fetal abnormalities, multifetal gestation, abnormal placentation, poor maternal wt gain or nutrition
-
__% of women are GBS vaginal/rectal colonized
10-30%
-
What is the most common cause of neonatal sepsis
GBS
-
GBS bacteruria indicates
Heavy colonization
-
What is something you see in babies born to mothers on AZT for HIV
Lower white counts and macrocytic anemia (will resolve over time)
-
What is the average volume of amniotic fluid at term
800mL
-
How is oligohydramnios determined
Identification of the largest pocket of fluid measuring less than 2cmx 2cm or the total of 4 quadrants less than 5 cm
-
What is oligohydramnios associated with
SGA fetus, renal tract abnormalities (renal agenesis), and urinary tract dysplasia
-
The clinical manifestation of oligohydramnios is a direct result of __
The impairment of urine flow ot the amniotic fluid in the late part of the first half of pregnancy or during the second and third trimesters
-
Infants in the __ percentile are classified as having intrauterine growth restriction (IUGR)
< or =10th
-
Infants in the __ percentile are classified as large for gestational age (LGA)
> or = 90th
-
Both IUGR and LGA fetuses have increased risk for __
Perinatal morbidity and mortality
-
A pregnancy cannot be described as IUGR unless what is known with certainty
Gestational age
-
What does symmetric IUGR refer to
Infants in which all organs are decreased proportionally
-
Symmetric IUGR infants are more likely to have __
An endogenous defect that results in impairment of early fetal cellular hyperplasia
-
What does asymmetric IUGR refer to
Infants in which all organs are decreased disproportionately (abdominal circumference is affected to a greater degree than head circumference)
-
Asymmetric IUGR infants are more likely caused by __
Intrauterine deprivation that results in redistribution of flow to the brain and heart at the expense of less important organs such as the liver and kidneys
-
An infant with an autosomal __ is more likely to be IUGR
Trisomal
-
What is the most common autosomal trisomy and what is the rate
Trisomy 21 (Down syndrome) 1 in 600 live births
-
What is the second most common autosomal trisomy and what is the rate
Trisomy 18 (Edward’s syndrome) 1 in 6000-8000 live births
-
Turner’s syndrome is associated with an average birthweight of approximately __ below average
400g
-
Fetuses with neural tube defects are frequently
IUGR weighing approximately 250g less than controls
-
Chronic intrauterine infection is responsible for __% of IUGR pregnancies
5-10
-
What is the most commonly identified pathogen responsible for IUGR
CMV
-
What is the most common protozoan, acquired by eating raw meat, that is responsible for IUGR
Toxoplasma gondii
-
Bacterial infections occur commonly in pregnancy and frequently are implicated in premature delivery, however they are not commonly associated with IUGR. The exception to this rule is chronic infection with __
Listeria monocytogenes
-
What is the clinical picture of an infant born to a mother infected with chronic listeria monocytogenes
Critically ill, encephalitis, pneumonitis, myocarditis, hepatosplenomegaly, jaundice, and petechiae
-
Multiple gestation is associated with a __% increased incidence of IUGR fetuses
20-30
-
What is the most common maternal complication causing IUGR
Hypertension
-
Women who stop smoking before __ weeks gestation are not at increased risk for having an IUGR infant
16
-
Poor maternal wt gain is associated with an increased risk of having an IUGR infant. Daily intake must be reduced to less than __kcal/d before a measurable effect on birthweight becomes evident
1500
-
What are some vascular diseases that are risk factors for having an IUGR infant
Collagen vascular disease, insulin-dependent diabetes mellitus associated with microvasculopathy and preeclampsia
-
What is the best parameter for early dating of pregnancy on ultra sound
Crown-rump length
-
What are the most accurate parameters for dating of pregnancy in the second trimester
Biparietal diameter, and HC
-
what is the most accurate parameter for dating of pregnancy in the third trimester
Head circumference
-
What is the single most common preventable cause of IUGR in infants in the US
Smoking
-
Data shows that IUGR infants appear to catch up in weight in the first __ of life
6 months
-
Taken as a group IUGR infants have more __ than do their AGA peers
Neurologic and intellectual deficits
-
The incidence of __ is increased in IUGR infants
Sudden infant death syndrome
-
In the second half of pregnancy, increased concentrations of __ combine to produce modest maternal insulin resistance which is countered by postprandial hyperinsulinemia
-
Human placental lactogen, free and total cortisol, and prolactin
- Maternal obesity is associated with a __ increased likelihood of fetal macrosomia
- 3-4 fold
-
Male fetuses are __g heavier on average than female fetuses
150
-
What is the best single measure in evaluating macrosomia by ultrasound in diabetic mothers
Abdominal circumference
-
Estimated fetal wt. by __ is not very accurate
Ultrasound
-
What is the most common medical complication of pregnancy
Diabetes mellitus
-
Preexisting diabetes mellitus affects approximately __ per 1000 pregnancies
1-3
-
Defined as any degree of glucose intolerance with first recognition during pregnancy
Gestational diabetes
-
GDM complicates __% of pregnancies
4
-
Women with GDM have an approximately __% risk of developing type 2 diabetes over the next 10 years
50
-
__ is the hormone mainly responsible for insulin resistance and lipolysis. It is similar in structure to growth hormone and acts by reducing the insulin affinity to insulin receptors
Human placental lactogen
-
H A1C can predict the risk for __ when measured in the first trimester
Malformation
-
Higher glucose level in mothers lead to higher glucose levels in the fetus. This leads to higher levels of insulin which can cause __ in the fetus
Macrosomia, central fat deposition, enlargement of internal organs such as the heart
-
What are risk factors for developing GDM
Obesity, prior hx of GDM, heavy glycosuria, unexplained stillbirth, prior infant with major malformation, family hx of DM in first degree relative
-
When should at risk pregnant women be screened for GDM
As soon as feasible and again between 24 and 28 weeks
-
Which women can be omitted for GDM screening
Age <25, normal body wt, no family hx, no hx of abnormal glucose metabolism/poor OB outcome, and not a member of an ethnic or racial group at high risk
-
What are the ethnic or racial groups with a high prevalence of diabetes
Hispanic Americans, Native Americans, Asian Americans, African Americans, Pacific Islanders
-
What is the mainstay of treatment in the pregnant women with pregestational diabetes
Rigorous control of blood glucose
-
What is an optimal fasting glucose in pregnancy
70-95
-
What is an optimal 1-hr postprandial glucose value during pregnancy
Less than 140
-
What is an optimal 2-hr postprandial glucose value during pregnancy
Less than 120
-
Characterized by the onset of hypertension and proteinuria, usually during the third trimester of pregnancy
Preeclampsia
-
Characterized by a history of high blood pressure before pregnancy, elevation of BP during the first half of pregnancy, or high blood pressure that lasts for longer than 12 weeks after delivery
Chronic hypertension
-
An ECG may reveal __ in the patient with long-standing hypertension
Left ventricular hypertrophy
-
What is mild hypertension
Systolic >/= 140, diastolic >/=90
-
What is severe hypertension
Diastolic >/= 180, diastolic >/=110
-
what is proteinuria as defined for preeclampsia
Urinary excretion of >/= 0.3g protein in a 24 hour urine specimen, usually correlates with a finding of 1+ or greater on dipstick
-
new onset of grand mal seizures in a woman with preeclampsia that cannot be attributed to other causes
Eclampsia
-
how is preeclampsia distinguished from gestational hypertension
There is no proteinuria in gestational hypertension
-
what are the mainline antihypertensives used during pregnancy
Methyldopa, labetalol, nifedipine
-
normal pregnancy is associated with decreased maternal sensitivity to __. This effect leads to expansion of the intravascular space
Endogenous vasopressors
-
women destined to develop preeclampsia do not exhibit normal refractoriness to __. As a result normal expansion of the intravascular space does not occur
Endogenous vasopressors
-
in addition to the classic findings of hypertension and proteinuria, women with preeclampsia may complain of what other symptoms
Scotomata, blurred vision, or pain in the epigastrium or right upper quadrant
-
lab work of patients with preeclampsia will reveal __
Elevated levels of hematocrit, lactate dehydrogenase, serum transaminase, and uric acid, and thrombocytopenia
-
in the management of preeclampsia, with few exceptions, maternal interests are best served by __
Immediate delivery
-
how are women with mild preeclampsia before 37 weeks managed
Expectantly with bed rest, twice-weekly antepartum testing, and maternal evaluation
-
severe preeclampsia mandates __
Hospitalization
-
in the case of severe preeclampsia delivery is indicated it the gestational age is __ weeks or greater, fetal pulmonary is confirmed, or evidence of deteriorating maternal or fetal status is seen
34
-
in the case of severe hypertension what is the goal of antihypertensives
- Systolic <160 and diastolic <105
- in the case of severe preeclampsia acute blood pressure control may be achieved with what drugs
-
Hydralazine, labetalol, or nifedipine
- in severe preeclampsia between 33 and 35 weeks consideration should be given to __ for pulmonary maturity studies
- Amniocentesis
-
loss of patellar reflexes is observed at magnesium levels of __mg/dL or higher
10
-
respiratory paralysis may occur at magnesium levels of __ or higher
15
-
Increased maternal age is defined as a mother who will be __ years or older on the day of delivery
35
-
Why do we worry about increased maternal age
The risk to have a child with a chromosome condition is increased
-
Multiple pregnancy losses are defined as __ pregnancy losses
Three or more
-
Maternal conditions that may increase the risk of birth defects
Insulin dependent diabetics, lupus, seizure disorders, substance abuse
-
An exposure during embryogenesis which has a harmful effect on the developing fetus
Teratogens
-
What are the two systems that continue to develop throughout pregnancy
Brain and genitalia
-
What is First trimester screening or “Nuchal Translucency Screening”
Ultrasound measurements of the nuchal translucency obtained 10-13 6/7 gestational weeks. Designed to identify fetuses at risk for Down syndrome, trisomy 13 and trisomy 18
-
What does CVS stand for
chorionic villus sampling, basically a biopsy of placental tissue
-
Ultrasound can identify __% of babies with Down syndrome
50
-
Ultrasound cannot __ all chromosome conditions or birth defects
Rule out
-
Ultrasound an identify __% of babies with any chromosome condition, although those that are detected tend to be the most severe
30
-
A fluid collection in 3 or more body parts
Hydrops
-
The earlier a spontaneous abortion occurs the more likely it was due to __
A chromosomal abnormality
-
Couples who experience habitual abortion constitute about __% of the population
0.005
-
Recurrent pregnancy loss is now defined as __ spontaneous abortions
2 or more
-
What are the three most common trisomic conditions seen in living individuals
Trisomy 13,18 and 21
-
What is the most frequent abnormality related to a chromosome abnormality
Down syndrome
-
What is the most common type of Down syndrome
Trisomy 21
-
There is a positive correlation with the frequency of Down syndrome and __
Maternal age
-
Babies with Down syndrome are more often born to __ mothers
Teenage, and over 35
-
What is the incidence of babies born with Down syndrome to mothers over the age of 45
1 in 40 deliveries
-
What is the incidence of babies born with Down syndrome to mothers over the age of 40
1 in 100 deliveries
-
What is the incidence of babies born with Down syndrome in the general population
1 in 600 deliveries
-
What are some examples of neural tube defects
Anencephaly, spina bifida, and meningomyelocele
-
Fetal movements associated with __ provide reassurance that the fetus is not acidotic or neurologically depressed
Accelerations of fetal heart rate
-
A reactive and therefore reassuring non-stress test is defined as
2 or more FHR accelerations, at least 15 bpm above baseline and lasting at least 15 seconds within a 20 min period
-
What are high levels of maternal serum AFP associated with
Open neural tube defects
-
__ levels in amniotic fluid appear to be more specific than the AFP test in predicting neural tube defects
Acetylcholinesterase
-
Low levels of AFP in conjunction with estriol and comparatively high levels of hCG have been shoen to be predictive for __
Down syndrome
-
__ is the most common congenital cause of severe mental retardation with an incidence of about 1.3 per 1000 live births
Down syndrome
-
What is the most common consideration in selecting women for diagnostic amniocentesis
Advanced maternal age
-
After __ weeks both amniotic fluid and maternal plasma volume decrease
38
-
In a normal pregnancy the hCG doubles every __
48 hours
-
Beta-hCG is first detectable in maternal blood __ after conception
6-8 days
-
False positive pregnancy tests occur at hCG levels of __mIU/ml
5-25
-
If the fetus is lost before 22 weeks it is classified as a __
Miscarriage
-
If the fetus is lost after 22 weeks of gestation it is classified as a __
Stillbirth
-
What is considered the gestational age of viability
22 weeks
-
During pregnancy hemodilution is normal and produces __
Physiologic Anemia
-
During pregnancy body water increases by __
6.5-8.5L (most significant adaptation in PG)
-
How is the heart affected during pregnancy
Displaced to the left and upward, increase in left ventricular end diastolic dimension, output is increased by 30-50%
-
What are some normal changes in pregnancy that may mimic heart disease
Dyspnea (most common complaint before 20 wks), decreased exercise tolerance/ fatigue/ occasional orthopnea/ chest discomfort, Edema
-
What happens to nasal mucosa during pregnancy
It becomes more edematous and erythematous, hypersecretion of mucus
-
What happens to lung volume during pregnancy
Decreases by 5%, max volume that can be inhaled increased by 5-10%
-
What happens to pulmonary function during pregnancy
Hyperventilation
-
Pregnancy causes a state of chronic respiratory __
Alkalosis
-
The kidneys excrete more __ during pregnancy
Bicarb
-
What changes with WBC’s during pregnancy
Increased by 5,600-12,000
-
Renal plasma flow __ in pregnancy
Increases
-
Because of dilation of the renal pelvis there is an increased incidence of __ in pregnancy
Pyelonephritis
-
What happens to appetite during pregnancy
Increased by about 200 Kcal/day
-
What happens to the stomach during pregnancy
Tone and motility decreases, increased GERD
-
Morning sickness complicates __% of pregnancies
70
-
What is the time frame of morning sickness (onset/improvement)
Onset in 4-8 weeks, improvement by 14-16 weeks
-
What is the treatment of morning sickness
Largely supportive (reassurance, avoid triggers, frequent small meals, acupressure/ginger/V B6
-
What are the skin changes in pregnancy
Hyperpigmentation, linea alba becomes linea nigra, pigmented nevi/freckles/recent scars
-
What are the hair changes in pregnancy
Mild degree of hirsutism
-
Striae (stretch marks) affect up to __% of pregnant women
0.9
-
In the fetus what is the vasculature that bypasses the liver
Ductus venosus
-
What is the bypass that allows blood to flow from the right atrium to the left atrium
Foramen ovale
-
What is the bridge that allows blood to pass from pulmonary veins to the aorta
Ductus arteriosus
-
When does the foramen ovale change to the fossa ovalis
When the baby takes its first breath, the pressure from the lungs closes the valve
-
What happens to the ductus venosus and the ductus arteriosus after a child is born
They become ligaments (ligamentum venosum, ligamentum arteriosum)
-
The hypervolemia of pregnancy compensates for maternal blood loss at delivery, which averages __ml for vaginal and __ml for c-section
500-600, 1000
-
With uterine enlargement and diaphragmatic elevation, the heart rotates on its long axis in left upward displacement. As a result the apical beat shifts __
Laterally
-
if hCG results uncertain, repeat test in:
2 days
-
very high hCG levels seen in:
molar PG (gestational trophoblastic disease)
-
Not normal symptoms (re: heart)
syncope, chest pain with exertion, progressive orthopnea, and hemoptysis
-
Physiologic process by which a fetus is expelled from the uterus
Labor
-
Defined as an increase in myometrial contractility resulting in effacement and dilation of the uterine cervix
Labor
-
What are the two major functions of contractions during labor
To dilate the cervix, to push the fetus through the birth canal
-
What are the three mechanical variables during delivery known as the three P’s
the powers, the passenger, and the passage
-
One of the three P’s it is the force generated by uterine musculature
Powers
-
What does an external tocodynamometer measure
Number of contractions in an average 10 minute window, intensity, and duration of contractions
-
What is the most precise method of measuring contractions
Intrauterine pressure monitoring via internal pressure transducers (IUPC)
-
What is classically considered to be adequate labor
3-5 contractions in 10 minutes, however there is no consensus for criteria
-
Macrosomia is considered to be an infant over __
4,500 g
-
What is the lie of the fetus
The longitudinal axis of the fetus to the uterus
-
What are the different presentations of the fetus
vertex, breech, shoulder, compound
-
What does the station of the fetus mean
A measurement of descent through the birth canal
-
How often are breech presentations found in term pregnancies
3-4%
-
External cephalic version is routinely done after __ weeks
36
-
What landmarks designate 0 station for the fetus
Ischial spines
-
Cardinal movements of labor: passage of widest diameter of presenting part to below the plane of the pelvis
Engagement
-
Cardinal movements of labor: downward passage of presenting part through the pelvis
Descent
-
Cardinal movements of labor: passive flexion of fetal head as it descends due to resistance related to body pelvis
Flexion
-
Cardinal movements of labor: rotation of presenting part (usually from transverse to anterior-posterior)
Internal rotation
-
Cardinal movements of labor: brings base of occiput in contact with the inferior margin of the pubic symphysis, head is delivered by extension
Extension
-
Cardinal movements of labor: rotation to the correct anatomic position in relation to the fetal torso
External rotation (restitution)
-
Cardinal movements of labor: delivery of body of fetus
Expulsion
-
What are the Cardinal movements of labor
Engagement, descent, flexion, internal rotation, extension, external rotation (restitution), expulsion
-
What is the first stage of labor
Onset of labor to full dilation
-
What is the second stage of labor
Interval between full dilation (10cm) and delivery
-
What is the third stage of labor
Time from delivery to expulsion of placenta
-
What are the risks of parenteral pain management in labor (fentanyl PCA)
Maternal risk for aspiration and respiratory depression, fetal risk for respiratory depression (common need for Narcan at delivery)
-
An epidural may slow down labor, however it does not increase the risk of __
C-section
-
__ is characterized by the slow, abnormal progression of labor
Dystocia of labor
-
What is the leading indication of primary c-section
Dystocia of labor
-
What is the rate of c-section in the US
1 in every 10 births
-
60% of all c-sections in the US are attributable to the diagnosis of __
Dystocia of labor
-
What terms should we never use when talking about dystocia of labor
Failure to progress, or CPD (cephalopelvic disproportion)
-
What are acceptable terms to use when referring to dystocia of labor
Labor slower than normal (protraction disorder), complete cessation of progress (arrest disorder)
-
What are the risk factors for prolonged labor
Older, medical (DM, HTN, obesity), macrosomia, prolonge rupture of membranes and or chorioamnionitis, short maternal stature, high station at complete dilation, occiput posterior position, pelvic abnormalities
-
What are the intervention options for arrest of descend
Forceps, vacuum, c-section
-
What is AROM
Artificial rupture of membranes
-
What are the contraindications of labor induction
Prior classical c-section, active genital herpes, placenta or vasa previa, umbilical cord prolapse, transverse lie
-
What is the best tool to predict the likelihood of successful labor induction (resulting in vaginal delivery)
Bishop score
-
A bishop score of __ or greater is favorable for induction of labor
6
-
What are cervical ripening agents
Prostaglandins such as misoprostol
-
List the methods of labor induction
Cervical ripening agents (misoprostol), membrane stripping, oxytocin, mechanical dilation, amniotomy (artificial rupture of membranes)
-
What is the mechanism by which membrane stripping works to induce labor
Increases prostaglandin release
-
Delivery that requires additional maneuvers following failure of gently downward traction on the fetal head to effect delivery of the shoulders
Shoulder dystocia
-
What is the rate of shoulder dystocia
.06-1.4% of deliveries
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What are the risk factors for shoulder dystocia
Maternal obesity, diabetes, hx of macrosomic infant, current macrosomia, hx of shoulder dystocia
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Warning signs of shoulder dystocia
Prolonged 2nd stage, recoil of head on perineum (turtle sign), lack of spontaneous restitution
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Fetal complications of shoulder dystocia
Brachial plexus injury, clavicle/humerus fx, asphyxia
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Treatment for shoulder dystocia
McRoberts maneuver, episiotomy, suprapubic pressure, Rubin’s screw, Wood’s screw, delivery of posterior shoulder (humerus fx), Zavanelli
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What is McRoberts maneuver
Dorsiflexion of hips against the abdomen to ease birth of fetus with shoulder dystocia.
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What is the most common cause of postterm pregnancy
Error in dating
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With postterm pregnancy what are the risks to the fetus
Stillbirth, meconium aspiration, intrauterine infection, uteroplacental insufficiency
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With postterm pregnancy what are the risks to the mother
Increased labor dystocia, perineal injury related to macrosomia, and c-section rate
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What are the leading causes of preterm deliveries
Preterm labor (PTL) and preterm premature rupture of membranes (PPROM)
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Preterm delivery is before __ weeks
37
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Major determinant of infant mortality in developed countries
Preterm delivery
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Preterm delivery is particularly acute among what group
African Americans
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Leading cause of developmental disability in children
Preterm delivery
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What are the key risk factors for preterm delivery
Smoking, African American, maternal age (young and old), social factors (poverty, poor housing, crime)
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The fetal fibronectin test has a high __ value in predicting delivery within the next 14 days
Negative predictive
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What is the best tool we have right now to determine patients not at risk for imminent delivery
Fetal fibronectin and cervical length
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What is the purpose for prolonging pregnancy when the patient goes into preterm labor
To allow administration of steroids for fetal lung maturity and maternal transport to a facility with a NICU
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What doesn’t work in preventing preterm labor
Bedrest, hydration, pelvic rest, antibiotics
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What are the tocolytic agents used in the management of pre term labor
Beta-mimetic (terbutaline), magnesium sulfate, calcium channel blockers (Procardia), prostaglandin synthetase inhibitors (indomethacin)
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What should be given to women at risk for preterm delivery between 24-34 weeks to reduce the risk of respiratory distress syndrome, mortality, and intraventricular hemorrhage
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Antenatal steroids (betamethasone, dexamethasone)
What are the risk factors for PPROM
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Intraamniotic infection, prior hx, lower SES/teens, smokers, hx of STD, hx of cervical cerclage, uterine overdistention
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What do you do if the mother goes in to labor any time after 34 weeks
Proceed with delivery, GBS prophylaxis
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What do you do if the mother goes in to labor between 24/23 -31 weeks
Expectant management, GBS prophylaxis, steroids recommended, tocolysis, antibiotics
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What do you do if the mother goes in to labor before 24/23 weeks
Patient counseling about poor outcome, expectant management, no steroids, no GBS prophylaxis or antibiotics
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The only sonogram that is indicated in a normal pregnancy is done at __, it is called the anatomy ultrasound
18 weeks
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Two major goals of prenatal care in the last half of pregnancy are diagnosis of __
Preeclampsia and fetal malpresentation
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What are the routine examination pieces that are done at each prenatal visit
Measurement of blood pressure, measurement of uterine fundus to assess fetal growth, auscultation of fetal heart tones/assessment of fetal activity, (determination of fetal presentation in the third trimester)
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What are some safe and common medications used during pregnancy
Acetaminophen, Benadryl, Claritin/Zyrtec, Sudafed (with caution/elevation of BP), Metamucil
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Two main medications to avoid in pregnancy
NSAIDS, fluoroquinolones
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In general what antibiotics are safe in pregnancy
Any of the penicillins
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If the patient is allergic to penicillin what is another antibiotic that can be used during pregnancy
Clindamycin
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Presumptive symptoms of pregnancy
Amenorrhea, N/V, breast tenderness, fatigue, urinary frequency, quickening, increased basal body temp, chloasma, linea nigra, stretch marks, spider telangiectases
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When do most women experience quickening
18-20 weeks primigravidas, 14-16 weeks multigravidas
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Name the sign: Bluish or purplish discoloration of vagina and cervix
Chadwick’s sign
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Name the sign: Softening of the uterine isthmus
Hegar’s sign
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Name the sign: Softening of the cervix
Goodell’s sign
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Positive manifestations of pregnancy
Fetal heart tones, palpation of fetus, ultrasound of fetus
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When can fetal heart sounds be heard with Doppler
10 weeks
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When can the fetus be palpated
22 weeks
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When can you discover cardiac activity on ultrasound of the fetus
5-6 weeks
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When can you see limb buds on ultrasound of the fetus
7-8 weeks
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When can you see general movement on ultrasound of the fetus
9-10 weeks
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Serum pregnancy test can detect pregnancy as early as __ after conception
1 week
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When should a serum pregnancy test be done
When question of normal development, ectopic, signs of pregnancy loss, previous loss
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hCG is produced by the placenta about __ after fertilization
8 days
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hCG is detectable __ after conception
8-11 days
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hCG doubles every __
48 hours
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when does hCG peak
10-12 weeks
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when do hCG levels return to normal after termination or delivery
21-24 days
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what does a very rapid increase in hCG indicate
Multiples, or molar pregnancy
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what does a very slow rising level of hCG indicate
Ectopic or non-viable pregnancy
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how long does a normal pregnancy last
280 days, 40 weeks, 10 lunar months, 9 calendar months
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What is Nagele’s rule
From the date of the last normal menstrual period, subtract 3 months and add 7 days
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What is the most accurate noninvasive method of finding gestational age
Ultrasound (esp early US); also is most widely used method to determine GA
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If cardiac activity can be seen by transvaginal ultrasound by 8 weeks there is only a __% risk of pregnancy loss
3
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When is a transabdominal ultrasound done
Once uterus above pelvic brim, about 8-12 weeks
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What is the window of time during which a transabdominal ultrasound can be used to evaluate fetal growth/anatomy
After 16 weeks, before 22 weeks
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__% of pregnancies are dangerous to the health of the mother and or fetus
5-20
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What are some major structural anomalies that can be detected on transabdominal ultrasound
DS markers; 2 vessel cord, neural tube defect, anencephaly, hydrocephaly, cleft lip/palate, diaphragmatic hernia
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When should prenatal care ideally start
3 months before conception
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A pregnant woman can get supine hypotensive syndrome after __ weeks
20
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The fundus of the uterus is at the pubic symphysis at __
8 weeks
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The fundus of the uterus is palpable in the abdomen at __
12 weeks
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The fundus of the uterus is at the midpoint between symphysis and umbilicus at __
16 weeks
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The fundus of the uterus is at the umbilicus at __
20 weeks
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When do you start measuring from the symphysis to fundus in centimeters
26-34 weeks
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When does fundal height start to decrease (as the head descends)
36 weeks
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What is included in the maternal blood tests
CBC, type and screen, RPR (syphilis), Rubella, Hep B, HIV, glucose tolerance test, maternal serum screen
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When is the maternal serum screen offered
15-20 weeks
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What is the purpose of the maternal serum screen
Screen for open neural tube defects (spina bifida, anecephaly) and chromosomal abnormalities (trisomy 21 and 18). If the mother would not do anything different with her pregnancy regardless of results test should not be done
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When is the 1 hour glucose challenge test done
26-28 weeks, earlier if at high risk for gestational diabetes (by 24, ideally by 12 wk)
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When should you check mom for group B strep
35-37 weeks
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What do you tell mom to do if she doesn’t feel baby move later in pregnancy
Tell her to drink some juice or water, lay on her left side and feel for movement for one hour. If there is still no movement tell her to come in for evaluation
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What is the normal fetal heart rate
110-160
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What is fetal bradycardia
<110
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What is fetal tachycardia
>160
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What is part of the fetal biophysical profile
Non-stress test, fetal breathing movements, fetal movements, fetal tone, amniotic fluid volume
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What score on the biophysical profile is considered normal
8-10
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What score on the biophysical profile is considered abnormal and requires intervention
4 or less
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Fetal US: 5-13 weeks, measure:
fetal crown-to-rump length
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Fetal US: after 13 weeks, measure:
femur length, abdominal circumference and biparietal diameter; after 30 weeks, accuracy decreases
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Quad screen: diff btw Trisomy 21 & 18
- DS: high hCG/DIA, low AFP/uE3; Edwards: low AFP, hCG, uE3; diff is high hCG in DS
- GDM RFs
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FH, h/o previous stillbirth, h/o macrosomia (>9lbs), prenatal wt >180lbs, advanced maternal age, history of HTN
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Antenatal visits start:
at 8-12 weeks (unless prior PG loss, fertility tx, or maternal illness)
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Most widely used test of fetal lung maturity
Fluorescence polarization; direct measure of surfactant concentration
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erythroblastosis fetalis =
heart failure, edema, ascites & pericardial effusion; d/t RBC destruction exceeding production
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Screening for Down syndrome can be performed when:
1st or 2nd trimester; 1st trimester test characteristics are better than those in 2nd trimester only
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Follow-up antenatal visits detect __% of fetuses with growth abnormality, prevent __% of eclampsia, & uncover __% of breech presentations prior to labor
50% of growth abnormality, prevent 70% of eclampsia, 80% of breech presentations
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What is the average volume of amniotic fluid at term
800 mL
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How is oligohydramnios determined
Identification of the largest pocket of fluid measuring less than 2cmx 2cm or the total of 4 quadrants less than 5 cm
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What is oligohydramnios associated with
SGA fetus, renal tract abnormalities (renal agenesis), and urinary tract dysplasia
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The clinical manifestation of oligohydramnios is a direct result of __
The impairment of urine flow ot the amniotic fluid in the late part of the first half of pregnancy or during the second and third trimesters
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What is the most common autosomal trisomy and what is the rate
Trisomy 21 (Down syndrome) 1 in 600 live births
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What is the second most common autosomal trisomy and what is the rate
Trisomy 18 (Edward’s syndrome) 1 in 6000-8000 live births
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Turner’s syndrome is associated with an average birthweight of approximately __ below average
400g
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Fetuses with neural tube defects are frequently
IUGR weighing approximately 250g less than controls
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Partial or complete detachment of placenta from uterine wall, after 20 weeks gestation
Abruptio Placenta
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What are some risk factors of abruptio placenta
Cocaine use, maternal hypertension, trauma
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Placenta previa is __ bleeding
Painless/silent
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Placenta abruption is __ bleeding
painful
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__% of women are GBS vaginal/rectal colonized
10-30%
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What is the most common cause of neonatal sepsis
GBS
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GBS bacteruria indicates
Heavy colonization
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What is something you see in babies born to mothers on AZT for HIV
Lower WBC counts & macrocytic anemia (will resolve over time)
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Chronic intrauterine infection is responsible for __% of IUGR pregnancies
5 to 10
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What is the most commonly identified pathogen responsible for IUGR
CMV
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What is the most common protozoan, acquired by eating raw meat, that is responsible for IUGR
Toxoplasma gondii
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Bacterial infections occur commonly in PG & frequently are implicated in PTD; but they are not commonly assoc w/IUGR; exception to this rule is chronic infx with:
Listeria monocytogenes
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What is the clinical picture of an infant born to a mother infected with chronic listeria monocytogenes
Critically ill, encephalitis, pneumonitis, myocarditis, hepatosplenomegaly, jaundice, and petechiae
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Early GBS =
1st 6 days of life; 75% of cases; in utero or during birth; RFs: PTL, PROM, PPROM
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Late GBS =
After 1st week of life; nosocomial or CA
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BV adverse outcomes
PTD/LBW; intraamniotic or placental infxn (ID & Rx did not improve outcomes); USPSTF: no routine screen; tx sx
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If PG pt pos for HBSAg:
check acute/chronic (HBcAb,LFT); test partner, if neg, vax
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Hep E antigen =
increased risk of infectivity (vertical trans in maternal chronic Hep B)
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Hep B vertical transmission: tx
Recombivax, HBIg to neonate after delivery (90% effective); mom can breastfeed after tx
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Most common effects of rubella transmission
Heart, eye, ear; risks are GA dependent
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VZV: perinatal exposure: tx
VZIg perinatally (5 days before - 2 days after delivery); acyclovir for maternal VZV
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Which vax can be given during PG?
Hep B, flu, tetanus (Tdap); DO NOT GIVE VZV or Rubella (live)
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GBS RFs and when to tx/not to tx
Do not tx if at term w/o RF; Tx if PTL or term w/RFs: fever, h/o GBS, ROM >24 hr
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Infants in the __ percentile are classified as having intrauterine growth restriction (IUGR)
< or =10th
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Infants in the __ percentile are classified as large for gestational age (LGA)
> or = 90th
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Both IUGR and LGA fetuses have increased risk for __
Perinatal morbidity and mortality
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A pregnancy cannot be described as IUGR unless what is known with certainty
Gestational age
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What does symmetric IUGR refer to
Infants in which all organs are decreased proportionally
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Symmetric IUGR infants are more likely to have __
An endogenous defect that results in impairment of early fetal cellular hyperplasi
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What does asymmetric IUGR refer to
Infants in which all organs are decreased disproportionately (abdominal circumference is affected to a greater degree than head circumference)
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Asymmetric IUGR infants are more likely caused by __
Intrauterine deprivation that results in redistribution of flow to the brain and heart at the expense of less important organs such as the liver and kidneys
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An infant with an autosomal __ is more likely to be IUGR
Trisomal
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Multiple gestation is associated with a __% increased incidence of IUGR fetuses
20-30
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What is the most common maternal complication causing IUGR
Hypertension
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Women who stop smoking before __ weeks gestation are not at increased risk for having an IUGR infant
16
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Poor maternal wt gain is associated with an increased risk of having an IUGR infant. Daily intake must be reduced to less than __kcal/d before a measurable effect on birthweight becomes evident
1500
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What are some vascular diseases that are risk factors for having an IUGR infant
Collagen vascular disease, insulin-dependent diabetes mellitus associated with microvasculopathy and preeclampsia
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What is the best parameter for early dating of pregnancy on ultra sound
Crown-rump length
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What are the most accurate parameters for dating of pregnancy in the second trimester
Biparietal diameter, and HC
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Most accurate parameter for dating of pregnancy in the third trimester
Head circumference
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Single most common preventable cause of IUGR in infants in the US
Smoking
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Data shows that IUGR infants appear to catch up in weight in the first __ of life
6 months
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Taken as a group IUGR infants have more __ than do their AGA peers
Neurologic and intellectual deficits
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The incidence of __ is increased in IUGR infants
Sudden infant death syndrome
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Maternal obesity is associated with a __ increased likelihood of fetal macrosomia
3-4 fold
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Male fetuses are __g heavier on average than female fetuses
150
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What is the best single measure in evaluating macrosomia by ultrasound in diabetic mothers
Abdominal circumference
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Estimated fetal wt. by __ is not very accurate
Ultrasound
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When do you screen with 1 hour glucose
At 24-28 weeks in patients >25 or family history of DM or Ethnic risk
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Risk factors for GDM
> 25 years, prior GDM/family hx, prior big baby/still birth, BMI greater than or equal to 27, chronic hypertension, glycosuria
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What is the biggest complication of GDM
Big babies that don’t want to come out (macrosomia/ shoulder dystocia)
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What are the birth traumas associated with macrosomia
Brachial plexus injury, clavicular injury, facial nerve injury
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Risk factors for fetal growth restriction
CVD (hypertension), smoking, fetal abnormalities, multifetal gestation, abnormal placentation, poor maternal wt gain or nutrition
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In second half of PG, increased concentrations of __ combine to produce modest maternal insulin resistance, which is countered by postprandial hyperinsulinemia
Human placental lactogen, free and total cortisol, and prolactin
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What is the most common medical complication of pregnancy
Diabetes mellitus
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Preexisting diabetes mellitus affects approximately __ per 1000 pregnancies
1 to 3
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Defined as any degree of glucose intolerance with first recognition during pregnancy
Gestational diabetes
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GDM complicates __% of pregnancies
4
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Women with GDM have an approximately __% risk of developing type 2 diabetes over the next 10 years
50
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__ is the hormone mainly responsible for insulin resistance and lipolysis. It is similar in structure to growth hormone and acts by reducing the insulin affinity to insulin receptors
Human placental lactogen
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HbA1C can predict the risk for __ when measured in the first trimester
Malformation
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Higher glucose level in mothers lead to higher glucose levels in the fetus. This leads to higher levels of insulin which can cause __ in the fetus
Macrosomia, central fat deposition, enlargement of internal organs such as the heart
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What are risk factors for developing GDM
Obesity, prior hx of GDM, heavy glycosuria, unexplained stillbirth, prior infant with major malformation, family hx of DM in first degree relative
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When should at risk pregnant women be screened for GDM
As soon as feasible and again between 24 and 28 weeks
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Which women can be omitted for GDM screening
Age <25, normal body wt, no family hx, no hx of abnormal glucose metabolism/poor OB outcome, and not a member of an ethnic or racial group at high risk
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What are the ethnic or racial groups with a high prevalence of diabetes
Hispanic Americans, Native Americans, Asian Americans, African Americans, Pacific Islanders
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What is the mainstay of treatment in the pregnant women with pregestational diabetes
Rigorous control of blood glucose
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What is an optimal fasting glucose in pregnancy
70-95
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What is an optimal 1-hr postprandial glucose value during pregnancy
Less than 140
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What is an optimal 2-hr postprandial glucose value during pregnancy
Less than 120
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If a young female patient is hypertensive and having a seizure she is __ until proven otherwise
Preeclamptic
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Hypertension complicates __ of all pregnancies
5-7%
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Preeclampsia/eclampsia is responsible for __% of hypertension in pregnancy
70
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Hypertension with proteinuria and or pathologic edema
Preeclampsia
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Hypertension without proteinuria or pathologic edema during pregnancy
Pregnancy induced hypertension
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Hypertension with proteinuria and or pathologic edema with convulsions
Eclampsia
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Signs and symptoms of preeclampsia
HA, hyperreflexia, visual changes, irritability, epigastric pain, edema of face/hands/abdomen, oliguria
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