OB 3

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OB 3
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2011-05-14 22:43:05
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OB 3 review made by fellow student
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  1. Blood volume increases by?
    50%
  2. Increase is stimulated by?
    Increase in estrogen -> RAAS
  3. Cardiac output increases by?
    40%
  4. Blood pressure
    Declines, lowest pt. at 24-48 weeks
  5. Venous pressure
    Increases in Les->edema and varicosities
  6. Peripheral vascular resistance
    Decreases in 1st trimester
  7. What type of heart murmur?
    Systolic ejection – in 90% of pregs. And S1 split
  8. CXR during pregnancy
    • Markings in lungs due to increase in pulmonary blood volume
    • Diaphragm elevated 4 cm
  9. Lung Vol. and Capacities?
    • Tidal vol. increases
    • Reserve, and residual vol. decreases
    • Tot. lung capacity decreases, and functional capacity decreases. Inspiratory vol. increases
  10. What are the Renal changes
    • Elevated gfr due to increase in plasma flow
    • Renin activity increases
  11. GI system
    • Organs displaced
    • Hypertrophic gums
    • Reflux in 80%, increase in gastrin
    • Decreased transit time
    • Increase risk of gall stone
  12. Liver
    Reduced plasma albumin
  13. Hematologic
    • Anemia
    • Iron deficiency common
    • Elevated leucocytes
    • Preg. Associated thrombocytopenia in 3rd trimester
  14. Skin
    • Hyperpigmentation,
    • Stretch marks, varicosities
  15. Metabolism
    Pica, food intake and appetite increase
  16. 3 phases of Fetal circulation
    • Intrauterine
    • Transport
    • Adult
  17. Intrauterine Phase
    • Dependent on placenta
    • Umbilical vein-o2 blood to liver- shows maternal and placental problems
    • Umbilical artery-from common iliac-shows fetal status
  18. Transition phase
    • Ligation of umbilical cord causes rise in arterial pressure
    • Rise in plasma CO2 and fall in PO2 cause breathing
    • Increase in pressure causes closure of the foramen ovale and ductus arteriosus.
  19. Adult Phase
    • Completed in 1st mos. Of life
    • Ductus and foramen completely close
  20. If ductus does not close?
    Systolic crescentoid murmur
  21. Recommended weight gain
    25-35 lb in pregnancy
  22. UTI
    Treat asymptomatic bacteria
  23. Immunizations
    • Safe- killed virus, toxoid, or recombinant
    • Unsafe- live attenuated vaccines
  24. HIV
    • Minimize vertical x-mission
    • Intrapartum AZT infusion and HAART
  25. HSV
    • Oral Acyclovir for prophylaxis before delivery
    • Mortality and morbidity associated w/ HSV infection
  26. Extreme n/v a sign of?
    Molar pregnancy or multiple gestation
  27. Hyperemesis gravidarum
    Req. hospitalization
  28. Spontaneous Abortion Risk Factors
    • Age
    • Drugs: smoking, caffeine, NSAIDs
    • Asherman’s
    • Uterine abnormality
    • Multiparity
    • DM
    • Thyroid
    • PCOS
  29. SAB presentation
    • ABD pain
    • Vag bleeding
    • Amenorrhea
    • Early pregnancy
  30. SAB Differential Diagnosis
    • Ectopic
    • Impending SAB
    • Infection
    • Cervical polyp
    • Physiologic implantation
  31. Ultra sound And HCG level
    Look for gestational sac early as 4.5 to 5 wks, or at 800hcg
  32. SAB Ultrasound Diagnosis
    • Absence of fetal cardiac activity
    • Absence of fetal pole
    • Abnormal yolk sac, fetal HR <100 or subchorionic hematoma=ominous sign.
  33. HCG Diagnosis
    Not increasing as expected in normal preg.
  34. Threatened SAB
    • Any Painless bleeding before 20th wk.
    • Closed os
    • Uterine size= EGA
  35. Inevitable abortion
    • ABD or lower back pain
    • Cervix dilated or ROM=preg. loss
  36. Complete Abortion
    • All POC passed
    • Common prior to 12 wks
  37. Incomplete abortion
    • Partial expulsion of gestational tissue
    • More likely after 12 wks.
    • Cervix open , uterus , EGA
    • Can have severe bleeding
  38. Missed abortion
    • Retention of a failed IUP for an extended time
    • DIC can occur in 2nd trimester if AB >6 wks
  39. Recurrent abortion
    >2 consecutive or 3 tot SABs
  40. Induced Abortion
    Termination of intact pregnancy
  41. Treatment of Threatened AB
    Pelvic rest
  42. Treatment of others
    • Serial HCG, pelvic rest
    • D and E
    • Misoprostol to induce labor
  43. Post abortion care?
    • Rhogam if RH neg.
    • Doxy with D&C
    • Methylergonovine maleate-controls hemorrhage
  44. Leading cause of death in 1st trimester?
    Ectopic pregnancy
  45. Risk Factors for ectopic pregnancy.
    • High: Tubal pathology, Previous ectopic, DES exposure, Tubal surgery
    • Med/Low: Recurrent PID, Infertility, Multiple sex partners, Smoking, douching, Age
  46. Most common location
    98% tubal
  47. S/S
    • ABD pain
    • Amenorrhea
    • Bleeding
    • Spotting
  48. If rupture
    Light headedness, shock
  49. Diagnosed with
    Serum hcg and ultrasound
  50. Treatment
    • Surgical if ruptured
    • Methotrexate
  51. Types of Gestational Trophoblastic Neoplasias
    • Hydatiform mole
    • Invasive mole
    • Choriocarcinoma
    • Placental-site trophoblastic tumor
  52. Tumor marker
    HCG
  53. Most common form of GTN
    Hydatiform mole
  54. Suspect Hydatiform mole when
    • Grape like vesicles fill/distend uterus
    • Hyperemesis gravidarum
    • Onset of preeclampsia prior to 24 wks
  55. Invasive mole
    Hydatiform mole that invades the adjacent structures
  56. Choriocarcinoma
    Cancer preceded by hydatiform mole
  57. Placental-site trophoblastic tumor
    Tumor confined to uterus, preceded by hydatiform mole or normal pregnancy
  58. GTN diagnosed by
    • HCG
    • Ultrasound
  59. Cervical insufficiency
    Painless changes in 2nd trimester causing recurrent pregnancy loss
  60. Causative Factors
    • Short cervix
    • Uterine abnormalities
    • Trauma from LEEP or Biopsy
    • Collagen abnormalities
    • Elevated serum relaxin
  61. Signs/Symptoms
    • Vag. Fullness and pressure
    • Discharge, spotting or bleeding
    • ABD or back discomfort
  62. Tx
    • Progesterone
    • Cerclage “purse string suture”
  63. Monozygotic
    Identical twins
  64. Dizygotic
    Fraternal twins
  65. Risks of twins
    • Preterm labor
    • IUGR
    • Preeclampsia
    • Post partum hemorrhage
    • Increased risk of SAB
  66. Who is a candidate for a prenatal diagnosis
    • >35 y/o
    • Abnormal screening results
    • Fam. HX
    • Multiple pregnancy losses
    • Maternal conditions –IDDM, lupus, sz, substance abuse
    • Exposure to teratogens
    • Consanguinity
    • Ethnicity-Ashkenazi Jewish
  67. Key Factors of screening counseling
    • Sequence of prenatal diagnosis
    • Impact of prenatal diagnosis
    • Ethical considerations
  68. Who should be offered CF screening
    All women
  69. 1st trimester screen
    • Offers early risk assessment,
    • Reduce number of invasive procedures
    • Cannot detect NTD or ventral wall defects
  70. Maternal serum screening
    • @ 15-22 wks.
    • Can Id NTD, aneuploidy
    • Correctly dates pregnancies
    • ID risk for renal agenesis (AFP low) and ventral wall defects (AFP high)
    • Cannot r/o all aneuploidies
  71. Downs syndrome AFP level
    LOW
  72. Open Neural Tube AFP level
    High
  73. Nuchal Lucency test
    Id Trisomies 13, 18, 21
  74. Chorionic Villus sampling
    • 10-12 wks gestation
    • Id aneuploidy and single gene conditions
    • 1/100 risk for miscarriage
  75. Early amniocentesis
    • 12-14 wks. Early diag. of aneuploidy and ONTD
    • Higher risk of miscarriage than normal amniocentesis
  76. Ultrasound findings assoc. w/ aneuploidy
    • Hydrocephaly
    • Hydrops
    • Omphalocele
    • Cardiac defects
    • Kidney and bladder defects
    • Meningomyelocele
    • Cystic hygroma
  77. Traditional amniocentesis
    • 15 wks to term,
    • Detects aneuploidy, ONTD, single gene, Rh and lung maturity
  78. Percutaneous Umbilical sampling
    After 16 wks
  79. Tests for thrombocytopenia
    • Fluorescent in situ hybridization
    • Id certain aneuploidy , Id chromosomal deletions
  80. Preeclampsia
    Proteinuria and/or pathologic edema
  81. Risk factors
    • <20 >35
    • Nulliparity
    • Multi-fetal gestation
    • Hydrops fetalis
    • Hydatidiform mole
    • Chromosomal anomalies
    • UTI
    • Gestational diabetes or DM
  82. Severe Preeclampsia
    • HA
    • Hyperreflexia
    • Photophobia
    • Epigastric pain due to elevated liver enzymes
    • Edema of face and hands
  83. Prevention
    Low dose asa
  84. Eclampsia
    Proteinuria and sz
  85. HELLP syndrome
    • Hemolysis
    • Elevated Liver enzymes
    • Low platelets
  86. Presentation of HELLP syndrome
    • Malaise fatigue (primary)
    • N/V
    • RUQ pain
    • Severe HTN
    • HA
    • +3 protein in urine
  87. Treatment of Preeclampsia and HELLP
    • Antihypertensives
    • Corticosteroids-improve liver function and fetal lung development
    • Anticonvulsants- mag sulfate
    • Bed rest
    • Delivery only cure
  88. Intrauterine Growth Restriction
    Weight <10th percentile
  89. Maternal risk factors
    • Cardiovascular or renal dz
    • Low maternal weight gain
    • Vaginal bleeding in pregnancy
    • Prior stillbirth
    • Smoking, etoh, coke, or harry use
  90. Diagnosis
    Clinical size less than date (<2cm than expected)
  91. IUGR caused by
    • Genetic-malformations, chromo abnormalities
    • Congenital-TORCHES
    • Placental-Placenta previa, small placenta
    • Multifetal gestation
  92. Treatment
    Ultrasound, antenatal treatment
  93. Gestational DM Screening
    24-28 wks with one hr. Glucola if >25 yo or fam. Hx of DM or ethnic risk
  94. Risk factors
    • > 25 y/o
    • Prior GDM or fam. Hx
    • Prior macrosomic infant >9lb
    • Obesity
    • Chronic hypertension
    • Glycosuria
  95. Diagnosis
    • 1 hr. Glucola challenge cutoff at 140 mg/dL.
    • 3 hr. test is done if abnormal
    • 2 abnormal values diagnose GDM
  96. Treatment
    • Diet
    • Tight BS control
    • Insulin if inadequate.
    • Metformin and glyburide controversial
  97. Pre-existing DM treatment
    Insulin
  98. Complications Maternal
    • Pre eclampsia
    • Infections
    • Macrosomia=c-section
    • Polyhydramnios
    • Preterm labor
  99. Complications Fetal
    • Macrosomia-birth injury
    • Major anomalies-cardiac, NTD
    • Predisposition to DM and obesity
  100. Whites classification
    System for categorizing DM during pregnancy
  101. Macrosomia
    Big baby, above 4000grams, or approx 9lbs
  102. Risk Factors
    • Abnormal OGTT
    • Maternal obesity, multiparity, previous LGA infant
  103. Complications of Macrosomia
    • C section
    • Prolonged labor
    • Birth trauma-shoulder dystocia, clav fx, nerve injury
  104. Normal amniotic fluid
    800-1000
  105. Polyhydramnios
    • Too much fluid caused by: DM, Twins, Hydrops,
    • Fetal abnormalities, >25 cm AFI
  106. Oligohydramnios
    • Too little fluid, <5 cm AFI
    • Post date, Fetal growth restrictions, premature ROM, Fetal renal abnormalities
  107. Labor def.
    Series of uterine contractions -> cervical effacement and dilation and voluntary bearing down
  108. Lightening
    Settling of fetal head in pelvis 2 wks prior to delivery
  109. Bloody show
    Passage of small amount of blood tinged mucus from vagina-sometimes signal onset of labor
  110. False labor
    Lack of cervical change in response to contractions
  111. Braxton Hicks
    Last 4-8 wks, irregular, painless with slowly increasing frequency
  112. Fetal presentations
    • Vertex-normal
    • Breech
    • shoulder
  113. Station
    Position of head in pelvis
  114. Cardinal movements of labor
    • Engagement-head below plane of pelvis
    • Flexion-passive flexion of fetal head
    • Descent-progression of fetus through pelvis
    • Internal rotation-rotation of presenting part
    • Extension-head is delivered by extension
    • External rotation-after delivery of head
  115. 1st stage of labor
    • Onset of labor to full dilation
    • Can last 6-8hrs
    • Progress monitored by cervical effacement
  116. 2nd Stage
    • Between full dilation and delivery
    • Desire to bear down, Descent of fetus
  117. 3rd Stage
    • Delivery until expulsion of fetus
    • Cervix and vagina should be examined for bleeding
    • Placenta usually separates from 2-10 mins
    • Placenta should be examined to detect abnormalities
  118. Assessment of contractions
    • Qualitatively- External Toco, observation/palp.
    • Quantitativly-measurement of intrauterine pressure (most precise)
  119. Latent phase
    Mild-15-20mins apart lasting for 60-90 secs
  120. Active Phase
    Cervix 4-8 cm, contractions 3 mins apart lasting for 1 min
  121. Cervix at 8-10cm
    Contractions last 1 min and are 2-3 mins apart
  122. Dystocia of labor
    Difficult child birth, slow abnormal progression of labor, leading cause of primary c section
  123. 3 P’s
    • Passage (pelvis)
    • Passenger (fetus)
    • Powers (expulsive force)
  124. Prolonged latent phase causes
    • Sedation
    • Anesthesia before active phase
    • Uterine dysfunction
    • Fetopelvic disproportion
  125. Slow Labor
    Slow cervical dilation in active phase and slow descent
  126. Slow labor causes
    • Fetopelvic disproportion
    • Malpositions of fetus
    • Aesthesia
    • Sedations and tumor
  127. Complete cessation of Progress
    • Arrest of dilatation
    • Or arrest of descent
  128. Prolonged Labor risk factors
    • Age
    • DM, HTN, Obesity
    • Macrosomia
    • Short maternal stature
    • High station at dilation
    • Pelvic abnormalities
  129. Complication
    Uterine rupture, postpartum hemorrhage, decreased uteroplacental perfusion
  130. McRoberts Maneuver
    Dorsiflexion of hips against abdomen – widens pelvis
  131. Episiotomy
    No evidence to support routine use
  132. Cause of pain during delivery
    • Ischemia of uterus during contractions
    • Dilation of cervix
    • Distention of vagina
  133. Pharmacologic options
    • Narcotics used in 1st stage
    • Regional anesthesia
    • General anesthesia used when regional anesthesia cannot be give for c section
  134. Post term pregnancy
    Beyond 42 wks
  135. Risk of post term
    • Meconium aspiration
    • Uterine infection
    • Labor dystocia,
    • Macrosomia and c sectio
  136. Indications for induction of delivery/Iatrogenic stimulation of contractions
    • If favorable cervix failure is low
    • Fetal compromise-non reassuring NST
    • Gestational HTN or PIH, preeclampsia/eclampsia
    • Postterm
    • PROM
    • Hx of rapid labor, distance from hospital
  137. Contraindications
    • Prior classical c section
    • Genital herpes
    • Placenta previa
    • Umbilical cord prolapse
    • Transverse lie
  138. Bishop score
    Predicts likelihood of successful labor induction, scores >6 are favorable
  139. Induction methods
    • Cervical ripening agents
    • Membrane stripping
    • Oxytocin
    • Mechanical dilation
    • Amniotomy
  140. Complications
    • Prolonged labor, premature separation of placenta
    • Placenta rupture and lac of cervix
    • Infection
    • Hemorrhage,
    • Cord prolapse
    • Poor apgar
  141. 3 types of breech
    • Frank
    • Complete
    • Footling
    • Compound presentation
    • Fetal extremity presents along with presenting part, hand presenting with head most common
  142. Vertex Malpositions
    Occiput posterior or transverse
  143. External Cephalic version
    Pressure on mothers abd to turn fetus after 36 wks
  144. 2 types of operative delivery
    • Operative Vaginal
    • Cesarean section
  145. Indication
    • Immediate or potential fetal compromise
    • Prolonged second stage
  146. Major Causes during pregnancy
    • Trauma –MVA, domestic
    • Ectopic
    • Placenta previa
    • Placenta abruptio
  147. Causes post partum
    • Uterine rupture
    • Uterine inversion
    • Birth trauma
    • Retained placenta
    • Uterine atony
    • Obstetric lacerations
    • DISC
    • Von Willebrand’s
  148. Uterine inversion
    fundus through cervix-shock out of proportion to blood loss
  149. Most common cause of Post partum Hemorrhage
    Uterine atony- uterus fails to contract
  150. Placenta accreta
    Adheres to myometrium
  151. Placenta increta
    Placenta invades myometrium-retained placental parts
  152. Placenta percreta
    Placenta invades through myometrium-hysterectomy
  153. Placenta Previa
    Painless vaginal bleeding, dx by ultrasound-c section
  154. Abruptio placenta
    • Painful vaginal bleeding and fetal distress
    • Premature separation of placenta
  155. Abruptio Risk factors
    • Hypertension
    • Trauma
    • Smoking, cocaine
    • Preterm rom
    • Thrombophilia
    • Chorioamnionitis
    • Rapid decompression of uterus
  156. Complications
    • DIC
    • Renal cortical tubular necrosis
    • Uterine atony
  157. Treatment for hemorrhage
    • Oxytocics
    • Bimanual message and compression
    • Surgical
  158. PROM
    • Rupture of membranes before onset of labor
    • If before 37 wks. -> PPROM
  159. Risk Factors
    • Intraamniotic infection
    • Prior hx
    • Lower SEC
    • Uterine overdistention
    • Cervical cerclage
  160. S/S
    Sudden gush of fluid or continued leakage, reduced size of uterus
  161. Sterile speculum exam looks for
    Pooling, ferning, Nitrazine positive
  162. PPROM Management
    • GBS prophylaxis
    • Steroids less than 32 weeks
  163. If chorioamnionitis present
    Actively delivered regardless of gestational age
  164. No chorioamnionitis
    Manage like preterm labor
  165. Antibiotics
    Prolong latent period and decrease infection rates
  166. Corticosteroids
    • Prior to 32 wks with no infection
    • Lung development, decrease in necrotizing enterocolitis and intraventricular hemorrhage
  167. Tocolytics
    Limit to 48 hrs to permit administration of corticosteroids
  168. Preterm Labor
    Delivery before 37 wks.
  169. Risk factors
    • Smoking
    • Maternal age
    • Social factors-stress
    • Prior preterm delivery (strong risk factor)
  170. Screening predictors
    • Cervical length-reliable
    • Fetal Fibronectin testing- negative predictor
  171. Prevention
    Progesterone
  172. Tocolytic therapy
    • Minimal success and no improvement of outcomes
    • Allows adm. of steroids and transport to hosp. with NICU
  173. Leading Cause of preterm deliveries?
    PTL and PPROM
  174. Influenza Vaccine
    Should be universally practiced
  175. GBS colonization in pregnancy
    10-30%, bacteruria indicates heavy colonization
  176. GBS in infant
    • Early- first 6 days of life
    • Late- after first 6 days- nosocomial or community acquired
  177. GBS culture
    35 to 37 wks.
  178. Treatment
    • If positive PCN
    • PCN allergy cefazolin or clindamycin
  179. Sickle cell anemia
    Doubles risk of asymptomatic bacteriuria
  180. Pathogens of ASB
    Gm neg- e coli, proteus, klebsiella
  181. Bacterial Vaginosis
    • Higher risk of preterm delivery
    • Rx for symptoms, treatment does not show improved outcomes
  182. Risk of HIV transmission to baby
    • No rx 30%
    • AZT alone 6%
    • AZT + VL undetectable
  183. If Hep B positive
    Acute Vs chronic via LFT and Core antibodies
  184. Treatment
    Give Recombivax and HBIg do neonate after delivery
  185. Can she have an amniocentesis ?
    Yes
  186. Can she breast feed?
    Yes after infant is vaccinated
  187. Syphilis Screen
    All OB pts. With VDRL, RPR
  188. Genital Herpes
    Treat with acyclovir (preg. Cat C)
  189. Rubella congenital effects
    Most common heart, eye, ears
  190. Live attenuated vaccine given?
    Post partum
  191. Impact of varicella
    • Higher fatality rate
    • Pneumonia
    • Encephalitis
    • If contracted before 20 weeks-microcephaly, limb
  192. Treatment
    Varicella immune globulin may interrupt transmission.
  193. TORCHES
    • TOxoplasmosis
    • Rubella
    • Cytomegalovirus
    • Herpes Simples

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