Obstetrics

Front 1

Definition of Overt DM

Back 1

Women who meet the following criteria at the first prenatal visit:

■Fasting plasma glucose ≥126 mg/dL
■A1C ≥6.5
■Random plasma glucose ≥200 mg/d, that is subsequently confirmed by elevated fasting plasma glucose or A1C, as described above
- Thresholds correlate with adverse cardiovascular events.

Front 2

Diagnosis of Gestational DM

Back 2

■ Early approach - at first prenatal visit. 50gm 1 hr GTT. >130 = positive.

■Fasting plasma glucose ≥92 mg/dL, but <126 mg/dL at any gestational age (fasting plasma glucose ≥126 mg/dL is consistent with overt diabetes)

■"One Step Approach" - At 24 to 28 weeks of gestation:
- 75 gram 2 hr GTT with at least one abnormal result: fasting plasma glucose ≥92 mg/dL but <126 mg/dL, one hour ≥180 mg/dL, or two hour ≥153 mg/dL = positive

■

Front 3

Adverse Outcomes of Gestational DM

Back 3

■Preeclampsia
■Hydramnios
■Fetal macrosomia
■Fetal organomegaly (hepatomegaly, cardiomegaly)
■Birth trauma
■Operative delivery
■Perinatal mortality
■Neonatal respiratory problems and metabolic complications (hypoglycemia, hyperbilirubinemia, hypocalcemia, erythremia)

Front 4

Long term risk to children of uncontrolled DM mothers.

Back 4

Obesity
Impaired fine and gross motor functions
Higher rates of inattention and/or hyperactivity
Increased risk of pre-DM and DM/ (from 18-27 yo = 8x risk)

Front 5

Goal for intrapartum CBG

Back 5

Goal 70-110

> 180 consistently associated with neonatal hypoglycemia.

Front 6

Insulin requirements in labor

Back 6

- Basal insulin is required to maintain euglycemia during the latent labor.

- With active labor - insulin requirement drops to almost zero.
- Glucose infusion requirement increases to about 2.5 mg/kg/min to maintain maternal glucose concentration at 70 to 90 mg/dL.

Front 7

When do you monitor glucose during labor?

Back 7

standard approach:
- every 2-4 hrs during the latent phase
- every 1-2 hrs during the active phase
- every hour during insulin infusion.

Exception = women maintained with diet/exercise. Could check every 4-6 hrs.

Front 8

Medication for hx. of preterm delivery?

Back 8

- 17α-Hydroxyprogesterone caproate (Delalutin).
- Indications: hx. of preterm delivery, short cervix on u/s exam.
- Usually IM or per vagina.
- Weekly, beginning 2nd trimester (16-20w) through 36 weeks.

Front 9

What is latent labor

Back 9

Point at which regular uterine contractions, gradually soften, efface, and begin to dilate the cervix.
- Generally accepted to be up to 4cm.

Front 10

What is prolonged latent labor?

Mgmt Options

Back 10

≥ 20 hours for the nullipara and ≥14 hours for the multiparous woman.

•For women who are tired and uncomfortable in early latent phase - suggested therapeutic rest rather than - - Morphine 0.15 mg/kg SC
- Approximately 85% of women will wake up in the active phase of labor.
•Pitocin is appropriate for a woman who is well rested or has already received therapeutic rest.

Front 11

Consequences of prolonged latent phase.

Back 11

Friedman found: women with prolonged latent phase who eventually achieved a normal pattern of dilation and descent were Not more prone to developing active phase protraction and arrest disorders than parturients with a normal latent phase, and perinatal mortality was not increased

Others, have reported prolonged latent phase is associated with a higher risk of subsequent labor abnormalities, and that newborns are more likely to be exposed to thick meconium, have depressed 5min Apgar scores, and require neonatal intensive care unit admission.

Front 12

Velamentous Cord insertion - what is it? and management.

Back 12

1. Placental end of cord insertion that consists of divergent umbilical vessels = not surrounded by whartons jelly = more fragile.

2. Management:
■Detailed fetal anatomic survey, including evaluation for coexistent vasa previa
■Serial assessment of fetal growth, every four to six weeks
■Fetal heart rate tracings weekly, beginning at 36 weeks of gestation, to look for recurrent variable decelerations from kinking or compression
■Counseling patients to call their providers as soon as labor begins
■Delivery by 40 weeks of gestation

Front 13

In uterol Recuscitation for poor FHT.

Back 13

* Scalp stimulation to provoke FHR acceleration should be attempted.
■Reposition
■Administer oxygen
■IV bolus
■D/C uterotonic drugs
■Administer a tocolytic drug (eg, terbutaline 250 mcg subcutaneously)
■For patients who were recently given epidural - alpha-adrenergic agonist to reduce sympathetic blockade
(eg, phenylephrine, ephedrine).

Front 14

Category I Tracing

Back 14

■Baseline rate: 110 to 160 beats per minute
■Moderate baseline fetal heart rate (FHR) variability (amplitude 6 to 25 bpm)
■No late or variable decelerations
■Early decelerations may be present or absent
■Accelerations may be present or absent

Front 15

Category III Tracing and why does it matter?

Back 15

1. Sign of fetal acidosis.

2. Definition
■Absent baseline fetal heart rate variability, and:

•Recurrent late decelerations
•Recurrent variable decelerations
•Bradycardia

OR

■A sinusoidal pattern

Front 16

Causes of fetal tachycardia

Back 16

■Maternal-fetal infection
■Medications (eg, beta-agonists, atropine, cocaine)
■Maternal hyperthyroidism
■Placental abruption
■Fetal hypoxia
■Elevated maternal catecholamine levels

- Rarely Aflutter or SVT - usually would see heart rate >200.

Front 17

Variable Decels w/o loss of variability or accelerations.

Back 17

- From cord compression.

- They do not typically result in adverse consequences, presumably because transient cord compression is well tolerated by the fetus. Thus, they do not require intervention.

Metabolic acidosis or mixed metabolic and respiratory acidosis can develop, however, with increasing duration, depth, and frequency of variable decelerations.
- Therefore, recurrent variable decelerations (>50 percent of contractions) require close surveillance for loss of variability and accelerations, which signify a category III tracing.

Front 18

Causes of Loss of variability without decelerations?

Back 18

■Fetal sleep cycle - generally last ~20 min, but may persist for as long as one hour. When the fetal sleep cycles are over, moderate variability should return.
■CNS depressants - The most common medications that decrease variability are opioids and magnesium sulfate.
- Effect of opioids on FHR variability generally lasts no more than two hours.
■Fetal hypoxemia

Front 19

Fetal Bradycardia

Back 19

Bradycardia with absent variability appears as a smooth FHR below 110 bpm.
- Ominous when prolonged > least 10 minutes) in the absence of hypothermia, complete heart block, or use of certain drugs (eg, beta-adrenergic blockers, paracervical block). When the FHR falls below 100, tissue perfusion may not be adequate; this degree of bradycardia is nonreassuring even when variability is present.

Front 20

Definition of Arrest of 2nd state

Back 20

■No progress (descent or rotation)


•Nulliparous women: ≥4 hours with epidural anesthesia and ≥3 hours without epidural anesthesia

•Multiparous women: ≥3 hours with epidural anesthesia and ≥2 hours without epidural anesthesia

Front 21

Arrest of Active Labor Risk factors

Back 21

1. Hypocontractile uterine activity.
2. Cephalopelvic disproportion: usually, fetal malposition (eg, extended or asynclitic fetal head) or malpresentation (mentum posterior, brow) rather than a true disparity between fetal size and maternal pelvic dimensions.
3. Anasthesia - generally no effect on stage 1, however shown to increase second stage by ~16 m.
(Epidural versus non-epidural or no analgesia in labour.AUAnim-Somuah M, Smyth R, Howell CSOCochrane Database Syst Rev. 2005)
4. Bandl's ring.
5. OP presentation.
6. Maternal obesity.