Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
157 Cards in this Set
- Front
- Back
|
IUGR -
What is it |
Wt. < 10th percentile
suspect if > 4 between fundal ht. (cm) and GA (wks) asymmetric - 80% placenta mediated: HTN poor nutrition maternal smoking symmetric - fetal problem: cytogenetic infection anomalies |
|
|
IUGR -
Dx |
Serial exams, US every 3-4 wks
NST, CST, BPP Doppler |
|
|
IUGR -
Tx |
■ Steroids
■ consider early delivery - esp. asymmetric ■ continuous FHR monitoring during labor ■ C-section if decelerations persist |
|
|
Oligohydramnios -
What is it |
■ Excess loss of fluid -
ROM (amniotic leak) ■ dec. in fetal urine produced fetal urinary tract abnorm obstructive uropathy ■ chronic uteroplacental insufficiency maternal HTN severe toxemia AFI < 5 on US |
|
|
Oligohydramnios -
Complications |
Pulmonary hypoplasia
club foot flattened facies IUGR fetal distress fetal hypoxia - (umbilical cord compression) |
|
|
Oligohydramnios -
Tx |
R/o inaccurate gestational
dates Tx underlying cause, if possible amnioinfusion - NaCl |
|
|
Polyhydramnios -
What is it |
Excess of fluid
AFI > 20 on US ■ Maternal DM ■ "baby can't swallow" - esoph atresia TEF duodenal atresia anencephaly ■ multiple gestations ■ twin-twin transfusion syn |
|
|
Polyhydramnios -
Dx/Tx |
US for fetal anomalies
glucose test Rh screening Tx depends on cause |
|
|
Polyhydramnios -
Complications |
Preterm labor
cord prolapse fetal malpresentation |
|
|
Rh Isoimmunization -
What is it |
Ag protein on RBC
AD maternal anti-Rh IgG ab => erythroblastosis fetalis 2nd pregnancy - fast production by memory plasma cells |
|
|
Rh Isoimmunization -
Hx/PE What do you ask on Hx |
Ask about -
prior delivery of Rh+ child ectopic pregnancy abortion blood transfusions amniocentesis abdom trauma |
|
|
Rh Isoimmunization -
Evaluation |
Maternal -
on 1st visit, check ABO & Rh if Rh- then check dad's Rh if dad Rh+ then check mom's titer at 26-28 wks if pos., test serially for high titers (> 1:16) fetal - amniocentesis or US-guided umbilical bld sample blood type Coombs' titer bilirubin level HCT reticulocytes postnatally - fetal cord blood Rh HCT |
|
|
Rh Isoimmunization -
Tx |
Prevention -
. at 28 wks., if mom Rh- and dad Rh+ or status unknown, give RhoGAM (IgG anti-D) . if baby Rh+ give RhoGAM postpartum, too . give RhoGAM to Rh- moms if have had abortion ectopic pregnancy amniocentesis vaginal bleeding placenta previa placental abruption sensitized Rh- moms with titers > 1:16 monitor closely serial US amniocentesis in severe cases - enhance lung maturity intrauterine blood transfusion init preterm delivery |
|
|
Rh Isoimmunization -
Complications |
Fetal hypoxia
=> lactic acidosis => heart failure => hydrops fetalis death kernicterus prematurity |
|
|
Gestational Trophoblastic Dis-
What is it |
Prolif of trophoblastic tissue
range of diseases benign or malignant . risk factors - age < 20 or > 40 def. in folate or B-carotene hydatidiform mole - 80% benign may progress to malignant . complete sperm fertilize empty ovum 46XX paternal derived . incomplete/partial fertilized by 2 sperm 69XXY has fetal tissue choriocarcinoma placental site trophoblastic tumor |
|
|
Gestational Trophoblastic Dis-
Hx/PE |
Hx -
1st trimester uterine bleeding hyperemesis gravidarum preeclampsia-eclampsia <24 wks excessive uterine enlargement hyperthyroidism PE - no fetal heartbeat enlarged ovaries with b/l theca-lutein cysts expulsion of grapelike cluster blood in cervical os |
|
|
Gestational Trophoblastic Dis-
Dx |
High B-hCG (> 100,000 mlU/mL)
"snowstorm" on pelvic US no fetus CXR - may have lung mets |
|
|
Gestational Trophoblastic Dis-
Tx |
D&C
monitor B-hCG no pregnancy for 1 yr if malignant - methotrexate dactinomycin residual uterine disease - hysterectomy |
|
|
Gestational Trophoblastic Dis-
Complications |
Malignant GTD
pulmonary or CNS mets trophoblastic PE acute respiratory insufficiency |
|
|
Placenta Abruptio -
What is it |
Premature separation
of normally implanted placenta any degree of separation MCC of late-trimester bleeding MCC of painful late-trimester bleeding |
|
|
Placenta Abruptio -
Risk factors |
HTN
abdominal/pelvic trauma tobacco coke previous abruption premature membrane rupture rapid decompression of overdistended uterus |
|
|
Placenta Abruptio -
Sx |
Painful, dark vaginal bleeding
that doesn't spontan stop abdom pain fetal distress |
|
|
Placenta Abruptio -
Dx |
Mainly clinical
(US sensitivity 50%) check for retroplacental clot |
|
|
Placenta Abruptio -
Tx |
Mild -
admit stabilize IV fetal monitoring type and cross blood bed rest moderate to severe - immediate delivery . if both stable: amniotomy vaginal delivery . if distress: C-section |
|
|
Placenta Abruptio -
Complications |
Hemorrhagic shock
DIC => ATN fetal hypoxia couvelaire uterus |
|
|
Placenta Previa -
What is it |
Abnorm implant of placenta:
total - covers internal os partial - partially covers marginal - at edge of os low-lying - near os without reaching it |
|
|
Placenta Previa -
Risk factors |
Prior C-sections
multiparity advanced maternal age multiple gestation prior placenta previa |
|
|
Placenta Previa -
Sxs |
Usu first occurs in late preg
painless, bright red bleeding may be heavy usually no fetal distress |
|
|
Placenta Previa -
Dx |
US
|
|
|
Placenta Previa -
Management |
No vaginal exam
premature fetus - stabilize tocolytics (MgSO4) serial US det. fetal lung maturity - by amnio and augment Delivery indicated if - persistent labor life-threatening bleeding fetal distress fetal lung maturity 36 wks. GA deliver by C-section vaginal - lower edge of placenta > 2cm from internal os |
|
|
Placenta Previa -
Complications |
Increased risk of pl. accreta
vasa previa preterm delivery PROM IUGR congenital anomalies |
|
|
PROM -
What is it |
ROM before onset of labor
> 37 weeks gestation may be due to - vaginal or cervical infections abnorm membrane physiology cervical incompetence |
|
|
PPROM (preterm PROM) -
What is it Risk factors |
ROM < 37 weeks gestation
risk factors - low socioeconomic status young maternal age smoking STDs |
|
|
Prolonged ROM -
What is it |
ROM > 24 hours prior to labor
|
|
|
PROM -
Hx/PE |
Gush of clear or blood-tinged
vaginal fluid may have uterine contractions |
|
|
PROM -
Evaluation |
Sterile speculum exam -
amniotic fluid (in vaginal vault) meconium vernix caseosa positive nitrazine paper test positive fern test US - assess fluid volume cultures smears no digital vaginal exam check for chorioamnionitis - fetal heart tracing maternal temp WBC count uterine tenderness |
|
|
PROM -
Tx |
Balance risk of infection when
delivery is delayed with risks due to fetal immaturity if no sign of infection - . tocolytics: B agonists MgSO4 NSAIDs Ca2+ ch blocker . prophylactic ABx . corticosteroids if signs of infection or fetal distress - . ABx . induce labor |
|
|
PROM -
Complications |
Increased risk of -
preterm L&D chorioamnionitis placental abruptio cord prolapse |
|
|
Preterm Labor -
What is it Risk factors |
Onset of labor bet. 20-37 wks
primary cause of neonatal M&M risk factors - multiple gestation infection PROM uterine anomalies previous preterm L or D polyhydramnios placental abruptio poor maternal nutrition low socioeconomic status Most pts have no identifiable risk factors |
|
|
Preterm Labor -
Hx/PE |
May have menstrual-like cramps
onset of low back pain pelvic pressure new vaginal discharge or bleeding |
|
|
Preterm Labor -
Dx |
Regular contractions
>3, 30 sec. each, over 30 min. concurrent cervical change contraindication to tocolysis? sterile speculum exam US UA/UC cultures for - chlamydia gonorrhea GBS |
|
|
Preterm Labor -
Tx |
Hydration
bed rest tocolytics steroids GBS prophylaxis - PCN or ampicillin |
|
|
Preterm Labor -
Complications |
RDS
IVH PDA NEC ROP BPD death |
|
|
Fetal Malpresentation -
What is it Risk factors |
Any presentation not vertex
(Normal is vertex) MC malpresentation - breech Risk factors - prematurity prior breech delivery uterine anomalies poly- or oligohydramnios multiple gestations PPROM hydrocephalus anencephaly placenta previa |
|
|
Fetal Malpresentation -
What are the subtypes |
Frank -
thighs flexed and knees extend footling - 1 or both legs extended below the butt complete - thighs and knees flexed |
|
|
Fetal Malpresentation -
Dx |
Leopold maneuver
|
|
|
Fetal Malpresentation -
Tx |
. Follow
. external version - risks of placental abruptio, cord compression prepare for emergency C-sect . elective C-section . breech vaginal delivery only if delivery imminent |
|
|
Postpartum Hemorrhage -
What is it MCC MC Risk Factor |
> 500 mL for vaginal delivery
> 1000 mL for C-section MCC - bleeding at placental implantation site MC risk factor - uterine atony due to overdistention |
|
|
Postpartum Hemorrhage -
Dx |
Palpation of soft, enlarged,
"boggy" uterus explore for lacerations and retained placental tissues |
|
|
Postpartum Hemorrhage -
Tx |
Bimanual uterine massage
oxytocin infusion methergine - if not HTN prostin (PGF2a) - if no asthma |
|
|
Mastitis -
What is it |
Cellulitis of perigland tissue
caused by - nipple trauma from breastfeeding & staph from baby's nostrils => nipple ducts |
|
|
Mastitis -
Hx/PE |
Sxs start 2-4 wks postpartum
usually unilateral breast tender erythema edema warmth maybe purulent nipple drainage |
|
|
Mastitis -
Dx |
Sxs
possible breastmilk culture inc. WBC fever |
|
|
Mastitis -
Tx |
Continue breastfeeding!!!
po ABx - PCN, diclox, erythro incise and drain abscess (if present) |
|
|
Sheehan's Syndrome -
What is it |
Postpartum pituitary necrosis
pituitary ischemia & necrosis => ant. pituitary insuff. due to massive obstetric blood loss & hypovol shock dec. prolactin |
|
|
Sheehan's Syndrome -
Hx |
No lactation
menstrual d/o fatigue loss of pubic & axillary hair |
|
|
Postpartum Fever-
What is it |
Genital tract infection
temp >= 38 C at least 2 of 1st 10 postpartum days not including 1st 24 hrs. |
|
|
Postpartum Fever-
Risk Factors |
MC - endometrial infection
C-section emergent C-section PROM prolonged labor multiple intrapartum vag exams intrauterine manipulations |
|
|
Postpartum Fever-
Causes (7 W's) |
Wind - atelectasis, pneumonia
water - UTI wound - incision, episiotomy walk - DVT, PE wonder drug womb - endomyometritis weaning - breast engorgement, abscess mastitis |
|
|
Postpartum Fever-
Dx |
UA/UC
BC pelvic exam - r/o hematoma r/o lochial block |
|
|
Postpartum Fever-
Tx |
. Admit
. broad-spectrum IV ABx - clindamycin, gentamicin until afebrile for 48 hrs. . if complicated - add ampicillin . if 3 drugs not effective after 48 hrs. - consider other Dxs |
|
|
Breastfeeding -
What inhibits prolactin rel. |
. Hi levels of progesterone &
estrogen during pregnancy . high levels also cause breast hypertrophy |
|
|
Breastfeeding -
Why can physiologically breastfeed after birth |
. Levels of progesterone and
estrogen drop after delivery of placenta . infant sucking stimulates rel. of prolactin & oxytocin |
|
|
Breastfeeding -
What gives passive immunity what gives active immunity |
Colostrum has hi IgA
IgA - passive immunity hi leukocyte levels - active |
|
|
Breastfeeding -
Contraindications |
HIV infection
active hepatitis meds - tetracycline chloramphenicol warfarin |
|
|
Hyperemesis Gravidarum -
What is it Risk factors |
Persistent vomiting
=> wt. loss > 5% (or poor wt. gain) dev. of dehydration and ketoacidosis persists past 16-18 wks - rare can damage liver risk factors - nulliparity molar pregnancy (inc. B-hCG) multiple gestations |
|
|
Hyperemesis Gravidarum -
Dx |
Serum electrolytes
hypoK-hypoCl metab alkalosis urine ketones BUN/Cr |
|
|
Hyperemesis Gravidarum -
Tx |
IV hydration
correct electrolyte def, Mg, P antiemetics fluids => freq. small meals as tolerated |
|
|
Gestational DM -
What is it Risk factors |
3-5% of all pregnancies
usu d/o of late pregnancy - usu Dx 24-28 wks hypergly in 1st trimester - usu means preexisting may be due to insulin-antag hormones from placenta risk factors - > 25 y/o obesity personal or family Hx prior macrosomia congen deformed infants |
|
|
Gestational DM -
Hx/PE |
Typically asymp
edema polyhydramnios LGA - warning sign |
|
|
Gestational DM -
Dx |
UA
tests done 24-28 weeks 2 abnorm glu tests to include- fasting >= 126 mg/dL random >= 200 or abnorm GTT 1 hr (50g) GTT >140 suggestive confirm with 3 hr (100g) GTT - any 2 of following: fasting >= 95 1 hr >= 180 2 hr >= 155 3 hr >= 140 |
|
|
Gestational DM -
Tx |
Tight mat. glu control - 90
ADA diet regular exercise add insulin if diet insuff. no oral hypogly periodic US and NST intrapartum insulin and dextrose during delivery may need to induce labor at 38-40 wks |
|
|
Gestational DM -
Complications |
> 50% develop glu intolerance
and/or DM Type 2 |
|
|
Pregestational DM & Pregnancy-
What is it |
HbA1C > 10% has ↑ risk of -
congen malformations ↑ mat./fetal morbidity during L&D |
|
|
Pregestational DM & Pregnancy-
Management of Mom |
Prenatal care
nutrition counseling Renal eval ophthalmologic eval CV eval Strict glucose control - Type 1 get insulin to maintain Fasting morning: ≤ 60-90 mg/dL Prelunch: 60-105 Two-hour postprandial: < 120 |
|
|
Pregestational DM & Pregnancy-
Management of Fetus |
16-20 weeks -
US AFP 20-22 wks - echo 3rd trimester - close surveillance NST, CST, BPP admit at 32-36 wks if DM poorly controlled fetus is of concern |
|
|
Pregestational DM & Pregnancy-
Management of Delivery and Postpartum |
Maintain 80–100 during labor
consider early delivery if - poor mat glu control preeclampsia macrosomia fetal lung maturity C-section if macrosomia monitor glucose postpartum |
|
|
Pregestational DM & Pregnancy-
Maternal Complications |
DKA
HHNK preeclampsia/eclampsia cephalopelvic disproportion (macrosomia) and need for C-section preterm labor infection polyhydramnios postpartum hemorrhage maternal mortality |
|
|
Pregestational DM & Pregnancy-
Fetal Complications |
Macrosomia
cardiac defects renal defects neural tube defects hypocalcemia polycythemia hyperbilirubinemia IUGR hypoglycemia from hyperinsulinemia RDS birth injury perinatal mortality |
|
|
Gestational & Chronic HTN -
What is it |
Both inc. risk of
preeclampsia & eclampsia, M&M Chronic - high before pregnant or before 20 wks. gestation gestational - after 20 wks. usu. after 37 wks. remits by 6 wks. postpartum MC in multifetal |
|
|
Gestational & Chronic HTN -
Dx |
Monitor BP routinely
if severe for 1st time - check for other causes |
|
|
Gestational & Chronic HTN -
Tx |
Methyldopa
B-blocker hydralazine no ACEI or diuretics |
|
|
Preeclampsia -
What is it Risk factors |
New-onset HTN
proteinuria nondep. (hands & face) edema > 20 wks. gestation Risk factors - nulliparity Black extremes of age multiple gestations molar pregnancy renal dis. (from SLE or DM1) family Hx chronic HTN |
|
|
Mild Preeclampsia -
Hx/PE |
Often asymp
BP > 140/90 on 2 occasions > 6 hrs. apart proteinuria nondependent edema |
|
|
Mild Preeclampsia -
Dx |
UA
24-hour urine protein CBC electrolytes BUN/Cr uric acid measure fetal age amniocentesis - lung maturity LFTs PT/PTT fibrinogen and FSP urine tox screen US NST/CST/BPP - as needed |
|
|
Mild Preeclampsia -
Tx |
Only cure - delivery
induce - IV oxytocin prostaglandins or amniotomy based on mom and fetus if far from term - bed rest expectant management |
|
|
Severe Preeclampsia -
Hx/PE |
Based on Sxs, organ damage,
fetal growth restriction BP > 160/110 on 2 occasions > 6 hrs. apart proteinuria HELLP syndrome RUQ/epigastric pain oliguria pulmonary edema/cyanosis cerebral changes visual changes hyperactive reflexes oligohydramnios or IUGR |
|
|
Severe Preeclampsia -
Dx |
UA
24-hour urine protein CBC electrolytes BUN/Cr uric acid measure fetal age amniocentesis - lung maturity LFTs PT/PTT fibrinogen and FSP urine tox screen US NST/CST/BPP - as needed |
|
|
Severe Preeclampsia -
Tx |
. Only cure - delivery
. control BP - hydralazine labetalol . MgSO4 - prevent Szs . postpartum - MGSO4 - 1st 24 hrs. monitor for Mg2+ toxicity: loss of DTRs respiratory paralysis coma Tx with IV Ca2+ gluconate |
|
|
Preeclampsia -
Complications |
Prematurity
fetal distress stillbirth placental abruption seizure DIC cerebral hemorrhage serous retinal detachment fetal/maternal death |
|
|
Eclampsia -
What is it |
Seizures in pts. with
preeclampsia antepartum, intra or post if post - MC within 48 hrs. |
|
|
Eclampsia -
Hx/PE |
MC Sxs before attack -
headache visual changes RUQ/epigastric pain Szs severe if not controlled with anticonvulsant therapy |
|
|
Eclampsia -
Dx |
UA
24-hour urine protein CBC electrolytes BUN/Cr uric acid measure fetal age amniocentesis - lung maturity LFTs PT/PTT fibrinogen and FSP urine tox screen US NST/CST/BPP - as needed |
|
|
Eclampsia -
Tx |
. Monitor ABCs
O2 . control seizures - MgSO4 consider IV diazepam . control BP - hydralazine labetalol . limit fluids foley catheter- monitor I/Os . monitor Mg2+ level . monitor for Mg2+ toxicity . monitor fetal status . postpartum - MgSO4 - 1st 24 hrs monitor for Mg2+ toxicity: loss of DTRs respiratory paralysis coma Tx with IV Ca2+ gluconate |
|
|
Eclampsia -
Complications |
Cerebral hemorrhage
aspiration pneumonia hypoxic encephalopathy thromboembolic events fetal/maternal death |
|
|
Alcohol -
Teratogenic Effect |
Fetal alcohol syndrome
microcephaly midfacial hypoplasia MR IUGR cardiac defects |
|
|
Cocaine -
Teratogenic Effect |
Bowel atresia
IUGR microcephaly |
|
|
Streptomycin -
Teratogenic Effect |
CN8 damage
ototoxicity |
|
|
Tetracycline -
Teratogenic Effect |
Tooth discoloration
bone growth inhib small limbs syndactyly |
|
|
Sulfonamides -
Teratogenic Effect |
Kernicterus
|
|
|
Quinolones -
Teratogenic Effect |
Cartilage damage
|
|
|
Isotretinoin -
Teratogenic Effect |
Heart and great vessel defects
craniofacial dysmorphism deafness |
|
|
Iodide -
Teratogenic Effect |
Congenital goiter
hypothyroidism MR |
|
|
Methotrexate -
Teratogenic Effect |
CNS malformations
craniofacial dysmorphism IUGR |
|
|
DES (Diethylstilbestrol) -
Teratogenic Effect |
Clear cell adenocarcinoma of
vagina/cervix genital tract abnorm cervical incompetence |
|
|
Thalidomide -
Teratogenic Effect |
Limb reduction (phocomelia)
ear and nasal anomalies cardiac and lung defects pyloric stenosis duodenal stenosis GI atresia |
|
|
Coumadin -
Teratogenic Effect |
Stippling of bone epiphyses
IUGR nasal hypoplasia MR |
|
|
ACEIs -
Teratogenic Effect |
Oligohydramnios
fetal renal damage |
|
|
Lithium -
Teratogenic Effect |
Ebstein's anomaly
other cardiac diseases |
|
|
Carbamazepine -
Teratogenic Effect |
Fingernail hypoplasia
IUGR microcephaly neural tube defects |
|
|
Phenytoin -
Teratogenic Effect |
Nail hypoplasia
IUGR MR craniofacial dysmorphism microcephaly |
|
|
Valproic Acid -
Teratogenic Effect |
Neural tube defects
craniofacial defects skeletal defects |
|
|
HELLP Syndrome -
What is it |
Variant of pre-eclampsia
Hemolytic anemia Elevated Liver enzymes Low Platelet count |
|
|
Physio Changes in Pregnancy -
CV |
Inc. HR x inc. SV = inc. CO
CO lowest - supine CO highest - lt. lat. position sys vascular resistance - dec. normal - systolic murmur, S3 abnorm - new diastolic murmur CVP unchanged FVP increases BP - dec. in 1st trimester diastolic more than systolic nadir at 24 wks. inc., but never to baseline uterus displaces heart up & Lt => looks like cardiomeg on CXR |
|
|
Physio Changes in Pregnancy -
Cervix |
Softens and cyanosis ~ 4 wks.
"bloody show" - at or near labor cervical mucus looks granular on slide |
|
|
Physio Changes in Pregnancy -
Endocrine |
Inc. thyroid blood flow
=> thyroid inc. in size inc. - TBG inc.- bound T3 & T4, and total unchanged - free T4 inc. - total & free cortisol adrenal gland unchanged in size HPL - maintains fetal glucose levels => prolonged postprandial hyperglycemia, fasting hyperinsulinemia, fasting hypertriglyceridemia exaggerated starvation ketosis |
|
|
Physio Changes in Pregnancy -
GI |
N/V resolves by 14-16 wks.
inc. acid reflux aspiration constipation predisposed to gallstones |
|
|
Physio Changes in Pregnancy -
Hematology |
"physiologic anemia" -
inc. plasma vol (50%) & RBC mass (30%) => dec. H&H => normal pregnancy Hb is 10-12 WBC inc. ESR inc. platelets unchanged hypercoagulable state inc. factors 7, 9, 10 & C MC nonobstetric cause of postpartum death - thromboembolic disease |
|
|
Physio Changes in Pregnancy -
Musculoskeletal |
Inc. motility -
sacroiliac sacrococcygeal pubic joints |
|
|
Physio Changes in Pregnancy -
Pulmonary |
TV - inc.
RR unchanged TV x RR = VE (min. ventilation) so, VE inc. dec. - RV (IRV, ERV, TLC) inc. - alveolar & arterial PO2 dec. - alv. & arterial PCO2 so, resp. alkalosis => inc. renal loss of bicarb => alkaline urine "dyspnea of pregnancy" - from inc. VE and dec. PCO2 |
|
|
Physio Changes in Pregnancy -
Renal |
Inc. renal blood flow
=> kidneys inc. in size (until 3 mos. postpartum) ureters - diameter inc. rt. > lt. (due to progesterone) dilation of collecting system can be mistaken for hydronephrosis inc. - GFR (by 50%) renal plasma flow Cr clearance aldosterone all leads to - decreased BUN, Cr, uric acid urine glucose inc. because reabsorb threshhold dec. |
|
|
Physio Changes in Pregnancy -
Skin |
. striae -
abdomen breast thighs . spider angiomas . palmar erythema . hyperpigmentation - linea nigra - midline chloasma - face perineum . diastasis recti |
|
|
Physio Changes in Pregnancy -
Uterus |
. 12 wks., uterus -
contracts ant. abdo wall displaces intestines felt above symphysis pubis . Braxton Hicks - irreg painless contractions throughout pregnancy => freq., rhythmic in 3rd trimester (false labor) |
|
|
Physio Changes in Pregnancy -
Vagina |
Thick, acidic secretions
Chadwick's sign |
|
|
Prenatal Care and Nutrition -
Estimated Delivery Date Gestational Age |
Nagele's rule -
EDD 1st day of LMP + 9 mos.+7 days GA determined by - uterine size heart tones (10 wks.) quickening (17-18 wks.) US - crown rump (5-12 wks.) biparietal diameter (20-30wks) |
|
|
Prenatal Care and Nutrition -
Weight Gain |
gain 25-35 lbs.
obese to gain less thin women to gain more need 2,000-2,500 kcal/day need additional - 300 kcal/day during pregnancy 500 kcal/day in breastfeeding |
|
|
Prenatal Care and Nutrition -
Nutrition |
Prenatal vitamins
1 mg/day of folate 30-60 mg/day of elemental iron |
|
|
Prenatal Labs -
Initial Visit |
CBC
UA/UC pap smear blood type Rh Ab screen rubella Ab titer HBV surface Ag test syphilis screen - RPR, VDRL cervical gonorrhea and chlamydia cultures PPD glucose testing sickle prep HIV |
|
|
Prenatal Labs -
15-19 weeks |
Maternal serum AFP (MSAFP)
or triple screen - MSAFP, estriol, B-hCG offer amniocentesis if >35 y/o |
|
|
Prenatal Labs -
18-20 wks |
US -
GA (if needed) fetal anatomy amniotic fluid volume placental location |
|
|
Prenatal Labs -
26-28 wks |
Glucose loading test (GLT)
HCT |
|
|
Prenatal Labs -
28 wks |
Rhogam (if needed)
|
|
|
Prenatal Labs -
32-36 wks |
HCT
screen for GBS - if pos. - PCN during labor cervical chlamydia and gonorrhea cultures if need |
|
|
AFP -
How to measure |
MSAFP at 15-20 wks.
results reported as - MoMs (multiples of the median) |
|
|
AFP -
What does elevated MSAFP mean |
> 2.5 MoMs
gastroschisis omphalocele multiple gestation incorrect gestational dating fetal death placental abnorm - abruptio open neural tube defects - anencephaly spina bifida • MCC of high - date is wrong if high - get US (check date) • if true age more than thought - why "high" value if still 15-20 wks, repeat MS-AFP • if date is right and no explanation on US - amnio for AF-AFP & acetylcholinesterase high levels - open NTD normal levels - still at risk for: IUGR stillbirth preeclampsia |
|
|
AFP -
Abnormally low MSAFP means |
< 0.85 MoM
• MCC of low - date is wrong check date - get triple marker screen if not available - then get US • if true age less than thought - why "low" value if still 15-20 wks, repeat MS-AFP • if date is right and no explanation on US - amnio for karyotype • sensitivity to detect chromosome abnorm inc. by triple screen trisomy 18 - all 3 are low trisomy 21 - AFP and estriol low B-hCG high |
|
|
Amniocentesis -
When done Risks Why done |
15-17 weeks
US-guided needle risks - fetal-maternal hemorrhage fetal loss why done - > 35 y/o at time of delivery Rh-sensitized pregnancy evaluate fetal lung maturity in conjunction with abnorm triple screen |
|
|
Chorionic Villus Sampling -
What is it Advantages Risks |
Transvaginal or
transabdom aspiration advantages - as accurate as amniocentesis available 10-12 wks. (amniocentesis - 15-17 wks.) risks - fetal loss 1% can't Dx neural tube defects if do < 9 wks - association with limb defects |
|
|
Percutaneous Umbilical
Blood Sampling (PUBS) - What is it |
Done in 2nd & 3rd trimesters -
fetal karyotyping fetal infection eval genetic diseases eval fetal acid-base status assess & Tx Rh isoimmunization erythroblastosis fetalis |
|
|
Labor -
First Stage |
Latent -
from onset of labor to 3-4 cm dilation active - from 4 cm to complete cervical dilation (10 cm) prolonged with cephalopelvic disproportion |
|
|
Labor -
Second Stage |
From complete cervical
dilation to delivery |
|
|
Labor -
Third Stage |
From delivery of infant to
delivery of placenta uterus contracts to establish hemostasis |
|
|
Nonstress Test (NST) -
What is it |
Left lateral supine
FHR - monitored by Doppler correlate with spontaneous fetal movement as reported by mom unrelated to contractions normal - accelerate 15 bpm above baseline for 15 seconds reactive test - 2 accelerations in 20 mins. repeat weekly nonreactive - 80% false pos. do vibroacoustic stimulation if persistently nonreactive, do BPP no accelerations can be due to GA < 30 wks. fetal sleeping fetal CNS anomalies moms' sedative admin fetal hypoxia |
|
|
Contraction Stress Test (CST)-
What is it |
Used in high-risk pregnancies
assess uteroplacental dysfunction monitor FHR during contraction positive - repetitive late decelerations during at least 3 contractions in 10 mins. > 36 wks. - deliver < 36 wks. - do BPP negative - no late decelerations fetus well repeat weekly |
|
|
Biophysical Profile (BPP) -
What is it |
US
Test the Baby, MAN! fetal T-one fetal B-reathing fetal M-ovement A-mniotic fluid volume N-onstress test 2 = normal 0 = abnorm neg test - 8 or 10 reassuring repeat weekly pos test - 4 or 6 > 36 wks - deliver < 36 wks - repeat in 12-24 hrs 0 or 2 highly predictive of hypoxia prompt delivery no matter GA modified BPP - NST & amnio fluid vol predictive value almost as good |
|
|
Vasa Previa -
What is it Risk Factors |
Fetal vessels cross internal os
if they rupture - exsanguinate very fast => fetal death Risk factors - accessory placental lobes multiple gestation velamentous insertion of umbilical cord |
|
|
Vasa Previa -
Hx/PE |
Classic triad -
ROM painless vaginal bleeding then fetal bradycardia |
|
|
Vasa Previa -
Dx |
Antenatal US with color Doppler
confirm - after delivery exam of placenta & fetal vessels rarely confirm before delivery |
|
|
Vasa Previa -
Tx |
Immediate C-section
|
|
|
Uterine Rupture -
What is it Risk Factors |
Complete separation of wall of uterus
with or without expulsion of fetus complete or incomplete rupture before or during labor Risk factors - previous classic uterine incision myomectomy excessive oxytocin stimulation grand multiparity marked uterine distention |
|
|
Uterine Rupture -
Hx/PE |
Nonreassuring fetal monitoring
vaginal bleeding abdom pain change in uterine contractility |
|
|
Uterine Rupture -
Dx |
Surgical exploration of uterus
|
|
|
Uterine Rupture -
Tx |
Immediate C-section
uterine repair - stable, young hysterectomy - unstable or no desire for more kids |
|
|
Multiple Gestation -
What is it Risk Factors |
Dizygotic -
dichorionic/diamnionic monozygotic - • separate by 72 hrs - dichorionic diamnionic • up to 4-8 days - monochorionic diamnionic twin-twin transfusion risk • donor twin - oligohydramnios growth retardation but better outcome • recipient twin - polyhydramnios polycythemia excessive growth complicated neonatal course • up to 9-12 days - monochorionic monoamnionic highest risk of all monozygote umbilical cord entanglement • > 12 days - conjoined usually lethal dizygotic risk factors - race geography family Hx ovulation induction monozygotic risk factors - no identifiable |
|
|
Multiple Gestation -
Complications |
Nutritional anemia
preeclampsia preterm labor malpresentation C-section postpartum hemorrhage |
|
|
Multiple Gestation -
Hx/PE |
Hyperemesis gravidarum -
more common from high levels of B-hCG uterus larger than dates MS-AFP very high |
|
|
Multiple Gestation -
Tx: Antepartum Intrapartum Postpartum |
Antepartum -
iron and folate monitor BP serial US intrapartum - vaginal - if both cephalic C-section - if 1st noncephalic controversial - if 1st cephalic and 2nd not postpartum - watch for postpartum hemorrhage from uterine atony (due to overextended uterus) |
