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157 Cards in this Set

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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)