• Shuffle
    Toggle On
    Toggle Off
  • Alphabetize
    Toggle On
    Toggle Off
  • Front First
    Toggle On
    Toggle Off
  • Both Sides
    Toggle On
    Toggle Off
  • Read
    Toggle On
    Toggle Off
Reading...
Front

Card Range To Study

through

image

Play button

image

Play button

image

Progress

1/196

Click to flip

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;

196 Cards in this Set

  • Front
  • Back
Compare and contrast two types of fetal heart monitoring: internal vs external.
Internal monitor
- bipolar spiral electrode directly to fetus

External monitor
- ultrasound doppler principle
- used to avoid membrane rupture and uterine invasion.
- less precise
At what rate is fetus considered tachycardic?
> 160 bpm
At what rate is fetus considered bradycardic?
< 110 bpm
What is the normal progression of baseline fetal heart rate along its gestation age? (hint: from 16 wks to term)
baseline fetal heart rate decreases an average of 24 bpm from 16wks to term.
Short term vs long term heart rate variability.
Short term: instantaneous change in HR from one beat (or R wave) to the next.

long term: oscillatory changes during course of 1 min and result in the waviness of baseline.
What is the significance of this?

- diminished beat to beat fetal heart rate variation
may indicate seriousely compromised fetus
What is the significance of this?

- sinusoidal fetal heart rate
fetal anemia
- D-isoimmunization
- ruptured vasa previa
- fetomaternal hemorrhage
- twin-to-twin transfusion
- merperidine, morphine, alphaprodine, butorphanol
Grade this fetal heart rate variability:

- < 5bpm variability
minimal variability
Grade this fetal heart rate variability:

- 6-25bpm variability
moderate variability
Grade this fetal heart rate variability:

- >25bpm variability
marked variability
What are some causes of fetal heart rate accelerations?
- fetal movement
- stimulation by uterine contractions
- umbilical chord occlusion
- fetal stimulation from pelvic exam
- fetal scalp blood sampling
- acoustic stimulation
- labor (accelerations are reassuring)
What is this type of fetal heart rate deceleration? and what can cause it?

- gradual deceleration >= 30s
- both onset and recovery coincides with uterine contraction
early deceleration
- fetal head compression (vagal stimulation)
- blocked by atropine
What is this type of fetal heart rate deceleration? and what can cause it?

- gradual decrease in fetal HR that begins at/after the peak of uterine contraction
late deceleration
- maternal hypotension (from analgesia)
- excessive uterine activity (oxytocin stimulation)
- placental dysfunction: placental abruption can cause severe late deceleration.
- maternal HTN, diabetes, collagen vascular disorders.
What is this type of fetal heart rate deceleration? and what can cause it?

- abrupt decrease in heart rate lasting <30s
- duration less than 2 min
- may occur before, during, or after a contraction
variable deceleration
- umbilical cord occlusion: elevated PCO2 and decreased PO2 with increased ACH at SA node via baroreceptor and chemoreceptor
- may respond to amnioinfusion
What is this type of fetal heart rate deceleration? and what can cause it?

- isolated decelerations lasting 2min or longer, but less than 10min
prolonged deceleration
- uteroplacental insufficiency
- epidural, spinal, paracervical analgesia
- uterine hyperactivity
- cord entanglement
- maternal supine hypotension
- maternal hypoperfusion/hypoxia of any cause
- placental abruption
- maternal seizures: eclampsia, epilepsy

Treatment
- IVF to correct hypoperfusion, anemia, acidosis if present
- stop pitocin if patient is on it
- maternal O2 therapy
- fetal capillary acid-base determination
- if not resolve, operate
In which stage of labor would you see ubiquitous decelerations?
2nd stage
How do you treat this?

- variable deceleration in the setting of decreased amnionic fluid
amniofusion
- 500-800cc bolus of warmed normal saline then
- continuous infusion at 3ml/hr
What to do next based on this fetal scalp sample?

- pH > 7.25
this is labor
What to do next based on this fetal scalp sample?

- pH 7.20 - 7.25
repeat within 30 min
What to do next based on this fetal scalp sample?

- pH < 7.20
repeat sample immediately
OR to deliver baby
What is considered a normal fetal response to vibroacoustic stimulation?
HR acceleration of at least 15bpm for at least 15s occurs within 15s after stimulation
What is the normal range of fetal pulse oximetry?
30-70%
What is a typical tocolysis treatment?
0.25mg terbutaline sulfate subQ injection
How is uterine activity calculated?
montevideo units
#contractions per 10min x uterine pressure above basline
Mild vs moderate vs severe type variable fetal heart rate decelerations.

- duration less than 30s regardless of HR drop or
- rate drop to 70-80 bpm range with duration >30s but < 60s
mild type
- no RX needed
Mild vs moderate vs severe type variable fetal heart rate decelerations.

- duration 30-60s, HR drop to < 70bpm or
- rate drop to 70-80 bpm range with duration >60s
moderate type
- maternal O2 therapy
- amnioinfusion
- d/c pitocin
- fetal capillary acid-base assay
- consider OR delivery
Mild vs moderate vs severe type variable fetal heart rate decelerations.

- duration > 60s
- rate drop to < 70bpm
severe type
- maternal O2 therapy
- amnioinfusion
- d/c pitocin
- fetal capillary acid-base assay
- consider OR delivery
Is this women pregnant?

- urine BhCG > 25
yes
Is this women pregnant?

- blood BhCG < 5
no
What maternal conditions are risks for the fetus? (major ones)
- HTN
- DM
- multiple gestation
- infections
- intrauterine growth retardation
- abnormal placentation
When is fetal heart tones detectable?
12 wks by doppler
18-20 wks by auscultation
What does this lab value indicate?

- progesterone < 5
not a viable pregnancy intrauterine or extrauterine
What does this lab value indicate?

- progesterone > 25
viable intrauterine pregnancy
When can you detect the gestational sac with abdominal ultrasound?
5-6 wks
- corresponds to BhCG 5000-6000
When can you detect pregnancy with transvaginal ultrasound?
3-4wks gestation
- correspondes to BhCG 2000
At what BhCG level is embryo visualizable by all technique and cardiac acitvity is detected?
> 4000
What is the growth rate of an embryo?
1mm/day
What is the diameter of the gestational sac is embryo visualized by U/S?
25mm
What is the diameter of the gestational sac is yolk sac visualized by U/S?
10cm
What are the routine OB lab tests?
- CBC to r/o anemia
- UA ans urine culture to evaluate UTI, renal function
- blood group Rh
- antibocy screen
- serology for syphilis: RPR, VDRL
- hep-B surface antigen
- rubella titer
- cervical cytology: pap smear
- cervical culture for gonorrhea/chlamydia
- Hgb electrophoresis: sickle cell and so on
- HIV titer
- MSAFP at 15-18 wks: evaluate neual tube defects, gastroschisis, Down syndrome
- Hct at 25-28 wks: r/o anemia
- glucose screen at 24-28 wks
Name an important screening test at 15-18 wks gestation.
- MSAFP at 15-18 wks: evaluate neual tube defects, gastroschisis, Down syndrome
Name 2 lab tests that are important at 24-28 wks gestation.
- Hct at 25-28 wks: r/o anemia
- glucose screen at 24-28 wks
List three methods to assess gestational age from most accurate to the least.
1. LMP if mon is confident of her dates
2. first trimester U/S
3. first trimester pelvic exam
4. fundal height in cm between 20 and 36 wks of gestation
What is the gestational age if the fundal height is at the umbilicus?
20 wks
What is the naegele's rule?
to determine the due date based on LMP
- LMP - 3mos + 7days
Frequency of prenatal visit:

- 0-32 wks
- 32-36 wks
- 36- labor
- 0-32 wks: every month visit
- 32-36 wks: every 2 wks visit
- 36- labor: every wk visit
What is the lab test required for every prenatal visit?
UA
- to determine glucosuria
and proteinuria
- trace amount is normal
What is the trend of maternal BP during pregnancy?
drop at the end of 1st trimester
raised in 3rd trimester
What BP findings suggest pregnancy associated HTN?
>30mmHg increase in sBP or
> 15mmHg increase in dBP
What is the normal maternal wt gain per month? and through the pregnancy?
monthly wt gain: 3-4 lb
pregnancy: 25-35 lb wt gain
What should you consider if fundal height suggest fetus is large for dates?
- incorrect assessment of gestational age
- multiple pregnancy
- macrosomia
- hydatidiform mole
- hydraminios
What should you consider if fundal height suggest fetus is small for dates?
- incorrect assessment of gestational age
- hydatidiform mole
- fetal growth restriction
- oligohydramnios
- intrauterine demise
When can U/S show evidence of Down syndrome?
10-13 wks gestation
- U/S would show nuchal thickness
At 20-22 wks u/s, what should we look for?
This is a level II ultrasound
- confirm dates
- look for anatomical anomalies: cardiac, bowel, cerebellum, cerebral ventricles, kidneys.
- assess fetal growth
What is considered a normoreactive NST at gestational age > 32 wks?
2 episodes of fetal heart rate accelerate by at least 15bpm over a period of 15s in 20min interval. (15x15 in 20)
What is considere a normoreactive NST at gestational age < 32 wks?
2 episodes of fetal heart rate accelerate by at least 10bpm over a period of 10s in 20min interval. (10x10 in 20)
CST vs OCT
CST: contraction stress test

OCT: oxytocin challenge test
Evaluation of fetal well being:

What to do next if CST/OCT is positive?
NST
- if normal reactive: false positive
- if nonreactive: worrisome
What are the components of biophysical profile?
- fetal breathing movements: 1FBM in at least 30s duration per 30min
- gross body movement: 3/30min
- fetal tone: 1 active extension with return to flexion
- reactive fetal heart rate
- qualitative amniotic : at least 1 pocket of amniotic fluid at at least 1cm in two perpendicular planes
Interpretation of the biophysical profile scores.
8-10: normal
6: equivocal and require further evaluation
<4: abnormal, require immediate intervention
What are some direct tests for fetal lung maturity?
- lecithin:sphingomyelin ratio (L:S ration) > 2
- phosphatidylgylerol (PG) present
- foam stability index (FSI) > 47
- fetal lung maturity (FLM) > 55
What are normal umbilical cord acid-base values?
Vein:
pH 7.34
PO2 30mmHg
PCO2: 35mmHg
HCO3: 20
base deficit: 5

Artery
pH 7.28
PO2 15mmHg
PCO2: 45mmHg
HCO3: 22
base deficit 7
What is the acid-base condition in this fetus?

- umbilical artery pH < 7.2
- PCO2 > 65mmHg
- HCO3 > 22 (normal)
- base deficit 6 (normal)
respiratory acidemia
- umbilical cord compression
What is the acid-base condition in this fetus?

- umbilical artery pH < 7.2
- PCO2 < 65mmHg (normal)
- HCO3 < 17
- base deficit 16
metabolic acidosis
What are some causes of fetal acidosis?
- poor fetal-maternal exchange
- acute umbilical cord compression: increased PCO2 (respiratory acidosis)
- uteroplacental insufficiency: inadequate exchange of O2 and CO2 in intervillous space
What is the acid-base condition in this fetus?

- umbilical artery pH < 7.2
- PCO2 > 65mmHg
- HCO3 < 17
- base deficit 9.6
mixed acidosis
What are the normal values for fetal capillary acid-bases?
pH: 7.25-7.4
PO2: 18-22mmHg
PCO2: 40-50mmHg
base deficit: 0-11
What to do next?

- fetal acidosis
- consider maternal venous sample first
What are some indications for fetal capillary pH sampling?
- early in labor in presence of IUGR or meconium staining with postdates gestation
- pathologic periodic changes
- unclear or confusing FHR tracing
What is the definition of hypertension in pregnancy?
- sustained systolic pressure >= 140mmHg or diastolic pressure >= 90mmHg
- present at least 2 occasions, more than 6hrs apart
How common is PIH (pregnancy induced hypertension)?
5-10%
What does this suggest?

- hypertension in late pregnancy in the absence of other findings
- transient hypertension of pregnancy
- gestational hypertension
What is the definition of preeclampsia?
development of hypertension with proteinuria induced by pregnancy in the second half of gestation
What level of BP is considered severe preeclampsia?
systolic BP > 160 0r
diastolic BP > 110
What are some multisystem alteration seen with preeclampsia?
- marked proteinuria
- oliguria
- cerebral or visual disturbance
- pulmonary edema
- cyanosis
- epigastric/RUQ pain
- hepatic dysfunction
- thrombocytopenia
- fetal growth restriction/oligohydramnios
What is eclampsia?
additional presence of convulsions in a women with preeclampsia
- most occurs within 24 hrs of delivery
What is the definition of chronic hypertension in pregnancy?
hypertension present before 20th week or beyond 6wk postpartum
What are some causes of chronic hypertension in pregnancy?
- essential hypertension
What systems are affected during eclampsia? (6)
- CV: increased CO, HTN
- hematologic: plasma olume contraction (increased Hct), thrombocytopenia/DIC
- renal: decreased GFR, proteinuria, decreased uric acid filtration
- neurologic: hyperreflexia, seizure
- pulmonary: pulmonary edema, capillary leak, left heart failure
- fetal effects: IUGR, oligohydramnios, low birth weight, placental abruption
What is the pathophysiology of preeclampsia?
vasospasm
What are some physical exam findings of preeclampsia?
- visual disturbances: scotomata
- headache: vessel spasm
- RUQ pain: liver involvement
- loss of consciousness, seizures
- rapid wt gain
What is the management for mild preeclampsia?
- bed rest: lateral decubitus position
- daily weighing
What is the management for severe preeclampsia?
- magnesium sulfate (IV or IM): 4g loading dose IV, 1-3g/hr infusion, therapeutic level: 4-7mEq/L)
- antihypertensive therapy when dBP > 110: hydralazine given at 5mg increment to acceptable BP level.
- monitor maternal and fetal well being
- deliver by induction or C-section
- 48hr delay in induction to allow steroid administration to enhance detal pulmonary maturity
How to treat eclampsia?
anticonvulsants
- magnesium sulfate (IV or IM)
- diazepam
- phenytoin
How to manage chronic hypertension of pregnancy?
- close monitor for superimposed preeclampsia/eclampsia
- encourage bed rest
- antihypertensive treatment if dBP > 110: methyldopa, labetalol, calcium channel blockers (amlodapine), diuretics.
How to manage eclamptic seizure?
Eclamptic seizure is usually self-limited, management should be aimed at preventing further episodes:
- initiate magnesium sulfate
- O2 treatment
- ABG, correct metabolic disturbances
- foley catheter to monitor UOP
What to do next?

- eclamptic seizure
- patient is on O2, magnesium sulfate initiated
- hypertensive
- low UOP
evidence of cardiac disturbance
- continuous electrocardiogram
What to do next?

- eclamptic seizure
- - patient is on O2, magnesium sulfate initiated, foley in
- fetal monitor showed bradycardia, decreased beat to beat variation, and late deceleration
these are self-limited and usually not dangerous to fetus unless they continue for >20min
What is HELLP syndrome?
Occur in patients with preeclampsia or eclampsia
- Hemolysis
- Elevated Liver enzyme
- Low Platelet count
How to manage patients with HELLP syndrome?
transfer to high risk obstetric center
- cadiovascular stabilization
- correction of coagulopathy: platelets when level is less than 20,000 and to patients with levels less than 50,000 if going to c-section.
- delivery
List some neonatal complications associated with PPROM (preterm premature rupture of membranes).
- respiratory distress syndrome
- intraventricular hemorrhage
- neonatal infection
- necrotizing entrocolitis
- neurologic and neuromuscular dysfunction
- sepsis
List some neonatal complications associated with PROM (premature rupture of membranes).
- intrauterine infection (chorioamnionitis) may lead to periventricular leukomalacia and cerebral palsy: Neisseria gonorrhea, bacterial vaginosis, GBS
- prolapsed umbilical cord
- placental abruption
T/F: The consequences of PPROM increase as gestational age decrease.
True
What are some risk factors for PROM?
- smoke: x2
- prior PROM
- short cervical length
- prior preterm delivery
- hydramnios
- multiple gestation
- bleeding in early pregnancy
What is the treatment for chorioamnionitis?
- antibiotics
- prompt delivery
What are some diagnostic test for ROM? (x3)
- nitrazine test: positive if turns blue (alkaline amniotic fluid)
- fern test
- pooling
- u/s
DDX for PROM.
- urinary incontinence
- physiologic vaginal secretions in pregnancy
- cervical discharge (infection)
- exogenous fluid (semen)
- vesicovaginal fistula
What can cause flase positives in nitrazine test for PROM?
- basic urine
- semen
- cervical mucus
- blood contamination
- antiseptic solutions
- vaginitis (especially trichomonas)
Factors to be considered in the management of patients with PROM.
- gestational age at the time of rupture
- presence of uterine contraction
- likelihood of chorioamnionitis
- amount of amniotic fluid around the fetus
- degree of fetal maturity
What is the diagnosis?

- PROM
- fever, tachycardia, uterine tenderness
chorioamnionitis
How to manage a term PROM?
- await onset of spontaneous labor for 12-24 hrs or
- induction of labor
How to manage a PPROM?
34-36wk gestation
- low risk group: immediate delivery or expectant management
- high risk of infection group: delivery asap with antibiotic treatment

significantly preterm
- no sign of infection: expectant management, CBC, daily check on uterine tenderness, u/s to determine amniotic fluid, antibiotics may prolong latency, daily fetal monitor
Increase or decrease during pregnancy?

- dental caries
- gingival disease
- dental caries: no change
- gingival disease: increase
During pregnancy. transit time in the stomach and small bowel increase by what percentage in the 2nd and 3rd trimesters?
15-30%
What is equlis?
pregnancy-related vascular swelling of the gums
What is the cause of ptyalism during pregnancy?
inability of patient to swallow normal amounts of saliva
What is the percentage increase in tidal volume in pregnancy?
30-40%
In a normal singleton pregnancy, maternal blood volume increase by what percentage?
45%
Where is pregnancy-associated systolic ejection murmur best heard?
left upper sternal border
Blood flow to which of the following organ is NOT increased?

- kidney
- breast
- skin
- brain
- eye
- brain
- eye
T/F: Plasma volume begins to increase at the 6th week of pregnancy and reaches its max at 30-34 wks.
True
T/F: Progesterone during pregnancy causes more dilation of the right ureter than the left.
True
What is chloasma?
change in facial pigmentation during pregnancy
What percentage of total cardiac output is channeled to the uterus at term?
20%
What is diastasis recti?
midline separation of the rectus muscles
- common during pregnancy
What percentage does BUN fall in the 1st trimester of pregnancy?
25%
What is the usual protein loss in pregnancy?
100-300mg/day
T/F: The breast enlargement associated with pregnancy is typically seem starting in the 1st trimester.
True
When would the vision change in pregnancy typically regress?
6-8wks postpartum
When should hair loss durind 2nd to 4th month postpartum return to normal?
6-12 months
How is HCO3 level in pregnant women compared to nonpregnant women?
significantly lower
What is rate of urine formation in the fetal kidney?
400-1200ml/day
What is the rate of umbilical blood flow in the 2nd half of the pregnancy?
100ml/mg_min
What is the normal % of breast enlargement during pregnancy?
25-50%
When do the maternal diastolic pressure and mean arterial pressure nadir?
16-20 wks
What is hyperemesis gravidarum?
nausea and vomiting of pregnancy persisting beyond middle of 2nd trimester or associated with wt loss, ketonemia, electrolyte imbalance
List some medications can be used to treat hyperemesis gravidarum.
- benedryl
- pepsid
- phenergan
- reglan
How do the following change during pregnancy?

- O2 pressure
- CO2 pressure
- tidal volume
- expiratory reserve volume
- residual volume
- inspiratory capacity
- vital capacity
- minute volume
- serum bicarbonate
- O2 pressure: increase
- CO2 pressure: decrease
- tidal volume: increase
- expiratory reserve volume: decrease
- residual volume: decrease
- inspiratory capacity: increase
- vital capacity: increase
- minute volume: increase
- serum bicarbonate: decrease
How much iron should you supplement pregnant women?
- 60 mg element iron/day or 300mg ferrous sulfate/day
What is Virchow's triad?
- hypercoagulability
- hemastasis
- endothelial injury
What are some hematologic changes during pregnancy?
- hypercoagulable state: incrased clotting factors and fibrin split products, decreased protein S, resistance to activated protein C
- hemastasis
- increased WBC
- increased plasma volume
- increased red cell mass
How do the following renal parameters change during pregnancy?

- renal plasma flow
- GFR
- renin
- angI and II
- renin substrate
- glucose excretion
- urinary output
- 24 hr protein
- creatinine
- uric acid
- BUN
- renal plasma flow: increase
- GFR: increase
- renin: increase
- angI and II: increase
- renin substrate: increase
- glucose excretion: increase
- urinary output: no change
- 24 hr urine protien: no change
- creatinine: decrease
- uric acid: decrease
- BUN: decrease
How does the uterus volume change during pregnancy?
from 10ml to 4-5L
How do the following change during pregnancy?

- ionized calcium
- total serum calcium
- PTH
- calcitonin
- ionized calcium: no change
- total serum calcium: decreased
- PTH: increased
- calcitonin: increased
- increased skeletal turnover
How do the following change during pregnancy?

- free T3, T4
- total T3 and T4
- free T3, T4: no change
- total T3 and T4: increase
How do the following change during pregnancy?

- cortisol
- deoxycorticosterone
- DHEAS
- cortisol: increase
- deoxycorticosterone: increase
- DHEAS: decrease
T/F: 70% of all glucose transferred from mother is consumed by placenta.
true
What do uptake of O2 and excretion of CO2 infetus depend on?
maternal and fetal blood-carrying capacity
How are the following parameter differ between mother and fetus?

- amount hemaglobin
- O2 sat
- amount hemaglobin: higher in fetus
- O2 sat: higher in fetus
Does maternal TSH cross placenta?
No
When does testicular and ovarian differentiation begin?
testicular differentiation: 6 wks
ovarian differentiation: 7 wks
What is "quickening" and when does it usually happen?
patient's initial perception of fetal movement: usually happens at 20 wk gestation
What does a + pregnancy test inidate?
- intrauterine pregnancy
- ectopic pregnancy
- trophoblastic disease
- spontaneous abortion
What is this sign?

- congestion and bluish color of the vagina
chadwick sign
- early sign of pregnancy
What is this sign?

- softening of the cervix
Hegar sign
- early sign of pregnancy
When does urine pregnancy test become positive?
4 wks following 1st day of the last mentrual period
In approximately what percentage of women is rubella titer positive?
85%
T/F: Specific screening for treponema is required when RPR is positve.
True
In normal pregnancy, how often should women engage in non-weight-bearing exercise?
3x per week
T/F: any test that indicates fetal maturity is associated with subsequent developement fo RDS in 5% or less of cases.
True
What medications could help with physiologic constipation of pregnancy?
- colace (docusate): stool softener
- metamucil (psyllium hydrophilic mucilloid): supplementary dietary fiber
Where do women experience more round ligament pain?
right goin because of dextrorotation of the gravid uterus
What are some types of preterm birth?
1. spontaneous PTB:
- 1/3 are PPROM
2. Indicated PTB: maternal or fetal reasons
Which race is at more risk at having preterm birth?
black > hispanic > white
What are some features of non-recurrent SPTB (spontaneous preterm birth)?
- second trimester bleeding
- trauma, substance abuse
- multiple gestations, hydramnios
What are some features of recurrent STPB?
- earlier gestational age at delivery (<32wks)
- African American
- genital tract infection and short cervix
What are some risk factors for SPTB?
- second trimester bleeding
- genitourinary infection
- black race
- low pre-pregnancy weight
- age < 18 yrs
- smoking
- prior preterm birth
Side effects of this tocolytic agent:

- beta-adrenergic: ex terbulaline
hyperglycemia
hypokalemia
hypotension
pulmonary edema
cardiac insufficiency
arrhythmia
MI
maternal death
Side effects of this tocolytic agent:

- magnesium sulfate
pulmonary edema
respiratory depression
cardiac arrest
maternal tetany
profound muscular paralysis
profound hypotension
How is cervical competence assessed?
cervical length
Diagnosis of PTL.
- contractions
- cervical change
- cervical sonography
- fetal fibronectin
What are some adjunctive therapies for PTL?
- antenatal steroids: beneficial when given < 34 wks gestation
- GBS prophylaxis
- maternal transport
Contraindications to tocolysis.
- mature fetus
- fetal distress/demise
- fetus incompatible with survival
- intraamniotic infection
- severe preeclampsia
- maternal shock
Tocolyse or not?

- cervix > 3cm or > 80% effaced
Yes
- PTL is confirmed
Tocolyse or not?

- cervix < 2cm and < 80% effaced
PTL diagnosis uncertain
- next to get fibronectin and ultrasound
- repeat exam in 1-2 hours
- tocolysis if cervical length < 20mm, fibronectin +, and cervical change
Tocolyse or not?

- cervix 2-3cm and < 80% effaced
PTL diagnosis uncertain
- next to get fibronectin and ultrasound
- repeat exam in 30min to 1hour
- tocolysis if cervical length < 20mm, fibronectin +, and cervical change
What are some measures of prevention of preterm birth?
- progesterone
- cervical cerclage
Criteria for diagnosis of cervical incompetency.
- 2 or more second trimester losses
- successive earlier losses
- painless dilation up to 4-6 cm
- absence of abruption
- cervical trauma
Criteria for urgent cerclage procedure.
- cervical shortening at 16-24 wks
- prior PTB < 28wks and CL < 20mm
- no PTB and CL < 15mm
- prolapsing membranes at < 24wks
List some tocolytic drugs.
- magnesium sulfate
- beta-mimetics: Ritodrine, terbulatine
- indomethacin: prostaglandin inhibitor, contraindicated for asthmatic patients
- calcium channel blockers: contraindicated for maternal liver disease
What is the gestational age?

- rate of fetal growth falls off
- placenta reaches max surface area
37th week
Early onset IUGR is associated with ____.
- irreversible reduction in organ size
- genetic factors
- immunologic abnormalities
Delayed onset IUGR is associated with ____.
- uteroplacental insufficiency
What is the most common maternal factor associated with IUGR?
hypertensive disease
Features of asymmetric IUGR.
- biparietal diameter appropriate for dates
- head to abdominal circumference ratio >95th percentile
- low amniotic fluid volume
Features of symmetric IUGR.
- normal to low amniotic fluid volume
- biparietal diameter smaller than expected for dates
- normal head-to-abdominal circonference
Assessment of IUGR by ultrasound includes ____.
- fetal doppler measurement
- evaluation of fetal growth
- percutaneous umbilical blood sample for genetic evaluation
- evaluation for amniotic fluid volume
What is an efficient screening procedure for IUGR?
serial fundal height measurement
Frequency of ultrasound evaluation for IUGR.
every 3-4 wks
Definition of hyperviscosity syndrome associated with IUGR.
fetal Hct > 65%
What is the recommendation for primary c section based on sonographic estimation of fetal weight?
- > 4500g for a women with diabetes
- > 5000 for a women without diabetes
What is the most common infection that causes IUGR(symmetric)?
CMV
Risk factors for IUGR.
- constitutionally small mother
- substance abuse
- poor maternal wt gain
- abnormal placentation: previa, marginal insertions, partial abruption
- previous IUGR
Potential sequela for IUGR.
intrapartum:
- fetal death
- meconium aspiration
- acidosis

postpartum
- seizure
- sepsis
- hypoglycemia
- hyperbilirubinemia

longterm
- CP
- chronic HTN
- heart and lung disease
- DM
- lower intelligence quotients
What are some antepartum monitors to assess fetal well being?
- nonstress test
- biophysical profile
- doppler velocimetry of umbilical artery
What is the appropriate fundal height for the following dates?

- 12 wk gestation
- 16 wk gestation
- 20 wk gestation
- 12 wk gestation: at pubic symphsis
- 16 wk gestation: half way between pubic symphsis and umbilicus
- 20 wk gestation: umbilicus

* need to re-evaluate if fundal height is off by more than 3 cm
What are some intrapartum complications of macrosomia?
- arrest of dilation or descent: need C section
- shoulder dystocia: HELPERZ
What is the HELPERZ mnemonic?
it is the sequence of maneuvers to help shoulder dystocia during delivery of a macrosomia baby
H - call for help
E - evaluate for episiotomy
L - leg with McRoberts maneuver
P - suprapubic pressure to collapse shoulder
E - extend posterior arm
R - rotate the baby with Wood's screw maneuver
Z - zavanelli's maneuver (push head back for a c section)
Definition of preterm labor.
- regular uterine contraction with a frequency of 10min or less and lasting at least 30s
- cervical dilation
What are some symptoms associated with preterm labor?
- low dull bachache
- pelvic pressure
- abdominal cramps
- change in vaginal discharge
What is this diagnoisis?

- positive pregnancy test
- tissue passed from vagina (spontaneousely or D&C)
- tissue does not demostrate chorionic villi
ectopic pregnancy until proven otherwise
- tissue passed from vagina is sometimes termed "decidual cast", similar to a spontaneous abortion.
DDX for ectopic pregnancy.
- threatened, missed, complete, incomplete abortion
- acute/chronic salpingitis
- follicular or corpus luteum cyst rupture
- endometriosis
- adnexal torsion
- gastroenteritis, appendicitis
Diagnostic steps in ectopic pregnancy.
1. pregnancy test
2. quantitative hCG every 2 days (normal should increase 66% in 48 hrs)
3. pelvic u/s to identify intrauterine pregnancy
4. WBC to r/o infection
5. progesterone level (if < 5ng/ml, fetus not viable)
6. curettage of uterine cavity to identify chorionic villi
7. culdocentesis to identify hemoperitoneum
Surgical management of ectopic pregnancy.
- linear salpingostomy, heal by secondary intention
- segmental section and reanastamosis
- salpingectomy
Medical treatment of ectopic pregnancy.
- expectant management: self regress
- methotrexate (po or IM or direct injection into gestational sac): for cases with <3.5cm diameter gestation on u/s.
- f/u serial hCG levels
- administer RhoGam if mother is Rh negative
List some non-tubal types of ectopic pregnancies.
1. Abdominal
- primary: associated with mullarian tract anomalies, endometriosis, PID, fallopian tube dysfunction
- secondary: aborted tubal ectopic pregnancy
- treated with surgical removal of fetus, and methotrexate to regress placenta (no surgical removal of placenta) or carry fetus to viability and deliver.

2. cervical pregnancy
- treated with conization, arterial embolization, or hysterectomy

3. ovarian pregnancy
- primary
- reimplanatation/secondary