Ob Kaplan Complications Chap 8

Front 1

Complications of twin pregnancies

Back 1

Antepartum- Anemia , Preeclampsia
Intrapartum- Preterm labor, malpresentation, c-section
Postpartum-hemorrhage

Front 2

what is zygosity

Back 2

how many eggs
1-identical twins
2-faternal

Front 3

what is chorionicity

Back 3

how many placentas

Front 4

what is amnionicity

Back 4

how many sacs

Front 5

Separation occuring day 1-3

Back 5

di
di

Front 6

separation occurring day 4-8

Back 6

mono
di

Front 7

separation occurring day 9-12

Back 7

mono
mono

Front 8

separation occurring day 13-15

Back 8

conjoined twins

Front 9

Which twins can have twin-twin transfusion

Back 9

Monochorionic
Diamniotic

Front 10

Describe each twin in twin-twin trnasfusion

Back 10

donor is anemic
recipient is polycythemic
**donor does better

Front 11

What is twin embolization syndrome

Back 11

occurs in monoamniotic

Front 12

Antepartum management of twins

Back 12

1. prevent anemia- iron & folate
2. early detection of preeclampsia- monitor BP
3. Prevent preterm delivery- PTL education
4. Early detection of Twin twin syndrome - serial sonos
5. Postpartum hemorrhage due to overdistended uterus (uterine atony)

Front 13

Mode of twin delivery

Back 13

1. ceph-ceph-vaginal delivery
2. ceph-Br- not sure
3. Br-ceph- c-section

Front 14

Dx of twins

Back 14

1. increase fundal height, AFP, hCG
2. sono

Front 15

Gender differences in twins

Back 15

must be
dizygotic
dichorionic
diamniotic

Front 16

Septum present on sono twins must be

Back 16

Mono
Mono
Di
day 4-8

Front 17

Septum absent on sono twins must be

Back 17

mono
mono
mono
day 9-12

Front 18

risk for
mono
mono
mono

Back 18

anemia
HTN
PTD
CS
PPH

Front 19

risk for
Mono
Mono
Di

Back 19

twin twin transfusion

Front 20

risks for
mono
mono
mono

Back 20

cord entangled

Front 21

Define isoimmunization

Back 21

a woman produces antibodies directed against foreign RBC surface antigen, often those of her fetus

Front 22

Questions to ask when suspecting isoimmunization

Back 22

1. Fetus at risk?
2. Fetus anemic?
3. Intervene?

Front 23

Complication that can occur if anemia is not treated with isoimmunization

Back 23

fetal hydrops

Front 24

What common cause of isoimmunization

Back 24

feto-maternal bleed RBC transfusion

Front 25

Most common RBC antigen for isoimmunization

Back 25

Big "D"=Rh neg

Front 26

Most common screening test for isoimmunization

Back 26

Indirect Coombs test /atypical antibody test (AAT)

Front 27

Most common neonatal outcomes in isoimmunization

Back 27

mild jaundice to erythroblastosis fetalis

Front 28

Risk factors for isoimmunizations (fetal-maternal bleed)

Back 28

1. amniocentesis
2. ectopic pregnancy
3. dilation & curettage
4. abruption placenta
5. placenta previa

Front 29

What is the most common effect of ABO incompatibility on risk of maternal isoimmunization

Back 29

protects against it

Front 30

What antibodies are found in
O blood type
A blood type
AB blood type

Back 30

O blood type -anti A & ant B
A blood type- anti B
AB blood type none

Front 31

How does ABO incompatibility protect against isoimmunization

Back 31

O blood type has anti A &B so A and B blood cells from fetus will be hemolysed before lymphocyte sees them and produce antibodies => Complete protection against isoimmunization.

A blood type- will hemolyze only B+ blood so A + blood cells will be seen by the lymphocytes and antibodies will be made against them=> Partial protection

AB blood type- no antibodies against A or B so both A & B will remain around to be seen by lymphocytes => no protection

Front 32

Is the fetus at risk for isoimmunization?

Back 32

All must be present:
1. Is mom antigen neg?
2. Is dad antigen positive
3. Are atypical Ab present ?
4. Are Ab assoc with HDN (hemolytic dz of newborn)
5. Is Ab titer >1:8?

Front 33

Is the fetus anemic? How is this assessed in isoimmunization?

Back 33

1. amniocentesis form amniotic bilirubin (breakdown product of hemoglobin; higher the bilirubin the lower Hb of baby)
2. PUBS (percutanous blood sample) for fetal Hct
3. Sono of middle cerebral artery peak systolic velocity (put doppler or circle of wilis, find middle cerebral artery, as anemia worsen peak systolic velocity increases)

Front 34

What is the most common management if fetal hematocrit os >25% (normal 35%)

Back 34

Repeat PUBS if <34 wks
Delivery if > 34 wks

Front 35

Is intervention required (delivery or interuterine transfusion)?

Back 35

1. Fetal Hctis <25%
2. MCA peak velocity high

Front 36

Mechanism of RhoGAM

Back 36

Passive anti-D IgG Ab
They look for D+ RBC => Hemolysis it before lymphocytes become activated

Front 37

When is RhoGAM done

Back 37

Usually:
1. at 28wks to Rh- moms
2. after delivery if baby Rh+

Special cases:
CVS, amnio, D&C, Ectopic, abruption, previa

Front 38

How much can 1 vial of RhoGAM neutralize?

How do you know if she needs more than 1 vial?

Back 38

300mg of RhoGAM neutralize 15 mL of RBC

use Kleihauer-Betke smear

Front 39

Preterm labor triad

Back 39

1. contractions 3 in 30 mins
2. 20-35 wks
3. cervix: 2cm or change in dilation or effacement on serial exams

Front 40

Common tocolytics

Back 40

1. MgSO4
2. B adrenergic agonists
3. PG synthesis inhibitors
4. Ca channel blockers

Front 41

What is increases surfactant? When should it be given?

Back 41

Betamethasone
<34 wks

Front 42

Things to consider for preterm labor

Back 42

1. criteria
2. contraindications
3. Give tocolytic
4. Give Surfactant
5. GBS prophylaxis

Front 43

Differential dx of uterine contractions

Back 43

1. uterine irritability
2. Braxton-Hicks contractions
3. Preterm contractions
4. Preterm labor

Front 44

Preterm contraction triad

Back 44

1. pregnancy 20-36 wks
2. >3 contractions in 30 min
3. dilated <2 cm + no cervix change

Front 45

What is the difference btw preterm labor and preterm contractions

Back 45

cervical changes

Front 46

Risk factor for preterm birth

Back 46

multiple gestations (50%)
Uterine anomaly (50%)
Previous preterm birth (25%)

Front 47

Factors responsible for Preterm birth

Back 47

1. Infection (most common)
2. cervical pathology (cervicitis, short cervix)
3. uterine overdistension (multiples)
4. ischemia
5. abnormal allograft rxn
6. allergic phenomena
7. endocrine d/o

Front 48

Symptoms of preterm labor

Back 48

1. lower abd pressure
2. back pain
3. vaginal discharge

Front 49

Contraindications to tocolysis

Back 49

1.OB- severe abruption, ruptured membranes, chorioamnionitis
2. Fetal- lethal anomaly, fetal demise, fetal jeopardy
3. Maternal- eclampsia, severe preeclampsia, advanced dilation

Front 50

Define tocolysis

Back 50

inhibiting uterine contractions

Front 51

Side effects of MgSO4

Back 51

Respiratory depression

Front 52

SIde effect of beta adrenergic agonists

Back 52

hyperglycemia
hypokalemia (K moves intracellularly)

Front 53

side effects of Ca channel blockers (Nifedipine)

Back 53

myocardial depression

Front 54

Side effects of PG synthetase inhibitors (indomethacin)

Back 54

1. oligohydramios (decr renal perfusion-> decre amniotic fluid)
2. Intrauterine closure of PDA

Front 55

Magnesium toxicity triad

Back 55

1. preterm labor tocolysis
2. respiratory depression
3. muscle weakness

Front 56

Tx for magnesium overdose

Back 56

1. stop Mg
2. Calcium gluconate

Front 57

Calcium channel blocker side triad

Back 57

1. Perterm labor tocolysis
2. tachycardia & hypotension
3. myocardial depression

Front 58

Beta agonist side effect triad

Back 58

1. preterm labor tocolysis
2. hypokalemia
3. hyperglycemia

Front 59

Indomethacin side effect triad

Back 59

1. preterm labor tocolysis
2. oligohydramnios
3. PDA closure in utero

Front 60

What is the function of progesterone

Back 60

to stabilize smooth muscle of uterus

Front 61

What should be your plan after tocolytics are given?

Back 61

since they only delay delivery for 48 hrs give Betamethasone if <34 wks to increase surfactant and do vaginal culture and put on IV Penicillin G for GBS prophylaxis

Front 62

What organisms cause chorioamnionitis

Back 62

normal vaginal flora- anerobes, gram +, gram -

Front 63

What is the tx for chorioamnionitis

Back 63

give both
gentamicin
clindymicin

Front 64

Definition of Premature rupture of membrane

Back 64

Definition. Rupture of the fetal membranes before the onset of labor, whether at term or pre-term.

Front 65

Risk factors for premature rupture of membrane

Back 65

Risk Factors. Ascending infection from the lower genital tract is the most common risk factor for PROM. Other risk factors are local membrane defects and cigarette smoking.

Front 66

Clinical presentation for premature rupture of membrane

Back 66

Clinical Presentation. Typical history is a sudden gush of copious vaginal fluid. On external examination, clear fluid is flowing out of the vagina. Oligohydramnios is seen on ultrasound examination.

Front 67

Ruptured membrane triad

Back 67

Ruptured Membranes
1.Posterior fornix pooling
2.Fluid is Nitrazine (phenaphthazine) (+)
3. Glass slide drying: fern (+)

Front 68

How is premature rupture of membrane diagnosed

Back 68

1. PROM is diagnosed by sterile speculum examination meeting the following criteria:
–Pooling positive—clear, watery amniotic fluid is seen in the posterior vaginal fornix
–Nitrazine positive—the fluid turns pH-sensitive paper blue
–Fern positive—the fluid displays a ferning pattern when allowed to air dry on a microscope glass slide

Front 69

How is chorioamnionitis diagnosed

Back 69

Chorioamnionitis is diagnosed clinically with all the following criteria needed: maternal fever and uterine tenderness in the presence of confirmed PROM in the absence of a URI or UTI.

Front 70

How do you manage premature rupture of membrane

Back 70

1. If uterine contractions occur, tocolysis is contraindicated.
2. If chorioamnionitis is present, obtain cervical cultures, start broad-spectrum therapeutic N antibiotics, and initiate prompt delivery.
3. If no infection is present, management will be based on gestational age as follows:

Front 71

Chorioamnionitis triad

Back 71

Chorioamnionitis
1. Ruptured membranes
2. Maternal fever
3. No UTI or URI

Front 72

How do you manage premature rupture of membrane at different gestational ages

Back 72

— Before viability (<24 weeks), outcome is dismal. Either induce labor or manage
patient with bed rest at home. Risk of fetal pulmonary hypoplasia is high.
— With preterm viability (24-33 weeks), conservative management. Hospitalize the patient at bed rest, administer IM betamethasone to enhance fetal lung maturity if <32 weeks, obtain cervical cultures, and start a 7-day course of prophylactic ampi¬cillin and erythromycin.
— At term (?34 weeks), initiate prompt delivery. If vaginal delivery is expected, use
oxytocin or prostaglandin as indicated. Otherwise, perform cesarean delivery.

Front 73

Etiology of Postterm pregnancy

Back 73

The most common cause of true postdates cases are idiopathic (no known cause). It does occur more commonly in young primigravidas and rarely with placental sulfatase deficiency. Pregnancies with anencephalic fetuses are the longest pregnancies reported.

Front 74

Management of post term pregnancy

Back 74

Management is based on two factors.
• Confidence in dates. Identify how much confidence can be placed on the gestational age being truly >42 weeks.
• Favorableness of the cervix. Assess the likelihood of successful induction of labor by assessing cervical dilation, effacement, position, consistency, and station.
— Favorable cervix is dilated, effaced, soft, and anterior to mid position.
— Unfavorable cervix is closed, not effaced, long, firm, and posterior.

Front 75

Management of Meconitun

Back 75

• In labor, amnioinfusion (with saline infused through an intrauterine catheter) to dilute meconium and provide a fluid cushion to prevent umbilical cord compression.
• After the head is delivered, suction the fetal nose and pharynx to remove any upper air¬way meconium.
• After the body is delivered, visualize the vocal cords with a laryngoscope to remove meconium below the vocal cords.

Front 76

concerns of post term pregnancy

Back 76

macrosomia
placenta fxn declines => hypoxic baby

Front 77

what should be done for a post term date unsure pregnancy

Back 77

NST &AFI
Await labor

Front 78

what should be done for a post term date sure and cervix favorable

Back 78

Amniotomy and IV oxytocin

Front 79

what should be done for a post term date sure with unfavorable cervix

Back 79

NST & AFI or PGE2