Obgyn - Exam 2, Lecture 11

Front 1

What are the 2 MCC for C-section?

Back 1

1. previous C-section
2. failure to progress during labor

Front 2

What are indications for C-section?

Back 2

1. cephalopelvic disproprotion
2. fetal and maternal anomalies; malformations
3. fetal malpresentation or posture
4. hx of uterine inversion
5. previous vaginal surgery; vertical uterine incision; reconstructive surgery
6. antepartum or intrapartum hemorrhage - previa abruption
7. medical or surgical disease of the fetus or mother
8. failed trial of or induction of labor
9. failed forceps or vacuum extractor delviery
10. cord prolapse
11. fetal distress
12. arrest of labor
13. fetal macrosomia
14. pelvic mass-firbroids
15. previous Cesarean with vertical incision
16. hx of complicated maternal birth injury, lacerations, fistulas
17. abnormal placenta or umbilicus - previa, abruption, cord prolapse

Front 3

What are 5 steps we take to prepare patient for C-section?

Back 3

1. hydrate well
2. maintain Hct of 30% or higher
3. type and hold blood
4. +/- prophylactic antibiotics
5. antacids to reduce acidity

Front 4

what are possible complications of anesthesia?

Back 4

hypotension, HA, decreased motor fnx

Front 5

What are the types of abdominal incisions used for c-sections?

Back 5

1. midline
2. paramedian
3. Pfannenstiel (MC)

Front 6

Which surgical incision provides the most desired effect but takes the most time to perform?

Back 6

Pfannenstiel

Front 7

Which surgical incision is less time consuming and less bloody?

Back 7

Infraumbilical vertical midline incision

Front 8

what is the average blood loss during a c-section?

Back 8

1000ml

Front 9

What is the most common complication of C-section?

Back 9

Infection: *endometritis, *wound infection, salpingitis

Front 10

what percent of patients have complications with C-section?

Back 10

5%

Front 11

Complications of C-section include?

Back 11

1. infection
2. uterine rupture
3. hysterectomy
4. hemorrhage
5. injury to organs
6. atelectasis/pneumonia
7. ileus
8. fetal injury
9. maternal death
10. aspiration
11. DVT
12. Pulm. embolism
13. anesthetic complications
14. effects of C-section on fetus/newborn --> increased incidence of transient tachypnea

Front 12

Candidates for VBAC include?

Back 12

patients with one or two prior low-transverse-C-section;adequate pelvis; no other uterine scars, anomalies or uterine rupture

Front 13

Contraindications to VBAC include:

Back 13

diabetes, htn, HSV infection, prior classical or T-shaped incision; inability to perform emergency C-section

Front 14

can we use oxytocin or and epidural with VBACs?

Back 14

yes

Front 15

Incision of perineum at send of second stage of labor is known as?

Back 15

episiotomy

Front 16

Common usage of episiotomy supported historically by alelged prevention of?

Back 16

perineal truama, pelvic relaxation and newborn injury

Front 17

What is the most common type of episiotomy in the US?

Back 17

Median episiotomy

Front 18

This type of episiotomy may be more difficult to repair, has more blood loss and is more difficult to heal but gives the most room.

Back 18

mediolateral

Front 19

What are the 4 types of forceps?

Back 19

Simpson, Tucker-McLean, Kielland and Barton, Piper

Front 20

Which forcep is used for occiput anterior?

Back 20

Simpson

Front 21

Which forceps it used to rotate from occiput posterior to occiput anterior and deliver?

Back 21

Tucker-McLean

Front 22

Which forceps is used to rotate occiput transverse to occiput anterior?

Back 22

Kielland and Barton

Front 23

which forceps is used to deliver the aftercoming head of breach?

Back 23

Piper

Front 24

When should perineal massage be done?

Back 24

should be done daily for at least 5-10 minutes starting 6 weeks prior to birthing

Front 25

what are contraindications to perineal massage?

Back 25

1. pelvic varicose veins
2. active herpes lesion

Front 26

When might forceps be used nowadays?

Back 26

not common anymore. used where this is fetal distress or maternal compromise and the inability to do a C-section quickly

Front 27

what are the prerequisites for Forceps delivery?

Back 27

cervix must be completely dilated
position (vertex) must be known
membranes must be ruptured
bladder must be empty

Front 28

What foreceps is used when fetal vertex is at 2+ station?

Back 28

low forceps

Front 29

this forceps are used with head is engaged and fetal head is above a 2+ station

Back 29

midforceps

Front 30

use this forceps when fetal head is at the perineum and scalp is visible at the introitus...

Back 30

outlet forceps

Front 31

What are the two types of vacuum extraction devices?

Back 31

1. malmstrom vacuum extractor
2. plastic cup extractor -- more widely used in USA

Front 32

what is the major complications for using forceps?

Back 32

trauma to scalp, including
1. scalp abrasion or laceration
2. cephalohematoma
3. intracranial hemorrhage
4. retinal hemorrhage
5. soft tissue laceration

Front 33

Define cervical incompetence:

Back 33

premature, painless dilatation of cervix (w/o being in labor), in the 2nd trimester of pregnancy that usually results in pregnancy loss.

Front 34

What is the MC risk factor for cervical incompetence?

Back 34

previous incompetence

Front 35

What is the MCC associated with stillbirth?

Back 35

fetal growth restriction (43%)

Front 36

Termination of pregnancy medically or operatively before viability is known as?

Back 36

induced abortion

Front 37

What are the two types of induced abortion?

Back 37

therapeutic, elective

Front 38

Interruption of pregnancy for the purpose of safeguarding the health of the mother is known as?

Back 38

therapeutic abortion

Front 39

when did therapeutic abortions become legal?

Back 39

1973

Front 40

When can therapeutic abortions be performed?

Back 40

Can be induced up to approximately 20-24 weeks gestation

Front 41

what is the treatment for cervical incompetence?

Back 41

cervical cerclage - placement of encircling suture around cervical os with heavy , nonabsorbable suture. Suturing prevents protrusion of amniotic sac and rupture.

Front 42

What are the two techniques for cervical cerclage?

Back 42

1. The shirodkar
2. The McDonald

Front 43

This cerclage technique is the most complicated. vaginal mucosa is dissected away from the cervix before placing suture. It is permanent

Back 43

The Shirodkar

Front 44

This cerclage technique is the simplest. Less trauma to cervix and less blood loss. no mucosal dissection and it is temporary

Back 44

The McDonald

Front 45

The simple purse string cerclage is also known as?

Back 45

The mcDonald

Front 46

what is the method of choice for early ddetection of cervical dilation in cervical incompetence?

Back 46

US. look for the "short cervix".

Front 47

The birth of a dead fetus is known as?

Back 47

stillbirth

Front 48

What is the etiology of 50% of stillbirths?

Back 48

unknown etiology

Front 49

What are some genetic causes of stillbirth?

Back 49

1. thrombophilias
2. chromosome abnormalities
3. single-gene disorders

Front 50

When a patient has a stillbirth what should we do to follow up and evaluate?

Back 50

review genetic, medical and OB hx
urge autopsy
dx imaging, xray, MRI
conduct chromosomal analysis, infection dz workup
provide counseling

Front 51

A spontaneous abortion is defined by the fetus being...

Back 51

less than 20 wks, or less than 500g

Front 52

interruption of pregnancy at the request of the mother is known as?

Back 52

elective voluntary abortion

Front 53

What does a pre-abortion work-up consist of?

Back 53

1. US to assure dates correspond with uterine size
2. Labs: ABO /Rh typing
3. administer Rhogam in Rh neg moms
4. careful patient counseling should be performed

Front 54

Maternal indications for therapeutic abortion

Back 54

1. CV dz
2. genetic syndromes
3. hematologic dz
4. metabolic
5. neoplastic
6. neurologic
7. renal
8. intrauterine infection
9. severe pre-eclampsia/eclampsia

Front 55

Which is a safer method of abortion? Surgical or medical?

Back 55

surgical

Front 56

This substance is used to dilate cervix slowly and gently before evacuation

Back 56

Laminaria

Front 57

The safest and most effective method to terminate pregnancies of 12 weeks or less is?

Back 57

Dilation of cervix and evacuation (D and E) - also known as suction curettage.
Over 90% of US induced abortions done this way

Front 58

What medical substances are being used for abortion?

Back 58

Abortifacients:
1. intravaginal prostglanding E2 with urea
2. methotrexate + misoprostol
3. mifepristone + misoprostol

Front 59

What is Mifepristone/Mifeprex made up of? How effective is it?

Back 59

19 norsteroid analogue. Progesterone antagonist (RU 486). 95% effective

Front 60

How does Mifepristone work?

Back 60

First, you need patient and prescriber agreement.
The norsteroid analogue blocks progesterone receptor sites in deciduas which leads to bleeding. It also increases prostaglandin levels which leads to uterine contractions. Pt. will have abd. pain for 1-2 weeks with bleeding. Requires 3 office visits. On day 14 confirm pregnancy termination.

Front 61

What are some complications of Abortion?

Back 61

1. hemorrhage
2. cervical injury
3. coagulation defects
4. retained products of conception
5. infection
6. perforation
7. infertility
8. Rh sensitization
9. embolism
10. live-born fetus
11. uterine rupture
12. asherman's syndrome

Front 62

What is the lay term for a second or third trimester abortion?

Back 62

Partial birth abortion. sometimes referred to as "intact dilation and extraction"

Front 63

What is the incidence of drug use in pregnancy?

Back 63

0.4 - 27%

Front 64

What are some signs of substance abuse?

Back 64

1. agitation
2. sedation
3. disorientation
4. tachycardia
5. hallucinations
6. hypertension
7. skin infections

Front 65

Prof. Lord wants us to know all the ways cocaine can be used:

Back 65

1. it can be smoked as crack
2. taken intranasally (my preferred method --JK!! obvi)
3. injected IV
the use of cocaine in pregnancy is increasing

Front 66

Pharmacologic effects of cocaine include:

Back 66

1. cardiovascular effects (fetal tachy and increased fetal o2 consumption
2. interferes with dopamine and Norepi reuptake = CNS irritability
3. maternal and fetal vasoconstriction and tachy, plus stimulation of uterine contractions

Front 67

What are the maternal complications of Cocaine use?*

Back 67

1. neurologic - seizure, rupture of aneurysm
2. cardiovascular - MI, HTN, arrhythmias, aortic rupture, sudden death
3. Infections
4. Obstetric - increase in preterm labor and delivery, IUGR, low birth weight, etc

Front 68

How do we manage cocaine use in pregnancy?

Back 68

1. detection
2. treatment

Front 69

How can we detect cocaine use in pregnancy?

Back 69

1. educate patients
2. question ALL patients about any drug use
3. examine patients for inflammation or nasal alae and IV sites
4. consider urine toxicology screening

Front 70

How do we treat patients who use cocaine during pregnancy?

Back 70

1. refer pt to a chemical dependency treatment center
2. obtains assistance from social services
3. prevent and treat premature labor and IUGR
4. begin biophysical testing no later than 32 wks
5. watch for abdominal pain

Front 71

How do we treat cocaine overdose?*

Back 71

1. control seizures, hyperthermia and HTN. Must decrease CNS irritability and sympathetic nervous system overactivity.
(treat seizures with MgSulfate, HTN and tachy with Propranolol, nitropursside, phentolamine)

Front 72

The branch of science concerned with the production, development, anatomy and classification of malformed fetuses is known as?

Back 72

Teratology

Front 73

What is the definition of Teratogen? *

Back 73

Any chemical (drug), infection, physical condition or deficiency that upon fetal exposure can alter fetal morphology or subsequent function.

Front 74

this drug was used as an anti-anxiolytic and anti-nausea agen in the first trimester before found to be teratogenic

Back 74

thalidomide

Front 75

This estrogenic hormone was meant to prevent a variety of reproductive problems but by the 1960s was found to cause increased risk of adenocarcinoma of the cervix and vagina and male reproductive anomalies.

Back 75

Diethylstillbesterol (DES)

Front 76

This development stage is from day 0 to 11 and known as the "all or none" phenomenon.

Back 76

Resistant period

Front 77

The period in which the fetus is most susceptible to adverse effects of teratogens is?

Back 77

from day 11 to 57 of gestation. Embryonic period

Front 78

A teratogen at this stage may cause a reduction in cell size and number.

Back 78

Lowered susceptibility stage (fetal period). From day 57 to gestation

Front 79

The ____ and _____ of administration of a teratogen alter the type and severity of the malformation produced.

Back 79

route and length. Abnormal developments increase in frequency and degree as dosage increases.

Front 80

What are the three types of structural defects?

Back 80

1. malformations
2. deformations
3. disruptions

Front 81

What kind of structural defect comes from an intrinsic abnormality in the process of development, usually in the first trimester; primary structural defect from a localized error of morphogenesis

Back 81

morphologic defect

Front 82

This type of structural defect is characterized by abnormal forms, shapes, or positions of a previously normal body part; caused by a non-disruptive mechanical force

Back 82

deformations

Front 83

club feet from oligohydramnios is an example of what kind of defect?

Back 83

structural defect

Front 84

This type of structural defect is a morphologic defect from extrinsic interference with a normally developing organ system, usually occurs later in gestation.

Back 84

Disruptions

Front 85

amniotic band syndrome is an example of what kind of structural defect?

Back 85

disruption

Front 86

What is amniotic band disruption syndrome?

Back 86

A group of fetal malformations associated with multiple fibrous strands of amnion that appear to develop or entangle fetal parts in utero. This leads to structural malformations and defromations and disruptions of function. ex: limb defects, amputations, simian creases, visceral defects, etc.

Front 87

What percent of pregnant women in the USA ingest over-the-counter or prescription drugs during pregnancy?*

Back 87

45-95%

Front 88

Risk factors for adverse fetal effects have been assigned to all drugs by the FDA based on what?*

Back 88

the teratogenic risk that the drug poses to the fetus

Front 89

What category? Controlled studies fail to show risk to fetus; possibilty of fetal harm appears remote

Back 89

Category A
ex. prenatal vitamins

Front 90

What category?
No evidence of risk in humans.

Back 90

Category B
ex: PCN, digoxin, epi

Front 91

What category?
Risk cannot be ruled out. Animal studies have shown either teratogenic or embryocidal effects on fetus OR appropriate animal data is not available.

Back 91

Category C
ex: furosemide, verapamil, beta blockers
give only when benefit outweighs potential fetal harm.

Front 92

What category?
Positive evidence of risk. Benefit may outweigh fetal risk in certain circumstances.

Back 92

Category D
ex: phenytoin

Front 93

What category?
Contraindicated in pregnancy

Back 93

Category X

Front 94

What is the most commonly abused substance during pregnancy? *

Back 94

ETOH

Front 95

what is the most common known teratogenic cause of mental retardation? *

Back 95

ETOH

Front 96

The effect of ETOH is related to the _____ in which it is consumed.

Back 96

trimester

Front 97

What is a safe level of ETOH consumption in pregnancy?

Back 97

NONE!

Front 98

FAS is associated with ____ ounces or more of ETOH a day. *

Back 98

1-2

Front 99

What are some features of FAS?

Back 99

1. mental retardation
2. growth retardations
3. abnormal facies
4. ocular and joint anomalies
5. CNS abnormalities
6. Behavioral disturbances
7. cardiac effects

Front 100

What features is maternal smoking of marijuana associated with?

Back 100

1. increased perinatal morbidity
2. preterm delivery
3. premature rupture of membranes
4. bleeding during pregnancy

Front 101

Has marijuana been shown to cause birth defects? Has Heroin?

Back 101

No evidence of either causing birth defects

Front 102

The major adverse fetal effect in heroin addicts is? *

Back 102

severe neonatal withdrawal

Front 103

what is the DOC for heroine addiction in pregnancy?

Back 103

Methadone

Front 104

This caused clear cell carcinoma in mom and offspring!

Back 104

Diethylstillbesterol (DES)

Front 105

What are the teratogenic risks from chemotherapy in pregnancy?

Back 105

high risk of fetal loss due to spontaneous abortion and stillbirth. After the period of organogenesis (1st trimester), there is no teratogenic risk from chemo in pregnancy.

Front 106

Sustained temps above _____ are teratogenic and associated with CNS defects, growth retardation, facial anomalies, minor limb anomalies.

Back 106

102F. ex: frequent saunas, febrile infections

Front 107

VSDs are a very common congenital heart defect associated with this maternal medical disorder:

Back 107

Diabetes Mellitus.

Front 108

This maternal disease is associated with mental retardation, microcephaly, congenital heart dz and low birthweight.

Back 108

phenylketonuria (PKU)

Front 109

Epileptics on anticonvulsants during pregnancy have a ____ fold increase in malformations of fetus*

Back 109

2-3 fold

Front 110

Growth and mental retardation, microcephaly, eyelid ptosis, depressed nasal bridge, craniofatial abnormalities and digital anomalies are associated with which syndrome?

Back 110

Fetal Hydantoin Syndrome

Front 111

Why might untreated epileptics be at an increased risk of delivering infants with birth defects?*

Back 111

maybe due to hypoxia from seizures

Front 112

"snuffles" rhinitis is associated with this infection

Back 112

syphilis

Front 113

what is the organism associated with syphilis?

Back 113

treponema pallidum

Front 114

All infants born to women with primary and secondary infection will be _____, but ____% will be asymptomatic*

Back 114

infected, 50%

Front 115

how should we treat a pregnant mother with syphilis?

Back 115

adequate abx therapy for the mother thought to provide adequate therapy for unborn child

Front 116

Congenital malformations in offspring of women who develop chickenpox in the first ___ weeks of pregnancy

Back 116

20 weeks

Front 117

There is ______ evidence proving herpes zoster causes congenital anomalies. *

Back 117

There is no good evidence

Front 118

Are Mumps teratogenic?*

Back 118

Not strictly but neonates exposed in utero are known to have cardiac, ear and eye malformation and urogenital abnormalities

Front 119

this disease can cause serious fatal illness in fetus including cardiac malformations, hepatitis, pneumonities, pancreatitis and adrenal necrosis

Back 119

enterovirus (Coxsackie B) "Fifths dz"

Front 120

highest risk of birth defects in first trimester including CNS, cardiovascular lesions, ocular defects, inner ear problems and IUGR are seen in this dz

Back 120

Rubella (german Measles)

Front 121

Risk of severe complications much higher for infants of mothers who had a primary infection in pregnancy compared to those with recurrent infection with this disease:

Back 121

CMV

Front 122

Neonatal effects of fetal CMV include?

Back 122

microcephaly, chorioretinities, deafness, HSM, cerebral calcification, mental retardation, heart block, petechiae

Front 123

If mother is infected with Herpes Simplex (HSV-D) what do you want to watch for in the infant?

Back 123

eye involvement and encephalitis

Front 124

This infection is associated with spontaneous abortion, perinatal death, abnormal growth, chorioretinities, microcephaly

Back 124

Toxoplasmosis

Front 125

what is the organism called in Toxoplasmosis?

Back 125

toxoplasma gondii

Front 126

What are the prerequisites for Forceps Delivery?

Back 126

1. cervix must be completely dilated
2. position (vertex) must be known
3. membranes must be ruptured
4. bladder must be empty

Front 127

Prereqs for forceps delivery include:

Back 127

1. cervix must be dilated
2. position must be known
3. membranes must be ruptures
4. bladder must be empty

Front 128

most common condition associated with still birth is ?

Back 128

fetal growth restriction (43%)

Front 129

what are two fetal indications for therapeutic abortion?

Back 129

Tay Sachs dz - genetic
anencephaly - major malformations

Front 130

Anti-D antibody titers provide limited info on severity of dz. T/F?

Back 130

True

Front 131

Indirect Coomb's titer greater than _______ is significant

Back 131

1:32

Front 132

High titers require______ to determne severity of fetal anemai

Back 132

amniocentesis

Front 133

How often do we repeat antibody titers if they have an Rh+ dad?

Back 133

monthly

Front 134

intrauterine transfusion and intravascualr transfusion are used to treat what dz?

Back 134

erythroblastosis fetalis

Front 135

When do we give Rh Immune globulin?

Back 135

1. 28 week for non-immunized mom
2. pospartum (72) if woman remains non immunized
3. following amnio or CVS
4. following evacuation of molar pregnancy
5. following ectopic
6. after tubale ligation or pregnancy termination
7. aftera accidental transufion
8. after platelet transfussion
9. afer clnical situation associated with spill of fetal cells into maternal circulation

Front 136

What is the standard dose of Rh Immune Globulin?

Back 136

300mcg cover fetal hemorrage of 30ml of fetal whole blood or 15ml of rbc

Front 137

what test do we do anytime a fetomaternal hemorrhage is suspected?

Back 137

kleihauer - betke test