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obgyn test 2 (key points)
Terms in this set (70)
Risk factors for pre eclampsia
*1. Nulliparity-preeclampsia predominantly disease of nullips
2. Age-extremes of age (teens and over 35 y.o.)
3. Multiparity (with the following, otherwise multiparity alone not a factor):
a. Multiple gestation
b. Fetal hydrops
c. Chronic hypertension
d. Preexisting or Gestational DM
e. Coexisting renal disease
f. Chronic vascular disease
4. African-American race
5. History of preeclampsia in a first degree relative
6. History of previous preeclampsia
8. Fetal hydrops
9. Collagen-vascular disease
10. Chromosomal abnormalities
Pt. presents with third trimester vaginal bleeding, what should you absolutely not do during your exam of the patient?
DO not do a digital exam if you don't know why they are bleeding
know painless vaginal bleeding vs bleeding with contractions vs bleeding with belly that doesn't relax
painless vaginal bleeding in 3rd trimester- placenta previa.
bleeding with contractions: spontaneous abortion
Hard tender belly- placental abruption
Risk factors for developing ectopic pregnancy?
-Exact cause of ectopic is not clear; tubal adhesions are common cause.
1. Pelvic Infection:
*Chronic salpingitis most common pathologic finding in fallopian tube
Infection in tube leads to fibrosis and scarring which retard progress of fertilized ovum on its way through tube.
*Chronic PID involves both tubes.
2. IUD Usage-4 to 9% rate of ectopic pregnancy
3. Previous Ectopic-increased risk of future ectopic approximately 10 fold
4. Increased maternal age
5. History of infertility/infertility treatment/medications
6. Uterotubal anomalies
MCC of immediate post partum hemorrhage
-uterine ATONY (hypotonic myometrium)
Teratogen is best defined as:
any chemical (drug), infection, physical condition or deficiency that upon fetal exposure can alter fetal morphology or subsequent function
Meds that you use for initial tx of pre-ecclampsia
*No cure for preeclampsia; only cure is delivery of fetus and placenta.
• Labetalol (Beta-blocker)
• Not all beta-blockers are acceptable; some IUGR, fetal bradycardia, fetal hypoglycemia
• Calcium channel blockers-Extend-release Nifedipine well tolerated
Cardiovascular meds to avoid in pregnancy?
• ACE Inhibitors- fetal malformations
• Warfarin congenital anomalies
• Phenytoin- Phenytoin syndrome
Do a c section. Know about MC infection post op day one? day 4-5? 4-7 days?
Infection = Most common complication of C-section
Antibiotic prophylaxis- cephalosporins are most commonly used.
*Endometritis first 24 hrs
*Mastitis- day 4-5 post op
*Wound infection-4-7 days post op
risk factors fo gestational diabetes
1. Age > 25 y.o. (In women age > 30 y.o., there is a 2.24 times greater risk than women 25-29 y.o.)
2. Strong family history of diabetes in 10 relative (1.68 risk)
•African-American women (1.75 risk)
•Hispanic (1.45 risk)
•Asian (2.32 risk)
4. History of macrosomia
5. *Current smoking increases risk for GDM by 1.43 times
6. Maternal obesity; excess weight gain in pregnancy
7. History of unexplained or recurrent spontaneous abortions, stillbirths or fetal death
8. History of major congenital anomaly
10. Previous history of GDM
11. History of polyuria, polydipsia, persistent glucosuria-needs work-up to rule out
diabetes vs lowered renal threshold for glucose (not abnormal in pregnancy). Glucosuria
in pregnancy is usually the result of lowered renal threshold.
12. History of preeclampsia
13. PCOS- already an insulin resistant state—risk factor for GDM
definition for sponatenous abortion
Abortion occurring naturally, without apparent cause.
Pregnancy terminating before the 20th completed week of gestation.
Expulsion of any or all of placenta or membranes and an immature, nonviable fetus.
know all of the abortion definitons
see separate quizlet
MC anemia in pregnancy
The most common causes of anemia in pregnancy are iron deficiency and acute blood loss.
review stuff about domesitc violence and abuse in pregnancy- they are at higher risk
Fetus- frequent uterine contractions (> 4 per hour); cervical dilation
Maternal-vaginal lacerations, cervical dilatation; pelvic fracture; urethral meatus-bleeding; damage
if you are abused during pregnacny what are are you more at risk for?
post partum depression
anti phospholipid antibodies and what it is associated
associated with Antipospholipid Antibody syndrome
Presence of circulating auto-antibodies against phospholipids compounds.
MC acquired blood protein defect associated with venous and/or arterial thrombosis.
risk factors for uterine atony
Can be d/t excessive:
1. Manipulation of the uterus
2. General anesthesia
3. Over distension of uterus from large fetus
5. Multiple fetuses
6. Prolonged labor, very rapid labor,
7. high parity (grand multips).
Uterine atony MCC of postpartum hemorrhage
rhogam is indicated for all the following people except who: (so know this list of indications)
1. At 28 weeks gestation to an Rh-negative, non-immunized woman when the father of the fetus is Rh-positive
2. Postpartum (within 72 hours) if the woman remains non-immunized and delivers an Rh-positive fetus.
3. Following amniocentesis or chorionic villus sampling.
4. Following evacuation of a molar pregnancy
5. Following an ectopic pregnancy
6. After a postpartum tubal ligation or pregnancy termination
7. After an accidental transfusion of Rh-positive blood to an Rh-negative mother
8. After a platelet transfusion.
9. After a clinical situation associated with a spill of fetal cells into the maternal circulation:
a. Placental abruption or undiagnosed uterine bleeding
b. Maternal trauma (automobile accident)
MCC of a UTI in pregnancy
Other organisms-Proteus, Klebsiella, Group B strep, Staph
look at infections with pregnacny
Risk of congenital anomalies (CNS); neonatal death from disseminated disease may
HSV- risk of prematurity, infection in neonate acquired through going through infected birth canal, can cause fetal disseminated dz in newborn, need to do c section if virus is active at time of delivery
Hep B- infections in third trimester associated with risk of prematurity and spread to fetus. Give Hep B vaccine at birth
Toxoplasmosis- Parasitic infection that can infect fetus in utero. Increased risk of abortion, stillbirth, severe congenital infections in fetus.
Parvovirus- Fifth's disease- can cause the following in fetus: asymptomatic infection, congenital anomalies-eye (very rare), miscarriage, fetal death, Hydrops Fetalis (due to severe nonimmune hemolytic anemia)
HIV-at increased risk for: PROM, low birth weight infants, HIV infected infants
varicella and be able to pull out what is true about pregnancy. what infections are a concern in pregnancy???
Varicella- congenital malformations in offspring of women who develop chickenpox in first 20 weeks of pregnancy.
These include skin scarring, vesicular rash, limb hypoplasia, club foot, microcephaly, seizures, CNS, kidneys, ocular abnormalities (cataracts, chorioretinitis), pneumonia
risk factors of cervical incompetence
Congenital or acquired (rapid delivery, use of forceps, trauma, breech extraction, treatment for CIN, rapid cx dilatation prior to GYN procedure)
Occurs secondary to insufficiency of internal cervical os
best candidate (Pre term labor) to receive tocolytics--- whose contractions are you going to stop? if they are ruptured don't stop labor, if they are infected, don't stop it
uses- to prevent preterm labor
Contrainidcations to use:
Advanced labor, mature fetus, anomalies of fetus
Intrauterine infection, significant vaginal bleeding, abruption, severe HTN of pregnancy
MC medical complication of pregnancy?
- seen in 5 to 9% of all pregnancies
- increased with obesity
-with proper tx has normal perinatal mortality rates
-can be managed with diet and careful monitoring in most cases
-50% of GDM eventually develop every DM
trends with an ectopic pregnancy when you are talking about the Hcg level
Watch rate of rise of HcG
(normal pregnancy doubles every 60 hours and ectopics do not, they plateau)
more gestational diabetes- know about how to screen, if they screen positive what do you do?
1. One hr glucose tolerance test
-ADA recommends screening all pregnant women for GDM between weeks 24-28 of gestation
-Performed before and after 50 g glucose load.
1. Fasting-105 mg/dl or above
2. One hour-140 mg/dl or above
2. three hr standard glucose tolerance test
-after 100g glucose load.
-Carbohydrate loading with 150 g/d carbohydrate diet for three days (one cup pasta, two servings of fruit, four slices of bread, and three glasses of milk every day).
-Then fast for 8 hrs before test.
-100 gm glucose load
-Blood drawn at fasting, 1, 2 and 3 hours.
*Two or more abnormal values make the diagnosis of gestational DM.
Overt Diabetes diagnosed when two or more plasma glucose levels equal or exceed criteria established by the National Diabetes Data Group (NDDG):
1. > 95 mg/dl (fasting)
2. > 180 mg/dl (1 hr)
3. > 155 mg/dl (2 hr)
4. > 140 mg/dl (3 hr)
*if you have one abnormal value- initiate diet therapy
ruputre of membrane... what tests can you do to confirm?
- pooling, ferning, nitrazine positive (blue), U/S
What you do if someone shows up with painless vaginal bleeding- what test is most appropriate?
PAINLESS VAGINAL BLEEDING IN THIRD TRIMESTER ----- THINK PLACENTA PREVIA
-DO NOT do a digital exam- could make hemorrhage worse
- Can do a sterile speculum exam- rule out other causes of hemorrahage suchs as polyps
review specifically- CMV and what is assoaciated with that, herpes, syphillis,and rubella!!!!!
-baby that got exposed to CMV... concerning time for them to be exposed, and if they are exposed what will it present like
Risk of severe complications higher for infants of mothers who had a primary infection compared to those with recurrent infection during pregnancy
Effects on CMV on neonate: microcephaly, chorioretinitis, deafness, HSM, cerebral calcification, mental retardation, heart block, petechiae, seizures
risk factors for placenta previa
Most important risk factor = previous C sections
1. Multiparity-80% previa in multiparas
2. Age over 35 (risk ratio 4.7) ? related to parity or independent risk
3. NO prior history
4. Previous placenta previa (4%-8%)
5. Previous C-sections-most important risk factor (1-4%); >4 C-sections (10% risk)
6. African-American/minority race (risk ratio 1.3)
7. Smoking-risk doubled
8. Cocaine use
Reasons not to give someone tocolytics?
1. Advanced labor-6,7,8cm dilated- they are in active labor
2. Mature fetus
3. Anomalies of fetus
4. Intrauterine infection
5. Significant vaginal bleeding
7. Severe hypertension of pregnancy
HIV care in pregnancy
*HIV positive pregnant females should receive mono or combo therapy.
*administration of AZT to the mother during the antepartum (start at week 14 of gestation through delivery) and intrapartum periods and to the infant for 6 weeks postpartum decrease in rate of transmission of HIV from mother to infant.
Capacity of HIV virus to mutate has lead to the use of combo therapy.
•2 nucleoside reverse transcriptase inhibitors & 1 protease inhibitor
•Use AZT/ZDV at delivery
•Vaginal delivery if viral load undetectable
•C-section for PROM, prolonged labor, chorioamnionitis, fetal distress
GBS screening, prophylaxis, when to screen when to prophylax
35-37 weeks screen all pregnant women for GBS, antibiotics during labor to those with positive test.
Intrapartum antibiotic use for women with risk factors, positive cultures (35-37 weeks), previous history of infant with invasive GBS, preterm
Antibiotics-IV Penicillin, Ampicillin, Clindamycin and Erythromycin for PCN allergic patients
what to do with people who break their water pre term- make sure they are exactly the gestational age that you think they are!
answer is probably check gestational age with PROM to determine your course of action you take- like whether you need to use steroids or not
there are numbers... how much Rhogam covers how many mL of fetal blood?
Standard dose-300 mcg dose of Rh immune globulin covers a fetomaternal hemorrhage of 30 ml of fetal whole blood or 15 ml of fetal red cells.
Why are ectopic prego increasing in the US?
Increased usage of IUDs? (unsure)
MCC of mental retardation in newborns?
all of the following things this mom with gestational diabetes is at risk for d/t her diabetes?
1. *Preeclampsia and eclampsia-increased four-fold in a pregnancy with diabetes
2. Infection-can be severe- pyelonephritis
3. Macrosomic infant-leads to problems with delivery. Fetal macrosomia affects heart, kidney, liver. Problems with heart increased cardiomyopathy and CHF due to excess glycogen deposition and hypertrophy of the heart muscle.
6. Postpartum hemorrhage
7. Risk of developing DM later in life-check BS 3 months postpartum and yearly
8. Pre-term labor
9. 5x increased risk of stillbirth
indications for c section
1. Cephalopelvic disproportion
2. Fetal and maternal anomalies; malformations
3. Fetal malpresentation or posture
4. Previous vaginal surgery; vertical uterine incision; reconstructive surgery
5. History of uterine inversion
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 delivery
10. Cord prolapse
11. Fetal distress
12. Fetal macrosomia-no longer an approved indication, aka-elective
13. Arrest of labor
14. Pelvic mass-fibroids
15. Previous cesarean section with vertical incision
16. History of complicated maternal birth injury-lacerations, fistulas
17. Abnormal placenta or umbilicus-previa, abruption, cord prolapse
Consuling someone for a vaginal birth after they had a c section, what can you not use?
do not use cervical ripening agents is answer
increased risk of uterine rupture!!!!
patients at increased risk for post partum cardiomyopathy
mom's with gestational diabetes
know how to differentiate the different types of third trimester bleeding
PAINLESS 3rd trimester bleeding = placenta previa
Blood + Mucus = blood show = labor is starting
* add more
review ICP in pregnancy - elevated bile acids and increased risk for fetal death
Intrahepatic Cholestasis of Pregnancy (ICP):
Second most common cause of jaundice in pregnancy.
Etiology not well defined but thought to be related to genetic predisposition (highest in Chileans)
Usually self-limited; benign course
1. Elevated serum bile acids
2. Elevated alkaline phosphatase (7 to 10 fold)
3. Slightly elevated total bilirubin
4. Prolonged prothrombin time
***ICP can cause sudden fetal death
know how mifepristone works
Progesterone antagonist (RU 486).
Blocks progesterone receptor sites -> bleeding
Increases prostaglandin levels -> uterine contractions.
all of the physical finding sound like pre eclampsia except:
1. Elevated blood pressure:
*Systolic pressure of 140 mm Hg or greater and/or diastolic pressure of 90 mm Hg or
greater is suspect for preeclampsia.
2. Weight Gain:
More than 2 lbs/wk or 6 lbs/mo. Usually weight gain is sudden with abnormal retention
Of fluid. Not included in diagnostic criteria.
Usually develops later than hypertension, >0.30 mg protein/ mg of creatinine OR > than 300 mg/24 hours
Significant in severe preeclampsia, may be precursor to seizure.
5. Epigastric Pain:
Sign of severe preeclampsia. Watch for convulsions
6. Visual Disturbances:
Slight blurring of vision to blindness. Due to arteriolar spasm, ischemia, and edema of
retina . Occasional retinal detachment.
7. Abnormal Lab-abnormal LFTs, hematocrit, decreased platelets (HELLP)
8. Chest pain/dyspnea- usually a late finding
do review of post partum blues and post partum depression. know the timing of the two. tx if needed for either one of them?
Post Partum Blues
-up to 85% of new mothers, 20% evolve to PPD
Begins 2-4 days after pregnancy, peaks days 5-7 resolves days 12-14
Sxs: mood lability, emotional hypersensitivity, irritability
Tx- not needed, resolves on its own
Post Partum Depression
-Begins later than the blues: about 4 weeks after delivery but may be overlooked
-Tx: antidepressant meds, psychotherapy, education, group support
*No evidence of serious adverse effects of anti-depressant exposure during breast feeding
ectopic pregnancy. know about how it presents
Classic presentation (rare): Amenorrhea and signs of early pregnancy followed by abnormal bleeding, abdominal pain, and fainting (from hypotension from bleeding)
1. *MC symptom is abdominal pain. Unilateral pelvic pain-knifelike and stabbing or dull and not well defined.
2. history of amenorrhea
3. Vaginal Bleeding (usually begins 7-14 days after missed period)
4. Tissue passage from vagina
5. s/sx associated with pregnancy
definiton for malformation- that is a quetsion
A morphologic defect of an organ or other part of the body from an intrinsic abnormality in the process of development, usually in the first trimester (ex. VSD)
primary structural defect from a localized error of morphogenesis.
placental abruptions is associated with all of the following except:
KNow this list of things abruption is associated with to answer question
1. Maternal hypertension
3. Sudden decompression of uterus leads to shearing effect on placenta as uterus contracts; seen with rupture of membranes in polyhydramnios or delivery of first infant in twin gestation
4. Cocaine use
review the different blood tests for rhogam admisntration
Indirect Coombs' Test
Direct Coomb's Test
management for uterine atony
vigorous massage to uterine fundus, ptosin or other uterine contracting agent
Blood and fluid replacement
Leading cause of neonatal sepsis?
Mc indication for c section?
prior C section
Why do we use steroids in pre term labor?
Used to induce fetal lung maturity.
Given at 24-34 weeks
Check L/S ratio (greater than 2) or presence of phosphatidylglycerol.
Also helps decrease intraventricular hemorrhage, necrotizing enterocolitis.
know all abortion definiton
see separate quizlet
Gold standard for diagnosed ectopic
*Serial testing of hCG B-subunit-very sensitive. Watch rate of rise (normal pregnancy doubles every 60 hours and ectopics do not, they plateau)
MCC of preterm labor
complications of pre eclampsia
3. Placental infarction
4. Placental abruption
5. Uteroplacental insufficiency
6. Perinatal death
Maternal Complications of Preeclampsia:
1. DIC; intracranial hemorrhage
2. CNS manifestations-stroke, retinal hemorrhage
3. Hepatic failure or rupture of the liver capsule
4. HELLP syndrome-hemolysis, elevated liver enzymes, low platelet count DIC
5. Permanent kidney damage, chronic renal failure
HELLP-hemolytic anemia, elevated liver enzymes, low platelet count
May occur without associated elevation of BP
Symptoms-nausea, vomiting, upper abdominal pain, headache
RUQ abdominal tenderness, enlarged liver, elevated LFTs
Treatment-delivery of infant
Complications-liver hemorrhage; liver damage
know about thyroid dysfunction in prego,
*In a normal pregnancy, the thyroid gland enlarges, occasionally to twice its normal size. Mainly due to colloid deposition hypertrophy.
*Patients usually euthyroid.
Category A drugs in pregnancy
A- no risk to fetus
(ex. pre-natal vitamins)
Category B Drugs
B- no evidence of risk in humans.
Animal studies (no risk) but no controlled study in prego
Animal studies (show risk) but that is not confirmed in controlled study in prego
(ex. PCN, digoxin, epinephrine, terbutaline)
Category C drugs
C- risk can't be ruled out
animal study (show risk)
Give drug only when benefit outweights potential fetal harm
(ex. furosemide, quinidine, verapamil, and beta blockers)
Category D Drugs
Positive evidence of risk
only use drug really in life threatening situations or for serious dz
contradicted in pregnancy
risk of using these drugs clearly outweights any potential benefit
MC type of headache in pregnancy?
Definition of Essential Chronic Hypertension (matching on exam)
•HTN that predates pregnancy or identified before 20 weeks.
•Does not resolve within 12 weeks postpartum
Definition of Gestational Hypertension (matching)
•HTN after 20 weeks gestation but NO proteinuria. Previously called "pregnancy induced hypertension" (PIH); resolves within 12 weeks of delivery
Definition of Chronic Hypertension with Superimposed Preeclampsia (matching)
•Chronic hypertension (had HTN before prego) with increasing blood pressures and proteinuria
Definiton of Preeclampsia (matching)
•*Gestational hypertension in presence of proteinuria (> 300 mg/24 hr or > 30 mg in 2 random samples); Edema (less reliable)
•*Usually occurs after 20 weeks gestation
1. Preeclampsia without severe features
2. Preeclampsia with severe features
-liver functions double, Cr over 1.1, if platelets drop, if they have pounding headaches, weird blurry vision
- Tx mom wtih severe features with Mg to prevent seizures
Definition of Eclampsia (matching)
•Occurrence of convulsions in a woman who meets criteria for preeclampsia
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