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OB PANCE
clinical Medicine
| Question | Answer |
|---|---|
| risk factors for developing GDM | Obesity, prior hx of GDM, heavy glycosuria, unexplained stillbirth, prior infant with major malformation, family hx of DM in first degree relative |
| When should at-risk pregnant women be screened for GDM | As soon as feasible and again between 24 and 28 weeks |
| Which women can be omitted from GDM screening | Age <25, normal body wt, no family hx, no hx of abnormal glucose metabolism/poor OB outcome, and not a member of an ethnic or racial group at high risk |
| A young PG pt who is hypertensive & having a seizure is __ until proven otherwise | Preeclamptic |
| Hypertension with proteinuria and or pathologic edema | Preeclampsia |
| Hypertension without proteinuria or pathologic edema during pregnancy | Pregnancy induced hypertension |
| Hypertension with proteinuria and or pathologic edema with convulsions | Eclampsia |
| S/S of preeclampsia | HA, hyperreflexia, visual changes, irritability, epigastric pain, edema of face/hands/abdomen, oliguria |
| HELLP = | Hemolysis, Elevated Liver enzymes, Low Platelets |
| Classic presentation of HELLP syndrome | Malaise/fatigue, N/V, HA, RUQ pain, severe elevated BP, 3+ protein/85% of the time |
| Hx of high BP before PG, elevation of BP during the first half of PG, or high BP that lasts for longer than 12 weeks after delivery: | Chronic hypertension |
| normal PG is assoc w/ decreased maternal sensitivity to __ which leads to expansion of the intravascular space | Endogenous vasopressors |
| women who develop preeclampsia do not exhibit normal refractoriness to __ (so normal expansion of the intravascular space does not occur) | Endogenous vasopressors |
| Preeclampsia sxs in addition to HTN & proteinuria | Scotomata, blurred vision, or pain in the epigastrium or RUQ |
| preeclampsia labs = | Elevated Hct, LDH, transaminases, uric acid; low plts |
| Mgmt of preeclampsia: usu maternal interests are best served by: | Immediate delivery |
| Mgmt of pts w/ mild preeclampsia before 37 weeks: | Expectantly with bed rest, twice-weekly antepartum testing, and maternal evaluation |
| severe preeclampsia mandates: | Hospitalization |
| Severe preeclampsia: delivery is indicated if fetal pulmonary is confirmed, evidence of deteriorating maternal or fetal status, or gestational age is: | 34 wks or greater |
| In severe preeclampsia between 33 and 35 weeks, consider __ for pulmonary maturity studies | Amniocentesis |
| 1st trimester bleed: DDx | implantation; impending SAB; ectopic; cervical polyp/ neoplasia |
| Any bleeding in the first half of an intrauterine pregnancy = | Threatened Ab |
| Threatened Ab = | bleeding, often painless; 25% of PG (1/2 go to SAB); closed os & EGA; need US |
| Rupture of membranes and/or cervix open, pregnancy loss unavoidable = | Inevitable Ab; cervix is dilated, bleeding increasing, cramping |
| Complete Ab: is common when? | Common prior to 12 weeks |
| Incomplete Ab more likely when? | After 12 weeks |
| ROM, fetus passed, but placental tissue retained; cervix open, gestational tissue seen in cervix, uterus <EGA; bleeding can be severe = | Incomplete Ab |
| Retention of a failed IUP for an extended period = | Missed Ab; AKA blighted ovum, anembryonic pregnancy; uterus < EGA, loss of PG sx |
| Missed Ab complication | DIC can occur in 2nd trimester if missed AB >6 weeks |
| Ominous sx of SAB | FHR <100; abnormal yolk sac; large subchorionic hematoma |
| Leading PG COD in 1st trimester: | Ectopic PG |
| Ectopic RF | Tubal surg; infxn/PID; infertility; multiple partners; SMK; douching; age; BTL/bipolar coag |
| Ectopic PG: sites | 95% fallopian tube (55% of those are in ampulla); unusual location assoc w/ART |
| Ectopic sx | PG/SAB sx; unilateral adnexal pain; shoulder pain; if rupture: lightheaded, shock; urge to defecate |
| gestational trophoblastic neoplasia (GTN) spectrum | malig: invasive mole, choriocarcinoma; PSTT (placental site trophoblastic tumor); benign: hydatidiform mole (complete/partial molar PG) |
| Painless cervical changes that occur in the second trimester and result in recurrent pregnancy loss = | Cervical insufficiency |
| Cervical insufficiency: congenital factors | short cervix (PTD risk x10 if 22 mm); mullerian or collagen abnml; FH |
| Cervical insufficiency: non-congenital factors | Trauma (cervical lac, LEEP, bx); high relaxin |
| Cervical insufficiency: sx | Vaginal fullness, pressure, spotting/bleed; watery/ mucus/ brown d/c; abd/back pain |
| Extravasation of blood into the myometrium = | Couvelaire uterus |
| Placenta previa sx | painless vaginal bleeding; dx by US; NOT BY PELVIC EXAM |
| Abruptio placenta RF | HTN; trauma; smoking; cocaine; PPROM; chorioamnionitis; rapid decompression of the uterus; thrombophilia |
| Causes of postpartum hemo | uterine rupture/ inversion; birth trauma; retained placenta; uterine atony; DIC; von W dz |
| Uterine inversion is assoc with: | associated with uterine atony, fundal placenta, first baby; not necessarily with cord traction |
| Uterine inversion sx | shock out of proportion to blood loss |
| Uterine atony RF | Chorioamnionitis; over-distended uterus; long labor; oxytocin in labor; MgSO4; genl anesthesia; multiparity; previous postpartum hemorrhage |
| Fetal heart monitoring: need to: | establish baseline (>10 min); check for: decelerations; accelerations; variability |
| fetal heart monitoring: accelerations if pt >32 weeks | 15 by 15 (15 bpm over 15 sec) |
| fetal heart monitoring: accelerations if pt <32 weeks | 10 by 10 (10 bpm over 10 sec) |
| What is the average volume of amniotic fluid at term | 800 mL |
| How is oligohydramnios determined | Identification of the largest pocket of fluid measuring less than 2cmx 2cm or the total of 4 quadrants less than 5 cm |
| Oligohydramnios is associated with: | SGA fetus, renal tract abnormalities (renal agenesis), and urinary tract dysplasia |
| The clinical manifestation of oligohydramnios is a direct result of: | impairment of urine flow ot the amniotic fluid in the late part of the first half of PG or during the second and third trimesters |
| Turner syndrome is assoc w/an average birthweight of approximately __ below average | 400g |
| Fetuses with neural tube defects are frequently: | IUGR weighing approximately 250g less than controls |
| Partial or complete detachment of placenta from uterine wall, after 20 weeks gestation = | Abruptio Placenta |
| Placenta previa is __ bleeding | Painless/silent |
| Placenta abruption is __ bleeding | painful |
| What is the most common cause of neonatal sepsis | GBS |
| What is the most commonly identified pathogen responsible for IUGR | CMV |
| What is the most common protozoan, acquired by eating raw meat, that is responsible for IUGR | Toxoplasma gondii |
| Bac infxn are common in PG & often implicated in PTD; not usu assoc w/IUGR; EXCEPT in chronic infx with: | Listeria monocytogenes |
| Clinical picture of an infant born to a mother infected with chronic listeria monocytogenes | Critically ill, encephalitis, pneumonitis, myocarditis, hepatosplenomegaly, jaundice, and petechiae |
| Early GBS = | 1st 6 days of life; 75% of cases; in utero or during birth; RFs: PTL, PROM, PPROM |
| Late GBS = | After 1st week of life; nosocomial or CA |
| BV adverse outcomes | PTD/LBW; intraamniotic or placental infxn (ID & Rx did not improve outcomes); USPSTF: no routine screen; tx sx |
| Most common effects of rubella transmission | Heart, eye, ear; risks are GA dependent |
| Both IUGR and LGA fetuses have increased risk for __ | Perinatal morbidity and mortality |
| A pregnancy cannot be described as IUGR unless what is known with certainty | Gestational age |
| Symmetric IUGR = | Infants in which all organs are decreased proportionally |
| Symmetric IUGR infants are more likely to have __ | An endogenous defect that results in impairment of early fetal cellular hyperplasia |
| Asymmetric IUGR = | Infants in which all organs are decreased disproportionately (abdominal circumference is affected to a greater degree than head circumference) |
| Asymmetric IUGR infants are more likely caused by __ | Intrauterine deprivation that results in redistribution of flow to the brain and heart at the expense of less important organs such as the liver and kidneys |
| An infant with an autosomal __ is more likely to be IUGR | Trisomy |
| Multiple gestation is associated with a __% increased incidence of IUGR fetuses | 20-30 |
| What is the most common maternal complication causing IUGR | Hypertension |
| Women who stop smoking before __ weeks gestation are not at increased risk for having an IUGR infant | 16 |
| Measurable effect on birthweight (risk of IUGR) seen with daily PO intake of: | <1500 kcal/d |
| Vascular dz = RFs for IUGR = | Collagen vascular disease, IDDM assoc w/microvasculopathy & preeclampsia |
| Best parameter for early dating of pregnancy on US: | Crown-rump length |
| Most accurate parameters for dating of PG in the second trimester | Biparietal diameter, and HC |
| Most accurate parameter for dating of pregnancy in the third trimester | Head circumference |
| Single most common preventable cause of IUGR in infants in the US | Smoking |
| Data show that IUGR infants appear to catch up in weight in the first __ of life | 6 months |
| Taken as a group IUGR infants have more __ than do their AGA peers | Neuro / intellectual deficits; higher SIDS incidence |
| Maternal obesity increases risk of fetal macrosomia by: | 3-4 fold |
| Male fetuses are __g heavier on average than female fetuses | 150 |
| Best single measure to evaluate macrosomia by U/S in diabetic mothers | Abdominal circumference |
| Estimated fetal wt. by __ is not very accurate | Ultrasound |
| Risk factors for GDM | > 25 years, prior GDM/family hx, prior big baby/still birth, BMI greater than or equal to 27, chronic hypertension, glycosuria |
| What is the biggest complication of GDM | Big babies that don't want to come out (macrosomia/ shoulder dystocia) |
| birth traumas associated with macrosomia | Brachial plexus injury, clavicular injury, facial nerve injury |
| RFs for fetal growth restriction | CVD (hypertension), smoking, fetal abnormalities, multifetal gestation, abnormal placentation, poor maternal wt gain or nutrition |
| In second half of PG, increased concentrations of __ combine to produce modest maternal insulin resistance, which is countered by postprandial hyperinsulinemia | Human placental lactogen, free and total cortisol, and prolactin |
| Defined as any degree of glucose intolerance with first recognition during pregnancy | Gestational diabetes |
| Women with GDM have an approximately __% risk of developing type 2 diabetes over the next 10 years | 50 |
| hormone mainly responsible for insulin resistance and lipolysis = | Human placental lactogen (similar structure to growth hormone: reduces insulin affinity to insulin receptors) |
| Higher maternal glucose => higher fetal glucose => higher levels of insulin => fetal: | Macrosomia, central fat deposition, enlargement of internal |
| Decelerations: new terminology | Periodic: assoc w/contraction; episodic: not assoc w/contraction - 2/2 other cause |
| Decelerations: old terms: Early | periodic, mirrors contraction |
| early deceleration usu 2/2: | head compression; low in pelvis; delivery may be imminent |
| Decelerations: old terms: Late | periodic, decrease in HR that does not return to baseline after contraction |
| late deceleration usu 2/2: | placental insufficiency |
| Decelerations: old terms: Variable | episodic, V- or W-shaped; usually 2/2 cord compression |
| fetal heart monitoring: variability | beat-to-beat variation in HR; 6-25 bpm difference = moderate |
| increase in myometrial contractility resulting in effacement and dilation of the uterine cervix = | Labor |
| the 3 mechanical variables during delivery: | the powers, the passenger, and the passage |
| an external tocodynamometer measures: | Number of contractions in an average 10 minute window, intensity, and duration of contractions |
| What is the most precise method of measuring contractions | Intrauterine pressure monitoring via internal pressure transducers (IUPC) |
| What is classically considered to be adequate labor | 3-5 contractions in 10 minutes, however there is no consensus for criteria |
| Macrosomia = an infant over: | 4,500 g |
| the lie of the fetus = | The longitudinal axis of the fetus to the uterus |
| station of the fetus = | A measurement of descent through the birth canal |
| External cephalic version is routinely done after __ weeks | 36 |
| What landmarks designate 0 station for the fetus | Ischial spines |
| Cardinal movements of labor: passage of widest diameter of presenting part to below the plane of the pelvis | Engagement |
| Cardinal movements of labor: downward passage of presenting part through the pelvis | Descent |
| Cardinal movements of labor: passive flexion of fetal head as it descends due to resistance related to body pelvis | Flexion |
| Cardinal movements of labor: rotation of presenting part (usually from transverse to anterior-posterior) | Internal rotation |
| Cardinal movements of labor: brings base of occiput in contact with the inferior margin of the pubic symphysis, head is delivered by extension | Extension |
| Cardinal movements of labor: rotation to the correct anatomic position in relation to the fetal torso | External rotation (restitution) |
| Cardinal movements of labor: delivery of body of fetus | Expulsion |
| the Cardinal movements of labor include: | Engagement, descent, flexion, internal rotation, extension, external rotation (restitution), expulsion |
| What is the first stage of labor | Onset of labor to full dilation |
| What is the second stage of labor | Interval between full dilation (10cm) and delivery |
| What is the third stage of labor | Time from delivery to expulsion of placenta |
| __ is characterized by the slow, abnormal progression of labor | Dystocia of labor |
| What is the leading indication of primary c-section | Dystocia of labor |
| 60% of all c-sections in the US are attributable to the diagnosis of __ | Dystocia of labor |
| RFs for prolonged labor | Older, medical (DM, HTN, obesity), macrosomia, prolonged ROM/ chorioamnionitis, short maternal stature, high station at complete dilation, occiput posterior position, pelvic abnormalities |
| What is AROM | Artificial rupture of membranes |
| the best tool to predict the likelihood of successful labor induction (resulting in vaginal delivery) | Bishop score (6 or greater = favorable for induction of labor) |
| What is the mechanism by which membrane stripping works to induce labor | Increases prostaglandin release |
| Delivery that requires additional maneuvers following failure of gently downward traction on the fetal head to effect delivery of the shoulders | Shoulder dystocia |
| RFs for shoulder dystocia | Maternal obesity, diabetes, hx of macrosomic infant, current macrosomia, hx of shoulder dystocia |
| Warning signs of shoulder dystocia | Prolonged 2nd stage, recoil of head on perineum (turtle sign), lack of spontaneous restitution |
| Fetal complications of shoulder dystocia | Brachial plexus injury, clavicle/humerus fx, asphyxia |
| What is McRoberts maneuver | Dorsiflexion of hips against the abdomen to ease birth of fetus with shoulder dystocia. |
| What is the most common cause of postterm pregnancy | Error in dating |
| With postterm pregnancy what are the risks to the fetus | Stillbirth, meconium aspiration, intrauterine infection, uteroplacental insufficiency |
| With postterm pregnancy what are the risks to the mother | Increased labor dystocia, perineal injury related to macrosomia, and c-section rate |
| What are the leading causes of preterm deliveries | Preterm labor (PTL) and preterm premature rupture of membranes (PPROM) |
| Preterm delivery is before __ weeks | 37 |
| Major determinant of infant mortality in developed countries | Preterm delivery |
| What are the key risk factors for preterm delivery | Smoking, cocaine, AA, maternal age (young and old), social (SES), infxn (GBS, UTI), low-wt mom |
| What is the purpose for prolonging pregnancy when the patient goes into preterm labor | To allow admin of steroids (betamethasone) for fetal lung maturity and maternal transport to a facility with NICU |
| What are the risk factors for PPROM | Intraamniotic infection, prior hx, lower SES/teens, smokers, hx of STD, hx of cervical cerclage, uterine overdistention |
| What do you do if the mother goes in to labor any time after 34 weeks | Proceed with delivery, GBS prophylaxis |
| What do you do if the mother goes into labor between 24-31 weeks | Expectant management, GBS prophylaxis, steroids recommended, tocolysis, antibiotics |
| What do you do if the mother goes in to labor before 24/23 weeks | Pt counseling about poor outcome, expectant management, no steroids, no GBS prophylaxis or Abx |
| What are the different presentations of the fetus? | Vertex, breech, shoulder, compound |
| What are the different lies of the fetus? | transverse, oblique, longitudinal |
| HELPERR = | For shoulder dystocia: call for Help, evaluate for Episiotomy, Legs (McRoberts), suprapubic Pressure, Enter maneuvers (Rubin, Woods), Remove posterior arm, Roll pt |
| Most common cause of secondary amenorrhea | Pregnancy |
| Female with acute abdominal pain (no characteristic acute abdomen pattern) | Ectopic pregnancy |
| Nagel's rule: | LMP + 7 days - 3 mo |
| Pregnant + rash, post-auricular or occipital LAD | Rubella; Give vaccine AFTER delivery |
| Pregnant, HA, visual disturbance | Pre-eclampsia |
| Pregnant < 20 wks gestation w/ vaginal bleeding, abd & pelvic pain. Blood from closed cervical os. | Threatened abortion |
| Pregnant < 20 wks gestation w/ vaginal bleeding, abd & pelvic pain. Tissue at or said to be passed from open cervical os. | Incomplete abortion (complete abortion will have empty uterus, complete passage of fetal tissue, pain resolves after passage of tissue) |
| Pregnant who drinks during pregnancy and inadequate peri-natal care | Fetal alcohol syndrome / low birth weight |
| Postpartum hemorrhage | Uterine Atony. Tx = uterine massage |
| Gravida-para format (G0P0) | G = total PG; P = no. of deliveries; Pabcd: a=term infants, b=premature, c=abortions, d=living kids |
| prenatal visits: | 6-8 wk post LMP; q 4 wk to 28 wks, then q 2 wks to 36 wks, then q wk |
| fundal height: 12 wks | uterus palpable above pubic symphysis; FHT noted w/Doppler (nl 120-160 bpm) |
| fundal height: 14-16 wks | midway btw pubic symphysis & umbilicus |
| fundal height: 20 wks | umbilicus; quickening |
| fundal height: 20-38 wks | fundal ht = gest age (+/- 2 cm) |
| fundal height: 38-40 wks | gravid uterus 2-3 cm below xiphoid |
| most common cause of ectopic PG | tubal occlusion 2/2 adhesions |
| di-di twins = | dichorionic (2 placentae) & diamniotic (2 amniotic sacs) |
| risks assoc w/PROM & PPROM | infxn (chorioamnionitis & endometritis); cord prolapse |
| preeclampsia RFs | NULLIPARITY; <20 or >35 yo; multi gestation, DM, HTN |
| types of placental abruption | external (most common, less severe); concealed (blood is retained btw detached placenta & uterus) |
| cervical exam of L&D | dilatation (to 10 cm); effacement (to 100%); station (ischial spines = 0, below is + in cm) |
| APGAR - blue all over = | 0 |
| APGAR - blue at extremities body pink = | 1 |
| APGAR - no cyanosis = | 2 |
| APGAR - absent pulse = | 0 |
| APGAR - pulse <100 = | 1 |
| APGAR - pulse > 100 = | 2 |
| APGAR - no response to stimulation = | 0 |
| APGAR - grimace/feeble cry when stimulated = | 1 |
| APGAR - sneeze/cough/pulls away when stimulated = | 2 |
| APGAR - no muscle tone = | 0 |
| APGAR - active movement = | 2 |
| APGAR - some flexion = | 1 |
| APGAR - no breathing = | 0 |
| APGAR - weak or irregular breathing = | 1 |
| APGAR - strong breathing = | 2 |
| critically low APGAR score: | 3 and below |
| fairly low APGAR score: | 4-6 |
| normal APGAR scores: | 7-10 |
| endometritis | usu post C-section or mem rupture >24 hr pre delivery; s/s 2-3 days post partum; fever >101F, uterine tenderness |
| immediately after delivery, uterus is at the level of: | umbilicus; involutes in 2 days; descends into pelvic cavity in 2 wks; normal by 6 wks |
| Chadwick sx: | bluish or purplish discoloration of vagina/cervix in PG (2/2 congestion of pelvic vasculature) |
| Hegar sx: | softening of the uterine isthmus in PG; by 6-8 weeks, palpable on bimanual exam |
| Goodell sx: | softening of the cervix in PG |
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