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clinical Medicine

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
Created by: duanea00