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MC cause of DIC in preg abruptio placenta
on US what measurements most accurate for est GA, how accurate 8-12 wks use crown rump (+/-5), 12-18 use biparietal (+/-7)
general guidelines for accuracy of US at difft trimesters for dating preg <20wk US considered pretty accurate, 1st tri can be off by 1wk, 2nd tri off by 2wk, 3rd tri off by 3wks
determination of pregnancy--cut off hCG 25mU/ml
when gestational sac visible 5wks
how AFI measured deepest vertical pockets of amniotic fluid in 4 quadrants
how polyhydramnios defined? Oligo? AFI>25 it's poly, if <5 it's oligo
where is top of fundus if 16wk? 20wk? 1/2 pubis to umbilicus for 16wk, at umbilicus for 20wk
for karyotyping when is chorionic villus sampling done? Amnio? Percut umbil blood sample? Risk for ea? CVS=9-12, 0.7%; amnio 15-20, risk 0.5%; PBUS >20wks risk 1-2%
risk of chromo abnlty in 35yo? Risk of Tri21? 1:365; 1:180
genetics of preg losses, % chromo abnl, what type 50% spont abortions have abnl chromo, 50% autosomal trisomies, 20% turners
ex of XL dominant where dz in females & males hypophosphatemic rickets
ex of XL dominant where dz in females and fatal in males incontinentia pigmenta, focal dermal hypoplasia
if child w CHD what risk of 2nd overall risk is 1%, 2nd child is 2%
if child w cleft lip, what risk of 2nd? If 2 children w cleft lip what risk of 3rd 4%, 10%
name major products of 3 germ layers Ecto=CNS/PNS, organs of seeing/hearing, integument (skin, hair, nails); Meso=mscle, cartilage, CVS, GU; Endo=lining GI and respir
role of paramesonephric/mullerian duct, how develops in males and females Present in all embyros. Y chrom induces gonades to secrete mullerian inhib factor which causes mullerian duct to involute. In females the mullerian duct forms fallopian tubes, uterus, cervix, prox vagina
role of mesonephric/Wolffian duct, how develops in males and females Need androgens (and working R) to continue to form vas deferens, seminal vesicles, epididymis, and efferent ducts. In females w/o androgens this involutes.
how female ext genitalia develop w/o hormones labia majora, minora, clitoris and distal vagina form
how male ext genitalia develop Need androgen stimulation for penis and scrotum. W/o androgen R will difft towards female ext genitalia
describe testosterone metabolism as relates to virilization ext genitalia Leydig cells secrete testosterone (maintains Wolffian duct), 5 alpha-reductase converts it into dihydrotestosterone (virilizes external genitalia)
describe FDA categorization of Rx during preg A-no risk, B-may have adverse effects in animals but no evidence in humans, C-risk cannot be r/o, X-contraindicated
describe phenytoin abnlties in fetus IUGR, epicanthal folds, saddle shaped nose, oral clefts, MR, microcephaly, nail hypoplasia, CHD
describe cocaine abnlties in fetus placental abruption, preterm, IVH, IUGR (also bowel atresia?)
describe marijuana abnlties in fetus preterm, no abnlties
describe risks for radiation : min risk if <5rad, intermediate 5-10, high risk >10rad
describe EtOH abnlties in fetus IUGR, midfacial hypoplasia, short palpebral fissures, CHD, MR, jt abnlties
describe istoretinoin abnlties in fetus congenital deafness, microtia, CNS defects, CHD
describe trimethadione abnlties in fetus short upturned nose, slanted eyebrows, CHD, IUGR, MR
describe bHCG structure, what produces it, and how levels change in preg 2 subunits, alpha is like LH, FSH, thyroptropin; produced by syncytiotrophoblast, first detected d10 after fertilization, peaks 9-10 wks, plateaus 20-22. Should dble q2-3 days early on
roles 3 bHCG maintain corpus luteum production of prog until placenta does that; regulates steroid biosyn in placenta and fetal adrenal gland; stimulates testost in fetal male testis
describe HPL structure and how levels change in preg like GH and prolactin in structure, levels parallel placenta grwth and keep rising throughout preg
describe progest--what produces it, and how levels change in preg After ovulation by luteal cells of corpus luteum for endomet secret changes for implant. By corpus luteum until 7-9 wks when both corpus luteum and placenta produce, >9wks just placenta. Later preg induces immune tolerance and prevent myometrial cxns.
high levels bHCG can indicate? Low levels? mltpls, hydatiform mole, choriocarcinoma, embryonal carinoma; ectopic, threatened/missed abortion
describe estradiol production, when high in life MC form during nonpreg reproductive years. Cholesterol à androgens in follicular theca cells, diffuse into follcular granulosa cells, where aromatase androgens à estradiol
describe estriol production, when high in life estogen during preg. DHEA-S from fetal adrenal gland à estriol by sulfatase in placenta
describe estrone production, when high in life estrogen during menopause. Adrenal adnrostenedione à estrone by peripheral adipose
what facial lesion assoc w preg Chloasma-blotchy pigment of nose and face
Chadwick sign? Chadwick sign=bluish/purple of vagina and cervix from incrsd vascularity
what position of preg women will make her CO highest L lateral (pressure off of IVC)
what happens to CVP, fem venous P, and PVR in preg CVP unchanged, femoral venous P incrses 2-3x (varicose veins, hemorrhoids); PVR declines 30% (bc PVR=BP/CO and BP decrses and CO incrses
define 1st, 2nd, 3rd tri 1-12; 13-26; 27-40
define abortion preg loss or termination <20wks
Antepartum death Antepartum death: fetal death 20wks-start of labor
Intrapartum death Intrapartum death: fetal death during labor
Fetal death: Fetal death: fetal death 20wks-birth (incl antepartum and intrapartum)
Perinatal death Perinatal death: death 20wks-28 days of life
Neonatal death Neonatal death: death birth-28 days of life
Infant death Infant death: birth-1yo
preterm 20-37wls
which mortality rates are per TOTAL births? Whch per LIVE births? Fetal & perinatal mortality is per total births, neonatal, maternal & infant mortality is per live births
define fertility rate live birth per 1000 women 15-45yo
define birth rate Birth rate-live births per 1000 total population
define Gs, Ps, As G=
check ups throughout preg q1mo until 30wks, q 2-3wks 30-36wks, q1wk >36wks
Maternal death define. MC cause Maternal death: during preg or within 90d (MC embolism
define lightening, when occur descent of fetal head into pelvis, easier maternal breathing but pelvic pressure. 36wks in primagravida
nml wgt gain in preg 5-8lbs in 1st tri, then 1lb/wk >20wks
causes low plts in preg ITP or preg induced thrombocytopenia (DIC is rare)
what labs need drawn on first prenatal (not incl infxs) Blood type, Rh, Ab screen (indirect Coombs), Sickle cell, CBC, UA/Ucx
what infxs labs need drawn on first prenatal rubella, syphilis, HBsAg, HIV (requires consent), GC/Chlamydia, TB
in addtl to labs on first prenatal visit, what other lab/exam need to do pap smear
determination of pregnancy--cut off hCG 25mU/ml
how polyhydramnios defined? Oligo? AFI>25 it's poly, if <5 it's oligo
how dx antiphospholipid syndrome need 1 of history: venous thrombosis, PE, stroke, reptd preg losses, fetal demise, and 1 of labs: cardiolipin Abs, lupus anticoag, incrsd PTT
what labs indicate anti phospholipid syndrome cardiolipin Abs, lupus anticoag, incrsd PTT
what are screening tools for Downs 1st tri=PAPP, nuchal translucency, and mAFP, 2nd tri=triple screen/quad screen
causes of high MSAFP neural tube, ventral wall, renal…twins and placental bleeding gives false high
what quad screen would suggest Downs hi bHCG and inhibin, low MSAFP, estriol
what PAPP value suggests Downs low along w high bHCG
glucola amt and when can dx with frank GDM w/o 3hr 50g glucose, if blood glucose in 1hr >140 is cut off do 3hr; can dx w/o 3hr if single fasting 110 or grtr or was 200 on glucola
amt of glu given and cut offs for 3hr GTT 100g given, cut offs: 95/180/155/140 [only need 2 abnml]
when test for GDM 24-28wks
if tri21 or tri18 screen is + what do? amnio for karyo
when check for anemia? What cut off? 24-28wks, Hb<10
MC genetic cause of Downs? 2nd meiotic nondisjunction (even if h/o on dad's side or smthg), 3% are inherited Robertsonian translocation
describe reactive nonstress testing, risk w/in next wk? FHR accelerations 2 accel in 20 min, where accel are _10bpm lasting _10 sec [15&15 if >32wks] and <2min. Fetal death rate 1:3000 in the next week. If positive repeat wkly
how often is nonreactive NST false +? What are some causes for false + fetus is asleep, immature or sedated, 80% are false positives, ie non hypoxemic
how f/u nonreactive NST vibroacoustic stimulation; if still nonreactive need BPP
how is contraction stress test done, indications? look at FHR in response to contractions, if not spontaneous cxns induce w oxytocin or nipple stimulation. Only use if BPP 4-6 and <36
describe a good CST, f/u? good=negative=no late decelerations w 3 cxns in 10min; f/u CST wkly
positive CST? What does it mean? Positive: repetitive late decelerations in 50% cxns, worrisome esp if tracing is also nonreactive…prompt delivery if 36wks! But 50% are false + when have good FHR variability
parameters in BPP NST reactivity (accels), extremity tone (extension/flexion), breathing, gross body mvmts, AFI
how polyhydramnios defined? Oligo? AFI>25 it's poly, if <5 it's oligo
how manage difft scores on BPP 8-10 is reassuring; ii. 4-6 is equivocal should deliver if ≥36, or repeat in 12-24hr if <36 or do CST; 0-2 indicates fetus in jeopardy, deliver immediately no matter what age
what's modified BPP? How accurate is it v BPP? NST + amniotic fluid index, predictive value almost as good as BPP
painLESS 3rd tri bleeding think placenta previa
risk factors placenta previa risk factors: mltpl gestation, prev placenta previa, multiparity, AMA
types placenta previa low lying, partial, complete/total/central
when can do vaginal delivery of placenta previa if lower placental edge >2cm from os
if <36 wks w placenta previa what do Conservative in hospital observation if mom and baby are stable
if 36 wks and lung maturity confirmed how manage placenta previa scheduled c/s if pt/baby stable
typical presentation of vasa previa Often see when ROM results in acute vaginal bleeding and fetal bradycardia,
cause of vasa previa rupture of vessels that cross membranes covering cervix, can be from velamentous insertion of umbilical cord or accessory/succenturiate placental lobe
risk factors for vasa previa velamentous insertion of umbilical cord, accessory placental lobes, multiple gestations
risk factors for placenta previa mltpl gestation, prev placenta previa, multiparity, AMA
define placenta accreta, key risk factor? placenta grows into myometrium- prev c/s at risk for this (ie in area of scar)
MC cause of 3rd tri painful bleeding, 2nd MC abruptio placenta, uterine rupture
describe pathophysiol of abruptio placenta Hemorrhage into decidua basalis behind nmlly implanted placenta (ie not in lower uterine seg
risk factors abruptio placenta HTN, trauma, cocaine, PROM, prev abruptio placentae
types of abruptio placenta, MC overt/external (MC), concealed ie retroplacental
degrees of abruptio placenta mild-moderate blood loss, no change FHT; moderate 25-50% separated, FHT shows tachy, decrsd var, or mild late decels; severe: abrupt sympt, FHT severe late decels, etc, severe DIC may occur
management abruptio placenta emergent c/s if mom or baby in jeopardy, vaginal delivery if 36 wks and bleeding heavy but controlled, conservative if stable and <36 wks, bldg is min or decrsing and cxns subsiding
describe uterine rupture and difft types, how difft from uterine dehiscence Complete separation of wall of uterus that can include the visceral peritoneum (complete) or not (incomplete) (difft from uterine dehiscence=gradual asympt separation of a uterine scar w/o bleeding)
key presentation of uterine rupture painful, heavy bleeding w contracted uterus, non reassuring FHT
management uterine rupture emergent c/s
risk factors uterine rupture classic c/s scar (20x more likely than lower transverse), transmural myomectomy, excessive oxytocin
types of abortions (5) threatened, missed, inevitable, incomplete, complete
describe threatened and missed abortions threatened=bleeding only; missed=nonviable preg, no bleeding or dilation
tx for missed abortion scheduled D&C or conservative waiting passage
describe inevitable abortion heavy bleeding, dilation, NO passing of POC
woman comes in with heavy bleeding, passing of some pcs--what dx? What tx? incomplete abortion if still cramping and bleeding, need emergent D
tx for inevitable abortion emergent D
describe completed abortion heavy bleeding, all POC have been passed and now cramping and bleeding minimal
how does fetal demise/death present <20wks, >20wks; how confirm dx <20wk appears as lack of fundal grwth, later w decrsd fetal mvmt. Confirm w sonographic lack of cardiac mvmt
causes for fetal demise (7) idiopathic (MC), placental, umbilical cord, fetal death, antiphospholipid, maternal trauma, DM macrosomiaoutgrowing placenta
placental causes for fetal demise abruptio placenta, infxn not allowing O2 xchg, macrosomia in DM outgrowing placenta
how dx antiphospholipid syndrome need 1 of history: venous thrombosis, PE, stroke, reptd preg losses, fetal demise, and 1 of labs: cardiolipin Abs, lupus anticoag, incrsd PTT
what labs indicate anti phospholipid syndrome cardiolipin Abs, lupus anticoag, incrsd PTT
for fetal demise how determine how deliver if <20 and don't want autopsy do D&E, otherwise do induction w vaginal PGE2 (if no DIC may want to wait few days to help family grieve)
tx fetal demise **first r/o DIC (plt, d-dimer, fibrinogen, PT/PTT). DIC esp at risk if >2 wks--if DIC must delivery immed
w/u after fetal demise can include cervical&placenta cultures, autopsy, karyotype, maternal blood for Kleihauer-Betke, total body xray for osteochondrodysplasia??
risk factors for dizygotic twins? Mono? dizyg=race, geography, FMH, ovulation induction; monozyg no known
incidence of twin w spontaneous ovulation and fertility tx 1:90 spontaneous, 1:10 if clomiphene, 1:3 if gonadotropins
when should accels become apparent 30wks
key complications assoc mltpl gestat 50% chance of premature delivery, 3x preE, 5x PTL, 5x c/s, placenta previa, PPH, nutritional, malpresentation (50%)
terminology of twins based on placenta Monochorion (1 placenta)=monozygotic (identical), can be mono or diamnion; dichorionic can be mono or dizygotic
terminology of twins based on zygotes Dizygotic MC (2/3), mltpl ovulation w 2 zygotes. ALWAYS dichorionic diamnionic; monozyg can be mono or di chorionic or amnionic
monozygotic based on when divided 72hrs=dichor diamnion; 4-8d (blastocyst)=monochor diamnion, 9-12d=monochor monoamnion, >12=conjoined
which twins at risk for twin twin transfusion? Cord entanglement twin-twin=monochorion (mono or diamnion); cord=monochor monoamnion
antepartum management of twins; how twin-twin transfusion defined monthly US to monitor grwth and twin-twin (defined as 25% wgt discordance or AFI discordance
when is baby at risk for hemolytic disease of newborn Abs are present that are assoc w hemo dz, titer at least 1:8, father is Ag +
if titer on indirect Coombs is 1:8, what do repeat titer monthly and keep managing conservatively as long as stays <1:8
name 2 tests for determining the amt of fetal-maternal transfusion Rosette test (+ or - if fetal-maternal hemorrhage has occurred), leihauer-Betke (acid dilution test that makes mom's RBC's pale but baby's stay red)
once know baby at risk for hemolytic dz of newborn, what do determine amt of anemia by amniotic fluid (Liley graph of OD450 for amt of fetal hemolysis), or PUBS w Hct
when is anemia for hemolytic dz of newborn considered significant; if significant anemia in baby from hemolytic dz of newborn what do? Liley zone III or Hct 25%; transfusion intrauterine or delivery if 34 wks
how much RhoGAM is given, after what events 300ug for 30ml whole blood (15ml RBC); all Rh - at 28wks, after delivery, w/in 72 hrs of CVS, amnio, D
how dz ROM must see all of: pooling of amniotic fluid in P Fornix, nitrazine paper turns blue, ferning pattern
risks of PROM, MC asc infxn (MC), local defects to membranes, smoking, serial damage to membranes from cxns
dx of chorio (clinical dx need all factors): maternal F, uterine tenderness w PROM but w/o evidence of URI or UTI
management of PROM if no chorio <24wks (previable) induce labor or allow bed rest at home; 24-35: hospitalize w bedrest, betamethasone <32wks, obtain cerv cx, 7d prophylactic Ab and erythro; 36wks=prompt delivery
management of PROM if chorio obtain cervical cx, start broad spec Abx, prompt delivery
risks PTL, 4 MC, 6 others h/o preterm, uterine anomaly, mlptl gest, PROM, also smoking, heavy physical labor, pyelo, chorio, poly, abd/pelvic surgery
how dx PTL 20-37 wks, 3 cxns >30sec in 30min, cervical dilation 2cm of a change in dilation or effacement
4 tocolytic agents Mg, b adrenergic (ritodrinke, terbutaline), indomethacin, CCB (nifedipine)
SE and mech of action of Mg as tocolytic, what do if OD competes w Ca++ for binding sites; SE: pul edema, mscl wknss, respir depression; if OD give Ca++gluconate
SE and mech of action of b adrenergics as tocolytic, contraindications (ritodrine, terbutaline): causes sm relax; SE: pul edema, hypotension, tachycardia, hyperglu, hypoK; Contraindications: cardiac dz, DM, uncontrolled hyperthyroidism
SE of indomethacin as tocolytic, contraindications SE: oligo, in utero closure of PDA, NEC; Contraindications: >32 w
mech of action and SE of nifedipine as tocolytic, contraindications decrses intracell Ca++, SE: hypotension, tachycardia, myocardial depression, contraindication=hypotension
contraindications tocolytics fetal: fetal demise/distress, lethal anomaly; maternal: severe PreE/eclampsia, advanced cervical dilation; Placenta: SROM, severe abruptio placentae, chorio
management PROM IVF w isotonic, Mg 5g IV for 20min, then 2g/h (if no contraindications for tocolytics), cervical cx and UA/Ucx before giving GBS prophylaxis (IV PCN G or erythro), IM betamethasone
cuases postdates MC idiopathic, more often in young pimagravidas, rarely placental sulfatase and anenceaphaly have longest
2 main risks postdates macrosomia and dysmaturity syndrome
management postdates check dates, if dates sure and favorable cervix induce; if dates sure but unfavorable either induce w PGE or manage w NST and AFI 2x/wk; unsure dates manage w NST&AFI 2x/wk
3 ways to prevent mec aspiration in post dates amnio infusion of NS, after delivery of head suction nose and pharynx; after delivery but before 2st breath aspirate neonatal tracheal mec using laryngoscope
def of HTN in preg 140/90 2x at least 6hrs apart
chornic HTN, what good px, worst Good outcome if £180/110, no end organ damage (Cr>1.4, HTN retinopathy, LVH), and fetal grwth is appropriate. Worst outcome if HTN_210/120
dx of mild preE HTN+proteinuria (_300mg/d or 1-2+ on dipstick) w/o UTI. No HA, epigastric pain, visual changes
dx of severe preE any of: 160/110, proteinuria >5g or 3+, signs of maternal jeopardy (plts <100K, hemolysis, incrsd ALT/AST, epigastric pain, persistent HA, visual disturb, pul edema, oliguria, cyanosis
dx of preE on top of chronic HTN new onset proteinuria, or sudden incrs in proteinuria or BP, or any of the maternal jeopardy signs (above)
how often preE on top of chronic HTN, who's at risk; what preg at risk for 25%; renal insuffic, HTN for 4 yrs, HTN in prev preg. Esp at risk for abruptio placenta
risks for develop preE nulliparity young or old, mltpl gest, molar preg, nonimmune hydrops, DM, chronic HTN, renal dz, SLE/small vessel/long standing DM (esp for severe)
pathophys of preE diffuse vasospasm from incrsd thromboxane and decrsd prostacyclin and decreased responsiveness to vasoactive substances, ie angiotensin causes decrsd perfusion incl fetal/plac; capillary wall injury(esp severe preE) ->vascular perm (edema, hemoconcentrat)
management chronic HTN in preg monthly US >30wks to assess for IUGR (if present wkly NST or BPP); monitor maternal BP, proteinuria. Likely need to d/c HTN meds since BP decrses in preg. Rx only for severe, to keep DBP 90-100 use: methyldopa or labetalol or atenolol [NO ACEI or diuretic
management mild preE <36wk in hospital conservatively as long as mom and baby are stable—keep watching for progression to severe preE. At 36wks labor is induced, sz prophylaxis MgSO4 during labor
management of severe PreE if no maternal jeopardy signs (what are they) and eclampsia prompt delivery at any age if evidence of maternal or fetal jeopardy (incl HA, epigastric, visual, low plts, elev LFTs, pul ed, oliguiria or cyanosis). sz prophylaxis MgSO4 during labor, hydralazine, labetalol or nifedipine to get DBP to 90-100
medical/conservative management of severe preE and when used If no signs of maternal or fetal jeopardy 26-34 wks managed in patient conservatively if BP can be brought to below 160/110; ICU w continuous IV Mg and give 2 doses of dexamethasone
HELLP, who more common in HELLP=hemolysis, elevated liver enzymes, low plts. 5-10% of preE. 2x more common in multigravidas. May not have HTN
which pop most likely to develop HTN after preg gestat HTN (HTN after 20wks w/o proteinuria)
acute fatty liver of preg, mortality rate can resemble preE w HTN, proteinuria, edema, epigatric pain, and DIC. See hypogly and incrsd serum ammonia. Maternal mortality 50%
Created by: ehstephns



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