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141 Cards in this Set
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diagnosis of pregnancy
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presumptive --> amenorrhea, breast tenderness, nausea, vomiting, hyperpigmentation, skin striae
probable --> increased uterine size, postitive beta-hCG positive --> hearing fetal heart tones, sonographic visualization of fetus, perception of fetal movements |
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pregnancy dating
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conceptual dating --> 266 days or 38 weeks
menstrual dating assuming 28 day cycle --> 280 days or 40 weeks calculate due date --> LMP - 3 months + 7 days +- 1 week |
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first trimester events and complications
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from conception to 13 menstrual weeks
nausea, vomiting, breast tenderness, frequent urination spotting and bleeding in 20% (50% of which will continue normally) average weght gain is 5-8 pounds complications --> spontaneous abortion |
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second trimester events and complications
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from 13-26 menstrual weeks
round ligament pain Braxton-Hicks contractions are painless quickening (maternal awareness of fetal movements) starting at 16 weeks average weight gain is 1 pound/week after 20 weeks complications --> incompetent cervix, premature membrane rupture, premature labor |
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third trimester events and complications
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26-40 menstrual weeks
lower back and leg pain urinary frequency Braxton-Hicks contractions lightening bloody show average weight gain is 1 pound/week after 20 weeks complications --> premature membrane rupture, premature labor, preeclampsia, urinary tract infection, anemia, gestational diabetes |
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1st trimester lab tests: CBC
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normal hemoglobin --> 10-12g/dL due to dilutional effect
MCV --> low hemoglobin and MCV (<80) suggests iron defficiency; low hemoglobin and high MCV (>100) suggests folate defficiency thrombocytopenia --> idiopathic thrombocytopenic purpura or pregnancy induced thrombocytopenia leukocytosis up to 16,000/mm3 is normal; leukopenia suggests immune suppression or leukemia |
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1st trimester lab tests: rubella IgG
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absence of antibodies has fetal risks; vaccine is contraindicated in pregnancy but recommended after delivery
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1st trimester lab tests: hepatitis B
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HbsAb --> successful vaccination
HbsAg --> previous or present infection; only routine hepatitis test on prenatal lab panel HbeAg --> highly infectious state |
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1st trimester lab tests: type, Rh and antibody screen
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blood type and Rh --> direct Coombs test; if Rh negative risk for anti-D isoimmunization
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1st trimester lab tests: STDs
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cervical cultures --> chlamydia and gonorrhea
syphilis --> VDRL; if positive --> MHA-TP or FTA-ABS hepatitis B --> HbsAg HIV (requires consent) --> screen with ELISA; if positive --> western blot |
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1st trimester lab tests: urine
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urinalysis --> suggests renal disease, diabetes, infection
urine culture --> to screen for asymptomatic bacteriuria (8% of pregnant women) |
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1st trimester lab tests: TB
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PPD --> done in high-risk populations, not routinely
if positive PPD --> chest x-ray if chest x-ray negative --> INH + B6 9 months if chest x-ray positive --> sputum culture and triple therapy until cultures return |
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1st trimester lab tests: cervical pap smear
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to identify cervical dysplasia or malignancy
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routine 1st trimester lab tests
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complete CBC
rubella IgG cervical culture (chlamydia, gonorrhea) HbsAg VDRL HIV urinalysis urine culture cervical pap smear |
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2nd trimester lab tests: MS-AFP
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elective prenatal test; (only 20% sensitivity for trisomy 21)
detects neural tube defects, ventral wall defects, twin pregnancy, placental bleeding, fetal renal disease, teratoma if >2.5 MoM --> ultrasound to confirm gestational age if error --> re-do MS-AFP if correct --> amniocentesis for AF-AFP and AF acetylcholinesterase (NTD) if <0.85 MoM --> ultrasound to confirm gestational age if error --> re-do MS-AFP if correct --> amniocentesis for karyotype (trisomy 21) |
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triple marker screen
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window is 15-20 weeks
MS-AFP, hCG and estriol trisomy 21 --> low MS-AFP and estriol with high hCG; perform amniocentesis for karyotype trisomy 18 --> all markers are decreased; perform amniocentesis for karyotype quadruple marker screen --> inhibin A; increases sensitivity for Down to 80% |
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gestational diabetes testing
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1-h 50g oral glucose tolerance test --> screening test to all pregnant women between 24-28weeks
if >140mg/dL at 1 hour --> 3-h 100g oral glucose tolerance confirmatory test after overnight fast if fasting blood glucose >125mg/dL --> diabetes mellitus; no further testing required else --> FBS: <95mg/dL 1h: <180mg/dL 2h: <155mg/dL 3h: <140mg/dL if one abnormal value --> impaired glucose tolerance if two abnormal values --> gestational diabetes |
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third trimester lab tests: CBC
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should be performed between 24-28weeks in all pregnancies checking for iron defficiency anemia and pregnancy induced thrombocytopenia
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third trimester lab tests: atypical antibody screen
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indirect Coombs test at 28 weeks for all Rh negative women
if no isoimmunization (no anti-D antibodies) --> RhoGAM else --> RhoGAM is futile |
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third trimester lab tests
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1h oral glucose tolerance test between 24-28weeks
CBC atypical antibody screen + RhoGAM |
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late pregnancy bleeding differential diagnosis
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cervical causes --> erosion, polyps, carcinoma
vaginal causes --> varicosities, lacerations placental causes --> abruptio placenta, placenta previa, vasa previa |
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late pregnancy bleeding work-up
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CBC
DIC work-up (platelets, PT, PTT, fibrinogen, D-dimer) type and cross-match sonogram for placental location never perform digital or speculum exam until sonogram rules out placenta previa |
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abruptio placenta presentation
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late trimester painful bleeding (external or retroplacental hematoma)
normal placental implantation DIC |
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abruptio placenta diagnosis
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painful late trimester bleeding with a normal fundal or lateral wall placental implantation (upper 2/3 uterus)
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abruptio placenta risk factors
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previous abruption
hypertension maternal trauma cocaine premature membrane rupture |
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abruptio placenta management
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if maternal or fetal jeopardy --> emergency cesarean
if bleeding is controlled and >36 weeks --> induce vaginal delivery with amniotomy if mother and fetus are stable and remote from from term with subsiding signs --> conservative in-hospital observation |
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abruptio placenta complications
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hemorrahgic shock with acute tubular necrosis and DIC
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placenta previa presentation and diagnosis
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late trimester painless bleeding
ultrasound shows placental implantation over the lower segment |
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placenta previa risk factors
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previous placenta previa
multiple gestation multiparity advanced maternal age |
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placenta previa management
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if maternal or fetal jeopardy --> emergency cesarean delivery
if mother and fetus are stable --> conservative in-hospital observation with blood transfusions if placental edge >2cm from internal cervical os --> vaginal delivery if 36weeks and lung maturity confirmed by amniocentesis --> scheduled cesarean delivery |
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placenta previa complications
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if placenta is implanted over previous uterine scar --> intractable bleeding requiring cesarean hysterectomy
if too much blood loss and hypotension ---> Sheehan or acute tubular necrosis |
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placenta accreta/increta/percreta
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accreta (MC) --> villi invade deeper layers of endometrium but not myometrium
increta --> villi invade the myometrium but not serosa or bladder percreta --> villi invade the serosa or bladder |
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vasa previa
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presentation --> rupture of membranes, painless vaginal bleeding and fetal bradycardia
diagnosis --> suspected when sonogram has previously revealed a vessel crossing the membranes over internal cervical os risk factors --> velamentous insertion of umbilical cord, accessory placental lobes, multiple gestation management --> immediate cesarean |
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uterine rupture
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presentation --> vaginal bleeding, loss of electronic fetal heart rate signal, abdominal pain, loss of station of fetal head
diagnosis --> surgical exploration of the uterus to identify the tear risk factors --> classic (vertical) uterine incision, myomectomy, excessive oxytocin stimulation management --> surgical immediate delivery with uterine repair or hysterectomy |
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GBS neonatal sepsis
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presentation --> newborn sepsis within hours of birth with bilateral pneumonia (50%) mortality
prevention --> IV penicillin G if --> positive GBS urine culture or previous baby with GBS sepsis positive vaginal culture at 36-37weeks risk factors: preterm gestation, membranes ruptured>18h, maternal fever |
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congenital toxoplasmosis
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can only occur during the parasitemia of a primary infection
40% of pregnant women are toxoplasmosis IgG seropositive fetal infection --> IUGR, fetal hydrops, microcephaly, itracranial calcifications neonatal findings --> chorioretinitis, seizures, hepatosplenomegaly prevention --> avoid infected cat feces, raw goat milk, undercooked meat |
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varicella infection
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neonatal findings --> zigzag skin lesions, micropthalmia, chorioretinitis, extremity hypoplasia
prevention --> varicella zoster immune globulin within 96h of exposure or live-attenuated vacciine to non-pregnant with no IgG treatment --> acyclovir if maternal varicella pneumonia, encephalitis or immunocompromised |
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congenital rubella
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presentation --> congenital deafness, congenital cataracts, congenital heart disease
prevention --> all pregnant women should be screened for ruberlla IgG; if negative then vaccination after delivery |
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cytomegalovirus infection
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fetal manifestations --> hydrops, IUGR, microcephaly, periventricular cerebral calcifications
neonatal findings --> sensorineural deafness; if symptomatic: petechiae, meningoencephalitis, jaundice treatment --> ganciclovir |
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HIV in pregnancy
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triple therapy recommended including ZDV
cesarean should be offered at 38 weeks breast feeding should be avoided |
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syphilis
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fetal --> hydrops, macerated skin, anemia, thrombocytopenia, hepatosplenomegaly
neonatal ---> Hutchinson teeth, mullberry molars, saber shins, saddle nose, VIII nerve deafness |
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obstetric complications
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cervical insufficiency
multiple gestations isoimmunization preterm labor premature rupture of membranes postterm pregnancy |
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hypertensive complications
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gestational hypertension
mild preeclampsia severe preeclampsia eclampsia chronic hypertension HELLP syndrome |
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medical complications in pregnancy
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cardiac disease
thyroid disease epilepsy diabetes anemia liver disease UTIs thrombophilias thromboembolism |
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cervical insufficiency
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painless cervical dilation at 18-22 weeks with possible delivery of previable baby
diagnosis --> ultrasound management --> elective cerclage or emergency cerclage if theres sonographic evidence and after ruling out labor and chorioamnionitis |
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multiple gestations
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Di-Di twins --> 2 zygotes; two placentas seen
mono-di twins --> one zygote; one placenta, two sacs mono-mono twins --> one zygote; one placenta, one sac presentation --> hyperemesis gravidarum due to high beta-hCG, uterus larger than dates, high AFP diagnosis --> more than one fetus on sonogram management --> iron and folate, monitor blood pressure, vaginal delivery if both cephalic, else cesarean |
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determination of fetal risk in isoimmunization
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present if:
atypical antibodies detected with indirect Coombs test antibodies are associated with hemolytic disease of newborn titer more than 1:8 father of baby is antigen positive else --> no risk if ATT <1:8 management is conservative; repeat titer monthly |
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determine degree of fetal anemia in isoimmunization
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amniocentesis bilirubin --> indirectly indicates fetal hemolysis; plotted on Liley graph; severe anemia if zone III
PUBS --> directly measures fetal hematocrit; severe anemia if <25% ultrasound doppler -->measures peak flow velocity of fetal blood through middle cerebral artery; higher velocity, more anemia |
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criteria for intervention in isoimmunization
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severe fetal anemia is diagnosed when Liley Is in zone 3 or PUBS shows fetal hematocrit <25%
perform intrauterine intravascular transfusion if <34 weeks delivery if >34 weeks |
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management of isoimmunization
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1) determine fetal risk
2) determine degree of anemia 3) intervene if severe anemia |
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prevention of isoimmunization
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RhoGAM routinely:
1) to Rh negative mothers at 28 weeks 2) within 72h of chorionic villus sampling, amniocentesis or D&C 3) within 72h of delivery of an Rh positive infant |
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preterm labor diagnosis
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pregnancy 20-36 weeks
>= 3 contractions in 30 min cervix >=2cm or changing all three should be positive for diagnosis |
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preterm labor presentation
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lower abdominal pain or pressure
lower back pain increased vaginal discharge bloody show |
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preterm contractions
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pregnancy 20-36 weeks
>=3 contractions in 30 minutes dilated <2cm and no change |
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tocolytic contraindications
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obstetric --> abruptio placenta, ruptured membranes, chorioamnionitis
fetal --> lethal anomaly, fetal demise maternal --> eclampsia, severe preeclampsia, advanced cervical dilation |
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tocolytic agents
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may prolong pregnancy but for no more than 72h to administrate maternal IM betamethasone for lung maturation and transport mother to a facility with neonatal intesive care
magnesium sulfate terbutaline nifedipine indomethacin |
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magnesium sulfate for tocolysis
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competitive inhibitor of calcium
side effects --> muscle weakness, respiratory depression, pulmonary edema contraindications --> renal insufficiency and myasthenia gravis treat overdose with IV calcium gluconate |
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terbutaline for tocolysis
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depends on myometrial beta2 receptor activity
side effects --> hypertension, tachycardia, hyperglycemia, hypokalemia contraindications --> cardiac disease, diabetes, uncontrolled hyperthyroidism |
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calcium channel blockers for tocolysis
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side effects --> tachycardia, hypotension, myocardial depression
contraindications --> hypotension |
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indomethacin for tocolysis
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decreases prostaglandin production
side effects --> oligohydramnios, PDA closure in utero contraindications --> gestational age >32 weeks |
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preterm labor management
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confirm labor with specific criteria
rule out contraindications for tocolysis IV hydration with IV fluids magnesium sulfate 5g IV for 20 minutes then 2g/h cervical and urine cultures for GBS prophylaxis maternal IM betamethasone if <34 weeks |
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preterm labor prevention
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women with history of previous preterm delivery should receive IM 17alpha-OH progesterone starting at 20 weeks
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premature rupture of membranes presentation
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sudden gush of copious vaginal fluid
clear fluid flowing out of vagina oligohydramnios seen in ultrasound |
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premature rupture of membranes diagnosis
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sterile speculum exam showing:
1) posterior fornix pooling of amniotic fluid 2) nitrazine positive fluid turns pH-sensitive paper blue 3) fern positive pattern when fluid is allowed to dry on glass slide |
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chorioamnionitis diagnosis
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need all criteria:
maternal fever and uterine tenderness in the presence of PROM in the absence of a URI or UTI |
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PROM management
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if uterine contractions are present --> tocolysis is contraindicated
if chorioamnionitis is present --> cervical cultures, IV antibiotics and prompt delivery if infection is absent and <24 weeks --> induce labor or manage with bed rest if 24-33 weeks --> bed rest, IM betamethasone, cervical cultures, 7-day prophylactic ampicillin+erythromycin if >34 weeks --> initiate prompt delivery with oxytocin or prostaglandins or cesarean |
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postterm pregnancy
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>40 weeks from conception or >42 mentrual weeks
can predispose to macrosomia (viable placenta) or dysmaturity syndrome (decaying placenta) if sure date and favorable cervix --> induce labor with oxytocin and artificial rupture of membranes else --> conservative |
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gestational hypertension
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pregnancy >20weeks
nonsustained BP >140/90 without proteinuria conservative management and preeclampsia should ruled out |
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mild preeclampsia
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pregnancy >20weeks
sustained hypertension >140/90 with proteinuria 1-2+ or >300mg on 24h urine hemoconcentration if stable and <36w --> conservative management and no antihypertensive or MgSO4 if >36w --> induce labor with dilute oxytocin and IV MgSO4 to prevent eclamptic seizures |
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severe preeclampsia
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preganancy >20weeks
sustained hypertension >160/110 + >300mg proteinuria sustained hypertension >140/90 + 3-4+ or >5g proteinuria sustained hypertension >140/90 with headache, epigastric pain, visual changes, DIC, elevated liver enzymes or pulmonary edema if maternal or fetal jeopardy --> IV MgSO4, hydralazine/labetalol and prompt delivery if no maternal or fetal jeopardy and 26-34 weeks --> conservative if BP can be lowered, IV MgSO4 and IM betamethasone |
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eclampsia
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unexplained grand mal tonic clonic seizures + hypertension + proteinuria
first step in management --> protect mother's airway and tongue MgSO4 aggressive prompt delivery lower diastolic BP with IV hydralazine or labetalol |
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chronic hypertension
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BP >140/90 with onset before 20 weeks
superimposed preeclampsia --> worsening BP, worsening proteinuria or maternal jeopardy |
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antihypertensive drugs in pregnancy
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if mild to moderate HTN --> may discontinue medications if theres normal decrease in BP
if severe hypertension --> methyldopa ACEIs and diuretics are contraindicated in pregnancy BP target is diastolic between 90-100 |
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chronic hypertension management
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if uncomplicated --> conservative; discontinuation of antihypertensives, serial sonograms, serial BP and urinalysis
if superimposed preeclampsia --> MgSO4, hydralazine/labetalol and prompt delivery |
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HELLP syndrome
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complication of preeclampsia
hemolysis + elevated liver enzymes + thrombocytopenia manage with prompt delivery |
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antepartum maternal overt diabetes measures
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Hemoglobin A1c on first visit and each trimester
early pregancy baseline 24h urine protein to assess renal status assess retinal status with fundoscopy home blood glucose monitoring |
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antepartum fetal assesment in overt diabetes
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triple marker screen at 16-18 weeks for NTDs
targetted ultrasound at 18-20 weeks if glycosylated hemoglobin is high --> fetal echo at 22-24 weeks monthly sonogram for macrosomy or IUGR no increased risk of anomalies in gestational DM because anomalies are in first trimester |
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intrapartum management of overt DM
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lung maturity is often delayed
target delivery date is 40 weeks amniocentesis for lecithin/sphingomyelin ration of 2.5 in the presence of phosphatidyl glycerol assures lung maturity cesarean is considered if macrosomia |
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postpartum management of overt DM
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watch for uterine atony related to overdistended uterus which causes postpartum hemorrhage
falling levels of hPL decreases insulin resistance so turn off insulin infussion |
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neonatal complications of overt DM
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hypoglycemia due to hyperinsulinism
hypocalcemia due to failure of parathyroids polycythemia due to high erythropoietin from relative hypoxia hyperbilirubinemia respiratory distress syndrome due to low surfactant |
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iron deficiency anemia
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general malaise, palpitations, andkle edema
hemoglobin <10g, MCV <80, RDW >15% FeSO4 325mg po tid prevent with elemental iron 30mg/day |
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folate deficiency anemia
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malaise, palpitations, ankle edema
hemoglobin <10g, MCV >100, RDW >15% fetal effects --> low birth-weight, NTDs treatment --> folate 1mg po/day prevent --> folate 0.4mg po/day; 4mg if risk of NTDs |
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sickle cell anemia
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screening --> peripheral test to detect hemoglobin S
final diagnosis --> hemoglobin electrophoresis to differentiate between SA trait and SS disease complications --> spontaneous abortions, IUGR, fetal deaths, preterm delivery treatment --> avoid hypoxia, folate supplements, monitor fetal well being |
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intrahepatic cholestasis of pregnancy
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intractable pruritus on the palms and soles, worst at night, without rash
diagnosis --> markedly increased serum bile acids, mild bilirubin elevation treatment --> gold standard is ursodeoxycholic acid; may also use cholestyramine and antihistamines in mild cases |
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acute fatty liver
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nonspecific --> nausea, vomit, anorexia, epigastric pain
hypertension, proteinuria, edema can mimic preeclampsia but hypoglycemia and high serum ammonia are specific can also have acute renal failure, pancreatitis, hepatic encephalopathy, coma moderate elevation of liver enzymes, hyperbilirubinemia and DIC prompt delivery is indicated |
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asymptomatic bacteriuria
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no urgency, frequency or burning
no fever positive urine culture with >100K CFU single antibiotic treatment |
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acute cystitis
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urgency, frequency, burning
no fever positive urine culture with >100K CFU antibiotic monotherapy |
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acute pyelonephritis
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urgency, frequency, burning
systemic signs --> fever with chills, anorexia, nausea, vomit, flank pain positive urine culture with >100K CFU hospital admission, hydration, IV antibiotics and tocolysis if needed |
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thrombophilia etiology and pregnancy complications
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factor V Leiden
prothrombin mutations hyperhomocysteinemia antithrombin III deficiency protein C/S deficiency antiphospholipid syndrome complications --> first trimester miscarriages, stillbirths, placental abruption, preeclampsia, pulmonary embolus (MC COD in pregnant women) |
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thrombophilia diagnosis
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all pregnant women with blood clot should be tested for:
factor V Leiden and prothrombin gene mutations hyperhomocysteinemia antithrombin III, protein C, protein S deficiency antiphospholipid syndrome recommended testing if: familiy history of thrombosis, pulmonary embolism, thrombophilias or pregnancy complications |
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thrombophilia treatment
|
subcutaneous heparin +- aspirin
low-molecular weight is better than unfractionated monitor blood levels for anticoagulation effect warfarin postpartum 6-8 weeks |
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superficial thrombophlebitis
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localized pain and sensitivity, erythema, tenderness, swelling
diagnosis of exclusion after ruling out DVT with doppler or venography manage with bed rest, local heat and NSAIDs |
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deep venous thrombosis
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pain and increased skin sensitivity, calf pain
diagnosis --> duplex Doppler (above knee) or venography (below knee); perform thrombophilia work-up treatment --> IV heparin |
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pulmonary embolus
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chest pain, dyspnea, tachypnea, normal x-ray, low pO2 on ABG, tachycardia
diagnosis --> initially spiral CT if CT negative and high risk symptomatic patient --> pulmonary angiography perform thrombophilia work-up management --> IV heparin |
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IUGR definition and etiology
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estimated fetal weight <5-10th percentile for gestational age
or birth weight <2,500grams fetal causes --> aneuploidy, TORCH, structural anomalies --> symmetrical placental causes --> infarction, abruption, twin-twin transfusion --> asymmetric maternal causes --> hypertension, small vessel disease, malnutrition, tobacco, alcohol, drugs |
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symmetrical IUGR
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all ultrasound parameters are smaller than expected
workup --> detailed sonogram, karyotype, screen for fetal infections |
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asymmetrical IUGR
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head sparing but abdomen small
serial sonograms, non-stress tests, amniotic fluid index (decreased), biophysical profile, umbilical artery Doppler |
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macrosomia definition and risk factors
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estimated fetal weight >90-95th percentile for gestational age
or birth weight >4,000-4,500 grams risk factors --> gestational or overt diabetes, prolonged gestation, obesity, weight gain |
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macrosomia complications and management
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maternal --> operative vaginal delivery, perineal lacerations, postpartum hemorrhage, emergency C-section
fetal --> shoulder dystocia, birth injury, asphyxia neonatal --> intensive care admission, hypoglycemia, Erb palsy manage with C-section |
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nonstress tests
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reactive NST:
>=2 accelerations in 20 min; >10 or 15 beats/min for >10 or 15 seconds interpretation --> reassuring of fetal well-being repeat weekly or biweekly non-reactive NST: no accelerations or did not meet criteria interpretation --> sleeping fetus, immature, sedated perform vibroacoustic stimulation test if still not reactive --> biophysical profile |
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amniotic fluid index
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<5cm --> oligohydramnios
5-8cm --> borderline 9-25cm --> normal >25cm --> polyhydramnios |
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biophysical profile
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NST, amniotic fluid volume, fetal gross body movements, fetal extremity tone and fetal breathing movements
8-10 --> highly reassuring; repeat weekly or as indicated 4-6 --> worriesome; delivery if >36weeks or repeat in 12-24 hours 0-2 --> fetal hypoxia; prompt delivery regardless of age |
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contraction stress test
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negative CST:
no late decelerations in the presence of 3 contractions in 10min reassuring of fetal well being repeat CST weekly positive CST: repetitive late decelerations in the presence of 3 contractions in 10min worriesome, especially in nonreactive NST prompt delivery |
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contraction stress test indications and contraindications
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indication --> BPP 4-6
contraindications --> should not stimulate contractions if: previous classical uterine incision previous myomectomy placenta previa incompetent cervix preterm membrane rupture preterm labor |
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umbilical artery Doppler
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absent or reversed diastolic flow is predicitive of poor perinatal outcome only in IUGR fetuses
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types of pelvis
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gynecoid, android, anthropoid, platypelloid
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fetal lie
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longitudinal --> fetus and mother in same vertical axis
transverse --> fetus at right angles to mother oblique --> fetus at 45 degree angle to mother |
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fetal presentation
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cephalic --> head first; most common
frank breech --> thighs flexed, legs extended complete breech --> thighs and legs are flexed footling breech --> thighs and legs are extended compound --> more than one anatomic part is presenting shoulder --> shoulder first |
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fetal position
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occiput anterior or posterior --> flexed head on cephalic presentation
sacrum anterior or posterior --> breech presentation mentum anterior or posterior --> extended head on face presentation |
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definition of labor
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effacement and dilation of the cervix with uterine contractions at least every 5min lasting 30s; resulting in delivery of fetus and expulsion of placenta
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physiology of labor
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increasing frequency of contractions
formation of gap junctions between uterine myometrial cells increasing levels of oxytocin and prostaglandins multiplications of specific receptors upper uterine segment --> contractile, mostly smooth muscle, thickens lower uterine segment --> passively thins out, mostly collagen fibers |
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cervical effacement and dilation
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0% effacement --> cervix is 2cmX2cm; oxytocin and prostaglandins break dissulfide likanges of collagen fibers
dilation --> complete dilation is 10cm as lower uterus is thinned and pulled up by upper uterus |
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movements of labor
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1) engagement --> presenting part moves below pelvic inlet
2) descent --> presenting part moves through curve of birth canal 3) flexion --> fetal chin on thorax 4) internal rotation --> fetal head from transverse to antero-posterior in mid pelvis 5) extension --> fetal chin moves away from thorax 6) external rotation --> fetal head rotates after passing pelvic outlet 7) expulsion --> delivery of fetal shoulders and body |
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stages of labor
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stage 1 latent phase --> regular uterine contractions-acceleration of cervical dilation; <14-20 hours
stage 1 active phase --> acceleration-10cm dilation; >1.2-1.5cm/hour stage 2 descent --> 10cm dilation-delivery; 1-2 hours stage 3 expulsion --> delivery of baby-delivery of placenta; <30min stage 4 --> 2h observation period |
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management of labor
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preadmission --> not admitted until cervical dilation is 3cm unless ROM; presentation is confirmed
admission --> IV access first stage --> assess fetal heart rate and perform serial vaginal exams checking dilation and descent stages 2 and 3 --> pushing efforts; episiotomy might be performed; IV oxytocin after delivery of placenta |
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prolonged latent phase
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pregnant with regular uterine contractions
cervix dilated 2cm no cervical change in 14 or 20 hours management --> rest and sedation |
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prolonged active phase
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pregnant with regular uterine contractions
cervix dilated >3cm cervical dilation <1.2 or 1.5cm management: normal contractions --> 2-3min, 45-60sesc, 50mmHg if hypotonic --> IV oxytocin if hypertonic --> morphine if adequate --> emergency cesarean |
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active phase arrest
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pregnant with regular uterine contractions
cervix dilated >3cm cervical dilation not changed for >2h management: normal contractions --> 2-3min, 45-60sesc, 50mmHg if hypotonic --> IV oxytocin if hypertonic --> morphine if adequate --> emergency cesarean |
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stage 2 arrest
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pregnant with regular uterine contractions
10cm dilation at +1 station no descent change in 3h management: IV oxytocin enhanced coaching if adequate and head not engaged --> emergency cesarean if adequate and head engaged --> obstetric forceps or vacuum extractor |
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prolonged third stage
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failure to deliver plaenta within 30 minutes in spite of oxytocin
suspect placenta acreta, increta or percreta may require manual placental removal or hysterectomy |
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prolapsed umbilical cord
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pregnnt with regular uterine contractions
amniotomy at -2 station severe variable decelerations management --> don't hold the cord or push back into uterus; place patient in knee-chest position; elevate presenting part and perform immediate cesarean delivery |
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shoulder dystocia
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second stage of labor
head has delivered no further delivery of body management --> suprapubic pressure; maternal thigh flexion; internal rotation of fetal shoulder |
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obstetric lacerations
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first degree --> vaginal mucosa
second degree --> vagina and muscles of perineal body third degreee --> vagina, perineal muscles, anal sphincter fourth degree --> vagina, perineal muscles, anal sphincter and rectal mucosa |
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obstetric anesthesia physiology
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stage 1 --> T10-T12
stage 2 --> S2-S4 pregnancy predisposes to hypoxia medications can pass the placenta to fetus give antacids prophylactically uterus should be laterally displaced |
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IV anesthetics
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narcotics and sedatives
active phase neonate may need naloxone antidote |
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paracervical block
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bilateral transvaginal injection to block Frankenhauser ganglion
active phase transitory fetal bradycardia |
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pudendal block
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bilteral transvaginal injection to block pudendal nerve at ischial spine
stage 2 |
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epidural block
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injection into epidural space to block lumbosacral roots
stages 1 and 2 side effects --> hypotension (treat with IV fluids and ephedrine); spinal headache |
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spinal block
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injection into subarachnoid space to block lumbosacral roots
stage 2 side effects --> hypotension |
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types of decelerations
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early --> with contractions
variable --> before or with contractions late --> after contractions (non reassuring) |
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reassuring FHR tracings
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baseline rate 110-160/min
accelerations no decelerations variability is present |
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nonreassuring FHR tracings
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baseline rate is tachycardia or bradycardia
accelerations absent repetitive variable decelerations repetitive late decelerations variability is absent |
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intrauterine resuscitation
|
decrease uterine contractions --> turn off oxytocin or administer 0.25 terbutaline
500mL bolus of normal saline 8-10L O2 by facemask amniofusion lateral position vaginal exam to rule out prolapsed umbilical cord scalp stimulation |
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fetal pH assessment
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normal fetal pH is 7.2 or more
fetal scalp blood pH postpartum umbilical arter blood pH |
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management of nonreassuring fetal monitoring tracings
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intrauterine resuscitation
if no normalization --> prompt delivery |
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forceps or vaccum extractor indications
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prolonged second stage (MC indication)
nonreassuring FHM tracings to avoid maternal pushing breech presentation |
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indications for cesarean
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cephalopelvic disproportion
nonreassuring tracings presentations other than cephalic |
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uterine atony
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risks --> rapid labor, chorioamnionitis, MgSO4, halothane, overdistended uterus
soft uterus palpable over the umbilicus treat with uterine massage and oxytocin, methylergonovine or carboprost |
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lacerations
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risks --> uncontrolled vaginal delivery, operative vaginal delivery
identifiable lacerations in the presence of a contracted uterus treat with surgical repair |
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retained placenta
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missing placental cotyledons in the presence of contracted uterus
treat with manual removal or uterine curetagge by sonogram |
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uterine inversion
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bleeding mass in the vagina and failure to palpate uterus
treat by lifting uterus back to its position and giving oxytocin |