USMLE Rx: OB
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Describing Early, Late Decelerations
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Early decelerations means that the FHR nadir occurs simultaneously with the contraction peak; Late means the nadir occurs afterwards
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Etiology: Mid to Late Decelerations
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dt Fetal Hypoxia (Uteroplacental Insuff) -Placenta Abruptio
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Etiology: Early Decelerations
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Fetal Head Compressions
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Etiology: Severe Late Decelerations
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Fetal Myocardial Depression
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Dx: PPROM
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Speculum (most specific) Nitrazine Paper Test Preterm Premature Rupture Of Membranes
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Risk Factors: PPROM
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Smoking Genital Infxns short cervical length Multiparity Preterm/Threatened abortions Previous PPROMs
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Complications: Maternal GBS
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Chorioamnionitis Neonatal Sepsis
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Etiology: Variable Decelerations
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Fetal Arrhythmias
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Maternal Asthma treatments during pregnancy
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SAFE! (both inhaled corticosteroids and beta 2 agonists)
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Weight Gain Guidelines during pregnancy
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3-4 lbs per month Total= 25-35lbs For BMI>30 15-25 lbs
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Dx: painful cramps and possibly water broke
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Serial exam (Speculum or gentle Digital Exam)
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Septic Ovarian Vein Thrombosis
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Usually due to Pelivc Infxn & Hypercoaguable state
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Tx: Septic Ovarian Vein Thrombosis
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Antibiotics and Heparin
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Sx: Chorioamnionitis
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Fever Maternal Tachycardia > 120bpm Fetal Tachycardia > ~170bpm Uterine/Fundus tender Leukocytosis Purulent/foul discharge
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Warfarin in obstetrics
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Teratogenic but okay to breast feed on!
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U/S of Neural Tube Defect
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can show fetal heriation of cerebellum in foramen magnum
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Measuring Intrauterine Growth
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wks 15-36= Fundal height +/- 4cm (wk 20=bellybutton) (ie 25 wk should be 21-29cm fundal height)
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Dx: IUGR
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U/S Asymmetric will show normal head size with decreased abdomen diameter/circumference
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Degrees of Perineal Lacerations
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1- Vaginal/Perineal Epithelium 2-Subepithelial of Vagina or Perineum 3- Involves Anal sphincter 4- Involves Rectal Mucosa
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Sx: Sheehan's
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Failure to lactate (decreased PRL) Loss of Pubic Hair (loss of LH/androgeens) Hyponatermia / ↓ACTH
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Etiology: Sheehan's
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Obstetric hemorrhage/HoTN
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Indications for RhO (D)
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@28wks (including ectopics/abortions etc) -Mom Rh- & Dad + or unknown AND within 72 hrs of delivery of an Rh+ newborn
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Sx: Uterine Atony
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Boggy enlarged Uterus Blood loss
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Guidelines for MTX Treatment after Mole
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βhCG plateaus over 3 weeks βhCG rises over 2 wks βhCG persistence 6 months after
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Thyroid labs for pregnancy
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Normal thyroid will show (↑Total): ↑T4 (Thyroxine) ↑T3 (Triidothyronine) This is due to ↑Thyroxine binding globulin
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Tx: Sheehan's
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Clomiphene (Hormone Replacement) -Glucocorticoids -Levothyroxine
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Dx: Sheehan's
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Labs first! -FSH/LH, Thyroid, Estradiol, Cortisol, (PRL??) Then CT/MRI
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Dx: Gestational Diabetes
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Screen: 1hr Fasting 50g oral test Diagnosing: 3 hr Fasting 100g test
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Risk Factors: Breech
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Altered Fetal Shape Altered Fetal Mobility Abnormal Uterine contour/volume Fibroids
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Risk Factors: Placenta Previa
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Hx Placenta Previa Smoking Multiparity/Multiple Gestations (dt scarring) Hx C-section AMA or teens
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HTN Treatment goal
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<150, <100 -
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HELLP stands for
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Hemolysis Elevated Liver enzymes Low Platelets
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Supine HoTN Syndrome
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Compression of IVC by uterus ~30 wks occcurs in 10% of preggers
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Criteria for Severe Preeclampsia
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>160/110 >5g proteinuria or 3+ disptick Visual changes, Pulm Edema, Oliguria <400mg/24hr
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Sx: Eclampsia
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Seizure (grand mal) + Preeclampsia
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Internal vs. External monitoring
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External usually Internal monitoring is only for when you know the membrane has already ruptured
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Quad Screen: Down's
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\"hi\" ↑hCG, Inhibin a ↓αfp, estradiol
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Tx: Mastitis
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Oral Cephalexin (or dic/oxacillin) (safe to breast feed with!)
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Etiology: Mastitis
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S. Aureus
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Absolute Contraindication to Vaginal Delivery
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Complete Placenta Previa -relatives: active HSV, untreated HIV, extensive uterine surgeries
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Triple Screen: Trisomy 18
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Edward's ↑NT ↓ hCG, PAPP-A (preg assoc plasma protein a)
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Tx: Non-reassuring FHR
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Initial Treatment: S top oxytocin S aline bolus S ide positioning S peculum Amniofusion
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Sx: Fetal Alcohol Syndrome
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smooth Philtrum thin Vermilion border short Palpebral fissures hypoplastic midface microcephaly CNS Growth Restriction VSD/Cardiac (\"Please Plan Very Carefully- Restrict your alcohol\")
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Tx: Placenta Abruptio- Unstable
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FFP and then C-Section
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Tx: Placenta Abruptio- Stable
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>36wk GAge= Vaginal Delivery If bleeding is mild and under <36wk GAge then administer Tocolytics (Mg), and then Betamethasone for lungs
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Sx: Hyperemesis Gravidarum
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First trimester (n/v) Ketonuria >5% prepregnancy weight loss Hypochloremic metabolic alkalosis
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Etiology: Hyperemesis Gravidarum
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possibly rapid rise in βhCG
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Low urine output can be due to
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Oxytocin's similar structure to ADH
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Indications for Cerclage
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Cervical Insufficiency (painLESS abortions) -Cerclage is mechanical reinforcements placed in early 2nd trimester
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Tx: Septic Abortion
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IV antibiotics and repeat D&C
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Tx: Hyperemesis Gravidarum
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Fluids, B6, Doxylamine (antihist), Promethazine, nausea meds
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Indications for Rho (D) besides labor
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Any exposure to fetal blood Trauma, Miscarriage, Abruption Amniocentesis
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Gestational Diabetes can lead to
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Macrosomia (shoulder dystocia) Polyhydramnios Cardiac Defects Preeclampsia Asymptomatic bacteruria Postpartum Hemorrhage
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HTN Meds to use
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Hydralazine Nifedipine Methyldopa (CI in Renal) Labetalol
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Retrovirals in preggers
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For HIV moms give them antivirals during antepartum and intrapartum
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Tx: Missed abortion
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Prostaglandins to induce or D&C
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Risk Factors: Ectopic Pregnancy
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DES PID or pelvic surgery Endometriosis
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Function of βhCG
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Maintain Corpus Luteum
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Produces βhCG
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Placental Trophoblasts
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Produces Progesterone
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Corpus Luteum
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Abruptio vs. Uterine Rupture
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Uterine Rupture has fetal bradycardia (or absence of FHR)
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Risk Factors: Uterine Rupture
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Previous C-section (particularly upper vertical cut) Oxytocin/Prostaglandins
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Tx: UTI in Pregger
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treat even ASYMPTOMATIC infxns Nitrofuratonin (3days) or Amoxicillin/Cephalexin (7days) Monthly urine screens afterwards
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Preggers are predisposed to develop
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PEs (hypercoaguable state)
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MC Location for Ectopic Pregnancy
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Ampulla of Fallopian
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Complications of Placenta Abruptio
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DIC Hemorrhagic Shock Fetal Hypoxia
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Human Placental Lactogen
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Secreted by Placenta bears similar structure to GH and causes insulin insensitivity resulting in hyperglycemia -also contributes to lactation
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Tx: Gestational Diabetes
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1L: Diet 2L: Insulin (no metformin/sulfonylurea!)
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Hysterosalpingogram shows
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Uterine & Tubal Pathologies -good for diagnosing reoccuring pregnancy losses
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Tx: Eclampsia
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Mg, stabilize and then deliver baby once stable
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Complications of HELLP
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Hepatic Failure Hepatic Infarction Hepatic Hematoma (and rupture)
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Maternal Vaccinations CI
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Live vaccines (ie MMRV)
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First stage defined as
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Latent: onset to 3-4cm dilation Active:4-10cm (full)
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First Stage Timeframe
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(Primi/Multiparious) Latent: 8 / 6 hrs Active: 5 / 2.5 hrs
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Second Stage Timeframe
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Pari: up to 3 hrs Multiparous: <30min
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Third Stage Timeframe
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Both: <.5 hrs
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MOA: Clomiphene
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E Rec agonist→ ↑GnRH→ Ovulation
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Tx: Antiphospholipid Pregnancy
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Heparin for APL patients
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Tx: PID Pregnancy
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In-vitro (since it's tubal infertility)
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Weight loss can help pregnancy occur for
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obese and PCOS women
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MOA: Mifepristone
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Ø Progesterone → No implantation (need 600mg)
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MOA: Levonogesterol
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Hi Dose Progesterone (induces abortion)
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McRobert's Maneuver
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Flex thighs during delivery and apply suprapubic pressure Prevents shoulder dystocia in macrosmia babies
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Threatened abortion is
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Bleeding/pain but the cervical os is still closed -Monitor (no indication that bedrest or other shiit is helpful)
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Tx: Immature fetal lungs
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Betamethasone
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MOA: Mg Sulfate (preg)
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Tocolytic → ↓Uterine contractions in preterm labor
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Tx: Hyperprolactinemia
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Bromocriptine (D agonist →ØPRL release)
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A perfect Bishop's score
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Posterior Position Firm consistency 9 means likely to spontaneously induce)
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Vaginal Bleed, <20wks, Cervix open
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Incomplete OR Inevitable Abortion
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Vaginal Bleed, <20wks, Cervix closed
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Threatened abortion, Molar pregnancy, or Ectopic Pregnancy
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Vaginal Bleed, >20wks, Cervix closed
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painLESS= Placenta Previa, Vasa Previa PAIN= Placental Abruptio, Uterine Rupture
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Tx: Ruptured Ectopic Pregnancy
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Salpingectomy (removal of fallopian tube)
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Tx: Unruptured Ectopic Pregnancy
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Salpingostomy (re-opening the fallopian) -MTX if <3.5cm; βhCG <6000; no fetal cardiac activity and no Hx of folic acid supplementation Both: follow up with serial βhCG
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Tx: Abruptio Placenta
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Large Bore IV + Foley and then: Stable?→ Tocolytics to delay Heavy Bleeding/>36wk→ Vaginal Delivery Unstable?→ Emergency C-Section
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Placenta Previa vs. Vasa Previa
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Vasa Previa has Fetal HR changes (both are painless bleeds)
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Causes of Oligohydramnios
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Ruptured Membrane Uteroplacental Insufficiency due to Maternal HTN, Preeclampsia, Collagen Vasc Dz, or placental factors like infarction/abrutpion -Potter's Syndrome or urinary tract abnormalities -ARPKD
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DIC in preggers is caused by
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Damage to placenta releases its thromboplastin into the blood
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Risk Factors: Postpartum Endometritis
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Prolonged membrane rupture C Sections Prolonged labor w/ multiple exams Age extremes Low Socioeconomics
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Tx: Maternal Chickenpox
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Give baby Varicella Zoster Ig after birth
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Indications for GBS Prophylaxis
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+ GBS (including bacteruria) Previously their infected newborn with GBS Unknown Status= preterms, prolonged ruptured membrane (>18hrs), or fever during pregnancy
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Nagele's Rule
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Last Period -3 months, + 7 days= Expected Delivery day
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Tx: Postpartum Endometritis
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IV Clindamycin and Gentamicin
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Sinusoidal Pattern on Fetal Monitoring
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Ominous sign! - Fetal anemia or compromise
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Differences between Amniocentesis and Chorionic Villus Sampling
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CVS= 10-12wks; can NOT detect open neural tube defects Amnio= 15-20wks
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Smoking predisposes the baby to
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Low Birth Weight
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Sx: Caudal Regression Syndrome
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Sacral agenesis, incontinence, LE flaccid paralysis, imperforate anus
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Etiology: Caudal Regression Syndrome
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Maternal Diabetes (MC) Folic Acid (less likely)
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Fetal Fibronectin
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Used as a negative screening tool. A negative fibronectin means theres almost no chance of labor in the next 2 weeks
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Dx: adnexal mass, preggers
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usually benign (assuming it's also a normal intrauterine pregnancy)
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Screen for Gestational Diabetes
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24-28 wks
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Intrahepatic Cholestasis of Pregnancy vs. Gallstones
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ICP- more or less painless, jaundice, icteric sclera, ↑Bile salts Gallstones- pain, fever
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Pregnancy Effects on Renal system
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↑ GFR, Aldosterone/RAAS ↓BUN:Cr
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Pregnancy Effects on CV system
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↑ CO ↓SVR
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Chadwick's Sign
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6-8wks and on Cyanosis and softening of cervix (indicates normal pregnancy)
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Sx: Peripartum Cardiomyopathy
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Lung crackles Murmu ↓EF
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Doing CVS before 9 weeks increases risk of
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Limb abnormalities
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How often do you monitor FHR in a noncomplicated patient?
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First Stage= q30min Second Stage= q15min
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How often do you monitor FHR in a complicated patient?
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First Stage= q15min Second Stage= q5min
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Categories A,B,C,D,X
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A= Humans testing, 1st trimester (and after) B= Animals safe OR animals arent safe but people were C= Animals werent safe, unclear in humans but benefits MAY outweigh risk D= Human risk is known BUT benefits may outweight risks X= NOT SAFE, risks clearly outweigh the benefits
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Timeline: Misoprostol and D&C
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IM-Miso (or MTX)= 7 weeks Vag/Subling/Bucc Miso= 7 weeks D&C= 13 weeks
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Oligohydramnios is defined by
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Amniotic Fluid Index <5
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Tx: HA in Preggers
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Acetaminophen (NSAIDs, Aspirin, Sumatriptan should be avoided)
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Timeline of structures seen in U/S
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1. Gestational Sac 2. Yolk Sac 3. Fetal Pole
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Tx: Membrane rupture + Fetal Bradycardia
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Sterile Vaginal Exam to check for uterine cord prolapse
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MC Complications of IUGR
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Meconium Aspiration RDS Asphyxia NEC
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Tx: Placenta Previa
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Bedrest with Betamethasone
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Pregnancy Effects on Respiratory system
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↑ TV, PaO2 ↓ ERV, PaCO2 RR stays the same
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Screening at first prenatal visit
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BURCH hep B Urine Rubella Chlamydia HIV
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Tx: Oligohydramnios
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Biweekly BPP monitoring and induction of fetal lung maturity
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5 Cardinal Movements of labor
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Engagement Descent Flexion Internal rotation Extension \"Engage D FIrE\"
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Tx: Retained Placenta
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1. Oxtytocin 2. Hand 3. Curettage
