2. Pregnancy Dx: hCG > 5 IU/mL, first detectable 6-8 d after ovulation. Softening of uterus/cervix, blue-ish vagina @ 6 wks; Palpable uterus on abd exam/heart tones @ 12 wks.
3. Fundal Height: defined as distance from symphysis to top of uterine fundus. Between 18-36 wks it should be equal to the gestational age in cm's (+ or - 2 cm).
4. Quad Screen: (2nd tri aneuploidy test): AFP, -hCG, Estriol, inhibin A.AFP: NTDs, Gastrochesis, Omphocele, fetal death. AFP in trisomy 18 or 21 or inaccurate dating
5. Vaginal Culture at 35-37 wks for Group B Strep if c/s is positive, give prophylactic penicillin in labor (to prevent early onset neonatal grp B strep sepsis)
CASTRO: Teratology/Prenatal Dx
1. Pregestational Diabetes: (uncontrolled glucose=teratogenic). Target goals: HbA1c < 6.5, FBS 70-90 mg/dL, and 1 hr PPBS 100-130 mg/dL. Assess for end-organ damage.
2. Hemoglobin Bart (a fetal thalassemia): deletion of all 4 alpha chain genes fetal anemiahigh output failurenon-immune hydrops fetalisfetal death.
3. Prenatal Screening: 1st tri-u/s for nuchal tanslucency, serum hCG, PAPP-A plus maternal agepos? offer diagnostic CVS. 2nd trim Screening: Quad Screen. Integrative
screening combines 1st tri & 2nd tri tests (95% detection of aneuploidy with 5% false positive rate)
4. maternal serum AFP: Open NTD (anencephaly, spina bifida, encephalocele)get amniocentesis (for acetylcholinesterase), gastroschisis, omphalocele, placental abruption,
fetal demise, multiple gestation or INCORRECT gestational age dating.
5. Valproic Acid teratogenic class X or D: causes NTDs (open spina bifida) and facial dysmorphisms.
6. Dilantin: Fetal Hydantoin Syndrome: craniofacial abn (clefts, hypertelorism), hypoplastic digits, cardiac abn, growth restrictions, mental deficiencies & neonatal coagulopathy
CASTRO: Normal/Abnormal Labor/Delivery & Post-partum Care
1. Engagement: biparietal diameter has entered plane of the inlet (aka "zero station"-lowest part of presenting baby is at ischial spine level).
2. True Labor: repetitive contractions w/ progressive effacement & dilation of the cervix (max dilation is usually 10 cm)
3. Active Phase of Labor: more rapid cervical dilation, assume if 4 cm dilated. q2hr exams to monitor. Give Penicillin for Group B strep prophylaxis. Avoid narcotics!
4. Active Phase Arrest: no change in dilation for 2 or more hrsdo Amniotomy w/ intrauterine pressure catheter (measures contraction strength) inadequate contractions if
<200 montevideos (contractions too weak) give Pitocin to induce (if this doesn't work, must do C-section)
5. Third Stage of Labor: b/w baby delivery & placenta deliv ~30 mins. Delivering Placenta: gentle traction on umbilical cord (lengethening of cord, sudden gush of blood,
globular configuration of uterus); if you pull on cord before placental separationuterine inversion ( hemorrhage & shock). After placenta delivery, watch out for uterine atony
w/ hemorrhage (avoid w/ oxytocin & uterine massage).
6. Endometritis -few days postpartum: fever, uterine tenderness, foul-smell. Polymicrobial. Tx: broad-spectrum antibiotics (Ampicillin & Gentamycin +/- Clindamycin)
7. Septic Pelvic Vein Thrombophlebitis - postpartum, variable timing. SPIKING fevers despite abx, right-sided uterine pain, ADD heparin. increased risk w/ c-sections.
CASTRO: Intra/Antepartum Care/Fetal Assessment
1. Non-Stress test (NST) is REACTIVE if has two instances of 15 beat accelerations lasting for 15 seconds within 20 minutes. This is NORMAL and reassuring. Safe to continue.
2. Biophysical Profile-in utero apgar score, amniotic fluid level. Umbilical Artery Doppler-reverse diastolic flow suggests lack of placental perfusion, indicates need for delivery.
3. Assess fetal lung maturity diagnostic amniocentesis for L:S ratio. (if Lecithin/Sphingomyelin ratio is > 2.0, means lungs are mature).
4. Fetal Heart Decelerations: Early Deceleration-(normal) benign head compression causing vagal reflex; vs Late DecelerationsUteroplacental Insufficiency (smooth slowing
of FHR that starts after contraction starts and ends after contraction finishes--seen in HTN, preeclampsia, abruption, IUGR and cocaine use.
CASTRO: OB clinical Cases
1. Class A-NO risk. Class B-no evidence of risk in humans (animal studies w/o risk & no controlled human studies); Class C-risk cannot be ruled out (animals w/ adverse, no
human studies; or no studies at all); Class D-positive evidence of risk (only use if benefit>known risk; eg Valproate, ACEi, Warfarin, Aminoglycosides), Class X-contraindicated
2. Definition of spontaneous abortion (miscarriage) is loss of fetus before 20 weeks.
3. Missed Abortion - Fetus has died & retained in the uterus (usually for more than 6 wks). Declining hCG levels. Closed cervical os. No heartbeat. No bleeding or contractions.
CASTRO: Med & Surg Complications of Pregnancy I & II
1. Preeclampsia: BP 140/90 AFTER 20 wks gestation (in without chronic HTN) PLUS Proteinuria 0.3 gm/24 hrs (30 mg/dL or 1+ on dipstick). Sx: edema @ hands/face
2. Severe features of preeclampsia: HA/visual disturbances, thrombocytopenia (or HELLP), Cr > 1.1 or doubled, LFTs/hepatic abnormalities (N/V/RUQ pain), pulm edema
3. HELLP syndrome: Hemolysis, Elevated Liver function(LDH>900, bilirubin>1.2), Low Platelets (<100,000), and usually drop in hbg/hct.
4. Eclampsia: grand mal seizures on top of preeclampsia sx, 50% occur intrapartum. tx: Magnesium Sulfate (caution if renal impairment).
5. Hypertensive Emergency in pregnancy: 160/105 tx: IV hydralazine or Labetalol. For tx of Chronic HTN in pregnancy: Methyldopa, Labetalol or Nifedipine.
6. Screening for Gestational Diabetes50g oral glucose challenge in 1st trimester; if abnormal3 hr glucose tolerance test (this step is diagnostic). Post-partum, do 75g GTT 2
months after delivery to see if persisting gestational diabetes or overt diabetes.
7. Diabetes effects on FETUS: hyperglycemia, hyperinsulinemia, surfactant, macrosomia, polyhydramnios, shoulder dystocia; Pregestational Diabetes increase risk of
miscarriage, congenital anomalies (cardiac & NTD), IUGR.
8. Diabetes effects on NEONATE: hypoglycemia (when cord is cut), hypocalcemia, delayed maturation, RDS, hyperbilirubin, polycythemia, cardiomyopathy.
CASTRO: Med & Surg Complications of Pregnancy III
1. Eisenmenger's Syndrome: primary pulmonary HTN and pregnancy is associated with 50% mortality rate! (are in danger of undergoing decompensation in pregnancy)
2. UTI: get UA, c/s. Tx: Nitrofurantoin or Cephalexin [AVOID sulfonamides in 3rd tri (bilirubin displacement); AVOID FQs (cartilage abn)] Pyelonephritis (Hematuria, flank
pain, CVA tender), risk of SEPTIC SHOCK, pulmonary edema, ARDS & preterm labor. Tx: Hospitalization, IV abx, hydration. If >1 infxn- supressive therapy.
3. Anti-phospholipid Syndome: at least 1 Ab assoc w thrombosis (anti-cardiolipin &/or lupus Ab) PLUS adverse obstetrical event (eg fetal demise). Tx: Heparin & lo dose aspirin
4. Intrahepatic Cholestasis of Pregnancy (Benign): diffuse pruritis (itching) without rash, +/- jaundice, no pain. Risks: fetal demise, preterm labor. Dx: increased Bile Acids. Tx:
Ursodeoxycholic Acid, antihistamines, freq antepartum testing, delivery baby at 37 wks.
5. Hyperthyroid pregnant: PTU at LOWEST dose (want to avoid thyroid storm), but since CAN cross placenta, will cause fetal goiter. Can also cause transient neonatal
thyrotoxicosis or hypothyroidism.
CASTRO: Obstetrical Complications I (IUGR, IUFD)
1. Diagnosis of IUGR: accurate GA, est fetal weight by u/s, population-specific growth curves. Clinical assessment: Do Fundal Height Assessment (screening) between 18-36
wks, cm's equal to GA. But get an U/S femur length/head circumference, etc of for more accurate dx.
2. Deliver IUGR fetus when: (1) fetal testing is non-reassuring (deceleration, oligohydramnios, abn umbilical doppler), fetus near term/fully mature, or no growth in 3 weeks.
3. LGA/Macrosomia: (wt > 4,000 grams) causes: maternal obesity, excessive wt gain, diabetes, gestational diabetes. Diagnose to avoid delivery problems (cephalopelvic
disproportion/shoulder dystocia)
4. IUFD: death in utero after 20 wks (stillbirth). Dx: u/s shows no cardiac activity. Tx: induce labor/operate. CAUTION: DIC can result from a retained fetus > 6 wks
CASTRO: Obstetrical Complications II (Pre-term, PROM, Post-term)
1. Preterm Labor prevention: modifiable factors, physical activity, Progesterone Supplementation (daily vaginal suppositories or IM injections 2nd trimester until 36 wks).
Tocolytics: MgSO4, Terbuatline/Ritodrine, Nifedipine, PG synthetase inhibitor (Indomethacin-caution: can cause premature closure of ductus, renal abn w/ oligohydramnios)
2. PROM: ruptured chorioamniotic membranes prior to labor onset, eg Chorioamnionitis- w/ fever, uterine tenderness, maternal/fetal tachycardia, poss purulent discharge-usually POLYMICROBIAL--Tx: broad spectrum antibiotics for aerobes/anaerobes PLUS must deliver baby!
4. PPROM: rupture chorioamniotic membr <37 weeks. Fetal complic: contraction deformity, amniotic band syndrome, pulm hypoplasia (2nd tri PPROM). Dx: Clear watery d/c
from cervical os & vaginal pooling NITRAZINE test "Ferning" pattern confirms it is cervical mucusruptured membranes confirmed send for GC/Chlamydia/GBS, U/S
for AFI/fetal lie/est fetal wt, external fetal HR monitoringBetamethasone if <34 wks, AVOID digital cervical unless in labor (risk infection)
5. Post-term Labor: after 42 wks. most common cause is INACCURATE DATING. Rare Causes: anencephaly, fetal adrenal hypoplasia, steriod sulfatase deficiency (XR, male w/
congenital ichthyosis). Complications: fetal postmaturity syndrome, macrosomia, placental dysfxn, Meconium Aspiration Syndrome (persistent pulm HTN, neurodev probs)
6. Oligohydramnios (AFI <5) caused by: PROM, renal/bladder anomalies, Uteroplacental insufficiency (eg IUGR, HTN, preeclampsia, maternal drug use), post-term pregnancy
CASTRO: Obstet Complications III (3rd Tri Bleeding/Rh Disease)
1. RhD Neg & Ab screen Posget Antibody ID & Titer (to determine if Anti(D) vs benign)if AntiD positive (Rh Neg sensitized) check Dad's Rh status/zygosityif fetus
RhD positiverecheck Ab titer every 4 wks after 20 wks GA if antiD titer 1:16Serial MCA Doppler on fetus to check for anemia [early sign of hydrops fetalis]
2. Give Rho-GAM to: (1) RhD Neg, Unsensitized (AntiD neg) @ 28 wks & IF RhD Pos baby, give it AGAIN 72 hrs from delivery; (2) to any RhD neg, unsensitized (antiD neg)
w/ abortion, ectopic, vaginal bleeding, abd trauma, amniocentesis or external/cephalic version. (also partial molar pregnancy, give to any molar bc often can't determine type)
3. Kleihauer Betke test used to determine extent of fetal maternal hemorrhage (estimate # fetal cells in maternal circulation)
4. Placenta Previa: placenta covers internal os; (Prev C-section STRONGLY assoc w/ Placenta Accreta) get Ultrasound if previa, NO VAGINAL EXAM in 3rd trim; always
deliver by another C-section! (presents w/ painless vaginal bleeding)
5. Abruptio Placentae: premature separation of a normally placed placenta. Risk factors: Maternal vascular disease. Findings: PAINFUL vaginal bleeding, uterine contractions,
signs of fetal hypoxia, hypovolemic shock.
FUCHS: Oxytocics/Tocolytics
1. Oxytocin: Gq/PLC/IP3/Ca2+ release/MLCKUterine Contractions (& local prostaglandins). USE: induce labor, stop postpartum bleed/adjunct to abortion. ADVERSE to
NEONATE: PVCs, bradycardia, CNS dmg, SZs, jaundice, retinal hemorrhage, death. ADVERSE to : PVCs, HTN/HoTN, N/V, pelvic hematoma, uterine
hypertonicity/spasm/rupture, fatal afibrinogenemia. SAH, severe water intox, SZs, coma & death (assoc w/ slow oxytocin infusion over 24 hrs). CONTRAINDICATIONS:
cephalopelvic disproportion, transverse fetal lie, c-section preferred, hypertonic uterine patterns, severe toxemia, cord prolapse, total placenta previa, casa previa.
2. Dinoprostone: prostaglandin E2. Cervix softening, ripening & dilation. USE: induce labor; abortion wk 12-20; or evacuation up to 28 wks. Dino preferred if Pt is asthmatic
(over carboprost). CAUTION: hx of glaucoma/asthma, CV/Renal/Liver dz; or if contraindications for vaginal delivery. (generally, a 2nd line therapy if can't use oxytocin)
3. Mifepristone (RU-486): Progesterone receptor blocker. progesterone production from CL, prostaglandins contracts uterus for expulsion of detached blastocyst in Rxinduced abortions thru day 49. (also used for hyperglycemia 2' to hypercortisolism in Cushing syndrome)
4. Methylergonovine (Ergot Alkaloid): -receptors/serotonin receptors, inhibits NO release vasoconstriction, uterine/cervical contractions. USE: tx postpartum hemorrhage.
SIDES: HTN, acute MI, stroke, HA/hallucinations, Ergotism (vascular ischemia & gangrene)
5. Magnesium Sulfate: inhibits Ca2+ influx uterine smooth mm relaxes uterus. USE: DELAYS labor; or Tx Eclampsia. CAUTION: bleeding disoders (slow blood clotting),
SIDES: heart block, renal failure, confusion/coma.
6. Terbutaline: -adrenergic/AC/cAMP relaxation of bronchial & uterine smooth mm. USE: Asthma & off-label inhibition of contractions. SIDES: nervousness/increased
glucose/decreased K. Tachycardia/HTN, musc cramps/dizziness/HA/insomnia/dry mouth/N/V.
MISC:
1. Betamethasone: given to accelerate development of fetal lungs if < 34 weeks preterm, to decrease risk of neonatal resp distress syndrome (RDS)
2. Right-sided hydronephrosis (mild) in pregnancy is a NORMAL finding because uterus is dextro-rotated (doesn't necessarily mean renal stone)
3. Diastolic murmurs--always ABNORMAL findings in pregnant women (systolic murmurs can be normal)
4. Normal fetal HR is 110-160 bpm.
5. Much higher risk of placenta accreta (when placenta grows too deeply into uterus) in with previous C-section (bc scarred uterine walls).
CAN CROSS PLACENTA: Coumadin/Warfarin, PTU, Methimazole, SLE Ab's (Anti-SSA/Anti-Ro; Anti-SSB/Anti-La), AntiD Ab's, IgG, Iodine, cortisol, glucose
Dilantin (phenytoid), DES, OCPs, Tetracyclines, Doxycycline, Valproate, Diazepam, Lithium, Toxoplasma, Thyroid stimulating immunoglobulin (from Graves), TRH
CANNOT CROSS PLACENTA: IgM, insulin, glucagon, free T3 or T4, thyroxine, Heparin, TSH
Causes of IUGR: Tobacco, Cocaine, Methamphetamine, EtOH, chemotherapy (methotraxate), Dilantin, Carbamazepine, Cystic Fibrosis, SLE, Congenital Rubella, Congenital
VZV, polyhydramnios, uteroplacental insufficiency, in utero infection, CMV, nutritional, multiple gestations, maternal hypertension, low maternal BMI
Tx of Pregnant Conditions:
- ALL young : 400 mcg/day (0.4 mg/d) of Folic Acid; but if AT RISK for NTDs: 4 g/day of Folic Acid (@ 1 month preconception & 1st trimester)
- Chronic/Essential HTN pregnant pt: Methyldopa, Nifedipine or labetalol (and monitor for IUGR)
- Pregestational Diabetes (pre-existing): Insulin (gold-standard) or Glyburide.
- Endometritis (puerperium complication): broad-spectrum antibiotics (Ampicillin + Gentamycin, with or without Clindamycin)
- Septic Pelvic Vein Thrombophlebitis: antibiotics + heparin
- Hypertensive emergency: IV Hydralazine
- Eclampsia: Magnesium Sulfate
- Pulmonary Embolism: Heparin
- Intrahepatic Cholestasis of Pregnancy: Ursodeoxycholic Acid & Antihistamines
Rx Treatments:
- Bacterial Vaginosis: Metronidazole (oral or topical) or Clindamycin (cream); [note: if hx of preterm or symptomatic-oral metro or oral clinda]
- Candida infection: topical -azoles (or 1 time oral fluconazole)
- Vagina Trichomonas: Metronidazole + treat partner
- Cervicitis: Ceftriaxone + Azithromycin
- Outpatient PID: Ceftri + Doxy +/- Metronidazole.
- Inpatient PID: IV Ceftriaxone + PO Doxycycline
- GBS prophylaxis/tx: Penicillin
- incomplete abortion: Misoprostol (or surgically vacuum)
- prevent recurrent genital HSV: daily acyclovir, famciclovir or valacyclovir (suppressive therapy)
- Chlamydia in pregnancy: azithromycin or amoxicillin
Statistics [2 questions]
- Fetal Death Rate: approx 7/1000
- 1 million pill users get pregnant in U.S. each year.
- NO contraceptives for 1 year will result in 85% pregnancy rate.
- 400K die yearly due to pregnancy & childbirth complications
- 51% of U.S. pregnancies are unintended
- 50K abortions are attempted daily.
- 30% of don't know how dangerous pregnancy is (risk of thrombosis, diabetes & HTN)