1.

Antiphospholipid antibody syndrome ( APS ) is associated with a false positive

VDRL ,
prolonged PTT, and thrombocytopenia. APS can promote arterial and venous thromboses
and a resultant tendency toward spontaneous abortions.Potential complications
include
recurrent first-trimester miscarriage , fetal demise , preeclampsia, and fetal
growth
res triction Prophylaxis with low dose aspirin and LMWHeparin are recommended to
avoid
pregnancy loss.warfarin c/i in pregnancy given postpartum

2.inevitable abortion presents with heavy vaginal bleeding, cramping, and a dilated
cervix(speculum-os open) without passage of gestational tissue(vaginal usg).
Surgical management
( eg , suction&curettage) is indicated for hemodynamically unstable
patients(bleeding,anemia)
otherwise expectant or medical(misoprostol).
add rho-d for isoimmunization
only if persistent bleeding after s&c-hysterectomy
oxytocin has no effect on 1st and 2nd trimester uterus(no receptors yet)

3.A complete abortion , a type of spontaneous abortio n, typically presents as

lower
abdominal pain and heavy vaginal bleeding with the passage of clots at <20 weeks
gestation. These symptoms worsen until the products of conception, often described
as
a solid or sack-like bloody, white mass, are expelled and the symptoms lessen and
resolve. Pelvic examination findings include a normal-size uterus with a closed
cervix . Ultrasonography rev ea ls an empty uterus and normal adnexa. A positive
13-
hCG is common in patients who present with a complete abortion as it can take up to
6
weeks for hCG levels to become undetectable. Risk factors for spontaneous abortion
include tobacco, alcohol, and cocaine use.

A threatened abortion also presents with pain, bleeding, and a

closed cervix at <20 weeks gestation, but ultrasound would reveal a normal in
traute rin e
gestation with a normal fetal heartbeat. Threatened abortions often have an
associated
subchorionic hematoma, an abnormal collection of blood between the placenta a nd
uterus.

4.inevitable abortion presents with vaginal bleeding, lower abdominal pain,and a

dilated cervix without expulsion of the products of conception. Ultrasound
typically
reveals a nonviable gestation in the lower uterine segment.

5.Septic abortion - medical emergency

Risk factors
R etained POC from :
Elective abortion with non sterile technique
Missed or incomplete abortion (ra re)
Clinical
Fever, chills , abdominal pain
Sanguinopurulent vaginal discharge
Boggy, tender uterus; dilated cervix
Pelvic ultrasound : Retained POC , thick endometrial stripe,echogenous with blood
flow

Management
Intravenous fluids
Broad-spectrum antibiotics
Suction curettage

6.Abruptio placentae refers to placental separation from the uterine wall occurring
before
fetal delivery of a normally implanted placenta(not lower segment impla).
Hypertension is the
most common risk factor; cocaine use and maternal
trauma(Blunt abdominal tr auma (eg, motor vehicle accident) is a significant risk
factor for
severe hemorrhage from abruptio placenta) are other important risk factors.
Abruptio placentae
typically presents with abdominal and/ or back pain and "painful" vaginal
bleeding(most common
late trimester bleed) .which can range from severe to absent. as bleeding may be
concealed
behind the placenta(increased fundal height). Blood may have an
uterotonic effect, causing a firm uterus and unusually low-amplitude but frequen t
contractions .clincial diagnosis
The extent of the placental detachment also can vary. Smaller separations can be
tolerated by the fetus, whereas larger separations can compromise fetal oxygenation
and
result in heart rate tracing abnormalities (eg, absent variability, recurrent
decelerations,
or fetal bradycardia or demise).DIC and profound hypotension in severe abruption
and
Couvelaire uterus refers to blood extravasating
between the myometrial fibers, appearing like bruises on the serosal surface.
usg -retroplacental hematoma
Management. Management is variable: 1st step iv fluids crystalloids.Emergency
is indicated for persistent bleeding and/ or
hypotension unresponsive to fluid resuscitation. A complete blood count should be
repeated after administration of intravenous fluids to determine if tr ansfusion of
crossmatched blood is appropriate.
Emergency cesarean deliveryThis is performed if maternal or fetal jeopardy is
pres-
ent as soon as the mother is stabilized.
Vaginal deliveryThis is performed if bleeding is heavy but controlled or
pregnancy
is >36 weeks. Perform amniotomy and induce labor. Place external monitors to assess
fetal heart rate pattern and contractions. Avoid cesarean delivery if the fetus is
dead.
Conservative in-hospital observationThis is performed if mother and fetus are
stable and remote from term, bleeding is minimal or decreasing, and contractions
are
subsiding. Confirm normal placental implantation with sonogram and replace blood
loss with crystalloid and blood products as needed.
7.Hypotension occurs in up to 10% of epidurals given during labor and can be easily
prevented and treated. Continuous epidural analgesia involv es in fusion of a low
concentration of a local anesthetic into the epidural space at the L2-L5 level,
blocking
nerv es r es ponsible fo r labor pa in . It is a hi ghly effective modality for pa
in relief in labor.
Hyp otension occurs when the s ympathetic nerve fibers responsible for vascular
tone are
blocked, resulting in vasodilation (venous p oo ling), decreased venous return to
the right
s id e of the h ea rt, a nd d ec r eased cardiac output. Persistent, untreated
hypotension can
r es ul t in d ecreased placental perfusion a nd ca n l ea d to fetal acidosis. It
ca n be
prevented by aggressive intravenous fluid volume expansion prior to epidural
placement.
Treatment includes left uterine displacement (positioning patient on the left side)
to
improve venous return, additional intravenous fluid bolus, or vasopressor
administration.

Depression of cervical spinal cord and brain stem acti vi ty occ urs when l oca l
anesth es ia asce n ds toward the h ead , al so kn o wn as a " hi gh spin al" or "
total spinal," a
dangerous complication of epidural anesthesia. It may happen with intratheca l
injection
or ove rdose of the anestheti c. First signs in clude hypotension, bradycardia, and
respiratory difficulty, and l ate r, di ap hr ag matic pa ralysis a nd possibly ca
rdi op ulm onary
arr est.

Leakage of cerebral spinal fluid may occur if the dura is in advertently

punctured during epidural placement. This results in leakage of spinal fluid and is
known
as a "wet tap." Patients may experience postural headaches that are worse with
sitting
up and i mproved wi th lying down after delivery. Hypotension is not characteristic

8.uteroplacental insufficiency in postterm pregnancy- When placental function is

impaired,
the compression of the uterine vessels during contractions can reduce delivery of
oxygenated
blood to the fetus. The feta l heart rate ( FHR ) slows in r espo n se to the r es
ul ta nt hy po xi a,
ca usi ng a late deceleration,whi ch is characte ri zed by a gradual FHR d ec r
ease wi th the
nadir occurring a fter the peak of the contraction. In addition, im pa i red feta l
perfusion
may r es ul t in poor ur in e pro du ction a nd oligohydramnios (a mni otic fl ui d
index :>5 cm or
deepest vertical pocket <2 cm on ultrasound).
Late-te rm (41 w ee ks gesta ti on) a nd post-te rm ( 42 w ee ks ge sta ti on) pr
eg nanci es are at
ri sk fo r uterop lacental insuff ic iency . Antenatal fetal surveillan ce is fre
qu ently initiated
at 41 weeks gestation with a biophysical profile ( BPP ), whi ch includes a nonstr
es s
test (N ST) a nd ultrasound evaluation of the a mni otic fluid vo lum e a nd fe tal
activity

9. Common causes of fetal tachycardia include maternal fever, maternal

hyperthyroidism,
medication use (eg,terbutaline), and abruptio placentae.

Chorioamnionitis is an Infection of the uterine decidua, placenta, amniotic fluid,

or
membranes that typically results from migration of vaginal flora through the cervix
and
ruptured membranes. Risk factors for chorioamnionitis include protracted labor,
prolonged membrane rupture (>24 hours), and nulliparity.
The presence of maternal fever (3 8 C [>100.4 F]) suggests chorioamnionitis as the
etiology of the fetal tachycardia. Other common si gns and symptoms of
chorioamnionitis
include maternal tachycardia, uterine fundal tenderness, and foul-smelling amniotic
fluid. Broad-spectrum intravenous antibiotics must be administered promptly to
treat
both mother and fetus

10."Oxytocin" is a potent uterotonic hormone secreted by the posterior pituitary

gland. A
synthetic analog of oxytocin is used in labor induction and augmentation as well as
in
the prevention and management of postpartum hemorrhage.
All agents used for labor induction, including oxytocin, can cause "uterine
tachysystole" ,
which refers to abnormally frequent contractions (>5 contractions in 10 minutes
averaged over a 30-minute period ). Induction drugs also increase the risk of
tetanic
(intense or prolonged) contractions, particularly at higher doses, such as in this
patient.
Although many fetuses tolerate tachysystole with no adverse outcome, fetal heart
rate
tracing abnormalities are more common with tachysystole due to insufficient uterine
relaxation between contractions. causing placental spiral artery constriction, a
decrease
in placental blood flow, and fetal hypoxia. Consequently, tac hy systole is
associated with
an increased risk fo r cesarean delivery, low umbilical cord pH, and neonatal
intensive
care unit admission.
also adverse effects are hyponatremia,hypotension(similarity to adh)

11.Reactive Nonstress test

Baseli ne of 110-160/min
Moderate variability (6-25/min)
>2accelerations in 20 minutes,each peaking >15/min above baseline & lasting >15
seconds

most likely cause of the lack of accelerations in this fetus with normal reported
fetal
movement is fetal sleep. Fetal sleep cycles can last as
long as 40minutes. A typical NST will last 20 minutes, but a nonreactive N ST
should
be extended to 40-120 minutes to ensure that fetal activity outside of sleep is
capt ur ed. Due to a high false-positive rate, a nonreact iv e N ST should be
followed with
either a biophysical profile or contraction stress test before concluding th at the
fetus may
be hypoxic and needs intervention

Graves disease can cause fetal hyperthyroidism due to transplacental

passage of maternal thyroid-stimul at ing antibodies, which is usually marked by
fetal
tachycardia (baseline fetal heart rate160/ m i n ).Methimazole is the first-line
drug for
hyperthyroidism in the second and third trimester of pregnancy and is not
associated with
fetal heart rate tracing abnormalities.

Fetal heart rate accelerations are the product of the fetal sympathetic
nervous system, which matures at 26-28 weeks

12severe congenital anomaly incompatible with life , so labor should be allowed to

proceed. patients with bilateral renal agenesis will not survive ou ts i de the
uterus
becau se of the se vere p ulm onary hy pop lasia associated with renal age nesis.
They will
survive in u te ro becau se the pl ace n ta o xy ge nates the feta l bl ood a nd
removes waste
produ cts fro m the feta l circulation.

13.Complications of shoulder dystocia: Risk factors include infant

large for gestational age (birth weight >4 kg ), maternal diabetes, and maternal
obesity.
Fractured clavicle
Upper-arm crepitus/bony irregularity
Decreased Moro reflex due to pain on affected side
Intact biceps & grasp reflexes

Fractured humerus
Upper-arm crepitus/bony irregularity
Decreased Moro reflex due to pain on affected side
Intact biceps & grasp reflexes

Erb-duchenne palsy
Decreased Moro & biceps reflex es on affected side
waiter's tip"
Exte nd ed elbow
P ro n ate d forea rm
Flexed wrist & fi ng ers
Intact grasp reflex

Klumpke palsy
Claw hand"
E xt ended wrist
Hypere xt ended metacarpo ph alangeal join ts
Flexed interphalangeal joints
Absent grasp reflex
Homer syndrome (ptosis, miosis)
 Intact Moro & biceps reflexes

Perinatal asphyxia
Variable presentation dependi ng on duration of hypoxia
Altered mental status (eg, irritability, lethargy), respiratory or
feeding difficulties, poor tone, seizure

14.Risk factors for fetal macrosomia

(Weight >4kg)
Maternal
Advanced age
Diabetes
Excessive weight gain during pregnancy or pr e-existing ob esity
Multiparity
Fetal
African-American or Hispanic ethnicity
Male sex

15Contraindications to breastfeeding
Maternal
Active untreated tuberculosis (mothers may start
breastfeeding 2 weeks after anti-tuberculin therapy)
Maternal HIV infection (in developed countries where
formula is readily available)
Herpetic breast lesions
Varicella infection <5 days before or 2 days after delivery
Chemotherapy or ongoing radiation therapy
Active abuse of alcohol or drugs
Infant Galactosemia
Hepatitis b and C are not considered contraindications,and mothers with
these conditions should be encouraged to breastfeed
Post-term pregnancy

16.breast engorgement , which can occur 3-5 days after delivery, when
colostrum is replaced by milk.Symptoms of engorgement include bilateral, symmetric
br east fullness , tenderness ,
and warmth , without fever. Intrapartum intravenous fluid administr at ion can also
cause
breast edema and exacerbate pain.
Cool compresses, acetam in ophen, and nonsteroidal anti-inflammatory drugs may be
used for symptom contro l. Patients should experience improvement as breastfeeding
or
regul ar pumping is established.

17Breech presentation describes a fetus whose buttocks or feet are the presenting
part in the birth canal. Risk factors for breech presentation include prematurit y,
multipa rity, multiple ges ta ti o n, ute rin e anomali es , fe tal anomali es , a
nd a bn o rm al
pl ace n ta ti on. Br eec h pr ese n ta ti on should be s usp ec ted if th e feta l
vertex (h ea d) is
pa lp ate d at the fundus or a fe tal pr ese nt in g part is not pa lp a bl e on
pelvic exa min a ti o n,
and should always be co nfirm ed by transabdomi na l u ltr asound.
Vaginal delivery of a singleton breech fetus is generally contraindicated due to a
higher
incidence of birth asphyxia and trauma compared to breech cesarean delivery.
"External cephalic version" ( EC V) involves manual conversion of the fetus to
vertex
presentation so that the patient can labor and potentially avoid cesarean delivery.
A patient
with a singleton breech fetus with no contraindications to vaginal
delivery(eg,placenta previa,
active herpes lesion,prior classical cesarean delivery) or ECV ( eg,ruptured
membranes ,
abnormal fetal heart tracing,oligohydramnios ) should be offered ECV at <:37 weeks
gestation. A history of a low transverse cesarean delivery is not a
contraindication for
EC V a nd d oes not d ec r ease the likelihood that EC V will be successf ul .
Contraindicati ons to external cephalic version
Indications for cesa rean de li very regardl es s of fetal lie (eg,
failure to progress during labor, non-reassuring fetal status)
Placental abnormalities (eg , placenta previa or abruption)
Oligohydramnios
Ruptured membranes
Hyperextended fetal head
Fetal or uterine anomaly
Multiple gestation

Internal podalic version is u se d fo r the b reec h e xtr action of a

malpr ese nting seco nd t win . Br eec h delivery of a seco nd twin has a lower ri
sk of
as phyxi a th an cesa r ea n delivery a nd is not co ntraindi ca ted. Beca u se in
te rn al po dalic
version involv es a v ag in al br eec h delive ry, it is co ntraindi cate d in s in
gl eto n ges tation s.

Cesa r ea n delivery is indi cate d if the pa tient refu ses EC V or if EC V

fa il s. Cesarean delivery for persi ste nt br eec h pr ese ntation is perfo rm ed
at 39 w ee ks
gesta ti on.

18. Dis or ders of the ac ti ve phase of labor

(1)Protraction
Cervical chan ge that is slower than expected
+!- inadequate contractions
rx oxytocin
(2)Arrest
No cervical change for >4 hours with adequate contractions
or
No cervical change for >6 hours with
inadequate contractions
rx cesarian delivery
With an intrauterine pressure catheter in place, the peak contraction pressure
minus the
baseline intrauterine pressure (both in mm Hg) determines the number of Montevideo
units (MVUs) for the contraction. Contractions generating >200 MVUs in a 10-minute
interval are considered adequate.

19.chorioamnionitis, also known as intraamniotic infection ( IAI). This

complication is common In patients who have prolonged rupture of the membranes
(ROM), which occurs before onset of labor and is defined as prolonged when rupture
lasts >18 hours between the time of rupture and birth. However, IAi can also occur
in
patients with intact membranes. Infections are usually polymicrobial (vaginal or
enteric
flora) and ascend from the vagina, move up the cervical canal into the uterus, and
spread
through the amniotic fluid, amniotic membranes, placenta, and uterine
decidua. Diagnosis is based on the presence of maternal fever and
1 of the following:
uterine tenderness, maternal or fetal tachycardia, malodorous amniotic fluid, or
purulent
vaginal discharge. Amniotic fluid does not need to be purulent or malodorous to
make
the IAI diagnosis.
Chorioamnionitis (intra-amniotic infection)

Risk factors
Prolonged rupture of membranes
Prolonged labor
Internal fetal or uterine monitoring devices
Presence of genital tract pathogens
diagnosis
Maternal fever > 38 C (100.4 F) P LU S >1 of
the following:
Maternal o Tachycardia >100 / min,Uterine tenderness,Malodorous /purulent
amniotic fluid
or vaginal discharge,White blood cells >15,000 / IJL
Fetal tachycardia >160 / min
Treatment
Broad-spectrum antibiotics Delivery oxytocin to accelerate labor
Complications
Maternal: Uterine atony, postpartum hemorrhage , endometritis
Neonatal: Premature birth, infection,encephalopathy,cerebral palsy,death
Chorioamnionitis is not an indication for cesarean delivery.Tocolysis is
contraindicated

20.Medroxy progesterone side effects may be similar to pregnancy symptoms ( eg ,

breast
tenderness , weight gain, fatigue). Women of childbearing age with absence of
menses
fo r >1 month should be evaluated for pregnancy.

21.The maternal serum quadruple test is performed in the second trimester (15-20
weeks)
and consists of maternal serum a-fetal protein (MSAFP),B hcg,estriol, and inhibin A

Down syndrome(21t)has a profile of low MSAFP, low

estriol, elevated b-hCG , and increased inhibin A level. The quadruple screen
detects
-80 % of fetuses with Down syndrome but has a false-positive rate of -5 %.
Patients with abnormal quadruple screening results can be offered cell -fr ee fetal
DNA
testing, which measures circulating , free maternal and fetal DNA in maternal
plasma and
has a sensitivity and specificity of up to 99 %. An ultrasound should be performed
to
evaluate for fetal anomalies.
Trisomy 18 - low bhcg low MSAFP , low estriol,normal inhhibin a

22.presentation of vaginal bleeding/spotting, lower abdominal pain, and

adnexal tenderness is su sp icious fo r an unruptur ed ectopic pregnancy. The
majority of
ectopic pregnancies occ ur in the fallopian tube. Most ectopic pr eg nanci es are
related
to p ri or in fection with c hl a my dia and/or go no rrh ea ca us in g tu ba l dam
age , and th ese
in fections are often asymptomatic (su bc lini ca l pe lvic in fla mm ato ry
disease). Other ri sk
factors in c lu de p ri or tu ba l su rge ry, p ri or ectopic pregnanc y, and in vi
tro fertili zat ion

The di ag nosis of ectopic pr eg nancy is made by a pregnancy test co mb in ed with

transvaginal u lt rasound (TV US ). Ectop ic pr eg nancy is virtually r ul ed out
if TV US
shows an in trau te rin e gestational sac in the sett in g of a pos itive p-h CG
test. Co nver se ly,
ectopic pr eg nancy is co n fi rm ed if the gestational sac is see n at an ectopic
si te. TV US is
al so usef ul in eva lu at in g fo r ru pture of the tu be or other structur es,
which pr ese nts as
free fl ui d (bl oo d) in the pe lvic c ul -de-sac and/or abdo men. Transabdominal
ul tr aso un d
ca nn ot reli ab ly visuali ze a gestational sac in ea rly pr eg nancy.
Lapa roscopy is the go ld sta n da rd for treatment fo r ru pture ectopic
pr egna ncy whi ch pr ese n ts with the add itional s ym pto ms of di ffu se abdo
min al pa in and
eventually hem od yn a mi c in stability. Lapa r oto my may be co nsi de r ed fo r
patien ts wi th
ac u te bl eed in g.

Ectopic pregnancy
Risk factors
Previous ectopic pregnancy
Previous pelvic / tubal surgery
Pelvic inflammatory disease
Clinical
diffuse Abdominal pain, amenorrhea, vaginal bleeding
Hypovolemic shock in ruptured ectopic pregnancy
Cervical motion , adnexal &/or abdominal tenderness
+/- Palpable adnexal mass
Positive hCG,shoulder pain (referred pain from the diaphragm),
urge to defecate (due to blood in the posterior cul-de-sac).
Diagnosis Transvaginal ultrasound showing adnexal mass,empty uterus
Management Stable: Methotrexate Unstable: Surgery

23Endometriosis can be found incidentally during unrelated surgery. Typical

intraoperative
findings are adhesions, powder-burn lesions, nodules, and "chocolate cysts."
Asymptomatic patients do not require treatment.
Conservative treatment of symptomatic endometriosis
includes nonsteroidal anti-inflammatory drugs, oral contraceptives , or a
progesterone intrauterine device (I UD). Copper IUD has no effect on endometriosis.
Leuprolide, a gonadotropin-releasing hormone agonist, treats symptomatic
endometriosis by suppressing estrogen stimulation of the ectopic endometrial
glands.
This medication is poorly tolerated due to menopausal symptoms. Definitive
treatment
consists of surgical resection and hysterectomy with oophorectomy.

24Chronic hypertension predates pregnancy but can be

diagnosed any time before 20 weeks gestation . To make a diagnosis of chronic
hypertension during pregnancy, blood pressure should be elevated at 2 measurements
taken >4hours apart .

Pregnancy - related risks due to hypertension

Maternal
Superimposed preeclampsia
Postpartum hemorrhage
Gestational diabetes
Abruptio placentae
Cesarean delivery
Fetal
Fetal growth restriction
Perinatal mortality
Preterm delivery
Oligohydramnios

25Conscientious refusal of treatment occurs when a provider refuses to provide care

due to
moral conflict. Providers who cannot, in good conscience, provide treatment that a
patient requests, are obligated to refer the patient in a timely fashion to another
provider
who can.

26Exercise is encouraged in normal, uncomplicated pregnancies to prevent excess iv

e
weight gain and improve or maintain overall fi tness and well-being. Exercise is
also
associated with a decreased risk of gestational diabetes mellitus and faster
recovery from
vaginal and cesarean delivery.
Absolute contraindications
Amniotic fluid leak
Cervical incompetence
Multiple gestation
Placenta abruption or previa
Premature labor
Preeclampsia/gestational hypertension
Seve re heart or lung disease

27.Fetal growth restr iction (FGR) is defined as an estimated fetal weight <10th
percentile for gestational age . Fetuses with growth restriction have increased
risk of
intrauterine demise and neonatal morbidity/mortality ( eg , prete rm de live ry) .
FGR ca n be characte ri zed as symmet ri c or a sy mm etric. Co n ge ni ta l di so
rders or in s ul ts
d urin g the fi rst t rim ester ( eg , aneuploid y, in fections) are the most co mm
on ca u ses of
sym met ri c F GR ( eg , the entire fetus is affected). As ymm et ri c F GR , the
res ul t of pl ace n ta l
dysf un ction dur in g the second and/or third trim ester , is associated with co
nditi ons that
ca u se pla cent al insufficiency (e g, hypertension, pregestational diabetes). In
normal
fetal de vel opme nt, the feta l abdo men grows ex po nentially during the seco nd
and third
t rim ester. In s ul ts ( eg , h ypoxe mi a) at t hi s stage of pr eg nancy ca u se
feta l bl ood flo w to be
red ist ri bu ted to the vi ta l or ga ns ( eg , brain) and away from the abdo men,
res ul t in g in an
asymmetric, or "he ad-sparin g," growth pattern
Management
W ee kly biophysical pr ofi l es
Serial umbilical artery Dopp ler so nography
Serial growth ultrasounds

Although the pathophysiology of hyperemesis i tse lf does

not affect the fetus, "poor in take and inadequate weight gain "in cr ease th e
risk of "fetal
growth restriction a nd low bi rth weigh t". Poo r m ate rn al weight ga in is al
so a ri sk facto r
for "preterm delivery" but not fo r postte rm birth

28.gestational hypertension needs weekly BPPs starting at 32 weeks gestation.

29. var i able decelerations , which are most likely due to "umbilical cord
compression" . The
release of amniotic fluid after amniotomy (artificial rupture of membranes) can
result in
mechanical compression and occlusion of the umbilical artery, particularly during
contractions, which increases the fetal systemic vascular resistance and blood
pressure.
Consequently, the fetal baroreceptor response decreases the fetal pulse as a means
of
decreasing fetal blood pressure.

"umbilical cord prolapse" also causes variable decelerations

In add ition to causing variable decelerations, umbilical cord compression can

impede
fetal -placental blood flow. Intermittent variable decelerations (associated with
<50% of
contractions) are well tolerated by the fetus and do not typically cause fetal
hypoxia; they
require close obse rvation wi tho ut intervention. Recurre nt variable
decelerations
occ ur with >50% of contractions a nd r eq uire treatment, as feta l ac id os is ca
n develop
wi th in creasing fr eq uency and se verity of decelerations
"Maternal repositioning "( eg , left lateral) is the first-line intervention a nd
may reduce
cord compression a nd improve blood flow to the placenta. Should these efforts fa
il,
"amnioinfusion" is a r easonable second -line intrauterine resuscitation option.
Because
co rd co mpr ession may r es ult from the r ed uction of a mni otic fluid after
rupture of
memb ranes, the in stillation of sa line into the a mni otic sac may decrease co rd
co mpr ession a nd e limin ate vari ab le decelerations.

30.A transverse lie occurs wh en the longitud in al a xi s of the fetus is pe r pe

ndic ul ar to the
longitudinal a xi s of the u te ru s. A fetus in transverse lie ca n be pos ition
ed either back up
(wi th the sp in e towa rd the m ate rn al h ea d) or back down (wi th the sp in e
towa rd the
ce rvix) . Risk facto rs fo r transver se lie in clude prematurity, u te rin e
anomali es, pl ace n ta
pre vi a, and mul tiple ges tation. Pa lpation of the feta l h ead n ea r the moth
er's si de and/or
absence of a fetal presenting part during digital cervical examination suggest
transverse
lie, but th e di ag n os is mu st be confirmed via ult rasound.
Transver se lie is typi ca lly transi ent p ri or to te rm. Most fetuses in
transver se lie
spontaneously convert to breech or vertex presentation. Consequently, an ultrasound
will be
required to assess fetal position at or around 37 weeks to determine delivery
management.

If the fetus re ma in s in transver se lie or co nverts to br eec h pr ese ntation

at 37
w ee ks gestatio n, external cephalic version ( EC V) ca n be offer ed

Although placenta previ a (pl ace n ta co ve rin g the os) is a

co ntraindication to v ag in al de livery, a pl ace n ta >2 em from the ce rvi ca l
os is n ot.

31.Preventing neonatal gr oup B Streptococcus infection

Un iversal screening
Rectovaginal culture at 35-37 weeks gestation
Indications
Prior delivery complicated by neonatal GBS infection
GBS bacteriuria or GBS urinary tract infection during
the current pregnancy (regardless of treatment)
GBS-positive rectovaginal culture
Unknown GBS status PLUS any of the following:
o <37 weeks gestation
o Intrapartum fever
o Rupture of amniotic membranes for >18 hours
Pr ophy laxis First-line treatment: Penicillin
Pr op hyl ax is sho ul d be given 4 hours before delivery.

32First trimester screening, also called the first trimester combined test, has two
steps:
mother's blood pregnancy-associated plasma protein-A and human chorionic
gonadotropin(HCG)
ultrasound exam baby's neck (nuchal translucency)
9-13wks Noninvasive
PAPP-A ca n be m eas ured with 13-
h CG a nd ultr aso und nu chal trans lu ce ncy with a detection r ate of -85 % for
Do wn
syndrom e. Fetu ses with Do wn syndr ome pr od u ce l ess PAPP-A. The marker is l
ess
acc ur ate wi th in cr eas in g gestational age a nd is ther efo re not u se d in
the seco nd
t rim ester.

second trimester, the quadruple screen is used to

maternal serum a-fetoprotein (MSAFP ),b- h CG ,unconjugated estriol,and inhibin A
The detec ti on r ate for Do wn s ynd ro me us in g the qu a dru ple sc r ee n is
-80 %.low MSA FP, low estriol, increased 13-hCG , and increased
inhibin A are associated wi th Do wn syndrom e. An ultrasound is opt im ally perfo
rm ed at
18-20 weeks gestation to eva lu ate feta l growth a nd id enti fy any st ru ctural
mal fo rm ations
( eg, e nd ocardial cus hi on defects, duodenal atr es ia, cystic hy gro ma). A co
mpl ete ly
no rm al exa min ation lowers the risk of aneuploid y; the i de ntification of ab
no rm al ma rk ers
in creases the ri sk.
Pat ien ts with a bn o rm al sc r ee ning tests ca n al so be offered cell-free
fetal DNA testing
of m ate rn al pl as m a. Ce ll -f r ee fe tal DNA tes tin g is hi ghly se nsiti ve
a nd specific for
aneuploid y,and can help avoid unnecessary amniocentesis.

33.Routine prenatal la b or a tory tests

Initial prenatal visit
Rh (D) type, anti bod y screen
He m og l ob in /hematoc ri t, MCV
HIV, VDRURPR, Hbsag
Ru be lla & va ri ce lla im muni ty
Pap test (i f sc r ee ning in dicated)
C hl a my dia PCR
Urin e c ul ture
Urin e pr ote in

24- 28 weeks
He m og l ob in/hematoc ri t
Antibody sc r ee n if Rh (D) n ega tive
50 -g 1-hour GCT
1-h our 50-g GCT, fo llow ed by co n fi rm ation wi th a 3-hour 10 0-g g lu cose
to leran ce test.

35 - 37 weeks
Gro up 8 Streptococcus culture

34.G est a tional diabetes m ellitus

Target blood glucose levels
F asting <95 mg/ dl (5 .3 mmoi/ L)
1- hou r postpra n dial <1 40 mg/d l (7 .8 mmoi/ L)
2- hou r postpra n dial <120 mg/d l (6 .7 mmoi/ L)
Treatment
1s t-line : Dietary modifications : evenly distributed
carbohydrate, protein, and fat intake over 3 meals and 2-4 snacks daily
2nd -line: Insulin, metformin, glyburide Insulin does not cross the placenta
for GDM that is unresponsive to dietary modifications and exercise.Oral medications
( eg , glyburide, metformin) are equivalent in efficacy and are widely u sed as
first-line
pharmacotherapy.
GDM are at increased risk for gestational hypertension,
preeclampsia, fetal macrosomia, a nd cesarean delivery. Although GD M resolves
after
childbirth, up to half of women will develop type 2 DM later in life . All pregnant
women
should be screened fo r GDM at 24- 28 weeks gestation. Patients with risk factors (
eg ,
obesity, pre vi ous GD M, pre vi ous m ac r oso mi c in fa nt) should be sc r ee
ned ea rly in
pr eg nancy and then r esc r ee ned at 24-28 w ee ks ges tation if the initial sc r
ee n is negativ e.

35Management of shoulder dystocia (BECALM)

B Breathe, do not push; lower head of the bed
E Elevate legs into McRoberts position -sharp hip flexion while in supine position
c Call for help - nurses, anesthesiologists, pediatricians, another physician
A Apply suprapubic pre ss ure - downward & lateral to release anterior shoulder
L Enlarge vaginal opening with episiotomy to facilitate extra maneuvers
M Maneuvers
Delivery of posterior arm
Pressure against baby's posterior shoulder either anteriorly or posteriorly
& anterior rotation (Woods co rkscrew or Rubin maneuver)
Mother on hands & knees- "all fours" (Gaskin maneuver)
Replacement of baby's head to vagina followed by cesarean delivery
(Zavanelli maneuver)

36.Theca lutein cysts

Presentation
Mul til oc ul ar
Bil ate ral
10-15 cm ova ri es
Pathogenesis
Ova ri an hy pe rst imul ation due to:
o Gestational trophoblastic disease(suction cureta or hysterectomy)
o Multi feta l gestation
o In fertility tr eatme nt
Clinical co urse Resolve with decreasing b- h CG levels

37.hypertension, proteinuria and edema, which are the hallmarks

of preeclampsia. Howev er,the gross proteinuria associated with a malar rash and a
strongly positive ANA shou ld raise suspicions for "systemic lupus erythematosus
(SLE )'. It
must be noted, however, that ANA titers may be weakly positive in normal pregnancy.
The distinction between SLE and preeclampsia during pregnancy is crucial because
both
conditions respond to different therapeutic approaches. In fact, treating
preeclampsia
with corticosteroids can aggravate it.
If the patient is known to have lupus before pregnancy, the appearance of
proteinuria
during pregnancy may represent lupus nephritis, preeclampsia or both. Signs that
favor
lupus as the origin of the proteinuria include a rapid aggravation of the
proteinuria,
associated clinical signs of active SLE, and the presence of RBC casts in the
urinalysis
which indicates true nephritis rather than simple protein loss. If the proteinuria
persists
after delivery, renal biopsy is then indicated and will most likely be diagnostic
of lupus
nephritis. SLE, however, rarely presents for the first time during pregnancy.

38.Management of PPROM

<34w eeks
Signs of infection or fetal compromise

No
Yes
Antibiotics
Antibiotics
Corticosteroids
Corticosteroids
Fetal surveilance
Magnesium if <32 weeks

Delivery

34-37 weeks

Antibiotics
+/- Corticosteroids
Delivery

To prevent neonatal group B Streptococcus ( GBS ) infection, intrapartum

intravenous penicillin should be administered to patients with PPROM who are
delivered and have either an unknown or positive GBS status.

39.HELLP syndrome ( microangiopathic Hemolysis,Elevated Liver enzymes,Low Platelet

count).
may be a variation of severe preeclampsia and affects 10% -20% of women with
preeclampsia.
Serious liver problems include centrilobular necrosis,hematoma formation,and
thrombi in the
portal capillary system. Th ese processes ca n cause liver swelling with distension
of th e
hepa ti c (Glisson's) capsule, resulting in right upper quadrant or epigastric pa
in .
Treatment
Delivery
Magnesium for seizure prophylaxis
Antihypertensive drugs

Preeclamptic patients have generalized arterial vasospasm leading to increased

systemic vascular resistance and high cardiac afterload . The heart becomes
hyperdynamic to try to overcome the systemic hypertension. Additional factors that
may
contribute to "pulmonary edema" include decreased renal function , decreased serum
albumin , and endothelial damage leading to in creased capillary permeability.
Management includes supplemen ta l oxygen, fluid restriction, and diuresis in
severe
cases. Fluid restriction and diuresis mu st be used wi th caution as plasma volume
is
e ff ectively decreased through third-spacing and placental perfusion can be
compromised.

40.Amniotic fluid embolism can cause sudden hypoxemic respiratory failure and
hypotensive shock. The pathogenesis involves amniotic fluid entering into the
maternal
c ir culation during labor or delivery.

41Hyperem es is gr av id arum
Risk fa ctors
Hydatidiform mole
Multifetal gestati on
History of hyperemesis gravidarum
Severe, persistent vomiting
Clinical
>5% loss of prepregnancy weight
Dehydration
Orthostatic hypotension
Ketonuria
Laboratory
Hypochloremic metabolic alkalosis
Hypokalemia
abnormaliti es
Hypoglycemia
Hemoconcentrat i on
Treatment
Admiss i on to hospital
Antiemetics & intravenous fluids

altered mental status ( eg, encephalopathy), oculomotor dysfunction ( eg ,

nystagmus), and gait
ataxia are suggestive of Wernicke encephalopathy ( WE ), a neurological disease due
to thiamine
deficiency. Although most commonly associated wi th alcoholism, WE can also occur
with
hyperemesis gravidarum ( HG ),a severe, persistent nausea and vomiting of pregnancy
that
results in weight loss and dehydration.Patients with HG often require glucose
infusions due to
prolonged hypoglycemia. However,glucose infusion prior to thiamine supplementation
can exacerbate WE and should be delayed until the patient has received t hi a min
e. WE
in pregnancy is associated wi th an in creased ri sk of spo n ta n eo us abortion;
t hi a min e
su pp lementation may dec r ease t hi s ri sk.

42.prolonged adm inistration of high doses of oxytocin can cau se water retention
and
hyponatremia. Hyponatremia c an present with headach es , abdominal pain, nausea,
vomiting, lethargy, and tonic-clonic seizures. Management of hyponatremia involves
gradual ad ministration of hyperton ic saline ( eg , 3% sa li ne) to normalize sod
ium leve ls .

43.Magnesium toxicity typically presents with hyporeflexia, lethargy, headache,

respir atory failure, and ultimately cardiac arrest,not with seizures.
magnesium level is in the therapeutic range for preeclampsia management
(approx im ately 5-8 mg/ dl ). Magnesium becomes toxic at concentrations >8 mg/ dl.

44.Sheehan sy ndr ome

Pathogenesis
Heavy peripartum blood loss complicated by
hypotension &/or blood transfusion
Postpartum pituitary infarction
Clinical
Symptoms of hypopituitarism (l prolactin,
ACT H, TSH, FSH, L H, &/or growth hormone):
o Lactation failure
o Am enorrhea
o Loss of sexual hair
o Anorexia/weight loss
o Lethargy
o Hyponatremia hypotension

45.Intrauterine fetal demise (IUFD) refers to fetal death at >20 weeks gestation
and
before the onset of labor. Al though IU FD most commonly occurs in uncomplicated
pregnancies, risk factors include nulliparity,fetal growth restriction, abnormal
fetal
karyotype, and tobacco use.
clinical
Before 20 weeks gestation, the most common finding is uterine fundus less than
dates.
after 20 weeks Patients typically present with decreased or absent fetal
movement. Fetal heart tones are not heard by Doppler sonography, and ultrasound
confirms the absence of f et al cardiac activity . Once the diagnosis is confirmed,
it is
critical to inform the parents as empath ic ally as possible.
Inability to find the fetal heart rate by Doppler sonography is not
diagnostic and can be due to fetal malpresentation or maternal obesity.
Management
20- 23 weeks
Dilation & evacuation
OR
Vaginal delivery

:>24 weeks
Vaginal delivery regardless of fetal presentation (eg, vertex, breech).

Complication dic if fetal demise >4 weeks

the pathophysiolo gy of iufd can be materna l,

fetal , or placental in origin. The fe tus shou ld under go autopsy, a nd
karyotype/genetic
studies shou ld be performed. The placenta should be eva lu ated gross ly and
microscopically for evidence of thrombosis, abruption, inf ection, or other
disease. Laboratory eva lu ation should be obtained for maternal antiphospholipid
antibody syndrome and fetomaternal hemorrhage. Other t es ting (eg, eva lu ation
for
thrombophilia, cultures) can be performed to confirm or exclude an et iology
suggested by
the patient's medical history.
As the et iology of IUFD helps determine the recurrence risk and prevention
strategies,
knowing the cause can be invaluable in counseling the patie nt regarding future
pregnancies. However, even after an opt im al evaluation, up to ha lf of cases have
no
ide n tifiab le etio l ogy .

Evaluation of fetal demise

fetal
Autop sy
Gross & microscopic ex amination of plac en ta signs of ab ru ption ( eg ,
clotted bl oo d)
or in fection, me mb ranes & cord ( eg , nu chal co rd s, tru e kn ots)
Karyotype/genet ic studies
M at ernal
Kleihauer-Betke test f or fetomaternal hemorrhage
Antiphospholipid ant ibodies
Coagulation studies

46. Fa lse labor

La tent labor

Timing Irregular,
Regular, increasing frequency
infrequent

Strength Weak
Increasing intensity

Pain None to mild

Yes

Cervical No
Yes{dilation, effacement}
change

reassure send home

47.Risk factors for preterm delivery include a history of prior preterm delivery,
maternal
age >40 years, and multiple gestation.

betamethasone 2 doses if preterm delivery <34wks

34-37 weeks controversial cesarean - 1 dose only : vaginal no betamethasone

48.An arrested second stage occurs when there is no fetal descent after pushing for
>3
hours in nulli parous patients or >2 hours in multiparous patients . Pregnant with
regular
uterine contractions 10 cm dilation at +1 station The most common
cause of a prolonged or arrested seco nd stage is fetal malposition.Deviations
from this position ( eg , occiput transverse, occiput posterior) can cause
cephalopelvic
disproportion and arrest of the second stage.

Management. This involves assessment of uterine contractions and maternal pushing

efforts.
IV oxytocin can strengthen the contraction.If they are both adequate, assess
whether the fetal
head is engaged. If the head is not engaged, proceed to emergency cesarean. If the
head is
engaged,consider a trial of either obstetric forceps or a vacuum extractor
delivery.

49.Low back pain is a very common complaint in the third trimester of pregnancy. It
is
believed to be caused by the increase in lumbar lordosis and the relaxation of the
ligaments supporting the joints of the pelvic girdle.

50.spontaneous abortion is a complication of amphetamine abuse. Although

amphetamines cross
the placenta, they are not linked to congenital structural abnormalities.
Amphetamine use
during pregnancy is associated with fetal growth restriction , preeclampsia,
abruptio placentae
, preterm delivery, intrauterine fetal demise , and an increased risk of maternal
mortality.

51.During an NST, the heart rate of a well-oxygenated fetus rises with fetal
movement
(accelerations ). A reactive NST (>2accelerations) has a high negative predictive
value to rule
out fetal ac idemia. A nonreactive NST has a high false-positive rate and low
positive predictive
value andcannot rule in fetal acid em ia.
A nonrea ct ive NST requires further evaluation with a biophysical profile (BPP) or
con tr action stress test (CST ). These tests are equivalent in assessing fetal
status and
are selected based on available resources and relevant contraindications. A BPP
includes an NST plus an ultrasound evaluation of the amniotic fluid index as well
as fetal
movement, tone, and breathing. A CST (Choice 0) is performed by administering
oxytocin or using nipple stimulation until 3 contractions occur every 10
minutes. Contraindications to CST include contraindications to labor (eg, placen ta
pr e vi a, prior myomectomy).

oligohydramnios (a single deepest pocket <2 cm or an a mni otic fluid index :>5 )
A score of 0/1o to 4/10 indicates fetal hypoxia du e to placental dysfunction
(placental
insufficiency) . Risk factors for placental insufficiency include advan ce d mate
rn al age,
tobacco use, hypertension ,and diabetes. The patient requires prompt delivery du e
to th e
high likelih oo d of fetal de mi se .

NST is usually perfo rm ed in hi gh- ri sk pr eg nancies start in g at 32-34 w ee

ks gestation or
wh en there is a l oss of pe rception of feta l movemen ts in any pr eg nancy. NST
is ca rri ed out
by r eco rding the feta l heart r ate while mo ni to rin g fo r spo n ta n eo us
perceived fetal
movemen ts . A test is co ns id er ed reactive (n o rm al) if in 20 minu tes there
are at least 2
acce lerations of the fetal heart rate of at least 15 beats/ min abo ve the
baseline and
lasting at least 15 seco n ds eac h.

contraction stress test (oxytocin challenge test), the mother is given an infusion
of oxytocin
sufficient to result in 3 contractions every 10 minutes , and the effect these
contractions
have on fetal heart activity is recorded. If a late deceleration is noted
at each contraction,the test is positive and delivery is usually recommended

52.Early puerperium is characterized by several physiol og ic pr oces s es that ca

n be
mi sta ken fo r signs of pa th ol og y. Imm e di ate ly after pl ace ntal delive
ry, shivering occ urs
co mm only a nd is th eo ri ze d to be du e to thermal imbalan ce. The uter us
contracts a nd
b eco m es firm a nd glo bul ar with the fundus typi ca lly 1 -2 cm above or below
th e
umbilicu s. During th e first fe w days after delive ry, lochia rubra occ urs,
which is a red or
re ddi sh-bro wn v ag in al di sc har ge (the no rm al shedding of the uterine
decidua a nd
bl oo d), as see n in this patien t. After 3-4 days, the di sc har ge b eco mes
thin a nd pink or
bro wn co lored (l oc hi a se r osa ). After 2-3 w ee ks, the di sc har ge b eco m
es whi te or yellow
(l oc hi a a lb a).
As thi s pa ti ent's exa min ation is no rm a l, only routine postpa rtum ca re is
indi cate d. This
in clud es pe rin ea l ca re, pa in man age me nt, a voiding trial, a nd lac tation
support. Fundal
and perineal pad checks should be perfo rm ed to sc r ee n fo r signs of p os tp a
rtum
hemo rrh age (e g, "b og gy" u te ru s. h ea vy v ag in al bl ee din g, unsta bl e
vi ta l signs).

53.Nocturnal leg pain is also common in pregnancy due to muscle cramping from
lactic and
pyruvic acid accumulation. Reassurance.Maternal adaptations to pregnancy include
increases
in cardiac output , plasma volume,and tidal volume. A systolic ejection murmur,
peripheral
edema, and dyspnea are common but benign symptoms that result from these changes.

55.In a normal pregnancy, both the glomerular filtration rate (GFR) and renal
blood flow
are increased, which cause the serum blood urea nitrogen a nd creatinine to become
decreased compa r ed to prepregnancy l eve l s. Re nal f un ction in creases gr ad
ually in the
fi rst t rim ester and reac h es 40 % -50 % abo ve the nonpr eg nant state by mid
pregnancy,
after which it rema in s un chan ge d un til te rm. Re nal basement membrane pe rm
eab ility is
al so in creased in pr eg nancy.
Due to the in cr ease in renal f un ction during pr eg nancy, patien ts on m ed
ications that are
renally excreted ( eg, gabapentin) require cl ose mo ni to rin g and dose ad
justmen ts as
necessary. In add itio n, a se rum creatinine of 1 .2 mg/ dl may be the upper limi
t of no rm al
in a nonpr eg nant woman but is co nsi de r ed renal in su ffic iency in a pr eg
nant woman

decrease in prote in S activity, an increase in fibrinogen, and an

increase in resistance to activated pr ote in C. The hy pe r coag ul ab le state is
li ke ly a
m ec ha ni sm to minimi ze bl eed in g during de livery

In nonpr egnant patients, renal excretion >150 mg of pr ote in is co nsi de r ed

ab no rm al. Ho wever, in pr eg nant patien ts, du e to the in cr ease in the GFR
and in renal
basement membrane pe rm eab ilit y, urinary excretion >300 mg of pr ote in is co
nsi de red
ab no rm al.

56.Maternal serum AFP (M SAFP ) is meas u red at 1 5-2 0 w ee ks gestation (opt im

ally at 16-18
w eeks ) to screen for feta l anomali es. MSAFP is u sed pr im arily to sc r ee n
fo r open neural
tube defects. In creased levels are al so associated with feta l abdomi na l wall
defects ( eg ,
gastroschisis, omphalocele) and multiple gestation. An ultraso und sho ul d be
perfor med
to eva lu ate the feta l an ato m y.

57Osteogen es is im perfecta is an au toso mal do min ant disease characte ri zed

by mu tations
in ty pe I co ll age n. Pat ien ts with the se vere ty pe II fo rm of t hi s
disease typi ca lly expire in
u te ro du e to mul tiple in trau te rin e and/or pe rin ata l fractur es. Clini ca
l fi ndin gs in c lu de lim b
defo rmi ti es, growth r eta rd ation, mul tiple fractur es and b lu e sc l erae

58.Causes of hyperandrogenism in pregnancy

Luteoma
Yell ow or yellow- brown masses (often with areas of hemorrhage) oflarge lutein
cells
Solid ovarian masses on ultrasound(50% are bilater al)
Regress sponta neously after delivery
Bilateral ovarian cysts on ultrasound
Theca luteum cyst
Associated with molar pre gnan cy & multiple gestation
Regress spontaneously after delivery low fetal virility.suction curettage is
indicated if the underlying cause is molar pr eg nancy.
Krukenberg tumor
 Bilateral solid ovarian masses on ultrasound
Metastases from primary Gi tr ac t cancer

Ultrasound is the go ld standa rd fo r di ag n os ing luteomas, which appear as so

lid ova ri an
masses (l ar ge lu te in ce lls) that are typi ca lly 6-10 em in diameter and
bilateral in half of
patien ts . Management p rim arily involv es clini ca l moni to ring and ultrasound
evalua ti on as
the masses and s ymp toms regress spontaneously after delivery. Howeve r, the
pa ti ent sh ould be in fo rm ed that a s ym ptomatic mate rn al luteoma pu ts a
female fetus at
high risk of virilization. In addition, the size of the luteomas should be
monitored due to
the rare but potential risk of mass effect (eg, hydrocephalus, obstructive labor)
and
ovarian torsion

59.Placenta previa is usually diagnosed during a routine antenatal ultrasound.

Pelvic rest
is r eco mm en ded fo r the duration of the pr eg nancy as in te r co u rse ca n ca
u se co ntractions,
whi ch in turn ca n l ead to bl eed in g ( as see n in t hi s pa ti ent) by shear
in g the pl ace n ta off
the cerv ix a nd lower u te rin e seg men t
Placenta previa is usually di ag n ose d du r in g routine prenatal ultrasound at 1
8-2 0
w ee ks gestation by id entif yin g the pl ace nta cove rin g the inte rn al ce rvi
ca l os. M os t
patients are as ym pto matic bu t at sig ni fica nt ri sk of painless bu t se vere
antepartum
hemorrhage.
Although pl ace n ta pre vi a may r eso lve spo n ta n eo usly by the third t rim
ester du e to growth
of the lower u te rin e seg ment a nd /or pl ace n ta l growth toward the fundus,
pelvic rest a nd
abstinence from intercourse (due to potential pe nile co ntact with the ce rvix)
are
reco mm e nd ed fo r all patien ts on ce the di ag n os is of pl ace n ta pre vi a
is mad e. Clinicians
should refra in fro m di gi ta l ce rvi ca l exa min ation as ce rvi ca l pe
netration ca n potentially
di s ru pt the pl ace n ta. Labo r and v ag in al delivery are al so co ntraindi
cate d. Cesarean
delivery is sc he dul ed for 36-37 w ee ks gestation as ce rvi ca l chan ges a nd
ute rin e
co ntractions ca n ca u se pa rtial placen ta l detac hm ent from the ce rvix. Sho
ul d a fo llow- up
ul tr aso un d show r eso lu tion of the pl ace nta pre vi a, the plan of care ca n
be modified
acco rdingly and the pe lvic rest rest ri ction ca n be li fte d.
fetal heart rate is normal

60.Placenta acc r eta Abnormal Placental Invasion

Accreta: deeper layers decidua basalis
Increta: myometrium not complete
Percreta: uterine serosa or bladder.
Risk factors for placenta accreta include a prior cesarean delivery, a history of
dilation and
curettage, a nd maternal age >35. Placenta accreta is typically diagnosed by
antenatal
ultrasound findings that include irregularity or absence of the placental-
myometrial interface
and intraplacental villous lakes . Antenatallydiagnosed placenta accreta is
delivered by
planned cesarean hysterectomy .Undiagnosed placenta accreta presents as difficulty
with
placental delivery. The placenta does not detach from the uterus, and this often
results in cord
avulsion and necessitates a manual extraction, which is then complicated by
placental
adherence and severe hemorrhage

61.Postpartum endometritis: infection of the uterine decidua, is the most common

etiology of
puerperal fever
Risk factors
Cesarean delivery
Chorioamnionitis
Group B Streptococcus colonization
Prolonged rupture of membranes
Operative vaginal delivery
Clinical
Fever >24 hours postpartum
Uterine fundal tenderness
Purulent lochia
Etiology Polymicrobial infection
Treatment Clindamycin & gentamicin
Treatment should be continued until the patient is afebrile for >24 hours. Neither
blood nor
endometrial cu ltur es are required for diagnosis,but further evaluation is
indicated if there
is no clinical im provement after 48 hours of antibiotic therapy.

Ceftriaxone is the treatment of choi ce for pyelon ep hritis in pr eg nan cy.

Ceftriaxone plus azithromycin is a dual therapy regimen that covers the most
common causes of ac u te ce rvi citis, Neisse ri a gonorrhoeae and C hl amyd ia
trachoma ti s.

Dicloxacillin is used in the treatment of lactational mastitis. It is a narrow-

spectrum penicillin
that covers the 2 most frequent pathogens,methicillin-sensitive Staphylococcus
aureus and
Group A Streptococcus.

62.Postpartum hemorrhage(PPH) is an obstetrical emergency and a major cause of

maternal mortality. Hemostasis after placental delivery is achieved by clottin g
and by
compression of the placental site blood vessels by myometrial contraction.
Disruption of
either of these processes can lead to PPH.Primary PPH occurs <24 hours after
delivery and is
most co mm only ca u se d by "uterine atony". Ato ny occ urs wh en the ute ru s b
eco m es fa tigu ed
( eg , prolon ge d labo r),over- di ste nd ed ( eg , fe tal weight >40 00 g [ 8.8
lb), multiple gesta ti o n)
, or unr es ponsive to o xyt oc in from o xy toc in r ece ptor sa tu ra tion. Other
ri sk factors for
atony in clude ope rative( eg , fo rceps-assi ste d) v ag in al delivery a nd hyp
ertensive di so rd er s.
The ute ru s fa ils to co nt rac t a nd is soft ("boggy ") and enlarged ( eg ,
above the umbilicus) on
physi ca l exa min a ti on.

endometrial stripe suggests an empty and normal uterine cavity

Postpartum uterine atony

Risk factors
Uterine fatigue from prolonged or induced labor
Chorioamnionitis
Uterine over-distension (multiple gestation,polyhydramnios)
Retained placenta
C linica l
Most common cause of postpartum hemorrhage
Enlarged, soft, boggy, poorly contracted uterus
Treatment
Bimanual uterine massage
Intravenous fluids, oxygen
Uterotonic medications (eg, oxytocin,methylergonovine, carboprost, misoprostol)
history of hy pertension is a contraindication to m ethylergonovine
Carboprost causes bronchoconstriction, and asthma is a contraindication to its use
in this
patient.

63.Pregnancies at 41 weeks or beyond are defined as late-term (41 w ee ks to 41 w

ee ks
a nd 6 days gestatio n) or postterm ( 2:42 w ee ks gestatio n) from the last
menstrual
pe ri od. Risk facto rs in clude nullipar ity, hi sto ry of p ri or postte rm pr eg
nanc y, m ate rn al
obes it y, a nd fetal anomali es ( eg , anen cep haly). An induction of labor ca n
be co ns id ered
fo r late-te rm pr eg n anc y a nd is r eco mm e nd ed fo r postte rm pr eg n anc i
es to prevent
co mplications (Table). Antepart um feta l test in g may be started at 41 w ee ks
gestation to
assess feta l well -be in g. Oligohydramnios (s in gle deepest verti ca l poc ket
of a mni otic
fl ui d s2 em or an a mni otic fl ui d in de x of <5 cm on tran sab do min al ul
trasound) is a
co mm on co mplication of prolon ged pr eg nanci es. An ag in g pl ace nta may have
dec reased
feta l perfusion, r es ul t in g in decreased re nal perfusion a nd decreased
urinary ou tp ut from
the fetu s. The di ag n os is of oli go hydra mni os is an indication fo r de
livery even if
antepart um feta l test in g is no rm al.
Fetal
Maternal
Oligohydramnios
Cesarean de livery
Meconium aspiration
Infec ti on
Stillbirth
Postpartum hemorrhage
Macrosomia
Perineal trauma
Convulsions