FIRST SHIFT (Dr. Cambronero) b.

Post wall ---7- 10 cm

 OVERVIEW in OB 13. Blood supply of the vagina
1. Define: a. Upper 3rd – cervicovaginal br of uterine artery
a. Abortion: expulsion of fetus < 500g b. Mid 3rd ----inf. Vesical
b. Neonatal Period: time of delivery until 28 days c. Lower 3rd – mid rectal & int. pudendal
c. Perinatal Mortality Rate: number of still birth + 14. Support structures of the vagina
neonatal deaths per 1000 total births a. Upper – cardinal lig, parametria
d. Perinatal Period: 20 wks AoG – 28 days after birth b. Mid---levator ani
e. LBW: < 2500g c. Lower—urogenital, pelvic diaphragm
f. VLBW: < 1500g 15. Vaginal abnormalities
g. ELBW: < 1000g a. Atresia
h. Direct Maternal Death: due to complication of b. Double vagina (2 introitus, distinct separate cervix)
pregnancy, labor, puerperium e.g. hemorrhage from c. Longitudinally septate vagina (interfere with
ruptured uterus descent)
2. What is the most common cause of Maternal Death d. Transv septate vagina (faulty canalization of
o HEMORRHAGE mullerian anlage)
3. Other causes of Maternal Death 16. Persistence of fusion between sinovaginal bulbs & vestibule
o HPN a. Imperforate hymen
o Infections 17. Blood supply to the perineum
o Obstructed Labor a. Int pudendal artery
o Complication of Abortion 18. Allows distention of the rectum during defecation & stretching
4. Perinatal Mortality Causes of the vagina during delivery
o Complication of placenta, cord, membranes a. Ischiorectal fossa
(21.13%) 19. 2, fat filled wedge shaped spaces found on either side of the
o Short gestation, LBW (13%) anal canal, comprise the bulk of the posterior triangle
o Intrauterine hypoxia (7.5%) a. Ischoretal fossa
o RDS (1.8%) 20. Size of the uterus
 ANATOMY OF THE FEMALE REPRODUCTIVE TRACT a. Puberty---2.5 -3.5 cm
A. External Organs b. Adult nullip – 6-8cm
1. All structures externally from pubis – perineum? c. Multip—9-10 cm
o Vulva (pudenda) 21. Relationship of body of the uterus &cervix
2. Fat-filled cushion overlying symphysis pubis a. Premenarche –body half as long as cervix
o Mons pubis b. Nullips—fundus & cervix equal length
3. Labia majora cont. directly with the mons pubis above and c. Multips—cervix is a little more than a third of the
merge into the perineum posteriorly as: total length of the uterus
o Posterior commissure
4. Lymph drainage of labia majora 22. Classification of mullerian anomalies
o Inguinal femoral nodes a. Class 1—vaginal hypoplasia & agenesis
5. Male homologue of the b. Class 2—unicornuate uterus ( increase infertility,
a. labia minora ---penile urethra (ventral shaft of the endometriosis, dysme, fetal wastage)
penis) c. Class 3 – uterine didelphys (complete absence of
b. labia majora---scrotum fusion of the mullerian ducts
c. clitoris—glans penis d. Class 4 –bicornuate uterus (2 mullerian ducts fail to
d. bartholin’s gland---bulbourethral (cowper’s) gland fuse)
e. vestibular bulbs---corpus spongiosum e. Class 5 ---septate uterus (failure of involution of
6. Almond shape, mature female structure of the urogenital sinus septum, increase spon. Abortion)
o Vestibule f. Class 6 – arcuate uterus (mild deviation from
7. Almond shape, aggregation of veins normally developed uterus)
Vestibular bulbs g. Class 7—DES induced (
8. Hymen in newborn: very vascular, redundant 23. Mocusal layer lining the the uterine cavity in nonpregnant
Pregnancy: epith thick, glycogen rich state
Menopause: thin w/ focal cornification a. Endometrium
9. Epithelium of the hymen 24. Lining epith of the endometrium
a. Strat. Squamous a. Single layer, high columnar, ciliated cells
10. Types of hymen 25. Zones of the endometrium
a. Annular (nullips) a. Functionalis ---shed off
b. Septate b. Basalis
c. Cribriform 26. Ligaments
11. Gonadal gender is estimated at…. a. Broad—winglike, extend from lat. Margins of the
a. 6 wks after conception uterus to the pelvis, divides pelvic cavity into A & P
12. Length of the vagina compartments
a. Ant wall --- 6-8 cm
 b. Cardinal – maintains position of the uterus & upper 47. Placental hormone important in the ―fail-safe mechanism‖
3rd of the vagina a. Hpl
c. Round—gubernaculums testes in men, from lateral 48. Major precursor for placental estrogen synthesis
portion of uterus—to inguinal canal, terminate in the a. DHEA
upper portion of the labia major 49. Functions of estrogen
27. Forms the lateral boundary of the pouch of douglas a. Regulates # of prolactin receptors
a. Uterosacral ligaments b. Increase lipid synth
28. Blood supply to the uterus c. Regulates/increase fetal lung surfactant
a. Uterine d. Stimulates PG production leading to labor
b. Ovarian artery 50. Estrogen which can be used to test for fetal well being
29. Length of the fallopian tubes a. Estriol
a. 8-14 cm 51. Principal urinary metabolite of progesterone
30. Divisions of the FT a. Pregnanediol
a. Interstitial 52. Progesterone production
b. Isthmus a. Normal, singleton----250mg/day
c. Ampulla b. Multiple fetuses--- > 600mg/day
d. Infundibulum 53. Precursor for fetal adrenal steroidogenesis
a. Cholesterol (LDL)
54. Fxns of progesterone
a. Initiation of parturition
b. Maintenance of pregnancy in utero
c. Inhibits cholesterol esterification
2nd shift (dr. Morata) d. Facilitate action of GABA
55. Largest organ of the fetus
31. Quickening a. Adrenal cortex
a. Prima –18th – 20th week 56. Daily steroid production
b. Multi – 14th -16th week a. 100-200mg/day
32. Uterine fundus felt at level of symphysis pubis 57. Product of conception
a. 12th week a. Embryo
33. Softening of the uterine isthmus 58. embryonic period
a. Hegar’s sign ( 6th-8th wk) a. 4 weeks after ovulation—arm &leg buds present
34. Cyanosis & softening of the cervix b. 6 weeks after fertilization—heart is completely
a. Goodell’s sign (4 weeks) formed
35. Spalding’s sign c. 8th week after fertilization—end of the embryonic
a. Liquefaction of the brain period
36. Robert’s sign 59. Fetal period
a. Gas bubbles a. 8 weeks after fertilization up to 40 weeks
37. Fundal height b. 12 weeks AOG – centers of ossification in most fetal
a. 12 wks – symphysis pubis bones
b. 20 weeks—umbilicus c. 16 wks AOG—gender correctly determined
c. 36 wks--- below xiphoid d. 20 wks aog- downy lanugo covers entire body
38. Chadwick’s sign’ e. 24wksaog—fat deposition begins
a. Voilaceous discoloration of the vagina f. 28wks aog—thin skin is red & covered by vernix
39. FHT heard by steth caseosa
a. 18th week g. 40 wks aog—features of fully developed NB
40. FHt by Doppler 60. Previable fetal period
a. 10 -12 weeks a. 11-20 weeks
41. Increase in cardiac output during pregnancy 61. Greatest transverse diameter of the fetal head
a. 30-50 % a. Biparietal dm (9.5 cm)
42. Principal prostaglandin of the endothelium 62. Bitemporal dm (8cm)
a. Prostacyclin (PGI2) a. Greatest distance between 2 temporal sutures
43. hcg 63. Adult levels of IgM are attained
a. 10 wks AOG – maximal levels a. 9 mos of age
b. 10th-12th weeks---begin to decline 64. B lymphocytes appear
c. 20 wks—nadir a. Liver – 9 wks AOG
d. 8- 10 days--- detectable b. Blood & spleen ---12 wks AOG
44. Main endocrine organ during pregnancy 65. Most pancreatic enzymes are present by
a. Placenta a. 16 wks AOG
45. Total iron requirement of pregnancy 66. Nervous system
a. 1 g/day a. Embryonic--- SC extends along entire length of vert
46. Total amount of water retained during pregnancy column
a. 6.5 L b. 24 wks AOG—SC extends to S1
 c. @birth ---L3  Complicated pregnancies: 1 to 2 weeks interval
d. Adult—L1 9. Fetal Heart sounds
67. Sensory organs  First heard at 16 to 19 weeks using a DeLee fetal stethoscope
a. 7 wks—taste buds, swallowing  Heart sounds audible by 22 weeks in all patients
b. 8 wks – flex neck & trunk 10. Fundal Height
c. 12 wks—urine prod  Gestational age equal to the fundal height between 20 to 31
d. 14-16—breathing movt weeks
e. 16 wks—close fingers 11. Trimesters of pregnancy
f. 24-26—suck and hear sounds  3 equal period consisting of 3 calendar months
g. 28- respond to light  1st trimester: up to 14 weeks
68. Highly modified endometrium of pregnancy
 2nd trimester : 14 weeks 1 day up to 28 weeks
a. Deciduas
 3rd trimester : 28 weeks 1 day up to 42 weeks
69. Zone of fibrinoid degeneration
12. Normal duration of pregnancy
a. Nitabuch’s layer
70. Inconstant deposition of fibrin at the bottom of the intervillous  280 days or 40 weeks, calculated from the first day of the last
space surrounding the villi normal menstrual period
a. Rohr stria  Estimated date of delivery (EDD)
71. Refers to all tissue products of conception (embryo, fetal o Calculated using Naegele’s rule
membranes, placenta) o Add 7 days to the first day of LMP; count back 3
a. Conceptus months
72. Stage of human development w/in uterine cavity 13. Definitions:
a. Blastocyst Parity – number of pregnancies reaching viability ( 20 weeks, 500
73. The cell that results from the fertilization of the ovum by a gm)
spermatozoon  Primipara
a. Zygote  Multipara
74. The villi in contact with the deciduas capsularis which  Nullipara
proliferate Gravida – a woman who is or has been pregnant regardless of
a. Chorion frondosum outcome
75. Represent fetal macrophages  Nulligravida
a. Hofbauer cells ( prominent & abundant in early  Primigravida
pregnancy)  Multigravida
14. Initial Prenatal Evaluation
THIRD SHIFT (Dr. Mendoza) Initiated as soon as there is likelihood of pregnancy
Preconceptional Counseling Should be no later than the 2nd missed period
15. Changes in the cervical mucus
1. Caffeine: More than 5 cups per day increase abortion rate - Beaded cervical pattern – low levels of NaCl
2. Fetal alcohol syndrome 16. Chadwick sign – changes in the vagina
o Growth restriction 17. Changes in uterus: Hegar sign
o Facial abnormalities 18. Funic soufflé – passage of blood through umbilical vessels
o Central nervous system dysfunction 19. Uterine soufflé – maternal blood flow always coincident with
3. Coitus: Not harmful until the last 4 weeks maternal pulses
4. Travel: not within 7 days of EDD 20. Neural Tube defects
5. FDA categories  Mutation in the Methylene Tetrahydrofolate Reductase gene
 A: human studies show no fetal risks  Overcome by periconceptional folic acid
e.g. prenatal multivitamins o 4 mg/day – for women w/ a prior baby w/ NTD
 B: animal studies show no risk but no human studies available or o 0.4 mg/day – reduction of the prior risk of first
adverse effects demonstrated in animal but no well – occurrence
controlled human studies 21. Phenylketonuria (PKU)
e.g. penicillins  Example of a disease the fetus cannot inherit but is affected
 C: no adequate animal or human studies; or there are adverse because of a maternal genetic predisposition
animal fetal effects but no available human data 22. Tay sach’s disease
 D: there is evidence of fetal risk, but benefits outweigh risks  Autosomal recessive neurodegeneration disorder
e.g carbamazepine 23. Thalassemias
phynetoin  Most common single gene disorder
 X: proven fetal risks outweigh any benefits 24. Psychiatric Disorder
o e.g. isotretinoin - Schizophrenia (0.8%)
6. GBS : vaginal and rectal cultures at 35- 37 weeks - Bipolar disease (0.5 %-1.0%)
7. Maternal serum AFP at 16-18 (or 15-20) - ADHD
8. Subsequent prenatal visits 25. Connective tissue disease
 Every 4 weeks until 28 weeks o Rheumatic arthritis improve during pregnancy but
 every 2 weeks until 36 weeks relapse within 6 months of deliveries
 weekly thereafter o Ankylosing spondylitis: increase back pain
 o Scleroderma: improvement of Reynaud’s phenomenon Maternal plasma concentration decreases by about 0.5
o SLE – most serious mEq/L by midpregnancy
26. Best predictor of perinatal outcome is serum creatinine level 10. Vitamins
27. Hyoerglycemia is teratogenic to the embryo:  Increased requirements can be met by an adequate diet:
 Neural tube defect Exception: Folic Acid
 Cardiac anomalies & renal anomalies 11. Folic Acid
 Sacral agenesis  Deficiency – Megaloblastic anemia
 Holoprosencephaly  400 ug supplementation important for prevention of neural
tube defects
High-Risk Pregnancy
1. Maternal age: 12. Fetal behavioral States
o Under 18 years old  1F
o Nullipara over 30 years Quiescent state (quiet sleep)
o Multipara over 35 years  2F
Maternal height: Frequent gross body movements
o 60 inches or less (153 cm or less) Continuous eye movements
Wider oscillation of fetal heart rate
BMI Recommended Rate (4 weeks) Analogous to REM or active sleep in neonates
Gain (kg)  3F
Low (<19.8) 12.7 – 18.2 2.3 Continuous eye movements in the absence of body
Normal (19.8 – 26.9) 11.4 – 15.9 1.8 movements
High (26.1 – 29.0) 6.8 – 11.4 1.2 No fetal heart rate accelerations
Obese (>29.0) 6.8 0.9 Existence of this state disputed
Twin gestation 15.9 – 20.4 2.7  4F
Vigorous body movements
2. Calories Continuous eye movements
Additional 300 kcal/day Fetal heart rate accelerations
Corresponds to awake state in infants
Nonpregnant Pregnant Lactating
Kcal 2200 2500 2600  Fetuses spend most time in states 1F and 2F
Protein 55 60 65  Urine production increases during 1F
(grams)  Fetal voiding and decreased urine production during 2F
3. Protein  Sleep-wake cycle: important determinant of activity
Average of 9 grams/day Varies from 20-75 minutes
13. Maternal perception
4. Carbohydrates  Several counting protocols:
Main source of energy o 10 movements in 2 hours
150 grams/day – 1st trimester o Fetal movements in 1 hour compared to an established
5. Fats baseline activity count
Most concentrated source of energy 14. Acceleration
15-25 grams/day  After 32 weeks
6. Iron o ≥ 15 bpm above the baseline rate
Average requirement for the whole duration of pregnancy o ≥ 15 seconds
– 41 mg/day  Before 32 weeks
30 mg elemental iron o 10 bpm
60-100 mg if: o ≥ 10 seconds
o Large woman 15. Nonstress Testing (NST)
o Multiple gestation  fetal heart rate accelerations = fetal movement
o Poor compliance to iron Reactive:
200 mg if overtly anemic o 2 or more accelerations within 20 minutes of
Not necessary in the 1st 4 months beginning the test
7. Zinc  Non-Reactive:
Second to iron as the most abundant trace element in the o No accelerations
body o Extend tracing to 40 minutes to account for fetal sleep
Deficiency: 16. Testing Frequency
o Dwarfism and hypogonadism  7 days
o Acrodermatitis enterohepatica  Shortened to twice weekly if indicated
Additional allowance of 8 mg/day or total of 12 mg/day 17. Decelerations during NST
8. Iodine  Not an indication of fetal compromise if:
Cretinism: Maternal deficiency o Isolated and brief (<30 seconds)
Overconsumption: Fetal goiter  Increased incidence of fetal compromise if:
9. Potassium o Repetitive (at least 3 in 20 minutes)
 o Duration longer than 1 minute  Characteristics:
18. Contraction Stress Testing (CST) o Discontinuopus
 Induction of uterine contractions o Paradoxical
o Oxytocin o Diurnal
o Nipple stimulation Types
 FHR and uterine contractions simultaneously recorded by an 1. Gasps or sighs
electronic fetal monitor  Frequency of 1 to 4 per minute
 Three contractions, ≥ 40 seconds 2. Irregular bursts
Interpretation  240 cycles/minute
 Negative  Associated with REM
o No late or significant variable decelerations
 Positive Maturation of Normal Fetal Breathing
o Late decelerations following 50% or more of contractions  Fetal respiratory rate decreased as respiratpry volume increased
(even if contraction frequency is fewer than 3 in 10  Occurs at about 33-36 weeks AOG
minutes)
 Equivocal – suspicious Interpretation and management
o Intermittent late decelerations  Score of 10:
o Significant variable decelerations o Normal non-asphyxiated fetus
 Equivocal – hyperstimulatory o No fetal indication for intervention
o Heart rate decelerations that occur with contractions o Repeat test weekly except in diabetic patient and
more frequent than every 2 minutes or longer than 90 postterm (2x)
seconds  Score of 8/10 (normal fluid) or 8/8
 Unsatisfactory o Normal non-asphyxiated fetus
o Fewer than 3 contractions in 10 minutes o No fetal indication for intervention
o Uninterpretable tracing o Repeat testing depending on protocol
19. Acoustic Stimulation Tests  Score 8/10 (decreased amniotic fluid volume)
 The fetus responds to sound o Chronic asphyxia
 125-400db o Deliver
20. Fetal Startle Response  Score 6:
o Artificial larynx o Possible fetal asphyxia
o May be repeated up to 3 times for up to 3 seconds o If fluid volume abnormal: deliver
 Fetal response: acceleration of the fetal heart rate o If normal fluid, > 36 weeks, favorable cervix, deliver
21. Biophysical Profile (BPP) o If repeat test ≤ 6; deliver
Scoring o If repeat test> 6: observe and repeat per protocol
 Score of 2: Presence of a variable  Score 4:
 Score of 0: Absence of a variable o Possible fetal asphyxia
 No score of 1 o Repeat test same day, if repeat test ≤6: deliver
 Maximum score of 10/10  Score 0-2:
o Almost certain fetal asphyxia
2 0 o Deliver
Fetal Tone  ≥ 1 episode of extension  No movements
of a fetal extremity with or no extension 23. Modified BPP
return to flexion or flexion  VAS NST + AFI
 ≥ 1 episode of opening or 24. Umbilical Artery Doppler Velocimetry
closing of the hand  Assesses blood flow by characterizing downstream impedance
Fetal  ≥ 1 episode of rhythmic  < 30 seconds of  Indices:
Breathing breathing lasting for ≥ 30 breathing within o Systolic/diastolic
seconds within 30 30 minutes o Pulsatility index
minutes o Resistance index
Fetal  ≥ 3 discrete body or limb  ≤ 2 movements  Best for IUGR
Movement movements within 30 in 30 minutes 25. MCA Doppler Velocimetry
minutes  Hypoxic fetus compensates by ―brain-sparing‖
Amniotic  Single vertical pocket > 2  Largest single  Reduced impedance (increased blood flow) to cerebral vessels
Fluid cm vertical pocket ≤
Volume  AFI >5 cm 2cm FETAL DEATH
 AFI ≤ 5 cm 1. Fetal Mortality: More than half occur before 28 weeks
NST  ≥ 2 accelerations of ≥ 15  0 or 1 2. Causes of Fetal Death
bpm for ≥15 seconds in acceleration in  Fetal (25-40%)
20-40 minutes 20-40 minutes  Placental causes (25- 35%)
 Maternal (5- 10%)
22. Fetal Breathing  Unexplained (25-35%)
 3. Spontaneous ICH (Intracranial Hemorrhage)
 Most common – isolated IVH without SAH and
subdural bleeding
4. Cephalhematoma
 Develops over one or both parietal bones and
limited by the periosteum
 Differentiate from caput succedaneum – focal
swelling of scalp (edema) over the
5. Brachial plexus injury
o Erb or Duchenne paralysis
 upper plexus (C5 – C6, occasionally C7)
 Paralysis of the deltoid and infraspinatus and flexor
muscles of the forearm
 Arm held straight and internally rotated with elbow
extended and wrist and fingers flexed
o Klumpke’s paralysis
 Lower plexus (C8 –T1)
 Flaccid hand
 Involvement of all brachial plexus nerve roots – flaccid
arm and hand
 Horner syndrome – ptosis, pupillary meiosis
(interruption of nerve fibers in the cervical
sympathetic chain)
6. Facial paralysis
o Pressure on facial nerve as it exits the stylomastoid
foramen
7. Fractures
a. Clavicle –common
b. Humerus – Greenstick type
DISEASE and INJURIES
1. Respiratory Distress Syndrome (RDS)
 Surfactant: type II pneumocytes
 CXR – air bronchogram (reticulogranular infiltrates with
an air-filled tracheobronchial tree)
 Prevention
o L/S ratio: Present in equal concentrations before
34 weeks
o Phosphatidylglycerol: Enhances the surface-
active properties of LS
o TDx-FLM: Measures surfactant-to-albumin ratio
 Value of 50 or greater predicted lung
maturity in 100 percent of cases
o Foam stability index or shake test
 Generation of a stable foam at the air-
liquid interface when mixed with ethanol
o Lamellar body count
o DPPC (Dipalmitoylphosphatidylcholine)
2. Intraventricular Hemorrhage (IVH)
 Common before 34 weeks
 Most develop within 72 hours of birth (longest – 24 days)
3. Necrotizing enterocolitis (NEC)
 Abdominal distention, ileus, bloody stool
 Pneumatosis intestinalis – bowel wall gas
4. Anemia
 Hgb= 17mg/dl at 34 weeks (below 14mg/dl is abnormal)
 Fetomaternal hemorrhage
 Kleihauer- Betke test (fetal Hgb is more resistant to
acid elution)
5. Isoimmunization
 ABO and Rh antigens
Immune hydrops
 Abnormal collection of fluid in more than 1 area of the fetal
body
 Identification
 Indirect Coomb’s test- mother (because antibodies are
bound)
 Direct Coombs test- neonate (maternal antibodies are
absorbed by the fetal RBC)
 IgG antibody titer
 Prevention
 Anti- D- immunoglobulin to D- negative
nonsensitized women
 1st dose at 28 weeks
 2nd dose after delivery if the infant is D+
Diseases of the Term Fetus and Neonate
Meconium Aspiration Syndrome (MAS)
 Peripartum inhalation of meconium  chemical
pneumonitis
Hemorrhagic disease of the Newborn (HDN)
 Spontaneous internal or external bleeding within 48 hours of
birth
 Abnormally low levels of vitamin K dependent clotting factors
(V, VII, IX, X), prothrombin, protein C and S
 Vitamin K treatment
PRENATAL DIAGNOSIS
1. Translocation – exchange of chromosome material from breaks
in two chromosomes before repair occurs
2. Inversion – genetic material from two breaks in the same
chromosome are inverted before the breaks are repaired
3. Fetuses at High Risk for Genetic or Congenital Disorders
 Fetal aneuploidy
 Isolated structural anomalies
 Familial genetic disease
4. Fetal aneuploidy
o 50% of 1st trimester abortions
5. Women with risk of fetal aneuploidy high enough to justify risk
of amniocentesis
 Singleton pregnancy with age ≥ 35 at delivery
- Midtrimester risk of Down syndrome : 1 in 250
 Dizygotic twin pregnancy with age ≥ 31 at delivery
- Midtrimester risk: 1 in 190
 Previous autosomal trisomy birth
 Previous 47,XXX or 47,XXY birth
- Previous 47, XYY and 45, X are not at high risk for recurrence
 Patient or partner is a carrier of chromosome translocation
6. Repetitive first trimester losses
 Majority of early losses: euploidic
7. Parental aneuploidy
 Trisomic individuals often sterile
 Except:  Expanded AFP test, AFP plus, triple screen or multiple marker
o Female trisomy 21 screen
o Female 47, XXX o Elevated HCG
o Male 47, XYY o Decreased unconjugated estriol
8. Congenital heart defects o Low MSAFP
 Most common isolated structural defects BUN study: Free beta- hCG, PAPPA-A, NT measurement and
 Most common recurrence of same defect: AV septal and laterality maternal age
defects FASTER Trial
 Most common recurrence of similar defects: left-sided, outflow tract  Underwent both 1st trimester free beta- hCG, PAPPA-A, NT
and septal defects measurement and maternal age screening, AND
9. Neural tube defects  2nd trimester hCG, AFP, estriol, inhibin and maternal age
 Environmental agents screening
o Hyperglycemia 17. Fragile X Syndrome: Most common cause of familial mental
o Hyperthermia – increases risk sixfold retardation
o Drugs
 United Kingdom: Highest 18. Cystic Fibrosis
10. Neural tube defects  Autosomal recessive
 Alpha-fetoprotein (AFP)  characteristics:
o Glycoprotein o Abnormal sweat chloride levels
o major fetal serum protein o Chronic pulmonary disease
11. AFP o pancreatic insufficiency
 Concentration increases until 13 weeks o liver disease
 Found in steadily increasing quantities in maternal serum after 12 o obstructive azoospermia
weeks  CF gene: long arm of chromosome 7
12. Maternal serum AFP screening o Encodes CFTR
 Between 14-22 weeks
19. Incidental finding of a Major Structural Defect
 Greatest sensitivity at 16-18 weeks
 Measured in ng/ml, reported as MOM Defect Aneuploidy Risk (%)
13. Elevated maternal serum AFP
Cystic hygroma 60-75
 Greater than 3.5 MOM Hydranencephaly Minimal
o Clearly indicate an increase fetal risk
14. Ultrasound examination 20. Routine Sonographic Screening for Major Structural
 Anencephaly Anomalies
 Spinal Defects
 Nuchal fold: most discriminatory during the first trimester
 Cranial signs of a spinal defect
21. Early Amniocentesis
o Lemon sign
o Banana sign  More positional foot deformities
o Obliteration of cistern magna 22. Chorionic Villus Sampling (CVS)
o Small BPD  10-13 weeks
o Ventriculomegaly  Relative contarindications:
 Risk of NTD is reduced by 95 % if no spine defects or cranial o Vaginal bleeding
signs are seen o Extreme uterine ante- or retro-version
o Patient habitus that precludes easy access
15. Amniocentesis  Absolute contraindication: infection
 Elevated AFAFP – determine AF acetylcholinesterase  Transabdominal CVS after 9 weeks – as safe as 2nd trimester
 Elevated AFAFP + negative acetylcholinesterase – amniocentesis
another etiology or fetal blood contamination  Complications:
 Fetal karyotype o Limb-reduction defects
o Both MSAFP and AFAFP are elevated o Oromandibular defects
o Elevated MSAFP + normal AFAFP – not o Cavernous hemangiomas
necessary  Midtrimester amniocentesis – associated with lowest number
o Elevated AFAFP – chromosomal abnormalities of uninformative results compared to CVS
fivefold over background
16. Down Syndrome
 Maternal age-related risk: most powerful predictor of
aneuploidy 23. Fetal Cells in maternal circulation
 Low MSAFP
 Sixfold increase of fetal cells in maternal blood if fetus is
Multiple marker screening aneuploid
1. Twin-to-twin Transfusion syndrome
  Therapeutic options; 3. Transverse
i. Amnioreduction ⌐ Best for detecting presence and extent of defects
ii. Endoscopic laser ablation
iii. Selective feticide Frontal scalloping or lemon sign (Spinal menigomyelocele)
2. Fetal Transfusion
Parvovirus Infection Banana Sign (Meningomyelocele). Develops when the cerebellum is
 Prior to 20 weeks bowed and inferiorly displaced, causing effacement of the cistern magna
o Severe transient aplastic anemia 7. Anomalies
o Heart failure  Hydrocepahlus
o Hydrops o ―Dangling choroid plexus” sign
3. Fetal Medical Therapy  NTD
 Administration of medications either to the mother o Failure of midline fusion of the neural plate
(steroids for fetal lung maturation) or directly to the o Anencephaly
fetus ⌐ Absence of cranial vault, hydramnios
 Direct Fetal therapy: o Encephalocele: herniation through a cranial defect of brain
i. Fetal thyrotoxicosis and meninges
ii. Cardiac arrhythmia o Meningocele: only meninges herniated
24. Fetal Surgery o Chiari III: cerebellar herniation
8. Spina Bifida Cranial Signs
Urinary shunts: Posterior urethral valve, urethral atresia, 1. Small BPD
ureteropelvic junction obstruction 2. Ventriculomegaly
3. Lemon sign: scalloping of frontal bone
Congenital Cystic Adenomatoid Malformation (CCAM) and 4. Banana sign: abnormal curvature of cerebellum
Pulmonary Sequestration o Sometimes cerebellum not visualized
 CCAMs-pulmonary hamartomas consisting of overgrown terminal 5. Effacement or obliteration of cisterna magna
bronchioles 9. Choroid Plexus Cyst
 PS-tissue mass that becomes completely separated from the lung  Neuroepithelial folds in the choroid plexus of the lateral ventricles
fill with CSF
ULTRASOUND  Identified in 70% of fetuses with trisomy 18
10. Cystic Hygromas
1. First trimester  Lymphatic system congenital malformation
 CRL o Failure of the development of the lymph connection to the
o Most accurate for dating (3-5 days error) jugular vein by 40 days gestation
 Gestational sac  60-70%: associated with aneuploidy
o Should be visible when serum β-hCG is 1800 Miu/ml  Large, multiseptated lesions: do not resolve
2. BPD easiest and most reproducible o Worse prognosis
± 7-10 days ⌐ Abnormal karyotype
3. FL strongly correlates with BPD and AOG ⌐ Develops hydrops
± 7-11 days ⌐ Diminished survival
4. AC has a wider variation 11. Diaphragmatic Hernia
o ± 2.8 weeks  Incomplete fusion of the pleuroperitoneal membrane
o Useful for EFW  More frequent on left
5. Third trimester o Four chamber cardiac view; heart pushed to the middle or to
 Variation of BPD and FL: ± 14-21 days the right by the stomach or bowel which appears as a cystic
6. Central nervous system structure behind the left atrium
 3 transverse (axial) cranial views: 12. Heart
1. Transthalamic view  Visualized sonographically at 6-7 weeks
⌐ Measure BPD and HC  4 chambers visualized during the 2nd trimester
⌐ Thalamus  Detailed evaluation not possible until 18 weeks
⌐ Cavum septum pellucidum 13. Four Chamber View
⌐ Frontal horns of the lateral ventricle  Central view to cardiac assessment
2. Transventricular view  Cardiac axis: apical angle 45˚ with the anterior chest wall
⌐ Atria of the lateral ventricles  Moderator band: apex of right ventricle
⌐ Choroid plexus  Foramen ovale flap: left atrium
⌐ Cranial contour
3. Transcerebellar view 14. Gastrointestinal tract
⌐ Cerebellum Stomach Bubble
⌐ Cisterna magna  Visible in 98% of fetuses after 14 weeks
⌐ Nuchal fold  Absence:
 Spinal view: o TEF
1. Sagittal o Esophageal atresia
2. Coronal
 o Diaphragmatic hernia 4. Syndrome
o Abdominal wall defects  Cluster of several abnormalities or defects due to a single cause
o Neurological abnormalities that inhibit fetal swallowing 5. Sequence
All abnormalities occur sequentially as the result of a single insult
Fetal Bowel
6. Association
 Appearance changes with gestational age
Particular anomalies occur together frequently but do not seem to
 Hyperechogenic bowel: brightness equivalent to or greater than
bone be linked etiologically
7. Aneuploidy
Abdominal Wall Defects  Numerical abnormality
 Common types: 8. Trisomy
o Omphalocele  Affected individual inherits an extra chromosome
Failure of the lateral ectomersodermal folds to meet in the  Mechanisms:
midline of the abdomen between the 3rd and 4th weeks
o Nondisjunction – failure of a chromosome pair to
o Gastrochisis
Occlusion of either the right umbilical vein or the terminal separate
segment of the right omphalomesenteric artery  Nondisjunction risk increases with maternal age
 Elevated serum maternal AFP o Chiasmata breakdown

Gastrointestinal Atresia Trisomy 21: Down syndrome

 Characterized by obstruction with proximal dilatation  95% due to maternal nondisjunction
 Esophageal atresia: hydramnios + absent fluid- filled stomach o 75%-during meiosis I
 Duodenal atresia: double- bubble sign (distention of stomach o 25%-during meiosisII
and 1st part of duodenum) Trisomy 18: Edward syndrome
Trisomy 13: Patau syndrome
Genitourinary Tract Cutis aplasia an polydactyly in combination
 Kidneys demonstrated at paraspinous area o Suggests either trisomy 13 or lethal deletion of 4p
o As early as 14 weeks (TAS)
XXX and XXY
o Routinely at 18 weeks
Pubertal development in females normal (XXX), normal fertility
 Obstructive uropathy XXY males do not virilize, infertile due to gonodal dysgenesis,
o Commonly: uteropelvic junction obstruction
gynecomastia and small testicles
 Renal Agenesis 9. Monosomy: No association with maternal age
o Potter Syndrome: severe oligohydramnios, pulmonary
hypoplasia, limb contractures, distinctive compressed facie
45, X
Turner syndrome or monosomy X
15. Doppler Velocimetry
Only monosomy compatible with life
Doppler Shift Principle
Most common aneuploidy in abortuses
 When a source of light or sound wave is relative to an observer,
the observer detects the shift in the wave frequency
10. Polploidy
 When sound waves strike a moving target, the frequency of the
sound waves reflected back is shifted proportionate to the velocity 2/3 of triploidy: from fertilization of one egg by 2 sperm
and direction of the moving target ½ from failure of meiotic division
Indices o Diploid chromosome complement in the egg, commonly in the
 Systolic/Diastolic (S/D) sperm
 Resistance index or Pourcelot Index (RI) o Paternal: Hydatidiform mole
 Pulsatility Index (PI)
If a fetus develops
Uterine and Arcuate Arteries Origin of the extra chromosome dictates phenotype
 High diastolic velocity, highly turbulent flow Extra maternal haplotype (digynic): severely growth restriced
fetus and placenta
Fetal Descending Aorta Extra paternal haplotype (diandric): relatively normal fetal size,
 Receives majority of RV output via DA placenta abnormally large and cystic

Limited Blood Flow 11. Chromosome deletions

 Middle cerebral artery most accessible Refers to a portion of the chromosome that is missing
Deletion 4p
GENETICS Wolf-Hirschhorn syndrome
Deletion 5p
1. Poor formation of tissue  Malformation Cri du Chat syndrome
2. Unusual forces on normal tissue  Deformation
3. Breakdown of normal tissue  Disruption
12. Translocations Mitochondrial inheritance
Reciprocal translocation  Derived exclusively from the mother
Double-segment translocation  No possibility of recombination
Rearrangement of chromosomal material in which breaks occur in
2 different chromosomes
Robertsonian translocation: MC DRUGS
Fusion of the centromeres result in the loss of one centromere
Isochromosomes Penicillins: Safest antimicrobials to use in pregnancy
Centromeres break transversely instead o longitudinally during Erythromycin: Commonly used if penicillin allergic
meiosis II or mitosis Cloramphenicol: Gray baby syndrome
All genes located on the lost chromosome are deleted Nitrofurantoin
o Q arm: phenotypically normal, abnormal gametes  Urinary antiseptic
o P arm: phenotypically abnormal, abnormal gametes  No increase in congenital anomalies
Chromosomal inversions  Hemolytic anemia in women with G6PD deficiency
2 breaks in the same chromosome and the intervening genetic Vancomycin: Clostridium difficile pseudomembranous colitis
material is inverted before the breaks are repaired
Paracentric: inverted material from one arm only, centromere is not Zidovudine (Azidothymidine - AZT)
within the inverted segment  Thymidine analog that decreases DNA synthesis by reverse
Pericentric: breaks are in each arm and the inversion includes the transcriptase inhibition
centromere Acyclovir and Ganciclovir
o Carriers at high risk to produce abnormal offspring  Purine nucleoside analogs
 Primary herpes and possibly varicella infections
Autosomal dominant Amantadine: Prevent or modify influenza
If only one member of a gene pair determines the phenotype Oseltamivir: Neuraminidase inhibitor
Carrier has a 50% chance of passing on the affected gene with Metronidazole: Vaginal trichomoniasis and bacterial vaginosis
each conception Lindane
Penetrance: Describes expression of a mutant gene  Topical for pediculosis pubis and scabies
Expressivity: Degree to which the phenotypic features are  Crotamiton
expressed o First line treatment of scabies
Anticipation Chloroquine: First line antimalarial
 Disease symptoms become progressively severe and age at Pyrimethamine and Spiramycin: Folic acid antagonist
manifestation become earlier with each succeeding generation
Autosomal recessive: Traits are expressed only if both copies of Antihypertensive Agents
the gene function identically Methyldopa
Consanguinity: Mating between third degree relatives  Widely used agent
Co-dominant genes: Different alleles in a gene pair both are expressed  Treatment of choice for chronic hypertension
in a phenotyope Sodium Nitroprusside: accumulation of cyanide in the fetal liver
Calcium Channel Antagonists
X – and Y – linked genes  Decreased uterine blood flow
 X – linked: usually recessive  First trimester use: limb defects
 X – linked dominat disorders affect females predominatly  Verapamil: fetal cardiac depression and arrest when used in
o Lethal in male offspring combination with Digoxin
Salicylates and Acetaminophen
13. Nonmendelian Patterns of Inheritance  Premature closure of the ductus arteriosus because of
Fragile X – syndrome (Martin – Bell syndrome) prostaglandin inhibition
 Most common form of familial mental retardation Narcotics
Huntington Disease  Meperidine, Morphine
 characterized by progressive chorea, bradykinesia, and rigidity with o Neonatal withdrawal symptoms
an insidious deterioration of intellectual function Illicit drugs
 Marijuana or Hashish
Imprinting o THC teratogenic in high doses in animals
 Certain genes are inherited in an inactivated or transcriptionally  Amphetamines, Methamphetamines
silent state o Symmetrical fetal growth restriction
 Example:  Heroin
o Maternal chromosome 15 missing: Angelman syndrome o Fetal growth restriction, perinatal death
o Paternal: Prader – Walli syndrome o Withdrawal symptoms

Unipaternal disomy TERATOLOGY

 Both member of one pair of chromosome are inherited from 1. Hadegen – agent that interferes with normal maturation and
the same parent function of an organ
2. Trophogen – agent that alters growt
 3. Exposure must occur during a critical developmental Sulfonamides
period  Compete for bilirubin biding sites
⌐ Embryopathy – first 8 weeks  Hyperbilirubinemia if used near term
⌐ Fetopathy – after 8 weeks  Trimethoprim – Folic Acid antagonist
 Embryonic period (2nd – 8th week) 6. Tobacco
⌐ Most crucial for malformations because of  Increased Poland sequence
organogenesis o Interruption of vascular supply to chest and arm
7. Thalidomide
Genetic and Physiological Mechanisms of Teratogenicity  Anomalies of the structures derived from the mesodermal
layer
1. Disruption of Folic Acid Metabolism  Upper limbs more severely affected
 Folic acid essential for production of methionine o Upper limb phocomelia: 27-30 days
o Cofactor in RNA and DNA synthesis o Lower limb phocomelia: 30-33 days
 Antagonists
o Hydantoin INTRAPARTUM ASSESSMENT
o Carbamazepine
o Valproic Acid Electronic Fetal Monitoring (EFM)
o Phenobarbital 1. Cardioregulatory Center
2. Fetal Genetic Composition  Collection of neurons in the ventral and lateral surfaces of the
 Interaction of environment and altered genes medulla in the region of the 4th ventricle
 Homozygosity of the fetus
2. Direct CRC connection
 Examples:
o Cigarette smoking and cleft palate in  Parasympathetic pathway via the vagal nuclei to the afferent
polymorphism of the TGF α-1 cardiac vagal fibers
3. Homeobox Genes  Sympathetic control via impulses traveling through the spinal
o Retinoic acid that can activate a gene prematurely cord, to the cervical and thoracic sympathetic ganglia ten to
o Valproic acid which activates 5’ the cardiac sympathetic fibers
 NTD in lumbosacral area 3. Indirect CRC control
 Sympathetic discharge and release of catecholamines from
Known Teratogens
1. Alcohol the fetal adrenal gland
 Most potent teratogen 4. Stimulation of the CRC
 Fetal Alcohol Syndrome (FAS)  Mediators:
2. Anticonvulsant medications  Aortic arch and carotid body chemoreceptors (acidemia)
Phenytoin: Hydantoin Syndrome  Aortic arch and atrial baroreceptors (volume)
Carbamazepine  Premise: fetal heart rate pattern charges reflect fetal oxygenation
Valproic Acid: Exclusively in the lumbosacral region
5. Internal EFM
3. Warfarin compounds
 Between 6-9 weeks – warfarin embropathy  Peak R-wave voltage most reliably detected
o Nasal hypoplasia  Electrical impulse is counted and not the actual heartbeat
o Stippled vertebral and femoral epiphyses 6. Fetal Heart Rate Patterns
o Inhibits post-translational carboxylation of  Baseline rate
coagulation proteins (osteocalcins)  Beat-to-beat variability
o Phenocopy of chondrodysplasia punctata  Periodic changes
(inherited defect of osteocalcin)
 2nd-3rd trimester – effect of fetal hemorrhage  Accelerations
o Dorsal midline CNS  Decelerations
 Agenesis of the corpus callosum o Early
 Dandy-Walker malformation o Late
 Midline Cerebellar Atrophy o Variable
4. Antineoplastic Drugs  Arrhythmias
Methotrexate/Aminopterin
 Sinusoidal pattern
 Alters folic acid metabolism
 MTX: abortifacient 7. Baseline beat-to-beat variability
 R-wave to R-wave oscillation
5. Antimicrobials  Important index of cardiovascular function
Tetracycline
 Yellow-brown discoloration of deciduous teeth 8. Long-term variability
 Deposited in fetal long bones  Oscillatory changes that occur during a course of 1 minute
Aminoglycosides  Result in waviness of the baseline FHR
 Streptomycin – CN VIII damage  Undetectable
 o Absent variability  Observed with acute, lethal asphyxia more than 1 hour fetal
 Minimal hypoxia with profound metabolic academia (pH less than 7.0)
o ≤ 5 bpm
 Moderate Criteria to Define an Acute Intrapartum Hypoxic Event as Sufficient
to Cause CP
o 6-25 bpm
 Metabolic acidosis (pH < 7, base deficit ≥ 12 mmol/L)
 Marked  Early onset severe or moderate neonatal encephalopathy
o > 25 bpm in infants born beyond 34 weeks
9. Accelerations  Spastic quadriplegic or dyskinetic CP
 Increase in the fetal baseline heart rate by at least 15 bpm lasting  Exclusion of other identifiable etiologies
for at least 15 seconds
 Signals fetal well-being Benefits of EFM
o Intact neurohormonal cardiovascular fetal control of behavioral  Current recommendations
o Intermittent auscultation or continuous EFM for
states
both low- and high-risk patients
10. Early Decelerations o Every 30 minutes (low-risk) and every 15
 Related to cervical dilation (active labor) minutes (high-risk) intervals during the first
 Head compression  dural stimulation  vagal nerve activation stage
11. Late Decelerations o Every 15 minutes (low-risk) and every 5 minutes
 Index of uterine perfusion or placental function (high-risk) during the second stage
12. Variable Deceleration
INTRAPARTUM SURVEILLANCE OF UTERINE ACTIVITY
 Most common pattern encountered during labor
Patterns of Uterine Activity
 Abrupt decrease in rate that varies with successive contractions  Montevideo Units
 Duration less than 2 minutes o Product of the intensity multiplied by the
 Occur only after fetal blood flow is reduced by at least 50% contraction frequency in 10 minutes
 Significant: decrease to less than 70 bpm and last more than  Braxton-Hicks – seldom < than 20 mmHg
60 seconds  After 30 weeks, activity starts to increase
13. Prolonged deceleration  Labor commences between 80 – 120 mm MVU
 Isolated decelerations lasting at least 2 minutes but shorter than 10  Palpable uterine contractions – beyond 10 mmHg
minutes  Associated with pain – 15mmHg
Normal Labor
14. Sinusoidal heart rate
 Minimum of 3 contractions averaging greater than 25 mmHg
 Usually due to fetal anemia and less than 4 minute intervals between contractions
 Characteristics:
o Stable baseline heart rate of 120-160 bpm MENSTRUATION
o Amplitude of 5-15 bpm 1. Cell bodies of the hypothalamus that produce GnRH: ant.
o Frequency of 2-5 cycles/min long-term variability Hypothalamus and medial basal hypothalamus
o Oscillation above or below the baseline 2. GnRH producing neurons (greatest number): arcuate nucleus
o Absence of accelerations of the medial basal hypothalamus*
15. Fetal scalp blood sampling 3. Major route of GnRH: tuberoinfundibular tract*
 > 7.25: allow labor to go on 4. Follicular phase: 1 pulse/hr
 7.20-7.25: repeat measurement within 30 minutes 5. Luteal phase: 1pulse/3 hr
 < 7.20: repeat measurement immediately while preparing to 6. Cause of hypothalamic pituitary failure: sever weight loss,
expedite delivery strenuous exercise, anorexia nervosa*
FETAL DISTRESS 7. Biogenic amines secreted by a nerve cell that produce an
Diagnosis action on another cell: neurotransmitters* (dopamine and NE)
 Normal 8. Dopamine: precursor of NE, inhibitory to GnRH
o Baseline 110 – 160 beats per minute 9. NE: release of GnRH
o Variability 6 -25
10. Neuromodulators: affect action of neurotransmitters (opiods :
o (+) accelerations
o No decelerations inhibitory, PGE: stimulatory, catecholestrogens)
 Abnormal 11. FSH: granulosa cells
o Recurrent late or variable decelerations + - Follicular growth* by inc. FSH and LH receptor;
undetectable variability enhanced by estrogen
o Substantial bradycardia + undetectable variability 12. LH: theca cells
FHR patterns and Brain Damage - Stimulate androgen synthesis (theca cells)
 Nonspecific FHR patterns mostly present prior to admission or
- Stimulate progesterone synthesis (corpus luteum)
an average duration of 72 minutes
 Abnormal brain histopathology not
 13. 2 cell two gonadotrophin concept *: LH (theca cells) –
androgens (androstenodione & testosterone) –aromatase –
FSH (granulose cells) – estrogens (estrone & estradiol)
14. Hormonogensis: secretory activity of the ovary
15. Folliculogenesis: gametogenic activity
16. Steroid hormones: estradiol, progesterone and
androstenodione
- Estradiol --- estrone
 100-500 ug* (daily)
 Lowest : onset of mens
 Peak: before midcycle LH peak
 SHBG
- Progesterone
 4 mg (follicular)
 30 mg (luteal)
 CBG
17. Meosis*: germ cells
 Prophase: diploid (46) – haploid (23)
18. Spermatogenesis: 53 days*
 Seminiferous tubules of the testes
 Primary spermatocytes – first meiotic division – 2
Secondary spermatocytes – 2nd meiotic division – 4
spermatids – spermatozoa (thru spermiogensis*)
19. Oogenesis and follicular maturation
1. Early follicular formation
 Day 24 of fetal life – oogonia from yolk sac –
gonadal ridge – primitive gonad
 3rd month *– increase oogonia -- 1st meitotic –
primary oocytes – primordial follicle (single layer of
granulose cells) – maturation arrested – 6 M to 2 M
follicles during neonatal period – 400,000* at
menarche – 8,000 at 40-44 y.o.
20. Primary oocyte – zona pellucida – granulose cells (2-5 layers)
–no antrum : primary /pre-antral follicles
21. Recruitment: cohort follicle
22. LH surge: 24 hours after the estradiol peak
23. OMI (oocyte maturation inhibitor): prevents the early
maturation of the oocyte
24. 34-36 hrs ff the onset of LH surge: follicular rupture and
oocyte extrusion
25. Pre-pvulatory: 1st meitotic division
26. Fertilization: 2nd meitotic division
27. Dominant follicle: corpus luteum
28. LDL cholesterol: substrate of progesterone synthesis in
corpus luteum
29. Corpus luteum of menstruation: corpus albicans
30. Hcg stimulation: 1st tri maintains steroid prod’n beyond 7th
gestational week
31. Life span of corpus luteum: 14+2 days
FOURTH SHIFT (Dr. Villaluz)
Parturition
1. Bring forth of young – parturition
2. 4 phase: quiescence, activation, stimulation, involution
3. Uterine tranquility with maintenance of cervical structure
integrity – quiescence
4. Progression of changes in uterus during last 6 – 8 week of
pregnancy – activation
5. Associated with the capacity of the cervix to retain water –
Hyaluronic acid
6. Causes collagen fiber cross linking – dermatan sulfate
7. Key protein that control myometrial contractility – Contraction-
associated protein
8. Fetal heads often times descends to or even through the
pelvic inlet – lightening
9. Uterine contraction that bring about progressive cervical
dilation and delivery
10. 3 stages of labor
 Stage of cervical effacement and dilatation
 Expulsion of fetus
 Separation and expulsion of placenta
1. Extrusion of mucus plug that has filled the cervical canal –
blood show
2. Causes pain during uterine contraction
 Hypoxia of the contacted myometrium
 Compression of the nerve ganglia in the cervix and
uterus by interblocking muscle bundles
 Stretching of the cervix during dilatation
 Stretching of the peritoneum overlying the fundus
1. Mechanical stretching of the cervix which enhance uterine
cavity – ferguson reflex
2. Duration of each contraction (active phase of labor) – 30 – 90
seconds (ave. 60s)
3. Firm or hard during contraction – upper uterine segments
4. Boundary bet. Two segments (upper and lower) marked by
ridge – Physiologic retraction ring
5. Pathologic retraction ring seen in obstructed labor – Bandl ring
6. Changes in uterine shape during labor
 Lengthening of the fetal ovoid due to straigthening
of fetal vertebral column (4-5 cm) cause by fetal
axis pressure
 Lengthening of the uterus
1. 3 principal structure of the cervix: collagen, smooth muscle,
extracellular matrix
2. Extracellular matrix includes: hyaluronic acid, dermatan
sulfate, glycosaminoglycans
3. Shortening of the cervical canal from 2 cm to a mere circular
orifice w/ almost paper thin edges – cervical effacement (
obliteration or taking up)
4. Centrifugal pull is exerted on the cervix leading to distention –
cervical dilatation
5. Active phase includes: acceleration, maximum slope,
deceleration
6. Levator ani consist of: pubococcygeus and iliococcygeus
7. Blood from the placental site pours into inverted sac –
Schultze mechanism
 8. Separation of the placenta occurs first at the periphery, with
results that blood collects bet. The membrane and uterine
walll and escapes through vagina – Duncan Mechanism
9. 2 theory of the mechanism regulating the initiation of labor
 Retreat from the pregnancy maintenance
 Uterotonin induction of parturition
10. Establish a conduit for exchange of small molecules and ions
between cell – connexons
11. 3 major class of cell surface receptors: G-protein linked, ion-
channel linked, enzyme linked
12. Fail safe system that maintains uterine quiescence:
 Action of estrogenand progesterone via intracellular
receptor
 Myometrial cell plasma membrane receptor-
mediated increases Camp
 Generation of Cgmp
 Myometrial cell ion channels
MECHANISM OF LABOR
1. Relation of the long axis of the fetus to that of the mother – lie
2. Fetal and the maternal axes may cross at a 45 degree angle –
oblique lie
3. Predisposing factors for transverse lie: mulitparity, placenta
previa, hydramnios,uterine anomaly
4. Occipital fontanel is the presenting part – vertex/occiput
5. Fetal neck sharply extended so that occiput and back come in
contact – face presentation
6. Partially flexed head w/ anterior fontanel or bregma presenting
– sinciput presentation
7. Partially extended head – brow presentation
8. Amniotice cavity is large compared w/ the fetal mass and
there is no crowding of the fetus by uterine walls – at 32
weeks
9. 3 configuration of breech presentation: frank, complete,
footling
10. Fetal attitudes/posture:
 Fetus forms ovoid mass
 Back becomes markedly convex
 Head sharply flexed in contact w/ the chest
 Thigh are flexed over the abdomen
 Legs are bent at the knees
 Arches of the feet rest upon the anterior surface of
the legs
11. Refers to relationship of an arbitrarily chosen portion of fetal
presenting part to the right/left side of the maternal birth canal
– fetal position
12. 2/3 of vertex – left occiput position 1/3 of vertex – right OP
13. Portion of the fetus chosen for orientation in shoulder
presentation – Acromion (scapula)
14. Methods of diagnosis fetal presentation/position: abdominal
palpation, vaginal examination, auscultation, ultrasound.
15. Identification of fetal pole (breech or head) occupies the
fundus – LM1
 BREECH – large nodular mass
 Head – hard, round, ballotable, mobile
16. Palms are place on either side of the maternal abdomen w/
gentle but deep pressure – LM2
 BACK – hard resistant structure
 FETAL EXTREMITIES – numerous small irregular
mobile parts
 ORIENTATION – directed anteriorly, transversely,
or posteriorly
17. Palpation of the presenting part – LM3
18. Examiner faces the mother’s feet and with the tips of first 3
fingers of each hand exerts deep pressure in the direction of
the axis of pelvic inlets – LM4
19. Cardinal movements of labor: engagement, descent, flexion,
internal rotation, extention, external rotation, and expulsion
20. Mechanism by w/c biparietal diameter passes through pelvic
inlet - engagement
21. Lateral defelction of head to a more ant./post. Position in the
pelvis – Asynclitism
22. Sagittal suture approaches the sacral promontory – Anterior
asynclitism
23. Sagittal suture lies close to symphysis – Posterior asynclitism
24. First requisite for birth of newborn – descent
25. Causes of descent:
 Pressure of amniotic fluid
 Direct pressure of the fundus w/ contraction
 Bearing down efforts of the maternal abdominal
muscle
 Extension and straightening of the fetal body
26. The occiput has to internally rotate to symphysis pubis
through 135 degree angle – Occiput post
27. Transverse arrest – incomplete rotation
28. Persistent occiput posterior – no rotation occurred
29. Edematous or swelling of fetal head due to prolong labor –
caput succedaneum
30. Overlapping of the parietal bones due to external compressive
forces – molding
31. Criteria for labor:
 Painful uterine contraction
 Ruptured of membrane
 Bloody show
 Complete cervical effacement
32. Friedmann 3 functional division:
 Preparatory – connective tissue component of the
cervix change considerably (affected)
 Dilatational – dilatation proceeds at is most rapid
rate (not affected by anestheis and sedation)
 Pelvic division – commences w/ deceleration phase
of cervical dilatation.
33. Point at w/c the mother perceives regular contraction( 4 cm) –
latent phase
34. Prolonged latent phase - >20hrs in nulliparas; >14 hrs in
multiparas
 35. Causes of prolonged latent phase: excessive sedation or
epidural anesthesia, false labor, unfavorable cervix
36. Active labor - >4cm with uterine contraction
37. Protraction – slow rate of cervical dilatation or descent :
nulliparas - <1.2 cm/hr <1cm descent/hr; Multiparas -
<1.5cm/hr and <2cm descent/hr
38. Arrest – complete cessation of dilatation and descent:
Dilatation – 2hrs with no cervical changes; descent – 1 hr w/o
fetel descent
39. Factors contribute to arrest: excessive sedation, vaginal
anesthesia, fetal malposition
40. Duration of 2nd stage of labor – 50 minutes in nulliparas; 20
minutes in multiparas
41. 18.5 hrs – nulliparas; 13.5 hrs – multiparas
42. Ruptured of membrane is significant for 3 reasons:
 Umbilical cord prolapsed and compression
 Pregnancy is at near term
 Intra-uterine infection is more likely
43. Vaginal discharge ph – 4.5 – 7.5
44. Amniotice fluid ph – 7 – 7.5
45. PH >6.5 – consistent with ruptured membrane
46. Level of the presenting fetal part in the birth canal – station
47. Dorsal lithotomy – most frequent maternal position
48. Encirclement of the largest head diameter by the vulvar ring –
crowning
49. Controlled delivery of the head: gloved-hand used to exert
pressure on the chin of the fetus through the perineum while
other hand exerts pressure superiorly against occiput – Ritgen
Maneuver
50. Signs of placental separation:
 Uterus becomes globular and as the rule firmer –
earliest sign
 Sudden gush of blood
 Uterus rises in the abdomen because placenta
passes down in the lower uterine segment and
vagina
 Umbilical cord protrudes farther out of vagina
51. Grave complication associated w/ delivery of the placenta –
inverted uterus
NEWBORN INFANT
52. Factors influence first breath air:
 Physical stimulation
 Deprivation of oxygen and accumulation of CO2
 Compression of thorax
53. Fetal failure to established respiration is caused by:
 Fetal hypoxia and acidosis
 Drugs administer to the mother
 Fetal immaturity
 Upper airway obstruction
 Pneumothorax
 septicemia
54. indicated for reversal of respiratory depression in newborn
infant – naloxone
55. very useful clinical tool to identify those neonate whoe require
resuscitation – APGAR
56. H2CO3 accumulates in fetal blood w/o increase in organic
acid – respiratory academia
57. Organic acid accumulates w/o increase in h2co3 – metabolic
academia
58. Both increase – mixed respiratory –metabolic acidemia
SIXTH SHIFT (Dr. Tingkahan)
ABORTION
-the termination of pregnancy prior to 20 weeks or less than 500g birth
weight
Abortion without medical or mechanical means – Spontaneous
abortion
The skull bones collapse, abdomen distends with blood stained fluid,
and organs degenerate – maceration
Amniotic fluid is absorbed, fetus becomes compressed and desiccated –
fetus compressus
-if dry and compressed – fetus papyraceous
Increase in age – increase risk of abortion
Accounts for most of pregnancy wasted – chromosomal abnormalities
Most frequent chromosomal anomaly assoc. With abortion – autosomal
trisomy
Second most common – monosomy X (45x)
Smoking more than 14 sticks / day – 2x increase risk of abortion
Alcohol consumption 2x a week = doubles risk, daily = triples risk
If IUD fails to prevent pregnancy, will result in – septic abortion
 Death due to toxic shock syndrome – Clostridium
sordellii
Uterine synechiae, from destruction of large areas by curettage –
asherman syndrome
Painless cervical dilatation in 2nd trimester with prolapse and ballooning
of membranes into the vagina, followed by expulsion of fetus –
incompetent cervix
Ballooning of the membranes into a dilated internal cervical os with
closed external os – funnelling
Contraindication to cerclage:
 Bleeding
 Uterine contraction
 Ruptured membranes
2 types of cerclage:
 Mcdonald: simplier
 Shirodkar: complicated; reserved for women with failure of
previous mcdonald / structural cervical abnormalities
Bloody vaginal discharge to a closed cervix – threatened abortion
Gross rupture of membranes with leaking amniotic fluid and cervical
dilatation – inevitable abortion
Uterus retains a dead fetus with closed cervix – missed abortion
Prolonged retention of a dead fetus causes – coagulation defects
3 or more consecutive spontaneous abortions – recurrent abortion
Insufficient progesterone secreted by the corpus luteum or placenta –
progesterone deficiency / luteal phase defect
Medical / surgical termination of pregnancy – induced abortion
Request of a woman to terminate pregnancy not for reasons of maternal
health – elective (voluntary) Abortion
Most common form of suction curettage – vacuum aspiration
MANAGEMENT
Dilatation and curettage
 Transcervical approach to abortion
  Mechanically scrapping out of contents with sharp curettage,  Serum progesterone
suction, or both  Uterine curettage
Dilatation and evacuation  Laparoscopy, occasionally laparotomy
 16 weeks, fetal size and structure dictate this use TREATMENT
 Large bore vacuum curette is used -tx of choice  Surgical
 Mechanical destruction and evacuation of fetal parts o If with tubal salvage – conservative
Dilatation and extraction o Salphingectomy (without salvage) – radical
 Similar to D&E except suction evacuation of the intracranial Salphingostomy :
content  remove small conceptus less than 2cm
 Minimizes uterine or cervical injury and distal third of the tube
Hygroscopic dilators – slowly dilating the cervix by drawing water from  incision not sutured, heal by secondary
cervical masses intention
Drugs for early trimester: Salphingotomy – incision is closed with 7-O vicryl
Antiprogestin – mifepristone Salphingectomy:
Antimetabolite – methotrexate  For ruptured and unruptured
Prostaglandin – misoprostol  Wedge shaped excision of the outer third
**Ovulation resumes as early as 2 weeks after abortion of tubes (corneal resection)
ECTOPIC PREGNANCY o Minimize recurrence of
Highest risk causing ectopic pregnancy – prior tubal surgery pregnancy in tubal stump
Most frequent site – ampulla Segmental resection and anastomosis – for unruptured
Usual outcome of ampullary pregnancy – abortion ectopic pregnancies
Usual outcome of isthmic pregnancy – rupture Result of incomplete removal of trophoblast – persistent ectopic
Large conceptus that becomes calcified – lithopedion pregnancy
Implantation at tubal segment that penetrates the uterine wall – Factors which increase risk:
interstitial / corneal  Small pregnancy less than 2cm
-Interstitial preg. are fatal due to severe hge from:  Early therapy
 Ovarian arteries  bHCG levels more than 3000 mIU/ml
 Uterine arteries  implantation medial to salphingostomy site
Tubal pregnancy accompanied by coexisting uterine gestation – antineoplastic drug acts as folic acid antagonist, effective against rapidly
heterotypic ectopic pregnancy proliferating trophoblast – systemic methotrexate
Consider if: most important contraindication to methotrexate – active intra
 Hx of assisted reproductive technique abdominal hge
(ART) ABDOMINAL PREGNANCY
 Persistent or rising HCG levels Imaging used to confirm abdominal pregnancy – MRI bitches!
 Uterine fundus larger than menstrual date CT is more superior to MRI but is less frequently used due to risk of –
 than one corpus luteum fetal radiation
 Absent uterine bleeding with S/S of Management of abdominal preg – termination of pregnancy
ectopic pregnancy Results when bacteria gain access to gestation – suppuration
Product of conception plant from uterine cavity to interstitial portion – Fetus is converted to yellowish, greasy mass – adipocere
tubo-uterine pregnancy Management of the placenta – leave it in place!
Fimbriated end extending to peritoneal cavity – tubo-abdominal OVARIAN PREGNANCY
pregnancy Most common cause – use of IUD
Adherent to tubal and partially to ovarian tissue – tubo-ovarian Management for early bleeding for small lesions – ovarian wedge
pregnancy resection / cystectomy
Characteristic pain of unruptured ectopic pregnancy – sharp, stabbing, For larger lesions – ovariectomy
or tearing; unilateral, lower abdomen CERVICAL PREGNANCY
Pain in the neck or shoulder especially during inspiration – -due to increase use of ART
diaphragmatic irritation Most common presenting sign – painless vaginal bleeding
Most frequent symptom of ectopic – pelvic and abdominal pain
If ruptured  anywhere in the abdomen GESTATIONAL TROPHOBLASTIC DISEASE
-pregnancy related trophoblastic proliferative abnormality
DIAGNOSES H. MOLE
HCG -abnormality of chorionic villi consisting of trophoblastic proliferation and
 Rapid and accurate determination of pregnancy edema of the villous stroma
 Greater than 150,000 MIU, consider ectopic -complete and partial
Serum progesterone Usual chromosomal composition of complete mole – 46XX  paternal
Value > 25 ng/dl – exclude ectopic pregnancy If 46XY – dispermic fertilization
Value < 5 ng/dl – suggests dead intrauterine fetus or ectopic Most common chromosomal composition of partial mole – triploid 
pregnancy 69XXX, 69XXY, 69XYY
Method of choice for Dx  Multimodality diagnosis: Over stimulation of letein elements by large amounts of HCG – theca
 Transvaginal sonography lutein cyst
 Serum bHCG Indication for oophorectomy – if ovary is extremely infracted
Universal symptom for H. Mole – bleeding; characteristic – intermittent PLACENTA PREVIA
for weeks to months -total, partial, marginal, low-lying
Thyrotoxicosis in H. Mole – due to the thyrotropin like effects of HCG -no digital internal exam
CLINICAL PRESENTATION Hemorrhage may continue after delivery due to – lower uterine segment
 Significant N&V contracts poorly
 Uterine bleeding is universal Simplest, most precise and safest method of placental localization –
 Uterine growth more rapid than expected transabdominal sonography
 Early preeclampsia may develop with large moles Management – CS
Diagnosis – sonography POSTPARTUM HGE
Treatment of choice – vacuum aspiration after removal oxytocin is -more than 500ml of blood loss after completion of 3rd stage
given after myometrium has contracted, thorough but gentle Delivery of the placenta:
curettage with large sharp curette  massage the fundus if not contracted
if pregnancy not desired – hysterectomy  administer 20U oxytocin in 1000ml LR
GESTATIONAL TROPHOBLASTIC NEOPLASIA o oxytocin bolus – never! causes hypotension
Choriocarcinoma – cancer of the chorionic epithelium, behaves like a and cardiac arrhythmias
sarcoma if bleeding is unresponsive to oxytotics – suspect genital laceration /
Important diagnostic feature – absence of villous pattern uterine rupture
Most common site of metastasis – lungs most common cause of late peurperial bleeding – retained placental
Excessive trophoblastic overgrowth and extensive penetration of fragments
trophoblastic cells – invasive mole placenta accreta - placental implantation with abnormally firm
Arise from placental implantation – placental site trophoblastic adherence to uterine wall
tumors placenta increta – invades myometrium
Characteristic histology – cytotrophoblastic cells; placenta percreta – penetrate to myometrium
Immunohistochemical staining – more prolactin producing postpartum hge due to necrosis of ant. Pituitary – Sheehan syndrome
cells, less gonodotropin releasing cells o failure of lactation
*serum bHCG are low compared to other mass o amenorrhea
CT scan of the chest and head is only recommended if CXR is o breast atrophy
abnormal o loss of pubic and axillary hair
If with brain metastasis - chemotherapy with radiotherapy o hypothyroidism
Placental site tumor treatment – hysterectomy; chemotherapy not as o adrenal cortical insufficiency
effective as other masses consequence of strong traction on an umbilical cord attached to
High risk – EMA-CO placenta in uterus – inversion of the uterus
Pregnancy after GTN: GENITAL TRACT LACERATION
o 6 months – molar vaginal lacerations frequently result from – forcep / vacuum
o 1 year – GTN injuries to levator ani results from – overdistention of the birth canal
o 2 years – metastasis other than lungs treatment for severe, enlarging vulvar hematoma – incision and
drainage
HEMORRHAGE most common cause for uterine rupture – separation of previous
-leading cause of matrernal mortality caesarean hysterectomy scar
Antepartum: placenta previa, placental abruption FLUID RESUCITATION
Postpartum: unterine atony, genital tract laceration Crystalloid solutions typically are used for initial resuscitation
Tearing of small veins as a consequence of effacement and dilatation – Women acutely bleeding – rapid transfusion if:
bloody show  hct less than 25 volumes %
Separation of placenta before delivery – placental abruption  haemoglobin less than 8g/dl
o Bleeding escapes to cervix- external hge  if there is imminent surgery, acute operative blood
o Bleeding retained between detached placenta and loss, acute hypoxia, vascular collapse
uterus – concealed hge **Whole blood is ideal for treatment of hypovolemia from
 Consumptive coagulopathy and bleeding catastrophic acute hge
cannot be estimated COMPLICATIONS OF TRANSFUSION
Most commonly associated with abruption – hypertension Haemolytic transfusion reaction – transfusion of incompatible blood
 Others: PPROM, smoking, cocaine, thrombophilias, component
trauma, uterine leiomyoma o DIC
Widespread extravasation of blood into the uterine musculature and o Acute renal failure
beneath the uterine serosa – couvalaire uterus / uteroplacental o Death
apoplexy Transfusion related acute lung injury (TRALI) – life threatening
Management – delivery; if immature – delay it condition characterized by sever dyspnea, hypoxia, and non cardiogenic
Contraindications to tocolysis – clinically evident placental abruption pulmonary edema
Amniotomy – if mature  Develop within 6 hours of transfusion
if immature – more helpful if sac is intact Bacterial contamination – most common is Yersinia enterocolittica
 aids in dilating the cervix
administer oxytocin – if no rhythmic contractions
 SEVENTH SHIFT (Dr. Albano) 2. What is the largest contributor to infant mortality?
PREGNANCY HYPERTENSION - preterm birth
1. In Gestational Hypertension the BP returns to normal in how many 3. What is the threshold of viability?
weeks? - 26 wks and at least 750 gms
- less than 12 weeks 4. When does active brain development normally occurs?
2. What are the minimum criterias of Pre-eclampsia? - 2nd and 3rd trimesters
- 140/90mmHg after 20 wks AOG 5. It is defined as the rupture of the membranes before labor and prior to
- proteinuria >/= 300mg/24hrs or +1 dipstick(30mg/dl) 37 wks?
3. It is a seizure that cannot be attributed to other causes in a woman - preterm premature rupture of membranes
with preeclampsia. 6. What are the pathogenesis of preterm labor?
- Eclampsia - progesterone withdrawal
4. What are the effects of a normal trophoblastic invasion to the -oxytocin initiation
uteroplacental arterial bed? -decidual activation
- low resistance 7. What is the major risk factor for preterm labor?
- low pressure - prior preterm delivery
- high flow system 8. What is the most common perinatal organism?
5. It is an inadequate maternal vascular response to placentation. -U. urealyticum
- Abnormal trophoblastic invasion 9. It is an irregular, nonrhythmical and either painful/painless contraction
6. It is a state of vasoconstriction and high resistance to UteroPlacental that can cause considerable confusion of a true preterm labor.
blood flow.. -Braxton hicks contraction
- Placental Ischemia 10. What are the criterias to document preterm labor?
7. What are the pathogenesis of PreEclampsia? - contractions of 4 in 20mins or 8 in 60mins
- Vasospasm - cervical dilatation >1cm
- endothelial cell activation - cervical effacement of >/= 80%
- increase pressor response 11. It is the bulging of the membranes into the endocervical canal and
8. What dietary mineral deficiency increases the risk for gestational protruding at least 25%of entire cervical length?
hypertension? - funnelling
- calcium 12. It is characterized by recurrent, painless cervical dilatation and
9. What is the definitive therapy for preeclampsia. spontaneous midtrimester birth in the absence of spontaneous
- Delivery membrane rupture, bleeding, or infection.
10. What is the effective anticonvulsant for eclampsia? - incompetent cervix
-MgSo4 13. Single dose corticosteroid therapy is recommended for what AOG?
11. What can you find in the arteries taken from the implantation site in - 24 to 32 weeks
preeclamptic women? 14. What is the cornerstone of treatment for preterm labor with intact
-atherosis membranes?
12. What is the fuckin’ hallmark of eclampsia? - avoid delivery prior to 34 wks
- hemoconcentration 15. What drug reduces intracellular ionized calcium levels and prevent
13. What glycoprotein associated with vascular endothelial cell activation of myometrial contractile proteins?
basement membrane injury? - Beta adrenergic receptor agonists (Ritodrine)
- fibronectin 16. What is the frequent, serious, and fatal side effect of B-agonists?
14. What is the most common finding in the kidney of an eclamptic - pulmonary edema
biatch at autopsy? 17. What is the third most common cause of acute respiratory distress
- glomerular capillary endotheliosis and death in pregnant women?
15. Also called occipital blindness in preeclamptic whore. -Tocolysis
- Amaurosis
16. What is the common antihypertensive agent used in preeclamptic POSTTERM BIRTHS
women? 1. What is the term for an infant that has a recognizable clinical features
- hydralazine indicating a pathologically prolonged pregnancy?
17. What antihypertensive drug linked with cyanide poisoning? - Post mature
-sodium nitroprusside 2. What is the preferred expression for an extended pregnancy or
18. What antihypertensive drug causes growth restriction? pregnancy for 42 completed weeks?
-labetalol -Post term/prolonged
19. What is the therapeutic dose of MgSO4? 3. What is the etiology of the skin changes of postmaturity?
- 4 to 7 meq/L - loss of protective effects of vernix caseosa
20. What is the treatment of MgSO4 toxicity (10g+absent patellar 4. What is the characteristic electronic monitor finding of uteroplacental
reflex)? insufficiency?
- Ca gluconate 1g IV and STOP taking the friggin drug mofo - late decelerations
5. What is the most common complication of a growth restricted post
PRETERM BIRTHS term infant?
1. What percentile designates an appropriate for gestational age weight - stillbirth
in newborns? 6. It is directly related to Cesarean delivery rate.
- Between the 10th and 90th percentile. - station of vertex
7. When is the time where initiation of fetal surveillance becomes a - symmetrical GR
reasonable option? 3. What type of growth restriction results from a late insult such as
- 41 weeks placental insufficiency from hypertension that would lead to brain
sparing.
MULTIFETAL PREGNANCY - asymmetrical GR
1. It is a result from fertilization of 2 separate ova and is influenced by 4. What biometric measurement is most commonly abnormal in cases of
race, heredity, age and parity. growth restriction?
- dizygotic - Abdominal circumference measurement
2. It is a result from fertilization of a single ovum and independent of
race, heredity, age and parity.. ABNORMALITIES OF PLACENTA, CORD AND MEMBRANES
- monozygotic 1. What type of placental anomaly has a large part of the fetal
3. It is the fertilization of 2 ova within the same menstrual cycle, but not membranes being covered by functioning villi?
at the same coitus. - Placenta Membranacea / Diffusa
-superfecundation 2. What type of placental anomaly has a missing central portion of
4. What age is the peak of pregnancy twinning? discoidal placenta?
- 37 y.o - Placenta fenestrate
5. What day does the chorion differentiates? 3. It has one or more small accessory lobes develop in the membranes
- day 4 at a distance from the main placenta.
6. What day does the amnion differentiates? - succenturiate lobe
-day 8 4. What placenta presents a central depression surrounded by a
7. In monozygotic twins, if division occurs within the first 72 hours after thickened, gray-white ring?
fertilization. - circumvallate placenta
- DIAMNIOTIC, DICHORIONIC 5. What placenta has a ring that does not have a central depression?
8. If division occurs, between the 4th to 8th day after fertilization. - circummarginate placenta
- MONOCHORIONIC, DIAMNIONIC 6. It is a placental hematoma that is of fetal vessel origin and it is found
9. If division occurs the 9th day -13th day after fertilization. in between the placenta and amnion.
- MONOCHORIONIC,MONOAMNIOTIC - Subamnionic hematoma
10. If division is initiated after the 13th day. 7. It is a benign tumor of the placenta.
- CONJOINED TWINS - Chorioangioma
11. As a determinant of twinning, which family history is more 8. It is a full thickness infection of the membranes.
important? - Chorioamnionitis
- Mother 9. It is a subsequent inflammation of the chorionic plate and the
12. It causes an elevation of maternal serum and amnionic afp and a umbilical cord.
positive acetylcholinesterase assay. - funisitis
- Vanishing twin 10. What is the normal length of the umbilical cord?
13. It is the most important determinant in risk assessment and -50 to 60 cm
management in multifetal gestation. 11. What is the fetal significance of hypocoiling?
- chorionicity - fetal demise
14. It has the most rates of perinatal mortality and neurological injury. 12. What is the fetal significance of hypercoiling?
- monochorionic diamionic - fetal growth restriction
15. It is a triangular projection of placental tissue is seen to extend - intrapartum fetal acidosis
beyond the chorionic surface between the layers of the dividing - asphyxia
membrane, then there are two fused placentas. 13. What is the perinatal prognosis if a two vessel umbilical cord is an
- twin peak sign isolated sonographic finding?
16. It is the right angle of relationship between the membranes and - better
placenta with no apparent extension of placenta between the dividing 14. What risk is associated with a two vessel cord in a nonisolated
membrane. finding?
- T sign - aneuploidy
17. It is the most definitive test to diagnose twinning. 15. It is the connection between 2 umbilical arteries that acts as a
- DNA fingerprinting pressure equalizing system between umbilical arteries.
18. It is the most common type of conjoined twins. - Hyrtl anastomosis
- parapagus 16. It is the cord insertion at the placental margin.
19. What mode of delivery do you prefer if the first twin is non-vertex - battledore placenta
and the second is vertex? 17. What type of insertion when the umbilical vessels spread within the
- C/S membranes at a distance from the placental margin?
- Velamentous Insertion
FETAL GROWTH DISORDER 18. What type of insertion when the umbilical vessels lose their
1. It is defined as birthweight >4000g. protective Wharton’s jelly before insertion?
- Macrosomia - furcate insertion
2. What type of growth restriction results from an early insult such as 19. What anomaly presents when the placental vessels overlie the
chemical exposure, viral infection and aneuploidy that causes a cervix, lie between the cervix and the presenting fetal part, and are
proportionate reduction of body size? supported only by membranes?
 - Vasa previa PUERPERAL INFECTION
20. It appears as a knob protruding from the cord surface and are focal 1. It is a term used to describe any bacterial infection of the genital tract
redundancies of a vessel or Wharton’s jelly and has no clinical after delivery.
significance. -puerperal infection
- False knots 2. What is the single most significant risk factor for the development of
21. Umbilical cord looped around the neck. uterine infection?
- nuchal cord - route of delivery
22. Umbilical cord as the presenting part. 3. What promotes bacterial synergy?
- Funic presentation - polymicrobial
23. What are causes of blood accumulations in umbilical cord? 4. What is the most important criterion for the diagnosis of postpartum
- short cord metritis?
-trauma - Fever
- entanglement 5. Chills that accompany fever is suggestive of what condtion?
24. It is a marked focal dilatation that may develop within the - bacteremia
intraamnionic part of umbilical vein. 6. What is the gold standard antimicrobial regimen?
- umbilical vein varix - clinda+genta
25. It is a rare congenital thinning of the vessel wall with diminished 7. What is the first symptoms of peritonitis?
support from wharton’s jelly. - adynamic ileus
- umbilical artery aneurysm 8. What condition suppurates, forming a fluctuant broad ligament mass
that may point above the inguinal ligament?
THE PUERPERIUM - parametrial phlegmon
1. How many days after delivery does the uterus begins to involute?
- 2 days EIGHT SHIFT (Dr. Villaluz)
2. How many weeks does the vaginal epithelium starts to proliferate? 8th shift (dr. villaluz)
- 4 to 6 weeks PULMO
3. It is describe as an arrest of involution. 1. Vital capacity & inspiratory capacity increase by…
- subinvolution a. 20%
4. How many weeks after delivery does lochia persist? 2. Tidal volume
- 4 to 8 weeks a. Increase by 40%
5. How many weeks after delivery does complete extrusion of the 3. Most common cause of bacterial pneumonia
placental site? a. S. pneumonia
- 6 weeks 4. Most common presenting sign/symptom in bacterial
6. It is defined as bleeding 24 hours to 12 weeks after delivery. pneumonia
- secondary postpartum hemorrhage a. Cough
7. Known as marked separation of the rectus. 5. Provide objective assessment of maternal oxygenation,
- diastasis recti ventilation & acid-base status
8. What are the blood and fluid changes after labor or postpartum? a. ABG
-marked leukocytosis 6. Hallmarks of asthma
- thrombocytosis a. Reversible airway obstruction
-leukopenia b. Vascular congestion
- relative lymphopenia c. Tenacious mucus
-absolute eosinopenia d. Mocusal edema
9. What are the bladder changes after labor or postpartum? 7. T/F. F-series prostaglandins & ergnovine exacerbate asthma
- inc. bladder capacity and should be avoided (TRUE)
- relative insensitivity to intravesical pressure 8. Single best measure reflecting severity of asthma
: overdistention a. FEV1
: incomplete emptying 9. Therapy for mild intermittent asthma
: excessive residual urine a. Inhaled B-agonist
10. How many kg will be loss due to uterine evacuation and normal 10. For severe persistent asthma
blood loss? a. High dose inhaled corticosteroids & long acting b
- 5 to 6 kg agonist & oral steroids
11. How many kg will be loss due to diuresis? 11. Drugs used in management of bacterial pneumonia
- 2 to 3 kg a. Macrolides (erythromycin…)
12. How many lobes does a female have? 12. Common complications with pneumonia
- 15 to 25 lobes a. Preterm delivery
13. The removal of this hormone stimulate a-lactalbumin production. b. PROM
- progesterone 13. Most common complication of Influenza pneumonia
14. What reflex initiated by suckling, which stimulates the a. Pneumonia
neurohypophysis to liberate oxytocin? 14. Most common HIV related disorder in pregnant women
-milk ejection or letting down reflex a. Pneumocystis pneumonia
15. Recommended 4 drug regimen for TB
a. Isoniazid
 b. Rifampin HEPATIC, GALLBLADDER & PANCREATIC DISORDERS
c. Pyrazinamide
d. Ethambutol 1. Most common cause of acute liver failure during pregnancy
16. Recommended initial tx for active TB in pregnant patients a. Acute fatty liver of pregnancy
a. Isoniazid 2. After infection w/ hep b, the 1st serologic marker is
b. Rifampin a. HBsAg
c. Ethambutol 3. Signifies intact viral particles that are present during early
17. Group of drugs w/c are ototoxic and thus contraindicated in acute hepatitis
TB infection a. HBeAg
a. Aminoglycosides ( streptomycin…) 4. Hepatitis virus which does not actually cause hepatitis
a. Hep G
RENAL & URINARY TRACT DISORDERS
HEMATOLOGIC DISORDERS
1. Clean voided specimen containing more than 100000 org/mL
is diagnostic 1. Anemia is defined as hemoglobin concentration
a. Asymptomatic bacteriuria a. <12g/dL—nonpregnant
2. Treatment for asymptomatic bacteruria b. <10 g/dL---pregnancy or puerperium
a. Nitrofurantoin 2. In a typical singleton gestation,maternal need for iron
3. If Asymptomatic bacteruria is not treated, how many percent a. 1000mg
of infected women will develop symptomatic infection? 3. Folic acid
a. 25% a. Nonpregnant--- 50-100ug/day
4. Recurrence rate of asymptomatic bacteruria b. Pregnant---400ug/day
a. 30% 4. Tx of preg indced megaloblastic anemia
5. Characterized by dysuria, urgency, & frequency a. Folic acid
a. Cystitis b. Nutritious diet
6. Lower urinary tract symptoms with pyuria accompanies by a c. Iron
sterile urine culture 5. Recommended vaccines for sickle cell & all asplenic patients
a. Chlamydia trachomatis urethritis a. Polyvalent pneumococcal
7. Most common serious medical complication of pregnancy b. HiB
a. Acute pyelonephritis c. Meningococcal vaccine
8. Cornerstone of treatment in acute pyelonephritis
a. IV hydration DIABETES
9. If there is no clinical improvement by 48-72 hrs…
a. Sonography 1. Diagnostic cutoff value for overt diabetes is a fasting plasma
10. Leading cause of septic shock glucose
a. urosepsis a. 126mg/dL or >
11. Common chief complaint in patients with stone disease 2. Screening performed between
a. Pain a. 24- 28 weeks
12. Most common cause of ESRD 3. Plasma glucose criteria
a. Diabetes a. Fasting ----95mg/dl (5.3mmol/L)
b. Hypertension b. 1 hr--- 180mg/dL (10.0mml/L)
c. Glomerulonephritis c. 2 hr------ 155 mg/dL (8.6mmol/l)
13. Acute nephritis d. 3 hr---- 140 mg/dl (7.8mmol/l)
a. Hypertension 4. Recommended caloric intake
b. Hematuria a. 30 kcal/kg/day (up to 35 kcal)
c. Red cell casts 5. Fetal effects of overt diabetes
d. Pyuria a. Miscarriage
e. Proteinuria b. Preterm delivery
14. Prototypical of acute nephritic syndrome c. Malformations
a. Acute post strep glomerulonephritis d. Altered fetal growth
15. Hallmark of nephrotic syndrome e. Unexplained fetal demise
a. Proteinuria f. Hydramnios
16. Rapid decrease in gfr over minutes to days 6. Neonatal morbidity & mortality in diabetes is due to
a. AKI a. RDS
b. Hypoglycemia
GI DISORDERS c. Hypocalcemia
1. T/F a female fetus, increases the risk of hyperemesis d. Hyperbilirubinemia &polycythemia
gravidarum by 1.5 fold (TRUE) e. Cardiomyopathy, long term cognitive devt
2. Most common cause of intestinal obstruction during f. Inheritance of diabetes
pregnancy 7. Maternal effects
a. adhesions a. Diabetic nephropathy
b. Diabetic retinopathy
 c. Diabetic neuropathy CARDIOVASCULAR (DR. MORATA)
d. Preeclampsia
e. DKA 1. Physiologic considerations assoc w/ heart disease during
f. Infections pregnancy
a. 50% increase in cardiac ouput
THYROID & ENDOCRINE DISORDERS b. Dec sys &pulmo vascular resistance
2. There is 3-4% of congenital HD in the offspring (TRUE)
1. Lab confirmation of hyperthyroidism 3. Periods during pregnancy when danger of decompensation is
a. Dec TSH, elev fT4 greatest
2. Cause of thyrotoxicosis in pregnancy a. 28-32 wks
a. Graves disease b. During labor & delivery ( CO increase 15-20%)
3. Tx of thyrotoxicosis c. Postpartum (4-5 days after delivery)
a. PTU (300-450mg/day) 4. Classification of HD during pregnancy
4. Methimazole embryopathy is characterized by a. Class 1- uncompromised, no limitation of movt
a. Esophageal /choanal atresia b. Class2- slight limit
b. Aplasia cutis c. Class 3—marked limitation
5. Considered a better indicator of thyroid status during the 1st 2- d. Class 4 – severely compromised (s/sx of angina dev
3 months of treatment for hyperthyroidism even @ rest)
a. Free T4 5. Predictors of cardiac complications
6. Treatment of thyroid storm & heart failure a. Prior HF, TIA, arryhtmia or stroke
a. PTU b. Class 3 or 4 or cyanosis
b. Lugol solution c. Left sided obs (MV area<2cm, AV ,1,5cm, peak LV
c. SSKI outflow grad >30 mmHg
7. Most common cause of hypothyroidism in pregnancy d. Ejection fraction <40 %
a. Hashimoto thyroiditis 6. Maternal mortality rate of surgically corrected HD is 3-4%
8. Daily iodine intake 7. Etiliogy of Aortic insufficiency
a. 220 ug/day ---pregnancy a. RF
b. 290 ug/day--- lactating women b. Con. Tissue abn
9. Fetal calcium needs c. Congenital
a. 300 mg/day d. Appetite suppressant drugs (fenfluramine,
dexfenfluramine)
CONNECTIVE TISSUE DISORDERS 8. Diagnostic criteria for peripartum cardiomyopathy
a. Devt of CF in the last month of preg w/in 5 mos after
1. Best screening test for SLE delivery
a. ANA b. Absence of identifiable cause for the CF
2. Antibodies relatively specific for lupus c. (-) HD prior to last month of pregnancy
a. dsDNA d. LV & systolic dysfunction demonstrated by classic
b. anti SM ECG criteria
3. Diagnostic criteria for SLE
a. SOAP BRAIN MD
4. Congenital heart block occurred almost exclusively in fetuses
of women w/ antibodies to
a. Ss-A
b. Ss-b
5. Tx of RA
a. NSAIDS

DERMATOLOGICAL DISORDERS

1. Most common pruritic pregnancy specific dermatosis

a. PUPPP (more commone w/ a male fetus)
i. Absence of linear C3
2. Char by small, pruritic rapidly excoriated lesions on the
forearms and trunks
a. Prurigo gestationis
3. Hallmark of pruritic folliculitis
a. Sterile pustules around the margin of erythematous
patches, begin at flexures & extend peripherally