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196 Cards in this Set
- Front
- Back
Compare and contrast two types of fetal heart monitoring: internal vs external.
|
Internal monitor
- bipolar spiral electrode directly to fetus External monitor - ultrasound doppler principle - used to avoid membrane rupture and uterine invasion. - less precise |
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At what rate is fetus considered tachycardic?
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> 160 bpm
|
|
At what rate is fetus considered bradycardic?
|
< 110 bpm
|
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What is the normal progression of baseline fetal heart rate along its gestation age? (hint: from 16 wks to term)
|
baseline fetal heart rate decreases an average of 24 bpm from 16wks to term.
|
|
Short term vs long term heart rate variability.
|
Short term: instantaneous change in HR from one beat (or R wave) to the next.
long term: oscillatory changes during course of 1 min and result in the waviness of baseline. |
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What is the significance of this?
- diminished beat to beat fetal heart rate variation |
may indicate seriousely compromised fetus
|
|
What is the significance of this?
- sinusoidal fetal heart rate |
fetal anemia
- D-isoimmunization - ruptured vasa previa - fetomaternal hemorrhage - twin-to-twin transfusion - merperidine, morphine, alphaprodine, butorphanol |
|
Grade this fetal heart rate variability:
- < 5bpm variability |
minimal variability
|
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Grade this fetal heart rate variability:
- 6-25bpm variability |
moderate variability
|
|
Grade this fetal heart rate variability:
- >25bpm variability |
marked variability
|
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What are some causes of fetal heart rate accelerations?
|
- fetal movement
- stimulation by uterine contractions - umbilical chord occlusion - fetal stimulation from pelvic exam - fetal scalp blood sampling - acoustic stimulation - labor (accelerations are reassuring) |
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What is this type of fetal heart rate deceleration? and what can cause it?
- gradual deceleration >= 30s - both onset and recovery coincides with uterine contraction |
early deceleration
- fetal head compression (vagal stimulation) - blocked by atropine |
|
What is this type of fetal heart rate deceleration? and what can cause it?
- gradual decrease in fetal HR that begins at/after the peak of uterine contraction |
late deceleration
- maternal hypotension (from analgesia) - excessive uterine activity (oxytocin stimulation) - placental dysfunction: placental abruption can cause severe late deceleration. - maternal HTN, diabetes, collagen vascular disorders. |
|
What is this type of fetal heart rate deceleration? and what can cause it?
- abrupt decrease in heart rate lasting <30s - duration less than 2 min - may occur before, during, or after a contraction |
variable deceleration
- umbilical cord occlusion: elevated PCO2 and decreased PO2 with increased ACH at SA node via baroreceptor and chemoreceptor - may respond to amnioinfusion |
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What is this type of fetal heart rate deceleration? and what can cause it?
- isolated decelerations lasting 2min or longer, but less than 10min |
prolonged deceleration
- uteroplacental insufficiency - epidural, spinal, paracervical analgesia - uterine hyperactivity - cord entanglement - maternal supine hypotension - maternal hypoperfusion/hypoxia of any cause - placental abruption - maternal seizures: eclampsia, epilepsy Treatment - IVF to correct hypoperfusion, anemia, acidosis if present - stop pitocin if patient is on it - maternal O2 therapy - fetal capillary acid-base determination - if not resolve, operate |
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In which stage of labor would you see ubiquitous decelerations?
|
2nd stage
|
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How do you treat this?
- variable deceleration in the setting of decreased amnionic fluid |
amniofusion
- 500-800cc bolus of warmed normal saline then - continuous infusion at 3ml/hr |
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What to do next based on this fetal scalp sample?
- pH > 7.25 |
this is labor
|
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What to do next based on this fetal scalp sample?
- pH 7.20 - 7.25 |
repeat within 30 min
|
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What to do next based on this fetal scalp sample?
- pH < 7.20 |
repeat sample immediately
OR to deliver baby |
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What is considered a normal fetal response to vibroacoustic stimulation?
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HR acceleration of at least 15bpm for at least 15s occurs within 15s after stimulation
|
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What is the normal range of fetal pulse oximetry?
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30-70%
|
|
What is a typical tocolysis treatment?
|
0.25mg terbutaline sulfate subQ injection
|
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How is uterine activity calculated?
|
montevideo units
#contractions per 10min x uterine pressure above basline |
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Mild vs moderate vs severe type variable fetal heart rate decelerations.
- duration less than 30s regardless of HR drop or - rate drop to 70-80 bpm range with duration >30s but < 60s |
mild type
- no RX needed |
|
Mild vs moderate vs severe type variable fetal heart rate decelerations.
- duration 30-60s, HR drop to < 70bpm or - rate drop to 70-80 bpm range with duration >60s |
moderate type
- maternal O2 therapy - amnioinfusion - d/c pitocin - fetal capillary acid-base assay - consider OR delivery |
|
Mild vs moderate vs severe type variable fetal heart rate decelerations.
- duration > 60s - rate drop to < 70bpm |
severe type
- maternal O2 therapy - amnioinfusion - d/c pitocin - fetal capillary acid-base assay - consider OR delivery |
|
Is this women pregnant?
- urine BhCG > 25 |
yes
|
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Is this women pregnant?
- blood BhCG < 5 |
no
|
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What maternal conditions are risks for the fetus? (major ones)
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- HTN
- DM - multiple gestation - infections - intrauterine growth retardation - abnormal placentation |
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When is fetal heart tones detectable?
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12 wks by doppler
18-20 wks by auscultation |
|
What does this lab value indicate?
- progesterone < 5 |
not a viable pregnancy intrauterine or extrauterine
|
|
What does this lab value indicate?
- progesterone > 25 |
viable intrauterine pregnancy
|
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When can you detect the gestational sac with abdominal ultrasound?
|
5-6 wks
- corresponds to BhCG 5000-6000 |
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When can you detect pregnancy with transvaginal ultrasound?
|
3-4wks gestation
- correspondes to BhCG 2000 |
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At what BhCG level is embryo visualizable by all technique and cardiac acitvity is detected?
|
> 4000
|
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What is the growth rate of an embryo?
|
1mm/day
|
|
What is the diameter of the gestational sac is embryo visualized by U/S?
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25mm
|
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What is the diameter of the gestational sac is yolk sac visualized by U/S?
|
10cm
|
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What are the routine OB lab tests?
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- CBC to r/o anemia
- UA ans urine culture to evaluate UTI, renal function - blood group Rh - antibocy screen - serology for syphilis: RPR, VDRL - hep-B surface antigen - rubella titer - cervical cytology: pap smear - cervical culture for gonorrhea/chlamydia - Hgb electrophoresis: sickle cell and so on - HIV titer - MSAFP at 15-18 wks: evaluate neual tube defects, gastroschisis, Down syndrome - Hct at 25-28 wks: r/o anemia - glucose screen at 24-28 wks |
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Name an important screening test at 15-18 wks gestation.
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- MSAFP at 15-18 wks: evaluate neual tube defects, gastroschisis, Down syndrome
|
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Name 2 lab tests that are important at 24-28 wks gestation.
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- Hct at 25-28 wks: r/o anemia
- glucose screen at 24-28 wks |
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List three methods to assess gestational age from most accurate to the least.
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1. LMP if mon is confident of her dates
2. first trimester U/S 3. first trimester pelvic exam 4. fundal height in cm between 20 and 36 wks of gestation |
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What is the gestational age if the fundal height is at the umbilicus?
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20 wks
|
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What is the naegele's rule?
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to determine the due date based on LMP
- LMP - 3mos + 7days |
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Frequency of prenatal visit:
- 0-32 wks - 32-36 wks - 36- labor |
- 0-32 wks: every month visit
- 32-36 wks: every 2 wks visit - 36- labor: every wk visit |
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What is the lab test required for every prenatal visit?
|
UA
- to determine glucosuria and proteinuria - trace amount is normal |
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What is the trend of maternal BP during pregnancy?
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drop at the end of 1st trimester
raised in 3rd trimester |
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What BP findings suggest pregnancy associated HTN?
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>30mmHg increase in sBP or
> 15mmHg increase in dBP |
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What is the normal maternal wt gain per month? and through the pregnancy?
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monthly wt gain: 3-4 lb
pregnancy: 25-35 lb wt gain |
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What should you consider if fundal height suggest fetus is large for dates?
|
- incorrect assessment of gestational age
- multiple pregnancy - macrosomia - hydatidiform mole - hydraminios |
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What should you consider if fundal height suggest fetus is small for dates?
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- incorrect assessment of gestational age
- hydatidiform mole - fetal growth restriction - oligohydramnios - intrauterine demise |
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When can U/S show evidence of Down syndrome?
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10-13 wks gestation
- U/S would show nuchal thickness |
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At 20-22 wks u/s, what should we look for?
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This is a level II ultrasound
- confirm dates - look for anatomical anomalies: cardiac, bowel, cerebellum, cerebral ventricles, kidneys. - assess fetal growth |
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What is considered a normoreactive NST at gestational age > 32 wks?
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2 episodes of fetal heart rate accelerate by at least 15bpm over a period of 15s in 20min interval. (15x15 in 20)
|
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What is considere a normoreactive NST at gestational age < 32 wks?
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2 episodes of fetal heart rate accelerate by at least 10bpm over a period of 10s in 20min interval. (10x10 in 20)
|
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CST vs OCT
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CST: contraction stress test
OCT: oxytocin challenge test |
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Evaluation of fetal well being:
What to do next if CST/OCT is positive? |
NST
- if normal reactive: false positive - if nonreactive: worrisome |
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What are the components of biophysical profile?
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- fetal breathing movements: 1FBM in at least 30s duration per 30min
- gross body movement: 3/30min - fetal tone: 1 active extension with return to flexion - reactive fetal heart rate - qualitative amniotic : at least 1 pocket of amniotic fluid at at least 1cm in two perpendicular planes |
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Interpretation of the biophysical profile scores.
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8-10: normal
6: equivocal and require further evaluation <4: abnormal, require immediate intervention |
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What are some direct tests for fetal lung maturity?
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- lecithin:sphingomyelin ratio (L:S ration) > 2
- phosphatidylgylerol (PG) present - foam stability index (FSI) > 47 - fetal lung maturity (FLM) > 55 |
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What are normal umbilical cord acid-base values?
|
Vein:
pH 7.34 PO2 30mmHg PCO2: 35mmHg HCO3: 20 base deficit: 5 Artery pH 7.28 PO2 15mmHg PCO2: 45mmHg HCO3: 22 base deficit 7 |
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What is the acid-base condition in this fetus?
- umbilical artery pH < 7.2 - PCO2 > 65mmHg - HCO3 > 22 (normal) - base deficit 6 (normal) |
respiratory acidemia
- umbilical cord compression |
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What is the acid-base condition in this fetus?
- umbilical artery pH < 7.2 - PCO2 < 65mmHg (normal) - HCO3 < 17 - base deficit 16 |
metabolic acidosis
|
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What are some causes of fetal acidosis?
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- poor fetal-maternal exchange
- acute umbilical cord compression: increased PCO2 (respiratory acidosis) - uteroplacental insufficiency: inadequate exchange of O2 and CO2 in intervillous space |
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What is the acid-base condition in this fetus?
- umbilical artery pH < 7.2 - PCO2 > 65mmHg - HCO3 < 17 - base deficit 9.6 |
mixed acidosis
|
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What are the normal values for fetal capillary acid-bases?
|
pH: 7.25-7.4
PO2: 18-22mmHg PCO2: 40-50mmHg base deficit: 0-11 |
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What to do next?
- fetal acidosis |
- consider maternal venous sample first
|
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What are some indications for fetal capillary pH sampling?
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- early in labor in presence of IUGR or meconium staining with postdates gestation
- pathologic periodic changes - unclear or confusing FHR tracing |
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What is the definition of hypertension in pregnancy?
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- sustained systolic pressure >= 140mmHg or diastolic pressure >= 90mmHg
- present at least 2 occasions, more than 6hrs apart |
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How common is PIH (pregnancy induced hypertension)?
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5-10%
|
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What does this suggest?
- hypertension in late pregnancy in the absence of other findings |
- transient hypertension of pregnancy
- gestational hypertension |
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What is the definition of preeclampsia?
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development of hypertension with proteinuria induced by pregnancy in the second half of gestation
|
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What level of BP is considered severe preeclampsia?
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systolic BP > 160 0r
diastolic BP > 110 |
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What are some multisystem alteration seen with preeclampsia?
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- marked proteinuria
- oliguria - cerebral or visual disturbance - pulmonary edema - cyanosis - epigastric/RUQ pain - hepatic dysfunction - thrombocytopenia - fetal growth restriction/oligohydramnios |
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What is eclampsia?
|
additional presence of convulsions in a women with preeclampsia
- most occurs within 24 hrs of delivery |
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What is the definition of chronic hypertension in pregnancy?
|
hypertension present before 20th week or beyond 6wk postpartum
|
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What are some causes of chronic hypertension in pregnancy?
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- essential hypertension
|
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What systems are affected during eclampsia? (6)
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- CV: increased CO, HTN
- hematologic: plasma olume contraction (increased Hct), thrombocytopenia/DIC - renal: decreased GFR, proteinuria, decreased uric acid filtration - neurologic: hyperreflexia, seizure - pulmonary: pulmonary edema, capillary leak, left heart failure - fetal effects: IUGR, oligohydramnios, low birth weight, placental abruption |
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What is the pathophysiology of preeclampsia?
|
vasospasm
|
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What are some physical exam findings of preeclampsia?
|
- visual disturbances: scotomata
- headache: vessel spasm - RUQ pain: liver involvement - loss of consciousness, seizures - rapid wt gain |
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What is the management for mild preeclampsia?
|
- bed rest: lateral decubitus position
- daily weighing |
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What is the management for severe preeclampsia?
|
- magnesium sulfate (IV or IM): 4g loading dose IV, 1-3g/hr infusion, therapeutic level: 4-7mEq/L)
- antihypertensive therapy when dBP > 110: hydralazine given at 5mg increment to acceptable BP level. - monitor maternal and fetal well being - deliver by induction or C-section - 48hr delay in induction to allow steroid administration to enhance detal pulmonary maturity |
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How to treat eclampsia?
|
anticonvulsants
- magnesium sulfate (IV or IM) - diazepam - phenytoin |
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How to manage chronic hypertension of pregnancy?
|
- close monitor for superimposed preeclampsia/eclampsia
- encourage bed rest - antihypertensive treatment if dBP > 110: methyldopa, labetalol, calcium channel blockers (amlodapine), diuretics. |
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How to manage eclamptic seizure?
|
Eclamptic seizure is usually self-limited, management should be aimed at preventing further episodes:
- initiate magnesium sulfate - O2 treatment - ABG, correct metabolic disturbances - foley catheter to monitor UOP |
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What to do next?
- eclamptic seizure - patient is on O2, magnesium sulfate initiated - hypertensive - low UOP |
evidence of cardiac disturbance
- continuous electrocardiogram |
|
What to do next?
- eclamptic seizure - - patient is on O2, magnesium sulfate initiated, foley in - fetal monitor showed bradycardia, decreased beat to beat variation, and late deceleration |
these are self-limited and usually not dangerous to fetus unless they continue for >20min
|
|
What is HELLP syndrome?
|
Occur in patients with preeclampsia or eclampsia
- Hemolysis - Elevated Liver enzyme - Low Platelet count |
|
How to manage patients with HELLP syndrome?
|
transfer to high risk obstetric center
- cadiovascular stabilization - correction of coagulopathy: platelets when level is less than 20,000 and to patients with levels less than 50,000 if going to c-section. - delivery |
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List some neonatal complications associated with PPROM (preterm premature rupture of membranes).
|
- respiratory distress syndrome
- intraventricular hemorrhage - neonatal infection - necrotizing entrocolitis - neurologic and neuromuscular dysfunction - sepsis |
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List some neonatal complications associated with PROM (premature rupture of membranes).
|
- intrauterine infection (chorioamnionitis) may lead to periventricular leukomalacia and cerebral palsy: Neisseria gonorrhea, bacterial vaginosis, GBS
- prolapsed umbilical cord - placental abruption |
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T/F: The consequences of PPROM increase as gestational age decrease.
|
True
|
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What are some risk factors for PROM?
|
- smoke: x2
- prior PROM - short cervical length - prior preterm delivery - hydramnios - multiple gestation - bleeding in early pregnancy |
|
What is the treatment for chorioamnionitis?
|
- antibiotics
- prompt delivery |
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What are some diagnostic test for ROM? (x3)
|
- nitrazine test: positive if turns blue (alkaline amniotic fluid)
- fern test - pooling - u/s |
|
DDX for PROM.
|
- urinary incontinence
- physiologic vaginal secretions in pregnancy - cervical discharge (infection) - exogenous fluid (semen) - vesicovaginal fistula |
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What can cause flase positives in nitrazine test for PROM?
|
- basic urine
- semen - cervical mucus - blood contamination - antiseptic solutions - vaginitis (especially trichomonas) |
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Factors to be considered in the management of patients with PROM.
|
- gestational age at the time of rupture
- presence of uterine contraction - likelihood of chorioamnionitis - amount of amniotic fluid around the fetus - degree of fetal maturity |
|
What is the diagnosis?
- PROM - fever, tachycardia, uterine tenderness |
chorioamnionitis
|
|
How to manage a term PROM?
|
- await onset of spontaneous labor for 12-24 hrs or
- induction of labor |
|
How to manage a PPROM?
|
34-36wk gestation
- low risk group: immediate delivery or expectant management - high risk of infection group: delivery asap with antibiotic treatment significantly preterm - no sign of infection: expectant management, CBC, daily check on uterine tenderness, u/s to determine amniotic fluid, antibiotics may prolong latency, daily fetal monitor |
|
Increase or decrease during pregnancy?
- dental caries - gingival disease |
- dental caries: no change
- gingival disease: increase |
|
During pregnancy. transit time in the stomach and small bowel increase by what percentage in the 2nd and 3rd trimesters?
|
15-30%
|
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What is equlis?
|
pregnancy-related vascular swelling of the gums
|
|
What is the cause of ptyalism during pregnancy?
|
inability of patient to swallow normal amounts of saliva
|
|
What is the percentage increase in tidal volume in pregnancy?
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30-40%
|
|
In a normal singleton pregnancy, maternal blood volume increase by what percentage?
|
45%
|
|
Where is pregnancy-associated systolic ejection murmur best heard?
|
left upper sternal border
|
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Blood flow to which of the following organ is NOT increased?
- kidney - breast - skin - brain - eye |
- brain
- eye |
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T/F: Plasma volume begins to increase at the 6th week of pregnancy and reaches its max at 30-34 wks.
|
True
|
|
T/F: Progesterone during pregnancy causes more dilation of the right ureter than the left.
|
True
|
|
What is chloasma?
|
change in facial pigmentation during pregnancy
|
|
What percentage of total cardiac output is channeled to the uterus at term?
|
20%
|
|
What is diastasis recti?
|
midline separation of the rectus muscles
- common during pregnancy |
|
What percentage does BUN fall in the 1st trimester of pregnancy?
|
25%
|
|
What is the usual protein loss in pregnancy?
|
100-300mg/day
|
|
T/F: The breast enlargement associated with pregnancy is typically seem starting in the 1st trimester.
|
True
|
|
When would the vision change in pregnancy typically regress?
|
6-8wks postpartum
|
|
When should hair loss durind 2nd to 4th month postpartum return to normal?
|
6-12 months
|
|
How is HCO3 level in pregnant women compared to nonpregnant women?
|
significantly lower
|
|
What is rate of urine formation in the fetal kidney?
|
400-1200ml/day
|
|
What is the rate of umbilical blood flow in the 2nd half of the pregnancy?
|
100ml/mg_min
|
|
What is the normal % of breast enlargement during pregnancy?
|
25-50%
|
|
When do the maternal diastolic pressure and mean arterial pressure nadir?
|
16-20 wks
|
|
What is hyperemesis gravidarum?
|
nausea and vomiting of pregnancy persisting beyond middle of 2nd trimester or associated with wt loss, ketonemia, electrolyte imbalance
|
|
List some medications can be used to treat hyperemesis gravidarum.
|
- benedryl
- pepsid - phenergan - reglan |
|
How do the following change during pregnancy?
- O2 pressure - CO2 pressure - tidal volume - expiratory reserve volume - residual volume - inspiratory capacity - vital capacity - minute volume - serum bicarbonate |
- O2 pressure: increase
- CO2 pressure: decrease - tidal volume: increase - expiratory reserve volume: decrease - residual volume: decrease - inspiratory capacity: increase - vital capacity: increase - minute volume: increase - serum bicarbonate: decrease |
|
How much iron should you supplement pregnant women?
|
- 60 mg element iron/day or 300mg ferrous sulfate/day
|
|
What is Virchow's triad?
|
- hypercoagulability
- hemastasis - endothelial injury |
|
What are some hematologic changes during pregnancy?
|
- hypercoagulable state: incrased clotting factors and fibrin split products, decreased protein S, resistance to activated protein C
- hemastasis - increased WBC - increased plasma volume - increased red cell mass |
|
How do the following renal parameters change during pregnancy?
- renal plasma flow - GFR - renin - angI and II - renin substrate - glucose excretion - urinary output - 24 hr protein - creatinine - uric acid - BUN |
- renal plasma flow: increase
- GFR: increase - renin: increase - angI and II: increase - renin substrate: increase - glucose excretion: increase - urinary output: no change - 24 hr urine protien: no change - creatinine: decrease - uric acid: decrease - BUN: decrease |
|
How does the uterus volume change during pregnancy?
|
from 10ml to 4-5L
|
|
How do the following change during pregnancy?
- ionized calcium - total serum calcium - PTH - calcitonin |
- ionized calcium: no change
- total serum calcium: decreased - PTH: increased - calcitonin: increased - increased skeletal turnover |
|
How do the following change during pregnancy?
- free T3, T4 - total T3 and T4 |
- free T3, T4: no change
- total T3 and T4: increase |
|
How do the following change during pregnancy?
- cortisol - deoxycorticosterone - DHEAS |
- cortisol: increase
- deoxycorticosterone: increase - DHEAS: decrease |
|
T/F: 70% of all glucose transferred from mother is consumed by placenta.
|
true
|
|
What do uptake of O2 and excretion of CO2 infetus depend on?
|
maternal and fetal blood-carrying capacity
|
|
How are the following parameter differ between mother and fetus?
- amount hemaglobin - O2 sat |
- amount hemaglobin: higher in fetus
- O2 sat: higher in fetus |
|
Does maternal TSH cross placenta?
|
No
|
|
When does testicular and ovarian differentiation begin?
|
testicular differentiation: 6 wks
ovarian differentiation: 7 wks |
|
What is "quickening" and when does it usually happen?
|
patient's initial perception of fetal movement: usually happens at 20 wk gestation
|
|
What does a + pregnancy test inidate?
|
- intrauterine pregnancy
- ectopic pregnancy - trophoblastic disease - spontaneous abortion |
|
What is this sign?
- congestion and bluish color of the vagina |
chadwick sign
- early sign of pregnancy |
|
What is this sign?
- softening of the cervix |
Hegar sign
- early sign of pregnancy |
|
When does urine pregnancy test become positive?
|
4 wks following 1st day of the last mentrual period
|
|
In approximately what percentage of women is rubella titer positive?
|
85%
|
|
T/F: Specific screening for treponema is required when RPR is positve.
|
True
|
|
In normal pregnancy, how often should women engage in non-weight-bearing exercise?
|
3x per week
|
|
T/F: any test that indicates fetal maturity is associated with subsequent developement fo RDS in 5% or less of cases.
|
True
|
|
What medications could help with physiologic constipation of pregnancy?
|
- colace (docusate): stool softener
- metamucil (psyllium hydrophilic mucilloid): supplementary dietary fiber |
|
Where do women experience more round ligament pain?
|
right goin because of dextrorotation of the gravid uterus
|
|
What are some types of preterm birth?
|
1. spontaneous PTB:
- 1/3 are PPROM 2. Indicated PTB: maternal or fetal reasons |
|
Which race is at more risk at having preterm birth?
|
black > hispanic > white
|
|
What are some features of non-recurrent SPTB (spontaneous preterm birth)?
|
- second trimester bleeding
- trauma, substance abuse - multiple gestations, hydramnios |
|
What are some features of recurrent STPB?
|
- earlier gestational age at delivery (<32wks)
- African American - genital tract infection and short cervix |
|
What are some risk factors for SPTB?
|
- second trimester bleeding
- genitourinary infection - black race - low pre-pregnancy weight - age < 18 yrs - smoking - prior preterm birth |
|
Side effects of this tocolytic agent:
- beta-adrenergic: ex terbulaline |
hyperglycemia
hypokalemia hypotension pulmonary edema cardiac insufficiency arrhythmia MI maternal death |
|
Side effects of this tocolytic agent:
- magnesium sulfate |
pulmonary edema
respiratory depression cardiac arrest maternal tetany profound muscular paralysis profound hypotension |
|
How is cervical competence assessed?
|
cervical length
|
|
Diagnosis of PTL.
|
- contractions
- cervical change - cervical sonography - fetal fibronectin |
|
What are some adjunctive therapies for PTL?
|
- antenatal steroids: beneficial when given < 34 wks gestation
- GBS prophylaxis - maternal transport |
|
Contraindications to tocolysis.
|
- mature fetus
- fetal distress/demise - fetus incompatible with survival - intraamniotic infection - severe preeclampsia - maternal shock |
|
Tocolyse or not?
- cervix > 3cm or > 80% effaced |
Yes
- PTL is confirmed |
|
Tocolyse or not?
- cervix < 2cm and < 80% effaced |
PTL diagnosis uncertain
- next to get fibronectin and ultrasound - repeat exam in 1-2 hours - tocolysis if cervical length < 20mm, fibronectin +, and cervical change |
|
Tocolyse or not?
- cervix 2-3cm and < 80% effaced |
PTL diagnosis uncertain
- next to get fibronectin and ultrasound - repeat exam in 30min to 1hour - tocolysis if cervical length < 20mm, fibronectin +, and cervical change |
|
What are some measures of prevention of preterm birth?
|
- progesterone
- cervical cerclage |
|
Criteria for diagnosis of cervical incompetency.
|
- 2 or more second trimester losses
- successive earlier losses - painless dilation up to 4-6 cm - absence of abruption - cervical trauma |
|
Criteria for urgent cerclage procedure.
|
- cervical shortening at 16-24 wks
- prior PTB < 28wks and CL < 20mm - no PTB and CL < 15mm - prolapsing membranes at < 24wks |
|
List some tocolytic drugs.
|
- magnesium sulfate
- beta-mimetics: Ritodrine, terbulatine - indomethacin: prostaglandin inhibitor, contraindicated for asthmatic patients - calcium channel blockers: contraindicated for maternal liver disease |
|
What is the gestational age?
- rate of fetal growth falls off - placenta reaches max surface area |
37th week
|
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Early onset IUGR is associated with ____.
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- irreversible reduction in organ size
- genetic factors - immunologic abnormalities |
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Delayed onset IUGR is associated with ____.
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- uteroplacental insufficiency
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What is the most common maternal factor associated with IUGR?
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hypertensive disease
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Features of asymmetric IUGR.
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- biparietal diameter appropriate for dates
- head to abdominal circumference ratio >95th percentile - low amniotic fluid volume |
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Features of symmetric IUGR.
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- normal to low amniotic fluid volume
- biparietal diameter smaller than expected for dates - normal head-to-abdominal circonference |
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Assessment of IUGR by ultrasound includes ____.
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- fetal doppler measurement
- evaluation of fetal growth - percutaneous umbilical blood sample for genetic evaluation - evaluation for amniotic fluid volume |
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What is an efficient screening procedure for IUGR?
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serial fundal height measurement
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Frequency of ultrasound evaluation for IUGR.
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every 3-4 wks
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Definition of hyperviscosity syndrome associated with IUGR.
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fetal Hct > 65%
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What is the recommendation for primary c section based on sonographic estimation of fetal weight?
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- > 4500g for a women with diabetes
- > 5000 for a women without diabetes |
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What is the most common infection that causes IUGR(symmetric)?
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CMV
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Risk factors for IUGR.
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- constitutionally small mother
- substance abuse - poor maternal wt gain - abnormal placentation: previa, marginal insertions, partial abruption - previous IUGR |
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Potential sequela for IUGR.
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intrapartum:
- fetal death - meconium aspiration - acidosis postpartum - seizure - sepsis - hypoglycemia - hyperbilirubinemia longterm - CP - chronic HTN - heart and lung disease - DM - lower intelligence quotients |
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What are some antepartum monitors to assess fetal well being?
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- nonstress test
- biophysical profile - doppler velocimetry of umbilical artery |
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What is the appropriate fundal height for the following dates?
- 12 wk gestation - 16 wk gestation - 20 wk gestation |
- 12 wk gestation: at pubic symphsis
- 16 wk gestation: half way between pubic symphsis and umbilicus - 20 wk gestation: umbilicus * need to re-evaluate if fundal height is off by more than 3 cm |
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What are some intrapartum complications of macrosomia?
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- arrest of dilation or descent: need C section
- shoulder dystocia: HELPERZ |
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What is the HELPERZ mnemonic?
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it is the sequence of maneuvers to help shoulder dystocia during delivery of a macrosomia baby
H - call for help E - evaluate for episiotomy L - leg with McRoberts maneuver P - suprapubic pressure to collapse shoulder E - extend posterior arm R - rotate the baby with Wood's screw maneuver Z - zavanelli's maneuver (push head back for a c section) |
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Definition of preterm labor.
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- regular uterine contraction with a frequency of 10min or less and lasting at least 30s
- cervical dilation |
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What are some symptoms associated with preterm labor?
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- low dull bachache
- pelvic pressure - abdominal cramps - change in vaginal discharge |
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What is this diagnoisis?
- positive pregnancy test - tissue passed from vagina (spontaneousely or D&C) - tissue does not demostrate chorionic villi |
ectopic pregnancy until proven otherwise
- tissue passed from vagina is sometimes termed "decidual cast", similar to a spontaneous abortion. |
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DDX for ectopic pregnancy.
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- threatened, missed, complete, incomplete abortion
- acute/chronic salpingitis - follicular or corpus luteum cyst rupture - endometriosis - adnexal torsion - gastroenteritis, appendicitis |
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Diagnostic steps in ectopic pregnancy.
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1. pregnancy test
2. quantitative hCG every 2 days (normal should increase 66% in 48 hrs) 3. pelvic u/s to identify intrauterine pregnancy 4. WBC to r/o infection 5. progesterone level (if < 5ng/ml, fetus not viable) 6. curettage of uterine cavity to identify chorionic villi 7. culdocentesis to identify hemoperitoneum |
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Surgical management of ectopic pregnancy.
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- linear salpingostomy, heal by secondary intention
- segmental section and reanastamosis - salpingectomy |
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Medical treatment of ectopic pregnancy.
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- expectant management: self regress
- methotrexate (po or IM or direct injection into gestational sac): for cases with <3.5cm diameter gestation on u/s. - f/u serial hCG levels - administer RhoGam if mother is Rh negative |
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List some non-tubal types of ectopic pregnancies.
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1. Abdominal
- primary: associated with mullarian tract anomalies, endometriosis, PID, fallopian tube dysfunction - secondary: aborted tubal ectopic pregnancy - treated with surgical removal of fetus, and methotrexate to regress placenta (no surgical removal of placenta) or carry fetus to viability and deliver. 2. cervical pregnancy - treated with conization, arterial embolization, or hysterectomy 3. ovarian pregnancy - primary - reimplanatation/secondary |