Oral Boards

0.2mg every 2-4 hours, IM

0.25mg, IM or intramyometrial, every 15-90 minutes, 8 dose max

Operative delivery

Nulliparity

Coagulation disorders

PEC

Multiple gestation

Compound presentation

Rapid descent

Branches of:

Internal pudendal artery (anterior)

Inferior rectal artery (posterior)

Uterine artery (paravaginal)

Perineal venous plexus

Rectal pain with minimal vulvar visualization of a hematoma.

Only if non-expanding.

Close observation

Ice packs

Pain management

Bladder drainage (if necessary)

- monitor I/Os

- Fluid resuscitate prn

- blood prn

Surgical management:

- ppx abx

- evacuate hematoma

- Identify and ligate bleeding vessels

- repair defect

- Artery embolization if surgical mgmt doesn't work

The relation of the fetal long axis to that of the mother.

Can be:

- longitudinal

- transverse

- oblique

Presenting part is the part of the baby that is closest to the birth canal.

Can be:

- cephalic

- breech

- shoulder

Further defines cephalic presentation.

Can be:

- vertex

- sinciput (anterior fontanel presenting)

- brow

- face

Refers to the relationship of a portion of the fetal presenting part to the right or left of the birth canal.

- Vertex: occiput

- Face: mentum (chin)

- Breech: sacrum

1. Engagement

2. Descent

3. Flexion

4. Internal Rotation

5. Extension

6. External Rotation (Restitution)

7. Expulsion

Sacral Promontory

Pubic Symphisis

Linea terminalis (lateral borders)

Shortest distance between pubic symphisis and sacral promontory.

- Usually >10cm but cannot be measured directly.

- measure diagonal conjugate and subtract 1.5-2cm

(Diagonal conjugate is the distance between the lowest margin of the pubic symphisis and the sacral promontory)

1. History:

- one or more second trimester losses associated with painless cervical dilation OR

- prior cerclage for painless cervical dilation in second trimester

2. Physical Exam:

- painless cervical dilation in second trimester

3. Ultrasound:

- previous spontaneous preterm delivery <34 weeks and current singleton pregnancy with cervical length <25mm before 24 weeks

Purse string suture of non-resorbable material inserted into the cervicovaginal junction.

Involves dissection of the vesicocervical epithelium to place the suture as close to the internal os as possible. Use non-resorbable suture.

Suture placed at the cervicoisthmic junction transabdominally (open or laparoscopic).

Reserved for previous failed transvaginal cerclage (resulting in second trimester loss) or if can't perform transvaginal cerclage (ie after trachelectomy). Can leave in place for subsequent pregnancies and deliver via cesarean.

- Previous spontaneous preterm delivery

- short cervix (<25mm)

- smoking

- previous LEEP/CKC or cervical instrumentation

- vaginal bleeding

- UTIs

- genital infection

- periodontal disease (not likely the dental disease itself but other associated traits)

18-23 months

- Endometrial (16-61% risk by age 70)

- Colon (18-61% risk by age 70)

- Ovarian (5-10% risk by age 70)

- Colonoscopy q1-2 years starting age 20-25 or 2-5 years before youngest affected family member

- Endometrial biopsy q1-2 years starting age 30-35

- menstrual calendar should be kept, if irregular should be investigated!

- risk reducing Hysterectomy with BSO at 40-45 or when done childbearing

- use progestin or COCs to decrease risk

Chromosome 17

Chromosome 13

45-85% for both

(Male breast cancer seen with BRCA2)

BRCA1: 39-46%

BRCA2: 10-27%

BRCA1: age 35-40

BRCA2: age 40-45

(Or when done with childbearing)

Nulliparity

Multifetal gestation

Previous PEC

CHTN

Pregestational diabetes

Gestational diabetes

Thrombophilia

Systemic Lupus Erythematous

Pregravid BMI >30

Antiphospholipid Syndrome

Age >35

Kidney disease

Obstructive Sleep Apnea

BLOOD PRESSURE

- sBP >140mmHg or dBP >90mmHg on two or more occasions more than 4 hours apart

(If sBP >160 or dBP>110 can diagnose within minutes)

PROTEINURIA

> 300mg in 24 hours or > 0.3mg/dL protein: creatinine ratio

OR

Severe features:

- plt <100K

- creatinine > 1.1mg/dL (or double baseline)

- LFTs twice upper limit of normal

- pulmonary edema

- persistent headache not responsive to medications and not accounted for by other diagnosis

- visual disturbances

Hepatic dysfunction with varying renal failure.

- low glucose

- liver dysfunction

- prolonged PTT

- high maternal and fetal mortality

Calcium gluconate 1g IV over 2 minutes

(Use lasix to increase renal excretion)

Myasthenia Gravis

Pulmonary Edema

Can use phenytoin or diazepam.

- If use phenytoin, monitor EKG

- If use diazepam, make sure able to intubate.

Decrease risk of severe PEC and FGR if started between 12-16 weeks.

- close BP monitoring (weekly clinic visits)

- serial ultrasound for fetal growth (q3-4 weeks)

- weekly antenatal testing

- weekly labs

- urine protein (if GHTN)

- myasthenia gravis

- hypocalcemia

- moderate to severe renal failure

- cardiac ischemia

- heart block

- myocarditis

9mg/dL

(Respiratory depression at 12mg/dL

Cardiac arrest at 30mg/dL)

In first trimester can cause renal dysgenesis and calvarial hypoplasia.

Can cause fetal growth restriction later.

Baseline labs:

- serum creatinine

- BUN

- electrolytes (esp K+)

- AST/ALT

- CBC

- spot urine prot ( if <0.15 no need for 24h urine if normal creatinine)

- EKG if >4 years disease or concern for long standing hypertension that may have been diagnosed late (echo if EKG abnormal)

Labetalol: 200-2400mg daily divided into 2-3 doses

Nifedipine XL: 30-120mg daily

Methyldopa: 500-3000mg daily divided into 2-3 doses

Monitor BPs

- q10 minutes for 1 hour, then

- q15 minutes for 1 hour, then

- q30 for 1 hour, then

- q hour for 4 hours

- Asthma

- myocardial disease

- decompensated cardiac function

- heart block and bradycardia

- sickle cell

- cystic fibrosis

- Tay- Sachs

- alpha or beta thalassemia

- phenylketonuria

Microarray

- advanced maternal age

- advanced paternal age (>40-50)

- paternal carrier of chromosome rearrangement

- parental aneuploidy or aneuploidy mosaicism

- prior child with structural birth defect

- parental carrier of genetic disorders

- previous child/fetus with aneuploidy

- structural anomalies on sono

CVS or amnio due to possibility of error

CVS: 10-13 weeks

Amnio: 15+ weeks

~1/500 generally

(But really depends on experience of provider)

CVS: 0.22% (1 in 455)

Amnio: up to 0.27% (1 in 370)

- characteristic facial features

- learning disabilities

- congenital heart defects (atrioventricular canal defects)

- intestinal atresia

- seizures

- childhood leukemia

- early onset Alzheimer's

First trimester screen is done between 10w0d and 13w6d.

Components:

- nuchal translucency (abnl is >3mm)

- serum free bhcg/total hcg

- pregnancy associated plasma protein A analyte level (PAPP A)

15w0d - 22w6d (though ideal is 16-18 wks)

Components:

1. Hcg

2. Alpha fetoprotein (AFP)

3. Inhibin A

4. Unconjugated estriol

(Also consider maternal factors such as age, weight, race, presence of diabetes, number of fetuses)

~80%

FTS 82-87%

Quad 81%

- Huntington disease

- Marfan syndrome

- achondroplasia

- osteogenesis imperfecta (types 1-4)

- polycystic kidney disease (type 1)

- Neurofibromatosis, type 1

- hemophilia A and B

- red/green color blindness

- Duchenne Muscular Dystrophy

> 14 hr in multip

> 20 hr in nullip

>6cm with ROM and one of the following:

- 4hr with adequate contractions and no cervical change (>200 Montevideo units over 10 minutes)

- 6hr with inadequate ctxns and oxytocin

Think of 3 Ps:

1. Power

2. Pelvis

3. Passenger

- maternal age

- gestational age

- parity

- prepregnancy BMI

- gestational weight gain

Obstetric complications like:

- PROM

- infection

- placental abruption

- Preeclampsia

- At least 2 hours of pushing for multips

- At least 3 hours of pushing for nullips

**Add 1 hour if epidural

Parity

Delayed pushing

Use of epidural

Large maternal BMI

Large fetal weight

OP position

Fetal station at complete dilation

- infection

- PPH

- high order perineal laceration

NT + PAPP-A then Quad

96% detection of Down syndrome

PAPP-A + quad

88% detection of Down syndrome.

Offer FTS:

If positive - offer diagnostic screen or cell free DNA test

If negative - offer second trimester screen

95% detection rate for Down syndrome

Offer FTS:

If negative - no further testing

If positive - offer diagnostic test or cell free DNA

If intermediate - offer quad screen

88-94% detection rate of Down Syndrome

- Renal pelvis dilation (pyelectasis)

- Short femur and humerus

- Echogenic bowel

Also a/w:

- congenital heart disease

- skeletal dysplasia

- Noonan syndrome

- high maternal BMI

- sampling before 10 weeks

- fetal aneuploidy

- spontaneous fetal and neonatal loss

- fetal growth restriction

- preeclampsia

- placental abruption

- preterm delivery

- Spina bifida

- anencephaly

- abdominal wall defect

- Placenta accreta spectrum

- low birth weight

- fetal to maternal bleeding (ie with Rh incompatibility)

Chem profile

UA

CBC

+/- EKG

- Early age of menarche (<11 yr)

- Shorter cycles

- Prolonged/heavy menses

- affected first degree relative

Low-level, homogeneous internal echoes (old blood).

Norethindrone 5mg daily

- NSAIDs

- COCs

- norethindrone

- provera (oral or Depot)

- GnRH agonist

- danazol (androgenic)

- abdominal and liver calcifications

- intracranial calcifications

- echogenic bowel and kidneys

- ascites

- hepatosplenomegaly

- microcephaly

- hydrops fetalis

- growth restriction

*(most of these more common with other abnormalities)

30%

- more common in third trimester, but more severe if transmission occurs in first trimester

About 25-30%

- spontaneous abortion (1st trimester)

- fetal demise, hydrops (2nd and 3rd trimester)

Rash, arthritis, flu-like illness

(Many are asymptomatic)

Serial weekly ultrasounds to assess for:

- growth restriction

- hydrops

- cardiomegaly

- ascites

- increased MCA dopplers

Monitor for 8-12 weeks after exposure/infection.

Maternal:

- check IgM and IgG levels.

- If IgG positive but IgM negative, likely previous infection.

- If IgM positive, monitor fetus for signs of infection.

- if both negative, repeat in 4 weeks if known exposure or suspicion

Fetal:

- amniotic fluid PCR

~60g