Professional Documents
Culture Documents
RISK FACTORS
I.
PRE-TERM LABOR
II.
III.
Presence of contraction of
sufficient strength and
frequency
to
effect
progressive dilatation and
effacement of the cervix
between 20 weeks and 37
weeks of gestation
Contractions of 4 in 20
minutes OR 8 in 60 minutes
PLUS: progressive change
in the cervix, cervical
dilatation greater than 2cm,
cervical effacement of 80%
or greater
Intrauterine infection
Bacterial vaginosis
Multiple pregnancy
Previous pre-term delivery
Cigarette smoking
Cervical incompetencies
Uterine abnormalities
Younger age of the mother
Lower socioeconomic class
Anti-phospholipid syndrome
OB complications
DIAGNOSIS
Vaginal examination: traditional method
UTZ: 30mm cut-off; look for decreased
cervical length, measurement, funneling,
positive stress test
Fibronectin test: positive at 50ng/mL
POST-TERM LABOR
Prolonged or extended
pregnancy (>42 weeks)
Significance of
deceleration:
compression
MANAGEMENT
variable
cord
Significance
of
late
deceleration: uteroplacental
insufficiency
INAPPROPRIATE FETAL
GROWTH
CLINICAL MANIFESTATIONS
Steroids
IV hydration
Nutritional supplementation
Hyperbaric oxygen
Bed rest
IV.
V.
Blood
volume
and
coagulation:
hemoconcentration (hallmark of preeclampsia)
HELLP syndrome: hemolysis, elevated liver
enzymes, low platelets
Cardiovascular, kidney, liver and brain
problems
Visual changes and blindness
Severe Pre-eclampsia: BP
160/110 mmHg; elevated
LDH, ALT or AST
Eclampsia: seizures that
cannot be attributed to other
causes in women with
preeclampsia; with sever
headache,
visual
disturbances and epigastric
pain
Heredity
Race
Maternal age and parity
Periconception intake of vitamins
Infertility treatment
Ultrasound
o Lambda sign: 1st trimester
o Twin peak sign: sign of dichorionicity
o Twin intervening membrane: sign of
monochronicity
History and PEfindings
Laboratory findings:
o Elevated alpha-fetoprotein and hCG are
not diagnostic
o No reliable biochemical marker
Mild Pre-eclampsia:
o Home health care
o Antepartum surveillance
o Delivery (40 weeks deliver the baby)
Severe Pre-eclampsia:
o Aggressive management: high neonatal
mortality and morbidity; prolonged NICU
stay; long-term disability
o Expectant management: fetal death;
asphyxia damage, increased maternal
morbidity
Hospitalization
(Tertiary
hospital)
MgSO4
Anti-hypertensives:
ACE
inhibitors are contraindicated
during pregnancy due to fetal
side effects such as defective
skull,
ossifications,
oligohydramnios,
neonatal
anuria
Corticosteroids
Prevention of Pre-eclampsia:
o Bed rest effective in the prevention of
pre-eclampsia; 3rd trimester
o Calcium supplementation significant
reduction in pre-eclampsia
o Low-dose aspirin only one that has
proven to be beneficial in preventing
pre-eclampsia in high risk patients;
decrease pre-term birth, SGA and
deaths; 16 weeks AOG
Management of Eclampsia:
o Control of convulsions: MgSO4
o IV anti-HPN drugs
o Delivery
Antepartum Management:
o Nutrition and weight gain
o Pre-natal diagnosis
o Fetal surveillance
o Prevention and treatment of pre-term
labor and delivery
o Timing of delivery: labor and delivery
Fetal presentation: most important
factor determining mode of delivery
Mode of delivery determined by:
fetal presentation/lie, estimated
fetal weight of twin B relative to
twin A, skill of OB, fetal status
o Management of TTTS:
Serial therapeutic amniocentesis
Septostomy
VI.
VII.
THYROID DISORDERS IN
PREGNANCY
Second most common
cause endocrine disease
affecting
women
of
reproductive age
BOTH hyperthyroidism and
hypothyroidism may initially
manifest during pregnancy
Obstetric conditions may
affect thyroid gland function:
gestational
trophoblastic
disease and hyperemesis
gravidarum
Hypothyroidism
o Subclinical hypothyroidism: High TSH +
normal FTI
o Untreated hypothyroidism is associated
with an increased risk of pre-eclampsia
o High incidence of LBW in neonates
associated with inadequately treated
hypothyroidism
o Cold
intolerance,
constipation,
slowness, lethrgy
VIII.
-
PULMONARY DISEASES
IN PREGNANCY
Pulmonary changes in
pregnancy:
Decrease in RV
Decrease in functional
residual capacity
Expiratory reserve volume
Total lung capacity
Increase in respiratory
capacity
Unchanged vital capacity or FEV1
and unchanged RR
Asthma
o
Chronic
inflammatory
disorder associated with
airway
hyperresponsiveness and
bronchospasm
o
Airflow obstruction
o
Rule of thirds in
pregnancy:
1/3
will
worsen, 1/3 will get
better, 1/3 will remain
unchanged
Bacterial Pneumonia
o
Major
complications
associated
with
pneumonia:
pre-term
labor
o
Etiology of uncomplicated
CAP: Pneumococcus, H.
influenzae,
atypical
agents (MOST COMMON
pathogens)
o
Most common cause of
pneumonia
during
pregnancy: S. pneumonia
o
Etiology of superinfection:
Diagnosis of Tuberculosis:
o
Sputum microscopy: test of
choice for initial work-up for
TB-symptomatic patients
o
3 early morning samples
o
At least 2 positive
o
If unable to bring up
sputum: give hypertonic
S. aureus
Etiology of aspiration
pneumonia: gram (-)
organisms
o
Triad of fever, cough and
dyspnea
o
Pneumonia during midpregnancy carries this
risk: IUGR
Aspiration Pneumonia
o
Aspiration
includes
bacteria in the oropharynx
and liquid or solid gastric
contents
o
Pneumonia
due
to
aspiration occurs 24
hours after solid particles
and gastric fluid
Tuberculosis
o
Chronic cough >2 weeks,
weight loss, sweat and
chills, body malaise, fever
o
Clinical clue: failure to
gain weight
Pulmonary Embolism
o
Venous thromboembolic
disease: leading cause of
morbidity and mortality
during pregnancy
o
Risk of DVT: highest in
the antepartum period
o
But the highest possibility
of pulmonary embolism is
immediately after delivery
o
Pregnancy:
hypercoagulable state
Clinical presentation: leg swelling, dyspnea,
tachypnea, tachycardia, palpitations
saline solution
For smear negative patient:
do culture and CXR
o
In high risk population and
with evidence of CXR the
cut-off value is 5mm
o
Latent infection diagnosis:
Quantiferon-TB Gold
Diagnosis of DVT:
o
Compressive UTZ and
Impedance Pletysmography
o
Do not use D-dimer test
Classic Triad:
o Chorioamnionitis
o Intracrainial calcification
o Hydrocephalus with seizure
Congenital Toxoplasmosis
o At birth maculopapular rash,
hepatosplenomegaly,
seizures,
convulsions
o Blindness,
deafness,
mental
retardation
Maternal SSx
o Non-tender
posterior
cervical
lymphadenopathy
o Flu-like symptoms
Serologic Test for IgG or IgM
o IgG: appears 1-2 weeks of infection;
peaks between 6-8 weeks
o IgM: appears within 1st week of infection
then declines over several months
PCR testing of amniotic fluid most accurate
test for fetal infection (2nd trimester)
IX. INFECTIONS
Toxoplasmosis
Rare
Rubella
Transmission: airborne
Cytomegalovirus
Most common cause of viral
intrauterine infection
Infection can oocur in-utero,
intrapartum and through
breastmilk
o
o
o
o
CMV infection:
o 4-8 week incubation period
o viremia: 3-12 months
o viral transmission via primary or
recurrent maternal infection
o Rate of transmission increases with
gestational age highest at 3rd
trimester
Recurrent CMV infection:
o Occur with immunosuppression and
during pregnancy
o Reactivation of endogenous virus
o Infected neonates with <8% chance
of hearing loss and chorioretinitis
o IgG confers good protection
Neonatal CMV infection:
o UTZ findings: ventriculomegaly,
oligohydramnios, echogenic bowel,
choroid plexus cyst, pleural effusion,
brain/liver calcifications
Congenital CMV:
o Blueberry muffin baby
o Jaundice,
thrombocytopenia,
hepatosplenomegaly, chorioretinitis,
deafness, microcephaly, etc.
Ulceration in genitalia with
severe local pain, dysuria,
sacral paresthesia, tender
inguinal lymph nodes, fever,
malaise
Primary First episode:
o HSV without prior HSV-1 or HSV-2
antibodies
o No fetal consequences unless
convert shortly before labor and
delivery
Non-primary First episode:
o HSV-2 confirmed with prior findings
of HSV-1 antibodies or vice-versa
o Symptoms milder
Recurrent Genital Herpes:
o Reactivation of HSV usually HSV-2
o Virons travel from skin or mucosa to
sensory dorsal root ganglion where
latency is established
Prevention:
o Hygiene
Prevention:
o Avoid sexual contact
o Condoms
o Suppression decreases recurrent genital
lesions
Primary HSV:
o Analgesia
o Hygiene
o Acyclovir 7-14 days or Valcyclovir
o Suppression: Acyclovir or Valcyclovir at 36
weeks to delivery
First episode within 6-12 weeks of delivery
o IV acyclovir intrapartum to both mother and
neonate
o Daily acyclovir or valcyclovir from 36 weeks
until delivery
Complicated CMV infection
o IV acyclovir
Recurrent HSV
o Analgesia
o Hygiene
o Acyclovir
o Suppression therapy
Varicella Zoster
Double-stranded
DNA
acquired in childhood
Reactivation
of
latent
varicella: Herpes Zoster
Transmission:
droplets
direct
contact
and
respiratory
Parvovirus
Human parvovirus B19
causes Fifth disease or
erythema infectiosum
Most common cause of
nonimmune hydrops
Hepatitis A
RNA virus transmitted via
fecal-oral route
Hepatitis B
Most common form of viral
hepatitis in pregnancy
HIV
-
Varicella
o Maculopapular vesicular purpuritic
lesions
Herpes Zoster
o Painful lesions over sensory nerve
root distributions
Maternal Primary Varicella
o Pneumonitis
o Bacterial superinfection (cellulitis,
abscess formation)
Congenital Varicella Syndrome
Neonatal VZV infection
o Fetal exposure just before or during
delivery
20-30% asymptomatic
Slapped check appearance
Rash spread to trunk and
extremities
Polyarthralgia
Modes of Delivery:
o With active lesion ! CS
o PPROM ! expectant
Supportive care
Anti-HAV IgM
Supportive
No perinatal transmission
Azidothymidine
Zidovudine
Continue monitoring CD4 count and HIVRNA levels
Penicillin
Ampicillin
For penicillin allergic:
o Clindamycin
o Erythromycin
Serum ferritin
Hepatitis B panel
Screen for HBV by HBsAg
HBV DNA quantitative PCR
Liver biopsy
Megaloblastic Anemia
Blood and bone-marrow
abnormalities form impaired
DNA synthesis
-thalassemia
-thalassemia
Overly
active
B
lymphocytes
that
are
responsible
for
autoantibody production
APS
XII.
Malaise
Fever
Arthritis
Rash
Pleuropericarditis
Photosensitivity
Anemia
Cognitive dysfunction
Recurrent arterial or venous thrombosis
Thrombocytopenia
Fetal losses especially during 2nd half of
pregnancy
CNS involvement
UTI
Progesterone
makes
muscle of the bladder less
motile
o
Common in pregnancy
Asymptomatic Bacteriuria
o
Presence of bacteria within
the urinary tract, excluding
urethra without symptoms
of infection
o
Prednisone + IVIg
Splenectomy
Azathioprine,
cyclophosphamide,cyclosporine
Clinical Criteria:
o Thrombosis
o Pregnancy (recurrent fetal losses)
Laboratory Criteria:
o Anticardiolipin antibodies
o Lupus anticoagulant
Routine assessment of renal function:
o
Proteinuria
should
be
assessed every pre-natal visit
o
Urine dipstick value > 1+ =
clean catch urine sample for
culture and microscopy
o
Persistent proteinuria: 24
hour urine culture needed
o
Proteinuria
>
300mg:
abnormal
Glucosuria
pregnancy
Hydroureter
hydronephrosis
and
PKD
o
o
Increased
clearance
tubular
Calcium
clearance
is
balanced
by
GUT
absorption
Physiologic hyponatremia
Urinary excretion of glucose
increases by 10 to 100 fold
is common in normal
Acute Cystitis
o
Honeymoon cystitis
o
Urinary frequency, urgency,
dysuria, hematuria and
suprapubic discomfort
Urethritis
o
Frequency:
common
complaint
o
C. trachomatis: common
causative organism
o
Patients with symptoms of
acute cystitis and (-) culture
o
Mucopurulent cervicitis may
be present
Pyelonephritis
o
Leading cause of septic
shock in pregnancy
o
High grade fever (spiking
appearance), chills, flank
pain, nausea and vomiting,
frequency, urgency, dysuria
Nephrolithiasis
o
Suspected UTI and (-) urine
culture
o
Patient with persistent/
recurrent UTI
Chronic Renal Disease
Degree of renal impairment: major
determinant of pregnancy outcome
o
IV hydration and analgesics
30% of symptomatic cases require surgical
intervention