Professional Documents
Culture Documents
I.
II.
A.
B.
C.
A.
B.
C.
D.
a.
b.
c.
d.
Massive edema.
e.
Presence of IUGR.
III.
IV.
V.
A.
B.
C.
A.
B.
Hospital management.
1.
Indications. No improvement of mild pregnancyinduced-hypertension with home bedrest or pre-eclampsia
with 2+ proteinuria, evidence of organ system
involvement.
2.
Orders. Bed rest with bathroom privileges is allowed. The
goal of IV fluids in severe cases is to replace urine output
and insensible losses.
3.
Laboratory evaluation and weights. Performed daily to
every other day. Antepartum surveillance including daily
fetal movement count, daily NSTs, and weekly amniotic
fluid determinations by ultrasound is essential. Monitor
symptoms such as headache, visual disturbances, and
epigastric pain.
4.
Delivery is treatment of choice. Delivery should be
accomplished when the fetus is mature but may be
5.
6.
a.
b.
c.
d.
7.
a.
VI.
VII.
c.
A.
Risks.
1.
2.
B.
b.
Management.
1.
Treatment of chronic hypertension can decrease
maternal and, to some extent, fetal morbidity. Appropriate
medications include methyldopa, hydralazine, and betablockers.
2.
During pregnancy, it is not appropriate to use:
a.
Sympathetic ganglion blockers (orthostatic
hypotension)
b.
Diuretics (aggravation of volume depletion)
c.
ACE inhibitors (associated with fetal defects
and neonatal renal failure)
3.
Laboratory evaluation is performed early in pregnancy.
4.
Obstetric visits are scheduled every other week at 24
weeks and weekly after 30 weeks.
5.
Early ultrasound is obtained for dating, and repeated
periodically to look for evidence of IUGR.
6.
Antenatal surveillance (NSTs) should begin at 34 weeks.
7.
Timing the delivery. The pregnancy should not be
allowed to go beyond 40 weeks. Delivery may be required
earlier if there is evidence of IUGR or fetal distress or if
hypertension cannot be controlled by bed rest and
medication.
8.
Intrapartum monitoring is required during labor.
9.
If there is evidence of IUGR, cesarean section is
preferable to a prolonged induction.
10.
I.
II.
Potential morbidity.
A.
Infants born to diabetic mothers have 5 times the normal risk of
respiratory distress syndrome, an increased risk of congenital
anomalies (especially with first trimester hyperglycemia), an
increased risk of neonatal hypoglycemia, hypocalcemia and jaundice.
B.
The mother has an increased incidence of preeclampsia, infection,
postpartum bleeding, and cesarean section (secondary to
macrosomia). There is also an increased risk of maternal injury
during vaginal delivery.
Evaluation.
A.
B.
C.
c.
2.
3.
I.
II.
Definition. IUGR is defined as a fetus that weighs less than the tenth percentile
for its gestational age.
A.
Symmetric IUGR (intrinsic): normal head circumference-toabdominal circumference ratio, caused by genetic disease or fetal
infection and has a poor prognosis.
B.
Asymmetric
IUGR
(extrinsic):
increased
head
circumference/abdominal circumference ratio, caused by placental
insufficiency; good prognosis with appropriate treatment.
Risk Factors.
A.
B.
C.
D.
E.
III.
Diagnosis. One should be suspicious when the fundal height does not exhibit the
predicted 1 cm/week growth between 20 and 36 weeks of gestation. A lag in
fundal height by 4 cm mandates ultrasonographic evaluation; otherwise, consider
ultrasound on a clinical basis. Serial ultrasonic scanning may confirm the
diagnosis.
IV.
Obstetrics: Amnioinfusion
I.
II.
A.
III.
IV.
B.
C.
Correction of oligohydramnios.
Technique.
A.
B.
C.
D.
Efficacy.
A.
B.
Induction of Labor
I.
II.
Induction Methods. Assess the inducibility of the cervix using Bishop score
(Table 14-3). Determine route of induction.
A.
Amniotomy.
1.
Cervix should be dilated enough to allow reaching the
membranes with the amniotomy hook. The fetus should be
vertex (unless breech delivery is planned) with the
B.
C.
D.
5.
I.
II.
III.
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I.
II.
A.
B.
C.
D.
E.
F.
Physical Exam.
A.
B.
Pelvic examination.
1.
11
III.
IV.
12
2.
3.
A.
Routine. Pap smear, CBC, UA, and culture to screen for bacteriuria,
ABO blood type, Rh type, antibody screen (indirect Coombs),
VDRL test, rubella antibody titer, and hepatitis B surface antigen.
Treat asymptomatic bacteriuria to prevent pyelonephritis during
pregnancy. Urine should also be screened for protein and glucose by
dipstick at each visit. Offer HIV testing. (Many states require testing
since AZT administered during pregnancy substantially decreases risk
of transmission of HIV to infant&endash;see Chapter 11.)
B.
A.
B.
C.
D.
E.
F.
28 to 32 weeks. Hematocrit
15 to 20 weeks. Serum triple-screen (alpha-fetoprotein [AFP], betaHCG, and estradiol). See below.
24 to 28 weeks. Blood glucose screen after 50 g of oral glucose and
urine culture.
36 weeks. Rh antibody screening if indicated. Consider GC,
Chlamydia, and herpes rescreening in high-risk women. Repeat
hematocrit if indicated. Consider testing for group B streptococci at
35 to 37 weeks (see recommendations below). Consider starting
acyclovir for patients with genital HSV which has been shown to
decrease transmission to the infant if given prophylactically.
V.
A.
B.
C.
I.
II.
III.
IV.
V.
VI.
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I.
II.
Vertical Transmission of GBS. GBS is the number one cause of neonatal sepsis
and meningitis in the United States. Infection occurs in 2 or 3 neonates per 1000
live births. Maternal colonization can be transient, and 20% to 25% of pregnant
females are carriers at any given time. In addition to threatening the life of a
neonate, GBS is also an important risk factor for the development of
chorioamnionitis in the mother, thereby increasing morbidity and the rate of
intrapartum complications.
III.
a.
b.
c.
B.
a.
14
b.
IV.
I.
Cause. Unknown. Probably not related to serum HCG levels, but other hormones
have been implicated (estradiol, thyroxine).
II.
III.
Outpatient Management
A.
B.
C.
D.
E.
F.
1.
15
IV.
2.
3.
4.
5.
6.
A.
B.
C.
D.
I.
A.
II.
16
Management.
A.
B.
C.
I.
II.
III.
A.
B.
C.
1.
2.
IV.
17
I.
B.
1.
2.
3.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
II.
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a.
b.
c.
vitamins;
Hospital Care.
A.
Physical examination.
1.
2.
3.
4.
Legs should be
thrombophlebitis.
examined
for
evidence
of
III.
Parent Education.
A.
Newborn care.
B.
Breast feeding and prevention of lactation or engorgement if
applicable.
IV.
Discharge.
A.
Discharge instructions.
V.
1.
2.
3.
4.
5.
6.
7.
Follow-up Exam.
A.
Postpartum check at 4 to 6 weeks.
B.
Newborn checkup typically at 1 to 2 weeks.
I.
II.
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1.
B.
C.
D.
20
E.
F.
G.
H.
Obstetrics: Labor
Introduction. This section is organized sequentially as events happen during labor and
delivery. It starts with the management of preterm labor and postdate pregnancies. It then
discusses the stages and management of labor, as well as the induction of labor. Finally, it
discusses the delivery itself.
Preterm Labor
I.
II.
Causes. Frequently unknown. Several factors have been associated with preterm
labor.
III.
A.
B.
Management.
A.
Initial examination.
1.
2.
21
B.
3.
4.
5.
Tocolysis.
1.
2.
3.
4.
a.
22
if labor is well
4 cm or more.
in the optimal
no large-scale
that tocolytics
Protocol.
1.
2.
3.
4.
b.
5.
FHR
and
monitoring.
6.
uterine
activity
1.
2.
3.
I.
II.
Definitions.
A.
B.
Diagnosis.
A.
B.
1.
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III.
2.
3.
4.
Management.
A.
B.
C.
Postdate Pregnancy
I.
Definitions.
A.
B.
C.
II.
Potential Morbidity.
A.
24
Etiology.
A.
B.
III.
Maternal.
B.
IV.
1.
2.
Operative
delivery, secondary
infection
and
hemorrhage are more common with postdate
pregnancies.
A.
B.
C.
I.
II.
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III.
IV.
Management.
A.
Preparation.
1.
Type and screen for 2 units of packed cells; intravenous
line should be inserted.
2.
The anesthesiologist, surgeon, and physician caring for the
newborn infant must be notified in advance and be
available.
B.
Labor.
1.
Electronic fetal monitoring is recommended.
2.
Oxytocin may be cautiously used to augment labor, and
close monitoring of uterine contractions (using intrauterine
pressure catheter) is necessary. Oxytocin must be titrated
with great care in a VBAC.
3.
The same expectations of normal progression during labor
should be applied to patients with a prior C-section.
4.
An experienced physician should be in attendance
throughout labor and delivery.
5.
Postpartum. Manual exploration of the uterus after
delivery of the placenta is indicated to assess scar
integrity.
I.
II.
1.
26
2.
3.
a.
b.
c.
I.
A.
B.
II.
1.
2.
3.
A.
B.
Protracted Active Phase. Rate of dilatation: <1.2 cm/hour in nullipara; <1.5 cm/hour in multipara. Cause: fetal malpositions (occi- put
posterior), CPD, hypotonic uterine contractions, and anesthesia.
Management: oxytocin stimulation. 70% require C-section.
C.
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D.
E.
F.
I.
28
Fetal Heart Rate. Electronic fetal heart rate monitoring may be performed by
means of external Doppler, or direct scalp lead when membranes are ruptured.
A.
B.
1.
2.
Variability.
a.
Short-term variability. Beat-to-beat variation
is normally 5 to 10 bpm (reliably assessed with
only a scalp lead).
b.
Long-term variability. Waviness of the FHR
tracing, which normally has a frequency of 3 to
10 cycles/min and an amplitude of 10 to 25
bpm.
c.
Decreased variability. Variability may be
decreased by fetal sleep cycles, CNS
depression secondary to hypoxia or drugs,
parasympatholytic agents, extreme prematurity,
or congenital anomalies. Loss of variability is
associated with a high incidence of fetal
acidosis and low Apgar scores.
3.
a.
b.
c.
d.
e.
4.
29
f.
g.
h.
II.
III.
A.
B.
C.
D.
I.
A.
30
4.
5.
6.
B.
31
C.
32
D.
33
I.
Overview.
A.
Incidence. 25% of all pregnancies <28 weeks of gestation, 3% to 4%
of all pregnancies at or beyond 34 weeks of gestation.
B.
Cause. Low birth weight, placenta previa, uterine and fetal
anomalies, contracted pelvis, multiple fetuses all contribute to breech
presentations.
II.
Types of Breech.
A.
Frank. Thighs and hips flexed, knees extended. 65% of cases are
frank.
B.
Complete. Thighs and hips flexed, one or both knees flexed. 10% of
cases.
C.
Incomplete or footling. One or both thighs extended, one or both
knees below the buttocks. 25% of cases.
III.
Obstetrics: Episiotomy
I.
II.
III.
34
I.
II.
III.
Incidence. Directly related to fetal size: >2500 g 0.15%; >4000 g 1.7%; >4500 g
10.0%.
Diagnosis. Suspect shoulder dystocia if there is reason to suspect macrosomia
(gestational diabetes, history of large infants, large maternal size, prolonged
gestation), or if second stage is prolonged. Consider C-section. In vaginal
deliveries, suspect dystocia if the head pulls back against the perineum after
delivery, and external rotation is difficult.
Management.
A.
Ensure adequate maternal anesthesia and cut a very generous
episiotomy.
B.
Attempt McRoberts maneuver. The mothers thighs are hyperflexed,
bringing her feet "to her ears." Have an assistant apply suprapubic
pressure. This causes the shoulder to move under the symphysis
pubis. Attempt delivery with gentle downward traction.
C.
Attempt the Woods screw maneuver. Gently rotate the posterior
shoulder by pushing on the posterior scapula until the shoulder passes
under the symphysis and can be delivered as the anterior shoulder.
D.
If this is unsuccessful, try delivering the posterior arm first and then
rotating the anterior shoulder into the oblique position for delivery.
E.
If all else fails, one may attempt deliberate fracture of the clavicle of
the impacted shoulder. The thumb and forefinger are used to push the
clavicle outward to avoid a pneumothorax. Although the fracture will
heal, damage to cervical nerve roots may occur and cause permanent
sequelae.
I.
Indications.
A.
B.
Maternal.
1.
Maternal diseases. Eclampsia or preeclampsia with noninducible cervix, diabetes mellitus (if macrosomic infant
precludes vaginal delivery), cardiac disease, cervical
cancer, active herpes genitalis. One double-blind clinical
trial showed that acyclovir suppression (400 mg PO TID)
given after 36 weeks of gestation significantly reduces the
need for cesarean section by preventing a herpetic
outbreak at term.
2.
35
3.
C.
D.
II.
Risks.
A.
B.
III.
I.
II.
III.
Etiology. Uterine atony accounts for most cases. Other causes include retained
placenta, cervical or vaginal tear, and coagulopathy.
IV.
Physical Exam.
36
A.
B.
V.
C.
D.
Management.
A.
B.
C.
D.
a.
b.
Uterine massage.
c.
d.
2.
3.
4.
5.
Prostaglandin F2 (Hemabate) IM or
intramyometrially 0.25 mg Q15 minutes up to
8 doses. Contraindicated if active cardiac,
renal, pulmonary, or hepatic disease.
Retained placenta or invasive placenta. Manual removal
of placenta, identify cleavage plain with intrauterine hand,
advance fingertips to separate. If can not identify
cleavage- probably invasive placenta and requires surgery.
Trauma. Identify laceration or hematoma and repair.
Consider uterine inversion and uterine rupture.
If cause is not identified or fails to respond to the above
measures, notify obstetric physicians, anesthesia, and
operating room personnel of potential need for surgical
intervention. Inform patient of the problem and what
measures are being taken to correct it. Get an appreciation
of her desires regarding further childbearing and
hysterectomy.
If uterine bleeding persists, surgery must be considered.
Packing or balloon tamponade (e.g., 24 French Foley with
70-80 cc water) is a temporary measure and is rarely
effective. Surgical alternatives include uterine artery and
hypogastric artery ligation. Hysterectomy is the treatment
of last resort when the patient desires future fertility but
may be preferred if sterility is desired.
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38