Dr.

Alis Uworld Notes For Step 2 CK

Ob
Pregnancy Tests

The Centers for Disease Control recommends that all pregnant women
without contraindications receive the influenza vaccination. The maternal
morbidity and mortality from influenza every year in pregnant women is
prevalent and preventable. The vaccine is recommended during flu
season and can be given in any trimester. Pregnant women often have
concerns about medications and vaccines in pregnancy; however, thousands
of women have been studied and there are no known fetal malformations
associated with this vaccine.
Quad Tests This test is done in the second trimester in order to detect
fetuses at an increased risk of Down syndrome, neural tube defects and
Edwards syndrome.

Alpha-fetoprotein (AFP) measurement can be used to screen for fetal

anomalies. Increased levels are seen in the presence of neural tube
defects, abdominal wall defects (gastroschisis. omphalocele),
multiple gestation and inaccurate gestational age.
Low levels of MSAFP can be associated with chromosomal anomalies, such
as Down syndrome and trisomy 18, and inaccurate gestational dates.
Ultrasonography should first be performed in the patient described to
rule out inaccurate dates as it is the most common cause of
abnormal AFP levels. Other tests can be done after the dates have been
confirmed by an ultrasound.

The most common cause of an abnormal maternal serum alpha-fetoprotein

(MSAFP) level is a gestational age error.

If dates are normal & still AFP is abnormal, next best step depends upon the
gestation age. Do Chorionnic Villous Sampling is gestational age is 12-14
week. Do Amniocentesis if gestational age is more than 15.

Pregnancy & Thyroid - Thyroid function during pregnancy is affected by

two separate mechanisms: an increase in thyroid binding globulin
(TBG) concentration and stimulation of the TSH receptor by chorionic
gonadotropin (hCG). An increase in circulating estrogen levels during
pregnancy leads to an increase in the production of TBG, which results in an
increase in the TBG-bound T3 and T4. As a result, elevated TBG leads to
increased total T4 and T3, whereas free T 4 and T3 remain normal.
TSH remains normal.

Pregnancy & Graves Disease - In many patients with Graves disease, the
circulating levels of thyroid stimulating immunoglobulin (TSI) remain as
high as 500 times the normal value for several months following
thyroidectomy. These lgG autoantibodies cross the placenta and can cause
thyrotoxicosis in the fetus and the neonate by directly stimulating the
fetal thyroid gland. Neonatal thyrotoxicosis is an uncommon clinical entity
characterized by goiter, tachypnea, tachycardia, cardiomegaly, restlessness,
diarrhea and poor weight gain in the infant typically within 1-2 days
following delivery.

Pregnancy & HSIL - During pregnancy the primary goal of colposcopy is

the exclusion of invasive cervical cancer. The management of any woman
with a cytologic specimen suggesting HSIL consists of colposcopy and
directed biopsy. Among women with HSIL cytology results, 1-2% harbor
invasive cancer. If the initial colposcopy & biopsy is negative, a
repeat colposcopy and biopsy should be done at 6-8 weeks after
delivery.
HSV & Labor Patients with herpes simplex virus (HSV) eruption on her
vulva - HSV eruptions manifest as painful lesions classically on the lips or
genital mucosa. Examination reveals solitary or grouped vesicles on an
erythematous base that evolve to shallow. "Punched-out" ulcerations or
erosions. The risk of neonatal HSV infection, which can be fatal, is drastically
increased if a normal vaginal delivery is done when the mother has an active
HSV eruption. Thus, the American College of Obstetrics and Gynecology
(ACOG) recommends caesarian delivery in all women who are in labor
with active genital HSV lesions. Do caesarian delivery even if no
cervical or vaginal lesions are present.

Pregnancy & DVT - Pregnancy is a major risk factor for deep venous vein
thrombosis, especially during the peripartum period. Femoral vein is a
deep vein. All the segments of femoral vein are considered deep veins. Deep
vein thromboses require anticoagulation with heparin.

Pregnancy & Renal Function - Renal plasma flow and glomerular filtration
rate are increased in pregnancy, which causes a decrease in the serum
BUN and creatinine from the patient's pre-pregnancy baseline. This
increase in renal function begins early in the first trimester, progresses
gradually until reaching 40% to 50% above the non-pregnant state by mid-
pregnancy, and remains unchanged until term.

Pregnancy & SLE - Hypertension in a pregnant female in the setting of

massive proteinuria. a malar rash, and a strongly positive ANA titer is most
likely due to systemic lupus erythematosus. Glomerulonephritis in general
will cause proteinuria, hematuria and RBC casts.

If the patient is known to have lupus before pregnancy, the appearance of

proteinuria during pregnancy may represent lupus nephritis, preeclampsia or
both. Signs that favor lupus as the origin of the proteinuria include a rapid
aggravation of the proteinuria, associated clinical signs of active SLE and the
presence of RBC casts in the urinalysis which indicates true nephritis
rather than simple protein loss. If the proteinuria persists after delivery, renal
biopsy is then indicated and will most likely be diagnostic of lupus nephritis.
SLE, however, rarely presents for the first time during pregnancy.

Pregnancy & Rheumatic Fever Pregnant young woman presents with

atrial fibrillation and symptoms of pulmonary edema, suggesting a diagnosis
of mitral stenosis. Rheumatic heart disease is the leading cause of mitral
stenosis worldwide. The consequence of untreated Streptococcus pyogenes
infection, rheumatic heart disease is most common in countries with limited
access to antibiotics. Affected women often become symptomatic during
pregnancy because of the physiologically increased total blood volume.
Pulmonary edema and atrial fibrillation may occur due to left atrial overload
and enlargement. Physical exam may reveal a diastolic rumble at the apex
and/or an opening snap.

Pregnancy & Syphilis It is recommended that all pregnant women be

screened for syphilis regardless of risk factors. Screening should be
performed at the first prenatal visit and is typically accomplished via the
rapid plasma reagin (RPR) or venereal disease research laboratory (VDRL)
test. When the screening test is positive, the diagnosis can be confirmed with
the fluorescent treponemal antibody absorption (FTA-ABS) test. Treatment is
with penicillin.

Any pregnant woman that has positive treponemal tests should be

considered infected with syphilis until proven otherwise.

Two to three weeks after infection with Treponema pallidum, patients

develop a painless papule at the site of inoculation. This papule
ulcerates, forming a chancre with punched-out base and raised. Indurated
margins, most lesions occur on the genitalia and are accompanied by
painless inguinal adenopathy. If left untreated, the chancre of primary
syphilis heals spontaneously within one to three months.

Serologic testing is used as a screening test for syphilis. and depends on

identification of antibodies to Treponema pallidum. Many patients with
primary syphilis have yet to form antibodies against the organism. Therefore,
serologic testing in primary syphilis results in a high rate of false-
negatives. Because of this, diagnosis of primary syphilis is best made via
spirochete identification on dark field microscopy
Untreated syphilis is associated with a very high prevalence of adverse fetal
outcomes (up to 80%) including stillbirth, neonatal death, and mental
retardation. Appropriate therapy should be promptly instituted. While
alternative antibiotics can sometimes be used in nonpregnant patients,
penicillin remains the drug of choice for the treatment of pregnant
patients with syphilis. In patients with penicillin allergy, it is first important
to verify that the patient truly has an allergy and not just an adverse
response. Skin testing can be used to confirm a true allergy. If the patient is
truly allergic, penicillin desensitization is recommended. It is typically
accomplished using incremental doses of oral penicillin V.

Vs

Like syphilis, Granuloma inguinale (Donovanosis) presents with

painless genital ulcers. These ulcers have a red, beefy base and there is
NO associated adenopathy. Unlike primary syphilis, the ulcer of granuloma
inguinale does not resolve without antibiotic treatment.

Pregnancy & HIV - The most important intervention for preventing spread
of HIV from mother to child is administration of zidovudine to the mother
throughout pregnancy and labor, as well as to the neonate for the
first 6 weeks of life. This intervention has been shown to decrease the rate
of transmission by 70%. The mother should also be counseled to not
breastfeed, as this increases the risk of transmission.

Pregnancy & GBS - Streptococcus agalactiae or Group B streptococcus

(GBS) is an important cause of infections in pregnant women, neonates and
young infants. It is a common colonizing organism in the human
gastrointestinal and genital tracts and maternal colonization increases the
risk of offspring developing GBS infections following birth. To decrease this
risk, all pregnant women are screened for colonization with vaginal and
rectal swabs at 35-37 weeks gestation or 2-3 weeks before delivery.
Women colonized with GBS receive prophylactic antibiotics (penicillin or
ampicillin) at the time of delivery. Women who have had GBS bacteriuria
during pregnancy or who have previously delivered a child that developed
an early-onset GBS infection are automatically given prophylactic antibiotics
regardless of the results of a rectovaginal culture.

Patients with preterm premature rupture of the membranes (PPROM) whose

group B streptococcus status is unknown should receive antibiotic
prophylaxis. If a woman is admitted to the hospital after 34 weeks
gestation with PPROM, delivery is usually recommended. Risks associated
with prematurity are diminished after this gestational age and complications
are higher with continued expectant management.
Pregnancy & Hirsuitism/Virilization

Solid ovarian tumors (viewed by ultrasonography) are almost always

malignant and demand immediate and, aggressive evaluation and treatment
in all age groups, except in pregnancy.

Pregnancy luteoma usually appears as bilateral, multinodular, solid

masses on both ovaries. It is characterized by replacement of the normal
ovarian parenchyma by solid proliferation of luteinized stromal cells under
the influence of human chorionic gonadotropin (HCG). Pregnancy luteoma is
most commonly seen in African-American multiparous women in their 30's or
40's. It is often asymptomatic, but 1/3 of patients develop symptoms of
hirsutism and virilization. It is a benign self-limited condition and requires no
treatment. Reassurance and follow-up with ultrasonogram is the
recommended course.
Pregnancy & Exercise - Exercise is encouraged during normal,
uncomplicated pregnancies. The intensity and duration of exercise that is
advisable during pregnancy depends at least in part on the individual
mothers pre-pregnancy exercise tolerance and routine. Mothers are allowed
to continue their prepregnancy exercise routines. Recommendations
from the American College of Obstetrics and Gynecology state that mothers
should attempt 30 minutes of exercise on most days at an intensity that does
not exceed a 12-14 on a 20 point scale. A more useful measure of
appropriate intensity is to inform the mother that she should be able to carry
on a conversation throughout her exercise routine. If she cannot, then the
intensity of her exercise is too great.

Benign Bilateral Edema of Pregnancy - Benign edema of pregnancy, Leg

cramps and mild leg edema are very common and occur in about one-third of
normal pregnancies. Symptomatic deep venous thrombosis (DVT) typically
presents with some combination of fever, unilateral leg pain, swelling,
redness and calf tenderness. Even though the presentation of DVT can
vary, bilateral edema (especially in a pregnant female) is most likely the
result of benign edema of pregnancy, rather than a DVT. Preeclampsia may
also present with bilateral leg edema, but the absence of hypertension or
proteinuria makes preeclampsia unlikely. Therefore, these patients can be
reassured and scheduled for routine follow-up.

Pregnancy & HTN - An increase in blood pressure that appears before 20-
weeks gestation is due to either chronic hypertension or a hydatidiform
mole.

Pregnancy & Low Back Pain - It is a very common problem in the 3rd
trimester that is mechanical in nature. The pain is minimal in the
morning, but increases at the end of the day. The main cause of this
pain is believed to be the increase in lumbar lordosis. In addition,
relaxation of the ligaments supporting the sacroiliac and other joints of the
pelvic girdle due to hormonal factors may contribute to the problem.

Pregnancy & Carpel Tunnel Syndrome - These patient presents with

paresthesias in the distribution of the median nerve, making carpal tunnel
syndrome (CTS), a median nerve compression neuropathy, the most likely
diagnosis. CTS symptoms are worsened by manual activity and often
wake the patient from sleep. Repetitive wrist flexion and extension is the
usual cause of CTS. The incidence is increased in pregnancy secondary to an
estrogen-mediated
depolymerization of ground substance, which causes interstitial edema in the
hands (and face) and thus increased pressure within the carpal tunnel.
Prolonged or repetitive wrist flexion and extension also increase carpal
tunnel pressure. Therefore, the initial treatment is a neutral position
wrist splint.

When splinting and analgesics fail to relieve CTS symptoms, direct injection
of corticosteroids into the carpal tunnel may help.

For CTS symptoms resistant to conservative interventions, or if hand

weakness and thenar muscle atrophy progresses, then open or endoscopic
surgical decompression of the carpal tunnel is indicated.

Pseudocyesis -This is an uncommon condition in which a woman presents

with many signs and symptoms of pregnancy such as amenorrhea,
enlargement of the breasts and abdomen, morning sickness, weight
gain, sensation of fetal movement and reported positive urine
pregnancy test per the patient. Ultrasound, however, will reveal a
normal endometrial stripe and the pregnancy test in office will be
negative. Pseudocyesis is usually seen in women who have a strong desire
to become pregnant. It has been suggested that the depression caused by
this need is behind the occurrence of some hormonal changes mimicking
those of pregnancy. This is a form of conversion disorder, and management
requires psychiatric evaluation and treatment.

Gestational Diabetes Diagnosing and appropriately treating gestational

diabetes is important as pregnancies in the setting of uncontrolled disease
are at increased risk of miscarriage, abnormally large size, congenital
malformations, preterm birth, pyelonephritis, preeclampsia, meconium
aspiration and stillbirth.

Screening for gestational diabetes should be performed in all pregnant

women. In high-risk women it is done at the first prenatal visit; in all other
patients it is done between the 24th and 28th weeks of gestation. The one
hour 50 gram oral glucose tolerance test ( OGTT) is used as the
initial screening test. After one hour, if the blood glucose value is less
than 140 mg/d, gestational diabetes is ruled out.

If the blood glucose value is > 140 mg/dL, a three hour 100 gram OGTT is
then performed. Gestational diabetes is diagnosed if two or more of the
serum glucose values obtained during the three hour test are elevated above
the values listed below:

Fasting serum glucose concentration >95 mg/dl

One-hour serum glucose concentration > 180 mg/dl
Two-hour serum glucose concentration > 155 mg/dl
Three-hour serum glucose concentration > 140 mg/dl

Once diagnosed, the patients should be first asked to do a trial of life style
modification with diet & exercise. If this fails to decrease the fasting blood
glucose lever to the ideal range, medical treatment should be started. The
ideal range of maternal fasting glucose is between 75 and 90 mg/dl.
Treatment of gestational diabetes is best accomplished with subcutaneous
insulin, which is classified as a category B agent and does not cross the
placenta.

Gestational diabetes carries numerous risks for the fetus including

macrosomia, hypocalcemia,
Hypoglycemia, hyperviscosity due to polycythemia, respiratory
difficulties, cardiomyopathy and congestive heart failure.
Polycythemia in an infant of a diabetic mother is the result of fetal hypoxia
that occurs in the face of the increased basal metabolic rate induced by
hyperglycemia. Increased erythropoietin production by the fetus increases
the red blood cell mass and oxygen carrying capacity of the blood.

Asymptomatic Bacteriuria - A positive urine culture (> 100,000 colony-

forming units per ml of a single organism in a midstream, clean catch urine
sample) confirms the diagnosis. Pregnancy is a risk factor for developing
urinary tract infections due to stasis of urine, owing to compression by the
enlarging uterus, as well as smooth muscle relaxation caused by
progesterone. Asymptomatic Bacteriuria, if untreated, may progress to
pyelonephritis in 30-40% cases. Pyelonephritis may cause septicemia,
preterm labor and low birth weight babies; hence, it is very important to
detect and treat asymptomatic bacteriuria or an overt urine infection in
pregnancy. Amoxicillin, ampicillin, nitrofurantoin and cephalexin for 7
days are commonly used to treat the patients.
Intrahepatic Cholestasis of Pregnancy - Intrahepatic cholestasis of
pregnancy (ICP) is a functional disorder of bile formation that develops in the
second and third trimesters of pregnancy. The condition is characterized by
intense pruritus and increased serum bile acid concentrations.
Incidence ranges from 0.2-4% and is highest among those individuals from
Bolivia or Chile. The etiology is unclear, but it is thought that genetic and
hormonal factors (eg, higher levels of estrogen or progesterone) influence
the development of ICP.

Clinical manifestations of ICP include intense, often intolerable

generalized pruritus that is especially significant on the palms and soles
and worsens at night. Evidence of skin excorations may be present.
Jaundice exists in 10-20% of patients. On laboratory evaluation, serum total
bile acids are typically increased and may be the only finding.

Liver function studies are sometimes suggestive of cholestasis, with

alkaline phosphatase and the total and direct bilirubin increased,
GGTP is usually either normal or only mildly elevated. Serum
aminotransferases may be quite high (sometimes> 1000 U/L), which
requires the ruling out of viral hepatitis.

The diagnosis of ICP is indeed one of exclusion. It is founded on the presence

of pruritus and elevated levels of serum bile acids and/or aminotransferases
in the absence of other diseases that could cause such findings.

Treatment is based on symptom relief and preventing complications in the

mother and fetus. Ursodeoxycholic acid is most promising, as it increases
bile flow and can relieve pruritus. Hydroxyzine and cholestyramine are
alternative therapies, though they appear to be less effective and can have
concerning side effects.

The maternal prognosis of those with ICP is good, as the condition resolves
shortly after delivery. There are no hepatic sequelae. ICP may recur in
subsequent pregnancies, and affected women are also at increased risk of
developing gallstones.

Intrahepatic cholestasis of pregnancy poses more danger to the fetus than to

the mother, as fetal prematurity, meconium-stained amniotic fluid, and
intrauterine demise are all known complications. Therefore, the preferred
approach in managing the pregnancies of women with ICP includes an early
delivery once fetal lung maturity is established.

Ectopic Pregnancy Ectopic pregnancy should be suspected in any patient

of childbearing age, presenting with a triad of amenorrhea, abdominal
pain and vaginal bleeding. In all cases of secondary amenorrhea,
administering a pregnancy test should be the first diagnostic step.

Transabdominal ultrasound cannot reliably visualize gestational sacs when

beta-HCG levels are below 6,500 IU/L, whereas transvaginal ultrasound
can demonstrate an intrauterine gestational sac when the beta-HCG is as low
as 1500 IU/L (sometimes even at 800 IU/L). Therefore, transvaginal
ultrasound is the test of choice for diagnosis of ectopic pregnancy at
beta-HCG levels of 1,500-6.500 IU/L.

If transvaginal ultrasound reveals an intrauterine sac in the setting of a

positive beta-HCG, then ectopic pregnancy is virtually ruled out. If
transvaginal ultrasound reveals an adnexal sac and no intrauterine sac in
this setting, then ectopic pregnancy is confirmed. If transvaginal ultrasound
fails to reveal an intrauterine or adnexal sac in this setting, then serial beta-
HCG measurements are necessary to rule in or out ectopic pregnancy (a
doubling of beta-HCG every 48 hours suggests a normal pregnancy, and a
slower rise in beta-HCG suggests an abnormal pregnancy).

An intrauterine pregnancy should be seen with transvaginal ultrasonography

at B-HCG levels of 1,500-2,000 miU/mL. If the level is < 1,000 miU/ml,
both B-HCG and transvaginal ultrasonography should be repeated in
2- 3 days.

Although laparoscopy is extremely accurate, it is a last resort in diagnosing

ectopic pregnancy.

Vs

Midcycle pain (Mittelschmerz) is common in women with regular

menstrual periods who are not taking birth control pills (i.e. women who
are ovulating). This pain is the result of ovulation itself, and as such tends
to occur about two weeks after the start of the last menstrual period.
Midcycle pain often lateralizes to the ovary that produced a mature ovum, so
it can be unilateral. The timing of these symptoms with regards to the
menstrual cycle and the absence of other worrisome physical examination
findings including fever help narrow the differential diagnosis.

Vs

Ovarian torsion is a medical emergency. Patients present with sudden-

onset lower quadrant abdominal pain that radiates to the groin or back
and is accompanied by nausea and vomiting. An adnexal mass is usually
present.

Abortion is a very controversial issue. Some physicians are willing to

perform the procedure and some are not. The American Medical Association
has recognized this and suggests that physicians be permitted to refuse a
patient's request to perform an elective abortion. The appropriate course of
action when a physician refuses to perform an abortion would be to refer
the patient to another physician who would be willing to perform the
procedure.

Spontaneous Abortion It is defined as fetal demise before the 20th

week of gestation and with a fetus weighing less than 500 grams. There
are numerous forms of spontaneous abortion.

Threatened abortion is characterized by any hemorrhage occurring before

the 20th week of gestation with a live fetus and a closed cervix.

The first step in a threatened abortion is to ascertain that the fetus is present
and alive. Once this is confirmed with ultrasound, management is
essentially reassurance and performance of an ultrasonogram one
week later. Bed rest and abstaining from sexual intercourse are usually
recommended because this will prevent any feelings of guilt on the part of
the parents in the case that pregnancy is actually lost; however, there is no
evidence of the benefit of these interventions on the outcome. Just because
there is bleeding per vagina doesnt mean you hospitalize the patient.
Nothing can be done in case of threatened abortion. So reassure & send
them home!

Missed abortion is characterized by fetal demise with retained products of

conception (fetus. placenta. etc.) and a closed cervix. Characteristically,
patients with a missed abortion will experience a loss of their pregnancy
symptoms (i.e. decreased nausea and breast tenderness) and some brown
discharge may be noted following fetal demise. The most appropriate next
step in making the diagnosis of a spontaneous abortion is a transvaginal
ultrasound to document the presence of intrauterine products of conception
and to attempt to visualize motion of the fetal heart.

Inevitable or Incomplete abortion is clinically characterized by rupture of

the gestational sac resulting in leakage of amniotic fluid from the vagina
accompanied by abdominal pain, uterine contractions and possibly bleeding.
Physical examination shows a dilated cervix and the products of conception
can be seen through it. Suction curettage is the treatment of choice in
inevitable abortion because the pregnancy cannot be maintained and, as in
this case, the fetus is typically expired.

Complete abortion is a form of spontaneous abortion where the whole

conceptus passes through the cervix. The cervix then closes, and the
associated pain and uterine contractions subside. Ultrasonography shows an
empty uterus.

Septic abortion can result from infection of retained products of

conception in the case of missed, incomplete, inevitable or elective
abortions. This condition is clinically characterized by fever, chills,
abdominal pain and a bloody I purulent vaginal discharge.
Examination shows lower abdominal tenderness and an enlarged, tender
uterus with a dilated cervix. Septic abortion is a medical emergency. Broad
spectrum antibiotics are given immediately after obtaining the
blood and cervical/ endometrial cultures. Immediate surgical
evacuation of the uterine contents is then required in order to remove
the infectious nidus. This is best done with gentle suction curettage.
Vigorous curettage should be avoided because of the risk of uterine
perforation.

Quantitative beta-HCG measurement can continue to be elevated

following a spontaneous abortion with retained products of
conception.

The most appropriate treatment for a missed abortion is removal of the

POC from the uterus. This can be accomplished surgically with dilation
and curettage, medically with vaginal misoprostol or expectantly with serial
imaging to ensure complete natural expulsion of the POC.

Oxytocin infusion would stimulate uterine contractions and likely expel the
retained fetus, but this can more readily be accomplished with vaginal
misoprostol without systemic effects and the additional invasiveness of an
intravenous catheter.

For all types of abortion, anti-D gamma globulin (RhoGAM) must be

administered to Rh-negative women who do not have anti-Rh antibodies.
Counseling sessions to give reassurance and to answer questions the couple
may have should always be considered.

Intrauterine Fetal Demise (IUFD) defined as the intrauterine death of a

fetus beyond 20 weeks gestational age. FetaI demise occurring before 20
weeks gestational age or death of a fetus weighing less than 500g is referred
to as a spontaneous abortion. Symptoms of IUFD are typically few; a
decreased sensation of fetal movement is the most common presenting
complaint.

The diagnosis is made by ultrasound when fetal heart movement cannot be

documented. FetaI heart tones will also be absent on Doppler studies.

The management of IUFD in a singleton pregnancy is prompt delivery of

the fetus and remaining products of conception. Retained products of
conception can result in hypofibrinogenemia and coagulopathy. If the
patient's fibrinogen level is above normal limits, no emergent procedure is
necessary. It is low fibrinogen and low platelets that cause concern for DIC.
The best next step in management is a discussion of the patients
options for therapy (Vaginal vs C Section) and the risks and benefits
associated with each option.

A fibrinogen and platelet levels in the low-normal range can indicate

developing DIC. This calls for a prompt induction of labor!

Hyperemesis gravidarum is a severe form of vomiting that complicates

approximately 1% of pregnancies. In hyperemesis gravidarum, vomiting
usually begins between weeks 4 and 10. While hyperemesis gravidarum can
be managed successfully with supportive therapy (fluids and nutrition) and
generally resolves on its own by mid-pregnancy, other causes of severe
vomiting during pregnancy must be considered. Gestational trophoblastic
disease (hydatidiform mole and choriocarcinoma) is one disease to consider
in such cases. The classical clinical triad for a hydatidiform mole is: enlarged
uterus, hyperemesis, and markedly elevated beta HCG (> 100,000). Thus,
measurement of quantitative beta HCG is an appropriate initial
diagnostic step in the evaluation of severe vomiting during pregnancy. If
the beta HCG level is markedly elevated an ultrasonogram should then be
performed.
1st trimester pregnancy + Nausea + Vomiting + Dehydration (dry
mucus membranes, decreased skin turgor) + orthostatic HTN =
Hyperemesis Gravidum!

Mild increase in ALT, AST, bilirubin, amylase, and lipase are seen in up to
50% of hospitalized patients. Elevated amylase and lipase are from salivary
gland due to vomiting. So ignore these.

Some patients may also have ketones in the urine. This may be due to either
starvation (you dont eat a lot when you are vomiting a lot) or Diabetic
ketoacidosis. DKA presents with an anion gap metabolic acidosis with
LOW bicarbonates while Hyperemesis Gravidum presents with
Hypochloremic metabolic alkylosis with HIGH bicarbonates. Elevated
bicarbonate levels suggest alkalosis from vomiting.

Abruptio placentae is a premature placental separation initiated by

hemorrhage in the decidua basalis. It is one of the most common causes of
antepartum hemorrhage. The diagnosis is mainly clinical although the
symptoms may vary. The most common clinical finding is dark red, third
trimester vaginal bleeding, which is found in 80% of cases. This bleeding
can be concealed in 20% of cases. A concealed hemorrhage may delay
the diagnosis of placental abruption and expose the patient and the fetus to
serious complications including coagulopathy, shock and death. Therefore,
the physician should keep a high index of suspicion for this condition in
patients in their third trimester presenting with uterine tenderness,
hyperactivity, and increased uterine tone as these may be the only
symptoms of abruption. Ultrasonography detects as few as 25% of all
placental abruptions. The role of ultrasound in the evaluation of antepartum
hemorrhage is primarily to rule out placenta previa and not to diagnose
abruptio placentae. Risk factors for abruptio placentae are:

Maternal hypertension and pre-eclampsia (Most common)

Placental abruption in a previous pregnancy
Trauma
Rapid decompression of a hydramnios
Short umbilical cord
Tobacco use and cocaine abuse
Folate deficiency

Inducing labor and opting for vaginal delivery may be used in cases
where labor is in an advanced stage.
Cesarean section is used in the management of placental abruption when
there are obstetrical indications, or when there is a rapid deterioration of
the state of either the mother (hypotension) or the fetus (variable
decelerations) and labor is in an early stage such that vaginal delivery is not
emergently possible.

VS

Uterine Rupture Typically, uterine rupture presents with Intense

abdominal pain associated with vaginal bleeding which can range from
spotting to massive hemorrhage. After the rupture occurs, the patient may
feel slightly relieved, but soon after, the pain returns in a more diffuse
fashion. The presenting part may retract and no longer be palpable on
pelvic exam, whereas the fetal limbs can become easily palpable on
abdominal examination. The clinical presentation is, however, highly
variable, so a high index of suspicion is required because any delay in
diagnosis may be fatal for both the mother and the fetus. Look for loss of
station & abnormal contour of the abdomen.

The chance of uterine rupture after a prior low transverse cesarean

section is less than 1%. If the patient had history of a prior classical
(vertical) uterine scar, the risk of rupture could have been as high as 9%.

Uterine rupture can be difficult to distinguish from abruptio placenta,

especially because they can both be caused by trauma.

Vasa Previa - Ruptured fetal umbilical vessel: an antepartum hemorrhage

that immediately occurs after amniotomy with very characteristic fetal heart
changes progressing from tachycardia to bradycardia to a sinusoidal pattern.
If fetal bleeding is suspected. an Apttest- which differentiates maternal from
fetal blood - can be performed to confirm the diagnosis.

Vasa previa is a rare condition in which the fetal blood vessels traverse the
fetal membranes across the lower segment of the uterus between the baby
and the internal cervical os (velamentous cord insertion). These vessels are
vulnerable to tearing during natural or artificial rupture of the membranes.
The condition carries a high fetal mortality rate (75%) due to fetal
exsanguinations, when this condition is diagnosed, the treatment is an
immediate caesarian section delivery ("crash C-section").

Preeclampsia
Mild Preeclampsia - Mild preeclampsia is defined clinically by hypertension
greater than 140/90 mmHg and proteinuria greater than 0.3g/24h
(300mg/24h) after the 20th week of gestation.

Severe preeclampsia is defined as a BP greater or equal to 160/110 and

the presence of one or more of the following signs:

1. Oliguria ( < 500mU24hr)

2. Altered consciousness, headache, scotoma or blurred vision
3. Pulmonary edema or cyanosis
4. Epigastric or right upper quadrant pain
5. Significant thrombocytopenia
6. Microangiopathic hemolysis
7. Altered liver function tests
8. Elevated serum creatinine levels
9. IUGR, or oligohydramnios.

Patients with severe preeclampsia are at greater risk of developing

eclampsia. However, 25% of eclamptic patients have a background of only
mild disease. In eclampsia, cerebral vasospasm results in cerebral
hypoxemia and generalized tonic-clonic seizures. 25% of cases of eclampsia
occur before labor, 50% occur during labor and 25% occur following delivery.
Increased reflex irritability is a worrisome sign in patients with preeclampsia
and it usually heralds the occurrence of seizures

Preeclampsia Management

The most effective treatment of preeclampsia and eclampsia is

delivery and evacuation of the placenta. However, many times delivery
cannot be performed because the pregnancy is far from term and the fetal
lungs have not yet matured.

In mild preeclampsia, if the pregnancy is at term and/or fetal lung

maturity is ascertained, delivery should be undertaken.

If the pregnancy is not at term and/or the fetal lungs are not yet mature,
then the patient is managed with bed rest and close observation.
Hypertension usually responds to these measures, but methyldopa can be
used to treat sustained blood pressures in excess of 160/110.
Dexamethasone administration between the 24th and 34th weeks of
gestation to accelerate lung maturity should be considered. Once the fetal
lungs are deemed mature, delivery should be carried out

Magnesium sulfate is used for the prevention of ecclamptic seizures. In

mild preeclampsia, it is administered during labor and within 24 hours of
delivery. In patients with severe disease, it is administered from the time of
admission and carried on until 24 hours after delivery.

Magnesium sulfate toxicity - neurologic exam performed in these patient

shows depressed deep tendon reflexes, which is the earliest sign of
magnesium sulfate toxicity. Magnesium causes toxicity by acting as a CNS
depressant and by blocking neuromuscular transmission. It is very important
for patients on magnesium sulfate to be closely observed with regular
examination of their deep tendon reflexes. The second sign of toxicity is
respiratory depression. The treatment of magnesium sulfate toxicity is
immediate discontinuation of the infusion and administration of calcium
gluconate.

Eclampsia - It is defined as all of the symptoms of preeclampsia as well as

seizures. The treatment of eclampsia is immediate termination of the
pregnancy in a fashion that will result in the lowest possible morbidity for
the mother and the fetus. This may include induction of labor or a
caesarian delivery. Other treatments are used to control the symptoms of
eclampsia until delivery can be accomplished. These include agents such as
hydralazine and labetalol to control hypertension (diuretics should be
avoided as they can decrease placental perfusion) and magnesium sulfate to
prevent the occurrence of further seizures.

The most effective agent used for the treatment and prevention of seizures
in eclampsia is magnesium sulfate. Lorazepam and phenytoin are more
useful in status epilepticus. Bottom line, management of eclampsia is
Mag Sulfate. Dont bother about anti epileptics.

Chronic hypertension in pregnancy implies hypertension that is not

pregnancy induced such as essential hypertension. It is diagnosed when
hypertension exists prior to pregnancy or when it appears before the
20th week of gestation. If proteinuria appears during the course of
pregnancy, the condition is then called chronic hypertension with
superimposed preeclampsia.

Methyldopa & Labetalol are the first-line medication for treatment of

hypertension in pregnancy.

Transient hypertension occurs in the second half of pregnancy or during

labor and delivery.
Proteinuria may be present but does not exceed 300mg/24hr. If at some
point the proteinuria exceeds 300mg/24hr, the diagnosis of preeclampsia is
made.

HELLP Syndrome - The work up reveals a thrombocytopenia,

microangiopathic hemolytic anemia (MAHA) as evidenced by the increase
in indirect bilirubin level and the presence of red blood cell fragments
on blood smear and elevated liver enzymes. These findings along with
evidence of preeclampsia are indicative of the HELLP syndrome (Hemolysis,
Elevated Liver enzymes, Low Platelet count). Right upper quadrant pain is
typical of this condition due to distention of the hepatic (Glisson's)
capsule.

Vs

Acute fatty liver of pregnancy (AFLP) - Acute fatty liver of pregnancy is a

complication of the third trimester of pregnancy. Patients are sometimes
asymptomatic, but may also complain of severe nausea, malaise, headache,
and abdominal pain. Over half of patients also have preeclampsia, and 60%
will develop acute renal failure. This condition can also cause a prolonged
PT & PTT and moderate to severe elevation of transaminase levels.
Histologically, acute fatty liver of pregnancy is characterized by
microvesicular fat deposition in the hepatocytes without evidence of
inflammation or necrosis.

Vs

Hemolytic uremic syndrome (HUS) also causes thrombocytopenia and

hemolytic anemia. As in HELLP syndrome, both PT and PTT are normal;
however. HUS also usually results in renal failure and not necessarily
associated with preeclampsia

HELLP Management -

Delivery is the definitive treatment of HELLP syndrome in women

beyond 34 weeks gestation, when fetal lungs are mature, or in the
presence of signs of fetal or maternal deterioration. For pregnancies less
than 34 weeks gestation, in which fetal lung maturity has not yet been
reached, management should depend on the state of both the mother and
fetus. Any deterioration requires stabilization and delivery, but if fetal well-
being is ascertained and the mother is stabilized, the dexamethasone
treatment should be considered and delivery should be performed when the
pregnancy reaches 34 weeks gestation or as soon as the fetal lungs become
mature.

When delivery is performed, mild coagulation disturbances correct

spontaneously. Platelet transfusions are indicated only when the
coagulopathy is in an advanced stage.

Preterm labor is defined as labor occurring after 20 weeks gestation and

before 37 weeks gestation. Labor in this case requires the occurrence of
documented uterine contractions at a rate of 4 per 20 minutes or more and
documented cervical changes consistent with labor. Respiratory distress
syndrome (RDS) is a common complication in preterm infants as fetal lung
maturity has not yet been reached. Other complications of preterm birth
include intraventricular hemorrhage, sepsis, necrotizing enterocolitis
and kernicterus. The mortality rate in preterm infants is greatly influenced
by the gestational age.

The management of acute preterm labor is dependent on the gestational age

of the fetus and the presence or absence of comorbidities that pose extreme
risk to the mother and fetus that would mandate a delivery regardless of
dates. In otherwise normal pregnancies, systemic corticosteroids are
administered when the gestational age is between 24 and 34 weeks. This
decreases the risk of neonatal respiratory distress. Tocolysis should then
be attempted with the goal being to maintain the pregnancy for at
least 48 hours in order to realize maximum benefit from the
steroids. Bed rest and tocolysis are continued as long as possible with a
long-term goal of reaching 34-36 weeks gestational age.

Prolonged (postterm) pregnancy is defined as any pregnancy at or

beyond 42 weeks gestational age measured from the last menstrual
period. Post term pregnancy can be managed with either induction of
labor or close twice weekly assessment of fetal well being. Patients with
an unfavorable cervix are typically managed expectantly while those with a
favorable cervix are managed with induction. Twice weekly monitoring with
ultrasonography is required to evaluate for oligohydramnios in postterm
pregnancies because amniotic fluid can become drastically reduced
within 24 to 48 hours. Oligohydramnios in these cases is defined as no
vertical pocket of amniotic fluid greater than 2 cm or an amniotic fluid index
of 5 cm or less.
Blood Groups - The four common blood types are 0. A. B. and AB. Patients
missing a blood type have antibodies to the missing antigens as shown
below.

A mother with blood group O and a father with blood group AB will have a
child with either blood group A or blood group B (both differ from the
mother's blood group). Hemolytic disease of the newborn (HDN) is mainly
seen in a group O mother who has a group A or B baby. The A and B antigens
are antigenic and cause the mother to form lgG antibodies to A or B that can
cross the placenta (can also form some lgM antibodies to the A antigen and
other minor antigens). Only the lgG antibodies can cross the placenta, but
varying titer levels result in HDN, which is mild in most patients, with
neonatal jaundice successfully treated with phototherapy. However, the titers
can be higher in certain populations (e.g .. Africans and African Americans)
and lead to more severe HDN.

ABO incompatibility reactions can occur in the first pregnancy because both
A and B antigens are found in food and bacteria in the environment. These
antigens can induce various degrees of antibody production in group O
individuals. In contrast, Rh(D) alloimmunization reactions typically occur in
the second pregnancy onwards, with greater severity. Also, Rh(D) antibodies
are typically all lgG at higher titers that cross the placenta and cause more
significant disease.
Exposure during the first pregnancy is usually required before causing
disease in the second pregnancy. This patient has low risk of
alloimmunization because both she and her husband are Rh(D)+.

Prevention of Rh Alloimmunization - Mothers who are Rh (D) negative

with an Rh (D) positive fetus may develop a strong immune response to the
Rh (D) antigen and ultimately cause fetal demise. Patients can develop
maternal alloimmunization from transplacental fetomaternal
hemorrhage during any pregnancy, needle contamination with Rh (D)
positive blood, and transfusion with Rh (D) positive blood. Transplacental
fetomaternal bleeding is the most common cause of maternal Rh (D)
alloimmunization and can also happen in miscarriage, abortion, ectopic
pregnancy, fetal death, and maternal abdominal trauma.
Current guidelines recommend Rh-blood typing and testing for Rh antibodies
at the first prenatal visit, as well as repeat Rh antibody testing at 28
weeks in unsensitized women with Rh (D) positive or Rh-unknown partners
to check for possible maternal alloimmunization during the pregnancy.
Patients who remain Rh (D) negative should then be treated with anti-D lg if
the fetus blood type is unknown or known to be Rh (D) positive.

Placental abruption is an event associated with excessive feto-maternal

hemorrhage; therefore. The presence and the amount of feto-maternal
transfusion should be determined. The qualitative test that helps to
determine the presence of feto-maternal hemorrhage is the rosette test. If
negative, the standard dose of anti-D immune globulin should be
administered. If positive, the amount of hemorrhage can be evaluated
using Kleihauer-Betke stain or fetal red cell stain using flow cytometry; the
dose of anti-D immune globulin should be corrected
accordingly.

Administration of anti-D gamma globulin (RhoGAM) prevents

isoimmunization by binding the D antigens on fetal blood in the maternal
circulation, thereby preventing the mother's immune system from reacting to
them. If a mother is not sensitized, anti-D immunoglobulin is indicated. If a
mother is already sensitized (antibody titers more than 1: 6),
administration of Rho GAM is not helpful and close fetal monitoring for
hemolytic disease is required. The critical antibody titers that put a fetus at
risk for hemolytic disease are usually between 1:8 and 1:32. But vary with
institution (frequently 1: 16 is cited as critical). A titer of 1:4 indicates that
the solution can be diluted 4 times and the antibodies are undetectable.
Thus, a titer of 1 :4 has fewer antibodies present than a titer of 1: 16
because the 1: 16 dilution has to be diluted 16 times in order to have the
antibody reach near undetectable levels.

True Vs False Labor

True Labor - True labor is characterized by contractions that occur at

regular intervals with a progressively shortening interval and increasing
intensity. The pain in true labor occurs in the back and upper abdomen
and is not relieved by sedation. Cervical changes are typically
observed.

False Labor - False labor usually occurs in the last 4- 8 weeks of pregnancy.
It is important to differentiate false labor from true labor. In false labor,
contractions are felt in the lower abdomen, are irregular, occur at an
interval that does not shorten and do not increase in intensity. In the last
month of pregnancy, patients may experience contractions that become
rhythmic, occurring every 10 to 20 minutes, and contractions of greater
intensity, mimicking more closely the contractions of actual labor. In all cases
of false labor, however, contractions are NOT accompanied by progressive
cervical changes and are usually relieved by sedation. All such patients
need reassurance.

Epidural Anesthesia Side Effects - One of the side effects of epidural

anesthesia is urinary retention caused by bladder denervation. Since the
anesthetic blocks both afferents and efferents from the bladder, the patient
fails to sense a full bladder and is unable to void voluntarily. The hypotonic
bladder gradually overdistends. When the bladder pressure rises above the
urethral pressure, urine is lost until the pressure equalizes, and the cycle is
repeated again. This incontinence is only transient and lasts until the effect
of the anesthetic wears off and the bladder regains normal function. Physical
examination may reveal a distended bladder. Postvoid residual urine
volumes are high. Treatment is by intermittent "in-and-out"
catheterizations until the patient is able to void on her own.

Hypotension complicates up to 10% of epidural blocks given during labor,

but if considered early, can be easily prevented and treated. The cause of
hypotension is sympathetic fiber block that results in vasodilatation of the
lower extremity vessels. Blood redistribution to the lower extremities and
venous pooling occur. Cardiac output decreases and hypotension results.

Fetal growth restriction (FGR) may be symmetrical and asymmetrical.

In symmetrical growth restriction, the insult to the fetus occurs before 28
weeks gestation and growth of both the head and the body is deficient.
Symmetric FGR is typically the result of fetal defects such as genetic
anomalies or early congenital infections (TORCH).
Asymmetric FGR results from insults occurring after 28 weeks because of
MATERNAL factors and is characterized by a normal or almost normal
head size and a reduced abdominal circumference.

FGR is suspected when fundal height is at least three cms less than
the actual gestational age in weeks, and confirmation of FGR is
subsequently obtained by ultrasonography. Abdominal circumference is
the most reliable index for estimation of fetal size because it is affected in
both symmetric and asymmetric fetal growth restriction.

Smoking is the single most prevalent preventable cause of FGR in

the United States. One in three cases of FGR is attributable to smoking,
and women who smoke while pregnant have a three to four-fold increased
risk of having a growth restricted infant.

Sheehans Syndrome - These patients have a severe postpartum

hemorrhage and are unable to lactate several days after delivery. This is
concerning for Sheehans syndrome. Under normal conditions, the
postpartum fall in estrogen and progesterone combine with nipple
stimulation by a suckling child to increase prolactin concentrations and
promote lactation. However, women who have massive postpartum
hemorrhage may develop anterior pituitary necrosis or Sheehans syndrome.
due to pituitary hypoperfusion. Hormones secreted from the anterior
pituitary include prolactin, thyroid stimulating hormone (TSH), and follicle
stimulating hormone
(FSH). Failure of lactation due to prolactin deficiency is the classic initial
presentation of Sheehans syndrome. Other complications resulting from
anterior pituitary failure include hypothyroidism, amenorrhea, genital
atrophy, loss of pubic and axillary hair and fatigue.

Prenatal Diagnostic Testing

Nuchal Translucency Measurement This is an ultrasound test that done

between 10 14 weeks. A thickened NT suggests aneuploidy & cardiac
defects. Next step is to do a CVS.

Chorionic villus sampling (CVS) is a technique that involves aspiration of

a small quantity of chorionic villi from the placenta. It can be done between
10 and 12 weeks of gestation thus offering the advantage of an early
diagnosis. These fetus-derived cells are then karyotyped and subjected to
fluorescence in situ hybridization (FISH) studies to detect aneuploidies.
Enzymatic deficiencies and specific known defects can also be screened for
using the sample obtained with CVS. CVS sampling is indicated in women
over 35 years following an abnormal ultrasound. This is because serum
screening does not provide a confirmatory diagnosis and is unable to indicate
a risk that is any greater than the risk of trisomy based solely on the
patients advanced age. The risk of complications is slightly higher than in
amniocentesis.

The procedure can be carried out transabdominally and transcervically by

inserting a needle or catheter into the fetal portion of the placenta and
aspirating a small amount of chorionic villi for testing. Risks of the procedure
include fetal death and limb reduction defects. An increased incidence of
distal limb reduction defects occurs when the procedure is carried out
before nine to ten weeks gestational age.

Amniocentesis this is an outpatient diagnostic procedure performed after

15 weeks under ultrasound guidance. The amniocytes obtained from the
centesis are used for karyotyping to diagnose Neural tube defects or
diagnose other aneuploidies.

Amniotic Fluid Embolism (AFE) - AFE is a well-recognized complication of

amniocentesis. It presents with sudden respiratory failure, and is often
accompanied by cardiogenic shock and seizures. Disseminated
intravascular coagulation (DIC) is a feared complication of AFE, and is
suggested by purpuric rash. Immediate management of AFE includes
adequate respiratory support. If facemask ventilation does not correct the
hypoxia, intubation & mechanical ventilation should be the next
step. Dont confuse amniotic fluid embolism with pulmonary embolism. They
are different things with different treatment.

Low molecular weight heparin would be an appropriate treatment if the

patient had experienced a pulmonary thromboembolism.

Cordocentesis or Percutaneous Umbilical Blood Sampling (PUBS) is

used for rapid karyotype
Analysis, fetal blood dyscrasias, such as fetal anemia and Rhesus
isoimmunization, IgG & IgM antibodies, blood gases anamolies are
suspected. It is done after 20 weeks. It is also indicated when mosaicism is
suspected by CVS or amniocentesis to further assess the fetal karyotype.

Fetoscopy A fetoscope is a transabodominal procedure performed with a

fibre optic scope in the OT after 20 weeks. Indications are intrauterine
surgery, fetal skin biopsy (Icthyosis Vulgaris) & Twin-Twin transfusion
syndrome.
Antepartum Fetal Testing

These tests are done to confirm the fetal well being. Decreased fetal
movements is the most common indication.

If NO fetal body movements felt by mother, do USG directly.

If decreased fetal body movements, 1st do a Non-Stress Test (NST). Do this

even if you can hear fetal heart tones. This test assesses the frequency
of fetal movements using an external fetal heart rate monitoring device.

Non Stress Test - Whenever the fetal body moves, there is an increase in
the heart rate called Accelerations. A Reactive NST is presence of 2
accelerations in 20 mins with the following criteria

1. The increase in heart rate should be more than 10 beats/min lasting

more than 10 secs of the child is less than 32 weeks or
2. The increase in heart rate should be more than 15 beats/min lasting
more than 15 secs of the child is more than 32 weeks.

Non Stress Test - Negative = BAD

Positive = GOOD

This is reassuring of fetal well being. If NST is reactive, next best step is to
Repeat weekly NSTs.

A Non Reactive NST means the above criteria are not met. This might
mean the baby is asleep or in trouble. To rule out sleeping, Vibroacustic
Stimulation Test. If the baby was asleep, this test will wake up the baby. A
positive test indicates fetal well being & a negative test calls to do a BPP.

Biophysical profile (BPP) is a scoring system designed to evaluate fetal

well being. It is indicated in high risk pregnancies or in case of maternal
or physician concern, decreased fetal movements or a non-reactive
NST. It consists of the following five parameters assessed by
ultrasonography:

Nonstress test (reactive)

Fetal tone (flexion or extension of an extremity)
FetaI movements (at least 2 in 30 minutes)
FetaI breathing movements (at least 20 seconds in 30 minutes)
Amniotic fluid volume (single pocket greater than 2cm in vertical axis)
The Higher, the better!

A total score of 8-10 is considered normal, and should only be repeated

once or twice weekly until term for high risk pregnancies.

1. In the presence of oligohydramnios (AFI <5) delivery is to be

considered since it can result in umbilical cord compression and
therefore fetal compromise.

2. If the score is 6 without oligohydramnios, contraction stress test should

be ordered. If this latter gives non-reassuring results, delivery is usually
indicated; if it gives suspicious results, repeat the next day.

3. If the score is 4 without oligohydramnios and fetal lungs are mature,

delivery should be considered. If fetal lungs have not yet reached their
maturity, steroids injection should be administered and BPP assessed
within 24 hours.

4. If the score is <4, the fetus should be delivered.

Amniotic Fluid Index this one is for assessment of placental

function!

Less than 5 = Oligohydramnios

5-8 = Borderline
9-25 = Normal
More than 25 = Polyhydramnios.

Bishop score of 8-10 is reassuring. Management is to repeat the test

weekly

Bishop score of 4-6 is worrisome. Management is to repeat BPP or

Contraction Stress Test.

Bishop score of 0-2 is highly predictive of fetal hypoxia &

management is prompt delivery.

Contraction Stress Test In a contraction stress test (Oxytocin challenge

test), the mother is given an infusion of oxytocin sufficient to result in 3
contractions per 10 minutes, and the effect these contractions have on fetal
heart activity is recorded. This test assesses the ability of the fetus to
tolerate the decreased blood flow that occurs during uterine contractions.
This test uses external fetal heart rate & contraction monitoring device.
Whenever uterus contracts, there is decreased blood flow to the fetus =
decreased O2 = Decrease in Heart rate. The decreased heart rate is delayed
in relation to the uterine contraction & is called Late Deceleration.

If NO late decelerations are seen in the presence of 3 uterine contractions in

10 mins, the CST is Negative & it is reassuring of fetal well being.
Management is repeat CSTs every week.

If late decelerations are seen in the presence of 3 uterine contractions in 10

mins, the CST is positive. Management is prompt delivery of the jabari!

Contraction Stress Test Negative = GOOD

Positive = BAD or Positive STRESS test indicates
Fetal STRESS!!!

Repetitive variable decelerations represent a non-reassuring fetal

heart rate (FHR) pattern. They are characterized by the erratic onset of
abrupt slowing of the FHR in association with uterine contractions and a
rapid return to baseline. Variable decelerations are common and are thought
to be the result of umbilical cord compression. Cord compression can
occur from low amniotic fluid levels or a nuchal cord. Intermittent variable
decelerations are usually well-tolerated by the fetus. Repetitive (~50% in a
20 min period) variable decelerations require prompt intervention.

The first step in the presence of any non-reassuring heart rate is to

administer oxygen and change maternal position. In addition,
uterotonic drugs need to be discontinued and maternal hypotension
evaluated and treated. Variable decelerations may require amnioinfusion,
which consists of infusion of fluid into the amniotic cavity.

Cesarean section is indicated when the non-reassuring pattern (Late

decelerations or Variable Decelerations ) is not remediated by
conservative measures.
Intrauterine fetal demise (IUFD) - IUFD is the death of a fetus in utero
that occurs after 20 weeks gestation and before the onset of labor. IUFD is
suspected when the patient reports the disappearance of fetal movements,
a decrease or stagnation in uterine size or when fetal heart sounds are no
longer heard. Beta-hCG levels may continue to be elevated due to ongoing
placental production of that hormone.

It can be caused by a multitude of conditions such as hypertensive disorders,

diabetes
Mellitus, placental and cord complications, antiphospholipid syndrome,
congenital anomalies and fetal infections such as the TORCH infections or
listeriosis. However, the cause remains unknown in 50% of cases. It is very
important to try to diagnose the cause of the fetal demise after the first
episode in order to prevent, if possible. a recurrence of the same issue in any
subsequent pregnancies. Autopsy of the fetus and placenta should be
performed.

Ultrasonography is a more reliable tool for confirming the diagnosis; it

demonstrates an absence of fetal movement and fetal cardiac activity.

Placenta Previa Management - placenta previa presents with painless

vaginal bleeding in the third trimester with 2/3 of cases presenting at 3rd
-weeks of gestation. Ultrasound is the method of choice for diagnosis.
Ultrasonography diagnoses placenta previa with an accuracy of 95% with
transabdominal ultrasonography and virtually 100% with transvaginal
ultrasonography. Pelvic examination is contraindicated in any patient
with antepartum hemorrhage until placenta previa is ruled out by ultrasound.

The management of placenta previa depends on the gestational age of the

fetus and the severity of the bleeding. If the mother is stable and the fetus is
at term, scheduled cesarean section is the treatment of choice. Until
the cesarean section is performed, the patient must be monitored closely;
her hematocrit should be followed and autologous blood made available.

If the pregnancy is not yet term and the mother is stable, expectant
management with close monitoring of the mother and fetus is the treatment
of choice. At 36 weeks gestation, amniocentesis should be done in order to
assess lung maturity. If the fetal lungs are mature, elective cesarean section
can be performed.

Emergency cesarean section is done in the case of extended or

massive bleeding, regardless of gestational age. Most women with
placenta previa respond well to conservative management and can be
treated with elective cesarean section once stabilized.
Induction of labor in this setting is dangerous as it will trigger uterine
contractions and aggravate bleeding from a placenta previa.

PPROM Rupture of the fetal membranes at any time before the onset of
labor is referred to as premature rupture of membranes (PROM). When
rupture occurs before term, it is known as preterm PROM (PPROM). The
diagnosis of ROM is mainly clinical. The patient usually complains of either a
gush or continual leakage of clear fluid from the vagina. On examination,
amniotic fluid may be noted in the vagina or leaking from the cervix when
the Valsalva maneuver or slight fundal pressure is applied. When PPROM is
diagnosed, amniotic fluid sampling to measure fetal lung indices is
mandatory. Ultrasound examination should also be performed to detect
fetal anomalies, determine gestational age and measure amniotic volume. If
the pregnancy is less than 34 weeks gestational age, and the US ratio is less
than 2.0, then prematurity is a major concern. Steroid treatment is
effective at this stage of pregnancy (between 24 and 34 weeks) in
accelerating lung maturity and should be used.

If AFI is normal, (5-25), no amnioinfusion is needed. C section is done if the

fetus is in distress.

The most important complication of PPROM is pulmonary hypoplasia

(immaturity). Steroids are used to enhance fetal lung maturity when
premature rupture of membranes occurs at less than 34-weeks of gestation.

Patients with preterm premature rupture of the membranes (PPROM) whose

group B streptococcus status is unknown should receive antibiotic
prophylaxis. If a woman is admitted to the hospital after 34 weeks
gestation with PPROM, delivery is usually recommended. Risks associated
with prematurity are diminished after this gestational age and complications
are higher with continued expectant management.

PROM - Rupture of the fetal membranes at any time before the onset of
labor is referred to as premature rupture of membranes (PROM).

lntraamniotic infection should be suspected in the setting of prolonged or

premature rupture of the membranes when maternal fever, leukocytosis,
uterine tenderness or tachycardia is detected. FetaI tachycardia is
another feature of chorioamnionitis.

The most important first intervention is treatment of the mother with

broad spectrum antibiotics as chorioamnionitis is frequently a
polymicrobial infection. Concomitantly with the administration of antibiotics,
delivery of the fetus should be expedited as the fetus in question is near
term (35 weeks gestation) and the amniotic membrane has ruptured. The
most appropriate means of expediting labor in this case would be
administration of oxytocin as the patient is already experiencing regular
uterine contractions and appears to be in the first stage of labor.

While delivery should be expedited in this case, caesarean section should be

reserved for cases where fetal distress is evident. FetaI tachycardia is a sign
of maternal infection.

Post Partum Hemorrhage - The first step in a situation of postpartum

hemorrhage is general supportive measures. These include:

1. Fundal or bimanual massage (stimulates the uterus to contract and

resolves hemorrhage in most cases)
2. Intravenous access
3. Crystalloid infusion to keep SBP above 90 mm Hg
4. Notification of blood bank for PRBC

Uterine atony is a common cause of postpartum hemorrhage. Risk

factors include uterine hyperdistention due to a large fetus, hydramnios or a
multiple gestation and increased parity. A uterotonic agent such as oxytocin
should be administered immediately. Oxytocin will cause contraction of
myometrial fibers and retraction of myometrial blood vessels, thereby
controlling bleeding in most cases.

Uterine artery embolization or ligation of the uterine or internal iliac arteries

can be used for a patient with stable vital signs and persistent bleeding
if the rate of loss is not excessive. It can be used as an alternative to a
hysterectomy in a stable patient who wishes to preserve fertility.

Uterine packing for tamponade is performed if medical therapy fails and in

conjunction with preparations for surgery.

Caesarean hysterectomy is used as the last resort but can be effective and
lifesaving in the treatment of postpartum hemorrhage.

Breech presentation occurs when the buttocks or lower extremities of the

fetus present first into the maternal pelvis. Approximately 25% of fetuses
less than 28 weeks gestation are in the breech presentation, but
most of these assume the cephalic presentation by 34-36 weeks gestation.
After 36 weeks the likelihood of spontaneous conversion to a cephalic
presentation is about 25%. External cephalic version (ECV) is indicated to
convert a breech into a cephalic presentation in patients where fetal
well-being has been documented by a nonstress test and there are no
contraindications to a vaginal delivery. ECV is indicated between 37 weeks
gestation and the onset of labor. ECV has been shown to reduce the rate of
cesarean sections, but the maneuver has the potential to result in fetal
distress, so it should only be performed when arrangements have been made
to allow for an emergent caesarian delivery.

While a vaginal delivery can be attempted, ECV should first be tried in

order to prevent the possible complications associated with breech delivery

Internal podalic version is indicated in twin delivery, to convert the

second twin from a transverse or oblique presentation to a breech
presentation for subsequent delivery.

Caesarian delivery is often used in breech presentations. Some indications

for caesarian delivery include a large fetus, a hyperextended head, a footling
breech and fetal distress.

Infertility

Infertility is defined as a failure to conceive after one year of unprotected,

regular sexual intercourse.

According to the recent studies, male factor accounts for 20-30% of the
infertility causes. Semen analysis should be performed early in the
evaluation of the infertile couple, usually as the initial screening test. It
evaluates sperm concentration, motility, and morphology and allows
identifying azoospermia and severe oligospermia as obvious causes of
infertility. Although cutoff values for semen analysis exist, there is a broad
overlap in the values of the semen measurements in fertile and infertile
samples; therefore. borderline results should be interpreted with caution.
Anovulation as a potential cause of infertility can be evaluated using basal
body temperature (BBT) measurement, serum progesterone measurement,
and endometrial sampling.

If The patient has regular menstrual cycles accompanied by midcycle pelvic

pain (mittelschmerz) and discharge consistent with ovulation (i.e .. "egg-like"
thickening or "spinnbarkeit"), & a rise in body temperature during the luteal
phase, These facts indicate that the patient is most likely ovulating, so
testing for ovulation is not likely to identify the cause of infertility.
A hysterosalpingogram is carried out by infusing radiocontrast material
into the uterus under fluoroscopy. Abnormalities in the uterine cavity or
fallopian tubes can be identified by this method. Causes of anatomic defects
in the uterus or fallopian tubes leading to infertility include a history of
pelvic inflammatory disease, endometriosis, in utero diethylstilbestrol
exposure, congenital malformations and other acquired abnormalities.

The most common cause for decreased fertility in women in their fourth
decade who are still experiencing menstrual cycles is age-related
decreased ovarian reserve. One in 5 women age 35-39 is no longer
fertile. Infertility due to aging can be assessed using an early follicular phase
FSH level, a clomiphene challenge test or an inhibin-B level.

Infertility due to Hypogonadotropic Hypogonadism- It is due to

hypothalamic dysfunction, a condition commonly associated with severe life
stressors, eating disorders and excessive exercise. In this condition,
insufficient pulses of GnRH from the hypothalamus cause pituitary LH
and FSH production to decrease. The imbalance of LH and FSH
production causes suppression of ovarian estrogen production and ovulation,
leading to amenorrhea.

The first-line intervention for inducing ovulation in this patient would be to

cut down on her life stress and exercise intensity. If this fails, replacing the
pulsatile GnRH release should be considered.

Cervical Insufficiency - Risk factors for cervical insufficiency (cervical

incompetence) include prior gynecological surgery especially a LEEP
procedure or cone biopsy of the cervix. Other risk factors include prior
obstetrical trauma, multiple gestation, Mullerian anomalies and a history
of a preterm birth or a second-trimester pregnancy loss. LEEP procedure and
prior 17 week spontaneous abortion all increase her risk for an
incompetent cervix.

Transvaginal ultrasound is considered the "gold standard" for

evaluating the cervix for possible cervical incompetence. The transvaginal
ultrasound is used to look for the presence of funneling of the cervix or
shortening of the cervical length. Cervical length should be more than 25mm
at 24 weeks. A cervical length below the 10th percentile for the gestational
age is considered a short cervix.

Delivery of a Dead baby or the one incompatible with life - Labor

should be allowed to proceed in patients where the fetus has been diagnosed
with a severe congenital anomaly incompatible with life. There is no need
for a cesarean section, which increases maternal morbidity, as the fetus
can be evacuated vaginally.

Postpartum endometritis - A puerperal infection should be suspected if a

woman experiences a fever greater than 38 C (100 .4 F) outside of the first
24 hours postpartum. Risk factors for endometritis include, but are not
limited to prolonged rupture of the membranes(> 24 hours), Prolonged
labor(> 12 hours), cesarean section and use of intrauterine pressure
catheters or fetal scalp electrodes. Clinically, endometritis is
characterized by fever, uterine tenderness, foul smelling lochia and
leukocytosis. Broad spectrum antibiotics are required to treat this typically
polymicrobial infection.

Given the polymicrobial nature of postpartum endometrial infections, the

most appropriate therapy is intravenous clindamycin + gentamicin.

Labor is defined as uterine contractions that result in cervical dilatation

and/or effacement. Labor is typically divided into three stages. Abnormal
labor can be described as either a protraction or an arrest of labor
and/or descent. Arrest of descent is defined as a lack of change (of descent
in fetal presenting part) in 2 hours for primigravid patients or 1 hour for
multigravid patients. For both types of patients, an extra hour for descent
is allowed if an epidural is in place.

The causes of protraction and arrest disorders can generally be broken into
disorders of the 3 P's: powers (i.e ..contractions). passenger (i.e .. baby).
or passage (i.e .. pelvis). The differential diagnosis would, therefore, include
hypotonic contractions, epidural anesthesia, cephalopelvic disproportion,
malpresentation, etc. If the uterine contractions appear adequate as per the
external tocometer & the infant is of normal size and appropriately presented
in the LOA position, then the most likely diagnosis in this case is an
abnormality in the passage of the fetus leading to cephalopelvic
disproportion, likely the result of prominent ischial spines felt on physical
examination. Increased molding of the fetal skull is also suggestive of
cephalopelvic disproportion. Given that there is an underlying anatomic
abnormality that is unlikely to resolve and that the arrest of dilatation and
descent has already been prolonged, operative management with
cesarean section is the best choice at this time.

Postpartum Fever - Low grade fever and leukocytosis are common

during the first 24 hours of the postpartum period. Intrapartum and
postpartum chills are also common.

Lochia Rubra It is the first discharge, red in color because of the large
amount of blood it contains. It typically lasts no longer than 3 to 5 days after
birth. It is characteristic of the first few days following delivery. No treatment
is necessary. Management is reassurance.

Lochia Serosa - After 3 to 4 days, the color becomes pale and the
discharge is then called lochia serosa. It subsequently turns white or yellow
and is then termed lochia alba. If a foul smelling lochia is noted,
endometritis should be suspected.

Postpartum Contraception - Lactation alone causes anovulation and

therefore some degree of contraception because the high prolactin levels
inhibit the release of GnRH from the hypothalamus. Lactation, however, is
not considered a reliable form of birth control as ovulation can resume
while a mother is still breastfeeding. Contraceptive methods that can be
used in the postpartum period include sterilization, barrier methods,
intrauterine devices and progestin-only oral contraceptives. Progestin-
only oral contraceptives are the preferred hormonal contraceptives in
lactating women as they do not affect the volume or composition of milk
produced by the mother, they have no known effects on the infant and they
do not carry the risk of venous thrombosis associated with combination pills.

Combined contraceptive pills may decrease milk production and pass into
the milk. The effects of combination oral contraceptive use on the
breastfeeding infant have yet to be determined.
Postpartum Lactation Supression - At delivery, milk production is
activated by two major mechanisms: the sudden decrease in estrogen and
progesterone that, prior to delivery, interfere with the action of prolactin on
lactation and the release of prolactin and oxytocin through the stimulatory
effect of suckling. Prolactin is responsible for milk synthesis whereas oxytocin
mediates contraction of the lactiferous glands and ducts resulting in the
excretion of milk. Lactation suppression is indicated for patients such as in
this case or those who do not desire to breastfeed. Lactation suppression is
accomplished by use of a tight-fitting bra, avoidance of nipple
stimulation or manipulation, application of ice packs to the breasts and
analgesics to manage the pain. There is no role for medications in the
suppression of breast milk production.

Bromocriptine was commonly used but is no longer FDA approved for this
purpose because of the side effects. It is a dopamine agonist that acts by
inhibiting prolactin secretion by the anterior pituitary thus suppressing
lactation.

Postpartum Breast Engorgement - Breast engorgement is common in the

first 24 to 72 hours after childbirth secondary to milk accumulation.
While it may occur at any point during breast feeding, it is especially
common early in the postpartum period when milk production is particularly
robust. Symptoms include breast fullness, tenderness, and warmth. It
typically peaks 3 to 5 days postpartum and improves spontaneously in most
patients. Cool compresses, acetaminophen and NSAIDs may be used for
symptom control.

Mastitis is a breast infection that causes unilateral breast pain with an

isolated firm, tender erythematous area accompanied by fever greater than
38 .3c. It is distinguished from plugged ducts by the presence of fever. Anti-
staphylococcal agents are first-line therapy.
Plugged ducts present similarly to mastitis but lack fever or systemic
symptoms. They are treated by improving the quality of breastfeeding.
Persistently plugged ducts resulting in galactocele may be treated with
aspiration.

Breast abscesses are rare and present similarly to mastitis but with a
palpable, fluctuant mass.
They are treated with antibiotics and drainage.