OVERVIEW in OB 13. Blood supply of the vagina 1. Define: a. Upper 3rd – cervicovaginal br of uterine artery a. Abortion: expulsion of fetus < 500g b. Mid 3rd ----inf. Vesical b. Neonatal Period: time of delivery until 28 days c. Lower 3rd – mid rectal & int. pudendal c. Perinatal Mortality Rate: number of still birth + 14. Support structures of the vagina neonatal deaths per 1000 total births a. Upper – cardinal lig, parametria d. Perinatal Period: 20 wks AoG – 28 days after birth b. Mid---levator ani e. LBW: < 2500g c. Lower—urogenital, pelvic diaphragm f. VLBW: < 1500g 15. Vaginal abnormalities g. ELBW: < 1000g a. Atresia h. Direct Maternal Death: due to complication of b. Double vagina (2 introitus, distinct separate cervix) pregnancy, labor, puerperium e.g. hemorrhage from c. Longitudinally septate vagina (interfere with ruptured uterus descent) 2. What is the most common cause of Maternal Death d. Transv septate vagina (faulty canalization of o HEMORRHAGE mullerian anlage) 3. Other causes of Maternal Death 16. Persistence of fusion between sinovaginal bulbs & vestibule o HPN a. Imperforate hymen o Infections 17. Blood supply to the perineum o Obstructed Labor a. Int pudendal artery o Complication of Abortion 18. Allows distention of the rectum during defecation & stretching 4. Perinatal Mortality Causes of the vagina during delivery o Complication of placenta, cord, membranes a. Ischiorectal fossa (21.13%) 19. 2, fat filled wedge shaped spaces found on either side of the o Short gestation, LBW (13%) anal canal, comprise the bulk of the posterior triangle o Intrauterine hypoxia (7.5%) a. Ischoretal fossa o RDS (1.8%) 20. Size of the uterus ANATOMY OF THE FEMALE REPRODUCTIVE TRACT a. Puberty---2.5 -3.5 cm A. External Organs b. Adult nullip – 6-8cm 1. All structures externally from pubis – perineum? c. Multip—9-10 cm o Vulva (pudenda) 21. Relationship of body of the uterus &cervix 2. Fat-filled cushion overlying symphysis pubis a. Premenarche –body half as long as cervix o Mons pubis b. Nullips—fundus & cervix equal length 3. Labia majora cont. directly with the mons pubis above and c. Multips—cervix is a little more than a third of the merge into the perineum posteriorly as: total length of the uterus o Posterior commissure 4. Lymph drainage of labia majora 22. Classification of mullerian anomalies o Inguinal femoral nodes a. Class 1—vaginal hypoplasia & agenesis 5. Male homologue of the b. Class 2—unicornuate uterus ( increase infertility, a. labia minora ---penile urethra (ventral shaft of the endometriosis, dysme, fetal wastage) penis) c. Class 3 – uterine didelphys (complete absence of b. labia majora---scrotum fusion of the mullerian ducts c. clitoris—glans penis d. Class 4 –bicornuate uterus (2 mullerian ducts fail to d. bartholin’s gland---bulbourethral (cowper’s) gland fuse) e. vestibular bulbs---corpus spongiosum e. Class 5 ---septate uterus (failure of involution of 6. Almond shape, mature female structure of the urogenital sinus septum, increase spon. Abortion) o Vestibule f. Class 6 – arcuate uterus (mild deviation from 7. Almond shape, aggregation of veins normally developed uterus) Vestibular bulbs g. Class 7—DES induced ( 8. Hymen in newborn: very vascular, redundant 23. Mocusal layer lining the the uterine cavity in nonpregnant Pregnancy: epith thick, glycogen rich state Menopause: thin w/ focal cornification a. Endometrium 9. Epithelium of the hymen 24. Lining epith of the endometrium a. Strat. Squamous a. Single layer, high columnar, ciliated cells 10. Types of hymen 25. Zones of the endometrium a. Annular (nullips) a. Functionalis ---shed off b. Septate b. Basalis c. Cribriform 26. Ligaments 11. Gonadal gender is estimated at…. a. Broad—winglike, extend from lat. Margins of the a. 6 wks after conception uterus to the pelvis, divides pelvic cavity into A & P 12. Length of the vagina compartments a. Ant wall --- 6-8 cm b. Cardinal – maintains position of the uterus & upper 47. Placental hormone important in the ―fail-safe mechanism‖ 3rd of the vagina a. Hpl c. Round—gubernaculums testes in men, from lateral 48. Major precursor for placental estrogen synthesis portion of uterus—to inguinal canal, terminate in the a. DHEA upper portion of the labia major 49. Functions of estrogen 27. Forms the lateral boundary of the pouch of douglas a. Regulates # of prolactin receptors a. Uterosacral ligaments b. Increase lipid synth 28. Blood supply to the uterus c. Regulates/increase fetal lung surfactant a. Uterine d. Stimulates PG production leading to labor b. Ovarian artery 50. Estrogen which can be used to test for fetal well being 29. Length of the fallopian tubes a. Estriol a. 8-14 cm 51. Principal urinary metabolite of progesterone 30. Divisions of the FT a. Pregnanediol a. Interstitial 52. Progesterone production b. Isthmus a. Normal, singleton----250mg/day c. Ampulla b. Multiple fetuses--- > 600mg/day d. Infundibulum 53. Precursor for fetal adrenal steroidogenesis a. Cholesterol (LDL) 54. Fxns of progesterone a. Initiation of parturition b. Maintenance of pregnancy in utero c. Inhibits cholesterol esterification 2nd shift (dr. Morata) d. Facilitate action of GABA 55. Largest organ of the fetus 31. Quickening a. Adrenal cortex a. Prima –18th – 20th week 56. Daily steroid production b. Multi – 14th -16th week a. 100-200mg/day 32. Uterine fundus felt at level of symphysis pubis 57. Product of conception a. 12th week a. Embryo 33. Softening of the uterine isthmus 58. embryonic period a. Hegar’s sign ( 6th-8th wk) a. 4 weeks after ovulation—arm &leg buds present 34. Cyanosis & softening of the cervix b. 6 weeks after fertilization—heart is completely a. Goodell’s sign (4 weeks) formed 35. Spalding’s sign c. 8th week after fertilization—end of the embryonic a. Liquefaction of the brain period 36. Robert’s sign 59. Fetal period a. Gas bubbles a. 8 weeks after fertilization up to 40 weeks 37. Fundal height b. 12 weeks AOG – centers of ossification in most fetal a. 12 wks – symphysis pubis bones b. 20 weeks—umbilicus c. 16 wks AOG—gender correctly determined c. 36 wks--- below xiphoid d. 20 wks aog- downy lanugo covers entire body 38. Chadwick’s sign’ e. 24wksaog—fat deposition begins a. Voilaceous discoloration of the vagina f. 28wks aog—thin skin is red & covered by vernix 39. FHT heard by steth caseosa a. 18th week g. 40 wks aog—features of fully developed NB 40. FHt by Doppler 60. Previable fetal period a. 10 -12 weeks a. 11-20 weeks 41. Increase in cardiac output during pregnancy 61. Greatest transverse diameter of the fetal head a. 30-50 % a. Biparietal dm (9.5 cm) 42. Principal prostaglandin of the endothelium 62. Bitemporal dm (8cm) a. Prostacyclin (PGI2) a. Greatest distance between 2 temporal sutures 43. hcg 63. Adult levels of IgM are attained a. 10 wks AOG – maximal levels a. 9 mos of age b. 10th-12th weeks---begin to decline 64. B lymphocytes appear c. 20 wks—nadir a. Liver – 9 wks AOG d. 8- 10 days--- detectable b. Blood & spleen ---12 wks AOG 44. Main endocrine organ during pregnancy 65. Most pancreatic enzymes are present by a. Placenta a. 16 wks AOG 45. Total iron requirement of pregnancy 66. Nervous system a. 1 g/day a. Embryonic--- SC extends along entire length of vert 46. Total amount of water retained during pregnancy column a. 6.5 L b. 24 wks AOG—SC extends to S1 c. @birth ---L3 Complicated pregnancies: 1 to 2 weeks interval d. Adult—L1 9. Fetal Heart sounds 67. Sensory organs First heard at 16 to 19 weeks using a DeLee fetal stethoscope a. 7 wks—taste buds, swallowing Heart sounds audible by 22 weeks in all patients b. 8 wks – flex neck & trunk 10. Fundal Height c. 12 wks—urine prod Gestational age equal to the fundal height between 20 to 31 d. 14-16—breathing movt weeks e. 16 wks—close fingers 11. Trimesters of pregnancy f. 24-26—suck and hear sounds 3 equal period consisting of 3 calendar months g. 28- respond to light 1st trimester: up to 14 weeks 68. Highly modified endometrium of pregnancy 2nd trimester : 14 weeks 1 day up to 28 weeks a. Deciduas 3rd trimester : 28 weeks 1 day up to 42 weeks 69. Zone of fibrinoid degeneration 12. Normal duration of pregnancy a. Nitabuch’s layer 70. Inconstant deposition of fibrin at the bottom of the intervillous 280 days or 40 weeks, calculated from the first day of the last space surrounding the villi normal menstrual period a. Rohr stria Estimated date of delivery (EDD) 71. Refers to all tissue products of conception (embryo, fetal o Calculated using Naegele’s rule membranes, placenta) o Add 7 days to the first day of LMP; count back 3 a. Conceptus months 72. Stage of human development w/in uterine cavity 13. Definitions: a. Blastocyst Parity – number of pregnancies reaching viability ( 20 weeks, 500 73. The cell that results from the fertilization of the ovum by a gm) spermatozoon Primipara a. Zygote Multipara 74. The villi in contact with the deciduas capsularis which Nullipara proliferate Gravida – a woman who is or has been pregnant regardless of a. Chorion frondosum outcome 75. Represent fetal macrophages Nulligravida a. Hofbauer cells ( prominent & abundant in early Primigravida pregnancy) Multigravida 14. Initial Prenatal Evaluation THIRD SHIFT (Dr. Mendoza) Initiated as soon as there is likelihood of pregnancy Preconceptional Counseling Should be no later than the 2nd missed period 15. Changes in the cervical mucus 1. Caffeine: More than 5 cups per day increase abortion rate - Beaded cervical pattern – low levels of NaCl 2. Fetal alcohol syndrome 16. Chadwick sign – changes in the vagina o Growth restriction 17. Changes in uterus: Hegar sign o Facial abnormalities 18. Funic soufflé – passage of blood through umbilical vessels o Central nervous system dysfunction 19. Uterine soufflé – maternal blood flow always coincident with 3. Coitus: Not harmful until the last 4 weeks maternal pulses 4. Travel: not within 7 days of EDD 20. Neural Tube defects 5. FDA categories Mutation in the Methylene Tetrahydrofolate Reductase gene A: human studies show no fetal risks Overcome by periconceptional folic acid e.g. prenatal multivitamins o 4 mg/day – for women w/ a prior baby w/ NTD B: animal studies show no risk but no human studies available or o 0.4 mg/day – reduction of the prior risk of first adverse effects demonstrated in animal but no well – occurrence controlled human studies 21. Phenylketonuria (PKU) e.g. penicillins Example of a disease the fetus cannot inherit but is affected C: no adequate animal or human studies; or there are adverse because of a maternal genetic predisposition animal fetal effects but no available human data 22. Tay sach’s disease D: there is evidence of fetal risk, but benefits outweigh risks Autosomal recessive neurodegeneration disorder e.g carbamazepine 23. Thalassemias phynetoin Most common single gene disorder X: proven fetal risks outweigh any benefits 24. Psychiatric Disorder o e.g. isotretinoin - Schizophrenia (0.8%) 6. GBS : vaginal and rectal cultures at 35- 37 weeks - Bipolar disease (0.5 %-1.0%) 7. Maternal serum AFP at 16-18 (or 15-20) - ADHD 8. Subsequent prenatal visits 25. Connective tissue disease Every 4 weeks until 28 weeks o Rheumatic arthritis improve during pregnancy but every 2 weeks until 36 weeks relapse within 6 months of deliveries weekly thereafter o Ankylosing spondylitis: increase back pain o Scleroderma: improvement of Reynaud’s phenomenon Maternal plasma concentration decreases by about 0.5 o SLE – most serious mEq/L by midpregnancy 26. Best predictor of perinatal outcome is serum creatinine level 10. Vitamins 27. Hyoerglycemia is teratogenic to the embryo: Increased requirements can be met by an adequate diet: Neural tube defect Exception: Folic Acid Cardiac anomalies & renal anomalies 11. Folic Acid Sacral agenesis Deficiency – Megaloblastic anemia Holoprosencephaly 400 ug supplementation important for prevention of neural tube defects High-Risk Pregnancy 1. Maternal age: 12. Fetal behavioral States o Under 18 years old 1F o Nullipara over 30 years Quiescent state (quiet sleep) o Multipara over 35 years 2F Maternal height: Frequent gross body movements o 60 inches or less (153 cm or less) Continuous eye movements Wider oscillation of fetal heart rate BMI Recommended Rate (4 weeks) Analogous to REM or active sleep in neonates Gain (kg) 3F Low (<19.8) 12.7 – 18.2 2.3 Continuous eye movements in the absence of body Normal (19.8 – 26.9) 11.4 – 15.9 1.8 movements High (26.1 – 29.0) 6.8 – 11.4 1.2 No fetal heart rate accelerations Obese (>29.0) 6.8 0.9 Existence of this state disputed Twin gestation 15.9 – 20.4 2.7 4F Vigorous body movements 2. Calories Continuous eye movements Additional 300 kcal/day Fetal heart rate accelerations Corresponds to awake state in infants Nonpregnant Pregnant Lactating Kcal 2200 2500 2600 Fetuses spend most time in states 1F and 2F Protein 55 60 65 Urine production increases during 1F (grams) Fetal voiding and decreased urine production during 2F 3. Protein Sleep-wake cycle: important determinant of activity Average of 9 grams/day Varies from 20-75 minutes 13. Maternal perception 4. Carbohydrates Several counting protocols: Main source of energy o 10 movements in 2 hours 150 grams/day – 1st trimester o Fetal movements in 1 hour compared to an established 5. Fats baseline activity count Most concentrated source of energy 14. Acceleration 15-25 grams/day After 32 weeks 6. Iron o ≥ 15 bpm above the baseline rate Average requirement for the whole duration of pregnancy o ≥ 15 seconds – 41 mg/day Before 32 weeks 30 mg elemental iron o 10 bpm 60-100 mg if: o ≥ 10 seconds o Large woman 15. Nonstress Testing (NST) o Multiple gestation fetal heart rate accelerations = fetal movement o Poor compliance to iron Reactive: 200 mg if overtly anemic o 2 or more accelerations within 20 minutes of Not necessary in the 1st 4 months beginning the test 7. Zinc Non-Reactive: Second to iron as the most abundant trace element in the o No accelerations body o Extend tracing to 40 minutes to account for fetal sleep Deficiency: 16. Testing Frequency o Dwarfism and hypogonadism 7 days o Acrodermatitis enterohepatica Shortened to twice weekly if indicated Additional allowance of 8 mg/day or total of 12 mg/day 17. Decelerations during NST 8. Iodine Not an indication of fetal compromise if: Cretinism: Maternal deficiency o Isolated and brief (<30 seconds) Overconsumption: Fetal goiter Increased incidence of fetal compromise if: 9. Potassium o Repetitive (at least 3 in 20 minutes) o Duration longer than 1 minute Characteristics: 18. Contraction Stress Testing (CST) o Discontinuopus Induction of uterine contractions o Paradoxical o Oxytocin o Diurnal o Nipple stimulation Types FHR and uterine contractions simultaneously recorded by an 1. Gasps or sighs electronic fetal monitor Frequency of 1 to 4 per minute Three contractions, ≥ 40 seconds 2. Irregular bursts Interpretation 240 cycles/minute Negative Associated with REM o No late or significant variable decelerations Positive Maturation of Normal Fetal Breathing o Late decelerations following 50% or more of contractions Fetal respiratory rate decreased as respiratpry volume increased (even if contraction frequency is fewer than 3 in 10 Occurs at about 33-36 weeks AOG minutes) Equivocal – suspicious Interpretation and management o Intermittent late decelerations Score of 10: o Significant variable decelerations o Normal non-asphyxiated fetus Equivocal – hyperstimulatory o No fetal indication for intervention o Heart rate decelerations that occur with contractions o Repeat test weekly except in diabetic patient and more frequent than every 2 minutes or longer than 90 postterm (2x) seconds Score of 8/10 (normal fluid) or 8/8 Unsatisfactory o Normal non-asphyxiated fetus o Fewer than 3 contractions in 10 minutes o No fetal indication for intervention o Uninterpretable tracing o Repeat testing depending on protocol 19. Acoustic Stimulation Tests Score 8/10 (decreased amniotic fluid volume) The fetus responds to sound o Chronic asphyxia 125-400db o Deliver 20. Fetal Startle Response Score 6: o Artificial larynx o Possible fetal asphyxia o May be repeated up to 3 times for up to 3 seconds o If fluid volume abnormal: deliver Fetal response: acceleration of the fetal heart rate o If normal fluid, > 36 weeks, favorable cervix, deliver 21. Biophysical Profile (BPP) o If repeat test ≤ 6; deliver Scoring o If repeat test> 6: observe and repeat per protocol Score of 2: Presence of a variable Score 4: Score of 0: Absence of a variable o Possible fetal asphyxia No score of 1 o Repeat test same day, if repeat test ≤6: deliver Maximum score of 10/10 Score 0-2: o Almost certain fetal asphyxia 2 0 o Deliver Fetal Tone ≥ 1 episode of extension No movements of a fetal extremity with or no extension 23. Modified BPP return to flexion or flexion VAS NST + AFI ≥ 1 episode of opening or 24. Umbilical Artery Doppler Velocimetry closing of the hand Assesses blood flow by characterizing downstream impedance Fetal ≥ 1 episode of rhythmic < 30 seconds of Indices: Breathing breathing lasting for ≥ 30 breathing within o Systolic/diastolic seconds within 30 30 minutes o Pulsatility index minutes o Resistance index Fetal ≥ 3 discrete body or limb ≤ 2 movements Best for IUGR Movement movements within 30 in 30 minutes 25. MCA Doppler Velocimetry minutes Hypoxic fetus compensates by ―brain-sparing‖ Amniotic Single vertical pocket > 2 Largest single Reduced impedance (increased blood flow) to cerebral vessels Fluid cm vertical pocket ≤ Volume AFI >5 cm 2cm FETAL DEATH AFI ≤ 5 cm 1. Fetal Mortality: More than half occur before 28 weeks NST ≥ 2 accelerations of ≥ 15 0 or 1 2. Causes of Fetal Death bpm for ≥15 seconds in acceleration in Fetal (25-40%) 20-40 minutes 20-40 minutes Placental causes (25- 35%) Maternal (5- 10%) 22. Fetal Breathing Unexplained (25-35%) 3. Spontaneous ICH (Intracranial Hemorrhage) Most common – isolated IVH without SAH and Immune hydrops subdural bleeding Abnormal collection of fluid in more than 1 area of the fetal 4. Cephalhematoma body Develops over one or both parietal bones and limited by the periosteum Identification Differentiate from caput succedaneum – focal Indirect Coomb’s test- mother (because antibodies are swelling of scalp (edema) over the bound) 5. Brachial plexus injury Direct Coombs test- neonate (maternal antibodies are o Erb or Duchenne paralysis absorbed by the fetal RBC) upper plexus (C5 – C6, occasionally C7) IgG antibody titer Paralysis of the deltoid and infraspinatus and flexor Prevention muscles of the forearm Anti- D- immunoglobulin to D- negative Arm held straight and internally rotated with elbow nonsensitized women extended and wrist and fingers flexed 1st dose at 28 weeks o Klumpke’s paralysis 2nd dose after delivery if the infant is D+ Lower plexus (C8 –T1) Flaccid hand Diseases of the Term Fetus and Neonate Involvement of all brachial plexus nerve roots – flaccid arm and hand Meconium Aspiration Syndrome (MAS) Horner syndrome – ptosis, pupillary meiosis Peripartum inhalation of meconium chemical (interruption of nerve fibers in the cervical pneumonitis sympathetic chain) Hemorrhagic disease of the Newborn (HDN) 6. Facial paralysis Spontaneous internal or external bleeding within 48 hours of o Pressure on facial nerve as it exits the stylomastoid birth foramen Abnormally low levels of vitamin K dependent clotting factors 7. Fractures (V, VII, IX, X), prothrombin, protein C and S a. Clavicle –common Vitamin K treatment b. Humerus – Greenstick type PRENATAL DIAGNOSIS DISEASE and INJURIES 1. Translocation – exchange of chromosome material from breaks 1. Respiratory Distress Syndrome (RDS) Surfactant: type II pneumocytes in two chromosomes before repair occurs CXR – air bronchogram (reticulogranular infiltrates with 2. Inversion – genetic material from two breaks in the same an air-filled tracheobronchial tree) chromosome are inverted before the breaks are repaired Prevention 3. Fetuses at High Risk for Genetic or Congenital Disorders o L/S ratio: Present in equal concentrations before Fetal aneuploidy 34 weeks Isolated structural anomalies o Phosphatidylglycerol: Enhances the surface- Familial genetic disease active properties of LS 4. Fetal aneuploidy o TDx-FLM: Measures surfactant-to-albumin ratio o 50% of 1st trimester abortions Value of 50 or greater predicted lung 5. Women with risk of fetal aneuploidy high enough to justify risk maturity in 100 percent of cases of amniocentesis o Foam stability index or shake test Generation of a stable foam at the air- Singleton pregnancy with age ≥ 35 at delivery liquid interface when mixed with ethanol - Midtrimester risk of Down syndrome : 1 in 250 o Lamellar body count o DPPC (Dipalmitoylphosphatidylcholine) Dizygotic twin pregnancy with age ≥ 31 at delivery - Midtrimester risk: 1 in 190 2. Intraventricular Hemorrhage (IVH) Common before 34 weeks Previous autosomal trisomy birth Most develop within 72 hours of birth (longest – 24 days) 3. Necrotizing enterocolitis (NEC) Previous 47,XXX or 47,XXY birth Abdominal distention, ileus, bloody stool - Previous 47, XYY and 45, X are not at high risk for recurrence Pneumatosis intestinalis – bowel wall gas 4. Anemia Patient or partner is a carrier of chromosome translocation Hgb= 17mg/dl at 34 weeks (below 14mg/dl is abnormal) Fetomaternal hemorrhage 6. Repetitive first trimester losses Kleihauer- Betke test (fetal Hgb is more resistant to Majority of early losses: euploidic acid elution) 7. Parental aneuploidy 5. Isoimmunization Trisomic individuals often sterile ABO and Rh antigens Except: Expanded AFP test, AFP plus, triple screen or multiple marker o Female trisomy 21 screen o Female 47, XXX o Elevated HCG o Male 47, XYY o Decreased unconjugated estriol 8. Congenital heart defects o Low MSAFP Most common isolated structural defects BUN study: Free beta- hCG, PAPPA-A, NT measurement and Most common recurrence of same defect: AV septal and laterality maternal age defects FASTER Trial Most common recurrence of similar defects: left-sided, outflow tract Underwent both 1st trimester free beta- hCG, PAPPA-A, NT and septal defects measurement and maternal age screening, AND 9. Neural tube defects 2nd trimester hCG, AFP, estriol, inhibin and maternal age Environmental agents screening o Hyperglycemia 17. Fragile X Syndrome: Most common cause of familial mental o Hyperthermia – increases risk sixfold retardation o Drugs United Kingdom: Highest 18. Cystic Fibrosis 10. Neural tube defects Autosomal recessive Alpha-fetoprotein (AFP) characteristics: o Glycoprotein o Abnormal sweat chloride levels o major fetal serum protein o Chronic pulmonary disease 11. AFP o pancreatic insufficiency Concentration increases until 13 weeks o liver disease Found in steadily increasing quantities in maternal serum after 12 o obstructive azoospermia weeks CF gene: long arm of chromosome 7 12. Maternal serum AFP screening o Encodes CFTR Between 14-22 weeks 19. Incidental finding of a Major Structural Defect Greatest sensitivity at 16-18 weeks Measured in ng/ml, reported as MOM Defect Aneuploidy Risk (%) 13. Elevated maternal serum AFP Cystic hygroma 60-75 Greater than 3.5 MOM Hydranencephaly Minimal o Clearly indicate an increase fetal risk 14. Ultrasound examination 20. Routine Sonographic Screening for Major Structural Anencephaly Anomalies Spinal Defects Nuchal fold: most discriminatory during the first trimester Cranial signs of a spinal defect 21. Early Amniocentesis o Lemon sign o Banana sign More positional foot deformities o Obliteration of cistern magna 22. Chorionic Villus Sampling (CVS) o Small BPD 10-13 weeks o Ventriculomegaly Relative contarindications: Risk of NTD is reduced by 95 % if no spine defects or cranial o Vaginal bleeding signs are seen o Extreme uterine ante- or retro-version o Patient habitus that precludes easy access 15. Amniocentesis Absolute contraindication: infection Elevated AFAFP – determine AF acetylcholinesterase Transabdominal CVS after 9 weeks – as safe as 2nd trimester Elevated AFAFP + negative acetylcholinesterase – amniocentesis another etiology or fetal blood contamination Complications: Fetal karyotype o Limb-reduction defects o Both MSAFP and AFAFP are elevated o Oromandibular defects o Elevated MSAFP + normal AFAFP – not o Cavernous hemangiomas necessary Midtrimester amniocentesis – associated with lowest number o Elevated AFAFP – chromosomal abnormalities of uninformative results compared to CVS fivefold over background 16. Down Syndrome Maternal age-related risk: most powerful predictor of aneuploidy 23. Fetal Cells in maternal circulation Low MSAFP Sixfold increase of fetal cells in maternal blood if fetus is Multiple marker screening aneuploid 1. Twin-to-twin Transfusion syndrome Therapeutic options; 3. Transverse i. Amnioreduction ⌐ Best for detecting presence and extent of defects ii. Endoscopic laser ablation iii. Selective feticide Frontal scalloping or lemon sign (Spinal menigomyelocele) 2. Fetal Transfusion Parvovirus Infection Banana Sign (Meningomyelocele). Develops when the cerebellum is Prior to 20 weeks bowed and inferiorly displaced, causing effacement of the cistern magna o Severe transient aplastic anemia 7. Anomalies o Heart failure Hydrocepahlus o Hydrops o ―Dangling choroid plexus” sign 3. Fetal Medical Therapy NTD Administration of medications either to the mother o Failure of midline fusion of the neural plate (steroids for fetal lung maturation) or directly to the o Anencephaly fetus ⌐ Absence of cranial vault, hydramnios Direct Fetal therapy: o Encephalocele: herniation through a cranial defect of brain i. Fetal thyrotoxicosis and meninges ii. Cardiac arrhythmia o Meningocele: only meninges herniated 24. Fetal Surgery o Chiari III: cerebellar herniation 8. Spina Bifida Cranial Signs Urinary shunts: Posterior urethral valve, urethral atresia, 1. Small BPD ureteropelvic junction obstruction 2. Ventriculomegaly 3. Lemon sign: scalloping of frontal bone Congenital Cystic Adenomatoid Malformation (CCAM) and 4. Banana sign: abnormal curvature of cerebellum Pulmonary Sequestration o Sometimes cerebellum not visualized CCAMs-pulmonary hamartomas consisting of overgrown terminal 5. Effacement or obliteration of cisterna magna bronchioles 9. Choroid Plexus Cyst PS-tissue mass that becomes completely separated from the lung Neuroepithelial folds in the choroid plexus of the lateral ventricles fill with CSF ULTRASOUND Identified in 70% of fetuses with trisomy 18 10. Cystic Hygromas 1. First trimester Lymphatic system congenital malformation CRL o Failure of the development of the lymph connection to the o Most accurate for dating (3-5 days error) jugular vein by 40 days gestation Gestational sac 60-70%: associated with aneuploidy o Should be visible when serum β-hCG is 1800 Miu/ml Large, multiseptated lesions: do not resolve 2. BPD easiest and most reproducible o Worse prognosis ± 7-10 days ⌐ Abnormal karyotype 3. FL strongly correlates with BPD and AOG ⌐ Develops hydrops ± 7-11 days ⌐ Diminished survival 4. AC has a wider variation 11. Diaphragmatic Hernia o ± 2.8 weeks Incomplete fusion of the pleuroperitoneal membrane o Useful for EFW More frequent on left 5. Third trimester o Four chamber cardiac view; heart pushed to the middle or to Variation of BPD and FL: ± 14-21 days the right by the stomach or bowel which appears as a cystic 6. Central nervous system structure behind the left atrium 3 transverse (axial) cranial views: 12. Heart 1. Transthalamic view Visualized sonographically at 6-7 weeks ⌐ Measure BPD and HC 4 chambers visualized during the 2nd trimester ⌐ Thalamus Detailed evaluation not possible until 18 weeks ⌐ Cavum septum pellucidum 13. Four Chamber View ⌐ Frontal horns of the lateral ventricle Central view to cardiac assessment 2. Transventricular view Cardiac axis: apical angle 45˚ with the anterior chest wall ⌐ Atria of the lateral ventricles Moderator band: apex of right ventricle ⌐ Choroid plexus Foramen ovale flap: left atrium ⌐ Cranial contour 3. Transcerebellar view 14. Gastrointestinal tract ⌐ Cerebellum Stomach Bubble ⌐ Cisterna magna Visible in 98% of fetuses after 14 weeks ⌐ Nuchal fold Absence: Spinal view: o TEF 1. Sagittal o Esophageal atresia 2. Coronal o Diaphragmatic hernia 4. Syndrome o Abdominal wall defects Cluster of several abnormalities or defects due to a single cause o Neurological abnormalities that inhibit fetal swallowing 5. Sequence All abnormalities occur sequentially as the result of a single insult Fetal Bowel 6. Association Appearance changes with gestational age Particular anomalies occur together frequently but do not seem to Hyperechogenic bowel: brightness equivalent to or greater than bone be linked etiologically 7. Aneuploidy Abdominal Wall Defects Numerical abnormality Common types: 8. Trisomy o Omphalocele Affected individual inherits an extra chromosome Failure of the lateral ectomersodermal folds to meet in the Mechanisms: midline of the abdomen between the 3rd and 4th weeks o Nondisjunction – failure of a chromosome pair to o Gastrochisis Occlusion of either the right umbilical vein or the terminal separate segment of the right omphalomesenteric artery Nondisjunction risk increases with maternal age Elevated serum maternal AFP o Chiasmata breakdown
Gastrointestinal Atresia Trisomy 21: Down syndrome
Characterized by obstruction with proximal dilatation 95% due to maternal nondisjunction Esophageal atresia: hydramnios + absent fluid- filled stomach o 75%-during meiosis I Duodenal atresia: double- bubble sign (distention of stomach o 25%-during meiosisII and 1st part of duodenum) Trisomy 18: Edward syndrome Trisomy 13: Patau syndrome Genitourinary Tract Cutis aplasia an polydactyly in combination Kidneys demonstrated at paraspinous area o Suggests either trisomy 13 or lethal deletion of 4p o As early as 14 weeks (TAS) XXX and XXY o Routinely at 18 weeks Pubertal development in females normal (XXX), normal fertility Obstructive uropathy XXY males do not virilize, infertile due to gonodal dysgenesis, o Commonly: uteropelvic junction obstruction gynecomastia and small testicles Renal Agenesis 9. Monosomy: No association with maternal age o Potter Syndrome: severe oligohydramnios, pulmonary hypoplasia, limb contractures, distinctive compressed facie 45, X Turner syndrome or monosomy X 15. Doppler Velocimetry Only monosomy compatible with life Doppler Shift Principle Most common aneuploidy in abortuses When a source of light or sound wave is relative to an observer, the observer detects the shift in the wave frequency 10. Polploidy When sound waves strike a moving target, the frequency of the sound waves reflected back is shifted proportionate to the velocity 2/3 of triploidy: from fertilization of one egg by 2 sperm and direction of the moving target ½ from failure of meiotic division Indices o Diploid chromosome complement in the egg, commonly in the Systolic/Diastolic (S/D) sperm Resistance index or Pourcelot Index (RI) o Paternal: Hydatidiform mole Pulsatility Index (PI) If a fetus develops Uterine and Arcuate Arteries Origin of the extra chromosome dictates phenotype High diastolic velocity, highly turbulent flow Extra maternal haplotype (digynic): severely growth restriced fetus and placenta Fetal Descending Aorta Extra paternal haplotype (diandric): relatively normal fetal size, Receives majority of RV output via DA placenta abnormally large and cystic
Limited Blood Flow 11. Chromosome deletions
Middle cerebral artery most accessible Refers to a portion of the chromosome that is missing Deletion 4p GENETICS Wolf-Hirschhorn syndrome Deletion 5p 1. Poor formation of tissue Malformation Cri du Chat syndrome 2. Unusual forces on normal tissue Deformation 3. Breakdown of normal tissue Disruption 12. Translocations Mitochondrial inheritance Reciprocal translocation Derived exclusively from the mother Double-segment translocation No possibility of recombination Rearrangement of chromosomal material in which breaks occur in 2 different chromosomes Robertsonian translocation: MC DRUGS Fusion of the centromeres result in the loss of one centromere Isochromosomes Penicillins: Safest antimicrobials to use in pregnancy Centromeres break transversely instead o longitudinally during Erythromycin: Commonly used if penicillin allergic meiosis II or mitosis Cloramphenicol: Gray baby syndrome All genes located on the lost chromosome are deleted Nitrofurantoin o Q arm: phenotypically normal, abnormal gametes Urinary antiseptic o P arm: phenotypically abnormal, abnormal gametes No increase in congenital anomalies Chromosomal inversions Hemolytic anemia in women with G6PD deficiency 2 breaks in the same chromosome and the intervening genetic Vancomycin: Clostridium difficile pseudomembranous colitis material is inverted before the breaks are repaired Paracentric: inverted material from one arm only, centromere is not Zidovudine (Azidothymidine - AZT) within the inverted segment Thymidine analog that decreases DNA synthesis by reverse Pericentric: breaks are in each arm and the inversion includes the transcriptase inhibition centromere Acyclovir and Ganciclovir o Carriers at high risk to produce abnormal offspring Purine nucleoside analogs Primary herpes and possibly varicella infections Autosomal dominant Amantadine: Prevent or modify influenza If only one member of a gene pair determines the phenotype Oseltamivir: Neuraminidase inhibitor Carrier has a 50% chance of passing on the affected gene with Metronidazole: Vaginal trichomoniasis and bacterial vaginosis each conception Lindane Penetrance: Describes expression of a mutant gene Topical for pediculosis pubis and scabies Expressivity: Degree to which the phenotypic features are Crotamiton expressed o First line treatment of scabies Anticipation Chloroquine: First line antimalarial Disease symptoms become progressively severe and age at Pyrimethamine and Spiramycin: Folic acid antagonist manifestation become earlier with each succeeding generation Autosomal recessive: Traits are expressed only if both copies of Antihypertensive Agents the gene function identically Methyldopa Consanguinity: Mating between third degree relatives Widely used agent Co-dominant genes: Different alleles in a gene pair both are expressed Treatment of choice for chronic hypertension in a phenotyope Sodium Nitroprusside: accumulation of cyanide in the fetal liver Calcium Channel Antagonists X – and Y – linked genes Decreased uterine blood flow X – linked: usually recessive First trimester use: limb defects X – linked dominat disorders affect females predominatly Verapamil: fetal cardiac depression and arrest when used in o Lethal in male offspring combination with Digoxin Salicylates and Acetaminophen 13. Nonmendelian Patterns of Inheritance Premature closure of the ductus arteriosus because of Fragile X – syndrome (Martin – Bell syndrome) prostaglandin inhibition Most common form of familial mental retardation Narcotics Huntington Disease Meperidine, Morphine characterized by progressive chorea, bradykinesia, and rigidity with o Neonatal withdrawal symptoms an insidious deterioration of intellectual function Illicit drugs Marijuana or Hashish Imprinting o THC teratogenic in high doses in animals Certain genes are inherited in an inactivated or transcriptionally Amphetamines, Methamphetamines silent state o Symmetrical fetal growth restriction Example: Heroin o Maternal chromosome 15 missing: Angelman syndrome o Fetal growth restriction, perinatal death o Paternal: Prader – Walli syndrome o Withdrawal symptoms
Unipaternal disomy TERATOLOGY
Both member of one pair of chromosome are inherited from 1. Hadegen – agent that interferes with normal maturation and the same parent function of an organ 2. Trophogen – agent that alters growt 3. Exposure must occur during a critical developmental Sulfonamides period Compete for bilirubin biding sites ⌐ Embryopathy – first 8 weeks Hyperbilirubinemia if used near term ⌐ Fetopathy – after 8 weeks Trimethoprim – Folic Acid antagonist Embryonic period (2nd – 8th week) 6. Tobacco ⌐ Most crucial for malformations because of Increased Poland sequence organogenesis o Interruption of vascular supply to chest and arm 7. Thalidomide Genetic and Physiological Mechanisms of Teratogenicity Anomalies of the structures derived from the mesodermal layer 1. Disruption of Folic Acid Metabolism Upper limbs more severely affected Folic acid essential for production of methionine o Upper limb phocomelia: 27-30 days o Cofactor in RNA and DNA synthesis o Lower limb phocomelia: 30-33 days Antagonists o Hydantoin INTRAPARTUM ASSESSMENT o Carbamazepine o Valproic Acid Electronic Fetal Monitoring (EFM) o Phenobarbital 1. Cardioregulatory Center 2. Fetal Genetic Composition Collection of neurons in the ventral and lateral surfaces of the Interaction of environment and altered genes medulla in the region of the 4th ventricle Homozygosity of the fetus 2. Direct CRC connection Examples: o Cigarette smoking and cleft palate in Parasympathetic pathway via the vagal nuclei to the afferent polymorphism of the TGF α-1 cardiac vagal fibers 3. Homeobox Genes Sympathetic control via impulses traveling through the spinal o Retinoic acid that can activate a gene prematurely cord, to the cervical and thoracic sympathetic ganglia ten to o Valproic acid which activates 5’ the cardiac sympathetic fibers NTD in lumbosacral area 3. Indirect CRC control Sympathetic discharge and release of catecholamines from Known Teratogens 1. Alcohol the fetal adrenal gland Most potent teratogen 4. Stimulation of the CRC Fetal Alcohol Syndrome (FAS) Mediators: 2. Anticonvulsant medications Aortic arch and carotid body chemoreceptors (acidemia) Phenytoin: Hydantoin Syndrome Aortic arch and atrial baroreceptors (volume) Carbamazepine Premise: fetal heart rate pattern charges reflect fetal oxygenation Valproic Acid: Exclusively in the lumbosacral region 5. Internal EFM 3. Warfarin compounds Between 6-9 weeks – warfarin embropathy Peak R-wave voltage most reliably detected o Nasal hypoplasia Electrical impulse is counted and not the actual heartbeat o Stippled vertebral and femoral epiphyses 6. Fetal Heart Rate Patterns o Inhibits post-translational carboxylation of Baseline rate coagulation proteins (osteocalcins) Beat-to-beat variability o Phenocopy of chondrodysplasia punctata Periodic changes (inherited defect of osteocalcin) 2nd-3rd trimester – effect of fetal hemorrhage Accelerations o Dorsal midline CNS Decelerations Agenesis of the corpus callosum o Early Dandy-Walker malformation o Late Midline Cerebellar Atrophy o Variable 4. Antineoplastic Drugs Arrhythmias Methotrexate/Aminopterin Sinusoidal pattern Alters folic acid metabolism MTX: abortifacient 7. Baseline beat-to-beat variability R-wave to R-wave oscillation 5. Antimicrobials Important index of cardiovascular function Tetracycline Yellow-brown discoloration of deciduous teeth 8. Long-term variability Deposited in fetal long bones Oscillatory changes that occur during a course of 1 minute Aminoglycosides Result in waviness of the baseline FHR Streptomycin – CN VIII damage Undetectable o Absent variability Observed with acute, lethal asphyxia more than 1 hour fetal Minimal hypoxia with profound metabolic academia (pH less than 7.0) o ≤ 5 bpm Moderate Criteria to Define an Acute Intrapartum Hypoxic Event as Sufficient to Cause CP o 6-25 bpm Metabolic acidosis (pH < 7, base deficit ≥ 12 mmol/L) Marked Early onset severe or moderate neonatal encephalopathy o > 25 bpm in infants born beyond 34 weeks 9. Accelerations Spastic quadriplegic or dyskinetic CP Increase in the fetal baseline heart rate by at least 15 bpm lasting Exclusion of other identifiable etiologies for at least 15 seconds Signals fetal well-being Benefits of EFM o Intact neurohormonal cardiovascular fetal control of behavioral Current recommendations o Intermittent auscultation or continuous EFM for states both low- and high-risk patients 10. Early Decelerations o Every 30 minutes (low-risk) and every 15 Related to cervical dilation (active labor) minutes (high-risk) intervals during the first Head compression dural stimulation vagal nerve activation stage 11. Late Decelerations o Every 15 minutes (low-risk) and every 5 minutes Index of uterine perfusion or placental function (high-risk) during the second stage 12. Variable Deceleration INTRAPARTUM SURVEILLANCE OF UTERINE ACTIVITY Most common pattern encountered during labor Patterns of Uterine Activity Abrupt decrease in rate that varies with successive contractions Montevideo Units Duration less than 2 minutes o Product of the intensity multiplied by the Occur only after fetal blood flow is reduced by at least 50% contraction frequency in 10 minutes Significant: decrease to less than 70 bpm and last more than Braxton-Hicks – seldom < than 20 mmHg 60 seconds After 30 weeks, activity starts to increase 13. Prolonged deceleration Labor commences between 80 – 120 mm MVU Isolated decelerations lasting at least 2 minutes but shorter than 10 Palpable uterine contractions – beyond 10 mmHg minutes Associated with pain – 15mmHg Normal Labor 14. Sinusoidal heart rate Minimum of 3 contractions averaging greater than 25 mmHg Usually due to fetal anemia and less than 4 minute intervals between contractions Characteristics: o Stable baseline heart rate of 120-160 bpm MENSTRUATION o Amplitude of 5-15 bpm 1. Cell bodies of the hypothalamus that produce GnRH: ant. o Frequency of 2-5 cycles/min long-term variability Hypothalamus and medial basal hypothalamus o Oscillation above or below the baseline 2. GnRH producing neurons (greatest number): arcuate nucleus o Absence of accelerations of the medial basal hypothalamus* 15. Fetal scalp blood sampling 3. Major route of GnRH: tuberoinfundibular tract* > 7.25: allow labor to go on 4. Follicular phase: 1 pulse/hr 7.20-7.25: repeat measurement within 30 minutes 5. Luteal phase: 1pulse/3 hr < 7.20: repeat measurement immediately while preparing to 6. Cause of hypothalamic pituitary failure: sever weight loss, expedite delivery strenuous exercise, anorexia nervosa* FETAL DISTRESS 7. Biogenic amines secreted by a nerve cell that produce an Diagnosis action on another cell: neurotransmitters* (dopamine and NE) Normal 8. Dopamine: precursor of NE, inhibitory to GnRH o Baseline 110 – 160 beats per minute 9. NE: release of GnRH o Variability 6 -25 10. Neuromodulators: affect action of neurotransmitters (opiods : o (+) accelerations o No decelerations inhibitory, PGE: stimulatory, catecholestrogens) Abnormal 11. FSH: granulosa cells o Recurrent late or variable decelerations + - Follicular growth* by inc. FSH and LH receptor; undetectable variability enhanced by estrogen o Substantial bradycardia + undetectable variability 12. LH: theca cells FHR patterns and Brain Damage - Stimulate androgen synthesis (theca cells) Nonspecific FHR patterns mostly present prior to admission or - Stimulate progesterone synthesis (corpus luteum) an average duration of 72 minutes Abnormal brain histopathology not 13. 2 cell two gonadotrophin concept *: LH (theca cells) – 2. 4 phase: quiescence, activation, stimulation, involution androgens (androstenodione & testosterone) –aromatase – 3. Uterine tranquility with maintenance of cervical structure FSH (granulose cells) – estrogens (estrone & estradiol) integrity – quiescence 14. Hormonogensis: secretory activity of the ovary 4. Progression of changes in uterus during last 6 – 8 week of 15. Folliculogenesis: gametogenic activity pregnancy – activation 16. Steroid hormones: estradiol, progesterone and 5. Associated with the capacity of the cervix to retain water – androstenodione Hyaluronic acid - Estradiol --- estrone 6. Causes collagen fiber cross linking – dermatan sulfate 100-500 ug* (daily) 7. Key protein that control myometrial contractility – Contraction- Lowest : onset of mens associated protein Peak: before midcycle LH peak 8. Fetal heads often times descends to or even through the SHBG pelvic inlet – lightening - Progesterone 9. Uterine contraction that bring about progressive cervical 4 mg (follicular) dilation and delivery 30 mg (luteal) 10. 3 stages of labor CBG Stage of cervical effacement and dilatation 17. Meosis*: germ cells Expulsion of fetus Prophase: diploid (46) – haploid (23) Separation and expulsion of placenta 18. Spermatogenesis: 53 days* 1. Extrusion of mucus plug that has filled the cervical canal – Seminiferous tubules of the testes blood show 2. Causes pain during uterine contraction Primary spermatocytes – first meiotic division – 2 Secondary spermatocytes – 2nd meiotic division – 4 Hypoxia of the contacted myometrium spermatids – spermatozoa (thru spermiogensis*) Compression of the nerve ganglia in the cervix and 19. Oogenesis and follicular maturation uterus by interblocking muscle bundles 1. Early follicular formation Stretching of the cervix during dilatation Day 24 of fetal life – oogonia from yolk sac – Stretching of the peritoneum overlying the fundus gonadal ridge – primitive gonad 1. Mechanical stretching of the cervix which enhance uterine 3rd month *– increase oogonia -- 1st meitotic – cavity – ferguson reflex primary oocytes – primordial follicle (single layer of 2. Duration of each contraction (active phase of labor) – 30 – 90 granulose cells) – maturation arrested – 6 M to 2 M seconds (ave. 60s) follicles during neonatal period – 400,000* at 3. Firm or hard during contraction – upper uterine segments menarche – 8,000 at 40-44 y.o. 4. Boundary bet. Two segments (upper and lower) marked by 20. Primary oocyte – zona pellucida – granulose cells (2-5 layers) ridge – Physiologic retraction ring –no antrum : primary /pre-antral follicles 5. Pathologic retraction ring seen in obstructed labor – Bandl ring 21. Recruitment: cohort follicle 6. Changes in uterine shape during labor 22. LH surge: 24 hours after the estradiol peak Lengthening of the fetal ovoid due to straigthening 23. OMI (oocyte maturation inhibitor): prevents the early of fetal vertebral column (4-5 cm) cause by fetal maturation of the oocyte axis pressure 24. 34-36 hrs ff the onset of LH surge: follicular rupture and Lengthening of the uterus oocyte extrusion 1. 3 principal structure of the cervix: collagen, smooth muscle, 25. Pre-pvulatory: 1st meitotic division extracellular matrix 26. Fertilization: 2nd meitotic division 2. Extracellular matrix includes: hyaluronic acid, dermatan 27. Dominant follicle: corpus luteum sulfate, glycosaminoglycans 28. LDL cholesterol: substrate of progesterone synthesis in 3. Shortening of the cervical canal from 2 cm to a mere circular corpus luteum orifice w/ almost paper thin edges – cervical effacement ( 29. Corpus luteum of menstruation: corpus albicans obliteration or taking up) 30. Hcg stimulation: 1st tri maintains steroid prod’n beyond 7th 4. Centrifugal pull is exerted on the cervix leading to distention – gestational week cervical dilatation 31. Life span of corpus luteum: 14+2 days 5. Active phase includes: acceleration, maximum slope, deceleration FOURTH SHIFT (Dr. Villaluz) 6. Levator ani consist of: pubococcygeus and iliococcygeus 7. Blood from the placental site pours into inverted sac – Parturition Schultze mechanism 1. Bring forth of young – parturition 8. Separation of the placenta occurs first at the periphery, with Head – hard, round, ballotable, mobile results that blood collects bet. The membrane and uterine 16. Palms are place on either side of the maternal abdomen w/ walll and escapes through vagina – Duncan Mechanism gentle but deep pressure – LM2 9. 2 theory of the mechanism regulating the initiation of labor BACK – hard resistant structure Retreat from the pregnancy maintenance FETAL EXTREMITIES – numerous small irregular Uterotonin induction of parturition mobile parts 10. Establish a conduit for exchange of small molecules and ions ORIENTATION – directed anteriorly, transversely, between cell – connexons or posteriorly 11. 3 major class of cell surface receptors: G-protein linked, ion- 17. Palpation of the presenting part – LM3 channel linked, enzyme linked 18. Examiner faces the mother’s feet and with the tips of first 3 12. Fail safe system that maintains uterine quiescence: fingers of each hand exerts deep pressure in the direction of Action of estrogenand progesterone via intracellular the axis of pelvic inlets – LM4 receptor 19. Cardinal movements of labor: engagement, descent, flexion, Myometrial cell plasma membrane receptor- internal rotation, extention, external rotation, and expulsion mediated increases Camp 20. Mechanism by w/c biparietal diameter passes through pelvic Generation of Cgmp inlet - engagement Myometrial cell ion channels 21. Lateral defelction of head to a more ant./post. Position in the pelvis – Asynclitism MECHANISM OF LABOR 22. Sagittal suture approaches the sacral promontory – Anterior 1. Relation of the long axis of the fetus to that of the mother – lie asynclitism 2. Fetal and the maternal axes may cross at a 45 degree angle – 23. Sagittal suture lies close to symphysis – Posterior asynclitism oblique lie 24. First requisite for birth of newborn – descent 3. Predisposing factors for transverse lie: mulitparity, placenta 25. Causes of descent: previa, hydramnios,uterine anomaly Pressure of amniotic fluid 4. Occipital fontanel is the presenting part – vertex/occiput Direct pressure of the fundus w/ contraction 5. Fetal neck sharply extended so that occiput and back come in Bearing down efforts of the maternal abdominal contact – face presentation muscle 6. Partially flexed head w/ anterior fontanel or bregma presenting Extension and straightening of the fetal body – sinciput presentation 26. The occiput has to internally rotate to symphysis pubis 7. Partially extended head – brow presentation through 135 degree angle – Occiput post 8. Amniotice cavity is large compared w/ the fetal mass and 27. Transverse arrest – incomplete rotation there is no crowding of the fetus by uterine walls – at 32 28. Persistent occiput posterior – no rotation occurred weeks 29. Edematous or swelling of fetal head due to prolong labor – 9. 3 configuration of breech presentation: frank, complete, caput succedaneum footling 30. Overlapping of the parietal bones due to external compressive 10. Fetal attitudes/posture: forces – molding Fetus forms ovoid mass 31. Criteria for labor: Back becomes markedly convex Painful uterine contraction Head sharply flexed in contact w/ the chest Ruptured of membrane Thigh are flexed over the abdomen Bloody show Legs are bent at the knees Complete cervical effacement Arches of the feet rest upon the anterior surface of 32. Friedmann 3 functional division: the legs Preparatory – connective tissue component of the 11. Refers to relationship of an arbitrarily chosen portion of fetal cervix change considerably (affected) presenting part to the right/left side of the maternal birth canal Dilatational – dilatation proceeds at is most rapid – fetal position rate (not affected by anestheis and sedation) 12. 2/3 of vertex – left occiput position 1/3 of vertex – right OP Pelvic division – commences w/ deceleration phase 13. Portion of the fetus chosen for orientation in shoulder of cervical dilatation. presentation – Acromion (scapula) 33. Point at w/c the mother perceives regular contraction( 4 cm) – 14. Methods of diagnosis fetal presentation/position: abdominal latent phase palpation, vaginal examination, auscultation, ultrasound. 34. Prolonged latent phase - >20hrs in nulliparas; >14 hrs in 15. Identification of fetal pole (breech or head) occupies the multiparas fundus – LM1 BREECH – large nodular mass 35. Causes of prolonged latent phase: excessive sedation or 55. very useful clinical tool to identify those neonate whoe require epidural anesthesia, false labor, unfavorable cervix resuscitation – APGAR 36. Active labor - >4cm with uterine contraction 56. H2CO3 accumulates in fetal blood w/o increase in organic 37. Protraction – slow rate of cervical dilatation or descent : acid – respiratory academia nulliparas - <1.2 cm/hr <1cm descent/hr; Multiparas - 57. Organic acid accumulates w/o increase in h2co3 – metabolic <1.5cm/hr and <2cm descent/hr academia 38. Arrest – complete cessation of dilatation and descent: 58. Both increase – mixed respiratory –metabolic acidemia Dilatation – 2hrs with no cervical changes; descent – 1 hr w/o fetel descent SIXTH SHIFT (Dr. Tingkahan) 39. Factors contribute to arrest: excessive sedation, vaginal ABORTION anesthesia, fetal malposition -the termination of pregnancy prior to 20 weeks or less than 500g birth 40. Duration of 2nd stage of labor – 50 minutes in nulliparas; 20 weight minutes in multiparas Abortion without medical or mechanical means – Spontaneous 41. 18.5 hrs – nulliparas; 13.5 hrs – multiparas abortion 42. Ruptured of membrane is significant for 3 reasons: The skull bones collapse, abdomen distends with blood stained fluid, Umbilical cord prolapsed and compression and organs degenerate – maceration Amniotic fluid is absorbed, fetus becomes compressed and desiccated – Pregnancy is at near term fetus compressus Intra-uterine infection is more likely -if dry and compressed – fetus papyraceous 43. Vaginal discharge ph – 4.5 – 7.5 Increase in age – increase risk of abortion 44. Amniotice fluid ph – 7 – 7.5 Accounts for most of pregnancy wasted – chromosomal abnormalities 45. PH >6.5 – consistent with ruptured membrane Most frequent chromosomal anomaly assoc. With abortion – autosomal 46. Level of the presenting fetal part in the birth canal – station trisomy 47. Dorsal lithotomy – most frequent maternal position Second most common – monosomy X (45x) Smoking more than 14 sticks / day – 2x increase risk of abortion 48. Encirclement of the largest head diameter by the vulvar ring – Alcohol consumption 2x a week = doubles risk, daily = triples risk crowning If IUD fails to prevent pregnancy, will result in – septic abortion 49. Controlled delivery of the head: gloved-hand used to exert Death due to toxic shock syndrome – Clostridium pressure on the chin of the fetus through the perineum while sordellii other hand exerts pressure superiorly against occiput – Ritgen Uterine synechiae, from destruction of large areas by curettage – Maneuver asherman syndrome Painless cervical dilatation in 2nd trimester with prolapse and ballooning 50. Signs of placental separation: of membranes into the vagina, followed by expulsion of fetus – Uterus becomes globular and as the rule firmer – incompetent cervix earliest sign Ballooning of the membranes into a dilated internal cervical os with Sudden gush of blood closed external os – funnelling Uterus rises in the abdomen because placenta Contraindication to cerclage: passes down in the lower uterine segment and Bleeding vagina Uterine contraction Ruptured membranes Umbilical cord protrudes farther out of vagina 2 types of cerclage: 51. Grave complication associated w/ delivery of the placenta – Mcdonald: simplier inverted uterus Shirodkar: complicated; reserved for women with failure of previous mcdonald / structural cervical abnormalities NEWBORN INFANT Bloody vaginal discharge to a closed cervix – threatened abortion 52. Factors influence first breath air: Gross rupture of membranes with leaking amniotic fluid and cervical Physical stimulation dilatation – inevitable abortion Deprivation of oxygen and accumulation of CO2 Uterus retains a dead fetus with closed cervix – missed abortion Compression of thorax Prolonged retention of a dead fetus causes – coagulation defects 3 or more consecutive spontaneous abortions – recurrent abortion 53. Fetal failure to established respiration is caused by: Insufficient progesterone secreted by the corpus luteum or placenta – Fetal hypoxia and acidosis progesterone deficiency / luteal phase defect Drugs administer to the mother Medical / surgical termination of pregnancy – induced abortion Fetal immaturity Request of a woman to terminate pregnancy not for reasons of maternal Upper airway obstruction health – elective (voluntary) Abortion Most common form of suction curettage – vacuum aspiration Pneumothorax MANAGEMENT septicemia Dilatation and curettage 54. indicated for reversal of respiratory depression in newborn Transcervical approach to abortion infant – naloxone Mechanically scrapping out of contents with sharp curettage, Serum progesterone suction, or both Uterine curettage Dilatation and evacuation Laparoscopy, occasionally laparotomy 16 weeks, fetal size and structure dictate this use TREATMENT Large bore vacuum curette is used -tx of choice Surgical Mechanical destruction and evacuation of fetal parts o If with tubal salvage – conservative Dilatation and extraction o Salphingectomy (without salvage) – radical Similar to D&E except suction evacuation of the intracranial Salphingostomy : content remove small conceptus less than 2cm Minimizes uterine or cervical injury and distal third of the tube Hygroscopic dilators – slowly dilating the cervix by drawing water from incision not sutured, heal by secondary cervical masses intention Drugs for early trimester: Salphingotomy – incision is closed with 7-O vicryl Antiprogestin – mifepristone Salphingectomy: Antimetabolite – methotrexate For ruptured and unruptured Prostaglandin – misoprostol Wedge shaped excision of the outer third **Ovulation resumes as early as 2 weeks after abortion of tubes (corneal resection) ECTOPIC PREGNANCY o Minimize recurrence of Highest risk causing ectopic pregnancy – prior tubal surgery pregnancy in tubal stump Most frequent site – ampulla Segmental resection and anastomosis – for unruptured Usual outcome of ampullary pregnancy – abortion ectopic pregnancies Usual outcome of isthmic pregnancy – rupture Result of incomplete removal of trophoblast – persistent ectopic Large conceptus that becomes calcified – lithopedion pregnancy Implantation at tubal segment that penetrates the uterine wall – Factors which increase risk: interstitial / corneal Small pregnancy less than 2cm -Interstitial preg. are fatal due to severe hge from: Early therapy Ovarian arteries bHCG levels more than 3000 mIU/ml Uterine arteries implantation medial to salphingostomy site Tubal pregnancy accompanied by coexisting uterine gestation – antineoplastic drug acts as folic acid antagonist, effective against rapidly heterotypic ectopic pregnancy proliferating trophoblast – systemic methotrexate Consider if: most important contraindication to methotrexate – active intra Hx of assisted reproductive technique abdominal hge (ART) ABDOMINAL PREGNANCY Persistent or rising HCG levels Imaging used to confirm abdominal pregnancy – MRI bitches! Uterine fundus larger than menstrual date CT is more superior to MRI but is less frequently used due to risk of – than one corpus luteum fetal radiation Absent uterine bleeding with S/S of Management of abdominal preg – termination of pregnancy ectopic pregnancy Results when bacteria gain access to gestation – suppuration Product of conception plant from uterine cavity to interstitial portion – Fetus is converted to yellowish, greasy mass – adipocere tubo-uterine pregnancy Management of the placenta – leave it in place! Fimbriated end extending to peritoneal cavity – tubo-abdominal OVARIAN PREGNANCY pregnancy Most common cause – use of IUD Adherent to tubal and partially to ovarian tissue – tubo-ovarian Management for early bleeding for small lesions – ovarian wedge pregnancy resection / cystectomy Characteristic pain of unruptured ectopic pregnancy – sharp, stabbing, For larger lesions – ovariectomy or tearing; unilateral, lower abdomen CERVICAL PREGNANCY Pain in the neck or shoulder especially during inspiration – -due to increase use of ART diaphragmatic irritation Most common presenting sign – painless vaginal bleeding Most frequent symptom of ectopic – pelvic and abdominal pain If ruptured anywhere in the abdomen GESTATIONAL TROPHOBLASTIC DISEASE -pregnancy related trophoblastic proliferative abnormality DIAGNOSES H. MOLE HCG -abnormality of chorionic villi consisting of trophoblastic proliferation and Rapid and accurate determination of pregnancy edema of the villous stroma Greater than 150,000 MIU, consider ectopic -complete and partial Serum progesterone Usual chromosomal composition of complete mole – 46XX paternal Value > 25 ng/dl – exclude ectopic pregnancy If 46XY – dispermic fertilization Value < 5 ng/dl – suggests dead intrauterine fetus or ectopic Most common chromosomal composition of partial mole – triploid pregnancy 69XXX, 69XXY, 69XYY Method of choice for Dx Multimodality diagnosis: Over stimulation of letein elements by large amounts of HCG – theca Transvaginal sonography lutein cyst Serum bHCG Indication for oophorectomy – if ovary is extremely infracted Universal symptom for H. Mole – bleeding; characteristic – intermittent PLACENTA PREVIA for weeks to months -total, partial, marginal, low-lying Thyrotoxicosis in H. Mole – due to the thyrotropin like effects of HCG -no digital internal exam CLINICAL PRESENTATION Hemorrhage may continue after delivery due to – lower uterine segment Significant N&V contracts poorly Uterine bleeding is universal Simplest, most precise and safest method of placental localization – Uterine growth more rapid than expected transabdominal sonography Early preeclampsia may develop with large moles Management – CS Diagnosis – sonography POSTPARTUM HGE Treatment of choice – vacuum aspiration after removal oxytocin is -more than 500ml of blood loss after completion of 3rd stage given after myometrium has contracted, thorough but gentle Delivery of the placenta: curettage with large sharp curette massage the fundus if not contracted if pregnancy not desired – hysterectomy administer 20U oxytocin in 1000ml LR GESTATIONAL TROPHOBLASTIC NEOPLASIA o oxytocin bolus – never! causes hypotension Choriocarcinoma – cancer of the chorionic epithelium, behaves like a and cardiac arrhythmias sarcoma if bleeding is unresponsive to oxytotics – suspect genital laceration / Important diagnostic feature – absence of villous pattern uterine rupture Most common site of metastasis – lungs most common cause of late peurperial bleeding – retained placental Excessive trophoblastic overgrowth and extensive penetration of fragments trophoblastic cells – invasive mole placenta accreta - placental implantation with abnormally firm Arise from placental implantation – placental site trophoblastic adherence to uterine wall tumors placenta increta – invades myometrium Characteristic histology – cytotrophoblastic cells; placenta percreta – penetrate to myometrium Immunohistochemical staining – more prolactin producing postpartum hge due to necrosis of ant. Pituitary – Sheehan syndrome cells, less gonodotropin releasing cells o failure of lactation *serum bHCG are low compared to other mass o amenorrhea CT scan of the chest and head is only recommended if CXR is o breast atrophy abnormal o loss of pubic and axillary hair If with brain metastasis - chemotherapy with radiotherapy o hypothyroidism Placental site tumor treatment – hysterectomy; chemotherapy not as o adrenal cortical insufficiency effective as other masses consequence of strong traction on an umbilical cord attached to High risk – EMA-CO placenta in uterus – inversion of the uterus Pregnancy after GTN: GENITAL TRACT LACERATION o 6 months – molar vaginal lacerations frequently result from – forcep / vacuum o 1 year – GTN injuries to levator ani results from – overdistention of the birth canal o 2 years – metastasis other than lungs treatment for severe, enlarging vulvar hematoma – incision and drainage HEMORRHAGE most common cause for uterine rupture – separation of previous -leading cause of matrernal mortality caesarean hysterectomy scar Antepartum: placenta previa, placental abruption FLUID RESUCITATION Postpartum: unterine atony, genital tract laceration Crystalloid solutions typically are used for initial resuscitation Tearing of small veins as a consequence of effacement and dilatation – Women acutely bleeding – rapid transfusion if: bloody show hct less than 25 volumes % Separation of placenta before delivery – placental abruption haemoglobin less than 8g/dl o Bleeding escapes to cervix- external hge if there is imminent surgery, acute operative blood o Bleeding retained between detached placenta and loss, acute hypoxia, vascular collapse uterus – concealed hge **Whole blood is ideal for treatment of hypovolemia from Consumptive coagulopathy and bleeding catastrophic acute hge cannot be estimated COMPLICATIONS OF TRANSFUSION Most commonly associated with abruption – hypertension Haemolytic transfusion reaction – transfusion of incompatible blood Others: PPROM, smoking, cocaine, thrombophilias, component trauma, uterine leiomyoma o DIC Widespread extravasation of blood into the uterine musculature and o Acute renal failure beneath the uterine serosa – couvalaire uterus / uteroplacental o Death apoplexy Transfusion related acute lung injury (TRALI) – life threatening Management – delivery; if immature – delay it condition characterized by sever dyspnea, hypoxia, and non cardiogenic Contraindications to tocolysis – clinically evident placental abruption pulmonary edema Amniotomy – if mature Develop within 6 hours of transfusion if immature – more helpful if sac is intact Bacterial contamination – most common is Yersinia enterocolittica aids in dilating the cervix administer oxytocin – if no rhythmic contractions SEVENTH SHIFT (Dr. Albano) 2. What is the largest contributor to infant mortality? PREGNANCY HYPERTENSION - preterm birth 1. In Gestational Hypertension the BP returns to normal in how many 3. What is the threshold of viability? weeks? - 26 wks and at least 750 gms - less than 12 weeks 4. When does active brain development normally occurs? 2. What are the minimum criterias of Pre-eclampsia? - 2nd and 3rd trimesters - 140/90mmHg after 20 wks AOG 5. It is defined as the rupture of the membranes before labor and prior to - proteinuria >/= 300mg/24hrs or +1 dipstick(30mg/dl) 37 wks? 3. It is a seizure that cannot be attributed to other causes in a woman - preterm premature rupture of membranes with preeclampsia. 6. What are the pathogenesis of preterm labor? - Eclampsia - progesterone withdrawal 4. What are the effects of a normal trophoblastic invasion to the -oxytocin initiation uteroplacental arterial bed? -decidual activation - low resistance 7. What is the major risk factor for preterm labor? - low pressure - prior preterm delivery - high flow system 8. What is the most common perinatal organism? 5. It is an inadequate maternal vascular response to placentation. -U. urealyticum - Abnormal trophoblastic invasion 9. It is an irregular, nonrhythmical and either painful/painless contraction 6. It is a state of vasoconstriction and high resistance to UteroPlacental that can cause considerable confusion of a true preterm labor. blood flow.. -Braxton hicks contraction - Placental Ischemia 10. What are the criterias to document preterm labor? 7. What are the pathogenesis of PreEclampsia? - contractions of 4 in 20mins or 8 in 60mins - Vasospasm - cervical dilatation >1cm - endothelial cell activation - cervical effacement of >/= 80% - increase pressor response 11. It is the bulging of the membranes into the endocervical canal and 8. What dietary mineral deficiency increases the risk for gestational protruding at least 25%of entire cervical length? hypertension? - funnelling - calcium 12. It is characterized by recurrent, painless cervical dilatation and 9. What is the definitive therapy for preeclampsia. spontaneous midtrimester birth in the absence of spontaneous - Delivery membrane rupture, bleeding, or infection. 10. What is the effective anticonvulsant for eclampsia? - incompetent cervix -MgSo4 13. Single dose corticosteroid therapy is recommended for what AOG? 11. What can you find in the arteries taken from the implantation site in - 24 to 32 weeks preeclamptic women? 14. What is the cornerstone of treatment for preterm labor with intact -atherosis membranes? 12. What is the fuckin’ hallmark of eclampsia? - avoid delivery prior to 34 wks - hemoconcentration 15. What drug reduces intracellular ionized calcium levels and prevent 13. What glycoprotein associated with vascular endothelial cell activation of myometrial contractile proteins? basement membrane injury? - Beta adrenergic receptor agonists (Ritodrine) - fibronectin 16. What is the frequent, serious, and fatal side effect of B-agonists? 14. What is the most common finding in the kidney of an eclamptic - pulmonary edema biatch at autopsy? 17. What is the third most common cause of acute respiratory distress - glomerular capillary endotheliosis and death in pregnant women? 15. Also called occipital blindness in preeclamptic whore. -Tocolysis - Amaurosis 16. What is the common antihypertensive agent used in preeclamptic POSTTERM BIRTHS women? 1. What is the term for an infant that has a recognizable clinical features - hydralazine indicating a pathologically prolonged pregnancy? 17. What antihypertensive drug linked with cyanide poisoning? - Post mature -sodium nitroprusside 2. What is the preferred expression for an extended pregnancy or 18. What antihypertensive drug causes growth restriction? pregnancy for 42 completed weeks? -labetalol -Post term/prolonged 19. What is the therapeutic dose of MgSO4? 3. What is the etiology of the skin changes of postmaturity? - 4 to 7 meq/L - loss of protective effects of vernix caseosa 20. What is the treatment of MgSO4 toxicity (10g+absent patellar 4. What is the characteristic electronic monitor finding of uteroplacental reflex)? insufficiency? - Ca gluconate 1g IV and STOP taking the friggin drug mofo - late decelerations 5. What is the most common complication of a growth restricted post PRETERM BIRTHS term infant? 1. What percentile designates an appropriate for gestational age weight - stillbirth in newborns? 6. It is directly related to Cesarean delivery rate. - Between the 10th and 90th percentile. - station of vertex 7. When is the time where initiation of fetal surveillance becomes a - symmetrical GR reasonable option? 3. What type of growth restriction results from a late insult such as - 41 weeks placental insufficiency from hypertension that would lead to brain sparing. MULTIFETAL PREGNANCY - asymmetrical GR 1. It is a result from fertilization of 2 separate ova and is influenced by 4. What biometric measurement is most commonly abnormal in cases of race, heredity, age and parity. growth restriction? - dizygotic - Abdominal circumference measurement 2. It is a result from fertilization of a single ovum and independent of race, heredity, age and parity.. ABNORMALITIES OF PLACENTA, CORD AND MEMBRANES - monozygotic 1. What type of placental anomaly has a large part of the fetal 3. It is the fertilization of 2 ova within the same menstrual cycle, but not membranes being covered by functioning villi? at the same coitus. - Placenta Membranacea / Diffusa -superfecundation 2. What type of placental anomaly has a missing central portion of 4. What age is the peak of pregnancy twinning? discoidal placenta? - 37 y.o - Placenta fenestrate 5. What day does the chorion differentiates? 3. It has one or more small accessory lobes develop in the membranes - day 4 at a distance from the main placenta. 6. What day does the amnion differentiates? - succenturiate lobe -day 8 4. What placenta presents a central depression surrounded by a 7. In monozygotic twins, if division occurs within the first 72 hours after thickened, gray-white ring? fertilization. - circumvallate placenta - DIAMNIOTIC, DICHORIONIC 5. What placenta has a ring that does not have a central depression? 8. If division occurs, between the 4th to 8th day after fertilization. - circummarginate placenta - MONOCHORIONIC, DIAMNIONIC 6. It is a placental hematoma that is of fetal vessel origin and it is found 9. If division occurs the 9th day -13th day after fertilization. in between the placenta and amnion. - MONOCHORIONIC,MONOAMNIOTIC - Subamnionic hematoma 10. If division is initiated after the 13th day. 7. It is a benign tumor of the placenta. - CONJOINED TWINS - Chorioangioma 11. As a determinant of twinning, which family history is more 8. It is a full thickness infection of the membranes. important? - Chorioamnionitis - Mother 9. It is a subsequent inflammation of the chorionic plate and the 12. It causes an elevation of maternal serum and amnionic afp and a umbilical cord. positive acetylcholinesterase assay. - funisitis - Vanishing twin 10. What is the normal length of the umbilical cord? 13. It is the most important determinant in risk assessment and -50 to 60 cm management in multifetal gestation. 11. What is the fetal significance of hypocoiling? - chorionicity - fetal demise 14. It has the most rates of perinatal mortality and neurological injury. 12. What is the fetal significance of hypercoiling? - monochorionic diamionic - fetal growth restriction 15. It is a triangular projection of placental tissue is seen to extend - intrapartum fetal acidosis beyond the chorionic surface between the layers of the dividing - asphyxia membrane, then there are two fused placentas. 13. What is the perinatal prognosis if a two vessel umbilical cord is an - twin peak sign isolated sonographic finding? 16. It is the right angle of relationship between the membranes and - better placenta with no apparent extension of placenta between the dividing 14. What risk is associated with a two vessel cord in a nonisolated membrane. finding? - T sign - aneuploidy 17. It is the most definitive test to diagnose twinning. 15. It is the connection between 2 umbilical arteries that acts as a - DNA fingerprinting pressure equalizing system between umbilical arteries. 18. It is the most common type of conjoined twins. - Hyrtl anastomosis - parapagus 16. It is the cord insertion at the placental margin. 19. What mode of delivery do you prefer if the first twin is non-vertex - battledore placenta and the second is vertex? 17. What type of insertion when the umbilical vessels spread within the - C/S membranes at a distance from the placental margin? - Velamentous Insertion FETAL GROWTH DISORDER 18. What type of insertion when the umbilical vessels lose their 1. It is defined as birthweight >4000g. protective Wharton’s jelly before insertion? - Macrosomia - furcate insertion 2. What type of growth restriction results from an early insult such as 19. What anomaly presents when the placental vessels overlie the chemical exposure, viral infection and aneuploidy that causes a cervix, lie between the cervix and the presenting fetal part, and are proportionate reduction of body size? supported only by membranes? - Vasa previa PUERPERAL INFECTION 20. It appears as a knob protruding from the cord surface and are focal 1. It is a term used to describe any bacterial infection of the genital tract redundancies of a vessel or Wharton’s jelly and has no clinical after delivery. significance. -puerperal infection - False knots 2. What is the single most significant risk factor for the development of 21. Umbilical cord looped around the neck. uterine infection? - nuchal cord - route of delivery 22. Umbilical cord as the presenting part. 3. What promotes bacterial synergy? - Funic presentation - polymicrobial 23. What are causes of blood accumulations in umbilical cord? 4. What is the most important criterion for the diagnosis of postpartum - short cord metritis? -trauma - Fever - entanglement 5. Chills that accompany fever is suggestive of what condtion? 24. It is a marked focal dilatation that may develop within the - bacteremia intraamnionic part of umbilical vein. 6. What is the gold standard antimicrobial regimen? - umbilical vein varix - clinda+genta 25. It is a rare congenital thinning of the vessel wall with diminished 7. What is the first symptoms of peritonitis? support from wharton’s jelly. - adynamic ileus - umbilical artery aneurysm 8. What condition suppurates, forming a fluctuant broad ligament mass that may point above the inguinal ligament? THE PUERPERIUM - parametrial phlegmon 1. How many days after delivery does the uterus begins to involute? - 2 days EIGHT SHIFT (Dr. Villaluz) 2. How many weeks does the vaginal epithelium starts to proliferate? 8th shift (dr. villaluz) - 4 to 6 weeks PULMO 3. It is describe as an arrest of involution. 1. Vital capacity & inspiratory capacity increase by… - subinvolution a. 20% 4. How many weeks after delivery does lochia persist? 2. Tidal volume - 4 to 8 weeks a. Increase by 40% 5. How many weeks after delivery does complete extrusion of the 3. Most common cause of bacterial pneumonia placental site? a. S. pneumonia - 6 weeks 4. Most common presenting sign/symptom in bacterial 6. It is defined as bleeding 24 hours to 12 weeks after delivery. pneumonia - secondary postpartum hemorrhage a. Cough 7. Known as marked separation of the rectus. 5. Provide objective assessment of maternal oxygenation, - diastasis recti ventilation & acid-base status 8. What are the blood and fluid changes after labor or postpartum? a. ABG -marked leukocytosis 6. Hallmarks of asthma - thrombocytosis a. Reversible airway obstruction -leukopenia b. Vascular congestion - relative lymphopenia c. Tenacious mucus -absolute eosinopenia d. Mocusal edema 9. What are the bladder changes after labor or postpartum? 7. T/F. F-series prostaglandins & ergnovine exacerbate asthma - inc. bladder capacity and should be avoided (TRUE) - relative insensitivity to intravesical pressure 8. Single best measure reflecting severity of asthma : overdistention a. FEV1 : incomplete emptying 9. Therapy for mild intermittent asthma : excessive residual urine a. Inhaled B-agonist 10. How many kg will be loss due to uterine evacuation and normal 10. For severe persistent asthma blood loss? a. High dose inhaled corticosteroids & long acting b - 5 to 6 kg agonist & oral steroids 11. How many kg will be loss due to diuresis? 11. Drugs used in management of bacterial pneumonia - 2 to 3 kg a. Macrolides (erythromycin…) 12. How many lobes does a female have? 12. Common complications with pneumonia - 15 to 25 lobes a. Preterm delivery 13. The removal of this hormone stimulate a-lactalbumin production. b. PROM - progesterone 13. Most common complication of Influenza pneumonia 14. What reflex initiated by suckling, which stimulates the a. Pneumonia neurohypophysis to liberate oxytocin? 14. Most common HIV related disorder in pregnant women -milk ejection or letting down reflex a. Pneumocystis pneumonia 15. Recommended 4 drug regimen for TB a. Isoniazid b. Rifampin HEPATIC, GALLBLADDER & PANCREATIC DISORDERS c. Pyrazinamide d. Ethambutol 1. Most common cause of acute liver failure during pregnancy 16. Recommended initial tx for active TB in pregnant patients a. Acute fatty liver of pregnancy a. Isoniazid 2. After infection w/ hep b, the 1st serologic marker is b. Rifampin a. HBsAg c. Ethambutol 3. Signifies intact viral particles that are present during early 17. Group of drugs w/c are ototoxic and thus contraindicated in acute hepatitis TB infection a. HBeAg a. Aminoglycosides ( streptomycin…) 4. Hepatitis virus which does not actually cause hepatitis a. Hep G RENAL & URINARY TRACT DISORDERS HEMATOLOGIC DISORDERS 1. Clean voided specimen containing more than 100000 org/mL is diagnostic 1. Anemia is defined as hemoglobin concentration a. Asymptomatic bacteriuria a. <12g/dL—nonpregnant 2. Treatment for asymptomatic bacteruria b. <10 g/dL---pregnancy or puerperium a. Nitrofurantoin 2. In a typical singleton gestation,maternal need for iron 3. If Asymptomatic bacteruria is not treated, how many percent a. 1000mg of infected women will develop symptomatic infection? 3. Folic acid a. 25% a. Nonpregnant--- 50-100ug/day 4. Recurrence rate of asymptomatic bacteruria b. Pregnant---400ug/day a. 30% 4. Tx of preg indced megaloblastic anemia 5. Characterized by dysuria, urgency, & frequency a. Folic acid a. Cystitis b. Nutritious diet 6. Lower urinary tract symptoms with pyuria accompanies by a c. Iron sterile urine culture 5. Recommended vaccines for sickle cell & all asplenic patients a. Chlamydia trachomatis urethritis a. Polyvalent pneumococcal 7. Most common serious medical complication of pregnancy b. HiB a. Acute pyelonephritis c. Meningococcal vaccine 8. Cornerstone of treatment in acute pyelonephritis a. IV hydration DIABETES 9. If there is no clinical improvement by 48-72 hrs… a. Sonography 1. Diagnostic cutoff value for overt diabetes is a fasting plasma 10. Leading cause of septic shock glucose a. urosepsis a. 126mg/dL or > 11. Common chief complaint in patients with stone disease 2. Screening performed between a. Pain a. 24- 28 weeks 12. Most common cause of ESRD 3. Plasma glucose criteria a. Diabetes a. Fasting ----95mg/dl (5.3mmol/L) b. Hypertension b. 1 hr--- 180mg/dL (10.0mml/L) c. Glomerulonephritis c. 2 hr------ 155 mg/dL (8.6mmol/l) 13. Acute nephritis d. 3 hr---- 140 mg/dl (7.8mmol/l) a. Hypertension 4. Recommended caloric intake b. Hematuria a. 30 kcal/kg/day (up to 35 kcal) c. Red cell casts 5. Fetal effects of overt diabetes d. Pyuria a. Miscarriage e. Proteinuria b. Preterm delivery 14. Prototypical of acute nephritic syndrome c. Malformations a. Acute post strep glomerulonephritis d. Altered fetal growth 15. Hallmark of nephrotic syndrome e. Unexplained fetal demise a. Proteinuria f. Hydramnios 16. Rapid decrease in gfr over minutes to days 6. Neonatal morbidity & mortality in diabetes is due to a. AKI a. RDS b. Hypoglycemia GI DISORDERS c. Hypocalcemia 1. T/F a female fetus, increases the risk of hyperemesis d. Hyperbilirubinemia &polycythemia gravidarum by 1.5 fold (TRUE) e. Cardiomyopathy, long term cognitive devt 2. Most common cause of intestinal obstruction during f. Inheritance of diabetes pregnancy 7. Maternal effects a. adhesions a. Diabetic nephropathy b. Diabetic retinopathy c. Diabetic neuropathy CARDIOVASCULAR (DR. MORATA) d. Preeclampsia e. DKA 1. Physiologic considerations assoc w/ heart disease during f. Infections pregnancy a. 50% increase in cardiac ouput THYROID & ENDOCRINE DISORDERS b. Dec sys &pulmo vascular resistance 2. There is 3-4% of congenital HD in the offspring (TRUE) 1. Lab confirmation of hyperthyroidism 3. Periods during pregnancy when danger of decompensation is a. Dec TSH, elev fT4 greatest 2. Cause of thyrotoxicosis in pregnancy a. 28-32 wks a. Graves disease b. During labor & delivery ( CO increase 15-20%) 3. Tx of thyrotoxicosis c. Postpartum (4-5 days after delivery) a. PTU (300-450mg/day) 4. Classification of HD during pregnancy 4. Methimazole embryopathy is characterized by a. Class 1- uncompromised, no limitation of movt a. Esophageal /choanal atresia b. Class2- slight limit b. Aplasia cutis c. Class 3—marked limitation 5. Considered a better indicator of thyroid status during the 1st 2- d. Class 4 – severely compromised (s/sx of angina dev 3 months of treatment for hyperthyroidism even @ rest) a. Free T4 5. Predictors of cardiac complications 6. Treatment of thyroid storm & heart failure a. Prior HF, TIA, arryhtmia or stroke a. PTU b. Class 3 or 4 or cyanosis b. Lugol solution c. Left sided obs (MV area<2cm, AV ,1,5cm, peak LV c. SSKI outflow grad >30 mmHg 7. Most common cause of hypothyroidism in pregnancy d. Ejection fraction <40 % a. Hashimoto thyroiditis 6. Maternal mortality rate of surgically corrected HD is 3-4% 8. Daily iodine intake 7. Etiliogy of Aortic insufficiency a. 220 ug/day ---pregnancy a. RF b. 290 ug/day--- lactating women b. Con. Tissue abn 9. Fetal calcium needs c. Congenital a. 300 mg/day d. Appetite suppressant drugs (fenfluramine, dexfenfluramine) CONNECTIVE TISSUE DISORDERS 8. Diagnostic criteria for peripartum cardiomyopathy a. Devt of CF in the last month of preg w/in 5 mos after 1. Best screening test for SLE delivery a. ANA b. Absence of identifiable cause for the CF 2. Antibodies relatively specific for lupus c. (-) HD prior to last month of pregnancy a. dsDNA d. LV & systolic dysfunction demonstrated by classic b. anti SM ECG criteria 3. Diagnostic criteria for SLE a. SOAP BRAIN MD 4. Congenital heart block occurred almost exclusively in fetuses of women w/ antibodies to a. Ss-A b. Ss-b 5. Tx of RA a. NSAIDS
DERMATOLOGICAL DISORDERS
1. Most common pruritic pregnancy specific dermatosis
a. PUPPP (more commone w/ a male fetus) i. Absence of linear C3 2. Char by small, pruritic rapidly excoriated lesions on the forearms and trunks a. Prurigo gestationis 3. Hallmark of pruritic folliculitis a. Sterile pustules around the margin of erythematous patches, begin at flexures & extend peripherally